Comprehensive Review of Pediatric Dentistry

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Comprehensive Review of Pediatric Dentistry Provided by: American Academy of Pediatric Dentistry

Release Date December 1, 2008

1-800-284-8433 • www.cmeinfo.com 639

Copyright American Academy of Pediatric Dentistry, 2008. All Rights Reserved.

American Academy of Pediatric Dentistry Comprehensive Review of Pediatric Dentistry

Growth & Development / Orthodontics Andrew L. Sonis, D.M.D. Trauma Constance M. Killian, D.M.D. Dental Materials Steven M. Adair, D.D.S., M.S. Pulp Therapy Steven M. Adair, D.D.S., M.S. Oral Pathology / Oral Medicine / Syndromes Andrew L. Sonis, D.M.D. Oral Pathology / Oral Medicine / Syndromes (cont'd) Andrew L. Sonis, D.M.D. Prevention Steven M. Adair, D.D.S., M.S. Special Needs Patients Constance M. Killian, D.M.D. Dental Development Steven M. Adair, D.D.S., M.S. Hospital Dentistry Constance M. Killian, D.M.D. Special Needs Patients (cont'd) Constance M. Killian, D.M.D. Behavior Management Constance M. Killian, D.M.D.

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PREFACE

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3


Comprehensive Review of Pediatric Dentistry Provided by: American Academy of Pediatric Dentistry

DVD #1

WARNING: The copyright proprietor has licensed the picture contained on this recording for personal use only and prohibits any other use, copying, reproduction, or performance in public, in whole or in part (Title 17 USC Section 501 506). © 2008

4


is not responsible in any way for the accuracy, medical and dental or legal content of this recording. You should be aware that substantive developments in the medical and dental fields covered by this recording may have occurred since the date of original release. Date of Original Release: December 1, 2008

This educational activity is a DVD format. The activity provides a comprehensive review of pediatric dentistry and is organized to assist American Academy of Pediatric Dentistry (AAPD) members in their preparation for the American Board of Pediatric Dentistry (ABPD) examinations. It is estimated that it should take the average learner 22 hours, including completion of the post-test and evaluation form, to complete this activity.

5


The American Academy of Pediatric Dentistry is recognized (May 2007 – June 2010) by the ADA Continuing Education Recognition Program (ADA CERP) to provide continuing education opportunities for dentists. Continuing education credit awarded for this activity may not apply toward license renewal in all states or meet

the requirements of other governing bodies. It is the responsibility of each practitioner or resident to verify the requirements of his or her state or governmental licensing board.

6


DESIGNATION The American Academy of Pediatric Dentistry designates this educational activity for a maximum of 22 hours of continuing education credits.

OBJECTIVES After viewing this program, the participant should have a better understanding of the following:

1. The major clinical and knowledge base areas of pediatric dentistry. 2. Select clinical cases. 3. The American Board of Pediatric Dentistry testing process.

7


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•

Type I – rod cores

•

Type II – peripheries of rods

•

Type III – delineation of rods not evident

335


Dentin histology is major factor in bonding success

Factors smear layer dentinal tubule density, size, length dentin sclerosis (caries-affected)

1 - 5" thick; dentin chips, debris Partly porous, but reduces fluid flow from tubules Weak attachment to dentin - ~6 MPa Biological “band-aid” Permeability increased by primers

336

Courtesy of Dr. Jorge Perdigao


Tubule diameter increases with depth toward pulp Superficial dentin fewer tubules per surface area less area for lateral diffusion of bonding agent

Bond strength decreases with progressive depth from DEJ water in dentinal fluid competes with collagen for hydrophilic monomers fluid dilutes concentration of monomer less intertubular dentin available for creation of hybrid layer

337

Courtesy of Dr. Jorge Perdigao


•

Sclerotic dentin denser in mineral content

•

Reduces penetration of bonding agent

•

Additional/extended etching on cariesaffected dentin increases tensile bond strength (Arrais et al 2004)

•

Removes or modifies smear layer, increases permeability

•

Demineralizes underlying dentin

•

Chemistry • • • • •

EDTA phosphoric acid maleic acid phosphoric/nitric acid/Al oxalate others

338


•

Current systems use hydrophilic wetting agents

•

Provides micro-mechanical retention to modified dentin

•

Wets/penetrates collagen meshwork, creates “hybrid layer,” increases wetability of dentin

Unfilled resin Bonds with composite restorative material Bonds with primer in hybrid layer Courtesy of Dr. Jorge Perdigao

339


Two-bottle etch and rinse system (total etch/complex)

One-bottle etch and rinse system (total etch/simplified)

Two-bottle self-etch system (self-etch/complex)

One-step self-etch system (self-etch/simplified) De Munck et al 2005

•

Etch-rinse-prime-bond (two bottle) system: • gold standard for bonding agents

•

Any simplification in the procedure results in loss of bonding effectiveness

•

Only two-step self-etch primer + adhesive approaches the gold standard

340


•

Self-etch systems modify but do not remove the smear layer

•

May result in less postoperative sensitivity

•

Not as good as total etch systems for enamel bonding

•

“Total etch technique”

•

Dentin is left slightly wet - “glistening”

•

Enamel and dentin bond strengths 21-30 MPa for permanent, 10-18 primary

341


Smear layer removed more easily than in permanent teeth 25-30% thicker hybrid layer Greater reactivity of primary dentin to conditioner; deeper demineralized zone; precludes complete penetration of primer and adhesive? Recommended less time for conditioning primary teeth (7 vs. 15 sec) Nor et al 1996, Torres et al 2007

•

Microtensile bond strength of adhesive systems similar with permanent and primary dentin (Soares et al 2005)

Shorter etch times may not be necessary with self-etch products

342


•

Osseointegrated (endosseous) implants • titanium or titanium alloy • surface treatments to enhance

osseointegration

• acid etching • grit blasting / acid etching

• surface treatment with hydroxyapatite

leads to biointegration

• direct biochemical bond of bone to implant surface independent of mechanical interlocking

•

Implants behave as ankylosed teeth

•

Can interfere with position of adjacent tooth germs, eruption of adjacent teeth

•

May become dislocated or lost as result of jaw growth

343


•

Cannot participate in drift and displacement mechanisms of growth in maxilla

Fixed!implants!that cross!the!midline!will restrict!maxillary!growth

•

In mandible, however, increases in width are generally related to posterior growth at rami Transverse!growth!in anterior!region!ends!in early!childhood

344


•

Most risky areas for implant placement in growing child are: • anterior and posterior maxilla • posterior mandible

•

Best site: • anterior mandible (but not for single tooth

replacement)

•

Mandibular rotation and resorption of anterior alveolar ridge may lead to displacement / loss of implants

345


Prior to placing implants, use a conventional prosthesis to: gain information on function and esthetics allow for as much growth as possible

Problem with prosthetic approach: retention Examples of implants in children with ectodermal dysplasia: see Kramer et al 2007, Guckes et al 1997

346


6-year-old white male with ectodermal dysplasia

Rockman RA, Hall KB, Fiebiger M. JADA 2007

Rexillium alloy copings cemented to maxillary and mandibular primaryteeth; copings used to hold “keeper” magnets

347


Cast metal frameworks

Magnets were attached with cold cure resin Some dental anatomy placed in maxillary posterior acrylic Mandibular acrylic left as monoplane

348


349


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Pulp Therapy in Primary and Young Permanent Teeth Steven M. Adair, DDS, MS Medical College of Georgia

Histologic Components of Primary Pulp •

Lymph vessels

•

Blood vessels

•

Nerve tissue

•

Collagenous fibers

•

Fibroblasts

•

Defense cells •

•

Lymphocytes

•

Odontoblasts

•

Odonto-/osteoclasts

•

macrophages, neutrophils

351

Histologically similar to young permanent pulp – cell rich, vascular


Comparative Morphology •

Increased number of accessory canals

•

Curved roots

•

Ribbon-like radicular pulp

•

Relatively longer roots in molars

•

Coronal pulp position

•

Apical resorption

•

Position/proximity of premolars

•

Larger pulp relative to crown size

•

Mesial pulp horns closer to DEJ than distal

Clinical Assessment of Pulp Status •

Problem: making histologic assessment from clinical signs and symptoms In general, the correlation between the clinical findings and the histologic condition is weak.

