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ESSAY ANSWERS - ORAL PATHOLOGY (As per Shafer's)

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Q1. Categorize Cysts of Odontogenic Origin. Discuss Etiology, Clinical, Radiographic, Histopathologic Features, Treatment, and Prognosis of Odontogenic Keratocyst (OKC)

Classification of Odontogenic Cysts

1. Dentigerous cyst (Follicular cyst)
2. Odontogenic keratocyst (OKC) / Primordial cyst
3. Lateral periodontal cyst
4. Gingival cyst of adult
5. Gingival cyst of newborn (Epstein's pearls, Bohn's nodules)
6. Eruption cyst
7. Calcifying odontogenic cyst (Gorlin cyst)
8. Glandular odontogenic cyst (Sialo-odontogenic cyst)

1. Radicular cyst (Apical periodontal cyst) - most common jaw cyst
2. Residual cyst
3. Paradental cyst (Inflammatory collateral cyst)
4. Buccal bifurcation cyst

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Odontogenic Keratocyst (OKC)

Etiology

• OKC arises from the cell rests of the dental lamina (remnants of Serres)
• May also arise from basal cells of the oral epithelium
• PTCH1 gene mutation (tumor suppressor gene on chromosome 9q) is implicated - the same gene mutated in Gorlin-Goltz syndrome (Nevoid Basal Cell Carcinoma Syndrome / NBCCS)
• Multiple OKCs are a hallmark of Gorlin-Goltz syndrome (along with bifid ribs, calcified falx cerebri, basal cell nevi)
• The WHO 2005 reclassified it as "Keratocystic Odontogenic Tumor (KCOT)" due to its aggressive neoplastic behavior, but the 2017 WHO classification reverted it back to OKC

Clinical Features

• Age: Peak incidence in 2nd-3rd decade; second smaller peak in 5th-6th decade
• Sex: Male predilection (M:F = 1.5:1)
• Site: Mandible >> Maxilla; Posterior mandible and ramus region (60-80%); Maxillary canine region in maxilla
• Symptoms: Usually asymptomatic in early stages; later causes painless swelling; may present as pain if infected; expands buccal cortex more than lingual
• Growth pattern: Grows anteroposteriorly within the medullary cavity with minimal cortical expansion - a distinguishing feature
• Multiple OKCs: In Gorlin-Goltz syndrome (autosomal dominant); associated features - bifid ribs, calcification of falx cerebri, frontal bossing, hypertelorism, basal cell carcinomas of skin
• Perforates the cortex at a later stage; may perforate into soft tissue
• Discharge of creamy white cheesy keratin material is characteristic
• High recurrence rate compared to other jaw cysts

Radiographic Features

• Unilocular (early/small lesion) or multilocular radiolucency (scalloped margins in larger lesions)
• Well-defined corticated (sclerotic) borders
• Grows in the anteroposterior direction within bone (important distinguishing feature from dentigerous cyst and ameloblastoma)
• Scalloped margins - due to finger-like extensions of the cyst lining
• Can be associated with an impacted tooth (resembling dentigerous cyst) or can be pericoronal
• Displacement of adjacent teeth rather than resorption of roots (root resorption is minimal - unlike ameloblastoma)
• Septa may be present in multilocular lesions
• In Gorlin-Goltz syndrome, bilateral and multiple radiolucencies are seen

Histopathological Features

1. Epithelium: Thin, uniform, 6-8 cell layers thick, parakeratinized squamous epithelium (orthokeratin in 10% of cases)
2. Basal cell layer: Palisaded, hyperchromatic, cuboidal to columnar basal cells with reverse polarity nuclei - "tombstone" or "picket-fence" appearance (nuclei away from basement membrane - reverse polarization)
3. Lumen: Contains white/yellow keratin flakes or watery fluid (due to osmotic effects)
4. Epithelial surface: Corrugated (rippled/wavy) parakeratinized surface is characteristic
5. Absence of rete ridges - flat interface between epithelium and connective tissue
6. Satellite cysts (daughter cysts) - small islands of epithelium in the fibrous wall - contributes to recurrence
7. Budding of basal layer into the fibrous wall
8. Fibrous cyst wall: Thin, non-inflamed (unless secondarily infected); when infected, the characteristic epithelium may be lost
9. Mitotic activity: Higher than other odontogenic cysts - supports neoplastic behavior

Treatment

• Due to its tendency to recur, treatment is more aggressive than other cysts:

1. Enucleation with Carnoy's solution application - Carnoy's solution (3 parts absolute alcohol, 1 part chloroform, 1 part glacial acetic acid + ferric chloride) applied for 3 minutes to the bony cavity after enucleation; fixes residual epithelium
2. Enucleation with peripheral ostectomy (bur or bone files) - removes residual epithelium in bony margins
3. Marsupialization - for large cysts to reduce size before definitive surgery; however, marsupialisation alone has high recurrence
4. Resection (for recurrent lesions or Gorlin-Goltz associated OKCs) - ensures complete removal
5. Cryotherapy (liquid nitrogen) - after enucleation, applied to bony walls

Prognosis

• High recurrence rate: 25-60% - highest among all odontogenic cysts
• Reasons for recurrence:
  1. Thin, friable lining that tears easily during removal
  2. Satellite/daughter cysts in the fibrous wall
  3. Budding of basal cells
  4. PTCH1 mutation - inherent neoplastic potential
• Recurrences usually occur within 5 years but can occur up to 10 years later
• Multiple recurrences require resection
• Malignant transformation is rare but documented (0.4%)
• In Gorlin-Goltz syndrome, prognosis is more guarded due to multiple lesions and systemic associations

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Q2. Classify Benign and Malignant Epithelial Tumors. Describe Oral Squamous Cell Carcinoma (OSCC)

Classification of Epithelial Tumors of the Oral Cavity

1. Squamous cell papilloma
2. Keratoacanthoma
3. Verruca vulgaris (Oral wart)
4. Condyloma acuminatum
5. Focal epithelial hyperplasia (Heck's disease)
6. Leukoplakia (premalignant/benign lesion)

1. Squamous Cell Carcinoma (SCC) - most common (>90%)
2. Verrucous carcinoma (Ackermann's tumor)
3. Spindle cell carcinoma (Sarcomatoid SCC)
4. Adenosquamous carcinoma
5. Basaloid SCC
6. Lymphoepithelial carcinoma
7. Mucosal melanoma
8. Minor salivary gland carcinomas

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Oral Squamous Cell Carcinoma (OSCC)

Definition

Incidence

• Most common oral malignancy (>90% of oral cancers)
• Accounts for approximately 3% of all malignancies
• More common in males (M:F = 2:1 traditionally, but increasing in females)
• Peak incidence: 5th-7th decade, but rising incidence in young adults (HPV-related)
• India has one of the highest incidences globally, particularly of the buccal mucosa type

Etiology (Risk Factors)

1. Tobacco: Most important risk factor
   • Smoking (cigarettes, bidis, pipes) - 2-4x increased risk
   • Smokeless tobacco (snuff, chewing tobacco) - associated with buccal mucosa SCC
   • Synergistic effect with alcohol - risk multiplied (15x)
2. Alcohol: Independent risk factor; acts as a solvent enhancing mucosal penetration of carcinogens; also causes nutritional deficiencies
3. Betel quid/Areca nut: Major risk factor in South/Southeast Asia; arecoline has direct mutagenic effect
4. Solar radiation: For lip SCC (UV-B); lower lip >> upper lip
5. Chronic irritation: Ill-fitting dentures, sharp teeth (debatable as independent factor)
6. Nutritional deficiencies: Iron deficiency (Plummer-Vinson syndrome), vitamin A and B complex deficiency

1. Human Papillomavirus (HPV): HPV-16 and HPV-18 - especially for oropharyngeal and tongue SCC in non-smokers; E6 oncoprotein inactivates p53; E7 inactivates Rb
2. Candida albicans: Chronic hyperplastic candidiasis may undergo malignant transformation
3. Herpes Simplex Virus (HSV): Proposed role, less established
4. Syphilis: Formerly implicated in tongue SCC

1. Immunosuppression (organ transplant recipients)
2. Genetic predisposition (Li-Fraumeni syndrome, Fanconi anemia)
3. Xeroderma pigmentosum (lip SCC)

1. Leukoplakia (especially non-homogeneous/erythroleukoplakia)
2. Erythroplakia - highest malignant potential (40-50%)
3. Oral submucous fibrosis
4. Oral lichen planus (erosive type)
5. Actinic cheilitis (lip)
6. Chronic discoid lupus erythematosus

Clinical Features

1. Lower lip (most common in Western countries - sun exposure)
2. Lateral border and ventral surface of tongue
3. Floor of mouth
4. Buccal mucosa (most common in India due to tobacco/betel chewing)
5. Gingiva and alveolar ridge
6. Soft palate and oropharynx
7. Hard palate (least common intraoral site)

1. Early lesion: May be asymptomatic; appears as a white patch (leukoplakia), red patch (erythroplakia), or mixed lesion; small ulcer or induration
2. Classic lesion:
   • Ulcer with indurated (raised, rolled, everted) borders - most characteristic
   • Hard, firm base on palpation
   • Surrounding erythema
   • Tendency to bleed on touch
3. Growth patterns:
   • Exophytic - fungating, cauliflower-like mass
   • Endophytic - ulcerative, infiltrative growth; worse prognosis
   • Verrucous - warty, white, slow-growing
4. Symptoms: Pain (not always early), dysphagia, dysarthria, trismus (if masticatory muscles involved), paraesthesia/anesthesia (nerve involvement - poor prognostic sign)
5. Lymph node involvement: Cervical lymphadenopathy; nodes become hard, fixed, matted in advanced disease
6. TNM Staging:
   • T1: ≤2 cm, DOI ≤5mm
   • T2: ≤2 cm DOI 5-10mm, or 2-4 cm DOI ≤10mm
   • T3: >4 cm or any size with DOI >10mm
   • T4: Very advanced local disease, invasion of adjacent structures

Histopathological Features

1. Invasive islands, nests, and cords of squamous epithelium breaching the basement membrane
2. Cell features:
   • Large cells with abundant eosinophilic cytoplasm
   • Pleomorphism, hyperchromatism
   • Abnormal mitotic figures
   • Intercellular bridges (desmosomal connections) - important feature of SCC
3. Keratin pearl (Epithelial pearl / Cell nest): Concentric whorls of squamous cells with central keratin - characteristic of well-differentiated SCC
4. Individual cell keratinization
5. Inflammatory infiltrate in adjacent stroma (lymphocytes, plasma cells) - may indicate immune response
6. Desmoplastic stroma - fibrous stroma surrounding invasive nests (poor prognostic feature)
7. Perineural invasion and vascular/lymphatic invasion - poor prognostic indicators

• Grade I (Well differentiated): >75% differentiated cells; abundant keratin pearls; mild pleomorphism
• Grade II (Moderately differentiated): 50-75% differentiated; fewer keratin pearls; moderate pleomorphism
• Grade III (Poorly differentiated): 25-50% differentiated; rare/absent keratin pearls; marked pleomorphism; numerous mitoses
• Grade IV (Anaplastic/Undifferentiated): <25% differentiated; no keratin; marked nuclear atypia

Treatment

1. Surgery: Wide local excision with clear margins (>1cm); neck dissection for nodal disease
2. Radiotherapy: Definitive or adjuvant; brachytherapy for accessible small lesions
3. Chemotherapy: Cisplatin-based; concurrent chemoradiation for advanced disease
4. Targeted therapy: Cetuximab (anti-EGFR)
5. Immunotherapy: Pembrolizumab, nivolumab (PD-1 inhibitors) for recurrent/metastatic disease

Prognosis

• Overall 5-year survival: approximately 50-60% (all stages combined)
• Stage I: ~80-90%; Stage IV: ~30%
• Lip SCC: Better prognosis (~90% 5-year survival)
• Floor of mouth, tongue: Worse prognosis due to early lymphatic spread
• Poor prognostic indicators: perineural invasion, lymphovascular invasion, positive margins, extranodal extension, DOI >10mm, high Broders grade

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Q3. Classify Fibro-Osseous Lesions. Describe Fibrous Dysplasia

Classification of Fibro-Osseous Lesions

1. Fibrous Dysplasia (Monostotic, Polyostotic, McCune-Albright syndrome)
2. Cemento-osseous dysplasia: a. Periapical cemento-osseous dysplasia (Periapical cemental dysplasia) b. Focal cemento-osseous dysplasia c. Florid cemento-osseous dysplasia (Gigantiform cementoma) d. Familial gigantiform cementoma

