question

What are the main non-odontogenic cysts?

answer

- Nasopalatine duct cyst - Solitary bone cyst - Aneurysmal bone cyst - Nasolabial cysts - Dermoid/epidermoid - Mucocoele (retention & extravasation) - Thyroglossal duct cyst - Lymphoepithelial cyst

question

What is the most common non-odontogenic cyst?

answer

Nasopalatine duct cyst!

question

What is another name for a nasopalatine duct cyst?

answer

Incisive canal cyst

question

What is believed to be the origin of a nasopalatine duct cyst?

answer

Epithelial embyrological remnants of the nasopalatine duct (connects oral and nasal cavities)

question

Where is the nasopalatine duct cyst usually found?

answer

B/w the apices of the maxillary central incisors (nasopalatine foramen region)

question

Given where the nasopalatine duct cyst occurs, what structures may you suspect it to contain?

answer

Nasopalatine nerves and sphenopalatine arteries

question

True or false. The presence of a nasopalatine duct cyst at the apices of the maxillary central incisors usually means they are non-vital.

answer

FALSE!! - maxillary central incisors are usually VITAL in the presence of a nasopalatine duct cyst (NON-ODONTOGENIC CYST!)

question

Are nasopalatine duct cysts usually symptomatic?

answer

No, usually asymptomatic and found as a swelling in the anterior palate => "cyst of incisive papilla" - if symptomatic, may be draining in the mouth => pain

question

How does a nasopalatine cyst appear radiographically?

answer

Well circumscribed, round/oval RL in/near midline of ant. maxilla b/w roots of central incisors - DISPLACED ROOTS, NO resorption - nasal spine/septum may be superimposed

question

How would you differentiate between the normal incisive foramen and a nasopalatine duct cyst?

answer

6mm = normal > 6mm = cyst (most are 1.0-2.5cm!)

question

What would the differentials be for a nasopalatine duct cyst?

answer

- Radicular cyst (assess vitality of teeth!) - Periodontal cyst (assess pockets?) etc

question

Other than location, how would you differentiate between a nasopalatine duct cyst and a nasolabial cyst?

answer

- does NOT contain neurovascular bundles

question

The lining of a nasopalatine duct cyst is said to be highly variable according to WHERE the cyst developed. Why is this so?

answer

Sits between oral and nasal cavities, hence lining may vary between their respective epithelial linings: - stratified squamous (OC) - ciliated pseudostratified columnar - sumple columnar/cuboidal

question

Moving from the lumen outwards, what makes up a typical nasopalatine duct cyst?

answer

- empty/fluid lumen - oral cavity/respiratory epithelial lining - Neurovascular bundles & mucous glands (maybe hyaline cartilage) - fibrovascular CT wall - NO INFLAMMATION!

question

How would you manage a nasopalatine duct cyst?

answer

- Surgical enucleation (palatal flap)

question

What complications would you expect from removal of a nasopalatine duct cyst and why?

answer

Paraesthesia of the palatal mucosa - removing nerves and BVs associated with the lesion

question

Where does a nasolabial cyst usually occur and why is this of significance when assessing it radiographically?

answer

Cyst in the SOFT TISSUE of the nasolabial fold (upper lip, lateral to midline) - because a soft tissue lesion, NO RADIOGRAPHIC Δ (unless large!)

question

What is the most common presentation of a nasolabial cyst?

answer

Filling of the nasal cavity obstructing it

question

Given where a nasolabial cyst commonly occurs, what would you expect it to be lined with?

answer

Respiratory epithelium - pseudostratified columnar epithelium (derived from nasolacrimal canal?)

question

What are other names given to a simple bone cyst?

answer

- Traumatic bone cyst - Solitary bone cyst - Unicameral bone cyst

question

What causes simple bone cysts?

answer

Unknown - ?like dry socket => intramedullary haemorrhage from trauma with CLOT failing to organise, degenerating and leaving empty bony cavity

question

Is there cortical expansion associated with simple bone cysts?

answer

No! - it's an empty bony cavity with NO EPITHELIAL LINING!

question

How would a simple bone cyst appear histologically?

answer

- NO lining! - may have thin wall of granulation tissue or fibrous CT

question

How do simple bone cysts usually present?

answer

- young pts (~18 years) - male: female = 3:2 - mandible >> maxilla - usually asymptomatic - incidental radiographic finding

question

What are simple bone cysts usually associated with?

answer

Cemento-osseus dysplasias! (may also be other pathologies)

question

***IMPORTANT*** Simple bone cysts are said to have a characteristic radiographic appearance. What are they?

answer

- Unilocular RL lesion with smooth, corticated outline - SCALLOPING around roots (UNIQUE) - NO DISPLACEMENT or ROOT RESORPTION! (LD intact!) - lesion is ABOVE the IDC

question

A radicular cyst is a potential DDx to a simple bone cyst. What may help you differentiate between the two?

answer

LD intact in teeth near the simple bone cyst (teeth should be vital??)

question

How would you manage a simple bone cyst?

answer

- Cavity opened surgically and noted that it's empty/straw coloured fluid with NO LINING - allow to bleed and form clot to help form bone and heal

question

An aneurysmal bone cyst is known to be neither a true cyst nor an aneurysm. What larger category of lesions is it a part of?

answer

Giant cell lesions of the jaw = these all look exactly the same histologically - fibrous CT - ↑ blood filled spaces (not true BVs; no endothelium) - ↑ OC-like giant cells (multinucleated)

question

What is an aneurysmal bone cyst?

answer

Giant cell lesion of the jaw containing fibrous CT, caverounous/blood filled spaces, young fibroblasts, multinucleated OC-like giant cells and reactive bony trabeculae & osteoid

question

What is believed to be the cause of an aneurysmal bone cyst?

answer

Unknown - ?vascular malformation causing Δ local haemodynamics leading to engorgement w/ attempted repair of a haematoma - usually 2° Δs associated with other lesions => giant cell tumour, fibrous dysplasia

question

How may an aneurysmal bone cyst present clinically?

answer

All bones, but in jaws ~20 years - females > males - mandible > maxilla - DISPLACES DENTITION - no root resorption!

question

True or false. Aneurysmal bone cysts cause an expansion of the bone.

answer

True! - hence displaces teeth cf simple bone cyst NOT causing bony expansion

question

How may an aneurysmal bone cyst appear radiographically?

answer

Uni OR multilocular (honeycomb or soap/bubble; according to locule size) - Blow out expansion of bone => thinning of cortex - may have reactive periosteal proliferation (proliferative periostitis)

question

Given the radiographic appearance of an aneurysmal bone cyst, what is an important DDx?

answer

Ameloblastoma - uni/multilocular lesion w/ bony expansion (note ameloblastoma is B & L expansion and CAUSES ROOT RESORPTION!)

question

How would you manage an aneurysmal bone cyst?

answer

Complete removal! => aggressive curettage

question

What issues are there with curettage of an aneurysmal bone cyst?

answer

- Intense bleeding (essentially a blood filled sponge) - due to bleeding, poor access to completely remove ∴ ↑ recurrence rate

question

Other than curettage, what methods may be employed to tx an aneurysmal bone cyst given what you know about it's contents?

answer

Bisphosphonates (inhibit OCs) - however long term side effects too severe - in near future, newer drugs w/ shorter half lives (eg RANK-L inhibitors) may be a better way to manage an aneurysmal bone cyst!

question

Can a dx of an aneurysmal bone cyst be made purely from it's histological appearance? Why?

answer

No! - it appears exactly like all the other giant cell lesions of the jaw - need to know more info (hx, radiographs etc) (i.e. ↑ OC-like giant cells, fibrous CT, ↑non-endothelialised blood filled spaces)

question

What is a Stafne defect also known as?

answer

Lingual mandibular salivary gland defect; an indentation on the lingual side of the mandible - contains salivary gland tissue! (caruncles etc)

question

How may a Stafne defect present clinically?

answer

- Men >> women - asymptomatic! (incidental finding)

question

How does a Stafne defect appear radiographically?

answer

Well demarcated, corticated RL lesion BELOW the IDC in the posterior mandible (may occur anteriorly too)

question

What may a Stafne defect appear like radiographically?

answer

Radicular cyst! - on smaller pA or BW films, a Stafne defect may appear as a radicular cyst apical to a tooth (test vitality!) - on an OPG you will find it is actually well away from the tooth apex and beneath the IDC

question

Odontogenic cysts can be divided into two groups, what are they?

answer

- Developmental - Inflammatory

question

What are some examples of developmental odontogenic cysts?

answer

- Gingival cysts of infants/adults - Odontogenic keratocyst (OKC) - Dentigerous cyst - Eruption cyst - Lateral periodontal cyst - Calcifying odontogenic cyst

question

What are some examples of inflammatory odontogenic cysts?

answer

- Radicular cyst - Residual cyst - Paradental cyst

question

What is the current name used for an odontogenic keratocyst?

answer

Keratocystic odontogenic tumour (old name is primordial cyst)

question

What is the dx of a keratocystic odontogenic tumour based on?

answer

Histological appearance

question

Why are KOT's important to know about?

answer

- AGGRESSIVE cysts (unlike other odontogenic cysts) - DIFFICULT TO REMOVE!

question

What is an important thing to remember about odontogenic cysts?

answer

Odontogenic epithelium plays a role in the development of the cyst!

question

Which odontogenic epithelia play roles in the development of odontogenic cysts?

answer

- Cell rests of Serre (dental lamina remnants) - Cell rests of Malassez - Dental lamina - Reduced enamel epithelium

question

Is it possible to dx a KOT from a radiograph? Why?

answer

No! - because it mimics many other lesions

question

When are KOT's most commonly seen?

answer

2nd decade (development of 8s) 5th decade

question

How may a keratocystic odontogenic tumour present clinically?

answer

- males > females - mandible > maxilla - asymptomatic until very larde - maybe pain/swelling, paraesthesia lower lip

question

Is there any expansion of the bone in KOT's? Why?

