Oral

Pathology
MDA Chapter 17

Comprehensive
2 hrs 30 mins

60 questions
Introduction
▪ Oral pathology is the study of diseases in the oral
cavity
▪ Only a dentist or physician may diagnose
pathologic (disease) conditions
▪ Important for the dental assistant to be able to
recognize the differences between normal and
abnormal conditions that appear in the mouth
WHY IS IT IMPORTANT FOR A
DENTAL ASSISTANT TO
RECOGNIZE NORMAL AND
ABNORMAL CONDITIONS IN
THE ORAL CAVITY?

▪ The dental assistant should

understand how oral abnormalities
affect the patient’s general health
and planned dental treatment.
Many systemic diseases as well as infectious diseases have oral
manifestations (signs and symptoms)

The dental assistant should also understand how oral abnormalities affect
the patient’s general health and planned dental treatment

Before you can recognize abnormal conditions, you must have a solid
understanding of the appearance of the normal oral conditions

Introduction
Neoplasm is a medical term for tumor.

This group of lesions has great potential for becoming malignant

(cancerous).

The dental assistant should be knowledgeable about the causes of these

diseases and should perform careful clinical examinations for premalignant
lesions.

Even if it is known that a tumor is benign (harmless), it is important that all

lesions are brought to the attention of the dentist, without alarming the
patient. Early recognition of the tumor could save the patient’s life.
 Why is it useful to have It is likely that one
more than one source of piece of information
Diagnosis
Making a
information for a will not be enough to
make a diagnosis.
diagnosis?

How can the dental assistant be helpful in the

formation of a diagnosis?

By collecting family history, asking patients

about symptoms, and reporting any lesions or
other abnormalities to the dentist.)

▪ Historical diagnosis • Laboratory diagnosis

▪ Clinical diagnosis
• Therapeutic diagnosis
▪ Radiographic
diagnosis • Surgical diagnosis
▪ Microscopic
diagnosis • Differential diagnosis
Historical
Diagnosis
▪ Family histories are important because
genetic disorders, such as
dentinogenesis imperfecta, may be
passed from generation to generation
▪ Melanin pigmentation of the gingiva is
common in dark-skinned individuals
▪ Medical histories can provide
information about medication the
patient may be taking that could have
an effect on the oral tissues
▪ Family history is also referred to as
heredity.
Dentinogenesis
Imperfecta
▪ Dentinogenesis imperfecta is a hereditary
condition that affects the formation of
dentin
▪ Teeth are opalescent and have an almost
amber color
▪ The enamel tends to chip away from the
dentin, and the weakened teeth become
worn down
▪ It is very difficult to restore these teeth.
Bond agents do not work properly with the
defective dentin, and it is very prone to
decay.
▪
Notice the teeth are opalescent and have
an almost amber color. The enamel tends
to chip away from the dentin, and the
weakened teeth become worn down.
Fissured
Tongue
▪ What is a clinical diagnosis?

▪ Clinical appearance of the lesion, including

the: color, size, shape, and location.
▪ The cause of fissured tongue is unknown.
Theories include vitamin deficiency and
chronic trauma.
▪ The top of the tongue is marked by deep
fissures or grooves, which become irritated if
food debris collects in them.
▪ The patient with a fissured tongue is advised
to brush the tongue gently with a soft
toothbrush to keep the fissures clean of debris
and irritants.
▪ No treatment is indicated for this condition.
Mandibular
Tori
▪ A) shows the clinical appearance of
bilateral mandibular tori. Torus is a
benign bony growth projecting outward
from the surface of a bone.
Torus Palatinus

▪ B) shows the clinical appearance of

lobulated torus palatinus.
▪ A torus palatinus is a bony overgrowth
in the midline of the hard palate.
Exostoses

• A benign bony growth projecting outward from the surface of a

bone
• Exostoses are on the outside of the jaw.

Torus palatinus

• A bony overgrowth at the midline of the hard palate

Torus mandibularis

• A bony overgrowth on the lingual surface of the mandible

• Tori are on the inside of the jaw.

Disturbances in Jaw
Development
Radiographic
Diagnosis
▪ Radiographic images are excellent in
providing information about:

➢ Periapical pathology
➢ Internal resorption
➢ Impacted teeth
PERIAPICAL
PATHOLOGY
▪ Why is this radiograph important for
patient care?

▪ Note the change in the bone of the

mandible resulting from an infection.
The pulp became infected as a result of
caries, and the infection caused bone
resorption.
Internal
Resorption
▪ The tooth often has a history of
trauma or pulp cap.
▪ Discoloration may or may not be
present.
 Severely decayed 3.7

Third Molar
Impaction
Radiograph showing
horizontal impaction of the
third molar, resulting in
tooth #37 with severe decay.

An impacted tooth occurs

when a tooth fails to fully
emerge through the
gingiva.

The most common teeth to

become impacted are the
wisdom teeth,
Tetracycline

▪ Staining of the dentition.

