January 6, 2005 ORAL PATHOLOGY

Dr. Childers (lec & appendix)

BLOOMS TAXONOMY OF EDUCATIONAL OBJECTIVES Blooms Triangle- aim to be at the top of the triangle Making evaluative judgments is why they call you doctor Knowledge- remembering something previously encountered Comprehension- Understanding of material being communicated, w/o necessarily relating it to other material Application- the use of abstractions in particular and concrete situations Analysis- Breaking down communication into its parts so that organization of ideas is clear Synthesis- putting elements into a whole Evaluation- judging the value of materials and methods for a given purpose DIFFERENTIAL DIAGNOSIS 5 Steps in developing a Differential Diagnosis o Describe the Lesion (soft tissue and radiographic lesions) o Consider the anatomic location o Consider the patient history o Consider the pathologic processes o Best 3 differential diagnoses Use this method, using exact vocabulary Must know certain factors that help you make a decision DESCRIBE THE LESION Describing the Soft Tissue Lesion SIZE- centimeters SHAPE- must give to dimensions O SURFACE CONTOUR ~ Papule- solid, raised lesion < 5mm in diameter (around the size of a pimple) ~ Nodule- Solid, raised lesion > 5mm in diameter (bigger than papule) Must take into consideration how it attaches to mucosa - Polypoid (resembles polyp in gross feature - Pedunculated (stalk attachment) - Sessile (broad base of attachment) - May need to manipulate tissue for clear description ~ Macule- Focal area of color change which is not elevated or depressed Non palpable, no mass to it, just a color change Purpura (hemorrhage to skin), Vascular Pigmented ~ Plaque- Lesion that is slightly elevated and is fiat on its surface Wipeable or not Smooth or papillary (growth exhibiting numerous surface projections ) ~ Ulcer- loss of epithelium covering & often some CT; often appears depressed or excavated st Can be 2 lesion i.e. vesicle (blister) 1 roof destroyed by mastication ulcer Vesicle- superficial blister 5mm in diameter, usually filled w/ clear fluid Bulla- large blister >5mm in diameter (a big vesicle) Describing the Soft Tissue Lesion SHAPE- (contd) o BORDERS~ Symmetrical ~ Serpiginous- snake like, scalloped ~ Iris

~ Sharp, rolled ~ Ill defined- is it well circumscribed or invading surrounding areas ~ Polygonal ~ Oval Round

COLOR Brown o Purple o Red o Black o Pink o Normal o Blue o White o Note the lip has 3 distinct parts to it, the Border, vermillion and LOCATION o precise anatomic location may influence final diagnosis o Distribution- Number ~ Solitary ~ Multiple o Arrangement ~ Grouped Alveolar mucosa Gingival mucosa ~ Disseminated o Surface vs. Deep PALPATION o Consistency- Soft, firm, hard, fluctuant, board o Tenderness o Mobility o Temperature Some Descriptive Examples of Soft Tissue Lesions
o

mucosa

LEFT: Size- use something as a standard, i.e. size of tooth, to estimate size of findings ~ Understand the order of magnitude o Lesions w/ same general look, color and texture, but the location of the lesion are different ~ The dorsal midline of tongue picture is candidiasis ~ The lateral lesion is cancer (note- cancer rarely appears on the dorsal midline of the tongue) Will describe the soft tissue lesions in more detail next semester Describing Radiographic Lesion SIZE o Centimeters o Anatomic boundries may be used o Pic of young patient, lesion around developing tooth ~ 2 cm, well circumscribed, encompassing developing tooth ~ Note its making calcified product on the mesial portion of the crown (must decide whether its making calcified product or its residual bone) ~ Note delay in eruption of tooth, 1st molar hasnt erupted ~ Extends from the 2nd primary molar to the distal of the 1st molar
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SHAPE O RELATION TO TEETH ~ Periapical (around the apex), pericoronal (around the crown) Impacted tooth Erupted tooth Root resorption or spiking Displacement ~ Alveolar, interradicular ~ PDL, lamina dura O BORDERS ~ Well demarcated ~ Poorly defined or ragged o LOCULATIONS~ Unilocular Radiolucent radiolucent lesion (resembling soap bubble, or tennis racket) having a single compartment Must consider location- pericoronal, periapical, other location ~ Multilocular Radiolucent radiolucent lesion having several or many compartments Soap bubble, Tennis racket o CORTEX ~ Cortex is the outer portion of area ~ Thickened ~ Expanded ~ Eroded, thinned O UNIQUE FEATURES o Diagram ~ 1- well circumscribed ~ 2- Well defined but not corticated (no white line) ~ 6- scalloped edge ~ 8- by apex ~ 11- mimicking periodontal disease DENSITY o Radiolucent ~ Poorly defined or ragged borders ~ Multifocal or generalized o Radioopaque- is it calcified ~ Well demarcated or Poorly demarcated ~ Multifocal Describing Radiographic Lesion DENSITY (contd) o Mixed Radiolucent/Radioopaque ~ Well demarcated ~ Poorly demarcated ~ Multifocal o Unique Radiographic Appearance ~ Ground glass- its fine trabeculation, gives smokey appearance i.e. smoke screen, glass, like you put on shower door ~ Cotton wool- assoc w/ disease in England, we would call cotton ball ~ Sunburst ~ Onion skin- multilayer o Soft tissue Radioopaque ~ Calcification NUMBER

Solitary Multifocal ANATOMIC LOCATION o May influence the final diagnosis Define type of imaging o Include copies of images
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ANATOMIC SITE Site o Gingival o Floor of mouth o Lip o Buccal Mucosa o Tongue Tissues o Epithelium o Fibrous o Vascular o Neural PATIENT HISTORY Age, gender, race, occupation Duration and Onset Relationship to o Habits, meds, heat, cold o Pregnancy, travel, season o Previous treatment Oral Symptoms Constitutional symptoms

o o o o

Palate Neck Maxilla Mandible Salivary gland Bone Odontogenic Hematopoietic

o o o o

PATHOLOGIC PROCESS Metabolic- altered metabolism Inflammatory/Infectious o Related to repair or reaction to injury o Infectious- viral, bacterial, mycotic Neoplastic o An abnormal mass of tissue w/ uncoordinated growth and removal of stimulus does not stop growth Developmentalo An error of morphogenesis, chromosomes, or genes ****KNOW THE DEFINITION OF A NEOPLASM****

Characteristics of Benign and Malignant Neoplasms

Neoplastic vs. Noneoplastic- will influence treatment plan

RECONCILIATION Reconcile the information Best 3 as differential Diagnosis o Plan treatment o Biopsy, aspirate, culture, cytology, antibiotics, lab studies o Referral PATIENT TREATMENT RECORD

SOAP note A- is where you come up w/ your DDs (differential diagnosis)

CLINCIAL DIFFERENTIAL DIAGNOSIS Each disease process may have more than one clinical presentation Each clinical presentation may represent more than one disease process Evaluate each patient individually, based upon your clinical judgment as to the weighted value of each feature For more details, the practitioner is referred to a textbook of oral pathology

1-13-06- Dr. Childers Lec 2 & Txt Ch. 14 pp. 534-552 BONE PATHOLOGY
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We will discuss Bone Diseases That Effect the Jaws o Many of these diseases are inherited o Generally disease that effect the teeth and other epidermal structures i.e. hair are generally autosomal dominant, but there are exceptions we are learning that many of the diseases have different types of inheritance may have both recessive and dominant inheritance also may have spontaneous mutations

Osteogenesis Imperfecta Inheritance o Autosomal Dominant, Autosomal Recessive, Spontaneous mutations o All effect collagen maturation Clinical Features o Fragile bones (fractures at birth), Bone deformities, Joint Hyperextensibility o Blue sclera o Hypoacusis- hearing impairment o Patients have lots of problems Radiographic Features o Osteopenia- Decreased calcification or density of bone

Bowing, Angulation, Deformity of Long Bones Multiple Fractures o Bone w/ thin cortex, fine trabeculation, and Diffuse osteoporosis o Wormian Bones- tiny small bones found at serrated borders of sutures b/w the cranial bones Oral Features o Teeth look clinically and radiographically identical to dentinogenesis imperfecta ~ Osteogenesis imperfecta affects bones and teeth ~ Dentinogenesis imperfecta only affects teeth o Opalescent Teeth- dont have transparent, translucent porcelain look ~ Teeth have a blue-brown translucence ~ Change coming from the effect of the dentin, not a problem w/ enamel, similar to tetracycline stain ~ Opalescent look ranges from mild to severe in different types o Both primary and permanent dentitions involved o Often have complete pulpal obliteration ~ Takes a bit to realize that there is no pulp ~ Some forms have extremely large pulps, but obliteration more common o Often have a lot of dental caries o Often Class III malocclusion ~ Caused by maxillary hypoplasia o Florid Cemento-osseous dysplasia ~ On rare occasion xrays show multifocal RL, mixed RL or RO that resemble those seen in florid COD Osteogenesis Imperfecta (contd) Types of Osteogenesis Imperfecta o Type I ~ Autosomal Dominant Inheritance ~ Most common, mildest ~ Blue sclera, bone fractures, hearing loss, hypermobile joints, bruising o Type II ~ Autosomal Dominant, Autosomal Recessive, Sporadic ~ Most Severe ~ Still borne or early death ~ Bleu sclera, extreme bone fragility, fractures during delivery o Type III ~ Autosomal Dominant, Autosomal Recessive ~ Most severe beyond perinatal (around time of birth, shortly before or after) age ~ Severe bone fragility, normal to blue sclera fades w/ age, lax ligaments, hearing loss ~ 1/3 survive to adulthood, most die in childhood from cardiopulmonary complications o Type IV ~ Autosomal Dominant ~ Mild to moderately severe bone fragility, normal to blue sclera, less fractures after puberty o Opalescent teeth may be present in all types Histopathological Features o Attenuated bone (thin, weakened) o Minimal matrix o Immature woven bone, does not transform to lamellar bone Treatment and Prognosis o Bone fracture management o Teeth often show attrition o Overall disability depends on severity of disease
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Osteopetrosis Osteo= Bone

Petrosis= petrified hard (Note- Osteosclerosis does not equal osteopetrosis)

Aka Albers-Schonberg Disease and Marble Bone Disease Rare disease of osteoclastic defect (More rare than osteogenesis imperfecta) o Bone not resorbed b/c osteoclasts do not function normally Infantile osteopetrosis o Ranges from malignant intermediate transient (return to normalcy) o Autosomal recessive o Increased Bone Density Marrow failure, frequent fractures o Narrowing of skull foramina compression of cranial nerves ~ Results in blindness, deafness, facial paralysis o Delayed tooth eruption ~ Osteomyelitis of jaw common complication of tooth extraction ~ Roots of teeth difficult to visualize b/c of density of surrounding bone Adult Osteopetrosis o Usually benign- less severe o Autosomal dominant o Axial skeleton has significant sclerosis, whereas long bones have little or no defects o Increased radiopacity of medullary portions of jaw bone o 40% Asymptomatic, but in symptomatic bone pain frequent Cleidocranial Dysplasia Aka cleidocranial dysostosis (old name), b/c little portion of the clavicle formed Inheritance o Autosomal Dominant and Spontaneous Mutation o Defect of Osteoblastic differentiation Clinical and Radiographical Features o Hypoplasia (under development), Malformation, or absence of clavicles ~ Patient has no clavicles so patient can touch shoulder o Short stature, Large heads, frontal bossing (big forehead), o Ocular hypertelorism (wide spread eyes), Depressed nasal bridge o Open skull sutures, wormian bones Oral Features o Increased prevalence of cleft palate o Retained deciduous teeth o Unerupted permanent and supernumery teeth ~ Note- can have supernumery teeth w/o this syndrome ~ Tooth eruptions not fully understood- hypothesized to cementum development, but controversial o Narrow ascending mandibular ramus, Mandible has coarse trabeculations w/ areas of increased density, pointed coronoid process, thin zygomatic arch o May develop class III malocclusion Treatment o None for skull, clavicular and bone anomalies o For dental problems- preferred treatment to extract primary and supernumerary teeth

related to

Focal Osteoporotic Marrow Defect Defect in bone marrow, aka hematopoetic bone defect o Normally, hematopoetic marrow not found in jaws, marrow is just fibro-fatty, not making RBCs o In these patients they have hematopoetic marrow, they are making rbc Not a true Neoplasm o May be aberrant bone regeneration following extraction o Persistent fetal marrow o Marrow hyperplasia to meet increased demand for rbcs Clinical Features o Always asymptomatic, rare disease o 75% adult females

70% posterior mandible, usually edentulous area No expansion Radiographic Features o Hematopoetic cells in radiograph o X-ray shows subtle change of trabeculation ~ Periapical view shows ill defined borders and fine trabeculation o Panoramic view ay appear radiolucent and well defined o Incidental findings o Usually several mm to cm Histological Features o Normocellular hematopoietic marraow o megacaryocytes and blood cells, the only way you would be able to see this is by biopsy Treatment and prognosiso Bx-dx, once diagnosis established, not further treatment is needed, prognosis excellent Idiopathic Osteosclerosis Idiopathic- unknown cause Osteo-bone Sclerosis- Increase in calcified material Definition o Focal increased radiodensity that is of unknown cause and cannot be attributed to any inflammatory, dysplastic, neoplastic, or systemic disorder ~ Not response to inflammation- note how both premolars look normal ~ Generally assoc w/ teeth that dont have anything wrong w/ them ~ Notice area of sclerosis under mandibular premolars o Fairly common, most dont need biopsy o If Lesions at periapical region of nonvital, carious, or inflamed pulp it is probably condesing osteitis or chronic sclerosing osteomyelitis ~ Note- -itis" usually deals w/ inflammation, which is not idiopathic Clinical features o 5% prevalence (this is a common disorder) o Slightly higher in Blacks and Asians st nd o Arise late 1 or early 2 decade o Static or slow increase in size (sclerotic area stabilizes once patient reaches full maturity) ~ May have slow increase in density to 4th decade o Asymptomatic, they do not cause pain, or an increase in size of bone o More common in mandible (90%) ~ 1st molar area, premolar, 2nd molar o Usually one, but may be multiple o Aka bone scar (she doesnt like that name), dense bone island, bone eburnation, bone whorl, enostosis, focal periapical osteopetrosis Radiographic Features o Well defined, rounded or elliptical radiodense area ~ Usually uniform density o No radiolucent rim (no capsule) o 3mm 2 cm o Often assoc w/ a root apex Histopathologic Features o Dense lamellar bone Diagnosis o Not usually biopsied (If you biopsy, you will just get vital bone) ~ Only considered if assoc w/ symptoms or significant cortical expansion o Diagnosis based on history, clinical features and radiographic findings o Must make differential as to whether it needs biopsy or not o Differentiation from condensing osteitis difficult but absence of deep restorations or caries, a periapical RO assoc w/ vital tooth is most likely idiopathic osteosclerosis
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Treatment and Prognosis o If discovered during adolescence, take periodic until area stabilizes o After that no treatment indicated Description of radiograph o 1cm, radioopacity in lower left mandible, well

radiographs

circumscribed

Massive Osteolysis Rare disease of unknown cause, aka hemangiomatosis of bone Destruction of bone (disappearing density) replaced by vascular proliferation followed by fibrous fill Clinical Features o Children and young adults o 50% report trauma preceded diagnosis o Usually in mandible (when there is maxillofacial involvement) ~ Similar lesions seen in other bones i.e. pelvis, humeral head and shaft, and axial skeleton o Signs and Symptoms- Mobile teeth, pain, malocclusion, deviated mandible, facial asymmetry, sleep apnea, pathologic fracture of mandible Radiographic Features o Radiolucent foci of varying size w/ poorly defined borders o Loss of lamina dura, thinning of cortex o Gradually coalesce enlarge and involve cortical bone portions of involved bone disappear Histopathologic Features o Nonspecific vascular proliferation w/ inflammation o In later stages tissue from area of bone loss I more collagenized Treatment and Prognosis o Variable clinical course, variable treatment o Radiation most successful but failures occur, and patient at risk for postradiation sarcoma

