Al OMPR exam 3

  1. What is the difference between Xerostomia and Salivary hypofunction
    • Xerostomia is subjective, it is a symptom
    • Salivary hypofunction is objective (sign) can have an objective measure
  2. Dry mouth epidemiology
    • 20% prevalence
    • women > men
    • Increase with medication use
    • Increase in elderly
  3. Total salivary production
    • Total salivary production: 500-600 ml/day
    • Stimulated: 300 ml/day 
    • Unstimulated: +200 ml/day
  4. Serous secretion
    50% of stimulated volume
    20% of unstimulated volume
    • Parotids
    • exits through Stenson's duct opens in parotid papila
  5. Mucous and serous (mixed gland) secretion.
    65% of unstimulated volume
    30% of stimulated volume
    • SubMandibular glands
    • exits through Warton's ducts oppening opens in caruncule
  6. Mucous (viscous secretion)
    Mucous (very viscous secretion)
    7-8% of unstimulated flow each
    • Sublingial gland: Bartolini and Rivinus
    • Minor salivary glands
  7. When is dry mouth perceived?
    After more than 50% of unstimulated salivary flow is lost (more than 150 ml/day)
  8. Sialometry
    • Difficult to gauge since dependent upon pt normal baseline
    • usntimulated<0.1 ml/min
    • stimulated <0.5 ml/min
    • low flow rates possible in absence of symptoms and viceversa
  9. What type of stimulation produces copious saliva by all glands with variable protein concentration?
    Parasympathetic stimulation
  10. What type of stimulation produces less volume and generally higher protein concentration in saliva?
    Sympathetic stimulation
  11. What causes dry mouth during anxiety?
    Central inhibition

    as a result of connections between the primary salivary centers and the higher centers of the brain
  12. Causes of salivary hypofunctions
    • Dehydration
    • medications (Rx and OTC)
    • direct damage to glands (radiotherapy, chemotherapy, HIV, Sjogren S)
    • Decreased mastication (teeth loss, soft diet)
    • Affections of the CNS (Alzheimer, Parkinson, cerebral palsy)
  13. How many Gy will cause temporary salivary dysfunction and how many will cause permanent salivary dysfunction?
    • 2+ Gy
    • 26+ Gy

    • Parotid more radiosensitive than submandibular
    • Dose and field are critical
  14. Autoimmune exocrinopathy
    Dry mouth and eyes
    • Sjogren Syndrome
    • 2-4 million in US. age: mid 50's Female > Male (9:1)
  15. Which are the types of Sjogren Syndrome (SS)
    • Primary SS: salivary and lacrimal involvement
    • Secondary SS: salivary and/or lacrimal involvement plus another connective tissue disease
  16. Dry mouth and oral consequences
    • Caries: incipient, recurrent, coronal, root surface
    • Dysphagia: difficulty swallowing, incresed duration of dry and wet swallowing, increased risk of aspiration pneumonia
    • Dysgeusia: altered taste
    • Candidiasis: erythematous, pseudomembranous, angular cheilitis.
    • Decreased denture retention: ↓ stability, ↑ complaints
    • Frictional Keratosis
    • Ulcerations: traumatic, aphthous
  17. Treatment of dry mouth
    • Salivary substitutes: Oasis, xerostomBiotene, aquoral, caphosol
    • Hydration: 64 oz of water, avoid alcohol, caffeine.
    • Sugarless chewing gum: increases stimulated flow rate (2-3x unstimulated rate)
    • Mucoadhesive disk: last 2-4 hours, contains a lubricating agent and citrus flavoring
    • Electric stimulation: GenNarino
    • Acupuncture
    • Prescription Medications: coordinate with prescribing physician, alter dose, administration time, reduce drugs with anticholinergic side effects
    • Spilanthes
  18. What medications can be used to treat Dry mouth?
    • Pilocarpine 5 mg tid qhs
    • Cevimeline 30mg tid
  19. Radiographic diagnostic: "fruit laden" branchless tree"
    Sjogren Syndrome

