(BQ) Part 2 book “The ADA practical guide to soft tissue oral disease” has contents: Differential diagnosis of common oral soft tissue lesions, guidelines for observation and/or referral of patients’ lesions, the art and science of biopsy and cytology, sample patient histories and discussion.
4 Differential Diagnosis of Common Oral Soft Tissue Lesions Following the initial comprehensive head and neck soft tissue examination (Chapter 1), the clinician can identify the lesion as arising in the soft tissue and provide its detailed description (Chapter 2), determine its appropriate category (e.g white lesion that rubs off, red lesion, and ulceration) as listed in Chapter 3, and then create a nonprioritized list of all possible soft tissue lesions that may produce a similar clinical picture The next step is to create a prioritized differential diagnosis list; the list should be rearranged with the most probable lesion ranked at the top and the least likely at the bottom The process of priority ranking can be complicated at times, so it behooves the clinician to be familiar with the signs and symptoms produced by a great many diseases and to possess statistical knowledge relative to the incidence of each disease entity The priority ranking is directly related to the relative incidence of the lesions if all other factors about the lesions are similar Thus, in developing a clinical differential diagnosis, the clinician first ranks the lesions in order of their relative frequency of occurrence and then modifies this order based on age, gender, race, and anatomic location A special case can exist in which two or more lesions are synchronously present If so, then seven possibilities must be considered: • Lesions A and B are completely unrelated: Lesions A and B are both present as a matter of chance • Lesions A and B are related: Lesion A and Lesion B are identical Lesion B is secondary to Lesion A Lesion A is secondary to Lesion B The ADA Practical Guide to Soft Tissue Oral Disease, Second Edition Michael A Kahn and J Michael Hall © 2018 by the American Dental Association Published 2018 by John Wiley & Sons, Inc 115 116 Diagnosis and Management Lesion A and Lesion B are both secondary to a third lesion, which may be occult Lesion A and Lesion B are manifestations of systemic disease Lesion A and Lesion B form part of a syndrome Once a prioritized ranking differential diagnosis list has been created, the clinician should recheck its credibility, particularly the top choices This entails further examination of the lesion, asking the patient additional questions, possibly ordering additional tests, and a final reevaluation of all gathered pertinent data The top choice or choices are referred to as the working or provisional diagnosis; in some instances, the first choice is overwhelmingly favored and becomes the singular working diagnosis The working diagnosis dictates the proper management of the lesion, including possible surgery The final diagnosis is usually provided by the pathologist who evaluates the biopsied tissue microscopically In some instances the microscopic appearance of the lesion is not diagnostic in its own right and must be correlated closely with the previously submitted or gathered information At times, an equivocal diagnosis remains, and the clinical findings during surgery must also be considered Diagnostic Tips and Pitfalls Acute Ulcers, Erosions, and Vesicles (Fig. 4.1) Traumatic ulcer Tip – Should heal in 7–10 days if the patient is immunocompetent; extremely common occurrence Pitfall – Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a very deep, slow‐healing traumatic ulcer that can take weeks to months to heal Also, factitial ulcers (self‐inflicted) may be repeatedly traumatized despite the patient’s denial Recurrent aphthous ulcer, minor type Tip – Occurs only on movable mucosa Pitfall – May appear identical to herpes simplex infection once the latter’s vesicle is ruptured Many systemic conditions also have oral aphthous‐like ulcerations Recurrent aphthous ulcer, major type Tip – Occurs only on movable mucosa Pitfall – Is not preceded by vesicle such as herpes simplex infection Primary herpes simplex infection Tip – Occurs anywhere in the mouth, on both movable and nonmovable mucosa (bound to bone, i.e hard palate and attached gingiva) In addition to painful ulcers the patient will also have fever, malaise, lymphadenopathy, and stomatitis, which always includes the gingiva Pitfall – Often misdiagnosed as acute necrotizing ulcerative gingivitis (ANUG) prior to the onset and recognition of vesicles Differential Diagnosis of Common Oral Soft Tissue Lesions Ulcer Shallow Aphthous ulcer, minor Deep Aphthous ulcer, major ANUG Ulcer/shallow erosion Multiple vesicles Shallow ulcerations Traumatic ulcer Herpes simplex infection Macules Heals in 7–10 days, if immunocompetent TUGSE lesions are deep, with delayed healing Primary Malaise, pain, fever, and inflamed tissues; occurs on all sites Recurrent Occurs on nonmovable mucosa only; no fever; inflamed areas are hot and raw Papule Deep ulcer Red, white Hot and raw Varicella (chicken pox) White, oral lesions precede skin rash Herpes zoster (shingles) Pain; unilateral distribution to midline; also occurs on skin Erosions/shallow ulcerations Vesicles Occurs on movable mucosa only, with red periphery and very painful Major type heals more slowly, with scarring ANUG begins at interdental papilla It is very painful, with severe fetid odor; occurs at multiple sites Allergic reaction Multiple patches 117 Ulcers Erythema multiforme Herpangina Necrotizing sialometaplasia Hemorrhagic, crusted lips; target lesions on skin Lesions are limited to the oropharynx Rapid onset, relatively painless Figure 4.1 Acute ulcerations, erosions, and vesicles (bullae) ANUG, acute necrotizing ulcerative gingivitis; TUGSE, traumatic ulcerative granuloma with stromal eosinophilia Recurrent herpes simplex infection Tip – A crop of intraoral ulcers that occurs only on nonmovable mucosa (bound to bone, i.e hard palate and attached gingiva); no other symptoms besides painful ulcers preceded by vesicles Pitfall – Mistaken for aphthous ulcer but preceded by a vesicle Unlike aphthous ulcers, herpes simplex ulcers not occur on movable mucosa ANUG Tip – Not a communicable disease Debridement results in rapid resolution Pitfall – Can become extensive and spread to oral mucosa not associated with the teeth (i.e acute necrotizing ulcerative mucositis (ANUM)) Allergic reaction Tip – Cannot be wiped off Pitfall – Mistaken for leukoplakia, erythroplakia, and lichen planus Erythema multiforme (EM) Tip – Acute, rapid, or explosive onset; lips with hemorrhagic crusts; can have “target” (bull’s‐eye appearing) skin lesions Pitfall – Not contagious; can become extensive; can be triggered by a drug reaction Herpangina Tip – Vesicles and subsequent not very painful ulcers are limited to the oropharynx including soft palate; often seen as an epidemic event in children Pitfall – Morphology mimics recurrent herpes, but there is limited involvement: only occurs on posterior movable mucosa 118 Diagnosis and Management 10 Varicella (chicken pox) Tip – White enanthem precedes cutaneous exanthem (rash); relatively painless Pitfall – Prevalence decreases with age; single occurrence (unlike herpes simplex) 11 Herpes zoster (shingles) Tip – Striking unilateral distribution up to the midline of both face and oral mucosa (when involved); painful Pitfall – At times can appear identical to recurrent herpes simplex infection of the oral mucosa 12 Necrotizing sialometaplasia Tip – Acute onset unlike malignancy, despite nonpainful deep ulceration (pain subsides when necrotic tissue sloughs out, leaving deep ulcer) with