This patient was treated
with tetracycline during
formation of the teeth.
Dental
fluorosis

➢ Also known as ‘mottled

enamel’
➢ Results from ingestion of
excessive fluoride during the
mineralization
➢ Varying degrees of discoloration
ranging from a few white spots to
extensive white areas
Abrasion

(Abnormal)
➢ the abnormal wearing away of
tooth structure, is caused by a
repetitive habit, such as
improper toothbrushing, most
often a back-and-forth
scrubbing motion that involves
excessive pressure.
➢ The use of an abrasive
dentifrice or a hard-bristled
toothbrush may also cause
abrasion
Attrition

(Normal)
▪ Attrition unlike abrasion is the
normal wearing away of tooth
structure during chewing
▪ Attrition is normal and occurs
with age on the incisal,
occlusal, and proximal
surfaces of the teeth.
Bruxism
▪ Bruxism is an oral habit that is characterized by
involuntary gnashing, grinding, and clenching of
the teeth.
▪ It is usually performed during sleep and is often
associated with stress or tension.
▪ Bruxism causes abnormal wear of the teeth

▪ In addition to stress reduction techniques, a night

guard or a removable splint is frequently used as a
temporary aid in the treatment of bruxism.
Microscopic Diagnosis

Biopsy

➢ When a suspicious lesion is present,

tissue is removed and sent to a
pathology laboratory, where it is
evaluated

microscopically This procedure is very

often used to make the definitive (final)
diagnosis
Use of a Probe to
Measure a Lesion
▪ The width and length of a lesion is
recorded. Using the probe provides a
convenient method.
❖ Biopsy is the removal and microscopic
examination of a section of tissue or other
material from the body for the purposes of
diagnosis.
Laboratory
Diagnosis

▪ How is a malignancy
diagnosed?
➢ For example, a white lesion
cannot be diagnosed based on
the clinical appearance alone.
It must be subjected to biopsy
to determine whether it is
malignant.
➢ It is essential that any
suspicious lesions be checked
to see whether they are
malignant.
 Blood chemistries and
Cultures done in the
other laboratory tests,
laboratory can be used
including urinalysis, can
to diagnose types of
provide information
oral infection
that leads to a diagnosis

Laboratory
Diagnosis

❖ Many blood disorders are determined

through laboratory diagnosis.
 Pernicious
Anemia
Angular Cheilitis

“chai-litis”
▪ inflammation of corners of the lips
▪ Oral manifestations of pernicious
anemia
▪ A condition in which the body does
not absorb vitamin B12
▪ People with this condition show
signs of anemia, weakness, pale skin,
and fatigue on exertion
▪ Other signs include nausea,
diarrhea, abdominal pain, and loss
of appetite
▪ Oral manifestations of pernicious
anemia include angular cheilitis
(ulceration and redness at the
corners of the lips), mucosal
ulceration, loss of papillae on the
tongue, and a painful burning
sensation of the tongue

▪ Pernicious anemia is caused by a

lack of intrinsic factor, a substance
needed to absorb vitamin B12 from
the gastrointestinal tract.
▪ Vitamin B12, in turn, is necessary
for the formation of red blood cells.
Therapeutic
Diagnosis
▪ Made by providing a treatment (therapy),
then seeing how the condition responds
▪ How can therapeutic diagnosis be made
using a treatment?
➢ For example, angular cheilitis could be
caused by a lack of the B-complex
vitamins. If the angular cheilitis improves
after the patient is given an antifungal
cream, the vitamin deficiency theory can
be ruled out.
▪ Therapeutic diagnosis is also defined as
an assessment of the objectives and
available methods of treatment for an
individual patient considering the specific
existing conditions.
Surgical Diagnosis

Traumatic bone
cyst

▪ The arrow points to a traumatic

bone cyst.

▪ A diagnosis made on the basis of

the findings of a surgical
procedure
▪ Helps distinguish between benign
and potentially harmful
conditions
▪ a traumatic bone cyst also looks
like a static bone cyst. However,
one condition would require
treatment and one would not.
Surgically opening the area and
inspecting it would prove
whether the radiolucency on the
radiograph is indeed a condition
that needs further treatment
Static Bone
Cyst

▪ The arrow points to a static

bone cyst.
▪ The expertise of the dentist is
the primary determining factor
in the making of a differential
diagnosis.
Differential
Diagnosis
▪ When two or more possible causes of a
condition are identified, a differential
diagnosis must be made
▪ The dentist will determine which tests
or procedures should be performed to
rule out the incorrect cause and make
a final diagnosis.
Acute/Chronic
Inflammation

Inflammation is the
body’s protective Inflammation can be
response to irritation or acute or chronic
injury

Acute inflammation
occurs if injury to the Chronic inflammation
tissue is minimal and occurs when injury or
shortlasting and the irritation to the tissue
tissue begins to repair continues
quickly
Oral Lesions

Lesion is a broad term for abnormal tissues in the oral cavity

➢ Can be a wound, a sore, or any other tissue damage caused by

injury or disease

Classified as to whether they:

➢ Extend below or extend above the mucosal surface
➢ Lie flat or even with the mucosal surface
Q ▪What are the classic
signs of inflammation?
 1. Redness
2. swelling

A
3. heat
4. pain
Ulcer

• A defect or break in continuity of the mucosa that results in a punched-out area similar to a crater

Erosion of the soft tissue

• A shallow defect in the mucosa caused by mechanical trauma(wound or injury).

Abscess

• A localized collection of exudate (pus) in a circumscribed area

• Pain to the patient that may be short and sharp or dull and continual.
• The treatment for irreversible pulpitis is root canal therapy or extraction.

Cyst

• A closed sac or pouch that is lined with epithelium and contains fluid or semisolid material

Lesions Extending Below

Mucosal Surface
Abscess
➢ Localized area of infection

➢ Abscesses are commonly found at the apex of a tooth

(periapical abscess).

