Physical and Chemical Injuries

CLINICAL FEATURES: As the name implies, the alteration consists of a white line that usually is bilateral. It may be scalloped and is located on the buccal mucosa at the level of the occlusal plane of the adjacent teeth (Fig. 8-1). The line varies in prominence and usually is restricted to dentulous areas. It often is more pronounced adjacent to the posterior teeth.

HISTOPATHOLOGIC FEATURES: Biopsy is rarely indicated. If a biopsy is performed, hyperorthokeratosis is seen overlying otherwise normal oral mucosa. On occasion, intracellular edema of the epithelium and mild chronic inflammation of the underlying connective tissue may be noted.

TREATMENT AND PROGNOSIS: No treatment is required for patients with linea alba, and no difficulties are documented as a result of its development. Spontaneous regression may occur.

CLINICAL FEATURES: Most frequently, the lesions in patients with morsicatio are found bilaterally on the anterior buccal mucosa. They also may be unilateral, combined with lesions of the lips or the tongue, or isolated to the lips or tongue. Thickened, shredded, white areas may be combined with intervening zones of erythema, erosion, or focal traumatic ulceration (Figs. 8-2 and 8-3). The areas of white mucosa demonstrate an irregular ragged surface, and the patient may describe being able to remove shreds of white material from the involved area.

The altered mucosa typically is located in the midportion of the anterior buccal mucosa along the occlusal plane. Large lesions may extend some distance above or below the occlusal plane in patients whose habit involves pushing the cheek between the teeth with a finger.

HISTOPATHOLOGIC FEATURES: Biopsy reveals extensive hyperparakeratosis that often results in an extremely ragged surface with numerous projections of keratin. Surface bacterial colonization is typical (Fig. 8-4). On occasion, clusters of vacuolated cells are present in the superficial portion of the prickle cell layer. This histopathologic pattern is not pathog-nomonic of morsicatio and may bear a striking resemblance to oral hairy leukoplakia (OHL), a lesion that most often occurs in people who are infected with the human immunodeficiency virus (HIV) (see page 268), or to uremic stomatitis (see page 851). A similar histopathologic pattern is noted in patients who chronically chew betel quid and has been termed betel chewer’s mucosa (see page 402). Similarities with linea alba and leukoedema also may be seen.

DIAGNOSIS: In most cases the clinical presentation of morsicatio buccarum is sufficient for a strong presumptive diagnosis, and clinicians familiar with these alterations rarely perform biopsy. Some cases of morsicatio may not be diagnostic from the clinical presentation, and biopsy may be necessary. In patients at high risk for HIV infection with isolated involvement of the lateral border of the tongue, further investigation is desirable to rule out HIV-associated OHL.

TREATMENT AND PROGNOSIS: No treatment of the oral lesions is required, and no long-term difficulties arise from the presence of the mucosal changes. For patients who desire treatment, an oral acrylic shield that covers the facial surfaces of the teeth may be constructed to eliminate the lesions by restricting access to the buccal and labial mucosa. For patients desiring either confirmation of the cause or preventive therapy, construction and use of two lateral acrylic shields connected by a labial stainless steel wire can provide quick resolution of the lesions while being acceptable aesthetically and not interfering with speech. Several authors also have suggested psychotherapy as the treatment of choice, but no extensive well-controlled studies have indicated benefits from this approach.

CLINICAL FEATURES: Most injuries are unintentional and arise from a variety of causes. As would be expected, simple chronic traumatic ulcerations occur most often on the tongue, lips, and buccal mucosa—sites that may be injured by the dentition (Fig. 8-5). Lesions of the gingiva, palate, and mucobuccal fold may occur from other sources of irritation. Overzealous toothbrushing can create linear erosions along the free gingival margins. Although these areas may superficially resemble a number of the chronic vesiculoerosive processes, thorough questioning of the patient often leads to the appropriate diagnosis. The individual lesions appear as areas of erythema surrounding a central removable, yellow fibrinopurulent membrane. In many instances, the lesion develops a rolled white border of hyperkeratosis immediately adjacent to the area of ulceration (Fig. 8-6).

Eosinophilic ulcerations are not uncommon but frequently are not reported. The lesions occur in peopleof all ages, with a significant male predominance. Most have been reported on the tongue, although cases have been seen on the gingiva, buccal mucosa, floor of mouth, palate, and lip. The lesion may last from 1 week to 8 months. The ulcerations appear very similar to the simple traumatic ulcerations; however, on occasion, underlying proliferative granulation tissue can result in a raised lesion similar to a pyogenic granuloma (see page 517) (Fig. 8-7).

Riga-Fede disease typically appears between 1 week and 1 year of age. The condition often develops in association with natal or neonatal teeth (see page 81). The anterior ventral surface of the tongue is the most common site of involvement, although the dorsal surface also may be affected (Fig. 8-8). Ventral lesions contact the adjacent mandibular anterior incisors; lesions on the dorsal surface are associated with the maxillary incisors. A presentation similar to Riga-Fede disease can be the initial finding in a variety of neuro logic conditions related to self-mutilation, such as familial dysautonomia (Riley-Day syndrome), congenital indifference to pain, Lesch-Nyhan syn-drome, Gaucher disease, cerebral palsy, or Tourette syndrome.

The atypical eosinophilic ulceration occurs in older adults, with most cases developing in patients older than age 40. Surface ulceration is present, and an underlying tumefaction also is seen. The tongue is the most common site, although the gingiva, alveolar mucosa, mucobuccal fold, buccal mucosa, and lip may be affected (Fig. 8-9).

HISTOPATHOLOGIC FEATURES: Simple traumatic ulcerations are covered by a fibrinopurulent membrane that consists of fibrin intermixed with neutrophils. The membrane is of variable thickness, and the adjacent surface epithelium may be normal or may demonstrate slight hyperplasia with or without hyperkeratosis. The ulcer bed consists of granulation tissue that supports a mixed inflammatory infiltrate of lymphocytes, histiocytes, neutrophils, and, occasionally, plasma cells. In patients with eosinophilic ulcerations, the pattern is very similar; however, the inflammatory infiltrate extends into the deeper tissues and exhibits sheets of lymphocytes and histiocytes intermixed with eosinophils. In addition, the vascular connective tissue deep to the ulceration may become hyperplastic and cause surface elevation.

Atypical eosinophilic ulcerations exhibit numerous features of the traumatic eosinophilic ulceration, but the deeper tissues are replaced by a highly cellular proliferation of large lymphoreticular cells. The infiltrate is pleomorphic, and mitotic features are somewhat common. Intermixed with the large atypical cells are mature lymphocytes and numerous eosinophils. Although an associated immunohistochemical profile rarely has been reported, several investigators have shown the large cells to be T lymphocytes, the majority of which react with CD30 (Ki-1). In many instances, molecular studies for T-cell clonality by polymerase chain reaction (PCR) have been performed on the CD30+ cells and demonstrated monoclonal rearrangement. Whether this monoclonal infiltrate represents a true low-grade lymphoma or an unusual reactive lymphoproliferative process has not been determined.

