Characteristic Cells in Oral Pathology

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Muhad Noorman P, Team dentowesome, Final year

Anitschkow cell: Modified macrophages with nuclei having caterpillar apperance ( linear bar of chromatin with peripheral radiating chromatins . Found in Recurrent Apthous stomatitis, Iron deficiency Anemia, megaloblastic Anemia, children receiving chemotherapy.

Langerhans cells : Bone marrow derived antigen presenting cells found in epidermis positive for CD1a and Bierbeck Granules. Increased in Langerhans cell histocytosis and decreased in Psoriasis etc.. Named after Paul Langerhans

Tzank Cells: Enlarged , Balooned up degenerating keratinocytes with enlarged vesicular hyperchromatic nucleus, basophilic cytoplasm and diminished nucleoli and perinuclear halo appearance. Named after Arnault Tzank. Found in Herpes Simplex infection, Herpes Zoster, Pemphigus vulgaris, Varicella.

Langhans Giant cells: They are formed by the fusion of epithelioid cells and contain multiple nuclei arranged in a horseshoe-shaped pattern in the cell periphery or are arranged circumferentially. Named after Theodor Langhans. Found in granulomatous lesions like Tuberculosis, tuberculous Leprosy.

Downey cells : Atypical lymphocytes, abundant pale blue cytoplasm and irregular chromatin . Found in infectious mononucleosis. Named after Hal Downey.

Warthin Finkeldy Giant cells : Giant cells with upto 100 nuclei, cytoplasmic and nuclear inclusions. Pathognomic of measels infection. Named after Warthin and Finkeldy.

Reed–Sternberg cells: They are named after Dorothy Reed Mendenhall and Carl Sternberg. They are large cells that either are multinucleated or have a bilobed nucleus (having an “owl’s eye” appearance) with prominent eosinophilic nucleoli.Reed–Sternberg cells are giant cells found in Hodgkin’s lymphoma (HL).

Gaucher Cells : Glucocerebroside laden macrophages containing tubular cytoplasmic inclusions. (Crumbled tissue paper apperance) Hallmark of gaucher disease. Staining positive for Wright and PAS stain.

Rushton bodies : Peculiar linear , curved- hyaline homogeneous structure found in wall of ODONTOGENIC cysts like periapical cyst, dentigerous cyst etc..

Ghost cells: Well defined, eosinophilc, elliptoid fused epithelial cells with blurred apperance. Found in Ghost cell odontogenic tumor, Calcifying epithelial odontogenic cyst, odontoma, craniopharyngioma etc..

Rusells bodies : Large eosinophilc immunoglobulin containing inclusion bodies found in plasma cells. Distented endoplasmic reticulum staining positive for PAS, CD38 etc. Found in chronic inflammations. Aggregate Is called Mott bodies.

Reference : Internet, Shafers oral pathology, Neville Oral pathology

ANGINA PECTORIS

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  • Angina pectoris (literally heart pain) is characterized by paroxysmal and usually recurrent attacks of substernal or precordial chest discomfort caused by transient myocardial ischemia.
  • The three overlapping patterns of angina pectoris : 1. Stable or typical angina 2. Prinzmetal variant angina 3. Unstable or crescendo angina

Stable angina :

  • It is the most common form and is also called typical angina pectoris
  • Cause : an imbalance in coronary perfusion (due to chronic stenosing coronary atherosclerosis) relative to myocardial demand, such as that produced by physical activity, emotional excitement or any other cause of increased workload.
  • Typical angina pectoris is usually relieved by rest or administering nitroglycerin (a vasodilator that increases perfusion)
  • Pharmacology – nitroglycerin is the drug of choice, administered sublingually with an initial dose of 0.5 mg, which usually relieves pain in 2-3 minutes.

Prinzmetal variant angina :

  • It is an uncommon form of episodic myocardial ischemia
  • Cause : coronary artery spasm
  • It is unrelated to physical activity, heart rate or blood pressure
  • Pharmacology – episodes of coronary vasospasm are treated with nitrates; for prophylaxis, nitrates and calcium channel blockers (Amlodipine, nifedipine and diltiazem) are effective.

