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Differential Diagnosis Of
Swellings Of Head & Neck

www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
Leader in continuing dental education

www.indiandentalacademy.com

www.indiandentalacademy.com
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 physician asks questions and performs
tests to eliminate possibilities until he or
she is satisfied that the single mo...
NEED FOR DIFFERENTIAL
DIAGNOSIS?
► Lesions of oral and perioral areas must be

identified and characterized so that specif...
ORDERLY STEPS TO IDENTIFY AND
CHARECTERIZE THE LESION
► Health history
► History of the specific lesion
► Clinical examina...
Reason for Health History ?
Two basic reasons :
► A pre-existing medical problem may affect
or be affected by the surgeons...
History of the lesion
Duration ?
2. Change of Size of the lesion ( size & rate )?
3. Has the lesion changed its
character(...
CLINICAL EXMINATION
To determine the clue to its nature.
► Includes Inspection,palpation,percusion
and auscultation.
►

1....
2 Surface of the lesion.
► Smooth,lobulated/irregular
3.Color of the lesion .
► Ex:A bluish swelling which blanch on
press...
Sharpness of the boundaries of the lesion.
► To determine whether mass is fixed to
bone, arising from bone and extending t...
5 Presence of fluctuation & pulsation .
► Pulsation : Indicates the fluid with in the
mass
► Fluctuation : Indicates a lar...
Radiographic examination
► Gives clue to the true nature of the lesion.
► Ex : A cyst appears as a radiolucency with

shar...
MID LINE SWELLINGS:
From above downwards:
In Sub Mental Region:
► Ludwig's Angina
► Enlarged sub mental lymph nodes
► Subl...
► In Supra sternal Space of Burns :
► Retrosternal goitre
► Thymic swelling
► A dermoid cyst may appear anywhere in the

m...
COMMON MIDLINE SWELLINGS
► Thyroid Swellings
► Ludwig's Angina
► Enlarged Lymph node
► Thyroglossal cyst

Dermoid Cyst
► L...
DIFFERENTIAL DIAGNOSIS OF THYROID
SWELLINGS

A Thyroid Swelling is recognized by its position, its
shape and by the fact t...
A.Non-Toxic Goitre{Simple Goitre}
►
►
►
►

►

Age b/w 5-20 yrs
Enlargement is uniform and is soft.
Due to increased TSH st...
B. TOXIC GOITRE :
PRIMARY TOXIC GOITRE: Has five characteristic
features:
1.
Exopthalmus
2.
Some enlargement of Thyroid Gl...
C . NEOPLASTIC

►
►

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

DIAGNOS...
Retrosternal goitre
► It may be substernal,wholly intrathorasic

/plunging I.e. intrathorasic but forced in to
the neck wh...
LUDWIGS ANGINA
Is a severe form of cellulites where infection
spreads Bilaterally involving tissue spaces of
submandibular...
LYMPH NODE SWELLING
Tuberculous Lymphnodes:Most commonest cause of
L.N swelling in Indian sub-continent.

First stage has ...
► Carcinomatous

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

NOTE : Greater cornu of hy...
THYROGLOSSAL TRACT CYST:
DIAGNOSTIC FEATURE:
► Typically present as
Asymptomatic midline
swelling that display
vertical mo...
DERMOID CYST
►

Its lining is derived from
multipotential cells with the
capability of giving raise to
tissues of one or m...
DIAGNOSTIC FEATURE:
► Presence of the secondary skin structures;

Hair& Sebaceous glands.
► If the dermoid cyst develops s...
LATERAL SWELLINGS:
According to their sites may be divided in to
► Sub mandibular Triangle
► Carotid Triangle
► Posterior ...
SUBMANDIBULAR TRAINGLE
► Enlarged lymph nodes
► Enlargement of submandibular salivary

gland
► Deep / Plunging ranula
► Ex...
CAROTID TRIANGLE
► Thyroid swelling – will be deep to

sternomastoid
► Aneurysm of the carotid artery
► Carotid body tumor...
POSTERIOR TRIANGLE
► Enlarged supraclavicular lymph nodes
► Cystic Hygroma
► Pharyngeal pouch
► Sub clavian aneurysm
► Lip...
SWELLINGS WHICH MAY OCCUR
ANY WHERE IN NECK
► Sebaceous cyst
► Lymph node swellings
► Thyroid enlargement
► Branchial cyst...
COMMON LATERAL SWELLINGS
►Lymph