TREATMENT AND PROGNOSIS: For traumatic ulcerations that have an obvious source of injury, the irritating cause should be removed. Dyclonine HCl or hydroxypropyl cellulose films can be applied for temporary pain relief. If the cause is not obvious, or if a patient does not respond to therapy, then biopsy is indicated. Rapid healing after a biopsy is typical even with large eosinophilic ulcerations (Fig. 8-10). Recurrence is not expected.

The use of corticosteroids in the management of traumatic ulcerations is controversial. Some clinicians have suggested that use of such medications may delay healing. In spite of this, other investigators have reported success using corticosteroids to treat chronic traumatic ulcerations.

Although extraction of the anterior primary teeth is not recommended, this procedure has resolved the ulcerations in Riga-Fede disease. The teeth should be retained if they are stable. Grinding the incisal mame-lons, coverage of the teeth with a light-cured composite or cellulose film, construction of a protective shield, or discontinuation of nursing have been tried with variable success.

In patients demonstrating histopathologic similarities to the cutaneous CD30+ lymphoproliferative disorder, a thorough evaluation for systemic lymphoma is mandatory, along with lifelong follow-up. Although recurrence frequently is seen, the ulcerations typically heal spontaneously, and the vast majority of patients do not demonstrate dissemination of the process. Further documentation is critical to define more fully this poorly understood process.

CLINICAL FEATURES: Most electrical burns occur in children younger than 4 years of age. The lips are affected most frequently, and the commissure commonly is involved. Initially, the burn appears as a painless, charred, yellow area that exhibits little to no bleeding (Fig. 8-11). Significant edema often develops within a few hours and may persist up to 12 days. Beginning on the fourth day, the affected area becomes necrotic and begins to slough. Bleeding may develop during this period from exposure of the underlying vital vasculature, and the presence of this complication should be monitored closely. The adjacent mucobuccal fold, the tongue, or both also may be involved. On occasion, adjacent teeth may become nonvital, with or without necrosis of the surrounding alveolar bone. Malformation of developing teeth also has been documented. In patients receiving high-voltage electrical injury, resultant facial nerve paralysis is infrequently reported and typically resolves over several weeks to months.

The injuries related to thermal food burns usually appear on the palate or posterior buccal mucosa (Fig. 8-12). The lesions appear as zones of erythema and ulceration that often exhibit remnants of necrotic epithelium at the periphery. If hot beverages are swallowed, swelling of the upper airway can occur and lead to dyspnea, which may develop several hours after the injury.

TREATMENT AND PROGNOSIS: For patients with electrical burns of the oral cavity, tetanus immunization, if not current, is required. Most clinicians prescribe a prophylactic antibiotic, usually penicillin, to prevent secondary infection in severe cases. The primary problem with oral burns is contracture of the mouth opening during healing. Without intervention, significant microstomia can develop and may produce such restricted access to the mouth that hygiene and eating become impossible in severe cases. Extensive scarring and disfigurement are typical in untreated patients.

To prevent the disfigurement, a variety of microstomia prevention appliances can be used to eliminate or reduce the need for subsequent surgical reconstruction. Compliance is the most important consideration when choosing the most appropriate device. Tissue-supported appliances appear most effective for infants and young children; older, more cooperative patients usually benefit from tooth-supported devices. In most cases, splinting is maintained for 6 to 8 months to ensure proper scar maturation. Evaluation for possible surgical reconstruction is usually performed after a 1-year follow-up.

Most thermal burns are of little clinical consequence and resolve without treatment. When the upper airway is involved and associated with breathing difficulties, antibiotics and corticosteroids often are administered. In rare cases, swelling of the airway mandates intubation or tracheotomy to resolve the associated dyspnea. In these severe cases, oral intake of food often is discontinued temporarily with nutrition provided by a nasogastric tube.

CLINICAL FEATURES: The previously discussed caustic agents produce similar damage. With short exposure, the affected mucosa exhibits a superficial white, wrinkled appearance. As the duration of exposure increases, the necrosis proceeds and the affected epithelium becomes separated from the underlying tissue and can be desquamated easily. Removal of the necrotic epithelium reveals red, bleeding connective tissue that subsequently will be covered by a yellowish, fibrinopurulent membrane. Mucosa bound to bone is keratinized and more resistant to damage, whereas the nonkeratinized movable mucosa is destroyed more quickly. In addition to mucosal necrosis, significant tooth erosion has been seen in patients who chronically chew aspirin or hold the medication in their teeth as it dissolves.

The use of the rubber dam can dramatically reduce iatrogenic mucosal burns. When cotton rolls are used for moisture control during dental procedures, two problems may occur. On occasion, caustic materials can leak into the cotton roll and be held in place against the mucosa for an extended period, with mucosal injury resulting from the chemical absorbed by the cotton. In addition, oral mucosa can adhere to dry cotton rolls, and rapid removal of the rolls from the mouth often can cause stripping of the epithelium in the area. The latter pattern of mucosal injury has been termed cotton roll burn (cotton roll stomatitis) (Fig. 8-18).

Caustic materials injected into bone during endodontic procedures can result in significant bone necrosis, pain, and perforation into soft tissue. Necrotic surface ulceration and edema with underlying areas of soft tissue necrosis may occur adjacent to the site of perforation.

HISTOPATHOLOGIC FEATURES: Microscopic examination of the white slough removed from areas of mucosal chemical burns reveals coagulative necrosis of the epithelium, with only the outline of the individual epithelial cells and nuclei remaining (Fig. 8-19). The necrosis begins on the surface and moves basally. The amount of epithelium affected depends on the duration of contact and the concentration of the offending agent. The underlying connective tissue contains a mixture of acute and chronic inflammatory cells.

TREATMENT AND PROGNOSIS: The best treatment of chemical injuries is prevention of exposure of the oral mucosa to caustic materials. When using potentially caustic drugs (e.g., aspirin, chlorpromazine), the clinician must instruct the patient to swallow the medication and not allow it to remain in the oral cavity for any significant length of time. Children should not use chewable aspirin immediately before bedtime, and they should rinse after use.

Superficial areas of necrosis typically resolve completely without scarring within 10 to 14 days after discontinuation of the offending agent. For temporary protection, some clinicians have recommended coverage with a protective emollient paste or a hydroxypropyl cellulose film. Topical dyclonine HCl provides excellent but temporary pain relief. When large areas of necrosis are present, such as that related to the use of silver nitrate or accidental intrabony injection of offending materials, surgical débridement and antibiotic coverage often are required to promote healing and prevent spread of the necrosis.

CLINICAL FEATURES: A variety of noninfectious oral complications are seen regularly as a result of both radiation and chemotherapy. Two acute changes, mucositis and hemorrhage, are the predominant problems associated with chemotherapy, especially in cancers, such as leukemia, that involve high treatment doses.

