22-03-17

Variaciones en la cavidad
oral y condiciones
comunes benignas
Dra. Karina Cordero T.
22 de marzo de 2017.

OBJETIVO DE LA CLASE DE HOY.

TIPOS DE VARIACIONES Palabras claves a manejar

FISIOLGICAS
Melanocitos Lengua surada
INFLAMATORIAS
Melanina Lengua Geogrca
Pigmentacin siolgica GlosiTs romboidal media
NEOPLSICAS
Mcula melanTca Fibroma/broma irritaTvo
AUTOINMUNES Melanoma pulis surado
Grnulo de Fordyce Torus/exostosis
Injerto gingival Anquiloglosia
Amgdala lingual Frenillo
DIAGNSTICO Y NECESIDAD
DE TRATAMIENTO

Pigmentaciones
Variaciones en la Enca / Mucosa
en la cavidad Paladar
lengua yugal
oral

Fisiolgicas Fisurada. Nevus Leucoedema

Grupos de Nevus
Lengua
Torus
Nevo blanco
variaciones geogrca esponjoso

o trastornos Asociadas al GlosiTs

EstomaTTs Frenillo
a estudiar consumo de
tabaco
romboidal
media
nicocnica prominente

Post Lengua Pseudobroma

inamatorias depapilada irritaTvo

Tatuajes
Lengua pilosa pulis surado
(amalgama)

Leucoplasia
pilosa
Pigmentaciones en la cavidad oral
Anquiloglosia,
etc

1
 18 Clinical Oral Medicine and Pathology

2.3 Fordyce Granules

22-03-17

Sebaceous glands, which are a normal feature of facial

SKIN CAN OFTEN BE IDENTIlED WITHIN THE BUCCAL MUCOSA
DUE TO THE PROXIMITY OF SKIN TO THE ORAL MUCOSA IN THIS
area. These are less commonly noted on the lip or the
labial mucosa (Figs. 2.4 and 2.5). Fordyce granules
appear white to yellow in color, are generally present
Pigmentaciones Bisiolgicas
18 atic. Sebaceous glands
Pigmentaciones Bisiolgicas
in clusters, may be slightly raised, and are asymptom-
Clinical Oraloral
in the Medicine and are
mucosa Pathology
non-
functional. Occasionally patients become aware of
2.3 Fordyce Granules
Fig. 2.1 Melanotic macule of the lower lip with dark brown
PIGMENTATION AND SHARPLY DElNED BORDERS 4HE LIPS ARE SLIGHTLY
chapped. Sebaceous glands, which are a normal feature of facial
SKIN CAN OFTEN BE IDENTIlED WITHIN THE BUCCAL MUCOSA
DUE TO THE PROXIMITY OF SKIN TO THE ORAL MUCOSA IN THIS
area. These are less commonly noted on the lip or the
labial mucosa (Figs. 2.4 and 2.5). Fordyce granules
appear white to yellow in color, are generally present
in clusters, may be slightly raised, and are asymptom-
atic. Sebaceous glands in the oral mucosa are non-
functional. Occasionally patients become aware of
Mcula melanTca: trmino clnico Pigmentacin siolgica racial
Fig. 2.1 Melanotic macule of the lower lip with dark brown
PIGMENTATION AND SHARPLY DElNED BORDERS 4HE LIPS ARE SLIGHTLY
chapped.

18 Clinical Oral Medicine and

2.3 Fordyce Granules

Fig. 2.2 0HYSIOLOGIC PIGMENTATION IN AN !FRICAN !MERICAN Fig. 2.4 Prominent Fordyce granules in the right buccal
child. The interdental papillae are affected to a variable degree; mucosa. Sebaceous glands, which are a normal feature
the nonkeratinized mucosa is entirely unaffected. SKIN CAN OFTEN BE IDENTIlED WITHIN THE BUCCA
DUE TO THE PROXIMITY OF SKIN TO THE ORAL MUCO

Pigmentaciones Bisiolgicas area. These are less commonly noted on the

labial mucosa (Figs. 2.4 and 2.5). Fordyce
appear white to yellow in color, are generally
in clusters, may be slightly raised, and are asy
atic. Sebaceous glands in the oral mucosa
functional. Occasionally patients become a

Fig. 2.1 Melanotic macule of the lower lip with dark brown
PIGMENTATION AND SHARPLY DElNED BORDERS 4HE LIPS ARE SLIGHTLY
chapped.

