Opath Final Review

Pulp and Periapical
Chapter 3
Also notes from biopsy techniques
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Teeth are non-vital
Two periapical films showing well defined radiopacity at apex of

Mn 1st molar, exibits root tip absorption and loss of lamina dura
and some widening of the PDL space. Both lesions are present
on teeth with crown or extensive caries
Differential
Condensing osteitis--look for large carious lesion or
crown (this is correct for previous 2 radiographs)
Idiopathic osteosclerosis (bone scar) (because the tooth is
non-vital you can rule this out--Also note that the PDL space
is rarely obliterated with bone scars
Osteoma (a smaller lesion)--look for multiple impacted
supernumerary teeth and odontomas--can tip you off to
Garnders
Periapical cemento-osseous dysplasia-- if pt. was female
and african and pulp vital! (so this can be ruled out)
Cementoblastoma--these can be differentiated by a thin
radiolucent border and they generally show fusion to the root
from which it arose
Treatment
Root canal therapy
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Patient reports severe

pain to heat extremes
Spontaneous pain
Response to Electric pulp
test is erractic
Onset has been about a
week
Occlusal view and periapical radiograph of

tooth #14 showing enlarged pulp and occlusal
mass protruding through the dentin
Differential
Irreversible pulpitis
Periapical abcess-remember if you see a cyst at
the apex it means that a cyst was there before the
abcess--abcess is acute--it dosent have enough
time to wear through the bone and make a welldefined radiolucency
Treatment
Endo
extraction
Sensitive to heat
extremes
Pain goes away when
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removed
No spontaneous pain
Responds at lower
currents to electric
pulp testing
Reversible Pulpitis
Differential Reversible pulpitis
Recurrent caries
Treatment
Remove agent that is causing the inflammation
Note the white

arrow
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Radiograph of
same tooth
Periapical Abscess
Tooth #3 has widened PDL on DB root, parulis (a result of
purulent drainage) has collected near the apex of the DB root
tip. No distinct radiolucency noted and pt reports acute onset
Differential
Scleroderma (systemic sclerosis) generalized widening of
PDL
Sarcoma or carcinoma
Treatment
Root canal therapy
If the teeth are VITAL and you see any

radioLUCENCY in the jaw you must biopsy!!
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Teeth are vital
Idiopathic (focal) Osteosclerosis
Differential
Cemento-osseous dysplasia
Complex odontoma
Treatment
None b/c its a radiopacity
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African woman, vital teeth
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Periapical cemento-osseous dysplasia
Differential
Complex odontoma
Idiopathic osteosclerosis
Treatment
None, you dont worry about a biopsy b/c
african and anterior MN
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Pt has history of
infected MN molar
and/or root
fracture & airway
obstruction
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Ludwigs Angina
Swelling of the submandibular, submental
and sublingual spaces with resulting airway
obstruction
Differential
Thyroid gland enlargement, Thyroglossal duct
cyst, dermoid cyst
Treatment
Aggressive use of antibiotics, drainage, in some
pts may need to perform tracheostomy
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Cavernous Sinus Thrombosis

Grave concern is raised when the infection
encroaches on the eyelid or affects vision,
because the ophthalmic (angular) veins lack
valves and spread of infection to the brain is
possible
Treatment
drainage, antibiotics, high mortality rate
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Teeth are vital
Periapical cyst or Granuloma

Loss of lamina dura around effected roots
Differential
Impossible to tell difference b/w cyst or granuloma
from radiograph alone--need biopsy (cysts are the
result of cell rests of Malassez being in the area of
inflammation)
Periapical scar-radiolucency will persist if scar is
formed
If on the side of root (not at apex) then lateral
radicular cyst
Treatment
Root canal therapy with follow up to make sure the
lesion has healed
Biopsy techniques
Get normal tissue with abnormal tissue

If surface lesion--dont need to go too deep
If swelling or mass--the deeper the better
Dont biopsy the middle of an ulcer
Lasso technique
Mark with sutures
Punch biopsy--5mm minimum
Include picture and differential with as much
clinical info as possible--this is very important
Contact the pt right away with results!!
Bone Pathology
Jadilyn Nguyen
Cherubism
Painless bilateral expansion in posterior mandible; 2 5 yo
X-ray: multilocular radiolucency with massive expansion, tooth
displacement & eruption failure; ground glass appearance
after stabilization of expansion
Histo: lots of giant cells; eosinophilic cuffing around blood
vessels
Tx: curettage post-puberty
DD: ameloblastoma, aneurysmal bone cyst,
hyperparathyroidism, intraosseous muco-epidermoid carcinoma,
fibrous dysplasia (page 805)
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Traumatic (simple) bone cyst

Not a true cyst; posterior mandible; asymptomatic or painless
swelling
X-ray: well-defined unilocular radiolucency; scalloped
appearance in multiple teeth involvement
Histo: fibrovascular CT & trabecular bone; cyst may be empty
Tx: surgical exploration & tissue submission; good prognosis,
rapid new bone formation
DD: periapical granuloma, periapical cyst, periapical cementoosseous dysplasia, periapical scar, dentin dysplasia type 1
(page 804)
Focal osteoporotic marrow defect

posterior mandible, few mm to cm; women; unknown
cause, not pathologic; asymptomatic, no jaw
expansion
X-ray: ill-defined radiolucency
Histo: cellular hematopoietic marrow
Tx: none
DD: hematopoietic bone marrow defect,
osteomyelitis, metastatic tumors, osteoradionecrosis,
multiple myeloma (page 806)
Idiopathic osteosclerosis (Bone

scar)
posterior mandible, associated with root
apex; cause unknown; Blacks & Asians in 3rd
4th decade of life; asymptomatic, no jaw
expansion, vital tooth
X-ray: well-defined focal radiodensity
Tx: none
DD: condensing osteitis or focal chronic
sclerosing osteomyelitis (nonvital tooth),
compact osteoma
Pagets disease
Men; Maxilla; simian stance: bone pain, fractures, bowing
deformity; gradual head & jaw enlargement; paralysis, loss of
hearing & sight; increased serum alkaline phosphatase &
urinary hydroxyproline; heart failure is a major complication
X-ray: radiolucent initially, classic cotton wool appearance
later on; hypercementosis, loss of lamina dura
Histo: less dense bone having mosaic pattern & increased
reversal lines (page 544)
Tx: PTH antagonists (Calcitonin & Bisphosphonates)
DD: cemento-osseous dysplasia, Gardner syndrome,
Gigantiform cementoma
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Central giant cell granuloma

10 30 yo; female; anterior mandible; mandibular
lesions frequently cross midline; asymptomatic or
painless expansion; nonaggressive & aggressive
lesions (perforation of cortical plates & root
resorption)
Rx: well-defined radiolucency
Tx: curettage; good prognosis, 15 20% recurrence
rate, no metastasis
DD: aneurysmal bone cyst, Peripheral giant cell
granuloma, brown tumors in hyperparathyroidism,
cherubism (page 805)
Aneurysmal bone cyst

Accumulation of blood-filled spaces in posterior mandible; cause
can be trauma, vascular malformation, neoplasm; most
commonly in long bone; rapid swelling with pain; bloodsoaked sponge tissue seen at surgery; may be associated
with central giant cell granuloma
X-ray: multilocular radiolucency with cortical expansion
Histo: blood-filled spaces surrounded by fibrovascular CT, giant
cells & bony trabeculae; not lined by endothelial cells
Tx: curettage & enucleation; variable recurrence rate but good
prognosis
DD: ameloblastoma, central giant cell granuloma, cherubism,
hyperparathyroidism, fibrous dysplasia (page 805)
Fibrous dysplasia
Replacement of normal bone by fibrous tissue &
non-functional trabeculae-like osseous tissue;
asymptomatic, self limiting
Monostotic & polyostotic forms
Histo: Chinese script characters trabeculae
Tx: surgical removal post-puberty; 25 50%
recurrence; radiation therapy contraindicated
Monostotic fibrous dysplasia

Jaws most commonly affected; maxilla
& adjoining bone; painless enlargement;
2nd decade
X-ray: ground glass appearance, illdefined; PDL narrowing, obscured
lamina dura
DD: hyperparathyroidism
Polyostotic fibrous dysplasia

