Mucosal pain disorders of the head and neck

Painful disease processes that affect the mucous membranes of the upper aerodigestive tract include viral and bacterial infections, hypersensitivity reactions, and immunopathologic disorders. The diagnosis and treatment of the most common diseases that cause pain are described.

Mucosal pain disorders of the head and neck

Painful disease processes that affect the mucous membranes of the upper aerodigestive tract include viral and bacterial infections, hypersensitivity reactions, and immunopathologic disorders. The diagnosis and treatment of the most common diseases that cause pain are described.

Oral lymphomas in HIV-infected patients: association with Epstein-Barr virus DNA

Nine instances of oral non-Hodgkin's lymphoma occurring in homosexual male patients infected with the human immunodeficiency virus were evaluated for clinical features, histopathologic features, lymphocyte phenotypic markers, and Epstein-Barr virus (EBV) DNA. Histologically, the tumors represented immunoblastic sarcoma and small noncleaved cell lymphomas, some manifesting Burkitt-like features. Five cases exhibited positive staining with monoclonal antibody L26, a B-cell marker; none of the tumors showed evidence of a T-cell lineage with the use of monoclonal antibody UCHL 1. DNA in situ hybridization studies disclosed the presence of EBV DNA sequences in seven instances. These findings indicate that most oral lymphomas among patients with AIDS, similar to extraoral lymphomas in this population, are of B-cell lineage and harbor EBV DNA.

Hairy leukoplakia: Epstein-Barr virus receptors on oral keratinocyte plasma membranes

Hairy leukoplakia (HL) is an oral white lesion associated with, and probably caused by, the Epstein-Barr virus (EBV) among persons who are seropositive for infection with human immunodeficiency virus. A unique feature of HL is its localization to the lateral portion of the tongue. To determine site differences for EBV receptors according to epithelial phenotype, these receptors were mapped in oral mucosa with the use of monoclonal antibodies HB5 and B2(specific for the Complement Fraction 3d/EBV receptor on B lymphocytes). Immunoperoxidase and immunofluorescence techniques were employed with the use of both cytologic suspensions and frozen tissue sections of oral epithelium. Pericellular plasma membrane immunoreactants were localized to upper spinous layer cells of the parakeratin phenotype; basal and parabasilar layers as well as all strata of orthokeratinized epithelia were negative. Those cells harboring EBV DNA as detected by in situ hybridization corresponded to cells with C3d/EBV receptors.

Detection of EBV and HPV DNA sequences in oral "hairy" leukoplakia by in situ hybridization

Oral "hairy" leukoplakia (OHL) is a white lesion of the oral mucosa, usually located on the lateral tongue among human immunodeficiency virus (HIV) positive acquired immunodeficiency syndrome (AIDS)-risk patients. The lesion has been reported to be associated with Epstein-Barr virus (EBV) and human papillomavirus (HPV). Twenty surgical biopsy specimens were evaluated for the presence of HPV genus-specific antigen, HPV 2/4, 6/11, and 16/18 DNA and EBV DNA by in situ hybridization employing formalin-fixed paraffin-embedded sections. Three cases exhibited immunoreactivity for HPV genus-specific antigen, with localization in cytopathically altered upper spinous layer keratinocytes. HPV 16, 18, or related DNA sequences were identifiable in a single case. Alternatively, employing an EBV long internal repeat subgenomic probe, 19 cases were found to harbor EBV DNA. In all positive cases, the hybrids were localized to upper spinous layer keratinocytes exhibiting nuclear/cytoplasmic vesiculation. It is concluded that OHL is consistently associated with EBV; furthermore, viral replication, as evidenced by DNA localization, corresponds to ultrastructural evidence of capsid and envelope assembly in the more differentiated layers of oral epithelium.

