Highlights (You will learn) ⬇️
1. Trigeminal Neuralgia
2. Post-herpetic Neuralgia
3. Giant-cell Arteritis
4. Other causes of facial pain
5. Approach to facial pain diagnosis
LINK:⬇️
Tag: dental Education
Differential Diagnosis of Periapical Radiolucencies
PA radiolucencies identification made easy! Happy learning..😀📖
- Periapical radiolucencies are most commonly odontogenic. Nonodontogenic radiolucencies tend to be not localized and span across the mandible or maxilla within the alveolus and sometimes extend inter-radicularly.
- The most common PA pathologies can be diagnosed based on the vitality responses from the teeth. Ruling out the tooth associated pathologies is an important step in securing a diagnosis from differential diagnosis panel of PA radiolucencies.
- Inter-relationship of possible results of periapical inflammation:
When formulating radiological differential diagnosis, features should be evaluated carefully, such as
- location
- locularity
- relation to dentition
- density of lesion
- margin
- type of radiological change (radiolucent/radiopaque/mixed)
- periosteal reaction
- cortical integrity, and
- clinical presentation.
🌫 General Radiographic features:
• Location: With periapical inflammatory lesions, which are pathological conditions of the pulp, the epicenter typically is located at the apex of a tooth.
• Periphery: Ill defined
• Effects on surrounding structures: Periapical lesions cause widening of PDL space at apical region of the root.
PA Radiolucencies: (Classification)
PERIAPICAL RADIOLUCENCIES
Developmental
Lateral periodontal cyst
- Definition: lateral periodontal cysts are cystic lesions that tend to occur on the lateral aspect of vital teeth. Epidemiology: lateral periodontal cysts account for fewer than 1% of the reported cases of odontogenic cysts.
- Clinical findings: most lateral periodontal cysts area located in the mandibular incisor-canine-premolar area.
- Radiographic findings: radiographically, lateral periodontal cysts present as a unilocular radiolucent lesion between the roots of teeth or associated with the lateral aspect of a tooth.
- Management: surgical enucleation with preservation of involved teeth is an appropriate treatment of lateral periodontal cysts. Recurrence is rare. The multiloculated variant called botryoid odontogenic cysts has been reported to demonstrate a higher recurrence rate than its unilocular counterpart.
Inflammatory Lesions
Apical periodontitis, periapical abscess
- Definition: spectrum of inflammation involving the PA area of teeth that results from pulpal infection by microorganisms.
- Epidemiology: apical periodontitis is the most frequent inflammatory lesion related to teeth in the jaws.
- Clinical findings: apical periodontitis can be classified as either asymptomatic or symptomatic; clinical examination of percussion and palpation of the tooth yields negative results in the former and usually positive results in the latter. The results of pulp sensitivity tests for both conditions, however, are negative. In the early stage of PA inflammation, the PA PDL can exhibit acute inflammation without abscess formation. This localized alteration may or may not proceed to abscess formation.
- Radiographic findings: in apical periodontitis, radiographs may show a thickened PDL space. If an abscess develops after a long-standing apical periodontitis, radiographs reveal a radiolucent area around the root apex.
- Management: apical periodontitis is an inflammatory disease caused by a persistent infection of the root canal system. The recommended treatment is the removal of the dead nerve and bacteria either through extraction of the tooth or root canal treatment. Antibiotics are recommended only when there is severe infection that has spread from the tooth into the surrounding tissues.
Cystic Lesions
Periapical (radicular) cyst
- Definition: radicular cyst is a cyst of inflammatory origin associated with a nonvital tooth.
- Epidemiology: radicular cysts represent the most common odontogenic cyst. Radicular cysts are most commonly associated with at the tooth apex, but a lateral radicular cyst can be associated with a lateral root canal.
- Clinical findings: radicular cysts are always associated with a nonvital tooth, and this is an important criterion for diagnosis.
- Radiographic findings: radiographs often show a well-defined radiolucent lesion at the apex of a tooth. Radicular cysts can displace or resorb the roots of adjacent teeth.
- Management: the treatment of radicular cysts can include nonsurgical root canal therapy to surgical treatment, such as apicoectomy.
Odontogenic keratocyst
- Definition: an odontogenic cystic lesion with distinctive histologic features. Recently reclassified back into a cystic category in the recent 2017 WHO Classification of Head and Neck Tumours. Current evidence seemed lacking to justify the continuation of classifying it as a tumor.
- Epidemiology: odontogenic keratocysts are the third most common cyst of the jaws.
