practical manual of oral pathology and microbiology (vijay wadhwan) (2010) [unitedvrg].pdf

Practical Manual of OralPathology and Microbiology

Practical Manual of OralPathology and Microbiology

Vijay WadhwanAssociate Professor

Department of Oral Pathology and MicrobiologySharad Pawar Dental College and Hospital

Sawangi (Meghe)Wardha, Maharashtra, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTDNagpur St Louis (USA) Panama City (Panama) London (UK) New Delhi

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Practical Manual of Oral Pathology and Microbiology 2010, Jaypee Brothers Medical Publishers (P) Ltd.

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted inany form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior writtenpermission of the author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is madeto ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvert-ent error (s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2010

ISBN 978-93-80704-35-7

Typeset at JPBMP typesetting unit

Printed at Ajanta Offset

Foreword

Memory makes you miserable when you forget the infinite, and enlightened when youforget the trivial.

Mere learning is not knowledge. A man of knowledge is not only a learned in hisfield but also guides his students accordingly on the same path.

Practical Manual of Oral Pathology and Microbiology by Dr Vijay Wadhwan, is indeedan innovative step towards the training of the undergraduate dental students in thesubject of Oral Pathology and Microbiology. Each of the first VII sections focuses onthe basic aspects of the differing pathologies encountered in the oral cavity. It has beenwell compiled by Dr Vijay Wadhwan and focus on the basics of the subject will certainlyhelp the students in (their quest of assimilating knowledge) streamlining their thoughtprocess.

The efforts of Dr Vijay Wadhwan are indeed worthy of appreciation and it willspare the students from going through innumerable textbooks as all the essentials aregiven in this practical manual.

I congratulate Dr Vijay Wadhwan and wish him and his book Practical Manual ofOral Pathology and Microbiology all success.

Ramakant S NayakPrincipal, Professor and Head

Department of Oral Pathology and MicrobiologyMaratha Mandals Nathajirao G Halgekar

Institute of Dental Sciences and Research CentreR.S. No. 47 A/2, Bauxite Road

Belgaum, Karnataka, India

Preface

Oral cavity is a part of body which is not only meant for tasting the delicacies but it alsoacts as a gateway for detection of many underlying systemic disease processes. Medicalknowledge and basic understanding of the diseases is undergoing a sea change due tothe advancement in the fields of immunohistochemistry, PCR, etc. This manual isintended to be a basic guide for identifying various commonly occurring oral diseases.It makes no pretence to be a comprehensive or balanced account of oral pathology as awhole.

For the undergraduate students, this is essentially a practical manual which containsthe basic precise and exacting methods to go about the routine practical work. Thismanual should be of value to undergraduates as they can draw the microscopic featuresin the space provided for drawing histopathological diagrams. The students are herebyencouraged to seek additional information on various topics from the various textbooks.

Vijay Wadhwan

Acknowledgments

I have gathered a posie of other mens flowers, and nothing but the thread that binds them ismine own. John Bartlett

Every man, whatever his accomplishments, always owes a deep debt of gratitude tomany people who he meets in the journey called life. During the preparation of thismanuscript, I have been fortunate enough to receive help and advice from wherever Isought it.

If the Almighty does not want something, it can never be done. I would like tothank Almighty for everything in my life.

I am indebted to my teachers for their words of wisdom, encouragement, andnurturing whatsoever was good in me. It is only due to the efforts of my teachersDr Mrs Alka D Kale, Dr Ramakant S Nayak and Dr Seema Hallikerimath, who taughtme with patience and who were willing to share all their knowledge that this manualhas been able to reach its destiny.

When eating a fruit, think of the person who planted the tree. I would like to thankDr Vijay Gupta and Dr Anil Singla who realized my potential and constantly encouragedme for my endeavors into the unknown.

My thanks would be incomplete if I dont mention the names of Dr AJ Pakhan, andDr RM Borle who let me utilize the library and other facilities in their institute.

We can only be said to be alive in those moments when our hearts are conscious ofour treasures. I would be neglecting my duties if I fail to mention the names ofDr Minal S Chaudhary, Dr Madhuri Gawande and Dr Abhiney Puri as these were theones who stood by me during my tough times.

Parents teach all the worthwhile values of human life. I owe it all to my fatherSh Vinod Kumar Wadhwan and my mother Smt Santosh, my in-laws Brig RS Malikand Mrs Chandrabala Malik and my uncle Sh Suraj Prakash and my aunt Late SmtSangeeta as they all proved to be my pillars of strength throughout.

No man can accomplish much without the help, support, and understanding of hisfamily. I hereby acknowledge with the deepest gratitude and affection the patienceand support of my wife Dr Sangeeta Wadhwan and our sons Siddharth and Siddhanth.I would also like to thank all the people whom I may have omitted by mistake.

Contents

Section IDefinitions ...............................................................................................................................1

Section IIClassifications ....................................................................................................................... 13

Section IIIRoutine and Advanced Diagnostic Procedures for Oral Lesions .................................. 37

Section IVStaining Procedures and Special Stains ............................................................................ 41

Section VNormal Values of Formed Elements in Blood ................................................................. 47

Section VICommon Syndromes Affecting Oral Cavity .................................................................... 51

Section VIIIdentifying Histopathological Features of Common Oral Lesions ............................... 63

Section VIIIHistopathological Diagrams ............................................................................................... 77

Section IXGross Specimen .................................................................................................................. 139

Recommended Reading ........................................................................................................ .161

Index .....................................................................................................................................163

CERTIFICATE

This is to certify that this record has been satisfactorily

completed by Mr/Ms/Mrs _________________________

Roll No. ____________________ Class___________ and

University Registration No. ________________ under my

guidance and to the best of his/her ability.

Staff-incharge Head of Department

Date:

SPACEFOR

PHOTOGRAPH

Instructions to Candidates

1. Use appropriate colors to draw diagrams.2. Practical record books and required pencils should be carried to every practical

class.3. Signatures should be obtained from the respective batch-in-charge after the

completion of diagrams of each chapter.4. Content page to be filled in and signatures to be obtained in time period specified

by the incharge.5. Candidates should not mishandle the microscopes and slides.6. Candidates should be punctual and regular.7. Cleanliness and discipline should be maintained.8. Good conduct is appreciated.

Index of Histopathological Diagrams

Sr. No. Date TitleGrade andSignature

Sr. No. Date TitleGrade andSignature

Index of Histopathological Diagrams

Section I

Definitions

2 Practical Manual of Oral Pathology and Microbiology

1. Aberrancy: It may be construed as anomaly in which a tissue develops at a sitefurther from where it is normally found.

2. Abfraction: It refers to the pathologic loss of tooth structure resulting fromrepeated tooth flexure caused by occlusal stresses. It appears as a wedge shapeddefect limited to cervical areas of teeth.

3. Abrasion: Abrasion is the pathologic wearing away of the tooth structure orrestoration secondary to the action of an external agent.

4. Abscess: An abscess is a localized collection of pus surrounded by an area ofinflamed tissue in which hyperemia and infiltration of leukocytes is marked.

5. Acantholysis: It is the pathological separation of epidermal or epithelial cellsby breakdown of desmosomes in spinous cell layer (seen in pemphigus).

6. Acanthosis: Excessive thickening of the spinous layer of squamous epithelium,resulting in broadening and elongation of rete pegs.

7. Acquired: Relating to something not of genetic origin but resulting from outsideinfluence.

8. Acute inflammation: It is a rapid response to an injurious agent that serves todeliver mediators of host defense leukocytes and plasma proteins to thesite of injury.

9. Acute: Having severe symptoms and a short course.10. Adenoma: Adenoma is the term applied to a benign epithelial neoplasm that

forms glandular patterns as well as to tumors derived from glands but notnecessarily reproducing glandular patterns.

11. Agenesis: It is the absence of a part of body caused by absence of primordium.12. Ageusia: It is the loss or absence of sense of taste.13. Aglossia: It is the congenital absence of the tongue.14. Agranulocytosis: A marked decrease in the number of granulocytes in the

peripheral blood, particularly neutrophils.15. Allergen: A substance capable of inducing hypersensitivity or an allergic reaction

in the host.16. Allergy: An altered state of reactivity to an antigen, including both types of

immune responses, protective as well as injurious. OR All immune processesharmful to the host, such as hypersensitivity or autoimmunity

17. Alopecia: Loss of hair18. Anachoresis: Localization of the transient bacteria in the bloodstream into areas

of inflammation, which are found in traumatized or inflamed pulp.19. Anaphylaxis: It is an antigen-antibody reaction produced by the parenteral

injection of an antigen causing hypersensitivity.20. Anaplasia: Lack of differentiation or replacement of specialized cells by

unspecialized, undifferentiated or stem cells is called anaplasia.21. Anastomosis: It is a communication between two vessels by collateral channels.22. Anemia: It is an abnormal reduction in the number of circulating red blood

cells, the quantity of hemoglobin and the volume of packed red cells in blood.23. Angioma: A tumor made up of blood (Hemangioma) or lymph (Lymphangioma)

vessels.

Definitions 3

24. Anomalad: It is a malformation together with its subsequently derived structuralchanges; the primary defect setting off a series of secondary or even tertiaryevents resulting in multiple anomalies.

25. Anomaly: Marked deviation from normal, especially as a result of congenitalor hereditary defects.

26. Anorexia: It is the lack or loss of appetite for food.27. Anosmia: It is the absence of sense of smell.28. Antagonist: It is tissue or muscle that counteracts the action of another tissue

or muscle.29. Antibody: An immunoglobulin molecule that reacts with a specific antigen

that induces its synthesis and with similar molecules.30. Antigen: Any substance capable of inducing a specific immune response and

of reacting with the products of that response.31. Aplasia: Aplasia refers to development of rudimentary structure caused by

failure of anlage to develop completely.32. Arteriosclerosis: Condition characterized by loss of elasticity and thickening

of arterial walls.33. Atresia: It is the congenital occlusion or absent of one or two major salivary

gland ducts.34. Atrophy: Shrinkage in the size of the tissue or of an organ by decrease in

number of cells and loss of cell substance.35. Attrition: Attrition may be defined as the physiologic wearing away of a

tooth as a result of tooth-to-tooth contact, as in mastication.36. Autoantibody: An antibody formed in response to, and reacting against, an

antigenic constituent of the ones own tissues.37. Autoimmune disease: The diseases where the autoimmune processes, humoral

or cellular are responsible for the pathogenesis of the disease.38. Autoimmunity: A condition in which structural or functional damage is

produced by the action of immunologically competent cells or antibodies againstthe normal components of the body.

