CYSTS OF THE JAWS AND BENIGN ODONTOGENIC TUMORS Cysts of the Jaw

CYSTS OF THE JAWS AND BENIGN ODONTOGENIC TUMORS
Cysts of the Jaw
Cysts (ie, fluid-filled epithelial-lined cavities in the jaw bones and soft tissues of the face, floor of the mouth, and neck) may cause either intraoral or extraoral swellings that may clinically

Teratomas and Dermoid Cysts

Teratomas are neoplasms that are composed of a mixture of tissues, more than one of which exhibits neoplastic proliferation.They are congenitally acquired and are usually found in the ovary. Rare examples, either arising from the oral cavity or protruding into the oral cavity from the base of the skull, have been described in children. The finding of various organlike structures (ie, teeth, tissue, hair, and skin) in these tumors and their common location in the ovary may give the

CHERUBISM

Cherubism is a rare disease of children that is characterized by bilateral painless mandibular (and often corresponding maxillary) swellings that cause fullness of the cheeks, firm protuberant intraoral alveolar masses, and missing or displaced teeth (Figure 7-16).Submaxillary lymphadenopathy is an early and fairly constant feature that tends to subside after the age of 5 years and that usually has regressed by the age of 12 years.

ANEURYSMAL BONE CYST, TRAUMATIC BONE CYST, AND STA- TIC BONE CYST

Aneurysmal bone cyst, unlike ossifying fibroma and fibrous dysplasia, occurs less frequently in the jaw bones than in the long bones and usually involves the mandible rather than the maxilla.Eighty percent of aneurysmal bone cysts occur in patients younger than 30 years of age; both sexes are equally affected. Microscopically, curetted material from the cavity resembles giant cell reparative granuloma but has more prominent vascular spaces, with evidence of old and recent hemorrhages and thrombosis and hyalinization of some of the vascular spaces. Like giant cell granuloma, it has no epithelial lining despite the common use of the word “cyst” to describe it. Aneurysmal bone cyst is to be differentiated from two other pseudocysts of the jaw: the so-called traumatic bone cyst

OSSIFYING FIBROMA

Differentiation of solitary lesions of ossifying fibroma and fibrous dysplasia can be quite difficult on histologic grounds alone, but the lesions generally can be distinguished if radiographic and clinical criteria are used together with an analysis of a biopsy specimen from the central part of the lesion. Fibrous dysplasia has a diffuse margin radiographically;

Other Benign Fibro-Osseous Lesions

Before 1970, “fibrous dysplasia” was used as an all-inclusive term for both the monostotic and polyostotic forms of fibrous dysplasia described above and for a variety of other fibroosseous lesions, notably ossifying fibroma, cementifying fibroma, and osteoblastoma(Figure 7-14). Histologic studies often failed to establish definitive differences between these lesions, particularly in regard to the problems of the matura-

Fibrous Dysplasia of Bone and Albright’s Syndrome

Fibrous dysplasia of bone results from an abnormality in the development of bone-forming mesenchyme.This is manifested by the replacement of spongy bone by a peculiar fibrous tissue, within which trabeculae or spherules of poorly calcified nonlamellar bone are formed by osseous metaplasia. Histologically, a given lesion may show a great variability of pattern,with some fields that are predominantly collagenous, some that are osteoid, and others that are fully ossified and calcified. Radiographically, the lesion will usually present varying degrees of radiopacity and lucency; some

Melanotic Neuroectodermal Tumor of Infancy

Melanotic neuroectodermal tumor of infancy has been classified both as a hamartoma and as a benign neoplasm, with recent authors favoring the latter etiology.It is a rare tumor, occurring both orally and extraorally (usually in children under 6 months of age) and showing a characteristic biphasic histologic picture of melanin-containing epithelial cells lining slitlike spaces and small round cells resembling neuroblasts.

Nerve Sheath Tumors and Traumatic Neuroma

The nerve sheath includes the Schwann cells, which surround individual axis cylinders; perineural fibroblasts, which form collagen networks between individual nerve fibers with their surrounding Schwann cells; and the epineurium, a sheath that envelops entire nerve trunks and that is composed of fibroblastic-type cells and collagen.