no overt history of trauma; usually occurs on the hard palate Pitfall – Mistaken for squamous cell carcinoma (clinically and histologically), which has chronic onset Squamous cell carcinoma is rare on hard palatal mucosa Chronic Vesicles, Bullae, Erosions, and Ulcers (Fig. 4.2) Erosive lichen planus Tip – Adjacent areas may exhibit white papules and striae; rare in children Pitfall – Desquamative gingivitis; allergic reaction Squamous cell carcinoma Tip – No history of trauma; nonhealing lesion with indurated margins particularly in high‐risk anatomical sites; often preceded by erythroplakia, to a lesser degree leukoplakia, and/or combination thereof; most often occurs on lateral tongue and floor of the mouth Pitfall – Biopsy required for diagnosis if no improvement with assumption that it is a chronic infection; early metastasis Vesicles (bullae)/erosions/ shallow ulcerations Pemphigus Oral lesions precede skin lesions; occurs most often on gingiva and oropharynx Mucous membrane pemphigoid Gingiva is the most common site Rule out eye, and genital involvement Erosions/shallow ulcerations Deep ulcers Erosive lichen planus Periphery can show white papules, plaques, and striae Squamous cell carcinoma No history of trauma TUGSE Trauma; tongue is the most common site; takes months to heal Factitial ulcer Ulcer is trauma induced, but trauma is denied by the patient Figure 4.2 Chronic ulcers TUGSE, traumatic ulcerative granuloma with stromal eosinophilia Differential Diagnosis of Common Oral Soft Tissue Lesions 119 Mucous membrane pemphigoid Tip – Rule out ocular or genital involvement; gingiva is the most common site; antibody deposition at the basement membrane zone Pitfall – Ocular involvement can lead to scarring and eventual blindness Pemphigus vulgaris Tip – Oral lesions (particularly in the posterior area) usually precede skin involvement; blood crusted lips; antibody to desmosomes Pitfall – Clinical similarity to EM but does not have acute onset like EM Traumatic ulcerative granuloma with stroma eosinophilia (TUGSE; t raumatic granuloma; eosinophilic ulcer) Tip – Lateral tongue is the most common site Biopsy/surgery may trigger resolution Pitfall – May mimic deep fungal infections and squamous cell carcinoma, so biopsy should be performed for diagnosis TUGSE can occur on other oral mucosal sites besides the tongue Factitial ulcer (self‐induced) Tip – Lacks induration and ragged outline Trauma is denied by the patient, but the presence of ulcer is unexplained Pitfall – Biopsy without further delay if ulcer persists after weeks to rule out malignancy Lumps, Bumps, and Swellings (Papules, Nodules, Tumors, Vesicles, Bullae) (Fig. 4.3) Mucocele Tip – If it develops fibrosis, it can feel firm (papule, nodule) Mucocele is usually blue with cyclical growth and regression Pitfall – It will recur if mucin and associated damaged minor salivary gland lobule are not removed Fibroma Tip – History of trauma; smooth surface, normal color, and asymptomatic; can begin as a pyogenic granuloma Hard palate growth beneath ill‐fitting maxillary denture base (“leaf fibroma”) is a special type Pitfall – Benign mesenchymal tumors can look identical to fibroma, so a biopsy is necessary for a diagnosis Also, fibroma can be mistaken for a fibrosed parulis or mucocele Salivary gland tumors Tip – Firm; cannot tell clinically if lesion is benign or malignant, but recent growth spurt or pain and loss of mobility or sensation are worrisome signs Unlike a mucocele, a salivary gland tumor does not exhibit cyclical growth and regression Pitfall – Lack of pain does not always indicate that tumor is benign Sialolith Tip – Floor of the mouth usually; if palpable, feels very hard Sialolith often can be seen on a radiograph Pitfall – Patient may report tenderness, pain, or fullness at mealtime 120 Diagnosis and Management Pustule Parulis Yellow; odontogenic or periodontal infection-related Vesicle (Bulla) Mucocele Pink/blue; >lower lip; cycle of increase/ decrease in size Papule/nodule/tumor Verruca Vulgaris Benign Malignant Fibroma Firm, smooth, pink Papilloma White/ pink rough surface Salivary gland tumor Sialolith Hard RLH Pink/yellow, at Waldeyer’s ring Inflammatory papillary hyperplasia Movable, no pain Fixed; pain/dysesthesia, growth spurt Epulis fissuratum Ill-fitting denture; vestibule Pyogenic granuloma Red, bleeds easily; >gingiva Peripheral giant cell granuloma Only gingiva Peripheral ossifying fibroma Only gingiva Lymphoma, non-Hodgkin’s extranodal Boggy; >junction of h/s palate Benign mesenchymal neoplasms (e.g nerve, fat, muscle, and vascular) Hematoma Generalized gingival enlargement Submucosal nodules Acute trauma; blanches Hereditary, drug-induced, or systemic disease >Denture-related; often superimposed yeast Figure 4.3 Lumps, bumps, and swellings RLH, reactive lymphoid hyperplasia; h/s, hard and soft Parulis Tip – Associated with a nonvital tooth or significant periodontal bone loss If an adjacent infection becomes chronic, it can develop fibrosis and feel firm (papule, nodule) Pitfall – During the quiescent phase parulis can become fibrosed and appear to be a fibroma Epulis fissuratum Tip – Associated with ill‐fitting denture flange on the vestibule, except for the variant that occurs on the hard palate (leaf fibroma) Pitfall – Following removal, remake denture to avoid recurrence of lesion Pyogenic granuloma Tip – Painless; bleeds easily Pitfall – Remove both the lesion and the irritant that triggers its reactive growth Rule out malignancy such as extranodal lymphoma or Kaposi’s sarcoma Peripheral ossifying fibroma Tip – Confined to attached gingiva; may be red but is not as easily hemorrhagic as pyogenic granuloma Pitfall – Recurs if not excised down to the periosteum and if the reactive trigger factor is not found and eliminated Recurrence is common Peripheral giant cell granuloma Tip – Confined to attached gingiva; often has a purple hue due to the amount of hemosiderin deposited Differential Diagnosis of Common Oral Soft Tissue Lesions 121 Pitfall – Recurs if not excised to the periosteum and if the reactive trigger factor is not found and eliminated Cupping of the underlying bone can suggest an intrabony defect Also, a type that arises in the jaw, central giant cell granuloma, can perforate the cortical plate and involve the overlying soft tissues 10 Lymphoma (non‐Hodgkin’s) Tip – Boggy, edematous consistency; bluish Occurs most often at the junction of hard and soft palate Pitfall – Can resemble salivary gland tumor but more diffuse On the gingiva it can mimic pyogenic granuloma 11 Reactive lymphoid hyperplasia (accessory lymphoid aggregates) Tip – Usually in the area of Waldeyer’s ring (oropharynx) Pitfall – Progressive enlargement is not typical of this entity 12 Generalized gingival enlargement Tip – Morphology and treatment depend on the cause Pitfall – Rule out systemic or drug‐related association (clinical correlation) Biopsy is needed 13 Benign mesenchymal neoplasms Tip – Arise from endogenous structures in the lamina propria All benign mesenchymal neoplasms are firm (nerve, fat, muscle, connective tissue) except vascular (hemangioma) or lymphatic (lymphangioma) 14 Hematoma Tip – Usually history of trauma Initially lesion is flat and then becomes elevated; does not blanch Pitfall – Large areas of extravasated blood can be due to atraumatic systemic conditions such as leukemia 15 Squamous papilloma Tip – Cauliflower‐like surface Pitfall – If proliferative, rule out condyloma (venereal wart) or verrucous carcinoma 16 Verruca vulgaris Tip – White, very rough, spiky surface Pitfall – If proliferative, rule out condyloma (venereal wart) or verrucous carcinoma 17 Inflammatory papillary hyperplasia Tip – Often seen in