:toc:

= pathological

• Bacterial infections
• Viral infections
• Mycotic infections
• Spread of oral infections
• Hematologic
• Dermatological
• Immunologic
• Metabolic
• Physical and chemical injury

• Healing of oral wounds

• Developmental abnormalities

• Cyst

• Tumors

• Bone and joint disorders

• Regressive alteration of teeth

• Dental caries
• Pulp and periapical

= Clinical

Parts involved

• lymph node
• lip
• cheeks
• palate
• floor of mouth
• tongue

Mucosal (Surface) Lesions Vesiculobullous Diseases Ulcerative Conditions White Lesions Red-Blue Lesions Pigmented Lesions Verrucal-Papillary Lesions Submucosal Swellings (By Region) Gingival Swellings Floor-of-Mouth Swellings Lips and Buccal Mucosal Swellings Tongue Swellings Palatal Swellings Neck Swellings Differential Diagnosis Approach to Jaw Lesions Cysts of the Jaws and Neck Odontogenic Tumors Benign Nonodontogenic Tumors Inflammatory Jaw Lesions Malignancies of the Jaws Metabolic and Genetic Diseases

Mucosal (Surface) Lesions

= Vesiculobullous Diseases

=== Herpes Simplex Infections - Primary herpetic gingivostomatitis - Multiple painful oral ulcers preceded by vesicles; may have similar perioral and skin lesions; fever and gingivitis usually present; usually affects children younger than 5 years of age Herpes simplex virus type 1 (occasionally type 2) Self-limited; heals in about 2 weeks; reactivation of latent virus results in secondary infections; circulating antibodies provide only partial immunity - Secondary herpes simplex infection - Multiple small ulcers preceded by vesicles; prodromal symptoms of tingling, burning, or pain at site of developing lesion(s); most common on lip, intraorally on palate and attached gingiva; adults and young adults usually affected; very common; called herpetic whitlow when occurs around fingernail Herpes simplex virus: represents reactivation of latent virus and not reinfection; commonly precipitated by stress, sunlight, cold temperature, low resistance, and immunodeficiency Self-limited; heals in about 2 weeks without scar; lesions infectious during vesicular stage; patient must be cautioned against autoinoculation; herpes type 1 infections have not been linked convincingly to oral cancer; any site affected in immunosuppressed patients CLINICAL OVERVIEW Abbreviations used throughout: AIDS, Acquired immunodeficiency syndrome; BP, bullous pemphigoid antigen; GI, gastrointestinal; HSV, herpes simplex virus; HHV8, human herpesvirus 8; HIV, human immunodeficiency virus; HLA, human leukocyte antigen; Ig, immunoglobulin; MEN III, Multiple endocrine neoplasia syndrome type III; NK, natural killer; SDHD, succinic dehydrogenase; STD, sexually transmitted disease; UV, ultraviolet; UVB, ultraviolet B. Continued O-2 Clinical Overview Disease Clinical Features Cause Significance Herpes Simplex Infections - Varicella - Painful pruritic vesicles and ulcers in all stages on trunk and face; few oral lesions; common childhood disease Varicella-zoster virus Self-limited; recovery uneventful in several weeks; vaccine available == Herpes zoster - Unilateral multiple ulcers preceded by vesicles distributed along a sensory nerve course; very painful; usually on trunk, head, and neck; rare intraorally; adults Reactivation of varicella-zoster virus Self-limited; may have a prolonged, painful course (post herpetic neuralgia); seen in debilitation, trauma, neoplasia, and immunodeficiency == Hand-foot-and-mouth disease - Painful ulcers preceded by vesicles on hands, feet, and oral mucosa; usually in children; communicable; oro-fecal transmission; rare Coxsackie viruses – (A16, others) (enterovirus family) Self-limited; recovery uneventful in about 2 weeks == Herpangina - Multiple painful ulcers in posterior oral cavity and pharynx; lesions preceded by vesicles; children most commonly affected; seasonal occurrence; rareCoxsackie viruses types A1, 6, 8, 10, 22, others; (enterovirus family) Self-limited; recovery uneventful in less than a week O-4 Clinical Overview Vesiculobullous Diseases—cont’d Disease Clinical Features Cause Significance - Measles (rubeola) - Oral Koplik’s spots precede maculopapular skin rash; fever, malaise, plus other symptoms of systemic viral infection Measles virus Self-limited; recovery uneventful in about 2 weeks; vaccine available == Pemphigus vulgaris - Multiple painful ulcers preceded by bullae; middle age onset; positive Nikolsky sign; progressive; remissions or control with therapy; rare Autoimmune; antibodies directed against desmosome-associated protein, desmoglein 3 Without treatment, may be fatal; significant morbidity from steroid therapy; oral lesions precede skin lesions in over half of cases; prognosis improved when treated early - Mucous membrane pemphigoid - Multiple painful ulcers preceded by vesicles and bullae; lesion may heal with scar; positive Nikolsky sign; may affect oral mucous membranes, eyes, and genitals; middle-aged or elderly women; uncommon; clinically may be confused with lichen planus, chronic lupus erythematosus of gingiva, pemphigus vulgaris and hypersensitivity Autoimmune; antibodies directed against basement membrane antigens, laminin 332, BP180, others Protracted course; may cause significant morbidity if severe; ocular scarring may lead to symblepharon or blindness; death uncommon - Bullous pemphigoid - Skin disease (trunk and extremities) with infrequent oral lesions; ulcers preceded by bullae; no scarring; elderly persons Basement membrane autoantibodies detected in tissue and serum Chronic course; remissions; uncommon - Dermatitis herpetiformis - Skin disease with rare oral involvement; vesicles and pustules; pruritic exacerbations and remissions typical; young and middle-aged adults Unknown; IgA deposits in sites of lesions; usually associated with gluten enteropathy Chronic course that may require diet restriction or drug therapy - Epidermolysis bullosa - Multiple ulcers preceded by bullae; positive Nikolsky sign; inheritance pattern determines age of onset during childhood and severity; may heal with scar; primarily a skin disease, but oral lesions often present; rare Hereditary, autosomal dominant or recessive; acquired adult form also exists Severe, debilitating disease that may be fatal in recessive form; simple operative procedures may elicit bullae; acquired form less debilitating