Pagets Disease of Bone Characterized by abnormal resorption and deposition of bone o Tend to think of skeleton as static, but it is dynamic, it is always laying down and breaking down o Patients turnover is out of sink, more laying down than breaking down o Patients get thickened and enlarged bones, affect entire body o Note bones are not stronger, b/c its defective bone Clinical Features o Common in Britain and US, rare in Africa and Asia o Occurs more in males, usually over 40 y.o. o Usually polyostotic (affect more than one bone) ~ Usually occurs in more than one bone, especially skull o Bone pain and osteoarthritic changes o Lumbar vertebrae, pelvis, skull, femur most commonly affected bones o Thickened, enlarged, weakened bones ~ Bowing of long bones ~ Enlargement of skull circumference o Unexpected elevation in serum alkaline phosphatase levels Oral Features o Jaw involvement (17%) o Diastema forms ~ start to have space b/w teeth (recall that this may occur in periodontal disease as well, so must distinguish) o Denture wont fit (usually bone resorbs under denture) o More frequent in maxilla than mandible o Mouth protrudes, enlargement of middle 1/3 of face

~ Normally maxilla has slight concavity Pagets Disease of Bone contd Radiographic Features o Must take radiograph to determine if its soft (i.e. hypergingiva) or hard tissue (bone enlargement in Pagets) o Decreased radiodensity w/ patch sclerosis ~ Cotton wool ~ pic- skull enlargement, notice abnormal texture of skull, has cotton wool appearance, cloudy finger like projections o Hypercementosis- cementum enlarged around each tooth (can occur w/o pagets) Diagnosis o Elevated serum alkaline phosphatase (so elevated that its off the charts, very high, this is major diagnostic feature) ~ but normal calcium and phosphorus o Combined with clinical and radiographic findings o Pagets goes thru phases- in biopsy~ increase in osteoblastic and osteoclastic cells ~ ncreased activity than expected in patient this age, causing reversal lines Treatment and Prognosis o Chronic and progressive o Dont really have cure, just treat the symptoms ~ Bone pain w/ analgesics ~ Serum alkaline phosphatase w/ parathyroid hormone antagonist ~ Make denture bigger o This is metabolic disease- so removing bone wont cure it, the bone wont heal well Complications o Extractions must consider hypercementosis o AV shunts, oral surgery during active phase may result in extensive hemorrhage o Poor healing o Osteosarcoma develops 1% (b/c of all this activity)- aggressive and assoc w/ poor prognosis Central Giant Cell Granuloma (or lesion) Central- within the bone (Note- periphery- is outside bone, in gingiva when discussing jaws) Non neoplastic lesion Common disease of unknown cause It is not a granuloma, just and old misnomer Clinical Features o Seen in young persons, ~ 60% under 30 ~ Can occur in all ages (2-80 y.o.) o Mandible > Maxilla ~ May cross midline in mandible ~ Usually anterior to 1st molar o Usually asymptomatic but may have expansion, pain, paresthesia, ulceration o Non aggressive lesions- No symptoms, Slow growth, no perforations or root absorption o Aggressive lesions- Pain and recurrence, Rapid growth, cortical perforation, root resorption o Benign fibrosseous lesion may mimic odontogenic lesion ~ i.e. if this lesion was in 18 yr old in posterior mandible it would look like an odontogenic lesion due to 3rd molar Central Giant Cell Granuloma (or lesion) contd

Left Pic- Well defined radio lucent area, notice thinnes of cortex of mandible Right Pic - Buccal and lingual expansion, w/ multiple loculations Radiographic Features o Radiolucent o Unilocular or multilocular o Well defined borders, but noncorticated o Notice shift is impacted tooth o This looks like an odontogenic lesion (neoplasm) , but its benign fibroseous lesion Histopathologic Features o May be assoc w/ aneurysmal bone cyst, central odontogenic fibroma o Microscopically we see multinucleated giant cells in a background ovoid cells cells ~ May show hemosiderin deposits ~ Looks like brown tumors of hyperparathyroidism ~ Pathologist would diagnose Central Giant Cell Granuloma hyperparathyroid cells b/c from microscope cant differentiate ~ Doc must do a serum test for hyperparathyroid- test Ca levels o Must rule out multifocal lesions (more than one lesion, in more quadrant), which suggests cherubism o Microscopically different than odontogenic lesion (odontogenic have giant cells) Treatment and Prognosis o Usually treated by thorough curettage (scraping) o Recurrence 15-20% (high) o Alternative treatment~ Corticosteroids, calcitonin, interferon ~ Sometimes injected w/ cortocosteroids to let them shrink a little bit than perform surgery o The more aggressive the treatment the lower the recurrence rate, but surgeon must choose balance o More difficult to treat once it breaks thru cortex of mandible o pic of excision, showing that disorder can be very aggressive Different than giant cell tumor, o which is lesion of the long bone, more aggressive, may become malignant
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rule out pathologist than one lesion wont

Cherubism Inheritance o Autosomal Dominant w/ high penetrance variable expressivity Clinical Features o Usually manifest b/w 2-5 y.o. ~ Progresses till puberty, stabilizes, regresses o Cherublike face o Upturned eyes o Usually bilateral symmetrical enlargement of posterior mandible angle and ascending rami ~ In maxilla involvement occurs in tuberosity areas

including

Eventually they are self limiting and will shrink a bit Tooth displacement and failure to erupt Radiographic Features o Multilocular, expansile, bilateral radiolucent areas ~ Virtually diagnostic o Rarely unilocular o Rarely other bones Syndrome Association o Ramon, Jaffe- Campanacci, Noonan-like Histopathologic Features o Multinucleated giant cells in a vascular, fibrous stroma ~ May show eosinophilic cuffing o These look the same microscopically as Central Giant Cell Granuloma , but occur in more than one quadrant Diagnosis and Treatment o Look at age, radiograph, biopsy, family, and location, to determine Dx of Cherubism o Natural history is unpredictable o May regress after puberty o Optimal therapy unknown (surgery vs. observation) o Rare disease
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Simple Bone Cyst Benign, empty or fluid filled cavity w/in bone, w/o an epithelial lining o Tends to be empty o Not a true cyst- b/c doesnt have a epithelium lining, filled w/ fluid Causes and Pathogenesis o Trauma-hemorrhage theory- trauma to bone that is insufficient to cause a fracture results in intraosseous hematoma if it doesnt repair it may liquefy resulting in a cystic defect o aka traumatic bone cyst, ~ implies trauma, while there isnt always a history of trauma Clinical Features o Occurs in almost every bone, most common in long bones o More common in mandible, esp premolar and molar areas o Most frequent b/w 10-20 y.o. o Rare under 5 yrs or over 35 y.o. o Usually asymptomatic ~ 20% have painless swelling Simple Bone Cyst (contd) Radiographic Features o Well delinieated radiolucent area ~ May be focally ill definied ~ Cyst in jaw like water balloon o 1 -10 cm o May scalloping b/w teeth roots o Vital teeth, generally do not show root resorption o Less commonly expansile o May occur in association w/ cemento-osseous dysplasia and other BFOL Histopathological Features o Lined by thin fibrovascular connective tissue (not epithelium) Diagnosis o Bx - Dx o Before a surgeon will biopsy a bony lesion ~ Must always aspirate b/c there may be a hemangioma (vascular lesion) in bone, if not present you get a serous fluid, not bloody

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~ Simple bone cyst tend to be empty ~ Biopsy gives scant tissue ~ But going to biopsy, helps stimulate healing Requires clinical/pathological/radiographic correlation No Ray, No say - must give pathologist a pic of x-ray for them to make diagnosis ~ Need clinical, pathologic, and radiographic correlation

Aneurysmal Bone Cyst Aneurysmal- vascular lesion Intraosseous accumulation of blood filled spaces (hemorrhagic extravasation) o May have giant cell granuloma like areas o Sinisoidal, large spaces filled w/ vascular tissue (not a hemangioma) Cinical Features o Occurs in long bones and verterbrae o Rare in jaws o Wide age range, mean approx 20 y.o. o Mandible > Maxilla ~ Commonly in posterior part of jaw o Rapidly growing swelling o May move teeth o Pain reported, but paresthesia, compressibility and crepitus are rarely seen Radiographic Features o Unilocular or multilocular radiolucent area o Cortical expansion and thiining o Borders may be well or poorly defined o May have small radioopaque foci Histopathological Features o Sinusoidal spaces filled w/ flood o Cellular fibrous CT o Multinucleated giant cells and osteoid o May be associated w/ central giant cel granuloma or other BFOL Aneurysmal Bone Cyst (contd) Diagnosis and Treatment o May do small biopsy- may have giant cells, but this can happen in a lot of diseases esp around the edges ~ Important to correlate, clinical radiograph and pathologic features ~ Recall- disease can have as many diseases as he pleases o Currettage or enucleation ~ Dark venous blood wells up ~ Tissue is like blood soaked sponge o Variable recurrence rate Pic 1- lateral obliqe film, notice how inferior border has expanded, its radiolucent, ill defined w/ a thin cortex Pic 2- radiolucent, multilocular, extending from posterior body up the ramus, expanding mandible (notice cortex close to tooth), displacing impatcted bone cyst (notice occlusal view of mandibular 3rd molar) o Differential- giant cell granuloma rule out hyperparathyroidism, cherusim Slide 40 From appendix- please refer to it, we didnt go over all of it Slide 41 Differential- Simple bone cyst, central giant cell granuloma (crosses midline),

Review remaining slides Quiz next week including picture

Oral Pathology Dr. Childers- Lec 3, chap 14 (pp.553FIBRO-OSSEOUS LESIONS

1-20-2006

Classifications are important b/c there are usually reasons that diseases are grouped together Fibro-osseous Lesions Classification of diverse processes that have: o Normal bone replaced by fibrous tissue w/ calcified tissue production It is not a specific diagnosis Histologically they often look the same, but radiographically they are different o Important to get radiograph w/ biopsy (no ray no say) o Need both pieces of info to make diagnosis Developmental, reactive, dysplastic, neoplastic processes o Prognosis for various processes w/in this classification are different, must be able to distinguish Fibrous Dysplasia Very common Developmental process (not neoplastic), usually starts in kids o Sporadic condition from postzygotic mutation in GNAS 1 gene

Tumorlike condition, characterized by replacement of normal bone by an excessive proliferation of cellular fibrous connective tissue mixed w/ bony trabeculae Types of Fibrous Dysplasia st o One of 1 thing to be determined is how many bones are involved: ~ Monostotic Fibrous Dysplasia Limited to a single bone If mutation occurs postnatal life, mutated cells are essentially confined to one site fibrous dysplasia affectss single bone 80-85% of all cases, jawxs most commonly affected site ~ Polyostotic Fibrous Dysplasia Affects many bones and may be associated w/ cutaneous and endocrine abnormalities If mutation occurs in undifferentiated stem cells in early embryologic life osteoblasts, melanocytes and endocrine cells will carry and express that mutated gene If mutation occurs during later period (once skeletal progenitor cells developed), multiple bone lesions of fibrous dysplasia w/o cutaneous and endocrine problems ~ Craniofacial Fibro Dysplasia Affects bone in the face and cranium Behaves like monostotic, eventhough if may affect multiple bones adjacent to maxilla I.e. - if infection in maxilla and zygoma it is not polyostotic, its craniofacial Clinical Features o Painless swelling of affected area o Growth generally slow nd o Usually diagnosed in 2 decade ~ Often 1st diagnosed by dentist, often begins in jaws o Occurs in Males = Females o Maxilla > Mandible Fibrous Dysplasia Radiographic Features o Ovoid or Fusiform- (football shaped) growth ~ As opposed to a neoplasm, oseofibroma (?) which has centriphical growth (sphere) ~ Shape of lesion impacts treatment o Borders are not well demarcated o Cortex is expanded o Cortex is often lesional bone ~ Its not eroded, its become lesion ~ Smooth clear border cortex become lesion ~ Treat this with a shave- b/c its not a neoplasm that needs to be completely removed, note this wont cure it o Ground Glass aka smoke screen aka orange peel finely granular trabeculations ~ Must know what normal bone looks like to identify this ~ Pic- Look under 1st molar and b/w 1st molar and 2nd premolar its not normal o Narrow PDL space and ill defined lamina dura o Pic- Axial CT- note you have cortex on one side, and lesion on other, get a feel for altered trabeculations o Lesional bone w/ smoke screen appearance o Pic- Maxillary lesion- to the right of septum, note these lesions have a little bit of cortex all around (remember thats not hard and fast rule) Polyostotoic Fibrous Dysplasia o More serious o Rare involvement of 2 or more bones o May be in conjunction w/ cutaneous and endocrineabnormalities o Jaffe-Lichtenstein syndrome ~ Caf au lait pigmentation- brown spots (macules)

Coast of Main- rough, rocky coast; irregular borders, typical for fibrous dysplasia Coast of California- smooth borders, more common in disorders neurofibromatosis McCune-Albright Syndrome ~ Caf au lait pigmentation ~ Assoc w/ syndromes like endocrinopathies Precoclous sexual development- patients develop early Pituitary adenoma hyperthyroid Usually dominated by symptoms related to long bone lesions ~ Hockey stick deformity- leg length discrepancy may involvement hockey stick shaped lesional bone; enlarged, Go thru different stages where they appear differently at lesion

polyostic like

resultfrom femur but not normal differenttimes of

Fibrous Dysplasia (contd) Histological Features o Chinese character trabeculations ~ Loosely arranged fibrous stroma (background), w/ small oddly shaped trabeculations ~ Trabeculae are not connected to one another o Monotonous pattern through out lesion o No osteoblastic rimming o Dont make diagnosis just on slide, need radiograph and clinical o Fuse directly to adjacent normal bone, so no capsule or line of demarcation is present Treatment o Excision usually not possible o Early treatment may induce growth o Cosmetic reduction shave down o 25-50% o Radiation therapy is contraindicated ~ it may induce osteosarcoma, which is rarely reported as a complication of fibrous dysplasia Prognosis o Osteosacrcoma rarely reported Cemento-osseous Dysplasia (COD) COD aka Osseous dysplasia Occurs only in the jaws (in tooth bearing areas) o Most common fibrous osseous lesion o Theorized to arise from PDL (a unique structure of the jaw), or a defect in extraligamenterary bone remodeling due to local factors or a possible underlying hormonal imbalance Classification (consider it a spectrum of disease) o Focal Cemento-osseous Dysplasia ~ Clinical Features Single site involvement 90% females- avg 38 y.o. Usually caucasian Asymptomatic Posterior mandible dominant site Lesions usually < 1.5cm ~ Radiographic Features Varies from radiolucent to radiopaque w/ radiolucent rim - Mostly mixed RL/RO pattern Borders are well defined but irregular

Lesions occur in edentulous and dentulous areas Focal lesion may represent early florid lesion - Cant distinguish from florid by radiograph alone Goes thru stages - 3rd pic shows early stage on right side of molar (?) - 4th pic- left side of molar may be further along note calcification inside

Cemento-osseous Dysplasia (COD) Classification (contd) o Periapical Cemento-osseous Dysplasia~ Clinical Features Periapical region of anterior mandible, usually multiple lesions - Kind of b/w focal and florid, often the beginning of florid Usually Females (10-14:1) Middle ages (Diagnosed 30-50y.o.) - Almost never under 20 Usually Black (70%) Teeth are almost always vital (alive), and rarely have restorations - Note vitality test are not 100% - You havent helped your patient if you do endodontic therapy and they dont need it Patient is Asymptomatic Application- No caries, middle aged black women, and you notice this on radiograph, a light should go off; keep an eye on it ~ Radiographic Features Early Lesions- Well circumscribed radiolucent area at apex of vital mandibular incisor teeth Looks like periapical granuloma or periapical cyst - Over time, lesion coalesce to for linear area encompassing apices of several teeth Later Lesions - Mixed radiolucent and radiopaque Mature Lesions - Circumscribed, dense calcification surrounded by a radiolucent rim - Usually Asymptomatic - PDL intact, not enlarged - Not fused to tooth - Seldom greater than 1cm diameter - Self limiting growth - Does not expand cortex ~ Differential- Periapical Pathology solitary, unilocular, well circumscribed, radiolucency at base of anterior tooth, most dentist think pulpal pathology - But may be beginning of periapical COD Must distinguish, are they symptomatic, do they fit the demographic it, watch it You dont treat periapical COD o Florid Cemento-osseous Dysplasia~ Clinical Features Multifocal involvement - More than one quandrant and sextant involved, not limited to anterior mandible Lesions come in all sizes and shapes, - Can be lumpy, or smooth