Fig. 2.2 0HYSIOLOGIC PIGMENTATION IN AN !FRICAN !MERICAN Fig. 2.4 Prominent Fordyce granules in the right buccal
child. The interdental papillae are affected to a variable degree; mucosa.
the nonkeratinized mucosa is entirely unaffected.

Pigmentacin posTnamatoria secundaria a mordida crnica de la mejilla

Fig. 2.3 0OSTINmAMMATORY PIGMENTATION OF THE RIGHT BUCCAL Fig. 2.5 Dense concentration of Fordyce granules in the left
(Melanoacantoma)
mucosa secondary to chronic cheek biting. buccal mucosa.
Fig. 2.2 0HYSIOLOGIC PIGMENTATION IN AN !FRICAN !MERICAN Fig. 2.4 Prominent Fordyce granules in the rig
child. The interdental papillae are affected to a variable degree; mucosa.
the nonkeratinized mucosa is entirely unaffected.

Tatuaje por amalgama

Fig. 2.3 0OSTINmAMMATORY PIGMENTATION OF THE RIGHT BUCCAL Fig. 2.5 Dense concentration of Fordyce granules in the left
mucosa secondary to chronic cheek biting. buccal mucosa.
Fig. 2.3 0OSTINmAMMATORY PIGMENTATION OF THE RIGHT BUCCAL Fig. 2.5 Dense concentration of Fordyce granules
mucosa secondary to chronic cheek biting. buccal mucosa.

