The ADA Practical Guide to Soft Tissue Oral Disease E-Book

Michael A. Kahn

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: ADA Practical Guide
• Sprache: Englisch

Seitenzahl: 320

Veröffentlichungsjahr: 2018

Beschreibung

The ADA Practical Guide to Soft Tissue Oral Disease, Second Edition is a fully updated new edition of this popular guide to oral and maxillofacial diseases likely to be encountered in general or specialist dental practices. * Easy-to-use, updated resource with brief synopses for everyday clinical reference * Includes self-testing clinicopathologic exercises to help readers further their skills and gain confidence in their knowledge * Focuses on decision making, from communicating diagnoses to developing and discussing treatment plans * Presents clinically oriented information on the most important aspects of common oral and maxillofacial diseases * Features detailed color illustrations, treatment algorithms, differential diagnosis, and case examples with discussion

Leseprobe

Table of Contents

Cover

Title Page

Preface to the Second Edition

Preface to the First Edition

Acknowledgments

Section I: Detection and Documentation

1 The Extraoral and Intraoral Soft Tissue Head and Neck Screening Examination

Physical Examination

Adjunctive Diagnostic Examination Methods and Devices

Conclusion

Cited References

Recommended Reading

Self‐Assessment Multiple‐Choice Questions and Answers/Explanations

2 Soft Tissue Head and Neck Pathology Description and Documentation

Anatomical Site of Lesions

Morphology of Lesions

Color of Lesions

Size of Lesions

Consistency of Lesions

Methodology for Documenting an Extraoral or Intraoral Soft Tissue Lesion

Cited Reference

Self‐Assessment Multiple‐Choice Questions and Answers/Explanations

Section II: Diagnosis and Management

3 Common Oral Soft Tissue Lesions

White Lesions

Red‐and‐White Lesions

Red Lesions

Blue and/or Purple Lesions

Brown, Gray, and/or Black Lesions

Yellow Lesions

Acute Ulcerations (Erosions) and Vesicles

Chronic Ulcers (Erosions) and Vesicles

Lumps and Bumps

Cited References

Recommended Reading

Self‐Assessment Multiple‐Choice Questions and Answers/Explanations

4 Differential Diagnosis of Common Oral Soft Tissue Lesions

Diagnostic Tips and Pitfalls

Recommended Reading

Self‐Assessment Multiple‐Choice Questions and Answers/Explanations

5 Guidelines for Observation and/or Referral of Patients’ Lesions

Nonbiopsied Lesion with Low Index of Suspicion

Biopsied Lesion Monitoring

Continued Monitoring of Biopsied Leukoplakias and Erythroplakias

Possible Future Adjuncts for Monitoring of Biopsied Leukoplakias and Erythroplakias

Cited References

Recommended Reading

Self‐Assessment Multiple‐Choice Questions and Answers/Explanations

6 The Art and Science of Biopsy and Cytology

Oral Mucosal Cytology Indications and Contraindications

Cytology Technique Tips and Pitfalls

Biopsy Indication and Contraindications

Scalpel Biopsy Dos and Don’ts

Punch Biopsy Dos and Don’ts

Recommended Reading

Self‐Assessment Multiple‐Choice Questions and Answers/Explanations

Section III: Clinicopathologic Exercises

7 Sample Patient Histories and Discussion

White Lesions

Red, Red‐and‐White, and Purpuric Lesions

Acute Oral Ulcerations

Chronic Vesiculoerosive and Ulcerative Lesions

Papillary Lesions

Pigmented Lesions

Soft Tissue Masses

Answers to Case Study Questions

Appendix A: Glossary of Descriptive Terminology

Recommended Reading

Appendix B: Formulary of Over‐the‐Counter and Prescription Medications Based on Disease Classification

Disclaimer

Antimicrobials

Antihistamine and Palliative Coating Agents

Topical Anesthetics and Chemical Cauterizers

Antifungals

Immunosuppressives: Steroids and Alternatives, Occlusive Dressings

Antivirals

Miscellaneous Over‐the‐Counter

Antianxiety

Antixerostomics

Prescription Writing Requirements and Safe Writing Practices

Cited Reference

Recommended Reading

Answers to End‐of‐Chapter Questions

Index

End User License Agreement

List of Illustrations

Chapter 01

Figure 1.1 Cervical lymph node levels.

Figure 1.2 (a) Oral cavity proper, frontal view. (b) Major components forming the boundaries of the oral cavity proper, sagittal view. The oral cavity (unshaded area) is divided from the oropharynx (shaded area) anteriorly/posteriorly at the posterior extent of the anterior two‐thirds of the tongue; the superior/inferior extent of the oral cavity is the hard palate and floor of the mouth; the superior/inferior extent of the oropharynx is the nasopharynx and hypopharynx.

