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Oral Pathology & Diagnosis

Identification and Management of Oral Diseases

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Course Objectives

By the end of this module, you will understand:

Classification of oral lesions
Diagnostic methodology
Reactive/inflammatory conditions
Infectious diseases
Premalignant lesions
Oral cancer
Salivary gland disorders
Bone pathologies

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Diagnostic Methodology

Clinical Evaluation

History:
- Duration
- Symptoms
- Medical history
- Risk factors
Examination:
- Location
- Size
- Color
- Texture
- Border

Oral Examination

Diagnostic Tools

Biopsy:
- Incisional
- Excisional
- Brush biopsy
Imaging:
- Periapical radiographs
- Panoramic
- CBCT
- MRI/CT
Lab tests:
- Microbiology
- Hematology
- Serology

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Reactive/Inflammatory Lesions

Traumatic Fibroma

Most common oral soft tissue lesion
Smooth, pink nodule
Cheek/lip/tongue
Treatment: Excision

Pyogenic Granuloma

Rapidly growing vascular lesion
Bleeds easily
Pregnant women (pregnancy tumor)
Treatment: Excision + remove irritant

Pyogenic Granuloma

Peripheral Giant Cell Granuloma

Bluish-purple gingival mass
May cause bone erosion
Treatment: Excision + curettage

Lichen Planus

Wickham's striae
Reticular/erosive forms
Treatment: Topical steroids
0.5-2% malignant transformation

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Infectious Diseases

Viral

Herpes Simplex:
- Primary herpetic gingivostomatitis
- Recurrent herpes labialis
- Treatment: Acyclovir/valacyclovir
HPV:
- Squamous papilloma
- Verruca vulgaris
- HPV-16/18: Oropharyngeal cancer

Oral Candidiasis

Fungal

Candidiasis:
- Pseudomembranous (thrush)
- Erythematous
- Angular cheilitis
- Treatment: Nystatin/fluconazole

Bacterial

Necrotizing ulcerative gingivitis
Actinomycosis (sulfur granules)
Syphilis (chancre, mucous patch)

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Premalignant Lesions

Leukoplakia

White plaque (cannot be scraped off)
3-5% malignant transformation
Risk factors: Tobacco, alcohol
Treatment: Excision + follow-up

Erythroplakia

Red velvety patch
90% show dysplasia/carcinoma
Most dangerous oral premalignancy
Treatment: Immediate biopsy

Oral Submucous Fibrosis

Burning sensation
Blanched mucosa
Trismus
7-13% malignant transformation
Associated with areca nut

Management Principles

Complete excision when possible
3-6 month follow-up
Eliminate risk factors
Chemoprevention (retinoids)

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Oral Squamous Cell Carcinoma

Clinical Features

Non-healing ulcer (>2 weeks)
Indurated borders
Erythroleukoplakia
Fixation to underlying tissues
Paresthesia (late sign)

Risk Factors

Tobacco (6x risk)
Alcohol (synergistic)
HPV-16 (oropharyngeal)
Betel quid
Chronic irritation

Common Sites

Ventral tongue
Floor of mouth
Soft palate
Retromolar trigone

Staging (TNM)

T: Tumor size (1-4)
N: Node involvement
M: Metastasis
5-year survival: 40-60%

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Salivary Gland Disorders

Non-Neoplastic

Mucocele:
- Lower lip
- Bluish translucent
- Treatment: Excision
Ranula:
- Floor of mouth
- Plunging variant
Sjögren's Syndrome:
- Autoimmune
- Xerostomia + keratoconjunctivitis
- Increased lymphoma risk

Pleomorphic Adenoma

Neoplastic

Pleomorphic adenoma:
- Most common benign tumor
- Parotid gland
- Mixed histology
Mucoepidermoid carcinoma:
- Most common malignant
- Low vs high grade
Adenoid cystic carcinoma:
- Perineural invasion
- Late metastases

