Op notes: Leprosy

Reference : shafers textbook, Google.

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Differential Diagnosis of Periapical Radiolucencies

PA radiolucencies identification made easy! Happy learning..😀📖

  • Periapical radiolucencies are most commonly odontogenic. Nonodontogenic radiolucencies tend to be not localized and span across the mandible or maxilla within the alveolus and sometimes extend inter-radicularly.
  • The most common PA pathologies can be diagnosed based on the vitality responses from the teeth. Ruling out the tooth associated pathologies is an important step in securing a diagnosis from differential diagnosis panel of PA radiolucencies.
  • Inter-relationship of possible results of periapical inflammation:

When formulating radiological differential diagnosis, features should be evaluated carefully, such as

  1. location
  2. locularity
  3. relation to dentition
  4. density of lesion
  5. margin
  6. type of radiological change (radiolucent/radiopaque/mixed)
  7. periosteal reaction
  8. cortical integrity, and
  9. clinical presentation.

🌫 General Radiographic features:

Location: With periapical inflammatory lesions, which are pathological conditions of the pulp, the epicenter typically is located at the apex of a tooth.

Periphery: Ill defined

Effects on surrounding structures: Periapical lesions cause widening of PDL space at apical region of the root.

PA Radiolucencies: (Classification)

PERIAPICAL RADIOLUCENCIES

Developmental

Lateral periodontal cyst

  • Definition: lateral periodontal cysts are cystic lesions that tend to occur on the lateral aspect of vital teeth. Epidemiology: lateral periodontal cysts account for fewer than 1% of the reported cases of odontogenic cysts.
  • Clinical findings: most lateral periodontal cysts area located in the mandibular incisor-canine-premolar area.
  • Radiographic findings: radiographically, lateral periodontal cysts present as a unilocular radiolucent lesion between the roots of teeth or associated with the lateral aspect of a tooth.
  • Management: surgical enucleation with preservation of involved teeth is an appropriate treatment of lateral periodontal cysts. Recurrence is rare. The multiloculated variant called botryoid odontogenic cysts has been reported to demonstrate a higher recurrence rate than its unilocular counterpart.

Inflammatory Lesions

Apical periodontitis, periapical abscess

  • Definition: spectrum of inflammation involving the PA area of teeth that results from pulpal infection by microorganisms.
  • Epidemiology: apical periodontitis is the most frequent inflammatory lesion related to teeth in the jaws.
  • Clinical findings: apical periodontitis can be classified as either asymptomatic or symptomatic; clinical examination of percussion and palpation of the tooth yields negative results in the former and usually positive results in the latter. The results of pulp sensitivity tests for both conditions, however, are negative. In the early stage of PA inflammation, the PA PDL can exhibit acute inflammation without abscess formation. This localized alteration may or may not proceed to abscess formation.
  • Radiographic findings: in apical periodontitis, radiographs may show a thickened PDL space. If an abscess develops after a long-standing apical periodontitis, radiographs reveal a radiolucent area around the root apex.
  • Management: apical periodontitis is an inflammatory disease caused by a persistent infection of the root canal system. The recommended treatment is the removal of the dead nerve and bacteria either through extraction of the tooth or root canal treatment. Antibiotics are recommended only when there is severe infection that has spread from the tooth into the surrounding tissues.
Mandibular left molar PA radiograph showing the initial apical changes in relation to the first molar secondary to a symptomatic gross carious lesion. If the offending causes remain, this will continue to an apical osteitis, resulting in loss of trabecular bone and possibly even cortical bone before it shows up radiographically.
Cropped panoramic radiograph showing localized osteomyelitis secondary to PA infection in relation to the mandibular left first and second molars (arrows).

Cystic Lesions

Periapical (radicular) cyst

  • Definition: radicular cyst is a cyst of inflammatory origin associated with a nonvital tooth.
  • Epidemiology: radicular cysts represent the most common odontogenic cyst. Radicular cysts are most commonly associated with at the tooth apex, but a lateral radicular cyst can be associated with a lateral root canal.
  • Clinical findings: radicular cysts are always associated with a nonvital tooth, and this is an important criterion for diagnosis.
  • Radiographic findings: radiographs often show a well-defined radiolucent lesion at the apex of a tooth. Radicular cysts can displace or resorb the roots of adjacent teeth.
  • Management: the treatment of radicular cysts can include nonsurgical root canal therapy to surgical treatment, such as apicoectomy.