1. Ossifying fibroma (cemento-ossifying fibroma)
2. Juvenile ossifying fibroma: a. Juvenile trabecular ossifying fibroma b. Juvenile psammomatoid ossifying fibroma

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Fibrous Dysplasia

Definition

Etiology / Etiopathogenesis

• Somatic (post-zygotic) activating mutation of the GNAS1 gene (on chromosome 20q13.2) encoding the Gs-alpha protein (alpha subunit of stimulatory G protein)
• The mutation (most commonly R201H or R201C) causes constitutive activation of adenylyl cyclase → elevated cAMP → abnormal differentiation of osteogenic precursor cells
• Results in increased proliferation of immature fibroblasts and failure of proper bone maturation
• Because it is a somatic (not germline) mutation, severity depends on when during embryogenesis the mutation occurs - early mutations = polyostotic, late = monostotic
• In McCune-Albright syndrome, the same GNAS1 mutation is present in multiple tissues (bone, skin, endocrine glands)

1. Monostotic fibrous dysplasia: Single bone involved (70-80% of cases); any bone; jaw involvement = monostotic
2. Polyostotic fibrous dysplasia: Multiple bones involved; unilateral > bilateral
3. Craniofacial fibrous dysplasia: Multiple craniofacial bones (variant of polyostotic)
4. McCune-Albright Syndrome (Polyostotic + Café-au-lait pigmentation + endocrine dysfunction): Precocious puberty (in females), hyperthyroidism, GH excess, Cushing syndrome

Clinical Features

• Age: Children and adolescents; onset typically in first two decades; lesions may stabilize after puberty (skeletal maturity)
• Sex: Equal sex distribution for monostotic form; slight female predilection for polyostotic
• Site: Maxilla (more common than mandible) in jaw involvement; posterior maxilla involved most often; maxillary lesions can be dramatic causing facial deformity
• When the maxilla is involved: may expand into orbit, nasal cavity, and zygoma - called "leontiasis ossea" (lion-like face) in severe cases
• Symptoms:
  • Painless, slow, progressive expansion of the affected bone
  • Facial asymmetry and swelling
  • Bony hard consistency
  • Displacement of teeth (not loosening) but tooth vitality maintained
  • When orbit involved: proptosis, diplopia
  • When temporal bone/skull base involved: cranial nerve compression → visual loss (optic nerve), hearing loss
  • Pain is uncommon unless fracture occurs
• Café-au-lait pigmentation: Brown skin macules with irregular "coast of Maine" borders (c.f. neurofibromatosis - smooth "coast of California" borders); typically ipsilateral to bone lesions in polyostotic form; present in McCune-Albright

Radiological Features

1. "Ground glass" or "orange peel" or "frosted glass" appearance - most characteristic; due to irregular trabeculae within fibrous stroma replacing the normal trabecular pattern
2. Ill-defined borders blending imperceptibly with adjacent normal bone (no sclerotic border) - distinguishes it from ossifying fibroma
3. Cortical thinning and expansion but cortex usually intact (unless fracture)
4. "Bowing" deformities of long bones ("shepherd's crook deformity" of femur in polyostotic)
5. In the jaw:
   • Homogeneous ground-glass opacity
   • Expands cortical plate
   • Widens the periodontal ligament space at base of roots
   • May displace inferior dental canal (mandible)
   • May cause obliteration of maxillary sinus
6. Three radiological patterns described by Edeiken et al.:
   • Pagetoid (most common): Mixture of radiolucent and radiopaque areas ("cotton wool")
   • Sclerotic: Dense ground-glass opacification
   • Cystic: Single large radiolucent area with thin rim of sclerosis

Histopathological Features

1. Cellular fibrous stroma: Composed of bland spindle fibroblasts arranged in loose whorled pattern (storiform pattern)
2. Irregular woven (immature) bone trabeculae within the fibrous stroma - characteristically described as:
   • "Chinese letters" or "alphabet soup" or "Chinese script" pattern - most characteristic description (Shafer's)
   • The trabeculae are thin, curvilinear, and randomly oriented
   • Lack of osteoblastic rimming (osteoblasts absent at the periphery of trabeculae) - distinguishes from ossifying fibroma where osteoblastic rimming is present
3. Osteoblasts absent at the periphery - the trabeculae appear to arise directly from the fibrous stroma ("woven bone arising directly from fibrous tissue")
4. Cartilage islands may be present (5-10%)
5. Cystic degeneration and areas of hemorrhage may occur in larger lesions
6. No capsule - fibrous tissue merges with normal adjacent bone

• Osteoblastic rimming present
• Well-defined capsule/border
• More spherical calcifications (psammoma-like)
• Tends to be solitary and well-demarcated radiographically

Treatment

• Conservative approach is preferred; most lesions stabilize after puberty
• Surgical recontouring (cosmetic osseous surgery) for cosmetically disfiguring or functionally compromising lesions
• Surgery should ideally be deferred until after skeletal maturity (to avoid recurrence)
• Bisphosphonates (pamidronate, zoledronic acid) - reduces pain and may slow progression; useful in polyostotic/severe forms
• Do not irradiate - radiation increases risk of sarcomatous transformation
• In McCune-Albright syndrome, treat the associated endocrine abnormalities

Prognosis

• Monostotic form: Good; lesions typically stabilize at puberty
• Polyostotic form: More unpredictable; recurrences after surgery more common
• Malignant transformation is rare (< 1%) but documented; risk increases with radiation therapy
• Malignant transformation produces osteosarcoma, fibrosarcoma, or chondrosarcoma at the site

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Q4. Classify Odontogenic Cysts. Describe Clinical and Histopathological Features of Calcifying Epithelial Odontogenic Cyst (CEOC)

Classification of Odontogenic Cysts

1. Dentigerous cyst
2. Odontogenic Keratocyst (OKC)
3. Lateral periodontal cyst / Botryoid odontogenic cyst
4. Gingival cyst of adult / Gingival cyst of newborn
5. Eruption cyst
6. Calcifying Epithelial Odontogenic Cyst (CEOC / Gorlin cyst)
7. Glandular odontogenic cyst

1. Radicular cyst (Periapical cyst) - most common
2. Residual cyst
3. Paradental cyst / Inflammatory collateral cyst
4. Buccal bifurcation cyst

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Calcifying Epithelial Odontogenic Cyst (CEOC) / Gorlin Cyst

Introduction

• Described by Gorlin et al. in 1962 (hence "Gorlin cyst")
• Also called Calcifying Ghost Cell Odontogenic Cyst (CGCOC)
• WHO 2005 reclassified it as "Calcifying Cystic Odontogenic Tumor (CCOT)" due to neoplastic features; but the 2017 WHO classification retained it in the cyst category as CEOC
• It represents a spectrum from simple cysts to solid tumors
• Considered an odontogenic counterpart of calcifying odontogenic cyst of skin (craniopharyngioma analog)

Clinical Features

• Age: Wide age range (2nd-3rd decade most common); bimodal distribution
• Sex: No significant sex predilection (slight female predilection in some series)
• Site:
  • Maxilla = Mandible (approximately equal)
  • Anterior jaw (incisor-canine region) more commonly involved
  • About 20% occur as peripheral (extraosseous) lesions - on the gingiva
• Presentation:
  • Intraosseous form: Painless bony swelling with cortical expansion
  • Peripheral form: Painless gingival swelling, sessile mass
  • Associated with impacted teeth or odontoma in about 30% of cases
  • Generally asymptomatic
• Variants (Praetorius classification):
  1. Simple cystic type (most common)
  2. Odontoma-associated cystic type (with odontoma)
  3. Ameloblastomatous proliferating cystic type
  4. Solid/Neoplastic type (Dentinogenic ghost cell tumor)

Radiographic Features

• Unilocular radiolucency - well-defined, corticated borders
• Calcifications within the radiolucency - varying sizes, from tiny flecks to large irregular masses - pathognomonic
• May be associated with an unerupted tooth crown (similar to dentigerous cyst)
• Associated odontoma may be seen as radiopaque structures within or adjacent to the lesion
• Cortical expansion; root resorption/displacement of adjacent teeth may occur

Histopathological Features

1. Cyst lining epithelium:
   • Odontogenic epithelium with ameloblast-like cells (tall columnar cells) in the basal layer
   • Stellate reticulum-like areas above the basal layer
   • Resembles reduced enamel epithelium / ameloblastic epithelium
2. Ghost cells (most characteristic feature):
   • Eosinophilic, anucleate, shadow cells within the epithelium
   • These are cells that have undergone aberrant keratinization and calcification
   • The nuclei are absent or appear as faint outlines ("ghost" of the nucleus)
   • Ghost cells may calcify (dystrophic calcification) - appears as basophilic amorphous material
   • This is the hallmark of the lesion - "ghost cell keratinization" or "shadow cells"
3. Dentinoid material: May be seen adjacent to the ghost cell areas - the epithelium can induce dentin-like material in the adjacent connective tissue stroma
4. Fibrous cyst wall containing variable inflammatory infiltrate
5. Foreign body giant cell reaction around ghost cells and calcifications - this creates a granulomatous response
6. In the ameloblastomatous variant: Areas resembling ameloblastoma are present within the epithelium

Treatment

• Enucleation and curettage
• Peripheral lesions: simple excision
• Recurrence is low for cystic types (~2-5%)
• The dentinogenic ghost cell tumor (solid/neoplastic form) may require more aggressive treatment with wider resection

Prognosis

• Generally good for the simple cystic type
• Rare recurrences
• Malignant transformation (Ghost cell odontogenic carcinoma) is extremely rare

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Q5 & Q6 & Q7 & Q10. Classify Odontogenic Tumors. Describe Ameloblastoma

Classification of Odontogenic Tumors (WHO 2017)

1. Ameloblastoma (conventional)
2. Ameloblastoma, unicystic
3. Ameloblastoma, extraosseous/peripheral
4. Metastasizing (malignant) ameloblastoma
5. Squamous odontogenic tumor
6. Calcifying epithelial odontogenic tumor (Pindborg tumor)
7. Adenomatoid odontogenic tumor (AOT)

1. Ameloblastic fibroma
2. Primordial odontogenic tumor
3. Odontoma (compound and complex)
4. Dentinogenic ghost cell tumor

1. Odontogenic fibroma
2. Odontogenic myxoma/myxofibroma
3. Cementoblastoma

1. Ameloblastic carcinoma
2. Primary intraosseous squamous cell carcinoma
3. Sclerosing odontogenic carcinoma
4. Clear cell odontogenic carcinoma
5. Ghost cell odontogenic carcinoma
6. Odontogenic carcinosarcoma
7. Odontogenic sarcomas

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AMELOBLASTOMA

Definition

Incidence and Frequency

• Most common clinically significant odontogenic tumor (~1% of all oral tumors)
• About 95% of odontogenic tumors are benign; ameloblastoma is the most important of the benign ones
• BRAF V600E mutation (in the MAPK pathway) found in >70% of mandibular ameloblastomas; FGFR2 and SMO mutations in maxillary tumors

Types of Ameloblastoma

• Age: Usually after 20 years; peak in 3rd-4th decade
• Sex: Equal or slight male predilection
• Site: Mandible 85% >> Maxilla 15%; Posterior mandible (molar-ramus region) most common site; in maxilla: posterior region
• Presentation:
  • Slow, painless expansion of the jaw - most common initial presentation
  • Gradual facial asymmetry and swelling
  • May have buccal and lingual cortical plate expansion with characteristic "eggshell crackling" sensation on pressure (parchment crackling)
  • Teeth become displaced but remain vital
  • Pain and paraesthesia if large or secondarily infected
  • Late presentation may show obvious facial disfigurement
  • No discharge (c.f. OKC - keratin discharge)

1. Multilocular radiolucency - "soap bubble" or "honeycomb" appearance - MOST CHARACTERISTIC of conventional ameloblastoma
2. Alternatively, unilocular pattern in smaller or early lesions
3. Well-demarcated borders with sclerotic rim (but this may be lost in aggressive lesions)
4. "Tennis racquet" or "windshield wiper" pattern - individual loculi of different sizes separated by bony septa
5. Marked root resorption - a key feature distinguishing from OKC (OKC causes root displacement, ameloblastoma causes resorption)
6. Cortical thinning and perforation in large lesions
7. Scalloped margins due to differential expansion
8. Association with impacted tooth (especially mandibular 3rd molar) - "dentigerous" type
9. Bayonet deformity of roots (knife-blade resorption)

1. Peripheral tall columnar cells (ameloblast-like) with reversed polarization (nuclei polarized away from the basement membrane - stellate reticulum side - opposite to normal ameloblasts) = "reverse polarization" - MOST IMPORTANT DIAGNOSTIC FEATURE
2. Central stellate reticulum-like cells (loose, angular/stellate cells resembling stellate reticulum of enamel organ)
3. Subnuclear vacuolization in peripheral cells

