ATLAS OF

COMMON ORAL
MUCOSAL DISEASES

For Dental Students

Faculty of Dentistry Ain-Shams University

1st Edition 2014
Department of oral Diagnosis, Oral Medicine and Periodontology
 Atlas of
Common Oral Mucosal Diseases
Mucosal Diseases affecting the oral cavity should be
diagnosed carefully, they range from benign
asymptomatic lesions to serious malignant or chronic
disorders. Dentists should be able to identify and
diagnose these lesions, through proper history taking and
identification of different clinical pictures of the lesions.
Photos of different oral mucosal diseases seen and
diagnosed in out patient clinic of Faculty of dentistry-Ain
Shams University over years were collected and titled
with brief description in this atlas for dental students.

This work was the effort of staff members and

postgraduate students in department of
Oral Diagnosis, Oral Medicine and Periodontology
Contributors
Staff Members of Oral Diagnosis, Oral Medicine and Periodontology Department

Head Of Department

Prof. Dr. Khaled Abdel Ghaffar

Professors Assistant Lecturers

Prof. Dr. Hala Kamal Dr. Ahmed Amr
Prof. Dr. Ahamd Gamal Dr. Mohamed El-Bahrawy
Prof.Dr. Hadir El-Dessouky Dr. Doaa Adel
Prof.Dr. Hala Abu El-Ela Dr. Yasmine Faik
Prof.Dr. Suzan Seif Allah Dr. Radwa Ragheb
Allah Dr. Hadeel Gamal
Dr. Suzan Mohamed
Assistant Professors Dr. Yasmine El-Sayed
Dr.Nevine Kheir EL Deen Dr. Mohamed Wagdy
Dr. Mohamed El-Mofty
Demonstrators
Lecturers Dr. Hagar Mohamed
Dr. Ahmed Abd El-Aziz Dr. Mahitab Mohamed
Dr. Fatma Hamed
Dr. Ola Mohamed Ezzatt Residents
Dr. Waleed Abbas Dr. Mohamed Zakaria
Dr. Nahil Nabil
Dr. Dalia Yosri
Dr. Dina Magdy
Contents
 White lesions ...........................1
 Leukodema …………….. ...….2
 Fordyce’s Granules………...…3
 Linea Alba Buccalis……..........4
 Smoker keratosis…………...…5
 Smokless tobacco keratosis…..6
 Nicotinic stomatitis………...…7
 Frictional Keratosis………...…8
 Cheek chewing……………......9
 Hairy Tongue ……………......10
 Geographic Tongue ……...….11
 Lichen Planus (LP)………......12
 Oral lesions of (LP) (1)…...…13
 Oral lesions of (LP) (2)……...14
 Oral lesions of (LP) (3)……...15
 Oral lesions of (LP) (4)……...16
 Skin lesions of (LP)………….17
 Contact lichenoid reaction......18
 Drug lichenoid reaction……..19
 Lupus Erythromatosus (LE)…20
 Skin lesion of (LE)………......21
 Leukoplakia……………….....22
 Speckled leukoplakia…….......23
 Erythroplakia……………........24
 Squamous cell carcinoma…….25
 Oral Candidiasis……………...26
 Pseudomembranous Candidia..27
 Angular chelitis…………...….28
 Median Rhomboid glossitis….29
 Denure Stomatitis…………….30
 Candidal leukoplakia…….......31
 Aspirin Burn……………….....32
 Uremic stomatitis……….........33
 Thermal Burn………………....34
 Materia Alba……………….....35
 Ulcerative lesions……………36
 Erythema Multiform (oral) …..37
 Steven-Jonson syndrome (SJS)38
 SJS Skin lesions………………39
 Recurrent hepes labialis………40
 Recurrent Aphthous Ulcer (1)..41
 Recurrent Aphthous Ulcer (2)..42
 Traumatic ulcer……………….43
 Malignant ulcer….……………44
Contents
 Pemphigus Vulgaris (Oral)…..45
 Pemphigus Vulgaris (Skin)…46
 MMP (Oral)…………...……..47
 MMP (Ocular)……………….48
 Epidermolysis Bullosa (Oral)..49
 Epidermolysis Bullosa (skin)..50
 Erosive Lichen planus………51
 Chronic Ulcerative stomatitis.52
 Exophytic lesions…………..53
 Pyogenic Granuloma………..54
 Pregnancy Tumor…………....55
 Peripheral giant cell granulom56
 Gingival hyperplasia………...57
 Epulis Fissuratum…………...58
 Pulp Polyp………………...…59
 Fibroma………………..…….60
 Fibroepithelial polyp………...61
 Lipoma…………..…………..62
 Papilloma……………………63
 Verruca Vulgaris……………..64
 Condyloma Accuminatum …..65
 Palatal Papillary Hyperplasia..66
 Verrocus carcinoma…………..67
 Mucocele……………………..68
 Ranula………………………..69
 Radicular Cyst………………..70
 Haemangima……………….....71
 Periodontal Abscess……….…72
 Pigmented lesions……………73
 Pigmented nevus………….......74
 Melanotic macule…………….75
 Drug induced melanosis……...76
 Smoker Melanosis…………...77
 Haemangioma………………..78
 Petechea……………………...79
 Echymosis/Haematoma……....80
 Amalgam tattoo ……………...81
 Black Hairy Tongue………......82
WHITE LESIONS
OF THE ORAL
MUCOSA
 White lesions of oral mucosa

