526: e1 – Flashcard
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What is: small, confined to areas of epidermis or mucosa, distinguished by color from surroundings. < 1 cm in diameter. Not elevated or depressed. Could be normal or local/systemic disease.
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Macule - ex. oral melanotic macule, ephelis, amalgam/india ink tattoo - Red, blue, or black stain
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Where is the wet line
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Junction of lips and labial mucosa
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Where is the vermillion
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Portion of the lip external to wet line
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Where is the vermillion border
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junction of lip with skin
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Where is the labial mucosa? What type of salivary glands are there?
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inner lining of lip - minor salivary glands present (mostly mucous).
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What salivary glands are on dorsal surface of tongue?
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Von ebner - serous
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Where is the buccal mucosa? Where does it extend to? What is the normal pink papule at the commissure called?
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Inner lining of cheek - extends posterior to retromolar pad and pterymomlandibular raphe. Caliculus anglers is the normal, pink papule at the commissure.
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What ducts open on the buccal mucosa?
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Opening of Stenson's Duct (from parotid gland) -> Parotid papilla. Also opening of minor salivary glands.
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What is the periodontium?
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Tissue that immediately surrounds and supports teeth: alveolar bone, periosteum, PDL, gingival sulcus, gingiva.
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Where are the maxillary and mandibular labial frena?
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Superior to the central incisors on the maxillary and mandibular arches. Picture: http://www.oralanswers.com/wp-content/uploads/2010/02/frenectomy_lingual_frenum_and_labial_frenum.jpg
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Where is the mucogingival junction?
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Border between unattached alveolar mucosa and attached gingiva
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Where is attached gingiva located?
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Coronally from alveolar mucosa to free marginal gingiva. Attached to periosteum.
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Where is marginal gingiva located?
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Gingival collar around cervix of tooth. Not attached to periosteum.
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Where is the interdental papilla?
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Marginal gingiva that extends between adjacent teeth
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What papillae are on the dorsum of the tongue?
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Filliform, fungiform, circumvallate, foliate
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What are the most numerous papillae, esp. on anterior 2/3 on the tongue, are slender and are for protection (do not have taste buds)?
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Filiform
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What are the mushroom shaped, slightly elevated papillae above filiform papillae that have taste buds?
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Fungiform
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What papillae are on posterior tongue and contain taste buds?
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Circumvallate
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What are the leaf-like papillae, that are vertical folds on the postero-lateral sides of the tongue?
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Foliate
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What are plica fimbriata?
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Linear projections on the ventral surface of tongue http://en.wikipedia.org/wiki/Plica_fimbriata#mediaviewer/File:Gray1013.png
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What are lingual varicosities?
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Blood vessels on ventral tongue in elderly people - considered normal http://media.dentalcare.com/images/en-US/education/ce337/fig50.jpg
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What is the difference between Ducts of Rivinus vs Bartolin's duct?
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Bartolin's duct is only sometimes present. Sublingual duct may drain from Bartolin's duct or multiple ducts (ducts of rivinus)
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What are the major structures on the floor of the mouth and where are they located?
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Below anterior half of tongue: lingual frenum (ventral tongue to genial tubercles), sublingual caruncle (elevated papule = opening of Wharton's duct), Ducts of Rivinus
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What kind of duct is Wharton's duct? (serous/mucus/mixed) Where are the contents coming from?
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aka Submandibular duct: mixed mucous+serous but more mucous. From submandibular gland.
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When the parotid gland isn't functioning normally, what does patient's saliva look like?
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Ropy saliva due to thick mucous secretions from submandibular gland
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How many salivary glands are in the hard palate?
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None
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Where is incisive papillae and where are they?
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Raised, pink ovoid structure behind and between maxillary incisors overlying nasopalatine foramen.
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What are rugae?
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Fibrous ridges in the anterior 1/3 of palate (no salivary glands here)
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Where is the median palatal raphe?
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Yellow-white fibrous band in midline on hard palate: http://o.quizlet.com/eEDlFxuC.GMwQ5QTZN2h1Q_m.jpg
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Where are fovea palatinae?
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Ducts of minor salivary glands; at junction of hard and soft palate; lateral to median palatal raphe
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Where is the uvula?
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Posterior soft palate
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Where is the oropharynx located? What are the borders?
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Junction between mouth and esophagus Borders: Uvula (anterior), Tonsillar pillars (anterolateral), Pharyngeal wall (posterior)
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Where are tonsils located?