Odontogenic keratocyst

CBCT panoramic reconstruction of maxilla showing a large well-defined lytic area coronal to the impacted right canine. Histologically confirmed as an odontogenic keratocyst.
  • Definition: an odontogenic cystic lesion with distinctive histologic features. Recently reclassified back into a cystic category in the recent 2017 WHO Classification of Head and Neck Tumours. Current evidence seemed lacking to justify the continuation of classifying it as a tumor.
  • Epidemiology: odontogenic keratocysts are the third most common cyst of the jaws.
  • Clinical findings: most common location of odontogenic keratocysts is the mandibular molar region.
  • Radiographic findings: odontogenic keratocyst size can be variable, ranging from a unilocular radiolucent lesion surrounding the crown of an unerupted tooth, resembling a dentigerous cyst, to a large size that results in facial deformity and destruction of surrounding structures. Lesions tend to grow in a posteroanterior direction, however, that results in a lack of cortical expansion.
  • Management: odontogenic keratocysts tend to be more aggressive in its growth pattern with a higher recurrence rate than other odontogenic cysts. Recurrence may be due, however, to incomplete removal or the presence of satellite (daughter) cysts. Treatment includes enucleation (with or without peripheral ostectomy, treatment with Carnoy solution), marsupialization, or resection.

Glandular odontogenic cyst

  • Definition: a developmental cyst with features that resemble glandular differentiation.
  • Epidemiology: glandular odontogenic cysts represent less than 1% of odontogenic cysts.
  • Clinical findings: there is a predilection for the mandible.But in the maxilla, the canine seems commonly involved. Swelling and expansion were the most common presenting complaints.
  • Radiographic findings: radiographically, glandular odontogenic cysts present as a well-defined unilocular or multilocular radiolucency associated with the roots of teeth; association with impacted teeth is rare.
  • Management: glandular odontogenic cysts have a tendency to recur especially when lesions are removed with simple enucleation.

Benign Tumors

Ameloblastoma

  • Definition: benign, slow-growing epithelial odontogenic neoplasm with unmitigated growth potential.
  • Epidemiology: ameloblastomas are the most common odontogenic tumors, excluding odontomas.89 In the United States, African Americans seem to have an overall 5-fold increase risk of disease compared with whites.
  • Clinical findings: tumor often presents as an asymptomatic swelling of the posterior mandible and can be associated with an unerupted tooth. Buccal and lingual expansion often is observed.
  • Radiographic findings: radiographs commonly show corticated multilocular (soap- bubble) radiolucency.
  • Management: the unmitigated growth potential and tendency to recur require operative management involving segmental or marginal resection. When treated by enucleation alone, much higher rates of recurrence are reported.
Panoramic radiograph showing a large well-defined, multilocular radiolucency extending from the area of first molar on the left into the ramus area. Note the expansion and thinning of the cortices. Ameloblastoma was confirmed histologically.

Malignant Tumors

Ameloblastic carcinoma

  • Definition: a rare, malignant counterpart for ameloblastoma. Not to be confused with metastasizing ameloblastoma, this is a histologically benign ameloblastoma metastasizing to distant sites. In the recent WHO Classification of Head and Neck Tumours, metastasizing ameloblastoma has been separated from ameloblastic carcinoma and included as a type of conventional ameloblastoma.
  • Epidemiology: incidence rate was 1.79 per 10 million person/year with male and black population predominance. The overall survival is 17.6 years.
  • Clinical findings: the most common site is the posterior mandible. Often, pain and expansion are the first clinical manifestations. Most cases arise de novo, but some arise in preexisting ameloblastomas.
  • Radiographic findings: radiographically, ameloblastic carcinomas can present as poorly defined, irregular radiolucencies consistent with a malignancy, or indistinguish- able from a benign radiolucency.
  • Management: generally considered radio-resistant tumor, radical surgical resection is the first line of treatment.

