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Differential Diagnosis Of Swellings Of Head & Neck

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The method of differential diagnosis was first suggested in use by Emil Kraepelin www.indiandentalacademy.com


In medicine, differential diagnosis (sometimes abbreviated DDx or ΔΔ) is the systematic method physicians use to identify the disease causing a patient's symptoms. Before a medical condition can be treated, it must be identified. The physician begins by observing the patient's symptoms, examining the patient, and often taking the patient's personal and family history. Then the physician lists the most likely causes. www.indiandentalacademy.com


The physician asks questions and performs tests to eliminate possibilities until he or she is satisfied that the single most likely cause has been identified. Once a working diagnosis is reached, the physician prescribes a therapy. If the patient's condition does not improve, the diagnosis must be reassessed www.indiandentalacademy.com


NEED FOR DIFFERENTIAL DIAGNOSIS? â–ş Lesions

of oral and perioral areas must be identified and characterized so that specific therapy can lead to elimination of the lesion.

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ORDERLY STEPS TO IDENTIFY AND CHARECTERIZE THE LESION ► Health

history ► History of the specific lesion ► Clinical examination ► Radiographic examination ► Laboratory examination ► Biopsy- If indicated.

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Reason for Health History ? Two basic reasons : â–ş A pre-existing medical problem may affect or be affected by the surgeons treatment of the patient â–ş Lesion

under investigation may be an oral manifestation of a systemic disease. www.indiandentalacademy.com


History of the lesion Duration ? 2. Change of Size of the lesion (size & rate)? 3. Has the lesion changed its character( Did the lump become an ulcer etc ) ? 4. Symptoms(Pain,dysphagia,anesthesia, Tenderness of adjacent L.N) associated with the lesion? 5.Any historic reason for the lesion ? (ex:Trauma,recent tooth ache etc ) 1.

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CLINICAL EXMINATION To determine the clue to its nature. ► Includes Inspection,palpation,percusion and auscultation. ►

1. ► ►

Role of anatomic location of the lesion ? Is to know which tissue are contributing to the lesion. Cause has to be elicited based on the anatomic location. www.indiandentalacademy.com


2 Surface of the lesion. ► Smooth,lobulated/irregular 3.Color of the lesion . ► Ex:A bluish swelling which blanch on pressure –A vascular lesion. One which do not blanch may be indicative of a Mucus containing lesion. www.indiandentalacademy.com


Sharpness of the boundaries of the lesion. ► To determine whether mass is fixed to bone, arising from bone and extending to soft tissues/Infiltrating in nature. 4.Consistancy of the lesion : ► As SOFT in case of Lipoma ► As FIRM –In case of FIBROMA ► As HARD –in case of an osteoma/tori

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5 Presence of fluctuation & pulsation . ► Pulsation : Indicates the fluid with in the mass ► Fluctuation : Indicates a large vascular component. 6. Lymph Node examination : Five imp. Characteristics has to be included. ► LOCATION ► SIZE (giving the diameter in centimeters) ► TENDERNESS (painful versus non-painful) ► DEGREE OF FIXATION (Movable/fixed) ► TEXTURE ( soft, hard/firm ) www.indiandentalacademy.com


Radiographic examination ► Gives

clue to the true nature of the lesion. ► Ex : A cyst appears as a radiolucency with sharp radiographic borders ► A ragged radiolucency may be indicative of the more aggressive lesion, such as malignancy. ► Use of radiographic dyes/Instruments in conjunction with routine radiographic procedures. www.indiandentalacademy.com


MID LINE SWELLINGS: From above downwards: In Sub Mental Region: ► Ludwig's Angina ► Enlarged sub mental lymph nodes ► Sublingual dermoid ► Lipoma www.indiandentalacademy.com


► In

Supra sternal Space of Burns : ► Retrosternal goitre ► Thymic swelling ►A

dermoid cyst may appear anywhere in the midline.