352


Assessment of Pain Types of Pain

Pulp Status

Spontaneous Nocturnal

Irreversible: Non-vital treatment

Constant Thermal Reversible: Vital treatment

Chemical Intermittent

Further Clinical Assessment •

Extent of lesion •

•

location, color

Mobility •

•

R/O root resorption

•

Soft tissue swelling

•

Lymphadenopathy

Sensitivity to percussion •

•

Pulp exposure •

•

hemorrhagic v necrotic

Pulp testing • • •

353

reliable in primary teeth

electrical thermal percussion


Reliability of Pulp Testing Teeth:

Primary

Young permanent

Mature permanent

Electrical

---

+

+

Thermal

+

+

++

Percussion

++

+

+

No single diagnostic test is reliable

Radiographic Criteria for Healthy Pulp •

Adequate periodontal support

•

No decalcified lesions or root fractures

•

No internal/external resorption or radiolucency

•

Integrity of lamina dura

•

See manual for more

354


Radiographic vs. Histologic Assessment Moss et al 1965: accessory canals in furcation area no vital pulp tissue with interradicular bone loss increased porosity of pulpal floor when infected

Wrbas et al 1997: 77.5% of mandibular primary molars had accessory canals in floor of chamber

Vital Pulp Therapy •

Protective base/liner

•

Indirect pulp treatment (IPT)

•

Direct pulp capping (DPC)

•

Pulpotomy • •

•

pharmacotherapeutic non-pharmacotherapeutic

Partial pulpotomy (permanent teeth)

355


Protective Base/Liner Indications (AAPD):

•

• • • • •

normal pulp dentin tubules exposed by cavity prep all caries removed minimize injury to pulp minimize post-op sensitivity

Objectives

•

• • • •

preserve pulpal vitality promote pulpal healing promote tertiary dentin formation minimize microleakage/sensitivity

Indirect Pulp Treatment •

Indications • • • • •

•

deep carious lesion no/reversible pulpitis incomplete caries removal no pulp exposure pulp vital

Objectives •

complete seal, preserve vitality, no post-tx signs or symptoms, no harm to succedaneous teeth, continued root development in permanent teeth

356


IPT Technique •

Apply medicament/material over carious or sound dentin [Ca(OH)2 most commonly used]

•

Vitality should be preserved

•

If planning to re-enter, wait 6-8 weeks for tertiary dentin; remove remaining caries, restore; eliminate microleakage

IPT Technique •

Need to re-enter controversial

•

Radiolucency beneath IPT decreased in size or did not increase under Dycal/ZOE in majority of cases (Maltz et al 2007)

•

Success rate up to ~90%

•

Stepwise excavation leads to fewer pulp exposures in young permanent teeth

357


IPT in Primary Teeth •

Recent data: •

•

•

•

IPT (GIC) had higher success rate than FMC pulpotomies Farooq et al 2000; Vij et al 2004 total etch technique more successful in primary molars than IPT (Ca[OH]2) Falster et al 2002 IPT (Ca[OH]2) success rate in primary molars was 95% in retrospective study Al-Zayer et al 2003 Carious dentin undergoes mineral gain when sealed in IPT Oliveira et al 2006

Indirect Pulp Treatment •

Vij et al 2004 0-1 year

1-2 years

2-3 years

>3 years

FMC success

95%

84%

76%

70%

IPT success

98%

96%

94%

94%

Treatment of deep dentinal lesions with caries control procedures prior to FMC or IPT improved the success of both.

358


Direct Pulp Cap •

Indications •

•

•

Small mechanical or traumatic exposure in primary teeth with normal pulp Small carious or mechanical exposure in permanent teeth with normal pulp

Contraindicated for carious exposure in primary teeth

Direct Pulp Cap: Objectives (AAPD) •

Preserve vitality

•

No post-treatment signs or symptoms

•

Pulp healing

•

Tertiary dentin

•

No pathologic changes

•

No harm to successors

•

Continued apexogenesis for permanent teeth

359


Pulp Capping Agents •

Ca(OH)2 still widely used and taught

•

ZOE - chronic inflammation

•

•

Mineral trioxide aggregate (MTA; permanent teeth) Total etch technique

Direct Pulp Cap - Bleeding • •

•

•

Success inversely related to bleeding at site Debris at exposure site: clean out with saline or anesthetic to prevent inflammation caused by dentinal chips; keep pulp moist Clot will prevent contact of material with the pulp; clot may release products that attract bacteria Success rate up to 80-90%; 50% if pulp inflamed

360


Biocompatibility of Materials with Dental Pulp •

Pulpal response to contact with a variety of materials is severe inflammation when bacterial microleakage occurs

•

Biocompatibility with dental materials allows pulpal healing in absence of microleakage

•

Dentin bridge formation possible even in contact with sterile food in germ-free environment

•

Biocompatibility is a function of microleakage

Partial Pulpotomy - Criteria •

No/recent pain of short duration

•

No swelling, mobility, rxn to percussion

•

No internal/external resorption, changes in PDL, radiographic abnormalities

•

Pulp exposure 1-2 mm, bleeding stops Radiographic>Histological

Formocresol pulpotomies may be empirical clinical successes, but histologically they are failures to one degree or another.

Actions of Formocresol •

Composition (open to interpretation) •

•

19% formaldehyde, 35% cresol in vehicle of 15% glycerin and water

Fixation with progressive fibrosis • • •

acidophilic zone: fixation pale staining zone: atrophy broad zone of inflammatory cells

•

Bactericidal - biggest benefit?

•

No dentin bridging

367


Fixation Preserves cellular detail Minimizes alteration from tissue in living state Inhibits autolytic changes and bacterial growth Coagulates protoplasm rendering it insoluble Increases affinity for particular stains

Dr. Suzi Seale

Histology Glutaraldehyde pulpotomy in monkey incisor

One week

Three weeks

368


Effects on Succedaneous Teeth Pruhs et al (1977)

Rolling and Poulsen (1978)

It is possible that enamel defects in premolars were caused by inflammation prior to the pulpotomy

Dilution of Formocresol •

1:5 dilution •

1 part FMC, 4 parts vehicle (3 parts glycerin, 1 part distilled water)

•

Histology and clinical success comparable to full strength

•

Neither produces ideal histology

•

Long-term clinical success of 1:5 still questioned by some

369


Glutaraldehyde •

Powerful fixing agent

•

Antibacterial

•

Large molecule

•

Minimal systemic distribution

•

Low antigenicity

•

Treatment concentration 2-5%

Ferric Sulfate •

FS forms protein complex, occludes capillaries; no antibacterial action

•

Must assume healthy radicular pulp (?)

370


Systematic Review of Ferric Sulfate •

Loh et al. 2004; 3 RCTs, 10 CTs analyzed

•

Clinically, FS significantly more successful than formocresol: OR 1.95

•

Radiographically, no difference between medicaments: OR 0.90

•

Conclusion: Pulpotomies performed with either material are likely to have similar clinical/radiographic success.

Meta-analysis of Ferric Sulfate vs FMC •

6 prospective controlled trials

•

Both treatments similar in clinical outcomes, radiographic success, other findings

•

Overall clinical success of FS: 78—100%

•

Overall radiographic success of FS: 42-97%

371


Mineral Trioxide Aggregate •

Gray: tricalcium silicate, tricalcium phosphate, tricalcium oxide, Fe, Al

•

Broadly similar to Portland cement

•

White: more esthetic

•

Hydrophilic particles set in presence of moisture 3-4 hours; compressive strength similar to IRM

•

Better seal than amalgam

•

Pricey (~$325/box of 5 1g packets)

MTA vs FMC Controlled Trials •

Aeinehchi et al 2007 •

•

•

significantly more teeth with root resorption in FMC group no root resorption in MTA group

Noorollahian 2004 •

no significant difference in radiographic success rates between FMC and MTA

372


Sodium Hypochlorite •

Vargas et al 2006

•

Compared NaOCl (N=32) and FS (N=28)

•

12 months: •

NaOCl: 100% clinical, 79% radiographic success

•

FS: 85% clinical, 62% radiographic success

Non-pharmacotherapeutic Pulpotomy •

Basic principles: • •

amputate infected coronal pulp treat remaining radicular pulp by controlled energy

•

neutralize residual infectious process

•

avoid dystrophic pulpal changes

•

avoid breakdown of periradicular supporting tissues

373


Electrosurgical Pulpotomy

Disadvantages Advantages heat leads to tissue destruction quick persistent inflammation self-limiting energy cannot be isolated to surface hemostasis root resorption good visibility pulp inflammation no systemic effect

RCT of Primary Pulpotomy Techniques •

Huth et al 2005

•

Prospective randomized controlled trial

•

200 primary molars, 107 patients

•

Treatments: • • • •

50 dilute FMC (control group) 50 Er:Yag laser 50 calcium hydroxide 50 ferric sulfate

