Oral Pathology Chapter 17

Oral Pathology Chapter 17
Copyright © 2005 by Elsevier Inc. All rights reserved.

Oral pathology is the study of diseases in the oral cavity.
Introduction Oral pathology is the study of diseases in the oral cavity. Only a dentist or physician may diagnose pathologic (disease) conditions, but it is important for the dental assistant to be able to recognize the differences between normal and abnormal conditions that appear in the mouth. Copyright © 2005 by Elsevier Inc. All rights reserved.

Terminology Used to Describe Oral Lesions
Lesion is a broad term for abnormal tissues in the oral cavity that includes wounds, sores, and any other tissue damage caused by injury or disease. Determining the type of lesion in a disease is one of the earliest steps in formulating a differential diagnosis. Types of lesions of the oral mucosa are classified as to whether they: Extend below or extend above the surface. Are flat or even with the surface. Copyright © 2005 by Elsevier Inc. All rights reserved.

Many systemic diseases as well as infectious diseases have oral manifestations (signs and symptoms).
The dental assistant should also understand how oral abnormalities affect the patient’s general health and planned dental treatment. Before you can recognize the abnormal conditions, you must have a solid understanding of the appearance of the normal oral conditions. Copyright © 2005 by Elsevier Inc. All rights reserved.

Lesions Extending Below the Surface
Ulcer: A defect or break in continuity of the mucosa that creates a punched-out area similar to a crater. Erosion of the soft tissue: A shallow defect in the mucosa caused by mechanical trauma. Abscess: A localized collection of pus in a circumscribed area. Cyst: A closed sac or pouch that is lined with epithelium and contains fluid or semisolid material. Copyright © 2005 by Elsevier Inc. All rights reserved.

You then can communicate effectively with other professionals.
The dental assistant should understand the terms used to describe pathologic conditions and record preliminary identification and descriptions of lesions. You should use these terms in the clinical setting so that they become part of your everyday professional vocabulary. You then can communicate effectively with other professionals. Copyright © 2005 by Elsevier Inc. All rights reserved.

Lesions Extending Above the Surface
Blisters: Also known as vesicles, lesions filled with a watery fluid. Pustule: Similar in appearance to a blister, but it contains pus. Hematoma: Also similar to a blister, but it contains blood. Plaque: Any patch or flat area that is slightly raised from the surface. Copyright © 2005 by Elsevier Inc. All rights reserved.

Sources of Information for Diagnosis
Historical Clinical Radiographic Laboratory Microscopic Surgical Therapeutic Differential findings Copyright © 2005 by Elsevier Inc. All rights reserved.

Historical Information
Family histories are important because of genetic disorders such as dentinogenesis imperfecta Melanin pigmentation of the gingiva is common in dark-skinned individuals. Copyright © 2005 by Elsevier Inc. All rights reserved.

Examples Of Conditions Diagnosed On The Basis Of Clinical Appearance
Fissured tongue Maxillary and mandibular tori Median rhomboid glossitis Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig A, Clinical appearance of bilateral mandibular tori (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig B, Clinical appearance of lobulated torus palatinus (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Radiographs Excellent in providing information about:
Periapical pathology Internal resorption Impacted teeth Copyright © 2005 by Elsevier Inc. All rights reserved.

Microscopic Diagnosis
When a suspicious lesion is present, tissue is removed and sent to a pathology laboratory where it is evaluated microscopically (biopsy). This procedure is very often used to make the definitive (final) diagnosis. For example, a white lesion cannot be diagnosed on the basis of the clinical appearance alone. It must have a biopsy to determine if it is malignant or not . Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig A white lesion is seen on the anterior floor and ventral surface of the tongue. (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Therapeutic Diagnosis
Therapeutic diagnosis is made by providing a treatment (therapy), then seeing how the condition responds. For example, angular cheilitis could be caused by a lack of the B-complex vitamins. It could simply be a fungal infection. If the angular cheilitis improved after the patient was given an antifungal cream, the vitamin deficiency theory could be ruled out. Copyright © 2005 by Elsevier Inc. All rights reserved.

