Periodontology MCQ

Oral Pathology
Chapter 17
Copyright © 2005 by Elsevier Inc. All rights reserved.

Introduction
Oral pathology is the study of
diseases in the oral cavity.
Only a dentist or physician may diagnose
pathologic (disease) conditions, but it is
important for the dental assistant to be
able to recognize the differences between
normal and abnormal conditions that
appear in the mouth.

Terminology Used to Describe Oral Lesions
• Lesion is a broad term for abnormal tissues in the
oral cavity that includes wounds, sores, and any
other tissue damage caused by injury or disease.
• Determining the type of lesion in a disease is one of
the earliest steps in formulating a differential
diagnosis.
• Types of lesions of the oral mucosa are classified as
to whether they:
– Extend below or extend above the surface.
– Are flat or even with the surface.

• Many systemic diseases as well as infectious
diseases have oral manifestations
(signs and symptoms).
• The dental assistant should also understand how
oral abnormalities affect the patient’s general health
and planned dental treatment.
• Before you can recognize the abnormal conditions,
you must have a solid understanding of the
appearance of the normal oral conditions.

Lesions Extending Below the Surface
• Ulcer: A defect or break in continuity of the mucosa
that creates a punched-out area similar to a crater.
• Erosion of the soft tissue: A shallow defect in the
mucosa caused by mechanical trauma.
• Abscess: A localized collection of pus in a
circumscribed area.
• Cyst: A closed sac or pouch that is lined with
epithelium and contains fluid or semisolid material.

• The dental assistant should understand the terms
used to describe pathologic conditions and record
preliminary identification and descriptions of lesions.
• You should use these terms in the clinical setting so
that they become part of your everyday professional
vocabulary.
• You then can communicate effectively with
other professionals.

Lesions Extending Above the Surface
• Blisters: Also known as vesicles, lesions filled

with a watery fluid.
• Pustule: Similar in appearance to a blister, but it
contains pus.
• Hematoma: Also similar to a blister, but it
contains blood.
• Plaque: Any patch or flat area that is slightly
raised from the surface.

Sources of Information for Diagnosis
• Historical
• Clinical
• Radiographic
• Laboratory
• Microscopic
• Surgical
• Therapeutic
• Differential findings

Historical Information
• Family histories are important because of

genetic disorders such as dentinogenesis
imperfecta
• Melanin pigmentation of the gingiva is
common in dark-skinned individuals.

Fig. 17-1 Dentinogenesis imperfecta
(From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.)

Fig. 17-2 Melanin pigmentation

Examples Of Conditions Diagnosed
On The Basis Of Clinical Appearance
• Fissured tongue
• Maxillary and mandibular tori
• Median rhomboid glossitis

Fig. 17-3 Fissured tongue

Fig. 17-4 A, Clinical appearance of bilateral mandibular tori

Fig. 17-4 B, Clinical appearance of lobulated torus palatinus

Fig. 17-5 Median rhomboid glossitis

Radiographs
• Excellent in providing information about:

– Periapical pathology
– Internal resorption
– Impacted teeth

Fig. 17-6 Periapical pathology

Fig. 17-7 Internal resorption

Fig. 17-8 Horizontal impaction of the third molar

Microscopic Diagnosis
• When a suspicious lesion is present, tissue is
removed and sent to a pathology laboratory
where it is evaluated microscopically (biopsy).
• This procedure is very often used to make the
definitive (final) diagnosis.
• For example, a white lesion cannot be diagnosed
on the basis of the clinical appearance alone.
It must have a biopsy to determine if it is
malignant or not .

Fig. 17-9 A white lesion is seen on the anterior
floor and ventral surface of the tongue.

Therapeutic Diagnosis
• Therapeutic diagnosis is made by providing a
treatment (therapy), then seeing how the condition
responds. For example, angular cheilitis could be
caused by a lack of the B-complex vitamins.
• It could simply be a fungal infection.
• If the angular cheilitis improved after the patient
was given an antifungal cream, the vitamin
deficiency theory could be ruled out.