Figure 1.3 Oropharynx. (a) Frontal view and (b) sagittal view.

Figure 1.4 A brush biopsy (cytology) kit as supplied by OralCDx (Oral Scan Laboratories, Suffern, NY).

Figure 1.5 A close‐up view of the OralCDx proprietary brush biopsy nylon cellular collection device.

Figure 1.6 A close‐up view of the Rovers cellular collection device (Rovers Medical Devices, the Netherlands).

Figure 1.7 A liquid cytology kit composed of an alcohol‐based fixative transport medium and gynecological‐type nylon cellular collection device.

Figure 1.8 Microlux DL (AdDent, Inc., Danbury, CT) oral mucosa reflectance adjunctive light‐emitting diagnostic device.

Figure 1.9 ViziLite Plus (Zila Pharmaceuticals, Division of Tolmar Corporation, Phoenix, AZ) oral mucosa reflectance adjunctive light‐emitting diagnostic device with second‐step marker system of trademarked toluidine blue.

Figure 1.10 Narrowband emission autofluorescence VELscope Vx (L.E.D. Dental, Inc., White Rock, British Columbia, Canada).

Figure 1.11 Narrowband emission (autofluorescence and vascular evaluation) and white‐light emission Identafi (StarDental, DentalEZ Group, Inc., Malvern, PA).

Figure 1.12 Narrowband emission DentLight DOE autofluorescence oral exam system (DentLight, Inc., Richardson, TX).

Chapter 02

Figure 2.1 Oral mucosa soft tissue morphologies. (a) Vesicle, an elevated blisterform lesion equal to or less than 0.5 cm in diameter. (b) Bulla, an elevated blisterform lesion greater than 0.5 cm in diameter. (c) Pustule, an elevated blisterform lesion exclusively containing a purulent exudate. (d) Papule, an elevated nonblisterform lesion equal to or less than 0.5 cm in diameter. (e) Nodule, an elevated nonblisterform lesion greater than 0.5 cm but equal to or less than 2.0 cm in diameter. (f) Tumor, an elevated nonblisterform lesion greater than 2.0 cm in diameter. (g) Plaque, a very slightly raised lesion usually greater than 0.5 cm in diameter with a broad, flat top. (h) Ulcer, a depressed lesion with loss in continuity of the surface epidermis or epithelium and extending beyond the basal cell layer into the connective tissue. (i) Macule/patch, a flat lesion of the epidermis or epithelium with an abnormal color.

Chapter 03

Figure 3.1 Common white coating of the dorsal tongue.

Figure 3.2 Acute pseudomembranous candidiasis of the buccal mucosa with a portion removed, revealing a red underlying base.

Figure 3.3 Chronic hyperplastic candidiasis with nonwipeable white surface.

Figure 3.4 (a) Mild case of chronic cheek nibbling (i.e. morsicatio buccarum) above and below the occlusal plane. (b and c) Extensive chronic cheek nibbling with numerous white wipeable tissue tags and nonwipeable white base.

Figure 3.5 (a) Thermal burn of the lateral anterior hard palate secondary to hot food. (b) Thermal burn of the lateral posterior hard palate.

Figure 3.6 (a) Chemical burn (i.e. aspirin burn) secondary to direct application of analgesic to the oral mucosa due to odontogenic pain. (b) Extensive chemical burn (i.e. aspirin burn) secondary to direct application of analgesic to the oral mucosa due to pericoronitis.

Figure 3.7 Linea alba due to mild frictional keratosis of the buccal mucosa’s occlusal plane.

Figure 3.8 (a–c) Leukoedema (spongiosis) of the buccal mucosa.

Figure 3.9 Snuff dipper’s keratotic leukoplakia of the posterior buccal mucosa at the site where the smokeless tobacco product is held.

Figure 3.10 (a) Sun‐damaged lower lip vermilion with actinic cheilitis. (b) Actinic cheilitis of the lower lip vermilion. (c) Actinic cheilitis of the lower lip vermilion exhibiting mottled colors and indistinct border with the skin. (d) Actinic keratosis with epithelial dysplasia and early invasive squamous cell carcinoma.

Figure 3.11 Classic reticular oral lichen planus of the anterior and posterior buccal mucosa.

Figure 3.12 Hyperplastic (leukoplakic) lichen planus of the dorsal tongue.

Figure 3.13 Benign alveolar ridge keratosis, which microscopically will demonstrate hyperkeratosis without dysplasia.