Granular Cell Tumor and Granular Cell Epulis

The granular cell tumor is an important oral hamartomatous lesion (1) because of its frequent occurrence as a nodule on the tongue and as its variant form on the gingiva (congenital epulis) (Figure 7-12) or other mucosal site; (2) because of the controversy as to its nature and cytologic structure; and (3) because of the overlying pseudoepitheliomatous hyperplasia that often leads to a misdiagnosis of squamous cell carcinoma and to unnecessary radical surgery.Histologically, these lesions are composed of masses of large eosinophilic granular

Glomus Tumor and Other Vascular Endothelial Growths

An unusual abnormality, glomus tumor (glomangioma) develops as a small painful unencapsulated nodule as a result of hamartomatous proliferation of the modified smooth-muscle pericytic cells found in the characteristic type of peripheral arteriovenous anastomosis known as the glomus.

Lymphangioma

Lymphangioma is histologically and etiologically similar to hemangioma, except that the abnormal vessels are filled with a clear protein-rich fluid containing a few cells (lymph) rather than blood.Lymphangiomas may occur alone or (more frequently) in association with hemangiomas or other anomalous blood vessels with which the lymphangiomatous vessels are anastomosed. The tongue is the most common oral location for this lesion. Together with hemangioma, lymphangioma is an important cause of congenital macroglossia.

HAMARTOMAS

Hamartomas are tumorlike malformations characterized by the presence of a cellular proliferation that is native to the part but that manifests growth cessation without potential for further growth.On the one hand, hamartomas are to be distinguished from malformations such as extra digits, supernumerary teeth, and ectopic salivary gland tissue, in which excessive tissue is present in its usual histologic relationship. On the other hand, hamartomas are to be distinguished from true benign tumors that have a relatively unlimited capacity for expansive growth (which may continue after the exciting agent has ceased to operate).

Hemangioma and Angiomatous Syndromes

Hemangiomas are tumorlike malformations composed of seemingly disorganized masses of endothelium-lined vessels that are filled with blood and connected to the main blood vascular system.They have been described in almost all locations in and about the oral cavity and face and may involve deep structures such as the jaw and facial bones, salivary glands, muscles,and the temporomandibular joint, as well as the surface mucosa and skin. They may occur as isolated lesions in the oral cavity (Figure 7-10), as multiple lesions affecting different parts of the body, and in association with other developmental anomalies in the various angiomatous syndromes described below. They range from simple red patches (nevus flammeus, port-wine stain)(Figure 7-11, A) or birthmarks (nongeneti-

Pseudoepitheliomatous Hyperplasia

Pseudoepitheliomatous hyperplasia is a rather common exuberant oral epithelial response in which the rete pegs are extended deeply into the underlying connective tissue in an irregular fashion. Keratin pearl formation may be prominent, but other signs of cellular atypia characteristic of carcinoma

Benign Lymphoid Hyperplasia

Unencapsulated lymphoid aggregates that are normally present in the oral cavity (primarily on the soft palate, the foliate papillae on the posterolateral aspects of the tongue dorsum, and the anterior tonsillar pillar) can increase in size as a result of benign (reactive) processes as well as lymphoid neoplasms. In the absence

Pseudosarcomatous Fasciitis (Nodular Fasciitis) and Proliferative Myositis

Pseudosarcomatous fasciitis, a non-neoplastic connective-tissue proliferation, usually occurs on the trunk or extremities of young adults; it appears as a rapidly growing nodule that histologically imitates a malignant mesenchymal neoplasm but that clinically behaves benignly. Many cases have been origi-

Giant Cell Granuloma (Peripheral and Central)