Surgical Diagnosis A diagnosis is made based on the findings from a surgical procedure. For example, on a radiograph a traumatic bone cyst also looks like a static bone cyst. However, one condition would require treatment, one would not. Surgically opening the area and inspecting the area would prove if the radiolucency on the radiograph was indeed a condition that needed further treatment or not. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-11 Traumatic bone cyst (Courtesy Dr. Edward V. Zegarelli
Fig Traumatic bone cyst (Courtesy Dr. Edward V. Zegarelli. From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-12 Arrow points to static bone cyst (Courtesy Dr. Edward V
Fig Arrow points to static bone cyst (Courtesy Dr. Edward V. Zegarelli. From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Diseases of the Oral Soft Tissues

Leukoplakia Leukoplakia means white patch.
Lesions vary in appearance and texture from a fine white transparency to a heavy, thick, warty plaque. The cause is unknown but is commonly linked to chronic irritation or trauma. Leukoplakia very often precedes the development of a malignant tumor. Copyright © 2005 by Elsevier Inc. All rights reserved.

Lichen Planus A benign, chronic disease affecting the skin and oral mucosa. Many factors have been implicated in lichen planus; however, the cause remains unknown. On the oral mucosa, the patchy white lesions have a characteristic pattern of circles and interconnecting lines called Wickham's striae. Copyright © 2005 by Elsevier Inc. All rights reserved.

Candidiasis A superficial infection caused by the yeastlike fungus, Candida albicans. Candidiasis does occur under conditions such as antibiotic therapy, diabetes, xerostomia (dry mouth), and weakened immunologic reactions. It can be the initial clinical manifestation for patients with acquired immunodeficiency syndrome (AIDS). Diaper rash, vaginitis, and thrush are also common types of candidiasis. Copyright © 2005 by Elsevier Inc. All rights reserved.

Types of Candidiasis Pseudomembranous candidiasis: thrush
Hyperplastic candidiasis Atrophic candidiasis Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-17 Chronic hyperplastic candidiasis
Fig Chronic hyperplastic candidiasis. The white appearance of the tongue did not wipe off, and it disappeared with antifungal treatment. (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Aphthous Ulcers Aphthous ulcers are also known as aphthous stomatitis or canker sores. Recurrent aphthous ulcers (RAU) is a disease that causes recurring outbreaks of blister-like sores inside the mouth and on the lips. Minor RAU: Episodes fewer than six times a year; lesions usually heal within 7 to 10 days. Major RAU: Outbreaks of larger, deeper ulcers that take longer to heal. Copyright © 2005 by Elsevier Inc. All rights reserved.

Cellulitis Inflammation spreads through the soft tissue or organ.
Swelling develops rapidly, with a high fever. The skin becomes very red, and there is severe throbbing pain as the inflammation localizes. Cellulitis associated with oral infections is potentially dangerous because it can travel quickly to sensitive tissues such as the eye or brain. Copyright © 2005 by Elsevier Inc. All rights reserved.

Conditions of the Tongue

Black Hairy Tongue Black hairy tongue may be caused by the oral flora imbalance after the administration of antibiotics. The filiform papillae are so greatly elongated that they resemble hairs. These elongated papillae become stained by food and tobacco, producing the name black hairy tongue. Copyright © 2005 by Elsevier Inc. All rights reserved.

Geographic Tongue The tongue develops multiple areas of desquamation (loss) of the filiform papillae in several irregularly shaped but well-demarcated areas. The smooth areas resemble a map, thus the name geographic tongue. Over a period of days or weeks, the smooth areas and the whitish margins seem to migrate across the surface of the tongue by healing on one border and extending on another. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fissured Tongue A variant of normal; its cause is unknown.
Some theories include a vitamin deficiency or chronic trauma over a long period. The dorsal surface (top) of the tongue appears to have deep fissures or grooves that become irritated if food debris collects in them. The patient with a fissured tongue is advised to brush the tongue gently with a soft toothbrush to keep the fissures clean of debris and irritants. Copyright © 2005 by Elsevier Inc. All rights reserved.