39. Bacteria: These are prokaryotic microorganisms that do not contain chlorophyll.They are usually unicellular and do not show branching, except in higher bacteria

40. Bacteremia: It refers to the circulation of bacteria in the blood.41. Biopsy: It is the gross and microscopic examination of tissue or cells removed

from living patients for the purpose of diagnosis or prognosis of the disease orthe confirmation of the normal condition.

42. Blanching: To extract the color out and make pale and white.43. Bleb: It is a bulla or other skin blister filled with blood or serous fluid usually

1 cm in diameter.44. Boil (Furuncle): It is a localized, painful skin abscess usually at the site of hair

follicle45. Bosselated: Marked by numerous bosses or rounded protuberances.46. Bruise: It is a superficial injury, caused by a blow with no laceration but with

discoloration of the skin and subcutaneous tissues produced by accumulationof blood.


47. Bulla (Blister): A bulla is a large, circumscribed, fluid containing, elevatedlesion of the skin more than 5 mm in size.

48. Calcification: The deposition of calcium salts in organic tissue causing hardening49. Callus: The unorganized network of woven bone formed about the ends of a

broken bone, which is absorbed as repair is completed and is finally replacedby true bone

50. Capsule: Compressed cartilaginous, fatty, fibrous membranous structureenveloping another structure, organ or part.

51. Carbuncle: A necrotizing infection of skin and subcutaneous tissues composedof a cluster of furuncles, usually due to Staphylococcus aureus, with multipledraining sinuses.

52. Carcinoma: Carcinomas are malignant neoplasms of the epithelial origin, whichtend to infiltrate the surrounding tissues and give rise to metastasis.

53. Carcinomatosis: The condition of widespread dissemination of cancerthroughout the body.

54. Carcinosarcoma: It is a malignant mixed tumor containing characteristics ofboth carcinomatous and sarcomatous tissues.

55. Carrier: One who harbors disease organisms in the body without manifestingsymptoms, thus acting as distributor of disease.

56. Causalgia: It is a burning pain, often with trophic skin changes arising afterperipheral nerve injury.

57. Cell: It is the fundamental, structural, and functional unit of living organismsconsisting of a nucleus surrounded by cytoplasm enclosed in a cell or plasmamembrane.

58. Cellulitis: A painful swelling of the soft tissue of the mouth and face resultingfrom a diffuse spreading of purulent exudate through the cleavage planes ofinterstitial and tissue spaces.

59. Central: In oral pathology, it is the lesion occurring within bone.60. Chemotherapy: It is the treatment of a disease by chemicals which affect

pathogenic organisms without harming the patient or it is the treatment ofmalignant neoplasms by chemical means.

61. Choriostoma: It refers to excessive amount of histologically normal tissuethat is present in abnormal location.

62. Chronic inflammation: It is considered to be inflammation of prolongedduration (weeks or months) in which active inflammation, tissue destruction,and attempts at repair are proceeding simultaneously.

63. Cleidocranial: Referring to the clavicle and head.64. Clubbing: Proliferation of the soft tissue about the terminal phalanges of fingers

or toes, without osseous changes.65. Cold abscess: It is a slow developing abscess generally about a bone or joint

and with little inflammation.66. Collagen: The protein substance of the white fibers of skin, tendon, bone,

cartilage and other connective tissue composed of molecules of tropocollagen.67. Commensals: The microorganisms living in perfect harmony with the host

without causing any disease.

Definitions 5

68. Congenital: Present at or before birth but not necessarily inherited.69. Cross infection: When infection is transferred from one host to another.70. Cyanosis: It is the bluish discoloration of the skin and mucous membranes,

often due to excessive concentration of reduced hemoglobin in the blood.71. Cyst: Cyst is defined as a pathological cavity which may or may not be lined by

epithelium and consists of fluid, semi-fluid or gaseous content (but not pus).True cyst is a cystic cavity always lined by epithelium.

72. Deformity: Distortion of any part or general disfigurement of the body.73. Degeneration: It refers to the gradual deterioration of tissue with loss of function

and chemical changes within the tissue.74. Dental caries: Dental caries is a microbial disease of calcified tissues of teeth,

characterized by demineralization of inorganic and destruction of organicsubstance of the tooth.

75. Desquamation: It refers to the shedding off or peeling off of epithelial elementschiefly of skin and mucous membranes, in scales or sheets.

76. Differentiation: Differentiation refers to the extent to which neoplastic cellsresemble comparable normal cells, both morphologically and functionally.

77. Diffuse: It is used in the description of a lesion where borders of the lesion arenot well defined or well delineated or localized.

78. Disease: Any deviation from normal structure or function of any body part,organ, or system that is manifested by characteristic set of symptoms and signsand whose etiology, pathology, and prognosis may be known or unknown.

79. Dominant: In genetics, a trait or characteristic that is manifested when it iscarried by only one of a pair of homologous chromosomes.

80. Dyskinesia: It is defined as distortion or impairment of voluntary motions asin cases of tic or spasm, leading to movements that are incomplete or onlypartial.

81. Dysplasia: Dysplasia, a term that literally means disordered growth, isencountered principally in epithelia, and is characterized by a constellation ofchanges that include a loss in the uniformity of individual cells as well as a lossin their architectural orientation.

82. Dystrophic calcification: Pathologic calcification that occurs in degeneratingand dead tissue.

83. Echymosis: A small hemorrhagic spot in the skin or mucous membrane, largerthan petechiae, forming a non-elevated, rounded or irregular blue or purplishpatch.

84. Ectopic: Displacement or malposition.85. Edema: An excess of fluid in the interstitial os serous cavities; it can be either

an exudate or a transudate.86. Enanthema: Eruptions on mucous membrane occurring as a symptom of any

disease.87. Endogenous infection: Infection produce within or caused by factors within

the body.88. Epulis: A non-specific term used for tumors and tumor-like masses of gingiva.


89. Erosion (of Teeth): It is irreversible loss of dental hard tissues by a chemicalprocess that does not involve bacterial action.

90. Erosion (of Soft Tissue): Erosion is a shallow defect in mucosa representingloss of epithelium down to but not including the stratum germinativum.

91. Erythema: It is the redness of the skin either diffuse or patchy, caused bycongestion of the subcutaneous capillaries.

92. Exanthema: An eruption characterizing an eruptive fever.93. Exogenous infection: Infection originating outside or caused by factors

outside the body.94. Exophytic: It refers to something growing outwards, and in oncology, it is

used for tumor projecting above the normal surface contours.95. Exostosis: A benign bony growth projecting outward from a bone surface.96. Exotoxin: It refers to a toxic secretion of bacterial cells which cause damage in

sites distant from the focus of infections and diffuse readily into surroundingtissue.

97. Extravasation: It is the discharge or escape of fluid from vessels into thesurrounding tissue.

98. Extrinsic: Having its origin outside and separated from a body, organ orpart.

99. Exudate: An exudate is an inflammatory extravascular fluid that has a highprotein concentration, cellular debris and has been deposited in tissues or tissuesurfaces.

100. Eyepiece: The lens or system of lenses of microscope nearest to the users eyeand serves further to magnify the image captured by the objective.

101. Facies: The expression or appearance of the face.102. Familial: Relating to a family, or affecting several members of the same family.103. Fissure: A narrow slit or cleft or groove which may be normal or abnormal.104. Fistula: It represents an abnormal passage or communication usually between

two internal organs, or leading from an internal organ to the body surface dueto destruction of the intervening tissue.

105. Focal infection or sepsis: Infection or sepsis at localized sites producinggeneralized effects.

106. Focus of infection: It refers to a circumscribed area of tissue, which is infectedwith exogenous pathogenic microorganisms and which is usuallylocated near a mucous or cutaneous surface.

107. Fracture: A break or rupture in bone.108. Fungi: These are eukaryotic, heterotropic organisms that live as saprobes or

parasites and possess rigid cell wall but lack chlorophyll.109. Fusiform: Spindle-shaped; tapered at both ends.110. Gangrene: It is the necrosis of tissue due to failure of the arterial blood supply

caused by injury or disease followed by bacterial invasion and putrefaction.111. Granulation tissue: It is the reparative tissue formed on the surface of wound

having soft, granular appearance showing histologically new small blood vesselsand fibroblast.

Definitions 7

112. Granuloma: A granuloma can be defined as any small nodular delimitedmicroscopic aggregation of mononuclear inflammatory cells or collection ofmodified macrophages that are transformed into epithelium-like cellssurrounded by rim of lymphocytes and occasionally plasma cells.

113. Granulomatosis: It refers to the formation of multiple granulomas.114. Hamartoma: It is defined as tumor-like nodule composed of an overgrowth of

mature cells and tissues with the tissue being native to the site, but withdisorganization.

115. Healing: Healing is the body response to injury by repair and replacement ofdamaged cells by healthy cells in an attempt to restore normal structure andfunction.

116. Hematoma: A localized collection of extravasated blood, usually clotted in anorgan, space or tissue.

117. Hemiplegia: It is the paralysis of one side of the body.118. Hereditary disease: The diseases which are transferred from parents to

offsprings. These may or may not be present at birth.119. Heredity: It refers to the genetic transmission of a particular trait or

characteristic from parent to offspring.120. Hyaline: Transparent or glassy appearance.121. Hydropic degeneration: It refers to replacement of the nuclei of stratum

basal by clear space due to edema and degeneration of cells.122. Hyperplasia: Hyperplasia is an abnormal increase in the number of cells in an

organ or tissue, resulting in increased volume of the organ or tissue.123. Hypertrophy: Hypertrophy refers to an increase in the size of cells, resulting

in an increase in the size of the organ.124. Hypoplasia: Hypoplasia refers to incomplete development or

underdevelopment of an organ with decreased numbers of cells.125. Iatrogenic Infection: The infections introduced by physician during

investigative, operative or other procedures126. Idiopathic: It is any spontaneous or primary disease with no apparent external

cause.127. Immunodeficiency: A deficiency of the immune response due to lack of or

decreased activity of lymphoid cells.128. Inapparent Infection: Infections in which clinical effects are not apparent.129. Infection: Invasion and multiplication of microorganisms in body tissues,

especially those causing local cellular injury due to their metabolism and toxicproducts.

