Download Pigmented Lesions of the Oral Mucosa

self-study
course
2015
course
one
The Ohio State University College of Dentistry is a
recognized provider for ADA CERP credit. ADA CERP is
a service of the American Dental Association to assist
dental professionals in identifying quality providers of
continuing dental education. ADA CERP does not
approve or endorse individual courses or instructors,
nor does it imply acceptance of credit hours by boards
of dentistry. Concerns or complaints about a CE
provider may be directed to the provider or to ADA
CERP at www.ada.org/goto/cerp.
The Ohio State University College of Dentistry is
approved by the Ohio State Dental Board as a
permanent sponsor of continuing dental education
ABOUT this
COURSE…
contact
us
phone
614-292-6737

READ the MATERIALS. Read and
review the course materials.

COMPLETE the TEST. Answer the
eight question test. A total of 6/8
questions must be answered correctly
for credit.

SUBMIT the ANSWER FORM
ONLINE. You MUST submit your
answers ONLINE at:
e-mail
[email protected]
web
dentistry.osu.edu/sms
Q:
Who can earn FREE CE credits?
A:
EVERYONE - All dental professionals
in your office may earn free CE
credits. Each person must read the
course materials and submit an
online answer form independently.
Q:
What if I did not receive a
confirmation ID?
A:
Once you have fully completed your
answer form and click “submit” you
will be directed to a page with a
unique confirmation ID.
Q:
Where can I find my SMS number?
A:
Your SMS number can be found in
the upper right hand corner of your
monthly reports, or, imprinted on the
back of your test envelopes. The SMS
number is the account number for
your office only, and is the same for
everyone in the office.
Q:
How often are these courses
available?
A:
FOUR TIMES PER YEAR (8 CE credits).
http://dentistry.osu.edu/sms-continuing-education

RECORD or PRINT THE
CONFIRMATION ID This unique ID is
displayed upon successful submission
of your answer form.
ABOUT your
FREE CE…
toll free
1-888-476-7678
fax
614-292-8752
FREQUENTLY asked
QUESTIONS…

TWO CREDIT HOURS are issued for
successful completion of this selfstudy course for the OSDB 2015-2016
biennium totals.

CERTIFICATE of COMPLETION is
used to document your CE credit and
is mailed to your office.

ALLOW 2 WEEKS for processing and
mailing of your certificate.

The Ohio State University College of
Dentistry is an American Dental
Association (ADA) Continuing
Education Recognized Provider
(CERP).
Page 1
2015
course
one
PIGMENTED LESIONS OF THE
ORAL MUCOSA
This course will help dental professionals to familiarize themselves with
common pigmented lesions of the oral mucosa and to derive a differential
diagnosis for various pigmented lesions.
INTRODUCTION
Pigmented lesions of the oral
mucosa are one of the leading
causes for which patients seek
professional treatment.
These
lesions can have a wide spectrum of
diagnoses and can be physiologic or
pathologic in origin. A variety of
discoloration, including brown, gray,
black, blue, purple, and yellow, can
occur on oral mucosa.
Patient
history, clinical presentation, and
location can be very helpful in
narrowing down the differential
diagnosis
of
these
various
pigmented lesions.
BROWN, GRAY, AND/OR
BLACK LESIONS
PHYSIOLOGIC PIGMENTATION
written by
neetha santosh, dds
edited by
rachel a. flad, bs
karen k. daw, mba, cecm
clinical appearance. No treatment
is necessary, unless for aesthetic
reasons.
POST-INFLAMMATORY
PIGMENTATION
Post-inflammatory pigmentation
occurs on the oral mucosa which
had
previous
injury
or
inflammation.
Clinical Features:
Like physiologic pigmentation,
post-inflammatory pigmentation
is seen more often in dark-skinned
individuals. The discoloration can
be focal or diffuse and is
commonly seen in patients with
chronic mucosal conditions such
as lichen planus, pemphigus, and
mucous membrane pemphigoid.
Physiologic pigmentation usually
occurs as diffuse discoloration of
oral mucosa in dark-skinned
individuals and it is considered a
normal variation.