➢ An abscess may be caused by bacteria in a badly

decayed tooth or by bacteria resulting from a severe
periodontal infection

➢ The patient’s symptoms include pain from pressure,

swelling, and severe responses to heat

➢ Often tender to percussion and palpation

➢ The tooth has become infected, and as the abscess

grows, it places a great deal of pressure in the area
because the fluid has no place to escape in the bone.

➢ Apical radiolucency shows on the radiograph to the

right
 Blisters: Also known as
vesicles; filled with a watery
fluid

Pustule - Similar in
appearance to a blister but
containing pus
Lesions
Extending Hematoma - Also similar to a
blister but containing blood
Above
Mucosal Plaque Any patch or flat area
that is slightly raised from the
Surface surface

❖ A plaque is any patch or flat area that is

slightly raised from the surface. Note:
This is not the same as dental plaque,
which is discussed in Chapter 15
Lesions Even
with Mucosal
Surface

▪ Lie flat or even with the

surface of the oral mucosa and
are well-defined areas of
discoloration
➢ An ecchymosis (ek-uh-moh-
sis)- which is the medical term
for bruising, is an example of
this type of lesion
 ▪ Nodules - which may appear below the
surface or may be slightly elevated, are
small, round, solid lesions
➢ When palpated, a nodule feels like a
pea beneath the surface
▪ Granuloma - in dentistry is often used
to describe a nodule that contains
Raised granulation tissue
or Flat ▪ Tumors are also known as neoplasms

Lesions ➢ A tumor may be benign or malignant

❖ When Palpated: If the nodule can be

rolled, it is a good sign that the lesion is
more likely benign rather than malignant.
❖ Malignancies are indurated; they are
invasive and grab surrounding tissue.
Diseases of the Oral Soft
Tissues

Leukoplakia “white patch”

• A white, leathery patch that cannot be

identified as any other type of lesion is termed
leukoplakia.
• Leukoplakia is a general term that means “white
patch.”
• Cause is unknown, but leukoplakia is commonly
linked to chronic irritation or trauma
• Is often seen in the lower lip of a person who
uses chewing tobacco. Normally, excessive
alcohol and tobacco usage, vitamin A deficiency,
or trauma are associated with the lesion.
• Leukoplakia often appears before a malignant
lesion develops, so early diagnosis and
treatment are important.
• The lesion should be firmly attached to the
underlying tissue, rubbing or scraping with an
instrument should not remove it.
Lichen Planus
“like-en-planus”
o This benign, chronic (long-duration)
disease affects the skin and oral mucosa
o Many factors have been implicated in
lichen planus; however, the cause
remains unknown
o The patchy white lesions on the oral
mucosa have a characteristic pattern of
circles and interconnecting lines called
Wickham striae
o Some forms of lichen planus can cause
erosive lesions which get worse with
stress
o A patient may exhibit pain while eating,
and some foods may irritate the
condition. The treatment is topical
steroid therapy.
Dentigerous
cysts

“dent-ay-gerous’
Dentigerous cysts around the
crown of an unerupted bicuspid
Candidiasis
“Can –did-dia-sis”
aka Thrush
▪ A fungal infection resulting in a superficial infection
caused by the yeastlike fungus Candida albicans

▪ When it affects the oral tissues, it is called thrush

or oral thrush.

▪ Occurs under conditions such as antibiotic therapy,

diabetes, xerostomia (dry mouth), and weakened
immunologic reactions

▪ Can be the initial clinical manifestation for patients

with acquired immunodeficiency syndrome (AIDS)

▪ Diaper rash, vaginitis, and thrush are other common

types of candidiasis

▪ Medications such as corticosteroids, chemotherapy,

and cancer-related related drugs can also cause
thrush. Smoking, poorly fitting dentures, and stress
can also lead to the development of oral thrush.
Thrush is possible to prevent in most cases by
modifying the risk factors.
 Creamy white plaques form in the mouth (resembles cottage cheese).
Pseudomembranous The patient frequently describes a burning sensation, an unpleasant taste, or the feeling of
candidiasis; also “blisters forming in the mouth.”
called thrush These “blisters” generally prove to be the pseudomembranous plaques. Pseudomembranous
is a term that describes a false membrane or tissue

Hyperplastic Appears as a white plaque that cannot be removed by scraping

candidiasis

Atrophic candidiasis Smooth red patches may appear on the dorsal areas of the tongue and palate

Types of Candidiasis
Thrush

▪ The most common oral fungal infection in

infants and children. It is not usually
serious, but it can be uncomfortable, and it
may cause difficulties with feeding.
▪ Oral thrush may occur in babies because
their immune systems have not yet
matured. They are less able to resist
infection.

▪ Tissues can be red and raw with soreness

and some mouth pain.

▪
Treatment is available. In a few cases, the
child’s pediatrician may prescribe
antifungal nystatin drops or a topical
antifungal drug to be applied to the area.
Pseudomembran
ous Candidiasis
“seu-do-membrane- PSEUDOMEMBRAN COMMON PATIENT
ous” OUS CANDIDIASIS. COMPLAINTS
INCLUDE A
BURNING
SENSATION, A BAD
TASTE IN THE
❖ Medical definition of MOUTH, AND THE
pseudomembranous: FEELING THAT
characterized by the BLISTERS ARE
FORMING.
presence or formation of a
false membrane. THE PLAQUES CAN
BE SCRAPED OFF
AND RARELY
BLEED.
Chronic Hyperplastic
Candidiasis

▪ Shows chronic hyperplastic candidiasis. The white

appearance of the cheek did not wipe off, and it
disappeared with antifungal treatment.