Unstable or Crescendo angina :

  • It refers to a pattern of increasingly frequent pain of prolonged duratio, that is precipitated by progressively lower levels of physical activity or that even occurs at rest
  • Cause : mostly by disruption of an atherosclerotic plaque with superimposed partial thrombosis and possibly embolization or vasospasm (or both)
  • Unstable angina thus serves as a warning that an acute MI may be imminent; indeed, this syndrome is sometimes referred to as preinfarction angina.
  • Pharmacology – it requires treatment with multiple drugs – antiplatelet drugs, anticoagulants, nitrates, beta blockers, CCBs and statins

Source : Robbins and Cotran’s book of pathology

Changes in the ageing heart

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CHAMBERS :

  1. Increased left atrial cavity size (2-4 cm generally)
  2. Decreased left ventricular cavity size (42-59 mm in men and 39-53 in women normally)
  3. Sigmoid shaped ventricular septum

VEINS :

    1. Aortic valve calcific deposits
    2. Mitral valve annular calcific deposits
    3. Fibrous thickening of leaflets
    4. Buckling of mitral leaflets towards the left atrium
    5. Lambl excrescenses (filiform fronds that occur at sites of valvular closure. They originate as small thrombi on endoardial suraces where the valve margins make contact)

    EPICARDIAL CORONARY ARTERIES :

    1. Tortuosity

    2. Increased cross sectional luminal area

    3. Calcific deposits

    4. Atherosclerotic plaque

    MYOCARDIUM :

    1. Increased mass
    2. Increased subepicardial fat
    3. Brown atrophy (atrophy of the heart muscle described as brown as fibers become pigmented by intracellular deposits of lipofuscin, a type of lipochrome granule)
    4. Basophilic degeneration (an accumulation within cardiac myocytes of a gray-blue byproduct of glycogen metabolism)
    5. Amyloid deposits

    AORTA :

    1. Dilated ascending aorta with rightward shift
    2. Atherosclerotic plaque
    3. Elastic fragmentation and collagen accumulation
    4. Elongated (tortuous) thoracic aorta
    B represents elongated tortuous aorta

    Source : Robbins and Cotran’s book of pathology

    Unique Clinical appearance in Oral pathology and Medicine

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    Muhad Noorman, Team dentowesome , Final year

    Apple jelly nodules in nasal septum: It is the nodular form of the tuberculosis in nasal mucosa. It begins in the vestibule and extends to adjoining skin and mucosa.

    Arnold head: In Cleidocranial dysplasia, the fontanelles may remain open until adulthood, but the sutures often close with interposition of wormian bones

    Blue Sclera: Osteogenesis imperfecta , EHLER danlos syndrome, Fetal Rickets, MARFANS Syndome etc.. Asymptomatic bluish discoloration of sclera due to thinning of sclera and exposing underlying vascular choroid.

    Ash-leaf spots: Hypomelanic macules in Tuberous sclerosis.

    Buffalo hump: Cushing’s syndrome, the fat relocalization in nape of the neck resembling the buffalo’s hump

    Bull neck: Diptheria, Cherubism

    Cerebriform tongue: Pemphigus vegetans. Also known as Furrowed tongue with numerous sulci and gyri

    Chipmunk facies: Thalassemia and Sickle cell anemia. The bones of the head and face become enlarged and deformed causing an abnormal appearance resulting in a typical “chipmunk/ rodent facies” appearance. This occurs because the bone marrow, the site of red blood cell production, becomes hyperactive in an attempt to produce sufficient red cells to over profound anemia.

    Cobble stone appearance: Lymphangioma, Inflammatory papillary hyperplasia, Heck’s disease

    Forschemmier spots : Forscheimer spots are enanthem seen as small, red spots (petechiae) on the soft palate in patients with rubella. Also found in palatal mucosa of Scarlet fever.

    Fournier’s molars: congenital syphilis, Mulberry molars

    Hamman’s crunch: Cervicofacial emphysema. It’s a crunching, rasping sound, synchronous with the heartbeat, heard over the precordium .

    Hebra nose: Rhinoscleroma. Epistaxis, nasal deformity, and destruction of the nasal cartilage are also noted.

    Iris pearl’s: Leprosy. Miliary lepromas or iris pearls near the pupillary margins, which are spherical yellowish opaque micronodules

    Koplik’s spots: Measles. Koplik spots are a prodromic viral enanthem of measles manifesting two days before the measles erythmatous cutaneous rash itself. They are characterized as clustered, white lesions on the buccal mucosa ( table salt appearance) near each Stensen’s duct (on the buccal mucosa opposite the maxillary 2nd molars) and are pathognomonic for measles.

    Lisch nodules: Neurofibromatosis. A Lisch nodule is a pigmented hamartomatous nodule found in iris which is an aggregate of melanocytes.

    Pastia’s lines: Scarlet fever. Pastia’s sign, Pastia lines or Thompson’s sign is a clinical sign in which pink or red lines formed of confluent petechiae are found in skin creases, particularly the crease in the antecubital fossa. Caused by erythrogenic toxins staphylococcus.

