Dr. Ban Tawfeek Shareef School of Dental Sciences /USM

Dr. Ban Tawfeek Shareef
School of Dental Sciences /USM

• Oral pathology in General , is the
study of diseases affecting the oral
cavity.
• Oral Pathology emphasizes diseases
that do not affect teeth or
periodontium

Clinical Oral pathology
• It
It is the specialty of dentistry and pathology
which deals with the nature, identification, and
management of diseases affecting the oral and
maxillofacial regions.
• It is a science that investigates the causes,
processes and effects of these diseases.
• The practice of oral pathology includes research,
diagnosis of diseases using clinical,
radiographic, microscopic, biochemical or other
examinations, and management of patients.

Oral pathology ( (medicine)
• It is a branch of dentistry that is
concerned with the diseases of the
teeth, oral cavity, and jaws, and with
the oral manifestations of systemic
diseases.

The Significance of Oral Pathology in Dental Practice
‣Oral pathologists are not needed to make
diagnoses of common diseases (period &
pulp disease , caries ).
-Those Common diseases can easily be
identified (clinical & radiographic exam. )
by general dentist & the concerned
specialists .

‣ Oral pathologists are needed to make
diagnoses of other diseases( less
common) that may occur from time to time in
dental patients like diseases :
-originate in the oral cavity.
-some may be caused by disease
elsewhere.
-still others may spread to the oral region
from distant sites.

• Serious consequences may occurs if un
common diseases are not recognized,
classified, and treated early.
• However there are problems which make for
microscopic examination mandatory:
‣ First, the early clinical appearance
of many conditions are subtle.
‣ Second, more overt clinical features
usually are not distinctive.

How to reach to a definitive diagnosis
• The process of diagnosis require
gathering information that relevant to
the patient and the lesion being
evaluated .
• There are eight distinct diagnostic
categories:

The DIAGNOSTIC PROCESS
• Historical Diagnosis
• Clinical diagnosis
• Radiographic Diagnosis
• Laboratory Diagnosis
• Microscopic Diagnosis
• Surgical Diagnosis
• Theraputic Diagnosis
• Differential Diagnosis.

1. Historical Diagnosis
Personal history, family history, past
and present medical and dental
histories, history of drug ingestion,
and history of the presenting disease
or lesion provides information
necessary for the definitive diagnosis.

2. Clinical Diagnosis
• Clinical Diagnosis is based on
-Clinical examination and palpation to
feel the (consistency ) of the lesion.
- Size , color, shape, location, and
history of the lesion.

3. Radiographic Diagnosis
• Radiograph(s) provides
sufficient information to
establish the diagnosis.

4. Laboratory Diagnosis
•Diagnostic laboratory tests
including blood chemistries and
urinalysis, can provide conclusive
information for a definitive
diagnosis.

5. Microscopic Diagnosis
• Evaluation of a biopsy specimen
taken from the lesion is often the
main component of the definitive
diagnosis.

6. Surgical Diagnosis
• Surgical intervention provides
conclusive evidence of the
diagnosis when the lesion is
opened.

7. Therapeutic Diagnosis
• Prescribing therapeutic drugs
and observing the results
based on clinical and historical
information.

8.Differential diagnosis
• Rearranging of list of possible
diagnosis with the most probable
lesion ranked at the top and the
least likely at the bottom.
• The clinician must be familiar
with the signs and symptoms
produced by many diseases .

8.Diff diagn
• The clinician must possess some
statistical knowledge of relative
incidence of each disease entity.
• The order by frequency may
need to be modified by
consideration of age, gender,
race, country of origin, and
anatomical location.

Routine head, neck and
oral cavity examination
procedure

Recommendation for successful exam.
procedure
• The head, neck and oral cavity are areas that
can be easily viewed.
• This simple procedure (Exam. ) may yield
important information regarding the health
status of this area of the body.
1. Before you can identify a lesion or abnormal
condition, it is necessary to have a solid
understanding of the basic and dental
sciences, such as human anatomy and
physiology, histology, and dental anatomy.

2. Once you have a solid understanding
of normal structures and those that
are variants of normal, findings that
deviate from normal and pathologic
conditions are more easily
recognized.
3. Both abnormal and normal soft
tissue can be inspected visually by
observation and by palpation
;observation is the key in maintaining
oral health.

