Practical Manual of Oral Pathology and Microbiology (Vijay Wadhwan) (2010) [PDF] [UnitedVRG].pdf

Practical Manual of Oral Pathology and Microbiology

Practical Manual of Oral Pathology and Microbiology

Vijay Wadhwan

Associate Professor Department of Oral Pathology and Microbiology Sharad Pawar Dental College and Hospital Sawangi (Meghe) Wardha, Maharashtra, India

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Practical Manual of Oral Pathology and Microbiology © 2010, Jaypee Brothers Medical Publishers (P) Ltd. All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error (s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2010 ISBN 978-93-80704-35-7 Typeset at JPBMP typesetting unit Printed at Ajanta Offset

Foreword Memory makes you miserable when you forget the infinite, and enlightened when you forget the trivial. Mere learning is not knowledge. A man of knowledge is not only a learned in his field but also guides his students accordingly on the same path. Practical Manual of Oral Pathology and Microbiology by Dr Vijay Wadhwan, is indeed an innovative step towards the training of the undergraduate dental students in the subject of Oral Pathology and Microbiology. Each of the first VII sections focuses on the basic aspects of the differing pathologies encountered in the oral cavity. It has been well compiled by Dr Vijay Wadhwan and focus on the basics of the subject will certainly help the students in (their quest of assimilating knowledge) streamlining their thought process. The efforts of Dr Vijay Wadhwan are indeed worthy of appreciation and it will spare the students from going through innumerable textbooks as all the essentials are given in this practical manual. I congratulate Dr Vijay Wadhwan and wish him and his book Practical Manual of Oral Pathology and Microbiology all success. Ramakant S Nayak Principal, Professor and Head Department of Oral Pathology and Microbiology Maratha Mandal’s Nathajirao G Halgekar Institute of Dental Sciences and Research Centre R.S. No. 47 A/2, Bauxite Road Belgaum, Karnataka, India

Preface Oral cavity is a part of body which is not only meant for tasting the delicacies but it also acts as a gateway for detection of many underlying systemic disease processes. Medical knowledge and basic understanding of the diseases is undergoing a sea change due to the advancement in the fields of immunohistochemistry, PCR, etc. This manual is intended to be a basic guide for identifying various commonly occurring oral diseases. It makes no pretence to be a comprehensive or balanced account of oral pathology as a whole. For the undergraduate students, this is essentially a practical manual which contains the basic precise and exacting methods to go about the routine practical work. This manual should be of value to undergraduates as they can draw the microscopic features in the space provided for drawing histopathological diagrams. The students are hereby encouraged to seek additional information on various topics from the various textbooks. Vijay Wadhwan

Acknowledgments “I have gathered a posie of other men’s flowers, and nothing but the thread that binds them is mine own.” — John Bartlett Every man, whatever his accomplishments, always owes a deep debt of gratitude to many people who he meets in the journey called life. During the preparation of this manuscript, I have been fortunate enough to receive help and advice from wherever I sought it. If the Almighty does not want something, it can never be done. I would like to thank Almighty for everything in my life. I am indebted to my teachers for their words of wisdom, encouragement, and nurturing whatsoever was good in me. It is only due to the efforts of my teachers Dr Mrs Alka D Kale, Dr Ramakant S Nayak and Dr Seema Hallikerimath, who taught me with patience and who were willing to share all their knowledge that this manual has been able to reach its destiny. When eating a fruit, think of the person who planted the tree. I would like to thank Dr Vijay Gupta and Dr Anil Singla who realized my potential and constantly encouraged me for my endeavors into the unknown. My thanks would be incomplete if I don’t mention the names of Dr AJ Pakhan, and Dr RM Borle who let me utilize the library and other facilities in their institute. We can only be said to be alive in those moments when our hearts are conscious of our treasures. I would be neglecting my duties if I fail to mention the names of Dr Minal S Chaudhary, Dr Madhuri Gawande and Dr Abhiney Puri as these were the ones who stood by me during my tough times. Parents teach all the worthwhile values of human life. I owe it all to my father Sh Vinod Kumar Wadhwan and my mother Smt Santosh, my in-laws Brig RS Malik and Mrs Chandrabala Malik and my uncle Sh Suraj Prakash and my aunt Late Smt Sangeeta as they all proved to be my pillars of strength throughout. No man can accomplish much without the help, support, and understanding of his family. I hereby acknowledge with the deepest gratitude and affection the patience and support of my wife Dr Sangeeta Wadhwan and our sons Siddharth and Siddhanth. I would also like to thank all the people whom I may have omitted by mistake.

Contents Section I Definitions ............................................................................................................................... 1 Section II Classifications ....................................................................................................................... 13 Section III Routine and Advanced Diagnostic Procedures for Oral Lesions .................................. 37 Section IV Staining Procedures and Special Stains ............................................................................ 41 Section V Normal Values of Formed Elements in Blood ................................................................. 47 Section VI Common Syndromes Affecting Oral Cavity .................................................................... 51 Section VII Identifying Histopathological Features of Common Oral Lesions ............................... 63 Section VIII Histopathological Diagrams ............................................................................................... 77 Section IX Gross Specimen .................................................................................................................. 139 Recommended Reading ........................................................................................................ .161 Index ..................................................................................................................................... 163

CERTIFICATE This is to certify that this record has been satisfactorily completed by Mr/Ms/Mrs _________________________ Roll No. ____________________ Class___________ and University Registration No. ________________ under my

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guidance and to the best of his/her ability.

Staff-incharge Date:

Head of Department

Instructions to Candidates 1. Use appropriate colors to draw diagrams. 2. Practical record books and required pencils should be carried to every practical class. 3. Signatures should be obtained from the respective batch-in-charge after the completion of diagrams of each chapter. 4. Content page to be filled in and signatures to be obtained in time period specified by the incharge. 5. Candidates should not mishandle the microscopes and slides. 6. Candidates should be punctual and regular. 7. Cleanliness and discipline should be maintained. 8. Good conduct is appreciated.

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Section I

Definitions

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1. Aberrancy: It may be construed as anomaly in which a tissue develops at a site further from where it is normally found. 2. Abfraction: It refers to the pathologic loss of tooth structure resulting from repeated tooth flexure caused by occlusal stresses. It appears as a wedge shaped defect limited to cervical areas of teeth. 3. Abrasion: Abrasion is the pathologic wearing away of the tooth structure or restoration secondary to the action of an external agent. 4. Abscess: An abscess is a localized collection of pus surrounded by an area of inflamed tissue in which hyperemia and infiltration of leukocytes is marked. 5. Acantholysis: It is the pathological separation of epidermal or epithelial cells by breakdown of desmosomes in spinous cell layer (seen in pemphigus). 6. Acanthosis: Excessive thickening of the spinous layer of squamous epithelium, resulting in broadening and elongation of rete pegs. 7. Acquired: Relating to something not of genetic origin but resulting from outside influence. 8. Acute inflammation: It is a rapid response to an injurious agent that serves to deliver mediators of host defense – leukocytes and plasma proteins – to the site of injury. 9. Acute: Having severe symptoms and a short course. 10. Adenoma: Adenoma is the term applied to a benign epithelial neoplasm that forms glandular patterns as well as to tumors derived from glands but not necessarily reproducing glandular patterns. 11. Agenesis: It is the absence of a part of body caused by absence of primordium. 12. Ageusia: It is the loss or absence of sense of taste. 13. Aglossia: It is the congenital absence of the tongue. 14. Agranulocytosis: A marked decrease in the number of granulocytes in the peripheral blood, particularly neutrophils. 15. Allergen: A substance capable of inducing hypersensitivity or an allergic reaction in the host. 16. Allergy: An altered state of reactivity to an antigen, including both types of immune responses, protective as well as injurious. OR All immune processes harmful to the host, such as hypersensitivity or autoimmunity 17. Alopecia: Loss of hair 18. Anachoresis: Localization of the transient bacteria in the bloodstream into areas of inflammation, which are found in traumatized or inflamed pulp. 19. Anaphylaxis: It is an antigen-antibody reaction produced by the parenteral injection of an antigen causing hypersensitivity. 20. Anaplasia: Lack of differentiation or replacement of specialized cells by unspecialized, undifferentiated or stem cells is called anaplasia. 21. Anastomosis: It is a communication between two vessels by collateral channels. 22. Anemia: It is an abnormal reduction in the number of circulating red blood cells, the quantity of hemoglobin and the volume of packed red cells in blood. 23. Angioma: A tumor made up of blood (Hemangioma) or lymph (Lymphangioma) vessels.

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24. Anomalad: It is a malformation together with its subsequently derived structural changes; the primary defect setting off a series of secondary or even tertiary events resulting in multiple anomalies. 25. Anomaly: Marked deviation from normal, especially as a result of congenital or hereditary defects. 26. Anorexia: It is the lack or loss of appetite for food. 27. Anosmia: It is the absence of sense of smell. 28. Antagonist: It is tissue or muscle that counteracts the action of another tissue or muscle. 29. Antibody: An immunoglobulin molecule that reacts with a specific antigen that induces its synthesis and with similar molecules. 30. Antigen: Any substance capable of inducing a specific immune response and of reacting with the products of that response. 31. Aplasia: Aplasia refers to development of rudimentary structure caused by failure of anlage to develop completely. 32. Arteriosclerosis: Condition characterized by loss of elasticity and thickening of arterial walls. 33. Atresia: It is the congenital occlusion or absent of one or two major salivary gland ducts. 34. Atrophy: Shrinkage in the size of the tissue or of an organ by decrease in number of cells and loss of cell substance. 35. Attrition: Attrition may be defined as the physiologic wearing away of a tooth as a result of tooth-to-tooth contact, as in mastication. 36. Autoantibody: An antibody formed in response to, and reacting against, an antigenic constituent of the one’s own tissues. 37. Autoimmune disease: The diseases where the autoimmune processes, humoral or cellular are responsible for the pathogenesis of the disease. 38. Autoimmunity: A condition in which structural or functional damage is produced by the action of immunologically competent cells or antibodies against the normal components of the body. 39. Bacteria: These are prokaryotic microorganisms that do not contain chlorophyll. They are usually unicellular and do not show branching, except in higher bacteria 40. Bacteremia: It refers to the circulation of bacteria in the blood. 41. Biopsy: It is the gross and microscopic examination of tissue or cells removed from living patients for the purpose of diagnosis or prognosis of the disease or the confirmation of the normal condition. 42. Blanching: To extract the color out and make pale and white. 43. Bleb: It is a bulla or other skin blister filled with blood or serous fluid usually 1 cm in diameter. 44. Boil (Furuncle): It is a localized, painful skin abscess usually at the site of hair follicle 45. Bosselated: Marked by numerous bosses or rounded protuberances. 46. Bruise: It is a superficial injury, caused by a blow with no laceration but with discoloration of the skin and subcutaneous tissues produced by accumulation of blood.

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47. Bulla (Blister): A bulla is a large, circumscribed, fluid containing, elevated lesion of the skin more than 5 mm in size. 48. Calcification: The deposition of calcium salts in organic tissue causing hardening 49. Callus: The unorganized network of woven bone formed about the ends of a broken bone, which is absorbed as repair is completed and is finally replaced by true bone 50. Capsule: Compressed cartilaginous, fatty, fibrous membranous structure enveloping another structure, organ or part. 51. Carbuncle: A necrotizing infection of skin and subcutaneous tissues composed of a cluster of furuncles, usually due to Staphylococcus aureus, with multiple draining sinuses. 52. Carcinoma: Carcinomas are malignant neoplasms of the epithelial origin, which tend to infiltrate the surrounding tissues and give rise to metastasis. 53. Carcinomatosis: The condition of widespread dissemination of cancer throughout the body. 54. Carcinosarcoma: It is a malignant mixed tumor containing characteristics of both carcinomatous and sarcomatous tissues. 55. Carrier: One who harbors disease organisms in the body without manifesting symptoms, thus acting as distributor of disease. 56. Causalgia: It is a burning pain, often with trophic skin changes arising after peripheral nerve injury. 57. Cell: It is the fundamental, structural, and functional unit of living organisms consisting of a nucleus surrounded by cytoplasm enclosed in a cell or plasma membrane. 58. Cellulitis: A painful swelling of the soft tissue of the mouth and face resulting from a diffuse spreading of purulent exudate through the cleavage planes of interstitial and tissue spaces. 59. Central: In oral pathology, it is the lesion occurring within bone. 60. Chemotherapy: It is the treatment of a disease by chemicals which affect pathogenic organisms without harming the patient or it is the treatment of malignant neoplasms by chemical means. 61. Choriostoma: It refers to excessive amount of histologically normal tissue that is present in abnormal location. 62. Chronic inflammation: It is considered to be inflammation of prolonged duration (weeks or months) in which active inflammation, tissue destruction, and attempts at repair are proceeding simultaneously. 63. Cleidocranial: Referring to the clavicle and head. 64. Clubbing: Proliferation of the soft tissue about the terminal phalanges of fingers or toes, without osseous changes. 65. Cold abscess: It is a slow developing abscess generally about a bone or joint and with little inflammation. 66. Collagen: The protein substance of the white fibers of skin, tendon, bone, cartilage and other connective tissue composed of molecules of tropocollagen. 67. Commensals: The microorganisms living in perfect harmony with the host without causing any disease.

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68. Congenital: Present at or before birth but not necessarily inherited. 69. Cross infection: When infection is transferred from one host to another. 70. Cyanosis: It is the bluish discoloration of the skin and mucous membranes, often due to excessive concentration of reduced hemoglobin in the blood. 71. Cyst: Cyst is defined as a pathological cavity which may or may not be lined by epithelium and consists of fluid, semi-fluid or gaseous content (but not pus). True cyst is a cystic cavity always lined by epithelium. 72. Deformity: Distortion of any part or general disfigurement of the body. 73. Degeneration: It refers to the gradual deterioration of tissue with loss of function and chemical changes within the tissue. 74. Dental caries: Dental caries is a microbial disease of calcified tissues of teeth, characterized by demineralization of inorganic and destruction of organic substance of the tooth. 75. Desquamation: It refers to the shedding off or peeling off of epithelial elements chiefly of skin and mucous membranes, in scales or sheets. 76. Differentiation: Differentiation refers to the extent to which neoplastic cells resemble comparable normal cells, both morphologically and functionally. 77. Diffuse: It is used in the description of a lesion where borders of the lesion are not well defined or well delineated or localized. 78. Disease: Any deviation from normal structure or function of any body part, organ, or system that is manifested by characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. 79. Dominant: In genetics, a trait or characteristic that is manifested when it is carried by only one of a pair of homologous chromosomes. 80. Dyskinesia: It is defined as distortion or impairment of voluntary motions as in cases of tic or spasm, leading to movements that are incomplete or only partial. 81. Dysplasia: Dysplasia, a term that literally means disordered growth, is encountered principally in epithelia, and is characterized by a constellation of changes that include a loss in the uniformity of individual cells as well as a loss in their architectural orientation. 82. Dystrophic calcification: Pathologic calcification that occurs in degenerating and dead tissue. 83. Echymosis: A small hemorrhagic spot in the skin or mucous membrane, larger than petechiae, forming a non-elevated, rounded or irregular blue or purplish patch. 84. Ectopic: Displacement or malposition. 85. Edema: An excess of fluid in the interstitial os serous cavities; it can be either an exudate or a transudate. 86. Enanthema: Eruptions on mucous membrane occurring as a symptom of any disease. 87. Endogenous infection: Infection produce within or caused by factors within the body. 88. Epulis: A non-specific term used for tumors and tumor-like masses of gingiva.