    References : Shafers Oral pathology. Burkets Oral Medicine

    Clinical Signs In Oral Pathology/ Medicine

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    Dentowesome- Muhad Noorman P
    Final year

    Asboe-Hansen sign (also known as indirect Nikolsky sign) refers to the extension of a blister to adjacent unblistered skin when pressure is put on the top of the intact bulla.

    Auspitz’s sign is the appearance of punctate bleeding spots when psoriasis scales are scraped off, named after Heinrich Auspitz.This happens because there is thinning of the epidermal layer overlying the tips of the dermal papillae and blood vessels within the papillae are dilated and tortuous, which bleed readily when the scale is removed.

    Button-hole sign: Neurofibromatosis. invagination of a nodule when pressed with a finger, a characteristic of neurofibromatosis

    Carpet tack lesions: Discoid lupus erythematosus. There are follicular hyperkeratotic plugs causing a carpet tack appearance as they project from the undersurface of the scale when it is removed from advanced lesions.

    Charcot’s triad: Seen in multiple sclerosis, characterized by intention tremor, nystagmus, dysarthria

    Crowe’s sign: Found in Neurofibromatosis. Presence of axillary freckling in people with neurofibromatosis type I.

    Gorlin sign: Ehler -Danlos Syndrome. Ability to touch the tip of the nose with tongue and touch the elbow with the tongue

    Higomenakis’s sign: Congenital syphilis. A unilateral enlargement of the sternoclavicular portion of the clavicle, seen in congenital syphilis

    Millian sign: Erysipelas. Involvement of the ear (Milian’s ear sign) is a distinguishing feature for erysipelas since this region does not contain deeper dermis tissue.

    Nikolsky’s sign: Epidermolysis bullosa, pemphigus, Severe Steven –Johnson syndrome etc. Application of lateral oblique pressure to skin yeild formation of new blisters.

    Oil drop sign: Psoriasis. A translucent discolouration in the nail bed that resembles a drop of oil beneath the nail plate.

    Reference: Neville Textbook of oral Pathology. Cawsons essential oral pathology
    Regezi and Batsakis Oral pathology

    POSTOPERATIVE CARE AFTER DENTOALVEOLAR SURGERY

    Dr.MehnazLeave a comment

    Good aftercare to prevent complications and unnecessary suffering, with loss of valuable time, is as important as a good operation.

    The main purpose of aftercare is to expedite healing and prevent or relieve pain and swelling.
    REST

    Rest is necessary for the prompt healing of wounds. Ambulatory patients should be directed to go home & remain quiet for several hours, preferably sitting in a comfortable chair or, if lying down, keeping the head elevated on several pillows.

    Diet
    • Only liquids and soft solids should be eaten the first day. They may be warm or cold but not extremely hot.
    • Food intake should not begin until several hours after surgery to avoid disturbing the blood clot.
    • If the extractions were limited to one side, chewing can be done on the unoperated side, but when local anesthesia has been used, chewing should be avoided until sensation has returned.
    • Fluids should be taken in greater amounts than usual to prevent dehydration from limited food intake.
    • A normal diet should be resumed as soon as possible, since this facilitates healing.
    Oral hygiene
    • The teeth should be brushed as usual, and on the day after surgery rinsing of the mouth should begin.
    • A saline solution (1/2 teaspoon of salt in a glass of warm water) is best for this purpose.
    • Commercial mouthwashes if used should be diluted with water due to the high alcohol content that can irritate the wound.
    • Hydrogen peroxide rinses should not be used initially as this agent can remove the blood clot.❌
    Pain
    • Some degree of postoperative pain accompanies many exodontic procedures and begins after the effects of anesthetic have left. This is considered a normal response to the unavoidable trauma of surgery.
    • In most cases, such pain lasts no more than 12 to 24 hours, although a traumatic periostitis may persist for several days.
    • Ordinarily this type of pain can be controlled by the use of cold packs (30 minutes per hour) during the first 24 hours & the proper administration of analgesic drugs.
    • For mild pain, as after a routine extraction, one of the antipyretic analgesics is usually adequate.
    • For moderate pain, such as after removal of an impacted tooth, a drug such as codeine or meperidine (Domerol) should be used.
    • Narcotics are needed only in rare instances.
    • The combination of a sedative drug with an analgesic agent can also be used but barbiturate alone should never be used to relieve pain as it can result in mental disorientation in a patient suffering from extreme pain.
    Swelling
    • The degree of swelling that occurs is generally in direct proportion to the degree of surgical trauma.
    • The application of cold to the operated site helps diminish postoperative swelling. If a rubber ice bag is not available, the ice can be placed in a plastic bag.
    • Cold can be applied intraorally by holding an ice cube in the mouth.
    • Pressure dressings can also be beneficial in limiting postoperative swelling.
    • Once swelling has reached the maximum (usually after 24 to 48 hours), cold is no longer effective, and heat, in the form of moist compresses, should be applied. It too should be used only 30 minutes per hour. The area should be lubricated with petroleum jelly to avoid burning the skin.
    • Intraoral heat is achieved by the use of hot isotonic saline rinses.
    Smoking
    • Cigarette smoking should be avoided after tooth extraction because it has been shown to increase the incidence of alveolar osteitis