▪ How long does treatment take?

▪ Common treatments can take 10 days to 2 weeks.

▪ Like all forms of candidiasis, complications or lack

of response to treatment may indicate a more
serious underlying disorder.
Aphthous Ulcers
“A-thus”
Also known as aphthous stomatitis or canker sores
Early signs are burning sensations and blister
formation. The ulcers form when the blisters break.
These tend to occur when a person is under stress.
They are not contagious.
Cellulitis
▪ Inflammation spreads through the soft tissue or organ

▪ Swelling develops rapidly, accompanied by a high

fever
▪ The skin becomes very red, and there is severe
throbbing pain as the inflammation localizes
▪ Cellulitis associated with oral infections is potentially
dangerous because it can travel quickly to sensitive
tissues such as the eye or brain
What are the keys to managing a case of cellulitis?
▪ Controlling inflammation and treating the underlying
infection
▪ Edema: Swelling caused due to excess fluid
accumulation in the body tissues.
(TOP) Patient with cellulitis from wisdom tooth infection.

(Bottom) shows cellulitis. Local edema associated with a dental

infection. The patient was hospitalized for treatment of the swelling.
 General term used to describe inflammation
and changes in the topography of the tongue

Inflammation and pain in the tongue can be

disfiguring and can also lead to difficulties in
obtaining sufficient nutrition.

Glossitis
(tongue) ❖ Topography is
the arrangement
of the natural
and artificial
physical features
of an area
Black Hairy
Tongue
May be caused by an imbalance of oral
flora after the administration of
antibiotics.
Can also be associated with chemo-
therapeutic agents such as drugs, hydrogen
peroxide mouth rinses.

The filiform papillae are so greatly

elongated that they resemble hairs

These elongated papillae become stained

by food and tobacco, hence the name

What would you expect to learn about a

patient’s
Treatmenthistory
of thisifcondition
he or sheispresented
to stop the
with a case of black hairy tongue?
known cause, if applicable, and use good
oral hygiene, including brushing the
tongue. In extreme cases, the filiform
papillae grow so long that they cause the
person to gag. If this happens, the papillae
can be trimmed to alleviate gagging.
Geographic
Tongue
▪ Tongue exhibits multiple areas of
desquamation (loss) of the filiform
papillae in several irregularly shaped
but well-demarcated areas
▪ The smooth areas resemble a map,
hence the name
▪ Over a period of days or weeks, the
smooth areas and the whitish margins
seem to migrate across the surface of
the tongue by healing on one border
and extending on another
Kaposi Sarcoma

▪ Kaposi sarcoma (arrows) in a patient

with acquired immunodeficiency
syndrome (AIDS).

▪ A, Skin. B, Gingivae.

▪ The oral lesions associated with Kaposi

sarcoma appear as flat patches or
swellings. Lesions may occur on the
palate, gingiva, and tongue.
▪ Kaposi sarcoma can become painful as
a result of ulceration or infection.
Sarcoma
▪ A number of AIDS patients present with an
unusual malignant vascular tumor called Kaposi’s
sarcoma
▪ One of the opportunistic infections that
occurs in patients with HIV infection
▪ Lesions may appear as multiple bluish,
blackish, or reddish blotches that are
usually flat in the early stages
▪ Kaposi sarcoma is one of the intraoral
lesions that is used to diagnose AIDS Kaposi
Sarcoma
❖ What is the current treatment for Kaposi
sarcoma?
✓ At present there is no effective treatment
for Kaposi sarcoma.
Oral Cancer

▪ Oral Cancer is a disease involving abnormal cell growth that has

the potential to invade or spread into all areas of the body.
▪ There are over 100 types of cancer.

▪ Oral cancer is one of the most common forms of cancer.

▪ It appears as a sore or growth in the mouth and the lips and does
not go away.
▪ It is not usually painful so it can go undetected, but if it is not
diagnosed and treated early, it can be life threatening.
▪ Oral cancer includes cancers of the lips, tongue, cheeks, floor of
the mouth, hard and soft palate, sinuses, and pharynx (throat) (
Oral Cancer

▪ Most oral cancers do not cause pain in the

early stages, and the thorough dentist is
most likely to be the first to detect them
▪ The risk factors for the development of
oral cancer include the following:
✓ Smoking cigarettes, cigars, or pipes

✓ People who use smokeless tobacco including

dip, snuff, or chewing products
✓ Alcohol use in excess, picture shows oral
cancer on the cheek.
✓ Family history of cancer

✓ Excessive exposure to the sun, especially at

a young age
✓ Infections such as hepatitis B, hepatitis C,
and human papillomavirus (HPV).
Signs of oral cancer

▪ A sore that bleeds easily or does not heal

▪ A color change of the oral tissues
▪ A lump, thickening, rough spot, crust, or small eroded area
▪ Pain, tenderness, or numbness anywhere in the mouth or on
the lips
▪ Difficulty chewing, swallowing, speaking, or moving the jaw or
tongue
▪ A change in the way the teeth fit together
Squamous Cell Carcinoma
Picture shows the clinical appearance of
squamous cell carcinoma of the lower lip.