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89. Erosion (of Teeth): It is irreversible loss of dental hard tissues by a chemical process that does not involve bacterial action. 90. Erosion (of Soft Tissue): Erosion is a shallow defect in mucosa representing loss of epithelium down to but not including the stratum germinativum. 91. Erythema: It is the redness of the skin either diffuse or patchy, caused by congestion of the subcutaneous capillaries. 92. Exanthema: An eruption characterizing an eruptive fever. 93. Exogenous infection: Infection originating outside or caused by factors outside the body. 94. Exophytic: It refers to something growing outwards, and in oncology, it is used for tumor projecting above the normal surface contours. 95. Exostosis: A benign bony growth projecting outward from a bone surface. 96. Exotoxin: It refers to a toxic secretion of bacterial cells which cause damage in sites distant from the focus of infections and diffuse readily into surrounding tissue. 97. Extravasation: It is the discharge or escape of fluid from vessels into the surrounding tissue. 98. Extrinsic: Having its origin outside and separated from a body, organ or part. 99. Exudate: An exudate is an inflammatory extravascular fluid that has a high protein concentration, cellular debris and has been deposited in tissues or tissue surfaces. 100. Eyepiece: The lens or system of lenses of microscope nearest to the users eye and serves further to magnify the image captured by the objective. 101. Facies: The expression or appearance of the face. 102. Familial: Relating to a family, or affecting several members of the same family. 103. Fissure: A narrow slit or cleft or groove which may be normal or abnormal. 104. Fistula: It represents an abnormal passage or communication usually between two internal organs, or leading from an internal organ to the body surface due to destruction of the intervening tissue. 105. Focal infection or sepsis: Infection or sepsis at localized sites producing generalized effects. 106. Focus of infection: It refers to a circumscribed area of tissue, which is infected with exogenous pathogenic microorganisms and which is usually located near a mucous or cutaneous surface. 107. Fracture: A break or rupture in bone. 108. Fungi: These are eukaryotic, heterotropic organisms that live as saprobes or parasites and possess rigid cell wall but lack chlorophyll. 109. Fusiform: Spindle-shaped; tapered at both ends. 110. Gangrene: It is the necrosis of tissue due to failure of the arterial blood supply caused by injury or disease followed by bacterial invasion and putrefaction. 111. Granulation tissue: It is the reparative tissue formed on the surface of wound having soft, granular appearance showing histologically new small blood vessels and fibroblast.

Definitions

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112. Granuloma: A granuloma can be defined as any small nodular delimited microscopic aggregation of mononuclear inflammatory cells or collection of modified macrophages that are transformed into epithelium-like cells surrounded by rim of lymphocytes and occasionally plasma cells. 113. Granulomatosis: It refers to the formation of multiple granulomas. 114. Hamartoma: It is defined as tumor-like nodule composed of an overgrowth of mature cells and tissues with the tissue being native to the site, but with disorganization. 115. Healing: Healing is the body response to injury by repair and replacement of damaged cells by healthy cells in an attempt to restore normal structure and function. 116. Hematoma: A localized collection of extravasated blood, usually clotted in an organ, space or tissue. 117. Hemiplegia: It is the paralysis of one side of the body. 118. Hereditary disease: The diseases which are transferred from parents to offsprings. These may or may not be present at birth. 119. Heredity: It refers to the genetic transmission of a particular trait or characteristic from parent to offspring. 120. Hyaline: Transparent or glassy appearance. 121. Hydropic degeneration: It refers to replacement of the nuclei of stratum basal by clear space due to edema and degeneration of cells. 122. Hyperplasia: Hyperplasia is an abnormal increase in the number of cells in an organ or tissue, resulting in increased volume of the organ or tissue. 123. Hypertrophy: Hypertrophy refers to an increase in the size of cells, resulting in an increase in the size of the organ. 124. Hypoplasia: Hypoplasia refers to incomplete development or underdevelopment of an organ with decreased numbers of cells. 125. Iatrogenic Infection: The infections introduced by physician during investigative, operative or other procedures 126. Idiopathic: It is any spontaneous or primary disease with no apparent external cause. 127. Immunodeficiency: A deficiency of the immune response due to lack of or decreased activity of lymphoid cells. 128. Inapparent Infection: Infections in which clinical effects are not apparent. 129. Infection: Invasion and multiplication of microorganisms in body tissues, especially those causing local cellular injury due to their metabolism and toxic products. 130. Inflammation: Inflammation is a protective tissue response to injury which serves to destroy, dilute or wall off both the injurious agent and the injured tissues. The classical signs of inflammation include pain (dolor), heat (calor), redness (rubor), swelling (tumor), and loss of function (function laesa). 131. Juxtaepithelial: Just beneath the epithelium. 132. Karyolysis: Dissolution of nucleus of a cell. 133. Karyopyknosis: Shrinkage of cell nucleus, with condensation of chromatin.

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Practical Manual of Oral Pathology and Microbiology

134. Karyorrhexis: Rupture of the cell nucleus in which the chromatin disintegrates into small granules. 135. Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. 136. Leukemia: A progressive malignant disease of the blood forming organs, marked by distorted proliferation and development of leukocytes and their precursors in the blood and bone marrow. 137. Leukoplakia: A white patch or plaque that cannot be scraped off and cannot be characterized clinically or pathologically as any other disease, which is more than 5 mm. 138. Localized: Lesion or condition happening within circumscribed or limited area. 139. Lump: A large mass of body tissue. 140. Lupus: Any of a group of skin diseases in which the lesions are characteristically eroded. 141. Lymphoma: Any neoplastic disorder of lymphoid tissue. 142. Macule: A macule is a circumscribed, non-raised area of altered coloration varying in size from a pinhead to several centimeters in diameter. 143. Metaplasia: It is a reversible change in which one adult cell type (epithelial or mesenchymal) is replaced by another adult cell type. 144. Metastasis: It is defined as spread of disease process from part of the body to another not directly connected with it due either to transfer of pathogenic microorganisms or to transfer of cells. 145. Micrometastasis: The spread of cancer cells from primary tumor to distant sites to form microscopic secondary tumors. 146. Mutation: A mutation may be defined as a permanent transmissible change in the genetic material. 147. Natal teeth: These are teeth which are present in the oral cavity at birth. 148. Necrosis: It refers to a spectrum of morphologic changes that follow cell death in living tissue, largely resulting from progressive degenerative action of enzymes on the lethally injured cell. 149. Neonatal teeth: These are teeth which erupt during the first 30 days of postnatal life. 150. Neoplasia: A neoplasm is an abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of the normal tissues and persists in the same excessive manner after cessation of the stimuli, which evoked the change (Willis 1952). 151. Nodule: A nodule is solid elevated lesion of the mucosa, varying in size from 5 mm to 2 cm. 152. Nosocomial infections: It refers to the cross infection occurring in hospitals. 153. Neuralgia: Paroxysmal pain extending along the course of one or more nerves. 154. Neuroma: A benign tumor growing from the nerves or chiefly composed of nerve cells or nerve fibers.

Definitions

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155. Nidus: The point of origin or focus of a morbid process. 156. Oncocyte: A large epithelial cell with an extremely acidophilic and granular cytoplasm, containing numerous mitochondria. 157. Oncosis: A morbid condition marked by the development of tumors. 158. Oral submucus fibrosis: An insidious chronic disease affecting any part of the oral cavity and sometimes the pharynx, preceded by and/or, associated with vesicle formation, it is always associated with juxtaepithelial inflammatory reaction followed by fibroelastic change of the lamina propria, with epithelial atrophy leading to stiffness of the oral mucosa and causing trismus and inability to eat. 159. Osteodystrophy: Osteodystrophy is a term for bone diseases which are neither inflammatory, nor neoplastic but are genetic, metabolic or of unknown cause leading to abnormal development of bone. 160. Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, caused by stimulation of specialized nerve endings. 161. Papule: A papule is a small, circumscribed, solid elevated area varying in size from a pinhead to 5 mm. The base is round or ovoid, and the surface configuration may be pointed, rounded or flattened. 162. Paralysis: Loss or impairment of motor functions in a part due to lesion of neural or muscular mechanism. 163. Parasites: A plant or animal that lives upon or within another living organism at whose expense it obtains some advantage. 164. Paresthesia: The term refers to morbid or perverted sensation like burning, prickling or crawling sensation of the skin. 165. Pathogen: Any disease producing agent or microorganism. 166. Pathogenesis: The development of disease from its inception to the appearance of characteristic symptoms or lesions. 167. Pathognomonic: Characteristic of one specific disease or pathological condition as distinct from any others. 168. Pathology: That branch of medicine which is concerned with the structural and functional changes caused by disease. 169. Petechiae: Minute red spots on skin or mucosa usually 1-2 mm in diameter caused due to escapement of blood. 170. Plaque: A plaque is a small or large, raised, firm, clearly demarcated area of gray or white discoloration. The surface texture may be relatively smooth, rough or pebbled. 171. Precancerous condition: A generalized state of body associated with a significant risk of cancer development 172. Precancerous lesion: A benign morphologically altered tissue that has a greater than normal risk of developing cancer as compared to its apparently normal counterpart.

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Practical Manual of Oral Pathology and Microbiology

173. Primary infection: Initial invasion and multiplication of pathogenic microorganisms in a host. 174. Pseudoepitheliomatous hyperplasia: In this condition the retepegs extend far downward towards connective tissue, usually accompanied by acanthosis. The cells are normal in size, shape and chromaticity 175. Purpura: Reddish to purple flat lesions caused by blood extravasated from vessels into the subcutaneous tissue. 176. Pus: Is an inflammatory exudates usually yellowish in color rich in leukocytes (mostly neutrophils), the debris of red cells, and in many cases, microbes. 177. Pustule: A pustule is a vesicular type of lesion containing purulent material instead of clear fluid. 178. Putrefaction: The enzymatic decomposition of proteins through the action of microorganisms, resulting in the production of various solid and liquid compounds and gases giving off a foul odor. 179. Regeneration: It refers to natural growth of cells and tissues to replace lost structures. 180. Re-infection: A second infection by same agent again or a second infection of an organ by different agent. 181. Repair: The physical or mechanical restoration of damaged or diseased tissue by proliferation of new cells or by surgical apposition. 182. Saprophyte: A saprophyte is a microorganism that lives on dead or decaying organic material. 183. Sarcoma: Malignant tumors arising in mesenchymal tissues are called sarcomas. 184. Sclerosis: An induration or hardening especially from inflammation and in diseases of interstitial substance. 185. Secondary Infection: New parasitic infection when the host defense is lowered by preexisting infectious diseases. 186. Sequestrum: A piece of dead bone separated from the sound bone as is seen sometimes in osteomyelitis. 187. Sinus: A sinus is a blind track leading from the surface down to the tissues. There may be a cavity in the tissue, which is connected to the surface through sinus. 188. Subclinical infection: Infections in which typical or clinical manifestations of the particular infectious disease are not present 189. Swelling: A swelling is a vague term, which denotes any enlargement or protuberance in the body and may include tumors. 190. Synctium: A multinucleate mass of protoplasm produced by the merging of cells. 191. Syndrome: Is an aggregate of signs and symptoms almost always occurring together and is associated with any morbid process. 192. Telangiectasia: It is a vascular lesion formed by dilation of the capillaries and small arteries. 193. Teratoma: This is a true neoplasm composed of multiple tissues which are not native to the site of growth.

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194. Teratology: A science dealing with the abnormal development and congenital deformations. 195. Transudate: A transudate is a fluid with low protein content and a specific gravity of less than 1.012. It is essentially an ultrafiltrate of blood plasma that results from osmotic or hydrostatic imbalance across the vessel wall without an increase in vascular permeability. 196. Ulcer: An ulcer is a defect or break in continuity of epithelial component of skin or mucosa, so that a depression or punched-out area exists. 197. Vesicle: A vesicle is a small (2 to 5 mm) circumscribed, elevated lesion composed of a thin surface covering overlying and containing an accumulation of fluid. 198. Virulence: The degree of pathogenicity of a microorganisms as indicated by the severity of disease produced and the ability to invade the tissues of the host. 199. Virus: A minute infectious agent lacking independent metabolism and is able to replicate in only living host cell. 200. Wheal: It is a flat edematous elevation of the skin frequently accompanied by itching. 201. Zoonosis: It refers to the diseases of animals transmissible to mankind.

Section II

Classifications

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Practical Manual of Oral Pathology and Microbiology

CLASSIFICATION OF DEVELOPMENTAL DISTURBANCES OF ORAL AND PARAORAL STRUCTURES Developmental Disturbances of Jaws • • • • • •

Agnathia Micrognathia Macrognathia Facial hemihypertrophy Facial hemiatrophy Abnormalities of dental arch relations.

Developmental Disturbances of Lips and Palate • • • • • • •

Congenital lips and commissural pits and fistula Double lip Cleft lip and palate Cheilitis glandularis Cheilitis granulomatosa Hereditary intestinal polyposis syndrome Labial and oral melanotic macule.

Developmental Disturbances of Oral Mucosa • Fordyces granules • Focal epithelial hyperplasia (Heck’s disease). Developmental Disturbances of Gingiva • Fibromatosis gingivae • Retrocuspid papilla. Developmental Disturbances of the Tongue • • • • • • • • • •

Microglossia Macroglossia Ankyloglossia Cleft tongue Fissure tongue Median rhomboid glossitis Benign migratory glossitis Hairy tongue Lingual varices Lingual thyroid nodule.

Developmental Disturbances of Oral Lymphoid Tissue • Reactive lymphoid aggregates • Lymphoid hamartoma

Classifications

• Angiolymphoid hyperplasia with eosinophils • Lymphoepithelial cyst. Developmental Disturbances of Salivary Glands • • • • • •

Aplasia Xerostomia Hyperplasia of palatal gland Atresia Aberrancy Developmental mandibular salivary gland depression.

Developmental Disturbances of Size of Teeth • Microdontia • Macrodonria. Development Disturbances in Shape of Teeth • • • • • • • • •

Gemination Fusion Concrescence Dilaceration Talon’s cusp Dens in dente Dens evaginatus Taurodontism Supernumerary roots.