Young patients; may be associated with caf
au lait skin pigmentation & endocrine
abnormalities (Albright syndrome)
X-ray: Ground-glass appearance
DD: florid cemento-osseous dysplasia,
idiopathic osteosclerosis, Pagets disease,
Gardner syndrome, osteopetrosis (page 809)
Cemento-osseous dysplasia
3 types: focal, periapical, florid
Rx: mixed radiodensity
Histo: cellular fibrous CT with fragments of bone &
cementum-like material
Tx: regular recall with prophylaxis; good prognosis;
do not biopsy or extract if sclerotic (osteomyelitis)
DD: ossifying fibroma, odontoma, ameloblastic fibroodontoma, adenomatoid odontogenic tumor,
cementoblastoma (page 809)
Focal cemento-osseous
dysplasia
Mixed radiodensity in posterior
mandible; asymptomatic; female
Periapical cemento-osseous
dysplasia
Mixed radiodensity in anterior mandible;
middle-aged African-American female;
vital teeth
Florid cemento-osseous
dysplasia
Mixed radiodensity affecting entire
mandible; middle-aged AfricanAmerican female
Ossifying fibroma
True neoplasm containing bony trabeculae,
cementum-like material, or both; female; posterior
mandible; asymptomatic or painless swelling
X-ray: well-defined unilocular radiolucency
Tx: enucleation; good prognosis
DD: lateral radicular cyst, lateral periodontal cyst,
central giant cell granuloma, cemento-osseous
dysplasia, Langerhans cell disease (page 805)
Gardner syndrome
Spectrum of serious diseases: familial colorectal
polyps, osteoma (craniofacial region), epidermoid
cysts, desmoid tumors, thyroid carcinoma
X-ray: mixed radiodensity in posterior mandible;
odontomas, supernumerary teeth, impacted teeth
Tx: prophylactic colectomy; poor prognosis, 50%
develop colorectal carcinoma by age 30
DD: florid cemento-osseous dysplasia, idiopathic
osteosclerosis, Pagets disease, polyostotic fibrous
dysplasia, osteopetrosis (page page 809)
Cementoblastoma
Posterior mandible, especially 1st permanent molar
area; children & young adults; pain & swelling
X-ray: mixed radiodense mass fused to root(s)
Histo: thick trabeculae of mineralized material,
cellular fibrovascular tissue & multinucleated giant
cells
Tx: extraction
DD: cemento-osseous dysplasia, odontoma,
ossifying fibroma, ameloblastic fibro-odontoma,
calcifying epithelial odontogenic tumor (page 809)
Osteosarcoma
Malignancy of mesenchymal cells producing
immature bone; caused by radiation; intramedullary,
juxtacortical, extraskeletal; swelling, pain, tooth
loosening, paresthesia, nasal obstruction
X-ray: ill-defined mixed radiodensity; root resorption,
PDL widening; sun-burst appearance
Histo: osteoids
Tx: intial complete surgical excision, combo therapy,
30 50% survival rate; metastasis to lung & brain
DD: osteomyelitis, metastatic carcinoma,
chondrosarcoma (page 810)
Chondrosarcoma
Young patients; maxilla; painless
X-ray: ill-defined radiolucency with scattered
radiopacity; sun-burst appearance
Histo: cartilage with varying maturity &
cellularity
Tx: initial complete surgical excision; rarely
metastasize; 15 year surival rate 44%
DD: osteosarcoma, osteomyelitis, metastatic
carcinoma (page 810)
Metastatic tumors of the jaws

Mandible; breast & prostate carcinoma most
common, metastasis found in nonhealing extraction;
older patients; pain, swelling, loose teeth, paresthesia
X-ray: irregular radiolucency; moth-eaten
appearance
Histo: undifferentiated
Tx: poor prognosis, most die within 1 year
DD: periapical cyst, periapical granuloma,
osteomyelitis, osteoradionecrosis, multiple myeloma
(page 806)
Bisphosphonate-related
osteonecrosis of the jaw
Painful exposed bone persisting for > 8
weeks; spontaneous or extraction; no
history of radiation therapy to the jaw
Tx: local irrigation, periodic
debridement, surgical trimming, bone
resection; invasive dental procedures
should be performed before initiation of
therapy
Developmental Pathology
Review
Orofacial Clefts
Differential Diagnosis (use the back of the book)
Description
--Cleft lip 25%, Cleft palate 30%, Cleft lip &palate 45%
CL CP are related etiologically and Isolated CP is a separate
entity
Pierre Robin Sequence (Mandibular Micrognathia, Cleft Palate,
Glossoptosis)
Common locations
Isolated CP is much less common
Isolated CL: Males > Females (1.5:1) CL + CP: Males > Females
(2:1)
Isolated CP: Females > Males
80% of isolated CL: Unilateral (70% occur on left side)
Cause
non-syndromic vs syndromic (3-8%)
Treatment Surgery
Bifid Uvula, Submucosal Palate Cleft, Oblique Facial Cleft,
Lateral Facial Cleft
Pierre Robin Sequence (Pierre

Robin Anomalad)
Differential Diagnosis
Description
1. Mandibular micrognathia: Prevents descending
of the tongue causing CP
2. Cleft palate: Wider and U-shaped than regular
CP
3. Glossoptosis: Causing airway obstruction
Cause
Developmental
Treatment
Infants must be kept prone (face down), which
allows gravity to pull the tongue forward and keep
the airway open. These problems abate over the
first few years as the lower jaw grows and assumes
a more normal size. Also, Tracheostomy.
Commissural lip Pits

Differential Diagnosis Angular Chelitis
Description
Common locations Commissural lip pits
12-20% of adults; 0.2-0.7% in children
Unilateral or bilateral, Accentuated with age?
or not developmental?
Blind fistulas; sometimes saliva, Infection can
occur
Associated with hearing loss, preauricular pits,
rib anomalies
Cause -- Failure of processes to fuse

Treatment none needed
Paramedian lip Pits
Differential Diagnosis -- none

Description-- Blind ends
Presence of salivary glands
van derWoude syndrome (AD)
Interferon regulatory factor 6 gene mutations (role in fusion of lip and palate); chr
1 long arm
Pits and cleft lip and/or cleft palate
Mental retardation; dental malformations
Popliteal pterigium syndrome

Same gene
Popliteal webs
Cleft lip and/or cleft palate
Syngnathia (webs connecting upper & lower jaw)

Common locations Lower Lip
Cause
Developmental
Treatment
Double Lip
Differential Diagnosis -- angioedema,
tumor
Description
Redundant fold of tissue on the mucosal side
of the lip
goiter
Common locations -- Upper lip > lower lip
Cause
Mostly congenital but also acquired as a result
of trauma, oral habits such as sucking on the
lip or as part of Ascher syndrome
Ascher syndrome: AD; Double lip;
bleparochalasis and nontoxic
Fordyce Granules
Differential Diagnosis H. Yellow Lesions
Superficial Absecess, Lymphoepithelial cyst,
Lipoma
Description
Sebaceous glands occurring on oral mucosa
considered ectopic
Occasionally they become hyperplastic or form keratinfilled cysts
Considered normal variation as reported in >80% of

the population
Common locations
Buccal mucosa and vermillion zone of upper lip
Cause
Treatment
Leukoedema
Lichen planus, other leukoplakic lesions, dentifrice
stomatitis (chemical burn)
Description
Diffuse grayish-white appearance of mucosa
Thick epithelium; intracellular edema
Common locations
Blacks > Whites
Buccal mucosa extending to the lips
Cause
Variation, not a disease
More prominent in smokers
Treatment -- None
Macroglossia
Description Enlargement of tongue
Cause
Congenital or Hereditary:
Vascular malformations: Hemangioma, lymphangioma

Hemihyperplasia
Metabolic diseases: Mucopolysaccharidoses
Syndromes: Downs, Beckwith-Wiedemann
Acquired:
Edentulous patients, Amyloidosis, Myxedema,
Acromegaly, Tumors
Treatment
Ankyloglossia
Differential Diagnosis -- none
Description
Short thick lingual frenum resulting in limitation
of tongue movement
Cause
Developmental
Treatment
Cut the frenum and attend speech classes
Lingual Thyroid
Differential Diagnosis H. Yellow lesion
Fordyce granules, Lipoma, Superficial abscess,
lymphoepithelial cyst
Description
Small remnants of thyroid tissue seen in 10% of
populations
~75% of pts with infantile hypothyroidism have lingual
thyroid
May be the only functioning thyroid tissue; Goiter,
Graves disease have been described
Common locations
Actual lingual thyroid less common (Females > Males)
Cause
Failure of thyroid to completely continue its path
Treatment -- excision
Fissured Tongue
Differential Diagnosis (use the back of the
book)
Description
Grooves and fissures, Entire tongue or part,
Usually asymptomatic, Prevalence increases
with age, Strong association with geographic
tongue and Melkersson-Rosenthal syndrome
(Fissured tongue, Orofacial granulomatosis,
Facial paralysis), Tongue brushing
Common locations
More prevalent in whites, blacks; less in
Hairy Tongue
Differential Diagnosis C. Papillary growths
(focal or diffuse)
HAIRY LEUKOPLAKIA,
Description
Marked hyperkeratinization of filiform papillae
Asymptomatic
Cause
Smokers, antibiotics, poor oral hygiene, radiation,
general debilitation
Staining (bacteria, coffee, tobacco)
Treatment
Brushing, Shaving, do not use Keratolytic agents
Varcosities
Differential Diagnosis F. Blue/purple lesions
Submucosal hemorrhage, Amalgam tattoo,
Mucocele, salivary duct cyst, hemangioma if deep
Description
Dilated and tortuous vein
Multiple or solitary (lips, buccal mucosa) or contain
Phleboliths
No association with hypertension or CPD
Common locations
Sublingual Area
Cause
Age, loss of Connective tissue area,
Exostoses
Differential Diagnosis G. Radiopacities (Well-demarcated boarders)

Retained root tip, Condensing osteitis, Idiopathic osteosclerosis,
pseudocyst of Mx sinus
Description
Localized bony protuberances arising from the cortical plate, Torus
palatinus and Torus mandibularis
Mass of non-neoplastic bone with minimal marrow

Common locations
Buccal exostoses: bilateral row of bony hard nodules along the facial
aspect of maxillary and/or mandibular alveolar ridge
Palatal exostoses: lingual aspect of tuberosity
Solitary exostoses: Trauma; local irritation
Reactive subpontine exostoses (subpontic osseous hyperplasia): develop
From alveolar crestal bone beneath the pontic of a posterior bridge
Cause
Variation of normal
Treatment
Treatment for painful/ulcerated cases or if diagnosis is uncertain
Subpontic Osseous Hyperplasia