Treatment:
Clinical Features:
SMOKER’S MELANOSIS
The discoloration is usually seen on
the gingiva, but can also involve the
labial mucosa, buccal mucosa, and
the tip of the fungiform papillae of
the tongue. The color can range
from light brown to black and is due
to an increased melanin deposition
in the basal layer of oral epithelium.
Smoker’s melanosis is a diffuse
pigmentation of the oral mucosa
seen among heavy smokers.
Chemicals in tobacco smoke, such
as nicotine, increases melanin
production which causes the
pigmentation.
Treatment:
Diagnosis is made by a typical
The pigmentation may resolve
gradually, once the condition is
treated.
Clinical Features:
Smoker’s melanosis is frequently
seen in light-skinned individuals.
Page 2
Females are more likely to be affected due to the
influence of female sex hormones along with
smoking. The anterior facial gingiva is the most
common location and presents as diffuse, light
brown pigmentation.
Treatment:
History of smoking, along with clinical
presentation, is usually sufficient to make a
diagnosis.
Smoker’s melanosis will resolve
gradually once the person quits smoking. A
biopsy of the area may be required if
pigmentation is in an unusual area, such as the
hard palate, or if there are any sudden changes in
clinical presentation.
DRUG-INDUCED PIGMENTATION
A variety of medications such as antimalarial
agents (chloroquine, hydroxychloroquine, and
quinidine),
tranquilizers
(chlorpromazine),
chemotherapeutic agents, minocycline, estrogen,
or medications to treat AIDS can cause druginduced pigmentation of the oral mucosa. The
pigmentation can be due to drug-induced
melanin production or by the deposition of drug
metabolites.
Gradual fading of the pigmentation is seen once
the offending drug is discontinued.
HAIRY TONGUE
Hairy tongue is described as a hair-like
appearance due to the elongation and keratin
accumulation on the filiform papillae of the dorsal
tongue. It can be due to an increase in keratin
production or a decrease in keratin removal from
the dorsal surface of the tongue.
Clinical Features:
Hairy tongue is mostly seen in heavy smokers or
people with poor oral hygiene. The midline of the
tongue, anterior to the circumvallate papillae, is
the most frequent location. Brown, yellow, or
black discoloration of elongated filiform papillae
is due to stains from tobacco and food or
pigment-producing bacteria.
Treatment:
Hairy tongue is diagnosed by its characteristic
clinical appearance. Scraping the tongue and
improving oral hygiene are the recommended
treatments.
Clinical Features:
AMALGAM TATTOO
Drug-induced pigmentation can cause the skin
and mucosal surfaces to have a diffuse or specific
pattern of pigmentation depending on the
medication. Females are more prone to be
affected due to the interaction with sex hormones.
Minocycline can cause blue-gray discoloration of
the bone and developing teeth. It usually affects
the hard palate and the facial surface of the
alveolar bone and can also cause rare
pigmentation of soft tissues such as the lips,
tongue, eyes, and skin. Antimalarial drugs and
tranquilizers can cause blue-black discoloration of
the hard palate. Estrogen, chemotherapeutic
agents, and medications to treat AIDS can cause
diffuse brown pigmentation of the skin and oral
mucosa.
An amalgam tattoo is the pigmentation of the
oral mucosa due to the implantation of amalgam.
Amalgam particles can be embedded into the oral
mucosa during restoration or removal of an
amalgam filling, or during the extraction of an
amalgam-filled tooth.
Treatment:
Clinical Features:
An amalgam tattoo usually appears as a black,
blue, or gray macule and commonly occurs on the
gingiva, alveolar mucosa, and buccal mucosa.
Usually an amalgam-filled tooth can be seen in
the vicinity of the lesion, unless the tooth has
been extracted. Amalgam material, which has
been embedded in the alveolar ridge, can be seen
as radiopaque fragments in radiographs of the
area.
Diagnosis can be made by the history of onset of
the pigmentation shortly after drug usage.
Page 3
Treatment:
Treatment:
Diagnosis is usually made by the clinical
appearance of the lesion and can be confirmed by
the presence of radiopaque amalgam fragments
in radiographs. If a clinical correlation cannot be
made or metallic fragments are not detected in a
radiograph, a biopsy of the lesion is
recommended to rule out melanocytic lesions. No
treatment is necessary unless there are aesthetic
reasons.