answer

Usually no due to A-P growth of KOTs in medullary bone - if there is any expansion, it's usually only BUCCAL! (cf ameloblastoma = B AND L expansion!)

question

***EXAM QUESTION*** What syndrome are keratocystic odontogenic tumours usually associated with?

answer

Gorlin Goltz Syndrome

question

What is Gorlin Goltz Syndrome?

answer

A Naevoid basal cell carcinoma syndrome => mutation of PTCH gene causing MULTIPLE BCCs and KOTs, also: - falx cerebri calcification - rib/vertebral abnormalities - ocular hypertelorism - epidermal cysts of skin

question

How may a KOT present radiographically?

answer

- Well defined RL w/ smooth corticated margins - usually unilocular but may be multilocular - may appear scalloped - not common for root resorption - commonly associated w/ lower 8s ∴ CAN SEE MIMICS MANY LESIONS!

question

Given that a KOT mimics many lesions radiographically, what DDx's should be listed if one suspects a KOT?

answer

- Dentigerous cyst - Ameloblastoma - Simple bone cyst - Radicular cyst - Residual cyst - Lateral perio cyst

question

What do you call a KOT that has replaced a tooth?

answer

Primordial cyst! => i.e. is of REPLACEMENT VARIETY because it develops in place of a tooth

question

What are the main types of KOTs?

answer

- Follicular/dentigerous (40%!) (esp lower 8s) - Envelopmental (encloses tooth) - Extraneous (separate from tooth) - Collateral (DDx lat. perio. cyst) - Replacement (i.e. primordial cyst)

question

You see a lesion that appears as a dentigerous cyst and a KOT radiographically. What differentiating features would you use to tell them apart?

answer

Presence of root resorption? - Yes: dentigerous - No: probably KOT

question

***EXAM QUESTION*** What are the histological features of a keratocystic odontogenic tumour?

answer

- LUMEN = cheesy KERATIN debris - LINING = flat parakeratinised epithelium with corrugated surface and NO RETE RIDGES (∴ epithelial lining comes off CT wall!) - WALL = thin friable FIBROVASCULAR CT w/ small satellite/daughter cysts in wall

question

The junction between the epithelial lining and the CT wall of a KOT is flat with no rete ridges. What implications does this have?

answer

Easy separation of epithelial lining from the CT wall => characteristic histological finding

question

Are there inflammatory cells associated with the KOTs?

answer

No! - is a developmental cyst, NOT inflammatory

question

KOTs are said to have satellite/daughter cysts associated with them. Where are they found exactly? Why is this important?

answer

Within the fibrovascular connective tissue wall of the KOT. - if not removed completely, will recur, ∴ check walls of cyst upon removal

question

Why is enucleation of KOTs difficult?

answer

Has a thin friable wall w/ the epithelium easily separating from it, hence difficult to remove in one piece

question

It is said that the further back in the mandible the KOT is present, the higher the recurrence rate. Why is this so?

answer

↓ access for surgeon to enucleate/curettage

question

What are the two main methods of treating KOTs?

answer

1. Marsupialisation (if large) 2. Enucleation 3. Curettage (if smaller can go straight to this)

question

What treatment options are there for KOTs?

answer

1. Marsupialisation (resection if very big) 2. Enucleation 3. Curettage 4. Peripheral ostectomy (0.2-0.5mm extra bone removed) 5. Cryotherapy 6. Chemical cauterisation (3 min) (?Carnoy's) => minimise recurrence

question

What is chemical cauterisation w/ Carnoy's solution?

answer

- placement of a toxic chemical to cause necrosis (Ferric chloride & alcohol)

question

What is marsupialisation?

answer

- decompression of the cyst causing cyst expansion to ↓ creating a thickening of the wall making it easier to remove

question

Naevoid basal cell carcinoma syndrome (Gorlin Goltz) has what type of inheritence pattern?

answer

Autosomal dominant

question

Gorlin Goltz syndroms involves a mutation in the PTCH gene. What is the PTCH gene responsible for?

answer

- a tumour suppressor gene on chromosome 9

question

What is the radiographic presentation of Naevoid basal cell carcinoma syndrome (Gorlin Goltz)?

answer

- multiple holes in bone - RLs associated w/ crowns of unerupted teeth (mimics dentigerous cysts) (otherwise, bifid ribs, calcified falx cerebri, hyphoscoliosis

question

What is the histological presentation of a naevoid basal cell carcinoma syndrome (Gorlin Goltz)?

answer

- Identical to KOTs, but may have more satellite/daughter cysts in the wall - BCCs

question

The management of naevoid basal cell carcinoma syndrome is said to be long term. What are they and why is this so?

answer

- enucleation of jaw cysts through life => ↑ daughter cysts = ↑ recurrence ∴ need to be removed - genetic counselling - avoid irradiation due to ↑ BCC tendency (NOT LIFE THREATENING!)

question

Given that naevoid basal cell carcinoma syndrome cysts are very similar to KOTs, what would you expect to see in these cysts histologically?

answer

- lumen filled w/ keratin - flat jxn b/w lining and wall - scalloped border

question

What is a dentigerous cyst?

answer

Cyst attached to the neck/CEJ of an UNERUPTED tooth and surrounds the crown (follicular cyst)

question

When do dentigerous cysts present most often?

answer

2-3 decade => lower 8 development

question

Which teeth are most commonly associated with dentigerous cysts?

answer

Lower 8 > upper 3s > upper 8s > lower 4/5s

question

Although usually identified on radiographs, why can it NOT be diagnosed via only radiographs?

answer

- because KOTs are a DDx! - hence must exclude this as it is an aggressive lesion

question

What is the radiographic appearance of a dentigerous cyst?

answer

- UNILOCULAR RL lesion around CROWN of UNERUPTED tooth - well-defined corticated/sclerotic margin - widening of follicle > 3-4mm - causes ROOT RESORPTION

question

Why would you expect a dentigerous cyst to cause root resorption?

answer

- cyst develops from follicle - follicle designed to resorb roots of 1° tooth, ∴ will resorb anything in the way

question

What are two important DDx's to dentigerous cysts, particularly from radiographs?

answer

KOT Ameloblastoma (unilocular variants)

question

What are the three types of dentigerous cysts?

answer

- Central - Lateral - Circumferential

question

Are dentigerous cysts painful?

answer

No. Usually found on routine radiographs

question

What is another differential to a dentigerous cyst? (other than KOT & ameloblastoma)

answer

Adenomatoid odontogenic tumour (2/3 tumour) - 2/3 in ant. maxilla - 2/3 associated w/ impacted teeth (usu. canine) - RL extends apically from CEJ (cf dentigerous, its more coronal)

question

How is a dentigerous cyst thought to develop?

answer

1. Impaction causing venous obstruction, ∴ oedema into follicle b/w REE and crown 2. pA pathology from 1° tooth, hence inflammatory oedema

question

True or false. Dentigerous cysts are ALWAYS associated with the CEJ of the affected tooth?

answer

True! - this is where the REE attaches to the tooth

question

What histological features are present in dentigerous cysts?

answer

- Lumen: empty (or clear fluid) - Lining: thin, resembles REE & squamous epithelium - Wall: thin, fibrous CT w/ occasional cell rests/foci of dystrophic calcification

question

How would you treat a dentigerous cyst?

answer

- Enucleation of cyst w/ removal/exo of impacted tooth ± curettage

question

How would you distinguish b/w a dx of a dentigerous cyst and an ameloblastoma?

answer

Dentigerous: - UNILOCULAR - ONLY B bony expansion (not L!) Ameloblastoma: - multilocular - causes B AND L bone expansion! (note both cause root resorption & otherwise similar radiographic appearance)

question

What is the difference b/w a dentigerous cyst an eruption cyst?

answer

Same thing, but ERUPTION cyst is in SOFT TISSUE => tooth impeded in the soft tissue, not in the bone (may be fibrous gingiva preventing it from coming out)

question

Given that an eruption cyst is associated with an impacted tooth within the soft tissues, what radiographic Δs would you expect?

answer

NONE! (or very little) - maybe a soft tissue shadow or slight widening of bony crypt

question

In which pts would you expect to see eruption cysts?

answer

CHILDREN! - could be 1° or permanent teeth

question

What is the clinical presentation of an eruption cyst?

answer

- Smooth, dome-shaped swelling either normal/blue colour overlying an impeded tooth - soft and painless unless infected = pain

question

Why may eruption cysts appear blue?

answer

- eruption haematoma i.e. a cystic cavity filled w/ blood)

question

Given what you know about eruption cysts, how would you expect it to present histologically?

answer

Same as dentigerous: - LUMEN: empty/fluid filled - LINING: REE, (if inflamed, may have Δ'ed to stratified squamous epithelium) - WALL: thin, chronically inflamed fibrous CT, close to overlying oral mucosa!

question

How would you manage an eruption cyst?

answer

- cut a wedge out of the lesion, decompressing it (release pressure) - allows tooth to erupt normally

question

How would a gingival cyst of infants present?

answer

Multiple or solitary white nodules/discrete swellings on the alveolar ridges of newborns/young infants

question

From what do gingival cysts of infants form?

answer

Remnants of the DENTAL LAMINA

question

What is the histological appearance of gingival cyst of infants?

answer

LUMEN: keratin filled LINING: stratified squamous lined epithelium WALL: fibrovascular CT

question

How would you manage a gingival cyst of infants?

answer

DO NOTHING! - it will be disrupted by the erupting teeth or eventually open onto the surface mucosa and resolve

question

What other lesions are similar to gingival cysts of infants?

answer

- Bohn's nodules (throughout palate) - Epstein's pearls (mid-palatine raphe)

question

How does a gingival cyst of adults differ from gingival cysts of infants?

answer

LUMEN: NO KERATIN! - anterior mandible (b/w canine/PM region) - occurs age 50-60 years

question

How does a gingival cyst of adults present?

answer

- Slowly enlarging painless and small blister/bullous. - normal/blue colour - teeth are VITAL!