May be symmetrical

Cemento-osseous Dysplasia (COD) Classification o Florid Cemento-osseous Dysplasia~ Clinical Features (contd) Usually asymptomatic but may have painful sequestra or expansion - Sequestra- A piece of necrotic tissue, usually bone, that has become separated from the surrounding healthy tissue - Symptomatic- pain, swelling, little portions of bone come to surface - Often have inflammatory component, seems like inflammation fires up disease process 90% Black Female, Middle age to elderly ~ Radiographic Features Same pattern of maturation as focal COD and periapical COD (radiolucent mixed radiopaque w/ radiolucent rim) More sharply defined radiolucent areas may represent simple bone cysts - Bone cyst may need treatment as well as Florid COD Lesions found in dentulous and edentulous areas

patient in 2 different times

Pics- same

COD Histopathologic Features o All 3 patterns are similar o Tissue consists of fragments of cellular mesenchymal tissue composed of spindle-shaped fibroblasts and collagen fibers w/ numerous small blood vesseW o Fibrous Connective tissue w/ woven bone, lamellar bone and cementum ~ Mature lesions have mineralized product that looks like ginger root- more bulbous o In final stage individual trabeculae fuse and form lobular masses composed of sheets or fused globules COD Diagnosis o Focal COD~ Usually needs biopsy ~ Surgical findings of gritty tissue that does not separate easily from adjacent bone o Periapical COD or Florid COD ~ Cinical and radiographic evidence ~ May not necessitate a biopsy Cemento-osseous Dysplasia (COD) COD Treatment o Since its not a neoplasm, it doesnt just shell out (come out easy), lesion comes out gritty ~ Ossifying fibroma, on contrary is a neoplasm and will shell out easily o May not require treatment

o o

o o

~ Root canal will not help- lesion wont heal During predominately radiolucent phase lesions cause few problems Once significant sclerosis present- lesions tend to be hypovascular and prone to necrosis w/ minimal provocation ~ Best treatment is regular recall w/ prophlaxis and reinforcement of good home hygiene Can cause complications ~ Difficult extractions ~ Ridges dont do well under dentures Symptomatic patients difficult to treat ~ Inflammatory component is like a chronic osteomelitis involving dysplastic bone and cementum ~ Antibiotics may not be effective ~ Sequestration of sclerotic cementum like masses occurs slowy and is followd by healing ~ Saucerization of dead bone may speed healing Prognosis for COD is good Simple bone cyst may need biopsy for diagnosis ~ Simple bone cysts often do not heal as rapidly as those in younger patients w/o COD

Familial Gigantiform Cementoma Rare Autotosmal Disorder, patient has big sclerotic masses in jaws o Disorder of gnathic bone that ultimately leads to the formation of massive sclerotic masses of disorganized mineralized material Clincal Features st th o Begins to manifest in 1 decade and continues till 5 decade ~ Rapid and expansive growth in adolescence o Both maxilla and mandible affected in multiple sites o Progresses to facial deformity and may have sequestra formation ~ Gnathic enlargement in most patients results in significant facial deformity o Teeth may be impacted, displaced and malocclusion may result o In final stage, affected bone is very sensitive to inflammatory stimuli and becomes necrotic w/ minimal provocation (similar to COD) ~ May have elevated alkaline phosphatase, anemia and adenomas of the uterus Radiographic Features o Begin as radiolucent areas and progress to dense sclerotic masses w/ a radiolucent rim o Initially similar to cemento-osseous dysplasia o As lesion progresses, affected sites replace much of normal bone w/in involved quadrant and devlop mixed RL/RO pattern Histopathological Features o Same as cemento-osseous dysplasia (Ginger-root, bulbous appearance) Treatment o Best recontoured during sclerotic phase ~ Before this phase, dyspastic tissue rapidly regrows Establish a Differential Diagnosis unilocular radioopacity, 2cm, well circumscribed, at apex of mandibular premolar, Note PDL in check Chart from Neville appendix radiopacities well demarcated borders

Pic- occlusal view- ground glass, radioopacity, had fibrous dysplasia Note this is not cotton wool- cotton wool is usually only seen w/ pagets disease Fusiform- has ovoid like appearance Occlusal view gives a lot of information, must take x-rays at different views to get full understaning

Chart from appendix- Poorly demarcated borders Must learn to understand differential Cemento-osseous dysplasia- can be well or poorly defined, sometimes disorders fall in more than one category Must describe what you see, develop a well developed differential diagnosis, and even if you are wrong, there is no malpractice here o i.e. have unilocular well defined, lesion at apex of non vital tooth you may do a root canal, but if you find out that is not the problem, you are not at fault, take biopsy, it may be metastatic prostate cancer but you werent at fault for doing root canal, thats why differential is important Chart- Ground glass Panoramic picture Multifocal, well demarcated, mixed lesions, 2-3cm, Differential- Florid Cementoosteus Dysplasa(2 quadrants) Note- panoramic radiographs are difficult to use as diagnosis in anterior region, familial gigantiform cementoma, pagets

Chart- Radiopacities- Multifocal or Generalized Pic- crop of panoramic Mixed, well demarcated, 2-3cm, body of mandible Dysplasia- cemento-osseus dysplasia, pagets, familial gigantiform cementoma Chart- mixed radiolucent/radioopaque lesions- well demarcated border

Pic- crop of panaromic pic Well circumscribed, radiolucent, 2-3cm, periapical region Diferential - Central Giant cell granuloma, simple bone cyst, aneurismal, periapical pulpal pathology

Chart unilocular radiolucencies, other locations Pic- panoramic Multifocal, well demarcated, radiolucent and mixed lesion (notice anterior region)

Differential- Florid cemento osteos dysplasia, pagets, cherubism (maybe), familial gigantiform

Chart- mixed RL/RO multifocal or generalized Chart- unique radiographic appearance- cotton wool

Oral Pathology - Dr. Childers Lecture 4, Chap 14 (pp. 563-574) FIBRO-OSSEOUS LESIONS of the JAW

1-27-2006

Ossifying Fibroma Aka Cementifying Fibroma, or Cemento-Ossifying Fibroma True osteogenic neoplasm of fibrous connective tissue and calcified product o Must keep in mind if its metabolic, neoplastic, developmental, etc o Origin is odontogenic or from PDL Clinical Features rd th o Wide age range most 3 and 4 decades o Occurs more in females than males o Mandible > Maxilla ~ Premolar and molar o Small tumors asymptomatic ~ May grow large causing facial asymmetry ~ Rarely assoc w/ pain and paresthesia o Surgically separates easily from surrounding bone (different than COD which is gritty) ~ There is a plane of separation, it is shelled out ~ Well circumscribed Radiographic Features o Can present similar to focal cemento-osseous dysplasia o Well defined and unilocular o May have sclerotic borders ~ may be very thin borders if lesion has been there for a long time o Radiolucent, mixed, or radiopaque ~ Rarely large radiopaque w/ thin radiolucent rim that is usually end stage focal cemento-osseous dysplasia o This is centriphical (sphere) growth, like a snowball ~ Unlike fibrous dysplasia that grows like fusiform (football) o May cause movement or resorption of teeth, or root divergence o May bow cortex downward-

~ Doesnt erode thru cortex, and cortex doesnt become lesional bone (like fibrous dysplasia) it just pushes thru bone (bow) Histopathologic Features o Well demarcated from surrounding bone ~ Grossly submitted as one mass or a few large pieces o Fibrous connective tissue w/ mineralized material ~ Variants of bone (hard tissue portion resembling trabeculae of osteoid and bone; and basophilic, poorly cellular spherules resemble cementum) o Osteoid and osteoblatic rimming are usually present o Variations in types of mineralized material help distinguish from fibrous dysplasia o Goes thru stages ~ May start of radiolucent, calcified material may be microscopic, then becomes more circumscribed o Gross Specimen ~ Looks like cut potato ~ Shelled out

Ossifying Fibroma contd Treatment and Prognosiso Enucleation (removal of lesion) usually possible due to circumscribed borders of lesion o Rare recurrence o No evidence of malignant transformation Juvenile Ossifying Fibroma Aka Juvenile Active Ossifying Fibroma and Juvenile Aggressive Ossifying Fibroma Variant of ossifying fibroma o Differs from conventional ossifying fibroma on the basis of patient: ~ Age (younger patient) ~ Site ~ Clinical behavior (more aggressive) o 2 forms- Trabecular and Psammonatoid Clinical Features o Slow growth o Wide Age range ~ Trabecular mean age 11 ~ Psammoma mean age 22 o More common in Maxilla o May show expansion o May impinge and extend into adjacent anatomic structures ~ Orbit, Nasal Cavity, Cranium ~ Psammoma variant also seen in orbital, frontal and Paranasal sinuses o Younger patients may have more aggressive growth ~ Slow growth typically, but can be very aggressive and grow Radiographic Features o Circumscribed radiolucent area, may contain radioopacities o Sinus lesions may appear as cloudy o Part of panoramic pic- radiolucent/mixed well circumscribed, (pushing superior cortex into coronoid process, and expanding has pushed developing tooth, approx 5 cm o CT Scan- mixed, expanding buccal cortex and a bit of the lingual, well circumscribed Histopathologic Features o Nonencapsulated but well demarcated o Fibrous CT stroma

fast

expansile inferior cortex),

Trabecular calcifications- are strands of osteoid lined by osteoblasts and osteoclasts Psammamatoid calcifications- are concentric rings of calcified material w/ brush borders Treatment o Smaller lesions may be locally excised o Larger lesions may need to resection o Must be treated aggressively Prognosis o Recurrence 30-58% o Malignant transformation not reported Osteoma Benign tumor of craniofacial skeleton o Pretty common lesion, rare in other bones o This is a neoplasm (controversial) ~ Somewhat like a tori, but tori arent neoplastic Clinical Features o Found in young adults o In Jaws- Arise on surface of bone or in medullary bone ~ Periosteal osteoma- on surface of bone as polypoid or sessile mass On mandible or maxilla, may reach large size facial deformity ~ Endosteal osteoma- w/in medullary bone** o Often asymptomatic, solitary lesions o Most located in lingual side of body of mandible posterior to premolars, or on the Condyle o Slow growing o May involve condyle ~ Result in change of occlusion, facial swelling, pain, limited opening, deviation of midline of chin twd unaffected side Associated with Gardeners Syndrome o Not every patient w/ osteoma will have gardeners syndrome o Must rule out Gardner Syndrome Radiographic Features o Radiopaque o Circumscribed sclerotic mass o May have trabeculation o Small endosteal osteomas hard to differentiate from foci of sclertotic bone representeing end stage of inflammatory process (i.e. condensing osteitis) or non-inflammatory process (i.e. idiopathic osteosclerosis) Histopathologic Features o Dense, Vital bone, May be: ~ compact bone- normal appearing dense bone w/ minimal marrow tissue ~ cancellous bone- trabeculae of bone and fibrofatty marrow o prominent osteoblastic activity Treatment o Conservative surgical exicision vs. periodic observation o Condylar osteoma usually removed surgically ~ Must be treated if you needed removable prosthesis Prognosis o Dont regularly recur o No reported malignant transformation
o o

Gardeners Syndrome Rare Autosomal Dominant Disorder o Chromosome 5 o Part of familial colorectal polyposis o Gardeners is familial- once one family member has it they check other family members Clinical Features nd o Colonic polyps arise in 2 decade

~ Adenomas transform into adenocarcinoma ~ malignant or premalignant polyps in colon Gardeners Syndrome Clinical Features (contd) o Oral manifesetations ~ Osteomas- arise in puberty Most commonly invove skull, paranasal sinuses, and mandible In mandibular angles- often assoc w/ facial deformity Osteomas seen before symptoms of bvowel polyps 3-6 osseous lesions Osteomas are histologically the compact type cant microscopically differentiate from solitary osteoma ~ Supernumerary teeth (not as common as cleidocranial dysplasia) ~ Impacted teeth o Other manifestations ~ Epidemoid cyst ~ Desmoid tumors ~ Thyroid Carcinoma ~ Other- involve skin, soft tissues, retina, skeletal system Treatment o Colectomy- remove colon to prevent future growth of tumors ~ High rate of malignant transformations 50-100% o Dentists are a part of diagnosis Differential o Kuteigers syndrome- also has polyps in colon but they are benign Osteoblastoma and Osteoid Osteoma OSTEOBLASTOMA- benign neoplasm of bone that arises from osteoblasts o resemble cementoblatoma, but not fused to root of tooth o Clincal Features ~ Rare in jaw ~ Slightly higher occurrence in mandible (in posterior regions) ~ Slightly higher occurrence in males ~ Usually < 20y.o. ~ 2 -4 cm ~ Painful- not well relieved by aspirin o Radiographic Features ~ Well defined or ill defined radiolucent area w/ patchy radiopaque foci ~ Mixed RL/RO o Histopathologic Featurs ~ Prominent reversal lines in calcified product ~ Calcified material surround by osteoblasts and osteoclasts Have a lot of ostoblasts ~ Prominent vascularity o Aggressive Osteoblastoma~ Tends to be larger than osteoblastoma ~ Epithelioid osteoblasts seen histologically ~ May resemeble osteosarcoma- which are very aggressive Osteoblastoma and Osteoid Osteoma contd OSTEOID OSTEOMA- related to osteoma o Clinical Features ~ Distinguished from osteoblastoma by size (looks like osteoblastoma, but smaller) ~ Rare in jaws ~ Focus of peripheral nerves, produce prostaglandins

~ Patients have nocturnal pain Often relieved by aspirin b/c lesion causes release or prostaglandins (which is relieved by aspirn) ~ Histologically similar to osteoblastoma Radiographic Features ~ Well circumscribed RL defect ~ Small radiopaque nidus giving a targetoid appearance Nidus is a point of calcification ~ May have sclerotic rim ~ Usually < 1 cm (note- osteoblastoma >2cm)

Cementoblastoma True odontogenic neoplasm Arises from cementoblasts o Better classified as odontogenic than bone o Probably classified as an odontogentic lesion, but radiographicallyseems like a benign ___??? Clinical Features o Rare o Mandible > Maxilla ~ Almost always near mandibular 1st permanent molar (50%) (premolar-molar region 90%) o Children and young adults o Pain and Swelling Radiographic Features o Radiopaque mass fused to tooth root o Surrounded by a thin radiolucent rim ~ Soft tissue halo around it o Outline of root is obscured by lesion ~ Lesion so attached to root that it is obliterated o Tooth is usually vital st o Pic- Notice radiolucent soft tissue halo, at the mandibular 1 molar ~ Notice how distal root is obliterated/obscured by lesion Histopathologic Features o Resembles osteoblastoma ~ Sheets of trabeculae w/ prominent reversal lines o Distinguished by fusion to tooth root o Cementoblasts on outer covering of root o Multinucleated Giant cells o Noncalcified matrix around periphery Treatment/Prognosis o Surgical extraction of tooth and lesion ~ It is a neoplasm- the entire thin needs to be removed o If completely removed they dont recur Chondroma Benign neoplasm of hyaline cartilage Found in jaws, more commonly in hands and feet Easily misdiagnosed, often asarcoma (microscopically and histologically) o Have aggressive microscopic appearance Clinical Features rd th o Arise in 3 and 4 decades o Usually found in condyle or anterior maxilla o Painless, slow growing tumors o May move teeth and resorb roots Radiographic o Mixed Radiolucent area w/ radiopaque center o Solitary site

Syndrome Assoc ~ Ollier disease: multiple, unilateral lesions ~ Maffucci syndrome: skeletal chondromatosis, soft tissue angiomas Histopathologic Features o Mass of mature hyaline cartilage o May mimic chondrosarcoma Treatment o Typically tumor removed completely
o