Diagnosis is typically made by the characteristic
clinical presentation of a flat, well-demarcated
brown macule. No treatment is necessary unless
for aesthetic reasons. If there is any change in size
or appearance of the lesion, surgical excision is
the treatment of choice. Excised tissue must be
submitted for histopathological examination
since the differential diagnosis of an oral
melanotic macule includes the oral melanocytic
nevus, amalgam tattoo, and melanoma.
NON-AMALGAM TATTOO
Graphite tattoos and intentional tattoos are some
types of intraoral exogenous pigmentations.
Clinical Features:
Graphite tattoos are commonly seen on the palate
and occur from the accidental embedding of
graphite particles from a pencil. The hard palate is
the most common site of graphite tattoos and an
isolated grayish macule of mucosa (similar to an
amalgam tattoo) is seen. Intentional tattoos can
be cultural tattoos seen on the maxillary facial
gingiva or amateur tattoos on the lower labial
mucosa.
Treatment:
No treatment is usually necessary. Corticosteroids
and laser therapy may be used to remove
intentional tattoos.
ORAL MELANOTIC MACULE
ORAL MELANOCYTIC NEVUS
The melanocytic nevus, also known as the
common mole, is a benign proliferation of nevus
cells. They can be congenital or acquired,
depending on the time of occurrence. An
intraoral melanocytic nevus is much less common
compared to its cutaneous counterparts.
Clinical Features:
The oral melanocytic nevus is more commonly
seen in females and is a well-demarcated macule.
The color can range from brown to black,
although it can sometimes present as a nonpigmented macule. Most of them are seen on the
palate, mucobuccal fold, and the gingiva. A
congenital melanocytic nevus is larger in size
compared to an acquired nevus.
Treatment:
Oral melanotic macules are the most common
melanocytic lesion affecting the oral cavity. It
appears as a flat, uniformly pigmented, welldemarcated brown macule.
Generally, no treatment is required for oral
melanocytic nevus except for aesthetic reasons.
Since the early stages of melanoma can mimic a
melanocytic
nevus,
histopathological
examination of a surgically excised nevus is
mandatory.
Clinical Features:
ORAL MELANOACANTHOMA
Oral melanotic macules can affect people of all
ages, but females are more frequently affected.
The vermillion zone of the lower lips is the most
common site of occurrence, and it can also affect
the buccal mucosa, gingiva, and palate. It occurs
due to an increase in brown melanin deposition in
the basal layer of the oral epithelium.
Oral melanoacanthoma is a benign, rapidly
enlarging melanocytic lesion in the oral cavity.
Some studies have shown association of trauma
with these lesions. Cutaneous melanoacanthoma
is not related to oral melanoacanthoma, which is
a pigmented seborrheic keratosis seen in older
Caucasians.
Page 4
Clinical Features:
Oral melanoacanthoma almost always occurs in
African-Americans, with females more commonly
affected than males, and usually occurs during
their 30s and 40s. Although the buccal mucosa is
the most common site of oral melanoacanthoma,
any oral mucosal site can be affected. It appears
as an asymptomatic, smooth, dark-brown to black
colored macule which rapidly grows in size over
the duration of a few weeks.
radiolucent defects on a radiograph. Sometimes,
oral melanomas develop with little or no
pigmentation.
These are called amelanotic
melanomas and are difficult to diagnose clinically,
as they may mimic a pyogenic granuloma.
Treatment:
A biopsy is usually performed to rule out a
differential diagnosis of early melanoma. There is
no need for subsequent treatment after
confirming
the
diagnosis
of
oral
melanoacanthoma, as most of the lesions will
gradually resolve on their own.
Oral Melanoma
Dr. Carl Allen, The Ohio State
University College of Dentistry
Treatment:
MELANOMA
Melanoma is a malignant neoplasm of
melanocytes.
Most of the melanomas are
cutaneous lesions, but can occur at any location in
the body where melanocytes are present.
Cutaneous melanoma is the third most common
type of skin cancer, after basal cell carcinoma and
cutaneous squamous cell carcinoma.
