Chapter 17 Oral Pathology Copyright 2003 Elsevier Science

Chapter 17 Oral Pathology Copyright 2003, Elsevier Science (USA). All rights reserved. No part of this product may be reproduced or transmitted in any form or by any means, electronic or mechanical, including input into or storage in any information system, without permission in writing from the publisher. Power. Point® presentation slides may be displayed and may be reproduced in print form for instructional purposes only, provided a proper copyright notice appears on the last page of each print-out. Produced in the United States of America ISBN 0 -7216 -9770 -4

Introduction Pathology is the study of disease. Oral pathology is the study of diseases in the oral cavity. Many systemic diseases as well as infectious diseases have oral manifestations. Copyright 2003, Elsevier Science (USA). All rights reserved.

Terminology Used to Describe Oral Lesions n n n Lesion is a broad term for abnormal tissues in the oral cavity that includes wounds, sores, and any other tissue damage caused by injury or disease. Determining the type of lesion in a disease is one of the earliest steps in formulating a differential diagnosis. Types of lesions of the oral mucosa are classified as to whether they: • Extend below or extend above the surface. • Are flat or even with the surface. Copyright 2003, Elsevier Science (USA). All rights reserved.

Lesions Extending Below the Surface n n Ulcer: A defect or break in continuity of the mucosa that creates a punched-out area similar to a crater. Erosion of the soft tissue: A shallow defect in the mucosa caused by mechanical trauma. Abscess: A localized collection of pus in a circumscribed area. Cyst: A closed sac or pouch that is lined with epithelium and contains fluid or semisolid material. Copyright 2003, Elsevier Science (USA). All rights reserved.

Lesions Extending Above the Surface n n Blisters: Also known as vesicles, lesions filled with a watery fluid. Pustule: Similar in appearance to a blister, but it contains pus. Hematoma: Also similar to a blister, but it contains blood. Plaque: Any patch or flat area that is slightly raised from the surface. Copyright 2003, Elsevier Science (USA). All rights reserved.

Diseases of the Oral Soft Tissues Copyright 2003, Elsevier Science (USA). All rights reserved.

Leukoplakia n n Leukoplakia means white patch. Lesions vary in appearance and texture from a fine white transparency to a heavy, thick, warty plaque. The cause is unknown but is commonly linked to chronic irritation or trauma. Leukoplakia very often precedes the development of a malignant tumor. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -2 Leukoplakia. Fig. 17 -2 Copyright 2003, Elsevier Science (USA). All rights reserved.

Lichen Planus n n n A benign, chronic disease affecting the skin and oral mucosa. Many factors have been implicated in lichen planus; however, the cause remains unknown. On the oral mucosa, the patchy white lesions have a characteristic pattern of circles and interconnecting lines called Wickham's striae. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -3 Lichen planus. Fig. 17 -3 Copyright 2003, Elsevier Science (USA). All rights reserved.

Candidiasis n n A superficial infection caused by the yeastlike fungus, Candida albicans. Candidiasis does occur under conditions such as antibiotic therapy, diabetes, xerostomia (dry mouth), and weakened immunologic reactions. It can be the initial clinical manifestation for patients with acquired immunodeficiency syndrome (AIDS). Diaper rash, vaginitis, and thrush are also common types of candidiasis. Copyright 2003, Elsevier Science (USA). All rights reserved.

Types of Candidiasis n Pseudomembranous candidiasis - Thrush n Hyperplastic candidiasis n Atrophic candidiasis Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -4 Erythematous candidiasis. Fig. 17 -4 Copyright 2003, Elsevier Science (USA). All rights reserved.

Aphthous Ulcers n n Aphthous ulcers are also known as aphthous stomatitis or canker sores. Recurrent aphthous ulcers (RAU) is a disease that causes recurring outbreaks of blisterlike sores inside the mouth and on the lips. – Minor RAU: Episodes fewer than 6 times a year; lesions usually heal within 7 to 10 days. – Major RAU: Outbreaks of larger, deeper ulcers that take longer to heal. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -7 Minor aphthous ulcer. Fig. 17 -7 Copyright 2003, Elsevier Science (USA). All rights reserved.

Cellulitis n n Inflammation spreads through the soft tissue or organ. Swelling develops rapidly, with a high fever. The skin becomes very red, and there is severe throbbing pain as the inflammation localizes. Cellulitis associated with oral infections is potentially dangerous because it can travel quickly to sensitive tissues such as the eye or brain. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -8 Cellulitis. Fig. 17 -8 Copyright 2003, Elsevier Science (USA). All rights reserved.

Conditions of the Tongue Copyright 2003, Elsevier Science (USA). All rights reserved.