(AKA Reactive Subpontine
Differential Diagnosis:
Exotoses)
Osteoma?
Description:
Bony protuberance beneath pontic, radiopacity on
radiograph. Non-neoplastic bony growth with minimal
marrow.
Common Locations:
Alveolar ridge beneath pontic
Cause:
Develop from alveolar crest bone beneath the pontic
of a posterior bridge
Treatment:
Remove if painful, ulcerative, or interferes with
hygiene or prosthesis
Torus Palatinus
Median Palatal Cyst (less hard than torus)??
Minor Salivary Gland Tumor (May have bluish hue,
less hard than torus)??
Description:
Bony protuberance on midline of palatal vault. Can
be flat, spindle, nodular, lobular
Common Locations:
Palate
Cause:
Multifactorial, genetic predisposition
Treatment:
Surgical excision to accommodate prosthesis
Torus Mandibularis
Description:
Bony protuberance on lingual aspect of mandible.
May see on periapical radiographs. Single or
multiple. Often bilateral
Common Locations:
Lingual aspect of mandible
Cause:
Multifactorial
Treatment:
Surgical excision to accommodate prosthesis
Eagle Syndrome
Carotid artery syndrome, stylohyoid syndrome,
traumatic eagle syndrome
Description:
Elongation of styloid process or mineralization
of stylohyoid process. May cause symptoms of
syncope, dysphagia, or pain if compressing
vessels/nerves.
Cause:
Trauma, tonsillectomy
Treatment:
If symptomatic, surgery. If not, do nothing.
Stafne Defect
Ameloblastoma (especially unicystic), odontogenic
keratocyst, residual cyst
Description:
Radiolucency with sclerotic borders near angle of
mandible in radiograph.
Common Locations:
Angle of mandible, anterior and upper ramus rarely.
Cause:
Developmental, but not present at birth
Treatment:
Confirm with sialogram, no treatment necessary
Biopsy to rule out other pathologic lesions
Hemihyperplasia
Beckwith-Wiedemann syndrome,
neurofibromatosis
Description:
Asymmetric overgrowth of one or more body
parts. May see unilateral macroglossia,
macrodontia
Common Locations: N/A

Cause:
Developmental
Treatment:
Cosmetic Surgery
Crouzon Syndrome
(AKA
Craniofacial
Dysostosis)
Aperts Sydrome (difference: mental retardation,
syndactyly)
Description:
Cloverleaf skull, ocular proptosis, blindness, hearing
deficit, underdeveloped maxilla, midface hypoplasia,
crowding of maxillary teeth, bifid uvula, beaten metal
radiographic appearance, headaches, normal
intelligence
Cause:
Mutation in FGFr2, Autosomal Dominant
Treatment:
Surgery
Aperts Syndrome
(AKA
Acrocephalosyndactyly)
Crouzon Syndrome (difference: normal
intelligence)
Description:
Tower skull, proptosis, vision loss, beaten
metal radiographic appearance, midface
hypoplasia, hypertelorism, pseudocleft palate,
crowding of maxillary teeth, bifid uvula,
syndactyly, mental retardation
Cause:
Mutation in FGFr2, A.D.
Treatment:
Surgery
Treacher-Collins Syndrome
(AKA Mandibulofacial
Dysostosis)
Description:
Characteristic face: hypoplastic zygoma causing

narrow face with depressed cheeks and
downward slanting palpebral fissures, ear
anomalies, underdeveloped mandible, condyle
and coronoid hypoplasia, lateral facial clefting,
cleft palate
Cause:
Defects of 1st & 2nd BA
AD, 60% new mutations, Mutation of TCOF1 gene
Treatment:
None necessary, may have surgery for cosmetic
purposes
Osteogenesis Imperfecta
Teeth may resemble dentin dysplasia type II (primary
teeth)
Description:
Group of disorders characterized by impairment of
collagen maturation. Weak bones, blue sclera,
hearing loss, long bone and spine deformity, joint
hyperextension. Oral manifestations are clinically the
same as dentinogenesis imperfecta: obliterated pulps,
bulbous crowns constricted cervically
Cause:
AD, AR, sporadic
Treatment:
Varies
Cleidocranial Dysplasia
Description:
Short stature, bulging heads, ocular hypertelorism, broad
base of nose, depressed nasal bridge.
Dental manifestations: narrow, high-arched palate,
increased prevalence of cleft palate, numerous
supernumerary teeth with distorted shapes, prolonged
retention of primary teeth, unerupted permanent teeth lack
secondary cementum
Cause:
AD, sporadic
Treatment:
No treatment
Full-mouth extractions and denture fabrication
Exposure of unerupted teeth followed by orthodontics
Osteopetrosis
Polyostotic Fibrous Dysplasia, Florid Cemento-Osseous
Dysplasia
Description:
Marked increase in bone density due to defect in osteoclast
function; decreased bone resorption with continued bone
formation
Infantile Type: More severe; anemia, infections, delayed
tooth eruption, narrowed cranial foramina, fractures and
osteomyelitis following extractions
Adult Type: less severe; bone pain, cranial nerve
compression, fractures
Cause:
Infantile: AR
Adult: AD
Treatment:
Bone marrow transplant for Infantile type
Allergies and Immunologic Chapter 9

Soft tissue tumors Chapter 12
Pyogenic Granuloma
-smooth, lobulated mass, usually pedunculated some sessile
- surface often has ulcerations, pink to red to purple, younger lesions are more pink
-75% in gingiva especially interdental papilla, more prevalent on facial gingiva
-reactive leasion (trauma or infection)
-common during pregnancy
-tx.- excision, if interdental papilla location is involved curette to bone

- remind patient recurrence is always possible, but its not high
Peripheral Fibroma/Fibroma
- usually sessile, smooth and pink
-most common tumor of the oral cavity
-buccal mucosa most common site, also interdental area
-typically reactive hyperplasia of CT, not usually a true neoplasm
-recurrence is rare
Peripheral Ossifying Fibroma

-nodular, pedunculated or sessile, red to pink, surface frequently ulcerated
-exclusive to the gingiva
-reactive lesion
-common in teenagers and young adults

Peripheral Giant Cell Granuloma

-sessile or pedunculated, red or reddish blue, nodular, usually <2cm, ulceration possible
-exclusive to gingiva
-reactive lesion (trauma or infection)
-5th to 6th decade
Epulis Fissuratum
-single or multiple folds of mucosal tissue
-anterior maxilla, but anywhere is possible
-from ill fiting dentures, reactive scar lesion of hyperplastic tissue in the vestibule
-tx: excision, and denture remake or reline
Inflammatory Papillary Hyperplasia

Diff. Dx squamous cell carcinoma BUT, not likely sq. cell because the roof of the mouth
is least likely place for sq. cell carc, but is the most likely for Inflam. Pap. Hyper.
-papillary surface, erythematous
-usually hard palate
-ill fitting denture, poor hygiene
-tx: remove denture, salt water, antifungals, excise tissue if necessary
NeuroFibromatosis (Von Recklinghausens disease of the skin)

-multiple neurofibromas, soft and squishy, caf au late spots
-small papules(<5mm) to larger soft nodules(>5mm)
-See pg 458 for list of Diagnostic Criteria
-neurofibromas can be located anywhere
-Autosomal Dominant, 50% new mutations
-5-16% can become malignant
-No specific tx. Therapy towards prevention and management of complications.
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TIFF (LZW) decompressor
Hemangioma
-Diff. Dx Ranula, Kaposis Sarcoma, erythroplakia, thermal burns,
-superficial tumor of the skin, raised and bosselated, bright red color, may be bluish if
deeper
-most common tumor of infancy, females>males, head and neck prevalence
-developmental
-tx: watchful neglect, it will likely regress
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Sturge-Weber Angiomatosis
-no diff. listed in book
-hamartomatous vascular proliferation, born with facial port wine stain,
-port wine stain usually distributed along one or more segments of trigeminal nerve
-non-hereditary development condition
-tx: depends on nature and severity of clinical features
Nodular mass of midline tongue (top of photo) has numerous clear

surface "blisters." Two satellite lesions are seen in lower portion of photo
Lymphangioma
-no diff. listed in book
-hamartomatous tumors of lymphatic vessels, soft, fluctuant masses, pebbly-vesicle like
appearance
-predilection for head and neck
-devlopmental
-tx: surgical removal, recurrence common, no tx recommended in certain cases
Congenital Epulis
-no diff. diagnosis listed in book
-pink to red, smooth surfaced, polypoid mass on the alveolar ridge of a newborn
-almost exclusive to alveolar ridge, 90% female, max>mand.
-rare, congenital
-tx: surgical excision
Melanotic Neurectodermal Tumor of infancy

-Peutz-Jeghers, Addisons disease, Neurofibromatosis, McCune-Albright
-rapidly expanding mass usually in anterior region of maxilla, usually blue or black
-Anterior Maxilla, occurs in first year of life
-rare neoplasm of neural crest origin
-tx: surgical removal
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QuickTime and a
Granular Cell Tumor