Pernicious Anemia Pernicious anemia is a condition in which the body does not absorb vitamin B12. People who have this condition show signs of anemia, weakness, pallor, and fatigue on exertion. Other signs can include nausea, diarrhea, abdominal pain, and loss of appetite. The oral manifestations of pernicious anemia include angular cheilitis (ulceration and redness at the corners of the lips), mucosal ulceration, loss of papillae on the tongue, and a burning and painful tongue. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-23 Iron deficiency. The tongue is devoid of filiform papillae
Fig Iron deficiency. The tongue is devoid of filiform papillae. Angular cheilitis was also present in this patient. (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Oral Cancer Oral cancer is one of the 10 most frequently occurring cancers in the world. The incidence, as well as the site, of the cancer varies greatly from country to country. In the Western countries, the site most often affected is the vermilion border of the lip. Most oral cancers do not cause pain in the early stages, and the thorough dentist is most likely to be the first to detect them. These cancers are fatal if not detected early enough or if left untreated. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig Squamous cell carcinoma of the lower lip (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Types of Oral Cancer A carcinoma is a malignant neoplasm (growth) of the epithelium (tissue lining the mouth). An adenocarcinoma is a malignant tumor that arises from the submucous glands underlying the oral mucosa. A sarcoma is a malignant neoplasm arising from supportive and connective tissue. An osteosarcoma is a malignant tumor involving the bone. In the mouth, the affected bones are the bones of the jaws. Although the cancer may start in the bone, it often spreads and involves the surrounding soft tissues. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig Panoramic radiograph showing destruction of the mandible by squamous cell carcinoma (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Leukemia A cancer of the blood-forming organs that is characterized by rapid growth of immature white blood cells. Oral symptoms of leukemia may be some of the first indications of the disease. Symptoms in the gingival tissues include hemorrhage, ulceration, enlargement, spongy texture, and magenta coloration of the gingiva. Enlargement of lymph nodes, symptoms of anemia, and general bleeding tendencies are typical. Copyright © 2005 by Elsevier Inc. All rights reserved.

Smokeless Tobacco Chewing tobacco or snuff presents a serious health hazard. It is a major concern because of the high rates of precancerous leukoplakia and oral cancer occurring among users of smokeless tobacco. Cancers of the pharynx, larynx, and esophagus occur 400 to 500 times more frequently. Smokeless tobacco is also linked to an increased incidence of tooth loss from periodontal disease. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-27 Tobacco chewer’s white lesion
Fig Tobacco chewer’s white lesion. Note the rough texture of the surface. (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Dental Implications of Radiation Therapy
Xerostomia: Lack of adequate saliva and the reduced blood supply can cause oral infections, delay healing, and make it very difficult to wear dentures. Radiation caries: Caused by the lack of saliva, usually appear first in the cervical areas of the teeth. The teeth also may become extremely sensitive to hot and cold stimuli. Osteoradionecrosis: Necrosis (death) of bone after radiation treatment. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-28 A and B, Radiation mucositis. C, Postradiation xerostomia
Fig A and B, Radiation mucositis. C, Postradiation xerostomia. (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Acquired Immunodeficiency Syndrome (AIDS)
Oral lesions are prominent features of AIDS and human immunodeficiency virus (HIV) infection. Oral lesions develop because of the breakdown of the immune system that occurs when the T-helper cells become depleted because of the disease. Copyright © 2005 by Elsevier Inc. All rights reserved.

Because the patient’s immune system is severely damaged, death is usually caused by an opportunistic infection. An opportunistic infection is one that normally would be controlled by the immune system but that cannot be controlled because of the HIV/AIDS, the immune system is not functioning properly. It is important to remember that some of the lesions that look like HIV- and AIDS-related infection may also be caused by other disorders. Copyright © 2005 by Elsevier Inc. All rights reserved.

