Everyday Encounters with
Oral Pathology:
Review, Refresh, Discover
Friday, October 24, 2014
Alice E. Curran, DMD, MS
University of North Carolina School of Dentistry
Division of Oral and Maxillofacial Pathology
Warm Up #1
Incidental Finding
2
Warm Up #2
His commissures are tender
3
Warm Up #3
Retained Primary Incisor
4
Warm Up #4
Soft fluctuant mass came up quickly
5
Warm Up #5
Tenderness after new denture placement
6
Warm Up #6
Mildly tender area of short duration;
has happened before
7
Warm Up #7
Firm midline mass moves when he swallows
8
Warm Up #8
Lesion disappears when stretched
9
Warm Up #9
This does not disappear when stretched
10
Warm Up #10
Child with gingival that grows, is removed and
grows back again
11
Warm Up #11
Adult with gingival overgrowth of recent onset
12
Warm Up #12
This patient’s tooth erupted this way
13
Warm Up #13
Asymptomatic found on routine exam
14
Discussion of Warm Ups
Torus Palatinus/Torus Mandibularis
Variations of Normal
Not considered pathologic but often
the target for injury
Can get rubbed on, burned or otherwise assaulted
16
Angular Cheilitis
• Sometimes called
Perleche
• Etiology is candida
albicans but
occasionally Staph is
involved
• Caused by:
• Management: correct
VDO or other issue
causing infection
• Vytone cream
• Alcortin A
– Overclosure
– Licking the commissures
– Immunodeficiency
17
Compound Odontoma
• Made up of tiny toothlets
• Enclosed in a follicle
• Acts like an impacted tooth and must be
treated as such to prevent further pathologic
changes
18
Mucocele
• A mucocele of salivary
glands is caused by
severing (cutting) of the
duct
• If the duct is severed
more deeply, a larger
more bluish fluctuant
mass will develop
Saliva spills out and
collects in the adjacent
tissue
19
Superficial Mucocele
• Occurs if severed duct is close to the surface
• Or due to mucosal inflammation that damages
end of duct
• Usually pop on their own
20
How does a mucocele differ from
Herpes Labialis?
•
•
•
•
•
1) Herpes is caused by a virus
2) It recurs in the same location
3) Occurs in a cluster of small vesicles
4) Vesicles are preceded by a prodrome
5) Vesicles coalesce, rupture and leave an
ulcer that crusts over
21
What is an ulcer?
• Loss of epithelial continuity with exposure of
the underlying connective tissue and nerve
• Hallmark is yellow necrotic center with red
halo
22
Traumatic Ulcer
• Post-anesthetic necrosis
– Child plays with numb lip
– No pain due to anesthesia but injury occurs
nevertheless
– Pain begins when anesthesia wears off
23
Practice Tip: Known traumatic ulcers should NOT
be treated with topical anti-inflammatory agents
• Anti-inflammatory agents include
– Topical triamcinolone (Kenalog), fluocinonide (Lidex) and
clobetasol (Temovate)
• These medications are designed to SUPPRESS an
inappropriate inflammatory response in autoimmune
diseases
• A traumatic injury NEEDS a healthy, functioning
immune response to carry out wound repair
• Using an anti-inflammatory agent will prolong healing
• LET NATURE TAKE ITS COURSE…use analgesics if
indicated
24
Geographic Tongue
Patients often believe they burned themselves
with something hot
•
•
•
•
•
•
Actually, the lesion occurs first
It is asymptomatic
Then they pour something hot on it
Pain comes from “loss of insulation”
No cure
Lesions have characteristic yellow halo and red
atrophic center. There is NO ULCER
25
Geographic Tongue and Geographic Mucositis
• There is no curative
treatment
• Etiology is still unknown
• Palliative treatment
– 50/50 Maalox and
Benadryl swished before
meals or whenever
symptoms flare
– Avoid hot or spicy foods
• 50/50 mixture:
• 1 teaspoon Maalox (or
other thick antacid
liquid)
• 1 teaspoon liquid
Benadryl
• Swish for 2 mins
• Expectorate
• Provides temporary
relief
Thyroglossal Duct Cyst
• Remnants of thyroglossal duct may form cysts
anywhere from the foramen cecum to just
above the suprasternal notch
• Soft, fluctuant
• Always in the midline of the neck
• If they adhere to the hyoid bone, the mass
appears to move as the patient swallows
27
Leukoedema
• Considered a variation of normal
• Milky white/opalescent lesions disappear
when stretched
• No treatment needed
28
Practice Tip for Tobacco Chewers who want to
quit:
Golden Eagle Herbal Chew:
starwest-botanical.com
Bacc-Off: baccoff.com/
Add a nicotine patch
Coffee-Based Alternatives:
http://www.getgrinds.com/info/
• Smokeless tobacco
lesions are reversible
but
periodontal problems
may persist
• Each pouch is equal to about
1/4 cup of coffee
• Swallow saliva rather than
spitting it out
29
Gingival Overgrowth
(formerly called Gingival Hyperplasia)
• Drugs are Associated with • Dilantin
Gingival Overgrowth
• Nifedipine
• Cyclosporine
Also associated with
A list of syndromes with
Hereditary GO are listed
in your handout
Heredity
Leukemia
30
Patient wants to know what happened to tooth
How can you tell when it happened?
• Age of eruption = Age of Crown Completion
2
This injury to developing
tooth germ occurred before
3.5 -4 years of age
31
Five Basic HPV Lesions Seen in the Oral Cavity
and Oropharynx
32
As a Clinician and Patient Educator, You Will be
Dealing with Questions about HPV
for Many Years to Come
Where will new information come from on this
emerging problem?
How do you know you can rely on it?
