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.