OMPR 4 pt 1

List (5) Epithelial Odontogenic Tumors
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List (5) Epithelial Odontogenic Tumors
- Ameloblastoma (also Peripheral Variant)
- Calcifying Odontogenic Cyst/CCOT
- Adenomatoid Odontogenic Tumor (AOT)
- Calcifying Epithelial Odontogenic Tumor
- Odontogenic Keratocyst/KCOT (discussed in cyst lecture)
List (3) Mesenchymal Odontogenic Tumors
Odontogenic Fibroma & Myxoma
Cemento-Ossifying Fibroma (also Peripheral Variant)
Cementoblastoma
Central Odontogenic Fibroma treatment
enucleation with curettage or excision
usually does not occur
List (2) Mixed Epithelial and Mesenchymal Odontogenic Tumors
Ameloblastic Fibroma
Odontoma
Ameloblastoma, a (fast/slow) growing epithelial odontogenic tumor. It is (malignant/benign), and locally aggressive
slow growing
benign
locally aggressive
(low transformation rate)
Ameloblastoma, an epithelial odontogenic tumor occurs mostly in (mandible/maxilla) and its usual clinical presentation is (symptomatic/asymptomatic) swelling of the affected bone. It has (high/low) recurrence
80% in mandible (mostly in molar ramus area) w/ asymptomatic swelling of the affected bone. With high recurrence

but note, can occur anywhere
Image: Ameloblastoma, an epithelial odontogenic tumor occurs mostly in (mandible/maxilla) and its usual clinical presentation is (symptomatic/asymptomatic) swelling of the affected bone. It has (high/low) recurrence
Which of the following epithelial odontogenic tumor presents with subnuclear vacuolization histologically
Ameloblastoma.
Ameloblastoma, an epithelial odontogenic tumor common follicular type
no capsule!
- islands with ameloblast-like epithelial cells surrounding areas resembling stellate reticulum

note: other forms: plexiform, granulated cell, desmoplastic, acanthomatous
If patient presents with Ameloblastoma, an epithelial odontogenic tumor what is the treatment
1st: radiograph & refer to OS for incisional biopsy

Resection with 1cm margins is best tx
Approx 15% recurrence rate
rare cases of ameloblastic carcinomas
Common radiographic appearance:

Ameloblastoma, an epithelial odontogenic tumor
usually well defined RL
Smaller tumors are unilocular
Larger tumors are multilocular
Image: Common radiographic appearance: Ameloblastoma, an epithelial odontogenic tumor
Calcifying Odontogenic Cyst, an epithelial odontogenic tumor is usually (unilocular/multilocular) and often affects what populationusually unilocular, but may be multilocular age range - children to adultsT/F The lining of a dentigerous cyst can give rise to OKC or ameloblastomaTRUE! Thats why you remove all the tissue.Calcifying Odontogenic Cyst, an epithelial odontogenic tumor affects mandible or maxilla moremandible = maxilla (anterior jaws favored)Calcifying Odontogenic Cyst, an epithelial odontogenic tumor, is often associated withcalcifications or unerupted teeth, or odontomasCalcifying Odontogenic Cyst, an epithelial odontogenic tumor, is usually (multi/uni) locular. And affects the (anterior/posterior) (mandible/maxilla)moreusually unilocular, but may be multilocular maxilla=mandible, anterior jaws favored (note: associated w/ calcifications or unerupted teeth or odontomas)T/F a Calcifying Odontogenic Cyst occurs anywhere and can cause bony hard buccal/palatal swelling?true! but mostly on anterior maxillaCalcifying Odontogenic Cyst (COC) radiographic apperancemost commonly found on anterior maxilla - well defined (mixed RL/RO) that may be associated with impacted tooth or odontomaCharacteristic dark pink "ghost" cells. Often see cyst lien, lining, wall and calcifications(COC) Calcifying Odontogenic CystCalcifying Odontogenic Cyst (COC) and AOT (Adenomatoid Odontogenic Tumor) treatment & (high/low) recurrence- simple enucleation - low recurrenceAOT (Adenomatoid Odontogenic Tumor) is usually (symptomatic/asymptomatic), (benign/malignant), (encapsulated/no capsule) and occurs mostly where and what demographicasymptomatic benign encapsulated 70% females <20yo anterior jaw ; maxilla > mandible associated with impacted/unerupted teeth usually caninesAOT (Adenomatoid Odontogenic Tumor) histologic appearanceencapsulate dust-like adenomatoid whorls and large masses of epithelial cells scattered calcifications within the tumorAOT (Adenomatoid Odontogenic Tumor) radiographic appearancewell-circumscribed RL with RO within the tumor finer than COC Simulates a dentigerous cyst but RL extends BEYONG CEJ often associated with impacted toothCOC/AOT tends to have courser, bigger calcifications where as (COC/AOT) has finer, more snowflake like clacifications. (not definitive)COC = courser AOT = finer(CEOT) Calcifying Epithelial Odontogenic Tumor (Pindbord Tumor) affects (maxilla/mandible) 2x more and is most common in what locationmandible 2x more premolar/molar area most associated w/ impacted teeth(CEOT) Calcifying Epithelial Odontogenic Tumor HistologyIslands and sheets of uniform epithelial cells w/ round nuclei, Congo red Amyloid-like deposits and calcifications in the tumor recall: amyloid is a protein that is assoc w MM, but this has nothing to do w MM(CEOT) Calcifying Epithelial Odontogenic Tumor radiographic appearanceunilocular or multilocular calcifications within the tumor appear as RO within the rL(CEOT) Calcifying Epithelial Odontogenic Tumor aka(Pindbord Tumor)Calcifying Epithelial Odontogenic Tumor (CEOT) treatmentconservative local resection good prognosis - less aggressive than ameloblastoma(5) Common Benign Odontogenic Multilocular RLMACHO Odontogenic Myxoma Ameloblastoma Central Giant Cell Granuloma Central Hemangioma Odontogenic KeratocystfCentral Odontogenic Fibroma is believed to be the counterpart of ___. Occurs mostly in ___assoc w peripheral ossifying fibroma (in ST) incidental but can cause cortical expansion if large MX = MD (in maxilla tend to be anterior to first molar) 1/3 associated with *UNERUPTED TOOTH*Central Odontogenic Fibroma is often an incidental finding but can cause cortical expansion. It is often well circumscribed but (encapsulated/unencapsulated). What are (2) Histologic typesunencapsulated Histo 1. Simple type 2. WHO typeOdontogenic Myxoma is through to arise from _cells of the dental follicle or dental papilla (~3-5% of all odontogenic tumors)Odontogenic Myxoma population and location. Large lesions can cause (painful/painless) expansion of bonewide age range 3rd decade most common MX = MD large lesions can cause painless expansion of boneOdontogenic Myxoma radiographic appearanceRL lesions but can be well circumscribed or irregular, unilocular or more commonly multilocular "soap bubble or honeycomb" appearance - scalloped borders around root and can cause displacement or bone expansionAlthough Odontogenic Myxoma can be unilocular, most commonly described as RL that can show soap bubbles or honey comb appearance that can displace teeth or cause bone expansion. It is (unencapsulated/encapsulated)unencapsulated (loose, soft and gelatinous) note: tx is to excise (high recurrence) and difficult to removeCementoblastoma (benign/malignant) (vital/nonvital tooth) (painless/painful) swelling more frequent in (maxilla/mandible)benign tumor of cementoblast *VITAL* teeth painful swelling mandible (mostly molar/premolar region)Cementoblastoma radiographic apparenceRO mass w/ RL rim usually posterior mandible fused to VITAL toothCementoblastoma treatment and recurrencesurgical extraction of tooth and attached tumor root amputation Endo is an option for smaller tumors Recurrence is unlikelyTumors in which the odontogenic epithelial component causes __ of the mesenchymal component to produce a product*induction*Odontoma is often associated with,unerupter tooth may prevent eruption of teeth usually small in size, but rare cases >6cm note: if large, can cause bone expansion(2) Types of Odontoma1. Compound (anterior jaw esp max) *well developed rudimentary tooth forms* 2. Complex (posterior jaws esp mand) *poorly developed mass if calcified deposits*Odontoma treatment and (high/low) recurrancesimple excision or enucleation low recurrence(AF) and (AFO) Ameloblastic Fibroma and Ameloblastic Fibro-odontoma are through together bc they are variations of same process. Typically present what age, locationfirst 2 decades (mean is 12yo) 70% posterior mandible 75% assoc w unerupted teeth(AF) Ameloblastic Fibroma clinicallysmall lesions are asymptomatic, found on routine exam large lesions can cause bone expansion if untreated multi locular or unilocular well defined sclerotic(AF & AFO) Ameloblastic Fibroma and Ameloblastic Fibro-odontoma difference?AFO same as AF but also see development of foci of enamel and dentin matrix in AFO(AF & AFO) Ameloblastic Fibroma and Ameloblastic Fibro-odontoma treatmentconservative surgical excision or curettage, early removed from surrounding bone excellent prognosis and unusual recurrance note: rare cases reported of development of ameloblastic fibrosarcoma in area of AF/AFOAmeloblastic Fibrosarcoma is the malignant counterpart of _ and more common in (males/females)ameloblastic fibroma (rare lesion which may arise in site of previous AF/AFO) more common in males 1.5xAmeloblastic Fibrosarcoma vs ameloblastic fibroma histologicallymalignant version we see *atypical mesenchymal stroma* (hyper chromatic large nuclei) tx: radical surgical excision as tumor is aggressive and infiltrative. Prognosis dependent on complete removal_ is the most common odontogenic "tumor". Although most likely hamartomas rather than true neoplasmOdontomaOdontoma is most common odotogenic "tumor". It is usually (symptomatic/asymptomatic) and what age group?asymptomatic (routine radiographic exam) mean age of 14Chrondroma & Chondrosarcoma (joined together bc EXTREMELY rare in the jaw and can become malignant)note: since 20% of chondrosarcomas in the jaw are misdiagnosed as condromas you need to be suspicious! All cartilaginous tumors arising in the jaws should be excised widely (60% recurrance)__ is a malignant tumor that forms cartilage. Patient's cc: painless swelling may be associated with tooth mobilityChondrosarcomaChondrosarcoma average age of onset and patient's CCavg age = 33yo CC: painless swelling with or w/o tooth mobilityChondrosarcoma radiographic features*symmetric widening of PDL space (can be initial presentation with chondrosarcoma and osteosarcoma)* - poorly defined RL often w/ scattered RO fociChondrosarcoma treatmentradical surgical excision on initial treatment (DOES NOT RESPOND TO RADIATION/CHEMO) prognosis is poorer than osteosarcoma tx failure usually due to uncontrolled local disease not metastasisWe must be very suspicious of Chondrosarcoma! Pt walks in complaining of ill-fitting denture & has histology shows chondrocytes present but no bone insolent and only one nucleus in each lacunae. Do we consider this a Chondrosarcoma??NO! CutRight Lesion as a reactive lesion to the denture! NO BONE INVOLVEMENT!