pathology bone and salivary gland disorder

torus (plural, tori)

• not a true tumor

• developmental lesion or lesion with a hereditary basis

• more common in women

• as an asymptomatic, bony hard, or lobulated mass

• no treatment is necessary, unless interfere with the fabrication of a denture

torus palatinus

• usually in the midline

torus mandibularis

• usually bilateral, in the premolar area

exostosis

• a small nodular excrescence of normal compact bone

• asymptomatic, on the buccal aspect of alveolar ridge

  • no treatment needed, unless any interference with denture

osteoma

• an asymptomatic, benign tumor composed of normal compact bone

• no sex predilection

• within the bone or as a mass attached to the outer surface of the bone

• within posterior mandible, as most common location

  • surgical excision as treatment, no recurrence

gardner symdrome

• autosomal dominant disorder

• presence of intestinal polyps as most serious feature

• possible malignant transformation into adenocarcinoma

symptoms of gardner syndromes

• mutiple osteomas

• mutiple odontomas

• supernumerary teeth

idiopathic osteosclerosis

• a focal area of increased bone density that cannot be attributed to any specific cause

• common

• also seen in other bones

• teens and young adults

• mandible (90% of cases) : premolar and 1st molar area

• adjacent teeth are vital

idiopathic osteosclerosis differential diagnosis

• contrast with condensing osteitis

• if the tooth is non vital - condensing osteosis

condensing osteitis

• features of condensing osteitis

• non-vital tooth or presence a source of inflammation

• widened PDL

• sclerosis of bone around roots in response to chronic inflammation

• may mimic idiopathic osteoscerosis

multiple osteomas and odontomas (supernumerary teeth)

• which of the following is associated with gardner syndrome

traumatic bone cyst (simple bone cyst)

• asymptomatic intra-osseous empty cavity

• not a true cyst

• may be associated with trauma, patients commonly young

• pseudocyst

• lined by a thin loose connective tissue, scalloped borders

aneurysmal bone cyst

• not a true cyst, caused by increased venous pressure with resultant dilation and rupture of the local vascular network

• “blood soaked sponge” as surgical finding

• arising in a pre-existing bone lesion

• may cause pain and swelling

• large unilocular or multilocular radiolucency

central giant cell granuloma

• a non neoplastic lesion

• more common in females

• mandible> maxilla

• more common in the anterior segment of the jaws

• unilocular or mutilocular radiolucency

• may be associated with jaw expansion and divergence of the adjacent teeth roots. inflammatory reaction

“within the jaw” type of giant cell granuloma

“central” in central cell granuloma suggests

central giant cell granuloma occlusal radiograph of mandible

• may demonstrate CGCG as cause of expansion of internal and external cortical bones

central giant cell granuloma maxillary occlusal radiograph

• demonstrates CGCG as cause of divergence of roots of maxillary central incisors

post surgical hyperostosis

• tumor like (reactive) growth of bone at the surgical site

• in periosteum following periodontal surgery such as a gingival graft

female patients, anterior mandible

• central giant cell granuloma is more common in

an intraosseous cavity without epithelial lining

• a traumatic bone cyst is best described as

benign fibro-osseous lesion of the jaws

• a group of diseases characterized by the replacement of bone with abnormal fibrous connective tissue interspersed with varying amounts of calcification

  • fibrous dysplasia

  • central ossifying/cementifying fibroma

  • cemento-osseous dysplasia

fibrous dysplasia classification

• unknown, maybe a developmental disease

central ossifying/cementifying fibroma classification

• neoplasm

cemento-osseous classification

• reactive lesion

fibrous dysplasia

• benign fibro-osseous lesion of the jaw

• uncommon, benign, chronic bone disease

• replacement of bone by fibrous connective tissue intermixed with delicate bony trabeculae

• monostatic type is most common, polyostotic type

• maxilla > mandible

• painless, gradual enlargement of the affected bone

• children and young adults

monostatic type of firbous dysplasia

• most common type

  • affects only 1 bone

polyostotic type

• type of fibrous dysplasia

• involvement of more than one bone

fibrous dysplasia radiographic characteristics

• “ground glass” appearance on radiograph

• abnormal bone blends into the normal adjacent bone

• ill-defined borders

fibrous dysplasia histopathologic features

• chinese letter appearance

central ossifying/ cementifying fibroma

• a benign fibro-osseous lesion of the jaw

• a true benign neoplasm composed of fibrous tissue containing bone, cementum-like material, or both