 They are multifactorial group of disorders, color of which is

produced by the scattering of the light through an altered
epithelial surface, or changes below or over the epithelium
 The diagnosis of oral white lesions should be made on the
basis of the medical history, clinical features, and laboratory
tests. And could be normal variants, keratotic or non keratotic
lesions
Normal Variants
Leukoedema - Fordyce's Granules - Linea Alba buccalis
Keratotic white lesions
Lichen Planus.
Smoker keratosis.
Contact lichenoid reactions
Smokeless tobacco keratosis
Drug Induced Lichenoid reactions
Nicotinic Stomatitis
Lupus Erythromatosus.
Frictional Keratosis.
Leukoplakia
Cheek Chewing.
Speckled leukoplakia.
Hairy Tongue
Erythroplakia
Geographic Tongue.
Squamous cell carcinoma
Non Keratotic white lesions
 Oral Candidiasis  Burn
 Acute Pseudomembranous Candidiasis  Chemical Burn
 Angular chelitis o Aspirin Burn
 Median Rhomboid Glossitis o Uraemic stomatitis
 Denture stomatitis  Thermal Burn
 Candidal Leukoplakia 1  Materia Alba
Leukoedema

Before stretching Disappear after stretching

Leukoedema is a normal variation due to increased thickness

of the epithelium and intracellular edema of the prickle-cell
layer. Clinically characterized by a grayish-white, opalescent
pattern of the mucosa and a slightly wrinkled surface, which
characteristically disappears when the mucosa is stretched.
It usually occurs bilaterally on the buccal mucosa.