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Dome-shaped, lymphoid tissue within tonsillar pillars
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What is Waldeyer's ring?
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Lingual (posterior tongue), pharyngeal and faucial (tonisllar pillars) tonsils
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What does white tissue suggest on a nodule (fibroma)?
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Hyperkeratinized
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What are some exam techniques used in a head and neck exam?
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Inspection, palpation, percussion of teeth, auscultation, olfaction, exploration
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What characteristics can palpation tell you about?
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Consistency (soft/firm/hard/nodular), tenderness, mobility, bilateral comparison, anatomic identification
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What is the most common oral cancer?
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Basal cell carcinoma
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How should you palpate lymph nodes? If enlarged, what should you then determine?
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Palpate bilaterally. If enlarged, determine mobility and consistency.
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What lymph nodes should you asses?
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Pre-auricular, submental, submandibular, anterior cervical, posterior cervical, and tonsillar
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A perioral and intraoral soft tissue exam is a systematic assessment of what structures?
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1. Lips, 2. Labial mucosa and sulcus, 3. Commissures, buccal mucosa, sulcus, 4. Gingiva and alveolar ridge, 5. Tongue, 6. Floor of mouth, 7. Hard and soft palate - Look for changes in CTSA: color, texture, swollen, and abnormalities
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T/F: you should observe lips with patient's mouth both open and closed.
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True
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T/F: Buccal mucosa can appear yellow and still be normal.
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True - this is due to fat content. There is a range in normal content.
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What is the linea alba?
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Whitish line along the occlusal plane
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T/F: Foliate papilla along the posterior and lateral aspects of the tongue are also high risk areas for oral squamous carcinoma.
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True
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T/F: Fissured tongue can occur because of aging and is considered normal; however bacteria can get into fissures and then the tongue can get inflamed. Then it's considered abnormal.
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True
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Why bimanually palpate the floor of the mouth?
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Sublingual gland and submandibular gland can get tumors - rare but you want to detect early tumors soon for better treatment. Parotid gland accounts for most salivary gland tumors.
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What is a differential diagnosis?
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List of lesions that something could be
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What does CTSA stand for?
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Color, Texture, Swelling, Abnormalities
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What are the areas where you don't see smooth and glistening tissue?
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Anterior palate and attached gingiva
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What surface textures suggest pathology is present?
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Smooth (not stippled), papillomatous, ulcerated, eroded, keratinized, necrotic
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What types of lesions are flat?
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Macules and patches
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What types of lesions are depressed?
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Erosions and ulcers
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What types of lesions are raised?
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Solid: papule, nodule, tumor, plaque Blister-like: vesicle, bulla, pustule, cyst
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What is a small (< 1 cm in size), flat patch that's different in color than adjacent tissues, usually alone, could be normal or pathologic?
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Macule
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What is a larger version of a macule?
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Patch
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What are some examples of patches?
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Amalgam tattoo, snuff-dipper's keratosis
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What are possible sources of pigment in the oral cavity?
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Melanin, metallic, blood (vascular). Pigmented lesions due to melanin are brown or black depending on depth of pigmentation there's variation in appearance. Blanching indicates vascular and should biopsy to rule out melanoma.
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Describe median rhomboid glossitis.
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large, ovoid, red, smooth-surfaced patch, candidiasis, not pigmented. Fungus will regress when treated.
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What are characteristics of erosions? Give examples.
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Soft tissue lesion, lose epithelial cells above basal layer, slightly depressed, could be due to ruptured vesicle, epithelial breakdown or trauma, heals well = no scar. Ex. Erosive lichen planus.
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What are characteristics of ulcers?
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Craterlike lesion. Lose full thickness of epithelium. Extends into connective tissue. Borders round or irregular. May scar. Can be traumatic, aphthous (recurrent) or viral. Painful. Common name: canker sore.
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What is the difference between superficial and depressed lesions?
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Superficial 3 mm in depth
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What would herpetiform aphthae, traumatic ulcers, and primary herpes appear like?
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Multiple small ulcerations with confluent erythematous borders, yellowish center in mandibular anterior vestibule. If had single lesion in vestibule would consider aphthous ulcer.
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Where are fibromas commonly found?
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In gingiva.
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What are solid raised lesions filled with? What are blisters filled with?
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Solid -> tissue, Blister -> fluid
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Describe a papule.