Developmental Disturbances in Number of Teeth • • • • •

Oligodontia Anodontia Supernumerary teeth Predeciduous dentition Post permanent dentition.

Developmental Disturbances in Structure of Teeth • • • • •

Amelogenesis imperfecta Dentinogenesis imperfecta Dentin dysplasia Regional odontodysplasia Dentin hypocalcification.

Disturbances of Growth (Eruption) of Teeth • Premature eruption • Delayed eruption

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• Multiple unerupted teeth • Embedded and impacted teeth • Ankylosed teeth. Fissural (Inclusion, Developmental) Cyst of Oral Region • • • • • • • • •

Median maxillary cyst Median palatal cyst Globulomaxillary cyst Median mandibular cyst Nasoalveolar cyst Palatal cyst of the neonate Thyroglossal tract cyst Benign cervical lymphoepithelial cyst Dermoid and epidermoid cysts.

WHO CLASSIFICATION OF TUMORS OF THE ORAL CAVITY AND OROPHARYNX Malignant Epithelial Tumors • Squamous cell carcinoma - 8070/3 – Verrucous carcinoma - 8051/3 – Basaloid squamous cell carcinoma - 8083/3 – Papillary squamous cell carcinoma - 8052/3 – Spindle cell carcinoma - 8074/3 – Acantholytic squamous cell carcinoma - 8075/3 – Adenosquamous carcinoma - 8560/3 – Carcinoma cuniculatum - 8051/3 • Lymphoepithelial carcinoma - 8082/3 Epithelial Precursor Lesions Benign Epithelial Tumors • Papillomas – 8050/0 – Squamous cell papilloma and verruca vulgaris – Condyloma acuminatum – Focal epithelial hyperplasia • Granular cell tumor - 9580/0 • Keratoacanthoma - 8071/1 Salivary Gland Tumors Salivary Gland Carcinomas • Acinic cell carcinoma - 8550/3 • Mucoepidermoid carcinoma - 8430/3

Classifications

• • • • • • • • • • •

17

Adenoid cystic carcinoma - 8200/3 Polymorphous low-grade adenocarcinoma - 8525/3 Basal cell adenocarcinoma - 8147/3 Epithelial-myoepithelial carcinoma - 8562/3 Clear cell carcinoma, not otherwise specified - 8310/3 Cystadenocarcinoma - 8450/3 Mucinous adenocarcinoma - 8480/3 Oncocytic carcinoma - 8290/3 Salivary duct carcinoma - 8500/3 Myoepithelial carcinoma - 8982/3 Carcinoma ex pleomorphic adenoma - 8941/3

Salivary Gland Adenomas • • • • • •

Pleomorphic adenoma - 8940/0 Myoepithelioma - 8982/0 Basal cell adenoma - 8147/0 Canalicular adenoma - 8149/0 Duct papilloma - 8503/0 Cystadenoma - 8440/0

Soft Tissue Tumors • • • • •

Kaposi sarcoma - 9140/3] Lymphangioma - 9170/0 Ectomesenchymal chondromyxoid tumor Focal oral mucinosis Congenital granular cell epulis

Hematolymphoid Tumors • • • • • • • • • •

Diffuse large B-cell lymphoma (DLBCL) - 9680/3 Mantle cell lymphoma - 9673/3 Follicular lymphoma - 9690/3 Extranodal marginal zone B-cell lymphoma of MALT type - 9699/3 Burkitt lymphoma - 9687/3 T-cell lymphoma (including anaplastic large cell lymphoma - 9714/3 Extramedullary plasmacytoma - 9734/3 Langerhans cell histiocytosis - 9751/1 Extramedullary myeloid sarcoma - 9930/3 Follicular dendritic cell sarcoma/tumor – 9758/3

Mucosal Malignant Melanoma – 8720/3 Secondary Tumors Morphology code of the International Classification of Diseases for Oncology (ICD0) {821} and the Systematized Nomenclature of Medicine {http://snomed.org) Behavior is coded

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/0 for benign tumors /3 for malignant tumors, and /1 for borderline or uncertain behavior. (Classification adopted from: World Health Organization Classification of Tumors, Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John W Eveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 163)

TNM CLASSIFICATION OF CARCINOMAS OF THE ORAL CAVITY (WHO) TNM Classification of Carcinomas of the Lip and Oral Cavity T - Primary Tumor TX T0 Tis T1 T2 T3

-

Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ Tumor 2 cm or less in greatest dimension Tumor more than 2 cm but not more than 4 cm in greatest dimension Tumor more than 4 cm in greatest dimension

T4a (Lip) Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin (chin or nose). T4a (Oral Cavity) Tumor invades through cortical bone, into deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, or skin of face. T4b (Lip and Oral Cavity) Tumor invades masticator space, pterygoid plates, or skull base; or encases internal carotid artery. Note: Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify a tumor as T4. N-Regional Lymph Nodes (The Regional Nodes are the Cervical Nodes) NX N0 N1 N2 N2a

-

Regional lymph nodes cannot be assessed. No regional lymph node metastasis. Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension Metastasis as specified in N2a, 2b, 2c below. Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension. N2b - Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension.

Classifications

19

N2c - Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension. N3 - Metastasis in a lymph node more than 6 cm in greatest dimension. Note: Midline nodes are considered ipsilateral nodes. M- Distant Metastasis MX - Distant metastasis cannot be assessed M0 - No distant metastasis M1 - Distant metastasis (Classification adopted from: World Health Organization Classification of Tumors, Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John W Eveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 164) Stage Grouping Stage 0

Tis

N0

M0

Stage I

T1

N0

M0

Stage II

T2

N0

M0

Stage III

T1, T2 T3

N1 N0, N1

M0

Stage IVA

T1, T2, T3 T4a

N2 N0, N1, N2

M0

Stage IVB

Any T T4b

N3 Any N

M0

Stage IVC

Any T

Any N

M1

(Classification adopted from: World Health Organization Classification of Tumors, Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John W Eveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 165).

WHO HISTOLOGICAL CLASSIFICATION OF TUMORS OF THE SALIVARY GLANDS Malignant Epithelial Tumors • • • • • •

Acinic cell carcinoma - 8550/3 Mucoepidermoid carcinoma - 8430/3 Adenoid cystic carcinoma - 8200/3 Polymorphous low-grade adenocarcinoma - 8525/3 Epithelial-myoepithelial carcinoma - 8562/3 Clear cell carcinoma, not otherwise specified - 8310/3

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Practical Manual of Oral Pathology and Microbiology

Basal cell adenocarcinoma - 8147/3 Sebaceous carcinoma - 8410/3 Sebaceous lymphadenocarcinoma - 8410/3 Cystadenocarcinoma - 8440/3 Low-grade cribriform cystadenocarcinoma Mucinous adenocarcinoma - 8480/3 Oncocytic carcinoma - 8290/3 Salivary duct carcinoma - 8500/3 Adenocarcinoma, not otherwise specified - 8140/3 Myoepithelial carcinoma - 8982/3 Carcinoma ex pleomorphic adenoma - 8941/3 Carcinosarcoma - 8980/3 Metastasizing pleomorphic adenoma - 8940/1 Squamous cell carcinoma - 8070/3 Small cell carcinoma - 8041/3 Large cell carcinoma - 8012/3 Lymphoepithelial carcinoma - 8082/3 Sialoblastoma - 8974/1

Benign Epithelial Tumors • • • • • • • •

Pleomorphic adenoma - 8940/0 Myoepithelioma - 8982/0 Basal cell adenoma - 8147/0 Warthin tumor - 8561/0 Oncocytoma - 8290/0 Canalicular adenoma - 8149/0 Sebaceous adenoma - 8410/0 Lymphadenoma – Sebaceous - 8410/0 – Non-sebaceous - 8410/0 • Ductal papillomas – Inverted ductal papilloma - 8503/0 – Intraductal papilloma - 8503/0 – Sialadenoma papilliferum-8406/0 • Cystadenoma - 8440/0 Soft Tissue Tumors • Hemangioma - 9120/0 Hematolymphoid Tumors • Hodgkin lymphoma • Diffuse large B-cell lymphoma - 9680/3 • Extranodal marginal zone B-cell lymphoma - 9699/3

Classifications

21

Secondary Tumors Morphology code of the International Classification of Diseases for Oncology (ICD0) {821} and the Systematized Nomenclature of Medicine {http://snomed.org) Behavior is coded /0 for benign tumors /3 for malignant tumors, and /1 for borderline or uncertain behavior. (Classification adopted from: World Health Organization Classification of Tumors, Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John W Eveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 210)

WHO HISTOLOGICAL CLASSIFICATION OF ODONTOGENIC TUMORS Malignant Tumors Odontogenic Carcinomas • • • • • •

Metastasizing (malignant) ameloblastoma - 9310/3 Ameloblastic carcinoma - primary type - 9270/3 Ameloblastic carcinoma - secondary type (dedifferentiated), Intraosseous - 9270/3 Ameloblastic carcinoma - secondary type (dedifferentiated), peripheral - 9270/3 Primary intraosseous squamous cell carcinoma - solid type - 9270/3 Primary intraosseous squamous cell carcinoma derived from keratocystic odontogenic tumour - 9270/3 • Primary intraosseous squamous cell carcinoma derived from odontogenic cysts 9270/3 • Clear cell odontogenic carcinoma - 9341/3 • Ghost cell odontogenic carcinoma - 9302/3 Odontogenic Sarcomas • Ameloblastic fibrosarcoma - 9330/3 • Ameloblastic fibrodentino-and fibro-odontosarcoma - 9290/3 Benign Tumors Odontogenic Epithelium with Mature, Fibrous Stroma without Odontogenic Ectomesenchyme • • • • • • • •

Ameloblastoma, solid/multicystic type - 9310/0 Ameloblastoma, extraosseous/peripheral type - 9310/0 Ameloblastoma, desmoplastic type - 9310/0 Ameloblastoma, unicystic type - 9310/0 Squamous odontogenic tumor - 9312/0 Calcifying epithelial odontogenic tumor - 9340/0 Adenomatoid odontogenic tumor - 9300/0 Keratocystic odontogenic tumor - 9270/0

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Practical Manual of Oral Pathology and Microbiology

Odontogenic Epithelium with Odontogenic Ectomesenchyme, with or without Hard Tissue Formation • • • •

Ameloblastic fibroma - 9330/0 Ameloblastic fibrodentinoma - 9271/0 Ameloblastic fibro-odontoma - 9290/0 Odontoma - 9280/0 – Odontoma, complex type - 9282/0 – Odontoma, compound type - 9281/0 • Odontoameloblastoma - 9311/0 • Calcifying cystic odontogenic tumor - 9301/0 • Dentinogenic ghost cell tumor - 9302/0 Mesenchyme and/or Odontogenic Ectomesenchyme with or without Odontogenic Epithelium • Odontogenic fibroma - 9321/0 • Odontogenic myxoma/myxofibroma - 9320/0 • Cementoblastoma - 9273/0 Bone-related Lesions • • • • • • •

Ossifying fibroma – 9262/0 Fibrous dysplasia Osseous dysplasias Central giant cell lesion (granuloma) Cherubism Aneurysmal bone cyst Simple bone cyst

OTHER TUMORS Melanotic neuroectodermal tumor of infancy - 9363/0 Morphology code of the International Classification of Diseases for Oncology (ICD0) {821} and the Systematized Nomenclature of Medicine {http://snomed.org) Behavior is coded /0 for benign tumors /3 for malignant tumors, and /1 for borderline or uncertain behavior. (Classification adopted from: World Health Organization Classification of Tumors, Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John W Eveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 284)

Classifications

CLASSIFICATION OF ODONTOGENIC CYSTS (M SHEAR) I. Cyst of Jaws A. Epithelial 1. Developmental cysts a . Odontogenic Odontogenic keratocyst Eruption cyst Primordial cyst Gingival cyst of adults Lateral periodontal cyst Calcifying epithelial odontogenic cyst Botryoid odontogenic cyst Glandular odontogenic cyst b . Non-odontogenic Nasopalatine duct Median palatine median alveolar and median mandibular cysts Globulomaxillary cyst Nasolabial cyst Midpalatal raphe cyst of infants 2 . Inflammatory cyst Radicular cyst Residual cyst Inflammatory collateral cyst Paradental cyst B. Non-epithelial • Simple bone cyst (traumatic bone cyst) • Aneurysmal bone cyst II. Cysts of Maxillary Antrum • Benign mucosal cyst of maxillary antrum • Surgical ciliated cyst of maxilla . III. Cysts of Soft Tissues of Mouth, Face and Neck • • • • • • •

Dermoid and epidermoid cyst Branchial cleft cyst (lymphoepithelial cyst) Thyroglossal duct cyst Anterior median lingual cyst Oral cyst with gastric or intestinal epithelium Cystic hygroma Nasopharyngeal cysts

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• Cyst of salivary glands • Parasitic cyst, hydatid cyst, cysticercosis cellulosae; Trichinosis

ULCERATIVE LESIONS OF THE ORAL CAVITY • • • • • •

Traumatic Infectious Allergic Neoplastic Systemic Unknown Etiology and Syndromes

Traumatic 1. Physical A. Odontogenic • Resorption of periapical area around a primary tooth, exposure of root and ulceration on lips and cheeks • Rough and Badly fitting restorations • Ulcers due to teeth present at birth with sharp edges • Pressure from the splints B. Non-odontogenic • Post injection ulcers on palate • Electric burn due to live wire • Post pertussis ulcer on frenum of tongue • Epileptic ulcer 2. Thermal changes • Hot liquids • Refrigent local anesthetic 3. Chemical • Drugs, Acids, Lime, Arsenic, Bismuth, lead and Aspirin 4. Actinic • Actinic chelosis on the lips • Radiation ulcer Infections 1. Non-specific (Streptococci and staphylococci) • Non-specific infected ulcer, which is primarily traumatic 2. Specific (Bacilli and Cocci) • Aphthous ulcer, and periadenitis mucosa, Necrotica recurrens or major aphthae. • Tuberculous ulcer. • Diphtheric ulcer. • Tularemia (rabbit fever). • Granuloma inguinale. • Leprosy.

Classifications

25

• Gonorrheal ulcer. • Pneumococcal ulcer. • Ulcers of oral cavity in infections with Bacillus pseudomonas and Bacillus aeruginosa A. Spirochetal • Vincent’s infection and Noma. • Syphilis • Yaws • Bejel B. Fungal • Candidiasis • North American blastomycosis. • South American blastomycosis. • Histoplasmosis. • Cryptococcosis. • Geotrichosis. • Sporotrichosis. • Coccidiomycosis. • Chronic candidiasis syndrome. • Aspergillosis. C. Rickettsial • Macular, papular, vesicular eruptions in oral cavity found in Rickettisal pox ulcer. • Rickettsiae like organisms (Bartonella) giving rise to ulcers. D. Viral • Herpes simplex virus • Herpes zoster • Herpengina • Chickenpox • Smallpox • AIDS • Infectious mononucleosis • Dengue • Tropical sprue • Lymphogranuloma venerum • Viral enteritis E. Protozoan • American Mucocutaneous Leishmaniasis • Oriental sore (leishmania tropica parasites) Allergic •

Local application 1. Stomatitis venenata • General administration 2. Stomatitis medicamentosa.

