The oral medicine and oral surgery–endo interface
Periapical disease presents with swellings and radiographic changes (osteolytic or osteosclerotic). It is therefore, essential for dentists to be aware of any non-endodontic lesions that may mimic periapical pathosis. Although many of the lesions presented in this chapter appear to have such distinct appearance that it may seem unlikely they would be confused with apical pathosis, hospital records and journals are full of cases where just that has happened. At best, this may be embarrassing and, at worst, it could cost a life. Such confusion need not represent incompetence since all dentists are taught the features of central tendency of any condition, as the commonest presenting characteristics. Only experience and further training will enable the full spectrum of normal distribution of disease presentation to be grasped. The problem is that presentations of many diseases can have overlapping features when the full spectrum of disease presentation is taken into account; the overlap is greater for some diseases than others, particularly when the time-line or natural history is considered. There may be greater overlap at the incipient stages.
Endodontists and dentists should therefore, remain familiar with alternative diagnoses and retain a broad surgical sieve at their finger-tips. The purpose of this chapter is not to provide encyclopaedic information about alternative disease states but to provide an organized summary listing of the factors to consider. Where suspicions are aroused by a disease presentation, an appropriate referral to a specialist should be sought.
When examining any lesion whether obviously related to a tooth or adjacent to a tooth, a standard description (Table 17.1) is undertaken in order to establish diagnosis or enable differential diagnosis.
Hard and soft tissue swellings are often encountered in the orofacial region and are most frequently hyperplastic, reactive proliferations of epithelium and connective tissue, due to irritation, chronic injury or infection. Self-limiting growths or benign neoplasms of connective tissue develop from fibrous tissue, endothelia, skeletal and smooth muscle, lipocytes, nerve sheaths and osteoprogenitor cells. Although usually slow growing some may be aggressive and cause local destruction. Malignant connective tissue sarcomas with their metastatic potential and rapid spread are rare but early detection is important before haematogenous spread occurs. Epithelial derived squamous cell carcinomas are however, the most common malignant neoplasm of the oral cavity.
Other tissues involved in orofacial soft tissue swellings may be epithelial (Table 17.3) in origin or related to the salivary glands (Table 17.4), haematological (Table 17.5) tissues or cysts (Table 17.6).
|Benign epithelial lesions||Squamous papilloma, epithelial polyp (Fig. 17.2)
Keratocanthoma, verrucous papilloma (Fig. 17.3a)
Leaflet papilloma (Fig. 17.3b,c)
|Benign pigmented lesions||Melanotic macule, naevi, seborrheic keratosis, actinic lentigo, Peutz–Jeghers syndrome, melasma, acanthosis nigricans|
|Epithelial hyperplasia||Hyperkeratosis, acanthosis, nicotinic stomatitis, proliferative verrucous leukoplakia|
|Epithelial atrophy||Oral submucous fibrosis|
|Epithelial dysplasia||Carcinoma in situ|
|Malignant epithelial neoplasms||Squamous cell carcinoma (Fig. 17.4), verrucous carcinoma (Fig. 17.5)|