2
Fordyce’s Granules
Fordyce’s granules are ectopic sebaceous glands of the
oral mucosa. Clinically the granules present as multiple,
asymptomatic, slightly raised whitish-yellow spots,
accentuated on stretching. The vermilion border of the
upper lip, the commissures, and the buccal mucosa are
the sites of predilection. 3
Linea Alba buccalis
Linea alba buccalis is a relatively common alteration of
the buccal mucosa. Clinically: Asymptomatic, bilateral,
linear elevation with a slightly whitish color at the level
of the occlusal line. Etiology Pressure, sucking from the
buccal surface of the teeth. No treatment is required
4
Smoker’s keratosis
Smoker’s keratosis is a reactive white lesion to smoking
habit. Clinically: The lesion appear as white keratotic
patches on the buccal mucosa more prominent at the
commisures. The lesion can not be rubbed off ,not
disappear on stretching with no loss of pliability and
flexibility 5
Smokeless tobacco keratosis
Smokless tobacco keratosis is a reactive white mucosal
lesion tobacco chewing habits. Clinically: It appear as
granular or wrinkled white keratotic lesion can not be
rubbed off , the lesions are seen in the area contacting
the tobacco (Giniva, vestibule and buccal and labial
mucosa, associated teeth discoloration and recession.
6
 Nicotinic Stomatitis
Nicotinic stomatitis is a common tobacco-related type of
keratosis, occurs exclusively on the hard palate,
associated with pipe and cigar smoking .The elevated
temperature, rather than the tobacco chemicals is
responsible for this lesion. Clinically: there is multiple
elevated white papules with red centers of inflamed
orifice of minor SG ducts. 7
 Frictional Keratosis
Frictional keratosis is a white lesion related to an
identifiable source of mechanical irritation and usually
resolves on elimination of irritant, Clinically: appears as
white area can not be wiped of with no loss of pliability
and flexibility, related to the source of irritation.
Treatment : removal of the cause and follow up
8
Cheek chewing
Cheek Chewing result from chronic irritation due to
repeated sucking and biting on the buccal mucosa and lip,
Clinically the lesions are characterized by a diffuse
irregular white area of small peeling and desquamation of
the epithelium. Rarely, erosions and petechiae may be
seen, usually bilateral but can be unilateral
9
Hairy Tongue
Hairy tongue is a relatively common disorder that is due
to marked accumulation of keratin on the filiform
papillae. Predisposing factors are poor oral hygiene,
oxidizing mouthwashes, antibiotics, excessive smoking,
emotional stress, and bacterial infection. Clinically
asymptomatic elongation of the filiform papillae The
color whitish to brown. 10
 Geographic Tongue
(Erythema Migrans)
Geographic tongue common benign condition, primarily
affecting the tongue ,unknown etiology. It may be
genetic. Clinically: multiple, well-demarcated,
erythematous, depapillated patches, typically surrounded
by a slightly elevated whitish border, persist for a short
time in one area, disappear completely, reappear in
another area. 11
 Lichen Planus

Lichen planus is a relatively common chronic inflammatory

disease of the oral mucosa and skin. the cause is not well
known, T cell-mediated autoimmune phenomena are involved in
the pathogenesis of lichen planus.

Clinically characterized by presence of Wickman’s striae ( white

fine keratotic lines at the periphery of the lesion accentuated on
stretching). The disease classified into : papular , reticular,
erosive, atrophic, bullous, pigmented.

Could be appear as white keratotic papules does not disappear

on stretching , can not be wiped off , no loss of pliability and
flexibility with Wickman’s striae at the periphery or as mixed
red and white lesion , the red atrophic area surrounded by
white keratotic lines, as white keratotic papules over diffuse
brown pigmented macules, or as large shallow ulcer covered
by yellowish pseudo membrane surrounded by red atrophic area
and Wickman’s striae at periphery.
12
Oral lesions of Lichen Planus
(1)
Papular Annular

13
Oral lesions of Lichen Planus
(2)

Pigmented Bullous/Erosive

14
Oral lesions of Lichen Planus
(3)

Plaque like Atrophic

15
Oral lesions of Lichen Planus
(4)

Wickham’s stiae Reticular

16
Skin lesion of lichen planus
Small flat topped, papules ,polygonal in outline , varying
in color from pink to violaceous to brown as the lesion
progress. Some pigmentation is left on the skin following
regression of the disease. Linear lesion may follow
trauma or scratching (Kobner phenomena).
17
Contact Lichenoid Reaction
Lichenoid reactions are a heterogeneous group of
lesions show clinical and histopathological similarities to
lichen planus, Causative factors Hypersensitivity to
dental restorative materials, amalgam, composite resins
and dental plaque accumulation. Clinically confined to
the mucosa directly in contact with the restorative
materials. 18
Drug Induced Lichenoid Reaction
The lesion appear clinically as lichen planus . The most
common drug that induced lichenoid reaction are:
Penicillamine , Antimalarials such as hydroxychloroquine
,Gold salts , beta-blockers, angiotensin converting enzyme
(ACE) inhibitors and diuretics , (NSAID), Oral
hypoglycaemic agents for type 2 diabetes.
19
Lupus Erythromatosus
Lupus erythematosus is a chronic immunologically
mediated disease. Classified into : Systemic , Disoid and
Subacute Lupus .Clinically appear as circumscribed
elevated white patch surrounded by red atrophic halo
with white keratotic border and very delicate wickham’s
striae 20
Skin lesions Of
Lupus Erythromatosis