130. Inflammation: Inflammation is a protective tissue response to injury whichserves to destroy, dilute or wall off both the injurious agent and the injuredtissues. The classical signs of inflammation include pain (dolor), heat (calor),redness (rubor), swelling (tumor), and loss of function (function laesa).

131. Juxtaepithelial: Just beneath the epithelium.132. Karyolysis: Dissolution of nucleus of a cell.133. Karyopyknosis: Shrinkage of cell nucleus, with condensation of chromatin.


134. Karyorrhexis: Rupture of the cell nucleus in which the chromatin disintegratesinto small granules.

135. Lesion: Any pathological or traumatic discontinuity of tissue or loss of functionof a part.

136. Leukemia: A progressive malignant disease of the blood forming organs,marked by distorted proliferation and development of leukocytes and theirprecursors in the blood and bone marrow.

137. Leukoplakia: A white patch or plaque that cannot be scraped off and cannotbe characterized clinically or pathologically as any other disease, which is morethan 5 mm.

138. Localized: Lesion or condition happening within circumscribed or limited area.139. Lump: A large mass of body tissue.140. Lupus: Any of a group of skin diseases in which the lesions are characteristically

eroded.141. Lymphoma: Any neoplastic disorder of lymphoid tissue.142. Macule: A macule is a circumscribed, non-raised area of altered coloration

varying in size from a pinhead to several centimeters in diameter.143. Metaplasia: It is a reversible change in which one adult cell type (epithelial or

mesenchymal) is replaced by another adult cell type.144. Metastasis: It is defined as spread of disease process from part of the body to

another not directly connected with it due either to transfer of pathogenicmicroorganisms or to transfer of cells.

145. Micrometastasis: The spread of cancer cells from primary tumor to distantsites to form microscopic secondary tumors.

146. Mutation: A mutation may be defined as a permanent transmissible change inthe genetic material.

147. Natal teeth: These are teeth which are present in the oral cavity at birth.148. Necrosis: It refers to a spectrum of morphologic changes that follow cell death

in living tissue, largely resulting from progressive degenerative action ofenzymes on the lethally injured cell.

149. Neonatal teeth: These are teeth which erupt during the first 30 days of postnatallife.

150. Neoplasia: A neoplasm is an abnormal mass of tissue, the growth of whichexceeds and is uncoordinated with that of the normal tissues and persists inthe same excessive manner after cessation of the stimuli, which evoked thechange (Willis 1952).

151. Nodule: A nodule is solid elevated lesion of the mucosa, varying in size from5 mm to 2 cm.

152. Nosocomial infections: It refers to the cross infection occurring in hospitals.153. Neuralgia: Paroxysmal pain extending along the course of one or more nerves.154. Neuroma: A benign tumor growing from the nerves or chiefly composed of

nerve cells or nerve fibers.

Definitions 9

155. Nidus: The point of origin or focus of a morbid process.156. Oncocyte: A large epithelial cell with an extremely acidophilic and granular

cytoplasm, containing numerous mitochondria.157. Oncosis: A morbid condition marked by the development of tumors.158. Oral submucus fibrosis: An insidious chronic disease affecting any part of the

oral cavity and sometimes the pharynx, preceded by and/or, associated withvesicle formation, it is always associated with juxtaepithelial inflammatoryreaction followed by fibroelastic change of the lamina propria, withepithelial atrophy leading to stiffness of the oral mucosa and causing trismusand inability to eat.

159. Osteodystrophy: Osteodystrophy is a term for bone diseases which are neitherinflammatory, nor neoplastic but are genetic, metabolic or of unknown causeleading to abnormal development of bone.

160. Pain: An unpleasant sensory and emotional experience associated with actualor potential tissue damage, caused by stimulation of specialized nerve endings.

161. Papule: A papule is a small, circumscribed, solid elevated area varying in sizefrom a pinhead to 5 mm. The base is round or ovoid, and the surfaceconfiguration may be pointed, rounded or flattened.

162. Paralysis: Loss or impairment of motor functions in a part due to lesion ofneural or muscular mechanism.

163. Parasites: A plant or animal that lives upon or within another living organismat whose expense it obtains some advantage.

164. Paresthesia: The term refers to morbid or perverted sensation like burning,prickling or crawling sensation of the skin.

165. Pathogen: Any disease producing agent or microorganism.166. Pathogenesis: The development of disease from its inception to the appearance

of characteristic symptoms or lesions.167. Pathognomonic: Characteristic of one specific disease or pathological condition

as distinct from any others.168. Pathology: That branch of medicine which is concerned with the structural

and functional changes caused by disease.169. Petechiae: Minute red spots on skin or mucosa usually 1-2 mm in diameter

caused due to escapement of blood.170. Plaque: A plaque is a small or large, raised, firm, clearly demarcated area of

gray or white discoloration. The surface texture may be relatively smooth,rough or pebbled.

171. Precancerous condition: A generalized state of body associated with a significantrisk of cancer development

172. Precancerous lesion: A benign morphologically altered tissue that has a greaterthan normal risk of developing cancer as compared to its apparently normalcounterpart.


173. Primary infection: Initial invasion and multiplication of pathogenicmicroorganisms in a host.

174. Pseudoepitheliomatous hyperplasia: In this condition the retepegs extend fardownward towards connective tissue, usually accompanied by acanthosis. Thecells are normal in size, shape and chromaticity

175. Purpura: Reddish to purple flat lesions caused by blood extravasated fromvessels into the subcutaneous tissue.

176. Pus: Is an inflammatory exudates usually yellowish in color rich in leukocytes(mostly neutrophils), the debris of red cells, and in many cases, microbes.

177. Pustule: A pustule is a vesicular type of lesion containing purulent materialinstead of clear fluid.

178. Putrefaction: The enzymatic decomposition of proteins through the action ofmicroorganisms, resulting in the production of various solid and liquidcompounds and gases giving off a foul odor.

179. Regeneration: It refers to natural growth of cells and tissues to replace loststructures.

180. Re-infection: A second infection by same agent again or a second infection ofan organ by different agent.

181. Repair: The physical or mechanical restoration of damaged or diseased tissueby proliferation of new cells or by surgical apposition.

182. Saprophyte: A saprophyte is a microorganism that lives on dead or decayingorganic material.

183. Sarcoma: Malignant tumors arising in mesenchymal tissues are called sarcomas.184. Sclerosis: An induration or hardening especially from inflammation and in

diseases of interstitial substance.185. Secondary Infection: New parasitic infection when the host defense is lowered

by preexisting infectious diseases.186. Sequestrum: A piece of dead bone separated from the sound bone as is seen

sometimes in osteomyelitis.187. Sinus: A sinus is a blind track leading from the surface down to the tissues.

There may be a cavity in the tissue, which is connected to the surface throughsinus.

188. Subclinical infection: Infections in which typical or clinical manifestations ofthe particular infectious disease are not present

189. Swelling: A swelling is a vague term, which denotes any enlargement orprotuberance in the body and may include tumors.

190. Synctium: A multinucleate mass of protoplasm produced by the merging ofcells.

191. Syndrome: Is an aggregate of signs and symptoms almost always occurringtogether and is associated with any morbid process.

192. Telangiectasia: It is a vascular lesion formed by dilation of the capillaries andsmall arteries.

193. Teratoma: This is a true neoplasm composed of multiple tissues which are notnative to the site of growth.

Definitions 11

194. Teratology: A science dealing with the abnormal development and congenitaldeformations.

195. Transudate: A transudate is a fluid with low protein content and a specificgravity of less than 1.012. It is essentially an ultrafiltrate of blood plasma thatresults from osmotic or hydrostatic imbalance across the vessel wall withoutan increase in vascular permeability.

196. Ulcer: An ulcer is a defect or break in continuity of epithelial component ofskin or mucosa, so that a depression or punched-out area exists.

197. Vesicle: A vesicle is a small (2 to 5 mm) circumscribed, elevated lesion composedof a thin surface covering overlying and containing an accumulation of fluid.

198. Virulence: The degree of pathogenicity of a microorganisms as indicated bythe severity of disease produced and the ability to invade the tissues of thehost.

199. Virus: A minute infectious agent lacking independent metabolism and is ableto replicate in only living host cell.

200. Wheal: It is a flat edematous elevation of the skin frequently accompanied byitching.

201. Zoonosis: It refers to the diseases of animals transmissible to mankind.

Section II

Classifications


CLASSIFICATION OF DEVELOPMENTAL DISTURBANCESOF ORAL AND PARAORAL STRUCTURES

Developmental Disturbances of Jaws

Agnathia Micrognathia Macrognathia Facial hemihypertrophy Facial hemiatrophy Abnormalities of dental arch relations.

Developmental Disturbances of Lips and Palate

Congenital lips and commissural pits and fistula Double lip Cleft lip and palate Cheilitis glandularis Cheilitis granulomatosa Hereditary intestinal polyposis syndrome Labial and oral melanotic macule.

Developmental Disturbances of Oral Mucosa

Fordyces granules Focal epithelial hyperplasia (Hecks disease).

Developmental Disturbances of Gingiva

Fibromatosis gingivae Retrocuspid papilla.

Developmental Disturbances of the Tongue

Microglossia Macroglossia Ankyloglossia Cleft tongue Fissure tongue Median rhomboid glossitis Benign migratory glossitis Hairy tongue Lingual varices Lingual thyroid nodule.

Developmental Disturbances of Oral Lymphoid Tissue

Reactive lymphoid aggregates Lymphoid hamartoma

Classifications 15

Angiolymphoid hyperplasia with eosinophils Lymphoepithelial cyst.

