12. Reactive Lesions

tumor of gingiva or alveolar mucosa is called…?

epulis

what condition is a tumor-like hyperplasia associated with flange of poorly-fitting denture?

epulis fissuratum

slide 4

Inflammatory fibrous hyperplasia, denture epulis

what are clinical features of epulis fissuratum?

• single or multiple folds of hyperplastic tissue in alveolar vestibule

• fibroepithelial polyp/leaf-like denture fibroma along palatal mucosa

epulis fissuratum

epulis fissuratum

epulis fissuratum

epulis fissuratum

epulis fissuratum

epulis fissuratum

epulis fissuratum

what are histopatholgic features of epulis fissuratum?

• Hyperparakeratosis or hyperorthokeratosis

• Papillary hyperplasia and/or pseudoepitheliomatous hyperplasia

• Hyperplasia of connective tissue

what is the treatment and prognosis of epulis fissuratum?

• surgical removal

• remake denture to prevent recurrence

Inflammatory Papillary Hyperplasia is associated with …?

• poorly-fitting dentures

• poor denture hygiene

• continuous denture wear

what condition is also known as denture papillomatosis and is a reactive tissue growth on the hard palate mucosa?

Inflammatory Papillary Hyperplasia

what are clinical features of Inflammatory Papillary Hyperplasia?

• on hard palate beneath denture base

• pink/red pebbly mucosa

  • erythema = secondary candidal infection

what is the difference between Inflammatory Papillary Hyperplasia and Epulis Fissuratum?

location

Inflammatory Papillary Hyperplasia → hard palate

Epulis Fissuratum → alveolar vestibule

Inflammatory Papillary Hyperplasia (with candidal infection)

Inflammatory Papillary Hyperplasia (alone. WITHOUT candidiasis cuz there’s no erythema)

Inflammatory Papillary Hyperplasia (with candidal infection)

Inflammatory Papillary Hyperplasia (with candidal infection)

what are histopathologic features of Inflammatory Papillary Hyperplasia?

• papillary growths on surface

• pseudoepitheliomatous hyperplasia

• Sialadenitis (inflammation of salivary glands)

what is the treatment and prognosis of Inflammatory Papillary Hyperplasia?

• mild cases → resolve with removal of denture

• established cases → relining/refabricating denture following excision of hyperplastic tissue

• antifungal therapy (as neeeded)

t/f: traumatic ulcers are a common oral pathology

true

describe the histopathology of traumatic ulcers

• ulcerated surface with fibrin membrane

• granulation tissue

• variable amounts of inflammation

traumatic ulcers

anesthetic-associated lip bite is a type of traumatic ulcer that is often secondary to what type of nerve block?

inferior alveolar nerve block (history of recent dental treatment)

what is a slow-healing, penetrating ulcer takes weeks to months to resolve?

Traumatic Ulcerative Granuloma

t/f: Traumatic Ulcerative Granuloma is a true granuloma

false. not a true granuloma (but can be mistaken for malignancy)

Traumatic Ulcerative Granulomas are most common where?

tongue

t/f: Traumatic Ulcerative Granuloma have a male predilection

true

Traumatic Ulcerative Granulomas are often surrounded by…?

white hyperkeratotic rim (may help distinguish from aphthous ulcers or SCCA)

Traumatic Ulcerative Granulomas

Traumatic Ulcerative Granulomas

Traumatic Ulcerative Granulomas

Traumatic Ulcerative Granulomas

Traumatic Ulcerative Granuloma

Traumatic Ulcerative Granuloma

what are histopathologic features of Traumatic Ulcerative Granuloma?

• numerous eosinophils

  • may be called Traumatic Ulcerative Granuloma with stroma eosinophilia (TUGSE)

• inflammation of skeletal muscle

• granulation tissue

what is the treatment and prognosis of Traumatic Ulcerative Granuloma?

• remove irritant

• excise excess tissue (if necessary)

• topical and/or intra-llesional steroids

• hyperplastic epithelium of mouth, skin, and genitalia

• lipid-laden macrophages beneath epithelium

• well-demarcated verrucous mass

• may resemble squamous papillomas or early carcinomas

What condition?

Verruciform Xanthoma

is Verruciform Xanthoma associated with HPV?

no. it is papillary but not associated with HPV

50% of oral lesions due to Verruciform Xanthoma are on what surfaces?

gingiva or alveolar mucosa

what colors can Verruciform Xanthoma lesions present as?

pink, white, red, yellow, orange

Verruciform Xanthoma

Verruciform Xanthoma

Verruciform Xanthoma

Verruciform Xanthoma

Verruciform Xanthoma

Verruciform Xanthoma

what are histopathologic features of Verruciform Xanthoma?

• Papillary, acanthotic surface covered by parakeratin

• Large macrophages with foamy cytoplasma

  

what is the treatment and prognosis of Verruciform Xanthoma?

• conservative excision

• recurrences are rare

what are some different types of chemical injuries?

• medicaments

• iatrogenic

what are some things that can cause factitial medicament chemical injuries?

• aspirin

• mouthwashes/hydrogen peroxide

• tooth-whitening products

factitial medicament chemical injury from aspirin tablet burn

factitial medicament chemical injury (aspirin burn)

factitial medicament chemical injury (aspirin burn)

factitial medicament chemical injury (listerine)

what are some things that can cause iatrogenic chemical injuries?

• silver nitrate

• phenol

• endodontic materials

• cotton roll “burn”

what can reduce incidence of iatrogenic chemical injuries?

rubber dam application

what is a cotton roll “burn”?