374


Huth et al 2005 •

Pulp hemostatis was an inclusion criterion

•

All treatment followed by ZOE, GIC

•

Final restoration: SSC or composite resin, based on amount of tooth destruction

•

Clinical and radiographic follow-up at 6, 12, 18, and 24 months •

•

2 blinded examiners (neither was an operator)

Some teeth lost to follow-up (exfoliation, patient drop-out): final sample – 175

Huth et al 2005 Total success rate %

12 months

24 months

FMC

96

85

Laser

93

78

Ca(OH)2

86

53*

Ferric sulfate

86

86

Clinical success rates were higher in all cases; *statistically significantly different

375


Huth et al 2005 •

Only calcium hydroxide performed significantly worse than FMC (p2 yrs f/u

•

95% of apical lesions demonstrated complete or progressive healing

•

Apical closure seen in 26% Simon et al 2007

•

Pulpal Revascularization of Immature Necrotic Permanent Teeth Assumption: •

•

Goal: •

•

apical portion of pulp may still be vital encourage this vital tissue to migrate coronally

Procedure: • •

disinfect root canal place triple antibiotic paste (ciprofloxacin, metronidazole, cefaclor)

385


Pulpal Revascularization of Immature Necrotic Permanent Teeth •

Procedure, cont’d • • • •

•

remove paste after several weeks induce bleeding by stimulating tissue beyond apex allow clot to reach CEJ cover with MTA, restore

Resulting clot acts as scaffold to aid growth of new tissue in canal

Pulpal Revascularization of Immature Necrotic Permanent Teeth

386


Pulpal Revascularization of Immature Necrotic Permanent Teeth

Expect continued root lengthening and thickening Pulp responsive to cold stimulus

387


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388


Oral Pathology and Oral Medicine Andrew L. Sonis, D.M.D. Senior Associate in Dentistry Children’s Hospital, Boston Clinical Professor Harvard University School of Dental Medicine Private Practice Newton, Massachusetts

Correction in manual: p. 73 & Alveolar bone: & Should be Intramembranous bone formation, not Endochondral bone formation

389


Developmental variations of normal oral structures

Epstein’s Pearls

&Epithelial inclusion cyst &Palatal midline

390


Bohn’s Nodules

&Buccal and lingual aspect of alveolus &Ectopic mucous glands

Dental Lamina Cysts

&Crest of the alveolus &Remnants of dental lamina

391


Hyperplastic foliate papillae &Lateral border of tongue &Easily traumatized &Normal lymphoid tissue

Fordyce granules & Ectopic sebaceous glands in oral mucosa & Elevated yellowish nodules & Maybe discrete or confluent & Common sites: buccal mucosa, upper lip

392


Median rhomboid glossitis & ? Result of anomalous vascularity vs. persistence of tuberculum impar & Usually asymptomatic, but may cause soreness/burning & Surface flat or slightly raised & Color varies from pale pink or whitish to bright red & Candidial infection present ~ 40%

Fissured tongue & Rarely seen before age 4 years & ? Genetic (A.D.) & 3-5% frequency, but higher in mentally retarded population & Maybe associated with Melkersson-Rosenthal syndrome

393


Leukoedema & Most commonly seen in blacks & Grayish-white thickening of buccal mucosa & Usually bilateral & Extensive intracellular edema of epithelium

Idiopathic osteosclerosis & Well-defined radiopacity in the toothbearing area of jaw & No surrounding radiolucent space & Not typical of any other condition & Mandibular premolar/molar area most common & Maybe related to root apex, but normal PDL

394


Stafne bone defect &Cyst-like radiolucent area near angle of mandible &Indentation of bone containing extension of submandibular gland

Bifid tongue & Developmental malformation & May coexist with orofaciodigital syndrome & Complete form requires surgical reconstruction

395


Bifid Uvula

&Minor expression of cleft palate &Must r/o sub mucous cleft &May require surgical correction

Macroglossia

396


Discrete Swellings or Lumps/Bumps &Congenital &Inflammatory &Traumatic &Neoplastic &Others

Lingual thyroid & Redundant thyroid tissue in tongue & Hypothyroidism~20 % & ~70% lack normal thyroid tissue in neck

397


Lingual thyroid & Redundant thyroid tissue in tongue & Hypothyroidism~20 % & ~70% lack normal thyroid tissue in neck

Vascular Malformations &Present at birth &Become clinically evident in late infancy/early childhood &May increase in size following trauma, infection, or endocrine changes &~35% associated with skeletal changes

398


Lymphangioma &Diffuse vs. discrete &Tongue most common site &Surface often papillary or vesicular &Tx: surgical excision

Hemangioma & Common vascular tumor of infancy & Usually appear early in infancy, grow rapidly until age 6-8 mos., then slowly involutes & Blanch on pressure & Generally do not involve the adjacent skeletal tissue & Tx: watch and wait

399


Hemangioma: Indications for Treatment &Kasabach-Merritt syndrome with severe thrombocytopenia ( chewing

427


Lupus Erythematosus & Immunologically-mediated disorders involving connective tissue & Discoid form (rare): & Skin disorder & ~20% have oral involvement & Systemic form (more common in children): & Arthralgia and rashes common & Affects many organ systems & Stomatitis common (3040%) & Tx: steroids

Systemic form

Lupus Erythematous

428


Lupus Erythematous

“Moon Facies”

Contact Dermatitis: Two Major Types & Irritant & I.e. harsh soaps, chemicals: direct toxic effect upon contact with mucosa/skin & Allergic contact dermatitis: T-cell mediated immune reaction requiring sensitization to specific antigen

429


Burns (thermal, chemical) & Common & White appearance due to necrotic tissue & Associated with a number of chemicals, i.e., ASA, formocresol, phosphoric acid, phenol, etc.

Chemical Burn

Thermal Burn

“Pizza Palate”

430


Lip Lesions

Causes of Angular Stomatitis & Candidiasis & Common finding in HIV infection

& Staphylococcal, streptococcal, or mixed infections & Nutritional deficiencies & Crohn’s disease & Anemia

431


Crohn’s Disease & Chronic inflammatory granulomatous disease & Affects entire G.I. tract (mouth to anus) & Etiology unknown, likely autoimmune & Oral lesions ~30% & Facial swelling & Ulcerations & Mucosal tags & Tx: antibiotics; 5-ASA; corticosteroids

Crohn’s Disease: mucosal tags

Cobblestone appearance

432


Oral concerns in patients with inflammatory bowel disease & Increased risk of aphthous ulcers & Increased risk of periodontal disease & Steroid therapy & Patient maybe immunosuppressed & Drug therapy may cause gingival hyperplasia (cyclosporin)

When does adrenal-pituitary axis suppression occur in prolonged steroid treatment?

& Pharmacological doses of steroids used for < 10 days & Relatively small risk of permanent adrenal insufficiency & Typically full recovery in 6-12 months

& Daily use > 30 days & High risk of transient or permanent adrenal suppression

& Alternative day & Very low risk

& Inhaled steroids & Essentially no risk

433


Who Needs Steroid Bump/Supplement? &Patients under stress &Fever > 101º &Surgery, I.e. third molar extractions &General anesthesia &Fractures &Prolonged fasting/vomiting

Causes of Lip Ulcerations/Vesicles/Blisters & Herpes simplex & Burns & Herpes zoster & Erythema multiforme & Epidermolysis bullosa & Impetigo & Allergic cheilitis

434


Herpes simplex &Herpes labialis & Reactivation of HSV & Recurrent & Antiviral agents of limited value

Herpes labialis

1 week f/u

435


Penciclovir (Denavir)

Denavir Promo

436


Burns & Maybe electric, thermal, chemical & Treatment directed at preventing contraction of orafice

Varicella/Zoster & Varicella zoster virus (chicken pox) & Crops of pruritic vesicles on skin and mucous membranes & Vesicles may precede fever & Begins on trunk and spreads to limbs/face

& Infectious 24 hrs. before to 6-7 days after vesicles appear & Incubation period may last up to 20 days & Resolves in 7-10 days & Tx: palliative and supportive

437


Herpes Zoster

Erythema Multiforme & Erythematous macules, papules, bullae, and erosions & Possible allergic etiology (drug reaction) & Target lesions & May have ocular, genital lesions (Stevens-Johnson syndrome) & Tx: palliation; steroids

438


Erythema Multiforme (StevensJohnson syndrome)

Epidermolysis Bullosa &Hereditary vesiculobullous disease of skin and mucous membranes &E.B. simplex: most common form & A.D.