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

www.indiande...
SWELLINGS OF
SALIVARY GLANDS

www.indiandentalacademy.com
DIFFERENTIAL DIAGNOSIS OF PAROTID
GLAND ENLARGEMENT

Acute suppurative Parotitis :
► Brawny oedematous swelling over parot...
► Sub

Acute & Acute parotitis: May be

uni/bilateral.
► Swelling seen during meals.
► Gland is firm ,Tender & Rubbery.
► ...
SJOGRENS SYNDROME
►

►
►

Is a chronic autoimmune
disease in which
lymphocytes infiltrates and
replace parenchyma of
saliv...
►
►
►

DIAGNOSIS : By SCHIRMER’S TEST-Decreased
lacrimal secretion
Significant lab changes includes:
Identification of aut...
SUB MANDIBULAR & SUBLINGUAL
SALIVARY GLANDS
CALCULUS :
►
►

►

More common in sub- mandibular gland .
Pathognomic feature ...
TUMORS OF SALIVARY GLAND
►
►

90 % of neoplasms of salivary glands occur in
PAROTID GLANDS.
10% in Sub mandibular glands a...
SALIVARY GLAND CANCERS IN
DESCENDING ORDER OF FREQUENCY
► Muco epidermoid

tumors
► Adenoid cystic carcinoma
► Epidermoid ...
PLEOMORPHIC ADENOMA
MIXED TUMOR –As there is

cartilage besides epithelial
cells.
► Second decade of life and has
female p...
WARTHINS TUMOR
►
►

►

Seen in sixth and
seventh decade of life.
Almost always occurs
in the lower portion of
the parotid ...
Carcinoma of Parotid gland
► Pts

are over 50yrs of age
► No sex predilection is seen
DIANNOSTIC FEATURE:
Main complaint i...
ADENOID CYSTIC CARCINOMA
►
►

►
►
►

Seen in adults with no
gender predilection
Is the malignancy of both
major & minor sa...
►

►
►

The characteristic
“SWISS CHEESE”
patterns that
characterizes this
lesion may be a very
prominent one.
Diagnostic ...
Swellings of jaws

Arising from mucoperiosteum :

Granulomatous,Fibrous,Sarcomatous&
Carcinomatous
Arising from tooth germ...
COMMON JAW SWELLINGS :

► Dentigerous

cyst

► Dental

cyst
► Adamantinoma
► Alveolar abscess
► Osteomyelitis
► Giant –cel...
Dentigerous cyst:
It originates after the crown of the
tooth has been completely formed by
the accumulation of fluid betwe...
Dental cyst/Periapical cyst
► Arises

from periapical
granuloma containing
epithelium that organizes In
to a true cyst.
► ...
► Age

AMELOBLASTOMA

20-30yrs
► Is a true neoplasm which does
not undergo differentiation to
the point of enamel formatio...
► Tends

to expand the bone rather that
perforating it
► Donot produce signs of nerve involvement
► Seldom painful unless ...
THREE TYPES BASED ON CLINICAL
RADIOGRAPHIC& HISTOPATHOLOGIC
APPERARENCES.
CONVENTIONAL AMELOBLASTOMA
2. UNICYSTIC AMELOBLA...
CONVENTIONAL
TYPE
Arise from de
novo/pre existing
unicystic type.
85% - in mandible
60% - in molar
region

UNICYSTIC TYPE
...
ALVEOLAR ABSCESS
Arises as a result of
infection following carious
involvement of the tooth &
Pulp infection.
► Tends to b...
OSTEOMYELITIS OF JAW