_ is the most common MALIGNANT bone tumor in the jaws ( ~33yo) and most common PRIMARY malignant bone tumor in patients <40yoOsteosarcoma (via metastatic disease)_ is the most common malignancy of the bone overallMultiple myeloma #2 is OsteosarcomaOsteosarcoma of the jaw has many different presentations. However what is common presentations25% present with toothache symmetric widening of PDL 25% have "classic sunburst pattern" via osteophytic bone production on surface of lesion loosening of teeth paresthesia of lip and nasal obstructionWhat non-odontogenic malignant tumor of the jaw? 25% present with toothache symmetric widening of PDL 25% have "classic sunburst pattern" via osteophytic bone production on surface of lesionOsteosarcoma note: is irregular and can cause swelling or destruction of mandibleOsteosarcoma of the jaw has many different radiographic presentations.symmetric widening of PDL (early change) dense sclerotic, mixed, or RLOsteosarcoma is more common in (mandible/maxilla) and (males/females)> mandible and malesA histology showing osteoid arising directly from a sarcomatous stroma (bone being formed by malignant cells) is defined asOsteosarcomaOsteosarcoma histology*must demonstrate osteoid arising directly from a sarcomatous stroma* (bone being formed by malignant cells)Osteosarcoma treatmentimportant to differentiate between chondrosarcoma bc tx is different Osteosarcoma = pre-op multiagent chemo and surgery. Radiation alone is not good enoughOsteosarcoma vs Chondrosarcoma treatmentRecall: Chondrosarcoma does not respond well to radiation or chemo (low prognosis) Osteosarcoma: pre-op chemo and surgeryOsteosarcoma treatment includes pre-op chemo and surgery. What is a favorable site and worst site of prognosis? what is the 5 year prognosisfavorable = mandibular symphysis worst = max sinus 5 year prognosis is ~20% (up tp 80% if caught and treated early)Peripheral (juxtacortical) osteosarcoma. Arises __ and (2) typesarises on the surface of the bone (vs. medullary site for usual forms of osteosarcoma) - usually long bones 1. Parosteal 2. PeriostealPeripheral (juxtacortical) osteosarcoma (2) types & describe1. Parosteal: (like a mushroom) well differentiated, but will recur with less then an unblock or radical surgery 2. Periosteal: (causes bone elevation) higher grade with prominent cartilaginous componentPeripheral (juxtacortical) osteosarcoma: (Parosteal/Periosteal): mushroom like growth on bone surface, no elevation of periosteum, no new bone formation, low gradeparostealPeripheral (juxtacortical) osteosarcoma: (Parosteal/Periosteal): usually sessile growth on bone surface, elevation of periosteum, new bone fills in space under periosteum. *Prognosis is better than medullary osteosarcoma but worse than Parosteal*PeriostealLangerhans Cell Disease aka (4)Histiocytosis X Langerhans cell granuloma Eosinophilic granuloma Langerhans cell histiocytosisLangerhans Cell Disease etiology, Gender predilection, age and locationetiology unclear Males >> Females Age: >50% under 10 yo Jaws affected 10-20% (common site: skull, rib, vertebrae, mandible)Langerhans Cell Disease occurs a lot in younger population. What are clinical and radiographic featuresCommon sites:: skull, rib, vertebra, mandible Often have pain or tenderness In jaws: loss of alveolar bone in molar area (looks like periodontitis)Langerhans Cell Disease (3) forms:1. Acute disseminated - multi system, infants high mortality 2. Chronic disseminated - (triad) unisystem, children, fairly high mortality 3. Eosinophilic Granuloma (chronic localized) - solitary or multiple bone lesions, adults, very low mortalityLangerhans Cell Disease has (3) forms. The Chronic Disseminated form has a classic triad1. Exophthalmus 2. Diabetes insipidus 3. Lytic defects in boneLangerhans Cell Disease has (3) forms. The Chronic Disseminated form's classic radiographic featureteeth floating in air note: also seen in Eosinophilic granuloma forLangerhans Cell Disease has (3) forms. The Chronic Disseminated form has a classic triad. What are some clinical and radiographic featuresClinical = mobility of teeth. Triad = exophthalmus, diabetes insidious, lytic defects in bone Radiograph: teeth floating in air, sharply punched out RL lesions, ill-definedLangerhans Cell Disease - Site of involvement depends on _ (20% jaws) other common site: skull, vertebra, mandible.depends on clinical form Neuplastic proliferation of Langerhans cells - (dendritic mononuclear cells normally found in the epidermis and mucosa) - (antigen presenting cells to T lymphocytes)Langerhans Cell Disease has (3) forms. patients in Eosinophilic granuloma?elderly men often presents with lung lesions; smoking) Localized lesions usually affecting one bone. If solitary = treatment is curettage and low dose RT Recall: acute and chronic affect younger populationLangerhans Cell Disease has (3) forms. Radiographically, Eosinophilic granuloma looks similar tomultiple myeloma Chronic disseminated (punched out lesions & floating teeth)Langerhans Cell Disease has (3) forms. Histology?All the same Diffuse infiltrate of mononuclear cells with cleaved or KIDNEY SHAPED NUCLEI and defined cell borders - variable #s of eosinophilsWith EM, in which disease can we see rod shaped BIRBECK GRANULES ?? (looks like tennis racquet)Langerhans Cell Disease!What are (5) differential diagnosis for alveolar bone loss in children1. Juvenile periodontitis 2. Langerhans Cell Histiocytosis (Acute/chronic) 3. Papillon-Lefevre syndrome 4. Cyclic neutropenia/agranulocytosis 5. Burkitt's lymphoma_ is the monoclonal expansion of malignant plasma cellsMultiple MyelomaMultiple Myeloma is due to the malignant plasma cells. What is the common age of onset, (pain/painless) and commonly involved bonesage = 40-70yo 70% present with pain and pathologic fracture Common bones = ribs, vertebrae, skullBence Jones Proteins in urine can be seen inMultiple Myeloma - light chains, usually kappa (anemia, thrombocytopenia and neutropenia due to crowding out of normal cells within bone barrow by proliferating malignant cells)_ is often the first sign of MMSolitary plasmacytosis (indiv bone lesion ~95% @ ramus and angle of mandible)Key radiographic feature of Multiple Myelomamultifocal disseminated disease with punched out RL often with an irregular outline and no sclerotic borderClinical signs of Multiple Myeloma include spiked levels of _ in serumElevated M spike, immunoglobulin (hyperglobulinemia) - mostly IgG and deposition of amyloid (macroglossia) in serumElevated M, immunoglobulin (hyperglobulinemia) - mostly IgG and deposition of amyloid (macroglossia) in serumassociated with multiple myelomamultiple myeloma treatmentchemotherapy with or without RT, bone marrow transplant, interferon, antibodies made against tumor cells, thalidomide but even with treatment many its do not survive >18-24mo__ is a highly malignant, undifferentiated, small round tumor with cells of unknown known origin (may be neural crest). Patient present with pain, swelling, fever, and elevated ESREwing SarcomaPatients who present with symptoms of Ewing Sarcoma may be misdiagnosed as _an infection or osteomyelitisEwing Sarcoma occurs more in M or F? & 50% of cases in _ and _M>F (younger population and >mandible) femur and pelvic bone in the jaws: the ratio of primary tumor to metastasis is 14:1Ewing Sarcoma occurs mostly in (males/females) (younger/older) population (maxilla/mandible)males younger population (5-30yo) mandible 2x White people > Blacks and asians note: lesions often perforate cortex and involve STEwing Sarcoma may present with pain, swelling, fever and elevated _.ESR: Elevated Erythrocytes Sedimentation rate (nonspecific test needs to be done)Ewing Sarcoma Clinical and Radiographic featuresparesthesia, loosening of teeth illdefined margins, root resorption possible onion skinning pattern esp in long bonesWhat are some "blue cell" tumorsEwing Sarcoma ChondrosarcomaEwing Sarcoma treatmentCombined therapy with multiagent chemo before radiation and surgery Gnathic Ewing Sarcoma has lower mortality rate than all other primary sitesWhat are the (6) most common metastatic carcinomas to the jaw bones??