&Junctional E.B.: several subtypes & A.R.

&Dystrophic E.B. & Dominant form & Recessive form

439


Epidermolysis Bullosa

Dystrophic EB-dominant form


Dystrophic EB- dominant form

440



Dystrophic EB-recessive form

Impetigo &Most commonly caused by: & staphylococcus aureus & beta hemolytic strep

&Tx: & Localized: topical antibiotics & Widespread: systemic antibiotics

441


Allergic cheilitis & Maybe due to contact irritation or true allergy & Tx: remove irritant or allergen

Causes of Diffuse Swelling of Lips & Edema secondary to trauma & Angioedema & Crohn’s disease & Cheilitis granulomatosis & MelkerssonRosenthal syndrome & Lymphangioma & Hemangioma

442


Hemangioma

7 months

12 years

5 years

Vascular malformation

S/p laser surgery

443


Causes of Localized Swellings of the Lips & Mucoceles & Tumors & Neuroma & Neurofibroma

& Cysts & Abscesses & Insect bites & Hematomas

Causes of Lip Crusting/Desquamation & Dehydration & Febrile illness & Chemical/allergic cheilitis & Mouth-breathing & Actinic cheilitis & Erythema multiforme & Psychogenic & Drugs

444


Soft Tissue Lesions in the Newborn/Infant

Vascular Malformations &Lymphangioma &Capillary malformation & Port wine stain

&Sturge Weber syndrome &Venous malformation & “cavernous hemangioma”

&Arterial malformation &Combined

445


Capillary Malformation:Port Wine Stain

Capillary Malformation:Port Wine Stain

446


Sturge Weber Syndrome & Venous angiomatosis of leptomeniges & Ipsilateral facial angiomatosis & Ipsilateral gyriform calcifications of cerebral cortex & MR & Seizures & Hemiplegia & Ocular defects & Telangiectasias

Sturge Weber Syndrome

447


Vascular Tumors &Hemangioma &Treatment modalities: & Steroids & Interferon & Pulsed dye laser & Chemotherapeutic agents & Embolization & Surgery

Congenital Epulis & Firm pedunculated mass arising from alveolus at birth & Maxillary lateral and canine region most common & Females>males & Maxilla>mandible & Tx: surgical excission

448


Congenital Epulis

Congenital Epulis

449


Melanotic Neuroectodermal Tumor of Infancy & Maxilla>mandible & Destructive lesion & Submucosal pigmentation (may appear blue clinically) & # urinary VMA & 15% may recur & Tx: radical excision

Melanotic Neuroectodermal Tumor of Infancy

450


Hemifacial Hypertrophy & Unilateral oral and facial enlargement & Usually evident at birth & Involves hard and soft tissues & Teeth may exfoliate prematurely & MR: 25% & Increased incidence of embryonal tumors & Tx: cosmetic surgery

Hemifacial Microsomia & Etiology unknown & Unilateral microtia, macrostomia, and failure of formation of mandibular ramus and condyle & 50% have cardiac pathology (PDA, VSD) & Tx: orthognathic surgery

451


452


453


Dwarfism

454


Seven major cateogories of causes of short stature 1. 2. 3. 4. 5. 6. 7.

Genetic Constitutional delay Chronic disease Chromosomal/syndromic Endocrine Psychosocial Intrauterine

Achondroplasia & 80% sporatic mutations, A.D. & 1/20,000 live births & Short limbed dwarfism & Enlarged head, depressed nasal bridge & Short, stubby, trident hands & Lordotic lumbar spine & Prominent buttocks & Protuberant abdomen

455


Hypopituitarism & Well proportioned body & Fine, silky hair, wrinkled atrophic skin & Hypogonadism & Delayed eruption /exfoliation & Malocclusion common due to small dental arches & Panhypopituitarism may lead to other systemic problems

Causes of Hypopituitarism & Tumors & Pituitary & Parasellar & Suprasellar (hypothalamic) & Radiation & Pituitary apoplexy

& Infiltrative diseases & Granulomatous diseases & Infection & Miscellaneous

456


Mucopolysaccharidoses

Nutritional

457


Chrondroectodermal Dysplasia (Ellis van Crevald syndrome) &Dwarfism &Polydactaly &Ectodermal dysplasia(hidrotic) affecting nails and teeth &Multiple frenae &Cardiac defects: 50%

Chondroectodermal Dysplasia

Nail dystrophy/ Spade-shaped hand

polydactaly

458


Chondroectodermal Dysplasia

Hallerman-Streiff syndrome (Oculo-mandibulo-dyscephaly) & Dyscephaly & Hypotrichosis & Microphthalmia & Cataracts & Beaked nose & Micrognathia & Short stature & May have supernumerary teeth/natal teeth

459


Syndromes Characterized by Senile-like Appearance &Progeria &Werner syndrome &Cockayne syndrome &RothmundThomson syndrome

Hypothyroidism & Large posterior fontanel & Macroglossia & Hypothermia & Lethargy & Hypotonia & Bradycardia & Delayed growth and skeletal maturation

460


Turner’s syndrome & 45X karyotype & 1/8000 & Females only & Near normal IQ & Sterile & Coarctation of aorta most common cardiac defect & Webbed neck & Enamel hypoplasia

Osteogenesis Imperfecta & Type I: mildest form & Associated with blue sclera; type IBdentinogenesis imperfecta

& Type II: perinatally lethal; severe fragility of connective tissues; multiple in utero fractures & Type III: progressive deforming; severe fragility; usually associated with in utero fractures & Type IV: similar to type I but more severe & Type IVB-dentinogenesis imperfecta

461


Osteogenesis Imperfecta

Osteogenesis Imperfecta Blue Sclera

462


Osteogenesis Imperfecta

Dentinogenesis Imperfecta

Self-Mutilation &Common in children with MR/psychological problems/autism &Usually due to repeated trauma

463


Autism &Profound withdrawal &Obsessive desire for preservation of sameness &Skillful relation to inanimate objects &Retention of intelligent, pensive physiognomy &Language development not understandable &Often self-abusive, self-stimulating

Congenital Indifference to Pain &Autosomal recessive &Frequent scarring of face with mutilations of lips, tongue, arms, legs &Mild mental retardation

464


Congenital Indifference to Pain

Lesch Nyhan syndrome & X-linked recessive & MR & Spastic CP & Choreoathetosis & Bizarre self-mutilating behavior & Absence of hypoxanthineguaninephosphoribosyltransferase

465


Erythematous Gingiva

&Gingivitis &Periodontitis

Characteristics of Gingivitis in Children & Most common periodontal infection in children and adolescents & Generally increases with age, eruption, puberty & Rounded gingival margins accentuate inflammatory changes; tissues may become fibrotic & Generally reversible with improved oral hygiene & Does not occur to same degree as in adults with comparable plaque

466


Systemic Factors influencing Gingivitis - Endocrine System & Puberty-associated, menstrual cycleassociated, pregnancy-associated & Presence of steroid hormones (esp. estrogen, progesterone) may amplify inflammatory changes in gingiva & Plaque is generally non-specific

Periodontitis & Prevalence of destructive disease in children & Age 5-11 years: 1-9% & Age 12-15 years: 1-46%

& Clinical attachment loss precedes radiographic bone loss & Disease threshold CEJ-ABC > 2 mm in primary dentition & Loss of lamina dura

467


Types and characteristics of periodontal disease in children & Aggressive periodontitis & Common characteristics of localized and generalized forms: & Primary findings: $ Rapid bone loss $ Familial aggregation: (?) genetic predisposition

& Secondary findings: $ Phagocyte abnormalities $ Hyper-responsive macrophage phenotype $ Reports of disease being self-limiting

Localized Aggressive Periodontitis &Prevalence in U.S. & Overall: 0.3% &African Americans: 10% &Hispanics: 5.5%

468


Localized Aggressive Periodontitis & Interproximal attachment loss on at least 2 permanent molars and incisors with attachment loss on no more than two additional teeth & No evidence of systemic disease

Localized Aggressive Periodontitis & Radiographic signs & vertical bone loss around molars & horizontal bone loss around incisors & rate of progression 3-5x times adult periodontitis (5 microns/day)

469


Localized Aggressive Periodontitis & Etiology & genetic basis?; familial distribution & Actinobacillus actinomycetemcomitans and bacteroides –like species & depressed neutrophil chemotaxis in ~70% & possible defect in phagocytosis