Acute form :

Is a serious sequela of
periapical infection that often results in a
diffuse spread of...
CHRONIC OSTEOMYLITIS

► Represents

the proliferative reaction of the
bone to a low-grade infection
► Pain & swelling are ...
CLINICOPATHOLOGIC SUBTYPES
1.Chronic Osteomyelitis with periostitis
‘garre’s osteomylitis’ :
► In more active lesions bony...
2.CHRONIC DIFFUSE
SCLEROSING OSTEOMYLITIS
:
► Cause

appear to be
related to low grade
bacterial infection through
periodo...
3.Focal sclerosing
Osteomyelitis: [BONY
SCAR] Is a common focal
bone opacification seen in
relation to low grade
inflammat...
TUMORS OF THE JAW
►
►
►
►
►
►
►
►
►
►
►
►
►
►

Lymphoma
Hodgkins lymphoma
Pagets disease
Hemangioma
Centrl gaint cell gran...
LESION
osteosarcoma

Ewings sarcoma

C/F

X-ray

Mandible.Pain,paresth Penetration of
esia.
the tumor
outside the
Microsco...
Burkitts

High grade
Poorly
child hood
define
lymphoma
malignancy.co d
mmon in
radiolu
maxilla.Tumor cency
growth is
expre...
CYSTIC
HYGRO
MA
Is a
variety
of
lymphan
gioma.
Rhabdo
myoma.

Charec. By large ,deeply
located cyst like lymphatic
vessels...
HEMANGIOMA
Benign tumor of
bd.vessel.
Present as flat /raised
lesion appearing
red/purple.

When congenital on
skin called...
FIBRO-OSSEOUS LESIONS OF
JAW

www.indiandentalacademy.com
► OSSYFYING FIBROMA
► FIBROUS DYSPLASIA
► DESMOPLSTIC FIBROMA
► OSTEOBLASTOMA
► OSTEOMA
► TORUS
► EXOSTOSIS
www.indiandent...
Ossyfying
fibroma
(A benign
neoplasm of
bone )

Fibrous
dysplasia.
Gradual
displacement
of normal
bone by
fibrous
connecti...
EXOSTOSIS

Bilateral row of exophytic
bone along facial
surfaceof alveolar ridge
A reactive hyperplasia of
buccal cortical...
GAINT CELL LESIONS OF THE
JAW

www.indiandentalacademy.com
► CENTRAL GAINT CELL GRANULOMA
► ANEURYSMAL BONE CYST
► HYPERPARATHYROIDISM
► CHERUBISM
► LANGERHANS CELL DISEASE
► PAGET’...
LESION

CGCG

C/F

X-RAY

2/3 decade Uni/multilocular.cor
Mand. Ant. tex may be
thin/perforated
Portion.
Localised
expansi...
Aneurysmal
bone cyst.
Intra bony
accumulation
of the blood
filled spaces
surrounded
by reactive
C.T may be
due to

Common ...
Cherubism

Self limiting. Bilaterally
symmetrical painless
expansion & all 4
quadrants are affectd .
After puberty.
Typica...
PAGETS
DISEASE

R.L alterations follow. In early phase
By develop. Of
osteoclasts &
Intermixed radiopacity. capillaries
Sy...
Langerhans cell disease
►
►

►
►
►
►
►

Is proliferationof langerhans
Cells.
L.Cells have
immunosurvillance function
.Tumo...
►

Microscopically: Pale cells
with macrophage like
appearance dominate the
field. When process appears
near the apex of t...
► both

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

► Ultra

structure of tumor cells shows
n...
REFERENCES:
► Differential diagnosis - MOORE
► Atlas of oral& maxillofacial pathology

REGEZI,SCIUBBA,POGREL
► Atlas of Cl...
Thank you
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Leader in continuing dental education

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Differential diagnosis of head and neck swellings /certified fixed orthodontic courses by Indian dental academy

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Differential diagnosis of head and neck swellings /certified fixed orthodontic courses by Indian dental academy

