POCKETBOOK

of ORAL DISEASE
for Elsevier:
Commissioning Editor: Alison Taylor
Development Editor: Lynn Watt
Project Manager: Andrew Riley
Designer/Design Direction: Stewart Larking
 POCKETBOOK
of ORAL DISEASE
Crispian Scully CBE
MD PhD MDS MRCS BSc FDSRCS FDSRCPS FFDRCSI FDSRCSE FRCPath
FMedSci FHEA FUCL DSc DChD DMed[HC] DrHC
Emiritus Professor, University College London, UK

Jose V Bagan MD DDS PhD

Professor of Oral Medicine, Valencia University and
Hospital General Universitario de Valencia, Valencia, Spain

Marco Carrozzo MD DSM

Professor of Oral Medicine, Newcastle University, Honorary Consultant,
Royal Victoria Infirmary Hospital, Newcastle upon Tyne, UK

Catherine M Flaitz DDS MS

Professor of Oral and Maxillofacial Pathology and Pediatric Dentistry,
The University of Texas School of Dentistry at Houston; Associate Faculty,
McGovern Center for Humanities and Ethics, The University of Texas
Medical School at Houston; and Associate Staff, Texas Children’s
Hospital, Baylor College of Medicine, Texas, USA

Sergio Gandolfo MD DDS

Professor, Head of the Oral Medicine and Oral Oncology
Section, Department of Oncology,
University of Turin, Orbassano (Turin), Italy

Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto 2012
 CONTENTS

Preface  ix
1 Introduction  1
Dangerous conditions  1
History  2
Examination  6
Anatomical features or developmental anomalies  18
Lesion descriptors  31
2 Differential diagnosis by signs and
symptoms  33
Bleeding  34
Burning mouth  37
Desquamative gingivitis  41
Dry mouth (hyposalivation and xerostomia)  42
Halitosis (oral malodour)  47
Mucosal blisters  51
Mucosal brown and black lesions  53
Mucosal erosions  60
Mucosal fissures or cracks  62
Mucosal purpura  68
Mucosal red lesions  70
Mucosal ulceration or soreness  74
Mucosal white lesions  81
Pain (orofacial)  89
Palsy (orofacial)  92
Sensory changes (orofacial)  96
Sialorrhoea (hypersalivation and drooling)  101
Swellings in the lips or face  103
Swellings in the mouth  107
Swellings in the neck  116
Swellings of the jaws  119
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 Pocketbook of Oral Disease

Swelling of the salivary glands  120

Taste disturbance  127
Tongue: furred  131
Tongue: smooth (glossitis)  134
Tongue swelling  136
Tooth abrasion  137
Tooth attrition  138
Tooth discolouration  139
Tooth erosion  143
Tooth hypoplasia  144
Tooth mobility or premature loss  147
Tooth number anomalies  148
Tooth shape anomalies  150
Trismus  152

3 Differential diagnosis by site  157

Cervical lymph node disease  158
Salivary gland disease  161
Lip lesions  179
Intraoral lesions  200
Coloured lesions: red  202
Coloured lesions: brown  207
Soreness/ulcers  211
White lesions  243
Intraoral soft tissue lumps and swellings  259
Tongue lesions  265
Palatal lesions  283
Gingival lesions  291
Jaw and musculoskeletal conditions  302
Neurological and pain disorders  318
Teeth-specific disorders  324

4 Iatrogenic conditions  329

Immunosuppressive therapy  329
Radiotherapy  332
Chemotherapy  334
Organ transplantation  335
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 Contents

Haematopoietic stem cell transplantation  335

Drugs  337
Other iatrogenic conditions  337
5 Immune defects and haematological defects
and malignancies  351
Human immunodeficiency virus (HIV) disease  351
Leukopenia and neutropenia  356
Leukaemias  358
Lymphomas  360
6 Diagnosis  363
Diagnosis of mucosal disorders  363
Diagnosis of salivary disease  364
Diagnosis of jaw disorders  365
Diagnosis of dental disorders  366
Diagnosis of pain and neurological disorders  366
7 Investigations  371
Blood tests  371
Microbiological tests  371
Salivary flow determination  371
Biopsy  372
Imaging  384
Adjunctive screening tests  385
8 Management protocols for patients with oral
diseases treated in primary care settings  387
9 Referral for specialist advice  395
10 Further information  397
Glossary of eponymous diseases and syndromes  397
Glossary of abbreviations  408
Further reading  412
Index  413

vii
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 PREFACE
This Pocketbook of Oral Disease is aimed at graduating dental care students
and, as such, assumes knowledge of basic sciences and human diseases
and offers the basics of oral diseases. The emphasis is on diagnosis and
treatment in primary care settings, and the rather complex language
and terminology is clarified in the glossaries of eponymous syndromes and
abbreviations at the back of the book.
Since reliable epidemiological data are sparse, we have termed conditions
seen by most practitioners as ‘common’, and those seen mainly by
specialists only, as ‘uncommon’ or ‘rare’. Graduating dentists are usually
expected to know mainly about ‘common’ conditions and those that can be
life-threatening.
The subject is presented initially by symptoms and signs, then discussing
the various sites and giving synopses of the various conditions most com-
monly seen. Diagnosis, investigations, referral and care in primary care
settings are then outlined.
This book was developed on the basis of a successful enterprise, the
Colour Guide to Oral Disease, published with Professor Roderick Cawson,
which was highly popular and went to several editions. Some of those illus-
trations appeared also in his Essentials of Oral Pathology and Oral Medicine,
co-authored with Edward Odell.
This current guide has been thoroughly updated and expanded, and
includes leading oral medicine clinicians as co-authors, originating from the
USA (Professor Catherine Flaitz), Spain (Professor Jose Bagan) and Italy
(Professor Marco Carrozzo and Professor Sergio Gandolfo), and includes
some material from the book Oral Medicine, co-authored with these Italian
colleagues.
Finally, our thanks are due to our patients and nurses, and, for various
pieces of advice, to our colleagues Drs Monica Pentenero, Pedro Diz Dios
and David Wiesenfeld.

C.S.
2012

ix
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 Introduction
1
Oral medicine has been defined as being ‘concerned with the oral health
care of patients with chronic recurrent and medically related disorders of the
mouth and with their diagnosis and non-surgical management’. Oral dis-
eases can affect people of any background, gender or age.
Children are usually most liable to dental caries and the sequelae of
odontogenic infections, and to acute viral infections, but oral diseases are
generally more common in adults, especially older people or people with
systemic disease. Immunocompromised individuals are especially prone to
oral disease, and also to serious outcomes.
Factors predisposing to oral disease may include:
• Genetic predisposition: prominent especially in autosomal dominant
conditions
• Systemic disease: including mental health issues
• Lifestyle habits: including poor oral hygiene and/or use of tobacco,
alcohol, betel and recreational drugs
• Iatrogenic (doctor-induced) influences: such as the wearing of oral
appliances; radiation therapy; transplantation procedures; drugs
• Nutrition: malnutrition and eating disorders.

Dangerous conditions
Many oral medicine conditions are recurrent or chronic and some are serious,
with considerable associated morbidity (illness), often affecting the quality of
life (QoL), and some are potentially lethal.
Conditions that are potentially dangerous or have a high mortality
include disorders such as pemphigus, cancer and chronic infections such
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 Pocketbook of Oral Disease

as HIV/AIDS, tuberculosis or syphilis (all of which may be lethal). Other

conditions have a high morbidity (incidence of ill health), and these include
temporal arteritis (cranial or giant cell arteritis), pemphigoid or Behçet
syndrome (which can lead to blindness), trigeminal neuralgia and facial
palsy (which may signify serious neurological diseases), and potentially
malignant oral disorders such as leukoplakia, lichen planus and submucous
fibrosis.
It is important to refer or biopsy a patient with any unusual lesion,
especially a single lesion persisting 3 or more weeks (which could be a
cancer), or if there are typically multiple persisting ulcers when a vesicu­
lobullous disorder such as pemphigus is suspected (since this is potentially
lethal).
Changes that might suggest malignant disease such as cancer could
include any of the following persisting more than 3 weeks:
• A sore on the lip or in the mouth that does not heal
• A lump on the lip or in the mouth or throat
• A white or red patch on the gums, tongue, or lining of the mouth
• Unusual bleeding, pain, or numbness in the mouth
• A sore throat that does not go away, or a feeling that something is
caught in the throat
• Difficulty or pain with chewing or swallowing
• Swelling of the jaw that causes dentures to fit poorly or become
uncomfortable
• A change in the voice, and/or
• Pain in the ear
• Enlargement of a neck lymph gland.
If in any doubt – refer the patient for a second or a specialist opinion.

History
The history gives the diagnosis in the majority (possibly about 80%) of cases.
Important questions to answer include, what is this chief or primary complaint
(Complaining of [CO] or Chief Complaint [CC]) and what is the history (History
of the Present Complaint [HPC]) – is this:
• The first episode?
• Persistent or recurrent?
• Changing in size or appearance?
2
 Chapter 1 • Introduction

and are there:

• Single or multiple lesions/symptoms?
• Specific or variable symptoms?
• Extraoral lesions?
The Relevant Medical History (RMH), Family History (FH) and Social History
(SH) should be directed to elicit a relevant history in terms of a range of
aspects. One way to remember all this is by the acronym GSPOT, MED,
RAGES:
• Genetics: family history?
• Social history?
• Pets?
• Occupation?
• Travel history?
• Medical history/medications?
• Eating habits?
• Drugs and habits? (drugs of misuse; tobacco; alcohol; betel; artefactual
[this means self-induced, or factitial])
• Respiratory features?
• Anogenital features?
• Gastrointestinal features?
• Eye features?
• Skin, hair or nail features?
Additionally, other aspects are needed in relation to complaints specific to
different systems, as detailed below.

History related to dental problems

The history related to dental (tooth) problems should also include at
least:
• date of onset of symptoms
• swelling details, such as duration and character
• pain details, such as duration, site of maximum intensity, severity,
onset, daily timing, character, radiation, aggravating and relieving
factors, relationship to meals and associated phenomena
• mouth-opening restriction
• changes in the occlusion of the teeth
• hyposalivation details.
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 Pocketbook of Oral Disease

Disorders that affect the teeth may appear to be unilateral, but the other
teeth should always be considered, and it is important to consider the pos-
sibility of related systemic disorders, especially those affecting:
• musculo-skeletal/connective tissue
• the neurological system (e.g. seizures)
• nutrition (eating disorders such as bulimia).

History related to mucosal problems

The history related to mucosal problems should also include at least:
• date of onset of symptoms
• lesional details, such as duration and character
• pain/discomfort details, such as duration, site of maximum intensity,
severity, onset, daily timing, character, radiation, aggravating and
relieving factors, relationship to meals and associated phenomena
• mouth-opening restriction.
Disorders that affect the mucosa may appear to be unilateral, but all the
other oral mucosa should always be examined, and it is important to consider
the possibility of related systemic disorders, especially infections, and those
affecting:
• the haematopoietic system (e.g. anaemia or leukaemia)
• the gastrointestinal tract (e.g. Crohn disease)
• the skin and/or anogenital (e.g. lichen planus) or conjunctival or other
mucosae (e.g. erythema multiforme)
• nutrition (disorders such as hypovitaminosis).

History related to salivary problems

The history related to salivary problems should also include at least:
• date of onset of symptoms
• swelling details such as site, duration and character, and relation to
meals and whether enlarging
• quality and quantity of saliva, both observed and perceived, and details
of any speech difficulties, dysphagia or taste alterations
• pain details, such as duration, daily timing, character, radiation,
aggravating and relieving factors, relationship to meals and associated
phenomena
• mouth-opening restriction
4
 Chapter 1 • Introduction

• history of dry eyes or dryness of other mucosa

• personal or family history of arthritis
• occupation, such as glass blowing or trumpet playing, which might
introduce air into the gland (pneumoparotid).
Disorders that affect the salivary glands may appear to be unilateral, but
the other glands should always be considered, and it is important to consider
the possibility of related systemic disorders, especially those affecting:
• lachrymal and other exocrine glands (e.g. Sjögren syndrome)
• endocrine glands (e.g. diabetes)
• hepatobiliary system (e.g. alcoholic cirrhosis may underlie sialosis)
• connective tissues (e.g. rheumatoid arthritis or systemic lupus
erythematosus).

History related to jaw problems

The history should also include:
• date of onset of symptoms
• precipitating factors (e.g. trauma)
• swelling details, such as duration and character
• pain details, such as site of maximum intensity, onset, duration,
severity, daily timing, character, radiation, aggravating and relieving
factors, relationship to meals and associated phenomena
• mouth-opening restriction
• history of dry eyes or dryness of other mucosa
• personal or family history of arthritis.
Disorders that affect the jaws or temporomandibular joint (TMJ) may
appear to be unilateral, but the other areas should always be evaluated, and
it is important to consider the possibility of related systemic disorders, espe-
cially infections and those affecting:
• bones (e.g. osteoporosis)
• joints (e.g. osteoarthritis)
• connective tissues (e.g. rheumatoid arthritis).

History related to pain and neurological problems

The history should also include at least (Box 1.1):
• date of onset of symptoms
• symptom details, such as duration and character, referred pain
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 Pocketbook of Oral Disease

Box 1.1  Characteristics of pain (SOCRATES)

Site
Onset
Character
Radiation
Associated features
Time course
Exacerbating and relieving factors
Severity

• pain details, such as duration, daily timing, character, radiation,

aggravating and relieving factors, relationship to meals, and associated
phenomena
• movement disorders
• sensory loss, including visual changes.
Disorders that affect the neurological system may appear to be
unilateral, but the cranial nerves and neurological system should always be
considered, and it is important to consider the possibility of related systemic
disorders, especially those affecting the cardiovascular system (e.g.
thromboembolism).

Examination
Careful examination is crucial and should include at the very least those
extraoral areas readily inspected, such as (usually) the head and neck, and
hands – with due consideration for culture.
Extraoral examination
Extraoral examination should include assessment of general features
such as:
• anxiety or agitation
• appearance
• behaviour
• breathing
• communication
• conscious level
• movements
6
 Chapter 1 • Introduction

• posture
• sweating
• temperature
• wasting
• weight loss or gain
and careful inspection of the face for:
• facial symmetry
• facial colour – for pallor (e.g. fear, anaemia) or
• facial erythema (e.g. anxiety, alcoholism, polycythaemia) or rashes
(e.g. infections, lupus) or other lesions (e.g. basal cell carcinoma)
• facial swellings – for soft tissue or salivary gland swellings (e.g.
allergies, infections or inflammatory lesions), enlarged masseter
muscles (masseteric hypertrophy) or bony enlargement
• fistulas or sinuses (which may be odontogenic in origin)
• pupil size (e.g. dilated in anxiety or cocaine abuse, constricted in opioid
abuse).
Neck examination is mandatory, especially examination of cervical lymph
nodes. Lesions in the neck may arise mainly from the cervical lymph nodes,
but also from the thyroid gland, salivary glands and heterotopic salivary
tissue, or from skin, subcutaneous tissues, muscle, nerve, blood vessels or
other tissues.
Lesions arising from the skin can usually be moved with the skin and are
generally readily recognizable.
Jaws
The jaws should be palpated to detect swelling or tenderness. Maxillary,
mandibular or zygomatic deformities, fractures or enlargements may be more
reliably confirmed by inspection from above (maxillae/zygomas) or behind
(mandible).
Following trauma, all borders and sutures should be palpated for tender-
ness or a step deformity (at the infraorbital rim, the lateral orbital rim,
the zygomatic arch and the zygomatic buttress intraorally).
The jaw joints (TMJ) should then be examined by inspecting:
• facial symmetry
• facial and intraoral discolouration and swelling (haematoma,
ecchymoses, laceration)
• jaw opening and movements
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 Pocketbook of Oral Disease

and by palpating the bones, main masticatory muscles (temporalis, mas-

seters and pterygoids), and TMJ – using fingers placed over the joints
in front of the ears, to detect pain, or swelling.
Finally, the dental occlusion should be examined.
The neurological system
Cranial nerve examination may also be needed (Table 1.1), by inspecting:
 facial symmetry and movement

 ocular movements

• testing trigeminal nerve

 corneal reflex (this tests Vth and VIIth cranial nerves); touching the

cornea gently with sterile cotton wool should produce a blink.

 touch (tested with cotton wool or stream of air)

 vibration (tested with a tuning fork)

 proprioception (move a joint slightly with the patient’s eyes closed

and ask them to recognize the direction of the movement)

 pain (pin-prick testing)

 temperature (test with a warm or cold object)

• hearing assessment
• examining the eyes
• testing taste sensation (gustometry) using stimuli on a cotton-tipped
applicator, including:
 citric acid or hydrochloric acid (sour taste)

 caffeine or quinine hydrochloride (bitter)

 sodium chloride (salty)

 saccharose (sweet)

 monosodium glutamate (umami taste).

Electrogustometry examines taste sensitivity by means of electric excit-

ability thresholds determined through the response to the irritation of taste
buds area with electrical current of different intensity.
Trigeminal motor functions that should be tested include:
• jaw jerk
• palpating muscles of mastication during function:
 masseters during clenching

 temporalis during clenching

 pterygoids during jaw protrusion.

8
 Chapter 1 • Introduction

Table 1.1  Cranial nerve examination

Nerve Test/examination/consequence
of lesion
Number Name

I Olfactory Smell
II Optic Visual fields
Visual acuity
Pupils equal reactive to light and
accommodation (PERLA)
Fundoscopy
III Oculomotor Eye movements
IV Trochlear Diplopia
V Abducens Nystagmus
VI Trigeminal Sensory-fine touch, pin prick, hot and cold
Masticatory muscle power
Corneal reflex
Jaw jerk
VII Facial Facial movements
Corneal reflex
Taste
VIII Vestibulocochlear Hearing
Balance
IX Glossopharyngeal Taste
X Vagus Gag reflex
Speech
Swallow
Cough
XI Accessory Rotate head
Shrug shoulders
XII Hypoglossal Tongue protrusion

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 Pocketbook of Oral Disease

Assess the mental state and level of consciousness (Glasgow Coma

Scale) and, if necessary:
• assess speech
 dysarthria (oropharyngeal, neurological or muscular pathology)

 dysphonia (respiratory pathology), or

 dysphasia (abnormal speech content due to damage in the brain

language areas)
• check for neck stiffness (meningeal inflammation)
• look for abnormal posture or gait (broad-based in cerebellar deficit,
shuffling in Parkinsonism, high stepping in peripheral leg neuropathy,
swinging leg in hemiparesis, etc).
Specific neurological disease may be encountered, and thus the dental
surgeon should be adept in examining the cranial nerves, especially the
trigeminal and the facial nerves.

Trigeminal (V) nerve

This nerve conveys sensation from the head, face and mouth, and motor
supply to the muscles of mastication, mylohyoid, anterior belly of digastric,
tensor veli palatini and tensor tympani.
Test: light touch sensation (with cotton wool); pain (with pin prick); corneal
reflex (touch the cornea with a wisp of cotton wool); open and close jaw
against resistance; jaw jerk.
Abnormal findings include facial anaesthesia (sensory loss), hypoaesthe-
sia (sensory diminution), dysaesthesia or paraesthesia (abnormal sensations
like ‘pins and needles’); abnormal reflexes; weakness and wasting of mas-
ticatory muscles.

Facial (VII) nerve

The facial nerve is motor to muscles of facial expression, stylohyoid, posterior
belly of digastric, and stapedius; secretomotor (parasympathetic fibres to
lachrymal, submandibular and sublingual salivary, nasal and palatine glands);
and taste (from anterior two-thirds of tongue via the chorda tympani).
Test: facial movements (eye shutting, smiling, etc.); Schirmer test (a
special paper strip to assess lacrimation); check for hyposalivation; taste
sensation (apply salty, sweet, sour and bitter substances to the tongue as
above); hearing, for hyperacusis. The facial nerve can be tested by asking
patients to close their eyes and lips tightly – the strength of closure can be
felt by manually trying to open them; asking patients to show their teeth;
10
 Chapter 1 • Introduction

asking patients to look upwards, raising the eyebrows and creasing the
forehead; and also asking patients to whistle or fill their cheeks with air with
their lips tightly pursed – if the face is weak, the patient will find it difficult
to hold in the air. Tapping each inflated cheek reveals the weakness.
Lesions
Abnormal findings include contralateral facial weakness with partial sparing
of the upper face (bilateral innervation) in upper motor neurone (UMN) lesions
(brain lesions); ipsilateral facial weakness, impaired lacrimation, salivation
and taste in lower motor neurone (LMN) lesions (e.g. Bell palsy, parotid
surgery, etc.).
Neurological disorders may appear to be unilateral, but the other cranial
nerves should always be examined. An overall neurologic examination should
be performed to evaluate for widespread disease. It is important to consider
drug use and the possibility of related systemic disorders.

Intraoral examination
For mouth examination:
• Use a good light via
 conventional dental unit light

 special loupes or

 otorhinolaryngology light.

• Remove any dental appliance to examine beneath.

• Examine all visible mucosa.
• Begin away from focus of complaint or location of known lesions.
• Examine the dorsum of tongue, ventrum of tongue, floor of the mouth,
hard and soft palate mucosa, gingivae, labial and buccal mucosa,
and teeth.
• A systematic and consistent approach to the examination is
important.
Mucosal lesions are not always readily visualized and, among attempts
to aid this, but not proven superior to conventional visual examination in
terms of specificity or sensitivity, are:
Toluidine blue staining (also known as tolonium blue or vital staining). The
patient rinses with 1% acetic acid for 20 seconds to clean the area, then
with plain water for 20 seconds, then with 1% aqueous toluidine blue
solution for 60 seconds, then again rinses with a 1% acetic acid for 20
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 Pocketbook of Oral Disease

seconds, and finally with water for 20 seconds. Toluidine blue stains some
areas blue – these are mainly but not exclusively pathological areas.
Chemiluminescent illumination. The technique uses light refraction and relies
on fluorophores that naturally occur in cells after rinsing the mouth with
1% acetic acid using excitation with a suitable wavelength. The visibility of
some lesions may thus be enhanced.
Fluorescence spectroscopy. Tissues are illuminated with light and lesions
change the fluorophore concentration and light scattering and absorption.
Their visibility may thus be enhanced.
There are limitations in these aids, discussed in Chapter 7, but combinations
of these approaches may enhance the evaluation of the tissues and assist
in the decision-making.
Lesions once identified should be described using standardized nomen-
clature, as shown in Table 1.3 at the end of the chapter, and entered onto
a diagram of the mouth. Photographs may be indicated.

The lips
The lips should be examined in a systematic fashion to ensure that all areas
are included. The lips should first be inspected and examination is then
facilitated if the mouth is gently closed and the lips everted.
The lips consist of skin on the external surface and mucous membrane
on the inner surface within which are bundles of striated muscle, particularly
the orbicularis oris muscle. The upper lip includes the philtrum, a midline
depression, extending from the columella of the nose to the superior edge
of the vermilion zone. The oral commissures are the angles where the upper
and lower lips meet.
The epithelium of the lip vermilion, the transitional zone between the
glabrous skin and the mucous membrane, is distinctive, with a prominent
stratum lucidum and a thin stratum corneum: the dermal papillae are numer-
ous, with a rich capillary supply, which produces the reddish-pink colour of
the lips. Melanocytes are abundant in the basal layer of the vermilion of
pigmented skin, but are infrequent in white skin. The vermilion zone contains
no hair or sweat glands but does contain ectopic sebaceous glands (Fordyce
spots) – yellowish pinhead-sized papules particularly seen in the upper lip
and at the commissures. They also appear intraorally, mainly in the buccal
mucosa. The lips feel slightly nodular because of the minor salivary glands
they contain, and the labial arteries are readily palpable. The normal labial
12
 Chapter 1 • Introduction

mucosa appears moist with a fairly prominent vascular arcade, and in the
lower lip particularly many minor salivary glands which are often exuding
mucus are visible.

Intraoral mucosae
The intraoral mucosa is divided into lining, masticatory and specialized types.
• Lining mucosa (buccal, labial and alveolar mucosa, floor of mouth,
ventral surface of tongue, soft palate, lips) is non-keratinized.
• Masticatory mucosa (hard palate, gingiva) is adapted to the forces
of pressure and friction and is keratinized.
• Specialized mucosa is seen where taste buds are found, on the lingual
dorsum mainly.

The tongue
The specialized mucosa on the dorsum of the tongue, adapted for taste
and mastication, is keratinized but pink. A healthy child’s tongue is rarely
coated but a mild and thin whitish coating is commonly seen in healthy
individuals.
The anterior two-thirds of the tongue, called the oral tongue, is embryo-
logically different from the posterior third, or pharyngeal tongue. The anterior
(oral) tongue also bears a number of different papillae. Filiform papillae,
which form an abrasive surface to control the food bolus as it is pressed
against the palate, cover the entire surface of the anterior two-thirds of the
tongue dorsum.
Fungiform papillae are fewer and are scattered between the filiform papil-
lae, mainly anteriorly; they are mushroom-shaped, red structures covered by
non-keratinized epithelium and with taste buds on their surface.
Circumvallate papillae are 8–12 large papillae each surrounded by a deep
groove into which open ducts of the serous minor salivary glands; they are
located adjacent and anterior to the sulcus terminalis – the line that sepa-
rates the oral from the pharyngeal tongue. The lateral walls of the circumval-
late papillae contain taste buds. Foliate papillae – 4–11 parallel ridges
alternating with deep grooves in the mucosa – lie on the lateral margins
posteriorly and also have taste buds.
The posterior tongue contains large amounts of lymphoid tissue – the
lingual tonsil – which is part of the Waldeyer ring of lymphoid tissue that
surrounds the entrance to the pharynx. The round or oval prominences of
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 Pocketbook of Oral Disease

lymphoid tissue with intervening lingual crypts lined by non-keratinized epi-

thelium lie between the epiglottis posteriorly and the circumvallate papillae
anteriorly. The posterior third of the tongue is usually divided in the midline
by a ligament. The posterior third of the tongue is thus embryologically and
anatomically distinct from the anterior two-thirds (the oral tongue) and the
two parts are joined at a V-shaped groove, the sulcus terminalis. The tongue
dorsum is best inspected by protrusion The floor of the mouth and tongue
ventrum are best examined by asking the patient to push the tongue first
into the palate and then into each cheek in turn. This raises for inspection
the floor of the mouth, an area where tumours may start (the ‘coffin’ or
‘graveyard’ area of the mouth). The tongue can be held with gauze to facili-
tate examination.
The posterior aspect of the floor of the mouth is the most difficult
area to examine well and one where lesions are most likely to be missed. It
can be inspected with the aid of a mirror but examination in the conscious
patient induces retching. Use of topical anaesthetics or examination under
conscious sedation or general anaesthesia (EUA) may be indicated in some
cases.
Abnormalities of tongue movement (neurological or muscular disease)
may be obvious from dysarthria or involuntary movements and any fibrillation
or wasting noted. The voluntary tongue movements and sense of taste should
be formally tested. Taste sensation can be tested with salt, sweet, sour,
bitter and umami by applying solutions of salt, sugar, vinegar (acetic acid),
5% citric acid and glutamate to the tongue on a cotton swab or cotton pellet.
The palate
The palate and fauces consist of a hard and keratinized anterior and non-
keratinized soft posterior palate, the tonsillar area and pillars of the fauces,
and the oropharynx. The mucosa of the hard palate is firmly bound down as
a mucoperiosteum (similar to the gingivae) and with no obvious vascular
arcades. Rugae are present anteriorly on either side of the incisive papilla
that overlies the incisive foramen.
The soft palate and fauces may show a faint vascular arcade. In the soft
palate, just posterior to the junction with the hard palate, is a conglomeration
of minor salivary glands, a region that is often also yellowish due to submu-
cosal fat or pigmented due to racial pigmentation.
The palate should be inspected and movements examined when the
patient says ‘Aah’. Using a mirror permits inspection of the posterior tongue,
14
 Chapter 1 • Introduction

tonsils and oropharynx, and can even offer a glimpse of the epiglottis and
larynx.
Glossopharyngeal palsy may lead to uvula deviation to the contralateral
side. It is also advisable to evaluate for vibration and mobility of the soft
palate to determine if a submucous cleft palate is present.
The gingivae
The gingivae consist of a free gingival margin overlapping the cemento-
enamel junction of the tooth and a strip of attached ‘keratinized’ gingiva
bound down to the alveolar bone that supports the teeth. The attached
gingiva is clearly demarcated from the non-keratinized vascular alveolar
mucosa. The gingivae in health are firm, pale pink, sometimes with melanin
racial pigmentation, with a stippled surface, and have sharp gingival papillae
reaching up between adjacent teeth to the tooth contact point.
The dentogingival junction is a unique anatomical feature concerned with
the attachment of the gingiva to the tooth. Non-keratinized gingival epithe-
lium forms a cuff surrounding the tooth, and at its lowest point on the tooth
is adherent to the enamel or cementum. This ‘junctional’ epithelium is unique
in being bound both on its tooth and lamina propria aspects by basement
membranes. Above this is a shallow sulcus or crevice (up to 2 mm deep),
the gingival sulcus or crevice.
The tooth root is connected to the alveolar bone by fibres of the periodon-
tal ligament, which run to the cementum. Bands of tissue, which may contain
muscle attachments (fraena), run from the labial mucosa centrally onto the
alveolar mucosa and from the buccal mucosa in the premolar region onto
the alveolar mucosa.
Examine particularly for abnormalities such as gingival redness, swelling,
ulceration or bleeding on gently probing the gingival margin, pocket depth
and for tooth mobility.
The buccal and labial mucosa
These mucosa are non-keratinized. The labial mucosa has a vascular pattern
and prominent minor salivary glands but these are not obvious in the buccal
mucosa.
Fordyce spots may be conspicuous, particularly in the upper lip and near
the commissures and retromolar regions in adults.
Stensen ducts (parotid papillae) can be seen opening by the crowns of
the maxillary second molars.
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 Pocketbook of Oral Disease

The teeth
The teeth develop from neuroectoderm, and development (odontogenesis)
of all the deciduous and some of the permanent dentition begins in the
fetus. Mineralization of the primary dentition commences at about 14 weeks
in utero and all primary teeth are mineralizing by birth. Tooth eruption
occurs after crown formation when mineralization is largely complete
but before the roots are fully formed (Table 1.2). The first or primary (decidu-
ous or milk) dentition begins to erupt at age 6 months and by 3 years is
complete, comprising two incisors, a canine and two molars in each of the
four mouth quadrants. There are 10 deciduous (primary or milk) teeth in
each jaw.
Permanent incisor and first molar teeth begin to mineralize at, or close
to, the time of birth, mineralization of other permanent teeth starting later.
The secondary or permanent teeth begin to erupt at about the age of 6–7
years and the deciduous teeth are slowly lost by normal root resorption. The
full permanent (adult) dentition consists of 16 teeth in each jaw: two incisors,
a canine, two premolars and three molars in each quadrant (Table 1.2).
Normally most teeth have erupted by about 12–14 years of age. However,
some deciduous (milk) teeth may still be present at the age of 12–13 years.
The last molars (third molars or ‘wisdom teeth’), if present, often erupt later
or may impact and never appear in the mouth.
A fully developed tooth comprises a crown of insensitive enamel, sur-
rounding sensitive dentine, and a dentine root which has a cementum rather
than enamel covering. Teeth contain a vital pulp (nerve). The fibres of the
periodontal ligament run from the alveolus to attach through cementum to
the dentine surface and thus attach the tooth to the jaw.
The salivary glands
The major salivary glands are the parotids, submandibular and sublingual
glands. Minor salivary glands are found elsewhere in the mouth – especially
in the lips, ventrum of the tongue and soft palate. The major salivary glands
should be inspected and palpated, noting any swelling or tenderness, and
the character and volume of saliva exuding from the salivary ducts.
Early enlargement of the parotid gland is characterized by outward deflec-
tion of the lower part of the ear lobe, which is best observed by inspecting

16
 Chapter 1 • Introduction

Table 1.2  Tooth eruption times

Deciduous (primary) teeth Upper (mth) Lower (mth)

A Central incisors 8–13 6–10

B Lateral incisors 8–13 10–16

C Canines (cuspids) 16–23 16–23

D First molars 13–19 13–19

E Second molars 25–33 23–31

Permanent (secondary) teeth Upper (yr) Lower (yr)

1 Central incisors 7–8 6–7

2 Lateral incisors 8–9 7–8

3 Canines (cuspids) 11–12 9–10

4 First premolars (bicuspids) 10–11 10–12

5 Second premolars (bicuspids) 10–12 11–12

6 First molars 6–7 6–7

7 Second molars 12–13 11–13

8 Third molars 17–21 17–21

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 Pocketbook of Oral Disease

the patient from behind. This simple sign may allow distinction of parotid
enlargement from simple obesity. Swelling of the parotid sometimes causes
trismus. The parotid duct (Stensen duct) is most readily palpated with the
jaws clenched firmly since it runs horizontally across the upper masseter
where it can be gently rolled, to open at a papilla on the buccal mucosa
opposite the upper molars.
The submandibular gland is best palpated bimanually with a finger of one
hand in the floor of the mouth lingual to the lower molar teeth, and a finger
of the other hand placed over the submandibular triangle (bimanual palpa-
tion). The submandibular duct (Wharton duct) runs anteromedially across the
floor of the mouth to open at the side of the lingual fraenum.
Examine intraorally for normal salivation from these ducts, and pooling of
saliva in the floor of the mouth. Any exudate obtained by massaging or
milking the ducts should be noted.
Examine for signs of hyposalivation (frothy or stringy saliva, lack of saliva
pooling or frank dryness). Place the surface of a dental mirror against the
buccal (cheek) mucosa; the mirror should lift off easily but, if it adheres to
the mucosa or draws a string of thick saliva as it is slowly moved away, then
hyposalivation is present.

Anatomical features or developmental anomalies

Anatomical features or developmental anomalies that may be noticed by
patients or clinicians and cause concern include:
• Bifid uvula: this is symptomless but may overlie a submucous cleft
palate. That may not immediately be obvious but there may be slight
nasal intonation of speech.
• Bony-hard enlargements:
 exostoses – benign, painless and self-limiting broad-based surface

bony-hard masses with normal overlying mucosa (Figures 1.1, 1.2)

seen on the facial aspect of the jaw, most commonly on the maxilla.
They begin to develop in early adulthood and may enlarge slowly
over years. They have no malignant potential.
 pterygoid hamulus – bilateral, palpable and bony hard lumps located

posterior to the last maxillary molars. They may give rise to concern
about an ‘unerupted tooth’.

18
 Chapter 1 • Introduction

Figure 1.1  Exostosis.

Figure 1.2  Exostosis.

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 Pocketbook of Oral Disease

Anatomical features or developmental anomalies (continued)

 torus mandibularis – fairly common benign, painless and self-
limiting broad-based surface bony-hard masses with normal
overlying mucosa seen lingual to the mandibular premolars, usually
bilaterally. These are variable in size and shape (Figures 1.3–1.5).
They have no malignant potential.

Figure 1.3  Torus mandibularis.

20
 Chapter 1 • Introduction

Figure 1.4  Torus mandibularis.

Figure 1.5  Torus mandibularis.

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 Pocketbook of Oral Disease

Anatomical features or developmental anomalies (continued)

 torus palatinus – fairly common benign, painless and self-limiting
broad-based surface bony-hard masses with normal overlying
mucosa seen in the centre of the hard palate. They may be
smooth-surfaced or lobulated (Figures 1.6 and 1.7). They have no
malignant potential.
 unerupted teeth – mainly third molars, second premolars and

canines.

Figure 1.6  Torus palatinus.

Figure 1.7  Torus palatinus.

22
 Chapter 1 • Introduction

• Fissured tongue is common (Figures 1.8, 1.9) and usually

inconsequential, although erythema migrans (geographic tongue) is
often associated. Fissured tongue is usually isolated and developmental
but can be associated with systemic disease (Down syndrome,
Melkersson–Rosenthal syndrome or Sjögren syndrome).
Figure 1.8  Fissured tongue.

Figure 1.9  Fissured tongue.

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 Pocketbook of Oral Disease

Anatomical features or developmental anomalies (continued)

• Fordyce spots: sebaceous glands seen mainly in the upper lip,
commissures and retromolar regions (Figures 1.10, 1.11).

Figure 1.10  Fordyce spots (Fordyce granules).

Figure 1.11  Fordyce spots (Fordyce granules).

24
 Chapter 1 • Introduction

• Leukoedema: a normal variation more prevalent in people of colour, in

which there is a white-bluish tinge of the buccal mucosa that
disappears when the cheek is stretched (Figures 1.12, 1.13).

Figure 1.12  Leukoedema.

Figure 1.13  Leukoedema:

same case as in figure 1.12
but after stretching mucosa.

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 Pocketbook of Oral Disease

Anatomical features or developmental anomalies (continued)

• Lingual varicosities: inconsequential dilated sublingual veins seen
mainly in older men (Figure 1.14).
• Lingual tonsils: rounded masses of normal lymphoid tissue covering the
posterior third of the tongue, and part of Waldeyer ring of lymphoid
tissue (along with the tonsils and adenoids).
• Papillae:
 incisive – in the anterior palate (palatal to and between the central

incisors); may be tender if traumatized

 lingual

a circumvallate – run in a V-shaped line across the posterior

aspect of the anterior (oral) tongue (Figure 1.15)
b filiform – these are the smallest lingual papillae and scattered
across the anterior two-thirds of the tongue (Figure 1.16)
c fungiform – bigger than the filiform but scattered in the same
way across the anterior two-thirds of tongue (Figure 1.16)
d foliate – bilateral but not necessarily symmetrical on the posterior
borders of the tongue; occasionally become inflamed (foliate
papillitis also called hypertrophy of the foliate papillae) and can
mimic carcinoma (Figure 1.17).

Figure 1.14  Sublingual

varices.

26
 Chapter 1 • Introduction

Figure 1.15  Circumvallate papillae

Figure 1.16  Filiform and fungiform
(erythema migrans also present).
papillae.

Figure 1.17  Foliate papillae.

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 Pocketbook of Oral Disease

Anatomical features or developmental anomalies (continued)

 retrocuspid – usually bilateral and found on the lingual gingiva in
the mandibular canine region, it resembles the incisive papilla
 salivary duct

a parotid (orifice of Stensen duct) – bilateral and may occasionally

be traumatized by biting, or by an orthodontic or other appliance
b submandibular duct – in floor of mouth on either side of lingual
fraenum.
• Racial pigmentation is the most common cause of oral pigmentation,
and can be seen in many people, particularly, but not exclusively,
in people of colour. Usually brown (rarely black), the pigmentation
especially is seen on the gingiva, dorsal tongue or palate
(Figures 1.18–1.20).
• Stafne bone cavity is most typically seen on radiographs as a unilateral,
ovoid, radiolucent defect near the angle of the mandible below the
inferior alveolar canal, and represents a cortical defect caused by an
extension of the submandibular salivary gland (Figure 1.21).

28
 Chapter 1 • Introduction

Figure 1.18  Racial pigmentation.

Figure 1.19  Racial pigmentation.

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 Pocketbook of Oral Disease

Anatomical features or developmental anomalies (continued)

Figure 1.20  Racial pigmentation.

Figure 1.21  Stafne bone cavity in mandible.

30
 Chapter 1 • Introduction

Lesion descriptors

Table 1.3  Descriptive terms of oral lesions

Term Meaning

Bulla Visible fluid accumulation within or beneath

epithelium (blister)
Desquamation The shedding of the outer layers of the skin/oral
mucosa
Ecchymosis Macular area of haemorrhage >2 cm in diameter
(i.e. a bruise)
Erosion Loss of most of epithelial thickness (often follows
a blister)
Erythema Redness of mucosa
Macule Flat, circumscribed alteration in colour or texture,
not raised
Naevus A pigmented lesion that is congenital or acquired
Nodule Solid mass under/within mucosa or skin >0.5 cm
in diameter
Papule Circumscribed palpable elevation <0.5 cm in
diameter
Pedunculated Polyp with a stalk
Petechia Punctate haemorrhagic spot 1–2 mm in diameter;
often multiple
Plaque Elevated area of mucosa or skin >0.5 cm in
diameter
Polyp Projecting mass of overgrown tissue
Pustule Visible accumulation of purulent exudate in
epithelium
Reticular Resembles a net
Sessile Stalkless and attached directly at the base
Continued

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 Pocketbook of Oral Disease

Table 1.3  Descriptive terms of oral lesions—cont’d

Term Meaning
Striae Thin lines or bands
Telangiectasis Dilatation of capillaries
Tumour Enlargement or swelling caused by normal or
pathological material or cells
Ulcer Loss of surface epithelium that extends to the
underlying tissues
Vesicle Small (<0.5 cm) visible fluid accumulation in
epithelium

32
 Differential diagnosis by
signs and symptoms
2
This chapter discusses the main signs and symptoms of diseases affecting
the orofacial region. Specific diseases are discussed in Chapter 3.
Pain is by far the most common symptom affecting the orofacial region
(see Pain, page 89). The other most common signs and symptoms of oro-
facial disease fall into a limited number of categories, namely:
• Coloured lesions
• Bleeding
• Soreness
• White lesions
• Ulceration
• Lumps/swelling
• Tooth mobility
• Halitosis
This can be remembered by the mnemonic Could Be Someone We Usually
Love To Hear.

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 Pocketbook of Oral Disease

Bleeding
Keypoints
• Bleeding may arise from wounds or from the gingival margins, or may
be into the tissues – where it appears as petechiae or ecchymoses
(purpura).
• Gingival bleeding is usually due to plaque-induced inflammation –
gingivitis or periodontitis.
• Gingival bleeding may be aggravated by, and purpura caused by,
disorders of haemostasis or drugs interfering with haemostasis.
• Purpura in the mouth is seen mainly at areas of trauma – usually at
the occlusal line and junction of the hard and soft palates.
• Bleeding of the lips may be seen where there is a lip fissure, or in
erythema multiforme or some types of pemphigus.
• Vascular anomalies such as telangiectasia or angiomas may bleed if
traumatized.

Box 2.1  Main causes of gingival bleeding

Gingivitis/periodontitis
Platelet defects
Drugs
Trauma

Causes may include:

• Gingivitis (plaque-induced) – by far the most common cause
(Figure 2.1)
• Thrombocytopenia (low blood platelet numbers)
 aplastic anaemia

 idiopathic (this means ‘of unknown cause’ but actually it is

autoimmune) thrombocytopenic purpura

 leukaemia (Figure 2.2)

• Medications that impair haemostasis: anticoagulants, platelet

aggregation inhibitors, chemotherapy, some herbal supplements
• Factitial or traumatic injury.
Oral bleeding occasionally arises from a vascular anomaly (Figure 2.3).
34
 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.1  Gingivitis – the common cause of gingival bleeding.

Figure 2.2  Leukaemia may present with gingival bleeding, swelling

and/or ulceration.

Figure 2.3  Hereditary haemorrhagic telangiectasia may chronically bleed.

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 Pocketbook of Oral Disease

Bleeding gums

Acute bleeding?
(often/severe)

No Yes

History of Generalised
bleeding No lymphadenopathy, Yes
tendency? or purpura?

Thrombocytopenia, leukaemia,
No Yes
coagulation defect, anticoagulation
therapy, HIV, primary herpetic
gingivostomatitis or other conditions
Pregnant Yes

Pregnancy
No
gingivitis

Gingival
ulceration Yes

No Necrotising
ulcerative
gingivitis
(NUG)
Chronic
marginal
gingivitis

Figure 2.4  Algorithm for bleeding gums diagnosis.

36
 Chapter 2 • Differential diagnosis by signs and symptoms

Burning mouth
Keypoints
• Burning mouth (glossodynia) is a common complaint.
• The cause is not usually known but it may be a nerve hypersensitivity.
• Burning mouth is not inherited.
• Burning mouth is not infectious.
• Burning mouth may occasionally be caused by some mouth conditions,
dry mouth, deficiencies, diabetes or drugs.
• Burning mouth has no long-term consequences.
• Burning mouth typically affects the anterior tongue bilaterally but may
affect other sites such as palate and/or lips.
• Oral examination is important to exclude organic causes of similar
discomfort – such as erythema migrans (geographic tongue),
candidosis, glossitis and lichen planus (Figure 2.5).

Figure 2.5  Burning mouth caused by lichen planus.

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 Pocketbook of Oral Disease

Burning mouth (continued)

• In the absence of a recognizable organic cause (Figure 2.6), the
condition is termed ‘burning mouth syndrome (BMS)’ and the
underlying basis may be psychogenic. These patients may also suffer
taste disturbances.
• Blood tests, biopsy or other tests may be required.
• Burning mouth syndrome may be controlled by some psychotropic
drugs or B vitamin.

Box 2.2  Main causes of burning mouth sensation

Erythema migrans
Lichen planus
Candidosis
Haematinic (iron, folate, vitamin B12) deficiency
Psychogenic

Causes may include (alphabetically):

• Allergies (including oral allergy syndrome)
• Bruxism/tongue thrusting
• Candidosis
• Dermatoses such as lichen planus
• Dry mouth and drugs such as angiotensin-converting enzyme (ACE)
inhibitors, proton pump inhibitors (PPIs) and protease inhibitors (PIs)
• Erythema migrans (geographic tongue)
• Fissured tongue
• Gastric reflux, and glossitis such as caused by haematinic deficiency,
such as
 B complex deficiency

 folate deficiency

 iron deficiency

 vitamin B
12 deficiency
• Hormonal (endocrine) problems such as diabetes and hypothyroidism.
Once these causes are excluded, the condition is termed ‘burning mouth
syndrome’, when the cause may be psychogenic, and include:
• Anxiety states
• Cancerophobia
38
 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.6  Burning mouth

syndrome (no lesions
discernible apart from mild
tongue furring).

• Depression
• Hypochondriasis.
A normal-appearing tongue may be seen in psychogenic causes, and with
a burning sensation caused by deficiency states, drugs (e.g. captopril and
other ACE inhibitors, proton pump inhibitors) and diabetes mellitus.
This section deals only with a normal-looking but burning tongue.

Burning mouth syndrome

Common, especially in middle-aged females.
Typical orofacial symptoms and signs: invariably persistent burning sensation
with no organic disease.
Main oral sites affected: anterior tongue (occasionally palate or lip).
Aetiopathogenesis: see above.
Gender predominance: female.
Age predominance: middle age or older.
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 Pocketbook of Oral Disease

Burning mouth

Mucosal lesion?

Yes No

Recent
cancer Hyperglycaemia? Yes
therapy?

Consider
Diabetes
mucositis
or Yes No No
erythrematous
candidosis

Hypothyroidism? Yes
Erythema
migrans
Candidosis Yes Other
Lichen planus mucosal Hypothyroidism
Contact allergy lesions? No

Cytotoxics,
protease or
proton pump Yes
inhibitors,
chlorhexidine

Drugs
No

Haematinic
deficiency? No

Depression, anxiety,
Yes
cancerophobia?

Haematinic Burning mouth

Figure 2.7  Algorithm for burning deficiency syndrome
mouth diagnosis.
40
 Chapter 2 • Differential diagnosis by signs and symptoms

Extraoral possible lesions: often psychogenic complaints or anxiety.

Main associated conditions: few profess anxiety about (for example) cancer
or sexually shared disease; some admit this on specific questioning.
Differential diagnosis: differentiate from organic causes.
Investigations: blood picture, glucose, thyroid hormone and haematinic assays
to exclude organic causes; psychiatric investigation for depression.
Main diagnostic criteria: clinical.
Main treatments: treat any organic cause. Topical anaesthetics and oral
distractors such as sucking on ice chips or sugarless candy, and chewing
sugarless gum may be temporarily effective. Otherwise, B vitamins, topical
capsaicin, psychotherapy (cognitive-behavioural therapy; CBT) or antide-
pressants are all occasionally helpful.

Desquamative gingivitis
Keypoints
• Desquamative gingivitis is not a disease entity but a clinical term for
persistently sore, glazed and red or ulcerated gingivae.
• The usual complaint is of persistently sore gingivae in many areas.
• Lichen planus or pemphigoid are the most common causes.

Box 2.3  Main causes of desquamative gingivitis

Pemphigoid
Lichen planus

Fairly common, it is almost exclusively a disease of middle-aged or older

females.
Typical orofacial symptoms and signs: soreness or stinging, especially on
eating spices or citrus foods, or taking acidic drinks. Gingivae are red and
glazed (patchily or uniformly), especially labially and in several sites. Gin-
gival margins and edentulous ridges tend to be spared. Erythema is exag-
gerated where oral hygiene is poor.
Main oral sites affected: facial gingivae.
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 Pocketbook of Oral Disease

Desquamative gingivitis (continued)

Aetiopathogenesis: lichen planus or mucous membrane pemphigoid,
and rarely pemphigus or other dermatoses (skin disorders) (Figures
2.8–2.10).
Gender predominance: female.
Age predominance: adult.
Extraoral possible lesions: cutaneous, mucosal or adnexal lesions of derma-
toses may be associated.
Differential diagnosis: differentiate mainly from acute candidosis, chronic
marginal gingivitis, and occasionally from plasma cell gingivitis.
Investigations: biopsy with immunostaining.
Main diagnostic criteria: clinical and histology.
Main treatments: improve oral hygiene; topical corticosteroids, or systemic
dapsone as appropriate. Corticosteroid creams used overnight in a poly-
thene splint may help. Frequent dental cleanings and periodontal mainte-
nance are important for disease control.

Dry mouth (hyposalivation and xerostomia)

Keypoints
• Xerostomia is a frequent, and the most common, salivary complaint but
is not synonymous with hyposalivation.
• Xerostomia is a subjective complaint of oral dryness, and objective
evidence of hyposalivation is far less common.
• Hyposalivation (hyposialia) is a reduction in saliva production – usually
defined as an unstimulated whole salivary flow rate <0.1 ml/min.
• Causes of hyposalivation are often iatrogenic (doctor-induced),
particularly with drugs (medications) or cancer therapy.
• Hyposalivation may also be caused by dehydration, or diseases
affecting the salivary glands.
• Xerostomia has similar causes to hyposalivation and, additionally, may
be psychogenic.
• Saliva helps swallowing, talking, and taste, and protects the
mouth. Where saliva is reduced there is a risk of dental caries
and tooth wear, halitosis, altered taste, mouth soreness
and infections.

42
 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.8  Desquamative gingivitis: associated with lichen planus.

Figure 2.9  Desquamative gingivitis: associated with lichen planus.

Figure 2.10  Desquamative gingivitis: associated with pemphigoid.

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 Pocketbook of Oral Disease

Dry mouth (hyposalivation and xerostomia) (continued)

Box 2.4  Main causes of dry mouth sensation

Drugs
Irradiation of salivary glands
Sjögren syndrome
Psychogenic

• Hyposalivation presents with obvious dryness (Figure 2.11) or frothy

scant saliva (Figure 2.12), or with complaints of difficulties with speech,
swallowing or denture retention; of soreness; or of complications such
as candidosis, caries or sialadenitis.

Causes of hyposalivation may include:

• Iatrogenic
 drugs (medications) with anticholinergic or sympathomimetic effects,

such as tricyclic antidepressants, phenothiazines and antihistamines

 irradiation of major salivary glands

 cytotoxic agents, bone marrow transplantation and chronic graft-

versus-host (GvHD) disease

• Non-iatrogenic
 dehydration, e.g. uncontrolled diabetes, diabetes insipidus, diarrhoea

and vomiting, hypercalcaemia, severe haemorrhage

 salivary gland disorders

a amyloidosis or other deposits

b cholinergic dysautonomia
c cystic fibrosis
d ectodermal dysplasia
e HCV infection
f HIV infection
g IgG4 syndrome
h salivary gland aplasia
i sarcoidosis
j Sjögren syndrome.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.11  Dry mouth, and lobulated tongue which may follow chronic
hyposalivation.

Figure 2.12  Dry mouth manifesting as frothy saliva.

Causes of xerostomia may ALSO include:

• Psychogenic states
 anxiety states

 bulimia nervosa

 depression

 hypochondriasis.

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 Pocketbook of Oral Disease

Dry mouth

Reduced salivary flow

rates and/or dry eyes, or Yes
positive Schirmer eye test?

No

Medications
Psychogenic Medications
Dehydration Yes implicated?
Irradiation

No

Antibodies
(ANA or
Scl 70)
Positive?
Yes No

Connective Antibodies
tissue (SS-A or SS-B) Yes
disease positive?

No

Labial gland biopsy

positive for aggregates
of lymphocytes?

Sjögren
No Yes
syndrome

Sicca syndrome,
sarcoidosis or IgG4 disease
Figure 2.13  Algorithm for dry mouth diagnosis.
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 Chapter 2 • Differential diagnosis by signs and symptoms

Halitosis (oral malodour)

Keypoints
• Oral malodour is a common subjective complaint but often far more
obvious to the sufferer than others.
• Malodour ‘if real’ can be measured with a gas chromatography or a
halimeter, but objective evidence for it by measuring volatile sulphur
compounds (VSCs) in the breath by halimetry or smelling the breath is
far less common.
• Malodour is common on awakening or if there is infrequent eating or
starvation, and is then sometimes called ‘physiological’.
• It is usually caused by diet, habits, dental plaque or oral disease.
• Oral malodour is to be anticipated in smokers, after eating odiferous
foods such as garlic or durian, or drinking excess alcohol or coffee.
• Oral malodour is common where there are oral infections.
• Malodour can sometimes be caused by sinus, nose or throat
conditions.
• Oral malodour occasionally arises from metabolic disorders but it is
only rarely caused by more serious disease.
• In the absence of an identifiable malodour or a defined organic cause,
the complaint of malodour may be psychogenic in origin.
• It often significantly improves with oral hygiene and tongue-brushing.
• It may also be helped by:
 regularly eating yoghurts or ingesting certain probiotics

 finishing meals with apples, carrots or celery

 chewing spearmint, tarragon, eucalyptus, rosemary, or cardamom

 avoiding habits such as smoking and odiferous foods, and avoiding

foods such as eggs, legumes, certain meats, fish and foods that
contain choline, carnitine, nitrogen and sulphur.

Box 2.5  Main causes of halitosis (oral malodour)

Odiferous foods
Smoking
Poor oral hygiene

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 Pocketbook of Oral Disease

Halitosis (oral malodour) (continued)

Causes may include:
• Starvation
• Lifestyle habits
 habits

a alcohol
b amyl nitrites
c solvent misuse
d tobacco
 volatile foodstuffs

a durian
b garlic
c highly spiced foods
d onions
• Drugs (see also Chapter 4): amphetamines, aztreonam, cytotoxic drugs,
disulfiram, melatonin, mycophenolate sodium, nicotine lozenges,
nitrates and phenothiazines
• Oral sepsis
 dental or periodontal sepsis (Figure 2.14)

 dry socket

 food impaction

 hyposalivation

 necrotizing ulcerative gingivitis

 oral malignancy

 osteochemonecrosis (bisphosphonates, denosumab, bevacizumab)

 osteomyelitis

 osteoradionecrosis of the jaw

 pericoronitis

 ulceration

• Oesophageal disease
 pouch

 reflux

• Sinusitis
• Nasopharyngeal disease
 foreign body

 infection

 neoplasm

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.14  Halitosis caused by periodontitis.