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Small, superficial elevated lesion < 1 cm Sessile (base of lesion is greatest width) or pedunculated (attachment to mucosa is smaller than greatest diameter of lesion) May be due to infection, inflammation, hyperplasia (increase in number of cells) or neoplasia Ex. Fibroma
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How is a pigmented nevus identified?
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By cells of origin, not clinical presentation. It's a benign tumor of nevus cell origin.
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Describe a nodule.
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Extends deep than a papule
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Describe retrocuspid papilla.
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Multiple small bilateral smooth surfaced papulonodular, pink, gingival structures lingual to teeth 22 and 27 - variant of normal
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Describe a plaque
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Flat, solid raised lesion - can be well-circumscribed or diffuse. Ex. cheek biting and lichen planus (plaque-like)
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T/F: Tumors that arise from below epithelium often have rough surface. Lesions that arise within epithelium have a smoother appearance that's more along the lines of a squamous papilloma.
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False - Tumors that arise below epithelium have smooth surface. Lesions within epithelium have corrugated appearance.
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Describe a vesicle.
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Blister-like lesion: small (< 1 cm), fluid filled, raised lesion. Has lymph or blood or serum. If superficial epithelium sloughs off, erosion or ulcer will result (ex. Pemphigus)
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What is a pustule?
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Vesicle filled with purulent exudate (ex. pus)
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Describe recurrent herpes labialis
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Cluster of punctate, yellowish-clear, vesicles at the vermillion-epidermal border
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Describe a bulla.
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Large (> 1 cm), fluid filled, raised lesion. If surface epithelium ruptures, get erosion or ulcer. Ex. Pemphigoid, pemphigus, bullous lichen planus.
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Describe a fissure. Where do these occur?
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Linear crack or cleft. Normal or abnormal. Occurs on tongue, lips, perioral tissue. Fissured tongue is a variant of normal. Infection of fissure may cause pain, ulceration, and inflammation. Ex. Angular Cheilitis. http://en.wikipedia.org/wiki/Angular_cheilitis#mediaviewer/File:Angular_Cheilitis.JPG
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What is a sinus tract? Give an example.
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Tract or fistula that leads from cavity to surface. A parulis is a dilated tract leading from an abscess to the mucosal surface.
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What is a cyst?
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Epithelial lined cavity or sac
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What is a wheal?
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Serum-filled papule or plaque
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What is a differential diagnosis?
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A list of possible diseases that should be considered based on a patient's clinical signs and symptoms
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What is a working diagnosis?
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Information gathered favors a certain diagnosis but more tests needed to be done to confirm diagnosis
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What is a final diagnosis?
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A definitive diagnosis that is made based on the summary of all information collected
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What is the diagnostic sequence of a lesion?
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1. Detect and examine lesion 2. Examine patient 3. Reexamine lesion 4. Classify lesion 5. List the possible diagnoses 6. Formulate the differential diagnosis 7. Develop working diagnosis 8. Final diagnosis
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What is a mucocele?
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Single, well circumscribed elevated lesion. Swelling of connective tissue because of a ruptured salivary gland. Only located in regions with minor salivary glands.
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What is acanthosis?
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Diffuse epidermal hyperplasia. Spinal layer increased in thickness.
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What white lesions can be scrapped off?
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Pseudomembranous candidiasis + Traumatic lesions (physical/chemical irritants)
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What does sessile mean?
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The base is the widest aspect of that lesion
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Describe pseudomembranous candidiasis ("thrush").
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- Cottage cheese/curdled appearance - Tangled mass of hyphae/desquamated epithelial cells - Plaques on buccal mucosa, palate, dorsal tongue - Remove by scrapping with tongue blade - Under mucosa is normal or erythematous - Due to exposure to broad-spectrum antibiotics/impaired immunity
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Describe traumatic white lesions.
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- White peeling or corrugated lesion - Superficial epithelium damaged - White patches, diffuse red, irregular borders - Moveable mucosa more susceptible than attached - Scar: linear, whitish-pink, well defined
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Describe thermal burns.
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- Affect palate or posterior buccal mucosa - Remnants of necrotic epithelium give whitish/yellowish color - Erythematous rim
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Describe chemical burns.
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- Medications held in mouth too long - Possibly due to acid etch materials - Short duration -> white, wrinkled mucosa - Increased duration -> necrosis, remove necrotic tissue -> bleeding connective tissue
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Describe frictional keratosis.