Esto NO es siolgico

2

DElNED AREA OF DEPAPILLATION ON THE RIGHT SIDE OF THE TONGUE
mboid Glossitis
itis erythema migrans showing subtle circular
DElNED
borders of the right buccal mucosa and con-
onsistent with benign migratory glossitis.
he tongue a map-like appearance, thus
erm geographic. In an affected indi-
ntation can change on a daily basis and
hMIGRATORYv !LTHOUGH THE CLINICAL PRE-
striking, there are few if any other con-
ic geographic tongue (these include oral
rythematous candidiasis, and leukopla-
GOOD HISTORY AND EXAMINATION LESIONS
iopsy.
PATIENTS MAY DESCRIBE SENSITIVITY OF THE
wise normally tolerated food and bev-
Y OR MAY NOT CORRELATE WITH THE EXTENT
d clinically. Management with topical
e effective in such cases. Importantly,
tongue sensitivity must be considered,
asis or immune-mediated conditions,
n there is recent or abrupt onset of
tests: None; diagnosis is based on
rance.
22-03-17
Lengua Bisurada
20 Clinical Oral Medicine and Pathology
Variaciones y alteraciones en la lengua
Fig. 2.8 Benign migratory glossitis in a child. There is a very
WELL
dorsum, while the rest of the surface is unaffected.
Lengua geogrBica o glositis
migratoria benigna
Fig. 2.7 &ISSURED TONGUE WITH EXTENSIVE GROOVES AND lSSURES
over the entire dorsal surface.
Diagnostic tests: None.
Biopsy: No.
Treatment: None. Fig. 2.9 Benign migratory glossitis of the ventral tongue and
mOOR OF MOUTH !S THIS REGION OF THE TONGUE DOES NOT NORMALLY
Follow-up: None.
contain papillae, only the white rimmed borders are noted.
2.7 Geographic Tongue
!LSO REFERRED TO AS benign migratory glossitis, geo-
GRAPHIC TONGUE IS A COMMON INmAMMATORY CONDITION OF
the tongue. Other oral mucosal sites can be affected less
frequently, in which case the condition is called stoma-
titis erythema migrans or ectopic geographic tongue.
'EOGRAPHIC TONGUE IS USUALLY EVIDENT IN EARLY CHILDHOOD
and rarely causes symptoms. The lesions demonstrate a
wide variety of clinical patterns, ranging from irregu-
larly shaped erythematous macules with surrounding
Fig. 2.10 %XTENSIVE BENIGN MIGRATORY GLOSSITIS AFFECTING THE
elevated white borders to patchy areas of depapillation entire tongue dorsum with prominent areas of depapillation
and smooth glossy mucosa (Figs. 2.82.11). These fea- surrounded by white rimmed borders.
Glositis romboidal media Lengua depapilada
21
Fig. 2.12 -EDIAN RHOMBOID GLOSSITIS WITH A WELL
depapillated patch in the posterior midline of the tongue dorsum
with normal surrounding tissue.
2.8 Median Rhomboid Glossitis
This is a poorly understood condition that affects the
tongue dorsum. It is characterized by a chronic, atro-
phic, erythematous, depapillated patch in the poste-
rior midline of the tongue dorsum typically measuring
between 0.25 and 2.0 cm in diameter (Fig. 2.12).
While there is great variation in clinical presentation
among patients, the size and quality of the lesion do
NOT TEND TO CHANGE SIGNIlCANTLY OVER TIME IN A GIVEN
individual.
3
While many cases are never symptomatic, mild dis-
COMFORT MAY DEVELOP SPECIlCALLY IN THE AREA OF ATRO-
phic change. If so, symptoms tend to come and go and
rarely persist for long. Because tissue biopsy often
DEMONSTRATES SUPERlCIAL CANDIDAL COLONIZATION AND AN
INmAMMATORY INlLTRATE IN THE UNDERLYING CONNECTIVE
tissue, there is some thought that median rhomboid
glossitis is mediated by chronic candidal colonization.
The tissue may be particularly susceptible to recurrent
fungal infection due to the reduced thickness of the
epithelium. Therefore, when a patient develops symp-
O EXCEPT VERY ATYPICAL PRESENTATIONS toms of tongue discomfort in the presence of median
: None in most cases. When symp- RHOMBOID GLOSSITIS lRST
LINE TREATMENT CONSISTS OF TOPICAL
S CONTAINING TOPICAL DEXAMETHASONE or systemic antifungal therapy. If symptoms persist fol-
 22-03-17

Lengua pilosa

Anemia megaloblstica

Leucoplasia pilosa
Diferenciar!
Pacientes
Leucoplasia pilosa Lengua pilosa inmunosuprimidos.
VEB.
Asintomtica,
bilateral, lengua.
No precancerosa.
Tratamiento.

hhp://patoral.umayor.cl/patoral/?p=1486 hhp://patoral.umayor.cl/patoral/?p=1486

4
 22-03-17

Anquiloglosia

hhp://patoral.umayor.cl/patoral/?p=1486

Tejido linfoide ectpico

Tejido linfoide ectpico
(amigdala lingual)