Oral squamous papillomas: detection of HPV DNA by in situ hybridization

Oral squamous papillomas were segregated from other papillary lesions on the basis of histopathologic features. Twenty representative papillomas were evaluated for the presence of papillomavirus genus-specific antigen with the use of an immunoperoxidase technique. These same tumors were analyzed for human papillomavirus (HPV) types 2, 4, 6, and 11 with biotinylated full-length double-stranded DNA probes by in situ hybridization. Only one case exhibited papillomavirus antigen reactivity. Alternatively, seven of twenty cases (35%) yielded positive results for HPV 6 or 11 DNA; one papilloma exhibited a dual infection with both HPV 2 and 6 when assayed under conditions of high-stringency hybridization. It is concluded that some oral squamous papillomas harbor HPV genotypes akin to those encountered in genital tract condylomas. Viral DNA can be detected in the absence of capsid antigen immunoreactivity, thereby obviating the use of antigen detection assays for determining the presence or absence of virus.

Oral granular cell tumors: a clinicopathologic and immunocytochemical study

To investigate the histogenesis of the granular cell, a large series of granular cell tumors was studied for clinical and histopathologic features with emphasis on immunocytochemical markers. The nongingival granular cell tumors (NGGCT) were found to be more prevalent among females than males by a ratio of 2:1 and arose on the tongue (67%), the buccal mucosa (13%), the lips (8%), the soft palate (6%), and other sites (6%). With the use of the avidin-biotin-peroxidase method, polyclonal rabbit antisera were employed. The antisera were directed to the following antigens: S-100 protein, myoglobin, myosin, actin, desmin, alpha-1-antitrypsin, and muramidase. Results indicated that granular cell tumors are not homogenous for immunocytochemical markers. Nongingival granular cell tumors were universally positive for S-100 protein and failed to exhibit immunoreactivity for myogenous or histiocytic markers. Alternatively, the gingival granular cell tumor of infancy was negative for all markers, whereas rhabdomyoma was reactive with myogenous markers and a subpopulation of tumor cells displayed S-100 protein immunoreactivity. The granular cell ameloblastoma was reactive only with antiserum to alpha-1-antitrypsin. Ultrastructurally, granular cells from one of two NGGCT showed a direct evolution from skeletal muscle fibers. It is concluded that the oral NGGCT is a tumor positive for S-100 protein that may arise from muscle or nerve sheath.

Human papillomavirus type 2 DNA in oral and labial verruca vulgaris

Twenty instances of verruca vulgaris, equally divided between oral mucosa and lip vermillion, were assayed for the presence of human papillomavirus (HPV) capsid antigen and type-specific DNA employing in situ hybridization methods. All 10 cases arising on lip vermillon expressed capsid antigen and harbored HPV Type 2 genomes as assessed under conditions of high stringency DNA hybridization. Oral verrucae rarely expressed capsid antigen; HPV Type 2 genomes were encountered in 20% of the cases.

Juvenile fibromatosis of the infratemporal fossa

A case of extensive juvenile fibromatosis of the infratemporal fossa in a 2-year-old child, which was evident only as progressive mandibular hypomobility, is reported. The current literature is reviewed with regard to the etiology of the fibroproliferative lesions, the histopathologic diagnosis, and treatment modalities. Although complete surgical resection is the treatment of choice, radiation therapy and chemotherapy have been recommended in extensive cases. Because of the immense size and location of the lesion in the case presented herein, the tumor was deemed inoperable and was treated with multimodality chemotherapy.

Demonstration of human papillomavirus DNA in oral condyloma acuminatum

Condyloma acuminatum arising on oral mucous membranes exhibits distinct histopathological features that allow for differentiation from the more common squamous papilloma. These lesions are parakeratinized with cryptic invagination of cornified cells extending into an acanthotic spinous cell layer. Superficial spinous layer koilocytosis is a prominent feature and the condylomatous papillomas exhibit a tendency for sessile architecture. Among 62 instances, the average age was 39.7 years with a predilection for the 3rd and 4th decades. The male to female ration was 5.7:1 and the tongue, gingiva and lips were the favored sites. Whereas 25% of the evaluated cases demonstrated upper spinous layer papillomavirus common antigen immunoreactivity, DNA in situ hybridization under conditions of high stringency disclosed the presence of human papillomavirus Types 6, 11 or related genomes in 85% of the lesions. A single case was found to harbor human papillomavirus Type 2.

