Oral Pathology

ORAL PATHOLOGY—-DANIEL TODD, MD

 

ANATOMY

ORAL CAVITY

VERMILLION BORDER OF LIPS TO THE —-ANT TONSILLAR PILLAR (PALATOPHARYNGEOUS)/JUNCTION HARD AND SOFT PALATE/CIRCUMVALLATE PAPILLAE

OROPHARYNX

PALATAL PLANE—-HYOID PLANE

OC/OP TASTE AND SENSATION

EPIGLOTTIS—-TASTE (SVA)-&-SENSATION(GSA)=INT BR OF SLN(ARNOLD’S)

BOT——–TASTE(SVA)-&–SENSATION(GSA)==LINGUAL BR OF GLOSSOPHARYNGEAL(JACOBSEN’S)

PALATE—–TASTE(SVA)=GSPN(VIDIAN N OF THE PTERYGOPALATINE CANAL=CN7)——–SENSATION(GSA)=GREATER PALATINE NERVE (V2)

ORAL TONGUE—-TASTE(SVA)=CHORDAE TYMPANI=CN7——-SENSATION(GSA)=LINGUAL NERVE (V3)

V3, 9 AND 10 CAN ALL GIVE YOU REFERRED OTALGIA!

TASTE = GUSTATION = THE ABILITY TO DISTINGUISH BETWEEN VARYING GUSTATORY STIMULI (BITTER, SWEET, SALTY, AND SOUR)

LIKE AUDITION AN ANALYTICAL SENSE—–VS OLFACTION AND VISION = SYNTHETIC SENSES

FLAVOR = TASTE + OLFACTION (75%) + TACTILE AND CHEMICAL SENSATION

CAN STIM A TASTE WITH IV SUBSTANCES—CHEMORECEPTORS

VARIOUS DYSGEUSIAS INCLUDE PHANTOGEUSIA, ECT…..HIGH INCIDENCE OF COMORBID DEPRESSSION

NO REAL TOPOGRAPHICAL MAP OF TASTE—-HOWEVER SOME PREDILECTIONS

BITTER = PRIMARILY BOT—-TRANSECT BOTH CHORDA TYMPANI NERVES AND YOU STILL TASTE BITTER (CN 9)

SOUR = SIDES OF TONGUE (FUNGIFORM PAPILLA)SWEET = DORSAL MID TONGUE

SALTY = TIP OF TONGUE

FILIFORM PAPILLAE REALLY HAVE NO GUSTATORY FUNCTION!

DENTAL

CLASS I OCCLUSION=NL=THE MESIAL-BUCCAL CUSP OF THE FIRST MAXILLARY MOLAR OPPOSES THE BUCCAL INTERCUSPAL GROOVE OF THE FIRST MANDIBULAR MOLAR.

CLASS II=MESIO-OCCLUSION-@BUCK TOOTH@–OVERBITE

CLASS III=DISTO-OCCLUSION-PROGNATHIA–@BULL DOG OR DICK TRACY LOOK@

AGES 7-11 ARE PRIMARY YEARS FOR MIXED DENTITION

UNIVERSAL SYSTEM FOR TOOTH NOMENCLATURE—–R-L TOP TO BOTTOM (START AND FINISH ON THE RIGHT)

ADULT—32 PERMANENT OR SECONDARY TEETH NUMBERED 1-32

CHILDREN—20 DECIDUOUS OR PRIMARY TEETH LETTERED A—T

TOOTH SURFACES—MESIAL (MIDLINE) VERSUS DISTAL —AND—- LINGUAL VS BUCCAL OR LABIAL

BELL’S PAULSEY

CAWTHORNE “ALL THAT PAULSIES IS NOT BELLS”—–A DX OF EXCLUSION

SIR CHARLES BELL 1829

IDIOPATHIC —NO MORE— (PROBABLY HSV)

100% FUNGIFORM PAPILITIS (A TONGUE BLADE Dx) (PROBABLE ORIGIN)

ERYTHEMATOUS CHORDA TYMPANI (NEURITIS)

PIGMENTED LESIONS

MELANOSIS (PHYSIOLOGIC PIGMENTATION)-NO TREATMENT REQUIRED

PEUTZ JEGERS SYNDROME = BROWN MELANIN

BISMUTH = BLACK

ARSENIC = BLACK

LEAD = BLUE-GRAY

SILVER = VIOLACEOUS BLUE GRAY——AMALGAM TATOO!

ADDISONS (NELSON’S SYNDROME) = BROWN

XANTHOCHROMATOUS Dz = YELLOW/GRAY

KAPOSIS = VIOLACEOUS

MELANOMA = BLACK

WHITE LESIONS

THRUSH—WIPES OFF

OLP(ORAL LICHEN PLANUS)-BILATERAL AND SYMMETRIC

LEUKOEDEMA—-USUALLLY IN BLACKS–NOT PREMALIGNANT

LEUKOPLAKIA

INFLAMMATORY/INFXOUS

ENANTHEM = A MUCOSAL ERUPTION

EXANTHEM = A CUTANEOUS ERUPTION(RASH)

ERYTHISM=EXCESSIVE SENSITIVITY TO STIMULATION AND HIGH LOCAL REACTIVITY

ERYTHRASMA=CHRONIC SKIN INFXN IN MAJOR SKIN FOLDS (CORYNEBACTERIUM MINUTISSIMUM)

AN EPITHELIAL MANIFESTATION OF AN INFXOUS Dz

USUALLY AN IMMUNOLOGIC PHENOM TO A VIRAL OR BACTERIAL AG

DERMATITIS (LATIN) = EXCZEMA (GREEK)

 

 

 

GINGIVITIS (ROUNDED PAPILLA) VS PERIODONTITIS—-REALLY A RADIOGRAPHIC DIAGNOSIS OF BONE LOSS

SYPHILIS

PRIMARY = CHANCRE (#1 LOCAL = PALATINE TONSIL)—ABOUT 3 WEEKS FOLLOWING EXPOSURE

SECONDARY

= SNAIL TRACK ULCERS,FORDYCE GRANULES(ECTOPIC SEBACEOUS GLANDS)OR SPOTS

TERTIARY = GUMMAS

CONG = MULBERRY MOLARS, PEG LATERALS, HUTCHINSON (SCREW DRIVER) INCISORS

NOMA/ CANCRUM ORIS/ GANGRENOUS STOMATITIS/ MORTIFICATION

A SYNERGISTIC GANGRENE

VINCENT’S ANGINA/ TRENCH MOUTH/ ANUG (ACUTE NECROTIZING ULCERATIVE GINGIVITIS)