Glossitis § Glossitis is the general term used to describe inflammation and changes in the topography of the tongue. Copyright 2003, Elsevier Science (USA). All rights reserved.

Black Hairy Tongue n n n Black hairy tongue may be caused by the oral flora imbalance after the administration of antibiotics. The filiform papillae are so greatly elongated that they resemble hairs. These elongated papillae become stained by food and tobacco, producing the name black hairy tongue. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -9 Black hairy tongue. Fig. 17 -9 Copyright 2003, Elsevier Science (USA). All rights reserved.

Geographic Tongue n n n The tongue develops multiple areas of desquamation (loss) of the filiform papillae in several irregularly shaped but well-demarcated areas. The smooth areas resemble a map, thus the name geographic tongue. Over a period of days or weeks, the smooth areas and the whitish margins seem to migrate across the surface of the tongue by healing on one border and extending on another. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -10 Geographic tongue. Fig. 17 -10 Copyright 2003, Elsevier Science (USA). All rights reserved.

Fissured Tongue n n A variant of normal; its cause is unknown. Some theories include a vitamin deficiency or chronic trauma over a long period. The dorsal surface (top) of the tongue appears to have deep fissures or grooves that become irritated if food debris collects in them. The patient with a fissured tongue is advised to brush the tongue gently with a soft toothbrush to keep the fissures clean of debris and irritants. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -11 Fissured tongue. Fig. 17 -11 Copyright 2003, Elsevier Science (USA). All rights reserved.

Pernicious Anemia n n Pernicious anemia is a condition in which the body does not absorb vitamin B 12. People who have this condition show signs of anemia, weakness, pallor, and fatigue on exertion. Other signs can include nausea, diarrhea, abdominal pain, and loss of appetite. The oral manifestations of pernicious anemia include angular cheilitis (ulceration and redness at the corners of the lips), mucosal ulceration, loss of papillae on the tongue, and a burning and painful tongue. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -12 Iron deficiency. The tongue is devoid of filiform papillae. Angular cheilitis was also present in this patient. Fig. 17 -12 Copyright 2003, Elsevier Science (USA). All rights reserved.

Oral Cancer Copyright 2003, Elsevier Science (USA). All rights reserved.

Oral Cancer n n n Oral cancer is one of the 10 most frequently occurring cancers in the world. The incidence, as well as the site, of the cancer varies greatly from country to country. In the Western countries, the site most often affected is the vermilion border of the lip. Most oral cancers do not cause pain in the early stages, and the thorough dentist is most likely to be the first to detect them. These cancers are fatal if not detected early enough or if left untreated. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -13 Squamous cell carcinoma of the lower lip. Fig. 17 -13 Copyright 2003, Elsevier Science (USA). All rights reserved.

Types of Oral Cancer n n A carcinoma is a malignant neoplasm (growth) of the epithelium (tissue lining the mouth). An adenocarcinoma is a malignant tumor that arises from the submucous glands underlying the oral mucosa. A sarcoma is a malignant neoplasm arising from supportive and connective tissue. An osteosarcoma is a malignant tumor involving the bone. In the mouth, the affected bones are the bones of the jaws. Although the cancer may start in the bone, it often spreads and involves the surrounding soft tissues. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -14 Panoramic radiograph showing destruction of the mandible by squamous cell carcinoma. Fig. 17 -14 Copyright 2003, Elsevier Science (USA). All rights reserved.

Leukemia n n A cancer of the blood-forming organs that is characterized by rapid growth of immature white blood cells. Oral symptoms of leukemia may be some of the first indications of the disease. Symptoms in the gingival tissues include hemorrhage, ulceration, enlargement, spongy texture, and magenta coloration of the gingiva. Enlargement of lymph nodes, symptoms of anemia, and general bleeding tendencies are typical. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -15 Leukemia. Fig. 17 -15 Copyright 2003, Elsevier Science (USA). All rights reserved.

Smokeless Tobacco n n Chewing tobacco or snuff presents a serious health hazard. It is a major concern because of the high rates of precancerous leukoplakia and oral cancer occurring among users of smokeless tobacco. Cancers of the pharynx, larynx, and esophagus occur 400 to 500 times more frequently. Smokeless tobacco is also linked to an increased incidence of tooth loss from periodontal disease. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -16 A, Rough texture on the labial mucosa. Fig. 17 -16 A Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -16 B, Rough surface on the anterior buccal mucosa. Fig. 17 -16 B Copyright 2003, Elsevier Science (USA). All rights reserved.