O-6 Clinical Overview

Ulcerative Conditions

Disease Clinical Features Cause Significance - Reactive lesions - Painful ulcer covered by yellow fibrin membrane; diagnosis usually evident from appearance when combined with history; common; traumatic factitial injuries are diagnostic challenge Trauma, chemicals, heat, radiation Self-limited; heals in days to weeks; factitial injuries follow unpredictable course - Syphilis - Primary (chancre): single, indurated, nonpainful ulcer at site of spirochete entry; spontaneously heals in 4-6 weeks - Secondary: maculopapular rash on skin; oral ulcers covered by membrane (mucous patches) - Tertiary: gummas, cardiovascular and central nervous system lesions - Congenital: dental abnormalities (mulberry molars, notched incisors), deafness, interstitial keratitis (Hutchinson’s triad) Spirochete: Treponema pallidum Primary and secondary forms are highly infectious; mimics other diseases clinically; if untreated, secondary type develops in 2-10 weeks; a minority of patients develop tertiary lesions; latency periods, in which there is no clinically apparent disease seen between primary and secondary stages and between secondary and tertiary stages; untreated, 30% progress to tertiary stage - Gonorrhea - Typically, genital lesions, with rare oral manifestations, painful erythema or ulcers, or both Neisseria gonorrhoeae May be confused with many oral ulcerative diseases - Tuberculosis - Indurated, chronic ulcer that may be painful—on any mucosal surface Mycobacterium tuberculosis Lesions are infectious; oral lesions almost always a result of lung lesions; differential diagnosis includes oral cancer and chronic traumatic ulcer - Leprosy - Skin disease, with rare oral nodules/ulcers Mycobacterium leprae Rare in United States but relatively common in Southeast Asia, India, South America - Actinomycosis - Typically seen in mandible, with draining skin sinus; wood-hard nodule with yellow, “sulfur” granulesActinomyces israelii Infection follows entry through a surgical site, periodontal disease, or open root canal Continued O-8 Clinical Overview Ulcerative Conditions—cont’d Disease Clinical Features Cause Significance - Noma - Necrotic, nonhealing ulcer of gingiva or buccal mucosa; rare; affects children Anaerobes in patient whose systemic health is compromised Often associated with malnutrition; may result in severe tissue destruction - Deep fungal diseases - Indurated, nonhealing, frequently painful, chronic ulcer, usually following implantation of organism from lung Histoplasma capsulatum, Coccidioides immitis, others Oral lesions are a result of systemic lesions; some types are endemic - Subcutaneous fungal diseases - Nonspecific ulcers of skin and, rarely, mucosa Usually Sporothrix schenckii Sporotrichosis usually follows inoculation via thorny plants - Opportunistic fungal infections - Occurs in compromised host; necrotic; nonhealing ulcer(s)Mucormycosis, Rhizopus, others Known collectively as phycomycosis; may mimic syphilis, midline granuloma, others; frequently fatal - Aphthous ulcers - Recurrent, painful ulcers found on tongue, vestibular mucosa, floor of mouth, soft palate and faucial pillars; not found on skin, vermilion, attached gingiva, or hard palate; usually round or oval; ulcers not preceded by vesicles; minor type: usually solitary, ,1.0 cm in diameter; common; major type: severe, heals in up to 6 weeks with scar .1.0 cm in diameter; herpetiform type: multiple, recurrent crops of ulcers from 0.1-0.3 cm diameterComplex aphthosis: concurrent recurrent oral aphthae and genital lesions without other Behçet’s disease components Unknown; probably an immune defect mediated by T cells; may be associated with hypersensitivity, deficiencies, malabsorption, or family history; not caused by virus; precipitated by stress, trauma, hormonal changes, certain foods; autoinflammatory disease recently suggested Painful nuisance disease; rarely debilitating, except major type; recurrences are the rule; more severe in patients with AIDS; may be seen in association with Crohn’s disease, or glutensensitive enteropathy (celiac sprue) - Behçet’s syndrome - Minor aphthae; eye lesions (uveitis, conjunctivitis); genital lesions (ulcers); arthritis occasionally seen Probably an immune defect; possibly autoimmune; hereditary: presence of HLA-B51 may be factors; autoinflammatory disease recently suggested Biopsy shows vasculitis and laboratory studies give nonspecific results; complications may be significant Continued O-10 Clinical Overview Ulcerative Conditions—cont’d Disease Clinical Features Cause Significance - Reactive arthritis (formerly Reiter’s syndrome) - Arthritis, urethritis, conjunctivitis, or uveitis; oral ulcers; usually in white men in third decade Unknown; immune response to bacterial antigen; usually follows STD or Shigella dysentery; HLA-B27 Duration of weeks to months; may be recurrent - Erythema multiforme - Sudden onset; painful, widespread, superficial ulcers; crusted ulcers on vermilion of lips; usually self-limited; young adults; may also have target or iris lesions of skin; may be recurrent, especially in spring and fall; some cases become chronic; uncommon Unknown; may be associated with hypersensitivity; may follow drug ingestion or infection such as herpes labialis or Mycoplasma pneumonia Cause should be investigated; can be debilitating, especially in severe forms, erythema multiforme major (Stevens-Johnson syndrome) and toxic epidermal necrolysis - Lupus erythematosus - Usually painful erythematous and ulcerative lesions on buccal mucosa, gingiva, and vermilion; radiating white keratotic areas may surround lesions; chronic discoid type: generally affects skin and mucous membrane only; acute systemic type: skin lesions may be erythematous with scale (classic sign is butterfly rash across nasal bridge); may have joint, kidney, and heart lesions; middle-aged women; uncommon Immune defect; patient develops autoantibodies, especially antinuclear antibodies Discoid type may cause discomfort and cosmetic problems; systemic type has variable prognosis from good to poor - Drug reactions - May affect skin or mucosa; erythema, white lesions, vesicles, ulcers may be seen; history of recent drug ingestion is important Potentially any drug via stimulation of immune systemReactions, such as anaphylaxis or angioedema, may require emergency care; highly variable clinical picture can make diagnosis difficult - Contact allergy - Lesions caused by direct contact with foreign antigen; erythema, vesicles, ulcers may be seen Potentially any foreign antigen that contacts skin or mucosa; cinnamon frequently cited Patch testing may be helpful for diagnosis; history is important Continued O-12 Clinical Overview Ulcerative Conditions—cont’d Disease Clinical Features Cause Significance - Wegener’s granulomatosis(granulomatosis with polyangiitis) - Inflammatory lesions (necrotizing vasculitis) of lung, kidney, and upper airway; may affect gingiva when intraoral; rare Unknown; possibly immune defect or infection May become life threatening as a result of tissue destruction in any of the three involved sites - Midline granuloma (ulcerating midline lymphoma) - Destructive, necrotic, nonhealing lesions of nose, palate, and sinuses; biopsy shows nonspecific inflammation; distinct from Wegener’s granulomatosis; rare Represents NK/T-cell lymphoma Poor prognosis; death may follow erosion into major blood vessels - Chronic granulomatous disease - Recurrent infections in various organs; oral ulcers; males; rare Genetic disease (X linked) Altered neutrophil and macrophage function results in inability to kill bacteria and fungi - Cyclic neutropenia - Oral ulcers with periodicity (every 3-6 weeks); infection; adenopathy; 3-5 day duration; periodontal disease Mutations in neutrophil elastase gene ELA2; autosomal dominant or new mutation Rare blood dyscrasia - Squamous cell carcinoma of the oral cavity - Indurated, nonpainful ulcer with rolled margins; most commonly found on lateral tongue and floor of mouth; males affected twice as often as females; clinical appearance may also include a white or red patch or mass DNA alterations due to carcinogens such as tobacco, UV light, oncogenic human papillomavirus type 16 or 18 (oropharynx); alcohol acts as cocarcinogen Overall 5-year survival rate is about 50%; improved prognosis if found in early stages, poor prognosis if metastasis to regional lymph nodes - Carcinoma of maxillary sinus - Patient may have symptoms of sinusitis or referred pain to teeth; may cause malocclusion or mobile teeth; may appear as ulcerative mass in palate or alveolus Unknown; some occur in woodworkers Prognosis only fair; metastases are not uncommon O-14 Clinical Overview