  1. 1. Differential Diagnosis Of Swellings Of Head & Neck www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. The method of differential diagnosis was first suggested in use by Emil Kraepelin www.indiandentalacademy.com
  4. 4. 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
  5. 5. 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
  6. 6. NEED FOR DIFFERENTIAL DIAGNOSIS? ► Lesions of oral and perioral areas must be identified and characterized so that specific therapy can lead to elimination of the lesion. www.indiandentalacademy.com
  7. 7. ORDERLY STEPS TO IDENTIFY AND CHARECTERIZE THE LESION ► Health history ► History of the specific lesion ► Clinical examination ► Radiographic examination ► Laboratory examination ► Biopsy- If indicated. www.indiandentalacademy.com
  8. 8. Reason for Health History ? Two basic reasons : ► A pre-existing medical problem may affect or be affected by the surgeons treatment of the patient ► Lesion under investigation may be an oral manifestation of a systemic disease. www.indiandentalacademy.com
  9. 9. 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. www.indiandentalacademy.com
  10. 10. 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
  11. 11. 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
  12. 12. 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 www.indiandentalacademy.com
  13. 13. 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 nonpainful) ► DEGREE OF FIXATION (Movable/fixed) ► TEXTURE ( soft, hard/firm ) www.indiandentalacademy.com
  14. 14. 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
  15. 15. MID LINE SWELLINGS: From above downwards: In Sub Mental Region: ► Ludwig's Angina ► Enlarged sub mental lymph nodes ► Sublingual dermoid ► Lipoma www.indiandentalacademy.com
  16. 16. ► In Supra sternal Space of Burns : ► Retrosternal goitre ► Thymic swelling ► A dermoid cyst may appear anywhere in the midline. www.indiandentalacademy.com
  17. 17. COMMON MIDLINE SWELLINGS ► Thyroid Swellings ► Ludwig's Angina ► Enlarged Lymph node ► Thyroglossal cyst Dermoid Cyst ► Lipoma ► www.indiandentalacademy.com
  18. 18. 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
  19. 19. 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 www.indiandentalacademy.com enormous
  20. 20. 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, www.indiandentalacademy.com later on auricular fibrillation and heart failure may
  21. 21. 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
  22. 22. 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
  23. 23. 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 www.indiandentalacademy.com Mediastinitis,Sub phrenic abscess ►
  24. 24. 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. www.indiandentalacademy.com
  25. 25. ► 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 ►A 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
  26. 26. 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
  27. 27. DERMOID CYST ► 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. www.indiandentalacademy.com
  28. 28. 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
  29. 29. LATERAL SWELLINGS: According to their sites may be divided in to ► Sub mandibular Triangle ► Carotid Triangle ► Posterior Triangle www.indiandentalacademy.com
  30. 30. SUBMANDIBULAR TRAINGLE ► Enlarged lymph nodes ► Enlargement of submandibular salivary gland ► Deep / Plunging ranula ► Extension of growth from the jaw ► Sjogren’s syndrome www.indiandentalacademy.com
  31. 31. 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 www.indiandentalacademy.com
  32. 32. POSTERIOR TRIANGLE ► Enlarged supraclavicular lymph nodes ► Cystic Hygroma ► Pharyngeal pouch ► Sub clavian aneurysm ► Lipoma [Dercum’s Disease] www.indiandentalacademy.com
  33. 33. SWELLINGS WHICH MAY OCCUR ANY WHERE IN NECK ► Sebaceous cyst ► Lymph node swellings ► Thyroid enlargement ► Branchial cyst ► Lipoma www.indiandentalacademy.com
  34. 34. COMMON LATERAL SWELLINGS ►Lymph node swelling ►Thyroid Swelling ►Salivary gland enlargement ►Branchial cyst www.indiandentalacademy.com
  35. 35. SWELLINGS OF SALIVARY GLANDS www.indiandentalacademy.com
