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
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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 Mandals 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 mens 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 dont 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
SPACE
FOR
PHOTOGRAPH
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.
Index of Histopathological Diagrams

Sr. No.
Date
Title
Grade and
Signature

Sr. No.
Date
Title
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Signature

Sr. No.
Date
Title
Grade and
Signature

Sr. No.
Date
Title
Grade and
Signature

Sr. No.
Date
Title
Grade and
Signature

Sr. No.
Date
Title
Grade and
Signature
Section I
Definitions
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.
Definitions
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 ones 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.
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.
Definitions
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.
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
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.
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
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.
10
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.
Definitions
11
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
14
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 (Hecks 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
Talons 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
15
16
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
18
/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
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

Eveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 165).
WHO HISTOLOGICAL CLASSIFICATION OF TUMORS

OF THE SALIVARY GLANDS
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
20
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
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
Behavior is coded
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
22
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
Behavior is coded
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)
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
23
24
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
Vincents 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.
26
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
Feltys syndrome
Sideropenic dysphagia
Acute toxic epidermal necrolysis
Necrotizing sialometaplasia
Lethal granuloma
Crohns disease
Pemphigoid
Coeliac disease
Erythema multiforme exudativum
Sweets syndrome
Classifications
CLASSIFICATION OF GIANT CELL LESIONS

Autoimmune
Wegners 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-Sch3ller-Christian disease
Letterer-Siwe disease
Eosinophilic granuloma
Fibrous histiocytoma
Hodgkins 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
27
28
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
Suprabasilar Blister
Pemphigus vulgaris and vegetans

Paraneoplastic pemphigus
Hailey Hailey disease
Darriers disease
Subepidermal Blister with Scant Inflammation
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.
30
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
32
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)
34
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

1.
2.
3.
4.
Squamous papilloma
Squamous acanthoma
Keratoacanthoma
Oral nevi

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
Kaposis sarcoma
Ewings 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
35
36
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
38
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
42
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 (Leukharts) 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. Massons 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...)
44
(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 : Grams staining
Ziehl-Neelsens 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.
Grams Stain
Crystal violet
Grams 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.
Grams staining is used for classification of bacteria.
For the provisional diagnosis.
Acid-fast Stain (Ziehl-Neelsens 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.
46
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
48
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 m
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
52
Acquired Immunodeficiency Syndrome (Common Oral Lesions Associated)
Hairy leukoplakia
Candidiasis
Kaposi sarcoma
Non-Hodgkins 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
Aschers Syndrome
Sagging eyelids
Lid skin is thin and atrophic
Double lip
Blepharochalasis
Non-toxic thyroid enlargement
Auriculotemporal Syndrome (Freys 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
54
Behcets 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
Cowdens Syndrome or Multiple Hamartoma Syndrome
MucocutaneousMultiple facial papules, acral keratoses, palmoplantar keratoses,
multiple oral papillomas, dermal fibromas, multiple skin tags, oral fibromas, scrotal
tongue, lipomas, cutaneous and oral malignancies
Thyroid glandGoiter, adenoma, hyperthyroidism, hypothyroidism, thyroiditis,
thyroglossal duct cyst, follicular adenocarcinoma
Female breastFibrocystic disease, anatomic abnormalities, virginal hypertrophy,
ductal adenocarcinoma, ductal papilloma
Male breastBenign gynecomastia
Female genitourinary systemMenstrual 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 systemHydrocele, varicocele, transitional cell carcinoma of
bladder
Gastrointestinal tractPolyps 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 abnormalitiesHigh head circumference,
Adenoid facies, highly arched palate, kyphosis, kyphoscoliosis, hand and foot
abnormalities, pectus excavatum, bone cysts
Nervous systemNeuromas of cutaneous nerves, neurofibroma, meningioma,
hearing loss
EyeCataracts, angioid streaks, congenital blood vessel anomaly, myopia
CREST Syndrome
Calcinosis cutis
Reynauds 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
AuralMild to moderate hearing deficit, atresia of external auditory canal
OralCleft lip, cleft palate, bifid uvula, lateral palatal swellings, obligatory mouth
breathing.
OtherCalcification of stylohyoid ligament, cervical spine anomalies.
Downs 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
Eagles 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
56
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
Fanconis 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
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)
FaciesMacrocephaly
Skeletal systemShort neck, broad chest, protruding abdomen, umbilical hernia,
short stature, restricted joint mobility
Other findingsProgressive 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 manifestationsWidely 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 manifestationsEnlarged 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.
58
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
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
60
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 symptomsPolyposis of small intestine, intermittent colic pain, intestinal
bleeding
SkinDiscreet, 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 manifestationsRound, 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
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
Reiters Syndrome
Urethritis associated with itching and burning sensation

Bilaterally symmetrical polyarticular arthritis
Conjunctivitis
Granular or vesicular lesions on tongue, gingiva
Sjgrens Syndrome (Primary, Sicca Complex)

Dry eyes
Dry mouth
Sjgrens Syndrome (Secondary)
Dry eyes
Dry mouth
Polyarteritis nodosa
Polymyositis or scleroderma
Rheumatoid arthritis
Staphylococcal Scalded Skin Syndrome (Ritters 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
62
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 Woudes 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
64
Fordyces 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 dysplasiaArchitectural disturbances limited to lower third of epithelium
accompanied by minimal cytological atypia.
Moderate dysplasiaArchitectural disturbances extending into the middle third of
epithelium accompanied by varied degree of cytological atypia.
Severe dysplasiaArchitectural disturbances involving more than two thirds of
epithelium with associated cytological atypia.
Carcinoma in situFull 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
66
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
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
68
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
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 Hodgkins Lymphoma
Cells arranged in nodular pattern