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Trauma-induced white plaque. Chronic mechanical irritation. Roughened keratotic surface Hyper plastic response - due to toothbrush abrasion, cheek biting, linea alba
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Describe effects of cheek chewing/biting.
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Usually on buccal or labial mucosa. On tongue is called (morsicatio linguarum) White areas may occur concurrently with traumatic ulcerations/erosions. Hyper plastic response to trauma.
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What is linea alba?
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Bilateral white line on buccal mucosa Hyperkeratosis of epithelium at interocclusal line No treatment required
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What are fordyce granules?
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Sebaceous (oily) glands on oral mucosa. In 80% of the population (normal variation). Multiple yellow or yellow-white papules. - On buccal mucosa, vermillion of upper lip
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What is leukoedema?
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90% of black adults. Variant of normal. - Grayish-white opalescent mucosa - Folded or wrinkled surface - Bilateral buccal mucosa - Stretch cheek to diagnose
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Describe reticular lichen planus.
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Autoimmune condition. Asymptomatic. Posterior buccal mucosa bilaterally, also on lateral and dorsal tongue, gingiva, and palate. Interlacing white lines called Wickham's striae.
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Describe nicotine stomatitis.
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Not premalignant. Due to heat, not chemicals. Diffuse, grey-white palate. Papules, red centers (inflamed salivary ducts). Marginal gingiva, interdental papilla, buccal mucosa involved.
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Describe smokeless tobacco keratosis/snuff dippers lesion.
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Thin, gray, grayish-white plaque. Pouch in vestibule stretches tissues. Translucent, blends with adjacent mucosa. Rippled "wet sand" effect. Due to absorption of nicotine, linked to quantity and duration. Loss of gingival and periodontal tissues. Destruction of facial surface of alveolar bone. Features depend on amount, # of sites. Histologically: parakeratin chevrons + acanthosis. Risk for squamous cell carcinoma.
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What is leukoplakia?
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White patch or plaque which cannot be removed by scraping and which cannot be diagnosed as a specific entity. Includes benign, precancerous, and malignant lesions.
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Describe Erythema Migrans (Geographic tongue, Benign migratory glossitis).
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Unknown etiology. Female predilection. Asymptomatic unless sensitive to hot/spicy. On dorsum, ant. 2/3 of tongue. Well defined erythematous zones at tip and lateral tongue. Rarely other intraoral sites. Atrophy of filliform papillae. Yellowish-white scalloped or serpentine border. Shows up, heals, then shows somewhere else. Associated w/fissure tongue.
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Describe erosive lichen planus.
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Less common than reticular LP. Peripheral radiating striae. Usually bilateral on buccal mucosa. If confined to gingiva -> desquamative gingivitis. Red (erythematous), atrophic areas with central ulceration. If disease severe -> epithelial separation clinically presenting as bullous LP. Epithelium atrophic or hyper plastic, destruction of basal layer, saw tooth rete ridges. Tx: steroids.
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Describe angular cheilitis. What is the treatment for this.
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Candidiasis at angles of mouth. Erythema, fissuring, scaling. usually alone but may occur concurrently with candidiasis at other sites. Older people, reduced vertical dimension. Saliva pools, moistness predisposes to fungi infection. Often concurrent bacterial infection. Tx: treat both bacterial infection and candidiasis: anti fungal + antibacterial
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Describe denture stomatitis.
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Chronic atrophic candidiasis. Erythema restricted to denture-bearing area. Patient wears denture continuously. Maxillary removable dental prosthesis. Possibly due to fungus, bacteria, improper design
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What are examples of extravascular blood related red lesions? Describe extravascular red lesions.
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Petechiae, purpura, ecchymoses, hematomas. Does not blanch (turn white/pale) upon pressure.
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What are examples of intravascular blood related red lesions?
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Varix/vascular anomaly, Thrombus, Hemangioma, Telangiectasias. These blanch upon pressure.
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What is a petechiae?
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Pinpoint, non raised, circular red spot on soft palate. Palatal petechiae: viral infection, scarlet fever, leukemia, platelet, or coagulation disorder - also might occur due to rupture of palatal capillaries from coughing/sneezing/vomiting. A purpura is a slightly larger area. Ecchymosis > 2 cm. All are macules.
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T/F: If a submucosal hemorrhage is flat, it could be an ecchymosis or a hematoma, but if it's raised, it must be a hematoma.
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True
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Describe varices/varicosities.
