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The first lec. In ORAL PATHOLOGY #

:Firstly Dr. Rima started the lecture by illustrating that You haven't to be absent more than 10% of lectures without medical excuse because you will be out of this .course so keep attendant If you have any comment or problem you cancommunicate with Dr.Rima in the DEANSHIP in sun. and wed. afternoon because the Dr. will be adviser to us as .3rd dental student year The first three lec.s will not be from the referencebook. There will be handouts and slides which will be .on e-learning .So let's start the first lec

Developmental disturbances
Slide # 2

-?What does developmental disturbance mean

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It means that the disturbances and changes due to development without specific cause; without infection, .neoplasia,tumor,reactive changes or soft tissue tumor What are the main structures which are in the oral ?cavity .Teeth, soft tissue and bone So we will talk about disturbances that will affect teeth , soft tissue and bone of oral and maxillofacial .region So you have to be able to differentiate .developmental changes and pathological changes

Slide #3
So starting by teeth disturbances in teeth might be :occurring in -;Size: macrodontia Vs. microdontia .Macrodontia: increasing in the tooth size .Microdontia: decreasing in the tooth size ;Number: hypodontia Vs. Supernumerary

Hypodontia : the number of teeth is less than the .normal number Supernumerary: the number of the teeth is more than .the normal number
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-.Eruption: premature eruption Vs. delayed eruption Shape: there are a lot of changes which affect the -.tooth shape Structure: tooth is composed of three parts; enamel, .dentine and pulp The changes of structure of every normal part will cause different developmental disease than the other .part

Slide # 4
Changes in tooth size will be either microdontia or .macrodontia Firstly, what is the difference between localized and ?generalized microdontia Localized microdontia: some of the teeth are affected, but in generalized microdontia most of the teeth are .affected :Generalized microdontia might be true or relative Relative generalized microdontia: if the teeth are.normal in size but the jaw is abnormally big

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But true generalized microdontia: when thedimension of the teeth is less than the normal sizes .of normal teeth

Note: Be careful when deciding if it's true or relative, because it may look as true microdontia, but by taking measurements then using charts or tables .specific for teeth size you might be wrong As you can see in this slide... As an example of localized microdontia : max. Lateral incisor is taper , it's smaller than normal one, and even its shape is abnormal, so it's called peg lateral. 3rd molar especially max. 3rd molar could be seen rounded, small and conical, so they may be very small .compared to adjacent molars Supernumerary teeth : ( super: extra , numerary : referred to the number ) these additional teeth are usually microdontia so these are microdontia and super numerous

Slide# 5
.Again macrodontia is increasing in the tooth size And it will be true (if teeth size is more than normal sizes of normal teeth) or relatives (If the jaw is small .(and the teeth are normal
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True macrodontia could be occurred due to hormone changes (increasing in growth hormone) and .other endocrine changes

Note: Localized microdontia is more

.common than localized macrodontia

So it's rarely to see one big tooth , in this case you .can see half of the teeth When we will discuss ENSHALLA developmental changes affecting the bone we will discuss hemifacial .hypertrophy Hemifacial hypertrophy: condition in which half of the teeth will be increased in the size, so there will be increasing in the size of half of the face, including: bone, soft tissue, teeth and tongue ( one half of the .(tongue will be bigger than the other half If size of the root of the tooth is increased it's called radiculomegaly and this usually occurred in mand. Canine . So there roots will be bigger than normal .ones

slide # 7 :Firstly these are some notes

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.An: prefix that indicate negation .Hypo: prefix that indicate decreasing

-.Hypodontia Vs. anodentia Anodontia: complete absence of teeth (for example .( 6 yr. pt. without having teeth Hypodontia: decreasing in teeth number (less than -.(normal :Note Syndrome in which there are no teeth (anodontia) is known as ectodermal dysplasia; abnormality in epithelium in some components of the body especially which are related to teeth, we know that teeth are formed by interaction between epithelium (which gives enamel) and mesenchyme ( which gives dentine, pulp and periodontal ligament)so .epithelium is important in teeth formation Now let's discuss hypohydrotic dysplasia Defenition: subtype of the syndrome in which sweet glands are also defective so the pts. Will be abnormal by missing normal sweating so they won't tolerate .high temperature