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Neoplastic • Carcinoma • Lymphoma • Hemangioendothelioma Systemic A. Blood diseases • Leukemia • Aplastic anemia • Agranulocytosis • Cyclic neutropenia • Pernicious anemia • Iron deficiency anemia • Macroglobulinemia • Polycythemia vera B. Vitamin deficiency • Riboflavin deficiency • Nicotinic acid deficiency • Vitamin C deficiency C. Reticuloendothelial system • Histocytosis X Unknown Etiology and Syndromes • • • • • • • • • • • • • • • • • • • •

Erythema multiforme Pemphigus Epidermolysis bullosa Erosive lichen planus Lupus erythematosus Acrodermatitis enteropathica Acrodynia Aortic arch syndrome Macroglobulinemia Zinsser-Cole-Engman syndrome Felty’s syndrome Sideropenic dysphagia Acute toxic epidermal necrolysis Necrotizing sialometaplasia Lethal granuloma Crohn’s disease Pemphigoid Coeliac disease Erythema multiforme exudativum Sweet’s syndrome

Classifications

CLASSIFICATION OF GIANT CELL LESIONS Autoimmune • Wegner’s granulomatosis • Allergic granulomatosis and vasculitis (Churg-Strauss syndrome) Neoplasms • • • • • • • • • • • •

Giant cell epulis Central giant cell granuloma Peripheral giant cell granuloma Brown tumors of hyperparathyroidism Giant cell fibroma Histocytosis x Hand-Schü3ller-Christian disease Letterer-Siwe disease Eosinophilic granuloma Fibrous histiocytoma Hodgkin’s disease (Reed-Sternberg cell) Osteogenic sarcoma

Infections Bacterial • Tuberculosis • Sarcoidosis • Leprosy Viral • Herpes simplex • Herpes zoster Fungal • Histoplasmosis • Aspergulosis • Blastomycosis Disorder of Blood Vessels • Temporal arteritis Lesions Associated with Genetic Diseases • Cherubism Miscellaneous • Aneurysmal bone cyst

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• Giant cells related to exogenous substances, e.g. suture and talc and to endogenous • Substances, e.g. keratin, fat cholesterol crystals (Classification adopted from: Classification of Oral and Paraoral disorders, Sanjay Saraf, Jaypee Brothers, New Delhi)

WORKING CLASSIFICATION FOR FIBRO-OSSEOUS JAW LESIONS (CHARLES WALDRON-1993) • Fibrous dysplasia • Reactive (dysplastic) lesions arising in the tooth bearing areas. • Periapical cemento-osseous dysplasia. • Focal cemento-osseous dysplasia. • Florid cemento-osseous dysplasia. • Fibro-osseous neoplasms. These are widely designated as cementifying fibroma, ossifying fibroma, or cementoossifying fibroma.

CLASSIFICATION OF VESICULOBULLOUS LESIONS Intracorneal and Subcorneal Blisters • Pemphigus foliaceus and erythematosus Intraepidermal Blisters • Viral blistering disease • Epidermolysis bullosa Suprabasilar Blister • • • •

Pemphigus vulgaris and vegetans Paraneoplastic pemphigus Hailey Hailey disease Darrier’s disease

Subepidermal Blister with Scant Inflammation • • • • •

Epidermolysis bullosa Bullous pemphigoid Burns Toxic epidermal necrolysis Drug reactions

Subepidermal Blisters with Lymphocytes • Erythema multiforme • Paraneoplastic pemphigoid • Bullous fixed drug eruptions

Classifications

29

Subepidermal Blisters with Eosinophils • Bullous pemphigoid • Drug reactions Subepidermal Blisters with Neutrophils • • • •

Dermatitis herpetiform Cicatrical pemphigoid Bullous lupus erythematosus Epidermolysis acquisita

Other • Drug overdosage related bullae • Cancer related bullae • Bullae associated with diabetes mellitus (Classification adopted from: Classification of Oral and Paraoral disorders, Sanjay Saraf, Jaypee Brothers, New Delhi)

CLASSIFICATION OF CARIES Depending on Nature of Attack Primary caries (Incipient, initial): First attack on tooth surface Secondary caries (Recurrent): Caries occurring at the margins or walls of existing restorations. Depending on the Progression of the Caries Acute: It is rapidly invading process that involves several teeth. Lesions are soft and light colored. Usually pulp is involved at the early stage. Examples of acute caries are: – Rampant caries – Nursing bottle caries – Radiation caries Chronic: These lesions are long standing and fewer in number. Depending on Surfaces Involved • Pit and fissure caries • Smooth surface caries. Based on Direction of Caries Attack I. Forward caries: Caries that proceeds from enamel to dentin. The lesion is triangle shaped with base of the triangle at the enamel surface and apex towards dentin. In pits and fissures base is at dentinoenamel junction and the apex is in the pit.

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II. Backward caries: Caries that proceeds from dentinoenamel junction towards enamel surface. This is also triangle shaped with base at dentinoenamel junction and apex towards enamel surface. Based on Number of Surfaces Involved Simple: Only one surface is involved by caries Compound: Two surfaces are involved. Complex: More than three surfaces involved. GV Black Classification based on treatment and restoration design Class I: These lesions begin in pits, fissures and defective grooves. These are seen in occlusal surface, occlusal two-thirds of molars and lingual pits of incisors. Class II: These are lesions seen on proximal aspects of molars and premolars. Class III: These are lesions involving proximal aspects of incisors that do not involve or necessitate removal of incisal edge. Class IV: These are lesions involving proximal aspects of incisors that involve or require removal of incisal edge. Class V: These are lesions present on gingival third of all the teeth. Class VI: Lesions found on incisal edges and cusp tips. Based on Location of the Lesion Pit and Fissure Caries – Occlusal – Buccal or lingual pit Smooth Surface Caries – Proximal – Buccal or lingual surface Root Caries Based on Tissue Involved Enamel caries Dentinal caries Cemental caries. Senile caries: It is caries associated with aging process. These are almost exclusively seen on root surface. Residual caries: It is caries that is not removed during restorative procedure. Arrested caries: Sometimes progress of caries is halted by treatment or change in condition. Such lesions are mineralized but retain brown color.

Classifications

31

(Classification adopted from: Textbook of Oral Pathology, Anil Ghom, Shubangi Mhaske, Jaypee Brothers, New Delhi)

CLASSIFICATION OF FRACTURE OF TEETH Ellis Classification Group I Group II Group III Group IV Group V Group VI

-

Enamel fracture Dentin fracture without pulp exposure Crown fracture with pulp exposure Root fracture Tooth luxation Tooth intrusion

Heathersay and Morile Classification Class I Class II Class III Class IV

- Fracture line does not extend below the level of attached gingiva - Fracture line extends below the level of attached gingival but not below the level of alveolar crest - Fracture line extends below the level of alveolar crest - Fracture line within the coronal third of root but below the level of alveolar crest

WHO Classification (1978) 873.60 873.61 873.62 873.63 873.64 873.66 873.67 873.68 873.69

-

Enamel fracture Crown fracture involving enamel and Dentin without pulp exposure Crown fracture with pulp exposure Root fracture Crown root fracture Luxation Intrusion or Extrusion Avulsion Other injuries such as soft tissue laceration

CLASSIFICATION OF GINGIVAL ENLARGEMENT Depending on the etiological factors and pathological changes, Gingival enlargement is classified as: I.

II.

Inflammatory enlargement A. Chronic inflammatory enlargement B. Acute inflammatory enlargement Noninflammatory hyperplastic enlargement (gingival hyperplasia) A. Drug-induced gingival hyperplasia B. Idiopathic hyperplastic enlargement

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III. Combined enlargement IV. Conditioned enlargement A. Hormonal enlargement B. Leukemic enlargement C. Enlargement associated with vitamin C deficiency D. Nonspecific conditioned enlargement (granuloma pyogenicum) V. Neoplastic enlargement (gingival tumors) A. Benign tumors of the gingiva B. Malignant tumors of the gingiva VI. Developmental enlargement Depending on the location and distribution, Gingival enlargement is designated as: Localized: Limited to the gingiva adjacent to a single tooth or group of teeth. Generalized: Involving the gingiva throughout the mouth. Marginal: Confined to the marginal gingiva. Papillary: Confined to the interdental papilla Diffuse: Involving the marginal and attached gingivae and papillae Discrete: An isolated sessile or pedunculated “tumor-like” enlargement.

CLASSIFICATION OF PERIODONTAL DISEASES AND CONDITIONS Gingival Disease • Plaque-induced gingival diseases • Nonplaque-induced gingival lesions Chronic Periodontitis • Localized • Generalized Aggressive Periodontitis • Localized • Generalized Periodontitis as Manifestation of Systemic Disease • Necrotizing periodontal diseases • Necrotizing ulcerative gingivitis • Necrotizing ulcerative periodontitis.

Classifications

33

Abscesses of Periodontium • Gingival abscess • Periodontal abscess • Combined lesion. Periodontitis Associated with Endodontic Lesions • Endodontic-periodontal lesion • Periodontal-endodontic lesion • Combined lesion. Developmental or Acquired Deformities and Conditions • Localized tooth-related factors that predispose to induced gingival disease or periodontitis • Mucogingival deformities and conditions around teeth • Mucogingival deformities and conditions on edentulous ridges • Occlusal trauma

CLASSIFICATION OF TEMPOROMANDIBULAR JOINT DISORDERS A. Developmental disturbances – Aplasia of mandibular condyle – Hypoplasia of mandibular condyle – Hyperplasia of mandibular condyle B. Traumatic disturbances – Luxation and subluxation (complete and incomplete dislocation) – Ankylosis – Injuries of articular disk – Fractures of condyle. C. Inflammatory disturbances of TM] – Arthritis due to specific infection – Rheumatoid arthritis – Osteoarthritis – Traumatic arthritis. D. Neoplastic disturbances of the temporomandibular joint E. Extraarticular disturbances of TM] Costen syndrome Myofacial pain-dysfunction syndrome. (Classification adopted from: Textbook of Oral Pathology, Anil Ghom, Shubangi Mhaske, Jaypee Brothers, New Delhi)

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CLINICAL AND HISTOLOGICAL DIFFERENCES BETWEEN BENIGN AND MALIGNANT TUMORS Clinical Differences Features

Benign

Malignant

Growth Capsule Fixity Degeneration Recurrences Metastasis

Slow and expanding Present Absent Rare Not common Absent

Rapid and infiltrating Absent Present Common Common Usually present

Histopathological Differences Features

Benign

Malignant

Cell character (Structurally) Differentiation Loss of polarity Blood vessels Nucleus Mitosis

Not changed

Changed

Differentiated Not seen Adult type As in normal cells Absent

Undifferentiated Present Embryonic type Hyperchromatic Present

Benign Epithelial Tumors 1. 2. 3. 4.

Squamous papilloma Squamous acanthoma Keratoacanthoma Oral nevi

Malignant Epithelial Tumors 1. 2. 3. 4. 5. 6. 7. 8. 9.

Basal cell carcinoma Squamous cell carcinoma Verrucous carcinoma Spindle cell carcinoma Adenoid squamous cell carcinoma Basaloid squamous cell carcinoma Transitional cell carcinoma Nasopharyngeal carcinoma Malignant melanoma

Classifications

Benign Connective Tissue Tumors 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Fibroma Giant cell fibroma Peripheral ossifying fibroma Central ossifying fibroma Peripheral giant cell granuloma Central giant cell granuloma Giant cell tumor of bone Lipoma Hemangioma Lymphangioma Myxoma Chondroma Osteoma Osteoblastoma

Malignant Connective Tissue Tumors 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Fibrosarcoma Histiocytoma Liposarcoma Hemangiopericytoma Hemangioendothelioma Kaposi’s sarcoma Ewing’s sarcoma Chondrosarcoma Osteosarcoma Lymphomas Plasmacytoma Multiple myeloma

Benign Muscle Tissue Tumors 1. 2. 3. 4.

Leiomyoma Angiomyoma Rhabdomyoma Granular cell myoblastoma

Malignant Muscle Tissue Tumors 1. 2. 3. 4.

Leiomyosarcoma Angiomyoma Rhabdomyosarcoma Malignant granular cell myoblastoma

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Benign Nerve Tissue Tumors 1. 2. 3. 4.

Neuroma Neurofibroma Neurolemmoma Melanotic neuroectodermal tumor of infancy

Malignant Nerve Tissue Tumors 1. Malignant peripheral nerve sheath tumor 2. Olfactory neuroblastoma

Section III

Routine and Advanced Diagnostic Procedures for Oral Lesions

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Practical Manual of Oral Pathology and Microbiology

Oral Cavity, just like any other organ of the body too suffers from various disease processes. These disease processes require careful evaluation so as to arrive at the correct diagnosis and plan the treatment accordingly. The different approaches and methods employed for the assessment of various oral lesion include: I. Predominantly morphological methods a. Exfoliative cytology b. Aspiration cytology c. Quantification of histopathology d. Histochemistry e. Immunohistochemistry – Epithelial surface antigens – Intracellular components and products – Alterations of the basement membrane zone – Stromal changes f. In situ hybridization g. Electronmicroscopy II. Functional methods a. Cellular proliferation studies b. DNA histograms, cytophotometry c. Changes in the immune status d. Analysis of cell products in circulating blood e. Examination of living tissue f. Experimental models III. Microbiological involvement

COMMONLY USED DIAGNOSTIC METHODS Exfoliative Cytology • • • • • • •

One of the most easily performed chair side diagnostic procedure Screening of large areas Unlimited repetition Can be helpful in early detection of malignancy Lesions caused by herpes virus and candidal lesion can be diagnosed by scraping Limited use in premalignant disorders, more valuable in red lesions Cytological examination may help in determining the site of biopsy.