33
Hierarchy in the Level of Evidence
Observational Research
• Anecdotal Evidence
• Case Reports
• Case Series
• Case-Control Studies
• Cross-Sectional Studies
Interventional Research
• Clinical Trials
– Randomized Controlled
Clinical Trials
– Double-Blinded
34
Anecdotal Evidence
• Description (i.e., short
narrative),
• “I know a person who..."; "I
know of a case where…”
• Reliability by objective
independent assessment
may be in doubt
• Anecdotal evidence does
not qualify as scientific
evidence because its nature
prevents it from being
investigated using the
scientific method
• Wisconsin mom: ‘Did HPV
vaccine kill my 12-year-old
daughter?’
– Mysterious death of Meredith
Prohaska being investigated
in Waukesha. Mother thinks it
was caused by vaccination
against sexually transmitted
virus.
• NEW YORK DAILY NEWS
• Saturday, August 9, 2014,
35
Case Reports/ Case Series
• Single individual or small
groups in which the possibility
of an association between an
observed effect and a specific
environmental exposure is
based on detailed clinical
evaluations and histories of
the individual(s).
• Most likely to be useful when
the disease is uncommon and
when it is caused exclusively
or almost exclusively by a
single kind of exposure
• May be first to provide clues in
identifying a new disease or
adverse health effect from an
exposure.
36
Cross Sectional Study
• Analysis of data
collected from a
population, or a
representative
subset, at one
specific point
in time
Association
Cause
37
Case Control Study
• Two existing groups are
identified and compared on
the basis of some supposed
causal attribute
• Often used to identify
factors that may contribute
to a medical condition
• Compares subjects who
have that condition/disease
(the "cases") with patients
who do not have the
condition/disease but are
otherwise similar (the
"controls")
38
The Scientific Method
• The scientific method is a group of techniques
for investigation, acquiring new Knowledge, or
correcting and integrating previous knowledge
• Scientists support a theory when a theory's
predictions are confirmed and challenging a
theory when its predictions are shown to be
false
39
Steps
•
•
•
•
•
•
Formulation of a question
Hypothesis- conjecture
Prediction
Testing
Analysis
Replication
40
Example
• Formulation of a question: If periodontal inflammation
causes preterm birth, does reducing periodontal
inflammation reduce preterm birth?
• Hypothesis- Removing periodontal pathogens influences
the growth of the fetus in a positive way
• Prediction- women who receive comprehensive perio
therapy will have few preterm babies
• Testing: in a large group of pregnant women, eliminate
periodontal pathogens and reduce periodontal
inflammation
• Analysis: see if women treated before delivery have fewer
preterm babies than women treated after delivery
41
Randomized Controlled Clinical Trials
• Study subjects are randomly
assigned to receive treatment
before the birth and the
control group receives
treatment after the birth.
• Advantage of randomization is
that it balances both known
and unknown prognostic
factors, in the assignment of
treatments
• After randomization, the two
groups are followed in exactly
the same way; the only
difference was when they
received periodontal therapy
42
Replication
• Different researcher
should be able to
replicate a study
• Compare Results
43
Peer-Reviewed Journals
http://guides.lib.jjay.cuny.edu/content.php?pid=209679&sid=1746812
• In academic publishing, the goal of peer review is to assess the quality
of articles submitted for publication in a scholarly journal.
• Before an article is deemed appropriate to be published, it must:
– Be submitted to the journal editor who forwards the article to experts in the field.
Because the reviewers specialize in the same scholarly area as the author, they are
considered the author’s peers (hence “peer review”).
– These impartial reviewers carefully evaluating the quality of the submitted
manuscript.
– Peer reviewers check the manuscript for accuracy and assess the validity of the
research methodology and procedures.
– If appropriate, they suggest revisions. If they find the article lacking in scholarly
validity and rigor, they reject it.
• Because a peer-reviewed journal will not publish articles that
fail to meet the standards established for a given discipline,
peer-reviewed articles that are accepted for publication
exemplify the best research practices in a field.
44
Features of a Peer-Reviewed Article
• Is the journal in which you found the article published or sponsored
by a professional scholarly society, professional association, or
university academic department? Does it describe itself as a peerreviewed publication? (To know that, check the journal's website).
• There is an:
–
–
–
–
–
Abstract (summary) at the beginning of the article
Methods and Materials
Results
Discussion
Conclusions
• Does the article have footnotes or citations of other sources?
• Does the article have a bibliography or list of references at the
end?
• Are the authors’ credentials listed?
• Is the article based on either original research?
45
Examples in Dental Hygiene
Peer-Reviewed
• Journal of Dental Hygiene
• International Journal of
Dental Hygiene
• Canadian Journal of Dental
Hygiene
Non Peer-Reviewed
• RDH Magazine
• Access Magazine
• Dimensions of Dental Hygiene
46
As a health care professional, you depend on
excellent research to help shape future practice
• Insist on the best evidence
• Don’t accept junk science
47
Oral Cancer Update
Good News
• Decline in prevalence of
traditional risk factors for oral
cancer in the US, tobacco and
alcohol, has led to a decline in
oral cancers associate with
these risk factors
• Persons with HPV-positive
oropharyngeal cancers have a
lower risk of dying or having
recurrence than those with
HPV-negative cancers
Bad News
• The incidence of
oropharyngeal cancer has
increased due to increase in
HPV infection
• In the United States, there
are about 12,000 new cases
of oropharyngeal SCC every
year
48
Risk Factors
•
•
•
•
•
Tobacco
Alcohol
Sunlight (lip)
Malnutrition
Immunocompromising
diseases
• HumanPapillomaVirus
• Unknown
~85%
~15%
49
• Recently, considerable information has been
published about the human papillomavirus
(HPV) status of the patient.
• Both hygienists and dentists are being asked
about HPV (specifically HPV 16) and its
connection to oral cancer.