Butterfly rash Alopecia

21
Leukoplakia
Leukoplakia a white patch or plaque, that cannot be
classified as any other disease entity. It is potentially
malignant. Tobacco, alcohol, chronic local friction, and
Candida albicans are important predisposing factors.
Clinically white keratotic patch does not disappear on
stretching , can not be rubbed off with loss of pliability
and flexibility. 22
Speckled Leukoplakia
Speckled Leukoplakia is a type of Leukoplakia
Clinically appear as granular , non hemogenous mixed
red and whit lesion (white keratotic patches distributed
over an atrophic area. This type have a high rate of
malignante transformation.
23
Erythroplakia
Erythroplakia is potentially malignant lesion appear
as a red, nonspecific patch or plaque that cannot be
classified clinically and pathologically under any other
disease. The lesion is asymptomatic, fiery red, well
demarcated plaque, with a smooth surface
24
Squamous-cell carcinoma
Squamous-cell carcinoma has a wide spectrum of
clinical features . In about 5–8% of cases, it appears in
the early stages as a white asymptomatic plaque
identical to leukoplakia with loss of pliability and
flexibility . Biopsy and histopathological examination are
important 25
Oral Candidiasis

Candidiasis is the most common oral fungal infection. It is

usually caused by Candida albicans, Predisposing factors are
local (poor oral hygiene, xerostomia, mucosal damage, dentures,
antibiotic mouthwashes) and systemic (broad-spectrum
antibiotics, steroids, immunosuppressive drugs, radiation, HIV
infection, hematological malignancies, neutropenia, iron-
deficiency anemia, cellular immunodeficiency, endocrine
disorders).
26
Pseudomembranous Candidiasis
Clinically appear as non keratotic white lesion appear as
creamy-white, slightly elevated, removable spots or
plaques. Rubbing the lesion off leaves raw bleeding
surface The lesions may be localized or generalized,
Xerostomia, a burning sensation, and an unpleasant taste
are the most common symptoms.
27
Angular cheilitis

Angular chelitis is a type of oral candidiasis appear as multiple

fissuring at the corner of the mouth.

28
Median Rhomboid Glossitis
Erythematous patches of atrophic papillae located in the
central area of the dorsum of the tongue and considered a
form of atrophic candidiasis.

29
Denture Stomatitis
(Denture sore mouth)
2-weeks after anti-
Before treatment
fungal treatment

Denture stomatitis a frequent condition in patients who wear

dentures for extended times. Mechanical irritation from
dentures, Candida albicans, or a tissue response to
microorganisms living beneath the dentures. Clinically appear
as diffuse erythema, edema, and sometimes petechiae , located
in the denture bearing area of the maxilla. The condition is
usually asymptomatic.
30
Candidal Leukoplakia
(Chronic hyperplastic candidosis)

Candidal leukoplakia is a variant of oral candidosis

Clinically presents as a white patch on the commissures
symptomless and regress after appropriate antifungal
therapy, a minor proportion may demonstrate dysplasia.

31
Aspirin Burn
Aspirin Burn: Non Keratotic White Lesion appear as
Localized white area formed of pseudomembrane can be
rubbed off leaving red painful surface with history of
placement of Aspirin or any chemical agent in this area
(Chemical Burn)..
32
Uraemic Stomatitis
Uremic stomatitis is a rare disorder that occur in patients
with acute or chronic renal failure due to Increased
concentration of urea and its products in the blood and
saliva. The pathogenesis of oral lesions is not clear, The
degradation of oral urea by the enzyme urease forms free
ammonia, may damage the oral mucosa (Chemical Burn).
33
Thermal Burn

Thermal burns to the oral mucosa are fairly common, usually

due to contact with very hot foods, liquids, or hot metal objects.
Clinically, the condition appears as a red, painful erythema that
may undergo desquamation, leaving erosions

34
Materia Alba
Materia alba results from the accumulation of food
debris, dead epithelial cells, and bacteria. It is common at
the dentogingival margin in patients with poor oral
hygiene. Clinically it presents as a soft, whitish plaque
that is easily detached after slight pressure leaving
normal mucosa. 35
 ULCERATIVE
LESIONS OF THE
ORAL MUCOSA
 Ulcerative Lesions in Oral Mucosa