• most patients are in 3-4th decades of life

• female predilection

• mandible> maxilla

• radiographically, a well-defined unilocular radiolucency with varying degrees of radiopacity

juvenile ossifying fibroma

• unilocular or mutilocular radiolucencies

• mixed radiolucent/radiopaque

• radiopacity depending on amount of cacification

cemento-osseous dysplasia

• a benign fibro-osseous lesion of the jaw

• a common fibro-osseous lesion that occurs in the tooth-bearing areas of the jaws

• in this setting “dysplasia” does not imply that the lesion if precancerous

  • periapical

  • focal

  • florid

periapical cemento-osseous dysplasia

• not a neoplasm

• adult females

• black population (70% of cases)

• periapical region of anterior mandible

• asymptomatic

• early lesions mimic periapical inflammatory pathology (early is radiolucent)

• involved teeth are vital

focal cemento-osseous dysplasia

• asymptomatic, found incidentally on radiographs

• female predilection (30-50 years of age)

• more common in white population

  • posterior mandible, most common location

florid cemento-osseous dysplasia

• involvement of multiple quadrants in the maxilla and mandible

• most often seen in black women

• treatment is often unnecessary

• osteomyelitis as one complication in edentulous patients

mandibular anterior region

• periapical COD primarily affects

paget disease of bone

• another name: osteitis deformans

• a chronic metabolic bone disease

• most common in men over the age of 50

• pelvis and spinal column

• jaws: maxilla> mandible

paget disease of bone clinical manifestations

• enlargement, deformity, and pain of affected bone

• jaws: spacing between the teeth, complaining of current denture

• involvement of skull bones: headache, dizziness, and deafness

cotton-wool appearance

• paget disease of bone radiographic features

• hypercementosis

histopathologic feature of paget disease

• mosaic pattern due to prominent reversal lines

paget disease of bone diagnosis

• laboratory evaluation is important in establishing the diagnosis of paget disease

• significant elevation of the level of serum alkaline phosphatase

osteoblastoma

• a benign tumor with cells showing osteoblastic differentiation

• a bone-forming tumor, but the bone as not as mature seen in osteoma

• mixed radiolucent/radiopaque

osteosarcoma

• a malignant tumor of bone-forming tissue

• most common primary malignant tumor of bone in patients under 40 years of age

  • gnathic

  • extragnathic

• treatment: surgery, adjuvant chemotherapy, radiotherapy

gnathic osteosarcoma

• 3rd and 4th decades

extragnathic osteosarcoma

• long bones

• 10-20 year olds

osteosarcoma radiographic features

• “sun ray” or “sun burst” appearance

• widening of the PDL of involved teeth

metastatic tumors of the jaws

• the most common form of malignancy involving bone

• mandible as the most frequent intraoral site for metastatic tumors of the jaws

• primary tumors: breast, lung, thyroid, prostate, and kidney

clinical features of metastatic tumors of the jaws

• pain, paresthesia or anesthesia of the lip

• swelling and expansion of the affected bone and loosening of the teeth

radiographic features of metastatic tumors of the jaws

• usually poorly-defined and radiolucent

• metastatic tumors from the breast, prostate gland, and lungs may form bone

• radiopaque

sun-ray or sun-burst appearance

• radiographically, osteosarcoma of the jaws may show

major salivary glands

• parotid

• submandibular

• sublingual

minor salivary glands

• distributed in the oral cavity

xerostomia

• subjective sensation of dry mouth

• in 25% of older adults, but not a normal aspect of aging

systemic diseases associated with xerostomia

• sjrogen syndrome

• diabetes mellitus

• diabetes insipidus

• sarcoidosis

• HIV infection

• graft-versus-host disease

• psycogenic disorders

developmental causes of xerostomia

• salivary gland aplasia

water/metabolic loss causes of xerostomia

• impaired fluid intake

• hemorrhage

• vomitting/diarrhea

latrogenic causes of xerostomia

• medications

• radiation therapy to the head and neck

local factors that contribute to xerostomia

• decreased mastication

• smoking

• mouth breathing

medications that may induce xerostomia

• antihistamines

• decongestants

• antidepressants

• antipsychotic

• antihypertensives

• anticholinergics

treatment of xerostomia

• stay hydrated with water throughout the day

• sugarless candy (stimulates flow)