HIV-Associated Gingivitis
There is often a bright red line along the border of the free gingival margin. Also known as atypical gingivitis (ATYP). In some cases, there may be progression of the bright red line from the free gingival margin over the attached gingival and alveolar mucosa. Copyright © 2005 by Elsevier Inc. All rights reserved.

HIV-Associated Periodontitis
HIV-associated periodontitis resembles acute necrotizing ulcerative gingivitis superimposed on rapidly progressive periodontitis. Other symptoms include: Interproximal necrosis and cratering Marked swelling Intense erythema over the free and attached gingiva Intense pain Spontaneous bleeding and bad breath Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig A, typical periodontal disease in a patient with HIV infection (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

HIV Cervical Lymphadenopathy
Enlargement of the cervical (neck) nodes Lymphadenopathy is frequently seen in association with AIDS. Copyright © 2005 by Elsevier Inc. All rights reserved.

HIV Lymphoma HIV lymphoma is the general term used to describe malignant disorders of the lymphoid tissue. In the immunocompromised individual, it may occur as a solitary lump or nodule, a swelling, or a nonhealing ulcer that occurs anywhere in the oral cavity. The swelling may be ulcerated or may be covered with intact, normal-appearing mucosa. Usually painful, the lesion grows rapidly in size and may be the first evidence of lymphoma. Copyright © 2005 by Elsevier Inc. All rights reserved.

Hairy Leukoplakia Hairy leukoplakia can be an important early manifestation of AIDS status. It is a filamentous white plaque usually found unilaterally or bilaterally on the lateral borders (sides) on the anterior portion of the tongue. It may spread to cover the entire dorsal surface of the tongue. It can also appear on the buccal mucosa, where it generally has a flat appearance. Copyright © 2005 by Elsevier Inc. All rights reserved.

Kaposi's Sarcoma Kaposi's sarcoma is one of the opportunistic infections that occur in patients with HIV infection. Kaposi's sarcoma lesions may appear as multiple bluish, blackish, or reddish blotches that are usually flat in the early stages. At present, there is no effective treatment for Kaposi’s sarcoma. Kaposi’s sarcoma is one of the intraoral lesions that are used to diagnose AIDS. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-34 Kaposi’s sarcoma in a patient with AIDS. A, Skin
Fig Kaposi’s sarcoma in a patient with AIDS. A, Skin. B, Gingivae. (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) A B Copyright © 2005 by Elsevier Inc. All rights reserved.

Herpes Simplex Herpes simplex lesions usually occur on the lip.
In immunocompromised patients, the lesions may occur throughout the mouth. An ulcer caused by the herpes virus that persists for longer than 1 month could be an indicator of AIDS. Patients that do not have HIV or AIDs may also suffer from herpes. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig Herpes simplex on the hard palate of a patient with HIV infection (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Human Papillomavirus Human papillomavirus appears most commonly in immunocompromised individuals. Diagnosis is made based on history, clinical appearance, and biopsy. They are a common finding in patients with early HIV infection. These warts appear spiky, and some have a raised, cauliflower-like appearance. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig Human papillomavirus on the lip of a patient with AIDS (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Developmental Disorders
Can result when there is a disturbance of the cells during the period when the cells divide. The result is usually a deformity of part of the body. Copyright © 2005 by Elsevier Inc. All rights reserved.

Types of Developmental Disorders
Inherited disorders: Different from developmental disorders because they are caused by an abnormal gene. A congenital disorder: One that is present at birth. It can be either inherited or developmental; however, the exact cause of most congenital abnormalities is unknown. Genetic factors: Malformations often due to genetic factors such as chromosome abnormalities. Environmental factors: Called teratogens and can include infections, drugs, and exposure to radiation. Copyright © 2005 by Elsevier Inc. All rights reserved.