Painful acute mucositis and dermatitis are the most frequently encountered side effects of radiation, but several chronic alterations continue to plague patients long after their courses of therapy are completed. Depending on the fields of radiation, the radiation dose, and the age of the patient, the following outcomes are possible:

TREATMENT AND PROGNOSIS: Optimal treatment planning involves the oral health practitioner before initiation of antineoplastic therapy. Elimination of all current or potential oral foci of infection is paramount, along with patient education about maintaining ultimate oral hygiene. Proper nutrition, cessation of tobacco use, and alcohol abstinence will minimize oral complications. Once cancer therapy is initiated, efforts must be directed toward relieving pain, preventing dehydration, maintaining adequate nutrition, eliminating foci of infection, and ensuring continued appropriate oral hygiene.

CLINICAL AND RADIOGRAPHIC FEATURES: In an excellent systematic review of 368 reported cases of bisphosphonate-associated osteonecrosis (BON), 94% were discovered in patients who were treated with the IV formulations (primarily pamidronate and zoledronic acid) for cancer, with 85% being reported in patients with multiple myeloma. Current estimates indicate that the prevalence of osteonecrosis in patients taking aminobisphosphonates for cancer is 6% to 10%. Prospective trials will be necessary to confirm these figures.

Osteonecrosis related to use of oral aminobisphosphonates is most uncommon (conservative estimate by drug industry: annual incidence is 0.7 per 100,000); however, prospective trials for the true incidence of this complication have yet to be performed. Risk factors for BON associated with the PO formulations include advanced patient age (older than 65 years), corticosteroid use, use of chemotherapy drugs, diabetes, smoking or alcohol use, poor oral hygiene, and duration of drug use exceeding 3 years. A predictive test for those at risk for bisphosphonate osteonecrosis has not been confirmed. Some investigators recently have suggested use of a serum marker for bone turnover, serum C-telopeptide (CTX), but additional prospective studies are needed to confirm the utility of this test.

Although a mandibular predominance has been noted, involvement of the maxilla or both jaws is not uncommon (Fig. 8-27). In 60% of these patients, the necrosis has followed an invasive dental procedure, with the remainder occurring spontaneously (Fig. 8-28). On occasion, the necrosis can occur after minor trauma to bony prominences, such as tori or other exostoses (Fig. 8-29). Affected patients have areas of exposed, necrotic bone that is asymptomatic in approximately one third.

Investigators have suggested that bone at imminent risk for osteonecrosis often will demonstrate increased radiopacity before clinical evidence of frank necrosis. These changes typically occur predominantly in areas of high bone remodeling, such as the alveolar ridges. Panoramic radiographs often will reveal a marked radiodensity of the crestal portions of each jaw, with a more normal appearance of the bone away from tooth-bearing portions. Periosteal hyperplasia also is not rare. In more severe cases, the osteonecrosis creates a moth-eaten and ill-defined radiolucency with or without central radiopaque sequestra (Fig. 8-30). In some cases the necrosis can lead to development of a cutaneous sinus or pathologic fracture (Fig. 8-31).

HISTOPATHOLOGIC FEATURES: Biopsy of vital bone altered by aminobisphosphonates is not common. In such cases the specimen often reveals irregular trabeculae of pagetoid bone, with adjacent enlarged and irregular osteoclasts that often demonstrate numerous intracytoplasmic vacuoles (Fig. 8-32). Specimens of active areas of BON reveal trabeculae of sclerotic lamellar bone, which demonstrate loss of the osteocytes from their lacunae and frequent peripheral resorption with bacterial colonization (Fig. 8-33). Although the peripheral bacterial colonies often resemble actinomycetes, the infestation is not consistent with cervicofacial actinomycosis.

TREATMENT AND PROGNOSIS: The clinical approach to patients treated with aminobisphosphonates varies according to the formulation of the drug, the disease being treated, and the duration of drug use. All patients who take these medications should be warned of the risks and instructed to obtain and maintain ultimate oral hygiene. The oral medications are extremely caustic; patients should be warned to minimize oral mucosal contact and ensure the medication is swallowed completely.

Routine dental therapy, in most cases, should not be modified solely on the basis of oral aminobisphosphonate use. All restorative, prosthodontic, conventional endodontic, and routine periodontic procedures can be implemented as needed. Although orthodontic treatment is not contraindicated, progress should be evaluated after 2 to 3 months of active therapy. At that point, therapy can proceed if the tooth movement is occurring predictably with normal forces. Invasive orthodontic techniques such as orthognathic surgery, four-tooth extraction cases, and miniscrew anchorage should be avoided, if possible. Because the medica-tion is drawn to sites of active bone remodeling, a drug holiday (or switching to a nonaminobisphosph-onate agent) during active orthodontics may be advantageous.

When manipulation of bone is considered (e.g., surgical endodontics, periodontal bone recontouring, oral surgery, implant placement), the patient should be advised of the potential complications of aminobisphosphonate use and the risk of BON. Written informed consent and documentation of a discussion of the benefits, risks, and alternative therapies are highly advised. For elective surgical procedures in patients with a duration of drug use exceeding 3 years, discontinuation of the medication 3 months before and 3 months after surgery has been suggested. Because of the reduced angiogenesis, osseous grafts should be used judiciously. If multiple sites require surgery, then one sextant should be treated with a 2-month disease-free follow-up before completion of the remaining sextants. During this interval, use of chlorhexidine twice daily is recommended. The sextant-by-sextant approach is not necessary for periapical inflammatory disease or abscesses, both of which can lead directly to osteonecrosis and demand immediate resolution.

Dental therapy in patients taking an IV formulation for cancer is much more problematic. Prevention is paramount. In patients evaluated before initiation of an IV aminobisphosphonate, the goal is to eliminate all dental infections and improve dental health to prevent future invasive therapy; this includes removal of large tori or partially impacted teeth. If only noninvasive therapy is necessary, then the initiation of the medication need not be delayed. If surgical procedures are performed, then a month-long delay in initiation of the medication is recommended, along with prophylactic antibiotic therapy (i.e., penicillin; quinolone and metronidazole, or erythromycin and metronidazole for those allergic to penicillin).

For patients presenting in the midst of active IV therapy, a number of clinicians have suggested that manipulation of bone should be avoided. Conventional endodontics is a better option than extraction. If a nonvital tooth is not restorable, then endodontics should be performed and followed by crown amputation. Teeth with 1+ or 2+ mobility should be splinted; those with 3+ mobility can be extracted.

For patients with BON, the goal of therapy is to stop pain. A number of clinicians believe that removal of bone typically results in further bone necrosis, and hyperbaric oxygen has not been beneficial. Asymptomatic patients should rinse daily with chlorhexidine and be monitored closely. Any rough edges of exposed bone should be smoothed. If the exposed bone irritates adjacent tissues, then coverage with a soft splint may prove beneficial. In symptomatic patients, systemic antibiotic therapy (i.e., penicillin with or without metronidazole, ciprofloxacin or erythromycin and metronidazole for those allergic to penicillin) and chlorhexidine usually lead to pain relief. If the antibiotics fail to stop the pain, then hospitalization with IV therapy is indicated. In recalcitrant cases the bulk of the dead bone is reduced surgically, followed by administration of systemic antibiotics. Because of the long half-life of bisphosphonates, discontinuation of the drug offers no short-term benefit. In isolated anecdotal reports of recalcitrant cases, discontinuation of the medication for 6 to 12 months occasionally has been associated with spontaneous sequestration and resolution.