Fig. 17-10 Angular cheilitis

Surgical Diagnosis
• A diagnosis is made based on the findings from a
surgical procedure.
– For example, on a radiograph a traumatic bone
cyst also looks like a static bone cyst.
• However, one condition would require treatment,
one would not. Surgically opening the area and
inspecting the area would prove if the radiolucency
on the radiograph was indeed a condition that
needed further treatment or not.

Fig. 17-11 Traumatic bone cyst
(Courtesy Dr. Edward V. Zegarelli. From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.)

Fig. 17-12 Arrow points to static bone cyst
(Courtesy Dr. Edward V. Zegarelli. From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.)

Diseases of the Oral Soft
Tissues

Leukoplakia
• Leukoplakia means white patch.

• Lesions vary in appearance and texture from a fine
white transparency to a heavy, thick, warty plaque.
• The cause is unknown but is commonly linked to
chronic irritation or trauma.
• Leukoplakia very often precedes the development
of a malignant tumor.

Fig. 17-14 Leukoplakia

Lichen Planus
• A benign, chronic disease affecting the skin

and oral mucosa.
• Many factors have been implicated in lichen
planus; however, the cause remains unknown.
• On the oral mucosa, the patchy white lesions
have a characteristic pattern of circles and
interconnecting lines called Wickham's striae.

Fig. 17-15 Lichen planus

Candidiasis
• A superficial infection caused by the yeastlike
fungus, Candida albicans.
• Candidiasis does occur under conditions such as
antibiotic therapy, diabetes, xerostomia (dry mouth),
and weakened immunologic reactions.
• It can be the initial clinical manifestation for patients
with acquired immunodeficiency syndrome (AIDS).
• Diaper rash, vaginitis, and thrush are also common
types of candidiasis.

Types of Candidiasis
• Pseudomembranous candidiasis: thrush

• Hyperplastic candidiasis
• Atrophic candidiasis

Fig. 17-16 Pseudomembranous candidiasis

Fig. 17-17 Chronic hyperplastic candidiasis. The white appearance of the
tongue did not wipe off, and it disappeared with antifungal treatment.

Aphthous Ulcers
• Aphthous ulcers are also known as aphthous
stomatitis or canker sores.
• Recurrent aphthous ulcers (RAU) is a disease that
causes recurring outbreaks of blister-like sores
inside the mouth and on the lips.
– Minor RAU: Episodes fewer than six times a year;
lesions usually heal within 7 to 10 days.
– Major RAU: Outbreaks of larger, deeper ulcers
that take longer to heal.

Fig. 17-18 Minor aphthous ulcer

Cellulitis
• Inflammation spreads through the soft tissue
or organ.
• Swelling develops rapidly, with a high fever.
• The skin becomes very red, and there is
severe throbbing pain as the inflammation
localizes.
• Cellulitis associated with oral infections is
potentially dangerous because it can travel
quickly to sensitive tissues such as the eye
or brain.

Fig. 17-19 Cellulitis

Conditions of
the Tongue

Glossitis
 Glossitis is the general term used to describe
inflammation and changes in the topography of
the tongue.

Black Hairy Tongue
• Black hairy tongue may be caused by the oral flora

imbalance after the administration of antibiotics.
• The filiform papillae are so greatly elongated that
they resemble hairs.
• These elongated papillae become stained by food
and tobacco, producing the name black hairy tongue.

Fig. 17-20 Black hairy tongue

Geographic Tongue
• The tongue develops multiple areas of desquamation
(loss) of the filiform papillae in several irregularly
shaped but well-demarcated areas.
• The smooth areas resemble a map, thus the name
geographic tongue.
• Over a period of days or weeks, the smooth areas
and the whitish margins seem to migrate across the
surface of the tongue by healing on one border and
extending on another.

Fig. 17-21 Geographic tongue

Fissured Tongue
• A variant of normal; its cause is unknown.
• Some theories include a vitamin deficiency or
chronic trauma over a long period.
• The dorsal surface (top) of the tongue appears to
have deep fissures or grooves that become irritated
if food debris collects in them.
• The patient with a fissured tongue is advised to
brush the tongue gently with a soft toothbrush to
keep the fissures clean of debris and irritants.