Capsule is thickened
Node divided into nodules by thick fibrous bands
Characteristic Reed-Sternberg cell
Mixed Cellularity Hodgkins Lymphoma

Diffuse infiltrate of lymphocytes
Classic Reed-Sternberg cells (Characteristic Binucleated, Owls eye appearance)
Lymphocyte Depleted Hodgkins Lymphoma
Decreased number of lymphocytes hence appears hypocellular
Numerous Reed-Sternberg cells
70
Lymphocyte Rich Hodgkins Lymphoma

Increased lymphocytes
Classic or lacunar Reed-Sternberg cells are seen
Nodular Lymphocyte Predominant Hodgkins Lymphoma
Rich in lymphocytes
Reed-Sternberg cells are not evident
Variant of Reed-Sternberg cell known as Popcorn cell is seen
Nodular Non-Hodgkins Lymphoma
Neoplastic cells aggregate in clusters
Germinal center formation
Diffuse Non-Hodgkins Lymphoma
Neoplastic cells are diffused
No evidence of germinal center formation
Burkitts 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)
Warthins Tumor
Two prominent histological components, i.e. Epithelial and Lymphoid tissue
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.
72
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
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
74
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 Tomes fibers
2. Zone of dentinal sclerosis
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.
Pagets 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
76
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
Histopathological Diagrams
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Gross Specimen
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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
Aschers 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
Behcets 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
Burkitts 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
Cowdens 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-Hodgkins lymphoma 70
Disorder of blood vessels 27
Disturbances of growth of teeth 15
Index
Downs syndrome 55
Dyskinesia 5
Dysplasia 5, 65
Dystrophic calcification 5
Functional methods 38
Fungi 6
Furuncle 3
Fusiform 6
Eagles 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
Grams stain 44
Granular cell ameloblastoma 73
Granulation tissue 6
Granuloma 6
Granulomatosis 7
Grinspan syndrome 57
F
Fanconis 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
Freys 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
165

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 Hodgkins lymphoma 69
rich Hodgkins 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 Hodgkins 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 Hodgkins
lymphoma 70
non-Hodgkins lymphoma 70
sclerosis Hodgkins 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
Pagets 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
167
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
Reiters 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

Sjgrens 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 Woudes syndrome 62
Verrucous carcinoma 67
Vesicle 11
Virulence 11
Virus 11
Vitamin deficiency 26
W
Warthins 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-Neelsens 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. Shafers, R Rajendran and B Sivapathsundaram. A Text Book of Oral Pathology,
6th Edition, Elsevier, 2009.
10. Shafers, R Rajendran and B Sivapathsundaram. A Textbook of Oral Pathology,
5th Edition, Elsevier, 2006.

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Practical Manual of Oral

Pathology and Microbiology

Practical Manual of Oral

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Practical Manual of Oral Pathology and Microbiology

First Edition: 2010

guidance and to the best of his/her ability.

Index of Histopathological Diagrams

Index of Histopathological Diagrams

Index of Histopathological Diagrams

Index of Histopathological Diagrams

Index of Histopathological Diagrams

Index of Histopathological Diagrams

Practical Manual of Oral Pathology and Microbiology

1. Aberrancy: It may be construed as anomaly in which a tissue develops at a site

24. Anomalad: It is a malformation together with its subsequently derived structural

Practical Manual of Oral Pathology and Microbiology

47. Bulla (Blister): A bulla is a large, circumscribed, fluid containing, elevated

68. Congenital: Present at or before birth but not necessarily inherited.

Practical Manual of Oral Pathology and Microbiology

112. Granuloma: A granuloma can be defined as any small nodular delimited

Practical Manual of Oral Pathology and Microbiology

155. Nidus: The point of origin or focus of a morbid process.

Practical Manual of Oral Pathology and Microbiology

173. Primary infection: Initial invasion and multiplication of pathogenic

Practical Manual of Oral Pathology and Microbiology

CLASSIFICATION OF DEVELOPMENTAL DISTURBANCES

Developmental Disturbances of Lips and Palate

Congenital lips and commissural pits and fistula

Developmental Disturbances of Oral Mucosa

Developmental Disturbances of Oral Lymphoid Tissue

Angiolymphoid hyperplasia with eosinophils

Developmental Disturbances of Size of Teeth

Developmental Disturbances in Number of Teeth

Developmental Disturbances in Structure of Teeth

Disturbances of Growth (Eruption) of Teeth

Practical Manual of Oral Pathology and Microbiology

Multiple unerupted teeth

Median maxillary cyst

WHO CLASSIFICATION OF TUMORS OF THE ORAL CAVITY

Adenoid cystic carcinoma - 8200/3

Salivary Gland Adenomas

Pleomorphic adenoma - 8940/0

Soft Tissue Tumors

Kaposi sarcoma - 9140/3]

Diffuse large B-cell lymphoma (DLBCL) - 9680/3

Mucosal Malignant Melanoma 8720/3

Practical Manual of Oral Pathology and Microbiology

/0 for benign tumors

TNM CLASSIFICATION OF CARCINOMAS OF THE ORAL CAVITY (WHO)

Primary tumor cannot be assessed