50
Human Papilloma Viruses
• There are over 150 HPVs
• “High” risk: 16, 18, 31, 33, 35, 39,
45, 51, 52, 56, 58
HPV 16 - most common HR
• “Low” risk: 2, 4, 6, 11, 13, 32, 40,
42, 43, 44, 53, 54, 61, 72, 73 and
81
• In the DNA, proteins E6 and E7
eliminate tumor suppressor
proteins p53 and Rb, allowing
tumors to progress.
• High Risk HPV proteins E6 and E7
are more active than in Low Risk
HPV
51
E6-E7
• In the DNA, proteins E6 • Tumor Suppressor
and E7 eliminate tumor
Proteins stop tumors
suppressor proteins p53
from growing.
and Rb, allowing tumors • If you take them away,
to progress.
the tumor grows.
• High Risk HPV proteins
• If HPV has E6 and E7,
E6 and E7 are more
the tumor suppressor
active than in Low Risk
stops and the tumor
HPV
grows.
HPV-Related Oropharyngeal Cancer
Transmission: Sexual Contact
53
What to do
with
conflicting
evidence?
54
Early Detection of Precursor Lesions
HPV-related
We do not know what an HPVinduced precursor lesion looks like
55
HPV Screening Tool must be able to
Detect E6 and E7
Screening kit detects HPV 16 and 18 ONLY (there are more HR
HPVs) AND there is no mention of E6 and E7
OralDNA® Tests
Oral HPV Testing with the OraRisk® HPV test
56
Then the question becomes:
• What to do with the results?
– There is no treatment for HPV oral infection
– We do not know if their HPV 16 and 18 will become oncogenic
• We know that HPVs often clear
• How often to retest?
– Most of the time HPV is cleared from the body through its own
immune system. If the person is tested again at a later date, the
results in most cases will be negative. Some individuals who
have ongoing positive results could be more susceptible to oral
cancer
• Essentially, we really do not know very much as to how this
entity behaves in all individuals
• We cannot predict in whom the virus will persist
57
Key is Prevention: Vaccines
• HPV vaccines are given as a series of three
shots over 6 months
• Cervarix and Gardasil protect against HPV 16
and 18 cervical cancers in women
• Gardasil also protects against genital warts
and cancers of the anus, vagina and vulva
• Both vaccines are available for females
• Only Gardasil is available for males
58
Who should get the HPV vaccine?
• Girls and boys aged 11 or 12 years
• Teen boys and girls who did not get the vaccine
when they were younger
• Teen girls and young women through age 26, as
well as teen boys and young men through age 21
• Gay and bisexual men (or any man who has sex
with men)
• Men and women with compromised immune
systems (including people living with HIV/AIDS)
through age 26, if they did not get fully
vaccinated when they were younger.
59
Will the vaccine prevent oropharyngeal cancer?
• The CDC reports that in a large sample of invasive
oropharyngeal squamous cell carcinomas, 62% were
positive for high-risk HPV types 16 and 18, which are
covered by the 2 commercially available vaccines
(Gardasil, Merck & Co.; Cervarix, GlaxoSmithKline).
• CDC researchers suggest that vaccines could prevent
most oropharyngeal cancers in the United States.
• Costa Rica HPV Vaccine Trial found that the Cervarix
vaccine reduced oral HPV infection in women by more
than 90%
• “Human Papillomavirus Prevalence in Oropharyngeal
Cancer before Vaccine Introduction, United States.”
Emerging Infectious Diseases Volume 20, Number 5—
May 2014
60
ADA’s
Statement on Human Papillomavirus and
Squamous Cell Cancers of the Oropharynx
• “Review the patient’s health history, particularly any
verbal or written indication of initially suggestive
symptoms, such as persistent sore throat, dysphagia,
hoarseness, ear pain, enlarged lymph nodes or weight
loss, should be carefully evaluated as part of the full
clinical assessment and head and neck examination.
• Educate themselves and their patients about the
relationship between HPV and oropharyngeal cancer,
especially the growing prevalence of these cancers in
younger non-smokers and non-drinkers.”
http://www.ada.org/1749.aspx
61
HPV Vaccine Related Deaths
• Of the 12,424 reports of adverse events, 772 (6% of all
reports) described serious adverse events, including 32
reports of deaths.
• Death reports were reviewed and there was no
common pattern to the deaths that would suggest they
were caused by the vaccine.
• With an autopsy, death certificate, or medical records,
the cause of death could be explained by factors other
than the vaccine.
• Some causes of death determined to date include
diabetes, other viral illness, illicit drug use, and heart
failure.
62
Summary
• Oral and oropharyngeal cancers have different
etiologies
– HPV is a risk factor for oropharyngeal cancer
– Tobacco and alcohol remain risk factors for oral cancer
• OPC is difficult to detect; hard to visualize risk areas
and we do not know what the precancerous form looks
like
• HPV detection kits can find HPV 16 and 18 but not E6
E7; we do not know what to do with positive results
• Vaccine is safe; studies to determine if it is protective
for OPC are still ongoing
63
Caution: Gum Bumps
64
• Case 1: 40 year-old healthy female on no
medications presents with this pink and red
mass that keeps her from flossing. It bleeds
when she tries. Radiographs show normal
bone contours and density.
65
Pyogenic Granuloma
• Represents an exuberant attempt by the tissues
to repair after a local injury
• In the oral cavity, local injury is often calculus
• Mass of granulation tissue that builds in response
to a low-grade chronic irritation; tissue never
proceeds to the next phase of wound repair
• Must be surgically removed so the normal
adjacent tissue can fill in and proceed with repair
of the site
66
2 Old Wives' Tales
• Pyogenic granulomas are seen only in
pregnant women
• Pyogenic granulomas are only seen on the
gingiva
67
These look like PGs but extend down to the
periosteum where they stimulate bone cells
Peripheral Ossifying Fibroma
• Pyogenic granulomas can
occur ANYWHERE,
compared to POF and PGCG
which only occur
over bone
Peripheral Giant Cell Granuloma
• They are referred to as “The
3 P’s”
• The main difference is
under the microscope
68
Management
• PG- simple excision
• Usually don’t recur
unless source of injury
is not removed.