Chondromyxoid Fibroma Very rare, benign neoplasm Found also in long bones Clinical Features o Wide age range 10-67 years (mean 30yrs) o Occurs more in Mandible o Pain and swelling noted Radiographic Features o Circumscribe Radiolucent area o Sclertoic or scalloped borders o 1-6.5cm Histopathologic Features o Lobules of cartilage (chondroid), myxoid material, and fibrous material ~ Myxoid is a gelatin like material clinically; microscopically it has an abundance in glycose aminoglycans (ground substance) o Spindle and pleomorphic cells Treatment o Conservatively by curettage ~ Curretage- scoop out ~ Opposed to resection where you cut on each side o Recurrence common in long bones, rare in jaws Synovial Chondromatosis (quickly reviewed in lecture) Nonneoplastic joint disease of unknown cause More common in long bone, but can found in jaw (in condyle) Clinical Features o Nonneoplastic arthropathy characterized by metaplastic development of cartilaginous nodules w/in the synovial membrane o 3 Stages~ foci of metaplastic cartilage arises in synovial lining ~ foci grow and detach- cartilage material in synovial membrane and joint ~ loose bodies in joint- cartilage material found only in joint o Middle aged patients o Females > Males o Joint selling, pain, crepitus, limited opening ~ Aka Joint mice- little pieces of cartilage that get in joint, painful, causing swelling Radiographic Features o Loose bodies- rounded, irregularly shaped, and variably sized radiopaque structures in fregion of joint o Irregular head of condyle head, irregularity of joint space, widened joint space Histopathologic Features o Nodules of cartilage w/in synovieum and lie losse in joint space Treatment o Pieces of loose cartilage removed by scope o Prognosis good w/ low frequency of recurrence Desmoplastic Fibroma (quickly reviewed in lecture)

Bony counterpart of soft tissue fibromatosis Clinical Features o Growth of fibrous CT in bone o <30 y.o. (mean 14yrs) o Primarily in Molar-angle-ramus area of mandible o Painless swelling o Locally aggressive Radiographic Features o Usually unilocular, but can be multilocular o Margins well or ill defined o Expansile o Thinned Cortex Histopathologic Features o Fibroblasts and Collagen Treatment and Prognosis o Usually treated determined by location, but typically they are excised

Pic 2 cm, well circumscribed radiolucent spherical lesion, mesial to root of nd 2 molar which is supererupted w/ large carius lesion Differential- periapical cyst or granuloma, simple cyst, focal ossifying dysplasia Chart- Unilocular radiolucencies- other locations Central ossifying fibroma Cemento osseous dysplasia Central giant cell granuloma Odontogenic keratocyst Central ossifying fibroma These are other choices that the previous radiograph may have been

Pic- 2 molars Radiolucent lesion, approx 2cm, ill defined borders, at apex of mandibular 1st and 2nd molars Differential- central giant cell granuloma, early phase of cementodysplasia, osteosarcoma Chart- radiolucencies- poorly defined or ragged borders o Periapical cyst or granuloma o Osteosarcoma o Ewings sarcoma o Hematopoietic bone marrow defect o Simple Bone cyst o Massive osteolysis Pic- segment of panoramic radiograph 1cm Radioopaque, well circumscribed, lesion at inferior border of mandible, below the 1st and 2nd mandibular molars, nd rd Differential- osteoma, hard to come up w/ 2 and 3 for this pic Chart- radiopacities- well demarcated borders Pic- Periapical radiographs Multilobular Spherical radioopacity approx 7 mm b/w roots of mandibular CI, o Note- multilobular used w/ radiopacities, whereas are radiolucent (like soapbubbles) Note- impacted tooth Differential- possible rudimentary supernumery teeth (not well formed, malformed teeth, ovoid with a little

osseous

radiolocular

bit of a taper), gardners, cleidocranial dysplasia Chart- radiopacities- multifocal or generalized o Florid cemento-osseous dysplasia o Idiopathic osteosclerosis o Pagets disease of bone o Polyostotic fibrous dysplasia o Osteopetetrosis

Pic- Segment of panaroamic radiograph Well circumscribed mixed lesion, approx 2-3 cm, radiolucent halo capsule, inferior to 2nd premolar and 1st molar, obliterating root Radiolucent Differential- cementoblastoma, ossifying fibroma, as a reach you may periapical COD, Chart- mixed RL/RO well demarcated borders o Developing tooth o Cemento-osseous dysplasia o Ossifiying fibroma o Calcifying odontogenic cyst o Osteoblastoma/osteiod odontoma o cementoblastoma Oral Pathology I Dr. Childers Lec 5 Chap 14 pp. 574-583 -

2-3-2006

MALIGNANT FIBRO-OSSEOUS LESIONS They are deadly, sneaky In dental office diagnosis often delayed from 6mo - 1 yr must think of it to diagnose it

Osteosarcoma Mesenchymal malignancy that is bone producing, making malignant bone Clinical Features o Extragnathic Osteosarcoma (outside jaw, i.e. long bones tibia) ~ Bimodal age peak- get very young patients and older patients Age 10-20- complain of knee pain (sneaky b/c can be thought to be due to growth) Over age 50 years- In jaws its mostly in adults o Rare in jaws (usually in long bones) o Mean age 33 years old ~ Wide age range but most 3rd and 4th decades (older than extragnathic occurrence) o Males > Females o Maxilla = Mandible ~ Inferior portion of maxilla (alveolar ridge, sinus floor, palate) ~ Posterior body and horizontal ramus of mandible o Pain, loose teeth- mimics periodontal disease and caries o Paresthesia- numbness, or altered sensation in nerve distribution; (key in thinking about this) o Nasal Obstruction, Slow growing Radiographic Features o Difficult to diagnose b/c clinical and radiographic hard to point out ~ Changes are subtle, you must think of it o Vary from dense sclerosis mixed radiolucent o Ill defined borders o Root resorption o Root Spiking- teeth become conical and spiked ~ Malignancy gets into PDL, easier coarse to travel then bone ~ Malignancy whips around root and replaces it

Symmetrical widening of PDL and movement of teeth Bone formation above CEJ (Good clue for malignancy) ~ In perio you get bone resporption, and its not easy to grow back, bone doesnt regenerate once perio treated ~ In xray where bone is above CEJ this should be red light, dont think its good b/c they dont have perio problem ~ Note- normal bone grows up to 2mm below CEJ o Pic- Note widening PDL, movement of the teeth (must get history to confirm) ~ Alveolar bone b/w molars is high (subtle), it looks a bit more radiopaque, but hard to see o Sun ray or Sunburst appearance on occlusal radiograph ~ Only in about 25% of cases, Is very subtle ~ Almost looks like cotton wool- so Pagets may be a differential, but recall Pagets is usually bilateral, where this is on one side Osteosarcoma Histopathologic Features o Malignant mesenchymal cells producing bone o Considerable histologic variability Treatment o Surgical excision w/ neoadjuvant or adjuvant (pre or post op) chemotherapy o This is view of specimen of excised jaw ~ Notice sunburst appearance (usually on occlusal, but get this view since this is no longer attached to patients) Prognosis o Local recurrence may cause death w/in 2 yrs ~ Recurrence assoc more frequently w/ maxillary tumors ~ Metastases asso c w/ mandibular tumors o Metastasis usually to lungs and brain o Survival 30-50% Subclassifications of Osteosarcoma O PERIPHERAL (JUXTACORTICAL ) OSTEOSARCOMA ~ Oseteosarcoma that originates on the surface of the cortex and does not involve the intramedullary bone Generally osteosarcoma starts in bone, but sometimes they start on surface ~ Parosteal (outside) Pedunculated nodule attached to the cortex No elevation of periostum, no new bone formation Good prognosis if treated adequately ~ Periosteal- (under periosteum) Sessile nodule under the periosteum Elevated eriosteum w/ new bone formation Fair prognosis if treated adequately O POSTIRRADIATION BONE SARCOMA ~ Sarcoma arising in a bone that has been previously irradiated Secondary to radiation, i.e. patient w/ squamous cell carcinoma ~ Develops 3-14 years after radiation ~ Correlates with radiation dose 0.2% w/ 7000cGy vs. 0% for less than 1000cGy ~ Oteosarcoma most common type, then fibrosarcoma, chondrosarcoma ~ Histology and prognosis same as for de novo
o o

Chondrosarcoma Mesenchymal malignancy that is cartilage producing Malginancy of cartilage

o Closely related to osteosarcoma, clinically you distinguish (both in clinical differential) Clinical Features th o Usually older patient- Peak age 7 decade ~ Wide age range (Mean age 41.6 yrs) ~ 20% under 20 yrs o Maxilla > Mandible o Painless mass or swelling (note pain w/ osteosarcoma) o Separation or loose teeth o Possible nasal obstruction, congestion, epistaxis, visual loss

Chondrosarcoma Radiographic Features o Note- same as patient on clinical pic o Very subtle on radiograph o Poorly defined borders o Radiolucent but may have mixed appearance or opaque ~ More commonly RL than osteosarcaoma ~ Variable amt of radiopaque foci, caused by calcification of cartilage matrix ~ May be multilocular radiolucent and mimic benign process o May have sunburst appearance o Symmetric widening of PDL Space o Rarifaction loss of trabeculation seen in palate of pic o Panogram not as good b/c loose detail on midline Histopathologic Features o Cartilage matrix o Cells may show varying degrees of maturation o May infiltrate b/w osseous trabeculae o Grade Correlates w/ growth and prognosis (dont need to know too much detail) ~ Grade I- Well differentiated, subtle variations from normal cartilage, most common ~ Grade II- Increased cellularity and pleomorphism ~ Grade III- Poorly differentiated, rare ~ Variants Clear cell chondrosarcoma- abundant clear cytoplasm Dedifferentiated chondrosarcoma Prognosis o Related to size, location and grade ~ Location influences resection o Radical surgical excision ~ Adjunctive radiation and chemotherapy o Recurrence is often late o Treated a bit differently than osteosarcoma o Generally do better than osteosarcoma Sub classification of Chondrosarcoma O MESENCHYMAL CHONDROSARCOMA ~ Small differentiated cells that dont make alot of cartilage (poorly differentiated sarcoma) ~ Aggressive but Rare ~ Clinical Features Jaws Common nd rd 2 or 3 decade Swelling and pain ~ Radiographic Features Circumscribed radiolucent area Stippled opacities ~ Histopathologic Features Small, undifferentiated mesenchymal cells

 Foci of well differentiated cartilage ~ Treatment/Treatment Surgical excision w/ wide margins Recurrence common but may be late, 10 year survival 28% Ewings Sarcoma Neuroectodermal malignancy t(11;22) o `Some features of neurons of features of ectodermal cells Clinical Features o Rare in jaws nd o Peak in 2 decade ~ 80% less than 20y.o. o Slight male predominance o Majority white, rare in Blacks o Painful swelling o Fever, leuckocytosis, elevated ESR (erythrocyte sedimentation rate) o Mandible > Maxilla o Paresthesia (numbness), loose teeth o Tumor penetrates thru cortex Soft tissue mass over bone o Clinical Differential- Chondrosarcoma, osteosarcoma, ewings sarcoma Radiographic Features o Ill defined, radiolucent area o May or may not have cortical destruction or expansion o Onsionskin (layering appearance)~ Lesion breaks thru periosteum it spreads body reacts body regenerates another layer of periosteum lesion spreads and breaks thru cycle continues ~ Problem w/ onionskin also occurs in garays osteomalytitis, which is rxn to non vital 1st molar in real young patient but this is just an infection not a malignancy o Pic - Occlusal view- lingual has sunburst like appearance, on buccal it has an onionskin like appearance Histolopathologic Features o Small round cells o May contain glycogen o Immunohistochemical studies show CD99 rxn o Gene studies for transolocation

Metastatic Tumors to the Jaws Most common is metastatic carcinoma o Breast, Lung, Prostate st o Kidney (renal cell carcinoma)- famous for showing up 1 as a metastatis ~ Often people dont know they have renal cell carcinoma see metastasis (this also happens in thyroid) o Hematogenous spread- spread thru blood (as opposed to lymph) Clinical Features o Older Patients, children rare o Mandible > Maxilla o Pain, swelling, loose teeth, mass, paraesthesia (Numb-chin

until they spread thru

Syndrome)

Metastatic Tumors to the Jaws Clinical Features o Non healing extraction site ~ A clue is the paraesthesia that you get w/ osteosarcoma and chondrosarcoma, except that it affects the chin; if patient comes in complaining of this and pain, an extraction wont help ~ Patients will have a non healing extraction site

~ If you threw out the tissue instead of biopsy you wouldnt know the problem They mimic a lot of things Radiographic Features o Usually radiolucent o Ill defined o Mimic periapical lesion- May have unilocular well circumscribed radiolucency w/ big restorations ~ Give RCT and it doesnt heal, must think of something else o Also may mimic periodontitis Histopathologic Features o May resemble primary site o Correlation w/ medical history and clinical evaluation Treatment and Prognosis o May be treated by excision or radiation o Poor prognosis ~ Patient stage IV o 5 year survival rare
o

Osteosarcoma w/ altered trabeculations Ill defined borders Tricky b/c supereruption looks like it is due to non opposing tooth Axial ct Well circumscribed, expansile, RO Altered trabeculation more solid and dense than normal medullary bone (try to find area of comparison to normal bone) Notice tooth movement Large RO thats pushing teeth around is reason for worry, but cant tell from this one image if its benign or malignant Differential- Osteosarcoma, Juvenile ossifying fibroma (these 1st 2 are often hard to distinguish), ewings sarcoma, osteoblastoma RCT therapy, apicoectomy done (removed apex), post and cord w/ apical seal Ill defined borders (radiolucency clear, but surrounding area not as clear), radiolucent, 23cm, periapical to the lateral mandibular incisor This is a metastatic lesion Endo wants us to make a differential This is not pulpal Differential- Pulpal, periapical granuloma, radicular cyst, metastatic tumor

Oral Pathology- Dr. Childers Lecture 6 & Text Ch.15 pp. 589-610 ODONTOGENIC CYSTS

2-10-2006

Odontogenic Cysts and Tumors Odontogenic cysts- encountered relatively commonly in dental practice Odontogenic tumors- uncommon lesions Important topic- definite Board Questions; not very controversial, pretty straight forward, generally are rare, but show up in jaws, so dentists are one to find Odontogenic Cysts Epithelium lined cysts in bone o Cyst- pathologic cavity lined by epithelium that may or may not be filled w/ fluid or epithelium o Almost unique to the jaws o Epithelium derived from odontogenic epithelium World Health Organization (WHO) Classification o Developmental Cysts of unknown cause o Inflammatory Cysts due to inflammation o There are several type of classifications Pic shows all odontogenic cysts in one Dentigerous Cyst Most common type of developmental odontogenic cyst (you will see this) Formed by the separation of the follicle from the developing crown of an unerupted tooth Primarily Developmental, but can get an inflammatory component o i.e. if partially erupted, bacteria can get in Clincial Features o Cyst attached to tooth at the CEJ ~ as crown developments, follicle is attached right at CEJ ~ this is distinguishing factor from other cysts i.e. follicle lower down on root ~ cant have this cyst in erupted tooth, b/c once tooth erupted follicle goes away

May involve any unerupted tooth ~ Most common mandibular 3rd molars rd Also incl. max canines, max 3 molars, mand 2nd premolars ~ Rare in decidous teeth ~ Rare in supernumerary or odontoma o Usually asymptomatic ~ May be expansile ~ May become infected and be assoc w/ pain and swelling Usually from partially erupted tooth or by extension from a periapical lesion of adjacent tooth o Patient Type ~ Discovered frequently in patients 10-30 y.o. ~ Slight male predilection ~ Prevalence higher for whites than for Blacks o Paradental cyst- assoc w/ periocoronitis and sometimes w/ enamel pearl ~ assoc w/ buccal aspect (where you get enamel pearl), its not necessarily around same area as dentigerous cyst Dentigerous Cyst contd Radiographic Features o Unilocular Radiolucency assoc w/ crown of impacted tooth ~ May appear multilocular if large (rare) o Well defined, Sclerotic border (white line indicative of slow growth, allows bone to recalcify) ~ An infected cyst may show ill-defined borders o Cyst-to-Crown Relationship ~ Central- Tooth crown may be in center of RL area ~ Lateral- cysts grows laterally along root surface and partially surrounds crown rd assoc w/ mesioangular impacted mandibular 3 molars that are partially erupted ~ Circumferential- crown and significant portionof root appears to lie w/in the cyst ~ or may extend down root o Cyst may displace teeth and/or resorb roots of adjacent erupted teeth o Dentigerous cyst vs. enlarged follicle ~ May be difficult to distinguish hyperplastic dental follicle from typical small dentigerous cyst ~ Normal space for follicle is about 2-3 mm ~ so it is dentigerious when it is larger than this 3-4mm ~ when space enlarged we call it a cyst o Pic- Solitary unilocular, radiolucency, look how cyst locks in at CEJ (that area should make you think dentigerous cyst), o Radiographic Differential: Odontogenic keratocyst, unilocular ameloblasts Histopathologic Features o Nonkeratinized squamous epithelium o Fibrous CT o Odontogenic (epithelial) rests present w/in fibrous wall o Inflamed cysts~ inflammatory cells ~ varying amts of hyperplasia ~ more definite squamous features o Rarely includes mucous cells, sebaceous cells or ciliated cells o Gross ~ Nodular thickening on luminal surface must be examined microscopically to rule out presence of early neoplastic change Treatment and Prognosis o Recurrence rare if completely remove o Treatment~ Completely remove cyst and unerupted tooth Notice pic- when you take it out, you have this sac
o