Figure 3.14 (a) Geographic tongue (also called benign migratory glossitis or erythema migrans) with flat red areas encircled by raised white rim. (b) Geographic tongue with red flat areas but lacking classic white raised border.

Figure 3.15 Chronic multifocal type of candidiasis.

Figure 3.16 (a) Bilateral and symmetrical distribution of erosive lichen planus of the facial attached gingiva. (b) Focal lesions of erosive lichen planus of the left maxillary facial attached and marginal gingiva.

Figure 3.17 Bilateral nicotine stomatitis of the hard palate.

Figure 3.18 Extensive erythroplakia of the soft palate.

Figure 3.19 Lichenoid contact allergic reaction (i.e. stomatitis venenata) of the posterior buccal mucosa secondary to cinnamon aldehyde flavoring agent.

Figure 3.20 (a) Chronic atrophic candidiasis of the maxilla beneath an acrylic removable denture. (b) Chronic atrophic candidiasis of the hard palate beneath a removable partial denture.

Figure 3.21 (a) Median rhomboid glossitis (chronic erythematous candidiasis), flat and raised, at the midline junction of the anterior two‐thirds and posterior one‐third of the dorsal tongue. (b) Median rhomboid glossitis (chronic erythematous candidiasis) of the posterior dorsal tongue.

Figure 3.22 Angular cheilitis (perleche) of the left commissure due to chronic erythematous candidiasis.

Figure 3.23 (a) Flat, irregular discontinuous areas of geographic tongue. (b) Flat red areas of geographic tongue in a child. (c) Ectopic geographic tongue (erythema migrans) of the middle lower labial mucosa.

Figure 3.24 (a) Erythroplakia (also called speckled leukoplakia) with microscopic carcinoma in situ in a patient immunosuppressed following a bone marrow transplant. (b) Erythroplakia of the middle one‐third lateral border of the tongue. (c) Erythroplakia of the left tonsillar fossa area. (d) Subtle erythroplakia at the mucogingival junction of the left maxillary central incisor area.

Figure 3.25 Unilateral hemangioma of a patient with Sturge–Weber syndrome.

Figure 3.26 Multiple pinpoint petechiae of the lower lip vermilion and labial mucosa.

Figure 3.27 Purpura of the lower lip secondary to trauma.

Figure 3.28 Petechiae and ecchymosis at the junction of the soft and hard palate.

Figure 3.29 Elevated hematoma (bulla) of the right anterior lateral tongue.

Figure 3.30 Telangiectasias of the lips in a patient diagnosed with hereditary hemorrhagic telangiectasia.

Figure 3.31 Plasma cell gingivitis of the entire maxillary and mandibular facial attached gingiva and alveolar mucosa.

Figure 3.32 An allergic reaction of the dorsal tongue secondary to a systemic medication regimen (i.e. stomatitis medicamentosa).

Figure 3.33 A solitary varix of the left lower vermilion border.

Figure 3.34 Sublingual varices seen in an elderly patient.

Figure 3.35 An amalgam tattoo of the facial attached gingiva in the area of the maxillary left central and lateral incisors.

Figure 3.36 (a) A large mucocele of the left lower labial mucosa. (b) A superficial mucocele of the hard palate. (c) A mucocele of the left lower lip with the extravasated mucin farther from the surface.

Figure 3.37 An eruption cyst (eruption hematoma) overlying and prior to the eruption of the left maxillary permanent central incisor.

Figure 3.38 A hemangioma of the anterior dorsum of the tongue.

Figure 3.39 A large multifocal Kaposi’s sarcoma of the mandibular gingiva.

Figure 3.40 An adenoid cystic carcinoma of the left posterior hard palate.

Figure 3.41 A gingival cyst of the adult on the right anterior maxillary gingiva.

Figure 3.42 A large blue nevus of the hard palate.

Figure 3.43 A malignant melanoma of the hard palate.

Figure 3.44 A melanocytic nevus of the hard palate.

Figure 3.45 A large malignant melanoma of the anterior maxillary gingiva.

Figure 3.46 Bilateral and symmetrical distribution of racial pigmentation of the attached gingiva.

Figure 3.47 Black hairy tongue of the dorsal surface.

Figure 3.48 (a) A melanotic macule (focal melanosis) of the maxillary anterior attached gingiva. (b) A labial melanotic macule of the right lower lip.

Figure 3.49 Palatal pigmentation secondary to chronic myeloid leukemia treated by protein kinase inhibitor systemic imatinib.

Figure 3.50 Smoker’s melanosis of the anterior facial mandibular gingiva.

Figure 3.51 Fordyce granules of the buccal mucosa.