conjunction with chronic erythematous candidiasis (denture sore mouth) due to poor oral hygiene and ill‐fitting denture Pitfall – Does not have to be associated with removable denture prosthesis White Lesions (Fig. 4.4) Dorsal white coating of tongue Tip – Brush tongue daily Acute pseudomembranous candidiasis Tip – Peels off easily, leaving a red raw base Hypertrophic candidiasis Tip – Can noninvasive cytology scraping and stain for fungal organisms Morsicatio (nibbling habit) Tip – Tissue tags are visible and can be removed with difficulty 122 Diagnosis and Management Alveolar ridge keratosis Papules Reticular lichen planus Plaque Leukoplakia Leukoedema Linea alba White coated tongue Hyperplastic candidiasis Hypertrophic lichen planus Not wipeable Plaque White Wipeable Macule Chemical burn – acute Plaque/scale Actinic cheilitis/keratosis Morsicatio – cheek, tongue, and lip nibbling Plaque Macule Scale Acute pseudomembranous candidiasis Thermal burn Chemical burn Actinic cheilitis/keratosis Figure 4.4 White lesions Thermal burn Pitfall – Can mistake a malignancy for a thermal burn Chemical burn Tip – Peels off with difficulty, leaving a red raw base Linea alba Tip – Occurs at the occlusal plane Leukoedema Tip – If the mucosa is stretched, the lesion tends to dissipate or disappear Leukoplakia Tip – Fails to resolve after 2 weeks despite attempts to eliminate it Pitfall – No correlation between the size of the lesion and the presence or absence of dysplasia 10 Actinic cheilitis Tip – Splotchy color and blurring of vermilion border with skin 11 Reticular lichen planus Tip – Bilateral and symmetrical in clinical presentation; asymptomatic; rare in children Pitfall – Lichenoid allergic reactions look identical to reticular lichen planus; clinical correlation is necessary 12 Hyperplastic lichen planus Tip – Individual white papules and striae at the borders of the plaque 13 Alveolar ridge keratosis Pitfall – Can be mistaken for leukoplakia Red Lesions (Fig. 4.5) Median rhomboid glossitis Tip – Midline dorsum just anterior to circumvallate papilla; flat or raised Differential Diagnosis of Common Oral Soft Tissue Lesions Red 123 Macule Chronic erythematous candidiasis Macule/flat Geographic tongue Macule/fissure/scale Angular cheilitis Macule/patch/plaque Erythroplakia Macule/vesicle/bulla Extravasated blood/hematoma Hemangioma Macule/flat/papule/nodule Median rhomboid glossitis Papule Telangiectasia Tumor Plasma cell gingivitis Erosion/ulceration Allergic reaction Figure 4.5 Red lesions Angular cheilitis Tip – Nonresolving Chronic erythematous candidiasis Tip – Outline matches the denture base Pitfall – Can appear similar to an allergic reaction to a denture’s acrylic base Geographic tongue Tip – Can lack a white border Pitfall – May not move around and change shape Erythroplakia Tip – Nonwipeable Hemangioma Tip – Blanches; can be reddish blue Extravasated blood, hematoma Tip – Does not blanch when compressed; trauma history Pitfall – Not developmental like hemangioma Telangiectasia Tip – Blanches when compressed Plasma cell gingivitis Tip – Bright red, diffuse distribution on attached and alveolar mucosa 10 Allergic reactions Tip – Cinnamon flavoring is the most common oral allergen Red‐and‐White Lesions (Fig. 4.6) Geographic tongue Tip – Can occur at other sites, including alveolar mucosa, palate, floor of the mouth, and vestibule Pitfall – Can be confused with ulcer Chronic multifocal candidiasis Tip – Usually on the anterior buccal mucosa Nicotine stomatitis Tip – Smoking tobacco and other heat‐induced lesion Red dots are inflamed minor salivary glands 124 Diagnosis and Management Macule/flat Macule (red) and plaque (white) Red and white Geographic tongue Chronic multifocal candidiasis Nicotine stomatitis Macule/erosion Erosive lichen planus Macule/vesicle/erosion/ulcer (red) and plaque/patch (white) Allergic reaction Plaque Erythroleukoplakia Papule/plaque Atrophic lichen planus Figure 4.6 Red‐and‐white lesions Erosive lichen planus Tip – Painful; bilateral and symmetrical distribution Atrophic lichen planus Tip – Bilateral and symmetrical distribution Erythroleukoplakia Tip – More likely to exhibit dysplasia in the red component Pitfall – Can be confused with thermal burn but does not heal Allergic reactions Tip – Often bilateral and symmetrical distribution Pitfall – Can appear similar to pemphigoid, pemphigus, erosive lichen planus, lupus erythematosus, and aphthous ulcers If not ulcerated, can appear similar to chronic erythematous candidiasis Yellow Lesions (Fig. 4.7) Fordyce granules Tip – Bilateral and symmetrical distribution Fordyce granules are more common in adults than in children (androgenic hormones stimulate sebaceous gland growth) Pitfall – Not to be mistaken for an infection If Fordyce granules become hyperplastic, they can form keratin‐filled pseudocyst Parulis and abscess Tip – Sign of nearby infection, particularly tooth related Radiographic placement of gutta‐percha point into the opening of fistula can help localize necrotic pulp of the tooth Incision and drainage by procedure or by gutta‐ percha can relieve pain of the offending tooth Pitfall – Infection can disseminate through bloodstream, resulting in fever, lymphadenopathy, and malaise Accessory lymphoid aggregates Tip – Small and nontender Pitfall – Extranodal lymphomas may mimic the accessory lymphoid a ggregates; can be pink if lymphoid tissue is deeper Answers to End‐of‐Chapter Questions 249 Answer A is incorrect Primary oral malignant melanoma is almost always seen on keratinized masticatory mucosa (i.e hard palate and attached gingiva) The amalgam tattoo is iatrogenic in nature and, therefore, is most often seen on the alveolar mucosa or attached gingiva but can occur anywhere within the oral cavity Answer B is incorrect Primary oral malignant melanoma is almost always seen on keratinized masticatory mucosa (i.e hard palate and attached gingiva) The labial mucosa is the most common oral site for melanotic macule Answer C is correct The hard palate is the most common site for the occurrence of primary oral malignant melanoma as well as melanocytic nevi They can form anywhere but the hard palate followed by the attached gingiva is the most common intraoral sites Answer D is incorrect Primary oral malignant melanoma is most common on the nonmovable, keratinized mucosa of the hard palate Answer A is incorrect Recurrent aphthous stomatitis in an immunocompetent patient is seen on oral tissues not bound to bone (i.e movable) Answer B is incorrect The hard palate is the most common site for the formation of an intraoral recurrent herpes simplex infection, which in an immunocompetent patient typically only arises on tissue attached to bone (i.e. nonmovable) Answer C is correct Recurrent aphthous stomatitis, in an immunocompetent patient, occurs exclusively on movable oral mucosa (i.e tissue not bound to bone) Therefore, in addition to the buccal and labial mucosae, the tongue, floor of the mouth, alveolar mucosa, oropharyngeal soft palate, and tonsillar pillars areas are frequent sites of occurrence Answer D is incorrect Recurrent aphthous stomatitis in an immunocompetent patient is seen on oral tissues not bound to bone, rather than bound to bone tissue such as attached gingiva Occasionally, it can initially form in movable tissue areas such as the vestibular alveolar mucosa and upon enlargement extend onto the attached gingiva Answer A is correct Herpangina is a self‐limited enteroviral disease of the oropharynx usually seen in school‐age children Usually treatment is only supportive (e.g antipyretics and analgesics) Answer B is incorrect Erythema multiforme is not caused by an infectious agent and results in severely painful, marked