• Pharyngeal disease
 foreign body

 infection (e.g. tonsillitis, tonsillolith)

 neoplasm

 pouch

• Systemic disease
 acute febrile illness

 metabolic disorders

– diabetic ketoacidosis
– hepatic failure
– renal failure
– trimethylaminuria
 Psychogenic (delusional)

– neuroses
– psychoses

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Malodour

Objective malodour? Psychogenic or

No
cerebral tumour

Yes

Poor oral hygiene? Yes Improve oral hygiene

No

Recently ingested
Yes Foods
odiferous foods?

No

Drugs/smoking? Yes Drugs: alcohol or smoking

No

Sinus, pharyngeal or
Malodour from nose? Yes
respiratory causes

No

Hyposalivation? Yes See ‘Dry mouth’

Hepatic, renal, gastrointestinal

No
disease, diabetes or trimethylaminuria
Figure 2.15  Algorithm for halitosis diagnosis.
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 Chapter 2 • Differential diagnosis by signs and symptoms

Mucosal blisters
Keypoints
• A blister, if solitary, may be due to saliva extravasation into the tissues
(mucocele).
• Blisters may be due to a subepithelial split, seen mainly in sub-
epithelial immune blistering diseases (e.g. pemphigoid) (Figure 2.16).
• Blisters due to intraepithelial vesiculation are less common and caused
particularly by pemphigus, and readily break to form erosions.
• Blisters rarely are caused by blood extravasation into the tissues
(purpura) (Figure 2.17).

Figure 2.16  Blistering in pemphigoid.

Figure 2.17  Blood blisters in purpura.

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Mucosal blisters (continued)

Box 2.6  Main causes of oral blisters

Mucoceles
Angina bullosa haemorrhagica
Pemphigoid
Trauma (mucosal burn)

Causes may include:

• Infections
 enteroviruses such as Coxsackie viruses and ECHO viruses

 herpes simplex virus

 herpes varicella-zoster virus

• Mucoceles
• Purpura, and angina bullosa haemorrhagica (localized oral purpura)
• Burns
• Cysts
• Skin diseases
 dermatitis herpetiformis

 epidermolysis bullosa (congenita and acquisita)

 erythema multiforme and Stevens–Johnson syndrome

 intraepidermal IgA pustulosis

 lichen planus (superficial mucoceles)

 linear IgA disease

 pemphigoid (usually mucous membrane pemphigoid)

 pemphigus (usually pemphigus vulgaris)

 Sweet syndrome

• Drugs
• Paraneoplastic disorders
• Amyloidosis.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Mucosal brown and black lesions

Keypoints
• Mucosal brown and black lesions are common.
• Most mouth pigmentation is inherited. The most common cause of
multiple oral brown lesions is racial or ethnic pigmentation, common
in people of colour but also seen in some Caucasians and most
noticeable on the facial gingivae, or other keratinized areas such as the
dorsum of tongue or palate.
• Most pigmented lesions affect only the mouth but they are occasionally
seen elsewhere or associated with other conditions.
• Otherwise, the cause is usually embedded amalgam, inflammation,
or drugs or social habits.
• The most common cause of single oral brown lesions are naevi
(Figure 2.18) or melanotic macules.
• Oral post-inflammatory pigmentation (pigmentary incontinence) is the
common cause of multiple oral brown lesions associated with chronic
inflammatory disorders (oral lichen planus and lichenoid lesions,
pemphigus, or pemphigoid).

Figure 2.18  Hyperpigmentation: naevus.

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Mucosal brown and black lesions (continued)

• The most common cause of single oral grey or black lesions is an
amalgam tattoo, where amalgam has become embedded during
restorative dental procedures (Figures 2.19, 2.20). A graphite tattoo
from a pencil broken in the mouth is uncommon.
• Rare causes of brown or black lesions include drugs (Figure 2.21) or
endocrinopathies such as Addisonian hypoadrenalism (Figure 2.22) and
neoplasms such as malignant melanoma and Kaposi sarcoma.
• Solitary brown or black lesions may raise concern about the possibility
of melanoma.
• Features suggestive of melanoma include (ABCDE):
Assymetry in shape
Border irregular
Colour variations or changes
Diameter (large size)
Elevation above mucosa
• Imaging, biopsy or other investigations may be indicated to differentiate
the causes.
• Pigmented lesions are often removed by surgery for histopathological
examination.
• There are usually no long-term consequences.

Figure 2.19  Hyperpigmentation: amalgam tattoo.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.20  Hyperpigmentation: amalgam tattoo (radiographic view).

Figure 2.21  Hyperpigmentation: drug-induced (antimalarials, minocycline and

others can be responsible).

Figure 2.22  Hyperpigmentation: in hypoadrenocorticism (Addison disease).

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Mucosal brown and black lesions (continued)

Box 2.7  Main causes of mucosal brown or black lesions

Racial
Naevus
Melanotic macule
Amalgam tattoo
Smoking

Causes may include:

• Racial
• Food/drugs
 beetroot

 betel nut

 chlorhexidine

 liquorice

 tobacco

 systemic drugs, such as minocycline, certain antimalarials and

chemotherapeutic agents
• Hormonal
 pregnancy (chloasma)

 Addison disease

 Albright syndrome (fibrous dysplasia)

• Others
 Kaposi sarcoma

 leukoplakia with pigmentary incontinence

 lichen planus with pigmentary incontinence

 melanoacanthoma

 melanoma

 melanotic macule

 naevus

 Peutz–Jeghers syndrome.

56
 Table 2.1  Features of most important isolated hyperpigmented oral lesions
Lesion Usual age of Morphology Colour Main locations Approximate Other
presentation size comments

Amalgam >5 years Macular Grey or black Floor of mouth, <1 cm May be
tattoo mandibular confirmed by
and maxillary radiography
gingivae
Graphite >5 years Macular Grey or black Palate <0.5 cm May be revealed
tattoo by radiography
Kaposi >young adult Macular Red, purple or Palate, gingivae Any Mainly in HIV/
sarcoma becoming black AIDS
nodular
Melanoma Any Macular Brown, grey or Palate, gingivae Any Rare
becoming black
nodular
Melanotic Any Macular Brown or black Lips, gingivae <1 cm Usually benign
macules Mostly in
Caucasians
Naevi 3rd–4th Raised Blue or brown Palate <1 cm Usually benign
decade
Purpura Any Macular Red, purple or Palate, buccal or Any Usually traumatic
Chapter 2 • Differential diagnosis by signs and symptoms

brown lingual and resolves

57
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Mucosal brown and black lesions (continued)

Black or brown hairy tongue
Common, especially in adult men.
Typical orofacial symptoms and signs: persistent brown or black hairy
appearance of tongue.
Main oral sites affected: central dorsum of tongue, mainly posteriorly but
extending anteriorly.
Aetiopathogenesis: unknown. Smoking, foods such as liquorice, drugs (e.g.
iron salts, chlorhexidine, bismuth) and poor oral hygiene (proliferation of
chromogenic microorganisms may predispose.
Gender predominance: male.
Age predominance: adult.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: candidosis.
Investigations: history of use of offending agents.
Main diagnostic criteria: clear-cut clinically.
Main treatments: improve oral hygiene; discontinue any drugs responsible;
scrape or brush tongue (in evenings with cold water); suck dry peach
stone (yes!).

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 Chapter 2 • Differential diagnosis by signs and symptoms

Hyperpigmentation

Yes Localised? No
Amalgam tattoo
confirmed
on radiography?
Relevant drug history

No Yes Yes

Haematoma Racial Antimalarials

Amalgam
Naevus Post-inflammatory Minocycline
tattoo
Melanoma Addison disease Tobacco use
Melanocanthoma HIV Betel nut liquid
Kaposi sarcoma Heavy metal toxicosis

No
Figure 2.23  Algorithm for hyperpigmentation diagnosis.

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Mucosal erosions (see also mucosal ulceration)

Keypoints
• Mucosal damage may lead to inflammation and/or partial-thickness
loss of epithelium, both of which appear red, or to loss of most of the
epithelium, which then may initially appear red but becomes covered
with a yellowish fibrinous slough. Full-thickness loss of epithelium
typically causes a grey or yellow lesion (an ulcer).
• Patients often present with a mix of these appearances; mucositis
is the term applied to widespread oral erythema, ulceration and
soreness.
• Any of the causes of mucosal blisters may result eventually in erosions.

Box 2.8  Main causes of mucosal erosions

Systemic disease (blood, infections, gastrointestinal, skin)
Malignant lesions
Local causes (e.g. burns)
Drugs

Causes may include:

• Any of the causes of mucosal blisters (may result eventually in erosions).
• Erosions are especially seen after burns, caused by drugs (Figure 2.24)
and lichen planus (Figure 2.25).
• Mucositis, and sometimes bleeding, is common after chemo- or
radio- or chemoradio-therapy, and graft-versus-host disease (GvHD).
Sometimes called mucosal barrier injury, mucositis is common
during the treatment of cancer but also in the conditioning prior to
haematopoietic stem cell transplantation (bone marrow transplants).

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.24  Erosion showing fibrinous slough.

Figure 2.25  Erosions induced by lichenoid adverse drug reaction. Erosions are
yellow: the white lesions are lichenoid.

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Mucosal fissures or cracks

Keypoints
• Fissures are common on the dorsum of the tongue (Figure 2.26) when
they are usually of genetic basis and, as there is no break in the
epithelium, they are symptomless unless, as is common, there is an
associated geographic tongue (erythema migrans) (Figure 2.27).
• Fissures otherwise are often associated with epithelial breaks and are
seen mainly on the lip, usually at the commissures (angular cheilitis or
stomatitis), rarely elsewhere (lip fissure).

Box 2.9  Main causes of mucosal fissures

Angular stomatitis
Lip fissure
Any cause of lip swelling (e.g. Crohn disease)

Causes may include:

• Angular stomatitis
• Lip fissure
• Down syndrome
• Crohn disease or orofacial granulomatosis (OFG)
• Actinic cheilitis.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.26  Fissured tongue in a patient with Crohn disease.

Figure 2.27  Fissured tongue in a patient with erythema migrans (geographic

tongue).

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Mucosal fissures or cracks (continued)

Angular stomatitis (perleche; angular cheilitis)
Common, especially in older edentulous patients who are denture-wearers.
Typical orofacial symptoms and signs: symmetrical erythematous fissures on
skin of commissures (Figures 2.28, 2.29), and (very rarely) commissural
leukopakia intraorally.
Main oral sites affected: commissures, bilaterally.
Aetiopathogenesis: usually due to infection with Candida albicans. Staphy-
lococcus aureus and/or streptococci may also be cultured from lesions.
Patients may have denture-related stomatitis or other forms of intraoral
candidosis. Other causes include lip incompetence, especially from ortho-
dontic appliances, iron deficiency, hypovitaminoses (especially B), malab-
sorption states (e.g. Crohn disease), HIV infection and other immune
defects.
Gender predominance: none.
Age predominance: older.
Extraoral possible lesions: none usually.
Main associated conditions: see aetiopathogenesis.
Differential diagnosis: see aetiopathogenesis.
Investigations: occasionally, blood picture and haematinic assays; investiga-
tions for diabetes and other immune defects; smears for fungal hyphae
and bacteriological culture, if refractory.
Main diagnostic criteria: usually clear-cut.
Main treatments: Eliminate any underlying systemic predisposing factors.
Treat intraoral candidal infection, in particular denture-related stomatitis.
Treat angular stomatitis with topical antifungal such as miconazole
or triamcinolone/nystatin combination, or fucidin or mupirocin if
staphylococcal.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.28  Angular stomatitis (cheilitis) causing fissuring at commissures.

Figure 2.29  Angular stomatitis causing fissuring at commissures.

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Mucosal fissures or cracks (continued)

Fissured (cracked) lip
Typical orofacial symptoms and signs: chronic discomfort and, from time to
time, some bleeding.
Main oral sites affected: typically in the lower lip (Figure 2.30), usually
median.
Aetiopathogenesis: a fissure may develop in the lip where a patient, typically
a child, is mouth-breathing. Sun, wind, cold weather and smoking are
thought to predispose. A hereditary predisposition for weakness in the first
branchial arch fusion may exist. Lip fissures are also common in Down
syndrome and when lips swell as, for example, in cheilitis granulomatosa
and orofacial granulomatosis/Crohn disease (Figure 2.31).
Gender predominance: males.
Age predominance: young adult.
Extraoral possible lesions: none usually.
Main associated conditions: see aetiopathogenesis.
Differential diagnosis: see aetiopathogenesis.
Investigations: see aetiopathogenesis. If diffuse lip swelling accompanies the
fissuring, biopsy is indicated.
Main diagnostic criteria: clinical. Differentiate from angular stomatitis and
cheilitis glandularis (occasionally).
Main treatments: predisposing factors should be managed if possible. Bland
creams or ointments (e.g. E45) may help the lesion heal spontaneously.
Short-term use of low-potency topical corticosteroids with or without anti-
fungals or antimicrobials may promote healing. If the fissure fails to heal,
excision, preferably with a z-plasty, laser ablation or cryosurgery may be
needed.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.30  Lip fissure.

Figure 2.31  Fissured lip in a patient with swelling from Crohn disease.

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Mucosal purpura
Keypoints
• Purpura is the accumulation of blood in the mucosa, appearing usually
as red or brown macules (Figure 2.32). Purpuric lesions do not blanch
on pressure (cf. vascular lesions such as haemangioma, telangiectasia).
• Petechiae are pinpoint-sized haemorrhages from small capillaries in
the skin or mucous membranes. Petechia is the term given to the
individual small red or red–blue spots which are about 1–5 mm in
diameter and make up the rash.
• Purpura is seen mainly in areas prone to trauma, such as at the
occlusal line (Figure 2.33) or junction of hard and soft palates.
• Occasional small traumatic petechiae at the occlusal line are common
in otherwise healthy patients. Otherwise, oral purpura is uncommon.
• Purpura is usually caused by trauma such as suction, but haemostatic
disorders may also present in this manner, so a blood picture (including
blood count and platelet count) and haemostatic function may be
indicated.

Box 2.10  Main causes of oral purpura

Trauma or suction
Platelet defects

Causes may include:

• Trauma (including suction, forceful coughing or vomiting)
• Thrombocytopenia
 autoimmune

 drugs

 leukaemias

 viral infections:

HIV
infectious mononucleosis
rubella
• Localized oral purpura (angina bullosa haemorrhagica)
• Amyloidosis
• Mixed connective tissue disease.
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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.32  Purpura.

Figure 2.33  Purpura.

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Mucosal red lesions

Keypoints
• Mucosal red lesions are usually inflammatory in origin.
• Mucosal red lesions may also be caused by epithelial loss (as in
desquamative gingivitis) or atrophy as in erythroplasia (erythroplakia)
– which usually represents severe epithelial dysplasia and is potentially
malignant, or redness may represent frank carcinoma or other
malignant neoplasms.
• Some mucosal red lesions are due to purpura or vascular anomalies
such as telangiectasia or haemangiomas (the latter are more commonly
purple or blue).

Box 2.11  Main causes of oral red lesions

Any inflammatory condition
Erythroplakia
Angioma

Causes may include:

Generalized redness
• Candidosis (Figure 2.34)
• Mucosal atrophy (e.g. avitaminosis B)
• Mucositis

Figure 2.34  Red lesion: candidosis may cause a glossitis.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Localized red patches

• Angiomas (Figures 2.35)
• Avitaminosis B12
• Burns
• Candidosis (erythematous, acute atrophic and denture-related) (Figures
2.36, 2.37)
• Carcinoma (Figure 2.38)
• Contact allergy
• Crohn disease and orofacial granulomatosis (OFG)
• Deep mycoses
• Desquamative gingivitis
• Drug allergies
• Erythroplakia (Figure 2.39)
• Geographic tongue (erythema migrans)
• Kaposi sarcoma
• Lichen planus
• Lichenoid reactions
• Lupus erythematosus
• Median rhomboid glossitis
• Mucositis
• Plasma cell gingivitis
• Purpura
• Sarcoidosis

Figure 2.35  Red lesion: angioma extending from lip to gingiva.

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Mucosal red lesions (continued)

Figure 2.36  Red lesion: Figure 2.37  Red lesion: candidosis causing
candidosis in the palate is common denture-related stomatitis.
in HIV/AIDS, presenting a ‘thumb
print’ appearance.

Figure 2.38  Red lesion: Figure 2.39  Red lesion: erythroplakia.

carcinoma.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Red lesions
Erythroplasia
Carcinoma
Solitary discrete Mycosis
Yes
red lesions ? Kaposi sarcoma
Other neoplasms
Amyloidosis
No Sarcoidosis
Crohn disease
OFG
Restricted to denture-bearing area? Denture hyperplasia
Angioma

Yes No

Petechiae? Redness of most of oral mucosa?

No Yes No Yes

Purpura Mucositis
Denture stomatitis Candidosis
Trauma Mucosal atrophy
Burn Avitaminosis B
Candidosis SLE
Skin disorders
Denture stomatitis
Burn Anaemia
OFG Erythema migrans
Sarcoidosis Lichen planus
Crohn disease Hyposalivation
Mycosis Candidosis
Tumour

Acute
Lichen planus, etc. Redness of
No candidosis
Kaposi sarcoma tongue only?

Any tongue
Yes No
depapillation?
Figure 2.40  Algorithm for red lesions. 73
 Pocketbook of Oral Disease

Mucosal red lesions (continued)

Telangiectases
• Hereditary haemorrhagic telangiectasia
• Post-irradiation
• Scleroderma

Mucosal ulceration or soreness (see also mucosal erosions)

Keypoints
• Soreness typically indicates a break in epithelial continuity, usually
caused by erosions or ulcers.
• Ulcers can have a wide range of causes.
• Single ulcers lasting more than 3 weeks are a special concern since
they may represent a malignant neoplasm (Figure 2.41) or a chronic
infection such as TB, syphilis or mycoses (fungal infections). Gingival
ulcers may be caused by these conditions, or acute necrotizing
gingivitis (Figure 2.42).
• Other persistent ulcers may have a systemic cause, such as a skin
disease like lichen planus, pemphigoid or even pemphigus.
• Recurrent ulcers may represent recurrent aphthous stomatitis (aphthae)
(Figures 2.43–2.45) but occasionally they manifest in systemic disease
and are then termed ‘aphthous-like’ ulcers (Figure 2.46).

Figure 2.41  Ulceration: carcinoma presenting as an ulcerated white lesion.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Box 2.12  Main causes of oral ulceraton

Systemic disease (blood, infections, gastrointestinal, skin)
Malignant lesions
Local causes (e.g. burns)
Aphthae
Drugs

Figure 2.42  Ulceration: necrotizing ulcerative gingivitis (NUG). The papillae

are ulcerated.

Figure 2.43  Ulceration: recurrent aphthous stomatitis (minor aphthae).

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Mucosal ulceration or soreness (continued)

Figure 2.44  Ulceration:
recurrent aphthous stomatitis
(major aphthae).

Figure 2.45  Ulceration:

recurrent aphthous stomatitis
(herpetiform ulcers).

Figure 2.46  Ulceration: Behçet

syndrome.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Causes may include:

Causes are diverse and may be remembered by the mnemonic So Many
Laws And Directives, which includes:
• Systemic
 blood

 infections

 gastrointestinal

 skin

• Malignancy
• Local
• Aphthae
• Drugs.
Systemic disease
The acronym BIGS (Blood, Infections, Gastrointestinal, Skin) may be used,
to include:
• Blood or vascular disorders: anaemia, neutropenias, leukaemias
• Infective: viruses (HIV, herpes simplex, chickenpox, herpes zoster,
hand, foot and mouth disease, herpangina, infectious mononucleosis),
bacteria (necrotizing ulcerative gingivitis, tuberculosis and atypical
mycobacterial infections, syphilis), fungi (e.g. aspergillosis,
histoplasmosis), parasites (leishmaniasis)
• Gastrointestinal: coeliac disease, Crohn disease and OFG, ulcerative
colitis
• Skin and connective tissue disease: lichen planus, pemphigus,
pemphigoid, erythema multiforme, lupus erythematosus.
Malignancy
Carcinoma and other malignant tumours such as lymphoma or salivary
neoplasms.

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Mucosal ulceration or soreness (continued)

Local causes
• Traumatic (may be artifactual – factitial [self-induced])
• Burns – chemical, electrical, thermal, radiation-induced
• Eosinophilic ulcer (traumatic ulcerative granuloma with stromal
eosinophilia – TUGSE)
• Necrotizing sialometaplasia.

Aphthae
Recurrent aphthous stomatitis (RAS), including aphthous-like ulcers as
seen in Behçet syndrome, and auto-inflammatory syndromes (e.g. PFAPA –
periodic fever, aphthae, pharyngitis, adenitis).
Drugs
• Drugs causing mucositis such as cytotoxic agents, particularly
methotrexate.
• Agents producing lichen-planus-like (lichenoid) lesions, such as
antihypertensives, antidiabetics, gold salts, non-steroidal anti-
inflammatory drugs (NSAIDs), antimalarials and other drugs.
• Agents causing local chemical burns (especially aspirin held in the
mouth).
• Drugs causing osteonecrosis. Bisphosphonate-related osteonecrosis
of the jaw (BRONJ), and osteochemonecrosis due to other agents
(denosumab, bevacizumab) may present as ulceration.

78
 Chapter 2 • Differential diagnosis by signs and symptoms

Acute ulceration

Single site only?

No Yes

Trauma Trauma
Burn Burn
RAS RAS
Allergy Pericoronitis
Eryrthema multiforme Allergy
Herpes viruses Herpes viruses
Coxsackie viruses Angular stomatitis
NUG Lip fissure
Mycosis Primary syphilis
Secondary syphilis Tuberculosis

Figure 2.47  Algorithm for acute ulceration diagnosis.

Persistent single ulcer

Normal remaining mucosa?

No Yes

Skin disease Malignant neoplasm

Crohn disease Chronic infection
Mucositis RAS
TUGSE
Behçet syndrome
Necrotising
sialometaplasia
Electrical burn

Figure 2.48  Algorithm for persistent single ulcer diagnosis.

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 Pocketbook of Oral Disease

Persistent
multiple ulcers

Single site?

No Yes

RAS Behçet syndrome

Blood disorder Chronic infection
Chronic infection Gastrointestinal
Skin disease Immune incompetence
(pemphigus, Drugs
pemphigoid,
erosive lichen planus,
lupus erythematosus),
Gastrointestinal
Immune incompetence
Drugs
Figure 2.49  Algorithm for persistent multiple ulcers diagnosis.

Recurrent
ulceration

Onset in childhood/adolescence?

Yes No

Extraoral lesions
or fever?

No Yes

RAS Aphthous-like ulcers in

Factitial ulcers Behçet syndrome
Transient lingual papillitis Neutropenias
Angular stomatitis Leukaemias
Lip fissure Autoinflammatory
syndromes
HIV
Crohn disease
Coeliac disease

Figure 2.50  Algorithm for recurrent ulcer diagnosis.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Recent multiple ulcers

Single site only?

No Yes

RAS Trauma
Blood disorder Factitial
Aphthous-like ulcers RAS
(e.g. HIV) Herpesvirus
Factitial ulcers

Figure 2.51  Algorithm for recurrent multiple ulcers diagnosis.

Mucosal white lesions

Keypoints
• White lesions are often due to material on the surface of the mucosa,
which wipes away with a gauze swab; materia alba (debris) and thrush
(candidosis) are the common causes.
• White lesions may be due to increased keratinization, such as in
keratosis or lichen planus. These do not wipe off with a gauze swab.

Box 2.13  Main causes of oral white lesions

Materia alba
Candidosis
Lichen planus
Keratosis
Leukoplakia

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Mucosal white lesions (continued)

Causes may include:
Hereditary
• Leukoedema
• White sponge naevus (Figure 2.52)
• Others (e.g. dyskeratosis congenita)
Acquired
• Debris (materia alba)
• Inflammatory
 infective: candidosis, candidal leukoplakia (Figure 2.53), hairy

leukoplakia (Epstein–Barr virus [EBV] related), syphilitic leukoplakia,

Koplik spots (measles virus), papillomas (human papillomavirus
– HPV) (Figure 2.54)

Figure 2.52  White lesion: genetic (white sponge naevus).

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.53  White lesion: infective (candidal leukoplakia).

Figure 2.54  White lesion: infective (papilloma).

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Mucosal white lesions (continued)

 non-infective: lichen planus and lichenoid lesions (Figure 2.55),
lichen sclerosis, lupus erythematosus, contact cinnamon allergy
• Neoplastic and potentially malignant disorders
 carcinoma (Figures 2.56–2.58)

Figure 2.55  White lesion: inflammatory (lichen planus).

Figure 2.56  White lesion: speckled white and red lump which was a carcinoma.
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 Chapter 2 • Differential diagnosis by signs and symptoms

(above) Figure 2.57  White lesion: speckled white and red lump which was a
carcinoma.

(right) Figure 2.58  White

lesion: verrucous carcinoma.

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Mucosal white lesions (continued)

 leukoplakias
 verrucous and speckled leukoplakia (Figures 2.59 and 2.60)
• Drug burns

Figure 2.59  White lesion: proliferative verrucous leukoplakia.

Figure 2.60  White lesion: proliferative verrucous leukoplakia.

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 Chapter 2 • Differential diagnosis by signs and symptoms

• Reactive/traumatic
 BARK (benign alveolar ridge keratosis)

 cheek biting (Figure 2.61)

 frictional hyperkeratosis

 nicotine stomatitis (stomatitis nicotinia; smokers keratosis)

(Figure 2.62).

Figure 2.61  White lesion: cheek biting (morsicatio buccarum).

Figure 2.62  White lesion: stomatitis nicotinia (smoker’s keratosis).

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White patch

Candidosis
Rubs off with gauze? Yes Materia alba
Burn (heat, drug, chemical)

No
Keratosis
Leukoplakia
Localised to one site? Yes Lichenoid lesions
Hyperplastic candidosis
Burn
Carcinoma
No
Leukoplakia
Keratosis
Plaque? Yes Lichen planus
White sponge naevus
Hyperplastic candidosis
Hairy leukoplakia
No
Lichen planus
Linea alba
Striated? Yes Leukoedema
Lupus erythematosus
Scar
No
Lichen planus
Syphilis
Gingival and palatal cysts
Papular? Yes of newborn
Fordyce disease
Koplik spots
No

Abraded? Yes Cheek chewing

Figure 2.63  Algorithm for white patch diagnosis.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Pain (orofacial)
Keypoints
• Facial or maxillofacial pain is common and most is of local
(odontogenic) cause.
• Vascular disorders such as migrainous neuralgia and giant cell arteritis
may present with orofacial pain.
• Some facial pain is referred from elsewhere, such as the chest and neck.
• Neurological disorders are an important cause of orofacial pain but,
except trigeminal neuralgia, they are uncommon.
• Pain may have a psychogenic basis but this can only be considered
when local, neurological, vascular and referred causes of pain have
been excluded. Even patients with psychogenic disorders can suffer
organic pain: ‘hypochondriacs can be ill’!
• History (Box 1.1), examination findings and imaging using radiography,
CT, MRI or ultrasonography are important in order not to miss detecting
organic disease and thus mislabelling the patient as having
psychogenic pain. MRI of the entire trigeminal nerve gives better
resolution of brainstem and cranial nerves than does CT, is
recommended for all patients, and certainly is mandatory if there are
atypical features, sensory or motor disturbances.
• Medical advice may well be indicated, especially if a neurological lesion
is at all possible and is urgently required if orofacial pain is:
 accompanied by pain elsewhere (chest, shoulder, neck or arm

– may be angina)
 accompanied by other unexplained symptoms or signs (numbness,

weakness, headaches, neck stiffness, nausea or vomiting – may be

intracerebral disease)
 focused in the temple on one side (may be giant cell arteritis –

a threat to vision).

Box 2.14  Main causes of orofacial pain

Local
Vascular
Referred
Neurological
Psychogenic

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Pain (orofacial) (continued)

Causes may include:
• Local diseases
• Vascular disorders
• Referred pain
• Neurological disorders
• Psychogenic pain.
Remember from the mnemonic Let Veterans Read Newspapers.

Local diseases
• Diseases of the teeth
 dentine sensitivity

 periapical periodontitis

 pulpitis

• Diseases of the periodontium

 lateral (periodontal) abscess

 necrotizing periodontitis

 necrotizing ulcerative gingivitis

 pericoronitis

• Diseases of the jaws

 dry socket

 fractures

 infected cysts

 malignant neoplasms

 osteochemonecrosis (bisphosphonate-related, denosumab,

bevacizumab)
 osteomyelitis

 osteoradionecrosis

• Diseases of the maxillary sinus (antrum)

 acute sinusitis

 malignant neoplasms

• Diseases of the temporomandibular joint

 arthritis

 temporomandibular pain dysfunction (facial arthromyalgia)

 others

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 Chapter 2 • Differential diagnosis by signs and symptoms

• Diseases of the salivary glands

 acute sialadenitis

 calculi or other obstruction to duct

 HIV salivary gland disease

 malignant neoplasms.

Vascular disorders
• Giant cell arteritis
• Migraine
• Migrainous neuralgia.
Referred pain
• Cervical spine
• Chest
• Eyes
• Ears
• Nasopharynx
• Others.
Neurological disorders
• Herpes zoster (including post-herpetic neuralgia)
• HIV neuropathy
• Lyme disease
• Malignant neoplasms involving the trigeminal nerve
• Multiple sclerosis
• Trigeminal neuralgia.
Psychogenic pain (oral dysaesthesia)
• Idiopathic (atypical) facial pain
• Atypical odontalgia, and other oral symptoms associated with anxiety or
depression
• Burning mouth syndrome (BMS).
Drugs
For example, vinca alkaloids.

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Orofacial pain

Dental cause?

No Yes

Idiopathic facial pain Caries

Oral dysaesthesia Trauma
Giant cell arteritis Periodontal disease
Referred pain Cracked tooth
TMJ pain Dentine hypersensitivity
Shingles Localised osteitis
(dry socket)

Figure 2.64  Algorithm for pain diagnosis.

Palsy (orofacial)
Keypoints
• Facial palsy (paralysis) is usually due to a facial nerve disorder but
myopathies may give the appearance of facial palsy.
• The common causes of facial palsy are a stroke (cerebrovascular
event), iatrogenic surgical trauma or Bell palsy.
• Bell palsy is fairly common and affects only the facial nerve; there are
no brain or other neurological problems.
• Bell palsy often has an infective cause – often herpes simplex virus
(HSV); consider other viruses (VZV, HIV), and bacteria (Borrelia
burgdorferi causing Lyme disease) mainly. It is not contagious.
• Bell palsy disproportionately attacks pregnant women and people who
have diabetes, influenza, a cold, or immune problems.
• There are usually no serious long-term consequences.
• Radiographs, scans and blood tests may be required.
• Treatment takes time and patience; corticosteroids and/or
antimicrobials can sometimes help.
• Most patients begin to get significantly better within 2 weeks,
and about 80% recover completely within 3 months.
• It rarely recurs, but can do so in ~ 5–10%.
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Box 2.15  Main causes of facial paralysis

Stroke (cerebrovascular event)
Bell palsy

Causes may include:

Mostly the cause is neurological – usually a stroke, or Bell palsy.
• Central causes
 cerebral palsy, tumour or cerebrovascular event (stroke)

 connective tissue disorders

 demyelinating disorders (e.g. multiple sclerosis)

 diabetes mellitus

 granulomatous diseases

a Crohn disease
b orofacial granulomatosis
c sarcoidosis
• Trauma to facial nerve or its branches, including local anaesthesia
• Infections affecting facial nerve (Bell palsy)
 viral infections (e.g. herpesviruses, retroviruses, Coxsackie viruses or

Guillain–Barré syndrome)
 bacterial infections (otitis media, Lyme disease)

 fungal infections (e.g. zygomycosis)

 parasitic infestations (e.g. toxoplasmosis)

 possible infections: Kawasaki disease (mucocutaneous lymph node

syndrome), Reiter disease (reactive arthritis)

• Middle ear disease
 cholesteatoma

 malignancy

 mastoiditis

 trauma (including surgery, and barotrauma – as in scuba diving)

• Parotid lesions
 parotid malignancy

 parotid trauma.

Clinical features: upper motor neurone lesions (e.g. stroke): unilateral palsy,
mainly in lower face may be features of stroke but hearing or taste normal.
Lower motor neurone lesions (e.g. Bell palsy): complete unilateral facial
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Palsy (orofacial) (continued)

palsy demonstrable when the patient smiles, whistles or tries to show their
teeth (Figures 2.65, 2.66); may also be loss of taste and/or hyperacusis.
Investigations: neurological; advanced imaging; blood pressure; blood tests
for diabetes and infective agents. Lyme disease, since it is amenable to
antibiotics, should be excluded – especially in endemic areas.
Management: Bell palsy: systemic corticosteroids, with or without antivirals;
stroke: physiotherapy and rehabilitation.

Figure 2.65  Bell palsy (at rest). Figure 2.66  Bell palsy (attempting a
smile) showing right-sided palsy.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Facial palsy Facial palsy only? No Refer to neurologist

Yes

Trauma to head or
Yes Consider trauma
facial nerve?

No

Middle ear lesion

Yes Consider middle ear cause
or surgery?

No

Parotid lesion? Yes Consider parotid lesion

No

History of recent
Yes Consider HSV
herpatic infection?

No

Contact with deer Consider Lyme disease

Yes
ticks possible?

No

HIV? Yes Consider HIV

Radiography (CT)

Figure 2.67  Algorithm for facial palsy diagnosis.

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Sensory changes (orofacial)

Keypoints
• The trigeminal nerve supplies sensation to most of the maxillofacial
region.
• Trauma is the usual cause of trigeminal sensory loss – and is seen
especially after mandibular third molar removal, orthognathic or cancer
surgery (Figures 2.68, 2.69).
• Other important causes of sensory loss include osteomyelitis and
malignant disease, often presenting as ‘numb chin syndrome’.
• Trigeminal sensory loss may manifest with accidental self-damage to
the skin or lip.
• Clinical tests for trigeminal nerve function include applying gentle
touch, pinpricks, or warm or cold objects to areas supplied by the
nerve – these are reduced in trigeminal sensory loss. The jaw jerk and
eye and corneal reflexes should also be examined. The patient’s ability
to chew and work against resistance tests motor function.
• In view of the potential seriousness of facial sensory loss, a full
neurological assessment must be undertaken, unless the loss is
unequivocally related to local trauma and, since other cranial nerves
are anatomically close, there may be associated neurological deficits in
intracranial causes of facial sensory loss.
• Possible investigations include:
 imaging (panoral, occipitomental, lateral and postero-anterior skull,

and MRI/CT of brain and skull base and mandibular division)

 a full blood count, erythrocyte sedimentation rate or C-reactive

protein, random sugar (glucose), syphilis and HIV serology,

autoantibody screen, plasma electrophoresis, calcium, phosphate
and alkaline phosphatase levels
 lumbar puncture – if disseminated sclerosis, carcinomatous

meningitis or leptomeningeal metastases are suspected.

• If the cornea is anaesthetic or hypoaesthetic, an eye pad should be
worn over the closed eyelids, since the protective corneal reflex is lost
and the cornea may easily be damaged. Facial hypoaesthesia results in
the loss of protective reflexes and a trigeminal trophic syndrome with
facial ulceration can follow.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.68  Numb chin syndrome, damaged right inferior alveolar nerve during
mandibular third molar removal.

Figure 2.69  Neoplasm in left mandibular ramus (multiple myeloma) presenting

with sensory loss.

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Sensory changes (orofacial) (continued)

• If there has been neurotmesis (cut nerve), rather than crushing
(neuropraxia), surgical correction can achieve good results.
• In benign, reversible causes of sensory loss, the underlying cause
should be corrected, and the patient reassured that there should be
some, if not full, return of sensation over the subsequent 18 months.

Box 2.16  Main causes of orofacial sensory loss

Trauma
Trigeminal nerve pressure from a lesion
Disseminated sclerosis

Causes may include:

• Trauma
• Numb chin syndrome
• Benign trigeminal neuropathy
• Psychogenic causes
• Congenital causes.

Trauma
Trauma to the mandibular division of the trigeminal nerve and inferior alveolar
nerve may be caused by:
• Inferior alveolar local analgesic injections
• Fractures of the mandibular body or angle
• Surgery (particularly cancer and orthognathic surgery or surgical
extraction of lower-third molars) or even endodontics or endosseous
implants.
Causes of damage to the mental nerve include:
• Surgery in the region
• Trauma from a denture – the mental foramen is close beneath a lower
denture and there is ipsilateral anaesthesia of the lower lip.
Causes of damage to the lingual nerve include lower third molar removal,
particularly when the lingual split technique is used. Ipsilateral lingual hypo-
aesthesia or anaesthesia usually result.
Causes of damage to branches of the maxillary division of the trigeminal
nerve include trauma (usually Le Fort II or III middle-third facial fractures).
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 Chapter 2 • Differential diagnosis by signs and symptoms

Numb chin syndrome

Numb chin syndrome (NCS) is unilateral chin numbness which may be
caused by:
• Trauma
• Osteomyelitis
• Inferior alveolar nerve malignant infiltration or compression by jaw
metastases (mainly lymphomas or breast cancer)
• Nasopharyngeal carcinomas may: invade the pharyngeal wall to
infiltrate the mandibular division of the trigeminal nerve, causing pain
and sensory loss in the region of the inferior alveolar, lingual and
auriculotemporal nerve distributions; invade the levator palati to cause
soft palate immobility; occlude the Eustachian tube to cause deafness
(Trotter syndrome)
• Metastatic or other deposit in the meninges or at the base of skull
• Sensory stroke.
Bilateral chin numbness, or circumoral numbness may be caused by:
• Hyperventilation
• Hypocalcaemia, including drug-induced (e.g. protease inhibitor,
ritonavir)
• Central nervous system toxicity from local anaesthetics
• Syringobulbia.
Benign trigeminal neuropathy
This is a long-standing sensory loss in one or more trigeminal divisions of
unknown cause, although it is important to exclude connective tissue dis-
eases and intracranial and extracranial causes before considering this to be
the final diagnosis. It seldom occurs until the second decade or affects the
corneal reflex. In some cases there is associated pain, which may be respon-
sive to amitryptiline.
Psychogenic causes
Hysteria, and particularly hyperventilation syndrome, may underlie some
causes of facial anaesthesia/hypoaesthesia. Typically then, the ‘anaesthesia’
is bilateral and associated with bizarre neurological complaints.
Congenital causes
Rare cases of facial sensory loss are congenital.

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Trigeminal
sensory loss

Isolated trigeminal
No Refer to neurologist
sensory deficit?

Yes

Head injury or trauma

Yes Consider trauma
to trigeminal nerve?

No

Drug cause? Yes Consider drugs

No

Diabetes? Yes Consider diabetes

No

Connective tissue Consider connective

disease? Yes tissue disease

No

Radiography Consider disseminated

Yes sclerosis
(and/or MRI)
Figure 2.70  Algorithm for trigeminal sensory loss diagnosis.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Sialorrhoea (hypersalivation and drooling)

Keypoints
• Healthy individuals produce and swallow from 0.5 to 1.5 litres of saliva
in 24 hours.
• Salivary flow above this is termed sialorrhoea, hypersialia,
hypersalivation or ptyalism.
• Most individuals are able to compensate for any increased salivation by
swallowing.
• Disturbed control of swallowing because of disorders of the orofacial
and/or palatolingual or pharyngeal musculature can lead to the overflow
of saliva from the mouth (drooling) (Figure 2.71).
• Drooling is normal in healthy infants, but usually stops by about 18
months of age and is considered abnormal if it persists beyond the age
of four years.
• Drooling can soil clothing and cause perioral skin breakdown and
infections, disturbed speech and eating, and can occasionally cause
aspiration-related and pulmonary complications.

Figure 2.71  Drooling in an infant who has had initial cleft lip repair.

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Sialorrhoea (hypersalivation and drooling) (continued)

Box 2.17  Main causes of sensation of sialorrhoea

Poor neuromuscular coordination
Oral painful lesion
Pharygneal or oesophageal obstruction
Psychogenic

Causes may include:

• Psychogenic (usually)
• Painful lesions or foreign bodies in the mouth
• Poor neuromuscular coordination
 cerebral palsy

 facial palsy

 other physical disability

 Parkinsonism

• Drugs (e.g. bethanecol, clozapine, nitrazepam, pilocarpine, risperidone)

• Poisoning
 heavy metals

 insecticides

 mercury

• Learning impairment
• Obstruction to swallowing
 pharyngeal

 oesophageal.

Management options range from conservative therapy (e.g. oral motor

training) to medication (e.g. benztropine, glycopyrrolate, scopolamine, botu-
linum toxoid), radiation, or surgery, and often a combination. A team includ-
ing at least an otolaryngologist, neurologist, dentist, speech, occupational
and physical therapists is needed.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Sialorrhoea

Swallowing Yes Excess saliva? Yes

normal?

Consider drugs,
No No pregnancy or GORD

Consider
psychogenic

Obstruction in mouth, Maxillofacial or ENT

Yes
pharynx or oesophagus? referral

Neurological
No
referral
Figure 2.72  Algorithm for sialorrhoea. GORD: gastro-oesophageal reflex disease.

Swellings in the lips or face

Keypoints
• Facial swelling that appears over a few minutes or hours may be
caused by angioedema.
• Facial swelling that appears over a few hours or days is most
commonly inflammatory in origin, often caused by trauma.
• Facial swelling that appears over a few hours or days may also be
caused by cutaneous, dental (odontogenic) or, rarely, systemic
infections.
• Facial swelling that appears over days or weeks may be seen in
masseteric hypertrophy.

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Swellings in the lips or face (continued)

• Facial swelling that appears over days or weeks may occasionally be
caused by granulomatous disorders (e.g. Crohn disease, orofacial
granulomatosis or sarcoidosis) (Figure 2.73).
• Facial swelling that appears over weeks or months is occasionally due
to systemic corticosteroid therapy or endocrine disease (Cushing
disease, hypothyroidism, acromegaly, diabetes mellitus).
• Facial swelling is commonly of slow onset in obesity.
• Facial swelling that is persistent is rarely caused by:
 fluid, as in vascular lesions (Figure 2.74) or lymphangiomas

(Figure 2.75)
 solids, such as primary neoplasms (Figure 2.76) or metastases,

deposits (e.g. amyloid) or foreign material (as in lip augmentation

with silicone or other fillers).

Box 2.18  Main causes of swelling of lips/face

Allergy
Inflammation
Trauma
Granulomatous condition (e.g. Crohn disease, orofacial granulomatosis
or sarcoidosis)
Neoplasm

Figure 2.73  Lip swelling: Crohn disease – showing typical lower lip swelling and
fissuring, and gingival involvement.
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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.74  Lip swelling: haemangioma.

Figure 2.75  Lip swelling: lymphangioma.

Figure 2.76  Lip swelling: carcinoma.

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Swellings in the lips or face (continued)

Causes may include:
Facial swelling is commonly inflammatory in origin – caused by cutaneous
or dental (odontogenic) infections or trauma.
• Infective
 oral or cutaneous infections, cellulitis, fascial space infections

 insect bites

• Traumatic
 traumatic or postoperative oedema or haematoma

 surgical emphysema

• Immunological
 allergic angioedema

 C1 esterase inhibitor deficiency (hereditary angioedema)

 Crohn disease, orofacial granulomatosis (OFG) or sarcoidosis

• Endocrine and metabolic

 Cushing syndrome and disease

 myxoedema

 nephrotic syndrome

 obesity

 systemic corticosteroid therapy

• Neoplasms
 congenital (e.g. lymphangioma)

 lymphoma

 oral and antral tumours

• Foreign bodies (including cosmetic fillers)

• Deposits
 amyloidosis

 others

• Cysts in soft tissues or bone

• Masseteric hypertrophy
• Bone disease
 fibrous dysplasia

 Paget disease.

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Swellings in the mouth

Keypoints
• Swellings in the mouth are often caused by infection or trauma (e.g.
oedema, haematoma, odontogenic infections, pyogenic granulomas)
(Figures 2.77, 2.78).

Box 2.19  Main causes of oral lumps or swelling

Allergy
Inflammation
Trauma
Granulomatous disorders (e.g. Crohn disease, orofacial granulomatosis
or sarcoidosis)
Neoplasm
Drugs

Figure 2.77  Intraoral swelling: periapical Figure 2.78  Intraoral swelling:

abscess. pregnancy tumour (pyogenic granuloma).

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Swellings in the mouth (continued)

• Swellings in the mouth may occasionally be caused by:
 neoplastic lesions (e.g. fibrous lumps [fibro-epithelial polyps],

carcinoma or lymphoma) (Figures 2.79–2.88).

Figure 2.79  Intraoral swelling: fibrous lump.

Figure 2.80  Intraoral swelling: fibrous lump.

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Figure 2.81  Intraoral swelling: papilloma.

Figure 2.82  Intraoral swelling: papilloma.

Figure 2.83  Intraoral swelling: papilloma (note also unrelated black stain on teeth).

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Swellings in the mouth (continued)

Figure 2.84  Intraoral swelling: granular cell myoblastoma (can be confused

histologically with carcinoma).

Figure 2.85  Intraoral swelling: carcinoma.

Figure 2.86  Intraoral swelling: carcinoma arising from a white lesion.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.87  Intraoral swelling: carcinoma arising from a white lesion.

Figure 2.88  Intraoral swelling: salivary neoplasm originally thought to be

a dental abscess.

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Swellings in the mouth (continued)

 granulomatous disorders (e.g. Crohn disease, orofacial
granulomatous disease (OFG), sarcoidosis) (Figures 2.89–2.91).
Figure 2.89  Intraoral swelling:
Crohn disease ‘cobblestoning’ of
mucosa (same patient as 2.90).

Figure 2.90  Intraoral swelling:

Crohn disease.

Figure 2.91  Intraoral swelling:

Crohn disease swelling and
chronic ulceration.

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 Chapter 2 • Differential diagnosis by signs and symptoms

• Swellings in the mouth are rarely caused by:

 fluid, as in angiomas (Figures 2.92–2.94) or angioedema

Figure 2.92 
Intraoral swelling:
haemangioma and
lymphangioma.

Figure 2.93  Intraoral

swelling: lymphangioma.

Figure 2.94  Intraoral

swelling: lymphangioma.

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Swellings in the mouth (continued)

 solids, such as some congenital neoplasms (Figure 2.95), foreign
material, metastases (Figure 2.96) or deposits (e.g. amyloid).
 Wegener granulomatosis – this can present an almost

pathognomonic ‘strawberry’ appearance of the gingival, or lumps or

ulcers elsewhere. There may be lung and kidney lesions, and serum
antineutrophil cytoplasmic antibodies (ANCA). Chemotherapy or
co-trimoxazole are indicated.
 tongue swelling (macroglossia) is discussed below. In macroglossia,

the tongue is indented by teeth, or too large to be contained in the

mouth. Ultrasound or MRI may be indicated; biopsy if there is
discrete swelling, but not if it is a vascular lesion.
• Gingival swelling is fairly common, often localized to the maxillary
anterior gingivae in hyperplastic gingivitis arising as a consequence of
mouth-breathing:
 epulides are localized gingival swellings – rarely are they true

neoplasms (Figure 2.97).

 generalized gingival swelling is commonly drug-induced, usually

aggravated by poor oral hygiene and starting interdentally, especially

labially. Papillae are firm, pale and enlarge to form false vertical
clefts
 generalized gingival swelling may occasionally be congenital

(hereditary gingival fibromatosis), deposits or due to leukaemia.

Epulides
Epulis is a term applied to any discrete swelling arising from the gingiva.
Typical orofacial symptoms and signs: fibrous epulides (irritation fibromas)
are most common; they typically form narrow, firm, pale swellings of an
anterior interdental papilla and may ulcerate. Pyogenic granulomas, giant
cell or neoplastic epulides are often softer, and a deeper red colour but
they cannot be distinguished clinically with certainty from fibrous epulides.
Main oral sites affected: facial gingivae.
Aetiopathogenesis: fibrous epulides may result from local gingival irritation,
leading to fibrous hyperplasia. Pyogenic granulomas are common lesions,
especially in children and teens where there are local factors, including
inadequate oral hygiene, malocclusion and orthodontic appliances, and
in pregnancy (pregnancy epulides) (the lesions themselves are not

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Figure 2.95  Intraoral

swelling: neurofibroma
(in generalized
neurofibromatosis).

Figure 2.96  Intraoral

swelling: metastatic
carcinoma (from breast
cancer.)

Figure 2.97  Intraoral

swelling: fibrous epulis
arising adjacent to imbricated
teeth.

histologically distinguishable). Giant cell epulides (giant cell granulomas)

are reactive lesions seen mainly in children caused by local irritation or
may result from proliferation of giant cells persisting after resorption of
deciduous teeth. Rarely, epulides represent metastatic disease or other
tumors.
Investigations: excision biopsy; radiography.
Main treatments: excision; remove local irritants (e.g. calculus).
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Swellings in the neck

Keypoints
• Swellings in the neck can arise from any tissue but most commonly
from the lymph nodes, salivary or thyroid glands.
• Cervical lymph node swellings may be mainly:
 inflammatory

 malignant (Figure 2.98).

• Salivary gland swellings may be caused mainly by:

 calculi or other obstruction to salivary flow

 IgG4 syndrome

 sarcoidosis

 sialadenitis (usually bacterial or viral)

 sialosis

 Sjögren syndrome

 tumours.

• Thyroid gland swellings are mostly caused by an inadequate intake of

iodine; other causes include:
 benign and malignant thyroid tumours

 Graves disease (non-painful generalized swelling of the thyroid gland

plus hyperthyroidism)
 thyroiditis: some types of thyroiditis are extremely painful, may

disturb thyroid function and may culminate in hypothyroidism

a pregnancy (postpartum thyroiditis)
b Hashimoto disease (chronic autoimmune thyroiditis)
c acute and subacute thyroiditis
d silent thyroiditis.
• Skin swellings are mainly:
 epidermoid/dermoid cyst

 intraoral abscess with cutaneous sinus tract

 Ludwig angina (submandibular and sublingual fascial spaces

infection).

Box 2.20  Main causes of neck sweliing

Allergy
Inflammation
Neoplasm

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.98  Cervical lymph node metastases from ipsilateral oral carcinoma.

Swellings in the side of the neck

Apart from lymph node or salivary gland swellings, these may include:
• Actinomycosis
• Branchial cyst
• Parapharyngeal cellulitis
• Pharyngeal pouch
• Cystic hygroma
• Carotid body tumours or aneurysms
• Muscle or other soft tissue neoplasm
• Focal myositis
• Myositis ossificans
• Proliferative myositis
• Nodular pseudosarcomatous fasciitis.
Swellings in the midline of the neck
These may be due to submental lymphadenopathy, or
• Ectopic thyroid
• Epidermoid/dermoid cyst
• Thyroglossal cyst
• Thyroid tumours or goitre
• ‘Plunging’ ranula.
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Enlargement of cervical lymph nodes only (no hepatosplenomegaly)?

Yes Oral, pharyngeal disease, etc.? Yes

History of Inflammatory
No Neoplastic
cat scratch?

Yes Cat scratch disease/toxoplasmosis

Heterophile antibodies? Yes Infectious mononucleosis

No Blood film normal? No Leukaemia

Viral
Yes
seropositive?

No Yes HIV Yes Tuberculosis

CMV Sarcoidosis
HHV-6 Carcinoma
Lymphoma

Hilar node enlargement or other lesions on chest radiography?

No Relevant drug history? Yes Drugs

No VDRL positive? Yes Syphilis

No

USgFNA lymph node biopsy to exclude carcinoma, lymphoma, etc.

Figure 2.99  Algorithm for cervical lymph node enlargement. USgFNA: ultrasound-
guided fine needle aspiration; VDRL: veneral disease research laboratory test.
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Swellings of the jaws

Keypoints
• Jaw swelling is most often caused by developmental enlargements
(e.g. tori or buccal exostoses), which are benign, painless, broad-based
and self-limiting, usually with normal overlying mucosa.
• Jaw swelling is less commonly due to odontogenic causes (unerupted
teeth, infections, cysts or neoplasms).
• Metastasis to the mouth is rare but is typically to the jaws, especially
the posterior mandible. Most metastases originate from cancers of the
breast, lung, kidney, thyroid, stomach, liver, colon, bone or prostate via
lymphatic or haematogenous spread, and present as lumps, ulceration,
tooth loosening, sensory change or pathological fracture.
• Jaw swelling may occasionally be caused by other inflammatory or
neoplastic disorders, or metabolic or fibro-osseous diseases.
• Imaging is almost invariably required to assist the diagnosis.

Box 2.21  Main causes of jaw swelling

Congenital
Odontogenic infections, cysts or neoplasms

Causes may include:

• Congenital (e.g. torus)
• Odontogenic
 unerupted teeth

 infections

 cysts

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Swellings of the jaws (continued)

 neoplasms (Figure 2.100)
 postoperative or post-traumatic oedema or haematoma
• Foreign bodies
• Bone disease
 fibrous dysplasia

 Paget disease

 cherubism.

Figure 2.100  Jaw swelling:

ameloblastoma showing
multilocularity on
radiography, seen in the
typical location (posterior
mandible).

Swelling of the salivary glands

Keypoints
• The most common salivary lesion is the mucocele, usually caused by
extravasation of saliva from a damaged minor salivary gland duct and
seen in the lower labial mucosa, sometimes caused by retention within
a gland.
• In children and young people, the most common cause of swelling of
one or more of the major glands is viral sialadenitis (mumps). Recurrent
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sialadenitis may be termed juvenile recurrent parotitis, but this is

probably a group of conditions variously caused by genetic factors,
ductal obstruction, ductal ectasia (dilatations), or diseases such as
Sjögren syndrome or sarcoidosis.
• In adults, salivary swelling is most commonly obstructive (e.g. by a
salivary stone or calculus [sialolith]) (Figures 2.101, 2.102) or

Figure 2.101  Salivary gland swelling: obstruction from submandibular salivary

calculus.

Figure 2.102  Salivary gland

swelling: obstruction in parotid duct
is often due to mucous plugs.