1. Follicular pattern: (Most common variant)
   • Islands of odontogenic epithelium surrounded by fibrous stroma
   • Peripheral columnar cells enclosing central stellate reticulum-like cells
   • Central cells may undergo cystic degeneration - forms "mural cysts" within islands
2. Plexiform pattern: (Second most common)
   • Anastomosing cords and strands of epithelium in a network pattern
   • Double layer of tall columnar cells (ameloblast-like) at periphery
   • Stroma often loose, myxoid with edema/hemorrhage ("plexiform ameloblastoma bleeds easily")
3. Acanthomatous pattern:
   • Central cells show squamous metaplasia with keratin formation
   • No keratin pearls (unlike SCC)
   • Peripheral columnar cells still present
4. Granular cell pattern:
   • Central cells transformed into large cells with coarse granular eosinophilic cytoplasm (lysosomes)
   • Resembles granular cell tumor; most aggressive behavior
5. Desmoplastic pattern:
   • Dense collagenous fibrous stroma compressing epithelial islands
   • Islands may be small and compressed; cells may not show classic features
   • Often shows mixed radiographic appearance (mixed radiolucent-radiopaque)
   • More commonly in anterior jaw; can be confused with fibro-osseous lesions
6. Basal cell pattern:
   • Resembles basal cell carcinoma of skin
   • Nests of dark-staining basaloid cells; least common variant

• Younger age group (2nd decade); M:F = 1.6:1
• Mandible (posterior) >> Maxilla
• Associated with impacted mandibular 3rd molar in 50-80% of cases
• Clinically and radiographically mimics dentigerous cyst
• Much better prognosis than conventional ameloblastoma

• Well-demarcated, unilocular radiolucency
• Usually associated with crown of unerupted tooth (pericoronal)
• Smooth corticated borders
• Less aggressive than conventional form

1. Luminal UAM: Ameloblastoma confined to the luminal surface (cyst lining); best prognosis
2. Intraluminal UAM: Ameloblastoma nodule projecting into the cyst lumen; good prognosis
3. Mural UAM: Ameloblastoma infiltrating into the cyst wall; worse prognosis; behaves like conventional ameloblastoma

• Arises in the gingival soft tissue
• Clinically: Sessile or pedunculated gingival mass; normal overlying mucosa
• Does not invade underlying bone (may cause superficial erosion)
• Excellent prognosis; local excision sufficient

Note on Malignant Ameloblastoma (Q7 addition):

• Defined as an ameloblastoma that metastasizes despite having histologically benign/low-grade features
• The primary and metastatic lesion both appear benign histologically
• Distinguished from Ameloblastic Carcinoma (which shows cytologic atypia)
• Metastasis: Most common site is lung, followed by lymph nodes, liver, bone
• Route: Usually hematogenous; also lymphatic
• Mechanism of metastasis unclear - possibly aspiration of tumor particles during surgery, or true hematogenous spread
• Prognosis: Poor; treatment depends on stage (surgery, radiation, targeted therapy with BRAF inhibitors if MAPK mutation confirmed)
• Not to be confused with ameloblastic carcinoma (which has cytologic malignancy)

Treatment of Ameloblastoma

1. Resection with 1 cm beyond radiographic margins - gold standard for conventional ameloblastoma; prevents the most important complication: recurrence
2. Conservative treatment (enucleation, curettage) - only for luminal/intraluminal unicystic types; high recurrence rate (50-90%) for conventional form
3. Carnoy's solution application as adjunct after conservative surgery
4. Neck dissection if nodal involvement
5. Reconstruction with bone grafts or free flaps after resection
6. BRAF inhibitors (dabrafenib/vemurafenib) - for recurrent or unresectable tumors with confirmed BRAF V600E mutation

Prognosis

• Conventional ameloblastoma: Good with resection; recurrence rate ~15-25% with conservative treatment
• Unicystic type: Excellent if treated adequately (recurrence <5% with adequate resection)
• Malignant ameloblastoma: Fair to poor
• Regular radiographic follow-up is mandatory (annual for minimum 5 years)

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Q8 & Q9. Classify Odontogenic Tumors. Describe Adenomatoid Odontogenic Tumor (AOT)

ADENOMATOID ODONTOGENIC TUMOR (AOT)

Introduction

• First described by Steensland (1905) and characterized by Harbitz (1915)
• Previously called "adenoameloblastoma," "ameloblastic adenomatoid tumor," "pseudoadenoameloblastoma"
• Current term: Adenomatoid Odontogenic Tumor - coined by Philipsen and Birn (1969)
• Considered a hamartoma or a benign epithelial odontogenic tumor with limited growth potential
• Referred to as "Two-thirds tumor" - 2/3 occur in females, 2/3 in maxilla, 2/3 associated with unerupted canines, 2/3 in patients under 20 years

Etiopathogenesis

• Arises from odontogenic epithelium: reduced enamel epithelium, enamel organ, or dental lamina remnants
• The characteristic duct-like structures may represent attempts at tubular/enamel formation
• The calcifications represent enamel matrix or dentin-like material
• Classified as a benign tumor with no known malignant potential

Classification (Variants):

1. Follicular type (most common, ~70%): Entirely intraosseous; associated with the crown of an unerupted tooth (pericoronal); mimics dentigerous cyst
2. Extrafollicular type (~25%): Intraosseous but not associated with unerupted tooth; anterior jaw between or above tooth roots
3. Peripheral type (~5%): Extraosseous; on the gingiva; rare

Clinical Features

• Age: Most common in young patients under 20 years; peak 2nd decade (14-16 years); called "teenager's tumor" informally
• Sex: Strong female predilection (F:M = 2:1)
• Site:
  • Anterior maxilla >> posterior maxilla > anterior mandible (rare in posterior mandible)
  • The maxillary canine region is the most common specific site
  • Often associated with an unerupted maxillary canine
• Presentation:
  • Slow-growing, painless swelling
  • Asymptomatic for long periods
  • Gradual facial asymmetry
  • May prevent eruption of associated tooth
  • Never causes cortical perforation into soft tissue (unlike ameloblastoma)
  • Usually discovered on routine radiographic examination
• Consistency: Firm, bony hard
• Size: Generally small (1-3 cm)

Radiographic Features

1. Well-demarcated, unilocular radiolucency with sclerotic border
2. Associated with an unerupted tooth (usually canine) - the radiolucency extends from crown tip beyond the cementoenamel junction (beyond the CEJ) - distinguishes from dentigerous cyst (which extends from CEJ)
3. Calcifications within the radiolucency - small, snowflake-like, discrete calcifications scattered throughout the lesion - MOST IMPORTANT distinguishing feature from dentigerous cyst
4. May displace adjacent teeth and root divergence
5. Minimal root resorption
6. Usually small in size
7. "Flecks of snow in a snowstorm" - description of calcifications within the lesion

Histopathological Features

1. Capsule: Well-defined fibrous capsule (distinguishes from other odontogenic tumors)
2. Sheets and whorls of spindle-shaped and polygonal epithelial cells in a nodular pattern
3. Duct-like (rosette-like) structures - most characteristic feature; pseudoductal spaces lined by a single row of tall columnar epithelial cells with nuclei polarized away from the lumen; these structures are not true ducts but represent tumor cell arrangements
4. Eosinophilic amorphous material within duct-like spaces - represents enamel matrix-like material
5. Calcifications: Various types present:
   • Enamel matrix-like material
   • Dentinoid material
   • "Laminated calcifications" in concentric rings
   • Liesegang-ring-like calcifications
6. Fibrous stroma: Sparse; loose connective tissue
7. Anucleate ghost cells may be present (similar to CEOC)
8. Absence of stellate reticulum - distinguishes from ameloblastoma (which has stellate reticulum cells)
9. No reversal polarization - epithelial cells do not show the reverse polarization seen in ameloblastoma
10. Vascular channels present within the tumor

• AOT has no stellate reticulum
• AOT has duct-like structures
• AOT has calcifications
• AOT is well-encapsulated
• AOT cells do not show reverse polarization

Management

• Enucleation - conservative; the tumor is well-encapsulated and shells out easily
• The capsule facilitates easy removal
• Curettage of the bony cavity
• Prognosis: Excellent - recurrence is extremely rare
• No malignant transformation reported
• Associated impacted tooth may be retained if periodontally sound, or removed

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Q11. Classify Oral Potentially Malignant Disorders (OPMDs). Describe Oral Lichen Planus

Classification of OPMDs (WHO 2007 - van der Waal)

1. Leukoplakia (most common OPMD)
2. Erythroplakia (highest malignant potential)
3. Erythroleukoplakia / Leukoerythroplakia
4. Oral submucous fibrosis (OSMF)
5. Oral lichen planus (erosive/atrophic forms)
6. Actinic cheilitis/keratosis (of lip)
7. Palatal lesions in reverse smokers
8. Discoid lupus erythematosus

1. Dyskeratosis congenita
2. Fanconi anemia
3. Sideropenic dysphagia (Plummer-Vinson syndrome)

• Erythroplakia: 40-50% (highest)
• Leukoplakia: 0.13-6%
• Oral lichen planus: 0-10%
• OSMF: 7-30%

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ORAL LICHEN PLANUS (OLP)

Definition

Epidemiology

• Prevalence: 0.5-2% of the general population
• Age: Middle-aged adults (4th-6th decade); rarely in children
• Sex: Strong female predilection (F:M = 1.4:1 to 2:1)
• Oral manifestations may precede, coincide with, or follow skin lesions

Etiology and Pathogenesis

• Exact etiology unknown (idiopathic); T-cell mediated immune reaction
• Pathogenesis (Shafer's):
  1. Keratinocytes express altered self-antigens or foreign antigens on their surface
  2. This triggers activation of CD4+ T-helper cells and CD8+ cytotoxic T cells
  3. CD8+ cytotoxic T cells attack basal keratinocytes → basal cell apoptosis → Civatte body formation
  4. Dense subepithelial band of lymphocytes (predominantly CD8+) accumulates
  5. Matrix metalloproteinases (MMPs) disrupt the basement membrane
  6. Resulting epithelial damage leads to characteristic clinical appearances

1. Drugs: NSAIDs (aspirin), antihypertensives (beta-blockers, ACE inhibitors, methyldopa), antimalarials (chloroquine), gold salts, penicillamine, sulfonylureas - cause lichenoid drug reactions
2. Dental materials: Amalgam fillings (oral lichenoid reactions adjacent to restorations) - "contact hypersensitivity"
3. Stress and anxiety - may trigger or exacerbate
4. Systemic diseases: Hepatitis C virus infection (strong association), diabetes mellitus, primary biliary cirrhosis, primary sclerosing cholangitis, lupus erythematosus, Sjögren's syndrome
5. Local trauma - Koebner phenomenon (lesions appearing at sites of trauma)

• Hepatitis C (strong, especially in Mediterranean and Japanese populations)
• Primary biliary cirrhosis, primary sclerosing cholangitis
• Lupus erythematosus
• Sjögren's syndrome

Clinical Features

1. Reticular (most common):
   • Wickham's striae - interlacing white lines forming a lacy/net-like pattern
   • Usually asymptomatic or mild burning sensation
   • Most commonly on buccal mucosa bilaterally
   • May be surrounded by erythema
2. Papular:
   • Small, white/grey papules (pinhead-sized)
   • Often seen as a precursor or early form
   • Asymptomatic
3. Plaque-type:
   • Homogeneous white plaques resembling leukoplakia
   • Usually on buccal mucosa or dorsal tongue
   • Must be differentiated from leukoplakia (check for striae at periphery, bilateral nature)
4. Atrophic (Erythematous):
   • Atrophied, reddened epithelium with white striae at periphery
   • Painful, burning sensation
   • Gingival involvement = desquamative gingivitis (atrophic OLP on attached gingiva)
   • Higher malignant potential
5. Erosive/Ulcerative: (Most symptomatic - highest malignant potential)
   • Irregular, painful ulcers with yellowish pseudomembrane
   • Surrounded by white striae radiating peripherally
   • Resistant to healing; recurrent
   • On buccal mucosa, tongue, gingiva
   • Significant pain; burning; affects eating and QoL
   • Desquamative gingivitis - when gingiva involved (may also be pemphigoid)
6. Bullous:
   • Vesicles and bullae which rapidly rupture leaving erosions
   • Rare form; very painful
   • Must be distinguished from pemphigus and pemphigoid

• Violaceous, flat-topped papules with Wickham's striae on the surface
• Wrists (volar surface), ankles, lumbosacral region, genitalia
• Pruritic (itchy)