question

How is the gingival cyst of adults thought to form?

answer

Tooth erupts beyond follicle, follicle gets left behind in the gingiva, forming a cyst from the REE (similar to lateral periodontal cyst, in that the follicle is left behind more coronal)

question

What is the histological appearance of gingival cysts of adults?

answer

LINING: thin, resembling REE & stratified squamous in areas. - WASSERHALLE cells: epithelial thickenings/plaques w/ clear watery cells in whirling formation WALL: CT - no inflammation!

question

***IMPORTANT*** In which cysts would you expect to see inflammation in the walls?

answer

- Radicular cysts - Residual cysts - Paradental cysts => they form due to inflammation! The othes are all developmental odontogenic cysts!!

question

What is a lateral periodontal cyst and how is it proposed to form?

answer

Cyst occurring in the lateral periodontal position, adjacent to the root where an inflammatory cause (radicular) or KOT are excluded

question

How is a lateral periodontal cyst dx made?

answer

Appears very much like a radicular cyst (assess vitality) and a keratocystic odontogenic tumour (biopsy), ∴ lateral periodontal cyst dx is made once these two are ruled out!

question

What is the radiographic appearance of a lateral periodontal cyst? Does this appear like any other lesions?

answer

Well defined unilocular round RL with a corticated margin that may also be multilocular (botyroid) associated with the root of a tooth. - appears like lateral radicular cyst or KOT

question

What is the histological appearance of a lateral periodontal cyst?

answer

Exactly the same as a gingival cyst of adults: LINING: thin resembling REE, with some stratified squamous cells with wasserhalle cells and whirling epithelial plaques - WALL: CT

question

How would you manage a gingival cyst of adults?

answer

Nothing!

question

How would you manage a lateral periodontal cyst?

answer

- surgical ENUCLEATION - if botyroid (multilocular) variant may require local excision/resection

question

What are Wasserhalle cells and in which lesions are they characteristic?

answer

Vacuolated cells with clear centre Characteristic in: - gingival cysts of adults - lateral periodontal cysts

question

***EXAM QUESTION*** You notice a unilocular, round RL lesion with a corticated border associated with the lateral aspect of two teeth. What would be your prioritised differential diagnoses and how would you distinguish between them?

answer

1. Radicular cyst (check vitality) 2. Keratocystic odontogenic tumour (biopsy lesion) 3. Lateral periodontal cyst 4. Mental foramen (check positioning)

question

What is the radiographic appearance of an gingival cyst of adults?

answer

None! - is purely a soft tissue lesion! - may have mild superficial bone erosion

question

What does a glandular odontogenic cyst resemble and how is it different?

answer

- similar histo to lateral periodontal cyst (& ∴ gingival cyst of adults) - LINING: non-keratinised stratified squamous, may have cilia. Glandular structures in lining w/ goblet cells! WALL: fibrovascular CT (w/ min. chronic inflam cells)

question

What is the radiographic appearance of glandular odontogenic cysts?

answer

- Large multilocular RLs in the jaw w/ corticated margins - IS AGGRESSIVE! - RARE!

question

How would you tx a glandular odontogenic cyst?

answer

Careful surgical excision! (not enucleation!)

question

What is another name for a calcifying odontogenic cyst?

answer

Calcifying cystic odontogenic tumour (CCOT) - i.e. a benign neoplasm of odontogenic origin

question

How does a calcifying odontogenic cyst present clinically?

answer

- may occur intra or extra-osseously - anterior mandible! (incisor/canine area) - asymptomatic/painles swelling

question

What are the radiographic features of a calcifying odontogenic cyst?

answer

Unilocular RL w/ a well-defined border containing radiopacities in the lumen (calcifications)

question

Although rare, what should always be a differential for a RL lesion in the anterior mandible?

answer

Calcifying odontogenic cyst (Could be dentigerous or KOT, but easily distinguished by radiopacities in lumen)

question

What is the histological appearance of calcifying odontogenic cysts?

answer

LINING: epithelium mimics ameloblastoma - contains GHOST CELLS that calcify (characteristic) LUMEN: - dysplastic dentine like tissue - may be associated with odontome!

question

When assessing a calcifying odontogenic cyst, what may you mistake it for histologically?

answer

Ameloblastoma! - hence need radiograph to confirm dx of calcifying odontogenic cyst

question

How would you tx a calcifying odontogenic cyst and why is this important?

answer

Enucleation! - important for correct dx, because ameloblastoma is tx'ed VERY differently! (ameloblastoma requires surgical resection, + normal tissue)

question

What are ghost cells and in what lesion are they characteristic?

answer

Epithelial cells that lose their nucleus and undergo degenerative calcification - characteristic of calcifying odontogenic cysts

question

What are the most common cysts we see in the maxilla and mandible?

answer

Inflamamtory cysts - radicular cysts

question

From what cells do radicular and paradental cysts form from?

answer

Epithelial residues in the PDL => Cell rests of Malassez! (paradental cysts may also arise from the gingival crevice/deep pockets)

question

In what age group are radicular cysts most often seen?

answer

3rd decade (20-30) - rare in 1st decade - not usually w/ 1° teeth

question

Why may radicular cysts be more common in men and in the maxilla cf women and the mandible respectively?

answer

- Females look after their teeth more - Maxilla is more likely to experience trauma, especially in anterior teeth

question

Where do radicular cysts most commonly present?

answer

@ apex of NON-VITAL maxillary anteriors (& in males>females => ↑ trauma hx)

question

How would a radicular cyst often present/be identified clinically? Why?

answer

- Routine radiography => generally asymptomatic w/ non-vital teeth, unless 2°ly infected (phoenix abscess)

question

True or false. Radicular cysts can occur @ the apex of vital teeth.

answer

False! - must be related to a non-vital tooth!

question

How may a radicular cyst present clinically?

answer

- asymptomatic usually (found on radiograph) - B ± P expansion maxilla, mainly B mandible - pain/infection if 2°ly infected

question

Would you only expect radicular cysts to form at the apex of carious teeth?

answer

No: - can also occur as sequelae of TRAUMATISED teeth! - dens in/evaginatus sequelae etc.

question

Can radicular cysts be associated with draining sinuses?

answer

Yes! - parulis? (if 2°'ly infected?)

question

Can you distinguish between a granuloma and a radicular cyst radiographically?

answer

No! Usually differentiated arbitrarily by size: - 15mm: probably cyst

question

What implications are there when trying to distinguish b/w a pA granuloma and a radicular cyst?

answer

Granuloma = granulation tissue that may form a scar or new bone and hence is tx'able by RCT - Cyst: RCT is ineffective, requires enucleation However this is very difficult to determine definitively, hence we tend to do RCT and if it doesn't resolve then exo and curettage the cyst

question

What is the radiographic appearance of a radicular cyst?

answer

- Round/oval unilocular RL associated apically/laterally to the root of non-vital tooth w/ well circumscribed margin - May have a sclerotic margin that's continuous w/ the lamina dura - root resorption = MAYBE

question

***IMPORTANT*** You see a lesion that appears like a radicular cyst radiographically, but has a moth eaten margin. What may it be?

answer

Radicular cyst that has been 2°'ly infected, hence the margin is moth eaten due to the inflammatory processes

question

***IMPORTANT*** What are the three stages in the pathogenesis of a radicular cyst?

answer

1. Initiation: proliferation of the epithelium derived from the cell rests of Malassez in the PDL 2. Cyst formation: epithelium grows around forming the cyst 3. Enlargement: Necrotic debris within cyst attracts fluid, ∴ ↑pressure and cyst growth!

question

True or false. Radicular cysts don't necessarily have to occur @ the apex of a non-vital tooth.

answer

True! - they can form laterally => lateral radicular cyst

question

You notice a pA RL and perform a RCT on the affected tooth. The tooth requires a crown as a definitive restoration, how long would you wait post RCT before crowning?

answer

At least 6 months (weeks?) - just like a bone #, it requires time to heal, usually 6-8 weeks before determining whether it heals or forms a scar (granuloma?)

question

True or false. All inflammatory cysts look the same histologically.

answer

True! - radicular, residual and paradental cysts all look identical histologically!

question

What is the histological appearance of radicular cysts?

answer

LUMEN: desquamated epithelial cells w/ necrotic debris. Cholesterol clefts! LINING: stratified squamous w/ proliferation and arcading patterns - spongiotic epithelium permeated by neutrophils, mucus cells and Rushton hyaline bodies WALL: fibrovascular CT w/ ↑↑mixed inflammatory cells (neutrophils, plasma, lymphocytes, Mø)

question

What is the significance of the contents of radicular cysts?

answer

- desquamated epithelial cells w/ necrotic debris and cholesterol clefts => draws in inflammatory fluid ∴ ↑ size of cyst

question

What is characteristic of the walls in radicular, residual and paradental cysts?

answer

Very inflamed!! - they are inflammatory cysts!! => ↑↑ mixed inflammatory cell infiltrate and may contain vegetable matter w/ surrounding giant cells (Pulse Granuloma; giant cell hyaline angiopathy)

question

What is the issue with the management of radicular cysts?

answer

Difficult to distinguish from pA granulomas ∴ usually perform RCT - if radicular cyst, RCT usually 'fails' - next RCT & apicectomy - otherwise EXO TOOTH & CURETTAGE OF CYST!

question

What is a residual cyst?

answer

A radicular cyst that was unsuccessfully/inadequately tx'ed - ∴ cyst in the jaw not associated w/ a tooth

question

What is the radiographic appearance of a residual cyst?

answer

Round, unilocular RL of varying size with a well defined corticated border @ a site of a previously extracted tooth

question

Why is the histological appearance of residual cysts slightly different to radicular cysts?

answer

The inflammatory process has subsided/inflam driver removed (i.e. pulp) - progressively less inflammation w/ time

question

How is the histological appearance of residual cysts different to radicular cysts?