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We are concerned with hypohydrotic as a subtype of ectodermal dysplasia because of having more than . one type Features: as you can see in slide # 9 you can notice abnormal hair ( very thin hair , protruded upper lip, bulging in frontal bone, no eyedraw, very thin eyelashes and there will be defective sweat glands and anodontia and hypodontia( in which there are decreasing in both number and size; hypodontia and (microdontia

Slide # 8
Causes : the defect in this syndrome is transmembrane protein in keratinocytes affecting .teeth, sweat glands and hair follicles

Q&A
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In other syndromes may there will be no teeth, but there will be impacted in the jaw and may will be supernumerary in this case it is not hypodontia because they are .present but interrupted

Q1: In anodontia , Are the teeth missing from the beginning ? Are they impacted ?in the bone Q2: Does calcium level affect the teeth ?to be missed A1: there are no teeth from the beginning, and even in the bone so to make sure make OPG (ortho pantomograph) or radiograph for the .whole jaw A2: Ca level affects on structure of .teeth not the number or the size

Slide # 11
This slide talks about teeth that will be missed congenitally; means that if the parent congenitally missing later incisor (for example) some of the .children will also have congenitally missing lateral For the permanent teeth: lateral incisor, 3rd molar, (not of us have four third molars), second premolar .especially upper For the deciduous teeth: maxillary laterals are the .most common congenitally absent teeth
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Slide # 12
:Supernumerary teeth -.Single or multiple; single: one extra tooth Multiple: more than one extra tooth -.Erupted or impacted A common location of supernumerary tooth is in the* midline of maxilla between two central incisors and it may erupt adversely like in the floor of the nose or .may be impacted ??????????Think about this case If the supernumerary tooth is impacted in the bone, ?what are changes could be happen It will resorb the adjacent teeth, it may have odontogenic tumor or odontogenic cyst, it may develop anything ( cyst , tumor,) like any other .normal teeth Maxilla is much more common to have.supernumerary teeth compared to mandible

:In maxilla

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Mesiodens: supernumerary tooth that erupt in themidline of maxilla (mesio; it erupted mesially to (both central incisors Paramolar : extra molar (fourth molar) which.erupts distally to the last molar Patients with cleft palate may developsupernumerary teeth in later incisor region, so these patients develop hypodontia ,or hyperdontia .(( supernumerary tooth

:In mandible .Premolars ,fourth molars and incisors

:In deciduous Maxillary lateral incisor may have supernumerary .teeth The shape is conical (indicates microdontia )or -.normal

Note: supernumerous teeth which are normal in .shape are called supplemental From the book: supplemental teeth: supernumerous teeth which morphologically .resemble those of normal series
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Slide # 13
:This slide shows supernumerous teeth
11

1 2

what do we call this supernumerous conical tooth-1 that is in the midline (between incisors) #1 ? .mesiodens if you look to lateral incisor tooth, you will see-2 (mesially ) supernumerous tooth,is it conical or ?supplemental #2 .It's supplemental because of its normal shape ?how many supernumerous teeth are there -3 .Three supernumerous teeth

Slide # 14

How many supernumerary teeth do you see?-1

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.(They are 2 (3rd and 4th premolars ?Are they conical or supplemental-2 They are supplemental because of their normal .shape

Slide # 15
What are syndromes in which there are multiple and ?impacted supernumerous teeth Cleidocranial dysplasia: (taken later) there will be no -.clavicle Gardner syndrome: serious syndrome in which all the.patients will develop adenocarcinoma of the colon Firstly, Dr. asked us if we took multiple osteoma, intestinal poly-p, intestinal adenoma in general pathology, then she asked: What is the difference ?between adenoma and poly-p in intestine -.Adenoma: pre-malignance. - Poly-p: benign