~ To preserve tooth, partially remove cyst wall ortho treatment to assist eruption ~ Marsupialization- for lager cysts; permits decompression of cyst excised later w/ less extensive surgical process o Rare transformation to ~ ameloblastoma (lining undergoes neoplastic transforamation) ~ squamous cell carcinoma (may arise in lining of dentigerous cyst) ~ intraosseous mucoepidermoid carcinomas (from mucous cells in lining) o Must inform patients that there is a small risk of transformation, and should be followed radiographically ~ i.e. older patient w/ impacted tooth cyst epithelium may change Eruption Cysts Soft tissue counter part to dentigerous cyst Result of separation of dental follicle from crown of erupting tooth that is w/in the soft tissues overlying the alveolar bone Clinical Features o Soft, often translucent swelling of gingival mucosa over the crown of an erupting tooth ~ Erupting tooth does break thru, and swelling occurs in mouth ~ Sometimes can be cut, and tooth would come thru o Usually < 10 y.o. st o Most common: 1 molars and maxillary incisors o Eruption Hematoma ~ Cyst may be filled w/ blood ~ Cyst may appear blue to purplish-brown color Radiographic Features o Can look like abscess clinically, but when you take a radiograph and see there is no pus, and tooth is coming thru, you know its an eruption cyst o Usually in children ~ May be in 3rd molars, but not typically, b/c even if cyst occurs its not due to 3rd molar trying to erupt Histopathologic Features o Usually only roof of cyst o Oral mucosa on one side o Stratified squamous lining on the other o Underlying lamina propria shows variable inflammatory cell infiltrate Treatment and Prognosis o May rupture spontaneously o May be unroofed surgically (simple incision) o Tooth usually erupts Odontogenic Keratocyst Some other classifications of Odontogenic cysts are: Odontogenic keratocysts and all others Biologically behaves differently than all other cysts This is an important odotogenic cysts Primordial Cyst- missing tooth and get cyst in its place, no longer called this Arises from dental lamina (that strand of epithelia that connects bell and developing tooth to surface) o In some patients when it does not completely dissolve, it can cause trouble o These cysts can occur all thru the bone Benign neoplastic cyst o Some may say that its not developmental, rather its neoplastic o It is an aggressive cyst Odontogenic Keratocyst contd

Clinical Features o Can occur in any age range, most 10-40 y.o. o Slight male predominance o Mandible- 60-80% of cases ~ Posterior body and ramus ~ Note- Can occur anywhere in jaw o May be small and asymptomatic or large w/ pain, swelling and infection o Tend to grow anterior-posterior without expansion ~ i.e. growing up ramus ~ Differential- dentigerous and radicular cysts of comparable size are usually assoc w/ expansion o Sometimes assoc w/ impacted tooth, sometimes not o Sometimes can be assoc w/ only soft tissue o They are assoc w/ syndrome: Nevoid basal cell carcinoma (Gorlin) syndrome ~ Most patients w/ syndrome have this cyst ~ Not all patients w/ this cyst have this syndrome ~ If patient has more the one odontogenic kerocyst, you think of syndrome o Has been reported as peripheral o Those occurring in anterior midline maxillary region can mimic nasopalatine duct cysts ~ This subset of keratocysts usually occurs in older individuals 70 y.o. Radiographic o Well defined radiolucent area w/ corticated borders o Multilocular radiolucency or unilocular o May encompass crown of unerupted tooth 25-40% ~ If unilocular, RL encompassing crown dentingerous cyst should be in differential o May resorb roots ~ (less common than noted w/ dentigerous and radicular cyst) o Radiographic Differential- dentigerous cyst, radicular cyst, residual cyst, lateral periodontal cyst, fibroosseous lesion (depending on location) Histopathologic Features*** o Diagnosis of odontogenic keratocyst is based on histopathologic features o Epithelial lining of stratified squamous epithelium, 6-8 cells thick o Inconspicuous rete ridges ~ Basal area smooth b/c of loss of rete ridges o Luminal surface is ~ Corrugated (wavy) ~ Parakeratin (still has nuclei) o Hyperchromatic and palisaded basal cell layer ~ Palisated = nuclei line up like a picket fence o Satellite cysts aka daughter cysts, goes along w/ dental lamina, can take out major cyst and see other smaller cysts o Inflammation may obscure diagnostic features o May be filled w/ transudate or keratinaceous debris o General pathologist- often dont know difference b/w odontogenic keratocyst and dentigerous cyst Odontogenic Keratocyst contd Treatment o Aspiration o Enucleation and curettage ~ Surgeons will aspirate anytime they go into bony lesion ~ Pic of aspiration is not a blood lesion (usually get some red

~ Curettage is a little controversial- most surgeons will take a bone bur and pull out lesions; with lesions in maxilla this is more difficult ~ Complete removal of the cyst in one piece is often difficult b/c of thin, friable nature of the cyst wall o Must refer for evaluation to rule out syndrome Prognosis o High recurrence rate (5-62%) o Must follow patient long term form recurrence ~ Many recurrence after 10 yrs later o Rarely do the turn to squamous cell carcinoma

Orthokeratinized Odontogenic Cyst Not a specific clinic diagnosis Clinical and Radiographic Features o Young adults o Males > Females o Mandible > Maxilla o Usually unilocular o Usually in a dentigerous relationship rd o Often involve unerupted 3 molar o Range from 1-7 cm o Differential- Dentigerous cyst ~ Have no clinical or radiographic features that differentiate them from an inflammatory or developmental odontogenic cyst ~ Behave like a dentigerous cyst- it doesnt recur; usually around impacted tooth Histopathologic Features o No nuclei keratin o Epithelial lining (stratified squamous) w/ orthokeratinized luminal surface o Basal area not palisaded ~ Dont confuse w/ odontogenic keratocyst* Treatment and Prognosis o Enucleation and curettage o Recurrence rare Nevoid Basal Cell Carcinoma Syndrome Autosomal dominant w/ high penetrance and variable expressivity Mutation in PTCH (patched), a tumor suppressor gene Clinical Features o Multiple basal cell carcinomas of the skin (Nevi = a lot) ~ Earlier age- puberty or 2nd-3rd decades ~ Non-sun exposed skin and midface ~ Blacks have fewer BCC o Odontogenic keratocysts ~ Multiple cysts ~ Young age ~ Most patients who have OKC dont have syndrome, but most have syndrome have OKC o Palmar and plantar pits (on palms) o Calcified falx cerebri o Intracranial calcification o Enlarged head circumference (frontal and temporoparietal bossing) ~ Mild ocular hypertelorism ~ Mild mandibular prognathism o Rib and vertebral anomalies- i.e. spina bifida, kyphoscoliosis o Ovarian fibroma, medulloblastoma, meningioma, cardiac fibroma, Histopathologic Features

patients who

rhabdomyoma

Same as isolated orthodontic keratocyst Basal cell tumors cannot be distinguished from ordinary basal cell carcinomas Treatment and Prognosis o Most manifestations not life threatening o Prognosis generally depends on the behavior of the skin tumors (BCC most serious) o The odontogenic keratocyst are treated by enucleation (the same ase as isolated ones) ~ But in may patients cysts will continue to develop resulting in varying degrees of jaw deformity from multiple cyst operations If patient has syndrome and its a spontaneous mutation they must be checked b/c they may have more serious lesions Differential- OKC should come to mind w/ this radiograph, also cherubism should come to mind
o o

Gingival Cyst of the Newborn Arise from remnants of the dental lamina Small, superficial, keratin-filled cysts found on alveolar mucosa of infants Similar inclusion cysts, o Eptsteins pearls- found in midline of palate (from fusion) o Bohns nodules found- remnants of salivary gland formation, seen bilaterally Clinical Features o Common; up to of all new borns o 2-3mm, white, papules on alveolar ridge of neonates o Maxilla > Mandible o Often multiple Gingival Cyst of the Newborn contd Clinical Features contd o See along alveolar ridge b/c thats where dental lamina is o Tiny white filled cystic area, They look like little rice grain o They dont require treatment Histopathologic Features o Parakeratinized epithelial lining filled w/ keratinaceous debris Treatment and Prognosis o No treatment indicated o Spontaneous involution ~ burst and heal w/ no real problem o Lesions rarely seen after 3 months of age Gingival Cyst of the Adult Arises from dental lamina (rest of Serres) Soft tissue counterpart to lateral periodontal cyst Clinical Features o Mandibular cuspid and premolar area (60-70% of time) ~ Maxillary cysts usually found in incisor, canine & PM area th th o 5 and 6 decade o Almost always on facial gingival or alveolar mucosa o Painless, dome shaped nodule < 0.5cm in diameter o Blue or gray o Superficial to the periosteum ~ Superficial to periosteum- These are not radiograph ~ When patient comes in w/ swelling on cyst must take radiograph to

in bone- seen from

determine if its bony May have some cupping of bone that is apparent when cyst excised ~ If significant bone missing, its arguably a lateral periodontal cyst that eroded the cortical bone, not a gingival cyst originating in mucosa Histopathologic Features o Similar to lateral periodontal cyst o Thin epithelial lining w or w/o focal plaques containing clear cells o Clear cells are glycogen rich, representing the dental lamina Treatment and Prognosis o Simple excision, Rare recurrence, Prognosis excellent
o

Lateral Periodontal Cyst (Botryoid Odontogenic Cyst) Arises from dental lamina, uncommon developmental odontogenic cyst Intrabony counterpart of Gingival Cyst of the Adult o Gingival cyst of adult related is just soft tissue o Lateral periodontal cyst is part of bone Differential- odontogenic keratocyst, simple bone cyst, central giant cell o Note- can have a pulpal origin lesion on lateral of root b/c there are lateral bit rare) Lateral Periodontal Cyst (Botryoid Odontogenic Cyst) contd Clinical Features o Occurs along the lateral surface of a tooth root o Usually asymptomatic th th o 5 to 7 decade (Rare before age 30) o 75% in mandibular premolar/cuspid/lateral incisor area ~ Should not think of this when RL around impacted tooth, in ramus or near molar ~ In maxilla, cysts appear around same region Radiographic Features o Well circumscribed o Radiolucent o Lateral to root of vital teeth o Less than 1.0cm o Botryoid odontogenic cyst- may appear multilocular ~ Polycystic appearance; grape like cluster of small individual cyst Histopathlogic Features o Thin epithelial lining w/ focal nodular thickenings and clear cells ~ Only 1-3 cells thick in most area Treatment and Prognosis o Conservative enucleation o May preserve adjacent teeth o Bone comes out as cyst, does not recur o Botryoid variant may recur ~ Botryoid- is the multilocular variant of lateral perio cyst ~ Microscopically they are the same except for one this is multilocular ~ They also have a slight higher % of occurring Calcifying Odontogenic Cyst (COC) Has features of both a cyst and a neoplasm Can also occur w/ other odontogenic tumors Variants o Intraosseous (central) o Extraosseous (peripheral)

granuloma canals (is a

Cystic Solid o Odontogenic ghost cell tumors Can have a lot of different features but can be lumped together b/c they dont know that much about it May be associated w/ other odontogenic tumors, commonly odontomas (20%) o Adenomatoid odontogenic tumors and ameloblastomas have also been associated w/ COC Clinical Features o Predominantly introsseous ~ But 13-30% appear as peripheral (extraosseous) o Maxilla = mandible o Incisor and cuspid area 65% of cases o Wide age range (mean 33 yrs) ~ COC assoc w/ odontomas tend to occur in younger patients (mean 17 y.o.) ~ Neoplastic variants appear in older patients Calcifying Odontogenic Cyst (COC) contd Radiographic Features o Calcifications may be microscopic and not show up radiographically o Central Lesions (Intraosseous) ~ Well Defined ~ Unilocular (occasionally appear multilocular) Radiolucency Radiopaque or mixed appearance from calcifications w/in radiolucency ~ Assoc w/ unerupted tooth 30% (most often a canine) ~ Usually 2-4 cm ~ Root resorption and divergence Notice pic- pushed impacted tooth (bicuspid) out of way ~ Bottom Radiograph RO mass above missing CI, unerupted tooth, tooth pushed out of way Mixed dentition of young patient, this isnt supernumery teeth, just looks jumble b/c lesion is pushing teeth out of way o Peripheral Lesions (Extraosseous) ~ If its peripheral it would be cyst just on gingival ~ Sessile or pedunculated gingival mass w/ no distinctive clinical feature ~ Can resemble common gingival fibromas, gingival cysts or peripheral giant cell granulomas ~ Notice pic- subtle lesion, slight expansion of palate Histopathologic Features o Cystic structure 86-98% of cases o Cyst lined by odontogenic epithelium ~ Basal layer resemble ameloblasts ~ Suprabasal layer resembles ameloblastoma o Ghost cells~ Altered epithelial cells characterized by loss of nuclei w/ preservation of basic cell outline ~ cant see nucleus, but see shadow of it, nucleus obscured by contents of cytoplasm o Calcified material, dentinoid material o 20% assoc w/ odontoma o Neoplastic (Solid) structures 2-16% of cases ~ Solid ones seem to act more aggressively ~ Peripheral cases are more often solid ~ Palisaded basal layer (like in OKC) and central stellate reticulum resemble ameloblastoma
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~ Ghost cells and dentinoid differentiate COC from ameloblastoma Treatment/Prognosis o Simple enucleation o Central lesions low recurrence rate, Peripheral lesions rarely recur o When occur w/ another tumors, prognosis same as for the other tumor o May have malignant features- Odontogenic ghost cell carcinoma ~ Recurrence common, 5 yrs survival 73% Glandular Odontogenic Cyst Rare developmenta cyst w/ salivary features No place in clinical differential b/c its rare Clinical Features o They are very aggressive, push teeth around, expand mandible, cross midline o Middle aged adults- avg 49 y.o. o Mandible 85% of cases o Predilection for anterior midline o May grow large (from <1cm to most of the jaw) o May present w/ pain or paresthesia ~ Assoc w/ large cyst ~ Small cyst asymptomatic Radiographic Features o Multilocular radiolucency w/ well defined sclerotic rim ~ May be unilocular Histopathologic Features o Cyst lined by squamous epithelium o Luminal cells are cuboidal to columnar (May have cilia) o May have mucous cells and mucous pools w/ mucicarminophilic material o Glandular b/c they have mucous cells in them o Epithelium lining has undergone change to become glandular epithelium o May form plaques or thickenings Treatment and Prognosis o Enucleation or curettage o Tends to recur