As mentioned in the discussion of the radiographic features, the alveolar ridges of patients affected with osteonecrosis exhibit significant sclerosis because of increased drug deposition in areas of high remodeling. Some investigators have successfully treated patients with BON by resection of all of the osteosclerotic areas with extension to the underlying more lucent and normally bleeding bone. As adjunctive therapy to enhance healing, the osseous defect can be covered with a resorbable collagen membrane impregnated with platelet-rich plasma.

Overall, the benefits of aminobisphosphonate therapy for osteoporosis and metastatic cancer appear to greatly outweigh the risk of developing BON. However, the oral medications should be prescribed only for those individuals with inadequate bone density and should be discontinued or switched to a nonaminobisphosphonate once the bone density returns to an acceptable level.

Increased bone density does not correlate necessarily to good bone quality. The negative effects of oversuppression of bone metabolism must be considered in all patients prescribed oral aminobisphosphonates. Several reports have documented spontaneous nontraumatic stress fractures with associated delayed healing in patients on long-term aminobisphosphonate therapy. Many physicians now believe that aminobisphosphonate therapy should be stopped after 5 years and not reinitiated until bone density studies confirm redevelopment of significant osteoporosis.

Dentists should be proactive and strongly encour-age patients to speak to their attending physicians for consideration of these factors during planning and execution of long-term care. For individuals scheduled to receive IV aminobisphosphonate therapy as part of their cancer management, the involved oncologist should recommend pretreatment dental evaluation and preventive care, with long-term, close follow-up.

CLINICAL FEATURES: Although methamphetamine abuse may occur throughout society, most users are men between the ages of 19 and 40 years. The effects of the medication last up to 12 hours, and the typical abuser reports use that exceeds 20 days per month, creating an almost continuous effect of the drug. The short-term effects of methamphetamine include insomnia, aggressiveness, agitation, hyperactivity, decreased appetite, tachycardia, tachypnea, hypertension, hyperthermia, vomiting, tremors, and xerostomia. Long-term effects additionally include strong psychologic addiction, violent behavior, anxiety, confusion, depression, paranoia, auditory hallucinations, delusions, mood changes, skin lesions, and a number of cardiovascular, CNS, hepatic, gastrointestinal, renal, and pulmonary disorders.

Many addicts develop delusions of parasitosis (formication, from the Latin word formica, which translates to ant), a neurosis that produces the sensation of snakes or insects crawling on or under the skin. This sensation causes the patient to attempt to remove the perceived parasites, usually by picking at the skin with fingernails, resulting in widespread traumatic injury. The factitial damage can alter dramatically the facial appearance in a short period of time, and these lesions have been nicknamed speed bumps, meth sores, or crank bugs.

Rampant dental caries is another common manifestation and exhibits numerous similarities with milk-bottle caries. The carious destruction initially affects the facial smooth and interproximal surfaces, but without intervention, the coronal structure of the entire dentition can be destroyed (Fig. 8-34). The carious destruction appears to be caused by poor oral hygiene combined with extreme drug-related xerostomia, which leads to heavy consumption of acidic and sugar-filled soft drinks or other refined carbohydrates.

TREATMENT AND PROGNOSIS: The oral health practitioner should be alerted when an emaciated, agitated, and nervous young adult presents with tachycardia, tachypnea, hypertension, hyperthermia, and rampant smooth surface and interproximal caries. Failure to recognize these signs can be serious. For up to 6 hours after ingestion, methamphetamine potentiates the effects of sympathomimetic amines. Use of local anesthetics with epinephrine or levonordefrin can lead to a hypertensive crisis, cerebral vascular accident, or myocardial infarction. Caution also should be exercised when administering sedatives, general anesthesia, nitrous oxide, or prescriptions for narcotics. Although cessation of the illicit drug use is paramount, patients should be encouraged during periods of xerostomia to discontinue use of highly acidic and sugar-filled soft drinks and to avoid diuretics such as caffeine, tobacco, and alcohol. In addition, the importance of personal and oral hygiene should be stressed. Preventive measures such as topical fluorides may assist in protecting the remaining dentition. A medical consultation with referral to a substance abuse center should be encouraged.

CLINICAL FEATURES: Anesthetic necrosis usually develops several days after the procedure and most commonly appears on the hard palate (Fig. 8-35). A well-circumscribed area of ulceration develops at the site of injection. The ulceration often is deep, and, on occasion, healing may be delayed. One report has documented sequestration of bone at the site of tissue necrosis.

TREATMENT AND PROGNOSIS: Treatment of anesthetic necrosis usually is not required unless the ulceration fails to heal. Minor trauma, such as that caused by performing a cytologic smear, has been reported to induce resolution in these chronic cases. Recurrence is unusual but has been reported in some patients in association with use of epinephrine-containing anesthetics. In these cases the use of a local anesthetic without epinephrine is recommended.

CLINICAL FEATURES: A marked female predominance is seen in cases of factitious origin, with most cases affecting those younger than 30 years of age. Mild cases feature chronic dryness, scaling, or cracking of the vermilion border of the lip (Fig. 8-36). With progression, the vermilion can become covered with a thickened, yellowish hyperkeratotic crust that can be hemorrhagic or that may exhibit extensive fissuring. The perioral skin may become involved and exhibit areas of crusted erythema (Fig. 8-37). Although this pattern may be confused with perioral dermatitis (see page 352), the most appropri ate name for this process is circumoral dermatitis. Both lips or just the lower lip may be involved.

In patients with chronic cheilitis, development of fissures on the vermilion border is not rare. In a prevalence study of more than 20,000 patients, these fissures involved either lip and were slightly more common in the upper lip. In contrast to typical exfoliative cheilitis, these fissures demonstrate a significant male predilection and a prevalence rate of approximately 0.6%. The majority arise in young adults, with rare occurrence noted in children and older adults.

Although the cause is unknown, proposed contributing factors include overexposure to sun, wind, and cold weather; mouth breathing; bacterial or fungal infections; and smoking. An increased prevalence of lip fissures has been noted in patients with Down syndrome and may be the result of the high frequency of mouth breathing or the tendency to develop orofacial candidiasis. Application of lipstick or lip balm appears to be protective. Fissure occurrence also may be related to a physiologic weakness of the tissues. Those affecting the lower lip typically occur in the midline, whereas fissures on the upper vermilion most frequently involve a lateral position. These are the sites of prenatal merging of the mandibular and maxillary processes.