    Can also be confirmed with the Schimer test (volume of eye tears)
  20. Duct injury, secretion spills in adjacent connective tissue
    • Mucocele: it may occur in any minor S. Gland (pseudocyst) most common location lower lip. 
    • Treatment with surgical excision
  21. Intra-ductal expansion due to a sialolith block
    Mucous cyst
  22. Salivary gland stone (major and minor) obstruction of the duct
    • Sialolithiasis: common in the floor of the mouth. Associated with the tortuous Wharton's duct.
    • Occlusal x-ray
    • Treatment: massage
    •                  sialogogues 
    •                  surgical removal
  23. Acute or chronic inflammation of any salivary gland (painful)
    • Sialadenitis. The unfection can be bacterial, viral (mumps) or fungal
    • acute: parotid, purulent discharge, low grade fever
    • Chronic: recurrent acute
  24. Treatment of acute and chronic sialadenitis
    • Acute: Antibiotics, rehydration, surgical drainage. 
    • Chronic: surgical removal of affected gland
  25. A mucocele in the floor of the mouth. It may break trough the mylohyoid muscle and enter the neck space
    • Ranula
    • Plunging Ranula
  26. Diffuse swelling of the affected gland. Unilateral. Replacement of salivary gland tissue by lymphocytes, Squamous metaplasia of duct epithelium. Predilection for women. Asymptomatic
    Bening lymphoepithelial lesion
  27. Replacement of salivary gland tissue by lymphocytes.
    Squamous metaplasia of duct epithelium
    Sjogren Syndrome

    • The diagnostic is done after a minor salivary gland biopsy
    • 2 specific antinuclear antibodies Anti SS-A and Anti SS-B
  28. Firm swelling. Non-inflammatory salivary gland enlargement. BILATERAL, asymptomatic.
    Acinar atrophy with infiltration of fat cell (gland replaced by fat)-DM and alcoholism-
    Hypertrophy of the salivary gland acinar cell -malnutrition (anorexa nervosa)
    • Sialadenosis: slowly swollen of parotid glands
    • Associated with diabetes, alcohol, malnutrition, asthma medication
  29. histopatology: 
    1. Capsue
    2. double layered duct
    3. plasmacitoyd cell: very pink with excentric nuclei
    • Pleomorphic adenoma (benign mixed tumor): the most common salivary gland tumor. Most commonly found on superficial lobe of parotid and palate.
    • treatment is surgical excision
  30. Slow growing painless mass with overlying mucosa. More uniform pathologic pattern. Usually found in the upper labial mucosa. Microscopically cystic appearance, purple lymphocytes, double layer pink granular cell
    • Monomorphic adenoma
    • (canalicular, trabecular, basal cell adenoma subtypes)
  31. Benign neoplasm that occurs almost only in the parotid. Might be associated with EBV and smoking. May occur bilateral
    • Warthin tumor (papillary cystadenoma lymphomatosum)
    • tratment surgical excision
  32. Slowly enlarging mass, painless. Occurs centrally in bone. Occurs in children. Epidermoid: island of epithelial cell joined togeather by desmosomes. Cystic spaces. Mucous cells
    Mucoepidermoid carcinoma. The most common malignancy of salivary glands