4. With knowledge of what is normal
and of what one expects to see, you
can routinely perform a systematic
examination of the patient.
5. Using primarily inspection and
palpation, the following method of
examination is offered as a basis for
establishing a logical order and
sequence.

Extra oral Examination
• Generalized appraisal of the patient
Face .
• Submental and submandibular
lymph node areas .
• Parotid area including lymph nodes
.
• Temporomandibular joint area .
• Ears .
• Neck and cervical lymph nodes
including supraclavicular nodes .
• Thyroid gland area .

Facial view shown
essential symmetry. Note
that in this case the left
side of the patient's face
looks a bit larger because
the head is turned to the
patient's right side
slightly.
Palpation of the submental
lymph node area with firm
pressure and rotating the
finger behind the chin.

Bimanual palpation of the
submandibular gland areas for
the gland and for lymph node .

Palpation of the
temporomandibular
joints at the tragus of the
ear as the patient opens
and closes the mandible.
Bilateral palpation and
gentle squeezing of the
sternocleidomastoid
muscle to locate the
cervical chain of nodes
just medial and deeper to
the muscle.

Palpation of the
supraclavicular area behind
the clavicular bone

Thyroid Gland Palpation
– Place hands over
the trachea.
– Have the patient
swallow.
– The thyroid gland
moves upward

Intra -oral Examination
• Lips and corners of the mouth.
• Mucous membranes of lips, labial
and buccal vestibule, gingivae,
buccal mucosae, papillae of the
parotid ducts.
• Hard palate and palatal gingivae.
• Soft palate .

Intra -oral Examination
• Tonsillar areas and posterior pharynx
.
• Tongue – dorsum (papillae), ventrum
(veins, fimbriated folds), lateral
borders (foliate papillae, bilateral) .
• Floor of the mouth and gingivae.
• Teeth (occlusion, congenitally
missing teeth , others).

Examination o the lip
• Evert the lip and examine the tissue.
• Observe frenum attachment/tissue
tension.
• Clear mucous filled pockets may be
seen on the inner side of the lip
(mucocele).
• -This is a frequent, non-pathologic
entity which represents a blocked minor
salivary gland.

Exam: Lips
• Color, consistency.
• Area for blocked minor salivary glands
• Lesions, ulcers.

Exam: Lips
• Palpate in the
vestibule,
observe color;
normal
variations in
color among
ethnic groups.
• Frenum:
– Attachment
– Level of attached
gingiva.

Exam: Lips-Sun exposure

Examination: Buccal Mucosa
• Observe color, character of the mucosa
– Normal variations in color among ethnic
groups
– Amalgam tattoo .
• Palpate tissue.
• Observe Stenson’s duct opening for
inflammation or signs of blockage.
• Visualize muscle attachments, hamular
notch, pterygomandibular folds.

Exam: Buccal mucosa
• Linea alba.
• Stenson’s duct.

Exam: Buccal mucosa
• Lesions – white,
red
-Lichen Planus.
-Leukedema.

Examination of hard palate
• Observe minor
salivary glands,
attached
gingiva.
• Note presence
of tori: tx plan
any preprosthetic
surgery .

Examination of soft palate
• How does soft palate raise upon “aah”?
• Vibrating line, tonsilar pillars, tonsils,
opharynx
• see that the soft palate vibrates, also
confirming the intactness of cranial
nerve VIII.

Examination of oropharanyx
• Color, consistency of tissue.
• Look to the back, beyond the soft palate.
• Note occasional small globlets of
transparent or pink opaque tissue which
are normal and may include lymphoid
tissue .

Exam:Tonsils
• Tucked in at base of anterior & posterior
tonsilar pillars.
• Globular tissue that has “punched out”
appearing areas.
• Regresses after adulthood.
• In the posterior aspect of the soft palate is a
circle of lymphoid tissue Waldeyer’s ring,
including the tongue.
• May see white “orzo rice like” or “torpedo”
shaped white concretions within the tissue.

Exam: Tonsils
Palatine tonsils are located on
each side situated between
the palatoglossal and the
palatopharyngeal folds .

Exam: Tonsils
Residual tonsil represent foci
that were not totally removed
at the tonsillectomy of
palatine tonsil .