• For gingival lesions,
carefully scale the area
when the lesion is
removed.
• Since the periosteum in
involved in the disease
process, POF and PGCG
should be excised down
to periosteum.
• Usually prevents
recurrence but not in all
cases.
69
Parulis
• An exophytic mass that appears on the gingiva
• It marks the end of the FISTULOUS TRACT
formed by the pus draining from an abscessed
tooth
• When you put a little pressure on it, pus
appears
• So if you see something that looks like a PG,
press on it. If you see pus, start pulp testing
the teeth
70
• Case 2: 11 year-old male presents with this
gingival mass While It bears some
resemblance to a PG, it is nontender, nonblanching, and does not bleed. Radiographs
show normal bone. Note it is well-defined,
bright red and has tiny dots and a pebbly
appearance.
71
Localized Spongiotic Gingival Hyperplasia
• A recently described lesion that most commonly affects
children but is seen in adults
• Probably associated with trauma but the etiology is still
unknown
• Nearly all lesions are located on the anterior gingiva, with 81%
affecting maxillary gingiva.
• Papillary, often pedunculated, red gingival overgrowth in
young patients and adults
• Viruses have not been shown to be the etiology
• Surgery is usually curative
• Some recur
– Topical corticosteroids
– Laser therapy
72
• Case 3: 70 year old female, non-smoker, nondrinker, presents with a nontender mass of
several months duration. Probing depths are
6-8mm. The tooth is now mobile. Radiographs
show localized bone loss.
73
Squamous Cell Carcinoma
• SCC of gingiva is rare
Tends to occur in low-risk patients
Not associated with HPV
Surface is often “stippled” red and white
74
• Case 4: A 54 year-old woman presents with
the chief complaint of swelling and bleeding
of the gingiva. The teeth are not mobile and
there is no radiographic evidence of disease.
She is in remission of her breast cancer that
was treated 2 years ago.
• Breast cancer metastasized to her gingiva
• Case 5: Several days following extraction of
#14, a soft tissue mass arose in the extraction
site.
76
Epulis Granulomatosum
• Granulation tissue proliferates out of a recent defect
of bone
• Sequestrum and/or necrotic debris remain in the
socket
• Biopsy is mandatory because intraosseous
malignancies may behave in an identical way
77
• Case 6: Small round exophytic mass
superimposed on the incisive papilla of
unknown duration.
78
What is a CYST?
• An epithelial-lined cavity filled
with fluid or semisolid material
• Think of a water balloon
• The plastic is the “epithelium”
and the water inside is the
fluid
• A tumor, or neoplasm, is a
solid mass, like a bowling ball
• Cysts and tumors are very
different entities
79
Nasopalatine Duct Cyst
• Originate in the nasopalatine duct located
within the incisive canals
• Terminal branch of the descending palatine
artery and nasopalatine nerve are also located
here
• Cystic changes within the epithelial lining of
the duct may lead to soft-tissue swelling
behind the maxillary central incisors
• Size and location along canal can vary
80
• Case 7: Mucosal-colored exophytic mass with
mildly pebbly surface on the lingual of the
canine
81
Giant Cell Fibroma
•
•
•
•
•
A very common variant of the fibroma
Etiology not always easily identified
Diagnosis is usually a surprise to the clinician
Treatment is the same as fibroma
Most commonly mistaken for a papilloma due
to the irregular surface texture
82
Gingival Cyst
• Arise from the Rests of Serres, they are often referred
to as dental lamina cysts
• Because Rests of Serres are found in the gingiva,
gingival cysts do not involve bone
• They do not appear on radiographs - radiograph will
not show a lesion
• Located in soft tissues surrounding the teeth, most
often on the facial gingiva
• Small, fluctuant, and may have a bluish tint
83
Doc, What’s Wrong with My Gums?
84
• Case 1: 57 year-old male presents with the chief
complaint that his gingiva is tender and painful.
He is afraid he has oral cancer. His previous
dentist gave him some “Magic Mouthwash” but it
failed to resolve his symptoms.
• In addition to his oral complaints, he mentions he
has a rash on his arm and his fingernails have
“dried up”.
85
Diagnosis: Lichen Planus
We generally think of lichen planus as this white lace-like plaque
on the buccal mucosa.
This is reticular lichen planus. It is non-painful and patients are
generally un aware of it. It does not require therapy.
Erosive lichen planus is a more severe form of the disease.
It is painful and requires therapy.
The lesions can be quite erosive and red but, almost always, a
hint of white striae can be seen.
86
Difference between Erosion and Ulcer
• Ulcers have no protective epithelial layer
• Erosions have a very, very thin protective
epithelial layer
87
Erosive Lichen Planus is one of the causes of socalled
“Desquamative Gingivitis”
• Desquamative Gingivitis is clinical descriptive
term only. It is not a diagnosis.
• Any time the gingiva is eroded, ulcerated or it
sloughs, the term
“desquamative gingivitis” can be used
88
Once you recognize that the gingiva is
desquamating…
• There are many different causes of
desquamative gingivitis
• Therefore, there are many different
treatments
• Our job is to determine what is causing it so it
can be treated properly.