Vasogenic facial pain (cluster headache)

8 cases of vasogenic facial pain are presented with delineation of differentiating clinical features. These vasogenic syndromes include classic episodic cluster headache, chronic cluster headache, and indomethacin responsive chronic cluster headache. Open clinical trials employing inhalation O2 therapy as an abortive treatment strategy utilized in combination with prophylactic nifedipine therapy proved highly efficacious in controlling pain among most classic and chronic cluster headaches. A single case of chronic paroxysmal hemicrania responded favorably to indomethacin.

Oral sialocysts

Epithelial-lined sialocysts of the minor oral salivary glands are rare when compared with the common mucous retention phenomenon or mucocele. One hundred twenty cases are reported and segregated into three distinct subtypes on the basis of clinicopathologic features. The true mucous retention cyst was most prevalent, occurring in patients older than 20 years, with no sex predilection. The floor of the mouth was the most common site. Reactive oncocytoid cysts arose in elderly patients and were more common among women. The buccal mucosa-mandibular vestibule was the favored site. Mucopapillary cysts are rare and may be confused histologically with low-grade mucoepidermoid tumors.

Oral hairy leukoplakia: ultrastructural features

Ten instances of a white plaque of the lateral tongue unique to homosexual males and referred to as oral hairy leukoplakia were analysed ultrastructurally. The surface epithelial layer exhibited extracellular, intracellular and intranuclear penetration by hyphae of Candida albicans, sometimes accompanied by coccobacilli in the extracellular space. The subcorneal epithelial layer included koilocytoid ballooned cells which had a paucity of cytoplasmic organelles and displayed condensation and emargination of the chromatin. Cells that exhibited these nuclear changes were found to be infected by a herpes-type virus which was visualized by electron microscopy in all ten cases. Clusters of nucleocapsids (86-110 nm in diameter) occurred in the nuclei and enveloped virions (111-175 nm in diameter) occurred in the cytoplasm and extracellular spaces. Virions showed budding from the nuclear envelope. Bundles of tubular structures (20 nm diameter) arranged in parallel occurred in the cytoplasm of some koilocytoid cells. There was no evidence by electron microscopy of the presence of papilloma virus within koilocytotic nuclei.

Oral condyloma planus (hairy leukoplakia) among homosexual men: a clinicopathologic study of thirty-six cases

Thirty-six cases of oral condyloma planus (hairy leukoplakia) occurring in homosexual men are reported. The average age is 36.6 years, with a range from 24 to 51 years, and the disorder exhibits a predilection for the fourth decade. More than 86% of the cases are localized to the tongue (72% lateral border, 14% ventral surface). Microscopically, surface candidiasis could be detected with periodic acid-Schiff staining in 88% of the instances. Parakeratosis with koilocytotic atypia was the characteristic histologic finding; however, comparison with twenty-five cases of leukoplakias exhibiting parakeratosis and twenty-five cases of candidiasis among heterosexual individuals disclosed that koilocytotic changes are not specific for condyloma planus. Follow-up data were obtained in thirty-two cases with a mean of 11 months. During this period six patients died or were hospitalized with a diagnosis of acquired immunodeficiency syndrome.

Cystic ameloblastoma. A clinicopathologic analysis

Thirty-three cases of ameloblastoma arising from odontogenic cyst linings are presented. Lesions of this nature have been referred to as "unicystic ameloblastoma." Our data support the findings of others in that this lesion differs from the solid invasive varieties of ameloblastoma, as the former occurs in a younger age group and exhibits a low rate of recurrence following enucleation or curettage. On the basis of histopathologic features we provide evidence that these lesions represent mural and luminal ameloblastomatous change in a pre-existing cyst rather than cystic degeneration of a solid tumor.

Ossifying fibroma: a clinicopathologic study of sixty-four cases

Sixty-four cases of neoplastic benign fibro-osseous lesions are presented, with clinical and radiographic follow-up in 23 instances. A marked predilection for female patients was observed, with the majority or cases arising in the molar-premolar region of the mandible. Radiographically, these neoplasms are well demarcated and may be radiolucent, radiolucent with central opacification (target appearance), or multilocular radiolucent. A benign fibro-osseous histopathologic pattern is observed with osseous, cemental, and/or ovoid-curvoid calcified deposits. This feature, along with confinement to tooth-bearing regions, supports a periodontal ligament origin. It appears that the distinction between cementifying and ossifying variants is academic, as no behavioral differences exist. The recurrence rate following curettage was found to be 28%.