TREATMENT AND PROGNOSIS: In those cases associated with an obvious cause, elimination of the trigger typically results in resolution of the changes. In those cases with no underlying physical, infectious, or allergic cause, psychotherapy (often combined with mild tranquilization or stress reduction) may achieve resolution. In cases for which no cause can be found, therapeutic interventions often are not successful.

Cases that result from candidal infections often do not resolve until the chronic trauma also is eliminated. Initial topical antifungal agents, antibiotics, or both can be administered to patients in whom chronic trauma is not obvious or is denied. If the condition does not resolve, then further investigation is warranted in an attempt to discover the true source of the lip alterations.

Hydrocortisone and iodoquinol (antibacterial and antimycotic) cream has been used to resolve chronic lip fissures in some patients (Fig. 8-38). Other reported therapies include various corticosteroid preparations, topical tacrolimus, sunscreens, and moisturizing preparations. In many cases, resistance to topical therapy or frequent recurrence is noted. In these cases, cryotherapy or excision with or without Z-plasty has been used successfully.

CLINICAL FEATURES: Submucosal hemorrhage appears as a nonblanching flat or elevated zone with a color that varies from red or purple to blue or blue-black (Fig. 8-40). As would be expected, traumatic lesions are located most frequently on the labial or buccal mucosa. Blunt facial trauma often is responsible, but injuries such as minor as cheek biting may produce a hematoma or areas of purpura (Fig. 8-41). Mild pain may be present.

The hemorrhage associated with increased intrathoracic pressure usually is located on the skin of the face and neck and appears as widespread petechiae that clear within 24 to 72 hours. Although it has not been as well documented as the cutaneous lesions, mucosal hemorrhage can be seen in the same setting and most often appears as soft palatal petechiae or purpura.

Hematoma formation associated with surgical implant preparation usually is associated with damage of the soft tissues adjacent to the lingual surface of the mandible and produces swelling and elevation of the floor of the mouth. Although the hemorrhage is noticeable immediately in most patients, the problem may not become evident clinically for 4 to 6 hours. Distension, elevation, and protrusion of the tongue may occur and be associated with inability to swallow or significant dyspnea.

Patients with antral hematomas typically complain of frequent nasal bleeding but also may experience unilateral nasal obstruction, hyposmia, headache, and malar swelling. Facial paresthesia and vision problems occur less frequently. Computed tomography (CT) typically demonstrates a soft tissue mass filling and expanding the antrum, often associated with proptosis and partial destruction or displacement of the sinus walls. In many instances, the radiographic appearance is worrisome for a malignant neoplasm.

TREATMENT AND PROGNOSIS: Often, no treatment is required if the hemorrhage is not associated with significant morbidity or related to systemic disease. The areas should resolve spontaneously. Large hematomas may require several weeks to resolve. If the hemorrhage occurs secondary to an underlying disorder, then treatment is directed toward control of the associated disease.

In cases of emergent hemorrhage associated with surgical implant placement, the first priority is to secure the airway. Although the hemorrhage can be controlled with conservative measures in some cases, the majority require surgical exploration with isolation and repair of the damaged vessel. Antral hematomas usually are removed via a Caldwell-Luc procedure for both therapeutic and diagnostic purposes. After successful removal, a search for the bleeding source or any underlying coagulopathy is recommended to prevent recurrence.

CLINICAL FEATURES: The most commonly reported lesion related to orogenital sex is submucosal palatal hemorrhage secondary to fellatio. The lesions appear as erythema, petechiae, purpura, or ecchymosis of the soft palate. The areas often are asymptomatic and resolve without treatment in 7 to 10 days (Fig. 8-42). Recurrences are possible with repetition of the inciting (exciting?) event. The erythrocytic extravasation is thought to result from the musculature of the soft palate elevating and tensing against an environment of negative pressure. Similar lesions have been induced from coughing, vomiting, or forceful sucking on drinking straws and glasses. Forceful thrusting against the vascular soft palate has been suggested as another possible cause.

Oral lesions also can occur from performing cunnilingus, resulting in horizontal ulcerations of the lingual frenum. As the tongue is thrust forward, the taut frenum rubs or rakes across the incisal edges of the mandibular central incisors. The ulceration created coincides with sharp tooth edges when the tongue is in its most forward position. The lesions resolve in 7 to 10 days but may recur with repeated performances. Linear fibrous hyperplasia has been discovered in the same pattern in individuals who chronically perform the act (Fig. 8-43).

HISTOPATHOLOGIC FEATURES: With an appropriate index of suspicion, biopsy usually is not required; however, a biopsy has been performed in some cases of palatal lesions secondary to fellatio. These suction-related lesions reveal subepithelial accumulations of red blood cells that may be extensive enough to separate the surface epithelium from underlying connective tissue. Patchy degeneration of the epithelial basal cell layer can occur. The epithelium classically demonstrates migration of erythrocytes and leukocytes from the underlying lamina propria.

TREATMENT AND PROGNOSIS: No treatment is required, and the prognosis is good. In patients who request assistance, palatal petechiae can be prevented through the use of less negative pressure and avoidance of forceful thrusting. Smoothing and polishing the rough incisal edges of the adjacent mandibular teeth can minimize the chance of lingual frenum ulceration.

CLINICAL AND RADIOGRAPHIC FEATURES: Amalgam tattoos appear as macules or, rarely, as slightly raised lesions. They may be black, blue, or gray. The borders can be well defined, irregular, or diffuse (Fig. 8-46). Lateral spread may occur for several months after the implantation. In most cases, only one site is affected, although multiple tattoos in a single patient may be present. Any mucosal surface can be involved, but the most common sites are the gingiva, alveolar mucosa, and buccal mucosa (Fig. 8-47).

Periapical radiographs, when taken, are negative in many cases. When metallic fragments are visible radiographically, the clinical area of discoloration typically extends beyond the size of the fragment. The fragments are densely radiopaque, varying from several millimeters to pinpoint in size (see Fig. 8-47). On occasion, the pattern of the amalgam dispersal has been sufficiently unique to be used as a distinctive characteristic in the identification of unknown deceased individuals.

The pattern of accidental localized foreign body tattoo other than amalgam is diverse and depends on the associated trauma that impacted the material. Mucosal graphite implantation is rarely documented, but it most likely occurs with a higher frequency than indicated by the number of cases reported. Examples in the literature have been presented as grayish areas of mucosal discoloration of the hard palate, the most likely site for pencil-related trauma.

Cosmetic tattooing is gaining in popularity and may include injection of permanent cosmetic inks into the eyelids and vermilion border of the upper and lower lips. On occasion, patients may react to the material and experience swelling, burning, and itching at the site, followed by enlargement and induration. In such cases, biopsy often reveals a granulomatous reaction to the foreign material.

The intentional intraoral tattoos that are not placed by health professionals occur most frequently on the anterior maxillary facial gingiva of individuals from a number of African countries and have been documented at institutions in the United States (Fig. 8-48). In these cases the anterior maxillary facial gingiva is given a heavy blue-black discoloration. Occasionally, tattoos (usually blue or black) are placed on the labial mucosa of adults in the United States to convey a personal, often vulgar, message (Fig. 8-49).