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Swelling of the salivary glands (continued)

inflammatory in origin (e.g. infective sialadenitis, sclerosing sialadenitis
[IgG4 syndrome], Sjögren syndrome, sarcoidosis) (Figures 2.103–2.105).
• Salivary swelling may be caused by salivary, or rarely systemic,
infections.
• Salivary swelling may occasionally be caused by neoplastic (Figures
2.106, 2.107) or other disorders (e.g. sialosis).

Fig 2.103  Salivary gland swelling: infection of acute sialadenitis produces pain,
swelling and erythema.

Figure 2.104  Salivary gland swelling; bilateral parotid inflammation in Mikulicz

disease (IgG4 syndrome).
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Figure 2.105  Salivary gland swelling:

parotitis. The gland is painful and swollen,
the skin erythematous, and mouth opening
is restricted.

Figure 2.106  Salivary gland swelling: Figure 2.107  Salivary gland swelling:
neoplasm (adenoid cystic carcinoma). neoplasm (pleomorphic adenoma).
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Swelling of the salivary glands (continued)

• Salivary swelling is also caused by:
 fluid, as in trauma (oedema or haematoma), mucocele (Figures

2.108, 2.109) or vascular lesions

 solids such as deposits (e.g. amyloid) or foreign material

 swelling of intra-salivary lymph nodes.

Box 2.22  Main causes of salivary gland swelling

Obstruction
Sialadenitis
Sjögren syndrome
Sialosis
Neoplasm

Causes may include:

• IgG4 syndrome
• Mucocele/ranula
• Neoplasms
• Sarcoidosis
• Sialadenitis
• Sialosis
• Sjögren syndrome.
Obstruction
Fairly common in submandibular duct or gland; rare in parotid.
Typical orofacial symptoms and signs: may be asymptomatic but typically
there is pain and swelling of gland at meals (Figures 2.106, 2.107,
2.116) and there can be a consequent bacterial sialadenitis. Obstruc-
tion of a minor salivary gland duct or a ductal tear may produce a
mucocele.
Main oral sites affected: submandibular mainly, in the duct or gland, or both
sites.
Aetiopathogenesis: calculus – the usual cause in the submandibular;
more likely to be a mucous plug, fibrous stricture or neoplasm in the
parotid.
Gender predominance: male.
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Figure 2.108 
Salivary gland
swellings: mucoceles
are usually solitary
but occasionally
multiple as here.

Fig 2.109  Salivary

gland swelling:
submandibular
obstruction (as here)
can mimic a
mucocele.

Age predominance: adult.

Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: differentiate from other causes of salivary swelling:
inflammatory – mumps, bacterial sialadenitis, IgG4 syndrome, Sjögren
syndrome, sarcoidosis; duct obstruction; neoplasms; others including sia-
losis, drugs and Mikulicz disease (IgG4 disease: sclerosing sialadenitis).
Investigations: ultrasound, radiography (but 40% of stones are radiolucent);
sialography if necessary.
Main diagnostic criteria: clinical and imaging.
Main treatments: surgical removal of obstruction (lithotripsy, endoscopic
removal, or incisional removal).
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Salivary gland

Single gland swollen?

Yes No

Yes Discrete swelling? No Fever? No

Increasing in size Pus expressed

No Yes
or causing pain? from ducts?

Dry eyes
Yes No and dry Yes
Yes
mouth?
Sialadenitis

Obstruction Obstruction Sjögren syndrome

Infection Infection HIV or HTLV-1
Neoplasm Sarcoidosis salivary gland disease
Lymph node Neoplasm IgG4 syndrome
enlargement
Size or pain
Yes
increases with meals?

No Obstruction

Hyposalivation?

No Yes

Sialosis Drugs
Sarcoidosis Sarcoidosis
Parotitis Sjögren syndrome
Warthin tumour HIV or HTLV-1
HIV salivary gland salivary gland disease
disease IgG4 syndrome

Figure 2.110  Algorithm for salivary gland swelling.

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Taste disturbance
Keypoints
• Taste cells scattered across the tongue are sensitive to the five tastes
– sweet, sour, bitter, salty and umami.
• Saliva is also essential to taste.
• Three tastes (sweet, bitter and umami) are mediated by receptors from
the G protein-coupled receptor family, while salt and sour are tasted
using ion channels.
• Taste is transmitted by three different cranial nerves:
 facial nerve from the anterior two-thirds of the tongue

 glossopharyngeal nerve from the posterior one-third of the tongue

 vagus nerve from the epiglottis.

• Taste disturbances are a common complaint, especially with

advancing age.
• Taste disturbance is termed dysgeusia, while loss is termed ageusia
if complete, hypogeusia if partial; bad taste is termed cacogeusia.
• Taste loss as proven objectively is uncommon.
• Many people who think they have a taste disorder actually have
a problem with smell, sometimes caused by nose, sinus or throat
conditions.
• Ageusia results mainly from tongue mucosal disorders, neurological
damage, B vitamin or zinc deficiency, or drugs.
• Dysgeusia may be caused by oral infections, hyposalivation,
chemotherapy, drugs, zinc deficiency or psychogenic causes.
• Patients who suffer from burning mouth syndrome often also suffer
from dysgeusia.
• History and clinical examination includes inspection of the oral cavity
and ear canal, as lesions of the chorda tympani have a predilection for
this site.
• Possible treatments include artificial saliva, pilocarpine (or cevimeline),
increased oral hygiene, zinc supplementation, alterations in drug
therapy, and alpha lipoic acid.

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Taste disturbance (continued)

Box 2.23  Main causes of taste disturbances
Anosmia
Endocrine (e.g. diabetes, hypothyroidism)
Glossitis
Hyposalivation
Iatrogenic (see Table 4.6)
Neurological disease (e.g. trauma, disseminated sclerosis, Bell palsy)
Old age
Zinc or vitamin deficiency

Causes may include:

Loss of taste
• Anosmia causing apparent loss of taste
 maxillofacial or head injuries (tearing of olfactory nerves)

 upper respiratory tract infections and sinus disease

• Neurological disease
 Bell palsy

 cerebral metastases

 cerebrovascular disease

 fractured base of skull

 frontal lobe tumour

 lesions of chorda tympani

 middle ear surgery

 multiple sclerosis

 posterior cranial fossa tumours

 trigeminal sensory neuropathy

• Psychogenic
 anxiety states

 depression

 psychoses

• Drugs
• Others

Cacogeusia
• Oral disease
 acute necrotizing ulcerative gingivitis

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 Chapter 2 • Differential diagnosis by signs and symptoms

 bisphosphonate-related osteonecrosis of the jaw (BRONJ)

 chronic dental abscesses
 chronic periodontitis

 dry socket

 food impaction

 neoplasms

 osteochemonecrosis (denosumab, bevacizumab)

 osteomyelitis

 osteoradionecrosis

 pericoronitis

 sialadenitis

• Hyposalivation
 drugs

 irradiation damage

 sarcoidosis

 Sjögren syndrome

• Psychogenic causes
 anxiety states

 depression

 hypochondriasis

 psychoses

• Drugs
 Chinese pine nuts

 smoking

• Nasal or pharyngeal disease

 chronic sinusitis

 nasal foreign body

 neoplasm

 oroantral fistula

 pharyngeal disease

 pharyngeal pouch

 tonsillitis

• Diabetes
• Respiratory disease
 bronchiectasis

 neoplasm

• Gastrointestinal disease
 gastric regurgitation

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Taste disturbance (continued)

• Liver disease
 liver failure

• Central nervous system disease

 temporal lobe epilepsy

 temporal lobe tumours

• Renal disease
 uraemia

Bad taste

Single gland swollen?

Yes

Hyposalivation? Yes See ‘Dry mouth’

No

Smoking or Smoking
on drugs or Yes Yes Drugs
using pine nuts? Pine nuts

No No Are smoking and drugs the cause?

Chronic sinusitis
Nasopharyngeal Oroantral fistula
or perinasal Yes Oronasal fistula
disease? Tonsillitis
Tonsillolith
No

Gastric reflux? Yes Hiatus hernia

Gastric disease

No

Psychogenic
Figure 2.111  Algorithm for bad taste.
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Tongue: furred
Keypoints
• A furred tongue in a healthy child is very uncommon.
• A furred tongue in a healthy adult is not uncommon and usually due to
the accumulation of debris, including microorganisms on the dorsum
(Figure 2.112).
• Dehydration or soft diet allows debris and bacteria to accumulate. An
upper denture also does not clean the tongue as effectively as palatal
rugae.
• The tongue when furred has a whitish or yellowish ‘fur’ which may be
further discoloured by feverish illnesses (e.g. herpetic stomatitis) (Figure
2.113), hyposalivation, or by foods, drugs or lifestyle habits (e.g.

Figure 2.112  Tongue coated for

no apparent reason. Much of this
is due to debris which can be
removed by brushing or scraping.

Figure 2.113  Tongue coated and

ulcerated in acute herpetic
stomatitis.

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Tongue: furred (continued)

tobacco or betel) and may even be brown or black (Figures
2.114–2.116).
• Thrush, chronic candidosis, hairy leukoplakia (lateral borders of tongue)
or other leukoplakias should be excluded.
• The underlying condition should be treated and the tongue brushed or
scraped at night before retiring to bed.

Box 2.24  Main causes of furred tongue

Poor oral hygiene
Hyposalivation
Smoking

Figure 2.114  Tongue coated – brown hairy tongue. This typically affects the
posterior tongue.

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Figure 2.115  Tongue coated – stained by betel use.

Figure 2.116  Tongue coated and stained by chlorhexidine mouthwash use.

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Tongue: smooth (glossitis)

Keypoints
• Glossitis is the term given to a smooth depapillated tongue and is not
a specific disorder.
• Glossitis can be caused by deficiencies of iron, folic acid, vitamin B12
(rarely other B vitamins), which can cause a sore tongue that may
appear normal, or may be red and depapillated (Figure 2.117); by
erythema migrans (geographic tongue); by lichen planus; by candidosis
(Figures 2.118, 2.119); and by Sjögren syndrome (Figure 2.120).

Box 2.25  Main causes of glossitis

Erythema migrans
Lichen planus
Hyposalivation
Candidosis
Haematinic deficiency

Figure 2.117  Tongue: glossitis; vitamin Figure 2.118  Tongue: glossitis;

deficiency. candidosis.

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.119  Tongue: glossitis; Figure 2.120  Tongue: glossitis; Sjögren

candidosis. syndrome in scleroderma.

Glossitis may be seen in:

• Erythema migrans
• Candidosis
• Sjögren syndrome
• Lichen planus
• Deficiency states.

Deficiency states
The tongue may appear completely normal or there may be linear or patchy
red lesions (especially in vitamin B12 deficiency), depapillation with erythema
(in deficiencies of iron, folic acid or B vitamins) or pallor (iron deficiency).
Lingual depapillation begins at the tip and margins of the dorsum but later
involves the whole dorsum. Various patterns are described. There may also
be oral ulceration and angular stomatitis.
• Rare types of deficiency include:
 riboflavin: papillae enlarge initially but are later lost

 niacin: red, swollen, enlarged ‘beefy’ tongue

 pyridoxine: swollen, purplish tongue.

• Diagnosis is from the blood picture (full blood picture, whole blood
folate, serum vitamin B12, ferritin). Vitamin assays or biopsy are rarely
indicated.
• Replacement therapy is indicated after the underlying cause of
deficiency is established and rectified.
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Tongue swelling
• Tongue swelling (macroglossia) is usually acquired and caused by
trauma, infection or allergy (angioedema).
• Uncommon congenital causes of macroglossia include: lymphangioma;
haemangioma; neurofibromatosis; Down syndrome; cretinism;
and Hurler syndrome (a mucopolysaccharidosis) (Figure 2.121).
• Rare acquired causes include amyloidosis and other deposits.
• In macroglossia, the tongue is indented by teeth, or too large to be
contained in the mouth.

Box 2.26  Main causes of enlarged tongue

Allergy
Trauma
Infection
Angioma
Neoplasm

Figure 2.121  Tongue

enlarged (macroglossia): in
Hurler syndrome – an inborn
metabolic error.

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Tooth abrasion
Keypoints
• Abrasion is a common form of tooth surface loss at the cervical
margin, caused mechanically by exogenous factors, typically
toothbrushing.
• Abrasion also causes gingival attachment loss.
• Initially there is gingival recession labially and the neck of the tooth is
exposed, sometimes with hypersensitivity. A groove forms as cementum
and dentine is abraded, especially on the maxillary canines. Abrasion, if
extreme, causes teeth to snap off (Figure 2.122) but otherwise the pulp
is rarely exposed since reactionary dentine is deposited.
• Desensitizing agents may help relieve symptoms. If aesthetically
displeasing or causing hypersensitivity, the abrasion may be restored
with composites or glass ionomer cements.

Box 2.27  Main causes of tooth abrasion

Overenthusiastic horizontal toothbrushing

Causes may include:

Usually, vigorous toothbrushing, especially horizontally with abrasive denti-
frices and hard brushes.

Figure 2.122  Teeth abrasion (also the patient has an unrelated desquamative
gingivitis).
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Tooth attrition
Keypoints
• Attrition is the most common form of tooth surface loss.
• Attrition is the mechanical wearing down of tooth surfaces by tooth–
tooth or tooth–prosthesis contact.
• Attrition is most common in people who suffer bruxism, or eat an
abrasive diet.
• The incisal edges, cusps and occlusal surfaces wear (Figure 2.123)
and, characteristically, opposing tooth facets will match perfectly in
occlusion.
• If the enamel is breached there is more loss of the softer dentine than
enamel, leading to a flat or hollowed surface – a facet.
• Unless attrition is rapid, the pulp is generally protected by obliteration
with secondary dentine formation and thus attrition rarely causes
dentine hypersensitivity.
• Restorative dentistry and occlusal splint therapy may be indicated.

Box 2.28  Main causes of attrition

Bruxism
Coarse diet

Causes may include:

The wearing away of tooth biting (occlusal) surfaces by mastication is most
obvious where there are excessive occlusal forces/movements such as in:

Figure 2.123  Teeth; attrition: secondary dentine deposition tends to avoid

hypersensitivity and pulp exposure.
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 Chapter 2 • Differential diagnosis by signs and symptoms

• a parafunctional habit such as bruxism (seen especially in profound

vegetative states, Rett syndrome or Fragile X syndrome)
• where the diet is particularly coarse (as in some unrefined diets) or
• where the teeth are of weaker composition (such as amelogenesis
imperfecta or dentinogenesis imperfecta). Interproximal attrition is far
less common.

Tooth discolouration
Keypoints
• Teeth may be discoloured, most commonly from superficial (extrinsic)
staining by bad oral hygiene, lifestyle habits such as use of tobacco or
betel, or drugs such as chlorhexidine (Figures 2.124, 2.125).

Figure 2.124  Tooth discoloration: from smoking and poor oral hygiene.

Figure 2.125  Tooth discoloration: from betel chewing. There is also tooth
surface loss.
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Tooth discolouration (continued)

• Extrinsic staining typically affects many teeth, predominantly in the
cervical third of the teeth.
• Less commonly, staining is internal (intrinsic) – usually from caries,
trauma or tooth restorations (Figure 2.126), or because the tooth has
become non-vital (Figures 2.127, 2.128).
• Intrinsic discolouration usually but not invariably affects the whole of
one or a few teeth or only parts of the teeth.

Box 2.29  Main causes of tooth discoloration

Superficial (extrinsic) staining is mainly from smoking, poor oral hygiene,
drugs, or betel use
Intrinsic staining is seen in non-vital teeth, from caries or restorations, or
tetracycline

Causes may include:

Extrinsic causes
• Brown/black stain
 betel

 chlorhexidine

 doxycycline

 iron medications

 stannous fluoride

 tea, coffee, wine and other beverages

 tobacco products

• Green stain
 chromogenic bacteria

 metals

• Orange stain
 chromogenic bacteria

 metals

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.126  Tooth discolouration: from caries.

Figure 2.127  Tooth discolouration: a traumatized non-vital tooth in a person who

suffers seizures.

Figure 2.128  Tooth discolouration: a non-vital tooth from caries.

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Tooth discolouration (continued)

Intrinsic causes
• White (opaque) stain
 incipient caries (primary or secondary teeth)

 mild trauma to teeth during enamel formation/amelogenesis

(secondary teeth), e.g., Turner tooth

 periapical infection of primary tooth predecessor

• Yellow stain
 amelogenesis imperfecta

 dentinogenesis imperfecta

 composites or glass ionomer or acrylic restorations

 tetracycline

 moderate trauma to teeth during amelogenesis (secondary teeth),

e.g., Turner tooth

 periapical infection of primary tooth predecessor

 trauma without haemorrhage

 traumatic injury to primary tooth or teeth

• Brown stain
 amelogenesis imperfecta

 dentinogenesis imperfecta

 severe trauma to teeth during amelogenesis (secondary teeth),

e.g., Turner tooth

 tetracyclines

 periapical infection of primary predecessor

 traumatic injury to primary tooth

 composite, glass ionomer, or acrylic restorations

 caries

 pulpal trauma with haemorrhage (necrotic tooth)

• Blue, grey, or black stain

 amalgam restoration

 dentinogenesis imperfecta

 metal crown margin associated with porcelain fused to metal crown

 tetracyclines

 trauma

• Green stain
 hyperbilirubinaemia (e.g., haemolytic disease of the newborn, biliary

atresia)
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 Chapter 2 • Differential diagnosis by signs and symptoms

• Pink stain
 internal resorption

 recent tooth trauma

 porphyria.

Tooth erosion
Keypoints
• Erosion is tooth surface loss as a consequence of chemical activity.
• Erosion typically affects several teeth and leaves smooth tooth surfaces.
• Ingestion of acidic materials such as carbonated beverages (carbonic
acid, e.g. cola) or fruit juices (citric acid) or vinegar (acetic acid)
produces smooth depressions on labial surfaces of anterior teeth
(Figure 2.129).
• In gastric regurgitation, palatal and lingual surfaces are eroded by the
gastric hydrochloric acid.
• A careful history is usually adequate to differentiate erosion from
abrasion, dentinogenesis imperfecta and amelogenesis imperfecta.
• Prevent the habit or treat regurgitation. Use a straw to drink acidic fluids.
Use desensitizers. If erosion is aesthetically unacceptable, restore.

Box 2.30  Main causes of tooth erosion

Consumption of acidic beverages and foods
Gastric acid reflux

Figure 2.129  Tooth surface loss: erosion (the left central incisor is nonvital
because of trauma).
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Tooth erosion (continued)

Causes may include:
Repeated and prolonged exposure to:
• acids (beverages such as carbonated [carbonic acid] and citrus [citric
acid] juices); foods rich in citrus fruits or containing vinegar (acetic
acid); or acidic atmospheres (e.g. carbonic or sulphuric acid); sodas,
sports drinks, energy drinks and alcoholic drinks, including wine, may
also be culpable
• gastric contents (gastro-oesophageal reflux disease [GORD]), pyloric
stenosis or bulimia [hydrochloric acid])
• alcoholic patients in particular are predisposed to erosion.

Tooth hypoplasia
Keypoints
• Hypoplasia of single teeth (Turner tooth): usually disturbed
odontogenesis caused by periapical infection of a deciduous
predecessor. It affects premolars mainly, especially mandibular. The
crown is opaque, yellow-brown and hypoplastic (Figure 2.130).
• Hypoplasia of multiple teeth; generally acquired as a result of fluorosis
(Figure 2.131), systemic illness or intervention (such as cancer
treatments) during the period of tooth development (chronological
hypoplasia). Pitting hypoplasia affects parts of developing crowns and,
since systemic disturbances are especially common during the first
year of life, defects usually affect tips of permanent incisors and first
molars (Figure 2.132).

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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.130  Tooth hypoplasia: a Turner premolar tooth.

Figure 2.131  Tooth hypoplasia: in fluorosis.

Figure 2.132  Tooth hypoplasia and microdontia of lateral incisor.

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Tooth hypoplasia (continued)

• Congenital syphilis is a rare cause of hypoplasia, producing notched
screwdriver-shaped incisors (Hutchinson incisors (Figure 2.133; and
abnormal molars (Moon or mulberry molars).
• Genetically determined causes of tooth hypoplasia may be seen rarely.

Box 2.31  Main causes of hypoplastic teeth

Trauma
Infection
Cancer therapy

Causes may include:

Congenital
• Amelogenesis imperfecta
• Cleidocranial dysplasia
• Epidermolysis bullosa
• Vitamin D resistant rickets (hypophosphataemia)
• Congenital hypoparathyroidism, Down and other syndromes
• Intrauterine infections (rubella; syphilis).
Acquired
Exposure of developing teeth to
• Trauma
• Infection
• Prematurity
• Hyperbilirubinaemia (kernicterus)
• Hypocalcaemia
• Severe infections
• Radiotherapy
• Cytotoxic chemotherapy
• Endocrinopathies (especially hypoparathyroidism)
• Severe nutritional deficiencies (as in coeliac disease)
• Nephrotic syndrome
• Severe fluorosis
• Molar – incisor hypomineralization (? caused by dioxin).
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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.133  Tooth hypoplasia: screwdriver-shaped incisors (Hutchinson incisors)

in congenital syphilis.

Tooth mobility or premature loss

Keypoints
• Most tooth mobility arises from plaque-related periodontitis or trauma,
and these can cause premature tooth loss.
• Tooth mobility in the absence of periodontitis may be caused by trauma
(including abuse) or a neoplasm.
• Early tooth loss usually has an obvious cause, such as trauma (in
sports, assaults or other injuries, extraction as a result of dental caries)
or for orthodontic reasons or, in adults, periodontal disease.
• Unexplained early tooth loss in children or adults may be a feature in:
 non-accidental injury

 immune defects (e.g. Down syndrome, diabetes mellitus, HIV/AIDS),

or cathepsin C deficiency (this includes Papillon–Lefèvre syndrome

[palmo-plantar hyperkeratosis] or leucocyte adhesion defects [LAD])
 hypophosphatasia

 neoplasms, or eosinophilic granuloma.

• Periodontitis that is disproportionate to the degree of plaque

accumulation may signify an underlying immune defect.
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Tooth mobility or premature loss (continued)

Box 2.32  Main causes of premature tooth mobility/loss
Trauma
Immune defects

Tooth number anomalies

Keypoints
• Definitions are:
 hypodontia: less than six missing teeth (excluding the third molars)

 oligodontia: six or more missing teeth (excluding the third molars)

 anodontia: no teeth present (typically seen in ectodermal dysplasia)

 hyperdontia: extra teeth (supernumerary teeth) present.

• Hypodontia is not uncommon.

 Most cases where teeth are missing from the arch (hypodontia) are

because the tooth has impacted, or been extracted or lost for other
reasons.
 Hypodontia is seen mainly in the second dentition.

 Hypodontia most often affects permanent third molars; up to

10–30% of the population may miss these teeth. After that,

incisor-premolar hypodontia (IPH) is most common, affecting mainly
mandibular second premolars and then maxillary lateral incisors.
Maxillary second premolars and maxillary and mandibular first
molars and canines are then affected.
 Teeth may sometimes be missing as part of systemic disease such

as ectodermal dysplasia, or as a consequence of cancer treatments.

 Hypodontia is often associated with retention of the deciduous

predecessor, and may be associated with delayed eruption, a

reduction in size of teeth, ectopic teeth, short roots, taurodontism,
tooth rotation, or hypocalcification.
• Hyperdontia, or additional (supernumerary) teeth, is not common.
 When normal permanent teeth erupt before the deciduous incisors

have exfoliated (i.e. the mixed dentition), it is not uncommon to see

what appear to be two rows of teeth in the lower incisor region,
particularly when there is inadequate space to accommodate the
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 Chapter 2 • Differential diagnosis by signs and symptoms

larger permanent teeth, but this is not true hyperdontia. The

situation here normally resolves as primary incisors are lost and the
mandible grows.
 Hyperdontia may occur in isolation but sometimes in cleft lip–palate
or as part of a syndrome such as craniofacial dysplasia. Extra teeth
may be found especially in the anterior maxilla and most typically
occur alone in otherwise healthy individuals.
 Most extra teeth are small and/or conical or tuberculate
(supernumerary teeth) and are seen in the maxillary midline where
they may remain unerupted and may cause a permanent incisor to
impact (mesiodens). Although a mesiodens may erupt, sometimes
it is inverted. Tuberculate supernumeraries are uncommon, often
paired, usually located palatal to the central incisors and they rarely
erupt.
 Some additional teeth are of normal form (supplemental teeth) but
these are uncommon, of unknown cause, and most frequently seen
in the maxillary lateral incisor region.
 Extra maxillary molars are sometimes termed distodens (they may
also be called paramolars or fourth molars if distal to the third,
some also call them distomolars).
 Additional teeth often erupt in an abnormal position and may cause
malocclusion, occasionally impede tooth eruption, or, rarely, are the
site of dentigerous cyst formation.

Table 2.2  Dental findings at various ages

Age Should be visible on radiography

Birth All primary teeth

Crypts of first molars
Age 2 years Crowns of premolars and second molars begin
Age 6 years Crowns of all permanent teeth except third molars
Age 18 years All permanent teeth

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Tooth number anomalies (continued)

Causes of hypodontia may include:
• Failure to erupt
• Premature loss
• Failure to develop – agenesis.
Hypodontia is usually seen in otherwise apparently healthy people,
but can also be a feature of local growth disorders such as:
• Cleft palate
• After radiotherapy to the area
• After chemotherapy
• Thalidomide exposure.
Hypodontia may also be seen in several syndromes, such as:
• Ectodermal dysplasia
• Incontinentia pigmenti
• Down syndrome
• Ehlers–Danlos syndrome.
Causes of hyperdontia may include:
• Supernumerary teeth may be seen in syndromic conditions typically in
association with:
 cleft lip/palate

 craniofacial (cleidocranial) dysplasia

 Gardner syndrome

 Sturge–Weber syndrome.

Box 2.33  Main causes of abnormal tooth numbers

Hypodontia – impacted tooth, cancer therapies, or genetic
Hyperdontia – genetic

Tooth shape anomalies

Keypoints
• Most anomalies of tooth shape are acquired but some are genetically
determined.
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 Chapter 2 • Differential diagnosis by signs and symptoms

• Acquired anomalies are usually termed hypoplasia.

• Genetic anomalies may include:
 conical teeth (Figure 2.134)

 connation (double tooth); affects deciduous teeth

 dens in dente

 enamel clefts

 macrodontia – all teeth enlarged

 microdontia – all teeth small

 taurodontism.

• Developmental dental anomalies may:

 exist in isolation or

 be associated with extraoral clinical manifestations in syndromes;

and they can be

 due to the action of teratogens, or

 of genetic origin.

• Dilaceration: bent root/tooth is typically acquired and affects mainly the

permanent incisors.
• In some cultures, tooth shape is deliberately altered for cosmetic or
other reasons.

Box 2.34  Main causes of anomalies of tooth shape

Infections
Trauma
Cancer therapies
Genetic

Figure 2.134  Tooth shape anomaly: peg-shaped lateral incisor.

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Tooth shape anomalies (continued)

Causes of genetic dental anomalies may include:
• Any interference with developmental processes can lead to clinical
anomalies and defects and some occasionally even result in tumours
arising from dental epithelial cells (odontogenic tumours).
• Genetic anomalies of enamel or dentine formation include defects of:
 structural proteins of enamel or dentine matrices, or

 the mineralization process.

• Amelogenesis imperfecta (AI) – the genetic disorder of enamel

formation has several forms. Defective enamel may also be seen in
several syndromes, and in metabolic disorders with known gene
mutations.
• Dentinogenesis imperfecta (DI) is a group of inherited alterations in
dentine formation. Abnormal dentine may also be a variable feature of
syndromes such as osteogenesis imperfecta.

Causes of acquired dental anomalies may include:

• Trauma
• Childhood infections
• Anticancer treatments
• Chronic fluoride intoxication
• Molar–incisor hypomineralization (MIH), which is defined as a
hypomineralization of systemic origin of one to four permanent first
molars frequently associated with affected incisors. MIH molars are
fragile and caries can develop very easily in them.

Trismus
Keypoints
• Trismus is an inability to open the mouth due to muscle spasm, but the
term is commonly used for any cause of restriction in mouth opening/
mandibular movement.
• Limited opening of the jaw is usually due to extra-articular disease with
masticatory muscle spasm secondary to stress, trauma or local infection
(e.g. pericoronitis around a partially erupted mandibular third molar).
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 Chapter 2 • Differential diagnosis by signs and symptoms

Figure 2.135  Trismus in oral submucous fibrosis in a betel chewer. The palate is
also affected.

• Occasionally, trismus is caused by joint (intra-articular) disease, or

conditions affecting the soft tissues such as scarring, infiltrating
neoplasms or oral submucous fibrosis (OSMF) (Figure 2.135).

Box 2.35  Main causes of trismus

Infections
Trauma
Submucous fibrosis
Neoplasms

Causes of acute trismus may include:

• Infection
 pericoronitis

 odontogenic abscess with soft tissue spread involving masticatory

muscles
 infratemporal fossa

 submasseteric space

 lateral pharyngeal space

 submandibular space

 sublingual space

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Trismus (continued)
 extension to neck
 Ludwig angina
 tonsillar or pharyngeal infection

 otitis

 tetanus

• Trauma
 mandible

 mid-face

 zygomatic arch impingement

 facial soft tissues

 postoperative

– wisdom teeth removal

– other jaw and oral surgery
– associated with haematoma
• Drug related
 extra-pyramidal reaction to anti-emetics

 malignant hyperthermia

• TMD – myofacial pain, bruxism.

Causes of subacute trismus may include:

• Tumour infiltration of muscles
 buccal

 retromolar

 tonsillar

 floor of mouth

 infratemporal fossa.

Causes of chronic trismus may include:

• Scar formation
 post-trauma or burn

 post-surgery

 post-radiotherapy

• Submucous fibrosis
• Scleroderma
• Post-traumatic (TMJ)
• TMJ ankylosis.
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 Chapter 2 • Differential diagnosis by signs and symptoms

Trismus

Recent trauma
Acute? Yes to head, TMJ Yes
or elsewhere?

Consider pericoronitis,
Head and neck odontogenic, TMJ, ear,
No Yes
infection? parotid or fascial
space infections

Radiation to
Yes Consider radiation
head and neck?
complications or Head and neck
tumour recurrence trauma?
No

Consider TMJ, zygomatic Yes No

or other trauma
Consider scarring,
tumour infiltration,
OSMF, scleroderma Consider tetanus or
or TMJ pathology drug reaction

Figure 2.136  Algorithm for trismus.

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 Differential diagnosis by site
3
Keypoints
• Few lesions affect only a single oral site: for example, cleft palate
affects only the palate.
• Some lesions affect mainly one site; erythema migrans (geographic
tongue), for example, almost exclusively affects the dorsum of tongue.
• Other conditions have a predilection for a limited number of sites;
pemphigoid, for example, affects mainly the gingivae while burning
mouth syndrome affects mainly the anterior tongue.
• Many disorders can affect almost any oral site; lichen planus, for
example, can affect most oral sites, and oral pain can appear in
any area.

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Cervical lymph node disease

Cervical lymph nodes must be examined in every patient. Though most causes
of enlargement (lymphadenopathy) are inflammatory (lymphadenitis), espe-
cially arising from local infection; others may be caused by malignant disease
(Figure 3.1) – either local, distant or systemic – or other serious causes.
Infection (the usual cause) may be:
• local viral or bacterial (dental, face, scalp, ear, nose or throat): including
staphylococcal and non-tuberculous mycobacterial lymphadenitis
• systemic
 viral glandular fever syndromes (EBV, CMV, HIV, HHV-6

[human herpesvirus 6]), and rubella

 tuberculosis or other mycobacterial infections, other bacterial

infections (brucella, cat-scratch fever, syphilis)

 parasitic, e.g. toxoplasmosis

 others, e.g. Kawasaki disease (mucocutaneous lymph node

syndrome; MLNS).
Other inflammatory causes may be:
• granulomatous disorders (e.g. sarcoidosis, Crohn disease, orofacial
granulomatosis)
• connective tissue diseases.
Malignant disease may be:
• local (oral, scalp, parotid, ear, nose or throat usually; rarely thyroid)
• systemic: carcinomas, lymphomas, leukaemias, Langerhans cell
his­tiocytosis – especially Letterer–Siwe disease, Wegener
granulomatosis.
Drugs – particularly phenytoin – may also be a cause.
Keypoints
• Lymphadenopathy is the term used when one or more lymph nodes
enlarge or swell.
• Lymph nodes swell mainly in inflammatory or neoplastic disorders.
• Lymph nodes that swell because of an inflammatory cause are often
tender but remain mobile (lymphadenitis).
• Lymph nodes that swell because of malignant involvement may become
hard and fixed.

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 Chapter 3 • Differential diagnosis by site

• It is crucial to establish whether only the regional (cervical) lymph

nodes alone are involved, or if there is generalized lymphadenopathy.
• Cervical lymph nodes may enlarge in some systemic disorders – when
there is typically generalized lymphadenopathy, and there may also be
hepato- and/or splenomegaly.

Causes may include:

• Inflammatory causes:
 infection (the usual cause)

 local viral (e.g. herpes simplex infections) or bacterial (dental, scalp,

ear, nose or throat) – including cat-scratch fever, staphylococcal

lymphadenitis and cervicofacial actinomycosis (Figure 3.2)

Figure 3.1  Neck lesion: lymphoma presenting as upper cervical lymph node
enlargement.

Figure 3.2  Neck lesion: actinomycosis showing purplish swelling in the typical
location.
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Cervical lymph node disease (continued)

 systemic: viral, e.g. infectious mononucleosis, cytomegalovirus, or
HIV infection; bacterial, including syphilis, tuberculosis, brucellosis;
fungal, rarely; parasitic, toxoplasmosis; Kawasaki disease
(mucocutaneous lymph node syndrome)
 others: sarcoidosis, Crohn disease, orofacial granulomatosis,

connective tissue diseases

• Malignant disease:
 local (oral, scalp, ear, nose or throat usually; rarely thyroid)

 systemic: leukaemias and lymphomas, carcinomas, Letterer–Siwe

disease
• Drugs:
 particularly phenytoin.

Clinical features:
 lymphadenitis: discrete tender, mobile, enlarged firm nodes; rarely

suppurate
 metastases: discrete or matted, fixed, enlarged, hard nodes (rubbery

in lymphomas); may ulcerate.

Investigations:
 culture and sensitivity testing, if infection is suspected

 search for lesion in drainage area (imaging if necessary)

 blood picture; monospot test or toxoplasma serological profile (TSP)

 fine needle aspiration biopsy (FNAB) or biopsy if neoplasm

suspected.
Diagnosis: see above.
Management:
 treat cause

 if oral disease is ruled out, then referral to appropriate health

provider is needed

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 Chapter 3 • Differential diagnosis by site

Salivary gland disease

Keypoints
• Salivary gland disease may present with swelling, pain or mouth
dryness (hyposalivation).
• Swelling may be obstructive, inflammatory, neoplastic or idiopathic
(e.g. sialosis).
• Pain may be due to obstructive, inflammatory, or neoplastic conditions.
• Dryness may be iatrogenic – for example after salivary gland
irradiation, chemotherapy or graft-versus-host disease, or due to
inflammatory disease such as Sjögren syndrome, or sarcoidosis.
Causes may include:
• Swellings:
 ductal obstruction (e.g. by calculus or tumour)

 inflammatory

a actinomycosis
b ascending (acute suppurative) sialadenitis
c HIV salivary gland disease
d IgG4 syndrome
e lymphadenitis
f mumps
g recurrent sialadenitis
h sarcoidosis
i Sjögren syndrome
j tuberculosis
 neoplasms

 other causes

a deposits: amyloidosis; haemochromatosis

b Mikulicz disease (lymphoepithelial lesion and syndrome, now
known to be IgG4 syndrome)
c sialosis (sialadenosis)
d drug-associated (see also)
• Salivary gland pain:
 duct obstruction (stones or other causes)

 inflammatory

a acute bacterial sialadenitis

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Salivary gland disease (continued)

b viral sialadenitis: HIV sialadenitis; EBV sialadenitis;
HCV sialadenitis; mumps
c recurrent sialadenitis
d Sjögren syndrome
 neoplastic (salivary gland malignant tumours)

 drug-associated (e.g. chlorhexidine, see also)

• Dryness:
 dehydration

 iatrogenic

drugs
irradiation
graft-versus-host disease
 diseases affecting salivary glands

sarcoidosis
Sjögren syndrome and IgG4 syndrome
viral infections (e.g. EBV; HCV; HIV).

Acute bacterial (ascending) sialadenitis

Rare, except when following hyposalivation.
Typical orofacial symptoms and signs: painful swelling of one gland only,
with red, shiny overlying skin, trismus, and purulent discharge from duct
(Figures 3.3, 3.4).
Main oral sites affected: parotid gland.
Aetiopathogenesis: usually a bacterial infection ascends the duct of a
reduced- or non-functioning salivary gland. Infectious agents include pneu-
mococci, Staphylococcus aureus or viridans streptococci.
Gender predominance: male.
Age predominance: older adults.
Extraoral possible lesions: none.
Main associated conditions: dehydration; poor oral hygiene.
Differential diagnosis: other causes of sialadenitis: mainly mumps.
Investigations: purulent exudate for culture and sensitivities.
Main diagnostic criteria: clinical features.
Main treatments: antimicrobials (flucloxacillin if staphylococcal and not aller-
gic to penicillin); sialogogues (saliva stimulants such as chewing gum or
pilocarpine).
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 Chapter 3 • Differential diagnosis by site

Figure 3.3  Salivary disease: parotitis showing enlarged left parotid gland.

Figure 3.4  Salivary disease: parotitis, intraorally showing purulent discharge from
Stensen duct.

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Salivary gland disease (continued)

Mucocele
Common.
Typical orofacial symptoms and signs: dome-shaped, bluish, translucent,
fluctuant, painless swelling, usually <10 mm diameter (Figure 3.5) which
may rupture. Recur frequently. Deeper mucoceles are less common, more
persistent and are often retention cysts (Figure 3.6).
Main oral sites affected: lower lip mainly. Superficial mucoceles are small
intra-epithelial lesions (<5 mm diameter) sometimes simulating a vesicu-
lobullous disorder but usually producing a small vesicle only; seen often in
the soft palate. Ranula is the term used for the ‘frog belly’ appearance
of a large retention mucocele in the floor of the mouth often arising from
the sublingual gland and, rarely, burrowing through the mylohyoid muscle
(plunging ranula).
Aetiopathogenesis: usually extravasation of mucus from a damaged minor
salivary gland duct; rarely retention of mucus within a salivary gland or its
duct.
Gender predominance: none.
Age predominance: young people.
Extraoral possible lesions: none except neck swelling and airway obstruction
if plunging ranula.
Main associated conditions: superficial mucoceles may be seen in lichen
planus or Graft versus host disease.
Differential diagnosis: diagnosis is clear-cut but neoplasm must be excluded,
particularly in the upper lip.
Investigations: microscopic features.
Main diagnostic criteria: clinical history and features.
Main treatments: if asymptomatic and small, observe; otherwise, use cryo-
surgery, laser ablation, micro-marsupialization or excision. Some lesions
spontaneously resolve. Systemic gamma linolenic acid (evening primrose
oil) has also been used.

Mumps (acute viral sialadenitis)

This is more common in childhood if vaccination with MMR (mumps, measles
and rubella vaccine) is not taken.

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 Chapter 3 • Differential diagnosis by site

Figure 3.5  Salivary disease: mucocele in a typical location – the lower

labial mucosa.

Figure 3.6  Salivary disease: mucocele in the floor of mouth (ranula).

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Salivary gland disease (continued)

Typical orofacial symptoms and signs: incubation period 14–21 days. Infec-
tions are often subclinical. Malaise, fever, anorexia and sialadenitis – painful,
diffuse swelling of one/both parotids and sometimes submandibulars may
be seen (Figure 3.7). Saliva is non-purulent but the duct is inflamed.
Trismus and occasionally dry mouth may be present.
Main oral sites affected: parotids bilaterally usually.
Aetiopathogenesis: mumps virus; rarely Coxsackie, ECHO, EBV or HIV
infection.
Gender predominance: none.
Age predominance: typically in children.
Extraoral possible lesions: complications are uncommon but may include
pancreatitis, encephalitis, orchitis, oophoritis and deafness.
Main associated conditions: as above.
Differential diagnosis: differentiate from obstructive and/or bacterial sialad-
enitis and recurrent juvenile parotitis mainly.
Investigations: mumps antibody titres (rarely needed); serum amylases or
lipases (occasionally); ultrasound.
Main diagnostic criteria: clinical history and features.
Main treatments: symptomatic (reduce fever, pain and malaise with para-
cetamol, and maintain hydration).

Necrotizing sialometaplasia (see page 289)

Salivary gland neoplasms
These are uncommon. Classification of the most common salivary
neoplasms is:
• Adenomas:
 pleomorphic adenoma (PA: mixed tumour)

 Warthin tumour (adenolymphoma or papillary cystadenoma

lymphomatosum)
 ‘monomorphic’: adenolymphoma/oncocytic adenoma/ (canalicular,

basal cell, others)

• Others:
 polymorphous low-grade adenocarcinoma

 mucoepidermoid carcinoma

 acinic cell carcinoma

 adenoid cystic and other carcinomas.

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 Chapter 3 • Differential diagnosis by site

Typical orofacial symptoms and signs: asymptomatic, firm and sometimes

nodular swelling in one gland (usually parotid) and possible eversion of ear
lobe (Figures 3.8). Warthin tumour may be bilateral. No hyposalivation.
Malignant neoplasms classically may grow rapidly, may cause pain, may
ulcerate and may involve nerves (e.g. facial palsy).
Figure 3.7  Salivary disease:
mumps – bilateral sialadenitis.

Figure 3.8  Salivary disease:

neoplasm; pleomorphic adenoma
in tail of parotid.

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Salivary gland disease (continued)

Main oral sites affected: most tumours involve the parotid (75%), where most
are benign pleomorphic adenomas (60%). Most other salivary tumours are
in the minor glands, where many are malignant (60%), often arising from
palatal glands (Figures 3.9–3.11). Few tumours are in the submandibular
or sublingual glands. Submandibular tumours can be benign or malignant.
Most sublingual gland tumours are malignant.
Neoplasms in major salivary glands 
Aetiopathogenesis: unknown, but age smoking, irradiation and viruses have
been implicated; more controversial is the possible effect of mobile
telephones.
Gender predominance: none.
Age predominance: middle and old age.
Extraoral possible lesions: none except for enlarged lymph nodes due to
metastasis.
Main associated conditions: usually none but a weak association with breast
cancer.
Differential diagnosis: differentiate from other neoplasms such as lympho-
mas or metastases, and from non-neoplastic salivary gland swellings.
Investigations: ultrasound and fine needle aspiration biopsy (FNAB).
Micro­scopy after parotidectomy (open biopsy may allow seeding and
recurrence).
Main diagnostic criteria: clinical, advanced imaging and microscopy.
Main treatments: surgical excision; radiotherapy also for some.
Intraoral (minor) salivary gland neoplasms 
• Intraoral salivary gland neoplasms are less common than neoplasms in
major glands, but a higher proportion are malignant.
• Mucoepidermoid carcinoma is the most common intraoral salivary
neoplasm, but adenoid cystic carcinoma and pleomorphic adenoma
(PA) are relatively common in the mouth.
• Salivary gland tumours in the tongue are usually malignant – and are
especially adenoid cystic carcinoma.
• Salivary gland tumours in the sublingual gland are usually malignant
but are rare.
• Salivary gland tumours in the lips are usually seen in the upper lip but
are typically benign (pleomorphic or other adenoma).
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 Chapter 3 • Differential diagnosis by site

Figure 3.9  Salivary disease: neoplasm in palatal minor glands.

Figure 3.10  Salivary disease: neoplasm – malignant tumour in sublingual gland.

Most tumours arising there are malignant.

Figure 3.11  Salivary disease: neoplasm.

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Salivary gland disease (continued)

Typical orofacial symptoms and signs: Pleomorphic adenomas are typically
rubbery and often lobulated (Figures 3.12, 3.13); benign neoplasms form
painless swellings. Malignant tumours are not initially distinguishable clini-
cally from benign tumours but, in their later stages, are often painful and
ulcerate, invade perineurally and they metastasize to upper cervical lymph
nodes.
Main oral sites affected: the palate is the intraoral site of predilection.
Aetiopathogenesis: unknown.
Gender predominance: females.
Age predominance: older persons.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: from other causes of lumps or ulcers, particularly:
 lower lip salivary tumours – from mucocele, benign connective

tissue tumours
 tongue salivary tumours – from carcinoma, benign connective tissue

tumours
 palatal salivary tumours – from oral carcinoma, benign connective

tissue tumours, lymphomas, antral carcinoma or necrotizing

sialometaplasia.
Main diagnostic criteria: ultrasound, advanced imaging and microscopy.
Main treatments: wide excision; radiation treatment if perineural invasion,
and microscopic examination.
Sarcoidosis
Uncommon granulomatous condition.
Typical orofacial symptoms and signs: salivary gland swelling usually
painless, bilateral (Figure 3.14). Often hyposalivation is present. May be
cervical lymphoadenopathy; mucosal nodules; gingival hyperplasia; or labial
swelling.
Main oral sites affected: lips, palate, major salivary glands.
Aetiopathogenesis: unknown.
Gender predominance: female.
Age predominance: adult.

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 Chapter 3 • Differential diagnosis by site

Figure 3.12  Salivary disease: neoplasm presenting as palatal swelling.

Figure 3.13  Salivary disease: neoplasm.

Figure 3.14  Salivary disease: sarcoidosis

presenting with parotid swelling.

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Salivary gland disease (continued)

Extraoral possible lesions: can affect any organ, typically lungs and lymph
nodes (e.g. hilar nodes); also ocular (e.g. uveitis) and skin (e.g. erythema
nodosum) lesions. The rare combination of parotitis, anterior uveitis, VIIth
cranial nerve paralysis and fever is termed uveoparotid fever (Heerfordt–
Waldenstrom) syndrome.
Main associated conditions: sometimes autoimmune disorders.
Differential diagnosis: from other causes of salivary gland swelling (par­
ticularly sialosis, Sjögren syndrome and IgG4 disease, hyposalivation, meta-
static disease, lymphomas, Wegener granulomatosis, rheumatoid nodules,
varicella–zoster infection and atypical infections such as Mycobacterium
avium complex, cytomegalovirus, and cryptococcosis.
Investigations: lesional biopsy; chest radiograph; gallium scan, raised serum
angiotensin-converting enzyme (SACE) and adenosine deaminase. Vitamin
D and prolactin levels are often increased.
Main diagnostic criteria: microscopy and SACE.
Main treatments: corticosteroids, methotrexate or other immunosuppressive
drugs if lungs or eyes are involved, or if there is hypercalcaemia.

Sialosis
Typical orofacial symptoms and signs: painless, usually bilateral salivary
gland swelling (Figure 3.15).
Main oral sites affected: parotids.
Aetiopathogenesis: the common feature is autonomic dysfunction. Frequently
idiopathic; known causes include:
 neurogenic: various drugs, such as isoprenaline

 dystrophic-metabolic: anorexia–bulimia, alcoholic cirrhosis, diabetes,

malnutrition, thyroid disease, acromegaly and pregnancy.

Gender predominance: male but depends on cause.
Age predominance: older patients.
Extraoral possible lesions: dependent upon aetiopathogenesis.
Main associated conditions: see aetiopathogenesis.
Differential diagnosis: sarcoidosis, Sjögren syndrome, IgG4 disease and
Warthin tumour mainly.
Investigations: ultrasound, MRI; blood glucose, liver function tests, immu-
noglobulins; possibly growth hormone levels.

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 Chapter 3 • Differential diagnosis by site

Main diagnostic criteria: clinical, ultrasound, MRI and exclusion of other

diagnoses.
Main treatments: identify and treat predisposing cause.

Sjögren syndrome
Uncommon, the cause is unknown but it is immunological and possibly viral.
The common features are dry mouth and dry eyes: joint and other problems
may be associated.
Typical orofacial symptoms and signs: saliva is frothy and not pooling; the
mucosa may be parchment-like with food debris (Figure 3.16), the lips

Figure 3.15  Salivary disease: sialosis (sialadenosis) – bilateral painless swellings.

Figure 3.16  Salivary disease: Sjögren syndrome; dry mouth and food residues.

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Salivary gland disease (continued)

often dry (Figure 3.17) and the tongue lobulated and depapillated (Figure
3.18). There may be complaints of dry mouth (hyposalivation): difficulty in
eating dry foods, disturbed taste, and disturbed speech and swallowing.

Figure 3.17  Salivary disease: Sjögren syndrome; dry lips.

Figure 3.18  Salivary disease: Sjögren syndrome; dry and lobulated tongue.

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 Chapter 3 • Differential diagnosis by site

Rampant caries, candidosis and recurrent sialadenitis may be seen (Figures

3.19 and 3.20). Salivary and lachrymal glands may sometimes swell

Figure 3.19  Salivary disease: Sjögren syndrome; caries.

Figure 3.20  Salivary disease: Sjögren syndrome; candidosis (angular stomatitis).

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Salivary gland disease (continued)

(Figures 3.21, 3.22). There may be conjunctival dryness and redness
(termed injection) (Figure 3.23) and rheumatoid disease (Figure 3.24).
Aetiopathogenesis: autoimmune inflammatory exocrinopathy.
Gender predominance: women.
Age predominance: middle age or older.
Extraoral possible lesions: dry eyes (keratoconjunctivitis sicca): initially
asymptomatic, later gritty sensation, itching, soreness or inability to cry.
Swollen lachrymal glands. Extraglandular disease may precede exocrine
problems by years, and includes fatiguability, fever and Raynaud phenom-
enon. Late complications include:
 glomerulonephritis

 lymphoma.

Main associated conditions: there is no connective tissue disease in primary

(SS-1, sometimes termed sicca syndrome) but, in secondary Sjögren
syndrome (SS-2) there is typically rheumatoid arthritis or less frequently
primary biliary cirrhosis, and occasionally other autoimmune disorders.
Sjögren syndrome predisposes especially to B cell non-Hodgkin lymphoma
(NHL) – a mucosa-associated lymphoid tissue (MALT) malignancy. The risk
is greatest in SS-1; affects up to 5% of patients and is seen mainly in
mucosal extranodal sites (salivary glands – especially the parotids, mouth,
skin, nodes, stomach, lung). Lymphoma is a high risk in those with persist-
ent salivary gland swelling, splenomegaly or lymphadenopathy. Diagnosis
of lymphoma is best by:
 ultrasonography

 high-resolution CT

 MRI

 MRI contrast sialography (gadolinium MRI with fat subtraction)

 histology.

Most of these lymphomas are relatively low-grade and require either no

treatment apart from regular follow-up or low-dose chemotherapy.

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 Chapter 3 • Differential diagnosis by site

Figure 3.21  Salivary disease: Sjögren Figure 3.22  Salivary disease:

syndrome; salivary gland swelling and Sjögren syndrome; salivary gland
ocular involvement. swelling.

Figure 3.23  Salivary disease: Sjögren Figure 3.24  Salivary disease:

syndrome; dry eyes (keratoconjunctivitis Sjögren syndrome; rheumatoid
sicca). arthritis showing finger ulnar
deviations.
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Salivary gland disease (continued)

Differential diagnosis: dry mouth can result from many other causes. Similar
sicca syndromes may be seen in HCV or HIV disease, IgG4 syndrome, or
in graft-versus-host disease (GVHD).
Investigations: salivary flow rates (reduced); auto-antibodies, especially rheu-
matoid factor, Ro (SS-A) and La (SS-B) antibodies; serum IgG4 levels, and
ultrasound. Labial salivary gland biopsy is carried out in some centres and
this and IgG4 levels are most helpful in Ro/La negative patients. Sialography
and/or scintigraphy are occasionally employed but are largely superseded
by ultrasound.
Main diagnostic criteria: clinical features plus Ro (SS-A) and La (SS-B) anti-
bodies, and ultrasound; occasionally labial salivary gland biopsy.
Main treatments: control underlying disease if possible (e.g. ciclosporin,
azathioprine, hydroxychloroquine and anti-B cell monoclonals such as the
anti-CD20 rituximab)
 dry eyes – methylcellulose eye drops or rarely ligation or cautery of

nasolacrimal duct
 dry mouth:

– saliva substitutes (mouth-wetting agents)

– saliva stimulants (sialogogues); sugar-free chewing gum, or
drugs (pilocarpine, cevimeline, anetholetrithione or bethanecol)
may be used to stimulate salivation
– interferon-alpha
– preventive dental care (oral hygiene, limitation of sucrose and
other sugar intake, use of fluorides, amorphous calcium
phosphate, chlorhexidine)
– treat infections.
IgG4 syndrome
IgG4 syndrome (‘IgG4 related systemic sclerosing disease’, ‘IgG4-related
autoimmune disease’, ‘IgG4-related systemic disease’, ‘IgG4-positive multi-
organ lymphoproliferative syndrome’) often manifests with enlarged salivary
glands (previously called Mikulicz disease or Kuttner tumour [sclerosing
sialadenitis]) and one-third also suffer from dry eyes and dry mouth and
arthralgias, so for many years this was considered a subgroup of Sjögren
syndrome.

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 Chapter 3 • Differential diagnosis by site

IgG4 syndrome affects mainly middle-aged men. Many other organs and
tissues are also involved, including pancreas (the most commonly affected
tissue), gall bladder, bile duct, retroperitoneum, kidneys, lung, prostate,
lymph nodes, breast, and thyroid and pituitary glands.
Patients have neither anti-Ro/SS-A nor anti-La/SS-B autoantibodies but
they have low titres of rheumatoid factor (RF), antinuclear autoantibodies
(ANA), and decreased serum complement. Treatment includes systemic
corticosteroids or anti-CD20 therapy (rituximab).

Lip lesions
Keypoints
• Lip lesions affecting the vermilion are often termed cheilitis.
• Cheilitis can have a wide range of causes.
• Common forms of cheilitis are traumatic, infective or follow
exposure to UV radiation, low humidity, or temperature extremes
(cold and heat).
• Blistering of the vermilion is commonly caused by a burn or herpes
labialis (‘cold sores’).
• Blistering of the labial mucosa is commonly caused by mucoceles.
• Coloured lesions of the lips are usually brown (labial melanotic
macules), red (telangiectasia) or purple/blue (angiomas).
• Bleeding from the lip may be from trauma or a fissure or
vesiculobullous disorder such as erythema multiforme or pemphigus.
• Soreness of the lips may be seen in any type of cheilitis, especially
factitious, allergic or infective varieties.
• White lesions of the lips are seen in actinic cheilitis, leukoplakia,
candidosis and lichen planus.
• Ulceration of the lips can have many causes – systemic, malignant, local
irritation, aphthae or drugs, but cancer and pemphigus are the most
serious.
• Lumps/swelling of the lips can be seen after trauma, in allergies, in
granulomatous disorders, neoplasms and from foreign bodies.