answer

LUMEN: same; desquamated epithelial cells from proliferation & necrotic debris. some cholesterol clefts LINING: stratified squamous epithelium w/ loss of arcading pattern w/ time and dystrophic calcification (occasional mucus cells) WALL: (same)fibrovascular CT w/ variable chronic inflammatory cell infiltrate

question

What are the main differences in the histological appearance of residual cysts vs radicular cysts/

answer

Difference in LINING & ↓ inflam in WALL - less proliferation of stratified squamous epithelium - loss of arcading pattern - dystrophic calcification

question

What is the management required of residual cysts?

answer

- UNLIKELY, but may ↓ size and resolve - Surgical ENUCLEATION & curettage

question

What is the typical clinical presentation of a paradental cyst/

answer

- inflammatory cyst on the LATERAL aspect of PARTIALLY ERUPTED LOWER 8! - associated w/ hx of pericoronitis (i.e. chronic pericoronitis)

question

What is the inflammatory stimulus in paradental cysts and how does this differ to radicular and residual cysts/

answer

- Chronic pericoronitis!! - in radicular/residual cysts, it is the infected and inflamed pulp of the tooth that is the driver of the development of the inflammatory cyst

question

True or false. Paradental cysts are associated with NON-VITAL teeth.

answer

False! - the driver of the inflammatory cyst is the CHRONIC PERICORONITIS

question

Are paradental cysts only associated with partically erupted lower 8s?

answer

No, usually w/ vital teeth w/ a hx of difficult eruption - lower 8s are commonly impacted, hence the association and peak in 3rd decade (20s)

question

***IMPORTANT*** What is the radiographic appearance of paradental cysts?

answer

Round RL w/ corticated border associated w/ PARTIALLY ERUPTED lower 8 - NO PDL WIDENING - NO ASSOCIATION W/ FOLLICULAR SPACE - may be superimposed over B roots

question

What may you expect to see associated w/ paradental cysts clinically?

answer

- Chronic pericoronitis - Deep periodontal pockets => hence both involve inflammation derived from the periodontium

question

How are paradental cysts believed to form? (pathogenesis)

answer

Chronic inflammation from periodontium causes proliferation of residual cell rests of Malassez

question

In relation to the lower 8s, where do paradental cysts usually form?

answer

Buccal and Distal to the lower 8

question

What is the histological appearance of paradental cysts?

answer

Exactly like radicular cysts!! - LUMEN: desquamated stratified squamous cells w/ necrotic debris * cholesterol clefts - LINING: proliferating non-keratinised stratified squamous epithelium w/ spongiotic neutrophils - WALL: fibrovascular CT w/ mixed chronic inflammatory cell infiltrate

question

How would you manage paradental cysts?

answer

Surgical ENUCLEATION - & extraction of impacted tooth

question

What is another name for sialadenosis?

answer

Sialosis

question

What is sialadenosis?

answer

Non-inflammatory enlargement of the salivary glands (usually the parotids) - BILATERAL! - usually recurrent! - caused by an underlying systemic disorder - slow growing and painful

question

Sialadenosis is described as bilateral enlargement of usually the parotids. What does it mean if it is bilateral?

answer

SYSTEMIC cause! - if it was unilateral, then probably a local issue

question

Sialadenosis is most commonly caused by endocrine, dystrophic metabolic and neurogenic causes. What are some endocrine examples?

answer

- Diabetes mellitus - Hypothyroidism

question

Sialadenosis is most commonly caused by endocrine, dystrophic metabolic and neurogenic causes. What are some dystrophic metabolic examples?

answer

- Alcoholism - Cirrhosis - Anorexia nervosa/Bulimia

question

Sialadenosis is most commonly caused by endocrine, dystrophic metabolic and neurogenic causes. What are some neurogenic examples?

answer

- ANS affecting drugs eg psychotropics, bronchodilators

question

What is the underlying mechanism of all causes of sialadenosis?

answer

Some form of peripheral autonomic neuropathy => disordered salivary metabolsim & secretion

question

Given that sialadenosis is a manifestation of peripheral autonomic neuropathy, what Δs may you expect in the salivary glands?

answer

- Constipated secretory cells => ↑ storage of secretory granules ∴ ↑ accumulation of granules => ↑ size of cells/acini => enlargement of parotids

question

Given what you know about sialadenosis, how would you manage it?

answer

- Tx the underlying cause! - Pilocarpine hydrochloride (to ↓ size of glands, Prof doesn't recommend) - For recurrent/persistent cases, parotidectomy to ↑ aesthetics

question

What is sialolithiasis?

answer

Obstruction of a salivary duct due to the presence of a sialolith

question

What is a sialolith?

answer

Calcified structures/stones that develop within a salivary duct system

question

Why do sialoliths form?

answer

Ca deposition around debris within the ductal lumen - thickened mucus (dehydration) - bacteria - ductal epithelial cells

question

In sialolithiasis, are there any systemic issues?

answer

No, there are no issues, particularly with Ca or PO4 metabolism

question

Where do sialoliths most often present and why?

answer

Duct of submandibular gland (Wharton's duct) - it's long and tortuous - more mucus secretions (cf parotid) - against gravity & mylohyoid

question

Other than Wharton's duct, where else may sialoliths form?

answer

Minor glands of UPPER LIP! (rarely in parotid duct; Stenson's) [1. submandibular gland 2. glands up upper lip]

question

How may sialolithiasis present clinically?

answer

- Episodic pain & swelling of affected gland - sialolith may be palpable - severity of pain ~ degree of obstruction

question

When would you expect pts with sialoliths to experience pain and why?

answer

During eating - gland trying to secrete saliva, but obstructed, ∴ pain! - usually no pain until sialolith is quite large

question

How is a dx of sialolithiasis made?

answer

Palpation, clinical exam and radiographs - RO mass within duct or gland

question

What is the histological appearance of a sialolith?

answer

- Round/oval w/ concentric laminations of calcified structures. - duct lining = SQUAMOUS METAPLASIA - acute/chronic sialadenitis of gland

question

How would you tx sialolithiasis?

answer

Depends on size and location of sialolith - superficial and small = massage out of duct orifice - large = surgical removal - may remove stones in fragments (lithotripsy)

question

What is the difference between sialadenosis, sialolithiasis and sialadenitis?

answer

- Sialadenosis = bilateral enlargement of the salivary glands (parotid) - Sialolithiasis: obstruction of salivary gland ducts by a calcified mass - Sialadenitis: inflammation of a salivary gland

question

What is a mucocoele?

answer

- clinical description of a localised swelling/'cyst' within a gland - Actual mucocoele, there are two types: 1. Extravasation (usually referred as mucocoele) 2. Retention

question

What may cause a mucocoele? (i.e. the extravasation type)

answer

Local trauma causing rupture of a salivary gland duct, spilling contents into the soft tissues ∴ NOT a true cyst (NO EPITHELIAL LINING!) - quite common! (esp 1st decade (0-10 years)

question

What would be the typical clinical presentation of a mucocoele?

answer

- Dome shaped mucosal swelling (most often lower lip) from 1-2mm to cms - Blue (from mucin) fluctuant swelling common in children and adults - also occurs on B mucosa and ventral tongue

question

Why are mucocoeles most commonly presented in the first decade of life?

answer

i.e. 0 - 10 years - mixed dentition, so large teeth easily bite lips (esp. lower lip) => trauma => mucocoele formation

question

You find a reddish/blue lump on the lower lip. What would be your differentials?

answer

- Mucocoele - retention cyst - pyogenic granuloma - fibroepithelial polyp - salivary neoplasm

question

What is the histological appearance of mucocoele/extravasation cyst?

answer

- area of spilled mucin w/ ↑↑ inflammatory infiltrate (mucin-filled foamy Mø; muciphages) - surrounding granulation tissue response - ruptured salivary gland duct

question

True or false. A mucocoele is a true cyst.

answer

False! - it has NO EPITHELIAL LINING - surrounded by granulation tissue - extravasated mucin creates ↑↑inflam response!

question

What is the management required for a mucocoele/extravasation cyst?

answer

- majority resolve - excellent prognosis - recurrent lesions require local surgical excision (remove minor adjacent glands to ↓ recurrence) => ok because ductal system re-canalises?

question

What's the difference between a mucocoele (extravasation cyst) and a retention cyst?

answer

Extravasation = rupture of duct & spillage of mucin Retention = dilatation of duct due to obstruction

question

Given the difference in pathogenesis of mucocoeles and retention cysts, what is a fundamental difference between the two?

answer

Retention cyst is a true cyst because epithelial lined (ductal epithelium) - mucocoele is not! (just surrounded by inflammatory granulation tissue)

question

What may cause the ductal obstruction leading to a salivary retention cyst?

answer

- stone (sialolith) - scarring (fibrosis of duct) - tumour pressing on duct

question

Where to salivary retention cysts occur most frequently?

answer

- FOM - could be either major or minor glands though

question

What is the typical clinical appearance of a retention cyst?

answer

Soft, fluctuant bluish dome-shaped swelling - pretty much the same as extravasation cyst

question

Given the differentials of a pyogenic granuloma, fibroepithelial polyp or a salivary neoplasm, what information would make your definitive dx be an extravasation or retention cyst?

answer

- Hx of trauma associated w/ clinical swelling - Pain on eating

question

What would you expect the lining of a retention cyst to appear like?

answer

Normal ductal epithelial lining - can vary from cuboidal, columnar to squamous

question

***IMPORTANT*** What feature can be used to differentiate between a salivary tumour and a mucocoele (extravasation)?

answer

- Mucocoeles usually occur in the LOWER lip - salivary tumours usually on UPPER lip

question

How would you tx a retention cyst?

answer

Conservative surgical excision (because benign) - if difficult, partial/total duct/gland removal

question

Histologically, what is the main difference between a mucocoele and a retention cyst?

answer

Retention cyst is still lots of mucus, but this time contained within epithelial lining

question

What is a ranula?

answer

Mucocoele (extravasation cyst) in the FOM (resembles frog underbelly; rana)

question

How does a ranula form? (mucocoele in FOM)

answer

Trauma in FOM causing mucin spillage from sublingual gland (could be submand too)

question

What is the clinical appearance of a ranula?