HISTOPATHOLOGIC FEATURES: Microscopic examination of amalgam tattoos reveals pigmented fragments of the metal within the connective tissue. Scattered, large, dark, solid fragments or numerous fine, black, or dark-brown granules may be seen (Fig. 8-50). The silver salts of the dental amalgam preferentially stain the reticulin fibers, especially those encircling nerves and vascular channels (Fig. 8-51).

The biologic response to amalgam appears related to particle size and the elemental composition of the amalgam. Large fragments often become surrounded by dense fibrous connective tissue with mild inflammation. Smaller particles typically are associated with a more significant inflammatory response that may be granulomatous or a mixture of lymphocytes and plasma cells. Graphite implantation appears similar microscopically to amalgam but can be differentiated by its pattern of birefringence after treatment with ammonium sulfide and by the lack of staining of the reticulin fibers. In addition, energy dispersive x-ray microanalysis can be used to identify the type of material present within areas of foreign body tattoos.

TREATMENT AND PROGNOSIS: To confirm the diagnosis of amalgam tattoo, the clinician can obtain radiographs of the areas of mucosal discoloration in an attempt to demonstrate the metallic fragments. The films should be capable of high detail, because many of the fragments are no larger than the point of a pin.

No treatment is required if the fragments can be detected radiographically. If no metallic fragments are found and the lesion cannot be diagnosed clinically, then biopsy may be needed to rule out the possibility of melanocytic neoplasia. On occasion, the amalgam implantation may create pigmentation in a cosmetically objectionable location such as the anterior maxillary facial gingiva. In such cases, conservative surgical excision can be performed; alternatively amalgam tattoos have been removed successfully with Q-switched ruby or alexandrite lasers. With respect to cosmetic tattoos, a variety of treatments such as corticosteroids and lasers have been used with variable results.

CLINICAL AND RADIOGRAPHIC FEATURES: Intraoral piercings are noted most frequently in adolescents and young adults, with a female predominance. The most commonly affected sites are the tongue, lips, buccal mucosa, and, rarely, the uvula. The selected site typically is pierced with a 14- to 16-gauge sheeted needle, then the jewelry of choice is threaded through the wound. The jewelry most often is gold, silver, or stainless steel; in the tongue, the most frequent adornment is a barbell (dumbbell might be a better name!) consisting of a metal rod with a ball that screws onto each end (Fig. 8-52). The lip jewelry is termed a labret and most often consists of a ring or a rod with a flat end attached to the mucosal side and a round ball for the cutaneous sur-face (Fig. 8-53).

If no complications occur, healing of the piercing site takes place within 4 to 6 weeks. Potential acute complications include pain, prolonged or profuse bleeding, swelling (to the point of airway obstruction in rare cases), infection including Ludwig’s angina and cerebellar brain abscess, lingual nerve damage, speech impediment, and allergy to the jewelry. Chronic complications include mucosal or gingival trauma, chipped or fractured teeth, hypersalivation, aspiration or swallowing of jewelry, tissue hyperplasia around the posts, and embedded jewelry. Gingival recession (labrets, barbells) and tooth fracture (barbells) are extremely common, with the prevalence closely related to the duration of use. Molars and premolars are fractured most frequently, with the damage associated more often with a short-stem barbell, whereas greater severity of gingival recession is associated with long-stem barbells and labrets.

In individuals with forked tongues, the anterior half of the tongue is split down the middle (Fig. 8-54). Risks of the procedure include inflammation, infection, profuse or prolonged hemorrhage, and permanent neurovascular damage. After healing, some individuals have developed the ability to control each half independently.

Susuk usually is shaped like a needle that is pointed on one end and blunt on the other. Most are made from silver or gold, measure 0.5 mm in diameter, and vary from 0.5 to 1.0 cm in length. Rarely, they are made from diamonds. The pins vary in number from one to many and are inserted subcutaneously, often in a symmetrical fashion. The orofacial region is the most common location, but some choose the chest, arms, breasts, and pubic region. In most instances, the individuals are middle-aged adults. Normally, no clinical evidence exists, either visually or by palpation, and the pins are discovered during routine radiography for unrelated medical or dental problems (Fig. 8-55).

TREATMENT AND PROGNOSIS: As mentioned, intraoral barbells and labrets are associated with an increasing prevalence of oral complications that relate closely with duration of use. The patient should be strongly encouraged to remove the jewelry. On removal, if the site demonstrates significant inflammation, local débridement, antibiotic therapy, and chlorhexidine mouthwash may be appropriate.

Except for slight sibilant distortions and shortening of the protrusive length of the tongue, few long-term adverse events have been noted in patients with forked tongues.

Susuk have not been associated with harmful effects, and no treatment is required. If the needles have a ferrous content, then magnetic resonance imaging (MRI) would be contraindicated. On occasion, affected individuals request removal of the susuk before they die because they believe their death will be excruciatingly painful.

CLINICAL FEATURES:

TREATMENT AND PROGNOSIS: The management of heavy metal intoxication involves removal from further exposure to the agent, supportive care, decontamination, and use of chelating agents. In some cases a medication may be responsible and can be discontinued; however, sometimes the source of the metal may be difficult to determine. In infants with radiographic evidence of gastrointestinal lead-containing paint chips, bowel irrigation with a polyethylene glycol electrolyte lavage solution may be warranted. In the past, two chelators, ethylenediaminetetraacetic acid (EDTA) (calcium disodium ethylenediaminetetraacetate) and BAL (2,3-dimercaptopropanol), were first-line therapy in the treatment of lead poisoning, whereas arsenic and mercury intoxication were treated with BAL. These medications may have significant side effects, and less toxic alternatives such as DMSA (2,3-dimercaptosuccinic acid) and DMPS (2,3-dimercaptopropane-1-sulfonate) now are available. No antidote exists for silver intoxication, and treatment is limited to supportive measures. Attempts to remove the bluish discoloration of facial argyria with dermabrasion have been unsuccessful. Encephalopathy associated with use of bismuth-containing surgical packs clears on removal of the material.

CLINICAL FEATURES: Although any mucosal surface may be affected, smoker’s melanosis most commonly affects the anterior facial gingiva (Fig. 8-57). Most people affected by this condition are cigarette users. In contrast, pipe smokers frequently exhibit pigmentations located on the commissural and buccal mucosae. Reverse smokers show alterations of the hard palate.

The areas of pigmentation significantly increase during the first year of smoking and appear correlated to the number of cigarettes smoked each day. A higher frequency is seen in females, and researchers have suggested that female sex hormones exert a synergistic effect when combined with smoking. Reports from Sweden, Germany, and Japan have shown tobacco smoking to be the most common cause for mucosal pigmentation in light-skinned adult populations.

HISTOPATHOLOGIC FEATURES: Biopsy specimens of affected areas in people with smoker’s melanosis reveal increased melanin pigmentation of the basal cell layer of the surface epithelium, similar to a melanotic macule (see page 379). In addition, collections of incontinent melanin pigmentation are seen free within the superficial connective tissue and in scattered melanophages.