-no diff. diagnosis in book
-nodular mass under skin or mucosa
-tongue and buccal muscoa
-schwann cell origin or neuroendocrine cells
tx: local excision
Allergic and Immunologic Diseases
Behcets Syndrome
- lesions similar to aphthous and major aphthous, Necrotizing Sialometaplasia, Anesthetic
Necrosis, Primary Syphillis (pg795)
-oral: diffuse erythema surrounding numerous irregular ulcerations
may have cutaneous lesions, conjunctivitis, uveitis
-eyes, mouth, genitals
-no clear cause, thought to have an immunogenic basis
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Sarcoidosis
-Erosive Lichen Planus, Squamous Cell Carcinoma, Cicatricial pemphigoid, Traumatic
granuloma (pg.795)
-multisystem granulomatous disorder, symptoms: dyspnea, dry cough, chest pain, fever,
malaise, fatigue
-lungs, lymph nodes, skin, eyes, and salivary glands
-evidence shows improper degradation of antigenic material with the formation of
noncaseating granulomatous inflammation
-*skin test = Kveim test
-60% have spontaneous resolution within 2 years, otherwise use corticosteroids
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Orofacial Granulomatosis
-no diff. Dx in book index
- highly variable presentation : nontender persistent swelling of one or both lips, may get
-Melkerson-Rosenthal= orofacil granulomatosis, facial paralysis, fissured tongue
-Lips alone are cheilitis granulomatosa
-lip is most common location
-unknown cause, thought to be an abnormal immune reaction
-tx: many practitioners us intralesional corticosteroids
-Extra from Lecture: must rule out fungal infection, TB, Sarcoidosis, Crohns Disease,
Chronic granulomatous disease, Foreign material, allergy
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Wegeners Granulomatosis
-Diff Dx (Generalized gingival enlargement)hyperplastic gingivitis, drug related
gingival hyperplasia, gingival fibromatosis, scurvy,
-Diff Dx (Vesiculoerosive and Ulcerative Lesions: Chronic) erosive lichen planus,
squamous cell carcinoma, cicatricial pemphigoid
-*Strawberry gingivitis, oral ulceration, no common pattern
-can involve any organ in the body
-initially involves upper resp. tract, kidney involement, systemic vasculitis
-cause not confirmed-possibly abnormal immune rxn
-tx-cyclophosphamide, prednisone, tremethoprim-sulfamethoxazole(localized areas)
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Erythema Multiforme
-traumatic ulcer, aphthous stomatitis, recurrent herpes labialis, allergic reactions
-crusted lips, multiple intraoral ulcerations, mouth hurts, cutaneous lesions, bulls eye,
target lesions, Stevens-Johnson syndrome
-lips, labial mucosa, buccal mucosa, tongue, pulms, soles of feet
-cause is poorly understood, likely immunologically mediated, 50% previous infection with
herpes simplex, also exposure drugs and medications
-tx: corticosteroids
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Allergic Stomatitis Dentifrice Stomatitis

-pseudomembranous candidiasis, morsicatio, sloughing traumatic lesion, mouthwash,
chemical burn
-burning, slight redness to brilliant erythematous lesion, edema possible, superficial
aphthous ulcerations possible, stinging tingling, *superficial epithelial sloughing
-located at site of contact
-dentifrice, medications, lip stick, metals
-tx: remove allergen, antihistamines if necessary
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Angioedema
-no diff. Dx listed in book
-diffuse edematous swelling of soft tissue, nontender, solitary or multiple
-face, lips, tongue, pharynx, larynx, hands, arms, legs, genitals, buttocks
-cause: mast cell degranulation which leads to histamine release and typical IgE
hypersensitivity reaction from drugs, foods, plants, dust, heat cold, stress, complement
cascade is common in hereditary andioedema
-tx: oral antihistamines, intramuscular epi,
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Epithelium Chapter 10
Squamous Cell Carcinoma

Most common oral malignancy
DD: keratoacanthoma, basal cell carcinoma (but not usually if
its intraoral), other cancers (like spindle cell carcinoma),
speckled erythroplakia
Tongue most common site
Look for metastasis to cervical lymph nodes
Histo depends on stage (various levels of differentiation, the
less differentiation the worse it is), keratin pearls, angiogenesis
Multifactorial disease
Treatment: surgical excision and radiation (may need neck
dissection if metastasized to cervical lymph nodes)
Keratoacanthoma
Important because it could be something much worse

Self limiting epithelial proliferation
DD: Squamous cell carcinoma, Basal cell carcinoma
Histo: acute angle between overlying epithelium and
lesion
Firm non-tender well demarcated sessile dome
shaped nodule with a central keratin plug
Treatment: make sure to biopsy, then surgical
excision
Sebaceous Hyperplasia
DD: Basal cell carcinoma, other facial tumors
Sebum can be expressed from center (unlike
BCC)
Histo: looks like normal sebaceous gland
except larger
Treatment: biopsy if unsure of diagnoses, and
then no treatment necessary
Basal Cell Carcinoma

Most common of all cancers
85% of them on the skin of the head and neck
DD: keratoacanthoma, squamous cell carcinoma,
sebaceous hyperplasia
Histo can vary
Extremely rare for metastasis to occur, but local
invasion common
Treatment: surgical excision with 5mm normal
borders (make sure to biopsy to rule out SCC!)
Actinic Chelitis
Rough, scaly lips, lose vermillion border
Due to chronic sun exposure
DD: squamous cell carcinoma,
leukoplakia (sometimes)
Histo: solar elastosis, bando of
accellular basophilic change
Treatment: encourage use of lip balm
with spf, biopsy to check for SCC
Verrucous Carcinoma
DD: squamous cell carcinoma, leukoplakia,
proliferative verrucous leukoplakia speckled
erythroplakia, verrucous vulgaris
Actually a low grade SCC, warty looking, usually
white but can be red
Often related to chewing tobacco users
Histo: deceptively benign, rete ridges appear to push
into the underlying connective tissue, often see lots of
keratin and parakeratin plugs
Focal Epithelial Hyperplasia

Usually found in kids and usually on labial, buccal,
and linqual mucosa
Soft, flattened or rounded papules, clustered or
scattered (can often coalesce)
DD: squamous papilloma, verrucous vulgaris,
condyloma acuminatum, verruciform xanthoma
Histo: Hallmarkabrupt acanthosis. Also, rete ridges
wide and club shaped
Treatment: surgical excision if needed for esthetics,
or you can leave it alone and it often regresses as the
patient gets older
Condyloma Acuminatum
Found in mouth, larynx, and genital areas
Usually sessile, pink, blunted surface
projections
DD: squamous cell carcinoma, verrucous
vulgaris, verruciform xanthoma, focal
epithelial hyperplasia
Histo: acanthotic, broader surface projections
than the other DDs, koilocytes
Treatment: conservative surgical excision
Verrucous Vulgaris
Focal hyperplasia of stratified squamous epithelium
(more likely to be on skin than intraorally)
DD: squamous papilloma, condyloma acuminatum,
verruciform xanthoma, focal epithelial hyperplasia
Contagious
Histo: fingerlike projections with connective tissue
cores, long rete ridges that have cupping, koilocytes
Treatment: liquid nitrogen cryotherapy, conservative
surgical excision, keratinolytic agents (only if you
know how to use them)
Verruciform Xanthoma
DD: verrucous vulgaris, condyloma accuminatum,
focal epithelial hyperplasia
Unlike many of its DDs, is not related to HPV
Can be yellow, white, or red; papillary or roughened
(picture shows a couple types in one spot)
Histo: this is a good one for histohas large
macrophages with foamy cytoplasmalso called
xanthoma cells; keratin layer often looks orange
Squamous Papilloma
White lesion, pedunculated or sessile, pointed or
blunted surface projections
DD: verrucous vulgaris, condyloma acuminatum,
verruciform xanthoma, focal epithelial hyperplasia
Most commonly on tongue, lips, soft palate
Histo: keratinized stratified squamous epithelium in
fingerlike projections with fibrovascular connective
cores; koilocytes can be seen to because related to
HPV
Dont forget things can be Trauma!!

(use it as your third differential
diagnosis if you can only think of two
others)
Idiopathic leukoplakia
Only decide on this as your final diagnosis if theres
no cause you can figure out from what questions you
ask Dr. Rohrer!
DD: leukoedema, smokeless tobacco keratosis,
licken planus, cheek chewing, nicotine stomatitis,
SCC, CIS (dont use all of these at once, just the
ones the particular leukoplakia he gives you looks
like)
Most common oral precancer
Lots of factors related to its etiology
Treatment: Biopsy! Surgical excision
Smokeless Tobacco Keratosis

Almost always found in mn vestibule (exception: pt.
holds smokeless tobacco in mx vestibule)
Grayish white lesion, often in conjunction with
gingival recession and facial alveolar bone
destruction
DD: leukoplakia, verrucous carcinoma, squamous
cell carcinoma
If patient stops habit and it goes away, then you dont
need to biopsy (give it about 2 weeks); otherwise,
biopsy to rule out more serious diagnoses
Erythroplakia and Speckled

Erythroplakia
Not goodthese usually end up as some
type of cancer
DD: Carcinoma in situ, squamous cell
carcinoma, trauma, denture stomatitis,
hemangioma, geographic tongue, radiation
mucositis, nicotine stomatitis, lichen planus,
candida (use the ones that fit the particular
lesion)
Treatment: Biopsy! Surgical excision
Seborrheic Keratosis
DD: actinic lentigo, lentigo simples,
melanocytic nevus
Raised exophytic proliferation
Chronic sun exposure
Histo: horn cysts
Not intraoral
Oral Mucosal Melanoma

ABCDs: asymmetrical lesion, border irregularity, color
variation, diameter >6mm or enlarging
DD: amalgam tatoo, oral melanotic macule,
melanocytic nevus, blue nevus
Most often on palate or gingiva
Histo: atypical melanocytes invading epithelium and
underlying connective tissue
Treatment: wide surgical excision
POOR prognosisthis lesion is why we should do
biopsies on all pigmented oral lesions!
Pigmented lesions that arent