Aspiration Cytology • • • •

Microinvasive procedure More valuable than exfoliative cytology in cases of solid tumors of oral cavity Useful in cases of salivary gland lesions Micronucleus test can be performed on exfoliated cells for assessment of chromosomal damage and thus of mutagenic influences on mucosa. • Micronuclei are chromatin particles derived from accentric chromosomal fragments which are not incorporated in the daughter nuclei after mitosis • Can be visualized by chromatin stains

Routine and Advanced Diagnostic Procedures for Oral Lesions 39

Biopsy Definition: Gross and microscopic examination of tissues of cells removed from a living patient for the purpose of diagnosis or prognosis of disease or the confirmation of normal conditions. Uses: • Diagnosis of a pathologic lesion. • Grading of tumor for diagnosis. • Determining neoplastic and non-neoplastic lesions. • Diagnosis of metastatic lesions. • Evaluation of recurrence • Therapeutic assessment. • Differentiation between benign and malignant lesions. Types Commonly used • Aspiration • Curettage • Excisional • Incisional • Fine needle • Punch • Scrape • Trephine • Exfoliative cytology • Unexplained Complications • • • • • •

Hemorrhage Infection Poor wound healing Spread of tumor cells Injury to adjacent organs Reaction to the local anesthesia

Less commonly used • Bite • Brush • Cone • Core • Endoscopic • Irrigation • Pressure • Shave • Sponge

Section IV

Staining Procedures and Special Stains

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Processing Definition: It is a process in which tissues are treated with various chemicals, in order to make the miscible with Paraffin wax (embedding medium). Procedure: Formalin fixed tissue is passed through series of chemicals in order to prepare the tissue so that sections can be taken and subsequently stained. (Fixative: 10% formalin) Dehydration of tissue by immersing in ⎯⎯⎯⎯⎯→ 70% Alcohol ⎯⎯⎯⎯⎯→ 1 hour Three changes in acetone Acetone I ⎯⎯⎯⎯⎯→ 1 hour Acetone II ⎯⎯⎯⎯⎯→ 1 hour Acetone III⎯⎯⎯⎯⎯→ 1 hour Clearing: To remove acetone from tissue

- Acetone + xylene 1 hr. - Xylene 1 hr. - Xylene 1 hr. After dehydration and clearing tissue is kept in molten Paraffin Wax for 2 hrs. Tissue is embedded with proper orientation in ‘L’ (Leukhart’s) Block using molten Paraffin Wax. The Paraffin block with tissue is mounted, fixed on metallic chuck on the microtome for acquiring serial section of 3-5 microns. Serial sections are taken on microscopic glass slide. Tissues are fixed to the slide with egg albumin. It is kept on the slide warmer and then stained with Hematoxylin and Eosin for routine microscopy. Routine and Special Stains Appearance under Microscope Name of Stain

Tissues

Reaction

1. Hematoxylin and Eosin

Nuclei Cytoplasm Muscle fibers Red blood cells Fibrin

Blue/Black Varying shades of pink Deep pink/Red Orange/Red Deep pink

2. Von Gieson

Nucleus Collagen Other tissues

Blue/Black Red Yellow (Contd...)

Staining Procedures and Special Stains 43

(Contd...) Name of Stain 3. Masson’s Trichrome

Tissues

Reaction

Nucleus Cytoplasm Muscle Erythrocytes Collagen

Blue/Black Red Red Red Blue

4. Periodic Acid Solution Carbohydrate (PAS) Nucleus (Periodic Acid-Schiff) Glycogen

Magenta Blue Magenta

5. Mallory Stain

Muscle striation Fibrin Myelin Collagen Cartilage Elastic fiber Cytoplasm

Dark blue Dark blue Dark blue Deep brown blue Deep brown blue Deep brown blue Pale pinkish

6. Sudan black

Unsaturated esters and triglycerides Phospholipids Sphingomyelin

Blue-black Gray Bronze in polarized light

7. Mucicarmine

Mucins Nuclei Background

Red Blue Unstained

8. Standard Toluidine blue

Amyloid and many other tissue components Amyloid

Orthochromatic blue

9. Congo Red

Amyloid, Elastic fibers, Eosinophil granules Nuclei

10. Giemsa

Protozoans and some other microorganisms Background Nuclei

Dark red birefringence in polarized light Red Blue Dark blue Pink-Pale blue Blue (Contd...)

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(Contd...) Name of Stain

Tissues

Reaction

11. Alcian blue

Acid mucins Nuclei

Blue Red

12. Alcian blue-Alcian yellow

Sulfated mucins Carboxylated mucins Mixtures of above Nuclei

Blue Yellow Green Red

Microbial Staining Classification of Stains • Simple Staining • •

• •

• • •

: Positive staining Negative staining Differential Staining : Gram’s staining Ziehl-Neelsen’s staining Special Staining : – Albert stain – Capsular stain – Flagellar stain Positive Staining : Bacteria Stained with basic stains, bacterial morphology appreciated. Negative Staining : When bacteria are very small, and encapsulated and cannot be demonstrated by +ve staining, then background is stained by using acidic dye in which the bacteria, stand out in contrast Indian ink : Imparts black/gray color. Nigrosin : Imparts blue/bluish violet or violet color Purpose of simple staining : is to study the structural details of bacteria.

Gram’s Stain • • • •

Crystal violet Gram’s lodine Absolute alcohol/Sprit Dilute carbol/Fuschin

• Crystal violet and distilled water • Acts as Mordant • Decolouriser • Counter stain

(Carbol Fuschin and distilled water) • Take uniform smear • Smear is dried fixed by passing over the sprit lamp. • Cover the Smear with crystal violet, gentian violet, Methyl violet, solution and allow to remain on the slide for 1 minute.

Staining Procedures and Special Stains 45

• Discard the crystalline violet (residual stain) cover the smear with fresh iodine solution for 1minute. • Rinse with absolute alcohol till you get clear color flow from the slide (10-15 sec.) • Wash with water • Cover with safranine dilute carbol fuschin (1.20) neutral red and allow it to remain for 1 minute • Rinse with water dry • Examine under oil immersion • Gram +ve organisms – Violet (Basophilic) • Gram –ve organisms – Pink (Eosinophilic) Cocci – oval or round in shape Gram +ve cocci – Arranged in clusters (Staphylococcus) – Arranged in chain (Streptococcus) Bacilli – Rod shaped • Gram +ve Bacilli – C. diptheriae, clostridium • Gram –ve Bacilli – Salmonella, Shigella • Organisms which resist decolorising with absolute alcohol take up violet color– Designated as gram +ve • Those organisms decolorised with acid alcohol. Counterstained with safranine take up pink color and are termed as Gram –ve organisms. • Gram’s staining is used for classification of bacteria. • For the provisional diagnosis. Acid-fast Stain (Ziehl-Neelsen’s Stain) • Mycobacteria have the power of retaining certain stain even after decolorized by mineral acids. Known as “Acid Fastness” (This is due to the presence of lipid mycolic acid). Solutions: • Strong Carbol fuschin (Basic Fuschin, Absolute alcohol, phenol and water) • Sulphuric acid 20% solution. • Methylene blue. • Preparation of smear • Fixation of the smear by gently passing the side over the flame. • Cover the side with carbol fuschin and heat the slide in intervals until steam rises for 5-7 minutes. Heating makes – Thick lipid cell wall of bacterium permeable to the dye • Wash in running tap water. • Decolorize with sulphuric acid (20%). Decolorization should be continued till the film becomes faintly pink. Decolorization must be done in stages and generally requires about 10 minutes.

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• Wash in running tap water • Counter stain the smear with methylene blue for 1-2 minutes. • Wash in running tap water • Blot, dry examine with oil immersion objective • Acid-Fast bacilli – Red • Tissue and other organisms – Blue Acid-Fast organisms • Mycobacterium tuberculi • Mycobacterium leprae

Section V

Normal Values of Formed Elements in Blood

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RED BLOOD CELL Normal Red Blood Cell Count Males: 5.5 ± 1.1 × 1012/l Females: 4.8 ± 1.1 × 1012/l Infants (Full term, cord blood): 5.0 ± 1.1 × 1012/l Children, 1 year: 4.4 ± 0.8 × 1012/l Children, 10-12 years: 4.7 ± 0.7 × 1012/l Hemoglobin Males: 15.5 ± 2.5 g/dl Females: 14.0 ± 2.5 g/dl Infants (Full term, cord blood): 16.5 ± 3.0 g/dl Children, 1 year: 12.0 ± 1.0 g/dl Children, 10-12 years: 13.0 ± 1.5 g/dl Packed Cell Volume (PCV: Hematocrit) Males: 0.47 ± 0.07 (l/l) Females: 0.42 ± 0.05 (l/l) Infants (Full term, cord blood): 0.54 ± 0.10 (l/l) Children, 1 year: 0.38 ± 0.06 (l/l) Children, 10-12 years: 0.41 ± 0.04 (l/l) Mean Cell Volume (MCV) Adults: 85 ± 8 fl Infants (Full term, cord blood): 106 fl Children, 1 year: 78 ± 8 fl Children, 10-12 years: 84 ± 7 fl Mean Cell Hemoglobin (MCH) Adults: 29.5 ± 2.5 pg Mean Cell Hemoglobin Concentration (MCHC) Adults and children: 33 ± 2 g/dl Mean Cell Diameter Adults: 6.7 - 7.7 µm Reticulocytes Adults and children: 0.2-2.0% (10 – 100 × 109/l) Infants (Full term, cord blood): 2-6% (mean 150 × 109/l)

Normal Values of Formed Elements in Blood 49

WHITE BLOOD CELL Normal White Blood Cell Count Adults: 4 – 11 × 109/l Infants (full term, at birth): 10 – 25 × 109/l Infants (1 year): 6 – 18 × 109/l Childhood (4-7 years): 5 – 15 × 109/l Childhood (8-12 years): 4.5 – 13.5 × 109/l Normal Differential White Blood Cell Count Adults Neutrophils Lymphocytes Monocytes Eosinophils Basophils

40 – 75% 20 – 50% 02 – 10% 01 – 06% < 01%

PLATELETS Normal Platelet Count Adults: 150 – 400 × 109/l

2.0 - 7.5 × 109/l 1.5 - 4.0 × 109/l 0.2 - 0.8 × 109/l 0.04 - 0.4 × 109/l 0.01 - 0.1 × 109/l

Section VI

Common Syndromes Affecting Oral Cavity

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Acquired Immunodeficiency Syndrome (Common Oral Lesions Associated) – – – – – – – – – – –

Hairy leukoplakia Candidiasis Kaposi sarcoma Non-Hodgkin’s lymphoma Bacterial infections Herpes zoster infection Varicella zoster infection Squamous cell carcinoma Xerostomia Aphthous stomatitis Gingivitis and periodontitis

Adrenogenital Syndrome – – – – –

Occurs due to hyperplasia or tumors of the adrenal cortex Pseudohermaphroditism Sexual precocity Virilism in women and feminization in men Premature eruption of teeth

Albright Syndrome – – – – – – – – – –

Mental retardation Olfactory dysfunction Low nasal bridge Short neck Calcifications in subcutaneous tissue in scalp, brain and along the extremities Short metacarpals and metatarsals Hypogonadism and hypothyroidism Enamel hypoplasia Widened root canals Delayed eruption

Apert Syndrome – – – – – – – – –

Hyperacrobrachycephaly Retruded middle third of face Mandibular prognathism Depressed nasal bridge, parrot-beaked nose and deviated nasal septum Hypertelorism, proptosis, downslanting palpebral fissures, strabismus Lips have trapezoidal configuration Palate constricted, high arched and usually has a median furrow V shaped maxillary alveolar ridge, crowding of teeth with bulging alveolar ridges Class III malocclusion with anterior open bite and anterior as well as posterior crossbite

Common Syndromes Affecting Oral Cavity 53

– Short hard palate and long and thick soft palate – Delayed eruption Ascher’s Syndrome – – – – –

Sagging eyelids Lid skin is thin and atrophic Double lip Blepharochalasis Non-toxic thyroid enlargement

Auriculotemporal Syndrome (Frey’s Syndrome) – Flushing, sweating and warmth and sometimes mild pain in the preauricular and temporal area of the involved side of face during strong salivary stimulus – Usually is seen after conservative parotidectomy or direct trauma to parotid region or mandibular condylar head – Etiology in most cases is trauma to auriculotemporal nerve. Baby Bottle Syndrome (Nursing Caries, Bottle Mouth Syndrome) – Widespread carious destruction of deciduous teeth, most commonly maxillary incisors followed by first molar and cuspids. – Carious process may completely destroy tooth crown. Basal Cell Nevus-Jaw Cyst-Bifid Rib Syndrome (Gorlin-Goltz Syndrome) – Cutaneous anomalies including basal cell carcinoma, benign dermal cysts and tumors, palmar pitting, palmar and plantar keratosis and dermal calcinosis – Dental and osseous anomalies including odontogenic keratocysts, mild mandibular prognathism, rib anomalies, vertebral anomalies and brachymetacarpalism – Ophthalmologic anomalies including hypertelorism with wide nasal bridge, dystopia canthorum, congenital blindness and internal strabismus – Neurologic anomalies including mental retardation, dural calcification, agenesis of corpus callosum, congenital hydrocephalus and occurrence of medulloblastomas – Sexual anomalies including hypogonadism in males and ovarian tumors in females. Beckwith-Wiedemann Syndrome – Increased birth weight, postnatal gigantism, accelerated osseous maturation, asymmetry, skeletal anomalies – Seizures, apnea, cyanosis, mental deficiency – Earlobe grooves, flame nevus, craniofacial dysmorphism, mild microcephaly – Umbilical hernia, hepatomegaly, splenomegaly, nephromegaly, genitourinary anomalies, cardiac anomalies, diaphragmatic anomalies, inguinal hernia, gastrointestinal anomalies. – Macroglossia, anterior open bite, prognathic mandible – Neonatal hypoglycemia, polycythemia, hypocalcemia, hypocholestremia, hyperlipidemia

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Behcet’s Syndrome – – – – –

Recurrent conjunctivitis Multiple recurrent Aphthous stomatitis Absence of lingual fungiform papillae Caused by pleuropneumonia like organism (PPLO) Genital lesions

BK Mole Syndrome – Autosomal dominant condition – Large pigmented nevi – High risk of melanoma development Chorda Tympani Syndrome – Sweating and flushing of skin of chin and submental region – May accompany surgery or injury to submandibular gland Cowden’s Syndrome or Multiple Hamartoma Syndrome – Mucocutaneous—Multiple facial papules, acral keratoses, palmoplantar keratoses, multiple oral papillomas, dermal fibromas, multiple skin tags, oral fibromas, scrotal tongue, lipomas, cutaneous and oral malignancies – Thyroid gland—Goiter, adenoma, hyperthyroidism, hypothyroidism, thyroiditis, thyroglossal duct cyst, follicular adenocarcinoma – Female breast—Fibrocystic disease, anatomic abnormalities, virginal hypertrophy, ductal adenocarcinoma, ductal papilloma – Male breast—Benign gynecomastia – Female genitourinary system—Menstrual irregularities, ovarian abnormalities (mainly cysts), leiomyomas, vaginal and vulvar cysts, adenocarcinoma of uterus, carcinoma of uterine cervix, carcinoma of ovary, transitional cell carcinoma of renal pelvis – Male genitourinary system—Hydrocele, varicocele, transitional cell carcinoma of bladder – Gastrointestinal tract—Polyps of upper GI tract, Polyps of colon and rectosigmoid, Diverticula of colon and sigmoid, Ganglioneuromas and neuromas, epithelioid leiomyoma of rectosigmoid, hepatic hamartoma, adenocarcinoma of cecum, adenocarcinoma of colon – Facial dysmorphism and skeletal abnormalities—High head circumference, Adenoid facies, highly arched palate, kyphosis, kyphoscoliosis, hand and foot abnormalities, pectus excavatum, bone cysts – Nervous system—Neuromas of cutaneous nerves, neurofibroma, meningioma, hearing loss – Eye—Cataracts, angioid streaks, congenital blood vessel anomaly, myopia

