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Clinical
Oral Medicine
and Pathology
Second Edition

Jean M. Bruch
Nathaniel S. Treister

123
Clinical Oral Medicine and Pathology
Jean M. Bruch • Nathaniel S. Treister

Clinical Oral Medicine

and Pathology
Jean M. Bruch Nathaniel S. Treister
Massachusetts Eye & Ear Infirmary Brigham & Women’s Hospital
Harvard Medical School Dana-Farber Cancer Institute
Boston, MA, USA Harvard School of Dental Medicine
Boston, MA, USA

ISBN 978-3-319-29765-1 ISBN 978-3-319-29767-5 (eBook)

DOI 10.1007/978-3-319-29767-5

Library of Congress Control Number: 2016938530

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
Preface to the Second Edition

What is oral medicine? Broadly speaking, it is the field of medicine that

encompasses the diagnosis and management of diseases affecting the oral
cavity. Many conditions produce oral signs and symptoms, and yet the oral
cavity is an unfamiliar zone for many clinicians. Physicians generally receive
little formal training in dental and oral medicine and tend to view the oral
cavity as a place reserved for their “dental” colleagues. Likewise, dentists are
experts in the diagnosis and management of diseases related to the teeth and
periodontium; however, the proportion of dental education dedicated to the
“non-dental” part of the oral cavity often falls short. For these reasons, it is
not at all uncommon for a patient to visit 5–10 doctors before receiving a cor-
rect diagnosis and appropriate treatment plan, often months to years follow-
ing the onset of symptoms. It was from this landscape that this book was
designed and written.
Given the wide range of clinical presentations, patients with oral com-
plaints may seek out or be referred to a variety of health-care providers,
including primary care physicians, dentists, otolaryngologists, oral surgeons,
dermatologists, neurologists, psychiatrists, and rheumatologists. Many of
these oral conditions can be recognized and managed without the need for
additional specialty referral. In this thoroughly revised and updated second
edition, we have attempted to provide a rational, concise, and yet comprehen-
sive approach to the practice of oral medicine for all clinicians who are likely
to encounter diseases of the oral cavity in their daily practice. In addition to
including a new chapter entitled “Oral Sequelae of Cancer and Cancer
Therapy,” the summary boxes throughout the book have been updated and
improved for fast and effective clinical reference. We have included specific
guidelines on diagnosis, management, and follow-up for all included oral
medicine conditions. Our intent was to create a clinically relevant and acces-
sible resource for health-care professionals, truly bridging the worlds of den-
tistry and medicine.

Jean M. Bruch
Nathaniel S. Treister

Boston, MA, USA

v
Acknowledgments

We would like to thank Eric Stoopler, Mark Lerman, Ross Kerr, Andres Pinto,
Juan Yepes, Vidya Sankar, Raj Lalla, Kevin Emerick, Francisco Marty, and
Dena Fischer for their critical and constructive comments on the text. We are
indebted to Mark Lerman, Andres Pinto, Sook-Bin Woo, Stephen Sonis, Ross
Kerr, Mark Schubert, and Scott De Rossi for their generous contributions of
clinical images. We are particularly grateful to our administrative and clinical
coworkers and professional colleagues for their continued dedication and
drive toward excellence in patient care. We extend our gratitude to our men-
tors and colleagues who have provided invaluable insight, guidance, and
inspiration and to our students, residents, and fellows for their continuous
enthusiasm for knowledge and growth. Most importantly, we cannot forget
our patients and their families, many of whom we will never forget, for put-
ting their trust in our care. And last, but not least, we extend a very warm
thanks to our loving families for their unconditional support of our profes-
sional and academic pursuits.

Jean M. Bruch
Nathaniel S. Treister

Boston, MA, USA

vii
About the Authors

Jean M. Bruch, D.M.D., M.D. Dr. Bruch earned her D.M.D. from Harvard
School of Dental Medicine in 1989 and M.D. from Harvard Medical School
in 1991. She subsequently completed surgical residency training programs in
oral and maxillofacial surgery at Massachusetts General Hospital and otolar-
yngology at Massachusetts Eye and Ear Infirmary as well as a fellowship in
laryngology. She currently practices otolaryngology at Massachusetts Eye
and Ear Infirmary with special interest in laryngology, salivary gland disor-
ders, and oral diseases. She is currently an Assistant Professor of
Otolaryngology at Harvard Medical School and spends time teaching medi-
cal students and otolaryngology residents.

Nathaniel S. Treister, D.M.D., D.M.Sc. Dr. Treister earned his D.M.D.

from the University of Pennsylvania School of Dental Medicine in 2000. He
subsequently completed his oral medicine residency and oral biology training
at Harvard School of Dental Medicine. He is board certified in oral medicine
and practices at Brigham and Women’s Hospital and Dana-Farber Cancer
Institute with special interest in oral mucosal diseases, salivary gland dis-
eases, and oral complications in cancer patients. He is the Chief of the
Division of Oral Medicine and Dentistry at Brigham and Women’s Hospital
and Dana-Farber Cancer Institute and an Associate Professor of Oral Medicine
in the Department of Oral Medicine, Infection and Immunity at Harvard
School of Dental Medicine.

