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A patient with enlarged interdental papilla, feeling tired and weak, huge ulceration on cheek. CBC showed Low hematocrit (low oxygenation and close to heart attack, low hemoglobin and high BLASTS (immature cells)....
- AML, acute myelogenous leukemia, the intradental papilla is full of blasts called a Myeloid sarcoma.
- ** First step was to get a CBC, complete blood count.
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Describe what is oral medicine?
Specialty dedicated to the oral health diagnosis and non-surgical treatment of medically compromised patients, could affect the maxillofacial region as well as oral cavity.
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How many people in USA suffer from soft tissue lesions and significant xerostomia?
- 20 mil and 30 mil respectively
- More than 3million with premalignant lesions
- 5 million with oral lichen plaus -mismanaged
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How many people with oral/pharyngeal cancer? whats the survival rate?
- 48,000
- 2/3rd will survive 5 years
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White lesions that can wipe off.... what can cause them?
- Pseudomembraneous candidiasis (THRUSH)
- Compromised immune system, HIV, diabetes
- Sterords
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Difference between clinical and differential diagnosis
- Clinical is based on exam and history, differential is a short list of possible diagnosis for the condition, working diagnosis is the top diagnosis on this short list.
- Definitive diagnosis: subject to an objective test, histopathology or biopsy
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pseudomembraneous candidiasis, there are other types of that could require definitive
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What is a Leukoplakia
- A clinical diagnosis of a white patch that does not wipe off and has no explanation for existing.
- Biopsy for leukoplakia must always be done to rule out malignancy
- Pemphigus is also a clinical diagnosis which requires definitive objective testing (serological tests can also be done).
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What is the time frame for acute/chronic
less than 3 weeks is acute, more than 3 weeks is chronic.
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First two characteristics to consider of an oral lesion?
Color and topography
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Why do lesions appear white
- Thickening of the superior layer of the epithelium (HYPERKERATOSIS), when wet looks white.
- Thick surface layer (HYPERPLASIA), and walls off the pink color and appears white
- Edematous cells, appears milky white, larger cells hypertrophic, LEUKOEDEMA
- Candida - sits on TOP of the epithelium, wipeable, CURD-LIKE lesion
- Lichen-planus : thickened epithelium with inflammatory infiltrate underneath
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Why do lesions appear red?
- Because of thin epithelium, an erosive condition
- Inflammatory lesion, classic red, widening of blood vessels in the area.
- Abnormal blood vessels: like in cancer, angiogenesis
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why do Black or brown lesions occur
- Invasion of foreign material - amalgam tattoo
- Melanocytes
- Nevus cells deep in the tissue
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Yellow or orange looking lesions occur because
- Lipomas
- Neurilemoma
- Fordyce granules
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Ulcers present as, and usual types
- A depression in the tissue, a "canyon"
- Minor aphthous ulcer: (most common), relatively shallow, with red border, typically round
- Bullous pemphigoid: gingiva, epithelium peeled away with pseudomembrane
- Major aphthous ulcer: very deep ulceration and painful
- SCCA: deep, painful, indurated and can cause necrosis
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Exophytic lesions are described in which ways
- Fluid filled
- vesicle - less than 5mm
- bulla - more than 5 mm
- Pustule - containing pus
- Solid
- Papule - less than 2mm
- Nodule- more than 5, but less than 2mm
- Tumor -more than 2mm
- Plaque - more than 5mm and flat
- MACULE - completely flat (non-exophytic)
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Sensitivity vs Specificity
- Sensitivity: ppl who have a positive result compared to the gold standard (which is always biopsy)
- Specificity: ppl who have a negative result compared to the gold standard. Low specificity means that people are told they are positive when in reality they are negative
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What lesions will show loss of fluorescence?
- Inflammatory lesions
- Dysplastic and cancerous lesions
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What percent of mild epithelial dysplasias become malignant over time?
- less than 5%
- severe dysplasia has a higher chance (but there are fewer patients with severe)
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When a white lesion is seen what is the first step?