Acute
damage by UV radiation is the most common
etiologic factor for cutaneous lesions. The risk
factors also include familial history of melanoma,
personal history of melanoma, congenital nevus
or dysplastic nevus, fair skin, light hair and eye
color, and higher frequency of sunburn. Oral
melanomas are comparatively rare and are less
than one percent of all melanomas; however, they
act more aggressively than cutaneous melanomas.
Clinical Features:
Melanomas are usually seen in older adults, with
the average age being 40 to 70 years old. They are
more common in Caucasians and have a male
predilection. The maxillary gingiva and the hard
palate are the most common sites of occurrence in
the oral cavity. Oral melanomas usually start as
irregular, brown- to black-colored macules. With
time, they increase in size and become exophytic
in appearance. Often, these exophytic masses can
get ulcerated and become painful. It can destroy
the underlying bone and can produce irregular
Any suspicious pigmented lesion on the hard
palate and maxillary gingiva should be biopsied.
Oral melanomas are usually treated by surgical
excision with wide margins.
Sometimes a
hemimaxillectomy is performed on patients
whose maxillary bone is also involved. Once the
diagnosis of oral melanoma is established, depth
of invasion of the lesion is measured, as oral
melanomas deeper than 0.5 mm have a poor
prognosis. The prognosis of oral melanomas are
very poor, due to difficulty in obtaining a clear
surgical margin during the initial treatment and
early chances of distant metastasis. Old age, male
gender, and amelanotic melanomas are other
factors contributing to a bad prognosis. Periodic
follow-up of melanoma patients are very
important as they have higher chances of
recurrence.
PEUTZ-JEGHERS SYNDROME
Peutz-Jeghers syndrome is an autosomal
dominant inherited condition and is manifested
by multiple freckle-like lesions of the hand,
periorificial skin (mouth, nose, anus, and genital
skin) and the oral mucosa, and multiple polyps of
the intestine. Patients with this syndrome are
more susceptible to develop cancer.
Page 5
Clinical Features:
Multiple dark freckle-like lesions on perioral skin is
the most characteristic presentation of this
syndrome. Even though they resemble freckles,
intensity of these lesions does not change with
sun exposure. Similarly, bluish-gray macules are
also seen on the vermilion zone of the lips, the
labial and buccal mucosa, and the tongue.
Treatment:
Since patients with Peutz-Jeghers syndrome have
higher chances of developing cancer, they should
be referred to a gastroenterologist to monitor for
the development of intestinal intussusception and
cancer.
ADDISON’S DISEASE
(HYPOADRENOCORTICISM)
Addison’s disease is a condition characterized by
decreased production of adrenal corticosteroid
hormones due to damage of the adrenal cortex.
Autoimmune diseases, infections (such as
tuberculosis and deep fungal infections), and
metastatic tumors are some of the etiologic factors
for adrenal cortex destruction.
BLUE AND/OR PURPLE LESIONS
MUCOCELE
Mucocele is a dome-shaped lesion of the oral
mucosa which forms due to damage of the salivary
gland duct and the release of mucin into the
surrounding soft tissues. Trauma is the most
common etiologic factor of a mucocele.
Clinical Features:
A mucocele is usually seen in children and young
adults, as they are more prone to biting the oral
mucosa. Mucoceles have a bluish hue due to the
spilled mucin content within the lesion.
A
mucocele is most often located on the lower lips,
but can also be seen on the buccal mucosa, the
floor of the mouth, the anterior ventral tongue, the
palate, and the retromolar pad. Patients often
report a history of periodic rupturing and reformation of the mucocele.
Clinical Features:
Gradual development of weakness, fatigue,
depression, and hypotension are a few of the
symptoms seen with Addison’s disease.
Hyperpigmentation of the skin, known as
bronzing, is one of the characteristic
presentations. In the oral cavity, diffuse or patchy
brown pigmentation may be seen.
Treatment:
Oral pigmentation can be one of the first signs of
Addison’s disease. History of recent appearance of
oral pigmentation should raise the suspicion for
Addison’s disease and the patient should be
referred to his/her general physician for a
complete physical work-up and laboratory studies
of serum cortisol and ACTH. Addison’s disease is
typically treated by corticosteroid replacement
therapy. In an event of a lengthy surgical
procedure, the dose of corticosteroids should be
increased to meet the body’s high stress level.