Developmental Disturbances of Salivary Glands

Aplasia Xerostomia Hyperplasia of palatal gland Atresia Aberrancy Developmental mandibular salivary gland depression.

Developmental Disturbances of Size of Teeth

Microdontia Macrodonria.

Development Disturbances in Shape of Teeth

Gemination Fusion Concrescence Dilaceration Talons cusp Dens in dente Dens evaginatus Taurodontism Supernumerary roots.

Developmental Disturbances in Number of Teeth

Oligodontia Anodontia Supernumerary teeth Predeciduous dentition Post permanent dentition.

Developmental Disturbances in Structure of Teeth

Amelogenesis imperfecta Dentinogenesis imperfecta Dentin dysplasia Regional odontodysplasia Dentin hypocalcification.

Disturbances of Growth (Eruption) of Teeth

Premature eruption Delayed eruption


Multiple unerupted teeth Embedded and impacted teeth Ankylosed teeth.

Fissural (Inclusion, Developmental) Cyst of Oral Region

Median maxillary cyst Median palatal cyst Globulomaxillary cyst Median mandibular cyst Nasoalveolar cyst Palatal cyst of the neonate Thyroglossal tract cyst Benign cervical lymphoepithelial cyst Dermoid and epidermoid cysts.

WHO CLASSIFICATION OF TUMORS OF THE ORAL CAVITYAND OROPHARYNX

Malignant Epithelial Tumors

Squamous cell carcinoma - 8070/3 Verrucous carcinoma - 8051/3 Basaloid squamous cell carcinoma - 8083/3 Papillary squamous cell carcinoma - 8052/3 Spindle cell carcinoma - 8074/3 Acantholytic squamous cell carcinoma - 8075/3 Adenosquamous carcinoma - 8560/3 Carcinoma cuniculatum - 8051/3

Lymphoepithelial carcinoma - 8082/3

Epithelial Precursor Lesions

Benign Epithelial Tumors

Papillomas 8050/0 Squamous cell papilloma and verruca vulgaris Condyloma acuminatum Focal epithelial hyperplasia

Granular cell tumor - 9580/0 Keratoacanthoma - 8071/1

Salivary Gland Tumors

Salivary Gland Carcinomas

Acinic cell carcinoma - 8550/3 Mucoepidermoid carcinoma - 8430/3

Classifications 17

Adenoid cystic carcinoma - 8200/3 Polymorphous low-grade adenocarcinoma - 8525/3 Basal cell adenocarcinoma - 8147/3 Epithelial-myoepithelial carcinoma - 8562/3 Clear cell carcinoma, not otherwise specified - 8310/3 Cystadenocarcinoma - 8450/3 Mucinous adenocarcinoma - 8480/3 Oncocytic carcinoma - 8290/3 Salivary duct carcinoma - 8500/3 Myoepithelial carcinoma - 8982/3 Carcinoma ex pleomorphic adenoma - 8941/3

Salivary Gland Adenomas

Pleomorphic adenoma - 8940/0 Myoepithelioma - 8982/0 Basal cell adenoma - 8147/0 Canalicular adenoma - 8149/0 Duct papilloma - 8503/0 Cystadenoma - 8440/0

Soft Tissue Tumors

Kaposi sarcoma - 9140/3] Lymphangioma - 9170/0 Ectomesenchymal chondromyxoid tumor Focal oral mucinosis Congenital granular cell epulis

Hematolymphoid Tumors

Diffuse large B-cell lymphoma (DLBCL) - 9680/3 Mantle cell lymphoma - 9673/3 Follicular lymphoma - 9690/3 Extranodal marginal zone B-cell lymphoma of MALT type - 9699/3 Burkitt lymphoma - 9687/3 T-cell lymphoma (including anaplastic large cell lymphoma - 9714/3 Extramedullary plasmacytoma - 9734/3 Langerhans cell histiocytosis - 9751/1 Extramedullary myeloid sarcoma - 9930/3 Follicular dendritic cell sarcoma/tumor 9758/3

Mucosal Malignant Melanoma 8720/3

Secondary Tumors

Morphology code of the International Classification of Diseases for Oncology (ICD-0) {821} and the Systematized Nomenclature of Medicine {http://snomed.org)Behavior is coded


/0 for benign tumors/3 for malignant tumors, and/1 for borderline or uncertain behavior.(Classification adopted from: World Health Organization Classification of Tumors,Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John WEveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 163)

TNM CLASSIFICATION OF CARCINOMAS OF THE ORAL CAVITY (WHO)

TNM Classification of Carcinomas of the Lip and Oral Cavity

T - Primary Tumor

TX - Primary tumor cannot be assessedT0 - No evidence of primary tumorTis - Carcinoma in situT1 - Tumor 2 cm or less in greatest dimensionT2 - Tumor more than 2 cm but not more than 4 cm in greatest dimensionT3 - Tumor more than 4 cm in greatest dimension

T4a (Lip)

Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin(chin or nose).

T4a (Oral Cavity)

Tumor invades through cortical bone, into deep/extrinsic muscle of tongue(genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, or skinof face.

T4b (Lip and Oral Cavity)

Tumor invades masticator space, pterygoid plates, or skull base; or encases internalcarotid artery.Note: Superficial erosion alone of bone/tooth socket by gingival primary is notsufficient to classify a tumor as T4.

N-Regional Lymph Nodes (The Regional Nodes are the Cervical Nodes)

NX - Regional lymph nodes cannot be assessed.N0 - No regional lymph node metastasis.N 1 - Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimensionN2 - Metastasis as specified in N2a, 2b, 2c below.N2a - Metastasis in a single ipsilateral lymph node, more than 3 cm but not more

than 6 cm in greatest dimension.N2b - Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest

dimension.

Classifications 19

N2c - Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm ingreatest dimension.

N3 - Metastasis in a lymph node more than 6 cm in greatest dimension.Note: Midline nodes are considered ipsilateral nodes.

M- Distant Metastasis

MX - Distant metastasis cannot be assessedM0 - No distant metastasisM1 - Distant metastasis(Classification adopted from: World Health Organization Classification of Tumors,Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John WEveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 164)

Stage Grouping

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage II T2 N0 M0

Stage III T1, T2 N1 M0T3 N0, N1

Stage IVA T1, T2, T3 N2 M0T4a N0, N1, N2

Stage IVB Any T N3 M0T4b Any N

Stage IVC Any T Any N M1

(Classification adopted from: World Health Organization Classification of Tumors,Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John WEveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 165).

WHO HISTOLOGICAL CLASSIFICATION OF TUMORSOF THE SALIVARY GLANDS


Acinic cell carcinoma - 8550/3 Mucoepidermoid carcinoma - 8430/3 Adenoid cystic carcinoma - 8200/3 Polymorphous low-grade adenocarcinoma - 8525/3 Epithelial-myoepithelial carcinoma - 8562/3 Clear cell carcinoma, not otherwise specified - 8310/3


Basal cell adenocarcinoma - 8147/3 Sebaceous carcinoma - 8410/3 Sebaceous lymphadenocarcinoma - 8410/3 Cystadenocarcinoma - 8440/3 Low-grade cribriform cystadenocarcinoma Mucinous adenocarcinoma - 8480/3 Oncocytic carcinoma - 8290/3 Salivary duct carcinoma - 8500/3 Adenocarcinoma, not otherwise specified - 8140/3 Myoepithelial carcinoma - 8982/3 Carcinoma ex pleomorphic adenoma - 8941/3 Carcinosarcoma - 8980/3 Metastasizing pleomorphic adenoma - 8940/1 Squamous cell carcinoma - 8070/3 Small cell carcinoma - 8041/3 Large cell carcinoma - 8012/3 Lymphoepithelial carcinoma - 8082/3 Sialoblastoma - 8974/1


Pleomorphic adenoma - 8940/0 Myoepithelioma - 8982/0 Basal cell adenoma - 8147/0 Warthin tumor - 8561/0 Oncocytoma - 8290/0 Canalicular adenoma - 8149/0 Sebaceous adenoma - 8410/0 Lymphadenoma

Sebaceous - 8410/0 Non-sebaceous - 8410/0

Ductal papillomas Inverted ductal papilloma - 8503/0 Intraductal papilloma - 8503/0 Sialadenoma papilliferum-8406/0

Cystadenoma - 8440/0

Soft Tissue Tumors

Hemangioma - 9120/0

Hematolymphoid Tumors

Hodgkin lymphoma Diffuse large B-cell lymphoma - 9680/3 Extranodal marginal zone B-cell lymphoma - 9699/3

Classifications 21

Secondary Tumors

Morphology code of the International Classification of Diseases for Oncology (ICD-0) {821} and the Systematized Nomenclature of Medicine {http://snomed.org)Behavior is coded/0 for benign tumors/3 for malignant tumors, and/1 for borderline or uncertain behavior.(Classification adopted from: World Health Organization Classification of Tumors,Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John WEveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 210)

WHO HISTOLOGICAL CLASSIFICATION OF ODONTOGENIC TUMORS

Malignant Tumors

Odontogenic Carcinomas

Metastasizing (malignant) ameloblastoma - 9310/3 Ameloblastic carcinoma - primary type - 9270/3 Ameloblastic carcinoma - secondary type (dedifferentiated), Intraosseous - 9270/3 Ameloblastic carcinoma - secondary type (dedifferentiated), peripheral - 9270/3 Primary intraosseous squamous cell carcinoma - solid type - 9270/3 Primary intraosseous squamous cell carcinoma derived from keratocystic

odontogenic tumour - 9270/3 Primary intraosseous squamous cell carcinoma derived from odontogenic cysts -

9270/3 Clear cell odontogenic carcinoma - 9341/3 Ghost cell odontogenic carcinoma - 9302/3

Odontogenic Sarcomas

Ameloblastic fibrosarcoma - 9330/3 Ameloblastic fibrodentino-and fibro-odontosarcoma - 9290/3

Benign Tumors

Odontogenic Epithelium with Mature, Fibrous Stromawithout Odontogenic Ectomesenchyme