ABORRELIS TREPOMEMA VINCENTIIOR SPIROCHEATA DENTICOLATA INFXN (BLEEDING GUMS/ FETID HALITOSIS)—-IT STINKS!—ALSO FEVER, H/A’S AND CERVICAL LAD

FETID HALITOSIS, SIALLORHEA, GINGIVAL BLEEDING,INTERDENTAL PAPILLARY NECROSIS

Rx= ORAL HYGEINE, DEBRIDEMENT, AND PCN—-NO REASON FOR HBO

ACTINOMYCOSIS (LUMP JAW = WOODEN TONGUE)

AN INDOLENT SUPPURATIVEANAEROBICINFXN—

LYMPH NODE NECROSIS—FISTULA FORMATION—DRAINING SINUS TRACTS–SULFUR GRANULES(DRUSEN= ROSETTES OF GRANULES)—–CAN LOOK LIKE A FUNGUS ON H&E

SMEARS DEMONSTRATE G+ RODS AND SULFUR GRANULES

CULTURE + INTHIOGLYCOLATE BROTHWITH CO2 ATMOSPHERE

Rx:

DEBRIDE—-IVPCN X 6 WKS THEN—PCN V 750 MG PO TID X6 MONTHS

(ALTERNATE DRUGS = TETRACYCLINE AND CLEOCIN)

CORYNEBACTERIUM DIPTHERIA

(PHAGE EXOTOXIN)—-EF-2

DIRTY GREY PHARYNGEAL MEMBRANE

NEURO AND CARDIO TOXIC—–CAN HAVE PALATAL OR DIPHRAGMATIC PARESIS AND DYSRYTHMIAS

SECOND Dz = SCARLET FEVER

FOLLOWS GABHS INFXN BY 3-5 DAYS

FLUSHED FACE

CIRCUMORAL PALLOR

PASTIAS LINES (INCREASED ERYTHEMA IN ANTECUBITAL FLEXOR CREASES)

WHITE STRAWBERRY TONGUE—–STREPTOCOCCAL STOMATITIS

BRANNY FINE SAND PAPER RASH—-LATER DESQUAMATES

HIGH ASO AND DNASE B TITERS

Rx

: PCN TO AVOID RARE GABHS SEQUELAE (PSGN/RHEUMATIC HEART Dz)

OROPHARYNGEAL TULAREMIA

NISSERIA GONORHEA

COMMNON IN HOMOSEXUAL MALES

DETECTED IN 6% OF ADOLESCENTS—-RUNS THE GAMUT FROM BEING ASX TO AND ACUTE PHARYNGITIS—-CAN ALSWAYS BE CONSIDERED A DANGER TO CAUSE DISSEMINATED GONNOCOCCEMIA

MUST Cx–CAN NOT GS—-CHOCOLATE (MTM) AGAR—–G+ DIPLOCOCCI

Rx

WITH PCN OR TETRACYCLINE OR TMP-SMX

PERTUSSIS—BORDETELLA PERTUSSIS—WHOOPING COUGH—–END INSP WHOOP

SUBCONJUNCTIVAL HEMORRAGE

Rx

WITH MACROLIDE?—DOES NOT ALTER THE COURSE OF THE DISEASE

HEMOPHILUS INFLUENZAE TYPE B—-CAN CAUSE A PHARYNGITIS OR SUPRAGLOTTITIS—ALWAYS LOOK AT THE LARYNX IN ALL CASES OF PHARYNGITIS

BLACK OR BROWN HAIRY TONGUE—-BASICALLY BACTERIAL PAPILLITIS

Rx

HYGEINE AND BRUSH THE TONGUE

 

 

THRUSH

–“MONILIASIS”–CANDIDA SPECIES–OFTEN SEEN IN INFANTS, ELDERLY PTS, AND IMMUNOCOMPROMISE—ASSOC WITH HIV

YEAST INFXN, DAIPER DERMATITIS, BURNED BUTT SYNDROME, CANDIDIASIS

PSEUDOMEMBRANOUS FORM

—-CREAMY WHITEPSEUDOMEMBRANOUS PATCHES—PAINFUL AND MAY BLEED A LITTLE WHEN YOU PULL THEM OFF—-DO WIPE OFF—IF IT DON’T WIPE OFF IT AINT CANDIDA

ERYTHEMATOUS (ATROPHIC) FORM

—-DUSKY RED, FLAT IRREG DEPAPILLATED LESIONS

ANY TIME YOU GET GLOSSAL PYROSIS WITH ERKYTHEMATOUS DEPAPILLATED “BALD” GLOSSITIS IN A POST RT PT THINK CANDIDAL INFXN!

ALSO OFTEN HAVE AERYTHEMATOUS ANGULAR CHEILITIS

START WITH NYSTATIN ORAL SUSPENSION 100,000 U/ML—SWISH AND SWALLOW 20 CC QID—CLOTRIMAZOLE LOZENGES QID

FOR REFRACTORY OR ESOPHAGEAL CASES OR ESOPHAGEAL INVOLVEMENT—-DIFLUCAN—–THINK OF HIV

CLEAN AND REFIT DENTURES—-CHANGE TOOTH BRUSH OFTEN

NYSTATIN AND TRIAMCINOLONE OINT TO LIPS FOR CHELITIS

CLOTRIMAZOLE ORMYCONAZOLE (MYCELEX) LOZENGES

PERIDEX ORAL RINSES

HISTOPLASMA CAPSULATUM (HISTOPLASMOSIS)