 Ulcer is defined as loss of all epithelial layers. In addition, the

term “erosion” is used to define a superficial loss of epithelium.
 The most common causes of these lesions are mechanical and
reactive factors, infectious diseases, and neoplasm, as well as
autoimmune and hematological disorders.
 They are either primary ulcerative or arise secondarily from
ruptured bullae or vesicles.
 Ulcers classified clinically to:
Acute Multiple, recurrent, single, and chronic multiple ulcers.
 Acute Multiple Ulcers:
 Erythema Multiforme
 Stevens–Johnson Syndrome
 Rucurrent Ulcers:
 Recurrent herpes labialis
 Recurrent aphthous ulcer RAU(minor –major)
 Single Ulcers:
• Traumatic ulcer
• Malignant ulcer (Squamous cell carcinoma)
 Chronic Multiple Ulcers:
• Pemphigus vulgaris PV Chronic Ulcerative stomatitis
• Mucous membrane pemphigoids Erosive lichen planus
• Epidermolysis Bullosa.
36
Erythema multiforme
(oral lesions)

It is an acute or subacute self-limiting disease that involves the

skin and mucous membranes. The oral lesions present as
coalescing small vesicles that rupture within two or three days,
leaving irregular, painful erosions covered by a necrotic
pseudomembrane. Bloody crusted lip is characteristic.
Prodromal symptoms such as headache, malaise, arthralgias,
and fever, may also be present.
37
Stevens–Johnson Syndrome
Stevens–Johnson syndrome, or erythema multiforme
major, is a severe form of erythema multiforme that
predominantly affects the mucous membranes Bloody
crusted extensive vesicle formation, followed by painful
erosions covered by grayish-white or hemorrhagic
pseudomembranes.The lesions may extend to the
pharynx, larynx 38
Stevens–Johnson Syndrome
(Skin lesions)

The characteristic skin patterns are Target- or Iris-like lesions,

with vesiculo-bullous lesions which appears first as red macules
then develop a vesicles , enlarge to bullae and end in extensive
skin sloughing which lead to death due to secondary infection
and or fluid and electrolyte imbalance. Involvement of eye and
other mucous membranes also occur

39
Recurrent herpes labialis

The lesion is due to reactivation of HSV-1. Precipitated by

fever, trauma, cold, heat, sunlight, emotional stress, and HIV
infection. Clinically common sites the lips and perioral skin,
present as multiple small vesicles arranged in clusters, rupture
leaving small ulcers that heal spontaneously within 6–10 days.
Prodromal symptoms are burning, itching, tingling, and
erythema.

40
Recurrent Aphthus Ulcer
(RAU)
Recurrent aphthous ulcers are among the most common
oral mucosal lesions, Etiology Recent evidence supports
the concept that cell-mediated immune responses play a
primary role in the pathogenesis. Predisposing factors
trauma, allergy, genetic predisposition, endocrine
disturbances, emotional stress, hematological
deficiencies, and AIDS.
Clinically Three clinical variations have been recognized:
minor, major and herpetiform ulcers.

Minor; small ulcer (< 1cm) Major ; Large ulcer

common in labial mucosa,
vestibule, buccal mucosa,
shallow , regular margin
surrounded by red halo,
non indurated base and
floor covered by whitish
fibrin, heal without scar .
(>1cm) common in soft
palate ,deep , regular
edematous margin
surrounded by red halo,
indurated base and floor
covered by whitish fibrin,
heal with scar after long
time

41
Recurrent Aphthus Ulcer
(RAU)

Minor RAU Major RAU

42
Traumatic ulcer

Traumatic Ulcer is common oral lesions, can be caused by a

sharp or broken tooth, rough fillings, dental instruments, biting,
denture irritation, sharp foreign bodies, etc. Clinically appear as
a single, painful ulcer with a smooth red or whitish-yellow
surface and a thin erythematous, non indurated and heal without
scarring within 6–10 days, spontaneously or after removal of the
cause. However, chronic traumatic ulcers may clinically mimic a
carcinoma.