White Lesions

Disease Clinical Features Cause Significance - Leukoedema - Common uniform opacification of buccal mucosa bilaterally Unknown Remains indefinitely; no ill effects - White sponge nevus - Asymptomatic, bilateral, dense, shaggy, white or gray, generalized opacification; primarily buccal mucosa affected, but other membranes may be involved; rare Hereditary, autosomal dominant (keratin 4 and/or 13 genes) Remains indefinitely; no ill effects - Hereditary benign intraepithelial dyskeratosis - Asymptomatic, diffuse, shaggy white lesions of buccal mucosa, as well as other tissues; eye lesions—white plaques surrounded by inflamed conjunctiva (pannus); rare Hereditary, autosomal dominant, duplication of chromosome 4q35 Remains indefinitely - Follicular keratosis - Keratotic papular lesions of skin and, infrequently, mucosa; lesions are numerous and asymptomatic Genetic, autosomal dominant, mutation in ATP2A2 gene Chronic course with occasional remissions - Focal (frictional) hyperkeratosis - Asymptomatic white patch, commonly on edentulous ridge, buccal mucosa, and tongue; does not rub off; common Chronic irritation, low-grade trauma May regress if cause eliminated - White lesions associated with smokeless tobacco - Asymptomatic white folds surrounding area where tobacco is held; usually found in labial and buccal vestibules; common Chronic irritation from snuff or chewing tobacco Increased risk for development of verrucous and squamous cell carcinoma after many years - Nicotine stomatitis - Asymptomatic, generalized opacification of palate with red dots representing salivary gland orifices; common Heat and smoke associated with combustion of tobacco Rarely develops into palatal cancer Continued

O-16 Clinical Overview White Lesions—cont’d Disease Clinical Features Cause Significance - Actinic cheilitis - Lower lip: atrophic epithelium, poor definition of vermilionskin margin, focal zones of keratosis; common UV light (especially UVB, 2900-3200 nm) May result in squamous cell carcinoma - Idiopathic leukoplakia - Asymptomatic white patch; cannot be wiped off; males affected more than females Unknown; may be related to tobacco and alcohol use May recur after excision; 5% are malignant and 5% become malignant; higher risk of carcinoma if dysplasia present - Hairy leukoplakia - Filiform to flat patch on lateral tongue, often bilateral, occasionally on buccal mucosa; asymptomatic Epstein-Barr virus infection Seen in 20% of HIV-infected patients; marked increase in AIDS; may occur in non– AIDS-affected immunosuppressed patients - Hairy tongue - Elongation of filiform papillae; asymptomatic Unknown; may follow antibiotic, corticosteroid use, tobacco habit Benign process; may be cosmetically objectionable - Geographic tongue (erythema migrans) - White annular lesions with atrophic red centers; pattern migrates over dorsum of tongue; varies in intensity and may spontaneously disappear; occasionally painful; common Unknown Completely benign; spontaneous regression after months to years Continued O-18 Clinical Overview White Lesions—cont’d Disease Clinical Features Cause Significance - Lichen planus - Bilateral white striae (Wickham’s); asymptomatic except when erosions are present; seen in middle age; buccal mucosa most commonly affected, with lesions occasionally on tongue, gingiva, and palate; skin/genital lesions occasionally present and are purple pruritic papules; forearm and lower leg most commonly affected skin sites Unknown; may be precipitated by stress; may be hyperimmune condition mediated by T cells May regress after many years; treatment may only control disease; rare malignant transformation - Dentifrice-associated slough - Asymptomatic, slough of filmy parakeratotic cells Mucosal reaction to components in toothpasteNone - Candidiasis - Painful elevated plaques that can be wiped off, leaving eroded, bleeding surface; associated with poor hygiene, systemic antibiotics, systemic disease, debilitation, reduced immune response; chronic infection may result in erythematous mucosa without obvious white colonies; common Opportunistic fungus: Candida albicans and rarely other Candida species Usually disappears 1-2 weeks after treatment; some chronic cases require long-term therapy - Mucosal burns - Painful white fibrin exudate covering superficial ulcer with erythematous ring; common Chemicals (aspirin, phenol), heat, electrical burns Heals in days to weeks - Submucous fibrosis - Areas of opacification with loss of elasticity; any oral region affected; rare May be due to hypersensitivity to dietary constituents such as areca (betel nut), capsaicin Irreversible; predisposes to oral cancer in about 10% of cases Continued O-20 Clinical Overview AIDS, Acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; UV, ultraviolet; UVB, ultraviolet B. White Lesions—cont’d Disease Clinical Features Cause Significance - Fordyce granules - Multiple asymptomatic, yellow, flat or elevated spots seen primarily in buccal mucosa and lips; seen in a majority of patients; many consider them to be a variation of normal Developmental Ectopic sebaceous glands (choristoma) of no significance - Ectopic lymphoid tissue - Asymptomatic elevated yellow nodules ,0.5 cm in diameter; usually found on tonsillar pillars, posterolateral tongue, and floor of mouth; covered by intact epithelium; common Developmental No significance; lesions remain indefinitely and are usually diagnostic clinically - Gingival cyst - Small, usually white to yellow nodule; multiple in infants, solitary in adults; common in infants, rare in adults Proliferation and cystic change of dental lamina rests In infants, lesions spontaneously rupture or break; recurrence not expected in adults - Parulis - Yellow-white gingival swelling caused by submucosal pus accumulation Periodontitis or dental abscess Periodic drainage until primary cause is eliminated - Lipoma - Asymptomatic, slow-growing, well-circumscribed, yellow or yellow-white mass; benign neoplasm of fat; occurs in any area Unknown Seems to have limited growth potential intraorally; recurrence not expected after removal O-22 Clinical Overview

Red-Blue Lesions

Disease Clinical Features Cause Significance - Congenital hemangiomas and vascular malformations - Red or blue lesion that blanches when compressed; extent of lesion usually difficult to determine; skin, lips, tongue, and buccal mucosa most commonly affected; common on skin, uncommon in mucous membrane, rare in bone; part of Sturge-Weber syndrome; telangiectasias (small focal dilations of terminal blood vessels) blanch when compressed; commonly found in sundamaged skin and seen with hereditary hemorrhagic telangiectasia (HHT) Some are benign congenital neoplasms, others are caused by abnormal vessel morphogenesis (vascular malformation); HHT: autosomal dominant; venous varix: congenital or induced by UV light May remain quiescent or may gradually enlarge; hemorrhage may be a significant complication; often a cosmetic problem; HHT: epistaxis and GI bleeding may be a problem - Pyogenic granuloma - Asymptomatic red mass composed of granulation tissue; most commonly seen in gingiva; may occur during pregnancy; may be secondarily ulcerated; common Trauma or chronic irritation; size modified by hormonal changes Remains indefinitely; recurrence if incompletely excised; reduction in size if cause removed or after pregnancy - Peripheral giant cell granuloma - Asymptomatic red mass of gingiva composed of fibroblasts and multinucleated giant cells; found most often in adults in the former area of deciduous teeth; produces cup-shaped radiolucency when in edentulous areas; uncommon Trauma or chronic irritation Remains indefinitely if untreated; a reactive lesion; clinical appearance similar to that of pyogenic granuloma - Erythroplakia - Asymptomatic red velvety patch usually found in floor of mouth or retromolar area in adults; seen in older adults; red lesions may have foci of white hyperkeratosis (speckled erythroplakia) Tobacco and alcohol Most (90%) are in situ or invasive squamous cell carcinoma - Kaposi’s sarcoma - May be seen in AIDS; usually on skin, but may be oral, especially in palate; red to blue macules or nodules; rare, except in immunodeficiency Endothelial cell proliferation in the setting of HHV8 infection Fair prognosis; poor when part of AIDS; incidence on the decline in AIDS patients under HAART treatment Continued O-24 Clinical Overview Red-Blue Lesions—cont’d Disease Clinical Features Cause Significance - Median rhomboid glossitis - Red lobular elevation anterior to circumvallate papillae in midline Chronic Candida infection Little significance; treat Candida albicans infection - Geographic tongue - White annular lesions with atrophic, red centers; white (keratotic) areas may be poorly developed, leaving red patches on dorsum of tongue; occasionally painful; common Unknown Little significance except when painful; not premalignant - Psoriasis - Chronic skin disease with rare oral lesions; red skin lesions covered with silvery scales; oral lesions red to white patches Unknown Must have skin lesions to confirm oral disease; exacerbations and remissions are typical - Vitamin B deficiency - Generalized redness of tongue caused by atrophy of papillae; may be painful; may have an associated angular cheilitis; rare in United States B complex deficiency Remains until therapeutic levels of vitamin B are administered - Anemia (pernicious and iron deficiency) - May result in generalized redness of tongue caused by atrophy of papillae; may be painful; patients may have angular cheilitis; females more commonly affected than males; Plummer-Vinson syndrome (sideropenic dysphagia); anemia (iron deficiency), mucosal atrophy, predisposition for oral cancer Some forms acquired, some hereditary Some types may be life threatening; oral manifestations disappear with treatment; complication of oral cancer with Plummer-Vinson syndrome - Burning mouth syndrome - Wide range of oral complaints, usually without any visible tissue changes; especially middle-aged women; uncommon in males Multifactorial (e.g., C. albicans, vitamin B deficiency anemias, xerostomia, idiopathic, psychogenic peripheral neuropathy), chronic trauma May persist despite treatment - Scarlet fever - Pharyngitis, systemic symptoms, strawberry tongue Group A streptococci Complications of rheumatic fever and glomerulonephritis Continued