 Oral cancers may quickly metastasize (muh-ta-stuh-

siuze) which means to spread to other regions of the
body, usually the neck and cervical lymph nodes.
 Nine out of ten oral cancers are of this type.
 Factors associated with causing carcinomas are sunlight
exposure and long-term use of tobacco or alcohol.
Normally, squamous cell carcinomas are seen in adults
over 40, but have also been found in younger patients.
More cases have been documented in males than females.
 Squamous cell carcinoma is found primarily on the floor
of the oral cavity under the tongue, on the sides or
borders of the tongue, and on the soft palate tonsil area.
 The lesion may first appear as a thickened, white
plaque that develops into an ulcer. As it grows, this ulcer
seems to encompass other tissues.
 Early detection is essential, because if the carcinoma
metastasizes into the lymph nodes, the survival rate is
greatly diminished.
Destruction of
Mandible by
Squamous Cell
Carcinoma
▪ Left side of a panoramic
radiograph shows destruction of
the mandible by squamous cell
carcinoma.
▪ More than 90% of oral cancers
are squamous cell carcinomas.
▪ Squamous cell cancer typically
begins in the outer lining layer of
cells in the oral cavity.
Types of Oral
Cancer
▪ Carcinoma: A carcinoma is one of the most common types
of cancer. A malignant neoplasm (tumour/growth) of the
epithelium (tissue lining the mouth), they are abnormal
cells that spread to other parts of the body. This cancer is
found on the lips, cheeks, and the floor of the mouth
▪ Adenocarcinoma: A malignant tumor that arises from the
submucous glands underlying the oral mucosa
There are two main types of sarcomas:
▪ Sarcoma: . A malignant neoplasm arising from supportive
and connective tissue is a type of cancer cell that occurs
in connective tissue cells. These tissues support the body
and include cartilage, tendons, bones, muscles, and the
fibrous tissue in organs
▪ Osteosarcoma: A malignant tumor involving the bone. It
develops in the bones, such as the jaws; and soft tissue
sarcoma, which occurs in all other types of connective
tissue.
Osteosarcoma
Oral cancer most often occurs in
those who use tobacco in any
form.

Alcohol use and poor diet also Risk

increase risk.
factors
of Oral
Prolonged exposure to the sun Cancer:
increases the risk of lip cancer.

More than 25% of oral cancers

occur in people who do not smoke
and have no other risk factors.
Cancer is detected by
specific signs and symptoms,
or by screening tests. Tissues
are then evaluated through
medical imaging and biopsy.

Treatment
Once the cancer has been
diagnosed it is often treated
with surgery, chemotherapy,
radiation therapy, targeted
therapy, or a combination of
these. Pain, nausea, and
symptom management are
part of the care.
Leukemia
What is it?

• A cancer of the blood-forming organs

▪ Characterized by rapid growth of immature white blood cells

▪ Oral symptoms of leukemia may be some of the first indications of the

disease

Symptoms in the gingival tissues include:

✓ hemorrhage

✓ Ulceration

✓ Enlargement

✓ spongy texture

✓ and magenta coloration of the gingiva

▪ Enlargement of lymph nodes, symptoms of anemia, and general bleeding

tendencies are typical

❖ Twenty percent of patients with chronic leukemia show no symptoms at

the time of diagnosis.
Smokeless
Tobacco
▪ Chewing tobacco or snuff presents a
serious health hazard
▪ It is a major concern because of the high
rates of precancerous leukoplakia and
oral cancer among users of smokeless
tobacco
▪ Cancers of the pharynx, larynx, and
esophagus occur 400 to 500 times more
frequently in users of smokeless tobacco
▪ Also linked to an increased incidence of
tooth loss from periodontal disease
▪ People often think of smokeless tobacco
as a healthy alternative to smoking
because there is no smoke, but it is very
harmful.
Therapy
for Oral
Cancer THERAPY: ORAL CANCERS
ARE TREATED
WITH SURGERY,
RADIATION
OFTEN, A
COMBINATION OF
THESE THREE IS
USED
RADIATION
THERAPY AND
CHEMOTHERAPY
ARE
THERAPY, OR CARCINOGENIC IN
CHEMOTHERAPY THEMSELVES.
SURVIVORS OF
ONE TYPE OF
➢ It is strongly recommended that CANCER ARE
PRONE TO
cancer patients visit the dentist ANOTHER TYPE OF
before commencing radiation CANCER LATER
therapy. ON.
➢ During treatment, the dentist can
work with the patient to monitor
complications such as dry mouth,
increased cavities, and painful mouth
sores.
 ▪ Xerostomia
➢ Lack of adequate saliva and the
reduced blood supply can cause oral
infections, delay healing, and make it
very difficult to wear dentures
▪ Radiation caries
Dental ➢ Caused by the lack of saliva, radiation
caries usually appears first in the
Implications cervical areas of the teeth
➢ The teeth also may become
of Radiation extremely sensitive to hot and cold
stimuli
Therapy ▪ Osteoradionecrosis
➢ Bone may be subject to necrosis
(death) after radiation treatment

❖ Radiation treatment for head and neck cancer has

effects on the salivary glands, blood vessels, and
bones of the jaws.
Postradiation
Effects
 Osteoradionecrosis is
more common in cases of
head and neck cancer, in
which the bone lies within B
the radiation field.

 Radiation technology
now involves the use of
sophisticated computer
algorithms to target the
beams and avoid healthy
tissue and bone.

A
Dental Implications of
Chemotherapy
Chemotherapeutic agents are powerful drugs that destroy or deactivate
rapidly dividing cancer cells

Significant adverse effects of these drugs frequently involve the oral

tissues

The chemotherapeutic drugs work because the cancer cells are dividing
more rapidly than normal cells are. Because they are dividing more rapidly,
they are more susceptible to the effects of these drugs.

Review table 17.2: Dental Implications of Chemotherapy.

