Dental Conference 3/6/2019

Transcription

1 Distinguishing the Benign from the Deadly: Oral Pathology Update Goals 1. How to evaluate an oral lesion Susan Muller, DMD, MS Professor Emeritus, Emory University 1 2 Stages for Evaluating Oral Lesions 1. Recognition of tissue alteration 2. Generating a differential diagnosis 3. Definitive diagnostic procedures 4. Recommendation for treatment 5. Clinical follow-up 3 4 A B CASE 1 Which one of these two lesions would cause you to be most concerned? A B CASE 2 These lesions are the same color. Which one would cause you to be most concerned? 5 6 1

2 CASE 3 Which one of these two lesions would cause you to be most concerned? A CASE 4 Which one of these two lesions would cause you to be most concerned? B A B 7 8 A CASE 5 Which one of these two lesions would cause you to be most concerned? Step 1. Recognition The Thought Process History of the condition How long has it been there? B 9 10 CASE 3 When did they first notice these lesions? A Step 1. Recognition The Thought Process History of the condition How long has it been there? Is this the first time, or has it happened before? B

3 A B CASE 1 Have they ever had anything like this before? Step 1. Recognition The Thought Process History of the condition How long has it been there? Is this the first time, or has it happened before? If it happened before, was it in the same spot or in a different area? Step 1. Recognition The Thought Process History of the condition Observation of the lesion Location Step 1. Recognition The Thought Process History of the condition Observation of the lesion Location Color

4 Step 1. Recognition The Thought Process History of the condition Observation of the lesion Location Color Size Shape Step 1. Recognition The Thought Process History of the condition Observation of the lesion Location Color Size Shape Texture or consistency Growth pattern A B CASE 5 What is the texture? What is the growth pattern? Stages for Evaluating Oral Lesions 1. Recognition of tissue alteration 2. Generating a differential diagnosis

5 Step 2. Differential Diagnosis: The Objective The objective of developing a list of possible diagnoses is to make sure that all significant conditions that could present in a specific manner are considered In other words. You cannot make a diagnosis if you do not think of it Step 2. Differential Diagnosis What is your impression of the condition? Developmental or congenital? Reactive inflammatory? Infectious? Tumor? Traumatic? Systemic Disease? Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Reactive Inflammatory DX- Pyogenic Granuloma

6 Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Reactive Inflammatory DX- Nicotine Stomatitis Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Developmental DX: Normal physiologic pigmentation Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Infectious DX: Candidiasis

7 Step 2. Differential Diagnosis What is your impression of the etiology of this lesion? Step 2. Differential Diagnosis: Helpful Pointers Traumatic DX: Traumatic ulcer Normal anatomy at the site : Frequent encounters with normal soft and hard tissues provides a ready framework for making a diagnosis. Tissue types contributing to the normal anatomy Lesions that could develop from the different tissues Gum Bumps

8 Localized Juvenile Spongiotic Gingivitis 12 WM: initial ortho consult progress pictures Chang JY, Kessler HP, Wright JM. Localized juvenile spongiotic gingival hyperplasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Sep;106(3):

9 A 29 year old white male noticed irritation after cementation of a three unit porcelain fused to metal bridge. He first noticed the irritation about 3 days after bridge delivery. These photos are one week after delivery The patient s health history was non-contributing and he had no history of allergies Dr. James Cade LSU School of Dentistry The metal used for the bridge contained mixtures of nickel, chromium, copper and palladium. A skin test only showed a slight reaction to nickle and negative to cement components The bridge was replaced by an all porcelain bridge. Within 3 weeks the lesions showed significant clinical healing Dr. James Cade LSU School of Dentistry Dr. James Cade LSU School of Dentistry At sick call appointment in the dental clinic, he was told to brush his teeth with his finger since a toothbrush was too painful. Dr. James Cade LSU School of Dentistry Before After

10 QUALITY CARE 46 year old white male Expansile mass of the posterior maxilla on the right side Patient was unaware of the lesion Clinical evidence suggests the pathoses has been present for several years Thanks to Dr. Doug Damm University of Kentucky Thanks to Dr. Doug Damm University of Kentucky Pencil Tattoo Thanks to Dr. Doug Damm University of Kentucky

11 Amalgam Tattoo Smokers Melanosis Increased melanin pigment in the basal layer of the epithelium Mandibular Sequestration Most often involves the lingual mandible near the mylohyoid ridge Spontaneous or related to extractions or dental work

12 Minocycline Staining Minocycline use may be associated with bluish gray to brownish mucosal pigmentation. Staining of underlying bony structures and tooth roots and enamel can occur Bridge was placed in Patient can no longer floss under pontic