89
Autoimmune
“Desquamative” Gingivitis
• Erosive lichen planus
• Mucous membrane
pemphigoid
• Pemphigus vulgaris
• Chronic ulcerative
stomatitis
• Discoid lupus
• Epidermolysis bullosa
acquisita
• Caused by
inappropriate immune
reaction to normal
tissues
• Each disease has a
different “target”
90
Erosive Lichen Planus
• Clinical Clues that it is ELP:
ELP Lesions do not “slough” or peel
They are large erosions in which the
epithelium “melts” away
• You may see lesions elsewhere that are clues
to the diagnosis:
– purple puritic rash on arms and legs
• Ulcers will have white striae around the
periphery
91
But even if you see all these things, a biopsy is
necessary to confirm your clinical impression
• There are mimics of lichen planus that fail to
respond to lichen planus treatment.
92
• Case 2: 46 year-old female returns to the
office after these new crowns were placed 4
weeks ago. She reports that her gingiva is
tender and painful.
• You notice this appearance around abridge
placed several weeks ago.
• This patient reports she cannot wear cheap
jewelry without developing a “rash”.
93
• Lichenoid Mucositis:
an contact allergic reaction to dental materials
that produces signs similar to those seen in
lichen planus. Present wherever the
restoration contact the mucosa.
94
Quick Test to determine if patient is
allergic to base metals
• Can they wear cheap jewelry and metal
watchbands?
• Lichenoid Mucositis can also be an allergic
reaction to systemic medications. This patient
is taking hydrochlorothiazide for hypertension.
• No restorative materials contact the lesions.
95
Lichen Planus vs. Lichenoid Mucositis
• Observe for direct
contact of restorative
material (most often
dental metals) to the
affected tissue
• Allergy-testing
specifically for dental
materials is available
• Check medical history
for medications
associated with
stomatitis
A biopsy can differentiate between lichen planus and
an contact allergy. So when in doubt, send a sample.
96
Allergic Reaction to Dental Materials:
Management
• Remove amalgam and place temporary; watch for
2-3 weeks; if lesion regresses, this helps to
confirm the diagnosis
• If this is not possible, a biopsy can help to confirm
a hypersensitivity reaction.
• Replace PFM with full porcelain
• If restorations cannot be replaced, treat patient
for an allergy with Benadryl elixir
• Some dermatologists will do dental material
patch testing …helpful for future restorations.
97
Source for Dental Material Patch Testing
• Dr. Joseph Fowler, MD
– Occupational Dermatology and Patch-Test Clinic
– University of Louisville School of Medicine
– 444 South First St, Louisville, KY 40202
– 502-583-7546
• Case 3: This 44 year old woman complains of pain
and tenderness whenever she eats or brushes.
She cannot eat spicy foods anymore. She has
tried changing her toothpaste and having her
teeth cleaned. She said small bubbles form,
quickly break and peel away her gums.
• Vesicles arise after gentle rubbing
• Her biopsy showed detached area filled with
fluid… a blister. The blister breaks and the tissue
sloughs away or
99
Nikolsky’s Sign is caused by destruction of
the epithelium's attachment to the
underlying tissues…
• The most serious problem for these patients is
development is Cicatricial Pemphigoid
characterized by scarring eye lesions
called symblepharon that can lead to
blindness
Cicatricial= scarring
• Treatment is potent corticosteroids and other
immunosuppressive drugs prescribed by
a dermatologist or oral pathologist
100
Clinical Differences between Erosive Lichen
Planus and Mucous Membrane
Pemphigoid
ELP
MMP
• Blisters are not common
• Striae are present
• Tissue erodes rather than
sloughs
• Affects skin
• Treatment is generally
topical corticosteroids
• Blisters form
• No striae
• Tissue sloughs in large
sections
• Can affect eyes
• Treatment tends to be
stronger steroids or other
stronger
immunosuppressive drugs.
101
Management Tips for ELP and MMP
Calculus accumulation will irritate the tissue and may induce a
flare-up. Local anesthesia is suggested to make the patient
…and you…more comfortable.
When these patients have routine SRP and prophylaxis, they will
be tender for several days afterwards. They should be
instructed on this. Also suggest they avoid spicy or abrasive
foods.
Their home care will suffer when they have an episode. This
makes them vulnerable to periodontal disease.
3-month recall will help.
102
Other Mucosal Diseases that Can Cause
“Desquamative Gingivitis”
• ADULTS
–
–
–
–
–
Pemphigus vulgaris
Discoid lupus erythematosus
Linear IgA disease
Erythema multiforme
Leukemia
• CHILDREN
– Cyclic neutropenia
– Leukocyte adhesion
deficiency
– Leukemia
103
Always Remember:
• When confronted with a patient with
persistent recalcitrant gingivitis that does not
respond to conventional therapy, consider an
autoimmune disorder as the underlying cause.
• Look for other signs within the oral cavity,
eyes or skin.
104
Caveat!
• A biopsy will be necessary to establish the
diagnosis.
• Clinical features are never adequate to
develop a treatment plan.
105
• Case 4: 75 year-old male presents with
nontender lesions that are destroying his
gingiva. He is on long-term steroid therapy for
rheumatoid arthritis. His dentist thought he
had oral cancer.
Histoplasmosis
A Fungal Infection
• His RA therapy suppresses his immune system
• One of the risk factors for histoplasmosis is
suppressed immune system
• Patients inhale the spores; lesions develop in
the lung
• When patients become immunosuppressed,
the fungi disseminate
107
Histoplasmosis in the United States
108
• Case 5: Patient complains her gums are
turning blue
• Minocycline Stain
Drug is taken up as bone turns over.
Will fade after cessation of the drug as the
bone continues to turn over.
109
• Case 6: This patient also complains that his
gums are turning blue/purple. Note they also
are enlarging. He received a kidney transplant
3 months ago and is on immunosuppressive
medication.
