Chapter 1

Introduction to Preliminary
Diagnosis of Oral Lesions

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 Outline
Vocabulary
The diagnostic process
Variants of normal
Benign conditions of unknown cause

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 Vocabulary
(pgs. 1-7)
Clinical Appearance of Soft Tissue Lesions
Soft Tissue Consistency
Color of Lesion
Size of Lesion
Surface Texture
Radiographic Terms Used to Describe
Lesions in Bone

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Clinical Appearance of Soft Tissue
Lesions
(pgs. 1-2)
Bulla
A circumscribed, elevated lesion that is more
than 5 mm in diameter, usually contains serous
fluid, and looks like a blister
Lobule
A segment or lobe that is a part of the whole;
these lobes sometimes appear fused together

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Clinical Appearance of Soft Tissue
Lesions (cont.)

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Clinical Appearance of Soft Tissue
Lesions (cont.)
(pgs. 1-2)
Macula
An area that is usually distinguished by a color
different from that of the surrounding tissue; it
is flat and does not protrude above the surface
of the normal tissue. A freckle is an example of
a macule.
Papule
A small, circumscribed lesion usually less than
1 cm in diameter that is elevated or protrudes
above the surface of normal surrounding
tissue.
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Clinical Appearance of Soft Tissue
Lesions (cont.)
(pg. 2)
Pedunculated
Attached by a stemlike or stalk base similar to
that of a mushroom
Pustules
Variously sized circumscribed elevations
containing pus

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Clinical Appearance of Soft Tissue
Lesions (cont.)

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Clinical Appearance of Soft Tissue
Lesions (cont.)
(pgs. 2-3)
Sessile
Describing the base of a lesion that is flat or
broad instead of stemlike
Vesicle
A small, elevated lesion less than 1 cm in
diameter that contains serous fluid

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Clinical Appearance of Soft Tissue
Lesions (cont.)

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 Soft Tissue Consistency
(pg. 2)
Nodule
A palpable solid lesion up to 1 cm in diameter
found in soft tissue; it can occur above, level
with, or beneath the skin surface.
Palpation
The evaluation of a lesion by feeling it with the
fingers to determine the texture of the area; the
descriptive terms for palpation are soft, firm,
semifirm, and fluid filled; these terms also
describe the consistency of a lesion.

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 Color of Lesion
(pg. 2)
Colors
Red, pink, salmon, white, blue-black, gray,
brown, and black are the colors used most
frequently to describe oral lesions; they can be
used to identify specific lesions and may also be
incorporated into general descriptions.
Erythema
An abnormal redness of the mucosa or gingiva
Pallor
Paleness of the skin or mucosal tissues

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 Size of Lesion
(pgs. 2-3)
Centimeter (cm)
One hundredth of a meter; equivalent to a little
less than one-half inch
Millimeter (mm)
One thousandth of a meter; the periodontal
probe is of great assistance in documenting
the size or diameter of a lesion that can be
measured in millimeters

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Size of Lesion (cont.)

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 Surface Texture
(pg. 3)
Corrugated
Wrinkled
Fissure
A cleft or groove, normal or otherwise, showing
prominent depth
Papillary
Resembling small, nipple-shaped projections
or elevations found in clusters

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 Radiographic Terms Used to
Describe Lesions in Bone
(pgs. 3, 5)
Coalescence
The process by which parts of a whole join
together, or fuse, to make one.
Diffuse
Describes a lesion with borders that are not
well defined, making it impossible to detect the
exact parameters of the lesion; this may make
treatment more difficult and, depending on the
biopsy results, more radical

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 Radiographic Terms Used to
Describe Lesions in Bone (cont.)

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 Radiographic Terms Used to
Describe Lesions in Bone (cont.)
(pgs. 3, 5)
Multilocular
Describes a lesion that extends beyond the confines of
one distinct area and is defined as many lobes or parts
that are somewhat fused together, making up the entire
lesion; a multilocular radiolucency is sometimes
described as resembling soap bubbles; an odontogenic
keratocyst often presents as a multilocular radiolucent
lesion
Radiolucent
Describes the black or dark areas on a radiograph;
radiant energy can pass through these structures; less
dense tissue, such as pulp, is seen as a radiolucent
structure

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 Radiographic Terms Used to
Describe Lesions in Bone (cont.)