Differential Diagnosis: 🔍

  • The 2 type of lesions that most often must be differentiated from periapical inflammatory lesions are Periapical cemental dysplasia & enostosis (dense bone island, osteosclerosis) at the apex of the tooth.
  • In the early radiolucent phase of Periapical cemental dysplasia, the D/D rely solely on clinical examination and a test of tooth vitality.
  • With long standing periapical inflammatory lesions, the pulp chamber of involved tooth may be wider than adjacent tooth.
  • More mature PCD show radio-opaque mass within radiolucent area which helps in D/D.
  • Also the common site for PCD is mandibular anterior region. External root resorption is more common with periapical inflammatory lesions than PCD.
  • When enostosis is centered on the root apex, it may mimic inflammatory lesion but the PDL space has normal width. Also the periphery of enostosis is well defined and does not blend with surrounding trabaculae.
  • Small radiolucent periapical lesions with well-defined periphery may be either granulomas/cysts.
  • Differentiation may not be possible unless other characteristics of cyst such as displacement and expansion of surrounding structure is not present.
  • Larger lesions >1cm are usually radicular cysts.
  • If the patient has had endodontic treatment or apical surgery, a periapical radiolucency may remain that resemble periapical rarefying osteitis.
  • Metastatic lesions such as leukemia may grow in periapical segment of PDL space with malignant bone destruction.
Periapical radiographs of case showing Enostosis (see arrows) in the mandibular left quadrant, in close proximity with the roots of the adjacent teeth
  • Enostosis are common findings that seldom require treatment; however, caution should be exercised when undertaking orthodontic movement in the area of a DBI due to a potential risk of root resorption. Accurate identification and multidisciplinary management are of utmost importance. Monitoring size changes is recommended until completion of patient’s growth.

Dentowesome|@drmehnaz🖊


References:

  1. https://link.springer.com/article/10.1007/s40368-020-00596-w
  2. https://www.researchgate.net/profile/Eugene-Ko-2/publication/
  3. SlideShare, Study Notes✍🏻

Swellings in the angle of Mandible, Floor of Mouth & Palate

Swellings at the angle of Mandible include: ✍🏻👇🏻

🔅Congenital disease

• Branchial Cleft Cyst

🔅Neoplasm

(i) Benign

  • Hemangioma
  • Lymphangioma, Cystic hygroma
  • Pleomorphic adenoma (mixed tumor)
  • Warthin tumor
  • Neurofibroma
  • Angiolipoma
  • Adenoma
  • Hamartoma
  • Lipoma
  • Oncocytoma

(ii) Malignant

  • Mucoepidermoid carcinoma
  • Squamous cell carcinoma
  • Adenoid cystic carcinoma
  • Acinic cell carcinoma
  • Adenocarcinoma
  • Rhabdomyosarcoma
  • Lymphoma, leukemia
  • Metastatic adenopathy

🔅Inflammation/Infection

  1. Parotitis
  2. Parotid Abscess
  3. Tuberculosis
  4. Sarcoidosis
  5. Sjögren disease
  6. HIV

Detailed View🔍

1) Branchial Cleft Cyst:

  • Failure of involution of clefts and pouches lead to cysts, fistulas or sinus tracts.
  • Its a painless fluctuant swelling
  • First branchial cleft cysts are rare usually located at parotid gland or periparotid region.
  • Second branchial cleft cyst – Type II are the most common
  • Typically, second branchial cleft cysts present as a rounded swelling just below the angle of mandible, anterior to the sternocleidomastoid

2) Hemangiomas:

They are the most common benign salivary gland mass. Capillary hemangiomas involve parotids

3) Lymphangiomas

They are congenital malformations of the lymphatic system that may involve the parotid gland (Soft asymptomatic neck mass associated with facial asymmetry)

4) Pleomorphic Adenoma:

Hard painless slow growing mass

5) Warthin Tumor:

Incorporation of heterotopic salivary gland ductal epithelium within intraparotid & periparotid nodes

6) Parotitis & Parotid Abscess:

  • Most common in children
  • Mumps is the most common viral cause of parotitis
  • The condition manifests tender swelling at the angle of Mandible
  • Sialadenitis is most commonly due to bacterial infections caused by Staphylococcus aureus.
  • Premature neonates and immunosuppressed individuals are affected.