HIV and AIDS
▪ Oral lesions are prominent features of acquired immunodeficiency syndrome (AIDS) and
human immunodeficiency virus (HIV) infection
▪ Oral lesions develop because of the breakdown of the immune system that occurs when
the T-helper cells become depleted as a result of the disease
▪ The Americans with Disabilities Act stipulates that a patient with HIV cannot be refused
treatment simply because of the disease.
➢ The only exception is the HIV patient with a special condition (e.g., severe periodontal
disease) that requires the care of a specialist.
▪ Patients who appear to be healthy and have no history of the disease may actually be
spreading the infection to others
❖ The term Universal Precautions is still referred to in the OSHA BBP Standard. Universal
Precautions is based on the concept that all human blood and body fluids (including
saliva) are to be treated as if known to be infected with a blood-borne disease such as
HBV, HCV, or HIV infection.
HIV and AIDS

▪ More than one third of all people living with HIV have oral
conditions related to their weakened immune systems.
▪ Combination antiretroviral therapy has made some oral health
problems less common but also involves side effects such as
xerostomia.
▪ HIV patients often die of pneumonia.
▪ They also are prone to Kaposi sarcoma.
Acquired Immunodeficiency
Syndrome
▪ Because the patient’s immune system is severely damaged,
death is usually caused by an opportunistic infection
▪ Opportunistic infection: One that normally would be
controlled by the immune system but cannot be controlled
because the immune system is not functioning properly
▪ Some of the lesions that look like HIV- and AIDS-related
infection may also be caused by other disorders
HIV Gingivitis

▪ There is often a bright red line along

the border of the free gingival margin
➢ HIV gingivitis progresses to HIV
periodontitis.
 HIV Periodontitis

Resembles acute HIV-associated HIV-associated Other symptoms

necrotizing periodontitis is periodontitis may include:
ulcerative gingivitis much more involve pain and
superimposed on aggressive than are spontaneous
rapidly progressive other forms of bleeding.
periodontitis periodontitis.
Interproximal necrosis and
cratering
Marked swelling
Intense erythema over the
free and attached gingiva
Intense pain
Spontaneous bleeding and
bad breath
Lymphadenop
athy
HIV Cervical
Lymphadenopathy

“lymph-aden-o-pathy”

What is it?
• Enlargement of the cervical
(neck) nodes
▪ Lymphadenopathy is frequently
seen in association with AIDS
▪ Many infections are associated
with lymphadenopathy.
▪ Care should be taken to avoid
alarming a presenting patient
without cause.
Candidiasis

▪ Often the initial oral sign of the

progression from HIV-positive status to
AIDS
▪ In a patient with a compromised
immune system, candidiasis can be a
very debilitating and serious disorder
➢ This is evaluated during the intraoral
examination by the dentist.
HIV
Lymphoma
▪ Lymphoma is the general term used
to describe malignant disorders of
the lymphoid tissue
▪ In the immunocompromised
individual, it may occur as a solitary
lump or nodule, a swelling, or a
nonhealing ulcer that occurs
anywhere in the oral cavity
▪ The swelling may be ulcerated or
may be covered with intact, normal-
appearing mucosa
▪ Usually painful, the lesion grows
rapidly and may be the first
evidence of lymphoma
▪ Treatment involves radiation
therapy for localized conditions and
chemotherapy if the cancer has
spread.
Shows intraoral lymphoma (arrow) in a patient with acquired
immunodeficiency syndrome (AIDS).
Biopsy is usually required for firm diagnosis.
Hairy Leukoplakia

✓ Can be an important early

manifestation of AIDS status
✓ A filamentous white plaque usually
found unilaterally or bilaterally on the
lateral borders (sides) on the anterior
portion of the tongue
✓ May spread to cover the entire dorsal
surface of the tongue
✓ Can also appear on the buccal mucosa,
where it generally has a flat
appearance
✓ In severe cases, prescription medicines
and pain relievers may be used to
treat symptoms.
Hairy Leukoplakia
VS
Black hairy tongue
Knowing the difference:

▪ Hairy Leukoplakia leaves a

filamentous white plaque usually found
unilaterally or bilaterally on the
lateral borders (sides) on the anterior
portion of the tongue
➢ Cause: can be an important early
manifestation of AIDS status
▪ Black hairy tongue, may be The
filiform papillae are so greatly
elongated that they resemble hairs
➢ Cause: by an imbalance of oral flora
after antibiotics.
Herpes simplex lesions usually
occur on the lip, fever
blisters or cold sore
highly contagious
The virus causes an ulcer-like
lesion
In immunocompromised patients,
the lesions may occur throughout
the mouth Herpes
An ulcer caused by the herpes
virus that persists for longer than
1 month may be an indicator of
Simplex
AIDS
Patients who do not have HIV or
AIDs may also suffer from herpes
This virus may be dormant for
years and then may become
activated and cause disease.
Because these sores frequently
develop when the patient has a
cold or fever of other origin, the
disease is now commonly known
as fever blisters or cold sore

Treatment: includes prescription medications

to promote healing and control outbreaks.
 ▪ Herpes simplex 1 typically occurs above the waist, normally
around the mouth.

▪ The Type I infection occurs in about three-fourths of middle-aged

adults. Forms of the virus are responsible for cold sores (painful
blisters around the mouth).

▪ These blisters, commonly called fever blisters, can appear solitary

or in a cluster of small blisters on the lips, called herpes labialis.

Herpes ▪ Normal inflammation surrounds the area.