OHIO AND MISSISSIPPI RIVER VALLEY

AIRBORN TRANSMISSION

PRIMARILY PULM MANIFESTATIONS

CAN CAUSE LESIONS ANYWHERE IN THE UPPER AERODIGESTIVE TRACT

PAINFUL SLOW GROWING ULCERATIVE LESIONS WITH HEAPED UP EDGES—LOOKS LIKE SCCA

PSUEDOEPITHELIOMATOUS OR PSUEDOCARCINOMATOUS HYPERPLASIA—-LOOK AT CLINICAL PICTURE

METHAMINE SILVER STAIN

PRIMARILY ANT 1/3 OF GLOTTIC LARYNX

HILAR LAD ON CXR

SCATTERED INFILTRATES

GROWS ON SABOURAD’S MEDIUM—-THINK HIV

Rx

AMPHO B—-THINK ABOUT THE POSSIBILITY OF HIV (IMMUNOCOMPROMISE)

BLASTOMYCES DERMATITIDIS (BLASTOMYCOSIS)

AIRBORN TRANSMISSION

PRIMARILY PULM MANIFESTATIONS–75% NODULAR INFILTRATES ON CXR

CAN CAUSE LESIONS ANYWHERE IN THE UPPER AERODIGESTIVE TRACT

LESS LIKELY THAN HISTO TO CAUSE EXTRA PULM LESIONS

SKIN LESIONS= SHARPLY DEMARKATED RAISED MARGINS WITH CENTRAL SCARRING

PSUEDOEPITHELIOMATOUS OR PSUEDOCARCINOMATOUS HYPERPLASIA—LOOKS LIKE SCCA CLINICALLY AND HISTOPATHOLOGICALLY

PRIMARILY GLOTTIC LARYNX

BROAD BASED BUDS

GROWS ON SABOURAD’S MEDIUM

METHAMINE SILVER—-LOOK FOR INTRAEPITHELIAL ABSCESS (MICROABSCESS) FORMATION

PAS STAIN +

CAN Dx BY IMMUNE SEROLOGY

Rx

AMPHO B FOR LIFE THREATENING Dz OR ITRACONAZOLE 400 MG Q D FOR 6 MO

VIRAL

HIV

OHL (ORAL HAIRY LEKOPLAKIA)

ASSOC. WITH +EBV TITERS–WHITE RAISED LESIONS–LAT TONGUE, Asx, FINE HAIR LIKE KERATIN PROJECTIONS, BALLOON CELLS, PARAKERATOSIS ACANTINOSIS—CANDIDIASIS

ALSO VIOLACEOUS LESIONS OF KAPOSIS SARCOMA (KS)—ASSOC WITH HSV 8 (KS VIRUS)—-PROBABLY SHOULD BE CALLED ANGIOSARCOMA—Rx WITH EXCISIONAL BIOPSY, LOW DOSE RT, OR INTRALESIONAL INBLASTINE

FIRST Dz = MEASELS

= RUBEOLLA = MORBILLI

MEASELS—KOPLIK SPOTS—MINUTE BRIGHT RED MACULES WITH A CENTRAL BLUE-WHITE SPECK—USUSALLY ON THE BUCCAL MUCOSA

DUE TO A PARAMYXOVIRUS

SPREAD BY RESP DROPLETS

10 DAY INCUBATION

PRIMARY VIREMIA

PRODROME OF FEVER, CORYZA, CONJUNCTIVITIS

3-5 DAYS–SECONDARY VIREMIA

KOPLIK SPOTS (ENANTHEM) = PATHOGNEUMONIC

MORBILLIFORM RASH—CELL MEDIATED IMMUNE RXN—COMMENCING ON FACE AND SPREADING DOWN

ALSO RESOLVES HEAD DOWN

MICRO: WARTHIN FINKELDAY GIANT CELLS

COMPLICATIONS: GIANT CELL BRONCHOPNEUMONIA, (SSPE)ENCEPHALOMYELITIS, O.M., ATYPICAL MEASELS

——?AN ETIOLOGY TO OTOSCLEROSIS

KAWASAKI SYNDROME (MUCOCUTANEOUS LYMPH NODE SYNDROME)—

1974

COMMON—AN ACURE FEBRILE MULTISYSTEM VASCULITIS—USUALLY IN CHILDREN < 5

PRESUMED TO BE AN IMMUNOLOGIC RXN TO AN INFXOUS AGENT WHICH EVOKES AN AUTOIMMUNE RESPONSE

SINE QUA NON = ACUTE FEBRILE PHASE LASTING > 5 D (7-10)

CONJUNCTIVITIS, MUSOSAL INJECTION, STRAWBERRY TONGUE

ERYTHEMATOUS DRY FISSURED LIPS

EXTREMITY SWELLING AND ERYTHEMA–REFUSAL TO WALK= MOST SPECIFIC FINDING

RASH

CERVICAL LAD

PROLONGED COURSE CAN LEAD TO CADz

HIGH WBC, ESR, IgE, AND PLTS(THROMBOCYTOSIS)

Rx: ASA 80MG/KG/DAY AND IgG 400MG/KG/DAY—-REYE SYNDROME RISK?

STEROIDS ARE CONTRAINDICATED

VARICELLA (CHICKEN POX

)

2 WK INCUBATION

MILD PRODROME

MUCOSAL ENANTHEM—NOT AS PAINFUL AS APTHOUS ULCERS

PRURITIC TEARDROP VESCICULAR RASH IN ASYNCHRONOUS CROPS

CAN EVENTUALLY LEAD TO HERPES ZOSTER—RAMSEY HUNT—SHINGLES

IS ALWAYS DERMATOMAL IN DISTRIBUTION—-TIP OF NOSE = HUTCHINSON’S SIGN—V1(MOST COMMON TRIGEMINAL BRANCH)—-OMINOUS OPHTHOMOLOGICALLY

HERPANGINA

COX A 1-6,8,10

FEVER, ULCERATIVE PHARYNGITIS—PRIMARILY ON ANT PILLARS

HAND FOOT AND MOUTH Dz

BUCCAL ENANTHEMS

COX A16, A5, A10—EV71

INC 3-7 DAYS

ULCERATE AND HEAL 7-10 DAYS

PHARYNGEALCONJUNCTIVAL FEVER

—–ADENOVIRUS (OFTEN A PREAURICULAR LYMPH NODE)