answer

Blue, dome shaped, fluctuant swelling in the FOM, lateral to the midline

question

What is a plunging ranula?

answer

When the ranula/mucocoele opens through the mylohyoid muscle and causes a neck/submandibular swelling

question

What you expect the histological appearance of a ranula to look like?

answer

Identical to mucocoele - mucin surrounded by granulation tissue with ↑↑ inflammatory cell infiltrate & mucophages (mucin filled foamy Mø)

question

How would you tx a ranula?

answer

- remove the lesion and the feeding gland (particularly if recurrent)

question

You see a dome shaped swelling in the FOM that is lateral to the midline, what would you suspect the lesion is?

answer

Ranula (most likely, what other DDx?)

question

What is sialadenitis?

answer

Inflammation of the salivary glands

question

What may cause sialadenitis?

answer

- Infection: bacterial (post surgery), viral (mumps) - radiation - Sialolithiasis (obstruction) - Immune (Benign LymphoEpithelial Lesion; BLEL, Sjogren's) Also sialadenosis, mucocoele/retention cyst

question

What is mumps and how is it related to sialadenitis?

answer

Mumps is a viral infection spread by aerosols causing parotitis (i.e. sialadenitis of parotid)

question

The histological appearance of sialadenitis differs b/w acute and chronic presentations. How may they differ?

answer

Acute: - ↑ neutrophils (& pus) in ducts and acini (parenchyma) Chronic: - ↑ lymphocytes in parenchyma - atrophy of salivary gland - fibrosis of gland (recurrent infection)

question

Given the main causes, how would you tx sialadenitis?

answer

- Nothing: viral, sialolithiasis etc. - Acute: ABs (bacterial) - Chronic: surgical removal (immune, recurrent issues/infection, severe mucocoele, severe sialadenosis)

question

What is xerostomia?

answer

SUBJECTIVE sensation of a dry mouth - CLINICAL TERM! (not a dx!)

question

What usually causes xerostomia?

answer

Usually, but not always: salivary gland HYPOFUNCTION Also: - developmental, H2O/metabolite loss, iatrogenic/drugs, systemic disease (Sjogrens, RA), local factors

question

What are some classic clues associated with a pt complaining of xerostomia?

answer

- Foamy/roapy/bubble saliva - Mirror & gloves stick to mucosa - difficulty eating/swallowing - ↑ CANDIDA INFECTION! - ↑ caries experience (esp. smooth surface; cervical/root caries)

question

True or false. A pt who has a dry mouth will usually complain of xerostomia/

answer

False. Some pts may have no complaints and it'll be something you notice

question

What are two pathological issues that may direct you to consider xerostomia as a compounding factor?

answer

- ↑ smooth surface caries (cervical/root) - ↑ candidal infection(s)

question

How should you manage pts w/ xerostomia?

answer

Difficult - artificial saliva (biotene) - ↑ water SIPPING - sugarless gum/candy (↑ stimulation) - Discontinue/Δ DRUGS (probably polypharmacy) => REFER TO ORAL MED, THEY WILL PROBABLY KNOW MORE!

question

What does BLEL stand for?

answer

Benign LymphoEpithelial Lesion aka Myoepithelial sialadenitis

question

***IMPORTANT*** How is BLEL/myoepithelial sialadenitis related to Sjogren's?

answer

BLEL is the histological dx and Sjogren's is usually the clinical presentation of this histological presentation (i.e. the histological apeearance of Sjogren's is BLEL)

question

Why is Sjogren's NOT associated with sialadenosis, despite causing bilateral enlargement of the major salivary glands?

answer

Because Sjogren's is an AUTOIMMUNE disorder and sialadenosis is the NON-INFLAMMATORY enlargement of the salivary glands!

question

***IMPORTANT*** Is Sjogren's the only cause of a BLEL (myoepithelial sialadenitis)?

answer

No! - some malignancies may also cause a benign lymphoepithelial lesion

question

***IMPORTANT*** What does BLEL look like? (i.e. what is the histological appearance?)

answer

- ↑↑ lymphocytic infiltrate (chronic) - destruction of acini - ductal epithelium persists - surrounding myoepithelial cells proliferate => epimyoepithelial islands)

question

What is Sjogren's syndrome?

answer

- CHRONIC, AUTO-IMMUNE disorder - unknown cause (histocompatibility Ags or EBV/HTLV infection) - involves dry mouth and eyes (xerostomia & xeropthalmia) => sicca syndrome

question

What is sicca syndrome?

answer

COMBINATION of - xerostomia (dry mouth) - xeropthalmia (dry eyes)

question

What is the difference b/w 1° and 2° Sjogren's syndrome?

answer

1°: only sicca syndrome 2°: sicca syndrome + another autoimmune disorder

question

True or false. Sjogren's syndrome is a rare disorder.

answer

FALSE! - quite common 80-90% in middle aged females

question

Which autoimmune disorders is Sjogren's usually related with?

answer

Any! - usually rheumatoid arthritis (RA) - also SLE

question

Given sicca syndrome is the typical presentation of Sjogren's, what other issues may you see clinically?

answer

- diffuse enlargement of salivary glands; BILATERAL (recall, systemic issue, ∴ has to be bilateral!) - 'fruit-laden branchless tree' appearance on sialogram

question

What is a sialogram?

answer

Radiographic assessment of the salivary glands by injection of a RO marker

question

What is the principal symptom of Sjogren's syndrome?

answer

XEROSTOMIA - usually associated w/ xeropthalmia (scratchy/itchy, gritty eyes) => sicca syndrome

question

You see a pt w/ bilateral parotid enlargement without dry eyes or mouth. What may be the cause?

answer

Systemic ANS issues/disruption (sialadenosis) - bulimia - ANS drugs - diabetes - hypothyroidism - alcoholism/cirrhosis

question

You see a pt w/ bilateral parotid enlargement w/ dry eyes or mouth. What may be the cause?

answer

Sjogren's syndrome!!

question

What laboratory investigations may you order to confirm a dx of Sjogren's syndrome given what you know about the disorder.

answer

- Auto-Ab assessment (Rheumatoid factor; RF, Anti-nuclear Abs!) - ESR (usually ↑'ed)

question

What is ESR and why is it helpful?

answer

Erythrocyte Sedimentation Rate - non-specific marker of inflammation => ↑ inflammation => ↑ fibrinogen in blood => ↑ RBCs sticking to each other => clumping ∴ ↑ sedimentation => ↑ ESR

question

You suspect a pt has Sjogren's, an autoimmune disorder. What WBCs would you be looking for histologically?

answer

Lymphocytes!!! (they are responsible for the autoimmunity!) - NOT NEUTROPHILS, Mø etc!

question

What is the histological presentation of Sjogren's?

answer

BLEL!! - ↑↑ lymphocytic infiltrate - acinar atrophy/destruction - epimyoepithelial islands (myoepithelial proliferation)

question

A biopsy of the minor salivary glands of the lower lip is helpful in the dx of Sjogren's. What may you expect to see?

answer

- BLEL - aggregation of lymphocytes (≥ 50 in 4mm of minor salivary glands)

question

How would you manage Sjogren's syndrome?

answer

Supportive! - xeropthalmia: artificial tears, block lacrimal ducts to ↑accumulation. (refer to opthamologist) - xerostomia: as above (saliva, sugarless gum/candy, F, antifungals)

question

What pharmacological agents may be used to assist in the management of xerostomia?

answer

Pilocarpine (Prof doesn't recommend because side effects may be out of realm of dentistry)

question

Pts w/ Sjogren's are @ ↑'ed risk of developing another dangerous condition. What is it?

answer

Lymphoma! (40% higher) - B cell non-Hodgkin lymphoma (MALT lymphoma)

question

Is Sjogren's said to cause sialadenosis or sialadenitis? Why?

answer

Sialadenitis - because Sjogren's is immune/inflam mediated and sialadenosis is the NON-INFLAMMATORY enlargement of the parotids!

question

What is cystic lymphoid hyperplasia in AIDS also known as?

answer

Lymphoepithelial cysts of HIV/AIDS

question

What is cystic lymphoid hyperplasia in HIV/AIDS?

answer

Peristent, painless, bilateral enlargement of the parotids due to multiple intraparotid cystic lesions

question

What syndrome is also associated with cystic lymphoid hyperplasia in AIDS which also reveals the typical histological appearance?

answer

Diffuse CD8 Interstitial Lymphocytosis Syndrome (DILS) => ↑↑ CD8 infiltration

question

How would you assess cystic lymphoid hyperplasia in AIDS which is a dx test?

answer

CT! - reveals the multiple bilateral cystic lesions

question

How would you manage cystic lymphoid hyperplasia in AIDS?

answer

Tx lesions & AIDS - superficial parotidectomy - radiation - multiple fine needle aspirates (FNAs) - oral prednisone - anti-retrovitals - anti-retroviral protease inhibitors

question

What is necrotising sialometaplasia and why is it important to know?

answer

Uncommon, local destructive inflammatory condition of usually the palatal salivary glands - mimics malignant lesions, clinically and histologically!!

question

What is the clinical presentation of necrotising sialometaplasia?

answer

- Palatal salivary glands (∴ post. hard palate! Note: high risk area!) - unilateral! - crater-like ulcer => raised-rolled edges, in palate and a solitary ulcer (HENCE MIMICS CANCER!)

question

What is the typical history associated with necrotising sialometaplasia?

answer

- Painful swelling in posterior hard palate causing paraesthesia - 2-3 weeks later, necrotic tissue sloughs off leaving ULCER!

question

How is necrotising sialometaplasia believed to occur?

answer

? Ischaemia to salivary tissue potentially due to trauma, LA or ill-fitting denture) causing infarction & necrosis

question

"Necrotising sialometaplasia" indicates there are necrotic and metaplastic components to the lesion. Where do these occur?