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COMMON MIDLINE SWELLINGS ► Thyroid

Swellings ► Ludwig's Angina ► Enlarged Lymph node ► Thyroglossal cyst ► Dermoid Cyst ► Lipoma

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DIFFERENTIAL DIAGNOSIS OF THYROID SWELLINGS A Thyroid Swelling is recognized by its position, its shape and by the fact that it moves upwards during deglutition. Term GOITRE denotes any enlargement of thyroid gland irrespective of its pathology. D.D Includes: 1. NON TOXIC GOITRE 2. TOXIC GOITRE 3. NEOPLASTIC 4. THYROIDITIS 5. OTHER RARE TYPES; AMYLOID GOITRE www.indiandentalacademy.com


A.Non-Toxic Goitre{Simple Goitre} ► ► ► ►

Age b/w 5-20 yrs Enlargement is uniform and is soft. Due to increased TSH stimulation in response to low level of circulating Thyroid hormones This goitre may develop PHYSIOLOGICALLY at the time of puberty when metabolic demands are high and in pregnancy when there is too much stress This goitre may subsides by it self [NATURAL INVOLITION] or with Iodine therapy.

PRESSURE EFFECTS are rare unless swelling is enormous www.indiandentalacademy.com


B. TOXIC GOITRE: PRIMARY TOXIC GOITRE: Has five characteristic features: 1. Exopthalmus 2. Some enlargement of Thyroid Gland 3. Loss of weight in spite of good appetite 4. Tachycardia 5. Tremor SECONDAY TOXIC GOITRE:It must be remembered that brunt of attack falls on CVS. There may be NO exopthalmus, NO tachycardia , but the pulse becomes irregular in rate and rythum.The patient complains of PRECORDIAL PAIN and exhaustion, later on auricular fibrillation and heart failure may set in. www.indiandentalacademy.com


C.NEOPLASTIC ► ►

Benign tumors are rare and can be either papillary or follicular adenoma. Malignant tumors:

DIAGNOSTIC FEATURE : ►

Hard feel & Indistinct outline of thyroid swelling.

Infiltrates to neighboring struc.like trachea,infrahyoid muscles, esophagus etc causing dyspnoea,dysphagia and hoarseness of voice.

Metastasis in bone may be the first symptom with pathological fracture/pulsating bone tumor.

No movement of thyroid due to fixation to surrounding structures. www.indiandentalacademy.com


Retrosternal goitre ► It

may be substernal,wholly intrathorasic /plunging I.e. intrathorasic but forced in to the neck while coughing.

DIAGNOSTIC FEATURE:

Presence of engorged veins over the upper part of the chest. ► Deviation of trachea ► Pt. becomes dysopneic on lying on one side only. www.indiandentalacademy.com


LUDWIGS ANGINA Is a severe form of cellulites where infection spreads Bilaterally involving tissue spaces of submandibular area: A. Submaxillary,B.Sublingual C. Sub mental spaces. ► Odontogenic in origin and rarely from trauma. ► DIAGNOSTIC FEATURE: INTRA ORALLY: ► Board like swelling of the tongue ► Elevated floor of the mouth ► Hoarseness of the voice ► Difficulty in swallowing and breathing ► ODEMA GLOTTIS is the most is the most dangerous complication ► Uncontrolled spread result in Mediastinitis,Sub phrenic abscess Pneumothorax ,fatal www.indiandentalacademy.com septicemia etc. ►


LYMPH NODE SWELLING

Tuberculous Lymphnodes:Most commonest cause of L.N swelling in Indian sub-continent.

First stage has solid enlargement → Periadenitis and glands become matted → whole mass liquefies “COLD ABSCESS" Fluctuation is not possible due to tough fascia superficial to abscess) →”COLLAR STUD “ abscess → Inflamed skin and sinus which refuses to heal.

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â–ş Carcinomatous

L.N: Majority of them lies deep to the anterior edge of sternomastoid muscle.