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Dilated or tortuous veins. Sublingual varix 60+ yrs. Multiple, bluish-purple elevated or papular blebs. Ventrolateral tongue, lips, BM.
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What are features of hemangioma?
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Benign neoplasm (tissue growth) of vascular origin. Excessive amount of normal tissue. Usually children. More common in females than males. Usually single lesions. May be nodules or macules. Vascular malformation-present at birth. Port wine stains - pink or purple macular lesions on the face.
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In general what do malignant tumors names end with?
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Carcinoma (malignant neoplasm of epithelial origin) or sarcoma (malignant neoplasm of mesenchymal origin).
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In general what do benign tumors names end with?
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"-oma" EXCEPTION: Melanoma + Fibroma.
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What is hypertrophy?
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Increase in the size of cells
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What is atrophy?
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Wasting away of cells
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What is hyperplasia?
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Excessive growth
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What are the metallic lesions we've covered?
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Amalgam tattoos, Bismuth line, Lead line
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What are examples of melanotic lesions?
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Racial pigmentation, melanotic macule, smoker's melanosis, acquired melanocytic nevus, malignant melanoma
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What are blue and purple lesions?
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Varicosities, submucosal hemorrhage, amalgam tattoo, hemangioma, blue nevus, malignant melanoma
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What are brown, grey, and/or black lesions?
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Amalgam tattoo, racial pigmentation, melanotic macule, smoker's melanosis, melanocytic nevus, malignant melanoma, drug ingestion, Neurofibromatosis, Peutz-Jeghers syndrome
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Describe amalgam tattoos.
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Incorporation of amalgam into the oral mucosa via mucosal abrasion, extraction sockets. Features: macules or slightly raised. Blue/black/grey. Well-defined or irregular or diffuse. Gingiva, alveolar mucosa, or buccal mucosa. Histo: granules of amalgam in connective tissue.
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What is a melanotic macule?
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Due to focal increase in melanin. Features: Usually solitary, well-demarcated, asymptomatic. - Lip vermillion, buccal mucosa, gingiva, palate. - Female predilection - Tan to dark brown, rarely blue/black If on lip, labial melanotic macule. If intraoral, then intraoral melanotic macule. Histo: melanin in basal, parabasal cells
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What is smoker's melanosis?
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Features: anterior facial gingiva (cigarettes), extent correlated with cigarettes/day - mucosa is irritated by smoke - female predilection - Histo: similar to melanotic macule - Gradually disappears with smoking cessation
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What is a freckle (ephelis)?
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Pigmented, non-raised lesion - Multiple - Remains same size - Darkens in sunlight - Increase in melanin w/o increase in melanocytes
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What are two syndromes associated with multiple pigmented lesions?
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- Neurofibromatosis - Peutz-Jeghers Syndrome
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Describe a neurofibroma.
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- Most common peripheral nerve neoplasm, involves Schwann cells and perineurial fibroblasts Features: solitary or component of neurofibromatosis -->young adults -->nodules and masses --> Usually nodules on skin - Histo: interlacing bundles of spindle-shaped cells - Tx: Excision: multiple lesions -> patient should be evaluated for neurofibromatosis.
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What's the difference between an incision and an excision?
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Incision: only a portion of a lesion is removed Excision: removal of the whole thing
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How is neurofibromatosis genetically transferred?
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Autosomal dominant (chromosome 17)
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What are the clinical features of neurofibromatosis?
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Multiple nodules throughout the body. Multiple neural tumors, especially neurofibromas. - Papules, nodules, pendulous masses (tumors develop at puberty, continue to adulthood) - Pigmentation on skin - Smooth edged, yellow-tan to brown macules
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T/F: Neurofibromatosis Type 1 cannot undergo malignant transformation to sarcoma.
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False
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How is Peutz-Jeghers syndrome transferred? How does it work?
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Autosomal dominant- mutation of LKB1 encodes a serine/threonine kinase -> get "freckles" on hands, premolar skin, oral mucosa + intestinal polyposis - Freckles do NOT increase in sun exposure (so not true freckles) - Intestinal polyps are hamartomas
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T/F: Patients with Peutz-Jeghers syndrome have 18x greater frequency of tumors of pancreas, genital tract, breast, ovary
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True
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Describe freckles associated with Peutz-Jeghers. Where are they locate? What is the treatment?
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Oral lesions - extension of freckling. Blue-grey macules on vermillion of lip, labial, buccal mucosa, tongue. Tx: monitor for intestinal obstruction, tumors