• Medicament concentrated against the tissue

  • e.g., Acid etch solution

• Removal without first moistening strips mucosa

what are some cancer treatments (antineoplastic therapies) that can cause Noninfectious Complications?

• chemotherapy

• radiotherapy

what are 2 acute changes that arise as Noninfectious Complications of Antineoplastic Therapy?

• mucositis

• hemorrhage

what are some oral complications that arise due to chemotherapy?

• mucositis (within days)

• bone marrow suppression

  • thrombocytopenia

  • agranulocytosis

• opportunistic infections

  • herpes simplex

  • candidiasis

chemotherapy-related oral mucositis

chemotherapy-related oral mucositis (ropey saliva due to affected salivary glands)

chemotherapy-related oral mucositis

what are causes of osteonecrosis of the jaws?

• Medication

• Radiation

• Infections

• Chemicals

• Trauma

• Idiopathic

osteonecrosis of the jaws

what are some anti-resorptive agents that can cause osteonecrosis of the jaws?

• Bisphosphonates

• Denosumab

what are some anti-angiogenic agents that can cause osteonecrosis of the jaws?

• monoclonal antibodies

• tyorsine kinase inhibitors

what classification of medications can cause osteonecrosis of the jaws?

• anti-resorptive agents

• anti-angiogenic agents

what are prereqs to diagnosing a pt with Medication-Related Osteonecrosis of the Jaws (MRONJ)?

• Current/previous treatment with anti-resorptive OR antiangiogenic agents

• Exposed bone OR bone that can be probed through a sinus tract persisting > 8 weeks

• No h/o radiation or obvious metastasis to the jaws

when evaluating Medication-Related Osteonecrosis of the Jaws (MRONJ), what are some other conditions to consider and rule out?

• Alveolar osteitis

• Gingivitis/periodontitis

• Sinusitis

• Caries

• Periapical pathology

• Fibro-osseous diseases

• Cancer

• Condensing osteitis

• Temporomandibular disorders

describe the pathogeneisis of Medication-Related Osteonecrosis of the Jaws (MRONJ)

• Anti-osteoclastic

• Anti-angiogenic

• Inflammatory/infectious

• Immune dysfunction

• Soft tissue toxicity

what are the 2 major classes of bisphosphonates?

• non-nitrogen containing

• nitrogen containing (more)

potency is related to likelihood of developing Medication-Related Osteonecrosis of the Jaws (MRONJ)

why might pts be taking bisphosphonates? (aka what are indications for bisphosphonates)

• Osteoporosis/osteopenia

• Multiple myeloma

• Metastatic carcinomas to bone

• Paget disease

• Osteogenesis imperfecta

anything to prevent bone or bone lesion

Medication-Related Osteonecrosis of the Jaws (MRONJ)

Medication-Related Osteonecrosis of the Jaws (MRONJ)

Medication-Related Osteonecrosis of the Jaws (MRONJ)

what is the AAOMS Staging of Medication-Related Osteonecrosis of the Jaws (MRONJ)?

• Stage 0: non-exposed

• Stage 1: exposed asymptomatic

• Stage 2: exposed symptomatic

• Stage 3: extensive disease

in Medication-Related Osteonecrosis of the Jaws (MRONJ), what may be noted before clinical evidence of necrosis?

increased radiopacity

which jaw is affected more by Medication-Related Osteonecrosis of the Jaws (MRONJ)?

Mandible affected more than maxilla, but discrepancy not as great as in osteoradionecrosis

what treatment is indicated for Medication-Related Osteonecrosis of the Jaws (MRONJ)?

• best treatment = prevention

• asymptomatic

  • chlorhexidine rinse

  • smooth rough edges of exposed bone

  • soft splint

• symptomatic

  • systemic antibiotic therapy and chlorhexidine

  • hyperbaric oxygen NOT beneficial

Medication-Related Osteonecrosis of the Jaws (MRONJ)

what dental considerations can be applied for Medication-Related Osteonecrosis of the Jaws (MRONJ)?

• prophylactic dental care

• less invasive procedures

• multiple extraction performed by quadrant

what oral complications occur with radiotherapy?

• saliva thickens (1 week)

• salivary gland hypofunction

• mucositis (1-2 weeks)

• osteoradionecrosis

• hypofunction (xerostomia)

• cervical caries

• hypogeusia

radiation related mucositis

cervical caries (radiotherapy complication)

radiotherapy related mucositis

osteoradionecrosis is a type of _____ necrosis.

ischemic

is there infection present in osteoradionecrosis?

not necessarily

which jaw is more often affected in osteoradionecrosis?

mandible

osteoradionecrosis can lead to what symptoms…?

pain, fracture

what levels of radiation place pts at low risk for osteoradionecrosis? greater risk?

• Low risk < 45 Gy

• Greater risk > 60 Gy

(after 1 year, incidence decreases)

why might osteoradionecrosis create a complication for dental prosthesis wearers?

Dental prosthesis intolerance due to xerostomia

what treatements are indicated for osteoradionecrosis?

• Debridement

• Antibiotics

• Hyperbaric oxygen?

• Prophylactic extractions

what treatments are indicated for hyposalivation caused by radiotherapy?

• Pilocarpine or cevimeline

• Topical fluoride

• Caphosol

what treatments (management therapies) are indicated for mucositis caused by radiotherapy?

• Viscous lidocaine

• Chlorhexidine

• Milk of magnesia

• Kaopectate rinse

• Palifermin

• Systemic morphine

• persistent scaling of vermilion

• excess production and desquamation of keratin

• various etiologies

• perioral skin may become involved

What condition?

Exfoliative Cheilitis