O-26 Clinical Overview Red-Blue Lesions—cont’d Disease Clinical Features Cause Significance - Erythematous candidiasis - Painful, hyperemic palate under denture; angular cheilitis; red, painful mucosa Chronic C. albicans infection; poor oral hygiene and illfitting denture are frequent predisposing factors Discomfort may prevent wearing denture; not allergic or premalignant - Plasma cell gingivitis - Red, painful tongue; angular cheilitis; red swollen attached gingiva Possible allergic reaction to dietary antigen such as mint- or cinnamon-flavored chewing gum; certain toothpastes Gingival lesions similar to lupus, lichen planus, and pemphigoid lesions - Drug reactions and contact allergies - Red, vesicular, or ulcerative eruption Hypersensitivity reaction to allergen Hypersensitivity reactions to drugs or HSV may produce erythema multiforme pattern clinically

Petechiae and Ecchymoses

• Traumatic lesions
  • Hemorrhagic spot (red, blue, purple, black) composed of extravasated blood in soft tissue; does not blanch with compression; may be seen anywhere in skin or mucous membranes after trauma; changes color as blood is degraded and resorbed Follows trauma such as that caused by tooth extraction, tooth bite, fellatio, chronic cough, vomiting Resolves in days to weeks; no sequelae
• Blood dyscrasias
  • Hemorrhagic spots (small—petechiae, large—ecchymoses) on mucous membranes resulting from extravasated blood; may be spontaneous or may follow minor trauma; spots do not blanch with compression; color varies with time; uncommon in general practice, but dental personnel may be first to observe Lack of clotting factor, reduced numbers of platelets for various reasons, or lack of vessel integrity May be life threatening; must be investigated, diagnosed, and treated

O-28 Clinical Overview

Pigmented Lesions

Disease Clinical Features Cause Significance - Physiologic pigmentation - Symmetric distribution; does not change in intensity; does not alter surface morphology Normal melanocyte activity None - Smoking-associated melanosis - Gingival pigmentation; especially women taking birth control pills Component in smoke stimulates melanocytes Cosmetic; may herald smoking-associated lesions elsewhere - Oral melanotic macule - Flat oral pigmentation less than 1 cm in diameter; lower lip, gingiva, buccal mucosa, palate usually affected; may represent oral ephelis, perioral lesions associated with PeutzJeghers syndrome, Addison’s disease, or post inflammatory pigmentation Unknown; post inflammatory; or traumatic Remains indefinitely; no malignant potential - Neuroectodermal tumor of infancy - Pigmented, radiolucent, benign neoplasm in maxilla, usually of newborns; pigment is melanin; rare; children and those 25 years old Unknown; neural crest origin Recurrence unlikely Continued O-30 Clinical Overview Pigmented Lesions—cont’d Disease Clinical Features Cause Significance - Melanocytic nevus - Elevated pigmentations; often nonpigmented when intraoral; uncommon orally; blue nevi seen in palate Unknown; due to nests of nevus cells Remains indefinitely; oral nevi often cannot be separated from melanoma clinically - Melanoma - Malignancy of melanocytes; some have a radial growth phase of years’ duration (in situ type) before vertical growth phase, but invasive type has only vertical growth phase; oral melanoma may appear first as insignificant spot, especially on palate and gingiva; adults affected
UV light may be carcinogenic on skin; unknown for oral lesions Skin: 65% 5-year survival; oral: 20% 5-year survival; in situ melanomas have better prognosis than invasive melanomas; unpredictable metastatic behavior - Amalgam tattoo - Asymptomatic gray-pigmented macule found in gingiva, tongue, palate, or buccal mucosa adjacent to amalgam restoration; may be seen radiographically if particles are large; no associated inflammation; common Traumatic implantation of amalgam Remains indefinitely and changes little; no ill effects - Heavy-metal pigmentation - Dark line along marginal gingiva due to precipitation of metal; rare Intoxication by metal vapors (lead, bismuth, arsenic, mercury) from occupational exposure Exposure may affect systemic health; gingiva pigmentation of cosmetic significance - Minocycline pigmentation - Gray pigmentation of palate, skin, scars, and bone, and rarely, of formed teeth hop(history of present illness) Ingestion of minocycline Must differentiate from melanoma; drug may cause intrinsic staining of teeth

O-32 Clinical Overview

Verrucal-Papillary Lesions

Disease Clinical Features Cause Significance - Papillary hyperplasia - Painless papillomatous “cobblestone” lesion of hard palate in denture wearers; usually red as a result of inflammation; common Soft tissue reaction to ill-fitting denture and probable fungal overgrowth Lesion is not premalignant; may show significant regression if denture taken away from patient; topical antifungals may help - Condyloma latum - Clinically similar to papillary hyperplasia; part of secondary syphilis Treponema pallidum Prognosis good with treatment - Squamous papilloma - Painless exophytic granular to cauliflower-like lesions; predilection for tongue, floor of mouth, palate, uvula, lips, faucial pillars; generally solitary; soft texture; white or same color as surrounding tissue; young adults and adults; common Most caused by nononcogenic human papillomavirus (HPV); some unknown Lesion has no known malignant potential; recurrence rare - Oral verruca vulgaris - Painless papillary lesion usually with white surface projections caused by keratin production; may be regarded as a type of papilloma; children and young adults; common on skin, uncommon intraorally Human papillomavirus (HPV) Little significance; may be multiple and a cosmetic problem - Condyloma acuminatum - Painless, pedunculated to sessile, exophytic, papillomatous lesion; adults; same color as or lighter than surrounding tissue; patient’s sexual partner has similar lesions; rare in oral cavity Human papillomavirus (HPV) Oral lesions acquired through autoinoculation or sexual contact with infected partner; recurrence common Continued O-34 Clinical Overview Verrucal-Papillary Lesions—cont’d Disease Clinical Features Cause Significance - Focal epithelial hyperplasia (Heck’s disease) - Multiple soft nodules on lips, tongue, buccal mucosa; transmissible; asymptomatic Papillomavirus (HPV 13 and 32) Little significance; may be included in differential diagnosis of mucosal nodules - Keratoacanthoma - Well-circumscribed, firm, elevated lesion with central keratin plug; may cause pain; develops rapidly over 4-8 weeks and involutes in 6-8 weeks; found on sunexposed skin and lips; rare intraorally; predilection for men Unknown; pilosebaceous origin Probably a self-healing squamous cell carcinoma. Difficult to differentiate clinically and microscopically from squamous cell carcinoma; may heal with scar - Verrucous carcinoma - Broad-based, exophytic, indurated lesions; usually found in buccal mucosa or vestibule; men most frequently affected; uncommon May be associated with use of tobacco Slow-growing malignancy; well differentiated, with better prognosis than usual squamous cell carcinoma; growth pattern is more expansile than invasive; metastasis uncommon - Pyostomatitis vegetans - Multiple small pustules in oral mucosa; males more than females Unknown May be associated with bowel disease such as ulcerative colitis or Crohn’s disease - Verruciform xanthoma - Solitary, pebbly, elevated or depressed lesion occurring anywhere in oral mucous membrane; color ranges from white to red; rare Unknown Limited growth potential; does not recur