Common Syndromes Affecting Oral Cavity 55

CREST Syndrome – – – – –

Calcinosis cutis Reynaud’s phenomenon Esophageal dysfunction Sclerodactly Telangiectasia of the face, oral mucosa, hands and upper trunk

Crouzon Syndrome (Craniofacial Dysostosis) – Craniosynostosis Coronal and sagittal coronal, sagittal, and lambdoidal Sagittal and lambdoidal – Neurologic frequent headaches, seizures, marked mental deficiency, Agenesis of corpus callosum – Ophthalmologic ocular proptosis, Exotropia, Poor vision, Optic atrophy, Blindness Nystagmus, iris coloboma, exposure conjunctivitis, exposure keratitis – Aural—Mild to moderate hearing deficit, atresia of external auditory canal – Oral—Cleft lip, cleft palate, bifid uvula, lateral palatal swellings, obligatory mouth breathing. – Other—Calcification of stylohyoid ligament, cervical spine anomalies. Down’s Syndrome (Trisomy-21) – – – – – – – – – – – – – –

Flat face Large anterior fontanel and open sutures Small slanting eyes with epicanthal folds Mental deficiency Open mouth with prognathism Sexual underdevelopment Cardiac abnormalities Hypermobility of joints Short stature Short neck Macroglossia and protrusion of tongue Fissured or pebbly tongue High arched palate Malformed teeth exhibiting enamel hypoplasia and microdontia

Eagle’s Syndrome – Elongation of the styloid process (Normal- 25 mm) or ossification of stylohyoid ligament causing dysphagia – Sore throat – Otalgia – Glossodynia – Headache – Vague orofacial pain or pain along the distribution of internal and external carotid arteries

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Ehlers-Danlos Syndrome – – – – – – – – –

Hyperelasticity of skin Hyperextensibility of joints Fragility of skin and blood vessels leading to excessive bleeding Defective healing of skin wounds Fragile and bruised oral mucosa Hypermobility of temporomandibular joint with frequent dislocation Hypoplasia of enamel Extensive periodontal destruction Lack of normal scalloping of DEJ

Fanconi’s Syndrome – – – – –

Congenital and sometimes familial aplastic anemia Bone abnormalities Microcephaly Hypogenitalism Olive brown pigmentation of skin

Focal Dermal Hypoplasia Syndrome (Goltz-Gorlin Syndrome) – – – – – – – – – – –

Focal absence of dermis associated with herniation of fat into the defect Skin atrophy Streaky pigmentation and telangiectasia Multiple papillomas of skin or mucosa Anomalies of the extremities including syndactly, polydactyly and adactyly Sunken eyes with sparse eyebrows and scalp hairs Ocular anomalies like iris and choroids colobomata and strabismus Mental retardation Papillomas of the lip, buccal mucosa and gingival Teeth are defective in size, shape and structure Cleft lips/cleft palate

Gardner Syndrome – – – – –

Multiple osteoma Multiple supernumerary teeth Compound odontoma Unerupted teeth Hypercementosis

Goldenhar Syndrome – Facies – Marked facial asymmetry, maxillary, malar and temporal bones are reduced in size and flattened – Eyes – Blepharoptosis, anophthalmia or microphthalmia, impaired vision – Ear – Anotia to ill defined mass of tissue, supernumerary ear tags, narrow external auditory canals, hearing loss

Common Syndromes Affecting Oral Cavity 57

– – – – – –

CNS – Skull defects, brain defects, mental retardation Lung – Incomplete lobulation to hypoplasia to agenesis Kidney – Absent kidney, double ureter, hydronephrosis GIT – Imperforate anus Heart – Transposition of great vessels, cardiomegaly, pulmonary stenosis Skeletal alterations – Decreased anterior posterior and vertical dimension of face, skull defects – Oral manifestations – Agenesis of mandibular ramus, agenesis of parotid gland, cleft lip and palate, delayed tooth development, malocclusion. Grinspan Syndrome – Lichen planus – Diabetes mellitus – Vascular hypertension Hunter Syndrome (Mucopolysaccharoidosis II) – Facies—Macrocephaly – Skeletal system—Short neck, broad chest, protruding abdomen, umbilical hernia, short stature, restricted joint mobility – Other findings—Progressive loss of intelligence in severe cases, increased muscle tone, hyperactive muscle reflexes, terminal convulsions, impaired vision, progressive loss of hearing, death of patient usually in early adulthood – Oral manifestations—Widely spaced teeth, enlarged tongue, condylar deformities, cystic alterations, sleep apnea, airway obstruction. Hurler Syndrome (Mucopolysaccharoidosis I-H) – – – – – – –

Growth failure after infancy Marked mental retardation Craniofacial dysmorphism and physical habitus Dysostosis multiplex Corneal clouding, Excessive urinary secretion of dermatan sulfate and heparan sulfate Histochemical and biochemical evidence of intracellular lysosomal storage of glycosaminoglycans – Microcephaly, hernias and recurrent respiratory infections – Oral manifestations—Enlarged and patulous lips, flattened philtrum, macroglossia, widely spaced teeth, anterior open bite, hyperplastic alveolar ridges, short and broad mandible, airway obstruction and sleep apnea. Jaw Winking Syndrome – Unilateral congenital ptosis – Rapid exaggerated elevation of the ptotic lid on moving the lower jaw to the contralateral side.

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Marfan Syndrome – – – – – – – – – –

Excessive length of tubular bone Arachnodactyly or spidery fingers Long and narrow skull and face Hyperextensibility of the joint with habitual dislocation Kyphosis or scoliosis Flat foot Bilateral ectopia lentis Myopia Aortic aneurysm and aortic regurgitation Valvular defects and cardiomegaly

Maroteaux Lamy Syndrome (Mucopolysaccharoidosis VI) – – – – – – – – – –

Prominent forehead Hypertelorism Depressed nasal bridge Full cheeks and lips Broad jaws Deformed chest with prominent sternum Hepatomegaly Vision and hearing defects Macroglossia Widely spaced teeth

Median Cleft Face Syndrome – – – – – – – – –

Face closely resembling embryonal face Frontonasal malformation Hypertelorism Secondary telecanthus Encephalomeningocele Widely spaced nostrils with broad nasal root, nose tags Preauricular tags, absent tragus Occasional mental deficiency Cleft lip-palate

Melkersson-Rosenthal Syndrome – Cheilitis granulomatosa – Facial paralysis – Scrotal tongue Multiple Endocrine Neoplasia (MEN) Syndrome Type 2 B (Multiple Mucosal Neuroma Syndrome) – Wide eyed expression

Common Syndromes Affecting Oral Cavity 59

– – – – – – – – – – – – – – –

Broad based nose Large nodular lips with submucosal nodules on vermillion border Eversion of upper eyelids Pedunclated neuromas on palpebral conjunctiva eyelid margins, cornea Neuromas of nose, larynx and bronchial mucosa Medullary carcinomas of thyroid Pheochromocytoma of adrenal gland Abdominal distension Megacolon Diverticulosis Marfanoid habitus Mucosal neuromas of lip, tongue, buccal mucosa, gingival Posterior crossbite High palatal vault Mandibular retrognathia

Myofacial Pain Dysfunction Syndrome – – – – – –

Spasm in masticatory muscles TMJ Crepitation Decreased TMJ mobility Periauricular pain Headache Tenderness on palpation.

Oral Facial Digital Syndrome – – – – –

Minor facial anomalies Cleft or lobulated tongue Oral frenulae Cleft palate Brachydactyly, syndactyly, clinodactyly, polydactyly

Papillon-Lefevre Syndrome – – – – – – – –

Diffusely red and scaly palm and soles Hyperkeratosis of palms Thickening of plantar skin Gingival swells, bleeds and becomes boggy Marked halitosis Deep periodontal pockets Early exfoliation of deciduous teeth Early exfoliation of permanent teeth

Parry-Romberg Syndrome (Progressive Hemifacial Atrophy) – Misshapen ear or small ear – Basilar kyphosis

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Atrophy of muscle, bone and cartilage on affected side Dark pigmentation of the affected side Atrophy of half upper lip and tongue Shorter ramus and body of mandible resulting in malocclusion Delayed eruption of teeth on affected side Jacksonian epilepsy, trigeminal neuralgia, facial paresthesia

Peutz-Jeghers Syndrome – GI symptoms—Polyposis of small intestine, intermittent colic pain, intestinal bleeding – Skin—Discreet, brown to bluish black macules usually about orifices of body – Ovarian cysts and tumors and uterine adenocarcinomas – Breast carcinoma and pancreatic carcinomas, gynecomastia and testis enlargement – Oral manifestations—Round, oval or irregular macules especially on lower lip of size 1mm to 1cm, macular lesions may also be found on buccal mucosa, gingival and palate, rarely oral papillomas and oral polyposis may also be seen. Pierre-Robin Syndrome – – – – – –

Cleft palate Micrognathia Glossoptosis Congenital heart defects Ocular anomalies Skeletal defects

Plummer-Vinson Syndrome (Paterson-Kelly Syndrome) – – – – – – –

Burning sensation associated with tongue and oral mucosa Angular cheilitis Atrophy of lingual papillae Dysphagia Esophageal webs Koilonychia Iron deficiency anemia

Ramsay Hunt Syndrome – Infection of geniculate ganglion resulting in vesicular eruptions of external ear and oral mucosa – Facial palsy of lower motor neuron – Severe pain in external auditory canal and pinna – Ipsilateral loss of taste sensation and lacrimation – Vesicular eruptions on tongue, buccal mucosa, peritonsillar area

Common Syndromes Affecting Oral Cavity 61

Rubinstein-Taybi Syndrome – – – – –

Developmental retardation Broad thumbs and great toes Delayed or incomplete descent of testis in males Bone age below fiftieth percentile Talons cusp

Reiter’s Syndrome – – – –

Urethritis associated with itching and burning sensation Bilaterally symmetrical polyarticular arthritis Conjunctivitis Granular or vesicular lesions on tongue, gingiva

Sjögren’s Syndrome (Primary, Sicca Complex) – Dry eyes – Dry mouth Sjögren’s Syndrome (Secondary) – – – – –

Dry eyes Dry mouth Polyarteritis nodosa Polymyositis or scleroderma Rheumatoid arthritis

Staphylococcal Scalded Skin Syndrome (Ritter’s Disease) – Begins abruptly with diffuse erythema and fever – Appearance of large flaccid bullae – Separation and exfoliation of superficial epidermis Stevens-Johnson Syndrome – – – – – –

Pseudomembrane covered vesicle or bulla Mucosal vesicles or bulla which rupture leaving raw eroded surface Halitosis Dysphagia Ocular lesions consist of photophobia, keratoconjunctivitis, panophthalmitis Genital lesions include nonspecific uretheritis, balanitis and/or vaginal ulcers.

Treacher Collins Syndrome – Antimongoloid palpebral fissures with a coloboma of outer portion of the lower lids and deficiency of eyelashes – Hypoplasia of facial bones especially malar bones and mandible – Malformation of external ear and occasionally middle and internal ear

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– Macrostomia, high palate, abnormal position and malocclusion of teeth – Blind fistulas between the angles of ear and angles of the mouth – Atypical hair growth in the form of tongue like process of the hairline extending towards the cheeks – Facial clefts and skeletal deformities – Birdlike or fishlike facies van der Woude’s Syndrome – Paramedian lip pits – Cleft lip and/or cleft palate Wiskott-Aldrich Syndrome – – – – – – –

Thrombocytopenic purpura Eczema usually beginning on face Increased susceptibility to infection Otitis media Bloody diarrhea Respiratory infection Malignant lymphoma

Section VII

Identifying Histopathological Features of Common Oral Lesions

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Fordyce’s Granules – – – –

Heterotropic collection of sebaceous glands similar to skin Absence of hair follicle Ducts opening onto the surface Normal connective tissue with blood vessels and few inflammatory cells

Fibromatosis Gingivae – – – –

Thick epithelium Elongated rete ridges Coarse collagen fibers Few blood vessels and inflammatory cells

Amelogenesis Imperfecta – Defect in matrix formation to total absence of matrix in hypoplastic type – Defect in matrix structure and mineral deposition in hypocalcification type – Defects of rod sheath and enamel rods in hypomaturation type. Dentin Dysplasia (Type I, Radicular Type) – – – –

Normal coronal dentin Calcified tubular dentin Osteodentin Characteristic lava flowing around boulders appearance

Dentin Dysplasia (Type II, Coronal Type) – Normal coronal dentin – Multiple true pulp stones Squamous Papilloma – Thin, long, finger like projections extending above the surface of epithelium – Thin central connective tissue core having nutrient blood vessels – Koilocytes are occasionally seen. Intradermal Oral Nevi – Nevus cells within connective tissue separated from epithelium by a well defined band. Junctional Oral Nevi – No zone of demarcation and nevus cells seem to be blending with epithelium – Nevus cells may seem to be growing into connective tissue giving rise to Abtropfung (Dropping off) effect. Compound Oral Nevi – Abtropfung effect as well as large nests of cells populating connective tissue

Identifying Histopathological Features of Common Oral Lesions 65

Blue Nevus – In common blue nevus, elongated melanocytes lie in bundles oriented parallel to epidermis in the middle and lower third of dermis – In cellular blue nevus high cellular activity is seen. Dysplasia – – – – – – – – – – – – –

Loss of architectural orientation Cellular pleomorphism Hyperchromatism Altered nuclear cytoplasmic ratio Increased and abnormal mitosis Individual cell keratinization and intraepithelial keratin pearl formation Drop shaped rete ridges Basal cell hyperplasia/more than one layer having basaloid appearance Increased number and size of nucleoli Abnormal variation in nuclear size Abnormal variation in nuclear shape Division of nuclei without division of cytoplasm Dyskaryosis or nuclear atypia including giant nuclei.

Note: Depending upon the presence of dysplastic features, the epithelial dysplasia is classified as mild, moderate and severe. Mild dysplasia—Architectural disturbances limited to lower third of epithelium accompanied by minimal cytological atypia. Moderate dysplasia—Architectural disturbances extending into the middle third of epithelium accompanied by varied degree of cytological atypia. Severe dysplasia—Architectural disturbances involving more than two thirds of epithelium with associated cytological atypia. Carcinoma in situ—Full thickness or almost full thickness architectural abnormalities in the viable cellular layers accompanied by marked cytological atypia). Leukoplakia – – – –

Hyperparakeratosis Hyperorthokeratosis Acanthosis Any or few or no features of epithelial dysplasia may be present.