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Lip lesions (continued)

Actinic burns and cheilitis
Mainly seen in fair-skinned individuals exposed in sunny climes or at high
altitude.
Typical orofacial symptoms and signs: erythema, oedema, vesiculation and
occasionally haemorrhage typify burns (Figures 3.25, 3.26); later whitish
lesions or keratosis characterize actinic cheilitis – which is potentially
malignant.
Main oral sites affected: lower lip.
Aetiopathogenesis: shortwave ultraviolet (UV) light (sunlight may also trigger
herpes labialis and lupus erythematosus).
Gender predominance: male.
Age predominance: old age.
Extraoral possible lesions: cutaneous cancers on other areas of the face and
exposed skin.
Differential diagnosis: from other causes of burns (e.g. friction and heat).
Investigations: biopsy.
Main diagnostic criteria: history and clinical features; biopsy persistent
lesions.
Main treatments: prophylaxis – reduce sun exposure; bland or barrier creams
(Uvistat); topical bleomycin, or lip shave.
Allergic angioedema
Uncommon: mainly seen in those with allergic (atopic) tendency.
Typical orofacial symptoms and signs: rapid development of oedematous
swelling (Figure 3.27).
Main oral sites affected: lip(s) and tongue; oedema may spread to involve
the neck and hazard the airway.
Aetiopathogenesis: type 1 allergic response.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: atopy (allergic rhinitis, hayfever or eczema).
Main associated conditions: as above.
Differential diagnosis: from hereditary angioedema (C1 esterase inhibitor
deficiency), and other causes of diffuse facial swelling including: oedema

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Figure 3.25  Lip lesion: actinic cheilitis from severe acute sun-exposure.

Figure 3.26  Lip lesion: actinic cheilitis (solar elastosis) with early carcinoma on
the right.

Figure 3.27  Lip lesion: angioedema causing facial and labial swelling.

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Lip lesions (continued)

from trauma, infection or insect bite; surgical emphysema; Crohn disease,
orofacial granulomatosis; sarcoidosis; cheilitis glandularis; lymphangioma;
haemangioma.
Investigations: allergy testing, C1 esterase inhibitor levels.
Main diagnostic criteria: history of atopic disease and/or exposure to aller-
gen; allergy testing (prick test).
Main treatments: mild angioedema – antihistamines; severe angioedema –
intramuscular adrenaline, and intravenous corticosteroids.

Angioma (haemangioma)
These are fairly common oral lesions.
Typical orofacial symptoms and signs: a painless reddish, bluish or purplish
soft vascular lesion which blanches on pressure (diascopy) (Figures
3.28, 3.29).
Main oral sites affected: most common on the lip, tongue, or buccal mucosa
as painless reddish, or often bluish or purplish soft lesions which usually
blanch on pressure, are fluctuant to palpation, are level with the mucosa
or have a lobulated or raised surface. Haemangiomas are at risk from
trauma and prone to excessive bleeding if damaged (e.g. during tooth
extraction). Occasionally, oral haemangiomas calcify (phlebolithiasis).
Aetiopathogenesis: haemangiomas represent hamartomas or vascular
anomalies. In children, they are usually congenital and developmental in
origin. In adults, they may be acquired.
Gender predominance: female.
Age predominance: many haemangiomas appear in infancy, most by the
age of 2 years, grow slowly and, by age 10, the majority have involuted
(resolved). In adults, however, haemangiomas rarely involute spontane-
ously; rather they remain static or slowly enlarge.
Extraoral possible lesions: haemangiomas are typically seen in isolation but
a few may be multiple and/or part of a wider syndrome such as:
 Sturge–Weber syndrome (angioma that extends deeply and rarely

involves the ipsilateral meninges, producing a facial angioma and

seizure disorder, sometimes with learning impairment)

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Figure 3.28  Lip lesion: haemangioma.

Figure 3.29  Lip lesion: haemangioma as in Figure 3.28 after diascopy.

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Lip lesions (continued)

 blue rubber bleb naevus syndrome (BRBNS) – multiple cutaneous
venous malformations in association with visceral lesions, most
commonly affecting the GI tract
 Maffucci syndrome – multiple angiomas with enchondromas

 Dandy–Walker syndrome – a congenital brain malformation involving

the cerebellum, or other posterior cranial fossa malformations.

Main associated conditions: as above.
Differential diagnosis: varicosities, pyogenic granuloma, lymphangioma,
Kaposi sarcoma and epithelioid angiomatosis.
Investigations: for large angiomas, angiography may be needed rather than
biopsy. After intravenous administration of contrast medium, enhancement
is observed in haemangiomas in areas corresponding to those with high
signal on T2-weighted MRI.
Main diagnostic criteria: angiomas blanch on pressure (diascopy), or contain
blood on aspiration with a needle and syringe.
Main treatments: most angiomas are small, of no consequence and need no
treatment but if they do for aesthetic or functional reasons or because of
previous episodes of significant bleeding, they respond well to cryosurgery,
laser ablation or intralesional injections of corticosteroids, sclerosing
agents, interferon alpha, or systemic corticosteroids or propranolol. Very
large haemangiomas may need to be treated with ligation or embolization
– mainly for cosmetic reasons or if bleeding is troublesome.
Carcinoma
Uncommon in England and Wales (600 cases/year) and declining: much
more common nearer the Equator, especially in white-skinned people.
Typical orofacial symptoms and signs: thickening, induration, crusting or
ulceration, usually at vermilion border of lower lip just to one side of midline
(Figures 3.30, 3.31). There is late involvement of the submental and other
lymph nodes.
Main oral sites affected: lower lip.
Aetiopathogenesis: predisposing factors include UV irradiation (sun), immu-
nosuppression and tobacco.

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Figure 3.30  Lip lesion: carcinoma. This is a typical location and seen mainly in
sun-exposed, older male Caucasian smokers.

Figure 3.31  Lip lesion: advanced carcinoma.

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Lip lesions (continued)

Gender predominance: male.
Age predominance: old age.
Extraoral possible lesions: cutaneous cancers on face and other sun-
exposed skin.
Main associated conditions: xeroderma pigmentosum and discoid lupus
erythematosus predisposed.
Differential diagnosis: from herpes labialis, keratoacanthoma, and (rarely)
basal cell carcinoma (on skin), molluscum contagiosum.
Investigations: biopsy. Fibreoptic pharyngolaryngoscopy with autofluores-
cence (symptom-directed bronchoscopy/oesophagoscopy); ultrasound-
guided fine needle aspiration biopsy of any neck mass; staging – supported
by MRI (or CT) from skull base to sternoclavicular joints (plus USgFNA and/
or FDG-PET if anything equivocal); CT thorax.
Main diagnostic criteria: biopsy is confirmatory.
Main treatments: surgery (wedge resection or lip shave) or irradiation. The
prognosis is good: 70% 5-year survival.

Discoid lupus erythematosus (DLE)

Rare. DLE may be categorized as:
• Localized DLE – the head and neck only are involved.
• Widespread DLE – other areas are affected, even if the head and neck
are also involved. People with widespread disease may have
abnormalities of blood or positive serology, and are more likely to
develop SLE (systemic lupus erythematosus).
Typical orofacial symptoms and signs: lesions on vermilion border are
scaly and crusting. Intraoral lesions have central atrophic and often indu-
rated red area with border of radiating white striae, and peripheral tel-
angiectasia (Figure 3.32). There is a small predisposition to carcinoma of
the lip.
Main oral sites affected: buccal mucosa, palate/alveolar ridges and lips
(almost always the lower lip).
Aetiopathogenesis: unclear: drugs, hormones and viruses may contribute in
genetically predisposed persons.
Gender predominance: females.

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Figure 3.32  Lip lesion: discoid lupus erythematosus. Lesions can mimic lichen
planus and can be potentially malignant.

Age predominance: adults.

Extraoral possible lesions: the discoid rash is usually on the face with red
patches that are thick and often scaly, appearing red with a whitish, or at
least, lighter-coloured, scaly rim. As the patches heal they tend to scar. If
discoid lupus occurs on the scalp the hair will be lost, leaving permanent
bald areas.
Main associated conditions: none; discoid lupus is a type of lupus that tends
to be confined to the skin and mucosa and other organs in the body are
not involved.
Differential diagnosis: systemic lupus erythematosus, lichen planus, leuko-
plakia (keratosis), lichenoid white lesions and carcinoma.
Investigations: biopsy; serology to exclude SLE.
Main diagnostic criteria: histology.
Main treatments: topical corticosteroids (e.g. betamethasone valerate
0.1% or clobetasol cream) or tacrolimus; cryosurgery or excision of
localized lesions; follow-up because of increased risk for malignant
transformation.

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Lip lesions (continued)

Erythema multiforme
Uncommon.
Typical orofacial symptoms and signs: serosanguinous exudate on ulcerated
swollen lips, and ulcers (Figures 3.33, 3.34).
Main oral sites affected: lips and oral mucosa.
Aetiopathogenesis: putative reaction to microorganisms (herpes simplex,
mycoplasma), to drugs (e.g. NSAIDs, antimicrobials, sulphonamides, beta
blockers, dapsone, salicylates, tetracyclines) or to other factors.
Gender predominance: males.
Age predominance: young adult.
Extraoral possible lesions: may affect mouth alone, or skin and/or other
mucosa. The minor form affects only one or two mucosal sites and/or the
skin. The major form (Stevens–Johnson syndrome) affects more than two
mucosal sites and is widespread, with skin rashes, fever and toxicity.
Rashes are various but typically ‘target’ lesions or bullae. The most severe
form is toxic epidermal necrolysis (TEN) when the lesions affect most of
the body surface and the condition is life-threatening.
Main associated conditions: as above.
Differential diagnosis: from other lip lesions, and other causes of mouth
ulcers – particularly primary herpes stomatitis and pemphigus.
Investigations: history of exposure to agents and biopsy.
Main diagnostic criteria: clinical picture; biopsy sometimes helpful.
Main treatments: minor form – symptomatic treatment and systemic cortico­
steroids; major form – systemic corticosteroids or other immunomodulatory
drugs.

Exfoliative cheilitis (factitious cheilitis, le tic de lèvres)

An uncommon chronic superficial inflammatory disorder characterized by
hyperkeratosis and desquamation of the vermilion epithelium.
Typical orofacial symptoms and signs: persistent scaling of the lips.

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Figure 3.33  Lip lesion: erythema multiforme (patient’s fingers).

Figure 3.34  Lip lesion: erythema multiforme in a young boy showing blood-
encrusted swollen lips.

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Lip lesions (continued)

Main oral sites affected: often starts in the centre of the lower lip (Figures
3.35–3.38) and spreads to involve the whole of the lower or of both lips.
The patient may complain of irritation or burning and can be observed
frequently biting or sucking the lips. Lip scaling and crusting is more or less
confined to the vermilion border, persisting in varying severity for months
or years. There may be bizarre yellow hyperkeratotic or thick haemorrhagic
crusts.
Aetiopathogenesis: most patients seem to have a personality disorder. A
preoccupation with the lips is prevalent in some individuals. In some cases
it appears to start with chapping or with atopic eczema, and develops into
a habit tic. Many cases are thus thought to be factitious, caused by
repeated self-induced trauma such as repetitive biting, picking, lip sucking,
chewing or other manipulation of the lips. Exacerbations have been associ-
ated with stress.
Gender predominance: female.
Age predominance: children and young adults.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: actinic cheilitis, contact cheilitis, glandular cheilitis,
lupus erythematosus, Candida infections (where it is sometimes termed
cheilo-candidosis), and HIV infection.

Figure 3.35  Lip lesion: chapping.

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 Chapter 3 • Differential diagnosis by site

Figure 3.36  Lip lesion: cheilitis (factitious or artefactual- self-induced).

Figure 3.37  Lip lesion: cheilitis (the skin erythema beneath the lower lip is from
licking).

Figure 3.38  Lip lesion: cheilitis (exfoliative). Note also the crenated tongue, from
pressing on the teeth.
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Lip lesions (continued)

Investigations: biopsy is sometimes indicated and allergy testing for severe
cases.
Main diagnostic criteria: diagnosis is restricted to those few patients whose
cheilitis cannot be attributed to other causes, such as contact sensitization
or UV light.
Main treatments: some cases resolve spontaneously or with improved oral
hygiene. Reassurance and topical corticosteroids may be helpful but often
exfoliative cheilitis is refractory to treatment. When a factitial cause is sus-
pected, a psychiatric consultation and care may be beneficial; some improve
with psychotherapy and antianxiolytic or antidepressant treatment.
Hereditary angioedema
Rare.
Typical orofacial symptoms and signs: as in allergic angioedema (above) but
precipitated by trauma, e.g. dental treatment. There is high mortality in
some families.
Main oral sites affected: lips and tongue.
Aetiopathogenesis: genetic defect of the inhibitor of activated first component
of complement C1 (C1 esterase inhibitor); autosomal dominant inheritance
generally.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: sometimes abdominal pain and there may be
swelling of the extremities.
Main associated conditions: rarely this condition is acquired in lymphopro-
liferative disorders.
Differential diagnosis: acute allergic angioedema and other causes of facial
swelling.
Investigations: serum C1 esterase inhibitor and C4 levels.
Main diagnostic criteria: family history. C1 esterase inhibitor and C4 serum
levels are reduced.
Main treatments: recombinant C1 esterase inhibitor; androgenic steroids
(danazol; oxandrolone) kallikrein inhibitors (ecallantide) and bradykinin
receptor antagonists (icatibant).
Herpes labialis
Common, especially in immunocompromised patients.
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 Chapter 3 • Differential diagnosis by site

Typical orofacial symptoms and signs: prodromal paraesthesia or irritation.

Erythema, then vesicles at/near mucocutaneous junction of the lip (some-
times termed ‘cold sores’ or ‘fever blisters’: Figures 3.39–3.42). Heals in
7–10 days.
Main oral sites affected: mucocutaneous junction of the lip.
Aetiopathogenesis: herpes simplex virus (HSV), usually type 1. HSV latent in
trigeminal ganglion after primary infection is reactivated as herpes labialis
(‘cold sores’). It is precipitated by sun, trauma, menstruation, fever, HIV
disease, immunosuppression etc.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: zoster, impetigo.
Main diagnostic criteria: clinical.

Figure 3.39  Lip lesion: herpes labialis Figure 3.40  Lip lesion: herpes labialis
– early vesicles. – later scabbed lesion.

Figure 3.41  Lip lesion: herpes labialis Figure 3.42  Lip lesion: herpes labialis
showing multiple pustules. on another occasion in the same
patient shown in Figure 3.41.
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Lip lesions (continued)

Main treatments: aciclovir, or penciclovir cream applied in prodrome. Oral
aciclovir, valaciclovir, or famciclovir for frequent recurrences or immuno-
compromised; i.v. antivirals may be needed for severely immunocompro-
mised patients.

Herpes zoster (’shingles’)

Typical orofacial symptoms and signs: pain and rash in a trigeminal der-
matome (Figure 3.43) followed by ipsilateral oral vesicles, then mouth
ulcers.
Main oral sites affected: any trigeminal nerve division.
Aetiopathogenesis: varicella-zoster virus (VZV), latent in the sensory ganglion
after chickenpox (varicella) is reactivated mainly in older, or immunocom-
promised people, such as in HIV infection.
Gender predominance: none.
Age predominance: older adults (immunocompetent). Any age in
immunocompromised.
Extraoral possible lesions: see above.
Main associated conditions: none.
Differential diagnosis: pain – may simulate toothache; rash – differentiate
from HSV infection. Mouth ulcers.
Investigations: there is no immunological test of value. Smears show viral
damaged cells.
Main diagnostic criteria: clinical features.
Main treatments: analgesics; aciclovir or penciclovir cream to rash;
for immunocompromised patients consider using famciclovir’ valaciclovir
tablets or aciclovir tablets, or intravenous aciclovir/foscarnet.

Labial melanotic macule

Typical orofacial symptoms and signs: asymptomatic smooth brown pig-
mented macule <1 cm in diameter (Figure 3.44).
Main oral sites affected: lower lip vermilion.
Aetiopathogenesis: congenital or acquired lesions derived from
melanoblasts.
Gender predominance: none.
Age predominance: adult.
Extraoral possible lesions: none.
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 Chapter 3 • Differential diagnosis by site

Figure 3.43  Lip lesion: zoster (shingles) – intact vesicles and crusted lesions.
There is typically also, severe pain in the area.

Figure 3.44  Lip lesion: melanotic macule.

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Lip lesions (continued)

Main associated conditions: none.
Differential diagnosis: racial pigmentation, amalgam tattoo, drug-induced
hyperpigmentation, pigmented naevus, malignant melanoma, Peutz–
Jeghers, Laugier–Hunziker and other syndromes.
Investigations: biopsy is essential to exclude malignant melanoma.
Main diagnostic criteria: clinical supported by histology.
Main treatments: excision biopsy if concerned.

Mucocele
See Figure 3.45.
Orofacial granulomatosis (OFG; see also Crohn disease,
pages 224 and 398)
An uncommon but increasing condition. The cause of OFG is unknown but
it may be immunological; it is not thought to be inherited and it is not thought
to be infectious. It appears related to conditions such as Crohn disease,
which may affect the gut and other tissues. Some patients with OFG have
food or food additive intolerance or allergy: most commonly this is to cin-
namaldehyde, carnosine, monosodium glutamate, cocoa, carbone, or sunset
yellow.
Typical orofacial symptoms and signs:
 facial and/or labial swelling (Figure 3.46)

 angular stomatitis and/or cracked or fissured lips

 ulcers

 mucosal tags and/or cobblestoning

 gingival hyperplasia

 cervical lymphadenopathy.

Sometimes effects of malabsorption. Variants include:

 Miescher cheilitis (cheilitis granulomatosa) – where lip swelling is

seen in isolation.
 Melkersson–Rosenthal syndrome – facial swelling with fissured

tongue and facial palsy: however, features can appear at different

times or only two out of three being.
Main oral sites affected: lips.
Aetiopathogenesis: unknown. Some have gastrointestinal Crohn disease or
sarcoidosis; others a postulated reaction to food or other antigens (e.g.
196
cinnamaldehyde or benzoates.
 Chapter 3 • Differential diagnosis by site

Figure 3.45  Lip lesion:

mucocele (excise and
histopathologically examine
but it may recur).

Figure 3.46  Lip lesion:

granulomatous cheilitis
– persistent painless swelling.

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Lip lesions (continued)

Gender predominance: male.
Age predominance: young adults.
Extraoral possible lesions: see above; many ultimately manifest Crohn
disease elsewhere.
Main associated conditions: see above.
Differential diagnosis: Crohn disease or sarcoidosis, tuberculosis and foreign
body reactions, especially to cosmetic enlargement.
Investigations: blood tests, radiology, endoscopy and biopsy to exclude Crohn
disease, sarcoidosis, or tuberculosis.
Main diagnostic criteria: diagnosis is confirmed by lesional biopsy.
Main treatments: control by avoiding allergens, or by using medicines –
topical or intralesional corticosteroids; topical tacrolimus; occasionally sys-
temic steroids, sulfasalazine or clofazimine.

Peutz–Jeghers syndrome
Rare; ‘circumoral melanosis with intestinal polyposis’.
Typical orofacial symptoms and signs: multiple hyperpigmented brown
macules.
Main oral sites affected: perioral and on labial (lower lip mainly) and/or buccal
mucosa and gingivae (Figures 3.47, 3.48).
Aetiopathogenesis: autosomal dominant disorder.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: hyperpigmented brown macules around nose and
eyes and rarely on trunk and on the hands and feet. Gastrointestinal polyps
– usually benign and in small intestine, predisposing to intussusceptions
and sometimes malignancy (mainly gastrointestinal and pancreatic but also
liver, lungs, breast, ovaries, uterus, testicles and other organs).
Differential diagnosis: racial pigmentation, Addison disease, freckles (ephe-
lides) and Laugier–Hunziker syndrome (similar features but also with nail
hyperpigmentation).
Investigations: gastrointestinal imaging and biopsy.
Main diagnostic criteria: clinical features pathognomonic.
Main treatments: reassure or excise for histological confirmation. Genetic
consultation and counseling. Molecular genetic testing of STK11 (LKB1)
reveals disease-causing mutations in nearly all individuals who have a
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 Chapter 3 • Differential diagnosis by site

Figure 3.47  Lip lesions: Peutz–Jegher syndrome – multiple pigmented macules.

Figure 3.48  Lip and palatal lesions: Peutz–Jegher syndrome.

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Lip lesions (continued)

positive family history and approximately 90% of individuals who have no
family history. Cancer screening.

Pyogenic granuloma
Uncommon.
Typical orofacial symptoms and signs: small (<1 cm), red, painless
mass that bleeds easily, ulcerates and grows rapidly – especially in
pregnancy.
Main oral sites affected: gingival margin, tongue, or rarely the lip (Figures
3.49, 3.50).
Aetiopathogenesis: possibly reactive vascular lesion. Inflammatory infiltrate
is superimposed.
Gender predominance: none.
Age predominance: children and young adults.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: fibrous epulis, angiomatous proliferation, giant cell
lesion, chancre, carcinoma, Kaposi sarcoma.
Investigations: biopsy.
Main diagnostic criteria: histopathology.
Main treatments: excision.

Intraoral lesions
Keypoints
• Coloured lesions if red are usually vascular, inflammatory or atrophic.
Brown lesions are usually naevi; black lesions are usually due to
amalgam tattoo.
• Soreness or ulceration is usually due to local causes or aphthae but
other causes, especially malignant or systemic diseases, must be
excluded.
• White lesions that wipe off with gauze are usually due to debris or
candidosis; others to lichen planus or keratosis.
• Lumps/swelling can have a range of causes but neoplasms are
amongst the most important.
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 Chapter 3 • Differential diagnosis by site

Figure 3.49  Lip lesion: pyogenic granuloma (excise and histopathologically

examine but it may recur).

Figure 3.50  Lip lesion: pyogenic granuloma (excise and histopathologically

examine but it may recur).

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Coloured lesions: red

Erythematous candidosis
Typical orofacial symptoms and signs: sore red mouth (Figures 3.51, 3.52).
Main oral sites affected: tongue, palate.

Figure 3.51  Intraoral lesion:

candidosis presenting as red
lesion.

Figure 3.52  Intraoral lesion:

candidosis on tongue (same
patient shown in Figure 3.51
– a ‘kissing lesion’.

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 Chapter 3 • Differential diagnosis by site

Aetiopathogenesis: candidosis may cause sore red mouth, especially in

patients on broad spectrum antimicrobials. Erythematous candidosis, espe-
cially on the palate or tongue, may also be a feature of HIV disease.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: see above.
Main associated conditions: see above.
Differential diagnosis: other causes of glossitis.
Investigations: swab and culture; blood tests.
Main diagnostic criteria: clinical and microbiology.
Main treatments: antifungals.
Erythroplasia (erythroplakia)
Much less common than leukoplakia, but far more likely to be dysplastic or
malignant.
Typical orofacial symptoms and signs: red velvety patch of variable configura-
tion, usually level with or depressed below surrounding mucosa (Figures
3.53–3.56) .
Main oral sites affected: soft palate or floor or mouth.
Aetiopathogenesis: tobacco, alcohol and betel use predispose.
Gender predominance: males.
Age predominance: older.
Extraoral possible lesions: none.
Main associated conditions: in some may be cancer in the upper aerodiges-
tive tract (nasal, pharyngeal, laryngeal, bronchial, oesophageal).

Figure 3.53  Intraoral lesion; erythroplakia (erythroplasia).

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Coloured lesions: red (continued)

Figure 3.54  Intraoral lesion: erythroplakia.

Figure 3.55  Intraoral lesion: erythroplakia.

Figure 3.56  Intraoral lesion: erythroplakia on tongue.

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 Chapter 3 • Differential diagnosis by site

Differential diagnosis: inflammatory and atrophic lesions, e.g. in deficiency

anaemias, geographic tongue (erythema migrans), lichen planus, ery-
thematous candidosis, contact allergy.
Investigations: biopsy for epithelial dysplasia and carcinoma.
Main diagnostic criteria: clinical and microscopic.
Main treatments: excise, but the prognosis is often poor.

Hereditary haemorrhagic telangiectasia

(HHT; Osler–Rendu–Weber syndrome)
Rare.
Typical orofacial symptoms and signs: telangiectases are present orally and
periorally (Figure 3.57) and may bleed, resulting in iron deficiency anaemia.
Main oral sites affected: palate, tongue, lips.
Aetiopathogenesis: autosomal dominant inheritance but family history may
be negative.
Gender predominance: none.
Age predominance: from birth.
Extraoral possible lesions: nose, gastrointestinal tract and occasionally on
palms or fingers.
Main associated conditions: iron deficiency anaemia. Predisposes to cerebral
emboli.
Differential diagnosis: scleroderma, chronic liver disease and post-irradiation
telangiectasia.
Investigations: clinical features; blood picture.

Figure 3.57  Intraoral

lesions: multiple
telangiectasia in hereditary
haemorrhagic telangiectasia.

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Coloured lesions: red (continued)

Main diagnostic criteria: clinical.
Main treatments: cryosurgery or laser if bleeding is troublesome; treat
anaemia.

Scleroderma
Typical orofacial symptoms and signs: oral opening restricted with micro­
stomia and pale fibrotic ‘chicken’ tongue; widened periodontal space on
radiography in a few, but teeth not mobile. Occasionally: telangiectasia
(Figures 3.58–3.60); secondary Sjögren syndrome; bone lesions.
Rare variant: CREST syndrome (calcinosis, Raynaud disease, esophageal
strictures, sclerodactyly, telangiectasia).
Main oral sites affected: lips, tongue, palate.
Aetiopathogenesis: autoimmune.
Gender predominance: female.
Age predominance: middle age.

Figure 3.58  Lip tightening in

scleroderma.

Figure 3.59  Lip lesion in same patient Figure 3.60  Intraoral lesion in same
shown in Figure 3.58: telangiectasia. patient shown in Figure 3.59: dry mouth
and caries in associated Sjögren
syndrome.
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 Chapter 3 • Differential diagnosis by site

Extraoral possible lesions: oesophagus, skin – tight and waxy, and on

extremities.
Main associated conditions: Raynaud disease, Sjögren syndrome.
Differential diagnosis: from oral submucous fibrosis, telangiectasia (e.g. HHT,
see below) and secondary Sjögren syndrome.
Investigations: serum autoantibodies (ANF and Scl 70 especially).
Main diagnostic criteria: clinical features; histopathology; auto-antibodies.
Main treatments: penicillamine, iloprost, cyclophosphamide.

Coloured lesions: brown

Addison disease (hypoadrenocorticism)
Rare.
Typical orofacial symptoms and signs: symptomless brown hyperpigmenta-
tion especially in sites usually pigmented or traumatized (Figure 3.61).
Main oral sites affected: gingiva, occlusal line.
Aetiopathogenesis: adrenocortical destruction from autoimmune hypoad-
renalism and, rarely, tuberculosis, histoplasmosis (sometimes in HIV/AIDS)
and carcinomatosis. Nelson syndrome is similar but iatrogenic, resulting
from adrenalectomy in the management of breast cancer.
Gender predominance: females.
Age predominance: young or middle age.
Extraoral possible lesions: hyperpigmentation, especially in sites usually
pigmented (breast areolae, and genitals), or traumatized (skin flexures).

Figure 3.61  Intraoral lesion; pigmentation in Addison disease.

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Coloured lesions: brown (continued)

Main associated conditions: rarely associated with HIV/AIDS, other autoim-
mune glandular disease; or candidosis-endocrinopathy syndrome.
Differential diagnosis: other causes of pigmentation, especially racial and
drugs.
Investigations: blood pressure; plasma electrolyte and cortisol levels and
response to ACTH (Synacthen test).
Main diagnostic criteria: clinical, hypotension, low cortisol.
Main treatments: idiopathic (autoimmune) Addison disease – replacement
therapy (fludrocortisone and corticosteroids). Other causes: treat cause,
give replacement therapy.

Amalgam tattoo
Common.
Typical orofacial symptoms and signs: asymptomatic black or bluish-black
(usually), solitary, small pigmented area beneath normal mucosa (Figures
3.62, 3.63).
Main oral sites affected: lower ridge or buccal vestibule, or floor of mouth.
Aetiopathogenesis: amalgam particles or dust can become incorporated in
healing wounds after tooth extraction or apicectomy or beneath mucosa.
Gender predominance: none.
Age predominance: adults.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: other causes of pigmentation, especially naevi and
melanoma.
Investigations: imaging (may rarely be radioopaque). In uncertain cases exci-
sion biopsy can be performed.
Main diagnostic criteria: clinical, imaging.
Main treatments: excision biopsy may be necessary if the lesion is not radio-
paque, in order to distinguish from naevus or melanoma.

Malignant melanoma
Typical orofacial symptoms and signs: heavily black pigmented macule
usually (occasionally non-pigmented), or later, nodules and ulceration
(Figure 3.64). It may spread across several centimetres and metastasize
to cervical lymph nodes and then the bloodstream. Worrying features in a
208
 Chapter 3 • Differential diagnosis by site

Figure 3.62  Intraoral lesion: pigmentation from an amalgam tattoo.

Figure 3.63  Intraoral lesion: extensive pigmentation from an amalgam tattoo.

Figure 3.64  Intraoral lesion: pigmentation from a melanoma.

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Coloured lesions: brown (continued)

pigmented lesion are rapid growth, irregular edge, nodularity or uneven or
changing colour.
Main oral sites affected: palate.
Aetiopathogenesis: malignant tumour of melanocytes.
Gender predominance: male.
Age predominance: older.
Extraoral possible lesions: regional lymph node involvement.
Main associated conditions: none.
Differential diagnosis: naevi and other pigmented lesions.
Investigations: biopsy.
Main diagnostic criteria: clinical, supported by histology.
Main treatments: wide excision biopsy, assessment of invasion depth. Prog-
nosis is poor unless treatment is exceptionally early – hence the need to
biopsy small pigmented lesions.
Naevi
Common.
Typical orofacial symptoms and signs: asymptomatic brownish or bluish
macules, usually <1 cm across (Figure 3.65).
Main oral sites affected: gingivae and hard palate.
Aetiopathogenesis: congenital.
Gender predominance: none.
Age predominance: adults.
Extraoral possible lesions: none.
Main associated conditions: none.

Figure 3.65  Intraoral

lesion: pigmented
naevus.

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 Chapter 3 • Differential diagnosis by site

Differential diagnosis: other causes of pigmentation, especially amalgam

tattoo, melanotic macule or melanoma.
Investigations: biopsy.
Main diagnostic criteria: clinical, supported by histology.
Main treatments: excision to exclude malignant melanoma.

Soreness/ulcers
Causes may be systemic or infectious.
Systemic causes
Blood (haematological) disorders (see page 356)
Anaemia, leucopenia and leukaemia may present with ulceration.
Infectious causes
Hand, foot and mouth disease
Very common. It usually occurs in small epidemics, in children.
Typical orofacial symptoms and signs: red papules that evolve to superficial
vesicles and ulcers, resembling herpetic stomatitis but with no gingivitis
(Figure 3.66).
Main oral sites affected: labial and buccal mucosa.
Aetiopathogenesis: Coxsackie viruses (usually A16; rarely A5 or 10).
Gender predominance: none.
Age predominance: young children.
Extraoral possible lesions: palmoplantar involvement with erythematous
papules and a few vesicles with perilesional erythema, mild fever, malaise
and anorexia.
Figure 3.66  Intraoral lesion:
ulceration in hand, foot and
mouth disease.

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Soreness/ulcers (continued)
Main associated conditions: rash – in a few days, found mainly on palms
and soles.
Differential diagnosis: herpetic stomatitis, chickenpox.
Investigations: none.
Main diagnostic criteria: clinical features. Serology is confirmatory but rarely
required.
Main treatments: symptomatic (soft diet; analgesics; reduce fever).

Herpangina
Uncommon. Small outbreaks are seen, usually among young children.
Typical orofacial symptoms and signs: pharyngeal ulcers, usually resembling
herpetic ulcers but affecting posterior mouth alone (soft palate and uvula)
and causing sore throat; no gingivitis.
Main oral sites affected: soft palate and uvula (Figures 3.67, 3.68).

Figure 3.67  Intraoral

lesions: ulceration in
herpangina. Lesions are
mainly on the palate.

Figure 3.68  Intraoral

lesions: ulceration in
herpangina.

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 Chapter 3 • Differential diagnosis by site

Aetiopathogenesis: Coxsackie viruses usually (A7, 9, 16; B1, 2, 3, 4 or 5);

ECHO viruses (9 or 17).
Gender predominance: none.
Age predominance: young children.
Extraoral possible lesions: cervical lymphadenitis (moderate); fever; malaise;
irritability, anorexia, vomiting.
Main associated conditions: none usually.
Differential diagnosis: herpetic stomatitis, hand, foot and mouth disease,
chickenpox.
Investigations: none.
Main diagnostic criteria: clinical features. Serology (theoretically) is
confirmatory.
Main treatments: symptomatic (see above).

Herpetic stomatitis
Common.
Typical orofacial symptoms and signs: multiple vesicles and round scattered
ulcers with yellow slough and erythematous halo; ulcers fuse to produce
irregular lesions (Figures 3.69–3.72). Gingivitis: diffuse erythema and
oedema, occasionally haemorrhagic.
Main oral sites affected: any.
Aetiopathogenesis: herpes simplex virus (HSV), usually type 1 in young
children. Type 2 often in older age groups.
Gender predominance: none.

Figure 3.69  Intraoral lesions: ulceration in herpetic stomatitis.

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Soreness/ulcers (continued)
Figure 3.70  Intraoral
lesions: ulceration in
herpetic stomatitis, with
gingival swelling and
erythema.

Figure 3.71  Intraoral lesions: ulceration in herpetic stomatitis.

Figure 3.72  Intraoral lesions: ulceration in herpetic stomatitis, with gingival

swelling and erythema.
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 Chapter 3 • Differential diagnosis by site

Age predominance: children and adolescents. It is also seen in adults,

especially in more affluent communities or among those who work with
children.
Extraoral possible lesions: cervical lymphadenitis (moderate); fever; malaise;
irritability, anorexia, vomiting.
Main associated conditions: rarely: skin lesions, ocular or CNS
involvement.
Differential diagnosis: other causes of mouth ulcers, especially hand, foot
and mouth disease, chickenpox and shingles, herpangina, erythema mul-
tiforme and leukaemia.
Investigations: none usually. Viral immunostaining, or DNA studies. Culture
or electron microscopy used occasionally. A rising titre of antibodies is
confirmatory.
Main diagnostic criteria: clinical.
Main treatments: symptomatic (soft diet and adequate fluid intake;
antipyretics/analgesics [paracetamol elixir]; local antiseptics; aqueous chlo-
rhexidine mouthwashes); aciclovir orally or suspension or tablets parenter-
ally in severe cases or immunocompromised patients.
Recurrences usually present as herpes labialis or unilateral palatal or
gingival lesions (Figure 3.73). In immunocompromised patients extensive oral
and cutaneous lesions can be seen (eczema herpeticum). HSV infection may
rarely precipitate erythema multiforme.

Figure 3.73  Intraoral lesions: ulceration in recurrent herpes

simplex can mimic zoster.
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Soreness/ulcers (continued)
Herpes varicella-zoster virus (chickenpox; varicella)
Common childhood exanthema (viral rash).
Typical orofacial symptoms and signs: ulcers: indistinguishable from HSV,
but no associated gingivitis (Figure 3.74).
Main oral sites affected: any.
Aetiopathogenesis: herpes varicella-zoster virus (VZV).
Gender predominance: none.
Age predominance: children.
Extraoral possible lesions: fever; rash – mainly on face and trunk (papules
then vesicles, pustules and scabs, in crops). Malaise, irritability, anorexia.
Cervical lymphadenitis. Rarely: pneumonia or encephalitis.
Main associated conditions: none.
Differential diagnosis: from other mouth ulcers, especially HSV and other viral
infections.
Investigations: none; cytology may help.
Main diagnostic criteria: clinical. Rising antibody titre is confirmatory.
Main treatments: symptomatic; immunoglobulin or aciclovir in immunocom-
promised patients. Immunize to prevent.

Shingles (herpes zoster)

Uncommon.
Typical orofacial symptoms and signs:
 pain – before, with and after rash

 rash: unilateral vesiculating, then scabbing in dermatome

 mouth ulcers: sheets of vesicles that rupture and coalesce to form

painful irregular ulcers that stop at the midline (Figure 3.75)

 main oral sites affected: mandibular zoster – ipsilateral on buccal

and lingual mucosa; maxillary – ipsilateral on palate and vestibule

 rarely: geniculate zoster (rash in ear, facial palsy and ulcers on

ipsilateral soft palate) – Ramsay Hunt syndrome.

Aetiopathogenesis: reactivation of VZV latent in sensory ganglia, often
because of immune defects.
Gender predominance: none.
Age predominance: older adults.
Extraoral possible lesions: fever; pain and rash in dermatome.
Main associated conditions: any immune defect (e.g. HIV/AIDS).
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 Chapter 3 • Differential diagnosis by site

Figure 3.74 
Intraoral lesion:
ulceration in
herpes
varicella-zoster
virus primary
infection
(chickenpox).

Figure 3.75 
Intraoral lesions:
unilateral
ulceration in
herpes
varicella-zoster
virus recurrence
(zoster or
shingles). There
is also an
ipsilateral rash,
and pain.

Differential diagnosis: toothache and other causes of ulcers, especially HSV.

Investigations: cytologic smear from fresh lesion for immunostaining or DNA
studies.
Main diagnostic criteria: clinical features.
Main treatments: antiviral therapy (aciclovir, famciclovir, valaciclovir in high
dose, orally or parenterally, especially in the immunocompromised) and
corticosteroids shorten the acute illness period; opioids and anticonvulsants
can reduce acute pain; tricyclic antidepressants, opioids and carbamazepine
can help relieve chronic pain; symptomatic treatment of ulcers. Ophthalmic
zoster: ophthalmological opinion.
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Soreness/ulcers (continued)
Infectious mononucleosis (glandular fever)
Common.
Typical orofacial symptoms and signs: sore throat, faucial swelling and
ulceration with creamy exudate and palatal petechia; occasional mouth
ulcers; cervical lymph node enlargement (Figures 3.76–3.78).
Main oral sites affected: fauces.
Aetiopathogenesis: Epstein–Barr virus (EBV).
Gender predominance: none.
Age predominance: adolescents.
Extraoral possible lesions: generalized tender lymphadenopathy; fever,
malaise, anorexia and lassitude.
Main associated conditions: macular rash, splenomegaly.
Differential diagnosis: streptococcal pharyngitis, diphtheria, Toxoplasma
gondii infection and other viral glandular-like fever syndromes (e.g. HIV
infection, HHV-6, cytomegalovirus) infection.
Investigations: Paul–Bunnell test for heterophil antibodies.
Main diagnostic criteria: clinical features; blood picture; serology.
Main treatments: symptomatic; metronidazole may improve sore throat.
Syphilis
Predominantly an infection of the sexually promiscuous (prostitutes, male
homosexuals, travellers, armed forces). Oral lesions uncommon. Non-
venereal treponematoses, including yaws, bejel and pinta, are rare in the
UK/USA.
Typical orofacial symptoms and signs:
 congenital syphilis: head and neck – frontal bossing, saddle nose,

Hutchinsonian incisors, Moon or mulberry molars and rhagades

(circumoral scars); others – learning impairment, interstitial keratitis
(blindness), deafness, sabre tibiae and Clutton joints

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 Chapter 3 • Differential diagnosis by site

Figure 3.76  Intraoral lesion: ulceration and candidosis; infectious mononucleosis

(glandular fever).

Figure 3.77  Intraoral lesion: infectious mononucleosis with palatal petechiae.

Figure 3.78  Intraoral lesion: infectious mononucleosis with palatal petechiae.

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Soreness/ulcers (continued)
 acquired syphilis: oral lesions may be seen in all three stages:
a primary syphilis – a Hunterian or hard chancre is a small papule
that develops into large painless indurated ulcer (Figure 3.79),
with regional lymphadenitis. Chancre is highly infectious, and
though usually on genitals, breast or perianally may appear on
lip, tongue or palate; heals spontaneously in 1–2 months.
b secondary syphilis – oral lesions are highly infectious and
include: mucous patches, split papules or snail-track ulcers
(Figure 3.80). Rash (coppery coloured, typically on palms

Figure 3.79  Intraoral lesion:

ulceration of a hard (Hunterian)
chancre in primary syphilis.

Figure 3.80  Intraoral lesion: ulceration in secondary syphilis. Ulcers sometimes

have a ‘snailtrack’ appearance.
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 Chapter 3 • Differential diagnosis by site

and soles), condylomata lata and generalized lymph node

enlargement can also be present.
c tertiary syphilis – oral lesions are non-infectious and include
glossitis (leukoplakia) and gumma (Figure 3.81). These may be
associated with cardiovascular complications (aortic aneurysm)
or neurosyphilis (tabes dorsalis; general paralysis of the insane;
Argyll Robinson pupils [react to focus but not to light]).
Main oral sites affected: chancre; on lip (upper) or intraorally – usually
tongue. Lesions of secondary syphilis – any site. Lesions of tertiary syphilis
– usually midline in palate, or dorsum of tongue.
Aetiopathogenesis: Treponema pallidum – sexually shared.
Gender predominance: none.
Age predominance: adults.
Extraoral possible lesions: as above.
Main associated conditions: HIV and other sexually shared infections.
Differential diagnosis: trauma, herpes labialis, pyogenic granuloma, carci-
noma. Very rarely: non-venereal treponematoses.
Investigations: T. pallidum in direct smear (darkfield examination) of primary-
and secondary-stage lesions. Serology positive from late in primary stage.
Main diagnostic criteria: serology.
Main treatments: penicillin (depot injection); if allergic to penicillin, use
erythromycin, clarithromycin or tetracycline. Contact tracing.
Figure 3.81  Intraoral lesion:
ulceration of a gumma in tertiary
syphilis.

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Soreness/ulcers (continued)
Tuberculosis
Uncommon generally; but seen mainly in alcoholics, diabetics, patients with
immune defects (including HIV infection), and particularly in groups from the
developing world (e.g. Asian, African). One-third of the world population is
infected.
Typical orofacial symptoms and signs: ulceration or lump – usually single
chronic ulcer on dorsum of tongue associated with (post-primary) pulmo-
nary infection (Figure 3.82).
Main oral sites affected: tongue, palate, gingivae.
Aetiopathogenesis: mycobacteria: usually M. tuberculosis, but rarely atypical
mycobacteria (non-tuberculous mycobacteria), e.g. M. avium-intracellulare,
M. scrofulaceum, M. kansasii, especially in HIV infection.
Gender predominance: none.
Age predominance: adult.
Extraoral possible lesions: cervical nodes, pulmonary.
Main associated conditions: HIV/AIDS patients commonly infected, especially
if from developing world.

Figure 3.82  Intraoral lesion: extensive tuberculous ulceration.

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 Chapter 3 • Differential diagnosis by site

Differential diagnosis: other causes of mouth ulcers, especially syphilis and

carcinoma.
Investigations: lesional biopsy; sputum culture; chest radiography.
Main diagnostic criteria: clinical, imaging, histology.
Main treatments: combination antimicrobial chemotherapy. TB may be multi-
drug resistant (MDR-TB) or have extended drug resistance (XDR-TB).

Gastrointestinal disorders
Oral lesions may affect people with coeliac disease, or inflammatory bowel
disease (IBD) – a collective term for diseases that cause inflammation in the
intestines and which encompasses the spectrum of disease seen in Crohn
disease and ulcerative colitis (UC).
Coeliac disease (CD: gluten-sensitive enteropathy; coeliac sprue,
nontropical sprue)
Most common genetic disease in Europe; approaches 1% in some
populations.
Typical orofacial symptoms and signs: variably ulceration, glossitis, angular
stomatitis, enamel hypoplasia (Figure 3.83).
Main oral sites affected: any.

Figure 3.83  Intraoral lesion: aphthous-like ulceration in coeliac disease

(gluten-sensitive enteropathy).
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 Pocketbook of Oral Disease

Soreness/ulcers (continued)
Aetiopathogenesis: genetic background of HLA-DQw2 or DRw3; a hypersen-
sitivity or toxic reaction of the small intestine mucosa to the gliadin com-
ponent of gluten (prolamine), a group of proteins found in all forms of wheat
and related grains (rye, barley, triticale) causing destruction of jejunal villi
(villous atrophy) and inflammation, leading to malabsorption.
Gender predominance: none.
Age predominance: none, but severe cases present at weaning.
Extraoral possible lesions: one of the great mimics in medicine, coeliac
disease may present at any age with malabsorption (leading to growth
retardation, vitamin and mineral deficiencies that may result in anaemia,
osteomalacia, bleeding tendencies and neurological disorders), abdominal
pain, steatorrhoea and behavioural changes. Intestinal lymphomas arise in
about 6% of individuals.
Main associated conditions: other autoimmune disorders including Sjögren
syndrome, food sensitivities, or lactose intolerance.
Differential diagnosis: other causes of ulcers, angular stomatitis and
glossitis.
Investigations: serum antibody screening – transglutaminase; full blood
count (ferritin, vitamin B12 and folate levels); stool examination; digestion/
absorption tests include lactose tolerance and D-xylose tests. Endoscopic
biopsy of jejunal mucosa.
Main diagnostic criteria: serum transglutaminase, and jejunal histology.
Main treatments: rectify nutritional deficiencies, and a gluten-free diet for life.

Crohn disease (see also Orofacial granulomatosis, page 196)

Uncommon.
Typical orofacial symptoms and signs: lip or facial persistent painless swell-
ing; mucosal cobblestoning or tags, gingival swelling, or ulcers – typically
solitary, persistent and ragged with hyperplastic margins (Figures 3.84-
3.87). Mouth ulcers can be due to Crohn disease itself, secondary to folate
or other deficiency, or coincidentally associated.
Main oral sites affected: lips, buccal mucosa, gingivae.
Aetiopathogenesis: susceptibility related to the CARD 15 gene, or autophagy
gene ATG16L1, which may hinder the ability to resist bacteria. Possible
microorganisms involved include Mycobacterium avium subspecies paratu-
berculosis, or Escherichia coli strains.
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 Chapter 3 • Differential diagnosis by site

Figure 3.84  Intraoral

lesions: Crohn disease
showing mucosal tags.

Figure 3.85  Intraoral

lesions: Crohn disease
showing mucosal tags and
ulceration.

Figure 3.86  Intraoral

lesions: Crohn disease
showing gingival erythema
and swelling.

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Soreness/ulcers (continued)

Figure 3.87  Intraoral lesions: Crohn disease showing mucosal ‘cobblestoning’.

Gender predominance: none.

Age predominance: young adults.
Extraoral possible lesions: can affect any part of gastrointestinal tract from
top to tail (mouth to anus) but especially the ileocaecal region, typically with
ulceration, fissuring and fibrosis of the wall. Complications include weight
loss, gastrointestinal obstruction, fistulas, perianal fissures, abscesses,
arthralgia, sclerosing cholangitis, renal stones or infections and a predis-
position to large bowel carcinoma comparable with that in ulcerative colitis,
and a slight predisposition to small bowel carcinoma.
Main associated conditions: as above.
Differential diagnosis: other causes of mouth ulcers, especially malignant
lesions or chronic bacterial infections. Also from ulcerative colitis, tubercu-
losis, ischaemic colitis, infections, infestations such as giardiasis, and
lymphoma.
Investigations: blood count; serum potassium, zinc and albumin (usually
depressed); erythrocyte sedimentation rate (raised), C-reactive protein
(raised) and seromucoid; faecal calprotectin; white cell scan; abdominal
plain-film and contrast radiography; ultrasound and MRI; and endoscopy
(sigmoidoscopy, colonoscopy) with biopsy.
Main diagnostic criteria: biopsy; blood picture; gastrointestinal results.
Main treatments: topical or intralesional corticosteroids; systemic or possibly
topical sulfasalazine, biological response modifiers such as infliximab.
At least some cases of OFG represent latent Crohn disease.
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 Chapter 3 • Differential diagnosis by site

Ulcerative colitis
Uncommon.
Typical orofacial symptoms and signs: mucosal pustules (pyostomatitis veg-
etans) or irregular chronic ulcers (Figure 3.88) can be associated with
ulcerative colitis, or may be secondary to anaemia due to chronic bowel
haemorrhage.
Main oral sites affected: any.
Aetiopathogenesis: unknown but autoimmunity, diet, sulphate-reducing bac-
teria, drugs such as isotretinoin, and a genetic basis have been suggested.
Gender predominance: none.
Age predominance: adults.
Extraoral possible lesions: persistent diarrhoea, frequently painless with
blood and mucus. In severe cases: iron deficiency anaemia, weight loss,
arthralgia, conjunctivitis, uveitis, iritis, finger clubbing, sacroileitis, ery-
thema nodosum, pyoderma gangrenosum, primary sclerosing cholangitis,
gallstones, renal calculi and thromboembolism.
Main associated conditions: predisposition to colorectal carcinoma.
Differential diagnosis: other causes of mouth ulcers, particularly Crohn
disease.
Investigations: biopsy; full blood picture; erythrocyte sedimentation rate/C-
reactive protein; sigmoidoscopy; colonoscopy; barium enema.
Main diagnostic criteria: raised erythrocyte sedimentation rate/C-reactive
protein, imaging and histology.
Main treatments: haematinics for any secondary deficiencies; topical corti-
costeroids (corticosteroid enemas) may be helpful; sulfasalazine.

Figure 3.88  Intraoral lesion: ulceration in pyostomatitis vegetans in ulcerative colitis.

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Soreness/ulcers (continued)
Skin disorders
Epidermolysis bullosa
Epidermolysis bullosa (EB) is a group of rare heritable mechanobullous dis-
orders characterized by skin cutaneous basement membrane zone (BMZ)
fragility.
Typical orofacial symptoms and signs: in EB simplex there are mainly skin
blisters after trauma, which heal without scars and oral lesions are rare,
but the junctional and dystrophic forms can present both skin and mouth
bullae in neonates, which heal slowly and scar (Figures 3.89, 3.90). Some
die; others improve slowly.
Main oral sites affected: any.
Aetiopathogenesis: genetic mostly, including various autosomal dominant
(relatively benign) and recessive (more severe) forms. Inherited EB may be
separated into three general types based upon the area of separation of
the blister: (a) the simplex (epidermal); (b) the junctional (basement mem-
brane zone); and (c) the dystrophic (dermal). Each type has many variants.
An acquired form has also been described (EB acquisita).
Gender predominance: none.
Age predominance: from early age.
Extraoral possible lesions: skin blistering.
Main associated conditions: none.
Differential diagnosis: other vesiculobullous disorders.
Investigations: family history; biopsy to exclude other blistering diseases.
Main diagnostic criteria: family history; histology.
Main treatments: avoid trauma. Antibiotics for skin lesions. Phenytoin may
benefit some. Corticosteroids are possibly helpful.

Erythema multiforme (see page 188)

Lichen planus
Lichen planus usually causes white lesions and is therefore discussed on
page 243. However, it can often present with erosions.

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 Chapter 3 • Differential diagnosis by site

Figure 3.89  Intraoral lesions: blisters and ulceration in epidermolysis bullosa.

Figure 3.90  Intraoral lesions: scarring and depapillation from ulceration in

epidermolysis bullosa.

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Soreness/ulcers (continued)
Lupus erythematosus (see also Discoid lupus erythematosus,
page 186)
Uncommon. Both discoid (DLE) and systemic (SLE) can affect the mouth,
and oral lesions can precede other manifestations in a minority of patients.
Typical orofacial symptoms and signs: DLE: characteristic features of
intraoral lesions include – central erythema, white spots or papules, radi-
ating white striae at margins and peripheral telangiectasia (Figures
3.91–3.93). SLE: lesions like those in DLE but usually more severe ulcera-
tion. SLE may also be associated with Sjögren syndrome and, rarely, TMJ
arthritis.
Main oral sites affected: any.
Aetiopathogenesis: unknown. Connective tissue disease (autoimmune).
Gender predominance: female.
Age predominance: adult.
Extraoral possible lesions: skin rash.
Main associated conditions: SLE is a multisystem disorder that is a great
mimic of other disorders and can manifest in most tissues/organs, espe-
cially heart, joints, lungs, blood vessels, liver, kidney and CNS. Raynaud
and Sjögren syndromes are often associated.
Differential diagnosis: DLE: differentiate from other causes of mouth ulcers,
and especially from SLE, lichen planus and leukoplakia.
SLE: differentiate from other causes of mouth ulcers, especially DLE.
Investigations: biopsy; blood picture; autoantibodies, especially crithidial
(double-stranded DNA). Antinuclear factors are present in SLE, not
DLE.
Main diagnostic criteria: autoantibodies; histology.
Main treatments: DLE – topical corticosteroids (rarely systemic); SLE – sys-
temic corticosteroids, azathioprine, chloroquine or gold.

Pemphigoid
There are several forms of pemphigoid but the forms that affect the mouth
are termed mucous membrane pemphigoid. Not an uncommon condition;
the cause is immunological, and not thought to be inherited or infectious. It
occasionally affects the skin, eyes, genitals or other sites.

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 Chapter 3 • Differential diagnosis by site

Figure 3.91  Skin lesion of lupus

erythematosus.

Figure 3.92  Intraoral lesion:

white lesion and ulceration of
lupus erythematosus.

Figure 3.93  Intraoral lesion:

white lesion of lupus
erythematosus. Such lesions may
mimic lichen planus.

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Soreness/ulcers (continued)
Pemphigoid must not be confused with the more serious pemphigus.
Typical orofacial symptoms and signs: blisters (sometimes blood-filled) can
present anywhere, but especially at sites of trauma (Figures 3.94–3.99).
Nikolsky sign may be positive (gentle trauma in an unaffected area causing
blister formation). Ulcers: may heal with scarring. ‘Desquamative gingivitis’
is common.
Main oral sites affected: palate, gingivae.
Aetiopathogenesis: autoimmune. It is rarely caused by drugs (e.g. furose­
mide) or other agents.
Gender predominance: female.
Age predominance: middle age or older.
Extraoral possible lesions: conjunctival lesions – leading to impaired sight
(entropion or symblepharon); laryngeal lesions – may lead to stenosis; skin
lesions – blisters rarely (unlike bullous pemphigoid which rarely affects the
mouth), eczematous-like lesions.

Figure 3.94  Intraoral lesion: Figure 3.95  Conjunctival

desquamation, erosion and ulceration in pemphigoid with shortening of
pemphigoid. fornix.

Figure 3.96  Conjunctival

pemphigoid with symblepharon.

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 Chapter 3 • Differential diagnosis by site

Figure 3.97  Intraoral lesion: pemphigoid; desquamative gingivitis the main cause
of chronically sore gingivae.