Histopathological Features

1. Hyperparakeratosis or Orthokeratosis (or rarely acanthosis) of the surface epithelium
2. Saw-tooth rete ridges - irregular, pointed downgrowths of the epithelium (though may be reduced in atrophic form)
3. Liquefactive (hydropic) degeneration of the basal cell layer - vacuolization and destruction of basal cells; the basal cells appear disrupted
4. Dense band-like infiltrate of lymphocytes (mainly T cells, predominantly CD8+) in the superficial lamina propria, just beneath the epithelium, hugging the basement membrane zone
5. Civatte bodies (colloid bodies / hyaline bodies): Round to oval eosinophilic bodies in the lower epithelium and superficial lamina propria; represent apoptotic/necrotic keratinocytes; specific but not pathognomonic
6. Max-Joseph spaces: Cleft-like separation between epithelium and lamina propria (due to basal cell degeneration); may lead to vesicle formation
7. Basement membrane zone: May show thickening and irregular deposits (eosinophilic band) due to fibrinogen deposition
8. No dysplasia in classic OLP (presence of dysplasia in OLP is controversial - some classify as "oral lichenoid dysplasia")

• Direct immunofluorescence (DIF): Fibrinogen deposits in the basement membrane zone (most common); also IgM deposits (as "Civatte bodies" stain for IgM); negative for IgG/IgA (unlike pemphigus/pemphigoid)
• Shaggy or granular fibrinogen deposits - characteristic

• "Compatible with OLP" if not all criteria met
• "OLP" if: bilateral lesions, characteristic striae, characteristic histopathology, DIF showing fibrinogen at BMZ

Malignant Transformation

• OLP has 0-10% risk of transformation to SCC
• Higher risk in: atrophic and erosive forms; tongue site; smoking patients
• Controversial - some argue that lesions that transform were actually oral lichenoid dysplasia initially
• WHO recommends monitoring all OLP patients every 6 months

Treatment

• No cure; symptomatic management

1. Topical corticosteroids (first line): Fluocinonide 0.05%, clobetasol propionate 0.05% (in Orabase); or steroid oral rinses (dexamethasone 0.1mg/5ml)
2. Systemic corticosteroids: For severe, recalcitrant, or widespread disease (prednisolone 40-60mg/day tapering)
3. Topical calcineurin inhibitors: Tacrolimus 0.1% ointment or pimecrolimus 1% cream - second line; note: black box warning for theoretical malignant potential
4. Topical retinoids: Isotretinoin gel - for plaque-type; less used
5. Hydroxychloroquine - for refractory cases
6. Dapsone, azathioprine, cyclosporine - for resistant disease
7. Identification and removal of triggering factors: Change amalgam fillings if contact lichenoid reaction; stop causative drugs
8. Hepatitis C treatment if associated
9. Supportive: Antifungal (secondary Candida overgrowth common with topical steroids), analgesics, dietary counselling

Prognosis

• Chronic, relapsing-remitting course
• No cure but symptoms can be controlled
• Malignant transformation: 0-10% (erosive form highest risk)
• Regular follow-up every 6 months is essential; biopsy any suspicious changes

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Q12. Classify Salivary Gland Tumors. Write in Detail about Aetiopathogenesis, Clinical Features, and Histopathological Features of Mucoepidermoid Carcinoma

Classification of Salivary Gland Tumors (WHO 2017)

1. Pleomorphic adenoma (most common salivary gland tumor overall)
2. Myoepithelioma
3. Basal cell adenoma
4. Warthin's tumor (Papillary cystadenoma lymphomatosum) - most common in parotid
5. Oncocytoma (Oxyphilic adenoma)
6. Lymphadenoma (Sebaceous and Non-sebaceous)
7. Cystadenoma
8. Sialadenoma papilliferum
9. Ductal papillomas (inverted ductal papilloma, intraductal papilloma)
10. Sebaceous adenoma
11. Canalicular adenoma (Minor glands - upper lip)

1. Mucoepidermoid carcinoma (most common malignant salivary gland tumor)
2. Acinic cell carcinoma
3. Adenoid cystic carcinoma (most common in minor salivary glands; "creeping" perineural invasion)
4. Polymorphous adenocarcinoma (Polymorphous low-grade adenocarcinoma - PLGA)
5. Epithelial-myoepithelial carcinoma
6. Clear cell carcinoma
7. Basal cell adenocarcinoma
8. Intraductal carcinoma
9. Sebaceous adenocarcinoma
10. Lymphoepithelial carcinoma
11. Oncocytic carcinoma
12. Salivary duct carcinoma (aggressive, resembles ductal carcinoma of breast)
13. Myoepithelial carcinoma
14. Carcinoma ex pleomorphic adenoma (malignant transformation of PA)
15. Secretory carcinoma (Mammary analogue secretory carcinoma - ETV6-NTRK3 fusion)
16. Squamous cell carcinoma (primary)
17. Sialoblastoma

1. Hemangioma (most common salivary gland tumor in children)
2. Lymphoma

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MUCOEPIDERMOID CARCINOMA (MEC)

Introduction

• Most common malignant salivary gland tumor (approximately 35% of all salivary gland malignancies)
• Described by Stewart, Foote, and Becker (1945)
• Can occur in major glands (parotid most common) and minor salivary glands (palate most common intraoral site)
• Named for its three characteristic cell types: mucous cells, epidermoid (squamous) cells, and intermediate cells

Etiopathogenesis

• CRTC1-MAML2 translocation t(11;19)(q21;p13) - characteristic genetic aberration found in ~50-60% of low and intermediate grade MECs; correlates with better prognosis
• CRTC3-MAML2 translocation - less common; associated with high-grade tumors; worse prognosis
• The MAML2 gene is a transcriptional co-activator for Notch signaling; the translocation disrupts Notch pathway and activates AREG (amphiregulin) which activates EGFR signaling
• EGFR overexpression found in many MECs
• HER2/neu amplification reported in some high-grade MECs

• MEC is thought to arise from intercalated duct reserve cells (multipotent cells capable of differentiating into both ductal and acinar cells)
• These reserve cells undergo neoplastic transformation and differentiate into the three cell types that characterize MEC:
  1. Mucous (goblet) cells: Tall columnar cells with mucus-filled cytoplasm; PAS and mucicarmine positive
  2. Epidermoid (squamous) cells: Large polygonal cells with abundant eosinophilic cytoplasm; intercellular bridges; do NOT produce keratin (unlike true SCC)
  3. Intermediate cells: Small basaloid cells that represent progenitor cells; can differentiate into either mucous or epidermoid cells; most numerous

• Radiation exposure is a well-recognized risk factor; radiation-induced MEC often occurs in the parotid of patients who received head and neck irradiation (e.g., for childhood malignancies)
• Possibly some association with EBV
• No strong association with tobacco or alcohol (unlike OSCC)

Clinical Features

1. Parotid gland - most common site (45-50% of parotid malignant tumors)
2. Minor salivary glands - second most common; palate is most common intraoral site
3. Submandibular gland - less common
4. Sublingual gland - rare

• Age: Wide age range; most common malignant salivary tumor in children; in adults - 4th-5th decade
• Sex: Slight female predilection
• Presents as a gradually enlarging parotid mass - initially painless
• Low-grade: Well-circumscribed, mobile, slow-growing
• High-grade: Rapid growth, poorly defined, fixed, pain (early), facial nerve paralysis (VII nerve involvement) - pathognomonic of malignancy
• Lymphadenopathy if metastatic

• Palate (most common intraoral site) - posterior hard palate and soft palate
• Presents as a bluish/reddish fluctuant swelling on the palate - resembles a mucocele due to mucus-filled cysts within the tumor
• May have surface ulceration in advanced cases
• Firm to fluctuant consistency
• Overlying mucosa may be normal, reddish, or ulcerated
• Slow growing, asymptomatic initially
• May also occur on buccal mucosa, retromolar area, floor of mouth, lips, and tongue
• Central MEC of jaw (rare): Arises within bone (mandible); thought to arise from entrapped salivary gland epithelium or mucous cells in the lining of a dentigerous cyst

Histopathological Features

1. Mucous cells:
   • Tall columnar/goblet-shaped cells
   • Large, pale, foamy cytoplasm filled with mucin
   • Eccentric, compressed, basally placed nucleus
   • PAS positive (periodic acid-Schiff), Mucicarmine positive, Alcian blue positive
   • Often line the lumens of microcystic spaces
2. Epidermoid (squamous) cells:
   • Polygonal, resembling squamous cells
   • Intercellular bridges (desmosomes) visible
   • Do NOT form keratin pearls (distinction from SCC)
   • More prominent in high-grade tumors
3. Intermediate cells:
   • Small to medium sized
   • Ovoid nuclei with scant cytoplasm
   • Resemble basal cells
   • Most numerous cell type
   • Can be confused with basaloid carcinoma
4. Clear cells: A fourth cell type - with abundant clear cytoplasm due to glycogen accumulation; more common in some variants

• Cysts and glands lined by mucous cells (microcysts filled with mucin)
• Solid sheets and nests of intermediate and epidermoid cells
• Mucous pools (extracellular mucin lakes) with chronic inflammatory reaction (mucin extravasation causes inflammation)
• Variable amounts of fibrous stroma

• Predominantly cystic architecture (>25% cystic spaces)
• Abundant mucous cells
• Well-differentiated
• Minimal cellular atypia and mitoses
• No necrosis
• Better prognosis (5-year survival ~95%)

• Mixed cystic and solid areas
• Intermediate cellularity
• Moderate atypia
• 5-year survival ~80%

• Predominantly solid pattern
• Abundant epidermoid and intermediate cells
• Sparse mucous cells (difficult to identify - need mucin stains)
• Significant pleomorphism and atypia
• Numerous mitoses, necrosis
• Perineural invasion, lymphovascular invasion
• Aggressive behavior; 5-year survival ~40-55%

• Intracystic component ≤25% (+2)
• Neural invasion (+2)
• Necrosis (+3)
• Mitoses >4/10 HPF (+3)
• Anaplasia (+4)
• Score 0 = Low grade; 2-3 = Intermediate; ≥4 = High grade

• Mucicarmine, PAS, Alcian blue: Confirm mucous cells (essential in high-grade tumors where mucous cells are sparse)
• CK7, CK19: Positive in luminal/ductal cells
• p63: Positive in epidermoid and intermediate cells
• DOG1: May be positive
• MAML2 FISH: For detecting CRTC1-MAML2 translocation (favorable prognosis marker)

Treatment

• Low-grade: Wide local excision with adequate margins; parotidectomy (superficial or total depending on location) with facial nerve preservation if possible
• Intermediate/High-grade: Total parotidectomy; may require sacrifice of facial nerve if involved; selective neck dissection (for high-grade); adjuvant radiotherapy
• Minor gland MEC: Wide local excision; adjuvant radiation for high-grade
• Central MEC of jaw: Resection of involved jaw segment

Prognosis

• Grade is the most important prognostic factor
• Low-grade: Excellent (5-year survival >90%)
• High-grade: Poor (5-year survival 40-50%)
• CRTC1-MAML2 translocation positive: Better prognosis
• Metastasis: High-grade tumors metastasize to cervical lymph nodes, lung, bone, brain

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Quick Reference Index

• OKC: Tombstone/picket-fence basal cells, corrugated parakeratinized surface, daughter cysts
• Ameloblastoma: Reverse polarization = "piano key nuclei," soap-bubble multilocularity, Follicular > Plexiform variants
• AOT: "Two-thirds tumor," duct-like rosettes, snowflake calcifications
• Fibrous dysplasia: Chinese letter/alphabet soup trabeculae, NO osteoblastic rimming, ground-glass radiology
• OLP: Civatte bodies, saw-tooth rete ridges, band lymphocytic infiltrate, DIF shows fibrinogen at BMZ
• MEC: Mucicarmine+ mucous cells, grade is key prognostic determinant, CRTC1-MAML2 = good prognosis

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ESSAY ANSWERS (Q13-Q25) - As per Shafer's Textbook of Oral Pathology

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Q13. Classify Salivary Gland Tumors. Write in Detail about Clinical Features and Histopathology of Mucoepidermoid Carcinoma

Clinical Features of Mucoepidermoid Carcinoma

• Most common malignant salivary gland tumor (30-35% of all salivary malignancies)
• Most common malignant salivary tumor in children and adolescents
• Most common site: Parotid gland (parotid accounts for 45% of all MEC cases)
• Second most common site: Minor salivary glands (palate - most common intraoral site)

• Wide age range: Can occur at any age
• Peak: 4th-5th decade in adults
• Slight female predilection