NOTE : Greater cornu of hyoid is often mistaken for Carcinomatous L.N. Pt. should be asked to swallow in which case the bone will move up but not the L.N â–şA

careful search for primary focus in mouth tongue, Larynx nasopharynx has to be made when ever a secondary Carcinomatous L.N is detected. www.indiandentalacademy.com


THYROGLOSSAL TRACT CYST: DIAGNOSTIC FEATURE: ► Typically present as Asymptomatic midline swelling that display vertical movement with tongue protrusion and swallowing. ► Majority of them are seen below Hyoid bone with 70% arising before pt. reaches age 20yrs . www.indiandentalacademy.com


DERMOID CYST â–ş

Its lining is derived from multipotential cells with the capability of giving raise to tissues of one or more germ layers. If the cyst wall consists of cutaneous structures ,it is called DERMOID CYST, if tissues such as cartilage,muscle,and brain from other germ layers are present ,it is called TERATOMA.

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DIAGNOSTIC FEATURE: ► Presence

of the secondary skin structures; Hair& Sebaceous glands. ► If the dermoid cyst develops superior to the Mylohyoid muscle ,the tongue is displaced ,leaving a mass in the floor of the mouth. ► When develops inferior to the Mylohyoid and geniohyoid muscle ,mass appears in the midline of the neck. www.indiandentalacademy.com


LATERAL SWELLINGS: According to their sites may be divided in to ► Sub mandibular Triangle ► Carotid Triangle ► Posterior Triangle

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SUBMANDIBULAR TRAINGLE ► Enlarged

lymph nodes ► Enlargement of submandibular salivary gland ► Deep / Plunging ranula ► Extension of growth from the jaw ► Sjogren’s syndrome

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CAROTID TRIANGLE ► Thyroid

swelling – will be deep to sternomastoid ► Aneurysm of the carotid artery ► Carotid body tumor ► Branchial cyst ► A Sternomastoid tumor in a new born

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POSTERIOR TRIANGLE ► Enlarged

supraclavicular lymph nodes ► Cystic Hygroma ► Pharyngeal pouch ► Sub clavian aneurysm ► Lipoma [Dercum’s Disease]

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SWELLINGS WHICH MAY OCCUR ANY WHERE IN NECK ► Sebaceous

cyst ► Lymph node swellings ► Thyroid enlargement ► Branchial cyst ► Lipoma

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COMMON LATERAL SWELLINGS ►Lymph

node swelling ►Thyroid Swelling ►Salivary gland enlargement ►Branchial cyst

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SWELLINGS OF SALIVARY GLANDS

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DIFFERENTIAL DIAGNOSIS OF PAROTID GLAND ENLARGEMENT

Acute suppurative Parotitis: ► Brawny oedematous swelling over parotid region with all signs of Inflammation. ► Fluctuation is the late feature owing to presence of strong fascia over the gland. Acute parotitis ,due to mumps : Is a nonsuppurative condition .May be unilateral but may become bilateral with in few days.

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► Sub Acute & Acute parotitis: May be

uni/bilateral. ► Swelling seen during meals. ► Gland is firm ,Tender & Rubbery. ► DIAGNOSIS confirmed by purulent/watery saliva ejected from duct on pressure. AURICULOTEMPORAL NERVE SYNDROME ( FREY’S SYND.): ► Occurs due to injury. Parotid region and cheek in front of it becomes red ,hot & painful during meals. ► Very soon beads of perspiration appears appear in this area.

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SJOGRENS SYNDROME ►

► ►

Is a chronic autoimmune disease in which lymphocytes infiltrates and replace parenchyma of salivary glands. Bilateral swelling of Parotid Gland. PRIMARY SJOGRENS:Dry eyes, Dry Mouth SECONDARY SJOGRENS: Prim. + Autoimmune disease, such as Rheumatic arthritis.

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► ► ►

DIAGNOSIS : By SCHIRMER’S TEST-Decreased lacrimal secretion Significant lab changes includes: Identification of auto antibodies (Rheumatoid factor, antinuclear antibodies,Sjogren’s syndrome – associated antibodies SS-A & SS-B.