Buccal Bifurcation Cyst rd Similar to paradental cyst- which usually occur distal or buccal of partially erupted mandibular 3 molars w/ a history of pericoronitis Uncommon inflammatory odontogenic cyst go in and try to clean out Clinical Features o Children 5-11 y.o. st o Buccal aspect of mandibular 1 permanent molar (May be bilateral) ~ When tooth erupts an inflammatory response may occur in surrounding follicular tissues that stimulates cyst formation st o Tenderness assoc w/ erupting mandibular 1 molar o Pushes roots to lingual, causing tipping o May have swelling and pus o Pocket formation of buccal aspect of molar (detected thru probing) Radiographic Features o Well circumscribed unilocular radiolucent area near buccal furcation (1-2cm) o Occlusal view shows roots tipped to lingual o May show proliferative periostitis Histopathologic Features o Nonspecific inflamed cyst, prominent chronic inflammatory cell infiltrate Treatment and Prognosis o Well circumscribed enucleation of the cyst w/o extraction of the tooth

o Usually complete healing w/ normalization of probing depths and evidence of bone fill w/in 1 yr Odontogenic Carcinoma Almost evey odontogenic cyst or tumor has been described to give rise to odontogenic carcinoma o Rare but does occur Typically in older patients rd Can mimic odontogenic teeth (thats why we like to extract impacted 3 molar especially w/ cyst around it) May arise de novo or from an odontogenic cyst or tumor o Residual periapical cyst, dentigerous cyst, lateral periodontal cyst, odontogenic keratocyst, orthokeratinized odontogenic cyst o Also may arise in an ameloblastoma or from the epithelial lining of odontogenic cysts Clinical Features o More common in older patients ~ Mean age 57 -61 y.o. o Males > Females o Pain and swelling o May be asymptomatic ~ Diagnosis made only after microscopic examination of a presumed odontogenic cyst Radiographic Features o Mimics any odotogenic cyst o May have ill defined borders Histopathologic Features o Most carcinomas arising in cysts have been well differentiated squamous cell carcinomas Treatment and Prognosis o Varies w/ size and location o 5 yrs survival about 50% o Often resemble squamous cell carcinoma- must rule out metastatic squamous cell carcinoma before accept as odontogenic carcinoma

WHO CLASSIFICATION OF ODONTOGENIC CYSTS Developmental Cysts o Dentigerous Cyst o Eruption Cyst o Odontogenic Keratocyst o Orthokeratinized Odontogenic Cyst o Gingival (Alveolar) Cyst of the Newborn o Gingival Cyst of the Adult o Lateral Periodonal Cyst o Calcifying Odontogenic Cyst o Glandular Odontogenic Cyst Inflammatory Cyst o Periapical (radicular) Cyst o Residual Periapical (radicular) Cyst o Buccal Bifurcation Cyst

3-17-2006 Oral Pathology I Dr. Childers Lec 8- Ch. 15 (pp. 610 619) ODONTOGENIC TUMORS Odontogenic Tumors Diverse group of lesions histologically and clinically WHO Classification of Odontogenic Tumors o Tumors of odontogenic epitheliumo Tumors of odontogenic ectomesenchyme o Mixed odontogenic tumors- composed of odontogenic epithelium and ectomesenchymal elements ~ Dental hard tissue may or may not be formed in these lesions o Note these are histologic classifications, you cant classify this way clinically ~ Need to make clinical differential as well Know odontogenesis (development of tooth) o Review histology of tooth development o i.e. Reduced enamel epithelium where inner and outer epithelium come together and collapse Odontogenic Tumors are very uncommon o Odontoma- more common, probably will see in practice o Ameloblastoma- most common after odontoma o Other types of odontogenic tumors are more rare, but you must know TUMORS OF ODONTOGENIC EPITHELIUM AMELOBLASTOMA Most important and common clinically significant odontogenic tumor NB- Odontoma is most common, but not as clinically significant o You must treat it, but it wont kill or disfigure patient Theoretically may arise from: o Rests of dental lamina o Developing enamel organ o Epithelial lining of an odontogenic cyst o Basal cells of the oral mucosa

Slow growing, locally invasive tumors that run a benign course in most cases 3 Different Clinicoradiographic Situations: o Conventional solid or multicystic- 86% o Unicystic- 13% o Peripheral (extraosseous)- 1% (outside the bone, a nodule on the gingival)

AMELOBLASTOMA Conventional Solid or Multicystic Ameloblastoma Most common type of ameloblastoma Solid or Multicystic Benign tumor Clinical Features rd th o Wide age range- 3 7 decades o Males = Females o Some studies show higher prevalence in blacks o 85% posterior mandible, molar ascending ramus area o 15% maxilla, posterior ~ More clinically significant ~ Harder to treat o Painless swelling ~ May be small and evident only in radiograph or grotesquely ~ Pain and paresthesia are uncommon ~ Notice in floor of mouth there is lingual expansion, need to Note- tori typically bilateral on mandible ~ 5cm buccal and lingual expansion (mass) in posterior portion of including the tuberosity Area buccal to bicuspids is where tooth was extracted Radiographic Features o Multilocular radiolucent lesion typically ~ Soap bubble appearance- when loculations are large ~ Honeycombed appearance- when loculations are small o May be unilocular- resemble any type of cystic lesion o Buccal and lingual expansion common ~ Recall odontogenic keratocyst will have a large extending to posterior portion of mandible w/o helps w/ differential o Root resorption o Tooth displacement o May encompass an impacted tooth Desmoplastic ameloblastoma o Radiographically resembles a fibro-osseous lesion o Mixed RL and RO appearance ~ Does not have typical multilocular RL appearance o It can be radio-opaque o Usually occurs in anterior regions of jaws esp maxilla Example- Radiolucent, multilocular well circumscribed, about 2cm b/w the roots canine and premolar, with some tooth displacement ~ Differential- lateral periodontal cyst, ameloblastoma, odontogenic central giant cell granuloma Conventional Solid or Multicystic Ameloblastoma Histopathologic Features
o

large take an x-ray maxilla tooth

lesion expansion

of conventional

of the keratocyst,

Microscopic patterns have little prognostic value ~ Follicular common Islands of epithelium resemble enamel organ epithelium in CT, looks similar to stellate reticulum Peripheral single layer of tall columnar ameloblast-like cells w/ reversed polarity (nuclei are at apical end of cell) ~ Plexiform- common Long, anastomosing cords or larger sheets of odontogenic epithelium, bounded by ameloblast like cells ~ Acanthomatous- extensive squamous metaplasia assoc w/ keratin formation occurs May be confused w/ squamous cell carcinoma or squamous odontogenic tumor ~ Granular Cell- abundant cytoplasm filled w/ eosinophilic granules that resemble lysosomes Seen in young patients and clinically aggressive tumors ~ Desmoplastic- islands& cords of odontogenic epithelium in dense collagenized stroma ~ Basal Cell Pattern- least common Nests of uniform basaloid cells Similar to basal cell carcinoma of skin histopathologically Treatment and Prognosis o More aggressive treatment, lower recurrence rates o Curettage- 50-90% recur ~ Conventional ameloblastoma tends to infiltrate b/w intact cancellous bone trabeculae at periphery of the lesion b4 bone resorption becomes radiographically evident ~ Margin of tumor often extends beyond its apparent radiographic or clinical margin ~ Curettage often leave small island of tumor w/in bone recurs o Marginal resection 15% recur ~ Should be at least 1cm past radiographic limits of the tumor o Maxillary tumors more difficult and dangerous, may infiltrate vital structures o May rarely transform to malignancy
o

Unicystic Ameloblastoma 10-15% of all ameloblastoma Unique clinical, radiographic, pathologic and prognostic features Clinical Features nd o Younger patients 50% in 2 decade o 90% in mandible, usually posterior o Often asymptomatic, but large lesions can cause painful swelling o Often resembles odontogenic cyst Radiographic Features rd o Often circumscribed RL around crown of unerupted 3 molar (resemble dentigerous cyst) o Other tumors appear as sharply defined RL areas and are considered primordial, radicular, or residual based on relationship to teeth o May have scalloped margina o Sometimes not assoc w/ impacted tooth Unicystic Ameloblastoma Histopathologic Features o Ameloblastoma may not be suspected until microscopic examination o Luminal- confined to cystic lining (luminal surface) ~ Fibrous cyst wall w/ a lining that consists totally or partially of ameloblastic epithelium ~ Basal layer of cells / hyperchromatic nuclei w/ reverse polarity and basilar cytoplasmic vacuolization

Intraluminal- nodules project into lumen ~ Nodules may be relatively small or largely fill cystic lumen ~ Sometimes nodule exhibits plexiform pattern seen in conventional ameloblastoma o Mural- infiltratres the fibrous wall Treatment and Prognosis o Diagnosis of unicystic ameloblastoma is made only after microscopic examination, b/c clinical and radiographic findings suggest that lesion is an odontogenic cyst o Enucleation or curettage suffice for luminal and intraluminal lesions ~ Mural lesions treatment is controversial- resection or radiographic observation o Recurrence rate 10-20%
o

Peripheral Ameloblastoma 1% of ameloblastoma Probably arises from rests of dental lamina beneath the oral mucosa or from basal epithelial cells of surface epithelium Clinical Features o Nonspecific gingival nodule ~ nonulcerated sessile or pedunculated gingival or alveolar mucosal lesion o Painless o Wide age range, avg 52y.o. o Most commonly found on posterior gingival and alveolar mucosa o Somewhat more common in mandibular areas o No bone involvement but may have some cupping Histopathologic Features o Same features as the intraosseous form of the tumor o Ameloblastic epithelium o Plexifom or follicular patterns most common o May be confused w/ a peripheral odontogenic fibroma microscopically esp if a prominent epithelial component is present Treatment and Prognosis o Innocuous (harmless) clinical behavior o Local surgical excision o Recurrence 15-20%- further excision almost always results in a cure Missed lecture- notes from book, pwr point, and audio complete, except skipped audio on histo slides explanation

3-24-2006 Oral Pathology Dr. Childers Lec 9 (text, lecture, and pwr point notes) ODONTOGENIC TUMORS contd (same pwr pt as lec 8) TUMORS OF ODONTOGENIC EPITHELIUM Malignant Ameloblastoma and Ameloblastic Carcinoma Rare, less than 1%, but can be deadly so you must know Malignant ameloblastoma- looks histologically just like conventional ameloblastoma but it metastasizes (i.e. to lung) o Ameloblatoma that metastasizes Ameloblastic carcinoma- cytologically malignant ameloblastoma o More aggressive lesion o When you look at slide it looks like malignancy o Looking invasive is not the distinguishing characteristic b/c conventional ameloblastoma is invasive o Cytologic features of malignancy include- Hyperchromatic nuclei, undifferentiated cells, abnormal and high # of mtitotic figures Clinical Features o More commonly in elderly, but also happens in kids o Wide age range 4-75 y.o. o Time to transformation 1-30yrs, avg 10 yrs ~ Sometimes its not transformation, but it starts off malignant, sometimes it never goes thru benign phase o Lung metastasis most common ~ Cervical lymph nodes 2nd most common site for metastasis Radiographic Features o Malignant Ameloblastoma appears same as conventional ~ Malignant ameloblastoma is not predictable b/c radiographically and histologically it looks like conventional o Ameloblastic Carcinoma may show ill defined borders and cortical destruction ~ Histologically and radiographically looks different than conventional Histopathologic Features o Malignant ameloblstoma- appears same as conventional o Ameloblastic carcinoma- cytologic features of malignancy ~ Mitotic figures ~ Increased nuclear to cytoplasmic ratio

~ Nuclear hyperchromatism ~ Necrosis ~ Dystrophic areas of calcification Treatment and Prognosis o Poor prognosis, Few cases for analysis o Patients with metastasis about 50% survival o Ameloblastic carcinoma locally destructive ~ Uniformly aggressive clinical course w/ perforations of cotical plates of jaw and extensions of tumor into soft tissue

Clear Cell Odontogenic Carcinoma Rare, discovered in 1985, 20 examples reported to date Clinical Features o Most patients over 50 years o Both maxilla and mandible reported o May have pain or be asymptomatic

Radiographic Features o Unilocular or multilocular radiolucent lesion o Boders may be ill defined or irregular Histopathologic Features o Epithelial cells with clear (eosinophilic) cytoplasm o Histologically you see clear cells (cytoplasm transparent on histology), but you have features of carcinoma and around periphery have odontogenic features o This is a histologic diagnosis, it will not be in clinical differential o May be difficult to distinguish from intraosseous mucoepidermoid carcinoma w/ prominent clear cell component ~ Note- mucin stains for clear cell odontogenic carcinoma are negative Treatment and Prognosis o Locally aggressive o Metastasis may occur (pulmonary or lymphatic) o Most require fairly radical surgery

Adenomatoid OdontogenicTumor (AOT) 3-7% of odontogenic tumors o More common, Tumor- think of solid instead of cystic Odontogenic Adenomatoid- -oid means like so its gland-like o Has specific clinical correlation which should make you think of this o Start to think of this when you see ducts Controversial whether its ectomesenchymal or epithelial o Considered here to be odontogenic epithelium o WHO considered to be mixed odontogenic epithelium and ectomesenchymal Clinical Feature o 10-19 yrs (66%) ~ Note- Clinically narrow age range o Maxilla (anterior) more common than mandible 2:1 o Females more common than males 2:1 ~ Note- specific clinical picture that should make you o Relatively small: < 3cm o Rarely peripheral- small sessile masses on the facial gingiva ~ Clinically cant be differentiate from gingival fibrous lesions o Often asymptomatic~ Discovered on routine xray or when tooth not erupted

think of AOT of the maxilla

o o o

75% pericoronal (must have unerupted tooth), mostly maxillary cuspid Larger lesions cause a painless expansion of bone So if you have an impacted cuspid in a female under 20 w/ RL over crown of it think AOT, also in differential will be dentigerous cyst and OKC

Adenomatoid OdontogenicTumor (AOT) contd Radiographic Features o 75% circumscribed, unilocular RL involving crown of unerupted tooth o Periocoraonal radiolucent enlargement of follicular space o Can be radiolucent or mixed ~ Can have small calcifications so it may go into your mixed differential ~ A pericoronal mixed RL and RO, solitary unilocular lesion, o May extend down root from CEJ (helps distinguish from dentigerous cyst) o Less often b/w roots of erupted tooth (not crown of unerupted tooth) o Description of pic- unilocular mixed lesion, approx 2cm b/w the maxillary lateral incisor and cuspid, displacing teeth will possibility of root resorption ~ Differential- remember its mixed, so there is not much, ossifying fibroma, adenomatoid odontogenic tumor, periapical osseous dysplasia o Differnetial for RL Dentigerous Cyst ~ Max impacted canine w/ RL around it, differential = AOT and dentigerous cyst ~ But usually a dentigerous cyst comes right in CEJ ~ So if it slips down apically to CEJ in this specific patient type (young girl) you may want to put AOT first, even though dentigerous cyst is more common Histopathologic Features o Well defined w/, Thick capsule o Tubular or Ductlike structures o Small calcifications o Narrow, anastomosing cords of epithelium in an eosinophilic loosely arranged matrix at periphery of tumor adjacent to the capsule Tretatment and Prognosis o Completely benign o Enucleation ~ usually shell out b/c its encapsulated, but usually have to take tooth out o Recurrence rare to never Calcifying Epithelial Odontogenic Tumor (Pindborg Tumor) Rare, less than 1% Clinical Features o Wide age range, mostly 30-50 yrs o 66% in mandible, posterior o Painless, Slow growing swelling o Rarely peripheral (peripheral variance is even more rare) ~ Appears as nonspecific, sessile gingival masses, most often on anterior gingiva Radiographic Features o Unilocular or multilocular (more often) o Often margins scalloped (from lytic defect) o Radiolucent or Mixed typically ~ May contain calcified structures of varying size and density ~ Driven snow (snow storm) appearance ~ But may also say RO o May be well circumscribed or not well circumscribed (pic is well circumscribed) rd o Assoc w/ impacted tooth (mandibular 3 molar) ~ Calcifications w/in tumor most prominent around crown of impacted tooth Calcifying Epithelial Odontogenic Tumor (Pindborg Tumor)- contd Histopathologic Features

Epithelial cells may have nuclear pleomorphism ~ b/c of nuclear pleomorphism thay have been misdiagnosed as cancer o Areas of amorphous, eosinophili, hyalinized (Amyloid-like) material o Concentric ring Calcifications (Liesegang rings) ~ Caused by calcifications w/in amyloid like material o Several variations: ~ Clear cell variant- clear cells significant portion of epithelial Treatment and Prognosis o Conservative local excision- resection includes a narrow rim of surrounding bone o Lesions is posterior mandible treated more aggressively o Recurrence around 15% (curettage has highest rate of recurrence)
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component