*"BLT and Cold Kosher Pickle" Breast Lungs Thyroid Colon Kidney ProstateT/F Primary tumors to the jaw are more common than metastatic tumorsFALSE! other way around Metastatic tumors to the jaw are more common than primaryThink __, _ or _ if lesion radiographically looks malignant and has RO with internal patternosteosarcoma chondrosarcoma osteoblastic metastasisEwing Sarcoma is clinically accompanied by signs of _INFLAMMATION (recall elevated ESR: Elevated Erythrocytes Sedimentation rate)_ clinically presents as multiple, well defined, punched out RLMultiple MyelomaBone affected by Non-Hodgkin's lymphoma radiographically appears to be _dissolvingLangerhans cell histiocytosis characteristically presents as __scooped out RL at the mid-root levelRemember to always include _ to jaw as a radiographic differential diagnosis for malignant lesionsmetastatic carcinomaTori are common exostosis and thought to be hereditary. (2) typesTorus palatinus Torus mandibularisTorus palatinus is an exostosis that usually more prevalent in males or females? located & occurs?> females esp native american and asians - midline of hard palate, symmetrical - sessile or pedunculate & HARD!Torus Mandibularis: affects M or F more? usually found? unilateral or bilateralM=F Found above the mylohyod attachment on the lingual aspect of the mandible 80% bilateral and symmetricExostoses are more common on __ and are (more/less) common than mandibular tori (8% of population)buccal aspect of maxilla (note: lower anterior is also common) less frequent than mandibular toriT/F Exostoses are considered reactive but not true neoplasmsTRUETori/Exostoses histologymature bone with scant fibrous CT marrow Mucosa overlying the bone is thin and easily traumatized.Tori/Exostoses treatmentno tx necessary unless they interfere with function or placement of prosthetic appliance, in which case they are surgically excisedT/F Osteomas are benign proliferation of bone and are considered a true neoplasmtrue recall: tori are notOsteoma occur almost exclusively in skull and facial bone. In jaws, they are most common?mandibular angle and condyleOsteomas (2) types1. Periosteal: growth from bone surface 2. Endosteal: growth within boneClinical differential diagnosis of Osteomas incldeodontoma condensing osteitis dense bone island calcifying odontogenic lesionEndosteal Osteoma histologicallymature compact or cancellous bone with sparse marrow (similar tori and exostosis)_ presents as an asymtpmatic hard swelling ON bone surface. On radiograph appears as a well circumscribed mushroom-lake growth.Periosteal OsteomasIf patient presents with multiple periosteal osteomas....think *GARDNER SYNDROME!*Garner Syndrome is transmitted as _, and _ gene.Autosomal dominant trait APC gene (associated with familial adenomatous polyposis syndrome) note: pt may have multiple osteomasGarner syndrome clinical manifestations includeintestinal polyposis of the colon and rectum (premalig) multiple odontomas impacted/supernumerary teeth soft tissue tumors & cysts (epidermal cysts, desmoid tumors, lipomas) Increased risk for thyroid carcinomaWhat are some diseases that come to mind when you see multiple RO dispersed throughout each quadPagets Florid CODWhy is it important for a patient with Gardner's syndrome and adenomatous polys treatedpts usually become symptomatic in their early 20s. First carcinoma usually by age 30 If left untreated, up to 100% of polyps will become malignant_ and _ are benign tumors of osteoblasts (cells that produce bone)Osteoid Osteoma/Osteoblastoma (note: distinguished by size, site of occurrence and symptoms)_ and _ are benign tumors of osteoblast. However _ produce prostaglandins therefore pain is relieved by prostaglandin inhibitors (ex: aspirin)osteoid osteoma & osteoblasts osteoid osteomas produce prostaglandin(Osteoid Osteoma/Osteoblastoma) is produces _ relieved by aspirinosteoid osteomas produce prostaglandin therefore relieved by aspirinOsteoid Osteoma & Osteoblastomas are more common in males/females? and located where?2x more common in males posterior mandible most common well circumscribed RL/RO lesion that my have a RL haloOsteoid Osteoma/Osteoblastoma radiographic features and progressionwell circumscribed RO/RL lesion (usually posterior mandible). May have RL halo Can grow at an alarming rate and have a "sunburst" type periosteal reaction(Osteoid Osteoma/Osteoblastoma) less than 2cm Nocturnal pain alleviated by aspirin central RO with a sclerotic border RARE in jaws most in femur and tibiaOsteoid Osteoma(Osteoid Osteoma/Osteoblastoma)? >2cm 2x more common in mandible dull localized ache NOT relieved by aspirin most often in vertebraeosteoblastomaOsteoblastoma and osteoid osteoma Histologyanastomosing osteoid trabecular and immature "woven" bone set in a well vascularized fibrous stroma - trabecular are rimmed by pulp, triangular shaped osteoblasts - Multinucleated osteoclasts are present and may be numerous - if attached to tooth, may be cementoblastomaOsteoid Osteoma and Osteoblastoma treatmentconservative local excision or curettage with this treatment 80-90% curative a small # will recur rarely, undergo transformation to osteosarcomaCGCG aka _ aka _central giant cell granuloma giant cell lesion giant cell tumorCGCG etiologyetiology unknown, possible a reaction to an intramedullary bleed, may be a neoplasm, may be developmental. Most are considered reactive not neoplasticCGCG's etiology is unknown, however some think that they are true neoplasms like giant cell tumor in long bones where _ mutations are found. (but not seen in CGCG_H3F3ACGCG age, prevalence, location, (symptomatic/asymptomatic)60% before 30 yo 60% female 70-75% mandible (anterior to molar & *cross midline*) Asymptomatic swelling may perforate the cortical plate and cause a ST lesionCGCG's radiographic featuresusually *anterior mandible*, crossing midline multilocular "soap bubble" appearance well defined, non corticated frequent displaces teeth and may perforate the cortical plate. recall: vs myxoma that tends to grow around tooth and ameloblastoma that resorbs tooth root)CGCG histologymultinucleated giant cells set in a well vascularized fibrous stroma. The stroma may be loose and edematous or quite cellular Areas of extravasated RBCs and hemosiderin deposits Same history as brown cell tumor of hyperparathyroidism cherubism and wall of aneurysmal bone cystDifferential diagnosis for history of multinucleated giant cells set in a well vascularized fibrous stroma. The stroma may be loose and edematous or quite cellular Areas of extravasated RBCs and hemosiderin depositsCGCG Brown tumor of hyperparathyroidism Cherubism Wall of aneurysmal bone cystIt is impossible to distinguish CGCG and Brown tumor by hyperparathyroidism via histology alone. A work up for those with brown tumor will show _elevated serum PTH, Ca and alkaline phosphataseCGCG treatmentcuretage or intra-lesional injections of corticosteroids, even bisphosphonates recurrence 15-20%Hemangiomas often occur in ST, but CENTRAL hemangioma occur in bone. They are more common in (males/females) and (maxilla/mandible)2x> in females and mandibleCentral Hemangioma Clinicalmost patients between 10-20yo (females) may be painful slow expanding swelling can see mobility of teeth or bleeding from gingival sulcus in the areaCentral Hemangioma Radiology featuresmultilocular RL with either small lobules (honeycomb) or large ones (soap bubbles) root resorption possble bruits or pulsation is not uncommonCentral Hemangioma Histologyunencapsulated lesion composed of multiple endothelial lined vascular channels Type: depends on size of vessels (Cavernous= large plated vessels) (Capillary = small vessels)difference between aneurysmal bone cyst and Cavernous hemangiomaAneurysmal = sinusoid cells Cavernous = epithelial linedMost Central Hemangioma are _ type. It is strongly recommended to _ prior to biopsymost are cavernous type because of possibility of severe hemorrhage, it is strongly recommended that all Central lesions (multilocular radiolucencies) are aspirated prior to biopsy or surgery.Central Hemangioma treatment- surgical resection - cryotherapy - radiation - injection of sclerosing agent if complications due to hemorrhage are avoided, the prognosis is goodIf Central Hemangioma where mental foramen and IACanal has shows serpentine enlargementAV malformation in bone Vascular lesionIf you see an enlarged canal or foramen with intact bone cortices, think __ or __benign neural or vascular tumors! note: neural looks like neurofibroma and schwannoma in boneBenign neural tumors within the bone or canal can look likeBlunderbuss canalDesmoplastic fibromarare tumor that is considered to be the osseous counterpart of ST fibromatosis 50% found in metaphysical region of the humerus and tibia Mandible 4th most commonly affected boneDesmoplastic fibroma common location and agemandible is 4th most commonly affected bone ( usually ascending ramus area) most pts <30yoDesmoplastic fibroma clinical presentationpainless swelling unilocular RL and may have sclerotic border expanded bone and thinned cortex can erode/perforate through bone and cause ST extension often see root resorptionDesmoplastic fibroma histologyinterconnecting fascicles of uniform fibroblasts set in a densely collagenized stroma. Fibroblasts are not atypical and there are rare mitotic figures Histologic dd: odontogenic fibroma and well differentiated fibrosarcomaDesmoplastic fibroma treatmentinitial: curettage, recurrance 30% although benign, often acts locally aggressive and can