DHY 207

Module 1: Variants of Normal

The Oral Systemic Link (What Your Dentist Knows About Your Health)

• Diabetes

• Osteoporosis

• Heart disease

• Premature births and low birth weight

• Leukemia

• Bulimia

• Gastroesophageal reflux disease (GERD)

• Kidney problems and vitamin deficiencies

What is Normal?

• If not within normal limits, you must know the etiology and pathogenicity

• Many conditions/lesions mimic other things so there is differential diagnosis

• Sometimes it is difficult to know without a biopsy

Differential Diagnosis

• Must accommodate the possibility that a lesion can be caused by any of several diseases

• A diagnosis based on appearance alone is likely to be incorrect

• Need a thorough evaluation of the suspected lesion

• Need to consider several diseases known to produce the primary manifestation of abnormality in the expectation that some possible causes can be eliminated

Distinct Clinical Appearance

• Legally not allowed to diagnose, but must know

Variants of Normal

• Fordyce granules

• Torus palatinus

• Mandibular tori

• Melanin pigmentation

• Retrocuspid papilla

• Lingual varicosities

• Linea alba

• Leukoedema

Variants of Normal: Fordyce Granules

• Clusters of ectopic sebaceous glands

• Most commonly observed on lips and buccal mucosa

• Appear as yellow lobules in clusters and are usually distributed over the buccal mucosa or vermillion border of the involved lips

• Considered a variant of normal

• There is no treatment

Variants of Normal: Torus Palatinus

• An exophytic growth of normal compact bone

• inherited and occurs more commonly in women

• asymptomatic, develop gradually, and are observed clinically in the midline of the hard palate

• may take on various shapes and sizes, ma be lobulated, and are covered b normal soft tissue

• It is an example of exostosis

• There is no treatment

• Radiographs may be difficult

• Use the bisecting technique

Variants of Normal: Mandibular Tori

• Outgrowths of normal, dense bone found on the lingual aspect of the mandible in the area of the premolars above the mylohyoid ridge

• Usually bilateral, often lobulated or modular, can appear fused together, and have no predilection for either sex

• Bilateral 90% of cases

• There is no treatment

• May cause elongation for mandibular lingual radiographs

• Elongation (teeth look long): the x-ray tube is under Therefore the angulation should be increased

Variants of Normal: Melanin Pigmentation

• The pigment that gives color to skin, eyes, hair, mucosa, and gingiva

• Most commonly observed in dark-skinned individuals

Variants of Normal: Retrocuspid Papilla

• A sessile nodule on the gingival margin of the lingual aspect of the mandibular cuspids (canines)

• HPV looks similar, but retrocuspid papilla is ALWAYS behind the canines

Variants of Normal: Lingual Varicosities

• Usually observed on the ventral and lateral surfaces of the tongue

• Clinically, red to purple enlarged vessels or clusters are seen

• Most commonly observed in individuals older than 60 years of age; thought to be related to the aging process

• A recent study suggested that lingual varicosities may be associated with a history of smoking or cardiovascular disease

Variants of Normal: Linea Alba

• A “white line” that extends anteroposteriorly on the buccal mucosa along the occlusal plane

• Can monitor for dysplasia and address stress/clenching to patient

• May be bilateral

• May be more prominent in patients who have a clenching or bruxing habit

Variants of Normal: Leukoedema

• Opalescence on buccal mucosa; diffuse grey-white film within tissue that cannot be removed

• Ethnically predisposed to black adults, but can be seen on caucasians

• Histologically, see thickening (acanthosis) of the epithelium; must be due to endocrine disturbance

• If stretch the cheek, it becomes less prominent

• More pronounced in smokers but benign anomaly that requires no treatment

Benign Conditions of Unknown Cause

• Lingual thyroid nodule

• Median rhomboid

• Glossitis

• Geographic tongue

• Fissured tongue

• Hairy tongue

Benign Conditions of Unknown Cause: Lingual Thyroid Nodule

• Dorsal of tongue

• When thyroid tissue does not descend or remnants become trapped

• A high predilection for females

• Emergence linked with hormonal changes

• Clinically, a mass in the midline of the dorsal surface of the tongue posterior to the circumvallate papillae in the area of the foramen cecum

• Usually has a sessile base and is 2-3 cm in width

• Upon histologically examination, normal thyroid tissue is found

• Treatment:

• Evaluation of the patient to determine whether the thyroid gland is present in its normal location

Benign Conditions of Unknown Cause: Median Rhomboid Glossitis

• Cause is not clear

• May be associated with a chronic infection of Candida albicans

• Clinically, appear as as a flat or slightly raised oval or rectangular erythematous area in the midline of the dorsal surface of the tongue, beginning at the junction of the anterior and middle thirds and extending posterior to the circumvallate papillae

• Treatment:

• No specific treatment exists

• An anti-fungal treatment works sometimes if it’s related to fungus

• May resolve spontaneously

Benign Conditions of Unknown Cause: Geographic Tongue

• AKA erythema migrans or benign migratory glossitis

• The cause is not clear

• Genetic factors may play a role

• Clinically, involves dorsal and lateral areas of the tongue

• Diffuse areas devoid of filiform papillae may be observed

• There appears to be remission and changes in the depapillated areas

• Treatment:

• Usually none indicated

• occasionally, the patient may complain of a burning discomfort

• Ectopic geographic tongue

• Very rare

• May be found on areas other than tongue like the inner lip

Benign Conditions of Unknown Cause: Hairy Tongue

• An increased accumulation of keratin on the filiform papillae resulting in a white “hairy” appearance

• The elongated filiform papillae are white

• In black hairy tongue, the papillae are black due to chromogenic bacteria

• Recurring

• Treatment:

• Directing the patient to brush the tongue gently with a toothbrush to remove debris

• Advise not to use toothpaste on tongue because it is too abrasive

Benign Conditions of Unknown Cause: Fissured Tongue

• The cause is unknown

• Seen in about 5% of the population

• Probably involves genetic factors

• Clinical, the dorsal surface of the tongue appears to have deep fissures or grooves

• Treatment:

• Good homecare

• Patient is predisposed to bacteria accumulation