- Clinical findings: most common location of odontogenic keratocysts is the mandibular molar region.
- Radiographic findings: odontogenic keratocyst size can be variable, ranging from a unilocular radiolucent lesion surrounding the crown of an unerupted tooth, resembling a dentigerous cyst, to a large size that results in facial deformity and destruction of surrounding structures. Lesions tend to grow in a posteroanterior direction, however, that results in a lack of cortical expansion.
- Management: odontogenic keratocysts tend to be more aggressive in its growth pattern with a higher recurrence rate than other odontogenic cysts. Recurrence may be due, however, to incomplete removal or the presence of satellite (daughter) cysts. Treatment includes enucleation (with or without peripheral ostectomy, treatment with Carnoy solution), marsupialization, or resection.
Glandular odontogenic cyst
- Definition: a developmental cyst with features that resemble glandular differentiation.
- Epidemiology: glandular odontogenic cysts represent less than 1% of odontogenic cysts.
- Clinical findings: there is a predilection for the mandible.But in the maxilla, the canine seems commonly involved. Swelling and expansion were the most common presenting complaints.
- Radiographic findings: radiographically, glandular odontogenic cysts present as a well-defined unilocular or multilocular radiolucency associated with the roots of teeth; association with impacted teeth is rare.
- Management: glandular odontogenic cysts have a tendency to recur especially when lesions are removed with simple enucleation.
Benign Tumors
Ameloblastoma
- Definition: benign, slow-growing epithelial odontogenic neoplasm with unmitigated growth potential.
- Epidemiology: ameloblastomas are the most common odontogenic tumors, excluding odontomas.89 In the United States, African Americans seem to have an overall 5-fold increase risk of disease compared with whites.
- Clinical findings: tumor often presents as an asymptomatic swelling of the posterior mandible and can be associated with an unerupted tooth. Buccal and lingual expansion often is observed.
- Radiographic findings: radiographs commonly show corticated multilocular (soap- bubble) radiolucency.
- Management: the unmitigated growth potential and tendency to recur require operative management involving segmental or marginal resection. When treated by enucleation alone, much higher rates of recurrence are reported.
Malignant Tumors
Ameloblastic carcinoma
- Definition: a rare, malignant counterpart for ameloblastoma. Not to be confused with metastasizing ameloblastoma, this is a histologically benign ameloblastoma metastasizing to distant sites. In the recent WHO Classification of Head and Neck Tumours, metastasizing ameloblastoma has been separated from ameloblastic carcinoma and included as a type of conventional ameloblastoma.
- Epidemiology: incidence rate was 1.79 per 10 million person/year with male and black population predominance. The overall survival is 17.6 years.
- Clinical findings: the most common site is the posterior mandible. Often, pain and expansion are the first clinical manifestations. Most cases arise de novo, but some arise in preexisting ameloblastomas.
- Radiographic findings: radiographically, ameloblastic carcinomas can present as poorly defined, irregular radiolucencies consistent with a malignancy, or indistinguish- able from a benign radiolucency.
- Management: generally considered radio-resistant tumor, radical surgical resection is the first line of treatment.
Differential Diagnosis: 🔍
- The 2 type of lesions that most often must be differentiated from periapical inflammatory lesions are Periapical cemental dysplasia & enostosis (dense bone island, osteosclerosis) at the apex of the tooth.
- In the early radiolucent phase of Periapical cemental dysplasia, the D/D rely solely on clinical examination and a test of tooth vitality.
- With long standing periapical inflammatory lesions, the pulp chamber of involved tooth may be wider than adjacent tooth.
- More mature PCD show radio-opaque mass within radiolucent area which helps in D/D.
- Also the common site for PCD is mandibular anterior region. External root resorption is more common with periapical inflammatory lesions than PCD.
- When enostosis is centered on the root apex, it may mimic inflammatory lesion but the PDL space has normal width. Also the periphery of enostosis is well defined and does not blend with surrounding trabaculae.
- Small radiolucent periapical lesions with well-defined periphery may be either granulomas/cysts.
- Differentiation may not be possible unless other characteristics of cyst such as displacement and expansion of surrounding structure is not present.
- Larger lesions >1cm are usually radicular cysts.
- If the patient has had endodontic treatment or apical surgery, a periapical radiolucency may remain that resemble periapical rarefying osteitis.
- Metastatic lesions such as leukemia may grow in periapical segment of PDL space with malignant bone destruction.
- Enostosis are common findings that seldom require treatment; however, caution should be exercised when undertaking orthodontic movement in the area of a DBI due to a potential risk of root resorption. Accurate identification and multidisciplinary management are of utmost importance. Monitoring size changes is recommended until completion of patient’s growth.