be associated with considerable morbidity In spectrum of fibrous tissue lesions, this lies between benign and malignant radical surgery may be requiredThe sphenoid sinuses usually develop during the _ month of pregnancy from the invagination of the _fourth month sphenoid-ethmoidal recessEthmoid air cells develop during the _ month of pregnancy and anterior ones usually develop from _ meatus, while posterior ones from the _ meatusfifth month anterior = middle meatus posterior = superior meatusThe frontal sinus usually develops in __ from invagination of _ to _5-6 years old from invagination of nose to frontal boneMax sinuses are located (superior/inferior) to the max alveolar process. The max sinuses drain to the ___ via __superior drain to the middle meatus via the osteomeatal complexThe max sinus drains into the middle meatus via the osteomeatal complex. It is composed of _uncinate process of ethmoid, infundibulum, and semilunar hiatusWater's view to study max sinusis when patient's head is tilted up. It is really great for seeing the max sinus - can see max sinus without superimpositoin of zygomatic processesDiseases of the Max sinus can be intrinsic or extrinsic. Which is more common?Intrinsic! but usually incidental findings note: extrinsic comes from surrounding structures_ Sinonasal pathology is when the disease originates from tissues within the sinus. Please give a few examplesIntrinsic (ex: mucositis, sinusitis, retention of pseudocyst, polyps, benign and malignant neoplasms of paranasal sinuses)Intrinsic or Extrinsic sinonasal pathology? Mucositis, sinusitis, retention of pseudocyst, polyps, benign and malignant neoplasms of paranasal sinusesIntrinsic_ sinonasal pathology is when disease originates from outside the sinus. Usually inflammatory disease, odontogenic cysts, benign odontogenic neoplasms, or bone dysplasiaextrinsicIntrinsic sinonasal pathology: __ is a common inflamed mucosa which becomes 10-15x thicker when inflamed from infection or allergen. Usually an incidental findingMucositisIntrinsic sinonasal pathology: Mucositis radiographic featuresRO band paralleling the contour of the sinus wall 10-15x thicker than normal due to allergen or infectionIntrinsic sinonasal pathology: Sinusitissinus mucosa becomes inflamed and thickened from infection/allergen, which may lead to ciliary dysfunction, retention of sinus secretion and blockage of sinus drainage10% of max sinusitis are related todental infectionIntrinsic sinonasal pathology: (3) types of sinusitis1. Acute - (common cold) (pain to pressure) 2. Chronic (sequela of acute >3mo) 3. Pansinusistis (all paranasal sinuses affected, rule out cystic fibrosis in pediatric patients)If you see a non-odontogenic sinusitis, you shouldrefer to ENTIntrinsic sinonasal pathology: Sinusitis radiographic featureswill stay inside sinus opacification of the sinusIntrinsic sinonasal pathology: localized, submucosal accumulation of fluid forming a sessile, dome shaped swelling along the sinus borderantral pseudocyst (retention pseudocyst) note: common incidental finding on PANOIntrinsic sinonasal pathology: antral pseudocyst akaretention pseudocystIntrinsic sinonasal pathology: antral pseudocyst radiographic features?well defined, non-corticated and dome shaped RO mostly along floor of max sinusAntral meaning _ pseudocyst meaning _antral = related to max sinus pseudocyst = no epithelial lining so accumulation of fluid UNDERNEATH the mucosa of the sinus.Radicular cyst vs Antral pseudocystLook at the CORTICATION! Antral = noncorticated (no RO line) - no treatment Radicular = associated with PAP of root and commonly inferior to the follow of the sinus - ext or endoIntrinsic sinonasal pathology: Antrolith definedeposition of mineral salts (calcium phosphate/carbonate/magnesium) around an exogenous or endogenous sinusIntrinsic sinonasal pathology: Antrolith population, common location and small vs largepopulation = pediatric and adult population Location: mostly adjacent to floor of max sinus Small = incidental radiographic finding Large = sinus obstruction, sinusitis, nasal discharge, painIntrinsic sinonasal pathology: Antrolith causecan be root tip, dental material, kids putting things up their nose intrinsic: blood clots, mucous etcIntrinsic sinonasal pathology: Benign neoplasia (4) typesOsteoma Schneiderian papilloma True sinus mucocele PseudotumorExpansion of a sinus is a (sign/symptom)symptomSinonasal pathology: Benign neoplasia clinical featuresclinically, benign and malignant have similar presentations (unilateral nasal bleeding, *nasal* obstruction, discharge, epistaxis) - *recurring sinusitis for years and sudden nasal obstruction on same side* - pain/swelling - effects adjacent anatomic structures (esp orbital extension)Intrinsic sinonasal pathology: Benign neoplasia radiographic features*mass* in sinus *expanded/missing sinus walls and opacified sinus*Intrinsic sinonasal pathology: Malignant Neoplasia (5) types1. SCC 2. Lymphoma 3. Salivary gland-like adenocarcinoma 4. Melanoma 5. SarcomaIntrinsic sinonasal pathology: Malignant Neoplasia clinical features (recall: similar to benign)unilateral *nasal* obstruction, nasal discharge, epistaxis - *recurring sinusitis for years and sudden nasal obstruction on same side* - pain/swelling - effect of adjacent anatomic structures (eg orbital extension)Intrinsic sinonasal pathology: Malignant Neoplasia radiographic features*mass* in sinus *bone destruction and opacified sinus before symptoms*Intrinsic sinonasal pathology: Sinus Neoplasia treatmentREFERRAL FOR THOROUGH INVESTIGATION AND BIOPSY IS STRONGLY ADVISED FOR ANY UNEXPLAINED RADIOPACITY IN THE MAX SINUS OF A 40+ YEAR OLD PTExtrinsic Max Sinus Disease: _ refers to the lamellar, periosteal reaction from periapical inflammatory responsePeriostitisExtrinsic Max Sinus Disease: Periostitis is the lamellar, periosteal reaction from periapical inflammatory disease. How?Exudate from infected tooth diffuses through the cortical bone, lifts and stimulates the periosteal lining to produce layer(s) of new boneExtrinsic Max Sinus Disease: Periostitis radiographic featureslamellar periosteal reaction that produces new layer of bone. Onion skin appearance (usually parallel line to the floor of the sinus) Floor of max sinus, inferior buccal and lingual mandibular cortices also commonOdontogenic Cyst or Neoplasm affecting the max sinusrecall: the max sinus is filled with air and the neoplasm will grow upwards and follow path of least resistanceThe MOST common incidental sinus entities you will encounter as a general dentist include _ and _antral pseudocyst and mucositisClinically correlate your radiographic findings of an opacified sinus. _ is the most likely disease. _ are raresinusitis neoplasmsOdontogenic diseases that may present int he sinus include __ that can affect sinus floor/wall integrity and may cause sinus symptomsdental infections jaw cysts neoplasmsHow are occlusal radiographs useful for imaging of trauma?good to see alveolar process of maxilla and mandibular boneFor more complicated traumatic fractures (ie Left or Zygomatic etc) _ images may be helpfulmedical evaluation medical CT CBCTTypes of imagingPA - tooth fracture Occlusal - bone/alveolar bone PAN - whole jaw, condylar fracture, TMJ CBCT - zygomatic, LefortPlease list some dento-alveolar and mandibular trauma where imaging of trauma can be useful- concussion/luxation/avulsion - dental crown +/- root fracture - alveolar process fracture - mandibular fracture - mid facial fracture - monitor healing - sequelae of untreated traumaTraumatic injuries of teeth: _ is a crush injury to vascular structures and periodontal ligament at the root apex of the tooth, resulting in inflammatory edemaConcussionTraumatic injuries of teeth: _ is displacement of tooth from its socket after severing periodontal attachmentluxation (intrusive/extrusive/lateral)Traumatic injuries of teeth: _ is complete displacement of tooth from alveolar processavulsionTraumatic injuries of teeth: concussion radiographic featuresedema around apical region of tooth may have PDL space widening esp around area of concussion(3) types of luxations1. Intrusive (into alveolar process) 2. extrusive (tooth partially displaced out of the socket) 3. Lateral (tooth displaced in a direction other than intrusive/extrusive)Traumatic injuries of teeth: Luxation (Intrusion) radiographic featurestooth displaced towards the socket - thinning or loss of PDL around apex - may or may not see fractureTraumatic injuries of teeth: Luxation (Extrusion) radiographic featureswidening of the PDL space especially more obvious in the apical region of toothFracture of teeth can be Dental crown, Dental root, or combo. Please list (3) dental crown fractures1. Infraction of the crown 2. Uncomplicated crown fracture 3. Complicated crown fractureFracture of teeth can be Dental crown or Dental root. Please list (2) dental root fractures1. Horizontal root fracture 2. Vertical root fractureDental crown fracture: _ is a crack in enamel without loss of enamel, dentin or pulpinfraction of the crownDental crown fracture: _ is a fracture of enamel +/- dentin withOUT pulpal involvementuncomplicated crown fractureDental crown fracture: __ is a fracture through enamel, dentin and pup involvement/exposurecomplicated crown fractureDental root fracture: horizontal root fractures typically occur at __ of (anterior/posterior) teeth and often accompanied by fractures of alveolar processmid-root level anterior teethDental root fracture: vertical root fracture usually