43
Malignant ulcer (SCC)
Squamous-cell carcinoma represents about 90% of oral
cancers, and accounts for 3–5% of all cancers. The cause is
multifactorial. Classically, a carcinomatous ulcer has an
irregular papillary surface, elevated borders, and a hard
base on palpation. The lesions are almost always chronic and
indurated. Common in the lateral border, and the ventral
surface of the tongue 44
 Pemphigus vulgaris

Pemphigus is a severe chronic bullous autoimmune

mucocutaneous disease. potentially life –threatening diseases that
cause blisters and erosion of skin and mucous membranes , auto
antibodies against adhesion molecule lead to loss cell to cell
adhesion and intaepithelial bullae formation. Oral lesions are
characterized by the formation of bullae, which rapidly rupture,
leaving painful erosions over normal looking mucosa with a
tendency to extend peripherally.
45
Skin lesions Of
Pemphigus vulgaris

The skin lesions present as flaccid bullae that rupture quickly,

leaving persistent eroded areas. Nikolsky’s sign is positive.
Any skin area may be involved.

46
 Scarring

Mucous Membrane Pemphigoid

Cicatricial pemphigoid, or mucous membrane
pemphigoid, is a chronic bullous mucocutaneous disease
that primarily affects mucous membranes, and results in
atrophy or scarring. The oral lesions are characterized
by recurrent vesicles or bullae that rupture, leaving large,
superficial painful ulcerations. Repeated recurrences may
lead to scarring. 47
Mucous Membrane Pemphigoid
(Ocular Lesion)

Ocular lesions consist of conjunctivitis, symblepharon,

entropion, trichiasis, dryness, and corneal opacity, frequently
leading to blindness.

48
Epidermolysis Bullosa
Epidermolysis bullosa is a group of usually inherited
mucocutaneous bullous disorders, appear at birth or early
in infancy. Oral lesions present as bullae, usually in areas
of friction, which rupture, leaving shallow ulcers, and
later atrophy and scarring. The disease result due to
genetic defect. 49
Epidermolysis Bullosa
(Extraoral scarring)

50
Erosive lichen Planus

Desquamative gingivitis

51
Chronic Ulcerative Stomatitis
Chronic Ulcerative Stomatitis is a rare distinct clinical
and immuno-pathological entity in which antinuclear
antibodies are directed against the chronic ulcerative
stomatitis protein may to apoptotic epithelial injury,
misdiagnosed with erosive lichen clinically but respond
to antimalarial drugs 52
 EXOPHYTIC
LESIONS OF THE
ORAL MUCOSA
Exophytic Lesions In Oral Mucosa

 Exophytic lesions is a descriptive term to characterize a firm or

solid, raised, usually asymptomatic swelling that is larger than 0.5
cm in diameter.
 Both epithelial and mesenchymal lesions can represent as
exophytic lesions, Benign and malignant neoplasms, reactive
lesions, infections, and systemic diseases are included in this
group of lesions. The location, consistency, surface, inflammation,
and presence or absence of pain are important clinical signs and
symptoms for the differential diagnosis of these lesions. They can
be classified into:
 Hemorrhagic swelling  Non Hemorrhagic
 Pyogenic Grnauloma  Traumatic Fibroma.
 Pregnancy Tumors  Fibro epithelial polyp
 Peripheral Giant-Cell Granuloma  Lipoma
 Gingival Hyperplasia
 Epulis Fissuratum
 Pulp polyp
 Papillary swelling  Compressible swelling
• Papilloma.  Mucocele
 Verruca vulgaris  Ranula.
 Condyloma acuminatum.  Radicular Cysts.
 Palatal Papillary Hyperplasia.  Hemangioma.
 Verrocucous carcinoma  Periodontal abscess

53
Pyogenic Granuloma
Pyogenic granuloma is a common tumor like granulation
tissue reaction to mild irritation and trauma. Clinically
appear as easily bleeding, soft , sessile or pedunculated
swelling , deep red in color, The surface may be smooth or
lobulated or ulcerated, and is covered by a whitish-yellowish
fibrinous membrane. It grows rapidly. The gingiva is
commonly affected. 54
Pregnancy tumor
Pregnancy tumor appear clinically as pyogenic granuloma
but in the pregnant female .