Ameloblastoma, solid/multicystic type - 9310/0 Ameloblastoma, extraosseous/peripheral type - 9310/0 Ameloblastoma, desmoplastic type - 9310/0 Ameloblastoma, unicystic type - 9310/0 Squamous odontogenic tumor - 9312/0 Calcifying epithelial odontogenic tumor - 9340/0 Adenomatoid odontogenic tumor - 9300/0 Keratocystic odontogenic tumor - 9270/0


Odontogenic Epithelium with Odontogenic Ectomesenchyme,with or without Hard Tissue Formation

Ameloblastic fibroma - 9330/0 Ameloblastic fibrodentinoma - 9271/0 Ameloblastic fibro-odontoma - 9290/0 Odontoma - 9280/0

Odontoma, complex type - 9282/0 Odontoma, compound type - 9281/0

Odontoameloblastoma - 9311/0 Calcifying cystic odontogenic tumor - 9301/0 Dentinogenic ghost cell tumor - 9302/0

Mesenchyme and/or Odontogenic Ectomesenchymewith or without Odontogenic Epithelium

Odontogenic fibroma - 9321/0 Odontogenic myxoma/myxofibroma - 9320/0 Cementoblastoma - 9273/0

Bone-related Lesions

Ossifying fibroma 9262/0 Fibrous dysplasia Osseous dysplasias Central giant cell lesion (granuloma) Cherubism Aneurysmal bone cyst Simple bone cyst

OTHER TUMORS

Melanotic neuroectodermal tumor of infancy - 9363/0Morphology code of the International Classification of Diseases for Oncology (ICD-0) {821} and the Systematized Nomenclature of Medicine {http://snomed.org)Behavior is coded/0 for benign tumors/3 for malignant tumors, and/1 for borderline or uncertain behavior.(Classification adopted from: World Health Organization Classification of Tumors,Pathology and Genetics, Head and Neck Tumors, Edited by: Leon Barnes, John WEveson, Peter Reichart, David Sidransky, IARC Press, Lyon 2005. Pg. 284)

Classifications 23

CLASSIFICATION OF ODONTOGENIC CYSTS (M SHEAR)

I. Cyst of Jaws

A. Epithelial

1. Developmental cystsa . Odontogenic

Odontogenic keratocystEruption cystPrimordial cystGingival cyst of adultsLateral periodontal cystCalcifying epithelial odontogenic cystBotryoid odontogenic cystGlandular odontogenic cyst

b . Non-odontogenicNasopalatine ductMedian palatine median alveolar and median mandibular cystsGlobulomaxillary cystNasolabial cystMidpalatal raphe cyst of infants

2 . Inflammatory cystRadicular cystResidual cystInflammatory collateral cystParadental cyst

B. Non-epithelial

Simple bone cyst (traumatic bone cyst) Aneurysmal bone cyst

II. Cysts of Maxillary Antrum

Benign mucosal cyst of maxillary antrum Surgical ciliated cyst of maxilla .

III. Cysts of Soft Tissues of Mouth, Face and Neck

Dermoid and epidermoid cyst Branchial cleft cyst (lymphoepithelial cyst) Thyroglossal duct cyst Anterior median lingual cyst Oral cyst with gastric or intestinal epithelium Cystic hygroma Nasopharyngeal cysts


Cyst of salivary glands Parasitic cyst, hydatid cyst, cysticercosis cellulosae; Trichinosis

ULCERATIVE LESIONS OF THE ORAL CAVITY

Traumatic Infectious Allergic Neoplastic Systemic Unknown Etiology and Syndromes

Traumatic

1. PhysicalA. Odontogenic

Resorption of periapical area around a primary tooth, exposure of rootand ulceration on lips and cheeks

Rough and Badly fitting restorations Ulcers due to teeth present at birth with sharp edges Pressure from the splints

B. Non-odontogenic Post injection ulcers on palate Electric burn due to live wire Post pertussis ulcer on frenum of tongue Epileptic ulcer

2. Thermal changes Hot liquids Refrigent local anesthetic

3. Chemical Drugs, Acids, Lime, Arsenic, Bismuth, lead and Aspirin

4. Actinic Actinic chelosis on the lips Radiation ulcer

Infections

1. Non-specific (Streptococci and staphylococci) Non-specific infected ulcer, which is primarily traumatic

2. Specific (Bacilli and Cocci) Aphthous ulcer, and periadenitis mucosa, Necrotica recurrens or major aphthae. Tuberculous ulcer. Diphtheric ulcer. Tularemia (rabbit fever). Granuloma inguinale. Leprosy.

Classifications 25

Gonorrheal ulcer. Pneumococcal ulcer. Ulcers of oral cavity in infections with Bacillus pseudomonas and Bacillus

aeruginosaA. Spirochetal

Vincents infection and Noma. Syphilis Yaws Bejel

B. Fungal Candidiasis North American blastomycosis. South American blastomycosis. Histoplasmosis. Cryptococcosis. Geotrichosis. Sporotrichosis. Coccidiomycosis. Chronic candidiasis syndrome. Aspergillosis.

C. Rickettsial Macular, papular, vesicular eruptions in oral cavity found in Rickettisal

pox ulcer. Rickettsiae like organisms (Bartonella) giving rise to ulcers.

D. Viral Herpes simplex virus Herpes zoster Herpengina Chickenpox Smallpox AIDS Infectious mononucleosis Dengue Tropical sprue Lymphogranuloma venerum Viral enteritis

E. Protozoan American Mucocutaneous Leishmaniasis Oriental sore (leishmania tropica parasites)

Allergic

Local application1. Stomatitis venenata

General administration2. Stomatitis medicamentosa.


Neoplastic

Carcinoma Lymphoma Hemangioendothelioma

Systemic

A. Blood diseases Leukemia Aplastic anemia Agranulocytosis Cyclic neutropenia Pernicious anemia Iron deficiency anemia Macroglobulinemia Polycythemia vera

B. Vitamin deficiency Riboflavin deficiency Nicotinic acid deficiency Vitamin C deficiency

C. Reticuloendothelial system Histocytosis X

Unknown Etiology and Syndromes

Erythema multiforme Pemphigus Epidermolysis bullosa Erosive lichen planus Lupus erythematosus Acrodermatitis enteropathica Acrodynia Aortic arch syndrome Macroglobulinemia Zinsser-Cole-Engman syndrome Feltys syndrome Sideropenic dysphagia Acute toxic epidermal necrolysis Necrotizing sialometaplasia Lethal granuloma Crohns disease Pemphigoid Coeliac disease Erythema multiforme exudativum Sweets syndrome

Classifications 27

CLASSIFICATION OF GIANT CELL LESIONS

Autoimmune

Wegners granulomatosis Allergic granulomatosis and vasculitis (Churg-Strauss syndrome)

Neoplasms

Giant cell epulis Central giant cell granuloma Peripheral giant cell granuloma Brown tumors of hyperparathyroidism Giant cell fibroma Histocytosis x Hand-Sch3ller-Christian disease Letterer-Siwe disease Eosinophilic granuloma Fibrous histiocytoma Hodgkins disease (Reed-Sternberg cell) Osteogenic sarcoma

Infections

Bacterial

Tuberculosis Sarcoidosis Leprosy

Viral

Herpes simplex Herpes zoster

Fungal

Histoplasmosis Aspergulosis Blastomycosis

Disorder of Blood Vessels Temporal arteritis

Lesions Associated with Genetic Diseases Cherubism

Miscellaneous Aneurysmal bone cyst


Giant cells related to exogenous substances, e.g. suture and talc and to endogenous Substances, e.g. keratin, fat cholesterol crystals

(Classification adopted from: Classification of Oral and Paraoral disorders, SanjaySaraf, Jaypee Brothers, New Delhi)

WORKING CLASSIFICATION FOR FIBRO-OSSEOUS JAW LESIONS(CHARLES WALDRON-1993)

Fibrous dysplasia Reactive (dysplastic) lesions arising in the tooth bearing areas.

Periapical cemento-osseous dysplasia. Focal cemento-osseous dysplasia. Florid cemento-osseous dysplasia.

Fibro-osseous neoplasms.

These are widely designated as cementifying fibroma, ossifying fibroma, or cemento-ossifying fibroma.

CLASSIFICATION OF VESICULOBULLOUS LESIONS

Intracorneal and Subcorneal Blisters

Pemphigus foliaceus and erythematosus

Intraepidermal Blisters

Viral blistering disease Epidermolysis bullosa

Suprabasilar Blister

Pemphigus vulgaris and vegetans Paraneoplastic pemphigus Hailey Hailey disease Darriers disease

Subepidermal Blister with Scant Inflammation

Epidermolysis bullosa Bullous pemphigoid Burns Toxic epidermal necrolysis Drug reactions

Subepidermal Blisters with Lymphocytes

Erythema multiforme Paraneoplastic pemphigoid Bullous fixed drug eruptions

Classifications 29

Subepidermal Blisters with Eosinophils

Bullous pemphigoid Drug reactions

Subepidermal Blisters with Neutrophils

Dermatitis herpetiform Cicatrical pemphigoid Bullous lupus erythematosus Epidermolysis acquisita

Other

Drug overdosage related bullae Cancer related bullae Bullae associated with diabetes mellitus

(Classification adopted from: Classification of Oral and Paraoral disorders, SanjaySaraf, Jaypee Brothers, New Delhi)

CLASSIFICATION OF CARIES

Depending on Nature of Attack

Primary caries (Incipient, initial): First attack on tooth surfaceSecondary caries (Recurrent): Caries occurring at the margins or walls of existingrestorations.

Depending on the Progression of the Caries

Acute: It is rapidly invading process that involves several teeth. Lesions are soft andlight colored. Usually pulp is involved at the early stage. Examples of acute cariesare: Rampant caries Nursing bottle caries Radiation cariesChronic: These lesions are long standing and fewer in number.

Depending on Surfaces Involved

Pit and fissure caries Smooth surface caries.

Based on Direction of Caries Attack

I. Forward caries: Caries that proceeds from enamel to dentin. The lesion is triangleshaped with base of the triangle at the enamel surface and apex towards dentin. Inpits and fissures base is at dentinoenamel junction and the apex is in the pit.