acute‐onset oral ulcerations Answer C is incorrect Primary oral herpes infections are usually numerous acute‐onset vesicles and upon rupture, subsequent ulcerations that are multifocal and painful throughout the oral cavity Answer D is incorrect Herpes zoster (“shingles”) is an extremely painful reactivation of the varicella‐zoster virus that characteristically appears unilaterally demarcated by an abrupt margin at the midline Answer A is incorrect The tongue is not a preferred site for the chronic vesiculoerosive (ulcerative) lesions of mucous membrane pemphigoid and this disease does not typically appear as a solitary lesion 250 Answers to End‐of‐Chapter Questions Answer B is incorrect The vesicles and subsequent ulcers of pemphigus vulgaris can form anywhere within the oral cavity and is chronic and progressive Lateral tongue involvement will be accompanied by lesions elsewhere including possible preceding or proceeding skin involvement Answer C is correct A chronic, persistent ulcer on the posterior lateral tongue should always be investigated for the possibility of malignancy Following the lateral or ventral surfaces of the tongue the most common oral sites for the initial involvement of squamous cell carcinoma are the floor of the mouth and soft palate, respectively Answer D is incorrect Erosive lichen planus is a chronic mucocutaneous condition with oral involvement, usually multifocal and bilateral, with periods of remission and exacerbation 10 Answer A is incorrect Mucosal epithelium is exclusively involved with mucous membrane pemphigoid including oral, genital, and ocular (i.e conjunctiva) Answer B is correct When the conjunctival mucosa of the eye is involved by mucous membrane pemphigoid’s ulcerations their subsequent scarring resolution can ultimately lead to blindness Therefore, a diagnosis of oral mucous membrane pemphigoid should be followed by an evaluation of the ocular mucosa by an ophthalmologist Answer C is incorrect Paraneoplastic pemphigus vulgaris has been associated with an increased risk of lymphoma development, but not mucous membrane pemphigoid Answer D is incorrect Lymphocytic infiltration and loss of intestinal villi are characteristics of celiac disease, but not mucous membrane pemphigoid 11 Answer A is incorrect A varicella infection would be chicken pox with widespread lesions, especially on the skin, that would begin as vesicles The painful reactivation viral infection, herpes zoster (shingles), would also begin as vesicles that transform into shallow ulcers Answer B is incorrect A superficial burn would not result in the deeply cratered ulceration usually seen with necrotizing sialometaplasia Answer C is incorrect The potential presence of epithelial dysplasia is always a primary concern with an unexplained, nonhealing ulcer, but necrotizing sialometaplasia is not a dysplastic process Answer D is correct Necrotizing sialometaplasia is thought to be caused by a brief, transitory ischemic event that compromises local vasculature The end result is a large area of coagulative necrosis followed by deep ulceration that subsequently heals on its own Sometimes the occurrence can be associated with a known trauma such as a palatal anesthetic injection with vasoconstrictor; however, other times the cause is obscure 12 Answer A is incorrect A fibroma can arise on the gingiva but it will be pink and will not be hemorrhagic Answer B is correct A pyogenic granuloma consists of vascular granulation tissue that forms in response to a local irritant It occurs more frequently in pregnant women but the use of the term “pregnancy tumor” is discouraged Answers to End‐of‐Chapter Questions 251 Answer C is incorrect An epulis fissuratum is associated with an ill‐fitting denture and arises secondary to chronic trauma It will be pink and does not bleed upon manipulation Answer D is incorrect A parulis is most often seen on the gingiva associated with an endodontic or periodontal abscess It appears as a yellow pustule and is not hemorrhagic 13 Answer A is incorrect Although Candida albicans is a normal oral cavity inhabitant, its colonization resulting in white plaques would not be a normal result Answer B is incorrect An inflammatory exudate would be more localized and the result of an infection Answer C is incorrect Overgrowth of the filiform papillae, hairy tongue, could result in food retention, but it would have a recognizable raised clinical appearance with secondary staining Answer D is correct The filiform papillae are heavily keratinized and their normal desquamation gives the tongue a white appearance The appearance can vary based on types of food ingested and masticatory function that can rub away the sloughed cells 14 Answer A is incorrect The white “cottage cheese” appearing surface of acute pseudomembranous type can be wiped away leaving a pink or red mucosal base Answer B is correct Chronic hyperplastic type clinically presents as a nonspecific leukoplakia; therefore, it is often biopsied for definitive diagnosis to rule out the presence of dysplasia or carcinoma Answer C is incorrect Acute atrophic type is usually painful and typically follows a course of broad‐spectrum antibiotic It results in the diffuse loss of filiform papillae of the dorsal tongue resulting in a reddened, “bald” appearing tongue Answer D is incorrect Chronic atrophic (denture stomatitis) type is red and is seen beneath a denture that is often worn 24 h/day It must be distinguished from a rare allergic reaction to the denture base material 15 Answer A is correct Hairy leukoplakia is a non‐wipeable white plaque that requires biopsy with subsequent special stains to detect herpetic family viral particles necessary for its diagnosis and to also rule out the presence of epithelial dysplasia Answer B is incorrect Linea alba is a normal finding at the occlusal plane of the buccal mucosa and is clinically diagnosable A similar pattern can be seen on the lateral tongue and must be clinically confirmed or a tissue biopsy may be necessary Answer C is incorrect Morsicatio linguarum is a habitual nibbling of the tongue resulting in variably thickened hyperkeratosis Unlike hairy leukoplakia, its surface shreds of tissue are wipeable If the mild traumatic habit can be controlled then the lesion should be resolved Answer D is incorrect Leukoedema appears as a diffuse, filmy white area, typically seen bilaterally and symmetrically on the buccal mucosa that tends to dissipate or disappear when the mucosa is stretched 252 Answers to End‐of‐Chapter Questions 16 Answer A is incorrect Actinic cheilitis is caused by ultraviolet radiation exposure from the sun, not the low dosage of dental X‐ray exposure Answer B is incorrect Actinic cheilitis is most common in older men It is a cumulative result of many years of chronic sun exposure Answer C is incorrect Due to normal facial profile anatomy, the chronic ultraviolet radiation of the sun strikes the lower lip vermilion much more commonly than the upper lip vermilion Answer D is correct Actinic cheilitis is considered a potentially malignant disorder Patient counseling to reduce sun exposure and tissue biopsy of any nonhealing ulceration is recommended 17 Answer A is incorrect Oral lichen planus involving the alveolar mucosa will typically exhibit classic white Wickham’s striae with possible concomitant erosions Answer B is incorrect The buccal mucosa is the most common site for oral lichen planus and usually exhibits bilateral and symmetrically distributed classic white Wickham’s striae Answer C is correct The hyperkeratotic filiform papillae of the dorsal tongue typically result in the formation of white plaques when affected by oral lichen planus Answer D is incorrect The hard palate