As a dentist you are supposed to be the first one to discover if your patient has Gardner syndrome or not, by taking radiograph then you notice that there are a lot of impacted and multiple supernumerous teeth, What will your diagnosis be since both of cleidocranial dysplasia and Gardner syndrome have this feature( multiple and impacting supernumerous ?teeth In cleidocranial dysplasia Pts. There will be NO clavicle, so there is approximation between
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shoulders, if not your diagnosis will be Gardner syndrome, and then genetic diagnosis will be done, .then Pts. Start to treat their intestinal adenoma

Slide # 16
Disturbances in eruption will be either pre-mature or .delayed eruption or impacted teeth What's the difference between natal teeth and neonatal ?teeth Natal teeth: one or more tooth that present in infant .mouth at birth Neonatal teeth: one or more tooth that present in the .first month of birth The deal Q is: Are these teeth supernumerous (that could ?be extracted) or deciduous They are deciduous, so there are no associated problems with this tooth, NO ulceration, NO feeding problems, so .we keep them without extraction Note: any chronic irritant is not acceptable in oral cavity, like fractured tooth or sharp cusp and fractured .restoration because they will induce chronic irritation If you remember when we took neoplasia in 2nd year, wetook chronic irritation it's a chronic inflammation which has a lot of inflammatory mediators and chemokines which induce proliferation of cells and then mutation will .be more
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Chronic irritation is a questionable not confirmed cause.of oral carcinoma Slide # 18 :Causes of impacted teeth -:Physical barrier Impacted tooth is one of the other disturbances of eruption, actually there must be a barrier; it could be soft tissue like in gingival fibromatosis or very thick gingiva or the adjacent tooth is inclined or there are impacted supernumerous teeth or impacted adjacent tooth. So it's something obstruct the way of the tooth or the tooth itself is inclined so the path of .eruption may be abnormal Crowding, odontogenic cyst ,supernumerous tooth ,or.the tooth itself has odontogenic tumor :Examples 3rd molars; sometimes it's inclined mesially or distally so abnormal path of eruption, or the adjacent tooth prevent .the normal path Maxillary canines: if they are horizontally lying in maxilla.so they will be impacted Treatment: in need to surgical TM then orthodontic TM .to pull canines down ,Delayed eruption is another disturbance of eruption :Causes
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Cleiodocranial dysplasia : because of the presence ofmultiple and impacted supernumerous teeth they will .delay the eruption of normal adjacent teeth Gingival fibromatosis : so Pts. Need surgical TM to allow.teeth to erupt Slide # 19 If you are asked from your relatives about a case in aninfant mouth that there is a small piece of bone over an erupting 2nd deciduous molar (for example) sure you will !!answer quickly It's a bone sequestrum . When the tooth is erupting it resorbs the bone, so may will still a small unresolved .bone on the occlusal surface of this erupting molar It's normal condition and it will be lost by itself, it is not .pathological so there is no need to TM Note: this condition is different from sequestrum .)osteomyelitis so you have to be accurate ) AS A SUMMARY: eruption sequestrum is a specule of calcified tissue that is extruded from the alveolar mucosa, and it has strange appearance, it requires no .TM Slide # 20 :Disturbance in the shape of the tooth :Dileceration
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Definition: disturbance in the shape of the tooth, it's a curve in its root and this curve occurs before mineralization, because if it occurs after mineralization ( like in trauma) fractures may occur because it's hard and brittle but before mineralization a sharp curve .may occur and mineralization may follow When I asked the Dr. if dileceration just involves in the" root without the crown she answered that just in severe " cases crown is involved As a summary: dileceration involves variable severity and location along the root and just in severe case .crown is involved :Causes -.Trauma during teeth development -.Continued root formation - .Idiopathic :Complication -.Difficult extraction -(Difficult RCT (root canal treatment There is Q. which I couldn't hear but Dr. answered that normal procedures (caries, composite filling,)could done easily but the problem in RCT and extraction because it needs special consideration . Apexectomey .could be done by cutting apex then fill it Slide # 21
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: The other disturbance in shape is Taurodontism If you compare the two teeth at this radiograph at the furcation site; in the normal tooth there is furcation site then two roots, but in the other tooth there are two short roots, so the problem here is apical placement ( the .(furcation site is downward to the apex :Complication .Difficult RCT : difficulty in finding canals orifices Difficult extraction: special care when using forceps to extract the tooth from its furcation site which is .downward

