Color Atlas of Oral and Maxillofacial Diseases E Book

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To our colleagues, many of whom have shared these cases with us.
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Contents

1 Developmental Defects of the Oral and Maxillofacial Region, 1

2 Pathology of Teeth, 41

3 Pulp and Periapical Disease, 79

4 Periodontal Pathology, 93

5 Bacterial Infections, 109

6 Fungal and Protozoal Infections, 125

7 Viral Infections, 141

8 Physical and Chemical Injuries, 169

9 Allergies and Immunologic Diseases, 205

10 Epithelial Pathology, 223

11 Salivary Gland Pathology, 273

12 Soft Tissue Tumors, 299

13 Hematologic Disorders, 349

14 Bone Pathology, 367

15 Odontogenic Cysts and Tumors, 411

16 Dermatologic Diseases, 457

17 Oral Manifestations of Systemic Disease, 505

Index, 529

v
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Preface

By its very nature, the discipline of pathology encompasses not only the microscopic
diagnosis of disease, but also the recognition and diagnosis of lesions on a clinical and
radiographic basis. As oral and maxillofacial pathologists, we naturally spend a significant
amount of our time in the laboratory examining tissue specimens for diagnosis. However,
we also have the great opportunity and privilege to see many patients in a clinical setting
for both the diagnosis and management of various oral diseases. As a matter of fact, it
is this fascination with disease on a clinical basis that first stimulated our interest to enter
the specialty of oral and maxillofacial pathology.
With this in mind, we are pleased to offer this collection of photographs and radiographic
images of oral, head, and neck diseases. These illustrations represent a compilation of
what we consider to be among the best clinical teaching material that we have accrued
over the course of our careers. The book has been designed primarily with the dental
professional in mind, but it also should be useful to other health care providers who treat
oral diseases, such as otolaryngologists and dermatologists.
In keeping with an atlas format, we have decided to include more pictures rather than
more words. The chapters are organized by broad disease categories, which match the
sequence of how we initially lecture about these topics in the classroom. A wide variety
of lesions has been included, but we have tried to emphasize more commonly occurring
and important disorders. No photomicrographs are included in this book. Although we
obviously recognize the importance of histopathology in the diagnosis of disease, we
think that the purpose of this book is better served by limiting it to clinical photographs
and radiographs.

vii
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Acknowledgments

We are deeply indebted to our friends and colleagues who have shared many of the
images included in this atlas or who have referred patients for us to examine and photograph.
We have attempted to be as thorough as possible in listing credit to these individuals in
the figure legends. However, if anyone’s name has been inadvertently omitted, please
accept our apologies.
We would like to acknowledge some of the many teachers who have mentored us
during our careers, particularly those individuals who stimulated and fostered our interest
in clinical oral pathology. This list includes Drs. George Blozis, Jerry Bouquot, George
Gallagher, Susan Müller, Charles Waldron, and Ronnie Weathers.
We also wish to thank Alexandra Mortimer, Jennifer Flynn-Briggs, Kate Mannix,
Caroline Dorey-Stein, and Taylor Ball at Elsevier for their editorial expertise and patience
as we worked on this project. Finally, our families deserve more personal thanks and
praise for their love and support during the preparation of this book.

ix
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Developmental Defects
1
of the Oral and
Maxillofacial Region

Cleft Lip and Palate, 2 Reactive Subpontine Exostosis, 18

Bifid Uvula, 2 Torus Mandibularis, 20
Double Lip, 2 Torus Palatinus, 22
Commissural Lip Pits, 4 Eagle Syndrome, 22
Paramedian Lip Pits and Van der Stafne Defect, 24
Woude Syndrome, 4 Epstein Pearls, 26
Fordyce Granules, 6 Nasopalatine Duct Cyst, 26
Leukoedema, 8 Epidermoid Cyst, 28
Ankyloglossia, 8 Pilar Cyst, 28
Lingual Thyroid, 10 Dermoid Cyst, 30
Fissured Tongue, 10 Thyroglossal Duct Cyst, 30
Hairy Tongue, 12 Branchial Cleft Cyst, 30
Varicosities, 14 Oral Lymphoepithelial Cyst, 32
Caliber-Persistent Artery, 14 Progressive Hemifacial Atrophy, 32
Coronoid Hyperplasia, 16 Hemihyperplasia, 34
Condylar Hyperplasia, 16 Segmental Odontomaxillary
Bifid Condyle, 16 Dysplasia, 36
Exostoses, 18

