11: Miscellaneous Lesions

Chapter 11

Miscellaneous Lesions

Aim

This chapter aims to outline the non plaque-induced periodontal lesions and manifestations of systemic diseases that do not readily fall under the descriptive headings used in the previous 10 chapters. These lesions present primarily as incidental or intentional radiological findings, as gingival bleeding that is inconsistent with local irritants, as para-gingival swellings or annular lesions.

Outcome

At the end of this chapter the reader should have a clear insight into the nature, diagnosis and management of lesions that are discussed therein.

Introduction

Table 11-1 summarises the non-radiological lesions to be discussed. Tables 11-2 to 11-4 list those lesions normally detected radiologically and consistent with the general approach taken within this text, categorised by radiological appearance. The approach taken is similar to that of Langlais, Langeland and Nortjé in Diagnostic Imaging of the Jaws, which is recommended for further reading. Radiological features of periodontitis are not discussed, and those lesions of the soft tissues that can appear on radiographic films are also beyond the scope of this chapter. Only those lesions and conditions likely to present to the periodontal clinician rather than the radiologist will be discussed briefly.

Table 11-1 Miscellaneous lesions presenting in and around the periodontal tissues
Category Condition Sub-Classification Discussed or Refer Reader
Uncontrolled/ un-explained gingival bleeding Myelodysplasia Primary discussed
Secondary discussed
Clotting factor deficiencies Factor VIII discussed
Factor IX discussed
Idiopathic thrombocytopenic discussed purpura (ITP) discussed
Platelet pool storage disease discussed
Acute leukaemia discussed
Chronic leukaemia discussed
Thrombocytopaenia Secondary to liver disease discussed
Drug-induced discussed
HIV-associated discussed
Benign familial thrombocytopaenia discussed
Aplastic anaemia discussed
Thrombasthenia discussed
Patients on warfarin discussed
Para-gingival swellings Osteomas discussed
Gardner’s syndrome discussed
Mandibular/maxillary tori discussed
Annular lesions Erythema migrans discussed
Erythema multiforme Stevens Johnson syndrome discussed

 

Table 11-2 Radiological lesions or conditions involving or associated with the roots
Radiological Categorisation Condition Sub-group Discussed or Refer Reader
Root resorption Internal root resorption reader referred
External root resorption Cervical
Infra-cervical
discussed
Inter- and peri-radicular radiolucencies Scleroderma (systemic sclerosis) discussed
Periapical cemental dysplasia discussed
Lateral developmental periodontal cyst (Botyroid cyst) discussed
Lateral inflammatory periodontal cyst discussed
Gingival cyst discussed
Incisive canal cyst discussed
Solitary bone cyst reader referred
Median mandibular cyst reader referred
Squamous odontogenic tumour discussed
Ameloblastoma Classical
Unicystic
Peripheral
Malignant
discussed
Ameloblastic fibroma discussed
Histiocytosis-X Unifocal (solitary eosinophilic granuloma)
Inter- and periradicular radiopacities Periapical osteosclerosis (sclerosing osteitis) discussed
Condensing osteitis discussed
Hypercementosis discussed
Cementomas Cementoblastoma discussed
Periapical cemental dysplasia discussed
Gigantiform cementoma discussed
Cementicles discussed
Ossifying fibroma discussed

 

Table 11-3 Radiolucent lesions
Radiological Categorisation Condition Sub-group Discussed or Refer Reader
Well circumscribed radiolucencies Odontogenic keratocyst discussed
Inflammatory cysts Periapical discussed
Peri-implant discussed
Neural sheath tumours Neurilemmoma discussed
Schwannoma discussed
Neurofibroma discussed
Neurofibromatosis discussed
Multi-locular radiolucencies Odontogenic keratocyst and Gorlin-Goltz syndrome discussed
Botyroid cyst (lateral developmental periodontal cyst) discussed
Ameloblastoma Polycystic discussed
Malignant discussed
Odontogenic myxoma discussed
Giant cell tumour of bone (central giant cell granuloma) discussed
Arterio-venous malformation discussed
Aneurysmal bone cyst discussed
Central haemangioma reader referred
Sturge Weber syndrome Arterio-venous malformations discussed
Cherubism discussed
Odontogenic fibroma reader referred
Ossifying fibroma Calcifying/ossifying fibrous epulis discussed
Poorly defined radiolucent lesions Osteomyelitis discussed
Osteoradionecrosis Sterile
Septic
discussed
Intraosseous carcinoma discussed
(Epidermoid carcinoma)
Gingival carcinoma Squamous cell discussed
Cuniculatum discussed
Mucoepidermoid carcinoma reader referred
Clear cell carcinoma reader referred
Ameloblastic carcinoma discussed
Metastatic tumour Adenocarcinoma of lung reader referred
Prostate carcinoma reader referred
Breast carcinoma reader referred
Renal carcinoma reader referred
Melanoma reader referred
Fibrosarcoma reader referred
Ewings sarcoma reader referred
Radiolucent lesions as presentations of disseminated disease Histiocytosis-X Progressive (disseminated or Letterer-Siwe disease) discussed
Multifocal (Hand-Schuller-Christian syndrome) discussed
Multiple myleoma discussed
Non-Hodgkins lymphoma discussed
Burkitt’s lymphoma reader referred
Leukaemia discussed
Generalised radiolucencies Hypophosphatasia Neonatal (Lethal) discussed
Infantile discussed
Childhood discussed
Adult discussed
Pseudo-hypophosphatasia
(Odontohypophosphatasia)
discussed
Hyperparathyroidism Brown tumours discussed
Sickle cell anaemia discussed
β-thalassaemia reader referred
Radiolucent lesions with radiopacities Periapical cemental dysplasia discussed
Calcifying odontogenic cyst discussed
Calcifying epithelial odontogenic tumour discussed
Adenomatoid odontogenic tumour discussed
Ameloblastic fibroadenoma reader referred
Odontomes Compound discussed
Complex discussed