have fracture plane that is oriented __facial-linguallyDental root fracture: vertical root fracture is typically caused by _ and affects _ teeth mostiatrogenic and affects mandibular molars(5) Radiographic signs of fracture- 1-2 sharply defined RL lines CONFINED WITHIN the fractured tooth or bone - localized widening of PDL space - change in occlusal plane - Step defect of outer anatomic border - increased RO of anatomic structure (overlapped fractured fragments)Dental crown fracture radiographicallysame clinically flattening of surface of tooth loss of tooth structureHorizontal root fracture is most common on what teeth?anterior max incisorsA horizontal root fracture has a better prognosis when....closer to the apexVertical root fracture radiographic features- presence of RL line that is vertically extending from he CEJ to apical aspect of tooth - PDL eidening and RL plane that is close to area if endo treatedIt is often more difficult to see vertical/horizontal root fracturesvertical is more difficult because most of the time there is no displacement of fractured fragments andDirect vs Indirect Radiographic featuresDirect: we se fracture Indirect: we do not see fracture but see radiographic findings that hint a fracture (ie: J shaped RL or widened PDL space)What are clinical tests we can do to check for fracturebite test perio probe(2) groups of Alveolar process fracture1. Simple alveolar fracture (often horizontal and only involves one cortical plate) 2. Fracture of entire alveolar process (involves both cortical places, often associated with extruded teeth and root fractures)_ is an alveolar process fracture that involves both cortical places, often associated with extruded teeth and root fracturesFracture of entire alveolar process (dental fracture, root fracture, extruded teeth)_ is an alveolar process fracture that often horizontal and only involves one cortical platesimple alveolar fracture (can be associated with dental extraction)_ is one of the most commonly fracture facial bone. Most common area is the __ (30-40%), followed by __ (25-50%) and least _ (15%)mandible - body of mandible (30-40%) - Angle of mandible(25-50%) - condyle (15%)ramus alveolar process coronoid symphysis (midline) please list from most to least likely to fracturesymphysis (midline) > ramus > alveolar process > coronoidWhat is the difference between favorable vs unfavorable mandibular fracturesfavorable: fragments are displaced on the same path of muscle attachment unfavorable: fractures are NOT in pathology of muscle attachment so will be displacedWhenever you see a fracture on body of mandible, there is a high chanceof fracture on the condylar neck of same or opposing side (so take a PANO)Midfacial fractures are classified viaLefort FracturesLeFort FracturesType I: (separation of alveolar process from rest of face) (horizontal maxillary fracture from anterior nasal spine to inferior aspect of nose and max sinus and goes posteriorly to pterygoid plates of spend bone) maxilla dissociated from skull base - nasal aperture; "floating palate" Type II: Pyramidal shape and separation of max bone from rest of face so extends from the pterygoid plates on sphenoid bone to the lateral walls of max sinus superior aspect of nasal cavity (central midface dissociation - inferior orbital rim, orbital floor; "pyramidal") Type III: line passes from nasal frontal suture, maxofrontal suture and orbital walls and zygomatic arch. Whole mid face from rest of skull. complete midface dissociation - lateral orbital wall, zygomatic arch; "floating face"Lefort Fracture _: line passes from nasal frontal suture, maxofrontal suture and orbital walls and zygomatic arch. Whole mid face from rest of skull. complete midface dissociation - lateral orbital wall, zygomatic arch; "floating face"3Lefort #: Pyramidal shape and separation of max bone from rest of face so extends from the pterygoid plates on sphenoid bone to the lateral walls of max sinus superior aspect of nasal cavity (central midface dissociation - inferior orbital rim, orbital floor; "pyramidal"2When monitoring healing. You need to use __ imagingplain film! normal time line: 1-2 weeks may see increase in fracture bc edema and increased RL plane 5-6 weeks: radiographic evidence of bone formation (RL not as large) several months: complete remodeling of fractureT/F It is possible to see incidental healing of dental fracturestrue! recall: we are unable to make dentin or enamel unless tertiary. but sometimes we have bone formation around fracture and bone keeps broken fragments in the same place, so no effect on PDL space and teeth.If patient has a history of trauma and no treatment, we may see sequelae of untreated trauma. for exampleunresolved tooth resorption (more odontoblasts, formation of secondary dentin in pulp and obliteration of the root canal)_ root resorption is common esp if avulsion of tooth happened. Therefore it is very time sensitiveexternal root resorptionIf patient has a history of trauma and no treatment, we may see sequelae of untreated trauma. For example in an untreated mandibular fracturesecondary infection (osteomyelitis) misalignment of root fractureWhen suspecting a fractured tooth, it is important to take a minimum of __ images for dentoalveolar trauma at ___ to test the fracture plane on imaging2 images at different x-ray beam angulationsAlways use _ and _ for dento-alveolar trauma because intraoral images have superior resolution when compared to panoPA and occlusal imagingPeriapical pathology terms: Condensing Osteitisincrease RO density of bone due to infection or inflammation of the bonePeriapical pathology radiographic term: Rarefying Osteitisit is a radiographic presentation that may be suggestive of a root fracture! J shaped lesion (RL - decrease in density of the bone) recall: condensing osteitis is increase RO_ is a radiographic term to help describe a J shaped RL near the periodical region that is suggestive of the presence of vertical root fracture. You must clinically correlate itRarefying OsteitisPeriapical cemento-osseous dysplasia is usually (nonvital/vital)vital note: if non-vital, it is indicative of inflammatory lesionCondensing OsteitisDiffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus, usually seen at apex of tooth. Nonvital toothCondensing Osteitis vs Dense Bone islandDense bone island is associated with vital tooth, well defined homogenous RO, PDL space is intact Condensing Osteitis: inflammatory response usually non vital tooth with widened PDL spaceWhat are the (3) radiographic findings of a periapical inflammatory lesion?- loss of bone density (aka rarefying osteitis) - Increase density of bone (condensing osteitis) - combination of rarefying osteitis/condensing osteitisCommon radiographic feature of radicular cystepicenter: apex of NONvital tooth well defined corticated unilocular round internal structure is RLRadicular cyst is commonly associated with (vita/nonvital) toothnonvitalRadicular cyst: a cysts that results when rests of __ in the PDL are stimulated to proliferate and undergo cystic degeneration by inflammatory products from a (vital/nonvital) toothepithelial cells (Malassez) non-vital toothRadicular cyst is associated with inflammatory product from a nonvital tooth. Grows by _osmotic pressurelateral radicular cyst -tooth can be vital or not?non vital loss of lamina dura and loss of PDL spaceLateral Radicular Cyst vs. Lateral periodontal cyst. Which is often well defined, corticated and usually associated with vital toothlateral periodontal cyst recall: lateral radicular cyst = nonvital toothRadicular cyst vs Nasopalatine cystrecall: radicular cyst = nonvital, LOSS OF LAMINA DURA and widening of PDL spaceIt is important to note: when looking at a large radicular cyst that is not associated with NONvital teeth, you need to consider other RL like...OKC Ameloblastoma__ is a hallmark of osteomyelitisformation of sequestrum (necrotic bone ischemic injury caused by the inflammatory process)define osteomyelitisinflammation of bone involving bone marrow, cortex, cancellous portion and periosteumHallmark of osteomyelitis is _ . It can occur via _sequestrum (necrotic bone (ischemic injury caused by the inflammatory process) via abscessed teeth, postsurgical infection, hematogenous spreadOsteomyelitis location: periphery: internal structure: effect on surrounding structure- > posterior body of mandible - illdefined, better defined on chronic type - sclerotic, can be mixed - linear periosteal bone reaction/onion skin - resorbed cortical bone - onion skin appearanceOsteomyelitis with proliferative periostitis (periostitis ossificans)periosteal reaction to the presence of inflammation. affected patients tend to be primarily children and young adults with a mean age of 13 yearsIf a patient had a history of radiation therapy (ie for SCC), we do not say osteomyelitis...we say?osteoradionecrosis note: medication, radiation, and myelitis usually have same radiographic features so you have to ask about the medical history!Define osteoradionecrosisbone death resulting from exposure to therapeutic radiation doses > 50 Gyosteoradionecrosis is bone death resulting from exposure to therapeutic radiation doses ___>50 GyOsteoradionecrosis clinical features: more common in (maxilla/mandible)mandible, exposed bone to the oral cavity, site of previous traumaosteoradionecrosis is the same radiographically as _.osteomyelitis therefore it is important to take medical historyMedication related osteonecrosis of the jaws is associated