Clear cell odontogenic tumor--a new histologic variant with aggressive potential

This report delineates the clinical and laboratory findings for a previously unreported neoplasm of putative odontogenic origin. We describe the clinical, radiographic, operative, histologic, histochemical, and ultrastructural findings of the tumor in three women. All lesions were centrally located in the jaw bones, were expansile, and, except for mobile teeth and/or jaw enlargement, exhibited few symptoms. Radiographically, there was bone and tooth destruction resulting in poorly delineated margins. Microscopically, the tumors were nearly identical in that they consisted primarily of large sheets and islands of uniform vacuolated and clear cells without evidence of amyloid deposition, calcification, or glandular differentiation. One of the lesions recurred 1 1/2 years after removal without evidence of metastasis. The results, based only on these cases, suggest that this is a locally aggressive neoplasm of odontogenic origin. Casual microscopic examination of this rare neoplasm could result in misdiagnosis as a metastatic clear cell neoplasm, especially renal cell carcinoma.

Psychometric profiles and facial pain

The myofacial pain-dysfunction syndrome and atypical facial pain are the most prevalent chronic pain disorders of the facial region. Previously, the myofacial pain-dysfunction syndrome included all TMJ/masticatory muscle pain, jaw dysfunction, and joint clicking. We have segregated two major subgroups subsumed within this diagnostic classification and have assigned them to a myogenic facial pain (MFP) group and a TMJ internal derangement (TMJID) group. Significant age and personality differences were uncovered when these subpopulations were compared to subjects with atypical facial pain (AFP). Both MFP and TMJID groups are relatively homologous, involving younger persons than AFP subjects. Alternatively, when MFP, TMJID, and AFP subjects were compared for differences in MMPI psychometric scales, MFP and AFP subjects exhibited significantly higher scores, particularly for hypochondriasis, depression, and hysteria, than did TMJID subjects. It is concluded that subcategorization of myofascial pain-dysfunction patients into a myogenic pain group and a TMJ internal derangement group is justified on the basis of psychometric differences. Furthermore, psychopathologic factors are more significant among MFP and AFP subjects than among TMJID patients.

Dental occlusal wear and degenerative disease of the temporomandibular joint: a correlational study utilizing skeletal material from a contemporary population

Forty crania and mandibles with intact dentition exceeding twenty-six teeth and bilaterally intact condyle-fossa apparatus were evaluated for attrition and degenerative joint disease. The skeletal specimens all represent a twentieth-century contemporary American population from the Atkinson Skull Collection at the University of the Pacific School of Dentistry. While 23.1% of this sample exhibited some degree of erosive osseous degenerative wear involving the condyle or articular fossa and 76.3% exhibited occlusal tooth wear, no significant correlation between the degree of attrition and the severity of degenerative joint disease could be documented.

Clear cell odontogenic tumor: histochemical and ultrastructural features

Clear cell odontogenic tumor, a rare epithelial jaw lesion of putative odontogenic origin, histologically resembles clear cell adenocarcinomas. Ultrastructural and histochemical features are described and support a non-glandular derivation. The intraosseous neoplasm is characterized by ovoid nests of clear or finely stippled cells with a mature collagenous stroma. These cells are PAS-positive, diastase labile and fail to bind alcian blue. Enzyme histochemical reactions disclose dehydrogenase, non-specific esterase, and acid phosphatase positivity. Fine structural characteristics include plasma membrane microvilli, desmosomes, endoplasmic reticulum, free ribosomes, glycogen rosettes and lysosomes. Many cells exhibit a paucity of cytoplasmic organelles with prominent vacuolization. Centrioles and annulate lamellae are also encountered. Summarily, clinical, radiographic, histochemical and ultrastructural features indicate that this neoplasm is probably of epithelial odontogenic origin with cytodifferentiation emulating glycogen-rich presecretory ameloblasts.