MONONUCLEOSIS

(EBV CAUSES 90%)—CAN ALSO BE CMV, TOXO, RUBELLA, HAV, ADENOVIRUS—-CMV–URINE CULTURE AFTER INNOCULATION IN HUMAN DIPLOID TISSUE CULTURE

FATIGUE, ODYNOPHAGIA, CHILLS, DYSPNEA, DEHYDRATION

FEVER, FATIGUE, LAD, 50% H-S MEGALLY, EXUDATIVE TONSILLOPHARYNGITIS, POST TRIANGLE LAD, RARELY ASEPTIC MENINGITIS

LOW ESR, HEMOLYTIC ANEMIA, THROMBOCYTOPENIC PURPURA, JAUNDICE, NEURO ABNL, AIRWAY COMPROMISE

Dx: CBC WITH PBS, MONOSPOT, Hx, PE

Rx: STEROIDS (DECADRON 10 MG 1V Q 6 OR MEDROL DOSE PACK OR 16 MG P.O. QOD X 2), FLAGYL OR CLEOCIN HELPS WITH TONSILLOPHARYNGITIS INFLAMMATION OF SUPERINFXN AND OVERGROWTH OF ANAEROBES

DO NOT USE AMINOPCN—-50% MORBILLIFORM RASH (MAY FOLLOW IN DAYS OR WEEKS)

A HERPES FAMILY VIRUS

INFECTS B CELLS—–INCITES AN ABSOLUTE LYMPHOCYTOSIS

ACTIVATES ATYPICAL T-LYMPHOCYTES=DOWNEY CELLS

ABSOLUTE LYMPHOCYTOSIS WITH > 50% ATYPICAL REACTIVE T-LYMPHOCYTES (DOWNEY CELLS)

ELEVATES LFT’S

LOW ESR

HETEROPHILE ANTIBODY = + SERUM AB TO HORSE RBC’S—-=MONOSPOT TEST

CHILDREN LESS THAN 10 USUALLY TEST –

15% DO NOT TURN + FOR WEEKS

FALSE + IS COMMON WITH CECLOR(SERUM SICKNESS), RA, HODGKINS, BRUCELLOSIS, HEPATITIS

PAUL-BUNNELL HETEROPHILE AB TEST = SERUM AB TO SHEEP RBC’S

IF NEGATIVE

GET EBV AB (IGG OR IGM), VCA (VIRAL CAPSID AG), EBNA (EBV NUCLEAR AG)

DNA INSITU HYBRIDIZATION—-EBV—OHL (THINK AIDS)—-MAY HAVE SUPERIMPOSED THRUSH

RECURRENT APTHOUS STOMATITIS (CANKERS/ APTHOUS ULCERS)

MOST COMMON ON BUCCAL MUCOSA (NON-KERITONIZING MUCOSA)

NO FEVER!—-VS HERPES

ALWAYS ON MOVABLE MUCOSA

—NON-KERITONIZING (FOM, BUCCAL, LABIAL)—NOT GINGIVA LIKE PRIMARY HERPETIC GINGIVOSTOMATITIS

OFTEN FOLLOW TRAUMA OR STRESS

80% MINOR RAS

< 1 CM

FEMALE > MALE

PAINFUL

HEAL WITHOUT SCAR IN 7-10 DAYS

10% MAJOR = SUTTON’S Dz

1-3 CM

LAST 30 DAYS AND BEYOND

PAINFUL

SCAR

10% HERPETIFORM——OFTEN IMPOSSIBLE TO DIFFERENTIATE FROM PRIMARY HERPETIC GINGIVOSTOMATITIS

1-2 MM

PRIMARILY ANT/LAT TONGUE

RELATIONSHIP WITH CELIAC SPRUE

MAY COELESCE INTO LARGER ULCERS

HSV

PAINFUL—-OFTEN ATTACK GINGIVA

MORE COMMON IN CHILDREN

FUNGIFORM PAPILITIS MAY ACCOMPANY BELL’S PAULSEY FROM CHORDA TYMPANI NEURITIS

IDIOPATHIC—-HSV, STREP SANGUIS, B12, FOLATE, FE++ DEFEICIENCY

HORMONAL CHANGES, STRESS, TRAUMA, FOOD ALLERGIES, IMMUNE ABNL,

HEREDITARY?, ACIDITY

Rx: AVOID SYSTEMIC STERIODS IN HIGH DOSES—-

ORAL HYGEINE, TOPICAL TETRACYCLINE SYRUP, TOPICAL STEROIDS, PREDNISOLONE MOUTH RINSE (KENALOG-ORABASE/ ORABASE-HC)—-VERY IMPORTANT METHOD OF APPLICATION—-STAY NPO FOR 1 HOUR AFTER APPLICATION.

ANTACIDS, KAOPECTATE,PERIDEX(CHLORHEXIDINE GLUCONATE), XYLOCAINE, COLCHICINE

MAY CAUTERIZE—AGNO3, LACTOBACILLUS

ZILACTIN (B

) Q 2 HOURS PRN

MAGIC MOUTH WASH

TRY FOUR 1 GM TABLETS OF CARAFATE ADDED TO A 45 ML BOTTLE OF OCEAN NASAL SPRAY AND SPRAY THIS INTO THE THROAT 3 TIMES QID

PRIMARY HERPETIC GINGIVOSTOMATITIS (USUALLY HSV I, RARELY HSV II)

USUALLY CHILDREN OR YOUNG ADULTS

ADULTS TOLERATE IT LESS WELL

INFLAMED ERYTHEMATOUS GINGIVA WITHOUT INTERDENTAL PAPILLARY NECROSIS (VS ANUG)—USUALLY ONKERITONIZED NON-MOBILE MUCOSA—POSSIBLE LOW GRADE FEVER

VIRAL CYTOPATHIC EFFECT (INCLUSION BODIES)

RECURRENT HERPES LABIALIS (COLD SORE)—–5% ACYCLOVIR CREAM 5 TIMES A DAY

R/O BEHCETS, HIV, EBV(MONO), INFLAMMATORY BOWEL Dz (CROHN’S Dz), CELIAC Dz (SPRUE–GLUTEN SENSITIVE ENTEROPATHY), SYPHILIS, ALLERGY

MAY BE IN CHILDREN AGE 3 AND ON

USUALLY HAVE A FEVER!