Melanoma
Including oral melanotic macule
(increased amount of melanin
production), Lentigo Simplex (increased
number of melanocytes), melanocytic
nevus (usually no dendritic processes),
blue nevus, amalgam tattoo
Biopsy this stuff to make sure its not
melanoma
Proliferative Verrucous
Leukoplakia
Multiple keratotic plaques with roughened surface projections
High risk oral white lesion
DD: squamous cell carcinoma, idiopathic leukoplakia, verrucous
carcinoma
Females more than males, Gingiva most likely place
Histology NOT predictive
Possibly HPV related (16 and 18), lots get SCC in other parts of
oral cavity
Treatment: total surgical excision and frequent follow up and
remove again if it comes back
(Note there are some good pictures of this in the book and
notes)
Hematopoetic disorders
Hemophilia
No petichiae
Everythings normal except PTT
Arthritis and ankylosis
Ask about skin lesions (bruises, swollen
joints)
Thrombocytopenia
Pinpoint petichiae, echymosis,
hematoma
Gingival hemorrhage
Decreased platelet count
Skin and oral lesions
Thrombasthenia
Petichiae, echymosis
Platelet count is NORMAL
Defect in platelet aggregation
(increased bleeding time)
Vitamin C deficiency
Petichiae, echymosis, PERIODONTAL
DISEASE
Hereditary hemorrhagic
telangiectasia
Dorsum of tongue, lips, epistaxis
GI bleeding leads to iron deficiency
Prophylactic Abx
Iron Deficiency Anemia

Bald tongue, atrophic mucosa, angular
cheilitis, aphthous stomatitis
Plummer-Vinson syndrome
Pernicious anemia
Defective intrinsic factor

Burning tongue
Atrophic glossitis
Angular cheilitis
Sickle Cell Anemia

Reduced trabeculation of mandible
Hair-on-end appearance on radiographs
-Thalassemia
Usually detected during first year of life
Extramedullary hematopoiesis
Painless enlargement of maxilla and
mandible
Chipmunk facies
Hair-on-end appearance
Leukopenia
Oral ulcerations
ANUG-like gingivitis
Neutropenia
Cultures will test positive for S. aureus
and gram (-) bacteria
Gingival ulcers w/o erythematous
periphery
Leukemia
Infections (Candidiasis, herpes)

Ulcerations
Hemorrhage
Chloroma
Periapical lesions
Gingival hyperplasia
Non-hodgkin lymphoma
Buccal vestibule, gingiva, palate, jaws
Erythematous, purplish, yellowish,
ulcerated or not, toothache,
paresthesia, irregular radiolucencies
Burkitts lymphoma
B cell lymphoma; EBV-virus
Histo: starry sky pattern
Multiple Myeloma
Plasma cell origin

Older men
Amyloidosis
Punched out radiolucencies
Myeloma-associated
Amyloidosis
Macroglossia, xerostomia
Petechiae, ecchymoses
At risk for orthostatic hypotension
Amyloid deposits around ear, lips, &
eyelids
Lethal Midline Granuloma
T cell lymphoma
Nasal symptoms, hard palate
Deep ulcers and secondary infection
Angiocentrism
Langerhans Cell Disease

Dendritic cells (APC)
Monostotic or polyostotic eosinophilic
granuloma
Chronic: Hand-Schuler-Christian
Accute: Letterer-Siwe
Teeth floating in air, dull
pain/tenderness
Often only soft tissue involvement in
jaws
Viral Infections
Primary Herpetic
Gingivostomatitis
DDx:
***Traumatic ulceration
***Aphthous stomatitis
***Recurrent herpes simplex (of course!)
**Allergy
**ANUG
**Mucosal burns
**Erythema multiforme
*Herpes Zoster
Primary Herpetic
Gingivostomatitis
Description:
Acute onset
Pinhead vesicle collapse forming small erythmatous lesions
Lesions coalesce forming shallow, irregular, yellowish
ulcerations w/ a red rim.
punched-out erythmatous erosions on free gingiva
Histo: Intraepithelial vesicles have
Acantholytic eppithelial cells (Tzanck cells)
Ballooning degeneration
Glassy nuclei
Primary Herpetic
Gingivostomatitis
Location:
Lips, tongue, gingiva
Cause: HSV 1
Treatment:
Anitvirals, early
Recurrent Herpes Labialis

DDx: similiar
Description: Multiple,small, erythmatous papules that
cluster forming fluid-filled vesicles that rupture and
crust
Location: vermillion border
Cause: HSV 1
Tx:
antivirals (acyclovir)
Zovirax ointment
Abreva, Denavir
Recurrent Intraoral Herpes

Simplex
DDx: similar, + toothbrush abrasion

Description: coalescing lesions
Location: FIXED MUCOSA
Cause: HSV 1
Tx: antivirals, (acyclovir)
Herpes Zoster
DDx: similar to Herpes Simplex
Description: unilateral distribution,
extremely painful vesicles
Location: depends on nerve distribution
Cause: recurrent VZV (Varicella)
Tx:
antivirals (acyclovir)
Non-asprin antipyretics
Bacteria
Bacterial infections
1) Impetigo:
- superficial skin infection caused by
staph aureus/strep pyrogenes
- crusty skin
-tx = topical antibiotics
-Vesicles replaced by crusts
-Differentials (on face):
-Exfoliative cheilitis
-Herpes Simplex
2) Scarlet Fever
- Begins as tonsillitis
(Alpha/Beta hemolytic
strep), rash leading to
desquamation.
Skin rash
3-12 years age
- can lead to rheumatic

fever, glomerulonephritis
3) Tuberculosis
Mycobacterium
tuberculosis
Person to person
contact
- 5% of infections
progress to active
disease
- lungs, oral lesions
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decompressor
4) Noma (necrotizing
stomatitis, gangrenous
stomatitis)
- infection resulting from
normal flora
Poverty,malnutrition, poor
oral hygiene, sanitation,
illness, malignancy,
immunodeficiency
Infection can begin as NUG
5) Actinomycosis
- most common is
actinomycosis isrealli
- acute or chronic
-lumpy jaw, yellow
sulfur granules
-tx = antibiotics +
drainage
Physical and Chemical injuries
Cheek chewing
-Morsicatio buccarum, chronic chewing of
cheek,
Differential Diagnosis: ragged, white lesion (can
or cannot be scraped off), may appear to be
pealing off, hyperkeratosis
Description--PE style pedunculated, sessile etc
Common locations- anterior buccal mucosa,
labial mucosa, lateral boarder of tongue
Aspirin burn
-
habit of placing aspirin on gums, very

painful, obtain hx from pt.
Chemical burn
White, able to be rubbed off,
erythematous underneath
Peroxide burn
caused by pt rinsing with peroxide. (tx
for ANUG)
Chemical burn
Thermal burns
Most often caused by pizza
White, red or speckled lesions
Cotton roll stomatitis

-
iatrogenic, sizing (paste) sticks to

tissue. Wet cotton before removing.
Sloughing traumatic lesion
Riga Fide
early erupted tooth, infant w/ ulcer on
undersurface of tongue
Ulcer caused by a single tooth

- tx: excise to create clean edges,
common on lower lip and lateral
tongue.
Toothbrush abrasion
- horizontal pattern of erosion on
attached gingival, possible to mistake
for recurrent intraoral herpes simplex
Ionizing radiation damage

skin damage: telangectasia, hair loss,
mucositis, (serous glands), xerostomia
(prevention with good oral hygiene is
key!) Osteoradionecrosis: Damage to
blood vessels, microorganisms cant be
controlled by bodys defenses, bone
death results
Red lesions
Acid erosion of enamel

caused by stomach acid (reflux or
bulimia), lemons, tomato juice. Teeth
concave
Abnormalities of teeth and

forensics
Teeth Abnormalities
Hypodontia
Genetic and environmental influence
This particular case is ectodermal
hypoplasia
Evolution 3rd molars 20% gone

Most common: 3rd molars, mx laterals
Permanent more often than deciduous
Associated w/ microdontia
Tx: pros
Hyperdontia
Usually only a single tooth
Most often: permanent, maxilla,
unilateral
Appropriate names: mesiodens
(midline), distomolar (distal of arch),
paramolar (buccal or lingual of arch)
Early dx, extraction
Hyperdontia
ALWAYS COUNT TEETH FIRST
Microdontia
Small teeth duh
From genetics, possibly hypopituitarism
(pituitary dwarfism), Downs syndrome
Most often peg lateral or 3rd molars
Porcelain crowns pay off that student
debt!
Macrodontia
Big teeth
Associated w/ pituitary gigantism,
hemihyperplasia, and pineal hyperplasia
Gemination
One tooth bud two crowns
NORMAL COUNT
Primary > permanent; usually anterior
maxilla
Endo and possible surgical division
Fusion
Two tooth buds one tooth
Separate pulp canals usually
MISSING TOOTH in count

Surgical separation may be possible if
done w/ endo
Concrescence
Union of two teeth by cementum only
Developmental or postinflammatory
causes
Repair by cementum, no dentin interaction
Posterior maxilla; 2nd and 3rd molars

Difficult extraction, but no specific
therapy warranted
Cusp of Carabelli
ML cusp of maxillary molar
If you dont know this one, go tell Dr.
Madden you need to repeat Oral
Anatomy next fall w/ the first years.
No Tx
Talon Cusp
Extra cusp on lingual surface of anterior
teeth
May have pulp
Tx: Slow incremental grinding, CaOH,
etch and composite seal
Dens Evaginatus
Central groove or lingual ridge of buccal
cusp of premolar or molar
Bilateral possibly
Pulpal extension
Prone to fracture
Apexification
Tx: elimination of occlusal interferences
Dens Invaginatus
Invagination of crown lined by enamel
Any tooth
Coronal invagination confined to
crown
Radicular abnormal proliferation of
Hertwigs root sheath
Tx: prophylactic restoration
Ectopic Enamel
Enamel extensions from CEJ towards
bifurcation
Weak periodontal attachment
Tx: meticulous oral hygiene to prevent
perio problems
Taurodontism
Enlarged pulp chamber
Increased apico-occlusal height
Bifurcation close to apex
No tx
Hypercementosis
Non-neoplastic deposition of excessive
cementum continuous w/ radicular
cementum
Intact lamina dura
Associated w/ Pagets disease of the
bone (not so much with the nipple
though)
No tx, beware for extraction (refer!)
Dilaceration
Abnormal angulation or bend in the root
or crown
From injury
No tx, use as abutment requires
splinting
Single Incisor
Holoprosencephaly
Defect in the midline of face
Growth retardation w/o
endocrinopathies
Rare as isolated finding
No Tx.
Amelogenesis Imperfecta:
Generalized Pitted Hypoplastic
Type
Inadequate deposition of organic matrix