55
Peripheral Giant-Cell Granuloma
Peripheral giant-cell granuloma is a relatively uncommon
reactive tumor of the oral cavity in response to Local
irritation or trauma. It is thought to arise from a periodontal
ligament or periosteum. Clinically appear as easily bleeding
soft swelling on the gingiva or edentulous alveolar ridge,
could be sessile or pedunculated mass, dark red in color
56
Gingival Hyperplasia
Gingival Hyperplasia is a relatively common lesion of the gingiva
whether plaque induced or due to drugs. The most common drugs
that induce the lesion are phenytoin, ciclosporin, and calcium channel
blockers. The overgrowth is usually related to the dose of the drug,
the duration of therapy, and the presence of dental plaque. Clinically,
both marginal gingiva and interdental papillae appear enlarged and
firm, with little or no inflammation and may be localized or
generalized. 57
 Epulis Fissuratum

Epulis fissuratum, or denture fibrous hyperplasia, is a relatively

common hyperplasia of the fibrous connective tissue. Poorly fitting
partial or complete denture is the main cause. Clinically the lesion
presents as multiple or single inflamed and elongated papillary
folds, usually in the mucolabial or mucobuccal grooves . The
lesions are mobile, and usually ulcerated at the base of the folds.

58
Pulp Polyp
Pulp polyp is found in an open carious lesion,
fractured tooth or when a dental restoration is missing.
Clinically appear as small , red , soft, easily bleeding
swelling protruded from the pulp of badly decayed tooth.

59
Fibroma
Fibroma is the most common benign tumor of the oral
cavity, and originates from the connective tissue. It is a
reactive, rather than a true neoplasm. Clinically appear as
asymptomatic , non hemorrhagic ,well-defined, firm,
sessile or pedunculated tumor with a smooth surface of
normal epithelium. 60
Fibro epithelial polyp
It is one of fibrous hyperplasia due to chronic irritation
and trauma. Clinically it appear as asymptomatic , non
hemorrhagic ,well-defined, firm, sessile or pedunculated
capsulated tumor with a smooth surface of normal
epithelium.
61
Lipoma
Lipoma is a benign tumor of fat tissue, and is relatively
rare in the oral cavity. Clinically it appears as an
asymptomatic, well-defined tumor, sessile or
pedunculated, yellowish or pink color , soft in
consistency , with smooth surface and not hemorrhagic.
62
Papilloma
Papilloma is a common benign proliferation, originating
from the stratified squamous epithelium .Clinically,
papilloma appear as painless, exophytic, well-
circumscribed ,pedunculated lesion. it consists of
numerous fingerlike projections, which give the lesion a
“cauliflower” appearance, white or grayish color.
63
Verruca vulgaris
(Common Wart)
Verruca vulgaris is a benign, mainly cutaneous lesion that may
rarely appear in the oral mucosa. The main cause of the lesion is
Human papillomavirus , usually occur on the vermilion border
and the lip mucosa, commissures, and tongue. Clinically
appears as a painless, small, sessile, and well-defined exophytic
growth with a cauliflower surface and whitish color, single or
multiple. lesion on fingers and genital area could be reported
64
Condyloma acuminatum
Condyloma acuminatum is a sexually transmitted benign
lesion, mainly occurring in the anogenital region, and rarely
in the mouth. The main cause is Human papillomavirus,
types 6 and 11. Clinically the lesions appear as single, or
more often multiple, small, sessile, well-demarcated,
exophytic masses with a cauliflower-like surface , whitish or
normal color 65
Palatal Papillary Hyperplasia
Palatal Papillary Hyperplasia appears as an
asymptomatic erythematous area, with a small papillary
projection on the hard palate. It associated with poor
denture fitting and in the patient who wear the denture 24
hours a day.
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Verrucous carcinoma
Verrucous carcinoma is a low-grade variant of squamous
cell carcinoma. Typically, it presents as an exophytic, whitish
mass with a papillary or verruciform surface . Along with the
clinical features, biopsy and histopathological examination
should be performed to rule out other papillary growths.
Verrucous carcinoma is well-differentiated, slow-growing,
rarely metastasizes 67
Mucocele
Mucoceles are a common phenomenon , originating from
minor salivary glands and their ducts. Local minor trauma
and duct rupture or ductal obstruction Clinically presents as
a painless, dome-shaped, solitary, bluish or translucent,
fluctuant swelling that ranges in size from a few millimeters
to several centimeters in diameter. The lower lip is the most
common site 68
Ranula
Ranula is a form of mucocele that occurs exclusively on
the floor of the mouth.Trauma or ductal obstruction is the
main cause. Clinically it presents as a smooth, fluctuant,
painless swelling on the floor of the mouth, lateral to the
midline, The color ranges from normal to a translucent
bluish, and the size is usually in the range of 1–3 cm.
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Radicular Cysts

It is the most common odontogenic cysts . It is caused

by pulpal necrosis secondary to dental caries or trauma,
clinically it appear as asymptomatic mass , compressible
related to decay tooth but a secondary infection can
cause pain . On radiographs, it appears a radiolucency
around the apex of a tooth's root.