Mucocele
Dr. Neetha Santosh, The Ohio State
University College of Dentistry
Treatment:
The majority of mucoceles break and heal by
themselves. Some long-standing lesions may
require surgical excision. Care should be taken to
remove the offending salivary gland along with
the mucocele to avoid chances of recurrence. The
surgically removed lesion should be submitted for
microscopic examination to rule out a salivary
gland tumor.
SALIVARY GLAND TUMORS
Salivary gland tumors can be benign or malignant
lesions. They can affect either the major salivary
Page 6
glands (parotid, submandibular, and sublingual
salivary glands) or the minor salivary glands seen in
the oral cavity on the soft palate, tongue, labial
mucosa, buccal mucosa or the retromolar pad area.
the facial gingiva of the mandibular canine and
premolar. Clinically, they appear as a domeshaped, painless, bluish or blue-gray swelling. The
lesions are usually less than 1 cm in diameter.
Clinical Features:
Treatment:
Salivary gland tumors are seen in middle aged or
older adults with females having a higher chance
of developing them. Inside the oral cavity, the
palate is the most common location to develop
salivary gland tumors, followed by the lip, buccal
mucosa, tongue, and retromolarpad area. They
usually present as a slow-growing, painless,
fluctuant mass. Most of them have a bluish
discoloration and can be ulcerated due to trauma.
The diagnosis is usually confirmed by a
histopathologic examination and an absence of
jaw involvement. Gingival cysts of the adult are
usually treated by surgical excision and have an
excellent prognosis.
Treatment:
A biopsy of any bluish pigmented mass should be
done to achieve the correct diagnosis, as certain
salivary gland tumors can mimic a mucocele
clinically. Treatment of salivary gland tumors
varies based on diagnosis of a benign or malignant
condition.
GINGIVAL CYSTS OF THE ADULT
Gingival cysts of the adult is a developmental cyst
on the gingiva, arising from the remnants of dental
lamina. It represents the soft tissue counterpart of
lateral periodontal cysts, which have the same
clinical and microscopic features, but occurs within
the jaw.
ERUPTION CYST (ERUPTION HEMATOMA)
An eruption cyst is a cyst that forms in the soft
tissue that lies above an erupting crown. It
represents the soft tissue counterpart of
dentigerous cysts.
Clinical Features:
Eruption cysts usually occur in children under 10
years of age. Deciduous central incisors and
permanent first molars are the most prone to
acquiring an eruption cyst. Clinically, the cyst
appears as a soft, clear swelling on the gingiva of
erupting teeth. Eruption cysts are prone to
trauma, which gives them a blue or purple color
due to blood in the cystic fluid.
Treatment:
No treatment is usually required, as eruption cysts
normally break by themselves once the tooth
erupts. Resilient cysts can be treated by excising
the superficial portion of the cyst.
VARICOSITIES (VARICES)
Varices are abnormally dilated veins with a
tortuous course. They are considered to arise due
to age-related degeneration of connective tissue
that surrounds the blood vessels.
Gingival Cyst
Dr. Carl Allen, The Ohio State
University College of Dentistry
Clinical Features:
Gingival cysts of the adult usually affect adults over
40 years of age. The cysts are commonly found on
Clinical Features:
Varices are commonly seen in adults 60 years of
age or older. A sublingual varix is the most
common of the oral varices. They are most often
seen as multiple, painless, bluish-purple elevated
Page 7
blebs on the lateral border and ventral surface of
the tongue. They can also be seen as single lesions
on the labial and buccal mucosa.
Treatment:
No treatment is usually required for sublingual
varices. Isolated lesions on the labial and buccal
mucosa can be surgically excised for aesthetic
reasons.
SUBMUCOSAL HEMORRHAGE
A submucosal hemorrhage occurs in the oral cavity
due to trauma, which results in bleeding and
extravasation of blood within the mucosa. Based
on the size of the hemorrhage, it can be referred to
as a petechiae, purpura, ecchymosis, or a
hematoma . Petechiae are tiny pinpoint
hemorrhages smaller than 3 mm in diameter.
Purpuras are slightly larger than petechiae, often
between 3 mm and 1 cm in diameter. Ecchymosis
is a submucosal hemorrhage greater than 2 cm.