Normal mineralization
Pinpoint/head pits in rows or columns
Pitting does not correspond with any
environmental change
Tx: restorations ASAP, dentures,
veneers, glassionomers for better dentin
adhesion
Diffuse Smooth Hypoplastic Type
Thin, hard, glossy enamel

Crown prep like, open bite
Opaque white to brown
Radiographically: peripheral thin enamel
outline
Unerupted teeth begin to resorb
adhesion
Hypomaturation Type Diffuse Xlinked
Deciduous are opaque white and

mottled
Permaments are yellow-white; darken
w/ age
Fast enamel loss
Reduced contrast
adhesion
Diffuse X-linked Hypomaturation
FEMALE
Notice lyonization effect
Random asymmetric bands

Transillumination highlights bands
Amelogenesis Imperfecta: SnowCapped Hypomaturation Type

Zone of white opaque enamel on incisal
and occlusal surface
Looks like fluorosis
Both dentitions
Hypocalcified Type
No significant mineralization
Normal teeth at eruption
Enamel very thin and easily lost
Yellow or brown color
Heavy calculus
Open bite
adhesion
Tricho-Dento-osseous
Syndrome
Enamel hypoplasia and hypomaturation

Kinky hair
Osteosclerosis
Brittle nails
Taurodontism
(Hes supposed to be short)
Dentinogenesis Imperfecta
Deciduous more severe
Blue/brown discoloration of bulbous
crowns
Hypoplastic enamel, obliterated pulp
chamber
Short stature part of Osteogenesis
Imperfecta
Tx w/ overlay dentures, use F- releasing
glass ionomer cements
Shell Teeth
Brandywine isolate of dentinogenesis
imperfecta
Normal enamel thickness, almost no
dentin, enlarged pulps
Dentin Dysplasia Type I

Rootless Teeth
Normal color and anatomy of crown
Dentinal disorganization, tooth mobility
and premature exfoliation, fracture
easily
Little/no detectable pulp, crescent pulp
chamber
Dentin Dysplasia Type II

Normal root length
Deciduous teeth are amber to brown w/
bulbous crowns, cervical constrictions,
thin roots and obliterated pulp chambers
Permanent teeth have normal color and
enlarged flame-like pulp chambers
Regional Odontodysplasia
Ghost teeth
Usually only one quadrant, but both
dentitions
Affected teeth fail to erupt, yellow-brown
color
Tx: endo on nonvital teeth, tooth
preparation is contraindicated
Vitamin D-resistant Rickets

Large pulp chambers and pulp horns
extending to DEJ
Hypophosphatemia, decreased Ca
absorption
Microexposures, multiple periapical
lesions
Hypophosphatasia
No Cementum, premature loss of teeth
Alkaline phosphatase mutation
decreased alkaline phosphatase and
increased phosphoethanolamine
Differential: rickets
Turners teeth
Discoloration, enamel hypoplasia,
dilaceration or total malformation
From periapical inflammatory disease in
deciduous teeth (usually posterior) or
trauma (usually anterior)
Extent depends on time and severity
Fluorosis
White chalky areas; aesthetic concern
in anterior
From recent increase in fluorosis
Hypomineralized enamel; retention of
amelogenin
Caries resistant
Can be in other areas, consider snowcapped amelogenesis imperfecta
Hutchinsons Triad
Hutchinsons Incisors, 8th Cranial N.
Deafness, Interstial Keratitis
Think congenital syphilis
Mulberry Molar
Caused by syphilitic hypoplasia
Attrition
Occlusal and incisal surface from
bruxism
Tx: diagnose, long-term monitoring,
varnishing for sensitivity, mouth guards,
brushing only in morning
Abrasion
External agent
Demastication
Erosion
Chemical loss of tooth structure
May include abfraction in differential,
but abfraction tends to be more angular
shaped and along cervical edge
Root Resorption
Internal: balloon-like
External: moth-eaten
Tx: identification and elimination of
accelerating factors. Endo, CaOH,
extraction
Congenital erythropoietic
porphyria
Increased synthesis and secretion of
porphyrins
Enamel and dentin both stained
Differential: hyperbilirubinemia, trauma,
localized red blood cell destruction,
leprosy
Tx: external bleaching of vital teeth,
internal bleaching of nonvital,
restorations, composite buildups,
Tetracycline Staining
Yellow to dark brown
Crosses placental barrier
Severity: time of administration, dose,
duration
Tx: microabrasion, fine pumice,
hydrogen peroxide
Forensic Dentistry
Abuse
Signs: laceration of labial or lingual
frenum
Repeated fracture or avulsion
Zygomatic arch and nasal fractures
Bilateral contusions of lip commissure
Tx: take pictures, document well, fix,
call the authorities
Dermatologic diseases
Lichen Planus
Description:
interlacing white lines (Wickhams striae) that wax and wane over time
dorsal tongue: keratotic plaque with papillae atrophy
Erosive: atrophic, erythematus areas with central ulceration, borders
have fine, white radiating striae
Sites: posterior buccal mucosa bilaterally; also tongue, gingiva,
palate, vermillion border
General info:
Most common rare oral disease (1% cutaneous, 0.1-2.2% orally)
Cutaneous and oral manifestations
3 major types: Reticular, Erosive, Atrophic
Orally: more common in women, after 4th decade
Autoimmune disease tissue lymphocytes react to epithelial
antigen
Lichen Planus: What else to you look for?

Always look for and ask about skin lesions (11%)
Characteristics of skin lesions:
Raised, violaceous papules, extremely itchy (may
see fine lacelike network of white lines bordering
skin lesion)
Most commonly dorsal on flexor surfaces of lower
arms, shins and trunk
Lichen
Planus:
Histology
1. Hyperkeratosis
Normal Oral Mucosa
2. Acanthosis
3. Irregular rete ridges sawtooth
4. Band-like infiltrate of
lymphocytes
5. Liquefactive degeneration of the
basal cell layer
Reticular LP:
Lichenoid Drug reaction
Graft-versus-host disease
Leukoedema (usually in blacks, white,
wrinkled/streaked appearance; disappears with
stretching)
Leukoedema
Lichen Planus: Differential

Diagnosis
Erosive LP:
Cicatricial Pemphigoid (multiple areas of erythema
and diffuse irregular ulcerations; Nikolsky + (LP is
not))
Pemphigus Vulgaris (mulitple oral blisters and
ulcers usually precceding skin lesions, Nikolsky +)
Lupus erythematous (red and white lesions
usually w/ skin lesions)
Lichen Planus
TREATMENT:
LP is incurable :
Asymptomatic (Reticular or Atrophic): normal
oral hygiene
Sympotmatic (erosive): topical fluorinated
corticosteroids
Flucocinonide (Lidex) GEL, Betamethasone
(Diprolene) GEL, Clobetasol (Temovate) GEL
If bad, break the cycle with systemic predisone
Graft-versus-Host Disease
Description:
fine, reticular network of striae resembling LP
but more diffuse pinpoint, white, papular
Tongue, labial mucosa, buccal mucosa
burning sensation (dont overlook candida)
may see ulcerations from chemo
General facts:
After bone marrow transplantimmunocompetent cells transferred to host
Histologically looks a lot like lichen planus
Clinical severity varies
Graft-versus-host disease
Lichen Planus (clinically and to a point histologically)
Lichenoid Drug Reaction
What youd ask:

Have you had a bone marrow transplant or other type of graft/transplant
Treatment:
Reduce or prevent occurrence/reoccurence (good HLA matching,
immunosuppressants)
Topical steroids may help healing of focal oral ulcerations
Since xerostomia is an issue may recommend preventative fluoride
Psoriasis
Description:
Range from white/red plaques to ulcerations
Some say erythema migrans intraoral psoriasis
because slight association (no direct correlation
though)
General Info:
Common chronic skin disease (1-2% population)
Genetic influence
Appears to be autoimmune
Activate T lympocytes appear to activate a very
complicated scenario leading to increased
proliferative activity of cutaneous keratinocytes
ORAL INVOLVEMENT QUITE RARE
Psoriasis
What else to look for?
Cutaneous lesions: well-demarcated, erythematous plaque
with a silvery scale on surface
Located symmetrically commonly on scalp, elbows, knees
Usually asymptomatic, sometimes itchy
Tend to resolve in the summer (UV light)
4% pts have psoriatic arthritis; may involve TMJ
Other red/white lesions like Lichen Planus, Cicatricial
Pemphigoid, Pemphigus vulgaris BUT oral lesions so rare
that unless you had skin lesions too you probably would
think about psoriasis
Treatment
Mild lesions: no treatment
Moderate involvement: topical corticosteroids
Severe cases: UV light therapy, systemic
Normal Oral Mucosa
Histopathology of
psoriasis
Note: the histo slide was from lecture but the description is from the book
Characteristic pattern
surface epithlium marked parkeratin production
elongated rete ridges
CT papillae contain dilated capillaries approach epithelial
surface
collection of neutrophils (Munro abcesses) in parakeratin layer
Slide 1/2
Slide 2/2
Systemic
Lupus
Erythematosus
Description:
Oral lesions non-specific
(difficult to diagnose): similar to LP
(SLE)
but usually deeper perivascular infiltrates ; varying degree of
ulceration, pain, erythema , hyperkeratosis may be present
General info:
most common connective tissue disease in US