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SUB MANDIBULAR & SUBLINGUAL SALIVARY GLANDS CALCULUS: ► ►

More common in sub- mandibular gland. Pathognomic feature : Swelling of the gland during meals often preceded by salivary colic. Bi digital palpation if stone is present in the duct.

MUCUS CYCT : ► ►

Due to cystic degeneration of glands of Blandin & Nunh. Fluctuant ,Blue/amber colored and translucent mass www.indiandentalacademy.com


TUMORS OF SALIVARY GLAND ► ►

90% of neoplasms of salivary glands occur in PAROTID GLANDS. 10% in Sub mandibular glands and very rarely in the sublingual and ectopic salivary glands.

►¾ of epithelial lesions in parotid are clearly ►

BENIGN . Remaining 1/4 is composed of definite carcinomas along with muco-epidermoid and acinic cell tumors which are considered as cancers of variable aggressiveness. Majority of tumors in sub-mandibular gland are MALIGNANT. www.indiandentalacademy.com


SALIVARY GLAND CANCERS IN DESCENDING ORDER OF FREQUENCY ► Muco

epidermoid tumors ► Adenoid cystic carcinoma ► Epidermoid carcinoma ► Undifferentiated carcinomas ► Carcinomas arising in PLEOMORPHIC ADENOMAS (MALIGNANT MIXED TUMORS)

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PLEOMORPHIC ADENOMA MIXED TUMOR –As there is

cartilage besides epithelial cells. ► Second decade of life and has female prediction DIAGNOSTIC FEATURE: ► ► ► ►

Lobulated painless swelling persisting over many months/years It is neither adherent to skin/ masseter Tumor is firm but variable consistency is a diagnostic feature Facial nerve remains free. www.indiandentalacademy.com


WARTHINS TUMOR ► ►

Seen in sixth and seventh decade of life. Almost always occurs in the lower portion of the parotid overlying the angle of the mandible. These are encapsulated lesions and do not undergo malignant transformation www.indiandentalacademy.com


Carcinoma of Parotid gland ► Pts are

over 50yrs of age ► No sex predilection is seen DIANNOSTIC FEATURE: Main complaint is rapidly enlarging swelling which is painless to start but becomes painful later on jaw movements. ► Pain is radiating to ear& over sideof the face. ► Surface is irregular and margin is often indistinct ► Consistency is firm to hard ► Facial nerve is involved ► Swelling is fixed to deeper structures and gradually restricts jaw movements www.indiandentalacademy.com


ADENOID CYSTIC CARCINOMA ► ►

► ► ►

Seen in adults with no gender predilection Is the malignancy of both major & minor salivary gland DIAGNOSTIC FEATURE: Growth rate is slow but persistent Have propensity for nerve innervations and may cause facial paralysis when occurring in parotid region www.indiandentalacademy.com


► ►

The characteristic “SWISS CHEESE” patterns that characterizes this lesion may be a very prominent one. Diagnostic microscopic feature: Cribriform,tubular,trabec ular,&solid patterns,areas showing distinct & separate[ cookie cutter] islands of tumor. www.indiandentalacademy.com


Swellings of jaws Arising from mucoperiosteum: Granulomatous,Fibrous,Sarcomatous& Carcinomatous Arising from tooth germs: â–ş ODONTOMES:Dental cyst,Dentigerous cyst,Adamantinoma â–ş

Osseous Tumors Inflammatory Group: Alveolar abscess,Osteomyelitis,Actinomycosis etc. www.indiandentalacademy.com


COMMON JAW SWELLINGS:

► Dentigerous cyst ► Dental cyst ► Adamantinoma ► Alveolar

abscess ► Osteomyelitis ► Giant –cell granuloma

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Dentigerous cyst: It originates after the crown of the tooth has been completely formed by the accumulation of fluid between the reduced enamel epithelium and the tooth crown. ► Bone expansion with extreme displacement of the teeth. DIAGNOSTIC FEATURE: ► Associated always with impacted/ unerupted tooth. ► Cystic involvement may result in HOLLOWING OUT of the entire ramus extending up to coronoid process as well as condyle and cortical expansion due to pressure of the lesion. ► X-RAY: Always radiolucent and www.indiandentalacademy.com unilocular. ►