Radiographic characteristics of central ossifying fibroma

Sixty-four instances of histologically documented ossifying and/or cementifying fibromas were evaluated. Adequate radiographs were available in 43 of the cases. Most of these benign fibro-osseous neoplasms occurred in women, with a predilection for the third and fourth decades. Six distinct radiographic patterns could be identified: (1) radiolucent, superimposed over teeth or residing in edentulous regions (28%); (2) radiolucent with opaque foci, lying in edentulous areas or superimposed over teeth (42%); (3) radiolucent, interposed between contiguous teeth (5%); (4) radiolucent with opaque foci, interposed between contiguous teeth (9%); (5) multilocular expansile (7%); and (6) aggressively expansile with opacification (9%). All lesions exhibited well-defined margins. Root resorption was a feature in 11% of the sample, and root divergence occurred in 17% of the cases.

Atypical histiocytic granuloma. Light microscopic, ultrastructural, and histochemical findings in an unusual pseudomalignant reactive lesion of the oral cavity

Four cases of an ulcero-proliferative lesion of putative histiocytic origin, arising in the oral cavity, are described. This lesion, which has not been defined previously, is easily confused histologically with a malignant process of lymphoid origin, thereby representing a pseudolymphomatous proliferation. Light microscopic, ultrastructural, and histochemical characteristics including immunoglobulin negativity, positive esterase reactivity, and positive peanut lectin binding support a histiocytic origin. These lesions are not associated with systemic disease or dissemination and heal spontaneously despite their worrisome microscopic appearance.

Focal sclerosing osteomyelitis/focal periapical osteopetrosis: radiographic patterns

Forty-one histologically documented instances of focal sclerosing osteomyelitis and focal periapical osteopetrosis have been evaluated for radiomorphologic characteristics. These reactive lesions exhibit five distinct patterns that include periapical focal opacifications, target lesions, radiolucencies, multiconfluent configurations, and opacifications with concomitant root resorption. While an irritational origin can usually be detected in chronic sclerosing osteomyelitis, the cause of focal periapical osteopetrosis remains enigmatic.

A modified auriculotemporal nerve block for regional anesthesia of the temporomandibular joint

A technique for producing regional auriculotemporal nerve analgesia is described. Undesirable side effects have been minimized by avoiding facial nerve branches and blood vessels, and injection at the site of the nerve trunk.

Focal acantholytic dyskeratosis of the oral mucosa

Focal acantholytic dyskeratosis represents a clinically heterogeneous group of dermatologic and mucosal lesions which share common histologic features. Oral mucosal variants of this condition are extremely uncommon. Two intraoral cases are presented, of which one depicts a solitary nodular pattern (warty dyskeratoma) and the other represents a papular lesion exhibiting multiple acantholytic foci.

Radiographic characteristics of cystogenic ameloblastoma

Radiographic patterns encountered in mandibular cystogenic ameloblastoma, a variant encountered among teen-agers and young adults, are described and correlated with age and recurrence after surgery. More than 75% of the cases are located in the posterior mandibular ramus area, and 50% are associated with an impacted third molar. The predominant radiographic patterns include unilocular and scalloped or macromultilocular pericoronal , interradicular , or periapical expansile radiolucencies.

The role of dental restorative metals in the pathogenesis of oral lichen planus

Twenty-four subjects with oral lichen planus and twelve control subjects without oral mucosal disease were patch tested with dental restorative metals and selected metallic salts. Twenty-one percent of the lichen planus population exhibited a positive skin response to one or more challenge materials, as compared to 8% of the control population. It is concluded that oral lichen planus subjects show a higher correlation with delayed hypersensitivity to dental metals than a control population; however, a cause-and-effect relationship cannot be substantiated.

Oral and gingival changes in systemic sclerosis (scleroderma)

Nineteen patients with systemic sclerosis, including two with CREST syndrome variant, were clinically evaluated for oral and gingival manifestations of their disease. Subjectively over 50% complained of xerostomia, limited opening, recurrent "mouth sores" and dysphagia. Four patients indicated that they had been refused dental care due to limited accessibility to the oral cavity. Objectively, physical examination disclosed prominent lingual and buccal mucosal crenations and loss of tongue mobility with fibrotic induration in 25% of the subjects examined. Three of the patients with advanced disease exhibited foci of severe gingival recession due to fibrous strictures and attached gingiva stripping. None of the patients showed any indication of uncontrolled dental disease secondary to xerostomia.