Squamous Odontogenic Tumor Rare Arise from neoplastic transformation of dental lamina or perhaps epithelial rests of Malassez Appears to originate w/in lateral portion of PDL of an erupted tooth o Important b/c it can mimic periodontal disease o Looks similar radiographically Clinical Features o Wide age range 8-74 yrs, avg age 38 yrs o Randomly distributed thru out alveolar process, w/ no site of predilection o Painless or mildly painful swelling o Assoc w/ tooth mobility o May be asymptomatic (lesions detected during routine radiograph) o Multiple lesions in one patient have been reported o Rarely peripheral Radiographic Features o Non specific triangular RL area lateral to root o May mimic periodontal bone loss o Somewhat ill defined borders or may show a well-defined sclerotic border o Small lesions < 1.5 cm Histopathologic Features o Bland, squamous epithelium o Microscystic vacuolization and individual cell keartinizations w/in epithelial islands o Small microcysts Treatment and Prognosis o Conservative local excision or curettage o Rarely recurs o Maxillary tumors may be somewhat more aggressive than mandibular, w/ greater tendency to invade adjacent structures (probably from porous nature of maxillary bone)

4-7-2006 - Oral Pathology I Dr. Childers Lec 10, Ch. 15 (pp. 627-637) ODONTOGENIC TUMORS -contd from lec 8&9 MIXED ODONTOGENIC TUMORS Ameloblastic Fibroma Note ameloblastic fibroma is rare, usually not in differential before ameloblastoma, but note age difference (ameloblastoma avg age 33 yrs old) Clinical Features o True mixed Neoplasm ~ Epithelial and mesenchymal tissues are both neoplastic ~ It is less aggressive, more emphasis on fibroma not ameloblastoma o Young patients mostly (dont have all permanent teeth) ~ Parents reports as missing permanent teeth ~ Occasionally in middle-aged patient o Males slightly > occurrence than females o 70% posterior mandible o Small lesions asymptomatic o Large lesions may be expansile o Peripheral never reported Radiographic Features o Multilocular or unilocular radiolucent lesion o Well defined borders, may be sclerotic o 75% unerupted tooth st o Notice unerupted manidibular 1 molar (notice difference b/w that and normal unerupted developing maxillary 2nd molar) st o Unilocular RL well circumscribed lesion that displaced permanent 1 molar inferiorly Histopathologic Features o Solid tumor often encapsulated ~ Solid, soft tissue mass w/ a smooth outer surface o Mesenchymal stroma resembles dental papilla ~ This is not fibrous connective tissue, this is a stroma, that is neoplastic ~ It is a mesenchymal background (part of the tumor) ~ Consists of plump stellate and ovoid cells in a loose matrix o Odontogenic epithelium w/in stroma has 2 patterns: ~ Long narrow cords of odontogenic epithelium in anastomosing (connecting) arrangements ~ Islands of ameloblastic epithelium resemble follicular stage of developing enamel organ Treatment and prognosis o Conservative excision initially, more aggressive if recurrence

Considerable recurrence rate Ameloblastic fibrosarcoma~ When they frequently recur, they become more irritated and may transform to malignancy ~ They also may become malignant denovo ~ the epithelial stays the same, but the mesenchymal portion transforms to malignant ~ If found they will take a significant, aggressive resection and reconstruction MIXED ODONTOGENIC TUMORS contd
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Ameloblastic Fibroma contd

Multilocular well circumscribed radiolucent (or mixed) lesion, 1-2cm, located b/w 1st and 2nd mandibular premolars, displacing roots of teeth Tissues Present- Bone, neural, vascular, odontogenic Differentialo Note- if you say mixed, you cant say OKC o Radiolucent- odontogenic keratocyst, ameloblastic fibroma, lateral periodontal cyst Multilocular mixed radiolucent/radioopaque (or radiolucent), lesion starting distal to mandibular 2nd premolar extending up the body of the ramus, displacing the developing 1st molar inferiorly Differential- OKC, ameloblastic fibroma, dentigerous cyst

Ameloblastic Fibro-Odontoma Odontoma- benign tumor of odontogenesis o Haphazard arranged of enamel, dentin and pulp; it has calcified material (usually dentin) Ameloblastic Fibro-Odontoma and Odontoma are separate entities, but once thought to be the same o Ameloblastic Fibro-odontoma- a true neoplasm, may show progressive growth, considerable deformity and bone destruction o Odonotma- developmental anomaly, not a neoplasm Clinical Features o Average age 10 y.o. o Posterior Maxilla and Mandible st o Often discovered at failure of 1 molar to erupt o Usually asymptomatic or Large lesions may cause painless swelling Radiographic Features o Unilocular or rarely multilocular radiolucent lesion o Well defined borders o Variable amount of calcification (dentin and enamel) ~ Appear as small radioopacities or a solid mass o Often includes unerupted tooth o Presentation varies: Completely RL largely calcified w/ radiolucent rim Histopathologic Features o Microscopically identical to ameloblastic fibroma but w/ enamel or dentin formation ~ Ameloblastic epithelium ~ Mesenchymal stroma o Calcified enamel and/or dentin ~ The more calcified areas may appear as rudimentary small teeth ~ If you see calcifications on xray put Ameloblastic fibro-odontoma higher on differential o Ameloblastic fibro-dentinoma- calcifying component only of dentin matrix and dentinoid material MIXED ODONTOGENIC TUMORS contd

Ameloblastic Fibro-Odontoma (contd) Treatment and Prognosis o Conservative curettage o Recurrence unusual o Less aggressive, Rare to see malignant transformation (Ameloblastic Sarcoma)

Solitary well circumscribed mixed radiolucency at root of primary cuspid Differential- ameloblastic fibro-odontoma, odontoma, ossifying fibroma (remember to think about benign fibro-osseous lesion)

Ameloblastic Fibrosarcoma Malignant counterpart of ameloblastic fibroma o Very serious, very aggressive disease o Patient usually has history of multiple recurrence of ameloblastic fibroma o But may arise de novo Clinical Features o Males > Females Young patients- avg. 28.5 y.o. o 80% mandible o Pain and rapid growth Radiographic Features o Suggest Malignancy ~ Ill defined borders ~ Radiolucent ~ Destructive Histopathologic Features o Ameloblastic epithelium typically benign but scanty o Mesenchymal portion is cellular w/ hyperchromatism, mitoses ~ Its soft tissue, not epithelium that is malignant (not you recognize histology, just understand it) Treatment and Prognosis o Radical surgical excision o Locally aggressive Odontoma Most common odontogenic tumor They are a developmental anomaly (harmatoma), not a true neoplasm Hamartoma- A focal malformation that resembles a neoplasm, grossly and even microscopically, but results from faulty development in an organ; composed of an abnormal mixture of tissue elements normally present in that site, and are not likely to in compression of adjacent tissue (in contrast to a neoplasm) Primarily made of enamel and dentin w/ variable amt of pulp and cementum Odontoma 2 Types: o Compound Odontoma- composed of multiple small toothlike structures ~ More frequently diagnosed ~ Differential- is supernumary tooth, depending on person looking at it o Complex Odontoma- conglomerate mass of enamel and dentin ~ No anatomic resemblance to tooth, except maybe same density o Know classifications for board questions (shes not too hung up on)

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Clinical Features st nd o Young patient- detected in 1 and 2 decade o Asymptomatic- detected in routine radiograph or when taken b/c tooth failed to develop o Maxilla > Mandible o Usually small and < size of tooth ~ When large may cause expansion o Assocw/ unerupted tooth or often found b/w roots of erupted teeth o Compound (tooth-like) more common in anterior maxilla o Complex (haphazard) more common in posterior jaw o Rarely may be peripheral~ Peripheral odontoma analogous to tooth erupting Radiographic Features o Compound Odontomas- Toothlike structures w/ a thin radiolucent halo o Complex Odontomas- Radioopaque mass w/ thin radiolucent halo o Radiolucent halo- analogous to tooth follicle around developing tooth o Developing Odontoma- may show little calcification and appear as circumscribed radiolucent lesion o Pic ~ Solitary, unilocular, mixed radiolucent area thats overlying midroot of the 1st premolar ~ Differential- ossifying fibroma, ameloblastic fibro-odontoma, odontoma Differential short b/c not a lot of lesions making product Histopathologic Features o Varying arrangement of enamel matrix, dentin, pulp in a fibrous stroma: ~ Developing odontomas structures that resemble tooth germs are present ~ Complex- mostly tubular dentin enclosing hollow structures that contained enamel, w/ a thin layer of cementum around periphery o May have ghost cells- in 20% of complex odontomas o Dentigerous cyst- may arise from epithelial lining of fibrious capsule of complex odontoma Treatment and Prognosis o Simple local excision o Do not recur- they are just haphazard mistake of odontogenesis Calcifying mass w/ RL rim overlying crown of unerupted 1st molar Differential- ossifying fibroma, ameloblastic fibro-odontoma, odontoma, calcifying odontogenic cyst (better than saying ossifying fibroma b/c it was pericoronal, in the follicular space of developing tooth) o Recall- calcifiying odontogenic cyst often occurs w/ odontoma

TUMORS OF ODONTOGENIC ECTOMESENCHYME Central Odontogenic Fibroma Uncommon and controversial Clinical Features o Wide age range, avg 40 y.o. o Females > Males (2.2:1) o 33% assoc w/ unerupted tooth st o In maxilla- most lesions occur anterior to 1 molar st o In mandible- most lesions occur posterior to 1 molar o Small lesions asymptomatic o Larger lesions expansile and loosen teeth Radiographic Features o This is in radio-opaque and radio lucent list o Smaller lesions- Well defined, Unilocular radiolucent ~ Often assoc w/ periradicular area of tooth o Larger lesions-Well defined, multilocular radiolucent

May have radiopaque flecks Root resorption and divergence Histopathologic Features o Simple Type~ Fibroblasts, collagen, scanty epithelium ~ Occasional foci of dystrophic calcification may be present o WHO type- more complex pattern ~ Fibroblasts, collagen, abundant epithelium o Small calcifications o May have giant cell granuloma like component Treatment and Prognosis o Enucleation and curettage o Few recurrences
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Peripheral Odontogenic Fibroma Soft tissue counter part of central odontogenic fibroma Clinical Features o Slow growing, firm, Sessile gingival mass (Bump on the gums) ~ Cant clinically differentiate from common fibrous gingival lesions ~ Wouldnt put so much on clinical differential (but know that bump occurs) o Doesnt involve underlying bone o Nomal overlying mucosa o 0.5 to 1.5 cm o Often facial mandibular gingival nd th o Wide age range- 2 7 decade o Take xray to make sure not a lesion in bone Histopathologic Features o Similar to WHO type central odontogenic fibroma Treatment and Prognosis o Local surgical excision o Recurrence reported Enlargement of dental papilla Granular Cell Odontogenic Tumor Rare Similar to central odontogenic fibroma, except for fibrous stroma you have granules Clinical Features o Adults o Mandible > Maxilla o Premolar, molar region o May be asymptomatic or painless expansion Radiographic Feaatures o Well defined radiolucent area o Unilocular or multilocular o May have small calcifications Histopathologic Features o Background filled w/ eosinophilic granular cells ~ Anytime you have granules you need to know what it represents mitochondria and lysosomes look granular under light microscope o Filled w/ lysosomes o Narrow cords or small island of odontogenic epithelium scattered among granular cells o May have small cementum-like or dystrophic calcifications Treatment and Prognosis o Curettage is adequate o Recurrence not reported This is less common, wouldnt be in clinical differential

Odontogenic Myxoma Arise from ectomesenchyme Myxoma- A benign neoplasm derived from CT, that resemble primitive mesenchymal tissue A neoplasm Clinical Features o Wide age range- avg. 25-30 y.o. o Mandible > Maxilla o Larger lesion painless expansion o May show rapid growth, may be aggressive Radiographic Features o Unilocular or multilocular radiolucency ~ Multilocular (aka Tennis racket) appearance may look like hemangioma in bone (surgeons must aspirate when they go in) o Displace or resorb tooth root o Margins often irregular or scalloped o May be poorly defined Histopathologic Features o Loose, myoid stroma, o More collagenized variants may be called: ~ Fibromyxoma or Myxofibroma Treatment and Prognosis o Curettage or resection ~ Myxoid tissue has gelatinous texture, sometimes hard to incise o 25% recurrence rate Differential- Can now consider OKC, ameloblastic fibroma and odontogenic myxoma

4-14-2006 Dr. Farquharson Lec Notes (incl handout) & some notes from text Ch. 2 DEVELOPMENTAL DISTURBANCES

Oral Pathology I

Developmental Alterations in the Number of Teeth HYPODONTIA o Anodontia- lack of total tooth development o Hypodontia- Congenital absence of some teeth from dental arch ~ Oligodontia- sub division of hypodontia, lack of development of > 6 teeth ~ Pseudohypodontia- clinically absent teeth, developed but impacted o Cause~ Dental lamina obstruction or disruption during early stage of embryogenesis Inappropriate amount of dental lamina developed (too much or too little) Environmental influence- dental lamina sensitive, damage b4 tooth formation can result in hypodontia, examples: - Trauma, Infection, chemotherapeutic meds, endocrine disturbances o Associated Syndromes include: ~ Ectodermal dysplasia- which can result in: Conical teeth, Hypodontial, Anodontia o Clinical Presentation ~ Uncommon in deciduous dentition ~ In permanent dentition most common 3rd molars then 2nd Premolars and lateral incisors o Tx- orthodontics, prosthodontics

SUPERNUMERARY TEETH (HYPERDONTIA) o Hyperdontia- development of increased # of teeth, additional teeth are termed supernumerary o Supernumary teeth- may have normal morphology but tend to be smaller than normal ~ Mesiodens- in anterior location (usually maxillary) ~ Distomolar or distodens- accessory 4th molar ~ Paramolars- in posterior region, lingual or buccal to molar tooth o Cause- by increased activity of the dental lamina o Associateed Syndromes include: ~ Gardners syndrome ~ Cleidocranial dysostosis o many times diagnosed radiographically o Clinical Presentation ~ More frequent in permanent dentition ~ Most common sites: Extra molar than premolar (Dr. Farquharson in lecture)

*Maxillary incisors maxillary 4th molars and mandibular 4th molars, PM, canines, and lateral incisors (text p. 71) ~ Variable eruption 75% in anterior fail to erupt Tx- surgical removal and orthodontics

NATAL TEETH o Natal teeth- teeth present (erupted) in newborns o Neonatal teeth- are teeth that erupt 1 month after birth o May be predeciduous supernumerary and require extraction, but most are prematurely erupted deciduous (not supernumerary) Eruption Defects ECTOPIC LOCALIZATION, ERUPTION o Dental Transposition- normal teeth erupt in inappropriate position o Eruption of a normal tooth into another location in the dental arch o Ectopic - Normal structure that occurs in wrong place; canine erupts in incisior area o Patient has TMJ and occlusion issues o Seen in incisors, canines and 1st molars o Tx-surgical-orthodontic

ANKYLOSIS o The cessation of eruption after emergence, occurs from an anatomic fusion of tooth cementum or dentin w/ alveolar bone o Clinical Presentation ~ Appears clinically as an eruption defect, frequently followed by irregular occlusion. ~ It is characterized by occlusion surface retention of the affected teeth, at a level at least 1mm or more cervical to the adjacent teeth o Cause- local trauma or metabolic factors or genetics o Affects primary and permanent molars. o Radiograph shows break of periodontal membrane continuity ~ Doesnt usually erupt completely, doesnt develop PDL locked in bone o Tx- surgical removal if becomes symptomatic

Developmental Alterations in Size of Teeth MICRODONTIA o Teeth that appear smaller in size compared to normal ~ X-chromosome -responsible for size and shape of teeth o females>males o Generalized microdontia ~ Rare and is associated (caused by) with congenital hypopituitarism o Localized microdontia ~ More common and is frequently followed by hypodontia ~ Common in permanent teeth ~ seen in upper laterals and third molars shapes conical or pegged o Associated syndromes ~ Ectodermal dysplasia, Trisomy 21, Dleft lip and palate o Tx- composites/porcelain crowns

MACRODONTIA o Teeth that appears larger than the normal o Generalized macrodontia ~ Seen in pituitary gigantism (from hyperpituitarism) ~ Giganitism - effects growth prior to closure of epiphyseal plate o Associated syndromes ~ Cranialfacial dysostosis