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 Radiographic Terms Used to
Describe Lesions in Bone (cont.)
(pgs. 4, 6)
Radiolucent and radiopaque
Terms used to describe a mixture of light and dark areas
within a lesion usually denoting a stage in the lesions
development; for example, in a stage I periapical
cemento-osseous dysplasia (cementoma), the lesion is
radiolucent; in stage II it is radiolucent and radiopaque
Radiopaque
Describes the light or white area on a radiograph that
results from the inability of radiant energy to pass
through the structure; the more dense the structure, the
more light or white it appears on the radiograph
(Note: Caries 4MO, 5DO, 28DO)

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 Radiographic Terms Used to
Describe Lesions in Bone (cont.)

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 Radiographic Terms Used to
Describe Lesions in Bone (cont.)
(pgs. 4-6)
Root resorption
Observe radiographically when the apex of the tooth
appears shortened or blunted and irregularly shaped; it
occurs as a response to stimuli, which can include a
cyst, tumor, or trauma
External resorption arises from tissue outside the tooth,
such as the periodontal ligament, whereas internal
resorption is triggered by pulpal tissue reaction from
within the tooth; in the latter the pulpal area can be seen
as a diffuse radiolucency beyond the confines of the
normal pulp area.

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 Radiographic Terms Used to
Describe Lesions in Bone (cont.)

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 Radiographic Terms Used to
Describe Lesions in Bone (cont.)
(pgs. 5, 7)
Scalloping around the root
A radiolucent lesion that extends between the roots, as
seen in a traumatic bone cyst; this lesion appears to
extend up the periodontal ligament
Unilocular
Having one compartment or unit that is well defined or
outlined as in a simple radicular cyst
Well circumscribed
Term used to describe a lesion with borders that are
specifically designed and in which one can clearly see
the exact margins and extent

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 Radiographic Terms Used to
Describe Lesions in Bone (cont.)

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 The Diagnostic Process
(pg. 8)
Making a Diagnosis
The process of diagnosis requires gathering
information that is relevant to the patient and
the lesion being evaluated; this information
comes from various sources
There are eight distinct diagnostic categories
that contribute segments of information leading
to a definitive or final diagnosis

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The Diagnostic Process (cont.)
(pgs. 8-23)
Clinical diagnosis
Radiographic diagnosis
Historical diagnosis
Laboratory diagnosis
Microscopic diagnosis
Surgical diagnosis
Therapeutic diagnosis
Differential diagnosis

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 Clinical Diagnosis
(pgs. 8-10)
The strength of the diagnosis comes from
the clinical appearance of the lesion.
The clinician can establish a diagnosis for
some lesions based on color, shape, location,
and history of the lesion.

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 Clinical Diagnosis (cont.)
(pgs. 8-10)
Examples of lesions that may be clinically
diagnosed include Fordyce granules, torus
palatinus, mandibular tori, melanin pigmentation,
retrocuspid papillae, and lingual varicosities.
Other benign conditions of unknown cause that
are recognized by their distinct clinical
appearance include fissured tongue, median
rhomboid glossitis, geographic tongue, and hairy
tongue.

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Clinical Diagnosis (cont.)

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Clinical Diagnosis (cont.)

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Clinical Diagnosis (cont.)

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Clinical Diagnosis (cont.)

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 Clinical Diagnosis (cont.)
(pgs. 8, 10)
The diagnostic process may require
historical information in addition to the
clinical findings.
An example is an amalgam tattoo.
Any history in the area can be very helpful in
confirming the clinical impression.

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Clinical Diagnosis (cont.)

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 Radiographic Diagnosis
(pgs. 10-14)
In a radiographic diagnosis, the radiograph
provides sufficient information to establish
the diagnosis.
Examples of conditions for which the radiograph
provides the most significant information include
periapical pathosis, internal resorption, external
resorption, heavy interproximal calculus, dental
caries, compound odontoma, complex
odontoma, supernumerary teeth, impacted or
unerupted teeth, and calcified pulp

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Radiographic Diagnosis (cont.)

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Radiographic Diagnosis (cont.)

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Radiographic Diagnosis (cont.)

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Radiographic Diagnosis (cont.)

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Radiographic Diagnosis (cont.)
(pgs. 10, 14, 15-17)
Normal anatomic landmarks are also easily
observed radiographically.
In some cases, the radiograph may show very distinct
and well-defined structures, such as nutrient canals and
mixed dentition.
Unusual radiographic findings are illustrated
These include cubic zirconia, amalgam fragment,
eyeglasses, amalgam overhang, instruments from root
canal procedures, curette, retained primary tooth,
shotgun pellet, and nose ring.