Kaposi’s Sarcoma
• Caused by infection with human herpes virus 8 (HHV8)
• Seen in immunosuppressed patients i.e., HIV+ and
transplants
• Like other herpes viruses, it prefers to infect keratinized
epithelium
• Oral cavity is involved in about 30% of cases
– Hard palate
– Gingiva
• Lesions in the mouth may be easily damaged by
chewing and bleed or suffer secondary infection
111
Case 7: 61 year old male
15 year history of chronic lymphocytic leukemia
(CLL)
•
•
•
•
Bilateral cervical lymphadenopathy
Periodontitis, over-contoured crowns
Recent gingival enlargement
Biopsy shows leukemia cells within the
gingival tissues
• Case 8: Patient complains her RPD no longer
fits. She wants implants. She also complains
that she has a persistent chronic sinusitis that
has not responded to antibiotics.
• Strawberry gingivitis of Wegener’s
granulomatosis
Wegener’s Granulomatosis:
• Autoimmune inflammation of blood vessels;
primarily affects the upper airways and
kidneys, wherever there are small blood
vessels
• Treatment includes prednisone and
cyclophosphamide
114
• Case 9: Patient complains of generalized
tenderness and very mild superficial sloughing
of the gingiva for several weeks duration. She
has increased her oral hygiene a home but
nothing seems to help.
115
Cinnamon Stomatitis
• Can be localized to where gum or candy is
held
• Generalized if cinnamon flavored tooth paste
or mouthwash is used
116
What Lurks Beneath?
117
Denture and Prosthesis-Related Injury
• Denture Stomatitis
– A general term for generalized inflammation of
denture-bearing tissues
– Not a diagnosis
– Possible etiologies
• Allergy to acrylic
• Candidiasis
• Poor fitting denture
118
• Denture Ulcer
A traumatic ulcer
Adjust the denture for healing
Do not use topical anti-inflammatory agents
119
Asymptomatic Conditions in Patients Whose
Dentures Do Not Fit Properly
• Epulis Fissuratum occurs along the flange
(edge) of an ill-fitting or loose denture
• Most common location is the buccal or labial
vestibules in anterior oral cavity
• Represents a protective attempt to minimize
or prevent displacement of the denture into
adjacent delicate tissues
120
Epulis Fissuratum
• Thick, hyperplastic (fissured) folds of tissue
form in response to biting forces.
• Sometimes resembling a “wave breaking on
the shore”
• Removing or repairing the denture usually
does not lead to resolution
• Must be surgically removed before new
denture is made
121
Fibroepithelial Polyp
• Also forms because of an ill-fitting denture
• Instead of forming at the edge of the denture,
this lesion forms on the palate under the denture
• Characteristics include a flattened but
pedunculated mass
• It sits snugly into the palate, sometimes causing a
cup-shaped deformity
• Treatment is surgical excision before construction
of a new denture
122
Inflammatory Papillary Hyperplasia
• Occurs on the hard palate under complete upper
or partial dentures
• Asymptomatic , erythematous and velvety smooth
to the touch
• Etiology: result of mild chronic irritation in
individuals who wear their dentures continuously
or whose dentures are ill-fitting
• RARELY is candida albicans present
• Has been observed in dentate patients with
narrow, high-vaulted palates
123
Denture Stomatitis Associated with Candida
• Tissue tends to be very sore and tender
• Patients complain of burning sensation
124
Why is it red?
• In school, you learned that candidiasis forms
white curdy plaques that wipe off and leave a
red raw surface
• The prosthesis acts to wipe off the colonies as
they form so they never get a chance to
accumulate… all you see if the red raw surface
125
• 56 year-old Hispanic male presents with the
chief complaint that his palate is painful and
burning since placement of his new upper
denture.
• While we are on candidiasis, steroid asthma
inhalers also can predispose the patient to
candidiasis
126
Reactive Subpontic Osseous Hyperplasia
(subpontine exostosis)
• Patient complains that she can no long insert her floss
threader under her bridge
• Subpontic osseous hyperplasia is an growth of bone
occurring on the edentulous ridge beneath a fixed partial
denture
• Chronic irritation and functional stresses may be etiology
• Treatment is surgical recontouring due to the
impingement of the growth on the pontic and the
inability of the patient to maintain adequate oral hygiene
in the area.
127
Peri-Implantitis
• Inflammation and granulation tissue around
dental implants
• May be confined to the soft tissues but can
extend down to the bone tissue supporting
the implant
• Extension into bone may be a sign of
impending implant failure
128
• 70 year-old woman complains her upper
denture no longer fits. The dentist makes her
a new denture….
• Asymmetry of the palate was not addressed
• Palate is a common location for both benign
and malignant salivary gland neoplasms.
• Patient will report a slowly growing painless
mass.
129
Necrotizing Sialometaplasia occurs when the minor
glands experience ischemia due to vasoconstrictors in
anesthetic
• Arises soon after having a palatal injection for
a dental procedure
130
Verrucous Carcinoma
• 79 year old patient reports her denture no
longer fits. You note this exophytic red and
white verrucous mass.
• Verrucous Carcinoma, a low grade form of oral
cancer often associated with tobacco chewing
and dipping.
• Duration of habit is strongest predictor of
development of verrucous carcinoma
131
Update on
Osteonecrosis of the Jaws Related to
Anti-Resorptive Therapy
•
•
•
•
First described in 2003 in patients using bisphosphonates
First called Bisphosphonate- Related Osteonecrosis (BRONJ)
Now seen in patients taking other anti-resorptive medications
Despite 1259 articles now on PubMed, there is still a lot to be
learned
132
Quick Review of Bone
• https://www.youtube.com/watch?v=inqWoak
kiTc
133
What is Osteonecrosis?