involved with oral lichen planus exhibits classic white Wickham’s striae similar to those seen on the buccal and alveolar mucosae Chapter 4 Answer A is correct Both primary herpes simplex infections and necrotizing ulcerative gingivitis cause significant swelling and painful ulcerations of the attached gingiva; however, only primary herpes infection demonstrates acute onset with preceding vesicles that subsequently rupture into small shallow ulcerations Necrotizing ulcerative gingivitis has more extensive ulcers that result in loss of the interdental papillae Answer B is incorrect The acute onset shallow ulcers of aphthous stomatitis are not preceded by vesicles and not occur on the attached gingiva in immunocompetent patients Answer C is incorrect Erythema multiforme has an explosive acute onset with development of painful ulcers, without preceding vesicles, on the lips and movable oral mucosa but does not typically involve the nonmovable mucosa (i.e attached gingiva or hard palate) Answer D is incorrect Oral pemphigus vulgaris can eventually appear clinically similar to erythema multiforme; however, it occurs in a significantly older age population Answer A is incorrect Both of these conditions cause painful erosions Answer B is incorrect Both of these conditions can be seen throughout the oral cavity Answers to End‐of‐Chapter Questions 253 Answer C is correct Pemphigus vulgaris is a slow‐onset, chronic, and progressive disease process, while erythema multiforme is an acute condition often with an explosive onset over just several hours Answer D is incorrect Both of these conditions have cutaneous involvement Answer A is incorrect Edema would result in a soft rebounding sensation when palpated and, if superficial enough, a translucent blue color Answer B is incorrect Granulation tissue will usually be seen as bright red Answer C is incorrect A foreign body granuloma is not associated with the peripheral giant cell granuloma and exhibits granulomas A pyogenic granuloma lacks a granuloma and, therefore, its name is a misnomer Answer D is correct The peripheral giant cell granuloma is a very vascular lesion due to an abundance of granulation tissue The breakdown of red blood cells’ hemoglobin (red) and their hemosiderin pigment (golden brown) results in a purplish hue Answer A is incorrect The pyogenic granuloma is not associated with a purulent exudate and thus lacks pustule formation; it does have the morphology of a papule or nodule with variable firmness Answer B is correct When acute inflammation at the apex of a nonvital tooth drains through a fistula to the surface mucosa, the resulting fluctuant parulis, morphologically a pustule, can collect and drain purulent exudate If the inflammatory disease process becomes chronic and quiescent then the pustule can become more papular (nodular) in morphology due to increased fibrosis and resultant firmness Answer C is incorrect Lymphoid aggregates are only noticeable as papules or nodules following inflammatory stimulation; they not change their morphological form Answer D is incorrect The peripheral giant cell granuloma has the morphology of a papule or nodule; it is not associated with an acute inflammatory process that leads to purulent exudate formation within a pustule Chapter 5 Answer A is incorrect Five days is an insufficient time to allow a traumatic‐induced reactive lesion (e.g friction and chemical thermal burn) or an immunologic‐ based disease process (e.g aphthous stomatitis, allergic reaction) to exhibit at least early signs of clinical healing or resolution Therefore, this time interval could lead to an unnecessary tissue biopsy Answer B is correct A maximum of weeks is an adequate time for an ulceration, erythroplakia, or leukoplakia to either respond to clinical attempts to resolve or to, at least, begin to spontaneously exhibit signs of complete resolution Unresolved lesions of this type, especially in known high‐risk areas to undergo malignant transformation, should be biopsied Answer C is incorrect There is no present means to predict how long it will take for a biopsy‐proven dysplastic lesion to become malignant, if ever It is known that most harmless ulcerative, leukoplakic, or erythroplakic lesions will, at a 254 Answers to End‐of‐Chapter Questions minimum, begin to resolve within weeks of discovery if their suspected cause is eliminated due to the oral cavity’s rapid e pithelial turnover rate A documented attempt should be made to see the patient no later than in 2 weeks following the lesion’s initial documentation Answer D is incorrect Following a non‐resolving suspicious lesion, for months, especially at a high‐risk site for malignant transformation, is placing the patient at risk for a more advanced, undiagnosed serious disease Answer A is incorrect The general dentist is responsible for providing a comprehensive oral soft tissue head and neck examination If a lesion is detected, then the dentist should schedule a treatment recommendation with follow‐up or refer to a specialist Answer B is incorrect An oral surgeon will often be the person performing the tissue biopsy but is not who should be ultimately responsible for deciding whether to perform it or not Answer C is incorrect The primary care physician can be source of patient guidance and referral but is not likely to be involved with the decision to perform a tissue biopsy Answer D is correct Patient autonomy dictates that treatment is guided by the consent of an adult patient Treatment cannot be done without documented consent of an adult; minors, however, may have treatment without their consent It is the responsibility of all health‐care providers to give complete and accurate information, so patient informed consent can be given and acknowledged Answer A is incorrect The hard palate is the most common site for oral melanoma; however, it is also the most common site for melanocytic nevus and some drug‐related pigmentation Although buccal mucosa pigmentation is not as clinically suspicious for melanoma as the hard palate, the anatomic site is not an accurate way to differentiate them Answer B is correct Tissue biopsy is the most accurate way to achieve an accurate diagnosis If the clinical history (e.g medications, amalgam tattoo) does not allow a diagnosis, an unexplained oral pigmentation should be biopsied unless the surgical procedure would endanger the safety or health of the patient, or if the patient refuses the procedure The refusal should be documented in the patient’s chart Answer C is incorrect Lateral spread of pigmentation over time can be an ominous clinical sign for oral melanoma but a similar pattern can be seen with certain medications, Addison’s disease, and other rare benign pigmentations (e.g oral melanoacanthoma) Answer D is incorrect Most oral melanomas and melanocytic nevi begin as macules that become elevated as the connective tissue (lamina propria) becomes involved over a variable amount of time Answer A is incorrect A diagnosis of epithelial dysplasia, especially in the high‐risk sites of lateral/ventral tongue, floor of the mouth, and the soft palate, should be excised (total removal) immediately These lesions have the potential to become invasive squamous cell carcinoma and a 6‐month interval does not account for the present inability to predict when or if malignant transformation will occur Answers to End‐of‐Chapter Questions 255 Answer B is incorrect Narrowband imaging is not a valid and reliable monitoring test to determine which dysplastic lesions will become a higher grade, invasive, or remain static Answer C is incorrect Cytology sampling only harvests disaggregated cells of the epithelium and therefore is not reliable for determining if a lesion