When a hemorrhage produces a mass, it is then
called a hematoma.
HEMANGIOMA
Hemangiomas are benign developmental vascular
neoplasms. They are the most common tumors
seen in infants and children.
Clinical Features:
Hemangiomas are more common in females.
Caucasians are more prone to develop this lesion.
The head and neck area manifests 60% of all
hemangiomas occurring in the body. Intraorally,
the tongue is the most common site of occurrence
and usually presents as a red or blue-purple mass.
Hemangiomas can be of two types depending on
the time of occurrence, namely congenital and
infantile hemangiomas. Congenital hemangiomas
are formed completely at the time of birth, while
infantile hemangiomas usually develop in the first
few weeks after birth. 50% of the hemangiomas
resolve by themselves by age 5 and 90% will be
resolved by age 9. Occasionally, intraosseous
hemangiomas can be diagnosed in the jaws. The
mandible is more commonly affected than the
maxilla and a radiographic examination shows a
multilocular radiolucent defect.
Clinical Features:
Treatment:
A submucosal hemorrhage presents as a reddishpurple, flat or elevated lesion, mostly on the labial
or buccal mucosa. Blunt trauma, cheek biting,
violent coughing, upper respiratory infections,
anticoagulant medication usage, and coagulation
disorders are some of the common causes of a
submucosal hemorrhage.
Treatment:
A diagnosis is made by the correlation of trauma
history or medication usage and clinical
presentation. If a diascopy is performed, these
lesions should not blanch, as blood is entrapped
within the mucosa and not within the blood vessel.
Usually, treatment is not required for a submucosal
hemorrhage and lesions should completely resolve
within two weeks. If they do not heal within two
weeks, a coagulation disorder or other systemic
disease should be ruled out by laboratory
investigations.
Hemangiomas are diagnosed by the clinical history
of the presence of the lesion and by clinical
appearance. A diascopy can be performed to see if
the red or purple lesion is caused by either blood
within the blood vessels or leaked blood. A
diascopy is performed by firmly pressing a glass
slide against the lesion and if the lesion is caused
by blood within the blood vessels, as in
hemangioma, the lesion will blanch. Hemorrhagic
lesions such as petechial, purpura, or ecchymosis
will not blanch, since those are caused by leaked or
extravasated blood. Hemangiomas usually require
no treatment, since the majority will resolve by
themselves.
Sclerotherapy, with ethanol or
corticosteroids, can be used to decrease the size of
the lesion and the remaining lesion can be
removed by surgical excision or cryotherapy. Any
surgically excised tissue should be submitted for
histopathologic examination to confirm the
diagnosis.
Page 8
KAPOSI’S SARCOMA
Kaposi’s sarcoma is a malignant vascular neoplasm.
Human herpes virus 8 (HHV-8) is the causative
factor for Kaposi’s sarcoma.
Clinical Features:
Kaposi’s sarcoma usually has four different clinical
presentations:
classic,
endemic,
iatrogenic
(transplantation associated), and AIDS-related. The
classic form of Kaposi’s sarcoma usually affects
elderly men on the lower extremities. The endemic
form of Kaposi’s sarcoma is seen in young children
living in Equatorial Africa and affects various lymph
nodes in the body. The iatrogenic form is seen in
renal transplant patients and arises due to the loss
of immunity caused by immunosuppressive drugs
taken following renal transplantation. AIDS-related
Kaposi’s sarcoma is seen in the end stages of HIV
infection and its incidence is decreasing due to
anti-AIDS therapy. Oral lesions are seen in almost
50% of AIDS-related Kaposi’s sarcoma. In the oral
cavity, Kaposi’s sarcoma commonly affects the hard
palate, gingiva, and the tongue. It usually starts as
a purple patch, evolves into a plaque stage, and
finally develops into purple nodular masses.
Blue Nevus
Dr. Carl Allen, The Ohio State
University College of Dentistry
Clinical Features:
Blue nevus is commonly seen in children and
young adults. Females are more prone to develop
this nevus. It is usually seen on the hard palate as
a small, blue or bluish-black macule.
