The ADA practical guide to soft tissue oral disease 2nd edition

www.ajlobby.com The ADA Practical Guide to Soft Tissue Oral Disease www.ajlobby.com www.ajlobby.com The ADA Practical Guide to Soft Tissue Oral Disease Second Edition Michael A Kahn, DDS Diplomate and Director, American Board of Oral and Maxillofacial Pathology Professor Emeritus and Chair (ret.), Department of Oral and Maxillofacial Pathology, Oral Medicine, and Craniofacial Pain Tufts University School of Dental Medicine Boston, MA J Michael Hall, DDS, MABMH Diplomate, American Board of Oral and Maxillofacial Pathology Associate Professor (ret.), Department of Oral and Maxillofacial Pathology, Oral Medicine, and Craniofacial Pain Tufts University School of Dental Medicine Boston, MA www.ajlobby.com 1st Edition © 2014 by John Wiley & Sons, Inc 2nd Edition © 2018 by the American Dental Association Edition History John Wiley & Sons, Inc and the ADA (1e, 2014) All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions The right of Michael A Kahn and J Michael Hall to be identified as the author(s) of this work has been asserted in accordance with law Registered Office(s) John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA Editorial Office 111 River Street, Hoboken, NJ 07030, USA For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand Some content that appears in standard print versions of this book may not be available in other formats Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make This work is sold with the understanding that the publisher is not engaged in rendering professional services The advice and strategies contained herein may not be suitable for your situation You should consult with a specialist where appropriate Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages Library of Congress Cataloging‐in‐Publication Data Names: Kahn, Michael A., author | Hall, J Michael, author | American Dental Association,   issuing body Title: The ADA practical guide to soft tissue oral disease / Michael A Kahn, J Michael Hall Other titles: American Dental Association practical guide to soft tissue oral disease |   Practical guide to soft tissue oral disease Description: Second edition | Hoboken, NJ : Wiley, 2018 | Includes bibliographical   references and index | Identifiers: LCCN 2017057994 (print) | LCCN 2017060299 (ebook) | ISBN 9781119437598 (pdf) |   ISBN 9781119437307 (epub) | ISBN 9781119437338 (pbk.) Subjects: | MESH: Mouth Diseases | Soft Tissue Neoplasms | Diagnosis, Oral Classification: LCC RK529 (ebook) | LCC RK529 (print) | NLM WU 140 | DDC 617.5/22–dc23 LC record available at https://lccn.loc.gov/2017057994 Cover Design: Wiley Cover Images: ©Michael A Kahn Set in 9.5/12pt Palatino by SPi Global, Pondicherry, India Printed and bound in Singapore by Markono Print Media Pte Ltd 10 9 8 7 6 5 4 3 2 1 www.ajlobby.com Contents Preface to the Second Edition vii Preface to the First Edition ix Acknowledgmentsxi Section I Detection and Documentation 1 The Extraoral and Intraoral Soft Tissue Head and Neck Screening Examination Soft Tissue Head and Neck Pathology Description and Documentation 23 Section II Diagnosis and Management 35 Common Oral Soft Tissue Lesions 37 Differential Diagnosis of Common Oral Soft Tissue Lesions 115 Guidelines for Observation and/or Referral of Patients’ Lesions 129 The Art and Science of Biopsy and Cytology 137 Section III Clinicopathologic Exercises 147 Sample Patient Histories and Discussion 149 v www.ajlobby.com   vi Contents Appendix A: Glossary of Descriptive Terminology 221 Appendix B: Formulary of Over‐the‐Counter and Prescription Medications Based on Disease Classification: Common Errors of Prescription Writing 225 Answers to End‐of‐Chapter Questions 245 Index259 www.ajlobby.com Preface to the Second Edition We are grateful for the positive reception within the dental and medical communities of this textbook’s first edition In this second edition its intention remains the same  –  to be a practical guide and reference source for the basic clinical aspects of soft tissue oral and maxillofacial disease We also appreciate the constructive feedback received by colleagues that aided in this edition’s revisions The names and organization of the book’s chapters remain the same Within each chapter the cited references and/or recommended readings have been updated; however, in addition, the end of each chapter now contains self‐ assessment multiple‐choice questions with feedback comments on the correct answer and distractors The revisions of Chapter 1 notably include a number of newly marketed diagnostic adjunctive devices and methods Chapter 3 provides updated information on some of its pathologic conditions, particularly the nature of hemangiomas versus vascular malformations and the increasing clinical impact the human papillomavirus type 16 has on malignant transformation (i.e squamous cell carcinoma) of specialized oropharyngeal epithelium as opposed to the oral cavity proper Chapter 5 introduces the term “oral potentially malignant disorders” and initial commercial products designed to add additional information to their predicted clinical behavior and management Appendix B has been extensively updated to reflect the ever‐changing drug formulary available to the clinician to treat oral soft tissue diseases Lastly, some of the photographic images have been added or updated to enhance a lesion’s features We hope our efforts have enhanced the utility of this textbook for your chairside evaluation, differential diagnosis formulation, establishment of provisional and final diagnosis, and management of your patient’s diagnosed oral mucosal diseases Michael A Kahn J Michael Hall vii www.ajlobby.com www.ajlobby.com   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 WILEY 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The ADA Practical Guide to? ?Soft Tissue Oral Disease www.ajlobby.com www.ajlobby.com The ADA Practical Guide to Soft Tissue Oral Disease Second Edition Michael A Kahn, DDS Diplomate and Director,... Title: The ADA practical guide to soft tissue oral disease / Michael A Kahn, J Michael Hall Other titles: American Dental Association practical guide to soft tissue oral disease |   Practical guide. .. in the dental record The lesion’s size, expressed in metric system units (length and width at their greatest dimension and, in some The ADA Practical Guide to Soft Tissue Oral Disease, Second Edition