Dental cyst/Periapical cyst ► Arises

from periapical granuloma containing epithelium that organizes In to a true cyst. ► Is associated with carious tooth. ► Develops at the apex of the tooth with necrotic pulp ► EGG SHELL CRACKLING when bone is thinned out ► Fluid within the cyst is clear and contains Cholesterol. www.indiandentalacademy.com


AMELOBLASTOMA

► Age 20-30yrs ► Is

a true neoplasm which does not undergo differentiation to the point of enamel formation ► Mandible is more commonly effected ► DIAGNOSTIC

FEATURE: ► Unicentric,NonFunctional,Intermittent,Anatom ically benign & Clinically persistent

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► Tends to

expand the bone rather that perforating it ► Donot produce signs of nerve involvement ► Seldom painful unless secondarily infected. ► X-ray: Multilocular cyst like lesion of the jaw. ► Compartmented appearance with septa of the bone extending into the R.L tumor mass.

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THREE TYPES BASED ON CLINICAL RADIOGRAPHIC& HISTOPATHOLOGIC APPERARENCES. CONVENTIONAL AMELOBLASTOMA 2. UNICYSTIC AMELOBLASTOMA 3. PERIPHERL[EXTRAOSSEOUS] 1.

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CONVENTIONAL TYPE Arise from de novo/pre existing unicystic type. 85% - in mandible 60% - in molar region

Pain less, Slow growing which are asymptomatic unless reach large size. Painless Swelling of bone is the presenting feature.Buccal& lingual cortical expansion is common

Multilocular R.lucency. SOAP BUBBLE-When loculations are large HONEY COOMB – When loculations are small. Well defined margins

UNICYSTIC TYPE Second/third decade.

Can not be differentiated from Dentigerous cyst/OKC.Definitive diagnosis requires correlation of clinical finding of a cyst at the time of surgery

Typically shows unilocular R.L associated with crown of unerrupted tooth.

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ALVEOLAR ABSCESS Arises as a result of infection following carious involvement of the tooth & Pulp infection. ► Tends to bulge towards the external surface DIAGNOSTIC FEATURE: Dull and constant aching with slightly extruded tooth EXCRUCIATING PAIN is a characteristic feature www.indiandentalacademy.com ►


OSTEOMYELITIS OF JAW

Acute form: Is a serious sequela of

periapical infection that often results in a diffuse spread of infection throughout the medullary spaces, with subsequent necrosis of variable amount of bone. ► Because of intense exudation of plasma fluids & blood cells ,pain is primary feature of this bony encased inflammatory response. ► Involved teeth are loose & sore ► Lip anesthesia is a common development in case of mandibular involvement. X-RAY :Diffuse lytic changes in the bone begin to appear, Individual trabeculae become fuzzy and indistinct. www.indiandentalacademy.com


CHRONIC OSTEOMYLITIS ► Represents

the proliferative reaction of the bone to a low-grade infection ► Pain & swelling are variable in chronic osteomylitis.It is usually low-grade &intermittent. ► Radiographic patterns vary from case to case, ranging from radiolucent to mixed MOTH EATEN to opaque, depending on duration, intensity of inflammation & individual biologic response. ► Generally a slow progressive lesion yields more opaque material [sclerotic bone/bony scar] www.indiandentalacademy.com


CLINICOPATHOLOGIC SUBTYPES 1.Chronic Osteomyelitis with periostitis ‘garre’s osteomylitis’ : ► In more active lesions bony inflammatory process may extend to involve the periostium,resulting in peripheral expansion of the mandible, which characterizes ‘garre’s Osteomyelitis’ ► Radiographically: Concentric opaque layers ,representing the several stages of cortex expansion ► MAY MIMIC FIBROUS DYSPLASIA BOTH CLINICALLY & MICROSCOPICALLY www.indiandentalacademy.com


2.CHRONIC DIFFUSE SCLEROSING OSTEOMYLITIS : ► Cause appear

to be related to low grade bacterial infection through periodontal membrane.. ► X-RAY: Dense generalized opacification of the entire jaw. ► May be confused with fibrous dysplasia.