Exostoses Exostosis is a benign bony growth projecting outward from the surface of a bone. An exostosis also may be referred to as a torus. (A torus is a bulging projection. The plural is tori.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Disturbances in the Development of the Jaw, Lips, Palate, and Tongue

Types of Developmental Disturbances of the Jaw, Lips, Palate, and Tongue
Cleft lip: Results when the maxillary and medial nasal processes fail to fuse. Cleft palate: Results when the palatal shelves fail to fuse with the primary palate. Cleft uvula: The mildest form of cleft palate. Cleft palate, with or without cleft lip, occurs once in 2500 live births. Ankyloglossia: Often called “tongue-tied,” results in a short lingual frenum that extends to the apex of the tongue. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-40 A newborn with bilateral complete cleft lip and palate
Fig A newborn with bilateral complete cleft lip and palate. Note severe angulation of the premaxillary segment. (From Kaban LB, Troulis M: Pediatric oral and maxillofacial surgery, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Disturbances in Tooth Development and Eruption

Disturbances in Tooth Development
Ameloblastoma is a tumor composed of remnants of the dental lamina. Anodontia is the congenital absence of teeth. Supernumerary teeth are teeth in excess of the 32 normal permanent teeth. Macrodontia is abnormally large teeth. Microdontia is abnormally small teeth. Dens in dente (tooth within a tooth) results in the formation of a small tooth-like mass of enamel and dentin within the pulp. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig Radiograph showing two supernumerary teeth in region of the permanent premolars (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Disturbances in Enamel Formation
Amelogenesis imperfecta is a hereditary abnormality in which there are hypoplasia-type defects in the enamel formation. Hypocalcification is the incomplete calcification or hardening of the enamel. Hereditary enamel hypoplasia is a type of amelogenesis imperfecta that is characterized by teeth with crowns that are hard and glossy, yellow, and cone shaped or cylindrical. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig Note loss of enamel in these teeth in a patient with hypocalcified amelogenesis imperfecta. (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Abnormal Eruption of the Teeth
Premature eruption is natal teeth present at birth. Neonatal teeth are those that erupt within the first 30 days of life. Ankylosis is deciduous teeth in which bone has fused to cementum and dentin, preventing exfoliation. Impaction occurs when any tooth remains unerupted in the jaws beyond the time at which it should normally erupt. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-48 A radiograph of ankylosis of a deciduous molar (Courtesy Dr
Fig A radiograph of ankylosis of a deciduous molar (Courtesy Dr. Margot Van Dis. From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig. 17-49 Impactions in mixed dentition visible on a dental radiograph

Additional Disturbances in Tooth Development and Eruption
Variation in form includes extra, missing, or fused cusps or anomalies of roots; however, the most common variations are peg-shaped teeth. Hutchinson's incisors are a variety of peg-shaped teeth, usually associated with maternal syphilis. Fusion is the joining together of the dentin and enamel of two or more separate developing teeth. Gemination is an attempt by the tooth bud to divide. When this attempt is not successful, an incisal notch indicates it. Copyright © 2005 by Elsevier Inc. All rights reserved.

Miscellaneous Disorders
Abrasion is the abnormal wearing away of tooth structure that is caused by a repetitive mechanical habit such as improper toothbrushing. Attrition is the normal wearing away of tooth structure during mastication (chewing). Bruxism is an oral habit consisting of involuntary gnashing, grinding, and clenching of the teeth in movements other than chewing. It is usually performed during sleep and is commonly associated with stress or tension. Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig Abrasion at the cervical area of mandibular premolars caused by toothbrushing. (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Fig Bruxism caused attrition of the mandibular anterior teeth (From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.

Miscellaneous Disorders-cont’d
Bulimia is an eating disorder characterized by food binges and followed by self-induced vomiting. The dental professional is often the first health care professional to identify a patient with bulimia. Copyright © 2005 by Elsevier Inc. All rights reserved.

Oral Pathology Chapter 17

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