1
 Cleft Lip and Palate
Fig. 1.1
Cleft lip (CL) is a common congenital anomaly that is caused by defective fusion of the medial nasal and
maxillary processes during embryologic development. Approximately 80% of cases are unilateral and 20%
are bilateral. Cleft palate (CP), which results from failure of the lateral palatal shelves to fuse, often occurs
in conjunction with CL, although it also may develop as an isolated defect. CL alone and CL with CP are
etiologically related conditions that can be grouped together as CL ± CP (CL with or without CP). CP
only (CPO) represents a separate entity from CL ± CP. Orofacial clefting is seen with greater frequency
in a variety of specific genetic syndromes, although more often it occurs in a sporadic fashion due to a
combination of environmental and genetic factors. Factors known to increase the risk for clefts include
maternal smoking, alcohol consumption, and phenytoin usage.
The frequency of CL ± CP varies considerably among different racial/ethnic groups. Among whites,
the frequency is estimated at 1 per every 700 to 1000 births. The prevalence in blacks is much lower, with
a rate of 0.4 cases per 1000 births. In contrast, the rate in Asian populations is about 1.5 times that seen
in whites. The highest rate occurs in Native Americans, with a frequency of 3.6 per 1000 births. CL ± CP
is more common in males, whereas CPO is more common in females.
Orofacial clefting can result in a variety of problems related to appearance, feeding, speech, hearing,
and socialization skills. Management involves a dedicated craniofacial team, which may include specialists
in genetics, oral and maxillofacial surgery, orthodontics, otolaryngology, pediatric dentistry, pediatric
medicine, plastic surgery, prosthodontics, psychology, and speech pathology. Treatment may require multiple
surgeries, with repair of CL usually accomplished around 2 to 3 months after birth and surgical correction
of CP undertaken between 6 and 12 months of life.

Bifid Uvula (Cleft Uvula)

Fig. 1.2
During the embryologic formation of the hard and soft palate, the lateral palatal shelves normally fuse in
the midline. This fusion begins in the anterior region of the palate and progresses posteriorly to the uvula.
If the fusion is not totally completed, then a bifid uvula may occur, which represents the most minimal
manifestation of a cleft palate (CP). Sometimes a bifid uvula may be associated with a submucous palatal
cleft in which the overlying mucosa is intact but there is a defect in the formation of the musculature of
the soft palate. Submucous clefts also may be associated with a notched defect of the midline bone of the
posterior hard palate. Bifid uvula is more common than complete CP, with an estimated overall prevalence
of 1% to 2%. The frequency is much higher in Asian and Native American populations. In most instances,
bifid uvula is an incidental finding that does not cause any problems. If an associated submucous CP is
present, velopharyngeal insufficiency may be present, which can result in hypernasal speech. A bifid uvula
can be associated with certain genetic conditions, such as van der Woude syndrome and Loeys-Dietz
syndrome (hypertelorism, bifid uvula or CP, and aortic aneurysm with tortuosity).

Double Lip
Fig. 1.3
Double lip is an uncommon oral anomaly in which there is an excess fold of tissue along the mucosal
surface of the lip. It either may be congenital or develop later in life. The upper lip is affected more frequently
than the lower lip, although sometimes both lips are involved. The redundant tissue may be seen bilaterally
in a symmetric fashion, or it may appear primarily on one side. When the lips are at rest, a double lip may
not be noticeable; however, when the patient smiles, the excess tissue will become evident. Double lip
occasionally may be a component of Ascher syndrome, which is characterized by the following triad:
(1) double lip, (2) blepharochalasis (edema and sagging of the upper eyelid), and (3) nontoxic thyroid
enlargement.
No treatment may be required for mild forms of double lip. However, more severe examples can be
managed by surgical excision of the excess tissue for cosmetic purposes.