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3.Focal sclerosing Osteomyelitis: [BONY SCAR] Is a common focal bone opacification seen in relation to low grade inflammation at the apex of teeth with chronic pulpitis.

â–ş Also seen after

healing of an extraction socket www.indiandentalacademy.com


TUMORS OF THE JAW ► ► ► ► ► ► ► ► ► ► ► ► ► ►

Lymphoma Hodgkins lymphoma Pagets disease Hemangioma Centrl gaint cell granuloma Burkitts lymphoma Osteoma Annurysmal bone cyst Cystic hygroma Ewings sarcoma Multiple Myloma Osteosarcoma Maxillary sinus carcinoma Rhabdomyoma

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LESION

C/F

X-ray

HISTOLOG

osteosarcoma

Mandible.Pain,paresth esia. Microscopic D.D: CGCG.

Penetration of the tumor outside the cortex results in “SUN BURST" pattern of bone formation

Diagnosis require presence of atypical cells in association with immature haphazardly distributed calcifies osteoid

Ewings sarcoma

Facial neuralgia, lip paresthesia .Bones involved : long bones,skull,pelvic girdle. may be assoc. with significant necrosis and confused with inflammatory process

Laminated periosteal hyperplasia of cortical bone overlying tumor bed shows ‘ONION SKINNING’ appear.

Demonstration of MIC-2 gene product with o13A antibody can be an diagnostic tool

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Burkitts lymphoma

High grade Poorly child hood defined malignancy.co radiolu mmon in cency maxilla.Tumor growth is expressed in jaws with pain &paresthesia,a bdomen&retro peritonium,abd omen Multiple myloma Charect. Multiple sharply marginated punched out lesion with pain &some times www.indiandentalacademy.com patho.fracture

Poorly defined lymphoid cells are seen.reactive phagocytic macropha. in tumor gives “STARRY SKY� appear.

Abnorm.AB is responsible for hyperviscosity &rouleaux formation of bd.vessel & appearance of light chains in urine (BenceJones protein )


CYSTIC HYGROM A Is a variety of lymphan gioma.

Charec. By large ,deeply located cyst like lymphatic vessels.pressure effects are not uncommon.

Rhabdom Common in pharynx,larynx, yoma. and grow considerable size.fetal rhabd. Occurs in children and common on face & pre auricular region

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Histology: Circum. Mass of cells with eosinophillic cytplasm is charec.`


HEMANGIOMA Benign tumor of bd.vessel. Present as flat /raised lesion appearing red/purple. Size:1cm-severe disfigurement. Are often asymptomatic but exhibit hemorrhage when traumatized

When congenital on skin called BIRTH MARKsize:1cm – severe disfigurement

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FIBRO-OSSEOUS LESIONS OF JAW

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► OSSYFYING

FIBROMA ► FIBROUS DYSPLASIA ► DESMOPLSTIC FIBROMA ► OSTEOBLASTOMA ► OSTEOMA ► TORUS ► EXOSTOSIS www.indiandentalacademy.com


Ossyfying fibroma (A benign neoplasm of bone )

Molar ramus region.More common in women.A well circumscribed lesion with distinct margins.

Radiolucent

Fibrous dysplasia. Gradual displacement of normal bone by fibrous connective tissue &structurally weak fibrillar bone

May be ILL defined mono/polystotic.polystoti margins& c associated with blends in endocrine surrn.bone. disorders[ Albrights Character. syndrome]It is self limiting,slow growing ground unilateral swelling & is glass appear. asymptomatic.Invol. of cranial ostia may cause seen best nasal in occlusal obstruction,sinusitis,heari www.indiandentalacademy.com view. ng&visual disturbances. D.D: garre’s Osteomylitis

It is sharply demarcated from surrounding bone.promin ant osteoblast rimming the new bone


EXOSTOSIS

Bilateral row of exophytic bone along facial surfaceof alveolar ridge A reactive hyperplasia of buccal cortical bonecoz of excessive occlusal forces

Has dense hyperplastic cortical type bone

TORUS:

Is a nodular bony protruberance of either mid-line of palate/lingual mandible Develops in second decade of life Asymptomatic unless surface is traumatized www.indiandentalacademy.com during mastication

Microscopica lly:Dense hyperplastic cortical type bone.


