27 APR 2022

27 APR 2022 · DEVELOPMENTAL CONDITIONS Developmental conditions are soft tissue or hard tissue defects that occur during the development of the individual, either before or after birth. LIP PITS - Depressions or concavities seen on lip - Seen with Van Der Wood syndrome along with cleft lip FORDYCES GRANULES - Ectopic sebaceous glands - On buccal mucosa - Usually seen as Bilaterally symmetrical LEUKOEDEMA - White or whitish grey edematous (fluid) lesion of buccal mucosa - It dissssipiates when cheek is stretched ANGIOMAS - ANGIO - VESSELA OMA - TUMOR - TUMORS composed of blood vessels or lymph vesseLs - A salivary gland tumor that mestasises to bone CENTRAL HEMANGIOMA – IV - Commonly in upper lip - There is congenital focal proliferation of capillaries - Absolute contradiction – extraction of a tooth** - Multilocular radiolucency lesion - Associated syndrome – Struge Weber Syndrome - Port wein steins + calcification of duramatter - Strawberry appearance of skin – capillary hemangioma Other variants - Strawberry appearance of gingiva – warners granulomatosum - Strawberry appearance of tongue (white coated tongue with red inflamed fungiform papilla)– scarlet fever (bacterial infection) - Raspberry appearance of plate – papillary hyperplasia(denture) LYMPHANGIOMA CONGENITAL FOCAL PROLIFERATION OF LYMPH VESSELS -Oral lymphangiomas are very rare - appear as purple spots on tongue DEVELOPMENTAL SOFT TISSUE CYST - DERMOID CYST - Mass in the midline of the body – intraoral or extra oral - Intraorally – floor of the mouth if above mylohyoid - Mass will be seen in the upper neck if it forms below the mylohyoid - Contains hair, sebaceous glands etc – doughy consistency BRANCHIAL CYST - Lateral neck cyst - Epithelial cyst within lymph node of neck PSEUDOCYSTS OF JAW STAFNE / STATIC BONE CYST - Radiolucency in the post mandible below the mandibular canal - Its is not a cyst- just a picture caused due to lingual concavity of the jaw, ie. An invagination in the lingual surface of the jaw - just variation of normal anatomy. NASOPALATINE / MEDIAN PALATINE / Incisive canal cyst CYST - Seen b/w roots of Central incisors - R/F - Divergence of roots - The nasopalatine cyst appears as a well-defined, round radiolucency in the midline of the anterior maxilla - Sometimes it appears to be ‘heart-shaped’ because of superimposition of the anterior nasal spine. - Radiological assessment should include examination of the lamina dura of the central incisors (to exclude a radicular cyst) and assessment of size (the nasopalatine foramen may reach a width of as much as 10 mm). - Qn. Pt. came to the clinic complaining from pain related to swelling on maxillary central incisor area with vital (under percussion) - nasopalatine cyst - Qn. 40-60y, Male, in maxilla in the midline between the roots of upper central incisors which are vital. - Intra-osseous lesion is well circumscribed rounded or Heart-shape RL. area (due to superimposition of nasal spine) GLOBULOMAXILLARY CYST - Seen between Lateral incisor and Canine - Inverted pear shape - Variant of OKC or lateral periodontal cyst - Vital tooth bilateral SOLITARY BONE CYST – Haemorrhagic /Simple / Traumatic bone cyst - A pseudocyst- ie. No epithelial lining - Kids doing sports- injury - R/F – scalloped border around teeth*** - Treatment is curettage and closure

27 APR 2022 · TEETH ANOMALIES DUE TO DEFECT IN THE INITIATION AND PROLIFERATION FUSION AND GEMINATION - Differentiated by radiography only DILACERATION - Cause – mild trauma during root formation stage - Bending of crown / root TAURODONTISM - Bull teeth (elongation of root trunk) - Syndrome – Klinfilter Syndrome Dens In Dente / Dense Invagination - R/F – teeth inside the pulp of a tooth - Most common with upper lateral incisor ENAMEL PEARL - After extraction a molar you found a hard tissue at the furcation like pearl. - Tooth # 36 planned to extraction on x-ray no PDL after extraction u found lesion like pearl on furcation SUPERNUMERARY TEETH - Most common – mesiodense - Condition where multiple impacted teeth - Cleido cranial dysplasia - Gardner’s syndrome - Trecher Collin’s syndrome - Cleft lip and palate HYPODONTIA - Young female patient with skeletal class 1 there is spacing present in anterior teeth. Her mother also have mild spacing due to missing upper lateral. What is cause of spacing in patient - HYPODONTIA ANODONTIA - Syndrome – ectodermal Dysplasia