Giant cell granuloma occurs either as a peripheral exophytic lesion on the gingiva (giant cell epulis, osteoclastoma, peripheral giant cell reparative granuloma) or as a centrally located lesion within the jaw,skull, or facial bones(Figures 7-5, A, and 7-6). It was first described (by Jaffe) as central giant cell reparative granuloma.Both peripheral and central lesions are histologically similar and are considered to be examples of benign inflammatory hyperplasia in which cells with fibroblastic, osteoblastic, and osteoclastic potentials predominate. The

Pyogenic Granuloma, Pregnancy Epulis, and Peripheral Ossifying Fibroma

Pyogenic granuloma is a pedunculated hemorrhagic nodule that occurs most frequently on the gingiva and that has a strong tendency to recur after simple excision(Figure 7-4). Chronic irritation as a causative factor for these lesions may sometimes be hard to identify, but the fact that they are usually located close to the gingival margin suggests that calculus, 

Fibrous Inflammatory Hyperplasias and Traumatic Fibromas FIBROMA, EPULIS FISSURATUM, AND PULP POLYP

Fibrous Inflammatory Hyperplasias and Traumatic Fibromas
FIBROMA, EPULIS FISSURATUM, AND PULP POLYP
Fibrous inflammatory hyperplasias may occur as either pedunculated or sessile (broad-based) growths on any surface of the oral mucous membrane ( Figure 7-2). They are called fibromas if they are sessile, firm, and covered by thin squamous epithelium. On the gingiva, a similar lesion is often referred to as an

INFLAMMATORY (REACTIVE) HYPERPLASIAS

The term “inflammatory hyperplasia” is used to describe a large range of commonly occurring nodular growths of the oral mucosa that histologically represent inflamed fibrous and granulation tissuse. The size of these reactive hyperplastic masses may be greater or lesser, depending on the degree to which one or more of the components of the inflammatory reaction and healing response are exaggerated in the particular lesion. Some are predominantly epithelial overgrowths with only scanty connective-

NORMAL STRUCTURAL VARIANTS

Structural variations of the jaw bones and overlying oral soft tissues are sometimes mistakenly identified as tumors, but they are usually easily recognized as within the range of normal variation for the oral cavity; biopsy in these cases is rarely indicated. Examples of such structural variants are ectopic lymphoid nodules, or “oral tonsils” (small and slightly reddish nodular elevations of a localized area of the oral mucosa as distinct from the pharyngeal mucosa); tori; a pronounced retromolar pad remaining after the extraction of the last molar teeth; localized nodular connective-tissue thickening of the attached gingiva; the papilla associated with the opening of Stensen’s duct; a circumvallate dorsum of the tongue; and sublingual varicosities in older individuals.

BENIGN TUMORS OF THE ORAL CAVITY

NORMAL STRUCTURAL VARIANTS ▼ INFLAMMATORY (REACTIVE) HYPERPLASIAS
Fibrous Inflammatory Hyperplasias and Traumatic Fibromas Pyogenic Granuloma, Pregnancy Epulis, and Peripheral Ossifying
Fibroma Giant Cell Granuloma (Peripheral and Central) Pseudosarcomatous Fasciitis (Nodular Fasciitis) and Proliferative
Myositis Pseudoepitheliomatous Hyperplasia Benign Lymphoid Hyperplasia
▼ HAMARTOMAS

REFERENCES PIGMENTED LESIONS OF THE ORAL MUCOSA

1. Watson WL, McCarthy WE. Blood and lymph vessel tumors: a report of 1,056 cases. Surg Gynecol Obstet 1970;71:569.
2. Royle HR, Lapp R, Ferrara ED. The Sturge-Weber syndrome. Oral Surg Oral Med Oral Pathol 1979;71:569.
3. Weathers DR, Fine RM. Thrombosed varix of the oral cavity. Arch Dermatol 1971;104:1971.

SUMMARY

Oral pigmentations may be focal, diffuse, or multifocal. They may be blue, purple, brown, gray, or black. They may be flat or tumefactive. Importantly, some are harbingers of internal disease; some are localized harmless accumulations of melanin,

Pigmentation Related to Heavy-Metal Ingestion

Many years ago, a variety of metallic compounds were used medicinally, but such medicaments are either no longer or rarely still in use. Ingestion of heavy metals or metal salts can be an occupational hazard since many metals are used in industry and in paints. Lead, mercury, and bismuth have all been shown to be deposited in oral tissue if ingested in sufficient quantities or over a long course of time.