Treatment:
A biopsy is usually performed to rule out a
differential diagnosis of an early melanoma,
because of the similar clinical location and
appearance. Once the blue nevus is surgically
removed, chance of recurrence is rare.
Treatment:
The diagnosis of Kaposi’s sarcoma is achieved by
examining the tissue under a microscope. The
HHV-8
virus
can
be
identified
by
immunohistochemical staining. The treatment of
Kaposi’s sarcoma depends on the clinical
presentation.
Surgical excision, systemic or
intralesional chemotherapy, and radiation therapy
are various choices of treatment for Kaposi’s
sarcoma.
BLUE NEVUS
Blue nevus is a benign proliferation of nevus cells
deep within the tissue. Blue nevus gets its name
from the blue color of the lesion due to the Tyndall
effect. Since the nevus is located deep within the
tissue, when the light is reflected back, colors with
longer wavelengths, such as red and yellow, will be
absorbed by the tissue and colors with shorter
wavelengths, such as blue, will be reflected back.
YELLOW LESIONS
FORDYCE GRANULES
Fordyce granules are ectopic sebaceous glands
seen on the oral mucosa.
Clinical Features:
Fordyce granules are more commonly seen in
adults. They present as multiple yellow papules
on the buccal mucosa or vermilion zone of the lip.
The lesions are normally asymptomatic.
Treatment:
The diagnosis of Fordyce granules is made by
typical clinical location and presentation. No
treatment is required for Fordyce granules.
Page 9
PARULIS
Clinical Features:
Parulis (gum boil) is a focal collection of pus on
alveolar or palatal mucosa, formed due to a sinus
tract draining dental abscess.
Lipoma is commonly seen in adults over 40 years
of age. The buccal mucosa and the buccal
vestibule are the most common sites for
occurrence, followed by the tongue, the floor of
the mouth, and the lips. Clinically, it presents as a
painless, soft, yellow nodular mass which is
usually less than 3 cm in size.
Clinical Features:
Parulis usually presents as small, yellow-red
nodules on the alveolar or palatal mucosa of a the
non-vital tooth. The lesion periodically ruptures
and discharges a foul-tasting pus. It can be
asymptomatic or painful, depending on the
amount of pus accumulated within the alveolar
bone.
Treatment:
Conservative surgical excision is the treatment of
choice and the chance of recurrence is very rare.
JAUNDICE (ICTERUS)
Treatment:
Pulp testing or radiographic evaluation following
insertion of a gutta-percha point into sinus tract
can help in determining the responsible non-vital
tooth.
Parulis will be completely resolved
following endodontic therapy or extraction of the
responsible non-vital tooth.
ORAL LYMPHOEPITHELIAL CYST
Oral lymphoepithelial cysts are developmental
cysts that arise in oral lymphoid tissue.
Clinical Features:
Oral lymphoepithelial cysts are common in young
adults. The floor of the mouth, ventral surface and
lateral border of the tongue, the soft palate, and
the area of the palatine tonsil are the most
common locations to develop this cyst. Clinically, it
presents as small, yellow-white nodules on the oral
mucosa.
Treatment:
Oral lymphoepithelial cysts are usually treated by
surgical removal and they do not recur.
LIPOMA
Lipoma is a benign neoplasm of adipose tissue.
Lipoma is the most common soft tissue neoplasm
in the body, but its occurrence in the oral cavity is
not as common. Although this lesion is seen more
in obese individuals, a decrease in calorie
consumption does not decrease the size of lipoma.
Jaundice is a condition characterized by yellowish
pigmentation of skin and mucosa, due to
increased bilirubin in the blood. The increase can
be due by the rapid break down of red blood cells
in disorders such as autoimmune hemolytic
anemia, or due to decreased processing of
bilirubin by the liver in conditions such as viral
infections and alcohol induced hepatotoxicity.
Jaundice can also be seen in newborn babies or
individuals having gall stones or cancer.
Clinical Features:
Jaundice is characterized by diffuse, yellowish
pigmentation of the skin and mucosa, with the
severity depending on the blood bilirubin count.
Tissues with a higher amount of elastin, like
sclera, the soft palate, and the lingual frenulum
will have greater yellow pigmentation, since
elastin fibers have a higher tendency to bind with
bilirubin.