27 APR 2022 · MUCOSAL – REACTIVE LESIONS Trauma and chemicals are frequent causes of oral lesions. Some of these lesions have an iatrogenic cause (i.e., caused by the dental practitioner). FRICTIONAL KERATOSIS - BUCCAL MUCOSA, TONGUE, - CAUSES - CHRONIC BITING - A SHARP CUSP - OVER EXTENDED DENTURE - ORTHO APPLIANCE LINEA ALBA - White line in the buccal mucosa NICOTINA STOMATITIS - Red dots, which are inflamed minor salivary duct openings - histology of nicotina stomatitis : hyperkeratosis and acanthosis - only premalignant in smokers TRAUMATIC ULCER - Very common - Due to constant rubbing against sharp tooth surface HAIRY TONGUE - Will discuss in tongue lesions

27 APR 2022 · MUCOSAL – INFECTIONS Oral infections are viral, bacterial, or fungal in nature. The most commonly encountered infections are viral, usually herpes simplex virus (HSV) infections. Clinical presentation of viral infections depends on viral type: herpes causes mucosal ulceration (preceded by vesicles), human papillomavirus (HPV) typically induces a verruciform (warty) lesion, and Epstein-Barr virus (EBV) causes a white lesion (hairy leukoplakia). Most bacterial and fungal infections manifest as chronic ulcers. The fungus Candida albicans can cause either white or red lesions. VIRAL INFECTIONS HERPES SIMPLEX VIRUS– stress /exam PRIMARY - Majority of primary herpetic infections are asymptomatic - It affects pan-orally means anywhere in and around the mouth - It is self-limiting- will go away on its own usually - Common in childhood - Treatment – palliative, painkillers usually RECURRENT - The HSV stays latent in trigeminal ganglion - Triggered if body is highly stressed out. Or sunlight. Or is under immunosuppressives. - Site – multiple ulcers 🡪 only on kertinized tissue ie. Attached gingiva, hard palate, vermillion border, etc – distinguishing factor from primary & secondary - C/F – herpetic whitlow on finger tip of examined doc- so it is advised that dentist should not touch patient until it resides - Herpes labialis 🡪 vermillion border - Itching and vesicle appearance every year ** - Qn. Child came with pain and fatigue + multiple vesicles on hard palate (last year he had the same and went away after one week). – recurrent herpex simplex - Rx - % acyclovir cream VARICELLA ZOSTER – CHICKEN POX - Chickenpox in childhood - Itchy vescicles. - Latent in trigeminal ganglion VZV - Recurrent – HERPES ZOSTER / SHINGLES SYNDROME RAMSY HUNT SYNDROME - Herpes zoster reccurent inf In geniculate ganglion affecting cranial nerves 7 (facial) & 8 (vestibulopharyngeal) 🡪 facial paralysis, vertigo-dizziness, deafness- - C/F : Herpes Zoster Rashes usually do not cross the midline, and is primarily in the thoracic region. - Treatment - acyclovir COCKSAKIE VIRUS – HERPANGINA - Caused by COK SACKIE VIRUS - Below 5 years children - Hand-Foot-Mouth Disease - Causes herpangina at Sites – post part of oral cavity 🡪 Soft palate, tonsil, uvula - C/F – facial pallor, sore throat MEASLES- Rubeola - Viral infection – rubella virus - Primary is self limiting - mostly affecting children - Koplik’s sign *** - Bluish white spots on buccal mucosa - Present before the onset of classical skin rash of measles as a sign - Rx – Acyclovir EPSTEIN BAR VIRUS EBV - Oral hairy leukoplakia - White patch on lateral tongue that does not wipe of - Opportunistic infection - Usually associated with HIV and the immunosuppression associated with that EBV*** causes diseases like : - Burkits lymophoma - Nasopharyngeal carcinoma } cancers - Infectious mononucleosis - Oral hairy leaukoplakia } infection Additional Notes: HUMAN IMMUNODEFICIENCY VIRUS HIV – AIDS - Slim disease - Caused by retro virus(P24 antigen) - Oral manifestationof HIV in a child – herpetic gingivostomatitis**** - Incubation period – 9-11 years***** (Hep B incubation period is 4 months) - Most common cancer – Kapossi’s sarcoma 4 stages Stage 1 — symptomatic Stage 2 — asymptomatic Stage 3 — T-cells damaged — thymus and lymphoid nodes affected ,Persistant generalised lymphadenopathy Stage 4 — AIDS occurs — Body is completely weak and aquires infection Scenario Qn. A child born to an HIV +ve mother takes nystatin drop, diagnosis is candidiasis/oral thrush - Prophylaxis if needle prick dentist - Rx – 1 NRT + 2 NNRT for 4 weeks (for doctor) Investigation + Screening test – ELISA + Confirmation — western Blot + Best investigation – PCR + Saliva in HIV is not contagious + Saliva in Hep B is contagious HUMAN PAPILLOMA VIRUS - Causes papilloma / wart - Benign epithelial pedunculates/ sessile proliferation of skin or mucosa