  36. 36. 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. www.indiandentalacademy.com
  37. 37. ► 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. www.indiandentalacademy.com
  38. 38. 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. www.indiandentalacademy.com
  39. 39. ► ► ► 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. www.indiandentalacademy.com
  40. 40. 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
  41. 41. 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
  42. 42. 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 ) www.indiandentalacademy.com
  43. 43. 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
  44. 44. 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 www.indiandentalacademy.com transformation
  45. 45. 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
  46. 46. 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
  47. 47. ► ► ► The characteristic “SWISS CHEESE” patterns that characterizes this lesion may be a very prominent one. Diagnostic microscopic feature: Cribriform,tubular,trabe cular,&solid patterns,areas showing distinct & separate[ cookie cutter] islands of tumor. www.indiandentalacademy.com
  48. 48. Swellings of jaws Arising from mucoperiosteum : Granulomatous,Fibrous,Sarcomatous& Carcinomatous Arising from tooth germs: ► ODONTOMES:Dental cyst,Dentigerous cyst,Adamantinoma ► Osseous Tumors Inflammatory Group: Alveolar abscess,Osteomyelitis,Actinomycosis etc. www.indiandentalacademy.com
  49. 49. COMMON JAW SWELLINGS : ► Dentigerous cyst ► Dental cyst ► Adamantinoma ► Alveolar abscess ► Osteomyelitis ► Giant –cell granuloma www.indiandentalacademy.com
  50. 50. 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. www.indiandentalacademy.com ► X-RAY: Always radiolucent and unilocular. ►
  51. 51. 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
  52. 52. ► Age AMELOBLASTOMA 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 www.indiandentalacademy.com
  53. 53. ► 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. www.indiandentalacademy.com
  54. 54. THREE TYPES BASED ON CLINICAL RADIOGRAPHIC& HISTOPATHOLOGIC APPERARENCES. CONVENTIONAL AMELOBLASTOMA 2. UNICYSTIC AMELOBLASTOMA 3. PERIPHERL[EXTRAOSSEOUS] 1. www.indiandentalacademy.com
  55. 55. CONVENTIONAL TYPE Arise from de novo/pre existing unicystic type. 85% - in mandible 60% - in molar region UNICYSTIC TYPE Second/third decade. Pain less, Slow growing which are asymptomatic unless reach large size. Multilocular R.lucency. Painless Swelling of bone is the presenting feature.Buccal& lingual cortical expansion is common HONEY COOMB – When loculations are small. Well defined margins Can not be differentiated from Dentigerous cyst/OKC.Definitive diagnosis requires correlation of clinical finding of a cyst at the www.indiandentalacademy.com time of surgery SOAP BUBBLE-When loculations are large Typically shows unilocular R.L associated with crown of unerrupted tooth.
  56. 56. 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 ►
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. 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. www.indiandentalacademy.com
  61. 61. 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. ► Also seen after healing of an extraction socket www.indiandentalacademy.com
  62. 62. 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 www.indiandentalacademy.com
  63. 63. LESION osteosarcoma Ewings sarcoma C/F X-ray Mandible.Pain,paresth Penetration of esia. the tumor outside the Microscopic D.D: cortex results CGCG. in “SUN BURST" pattern of bone formation Facial neuralgia, lip Laminated paresthesia .Bones periosteal involved : long hyperplasia of bones,skull,pelvic cortical bone girdle. may be assoc. overlying with significant tumor bed necrosis shows ‘ONION and confused with SKINNING’ www.indiandentalacademy.com inflammatory process appear. HISTOLO G Diagnosis require presence of atypical cells in association with immature haphazardly distributed calcifies osteoid Demonstration of MIC-2 gene product with o13A antibody can be an diagnostic tool