O-36 Clinical Overview

Submucosal Swelling (By Region)

Gingival Swellings

Disease Clinical Features Cause Significance - Pyogenic granuloma - Asymptomatic red mass found primarily on gingiva but may be found anywhere on skin or mucous membrane where trauma has occurred; common Reaction to trauma or chronic irritation May recur if incompletely excised; usually does not cause bone resorption - Peripheral giant cell granuloma - Asymptomatic red mass of gingiva; cannot be clinically separated from pyogenic granuloma; uncommon Reaction to trauma or chronic irritation Completely benign behavior; unlike central counterpart; recurrence not anticipated - Peripheral fibroma (focal fibrous hyperplasia) - Firm mass; color same as surrounding tissue; no symptoms; common; may be pedunculated or sessile Reaction to trauma or chronic irritation Represents overexuberant repair process with proliferation of scar; occasional recurrence seen with peripheral ossifying fibroma - Parulis - Red mass (or yellow if pus filled) occurring usually on buccal gingiva of children and young adults; usually without symptoms Sinus tract from periodontal or periapical abscess Cyclic drainage occurs until underlying problem is eliminated - Exostosis - Bony hard nodule(s) covered by intact mucosa found attached to buccal aspect of alveolar bone; asymptomatic; common; usually appears in adulthood Unknown No significance except in denture construction Continued

O-38 Clinical Overview Gingival Swellings—cont’d Disease Clinical Features Cause Significance - Gingival cyst - Small, elevated, yellow to pink nodule(s); multiple in infants, solitary in adults; common in infants, rare in adults Proliferation and cystic change of dental lamina rests Known as Bohn‘s nodules or Epstein’s pearls in infants; lesions are unroofed during mastication; adult lesions do not occur - Eruption cyst - Bluish (fluid- or blood-filled) sac over crown of erupting tooth; uninflamed and asymptomatic; uncommon Hemorrhage into follicular space between tooth crown and reduced enamel epithelium None; should not be confused with neoplasm - Congenital epulis of newborn - Firm,pedunculated or sessile mass attached to gingiva in infants; same color as or lighter than surrounding tissue; rare Unknown Benign neoplasm of non-neural granular cells. Different cells to those in a granular cell tumor of adult; does not recur - Generalized soft tissue hyperplasia - Firm, increased bulk of free and attached gingiva; usually asymptomatic; pseudopockets; nonspecific type common, others (drug induced, hormone modified, leukemia induced, genetically influenced) uncommon to rare Local gingival irritants plus systemic drugs (phenytoin [Dilantin], nifedipine, cyclosporine), hormone imbalance, leukemia, or hereditary factors/syndromes Cosmetic, as well as hygienic, problem; causative factors should be eliminated if possible; control of local factors can lead to improvement O-40 Clinical Overview Floor-of-Mouth Swellings Disease Clinical Features Cause Significance - Mucus retention cyst (ranula) - Elevated, fluctuant, bluish white mass in lateral floor of mouth; cyclic swelling often; usually painful; uncommon Sialolith blockage of duct or traumatic severance of duct Most are due to sialoliths, some are due to severance of duct with extravasation of mucin into soft tissues; recurrence not uncommon - Lymphoepithelial cyst - Asymptomatic nodules covered by intact epithelium ,1 cm in diameter; any age; characteristically found on faucial pillars, floor of mouth, ventral and posterior-lateral tongue; yellowish pink; uncommon within oral cavity, common in major salivary glands Developmental defect Ectopic lymphoid tissue of no significance; recurrence not expected - Dermoid cyst - Asymptomatic mass in floor of mouth (usually midline) covered by intact epithelium of normal color; young adults; feels doughy on palpation; rare Proliferation of multipotential cells; stimulus unknown Recurrence not expected; called teratoma when tissues from all three germ layers are present; dermoid when secondary skin adnexa are present - Intraoral (minor) salivary gland tumor - Solitary, firm, asymptomatic mass usually covered by epithelium; malignant tumors may cause pain, paresthesia, or ulceration; young adults and adults; most common in palate, followed by tongue, upper lip, and buccal mucosa; uncommon Unknown Approximately half of minor salivary gland tumors are malignant; malignancies may metastasize to bones and lungs, as well as to regional lymph nodes; pleomorphic adenoma is most common benign neoplasm - Mesenchymal neoplasm - Firm, asymptomatic tumescence covered by intact epithelium; may arise from any connective tissue cell Unknown Benign tumors not expected to recur; malignancies rare O-42 Clinical Overview Lips and Buccal Mucosal Swellings Disease Clinical Features Cause Significance - Focal fibrous hyperplasia (oral fibroma) - Firm, asymptomatic nodule covered by epithelium unless secondarily traumatized; usually found along line of occlusion in buccal mucosa and lower lip; common Reaction to trauma or chronic irritation Represents hyperplastic scar; limited growth potential, and no malignant transformation seen - Salivary gland tumor - Solitary, firm, asymptomatic mass usually covered by epithelium; malignant tumors may cause pain, paresthesia, or ulceration; young adults and adults; most common in palate, followed by tongue, upper lip, and buccal mucosa; uncommon Unknown Approximately half of minor salivary gland tumors are malignant; malignancies may metastasize to bones and lungs, as well as to regional lymph nodes; pleomorphic adenoma is most common benign neoplasm - Mucus retention cyst - Solitary, usually asymptomatic, mobile, nontender; covered by intact epithelium; color same as surrounding tissue; adults over 50 years of age; common in palate, cheek, floor of mouth; uncommon in upper lip, rare in lower lip Blockage of salivary gland excretory duct by sialolith Recurrence not anticipated if associated gland removed; clinically indistinguishable from more significant salivary gland neoplasms - Mucus extravasation phenomenon (mucocele) - Bluish nodule (normal color if deep) usually covered by epithelium; may be slightly painful and have associated acute inflammatory reaction; most frequently seen in lower lip and buccal mucosa, rare in upper lip; adolescents and children; common Traumatic severance of salivary gland excretory ductRecurrence expected if contributing salivary gland is not removed, or if adjacent ducts are severed; not a true cyst - Mesenchymal neoplasm - Firm, asymptomatic tumescence covered by intact epithelium; may arise from any connective tissue cell Unknown Benign tumors not expected to recur; malignancies rare