27 APR 2022 · BACTERIAL INFECTIONS SYPHILIS - Treponema palladium** (spirochetes), - Sexually transmitted disease (STD) - Primary 🡪secondary 🡪 tertiary 🡪 death - WASSERMANS TEST PRIMARY SYPHILIS - Chancre – infectious ulcer – painless and indurated(not cancerous) - Remember syphilis first appers as ulcer*** - Non contagious - Site – dorsal surface of tongue SECONDARY SYPHILIS - Highly contagious - Mucocutaneous lesion 🡪 split ulcer - Eg: condyloma lacta 🡪 snail track ulcer TERTIARY SYPHILIS - Oral manifestation – gummatous ulcer in palate - CNS involved, CVS also involed 🡪 becomes a systemic problem CONGENITAL SYPHILIS - In the baby who is born to a mother with syphilis - Hutchinsons triad ∆ -- hearing loss, mulberry molars— screwdriver inciors, notched incisors . bulbous molar, ocular keratitis ( CORNEAL SCARRING), copper stained lesions. - Egaw menosky *** (thickening of clavicle) — facial VII nerve palsy + deafness (not a feature of triad) — interstitial hyperkeratosis - Rx – penicillin for 10 days - Qn. 8years Patient came to your clinic has impaired hearing, upon examination his mouth you found copper color lesion, notched incisor and mass on the occlusal surface of the molars. TUBERCULOSIS - Caused by inhaling mycobacterium Tuberculosis - Oral non-healing chronic ulcers, after lung infections - PRIMARY 🡪 Ghon’s complex SCARLET FEVER - Caused by streptococcus pyogenes - Candisiasis may be Seen on scarlet fever patients who are on continuos antibiotics**** - Strawberry appearance of tongue (white coated tongue with red inflamed fungiform papilla)– scarlet fever (bacterial infection) - Treatment - pencillin FUNGAL INFECTIONS Candidiasis - ORAL THRUSH - Fungal / poor oral hygiene - Seen on scarlet fever patients who are on continuous antibiotics**** - Pseudomembraneous 🡪 white plaque that rubs off - Ie. Scrapable , leaving erythmatic area. Basically looks like fungal dirt that you can remove by cleaning your tongue!!! - Median rhomboid glossitis – seen in patients wearing denture –or renal pts ** - Nystatin topical or go for systemic nystatin - But if pt has been on long term antibiotics – go for fluconazole. **** - Child 3 yrs old with oral candidiasis ? Nystatin oral suspension************