The virus responsible for the disease is transmitted through

Simplex
▪
physical contact and is seen normally in children around the age
of 6 as herpetic gingivostomatitis (the initial infection).

Type I
▪ The virus, which is infectious both during the onset of the
vesicular stage and throughout the crusted stage, is often
unknowingly passed by adults to children during kissing.

▪ It exhibits symptoms much like the flu. Fever, along with body
aches, is apparent, followed by scattered ulcers in the oral
mucosa or on the lips.

▪ The symptoms reappear throughout life and usually last from 7

to 14 days. If the condition is caught early, medication is
available to alleviate discomfort

▪ Type II may appear in the oral cavity, but normally appears below
the waist and is commonly called genital herpes.
HERPES
SIMPLEX
ULCERATION
▪ Shows herpes simplex ulceration of the
hard palate in a patient with human
immunodeficiency virus (HIV) infection.
Arrows point to the ulcer.
▪ In immunocompromised patients,
lesions most commonly occur on the roof
of the mouth.
 ▪ In the immunocompromised patient,
the latent herpes zoster virus, also
known as shingles, may cause
intraoral manifestations in the form
of blisters
▪ These blisters break and form ulcers

Herpes ▪ The lesions are very painful

▪ The virus lives along a nerve fiber,
Zoster or dermatome. Stress causes the
virus to become “unshackled.”
▪ The appearance of the lesion can be
correlated with the level of the
spinal column from which the virus
originated.
Human
Papillomavirus
HPV
▪ Human papillomavirus appears most
commonly in immunocompromised
individuals
▪ Diagnosis is made on the basis of
history, clinical appearance, and
biopsy findings
▪ Lesions are a common finding in
patients with early HIV infection
▪ These warts appear spiky, and some
have a raised, cauliflower-like
appearance
▪ A doctor can prescribe topical
medications, excise warts surgically, or
freeze warts (cryosurgery). Warts can
return after treatment.
Developmental
Disorders
▪ Can result when there is a disturbance
of the cells during the period when the
cells divide
▪ The result is usually a deformity of
part of the body
 tal
disorder
is one
that is
present
at birth
Inherited disorders Either
are different from inherite
developmental d or
develop
disorders because mental;
they are caused by an howeve
abnormal gene r, exact
cause of
most
congeni
tal
Malform
abnorm
ations
alities
that areis
unknow
often
n
Types of
the
result of Developmental
Genetic factors genetic
Disorders
factors
such as
chromos
omal
abnorm
alities

Called
teratog
ens;
include
infectio
Environmental ns,
factors drugs,
and
exposur
e to
radiatio
n
Why would it be important for a
dentist to know that a patient is
pregnant?

This is important because some

disorders are inherited, which means
they could pass to the baby. pregnancy
It is also important that the pregnant
patient not be exposed to any radiation
from x-rays.

Examples of teratogens that can affect

the developing baby are infections,
drugs, and exposure to radiation.
 A
B

Disturba
nces in
Jaw
Develop
ment

A) Micrognathia- abnormally small jaws

B) Macrognathia “macro-nath-ia” - Abnormally large jaws.

Disturbances in Lip, Palate,
and Tongue Development
▪ Cleft lip
➢ Results when maxillary and medial nasal processes fail to fuse

▪ Cleft palate
➢ Results when palatal shelves fail to fuse with primary palate
➢ Cleft palate, with or without cleft lip, occurs in 1 per 2500 live
births
➢ Infants with clefts routinely lose permanent teeth in the course of
treatment and development.

▪ Cleft uvula
➢ The mildest form of cleft palate
Bilateral Complete
Cleft Lip and Palate
▪ shows a newborn with bilateral complete cleft lip
and palate. Note severe angulation of the
premaxillary segment.
▪ With a cleft lip, an infant’s dentition may be
affected if the cleft involves the gum; otherwise, it
is likely that dentition will be normal.
▪ A cleft of the palate and gum (alveolus) can
produce a variety of dental problems, including
missing teeth, misshapen or misplaced teeth, and
teeth that are slow to erupt.
Ankyloglossia
“anki-lo-glossia”

“tongue tied”
▪ Ankyloglossia
▪ tongue-tie; results in a short lingual frenum
that extends to the apex of the tongue

▪ Modern dental techniques make it possible to

preserve original dentition through careful
monitoring and a treatment plan.

▪ Does not affect speech development.

▪ Surgical procedures include a frenotomy or
frenuloplasty.
Ameloblastoma
• A tumor composed of remnants of the dental
lamina
Anodontia
• Congenital absence of teeth

Supernumerary teeth Disturbances

• Teeth in excess of the normal number in Tooth
Development
Macrodontia and microdontia and Eruption
• Abnormally large or small teeth

Dens in dente (tooth within a tooth)