O-44 Clinical Overview

Tongue Swellings

Disease Clinical Features Cause Significance - Focal fibrous hyperplasia (traumatic fibroma) - Firm, asymptomatic nodule covered by epithelium unless secondarily traumatized; usually found along line of occlusion in buccal mucosa and lower lip; common Reaction to trauma or chronic irritation Represents hyperplastic scar; limited growth potential, and no malignant transformation seen - Pyogenic granuloma - Asymptomatic red mass found primarily on gingiva but may be found anywhere on skin or mucous membrane where trauma has occurred; common Reaction to trauma or chronic irritation May recur if incompletely excised; usually does not cause bone resorption - Granular cell tumor - Painless elevated tumescence covered by intact epithelium; color same as or lighter than surrounding tissue; strong predilection for dorsum of tongue but may be found anywhere; any age; uncommon Unknown; cell of origin probably Schwann cell Does not recur; of significance in that it must be differentiated from other lesions; no malignant potential - Neurofibroma/palisaded encapsulated neuroma - Soft, single or multiple, asymptomatic nodules covered by epithelium; same as or lighter than surrounding mucosa; most frequently seen on tongue, buccal mucosa, and vestibule but may be seen anywhere; any age; uncommon Unknown; cell of origin is probably Schwann cell; NF-1 gene mutation if part of neurofibromatosis syndrome Recurrence not expected; multiple neurofibromas should suggest neurofibromatosis-1 (von Recklinghausen’s disease of nerve, which includes neurofibromas and .6 café-au-lait macules); palisaded encapsulated neuromas are not syndrome associated - Mucosal neuroma - Multiple; lips, tongue, buccal mucosa; may be associated with MEN III syndrome Unknown; MEN III syndrome is autosomal dominant MEN III syndrome (pheochromocytoma, medullary carcinoma of thyroid, and mucosal neuromas) - Salivary gland tumor - Solitary, firm, asymptomatic mass usually covered by epithelium; malignant tumors may cause pain, paresthesia, or ulceration; young adults and adults; most common in palate, followed by tongue, upper lip, and buccal mucosa; uncommon Unknown Approximately half of minor salivary gland tumors are malignant; malignancies may metastasize to bones and lungs, as well as to regional lymph nodes; pleomorphic adenoma is most common benign neoplasm - Lingual thyroid - Nodular mass in base of tongue; may cause dysphagia; young adults; rare Incomplete descent of thyroid anlage to neck Lingual thyroid may be patient’s only thyroid tissue O-46 Clinical Overview

Palatal Swellings

Disease Clinical Features Cause Significance - Salivary gland tumor - Solitary, firm, asymptomatic mass usually covered by epithelium; malignant tumors may cause pain, paresthesia, or ulceration; young adults and adults; most common in palate, followed by tongue, upper lip, and buccal mucosa; uncommon Unknown Approximately half of minor salivary gland tumors are malignant; malignancies may metastasize to bones and lungs, as well as to regional lymph nodes; pleomorphic adenoma is most common benign neoplasm - Palatal abscess from periapical lesion - Painful, pus-filled, fluctuant tumescence of hard palate; color same as or redder than surrounding tissue; associated with nonvital tooth Extension of periapical abscess through palatal bone Pus may spread to other areas, seeking path of least resistance - Lymphoma - Asymptomatic, spongy to firm tumescence of hard palate; rare in adults; increased frequency in immunosuppressed patients Unknown May represent primary lymphoma (non-Hodgkin’s type); lymphoma workup indicated; high grade lesions more frequent in immunosuppressed patients - Torus - Asymptomatic, bony, hard swelling of hard palate (torus palatinus); bony, exophytic growths along lingual aspect of mandible (torus mandibularis); very slow growth; young adults and adults; affects up to 25% of population Unknown No significance; should not be confused with other palatal lesions - Neoplasm of maxilla or maxillary sinus - Palatal swelling with or without ulceration; pain or paresthesia; may cause loosening of teeth or malocclusion; denture may not fit; any age; rare Unknown May represent benign or malignant jaw neoplasm or carcinoma of maxillary sinus; poor prognosis for malignant lesions O-48 Clinical Overview Neck Swellings Disease Clinical Features Cause Significance - Branchial cyst - Asymptomatic uninflamed swelling in lateral neck; soft or fluctuant; children and young adults; rare Developmental proliferation of epithelial remnants within lymph nodes Clinical diagnostic problem - Lymphadenitis— nonspecific, bacterial, fungal - Single or multiple painful nodules (lymph nodes) in neck, especially submandibular and jugulodigastric areas; lesions are usually soft when acute and usually are not fixed to surrounding tissue; nonspecific type common Any oral inflammatory condition, especially dental abscess; oral tuberculosis, syphilis, or deep fungus may affect neck nodes Neck disease often reflects oral disease - Metastatic carcinoma to lymph nodes - Often single but may be multiple (rarely bilateral), indurated masses; fixed and nonpainful; most frequently affects submandibular and jugulodigastric nodes; adults Metastatic carcinoma of the oral cavity, base of tongue, and oropharynx, and less frequently, from distant sites Signifies advanced disease with poorer prognosis - Lymphoma - Single or bilateral swellings in lateral neck; indurated, asymptomatic, and often fixed; patient may have weight loss, night sweats, and fever; young adults and adults; uncommon Unknown After diagnostic biopsy, staging procedures are done; prognosis poor to excellent, depending on stage and specific type; increased frequency in immunosuppressed patients - Parotid lesion - When tail of parotid affected, neck mass may occur; neoplasm: indurated, asymptomatic, single mass (Warthin’s tumor: may be bilateral); Sjögren’s syndrome: bilateral, diffuse, soft swelling plus sicca complex, affects primarily older women; infection: unilateral, diffuse, soft, painful mass Neoplasm: unknown; Sjögren’s syndrome: autoimmune; infection: viral, bacterial, or fungal; metabolic disease: diabetes, alcoholism Requires diagnosis and treatment by experienced clinician Continued

O-50 Clinical Overview Neck Swellings—cont’d Disease Clinical Features Cause Significance - Carotid body tumor - Firm, movable mass in neck at carotid bifurcation; bruit and thrill may be apparent; adults; rarely hereditary Neoplastic transformation of carotid body cells; SDHD gene mutation Morbidity from surgery may be profound because of tumor attachment to carotid sheath - Epidermal cyst - Elevated nodule in skin of neck (or face); usually uninflamed and asymptomatic; up to several centimeters in size; covered by epidermis and near skin surface; common Epithelial rest proliferation Recurrence not expected; more superficially located than other neck lesions discussed - Lymphangioma - Spongy, diffuse, painless mass in dermis; may become large; lighter than surrounding tissue to red-blue; crepitance; children; rare Developmental May be disfiguring or cause respiratory distress - Thyroglossal tract cyst - Midline swelling in neck above level of thyroid gland; often moves when swallowing; may develop sinus tract; most common developmental cyst of neck Failure of complete descent of thyroid tissue from foramen caecum in utero with subsequent cyst formation Recurrence not uncommon because of tortuous course of cystic lesion - Thyroid gland tumor - Paramedian swelling in area of thyroid gland; firm, asymptomatic; uncommon Unknown Prognosis poor to excellent, depending on stage and histologic type of tumor - Dermoid cyst - Swelling in floor of mouth or midline of neck; young adults Unknown Recurrence not expected