Hairy Tongue

Hairy tongue is a relatively common condition of unknown etiology.The lesion involves the dorsum, particularly the middle and posterior one-third. Rarely are children affected. The papillae are elongated, sometimes markedly so, and have the appearance of hairs. The hyperplastic papillae then become pigmented by the colonization of chromogenic bacteria, which can impart a variety of colors ranging from green to brown to black. Various foods, particularly coffee and tea, probably contribute to the diffuse coloration.

Graphite Tattoo

Graphite tattoos tend to occur on the palate and represent traumatic implantation from a lead pencil. The lesions are usually macular, focal, and gray or black. Since the traumatic event usually occurred in the classroom during grade school,

GRAY/BLACK PIGMENTATIONS Amalgam Tattoo

GRAY/BLACK PIGMENTATIONS
Amalgam Tattoo
By far, the most common source of solitary or focal pigmentation in the oral mucosa is the amalgam tattoo. The lesions are macular and bluish gray or even black and are usually seen in the buccal mucosa, gingiva, or palate (Figure 6-12).

Hemochromatosis

The deposition of hemosiderin pigment in multiple organs and tissues occurs in a primary heritable disease with a prominent male predilection or may evolve secondary to a variety of diseases and conditions, including chronic anemia, porphyria, cirrhosis, postcaval shunt for portal hypertension, and excess intake of iron.The oral mucosal lesions of hemochromatosis are brown to gray diffuse macules that tend to occur in the palate and gingiva.

Petechia

Capillary hemorrhages will appear red initially and turn brown in a few days once the extravasated red cells have lysed and have been degraded to hemosiderin. Petechiae secondary to platelet deficiencies or aggregation disorders are usually not limited to the oral mucosa but occur concomitantly on skin.

BROWN HEME-ASSOCIATED LESIONS Ecchymosis

BROWN HEME-ASSOCIATED LESIONS
Ecchymosis
Traumatic ecchymosis is common on the lips and face yet is uncommon in the oral mucosa. Immediately following the traumatic event, erythrocyte extravasation into the submucosa will appear as a bright red macule or as a swelling if a hematoma forms. The lesion will assume a brown coloration within a few days, after the hemoglobin is degraded to hemosiderin (Figure 6-11).

Peutz-Jeghers Syndrome

In Peutz-Jeghers syndrome (discussed more fully in Chapter 7), oral pigmentation is distinctive and is usually pathognomonic.Multiple focal melanotic brown macules are concentrated about the lips while the remaining facial skin is less strikingly involved. The macules appear as freckles or ephelides, usually measuring < 0.5 cm in diameter (Figure 6-10).

HIV Oral Melanosis

HIV-seropositive patients with opportunistic infections may have adrenocortical involvement by a variety of parasites,

Endocrinopathic Pigmentation

Bronzing of the skin and patchy melanosis of the oral mucosa are signs of Addison’s disease and pituitary-based Cushing’s syndrome.In both of these endocrine disorders, the cause of hyperpigmentation is oversecretion of ACTH, a hormone with melanocyte-stimulating properties. In Addison’s

Pigmented Lichen Planus

Lichen planus (discussed in detail in Chapter 5) is a disease that generally presents as a white lesion, with variants showing red and desquamative lesions. Rarely, erosive lichen planus can be associated with diffuse melanosis.

Smoker’s Melanosis

Diffuse macular melanosis of the buccal mucosa, lateral tongue, palate, and floor of the mouth is occasionally seen among cigarette smokers(Figure 6-8). Although no cause-and-effect relationship has been proven and although most smokers (even heavy smokers) usually fail to show such changes,

Café au Lait Pigmentation

In neurofibromatosis, an autosomal dominant inherited disease, both nodular and diffuse pendulous neurofibromas occur on the skin and (rarely) in the oral cavity. A concomitant finding is the presence of “café au lait” pigmentation.