Erythroplakia – Atrophic or hyperplastic epithelium with lack of keratinization – Thin epithelium – Moderate degree of inflammation

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Oral Lichen Planus – Parakeratinized atrophic epithelium – Liquefaction degeneration of the basal cell layer – Variable thickness of band of chronic inflammatory cells juxtaepithelially. Oral Submucous Fibrosis (OSMF) – – – – –

Hyperplastic epithelium in early OSMF Progressive OSMF shows atrophic epithelium Juxtaepithelial inflammatory cell reaction Hyalinization and homogenization of collagen bundles Blood vessels may be normal, dilated or constricted depending on clinical staging of OSMF.

Basal Cell Carcinoma – Nests, sheets or islands of cells in connective tissue stroma having typical large, hyperchromatic, oval nuclei with little cytoplasm. – Cells at periphery show palisading – Variable mitotic figures Well Differentiated Squamous Cell Carcinoma – Invasion of connective tissue by lesional epithelium through the basement membrane in the form of islands, sheets or nests – Individual cell keratinization/Formation of epithelial or keratin pearls – Variable number of mitotic figures – Hyperchromatic nuclei – Variable degree of inflammatory cells and angiogenesis Moderately Differentiated Squamous Cell Carcinoma – Invasion of connective tissue by lesional epithelium through the basement membrane in the form of islands, sheets or nests although the resemblance to squamous epithelium is less pronounced – Alteration in the shape and size of individual cells more pronounced – Rapid growth rate of malignant cells – Increased number of mitotic figures – Lack of keratinization – Marked connective tissue response in the form of inflammation and angiogenesis. Poorly Differentiated Squamous Cell Carcinoma – Invasion of connective tissue by malignant epithelial cells which bear little resemblance to cell of origin. – All or most of the dysplastic features are evident with the malignant cells – Loss of intercellular junctions

Identifying Histopathological Features of Common Oral Lesions 67

– Connective tissue response in the form of inflammatory cells and angiogenesis – Most difficult to diagnose Verrucous Carcinoma – – – – –

Abrupt transition from normal to lesional epithelium Bulbous rete ridges True invasion absent Cleft like spaces lined by thick parakeratin Parakeratinized plugging is hallmark of the lesion and is seen extending into epithelium – Intraepithelial abscess formation may occur – Less cellular atypia than Squamous cell carcinoma – Intense chronic inflammatory cell infiltrate in subjacent connective tissue Malignant Melanoma – Atypical melanocytes are seen either at the junction of epithelium and connective tissue (Radial growth phase) or invading the connective tissue (Vertical growth phase) – Loosely arranged cords or sheets of pleomorphic cells – Moderate to intense mitotic activity – Hyperchromatism – Melanin pigment is observed in malignant cells Fibroma – – – –

Covered by stratified squamous epithelium Rete ridges may show shortening due to stretching of epithelium Connective tissue shows interlacing collagenous fibers Trauma may lead to proliferation of blood vessels and inflammatory cells

Ossifying Fibroma – – – – – –

Intact or ulcerated stratified squamous epithelium Cellular connective tissue stroma Plump proliferating fibroblasts Calcifications either in the form of bone or acellular cementum is evident In some instances multinucleated giant cells may be seen Inflammatory cells population dependent on secondary factors like trauma or infection.

Peripheral Giant Cell Granuloma – Proliferating multinucleated giant cells containing few to several dozen nuclei – Delicate reticular and fibrillar connective tissue stroma – Zone of dense connective tissue separates giant cell proliferation from surface epithelium

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– Acute and chronic inflammatory cell infiltrate is present – Foci of calcified tissue may be evident. Central Giant Cell Granuloma – – – – –

Loose fibrillar connective tissue stroma Whorled appearance of collagen fibers Giant cells distributed evenly throughout stroma Number of nuclei may vary from few to several dozen Foci of osteoid or bone may be seen

Aneurysmal Bone Cyst – Fibrous connective tissue stroma containing cavernous or sinusoidal blood filled spaces – Numerous young fibroblasts – Patchy distribution of multinucleated giant cells – Reactive bone formation – Varying amount of hemosiderin is present Lipoma – Thin fibrous capsule and well circumscribed lesion – Contains mature fat cells – Cartilaginous or osseous metaplasia may be seen Capillary Hemangioma – Small capillaries lined by single layer of endothelial cells Cavernous Hemangioma – Large dilated blood sinuses with thin walls having endothelial lining – Sinusoidal spaces filled with blood Myxoma – Loosely arranged tissue with moderate amount of reticulin fibers and mucoid material – Stellate shaped cells – Invasion of the surrounding tissue Chondroma – Hyaline cartilage with areas of calcification or necrosis – Cartilage cells appear as small cells which are uninucleated Osteoma – Made up of either dense normal appearing compact bone or cancellous bone – Usually a well circumscribed lesion – On rare occasions foci of cartilage or myxomatous tissue may be evident

Identifying Histopathological Features of Common Oral Lesions 69

Fibrosarcoma (Well Differentiated) – Multiple plump fibroblasts with pale eosinophilic cytoplasm and deeply staining nuclei – Few mitotic figures – Cells are not pleomorphic Fibrosarcoma (Moderately Differentiated) – – – –

Cellular tumors with typical herringbone pattern Cellular pleomorphism evident Rich collagenous stroma Few areas of hyalinization

Fibrosarcoma (Poorly Differentiated) – – – – – –

Highly anaplastic lesions Marked cellularity Marked cellular atypia Marked pleomorphism Sparse collagenous stroma Abundant round cells

Chondrosarcoma – Hypercellularity with many cells containing plump nuclei – Binucleated cells are evident – Giant cartilage cells Osteosarcoma – Proliferation of atypical osteoblasts – Formation of osteoid by malignant osteoblasts – Stromal cells are spindle shaped and atypical with irregular shaped nuclei Nodular Sclerosis Hodgkin’s Lymphoma – – – –

Cells arranged in nodular pattern Capsule is thickened Node divided into nodules by thick fibrous bands Characteristic Reed-Sternberg cell

Mixed Cellularity Hodgkin’s Lymphoma – Diffuse infiltrate of lymphocytes – Classic Reed-Sternberg cells (Characteristic Binucleated, Owl’s eye appearance) Lymphocyte Depleted Hodgkin’s Lymphoma – Decreased number of lymphocytes hence appears hypocellular – Numerous Reed-Sternberg cells

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Lymphocyte Rich Hodgkin’s Lymphoma – Increased lymphocytes – Classic or lacunar Reed-Sternberg cells are seen Nodular Lymphocyte Predominant Hodgkin’s Lymphoma – Rich in lymphocytes – Reed-Sternberg cells are not evident – Variant of Reed-Sternberg cell known as Popcorn cell is seen Nodular Non-Hodgkin’s Lymphoma – Neoplastic cells aggregate in clusters – Germinal center formation Diffuse Non-Hodgkin’s Lymphoma – Neoplastic cells are diffused – No evidence of germinal center formation Burkitt’s Lymphoma – Homogenous cells with round to oval nuclei and multiple nucleoli – Characteristic starry sky appearance by scattered macrophages containing phagocytic cellular debris Traumatic Neuroma – Consists of irregular and interlacing neurofibrils and Schwann cells – Connective tissue stroma may be sparse to plenty Neurofibroma – Proliferation of delicate spindle cells with thin, wavy nuclei – Delicate collagen fibers Pleomorphic Adenoma – – – – – – – –

Usually encapsulated which may be complete or incomplete Cell and tissue pleomorphism is seen Epithelium forms sheets or strands or duct like structures Myoepithelial cells with prominent dark nuclei and clear cytoplasm is seen Squamous metaplasia is common Areas of myxomatous tissue, cartilage and osseous metaplasia is seen Hyalinization of the stroma is seen Cells with plasmacytoid morphology (Hyaline cells)

Warthin’s Tumor – Two prominent histological components, i.e. Epithelial and Lymphoid tissue

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– – – – –

Cyst formation is evident Papillary projections into cystic spaces Lymphoid matrix showing germinal center formation Epithelium arranged in double layer Layer adjacent to lumen consists of regularly arranged, tall columnar cells with nuclei well polarized towards the lumen – Cells of outer layer are less regularly arranged and are less numerous. Mucoepidermoid Carcinoma – – – – – –

Varying proportions of mucus secreting, epidermoid and intermediate type cells Mucin filled cystic spaces Keratinization rare Cellular atypia depending upon the grade of carcinoma Areas of hemorrhage, necrosis, fibrosis may be seen Foreign body giant cell reaction may be seen

(Note: Sometimes due to lack of mucus cells, the tumor may be histologically mistaken for a squamous cell carcinoma) Adenoid Cystic Carcinoma – Any one of the various growth patterns may predominate, i.e. Cribriform, Solid, or Tubular – Cribriform pattern shows basaloid epithelial cell nests forming multiple cylindrical cysts like patterns referred to as Swiss Cheese pattern. – Tubular pattern shows tubular structures lined by stratified cuboidal epithelium – Solid pattern shows solid groups of cuboidal cells with little tendency to form cyst or duct. Dentigerous Cyst – Thin 2-3 cell layer epithelium resembling reduced enamel epithelium lining the lumen – Rete peg formation absent unless secondarily infected – Sometimes presence of Rushton bodies in lining epithelium – Thickened connective tissue wall composed of loose fibrous connective tissue stroma – Presence of islands of odontogenic epithelium. Calcifying Epithelial Odontogenic Cyst – Lining of the cyst may be squamous epithelium with cuboidal or ameloblast like cells – May contain areas resembling stellate reticulum – Pale, swollen, eosinophilic cells with faintly visible nuclei are seen. These are known as ghost cells. – Calcified ghost cells are seen.

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– Ameloblastomatous proliferations may be seen. – Presence of odontomes may also be seen Radicular Cyst – – – – – – –

Variable thickness of epithelium. Proliferation of epithelium in arcading manner Rushton bodies may be seen Mature collagenous connective tissue wall Variable degree of inflammation is seen in connective tissue wall Chief inflammatory cells are lymphocytes and plasma cells. Other findings are: areas of hemorrhage, bone spicules, multinucleated giant cells and cholesterol crystals

Odontogenic Keratocyst (Keratinizing Cystic Odontogenic Tumor) – Lining epithelium is parakeratinized, corrugated – Uniform thickness of epithelium 6-8 cell layer – Prominent palisaded, polarized basal layer referred to as Picket fence or Tomb stone appearance – Flat epithelium, connective tissue interface – Intense inflammation may lead to increased thickness of epithelium, rete peg formation, loss of keratinized surface – Satellite or daughter cysts in the connective tissue wall. Follicular Ameloblastoma – Islands of tumor cells composed of peripheral cuboidal or columnar cells with well polarized nuclei. Cells resemble ameloblasts or preameloblasts – Central mass of these islands is made up of polyhedral, loosely arranged cells resembling Stellate reticulum. – Stellate reticulum may show cystic degeneration – Cystic degeneration may also be seen in the connective tissue, however, it is less common. Plexiform Ameloblastoma – The ameloblast like tumor cells are arranged as interconnecting strands of cells – Strands are bounded by layer of columnar cells and inbetween there is presence of stellate reticulum like cells – Cystic degeneration is seen in the connective tissue stroma commonly. Acanthomatous Ameloblastoma – Islands similar to those of follicular ameloblastoma are seen – The stellate reticulum cells usually undergo squamous metaplasia with individual cell keratinization of keratin pearl formation is seen

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Desmoplastic Ameloblastoma – Islands similar to follicular pattern are seen or sometimes features of plexiform ameloblastoma may predominate – The connective tissue stroma is dense, usually hyalinized and is hypocellular. Granular Cell Ameloblastoma – Islands similar to those of follicular ameloblastoma are seen – The cytoplasm of stellate reticulum cells is transformed and it takes on coarse, granular, eosinophilic appearance – Ultrastructurally these granules represent lysosomal aggregates. Unicystic Ameloblastoma – Hyperchromatism of basal cell nuclei – Palisading with polarization of basal cells – Cytoplasmic vacuolization with intercellular spacing of lining epithelium (Note: These features together are known as Vickers and Gorlin criteria.) – Intraluminal or Intramural proliferation of tumor nodules – Isolated islands of ameloblastoma occurring in connective tissue wall Calcifying Epithelial Odontogenic Tumor – Polyhedral epithelial cells which may be closely packed in sheets or scattered small islands in bland connective tissue stroma – Prominent intercellular bridges – Homogenous hyalinized material between epithelial cells which has staining characteristics of amyloid – Presence of hematoxyphilic, concentrically lamellated masses known as Leisegang rings. Adenomatoid Odontogenic Tumor – – – – –

Well defined fibrous capsule Whorls and strands of epithelium Presence of microcysts Cysts may contain homogenous eosinophilic material Microcyst lumina are frequently lined by eosinophilic rim of varying thickness known as Hyaline ring

Ameloblastic Fibroma – Scattered islands of odontogenic epithelium in various patterns like nests, strands, rosettes and cords – Stellate reticulum frequently absent – Primitive connective tissue closely resembling dental papilla – Hyalinization may be seen

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Odontoma – Disorderly arrangement of normal appearing enamel or enamel matrix, dentin, pulp and cementum – Ghost cells are found frequently – Connective tissue capsule surrounding an odontome resembles normal follicle. Odontogenic Myxoma – – – – –

Loosely arranged spindle shaped and stellate cells Hypocellularity Intercellular mucoid material is seen Nests of odontogenic epithelium may be seen Tiny capillaries and strands of collagen fibers may also be seen.