 

Table 11-4 Radio-opaque lesions
Radiological Categorisation Condition Sub-group Discussed or Refer Reader
Focal radioopacities Garrè’s osteomyelitis reader referred
Hyperostosis reader referred
Osteoma discussed
Osteoblastoma reader referred
Osteoclastoma reader referred
Osteosarcoma discussed
Osteogenic sacroma reader referred
Chondroma reader referred
Chondroblastoma reader referred
Chondrosarcoma reader referred
Generalised radiopacities Gardner’s syndrome discussed
Osseous dysplasia reader referred
Sclerosing osteomyelitis discussed
Fibrous dysplasia discussed
Albright’s syndrome discussed
Paget’s disease discussed
Osteopetrosis Albers-Schönberg disease discussed
Hyperostosis discussed

Uncontrolled/Unexplained Gingival Bleeding

When patients present with gingival bleeding that is not consistent with levels of plaque or inflammation, underlying systemic disease should be suspected and appropriate investigations undertaken.

Myelodysplasia

The myelodysplastic syndromes (MDS) are rare haematological disorders of the myeloid cell lineages. They have an incidence of 4:100,000, are heterogeneic in nature and thought to be part of the same spectrum of disorders that give rise to acute myeloid leukaemia (AML). Previously called ‘preleukemia’, MDS has been diagnosed following persistent herpes labialis, severe oral mucosal ulceration and unexplained or spontaneous gingival bleeding, which was inconsistent with plaque levels (Chapple et al, 1999). The incidence of MDS appears to be increasing, and due to the high mortality rates associated with this group of disorders, it is important that the dental surgeon, who may be the first person to whom patients with MDS present, is aware of this group of disorders. Presentation is normally in patients over 60 years of age.

Clotting Factor Deficiencies

Clotting factor deficiencies that may give rise to excessive gingival bleeding include:

  • Von-Willebrand Factor deficiency (important for platelet adhesion).

  • Factor II.

  • Factor VII.

  • Factor VIII (haemophilia). Many haemophiliacs now self-manage by injection of recombinant factor VIII.

  • Factor IX (congenital factor IX disease, also called Christmas disease or haemophilia B).

  • Factor X.

  • Factor XII deficiency (Hageman factor).

Idiopathic Thrombocytopenic Purpura (ITP)

ITP is a chronic autoimmune condition of insidious onset without any identifiable or associated illness. It is a chronic condition that typically affects young and middle aged adults, with a female: male ratio of 3:1. In 30% of adults it is persistent and appears resistant to most forms of treatment. The pathogenesis involves increased platelet destruction by autoantibodies to platelet membrane antigens (glycoprotein 11b/111a).

Platelet Pool Storage Disease

This is a mild congenital bleeding disorder, generally managed by Desmopressin acetate (DDAVP) medication. It is associated with:

  • Glanzmann’s thrombasthenia – a condition caused by lack of a protein required for platelet aggregation, bleeding might be severe.

  • Bernard-Soulier syndrome – a congenital disorder where platelets lack receptors to adhere to vessel walls. Bleeding may also be severe with this disorder.

Acute Leukaemia

This is discussed in Chapter 8.

Chronic Leukaemia

See Chapter 8.

Thrombocytopaenia

Thrombocytopaenia is by definition a platelet deficiency, the defining level being <150,000 platelets per ml of blood. In clinical terms, control of haemorrhage does not normally become a problem in non-surgical periodontal therapy unless platelet levels fall below 60,000 per ml. There may be many underlying causes of thrombocytopaenia and these include:

  • Advanced liver disease.