- Come up with a differential diagnosis if the lesion cannot be explained any other way, will need a biopsy if suspected cause is removed but lesion persists.
- Leukoplakia is a clinical diagnosis of a white lesion that has NO explanation.
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Genetic disorder that leads to increase in keratin production in a generalized fashion all over the mucosa
- White sponge nevus
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Condition seen mostly in women in their 6th and 7th decade of life, white lesions on the oral mucosa, slow progression. Finger-like spikey projetions that dont wipe off, Multifocal most of the time.
Proliferative verrucous leukoplakia
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An ongoing (chronic) inflammatory condition that affects mucous membranes inside your mouth, may appear as white, lacy patches; red, swollen tissues; or open sores. These lesions may cause burning, pain or other discomfort.
Oral Lichen Planus, has the potential for developing malignanccy
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Most unexplained leukoplakias endo up being
- Hyperkeratosis (about 4/5 80%),but this is a histopathalogic diagnosis
- about 12% of leukoplakias are dysplasias, 3% are CIS and 5% are SSC
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2 features looked at under microscope at high and low power, to evaluate tissue
- Low power - structure
- high power - cellular morphology
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Unique feature histologically of SCC
Keratin pearls seen in connective tissue (keratin should never be seen in CT)
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How is epithelial dysplasia classified?
- mild - maturational changes only involve basal third of epithelium
- moderate- up to basal 2/3
- severe - more than basal 2/3
- CIS - full thickness change of epithelium (but basal membrane is in tact)
- * After basement membrane is disrupted, this is now considered a cancer not a dysplasia
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High risk form of leukoplakia, with predileccion to women that usually do not have the risk factors, involves multiple sites with a roughened white leukoplakia appearace
PVL, proliferative verroucous leukoplakia
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In the histopathalogic grading of SCC, which has the worst prognosis?
- Poorly-differentiated has the worst prognosis
- well differentiated has the best prognosis
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Common premalignant alteration of the lower lip vermillion
Actinic chelitis (10% SSC formation)
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Well differentiated carcinoma with keratin filled papillary projections, has no invasion of basement membrane and rarely metastasizes.
Verrucous carcinoma
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High risk sites for oral melanomas?
Palate and maxillary gingiva
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Any unexplained pigmented spot on gingiva or palate....
Requires biopsy, especially irregular, recent onset
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The most common mutation in head and neck carcinoma (guardian of the genoma and the tumor suppresive gene)
TP53
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Relation between Methylation and gene expression
- They are inversely proportional, the lower the methylation the more genes are expressed.
- SCC have higher methylation than dysplasias
- Methylation is a tightening around the histosome that prevents a gene from expressing
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Which test is used for HPV+ oralpharyngeal cancer?
RNA ins hybridization
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Wartlike, multifocal, slow growing, persistent and irreversible hyperkeratoic lesion usually seen in elderly women.
PVL
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Patients with any type of lymphadenopathy
Have cancer until proven otherwise
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What are the main sites of HPV cancers
- Oropharynx, Base of tongue or tonsils
- There are 2 main Head and neck cancers; HPV positive or negative
- Sexual behavior in younger patients are risks
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THe histology of HPV vs non-HPV cancers
- HPV are usually Basaloid
- Non-HPV are usually keratinized
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Which type of HPV gives what percent on oral cavity vs oropharyx cancers?
- HPV 16. more than 70% oropharynx (have a high survival advantage)
- 6% of all other oral cavity cancers
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SAliva HPV testing can find the HPV subtype but cant find
difference between integrated DNA (oropharyngeal cancer) and episomal DNA
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What percent of oral cancers are SCC
91%
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About 48,000 new oral and oropharynx cancers are estimated per year. what percent of total
2.5%
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WHo has the higher incidnce of oral cancers
- Men 16.2/100k 3.8 mortality, women are just 6.2 with 1.4 mortality
- Median age is 62
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What does the T stand for in cancer
- T is the size. N are the nodes, M is metastasizes
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hPotentially malignant disorders are more prevalant in...
- Men, by 3x
- global prevalence of 1-5%
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