Physiologic Pigmentation

Black people, Asians, and dark-skinned Caucasians frequently show diffuse melanosis of the facial gingiva.In addition, the lingual gingiva and tongue may exhibit multiple, diffuse, and

Drug-Induced Melanosis

A variety of drugs can induce oral mucosal pigmentation.
These pigmentations can be large yet localized, usually to the hard palate, or they can be multifocal, throughout the mouth. In either case, the lesions are flat and without any evidence of nodularity or swelling. The chief drugs implicated are the quinoline, hydroxyquinoline, and amodiaquine antimalarials.

Malignant Melanoma

On the facial skin, the malar region is a common site for melanoma because this area of the face is subject to significant solar exposure. In fact, cutaneous melanoma is most common among white populations that live in sunbelt regions of the world. Facial cutaneous melanomas may appear macular or nodular, and the coloration can be quite varied, ranging from brown to black to blue, with zones of depigmentation. An important difference is that unlike common nevi that exhibit smooth outlines, melanomas show jagged irregular margins. These lesions are more common among elderly

Nevocellular Nevus and Blue Nevus

Unlike ephelides and melanotic macules, which result from an increase in melanin pigment synthesis, nevi are due to benign proliferations of melanocytes.There are two major types, based on histology, and these two types tend to show differences clinically as well, particularly in tint and

BROWN MELANOTIC LESIONS Ephelis and Oral Melanotic Macule

BROWN MELANOTIC LESIONS
Ephelis and Oral Melanotic Macule
The common cutaneous freckle, or ephelis,represents an increase in melanin pigment synthesis by basal-layer melanocytes, without an increase in the number of melanocytes. On the skin, this increased melanogenesis can be attributed to actinic exposure. Ephelides can therefore be encountered on the vermilion border of the lips, with the lower lip being the favored site since it tends to receive more solar exposure than the upper lip (Figure 6-4).

Hereditary Hemorrhagic Telangiectasia

Characterized by multiple round or oval purple papules measuring less than 0.5 cm in diameter, hereditary hemorrhagic telangiectasia (HHT) is a genetically transmitted disease, inherited as an autosomal dominant trait(Figure 6-3). The lesions represent multiple microaneurysms, owing to a weakening defect in the adventitial coat of venules. The lesions are so distinct as to be pathognomonic. There may be more than 100 such purple papules on the vermilion and mucosal surfaces of the lips as well as on the tongue and buccal mucosa. The facial skin and neck are also involved. Examination of the 

nasal mucosa will reveal similar lesions, and a past history of epistaxis may be a complaint. Indeed, deaths have been reported in HHT attributable to epistaxis. The lesions may be seen during infancy but are usually more prominent in adults.

Kaposi’s Sarcoma

A tumor of putative vascular origin, Kaposi’s sarcoma (KS)
was rarely encountered in the oral cavity prior to 1983. The classic form generally appeared in two distinct clinical settings: (1) elderly men (in the oral mucosa and on the skin of the lower extremities) and (2) children in equatorial Africa (in lymph nodes). The former is the classic form as originally described by Moritz Kaposi and is an indolent tumor with slowly progressive growth. Although classified as a malignancy, classic Kaposi’s sarcoma does not show a great tendency for metastasis and probably has never caused the death

Angiosarcoma

Malignant vascular neoplasms, distinct from Kaposi’s sarcoma, are not related to human immunodeficiency virus (HIV) and can arise anywhere in the body. Although the oral cavity is an extremely rare site for such tumors, those that occur will (if superficial)

Varix

Pathologic dilatations of veins or venules are varices or varicosities, and the chief site of such involvement in the oral tissues is the ventral tongue.Varicosities become progressively prominent with age; thus, lingual varicosities are encountered in elderly individuals. Lingual varicosities appear as tortuous serpentine blue, red, and purple elevations that course over the ventrolateral surface of the tongue, with extension anteriorly. Even though they may be quite striking in some patients, they represent a degenerative change in the adventitia of the venous wall and are of no clinical consequence. They are painless and are not subject to rupture and hemorrhage.