• General term for death of bone
• In addition to Anti-Resorptive medications,
osteonecrosis of the Jaws (ONJ) is associated
with
– cancer treatments,
– infection
– radiation therapy
– steroid use
– Idiopathic – no known etiologic factor
134
Bone Remodeling
• Process by which the body continuously
removes old bone tissue and replaces it with
new bone
• Driven by
– osteoblasts (which secrete new bone)
– osteoclasts (which break down old bone)
• If osteoclasts predominate, then bone
resorption and weakness results
135
Bone Remodeling and Regulation of Osteoclast
Activity
• https://www.youtube.com/watch?v=P8OtBv7
75mQ
• https://www.youtube.com/watch?v=GpMV19
7xZXc
• https://www.youtube.com/watch?v=0dV1Bwe
2v6c
136
Anti-Resorptive (Anti-Osteoclastic Activity)
Medications
• Anti-resorptives are drugs used to treat
– 1)osteoporosis
– 2)cancer metastasis to bone: multiple myeloma,
breast, prostate and lung cancer
– 3)Paget’s disease of bone
137
Anti-Resorptive Therapy: How Osteoclast
Activity is Reduced or Stopped
Bisphosphonates
• Ibandronic acid-Boniva
• Alendronic acid-Fosamax
• Pamedronic acid- Aredia
• Risenadronic acid- Actonel
• Zolendronic acid-Zometa
Monoclonal Antibody
• Denosumab marketed as
Prolia and Xgeva
Despite the major benefits of these medications, their use
has significant implications for dentistry. Serious oral
complications in some patients have been reported.
138
Parenteral vs Oral Administration
• Parenteral (Zometa, Aredia)
– For patients with cancer involving the skeleton
– Other non-cancerous conditions such as Paget’s
disease
– Incidence reported up to 10%
• Oral (Fosamax, Boniva, Actonel)
– For osteopenia and osteoporosis
– Incidence is much lower- 0.34%
139
How Do Bisphosphonates Work?
• Drugs that act on bone metabolism by binding and
blocking the enzyme farnesyl disphosphate synthase
• This prevents adhesion of the osteoclast to the bone
surface and prevent formation of the “sealed zone”
• Disrupting or blocking these proteins stops
osteoclasts from resorbing bone
• So patients on these drugs have reduced bone loss
and reduced bone turnover
140
How do bisphosphonates cause ONJ?
• Bone turnover is a normal process that keeps bones vital.
• Reducing bone turnover reduces bone’s ability to respond to
injury in the form of microdamage
• Microdamage that is normally corrected by bone cells now
accumulates.
• The injured bone eventually dies - osteonecrosis
• Some bisphosphonates also reduce blood flow through bone
and reduce blood vessel formation. Reduced blood supply
may help cause osteonecrosis.
• Bisphosphonates are retained within the bone so stopping the
drug does not reverse its effects until the bone is completely
turned over
141
Monoclonal Antibody: Denosumab
• Precursors to osteoclasts, called pre-osteoclasts, express surface
receptors called RANK
• RANK is activated by RANKL (the RANK-Ligand) on surface
osteoblasts. This causes maturation of osteoclasts
• Denosumab (-mab = monoclonal antibody) inhibits maturation of
osteoclasts by inhibiting RANKL. The MAB sees RANKL as foreign
and binds to it, preventing its activity
• This protects bone from degradation and helps slow the
progression of osteoporosis
• Marketed as Prolia® : treatment of postmenopausal women with
osteoporosis at high risk for fracture.
• Marketed as Xgeva™, prevention of bone loss due to
– androgen deprivation therapy in non-metastatic prostate cancer
– prevention of bone loss due to chemotherapy in breast cancer
– treatment of bone destruction caused by rheumatoid arthritis
142
Drug Activity
• Suppresses Bone Turnover
– Bone takes up the drug
– Osteoclasts resorb that bone and are then
inhibited from resorbing more
– Old bone is not removed
• Soft Tissue Toxicity
– Increases in low pH environment such as local
infection
143
Who is at risk for developing ONJ?
• The group with the highest risk for developing
ONJ are patients with cancer who are treated
with intravenous (IV) bisphosphonates such as
Aredia and Zometa.
• These drugs don’t treat the cancer but help
maintain the strength of bone that is affected
by cancer.
144
Who is at risk for developing BRON?
• At a much lower risk than cancer patients who
take Aredia or Zometa are patients who take oral
bisphosphonates for osteoporosis to help prevent
bone fractures
– Fosamax----alendronate
– Boniva------ ibandronate
– Actonel----- risendronate
But they are still at risk.
There is no zero degree of risk.
145
Compare Oral vs Injected Drug
• Patients on injectable
form have higher
incidence of ONJ than
those on oral
formulations
• Incidence was 2.0% in
the denosumab group
and 1.4% in the
zoledronic acid group
• Rates of ONJ were not
statistically significantly
different between
Bisphos and MAB
treatment groups
146
Why the Jaws and Not Other Bones?
• In jaws, there is high alveolar bone turnover
• Exacerbated by
– trauma such as tooth extraction
– exposure to microbial pathogens
147
Suspected Local Risk Factors for ONJ
•
•
•
•
History of dentoalveolar surgery
Age
Caucasian
Concomitant oral disease
– Periodontal disease
– Periapical abscess
• Local anatomy
– Mylohyoid ridge
– Tori
148
Other Suspected Risk Factors
• Corticosteroid therapy
• Diabetes
• Smoking
• Alcohol
• Poor oral hygiene
• Chemotherapy
The relative risk of each of these factors has not
been determined
149
Extraction as Risk Factor
• It is unclear if exposure of bone triggers ONJ
or if it uncovers pre-existing necrotic bone
• In study of 120 patients with ONJ, 51% had hx
of tooth extraction: 23% of those had nonhealing extraction site.
• Another 9 patients had teeth in field of ONJ
extracted with no worsening of the ONJ.