Fig. 17-22 Fissured tongue

Pernicious Anemia
• Pernicious anemia is a condition in which the body
does not absorb vitamin B12.
• People who have this condition show signs of anemia,
weakness, pallor, and fatigue on exertion.
• Other signs can include nausea, diarrhea, abdominal
pain, and loss of appetite.
• The oral manifestations of pernicious anemia include
angular cheilitis (ulceration and redness at the corners
of the lips), mucosal ulceration, loss of papillae on the
tongue, and a burning and painful tongue.

Fig. 17-23 Iron deficiency. The tongue is devoid of filiform papillae.
Angular cheilitis was also present in this patient.

Oral Cancer

Oral Cancer
• Oral cancer is one of the 10 most frequently
occurring cancers in the world.
• The incidence, as well as the site, of the cancer
varies greatly from country to country. In the Western
countries, the site most often affected is the
vermilion border of the lip.
• Most oral cancers do not cause pain in the early
stages, and the thorough dentist is most likely to be
the first to detect them. These cancers are fatal if not
detected early enough or if left untreated.

Fig. 17-24 Squamous cell carcinoma of the lower lip

Types of Oral Cancer
• A carcinoma is a malignant neoplasm (growth) of the
epithelium (tissue lining the mouth).
• An adenocarcinoma is a malignant tumor that arises from

the submucous glands underlying the oral mucosa.
• A sarcoma is a malignant neoplasm arising from supportive

and connective tissue.
• An osteosarcoma is a malignant tumor involving the bone.

In the mouth, the affected bones are the bones of the jaws.
Although the cancer may start in the bone, it often spreads
and involves the surrounding soft tissues.

Fig. 17-25 Panoramic radiograph showing destruction
of the mandible by squamous cell carcinoma

Leukemia
• A cancer of the blood-forming organs that is
characterized by rapid growth of immature white
blood cells.
• Oral symptoms of leukemia may be some of the first
indications of the disease.
• Symptoms in the gingival tissues include
hemorrhage, ulceration, enlargement, spongy
texture, and magenta coloration of the gingiva.
• Enlargement of lymph nodes, symptoms of anemia,
and general bleeding tendencies are typical.

Fig. 17-26 Leukemia

Smokeless Tobacco
• Chewing tobacco or snuff presents a serious
health hazard.
• It is a major concern because of the high rates of
precancerous leukoplakia and oral cancer occurring
among users of smokeless tobacco.
• Cancers of the pharynx, larynx, and esophagus
occur 400 to 500 times more frequently.
• Smokeless tobacco is also linked to an increased
incidence of tooth loss from periodontal disease.

Fig. 17-27 Tobacco chewer’s white lesion.
Note the rough texture of the surface.

Dental Implications of Radiation Therapy
• Xerostomia: Lack of adequate saliva and the reduced

blood supply can cause oral infections, delay
healing, and make it very difficult to wear dentures.
• Radiation caries: Caused by the lack of saliva,
usually appear first in the cervical areas of the teeth.
The teeth also may become extremely sensitive to
hot and cold stimuli.
• Osteoradionecrosis: Necrosis (death) of bone after
radiation treatment.

Fig. 17-28 A and B, Radiation mucositis. C, Postradiation xerostomia.

Acquired Immunodeficiency Syndrome
(AIDS)
• Oral lesions are prominent features of AIDS and

human immunodeficiency virus (HIV) infection.
• Oral lesions develop because of the breakdown of
the immune system that occurs when the T-helper
cells become depleted because of the disease.

• Because the patient’s immune system is severely
damaged, death is usually caused by an
opportunistic infection.
• An opportunistic infection is one that normally would
be controlled by the immune system but that cannot
be controlled because of the HIV/AIDS, the immune
system is not functioning properly.
• It is important to remember that some of the lesions
that look like HIV- and AIDS-related infection may
also be caused by other disorders.

HIV-Associated Gingivitis
• There is often a bright red line along the border of

the free gingival margin.
• Also known as atypical gingivitis (ATYP).
• In some cases, there may be progression of the
bright red line from the free gingival margin over
the attached gingival and alveolar mucosa.