ix
Contents

1 Normal Anatomy .......................................................................... 1

Introduction .................................................................................... 1
Surface Landmarks ........................................................................ 1
Oral Mucosa ................................................................................... 1
Tongue............................................................................................ 4
Floor of Mouth ............................................................................... 6
Palate .............................................................................................. 7
Dentition ........................................................................................ 7
Temporomandibular Joint .............................................................. 9
Innervation ..................................................................................... 10
Jaws and Teeth ........................................................................... 10
Tongue........................................................................................ 11
Muscles of Mastication and Facial Muscles .............................. 12
Salivary Glands .............................................................................. 12
Lymphatics ..................................................................................... 15
Sources ........................................................................................... 16
2 Variants of Normal and Common Benign Conditions .............. 17
Introduction .................................................................................... 17
Physiologic Pigmentation .............................................................. 17
Fordyce Granules ........................................................................... 19
Gingival Grafts ............................................................................... 20
Lingual Tonsil ................................................................................ 20
Fissured Tongue ............................................................................. 21
Geographic Tongue ........................................................................ 22
Median Rhomboid Glossitis .......................................................... 23
Fibroma .......................................................................................... 24
Inflammatory Papillary Hyperplasia .............................................. 25
Tori and Exostoses ......................................................................... 27
Ankyloglossia and Prominent Frenula ........................................... 29
Sources ........................................................................................... 30
3 Diagnostic Tests and Studies ....................................................... 31
Introduction .................................................................................... 31
Examination ................................................................................... 31
Culture Techniques ........................................................................ 33
Bacterial Cultures....................................................................... 33
Fungal Cultures .......................................................................... 33

xi
xii Contents

Viral Cultures ............................................................................. 33

Blood Tests ..................................................................................... 34
Radiographic Studies ..................................................................... 34
Plain Films ................................................................................. 34
Computed Tomography.............................................................. 34
Magnetic Resonance Imaging .................................................... 35
Other Imaging Studies ............................................................... 35
Cytology......................................................................................... 35
Tissue Biopsy ................................................................................. 37
Adjuvant Tests ................................................................................ 41
Sources ........................................................................................... 43
4 White Lesions ............................................................................... 45
Introduction .................................................................................... 45
Leukoedema ................................................................................... 45
Linea Alba ...................................................................................... 47
Cheek Biting .................................................................................. 48
Hairy Tongue.................................................................................. 49
Oral Hairy Leukoplakia ................................................................. 50
Nicotinic Stomatitis ....................................................................... 51
White Sponge Nevus...................................................................... 52
Chemical Burn ............................................................................... 52
Exfoliative Cheilitis ....................................................................... 53
Sources ........................................................................................... 55
5 Immune-Mediated and Allergic Conditions .............................. 57
Introduction .................................................................................... 57
Angioedema ................................................................................... 57
Orofacial Granulomatosis .............................................................. 59
Traumatic Ulcerative Granuloma ................................................... 60
Aphthous Stomatitis ....................................................................... 61
Behcet Disease ............................................................................... 64
Erythema Multiforme..................................................................... 64
Oral Lichen Planus......................................................................... 69
Mucous Membrane Pemphigoid .................................................... 73
Pemphigus Vulgaris........................................................................ 75
Other Autoimmune Vesiculobullous Diseases ............................... 76
Paraneoplastic Pemphigus ......................................................... 76
Epidermolysis Bullosa Acquisita ............................................... 76
Linear IgA Disease .................................................................... 77
Sources ........................................................................................... 77
6 Pigmented Lesions ....................................................................... 79
Introduction .................................................................................... 79
Melanotic Lesions .......................................................................... 79
Melanotic Macule ...................................................................... 79
Pigmented Nevus ....................................................................... 81
Mucosal Melanoma.................................................................... 82
Inflammatory Pigmentation ....................................................... 82
Contents xiii

Endocrine-Related Pigmentation ............................................... 83

Drug-Induced Pigmentation ....................................................... 84
Nonmelanotic Pigmentation........................................................... 86
Amalgam Tattoo ......................................................................... 86
Heavy Metals ............................................................................. 86
Hemochromatosis ...................................................................... 87
Vascular Lesions ............................................................................ 88
Varix ........................................................................................... 88
Hemangioma .............................................................................. 89
Pyogenic Granuloma.................................................................. 90
Kaposi Sarcoma ......................................................................... 91
Other .......................................................................................... 92
Sources ........................................................................................... 93
7 Oral Infections.............................................................................. 95
Introduction .................................................................................... 95
Bacterial Infections ........................................................................ 95
Odontogenic Infections .............................................................. 96
Parotitis ...................................................................................... 106
Fungal Infections ........................................................................... 108
Oral Candidiasis ......................................................................... 108
Deep Fungal Infections .............................................................. 111
Viral Infections............................................................................... 111
Herpes Simplex Virus ................................................................ 111
Varicella Zoster Virus................................................................. 114
Cytomegalovirus ........................................................................ 115
Epstein-Barr Virus...................................................................... 116
Human Papilloma Virus ............................................................. 117
Enterovirus ................................................................................. 119
Sources ........................................................................................... 120
8 Salivary Gland Disease ................................................................ 121
Introduction .................................................................................... 121
Mucus Extravasation and Retention Phenomena ........................... 121
Mucocele .................................................................................... 121
Ranula ........................................................................................ 123
Mucus Retention Cyst ................................................................ 124
Sialadenitis ..................................................................................... 125
Sialolithiasis ............................................................................... 125
Necrotizing Sialometaplasia ...................................................... 127
Sialadenosis (Sialosis) ................................................................... 128
Xerostomia ..................................................................................... 128
Sjögren Syndrome...................................................................... 129
Iatrogenic ................................................................................... 130
Neoplasia........................................................................................ 131
Benign Tumors ........................................................................... 132
Malignant Tumors ...................................................................... 132
Sources ........................................................................................... 133
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