II. Backward caries: Caries that proceeds from dentinoenamel junction towardsenamel surface. This is also triangle shaped with base at dentinoenamel junction andapex towards enamel surface.

Based on Number of Surfaces Involved

Simple: Only one surface is involved by cariesCompound: Two surfaces are involved.Complex: More than three surfaces involved.

GV Black Classification based on treatment and restoration designClass I: These lesions begin in pits, fissures and defective grooves. These are

seen in occlusal surface, occlusal two-thirds of molars and lingual pits ofincisors.

Class II: These are lesions seen on proximal aspects of molars and premolars.Class III: These are lesions involving proximal aspects of incisors that do not involve

or necessitate removal of incisal edge.Class IV: These are lesions involving proximal aspects of incisors that involve or

require removal of incisal edge.Class V: These are lesions present on gingival third of all the teeth.Class VI: Lesions found on incisal edges and cusp tips.

Based on Location of the Lesion

Pit and Fissure Caries

Occlusal Buccal or lingual pit

Smooth Surface Caries

Proximal Buccal or lingual surface

Root Caries

Based on Tissue Involved

Enamel cariesDentinal cariesCemental caries.

Senile caries: It is caries associated with aging process. These are almost exclusivelyseen on root surface.

Residual caries: It is caries that is not removed during restorative procedure.

Arrested caries: Sometimes progress of caries is halted by treatment or change incondition. Such lesions are mineralized but retain brown color.

Classifications 31

(Classification adopted from: Textbook of Oral Pathology, Anil Ghom, ShubangiMhaske, Jaypee Brothers, New Delhi)

CLASSIFICATION OF FRACTURE OF TEETH

Ellis Classification

Group I - Enamel fractureGroup II - Dentin fracture without pulp exposureGroup III - Crown fracture with pulp exposureGroup IV - Root fractureGroup V - Tooth luxationGroup VI - Tooth intrusion

Heathersay and Morile Classification

Class I - Fracture line does not extend below the level of attached gingivaClass II - Fracture line extends below the level of attached gingival but not below

the level of alveolar crestClass III - Fracture line extends below the level of alveolar crestClass IV - Fracture line within the coronal third of root but below the level of

alveolar crest

WHO Classification (1978)

873.60 - Enamel fracture873.61 - Crown fracture involving enamel and Dentin without pulp exposure873.62 - Crown fracture with pulp exposure873.63 - Root fracture873.64 - Crown root fracture873.66 - Luxation873.67 - Intrusion or Extrusion873.68 - Avulsion873.69 - Other injuries such as soft tissue laceration

CLASSIFICATION OF GINGIVAL ENLARGEMENT

Depending on the etiological factors and pathological changes, Gingivalenlargement is classified as:

I. Inflammatory enlargementA. Chronic inflammatory enlargementB. Acute inflammatory enlargement

II. Noninflammatory hyperplastic enlargement (gingival hyperplasia)A. Drug-induced gingival hyperplasiaB. Idiopathic hyperplastic enlargement


III. Combined enlargementIV. Conditioned enlargement

A. Hormonal enlargementB. Leukemic enlargementC. Enlargement associated with vitamin C deficiencyD. Nonspecific conditioned enlargement (granuloma pyogenicum)

V. Neoplastic enlargement (gingival tumors)A. Benign tumors of the gingivaB. Malignant tumors of the gingiva

VI. Developmental enlargement

Depending on the location and distribution, Gingival enlargement is designatedas:

Localized: Limited to the gingiva adjacent to a single tooth or group of teeth.

Generalized: Involving the gingiva throughout the mouth.

Marginal: Confined to the marginal gingiva.

Papillary: Confined to the interdental papilla

Diffuse: Involving the marginal and attached gingivae and papillae

Discrete: An isolated sessile or pedunculated tumor-like enlargement.

CLASSIFICATION OF PERIODONTAL DISEASES AND CONDITIONS

Gingival Disease

Plaque-induced gingival diseases Nonplaque-induced gingival lesions

Chronic Periodontitis

Localized Generalized

Aggressive Periodontitis

Localized Generalized

Periodontitis as Manifestation of Systemic Disease

Necrotizing periodontal diseases Necrotizing ulcerative gingivitis Necrotizing ulcerative periodontitis.

Classifications 33

Abscesses of Periodontium

Gingival abscess Periodontal abscess Combined lesion.

Periodontitis Associated with Endodontic Lesions

Endodontic-periodontal lesion Periodontal-endodontic lesion Combined lesion.

Developmental or Acquired Deformities and Conditions

Localized tooth-related factors that predispose to induced gingival disease orperiodontitis

Mucogingival deformities and conditions around teeth Mucogingival deformities and conditions on edentulous ridges Occlusal trauma

CLASSIFICATION OF TEMPOROMANDIBULAR JOINT DISORDERS

A. Developmental disturbances Aplasia of mandibular condyle Hypoplasia of mandibular condyle Hyperplasia of mandibular condyle

B. Traumatic disturbances Luxation and subluxation (complete and incomplete dislocation) Ankylosis Injuries of articular disk Fractures of condyle.

C. Inflammatory disturbances of TM] Arthritis due to specific infection Rheumatoid arthritis Osteoarthritis Traumatic arthritis.

D. Neoplastic disturbances of the temporomandibular jointE. Extraarticular disturbances of TM]

Costen syndromeMyofacial pain-dysfunction syndrome.

(Classification adopted from: Textbook of Oral Pathology, Anil Ghom, ShubangiMhaske, Jaypee Brothers, New Delhi)


CLINICAL AND HISTOLOGICAL DIFFERENCES BETWEEN BENIGNAND MALIGNANT TUMORS

Clinical Differences

Features Benign Malignant

Growth Slow and expanding Rapid and infiltratingCapsule Present AbsentFixity Absent PresentDegeneration Rare CommonRecurrences Not common CommonMetastasis Absent Usually present

Histopathological Differences

Features Benign Malignant

Cell character Not changed Changed(Structurally)Differentiation Differentiated UndifferentiatedLoss of polarity Not seen PresentBlood vessels Adult type Embryonic typeNucleus As in normal cells HyperchromaticMitosis Absent Present


1. Squamous papilloma2. Squamous acanthoma3. Keratoacanthoma4. Oral nevi


1. Basal cell carcinoma2. Squamous cell carcinoma3. Verrucous carcinoma4. Spindle cell carcinoma5. Adenoid squamous cell carcinoma6. Basaloid squamous cell carcinoma7. Transitional cell carcinoma8. Nasopharyngeal carcinoma9. Malignant melanoma

Classifications 35

Benign Connective Tissue Tumors

1. Fibroma2. Giant cell fibroma3. Peripheral ossifying fibroma4. Central ossifying fibroma5. Peripheral giant cell granuloma6. Central giant cell granuloma7. Giant cell tumor of bone8. Lipoma9. Hemangioma

10. Lymphangioma11. Myxoma12. Chondroma13. Osteoma14. Osteoblastoma

Malignant Connective Tissue Tumors

1. Fibrosarcoma2. Histiocytoma3. Liposarcoma4. Hemangiopericytoma5. Hemangioendothelioma6. Kaposis sarcoma7. Ewings sarcoma8. Chondrosarcoma9. Osteosarcoma

10. Lymphomas11. Plasmacytoma12. Multiple myeloma

Benign Muscle Tissue Tumors

1. Leiomyoma2. Angiomyoma3. Rhabdomyoma4. Granular cell myoblastoma

Malignant Muscle Tissue Tumors

1. Leiomyosarcoma2. Angiomyoma3. Rhabdomyosarcoma4. Malignant granular cell myoblastoma


Benign Nerve Tissue Tumors

1. Neuroma2. Neurofibroma3. Neurolemmoma4. Melanotic neuroectodermal tumor of infancy

Malignant Nerve Tissue Tumors

1. Malignant peripheral nerve sheath tumor2. Olfactory neuroblastoma

Section III

Routine and Advanced DiagnosticProcedures for Oral Lesions


Oral Cavity, just like any other organ of the body too suffers from various diseaseprocesses. These disease processes require careful evaluation so as to arrive at thecorrect diagnosis and plan the treatment accordingly. The different approaches andmethods employed for the assessment of various oral lesion include:I. Predominantly morphological methods

a. Exfoliative cytologyb. Aspiration cytologyc. Quantification of histopathologyd. Histochemistrye. Immunohistochemistry

Epithelial surface antigens Intracellular components and products Alterations of the basement membrane zone Stromal changes

f. In situ hybridizationg. Electronmicroscopy

II. Functional methodsa. Cellular proliferation studiesb. DNA histograms, cytophotometryc. Changes in the immune statusd. Analysis of cell products in circulating bloode. Examination of living tissuef. Experimental models

III. Microbiological involvement

COMMONLY USED DIAGNOSTIC METHODS

Exfoliative Cytology

One of the most easily performed chair side diagnostic procedure Screening of large areas Unlimited repetition Can be helpful in early detection of malignancy Lesions caused by herpes virus and candidal lesion can be diagnosed by scraping Limited use in premalignant disorders, more valuable in red lesions Cytological examination may help in determining the site of biopsy.

Aspiration Cytology

Microinvasive procedure More valuable than exfoliative cytology in cases of solid tumors of oral cavity Useful in cases of salivary gland lesions Micronucleus test can be performed on exfoliated cells for assessment of

chromosomal damage and thus of mutagenic influences on mucosa. Micronuclei are chromatin particles derived from accentric chromosomal fragments

which are not incorporated in the daughter nuclei after mitosis Can be visualized by chromatin stains

Routine and Advanced Diagnostic Procedures for Oral Lesions 39

Biopsy

Definition: Gross and microscopic examination of tissues of cells removed from aliving patient for the purpose of diagnosis or prognosis of disease or the confirmationof normal conditions.Uses: Diagnosis of a pathologic lesion. Grading of tumor for diagnosis. Determining neoplastic and non-neoplastic lesions. Diagnosis of metastatic lesions. Evaluation of recurrence Therapeutic assessment. Differentiation between benign and malignant lesions.

