CH 17

Chapter 17
Oral Pathology
Copyright 2003, Elsevier Science (USA).

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ISBN 0-7216-9770-4
Introduction
Pathology is the study of disease. Oral
pathology is the study of diseases in the oral
cavity.
Many systemic diseases as well as
infectious diseases have oral
manifestations.
Copyright 2003, Elsevier Science (USA). 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.
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.
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.
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.
Fig. 17-2 Leukoplakia.
Fig. 17-2
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.
Fig. 17-3 Lichen planus.
Fig. 17-3
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.
Types of Candidiasis
Pseudomembranous candidiasis
Thrush
Hyperplastic candidiasis
Atrophic candidiasis
Fig. 17-4 Erythematous candidiasis.
Fig. 17-4
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 blisterlike
sores inside the mouth and on the lips.
Minor RAU: Episodes fewer than 6 times a
year; lesions usually heal within 7 to 10 days.
Major RAU: Outbreaks of larger, deeper
ulcers that take longer to heal.
Fig. 17-7 Minor aphthous ulcer.
Fig. 17-7
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.
Fig. 17-8 Cellulitis.
Fig. 17-8
Conditions of the
Tongue
Glossitis
Glossitis is the general term used to

describe inflammation and changes in the
topography 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.
Fig. 17-9 Black hairy tongue.
Fig. 17-9
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.
Fig. 17-10 Geographic tongue.
Fig. 17-10
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.
Fig. 17-11 Fissured tongue.
Fig. 17-11
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.
Fig. 17-12 Iron deficiency. The tongue is devoid of filiform papillae.

Angular cheilitis was also present in this patient.
Fig. 17-12
Oral Cancer
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.
Fig. 17-13 Squamous cell carcinoma of the lower lip.
Fig. 17-13
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.
Fig. 17-14 Panoramic radiograph showing destruction of the mandible by

squamous cell carcinoma.
Fig. 17-14
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.
Fig. 17-15 Leukemia.
Fig. 17-15
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.
Fig. 17-16 A, Rough texture on the labial mucosa.
Fig. 17-16 A
Fig. 17-16 B, Rough surface on the anterior buccal mucosa.
Fig. 17-16 B
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.
Acquired Immunodeficiency Syndrome (AIDS)

Oral lesions are prominent features of AIDS
and 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.
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.
HIV-Associated Periodontitis
HIV-associated periodontis 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
Fig. 17-18, Atypical periodontal disease in a patient with HIV infection.
Fig. 17-18 A & B
HIV Cervical Lymphadenopathy
Enlargement of the cervical (neck) nodes.
Lymphadenopathy is frequently seen in

association with AIDS.
Fig. 17-19 HIV cervical lymphadenopathy.
Fig. 17-19
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.
Fig. 17-21 HIV lymphoma.
Fig. 17-21
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) in 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.
Fig. 17-22 Hairy leukoplakia.
Fig. 17-22
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

Kaposis sarcoma.
Kaposis sarcoma is one of the intraoral lesions

that is used to diagnose AIDS.
Fig. 17-23 Kaposis sarcoma in a patient with AIDS. A, Skin. B, Gingivae. (From
Ibsen O, PhelanJ: Oral pathology for the dental hygienist, ed 3, 2000, Saunders.)
Fig. 17-23
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.
Fig. 17-24 Herpes simplex on the hard palate of a patient with HIV
infection.
Fig. 17-24
Human Papilloma Viruses
Human papilloma viruses appear 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.
Fig. 17-25 Human papillomaavirus on the lip of a patient with AIDS.
Fig. 17-25
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.
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.
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.)
Fig. 17-27 Torus palatinus.
Fig. 17-27
Fig. 17-28 Torus mandibularis.
Fig. 17-28
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.
Fig. 17-29 Cleft lip.
Fig. 17-29
Fig. 17-30 Ankyloglossia.
Fig. 17-30
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 toothlike mass of enamel and
dentin within the pulp.
Fig. 17-31 Partial anodontia.
Fig. 17-31
Fig. 17-32 Radiograph showing two supernumery teeth in region of the

permanent premolars.
Fig. 17-32
Disturbances in Enamel Formation
Amelogenesis imperfecta is a hereditary

abnormality in which there are hypoplasiatype
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.
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.
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.
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.
Miscellaneous Disorders contd
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.
Fig. 17-39 Improper toothbrushing can cause abrasion.
Fig. 17-39
Fig. 17-40 A and B, Attrition of adult dentition.
Fig. 17-40
Fig. 17-41 Bruxism caused attrition of the mandibular anterior teeth.
Fig. 17-41
Fig. 17-42 A and B, Erosion caused by bulimia.
Fig. 17-42 A & B

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Chapter 17

Copyright 2003, Elsevier Science (USA).

Copyright 2003, Elsevier Science (USA). All rights reserved.

Terminology Used to Describe Oral Lesions

Lesion is a broad term for abnormal tissues in the

Determining the type of lesion in a disease is one of

Types of lesions of the oral mucosa are classified as

Copyright 2003, Elsevier Science (USA). All rights reserved.

Lesions Extending Below the Surface

Ulcer: A defect or break in continuity of the

Erosion of the soft tissue: A shallow defect in

Abscess: A localized collection of pus in a

Cyst: A closed sac or pouch that is lined with

Copyright 2003, Elsevier Science (USA). All rights reserved.

Lesions Extending Above the Surface

Blisters: Also known as vesicles, lesions

Pustule: Similar in appearance to a blister,

Hematoma: Also similar to a blister, but it

Plaque: Any patch or flat area that is

Copyright 2003, Elsevier Science (USA). All rights reserved.

Diseases of the Oral Soft

Copyright 2003, Elsevier Science (USA). All rights reserved.

Leukoplakia means white patch.

Lesions vary in appearance and texture

The cause is unknown but is commonly

Leukoplakia very often precedes the

Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17-2 Leukoplakia.

Copyright 2003, Elsevier Science (USA). All rights reserved.

A benign, chronic disease affecting the skin

Many factors have been implicated in lichen

On the oral mucosa, the patchy white

Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17-3 Lichen planus.

Copyright 2003, Elsevier Science (USA). All rights reserved.

A superficial infection caused by the yeastlike

Candidiasis does occur under conditions such

It can be the initial clinical manifestation for

Diaper rash, vaginitis, and thrush are also

Copyright 2003, Elsevier Science (USA). All rights reserved.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17-4 Erythematous candidiasis.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Aphthous ulcers are also known as aphthous

Recurrent aphthous ulcers (RAU) is a disease

Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17-7 Minor aphthous ulcer.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Inflammation spreads through the soft tissue or

Swelling develops rapidly, with a high fever.

The skin becomes very red, and there is severe

Cellulitis associated with oral infections is

Copyright 2003, Elsevier Science (USA). All rights reserved.

Fig. 17-8 Cellulitis.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Glossitis is the general term used to

Copyright 2003, Elsevier Science (USA). All rights reserved.

Black Hairy Tongue

Black hairy tongue may be caused by the

The filiform papillae are so greatly elongated

These elongated papillae become stained by

Copyright 2003, Elsevier Science (USA). All rights reserved.