• daily fluoride application

• biotene products

• artificial saliva

• systemic drugs

  • pilocarpine (salagen)

  • cevimeline (evoxac)

sialadentitis

• inflammation of the salivary glands

• can be due to a variety of infections and non infectious causes

• mumps, as most common viral cause

• staphylococcus aureus is the most common bacterial cause

• most bacterial infections are the result of reduced salivary flow or ductal obstruction, allowing retrograde spread of bacteria

• mumps

most common viral cause of sialadenitis

staphylococcus aureus

• most common bacterial cause of sialadentitis

• most bacterial infections are the result of reduced salivary flow or ductal obstruction, allowing retrograde spread of bacteria

mucous extravasation phenomenon (mucocele)

• mucous spillage into the soft tissues due to rupture of a minor salivary gland duct

• causes by local trauma (common in kids)

• fluid-filled lesions that is often blue or translucent in color

• lower lip is the most common location

ranula

• a mucocele in the floor of the mouth

superficial mucoceles

• minor gland ducts close to mucosal surface involved

• cause by mucosal inflammation rather than rupture of duct

• tiny, clear, and bubble-like

• soft palate, retromolar region, and the posterior buccal mucosa as the common sites

• more common in patients with xerostomia

ranula

• mucoceles in the floor of the mouth, trauma induced

• lateral to the midline, painless swelling

• appearance similar to the underbelly of a frog (rana)

• possible displacement of the tongue

  • cervical or plunging

  • oral

oral ranula

• superior to the mylohyoid muscle

cervical or plunging ranula

• below the mylohyoid muscle

salivary duct cyst

• a mucous retention phenomenon, called mucous retention cysts or sialocyst

• a true cyst

• similar to mucocele clinically

• blockage of the salivary duct (by salivary gland stone) → cystically dilation of the duct

• surgical excision as treatment

stress

• most common cause of xerostomia

cysts of blandin-nuhn

• mucoceles or mucous duct cysts forming in blandin-nuhn glands as mixed glands located in anterior ventral tongue

• usually pedunculated and dome shaped

sialolithiasis (salivary stones)

• calcified structures, develop within the salivary ductal system

• proposed etiology: deposition of calcium salts around a nidus of debris (bacteria, foreign body, epithelial cells, mucous plug, etc)

• chronic sialadenitis and partial duct obstruction promotes stone formation

• submandibular gland duct as most common location

salivary stones (sialolithiasis) clinical signs

• episodic pain or swelling of the affected gland at midline

sialolithiasis (salivary stone) treatment

• can sometimes be worked toward the orifice and “passes” by heat, increased fluid intake, and milking/massaging of the gland

• lithotripsy (shock waves break up stone into smaller pieces that can be passed)

• surgical removal is often indicated

• the associated gland may also need to be removed if significant inflammatory damage has occured

sialadenosis

• nonneoplastic, noninflammatory salivary gland enlargement, usually involving the parotid gland

• cause by peripheral neuropathy of the autonomic nerve supply

• 50% of cases associated with underlying systemic factors, including diabetes, hypothyroidism, bulemia, malnutrition, alcohol abuse, and drugs

• as a side effect of certain antihypertensive or psychotropic drugs

adenomatoid hyperplasia

• increase in the number of gland acini in minor salivary gland

• seen as firm, nontender mass, mimicking a minor salivary gland tumor

• hard palate as the most common location

nectrotizing sialometaplasia

• an inflammatory process

• caused by ischemia → infarction → necrosis and ulcer → sloughing necrotic tissue → healing

• potential/suggested predisposing factors

  • injury (trauma, dental injection, previous surgery)