Torus y exostosis

Alteraciones en paladar

5
TWO
2.12 TOAnkyloglossia
THREE WELL DElNED SMOOTH
and Prominent LOBULES &IG 2.23).
Frenula 25
%XOSTOSES APPEAR CLINICALLY IDENTICAL TO MANDIBULAR TORI
ON THE BUCCAL
the lingual aspectSURFACE OF THE inferior
of the mandible MANDIBLE OR premo-
to the MAXILLA
(Fig. 2.6). These
LARS BILATERALLY can growTORI
-ANDIBULAR to ALSO
be quite
EXHIBITlarge yetRANGE
A WIDE rarely
of presentations;
HAVE ANY DISCERNABLE however,
EFFECT lesions usually FACIAL
ON THE EXTERNAL demonstrate
APPEAR-
TWO TOOn
ance. THREE WELL DElNED
intraoral SMOOTH
periapical LOBULES
dental &IG 2.23).
radiographs, the
%XOSTOSESareas
involved APPEAR CLINICALLY
appear IDENTICAL
as dense TO MANDIBULAR
radiopacities withinTORIthe
ON THE AND
MAXILLA BUCCAL SURFACE&IG
MANDIBLE OF 2.24).
THE MANDIBLE OR MAXILLA
(Fig. 2.6).
4ORI ANDThese can grow
EXOSTOSES to beDOquite
GENERALLY large yet
NOT REQUIRE ANYrarely
TREAT-
HAVE ANY
ment. TheDISCERNABLE EFFECT ON
covering mucosa may THEoccasionally
EXTERNAL FACIAL APPEAR-
become irri- Fig. 2.23 Mandibular tori in the premolar region with multiple

22-03-17
ance.orOn
tated intraoral
ulcerated periapical
secondary dental which
to trauma, radiographs, the
is managed lobules.
involved areas appear
symptomatically. as dense
If denture radiopacities
fabrication within
is required, torithe
can
MAXILLA
BE AND MANDIBLE
SURGICALLY REMOVED &IG 2.24). RETENTION OF THE PROS-
TO MAXIMIZE
4ORIand
thesis AND EXOSTOSES
minimize theGENERALLY DO NOT REQUIRE ANY
risk of pressure-induced TREAT-
trauma.
ment. The covering mucosa may occasionally become irri- Fig. 2.23 Mandibular tori in the premolar region with multiple
tated or ulcerated secondary to trauma, which is managed lobules.
symptomatically. If denture fabrication is required, tori can
BE SURGICALLY REMOVED TO MAXIMIZE RETENTION OF THE PROS-
thesis and minimize the risk of pressure-induced trauma.

Fig. 2.24 2ADIOGRAPHIC APPEARANCE OF A MAXILLARY TORUS AS A

WELL DElNED RADIOPACITY

Fig. 2.21 -AXILLARY TORUS WITH A STALK LIKE ATTACHMENT TO THE Diagnostic tests: None.
underlying palatal bone. Fig. 2.24 2ADIOGRAPHIC APPEARANCE OF A MAXILLARY TORUS AS A
Biopsy: No.
WELL DElNED RADIOPACITY
Treatment: None.
Follow-up: None.
Fig. 2.21 -AXILLARY TORUS WITH A STALK LIKE ATTACHMENT TO THE Diagnostic tests: None.
underlying palatal bone. Biopsy: No.
Treatment:
2.12 None.
Ankyloglossia and Prominent
Follow-up: None.
Frenula

!BNORMAL PROMINENCE OF frenula (tissue attachments

2.12 Ankyloglossia and Prominent
of the anterior tongue and labial mucosa), can result in
Frenula
a variety of complications. In the case of the lingual
frenulum, this can lead to problems with speech devel-
!BNORMAL
opment orPROMINENCE OF frenula
infant feeding, and is(tissue attachments
referred to ankylo-
ofglossia
the anterior tongue
or tongue andLocalized
tie. labial mucosa), can result
periodontal in
recession
Fig. 2.22 -ULTILOBULATED MAXILLARY TORUS SHOWING SLIGHT a on
variety of complications.
the lingual aspect of theIn the case incisors
central of the lingual
can also
asymmetry. OCCUR !this
frenulum, can lead labial
PROMINENT to problems with speech
mandibular devel-can
frenulum
opment or infant feeding, and is referred to ankylo-
glossia or tongue tie. Localized periodontal recession
Fig. 2.22 -ULTILOBULATED MAXILLARY TORUS SHOWING SLIGHT on the lingual aspect of the central incisors can also
asymmetry. OCCUR ! PROMINENT labial mandibular frenulum can