answer

- ACINAR necrosis (but lobular architecture remains) - DUCTAL metaplasia (squamous metaplasia)

question

How would you manage necrotising sialometaplasia?

answer

NOTHING! - heals itself, but may take several weeks if large (heals after biopsy because bleeds and stimulates granulation tissue and scars?) => IMPORTANCE OF DIAGNOSIS!! (distinguish from SCC)

question

What structures are present from the gland to the final excretory duct?

answer

Acinus -> intercalated duct -> striated duct -> excretory duct

question

True or false. There are different types of acinar cell types.

answer

True! - Serous (parotid) - Mucous (palate/lip/buccal) - Seromucous (combination; submand, subling & tongue)

question

Lymphoid tissue, sebaceous glands and nerves are only associated with one group of the salivary glands. Which one?

answer

- Parotid => facial nerve

question

What is the name of the duct for the parotid gland?

answer

Stensen's duct

question

What is the name of the duct for the submandibular gland?

answer

Wharton's duct

question

What is the name of the duct for the sublingual gland?

answer

Bartholin's duct (Rivinus ducts?)

question

Salivary glands contain glandular tissue, muscle, fat, blood vessels etc. From which tissue do neoplasms usually arise?

answer

Epithelial parenchymal origin from the glands - can occur from others, i.e. the mesenchyme, but are rare

question

In which gland are tumours most commonly found?

answer

Parotid - because it's the largest? - 2nd most common are the minor salivary glands as a whole

question

Which salivary gland tumours are dentists more likely to identify?

answer

- tumours of minor salivary glands because they're I/O - parotid gland tumours will probably present as a neck/cheek swelling and hence pt will probably present to the GP first

question

Given that parotid tumours are the most common of all salivary gland tumours, where do they occur most commonly?

answer

- Superficial lobe!

question

True or false. Most tumours in the parotid gland are benign.

answer

True!

question

What is the most common salivary tumour of the upper lip?

answer

Canalicular adenoma (benign)

question

Which three areas of the mouth are prone to malignant tumours of salivary glands?

answer

Tongue, FOM and retromolar area

question

What is the most common malignant tumour of salivary gland origin?

answer

Mucoepidermoid carcinoma

question

What is the most common benign tumour of salivary gland origin?

answer

Pleomorphic adenoma - most common in parotid - then palate/submandibular

question

What does pleomorphic mean?

answer

- variability of cell size/shape/nuclei

question

What cells do pleomorphic adenomas arise from?

answer

Epithelial: - ductal - myoepithelial (hence 'pleomorphic')

question

What is the most common salivary gland neoplasm? (consider both benign and malignant)

answer

Pleomorphic adenoma - most common salivary gland neoplasm

question

True or false. Salivary gland neoplasms ALL have a female predilection in incidence.

answer

True! (except for Wharton's tumour; i.e. submandibular gland tumour)

question

How does a pleomorphic adenoma present clinically?

answer

- Asymptomatic, unilateral swelling - usually affects the superficial lobe of the parotid (hence care w/ n. w/ biopsy) - if in the palate, posterolaterally!

question

Pleomorphic adenomas in the parotid are mobile initially but in the palate are not. Why is this?

answer

- loose CT in parotid allows tumour to grow within it slowly - in palate, there's no submucosa posterolaterally, so not much room to penetrate => NOT MOBILE

question

True or false. Fibrous epuli (lumps on gingiva) etc are DDx's for pleomorphic adenomas in the palate.

answer

FALSE! - salivary glands are ONLY in POSTEROLATERAL palate - gingiva is more anterior!

question

What is the main difference between the anterolateral palate and the posterolateral palate?

answer

Anterolateral = fatty submucosa Posterolateral = glandular! - ∴ palatal salivary neoplasms occur posterolaterally!

question

True or false. It is easy to distinguish between benign and malignant salivary gland tumours clinically.

answer

False! - can't tell the difference until you take a biopsy - hx of slow growth & no pain, probably benign - hx of rapid and painful growth, probably malignant

question

What is the histological appearance of a pleomorphic adenoma?

answer

=> epithelial and stromal component - well circumscribed FIBROUS CAPSULE (esp. in major glands)- tumour cells may infiltrate capsule (PSEUDOPONIA) => prone to recurrence - biphasic appearance; glandular epithelium + myoepithelial cells - excess background stroma

question

You take a biopsy of a swelling in the posterolateral palate and notice the lesion has a thick fibrous capsule. Is this more likely to be benign or malignant?

answer

Benign! - probably a pleomorphic adenoma!! (most common!)

question

What does the epithelial component of a pleomorphic adenoma comprise of?

answer

- duct and cystic structures - sheets of epithelial cells - keratinising cells (+some mucus cells) - myoepithelial cells (produce stroma!)

question

What do myoepithelial cells look like and what is the their function?

answer

- Spindled, epithelioid, plasmacytoid (like B cells) - produce stroma!

question

What does the stromal component of pleomorphic adenomas consist of?

answer

- myxoid/chondromyxoid areas - hyalinised stroma - fat - bone

question

True or false. No two pleomorphic adenomas look the same.

answer

True! - as the name suggests, the tumour cells vary greatly and there are many permutations possible

question

Why would you avoid enucleation of pleomorphic adenomas?

answer

Due to the infiltration of the tumour cells into the fibrous capsule, may cause seeding and recurrence!

question

Given that you would avoid enucleation of pleomorphic adenomas, how would you treat them?

answer

Surgical excision! - parotid: care w/ facial n (usu. in superficial lobe) - submandibular: remove entire gland! - palatal: excise down to periosteum => EXCELLENT PROGNOSIS

question

True or false. Pleomorphic adenomas can undergo malignant degeneration if they sit around long enough.

answer

True!! => "Malignant pleomorphic adenoma"! - sudden Δ size/pain/n. involvement

question

What is a canalicular adenoma and where does it usually occur?

answer

Uncommon tumour of minor salivary gland, slowly growing painless mass - usually lump in UPPER LIP!

question

A canalicular adenoma is said to be monomorphic in nature. What does this mean?

answer

- it is made up ONLY of ductal cells - there is no stromal involvement in the growth of these benign tumours

question

How would you tx a canalicular adenoma?

answer

Local surgical excision - may be multifocal

question

What does a canalicular adenoma appear like clinically?

answer

Mucocoele (extravasation & retention!) - usually lower lip - Canalicular adenoma = UPPER LIP!

question

You find an asymptomatic lump on the upper lip. What are your two main differentials/

answer

1. canalicular adenoma 2. pleomorphic adenoma

question

From which structures of the salivary gland do the main malignant tumours arise from?

answer

- acinus/intercalated duct (∴ ductal + myoepithelial cells) - excretory duct (terminal end) (∴ no myoepithelial cells, but squames present?)

question

A pleomorphic adenoma is said to grow over 6 years. A mucoepidermoid carcinoma is the most common malignant salivary gland tumour, how long does this usually take to grow?

answer

≤ 1 year ∴ rapid growth

question

Where do mucoepidermoid carcinomas occur most commonly/

answer

Parotid! - as an asymptomatic swelling

question

You find a lump in the posterolateral palate. What are your differentials and how would you distinguish between them/

answer

1. pleomorphic adenoma (slow growing) 2. mucoepidermoid carcinoma ("popped in over the last 6 months"; rapid growth!) 3. Polymorphous low-grade adenocarcinoma (PLGA; if not the above, then probably this) => otherwise they look the same clinically!

question

What cells are present in mucoepidermoid carcinomas? (use name as hint)

answer

Mucus cells Epidermoid cells (i.e. squamous cells) Intermediate cells/progenitor cells

question

How do you distinguish between a pleomorphic adenoma and a mucoepidermoid carcinoma histologically?

answer

They look similar histologically - mucoepidermoid carcinomas have n. involvement?

question

What tx options are there for a mucoepidermoid carcinoma?

answer

- Parotid: superficial parotidectomy ± facial n. - Submandibular: clean out triangle; gland and nodes - Minor: excise & if against bone, remove bone too - Neck dissection if metastasised

question

What is the prognosis after tx of mucoepidermoid carcinomas?

answer

Depends on the grade - low 95%, high 30-40% survival

question

What is a common feature amongst the malignant salivary tumours?

answer

Neurotropism - they tend to involve the surrounding nerves!! - more so with adenoid cystic carcinomas!!

question

Where do adenoid cystic carcinomas tend to occur?

answer

Both major and minor glands - collectively, more so in the minor glands => palate, tongue and cheek

question

What is the usual clinical presentation of an adenoid cystic carcinoma?

answer

- rapid growth - pain & nerve dysfunction early in development!!

question

You spot a lump in the cheek that is bluish, elevated. What differentials could you have?

answer

Could be many things, however if pt points out they have "numb chin", then probably malignant and an adenoid cystic carcinoma!! eg for DDx? 1. Mucocoele 2. Pyogenic granuloma 3. Adenoid cystic carcinoma (unless 'numb chin')

question

What is the histological appearance of adenoid cystic carcinomas?

answer

- ductal & myoepithelial cells (∴ ductal and stromal components) - nerve involvement - 3 patterns: 1. holes like Swiss cheese (Cribiform) 2. tubular (ducts) 3. solid sheet (cribiform + tubular together)

question

What does the solid sheet histological pattern in adenoid cystic carcinoma indicate?

answer

Sheets of pleomorphic cells w/ necrotic areas

question

What is the general growth of adenoid cystic carcinomas?

answer

Slow growing that persist, ∴ good 5 year prognosis but poor 20 yr prognosis - slow killing! - solid pattern have highest recurrence rates

question

You find that an adenoid cystic carcinoma has recurred after tx. What does this mean?

answer

Probably incurable - surgeons only have one go @ removing it

question

What is a polymorphous low-grade adenocarcinoma (PLGA) also known as?

answer

- Lobular carcinoma - Terminal duct carcinoma

question

In which salivary glands are polymorphous low-grade adenocarcinomas most common?