GAINT CELL LESIONS OF THE JAW

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► CENTRAL

GAINT CELL GRANULOMA ► ANEURYSMAL BONE CYST ► HYPERPARATHYROIDISM ► CHERUBISM ► LANGERHANS CELL DISEASE ► PAGET’S DISEASE

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LESION

CGCG

C/F

2/3 decade Mand. Ant. Portion. Localised expansion of the affected bone

X-RAY

Uni/multilocular.cor tex may be thin/perforated MICROSCOPIC D.D :Aneurysmal bone cyst, Cherubism,osteosar coma with gaint cells., Hyperparthyroidism .

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HISTOLO GY Stroma may be fibrotic.New bone may be present,esp. at the peripheryRec ent/old hemorrhage is typically found.


Aneurysmal bone cyst. Intra bony accumulation of the blood filled spaces surrounded by reactive C.T may be due to

Common in mandible Sudden increase in size of bone

Shows “expansile soap bubble R.L or “Honey Coomb” appearance.

Stroma may show sinosidal vascular channels that are not lined by endothelial cells.Varying amount of haemosiderin is seen.

DD: CGCG

secondary reaction to intraossous haematoma.

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Cherubism

Self limiting. Bilaterally symmetrical painless expansion &all 4 quadrants are affectd. After puberty. Typical cherubic facies.Teeth may be missing/malformed/disp laced.single involv. Of maxilla results in stretching of skin of upper face to expose sclera below iris of eye resultingin “Eyes upturned to heaven” appearance.

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Charec.” Soap Bubble” appearan ce.

Distinctive perivascul ar cuffing of collagen may be seen around cappilaries D.D : CGCG


PAGETS DISEASE Symmetric maxillary enlargement LOINLIKE FACE.Non-fitting dentures. Lab Feat: Elevated serum alik.phosp.,& Urinary hydroxyproline levels but calcium & phos. Levels are normal

R.L alterations follow. By develop. Of Intermixed radiopacity. Exibits charec. COTTON WOOL pattern. Hypercementosis /resorption may be seen.

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In early phase osteoclasts & capillaries dominate.End stage is densly sclerotic and exhibits a mosaic pattern that reflects remodelling process.


Langerhans cell disease ► ►

► ► ► ► ►

Is proliferationof langerhans Cells. L.Cells have immunosurvillance function .Tumor formation is related to chronic antigenic stimulation Three forms: 1.Letterer siwe disease 2.Hand-Schuller-christian syndrome 3.Eosinophilic granuloma Pain,swelling and spontaneous tooth loss. FLOATING TEETH radiographic image is seen when alv. Process is involved www.indiandentalacademy.com


â–ş

Microscopically: Pale cells with macrophage like appearance dominate the field. When process appears near the apex of the tooth it may be confused with periapical granuloma.

â–ş

The normal cellular counter parts to these tumor cells are found among prickle cells.

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â–ş both

normal lang. cells and tumor cells are negative for macrophage antigens

â–ş Ultra

structure of tumor cells shows numerous langerhans/BIRBECK granules that characterizes normal langerhans cell .

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REFERENCES: ► Differential

diagnosis - MOORE ► Atlas of oral& maxillofacial pathology REGEZI,SCIUBBA,POGREL ► Atlas of Clinical oral pathology BRAD W. NEVILLE ,DOUGLAS D.DAMM ► Text book of Oral pathology- SHAFERS ► Text book of General surgery - DAS www.indiandentalacademy.com


Thank you www.indiandentalacademy.com Leader in continuing dental education

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