Exam: Tonsils
Accessory tonsils
near the base of the uvula

Exam: Tonsils
• More tonsillar tissue
can be noted by
depressing the tongue
down and having the
patient say "ah".
• In the posterior
pharyngeal wall are
tissues that are
tonsillar and can
become reactive and
then noted as bright
pink, fleshy masses.

Exam: Tonsils
• Tonsillar tissue
(lingual tonsils)
at the very base
of the tongue
beyond the
circumvallate
papillae and
usually are seen
only with a mirror
reflecting light on
them.

Exam: Tonsils
• Tonsillar tissue
on the lateral
surfaces, most
posterior, in the
foliate papillae
bilaterally.

Examination of the tongue
• The tongue and the floor of the mouth
are the most common places for oral
cancer to occur.
• It can occur other places; so visualize
all areas.
• You may observe :
– On the dorsal surface , filliform, fugiform,
foliate , Circumvalate papillae, epiglottis.

Exam: Tongue
• Have the patient
stick out their
tongue.
• Wrap the tongue
in a dry gauze and
gently pull it from
side to side to
observe the lateral
borders.
• Retract the tongue
to view the inferior
tissues.

Exam: Tongue Dorsal surface /Tongue
papillae

Exam: Tongue/ventral surface
Lingual frenum
attachment
Ventral surface
Lingual varicosities

Exam: Tongue
• You may observe
geographic tongue
(erythema migrans).

Exam: Tongue
• Observe signs of
nutritional
deficiencies, immune
dysfunction

Exam: Tongue
• You may observe
oral cancer.
You should
differentiate CA
from
• Enlarged foliate
papillae of smokers
, which may undergo
bilateral reactive
hyperplasia.
SCC
Enlarged foliate papillae

Exam: Floor of mouth
• Visualize, palpate –
bimanually.
• Must dry to observe
-Does “lesion” if
present wipe off?
• Observe Wharton’s duct.

Exam: Floor of mouth
• Remember the two most likely areas for
oral cancer?
– lateral border of the tongue
– Floor of mouth.
• Oral Cancer:SCC
–Red
– White
– Red and White
• Does the patient have important risk
factors for oral cancer?
– Counseling for smoking and alcohol
• Cessation .

Exam: Floor of mouth/SCC

Examination of gingivae
• Note color, tone, texture, architecture
& mucogingival relationship.
• Differentiation between the lesion
and normal variation is essential .

Gingivae /Normal variations
Retrocuspid
papillae
gingival nodules
gingival mandibular ridges

Examination of gingivae
• How would you describe the gingiva?
– Marginal vs. generalized?
– Erythematous vs. fibrous
• Drug reactions: Anti-epileptic, calcium
channel blockers, immunosuppressant .
Erythematous
Fiibrous

Examination of Teeth
• Next, the teeth can
be examined.
• One checks for any
developmental ,
congenital dental
defect,
malocclusion .
• or congenitally
missing teeth if any.

Triaging Lesions *
• Describe it’s s characteristics:
– Size, shape, color, consistency, location.
• How long has it been present?
• Is it related to a trauma?
– Fractured cusp, occlusal trauma.
• Has it occurred before?
• Can you wipe it off?
• Does the patient have specific risk
factors for neoplastic lesions?

Triaging Lesions *
• Any lesion that is suspicious should
be re-evaluated evaluated in 2 weeks.
– Lesions due to infectious processes would
have healed in that time frame.
– If it remains, the lesions should be biopsied.

Characteristics of the lesion
• Size, shape, color, consistency &
location.
• Size, shape, color& location of the
lesion will be discussed in
Classification & clinical
appearance of oral lesions
(lecture) .

Consistency of lesion on Palpation
• Soft
• Hard
• Cheesy .
• Fluctuant.
• Rubbery.
• Firm.
• Bony .
• Indurated.

• Soft : Lesion
composed of
soft tissue .

• Hard :Lesion not
easily penetrated ,
cut or separated
into parts ;
not yielding into
pressure ;firm
;solid ; compact .

• Cheesy :Lesion
texture is similar to
cruds of cheese
• Fluctuant :Wave
like motion that is
felt when a fluid
containing
structure is
palpated .

• Rubbery :Lesion
texture
resembling a
rubber ; having
elasticity .
• Firm: Fixed
closely
compressed;
compact lesion.

• Bony :Lesion
consisting of
bone or of bones ;
full of bones ;
pertaining to
bones .
• Indurated: An
excessive
hardening or
firmness.