Dentowesome|@drmehnaz🖊
References:
CORTICOSTEROIDS IN DENTISTRY
🔷 Introduction:
Steroids are a group of hormones produced naturally in the body.
The adrenal cortex consists of 3 zones:
- Zona Glomerulosa synthesizes Aldosterone, the most potent Mineralocorticoid in humans.
- Zona Fasciculata – produces hydrocortisone (a glucocorticoid)
- Zona Reticularis produces Adrenal Androgens
• Glucocorticoid secretion is regulated by ACTH produced in the anterior pituitary. Cortisol has a -ve feedback on ACTH production.
• In Addison diseases, Glucocorticoid secretion impaired & ACTH is ⬆️
🔷 Corticosteroid Action & its regulation
- Glucocorticoid – Hepatic Glycogen deposition
- Mineralocorticoid – Sodium, electrolyte-fluid balance.
- Glucocorticoid play critical role in body’s response to stress.
Stress
⬇️
Release of cytokines (IL-1)
⬇️
⬆️ cortisol levels
🔷 Classification:
🔷 Steroid synthesis:
The substrate for steroid production is cholesterol. It is mobilized from the outer to the inner mitochondrial membrane by the steroidogenic acute regulatory (StAR) protein.
🔷 Glucocorticoids:
1) Hydrocortisone
• Action: Anti-allergy, anti-inflammatory
• Therapeutic Uses:
- intralesional injection in dose of 20-50 mg/mL
- Topical application
- Tablet in dose of 100mg/day can be given systemically to relieve burning sensation.
- Tab. Cortisol(25mg) combined with dexamethasone(90mg) can be given at biweekly interval.*
Action: Fibrinolytic,Anti-allergic, anti-inflammatory*
It causes ⬇️ fibroblastic production & deposition of collagen*
- Topical application with orabase
- Intralesional injection of hydrocortisone acetate (25mg/ml)
- Topical application (0.25-0.5%) to the affected area
- Intra-articular injection (25mg/ml)
- 20-30mg/day in divided doses
• Trade Name: CORTEF, ORABASE-HCA
• Preparation:
- Oral: 5 – 20 mg tab.
- Topical – 1% eye drop solution; 0.025 nasal drops, 0.25-2.5% skin creams
• Hydrocortisone acetate 25-50 mg/mL for soft tissue suspensions
• Hydrocortisone sodium phosphate: 50mg/mL IV, IM, SC
2) Cortisone:
• Uses:
- OSMF
- Addison disease
- Hodgkin lymphoma
3) Prednisolone:
• Action: Anti-allergic, anti-inflammatory, immunosuppressive
• Uses:
- Rheumatoid arthritis: 10mg/day in divided doses
- Collagen disease: 1mg/kg
- SLE: IM/IV; Topical application 2-3 times daily
- Leukemia: ALL as maintenance dose
- Erythema multiforme, pemphigus, bullous pemphigoid, behchet’s syndrome
- Bronchial asthma: 40-60 mg
- Post-herpetic neuralgia
- Amyloidosis, cyclic neutropenia, purpura
• Trade name: DELTA-CORTEF, PRELONE
4) Triamcinolone:
• Uses:
- Lichen planus: Topical application 3-4 times daily
- Erythema multiforme: 40-100 mg/day or inhalation doses
- Recurrent aphthae: Oral (2-4 mg/day)
- Desquamative gingivitis, OSMF, contact chelitis – intralesional (2-3 mL/day)
• Trade name: Kenolog cream
5) Dexamethasone:
• Uses:
👉🏻Mainly used for adrenal cortical suppression
- Allergic diseases, serum sickness, urticaria, hay fever, angioneurotic edema: IV; topically 2-4 times a day
- Benign migratory glossitis: Topical application
- Shock, cerebral edema, occular diseases.
• Trade name: DECADRON
6) Betamethasone:
• Action: Anti-allergy, anti-inflammatory
• Uses: Lichen planus, pemphigus, Aphthae ulcer
Dr. Mehnaz Memon🖊
References: Self Notes, Image chart source: Classification of Drugs with DOC by Vikas Seth (Third Edition)
ATROPHY
🔍Tap to View in full size!
Brown atrophy of the heart in gross and microscopic examinations characterized by decrease size and brown coloration
Dr. Mehnaz Memon🖊
References: Textbook of Pathology, Harsh Mohan; Random google Images
BULLOUS PEMPHIGOID
A chronic, autoimmune, sub-epidermal blistering skin disease that rarely involves mucous membrane.