HIV-Associated Periodontitis
• HIV-associated periodontitis resembles acute
necrotizing ulcerative gingivitis superimposed
on rapidly progressive periodontitis.
• Other symptoms include:
– Interproximal necrosis and cratering
– Marked swelling
– Intense erythema over the free and attached gingiva
– Intense pain
– Spontaneous bleeding and bad breath

Fig. 17-29 A, typical periodontal disease
in a patient with HIV infection

HIV Cervical Lymphadenopathy
• Enlargement of the cervical (neck) nodes

• Lymphadenopathy is frequently seen in
association with AIDS.

Fig. 17-30 HIV cervical lymphadenopathy

HIV Lymphoma
• HIV lymphoma is the general term used to describe
malignant disorders of the lymphoid tissue.
• In the immunocompromised individual, it may occur
as a solitary lump or nodule, a swelling, or a
nonhealing ulcer that occurs anywhere in the oral
cavity.
• The swelling may be ulcerated or may be covered
with intact, normal-appearing mucosa.
• Usually painful, the lesion grows rapidly in size and
may be the first evidence of lymphoma.

Fig. 17-32 HIV lymphoma

Hairy Leukoplakia
• Hairy leukoplakia can be an important early
manifestation of AIDS status.
• It is a filamentous white plaque usually found
unilaterally or bilaterally on the lateral borders
(sides) on the anterior portion of the tongue.
• It may spread to cover the entire dorsal surface of
the tongue. It can also appear on the buccal mucosa,
where it generally has a flat appearance.

Fig. 17-33 Hairy leukoplakia

Kaposi's Sarcoma
• Kaposi's sarcoma is one of the opportunistic
infections that occur in patients with HIV infection.
• Kaposi's sarcoma lesions may appear as multiple
bluish, blackish, or reddish blotches that are usually
flat in the early stages.
• At present, there is no effective treatment for
Kaposi’s sarcoma.
• Kaposi’s sarcoma is one of the intraoral lesions that
are used to diagnose AIDS.

Fig. 17-34 Kaposi’s sarcoma in a patient
with AIDS. A, Skin. B, Gingivae.

Herpes Simplex
• Herpes simplex lesions usually occur on the lip.
• In immunocompromised patients, the lesions may
occur throughout the mouth.
• An ulcer caused by the herpes virus that persists
for longer than 1 month could be an indicator of
AIDS.
• Patients that do not have HIV or AIDs may also
suffer from herpes.

Fig. 17-35 Herpes simplex on the hard palate
of a patient with HIV infection

Human Papillomavirus
• Human papillomavirus appears most commonly
in immunocompromised individuals.
• Diagnosis is made based on history, clinical
appearance, and biopsy.
• They are a common finding in patients with early
HIV infection.
• These warts appear spiky, and some have a raised,
cauliflower-like appearance.

Fig. 17-36 Human papillomavirus on the lip of a patient with AIDS

Developmental Disorders
Can result when there is a disturbance of the cells
during the period when the cells divide.
The result is usually a deformity of part of the body.

Types of Developmental Disorders
• Inherited disorders: Different from developmental
disorders because they are caused by an abnormal gene.
• A congenital disorder: One that is present at birth. It can

be either inherited or developmental; however, the exact
cause of most congenital abnormalities is unknown.
• Genetic factors: Malformations often due to genetic

factors such as chromosome abnormalities.
• Environmental factors: Called teratogens and can include

infections, drugs, and exposure to radiation.

Exostoses
• Exostosis is a benign bony growth projecting
outward from the surface of a bone.
• An exostosis also may be referred to as a torus.
(A torus is a bulging projection. The plural is tori.)

Fig. 17-38 Torus palatinus

Fig. 17-39 Torus mandibularis

Disturbances in the
Development of the Jaw, Lips,
Palate, and Tongue

Types of Developmental Disturbances
of the Jaw, Lips, Palate, and Tongue
• Cleft lip: Results when the maxillary and medial nasal
processes fail to fuse.
• Cleft palate: Results when the palatal shelves fail to
fuse with the primary palate.
• Cleft uvula: The mildest form of cleft palate. Cleft
palate, with or without cleft lip, occurs once in 2500
live births.
• Ankyloglossia: Often called “tongue-tied,” results in
a short lingual frenum that extends to the apex of the
tongue.