has become invasive (i.e breached the stratified squamous epithelium’s basement membrane zone) Answer D is correct Excisional biopsy (total removal) with periodic follow‐up is recommended The patient should be informed to alert the clinician if there is any change in the biopsied area prior to the next scheduled observation appointment Suggested documentation includes written description of the lesion with supportive clinical photographs Counseling the patient to abstain from traditional risk factors such as tobacco use and excessive beverage alcohol consumption is also appropriate Chapter 6 Answer A is incorrect Oral cytology samples only gather epithelial cells of the oral mucosa Clinically visible and suspicious pigmentations, such as an amalgam tattoo, which are located in the lamina propria, are, therefore, not sampled with a proper brush cytology technique Answer B is correct A brush cytology specimen is composed of many disaggregated cells spread over an area on the microscope slide; the tissue’s architecture is not intact Judgment of epithelial dysplasia’s presence and grading requires not only full thickness of the epithelium, as obtained with some cytology brushes and tissue biopsy, but also architecturally intact tissue layers Answer C is incorrect For screening purposes an adequate sample of cells from all epithelial levels can be harvested if the procedure is performed correctly Answer D is incorrect This specific brush cytology technique has earned the ADA Seal of Acceptance and, therefore, has been deemed safe and demonstrated efficacy according to requirements developed by the ADA Council on Scientific Affairs Answer A is incorrect Water will not fix the tissue but instead cause tissue necrosis and significant artefactual changes that will render the tissue unusable for microscopic diagnosis Answer B is incorrect Saline will not fix the tissue but instead cause tissue necrosis and significant artefactual changes that will render the tissue unusable for microscopic diagnosis Answer C is incorrect Michel’s solution will not fix the tissue, but instead is used for preservation of tissue during its transport from the clinician’s office to the specimen‐processing laboratory In oral pathology it is most often used for direct immunofluorescence testing and supportive diagnosis of suspected conditions such as pemphigoid and pemphigus 256 Answers to End‐of‐Chapter Questions Answer D is correct While some artefactual changes will occur with the use of alcohol, it will fix the tissue to a sufficient degree to allow microscopic diagnosis Answer A is correct Slight pinpoint bleeding at the brushed cytology site indicates a successful harvest of all epithelial cell layers, including the deep basal layer, as well as the subjacent basement membrane zone since the connective tissue (lamina propria), but not the overlying epithelium, possesses blood vessels A lack of pinpoint bleeding at the brushed cytology site is a likely indication that the harvested sample includes only surface keratin and more superficial layers of epithelial cells Answer B is incorrect The sensation of pain or discomfort is a very subjective symptom and does not indicate that sufficient pressure and rotation of the collection brush was employed to obtain all epithelial cell layers Answer C is incorrect When pushing on the collection brush to harvest cells the tissue is likely to blanch; however, that does not ensure obtaining a sample with the lowest basilar and parabasilar epithelial cell layers Answer D is incorrect Vesicle formation upon lateral pressure to tissue (i.e Nikolsky sign) can be seen with some blistering‐forming diseases such as mucous membrane pemphigoid; however, brush cytology sampling is not helpful for the diagnosis of these conditions and warrants a tissue biopsy be performed instead Answer A is incorrect For some morphology, such as an ulcer, the center of the lesion will lack surface epithelium and, therefore, nonspecific reactive granulation tissue may be the only tissue obtained Answer B is incorrect A tissue biopsy specimen should include the full t hickness of surface epithelium and enough subjacent connective tissue (lamina propria) to see any pathologic condition that exists; therefore, about a 4 mm‐ deep thickness is desired Some red blood cells will be present on the processed tissue microscopic slide, but they will not interfere with the diagnostic process Answer C is correct The inclusion of adjacent normal tissue besides lesion tissue will help provide the oral pathologist perspective to the specimen, allowing evaluation of the disease process at its interface with the uninvolved tissue Answer D is incorrect Although white areas of lesions, particularly erythroleukoplakias, are less likely to be dysplastic than red areas, all areas of lesions that are long‐standing and cannot be explained by clinical circumstances or attempted clinician intervention should be biopsied Answer A is correct A properly performed tissue biopsy will give cellular confirmation of the disease process Generally speaking, a scalpel biopsy is preferred over a punch biopsy Answer B is incorrect Cytology can sometimes provide some diagnostic clues; however, it is a screening procedure and not diagnostic with the exception of active herpes simplex infections and the presence of spores and hyphae of Candida spp Answers to End‐of‐Chapter Questions 257 Answer C is incorrect A culture will identify pathogenic organisms that are present but it will not provide any details about the cellular disease process Lesions that are suspected to be the result of an infection, particularly bacterial, are often cultured at the time of biopsy Answer D is incorrect In‐situ hybridization is an adjunctive molecular biology test done on a biopsy specimen to look for foreign DNA, such as that seen with some viruses that cause neoplasia (e.g HPV type 16‐associated oropharyngeal squamous cell carcinoma) Index Note: Page numbers in italics refer to figures and photos Abscess, 75, 101, 124, 125 Acanthosis, 30 Accessory lymphoid aggregate (reactive, lymphoid hyperplasia), 75, 76, 77, 120, 121, 124, 125 Acquired melanocytic nevus, 69–70, 70, 126, 127 Actinic cheilitis (cheilosis), 45, 46, 122, 122 Acute pseudomembranous candidiasis, 37, 38, 121, 122 Acyclovir, 236–237 Addisonian pigmentation, 74 Adenoid cystic carcinoma, 68, 98, 100 AIDS medications, pigmentation related to, 74 Allday dry mouth spray, 241 Allergic reactions, 53, 53, 62, 63, 84, 85, 85, 86, 117, 117, 123, 124 Alprazolam, 239, 241 Alveolar ridge keratosis, 48, 48, 122, 122 Amalgam tattoo, 63, 65, 71, 125, 126, 127, 127, 132, 138 American Academy of Oral and Maxillofacial Pathology (AAOMP), 140, 144 American Association of Endodontists, 140 American Association of Oral and Maxillofacial Surgeons, 140 Amitriptyline, 239, 241 Amlexanox oral paste, 235 Anatomical site of lesions, 24–25 Anesthetics, topical, 227–228 Angular cheilitis (perleche), 55–56, 56, 123, 123 Antianxiety agents, 239 Antifungals, 228–230 Antihistamine agents, 226–227 Antimicrobials, 226 Antivirals, 236–238 Antixerostomics, 239–242 ANUG See necrotizing ulcerative gingivitis Aphthous ulcers, 78, 80, 116, 117 Aquoral artificial saliva, 240 Aspirin burn (aspirin burn), 39, 41–42, 42, 122, 122 Azathioprine, 235 Behcet’s disease, 81 Benign mesenchymal neoplasms, 106–107, 108, 120, 121 Benign migratory glossitis, 49–50, 49, 56, 57, 123, 123, 124 Benign nerve sheath tumor, 108 Benzocaine, 227, 228 Betamethasone dipropionate, 231, 232 Betamethasone valerate ointment, 231, 232 Biochromes, 29 Biopsies decision‐making related to, 130–131 incisional and excisional, 141, 142 The ADA Practical Guide to Soft Tissue Oral Disease, Second Edition