Figure 3.98  Intraoral lesion: pemphigoid; Nikolsky sign.

Figure 3.99  Intraoral lesion: pemphigoid; blister.

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Soreness/ulcers (continued)
Main associated conditions: some subtypes (anti-laminin 332) are associated
with internal malignant disease.
Differential diagnosis: other causes of mouth ulcers, especially pemphigus
and localized oral purpura.
Investigations: biopsy.
Main diagnostic criteria: biopsy – subepithelial split, including immunostain-
ing (C3 and IgG, IgA at basement membrane). Direct immunofluorescence
(DIF) and salt-split skin indirect immunofluorescence (IIF).
Main treatments: potent topical corticosteroids or systemic corticosteroids
with or without immunosuppressants or dapsone.

Pemphigus
Rare but potentially lethal. An immunological disease, the reaction damaging
the skin and mucosae. It affects the mouth, skin and other sites. It is most
commonly seen in persons from around the Mediterranean but is not usually
inherited.
There are several variants, the most common being pemphigus vulgaris,
which is mainly a disease of people from Asia or around the Mediterranean,
and Ashkenazi Jews.
A rare pemphigus variant called paraneoplastic pemphigus is associated
with malignant tumours (especially chronic lymphocytic leukaemia and non-
Hodgkin lymphomas), typically causing extensive oral lesions with almost
constant involvement of the lips with crusted lesions.
Typical orofacial symptoms and signs: oral lesions are most common in
pemphigus vulgaris and often precede skin lesions. Blisters anywhere on
the mucosa rupture rapidly to leave ragged red lesions followed by erosions
and ulceration (Figures 3.100, 3.101). Nikolsky sign is positive.
Main oral sites affected: palate, gingivae or any traumatized area.
Aetiopathogenesis: autoimmune – circulating autoantibodies to desmoglein
of epithelial intercellular substance. Antibodies to desmoglein 3 cause oral
lesions and to desmoglein 1 cause skin lesions. Pemphigus is rarely caused
by drugs (e.g. penicillamine) or other agents.
Gender predominance: female.
Age predominance: older adults.
Extraoral possible lesions: skin lesions are large flaccid blisters especially
where there is trauma. Lesions may affect other mucosa.
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 Chapter 3 • Differential diagnosis by site

Figure 3.100  Intraoral lesion:

ulceration in pemphigus. There is a
red lesion of early pemphigus
surrounded by mucosa which is
necrotic and appears whitish.

Figure 3.101  Intraoral lesion:

ragged red lesions leading
eventually to ulceration in
pemphigus.

Main associated conditions: rarely, myasthenia gravis or thymoma.

Differential diagnosis: other causes of mouth ulcers, especially mucous
membrane pemphigoid and erythema multiforme.
Investigations: biopsy and serology; DIF and IIF.
Main diagnostic criteria: histology to show acantholysis, including direct
immunofluorescence to show IgG and C3 binding to intercellular attach-
ments of epithelial cells. Serology (antibodies to epithelial intercellular
substance), using enzyme-linked immunosorbent assay (ELISA) for anti-
desmoglein 3 and 1.
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Soreness/ulcers (continued)
Main treatments: largely based on systemic immunosuppression using
systemic corticosteroids plus mycophenolate mofetil, or azathioprine or
cyclophosphamide. In recalcitrant cases, intravenous immunoglobulins or
rituximab.

Malignancy (see page 269)

Most malignant oral ulcers are squamous cell carcinomas but other primary
tumours can be antral (rarely), or of salivary glands, lymphomas, Kaposi
sarcoma or metastases.
Local causes
Ulcers of local cause are common but rarely present for care as they are
usually self-limiting and the aetiology often quite obvious to the patient.
Causes may include:
• Trauma, including from orthodontic appliances, dentures (Figures
3.102, 3.103) or interdental wiring, ulceration of lingual fraenum
caused by repeated coughing or cunnilingus, and self-induced lesions
due to cheek biting (a neurotic habit) and in some rare syndromes.
Other causes to be considered include child abuse, or pterygoid ulcers
of palate in neonates (Bednar’s aphthae).
• Burns (from electrical injury, heat or cold, or chemicals) or radiation
(mucositis).
Most ulcers of local cause resolve with use of antiseptics such as aqueous
chlorhexidine. Failure to resolve within 3 weeks mandates biopsy.
Aphthae (recurrent aphthous stomatitis – RAS)
Common. Children may inherit ulcers from parents.
Aphthous ulcers are not thought to be infectious. The cause is not known
but some follow use of toothpaste with sodium dodecyl sulphate, certain
foods/drinks, or stopping smoking. Some vitamin or other deficiencies or
conditions may predispose to ulcers. No long-term consequences are known.
Typical orofacial symptoms and signs: recurrent ulcers usually lasting from
1 week to 1 month. There are three distinct clinical patterns:

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 Chapter 3 • Differential diagnosis by site

Figure 3.102  Intraoral lesion: ulceration from overextended denture flange.

Figure 3.103  Intraoral lesion: ulceration from chronic trauma; note white border.

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Soreness/ulcers (continued)
 Minor aphthae – small ulcers (<4 mm) on mobile mucosa, healing
within 14 days, no scarring (Figure 3.104).
 Major aphthae – large ulcers (may >1 cm), any site including

dorsum of tongue and hard palate, healing within 1–3 months, with
scarring (Figure 3.105) .
 Herpetiform ulcers – multiple minute ulcers that coalesce to

produce ragged ulcers (Figure 3.106).

Main oral sites affected: buccal vestibule, ventrum of tongue, floor of mouth.
Aetiopathogenesis: immunological changes are detectable but there is no
reliable evidence of autoimmune disease or any classical immunological
reactions. Aphthae may be due to changes in cell-mediated immune
responses and cross-reactivity with Streptococcus sanguinis. Underlying
predisposing factors are seen in a minority with aphthous-like ulcers:
haematinic (iron, folate or vitamin B12) deficiency in about 10%, relationship
with luteal phase of menstruation (rarely), ‘stress’, food allergies (possibly)
and smoking cessation.
Gender predominance: none.
Age predominance: onset usually in childhood or adolescence.
Extraoral possible lesions: none by definition.
Main associated conditions: none; if other manifestations are present, the
ulcers are termed ‘aphthous-like’ ulcers.
Differential diagnosis: other causes of mouth ulcers, especially coeliac
disease, Crohn disease, Behçet syndrome, autoinflammatory disorders or
HIV/AIDS.
Investigations: full blood picture, haematinic assays, transglutaminase and
erythrocyte sedimentation rate, to exclude systemic diseases.
Main diagnostic criteria: history of recurrences and clinical features. There
is no immunological test of value.
Main treatments: treat any underlying predisposing factors. Treat aphthae
with chlorhexidine 0.2% aqueous mouthwash or systemic vitamin B12, or
topical corticosteroids (hydrocortisone hemisuccinate oromucosal tablets
or beclomethasone as a mouthwash or fluocinonide gel), or amlexanox. In
adults only, tetracycline (doxycycline) rinses. Rarely, other potent topical
corticosteroids (e.g. betamethasone, clobetasol) may be needed. Specialists
may offer systemic immunomodulatory agents such as steroids, colchicine
or thalidomide (not if there is any possibility of pregnancy).
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 Chapter 3 • Differential diagnosis by site

Figure 3.104  Intraoral lesion: ulceration of minor aphthae (small and of only a
week or so duration).

Figure 3.105  Intraoral lesion: ulceration of major aphthae (large and persistent for
several weeks). These tend to heal with scarring.

Figure 3.106  Intraoral lesion: ulceration of herpetiform ulcers (some ulcers have
coalesced).
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Soreness/ulcers (continued)
Aphthous-like ulcers
This term is applied to recurrent oral ulcers that may clinically mimic aphthae
but are seen in patients with definable systemic immune diseases such as:
• Behçet syndrome (Figure 3.107).
• Gastrointestinal disorders; coeliac disease or Crohn disease
(Figure 3.108).
• Autoinflammatory conditions.
• Immune defects such as HIV/AIDS and cyclic neutropenia.
Behçet syndrome
Rare: most common in peoples from around the area of the old Silk Road of
Marco Polo, and particularly in people from Japan, Korea and Turkey.
Typical orofacial symptoms and signs: recurrent ulcers often mimicking
major aphthae.
Main oral sites affected: palate.
Aetiopathogenesis: immunological changes resemble those in aphthae.
Immune complexes, possibly with herpes simplex virus, may be implicated
in persons with specific HLA associations (B5101).
Gender predominance: male.
Age predominance: adults.
Extraoral possible lesions: non-specific features which may precede mucosal
ulceration include sore throats, myalgias, migratory erythralgias, malaise,
anorexia, weight loss, weakness, headache, sweating, lymphadenopathy,
large joint arthralgia and pain in substernal and temporal regions. Multi-
system disorder may include:
 eye disease: reduced visual acuity, uveitis, retinal vasculitis

 skin disease: acneiform rashes; pustules at venepuncture sites

(pathergy); pseudofolliculitis and erythema nodosum (tender red

nodules over shins)
 joint disease: arthralgia of large joints

 neurological disease: headache, psychiatric, motor or sensory

manifestations; meningoencephalitis, cerebral infarction

(stroke), psychosis, cranial nerve palsies, cerebellar and spinal
cord lesions
 others: genital ulcers, thromboses, colitis, renal disease, etc.

Main associated conditions: as above.

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 Chapter 3 • Differential diagnosis by site

Figure 3.107  Intraoral lesion: aphthous-like ulceration in Behçet syndrome.

Figure 3.108  Intraoral lesion: aphthous-like ulceration in vitamin B12 deficiency.

Differential diagnosis: other oculomucocutaneous disorders, especially ery-

thema multiforme, syphilis and Reiter syndrome (reactive arthritis), and
inflammatory bowel disease.
Investigations: erythrocyte sedimentation rate, C-reactive protein, full blood
picture, HLA typing.
Main diagnostic criteria: there is no immunological test of value. Clinical fea-
tures – mouth ulcers (at least three episodes in a year) plus two or more of:
 genital ulcers

 ocular lesions

 CNS lesions

 skin lesions and pathergy.

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Soreness/ulcers (continued)
Main treatments: oral ulcers: treat as for aphthae (above). Specialists
may offer systemic immunosuppression using colchicine, corticosteroids,
azathioprine, ciclosporin, dapsone or thalidomide (not if there is any pos-
sibility of pregnancy).
Drugs (see also pages 337)
Mouth ulcers can be caused by burns from drugs left in the mouth, or by
various other mechanisms, but often the mechanism is unclear. Drugs that
can cause ulceration (Figure 3.109) include those that are:
• cytotoxics – ulcers or mucositis can follow the use of any
chemotherapeutic agent
• bone marrow suppressants e.g. drugs such as antithyroid agents
• drugs that cause lichenoid reactions – antimalarials, antihypertensives.

Figure 3.109  Intraoral lesion: erosions in the buccal mucosa caused by a drug
reaction to penicillamine.

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 Chapter 3 • Differential diagnosis by site

White lesions
Cancer
Keratinizing carcinomas may appear as oral white lesions ab initio or may
occasionally arise in other oral white lesions, notably in some keratoses,
dyskeratosis congenita, oral submucous fibrosis, or in lichen planus.
Candidosis
Thrush (acute pseudomembranous candidosis)  Common but rare in
healthy patients.
Typical orofacial symptoms and signs: white or creamy papules or plaques
that can be wiped off to leave a red base (Figure 3.110).
Main oral sites affected: any.
Aetiopathogenesis: neonatal immature immune system; oral microflora dis-
turbed by drugs (antibiotics, corticosteroids or those impairing salivation);
hyposalivation; or immune defects, especially HIV/AIDS, immunosuppres-
sive treatment, leukaemias, lymphomas and diabetes.
Gender predominance: none.
Age predominance: extremes of life.
Extraoral possible lesions: see aetiopathogenesis.

Figure 3.110  Intraoral lesion: white lesions of acute candidosis (’thrush’) on

erythematous background. These lesions will wipe off with a gauze swab.
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White lesions (continued)

Main associated conditions: see aetiopathogenesis.
Differential diagnosis: mucosal sloughing, Koplik or Fordyce spots.
Investigations: cytologic smear with periodic acid Schiff (PAS) or Gram stain
(hyphae); full blood picture.
Main diagnostic criteria: clinical.
Main treatments: treat predisposing cause. Antifungals: nystatin oral suspen-
sion or pastilles or miconazole gel or tablets or fluconazole tablets (in USA,
clotrimazole troches).
Candidal leukoplakia (limited type)  Common.
Typical orofacial symptoms and signs: leukoplakia, often speckled (Figures
3.111, 3.112). There is a higher malignant potential than many other
leukoplakias.
Main oral sites affected: commissures and sometimes tongue.
Aetiopathogenesis: unclear – smoking predisposes.
Gender predominance: male.
Age predominance: adult.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: lichen planus, leukoplakia, cheek biting.
Investigations: biopsy; blood picture.
Main diagnostic criteria: clinical and histology.
Main treatments: smoking cessation. Antifungals: nystatin oral suspension
or pastilles; miconazole gel or tablets, or fluconazole tablets may help
(in USA, clotrimazole troches). Remove (excision or cryosurgery).
Chronic mucocutaneous candidosis  Rare.
Typical orofacial symptoms and signs: white or creamy plaques or persistent
widespread leukoplakia that cannot be wiped off.
Main oral sites affected: tongue.
Aetiopathogenesis: genetic immune defect.
Gender predominance: none.
Age predominance: from infancy usually.
Extraoral possible lesions: cutaneous – nail and skin candidosis.
Main associated conditions: rarely familial multiple endocrinopathies, iron
deficiency or thymoma.
Differential diagnosis: lichen planus, leukoplakia.
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 Chapter 3 • Differential diagnosis by site

Figure 3.111  Intraoral lesion: white

lesions of chronic candidosis
(candidal leukoplakia).

Figure 3.112  Intraoral lesion: white

lesions of chronic candidosis
(candidal leukoplakia).

Investigations: family history; biopsy; blood picture; autoantibody; endocrine

studies.
Main diagnostic criteria: clinical and histology.
Main treatments: treat predisposing cause. Smoking cessation. Antifungals:
nystatin oral suspension or pastilles; miconazole gel or tablets, or flucona-
zole tablets may help (in USA, clotrimazole troches). Remove (excision or
cryosurgery).
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White lesions (continued)

Cheek biting (morsicatio buccarum)
Common.
Typical orofacial symptoms and signs: symptomless abrasion of superficial
epithelium leaves whitish fragments on reddish background.
Main oral sites affected: invariably restricted to lower labial mucosa and/or
buccal mucosa near occlusal line. The lesions may range from a linea alba
on the buccal mucosae or/and lateral margins of tongue, through to definite
cheek biting (Figures 3.113–3.117). May also be due to masseteric
hypertrophy.
Aetiopathogenesis: anxious personality or anxiety neurosis (see also Fric-
tional keratosis.
Gender predominance: female.
Age predominance: young adult.
Extraoral possible lesions: psychologically related disorders, e.g. temporo-
mandibular pain-dysfunction syndrome. Rarely, self-mutilation is seen in
psychiatric disorders, learning impairment or some rare syndromes.
Main associated conditions: none.
Differential diagnosis: other causes of white lesions, particularly cinnamon
contact allergy and, rarely, white sponge naevus.
Investigations: none.
Main diagnostic criteria: clinical.
Main treatments: stop the habit if possible.

Figure 3.113  Intraoral lesion:

white lesions from occlusal
frictional trauma (linea alba).

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 Chapter 3 • Differential diagnosis by site

Figure 3.114  Intraoral lesion:

white lesions from cheek biting
(morsicatio buccarum).

Figure 3.115  Intraoral lesion:

white lesions from cheek biting
can mimic white sponge
naevus.

Figure 3.116  Intraoral lesion: white lesions

from stress causing self-induced lesions (see Figure 3.117  Intraoral lesion:
also Figure 3.124). There are Fordyce spots at white lesions from stress
the commissure. causing self-induced lesions.
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White lesions (continued)

Leukoplakia
Hyperkeratotic white mucosal lesions of unknown cause. There are no spe-
cific histopathological connotations. Common. Leukoplakia is a potentially
malignant disorder.
Typical orofacial symptoms and signs: symptomless white patches or
plaques; most are smooth (homogeneous leukoplakias); some are warty
(verrucous leukoplakia); some are mixed white and red lesions (speckled
leukoplakias) (Figures 3.118–3.123). Malignant potential is:
 low in homogeneous leukoplakias

 higher in verrucous leukoplakias, and is

 highest in speckled leukoplakias.

The most important risk factors for malignant transformation are the site
(location on the tongue and/or floor of the mouth) and presence of epithelial
dysplasia.
Main oral sites affected: no special site predilection. Sulcus is mainly affected
in presence of tobacco/betel quid chewing.
Aetiopathogenesis: most cases are idiopathic. Others are related to risk
habits such as smoking, smokeless tobacco, alcohol, snuff-dipping, betel
quid chewing.
Gender predominance: males.
Age predominance: older.
Extraoral possible lesions: see aetiopathogenesis.
Main associated conditions: those caused by lifestyle.
Differential diagnosis: other causes of white lesions.
Investigations: biopsy for epithelial dysplasia and carcinoma.
Main diagnostic criteria and treatments: in all, habits such as tobacco,
alcohol and betel use should be stopped.
 Idiopathic leukoplakias: excision with scalpel or laser is

recommended but this may not reduce transformation, and lesions

may recur.
 Frictional keratoses: mainly affect occlusal line and on alveolar

ridges, are homogeneous and resolve when irritation removed.

 Snuff-dipping: associated predominantly with verrucous keratoses

which can progress to verrucous carcinoma. Excision is

recommended.

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 Chapter 3 • Differential diagnosis by site

Figure 3.118  Intraoral lesion: Figure 3.119  Intraoral lesion: white lesions of
white lesions of sublingual leukoplakia.
leukoplakia.

Figure 3.120  Intraoral lesion: white lesions of Figure 3.121  Intraoral lesion:
plaque-like lichen planus – difficult to white lesions of keratosis from
distinguish from leukoplakia. friction of tooth-brushing (note
abrasion).

Figure 3.122  Intraoral lesion: white Figure 3.123  Intraoral lesion: white
lesions of keratosis from friction of lesions of sublingual leukoplakia.
tooth-brushing (note abrasion).
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White lesions (continued)

 Tobacco-related keratosis: typically resolve on stopping the habit.
 Candidal leukoplakia: C. albicans can cause or colonize other
keratoses, particularly in smokers, and is especially likely to form
speckled leukoplakias at commissures. It may be dysplastic and
have higher premalignant potential than some other keratoses.
Candidal leukoplakias may respond to antifungals and stopping
smoking.
 Syphilitic leukoplakia: especially on the dorsum of tongue, is a

feature of tertiary syphilis but is rarely seen now. Malignant potential

is high. Antimicrobials are indicated.
 Hairy leukoplakia: has a corrugated surface and mainly affects

margins of the tongue almost exclusively. It is seen in the

immunocompromised and is a complication of HIV infection and a
predictor of those who will progress to full-blown AIDS. The
condition appears to be benign, and self-limiting, or may respond
to aciclovir.
 Leukoplakia in chronic renal failure: symmetrical soft keratosis may

complicate chronic renal failure, but resolves after treatment by

renal transplantation or dialysis.
 Sublingual leukoplakia: seen in the floor of the mouth/ventrum of

tongue, they were formerly thought to be naevi (congenital) but,

although of unknown aetiology, are now reported to have malignant
transformation. Often homogeneous, there may be speckled areas.
The surface has an ‘ebbing tide’ appearance. Opinions vary as to
whether the lesion should be left undisturbed or removed surgically
or by laser or cryoprobe.

Lichen planus (LP)

Common condition affecting stratified squamous epithelium (the mouth, skin,
hair, nails or genitals) but the cause is unknown. Children do not usually
inherit it from parents; it is not thought to be infectious but it is sometimes
related to diabetes, drugs, dental fillings, or other conditions. Autoimmune
conditions may occasionally be associated.
Typical orofacial symptoms and signs: lesions may be asymptomatic, espe-
cially if only white. Lesions tend to be bilateral and are occasionally hyper-
pigmented. They may include (Figures 3.124–3.135):
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 Chapter 3 • Differential diagnosis by site

Figure 3.124  Intraoral

lesions: white lesions and
erosions of plaque-like lichen
planus which mimics
leukoplakia.

Figure 3.125  Skin lesions

of lichen planus (purple,
pruritic, papules).

Figure 3.126  Intraoral

lesions: white reticular
lesions of lichen planus in
the most common site
affected.

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White lesions (continued)

Figure 3.127  Intraoral lesions: white and red lesions and desquamative gingivitis
of lichen planus.

Figure 3.128  Intraoral lesions: white lesions of lichen planus.

Figure 3.129  Nail lesions of lichen planus.

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 Chapter 3 • Differential diagnosis by site

Figure 3.130  Intraoral

lesions: white and red
lesions of lichen planus.

Figure 3.131  Intraoral

lesions: white and red
lesions of lichen planus.

Figure 3.132  Intraoral

lesions: white and red
lesions of lichen planus.

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White lesions (continued)

Figure 3.133  Intraoral
lesions: white reticular
lesions of lichen planus.

Figure 3.134  Intraoral

lesions: white lesions of
lichen planus.

Figure 3.135  Intraoral

lesions: white lesions of
lichen planus.

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 Chapter 3 • Differential diagnosis by site

 white lesions most commonly; reticular lesions are most often found
but papular or plaque-like white lesions also
 red lesions of atrophic LP may cause soreness and also can

simulate erythroplasia. LP can cause ‘desquamative gingivitis’.

 erosions are irregular, persistent and painful, with a yellowish slough,

and are often associated with other LP lesions.

Main oral sites affected: buccal mucosa, sometimes on the tongue or
gingivae.
Aetiopathogenesis: usually no aetiological factor is identifiable. A minority are
due to drugs (lichenoid lesions, graft-versus-host disease, liver disorders
(e.g. HCV infection) or reactions to amalgam or gold.
Gender predominance: female.
Age predominance: middle age or older.
Extraoral possible lesions: skin rash: pruritic, polygonal, purplish papules
predominantly on flexor surfaces of wrists, and shins, rarely on the face.
Trauma may induce lesions (Koebner phenomenon). Genital lesions (similar
to oral). Alopecia or nail deformities are seen occasionally.
Main associated conditions: rarely graft-versus-host disease, liver disorders
(e.g. HCV infection), autoimmune disorders.
Differential diagnosis: other causes of white lesions and ulcers, especially
DLE and keratoses.
Investigations: drug history; biopsy.
Main diagnostic criteria: clinical supported by histology.
Main treatments: asymptomatic: no treatment. Symptomatic: corticosteroids
topically and, rarely, intralesionally or systemically. Other drugs such as
retinoids, griseofulvin, ciclosporin or tacrolimus have not proved reliably
superior, or may have adverse effects. There is a small malignant potential
in LP (1–3% after 10 years).

Linea alba
Common.
Typical orofacial symptoms and signs: symptomless horizontal white raised
linea keratosis.
Main oral sites affected: buccal mucosa and often lateral margin of tongue
bilaterally.

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White lesions (continued)

Aetiopathogenesis: trauma usually in a patient who clenches or grinds the
teeth.
Gender predominance: none.
Age predominance: adult.
Extraoral possible lesions: masseteric hypertrophy in some.
Main associated conditions: attrition.
Differential diagnosis: cheek biting, lichen planus, leukoplakia.
Investigations: none.
Main diagnostic criteria: clinical features.
Main treatments: reassurance; relaxation therapy.

Measles
Rarely seen.
Typical orofacial symptoms and signs: Koplik spots – small white spots on
oral mucosa during prodrome (Figure 3.136).
Main oral sites affected: buccal mucosa.
Aetiopathogenesis: measles virus.
Gender predominance: none.
Age predominance: children.
Extraoral possible lesions: rash – maculopapular; conjunctivitis, runny nose,
cough; fever, malaise and anorexia.
Main associated conditions: none.
Differential diagnosis: thrush, Fordyce spots.
Investigations: none.
Main diagnostic criteria: clinical features; rising antibody titre confirmatory.
Main treatments: symptomatic (see herpes simplex).

Oral submucous faibrosis (OSMF)

Uncommon.
Typical orofacial symptoms and signs: tight vertical bands in buccal mucosa
that may progress to severely restricted oral opening (Figure 3.137).
Main oral sites affected: buccal mucosa, sometimes palate or tongue.
Aetiopathogenesis: use of areca nuts (alone as paan, or with betel leaf and
sometimes tobacco and spices in betel quid) and thus virtually only a
disease of adults from the Indian subcontinent and SE Asia.

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 Chapter 3 • Differential diagnosis by site

Figure 3.136  Intraoral lesion: white lesions of Koplik spots in measles prodrome.

Figure 3.137  Intraoral lesion: oral submucous fibrosis showing pallor, banding
and restricted oral opening.

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White lesions (continued)

Gender predominance: female.
Age predominance: adult.
Extraoral possible lesions: can affect oesophagus, and can predispose to
cancers in liver, mouth, oesophagus, stomach, prostate, cervix and lung.
Main associated conditions: often anaemia is present. Maybe other betel
adverse effects.
Differential diagnosis: from scars, lichen planus and scleroderma.
Investigations: biopsy; haematology.
Main diagnostic criteria: clinical features; biopsy; haematology.
Main treatments: stop use of areca nut and chillies and tobacco. Asympto-
matic: observe only. Symptomatic with restricted opening: exercises,
expansion appliances to increase oral opening, intralesional corticosteroids,
surgery. Possibly penicillamine or interferon. Malignant potential – carci-
noma possibly in up to 25%.

White sponge naevus

Rare genetic condition.
Typical orofacial symptoms and signs: asymptomatic, diffuse, bilateral white
lesions with shaggy or spongy, wrinkled surface (Figure 3.138).
Main oral sites affected: buccal mucosa, but sometimes tongue, floor of
mouth, or elsewhere.

Figure 3.138  Intraoral

lesion: white lesions of white
sponge naevus (extends
beyond occlusal area).

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 Chapter 3 • Differential diagnosis by site

Aetiopathogenesis: autosomal dominant, but family history may be

negative.
Gender predominance: none.
Age predominance: from infancy but often recognized later in life.
Extraoral possible lesions: may involve the pharynx, oesophagus, nose, geni-
tals and anus.
Main associated conditions: none.
Differential diagnosis: other white lesions, especially cheek biting.
Investigations: biopsy.
Main diagnostic criteria: clinical features; histology is confirmatory.
Main treatments: reassurance.

Intraoral soft tissue lumps and swellings

Carcinoma (see page 269)
Denture-induced hyperplasia (denture granuloma)
Common.
Typical orofacial symptoms and signs: painless lump that does not enlarge,
has a smooth pink surface, and lies parallel with alveolar ridge and may
be grooved by denture margins (Figures 3.139, 3.140).

Figure 3.139  Intraoral lesion: swelling Figure 3.140  Intraoral lesion: swelling
of denture-induced hyperplasia (see of denture-induced hyperplasia.
Figure 3.140).

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Intraoral soft tissue lumps and swellings (continued)

Main oral sites affected: anterior lower buccal sulcus.
Aetiopathogenesis: pressure from denture flange causes chronic irritation
and hyperplastic response. It is usually related to lower complete denture.
Gender predominance: none.
Age predominance: middle age or older.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: other causes of lumps, especially malignancy.
Investigations: biopsy (excision).
Main diagnostic criteria: usually the diagnosis is clear-cut if the lesion is in
relation to denture flange. If ulcerated, it may mimic carcinoma (rarely).
Main treatments: excision biopsy to confirm diagnosis; relieve denture flange
to prevent recurrence.
Fibrous nodule or lump (‘fibroepithelial polyp’)
Common.
Typical orofacial symptoms and signs: pedunculated or broadly sessile,
sometimes ulcerated, firm or soft swelling with normal overlying mucosa
(Figures 3.141, 3.142). It is termed epulis if on gingival margin.
Main oral sites affected: buccal mucosa, gingiva, palate, tongue.
Aetiopathogenesis: chronic irritation causing fibrous hyperplasia.
Gender predominance: none.
Age predominance: adults.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: papilloma, any other soft tissue tumour.
Investigations: excise for histological confirmation.
Main diagnostic criteria: clinical, confirmed by histology.
Main treatments: excision biopsy.

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 Chapter 3 • Differential diagnosis by site

Figure 3.141  Intraoral lesion: swelling of fibrous lump (fibroepithelial polyp): the
smooth lesion was firm and has normal overlying mucosa.

Figure 3.142  Intraoral lesion: swelling of fibrous lump (fibroepithelial polyp).

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Intraoral soft tissue lumps and swellings (continued)

Lymphangioma
Rare.
Typical orofacial symptoms and signs: colourless, sometimes finely nodular
soft or fluctuant mass (Figure 3.143). Bleeding into lymphatic spaces may
cause sudden purplish discoloration. If in tongue and extensive, it is a rare
cause of macroglossia. If in lip, it is a rare cause of macrocheilia.
Main oral sites affected: tongue, lip.
Aetiopathogenesis: hamartoma or benign neoplasm of lymphatic channels.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: papillomas when small.
Investigations: aspirate, biopsy.
Main diagnostic criteria: clinical and histology.
Main treatments: excise for microscopy.
Human papillomavirus (HPV) infections
HPV most commonly produce papillomas, but are also implicated in various
warts including venereal warts (condyloma acuminatum), and rare disorders,
e.g. multifocal epithelial hyperplasia (Heck disease).
Typical orofacial symptoms and signs: lesions can be warty papules or more
smooth-surfaced, and white or pink in colour (Figures 3.144, 3.145). Vari-
ants include:
 Warts – rare in mouth – are usually transmitted from skin lesions

(verruca vulgaris) and are found predominantly on the lips.

 Papillomas are most common; they are papillated asymptomatic,

pedunculated, either pink or white if hyperkeratinized.

 Condyloma acuminatum (genital warts), transmitted from anogenital

lesions, are found on the tongue or palate. A higher prevalence is

seen in patients with multiple sexual partners, those with sexually
shared diseases or those who are immunocompromised, as in
HIV/AIDS.
 Multifocal epithelial hyperplasia (Heck disease) is rare, predominantly

affects Inuits (Eskimos) and American Indians and causes multiple

papules.
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 Chapter 3 • Differential diagnosis by site

Figure 3.143  Intraoral

lesion: swelling caused by
lymphangioma.

Figure 3.144  Intraoral

lesion: papilloma.

Figure 3.145  Intraoral

lesion: papilloma.

Main oral sites affected: lip, tongue, palate

Aetiopathogenesis: HPV infection.
Gender predominance: none.
Age predominance: wide age range depending on the type.
Extraoral possible lesions: sexually shared infections in some.
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Intraoral soft tissue lumps and swellings (continued)

Main associated conditions: papillomas are found also in some rare syn-
dromes (e.g. Cowden multiple hamartoma syndrome).
Differential diagnosis: fibrous hyperplasia, giant cell fibroma, neoplasms.
Investigations: biopsy.
Main diagnostic criteria: clinical and histology.
Main treatments: excision and microscopy; laser; cryosurgery.
Neoplasms (page 269)
See Figures 3.146 and 3.147.

Figure 3.146  Intraoral

lesion: white lesion thought
to be keratosis but proved to
be carcinoma.

Figure 3.147  Intraoral

lesion: white lesion of
candidal (speckled)
leukoplakia, which contained
a carcinoma.

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 Chapter 3 • Differential diagnosis by site

Tongue lesions
Keypoints
• Coloured lesions on the tongue are often red and caused by erythema
migrans (geographic tongue), lichen planus, glossitis or candidosis but
may indicate erythroplasia or carcinoma.
• Purple or blue lesions on the tongue are usually of vascular origin
(e.g. angioma or Kaposi sarcoma).
• Amalgam tattoos may cause grey or black macules seen in the
ventrum of tongue, floor of mouth.
• Bleeding from the tongue is mainly from trauma or a vascular lesion
such as telangiectasia.
• Soreness of the tongue may be caused by a burn or trauma, mucositis,
or red or ulcerated lesions (see Ulceration).
• White lesions on the tongue may be caused by debris (coated tongue),
thrush (candidosis), lichen planus or keratosis, carcinoma or, rarely, a
congenital cause.
• Ulceration may be due to local causes (especially trauma), aphthae,
malignancy, drugs (e.g. nicorandil), or systemic disease (blood,
infectious, gastrointestinal, or skin disease). Lichen planus is a fairly
common cause of erosions.
• Localized tongue swellings may be congenital (e.g. lingual thyroid,
haemangioma, lymphangioma, lingual choristoma); inflammatory
(infection, abscess, median rhomboid glossitis, granuloma, foliate
papillitis, insect bite); traumatic (e.g. oedema, haematoma); neoplastic
(fibrous lump, papilloma, neurofibroma, carcinoma, sarcoma, granular
cell tumour [granular cell myoblastoma]); or can be due to a foreign
body, cyst, wart or condyloma.
• Diffuse tongue swellings may be congenital (e.g. Down syndrome,
cretinism, mucopolysaccharidoses, lymphangioma, haemangioma);
inflammatory (infection, insect bite, Ludwig angina); traumatic (oedema,
haematoma); angioedema; metabolic (multiple endocrine adenomatosis
type 3 [2b]; deposits (glycogen storage disease, I cell disease,
mucopolysaccharidoses, amyloidosis); acromegaly; or muscular
(Beckwith–Wiedemann syndrome).
• Sore tongue may be associated with obvious localized lesions (any
cause of oral erosion, glossitis or ulceration), foliate papillitis, transient

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Tongue lesions (continued)

lingual papillitis, geographic tongue, median rhomboid glossitis,
deficiency glossitis (anaemias, avitaminosis B), candidosis, or mucositis
(chemotherapy, graft-versus-host disease, or post-irradiation).
• Sore tongue may be a complaint with no identifiable physical
abnormality in anaemia/sideropenia, depression or cancerophobia,
diabetes, glossodynia (burning mouth syndrome), or hypothyroidism.

Ankyloglossia (tongue-tie)
Rare, especially complete or lateral ankyloglossia; partial is more common.
Typical orofacial symptoms and signs: the lingual fraenum anchors the
tongue tip, restricting protrusion and lateral movements (Figure 3.148).
Breastfeeding may be impaired. Later in life, oral cleansing, sometimes
speech, playing a wind instrument, licking an ice-cream cone or even
kissing can be impeded. Lingual gingival recession develops in some cases.
Main oral sites affected: tongue only.
Aetiopathogenesis: may be genetic basis. Most cases are partial.
Gender predominance: male.
Age predominance: from birth.
Extraoral possible lesions: none.
Main associated conditions: some rare syndromes such as orofaciodigital,
Opitz and Beckwith–Wiedemann syndromes.
Differential diagnosis: from tethering of tongue by scarring in epidermolysis
bullosa.
Investigations: assessment of speech or functional nutritional intake
disorders.
Main diagnostic criteria: clinical.
Main treatments: surgery or laser fraenectomy if it causes a severe
impairment.
Amyloidosis
Rare.
Typical orofacial symptoms and signs: manifestations may include mac-
roglossia or deposits elsewhere, and petechia or blood-filled bullae (second-
ary purpura due to blood clotting factor X binding to amyloid) (Figure 3.149).
Main oral sites affected: tongue, lip.

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 Chapter 3 • Differential diagnosis by site

Figure 3.148  Tongue lesion:

ankyloglossia (tongue-tie).

Figure 3.149  Tongue lesion:

macroglossia from amyloidosis,
also showing purpura.

Aetiopathogenesis: amyloid is deposited in tissues of eosinophilic hyaline

material, which has a fibrillar structure on ultramicroscopy. Oral amyloidosis
is almost exclusively primary, when the deposits are of immunoglobulin
light chains (as in myeloma-associated amyloid). Secondary amyloidosis is
now seen mainly in rheumatoid arthritis, ulcerative colitis and autoinflam-
matory disorders, and rarely affects the mouth, and different proteins (AA
proteins) are present. Amyloidosis in long-term renal dialysis patients
(dialysis-related amyloid) is caused by deposition of β2-microglobulin.
Gender predominance: none.
Age predominance: adult.
Extraoral possible lesions: cutaneous purpura, including periorbital.
Main associated conditions: concurrent autoimmune, chronic infectious dis-
eases or malignancies, especially multiple myeloma.
Differential diagnosis: from other causes of macroglossia, and from other
causes of petechia/bullae, such as localized oral purpura and bleeding
tendency.
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Tongue lesions (continued)

Investigations: biopsy. Oral deposits may be detected histologically even in
the absence of clinically apparent lesions. Blood picture; erythrocyte sedi-
mentation rate and marrow biopsy; serum proteins and electrophoresis;
urinalysis (Bence Jones proteinuria); skeletal survey for myeloma.
Main diagnostic criteria: histology and staining with dyes such as Congo red.
Main treatments: chemotherapy with melphalan, corticosteroids or fluoxy­
mesterone. Surgical reduction of the tongue is inadvisable as the tissue is
friable, often bleeds excessively and the swelling quickly recurs.
Benign nerve sheath tumor (neurofibroma;
neurilemmoma [schwannoma])
Rare.
Typical orofacial symptoms and signs: slowly enlarging painless mass
(Figure 3.150).
Main oral sites affected: usually in tongue.
Aetiopathogenesis: benign neoplasm of neurilemmal cells of axonal sheath.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: skin café-au-lait hyperpigmentation.
Main associated conditions: multiple neurofibromas can sometimes be
found in von Recklinghausen neurofibromatosis. Macroglossia and bone
hypertrophy are rarely present. Neurofibromas occasionally undergo sar-
comatous change. Mucosal neuromas (plexiform neuromas) may be seen
in multiple endocrine neoplasia type III or IIB syndrome (with medullary
carcinoma of the thyroid).
Differential diagnosis: from other soft tissue tumours.
Investigations: ultrasound, histopathology; genetic evaluation if multiple
findings.
Main diagnostic criteria: ultrasound, advanced imaging histopathology.
Main treatments: excision and microscopic examination; genetic counselling
when appropriate.

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 Chapter 3 • Differential diagnosis by site

Black hairy tongue (see page 58)

Carcinoma
Most oral cancer is squamous cell carcinoma. Uncommon but important.
Typical orofacial symptoms and signs: may present as a single persistent
ulcer, red or white lesion, lump or fissure or cervical lymphadenopathy.
Usually forms a chronic indurated ulcer typically with raised rolled edge
and granulating floor (Figures 3.151–3.157). Sometimes manifests with
pain. When on gingiva or alveolus it may present with tooth mobility or
non-healing extraction socket.

Figure 3.150  Tongue lesion: swellings on

tongue, lips and face due to
neurofibromatosis.

Figure 3.151  Tongue lesion:

carcinoma.

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Tongue lesions (continued)

Figure 3.152  White lesion

that proved on biopsy to be
carcinoma.

Figure 3.153  White lesion

which developed carcinoma
as in 3.154.

Figure 3.154  Carcinoma.

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 Chapter 3 • Differential diagnosis by site

Figure 3.155  Tongue

lesion: red lesion that proved
on biopsy to be carcinoma.

Figure 3.156  Tongue

lesion: white lesion that
proved to be a carcinoma.

Figure 3.157  Tongue

lesion: carcinoma.

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 Pocketbook of Oral Disease

Tongue lesions (continued)

Main oral sites affected: posterolateral margin of tongue.
Aetiopathogenesis: tobacco and/or alcohol or betel use, human papilloma-
virus (HPV) and potentially malignant disorders may predispose to carci-
noma. Potentially malignant disorders include erythroplakia, dysplastic
leukoplakias, candidosis, tertiary syphilis, lichen planus, discoid lupus ery-
thematosus, Fanconi anaemia, dyskeratosis congenita, oral submucous
fibrosis and Paterson–Kelly syndrome.
Gender predominance: male.
Age predominance: older adults.
Extraoral possible lesions: cervical lymph node or distant metastases;
patients must be thoroughly examined and investigated for these and
second primary tumours elsewhere in the upper aerodigestive tract.
Main associated conditions: tobacco, alcohol or betel use.
Differential diagnosis: other causes of mouth ulcers, especially major
aphthae, traumatic granuloma or, rarely, chronic infections, e.g. tubercu-
losis or deep mycosis (e.g. histoplasmosis).
Investigations: biopsy, fibreoptic pharyngolaryngoscopy with autofluores-
cence (symptom-directed bronchoscopy/oesophagoscopy); ultrasound-
guided fine needle aspiration (USgFNA) biopsy of any neck mass; staging
– tumour, node and metastasis (TNM) – supported by MRI (or CT) from
skull base to sternoclavicular joints (plus USgFNA and/or FDG-PET if any-
thing equivocal). CT of thorax.
Main diagnostic criteria: clinical confirmed by histology.
Main treatments: one or more of the following – frequently using surgery,
sometimes also irradiation and, occasionally, chemotherapy or photody-
namic therapy (PDT). Morbidity can be high after surgery (aesthetics,
impaired speech and swallowing) but higher with radiotherapy (mucositis,
hyposalivation, osteoradionecrosis, taste disturbance, trismus).
The prognosis of intraoral carcinoma is poor – about 50% 5-year survival rates
– because of the high proportion of late-stage cases at presentation.

Candidal glossitis
Uncommon.
Typical orofacial symptoms and signs: diffuse erythema and soreness (Figure
3.158). There may also be patches of thrush, chapped lips and angular
cheilitis.
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 Chapter 3 • Differential diagnosis by site

Main oral sites affected: tongue and vestibule, especially the upper buccal
sulcus posteriorly.
Aetiopathogenesis: opportunistic infection with candidal species, particularly
C. albicans. Predisposing factors include broad-spectrum antimicrobials,
particularly tetracycline; hyposalivation; topical corticosteroids (more often
thrush); immune defect (more often thrush).
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: in women, vaginal candidosis.
Main associated conditions: see aetiopathogenesis.
Differential diagnosis: from deficiency glossitis, contact allergy, geographic
tongue, lichen planus.
Investigations: cytologic smear for candidal hyphae.
Main diagnostic criteria: clinical.
Main treatments: treat predisposing cause; antifungals.

Figure 3.158  Tongue lesion:

depapillation (glossitis) in
hyposalivation complicated by
candidosis.

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 Pocketbook of Oral Disease

Tongue lesions (continued)

Crenated tongue
Common.
Typical symptoms and signs: shallow impressions of the margins of the
tongue due to the neighbouring teeth (Figure 3.159).
Main oral sites affected: lateral borders of tongue.
Aetiopathogenesis: frequent in macroglossia, bruxism and in persons who
have the habit of pressing the tongue hard against the teeth.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: none.
Main associated conditions: often associated with linea alba and sometimes
with tooth attrition.
Differential diagnosis: differentiate from causes of macroglossia.
Investigations: none.
Main diagnostic criteria: history and clinical features.
Main treatments: the condition is of no consequence; reassure.
Deficiency glossitis (see page 134)
Erythema migrans (benign migratory glossitis;
geographic tongue)
Common: 1–2% of adults. The cause is genetic and it is associated com-
monly with a fissured tongue and, rarely, with psoriasis.
Typical orofacial symptoms and signs: often asymptomatic, occasionally
sore, especially with acidic foods (e.g. tomatoes). There are irregular, pink
or red depapillated macular areas, of variable and varying sizes and shapes
(hence ‘geographic’, as it resembles a map), sometimes surrounded by
distinct yellowish slightly raised margins (Figures 3.160–3.164). Red areas
change in shape, increase in size, and spread or move to other areas within
hours.

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 Chapter 3 • Differential diagnosis by site

Figure 3.159  Tongue

lesions: crenated due to
stress and clenching.

Figure 3.160  Tongue lesions:

erythema migrans (geographic tongue).

Figure 3.161  Tongue lesions:

erythema migrans (geographic
tongue).

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 Pocketbook of Oral Disease

Tongue lesions (continued)

Figure 3.162  Tongue lesions: erythema
migrans (geographic tongue).

Figure 3.163  Tongue lesions: erythema

migrans (geographic tongue).

Figure 3.164  Tongue lesions:

erythema migrans (geographic
tongue).

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 Chapter 3 • Differential diagnosis by site

Main oral sites affected: typically involves the dorsum of the tongue, rarely
adjacent oral mucosa (Figure 3.165).
Aetiopathogenesis: genetic. the pathology resembles psoriasis and the
lesions are associated with psoriasis in 4%.
Gender predominance: none.
Age predominance: found from infancy.
Extraoral possible lesions: none.
Main associated conditions: the tongue is often also fissured; relatives may
have psoriasis.
Differential diagnosis: similar lesions may be seen in psoriasis and Reiter
syndrome (reactive arthritis) (transiently). There may also be confusion with
lichen planus and lupus erythematosus.
Investigations: history of migrating pattern.
Main diagnostic criteria: clinical.
Main treatments: reassure; benzydamine topically may ease discomfort.

Figure 3.165  Erythema migrans is rarely seen elsewhere.

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Tongue lesions (continued)

Fissured (scrotal) tongue
Common.
Typical symptoms and signs: multiple fissures on dorsum only (Figure 3.166).
Sometimes the tongue is sore, commonly because of associated erythema
migrans.
Main oral sites affected: dorsum of the tongue.
Aetiopathogenesis: hereditary; increases with age.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: none.
Main associated conditions: fissured tongue is found in many normal persons,
but more often in Down syndrome and in Melkersson–Rosenthal syndrome
(fissured tongue, cheilitis granulomatosa, and unilateral facial nerve
paralysis).
Differential diagnosis: lobulated tongue of Sjögren syndrome.
Investigations: none, but blood picture if tongue is sore.
Main diagnostic criteria: clinical; the diagnosis is usually clear-cut.
Main treatments: the condition is of no consequence; reassure.

Foliate papillitis
Common.
Typical symptoms and signs: foliate papillae occasionally become inflamed
or irritated, with associated enlargement and tenderness, and upon exami-
nation these areas are enlarged and somewhat lobular in outline with an
intact overlying mucosa (Figure 3.167).
Main oral sites affected: posterolateral margin of the tongue.
Aetiopathogenesis: reactive hyperplasia of lymphoid tissue in deep crypts of
foliate papillae.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: carcinoma.
Investigations: if carcinoma suspected biopsy is mandatory.
Main diagnostic criteria: history and clinical features.
Main treatments: reassure.
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 Chapter 3 • Differential diagnosis by site

Figure 3.166  Tongue lesion: foliate papillitis.

Figure 3.167  Tongue lesion: depapillation and fissuring in hyposalivation.

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 Pocketbook of Oral Disease

Tongue lesions (continued)

Macroglossia (see page 114)
Median rhomboid glossitis (central papillary atrophy, posterior
lingual papillary atrophy, posterior midline atrophic candidosis)
Uncommon.
Typical orofacial symptoms and signs: rhomboidal (diamond-shaped) red, or
nodular and depapillated or white, in midline of dorsum of tongue, just
anterior to circumvallate papillae due primarily to the absence of filiform
papillae (Figures 3.168, 3.169).
Main oral sites affected: tongue only.
Aetiopathogenesis: acquired, and is sometimes infected with Candida
species. Smoking may predispose by increasing carriage of Candida.
Similar lesions may be seen in HIV infection.
Gender predominance: males who smoke.
Age predominance: adults.
Extraoral possible lesions: none.
Main associated conditions: may also be candidosis in the palate (‘kissing
lesion’) and elsewhere (‘multifocal candidosis’).
Differential diagnosis: from erythema migrans, erythroplasia and carcinoma
(see above), rarely lingual thyroid, gumma, tuberculosis, deep mycosis, or
granular cell tumour.
Investigations: cytologic smear for Candida albicans. Biopsy is rarely required
(can show pseudoepitheliomatous hyperplasia). Prior to biopsy, ensure the
lesion does not represent a lingual thyroid, as this may be the only thyroid
tissue present.
Main diagnostic criteria: clinical.
Main treatments: antifungals if candidal; stop smoking; reassure. Remove if
recalcitrant or concerned about carcinoma.

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 Chapter 3 • Differential diagnosis by site

Figure 3.168  Tongue lesion: median rhomboid glossitis (a candidal lesion).

Figure 3.169  Tongue lesion: median rhomboid glossitis.

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 Pocketbook of Oral Disease

Tongue lesions (continued)

Traumatic ulcerative granuloma (TUG; also known as traumatic
ulcerative granuloma with stromal eosinophilia [TUGSE])
Uncommon.
Typical orofacial symptoms and signs: chronic single ulcer or lump (Figure
3.170).
Main oral sites affected: lateral margin of the tongue.
Aetiopathogenesis: traumatic in origin. Characterized by a diffuse, pseu­
doinvasive, mixed inflammatory reaction that includes numerous eosin­
ophils and often extends deep into the submucosa and may involve
underlying muscle, and can represent a subset of CD30+ lymphoprolifera-
tive disorders.
Gender predominance: none.
Age predominance: none.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: other causes of ulceration – the rare appearance of
the traumatic ulcerative granuloma and the clinical similarity to carcinoma
cause difficulties in diagnosis. Riga–Fede disease is a form of TUGSE that
appears rarely; it usually occurs on the anterior ventrum of the tongue in
infants who have natal lower incisors due to irritation during suckling.

Figure 3.170  Tongue lesion: TUGSE (traumatic ulcerative granuloma with stromal
eosinophilia).
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 Chapter 3 • Differential diagnosis by site

Investigations: possible biopsy; determine if a foreign body is present.

Main diagnostic criteria: clinical and histology.
Main treatments: this is a benign persistent lesion, eventually self-healing.
Symptomatic care is indicated, with excision if not spontaneously healing
in 3 weeks.

Palatal lesions
Keypoints
Cleft palate is a dramatic lesion with multiple implications, but surprisingly
few other conditions are found only or mainly in the palate.
• Coloured lesions in the palate are not uncommon. Red lesions may be
caused by candidosis, pemphigus, erythroplasia, Kaposi sarcoma or
other lesions. Redness restricted to the denture-bearing area of the
palate is almost invariably denture-related stomatitis (candidosis),
although erythematous candidosis of HIV disease can commonly occur
as a red patch of the palate. Brown pigmented lesions in the palate are
usually naevi, but Kaposi sarcoma and melanoma have a predilection
for this site also and may be brown, black or bluish.
• Bleeding from the palate is rare but may be seen from telangiectasia or
in localized oral purpura.
• Soreness in the palate is frequently of local cause such as trauma or
from a burn (but see Ulceration).
• White lesions may be seen in the palate, especially in smoker’s
keratosis, leukoplakia (mainly proliferative verrucous leukoplakia; PVL),
candidosis and lupus erythematosus and, on the palatal gingivae
mainly, lichen planus.
• Ulceration in the palate is uncommon, and usually due to local causes
(e.g. burns, trauma), aphthae, or systemic conditions (e.g. recurrent
herpes, pemphigoid, pemphigus and lupus erythematosus) but
occasionally due to ulcerated neoplasms such as lymphoma, salivary
gland tumours or carcinoma (oral or antral).
• Lumps/swelling is most commonly caused by unerupted teeth or torus
palatinus – a common central developmental abnormality. Acquired
lumps are often dental abscesses, but fibrous lumps, HPV-associated
warts, and neoplasms (particularly carcinomas, salivary neoplasms,
Kaposi sarcoma and lymphomas) must be excluded.
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Palatal lesions (continued)

Angina bullosa haemorrhagica (ABH; localized oral purpura)
Not uncommon.
Typical orofacial symptoms and signs: blood blisters of rapid onset, with
breakdown in a day or two to ulcer (Figure 3.171). No bleeding tendency.
Main oral sites affected: soft palate, posterior buccal mucosa and occasion-
ally the lateral border of the tongue.
Aetiopathogenesis: trauma in most cases; occasionally associated with use
of corticosteroid inhalers.
Gender predominance: none.
Age predominance: older.
Extraoral possible lesions: pharyngeal involvement occasionally.
Main associated conditions: none.
Differential diagnosis: thrombocytopenia; pemphigoid; amyloidosis.
Investigations: confirm platelet count, full blood picture and haemostasis
normal; biopsy (rarely) to exclude pemphigoid.
Main diagnostic criteria: clinical and blood tests.
Main treatments: reassure; topical analgesics.

Denture-related stomatitis
Common, sometimes termed denture sore mouth, but rarely sore. It is
caused mainly by a yeast (Candida) that usually lives harmlessly in the mouth
and elsewhere and the condition may be precipitated by prolonged wearing
of a dental appliance, especially at night, which allows the yeast to grow. It
predisposes to sores at the corners of the mouth (angular stomatitis or
cheilitis).
Typical orofacial symptoms and signs: diffuse erythema of denture-bearing
area only (Figures 3.172–3.176), with occasional petechia or thrush. It is
almost always asymptomatic, the only known complications being angular
stomatitis and aggravation of palatal papillary hyperplasia.
Main oral sites affected: almost invariably the hard palate alone.
Aetiopathogenesis: usually C. albicans. Constant denture-wearing predis-
poses, but other factors may include poor denture hygiene, and occasion-
ally hyposalivation, high carbohydrate diet and immune defects.
Gender predominance: none.
Age predominance: older patients.
Extraoral possible lesions: may be angular stomatitis.
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 Chapter 3 • Differential diagnosis by site

Figure 3.171  Palatal lesion:

collapsed blood blister from
localized oral purpura
(angina bullosa
haemorrhagica).

Figure 3.172  Palatal lesion:

erythema in denture-related
stomatitis (see same patient
shown in Figure 3.173).

Figure 3.173  Palatal lesion:

erythema in denture-related
stomatitis (patient as in
Figure 3.172).

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 Pocketbook of Oral Disease

Palatal lesions (continued)

Figure 3.174  Palatal lesion:
erythema in denture-related
stomatitis.

Figure 3.175  Palatal lesion:

papillary hyperplasia.

Figure 3.176  Palatal

lesion: extensive papillary
hyperplasia.

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 Chapter 3 • Differential diagnosis by site

Main associated conditions: edentulous; if dentate, usually narrow V-shaped

palate; may have candidal glossitis.
Differential diagnosis: nicotine stomatitis (red form).
Investigations: possibly cytologic smear for hyphae.
Main diagnostic criteria: clear-cut clinically.
Main treatments: leave dentures out at night and for 1 hour immerse in
antifungal solution (e.g. hypochlorite, chlorhexidine); topical antifungals;
attention to dentures; relining with soft material.
Kaposi sarcoma (KS)
Typical orofacial symptoms and signs: lesions are initially red, purple or
brown macules (Figures 3.177, 3.178). Later these become nodular,
extend, disseminate and may ulcerate.
Main oral sites affected: palate (over the greater palatine vessels) or
gingivae.
Aetiopathogenesis: human herpesvirus-8 (HHV-8), now termed Kaposi
sarcoma herpesvirus (KSHV). A malignant neoplasm of endothelial cells,
KS is virtually unknown in the mouth except in HIV/AIDS and related syn-
dromes (commonly) or in immunosuppressed organ transplant patients
(rarely).