LAP Diagnosis & History and clinical findings & & & &

Medical history Familial pattern Ethinicity Loss of attachment pattern

& Radiographic findings & Pattern of bone loss

& Microbiologic findings & DNA probing

470










471






Treatment: Surgical and nonsurgical root debridement with antimicrobial therapy & Scaling, curettage, root planing & Antibiotic therapy & & & &

tetracycline, doxycycline amoxicillin metranidazole metranidazole + Augmentin

& Periodontal surgery & Regenerative techniques & root conditioning, composite graft, ePTFE membranes

472


Generalized Aggressive Periodontitis & Prevalence in U.S. & Overall: 0.15% & Higher in males and African Americans

& Generalized attachment loss including at least 3 teeth that are not 1st molars

GAP & Considered a disease of adolescents and young adults & Marked periodontal inflammation with heavy plaque and calculus & Subgingival bacterial cultures typically nonmotile, facultative, anaerobic gram (-) rods & Suppressed neutrophil chemotaxis

473


GAP - Radiographic Signs

Generalized Aggressive Periodontitis & Treatment & surgery & scaling, root planing, curettage & Antibiotics & Does not always respond to conventional mechanical and antibiotic therapy & Culture and sensitivity maybe helpful in refractive cases

474


c.c.: premature loss of primary incisors & 3 y.o Caucasian male is referred by pediatrician for consultation with c.c. of premature loss of primary incisors & This is the patient’s first dental visit

History of Present Illness & Mother noticed teeth becoming loose several months ago & 5 days ago teeth spontaneously exfoliated & Mother denies any history of trauma & Mother presents primary incisor which appears grossly normal with age appropriate root length

475


Past Medical History & Prenatal history: unremarkable & Family history: unremarkabale & Hospitalizations: Patient sustained broken leg at age 30 months following a “minor fall” & Meds: none & ROS: wnl & NKA & Childhood illnesses: 2 bouts of O.M.

Clinical findings: & Extra-oral soft tissues WNL & Intra-oral soft tissues WNL & Missing primary incisors & 2+/3 mobility of remaining incisors & No mobility of remaining primary teeth

476


Potential causes of premature loss of primary teeth & Trauma & Genetic/ hereditary & Neoplasms & Infectious & Miscellaneous

Trauma & Accidental & Psychiatric/self-abuse & Iatrogenic & Radiotherapy & Intubation

& Child abuse

477


Genetic & Acatalasia & Chediak-Higashi syndrome & Chronic neutropenia & Dentin dysplasia & Down syndrome & Hypophosphatasia & Hypophosphatasia vitamin D resistant rickets & Lesch-Nyhan syndrome & Papillon-Lefévre syndrome

Neoplasms & Lymphoma & Leukemia & Langerhans’ cell histiocytosis & Soft and hard tissue neoplasms (benign and malignant)

478


Infectious & Dental abscess & Osteomyelitis & Periodontitis

Miscellaneous & Acrodynia & Odontodysplasia & Vitamin C deficiency & Leukocyte adhesion deficiency-1

479


Differential Diagnosis & Hypophosphatasia & TNSALP & Urinary phosphoethanolamine

& Papillon-LeFévre syndrome & Examine palmar/plantar surfaces for hyperkeratosis

& Periodontitis & DNA probing

Congenital Causes of Erythematous Gingiva & Hereditary hemorrhagic telangiectasia & AD & Mucosal and cutaneous telangiectases & May result in repeated bleeding episodes

& Sturge Weber syndrome

480


Hereditary Hemorrhagic Telangiectasia

Palatal telangiectases

Acquired Causes of Erythematous Gingiva & Trauma & Physical, chemical, radiation, thermal

& Drugs: chlorhexidene, cinnamonaldehyde & Infectious: candidiasis & Desquamative gingivitis & Leukemia

481


Causes of Gingival Bleeding & Localized disease & & & & & &

& Systemic disease & & & & & &

Periodontal disease Chronic gingivitis Chronic periodontitis ANUG HIV gingivitis HIV periodontitis

& & & &

Clotting defects Hepatobiliary disease Hemophilias Von Willebrand’s disease Vitamin K deficiency Lymphoproliferative disorders ITP Hereditary hemorrhagic telangiectasia Ehlers-Danlos syndrome Scurvy

Causes of Gingival Bleeding (cont.) &Drugs & Anticoagulants & NSAID &ASA &Non-ASA & Cytotoxics & Sodium valproate

482


Generalized Gingival Enlargement: Congenital &Gingival fibromatosis &Mucopolysaccharidoses

Generalized Gingival Enlargement: Acquired & AML & Aplastic anemia & Drugs & Phenytoin & Cyclosporin & Calcium-channel blockers & Sodium valproate (rare) & Tranexamic acid (rare)

& Scurvy

483


Acute Myelogenous Leukemia

Pre-chemotherapy

Post-chemotherapy

Localized Gingival Enlargement: Congenital & Fabry’s disease & Cowden’s disease & Tuberous sclerosis & Focal dermal hypoplasia & Sturge-Weber syndrome & Congenital granular cell tumor

Cowden’s Disease

484


Tuberous Sclerosis & A.D. & Seizures (90%) & MR (60%) & Angiofibromas of face (70%) & May involve oral mucosa

& Enamel defects

Localized Gingival Enlargement: Acquired & Heck’s disease & Lymphoma & Histiocytosis & Peripheral giant cell epulis & Pyogenic granuloma & Peripheral ossifying fibroma & Papilloma & Crohn’s disease & Neoplasms

Pyogenic granuloma Peripheral Giant Cell Epulis

485


Peripheral Ossifying Fibroma

Initial presentation

Relapse 2y later

Fibro-osseous lesions

486


Fibro-osseous lesions

Facial Swelling/Enlargement-Hard Tissue: Congenital &Albright’s syndrome &Cherubism &Hemihypertrophy

487


Albright’s Syndrome & Polyostotic fibrous dysplasia & Abnormal skin pigmentation & “coast of Maine” café-au-lait spots

Kennebunkport

& Endocrine dysfunction & Precocious puberty

& X-ray: ground glass

Albright’s syndrome

Ground glass

“Chinese characters”

488


Cherubism & A.D. & Bilateral fullness of cheeks & Hypertelorism & Irregularly spaced 1º dentition & Giant cell histology & X-ray: multilocular radioluncencies

Cherubism

Multilocular radioluncencies

Giant cell histology

489


Facial Swelling/Enlargement-Hard tissue : Acquired/Inherited

&Fibrous Dysplasia &Sickle cell anemia &Thalassemia &Neoplasms

Monostotic Fibrous Dysplasia

Sickle Cell Anemia

Hair on end

490


Neoplasm: Neuroblastoma

“racoon eyes” Periorbital ecchymosis

Obstruction of palpebral vessels

Facial Swelling: Inflammatory &Oral infections &Cutaneous infections &Insect bites Poison Ivy

491


Facial Swelling: Inflammatory

Odontogenic Infection

Facial Swelling: Traumatic &P/O edema/hematoma &Traumatic edema/hematoma &Surgical emphysema

492


Facial Swelling: Immunologic

&Allergic angioedema &HANE

Facial Swelling: Immunologic

&Allergic angioedema &HANE

493


Facial Swelling: Endocrine/Metabolic & Systemic corticosteroids & Cushing’s disease/syndrome & Myxedema & Acromegaly & Obesity & Nephrotic syndrome

Facial Swelling: Others & Cysts

Most common cause of lumps in children

& Nasolabial cyst & Soft tissue cyst & Forms deep to nasolabial fold & May cause obliteration of nasolabial fold & Tx: surgical excision

& Vascular malformations & Vascular tumors & Melkersson-Rosenthal syndrome & Crohn’s disease

494


Nasolabial Cyst

Nasolabial Cyst

495


Facial Swelling: Major Salivary Glands: Inflammatory & Mumps & Recurrent parotitis & Sjögren’s syndrome & Ascending sialadenitis & Recurrent sialadenitis & Sarcoidosis & Actinomycosis

Facial Swelling: Major Salivary Glands: Neoplasm

Pleomorphic adenoma

496


Facial Swelling: Major Salivary Glands: Others & Duct obstruction & Sialosis & Parotid & Submandibular & Mikulicz disease & Amyloidosis & HIV disease


497




498


HIV Disease

&Bilateral parotid enlargement

Facial Swelling: Major Salivary Glands: Drug associated & Chlorhexidene & Phenylbutazone & Iodine compounds & Thiouracil & Catecholamines & Sulphonamides & Phenothiazines & Methyldopa