:Association :This disturbance is associated with -.Amelogenesis imperfect -.Down syndrome - .Klinefilter syndrome slide #23 The third change is dense invaginatus Firstly what is the difference between invagination and ?evagination In invagination: downward growth occurs the growth goes inside the tooth or the organ BUT in evagination: .it goes outside
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First of all to get the idea of dense invaginatus you have to know that enamel has the highest opacity comparing .to other parts of tooth If you look at tooth on the left in slide # 24 you will notice high radio density for enamel, in other words enamel is more opaque compared to dentine so what happens is: before mineralization there is invagination of enamel through crown or root so enamel will be in abnormal site and we can guess that by high radio density of enamel or aesthetic problem of the tooth ( I think it will be bulgy in severe cases) so enamel will move to the pulp champer or ( sometimes) to the pulp .canal then goes up So you can guess that pit has an open side ( in oral cavity) and closed side( in the pulp) which is lined by enamel( so you will notice high opacity site comparing to .(adjacent dentine -?What is the significance of this pit By this pit, food and bacteria will be accumulated and caries will occur, then the lining of the pit may perforate (perforation due to the analysis of food debris by bacteria so acids will be formed) and that will cause pulpitis (inflammation of the pulp) by the entrance of the bacteria, then the pulp may will be necrotic or the products of the bacteria will go in the apical area then form abscess or granuloma or inflammation in the .alveolar bone

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So as a summary: the significance of the dense invaginatus is the exposure of the pulp silently (because this process is gradual) then forming an abscess then your patient may come with draining abscess. Prevention: with fissure sealant to prevent pulp .exposure Detection: by making radiograph and by using prop or .thin file so it will reach variable ways .Causes: idiopathic or trauma The tooth may will be extracted to aesthetic reasons only .in severe cases

If you look at the same slide on the right in this case dense invaginatus is severe because it reaches the apex so this invaginatus is severe , dilated , has calcified mass, changing in crown shape and doesn't look as pit or canal this case is called dilated odontume ( so named because it's wide and reaches the pulp and has a .(collection of enamel and dentine and some pulp So the most severe form of dense invaginatus is dilated .odontome Dr. asked us if there is congenitally absent decidous lateral incisor . Will there be congenitally absent .permanent lateral incisor? The answer is YES Dr.Rima reminds us about cusp of carabelli that it's additional cusp in mesiolingual surface of the upper first .(molar ( as in slide # 25
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Slides # 26 & 27
Dense evaginatus. In this case extra cusp will usually .on premolars especially lower ones Why is this extra cusp considered as significant ??? ???case It may interfere with occlusion because it's simply extra .cusp If it's fractured, dentine will be exposed then sensitivitywill happen, and even pulp exposure because of the .presence of pulp horn inside this cusp So patients with this case ( dense evaginatus) can't treated by just trimming because that will expose .dentine or pulp but instead of this RCT could be done Another cusp which is talon cusp, extra cusp( has enamel, dentine and pulp) that's usually on the upper anterior teeth ( usually central incisors and sometimes lateral incisor) it interferes with the occlusion and it can't .be just trimmed, RCT could be done This cusp could have grooves in either sides or pits so food and bacteria could be accumulated and caries could happen, so fissure sealant could be used to prevent .food accumulating :Radiograph in slide #26 Do you notice that dense invaginatus is the adverse ofdense evaginates? In dense invaginatus the radiopaque (
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enamel) is toward the pulp, but in dense evaginatus it's .toward the incisal edge Note: if we don't reach pulp in trimming there is no need to RCT, but if trimming makes exposed dentin in this .case filling material could be used Supernumerary roots are rare, most common on premolars ,canines and 3rd molars.. and there significance will be in both RCT( we have to find the extra root to treat it because we can't treat infections by treating root and leave others) and in extraction because if we don't detect it, it may still without removing, so taking radiograph is important in both RCT and extraction even if the tooth is about to be .extracted