Types

Commonly used Less commonly used Aspiration Bite Curettage Brush Excisional Cone Incisional Core Fine needle Endoscopic Punch Irrigation Scrape Pressure Trephine Shave Exfoliative cytology Sponge Unexplained

Complications

Hemorrhage Infection Poor wound healing Spread of tumor cells Injury to adjacent organs Reaction to the local anesthesia

Section IV

Staining Proceduresand Special Stains


Processing

Definition: It is a process in which tissues are treated with various chemicals, inorder to make the miscible with Paraffin wax (embedding medium).

Procedure: Formalin fixed tissue is passed through series of chemicals in order toprepare the tissue so that sections can be taken and subsequently stained.(Fixative: 10% formalin)

Dehydration of tissueby immersing in 70% Alcohol 1 hour

Three changes in acetoneAcetone I 1 hourAcetone II 1 hourAcetone III 1 hour

Clearing:To remove acetone from tissue - Acetone + xylene 1 hr.

- Xylene 1 hr.- Xylene 1 hr.

After dehydration and clearing tissue is kept in molten Paraffin Wax for 2 hrs.Tissue is embedded with proper orientation in L (Leukharts) Block using molten

Paraffin Wax.The Paraffin block with tissue is mounted, fixed on metallic chuck on the microtome

for acquiring serial section of 3-5 microns.Serial sections are taken on microscopic glass slide.Tissues are fixed to the slide with egg albumin. It is kept on the slide warmer and

then stained with Hematoxylin and Eosin for routine microscopy.

Routine and Special Stains Appearance under Microscope

Name of Stain Tissues Reaction

1. Hematoxylin Nuclei Blue/Blackand Eosin Cytoplasm Varying shades of pink

Muscle fibers Deep pink/RedRed blood cells Orange/RedFibrin Deep pink

2. Von Gieson Nucleus Blue/BlackCollagen RedOther tissues Yellow

(Contd...)

Staining Procedures and Special Stains 43

(Contd...)


3. Massons Trichrome Nucleus Blue/BlackCytoplasm RedMuscle RedErythrocytes RedCollagen Blue

4. Periodic Acid Solution Carbohydrate Magenta(PAS) Nucleus Blue(Periodic Acid-Schiff) Glycogen Magenta

5. Mallory Stain Muscle striation Dark blueFibrin Dark blueMyelin Dark blueCollagen Deep brown blueCartilage Deep brown blueElastic fiber Deep brown blueCytoplasm Pale pinkish

6. Sudan black Unsaturated esters and Blue-blacktriglyceridesPhospholipids GraySphingomyelin Bronze in polarized

light

7. Mucicarmine Mucins RedNuclei BlueBackground Unstained

8. Standard Toluidine Amyloid and many other Orthochromatic blueblue tissue components

Amyloid Dark red birefringencein polarized light

9. Congo Red Amyloid, Elastic fibers, RedEosinophil granulesNuclei Blue

10. Giemsa Protozoans and some other Dark bluemicroorganismsBackground Pink-Pale blueNuclei Blue

(Contd...)



11. Alcian blue Acid mucins BlueNuclei Red

12. Alcian blue-Alcian Sulfated mucins Blueyellow Carboxylated mucins Yellow

Mixtures of above GreenNuclei Red

Microbial Staining

Classification of Stains

Simple Staining : Positive stainingNegative staining

Differential Staining : Grams stainingZiehl-Neelsens staining

Special Staining : Albert stain Capsular stain Flagellar stain

Positive Staining : Bacteria Stained with basic stains, bacterial morphologyappreciated.

Negative Staining : When bacteria are very small, and encapsulated andcannot be demonstrated by +ve staining, thenbackground is stained by using acidic dye in which thebacteria, stand out in contrast

Indian ink : Imparts black/gray color. Nigrosin : Imparts blue/bluish violet or violet color Purpose of simple

staining : is to study the structural details of bacteria.

Grams Stain

Crystal violet Crystal violet and distilled water Grams lodine Acts as Mordant Absolute alcohol/Sprit Decolouriser Dilute carbol/Fuschin Counter stain

(Carbol Fuschin and distilled water)

Take uniform smear Smear is dried fixed by passing over the sprit lamp. Cover the Smear with crystal violet, gentian violet, Methyl violet, solution and

allow to remain on the slide for 1 minute.

(Contd...)

Staining Procedures and Special Stains 45

Discard the crystalline violet (residual stain) cover the smear with fresh iodinesolution for 1minute.

Rinse with absolute alcohol till you get clear color flow from the slide (10-15 sec.) Wash with water Cover with safranine dilute carbol fuschin (1.20) neutral red and allow it to remain

for 1 minute Rinse with water dry Examine under oil immersion Gram +ve organisms Violet (Basophilic) Gram ve organisms Pink (Eosinophilic)Cocci oval or round in shape

Gram +ve cocci Arranged in clusters (Staphylococcus) Arranged in chain (Streptococcus)

Bacilli Rod shaped Gram +ve Bacilli C. diptheriae, clostridium Gram ve Bacilli Salmonella, Shigella Organisms which resist decolorising with absolute alcohol take up violet color

Designated as gram +ve Those organisms decolorised with acid alcohol. Counterstained with safranine

take up pink color and are termed as Gram ve organisms. Grams staining is used for classification of bacteria. For the provisional diagnosis.

Acid-fast Stain (Ziehl-Neelsens Stain)

Mycobacteria have the power of retaining certain stain even after decolorized bymineral acids. Known as Acid Fastness (This is due to the presence of lipidmycolic acid).

Solutions: Strong Carbol fuschin (Basic Fuschin, Absolute alcohol, phenol and water) Sulphuric acid 20% solution. Methylene blue. Preparation of smear Fixation of the smear by gently passing the side over the flame. Cover the side with carbol fuschin and heat the slide in intervals until steam rises

for 5-7 minutes.Heating makes Thick lipid cell wall of bacterium permeable to the dye

Wash in running tap water. Decolorize with sulphuric acid (20%). Decolorization should be continued till

the film becomes faintly pink. Decolorization must be done in stages andgenerally requires about 10 minutes.


Wash in running tap water Counter stain the smear with methylene blue for 1-2 minutes. Wash in running tap water Blot, dry examine with oil immersion objective Acid-Fast bacilli Red Tissue and other organisms Blue

Acid-Fast organisms Mycobacterium tuberculi Mycobacterium leprae

Section V

Normal Values of FormedElements in Blood


RED BLOOD CELL

Normal Red Blood Cell Count

Males: 5.5 1.1 1012/lFemales: 4.8 1.1 1012/lInfants (Full term, cord blood): 5.0 1.1 1012/lChildren, 1 year: 4.4 0.8 1012/lChildren, 10-12 years: 4.7 0.7 1012/l

Hemoglobin

Males: 15.5 2.5 g/dlFemales: 14.0 2.5 g/dlInfants (Full term, cord blood): 16.5 3.0 g/dlChildren, 1 year: 12.0 1.0 g/dlChildren, 10-12 years: 13.0 1.5 g/dl

Packed Cell Volume (PCV: Hematocrit)

Males: 0.47 0.07 (l/l)Females: 0.42 0.05 (l/l)Infants (Full term, cord blood): 0.54 0.10 (l/l)Children, 1 year: 0.38 0.06 (l/l)Children, 10-12 years: 0.41 0.04 (l/l)

Mean Cell Volume (MCV)

Adults: 85 8 flInfants (Full term, cord blood): 106 flChildren, 1 year: 78 8 flChildren, 10-12 years: 84 7 fl

Mean Cell Hemoglobin (MCH)

Adults: 29.5 2.5 pg

Mean Cell Hemoglobin Concentration (MCHC)

Adults and children: 33 2 g/dl

Mean Cell Diameter

Adults: 6.7 - 7.7 m

Reticulocytes

Adults and children: 0.2-2.0% (10 100 109/l)Infants (Full term, cord blood): 2-6% (mean 150 109/l)

Normal Values of Formed Elements in Blood 49

WHITE BLOOD CELL

Normal White Blood Cell Count

Adults: 4 11 109/lInfants (full term, at birth): 10 25 109/lInfants (1 year): 6 18 109/lChildhood (4-7 years): 5 15 109/lChildhood (8-12 years): 4.5 13.5 109/l

Normal Differential White Blood Cell Count

Adults

Neutrophils 40 75% 2.0 - 7.5 109/lLymphocytes 20 50% 1.5 - 4.0 109/lMonocytes 02 10% 0.2 - 0.8 109/lEosinophils 01 06% 0.04 - 0.4 109/lBasophils < 01% 0.01 - 0.1 109/l

PLATELETS

Normal Platelet Count

Adults: 150 400 109/l

Section VI

Common Syndromes AffectingOral Cavity


Acquired Immunodeficiency Syndrome (Common Oral Lesions Associated)

Hairy leukoplakia Candidiasis Kaposi sarcoma Non-Hodgkins lymphoma Bacterial infections Herpes zoster infection Varicella zoster infection Squamous cell carcinoma Xerostomia Aphthous stomatitis Gingivitis and periodontitis

Adrenogenital Syndrome

Occurs due to hyperplasia or tumors of the adrenal cortex Pseudohermaphroditism Sexual precocity Virilism in women and feminization in men Premature eruption of teeth

Albright Syndrome

Mental retardation Olfactory dysfunction Low nasal bridge Short neck Calcifications in subcutaneous tissue in scalp, brain and along the extremities Short metacarpals and metatarsals Hypogonadism and hypothyroidism Enamel hypoplasia Widened root canals Delayed eruption

Apert Syndrome

Hyperacrobrachycephaly Retruded middle third of face Mandibular prognathism Depressed nasal bridge, parrot-beaked nose and deviated nasal septum Hypertelorism, proptosis, downslanting palpebral fissures, strabismus Lips have trapezoidal configuration Palate constricted, high arched and usually has a median furrow V shaped maxillary alveolar ridge, crowding of teeth with bulging alveolar ridges Class III malocclusion with anterior open bite and anterior as well as posterior

crossbite

Common Syndromes Affecting Oral Cavity 53

Short hard palate and long and thick soft palate Delayed eruption

Aschers Syndrome

Sagging eyelids Lid skin is thin and atrophic Double lip Blepharochalasis Non-toxic thyroid enlargement

Auriculotemporal Syndrome (Freys Syndrome)

Flushing, sweating and warmth and sometimes mild pain in the preauricular andtemporal area of the involved side of face during strong salivary stimulus

Usually is seen after conservative parotidectomy or direct trauma to parotid regionor mandibular condylar head

Etiology in most cases is trauma to auriculotemporal nerve.