499


Intraoral Ulcerations

Traumatic & Very common & Usually caused by accidental biting, hard foods, appliances, etc. & Less common causes: child abuse, recurrent bouts of severe coughing, oral sex

500


Neoplastic &Carcinoma &Histiocytosis &Other malignancies Lymphoma

Recurrent Aphthous Stomatitis & Isolated & Behçet’s syndrome & MAGIC syndrome & Mouth, genital lesions/inflamed cartilage

& Sweet’s syndrome & Acute febrile neutrophilic dermatosis

& PFAPA & Periodic Fever/Aphthous ulcers/Pharyngitis/Adenitis

501


Recurrent Aphthous Ulcers &Etiology unknown &Predisposing factors, I.e. stress &Involves “unbound” mucosa &Tx: palliative

& Minor: most common & Shallow, round ulcer & Erythematous halo & 7-10 day duration

& Major: less common & Deep, large ulcers & 3-6 week duration

& Herpetiform: rare & Clusters of small ulcers & 1-2 week duration

Apthous Ulcers: treatment modalities

502


Behçet’s Syndrome & Etiology unknown & Rare in children < 5 y & Males > females (5:1) & Oral, genital, ocular, and skin lesions & Mucosal lesions similar to aphthous ulcers & Tx: steroids

Behçet’s Syndrome

503


Systemic Disease: Cutaneous & Erosive lichen planus & Pemphigus vulgaris & Mucous membrane/bullous pemphigoid & Erythema multiforme & Dermatitis herpetiformis & Epidermolysis bullosa

Pemphigus Vulgaris

Systemic Disease: Gastrointestinal &Crohn’s disease &Chronic inflammatory granulomatous disease &Affects entire GI tract &Etiology unknown, likely autoimmune &Oral lesions (~30%) &Tx: antibiotics, 5-ASA, corticlsteroids

504


Systemic Disease: Connective Tissue Disease &Lupus erythematosus &Reiter’s syndrome &Mixed connective tissue disease &Felty’s syndrome Systemic Lupus Erythematosus

Oral infectious disease &Herpetic gingivostomatitis &Hand, foot, and mouth disease &Herpangina &Acute necrotizing ulcerative gingivitis

505


Herpetic gingivostomatitis & HSV type1 typically & Oral ulcers, gingivitis, fever, lymphadenopathy & Painful & Tx: palliative and supportive

Hand, Foot, and Mouth Disease & Cocksackie virus & Epidemic & Fever, malaise, lymphadenopathy & Vesicles and ulcerations intraorally and on hands, arms, feet, legs & Duration 7-10 days & Tx: supportive and palliative

506


Hand, Foot, and Mouth Disease

Herpangiana & Cocksackie virus & Multiple vesicular lesions involving tonsillar pillars, uvula, soft palate & Vesicles rupture leaving ulceration & Malaise, fever & Most common in summer months & Tx: supportive and palliative

507


Acute Necrotizing Ulcerative Gingivitis & Fusospirochetes & Rare in children & Necrosis, ulceration, punched out papillae & Sore, bleeding gingiva & Foul breath & Tx: oral hygiene, topical and/or systemic antibiotics

Systemic Disease: Infective (cont.) & Histoplasmosis & Coccididioidomycosis & Blastomycosis & HIV & Gram-negative infection

& Atypical mycobacterium infection & Syphilis & Aspergillosis & Cryptocococcosis & Leishmaniasis & Tularemia & Lepromatous leprosy & Paracoccidiodomycosis

508


Systemic Disease: Drugs

&Cytotoxics &Methotrexate &5-FU

Systemic Disease: Others & Wegener’s granulomatosis & Midline lethal granuloma & Histiocytosis & Noma Noma

509


Histiocytosis (Langerhans Cell Histiocytosis) & Variety of disorders of mononuclear phagocytes & Acute disseminated & Infants

& Chronic & Skull lesions & Diabetes insipitus & Exopthalamus

& Acute localized & Limited to bone

Histiocytosis

510


Generalized Pigmentation Vitiligo

Racial &No direct correlation between skin color and oral pigmentation &Typically seen only on gingiva

511


Food/Drugs &Carotenemia &Antimalerial drugs &Minocycline &Doxorubicin Carotenemia

Food/Drugs &Carotenemia &Antimalerial drugs &Minocycline &Doxorubicin Minocycline

512


Endocrinopathies &Addison’s disease &Nelson’s syndrome &Ectopic ACTH production Addison’s Disease

Others & Pigmentary incontinence & Albright’s syndrome & Hemochromatosis & $-thalassemia & ACTH therapy & Biliary atresia & Heavy metals

Biliary Atresia

513


Localized Pigmentation & Ecchymoses & Ephelis & Melanoma & Melanoacanthoma & Melanotic macule & Nevus & Peutz-Jeghers syndrome & Kaposi’s sarcoma

& Neurofibromatosis & Neuroectodermal tumor & Tattoos & Epithelioid angiomatosis & Smoker’s melanosis & Acanthosis nigricans

Localized Pigmentation & Ecchymoses & Ephelis & Melanoma & Melanoacanthoma & Melanotic macule & Nevus & Peutz-Jeghers syndrome & Kaposi’s sarcoma

& Neurofibromatosis & Neuroectodermal tumor & Tattoos & Epithelioid angiomatosis & Smoker’s melanosis & Acanthosis nigricans

514


Peutz-Jeghers Syndrome &A.D. &Perioral and intraoral pigmentation &Intestinal polyposis &Tx: intestinal polyps may occasionally require surgical intervention

Peutz-Jeghers Syndrome

515


Soft Tissue Neck Mass/Swelling

Cervical Lymph Nodes: Inflammatory &Lymphadenitis &Glandular fever syndromes &Mycotic infections &Other infections

516


When to consider biopsy of lymph node: &? of malignancy, i.e. fixed node &Suspected atypical mycobacterium &Failure to respond to antimicrobials &After 3 months of observation with either no change or increase in size

Cervical Lymph Nodes: Neoplasms &Primary malignancy & Hodgkin’s disease & Leukemia & Lymphoma

&Secondary malignancy

Hodgkin’s Disease

517


Cervical Lymph Nodes: Others &Connective tissue disease &Drugs &Mucocutaneous lymph node syndrome

Mucocutaneous lymph node syndrome (Kawasaki’s disease)

Salivary Glands &Mumps &Tumors &HIV &Sjögren’s syndrome &Sarcoidosis &Sialadenitis &Sialosis

518


Side of Neck Swelling/Mass &Actinomycosis &Branchial cleft cyst &Parapharygeal cellulitis &Pharyngeal pouch &Cystic hygroma &Carotid body tumor

Middle of Neck Swelling/Mass & Submental lymphadenopathy & Thyroglossal duct cyst & Ectopic thyroid & Thyroid tumor & Plunging ranula & Ludwig’s angina & Dermoid cyst

Thyroglossal Duct Cyst

519


Palatal Lesions/Malformations

Cleft Palate & Isolated (with and without cleft lip) & Associations (reported with > 100 syndromes) & Pierre-Robin sequence & Cleidocranial dysplasia & Down syndrome & Mandibulofacial dysplasia & Orofaciodigital syndrome & Apert’s syndrome & Crouzon’s syndrome

520


Cleft Palate

Pierre-Robin Sequence &Glossoptosis &Micrognathia &Cleft palate &15-25% cardiac defect

521


Cleidocranial Dysplasia & Brachycephaly & Frontal and parietal bossing & Depressed nasal bridge & Delayed closure of sutures and fontanels & Wormian bones

& Supernumerary teeth

& Clavicular defect & Delayed or failure of exfoliation of 1º teeth & Delayed eruption of 2º teeth & Highly arched palate often with submucous or complete cleft & Roots lack layer of cellular cementum

Cleidocranial Dysplasia

522


Cleidocranial Dysplasia

Wormian bones

Multiple unerupted teeth

Mandibulofacial Dysostosis (Treacher Collins Syndrome) & Defect of 1st branchial arch/pouch/groove & Microtia/malformed ears & Hypoplastic midface & Downward sloping palpebral fissures & Coloboma & Hypoplastic mandible

& 30% cleft palate

523


524


Orofaciodigital Syndrome & Type 1 most common form & X-linked dominant trait & MR

& Oral findings: & Multiple hyperplastic frenae & Bifid/multilobed tongue & Hypodontia (mandibular lateral incisors) & Supernumerary teeth & Cleft palate

525


Orofaciodigital Syndrome

“Copper-beaten Skull” &Craniosynostosis & Apert’s syndrome & Crouzon’s syndrome & Pfeiffer’s syndrome