Michael A Kahn and J Michael Hall © 2018 by the American Dental Association Published 2018 by John Wiley & Sons, Inc 259 260 Index Biopsies (cont’d) indications and contraindications, 137–138 lesions, monitoring, 131–133 punch biopsy dos and don’ts, 144–145 scalpel biopsy, dos and don’ts, 141–144 soft tissue, indications for, 130 Biopsy kit, typical, 143 Bio/Screen oral exam light, 14 Bite, traumatic, 98 Black lesions, 31, 69–74, 126–127, 127 Blind pouches, 28 Blisterform lesions, 25–26 Blue and/or purple lesions, 31, 32, 63–69, 126 Blue lesions, 30, 125–126 Blue nevus, 68, 69, 126, 126 Brown lesions, 31, 69–74, 126–127, 127 Brush biopsy, 131, 137, 138 Brush biopsy (cytology) kit, 10, 10, 11 Buccal mucosa, lesions of, 25 Bullae, 26, 26, 31, 32, 117, 118, 118–119, 120, 125, 126 Burning mouth syndrome, 241–242 Canalicular adenoma, 98, 100 Cancer, biopsy and diagnosis of, 140 Candida albicans, 43, 52, 55 Candidal leukoplakia, 38, 39 Candidiasis, 37, 38 acute pseudomembranous type, 37, 38, 121, 122 chronic atrophic type, 53–54, 54 chronic erythematous type, 54–55, 55, 56, 56, 123, 123 chronic hyperplastic (hypertrophic) type, 38, 39 chronic multifocal type, 50, 50, 123 Canker sores, 78, 79 Carbamazepine, 242 Carotene, lesion color and, 29 Celiac disease, 81 Cervical lymph node levels, Chemical burn (aspirin burn), 39, 41–42, 42, 122, 122 Chemical cauterizers, 228 Chemiluminescent screening devices, 13–14 Chicken pox (varicella), 88, 89, 117, 118 Chlordiazepoxide, 239 Chlorhexidine gluconate, 226 Chromophores, 14, 16 Chronic erythematous candidiasis, 54–55, 55, 56, 56, 123, 123 Chronic hyperplastic type of candidiasis, 38, 39 Chronic vesiculoerosive and ulcerative lesions answers to study questions, 207–208 sample case histories, 170–175 Clobetasol propionate cream or ointment, 232 Clonazepam, 242 Clotrimazole, 228–229 Cold sores, 81, 83 Color of lesions, 29–32 black, 31 blue, 30 brown, 31 gray, 31 pink, 30 purple, 31 red, 29 red‐and‐white, 30 translucent, 32 white, 30 yellow, 31 Consistency of lesions, 32 Corticosteroids, topical, classes of relative potencies, 231–235 Cyclic neutropenia, 81 Cytology oral mucosal, indications and contraindications, 137–138 technique tips and pitfalls, 139–140 Debacterol, 228 Dental history, DentLight D.O.E Oral Exam System, 14, 15 Depressed lesions, 23, 27–28 Desonide, 234 Dexamethasone, 235, 236 elixir, 233 Diazepam, 239 Differential diagnosis, of common oral soft tissue lesions, 115–127 prioritized ranking list, 115–116 tips and pitfalls, 116–127 Diphenhydramine, 226–227, 236, 240 Docosanol cream, 238 Doxepin, 242 Drug ingestion, 72–73, 74, 127, 127 Dysplasia, 10, 16, 17, 43, 45, 53, 56, 93, 132, 133 Dysplasia, cytology procedures and, 138 Ecchymosis, 29, 60, 61, 221 Edentulous alveolar ridge mucosa, lesions of, 25 Elevated lesions, 23 Epulis fissuratum, 101, 103, 120, 120 Erosions, acute, 116–118, 117, 118 Erosive lichen planus, 50, 51, 92, 92, 118, 118, 124, 124 Index Eruption cyst (eruption hematoma), 65, 67, 125, 126 Erythema migrans, 49–50, 49, 56, 57, 123, 123 Erythema multiforme, 84, 86, 87, 117, 117 Erythroleukoplakia, 52, 52–53, 124, 124 Erythroplakias, 52, 56, 58, 123, 123 biopsied, continued monitoring of, 132, 133 oral mucosa cytology indications/ contraindications, 138 Excisional biopsy, 141 Exfoliative cytology, 10 Extraoral sites, physical examination, 5–6 Extravasated blood, 59–60, 123, 123 Facial rash, secondary to latex allergy, 85–86 Factitial ulcers, 95, 98, 118, 119 Famciclovir, 237–238 Fever blister, 81, 83 Fibroma, 95, 99, 119, 120 Flat lesions, 23, 28 Floor of mouth examining, lesions of, 24 Fluconazole, 229 Fluocinonide gel or ointment, 233 Fluoxetine, 242 Fordyce granules, 75, 75, 124, 125 Formalin, 143 Formulary of OTC and prescription medications, 225–244 antianxiety, 239 antifungals, 228–230 antihistamine and palliative coating agents, 226–227 antimicrobials, 226 antivirals, 236–238 antixerostomics, 239–242 chemical cauterizers, 228 disclaimer, 225 immunosuppressives alternative to steroids, 235 occlusive dressings, 235–236 selected topical corticosteroids, 231–235 used in conjunction with a lowered dose of steroids, 235 miscellaneous, 238 prescription writing requirements and safe writing practices, 243–244 topical anesthetics, 227–228 Gabapentin, 242 Generalized gingival enlargement, 106, 107, 120 261 Geniohyoid muscles, Geographic tongue, 49, 49–50, 56, 57, 123, 123, 124 Gingival cyst, of the adult, 68, 69, 126, 126 Gingival enlargement, generalized, 106, 107 Gingiva, lesions of, 24–25 Gingival vesicles, erosions, and ulcerations, 94 Gray lesions, 31, 69–74, 126–127, 127 Gum boil, 75, 76, 101, 103, 222 “Hairy” leukoplakia, 43 Hairy tongue, 72, 72, 127, 127 Hamular notch, lesions of, 25 Hard palate examining, lesions of, 25 Head and neck soft tissue pathology, descriptive features of, 23 Hemangiomas, 56, 59, 59, 65, 67, 106, 123, 123, 125, 126 Hematomas, 29, 59, 60, 61, 107, 109, 120, 121, 123, 123 Hemosiderin, 31 Herpangina, 86, 88, 117, 117 Herpes simplex type 1, 81, 82, 121, 123 Herpes zoster (“shingles”), 88, 90, 90, 117, 118 Herpetic gingivostomatitis, 81, 82, 116, 117 Herpetiform type ulcer, 80, 81 HIV infection, oral manifestation of, 74 HIV‐positive patients, “hairy” leukoplakia in, 43 HPV 16, 17, 43, 52 HPV 18, 43, 52 Hues, of lesions, 23 Hydrocortisone, 229 Hydrocortisone acetate ointment, 231 Hydroxyzine, 239 Hyperkeratosis, 30, 48, 132 Hyperplastic/hypertrophic candidiasis, 38, 39, 121, 122 Hyperplastic/hypertrophic lichen planus, 47, 48, 122, 122 Identafi oral cancer screening system, 14, 16 Imatinib, palatal pigmentation and treatment with, 74 Incisional biopsy, 141, 142 Inflammatory papillary hyperplasia, 108, 110, 120, 121 Intraoral sites, physical examination of, 6–9 Kaposi’s sarcoma, 65, 67, 126, 126 Keloid, 28 262 Index Labels, biopsy specimens, 143 Laser biopsies, 142 Latex allergy, facial rash secondary to, 85–86 Lesions anatomical site of, 24–25 atrophy and scarring and, 28 biopsied leukoplakias and erythroplakias, continued monitoring of, 132, 133 biopsied, monitoring, 131–133 blue and/or purple, 63–69, 125–126, 126 brown, gray, and/or black, 69–74, 126–127, 127 chronic vesiculoerosive and ulcerative, 170–175, 207–208 color of, 29–32 consistency of, 32 depressed, 23, 27–28 elevated, 23, 25–27 extraoral or intraoral, documenting, 32–33 flat, 28 indications for soft tissue biopsy, 130 morphological types of, 23 morphology of, 25–28 nonbiopsied, with low index of suspicion, 131 papillary, 176–182, 208–212 pigmented, 132, 182–187, 212–214 precise and accurate clinical descriptions of, 24 red, 53–63, 122–123, 123, 158–165, 201–205 red‐and‐white, 49–53, 123–124, 124, 158–165, 201–205 size of, 23–24, 32 white, 37–48, 121–122, 122, 149–157, 199–201 yellow, 124–125, 125 Leukoedema, 43, 44, 122, 122 Leukoplakia, 43–45, 122, 122 biopsied, continued monitoring of, 132, 133 candidal, 38, 39, 121, 122 keratotic, 45 oral mucosal cytology indications/ contraindications, 138 Lichen planus, 92, 92 atrophic and erosive, 50, 51, 118, 118, 124, 124 hyperplastic/hypertrophic, 47–48, 48, 122, 122 reticular, 45, 47, 47, 122, 122 Lichenoid contact allergic reaction, 53 Lidocaine, 227–228, 235 Linea alba, 7, 42, 43, 122, 122 Lipomas, 78, 78, 106, 125, 125 Lips examining, lesions of, 24 Liquid‐based cytology process, 131, 138 Liquid cytology kit, 12, 139, 139 Lorazepam, 239 Lumps and bumps, 95–110, 119–121, 120 Lymph nodes, Lymphoepithelial cysts, 77, 77–78, 125, 125 Lymphoma (non‐Hodgkin’s), 105, 105–106, 120, 121 Macules, 26, 28, 31, 122, 123, 124, 126, 127 Malignant melanoma, 68–69, 70, 71, 126, 126–127, 127 Maxillary tuberosity, 25 Maxisal liquid, 241 Median rhomboid glossitis, 54, 55, 122, 123 Medical history, Melanin, lesion color and, 29, 30, 