BLUE/PURPLE VASCULAR LESIONS Hemangioma

BLUE/PURPLE VASCULAR LESIONS
Hemangioma
Vascular lesions presenting as proliferations of vascular channels are tumorlike hamartomas when they arise in childhood; in adults (particularly elderly persons), benign vascular proliferations are generally varicosities. The hemangiomas of childhood are found on the skin, in the scalp, and within the connective tissue of mucous membranes. Approximately 85% of childhood-onset hemangiomas spontaneously regress after puberty.

PIGMENTED LESIONS OF THE ORAL MUCOSA

BLUE/PURPLE VASCULAR LESIONS
Hemangioma Varix Angiosarcoma Kaposi’s Sarcoma Hereditary Hemorrhagic Telangiectasia
▼ BROWN MELANOTIC LESIONS
Ephelis and Oral Melanotic Macule Nevocellular Nevus and Blue Nevus Malignant Melanoma Drug-Induced Melanosis Physiologic Pigmentation Café au Lait Pigmentation Smoker’s Melanosis Pigmented Lichen Planus Endocrinopathic Pigmentation HIV Oral Melanosis Peutz-Jeghers Syndrome

REFERENCES RED AND WHITE LESIONS OF THE ORAL MUCOSA

1. Martin JL. Leukoedema: a review of the literature. J Natl Med Assoc 1992;84(11):938–40.
2. Durocher RT, Thalman R, Fiore-Donno G. Leukoedema of the oral mucosa. J Am Dent Assoc 1972;85:1105–9.
3. Martin JL, Crump EP. Leukoedema of the buccal mucosa in Negro children and youth. Oral Surg Oral Med Oral Pathol 1972;34:49–58.
4. Martin JL. Leukoedema: an epidemiological study in white and African Americans. J Tenn Dent Assoc 1997;77(1):18–21.

Hairy Tongue (Black Hairy Tongue)

“Hairy tongue” is a clinical term describing an abnormal coating on the dorsal surface of the tongue. The incidence of this condition ranges from 0.5% in the United States to 12.8% among Israeli male geriatric patients and 57% among imprisoned Greek drug addicts.Hairy tongue results from the defective desquamation of cells that make up the secondary filiform papilla. This buildup of keratin results in the formation of highly elongated hairs, which is the hallmark of this entity.

MISCELLANEOUS LESIONS Geographic Tongue

MISCELLANEOUS LESIONS
Geographic Tongue
Geographic tongue (erythema migrans, benign migratory glossitis, erythema areata migrans, stomatitis areata migrans) is a common benign condition affecting primarily the dorsal surface of the tongue. Its incidence varies from slightly over 2% in the US population to 11 to 16% in other populations.

GINGIVAL AND PALATAL CYSTS OF THE NEWBORN AND ADULT Features in the Newborn

GINGIVAL AND PALATAL CYSTS OF THE NEWBORN AND ADULT
Features in the Newborn
Gingival cysts of the newborn are often multiple sessile domeshaped lesions measuring about 2 to 3 mm in diameter. They are chalk white and present predominantly on the maxillary anterior alveolar ridge just lingual to the crest.

FORDYCE’S GRANULES

Fordyce’s granules are ectopic sebaceous glands or sebaceous choristomas (normal tissue in an abnormal location) within the oral mucosa. Normally, sebaceous glands are seen within the dermal adnexa, in association with hair follicles; however, Fordyce’s granules do not exhibit any association with hair structures in the oral cavity. This condition is seen in approximately 80 to 90% of the population.