Swellings in the floor of Mouth: 👇🏻✍🏻

Ranula presents as a translucent blue, dome-shaped fluctuant swelling & contains viscid, glairy jelly like fluid
  1. Ranula – a type of mucocele found on the floor of the mouth. Present as a swelling of connective tissue consisting of collected Mucin from a ruptured salivary gland by local trauma.
  2. Swellings in the floor of the mouth are more likely to arise from structures above the Mylohyoid muscle. The commonest swellings in the floor of the mouth are denture induced hyperplasia & salivary calculus.
  3. Swellings in the floor of the mouth may inhibit swallowing & speech.
  4. Mandibular tori produce bony hard swelling lingual to the lower premolars.

Differential diagnosis of swellings of the floor of the mouth or neck (Jham et al., 2007): https://www.researchgate.net/figure/Differential-diagnosis-of-swellings-of-the-floor-of-the-mouth-or-neck-Jham-et-al-2007_tbl1_287206404


Swellings on the Palate: 👇🏻✍🏻

  1. Torus palatinus is an intrinsic bone lesion whereas a dental abscess pointing on the palate (usually from the palatal roots of the 1st & 2nd maxillary molars or from upper lateral incisors) is extrinsic.
  2. Salivary neoplasms
  3. Invasive carcinoma from the maxillary sinus may produce a palatal swelling.
  4. Kaposi’s sarcoma, typical of HIV/AIDS may also present as lump on palate.
  5. Paget’s disease.

Differential diagnosis of palatal swellings: https://www.researchgate.net/figure/Differential-diagnosis-of-palatal-swellings_tbl1_221967546

Dentowesome|@drmehnaz🖊


Image source: Google.com

Types Of Caries

• Clinical Classification of Caries:

1️⃣ According to Anatomical Site –

  • Pit & fissure caries
  • Smooth Surface Caries
  • Cervical
  • Root caries

2️⃣ According to rate of caries progression –

  • Acute dental caries
  • Chronic dental caries

3️⃣ According to nature of attack-

  • Primary
  • Secondary

4️⃣ Based on chronology –

  • Infancy caries
  • Adolescent caries

A. Pit & Fissure Caries:

https://dentowesome.in/2020/05/11/pit-fissure-caries/

B. Smooth surface caries:

  • On proximal surface of teeth or gingival 3rd of buccal & lingual preceded by formation of plaque.
  • Early while chalky spot – decalcification of enamel.

C. Linear Enamel Caries:

  • Atypical form
  • Found in primary dentition
  • Gross destruction of labial surface of incisor teeth

https://dentowesome.in/2020/05/07/dental-caries/

D. Root caries:

  • Soft progressive lesion that is found everywhere on root surface that has least connective tissue attachment & is exposed to oral enviornment.
  • Older age group & gingival recession

E. Acute Dentinal Caries:

  • Rapid clinical course
  • Early pulp involvement
  • Initial lesion is small, while rapid spread of process at DEJ & diffuse involvement of dentin produce large internal excavation.

F. Rampant Caries:

Sudden, rapid & almost uncontrolled destruction of teeth affecting surface that are relatively caries free.

G. Nursing bottle caries (Baby bottle syndrome)

Affect deciduous teeth due to prolonged use of nursing bottle containing milk, sugar or honey.

💬 What is 👶 bottle decay? What causes it and how to prevent it? 👇🏻

H. Chronic dental caries: (Slower progress)

I. Recurrent caries: (Presence of leaky margins)

J. Arrested caries:

  • No tendency of future progression, caries become static.
  • Brown pigmentation in the hard tissue.

Dentowesome|@drmehnaz🖊


Image Source: Google.com

Ameloblastoma

Odontogenic cysts and tumors are the most important topics in Oral Pathology. Ameloblastoma itself is quite a large topic to talk about.

So on a rough basis, Ameloblastomas are basically tumors. They are tumors of Odontogenic (tooth forming tissue) in origin. They are benign in nature.

I have included detailed notes for types, clinical features and histology. Treatment I shall share on a more detailed version in coming blogs.

Reference to content : Shaffer’s Oral Pathology, 7th edition. Neville 3rd Edition

Histological Diagrams from: Maji Jose Manual of Oral Pathology and histology 2nd Edition.

Thank you.