Estomatitis nicotnica Lesiones secundaria a felatio

Enca / Mucosa yugal

6
 22-03-17

Leucoedema Leucoedema

Nevus blanco esponjoso Fibroma/PseudoBibroma irritativo

Fibroma/PseudoBibroma irritativo pulis Bisurado

7
 22-03-17

Frenillo prominente
26 Clinical Oral Medicine and Pathology

Fig. 2.25 4HICK MAXILLARY FRENULUM IN A  YEAR OLD BEFORE a) and after (b) surgical repositioning.

similarly affect the facial aspect of the same teeth. review of the literature. Oral Surg Oral Med Oral Pathol Oral
High insertion of the maxillary frenulum onto the gin- 2ADIOL %NDOD n
!SSIMAKOPOULOS $ 0ATRIKAKOS # &OTIKA # ET AL "ENIGN MIGRA-
giva may lead to formation of a gap, or diastema, tory glossitis or geographic tongue: an enigmatic oral lesion.
between the central incisors (Fig. 2.25). These condi- !M * -ED n
TIONS ARE TYPICALLY IDENTIlED IN YOUNG CHILDREN BY THEIR 2OGERS 23 "RUCE !* 4HE TONGUE IN CLINICAL DIAGNOSIS * %UR
dentist or pediatrician. If indicated, treatment is simple !CAD $ERMATOL 6ENEREOL n
#ANAAN 4* -EEHAN 3# 6ARIATIONS OF STRUCTURE AND APPEARANCE
SURGICAL REPOSITIONING OR EXCISION OF THE ORAL MUCOSA $ENT #LIN .ORTH !M n
Carter LC. Median rhomboid glossitis: review of a puzzling
Diagnostic tests: None. entity. Compendium 1990;11:446, 44851
#ICEK 9 %RTAS 5 4HE NORMAL AND PATHOLOGICAL PIGMENTATION OF
Biopsy: No. oral mucous membrane: a review. J Contemp Dent Pract
Treatment: Referral to an oral surgeon that spe- 2003;15:7686
cializes in pediatrics for surgical evaluation. )NFANTE #OSSIO 0 -ARTINEZ DE &UENTES 2 ET AL )NmAMMATORY
Follow-up: None. papillary hyperplasia of the palate: treatment with carbon
DIOXIDE LASER FOLLOWED BY RESTORATION WITH AN IMPLANT
SUPPORTED PROSTHESIS "R * /RAL -AXILLOFAC 3URG 
45:65860
*AINKITTIVONG ! ,ANGLAIS 2 'EOGRAPHIC TONGUE CLINICAL CHAR-
Sources acteristics of 188 cases. J Contemp Dent Pract
2005;6:12335
Segal LM, Stephenson R, Dawes M, et al. Prevalence, diagnosis,
!NTONIADES $: "ELAZI - 0APANAYIOTOU 0 #ONCURRENCE OF TORUS and treatment of ankyloglossia; methodologic review. Can
PALATINES WITH PALATAL AND BUCCAL EXOSTOSES CASE REPORT AND Fam Physician 2007; 53:102733

OTRAS LESIONES

18 Clinical Oral Medicine and Pathology

2.3 Fordyce Granules

Sebaceous glands, which are a normal feature of facial

SKIN CAN OFTEN BE IDENTIlED WITHIN THE BUCCAL MUCOSA
DUE TO THE PROXIMITY OF SKIN TO THE ORAL MUCOSA IN THIS
area. These are less commonly noted on the lip or the
labial mucosa (Figs. 2.4 and 2.5). Fordyce granules
appear white to yellow in color, are generally present
in clusters, may be slightly raised, and are asymptom-
atic. Sebaceous glands in the oral mucosa are non-
functional. Occasionally patients become aware of

Fig. 2.1 Melanotic macule of the lower lip with dark brown
PIGMENTATION AND SHARPLY DElNED BORDERS 4HE LIPS ARE SLIGHTLY
chapped. Grnulos de Fordyce

Fig. 2.2 0HYSIOLOGIC PIGMENTATION IN AN !FRICAN !MERICAN Fig. 2.4 Prominent Fordyce granules in the right buccal
child. The interdental papillae are affected to a variable degree; mucosa.
the nonkeratinized mucosa is entirely unaffected.