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Bone Pathologies

Cysts

Periapical cyst:
- Non-vital tooth
- Treatment: RCT or extraction
Dentigerous cyst:
- Around crown of unerupted tooth
- Associated with impacted 3rd molars
Odontogenic keratocyst:
- High recurrence rate
- Part of Gorlin-Goltz syndrome

Fibro-osseous Lesions

Fibrous dysplasia:
- Ground-glass appearance
- Monostotic vs polyostotic
Paget's disease:
- Cotton-wool appearance
- Increased alkaline phosphatase

Other Conditions

Osteonecrosis (bisphosphonates)
Central giant cell granuloma
Cherubism (familial)

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Vesiculobullous Diseases

Pemphigus Vulgaris

Intraepithelial blistering
Nikolsky's sign positive
Oral lesions precede skin
Treatment: Systemic steroids

Mucous Membrane Pemphigoid

Subepithelial blistering
Scarring possible
Desquamative gingivitis
Treatment: Topical/systemic steroids

Erythema Multiforme

Target lesions
HSV trigger
Blood crusted lips
Treatment: Supportive + antivirals

Diagnostic Tests

Direct immunofluorescence
Indirect immunofluorescence
Histopathology

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White Lesions

Benign

Linea alba:
- Buccal mucosa along occlusion line
- No treatment needed
Leukoedema:
- Gray-white diffuse opacity
- Disappears on stretching
Frictional keratosis:
- From chronic irritation
- Resolves after irritant removal

Hairy Leukoplakia

Pathological

Hairy leukoplakia:
- EBV infection
- Lateral tongue
- HIV marker
Lichen planus:
- Wickham's striae
- Reticular pattern
Squamous cell carcinoma:
- Non-homogeneous leukoplakia
- High risk features

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Red-Blue Lesions

Vascular

Hemangioma:
- Congenital vascular malformation
- Blanches on pressure
Varicosities:
- Sublingual veins
- Age-related
- No treatment needed

Inflammatory

Erythematous candidiasis:
- Denture stomatitis
- Antibiotic-associated

Neoplastic

Kaposi's sarcoma:
- HHV-8 associated
- Purplish nodules
- AIDS-defining lesion

Systemic

Petechiae/purpura:
- Thrombocytopenia
- Coagulopathies

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Pigmented Lesions

Exogenous

Amalgam tattoo:
- Most common pigmentation
- Radiopaque particles
- No treatment needed
Smoker's melanosis:
- Anterior gingiva
- Reversible after quitting

Endogenous

Melanotic macule:
- Lower lip/gingiva
- Uniform pigmentation

Neoplastic

Melanoma:
- Most lethal oral cancer
- Palate/maxillary gingiva
- ABCDE criteria

Systemic

Addison's disease:
- Diffuse pigmentation
- ACTH stimulation
Peutz-Jeghers:
- Perioral freckling
- Intestinal polyps

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Oral Manifestations of Systemic Disease

Hematologic

Anemia:
- Pallor
- Angular cheilitis
- Atrophic glossitis
Leukemia:
- Gingival hyperplasia
- Petechiae
- Spontaneous bleeding

Endocrine

Diabetes:
- Periodontitis
- Candidiasis
- Xerostomia

Crohn's Oral Manifestation

Gastrointestinal

Crohn's disease:
- Cobblestone mucosa
- Linear ulcers
GERD:
- Dental erosion
- Burning sensation

Immunodeficiency

HIV:
- Hairy leukoplakia
- Kaposi's sarcoma
- Necrotizing periodontitis

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Oral Pathology Icon

Key Takeaways

Thorough history and exam are essential
Biopsy persistent lesions (>2 weeks)
Recognize high-risk features of malignancy
Understand oral-systemic disease connections
Reactive lesions often resolve with irritant removal
Early cancer detection improves prognosis
Multidisciplinary approach often needed

Questions and Discussion

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