Dental Implications of Radiation Therapy n n n Xerostomia: Lack of adequate saliva and the reduced blood supply can cause oral infections, delay healing, and make it very difficult to wear dentures. Radiation caries: Caused by the lack of saliva, usually appear first in the cervical areas of the teeth. The teeth also may become extremely sensitive to hot and cold stimuli. Osteoradionecrosis: Necrosis (death) of bone after radiation treatment. Copyright 2003, Elsevier Science (USA). All rights reserved.

Acquired Immunodeficiency Syndrome (AIDS) §Oral lesions are prominent features of AIDS and HIV infection. §Oral lesions develop because of the breakdown of the immune system that occurs when the T-helper cells become depleted because of the disease. Copyright 2003, Elsevier Science (USA). All rights reserved.

HIV-Associated Gingivitis n n n There is often a bright red line along the border of the free gingival margin. Also known as atypical gingivitis (ATYP). In some cases, there may be progression of the bright red line from the free gingival margin over the attached gingival and alveolar mucosa. Copyright 2003, Elsevier Science (USA). All rights reserved.

HIV-Associated Periodontitis n n HIV-associated periodontis resembles acute necrotizing ulcerative gingivitis superimposed on rapidly progressive periodontitis. Other symptoms include: • Interproximal necrosis and cratering • Marked swelling • Intense erythema over the free and attached gingiva • Intense pain • Spontaneous bleeding and bad breath Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -18, Atypical periodontal disease in a patient with HIV infection. Fig. 17 -18 A Copyright 2003, Elsevier Science (USA). All rights reserved.

HIV Cervical Lymphadenopathy n n Enlargement of the cervical (neck) nodes. Lymphadenopathy is frequently seen in association with AIDS. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -19 HIV cervical lymphadenopathy. Fig. 17 -19 Copyright 2003, Elsevier Science (USA). All rights reserved.

HIV Lymphoma n n HIV lymphoma is the general term used to describe malignant disorders of the lymphoid tissue. In the immunocompromised individual, it may occur as a solitary lump or nodule, a swelling, or a nonhealing ulcer that occurs anywhere in the oral cavity. The swelling may be ulcerated or may be covered with intact, normal-appearing mucosa. Usually painful, the lesion grows rapidly in size and may be the first evidence of lymphoma. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -21 HIV lymphoma. Fig. 17 -21 Copyright 2003, Elsevier Science (USA). All rights reserved.

Hairy Leukoplakia n n n Hairy leukoplakia can be an important early manifestation of AIDS status. It is a filamentous white plaque usually found unilaterally or bilaterally on the lateral borders (sides) in the anterior portion of the tongue. It may spread to cover the entire dorsal surface of the tongue. It can also appear on the buccal mucosa, where it generally has a flat appearance. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -22 Hairy leukoplakia. Fig. 17 -22 Copyright 2003, Elsevier Science (USA). All rights reserved.

Kaposi's Sarcoma n n Kaposi's sarcoma is one of the opportunistic infections that occur in patients with HIV infection. Kaposi's sarcoma lesions may appear as multiple bluish, blackish, or reddish blotches that are usually flat in the early stages. At present, there is no effective treatment for Kaposi’s sarcoma is one of the intraoral lesions that is used to diagnose AIDS. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -23 Kaposi’s sarcoma in a patient with AIDS. A, Skin. B, Gingivae. (From Ibsen O, Phelan. J: Oral pathology for the dental hygienist, ed 3, 2000, Saunders. ) Fig. 17 -23 Copyright 2003, Elsevier Science (USA). All rights reserved.

Herpes Simplex n n Herpes simplex lesions usually occur on the lip. In immunocompromised patients, the lesions may occur throughout the mouth. An ulcer caused by the herpes virus that persists for longer than 1 month could be an indicator of AIDS. Patients that do not have HIV or AIDs may also suffer from herpes. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -24 Herpes simplex on the hard palate of a patient with HIV infection. Fig. 17 -24 Copyright 2003, Elsevier Science (USA). All rights reserved.

Human Papilloma Viruses n n Human papilloma viruses appear most commonly in immunocompromised individuals. Diagnosis is made based on history, clinical appearance, and biopsy. They are a common finding in patients with early HIV infection. These warts appear spiky, and some have a raised, cauliflower-like appearance. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -25 Human papillomaavirus on the lip of a patient with AIDS. Fig. 17 -25 Copyright 2003, Elsevier Science (USA). All rights reserved.

Developmental Disorders § Can result when there is a disturbance of the cells during the period when the cells divide. The result is usually a deformity of part of the body. Copyright 2003, Elsevier Science (USA). All rights reserved.