Non-specific early multisystem symptoms
Women 8-10 x >men
Weight loss, fatigue, malaise
Butterfly (malar) rash 50%
Reaction to sun (sun makes worse as apposed to psoriasis)
Cutaneous and oral manifestations
Increase activity of B cells and abnormal function of T cells
Antigen/antibody complex; Anti-nuclear antibodies
Interplay of genetic and environmental factors (precise cause
unknown)
Kidney Failure most significant factor (40-50%) due to Ab/Ag
complex trapped in glomeruli-cause inflammation and damage
Cardiovascular involvement important
Oral lesions 5-40% - palate, buccal mucosa, ginvigae
Chronic Cutaneous Lupus

Erythematosus (Discoid Lupus)
Lesions limited to skin and mucosa (no systemic
involvement)
Oral lesions look like erosive LP (ulcerative or
atrophic, erythematous central zone surrounded by
white, fine, radiating striae
But, to ddistinguish from erosive LP, there are
ALWAYS skin lesions
Skin lesions: scaly, erythematous patches frequently
distributed on sun-exposed skin, especially head and
neck
Healing may result in cutaneous atrophy w/
scarring and hypopigmentation or
SLE and CCLE

Erosive Lichen Planus
Treatment:
Systemic therapy usually helps with SLE oral
lesions
topical corticosteroids for CCLE oral lesions
Hypohidrotic Ectodermal
Dysplasia
Best know member of ectodermal dysplasia
(group of interited conditions in which 2 or more
ectodermally derived structures fail to develop
Usually x-linked
Heat intolerance
Fine, sparse blond hair
Hyperpigmented, wrinkled periocular skin
Midface hypoplasia
Oligodontia or hypodontia (anodontia
uncommon)
Crown shape abnormal
White Sponge Nevus

Description:
symmetric, thickened, white, corrugated or velvety, diffuse
plaques
Bilateral buccal mucosa (can be other areas of oral mucosa)
other common intraoral sites: ventral tongue, labial mucosa,
soft palate, alveolar mucosa, floor of mouth
General Info:
Autosomal dominant
Defect in normal keratinization of oral mucosa
Extraoral mucosal sites have been reported
Generally asymptomatic
Appears at birth or in early childhood; may develop during
adolescence
Probably not the most important

histology slide, but he included it in
his lecture
(from book)
Characteristic but not
pathognomonic:
Prominent
hyperparakeratosis
Marked acanthosis
with clearing
(vacuolation) of of
cytoplasm cells in
spinous layer
White Sponge Nevus

Differential Diagnosis (white lesion cannot be
scrapped off)
Cheek chewing
Cinnamon stomatitis
Treatment:
Totally benign lesion, no treatment needed
Prognosis wonderful!
Dariers Disease (dyskeratosis

follicularis)
Description:
Multiple, normal-colored or white, flattopped papules that
when confluent resemble cobbelstone
Usually on hard palate and alveolar mucosa
General info:
Autosomal dominant
Lack of cohesion of epithelial cells
Abnormal desmosomes
Warty dyskeratoma (isolated Dariers) histologically
identical but not related
inflammatory papillary hyperplasia
nicotine stomatits
Dariers disease
Cutaneous lesions:
numerous erythematous, often
pruritic, papules
typically on trunk and scalp
Histopathology:
Cutaneous or mucosal lesion shows

dyskeratotic process:
central keratin plug
acontholysis
test tube shaped rete ridges

BONUS Slide: this slide was not presented to
us and is probably not improtant, but shows the
keratin plug and acontholysis; enlarge at your
dyskeratitic cells: corps ronds (round

bodies), grains (resemble cereal grains)
Ehlers-Danlos Syndrome
A group of connective tissue disorders
Production of abnormal collagen
Typical fifindings
Hypermobility of joints
Marked elasticity of skin
Easy bruisability
Circus rubber man and contortionist
Gorlin sign = ability to touch tip of nose with
tongue (50%)
May have abnormal teeth (malformed, stunted
roots, large pulp stones, hypoplastic enamel)
Accurate diagnosis of the specific type is critical
Multiple Hamartoma (Cowden)

Syndrome
Diagnosis based on finding 2 of the
following
1 Multiple facial trichilemmomas
2 Multiple oral papules
3 Acral keratoses
Signifificant because of the high

percentage of individuals who develop
malignancies
Thyroid adenocarcinoma
Fibrocystic disease/carcinoma of the
breast
Cicatrical (scarring) Pemphigoid

Description:
Sloughing, bleeding, painful, fire engine red gingiva
May see vesicles or bullae, which rupture and leave
large, superficial, ulcerated denuded areas of mucosa
Can be found in any area of the oral cavity, or limited
to specific area commonly gingiva
General Info
Classical description is eyes, mouth and genitals
Vast majority involve only the oral mucosa
Autoantibodies against component of basement
membrane
Erosive Lichen Planus
Pemphigus vulgaris
Positive
Nikolsky
Sign
Histopathology:
Split between surface epithelium and underlying
CT
Mild chronic inflammatory cell infiltrate in superficial
mucosa
Direct immunofluorescence: continuous linear band

of immunoreactants at basement membrane zone
(need intact (not ulcer) tissue sample)
Cicatricial Pemphigoid
Treatment:
Very diffificult to treat
Topical corticosteroids, scrupulous oral hygiene,
chlorhexidine
Systemic corticosteroids
Medical Intervention
Dapsone
Immunosuppressive Agents
Most important - refer to an ophthalmologist

Refer to dermatologist if standard steroid
treatment doesnt work
Pemphigus Vulgaris (common pemphigus)

Description:
Superficial ragged erosions and ulcerations hapzaradly
distributed on oral mucosa
Palate, labial mucosa, buccal mucosa, ventral tongue,
ginvigae
Vesicles or bulla rarely seen because they rupture early due to
thin, friable roof
General Info:
Fatal if untreated -Death from infection following
loss of epidermis
More people die now from the treatment than from the
disease
Very important to dentists
Oral 90%
Begins as oral 60-70%
Confined to oral 45%
Autoantibodies to desmosomes
Pemphigus vulgaris
Cutaneous lesions:
Flaccid vesicles or bullae that rupture quickly
(fragile)
Leaving erythematous, denuded surface
Ocular: may see bilateral conjuntivitis, but

not scarring (cicatrical pemphigoid)
Positive Nikolsky Sign
Histopathology:
intraepithelial separation
entire superficial epithelium may strip of
leaving basal cells row of tombstones
acantholysis
Rounded cells (Tzanck cells) in
intrepithelial cleft
Direct immunofluorescence
Immunoreactants
deposited in intacellular
areas between surface
epithelial cells
Pemphigus vulgaris
Treatment
Systemic corticosteroids (predisone) because its
a systemic disease
Immunosuppressive therapy
Topical corticosteroids may be helpful (absorb to
increase systemic dose)
Prognosis
Lots of potential problems w/ long-term steroid use
leading to mortality rate of 5-10%
Paraneoplastic Pemphigus
Patients have a neoplasm, usually a
lymphoma or CLL
Probable cross reaction between
antibodies produced to the tumor and to
the desmosomes and BMZ
High morbidity and mortality
Oral: may look like erythema
multiforme or herpes simplex infection
Erythema
Multiforme
Description:
Ulceration of labial mucosa with hemorrhagic crusting

of vermillion zone of lips
General Info:
Acute onset
Teens and young adults
Males > Females
Often recurrent
Uncertain etiopathogenesis: may follow herpes
simplex infection or meds like antibiotics or
analgesics
The Hallmark Lesion is CRUSTED LIPS
Stevens-Johnson syndrome : EM w/ sever
Erythema multiforme
Paraneoplastic Pemphigus
Primary herpetic gingivostomatitis
Treatment: systemic
corticosteroids, eliminate
causative drug, topical
corticosteroids
Cutaneous lesions
Flat, round dusky-red hue, may be slightly elevate w/ necrotic
centers
Concentric, circular erythematous rings (target lesions)
Erythema Migrans (geographic tongue,

benign migratory glossitis)
Description:
Anterior 2/3 tongue, multiple well-demarcated zones
of erythema due to atrophy of filiform papillae,
surrounded by slightly elevated, yellowish-white
serpintine or scalloped border
Tends to wander heal in one area and develop
again in another area
General Info:
Etiopathogenesis still unknown
Relation to fissured tongue (5% w/ fissured tongue, 90%
geogrpahic tongue have fissured tongue too)
Histologically looks like psoriasis
Erythema Migrans
?
Treatment:
Assure patient of benign status
Rare instances of pain need topical
steroids
Oral manifestations
of systemic diseases
Systemic Diseases and their