Figure 3.52 (a) A yellow parulis (gum boil) associated with the fistula of a nonvital tooth. (b) A red‐yellow parulis (gum boil) due to lessened neutrophilic component following tooth extraction.

Figure 3.53 Accessory lymphoid hyperplasia aggregates of the oropharynx.

Figure 3.54 Accessory lymphoid hyperplasia aggregates of the posterior lateral tongue (i.e. lingual tonsil).

Figure 3.55 Oral lymphoepithelial cyst of the soft palate.

Figure 3.56 Lipoma of the right lower labial mucosa.

Figure 3.57 (a) A slow‐to‐heal traumatic ulcerative granuloma with stromal eosinophilia of the lateral tongue. (b) A nonspecific traumatic ulceration of the lateral tongue.

Figure 3.58 (a) A minor aphthous ulcer of the lower labial mucosa (movable mucosa site). (b) A major aphthous ulcer of the soft palate (deeper and larger than the minor type). (c) Herpetiform aphthous ulcers of the tongue.

Figure 3.59 (a) A patient with symptomatic primary herpetic gingivostomatitis. (b) A patient with primary herpetic gingivostomatitis demonstrating vesicles and shallow ulcerations on both movable and nonmovable mucosa.

Figure 3.60 (a) Recurrent herpes simplex infection of the hard palate. (b) Recurrent herpes labialis of the lower vermilion border. (c) Recurrent herpes labialis of the upper vermilion border demonstrating intact and ruptured vesicles.

Figure 3.61 Necrotizing ulcerative gingivitis with punched‐out, necrotic interdental papillae.

Figure 3.62 (a) An ulcerative allergic reaction of the buccal mucosa. (b) A vesiculoulcerative allergic reaction of the lower lip. (c) A cluster of dorsal tongue ulcerations due to an allergic reaction (stomatitis medicamentosa). (d) A facial rash secondary to a latex allergy from a clinician’s glove.

Figure 3.63 (a) An erythema multiforme patient with ulcers, hemorrhage, and crusts of the upper and lower lips. (b) Same patient as (a), with intraoral vesicles, erosions, and ulcerations. (c) Intraoral ulcerative lesions of erythema multiforme.

Figure 3.64 Herpangina vesicles and ulcers confined to the oropharynx (i.e. soft palate, base of tongue, posterior pharyngeal wall).

Figure 3.65 (a) Gingival vesicular‐ulcerative enanthem prodrome of varicella (chicken pox). (b) Palatal vesicular prodrome of varicella (chicken pox). (c) Extensive vesicular‐ulcerative prodromal outbreak of varicella (chicken pox).

Figure 3.66 (a) Unilateral distribution on the hard palate of oral herpes zoster (shingles). (b) Unilateral distribution of cutaneous facial herpes zoster (shingles).

Figure 3.67 (a) Dusky red swelling of early onset of necrotizing sialometaplasia. (b) Rapidly appearing bilateral deep ulcerations of necrotizing sialometaplasia. (c) Bilateral necrotizing sialometaplasia ulcerations.

Figure 3.68 Extensive erosive lichen planus of the posterior maxillary gingiva.

Figure 3.69 (a) Squamous cell carcinoma of the lateroventral tongue. (b) Leukoplakia of the right lateral tongue that upon biopsy was determined to have epithelial dysplasia and invasive squamous cell carcinoma. (c) Verrucous carcinoma of the right anterior buccal mucosa.

Figure 3.70 (a) Gingival vesicles, erosions, and ulcerations of oral mucous membrane pemphigoid. (b) Ocular involvement of mucous membrane pemphigoid resulting in scarring with symblepharon formation.

Figure 3.71 (a) Gingival erosions and ulcerations of pemphigus vulgaris. (b) Gingival and lingual involvement of pemphigus vulgaris. (c) Same patient as (b) with lower labial mucosal involvement also. (d) Extensive oral involvement of pemphigus vulgaris.

Figure 3.72 Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) of the tongue.

Figure 3.73 Self‐inflicted (factitial) ulcer of the left anterior maxillary vestibule.

Figure 3.74 Traumatic bite of the lower lip resulting in a mucocele (mucous extravasation phenomenon).

Figure 3.75 (a) Traumatic (irritation) fibroma of the buccal mucosa secondary to accidental biting. (b) Traumatic fibroma of the tip of the tongue secondary to biting. (c) Traumatic fibroma slightly inferior to the right occlusal plane of the buccal mucosa.

Figure 3.76 (a) Large, firm swelling of mucoepidermoid carcinoma of the buccal mucosa. (b) Large, unilateral, firm, and slightly tender posterior swelling of the hard palate near the junction with the soft palate diagnosed as adenoid cystic carcinoma. (c) Firm, mobile submucosal swelling of the upper lip’s midline diagnosed as monomorphic adenoma (canalicular adenoma).