with ___, especially __anti-resorptive medication, especially bisphosphonate (metastatic tumors, metabolic bone diseases and osteoporosis)Medication related osteonecrosis of the jaws clinicallyexposed bone, pain and swelling at the site of extraction in the patient with history of antiresorptive medication useMedication related osteonecrosis of the jaws radiographically is same as _ and _ plusosteoradionecrosis and chronic osteomyelitis + thickening of lamina duraRadiographically, for which medication we see thickening of the lamina dura and osteoradionecrosis of the jawbisphosphonatesPlease describe Endocrine and Metabolic diseases and key concepts pertaining to imagingAbnormalities with disturbances in the balanced serum concentrations of calcium and phosphate and/or through abnormal functioning osteoblasts, osteocytes and osteoclasts. Diseases that alter the normal form and function of bone and normal formation of teeth(2) types of hyperparathyroidismprimary: uncontrolled parathyroid hormone production by parathyroid neoplasm (adenoma >> hyperplasia>adenocarcinoma) secondary: continuous parathyroid hormone production in response to chronic low serum calcium levels (renal osteodystrophy)continuous parathyroid hormone production in response to chronic low serum calcium levels (renal osteodystrophy)secondary hyperparathyroidismuncontrolled parathyroid hormone production by parathyroid neoplasm (adenoma >> hyperplasia>adenocarcinoma)primary hyperparathyroidismHyperparathyroidism has (2) types but what is the general definition and effect on bone/imagingexcess circulating parathyroid hormone increases bone remodeling but tips the balance of osteoblastic & osteoclastic activity in favor of osteoclastic resorptionhyperparathyroidism has an (excess/deficient) amount of parathyroid hormone. Therefore causing increased favor for (osteoblast/osteoclast)excess parathyroid hormone favors osteoclast (Resorption)Hyperparathyroidism common radiographic findings- *brown tumors* - presence of erosion (resorption) of subperiosteal phalanges of the hands - RL decreased density of bone (osteopenia) - punctate or nodular calcifications in the joints and kidneys - entire calvaria has *granular* appearance classically known as "salt and pepper" skull - *loss of lamina dura*If you have a young patient that presents with a multilocular RL with separation you must rule outhyperparathyroidism (recall: brown tumor has similar radiographic feature to CGCG)Which endocrine/metabolic disease is associated with - entire calvaria has granular appearance classically known as "salt and pepper" skull and decreased bone density via imagingHyperparayhtroidismHypoparathyroidism principal radiographic change & imaging of the jawscalcification of the basal ganglia jaws: dental enamel HYPOplasia, external root resorption, delayed eruption or root dilacerationHypoparathyroidism has (insufficient/increased) secretion of the PTH. This is due toinsufficient - damage or removal of the parathyroid glands during thyroid surgeryCommon radiographic findings for hypoparathyroidism- lack of enamel formation, external root resorption and delayed eruption - dental enamel HYPOplasia, external root resorption, delayed eruption or root dilacerationDefine hyperpituitarism general definition and (2) typeshyper function of the anterior lobe of pituitary gland, caused by a benign functioning tumor of anterior lobe (1) - gigantism (younger) (2) - acromegaly (Adult)Hyperpituitarism is the hyper functioning of the (anterior/posterior) lobe of the pituitary gland caused by a benign functioning tumoranterior note: two types = gigantism and acromegalyHyperpituitarism common radiographic features of the jaws and teethenlargement of jaws, (mostly mandible) Class III skeletal spacing of the teeth hypercementosisHyperpituitarism general radiographic features- enlargement "ballooning" of the sella turcica - enlargement of the paranasal sinuses (esp the front sinus) - thickening of the outer table of the skullThe __ is where the pituitary gland is locatedsella turcicaHyperpituitarism: patients often have enlargement of (maxilla/mandible) and therefore class _ enlargementmandible class 3Hypopituitarism is the reduced secretion of pituitary hormone. This leads to __, and findings in the jaws includeDwarfism - normal eruption of primary dentition but delayed exfoliation - small jaws --> crowding and malocclusion_ is the most common disorder of carb metabolism. What are the (2) typesDiabetes Mellitus Type 1 - insulin dependent (its usually hyperglycemia and ketoacidosis) Type 2 = not responding to levels of insulinDiabetes Mellitus common oral manifestations are typically limited to type 1 and uncontrolled type 2. What are common oral manifestationsperiodontal disease diabetic sialadenosis delayed wound healing and increased risk of infection fungal infectionsPlease list some metabolic bone diseases (9)1. Osteoporosis 2. Osteopetrosis 3. Rickets/Osteomalacia 4. Renal Osteodystrophy 5. Hypophosphatasia 6. Hypophosphatemia 7. Progressive Systemic Sclerosis (Scleroderma) 8. Sickle Cell anemia 9. Thalassemia_ refers to the generalized decrease in bone mass in which the histologic appearance of bone is normal. Common in the aging process (esp post-menopausal women, nutritional deficiencies, corticosteroids/heparin, or inactivityOsteoporosisOsteoporosis can be seen in patients withaging (postmenopausal women) nutritional deficiencies hormonal imbalance corticosteroids/herparin therapyOsteoporosis are (more/less) prone to fractures.more prone (distal radius, proximal femur, ribs, and vertebrae)Osteopetrosis (define)defect in the differentiation and function of osteoclasts. therefore bone is dense, fragile and susceptible to fracture and infection (poor vascularity --> osteomyelitis) (compression of CNs --> blindness, deafness, vestibular nerve dysfunction, facial nerve paralysis) *impacted teeth* *linear periosteal reaction*Patients with Osteopetrosis are (more/less) likely to get osteomyelitis. Why?more likely, denser bone and poor vascularityOsteopetrosis we see an (increase/decreases) in bone density Osteoporosis we see an (increase/decrease) in bone densityOsteopetrosis = INCREASE in bone density (osteoclasts are not working) Osteoporosis = DECREASE in bone density (osteoclasts are winning bc poor differentiation)Osteopetrosis: we have a defect in the function of (osteoblasts/osteoclasts) so we have an (increase/decrease) in function and (less dense/more dense) bonedecreased osteoclast function MORE dense bone (bc no resorption)Osteoporosis we see an increase/decrease size of skull foraminadecrease (Recall osteoclasts are not working so more dense bone)Rickets and Osteomalacia defineinadequate serum and extracellular levels of calcium and phosphate (failure of normal vitamin A activity) Rickets = kids Osteomalacia (adults)Rickets (osteomalacia of children)disease affecting the growing skeleton in infants and children (inadequate serum/extracell levels of calcium and phosphate, failure of normal activity of vitamin D)Failure of normal activity of vitamin D due to- lack of vitamin D diet - GI malabsorption problems - Lack of UV light - Liver or Kidney disease - defect in the intestinal target cell responserickets/osteomalacia? - growth retardation - short stature - bowing of long bones of legs and waddling gait - radiographic manifestations in teeth esp <3 yo and jawsrickets (children) note: will see hypo calcification and demineralized teeth. Thinning of enamel bc not enough calcium/phosphate/vitDrickets/osteomalacia? - weak fragile bone structure - diffuse skeletal pain - susceptible to fracture with minor injury - radiographic manifestations in the jaws are (common/uncommon)osteomalacia radiographic features in the jaws are UNCOMMONrickets/osteomalacia? - Radiographic features in the jaws are UNCOMMONosteomalaciaRenal Osteodystrophy definechronic renal failure produces bone changes by interfering with the hydroxylation of vitamin D in the kidneys --> hypocalcemia --> inhibit the normal calcification of bone and teeth - secondary hyperparathyroidismchronic renal failure produces bone changes by interfering with the hydroxylation of vitamin D in the kidneys --> hypocalcemia --> inhibit the normal calcification of bone and teeth - secondary hyperparathyroidismRenal Osteodystrophyrenal osteodystrophya general term that refers to bone disease related to CKD and caused by over - or underproduction of parathyroid hormoneHow does renal osteodystrophy cause oral defects?CKD interferes with hydroxylation of vitamin D --> hypocalcemia --> inhibits normal calcification of bone and teeth note: we can have increase or decrease in bone formationrenal osteodystrophy common oral findingsdecrease in bone density and increase elsewhere inhibition of normal calcification of bone and teeth loss of lamina duraHypophosphatasia define and types (4)*RARE metabolic bone disease due to lack of tissue-nonspecific alkaline phosphatase* prenatal infantile childhood adultHypophosphatasia: a RARE metabolic bone disease due to lack oftissue-nonspecific alkaline phosphataseHypophosphatasia common factors (3)1. low levels of tissue nonspecific alkaline phosphatase 2. High blood and unironary phosphoethanolamine 3. Rickets-like skeletal malformationsHypophosphatasia (3) common dental manifestations1. *premature shedding of primary incisors* 2. enamel hypoplasia 3. enlarged pulp chambers and root canalsThese are common presentations of what metabolic bone disorder? 