Fig. 17-40 A newborn with bilateral complete cleft lip and palate.
Note severe angulation of the premaxillary segment.
(From Kaban LB, Troulis M: Pediatric oral and maxillofacial surgery, St. Louis, 2004, Saunders.)

Fig. 17-41 Ankyloglossia

Disturbances in
Tooth Development and Eruption

Disturbances in Tooth Development
• Ameloblastoma is a tumor composed of remnants
of the dental lamina.
• Anodontia is the congenital absence of teeth.
• Supernumerary teeth are teeth in excess of the 32
normal permanent teeth.
• Macrodontia is abnormally large teeth.
• Microdontia is abnormally small teeth.
• Dens in dente (tooth within a tooth) results in the
formation of a small tooth-like mass of enamel and
dentin within the pulp.

Fig. 17-42 Partial anodontia
(From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 3, Philadelphia, 2000, Saunders.)

Fig. 17-43 Radiograph showing two supernumerary teeth
in region of the permanent premolars

Disturbances in Enamel Formation
• Amelogenesis imperfecta is a hereditary abnormality
in which there are hypoplasia-type defects in the
enamel formation.
• Hypocalcification is the incomplete calcification or
hardening of the enamel.
• Hereditary enamel hypoplasia is a type of
amelogenesis imperfecta that is characterized by
teeth with crowns that are hard and glossy, yellow,
and cone shaped or cylindrical.

Fig. 17-47 Note loss of enamel in these teeth in a patient
with hypocalcified amelogenesis imperfecta.

Abnormal Eruption of the Teeth
• Premature eruption is natal teeth present at birth.
• Neonatal teeth are those that erupt within the first
30 days of life.
• Ankylosis is deciduous teeth in which bone has
fused to cementum and dentin, preventing
exfoliation.
• Impaction occurs when any tooth remains unerupted
in the jaws beyond the time at which it should
normally erupt.

Fig. 17-48 A radiograph of ankylosis of a deciduous molar
(Courtesy Dr. Margot Van Dis. From Ibsen OC, Phelan JA: Oral pathology for the dental hygienist, ed 4, St. Louis, 2004, Saunders.)

Fig. 17-49 Impactions in mixed dentition
visible on a dental radiograph

Additional Disturbances in
Tooth Development and Eruption
• Variation in form includes extra, missing, or fused
cusps or anomalies of roots; however, the most
common variations are peg-shaped teeth.
• Hutchinson's incisors are a variety of peg-shaped
teeth, usually associated with maternal syphilis.
• Fusion is the joining together of the dentin and
enamel of two or more separate developing teeth.
• Gemination is an attempt by the tooth bud to divide.
When this attempt is not successful, an incisal notch
indicates it.

Miscellaneous Disorders
• Abrasion is the abnormal wearing away of tooth
structure that is caused by a repetitive mechanical
habit such as improper toothbrushing.
• Attrition is the normal wearing away of tooth
structure during mastication (chewing).
• Bruxism is an oral habit consisting of involuntary
gnashing, grinding, and clenching of the teeth in
movements other than chewing. It is usually
performed during sleep and is commonly associated
with stress or tension.

Fig. 17-50 Abrasion at the cervical area of
mandibular premolars caused by toothbrushing.

Fig. 17-51 A and B, Attrition of adult dentition

Fig. 17-52 Bruxism caused attrition of the mandibular anterior teeth

Miscellaneous Disorders-cont’d
• Bulimia is an eating disorder characterized by

food binges and followed by self-induced
vomiting.
• The dental professional is often the first health
care professional to identify a patient with
bulimia.

Fig. 17-53 A and B, Erosion caused by bulimia
A B

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Oral Pathology

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– Are flat or even with the surface.

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• Blisters: Also known as vesicles, lesions filled

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• Family histories are important because of

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• Excellent in providing information about:

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• Leukoplakia means white patch.

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• A benign, chronic disease affecting the skin

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• Pseudomembranous candidiasis: thrush

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• Black hairy tongue may be caused by the oral flora

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• An adenocarcinoma is a malignant tumor that arises from