Figure 3.77 (a) Focal swelling of the right anterior floor of the mouth adjacent to the midline with salivary stone and acute sialadenitis. (b) Patient reported a sense of floor‐of‐mouth fullness prior to eating; biopsy yielded Wharton’s duct sialolith. (c) Sialolith of Stensen’s duct near the buccal mucosal orifice.

Figure 3.78 Nonvital right mandibular canine with associated parulis (gum boil).

Figure 3.79 Ill‐fitting complete maxillary removable denture with epulis fissuratum of the vestibule.

Figure 3.80 Semifirm and hemorrhagic pyogenic granuloma of the left anterior maxillary gingiva.

Figure 3.81 Large peripheral ossifying fibroma of the anterior mandibular gingiva.

Figure 3.82 Peripheral giant cell granuloma of the left facial mandibular alveolar mucosa and vestibule.

Figure 3.83 Non‐Hodgkin’s lymphoma of the hard palate.

Figure 3.84 Reactive lymphoid aggregate (hyperplasia) of the right ventral tongue.

Figure 3.85 (a) Generalized hereditary gingival fibromatosis partially obscuring the clinical crowns. (b) Generalized gingival hyperplasia induced by patient’s use of the anticonvulsant phenytoin.

Figure 3.86 (a) Peritonsillar swelling that when biopsied proved to be a benign nerve sheath tumor, schwannoma (neurilemoma). (b) Schwannoma of the upper lip.

Figure 3.87 Large hematoma of the ear’s pinna.

Figure 3.88 Squamous papilloma of the lateroventral tongue.

Figure 3.89 Inflammatory papillary hyperplasia of the hard palate associated with a removable full denture’s base.

Chapter 04

Figure 4.1 Acute ulcerations, erosions, and vesicles (bullae). ANUG, acute necrotizing ulcerative gingivitis; TUGSE, traumatic ulcerative granuloma with stromal eosinophilia.

Figure 4.2 Chronic ulcers. TUGSE, traumatic ulcerative granuloma with stromal eosinophilia.

Figure 4.3 Lumps, bumps, and swellings. RLH, reactive lymphoid hyperplasia; h/s, hard and soft.

Figure 4.4 White lesions.

Figure 4.5 Red lesions.

Figure 4.6 Red‐and‐white lesions.

Figure 4.7 Yellow lesions.

Figure 4.8 Blue and/or purple lesions.

Figure 4.9 Brown, gray, and black lesions.

Chapter 05

Figure 5.1 A commercially available laboratory‐based kit that is stated to assist the clinician in epithelial dysplasia risk stratification. Image courtesy of John Davis, Proteocyte Diagnostics, Inc.

Chapter 06

Figure 6.1 A typical available liquid cytology kit composed of instructions, requisition form, prepaid overnight mailer and shipping container, alcohol‐based transport/fixative media container, and sterile nylon or plastic bristle collection device.

Figure 6.2 A typical available biopsy kit composed of instructions, requisition form, prepaid overnight mailer and shipping container, and 10% neutral buffered formalin container.

Guide

Cover

Table of Contents

Begin Reading

Pages

iii

iv

ix

ix

xi

1

3

4

5

6

7

8

9

10

11

12

13

14

16

17

15

18

19

20

21

23

24

25

26

27

28

29

30

31

32

33

34

35

37

38

39

41

42

43

45

47

48

49

50

51

52

53

54

55

56

59

60

61

62

63

64

65

68

69

70

71

72

73

74

75

40

77

78

87

79

44

80

81

82

46

83

84

85

86

88

89

90

91

92

57

93

94

58

95

67

96

97

99

100

101

66

102

103

104

105

106

107

108

109

110

111

112

76

113

98

115

116

118

119

120

121

122

123

124

125

126

127

128

129

130

131

132

133

134

135

137

138

139

140

141

142

143

144

145

146

147

149

150

151

152

153

154

155

156

157

158

159

160

161

162

163

164

165

166

167

168

169

170

171

172

173

174

175

176

177

178

179

180

181

182

183

184

185

186

187

188

189

190

191

192

193

194

195

196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

219

221

222

223

225

226

227

228

229

230

231

232

233

234

235

236

237

238

239

240

241

242

243

244

245

246

247

248

249

250

251

252

253

254

255

256

257

259

260

261

262

263

264

The ADA Practical Guide to Soft Tissue Oral Disease

Second Edition

Michael A. Kahn, DDS

Diplomate and Director, American Board of Oral and Maxillofacial PathologyProfessor Emeritus and Chair (ret.), Department of Oral and MaxillofacialPathology, Oral Medicine, and Craniofacial PainTufts University School of Dental MedicineBoston, MA