    • Two grade prognosis. Low grade: mimics benign neoplasm. A lot of mucous cells and prominent cyst formation, soft- fluctuant, good prognosis
    • High grade: malignant tumor, shows necrosis, neural invasion and mitotic activity. Solid firm tumor. poor prognosis. Surgery plus radiation. Occurs centrally in bone
  33. Slow growing tumor, infiltrates around nerves (painful) histologically swis chees pattern (cribiform)
    • Adenoid cyst carcinoma (cylindroma)
    • recurrence is common with metastasis. Palate is a common site. Bad long term prognosis
  34. Malignat mixed tumor of the salivary glands
    • Carcinoma ex pleomorphic adenoma: malignant transformation of pleomorphic adenoma. Long standing tumor
    • Carcinosarcoma: both epithelial and connective tissue elements are malignant
    • Metastizing mixed tumor: histopathologic identical to pleomorfic adenoma with distant metastasis
  35. Clinical features of adenomas
    • encapsulated
    • freely movable
    • slow growing
    • non-tender
  36. Clinical features of adenocarcinomas
    • infiltrative
    • fixed
    • rapid or slow growing
    • larger, painful, rapidly growing
    • ulcerated over mucosa
  37. 2 basic x-ray at the dentist office to diagnose a sialolith
    • Occlusal film
    • panoramic
  38. What should be done to increase the chance of capture the obstruction of the gland on the xray?
    Reduce by half the expossure time. This will reduce the burnout
  39. imaging tools for salivary gland disease that general dentist can request. Uses contrast iodine base material that goes into the salivary gland to see it
    • Conventional sialogram:
    • CBCT sialogram:
  40. Contraindication of sialograms
    • Acute inflammation of salivary glands: can cause foreign body reaction
    • Known sensitivite to iodine-contrast agents
    • Anticipated tyroid function test: can give false positive to the thyroid test
  41. What is the modality of choice to image any soft tissue?
    MRI: used for salivary gland neoplasm where soft tissue information is needed
  42. Where is the most common place of sialolith formation and why?
    Submandibular glands: because of the tortuous ducts path towards the floor of the mouth, that is prone to trap mucous secretions (will calcify) The other reason is the secretion been mucous that is more thick
  43. What kind of radiographic imaging should be prescribed for a patient:
    Intermittent, unilateral swelling of the right floor of the mouth at the mealtime
    swelling resolves after meal
    Hard, mobile nodule
    • Either size 4 occlusal film
    • or Panoramic film

    salivary flow obstruction due to a sialolith
  44. What kind of radiographic imaging should be prescribed for a patient:
    Persistent, unilateral swelling of 3 years duration by the left angle of the jaw
    Swelling enlarges at mealtime but never fully resolves afterward

    Case 2: salivary flow obstruction secondary to a sialolith
  45. What kind of radiographic imaging should be prescribed for a patient:
    Intermitent, unilateral, right cheek swelling of 1 week duration.
    Swelling enlarges at mealtime but never fully resolves afterward. 
    No significant clinical findings
    • Panoramic: but the image shows nothing significant.
    • Not all salivary stones are calcified. Mucous plugs

    Case3: the pt must be sent for a CBCT sialogram. The result, salivary flow obstruction due to small, non calcified, sialolith
  46. What kind of radiographic imaging should be prescribed for a patient:
    several episodes of asymptomatic swelling of submandibular gland in the past year. Episodes resolve with antibiotics. Symptoms unrelated to mealtime
    • Sialodochitis. This is a reactive infection of inflammatory cause.
    • Occlusal and pano won't show nothing.
    • A CBCT sialogram is indicated for the patient
  47. inflammation of the salivary duct:
  48. Recurrent pain and swelling of the right parotid gland
    History of 2 similar episodes spaced 1 year apart and resolved with antibiotics
    Both the ductal and the acinar gland are inflamed. Sialadenitis and sialodochitis are happening at the same time