Rx:

SYMPTOMATICALLY OR WITH ACYCLOVIR/ZOVIRAX/FAMCYCLOVIR– LIKE APTHOUS ULCERS

DO NOT TOUCH THE EYES OR YOU COULD HAVE A PROBLEM!!!—NASOCILIARY NERVE INVOLVEMENT AND CORNEAL ATTACK

HERPES BLISTERS—SEE MULTINUCLEATED DYING CELLS

LOWER LIP > UPPER LIP

AUTOIMMUNE

PEMPHIGUS (THOST 1911)

VESICULAR Dz (<1CM)—–BULLOUS Dz (>1CM)

AN AUTOIMMUNE Dz AGAINST THE STRATUM SPINOSUM (INTRAEPIDERMAL)—PEMPHIGUS OR AGAINST THE B.M. (PEMPHIGOID)

RARELEY EVER SEE INTACT BULLA

PEMPHIGUS (MORE COMMON)—–INTRAEPITHELIAL (MORE SUPERFICIAL-ABOVE THE BASILAR MEMBRANE)

AGE 50—-MALE = FEMALE

HIGH INCIDENCE IN ASHKENAZIC JEWS (LIKE NIEMAN PICK AND TAY SACHS SPHINGOLIPIDOSIS)

INTRAEPITHELIAL—-2/3 OC +

ACANTHOLYSIS= SEPARATION/DISSOLUTION OF THE INTERCELLULAR BRIDGES IN “PRICKLE” CELL LAYER (STRATUM SPINOSUM) OF THE EPIDERMIS= +NICKOLSKY SIGN

NONSCARRING

IGG AND C3—-BASAL CELL LAYER REMAINS ATTACHED TO THE L.P.—-SUPRABASILAR CLEFTING—–“ROW OF TOMB STONES–+TZANC CELLS(LIKE HSV)

VEGETANS—-INDOLENT

VULGARIS

—RAPID ACUTE (33% FATAL IF ESOPHAGUS INVOLVED)

Rx:

STEROIDS (TOPICAL AND SYSTEMIC) , MTX, CYCLOPHOSPHAMIDE, AZATHIOPRIN

PEMPHIGOID (PEMPHIGUS LIKE)—–SUBEPITHELIAL

AUTOIMMUNE Dz AGAINST THEB.M.—–LEADS TO SCARRING!—AGAIN RARELY SEE INTACT BULLA

SUBEPITHELIAL CLEFTING

FEMALE > MALE

AGE 70

CICATRICIAL(SCARRING)

AFFECTS THE MUCOSAL SURFACES—-O.C., OP, SUPRAGLOTTIC LARYNX, CONJUNCTIVA—SYNBLEPHARON—THE MOST SERIOUS CONSEQUENCE IS BLINDNESS

BULLOUS

MORE AFFECTS THE CUTANEOUS FLEXOR SURFACES

Rx:

DAPSONE, PENNICILLAMINE

NECROTIZING SIALOMETAPLASIA

A BENIGN LESION WHICH REPRESENTS A NONSPECIFIC RXN OF SALIVARY GLANDS AND MUCOUS GLANDS TO ISCHEMIA!!! GLANDS RETAIN THEIR ARCHITECTURE—CAN BE IN THE NOSE—EPISTAXIS

LESION OFTEN RESEMBLING CARCINOMA AT THE JUNCTION OF THE HARD AND SOFT PALATE—CELLS HAVE UNDERGONE METAPLASTIC CHANGES BUT THE GLANDS RETAIN THEIR NORMAL ARCHITECTURE—PROPIGATED BY SMOKING

Dx

= Bx—-DIFF Dx = SCCA, FOLLICULAR LYMPHOID HYPERPLASIA, AND MINOR SALIVARY GLAND CA

Rx

= OBSERVATION AND SYMPTOMATIC TREATMENT

BEHCET’S Dz

(SYNDROME)

BEHCET = A TURKISH DERMATOLOGIST (1937)

A CHRONIC IDIOPATHIC SYSTEMIC VASCULITIS (INFLAMMATORY DISORDER)

MALE > FEMALE

3RD DECADE

HIGH INCIDENCE IN TURKEY, JAPAN, EUROPE

MAJOR TRIAD: RECURRENT APTHOUS ULCERS (100%), GENITAL ULCERS(65%), OCULAR INFLAMATION (IRIDOCYCLITIS)—-CAN LEAD TO BLINDNESS IN ABOUT 3 YEARS—ALSO PROMINENT IS CUTANEOUS VASCULITIS(HYPERIRRITABLE SKIN)

APTHOUS ULCERS ARE CHARACTERISTICALLY “PUNCHED OUT” WITH SURROUNDING ERYTHEMA AND COVERED WITH A PALE PSEUDOMEMBRANE—-PAINFUL–OCCUR IN CLUSTERS

PROGRESSIVE SNHL

AN AVERAGE OF 4 YEARS FROM ONSET TO DIAGNOSIS

OFTEN + FHx

MINOR Sx: ARTHRALGIAS, MENINGOENCEPHALITIS(LATE=ASEPTIC MENINGITIS—-THE PRIMARY CAUSE OF DEATH), FORCED LAUGHTER, THROMBOPHLEBITIS(DVT), BULBAR PAULSEY, ESOPHAGITIS, COLITIS, C-V DISORDER, GLOMERULAR NEPHRITIS

LEUKOCYTOSIS

HIGH ESR AND CIRCULATING IMMUNE COMPLEXES, HIGH AB TO MUCOSAL CELLS

EOSINOPHILIA

Rx:

COLCHICINE FOR ULCERS, STEROIDS, AZOTHIAPRINE, CYCLOSPORIN A

POSSIBLE SURGERY

ERYTHEMA MULTIFORME = COMMON FINAL PATHWAY

CIRCULAR BLOTCHES ON SKIN AND MUCOUS MEMBRANES

IRIS OR TARGET LESIONS

FIXED DRUG RXN

—–THINK SULFA

STEVENS JOHNSON SYNDROME

—-WHEN ERYTHEMA MULTIFORME GETS AWAY FROM YOU

EMERGENCY

STOP OR TREAT THE ETIOLOGY—-DRUGS, HERPES,MYCOPLASMA, STREP

STEROIDS?—-CAN EASILY BLIND THE PATIENT

CLOX (ANTI STAPH)–TO TREAT SECONDARY SKIN INFXNS

HIVES = NETTLE RASH = URTICARIA

(70% IDIOPATHIC)

> 6 WEEKS = CHRONIC URTICARIA

A SUPERFICIAL DERMIS PHENOM (VS QUINKES ANGIOEDEMA = DEEP DERMAL)

CROHN’S DISEASE

CAN PRESENT WITH ONLY AN OC LESION

RADIATION INDUCED MUCOSITIS/XEROSTOMIA

HYPOGEUSIA BISGINS ALMOST IMMEDIATELY (LEAST TO SALT DETECTION)

10 GY—-MUCOSITIS BEGINS

60 GY—–XEROSTOMIA (IS PERMANENT)—-CAN PRETREAT WITH PILOCARPINE (TRY EYE DROP—MUCH CHEAPER)

B2/RIBOFLAVIN

—DERMATITIS, CHEILOSIS, ATROPHIC GLOSSITIS, GINGIVOSTOMATITIS

B6/PYRIDOXINE

—SIDEROBLASTIC ANEMIA, ANGULAR CHELSOSIS

VIT C

—COLLAGEN SYNTHESIS, SCURVY(SCORBITUS)–BLEEDING GUMS, IRON ABSORPTION (IDA), OXALATE (KIDNEY STONES)

NIACIN

—PELLAGRA(DIARRHEA, DERMATITIS (CASAL’S NECKLACE), DEMENTIA—DEATH)—ANGULAR CHEILOSIS AND GLOSSOPYROSIS(BURNING TONGUE)

ZINC DEFICIENCY—-ACRODERMATITIS ENTEROPATHICA

———ERYTHEMATOUS, SWOLLEN MUCOSA—-SECONDARY CANDIDA INFXNS

VITAMIN A DEFECT—KERATOSIS FOLLICULARIS—-DARIER’S DISEASE

PERNICIOUS= TENDING TOWARDS DEATH

(B12) ANEMIA—MUCOSA AND LIPS ARE PALE GRAY, TONGUE IS SHINEY-SMOOTH-BEEFY RED(USUALLY FROM AN AUTOIMMUNE Dz AGAINST THE PARIETAL CELLS OF THE STOMACH

B12/COBALAMINE

—SYNTHESIZED ONLY BY BACTERIA (ANTAGONIZED BY DIPHILIBOTHERUM LATUM (TAPE/FISH WORM))—-NEED R-PROTEIN FROM STOMACH AND ABSORBED TERMINAL ILEUM—CAUSES SUB ACUTE SCLEROSING CORD DEGENERATION—-SECONDARY FOLATE DEFICIENCY—-MEGALOBLASTIC ANEMIA

IDA

(THINK PLUMMER VINSON’S)

PLUMMER-VINSON SYNDROME (PVS)—PATTERSON-KELLY-BROWN SYNDROME—SIDEROBLASTIC DYSPHAGIA—SIDEROPENIC DYSPHAGIA

HIGH INCIDENCE WITH SCANDINAVIAN DESCENT

PRIMARILY NORTHERN HEMISPHERE

FEMALE 9:1

COMMONLY ASSOC. WITH HYPOTHYROIDISM

USUALLY AGE 20-50

90% OF PTS EDENTULOUS

50% INCIDENCE OF MULT CIRCULATING ANTIBODIES

HIGH INCIDENCE (UP TO 50%) OF POST CRICOID (PARTY WALL) AND CERVICAL ESOPHAGEAL CARCINOMAS (ALSO OP/OC)

DYSPHAGIA (86% UPPER ESOPHAGEAL/PHARYNGEAL WEBS)—ATROPHIC DEGENERATION OF PHARYNGEAL AND ESOPHAGEAL MUSCULATURE

BLUE SCLERA

ACHLORHYDRIA (35%)

ATROPHIC GASTRITIS (40%)

PERLECHE = ANGULAR CHELITIS/CHEILOSIS = FISSURES AT THE CORNERS OF THE MOUTH

ATROPHIC GLOSSITIS–ASH GRAY ORAL MUCOSA

SPLENOMEGALLY

(IDA) IRON DEFICEINCY ANEMIA

MICROCYTIC, HYPOCHROMIC, ANISOCYTOSIS (RDW>14)

PICA (COMPULSIVE CONSUMPTION OF NON-NUTRITIVE SUBSTANCES)—PAGOPHAGIA (ICE)

KIOLONYCHIA (SPOON NAILS)–FURROWED FINGER AND TOE NAILS

PALLOR, TACHY

Dx

= MODIFIED BARIUM SWALLOW, CBC WITH PBS

TANGIER’S DISEASE

—BASICALLY XANTHELASMA OF THE PALATINE TONSILS DUE TO A DYLIPIDEMIA

GEOGRAPHIC TONGUE OR MIGRATORY GLOSSITIS

—-IDIOPATHIC–REALLY FILIFORM ATROPHY ASSOC WITH PAPILLARY SLOUGHING AND RECONSTITUTION–USUALLY ASX—-Rx SYMPTOMATICALLY—OFTEN A COMORBID CANDIDAL INFXN IF IT BURNS—-?FOOD ALLERGY?

OLP (ORAL LICHEN PLANUS)

BELEIVED TO BE AN ALLERGIC PHENOM (DELAYED HYPERSENSITIVITY)–CMI–ACTIVATED T-LYMPHOCYTES THAT BECOME CYTOTOXIC FOR THE BASAL KERATINOCYTES—CAN OCCASIONALLY SEE APOSITIVE NICKOLSKI’S SIGN

USUALLY NO ETIOLOGY IDENTIFIED—CAN BE ASSOC WITHHCV

THE WHITE DOES NOT WIPE OFF!

