INTRAORAL DIAGNOSIS

developmental lesions

cleft palate

hairy tongue

ankyloglossia

varix or varicosity

torus or exostosis

ankyloglossia

aka: tongue-tie

a condition in which the lingual frenum is attached too far anteriorly toward the tip of the tongue

prevents the tip of the tongue from reaching the hard palate when the mouth is open

• effects:

  • aberration in speech

  • depending on the severity of the condition

• management:

  • surgical correction when causes speech, swallowing, or other functional problems

hairy tongue

a condition in which the filiform papillae become markedly long, resulting in an appearance like a long-tufted carpet

• causes of discoloration

  • the long filiform papillae may trap chromogenic bacteria, fungi, and food pigmentations

  • this can give the tongue various colors: white, brown, or black

• management:

  • brushing the tongue with a toothbrush or using a tongue scraper will usually eliminate the discoloration

various colors of hairy tongue

white, brown, black

appearance of hairy tongue

long-tufted carpet

varix / varicosity

refers to dilation of a vein

• treatment (TX)

  • no treatment is required

  • clinician must be able to differentiate this from other vascular or pigmented lesions found in the oral cavity

clinical appearance of varicosity

blanch with pressure

purple or blue papules

nodules or tortuous dilated veins

common locations of varicosity

lower lip in older adults

ventral surface of the tongue

torus or exostosis

an exostosis that occurs in one of two locations intra-orally

benign protuberances of bone that may arise on the cortical surface of the jaws

• treatment:

  • surgical removal may be required if removable prostheses are planned

clinical appearance of exostosis

can be solitary or multiple

nodular masses on the buccal alveolar process

sometimes become confluent, forming a shelflike protuberance

torus mandibularis

may be unilateral or bilateral

appears on the lingual surface of the mandible near the canines and premolars

cleft palate

can occur with or without cleft lip

traumatic and reactive lesions

fibroma

linea alba

mucocele

hematoma

hyperkeratosis

amalgam tattoo

traumatic ulcers

nicotine stomatitis

pyogenic granuloma

chewing / biting of mucosa

chewing or biting of mucosa

lesions caused by chronic chewing of the mucosa

usually habit or stress induced, occur in children or adults

• clinical considerations

  • problematic for CD patients

  • causes problems in vertical dimension

linea alba

similar to reticular papilla (Striae of Wickham)

a linear thickening of the buccal mucosa (hyperkeratosis) that occurs along the occlusal plane

• clinical consideration

  • biopsy may be warranted in the presence of persistent trauma or unresolving ulceration

clinical appearance of linea alba

scalloping shape, representing occlusal indentations

traumatic ulcers

usually heal in 1 or 2 weeks

a lesion characterized by focal loss of epithelium

result from a cut, abrasion, or irritation of the mucosa

clinical appearance of traumatic ulcers

vary in size and shape

red borders caused by inflammation

hyperkeratosis

used clinically to refer to white areas on oral mucosa without annotation as to the cause of the condition

a term referring to a microscopic layer of thickened parakeratin and/or orthokeratin of the mucosal epithelium

• treatment:

  • these lesions must be monitored

  • biopsy may be appropriate if changes in lesion color, shape, borders, or surface texture are observed

most common cause of hyperkeratosis

chronic irritation or frictional keratosis

clinical appearance of hyperkeratosis

whitish appearance in the moist environment of the oral cavity because of the thickened keratin layer

amalgam tattoo

usually an incidental finding

amalgam in the gingiva, alveolar process, palate, or buccal mucosa may produce a tattoo

• clinical consideration:

  • dental team must be able to conclusively differentiate an amalgam tattoo from other types of intraoral pigmented lesions

appearance of amalgam tattoo

dark blue or black discoloration

ranging in size from a few millimeters to 1cm

• radiograph:

  • radiopaque granules consistent with metal fragments

nicotine stomatitis

occurs on the posterior hard palate and anterior soft palate of smokers, especially pipe smokers

• cause:

  • caused by heat on the mucosa

  • not actually by the nicotine itself!