Figure 3.177  Palatal lesion: Kaposi sarcoma – multiple purple-brown macules in

typical locations.

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Palatal lesions (continued)

Figure 3.178  Palatal lesion: Kaposi sarcoma – nodular lesion.

Gender predominance: males.

Age predominance: adult.
Extraoral possible lesions: KS elsewhere, especially on the nose.
Main associated conditions: infections, tumours and encephalopathy of HIV/
AIDS.
Differential diagnosis: from other pigmented lesions, especially epithelioid
angiomatosis, haemangiomas and purpura.
Investigations: biopsy; HIV testing.
Main diagnostic criteria: biopsy is confirmatory.
Main treatments: management of underlying predisposing condition if pos-
sible; radiotherapy; vinca alkaloids and other chemotherapy drugs.

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 Chapter 3 • Differential diagnosis by site

Lupus erythematosus (see page 230)

Necrotizing sialometaplasia
A rare non-neoplastic inflammatory condition of the salivary glands that
clinically mimics cancer.
Typical orofacial symptoms and signs: single, often painless, persistent ulcer
(Figure 3.179); less frequently, pain and numbness. The clinical features
may suggest cancer.
Main oral sites affected: soft palate or alveolar ridge.
Aetiopathogenesis: salivary gland ischaemia related to trauma, vascular
obstruction or smoking, leading to infarction.
Gender predominance: male.
Age predominance: older.
Extraoral possible lesions: occasionally the condition affects the pharynx,
breast or other sites.
Main associated conditions: none usually.
Differential diagnosis: other causes of ulcers, especially squamous cell car-
cinoma, salivary gland malignancy or lymphoma.
Investigations: biopsy.
Main diagnostic criteria: clinical and histology.
Main treatments: clinical and histopathological features of necrotizing
sialometaplasia often simulate those of malignancies such as squamous
cell carcinoma or salivary gland malignancy – but it is self-healing.

Figure 3.179  Palatal lesion: necrotizing sialometaplasia clinically and histologically

can mimic carcinoma.

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Palatal lesions (continued)

Smokers’ keratosis (stomatitis nicotina; nicotine stomatitis)
Uncommon. This lesion appears to be benign in itself, but carcinoma may
develop nearby.
Typical orofacial symptoms and signs: symptomless. Red orifices of swollen
minor salivary glands of palate within a widespread white lesion involving
most of the hard and often the soft palates give striking appearance of red
spots on white background (Figures 3.180, 3.181).
Main oral sites affected: palate.

Figure 3.180  Palatal lesion: smokers’ keratosis (stomatitis nicotina) and

tar-stained teeth from tobacco.

Figure 3.181  Palatal lesion: smokers’ keratosis (stomatitis nicotina) and

tar-stained teeth from tobacco.
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 Chapter 3 • Differential diagnosis by site

Aetiopathogenesis: pipe smoking is an important cause but heavy cigarette

use more common.
Gender predominance: male.
Age predominance: older.
Extraoral possible lesions: may be nicotine-stained fingers.
Main associated conditions: tobacco-associated disorders.
Differential diagnosis: Darier disease, inflammatory papillary hyperplasia,
erythroleukoplakia.
Investigations: biopsy.
Main diagnostic criteria: clinical and biopsy.
Main treatments: tobacco cessation.

Oral submucous fibrosis (see page 256).

Gingival lesions
Most gingival and periodontal diseases are inflammatory and related to
dental plaque, and others may be aggravated by the effects of plaque
accumulation. Dental bacterial plaque is a complex biofilm containing various
microorganisms which forms rapidly on teeth, particularly between them,
along the gingival margin and in fissures and pits. Plaque is not especially
obvious clinically, although teeth covered with plaque lack the lustre of
clear teeth. Various dyes (disclosing solutions) can be used to reveal the
plaque.
Keypoints
• Coloured lesions of the gingivae are usually red and most are
inflammatory and plaque related. Chronic gingivitis is the most
common, the redness being restricted to the gingival margins. More
diffuse erythema may signify desquamative gingivitis – typically caused
by pemphigoid or lichen planus. Red lesions occasionally may be
vascular or due to atrophy or malignancy. Brown gingival lesions may
be racial, due to tobacco or betel use, or naevi, and grey or black
lesions are often due to amalgam tattoos.
• Bleeding from the gingivae is usually due to plaque-induced gingivitis
but a bleeding tendency such as leukaemia is occasionally responsible.

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Gingival lesions (continued)

• Soreness of the gingiva may be caused by ulceration – in children
often due to herpetic stomatitis (Figure 3.182).
• Soreness, if persistent and widespread, is often caused by
desquamative gingivitis (Figure 3.183).
• White lesions of the gingivae may be caused by debris (materia alba),
thrush (candidosis), lichen planus or keratosis – mainly proliferative
verrucous leukoplakia.
• Ulceration of the gingiva is usually traumatic or caused by primary or
recurrent herpes simplex infection, or infrequently by necrotizing
gingivitis which may be indicative of immunodeficiency, especially acute
leukaemia, neutropenias or HIV disease. The gingivae can, however, be
affected by most other causes of mouth ulcers.
• Lumps/swelling of the gingivae if localized is usually fibrous epulides or
pyogenic granuloma but malignancy (usually lymphoma, carcinoma or
myeloma) must be excluded. If generalized, swelling may be congenital,
inflammatory, or drug-induced, but occasionally is seen in malignant
disease such as leukaemia. Gingival swelling is most characteristic of
acute myelomonocytic leukaemia, is most common in adults and is
characterized by swelling, petechia, ecchymoses or haemorrhage and
ulceration.
• Tooth mobility is usually caused by periodontitis or trauma but an
immune defect or malignancy or odontogenic tumour may be
underlying. The association between inflammatory periodontal disease
and candidate gene polymorphisms is controversial, but interleukin-1
(IL-1), IL-6, IL-10, IL-12, IL-16 and vitamin D receptor may be
involved. A range of immunodeficiencies or other defects or lifestyle
choices may underlie accelerated or aggressive periodontitis.
• Halitosis (oral malodour) is usually caused by oral or periodontal
infections or ulcers.

Acute ulcerative gingivitis (AUG; acute necrotizing ulcerative

gingivitis, ANUG)
Uncommon, except in immune defects or where hygiene is lacking.
Typical orofacial symptoms and signs: severe gingival soreness and profuse
bleeding, halitosis and a bad taste.

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Figure 3.182  Gingival lesions: ulceration in primary herpes simplex stomatitis.

Figure 3.183  Gingival lesions: erosions and desquamation in lichen planus.

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Gingival lesions (continued)

Main oral sites affected: ulcers at the tips of interdental papillae, occasionally
spreading along gingival margins (Figures 3.184, 3.185).
Aetiopathogenesis: non-contagious anaerobic infection associated with over-
whelming proliferation of Borrelia vincentii and fusiform bacteria. Predis-
posing factors include poor oral hygiene, smoking, viral respiratory infections
such as EBV, and immune defects such as in HIV/AIDS.
Gender predominance: male.
Age predominance: adolescents and young adults.
Extraoral possible lesions: malaise, fever and/or cervical lymph node enlarge-
ment (unlike herpetic stomatitis) are rare. Cancrum oris (noma) is a rare
complication, usually seen in debilitated children, when necrosis of the
buccal mucosa leads to perforation of the cheek and an orofacial fistula.
Main associated conditions: immune defects.
Differential diagnosis: acute leukaemia or herpetic stomatitis.
Investigations: smear for fusospirochaetal bacteria and leukocytes; blood
picture and haematinics; HIV tests and occasionally other immune studies.
Main diagnostic criteria: clear-cut.
Main treatments: amoxicillin or metronidazole (penicillin in pregnant females);
oral debridement and hygiene instruction. Peroxide or perborate mouth-
washes. Periodontal assessment.
Alveolar ridge keratosis
Common.
Typical orofacial symptoms and signs: painless white lesions on alveolus.
Main oral sites affected: usually posterior alveolar ridge (Figures 3.186,
3.187), often bilateral (bilateral alveolar ridge keratosis, BARK) and typically
in retromolar area.

Figure 3.184  Gingival

lesions: ulceration in
necrotizing ulcerative
gingivitis.

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 Chapter 3 • Differential diagnosis by site

Figure 3.185  Gingival lesions: ulceration in necrotizing ulcerative gingivitis.

Figure 3.186  Gingival lesion: keratosis from trauma of mastication on alveolar

ridge.

Figure 3.187  Gingival lesion: keratosis from trauma on alveolar ridge.

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Gingival lesions (continued)

Aetiopathogenesis: friction from mastication.
Gender predominance: none.
Age predominance: adults.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: leukoplakia.
Investigations: biopsy only if concerned (histology features are similar to
those of skin lichen simplex chronicus)
Main diagnostic criteria: clinically obvious.
Main treatments: reassurance.

Chronic marginal gingivitis

Almost universal in adults to some degree.
Typical orofacial symptoms and signs: erythema, oedema and painless swell-
ing of marginal gingivae with bleeding on brushing or eating hard foods
(Figure 3.188).
Main oral sites affected: any.
Aetiopathogenesis: dental bacterial plaque.
Gender predominance: none.
Age predominance: adolescents and adults.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: desquamative gingivitis.
Investigations: periodontal probing.
Main diagnostic criteria: clinically obvious.
Main treatments: oral hygiene, including scaling; root-planing etc., if
periodontitis-associated.

Drug-induced gingival swelling (drug induced gingival

overgrowth: DIGO)
Common.
Typical orofacial symptoms and signs: gingival enlargement characteristically
affects the interdental papillae first, which enlarge and are firm, pale and
tough, with coarse stippling (Figures 3.189, 3.190).
Aetiopathogenesis: the gene encoding CTLA-4 (cytotoxic T-lymphocyte
antigen 4) may influence the gingival swelling, which is a recognized
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Figure 3.188  Gingival lesion: marginal gingivitis.

Figure 3.189  Gingival lesion: drug-induced swelling.

Figure 3.190  Gingival lesion: drug-induced swelling.

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Gingival lesions (continued)

adverse effect of phenytoin, calcium channel blockers (dihydropyridines,
especially nifedipine) and ciclosporin. The swelling is aggravated by dental
bacterial plaque.
Main oral sites affected: any.
Gender predominance: none.
Age predominance: adolescents and adults.
Extraoral possible lesions: possible hirsutism.
Main associated conditions: none.
Differential diagnosis: hereditary gingival fibromatosis.
Investigations: periodontal probing.
Main diagnostic criteria: clinically obvious.
Main treatments: if the drug can be stopped and oral hygiene improved,
the lesions may regress. Often, excision of the enlarged tissue may be
indicated.

Hereditary gingival fibromatosis (HGF)

Uncommon.
Typical orofacial symptoms and signs: gingival enlargement characteristically
affects the interdental papillae first, which enlarge and are firm, pale
and tough, with coarse stippling (Figure 3.191). Generalized painless
gingival enlargement is obvious especially during the transition from
deciduous to permanent dentition. The swelling, if gross, may move or
cover the teeth and even bulge out of the mouth. There are occasional
associations with supernumerary teeth. Variants include tuberosity enlarge-
ments (Figure 3.192).
Aetiopathogenesis: autosomal dominant or recessive. The gene responsible
may be SOS1 on chromosome 2.
Main oral sites affected: any.
Gender predominance: male.
Age predominance: from early childhood.
Extraoral possible lesions: possible hirsutism and, rarely, sensorineural deaf-
ness and rare syndromes.
Main associated conditions: none usually.
Differential diagnosis: drug-induced gingival swelling; juvenile hyaline
fibromatosis and infantile systemic hyalinosis.
Investigations: periodontal probing.
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Figure 3.191  Gingival lesion: swelling in hereditary gingival fibromatosis.

Figure 3.192  Gingival lesions: swelling in a variant of hereditary gingival

fibromatosis.

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Gingival lesions (continued)

Main diagnostic criteria: clinically obvious. The family history is positive.
Main treatments: often, excision of the enlarged tissue may be indicated.

Pregnancy gingivitis
Common mainly after 2nd month of pregnancy.
Typical orofacial symptoms and signs: erythema, swelling and liability to
bleed (Figure 3.193).
Main oral sites affected: gingivae.
Aetiopathogenesis: exacerbation of chronic gingivitis by pregnancy. A prolif-
erative response at the site of a particularly dense plaque accumulation
may lead to pregnancy epulis (pyogenic granuloma).
Gender predominance: female.
Age predominance: adolescents and adults.
Extraoral possible lesions: features of pregnancy.
Main associated conditions: pregnancy.
Differential diagnosis: gingivitis, pyogenic granulomas.
Investigations: none.
Main diagnostic criteria: history and clinical.
Main treatments: oral hygiene.

Pregnancy epulis
Common mainly after 2nd month of pregnancy.
Typical orofacial symptoms and signs: soft, red or occasionally firm, swelling
of dental papilla (Figure 3.194). It may be asymptomatic unless traumatized
by biting or toothbrushing.
Main oral sites affected: gingivae facially and anteriorly.
Aetiopathogenesis: pyogenic granuloma – proliferative response at the site
of a particularly dense plaque accumulation.
Gender predominance: female.
Age predominance: adolescents and adults.
Extraoral possible lesions: features of pregnancy.
Main associated conditions: pregnancy.
Differential diagnosis: gingivitis, fibrous epulis, giant cell tumour, Wegener
granulomatosis.
Investigations: none usually. Biopsy sometimes; pregnancy test
occasionally.
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 Chapter 3 • Differential diagnosis by site

Main diagnostic criteria: history and clinical.

Main treatments: oral hygiene. If asymptomatic, leave alone – may regress
after childbirth (parturition). If symptomatic or if patient desires, excision
biopsy.

Figure 3.193  Gingival lesion: swelling in pregnancy gingivitis.

Figure 3.194  Gingival lesion: swelling caused by pyogenic granuloma in

pregnancy (pregnancy epulis).
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Jaw and musculoskeletal conditions

Keypoints
• Odontogenic infections are a common cause of lesions in the jaws
(Figures 3.195, 3.196).
• Other infections such as actinomycosis and osteomyelitis are far less
common but almost invariably more serious.
• Jaw cysts and tumours are uncommon and usually of odontogenic
origin and some (ameloblastoma and keratocystic odontogenic tumour)
are problems since they tend to recur after treatment.
• Diseases of bone such as fibro-osseous lesions are uncommon but can
be disfiguring and aggressive.
• Bone necrosis (osteonecrosis) can follow radiotherapy to the jaws, or
the use of drugs (bisphosphonates especially).

Actinomycosis
Rare.
Typical orofacial symptoms and signs: chronic purplish swelling eventually
discharging pus through sinuses.
Main oral sites affected: below mandibular angle (not arising from the lymph
nodes).
Aetiopathogenesis: bacterial infection that may follow jaw fracture or tooth
extraction. Caused usually by Actinomyces species such as A. israelii or
A. gerencseriae, it can also be caused by Propionibacterium propionicun.
Gender predominance: male.
Age predominance: young adult.
Extraoral possible lesions: lung or gastrointestinal.
Main associated conditions: none except possible preceding trauma.
Differential diagnosis: mycobacterial or mycotic infection, or other causes of
facial swelling.
Investigations: examination of purulent leakage for ‘sulphur granules’ (bacte-
rial colonies), culture and sensitivities.
Main diagnostic criteria: history, clinical and microbiology.
Main treatments: prolonged antibacterial therapy, usually with penicillin.

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Figure 3.195  Jaw lesions: infection – actinomycosis.

Figure 3.196  Jaw lesions: infected odontogenic cyst.

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Jaw and musculoskeletal conditions (continued)

Antral carcinoma
Rare; usually a squamous carcinoma.
Typical orofacial symptoms and signs: may be asymptomatic until carcinoma
invades orbit or other structures to cause swelling of cheek or eye area,
nasal obstruction or pain. Symptoms depend on main direction of spread.
 Oral invasion: pain and swelling of palate (Figure 3.197), alveolus or

sulcus. Teeth may loosen.

 Ocular invasion: ipsilateral epiphora (tears overflowing), diplopia

(double vision) or proptosis (eye protrusion).

 Nasal invasion: nasal obstruction or a bloodstained discharge.

Main oral sites affected: may penetrate palate or maxillary vestibule.

Aetiopathogenesis: the only identified predisposing factor appears to be
occupational exposure to wood dust.
Gender predominance: male.
Age predominance: older.
Extraoral possible lesions: see above.
Main associated conditions: none.
Differential diagnosis: sinusitis, polyps and salivary gland neoplasms.
Investigations: biopsy, radiographs and MRI.
Main diagnostic criteria: clinical supported by histology and imaging (shows
opaque antrum and later destruction of antral wall or floor).
Main treatments: surgery (sometimes with radiotherapy). Prognosis 10–30%
5-year cure rate; better in those with no lymph node involvement.

Fibrous dysplasia
Rare fibro-osseous disorder.
Typical orofacial symptoms and signs: painless unilateral swelling of jaw
(Figure 3.198).
Main oral sites affected: posterior maxilla.
Aetiopathogenesis: mutation in the gene encoding G protein.
Gender predominance: none.
Age predominance: from childhood. The polyostotic type is seen mainly
in young children and the monostotic type is more common in the
twenties.
Extraoral possible lesions: see below.

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 Chapter 3 • Differential diagnosis by site

Figure 3.197  Jaw lesions: antral carcinoma.

Figure 3.198  Jaw lesions: fibrous dysplasia in one maxilla.

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Jaw and musculoskeletal conditions (continued)

Main associated conditions: Albright syndrome is polyostotic fibrous dyspla-
sia with skin hyperpigmentation and endocrinopathy (precocious puberty in
females and hyperthyroidism in males).
Differential diagnosis: central ossifying fibroma, diffuse sclerosing osteomy-
elitis, segmental odontomaxillary dysplasia, Paget disease.
Investigations: radiography; biopsy.
Main diagnostic criteria: CT can best assess the extent; histology.
Main treatments: typically self-limiting and no treatment needed. Bisphos-
phonates can help and cosmetic surgery may be indicated if there is major
deformity or the eye is affected.

Gardner syndrome
This rare condition presents with jaw osteomas, polyposis coli, epidermoid
cysts, desmoid tumours and pigmented lesions of fundus of eye.
Langherhans cell histiocytoses (histiocytosis X)
This rare disorder of Langherhans dendritic cells includes:
• Solitary eosinophilic granuloma of bone – localized chronic form.
• Multifocal eosinophilic granuloma (Hand–Schuller–Christian disease)
– disseminated chronic form.
• Letterer–Siwe disease – disseminated acute form.

Masseteric hypertrophy
Uncommon.
Typical orofacial symptoms and signs: painless bilateral or unilateral swelling
of masseter muscle(s) (Figure 3.199).
Main oral sites affected: masseter.
Aetiopathogenesis: clenching or bruxism.
Gender predominance: none.
Age predominance: adult.

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 Chapter 3 • Differential diagnosis by site

Extraoral possible lesions: see below.

Main associated conditions: linea alba; crenated tongue; tooth attrition.
Differential diagnosis: may clinically simulate the appearance of a
parotid mass.
Investigations: cross-sectional imaging.
Main diagnostic criteria: clinical.
Main treatments: typically self-limiting and no treatment needed. Botulinum
toxoid can help. Surgery may be indicated if there is a serious cosmetic
defect.

Figure 3.199  Jaw lesions: bilateral masseteric hypertrophy due to clenching and
bruxism.

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Jaw and musculoskeletal conditions (continued)

Odontogenic cysts and tumours
Uncommon. Cysts can be inflammatory (radicular, residual and paradental)
or developmental (several subtypes), and cysts and tumours are classified
into specific types by the World Health Organization (1992 and 2005).
Typical orofacial symptoms and signs: often asymptomatic and an incidental
finding on imaging (Figures 3.200–3.205). Slow-growing but may eventu-
ally cause:
 swelling; initially a smooth bony hard lump with normal overlying

mucosa but, as bone wall thins, it may crackle on palpation (‘egg

shell’ crackling), and may resorb bone to show as a bluish fluctuant
swelling
 discharge

 pain; if infected or the jaw fractures pathologically.

Main oral sites affected: mandible.

Aetiopathogenesis: odontogenic cysts and tumours arise from odontogenic
ectoderm, mesenchyme or a combination (ectomesenchyme) and may be
at the site of a tooth germ, or associated with a tooth.
Gender predominance: male.
Age predominance: adult.
Extraoral possible lesions: facial enlargement if large size.
Main associated conditions: keratocystic odontogenic tumour (KCOT,
formerly termed odontogenic keratocyst) has a tendency to recur and
may be associated with naevoid basal cell carcinoma syndrome (Gorlin
syndrome).
Differential diagnosis: central jaw granuloma, early fibro-osseous lesions.
Investigations: imaging; biopsy; occasionally aspiration.
Main diagnostic criteria: clinical, imaging and histology.
Main treatments: surgery; enucleation or marsupialization. Most odontogenic
cysts and most tumours have a good prognosis. Ameloblastoma and KCOT
are a particular problem since these odontogenic tumours must be excised
but tend to recur. Malignant tumours are rare but have a poor prognosis.

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 Chapter 3 • Differential diagnosis by site

Figure 3.200  Jaw lesions:

complex odontome.

Figure 3.201  Jaw lesions:

ameloblastoma, which
coincidentally envelops the
third molar.

Figure 3.202  Jaw lesions:

keratocystic odontogenic
tumour.

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Jaw and musculoskeletal conditions (continued)

Figure 3.203  Jaw lesions:
dentigerous cyst (compare
with Figure 3.201).

Figure 3.204  Jaw lesions:

radicular cyst.

Figure 3.205  Jaw lesions:

central giant cell granuloma.

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 Chapter 3 • Differential diagnosis by site

Osteitis (alveolar osteitis or dry socket)

Common.
Typical orofacial symptoms and signs: onset of fairly severe pain 2–4 days
after tooth extraction, bad taste and halitosis. The socket contains no clot,
the surrounding mucosa is inflamed and the area is tender to palpation.
Main oral sites affected: molar regions.
Aetiopathogenesis: the extraction socket blood clot breaks down from the
action of fibrinolysins, and the socket becomes ‘dry’ with localized osteitis.
Most common after traumatic extraction under local anaesthesia in the
mandibular molar region. Smoking, oral contraceptive use, immuno­
compromising conditions, bone disorders and use of bisphosphonates
predispose.
Gender predominance: male.
Age predominance: young adult.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: fracture, osteomyelitis, osteosarcoma, other jaw
malignancies.
Investigations: imaging may be indicated to exclude other causes of post­
operative pain such as pathology associated with another tooth or a jaw
fracture.
Main diagnostic criteria: clinical.
Main treatments: irrigate socket and dress with an obtundent antiseptic
preparation. Systemic antimicrobial therapy is rarely warranted.

Osteomyelitis
Rare.
Typical orofacial symptoms and signs: severe pain and tenderness, swelling,
labial hypoaesthesia and eventual loss of teeth, discharge of pus and
necrotic bone (sequestrate).
Main oral sites affected: mandible.
Aetiopathogenesis: mixed infection (usually bacterial), typically originating
from trauma or odontogenic infection. Predisposed by trauma, tobacco,
alcohol, anaemia, immune defects and malnutrition.
Gender predominance: male.
Age predominance: young adult.

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Jaw and musculoskeletal conditions (continued)

Extraoral possible lesions: sinuses.
Main associated conditions: fever.
Differential diagnosis: dry socket, osteonecrosis, actinomycosis.
Investigations: imaging, pus for Gram staining, aerobic and anaerobic culture
and sensitivities, full blood picture, white cell count and erythrocyte sedi-
mentation rate.
Main diagnostic criteria: history and clinical features, raised erythrocyte
sedimentation rate and white cell count, and imaging findings once the
acute inflammatory reaction leads to bone lysis (osteolysis usually takes
2–3 weeks). MRI has high sensitivity in detecting cancellous marrow abnor-
malities. Bone scan may be indicated.
Main treatments: aggressive therapy with penicillin, clavulanic acid/
amoxicillin, or clindamycin and metronidazole. Analgesia. Later, seques-
trectomy may be indicated.

Osteonecrosis
Uncommon jaw osteonecrosis is an important condition that can be caused
by exposure to the following (most important is highlighted):
• Bevacizumab
• Bisphosphonates
• Bortezomib
• Corticosteroids
• Denosumab
• Heavy metals
• Immunocompromising states
• Irradiation in the head and neck
• Red phosphorus
• Severe herpes zoster or other infections
• Sunitinib
• Thalidomide
• Toxic endodontic materials.
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) 
Uncommon.
Typical orofacial symptoms and signs: exposed bone in a non-irradiated
mouth, with or without external sinuses, pain and pathological fracture.

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 Chapter 3 • Differential diagnosis by site

Main oral sites affected: mandible.

Aetiopathogenesis: damage to osteoclasts from intravenous bisphospho-
nates (pamidronate and/or zoledronic acid) and very occasionally from oral
bisphosphonates such as alendronic acid. Predisposing factors for BRONJ
also include use of other anti-angiogenic agents, advanced age, diabetes
and dental trauma. Genetic factors may be a risk factor. Exodontia (tooth
extraction) is the main precipitant.
Gender predominance: female.
Age predominance: older adults.
Extraoral possible lesions: may be sinus on face or neck.
Main associated conditions: none.
Differential diagnosis: osteomyelitis and osteoradionecrosis.
Investigations: radiography.
Main diagnostic criteria: clinical supported by imaging (bone has a moth-
eaten appearance similar to that seen in osteoradionecrosis).
Main treatments: minimal interference is recommended; antimicrobials and
analgesics only. Prevention is crucial. In advanced cases surgical debride-
ment or resection in combination with antibiotic therapy may offer palliation
with resolution of acute infection and pain.
Osteoradionecrosis (ORN) 
Uncommon.
Typical orofacial symptoms and signs: exposed bone in an irradiated mouth,
with or without external sinuses, pain and pathological fracture.
Main oral sites affected: mandible.
Aetiopathogenesis: radiation-induced endarteritis obliterans. Risk of ORN is
greatest when radiation dose exceeds 60 Gy, from 10 days before to
several years after radiotherapy (particularly at 3–12 months) and in the
malnourished or immunoincompetent patient. The initiating event is often
exodontia.
Gender predominance: none.
Age predominance: older adult.
Extraoral possible lesions: may be sinus on face or neck.
Main associated conditions: severe salivary gland hypofunction, caries,
restricted mouth opening.
Differential diagnosis: osteomyelitis, osteosarcoma, other malignancies of
the jaw.
Investigations: radiography.

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Jaw and musculoskeletal conditions (continued)

Main diagnostic criteria: history and clinical features, imaging (‘moth-eaten’
appearance of the jaw).
Main treatments: local cleansing, and antimicrobials, especially tetracycline
(which has high bone penetrance) long-term are indicated; hyperbaric
oxygen and sequestrectomy may assist. Emphasis on oral disease preven-
tion. In severe cases surgery with jawbone reconstruction is needed.

Paget disease
Uncommon fibro-osseous disease affecting bone and cementum.
Typical orofacial symptoms and signs: progressive jaw swelling often associ-
ated with severe bone pain and hypercementosis. Dense bone and hyper-
cementosis make tooth extraction difficult, and there is a liability to
haemorrhage and infection.
Main oral sites affected: maxilla.
Aetiopathogenesis: genes involved include the sequestosome1 gene, with
disorganization of osteoclastogenesis (osteoclast formation), disrupted
bone remodelling and an anarchic alternation of bone resorption and
apposition causing mosaic-like ‘reversal lines’. Viruses have been impli-
cated – possibly measles or respiratory syncytial virus.
Gender predominance: male.
Age predominance: older.
Extraoral possible lesions: typically polyostotic (affects several bones) and
may affect skull, skull base, sphenoid, orbital and frontal bones, bowing of
long bones, pathological fractures, broadening/flattening of chest and
spinal deformity. Increased bone vascularity can lead to high-output cardiac
failure. The healing after extractions is delayed. Predisposition to osteosa-
rcoma. Constriction of skull foraminae may cause cranial neuropathies.
Main associated conditions: as above.
Differential diagnosis: bone neoplasms.
Investigations: biochemistry (see below), radiography, biopsy.
Main diagnostic criteria: radiography (in early lesions, large irregular areas
of relative radiolucency [osteoporosis circumscripta] are seen, but later
there is increased radio-opacity, with appearance of ‘cotton wool’ pattern);
normal serum calcium and phosphate but raised serum alkaline phos-
phatase and urinary hydroxyproline, histology.
Main treatments: bisphosphonates or calcitonin.
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 Chapter 3 • Differential diagnosis by site

Sinusitis
Common.
Typical orofacial symptoms and signs: nasal drainage (rhinorrhea or post-
nasal drip), nasal blockage, pain in teeth worse on biting or leaning over,
halitosis. There may be tenderness on palpation over the maxillary sinuses,
nasal turbinate swelling, erythema and injection; mucus; sinus tenderness;
allergic ‘shiners’ (dark circles around eyes), pharyngeal erythema, otitis, etc.
Aetiopathogenesis: bacterial infection is more likely after:
 allergic (vasomotor) rhinitis and nasal polyps

 viral upper respiratory tract infection (URTI)

 diving or flying

 nasal foreign bodies

 periapical infection of maxillary posterior teeth

 oro-antral fistula

 prolonged endotracheal intubation

 cilia damage (e.g. tobacco smoke exposure.

In acute sinusitis, Streptococcus pneumoniae, Haemophilus influenzae

and (in children) Moraxella catarrhalis. Staphylococcus aureus may occasion-
ally be implicated. In chronic sinusitis, also anaerobes, especially Porphy-
romonas (Bacteroides).
Gender predominance: none.
Age predominance: teens and up to 40 years.
Extraoral possible lesions: headache, fever, cough, malaise.
Main associated conditions: otitis.
Differential diagnosis: referred pain, or TMJ pathology.
Investigations: none usually; radiography, nasendoscopy.
Main diagnostic criteria: history, clinical (sinus tenderness and dullness on
transillumination), imaging.
Main treatments: analgesics, decongestants (ephedrine), antibiotics for at
least 2 weeks in acute sinusitis – amoxicillin (or ampicillin or co-amoxiclav),
or a tetracycline such as doxycycline, or clindamycin. Chronic sinusitis
responds best to drainage by functional endoscopic sinus surgery (FESS).
Temporomandibular pain-dysfunction syndrome (TMPD;
myofascial pain dysfunction [MFD], facial arthromyalgia [FAM],
mandibular dysfunction, or mandibular stress syndrome)
A common complaint, it appears to be related to muscle spasm (and sub-
sequent ischaemic pain) arising from stress, joint damage or habits (e.g.
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Jaw and musculoskeletal conditions (continued)

tooth clenching or grinding). There are no serious long-term consequences;
arthritis does not result and it is not inherited. Various treatments such as
rest, exercises, splints, physiotherapy, or drugs may be advocated but the
symptoms usually clear spontaneously after some months; hence, it is one
of the most controversial areas in dentistry.
Typical orofacial symptoms and signs: triad of temporomandibular joint (TMJ)
symptoms – clicking, jaw limitation of opening or locking, and pain (mainly
from masticatory muscle spasm).
Main oral sites affected: TMJ area but can spread fairly widely, ipsilaterally
(Figure 3.206).
Aetiopathogenesis: trauma and stress appear to predispose through increas-
ing tension in the masticatory muscles.
Gender predominance: female.
Age predominance: teens and up to 40 years.
Extraoral possible lesions: headaches, neck aches and lower back pain.
Main associated conditions: psychogenic disorders.
Differential diagnosis: referred pain, rheumatoid arthritis, osteoarthritis, or
other TMJ pathology.
Investigations: none usually; radiography if TMJ pathology suspected.
Main diagnostic criteria: history, clinical (may be crepitus from the TMJ,
limited or deviated opening, clicking or popping in the TMJ and/or diffuse
tenderness or spasm on palpation of masseter, temporalis, medial or lateral
pterygoid muscles).
Main treatments: treatment is indicated if there is pain. Try analgesics;
reduce psychological stress (by reassurance), rest TMJ by use of:
 soft diet

 avoidance of trauma, wide-opening and abnormal habits

 warmth, massage and remedial jaw exercises

 non-steroidal anti-inflammatory drugs, topically as a gel, or

systemically.
It may sometimes also be helpful to use:
 muscle relaxants (e.g. benzodiazepines)

 hard plastic occlusal splints.

Surgery may be required for the extremely small number with obvious intra-
articular pathology.
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 Chapter 3 • Differential diagnosis by site

Figure 3.206  Temporomandibular joint lesions: location of pain from TMJ

pain-dysfunction.

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 Pocketbook of Oral Disease

Neurological and pain disorders

Keypoints
• Facial palsy is most commonly caused by a stroke, or Bell palsy,
• Infections may cause Bell palsy and, since it is a treatable cause, Lyme
disease should always be excluded.
• Orofacial pain mostly has an odontogenic or other local cause.
• Idiopathic facial pain may indeed be idiopathic, but organic causes
must be excluded.

Bell palsy
Typical orofacial symptoms and signs: lower motor neurone lesion with
complete unilateral facial palsy (Figures 3.207, 3.208); and sometimes loss
of taste and/or hyperacusis (heightened hearing).
Aetiopathogenesis: inflammation and oedema of the facial nerve, usually in
the stylomastoid canal, with demyelination, usually caused by a virus (e.g.
HSV, HIV) or bacteria (otitis media; Borrelia burgdorferi – Lyme disease).
Gender predominance: none.
Age predominance: young adult.
Extraoral possible lesions: none.
Main associated conditions: rarely pregnancy, diabetes, hypertension, Crohn
disease/OFG, sarcoidosis, lymphoma.
Differential diagnosis: stroke, inflammatory, traumatic and neoplastic lesions.
Investigations: neurological; MRI or CT; blood pressure; fasting blood sugar
level tests to exclude diabetes; serology to exclude virus infections; serum
angiotensin-converting enzyme (SACE) levels to exclude sarcoidosis; serum
antinuclear antibodies (ANA) to exclude connective tissue disease; and
enzyme-linked immunosorbent assay (ELISA) for B. burgdorferi to exclude
Lyme disease.
Main diagnostic criteria: clinical.
Main treatments: treat defined causes; systemic corticosteroids.

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 Chapter 3 • Differential diagnosis by site

Figure 3.207  Neurological: right sided facial palsy.

Figure 3.208  Neurological: right sided facial palsy.

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Neurological and pain disorders (continued)

Giant cell arteritis (cranial or temporal arteritis)
Rare but may threaten sight and is thus an emergency.
Typical orofacial symptoms and signs: pain on chewing, or headache
usually concentrated in the temple – which may be tender to touch (Figure
3.209).
Main oral sites affected: temple; rarely tongue or lip.
Aetiopathogenesis: inflammatory condition that affects medium-sized arter-
ies, in particular the temporal and optic artery.
Gender predominance: female.
Age predominance: older.
Extraoral possible lesions: superficial temporal artery may be dilated and
tender.
Main associated conditions: polymyalgia rheumatica.
Differential diagnosis: other causes of headache.
Investigations: erythrocyte sedimentation rate, arterial biopsy, echo Doppler.
Main diagnostic criteria: clinical supported by raised erythrocyte sedimenta-
tion rate, and arteritis on biopsy.
Main treatments: can lead to a sudden loss of vision from retinal artery
blockage – an emergency necessitating systemic corticosteroid
treatment.

Idiopathic facial pain (atypical facial pain)

Common. The cause is not completely known but may the pain may result
from increased nerve sensitivity and there may be a background of stress.
Atypical odontalgia (chronic continuous alveolar dental pain: CCADP) is gen-
erally regarded as a variant.
Typical orofacial symptoms and signs: a dull boring or burning continuous
poorly localized pain that does not disturb sleep and is confined initially to
a limited area (unrelated to the trigeminal nerve distribution) on one side
only, but may spread. Other features are a lack of objective signs, lack of
detectable dental/jaw problems and a poor treatment response. Often also
multiple other complaints, such as dry mouth and bad taste.
Main oral sites affected: maxilla.
Aetiopathogenesis: no known organic cause – rather, a psychogenic basis.
Gender predominance: female.
Age predominance: older.
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 Chapter 3 • Differential diagnosis by site

Temporal artery swells

and may be tender

Vision
(blurred or double
vision, blindness)

Other arteries also may swell

Figure 3.209  Neurological and pain disorders: giant cell arteritis features.

Extraoral possible lesions: headaches, chronic back pain, irritable bowel

syndrome and/or dysmenorrhoea.
Main associated conditions: stress, anxiety, a few have hypochondriases,
neuroses (often depression) or psychoses.
Differential diagnosis: other causes of orofacial pain including local and
neurological causes, and Lyme disease.
Investigations: dental, otolaryngological, and neurological examination, and
imaging (tooth/jaw/sinus/skull radiography and MRI/CT scan of the head
with particular attention to skull base), serology for Borrelia burgdorferi.
Main diagnostic criteria: clinical, with negative investigation results.
Main treatments: cognitive-behavioural therapy (CBT); antidepressant trial,
e.g. nortriptyline, may be warranted. There is a high level of utilization of
healthcare services with multiple failed consultations and treatment
attempts.
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Neurological and pain disorders (continued)

Trigeminal neuralgia
Uncommon.
Typical orofacial symptoms and signs: pain is unilateral in branch or division
of trigeminal nerve and is severe, sharp ‘stabbing’ intermittent, lasting
seconds only. Often there is a trigger zone. There are no other neurological
symptoms or signs.
Main oral sites affected: mandibular division of trigeminal nerve (Figure
3.210).
Aetiopathogenesis: unknown; possibly pressure from an arteriosclerotic pos-
terior inferior cerebellar artery on the trigeminal nerve root.
Gender predominance: female.
Age predominance: older.
Extraoral possible lesions: trigger zones on face.
Main associated conditions: none.
Differential diagnosis: other causes of orofacial pain – local causes (usually
dental); neurological disorders (multiple sclerosis or brain tumour); vascular
causes (migrainous neuralgia; cranial arteritis); psychological disorders
(idiopathic facial pain, oral dysaesthesia) and referred (cardiac) pain very
rarely.
Investigations: MRI of trigeminal nerve (Figure 3.211).
Main diagnostic criteria: clinical, and typical beneficial response to the anti-
convulsant carbamazepine.
Main treatments: carbamazepine prophylaxis (care in Han Chinese who may
be hypersensitive); uncontrolled pain may be treated by injecting glycerol
or freezing the peripheral nerve (cryosurgery), or neurosurgery.

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 Chapter 3 • Differential diagnosis by site

Figure 3.210  Neurological and pain disorders: neuralgia can affect one or
occasionally more trigeminal nerve divisions. Arrow: lancinating pain in the
mandibular division (the most common site).

Figure 3.211  Neurological and pain disorders: brain scans may be indicated to
exclude a tumour or other pathology.
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Teeth-specific disorders
Amelogenesis imperfecta
Uncommon genetic condition.
Typical orofacial symptoms and signs: several types include:
 Hypocalcified type: normal enamel matrix and morphology but

incomplete calcification. Morphology is normal but the enamel is

opaque, white to brownish-yellow and darkening with age and the
teeth are soft and chip under attrition.
 Hypoplastic type: defective matrix but normal calcification results in

the enamel being hard and shiny but malformed, often pitted and
stained (Figure 3.212).
 Hypomineralized type: defect in the maturation of the enamel’s

crystal structure. Causes soft enamel, which is mottled, opaque

white, yellow and brown (Figure 3.213).
Aetiopathogenesis: genetic defect with wide variety of patterns.
Gender predominance: none.
Age predominance: from infancy.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: fluorosis, tetracycline staining, dentinogenesis imper-
fecta, incisor-molar hypomineralization, environmental enamel hypoplasia,
oculo-dento-digital dysplasia.
Investigations: imaging.
Main diagnostic criteria: clinical, family history; radiography of teeth.
Main treatments: remineralization of teeth and restorative dental care.

Caries
See dental textbooks.

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 Chapter 3 • Differential diagnosis by site

Figure 3.212  Teeth inherited defects – amelogenesis imperfecta (hypoplastic

type).

Figure 3.213  Teeth inherited defects – amelogenesis imperfecta (hypocalcified

type).

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 Pocketbook of Oral Disease

Teeth-specific disorders (continued)

Dentinogenesis imperfecta
Rare.
Typical orofacial symptoms and signs: teeth are abnormally translucent,
yellow to blue-grey (Figures 3.214, 3.215). Enamel splits off. Roots are
short; pulp is rapidly obliterated by secondary dentine:
 Type I (associated with osteogenesis imperfecta); most severe in

deciduous dentition; bone fractures; blue sclera; progressive

deafness
 Type II (hereditary opalescent dentine): defect equal in both

dentitions
 Type III (brandywine type): associated with occasional shell teeth.

Aetiopathogenesis: usually autosomal dominant inheritance.

Gender predominance: none.
Age predominance: from birth.
Extraoral possible lesions: Type I is associated with osteogenesis
imperfecta.
Main associated conditions: as above.
Differential diagnosis: amelogenesis imperfecta, tetracycline staining and
dentine dysplasia.
Investigations: imaging.
Main diagnostic criteria: family history; radiography of teeth/bones.
Main treatments: restorative dental care.

Fluorosis
Uncommon in UK/USA. Particularly common in parts of Middle East, India
and Africa.
Typical orofacial symptoms and signs: many teeth affected:
 mildest form: white flecks or spotting or diffuse cloudiness

 more severe: yellow-brown or darker patches

 most severe: yellow-brown or darker patches, sometimes with

pitting (Figure 3.216).

Aetiopathogenesis: enamel defects caused by high levels of fluoride in drink-
ing water.
Gender predominance: none.
Age predominance: from time of tooth appearance.
Extraoral possible lesions: none.
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 Chapter 3 • Differential diagnosis by site

Figure 3.214  Teeth inherited defects: dentinogenesis imperfecta – typical

discoloration and attrition.

Figure 3.215  Teeth inherited defects: dentinogenesis imperfecta – typical

discoloration and attrition.

Figure 3.216  Teeth acquired defects: severe fluorosis in a person born in Africa
in a very high fluoride area.
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 Pocketbook of Oral Disease

Teeth-specific disorders (continued)

Main associated conditions: none.
Differential diagnosis: amelogenesis imperfecta and tetracycline staining.
Investigations: data about fluoride content of drinking water.
Main diagnostic criteria: clinical.
Main treatments: veneers or crowns.

Tetracycline staining
Should be rare but is still not uncommon.
Typical orofacial symptoms and signs: yellow, brown or greyish tooth hyper-
pigmentation, especially cervically (Figure 3.217). Teeth may also be
hypoplastic.
Main oral sites affected: anterior teeth.
Aetiopathogenesis: tetracyclines given to children or before birth to their
pregnant or nursing mothers.
Gender predominance: none.
Age predominance: from time of tooth appearance.
Extraoral possible lesions: none.
Main associated conditions: none.
Differential diagnosis: dentinogenesis imperfecta and amelogenesis
imperfecta.
Investigations: history of exposure to tetracycline. Teeth fluoresce in ultravio-
let light if tetracycline deposition is severe.
Main diagnostic criteria: clinical.
Main treatments: bleaching, veneers or crowns.

Figure 3.217  Teeth acquired defects: tetracycline staining – multiple coloured

bands from repeated therapy.
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 Iatrogenic conditions
4
An increasing number of therapeutic procedures important in modern medi-
cine and surgery can produce iatrogenic (doctor-induced) unwanted orofacial
complications (Tables 4.1–4.6).

Immunosuppressive therapy
Immunosuppressive therapy is designed to suppress T lymphocyte function,
and leads to immunoincompetence and liability to infections, especially with
viruses (Figures 4.1–4.3), fungi (Figure 4.4) and mycobacteria (Table 4.1).
Such infections may spread rapidly; may be opportunistic; and may be
clinically silent or atypical.

Table 4.1  Orofacial complications of immunosuppression

Viral infections Herpesviruses (HSV, VZV, CMV, EBV, KSHV)

and human papillomaviruses (HPV)
Fungal infections Usually with Candida species but also deep
mycoses (e.g. zygomycosis, histoplasmosis)
Bacterial infections Especially with tuberculosis and other
mycobacterial infections
Virally related malignant Kaposi sarcoma, lymphomas, carcinomas
disease

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Immunosuppressive therapy (continued)

Figure 4.1  Herpes zoster (shingles) of the mandibular division of the trigeminal
nerve.

Figure 4.2  Herpes zoster (shingles) of the mandibular division of the trigeminal
nerve.

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 Chapter 4 • Iatrogenic conditions

Figure 4.3  Wart (human papillomavirus infection).

Figure 4.4  Candidosis can complicate systemic or local immunosuppression (from

steroid inhalers, as here).

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Radiotherapy
Radiation therapy is widely used, especially to control malignant
neoplasms, and if involving the mouth and salivary glands invariably pro-
duces complications (Table 4.2). These complications may be minimized by
using:
• minimal radiation doses and fields
• IMRT (intensity-modulated radio therapy) or IGRT (image-guided
radiotherapy)
• mucosa-sparing blocks
• amifostine (a free radical scavenger) before therapy.

Table 4.2  Orofacial complications of radiotherapy

Condition Causes Comments

Mucositis After external beam Dose-dependent diffuse

radiotherapy involving erythema and
the maxillofacial ulceration after 10–15
tissues days (Figure 4.5)
Hyposalivation Damage to salivary (Figure 4.6) Can lead to
glands dysphagia, disturbed
taste, candidosis,
sialadenitis and
radiation caries
Osteoradionecrosis Pain, jaw necrosis and
infection
Trismus Inflammation and Distinguish from
scarring tumour spread
Taste loss Damage to taste buds Temporary
Telangiectasia Late
Jaw and tooth Abnormal Children treated for
hypoplasia development neuroblastoma are at
particularly high risk
Facial palsy Carotid artery damage Cerebrovascular event
(stroke)

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 Chapter 4 • Iatrogenic conditions

Figure 4.5  Mucositis can

produce widespread erosions
and ulcers.

Figure 4.6  Radiation-induced hyposalivation is invariable after radiation involving

major salivary glands.

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Chemotherapy
Chemotherapy is widely used, especially to treat lymphoproliferative condi-
tions and malignant neoplasms. There can be several complications (Table
4.3). Mucositis is an almost invariable complication and may also be a
predictor of gastrointestinal toxicity and of hepatic veno-occlusive disease.
It is caused by cisplatin, etoposide, fluorouracil and melphalan, mucositis is
especially seen with chemo-radiotherapy regimens, involving:
• cisplatin and fluorouracil
• cisplatin, epirubicin, bleomycin
• carboplatin.

Table 4.3  Orofacial complications of chemotherapy

Condition Causes Comments
Mucositis Cytotoxic drugs impair Pain appears within 3–7
the mucosal barrier days, mucosa reddens
and immunity and thins, may slough
and become eroded and
ulcerated and sometimes
bleeds. Erosions/ulcers
often become covered by
a yellowish white fibrin
clot termed a
pseudomembrane
Taste sensation poor oral hygiene, Often temporary
changed gastric reflux,
infections, drugs

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 Chapter 4 • Iatrogenic conditions

Organ transplantation
Transplant recipients are treated with immunosuppressive therapy designed
to suppress T lymphocyte function, and they therefore have an increased
risk of infections and some malignant neoplasms (Table 4.4).

Table 4.4  Orofacial complications of organ transplantation

Viral infections Herpesviruses (HSV, VZV, CMV, EBV, KSHV)

and human papillomaviruses (HPV),
Fungal infections Usually with Candida species but also deep
mycoses (e.g. zygomycosis, histoplasmosis)
Bacterial infections Especially with tuberculosis and other
mycobacterial infections. Bacterial sepsis is
the most common cause of deaths occurring
during the first post-transplantation months
Virally related malignant Kaposi sarcoma, lymphomas, carcinomas,
disease post-transplant lymphoproliferative disease

Haematopoietic stem cell transplantation

Haematopoietic stem cell transplantation (HSCT or bone marrow transplant)
is increasingly used to treat haematological conditions, neoplasms and some
genetic defects. Patients are first profoundly immunosuppressed to minimize
graft rejection by ‘conditioning’, often using cyclophosphamide, plus total
body irradiation (TBI), or busulphan and are thus very susceptible to infec-
tions. Patients must be isolated and may require transfusions of granulo-
cytes, platelets, red cells, granulocyte colony stimulating factors and
antimicrobials until the donor bone marrow is functioning. HSCT may be
complicated by mucositis, infections, neoplasms, bleeding, or graft-versus-
host disease (GvHD) (Table 4.5).

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Table 4.5  Orofacial complications of haematopoietic stem cell

transplantation
Condition Causes Comments

Mucositis Cytotoxic drugs Pain appears within 3–7 days,

impair the mucosa reddens and thins, may
mucosal barrier slough and become eroded and
and immunity ulcerated and sometimes bleeds.
Erosions/ulcers often become
covered by a yellowish white fibrin
clot termed a pseudomembrane
Bleeding Bone marrow Bleeding from gingivae and into
damage tissues
Infections Viral Herpesviruses (HSV, VZV, CMV,
EBV, KSHV) and human
papillomaviruses (HPV)
Fungal Usually with Candida species,
but also deep mycoses (e.g.
zygomycosis, histoplasmosis)
Bacterial Especially with tuberculosis and
other mycobacterial infections.
Bacterial sepsis is the most
common cause of deaths
occurring during the first
post-transplantation months
Virally related Kaposi sarcoma, lymphomas,
malignant disease carcinomas, post-transplant
lymphoproliferative disease
Graft-versus- Donor lymphocytes Mucositis, lichenoid reactions
host disease attack recipient, (Figure 4.7) or hyposalivation
(GvHD) causing this
potentially lethal
disorder
Drug effects Ciclosporin Gingival swelling, predisposition to
Tacrolimus neoplasms

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 Chapter 4 • Iatrogenic conditions

Figure 4.7  Chronic

graft-versus-host disease is
common after haematopoietic
stem cell transplantation
(bone marrow transplants).

Drugs
Drugs may give rise to a range of orofacial symptoms and signs (Table 4.6)
by a wide range of mechanisms – often unknown.

Other iatrogenic conditions

A range of dental operative procedures may cause iatrogenic disease, which
are discussed in textbooks of operative dentistry, prosthodontics and oral
surgery. These may range from complications of restorative procedures –
such as amalgam tattoos (Figure 4.20), or lichenoid lesions (Figure 4.21);
dental abscess formation (Figure 4.22); denture-related hyperplasia (Figure
4.23) and stomatitis (Figures 4.24, 4.25); and complications of exodontia
such as dry socket and oroantral fistula (Figure 4.26).

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Table 4.6  Orofacial adverse effects from drugs

Lesions Main drugs implicated

Abnormal facial Metoclopramide

movements (dyskinesias) Phenothiazines
Angioedema Aldesleukin (human recombinant IL-2)
Angiotensin-converting enzyme (ACE)
inhibitors
Interferon (IFN)-alpha
Many others
Burning sensation ACE inhibitors
Protease inhibitors
Proton pump inhibitors
Candidosis Any drug that causes hyposalivation
Broad-spectrum antimicrobials
Cytotoxic drugs
Immunosuppressants
Dental hypoplasia Cytotoxic drugs
Dry mouth Antihistamines
Antihypertensives
Calcium channel blockers
Lithium
Phenothiazines
Tolterodine
Tricyclic antidepressants
Erythema multiforme NSAIDs
Barbiturates
Sulphonamides
Very many others
Gingival swelling Calcium channel blockers such as nifedipine
Phenytoin
Ciclosporin
Tacrolimus (Figures 4.8–4.10)

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 Chapter 4 • Iatrogenic conditions

Table 4.6  Orofacial adverse effects from drugs—cont’d

Lesions Main drugs implicated
Halitosis Amphetamines
Amyl nitrites
Aztreonam
Cytotoxic drugs
Disulfiram
Melatonin
Mycophenolate
Nicotine
Nitrates
Phenothiazines
Solvent misuse
Herpesvirus infections Cytotoxic drugs
Immunosuppressants
Hyperpigmentation ACTH
Amlodipine
Antimalarials (Figure 4.11)
Betel
Busulfan
Capecitabine
Hydroxyurea
Ketoconazole
Minocycline (Figure 4.12)
Palifermin
Peginterferon and ribavirin
Tobacco
Zidovudine
Human papillomaviruses Immunosuppressive agents
(HPV)
Lichenoid lesions A range of drugs, especially NSAIDS
(Figure 4.13)
Maxillofacial Alcohol
developmental defects Anticonvulsants
Cytotoxic drugs
Continued
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Table 4.6  Orofacial adverse effects from drugs—cont’d

Lesions Main drugs implicated
Mucositis Cytotoxic agents
Osteonecrosis of the jaws Bevacizumab
Bisphosphonates (Figures 4.14, 4.15)
Denosumab
Sunitinib
Pain Doxorubicin
Vinca alkaloids
Pemphigoid Furosemide
Pemphigus ACE inhibitors
Aspirin
Captopril
Enalapril
Fosinopril
Levodopa
Nifedipine
NSAIDs
Penicillamine
Penicillin (benzyl)
Propranolol
Ramipril
Rifampicin
Thiols
Potentially malignant Alcohol
disorders and oral Betel
carcinoma Immunosuppressants
Khat
Tobacco
Sensory changes Articaine
Capsaicin
Carmustine
Labetalol
Prilocaine
Sulthiame

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 Chapter 4 • Iatrogenic conditions

Table 4.6  Orofacial adverse effects from drugs—cont’d

Lesions Main drugs implicated
Sialorrhoea Aripiprazole
Benzodiazepines
Cevimeline
Cholinesterase inhibitors
Clozapine
Neuroleptics
Pilocarpine
Quetiapine
Sialosis Alcohol
Anti-thyroid drugs
Methyl dopa
Valproic acid
Sympathomimetic agents such as isoprenaline
Taste disturbance ACE inhibitors (e.g. captopril, eprosartan)
Amiloride
Antidepressants
Any chemotherapeutic
Any drug causing dry mouth
Bisphosphonates
Chlorhexidine
Clarithromycin
H1-antihistamines (e.g. azelastine and
emedastine)
Lithium
Metformin
Metronidazole
Omeprazole
Penicillamine
Pesticides (organochloride compounds and
carbamates)
Subutramine
Terbinafine
Tetracyclines
Zopiclone
Continued
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 Pocketbook of Oral Disease

Table 4.6  Orofacial adverse effects from drugs—cont’d

Lesions Main drugs implicated
Tics Anticonvulsants
Antiparkinsonian drugs
Caffeine
Methylphenidate
Tooth discoloration Extrinsic – chlorhexidine, some antibiotics,
tobacco and iron preparations (Figures
4.16, 4.17)
Intrinsic – tetracyclines
Tooth root anomalies Cytotoxic drugs
Phenytoin
Ulcers Alendronate
Carbimazole
Cytotoxic drugs (Figure 4.18)
Deferiprone
Nicorandil (Figure 4.19)
NSAIDs
Sirolimus
Tacrolimus

Figure 4.8  Drug-induced gingival swelling (phenytoin) typically originates from

interdental papillae.
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 Chapter 4 • Iatrogenic conditions

Figure 4.9 
Drug-induced
gingival swelling
(nifedipine).