Oral Manifestations
Amyloidosis
-a condition characterized by extracellular deposition of
amyloid
-symptoms depend on organ(s) affected
Oral findings:
-macroglossia; diffused or nodular enlargement of the
tongue
-petechiae and ecchymoses
-amyloid nodules on the tongue, sometimes ulcerated
(pic 4)
-need to rule out multiple myeloma!
-histo will have congo red stain (pic 2) demonstrating
characteristic apple-green birefirgence when viewed with
polarized light
-no effective therapy; colchicines, prednisone, and melphalan
improves prognosis if no cardiac and renal involvement
Plummer-Vinson Syndrome
a condition characterized by iron-deficiency
anemia
Oral findings:
-burning sensation on of tongue and oral
mucosa, red dorsal tongue, and difficulty
swallowing
-angular cheilitis
High rate of oral and esophageal
carcinoma
Hypochromic microcytic anemia
Tx: dietary iron supplements
Pernicious Anemia
Poor absorption of cobalamin /B12/extrinsic
factor
Due to loss of intrinsic factor from parietal
cells of stomach lining due to autoimmune
destruction
Strict vegetarians may develop B12
Deficiency
Oral findings:
-tongue atrophy and erythema (pic)
-burning sensation in the mouth
Tx: monthly intramuscular injections of
Pituitary Dwarfism
insufficient growth hormone
short stature, but appropriate body
proportions and normal skull size
Oral findings:
-delayed pattern of eruption, delayed
shedding of deciduous and devt of
perm. roots
Tx: replacement therapy
Giantism
Too much growth hormone before
closure of epiphyseal plates; associated
with pituitary adenoma
Bones grows vertically and horizontally
Oral finding: true generalized
macrodontia
Tx: removal of adenoma, radiation
therapy
Ddx (for macrodontia): facial
Acromegaly
Too much growth hormone (after closure)
due
to pituitary adenoma
Bones grow horizontally
Complications: HTN
Oral findings:
mn prognathism(overgrowth) causing ant.
open bite, diastema formation, soft tissues
changes causes uniform macroglossia
Tx: remove tumor mass
17-18 17-20
Hypothyroidism
Thyroid hormone insufficient
symptoms related to decrease metabolic rate
-Cretinism (infancy)
Myxedema adult form because of deposition of
glycosaminoglycan ground substance in
subcutaneous tissues
Oral findings:
-enlarged tongue secondary to edema (pic 1)
-thickened lips
-deciduous teeth may fail to erupt (formation fine) (pic
2)
Tx: thyroid replacement therapy
Ddx: Hypodontia
Hyperthyroidism
Excess thyroid hormone (due to Graves
disease mostly), auto-antibodies against
TSH receptors or tumor, thyroid gland
enlarged, bulging eyes, increased
metabolism
Risk of thyroid storm
Tx: reactive iodine
Hypoparathyroidism
A rare condition usually due to accidental
removal of parathyroid glands, may be
autoimmune, leads to drop in serum
calcium and hypocalcemia.
Oral findings:
-chvosteks sign (twitching of upper lip
when tap facial nerve just below
zygogmatic process)
-pitting enamel hypoplasia (pic) and failure
to erupt (if during odontogenesis)
Ddx: environmental enamel hypoplasia,
pseudohypoparathyroidism
click image to return
Pseudohypoparathyroidism
Normal levels of hormone but the biochemical
pathways malfunctions and absorbs less Ca in
blood
Midface hypoplasia, obesity, round face, short
neck
Oral findings:
generalized enamel hypoplasia (pic 1)
widened pulp chambers with intrapulpal
calcifications (daggered)
oligodontia
delayed eruptions
blunting of apices
Ddx: renal osteodystrophy,
Hyperparathyroidism
Excess production of parathyroid hormone (PTH), continuously produced due to

chronically low serum calcium levels primarily due to chronic renal failure failing to
produce adequate vitamin D (for Ca absorption)
Stones (kidney stones)
Bones: variety of osseous changes oral manifestations:
(a) generalized loss of lamina dura (pic 2) and alterations in trabeculae seen as
ground glass appearance
(b) leads to brown tumor (NOT BROWNS TUMOR) ML RL (pic 3), histo looks like
giant cell granuloma
(c) if brown tumor is persistent, gets replaced by osteitis fibrosa cystic ( severe)
(d) Renal osteodystorphy occurs in secondary hyperparathyroidism due to end
stage renal failure generalized enlargement of the jaws. (pic 1)
Abdominal groans (duodenal ulcers)
A diagnosis of central giant cell lesion (much more common) will
always carry the caveat that it cannot be distinguished from
hyperparathyroidism and that must be ruled out.
Ddx: Fibrous dysplasia (also has loss of lamina dura and ground glass), cherubism
(multi-locular and enlargement of jaws), central cell granuloma, KOT, ameloblastoma
(all are multi-locular in radiogr)
Hypercortisolism
(Cushings syndrome)
Due to sustained increase in glucocorticoid levels
Usually due to corticosteroid therapy or adrenal cortical tumor
If caused by adrenal or pituitary tumor, Cushings disease
Findings:
Moon facies
Buffalo hump (pic 1)
Reddish-purple abdominal striae (pic 2)
Hirsutism
Poor healing
Osteoporosis
Hypertension
Mood changes
Hyperglycemia
Muscle wasting and weakness
Addisons Disease
(Hypoadrenocorticism)
insufficient production of adrenalcortical steroids due to
destruction of adrenal cortex ; secondary to
malfunctioning pituitary
Features: fatigue, irritability, depression, weakness,
hypotension
increased beta-lipotropin or ACTH causes excess melanin
production
Generalized hyperpigmentation of skin (esp. sun exposed
skin bronzing)
Oral finding:
-diffuse of patchy pigmentation caused by excess
pigmentation
Tx: corticosteroid replacement therapy
Ddx: oral melanotic macules, melanoma, peutz-jeghers
Diabetes Mellitus
A common disorder of carb metabolism leading to increase in blood
glucose levels (hyperglycemia)
Type I IDDM or juvenile
Type II - non-insulin dependent
Complications:
- peripheral Vascular disease- leading cause of kidney failure,
ischemia and amputation of limbs, blindness
3 Ps: Polyphagia, Polyuria, Polydypsia
Oral findings: (generally limited to Type I)
-erythematous enlargement of gingival tissues (pic 1)
-bilateral englargement of parotid glands
-oral candidiasis (pic 2)
-zygomycosis (tissue necrosis)
-xerostomia
Ddx: Primary herpetic gingivostomatitis, ANUG, candidiasis
Hypophosphatasia
metabolic bone disease characterized by
decreased serum alkaline phosphatase
(thought to play a role in bone production)
and increase phosphoethanolamine in
urine and blood
Bone defects similar to rickets
Oral findings:
No cementum (pic #2) on teeth leading to
premature loss of teeth without evidence
of inflammatory response (pic #1)
Ddx: idiopathic hypodontia
Vitamin D-Resistant Rickets

Rickets resistant to vitamin D (as tx) due to
decreased capacity to reabsorb phosphate
Oral findings:
large pulp chambers with pulp horns that
extend almost to the DEJ leading to very
small pulp exposures leading to multiple
periapical lesions and gingival sinus tracts
on normal looking teeth, pulp typically nonvital
Tx: calcitriol and phosphate, endo, monitor
serum and urine ca levels
Crohns Disease
(Regional Enteritis)
Inflammatory/immunologically mediated
condition
primarily affects the distal portion of small
intestine and proximal colon
Manifestations anywhere in the GI tract,
including the mouth
Oral lesions:
May precede GI lesions in 30%
Granulomas (orofacial granulomatosis)
Cobblestone lesions (pic 1)
linear Aphthous-like ulcerations (pic 2)

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Pulp and Periapical

Teeth are non-vital

Two periapical films showing well defined radiopacity at apex of

Patient reports severe

Occlusal view and periapical radiograph of

Note the white

If the teeth are VITAL and you see any

Teeth are vital

Idiopathic (focal) Osteosclerosis

African woman, vital teeth

Periapical cemento-osseous dysplasia

Cavernous Sinus Thrombosis

Teeth are vital

Periapical cyst or Granuloma

Get normal tissue with abnormal tissue

Traumatic (simple) bone cyst

Focal osteoporotic marrow defect

Idiopathic osteosclerosis (Bone

Central giant cell granuloma

Aneurysmal bone cyst

Monostotic fibrous dysplasia

Polyostotic fibrous dysplasia

Metastatic tumors of the jaws

Pierre Robin Sequence (Pierre

Commissural lip Pits

Cause -- Failure of processes to fuse

Paramedian lip Pits

Differential Diagnosis -- none

Popliteal pterigium syndrome

Syngnathia (webs connecting upper & lower jaw)

Considered normal variation as reported in >80% of

Vascular malformations: Hemangioma, lymphangioma

Differential Diagnosis G. Radiopacities (Well-demarcated boarders)

Mass of non-neoplastic bone with minimal marrow

Subpontic Osseous Hyperplasia

Common Locations: N/A

Characteristic face: hypoplastic zygoma causing

Allergies and Immunologic Chapter 9

-tx.- excision, if interdental papilla location is involved curette to bone

Peripheral Ossifying Fibroma

-tx.- excision, if interdental papilla location is involved curette to bone

Peripheral Giant Cell Granuloma

Inflammatory Papillary Hyperplasia

NeuroFibromatosis (Von Recklinghausens disease of the skin)

Nodular mass of midline tongue (top of photo) has numerous clear

Melanotic Neurectodermal Tumor of infancy

Granular Cell Tumor

Allergic and Immunologic Diseases

Allergic Stomatitis Dentifrice Stomatitis

Squamous Cell Carcinoma

Important because it could be something much worse

Basal Cell Carcinoma

Focal Epithelial Hyperplasia

Dont forget things can be Trauma!!

Smokeless Tobacco Keratosis

Erythroplakia and Speckled

Oral Mucosal Melanoma

Pigmented lesions that arent

Iron Deficiency Anemia

Defective intrinsic factor

Sickle Cell Anemia

Infections (Candidiasis, herpes)

Plasma cell origin

Lethal Midline Granuloma