  • HIV-associated thrombocytopaenia.

  • Secondary to immunosuppressant and cytotoxic drugs.

  • Idiopathic thrombocytopaenic purpura (ITP).

  • Platelet pool storage disease.

  • Other auto-immune diseases.

  • Wiskott-Aldrich syndrome.

Aplastic Anaemia

This is a rare condition that is associated with reduced haemopoetic tissue and a pancytopaenia. Gingival bleeding and advanced periodontal bone loss have been reported.

Thrombasthenia

See Glanzmann’s thrombasthenia above.

Patients on Warfarin

Warfarin is the most commonly employed anticoagulant used in patients with a history of:

  • Cerebro-vascular accident (stroke).

  • Myocardial infarction.

  • Thyrotoxicosis with associated cardiac arrhythmias.

Warfarin is a competitive antagonist of vitamin K, which is required for the production in the liver of Factors II, VII, IX and X. These factors are utilised in the coagulation cascade. Warfarin affects the prothrombin time (a measure of the extrinsic coagulation pathway), which is measured in a standardised way as the International Normalised Ratio (INR). An INR of 1.0 is normal, but an increasing ratio is associated with reduced coagulation. A growing body of opinion suggests that provided the INR is ≤ 4 and, local haemostatic measures are employed, periodontal and minor oral surgical procedures can be carried out with minimal post-operative haemorrhage. It is, therefore, less likely that warfarin doses may need to be adjusted in such patients. However, certain drugs may potentiate the action of warfarin and these include:

  • Penicillin V.

  • Amoxicillin.

  • Miconazole (including topical applications).

  • Erythromycin.

  • Metronidazole.

  • Fluconazole.

If bleeding does not respond to local measures in patients taking warfarin, the use of tranexamic acid is recommended. Tranexamic acid is a non-physiological inhibitor of fibrinolysis and an extremely effective haemostatic agent when used as a mouthwash (5%, 10mls as a rinse for two minutes and then spit out). It can be used four times daily for five to seven days, but avoid food and drink for one hour after rinsing.

Para-Gingival Swellings

Osteomas

Clinical appearance

  • Solitary or multiple well-circumscribed swellings (Fig 11-1).

  • Bony hard.

  • Surface epithelium is intact (no ulceration).

QE43-44_Chapple_fig223.jpg

Fig 11-1 Well circumscribed benign osteoma affecting the UL3 region.

Clinical symptoms

  • Painless swelling.

Aetiology

These are benign slow growing tumours of mature bone, usually diagnosed in adult life.

Involvement of non-gingival sites

Multiple osteomas of the jaw are a feature of Gardner’s syndrome, a rare autosomal dominant condition. The syndrome also includes:

  • Polyposis coli (high incidence of malignant transformation).

  • Sebaceous cysts of the skin.

  • Multiple fibrous tumours of skin.

  • Multiple supernumerary teeth.

  • Multiple impacted permanent teeth.

Differential diagnosis

  • Torus palatinus or mandibularis.

  • Osteoblastoma.

  • Osteochondroma (usually in children).

  • Ossifying fibroma.

  • Ameloblastoma.

  • Fibrosarcoma.

Clinical investigation

  • Radiology.

  • Biopsy.

Management

No treatment unless aesthetic or functional problems have arisen due to the size of the osteoma. In the latter case, surgical re-contouring may be indicated.

Gardner’s Syndrome

See above.

Mandibular Tori

Tori are examples of bony ‘exostoses’, which are benign outgrowths of bone. Normally tori are developmental but they may arise following chronic stimulation as reactive exostoses. The torus palatinus clasically arises in the midline of the palate and the torus mandibularis arises lingual to the mandibular premolar teeth (Fig 11-2). No treatment is indicated unless pre-prosthetic surgery is deemed necessary.

QE43-44_Chapple_fig225a.jpg

Fig 11-2 Classical mandibular tori.

Annular Lesions

Erythema Migrans

Clinical appearance

Erythema migrans may arise in several oral mucosal sites, but usually involves the tongue, where prevalence figures are approximately 2% (Fig 11-3). The term describes red patches, said to look like a map, which vary in size and location, often with a yellow margin surrounding areas of depapillation.

QE43-44_Chapple_fig225b.jpg

Fig 11-3 Erythema migrans.

Clinical symptoms

  • Usually asymptomatic.

  • Soreness of the tongue, especially with salty or spicy foods.

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Jan 15, 2015 | Posted by in Periodontics | Comments Off on 11: Miscellaneous Lesions
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