  64. 64. Burkitts High grade Poorly child hood define lymphoma malignancy.co d mmon in radiolu maxilla.Tumor cency growth is expressed in jaws with pain &paresthesia, abdomen&retr operitonium,ab Multiple myloma domen Charect. Multiple sharply marginated punched out lesion with pain &some www.indiandentalacademy.com times 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 (Bence-Jones
  65. 65. CYSTIC HYGRO MA Is a variety of lymphan gioma. Rhabdo myoma. Charec. By large ,deeply located cyst like lymphatic vessels.pressure effects are not uncommon. Common in pharynx,larynx, and grow considerable size.fetal rhabd. Occurs in children and common on face & pre auricular region www.indiandentalacademy.com Histology: Circum. Mass of cells with eosinophillic cytplasm is charec.`
  66. 66. HEMANGIOMA Benign tumor of bd.vessel. Present as flat /raised lesion appearing red/purple. When congenital on skin called BIRTH MARKsize:1cm – severe disfigurement Size:1cm-severe disfigurement. Are often asymptomatic but exhibit hemorrhage when traumatized www.indiandentalacademy.com
  67. 67. FIBRO-OSSEOUS LESIONS OF JAW www.indiandentalacademy.com
  68. 68. ► OSSYFYING FIBROMA ► FIBROUS DYSPLASIA ► DESMOPLSTIC FIBROMA ► OSTEOBLASTOMA ► OSTEOMA ► TORUS ► EXOSTOSIS www.indiandentalacademy.com
  69. 69. Ossyfying fibroma (A benign neoplasm of bone ) Fibrous dysplasia. Gradual displacement of normal bone by fibrous connective tissue &structurally weak fibrillar Molar ramus region.More common in women.A well circumscribed lesion with distinct margins. Radiolucent 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 unilateral swelling & is ground glass asymptomatic.Invol. of appear. cranial ostia may cause nasal seen best www.indiandentalacademy.com obstruction,sinusitis,hea in occlusal ring&visual It is sharply demarcated from surrounding bone.promin ant osteoblast rimming the new bone
  70. 70. 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 Microscopic ally:Dense hyperplastic cortical type bone. Develops in second decade of life www.indiandentalacademy.com Asymptomatic unless
  71. 71. GAINT CELL LESIONS OF THE JAW www.indiandentalacademy.com
  72. 72. ► CENTRAL GAINT CELL GRANULOMA ► ANEURYSMAL BONE CYST ► HYPERPARATHYROIDISM ► CHERUBISM ► LANGERHANS CELL DISEASE ► PAGET’S DISEASE www.indiandentalacademy.com
  73. 73. LESION CGCG C/F X-RAY 2/3 decade Uni/multilocular.cor Mand. Ant. tex may be thin/perforated Portion. Localised expansion of the affected bone MICROSCOPIC D.D :Aneurysmal bone cyst, Cherubism,osteosa rcoma with gaint cells., Hyperparthyroidism . www.indiandentalacademy.com HISTOLO GY Stroma may be fibrotic.New bone may be present,esp. at the peripheryRe cent/old hemorrhage is typically found.
  74. 74. 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. www.indiandentalacademy.com
  75. 75. 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. www.indiandentalacademy.com Charec.” Soap Bubble” appeara nce. Distinctive perivascul ar cuffing of collagen may be seen around cappilarie s D.D : CGCG
  76. 76. PAGETS DISEASE R.L alterations follow. In early phase By develop. Of osteoclasts & Intermixed radiopacity. capillaries Symmetric dominate.End stage maxillary Exibits charec. is densly sclerotic and enlargement COTTON WOOL exhibits a mosaic pattern. LOINLIKE pattern that reflects FACE.Non-fitting Hypercementosis remodelling process. dentures. /resorption may be seen. Lab Feat: Elevated serum alik.phosp.,& Urinary hydroxyproline levels but calcium & phos. Levels are www.indiandentalacademy.com
  77. 77. 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
  78. 78. ► 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. ► The normal cellular counter parts to these tumor cells are found among prickle cells. www.indiandentalacademy.com
  79. 79. ► both normal lang. cells and tumor cells are negative for macrophage antigens ► Ultra structure of tumor cells shows numerous langerhans/BIRBECK granules that characterizes normal langerhans cell . www.indiandentalacademy.com
  80. 80. 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
  81. 81. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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