O-52 Clinical Overview Differential Diagnosis Approach to Jaw Lesions Cysts of the Jaws and Neck Disease Clinical Features Radiographic Appearance Other Features - Periapical (radicular) cyst - Any age; peaks in third through sixth decades; common; apex of any nonvital erupted tooth, especially anterior maxilla Well-defined radiolucency at apex of nonvital tooth Cannot be distinguished radiographically from periapical granuloma; develops from inflammatory stimulation of rests of Malassez; incomplete enucleation results in residual cyst; chronic process and usually asymptomatic; common - Dentigerous cyst - Young adults; associated most commonly with impacted mandibular third molars and maxillary third molars and cuspids Well-defined radiolucency around crown of impacted teeth Some become very large, with rare possibility of pathologic fracture; complication of neoplastic transformation of cystic epithelium to ameloblastoma and, rarely, to squamous cell or mucoepidermoid carcinoma; common; eruption cyst: gingival tumescence developing as a dilation of follicular space over crown of erupting tooth - Lateral periodontal cyst - Adults; lateral periodontal membrane, especially mandibular cuspid and premolar area Well-defined radiolucency; usually unilocular but may be multilocular; usually interproximally within the alveolar segment Usually asymptomatic; associated tooth is vital; origin from rests of dental lamina; some keratocysts are found in a lateral root position; gingival cyst of adult is soft tissue counterpart - Gingival cyst of newborn - Newborn; gingival soft tissues Usually not apparent on radiographNewborns—common, multiple, no treatment; adult gingival cyst is rare, solitary, and treated by local excision Continued O-54 Clinical Overview Cysts of the Jaws and Neck—cont’d Disease Clinical Features Radiographic Appearance Other Features - Odontogenic keratocyst/keratocystic odontogenic tumor - Any age, especially adults; mandibular molar-ramus area favored; may be found in position of dentigerous, lateral root, periapical cyst Well-defined radiolucency; unilocular or multilocular Recurrence rate of 5%-62%; may exhibit locally infiltrative behavior; may be part of nevoid basal cell carcinoma syndrome (keratocysts, skeletal anomalies, basal cell carcinomas); PTCH gene mutations - Calcifying odontogenic cyst(calcifying cystic odontogenic tumor) - Any age; maxilla favored; gingiva second most common site Well-defined radiolucency; may have opaque foci Origin and behavior are in dispute; ghost cell keratinization characteristic; rare - Glandular odontogenic cyst - Any age; mandible favored Well-defined radiolucency Recurrence potential - Globulomaxillary lesion - Any age; between roots of maxillary cuspid and lateral incisor Well-defined unilocular or multilocular radiolucencyTeeth are vital; asymptomatic; anatomic designation; not a specific entity but represents one of several different odontogenic cysts/ tumors - Nasolabial cyst - Adults; soft tissue of upper lip, lateral to midline No change Origin likely from remnants of nasolacrimal duct; rare - Nasopalatine canal cyst - Any age; nasopalatine canal or papilla Well-defined midline maxillary radiolucency; may be oval or heart shaped Teeth are vital; may be symptomatic if secondarily infected; may be difficult to differentiate from normal canal; common Continued O-56 Clinical Overview Cysts of the Jaws and Neck—cont’d Disease Clinical Features Radiographic Appearance Other Features - Median mandibular lesion - Any age; midline of mandible Well-defined radiolucency Teeth are vital; asymptomatic; represents one of several different odontogenic cysts/ tumors - Aneurysmal bone cyst - Second decade favored; either jaw; also long bones and vertebrae Radiolucency, may be poorly defined; may have honeycomb or soap bubble appearance Represents vascular lesion in bone consisting of bloodfilled sinusoids; blood wells up when lesion is entered; cause and pathogenesis unknown; rare; follow-up important - Traumatic (simple) bone cyst - Second decade favored; mandible favored Well-defined radiolucency often extending between roots of teeth Represents dead space in bone without epithelial lining; cause and pathogenesis unknown; uncommon in oral region; can be part of florid osseous dysplasia - Static (Stafne) bone cyst - Developmental defect; mandibular molar area below alveolar canal Well-defined oval radiolucency; does not change with time Represents lingual depression of mandible; filled with salivary gland or other soft tissue from floor of mouth; asymptomatic; an incidental finding that requires no biopsy or treatment; uncommon - Focal osteoporotic bone marrow defect - Adults; mandible favored Radiolucency; often in edentulous areasContains hematopoietic marrow; probably represents unusual healing in bone; must be differentiated from other, more significant lesions; uncommon O-58 Clinical Overview

Odontogenic Tumors

Disease Clinical Features Radiographic Appearance Other Features - Ameloblastoma - Fourth and fifth decades; mandibular molar-ramus area most common site Radiolucent; usually well circumscribed; unilocular or multilocular Exhibits locally infiltrative behavior; rarely metastasizes (usually to lung); asymptomatic, uncommon; in mandible associated with BRAF V600E mutations and in maxilla associated with SMO mutations - Squamous odontogenic tumor - Mean age of 40 years; second through seventh decades; alveolar process; anterior more than posterior Radiolucency; well defined Conservative therapy; few recurrences; rare - Calcifying epithelial odontogenic tumor (Pindborg tumor) - Mean age around 40 years; second through tenth decades; mandibular molarramus area favored Radiolucent with or without opaque foci; usually well circumscribed; unilocular or multilocular Behavior and prognosis are similar to those for ameloblastoma; rare - Clear cell odontogenic tumor - Seventh decade; mandible, maxilla Radiolucency; well defined Rare - Adenomatoid odontogenic tumor - Second decade; anterior jaws; female gender preference Well-defined radiolucency; may have opaque foci Usually associated with crown of impacted tooth; no symptoms - Dentinogenic ghost cell tumor - Any age; maxilla favored Well-defined radiolucency; may have opaque foci Origin and behavior are in dispute; ghost cell keratinization characteristic; rare - Odontogenic myxoma - Mean age of about 30 years; ages 10-50 years; any area of jaws Radiolucent lesion; often multilocular or honeycombed; may be poorly defined peripherally Tumors may exhibit aggressive behavior; no symptoms; uncommon; recurrence not uncommon - Central odontogenic fibroma - Any age; any area of jaws Radiolucency; usually multilocular Two microscopic subtypes exhibit same benign clinical behavior; differentiate from desmoplastic fibroma - Cementifying fibroma - Fourth and fifth decades; posterior mandible Well-defined radiolucency; may have radiopaque foci Asymptomatic; grows by local expansion; recurrence unlikely; rare Continued O-60 Clinical Overview Odontogenic Tumors—cont’d Disease Clinical Features Radiographic Appearance Other Features - Cementoblastoma - Second and third decades; root of posterior tooth; mandible more than maxilla Radiopaque lesion; attached to and replaces root; opaque spicules radiate from central area May cause cortical expansion; tooth and lesion removed together; no symptoms; rare - Periapical cemento-osseous dysplasia - Fifth decade; mandible, especially apices of anterior teeth; usually more than one tooth affected Starts as periapical radiolucencies that eventually become opaque in months to years May be a reactive process; always associated with vital teeth; requires no treatment; asymptomatic; common; rare variant known as florid cemento-osseous dysplasia represents severe form that may affect one to four quadrants and may have complications of chronic osteomyelitis and traumatic bone cysts - Odontoma - Second decade; any location, especially anterior mandible and maxilla Radiopaque; compound type: tooth shapes apparent; complex type: uniform radiopaque mass May block eruption of a permanent tooth; complex type rarely causes cortical expansion, no recurrence; compound type appears as many miniature teeth; complex type is conglomeration of enamel and dentin; probably represents hamartoma rather than neoplasm; common - Ameloblastic fibroma and ameloblastic fibro-odontoma - First and second decades; mandibular molar-ramus area; often in a dentigerous relationship with tooth Well-defined radiolucency; may be multilocular and large; fibro-odontoma may have associated opaque mass representing an odontoma Well encapsulated; recurrence not expected; no symptoms; if odontoma present, lesion is called ameloblastic fibro-odontoma; rare