answer

- Limited to MINOR salivary glands => usually the palate

question

You find a lump in the posterolateral palate. What would your differentials be. Would they Δ if the lump was associated with loss of a tooth/

answer

1. pleomorphic adenoma 2. mucoepidermoid carcinoma 3. PLGA if tooth lost, then probably malignant, ∴ 1. mucoepidermoid carcinoma 2. PLGA

question

What is the histological appearance of a polymorphous low grade adenocarcinoma?

answer

- Morphologically diverse - Cytologically uniform: -- isomorphic tumour cells (ductal+myoepithelial; uniform oval nuclei w/ small overlapping nucleoli) (i.e. cells are uniform)

question

You get a histological slide that appears malignant. What are your differentials?

answer

1. mucoepidermoid carcinoma 2. adenoid cystic carcinoma 3. polymorphous low grade adenocarcinoma (PLGA)

question

How would you tx a polymorphous low grade adenocarcinoma?

answer

Wide excision (small death rate: 1%) - recurs locally - rarely metastasises (6%)

question

What is cherubism?

answer

Genetic and rare developmental jaw condition (autosomal dominant)

question

What is the clinical presentation of cherubism?

answer

Cherub face (fullness of cheeks & jaws, + upturned eyes to 'heaven' due to observed sclera beneath iris) - occurs b/w 2-5 year olds until puberty, then slowly regresses - post. mandible involvement: begins @ angle and spreads through body & ramus - painless - widening/distortion of alveolar ridges w/ tooth displacement (or lack of eruption)

question

What is the radiographic appearance of Cherubism?

answer

Multilocular, bilateral, soap-bubble like expansile/destructive RLs - thinning of cortical plates (maybe even perforation)

question

***IMPORTANT*** True or false. The histology of all giant cell lesions are the same.

answer

True! - multinucleate giant cells - fibrous stroma - extravasated RBCs - haemosiderin pigment - minor variations eg hyperparathyroidism has tunnelling of giant cells through bone

question

How would you distinguish cherubism from other giant cell lesions?

answer

- Histologically identical - Clinical features and hx are characteristic

question

What is the issue with the tx of cherubism?

answer

Usually self-limiting and goes into remission and shrinkage after - leaving too late may lead to permanent deformities - early tx may further activate lesion => rapid growth

question

What tx modalities are there for cherubism?

answer

- Curettage - Observation - Calcitonin or Bisphosphonates (side effects!) - conservative cosmetic surgery NO RADIATION!

question

What is a peripheral giant cell granuloma?

answer

? a reactive lesion as a result of local trauma - relatively common - microscopically resembles central giant cell granuloma

question

What is the typical clinical presentation of a peripheral giant cell granuloma?

answer

- on GINGIVA or EDENTULOUS RIDGE ONLY - red/blue nodular mass - maxilla - resembles pyogenic granuloma - may be ulcerated - can be sessile or pedunculated - in 40-50s (middle aged)

question

What is the radiographic appearance of a peripheral giant cell granuloma?

answer

- Cupping resorption of bone - reactive woven bone (maybe)

question

What are the differentials for a peripheral giant cell granuloma?

answer

1. pyogenic granuloma 2. central giant cell granuloma that has broken through bone and presenting in soft tissue

question

What is the histological appearance of a peripheral giant cell granuloma?

answer

- Fibrovascular stroma - multi-nucleated OC-like giant cells - extravasated RBCs - haemosiderin pigment - BENEATH ORAL MUCOSA! (separated by Grenz zone (dense fibrous CT))

question

How would you tx a peripheral giant cell granuloma?

answer

- local excision (conservative) - scaling & polishing of adjacent teeth (remove irritation) ~ 10 - 15% will recur

question

Is a central giant cell granuloma considered to be neoplastic?

answer

No - it may be aggressive like a neoplasm though

question

As a rule of thumb, what age groups do each of the giant cell lesions occur mostly in?

answer

Young = cherubism, aneurysmal bone cyst (4-20) Middle age = peripheral/central giant cell granuloma (20-50) Older age = hyperparathyroidism (>60)

question

How do most central giant cell granulomas present clinically?

answer

- Middle age range (20-50) - mostly females - mostly ANTERIOR MANDIBLE - asymptomatic & found on routine radiograph

question

Central giant cell granulomas are usually split into two sub-groups, what are they?

answer

Non-aggressive - more common, slow growing w/ no cortical perforation/root resorption Aggressive - painful, rapidly growing, cortical perforation & root resorption

question

What is the typical radiographic appearance of central giant cell granulomas?

answer

- RL defect ranging 5mm - 10cm - uni or multi-locular

question

What is the histological appearance of a central giant cell granuloma?

answer

Similar to most giant cell lesions: - fibrovascular stroma - multinucleated OC-like giant cells - extravasated RBCs w/ haemosiderin deposits PLUS - foci of osteoid & newly formed bone within lesion (rules out ↑PTH?)

question

How would you tx central giant cell granulomas?

answer

- if small, CURETTAGE - recurrence however (11-50%), and may require more radical surgery Otherwise - corticosteroids - calcitonin - interferon

question

True or false. The management of central giant cell granulomas have a poor prognosis.

answer

False. Long term prognosis is usually good

question

True or false. An aneurysmal bone cyst is epithelial lined.

answer

False. It's not a true cyst and also not a vascular aneurysm

question

What is the clinical appearance of an aneurysmal bone cyst?

answer

Mandible > maxilla - displaces dentition but NO RESORPTION - generally in younger pts (~20 years)

question

What is the radiographic appearance of an aneurysmal bone cyst?

answer

- Uni/multilocular (honeycombed/soap-bubble like) - blow out expansion of cortex (causes thinning) - periosteal proliferation maybe

question

You see a multilocular blow out lesion in the mandible on an OPG. What would your differentials be?

answer

1. Ameloblastoma 2. Aneurysmal bone cyst 3. Central giant cell granuloma

question

What is the histological appearance of a central giant cell granuloma?

answer

Same as all giant cell lesions - fibrous CT stroma (around blood filled spaces) - multinucleated OC-like giant cells - ↑↑ Cavernous/blood-filled spaces! + reactive bone trabeculae/osteoid

question

How would you tx an aneurysmal bone cyst?

answer

- Complete removal! (aggressive curettage) - high recurrence rate (if not adequately curettaged) - ↑↑ bleeding!

question

What are causes of 1° hyperparathyroidism?

answer

1. Parathyroid adenoma (80%) - only one PT gland enlarged 2. Hyperplasia - all 4 PT glands enlarged 3. Carcinoma (2%)

question

What is a cause of 2° hyperparathyroidism?

answer

- Chronic renal disease => loss of Ca, break down bone via ↑ PTH

question

In which pts does hyperparathyroidism occur more commonly?

answer

Older pts = >60 year old females

question

What Δs in the bones may you see in a pt with hyperparathyroidism?

answer

- Generalised loss of LD - Brown tumours (RL in bones due to ↑OC activity from ↑PTH)

question

What is the radiographic appearance of hyperparathyroidism?

answer

Uni/multilocular RLs in the mandible - also clavicle & ribs (but any bone possible)

question

Hyperparathyroidism can be considered a giant cell condition. What would you expect the histology to appear like?

answer

- fibrovascular CT - multinuclear OC-like giant cells - extravasated blood plus unique to ↑PTH - TUNNELLING lesion through bone

question

You observe a histological slide and find it's a giant cell lesion. What is it likely to be?

answer

1. Central giant cell granuloma Then the following ranked according to hx: - peripheral giant cell granuloma - cherubism - aneurysmal bone cyst - hyperparathyroidism

question

You find a giant cell lesion after histological analysis. The hx reveals the pt is 65. What would be you first differential?

answer

Hyperparathyroidism!

question

How would you tx 1° & 2° hyperparathyroidism?

answer

↓ PTH! 1° = remove hyperfx tissue/tumour 2° = vit D metabolites/renal transplant => out of our hands

question

What % of oral cancers are SCCs?

answer

>90%

question

True or false. Men are 2x likely to develop oral cancer than women

answer

True

question

What are the general trends regarding the incidence of oral cancer?

answer

> 45 years (but is Δing) Males > females (2x) Low socioeconomic status

question

True or false. The risk of dying from oral cancer is high in NSW.

answer

False. - it's low - we have a high incidence, but low mortality

question

What are the three MAJOR risk factors for oral cancer (note can be E/O and I/O)?

answer

- UV light (lip; ∴ E/O cancer) - tobacco use (smoking & chewing; I/O) - alcohol (esp. w/ smoking; I/O)

question

What other risk factors are there for oral cancers?

answer

- Areca nut - Poor diet (deficiencies => thinning of mucosa => ↑carcinogen effects) - Syphilis - HPV 16 & 18? (oropharyngeal)

question

***IMPORTANT*** True or false. Up to 75% of oral cancers are preventable.

answer

TRUE!

question

Most pts present with oral cancer when the cancer is quite large (>2cm). How can this be prevented?

answer

EARLY/FREQUENT SCREENING - assess high risk sites

question

***IMPORTANT*** What is the natural hx of oral cancer?

answer

Normal cells exposed to carcinogens -> mutations -> WHITE/PATCH (pre-malignant) -> asymptomatic cancer -> swelling/pain/ulceration (non-healing; quite advanced now) -> death

question

What is the gold standard in screening for pre-malignant lesions and oral cancer?

answer

ORAL EXAMINATION! - good lighting (cytology/biopsy, staining, etc come later)

question

True or false. Erythroplakias are considered to be worse than leukoplakias

answer

True! - higher chance of malignant Δ

question

What is an important differential to erythroplakia and how can they be distinguished/

answer

Fe deficiency anaemia - however this would have red mucosa EVERYWHERE - erythroplakia is usually more localised

question

What is the average time it takes for a leukoplakia to develop into a SCC?

answer

~ 8 years

question

You notice severe dysplasia in a histological specimen. Would you be concerned?

answer

Yes - rate of malignant transformation is 43% (cf 3-4% for mild/moderate dysplasia)

question

True or false. There is a specific oncogene that is expressed, or tumour suppressor gene that is inhibited that leads to the formation of an OSCC?