MAY AFFLICT EITRHER SKIN OR ORAL MUCOSA

COMMON–1% OF GENERAL POP

USUALLY OLDER WOMEN

GROSSLY A LACEY, STRIATED, KERATOTIC APPEARANCE (WICKHAM’S STRIAE)

CAN HAVE CONCOMMINANT CUTANEOUS VIOLACEOUS PRURITIC PAPULES ON FLEXOR SURFACES

CAN BE DRUG INDUCED

SEVERAL CLINICAL PATTERNS:

ATROPHIC

EROSIVE—–ULCERATIVE (ELDERLY)—-PREMALIGNANT

—-NOW TERMEDLICHENOID DYSPLASIA

INCREASED PROPENSITY TO DEV SCCA-(1-2%)—FROM BOTH AFFECTED AND UNAFFECTED MUCOSA—ESPECIALLY IN THEULCERATIVE TYPE—LICHENOID DYSPLASIA

PAPULAR

PLAQUE (TOBACCO USERS)

PRIMARILY ONBUCCAL MUCOSA—ALSO DORSAL/LAT TOUNGUE

FREQUENTLY MULTIFOCAL AND BILAT

SHOULD BE REGUARDED AS A SENTINEL LESION—-REQUIRING SURVEILLANCE AS IT HERALDS A YET UNDEFINED IMMUNOLOGIC OR GENETIC DEFECT—AT LEAST THINK OF A BIOPSY

LEUKOEDEMA

—USUALLY IN BLACKS—NOT PREMALIGNANT

LEUKOPLAKIA

—-IS PREMALIGNANT

ERYTHROPLAKIA

—VERY PREMALIGNANT

FORDYCE SPOTS

(GRANULES) = SEBACEOUS GLANDS, PINPOINT YELLOW ERUPTIONS USUALLY POST ON THE BUCCAL MUCOSA—-IDIOPATHIC OR SYPHILIS

SEBACEOUS GLAND HYPERPLASIA

TORUS MANDIBULARIS OR PALATI

–NL VARIANT

MENOPAUSAL

—SENILE ATROPHY/GINGIVOSTOMATITIS (DRY BURNING TONGUE) GLOSSOPYROSIS

THALLESEMIA

–DIFFUSE PALLOR AND CYANOSIS

STURGE-WEBER(PWS)

ANDOSLER WEBER RENDU—TELANGIECTASIA

LINGUAL THYROID

ECTOPIC THYROID—ANYWHERE FROM CIRCUMVALLATE PAPILLA TO EPIGLOTTIS

MUST BE POST TO CIRCUMVALLATE PAPILLA AND TUBERCULUM IMPAR

IS A FAILURE OF DESCENT (?ARRESTING MATERNAL ANTIBODIES)

4TH WEEK–FORAMEN CECUM LINGUALE

DESCENDS DOWN PRIOR TO FORMATION OF THE BOT OR HYOID BONE

TGDC LINED WITH EPITHELIUM

TOWARDS THE END OF DESCENT IT IS JOINED BY THE LATERAL FOURTH POUCH NEUROECTODERMAL C-CELLS (PARAFOLLICULAR CELLS) FROM THE ULTIMOBRANCHIAL BODY——CAN FORM MEDULLARY CA

INCIDENCE = 1/100,000

FEMALE 4.7:1

33% CLINICALLY HYPOTHYROID

70-100% HAVE LINGUAL THYROID AS ONLY FUNCTIONING THYROID TISSUE

VERY RARELY UNDERGO MALIGNANT DEGENERATION—-27 CASES (APPEARS TO HAVE THE SAME INCIDENCE AS THYROID IN THE NL LOCATION

CAVEATE—-CANNOT HAVE MEDULLARY THYROID CA HERE AS THE C-CELLS (PARAFOLLICULAR CELLS) MIGRATE IN FROM THE ULTIMOBRANCHIAL BODY

OFTEN WILL PRESENT WITH A MASS EFFECT —- DYSPHAGIA, DYSPHONIA, DYSPNEA, EVEN STRIDOR—–RARELY MAY HEMORRAGE—RED VASCULAR APPEARING SMOOTH MIDLINE BOT MASS

OFTEN PRESENT AT A TIME OF STRESS WHEN HIGH TSH LEVELS PROMOTE GLANDULAR HYPERPLASIA

Dx:

ALWAYS PALPATE FOR NL THYROID GLAND

LAB: TSH, T3, T4, THYROGLOBULIN

CT WITH NO CONTRAST—NL THRYROID NATURALLY HAS ACCUMULATED I-

FIRST STEP—-TN99 SCAN—-DIAGNOSTIC—-AVOIDS THE NEED FOR Bx

Rx

: SYNTHROID SUPPRESSION—-LOWERS TSH—DECREASES GLANDULAR HYPERPLASIA—-DECREASES SYMPTOMS

IF THIS FAILS—REPEAT IMAGING STUDIES——SURGERY—-CAN USUALLY SUPPRES THEM THROUGH PUBERTY AND THEN THEY ARE ABLE TO GET ALONG WITHOUT TOO MANY SYMPTOMS

IF NOT A SURGICAL CANDIDATE CONSIDER I131 (RAI)

 

RANNULA=”FROG BELLY APPEARANCE”—-SIALOCELE—-PTYALOCELE

A SUBLINGUAL GLAND (FOM) RETENTION CYST(MUCOCELE) (USUALLY FROM DUCTAL OBSTRUCTION)

SMALLEST, ALMOND SIZE, 5% OF SALIVA

BLOOD SUPPLY = Br OF THE LINGUAL ARTERY

2/3 MUCOUS, 1/3 SEROUS

SUP. SALIVATORY NUCLEUS–CN VII(NERVUS INTERMEDIUS)–CHORDA TYMPANI–SUBMANDIBULAR GANGLION(LOXLEY’S/LANGLEY’S)–POST GANGLIONICS

IMMEDIATELY ON MYLOHYOID MUSCLE IN FOM(NEAR SYMPHYSIS OF MANDIBLE)

NO DISCRETE CAPSULE (NOT INVESTED BY SUP. DCF)

NUMEROUS DUCTS OF RIVINUS(POST TO WHARTONS)–OCCASIONALLY COALESC TO FORM BARTHOLIN’S DUCT—EMPTY ON LINGUAL PLICAE(PLICAE SUBLINGULARIS

USUALLY THE ORIGIN OF A RANULA—-SHOULD REMOVE IT TO PREVENT RECURRENCE!