13 Subpontine Hyperostosis JAWS STAYED IN KENTUCKY AFTER FILMING GOLDFINGER Thanks to Dr. Doug Damm, UK Cheek Biting How Cheeky Chronic cheek chewing show thickened, shredded areas with zones or erythema or superficial ulcerations Lip Biting Smokeless Tobacco Keratosis

14 Smokeless Tobacco Smokeless tobacco keratosis has a much smaller risk of developing cancer than oral leukoplakia that develops in tobacco smokers. Smokeless tobacco keratosis, after habit cessation, is routinely reversible M with a 10 year history of ST use 6 weeks after stopping In the last year uses 1 ½ cans of Skoal daily Oral Submucous Fibrosis Chronic, irreversible disease associated with the use of betel nut, quid, nass, paan and other substances commonly used in India and other South-Central Asian countries Early signs include blanching of the mucosa Trismus About 7% malignant transformation rate A 47 year old Asian male reported frequent daily use of betel quid containing slaked lime, areca nut, betel leaf and tobacco for more than 25-years. Approximately, 3-months ago he stopped chewing betel quid. Chung CH et al. Oral precancerous disorders associated with areca quid chewing, smoking, and alcohol drinking in southern Taiwan. J Oral Pathol Med Sep;34(8):

15 Blanching of the Mucosa Source: Dr. Susan Muller Trismus from Betel Nut Use Trismus Patient With Oral Cancer Source: Dr. Susan Muller Source: Dr. Susan Muller Advanced Oral Cancer in a Betel Nut User Cinnamon Reaction Source: Dr. Susan Muller

16 Lichenoid Reaction to Amalgam Lichenoid Reaction to Brackets or Bands yr. old Female 12 year old male Crohn Disease 12 WM: initial ortho consult Can involve any portion of the alimentary tract Annual incidence in North American ranges from 3 to 30 cases per 100,000 Bimodal age of onset with average age of 30 years First peak before age of 30 and second but smaller peak around 50 years Oral manifestations may precede GI involvement. Oral involvement of CD reported in up to 80% of pediatric patients progress pictures

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18 Diagnosis Foreign material giant cell reaction consistent with dermal filler Sculptra Poly-L-lactic acid, to replace lost collagen Corrects shallow to deep facial wrinkles, and folds Lip Bumps Aphthous Ulcer

19 Melanotic Macule Unknown etiology which represents a focal increase in melanin deposits Occurs at any age Vermilion zone of the lower lip is the most common site followed by buccal mucosa and palate Actinic Cheilitis The earliest clinical changes include atrophy of the lower lip with blotchy pale areas. There is blurring of the interface between the vermilion and the skin

20 Actinic Cheilitis Actinic Cheilitis As the lesion progresses, rough, scaly areas develop. Chronic focal ulcers may develop and last for months Funny Tongues Geographic Tongue Aspirin Burn This is a 48 year old Hispanic female who presented to the ODR clinic. CC: Something is wrong with my tongue it looks funny

21 Tongue Biting AF Cadet with lesions on tongue that come and go No hx of tobacco use No obvious rough-surfaced restorations Asymptomatic Transient Lingual Papillitis Oral Leukoplakia Sites of Oral Leukoplakia More than 2/3 or oral leukoplakia are found at 3 sites: lip vermilion, gingiva, and buccal mucosa Sites where leukoplakia are most likely to be associated with pre-cancer/cancer: tongue, lip vermilion and floor of mouth (account for 93% of all leukoplakia associated with dysplasia or cancer)

22 F with no tobacco hx 25 M with tongue cancer year old female What s so special about the oral tongue?

23 Why?.is the tongue becoming the most frequent site of OSCC? Tongue.is the tongue the overwhelming site of OSCC in young patients? Palatal Lesions Superficial Mucocele

24 year-old Asian male: reports that his skin has become lighter within past two years. PMH : Chronic myelocytic leukemia, hypertension, coronary artery disease and myocardial infarction, treated with coronary stents placement and cardiac defibrillator implantation. Current medications: Imatinib mesylate (Gleevec), Metoprolol succinate (Toprol XL), Lisinopril (Zestril), Niacin (Niaspan) and aspirin. Osteonecrosis due to bisphosphonates

25 Benign Squamous Papilloma HPV related Oropharyngeal Squamous Cell Carcinoma What s The Hype About HPV? The incidence of oropharyngeal SCC has increased from 1973 to 2004 in the US We are seeing younger patients with OPSCC who have NEVER SMOKED Why? HPV Eddie van Halen Poison Drummer Rikki Rockett

26 Tongue Oropharynx What is HPV? Genital warts Laryngeal papillomas Cervical Ca Oropharyngeal Ca Papillomas Anogenital cancer Oropharyngeal Cancer Symptomatology Pain Dysphagia Otalgia Neck mass Foreign body sensation Hemoptysis Weight loss Voice changes