526


Apert’s Syndrome & Syndactaly & Shallow orbits, ocular hypertelorism & Parrot nose & 30% cleft palate & Mental retardation & Crowded dentition & V-shaped maxilla & Class III with openbite

Apert’s Syndrome

Syndactaly

527


Crouzon’s Syndrome & Brachycephaly & Maxillary hypoplasia & Ocular hypertelorism & Parrot nose & Crowded dentition & V-shaped maxillary arch & Exopthalamus

528


529


Palatal Swelling/Lump: Developmental &Unerupted tooth &Torus palatinus &Cysts

Palatal Swelling/Lump: Inflammatory &Abscess &Cyst &Papillary hyperplasia &Sarcoidosis

530


Palatal Swelling/Lump: Neoplasm & Minor salivary gland tumor & Fibroma & Kaposi’s sarcoma & Papilloma & Neuroma & Neurofibroma

Kaposi’s sarcoma

Halitosis & Oral sepsis & Food impaction & Chronic dental/periodontal sepsis & ANUG & Dry socket & Pericoronitis & Xerostomia & Oral ulceration

531


Halitosis: Nasopharyngeal Disease

& Foreign body & Sinusitis & Tonsillitis & Neoplasm

Halitosis: Nasopharyngeal Disease

& Foreign body & Sinusitis & Tonsillitis & Neoplasm

532


Volatile Foodstuffs

&Garlic &Onions &Highly spiced foods

Drugs & & & & & & & & & & &

Solvent abuse Alcohol Smoking Choral hydrate Nitrates/nitrites Dimethyl sulphoxide Disulphiram Cytotoxic drugs Phenothiazines Amphetamines Paraldehyde

533


Radiographic Key Concepts

See what’s under the surface…

Radiographic Description and Interpetation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Shape Size Anatomic location Degree of lucency or opacity Recognizable structure(s) Single or multiple Unilocular or multilocular Quality of border Cortical involvement Lamina dura PDL Root resorption VCU School of Dentistry, Dept. of Oral Pathology

534


Differential Diagnosis of Radiographic Lesions 1. Benign and Neoplastic Lesions 2. Inflammatory Lesions 3. Aggressive and Malignant Lesions

Benign Cystic and Neoplastic Lesions & Uncommon occurance & Non-tender to palpation & Slow growing (months to years) & Localized expansion & Surrounding mucosa normal & Usually etiology unknown & No systemic involvement & May interfere with tooth eruption & Subtle facial asymmetry

535


Radiolucent lesions & Pericoronal location & Unilocular & Eruption cyst & Dentigerous cyst & Unicystic ameloblastoma

& Multilocular & Odontogenic keratocyst $ Basal cell nevus syndrome

& Ameloblastic fibroma

Eruption Cyst & Follicular cyst involving soft tissue & Most frequently involves 1º dentition/permanent molars & Bluish, painless swelling over erupting tooth & Tx: typically none necessary as cysts spontaneously rupture & Typically don’t interfere with eruption

536


Dentigerous Cyst & Surrounds crown/attached to neck of unerupted tooth & Cystic enlargement of dental follicle & Usually asymptomatic & Tx: surgical enucleation

Ameloblastoma (Unicystic) & Most common primary tumor of jaws & 80% in molar/ramus area of mandible & Frequently contain tooth & May mimic dentigerous cyst & 10% recurrance rate & Tx: surgical excession

537


538


539


540


Odontogenic Keratocyst & Most often found in mandible & Bone expansion uncommon & Pain, discharge, or paresthesia uncommon & Tx: “vigorous” enucleation & Recurrence not uncommon

541


Common Findings in Basal Cell Nevus Syndrome & & & & & & & & & &

Enlarged occipitofrontal circumference Mild ocular hypertelorism Multiple basal cell carcinomas Odontogenic keratocysts of the jaws Epidermal cysts of skin Palmar and/or plantar pits Calcified falx cerebri Rib anomalies Spina bifida occulta of cervical or thoracic vertebrae Hyperpneumatization of paranasal sinuses

Basal Cell Nevus Syndrome

542


Ameloblastic Fibroma & Slow growing benign tumor & Usually asymptomatic & Posterior mandible most common site & Tx: conservative excision & Note: ameloblastic fibrosarcomas have arisen in ameloblastic fibromas

Peripheral or central location & Unilocular & & & &

Traumatic bone cyst Nasopalatine duct cyst Globulomaxillary cyst Median palatal cyst

543


Traumatic Bone Cyst & Mandible most common site & Usually asymptomatic w/o expansion & Teeth are vital & Tx: surgical intervention

Traumatic Bone Cyst pretreatment

Post-treatment

544


• 16yo M • Incidental finding of radiolucent lesion in posterior mandible • Healthy

545


546


547


Traumatic bone cyst •First described by Lucas in 1929 •Hemorrhagic bone cyst, solitary bone cyst, unicameral bone cyst, extravasation cyst, idiopathic bone cavity •Pathogenesis not understood – Trauma • Intraosseous hematoma'enzymatic clot liquification leads to bone resorption… • subperiosteal hematoma compromises blood supply'osteoclastic bone resorption Xanthanaki AA, Konstantinos CI, et al. Traumatic bone cyst of possible iatrogenic origin: Case report and review of the literature. Head and Face Medicine. 2006; 40:1-5.

Nasopalatine Duct Cyst &Derived from epithelium of nasopalatine duct &May perforate labial plate &Teeth are vital

548


Nasopalatine Duct Cyst

Globulomaxillary Cyst & Originally thought to occur due to epithelial entrapment & Most likely radicular cyst & May cause displacement of teeth & Tx: surgical enucleation

549


Globulomaxillary Cyst

Median Palatal Cyst & Fissural cyst & Epithelial entrapment & Maybe confused for posteriorly positioned nasopalatine duct cyst & Firm of flucuant swelling of midline of hard palate & Tx: surgical excision

550


Median Palatal Cyst

Unilocular when small/multilocular when large & Central giant cell granuloma & Aneurysmal bone cyst & Central hemangioma & Odontogenic myxoma & Cherubism

551


Central Giant Cell Granuloma & Painless swelling sometimes causing displacement of teeth & Posterior mandible most common site & Tx: curettage & R/O other jaw lesions with giant cell histology

J.L. & 4 yo male & Otherwise healthy & Left mandibular swelling & No pain or paresthesia

552


553


554


555


556


Aneurysmal bone cyst & Eccentric ballooning of mandible & 50% associated with pain & Associated with concurrent lesion

Aneurysmal bone cyst & Eccentric ballooning of mandible & 50% associated with pain & Associated with concurrent lesion

557


HS 6 yo female

558


559


Central hemangioma & Vague margins & Gingival bleeding, bruit, pulsation & Tooth mobility & Potentially life threatening

560


Odontogenic myxoma & Faint radiopaque striations & Posterior mandible & Moderate recurrance rate

A.L.

561


562


563


564


Cherubism & Bilateral & “Burns out” over time

565


A.B. & Painless midface swelling & 4yo F & Healthy

2005

2005

566


567


2005

2007

2005

2007

568


Mixed radiolucent-radiopaque & Pericoronal location & Calcifying odontogenic cyst & Adenomatoid odontogenic tumor & Ameloblastic fibro-odontoma

& Periapical or central location & Central ossifying fibroma & Juvenile ossifying fibroma

Calcifying Odontogenic Cyst & Affects both maxilla and mandible & Painless swelling/ may expand & Radiographic: may contain scattered radiopacities & 25% associated with odontoma & Tx: surgical excision

569


Adenomatoid Odontogenic Tumor & 90% appear before 30 y & 60% form in anterior maxilla & 75% associated with unerupted tooth (canine) & Radiographic: may contain faint radiopaque foci & Tx: surgical excision

Adenomatoid Odontogenic Tumor & 90% appear before 30 y & 60% form in anterior maxilla & 75% associated with unerupted tooth (canine) & Radiographic: may contain faint radiopaque foci & Tx: surgical excision

570


Ameloblastic Fibro-odontoma & Most often found in children & Typically asymptomatic and discovered radiographically & Most frequently associated woth unerupted tooth

571


572


Periapical or Central Location & Central ossifying fibroma & Juvenile ossifying fibroma

573


Central ossifying fibroma & Maybe unilocular or multilocular & Progresses from radiolucent to radiopaque

Juvenile ossifying fibroma & Multilocular & Maxilla>mandible & Aggressive

574


DR 8yo male

575


576


577


Radiopaque & Pericoronal location & Odontoma

& Periapical or central location & Fibrous dysplasia & Cementoblastoma & Osteoblastoma