1. premature shedding of primary incisors 2. enamel hypoplasia 3. enlarged pulp chambers and root canalsHypophosphatasia recall: (4) types prenatal, infantile, childhood and adultHypophosphatemia*RARE heterogenous group of inherited metabolic disorders characterized by DECREASED PHOSPHATE REABSORPTION in the distal renal tubules*Hypophosphatemia vs HypophosphatasiaHypophosphatemia: RARE heterogenous group of inherited metabolic disorders characterized by DECREASED PHOSPHATE REABSORPTION in the distal renal tubules Hypophosphatasia: RARE metabolic bone disease due to lack of tissue-nonspecific alkaline phosphataseHypophosphatemia clinical manifestationsrickets-like skeletal malformationsHypophosphatemia dental manifestations (3)- enlarged pulp chambers and rot canals - Periapical and periodontal abscesses of no obvious cause - enamel hypoplasiaHypophosphatemia oral manifestations: bone looks _ everywhere. It is very (Thin/thick)thin not able to follow floor of sinusProgressive Systemic Sclerosis (Scleroderma)Visceral organ fibrosis, facial tightening, sclerodactyly. (excess collagen deposition resulting in hardening of the skin and tissues (sclerosis)Progressive Systemic Sclerosis (Scleroderma) commonly affects (M/F) and oral manifestations includefamales - xerostomia, increased # of DMFS - thickened, leathery quality skinScleroderma teeth/oralUNIFORM enlargement of PDL space recall: widening of PDL space also seen in malignancy, but scleroderma is uniform and everywhereSickle Cell Anemia definechronic hemolytic blood disorder abnormal hemoglobin, resulting in anemia --> increasing the production of RBC --> requires compensatory hyperplasia of the bone marrowchronic hemolytic blood disorder abnormal hemoglobin, resulting in anemia --> increasing the production of RBC --> requires compensatory hyperplasia of the bone marrowSickle Cell AnemiaSickle Cell Anemia common skull presentationhair on end appearance!Sickle Cell Anemia radiographic findings- enlargement of bone marrow spaces - thinner trabeculation - loos more osteopenic - presence of RL lesions around apices on intact teeth with no cariesThalassemia define- defect in hemoglobin synthesis - RBC with reduced hemoglobin content and short life span (result is hyperplasia of the bone marrow component of bone, which results in fewer trabecular per unit area and can change overall shape of bone)- defect in hemoglobin synthesis - RBC with reduced hemoglobin content and short life spanThalassemiaThalassemia often presents with protrusive (maxilla/mandible)maxillaSuspect systemic endocrine and metabolic diseases if radiographs show..generalized decrease in bone density or jaws (Thin cortices, granular cancellous bone, loss of lamina dura) refer to physician for *lab tests* to make diagnosisCan include certain systemic endocrine/metabolic diseases as radiographic differentials in the presence of: - localized focus of RL?think brown tumor of hyperparathyroidismCan include certain systemic endocrine/metabolic diseases as radiographic differentials in the presence of: mandibular prognathism and incisors glaringthink acromegalyacromegaly common radiographic differentialmandibular prognathism and incisors glaringCan include certain systemic endocrine/metabolic diseases as radiographic differentials in the presence of: premature shedding of incisorshypophosphatasiahypophosphatasia radiographic differentialpremature shedding of incisorsCan include certain systemic endocrine/metabolic diseases as radiographic differentials in the presence of: enamel hypoplasia, enlarged pulp chambers and periapical abscess of no obvious causethink hypophosphatemiahypophosphatemia common radiographic differentialenamel hypoplasia, enlarged pulp chambers and periodical abscess of no obvious causeCommon Premalignant and malignant skin neoplasms- solar/actinic keratosis - keratoacanthoma - SCC - Basal cell carcinoma - malignant melanomaactinic keratosis is akasolar keratosis (Actinic cheilitis or cheiosis on lips)actinic keratosis age and clinical appearance> 40 yo (but can occur in 20-30s) high UV radiation multiple, discrete, flat or elevated keratitis lesions (3-10mm in diameter)What are the odds that actinic keratosis may develop into invasive cutaneous horns or skin cancers.1 in 20_ is a relatively common low-grade malignany that originates in the pilosebaceous glands and closely and pathologically resembles SCCKeratoacanthomaKeratoacanthoma is a (low/high) grade malignancy that originates in the __ glands. Characterizes by (slow/rapid) growth over a few weeks to months. Followed by spontaneous resolution over 4-6 months in most caseslow grade originates in the pilosebaceous glands rapid growth but then healsKeratoacanthoma clinical appearancefirm, roundish, skin-colored or reddish papule that rapidly progress to dome shaped nodules with smooth shiny surface and central crateriform ulcerations or keratin plug that may project like a hornKeratoacanthoma usually grows in (3) phases1. rapid growth (1-2cm) 2. spontaneous resolution (4-6 mo) 3. short stationery phase before it regresses.approx _% of americans who live to age 65 will have skin cancer at least once40-50%approx 1:2 people will have skin cancer at least once in their life. Signs and symptoms of this will present with- new growth or a sore that does not heal - skin cancer seldom cause pain - dont all look the sameRisk factors for melanoma (4)- light hair color - freckling - large number of common nevi (> 100) - presence of typical nevirisk factors for basal cell carcinoma (2)- sun exposure indices (freckling, actinic keratosis, solar lentigines) - tendency to severely burn and number of such burns(3) risk factors for SCC- sun exposure indices (freckling, actinic keratoses) - tendency to severely burn a number of such burns - light hair colorFitzpatrick Skin Scale (measures risk for skin cancer)Type 1: (scores 0-7) White/subject to sunburn Type 2: ( 8-16) Tan/capable of tanning Type 3: (scores 17-25) dark/capable of tanning Type 4: (scores 25-30) dark Type 5-6 (>30) very dark_ is most common skin cancer and most common cancer! It is a malignant tumor that arises in the basal cells of the epidermisbasal cell carcinomabasal cell carcinoma is the most common skin cancer and cancer overall. It accounts for _% of all skin cancers in the US. What is the progression?80% slow growing cancer than SELDOM metastasizesTypes of basal cell carcinoma (6)Nodular (most common in H/N) Pigmented Cystic Superficial Micronodular Morpheaform and infiltrating_ type of basal cell carcinoma is most common in head and neck regionNodularNodular type of basal cell carcinoma clinical appearancewaxy papule(s) with central depression pearly apperance, bleeding, crusting, rolled (raised) border, translucency, Telagiectasia over the surface, history of bleeding with minor traumabasal cell carcinoma (nodular type) can be removed through ___.Moh's surgery: remove it in real time and ensure clean borders.Cutaneous Squamous Cell Carcinoma (SCC) may present with a variety of primary morphologies with or without associated symptoms. What is a typical clinical appearanceraised, firm, pink to flesh colored keratin papule or plaque with or without a cutaneous hornBasal cell carcinoma is a malignant tumor that is (fast/slow) growing that (commonly/seldomly) metastasizesslow growing malignant tumor that seldomly metastasizesMelanomas account for approx _% of skin cancers4%Melanomas (4% of all skin cancers) have 4 major clinical-histo subtypes1. superficial spreading (most common) 2. nodular 3. lentil maligna 4. aural lentiginous melanomasMelanomas (4 subtypes): which is most common and area?superficial spreading is the most common melanoma. present on trunk/torso/arms/legsMelanomas: nodular subtype clinical apperanceelevated, vertical growth phase, spread more quickly than othersMelanomas: Lentigo maligna subtypesun exposed, older individuals, fair complexion, expands laterally for years before it invadesMelanomas: Acral lentiginous subtypemost common form on dark skin individuals and MOST COMMON ORAL MELANOMA!ABCDE to diagnose melanomaAsymmetry Border Color varied Diameter (>6mm as a rule) Evolving over timeAll Benign hyperplasias and Neoplasias of Melanocytes appear asbrown macules or patchesBenign hyperplasias and Neoplasias of Melanocytes etiology, apperance, and treatmentall appear as brown macule or patches - may be acquired or congenital - most require NO treatment moles = melanocytic neviSeborrheic Keratoses commonly appears after _ years old40 yo "morgan freeman"Seborrheic Keratoses (think Morgan freeman) clinical appearancewaxy stuck on look one or clusters of dozens usually starts off light tan, then darken to brown or black NOT CAUSED BY SUN EXPOSURE AND NO RISK FOR SKIN CANCERPlease list some viral skin infectionsHSV VZV HPV Molluscum contagiosumIn an adult >40 yo - a neck mass should be _considered malignant until proven otherwiseIf you have an infection in the oral cavity, that would drain to the _ or _submental or submandublarIf you have an infection in the oral cavity, Oropharynx would drain more into _ lymph nodescervical lymph nodesIf you don't feel lymph nodes you should write WNL on axiumFALSE! you should write no lymphadenopathy appreciated(3) common lateral Congenital neck masses.1. Branchial cleft cyst 2. Layngocele 3. Cystic hygroma(3) common Congenital midline neck masses1. thyroglossal duct cst 2. dermoid cyst 3. pyramidal lobeBranchial cleft cyst6th week of gestation 2nd bronchial arch grows over 3-4th arches and fuses with caudal