Figure 4.10 
Drug-induced
gingival swelling
(diltiazem and
ciclosporin):
common after
organ
transplantation
because of
anti-rejection
therapy.

Figure 4.11  Drug-induced

palatal pigmentation
(hydroxychloroquine).

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 Pocketbook of Oral Disease

Figure 4.12  Drug-induced palatal pigmentation (minocycline).

Figure 4.13  Drug-induced lichenoid lesions.

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 Chapter 4 • Iatrogenic conditions

Figure 4.14 
Bisphosphonate
related
osteonecrosis
(most common
after intravenous
bisphosphonates
used in cancer
patients).

Figure 4.15 
Bisphosphonate-
related
osteonecrosis.

Figure 4.16 
Tooth staining
(chlorhexidine).

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 Pocketbook of Oral Disease

Figure 4.17 
Tooth staining
(chlorhexidine,
smoking and
poor oral
hygiene).

Figure 4.18 
Drug-induced
ulceration
(methotrexate).

Figure 4.19 
Drug-induced
ulceration
(nicorandil, a
potassium
channel
activator, which
can also cause
anal ulceration).

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 Chapter 4 • Iatrogenic conditions

Figure 4.20  Amalgam tattoo.

Figure 4.21  Amalgam

related lichenoid reaction.

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 Pocketbook of Oral Disease

Figure 4.22  Iatrogenic dental

abscess related to the
crowned incisor.

Figure 4.23  Denture-related hyperplasia.

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 Chapter 4 • Iatrogenic conditions

Figure 4.24 
Denture-related
stomatitis.

Figure 4.25 
Denture-related
stomatitis.

Figure 4.26 
Traumatic
oroantral fistula,
after the
maxillary
tuberosity
fractured and
was removed.

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 Immune defects and
haematological defects
5
and malignancies
Human immunodeficiency virus (HIV) disease
HIV is a retrovirus transmitted sexually, via blood, or to the neonate, which
has produced a global pandemic, especially affecting people in the develop-
ing world. There can be a range of orofacial complications seen in HIV
disease (Figure 5.1), and in the acquired immune deficiency syndrome (AIDS)
– defined as a CD4 T lymphocyte count of less than 200 cells per microlitre
(µl) of blood (Table 5.1).
Orofacial lesions in HIV disease have been classified as follows:
• Group I: Lesions strongly associated with HIV infection
 Candidosis

erythematous Figures 5.2–5.5)

hyperplastic
thrush
 Hairy leukoplakia (EBV) (Figures 5.6 & 5.7)

 HIV-gingivitis (linear gingival erythema) (Figure 5.8)

 Necrotizing ulcerative gingivitis (Figure 5.9)

 HIV-periodontitis

 Kaposi sarcoma

 Non-Hodgkin lymphoma

• Group II: Lesions less commonly associated with HIV infection

 Atypical ulceration (oropharyngeal)

 Salivary gland diseases (Figure 5.10)

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 Pocketbook of Oral Disease

Human immunodeficiency virus (HIV) disease (continued)

Table 5.1  Orofacial complications in HIV/AIDS

Viral infection Herpesviruses (Figure 5.1), and HPV

mainly
EBV is a herpesvirus that can cause hairy
leukoplakia (Figures 5.6, 5.7) which
mainly affects margins of the tongue
and is a predictor of progression to
full-blown AIDS. EBV may cause
lymphoma
Fungal infections Candidosis (Figures 5.2–5.5)
Bacterial infection Necrotizing ulcerative gingivitis/
periodontitis (Figures 5.8, 5.9)
Virally-related neoplasms Kaposi sarcoma, lymphoma

Figure 5.1  HIV disease: chronic candidosis, and herpes simplex ulceration.

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Chapter 5 • Immune defects and haematological defects and malignancies

Figure 5.2  HIV disease:

erythematous candidosis in
the classic ‘thumbprint’
distribution.

Figure 5.3  HIV disease:

erythematous candidosis.

Figure 5.4  HIV disease:

erythematous candidosis.

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Human immunodeficiency virus (HIV) disease (continued)

Figure 5.5  HIV disease:
white candidosis
(pseudomembranous
candidosis).

Figure 5.6  HIV disease: hairy

leukoplakia related to
Epstein–Barr virus (EBV)
infection.

Figure 5.7  HIV disease: hairy

leukoplakia appears
corrugated rather than hairy
and can be seen in any
immunocompromised
patients.

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Chapter 5 • Immune defects and haematological defects and malignancies

Figure 5.8  HIV disease:

‘linear’ gingivitis (linear
gingival erythema).

Figure 5.9  HIV disease:

necrotizing ulcerative
gingivitis.

Figure 5.10  HIV disease: salivary

gland disease (may be caused by BK
virus) can cause swelling and
hyposalivation.

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Human immunodeficiency virus (HIV) disease (continued)

a dry mouth
b unilateral or bilateral swelling of major salivary glands
(Figure 5.10)
 Viral infections (other than EBV)

a cytomegalovirus
b herpes simplex virus
c human papillomavirus (warty-like lesions) (see page 262):
condyloma acuminatum, focal epithelial hyperplasia and verruca
vulgaris
d varicella-zoster virus: herpes zoster (see page 216) and varicella.
• Group III: lesions possibly associated with HIV infection. These are a
miscellany of rare diseases.

Leukopenia and neutropenia

Leukopenia and neutropenia are haematological defects that may result from
viral infections (especially HIV infection), drugs, irradiation, or can be
idiopathic.
Genetic (ELANE–related neutropenia) includes congenital neutropenias
and cyclic neutropenia. Patients suffer fever, respiratory and cutaneous
infections, lymphadenopathy and often orofacial lesions (Table 5.2).

Table 5.2  Orofacial complications of leukopenia

Infections Mucosal (Figure 5.11) cutaneous, periodontal,

antral, or postoperative
Ulcers Characteristically persistent ulcers lacking an
inflammatory halo (Figures 5.12, 5.13)
Lymphadenopathy Cervical or general

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Chapter 5 • Immune defects and haematological defects and malignancies

Figure 5.11  Leukopenia:

skin infections, as here, if
with oral and respiratory
infections suggest an immune
defect.

Figure 5.12  Leukopenia: oral

ulceration lacks an
inflammatory halo.

Figure 5.13  Leukopenia:

gingival margin ulceration
in the patient shown in
Figure 5.11.

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Leukaemias
Malignant neoplasms arising from lymphoid or myeloid cells affect the mouth
in many ways (Table 5.3).

Table 5.3  Orofacial complications of leukaemias

Anaemia Pallor

Infections Mucosal, cutaneous (Figure 5.14),

periodontal, antral, or postoperative
Ulcers Characteristically persistent ulcers
lacking an inflammatory halo
(Figures 5.15–5.17)
Bleeding Gingival bleeding and oral purpura
(Figures 5.18, 5.19)
Gingival swelling Caused by leukaemic deposits
mainly in acute myeloid leukaemia
Labial or chin anaesthesia, facial Caused by leukaemic deposits.
palsy, radiographic changes Discrete radiolucencies in the lower
third molar region, destruction of
lamina dura and widening of the
periodontal space or teeth which
may appear to be ‘floating in air’
Lymphadenopathy Generalized, with
hepatosplenomegaly

Figure 5.14  Leukaemia:

leukaemic deposits in a child
with acute leukaemia mimic
herpes labialis (which is also
common in people with
immune defects or malignant
disease).

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Chapter 5 • Immune defects and haematological defects and malignancies

Figure 5.15  Leukaemia:

atypical ulceration, together
with necrotizing ulcerative
gingivitis.

Figure 5.16  Leukaemia:

atypical ulceration, together
with necrotizing ulcerative
gingivitis.

Figure 5.17  Leukaemia:

atypical ulceration, covered by
fibrin clot.

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Leukaemias (continued)

Figure 5.18  Leukaemia: atypical ulceration, together with purpura.

Figure 5.19  Leukaemia: gingival swelling, purpura, haemorrhage and ulceration.

Lymphomas
Malignant neoplasms arising from lymphocytes, lymphomas affecting the
oral cavity are mainly B cell lymphomas, and can present in a number of
ways (Table 5.4).
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Chapter 5 • Immune defects and haematological defects and malignancies

Table 5.4  Orofacial complications of lymphomas

Gingival or facial swelling Caused mainly by non-Hodgkin lymphoma

(Figure 5.20)
Ulceration Characteristically persistent ulceration
(Figure 5.21)
Tooth loosening Or non-healing extraction socket
Lymphadenopathy Cervical or general

Figure 5.20  Lymphoma

presenting as a swelling in a
typical site. Non-Hodgkins
lymphomas are most common
on the gingiva or fauces.

Figure 5.21  Lymphoma

presenting as atypical
ulceration; any solitary ulcer
persisting 3 or more weeks
should be biopsied.

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 Diagnosis
6
A careful history will often lead to a provisional diagnosis but a careful full
clinical examination is always indicated, not least because an unsuspected
lesion may be present in addition to the patient’s main complaint. The clini-
cian is often then in a position to formulate the diagnosis, or at least a list
of differential diagnoses. In the latter case, the diagnosis is provisional, and
investigations or another opinion (e.g. specialist referral) may be necessary
to reach a firm diagnosis.
Bearing in mind the fact that the whole orofacial tissues and cervical
nodes must be examined in every patient, this chapter details diagnosis of
disorders in the various sub-sites.

Diagnosis of mucosal disorders

Mucosal disorders are diagnosed mainly from history and examination find-
ings. All mucosae should be examined, in order to detect early lesions. Begin
away from the focus of complaint or known lesions. Labial, buccal, floor of
the mouth, ventrum of tongue, dorsal surface of tongue, hard and soft palate
mucosae, gingivae and teeth should be examined in sequence, recording
lesions on a diagram.
Mucosal lesions are not always readily seen and, among attempts to help
improve visualisation, are:
• toluidine blue (vital) staining
• chemiluminescent illumination
• fluorescence spectroscopy and imaging.
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 Pocketbook of Oral Disease

These are discussed in Chapter 7.

Investigations that may be diagnostically helpful can include biopsy
examination, blood tests and microbiological investigations. Informed consent
and confidentiality is required for all investigations.
Biopsy is the removal of tissue for diagnosis by histopathological and
often immunological examination. Indications for biopsy include mucosal
lesions that:
• have malignant or potentially malignant features
• are enlarging
• persist > 3 weeks
• are of uncertain aetiology
• fail to respond to treatment
• cause concern.
Blood tests, microbiology tests and other investigations are discussed in
Chapter 7. Testing for infections can be a very sensitive issue, especially in
the case of human immunodeficiency virus (HIV) and other sexually shared
infections and tuberculosis. HIV testing in particular remains voluntary and
confidential, and patients must be counselled properly beforehand.

Diagnosis of salivary disease

Salivary disorders are diagnosed mainly from history and examination find-
ings. The salivary glands should be examined by inspecting:
• symmetry
• evidence of enlargement glands
• ducts for salivary flow
and by palpating the parotid glands in front of the ears, to detect pain, or
swelling, and the submandibular glands by bimanual palpation between
fingers inside the mouth and extraorally.
It is also important to examine the eyes for dryness, redness or discharge,
and the oral mucosa; note particularly angular cheilitis, dryness and lingual
depapillation or erythema.
Investigations required may include:
• plasma viscosity or erythrocyte sedimentation rate (ESR) or C reactive
protein (CRP)
• antibodies
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 Chapter 6 • Diagnosis

 antinuclear antibodies for lupus erythematosus or rheumatoid arthritis

 rheumatoid factor for rheumatoid arthritis
 SS-A (Ro) and SS-B (La) antibodies for Sjögren syndrome (and allied

autoantibodies, e.g. anti-mitochondrial antibodies for primary biliary

cirrhosis)
 mumps, HIV, HCV or other viral antibodies

• imaging using:
 ultrasound

 orthopantomogram and reverse orthopantomogram

 oblique lateral views

 lateral skull views

 occlusal views

• CT scan
• MRI (which avoids irradiating the patient)
• biopsy: fine needle aspiration biopsy under ultrasound guidance is
commonly used.

Diagnosis of jaw disorders

Jaw disorders are diagnosed mainly from history and examination findings.
It is especially important to consider the rest of the skeleton, as some jaw
disorders are only part of a wider problem.
Investigations required may include:
• full blood picture
• plasma viscosity or erythrocyte sedimentation rate or C-reactive protein
• blood biochemistry – typical features in metabolic disorders such as
hyperparathyroidism, fibro-osseous disorders, sarcoidosis:
 calcium

 phosphate

 alkaline phosphatase

 parathyroid hormone levels

 serum angiotensin-converting enzyme (SACE)

• serum antibodies
 antinuclear antibodies – for lupus erythematosus or rheumatoid

arthritis
 rheumatoid factor – for rheumatoid arthritis

 extractable nuclear antibodies, including SS-A and SS-B antibodies

– for Sjögren syndrome

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 Pocketbook of Oral Disease

• imaging
 orthopantomogram

 oblique lateral views

 three-dimensional information may be gained from:

a tomography in both the coronal and sagittal planes

b cone beam CT and T1 and T2 weighting
 radionuclide scanning

 MRI – avoids irradiating the patient but is best for soft tissue lesions

• biopsy.

Diagnosis of dental disorders

Disorders affecting teeth are diagnosed mainly from history and examination
as discussed in dental texts. All findings should be charted using one of
various systems of tooth notations.
Investigations required may include:
• pulp vitality testing
• imaging
 plain radiography

a periapical radiographs
b bitewings
c oblique lateral views
 tomographic views

a dental pan-oral tomographic views

b other tomographic views
 three-dimensional information from:

a tomography in both the coronal and sagittal planes

 CT scan.

Diagnosis of pain and neurological disorders

Pain
In patients with orofacial pain, it is crucial to exclude local causes, such as
odontogenic, by carefully examining the teeth, jaws and joints, mucosae and
salivary glands. The cranial nerves should also be examined by inspecting:
• facial symmetry and movement
• fasciculation or deviation of tongue from the centre when protracted
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 Chapter 6 • Diagnosis

• ocular movements
• hearing testing
• trigeminal nerve functions; those that should be tested include:
 corneal reflex (this tests Vth and VIIth cranial nerves); puffing air or

touching the cornea gently with sterile cotton wool should produce a
blink
 skin sensation, by using:

a light touch (a puff of air or cotton wool)

b pin point (sterile needle)
c temperature
d vibration
e two-point discrimination
 motor function by testing the jaw jerk, and palpating:

a masseters during clenching

b temporalis during clenching
c pterygoids during jaw protrusion
 taste sensation. Gustometry uses stimuli on a cotton bud, including:

citric acid or hydrochloric acid (sour taste), caffeine or quinine

hydrochloride (bitter), sodium chloride (salty taste), saccharose
(sweet), monosodium glutamate (umami taste).
Investigations required may include:
• imaging
 jaw/skull radiography

 CT

 MRI, which avoids irradiating the patient, has almost completely

replaced CT as the modality of choice for investigating trigeminal

neuropathy, though CT still plays a role in the assessment of skull
base foramina and facial skeleton
 ultrasound

• biopsy
• urinalysis
• blood tests
 plasma viscosity or erythrocyte sedimentation rate or C-reactive

protein
 full blood count

 SACE

 random glucose

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 Pocketbook of Oral Disease

 antibodies
a antinuclear antibodies for lupus erythematosus or rheumatoid
arthritis
b rheumatoid factor (RF) for rheumatoid arthritis
c SS-A (Ro) and SS-B (La) antibodies for Sjögren syndrome
d RNP antibodies for mixed connective tissue disease
e viral antibodies.

Suspected neurological disorders

Neurological disorders may be serious in consequence and thus a neurologi-
cal opinion may be required in patients with facial palsy, facial sensory loss,
or some patients with pain.
It is also important to consider drug use (including recreational drugs and
alcohol) and the possibility of related systemic disorders, especially:
• infections (e.g. Lyme disease and HIV)
• cardiovascular disorders (some facial pain may be referred from cardiac
or other lesions in the chest)
• respiratory disorders (e.g. sarcoidosis or neoplasms)
• connective tissue disorders, such as lupus erythematosus
• endocrine gland disorders (e.g. diabetes)
• mental health disorders
• nutrition (e.g. eating disorders such as bulimia).
It may be important to:
• check the vital signs (pulse, respiration, temperature, blood pressure)
• look for abnormal posture or gait (e.g. broad based in cerebellar
disorders, shuffling in Parkinsonism, swinging leg in stroke)
• assess level of consciousness (Glasgow Coma Scale) and, if necessary,
mental state
• assess speech
 dysarthria (oropharyngeal, neurological or muscular pathology)

 dysphonia (respiratory pathology) or

 dysphasia (damage in the brain language areas)

• check for neck stiffness (meningeal inflammation)

• look for tremor (anxiety, drugs, coffee, alcohol or drug withdrawal, CVA,
hyperthyroidism, Parkinsonism), tics (partially controlled repetitive
movements), maxillofacial dyskinesias (involuntary tic-like movements
involving the lips and the tongue – a long term side-effect of
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 Chapter 6 • Diagnosis

antipsychotics), etc., fasciculations (involuntary twitches of groups of

muscle fibres (e.g. in motor neurone disease), dystonia (e.g. torticollis),
myoclonus (sudden jerky muscle movements), wasting (motor neurone
disease or myopathy)
• test cranial nerves
• If there is any suspicion of a neuropathy there should be a general
neurological examination.

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 Investigations
7
Informed consent and confidentiality are required for all investigations, and
the advantages should clearly outweigh any dangers or disadvantages.

Blood tests
Blood tests can help determine disease states, but should be requested only
when clinically indicated. There is always a danger of needlestick injury.
Furthermore, abnormal ‘blood results’ do not always mean disease and
false-positive results are possible. Serum is used for assaying antibodies,
which can help diagnose infections and autoimmune disorders, and for
assaying most biochemical substances (e.g. ‘liver enzymes’).

Microbiological tests
Microbiological diagnosis is based on either demonstration of the microor-
ganism or its components (antigens or nucleic acids) directly in samples or
tissues, which are best used as results are speedily obtained. The demon-
stration in the serum of a specific antibody response can be helpful.

Salivary flow determination

Unless the baseline salivary flow rate for an individual patient is known, it is
impossible to be certain if there has been a reduction in salivary flow, since
the salivary flow rate varies widely from person to person. Salivary flow rates
also vary over time and so estimates should be taken on several
occasions.
Normal and reference values are shown in Table 7.1.
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Table 7.1  Whole saliva flow rates* (ml/min)

Normal Hyposalivation

Unstimulated (resting) 0.3–0.4 ml/min <0.1 ml/min

Stimulated 1–2 ml/min <0.5 ml/min
*Unstimulated salivary flow rate (USFR) measurement of whole saliva uses a simple
draining test for 5 minutes at rest: a rate less or equal to 0.1 ml/min suggests
hyposalivation.

Biopsy
Before beginning, it is important to decide whether an excisional or incisional
biopsy is indicated.
Excisional biopsy
Excisional biopsy (Figures 7.1–7.4) is used for small superficial lesions (max
1 cm). If a malignant tumour is suspected, even if small, an excisional biopsy
must be done by a specialist.

Figure 7.1  Instrumentation for excisional biopsy. Shown are: retractor, aspirator,
surgical blade No. 15, surgical forceps, scissors, sutures (catgut or silk 3 or 4),
two needle holders, LA (local anaesthetic) syringe and anaesthetic, blotting paper.
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 Chapter 7 • Investigations

Figure 7.2  (A, B) Excisional biopsy must be used for small superficial lesions
(max 1 cm).

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Biopsy (continued)

Figure 7.3  (A, B) Remove the tissue completely.

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 Chapter 7 • Investigations

Figure 7.4  Finally, after achieving haemostasis, suture.

Incisional biopsy
Choose the area to biopsy based on:
• appraisal of the clinical appearance (red areas rather than white)
• vital staining with toluidine blue.
An incisional biopsy (Figures 7.5–7.13) can be performed with a scalpel,
or dermatology punch.
Steps of incisional biopsy preceded by vital staining, if used
The procedure is shown in Figures 7.14 and 7.15.
Oral lichen planus biopsy (Figures 7.16, 7.17)
For oral lichen planus, the choice of biopsy must consider the following:
• The sample should contain one or more papule or, alternatively, part of
striae or plaques.
• The best site is the buccal mucosa; try to avoid, if possible (unless
there is the possibility of malignant change), white plaques on the
dorsum of the tongue, erosions and ulcers and red atrophic areas,
because they are often difficult to interpret histologically.
• The specimen must be sufficiently large and deep.

Note: In cases where the histopathological diagnosis is doubtful it can be

useful to carry out direct immunofluorescence, which may show linear
deposits of fibrin in the basement membrane zone in lichen planus.
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 Pocketbook of Oral Disease

Biopsy (continued)
Figure 7.5  Simple
incisional biopsy. This is
indicated in
homogeneous lesions,
such as white papules or
plaques.

Figure 7.6  A simple

incisional biopsy can be
made not only in
homogeneous lesions but
also in red or erosive
areas.

Figure 7.7  A mapping

incisional biopsy consists
of taking several
specimens from different
areas. It is usually carried
out in non-homogeneous
lesions.

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 Chapter 7 • Investigations

Figure 7.8  The incisional

biopsy may be preceded by vital
staining with toluidine blue (see
above). It consists in biopsying
several stained areas (royal blue
ones). It is carried out in
non-homogeneous lesions with
extensive red areas.

Figure 7.9  Instrumentation for

incisional biopsy. Shown are: LA
syringe and anaesthetic, scalpel
with surgical blade No. 15,
surgical forceps, blotting paper.

Figure 7.10  Fixative for biopsy specimen. Typically this

is 10% formalin in a sufficiently large watertight
container with self-adhesive label on which immediately
to write the name of the patient (and hospital number).
The volume of formalin must be at least three times that
one of the pieces of tissue to fix. For immunostaining,
the tissue is not put in formalin but in OCS or Michel
solution, or frozen in liquid nitrogen.

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 Pocketbook of Oral Disease

Biopsy (continued)

Figure 7.11  Considerations before starting. Examine the lesion carefully and
decide (i) which type of incisional biopsy you need, (ii) which area(s) should be
biopsied and (iii) whether it is useful to undertake vital staining. The choices are
based on the clinical appearances of the lesion.

Figure 7.12  Anaesthesia. Do not inject the LA directly into the lesion or with
strong pressure, since it is possible to cause pain, damage the tissue and create
artefacts.
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 Chapter 7 • Investigations

WRONG

Figure 7.13 (A–E)  The sample: never sample a necrotic zone (A). Do not excise
a wedge since this samples little of the basal layers (B).

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Biopsy (continued)

CORRECT Figure 7.13, cont’d The

biopsy must be sufficiently
deep to include the
epithelium–connective tissue
interface (C). The biopsy
should be at least 4–5 mm
diameter. Take care not to
damage the biopsy with
forceps; for more delicate
C lesions (e.g. bullous diseases)
use anatomical forceps (D) or
a suture. Place the specimen
blotting paper with the
epithelium upwards to allow
orientation by the pathologist
(E). Put the sample
immediately into the fixative.

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 Chapter 7 • Investigations

Figure 7.14  (A, B) Vital

staining is used when
lesions are non-
homogeneous, or mixed
red and white lesions, or
where there is an
extensive red component.

Figure 7.15  The sample taken

should include both areas that are
stained and not.

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 Pocketbook of Oral Disease

Biopsy (continued)
Figure 7.16  Striae are good
areas to biopsy to establish
the diagnosis of oral lichen
planus.

Figure 7.17  Remember that

oral lichen planus can be a
potentially malignant
condition. Therefore carefully
evaluate the lesions to decide
which areas to biopsy and if
there is any reason to suspect
early oral cancer, proceed
with precaution and refer the
patient to a specialist.

Direct immunofluorescence
For oral mucosal diseases which may have an autoimmune or immune
pathogenesis (mainly bullous diseases), direct immunofluorescence (DIF)
analysis is sometimes fundamental to establishing the diagnosis. For DIF a
large biopsy is necessary so that sufficient material is available for half of
the specimen to be conserved NOT in formalin. Use Michel solution, OCT or
PBS (phosphate buffered saline) and process for DIF; the other half of the
sample is fixed in formalin and processed routinely and embedded in paraffin
for conventional histology (Figure 7.18).
For lichen planus or lupus erythematosus the criteria to follow are those
above. For bullous diseases the sample:
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 Chapter 7 • Investigations

• must be taken in areas where epithelium is present (no erosions or

ulcers)
• must be handled gently to avoid any epithelium–connective tissue split
during removal of the specimen (a scalpel rather than punch is best
used)
• must be taken perilesionally

A B C

Biopsy of desquamative gingivitis, The OCT must be poured in its

avoiding the areas in which the container without creating bubbles;
epithelium is too easily detached the fragment must be carefully
laid on the bottom with the
epithelium upwards

Part of the sample is preserved

in one of these two types and
carried immediately to a laboratory

D E

One half of the specimen is The other half is fixed in

preserved in PBS formalin for traditional histology

Figure 7.18 (A–E)  Direct immunofluorescence procedure.

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 Pocketbook of Oral Disease

Imaging
Because of the adverse effects of ionizing radiation and the cumulative effect
of radiation hazard, clinicians requesting examination or investigation using
X-rays must satisfy themselves that each investigation is necessary and that
the benefit outweighs the risk.
Ultrasound and magnetic resonance imaging avoid
radiation hazards.
Computed axial tomography (CT or CAT)
This imaging technique shows the bone and teeth white, can be useful in
diagnosis of lesions involving hard tissue, but gives a fairly high radiation
exposure. Cone beam CT (CBCT) is becoming widely utilized for imaging
bone/dental pathology of the jaws and has the advantage of a lower radiation
dose to the patient than conventional CT.
Dental panoramic tomography (DPT; or orthopantomography
[OPTG])
This imaging technique gives a good overview of the dentition, maxillary
sinuses, mandibular ramus and temporomandibular joints, but is subject to
considerable and unpredictable geometric distortion, is greatly affected by
positioning errors and has relatively low spatial resolution compared with
intraoral radiographs.
Intraoral radiography
Intraoral radiography includes periapical, bitewing and occlusal projections
and allows detection of small carious lesions and periapical radiolucencies
not always detectable with DPT.
Magnetic resonance imaging (MRI)
MRI gives good images of soft tissues and is the modality of choice to aid
in the diagnosis and management of:
• trigeminal neuralgia
• idiopathic facial pain.
The disadvantages of MRI are that it is:
• liable to produce image artefacts where metal objects are present
(dental restorations, orthodontic appliances, metallic foreign bodies,
joint prostheses, implants, etc.)

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 Chapter 7 • Investigations

• contraindicated in
 implanted electric devices (e.g. heart pacemakers, cardiac

defibrillators)
 ferromagnetic intracranial vascular clips

 prosthetic cardiac valves containing metal

 obesity

 claustrophobia.

Ultrasound scanning (US)

Ultrasound scanning is non-invasive and the first-line imaging modality to
use in diagnosis of soft tissue swellings (e.g. lymph nodes, thyroid or salivary
glands) and in assisting fine needle aspiration biopsy (ultrasound-guided FNA
or FNAB).

Adjunctive screening tests

Saliva pH test
This may help assess caries risk but not the advertised assessment of
susceptibility to cancer, heart disease, osteoporosis, arthritis, and many
other degenerative diseases.
Breath analyser
This may help assess oral malodour, but only measures a limited range of
gases in the breath.
Visualization aids
It is likely that very small and very early lesions could be overlooked by visual
examination of the mouth. The search is on for techniques to detect carci-
noma at a very early stage – but the very earliest stages are surely at the
microscopic or submicroscopic levels. A number of clinical aids have been
developed in attempts to be:
• adjuncts to visual examination
• helpful to identify sites for biopsy.

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 Pocketbook of Oral Disease

These are discussed in Chapter 1.

However, all current aids suffer from low specificity and/or sensitivity (see
Table 7.2)

Table 7.2  Commercial visualization devices

Sensitivity % Specificity %

Brush biopsy 71.4–100 32–100

ViziLite 100 0–14.2
VELscope 98–100 94–100

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 Management protocols
for patients with oral
8
diseases treated in
primary care settings

This chapter tabulates the typical management in primary dental care of

patients with the more common complaints.

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 Pocketbook of Oral Disease

Condition Typical main Investigations that

clinical features may be indicated for
diagnosis in addition to
history and examination

Aphthous stomatitis Recurrent oral ulcers Full blood picture. Exclude

only underlying systemic
disease (e.g. ESR for
autoinflammatory
disease;
transglutaminase for
coeliac disease;
haematinic assays for
deficiencies)
Allergic reactions Swelling, erythema or Allergy testing
erosions
Burning mouth Glossodynia Full blood picture,
syndrome haematirics, glucose,
thyroid function,
electrolytes
Candidosis White or red Consider smear, or biopsy.
(including angular persistent lesions Consider immune defect
stomatitis and
denture-related
stomatitis)
Chapped lips Dry, flaking lips May be dry mouth
Dental infections Pain usually Vitality test
and pain aggravated by Radiology
pressure or heat
Dry mouth Dryness Full blood picture
Caries Exclude underlying systemic
Candidosis disease (e.g. glucose for
Sialadenitis diabetes; SSA and SSB
antibodies for Sjögren
syndrome)

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 Chapter 8 • Management protocols in primary care settings

Therapeutic protocols High levels of

available
evidence for
treatment*

Vitamin B12, aqueous chlorhexidine, corticosteroids Yes (for all)

topically (e.g. hydrocortisone, betamethasone),
amlexanox or, only in adults, topical tetracycline
(doxycycline)

Avoid precipitant. Consider antihistamines (e.g. Yes

loratidine)
Reassurance, CBT. GMPs or specialists may use Yes
tricyclic antidepressants or SSRIs

Antifungals, leave out dental appliances, allowing the Yes

mouth to heal. Disinfect the appliance (as per
additional instructions). Use antifungal creams or
gels (e.g. miconazole) or tablets (e.g. nystatin or
fluconazole), regularly for up to 4 weeks
Topical petrolatum gel or bland creams No
Restorative dentistry Yes

Preventative dental care

Mouth wetting agents
Sialogogues

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 Pocketbook of Oral Disease

Condition Typical main Investigations that

clinical features may be indicated for
diagnosis in addition to
history and examination
Erythema migrans Desquamating –
patches on tongue
Halitosis Oral malodour Oral/ENT examination and
radiography
Herpetic infection Oral ulcers, gingivitis, Sometimes PCR or
fever immunostain
Hyposalivation Dry mouth. May be Assess salivary flow rate.
dry eyes, or a Exclude drugs, diabetes,
connective tissue Sjögren syndrome
disease (serology – SS-A (Ro)
and SS-B (La)
antibodies), HCV and
HIV. Ultrasound.
Consider labial gland
biopsy, sialography, MRI
or scintiscan
Idiopathic facial pain Persistent dull ache Imaging to exclude organic
typically in maxilla disease
in an older female
Keratosis Flat, raised or warty Biopsy
white lesion
Leukoplakia Flat, raised or warty Biopsy
white or white
and red lesion
(erythroleukoplakia)

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 Chapter 8 • Management protocols in primary care settings

Therapeutic protocols High levels of

available
evidence for
treatment*
Reassurance ± benzydamine No

Treat underlying cause No

Symptomatic – aciclovir suspension or tablets Yes

Preventive dentistry. Mouth wetting agents (artificial Yes

salivas, of which there are several available) and
artificial tears; salivary stimulants (sialogogues) –
such as sugar-free chewing gum, or systemic
pilocarpine or cevimeline

Reassurance, CBT. GMPs or specialists may use Yes (for CBT and
SSRIs or tricyclics tricyclics)

Stop tobacco, betel or alcohol use. Excise if No

dysplastic
Stop tobacco, betel or alcohol use. Excise No

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 Pocketbook of Oral Disease

Condition Typical main Investigations that

clinical features may be indicated for
diagnosis in addition to
history and examination
Lichen planus Mucosal white or Biopsy –
other lesions. immunofluorescence
Polygonal purple may be useful
pruritic papules on
skin. May be
genital or skin
adnexal
involvement
Necrotizing Interdental papillary Smear may help
ulcerative ulceration and Consider immune defect
gingivitis bleeding, halitosis,
pain
Pemphigoid Blisters, mainly in Biopsy – immunostaining
mouth occasionally
on conjunctivae,
genitals or skin.
Scarring
TMJ TMJ pain, click, Occasionally imaging,
pain-dysfunction limitation of rarely arthroscopy
movement

392
 Chapter 8 • Management protocols in primary care settings

Therapeutic protocols High levels of

available
evidence for
treatment*
Corticosteroids (e.g. betamethasone or clobetasol Yes (for steroids
propionate) topically. Aloe vera gel may be tried. and aloe vera)
Stop tobacco or any causal drug use

Antimicrobials: penicillin or metronidazole. Oral Yes

hygiene improvement. Mechanical debridement.
Consider excluding HIV

Topical corticosteroids (e.g. betamethasone or Yes

clobetasol propionate). Specialists may use
dapsone, systemic steroids or other
immunosuppressives

Reassurance, occlusal splint, anxiolytics or muscle No

relaxants (e.g. benzodiazepines such as diazepam
or temazepam)
*Some of the evidence is controversial.
Abbreviations: CBT, cognitive-behavioural therapy; GMP, general medical practitioner;
HCV, hepatitis C virus; PCR, polymerase chain reaction; SSRI, selective serotonin re-uptake
inhibitor; HIV, human immunodeficiency virus.
In UK, registered dentists are legally entitled to prescribe from the entirety of the British
National Formulary (BNF) and BNF for Children (BNFC), but within the National Health
Service (NHS) dental prescribing is restricted to those drugs contained within the List of
Dental Preparations in the Dental Practitioners Formulary (DPF).

393
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 Referral for specialist advice
9
Clinicians should endeavour to recognize the early signs of serious disease
and to direct the patient to the appropriate specialist for a second opinion,
including results of any relevant investigations.
Patients who may benefit from specialist referral include those where
there is:
• a possibly complex or serious diagnosis (e.g. cancer, pemphigus,
HIV/AIDS Behçet disease, Crohn disease)
• a doubtful diagnosis
• extraoral involvement or possible systemic disease
• investigations required, but not possible, or appropriate to carry out, in
primary care
• a situation where therapy may not be straightforward and may require
complex agents
• a situation where drug use needs to be monitored with laboratory or
other testing
• a patient who needs repeated access to an informed opinion, outside
normal working hours.
Essential details of a referral letter include the following:
• Name and contact details of the patient, including age, address and
day-time telephone number.
• Name and contact details of the referring and other clinicians (name,
address, telephone, fax and e-mail)
• History of present complaint with brief details and description of the
nature and site of lesion(s)
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 Pocketbook of Oral Disease

• Urgency of referral
• Social history
• Medical history
• Special requirements, e.g. for interpreter, sign language expert or
special transport.

Shared clinical care

Table 9.1  Responsibilities of parties involved in shared clinical care
(shared care implies good communication between all parties)
Specialist General Patient
practitioner (GP)

Write to GP Tell Specialist, with Comply with

suggesting reasons, if they recommended care
shared care cannot share care
Provide GP with Prescribe certain Ensure understanding
care guidelines treatment agents of care regimen
Provide GP with Provide patient with Ensure attendance of
contact details suitable written monitoring
information
Report adverse Undertake monitoring Report to and seek
treatment of patient health advice from GP on any
effects concerns
Prescribe Refer to Specialist if Understand that care
certain treatment fails may be curtailed if
treatment patient fails to comply
agents with above
Report to and seek
advice from Specialist
on any concerns
Report adverse
reactions to
Specialist, and stop
treatment in cases of
severe reactions

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 10
Further information
Glossary of eponymous diseases and syndromes
Addison disease
Autoimmune hypoadrenocorticism.
Albers–Schönberg disease
Osteopetrosis.
Albright syndrome (McCune-Albright syndrome)
Polyostotic fibrous dysplasia, skin pigmentation and endocrinopathy
(usually precocious puberty in girls).
Apert syndrome
Congenital craniosynostosis and syndactyly.
Ascher syndrome
Congenital double lip with blepharoclasia and thyroid goitre.
Beckwith–Wiedemann syndrome
Congenital gigantism, omphalocoele or umbilical hernia.
Behçet disease (Adamantiades syndrome)
Oral ulcers, genital ulceration and uveitis.
Bell palsy
Lower motor neurone facial palsy, caused by inflammation in the
stylomastoid canal.
Block–Sulzberger disease (incontinentia pigmenti)
Congenital hyperpigmented skin lesions, skeletal defects, learning
disability and hypodontia.
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Bloom syndrome
Congenital telangiectasia, depigmentation, short stature.
Bourneville disease (epiloia, tuberous sclerosis)
Nail fibromas (subungual fibromas), hamartomas in the brain, kidneys
and heart, and skin nodules in the nasolabial fold (adenoma sebaceum).
Burkitt lymphoma
Lymphoma caused by Epstein–Barr virus, most common in sub-Saharan
Africa, often affecting the jaws.
Cannon disease
Congenital white sponge naevus.
Carabelli cusp
Congenital additional palatal cusp on upper molars.
Chediak–Higashi syndrome
Congenital defective neutrophil function, susceptibility to infection, skin
pigmentation.
Chondroectodermal dysplasia (Ellis–van Creveld syndrome)
Autosomal recessive; polydactyly and chrondrodysplasia.
Cowden syndrome
Congenital multiple hamartoma syndrome, with oral papillomatosis and
risk of breast and thyroid cancer.
Cri-du-chat syndrome
Short arm of chromosome 5 deletion, resulting in microcephaly,
hypertelorism and laryngeal hypoplasia causing a characteristic
shrill cry.
Crohn disease
Granulomatous disorder that affects mainly the ileum or any part of the
gastrointestinal tract, including mouth.
Crouzon syndrome
Autosomal dominant premature fusion of cranial sutures, mid-face
hypoplasia and proptosis.
Cushing syndrome
Hyperadrenocorticism.
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 Chapter 10 • Further information

Darier disease
Inherited skin disorder with follicular hyperkeratosis, and white oral
papules.
Di George syndrome
Congenital immunodeficiency with cardiac defects and
hypoparathyroidism due to third branchial arch defect.
Down syndrome (trisomy 21)
The commonest recognizable congenital chromosomal anomaly.
Patients have learning disability, are of short stature with brachycephaly,
mid-face retrusion and upward sloping palpebral fissures (mongoloid
slant).
Eagle syndrome
An elongated styloid process associated with dysphagia and pain on
chewing, and on turning the head towards the affected side.
Ehlers–Danlos syndrome
A group of congenital disorders of collagen characterized by
hyperflexibility of joints, hyperextensible skin and bleeding and bruising.
Ellis–van Creveld syndrome (chondroectodermal dysplasia)
Congenital polydactyly, dwarfism, ectodermal dysplasia. Hypodontia and
hypoplastic teeth. Multiple fraenae.
Epstein–Barr virus
A herpesvirus that has been implicated in infectious mononucleosis, hairy
leukoplakia, nasopharyngeal carcinoma and some lymphomas.
Fabry disease (angiokeratoma corporis diffusum universale)
X-linked recessive error of glycosphingolipid metabolism with punctate
skin angiokeratomas on scrotum, hypertension, fever, renal disease and
risk of myocardial infarction.
Fallot tetralogy
Pulmonary stenosis, over-riding aorta, ventricular septal defect and right
ventricular hypertrophy.
Fanconi anaemia
Congenital anaemia, abnormal radii, risk of oral carcinoma and
leukaemia.
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Felty syndrome
Rheumatoid arthritis and neutropenia.
Fordyce disease
Congenital ectopic sebaceous glands.
Frey syndrome
Gustatory sweating and flushing of skin after trauma due to
crossover of sympathetic and parasympathetic innervation to the salivary
gland and skin.
Gardner syndrome
Autosomal dominant syndrome of intestinal polyposis, multiple osteomas
and fibromas and pigmented lesions of fundus of eye.
Gilles de la Tourette syndrome
Coprolalia (utterance of obscenities).
Goldenhar syndrome
A variant of congenital hemifacial microsomia, with microtia (small ears),
macrostomia, agenesis of mandibular ramus and condyle, vertebral
abnormalities and epibulbar dermoid cysts.
Goltz syndrome (focal dermal hypoplasia)
An inherited condition that involves many body systems but takes its
name from patchy skin abnormalities.
Gorlin–Goltz syndrome (multiple basal cell naevi syndrome)
Multiple basal cell carcinomas, keratocystic odontogenic tumours,
vertebral and rib anomalies.
Graves disease
Hyperthyroidism with ophthalmopathy and exophthalmos.
Guillain–Barré syndrome
Acute demyelination.
Hailey–Hailey disease
Autosomal dominant benign familial pemphigus presenting in second or
third decade with skin and oral blisters and vegetations.
Hallermann–Streiff syndrome
Congenital cranial anomalies, micro-ophthalmia, cataracts, mandibular
hypoplasia and abnormal TMJ.
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 Chapter 10 • Further information

Hand–Schüller–Christian disease
Langerhans histiocytosis causing skull lesions, exophthalmos and
diabetes insipidis.
Heck disease
Multifocal epithelial hyperplasia associated with human papillomavirus
infection.
Heerordt syndrome
Sarcoidosis with lachrymal and salivary swelling, uveitis and fever
(uveoparotid fever).
Henoch–Schönlein purpura
Allergic purpura, which may cause oral petechiae.
Hodgkin disease
Lymphoma.
Horner syndrome
Unilateral:
ptosis (drooping of the upper eyelid)
anhydrosis (loss of sweating) of the ipsilateral face
miosis (pupil constriction)
enophthalmos (retruded eyeball) sometimes.
Hunterian chancre
Syphilitic primary chancre.
Hurler syndrome
Congenital mucopolysaccharidosis causing growth failure, learning
disability, large head, frontal bossing, hypertelorism, coarse face
(gargoylism) and mandibular radiolucencies.
Hutchinson teeth
Screwdriver-shaped incisor teeth in congenital syphilis
Kaposi sarcoma
Sarcomatous lesion caused by human herpesvirus-8 (KSHV; Kaposi
sarcoma herpesvirus), seen mainly in AIDS.
Kartagener syndrome
Congenital dextrocardia, immunodeficiency and sinusitis.
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Kawasaki disease (mucocutaneous lymph node syndrome)

Idiopathic disorder with fever, lymphadenopathy, desquamation of hand
and feet, cheilitis and cardiac lesions.
Kelly syndrome
Atrophy of edentulous anterior maxilla caused by retained mandibular
anterior teeth.
Kikuchi–Fujimoto disease
A self-limited lymphadenopathy that can be confused histologically and
clinically with lymphoma or systemic lupus erythematosus.
Klippel-Feil anomaly
Congenital association of cervical vertebrae fusion, short neck, low-lying
posterior hairline, syringomyelia and other neurological anomalies and
sometimes unilateral renal agenesis and cardiac anomalies.
Kuttner disease
Chronic sialadenitis in IgG4 disease.
Laband syndrome
Hereditary gingival fibromatosis with skeletal anomalies and large digits.
Langerhans cell histiocytoses (histiocytosis X)
Langerhans cell histiocytoses includes:
solitary eosinophilic granuloma of bone;
multifocal eosinophilic granuloma (Hand–Schüller–Christian disease);
Letterer–Siwe disease.
Laugier–Hunziker syndrome
Acquired, benign hyperpigmented macules of the lips and buccal mucosa
and nails.
Laurence–Moon–Biedl syndrome
Congenital retinitis pigmentosa, obesity, polydactyly, learning disability
and blindness.
Lesch–Nyhan syndrome
Congenital purine metabolism defect causing learning disability,
choreoathetoid cerebral palsy and self-multilation.
Letterer–Siwe disease
Rapidly progressive disseminated form of Langerhans histiocytosis which
can be fatal because of pancytopenia and multisystem disease.
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 Chapter 10 • Further information

Lyme disease
Infection with deer tick-borne Borrelia burgdorferii causing rashes, fever,
arthopathy and facial palsy (first reported in the town of Lyme,
Connecticut, USA).
Maffucci syndrome
Multiple enchondromas, haemangiomas, and risk of malignant
chondrosarcomas.
Mantoux test
Skin test for delayed-type hypersensitivity reaction to bacille Calmette-
Guérin (BCG; for tuberculosis).
Marcus Gunn syndrome
Jaw-winking syndrome (eyelid winks during chewing), with ptosis.
Marfan syndrome
Autosomal dominant tall, thin stature and arachnodactyly (long, thin
spider-like hands), lens dislocation, aortic aneurysms and regurgitation,
floppy mitral valve, and occasionally cleft and bifid uvula. Joint laxity is
common.
Melkersson–Rosenthal syndrome
Facial paralysis, oedema and fissured tongue – probably a variant of
orofacial granulomatosis.
Miescher cheilitis
Oligosymptomatic orofacial granulomatosis or Crohn disease clinically
affecting the lip alone.
Mikulicz disease
Salivary gland and lacrymal gland swelling often related to IgG4 systemic
disease.
Mikulicz ulcer
Minor aphthous ulceration.
Moebius syndrome
Congenital anomaly involving multiple cranial nerves, including the
abducens (VI) and facial (VII) nerves, and often associated with limb
anomalies.
Moon molars
Hypoplastic molars from congenital syphilis.
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Munchausen syndrome
Fabrication of stories aimed at the patient receiving operative
intervention.
Nikolsky sign
Blistering or extension of a blister on gentle pressure (e.g. in pemphigus
and pemphigoid).
Noonan syndrome
Congenital short stature, webbed neck sometimes with cardiac
anomalies, pulmonary stenosis and cherubism.
Osler–Rendu–Weber disease (hereditary haemorrhagic
telangiectasia: HHT)
Autosomal dominant disorder. Telangiectases orally and periorally but
also in nose, gastrointestinal tract and occasionally on palms.
Paget disease
Acquired idiopathic disorder of bones presenting with progressive jaw
swelling, hypercementosis and deformity.
Papillon–Lefèvre syndrome
Congenital defect in cathepsin causing palmoplantar hyperkeratosis and
juvenile periodontitis which affects both dentitions, and
immunodeficiency.
Parrot nodes
Frontal bossing in congenital syphilis.
Paterson–Kelly syndrome (Plummer–Vinson syndrome)
Association of dysphagia (post cricoid web of candida), microcytic
hypochromic anaemia, koilonychia (spoon-shaped nails) and angular
cheilitis.
Paul–Bunnell test
Serological test for heterophile antibodies in infectious mononucleosis
(glandular fever).
Peutz–Jeghers syndrome
Autosomal dominant condition of circumoral melanosis and intestinal
polyposis.
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 Chapter 10 • Further information

Pierre Robin syndrome

Congenital micrognathia, cleft palate and glossoptosis.
Prader–Willi syndrome
Congenital obesity, hypogonadism, learning disability, diabetes and
dental defects.
Ramsay Hunt syndrome
A lower motor neurone facial palsy due to herpes zoster of the geniculate
ganglion of the VIIth nerve.
Rapp–Hodgkin syndrome
Ectodermal dysplasia, kinky hair, cleft lip/palate, popliteal pterygium and
ectrodactyly.
Raynaud syndrome
Vascular spasm in response to cooling, seen in the digits in connective
tissue disorders.
Reiter syndrome
The association of arthritis, urethritis and balanitis, and conjunctivitis.
Rett disease
Congenital bruxism and hand-wringing, often with learning
disability.
Riley–Day syndrome
Inherited dysautonomia; sympathetic dysfunction, enlarged salivary
glands and sialorrhoea and self-mutilation, seen particularly in Ashkenazi
Jews.
Romberg syndrome (hemifacial atrophy)
Progressive atrophy of the soft tissues of half the face, associated with
contralateral Jacksonian epilepsy and trigeminal neuralgia.
Sabin–Feldman test
Serological test for toxoplasmosis.
Seckel syndrome
Congenital microcephaly, learning disability, zygomatic and mandibular
hypoplasia.
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Shprintzen syndrome (velo-cardio-facial syndrome)

A congenital anomaly with cleft palate, heart defect, abnormal face,
learning disability, short stature and microcephaly.
Sipple syndrome (multiple endocrine neoplasia type 2a)
Multiple endocrine neoplasia (MEN) type 3 (MEN 3; sometimes
called 2b).
Sjögren syndrome (secondary Sjögren syndrome)
Hyposalivation and keratoconjunctivitis sicca, i.e. dry mouth and dry eyes
with connective tissue disease.
Smith–Lemli–Opitz syndrome
Congenital short stature, learning disability, syndactyly, urogenital and
maxillary anomalies.
Stevens–Johnson syndrome
Severe erythema multiforme.
Still syndrome
Juvenile rheumatoid arthritis.
Sturge–Weber syndrome (encephalotrigeminal angiomatosis)
Congenital angioma of upper face (naevus flammeus), and underlying
bone with convulsions, and hemiplegia.
Sutton ulcers
Major aphthae.
Sweet syndrome
Acute neutrophilic dermatosis; red mucosal lesions and aphthae.
Takayasu disease
Pulseless aorta and large arteries.
Thibierge–Weissenbach syndrome
Diffuse cutaneous scleroderma.
Treacher Collins syndrome (mandibulofacial dysostosis)
Autosomal dominant defect in the first branchial arch with downward
sloping (antimongoloid slant) palpebral fissures, hypoplastic malar
complexes, mandibular retrognathia, deformed pinnas, hypoplastic
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 Chapter 10 • Further information

sinuses, colobomas in the outer third of the eye, middle and inner ear
hypoplasia (deafness).
Tricho-dento-osseous syndrome
Autosomal dominant; kinky hair, amelogenesis imperfecta and brittle
nails.
Trotter syndrome
Acquired unilateral deafness, pain in the mandibular (third) division of the
trigeminal nerve, ipsilateral palatal immobility and trismus. Due to
invasion of the nasopharynx by malignant tumour.
Turner teeth
Hypoplastic tooth due to damage to the developing tooth germ.
Von-Recklinghausen disease
Multiple neurofibromas with skin pigmentation, skeletal abnormalities and
central nervous system involvement.
Waardenburg syndrome
Congenital heterochromia iridis (different-coloured eyes), deafness and
white forelock, with prognathism.
Waldeyer ring
Lymphoid tissue surrounding the entrance to the oropharynx (tonsils and
adenoids).
Warthin tumour
Salivary gland tumour.
Wegener granulomatosis
Idiopathic granulomatous disorder affecting lungs, kidneys and
sometimes mouth.
Wiskott–Aldrich syndrome
X-linked recessive immunodeficiency characterized by thrombocytopenic
purpura, eczema, recurrent infections and lymphoreticular malignancies.