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Radiographic Diagnosis (cont.)

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Radiographic Diagnosis (cont.)

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 Historical Diagnosis
(pgs. 14-18)
Personal history, family history, past and
present medical and dental histories,
history of drug ingestion, and history of the
presenting disease or lesion can provide
information necessary for the final
diagnosis.
Pathologic conditions in which the family history
contributes a significant role in diagnosis include
amelogenesis imperfecta, dentinogenesis
imperfecta, and other genetic disorders.
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Historical Diagnosis (cont.)

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 Historical Diagnosis (cont.)
(pgs. 18-19)
A patients medical or dental status,
including drug history, can also contribute
significant information to a diagnosis.

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Historical Diagnosis (cont.)

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 Historical Diagnosis (cont.)
Examples include
A history of ulcerative colitis may contribute to the
diagnosis of oral ulcers.
Gingival enlargement due to treatment with a calcium
channel blocker
A history of a skin graft from the hip to the ridge and
mucobuccal fold area can provide significant information
relevant to the diagnosis of a white- or brown-pigmented
area on the mandibular ridge and vestibule.
Periapical cemento-osseous dysplasia, which is found
most frequently in black women in the third decade.

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 Laboratory Diagnosis
(pgs. 18, 20)
Clinical laboratory tests, including blood
chemistries and urinalysis, can provide
information that contributes to a diagnosis.
An example is an elevated serum alkaline
phosphatase level, significant in the diagnosis
of Pagets disease.
Laboratory cultures are helpful in
determining the diagnosis of oral
infections.

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Laboratory Diagnosis (cont.)

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 Microscopic Diagnosis
(pgs. 18-20)
The microscopic examination of the biopsy
specimen taken from the lesion in question
contributes significant information.
It is most important that an adequate tissue
sample be removed for microscopic evaluation.

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 Microscopic Diagnosis (cont.)
(pg. 19)
Brush test can be used to obtain
information from oral mucosal epithelium.
A circular brush is used to obtain cells from the
full thickness of epithelium.
The results of this test may help determine if a
scalpel biopsy is needed to establish a
definitive diagnosis.

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 Microscopic Diagnosis (cont.)
(pgs. 19-20)
A white lesion cannot be diagnosed based
on clinical appearance alone.
The microscopic appearance of this type of
white lesion can vary from a thickening of
epithelium to epithelial dysplasia, which can be
premalignant.

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Microscopic Diagnosis (cont.)

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 Surgical Diagnosis
(pgs. 20-21)
Diagnosis is made using the information gained
during the surgical procedure.
Examples include
Traumatic bone cyst
May appear as a radiolucency that scallops around the
roots
When the lesion is opened surgically, an empty void is
found.
Lingual mandibular bone cavity
Surgical examination of the well-circumscribed, radiolucent
area reveals salivary gland tissue entrapped during
development.

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Surgical Diagnosis (cont.)

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 Therapeutic Diagnosis
(pgs. 20-21)
Nutritional deficiencies are common conditions to
be diagnosed by therapeutic means.
Examples include
Angular cheilitis
May be associated with a deficiency of B-complex vitamins
Most commonly a fungal condition and responds to topical
application of an antifungal cream or ointment such as
Nystatin
ANUG
Responds to hydrogen peroxide

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Therapeutic Diagnosis (cont.)

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 Differential Diagnosis
(pgs. 21-23)
That point in the diagnostic process when
the practitioner decides which test or
procedure is required to rule out the
conditions originally suspected and
establish the definitive or final diagnosis
See Box 1-1: Case study illustrating how the
diagnostic processes work together and how
differential diagnosis is used.

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 Variants of Normal
(pgs. 23-25)
Fordyce Granules
Torus Palatinus
Mandibular Tori
Melanin Pigmentation
Retrocuspid Papilla
Lingual Varicosities
Linea Alba
Leukoedema

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 Fordyce Granules
(pgs. 22-23)
Clusters of ectopic sebaceous glands
Most commonly observed on lips and buccal
mucosa
Appear as yellow lobules in clusters and are
usually distributed over the buccal mucosa or
vermilion border of the involved lips
Considered a variant of normal
Treatment
None

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Fordyce Granules (cont.)

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 Torus Palatinus
(pg. 23)
An exophytic growth of normal compact bone
Inherited and occurs more commonly in women
Asymptomatic, develop gradually, and are observed
clinically in the midline of the hard palate
May take on various shapes and sizes, may be
lobulated, and are covered by normal soft tissue
Treatment
None, unless they interfere with speech, swallowing, or
a prosthetic appliance

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Torus Palatinus (cont.)