• Formation of a small toothlike mass within the
pulp
• Disturbances in tooth development may be
linked to congenital diseases, but most are not.
• Developmental dental disturbances may be
hereditary.
Partial
Anodontia
▪ Shows partial anodontia.
▪ Anodontia in the primary teeth does
not necessarily indicate a similar
prognosis for the permanent dentition.
Unerupted
Supernumerary
Teeth
▪ Radiograph shows unerupted
supernumerary teeth.
▪ How are supernumerary teeth
classified? Supernumerary teeth are
classified according to their form and
location. Their presence may give rise to
a variety of clinical problems.
 ▪ Amelogenesis imperfecta is a
hereditary abnormality in which
there are hypoplasia-type
(incomplete development or
underdevelopment) defects in the
enamel formation
▪ Hypocalcification is the incomplete
calcification or hardening of the
Disturbances enamel
in Enamel ▪ Hereditary enamel hypoplasia is a
type of amelogenesis imperfecta
Formation that is characterized by teeth with
crowns that are hard and glossy,
yellow, and cone-shaped or
cylindrical
▪ In amelogenesis imperfecta,
abnormal enamel breaks off from
normal underlying dentin.
Enamel Loss
▪ Shows loss of enamel in these teeth in a patient
with hypocalcified amelogenesis imperfecta.
▪ As a result of amelogenesis imperfecta, a person's
teeth are covered with thin, malformed enamel.
▪ Amelogenesis imperfecta is an inherited condition
that is transmitted as a dominant trait.
Abnormal Eruption
of the Teeth
▪ Q: What is eruption?

➢ A: When a tooth comes through the gingiva, it is known as

[active] tooth eruption; it is a normal process of the body.
▪ Premature eruption
➢ In premature eruption, teeth are present at birth
(natal teeth)
➢ Neonatal teeth are those that erupt within the first 30
days of life

▪ Ankylosis
➢ In deciduous teeth affected by ankylosis, bone has
fused to cementum and dentin, preventing exfoliation

▪ Impaction
➢ Occurs when any tooth remains unerupted in the jaw
beyond the time at which it should normally erupt
Ankylosis

(fused/anchored)
▪ Radiograph showing ankylosis of a deciduous
molar.
▪ Ankylosis can occur at any time during eruption.

▪ The teeth become submerged relative to their

neighbors.
Impactions in
Mixed Dentition
▪ Shows impactions in mixed dentition visible on a
dental radiograph.
▪ What are the processes that can lead to
impaction?
▪ Premature loss of baby teeth and tooth crowding
 Additional
Disorders:
Bulimia
▪ Bulimia is an eating disorder that is characterized by food bingeing followed by
self-induced vomiting.
▪ The diseases of anorexia nervosa (the loss of at least 15 percent body weight, and an
intense fear of gaining weight) and bulimia.
▪ Episodes of out-of-control eating followed by purging) have several implications in
oral pathology.
▪ Anorexia nervosa is a disease in which extreme aversion to food is present.
▪ The dental professional is often the first healthcare professional to identify a patient
with bulimia, because of the pattern of erosion that becomes apparent on the lingual
surfaces of the teeth.
▪ Bulimia has also been linked to an increased rate of cavities.
▪ Due to constant vomiting/purging, the lingual surfaces of the anterior teeth become
decalcified, and the enamel is eroded.
▪ The occlusal surfaces of the posterior teeth become eroded, causing existing
restorations to deteriorate. Rampant caries and enlargement of the parotid glands
are also problems, along with the other symptoms of the disease, which are life-
threatening.
 Orofacial
Piercings
▪ Piercing of parts of the face and oral cavity followed
by the insertion of various objects has recently
become popular among some segments of the
population.
▪ The dental complications of this practice can include
chipped teeth, broken teeth, and serious infection at
the sites of the piercings.
▪ Infection can spread throughout the head and neck
area with serious results.
Temporomandibular
Disorders (TMD)
▪ Temporomandibular Disorders (TMD)

▪ One reason TMD is difficult to diagnose is that the symptoms

are so varied.
▪ Pain, joint sounds, and limitations in movement occur most
often.
▪ Patients with TMD may report a wide range of pain types,
including:

▪ Headache; pain in and around the ear (when no infection is

present), pain on chewing; and pain in the face, head, and
neck. Spasms (“cramps”) of the muscles of mastication can
become part of a cycle that results in tissue damage,
increased pain, muscle tenderness, and more spasms.

▪ TMD is a complex disorder that involves many factors, such

as stress, clenching, and bruxism.
▪ Clenching is holding the teeth tightly together for prolonged
periods.
▪ Bruxism is habitual grinding of the teeth, especially at night.
TMD can also be caused by trauma to the jaw, systemic
diseases such as osteoarthritis, or wear as a result of aging
Meth Mouth
▪ The oral effects of methamphetamine use, which
are devastating, are referred to as meth mouth
▪ Meth is potent and extremely harmful to the
central nervous system that can cause brain
damage, as well as severe oral health effects.
▪ Causes drug-related xerostomia (dry mouth), poor
oral hygiene, frequent consumption of highly
sugared soft drinks, and clenching and grinding of
the teeth all contribute to rampant caries
Gingival Hyperplasia

A condition known as gingival

hyperplasia occurs when the
connective tissue grows over the
teeth

This fibrous mass is not

uncomfortable to the patient but
can inhibit eating and alter the
patient’s appearance.

There are numerous causes of this

condition: plaque, orthodontic
braces, and various drugs.
Phenytoin (DilantinTM) causes this
symptom.
Acute Necrotizing
Ulcerative
Gingivitis
▪ The tissues present with bleeding,
infection, pain, and a foul odor in a
condition known as acute necrotizing
ulcerative gingivitis (ANUG)
▪ This infectious disease is seen
primarily in young adults and
adolescents. Poor hygiene, lack of
sleep, poor nutrition, and stress are
precipitating factors. It was referred
to as trench mouth years ago due to
the fact that many soldiers who fought
in the trenches developed ANUG.
▪ It is also seen on college campuses
around final exam time.
Questions?
▪ To Do: MDA

▪ Recall questions 1-31

▪ Critical thinking 1-3