J. Michael Hall, DDS, MABMH

Diplomate, American Board of Oral and Maxillofacial PathologyAssociate Professor (ret.), Department of Oral and MaxillofacialPathology, Oral Medicine, and Craniofacial PainTufts University School of Dental MedicineBoston, MA

1st Edition © 2014 by John Wiley & Sons, Inc.2nd Edition © 2018 by the American Dental Association

Edition HistoryJohn Wiley & Sons, Inc. and the ADA (1e, 2014)

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Michael A. Kahn and J. Michael Hall to be identified as the author(s) of this work has been asserted in accordance with law.

Registered Office(s)John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA

Editorial Office111 River Street, Hoboken, NJ 07030, USA

For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.

Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.

Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging‐in‐Publication Data

Names: Kahn, Michael A., author. | Hall, J. Michael, author. | American Dental Association, issuing body.Title: The ADA practical guide to soft tissue oral disease / Michael A. Kahn, J. Michael Hall.Other titles: American Dental Association practical guide to soft tissue oral disease | Practical guide to soft tissue oral diseaseDescription: Second edition. | Hoboken, NJ : Wiley, 2018. | Includes bibliographical references and index. |Identifiers: LCCN 2017057994 (print) | LCCN 2017060299 (ebook) | ISBN 9781119437598 (pdf) | ISBN 9781119437307 (epub) | ISBN 9781119437338 (pbk.)Subjects: | MESH: Mouth Diseases | Soft Tissue Neoplasms | Diagnosis, OralClassification: LCC RK529 (ebook) | LCC RK529 (print) | NLM WU 140 | DDC 617.5/22–dc23LC record available at https://lccn.loc.gov/2017057994

Cover Design: WileyCover Images: ©Michael A. Kahn

Preface to the Second Edition

We are grateful for the positive reception within the dental and medical communities of this textbook’s first edition. In this second edition its intention remains the same – to be a practical guide and reference source for the basic clinical aspects of soft tissue oral and maxillofacial disease. We also appreciate the constructive feedback received by colleagues that aided in this edition’s revisions.

The names and organization of the book’s chapters remain the same. Within each chapter the cited references and/or recommended readings have been updated; however, in addition, the end of each chapter now contains self‐assessment multiple‐choice questions with feedback comments on the correct answer and distractors. The revisions of Chapter 1 notably include a number of newly marketed diagnostic adjunctive devices and methods. Chapter 3 provides updated information on some of its pathologic conditions, particularly the nature of hemangiomas versus vascular malformations and the increasing clinical impact the human papillomavirus type 16 has on malignant transformation (i.e. squamous cell carcinoma) of specialized oropharyngeal epithelium as opposed to the oral cavity proper. Chapter 5 introduces the term “oral potentially malignant disorders” and initial commercial products designed to add additional information to their predicted clinical behavior and management. Appendix B has been extensively updated to reflect the ever‐changing drug formulary available to the clinician to treat oral soft tissue diseases. Lastly, some of the photographic images have been added or updated to enhance a lesion’s features.

We hope our efforts have enhanced the utility of this textbook for your chairside evaluation, differential diagnosis formulation, establishment of provisional and final diagnosis, and management of your patient’s diagnosed oral mucosal diseases.

Michael A. KahnJ. Michael Hall

Preface to the First Edition

This textbook is intended to be a practical guide and reference source for the basic clinical aspects of soft tissue oral and maxillofacial disease. It is not intended to be an all‐encompassing tome of oral pathology but rather to include those aspects of this dental specialty that are its most important foundational information and the most frequently encountered orofacial soft tissue diseases. The book is intended for health‐care practitioners whose occupation involves encountering a variety of conditions and diseases of the oral cavity and its contiguous anatomic structures; it is not intended to be a reference source for oral medicine (i.e. details of the medical aspects of a particular disease within the oral cavity).

We envision this book not as one to reside on a clinician’s library shelf gathering dust and rarely referred to, but rather one used regularly within the dental operatory to help the clinician’s decision making: that is, deciding what is the best thing to do for the patient when a pathologic condition is initially discovered, how to determine its most likely provisional diagnosis or differential diagnosis, whether to biopsy or refer for consultation by a dental or medical specialist, and how to most accurately and effectively communicate that information to the patient so the patient can give informed consent about his or her treatment course and management.