Oral Kaposi's sarcoma associated with acquired immunodeficiency syndrome among homosexual males

Clinical disease states encountered in the acquired immunodeficiency syndrome (AIDS) have been reviewed with an emphasis on oral Kaposi's sarcoma. The disease is reaching epidemic proportions among homosexual males and is characterized by onset of fever, malaise, diarrhea, and lymphadenopathy. Subsequent to these initial nonspecific signs and symptoms, patients develop a variety of opportunistic infections or Kaposi's sarcoma (or both). The oral lesions of Kaposi's sarcoma are characterized by red, blue, or purple plaques or nodules encountered primarily, yet not exclusively on the palate. Other oral manifestations of AIDS include candidiasis and herpetic stomatitis. Epidemiologic studies suggest the probability of a transmissible agent, perhaps a virus. It is recommended that dental care should be rendered to these patients, using mask and gloves with autoclave sterilization of all instruments.

Intraoral and labial keratoacanthoma

Keratoacanthoma (KA) is a relatively common skin lesion of questionable histogenic origin. Although cutaneous KAs are considered to arise from hair follicles, the rare cases reported occurring on mucous membranes would suggest possible origin from surface epithelium. A review of the literature revealed six previous cases involving oral mucosa. Seven new cases of keratoacanthoma are presented. Four occurred on the lower lip, and three arose from intraoral mucosal tissue, accounting for a total of nine reported intraoral cases.

Effects of suspected foodstuff challenging agents in the etiology of recurrent aphthous stomatitis

Two hundred eighteen professional students were surveyed to uncover any association of recurrent aphthous stomatitis (RAS) with a history of allergic diathesis. No significant relationship was uncovered. From this population approximately equal numbers of RAS-positive and RAS-negative subjects were challenged with suspected foodstuff agents thought to have a potential causative role in occurrence of the disease. The results failed to document any causative effect with regard to tomatoes, strawberries, or walnuts.

Programmed instruction in general pathology: evaluation of performance in comparison to conventional instruction and scholastic achievement

Previous studies relating the efficacy of various teaching methods to student achievement levels have yielded conflicting results. This study compares programmed instruction in pathology with conventional instruction for students exhibiting different levels of academic achievement, as measured by undergraduate GPA. The results of this study reveal that no significant difference in examination performance exists regardless of the teaching method employed when achievement level is considered.

Maxillary intraosseous neuroepithelial structures resembling those seen in the organ of Chievitz

Epithelial rests residing within nerve fibers coursing through histologically normal osseous marrow spaces are described. These structures appear to be identical to those found in the pterygomandibular space in a structure known as the organ of Chievitz. Their function is unknown, and yet it is hypothesized that they play a role in neurosensory mechanisms.

Sebaceous choristoma of the thyroglossal duct

The presence of sebaceous glands within the oral mucosa is not uncommon. Such Fordyce granules are frequently seen on the buccal mucosa and lips, as well as in the retromolar area, gingiva, and palate. Whereas sebaceous elements are rarely encountered on the tongue, three cases of ectopic sebaceous glands have been reported in association with apparently patent thyroglossal ducts. An interesting case of a previously unreported sebaceous choristoma of the thyroglossal duct is described.

Symptomatic osteoarthritis of the temporomandibular joint: report of a case

A case of osteoarthritis in the TMJ which manifested clinical symptoms, radiographic changes, and the classic microscopic alterations has been presented. Whether the condition was a primary or secondary form of the disease could not be unequivocally ascertained, as the symptoms preceded the injection of a sclerosing solution and a mandibular fracture, both of which could be significant contributing factors to a trauma-induced secondary osteoarthritic change. Nevertherless, a lack of symptoms in other joints would tend to exclude a generalized (primary) form of osteoarthropathy. In this regard, symptoms referable to the TMJ (to the exclusion of other joints) are more consistent with findings of secondary osteoarthritic change. Whether osteoarthritic changes were discernible by radiography in the TMJ before the traumatic episodes recorded in the history is unknown. Indeed, a developmental anatomic anomaly could not be ruled out. Regardless of whether the changes were the result of primary degenerative disease or chronic trauma, the symptoms were adequately resolved by surgical intervention.