PLUNGING RANULA—DIVES THROUGH THE MYLOHYOID–PRESENTS AS A SUBMENTAL MASS—-MAY REQUIRE AN EXTERNAL APPROACH

MOST SOURCES SAY TO EXCISE SUBLINGUAL GLAND OF ORIGIN TO PREVENT RECURRENCE

GRANULAR CELL TUMOR

–GRANULAR CELL MYOBLASTOMA

NEURAL ORIGIN(+S-100, NEURON SPECIFIC ENOLASE, +PAS)

PROBABLY OF SCHWANN CELL ORIGIN

10% MULTICENTRIC, 5% RECURRENCE

PREPONDERANCE FOR H&N > 50%(PRIMARILY THE DORSAL TONGUE)

PRIMARILY PRESENT AS A PAINLESS MASS

MAY ALSO PRESENT ON THE POST TVC’S OR ARYTENOIDS

DESCRIBED BY ABRIKOSSOF IN 1926

FEMALE 2:1

BLACKS>WHITES

2% MALIGNANT

OVERLYING EPITHELIUM MAY SHOW PSEUDOEPITHELIOMATOUS/PSEUDOCARCINOMATOUS HYPERPLASIA–CAN BE MISTAKEN FOR SCCA—SYPHILIS, BLASTO, TB, PACHYDERMA LARYNGIS, RT CHANGES, PAPILLARY KERATOSIS

EPULIS

–(FISSURATUM)–CHRONIC, PAINLESS, USUALLY TRAUMATIC—IDENTICLE HISTOLOGY AS ABOVE ONLY OFF THE GINGIVA

PERIPHERAL FIBROMA

—ALWAYS IN THE GINGIVA NEAR THE TEETH—CAN ACTUALLY MOVE THE TEETH—-FEMALE IS MORE COMMON—CONTAIN BONEY OR CEMENTUM INCLUSIONS

NICOTINIC STOMATITIS

—RED CENTERS—USUALLY ON THE PALATE OF PIPE SMOKERS—RELATES AN IRRITATIVE PHENOMENON OF THE MINOR SALIVARY GLANDS

PAPILLARY HYPERPLASIA

—-SEEN ON THE PALATE OF EDENTULOUS PTS—-OF TRAUMATIC ETIOLOGY FROM DENTURES—LOOKS LIKE NICOTINIC STOMATITIS WITHOUT THE RED CENTERS

TRAUMATIC ULCERS

—USUALLY IN THE OCCLUSSAL PLANE—HX OF TRAUMA

IRRITATION FIBROMA

—TRAUMATIC IN ETIOLOGY—USUALLY FROM A PYOGENIC GRANULOMA

PYOGENIC GRANULOMA

–“PREGNANCY TUMOR”—VERY VASCULAR—OFTEN TRAUMATIC IN ETIOLOGY—CAN EVENTUALLY FORM A FIBROMA

MUCOCELE-

-USUALLY BLUISH IN COLOR—-THE RESULT OF BLUNT TRAUMA TO A MINOR SALIVARY GLAND

LOBULAR CAPILLARY HEMANGIOMA

PRIMARILY ON LIP = PYOGENIC GRANULOMA (OFTEN FROM TRAUMA) — LEADS TO REACTIVE FIBROMA

Rx EXCISION

CHERUBISM-

–A GIANT CELL LESION—-BILAT POST MANDIBULAR RADIOLUSCENCIES

BOGGY SWELLING OF THE HARD PALATE WITH TELANGIECTASIA OVER IT—–THINKMALIGNANT LYMPHOMA

MELANOTIC NEUROECTODERMAL TUMOR OF INFANCY

—–ANT MAXILLA

FORDYCE GRANULES

—REALLY NONCONSEQUENTIAL—-HETEROTOPIC OR ECTOPIC SEBACEOUS GLANDS

MOUTH TREATMENTS:

 

ADD 5 ML OF 95% ETHANOL TO VIAL OF 40% TRIAMCINOLONE ACETONIDE INJECTIBLE—CAN DOUBLE THE TAC

QS TO 200 ML WITH STERILE WATER (NOT BACTERIOSTATIC)

SHAKE WELL BEFORE USING—-EXPIRES IN 6 MONTHS

5-10 ML SWISH AND SPIT QID, PC (AFTER MEALS) AND HS. NPO ½ – 1 HOUR AFTER

CAN ADD IN 2% VISCOUS LIDOCAINE AND OR NYSTATIN SUSPENSION AND DIRECT USE IDENTICALLY.

PERIDEX

, PERIOGARD (CHLORHEXIDINE 0.12% ORAL RINSE)—-15 ML SWISH AND SPIT BID, PC, AM AND HS. NPO ½ HOUR.

NYSTATIN ORAL SUSPENSION

(100,000 UNITS PER ML)—5 CC SWISH AND SPIT (SWALLOW FOR PHARYNGEAL INVOLVEMENT) PC AND HS. NPO ½ HOUR.

MAGIC MOUTH WASH

—30 ML DIPHENHYDRAMINE LIQUID (12.5 MG/5ML) + 60 ML MYLANTA + 4 G CARAFATE

5 ML SWISH AND SPIT OR SWISH AND SWALLOW TID, AC, AND HS.

KENALOG IN ORABASE

— APPLY PASTE DIRECLTLY TO LESIONS TID, PC, AND HS. NPO 30 MIN.

MYCELEX LOZENGES

—DISSOLVE IN MOUTH Q 3 HOURS WHILE AWAKE (5/DAY). NPO ½ HOUR.

DIFLUCAN 100MG TABS.

1 PO BID FOR 10-14 DAYS.

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