& Peripheral location & Torus/exostosis & Osteoma

578


Radiopaque: pericoronal location Odontoma & Compound & Small separate denticles (tooth-like) & Anterior maxilla

& Complex & irregular mass of hard and soft dental tissues & Morphology grossly distorted

& May interfere with tooth eruption & Tx: surgical enucleation

Complex odontoma

Radiopaque: periapical or central location Fibrous dysplasia & Non-neoplastic condition & Maybe multifocal & Maxillary premolar/ molar region & Progresses from radiolucent to radiopaque & “Ground glass” appearance

& Poorly defined margins & Expansile, but “burns out” with time

579






580


C.B. & 6 yof & 1 yr s/p dental extraction LUQ, ? Mesial drift of molar & Painless swelling in palate, expanding rapidly & PMH: s/p laser ablation of L temporal hemangioma & Alls: Latex, tape & FH: Brother with von Willebrand

581


582


583


584


Cementoblastoma & Cementum-like tissue resorbs/fuses with root & 50% patients > 20 yrs & 75% form in mandible & Usually molar or premolar & Expansion/pain common

& Tx: extraction/removal of tooth and mass

585


Osteoblastoma & Posterior mandible & Progresses from radiolucent to radiopaque & Pain common & Vital tooth & May demonstrate “sunburst” appearance

Radiopaque: peripheral location Torus/exostosis & Non-neoplastic & Rare before age 10 y & May interfere with appliance therapy

586


Radiopaque: peripheral location Torus/exostosis & Non-neoplastic & Rare before age 10 y & May interfere with appliance therapy

Osteoma/Gardner’s syndrome & A.D. & Multiple osteomas & Epidermoid/dermoid cysts (50-60%) & Multiple polyposis of large intestines with high malignant potential & Multiple supernumerary/impacted teeth

587


Gardner’s Syndrome

Inflammatory lesions & Common & Tender or painful to palpation & Rapid enlargement (days to weeks) & Diffuse or localized enlargement & Red, tender, swollen mucosa & Fluctuates in size

& Drainage, sinus tract formation & Cause is often apparent & Mobile, non-vital tooth & Systemic involvement occurs with advanced infection & Trismus, occasional paresthesia & Regression with treatment of source

588


Localized lesions & Periapical location & Radiopaque & Focal sclerosing osteomyelitis

& Radiolucent & Periapical abscess & Periapical granuloma & Periapical cyst

Focal sclerosing osteomyelitis & Chronic pulpal disease & Non-expansile & Posterior mandible & Well-defined margins

589


Periapical abscesses associated with Dentin Dysplasia, type I & Amber colored crowns & Obliteration of pulp chamber & Poor root formation & Periapical radiolucencies around malformed roots

Periapical Granuloma & Chronic infection & Flare-ups common & Unilocular, distinct margins & Non-vital tooth

590


Periapical Cyst & Tender? & Well-defined margin & Non-vital tooth & Granuloma develops into cyst

& Maybe expansile & May cause displacement of unerupted tooth & Variation: lateral radicular cyst

Lateral Radicular Cyst

&Forms at side of necrotic tooth as result of lateral canal

591


Pericoronal location: Paradental Cyst & Inflammatory cyst & Most frequently associated with partially erupted third molars & Mandibular buccal infected cysts & Buccal aspect of 1st molars in children & Pain/swelling & Tx: enucleation

Peripheral cortex location: Traumatic osteoma & Radiopaque & History of facial trauma & Inferior border of mandible & Maybe associated with jaw fracture & Irregular or sunburst appearance

592


Diffuse lesions & Radiolucent/infectious etiology & Acute osteomyelitis

& Mixed radiolucent/radiopaque/infectious etiology & Chronic diffuse sclerosing osteomyelitis & Chronic osteomyelitis with prolerative periostitis (Garre’s osteomyelitis)

& Mixed radiolucent/radiopaque/idiopathic & Infantile cortical hyperostosis

Mixed radiolucent/radiopaque/infectious etiology: Chronic diffuse sclerosing osteomyelitis & Chronic dental infection & Indistinct borders & Mottled bone pattern & Sequestrum common & May result in ankylosis & Posterior mandible

593


Chronic osteomyelitis with proliferative perostitis & Chronic dental infection & Diffuse, expansile & Indistinct margins & Mottled bone pattern & “Onion skin” appearance & Posterior mandible

Proliferative periostitis

Mixed Radiolucent/radiopaque/idiopathic: Infantile cortical hyperostosis Inherited disease (A.D.) Onset prior to 6 m of age Tender, soft tissue swelling Febrile Lymphadenopathy Bilateral mandibular involvement & “Onion skin” appearance & Spontaneous resolution & & & & & &

594


Aggressive and Malignant Lesions & Uncommon or rare & Maybe tender or painful & Moderate to rapid growth (days to weeks to years) & Diffuse enlargement & May have multifocal distribution & Mucosa red, ulcerated & Lymph nodes firm and fixed

Vital, mobile teeth Extrusion of teeth Progressive increase in size No apparent cause or source & Systemic involvement common & Frequent paresthesia/anesthesia & Trismus with advanced disease & & & &

Unifocal and radiolucent & Benign & Neuroectodermal tumor of infancy & Desmoplastic fibroma of bone & Localized histiocytosis (Eosinophilic granuloma)

& Malignant & Central sarcoma of bone & Primary soft tissue malignancies adjacent to bone

595


Neuroectodermal tumor of infancy & Anterior maxilla & Poorly defined margins & Expansile & May displace developing teeth/tooth buds & Pigmented surface & Recurrence moderate to high

Desmoplastic fibroma of bone & Maybe multilocular & Poorly defined margins & Expansile & “Floating” toothbuds & Soft tissue extension & High recurrence rate

596


Localized histiocytosis (eosinophilic granuloma) & Maybe multifocal & Punched radiolucencies & Usually non-expansile

& “Floating” teeth & Often soft tissue involvement

Central sarcomas of bone & Body of mandible & Paresthesia & Unilocular or multilocular & Cortical perforation

597


Primary soft tissue malignancies adjacent to bone & Well to poorly defined margins & “Cupped” out appearance & Fine “ground glass” appearance

Primary soft tissue malignancies adjacent to bone & Well to poorly defined margins & “Cupped” out appearance & Fine “ground glass” appearance

598


Unifocal and mixed radiolucent-radiopaque & Ewing’s sarcoma & Osteosarcoma & Mesenchymal chondrosarcoma

Ewing’s sarcoma & Posterior mandible and ramus & Painful expansion & Febrile & Leukocytosis & “Moth-eaten” appearance & Periosteal proliferation

599


Multifocal and radiolucent & Disseminated histiocytosis & Burkitt’s lymphoma & Leukemia (AML) & Metastic disease

Disseminated histiocytosis & Multiple organ involvement & Pain & Lymphadenopathy & Gingival involvement & Premature exfoliation of teeth & “Floating” teeth appearance

600


Disseminated histiocytosis & Multiple organ involvement & Pain & Lymphadenopathy & Gingival involvement & Premature exfoliation of teeth & “Floating” teeth appearance

E.D. •PMH: normal development •E/O: •Slight mand asymmetry •Palpable, nontender mass left preauricular area •I/O: •palpable mass left ramus •normal dentition

601


602


Burkitt’s lymphoma & Posterior maxilla and mandible & Single or multiple quadrants & Painful swelling & First signs often tooth mobility & “Moth eaten” or multilocular radiocency & Periosteal bone formation

603


Leukemia (AML) & Widespread involvement & Occasional gingival enlargement due to leukemic infiltrates & Loss of lamina dura & Diffuse, poorly defined radiolucency & Occasional periosteal bone formation

604


605


Differential Diagnosis & Leukemic infiltrate & Ewing’s Sarcoma & Primary malignancy (NH Lymphoma) & Langerhans Cell Histiocytosis (E.G.) & Giant Cell Granuloma/Tumor

606


Metastic disease & Posterior mandible & Poorly defined radiolucency & Soft tissue extention common & paresthesia

607


Metastic disease & Posterior mandible & Poorly defined radiolucency & Soft tissue extention common & paresthesia

608


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Comprehensive Review of Pediatric Dentistry

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Pediatric Board Review Symposium

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Pediatric Oncology A Comprehensive Guide

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Pediatric Emergency Medicine : A Comprehensive Study Guide

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Pediatric Radiology Review (Contemporary Medical Imaging)

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