answer

False. Not attributed to a particular gene - accumulation of genetic lesions!

question

What is the issue with screening for oral cancer w/ respect to dentists vs GPs?

answer

- GPs see more of the pts, but lack the tools/training to identify oral cancer - Dentists have the training and tools, but lack the routine pt attendance due to EXPENSE! (no free exams, cf GPs!)

question

Why is the prognosis generally poor for pts with OSCC?

answer

- they present late! => ↑↑ chance of metastases (usu. regional lymph nodes) => 50% 5yr survival

question

What is the main issue with survival of pts w/ OSCC other than they present late?

answer

1 in 4 will develop a new upper aero-digestive tract malignancy - ↑↑ if carcinogenic habits are continued

question

What are some potentially malignant lesions?

answer

- leukoplakia - proliferative verrucous leukoplakia - erythroplakia - oral submucous fibrosis - actinic keratosis - actinic cheilitis (note NOT ANGULAR, the whole lip)

question

What are the most important 1° prevention measures that should be employed?

answer

- Avoid tobacco, excessive alcohol & sunlight! - Health EDUCATION!

question

What are some examples of 2° prevention?

answer

- intervention/excision of leuko/erythroplakias - elimination of risk factors - opportunistic screening

question

Why is a biopsy mandatory for leukoplakias?

answer

Because it's a dx that cannot be attributed to any other condition clinically or microscopically - a dx by exclusion

question

What differentials are there for leukoplakia?

answer

Leukoedema - Linea alba (cheek chewing) - Frictional keratosis - aspirin burn - candidiasis - lichen planus - white sponge naevus

question

***IMPORTANT*** What must you assess if you suspect a leukoplakia?

answer

- Colour - Texture (homo/heterogenous) - Site - Size (also tobacco associated?, candida?, dysplasia?)

question

What might you expect histologically from a leukoplakia?

answer

- Hyperkeratosis - epithelial dysplasia - bulbous rete ridges (tear drop shape)

question

How would you manage leukoplakia?

answer

Controversial - no/mild dysplasia: watch/↓ habits - moderate dysplasia: remove

question

What is the difference between carcinoma in situ and carcinoma?

answer

Carcinoma in situ = hasn't spread! Carcinoma = metastasised

question

What pre-malignant lesion occurs typically in older women that have never smoked/drunk alcohol?

answer

Proliferative verrucous leukoplakia

question

What are the key features of proliferative verrucous leukoplakia?

answer

- Uncommon - EXTENSIVE & MULTIPLE keratotic plaques - females > males (4:1) - older age (50-65) - only 1/3 have risk factors

question

What would you expect histologically from proliferative verrucous leukoplakia?

answer

- Hyperkeratosis/hyperplasia - variable dysplasia

question

How would you manage proliferative verrcucous leukoplakia?

answer

- surgery/ablation - recurrence common - malignant transformation common

question

What is an erythroplakia?

answer

Red patch that cannot be dx'ed as any other condition clinically or microscopically - more serious/advanced than leukoplakia

question

What is the typical clinical appearance of an erythroplakia?

answer

Velvety red, well demarcated patch - usually affects LATERAL TONGUE< FOM or SOFT PALATE.

question

What would be differentials for an erythroplakia?

answer

- Erythematous candidiasis - Reactive inflammatory lesion - Erosive lichen planus - apthous ulcers - viral ulceration etc

question

Why are erythroplakias considered to be more severe than leukoplakias?

answer

Histologically, 90% have severe dysplasia

question

What would you expect the histological appearance of an erythroplakia to look like?

answer

- no keratin - thin epithelium - severe dysplasia - bulbous rete ridges

question

What is oral submucous fibrosis?

answer

- chronic progressive scarring of oral mucosa (fibrous banding) - leads to gradually ↑ing trismus - associated w/ betel & areca nut chewing - leukoplakia lesions (some)

question

What is contained in the betel & areca nut that is of significance?

answer

Alkaloid - gives mild euphoria - stimulates collagen synthesis => fibrous banding of oral mucosa

question

Where would you expect to see oral submucous fibrosis?

answer

Vestibule, palate, B mucosa - the betel nut quid is placed here and chewed?

question

What is the histological appearance of oral submucous fibrosis?

answer

Hyperkeratosis - epithelial atrophy & atypia - pronounced submucosal collagen deposition

question

How would you manage oral submucous fibrosis?

answer

- Cannot be stopped or reversed!! - BIOPSY (confirm dx & check dysplasia) => 8% malignant transformation into SCC - discontinue habit - intralesional GCS to improve trismus - severe cases = surgery to split fibrous bands, skin graft

question

What is actinic keratosis?

answer

Premalignant sun-induced (UV) skin lesion - scaly plaque w/ sandpaper texture - common on the facial skin and vermillion zone of > 40 yr olds

question

What is the histological appearance of actinic keratosis?

answer

- Hyperkeratosis (parakeratin) - epithelial dysplasia/superficial SCC

question

How would you manage actinic keratosis and what prognosis does it usually have?

answer

- lesions tx'ed w/ cryotherapy (liquid N2), surgical excision or laser ablation - Regular monitoring for new lesions! - Prognosis: Fair-good

question

What is actinic cheilosis/cheilitis?

answer

Actinic keratosis on the vermilion zone - usually the lower lip ∴ scaling/crusting/ulceration/fissuring of the lips

question

How would you tx actinic cheilitis?

answer

- Vermilionectomy + advancement of labial mucosa - laser ablation

question

Describe the features of an oral squamous cell carcinoma (OSCC).

answer

- Irregular shape - heterogeneous (red & white) - ulcerated - raised, rolled margins (exo/endophytic growth) - indurated (firmer) - painless/asymptomatic until later - moth-eaten RL if bone involvement

question

What are the common signs for an OSCC?

answer

- Lip (progresion of actinic cheilitis) - Tongue (lateral) - FOM - retromolar

question

Where are the less common sites for OSCCs?

answer

- Gingiva/alveolar mucosa (usually women w/ no risk factors; link to proliferative verrucous leukoplakia?) - Palate (lateral soft palate: link to HPV. Otherwise probably salivary) - Buccal mucosa

question

Why is a SCC of the lip common?

answer

- 2° to UV light exposure (actinic cheilitis)

question

True or false. SCC of the lip has a good prognosis.

answer

True - usu. slow growing & well differentiated

question

If a SCC presents in a younger pt (<40 years), where in the mouth is it common?

answer

- Lateral tongue - FOM

question

SCCs of the tongue and FOM are usually associated with certain habits. What are they?

answer

- Hx cigarette smoking - Alcohol abuse

question

True or false. Erythroplakias have a 50% incidence of SCC development @ presentation.

answer

True

question

What is a habit that may lead to SCC formation in the palate?

answer

- Reverse smoking

question

What are some important differential dx to SCCs?

answer

- non-specific ulcer (traumatic) - specific infections (TB, syphilis) - Immune-mediated conditions (Wegener's granulomatosis, Crohn's) The bottom two all have long-standing, non-healing ulcers. They usually don't have raised rolled margins though

question

How would you distinguish between an ulcer (of any kind) and a SCC?

answer

Any non-specific ulcer, regardless of cause, should resolve within 2 weeks. - if not, SCC suspicion!! (non-specific ulcers go down on the DDx list)

question

How would an SCC present radiographically?

answer

If bone involvement (late) - moth-eaten RL w/ poorly defined border - may lead to pathologic # of bone

question

***IMPORTANT*** What histological features would you expect from a SCC?

answer

- dysplastic surface epithelium - invasive cords & nests of malignant squamous epithelial cells (no longer confined by BM) - tumour cells: ↑ nuclear:cytoplasm ratio, ↑mitotic activity, ↑pleomorphism - varying degrees of keratin (well vs poor differentiated)

question

As a guide (not definitive), how can you tell if a cancer is well or pooly differentiated, and what does this mean?

answer

- Well differentiated = ↑keratin and squames => less mitoses ∴ ↓likely to metastasise - Poorly differentiated = less keratin, ↑mitoses, ↑likelihood metastases

question

What is the most important prognostic factor of an oral SCC?

answer

Lymph node involvement (esp cervical) => ↓ cure chance by 50% (i.e. later we pick it up = ↑ metastatic chance)

question

What are the most common nodes involved in a SCC metastases?

answer

1- submandibular 2- jugulodigastric 3- jugulo-omohyoid 4- cervical nodes 5- nodes of post. triangle

question

How can you assess if there is nodal involvement of an SCC?

answer

Fine needle aspirate of the node - if +ve => resect node

question

What does the TNM clinical classification assess?

answer

Extent of spread of a malignant tumour - via clinical ± radiographic exams ∴ PROGNOSIS!

question

What does TNM refer to?

answer

T = 1° tumour assessment (size) N = Node involvement; uni/bilateral & size (regional nodes) M = metastases (distant?)

question

What is treatment of SCCs guided by?

answer

TNM staging - wide surgical excision? - radiation? - combination? - chemo?

question

What is the prognosis of SCCs usually?

answer

Poor, because of late identification - metastasised to regional nodes - 5 yr survival = 50%

question

What is another oral cancer that is not as common as SCC?

answer

Verrucous carcinoma

question

How may a verrucous carcinoma present?

answer

Diffuse white/mixed plaque on alveolar mucosa, hard palate & B mucosa - tends to grow laterally ∴ prognosis is better than SCC (less likely to metastasise)

question

What is a key feature of verrucous carcinomas?

answer

Grows outwards and becomes extensive, continues to enlarge if not removed - cf SCC, grows deeper and ∴ raised rolled margins - few mitoses & pleomorphs, well differentiated, ∴ can be mistaken as benign

question

Can verrucous carcinomas transform into SCCs?

answer

Yes - 20-25% after complete excision

question

How are verrucous carcinomas usually treated?

answer

- surgical excision (usually quite extensive) - radio tx, but this is not recommended as thought it transforms them to SCCs

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