• Painless, slowly enlarging mass in the preauricular/parotid region
• Low-grade: Well-circumscribed, mobile, smooth surfaced; mimics benign pleomorphic adenoma clinically
• High-grade: Rapid growth, poorly circumscribed, fixed to underlying structures; early facial nerve (VII) paralysis - a sinister sign indicating nerve invasion; pain
• Skin involvement and ulceration in advanced cases
• Cervical lymphadenopathy (high-grade tumors)
• Trismus if masseter/pterygoid infiltrated

• Most common on the posterior hard palate and soft palate
• Also: Buccal mucosa, retromolar area, floor of mouth, upper lip, tongue
• Presents as a blue/red, dome-shaped fluctuant swelling - the characteristic bluish color is due to mucus-filled cysts near the surface
• Resembles a mucocele clinically
• May be soft (cystic/low-grade) or firm (solid/high-grade)
• Overlying mucosa initially intact; may ulcerate with time
• Generally asymptomatic; discovered incidentally or when large enough to cause discomfort
• Size: Usually 1-4 cm

• Rare; occurs in mandible > maxilla
• Presents as jaw swelling, jaw pain, loosening of teeth
• Radiolucency on X-ray (may be multilocular - mistaken for ameloblastoma or OKC)
• Thought to arise from mucous cells entrapped in bone during odontogenesis or from lining of a dentigerous cyst

Histopathological Features

• Large cells with abundant pale, vacuolated, foamy cytoplasm filled with mucin
• Nucleus eccentrically placed, compressed basally ("signet ring"-like appearance)
• Line the inner surface of cystic spaces
• Mucicarmine positive (bright red staining)
• PAS positive (magenta staining)
• Alcian blue positive (blue staining for acidic mucins)

• Polygonal cells with abundant eosinophilic cytoplasm
• Intercellular bridges (desmosomes) visible on H&E
• Form sheets and nests
• Do NOT produce keratin pearls - critical distinction from squamous cell carcinoma
• More prominent in high-grade tumors
• May show individual cell keratinization

• Small to medium-sized basaloid cells
• Oval to round nuclei; scant cytoplasm
• Most numerous cell type overall
• Represent the progenitor (stem) cell population
• Can differentiate into either mucous or epidermoid cells
• When predominant: tumor looks like basaloid carcinoma - require mucin stains for diagnosis

• Cytoplasm clear due to glycogen accumulation
• PAS positive (diastase-sensitive) - glycogen
• More common in certain variants; may be mistaken for clear cell carcinoma

• Predominantly cystic architecture (>25% cystic component)
• Large cysts lined by mucous cells with smaller epidermoid and intermediate cells at base
• Abundant mucin-filled spaces
• Mucin extravasation into stroma → inflammatory response (histiocytes, giant cells)
• Minimal cellular pleomorphism
• Rare mitoses
• No necrosis
• Thin fibrous septa between cysts

• Mixed cystic and solid areas (15-25% cystic)
• Both mucous and epidermoid cells clearly identifiable
• Moderate pleomorphism
• Scattered mitoses
• Focal areas of necrosis may be present

• Predominantly solid sheets and nests of cells (<15% cystic component)
• Epidermoid and intermediate cells predominate
• Mucous cells sparse and difficult to identify on H&E → mucin stains (mucicarmine) essential for diagnosis
• Marked nuclear pleomorphism and hyperchromatism
• Numerous mitotic figures (>4/10 HPF)
• Tumor necrosis
• Perineural invasion - very characteristic of high-grade MEC
• Lymphovascular invasion
• Invasive growth pattern into adjacent structures
• Desmoplastic stroma

• Mucicarmine, PAS, Alcian blue - confirm mucous cells
• These stains are mandatory for diagnosis in high-grade tumors where mucous cells are sparse

• CK7, CK19: Positive (ductal differentiation)
• p63, p40: Positive (epidermoid/basal cells)
• CK5/6: Positive in epidermoid cells
• Vimentin: Variable
• MAML2 FISH: CRTC1-MAML2 translocation - 50-60% positive; marker of better prognosis

• Low grade: Predominantly cystic, abundant mucous cells, minimal atypia - excellent prognosis (5-year survival ~95%)
• Intermediate: Mixed pattern - good prognosis (~80%)
• High grade: Predominantly solid, sparse mucous cells, marked atypia, necrosis, perineural invasion - poor prognosis (~40-55% 5-year survival)

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Q14. Classify Salivary Gland Tumors. Describe Etiology, Clinical, Radiographic, Histopathological Features, Treatment, and Prognosis of Pleomorphic Adenoma

PLEOMORPHIC ADENOMA (PA)

Introduction

• Also called "Mixed Tumor" - because of its mixture of epithelial and mesenchymal-like (stromal) components
• Most common benign salivary gland tumor (65-70% of all salivary gland tumors)
• Most common tumor of the parotid gland
• Most common salivary gland tumor overall

Etiology

• Exact etiology unknown
• Chromosomal translocations:
  • t(3;8)(p21;q12) involving the PLAG1 gene (pleomorphic adenoma gene 1) on chromosome 8q12 - most common; PLAG1 encodes a zinc-finger transcription factor
  • t(5;8)(p13;q12) - PLAG1 fused to LIFR
  • 12q13-15 rearrangements involving HMGA2 gene - second most common
• Radiation exposure: Prior head and neck radiation is a risk factor (also for malignant transformation)
• Myoepithelial cells appear to be the key cell of origin - they contribute to both the epithelial and mesenchymal-like (chondromyxoid) elements
• The "pleomorphism" refers to histological diversity (multiple tissue types), not nuclear pleomorphism

Clinical Features

• Age: 4th-6th decade; most common in adults; rare in children
• Sex: Slight female predilection (F:M = 1.2:1)

• Presents as a slow-growing, painless mass in the parotid region
• Location: Superficial lobe of parotid (tail of parotid) - most common
• Mobile (in early stages), firm/rubbery consistency
• Surface: Smooth or bosselated (lobulated) - due to pseudopod extensions
• No facial nerve involvement - absence of facial palsy is characteristic of benign disease; presence = malignancy or malignant transformation
• Size: Can reach several centimeters if left untreated; usually 2-5 cm at presentation
• Duration: Months to years (very slow growth)
• Deep lobe parotid PA: May present as parapharyngeal mass causing dysphagia, dysarthria ("dumbbell" tumor extending through stylomandibular tunnel)

• Hard palate (most common intraoral site) → posterior hard palate lateral to midline
• Also: Lips (upper > lower), buccal mucosa, tongue, floor of mouth
• Smooth, round, dome-shaped submucosal swelling
• Non-tender, firm, slow-growing
• Overlying mucosa normal (intact, freely moveable over the lesion)
• Palatal PA: Located lateral to midline (to distinguish from torus palatinus which is exactly in midline)
• Hard, bony-hard consistency when long-standing (due to chondroid/osseous metaplasia within tumor)

• Presents as a submandibular swelling
• Slow-growing, painless
• Differentials: Lymph node, submandibular gland stone (distinguishable by tenderness and salivary function tests)

Radiographic Features

• Usually no radiographic changes unless very large
• Large palatal PA may show "saucerization" (shallow depression/erosion) of the hard palate bone - due to pressure resorption

• Well-circumscribed, homogeneous, or heterogeneous mass
• Enhances with contrast
• Parotid PA: Well-defined hypodense or isodense mass with a thin capsule
• May show calcifications within the tumor

• T1: Iso/hypointense
• T2: Hyperintense (bright signal due to myxoid/chondroid stroma with high water content) - characteristic
• Well-defined borders
• Helps delineate parapharyngeal extension and deep lobe involvement

• Round, well-defined, hypoechoic mass with posterior acoustic enhancement
• Fine needle aspiration cytology (FNAC) guided by ultrasound - diagnostic

• Cold nodule (no uptake) - PA does not concentrate pertechnetate
• Warthin's tumor: Hot nodule (increased uptake due to oncocytic cells)

Histopathological Features

• Encapsulated mass (capsule may be incomplete - pseudocapsule)
• Cut surface: White-grey, glistening; areas of chondroid (bluish, cartilaginous) tissue; myxoid (gelatinous) areas; occasional calcifications or bone

• Ductal (luminal) cells: Cuboidal to columnar cells lining duct-like structures and tubules; inner cell layer
• Myoepithelial cells: Outer cell layer; appear as spindle-shaped, stellate, plasmacytoid (hyaline, Russell body-like), or clear cells; these are the KEY cells of PA
• Myoepithelial cells are responsible for the mesenchymal-like (chondroid, myxoid) stroma by secreting extracellular matrix components

• Chondroid areas (cartilage-like): Bluish myxoid stroma with lacunae containing chondrocyte-like cells - most characteristic; this is metaplastic cartilage
• Myxoid stroma: Loose, pale blue, mucoid background matrix
• Mucoid stroma
• Osseous metaplasia: Bone formation within long-standing tumors
• Adipose tissue, squamous metaplasia, mucous cell metaplasia - variable

• Present but may be incomplete/thin (pseudopodal projections of tumor may extend through the capsule - this is why mere enucleation leads to recurrence)
• Pseudopods of tumor tissue project through the capsule - critical surgical implication
• Capsule is thick in parotid PA, thin/absent in minor gland PA

• Ductal cells: CK7, CK19 positive
• Myoepithelial cells: S-100 protein, SMA (smooth muscle actin), GFAP, calponin, p63 positive

Malignant Transformation (Carcinoma ex Pleomorphic Adenoma):

• Occurs in 5-15% of long-standing PAs (especially after 15+ years)
• Risk increases with time: ~1.5% at 5 years, ~10% at 15 years
• Features suggesting malignancy: Rapid increase in growth rate, pain, nerve palsy, fixation, ulceration
• Histologically: Areas of PA with adjacent frankly malignant cells (usually salivary duct carcinoma or adenocarcinoma)
• Prognosis: Poor if widely invasive

Treatment

• Parotid PA: Superficial parotidectomy with preservation of the facial nerve (nerve monitoring recommended); NOT enucleation (high recurrence due to pseudopods breaking capsule)
• Submandibular PA: Total submandibular gland excision
• Minor gland PA: Wide local excision with a margin of normal tissue
• Recurrent PA: Re-excision; total parotidectomy with nerve monitoring
• Enucleation is contraindicated - rupture of capsule during removal → spillage of cells → multiple recurrence nodules ("recurrent pleomorphic adenoma")

Prognosis

• Excellent after adequate surgery (recurrence rate <3-5% with proper parotidectomy)
• Recurrence after enucleation: 25-45%
• Malignant transformation: 5-15% overall (risk proportional to duration)
• Metastasizing pleomorphic adenoma (extremely rare): Histologically benign but metastasizes

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Q15 & Q24. Classify Viral Diseases. Explain Herpes Simplex Viral Infections / Discuss Herpes Infection in Detail

Classification of Viral Diseases Affecting the Oral Cavity

1. Herpes Simplex Virus Type 1 (HSV-1) - Herpes labialis, Primary herpetic gingivostomatitis
2. Herpes Simplex Virus Type 2 (HSV-2) - Genital herpes; oral involvement increasing
3. Varicella-Zoster Virus (VZV/HHV-3) - Chickenpox (varicella), Herpes zoster (shingles)
4. Epstein-Barr Virus (EBV/HHV-4) - Infectious mononucleosis, Hairy leukoplakia, Burkitt's lymphoma
5. Cytomegalovirus (CMV/HHV-5) - Oral ulcers (immunocompromised)
6. HHV-6, HHV-7 - Roseola infantum
7. HHV-8 (KSHV) - Kaposi's sarcoma

1. Human Papillomavirus (HPV) - Squamous cell papilloma, Verruca vulgaris, Condyloma acuminatum, Focal epithelial hyperplasia (Heck's disease)

1. Molluscum contagiosum

1. Coxsackievirus A - Herpangina, Hand-Foot-Mouth Disease (HFMD)
2. Echovirus

1. Mumps virus - Parotitis
2. Measles virus - Koplik's spots

1. HIV - HIV-associated oral lesions (candidiasis, hairy leukoplakia, Kaposi's sarcoma, NUG/NUP)

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HERPES SIMPLEX VIRUS (HSV) INFECTION

The Virus

• Double-stranded DNA virus belonging to the family Herpesviridae
• Two types: HSV-1 (oro-facial; "above the waist") and HSV-2 (genital; "below the waist") - though this distinction is now blurred
• HSV-1 is responsible for >90% of oral herpes infections
• Key property: Establishes latency in sensory nerve ganglia after primary infection - HSV-1 in the trigeminal ganglion (specifically the Gasserian ganglion)