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Hemangioma

Hemangioma is a relatively common benign proliferation of

blood vessels that primarily develops during childhood.
Clinically appear as soft , smooth or lobulated, sessile or
pedunculated , may be seen in any size from a few millimeters
to several centimeter mass , red in color and blanch on
pressure.

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Periodontal Abscess

Periodontal abscess is formed by localized pus accumulation

in a preexisting periodontal pocket. Gram-positive and Gram-
negative microorganisms, anaerobic microbes are the main
cause. Clinically appears as a painful, soft, red gingival
swelling. On pressure, pus exudes from the cervical area of
the tooth.

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 PIGMENTED
LESIONS OF THE
ORAL MUCOSA
Pigmented lesions in oral cavity

 Pigmented oral lesions are a large group of disorders in which

the dark or brown color is the essential clinical characteristic.
The dark color of the lesions is due to melanin production by
either melanocytes or nevus cells. In addition, exogenous
deposits and pigment-producing bacteria can also produce
pigmented lesions.
 They can classified into:
Focal Brown lesion Diffuse/multifocal Brown lesion
 Nevus.  Drug induced melanosis
 Melanotic Macule.  Smoker melanosis

Focal Blue/Red lesion Diffuse/multifocal Blue/Red lesion

 Hemangioma  Petechiea

Ecchymosis and hematoma

Focal Black lesion Diffuse/multifocal Black lesion

 Amalgam Tattoo  Black Hairy tongue

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Pigmented Nevus
Congenital pigmented naevi is a hamartoma of
melanocytes initially appear as flat, pigmented lesions of
various sizes. They are usually solitary lesions, appear
after birth in the first two years of as the lesion ages, it
tends to become raised. The main clinical concern is the
development of malignant melanoma.
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Melanotic Macule
Oral melanotic macule is a non-cancerous dark spot
found on the lips or inside the mouth. Oral melanotic
macule found on the lip is called a labial melanotic
macule. Clinically appears as a solitary, flat, tan-to-dark-
brown spot usually less than 7 mm in diameter. It has a
well-defined border and a uniform color.
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Drug Induce Pigmentation

Drug-induced oral pigmentation is a relatively common

condition, caused by increased melanin production or drug
metabolite deposition. Antimalarials, tranquilizers, minocycline,
azidothymidine, ketoconazole, phenolphthalein, and others are
the most common drugs that induce pigmentation. Clinically
appear as irregular brown or black macules or plaques, or diffuse
melanosis.
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Smoker melanosis
Smoker’s melanosis, or smoking-associated melanosis,
is a benign abnormal melanin pigmentation of the oral
mucosa. Tobacco smoke that stimulates melanocytes is
the main cause. Clinically, it appears as multiple brown
pigmented macules.
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Hemangioma
Hemangioma is a relatively common benign
proliferation of blood vessels that primarily develops
during childhood. Clinically appearance ;range from flat
reddish blue macule to a blue nodule, the color depend on
the depth of vascular proliferation within the oral
submucosa. The lesion can be blanch on pressure.
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Petechiea
Macular discoloration resulting from bleeding into
connective tissue less than 2mm . Result due to traumatic
injury or abnormal haemostatic function.

79
Ecchymosis /Heamatoma
Macular discoloration resulting from bleeding into
connective tissue more than 2mm . Clinically appear as
large red macule can not be blanch on pressure and color
change from red to brown few days after hemoglobin is
degraded to hemosiderin.
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Amalgam tattoo
Amalgam deposition (tattoo) is a common oral disorder.
Result due to Implantation of dental amalgam into the
oral mucosa. Clinically appear as a well-defined
irregular or diffuse flat area, with a bluish-black
discoloration.
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Black Hairy Tongue
Hairy tongue appear black as a result of the growth of
pigment-producing bacteria that colonize the elongated
Filiform papillae. In addition, the black color may also be
due to staining from food and tobacco.

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