O-62 Clinical Overview Benign Nonodontogenic Tumors Disease Clinical Features Radiographic Appearance Other Features - Ossifying fibroma - Third and fourth decades; body of mandible favored Well-defined radiolucency; may have radiopaque foci Slow growing and asymptomatic; may be indistinguishable from cementifying fibroma; does not recur; microscopy often similar to that of fibrous dysplasia; uncommon - Fibrous dysplasia - First and second decades; maxilla favored Poorly defined radiographic mass; diffuse opacification often described as “ground glass” Slow growing and asymptomatic; causes cortical expansion; may cease growing after puberty; cosmetic problem treated by recontouring. Variants: monostotic: one bone affected; polyostotic: more than one bone affected; Albright’s syndrome: fibrous dysplasia plus café-au-lait skin macules and endocrine abnormalities (precocious puberty in females); Jaffe-Lichtenstein syndrome: multiple bone lesions of fibrous dysplasia and skin pigmentations - Osteoblastoma - Second decade; either jaw Well-defined, lucent to opaque lesion Diagnostic feature of pain; determination by microscopy often difficult; may be confused with osteosarcoma; recurrence not expected; rare - Chondroma - Any age; any location, especially anterior maxilla and posterior mandible Relative radiolucency; may have opacities May be difficult to separate microscopically from welldifferentiated chondrosarcoma; rare - Osteoma - Any age; either jaw Well defined Asymptomatic; may be part of Gardner’s syndrome (osteomas, intestinal polyps, cysts and fibrous lesions of skin, supernumerary teeth); rare Continued O-64 Clinical Overview Benign Nonodontogenic Tumors—cont’d Disease Clinical Features Radiographic Appearance Other Features - Central giant cell granuloma - Children and young adults; either jaw Usually well-defined radiolucency; may be multilocular or, less frequently, unilocular May exhibit aggressive behavior; low recurrence rate; asymptomatic; uncommon; rule out hyperparathyroidism - Hemangioma of bone - Young adults; either jaw Radiolucent lesion; may have a honeycomb pattern or may be multilocular Hemorrhage is significant complication with treatment; asymptomatic; rare - Langerhans cell histiocytosis - Children and young adults; any bone Single or multiple radiolucent lesions; some described as punched out; lesions around root apices sometimes described as resembling socalled floating teeth Three variants: Letterer-Siwe syndrome (acute disseminated): organs and bone affected, infants, usually fatal; Hand-Schüller-Christian syndrome (chronic disseminated): bone lesions, exophthalmos, diabetes insipidus, and organ lesions; children, fair prognosis; eosinophilic granuloma (chronic localized): bone lesions only, children and adults, good prognosis; surgery, radiation, or chemotherapy; cause unknown

O-66 Clinical Overview Inflammatory Jaw Lesions Disease Clinical Features Radiographic Appearance Other Features - Acute osteomyelitis - Any age; mandible favored Little radiographic change early; after 1-2 weeks, a diffuse radiolucency appearsPain or paresthesia may be present; pus producing if due to Staphylococcus infection; uncommon in severe form; most frequently caused by extension of periapical infection - Chronic osteomyelitis - Any age; mandible favored Focal or diffuse; lucent with sclerotic foci described as moth-eaten pattern; focal sclerotic type: well-defined opacification; diffuse sclerotic type: diffuse opacification; Garré’s type: onionskin periosteum Usually asymptomatic but may be painful; most cases related to chronic inflammation in bone of dental origin; many cases not treated; nonvital teeth should be extracted or root canals filled; common; Garré’s type treated by endodontics or extraction of offending tooth O-68 Clinical Overview Malignancies of the Jaws Disease Clinical Features Radiographic Appearance Other Features - Osteosarcoma - Third and fourth decades; mandible or maxilla; juxtacortical subtype arises from periosteum Poorly defined radiolucency, often with spicules of opaque material; sunburst pattern may be seen; juxtacortical lesion appears as radiodense mass on periosteum Swelling, pain, and paresthesia are diagnostic features; patients may have vertical mobility of teeth and uniformly widened periodontal ligament space; prognosis fair to poor, good prognosis for juxtacortical lesions - Chondrosarcoma - Adulthood and old age; maxilla favored slightly Poorly defined, lucent to moderately opaqueSwelling, pain, or paresthesia may be present; prognosis fair to poor, better if in mandible; often misdiagnosed as benign cartilage lesion; rare - Burkitt’s lymphoma Children; mandible or maxilla - Diffuse radiolucency Malignancy of B lymphocytes linked to specific chromosome translocation. Frequent but not universal Epstein-Barr virus infection; pain, tooth mobility or paresthesia may be presenting symptom; prognosis fair; rare in United States Continued O-70 Clinical Overview Malignancies of the Jaws—cont’d Disease Clinical Features Radiographic Appearance Other Features - Ewing’s sarcoma - Children and young adults; mandible favored Diffuse radiolucency; poorly defined; periosteal onionskin reaction may be present; may be multilocular Swelling, pain, or paresthesia may be present; prognosis is poor; unknown cellular origin; specific translocation t(11;22) involving EWS-FLI1 genes; rare - Multiple myeloma - Adults; mandible favored Well-defined radiolucencies described as “punched-out” lesions; some lesions diffuse Swelling, pain, or numbness may be presenting complaint; Bence Jones protein in urine of a majority of patients; rare to have only jaw lesions; prognosis is poor; solitary lesions eventually become disseminated - Metastatic carcinoma - Adults; mandible favored; occasionally present as soft tissue masses Ill-defined, destructive radiolucency; may be multilocular; some tumors may have radiopaque foci (e.g., prostate, breast, lung) Pain or paresthesia common; origin is most likely from a malignancy of breast, kidney, lung, colon, prostate, or thyroid; uncommon O-72 Clinical Overview Metabolic and Genetic Diseases Disease Clinical Features Radiographic Appearance Other Features - Paget’s disease - Age over 40 years; maxilla favored; bilateral and symmetric; affects entire bone Diffuse radiolucent to radiopaque bone changes; opaque lesions described as cotton wool; hypercementosis, loss of lamina dura, obliteration of periodontal ligament space, and root resorption commonly be seen Patients develop pain, deafness, blindness, and headache caused by bone changes; initial complaint may be an ill-fitting denture; diastemas may develop; complications of hemorrhage early, infection and fracture late; serum alkaline phosphatase elevated; cause unknown but affects bone metabolism - Hyperparathyroidism - Any age; mandible favored Usually well-defined radiolucency(ies); may be multilocular; a minority of patients show loss of lamina dura Usually asymptomatic; microscopically identical to central giant cell granuloma; serum calcium level elevated; most caused by parathyroid adenoma; rare - Acromegaly - Adults (after closure of epiphyses); mandible; uniform, bilateral; coarse facial features Large jaw; splayed teeth Excess production of growth hormone after closure of epiphyses (condylar growth becomes active); prognathism, diastemas may appear; rare Continued O-74 Clinical Overview Metabolic and Genetic Diseases—cont’d Disease Clinical Features Radiographic Appearance Other Features - Infantile cortical hyperostosis - Infants; mandible and other bones of skeleton Cortical thickening/sclerosis Cause unknown; self-limited; treatment is supportive Phantom bone disease Young adults; mandible more than maxilla Gradual development of radiolucency of entire boneCause unknown; no treatment - Cherubism - Children; mandible favored; uniform, bilateral Bilateral multilocular radiolucenciesAutosomal-dominant inheritance pattern; mutation of SH3BP2 gene; cherub-like face; microscopy similar to that for central giant cell granuloma; process stabilizes after puberty; rare - Osteopetrosis - Infantile and adult forms; both jaws and skull involved Diffuse, homogeneous, and symmetric opacification; may cause arrested root development and delayed eruption Dominant forms are infantile, recessive (severe), and adult; intermediate form also recessive but milder presentation; results in inhibition of bone resorption; patients can develop anemia, blindness, and deafness; complications: include osteomyelitis and fracture; rare

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