pericardial swelling forming cervical sinusBranchial cleft cyst. __ is most common type2nd bronchial cystThyroglossal duct cyst: can/cannot reoccurclinical presentation are 2-4th decade can reoccurCommon Benign Neoplastic lesion on lateral neck associated with parotidpleomorphic adenomaCommon Benign Neoplastic lesions on lateral neck associated with vascular lesion (2)carotid body tumor aneurysmCommon Benign Neoplastic lesions on lateral necklipoma, fibroma, hemangioma, teratoma, nerve or nerve sheath tumorCommon Benign Neoplastic lesions on midline of neck associated with thyroid (4)- follicular adenoma - colloid nodule - multi nodular goiter - thyroid cystWhat extra oral findings are common with Graves diseaseenlarged thyroid! goiter! owl looking eyes (exophthalmos)Primary malignant neoplasms of the neck include (2)1. Lymphoma (Hodgkins) NonHodgkins 2. Salivary gland neoplasmMetastatic malignant neoplasm of lateral neck includeUsually SCCCommon Thyroid malignant neoplasms of the neck midline include (4)Papillary* Follicular Medullary AnaplasticCommon Inflammatory/infectious neck masses include (6)1. Reactive adenopathy 2. Granulomatous disease 3. Sarcoidosis 4. Salivary glands 5. Thyroiditis 6. Plunging ranula1. Reactive adenopathy 2. Granulomatous disease 3. Sarcoidosis 4. Salivary glands 5. Thyroiditis 6. Plunging ranula are all examples odcommon inflammatory/infectious neck massesThese can all present with __ 1. Tonsilitis, viral URTI 2. Mononucleosis 3. Aids 4. Kawasaki diseaseCommon Inflammatory/infectious neck masses include *Reactive adenopathy*Common Inflammatory/infectious neck masses include Reactive adenopathy. Please list (4) common manifestations1. Tonsilitis, viral URTI 2. Mononucleosis 3. Aids 4. Kawasaki diseaseCommon Inflammatory/infectious neck masses include Granulomatous disease. Please list (4) common presentations1. TB 2. Syphilis 3. Toxoplasmosis 4. Cat Scratch diseaseThese can all present with _ 1. TB 2. Syphilis 3. Toxoplasmosis 4. Cat Scratch diseaseCommon Inflammatory/infectious neck masses include Granulomatous diseaseCommon Inflammatory/infectious neck masses include Salivary glands. Please give (2) examplesSialadenitis/SialolithiasisSialadenitis etiologyobstructive vs non-obstructive bacterial vs viral (most common is mumps)Sialadenitis due to bacterial is most common. Which is the most common bacterial infectionStaph aureusSialadenitis common presentationacute pain and swelling of parotid (most common) or submandibular gland with or without feverl Abscess are uncommonAlways look for common extra-oral signs of thrombocytopenia. (2)1. AV Shunt in dialysis patient 2.. Purpura in a patient with thrombocytopeniaCommon extra oral findings on the handsClubbing Onychomycosis Systemic sclerosis Hereditary Hemorrhagic TelangectasiaSupernumerary teeth aka _ and causehyperdontia unknown cause - familial tendency (inherited as an autosomal recessive trait)_ is a result of excess dental lamina in the jawshyperdontia (supernumerary teeth)T/F in Supernumerary teeth (aka hyperdontia) teeth may be normal or abnormal. and occurs in 1-4% of populationtrueSupernumerary teeth can occur in both primary and permanent dentition, but more common in which?permanent dentitionSupernumerary teeth has a greater incidence in (males/females) and what ethnicitymales asians and native americansSupernumerary teeth can be associated with systemic illnesses.Cleidocranial Dysostosis (congenital that affects bone and teeth) Gardner's or Familial colorectal polyposis (autodominant)Supernumerary teeth mandibular premolars aka maxillary incisors akaperidens mesiodensSupernumerary teeth in molar area akadistodens, paramolar or fourth molarSupernumerary teeth treatmentremove or keep under observation depends on position/number; effect on normal dentitionabsence of one or few teethhypodontia (3-10% of population)absence of numerous teetholigodontiaabsence of all teethanodontiaMost common missing teeth3rd molars > second premolars > max laterals > mandibular centralsWhat systemic disease is anodontia and oligodontia commonly seen inEctodermal dysplasia (group of syndromes all deriving from abnormalities of the ectodermal structures)Management of missing teethortho, resto, implants, prosthetic procedures (ie flipper, dentures, implants)Most common microdontia seen inlateral incisors (peg shaped) note: treatment can be crowns or veneersMicrodontia's number and distribution may be indicative of syndromes such ascongenital heart disease or progeria (early aging)Macrodontia (2) types1. Relative - teeth are normal size but occur in smaller jaw (kids 6-7 years old with buck teeth) 2. True macrodontiaT/F Macrodontia commonly affects entire dentitionFALSE! rarely affects entireTrue generalized Macrodontia may occur withpituitary gigantismMacrodontia causeunknown but may resemble fusion or geminationfusion vs geminationfusion = 2 roots 1 crown gemination = 1 root and 2 crowns - fusion "missing 1 tooth" - gemination - normal number of teethTranspositiontwo teeth have changed spacesPlease list some examples of alternations in teeth morphologyfusion gemination concresence taurodontism dilaceration hypercementosis dens invaginatus amelogenesis imperfecta dentinogenesis imperfecta dentin dysplasiaFusion of teeth akaSynodontiaSynodontia aka Fusion is the joining of teeth. It is more common indeciduous teeth (single large crown with two root canals)Gemination (twinning)a single enlarged tooth in which the tooth count is normal appears as two crowns with a common root_ is joining of two or more teeth by cementum and causeconcrescence unknown cause but suspected the restricted space during development, local trauma, excess occlusal force, or local infection ma paly a roletrue vs acquired concresencetrue = occurring during development acquired = after developmentTaurodontia aka Taurodontism definebody of tooth is enlongated extension of pulp chamber into the elongation Roots are short, crown size is normal (looks like a bull)Taurodontia aka Taurodontism can occur in primary and permanent dentition. Reported greater frequency with what diseaseTrisomy 21 (down syndrome)Taurodontia aka Taurodontism treatmentnoneDilaceration define and etiologydisturbance in tooth formation producing a sharp bend or curve in tooth "S-shaped root" may be due to trauma during developmentDilaceration problems in root and crownroot: problems with RCT/EXT Crown: restoration with prosthetic crown to improve function or estheticbuild up of cementum on the root of the tooth and have club shape appearancehypercementosishypercementosis is often seen in patients who have _ , _paget's disease/hyperpituitarism (gigantism/acromegaly)T/F Cause of Hypercementosis is unknown but my be due to inflammationtrue (ie periapica lesion)Dens Invaginatus akadens in dente, dilated odontome, gestant odontomeDens Invaginatus defineinvagination of enamel organ within the body of the toothpoint invagination of the enamel is usually the _ of a toothcingulumDens Invaginatus is more common in root or crown of toothcrown (so enamel organ on the cingulum)Dens Invaginatus cause and treatmentcause: high degree of inheritability exists treatment: placement of restoration in defect, failure of early treatment may result in tooth loss or need for RCT_ interferes with normal enamel formation. Hereditary, autosomal dominant or recessive, two types are X-linkedAmelogenesis ImperfectaAmelogenesis Imperfecta: (4) typeshypoplasia (thin enamel) hypo maturation (mottled appearance) hypo calcification (enamel poorly mineralized/fractures easily) hypomaturation + hypo calcification (mottled enamel/poorly mineralizedAmelogenesis Imperfecta treatmentrestore function and esthetics of teethDentinogenesis Imperfecta: hereditary opalescent dentin. autosomal (dominant/recessive)dominantT/F Early calcifications of pulp chamber and canals are commonly seen in Dentinogenesis ImperfectatrueDentinogenesis Imperfecta clinicalbulbous crowns short narrow roots esp in permanent teeth poor enamel thin or chip easilyDentinogenesis Imperfecta (2) typesType 1 - associated with OSTEOGENESIS imperfecta (osseous fractures) Type 2 - similar to type 1 but only affects dentin (no skeletal)Dentinogenesis Imperfecta treatmentno ext from 5-15 years, full over dentures preferred adults: extraction and replacement recommendedDentin Dysplasia is autosomal (dominant/recessive) and resembles _ and is more/less commondominant resembles dentinogenesis imperfecta less commonDentin Dysplasia typesType1 1 : radicular, mostly normal in color and shape in both dentititions, sometimes blue/brown translucency .Dentin dysplasia type __: radicular, mostly normal in color and shape in both dentititions, sometimes blue/brown translucency . often misalignment/exfoliate with little or no trauma roots are short and misshaped calcified canals before eruption 20% of teeth have PAPs (cysts or granulomas)type 1 radicularDentin dysplasia type _: calcified canals after eruption; pulp chambers flame shaped with multiple pulp stonestype 2 coronalDentin dysplasia difference from dentinogenesis imperfectadentin dysplasia does NOT have bulbous crowns or short narrow rootsT/F dentin dysplasia presents with bulbous crowns or short narrow rootsFALSE! it does not you're thinking dentinogenesis imperfectaCystic Teratoma of the ovaryteeth that need a GPS system a teratoma is an unecapsulated tumor with tissue or oran components resembling normal derivatives of all three germs (lol like in my big fat greek wedding when grandma thought she was prego)