9- reactive lesions

2 types of denture-related lesions

1. epulis fissuratum

2. inflammatory papillary hyperplasia

definition of epulis

tumor of gingiva or alveolar mucosa

2 clinical features of epulis fissuratum

1. single/multiple folds of hyperplastic in alveolar vestibule 

2. fibroepithelial polylp/leaf-like denture fibroma may be seen along palatal mucosa 

3 histopathologic features of epulis fissuratum

1. hyperparakeratosis/hyperorthokeratosis 

2. papillary hyperplasia and/or pseudoepitheliomatous hyperplasia 

3. hyperplasia of CT 

2 tx options for epulis fissuratum

1. surgical removal

2. remake denture to prevent recurrance

3 clinical features of inflammatory papillary hyperplasia

1. hard palate beneath denture base

2. pink/red pebbly mucosa

3. erythema suggests secondary candidal infection

3 histopathologic features of inflammatory papillary hyperplasia

1. papillary growths on surface

2. may show pseudoepitheliomatous hyperplasia

3. sialadenitis

tx for inflammatory papillary hyperplasia

1. mild cases: remova denture 

2. established cases: excision → relining/refabricating denture 

3. antifungals if needed

what’s a common oral pathology associated w/ trauma

traumatic ulcers

3 histopathologic features of traumatic ulcers

1. ulcerated surface w/ fibrin membrane

2. granulation tissue

3. variable amounts of inflammation

what’s traumatic ulcerative granuloma 

penetrating ulcer that takes weeks-months to resolve 

clinical features of traumatic ulcerative granulomas

1. commonly on tongue

2. often surrounded by white hyperkeratotic rim

traumatic ulcerative granulomas affect men or women more

men

3 histopathological features of traumatic ulcerative granulomas

1. numerous eosinophils 

2. inflammation of skeletal muscle 

3. granulation tissue 

3 tx options for traumatic ulcerative granulomas

1. remove irritant 

2. excision of excess tissue 

3. topical/intra-lesional steroids 

name of pathology that involves hyperplasia of mouth, skin, genitalia epithelium

verruciform xanthoma

4 clinical features of verruciform xanthoma

1. 50% of oral lesions on gingiva/alveolar mucosa

2. may be pink, white, red, yellow, orange

3. well-demarcated verrucous mass

4. may resemble squamous papillomas or early carcinomas

2 histopathologic features of verruciform xanthoma 

1. papillary, acanthotic surface covered by parakeratin

2. large macrophages w/ foamy cytoplasm 

tx option for verruciform xanthoma 

excision

what is this 

verruciform xanthoma 

what is this

verruciform xanthoma 

what is this

verruciform xanthoma 

what is this

verruciform xanthoma 

2 types of chemical injuries

medicament:

1. factitial (self-inflicted)

2. iatrogenic (by provider)

3 causes of factitical medicament chemical injuries

1. aspirin 

2. mouthwashes/hydrogen peroxide 

3. tooth-whitening products 

what is this

aspirin burn

what is this

aspirin burn

what is this

aspirin burn

what is this

mouthwash burn

5 causes of iatrogenic medicament chemical injuries

1. silver nitrate

2. phenol

3. endodontic materials

4. cotton roll “burn”

5. rubber dam application reduces incidence

2 noninfectious complications of chemo/radiation

1. mucositis

2. hemorrhage

3 complications of chemo

1. mucositis (within days)

2. bone marrow suppression: thrombocytopenia, agranulocytosis

3. opportunistic infections: herpes simplex, candidiasis

what is this

oral mucositis developed after chemo

what is this 

oral mucositis developed after chemo

what is this

osteonecrosis of the jaws 

6 causes of osteonecrosis of the jaws 

1. meds

2. radiation 

3. infection 

4. chemicals 

5. trauma 

6. idiopathic 

2 med classes that can cause osteonecrosis of the jaws 

1. anti-resorptive agents:

   1. bisphosphonates

   2. denosumab (prolia, xgeva)

2. anti-angiogenic agents:

   1. monocloncal antibodies (bevacizumab)

   2. tyrosine kinase inhibitors (sunitinib, sorafenib)

3 requirements for diagnosis of medication-related osteonecrosis of the jaws (MRONJ)

1. current/previous tx w/ anti-resorptive or anti-angiogenic agents

2. no hx of radiation/obvious metastasis of jaws 

3. exposed bone or bone that can be probed through a sinus tract persisting > 8 weeks 

9 conditions to rule out when diagnosing medication-related osteonecrosis of the jaws (MRONJ)

1. Alveolar osteitis

2. Gingivitis/periodontitis

3. Sinusitis

4. Caries

5. Periapical pathology

6. Fibro-osseous diseases

7. Cancer

8. Condensing osteitis

9. Temporomandibular disorders

5 pathogeneses of MRONJ

1. Anti-osteoclastic

2. Anti-angiogenic

3. Inflammatory/infectious

4. Immune dysfunction

5. Soft tissue toxicity

which type of bisphosphonates are more potent 

nitrogen containing 

which nitrogen containing bisphosphonates is most potent 

zoledronic acid (zemeta) → more likely to cause MRONJ

5 indications for bisphosphonates 

1. Osteoporosis/osteopenia

2. Multiple myeloma

3. Metastatic carcinomas to bone

4. Paget disease

5. Osteogenesis imperfecta

what is this

medication-related osteonecrosis of the jaws (MRONJ)

4 classifications of medication-related osteonecrosis of the jaws (MRONJ)

1. stage 0: non-exposed

2. stage 1: exposed + asymptomatic

3. stage 2: exposed + symptomatic

4. stage 3: extensive

medication-related osteonecrosis of the jaws (MRONJ) affects max or mand more

mand

T/F: MRONJ can show increased radiopacity before presenting w/ clinical evidence of necrosis

true

3 tx options for asymptomatic pts w/ MRONJ

1. chlorhexidine rinse

2. smooth rough edges of exposed bone

3. soft splint

tx option for symptomatic pts w/ MRONJ

antibiotic therapy + chlorhexidine

3 dental considerations for MRONJ

1. prophylactic dental care 

2. prioritize less invasive procedures 

3. if multiple ext needed, perform by quadrant 

3 complications of radiation

1. thickened saliva via salivary gland hypofunction

2. mucositis

3. osteoradionecrosis (radiation-induced osteonecrosis) 

2 oral complications of radiation

1. increased incidence of cervical caries

2. hypogeusia (reduced taste)

osteoradionecrosis affects max or mand more

mandible 

which age of ppl who are more at risk for osteoradionecrosis

60+ years old

3 tx options for radiation induced hyposalivation

1. pilocarpine/cavimeline

2. topical fluoride

3. caphosol

3 tx options for osteoradionecrosis

1. debridement

2. antibiotics

3. prophylactic ext

6 management options for radiation induced mucositis 

1. viscous lidocaine 

2. chlorhexidine 

3. milk of magnesia 

4. kaopectate rinse 

5. palifermin 

6. systemic morphine 

what is this

exfoliative cheilitis: excess production + desquamation of keratin

exfoliative cheilitis affects men or women more

women

what is this 

“Meth Mouth” 

3 orofacial complications of meth abuse

1. xerostomia

2. bruxism

3. poor hygiene

7 acute potential complications oral piercings

1. pain

2. bleeding 

3. swelling (potential airway obstruction) 

4. infection 

5. lingual nerve damage 

6. speech impairment 

7. allergy 

4 chronic potential complications

1. soft tissue trauma 

2. fractured teeth 

3. hypersalivation 

4. tissue hyperplasia around posts 

what is this

“Susuk” implantation, common in southeast Asia