Etiopathogenesis (Mechanism of Infection)

1. HSV-1 enters via oral mucosa, skin (broken epithelium), or respiratory tract
2. Virus infects epithelial cells → replicates → causes cell lysis and vesicle formation
3. Virus travels centripetally (retrograde axonal transport) to the trigeminal ganglion
4. In the ganglion: Latency is established - viral DNA persists as episomal DNA in neuronal nuclei without active replication; no symptoms during latency
5. Viral proteins LAT (Latency-Associated Transcripts) maintain latency

1. Various triggers stimulate the virus to reactivate
2. Virus travels centrifugally (anterograde axonal transport) back to the periphery
3. Replication in epithelial cells → recurrent lesions (usually in same location)
4. Triggers for reactivation:
   • Fever, upper respiratory tract infections ("fever blister")
   • Emotional stress, fatigue
   • UV light/sunlight exposure (lip lesions)
   • Menstruation, hormonal changes
   • Trauma, dental procedures
   • Immunosuppression (corticosteroids, chemotherapy, HIV)
   • Cold, wind exposure

• HSV infects and lyses epithelial cells
• Ballooning degeneration of infected cells → intranuclear inclusions form → cells rupture → intraepithelial vesicle forms
• Inflammatory infiltrate (neutrophils, lymphocytes) in the lamina propria

PRIMARY HERPETIC GINGIVOSTOMATITIS (PHGS)

• Age: Most common in infants and young children (6 months - 5 years); also in young adults (first exposure)
• Prodrome (1-2 days): Fever (38-40°C), malaise, irritability, cervical lymphadenopathy (submandibular nodes most commonly affected - tender, enlarged)
• Oral lesions:
  • Multiple, painful vesicles (2-3mm) that rapidly rupture to form shallow, irregular ulcers covered by yellowish/grey pseudomembrane with red halo
  • Lesions on attached and free gingiva, tongue, lips, buccal mucosa, hard palate
  • GENERALIZED acute gingivitis - fiery red, swollen, bleeding gingiva is characteristic (distinguishes from herpangina where gingiva is spared)
  • Coalescence of ulcers creates larger irregular ulcerations
• Systemic symptoms: High fever (up to 40°C), dysphagia (difficulty swallowing), drooling, refusal to eat/drink in children
• Duration: Acute phase lasts 7-10 days; complete resolution in 14 days
• Self-limiting in immunocompetent individuals

RECURRENT HERPES LABIALIS (RHL) - "Cold Sore" / "Fever Blister"

• Most common recurrent form
• Site: Vermilion border of the lip (labial-cutaneous junction) - most common; also perioral skin
• Prodrome (12-24 hours): Tingling, burning, itching at the site before visible lesion
• Stages:
  1. Prodrome: Tingling/burning
  2. Erythema: Redness of skin
  3. Papule: Small firm papule
  4. Vesicle: Clear fluid-filled blister (most infectious stage)
  5. Ulcer/crust: Vesicle ruptures → shallow ulcer → crusting
  6. Healing: Without scarring in 7-10 days
• Recurrence: Same site each time (due to same nerve ganglion reactivating)
• Frequency: Varies (several times/year to once in years)

RECURRENT INTRAORAL HERPES (RIH)

• Site: Keratinized mucosa - hard palate and attached gingiva (not movable mucosa - unlike recurrent aphthous stomatitis which affects non-keratinized mucosa)
• Small cluster of 1-2mm vesicles that coalesce and rupture forming irregular painful ulcers
• Heal in 7-14 days
• Triggered by dental procedures, trauma
• Key distinction from aphthous: Herpes on keratinized mucosa; aphthous on non-keratinized movable mucosa

Histopathological Features

1. Ballooning degeneration: Infected keratinocytes become greatly enlarged with pale, vacuolated cytoplasm ("balloon cells")
2. Acantholysis: Weakening of intercellular adhesion → loss of cohesion between cells → intraepithelial vesicle
3. Intraepithelial vesicle formation (suprabasal level)
4. Intranuclear inclusions (Cowdry Type A inclusions):
   • Large, eosinophilic intranuclear inclusion bodies
   • Surrounded by a clear halo
   • Peripheral condensation of chromatin at nuclear membrane ("margination of chromatin")
   • These inclusions represent sites of viral replication within the nucleus
5. Multinucleated giant cells (syncytial cells) - formed by fusion of infected cells; nuclei show the same inclusion bodies and margination
6. Reticular degeneration: Less prominent; also contributes to vesicle
7. Inflammatory infiltrate: Lymphocytes, neutrophils, plasma cells in lamina propria
8. Secondary infection: PMN infiltrate in the vesicle and ulcer base if secondarily infected

Laboratory Investigations

1. Tzanck smear (Tzanck test):
   • Scraping from the base of a fresh vesicle stained with Giemsa or Wright stain
   • Positive: Shows multinucleated giant cells (balloon cells) with intranuclear inclusions
   • Rapid, inexpensive, but not specific for HSV vs. VZV
2. Viral culture:
   • Gold standard for confirmation
   • Material: Vesicle fluid or swab from ulcer
   • Cytopathic effect (CPE) in cell cultures within 24-72 hours
   • Time-consuming but definitive
3. PCR (Polymerase Chain Reaction):
   • Most sensitive and specific test
   • Can detect and differentiate HSV-1 vs. HSV-2
   • Used for CNS involvement (CSF PCR for herpes encephalitis)
4. Direct Immunofluorescence (DIF):
   • Fluorescent-labeled antibodies to detect HSV antigens in smears or biopsy
   • Rapid and specific
5. ELISA for serology:
   • IgM antibodies: Indicate primary/acute infection
   • IgG antibodies: Indicate past infection/immunity
   • Useful for seroprevalence studies; less useful for acute diagnosis
6. Biopsy and histopathology:
   • Shows ballooning degeneration, multinucleated giant cells, Cowdry Type A inclusions
   • Used when diagnosis is uncertain

Management

• Supportive care is the mainstay in mild-moderate cases
• Antiviral therapy:
  • Acyclovir (main drug): 200 mg 5 times/day for 5-7 days (children: 15 mg/kg 5x/day)
  • Most effective if started within 72 hours of symptom onset
  • Valacyclovir (prodrug of acyclovir): Better bioavailability
  • Famciclovir: Alternative
• Analgesics (paracetamol, ibuprofen) for pain and fever
• Topical anesthetics (lidocaine gel, benzocaine) for oral pain relief
• Adequate fluid intake (prevent dehydration, especially in children)
• Antifungals if secondary candidiasis
• Chlorhexidine 0.12% mouthwash - reduces secondary bacterial infection

• Topical acyclovir 5% cream - applied at prodromal stage; reduces duration
• Oral acyclovir for more severe or frequent recurrences
• Penciclovir 1% cream - more effective than acyclovir topically
• Sunscreen for UV-triggered cases
• Suppressive therapy (daily acyclovir 400mg BD) for patients with >6 recurrences/year

• IV acyclovir for severe disease
• Resistance to acyclovir: Foscarnet or cidofovir used

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Q16 & Q21. Define Dental Caries. Describe Theories, Etiology, Clinical Features, and Histopathological Features

Definition

• The word "caries" comes from Latin meaning "rottenness"
• It is one of the most prevalent diseases worldwide

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THEORIES OF DENTAL CARIES

• Proposed by W.D. Miller ("Chemico-Parasitic Theory")
• Two-stage process:
  • Stage 1: Acid produced by oral bacteria (S. mutans, Lactobacillus) through fermentation of dietary carbohydrates dissolves the inorganic mineral of enamel (demineralization)
  • Stage 2: Proteolytic enzymes break down the organic matrix of dentin
• Limitations: Does not explain why enamel lesion occurs at specific sites (plaque-prone areas); does not account for buffering capacity of saliva

• Proposed by Gottlieb (later supported by Pincus and Burgess)
• Primary attack is on the organic matrix (proteins) of enamel (particularly the enamel sheaths - "keratinous" component)
• Proteolytic organisms destroy the protein framework first → minerals then dissolve
• Explanation: Lesion starts in the enamel prism sheaths (protein-rich areas)
• Limitation: Enamel is only 1% organic matrix; the initial zone of enamel attacked in early caries shows mineral loss before protein loss

• Combined theory proposed by Schatz and Martin
• Microorganisms produce proteolytic enzymes that break down the organic components of enamel
• The breakdown products are chelating agents (especially keratinolytic substances) that form soluble chelates with calcium ions → remove calcium from enamel at neutral or alkaline pH
• Explains caries initiation without acid (at neutral pH)
• Limitation: Chelation occurs at alkaline/neutral pH, not the acid pH found in dental plaque

• Sucrose itself acts as a chelating agent
• Less accepted

• Proposed caries as an autoimmune disease
• Not widely accepted

• Bacteria produce phosphatase enzymes that remove phosphate from enamel → calcium phosphate dissolves
• Historical interest only; not currently accepted

1. Susceptible host (tooth)
2. Cariogenic microorganisms (dental plaque bacteria)
3. Fermentable carbohydrate substrate (diet)
4. Time (4th factor added by Newbrun) - these factors must act together over time

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ETIOLOGY OF DENTAL CARIES

Host Factors (Tooth and Saliva):

• Tooth morphology: Deep pits and fissures retain plaque (occlusal caries); tight contact points (proximal caries)
• Tooth position: Crowded, mal-aligned teeth more susceptible
• Enamel structure: Hypomineralized or hypoplastic enamel more susceptible
• Chemical composition: Fluoride incorporation into enamel → fluorapatite (more acid-resistant than hydroxyapatite); zinc, tin also protective; selenium, magnesium increase susceptibility

• Flow rate: Decreased salivary flow (xerostomia) greatly increases caries risk; saliva washes away food debris and bacteria
• Buffering capacity: Saliva buffers acid via bicarbonate system; reduced buffering = increased caries
• Antibacterial factors: IgA, lactoferrin, lysozyme, peroxidase system (inhibit bacterial growth)
• Remineralization: Saliva is supersaturated with calcium and phosphate → promotes enamel remineralization
• Viscosity: Thick mucoid saliva less protective

• Systemic fluoride (fluoridated water, supplements) incorporates into enamel during development as fluorapatite
• Topical fluoride (toothpaste, varnish, gels) promotes remineralization of early lesions; inhibits bacterial enzyme activity

Microbial Factors:

1. Streptococcus mutans - primary cariogenic organism:
   • Produces glucosyltransferase (GTF) → synthesizes extracellular glucan (mutan) from sucrose → allows adherence to smooth surfaces
   • Ferments sucrose to lactic acid (most efficient acid producer)
   • Tolerates low pH ("aciduric" and "acidogenic")
   • Thrives in plaque microenvironment
2. Lactobacillus species (L. acidophilus, L. casei):
   • Important in dentinal caries progression
   • Highly acidogenic and aciduric
   • Indicators of caries activity (high Lactobacillus counts = active caries)
3. Streptococcus sobrinus: Similar to S. mutans; important in some populations
4. Actinomyces species: Implicated in root caries (root surface caries in elderly)
5. Other bacteria: Veillonella (metabolizes lactic acid - somewhat protective), Bifidobacterium

Dietary Factors:

• Fermentable carbohydrates are the substrate
• Sucrose is the most cariogenic sugar:
  • Fermented to acids by plaque bacteria
  • Used by S. mutans to synthesize glucan (for adhesion)
• Frequency of sugar exposure is more important than total quantity
• Physical form: Sticky foods (toffee, caramels) more cariogenic than liquid forms; remain in contact longer
• Stephan curve: pH drops within 2-5 minutes of sugar intake; returns to resting pH in 30-60 minutes; repeated exposures keep pH below critical pH (5.5) for prolonged periods

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CLINICAL FEATURES OF DENTAL CARIES

1. Pit and fissure caries: Occlusal surfaces; most common in posterior teeth
2. Smooth surface caries (Proximal): Contact areas between adjacent teeth; early: white/chalky spot
3. Cervical/Gingival margin caries: At CEJ; associated with plaque accumulation
4. Root caries: On exposed root surfaces (elderly patients, recession)
5. Rampant caries (Nursing bottle caries / Early Childhood Caries): Multiple rapidly developing lesions; upper anterior teeth typically affected in nursing bottle syndrome

• Subsurface demineralization without cavitation
• Appears as chalky white opaque area (white spot) on dried enamel
• No cavitation
• Reversible - can remineralize with fluoride and diet modification
• No pain

• Cavitation limited to enamel
• Small cavity, possible discoloration (brown/black)
• No pain (enamel has no nerve supply)