Types of Developmental Disorders n n Inherited disorders: Different from developmental disorders because they are caused by an abnormal gene. A congenital disorder: One that is present at birth. It can be either inherited or developmental; however, the exact cause of most congenital abnormalities is unknown. n Genetic factors: Malformations often due to genetic factors such as chromosome abnormalities. n Environmental factors: Called teratogens and can include infections, drugs, and exposure to radiation. Copyright 2003, Elsevier Science (USA). All rights reserved.

Exostoses n n Exostosis is a benign bony growth projecting outward from the surface of a bone. An exostosis also may be referred to as a torus. (A torus is a bulging projection. The plural is tori. ) Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -27 Torus palatinus. Fig. 17 -27 Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -28 Torus mandibularis. Fig. 17 -28 Copyright 2003, Elsevier Science (USA). All rights reserved.

Disturbances in the Development of the Jaw, Lips, Palate, and Tongue Copyright 2003, Elsevier Science (USA). All rights reserved.

Types of Developmental Disturbances of the Jaw, Lips, Palate, and Tongue n Cleft lip: Results when the maxillary and medial nasal processes fail to fuse. n Cleft palate: Results when the palatal shelves fail to fuse with the primary palate. n n Cleft uvula: The mildest form of cleft palate. Cleft palate, with or without cleft lip, occurs once in 2500 live births. Ankyloglossia: Often called "tongue-tied, " results in a short lingual frenum that extends to the apex of the tongue. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -29 Cleft lip. Fig. 17 -29 Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -30 Ankyloglossia. Fig. 17 -30 Copyright 2003, Elsevier Science (USA). All rights reserved.

Disturbances in Tooth Development and Eruption Copyright 2003, Elsevier Science (USA). All rights reserved.

Disturbances in Tooth Development n Ameloblastoma is a tumor composed of remnants of the dental lamina. n Anodontia is the congenital absence of teeth. n Supernumerary teeth are teeth in excess of the 32 normal permanent teeth. n Macrodontia is abnormally large teeth. n Microdontia is abnormally small teeth. n Dens in dente (tooth within a tooth) results in the formation of a small toothlike mass of enamel and dentin within the pulp. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -31 Partial anodontia. Fig. 17 -31 Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -32 Radiograph showing two supernumery teeth in region of the permanent premolars. Fig. 17 -32 Copyright 2003, Elsevier Science (USA). All rights reserved.

Disturbances in Enamel Formation n Amelogenesis imperfecta is a hereditary abnormality in which there are hypoplasia‑type defects in the enamel formation. Hypocalcification is the incomplete calcification or hardening of the enamel. Hereditary enamel hypoplasia is a type of amelogenesis imperfecta that is characterized by teeth with crowns that are hard and glossy, yellow, and cone shaped or cylindrical. Copyright 2003, Elsevier Science (USA). All rights reserved.

Abnormal Eruption of the Teeth n n Premature Eruption is natal teeth present at birth. Neonatal teeth are those that erupt within the first 30 days of life. Ankylosis is deciduous teeth in which bone has fused to cementum and dentin, preventing exfoliation. Impaction occurs when any tooth remains unerupted in the jaws beyond the time at which it should normally erupt. Copyright 2003, Elsevier Science (USA). All rights reserved.

Additional Disturbances in Tooth Development and Eruption n Variation in form includes extra, missing, or fused cusps or anomalies of roots; however, the most common variations are peg-shaped teeth. n Hutchinson's incisors are a variety of peg-shaped teeth, usually associated with maternal syphilis. n Fusion is the joining together of the dentin and enamel of two or more separate developing teeth. n Gemination is an attempt by the tooth bud to divide. When this attempt is not successful, an incisal notch indicates it. Copyright 2003, Elsevier Science (USA). All rights reserved.

Miscellaneous Disorders n n n Abrasion is the abnormal wearing away of tooth structure that is caused by a repetitive mechanical habit such as improper toothbrushing. Attrition is the normal wearing away of tooth structure during mastication (chewing). Bruxism is an oral habit consisting of involuntary gnashing, grinding, and clenching of the teeth in movements other than chewing. It is usually performed during sleep and is commonly associated with stress or tension. Copyright 2003, Elsevier Science (USA). All rights reserved.

Miscellaneous Disorders- cont’d n n Bulimia is an eating disorder characterized by food binges and followed by self-induced vomiting. The dental professional is often the first health care professional to identify a patient with bulimia. Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -39 Improper toothbrushing can cause abrasion. Fig. 17 -39 Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -40 A and B, Attrition of adult dentition. Fig. 17 -40 Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -41 Bruxism caused attrition of the mandibular anterior teeth. Fig. 17 -41 Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17 -42 A and B, Erosion caused by bulimia. Fig. 17 -42 A Copyright 2003, Elsevier Science (USA). All rights reserved.