LUPUS ERYTHEMATOSUS (SYSTEMIC AND DISCOID) Clinical Features, Diagnosis, and Treatment

LUPUS ERYTHEMATOSUS (SYSTEMIC AND DISCOID)
Clinical Features, Diagnosis, and Treatment

Systemic lupus erythematosus (SLE) is a prototypical example of an immunologically mediated inflammatory condition that causes multiorgan damage. (SLE is discussed in more detail in Chapter 18, under “Connective Tissue Diseases”; the brief description here emphasizes its clinical manifestations on the oral mucosa.)

LICHENOID REACTIONS

Lichenoid reactions and lichen planus exhibit similar histopathologic features.Lichenoid reactions were differentiated from lichen planus on the basis of (1) their association with the administration of a drug, contact with a metal, the use of a food flavoring, or systemic disease and (2) their resolution when the drug or other factor was eliminated or

ORAL LICHEN PLANUS

Oral lichen planus (OLP) is a common chronic immunologic inflammatory mucocutaneous disorder that varies in appearance from keratotic (reticular or plaquelike) to erythematous and ulcerative. About 28% of patients who have OLP also have skin lesions.The skin lesions are flat violaceous papules with a fine scaling on the surface. Unlike oral lesions, skin lesions are usually self-limiting, lasting only 1 year or less. The lack of sound epidemiologic studies and the variations in signs as well as symptoms make estimates of prevalence difficult.

ERYTHROPLAKIA

Erythroplakia has been defined as a “bright red velvety plaque or patch which cannot be characterized clinically or pathologically as being due to any other condition.”The word is an adaptation of the French term “erythroplasie de Queyrat,”which describes a similar-appearing lesion of the glans penis with a comparable premalignant tendency. Although red lesions of the oral mucosa have been noted for many years, the use of the term “erythroplakia” in this context has been common for only about 25 years.

BOWEN’S DISEASE

Bowen’s disease is a localized intraepidermal squamous cell carcinoma of the skin that may progress into invasive carcinoma over many years. Bowen’s disease also occurs on the male and female genital mucosae and (rarely) in the oral mucosa as an erythroplakic, leukoplakic, or papillomatous lesion.

IDIOPATHIC “TRUE” LEUKOPLAKIA

Leukoplakia is a white oral precancerous lesion with a recognizable risk for malignant transformation. In 1972, the World Health Organization (WHO) defined a precancerous lesion as a “morphologically altered tissue in which cancer is more likely to occur than in its apparently normal counterpart.”

Parulis

A parulis, or gumboil, is a localized accumulation of pus located with the gingival tissues (Figure 5-25). It originates from either an acute periapical abscess or an occluded periodontal pocket. The cortical bone is destroyed by the inflammatory process, and the gumboil often appears as a yellowish

Mucous Patches

A superficial grayish area of mucosal necrosis is seen in secondary syphilis; this lesion is termed a “mucous patch.” Secondary syphilis usually develops within 6 weeks after the primary lesion and is characterized by diffuse maculopapular eruptions of the skin and mucous membranes.

TREATMENT OF ORAL CANDIDIASIS

A variety of topical and systemically administered medications are now available to supplement the older polyene antifungal antibiotics nystatin and amphotericin B. An imidazole derivative (clotrimazole) is available for topical use. Systemic therapy includes the use of any one of these three: ketoconazole, itraconazole, and fluconazole. Fluconazole and amphotericin B may be used intravenously for the treatment of the resistant lesions of CMC and systemic candidiasis.

IMMUNOCOMPROMISED (HIV)-ASSOCIATED CANDIDIASIS

Oral candidiasis is the most frequent opportunistic infection associated with immunocompromised individuals.
The role of weakened specific immune defense mechanisms is apparent from the fact that patients who are on immunosuppressive drug regimensor who have HIV infection,cancer, or hematologic malignancies have an increased susceptibility to

CHRONIC MUCOCUTANEOUS CANDIDIASIS

Persistent infection with Candida usually occurs as a result of a defect in cell-mediated immunity or may be associated with iron deficiency. Hyperplastic mucocutaneous lesions, localized granulomas, and adherent white plaques on affected mucous membranes are the prominent lesions that identify chronic mucocutaneous candidiasis (CMC) (Figure 5-24).