27 APR 2022 · MUCOSAL – IMMUNOLOGIC These conditions are related to autoimmune (when our immune system attacks our own body) or hyperimmune (immune system just over reacts) reactions to some stimuli. Clinical manifestations include vesicles or bullae, ulcers, erythema, and white patches They are treated with steroids !! APHTHOUS ULCER - Main cause Is stress Site - Present only in non keratinized tissue (opp to hsv infection) - Ie; soft palate, buccal mucosa, ventral surface of tongue, labial mucosa, Clinical Types of Aphthous Ulcers : MINOR & MAJOR MINOR APHTHOUS ULCERS - One to several painful oval ulcers 0.5 cm - Very painful and may be debilitating - May take several weeks to heal, even 21 days - Will heal with scarring - Rx Corticosteroids (triamcinolone ointment) - Rx – Triamcinolone ointment or kenakort Syndromes with Aphthous: - Behcet syndrome – multiple aphthous ulcer + vasculitis - Reiter syndrome – multiple aphthous ulcer + arthritis + urethritis + conjunctivitis ERYTHEMA MULTIFORME - Lesions seen on skin and mouth - BULL’S EYE or Target or IRIS RIM lesion - Allergic to medication like sulfa allergie, penicillin , barbiturate - Infection like HSV + Mycoplasma - Associated with Steven-Johnson Syndrome - Type III hypersensitivity reaction - Skin lesion + oral lesion + conjunctivitis + urethritis - And Bull’s eye ulcers - QN 🡪 the patient will have bulls eye on the skin and oral ulcers LICHEN PLANUS - Autoimmune disease of skin and mucous membrane - Precipitating factors – stress + hep C*** - Site – skin + oral mucous membrane - Variants – retricular lichen planus- most common - Wickham’s striae - H/F – civette bodies, rete pegs - Grin’s span syndrome – hypertension + diabetes mellitus + lichen planus - Rx – steroids (autoimmune na**) - Long case picture shown white patches in buccal mucosa 15 yr old child had exams last week. Histopatholgy civatte bodies , hyperkeratosis etc -Qn. Case 14 years old patient presents with white lace pattern lesions on skin and buccal mucosa, stressed, history of hep C 🡪lichen planus - Rx corticosteroids SYSTEMIC LUPUS ERYTHOMATOSIS - Another auto immune disease - Multiple organ involved - Characteristic feature – BUTTERFLY RASH - Rx corticosteroids PEMPHIGUS VULGARIS - Autoimmune – Ig G present - Immune fluorescent test : +ve - Most commonly affected site buccal 🡪 palatal 🡪lingual 🡪 labial - Gingiva is least commonly affected site - Auto antibodies against desmosomes** - Rx – Steroids C/F - 1st Bullae + then painful vesicle - Suprabasilar split** - Acantholysis - Intra epidermal - Nickolskys sign +ve (also seen in Hailey – Hailey disease, toxic epidermolysis bullae) Ie. When rubbing the affected skin 🡪 results in exfoliation of the skin - Histopathology – Tzanck cells seen** QN - The right corticosteroid daily dose for pemphigus vulgaris is: 50-100mg STEROIDS - 100mg hydrocortisone. (Max. is 120mg. daily prednisone) 1-2 mg/kg/daily. (max. is 120 mg. daily prednisone). BULLOUS PEMPHIGOID - Autoimmune – Ig G present - Immune fluorescent test : +ve - Auto antibodies against basement membrane** - Rx – steroids C/F - Bullae + vesicle ( Remember it as BULLOUS PEMPHIGOID ) - Sub basilar split - Sub epidermal bullae - Nickolsky’s sign - -ve - Desquamative gingivitis + skin lesion

27 APR 2022 · STEROIDS Examples are (usually taken 1mg/kg/day) - Hydrocortisone - Prednisolone - Betamethasone - Dexamethasone INDICATION – AUTOIMMUNE DISEASES - Sjogren’s syndrome - Lichen planus - Pemphigus + pemphigoid - SLE+DLE - OSMF - Apthous ulcer - Addisons disease – no adrenal glands - Leukoplakia ∴ will be on long term steroid therapy CONTRAINDICATION - Viral infection - D M - Peptic Ulcer STEROID SCENARIOS (long term steroid patients) - QN Patient has adrenal insufficiency come to your clinic and start developing signs of adrenal crisis you would administer: 2 ml. (100 mg.) hydrocortisone In a clinical scenario, there are 2 cases: - If Patient takes steroid dose of 30-50 mg 🡪 * Double the dose of steroid just before the procedure on that day only, later follow normal dosage - If pt taking above 50 mg 🡪 Follow same dosage , no changes required