• Cavity extends to dentin
• Pain: Sensitivity to sweet, cold (dentinal hypersensitivity due to hydrodynamic mechanism)
• Faster progression (dentin less mineralized; radiating dentinal tubules facilitate spread)
• Discolored, softened dentin (brown carious dentin)
• Pulp may mount defensive response (reparative dentin, calcification)

• Pain: Severe, spontaneous, lingering (pulpitis)
• Eventually pulp necrosis → periapical pathology

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HISTOPATHOLOGICAL FEATURES OF DENTAL CARIES

Enamel Caries (Histology)

• Relatively intact and less affected than underlying zones initially
• Appears relatively radiopaque (less porous)
• Protected by high fluoride content (surface enamel is more fluoridated), rapid remineralization from saliva
• Pore volume: ~1-2% (slightly increased from normal's ~0.1%)
• This intact surface zone explains why early caries is subsurface (the "hidden" lesion)

• Largest and most extensively demineralized zone
• Located beneath the intact surface zone
• Pore volume: 25-30% or more (high degree of demineralization)
• Appears radiolucent (dark in polarized light, translucent zone on microradiograph)
• Enamel prism structure visible but highly porous
• Striae of Retzius become prominent (lines of increased porosity)

• Located inner to the body of the lesion
• Small pores filled with organic material or remineralized mineral
• Positive birefringence in polarized light → appears dark (hence "dark zone")
• Represents an active remineralization zone (pores filled with mineral being deposited)
• Indicator of disease activity: Wide dark zone = good prognosis (active repair)

• At the innermost aspect, adjacent to sound enamel
• Earliest detectable zone in a carious lesion
• Increased porosity (0.1% → ~1% pore volume) representing earliest demineralization
• Mineral loss along enamel prism boundaries (sheaths)
• Appears translucent in polarized light (negative birefringence)

Dentinal Caries (Histology)

• Outermost; completely destroyed/disintegrated dentin
• Soft, discolored (brown-black) dentin
• Bacterial invasion with masses of bacteria within dentinal tubules
• Dead tracts (dentinal tubules devoid of odontoblast processes)
• Removed during cavity preparation

• Bacteria present within dentinal tubules
• Tubules distorted and widened
• Early liquefaction necrosis

• Mineral dissolving ahead of bacterial invasion
• Dentinal tubules dilated; odontoblast processes intact
• No bacteria yet in this zone
• Acid diffuses ahead of bacteria

• Protective response - odontoblasts deposit mineral within dentinal tubules → tubular sclerosis
• Appears translucent on ground sections (tubules filled with mineral resemble surrounding dentin)
• Acts as a barrier between caries and pulp
• Deeper: Reparative (tertiary) dentin laid down by odontoblasts

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Q17. Describe Aetiopathogenesis, Clinical Features, and Histopathology of Lichen Planus

1. An antigen (exogenous or altered self-antigen) is presented by keratinocytes
2. Antigen presentation activates CD4+ T-helper cells in the lamina propria
3. Activated T cells release cytokines (IFN-γ, TNF-α) → upregulate MHC class I on keratinocytes
4. CD8+ cytotoxic T cells recognize MHC-I-antigen complexes on basal keratinocytes
5. CD8+ T cells kill basal keratinocytes via Fas/FasL pathway → apoptosis → Civatte body formation
6. MMP-9 secreted by T cells degrades the basement membrane → epithelial disruption
7. Mast cell degranulation in lamina propria contributes to chronic inflammation
8. TNF-α induces keratinocyte apoptosis and maintains the inflammatory cycle
9. The "interface" between epithelium and lamina propria is the battleground → interface dermatitis pattern

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Q18. Describe Hereditary Disorders Affecting Enamel and Dentin

HEREDITARY DISORDERS OF ENAMEL

AMELOGENESIS IMPERFECTA (AI)

• Enamel quantity reduced; hard and well-calcified but thin
• Sub-types: Ia (autosomal dominant, pitted), Ib (autosomal dominant, local pitting), Ic (autosomal dominant, smooth, local), Id (autosomal dominant, smooth, generalized), Ie (autosomal recessive, rough), If (X-linked dominant)
• Clinical: Enamel pitting, grooving, or thinning; enamel hard (normal hardness); yellowish or brown discoloration
• Radiology: Enamel present but thin; contrast between enamel and dentin less than normal

• Enamel quantity normal but soft (under-calcified); protein-rich enamel
• Sub-types: IIa (X-linked), IIb (autosomal recessive, pigmented), IIc (autosomal recessive, snow-capped)
• Clinical: Enamel normal thickness but mottled (white, opaque/milky areas); soft, flakes off easily; "Snow-capped" teeth (white opaque tips)
• Radiology: Enamel same density as dentin (fails to show radiopaque differentiation from dentin)
• Associated with taurodontism in some syndromes

• Enamel matrix quantity normal but very poorly calcified
• Most severe form functionally
• Autosomal dominant or recessive
• Clinical: Enamel normal thickness but extremely soft (can be removed with scaler), chalky white, rapidly lost after eruption leaving exposed dentin; open bite common; severe sensitivity; brown/orange discoloration
• Radiology: Enamel appears same density or less than dentin (low mineral content)

• Combined defect; taurodont molars (large pulp chambers)

• Hypoplastic: Reduced enamel thickness; enamel rods deficient in number and organization; pits correspond to absent rod clusters
• Hypomaturation: Normal enamel thickness; rods present but incompletely crystallized; interprismatic space increased
• Hypocalcified: Normal enamel thickness; markedly reduced crystal size and density; abundant protein matrix

• Composite resin restorations, crowns
• Overdentures in severe cases
• Extraction and prosthetic rehabilitation in adults with severe AI
• Orthodontic treatment if malocclusion

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HEREDITARY DISORDERS OF DENTIN

DENTINOGENESIS IMPERFECTA (DI)

• Dentin defect occurring in patients with OI (brittle bone disease)
• COL1A1 or COL1A2 gene mutation (Type I collagen)
• Blue sclerae, joint hypermobility, hearing loss (OI features) in addition to dental defects
• Dental features similar to Type II but may be milder
• Only 25% of OI patients have significant dental involvement

• Autosomal dominant; gene: DSPP (dentin sialophosphoprotein) on chromosome 4q21
• Clinical features:
  • Affects both primary and permanent dentitions
  • Opalescent/translucent/bluish-brownish amber appearance - the most distinctive clinical feature; teeth appear brown, violet, or "opalescent blue" due to abnormal dentin showing through thin enamel
  • Enamel normal but fractures and chips off due to lack of support from abnormal dentin (dentin-enamel junction abnormal)
  • Once enamel is lost: Rapid attrition of exposed dentin → severely worn-down teeth
  • Primary dentition more severely affected than permanent dentition
  • Teeth may eventually wear down to gingival level
• Radiographic features:
  • Obliteration of pulp chambers and root canals - most characteristic radiographic finding (due to continued deposition of abnormal dentin into pulp space)
  • Bulbous/bell-shaped crowns with constriction at the CEJ
  • Short, blunted roots (cervical constriction)
  • Periapical radiolucencies may occur without obvious caries (due to dentin defects exposing pulp)
• Histopathological features:
  • Enamel: Normal
  • DEJ (Dentinoenamel Junction): Abnormal; flat/irregular instead of scalloped → poor adhesion → enamel fractures
  • Dentin: Atubular/tubular-deficient dentin (reduced number of dentinal tubules; tubules irregular, less organized, tortuous)
  • Large areas of interglobular dentin (calcification globules fail to fuse)
  • Inclusion bodies within odontoblasts
  • Reduced dentin quality with increased protein and water content

• Rare; isolated population in Maryland (Brandywine isolate)
• Both deciduous and permanent dentitions affected
• Shell teeth: Very thin, abnormal dentin with large pulp chambers
• Multiple pulp exposures
• Radiographically: Shell-like appearance with very large pulp chambers
• DSPP mutation also implicated

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DENTIN DYSPLASIA (DD)

• Autosomal dominant
• Clinically: Normal-appearing crowns (color and shape appear normal - this distinguishes from DI)
• Primary: May appear slightly amber; permanent: Normal clinical appearance
• Radiographic hallmark: Complete obliteration of root canals and pulp chambers + extremely short rootless or rootlet roots with periapical radiolucencies (flamelike or chevron-shaped pulp remnants)
• Teeth mobile; premature exfoliation due to abnormally short roots
• Histopathology: Abnormal, atubular dentin in roots; "cascade of dentin droplets" = multiple small fragments of calcified dentin in the pulp

• Autosomal dominant; very rare
• Primary teeth: Bluish/amber discoloration (like DI-II)
• Permanent teeth: Normal color
• Radiographic: "Thistle tube" pulp chambers (flame-shaped, elongated pulp horns); root canals thin but present; pulp stones; no pulp obliteration as in Type I

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REGIONAL ODONTODYSPLASIA (Ghost Teeth)

• Non-hereditary but included here as a developmental enamel/dentin defect
• Affects a group of teeth in one region (upper anterior most common)
• Extremely deficient enamel and dentin
• Radiographically: Extremely thin, "ghostly" appearance of teeth → called "ghost teeth"
• Large pulp chambers, short roots
• Treatment: Extraction and prosthetic rehabilitation

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Q19 & Q23. Describe Etiology, Clinical Features, Histological Features, and Differential Diagnosis of Pemphigus / Pemphigus Vulgaris

VESICULOBULLOUS LESIONS OF THE ORAL CAVITY (Enumeration)

1. Pemphigus vulgaris (PV)
2. Pemphigus vegetans
3. Mucous membrane (cicatricial) pemphigoid
4. Bullous pemphigoid
5. Linear IgA disease
6. Dermatitis herpetiformis
7. Epidermolysis bullosa acquisita
8. Paraneoplastic pemphigus

1. Epidermolysis bullosa (simplex, junctional, dystrophic)
2. Darier's disease (keratosis follicularis)

1. Primary herpetic gingivostomatitis (HSV)
2. Herpes zoster
3. Herpangina (Coxsackievirus)
4. Hand-foot-mouth disease

1. Erythema multiforme (acute)
2. Stevens-Johnson syndrome
3. Angina bullosa hemorrhagica

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PEMPHIGUS VULGARIS (PV)

Definition

Etiology and Pathogenesis

1. IgG autoantibodies are produced against desmoglein 3 (Dsg3) - a transmembrane glycoprotein component of desmosomes (cell junction proteins responsible for keratinocyte cohesion)
2. In mucosal PV: Anti-Dsg3 antibodies predominantly
3. In mucocutaneous PV (more severe): Anti-Dsg3 + Anti-Dsg1 antibodies
4. Antibodies bind to desmoglein → interfere with desmosome function → loss of cell-to-cell adhesion between keratinocytes = acantholysis
5. Acantholysis → separation of suprabasal keratinocytes → intraepithelial (suprabasal) blister formation
6. The basal cells remain attached to the basement membrane (like a "row of tombstones")
7. Complement activation and further inflammatory cascade

• Drugs: Penicillamine (most common drug trigger), ACE inhibitors (captopril), rifampicin, NSAIDs
• Stress
• Infections (? viral trigger)
• Genetic predisposition: HLA-DR4, HLA-DQ3 associations
• Thiol-containing drugs

Clinical Features

• Age: Most common in 4th-6th decade; rare in children
• Sex: Equal; slight female predilection in some studies
• Race: Higher incidence in Ashkenazi Jews, Mediterranean populations
• Serious disease: Before corticosteroids, mortality was ~75%; now reduced to ~5-10%

• Site: Any oral mucosal surface; buccal mucosa, gingiva, palate, lip, tongue
• Thin-walled vesicles/bullae form but rapidly rupture → leave painful, irregular, shallow ulcers with ragged edges
• Ulcers are surrounded by normal-appearing mucosa (not erythema - unlike aphthous)
• Nikolsky's sign POSITIVE (applying lateral pressure on normal-appearing mucosa adjacent to a bulla causes separation of epithelium) - hallmark clinical sign
• Asboe-Hansen sign (applying pressure on a bulla causes it to spread laterally) - also positive
• Ulcers bleed easily; very painful; interfere with eating
• Desquamative gingivitis: Reddish, eroded, desquamating gingiva
• Lesions heal slowly without scarring

• Large, flaccid (easily ruptured) bullae on normal or erythematous skin
• Any body surface; favors pressure sites, flexures
• Nikolsky's sign positive on skin
• Rapidly rupture → large denuded painful areas
• Risk of secondary infection, fluid/electrolyte loss, sepsis

• Pemphigus vegetans: Variant of PV; ulcers heal with warty vegetative lesions (vegetations) especially in body folds
• Pemphigus foliaceus: Superficial form; Dsg1 antibodies; skin only (no oral mucosa - Dsg1 absent in oral mucosa)
• Paraneoplastic pemphigus: Associated with lymphoproliferative malignancies (NHL, CLL, thymoma); most severe form