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 Mandibular Tori
(pgs. 23-24)
Outgrowths of normal, dense bone found
on the lingual aspect of the mandible in the
area of the premolars above the mylohyoid
ridge
Usually bilateral, often lobulated or nodular,
can appear fused together, and have no
predilection for either sex
Treatment
None, unless they interfere with fabrication and
placement of a prosthetic appliance
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Mandibular Tori (cont.)

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 Melanin Pigmentation
(pgs. 9, 23-24)
The pigment that gives color to skin, eyes,
hair, mucosa, and gingiva
Most commonly observed in dark-skinned
individuals

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Melanin Pigmentation (cont.)

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 Retrocuspid Papilla
(pgs. 9, 23)
A sessile nodule on the gingival margin of
the lingual aspect of the mandibular
cuspids

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Retrocuspid Papilla (cont.)

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 Lingual Varicosities
(pg. 24)
Usually observed on the ventral and lateral
surfaces of the tongue
Clinically, red-to-purple enlarged vessels or
clusters are seen.
Most commonly observed in individuals older
than 60 years of age; thought to be related to
the aging process

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Lingual Varicosities (cont.)

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 Linea Alba
(pg. 25)
A white line that extends
anteroposteriorly on the buccal mucosa
along the occlusal plane
May be bilateral
May be more prominent in patients who have a
clenching or bruxing habit

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 Linea Alba (cont.)

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 Leukoedema
(pg. 25)
A generalized opalescence on buccal
mucosa
Most commonly observed in black adults
If the mucosa is stretched, the opalescence
becomes less prominent.
Treatment
None

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Leukoedema (cont.)

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 Benign Conditions of Unknown
Cause
(pgs. 25-26)
Lingual Thyroid Nodule
Median Rhomboid Glossitis
Geographic Tongue
Fissured Tongue
Hairy Tongue

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 Lingual Thyroid Nodule
(pg. 25)
When thyroid tissue does not descend or
remnants become trapped
A high predilection for females
Emergence linked with hormonal changes

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Lingual Thyroid Nodule (cont.)
Clinically, a mass in the midline of the
dorsal surface of the tongue posterior to the
circumvallate papillae in the area of the
foramen cecum
Usually has a sessile base and is 2 to 3 cm in
width
Upon histological examination, normal thyroid
tissue is found.
Treatment
Evaluation of the patient to determine whether
the thyroid gland is present in its normal
location
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 Median Rhomboid Glossitis
(pgs. 25-26)
Cause is not clear.
May be associated with a chronic infection of
Candida albicans
Clinically, appears as a flat or slightly raised
oval or rectangular erythematous area in the
midline of the dorsal surface of the tongue,
beginning at the junction of the anterior and
middle thirds and extending posterior to the
circumvallate papillae.

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Median Rhomboid Glossitis (cont.)

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Median Rhomboid Glossitis (cont.)
Treatment
No specific treatment exists.
An antifungal treatment works sometimes.
May resolve spontaneously

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 Geographic Tongue
(pgs. 25-26)
The cause is not clear.
Genetic factors may play a role.
May be exacerbated by stress
Clinically, involves dorsal and lateral areas of
the tongue
Diffuse areas devoid of filiform papillae may be
observed
There appears to be remission and changes in
the depapillated areas

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Geographic Tongue (cont.)

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 Geographic Tongue (cont.)
(pg. 26)
Treatment
Usually none indicated
Occasionally, the
patient may complain
of a burning
discomfort.
Ectopic geographic
tongue
It may be found on
areas other than the
tongue.
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 Fissured Tongue
(pgs. 9, 26)
The cause is unknown.
Seen in about 5% of the population
Probably involves genetic factors
Clinically, the dorsal surface of the tongue
appears to have deep fissures or grooves.
Treatment
None

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Fissured Tongue (cont.)

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 Hairy Tongue
(pgs. 26-27)
An increased accumulation of keratin on
the filiform papillae resulting in a white,
hairy appearance
The elongated filiform papillae are white.
In black hairy tongue, the papillae are black
due to chromogenic bacteria.
Treatment
Directing the patient to brush the tongue gently
with a toothbrush to remove debris

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Hairy Tongue (cont.)

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 Discussion Questions
What is the difference between a macule and a
papule?
What are the elements of the diagnostic
process?
What variants of normal may be found within
the oral cavity?

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