Treatment:
Treatment of jaundice depends on the underlying
cause of hyperbilirubinemia.
Patients with
jaundice should be referred to their general
physician for a complete physical work-up and
laboratory investigations to determine the exact
cause.
Page 10
CONCLUSION
Pigmented lesions can have various clinical
presentations
ranging
from
physiologic
pigmentation to malignant conditions such as
melanoma. A correct diagnosis of a pigmented
lesion is very important as it can change previous
treatment plans. A biopsy of the lesion and
submission of the tissue for histopathological
examination is mandatory if clinical diagnosis is in
doubt.
REFERENCES
1) Neville B, Damm D, Allen C, Bouqot J. Oral &
Maxillofacial Pathology. 3rd ed. Philadelphia,
PA: Saunders Company; 2009.
2) Greenberg M, Glick M, Ship J. Burket’s Oral
Medicine. 11th ed. Hamilton, Ontario: BC Decker
Inc.; 2008.
ABOUT THE AUTHOR
NEETHA SANTOSH
NEETHA SANTOSH GRADUATED SUMMA CUM LAUDE FROM
CHRISTIAN DENTAL COLLEGE, INDIA, WHERE SHE FURTHER
COMPLETED HER GENERAL PRACTICE RESIDENCY. SHE THEN
PURSUED A POSTDOCTORAL FELLOWSHIP IN ORAL BIOLOGY AT
INDIANA UNIVERSITY SCHOOL OF DENTISTRY. CURRENTLY, SHE IS
DOING HER RESIDENCY IN ORAL AND MAXILLOFACIAL PATHOLOGY
AT THE OHIO STATE UNIVERSITY. HER RESEARCH AT OSU
PRIMARILY FOCUSES ON IDENTIFYING BIOMARKERS THAT CAN
PREDICT THE PROGRESSION OF ORAL PREMALIGNANT LESIONS TO
SQUAMOUS CELL CARCINOMA. HER FUTURE CAREER PLAN IS TO JOIN
ACADEMICS WHERE SHE CAN TEACH AND PRACTICE ORAL AND
MAXILLOFACIAL PATHOLOGY.
CE COURSES AVAILABLE FOR
PURCHASE
Need additional Continuing Education
credits before you renew your license?
Realized that you missed an SMS CE
course? All of our CE courses are
available once the due date has passed
for only $25 per course.
Courses Available for Purchase:
2013
Course 1 – Workplace Violence
Course 2 – Human Immunodeficiency
Virus
Course 3 –GI Disease and Oral Lesions
Course 4 – Human Papillomavirus
2014
Course 1 – Orofacial Pain
Course 2 – Gingival Pathology
Course 3 – Panoramic Radiography
and Radiolucencies of the Jaws
Course 4 – White Lesions of the Oral
Cavity
Please contact the SMS office if you are
interested in purchasing any of these
courses.
NEETHA SANTOSH CAN BE CONTACTED AT [email protected].
888-476-7678 (toll-free)
[email protected]
Page 11
post-test
instructions
-
answer each question ONLINE
press “submit”
record your confirmation id
deadline is February 15, 2015
1
T
F
The most common site of occurrence of oral
melanomas are the hard palate and the maxillary
gingiva.
2
T
F
Hemangiomas are most commonly seen in
adults.
3
T
F
Eruption cysts typically occur in children over 10
years of age.
F
Pigmented lesions of the oral mucosa are one of
the leading causes for which patients seek
professional treatment.
F
Patients with Peutz-Jeghers syndrome have
higher chances of developing gastrointestinal
cancer.
F
Although lipomas are most commonly seen in
obese individuals, a decrease in caloric
consumption will not decrease the size of the
lipoma.
SUBMIT
ONLINE
SUBMIT
ONLINE
4
5
6
T
T
T
7
T
F
Estrogen,
chemotherapeutic
agents,
and
medications to treat AIDS can cause diffuse
brown pigmentation of the skin and oral mucosa.
8
T
F
Fordyce granules are melanocytic lesions and
always require treatment.
director
john r. kalmar, dmd, phd
[email protected]
assistant director
karen k. daw, mba, cecm
[email protected]
channel coordinator
rachel a. flad, bs
[email protected]
Page 12