🔹Clinical Features:
Age: Elderly (>60 years)
Skin Lesions:
- Generalised non-specific rash, commonly on Limbs.
- Appears urticarial/eczematous; persist for several weeks to months.
- Vesicles & bullae arise in prodromal skin lesion as well as Normal skin.
- The blisters are thick walled and don’t rupture easily.
- ruptured blisters are usually sensitive and painful, have raw eroded area which heals rapidly.
Oral Manifestations:
Vesicles appear gingivally👇🏻
Erythematous & desquamate as result of minor frictional trauma
👉🏻 Oral lesions comprise of bullae/vesicle that rupture to form erosions and ultimately leave out ulcerations
👉🏻 Other sites:
- Buccal Mucosa
- Tongue
- Floor of the mouth
- Palate
🔹Diagnosis:
Apart from evaluating history, clinical presentation, histopathological analysis is carried out followed by direct immunofluorescence study for the differential diagnosis and confirmation of the condition.
👉🏻Histopathology:
- Acanthotic mucosa
- Subepidermal non-specific vesicles with fibrous exudate
👉🏻Direct immunofluorescence is found to be the gold standard test. Deposition pattern of different types of immunoreactants differentiates the various immune-mediated diseases. Direct immunofluorescence shows presence of IgG and C3 deposits along the basement membrane zone.
👉🏻Electron Microscopy: In bullous pemphigoid (BP), the 180 kD antigen (BPAG2) was shown by immuno-EM to be a transmembrane molecule and to possess an autoantibody binding site outside the cell, suggesting a major pathogenic role for the BPAG2 in blister formation.
🔹Differential Diagnosis:
• Mucous membrane pemphigoid can be differentiated from BP by its predominant involvement of mucosal surfaces and positive Nikolsky’s sign.
• Lichen planus pemphigoides is clinically differentiated by the presence of lichen planus lesions in addition to tense blisters.
• Nikolsky’s sign is present in case of pemphigus and cicatricial pemphigoid, but not in the case of BP.
🔹 Treatment:
👉🏻Treatment is based on the degree of cutaneous and oral involvement. Mostly, topical steroid (clobetasol propionate) gives satisfactory result in case of smaller area of skin involvement, whereas larger area of skin involvement and recurrent cases are treated satisfactorily with systemic steroids and immunosuppressive agents.
👉🏻Recommended dosage for oral prednisolone is 0.3–1.25 mg/kg body weight/day, controls disease within 1–2 weeks, followed by which the dose is tapered. Dexamethasone (100 mg in 500 mL 5% dextrose i.v. over 2–3 h for three consecutive days) is the preferred steroid for pulse therapy, either administered alone or in combination with cyclophosphamide.
Other drugs for treating BP include new antibody modulators, rituximab 375mg/m2weekly over 4 weeks and omalizumab subcutaneously 300–375 mg for every 6 weeks.
👉🏻Higher doses of systemic corticosteroids seem to be associated with higher mortality rates, which led to the addition of corticosteroid-sparing agents to the treatment of BP. The most frequently used immunosuppressive agent is azathioprine (0.5–2.5 mg/kg body weight/day). Others being cyclophosphamide, methotrexate, cyclosporine A, combination tetracycline/minocycline along with nicotinamide, and more recently, mycophenolate mofetil, a DNA synthesis inhibitor, and methotrexate, a folate antagonist.
👉🏻IVIg – A dose of 1–2 g/kg for five consecutive day cycle of 0.4 g/kg/day, although a 3-day cycle may be used in cases that are nonresponsive to conventional therapy.
Dr. Mehnaz Memon🖊
References:
- http://www.jiaomr.in/article.asp?issn=0972-1363;year=2018;volume=30;issue=4;spage=432;epage=435;aulast=Aparna
- https://www.cidjournal.com/article/S0738-081X(00)00178-4/abstract
- Shafer’s Textbook of Oral Pathology, 7th edition
GINGIVAL TUMOURS
BENIGN GINGIVAL TUMOURS
a. Fibromas
Page 1 of 3
Read More »MALLAMPATI SCORE
Nancy 13th edition
ROOT CANAL MORPHOLOGY
Source: Internet
GINGIVAL ENLARGEMENT
References: Essentials Of Periodontology by S Sahitya Reddy; Shafer’s Oral Pathology; Carranza’s clinical periodontology; Internet
FIBROUS DYSPLASIA
Dr. Mehnaz Memon🖊
Dentowesome 