Tuberculosis – Formation of granulomas in the affected part – Foci of caseous necrosis surrounded by epithelioid cells, lymphocytes and multinucleated giant cells – Ziehl-Neelsen stain for demonstration of mycobacterium. Actinomycosis – Granulomatous lesion with centrally abscess formation containing colonies of microorganisms – Colonies appear with peripheral radiating filaments giving rise to term Ray fungus – Polymorphonuclear leukocytes, multinucleated giant cells and macrophages are seen around the periphery of lesion. Pyogenic Granuloma – Highly vascular proliferation resembling granulation tissue – Numerous proliferating vascular channels are found with extravasated RBCs – Mixed inflammatory cell infiltrate of neutrophils, plasma cells and lymphocytes. Enamel Caries – Four zones are recognized 1. The translucent zone at the advancing front of the lesion 2. The dark zone lies adjacent and superficial to translucent zone 3. The body of the lesion lies between surface layer and dark zone 4. The surface zone Dentinal Caries – Beginning pulpally five distinct zones can be recognized in 1. Zone of fatty degeneration of Tome’s fibers 2. Zone of dentinal sclerosis

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3. Zone of decalcification of dentin 4. Zone of bacterial invasion of decalcified but intact dentin 5. Zone of decomposed dentin Mucocele (Mucus Extravasation Phenomenon) – Area of spilled mucin surrounded by granulation tissue – Predominant cells are macrophages (muciphages) – Presence of salivary gland tissue containing dilated ducts and chronic inflammatory cell infiltrate. Salivary Duct Cyst (Mucus Retention Phenomenon) – Lining epithelium is variable which may consist of cuboidal, columnar or atrophic Squamous epithelium – Mucoid secretions are present in the lumen – Oncocytic metaplasia may be present. Fibrous Dysplasia – Irregularly shaped trabeculae of immature bone in loosely arranged cellular, fibrous stroma – Bone tissue resembles Chinese letter pattern – Osteoblastic riming is absent. Paget’s Disease – Alternating resorption and formation of bone is seen giving rise to prominent resting and reversal lines – Jigsaw puzzle or mosaic pattern appearance of bone – Marrow spaces are filled with loose highly vascularized connective tissue. Cherubism – Multinucleated giant cells resembling osteoclasts – Collagenous stroma containing large number of spindle shaped fibroblasts – Numerous blood vessels with eosinophilic perivascular cuffing. Lichen Planus – – – – – – –

Hyperparakeratinization or hyperorthokeratinization Thickening of stratum granulosum Saw tooth appearance of rete pegs Subepithelial band of inflammatory cells Degeneration of basal cell layer Civatte, Hyaline or Cytoid bodies Histological clefts in epithelium known as Max Joseph spaces

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Pemphigus – – – –

Intraepithelial vesicle or bulla formation leading to suprabasilar split Loss of intercellular bridges between epithelial cells leading to acantholysis Tzanck cells (Clumps of epithelial cells lying free in vesicular space) Tzanck cells show hyperchromatism and large nuclei.

Section VIII

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Index A Aberrancy 2 Abfraction 2 Abrasion 2 Abscess 2 Abscesses of periodontium 33 Acantholysis 2 Acanthomatous ameloblastoma 72 Acanthosis 2 Acid-fast organisms 46 stain 45 Actinomycosis 74 Acute inflammation 2 Adenoid cystic carcinoma 71 Adenoma 2 Adenomatoid odontogenic tumor 73 Adrenogenital syndrome 52 Agenesis 2 Ageusia 2 Aggressive periodontitis 32 Aglossia 2 Agranulocytosis 2 Albright syndrome 52 Allergen 2 Allergy 2 Alopecia 2 Ameloblastic fibroma 73 Amelogenesis imperfecta 64 Anachoresis 2 Anaphylaxis 2 Anaplasia 2 Anastomosis 2 Anemia 2 Aneurysmal bone cyst 68 Angioma 2 Anomalad 3 Anomaly 3

Anorexia 3 Anosmia 3 Antagonist 3 Antibody 3 Antigen 3 Apert syndrome 52 Aplasia 3 Arteriosclerosis 3 Ascher’s syndrome 53 Aspiration cytology 38 Atresia 3 Atrophy 3 Attrition 3 Auriculotemporal syndrome 53 Autoantibody 3 Autoimmune disease 3 Autoimmunity 3

B Baby bottle syndrome 53 Bottle mouth 53 Bacilli 24 Backward caries 30 Bacteremia 3 Bacteria 3 Basal cell carcinoma 66 Beckwith-Wiedemann syndrome 53 Behcet’s syndrome 54 Benign connective tissue tumors 35 epithelial tumors 16, 20, 34 muscle tissue tumors 35 nerve tissue tumors 36 tumors 18, 21 Biopsy 3, 39 BK mole syndrome 54 Blanching 3 Bleb 3

164 Practical Manual of Oral Pathology and Microbiology Blister 4 Blood diseases 26 Blue nevus 65 Boil 3 Bone-related lesions 22 Bruise 3 Bulla 4 Burkitt’s lymphoma 70

C Calcification 4 Calcifying epithelial odontogenic cyst 71 tumor 73 Callus 4 Capillary hemangioma 68 Capsule 4 Carbol fuschin and distilled water 44 Carbuncle 4 Carcinoma 4 in situ 65 Carcinomatosis 4 Carcinosarcoma 4 Causalgia 4 Cavernous hemangioma 68 Cell 4 Cellulitis 4 Chemotherapy 4 Cherubism 75 Chondroma 68 Chondrosarcoma 69 Chorda tympani syndrome 54 Choriostoma 4 Chronic inflammation 4 periodontitis 32 Classification of caries 29 fracture of teeth 31 giant cell lesions 27 gingival enlargement 31 odontogenic cysts 23 periodontal diseases 32 temporomandibular joint disorder 33 vesiculobullous lesions 28 Cleidocranial 4 Clubbing 4 Cocci 24

Cold abscess 4 Collagen 4 Combined enlargement 32 Commensals 4 Common syndromes affecting oral cavity 51 Commonly used diagnostic methods 38 Compound oral nevi 64 Conditioned enlargement 32 Cowden’s syndrome 54 Multiple hamartoma syndrome 54 Crest syndrome 55 Cross infection 5 Crouzon syndrome 55 Craniofacial dysostosis 55 Cyanosis 5 Cysts of jaws 23 maxillary antrum 23 soft tissues of mouth 23 face 23 neck 23

D Deformity 5 Degeneration 5 Dental caries 5 Dentigerous cyst 71 Dentin dysplasia 64 Dentinal caries 74 Desmoplastic ameloblastoma 73 Desquamation 5 Development disturbances in shape of teeth 15 Developmental cysts 23 disturbances of gingiva 14 jaws 14 lips and palate 14 oral lymphoid tissue 14 salivary glands 15 size of teeth 15 tongue 14 enlargement 32 Differentiation 5 Diffuse non-Hodgkin’s lymphoma 70 Disorder of blood vessels 27 Disturbances of growth of teeth 15

Index Down’s syndrome 55 Dyskinesia 5 Dysplasia 5, 65 Dystrophic calcification 5

Functional methods 38 Fungi 6 Furuncle 3 Fusiform 6

E

G

Eagle’s syndrome 55 Echymosis 5 Ectopic 5 Edema 5 Ehlers-Danlos syndrome 56 Ellis classification 31 Enamel caries 74 Enanthema 5 Endogenous infection 5 Epithelial precursor lesions 16 Epulis 5 Erosion 6 Erythema 6 Erythroplakia 65 Exanthema 6 Exfoliative cytology 38 Exogenous infection 6 Exophytic 6 Exostosis 6 Exotoxin 6 Extra-articular disturbances 33 Extravasation 6 Extrinsic 6 Exudate 6 Eyepiece 6

Gangrene 6 Gardner syndrome 56 Genetic disease 27 Gingival disease 32 Goldenhar syndrome 56 Goltz-Gorlin syndrome 56 Gram’s stain 44 Granular cell ameloblastoma 73 Granulation tissue 6 Granuloma 6 Granulomatosis 7 Grinspan syndrome 57

F Fanconi’s syndrome 56 Fibroma 67 Fibromatosis gingivae 64 Fibrosarcoma 69 Fibrous dysplasia 75 Fissure 6 Fistula 6 Focal dermal hypoplasia syndrome 56 Focal infection 6 Focus of infection 6 Follicular ameloblastoma 72 Forward caries 29 Fracture 6 Frey’s syndrome 53

H Hamartoma 7 Healing 7 Heathersay and Morile classification 31 Hematolymphoid tumors 17, 20 Hematoma 7 Hemiplegia 7 Hemoglobin 48 Hereditary disease 7 Heredity 7 Histopathological diagrams 77 differences 34 Hunter syndrome 57 Hurler syndrome 57 Hyaline 7 Hydropic degeneration 7 Hyperplasia 7 Hypertrophy 7 Hypoplasia 7

I Iatrogenic infection 7 Inapparent infection 7 Infection 7 Inflammation 7 Inflammatory cyst 23

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166 Practical Manual of Oral Pathology and Microbiology disturbances 33 enlargement 31 Intracorneal and subcorneal blisters 28 Intradermal oral nevi 64 Intraepidermal blisters 28

J Jaw winking syndrome 57 Junctional oral nevi 64 Juxtaepithelial 7

K Karyolysis 7 Karyopyknosis 7 Karyorrhexis 7

L Lesion 8 Leukemia 8 Leukoplakia 8, 65 Lichen planus 75 Lip 18 oral cavity 18 Lipoma 68 Lump 8 Lupus 8 Lymphocyte depleted Hodgkin’s lymphoma 69 rich Hodgkin’s lymphoma 70 Lymphoma 8

M Macule 8 Malignant connective tissue tumors 35 epithelial tumors 16, 19, 34 melanoma 67 muscle tissue tumors 35 nerve tissue tumors 36 tumors 18, 21 Marfan syndrome 58 Maroteaux Lamy syndrome 58 Mean cell diameter 48 hemoglobin 48 concentration 48 volume 48

Median cleft face syndrome 58 Melkersson-Rosenthal syndrome 58 Metaplasia 8 Metastasis 8 Microbial staining 44 Micrometastasis 8 Mild dysplasia 65 Mixed cellularity Hodgkin’s lymphoma 69 Moderate dysplasia 65 Moderately differentiated squamous cell carcinoma 66 Morphology code of international classification 17, 1, 22 Mucocele 75 Mucus extravasation phenomenon 75 Mucoepidermoid carcinoma 71 Mucosal malignant melanoma 17 Multiple endocrine neoplasia syndrome 58 Multiple hamartoma syndrome 54 Mutation 8 Myofacial pain dysfunction syndrome 59 Myxoma 68

N Natal teeth 8 Necrosis 8 Neonatal teeth 8 Neoplasia 8 Neoplastic enlargement 32 gingival tumors 32 Neuralgia 8 Neurofibroma 70 Neuroma 8 Nidus 8 Nodular lymphocyte predominant Hodgkin’s lymphoma 70 non-Hodgkin’s lymphoma 70 sclerosis Hodgkin’s lymphoma 69 Nodule 8 Noninflammatory hyperplastic enlargement 31 Normal differential white blood cell count 49 platelet count 49 red blood cell count 48 white blood cell count 49 Nosocomial infections 8

Index

O Odontogenic carcinomas 21 epithelium 21, 22 keratocyst 72 myxoma 74 sarcomas 21 Odontoma 74 Oncocyte 9 Oncosis 9 Oral cavity 18 facial digital syndrome 59 lichen planus 66 submucus fibrosis 9, 66 Ossifying fibroma 67 Osteodystrophy 9 Osteoma 68 Osteosarcoma 69

P Packed cell volume 48 Paget’s disease 75 Pain 9 Papillon-Lefevre syndrome 59 Papule 9 Paralysis 9 Parasites 9 Paresthesia 9 Parry-Romberg syndrome 59 Pathogen 9 Pathogenesis 9 Pathognomonic 9 Pemphigus 76 Periodontitis as manifestation of systemic disease 32 associated with endodontic lesions 33 Peripheral giant cell granuloma 67 Petechiae 9 Peutz-Jeghers syndrome 60 Pierre-Robin syndrome 60 Plaque 9 Platelets 49 Pleomorphic adenoma 70 Plexiform ameloblastoma 72 Plummer-Vinson syndrome 60 Paterson-Kelly syndrome 60

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Poorly differentiated squamous cell carcinoma 66 Precancerous condition 9 lesion 9 Predominantly morphological methods 38 Primary caries 29 infection 9 Protozoan 25 Pseudoepitheliomatous hyperplasia 10 Purpura 10 Pus 10 Pustule 10 Putrefaction 10 Pyogenic granuloma 74

R Radicular cyst 72 Ramsay Hunt syndrome 60 Re-infection 10 Red blood cell 48 Regeneration 10 Reiter’s syndrome 61 Reticulocytes 48 Reticuloendothelial system 26 Rickettsial 25 Rubinstein-Taybi syndrome 61

S Salivary duct cyst 75 mucus retention phenomenon 75 Salivary gland adenomas 17 carcinomas 16 tumors 16 Saprophyte 10 Sarcoma 10 Sclerosis 10 Secondary caries 29 infection 10 tumors 17, 21 Sepsis 6 Sequestrum 10 Severe dysplasia 65 Sinus 10

168 Practical Manual of Oral Pathology and Microbiology Sjögren’s syndrome 61 Soft tissue 6 tumors 17, 20 Spirochetal 25 Squamous papilloma 64 Staphylococcal scalded skin syndrome 61 Stevens-Johnson syndrome 61 Subclinical infection 10 Subepidermal blisters with scant inflammation 28 Suprabasilar blister 28 Swelling 10 Synctium 10 Syndrome 10

T Teeth 6 Telangiectasia 10 Teratology 10 Teratoma 10 TNM classification of carcinomas of lip 18 oral cavity 18 Transudate 11 Traumatic disturbances 33 neuroma 70 Treacher Collins syndrome 61 Tuberculosis 74

U Ulcer 11

Ulcerative lesions of oral cavity 24 Uncertain behavior 18 Unicystic ameloblastoma 73

V Van Der Woude’s syndrome 62 Verrucous carcinoma 67 Vesicle 11 Virulence 11 Virus 11 Vitamin deficiency 26

W Warthin’s tumor 70 Well differentiated squamous cell carcinoma 66 Wheal 11 White blood cell 49 WHO classification of tumors of oral cavity and oropharynx 16 WHO histological classification of odontogenic tumors 21 tumors of salivary glands 19 Wiskott-Aldrich syndrome 62 Working classification for fibro-osseous jaw lesions 28

Z Ziehl-Neelsen’s stain 45 Zoonosis 11

Recommended Reading 1. Gorlin, Cohen and Levin. Syndromes of the Head and Neck, Oxford University press, 1990. 2. John D Bancroft. Theory and Practice of Histological techniques, 5th Edition, Churchill Livingstone, 2002. 3. Lakshman Samarnayake. Essential Microbiology for Dentistry, 3rd edition, Churchill Livingstone, Elsevier, 2007. 4. Leon Barnes, W Eveson, P Reichart and David Sidronsky. WHO Book of classifications, Head and Neck tumors, IARC Press, 2005. 5. Neville, Damm, Allen and Bouquot. Oral and Maxillofacial Pathology, 3rd Edition, Elsevier, 2009. 6. Prabhu, Wilson, Daftary and Johnson. Oral diseases in the tropics, 1st edition, Oxford University Press, 1993. 7. Robins and Cotran. Pathologic basis of disease, WB Saunders company, 2004. 8. Shafer, Hine and Levy. A Textbook of Oral Pathology. 4th Edition, WB Saunders Company, 1993. 9. Shafer’s, R Rajendran and B Sivapathsundaram. A Text Book of Oral Pathology, 6th Edition, Elsevier, 2009. 10. Shafer’s, R Rajendran and B Sivapathsundaram. A Textbook of Oral Pathology, 5th Edition, Elsevier, 2006.