Since 1984, when we began our residency training in oral pathology at Emory University’s School of Dentistry (Atlanta, GA), we have increasingly recognized specific essentials of oral pathology that need to be learned, understood, and used by all dentists; furthermore, we have witnessed common diagnostic pitfalls and management mistakes. This book is the culmination of our cumulative and collective experiential wisdom gained during our training as well as our subsequent years of being in teaching institutions. By interacting with dentists, with dental and dental hygiene students, and with physicians and patients in clinical and educational settings as well as by participation in active oral pathology biopsy services and clinical consultation clinics, we have become aware of the lesions commonly encountered but misunderstood by them or unknown to them.

Michael A. KahnJ. Michael Hall

Acknowledgments

We are deeply indebted to the team at Wiley Blackwell who initiated contact with us to consider this endeavor: to Ms. Shelby Allen and Rick Blanchette, whose vision and interest in our continuing education materials sparked an interest to share its content with a wider audience of dental practitioners and whose shepherding of the first edition resulted in its enthusiastic use and opportunity to create a second edition. For this second edition we give thanks to the guidance of Ms. Erica Judisch (Executive Editor, Veterinary Medicine and Dentistry), Ms. Anupama Sreekanth (Project Editor), Ms. Susan Engelken for cover design, and Ms. Natasha Wu (Assistant Production Editor).

At the American Dental Association (ADA), we thank Dr. Pamela Porembski (DDS, Senior Manager, Council on Dental Practice), Carolyn Tatar (Senior Manager, Product Development), and Dr. Kathleen O’Laughlin (DMD, Executive Director) for their belief in this initial endeavor, supplying support and assistance and working with many other members of the ADA to gain the project’s acceptance and affiliation.

We also thank our colleagues at the various institutions we have worked at, as they have shared their knowledge and teaching materials with us. In particular, Drs. Robert Goode, Lynn Solomon, and Eleni Gagari were involved in many of the materials used in constructing the content of Chapter 7. In addition, we are very grateful to our colleagues throughout the world who have shared their unrestricted‐use clinical images with us at regional and national oral pathology meetings. We thank Ms. Heidi Price for creating the original line drawings of Chapters 1 and 2.

Last, we thank our many patients and their clinicians who shared their patients and/or their biopsied tissue with us and our students, whose pathology questions spurred us to either respond from memory or seek additional references in order to answer.

M.A.K.J.M.H.

Section IDetection and Documentation

1The Extraoral and Intraoral Soft Tissue Head and Neck Screening Examination

It is paramount that the dental clinician establishes a repeatable, logical, sequentially organized, and systematic approach to screening the soft tissues of the head and neck region. It should be understood that this is not an “oral cancer screening,” since all abnormal conditions should be detected. Performing an oral cancer screening means looking for a single condition, cancer, at a single point in time; the dental clinician performs a complete exam, looking for all soft tissue abnormalities at a single point in time. There is no universally acknowledged step‐by‐step approach; therefore, the following is the one we adhere to and it can be modified as desired. The important point is that, whatever sequence is established, it should be strictly adhered to each time to ensure that no step is omitted. A suggested ideal sequence of steps for a complete oral mucosal screening procedure of a new patient includes the following:

Introduction to the patient

Patient’s chief complaint

History of the present illness

Medical (including social) and dental histories

Physical examination (to detect the site, morphology, and color of abnormalities)

Review of data and formulation of a clinical differential diagnosis

Additional clinical and laboratory tests ordered, as indicated

Final definitive diagnosis with a treatment/management plan formulated

Certainly, the clinician should establish a pleasant rapport with the patient so that excellent communication and trust are established. Often, the most critical or important piece of information a patient possesses does not get transmitted to the many forms filled out at the initial dental appointment. Once the patient’s trust, confidence, and respect have been secured, the patient’s chief complaint must be established. This can be a specific dental problem or a more generic goal such as “I need a checkup exam.”

If the patient voices a specific reason for the dental appointment, it is very important to gather as much subjective information from him or her as possible. The collective sets of subjective information are the patient’s symptoms. Symptoms include descriptions such as pain, burning, dry mouth, soreness, swelling, roughness, and paresthesia. Whatever the symptom, its specific nature should be questioned, such as onset, duration, periodicity, nature or character, severity, and triggering factors or association. This information helps establish the history of the present illness. The clinician gathers a pocketful of diagnostic clues provided by the patient and combines them with the clinician’s pathology knowledge to guide him or her to ask appropriate and insightful follow‐up questions. Thus, the clinician acts as a detective and must possess foundational knowledge of head and neck disease and pathology in order to learn more about the patient and gather more clues for the formulation of a well‐honed clinical differential diagnosis. Subsequent chapters of this book provide foundational knowledge – both general and specific – of the most common soft tissue head and neck pathology.