Lerman M, Wangling X, Treister, et al Conservative management of bisphosphonaterelated osteonecrosis of the jaws: Staging and treatment outcomes. Oral Oncology
2013:49(977-983)
150
Denture Irritation can cause exposure of drugaffected bone
151
Orthodontics
– There are no published studies examining the
effect of anti-resorptive therapy on orthodontic
treatment.
– Case reports have recounted inhibited tooth
movement in patients receiving bisphosphonates
– Patients should be advised of this potential
complication.
• Rinchuse DJ, Rinchuse DJ, Sosovicka MF, Robison JM,
Pendleton R. Orthodontic treatment of patients using
bisphosphonates: a report of 2 cases. Am J Orthod
Dentofacial Orthod 2007;131(3):321–326.
152
How is ONJ diagnosed?
• Diagnostic Criteria:
– Current or previous treatment with
bisphosphonates
– Persistent exposed bone for at least 8 weeks
– No history of radiation therapy to the jaws
 From AAOMS Position Paper on BRON, September 26, 2006
153
Conservative Management of
Osteonecrosis of the Jaws
• Increase re-epithelialization and favorable
outcomes with:
– Chlorhexidine gluconate rinses
– Antibiotics,
– Non-surgical sequestrectomy
– Local debridement
56 year-old female who has been taking oral Fosomax for
several years presents for routine care with this tender area.
155
58 year-old woman with breast cancer presents to have her teeth
cleaned. Part of her therapy includes IV Zometa for bone metastasis of
her cancer. #3 was carious and her dentist extracted it about 4 months
ago. It is asymptomatic but the socket has not healed.
156
• This patient has myeloma, a type of bone marrow
cancer. He was on IV zoledronic acid (Zometa) to help
strengthen the bone to resist the destruction by the
tumor. This is exposed necrotic bone under his
denture
157
66 year-old female with chief complaint of malodor and
pain under her dentures of several weeks duration
• Her medical history includes osteoporosis for
which she has been taking alendronate
(Fosamax) for several years
• Radiographs show ill-defined areas of mottled
bone.
158
Prevention of ONJ
• Patients should receive all necessary dental
treatment that involves the bone before
beginning treatment
– remove non-salvageable teeth
– complete any invasive dental procedures
– optimize periodontal health
– examine edentulous areas under prostheses and
smooth any denture roughness
• Drug therapy does not have to be delayed for
dental treatment; effects occur 1-3 years after
initiation
159
Prevention of ONJ
• After 1 year, avoid high-risk procedures: extractions,
implants, periodontal surgery
– RCT has lower risk than extraction
– Implants: more successful in patients on drugs short-term
or with low-potency drugs (oral).
– Implant placement requires the preparation of the
osteotomy site. The patient may be at increased risk when
extensive implant placement is necessary or when guided
bone regeneration is required to augment a deficient
alveolar ridge before implant placement.
• Edwards BJ, Hellstein JW, Jacobsen PL, et al Updated
recommendations for managing the care of patients receiving
bisphosphonate therapy. J AM Dent Assoc 2008:139:1674-7
160
Prevention After IV Drug Therapy is Initiated for
Cancer:
Asymptomatic Patients
• Good oral hygiene is essential
• Avoid procedures that require oral surgery
• Non-restorable teeth should be treated with crown
amputation or endodontic therapy
• Other routine dental treatment posed no increased
risk
• Avoid placement of implants in patients with high
and frequent doses of drug
161
Prevention After Oral Therapy is Initiated for
Osteoporosis:
Asymptomatic Patients
• For patients on drug for less than 3 years :
– No alteration in dental treatment plan.
• For patients on drug for more than 3 years :
– If systemic conditions permit, patient should take a 3-month
drug holiday before any surgical procedures
– Cover patient with antibiotics for procedure
– Drug should be restarted only after there is complete
osseous healing
– No alteration in treatment for routine nonsurgical dental care
162
What to do if patient develops ONJ?
• Objectives:
– Pain control
– Infection control (if present)
– Minimize ONJ progression
163
Stages of ONJ and Their Treatment
• Stage 1: exposed bone with no infection:
– Do not surgically debride the area
– Chlorhexidine gluconate rinse until area heals
– Use it to gently brush exposed bone like one
brushes teeth
164
Stages of ONJ and Their Treatment
• Stage 2: Exposed bone with pain and
infection:
– Chlorhexidine rinse
– Culture and sensitivity for microbes: penicillin,
metronidazole, clindamycin, Doxycycline and erythromycin
have been helpful
– Removal of sequestra but no surgical debridement
165
Stages of ONJ and its Treatment, Continued…
• Stage 3: exposed bone with pain, infection and one or more of
these: fracture; extra-oral fistula; osteolysis extending to
inferior border:
– Remove sequestra
– Surgical debridement to smooth surface of bone ONLY. Do not debride
down to vital bone.
– Antibiotic therapy
– Extraction of symptomatic teeth
– Discontinuation of IV drug therapy has no short-term benefit but longterm may if systemic conditions permit
• Discontinuation of oral anti-resorptive therapy is associated with gradual
improvement
– 6-12 months of cessation can lead to spontaneous sequestration or
resolution following debridement surgery
166
Patient Education
• All patients who are on anti-resorptive therapy or who are
contemplating beginning therapy should be adequately
informed of the potential risk of compromised bone healing
following oral surgery as well as the risk for development of’
lesions in areas of trauma.
• They should be informed about what surgical vs. nonsurgical
procedures are.
• Routine and essential dental care SHOULD NOT BE AVOIDED.
There may be more risk in non-treatment than in
development of ONJ.
• Teeth left untreated out of fear of ONJ may precipitate ONJ
through odontogenic infection or trauma.
• Remember: There is NO recommendation to avoid routine
essential dental care!
167
•
•
•
•
•
Dr. Alice E. Curran
University of North Carolina
School of Dentistry
alice_curran@unc.edu
919 537-3138