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Glossary of abbreviations
AC angular cheilitis
ANA antinuclear antibodies
bid or bd twice a day
BMS burning mouth syndrome
BNF British National Formulary
BP blood pressure
BRONJ bisphosphonate-related osteonecrosis of the jaw
BS Behçet syndrome
CAT computerised axial tomography
CBT cognitive-behavioural therapy
CMV cytomegalovirus
CNS central nervous system
CO complaining of
COPD chronic obstructive pulmonary disease
CRP C-reactive protein
CSF cerebrospinal fluid
CT computed tomography or chemotherapy
CVA cerebrovascular accident
CXR chest X-ray
DIF direct immunofluorescence
DLE disseminated lupus erythematosus
DPF Dental Practitioners Formulary
DXR radiotherapy
EB epidermolysis bullosa
EBV Epstein–Barr virus
ECG electrocardiogram
ELISA enzyme-linked immunosorbent assay
EM erythema multiforme
ENT ears, nose and throat

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 Chapter 10 • Further information

ESR erythrocyte sedimentation rate

FBC full blood count
FBP full blood picture
FH family history
FNA fine needle aspiration
FNAB fine needle aspiration biopsy
GDP general dental practitioner
GI gastrointestinal
GIT gastrointestinal tract
GMH general medical history
GMP general medical practitioner
GORD gastro-oesophageal reflux disease
GP general practitioner
GvHD graft-versus-host disease
HBV hepatitis B virus
HCV hepatitis C virus
HHV human herpesviruses
HIV human immunodeficiency virus(es)
HL Hodgkin lymphoma
HPA hypothalamus–pituitary–adrenal
HPC history of the present complaint
HPV human papillomaviruses
HSCT haematopoietic stem cell transplantation
HSV herpes simplex virus
IIF indirect immunofluorescence
KCOT keratocystic odontogenic tumour
KS Kaposi sarcoma
KSHV Kaposi sarcoma herpesvirus
LA local anaesthesia
LFT liver function tests
LP lichen planus

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MDR-TB multidrug resistant tuberculosis

MEN multiple endocrine neoplasia
mg milligram
MMP mucous membrane pemphigoid
MRI magnetic resonance imaging
MRS Melkersson–Rosenthal syndrome
MRSA methicillin-resistant Staphylococcus aureus
NHL non-Hodgkin lymphoma
NSAID non-steroidal anti-inflammatory drug
OFG orofacial granulomatosis
ORN osteoradionecrosis
OTC over-the-counter
PCR polymerase chain-reaction
PFAPA periodic fever, aphthae, pharyngitis, adenitis
PMH past medical history
POM prescription-only medicine
PPI proton pump inhibitor
prn as necessary
PV pemphigus vulgaris
qid or qds four times a day
RAS recurrent aphthous stomatitis
RF rheumatoid factor
RMH relevant medical history
SH social history
SJS Stevens–Johnson syndrome
SLE systemic lupus erythematosus
SS Sjögren syndrome
SSI sexually shared infections
SSRI selective serotonin re-uptake inhibitor
STI sexually transmitted infection
TB tuberculosis

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 Chapter 10 • Further information

tid three times a day

TMJ temporomandibular joint
TMPD temporomandibular pain-dysfunction syndrome
TN trigeminal neuralgia
TNF tumour necrosis factor
U&E urea and electrolytes
URTI upper respiratory tract infection
US ultrasound
UTI urinary tract infection
WBC white blood cell count
WCC white cell count
VZV varicella-zoster virus
XDR-TB extended drug-resistant tuberculosis

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Further reading
http://health.nih.gov/
<accessed 15 June 2011>
http://www.emedicine.com
<accessed 15 June 2011>
http://www.mayoclinic.com/health/DiseasesIndex/DiseasesIndex
<accessed 15 June 2011>
http://www.merckmanuals.com/professional/full-symptoms.html
<accessed 15 June 2011>

412
 Index
Page numbers ending in ‘b’, ‘f’ and ‘t’ refer to Boxes, Figures and Tables
respectively

Algorithms, diagnostic see under

A Diagnosis
Abrasion, tooth  137 Allergic angioedema  180–182, 181f
Abscess  107f, 348f Alveolar mucosa, examination  13
Aciclovir  194, 217 Alveolar osteitis (dry socket)  311
Acquired immunodeficiency syndrome Alveolar ridge keratosis  294–296,
(AIDS) see HIV/AIDS 295f
Actinic burns, and cheilitis  180, 181f Amalgam tattoo  54f–55f, 200, 208,
Actinomycosis  159f, 302, 303f 209f, 347f
Acute herpetic stomatitis  131f Ameloblastoma  120f, 308, 309f
Acute necrotizing ulcerative gingivitis Amelogenesis imperfecta  324–328,
(ANUG)  292–294 325f
Acute pseudomembranous candidosis Amifostine  332
(thrush)  243–244, 243f Amlexanox  238
Acute sialadenitis see Sialadenitis, Amoxicillin  294, 315
acute Amyloidosis  266–268, 267f
Acute ulcerative gingivitis (AUG)  292– Anaesthesia  41, 378f
294, 294f–295f Anatomical features  18–28, 19f–30f
Addison disease Angina  89
(hypoadrenocorticism)  54, 55f, Angina bullosa haemorrhagica
207–211, 207f (ABH)  284, 285f
Adenoid cystic carcinoma  123f, 168 Angioedema
Adenomas  166 allergic  180–182, 181f
Adenosine deaminase  172 hereditary  192
Adrenaline, intramuscular  182 treatment  182
413
 Index

Angiography  184 Basement membrane zone

Angioma (haemangioma)  71f, 105f, (BMZ)  228, 375
113f, 182–184, 183f Beckwith–Wiedemann
Angular stomatitis/cheilitis  64, 65f syndrome  265–266
Anitvirals  194, 217 Behçet disease  1–2, 76f, 240–242
Ankyloglossia (tongue-tie)  266 Bell palsy  92–93, 94f, 318, 319f
Antibodies  178, 318 Benign migratory glossitis  274–277,
Antifungals  64, 244–245 275f–277f
Antihistamines  182 Benign nerve sheath tumour  268
Antimalarials  55f, 242 Benign trigeminal neuropathy  99
Antimicrobials  162, 221, 294, 315 Benzydamine  277
Antinuclear antibodies (ANA)  318 Betel use
Anti-rejection therapy, gingival coated tongue  133f
swelling  343f oral submucous fibrosis  256
Antithyroid drugs  242 tooth discolouration  139f
Antral carcinoma  304, 305f trismus  153f
Aphthae  78 Bifid uvula  18
major  76f, 239f Bilateral masseteric hypertrophy  307f
minor  75f, 239f Biopsy
ulceration  236–238 defined  364
Aphthous-like ulceration  74, 238, excisional see Excisional biopsy
240 incisional see Incisional biopsy
Behçet disease  241f indications for  364
in coeliac disease  223f oral lichen planus  375, 382f
vitamin deficiency  241f of striae  382f
Argyll–Robinson pupils  221 ultrasound-guided fine needle
Artefactual cheilitis  191f aspiration  186, 272, 385
Aspirin  78 Bisphosphonate related
Attrition, tooth  138–139 osteonecrosis  345f
dentinogenesis imperfecta  327f Bisphosphonate related osteonecrosis
Atypical facial pain  320–321 of jaw (BRONJ)  78, 312–313
Autophagy gene ATG16L1  224 Black stain  142
Azathioprine  236 Bleeding  34, 35f–36f
Blisters
epidermolysis bullosa  229f
B mucosal  51–52
B cell lymphoma  360 pemphigoid  51f, 233f
Bad breath (halitosis)  47–49, Blood blisters, purpura  51f
49f–50f Blood disorders, ulceration  211

414
 Index

Blood tests  371 complicating

Blue rubber bleb naevus syndrome immunosuppression  331f
(BRBNS)  184 denture-related stomatitis  72f
Blue stain  142 erythematous see Erythematous
Bone marrow suppressants  242 candidosis
Bone marrow transplants see glossitis  70f, 134f–135f, 272–273,
Haematopoietic stem cell 273f
transplantation (HCST) in HIV/AIDS  72f, 351, 352f–353f
Bone necrosis see Osteonecrosis posterior midline atrophic  280,
Borrelia vincentii  294 281f
Breath analyser  385 red lesion, presenting as  70f, 72f,
Brown lesions  207–211, 207f, 209f 202f
Addison disease  207–211, 207f with Sjögren syndrome  175f
amalgam tattoo see Amalgam thrush  243–244, 243f
tattoo ‘thumb print’ appearance, in HIV/
malignant melanoma  208–210, AIDS  72f, 353f
209f on tongue  202f
naevi  210–211, 210f ulceration with  219f
Brown stain, tooth discolouration  142 white lesions  200, 243–245, 243f,
Bruxism  307f 245f, 354f
Buccal mucosa, examination  12–13, Carcinoma
15 adenoid cystic  123f, 168
Bullous diseases, direct antral  304, 305f
immunofluorescence for  382–383 with candidal leukoplakia  264f
Burning mouth  37f, 38–41, 40f ipsilateral oral  117f
Burning mouth syndrome (BMS)  lips  105f, 181f, 184–186, 185f
38–41 metastatic  115f, 117f
Busulphan  335 mimicking granular cell
myoblastoma  110f
mimicking keratosis  264f
C mucoepidermoid  168
Cacogeusia  128–130 mucosal red lesions  72f
Cancer see Malignant disease  269 mucosal white lesions  84f–85f
Candidal leukoplakia  83f, 244, 245f, necrotizing sialometaplasia
264f mimicking  289f
Candidosis squamous  269
candidal leukoplakia  83f, 244, swollen mouth  110f–111f
245f, 250 tongue lesions  269–272,
chronic mucocutaneous  244–245 270f–271f

415
 Index

ulceration  74f Ciclosporin, gingival swelling  343f

verrucous  85f Cigarette smoking see Smoking
white lesions  74f, 110f–111f Circumvallate papillae, tongue  13,
CARD 15 gene  224 27f
Caries Cisplatin  334
red lesions  206f Cleft lip repair, drooling in infant 
with Sjögren syndrome  175f 101f
tooth discolouration  141f Coeliac disease  223–224, 223f
Cavities see Caries Cold sores (herpes labialis)  192–194,
CD4 T lymphocyte count, in AIDS  193f, 215
351 mimicking leukaemia  358f
Central papillary atrophy  280, 281f Coloured lesions see Brown lesions;
Cervical lymph node Red lesions
disease  158–160 Commissures, oral  12, 65f
enlargement  118f, 159f Complications, orofacial
metastatic  117f chemotherapy  334t
Cervical lymph nodes, examination  7, haematopoietic stem cell
158 transplantation  336t
Chancre, in syphilis  220f HIV/AIDS  352t
Cheek biting (morsicatio immunosuppression  329t
buccarum)  87f, 246, 247f leukaemia  358t
Cheilitis  179, 191f leukopenia  356t
and actinic burns  180, 181f lymphoma  361t
artefactual  191f organ transplantation  335t
exfoliative  188–192, 191f radiotherapy  332t
factitious  188–192, 191f Computed axial tomography
granulomatous  197f (CT)  384–385
see also Lip lesions Cone beam CT (CBCT)  384
Cheilitis granulomatosa  196 Congenital conditions
Chemiluminescent illumination  12, neutropenia  356
363 sensory changes  99
Chemotherapy  114, 334, 334t syphilis  146, 218
Chicken-pox (herpesvirus varicella- tooth hypoplasia  146
zoster)  216, 217f see also Hereditary conditions
Chief Complaint (CC)  2 Conjunctival pemphigoid  232f
Chin, numb chin syndrome  96, 97f, Consciousness level  10
99 Corticosteroids
Chlorhexidine  133f, 139–140, 236, angioedema  182
238, 345f–346f aphthae  238

416
 Index

desquamative gingivitis  42 odontogenic  303f, 308, 309f–310f

discoid lupus erythematosus  187 radicular  310f
fissured lip  66 see also Tumours
IgG4 syndrome  179 Cytotoxics  242
pemphigus  236
sarcoidosis  172
shingles  217
D
swelling in lip or face due to  Dandy–Walker syndrome  184
104 Dangerous conditions  1–2
ulcerative colitis  227 Deficiency states  134f
Co-trimoxazole  114 glossitis  134f, 135
Cranial arteritis see Giant cell Dehydration, furred tongue  131
arteritis Dental caries see Caries
Cranial nerves Dental panoramic tomography
examination  8, 366–367 (DPT)  384
history  6 Dental problems, history  3–4
Crenated tongue  274, 275f Dentigerous cyst, jaw  310f
CREST syndrome  206 Dentine  16, 138f
Crohn disease  223 Dentinogenesis imperfecta  326,
fissured lip in  67f 327f
fissured tongue in  63f Dentogingival junction  15
gingival erythema and Denture flange, over-extended  237f
swelling  225f Denture-induced hyperplasia  259–
mucosal ‘cobblestoning’  226f 260, 259f, 348f
mucosal tags  225f Denture-related stomatitis  72f,
swollen lip  104f 284–287, 285f–286f, 349f
swollen mouth  112f Depapillation see Glossitis (smooth
ulceration  224–226, 225f–226f tongue)
see also Orofacial granulomatosis Desquamation  232f, 293f
(OFG) Desquamative gingivitis  41–42, 43f,
Crown formation  16 137f, 233f, 292
Cryosurgery  66, 187 Developmental anomalies  18–28,
CTLA-4 (cytotoxic T-lymphocyte 19f–30f
antigen 4)  296–298 Diagnosis  363–369
Cyclic neutropenia  356 bleeding gums  36f
Cyclophosphamide  236, 335 burning mouth  40f
Cysts cervical lymph node disease  118f
dentigerous  310f dental disorders  366
jaw  302 dry mouth  46f

417
 Index

facial palsy  95f hydroxychloroquine

halitosis  50f pigmentation  343f
hyperpigmentation  59f hyperpigmentation  55f
jaw disorders  365–366 lichenoid lesions  344f
mucosal disorders  363–364 lichenoid reaction, amalgam
neurological disorders, related  347f
suspected  368–369 methotrexate  346f
pain  366–368 minocycline pigmentation  344f
red lesions  73f mucosal black and brown
salivary disease  364–365 lesions  56
salivary gland swelling  126f mucosal erosions  61f
sialorrhoea (hypersalivation)  103f nicorandil use  346f
taste disturbance  130f orofacial pain  91
trigeminal sensory loss  100f palatal pigmentation  343f–344f
trismus  155f swelling in lip or face  104
ulceration, mucosal  79f–81f tooth staining  345f–346f
white patch  88f ulceration  78, 242, 242f, 346f
Diltiazem, gingival swelling  343f see also Iatrogenic conditions
Direct immunofluorescence (DIF)  234, DRW3  224
375, 382–383, 383f Dry eye (keratoconjunctivitis
Discoid lupus erythematosus sicca)  176, 177f
(DLE)  186–187, 187f, 230 Dry mouth  42–45, 45f–46f, 173–176
Discolouration, tooth  139–142, 290f, Sjögren syndrome with  173f–174f,
328 206f
dentinogenesis imperfecta  327f Dysaesthesia, oral  91
DLE see Discoid lupus erythematosus
(DLE)
Down syndrome  23, 278
E
Drooling  101–102, 103f Electrogustometry  8
Drug-induced conditions  337, Enamel  16
342f–346f Epidermolysis bullosa (EB)  228,
adverse effects  338t–342t 229f
bisphosphonate related Epithelium, loss of in mucosal
osteonecrosis  345f erosions  60
cervical lymph node disease  Epstein–Barr virus (EBV)  353f
160 Epulides  114–115
gingival swelling  296–298, 297f, Epulis
342f–343f fibrous  115f
halitosis  48 pregnancy  300–301, 301f

418
 Index

Erosions
lichen planus  293f
F
mucosal  60, 61f Facial (VII) nerve, examination 
see also Ulceration, mucosal 10–11
mucositis  60, 333f Facial arthromyalgia (FAM)  315–316,
pemphigoid  232f 317f
tooth  143–144 Facial swelling  7, 103–106
Erythema  191f, 214f, 225f Factitious cheilitis  188–192, 191f
Erythema migrans  63f Famciclovir  194, 217
with circumvallate papillae  27f Family History (FH)  3
tongue  274–277, 275f–277f Fauces  14, 361f
Erythema multiforme  188, 189f Fibre-optic
Erythematous candidosis  202–207, pharyngolaryngoscopy  186, 272
202f, 354f Fibrous dysplasia  304–306, 305f
‘thumb print’ appearance  353f Fibrous epulis  115f
Erythroplakia/erythroplasia  72f, Fibrous lump (fibroepithelial
203–205, 203f–204f polyp)  108f, 260, 261f
Etoposide  334 Filiform papillae, tongue  13, 27f
Examination Fusiform bacteria  294
buccal and labial mucosa  12–13, Fissures/cracks
15 in lip  66, 67f, 104f
cervical lymph nodes  7, 158 mucosal  62–66, 63f, 65f, 67f
cranial nerves  366–367 in tongue  23, 23f, 63f, 278, 279f
extraoral  6–7 Fistula  7, 349f
gingivae  15 Floor of mouth  13–14, 165f
jaws  7–8 Flucloxacillin  162
lips  12–13 Fluconazole  244–245
neurological system  8–11 Fluorescence spectroscopy  12, 363
palate  14–15 Fluorosis  145f, 326–328, 327f
salivary glands  16–18 Fluorouracil  334
teeth  16 Foliate papilae  13
tongue  13–14 Foliate papillitis  278
see also Investigations Fordyce spots/granules  12–13, 15,
Excisional biopsy  372, 372f–375f 24, 24f
Exfoliative cheilitis  188–192, Fucidin  64
191f Functional endoscopic sinus surgery
Exostosis  19f (FESS)  315
Extraoral examination  6–7 Fungiform papillae, tongue  13, 27f
Eye, dry  176, 177f Furred tongue  131–132, 132f–133f

419
 Index

herpetic stomatitis  214f–215f

G leukaemia  292, 360f
Gardner syndrome  306 pregnancy gingivitis  301f
Gastric reflux  38 Gingivitis
Gastrointestinal disorders acute ulcerative  292–294,
coeliac disease  223–224, 223f 294f–295f
Crohn disease see Crohn disease bleeding  35f
ulceration  223–227, 223f, chronic marginal  291, 296,
225f–226f 297f
ulcerative colitis  227, 227f desquamative  41–42, 43f, 137f,
Genetic factors see Hereditary 233f, 292
conditions hyperplastic  114
Genital warts  262 linear  355f
Geographic tongue see Erythema necrotizing ulcerative  75f,
migrans 292–294, 294f–295f, 355f,
Giant cell arteritis  1–2, 89, 320, 321f 359f
Giant cell granuloma, central  310f pregnancy  300, 301f
Gingivae, examination  15 Glandular fever (infectious
Gingival lesions  215, 291–301, mononucleosis)  218, 219f
293f–295f, 297f, 299f, 301f Glossitis (smooth tongue)  134–135,
alveolar ridge keratosis  294–296, 135f
295f benign migratory  274–277,
drug-induced swelling  296–298, 275f–277f
297f candidal  70f, 134f–135f,
gingival margin ulceration  357f 272–273, 273f
hereditary gingival deficiency states  134f, 135
fibromatosis  298–300, 299f epidermolysis bullosa  229f
lichen planus  293f hyposalivation  273f, 279f
primary herpes simplex median rhomboid  280, 281f
stomatitis  293f Glossopharyngeal palsy  15
see also Gingivitis Gluten-sensitive enteropathy (coeliac
Gingival margin  15, 292, 357f disease)  209f, 223f
Gingival swelling Graft-versus-host disease (GvHD)  60,
common nature of  114 335, 337f
Crohn disease  225f Gram stain  244
drug-induced  296–298, 297f, Granular cell myoblastoma  110f
342f–343f Granulomatous cheilitis  197f
hereditary gingival Graphite tattoo  54
fibromatosis  299f Green stain  142

420
 Index

Grey stain  142 Hereditary haemorrhagic

Gums, bleeding  34, 35f–36f telangiectasia (HHT)  35f, 205–206
multiple telangiectasia in  205f
Herpangina  212–213, 212f
H Herpes, recurrent  214f
Haemangioma (angioma)  71f, Herpes labialis  192–194, 193f, 215
182–184, 183f Herpes simplex ulceration  193,
swelling of lips or face  105f 352f
swollen mouth  113f Herpes zoster (shingles)  194, 195f,
Haematopoietic stem cell 216–217, 330f
transplantation (HCST)  60, 335, Herpesvirus varicella-zoster
336t, 337f (chickenpox)  216, 217f
Haemorrhage, leukaemia  360f Herpetic stomatitis  213–215,
Hairy leukoplakia  250 213f–215f
in HIV/AIDS  353f Herpetiform ulcer (recurrent aphthous
Hairy tongue stomatitis)  76f, 239f
black  58 Histiocytosis X  306
brown  58, 132f History  2–6
Halitosis  47–49, 49f–50f related to dental problems  3–4
Hand, foot and mouth disease  211– related to jaw problems  5
212, 211f related to mucosal problems  4
Hand–Schuller–Christian disease  306 related to pain and neurological
Hard palate  14 problems  5–6
Heck disease  262 related to salivary problems  4–5
Hereditary conditions History of the Present Complaint
angioedema  192 (HPC)  2
dentinogenesis imperfecta  327f HIV/AIDS  351–356, 352f–355f, 352t
gingival fibromatosis see Hereditary candidosis  72f, 351, 352f
gingival fibromatosis (HGF) definition of AIDS  351
haemorrhagic telangiectasia see erythematous candidosis  202–
Hereditary haemorrhagic 207, 202f, 354f
telangiectasia (HHT) ‘thumb print’ appearance  353f
mouth pigmentation  53 genital warts  262
mucosal white lesions  82, 82f hairy leukoplakia  353f
neutropenia  356 herpes simplex ulceration  352f
tooth shape anomalies  152 linear gingivitis  355f
see also Congenital conditions mortality rate  1–2
Hereditary gingival fibromatosis necrotizing ulcerative
(HGF)  298–300, 299f gingivitis  355f

421
 Index

orofacial complications  352t Hypomineralized amelogenesis

salivary gland conditions  355f imperfecta  324
testing for  364 Hypoplasia, tooth  144–146, 145f,
white candidosis  354f 147f
HLA-DQw2  224 Hypoplastic amelogenesis
Human immunodeficiency virus (HIV) imperfecta  324, 325f
see HIV/AIDS Hyposalivation  44, 45f
Human papillomavirus (HPV) examination  18
infections  262–264, 263f, 331f glossitis (smooth tongue)  273f,
Hurler syndrome  136f 279f
Hutchisons incisors  146, 147f radiation-induced  333f
Hydroxychloroquine tongue lesions  279f
pigmentation  343f Hysteria  99
Hyperpigmentation
amalgam tattoo  54f–55f, 208,
209f
I
diagnostic algorithm  59f Iatrogenic conditions  329–337
drug-induced  55f amalgam tattoo  54f–55f, 208,
features of most important 209f, 347f
hyperpigmented lesions  57t chemotherapy  114, 334, 334t
in hypoadrenocorticism  55f dental abscess  348f
naevus  53f denture flange,
Hyperplasia over-extended  237f
denture-induced  259–260, 259f, denture-induced hyperplasia  259–
348f 260, 259f, 348f
papillary  286f denture-related stomatitis  72f,
Hyperplastic gingivitis  114 284–287, 285f–286f, 349f
Hypersalivation (sialorrhoea)  haematopoietic stem cell
101–102, 103f transplantation  60, 335, 336t,
Hypersensitivity, avoiding by 337f
secondary dentine deposition  hyposalivation  44
138f immunosuppressive therapy  329,
Hyperventilation syndrome  99 330f–331f
Hypoadrenocorticism (Addison organ transplantation  335,
disease)  54, 55f, 207–211, 335t
207f radiotherapy  332, 332t, 333f
Hypocalcified amelogenesis traumatic oroantral fistula 
imperfecta  324, 325f 349f
Hypodontia  148–150 see also Drug-induced conditions

422
 Index

Idiopathic conditions Incisor-premolar hypodontia

facial pain  320–321 (IPH)  148
leukoplakia  248 Indirect immunofluorescence  234
IgG4 syndrome  122f, 178–179 Infections
IGRT (Image Guided Radio actinomycosis  302, 303f
Therapy)  332 acute bacterial sialadenitis  162
Image Guided Radio Therapy Bell palsy  93
(IGRT)  332 blisters  52
Imaging  120f, 384–385 cervical lymph node disease 
Immunocompromised individuals  1, 158
215 glandular fever (infectious
Immunofluorescence, direct  382– mononucleosis)  218, 219f,
383, 383f 240–242
Immunoglobulins, intravenous  236 hand, foot and mouth
Immunosuppressive therapy  329, disease  211–212, 211f
330f–331f herpangina  212–213, 212f
T lymphocyte function, designed to herpesvirus varicella-zoster  216,
suppress  329, 335 217f
IMRT (Intensity Modulated Radio herpetic stomatitis  213–215,
Therapy)  332 213f–215f
Incisional biopsy  375, 376f–383f, human papillomavirus  262–264,
382–383 263f, 331f
anaesthesia  378f leukopenia see Leukopenia
considerations before starting  378f mucosal white lesions  83f
dermatology punch, performed odontogenic cysts and tumours 
with  375 1, 303f, 308, 309f–310f
direct immunofluorescence  375, opportunistic  329
382–383, 383f recurrent herpes  214f
fixative for specimen  377f shingles  194, 195f, 216–217,
instruments  377f 330f
mapping  376f syphilis  218–221, 220f–221f
sample  379f–381f tuberculosis  222–223,
scalpel, performed with  375 222f
simple  376f Inflammation
vital staining  375, 377f, 381f bilateral parotid  122f
Incisor teeth cervical lymph node
development  16 disease  158–160
peg-shaped lateral  151f inflammatory bowel disease see
screwdriver-shaped  146, 147f Crohn disease; Ulcerative colitis

423
 Index

lichen planus  84f lymphangioma  105f, 113f, 262,

see also Lichen planus (LP) 263f
mucosal black and brown neoplasms, salivary glands  111f
lesions  53 neurofibroma  115f, 268
salivary glands  161 papilloma  109f
Inherited disorders see Hereditary periapical abscess  107f
conditions pregnancy tumour  107f
Instruments, biopsy  372f, 377f Investigations  371–386
Intensity Modulated Radio Therapy adjunctive screening
(IMRT)  332 tests  385–386
Intracerebral disease  89 blood tests  371
Intraoral examination  11–13 dental disorders  366
Intraoral lesions  200–264 excisional biopsy  372, 372f–375f
brown see Brown lesions fibre-optic
examination  11 pharyngolaryngoscopy  186, 272
mixed red and white  381f imaging  384–385
red see Red lesions incisional biopsy  375, 376f–383f,
white see White lesions 382–383
see also Ulceration jaw disorders  365–366
Intraoral radiography  384 microbiological tests  371
Intraoral salivary gland oral lichen planus biopsy  375,
neoplasms  168–170 382f
Intraoral swelling  107–115 pain  367–368
carcinoma  110f–111f salivary flow  371, 372t
with candidal leukoplakia  salivary gland conditions  364–365
264f scanning  323f, 385
metastatic  115f sensory changes, orofacial  96
mimicking keratosis  264f serum antibody screening  224
‘cobblestoning’ of mucosa  112f ultrasound-guided fine needle
Crohn disease  112f aspiration biopsy  186, 272, 385
denture-induced hyperplasia  259– see also Examination
260, 259f Ipsilateral oral carcinoma, cervical
epulides  114–115 lymph node metastasis from  117f
fibrous epulis  115f
fibrous lump  108f, 260, 261f
granular cell myoblastoma  110f
J
haemangioma (angioma)  113f Jaw and musculoskeletal
human papillomavirus conditions  302–316
infection  262–264, 263f actinomycosis  302, 303f

424
 Index

alveolar osteitis  311

ameloblastoma  120f, 309f
K
antral carcinoma  304, 305f Kaposi sarcoma herpesvirus
bilateral masseteric (HKHV)  287
hypertrophy  307f Kaposi sarcoma (KS)  54, 283,
bruxism  307f 287–288, 287f–288f
dentigerous cyst  310f KCOT  308
diagnosis  365–366 Keratoconjunctivitis sicca (dry
examination of jaw  7–8 eyes)  176, 177f
facial arthromyalgia  315–316, Keratocystic odontogenic tumour,
317f jaw  309f
fibrous dysplasia  304–306, 305f Keratosis
Gardner syndrome  306 alveolar ridge  294–296, 295f
giant cell granuloma, central  310f carcinoma mimicking  264f
histiocytosis X  306 frictional  248
history  5 smoker’s  250, 290–291, 290f
Langerhans cell histiocytoses  white lesions  249f
306 see also Sublingual keratosis
mandibular dysfunction/stress Koplik spots, in measles
syndrome  315–316, 317f prodome  257f
masseteric hypertrophy  306–307 Kuttner tumour (Mikulicz
metastasis to jaw  119 disease)  122f, 178–179
myofascial pain dysfunction  315–
316, 317f
odontogenic cysts and
L
tumours  303f, 308, 309f–310f La (SS-B) antibody  178
odontome, complex  309f Labial melanotic macule  194–196
osteitis  311 Labial mucosa, examination  12–13,
osteomyelitis  311–312 15
osteonecrosis  312–314 Langerhans cell histiocytoses  306
Paget disease  314 Laser ablation  66
radicular cyst  310f Laugier–Hunziker syndrome  196
sinusitis  315 Le tic de lèvres  188–192, 191f
swelling of jaw  119–120, 120f Lesions
temporomandibular pain– descriptions  31t–32t
dysfunction syndrome  315–316, examination  11
317f gingival see Gingival lesions
Juvenile recurrent parotitis  hyperpigmented, most
120–121 important  57t

425
 Index

intraoral see Intraoral lesions erosions and desquamation

lichenoid  78, 344f in  293f
lip see Lip lesions leukoplakia white lesions
mucosal black and brown  53–58, mimicking  249f
57t, 59f potentially malignant  1–2
see also Brown lesions ulceration  228
palatal see Palatal lesions white lesions  84f, 250–255,
parotid gland  93 251f–254f
skin, arising from  7 Lichenoid lesions  78, 344f
tongue see Tongue lesions Lichenoid reactions  242, 347f
Letterer–Siwe disease  306 Linea alba  255–256
Leukaemia  358, 358f–360f, 358t Linear gingivitis  355f
acute myelomonocytic  292 Lingual nerve, damage to  98
bleeding in  35f Lining mucosa, examination 
chronic lymphatic  234–236 12–13, 15
gingival swelling  292, 360f Lip lesions  179–200, 181f, 183f,
haemorrhage  360f 185f, 187f, 189f–191f, 193f, 195f,
herpes labialis mimicking  358f 197f, 199f
necrotizing ulcerative gingivitis adenomas  168
with  359f allergic angioedema  180–182,
with purpura  360f 181f
ulceration  359f–360f angioma  182–184, 183f
Leukoedema  25f carcinoma  181f, 184–186, 185f
Leukopenia  356, 356t, 357f cheilitis see Cheilitis
Leukoplakia  248–250 discoid lupus erythematosus  186–
candidal  83f, 244, 245f, 250, 187, 187f
264f erythema multiforme  188, 189f
in chronic renal failure  250 hereditary angioedema  192
hairy  250, 353f herpes labialis  192–194, 193f
idiopathic  248 herpes zoster  194, 195f
mimicking lichen planus  249f labial melanotic macule  194–196
potentially malignant  1–2 mucocele  197f
syphilitic  250 orofacial granulomatosis  196–198
verrucous, proliferative  86f, 292 Peutz–Jegher syndrome  196,
white lesions  249f 198–200, 199f
Lichen planus (LP) pyogenic granuloma  200
biopsy  375, 382f Lips
burning mouth  37f chapping  190f
desquamative gingivitis  41, 43f dry  174f

426
 Index

examination  12–13 mucosal ulceration  77

fissures/cracks in  66, 67f, 104f multiple myeloma  97f
lesions see Lip lesions potentially malignant  1–2,
racial pigmentation  28f–30f 382f
swelling  103–106, 104f–105f, sensory changes, orofacial  96
189f signs and symptoms, oral  2
tightening, in scleroderma  206f skin disorders  236
Lobulated tongue see also Malignant melanoma
following hyposalivation  45f sublingual gland  168, 169f
Sjögren syndrome with  174f white lesions  243–259
Loss of taste  128 Malignant melanoma  54, 208–210,
Lower motor neurone (LMN) 209f
lesions  11 Management protocols, primary care
Lupus erythematosus (LE)  230, 231f settings  387
see also Discoid lupus Mandibular dysfunction/stress
erythematosus (DLE) syndrome  315–316, 317f
Lymphadenopathy  158–159 Mapping incisional biopsy  376f
Lymphangioma  105f, 113f, 262, Masseteric hypertrophy  306–307
263f Masticatory mucosa, examination 
Lymphoid tissue, tongue  13–14 13
Lymphoma  159f, 176, 361f, 361t Measles  256, 257f
non-Hodgkin  234–236 Median rhomboid glossitis  280,
281f
Melanocytes  12–13
M Melanotic macules  53, 195f
Macrocheilia  262 Melkersson–Rosenthal syndrome  23,
Macroglossia (enlarged tongue)  114, 196, 278
136f, 267f Melphalan  334
Macules, melanotic  53, 194–196, Metastatic carcinoma  115f
195f Methotrexate use  78, 172, 346f
Maffucci syndrome  184 Metronidazole  294
Magnetic resonance imaging Michels solution  382
(MRI)  312, 384–385 Miconazole  64, 244–245
Malignant disease Microbiological tests  371
carcinoma see Carcinoma  269 Middle ear disease  93
cervical lymph node disease  160 Miescher cheilitis  196
chemotherapy  114, 334, 334t Migrainous neuralgia  89
leukaemia see Leukaemia Mikulicz disease (bilateral parotid
mortality rate  1–2 inflammation)  122f, 178–179

427
 Index

Milk teeth, development  16 purpura  68, 69f, 71, 74

Minocycline pigmentation  55f, red lesions  70–74, 72f
344f ulceration/soreness  74–78,
MMR (measles, mumps and rubella) 74f–76f, 79f–81f
vaccine  164–166 white lesions  81–87, 82f–88f
Molar teeth, development  16 Mucosal tags, Crohn disease 
Moon/mulberry molars  146 225f
Morsicatio buccarum (cheek Mucosa-sparing blocks  332
biting)  87f, 246, 247f Mucositis  60, 78, 333f, 334
Mortality rate, high  1–2 Multifocal epithelial hyperplasia 
Motor functions, trigeminal  8 262
Mouth Multiple myeloma  97f
burning  37–41, 37f, 40f Mumps (acute viral sialadenitis) 
dry  42–45, 45f–46f, 173–176, 120–121, 164–166, 167f
173f–174f, 206f Mycophenolate mofetil  236
floor of  13–14, 165f Myofascial pain dysfunction
mucocele in floor of  165f (MFD)  315–316, 317f
swollen see Intraoral swelling
see also Lip lesions; Lips; Teeth;
Tongue; Tongue lesions
N
Mucoceles, salivary gland  52, Naevus
120–124, 125f, 164, 165f brown lesions  210–211, 210f
in floor of mouth  165f hyperpigmentation  53f
lip lesions  197f white sponge  82f, 247f, 258–259,
superficial  164 258f
Mucoepidermoid carcinoma  168 Nasopharyngeal disease  48
Mucosal barrier injury see Neck
Mucositis actinomycosis, showing purple
Mucosal conditions swelling  159f
black and brown lesions  53–58, examination  7
57t, 59f lymphoma presenting as upper
blisters  51–52 cervical lymph node
diagnosis  363–364 enlargement  159f
erosions  60, 61f swollen  116–117
fissures/cracks  62–66, 63f, 65f, actinomycosis  159f
67f midline of neck  117
history  4 side of neck  117
intraoral examination  11–12 Necrotizing sialometaplasia  289,
neuromas  268 289f

428
 Index

Necrotizing ulcerative gingivitis

(NUG)  75f, 292–294, 294f–295f
O
in HIV/AIDS  355f Obstruction
in leukaemia  359f parotid duct  121f
Neoplasms salivary gland  121–122, 124–125,
in left mandibular ramus (multiple 125f
myloma)  97f Odontogenic cysts and tumours  303f,
salivary glands  111f, 123f, 308, 309f–310f
166–170, 167f, 169f, 171f Odontome, complex  309f
intraoral (minor)  168–170 Oesophageal disease  48
major glands  168 Opitz syndrome  266
palatal minor glands  169f Opportunistic infections  329
sublingual gland  169f Oral disease, predisposing factors  1
Nerve, tooth  16 Oral hygiene, poor: tooth
Neurilemmoma (benign nerve sheath discolouration  139f, 346f
tumour)  268 Oral lichen planus biopsy  375, 382f
Neuroectoderm, teeth developed Oral malodour  47–49, 49f–50f
from  16 Oral submucous fibrosis
Neurofibroma  115f, 268 (OSMF)  153f, 256–258, 257f
Neurofibromatosis  268, 269f Oral tongue  13
Neurological conditions see Pain/ Orbicularis oris muscle, lips  12
neurological conditions Organ transplantation  335, 335t
Neurological system, Oroantral fistula, traumatic  349f
examination  8–11 Orofacial granulomatosis
Neuropraxia (crushed nerve)  98 (OFG)  196–198
Neurotmesis (cut nerve)  98 see also Crohn disease
Neutropenia  356 Orofacial pain see Pain/neurological
Nicorandil use  346f conditions
Nicotine stomatitis (smoker’s Orofacial palsy  92–94, 94f–95f
keratosis)  87f, 290–291, 290f Oropharynx  14–15
Nifedipine, gingival swelling  Orthopantomography (OPTG)  384
343f Osler–Rendu–Weber syndrome
Nikolsky sign, pemphigoid  233f, (hereditary haemorrhagic
234 telangiectasia)  35f, 205–206, 205f
Nontropical sprue (coeliac Osteitis  311
disease)  209f, 223–224 Osteomyelitis  96, 311–312
Numb chin syndrome (NCS)  96, Osteonecrosis  78, 302, 312–314,
97f, 99 345f
Nystatin  64, 244–245 Osteoradionecrosis (ORN)  313–314

429
 Index

Palatal petechiae, with glandular

P fever  219f
Paediatric patients, dental caries in  1 Palatal pigmentation,
Paget disease  314 drug-induced  343f–344f
Pain/neurological conditions  Palate
318–322, 319f candidosis in HIV/AIDS  72f
benign trigeminal neuropathy  99 examination  14–15
diagnosis  366–369 see also Palatal lesions; Palatal
drug-induced  91 petechiae; Palatal pigmentation,
giant cell arteritis  320, 321f drug-induced
history  5–6 Palsy  1–2, 92–94, 94f–95f, 319f
idiopathic facial pain  320–321 Bell  92–93, 94f, 318, 319f
local diseases  90–91 glossopharyngeal  15
myofascial pain dysfunction  315– orofacial  319f
316, 317f Papillae
orofacial pain  89–91, 92f circumvallate  13, 27f
psychogenic pain  89, 91 filiform and fungiform  13, 27f
referred pain  91 foliate  13
salivary gland conditions  161–162 interdental  342f
scans for  323f parotid see Stensen ducts
temporomandibular pain– Papillary hyperplasia  286f
dysfunction syndrome  315–316, Papilloma
317f in HPV  262
trigeminal neuralgia  322, 323f mucosal white lesions  83f
vascular disorders  91 swollen mouth  109f
Palatal lesions  283–291, 285f–290f Paraneoplastic pemphigus  234–236
angina bullosa Parotid duct obstruction  121f
haemorrhagica  284, 285f Parotid gland
denture-related stomatitis  72f, enlargement  16–18, 163f
284–287, 285f–286f left
Kaposi sarcoma  287–288, enlarged  163f
287f–288f lesions  93
necrotizing sialometaplasia  289, pleomorphic adenoma in tail 
289f 167f
papillary hyperplasia  286f swelling, in sarcoidosis  171f
Peutz–Jegher syndrome  199f Parotid papillae see Stensen ducts
red  283 Parotitis  123f, 163f
smoker’s keratosis (stomatitis Paul–Bunnell test  218
nicotina)  87f, 290–291, 290f Peg-shaped lateral incisor  151f

430
 Index

Pemphigoid  230–234, 232f–233f Posterior lingual papillary

blistering in  51f, 233f atrophy  280, 281f
conjunctival  232f Posterior midline atrophic
desquamative gingivitis  41, 43f, candidosis  280, 281f
233f Pregnancy epulis  300–301, 301f
morbidity  1–2 Pregnancy gingivitis  300, 301f
ulceration  232f Pregnancy tumour  107f
Pemphigus  1–2, 51, 234–236, Primary herpes simplex
235f stomatitis  293f
Nikolsky sign  233f, 234 Primary syphilis  220, 220f
Penciclovir cream  194 Primary teeth, development  16
Pencillamine, reaction to  242f Propionibacterium propionicus 
Periapical abscess  107f 302
Periodic acid Schiff (PAS)  244 Psychogenic pain (oral
Periodontal ligament  15 dysaesthesia)  89, 91
Periodontitis  49f, 147, 292 Pterygoid hamulus  18
Perleche  64 Pulp, tooth  16
Permanent teeth, development  16 exposure, avoiding by secondary
Personality disorder  190 dentine deposition  138f
Petechia  68, 219f Pupil size, extraoral examination  7
Peutz–Jegher syndrome  196, Purpura
198–200, 199f blood blisters in  51f
Pharyngeal disease  49 with leukaemia  360f
Pharyngeal tongue  13 mucosal  68, 69f, 71, 74
Phenytoin, gingival swelling  342f oral localized  284, 285f
Philtrum, upper lip  12 Pyogenic granuloma  200, 201f
Phosphate buffered saline (PBS)  Pyostomatitis vegetans, in ulcerative
382 colitis  227f
Photodynamic therapy  272
Pigmentary incontinence  53
Pilocarpine  162
R
Pink stain  142 Racial pigmentation
Plaque accumulation  147 lips  28f–30f
Pleomorphic adenoma  123f, 167f, Radicular cyst, jaw  310f
170 Radiotherapy  332, 332t, 333f
pleomorphic salivary adenoma Ramsay–Hunt syndrome  216
(PSA)  168 Ranula (mucocele, in floor of
Polyp, fibroepithelial  108f, 260, mouth)  164, 165f
261f Raynaud syndrome  230

431
 Index

Recreational drugs  368

Recurrent aphthous stomatitis
S
(RAS)  75f–76f, 78, 236–238 Saliva
see also Aphthae frothy  45f, 173–176
Red lesions  202–207, 202f–206f reduced  42
angioma (haemangioma)  71f see also Dry mouth
candidosis  70f, 72f, 202f Saliva pH test  385–386
see also Erythematous candidosis Saliva stimulants  162
carcinoma, presenting as  72f Salivary flow determination  371,
diagnosis  73f 372t
erythematous candidosis  202– Salivary gland conditions  161–179,
207, 202f 163f, 165f, 167f, 169f, 171f,
erythroplakia  72f, 203–205, 173f–175f, 177f
203f–204f acute bacterial sialadenitis  162
hereditary haemorrhagic diagnosis  364–365
telangiectasia  35f, 205–206, history  4–5
205f in HIV/AIDS  355f
incisional biopsy  376f–377f inflammation  161
mucosal see Red lesions, investigations  371, 372t
mucosal mucoceles see Mucoceles, salivary
in palate  283 gland
pemphigus ulceration  235f mumps (acute viral
scleroderma  135f, 206–207, sialadenitis)  120–121, 164–166,
206f 167f
Red lesions, mucosal  70–74, 72f necrotizing sialometaplasia  289,
see also White lesions, mucosal 289f
Redness neoplasms see under Neoplasms
generalized  70 obstruction  121–122, 124–125,
localized red patches  71 125f
Referral for specialist pain  161–162
opinion  395–396 parotitis  163f
Referred pain  91 sarcoidosis  170–172, 171f
Relevant Medical History (RMH)  3 sialosis  172–173, 173f
Renal failure, leukoplakia  250 Sjögren syndrome see Sjögren
Rheumatoid arthritis  177f syndrome
Riga–Fede disease  282 sublingual gland, malignant
Rituximab  179, 236 tumour  169f
Ro (SS-A) antibody  178 submandibular salivary
Root, dentine  16 calculus  121f

432
 Index

swollen glands see under Salivary Sinusitis  315

glands Sjögren syndrome  173–178,
Salivary glands 173f–175f, 177f
examination  12–13, 16–18 candidosis  175f
radiation effects  333f caries  175f
swelling  116, 120–125, 121f– dry mouth  173f–174f, 206f
123f, 125f–126f, 161, 177f fissured tongue  23
Salt-split skin indirect glossitis  135f
immunofluorescence  234 keratoconjunctivitis sicca
Sarcoidosis  170–172, 171f with  177f
Scanning  323f, 385 lobulated tongue  174f
Scarring, epidermolysis bullosa  lupus erythematosus with  230
229f swelling of salivary glands
Schwannoma  268 with  177f
Scintigraphy  178 Skin disorders
Scleroderma  135f, 206–207, 206f blisters  52
Screening tests, adjunctive  385–386 epidermolysis bullosa  228, 229f
Sebaceous glands  12–13 leukopenia  357f
Secondary syphilis  220–221, 220f lichen planus see Lichen planus
Sensory changes, orofacial  96–99, lupus erythematosus  230, 231f
97f, 100f pemphigoid see Pemphigoid
congenital causes  99 pemphigus  234–236, 235f
psychogenic causes  99 swelling  116
Sepsis, oral  48 ulceration  228–236, 229f,
Serum angiotensin converting enzyme 231f–233f, 235f
(SACE)  172, 318 SLE see Systemic lupus
Serum antibody screening  224 erythematosus (SLE)
Shingles (herpes zoster)  194, 195f, Slough, fibrinous (erosions
216–217, 330f showing)  61f
Sialadenitis, acute  122f Smoking
bacterial  162 smoker’s keratosis (stomatitis
bilateral  167f nicotina)  87f, 250, 290–291,
viral  120–121, 164–166, 167f 290f
Sialogogues  162 tooth discolouration  139f, 290f,
Sialography  178 346f
Sialorrhoea (hypersalivation)  101– Snuff-dipping  248
102, 103f Social History (SH)  3
Sialosis  172–173, 173f Soft palate  14
Sinuses, extraoral examination  7 Soreness see under Pain; Ulceration

433
 Index

Specialist opinion, referral Sulphasalazine  227

for  395–396 Superficial lesions, excisional
Stafne cavity, in mandible  30f biopsy  372, 373f
Stensen ducts Supernumerary teeth  149
examination  15–18 Suture, excisional biopsy  375f
purulent discharge from  163f Swelling
Stevens–Johnson syndrome  188 drug-induced  296–298, 297f,
Stomatitis 342f–343f
acute herpetic  131f gingival see Gingival swelling
angular  64, 65f jaw  119–120, 120f
denture-related  72f, 284–287, in lips or face  7, 103–106,
285f–286f, 349f 104f–105f, 189f
herpetic  213–215, 213f–215f lymphoma  361f
primary herpes simplex  293f in mouth see Intraoral swelling
recurrent aphthous stomatitis  75f– neck  116–117, 159f
76f, 78 salivary glands  116, 120–125,
see also Aphthae 121f–123f, 125f–126f, 161,
Stomatitis nicotina (smoker’s 177f
keratosis)  87f, 250, 290–291, tongue  136, 269f
290f see also Macroglossia (enlarged
Stratified squamous epithelium, lichen tongue)
planus affecting  250–255 Swollen glands see under Swelling
Stress Symblepharon, with conjunctival
crenated tongue  275f pemphigoid  232f
white lesions from  247f Syphilis  1–2, 218–221, 220f–221f
Striae, biopsy of  382f Syphilitic leukoplakia  250
Sturge–Weber syndrome  182 Systemic lupus erythematosus
Sub-epithelial split  51 (SLE)  186, 230
Sublingual gland
malignant tumour  168, 169f
mucocele  164
T
Sublingual keratosis  249f, 250 T lymphocyte function,
Sublingual varices  26f immunosuppressive therapy  329,
Submandibular duct  18 335
Submandibular gland  18 Tacrolimus  187
Submandibular obstruction  125f Tar-stained teeth  290f
Submandibular salivary calculus  121f Taste buds  13
Submucous fibrosis  1–2 Taste disturbance  127–130,
Sulcus terminalis, tongue  13–14 130f

434
 Index

Taste sensation  14 coated

Tattoo, amalgam  54f–55f, 200, 208, acute herpetic stomatitis 
209f, 347f 131f
Teeth betel use  133f
development  16 brown hairy tongue  132f
examination  16 chlorhexidine mouthwash
surface loss  143f use  133f
unerupted  22, 283 no apparent reason  131f
see also Tooth abrasion; Tooth crenated  274, 275f
anomalies; Tooth attrition; Tooth enlargement see Macroglossia
discolouration; Tooth erosion; (enlarged tongue)
Tooth hypoplasia; Tooth examination  13–14
mobility filiform and fungiform papillae  13,
Telangiectases  74 27f
Telangiectasia fissured  23, 23f, 63f, 278,
multiple  205f 279f
see also Hereditary haemorrhagic furred  39f, 131–132, 132f–133f
telangiectasia (HHT) lesions see Tongue lesions
Temporomandibular pain–dysfunction lobulated  45f, 174f
syndrome (TMPD)  315–316, oral  13
317f pharyngeal  13
Temporal arteritis see Giant cell posterior  13–15
arteritis smooth (glossitis) see Glossitis
Temporomandibular joint (TMJ)  5, 7 (smooth tongue)
Tertiary syphilis  221, 221f swollen  136, 269f
Tetracycline  238, 328 see also Macroglossia (enlarged
Thrombocytopenia  34 tongue)
Thrush (acute pseudomembranous taste buds  13
candidosis)  243–244, 243f ulceration  131f
Thyroid gland swellings  116 Tongue dorsum  13–14
Tissue removal, excisional Tongue lesions  265–291, 267f,
biopsy  374f 269f–271f, 273f, 275f–277f, 279f,
Toluidine blue staining  11–12, 363, 281f
377f amyloidosis  266–268, 267f
Tongue ankyloglossia  266
black hairy  58 benign nerve sheath tumour 
brown hairy  58, 132f 268
candidosis on  202f candidal glossitis  70f, 134f–135f,
circumvallate papillae  13, 27f 272–273, 273f

435
 Index

carcinoma  269–272, 270f–271f amelogenesis imperfecta  324–

erythema migrans  274–277, 328, 325f
275f–277f dentinogenesis imperfecta  326,
foliate papillitis  278 327f
hyposalivation  279f fluorosis  326–328, 327f
median rhomboid glossitis  280, tetracycline staining  328
281f Torus mandibularis  20, 20f–21f,
neurofibromatosis  269f 22
traumatic ulcerative Torus palatinus  22f, 283
granuloma  282–283, 282f Total body irradiation (TBI)  335
Tonsils  14–15 Toxic epidermal necrolysis  188
Tooth abrasion  137 Transglutaminase  224
Tooth anomalies Transplantation
number  148–150 haematopoietic stem cell  60, 335,
shape  150–152 336t, 337f
Tooth attrition  138–139 organ  335, 335t
Tooth decay see Caries Trauma
Tooth discolouration  139–142 jaw examination  7
Tooth erosion  143–144 occlusal frictional  246f
Tooth eruption times  17t purpura in  68
Tooth hypoplasia  144–146, 145f, sensory changes  98
147f tooth discolouration  141f
Tooth mobility  147, 292 tooth loss  147, 292
Tooth staining ulceration  236, 237f
black stain  142 Traumatic oroantral fistula  349f
blue stain  142 Traumatic ulcerative granuloma
brown stain  142 (TUG)  282–283, 282f
drug-induced  345f–346f Traumatic ulcerative granuloma with
green stain  142 stromal eosinophilia (TUGSE)  282–
pink stain  142 283, 282f
smoking  139f, 290f, 346f Triamcinolone  64
white stain  142 Trigeminal (V) nerve, examination  10
yellow stain  142 Trigeminal nerve
see also Discolouration, tooth mandibular division, trauma to 
Tooth structure  16 98
Tooth-brushing friction, white maxillary division, damage to  98
lesions of keratosis from  shingles  330f
249f Trigeminal neuralgia  1–2, 89, 322,
Tooth-specific disorders 323f

436
 Index

Trigeminal sensory loss glandular fever (infectious

diagnosis  100f mononucleosis)  219f
Trismus  152–154, 153f hand, foot and mouth disease 
Tuberculosis (TB)  1–2, 222–223, 211f
222f herpangina  212f
Tumours herpes simplex, in HIV/AIDS 
benign nerve sheath  268 352f
jaw  302 herpetic stomatitis  213f–215f
Kuttner tumour (Mikulicz herpetiform  239f
disease)  178–179 infectious causes  211–223
odontogenic  1, 303f, 308, leukaemia  359f–360f
309f–310f leukopenia  357f
pregnancy  107f local causes  236–242, 237f, 239f,
sublingual gland  169f 241f
see also Cysts; Malignant disease lymphoma  361f
Turner tooth  144–146, 145f mucosal see Ulceration, mucosal
mucositis  60, 333f
in palate  283
U pemphigoid  232f
Ulceration primary herpes simplex
acute ulcerative gingivitis  292– stomatitis  293f
294, 294f–295f recurrent herpes  214f
aphthae  236–238 skin disorders  228–236, 229f,
aphthous-like  74, 238, 240 231f–233f, 235f
Behçet disease  241f syphilis  220f–221f
in coeliac disease  223f systemic causes  211
vitamin deficiency  241f tongue  131f
Behçet disease  76f, 240–242 trauma  236, 237f
blood disorders  211 tuberculosis  222f
and Crohn disease  112f varicella-zoster virus  217f
denture flange, see also Pain
over-extended  237f Ulceration, mucosal  74–78, 74f–76f,
drug-induced  78, 242, 242f, 79f
346f acute ulceration  79f
duration of single ulcers  BIGS acronym  77
74 diagnostic algorithms 
gastrointestinal disorders  223– 79f–81f
227, 223f, 225f–227f local causes  78
gingiva/gingival margin  292, 357f malignant disease  77

437
 Index

multiple ulcers  80f–81f Wharton duct  18

persistent  79f–80f White lesions
recurrent  80f–81f candidosis  200, 243–245, 243f,
single ulcer  79f 245f, 354f
So Many Laws and Directives carcinoma  74f, 110f–111f
acronym  77 cheek biting (morsicatio
systemic disease  77 buccarum)  87f, 246, 247f
see also Erosions, mucosal keratosis  249f
Ulcerative colitis (UC)  223, 227, Koplik spots, in measles
227f prodome  257f
Ultrasound scanning (US)  385 leukoplakia see Leukoplakia
Ultrasound-guided fine needle lichen planus see Lichen planus
aspiration biopsy  186, 272, 385 linea alba  255–256
Unerupted teeth  22, 283 lupus erythematosus  231f
Upper motor neurone (UMN) malignant disease  243–259
lesions  11 measles  256
mucosal see White lesions,
mucosal
V occlusal frictional trauma 
Valacyclovir  194, 217 246f
Varicella  216, 217f oral submucous fibrosis  153f,
Vascular disorders, orofacial pain  91 256–258, 257f
Vermilion, lip  12–13 stress  247f
Verrucous carcinoma  85f sublingual keratosis  249f
Verrucous leukoplakia, ulcerated, carcinoma presenting
proliferative  86f, 292 as  74f
Visualization aids  385–386 White lesions, mucosal  81–87,
Vitamin deficiency 82f–88f
aphthae  236–238 acquired causes  82–87
aphthous-like ulceration  241f carcinoma  84f–85f
glossitis  134f, 135 diagnostic algorithm  88f
Von Recklinghausen hereditary causes  82, 82f
neurofibromatosis  268 infective  83f
lichen planus  84f
papilloma  83f
W proliferative verrucous
Waldeyer ring of lymphoid tissue, leukoplakia  86f, 292
tongue  13–14 stomatitis nicotina  87f
Wegener granulomatosis  114 see also Red lesions, mucosal

438
 Index

White sponge naevus  82f, 247f,

258–259, 258f
Y
White stain, tooth discolouration  142 Yellow stain, tooth discolouration 
Wisdom teeth, development  16 142

X Z
Xerostomia  42–45 Z-plasty  66

439
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ABOUT THE AUTHORS

Crispian Scully CBE

MD PhD MDS MRCS BSc FDSRCS FDSRCPS FFDRCSI FDSRCSE FRCPath
FMedSci FHEA FUCL DSc DChD DMed[HC] DrHC
Crispian Scully is President of the International Academy of Oral Oncology and President-Elect
of the British Society for Oral Medicine. He has written and edited over 40 books, written over
150 book chapters and has over 900 papers cited on MEDLINE plus over 300 others. He is
Co-Editor of Oral Diseases, Medicina Oral, and Associate Editor of the Journal of Investigative
and Clinical Dentistry.
He has received the CBE, University of Helsinki Medal of Honour, University of Santiago de
Compostela Medal, University of Granada Medal, Fellowship of UCL, and honorary degrees from
the Universities of Athens, Granada, Helsinki and Pretoria. He has received the UK Dental Award
for the Most Outstanding Achievements in Dentistry, the Award of the Spanish Society for Oral
Medicine and the Hellenic Society for Oral Medicine.

Jose Vicente Bagan MD DDS PhD

Jose Bagan graduated in Medicine and Surgery at Valencia University, Spain, and then gained
his PhD at Valencia University. He directs the Service of Stomatology at Valencia University
General Hospital and is Full Professor of Oral Medicine at Valencia University. Jose is President
of the European Association of Oral Medicine and President of the Research Commission,
Valencia University General Hospital. He is Director of the journal Medicina Oral, Patología Oral
y Cirugía Bucal, and Associate Editor of the journal Oral Diseases as well as being on several
other Editorial Boards. Jose is the author of 10 books, 33 book chapters, and over 310 published
papers in oral medicine. He has been awarded 20 prizes in odontostomatology.

Marco Carrozzo MD DDS

Marco Carrozzo is Professor of Oral Medicine, School of Dental Sciences and Honorary Consult-
ant in Oral Medicine, RVI Hospital, Newcastle upon Tyne, UK. Marco graduated in Medicine and
Surgery at the University of Turin, Italy, and specialized in odontostomatology, becoming
researcher and Consultant in Oral Medicine at the University of Turin. He is author and co-author
of over 180 scientific publications including several papers on oral cancer and potentially
441