• treatment:

  • encourage the patient to STOP SMOKING

clinical appearance of nicotine stomatitis

sakura-like

the whiteness represents hyperkeratosis and the red spots

papules with an opaque white surface and a red dot in the center

pyogenic granuloma

an example of a tumescence

can occur anywhere in the oral mucosa or on the skin

an overgrowth of young, highly vascular granulation tissue

• cause:

  • reaction to chronic irritation or dental plaque

  • pregnancy or puberty, hormonal changes may cause exaggerated tissue reactions

• management:

  • dentist must identify and resolve the underlying cause (ex: iatrogenic restoration, foreign body, or dental infection)

[ note: misnomer – does not produce pus and is not a true granuloma ]

clinical appearance of pyogenic granuloma

lesion bleeds easily

bright red enlargement due to vascularity of granulation tissue and frequent loss of epithelium over the lesion

fibroma

refers to a reactive overgrowth of fibrous tissue and is not a true neoplasm

• cause / history:

  • patients usually report a history of trauma in the area

  • in such cases, the term "traumatic fibroma" is widely used

• management:

  • excisional biopsy should be considered if the lesion is unsightly, repeatedly traumatized, or habitually manipulated by the patient

  • excisional biopsy is more recommended than incisional biopsy

clinical appearance of fibroma

usually less than 1cm in dimension

well-circumscribed firm swelling on the lip or buccal mucosa

hematoma

consists of extravasated blood pooling under the epithelium or deep in the connective tissue or muscle, usually because of blunt trauma

• cause:

  • usually due to blunt trauma

  • occurs more often in individuals with bleeding disorders

  • occasionally administration of an inferior alveolar nerve block

• treatment:

  • can be expected to resolve spontaneously

clinical appearance of hematoma

a dark red papule or nodule that ruptures easily

infections or inflammations

parulis

candidiasis

herpes infection

angular cheilitis

verruca vulgaris

patent sinus tract

parulis

aka: gumboil

a small abscess on the gingiva, originating from an apical or periodontal abscess

• treatment:

  • will resolve if the source of infection is eliminated

clinical appearance of parulis

localized and often acute swelling on the gingiva with fluctuation

a yellow point appears at the center of the swelling before spontaneous drainage

patent sinus tract

results in continuous drainage of pus through the formed sinus tract

can develop following drainage of a parulis if the source of infection (commonly a necrotic pulp) is not removed

• treatment:

  • the papule may persist as a fibroma

  • the sinus tract will close when the source of infection is eliminated

appearance of patent sinus tract

this papule represents the opening of a fistula or sinus tract

asymptomatic papule of granulation tissue forms on the gingiva in response to chronic irritation from the drainage

herpes infection

generalized gingivitis may occur

primary infection is often subclinical

lesions usually resolve in 10-14 days without a trace

oral lesions are widespread with small vesicles forming anywhere on the lips and mucosa

• triggers:

  • stress, strong sunlight exposure, or immune suppression

• recurrent infection

  • recurring painful intraoral episodes may require antiviral medication

  • vesicles are short-lived; ulcers are discrete and typically smaller than 2mm

  • usually less severe; lesions occur only on keratinized tissue (perioral skin, gingiva, hard palate)

clinical appearance of herpes infection

vesicles coalesce and rupture

will then form widespread ulcers known as primary herpetic gingivostomatitis

pathophysiology of herpes infection

these viruses target epithelial cells, causing skin and mucosal lesions

after infecting epithelial cells → viruses replicate, enter neurons, and travel to nerve ganglia, where they remain latent until reactivated

upon reactivation, viruses travel back to skin or mucosa, causing lesions

[ both HSV-1 & HSV-2 → infect perioral skin and oral mucosa ]

subtle systemic symptoms of herpes infection

mild fever

pharyngitis

general malaise

treatment for herpes infection

acyclovir

types of herpes viruses that infect humans

varicella zoster virus (VZV)

herpes simplex virus type 1 (HSV-1)

herpes simplex virus type 2 (HSV-2)

candidiasis

an opportunistic infection of candida albicans

• treatment:

  • antifungal agents with persistent candidiasis

clinical forms of candidiasis

erythematous

pseudomembranous

chronic hyperplastic candidiasis

candida-associated angular cheilitis

central papillary atrophy (median rhomboid glossitis)

denture stomatitis – often included, though may be a reactive lesion rather than true infection

predisposing factors of candidiasis

HIV/AIDS

birth control pills

cancer, aging, pregnancy

diabetes mellitus, smoking

hyposalivation, chemotherapy

extended course of antibiotics

systemic or inhaled corticosteroids

pathophysiology of candidiasis

most healthy individuals have candida-specific innate immunity

infection occurs when innate defense mechanisms are defective, candida alters its virulence, or environmental factors favor growth

candida organisms are commensal in:

human gastrointestinal (GI) tract

lower female reproductive tract

angular cheilitis

presents as an inflammation at the corner of the mouth

occurs mostly in aged individuals with deep labial folds after loss of occlusal height (decreased VDO)

habitual licking of the corner of the mouth may also lead to development even without deep labial folds

• treatment:

  • topical antifungal agents

predisposing factors of angular cheilitis

deficiencies of vitamin B, iron or folic acid

causes of angular cheilitis

Candida albicans

Staphylococcus aureus

Beta-hemolytic streptococcus

habitual licking of the corner of the mouth may also lead to development even without deep labial folds

clinical appearance of angular cheilitis

deep labial folds become red, sore, and fissured due to constant saliva exposure

verruca vulgaris

latin for "common wart"

a benign epithelial lesion of the skin and mucous membrane

• cause:

  • human papillomavirus (HPV) types 1, 2, 4

• management:

  • similar to that for a fibroma

  • excisional biopsy

appearance of verruca vulgaris

a pedunculated or sessile papule with a whitish-pink cauliflower-like surface

can occur anywhere on the oral mucosa

autoimmune diseases

lichen planus

aphthous ulcers

atrophic glossitis

lichenoid reaction

aphthous ulcers

common oral mucosal disease

ulcerations with no known cause and a wide spectrum of severity and frequency of recurrence

• triggers:

  • represent an autoimmune reaction

  • precipitated by stress or hormonal changes

  • associated with systemic conditions such as vitamin deficiencies, iron deficiency, and inflammatory bowel diseases.

• treatment:

  • topical steroids for recurrent cases

appearance of aphthous ulcers

solitary or multiple nonspecific ulcers

usually on nonkeratinized oral mucosa

other names of aphthous ulcers

canker sores

aphthous stomatitis

recurrent aphthous ulcers

recurrent aphthous stomatitis

lichen planus

a chronic inflammatory skin disorder, can persist for months or years

believed to be a cell-mediated immune response, but exact cause is unknown

the oral component (OLP) may occur before, concurrent with, or after skin lesions

• management

  • topical or short-term systemic steroids for erosive form

clinical appearance of lichen planus

plaque, erosion, or ulceration of the oral mucosa

pruritic, purple eruptions with white streaks (Wickham striae) on the surface

bandlike, subepithelial lymphocytic infiltration and basement membrane degeneration, cause is unknown

lichenoid reaction

an oral mucosal condition that is clinically and histologically indistinguishable from OLP except for identifiable causes

when the cause (such as amalgam or an offending medication) is removed the lesion will resolve with time

atrophic glossitis

refers to papillary atrophy of the tongue

characterized by an absence of filiform and fungiform papillae

• treatment:

  • treatment varies depending on the underlying cause of the condition

associated conditions of atrophic glossitis

anemia

avitaminosis

sjögren syndrome

vitamin B deficiency

graft versus host disease

appearance of atrophic glossitis

fiery red, edematous, painful

hence the term "burning tongue”

cysts, tumors and neoplasms

leukoplakia

erythroplakia

squamous cell carcinoma

developmental odontogenic cysts

erythroleukoplakia (speckled erythroplakia)

developmental odontogenic cysts

a pathologic cavity lined with epithelium

contains fluid or semi-solid material in the lumen

arise from the epithelium of the tooth-forming apparatus

not inflammatory in nature, and thus are to be distinguished from periapical (radicular) cysts

types of developmental odontogenic cysts

dentigerous cysts

odontogenic keratocysts

lateral periodontal cysts

leukoplakia

derived from Greek, meaning "white patch"

a clinical diagnosis with no specific histologic implication

refers to a clinically evident white plaque or patch with malignant potential

• considered a diagnosis of exclusion after ruling out other white lesions such as:

  • frictional keratosis

  • smoker's keratosis

  • hyperplastic candidiasis

• treatment:

  • biopsy should be performed regardless of lesion location to rule out:

    • dysplasia (precancerous)

    • invasive cancer (malignancy)

    • carcinoma in situ (early malignancy)

erythroplakia

term used as a clinical diagnosis, not a histologic one, similar to oral leukoplakia

bright red, velvety plaques which cannot be characterized clinically or pathologically as being due to any other condition as per WHO (1978)

• clinical significance

  • studies show that 90% of lesions clinically diagnosed as erythroplakia are either premalignant or malignant

• treatment:

  • biopsies to confirm or rule out the presence of premalignancy or malignancy

erythroleukoplakia (speckled erythroplakia)

risk of premalignancy or malignancy is higher than for homogenous leukoplakia

• a clinical diagnosis describing:

  • oral leukoplakia → a red component, or

  • oral erythroplakia → intermingled with white plaque

• clinical studies show:

  • 14% of lesions are invasive carcinoma

  • 51% are epithelial dysplasia

• treatment:

  • biopsy is essential

  • sample should include the red area for accurate diagnosis

squamous cell carcinoma

the most common oral malignancy

differentiating this from benign lesions with similar features can be challenging

• clinical considerations:

  • early detection and treatment is the key for survival

  • oral healthcare providers are best qualified to examine oral tissues and identify suspicious lesion

  • any suspicious lesion, especially in patients with common risk factors, must be biopsied due to the morbidity and mortality associated with SCC

most common contributing factors of squamous cell carcinoma

tobacco and alcohol consumption

clinical appearance of squamous cell carcinoma

white or red plaque

ulceration, papule or nodule

lesion with mixed white and red components

common sites of squamous cell carcinoma

oropharynx

floor of the mouth

lateral border of the tongue

non-neoplastic salivary gland abnormalities

xerostomia

sialolithiasis

hyposalivation

sjogren syndrome

ranula & mucocele

mucocele

found on the lower lip

the common clinical term for mucous extravasation phenomenon

occurs when saliva is retained inside the duct, gland, or surrounding tissue spaces

extravasation phenomenon

the term used if saliva has escaped the duct

ranula

located in the floor of the mouth

essentially a type of mucocele in this specific location

a mucous extravasation phenomenon associated with the submandibular or sublingual glands

sialolithiasis

presence of salivary stones in the salivary glands

• rarely in:

  • sublingual glands

• less frequently in:

  • parotid gland

• most commonly found in:

  • submandibular gland

hyposalivation

aka: hypoptyalism

defined as a diminished secretion of saliva

xerostomia

aka: dry mouth

dryness of the oral cavity due to reduced or absent saliva

• causes:

  • primary → degenerative or autoimmune diseases affecting the salivary glands

  • secondary → conditions that inhibit salivary secretion, frequently as a side effect of:

    • medications

    • dehydration

    • hormonal imbalances

sialometry → used to measure salivary flow

sjogren syndrome

an autoimmune disorder affecting exocrine glands

specifically the lacrimal and salivary glands, causing dry eyes and dry mouth

primary sjögren syndrome

may also involve vaginal or nasal dryness

can be associated with chronic bronchitis

secondary sjögren syndrome

associated with other autoimmune diseases, such as:

• lupus

• sarcoidosis

• scleroderma

• rheumatoid arthritis

neoplastic salivary gland abnormalities

pleomorphic adenoma

pleomorphic adenoma

referred as benign mixed tumor

presents initially as a dome shaped mass without ulceration or symptoms