Eritema traumtico

Fig. 2.3 0OSTINmAMMATORY PIGMENTATION OF THE RIGHT BUCCAL Fig. 2.5 Dense concentration of Fordyce granules in the left
mucosa secondary to chronic cheek biting. buccal mucosa.

8
mirror.
Diagnostic tests: None; clinical appearance is
USUALLY CLASSIC AND SUFlCIENT FOR DIAGNOSIS
Biopsy: No.
Treatment: None.
Follow-up: None.
2.4 Gingival Grafts
In cases of severe gingival recession, gingival grafting
is performed as a periodontal surgical procedure to
restore the attached soft tissue, reduce root-surface
sensitivity, and prevent further tissue loss. The donor
tissue, which is harvested from the patients palate as
an autograft, has a distinct appearance that is typically
RAISED AND MORE PALE THAN THE ADJACENT GINGIVA 'RAFTS
Treatment: None.
Follow-up: None.
2.5 Lingual Tonsil
Lymphoid tissue is often found along the posterior
lateral tongue, forming part of Waldeyer ring. The
clinical presentation ranges from imperceptible to
STRIKINGLY PROMINENT ,INGUAL TONSILS APPEAR AS EXO-
PHYTIC MUCOSAL COLORED MASSES THAT MAY EXHIBIT FOLDS
AND CRYPTS AS SEEN IN THE PALATINE TONSILS !S WITH ANY
lymphoid tissue, these can become enlarged and tender
22-03-17
SECONDARY TO INmAMMATION )T IS GENERALLY UNDER THESE
circumstances that patients or physicians become
aware of their presence. Unilateral or asymmetrically
enlarged tissue should be considered for biopsy to rule
out other pathology such as lymphoma or squamous
cell carcinoma.
ARE GENERALLY EASILY RECOGNIZED VERY SHARPLY DElNED
and should not be mistaken for pathology (Fig. 2.6). If
there is any doubt, the patient should be able to pro-
vide suitable history regarding whether such a proce-
dure was performed.
Injertos gingivales Palabras claves a manejar
Fig. 2.6 &REE GINGIVAL GRAFT COVERING A PROMINENT EXOSTOSIS IN
an area of previous gingival recession. Note the thicker, more
CLEARLY DElNED KERATINIZED MUCOSA COMPARED TO THE ADJACENT
nonkeratinized tissue.
UN HOMBRE SABIO BUSCA LO QUE DESEA
EN SU INTERIOR; EL NO SABIO, LO BUSCA EN
LOS DEMS.
Diagnostic tests: None.
Biopsy: No, unless unilateral or otherwise suspicious.
Treatment: None.
Follow-up: None.
2.6 Fissured Tongue
There is remarkable variation in the appearance of
the tongue throughout the population. One common Melanocitos Lengua surada
finding is the presence of fissures and grooves along
the dorsal surface. These can range from shallow- Melanina Lengua Geogrca
appearing cracks to deep, penetrating fissures
(Fig. 2.7). These features may be associated with Pigmentacin siolgica GlosiTs romboidal media
geographic tongue (see below) and may rarely pre-
dispose to recurrent candidiasis (see Chap. 7). Most
Mcula melanTca Fibroma/broma irritaTvo
patients are universally asymptomatic; it is not
UNCOMMON FOR A PATIENT TO EXAMINE HIS OR HER
Melanoma pulis surado
tongue and become aware of fissuring following the
onset of otherwise unrelated symptoms, such as
Grnulo de Fordyce Torus/exostosis
burning mouth syndrome (see Chap. 10).
Injerto gingival Anquiloglosia
Amgdala lingual Frenillo