Following determination of the history of the patient’s present illness, the medical history is reviewed with the patient. Typically, the patient has previously completed a detailed form providing the clinician with basic information about childhood diseases, vaccinations, hospitalizations and prior surgeries, any current medical care, date of the last physical examination, and medications (i.e. prescription and over‐the‐counter, including herbs) being taken or previously used, especially in the past 6 months. Details about the medications, including name, dosage, and duration of use, are recorded. A complete review of systems (e.g. cardiovascular, pulmonary, renal, endocrine, nervous system) is performed to gather more details than the initial “yes” or “no” responses. In addition, the medical history also includes the patient’s psychological and socioeconomic profiles as well as social habits (e.g. tobacco and alcohol abuse).

Next, the dental history, including details of any oral habits, is gathered. It is important to note decayed, missing, and restored teeth as well as any active caries; periodontal disease; history of extractions and other oral surgery procedures; tooth vitality status; and any need for patient premedication. Any previous problems during dental care are discovered and discussed. Oral habits include the patient’s technique and frequency of flossing, brushing, use of mouthrinse, and occlusal disharmonies.

Physical Examination

It is popular to compare the left and right side for bilateral symmetry while understanding that perfect symmetry is often not present within the range of normal. This is particularly important in order to visualize enlarged lymph nodes or parotid glands.

Extraoral Sites

Specific sites include the following:

Hair and facial skin

External eyes

External ears

Temporomandibular joints

Facial muscles

Nasal vestibule

Thyroid gland (anterior neck)

Lymph nodes (lateral and posterior neck, supraclavicular notch)

Parotid gland

Assess the hair for thickness and loss; carefully examine the sun‐exposed facial skin for ultraviolet damage and lesion development, as well as the neck, ears, forehead, nasal bridge and alae, malar region, eyebrows/eyelids/eyelashes, vermilion of the lips, and the chin. Next, perform careful palpation of each of these sites to rule out the presence of deeper, connective tissue and other types of tissue swellings.

Palpate all lymph nodes and note any enlargement for additional testing since normal lymph nodes are soft and not palpable (Fig. 1.1). Specifically, the subcutaneous tissue is digitally kneaded with a rotating motion in the areas of lymph nodes based on the clinician’s knowledge of anatomy. This process can begin in the submental area, below and lingual to the chin, against the mylohyoid muscles. Next, palpate the submandibular nodes by pressing the tissue below the jaw against the medial side of the mandible or by bimanual palpation with one finger in the mouth and the other externally pushing up. Next, palpate the parotid gland and its associated lymph nodes – look and feel anterior and posterior to the ear. Next, palpate the cervical lymph node chain. The posterior cervical chain is along the back of the neck, and the anterior and deep cervical chain is along the front. An anatomical landmark for the latter nodes is the sternocleidomastoid muscle – trace from behind the ear to the clavicle, kneading deep and medial to it. The postauricular and retrosternomastoid region should also be palpated along with the back of the neck. Lastly, palpate the thyroid gland by placing fingers gently over it and have the patient swallow. Sometimes, in order to discover an enlargement, the grouped fingers are placed on one side of the larynx and pushed laterally while palpating the opposite side.

Figure 1.1 Cervical lymph node levels.

Intraoral Sites

Specific mucosal covered sites include the following:

Oral cavity (

Fig. 1.2

a,b)

Tuberosity/hamular notch

Attached gingiva

Retromolar pad/trigone area

Vestibule (also called the mucobuccal fold)

Buccal mucosa

Labial mucosa

Tongue (dorsal, ventral, and lateral surfaces)

Floor of the mouth

Hard palate

Submandibular and sublingual glands

Oropharynx (

Fig. 1.3

a,b)

Soft palate

Tonsillar pillars and fossa

Tongue (base)

Pharynx (lateral and posterior walls)

Figure 1.2 (a) Oral cavity proper, frontal view. (b) Major components forming the boundaries of the oral cavity proper, sagittal view. The oral cavity (unshaded area) is divided from the oropharynx (shaded area) anteriorly/posteriorly at the posterior extent of the anterior two‐thirds of the tongue; the superior/inferior extent of the oral cavity is the hard palate and floor of the mouth; the superior/inferior extent of the oropharynx is the nasopharynx and hypopharynx.

Figure 1.3 Oropharynx. (a) Frontal view and (b) sagittal view.

It is recommended that the same examination sequence be followed each time, first by visual examination and then by palpation. As mentioned previously, any sequence can be used as long as it is organized and there is understanding of the findings and the significance of deviations from normal. Palpation should be bimanual or bidigital and, whenever possible, by direct vision. The following is a detailed suggested descriptive narrative:

Lips