27 45M with left neck mass How Do We Get HPV? HOW DO WE GET HPV? D Souza s 2007 case control study found several risk factors for HPV 16 positive OPSCC: Behavior HPV + OR* (95% CI) Lifetime vaginal-sex partners > (2-9) Lifetime oral-sex partners >6 8.6 (2-34) Casual-sex partner 2.4 ( ) <18 yo at first intercourse 2.1 ( ) Rare condom use 2.1 (1.1-4) Sexual partner with h/o HPV associated cancer 3.9 (0.6-26)

28 Can You Catch HPV- Associated Cancer? YES!! Reports in the literature of 2 couples, partners, both non-smokers, non-drinkers getting tonsil cancer DNA sequences of the HPV were identical in each couple, but different from the other couple. Andrews, et al. J Infectious Disease, Catching Cancer Studies regarding oral sex and open mouth (French) kissing have had conflicting results Should we screen partners of HPV + oropharyngeal or cervical cancer patients? No, there is no evidence for it. If your partner is diagnosed with cancer, should you avoid oral/genital contact? No, you have already been exposed. cdc.gov You Probably Have Had HPV Lots of questions little answers Nearly 80 million people about one in four are currently infected with HPV in the United States. About 14 million people, including teens, become infected with HPV each year. About 80% of population have HPV exposure 99.1% clear the infection Unclear why some don t HPV infection cancer Over 30,000 people in the United States each year are affected by a cancer caused by HPV infection. CDC

29 Misconceptions about HPV An Abnormal Pap Test Means You Have High-Risk HPV Just because a few cells appear abnormal, requiring further screening, doesn't necessarily mean that you've got a cancer-causing strain of HPV. It could be due to local irritation, a non-hpv infection, a low-risk HPV type, or even a sample error. Misconceptions about HPV Condom Use Prevents HPV HPV is passed via skin contact, rather than bodily fluid. For that reason, condoms can lower the risk of the disease, but they are not a sufficiently preventive measure, as they are for viruses like HIV and bacteria like gonorrhea Misconceptions about HPV Misconceptions about HPV Oral Sex Is Safe From Cancer Risk While the HPV-cancer connection most often relates to cervical health, a 2011 Journal of Clinical Oncology study found what doctors have long observed: There has been a surge in HPVassociated oropharyngeal cancers. In fact, between 1988 and 2004, HPV-associated oropharyngeal cancers rose 225 percent. Oral sex is the primary culprit. HPV Vaccine Means I Don't Have To Worry About Cervical Cancer The HPV vaccine protects against four strains of the virus that are most often associated with cancer and genital warts, but that doesn't mean it prevents cancer entirely Misconceptions about HPV Misconceptions about HPV HPV Is A Serious, Life-Long Condition Genital Warts Can Be Pre-Cancerous About 90 percent of HPV infections are resolved by the body s immune system. Some strains of HPV (low risk) cause benign growths known as genital warts. Low risk HPV genital warts which affect about 1% of the sexually active U.S. adult population do not lead to cancer

30 Are There Screening Tests? The architecture of the tonsil and where cancer develops makes early visual or cytologic screening ineffective at this time Are There Screening Tests? If you spread them out, they re 2 feet by 2 feet. You can t swab them. It s just not possible. Marshall Posner, medical director for H&N cancer, Mt Sinai Medical Center HPV and Saliva Testing A saliva test can detect an oral HPV infection Not useful since 85% of population catches at least one of the different HPVs that circulate Most infections resolve in 1-2 years. <1% of oral HPV infections will go on to develop oropharyngeal carcinoma There is no FDA-approved test to diagnose HPV in the mouth or throat. Medical and dental organizations do not recommend screening for oral HPV. More research is needed to find out if screening for oropharyngeal cancers will have health benefits. Talk to your dentist about any symptoms that could suggest early signs of oropharyngeal cancer. CDC.gov HPV and Saliva Testing CDC vaccine guidelines At this time we don t know how a + saliva test translates into cancer risk and patient management. Creates unnecessary anxiety We are uncertain what the natural history of oral HPV infection is and no management protocols have been established. HPV vaccine recommended for preteen girls and boys at age 11 or 12 October 2016: dosing schedule changed Two doses of HPV vaccine if started before 15 th birthday, 6 months apart Three doses if on or after 15 th birthday Recommends vaccination through age 26 for females and males

31 CDC vaccine guidelines Laryngeal papillomas Only the 9-valent HPV vaccine is now administered Covers HPV 6, 11, 16, 18, 31, 33, 45, 52, 58 In the US, 64% of all HPV-associated cases are attributable to HPV16 or 18 and 10% attributable to 5 additional types: 31, 33, 45, 52, 58 HPV 6 and 11 cause 90% of anogenital warts and most cases of recurrent respiratory papillomatosis When in doubt about the malignant potential of an oral lesion biopsy! Questions?