Histopathological Features

1. Suprabasal acantholysis - loss of cohesion between suprabasal keratinocytes; cells separate from each other
2. Intraepithelial blister - suprabasal split; blister forms just above the basal cell layer
3. Tombstone appearance (Row of tombstones): Basal cells remain attached to the basement membrane while all other cells separate → basal cells appear like a row of tombstones (this is the MOST CHARACTERISTIC histological feature of PV)
4. Acantholytic cells (Tzanck cells): Free-floating, rounded, acantholytic keratinocytes within the blister fluid; large hyperchromatic nucleus, perinuclear halo of condensed cytoplasm; appear individually (loss of intercellular contacts); these are Tzanck cells
5. Inflammatory infiltrate: Predominantly eosinophils and lymphocytes in the blister and underlying connective tissue
6. Eosinophilic spongiosis: Accumulation of eosinophils between acantholytic cells (early/active lesions)
7. Blister roof: Layers of acantholytic epidermis/epithelium
8. Blister floor: Intact basal cell layer attached to basement membrane

Laboratory Investigations

• Smear from the base of a fresh blister, stained with Giemsa
• Shows Tzanck cells (acantholytic rounded keratinocytes with large nuclei and perinuclear halo)
• Rapid, easy, inexpensive - good screening test
• Not specific for PV (also positive in herpes infections)

• Perilesional biopsy (3-4 mm from the edge of the lesion, not the lesion itself) for best results
• Shows suprabasal acantholysis and tombstone arrangement as described above

• Perilesional biopsy placed in Michel's transport medium
• Shows intercellular IgG and/or C3 (complement) deposition in a "chicken-wire" or "fish-net" pattern throughout the epithelium (IgG coats the surface of all keratinocytes in a reticular/intercellular network)
• DIF positivity: >90% sensitivity

• Patient's serum incubated on substrate (monkey esophagus or guinea pig lip epithelium)
• Detects circulating anti-desmoglein antibodies
• Titer correlates with disease activity (higher titer = more active disease)
• Useful for monitoring treatment response

• Anti-Dsg3 ELISA: Mucosal disease
• Anti-Dsg1 ELISA: Skin/folliaceus-type disease
• Most sensitive and specific serological test
• Titer correlates with disease activity

• Applying lateral pressure/shear stress on normal mucosa/skin near lesions → bulla formation (positive)

Differential Diagnosis

Treatment

• Systemic corticosteroids (prednisolone): 1-1.5 mg/kg/day - mainstay of treatment; reduces autoantibody production
• Steroid-sparing immunosuppressants: Azathioprine, mycophenolate mofetil, cyclophosphamide
• Rituximab (anti-CD20): Depletes B cells → reduces autoantibody production; now first-line in moderate-severe PV
• IVIG (Intravenous immunoglobulin): For refractory cases
• Dapsone, gold salts: For mild cases
• Topical steroids for oral lesions (triamcinolone in Orabase)
• Wound care, nutritional support, infection prevention

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Q20. Describe Etiology, Clinical Features, Histopathological Features, and Treatment of Oral Lichen Planus

1. Identify and eliminate triggering factors (drugs, amalgam contacts, stress, Hepatitis C)
2. Topical corticosteroids: Clobetasol propionate 0.05% in Orabase (first line)
3. Intralesional corticosteroid injections for localized persistent lesions
4. Systemic prednisolone (40-60mg, tapered over 4-6 weeks) for severe/widespread disease
5. Topical tacrolimus 0.1% (second line; FDA warning for potential malignancy - theoretical)
6. Systemic hydroxychloroquine, azathioprine for refractory cases
7. Treat secondary candidiasis with antifungals (common complication of topical steroid use)
8. Long-term follow-up every 6 months; biopsy any suspicious change (erythroplasia, induration)

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Q22. Discuss Etiology, Clinical Features, Histopathological Features, and Treatment of Fibrous Dysplasia. Add a Note on Associated Syndromes

• Triad: Polyostotic fibrous dysplasia + Café-au-lait skin pigmentation + Autonomous endocrine hyperfunction
• Most common endocrine manifestation: Precocious puberty in females (most characteristic); also hyperthyroidism, growth hormone excess, Cushing syndrome, hyperparathyroidism, hypophosphatemia
• Café-au-lait spots: Irregular "coast of Maine" borders (large, often unilateral); usually ipsilateral to the skeletal lesions; may overlie the affected bone
• Caused by GNAS1 somatic activating mutation in G protein alpha subunit - same mutation as isolated FD but affecting more tissues (early embryonic mutation)

• Polyostotic fibrous dysplasia + intramuscular myxomas
• Benign soft tissue tumors (myxomas) near affected bones
• Must be distinguished from sarcoma
• GNAS1 mutation

• Hereditary FD-like condition
• Autosomal dominant; SH3BP2 gene mutation
• Bilateral posterior mandibular (and sometimes maxillary) lesions → cherubic appearance
• Spontaneous regression after puberty
• Histologically similar to giant cell lesions (not true FD histology)

• Older term for polyostotic FD + café-au-lait spots WITHOUT endocrine dysfunction (essentially polyostotic FD without the full MAS)

• <1% in spontaneous FD
• Increases significantly with radiation therapy (avoid radiation in FD)
• Most common malignancy: Osteosarcoma (most common), followed by fibrosarcoma and chondrosarcoma
• Suspect if rapid increase in size, pain, or new bone destruction

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Q25. Write the Sequelae of Pulpitis. Describe Clinical, Radiographic, Histopathological, and Microbiological Features of Periapical Granuloma

SEQUELAE OF PULPITIS

Pulpitis - Brief Overview

• Mild inflammation; pulp can recover if cause removed
• Pain: Sharp, brief, stimulus-evoked (cold > heat); disappears immediately after stimulus removed
• Vitality tests positive
• No periapical changes on X-ray
• Treatment: Remove irritant, place sedative dressing, restore

• Severe inflammation; pulp cannot recover
• Pain: Spontaneous, severe, lingering; persists after stimulus removed; thermal changes (heat increases pain, cold may temporarily relieve)
• Vitality tests may be exaggerated positive (acute) or negative (necrotic)
• Treatment: Root canal treatment or extraction

SEQUELAE OF PULPITIS (What happens when irreversible pulpitis is untreated):

Dental Caries → Pulp Hyperemia
                    ↓
             Acute Pulpitis
                    ↓
             Chronic Pulpitis
                    ↓
             Pulp Necrosis
                    ↓
         Spread to Periapical Tissues:
         
1. Periapical Abscess (Acute/Chronic)
2. Periapical Granuloma (most common chronic periapical lesion)
3. Periapical (Radicular) Cyst (most common jaw cyst - arises from granuloma)
4. Osteosclerosis / Condensing Osteitis (bony reaction to mild chronic inflammation)
5. Phoenix Abscess (acute exacerbation of chronic periapical abscess/granuloma)

Further Spread:
6. Cellulitis → Ludwig's Angina (life-threatening)
7. Osteomyelitis
8. Cavernous sinus thrombosis
9. Parapharyngeal/retropharyngeal abscess
10. Actinomycosis (chronic)

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PERIAPICAL GRANULOMA

Definition

Etiology

• Most common cause: Dental caries → pulp necrosis → bacterial toxins/byproducts exit through the apical foramen → periapical inflammation
• Also: Trauma, failed root canal treatment, fractured instruments, perforation, lateral canals
• Bacteria and their products (LPS/endotoxins, short-chain fatty acids, hydrogen sulfide, ammonia) stimulate an immune-inflammatory response in the periapical tissue
• The lesion represents a defensive attempt by the host to prevent bacterial spread from the canal into the jaw

Clinical Features

• Usually asymptomatic (most important clinical feature)
• If acute exacerbation ("Phoenix abscess"): Severe pain, swelling, tenderness
• Tooth is non-vital - negative response to pulp vitality tests (cold, EPT)
• Percussion sensitivity: Mild tenderness to percussion (tapping) in some cases
• Teeth may be slightly extruded (due to periapical inflammation thickening PDL)
• Sinus tract (parulis): In chronic cases, a draining sinus may open on the gingiva ("gum boil") or occasionally on the facial skin; represents a draining pathway for the chronic infection
• No swelling in the quiescent phase; swelling indicates acute exacerbation
• Overlying gingiva and mucosa appear normal
• Regional lymphadenopathy may be present if infected

Radiographic Features

1. Periapical radiolucency - most characteristic finding; located at or near the apex of the offending tooth (or at a lateral canal if lateral granuloma)
2. Well-demarcated but NOT corticated (no sclerotic border) - this is key; radicular cyst may have a corticated rim, but granuloma does not have a true cortical rim (though borders can appear well-defined)
3. Size: Usually <1 cm (periapical radiolucency >1-2 cm more likely to be a radicular cyst)
4. Loss of lamina dura at the apex of the tooth
5. Widening of the periodontal ligament space at the apex
6. Round or oval radiolucency at the apex
7. Radiographically, granuloma and cyst CANNOT be reliably distinguished on X-ray alone (biopsy is definitive)
8. CBCT: Better delineates the lesion; shows cortical plate perforation if present

• Neither can be reliably differentiated by X-ray
• Rule of thumb: Lesion >2 cm → more likely cyst; but this is not absolute

Histopathological Features

1. Core (Central area):
   • Granulation tissue - young connective tissue with proliferating capillaries, fibroblasts
   • Dense chronic inflammatory infiltrate: Lymphocytes (most numerous), plasma cells (immunoglobulin-secreting), macrophages, occasional neutrophils
   • Plasma cells are particularly numerous - they produce specific antibodies against the bacterial antigens (often seen with Russell bodies = plasma cells with immunoglobulin accumulation)
   • Macrophages/Histiocytes - phagocytose bacterial debris; may form foam cells (cholesterol-laden)
   • Cholesterol clefts: Needle-shaped spaces (clefts) in the tissue where cholesterol crystals were located (dissolved during processing) - surrounded by foreign body giant cells (multinucleated); cholesterol derived from breakdown of cell membranes
   • Foreign body giant cells around cholesterol clefts
2. Fibrous Capsule (Peripheral zone):
   • Dense fibrous connective tissue surrounding the granulation tissue core
   • Represents the body's walling-off mechanism
3. Epithelium (Epithelial cell rests - Malassez):
   • In approximately 45-50% of periapical granulomas, epithelial cell rests of Malassez (remnants of Hertwig's epithelial root sheath in the PDL) are found proliferating within the granuloma
   • These proliferating epithelial strands/nests are the precursor of radicular cyst formation
   • When the epithelial lining forms a complete cavity → radicular cyst
4. Neutrophils: Present when acute exacerbation occurs; form microabscesses within the granuloma
5. Russell bodies: Eosinophilic, PAS-positive spherical inclusions within plasma cells; represent accumulated immunoglobulins
6. Hyaline (Rushton) bodies: Hyaline, eosinophilic, linear or curved structures sometimes found within the epithelium of a granuloma or within the cyst lining; may represent degenerated RBCs, mineralized products, or cellular debris; origin debated

Microbiological Features

• The organisms responsible are those found in infected root canals
• Predominantly anaerobic organisms (due to low oxygen tension in necrotic pulp)
• Key organisms:

• Fusobacterium nucleatum (most common)
• Prevotella intermedia, Prevotella nigrescens
• Porphyromonas endodontalis, Porphyromonas gingivalis
• Peptostreptococcus micros
• Treponema denticola

• Streptococcus milleri group (S. anginosus, S. constellatus, S. intermedius) - important in acute periapical abscesses
• Lactobacillus species
• Enterococcus faecalis (especially in failed root canal treatment - resistant to many antibacterials)

• Candida albicans
• Actinomyces israelii (actinomycosis - presents with sulfur granules)

Treatment

1. Root canal treatment (RCT) / Endodontic treatment - primary treatment
   • Cleaning, shaping, and obturation of the root canal removes the bacterial source
   • Granuloma heals (radiographic bone fill) over 6-12 months
2. Extraction - if tooth not restorable
3. Periapical surgery (Periradicular surgery/Apicoectomy): If RCT fails; surgical removal of the apical 3mm of root + the granuloma
4. Antibiotics: Not indicated routinely; only if spreading infection or systemic involvement

Prognosis

• Excellent with adequate root canal treatment; >90% radiographic healing in 12-24 months
• Large lesions may be biopsied to confirm diagnosis (rule out cyst, cementoma, etc.)
• If not treated: May remain quiescent or progress to abscess or cyst

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Quick Reference Index for Q13-Q25