slide #28 :Disturbances in the shape of the tooth -Gemination -.Fusion -.Concrescence -.Hypercementosis -.Cervical enamel projection Double teeth include both gemination and fusion and if it's not gemination or fusion it will be macrodontia but it's .rarely to see just one macrodontia tooth
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Fusion: occurs when teeth germs are fused togother ( because teeth germs are present close to each other) , so one single big crown will form and it could be completely fused roots or not, but at least dentine should .be fused to be named as fusion Fusion could be completed or not according to the stage of the development y3ni when fusion occurs it will just include structures which are not harden yetso there will .be no fusion between hard structures Gemination: one tooth germ gives two teeth (( twinning definition difference Gemination One tooth germ gives two fused teeth No missing teeth fusion Union of teeth germs Missing teeth

Gemination looks like fusion clinically but you can differentiate between these two disturbances by counting the teeth if you find missing teeth it will be fusion, if .not it will be gemination -?How could it look in radiograph One big root and two fused crown .((twinning Concrescence: fusion by cementum which covers the roots so the fusion will be in the roots and there is special features in this disturbance that it's the only one which
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occur after tooth eruption so it could be developmental .or occurring later :Causes of concrescence -Mal alignment of teeth Hypercementosis: two adjacent teeth withoutconcrescence then by caries or inflammation in the preapical area hypercementosis will happen because .cementum is dynamic so it could deposit unlike enamel Significance : extraction of the two fused teeth in this case requires minor oral surgery by breaking the teeth .then cut them and then extract them in pieces ?How does the cementosis look like in radiograph The normal roots are taper, not bulgy or rounded as in concrescence case and we could see lamina durra and soft tissue( black line in the radiograph) which surround the cementum so that indicate the .presence of hypercementosis :Causes of hypercementosis High occlusal load: if the tooth is exposed to high occlusal stress it will start to deposit cementum to withstand the forces, as in high filling or by stressing .(on the teeth (bruxism Low occlusal load: if the tooth is under occlusion(infra occlusion) so there will be stimulation to the cementum to composite for a reason or another , as .in low filling
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Infection: low grade infection may will start to stimulatedeposition of cementum when reaching the pulp instead .of resorbing it -.Hormonal changes: as in hyperituitarism -.Paget's disease of the bone :Significance Extraction: instead of having taper roots which are easily extracted, there will be rounded, bulgy roots so difficulty will be faced, or it could cause concrescence with . adjacent tooth which is impacted or horizontally lying :Cervical enamel projection developmental change causing enamel to deposit over cementum; Normal location of the enamel is on the crown not on the root surface the significance is in the periodontal ligament . PDL will be between cementum and alveolar bone and if the enamel covers cement there will be no insertion to PDL on the cementum (because .enamel is much mineralized compared to cementum ?How could we detect it clinically By using prop you will notice that there is like a pocket between the gingiva and crown it can't be seen but .can be detected clinically :Cause Developmental change causing enamel to deposit over .cementum
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:Complication Accumulating food and bacteria so periodontitis will .occur Another abnormal site either than over cementum is furcation area in molars; in which droplet of enamel will be formed either having dentine in it or not and it's called .enamel pearl :Significance of enamel pearl Abnormal PDL insertion in that site so loss of the PDL .could be and so furcation involvement

.DONE BY: Mays Jaradat

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