~ Sturge-Weber Clinical Presentation ~ Seen in lower third molars, second premolars and upper central incisors ~ Morphology is rounded edges and can cause crowding o Tx- restorations Developmental Alterations in Shape of Teeth
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GEMINATION o Attempt of single tooth bud to divide, resulting in the formation of two partially or completely independent crowns with a shared root ~ Has normal amt of teeth (when you count double crown tooth as one) ~ Pulp chamber and root canal are usually common to both elements o Genetic factors involved are probably similar to those affecting the dental lamina in cases of hypodontia o Males = Females in prevalence o Occurs in upper and lower incisors o Tx- composite, crown or extraction FUSION o Union of 2 discrete tooth buds, resulting in formation of a tooth with an anomalous shape ~ Fusion leads to a reduced number of teeth (when dbl crown counted as one tooth) o Cause by local factors affecting interdental lamina persistence during dental organ development o seen in anterior teeth ~ when counting # fused tooth as one, you will have less teeth than normal o Tx- composites, crowns or extraction CONCRESCENCE o Fusion in which formed teeth are joined only along the line of cementum o Occurs before or after teeth erupt o Cause- probably due to dislocation of tooth germs during formation o In upper second and third molars and only on radiographs o Usually asymptomatic and only important if extractions will be done DILACERATION o Extensive bend in the root or the cervical area of the affected teeth o Cause- disruption of the Hertwig epithelial root sheath due to eccentric dislocation of the already formed crown in relation to the developing adjacent soft tissue o 3% of the successors in cases of traumatized primary teeth ~ Curved due to environment o Often in anterior teeth and could be a problem for extractions o Tx- none if asymptomatic DENS INVAGINATUS (DENS IN DENTE) o Clinical Presentation- Prominent lingual cusp and a centrally located pit o Cause- early invagination of enamel epithelium into dental papilla of underlying tooth germ ~ Dental papilla forms the pulp (tooth forms w/in developing pulp) o Seen in permanent teeth upper lateral incisors o Increased risk for caries in lingual pit o May effect restorations: ~ affects endodontic therapy if obstructing pulp ~ may cause pulpal exposure of little tooth o Tx- Preventative filings of the pit

Developmental Alterations in Shape of Teeth DENS EVAGINATUS o Clinical Presentation- Elevated, tuberculated appearance on occlusal surface of affected teeth

o o o o o

~ Contain enamel, dentin and pulp Cause- Focal hyperplasia of ectomesenchyme of the primitive dental papilla ~ Due to genetics Seen frequently in the Asian population affecting premolars and molars Complication pulp may extend into the tubercula (cusp), increased risk of pulp exposures Tx- occlusal reduction of cusp to stimulate secondary dentin or prevent occlusal trauma ~ Endodontic Therapy Note- Talon cusp is denevaginatus of anterior tooth (usually maxillary or central incisors)

ENAMEL PEARLS o Ectopic enamel- presence of enamel in usual location (mainly tooth root) o Ectopic nodular deposits of enamel at roots of involved teeth. ~ Can be extra or intra dental ~ Hemispheric structures may consist entirely of enamel or contain some underlying dentin o Cause unknown. ~ Arise from local activity of the Hertwigs epithelial root sheath remnants o Seen frequently in Asian and Eskimo populations and on permanent upper molars at furcation o Can only be detected on radiograph or gross inspection. Usually contains enamel and dentin o Tx- none TAURODONTISM o Enlargement of body and pulp chamber of a multirooted tooth w/ apical displacement of the pulpal floor and bifurcations of the roots ~ Defect usually found in multirooted teeth. ~ Characterized by prolonged crown and more apically root furcation, ~ Resulting in the creation of enlarged pulp chambers with increased occlusal-apical length. o 3 types based on degree of apical displacement of pulpal floor ~ Hypotaurodontism- mild ~ Mesotaurodontism- moderate ~ Hypertaurodontism- severe o Cause - Local factors and failure of Hertwigs epithelial root sheath to invaginate below crown at the proper time during dental development o Associated Syndromes: ~ Amelogenesis imperfecta type IV ~ Ectodermal dysplasia, ~ Downs and Klinefelter syndrome o Affects permanent 1 and 2 molars and can only be diagnosed on radiograph o Tx- none

Enamel Defects Enamel hypoplasia-pits, grooves and lines in the whole enamel surface or in certain areas. o Cause- infection, environmental or genetics during development or by hypoparathyroidism Amelogenesis imperfecta also produces enamel defects Possible reduction of the enamel thickness Tx- conservative esthetic restorations or prosthetic rehabilitation Enamel Defects AMELOGENESIS IMPERFECTA o Isolated defects of the enamel resulting exclusively from genetic factors o Cause- genetic factors during enamel formation phase. ~ Defect in the enamel matrix proteins amelogenin and enamelin on X and Y chromosome o Clinical Presentation ~ Affects all teeth primary and permanent ~ Can have a coloration issue, a snow capping issue, no enamel at all

~ Increase chance of caries b/c no enamel protecting ~ Always generalized, if its localized its just enamel hypoplasia 4 Types: ~ Type I (Hypoplastic) Autosomal Dominant[AD] Inadequate deposition of enamel matrix Reduced enamel thickness on surface of teeth. Does not develop properly Pitted and smooth patterns ~ Type II (Hypomature) Enamel does not mature Enamel matrix is laid down appropriately but there is defect in maturation of enamels crystal structure Teeth are normal in shape but have mottled, opaque white-brown-yellow discoloration The enamel is softer than normal and tips from underlying dentin Pigmented and snow capped ~ Type III (Hypocalcified) Reduced hardening of enamel Enamel matrix laid down appropriately but no significant mineralization occurs Appropriate shape on eruption but enamel is soft and easily lost becomes stained brown to balck and exhibits rapid calculus apposition Mineralized ~ Type IV Hypomature-Hypoplastic Exhibits hypoplasia in combination w/ hypomaturation Taurodontism Tx- crowns

Dentin Defects Dentinogenesis Imperfecta-AD o Genetic disorder affecting dentin collagen esp phase of tissue differentiation and organic matrix o Cause- Defect in collagen o Type I- assoc w/ Osteogenesis Imperfecta chromosome 7 and 17 o Type II- chromosome 4 ~ affects all teeth primary and permanent appears amber translucent/opalescent ~ radiograph shows obliteration of pulp chambers and root canals o Tx- prosthetic rehabilitation Dentin Defects Dentin Dysplasia o 2 types: ~ Type I- radicular dysplasia- extreme short roots- obliterated pulp; no roots ~ Type II- coronal dysplasia- complete obliteration of pulp, thistle roots and pulp stones; small thin roots w/ large crowns o Cause- Epithelial invagination of dental organ cells into the dental papilla ~ Producing ectopic formation of dentine o Tx- prosthetic rehabilitation

Odontodysplasia o Severe dental defect involving all dental tissues of both ectodermal and mesodermal origin o Cause- unknown, suggested that defect is related to a vascular deficiency o Affects primary and permanent dentition. o Seen more in the maxilla and involving an entire arch ~ Typically process affects a focal area of dentition ~ Involvement of more than 2 quadrants rare o Clinical Presentation

~ Teeth eruption is delayed and painful, occasionally teeth fail to erupt ~ Small irregular crowns that are yellow to brown, often w/ very rough surface ~ Caries assoc w/ periapical inflammatory lesions Radiograph shows: ~ ghost teeth appearance (teeth dont form fully) Extremely thin enamel and dentin surround an enlarged radiolucent pulp ~ Short roots ~ Wide pulp canals ~ Open apices -Tx- surgical removal and prosthetic rehabilitation

Odontomas Odontogenic hamartomas tumor containing dental calcified tissues o Hamartoma- development of tissue in normal area but having abnormal presentation Cause- unknown. Malformation of dental tissues and their formative elements Most common odontogenic tumor lesion. Diagnosed by radiograph Two types: o Complex odontoma- dont look like teeth; histologically only have enamel and dentin ~ Seen in premolar/molar region o Compound odontoma- look like teeth; histologically have enamel, dentin and pulp ~ Seen in anterior maxilla Prevents the eruption of adjacent permanent teeth Tx- surgical removal and orthodontic therapy Staining Intrinsic staining- thru medication or trauma, or congenital issue o Mottling a form of instrinsic staining ~ Due to excess amt of flouride w/in enamel and dentin (Flourosis) Extrinsic staining- thru bacteria, tobacco Cleft Lip/Palate Males > Females Bifid uvula- is form of clef palate Bifid tongue- slight form of cleft lip Ankyloglossia Tongue tie- developmental malformation in which tongue is abnormally fixed to floor of mouth or lingual aspect of the gingiva, due to a short and malpositioned lingual frenulum Malformation may cause partial or complete immobility of the tongue Tx- surgical clipping of the frenulum in severe cases Low Frenum attachment o Can cause recession that can lead to periodontal disease o Various syndromes associated (did not mention) Congenital lip pits and Double Lip Also assoc w/ various syndrome Fordyce Granules Ecotopic sebacacous glands- there is not treatment but should recognize and not confuse w/ conditions like measles (not seen in US) Exostoses extended growth of alveolar bone on buccal, normal bone growth, no need to operate dentures needed

Hypercementosis Often assoc w/ pagets disease; over growth of cementum Roots are bulbous, appear larger than normal on radiograph Can also be assoc w/ cementoblastoma (an odontogenic tumor) Usually asymptomatic Facial Hemiatrophy Parry-Romberg syndrome is a degenerative disorder characterized by atrophic changes of the deeper structures(e.g. fat, muscle, cartilage and bone) involving one side of the face Facial asymmetry due to some type of trauma or developmental o of face normal, other small o of tongue normal, other small o Progresses Cause unknown Clinical Presentation o Starts in childhood and seen in girls more than boys o Side of face affected is atrophied skin is wrinkled, shriveled and shows hypo or hyperpigmentation o Hypoplasia of maxilla, mandible, delayed eruption and malocclusion may occur o Atrophic process progresses slowly for some years then stabilizes Diagnoses is based on clinical finding. DDx- Scleroderma, Facial hemihypertrophy and Lipodystrophy Tx- plastic reconstruction and orthodontic therapy

4-21-2006- Dr. Fryer See Operative Text for additional info

Oral Pathology I

THE PATHOLOGY OF DENTAL CARIES Various Pathologies of Teeth Inflammatory Response- like general pathology, inflammation is a major contributing factor Trauma o Attrition wearing of away o Erosion o Abrasion Caries- acid demineralization by bacteria o White spots, brown spots Introduction Most common disease of the Oral Cavity o Periodontal disease (PDD) o Dental caries PDD and caries are perhaps the most expensive infections that most individuals have to contend w/ during a lifetime Definition of Caries Caries- infection microbiological disease of teeth that results in localized dissolution and destruction of the calcified tissues Dissolution, destruction = cavitation Cavitations or holes: signs of bacterial infection Treatment directed twd identification and management of the underlying disease Wholes or cavitation could be decay or erosion o Decay- you will get a catch or stick o Is it sticky or just narrow Want to remove caries and determine what patient is doing that allows them to be susceptible to decay Have a systematic approach Caries Risk Factors Prehistoric Caries and diet Model developed in 1960s

Overlap of the circles o Plaque, Tooth, Diet (3 outer circles) o Caries (w/in overlapping of circles) o Surrounding circles- Time, Flouride, Immune System, Saliva o Outer most circle- education, socioeconomic status, income, knowledge, attitude, behavior How are caries risk increased or decreased?

Hypothesis Concerning Caries Etiology Non specific Plaque Hypothesis- universal presence of potential pathogens in plaque and assumes all accumulations of plaque are cariogenic Specific Plaque Hypothesis- Accumulation of plaque is not always associated w/ disease o Aimed at elimination of specific patho-organisms, not removal or all plaque o Only a limited # of organisms can produce a carious response How should treatment be directed? o In theory if we know what bacteria causes decay we should be able to go in and attack them o Antibacterial Agent- chlorhexadine (anti plaque), fluoride o Homeostatic environment- There are also organisms that off set environment Etiologic Agents of Carious Lesions (Plaque, bacteria) Plaque and Bacteria most significant- TEST ?? Plaque and Bacteria o Bacteria ~ Streptococcus mutans (initiation) ~ Lactobacilli (progression) ~ Sites- TEST ?? Enamel s. mutans Dentin s. mutans, lactobacillus Root actinomyces ~ Environment of demineralization pH<5.5 and aneorobic o Bacteria by products o Accumulation is highly organized and ordered o Review in text how plaque accumulates o Survival dependant upon ability to adhere (recetoprs and sticky matrix coherence) Sucrose: frequency vs quantity (frequency is most important0 Flouride o Active enamel carious lesion- spreads o Arrested enamel carious lesion- caused by remineralization w/ fluoride ~ Note root better Tooth Alignment o Malalignment can contribute to caries problems by providing sheltered areas for plaque retention o Defective margins also a concern ~ It traps food Roles of Saliva o After __ comes the pellicle o Produces salivary pellicle ~ Where fluoride exchange happens ~ Review the Pellicle ~ After prophy you should wait for pellicle to reform so fluoride has place to exchange (a few minutes) o Antimicrobial o Clears bacteria and carbohydrates; buffers acid o Contains Ca/Phosphate/fluoride o Lubricates oral mucosa o Mediates taste acuity

Pathophysiology of carious lesion Common Sites of Development o Pits and Fissures- most common ~ Grooves help shelter bacteria o Proximal Enamel ~ Gingival area around the contact, 2nd most common o Root surface o Root and Proximal surface have more exposure to washing process of saliva Diagram Test ?? notice how enamel rods run o Tooth view is buccal-lingual direction shows various progression of lesions Spread of Caries- Pits and fissures o Enamel- base of triangle at DEJ o Dentin base of triangle at DEJ Spread of Caries- Smooth Surface (i.e. interproximal lesions) o Enamel- base of triangle at surface o Dentin base of triangle at surface? (dbl check) Location of Decayo Caries more frequent in distal of tooth as well as in mandibular teeth o Chart of Frequency ~ Common on distal of 1st molar surface of tooth ~ Common in mandibular in molars Demineralization Dissolution Progression in Enamel o Variable ~ pH 3-4: enamel etched, rough ~ pH 5- surface intact, subsurface mineral lost (porous) Caries Risk Assessment Incipient caries o Smooth surface opaque lesion located cervically Advanced Caries o Rampant caries/Milk bottle syndrome o Multiple lesions Arrested Caries o Darker (remineralized) o Commonly on interproximal surfaces at contact areas High Risk Patients o Orthodontic patients are high risk patients Root Caries Etiology Demineralization critical pH = 6.7 Lesion progression and mineral loss 2.5x greater than enamel Rapidly develops; slower thereafter Gingival recession Darkening of surface assoc w/ remineralization When doing Class V restoration make sure you get aacces to gingival floor to avoid an open margin Watch out for patients who had radiology therapy Listen to Lecture after break (about 1hr) Morphology of Enamel Caries and Progression of Decay Over period of time Must manage lesions General Presentation o Pit and fissure: inverted V (enamel < DEJ) o Smooth surf (prox): V shape (enamel > DEJ)

o Root Surface: U-shaped in cross section, progresses more rapidly Cross Section of Occlusal Caries

Histopathology of Caries Diagnosis and Prevention of Caries Diagnosis- visual and tactile Criteria for visual examination of caries o No or slight change in enamel translucency after prolonged air drying (>5sec) o Opacity or discoloration hardly visible on the wet surface, but distinctly visible after air drying o Opacity or discoloration distinctly visible w/o air drying o Localized enamel breakdown in opaque or discolored enamel and/or grayish discoloration from the underlying dentin o Cavitation in opaque or discolored enamel exposing the dentin Criteria for histologic examination of fissure caries o No enamel demineralization or a narrow surface zone of opacity (edge phenomenon) o Enamel demineralization limited to the outer half of the enamel layer o Demineralization involving b/w half of enamel and outer 1/3 of dentin o Demineralization involving the middle 1/3 of dentin o Demineralization involving the pulpal 1/3 of dentin Histology of Pulpal response to caries Reversible pulpitits Irreversible pulpitis o Acute o Chronic Histology of Dentinal Response to Caries Pathologic secondary dentin Physiologic secondary dentin