    Dr. Mehnaz Memon🖊

    References: Textbook of Oral Surgery – Daniel M Laskin

    How to prevent excessive bleeding during Dentoalveolar Surgery❓

    Dr.MehnazLeave a comment

    Types of bleeding are:

    1. Primary (during or immediately after surgery)
    2. Reactionary (Upto 48 hours due to a defective suture or as clot in the vessels has got disturbed)
    3. Secondary (8-14 days due to wound getting infected and capillaries have eroded surfaces)

    To prevent excessive blood loss during surgery we need to understand the source of bleeding i.e. possible reason for bleeding.

    Dr. Mehnaz Memon🖊

    Planning :-

    Dr Musaddika ShaikhLeave a comment

    It is defined as systemic approach to defining problem, setting priorities, developing specific objectives and goal, determining alternative strategies and methods of implementation.

    Planning results in formulation of plan.

    A Plan is a decision of coarse of action.

    Uses of planning :-

    • To match limited resources with many problems
    • To eliminate wasteful expenditure or duplication of expenditure
    • To develop best coarse of action to accomplish a define objective.

    Information needed for planning :-

    A) Sociodemographic population profile :-

    • Age
    • Ethnicity
    • Population
    • Mobility

    B) Existing service provision :-

    • Availability of services
    • Range of treatment available
    • Costs of care
    • Asset to service
    • Effectiveness of intervention

    C) Disease level :-

    • Epidemiological data
    • Range of condition
    • Severity of disease
    • Disease condition
    • Trends in disease

    D) Public concerns :-

    • Population priorities
    • View of health services
    • Demand on health services

    Planning cycle :-

    1. Indentify problem
    2. Determining priorities
    3. Developing of programme goals, objectives and activities
    4. Resource identification
    5. Identifying constraints
    6. Identify alternative strategies
    7. Develop implementation strategy
    8. Implementation
    9. Monitoring
    10. Evaluation

    Reference :-

    Writing :- Notes made from mastering bds and Soben Peter books

    Dental Manpower :-

    Dr Musaddika ShaikhLeave a comment

    It is defined as individual with kind of knowledge , skills and attitude needed to achieve predetermined health, targets and ultimately health status objectives.

    It requires continuous monitoring and evaluation.

    WHO has suggested following framework in formulating planes

    1. Analysis of existing situation
    2. Policy formulation

    Current status :-

    • India consist of 298 dental institutions which produces 25,000 to 30,000 BDS graduates every year.
    • In year 2004 dentist to population ratio in India was 1:30,000
    • Due to geographic imbalance between dental colleges the ratio is disturbed in rural and urban areas.
    • In urban areas dentist population ratio is 1:10,000 and in rural areas it is 1:2.5 lakhs.
    • In 1990 registered hygienist were 3000 while registered lab technicians were 5000 in India.
    • As per registration one can make one hygienist serve to 7 dentist and 1 lab technician provide services to 4 dentist while ideal ratio is 1:1.

    Reference :-

    Writing :- notes made from mastering bds and Soben Peter books

    Negligence :-

    Dr Musaddika ShaikhLeave a comment

    It is defined as lack of reasonable care and skill or willful negligence on part of doctor in treatment of patient whereby health or life of patient is endangered.

    There is failure of health care professionals to meet his or her responsibility to patient, with resultant injury to patient.

    Dental professionals are legally liable for their own negligence.

    Types of negligence :-

    1. Nerve damage
    2. Facial damage
    3. Failure to detect and treat gum disease
    4. Failure to carry out root canal treatment instead of extraction
    5. Fractured jaw during treatment
    6. Incorrect anesthesia

    Reference :-

    Writing :- notes made from mastering bds and Soben Peter books