Baby Bottle Syndrome (Nursing Caries, Bottle Mouth Syndrome)

Widespread carious destruction of deciduous teeth, most commonly maxillaryincisors followed by first molar and cuspids.

Carious process may completely destroy tooth crown.

Basal Cell Nevus-Jaw Cyst-Bifid Rib Syndrome (Gorlin-Goltz Syndrome)

Cutaneous anomalies including basal cell carcinoma, benign dermal cysts andtumors, palmar pitting, palmar and plantar keratosis and dermal calcinosis

Dental and osseous anomalies including odontogenic keratocysts, mild mandibularprognathism, rib anomalies, vertebral anomalies and brachymetacarpalism

Ophthalmologic anomalies including hypertelorism with wide nasal bridge,dystopia canthorum, congenital blindness and internal strabismus

Neurologic anomalies including mental retardation, dural calcification, agenesisof corpus callosum, congenital hydrocephalus and occurrence of medulloblastomas

Sexual anomalies including hypogonadism in males and ovarian tumors in females.

Beckwith-Wiedemann Syndrome

Increased birth weight, postnatal gigantism, accelerated osseous maturation,asymmetry, skeletal anomalies

Seizures, apnea, cyanosis, mental deficiency Earlobe grooves, flame nevus, craniofacial dysmorphism, mild microcephaly Umbilical hernia, hepatomegaly, splenomegaly, nephromegaly, genitourinary

anomalies, cardiac anomalies, diaphragmatic anomalies, inguinal hernia,gastrointestinal anomalies.

Macroglossia, anterior open bite, prognathic mandible Neonatal hypoglycemia, polycythemia, hypocalcemia, hypocholestremia,

hyperlipidemia


Behcets Syndrome

Recurrent conjunctivitis Multiple recurrent Aphthous stomatitis Absence of lingual fungiform papillae Caused by pleuropneumonia like organism (PPLO) Genital lesions

BK Mole Syndrome

Autosomal dominant condition Large pigmented nevi High risk of melanoma development

Chorda Tympani Syndrome

Sweating and flushing of skin of chin and submental region May accompany surgery or injury to submandibular gland

Cowdens Syndrome or Multiple Hamartoma Syndrome

MucocutaneousMultiple facial papules, acral keratoses, palmoplantar keratoses,multiple oral papillomas, dermal fibromas, multiple skin tags, oral fibromas, scrotaltongue, lipomas, cutaneous and oral malignancies

Thyroid glandGoiter, adenoma, hyperthyroidism, hypothyroidism, thyroiditis,thyroglossal duct cyst, follicular adenocarcinoma

Female breastFibrocystic disease, anatomic abnormalities, virginal hypertrophy,ductal adenocarcinoma, ductal papilloma

Male breastBenign gynecomastia Female genitourinary systemMenstrual irregularities, ovarian abnormalities

(mainly cysts), leiomyomas, vaginal and vulvar cysts, adenocarcinoma of uterus,carcinoma of uterine cervix, carcinoma of ovary, transitional cell carcinoma ofrenal pelvis

Male genitourinary systemHydrocele, varicocele, transitional cell carcinoma ofbladder

Gastrointestinal tractPolyps of upper GI tract, Polyps of colon and rectosigmoid,Diverticula of colon and sigmoid, Ganglioneuromas and neuromas, epithelioidleiomyoma of rectosigmoid, hepatic hamartoma, adenocarcinoma of cecum,adenocarcinoma of colon

Facial dysmorphism and skeletal abnormalitiesHigh head circumference,Adenoid facies, highly arched palate, kyphosis, kyphoscoliosis, hand and footabnormalities, pectus excavatum, bone cysts

Nervous systemNeuromas of cutaneous nerves, neurofibroma, meningioma,hearing loss

EyeCataracts, angioid streaks, congenital blood vessel anomaly, myopia


CREST Syndrome Calcinosis cutis Reynauds phenomenon Esophageal dysfunction Sclerodactly Telangiectasia of the face, oral mucosa, hands and upper trunk

Crouzon Syndrome (Craniofacial Dysostosis) Craniosynostosis Coronal and sagittal coronal, sagittal, and lambdoidal Sagittal

and lambdoidal Neurologic frequent headaches, seizures, marked mental deficiency, Agenesis of

corpus callosum Ophthalmologic ocular proptosis, Exotropia, Poor vision, Optic atrophy, Blindness

Nystagmus, iris coloboma, exposure conjunctivitis, exposure keratitis AuralMild to moderate hearing deficit, atresia of external auditory canal OralCleft lip, cleft palate, bifid uvula, lateral palatal swellings, obligatory mouth

breathing. OtherCalcification of stylohyoid ligament, cervical spine anomalies.

Downs Syndrome (Trisomy-21) Flat face Large anterior fontanel and open sutures Small slanting eyes with epicanthal folds Mental deficiency Open mouth with prognathism Sexual underdevelopment Cardiac abnormalities Hypermobility of joints Short stature Short neck Macroglossia and protrusion of tongue Fissured or pebbly tongue High arched palate Malformed teeth exhibiting enamel hypoplasia and microdontia

Eagles Syndrome Elongation of the styloid process (Normal- 25 mm) or ossification of stylohyoid

ligament causing dysphagia Sore throat Otalgia Glossodynia Headache Vague orofacial pain or pain along the distribution of internal and external carotid

arteries


Ehlers-Danlos Syndrome

Hyperelasticity of skin Hyperextensibility of joints Fragility of skin and blood vessels leading to excessive bleeding Defective healing of skin wounds Fragile and bruised oral mucosa Hypermobility of temporomandibular joint with frequent dislocation Hypoplasia of enamel Extensive periodontal destruction Lack of normal scalloping of DEJ

Fanconis Syndrome

Congenital and sometimes familial aplastic anemia Bone abnormalities Microcephaly Hypogenitalism Olive brown pigmentation of skin

Focal Dermal Hypoplasia Syndrome (Goltz-Gorlin Syndrome)

Focal absence of dermis associated with herniation of fat into the defect Skin atrophy Streaky pigmentation and telangiectasia Multiple papillomas of skin or mucosa Anomalies of the extremities including syndactly, polydactyly and adactyly Sunken eyes with sparse eyebrows and scalp hairs Ocular anomalies like iris and choroids colobomata and strabismus Mental retardation Papillomas of the lip, buccal mucosa and gingival Teeth are defective in size, shape and structure Cleft lips/cleft palate

Gardner Syndrome

Multiple osteoma Multiple supernumerary teeth Compound odontoma Unerupted teeth Hypercementosis

Goldenhar Syndrome

Facies Marked facial asymmetry, maxillary, malar and temporal bones are reducedin size and flattened

Eyes Blepharoptosis, anophthalmia or microphthalmia, impaired vision Ear Anotia to ill defined mass of tissue, supernumerary ear tags, narrow external

auditory canals, hearing loss


CNS Skull defects, brain defects, mental retardation Lung Incomplete lobulation to hypoplasia to agenesis Kidney Absent kidney, double ureter, hydronephrosis GIT Imperforate anus Heart Transposition of great vessels, cardiomegaly, pulmonary stenosis Skeletal alterations Decreased anterior posterior and vertical dimension of face,

skull defects Oral manifestations Agenesis of mandibular ramus, agenesis of parotid gland,

cleft lip and palate, delayed tooth development, malocclusion.

Grinspan Syndrome

Lichen planus Diabetes mellitus Vascular hypertension

Hunter Syndrome (Mucopolysaccharoidosis II)

FaciesMacrocephaly Skeletal systemShort neck, broad chest, protruding abdomen, umbilical hernia,

short stature, restricted joint mobility Other findingsProgressive loss of intelligence in severe cases, increased muscle

tone, hyperactive muscle reflexes, terminal convulsions, impaired vision,progressive loss of hearing, death of patient usually in early adulthood

Oral manifestationsWidely spaced teeth, enlarged tongue, condylar deformities,cystic alterations, sleep apnea, airway obstruction.

Hurler Syndrome (Mucopolysaccharoidosis I-H)

Growth failure after infancy Marked mental retardation Craniofacial dysmorphism and physical habitus Dysostosis multiplex Corneal clouding, Excessive urinary secretion of dermatan sulfate and heparan sulfate Histochemical and biochemical evidence of intracellular lysosomal storage of

glycosaminoglycans Microcephaly, hernias and recurrent respiratory infections Oral manifestationsEnlarged and patulous lips, flattened philtrum, macroglossia,

widely spaced teeth, anterior open bite, hyperplastic alveolar ridges, short andbroad mandible, airway obstruction and sleep apnea.

Jaw Winking Syndrome

Unilateral congenital ptosis Rapid exaggerated elevation of the ptotic lid on moving the lower jaw to the

contralateral side.


Marfan Syndrome

Excessive length of tubular bone Arachnodactyly or spidery fingers Long and narrow skull and face Hyperextensibility of the joint with habitual dislocation Kyphosis or scoliosis Flat foot Bilateral ectopia lentis Myopia Aortic aneurysm and aortic regurgitation Valvular defects and cardiomegaly

Maroteaux Lamy Syndrome (Mucopolysaccharoidosis VI)

Prominent forehead Hypertelorism Depressed nasal bridge Full cheeks and lips Broad jaws Deformed chest with prominent sternum Hepatomegaly Vision and hearing defects Macroglossia Widely spaced teeth

Median Cleft Face Syndrome

Face closely resembling embryonal face Frontonasal malformation Hypertelorism Secondary telecanthus Encepha

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