DIAGNOSIS: The clinician can make the diagnosis by correlating the smoking history with the clinical presentation and medical history. Other causes of melanin pigmentation, such as trauma, neurofibromatosis, Peutz-Jeghers syndrome, drug-related pigmentation, endocrine disturbances, hemochromatosis, chronic pulmonary disease, and racial pigmentation should be excluded.

TREATMENT AND PROGNOSIS: Cessation of smoking results in gradual disappearance of the areas of related pigmentation over a 3-year period. Biopsy should be considered when the pigmentation is in unexpected locations, such as the hard palate, or when there are unusual clinical changes, such as increased melanin density or surface elevation.

CLINICAL FEATURES: The clinical presentations of pigmentations related to drug use vary. Most agents produce a diffuse melanosis of the skin and mucosal surfaces, but others may cause a unique pattern. As in many cases of increased melanin pigmentation, females are more sensitive, most likely as a result of an interaction with sex hormones.

Use of phenolphthalein as a laxative has been associated with numerous small, well-circumscribed areas of hyperpigmentation on the skin. Similar areas of oral mucosal melanosis also can occur.

Long-term use of minocycline, a semisynthetic derivative of tetracycline, results in discoloration of the bone and developing teeth. The affected bone is dark green but creates a blue-gray discoloration as seen through the translucent oral mucosa. The most com-mon presentations include a linear band above the facial attached gingiva near the mucogingival junction and a broad zone of discoloration on the hard palate (Fig. 8-58).

Rare soft tissue pigmentation of the lips, tongue, eyes, and skin also has been reported with use of minocycline. The cutaneous pigmentation appears to be dose-dependent and is seen in up to 15% of patients being treated for acne and as many as 70% of those treated for rheumatoid arthritis. The pigmentation presents in three patterns, two of which are thought to be caused by deposition of drug metabolites that become chelated with iron. In the third pattern, the medication triggers a diffuse muddy-brown or gray cutaneous pigmentation resulting from increased melanosis of the epithelial basal cell layer and superficial connective tissue. This latter pattern is accentuated in sun-exposed areas, and the diagnosis can be made only when there is a direct association between initiation and cessation of the medication and the appearance and fading of the pigmentation. Minocycline-related pigmentation of the oral mucosa unrelated to discoloration of the underlying bone also has been reported, with patients exhibiting either widespread increased melanosis or focal accumulations of iron-containing particles (Figs. 8-59 and 8-60). Although the cutaneous and oral mucosal staining fade after discontinuation of the medication, the dental discoloration remains.

The classic presentation of intraoral pigmentation from use of antimalarial medications or tranquilizers is a blue-black discoloration limited to the hard palate (Fig. 8-61). In addition, the intake of antimalarial medications may occasionally lead to a more diffuse brown melanosis of the oral mucosa and skin.

Estrogen, chemotherapeutic agents, and medications used in the treatment of AIDS patients may result in a diffuse brown melanosis of the skin and mucosal surfaces. Any mucosal surface may be involved, but the attached gingiva and buccal mucosa are most frequently affected. The pattern and appearance of the oral mucosal involvement are similar to those seen in racial pigmentation.

TREATMENT AND PROGNOSIS: Although the discolorations of the oral mucosa may be aesthetically displeasing, they cause no long-term problems. In most instances, discontinuing the medication results in gradual fading of the areas of hyperpigmentation.

CLINICAL AND RADIOGRAPHIC FEATURES: In patients with reactive osseous and chondromatous metaplasia, an extremely tender and localized area of the alveolar ridge is typically noted that may be associated with local enlargement (Fig. 8-62). These changes almost always arise in patients with extensive atrophy of the mandibular alveolar ridge leading to a knife edge–like crest. Although most examples involve the posterior mandible, similar areas may rarely be seen overlying the maxillary alveolar ridge or associated with anterior portions of the mandible. Because of significant associated symptoms and occasional enlargement, biopsy is frequently performed.

HISTOPATHOLOGIC FEATURES: Histopathologic examination of reactive osseous and chondromatous metaplasia typically demonstrates a mass of hypercellular periosteum that blends into areas of osseous and chondromatous tissue. The bone and cartilage frequently exhibit atypical features, such as hypercellularity, pleomorphism, nuclear hyperchromatism, and occasional binucleated or multinucleated cells (Fig. 8-63). These alterations are worrisome for sarcoma, but the appropriate diagnosis can be made when an appropriate clinicopathologic correlation is made. In contrast, the cartilaginous rest discovered incidentally in maxillary specimens is usually very bland without any atypical features that would suggest malignancy.

TREATMENT AND PROGNOSIS: The thin mandibular ridges may be recontoured or supplemented with graft material to improve shape and to alleviate the symptoms associated with the localized periosteal hyperplasia. Implants also may reduce the traumatic injury to the ridge and lessen the chance of recurrence. If the ridge modification is not made, then the continued injury to the site occasionally results in recurrence of the lesion.

CLINICAL AND RADIOGRAPHIC FEATURES: In most instances, the sequestration arises without the patient’s awareness of any preceding trauma. The most frequent site of sequestrum development is the lingual surface of the posterior mandible along the mylohyoid ridge (Fig. 8-64). Focal involvement of exostoses also may occur. Although any exostosis may be involved, mandibular tori are affected most frequently.

The overlying mucosa typically demonstrates a focal area of ulceration that has been present for a period of time that varies from a few days to several months. The presence and intensity of associated pain are variable. Although most cases are unilateral, bilateral involvement may occur. On occasion an occlusal radiograph will reveal a faint radiopaque mass superimposed and partially lingual to the intact cortical plate.

The mylohyoid ridge often is prominent but typically protected from trauma by the lingual inclination of the adjacent molars. Absence of the adjacent molars or restorations that do not replace the normal inclination could predispose the area to repeated trauma; such alterations have been noted in the majority of affected patients.

HISTOPATHOLOGIC FEATURES: The sequestra consist of well-organized lamellar bone that exhibits loss of the osteocytes from their lacunae, along with peripheral resorption and bacterial colonization.

TREATMENT AND PROGNOSIS: Spontaneous loss of the dead bone or surgical removal of the sequestrum results in rapid healing. Recurrence is uncommon. In some instances, the dead bone is freely movable and easily removed. In other cases, the fragment is adherent to the underlying vital bone and must be surgically excised. In an attempt to avoid surgery, some clinicians use a tetracycline rinse in addition to topical corticosteroids. Alternatively, these patients can be recalled weekly for 2 to 4 weeks, during which time the dead bone may exfoliate spontaneously without the need for invasive therapy.

CLINICAL AND RADIOGRAPHIC FEATURES: Many symptoms have been attributed to sinus mucoceles; however, because of the confusion between pseudocysts and true mucoceles, it is unclear which symptoms are associated with pseudocysts and which are related to true sinus mucoceles. Most pseudocysts are asymptomatic; although it is rare, affected patients may exhibit facial fullness or report paresthesia, pain, or soreness on palpation. As true sinus mucoceles enlarge and expand bone, symptoms may develop and vary according to the location and the degree of expansion and destruction.