  • ill-fitting denture

  • adjacent tumor

• heals spontaneously over a period of 4-6 weeks

• posterior palate (75% of all cases)

sjogren syndrome

• an autoimmune disease

• affects the salivary and lacrimal glands

  • typically leads to xerostomia

  • keratoconjunctivitis → dry eye

  • chronic inflammatory connective tissue disease → rheumatoid arthritis

  • raynaud phenomenon (white fingers) → triggered by cold and emotional stress

oral manifestations of sjogren syndromes

• atrophy of the dorsal surface of the tongue

• cervical caries

• candidiasis

treatment for sjogren syndrome

• symptomatic

• artificial saliva, artificial tears

• sugarless gum or lozenges

• maintaining good oral hygiene, using fluoride toothpaste

• corticosteroids and immunosuppressive agents for severe cases

sublingual gland tumor prevalence

• 1% of all tumors

• 70-90% malignant

parotid gland tumor prevalence

• most common site

• 64-80% of all salivary tumors

• 15-32% malignant

submandibular gland tumor prevalence

• 8-11% of all salivary tumors

• 37-45% malignant

minor salivary gland tumor prevalence

• 9-25% of tumors

• 50% malignant

general clinical features of salivary gland tumors

• female predilection

• painless swellings as most common presentation

• malignancies may mimic benign tumors or be ulcerated

• pain need not indicate malignancy

• paresthesia suggestive of malignancy

• most common sites for minor salivary gland tumors in order

  • palate

  • upper lip

  • buccal mucosa

diagnosis of salivary gland tumor

• physical examination

• CT

• MRI

• ultrasound

• fine needle aspiration (FNA) - core sample of gland is taken with needle

• biopsy

benign salivary gland tumors

• pleomorphic adenoma

• warthin tumor (papillary cystadenoma lymphamatosum)

• canalicular adenoma

• basal cell adenoma

• salivary ducts papillomas

pleomorphic ademona

• benign salivary gland tumor

• most common salivary neoplasm

• painless, slow-growing firm mass, intraorally is commonly seen on palate

• female predilection

pleomorphic adenoma histopathologic features

• mixture of ductal and myoepithelial elements

• well-circumscribed, encapsulated

• ducts and cystic structures

• myoepithelial cells

• stromal changes: myxoid, hyalinized, focal areas of fat, chondroid, and osteoid

pleomorphic ademona treatment and prognosis

• surgical excision

• recurrence in multifocal cases

• small risk of malignant transformation (5% of all cases)

warthin tumor (papillary cystadenoma lymphomatosum)

• benign

• second most common benign partoid tumor

• almost exclusively in the partoid gland

• strong association with smoking

warthin tumor (papillary cystadenoma lymphomatosum) clinical features

• slowly growing painless mass

• MALE predilection, 6-7 decades of life

• most likely salivary gland tumor to appear bilaterally (5-14% of all cases)

warthin tumor histopathologic features

• cystic spaces lined by ductal oncocytic epithelium in papillary configuration

• lymphoid stroma with frequent germinal center formation

warthin tumor treatment and prognosis

• surgical removal

• 6-12% recurrence

canalicular adenoma

• benign salivary gland tumor

• exclusively in the minor salivary glands

• 75% in upper lip

• buccal mucosa, second most common site

• female predilection

• surgical excision as treatment

malignant salivary gland tumors

• may appear clinically innocuous

• may appear histopathologically innocuous

• may be associated with paresthesia, tumor fixation, or ulceration

types of malignant salivary gland tumors

• mucoepidermoid carcinomas

• polymorphoud low-grade adenocarcinoma

• adenoid cystic carcinoma

• acinic cell carcinoma

• carcinoma ex-pleomorphic adenoma

mucoepidermoid carcinoma

• most common malignant salivary neoplasm in adults and children

• second most common salivary tumor

• in US, 10% of all major gland tumors and 15-21% of minor gland tumors

• variable biologic potential (low, intermediate, and high grades)

mucoepidermoid carcinoma clinical features

• seen in wide age range

• female predilection

• parotid, most common site

• an asymptomatic swelling