27 APR 2022 · MUCOSAL – PREMALIGNANT PRE MALIGNANT LESIONS AND CONDITIONS Pre- malignant lesion – the lesion will become cancerous if the cause is not stopped / removed. Pre – malignangt condition – the condition may become cancerous if the cause is not stopped / removed Usually these lesions develop into SQCC. LEUKOPLAKIA - Most common pre – malignant lesion and condition - White lesion - Cause – tobacco - Most common leukoplakia – Homogenous L - Most dangerous leukoplakia – Verrucous L(growth present) Rx - Stop tobacco - Vit .A, Steroids, Vit.E = adjunct therapy ERYTHROPLAKIA - Red lesion – ie. will become carcinoma - Pre – malignant lesion - 90% becomes cancer DIFF BTWN WHITE LESION OF ORAL CAVITY : Leukoplakia - White colour - Cause – Tobacco - C/F – non scrapable - Rx – stop tobacco White Sponge Nevus - White colour - Familial or hereditary - Scrapable, no erythema left - No Rx. OSMF - Oral submucosal fibrosis - Cause – arecanut chewing C/F - Trismus - Vertical band in buccal mucosa - Burning sensation - Rx for mild to moderate - Hyaluronidase inj + steroids, xylocaine Rx for severe cases – excision of bands

27 APR 2022 · MUCOSAL – MALIGNANCIES The various types of carcinomas can manifest as non-healing ulcers, red patches, or irregular surface masses. - Carcinoma 🡪 epithelial - Sarcoma 🡪 mesenchymal / Connective tissue - Melanomas manifest as abnormally pigmented surface lesions that start at the junction of the epithelium and submucosa. SQUAMMOUS CELL CARCINOMA - QN - Stage of squamous cell carcinoma T2 N0 M0. - The most common malignant tumor of oral cavity -mostly affecting lateral surface of the tongue, secondarily the hard palate. - Associated with fixed and firm lymph nodes. - Its primary stage is red patch/ plaque - Most commonly seen intra orally - Least common – nasopharynx - Associated with Firm, fixed neck nodes LIP SCC - Reasons or Risk Factors: + Sunlight exposure + Human papilloma Virus (HPV) + Gene mutation + Tobacco chewing - Usually has good prognosis - If ulcer (SCC) is well differentiated– which is also the most common type – and shows late metastasis – therefore better prognosis - If ulcer has already metastasised – then poor prognosis - Plummer Vincent syndrome – mucosal atrophy + dysphagia + iron deficiency anemia + increased risk of ral cancer ie SQCC - Qn. 21 y old pt who has iron deficiency anemia + difficulty swallowing(dysphagia) with examination of barium sulphate you found : SQCC TONGUE SCC - Lateral border of tongue – most common SQCC - Usually metastasises fast ∴ poor prognosis - High reccurrence - Best biopsy for Sq. C C – INCISIONAL BIOPSY - During biopsy – tongue secured to suture or towel clip + clip - During examination – tongue secured by guaze piece VERRUCOUS CARCINOMA - It is a well differentiated form of SQCC - It shows cauliflower shaped lesions on both sin & mucosa** - Associated with betel nut chewing - It is a malignant type of lesion - Rx – surgical excision BASAL CELL CARCINOMA -Rodent ulcer - Due to sun exposure MALIGNANT MELANOMA - Most dangerous tumor - Malingnancy of melanocytes - Most common intra oral site – gingiva – anteriorly & palate - Least common – acral lentigo melanoma* - Blackish discolouration - Always originates from Nevus cells of connective Tissue NOTE: Melanotic Pigmented intra – oral lesions: - Malignant melanoma – black - Addison’s disease – seen in steroid d - Peutz Jagher’s Syndrome