2 1 Developmental Defects of the Oral and Maxillofacial Region

■ Figure 1.1
Cleft Lip
Unilateral cleft of the left upper lip. (Courtesy Dr.
Cathy Flaitz.)

■ Figure 1.2
Bifid Uvula
A midline cleft divides the uvula into two lobes.

■ Figure 1.3
Double Lip
An extra fold of tissue hangs down from the left
upper lip.

1 Developmental Defects of the Oral and Maxillofacial Region 3

 Commissural Lip Pits
Fig. 1.4
Commissural lip pits are tiny mucosal invaginations at the corners of the mouth near the vermilion
border. Such depressions have been noted in 12% to 20% of the adult population, whereas among children
the reported prevalence is only about 0.2% to 0.7%. Although such pits often are considered to be congenital
defects, their increased frequency in adult patients suggests that they usually do not appear until later in
life. Commissural lip pits occur more often in males than in females.
Commissural lip pits are typically asymptomatic unilateral or bilateral lesions that are discovered as
incidental findings. They appear as small punctate depressions extending to a depth of 1 to 4 mm on the
lip vermilion at the commissures. Because ducts from minor salivary glands may empty into the depth of
the pit, a small amount of mucoid secretion sometimes can be expressed. Commissural lip pits have been
associated with a higher prevalence of preauricular pits, but they are not associated with orofacial clefting.
Because of their asymptomatic nature, treatment rarely is required. However, if excessive salivary secretions
occur or secondary infection develops in a deep pit, then surgical excision may be considered.

Paramedian Lip Pits and Van der Woude Syndrome

Figs. 1.5 and 1.6
Paramedian lip pits are rare congenital invaginations that are seen on the vermilion border of the lower
lip, lateral to the midline. Such lesions are usually bilateral, although in some instances a single pit may
be found more centrally positioned or lateral to the midline. Paramedian lip pits are significant because
they usually are associated with van der Woude syndrome, an autosomal dominant condition that also
includes cleft lip (CL) and/or cleft palate (CP). Van der Woude syndrome is the most common form of
syndromic orofacial clefting, occurring in 1 out of every 40,000 to 100,000 births. It is estimated that 2%
of all CL and CP cases are part of van der Woude syndrome, which is caused by mutations of the gene
that encodes interferon regulatory factor 6 (IRF6). Some people with paramedian lip pits and van der
Woude syndrome may not demonstrate clefting or they may exhibit only a submucosal CP; however, such
individuals can transmit the full syndrome to their offspring. Paramedian lip pits also can be a feature
of two other syndromes that include orofacial clefting: popliteal pterygium syndrome and Kabuki
syndrome.
Paramedian lip pits appear as blind sinuslike depressions that can extend to a depth of 1.5 cm. A humped
swelling sometimes surrounds the central pore. Salivary secretions may be expressed because of minor
salivary gland ducts that empty into the depth of the pit. If the pits are a cosmetic problem for the patient,
then surgical excision can be performed.

4 1 Developmental Defects of the Oral and Maxillofacial Region

■ Figure 1.4
Commissural Lip Pit
A punctate depression is present at the right labial
commissure.

■ Figure 1.5
Paramedian Lip Pits in Van der Woude
Syndrome
Bilateral pits are seen adjacent to the midline of the
lower lip vermilion. (Courtesy Dr. Nadarajah Vigneswaran.)

■ Figure 1.6
Cleft Palate in Van der Woude Syndrome
Same patient as depicted in Fig. 1.5 with a cleft of the
soft palate. (Courtesy Dr. Nadarajah Vigneswaran.)

1 Developmental Defects of the Oral and Maxillofacial Region 5