Radiographically, the pseudocyst classically appears as a dome-shaped and slightly radiopaque lesion overlying the intact floor of the maxillary sinus (Figs. 8-66 and 8-67). Maxillary cysts and neoplasms can simulate the dome-shaped pattern of an antral pseudocyst, but close examination of these pathoses typically reveals the floor of the sinus covering the superior aspect of the lesion. When the maxillary sinus is involved by a true sinus mucocele, the entire sinus will be cloudy. As the lesion enlarges, the walls of the sinus may become thinned and eventually eroded. Surgical ciliated cysts are spherical lesions that are separate from the sinus and lack the dome-shaped appearance of pseudocysts (Fig. 8-68). As these postoperative cysts enlarge, they too can lead to perforation of the sinus walls. Retention cysts rarely reach a size that would produce detectable radiographic changes.

HISTOPATHOLOGIC FEATURES: Antral pseudocysts are covered by sinus epithelium and demonstrate a subepithelial inflammatory exudate that consists of serum occasionally intermixed with inflammatory cells (Fig. 8-69). Collections of cholesterol clefts and scattered small dystrophic calcifications may be seen. True sinus mucoceles and surgical ciliated cysts are true cystic structures lined by ciliated pseudostratified columnar epithelium, squamous epithelium with mucous cells, or metaplastic squamous epithelium (Fig. 8-70). A sinus retention cyst shows focal dilatation of a duct associated with the seromucous glands of the sinus lining. The lumen of the dilated duct is filled with thick mucus, often intermixed with chronic inflammatory cells.

TREATMENT AND PROGNOSIS: Typically, pseudocysts of the maxillary sinus are harmless, and no treatment is necessary. The adjacent teeth should be evaluated thoroughly, and any foci of infection should be eliminated. A few clinicians prefer to confirm their radiographic impression and rule out a tumor through drainage of the inflammatory exudate. Removal by means of a Caldwell-Luc operation should be performed on any radiographically diagnosed lesion that produces significant expansion or is associated definitively with symptoms such as headache.

Because sinus mucoceles and surgical ciliated cysts are expansile and destructive lesions, the traditional therapy for these pathoses is assured surgical removal. Numerous investigators also have shown that sinus mucoceles arising from ostial obstruction often do not require surgical excision and respond well to endoscopic middle meatal antrostomy and marsupialization of the mucocele.

CLINICAL AND RADIOGRAPHIC FEATURES: More than 90% of cases of cervicofacial emphysema develop during surgery or within the first postoperative hour. Cases with delayed onset are associated with increased postoperative pressure created by the patient. The initial change is one of soft tissue enlargement from the presence of the air in deeper tissues (Fig. 8-71). Pain is usually minimal, and crepitus is detected easily with gentle palpation. Subsequently, the enlargement increases and spreads because of secondary inflammation and edema. Variable pain, facial erythema, dysphagia, dysphonia, vision difficulties, and mild fever may occur. The facial enlargement often is confused with an angioedema, but the diagnosis can be made by identifying crepitus within the swelling.

Significant spread into the mediastinum can result in dysphonia, dysphagia, or dyspnea. Cardiac auscultation often reveals crepitus synchronous with the heart beat (Hamman’s crunch) in cases with mediastinal involvement. Pneumomediastinum can be confirmed on chest radiographs by observing displacement of the mediastinal pleura.

Pneumoparotid typically appears as a unilateral enlargement of the parotid that demonstrates crepitus on gentle palpation. Milking the parotid duct produces a frothy, air-filled saliva, rather than the typical clear, waterlike secretion.

TREATMENT AND PROGNOSIS: Broad-spectrum antibiotic coverage is recommended in all dental-related cases of cervicofacial emphysema. The body gradually removes the entrapped air during a 2- to 5-day period. Most cases spontaneously resolve without significant difficulty. Rare cases of respiratory distress have been noted, and assisted ventilation was required.

The first goal of therapy for pneumoparotid is discovery of the inciting event. In occupation-related cases, such as those seen in trumpet players, the individual should be coached to compress the cheeks during playing. This procedure contracts the buccinator muscle and compresses the parotid duct. Acute symptoms are treated with antibiotics, massage, hydration, sialogogues, and warm compresses.

CLINICAL AND RADIOGRAPHIC FEATURES: Myospherulosis may occur at any site within soft tissue or bone where the antibiotic has been placed. The initial report described involvement of the arms, legs, and gluteal and scapular regions. Most cases in the dental literature have occurred within bone at previous extraction sites where an antibiotic had been placed in an attempt to prevent alveolar osteitis. Although maxillary and oral soft tissue examples have been documented, most cases have occurred within mandibular surgical sites. In addition, myospherulosis is reported occasionally in a paranasal sinus after a surgical procedure in which a gauze packing coated with an antibiotic ointment was used.

The involved area may exhibit swelling or be discovered as an asymptomatic and circumscribed radiolucency in a previous extraction site (Fig. 8-72). In some cases pain and purulent drainage have resulted. On exploration of the lesion, a black, greasy, tarlike material is found.

HISTOPATHOLOGIC FEATURES: The histopathologic pattern is unique; it is the result of a tissue interaction with both the petroleum base and the antibiotic, typically tetracycline. Dense collagenous tissue is intermixed with a granulomatous inflammatory response showing macrophages and multinucleated giant cells. Within the connective tissue are multiple cystlike spaces that contain numerous brown- to black-staining spherules (Fig. 8-73). The collections of spherules sometimes are surrounded by an outer membrane known as a parent body, forming structures that resemble a “bag of marbles.” The spherules represent red blood cells that have been altered by the medication. The unusual dark coloration is due to the degradation of hemoglobin. To complicate matters, myospherulosis arising in a paranasal sinus occasionally is contaminated with respiratory fungal organisms, such as the zygomycetes or aspergillus.

TREATMENT AND PROGNOSIS: Myospherulosis is treated by surgical removal of the foreign material and associated tissue. Histopathologic examination of the altered tissue provides the definitive diagnosis. Recurrence is not expected. Those arising in a paranasal sinus and exhibiting fungal infestation respond well to local measures and do not require systemic antimicrobial therapy. Some investigators have recommended discontinuation of nasal packing with antibiotic ointment, because patients with antral myospherulosis have been found to be almost three times more likely than controls to develop adhesions and require revision of their sinus surgery.

A similar clinical and radiographic pattern has been seen in association with the use of powdered tetracycline in a polymer dressing. Although somewhat different histopathologically, this formulation also leads to a granulomatous foreign body reaction. Because of complications associated with both formulations, the practice of applying topical antibiotics to oral wounds should be approached with caution, and other methods of delivery should be considered. If topical antibiotics are used, then they should be accompanied by close follow-up to ensure appropriate clinical and radiographic evidence of healing of the surgical site.