    Sialogram will reveal both obstructions on the duct and fibrosis areas on the acinar portion of the gland
  49. Dry eyes and dry mouth. Trouble expressing saliva from all major salivary gland
    Left parotid sialogram will show a ''Fruit-laden" branchless tree. Patognomonic of Sjogren syndrome
  50. When you suspect a neoplasm or a tumor (malignant on benign) involving any of the salivary glands, what is the radiographic of choice
  51. Salivay gland imaging key points
    • 1. Take occlusal and apnoramic films of patient whom you suspect to have salivary flow obstruction 1/2 the exposure time
    • 2. Chose film based on the anatomical area of your clinical findings
    • 3. Refer when your films give negative findings.
    •   -Sialogram to rule out radiolucent, noncalcified sialoliths, sialadenitis and Sjogren Syndrome
    • 4. Request MRI to rule out salivary gland neoplasm
  52. Ground glass appearance in the maxilla
    Cotton wool appearance in the mandible 
    Caused by GNAS 1 mutation.
    • Fibrous dysplasia
    • Can cause a superior displacement of the IAN canal.
    • Can be monostotic, affecting only one bone Maxilla> Mandible
    • Or polyostotic affecting 2+ like in McCune-Albright (cafe au late skin macules and endocrine problems) or in Jaffe-Lichtenstein (cafe au late skin macules)
  53. Usually seen in 30+ years old, African American, asymptomatic incidental finding. 
    Commonly found in mandubular anterior incisors.
    Epicent is always on the root apex but the teeth are vital
    • Cemento-osseous dysplasia: teeth are vital checked with the vitality test. 
    • Can be periapical -anterior teeth-
    • focal -posterior mandible on edentilous areas
    • floral -multiple quadrant involved as seen on panoramic- (this subtypes are not clinicaly important only for exam)
  54. Multiple, well defined radiopacities with radiolucent rims at the periapical level of the mandibular or maxillary ridge
    Florid cemento-osseous dysplasia
  55. In which Bening fibrous osseous lesion an implant placement should be avoided?
    In cemento-osseous dysplasia because it will mature into a sclerotic radiopaque (calcified) masses of cementum/bone with minimal to no blood supply
  56. True neoplasm (benign) of the bone that will continue to grow w/o treatment. Can centrally grow in the bone causing the expansion of it.
    • Ossifying fibroma
    • Small lesions can be similar to cemento-osseous lesion. Another x-ray should be taken in 6-12 month to compare and if it is showing signs of growing that confirm Ossifying fibroma diagnostic
  57. Autosomal dominant condition affecting the entire skeleton. Short stature, hypoplastic clavicles. Supernumeray teeth, retention of primary t, delayed eruption of permanent t, and increase in prevalence of Cleft Palate
    Cleidocranial dysplasia
  58. Supernumeray teeth, osteomas and colon cancer
    Garder Syndrome: multiple jaw bone osteomas on the angle of the jaw. Premalignat colon polyps that will transform into malignancy and may kill the patient if not diagnostic on time
  59. Autosomal dominant, impaired collagen maturation, opalescent teeth, history of fracture (fragile bone)
    Osteogenesis imperfecta (Brittle bone disease)
  60. Autosomal dominant, bone marrow failure (hepatosplenomegaly) impairment of the osteoclastic function, increased bone density, delayed tooth eruption
    • Osteopetrosis (marble bone disease) The inability to repair the bone after an extraction will lead to osteomielitis
    • Can be infantile (severe) or adult (benign)
  61. Elevated serum alkaline phosphatase.
    Generalized, very exuberant hypercementosis
    Symmetrical cotton wool appearance
    • Paget's disease of bone
    • Progressive symmetric bilateral bone enlargement (my denture or my hat does not fit anymore)
  62. Key points to remember about polyostotic bone conditions
    • Supernumerary teeth: cleidocranial dysplasia (clavicle) and Gardner syndrome (colon)
    • Osteogenesis imperfecta (brittle bone disease): similar dendal findings as dentinogenesis imperfecta. Oppalescent teeth
    • Osteopetrosis: osteomyellitis can be a consequence of extraction due to the minimal blood supply
    • Progressive bone enlargment: common presentation of Paget disease of bone
  63. Progressive symmetric jaw enlargement.
    Hypercementosis and cotton wool appearence 
    Elevated serum alkaline phosphatase
    Paget's disease of bone
  64. Multilocular differential
    • MACHO
    • M- mixoma
    • A- ameloblastoma
    • C- central giant cell lesion
    • H- hemangioma
    • O- odontogenic keratocyst
  65. idiopathic increase bone formation leading to dense bone islands
    • idiopatic osteosclerosis: enostosis. The cancellous bone starts to create more bone untill it becomes as dense as cortical
    • completely homogeneous radiopaque, well defined, normal pdl space
  66. scallops around the roots; preserves lamina dura; usually seen on teenagers on the anterior mandible
    • Simple bone cyst
    • does not destroy bone. Can be seen in the presence of cemento-osseous dysplasia
  67. seen in pediatric patients. Expansile lesion centrally in bone. can be multilocular, purple hue due to vascularization
    Central giant cell lesion
  68. plump cheeck pediatric patien. Symetric and bilateral
  69. rare pseudocyst. Painfull, rapid growth, expansion of posterior mandible
    aneurismal bone cyst
Card Set
Al OMPR exam 3
13 lectures. Hematologic disease. Dry Mouth (2), salivary gland pathologies (2), Salivary gland Imaging, Odontogenic cyst, Non-odontogenic cyst, Bone diseases (3), Odontogenic tumor (2)