31 Melanocytic nevus, 69–70, 70, 126, 127 Melanoma (malignant), 68–69, 70, 71, 126, 126–127, 127 Melanotic macule, 72, 73, 127, 127 Methylprednisolone, 234 Miconazole, 229 Microlux DL oral mucosa reflectance adjunctive light‐emitting diagnostic device, 13, 13 Miles’ mixture, 231 Monomorphic adenoma, 100 Morphology of lesions, 25–28 Morsicatio (nibbling habit), 39, 40, 121, 122 Mucocele (mucous extravasation phenomenon; mucous retention phenomenon), 64–65, 66, 95, 98, 119, 125, 126, 138 Mucoepidermoid carcinoma, 98, 100 Mucous membrane pemphigoid, 94–95, 118, 119 Mycoplasma pneumoniae, 86 Mylohyoid muscle, Narrow‐spectrum (band) fluorescence, 14–16, 131 Necrosis, 27, 30, 31, 39 Necrotizing sialometaplasia, 90, 91, 92, 117, 118 Necrotizing ulcerative gingivitis, 82, 84, 84, 116, 117, 117 Neuralgias, 241–242 Neurilemoma, 106, 108 Neurofibroma, 106 Neuroma, 138 Neutral calcium, 240 NeutraSal, 240 Nicotine stomatitis, 51, 52, 123, 124 Nodules, 26, 26, 31, 32, 119–121, 120, 125, 126, 127 Nonbiopsied lesions, with low index of suspicion, 131 Index Nonblisterform lesions, 26–27 Non‐Hodgkin’s lymphoma, 105, 105–106, 120, 121 Nonsteroidal anti‐inflammatory medications, 144 Nortriptyline, 242 Numoisen liquid and lozenge, 240 Nutritional deficiency disorders, 81 Nystatin, 229–230, 235 Oasis mouthwash and mouth spray, 240–241 Occlusive dressings, 235–236 Oral cancer screening, Oral cavity, major components of, Oral CDx brush biopsy, 10, 11, 137, 138 Oral ID 2.0, 14 Oral mucosal cytology indications and contraindications, 137–138 uterine cervical cytology compared with, 137 Oral mucosal screening, complete, sequence of steps, Oral potentially malignant disorders, 131, 133 OraMark Test, 16 OraRisk HPV complete genotype, 17 OraRisk HPV 16/18/HR, 17 Orascoptic DK, 13 Oravig, 229 Oropharynx examining, frontal and sagittal views, lesions of, 25 Oxyhemoglobin, lesion color and, 29 Palliative coating agents, 226–227 Papillary lesions, 176–182, 208–212 answers to case study questions, 208–212 sample case histories, 176–182 Papilloma, 107, 109, 120, 121, 138 Pap smears, of oral cavity, 137 Papules, 26, 26, 30, 120, 122, 123, 124, 125, 126, 127 Parulis, 120, 124, 125 gum boil, 101, 103, 222 yellow, 75, 76 Patches, 28 Pedunculated, 27 Pemphigoid, 94–95, 118, 119 Pemphigus, 95, 96–97, 118 Penciclovir, 238 Perioral skin, lesions of, 24 Peripheral giant cell granuloma, 104, 105, 120, 120–121 Peripheral ossifying fibroma, 103, 104, 120 Perleche (perleche), 55–56, 56, 123, 123 263 Petechia, 29, 60, 60, 61 Phenytoin, generalized gingival hyperplasia and use of, 106, 107 Physical examination, 4–9 extraoral sites, 5–6 intraoral sites, 6–9 Physiologic pigmentation, 127, 127 Pigmented lesions, 29, 74, 74, 132 answers to case study questions, 212–214 sample case histories, 182–187 Pink lesions, 30 Pits, 28 Plaques, 26, 27, 30, 122, 123, 124, 125, 126 Plasma cell gingivitis, 61–62, 62, 123 Pleomorphic adenoma, 98 Polymorphous low‐grade adenocarcinoma, 98 Prednisolone syrup, 234 Prednisone, 230, 234 Prescriptions, writing requirements and safe writing practices, 243–244 Primary herpes simplex infection (herpetic gingivostomatitis), 81, 82, 116, 117 Prochlorperazine maleate, 239 Pseudomembranous candidiasis, of buccal mucosa, 38 Punch biopsy, dos and don’ts, 144–145 Purple lesions, 31 Purpura, 29, 60, 60 Purpuric lesions, 158–165, 201–205 answers to case study questions, 201–205 sample case histories, 158–165 Pustules, 26, 26, 120, 125 Pyogenic granulomas, 101, 103, 104, 120, 120 Racial pigmentation, 70–71, 71 Reactive lymphoid hyperplasia, 106, 106, 120 Recurrent herpes labialis, 81, 83 Recurrent herpes simplex infection, 81, 83, 117, 117 Red‐and‐white lesions, 30, 49–53, 123–124, 124 answers to case study questions, 201–205 sample case histories, 158–165 Red lesions, 29, 53–62, 122–123, 123 answers to case study questions, 201–205 sample case histories, 158–165 Reduced hemoglobin, lesion color and, 29 Reticular lichen planus, 45, 47, 47, 122, 122 Retromolar pad(s), lesions of, 25 Rovers cellular collection device, 12 SaliMark OSCC salivary DNA test, 16 SalivaMAX, 240 264 Index Salivary gland tumors, 65, 68, 68, 97–98, 101, 119, 120, 126, 126, 138 Saliva samples, 16–18 Saliva substitutes, prescription, 240–241 SalivaSure, 241 Sapphire Plus LD, 14 Scalpel biopsy, dos and don’ts, 141–144 Schwannomas, 106, 108 Sessile, 26, 27 “Shingles” (herpes zoster), 88, 90, 90, 117, 118 Sialadentitis, acute, 102 Sialolith, 101, 102, 119, 120 Size of lesions, 32 Smoker’s melanosis, 73, 74, 127, 127 Snuff dipper’s keratotic leukoplakia, 45 Soft tissue masses, 187–198, 214–219 answers to case study questions, 214–219 sample case histories, 187–198 Speckled leukoplakia, 52, 52, 53, 124, 124 Squamous cell carcinoma, 16, 17, 18, 92, 93, 94, 118, 118, 138 Squamous papilloma, 107, 109, 120, 121, 138 Staphylococcus aureus, 55, 56 Stensen’s duct, sialolith of, 102 Steroids, systemic, contraindications, 230 Stevens–Johnson syndrome, 86 Stomatitis medicamentosa, 84 Stomatitis venenata, 84 Straticyte, 133 Sturge–Weber syndrome, unilateral hemangioma with, 59 Sucralfate, 236 Telangiectasia, 61, 62, 123 Tetracaine, 236 Tetracycline, 236 Thermal burn, 39, 41, 122, 122 Thrush, 37, 38, 121, 122 Tissue reflectance, 13–14 Tobacco cessation programs, 132 Tongue dorsal, hyperplastic lichen planus of, 48 dorsal, white coating of, 38, 121 dorsolateral, macule or patch of, 28 examining, 8–9 geographic, 49, 49–50, 56, 57, 123, 123, 124 lesions of, 24 Transepithelial (full‐thickness sampling) cytology, 10–13 Translucent lesions, colors of, 32 Traumatic ulcerative granuloma with stromal eosinophilia, 79, 95, 97, 117, 118, 119 Traumatic ulcers, 78, 79, 116, 117 Treponema pallidum, 43, 52 Triamcinolone acetonide ointment or suspension, 234 Trigone area, lesions in, 25 TUGSE See Traumatic ulcerative granuloma with stromal eosinophilia Tumors, 26, 27, 31, 119–121, 120, 123 Ulcerative allergic reactions, 84, 85 Ulcers, 26 acute, 78–92, 116–118, 117, 118, 165–170, 205–206 answers to case study questions, 205–206 sample case histories, 165–170 biopsies of, 142 chronic (erosions), 92–95, 118, 118–119 chronic vesiculoerosive and ulcerative lesions, 170–175, 207–208 diagnostic tips and pitfalls, 116–127 factitial, 95, 98, 118, 119 margins, depth, and diameter of, 28 number and outline of, 27 traumatic, 78, 79, 116, 117 Uterine cervical cytology, oral mucosal cytology compared with, 137 Valacyclovir, 238 Varicella (chicken pox), 88, 89, 117, 118 Varix (varices), 63, 64, 125, 126 Vascular malformations, 56, 59 VELscope, 14, 15, 16 Verruca vulgaris, 120, 121, 138 Vesicles, 25, 26, 32, 120, 125 acute, 78–92, 116–118, 117 chronic, 92–95, 118–119 Vesiculoerosive lesions, chronic, 170–175, 207–208 Vesiculoulcerative allergic reaction, 85 Vestibule, mucobuccal fold, lesions of, 25 Vizilite Plus, 14, 14 Vizilite PRO oral lesion screening system, 14 Warthin’s tumor, 98 Wharton’s duct sialolith, 102 White coated tongue, 37, 122 White lesions, 30, 37–48, 121–122, 122 answers to case study questions, 199–201 sample case histories, 149–157 Xerostomia, drugs related to, 239–240 Yellow lesions, 31, 75–78, 124–125, 125 ... could be useful for oral cytology specimens Currently, the The ADA Practical Guide to Soft Tissue Oral Disease, Second Edition Michael A Kahn and J Michael Hall © 20 18 by the American Dental... protocol regarding biopsy documentation to ensure timely receipt and review of the written report and the follow‐up action, if any is needed [3] The ADA Practical Guide to Soft Tissue Oral Disease, ... (20 12) The limitations of the clinical oral examination in detecting dysplastic oral lesions and oral squamous cell carcinoma JADA 143 ( 12) : 13 32 13 42 Eversole, L.R (1996) Oral Medicine: A Pocket Guide