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A Colour Handbook of Oral Medicine This page intentionally left blank A Colour Handbook of Oral Medicine MICHAEL A.O. LEWIS PhD, BDS, FDSRCPS (Glas), FDSRCS (Edin), FDSRCS (Eng), FRCPath Professor of Oral Medicine University of Wales College of Medicine, Cardiff, UK RICHARD C.K. JORDAN DDS, MSc, PhD, FRCDC, Diplomate Am B Oral & Max Pathology, Diplomate Am B Oral Medicine Associate Professor of Oral Pathology and Pathology University of California San Francisco, California, USA MANSON PUBLISHING Copyright © 2004 Manson Publishing Ltd ISBN: Hardback 1–84076–032–X Paperback 1–84076–033–8 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 without the written permission of the copyright holder or in accordance with the provisions of the Copyright Act 1956 (as amended), or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 33–34 Alfred Place, London WC1E 7DP, UK. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. A CIP catalogue record for this book is available from the British Library. For full details of all Manson Publishing Ltd titles please write to: Manson Publishing Ltd, 73 Corringham Road, London NW11 7DL, UK. Tel: +44(0)20 8905 5150 Fax: +44(0)20 8201 9233 Website: www.manson-publishing.com Commissioning editor: Jill Northcott Project manager: Paul Bennett Copy-editor: Kathryn Rhodes Designer: Alpha Media Colour reproduction by Tenon & Polert Colour Scanning Ltd, Hong Kong Printed in China by New Era Printing Company Ltd Contents PREFACE ACKNOWLEDGEMENTS ABBREVIATIONS 1 INTRODUCTION A symptom-based approach to diagnosis History Clinical examination Normal structures Special investigation of orofacial disease Salivary gland investigations 2 ULCERATION General approach Traumatic ulceration Recurrent aphthous stomatitis Behçet’s disease Cyclic neutropenia Squamous cell carcinoma Necrotizing sialometaplasia Tuberculosis Syphilis Acute necrotizing ulcerative gingivitis Erosive lichen planus Lichenoid reaction Graft versus host disease Radiotherapy-induced mucositis Osteoradionecrosis 3 BLISTERS General approach Primary herpetic gingivostomatitis Recurrent herpes simplex infection Chickenpox and shingles Hand, foot, and mouth disease Herpangina Epidermolysis bullosa Mucocele Erythema multiforme Mucous membrane pemphigoid Pemphigus Linear IgA disease Dermatitis herpetiformis Angina bullosa hemorrhagica 4 WHITE PATCHES General approach Lichen planus Lichenoid reaction Lupus erythematosus Chemical burn Pseudomembranous candidosis (thrush, candidiasis) Chronic hyperplastic candidosis (candidal leukoplakia) White sponge nevus Dyskeratosis congenita Frictional keratosis Nicotinic stomatitis (smoker’s keratosis) Leukoplakia Squamous cell carcinoma Skin graft Hairy leukoplakia Pyostomatitis vegetans Submucous fibrosis 8 8 9 11 12 12 12 14 15 18 21 22 22 24 26 27 28 30 31 32 34 35 36 37 38 38 41 42 42 44 46 47 48 48 48 50 52 54 56 57 58 59 60 60 64 65 66 67 68 70 71 72 73 74 76 77 78 79 80 5 ERYTHEMA General approach Post-radiotherapy mucositis Contact hypersensitivity reaction Lichen planus Acute erythematous (atrophic) candidosis (candidiasis) Geographic tongue (benign migratory glossitis, erythema migrans) Median rhomboid glossitis (superficial midline glossitis) Angular cheilitis Iron deficiency anemia Pernicious anemia Folic acid (folate) deficiency Chronic erythematous (atrophic) candidosis (candidiasis) Erythroplakia Squamous cell carcinoma Infectious mononucleosis (glandular fever) 6 SWELLING General approach Bacterial sialadenitis Viral sialadenitis (mumps) Sialosis (sialadenosis) Mucocele and ranula Salivary gland tumor (major gland) Squamous cell carcinoma Crohn’s disease Orofacial granulomatosis Paget’s disease (osteitis deformans) Acromegaly Fibroepithelial polyp (focal fibrous hyperplasia, irritation fibroma) Drug-induced gingival hyperplasia Focal epithelial hyperplasia (Heck’s disease) Salivary gland tumor (minor gland) Denture-induced hyperplasia (denture granuloma) Pyogenic granuloma (pregnancy epulis) Peripheral giant cell granuloma (giant cell epulis) Squamous papilloma Infective warts (verruca vulgaris, condylomata acuminata) Bone exostosis Sialolith (salivary stone) Tongue piercing Lymphoma 7 PIGMENTATION (INCLUDING BLEEDING) General approach Amalgam tattoo (focal agyrosis) Hemangioma (vascular nevus) Sturge–Weber syndrome Melanocytic nevus (pigmented nevus) Melanotic macule Malignant melanoma Kaposi’s sarcoma Hereditary hemorrhagic telangiectasia (Rendu– Osler–Weber disease) Physiologic pigmentation Addison’s disease Betel nut/pan chewing Peutz–Jegher’s syndrome Black hairy tongue Drug-induced pigmentation Smoker-associated melanosis Thrombocytopenia 81 82 82 83 84 85 86 87 88 89 90 91 92 93 94 95 97 98 98 100 101 102 103 104 106 108 110 112 113 114 115 116 117 118 119 120 120 122 124 126 127 129 130 131 132 134 135 136 137 138 139 140 141 142 143 144 145 146 147 8 OROFACIAL PAIN (INCLUDING SENSORY AND MOTOR DISTURBANCE) General approach Trigeminal neuralgia Glossopharyngeal neuralgia Post-herpetic neuralgia Giant cell arteritis Burning mouth syndrome Atypical facial pain Atypical odontalgia Temporomandibular joint dysfunction (TMJ dysfunction) Facial nerve palsy (Bell’s palsy) Trigeminal nerve paresthesia or anesthesia 9 DRY MOUTH, EXCESS SALIVATION, COATED TONGUE, HALITOSIS, AND ALTERED TASTE General approach Xerostomia (dry mouth) Sjögren’s syndrome CREST syndrome Excess salivation (sialorrhea) Coated tongue Halitosis (bad breath) Altered taste INDEX 149 150 151 153 154 155 156 158 158 160 162 163 165 166 166 168 170 170 171 172 172 174 ORAL MEDICINE 8 Professor Lewis is especially grateful to Heather for her love and understanding, not only during the writing of this book, but also in the past at the time of many other professional commit- ments. In addition, special recognition must go to Professor Derrick Chisholm, Professor of Dental Surgery, University of Dundee for his continual guidance and friendship throughout a period of twenty years. Dr Jordan is grateful for the support and patience of his wife Yoon. He is also indebted to Dr Joseph Regezi of the University of California San Francisco for helpful discussions and advice. Special acknowledgement goes to Dr James Main at the University of Toronto for many years of education, mentoring, and friendship. In addition, he kindly provided some of the clinical illustrations for this book. Both authors would like to acknowledge the help of Professor Bill Binnie, Baylor College of Dentistry, Dallas for his comments on the initial outline of this book. A particular thank you must also go to Jill Northcott, Commissioning Editor at Manson Publishing for her patience during the preparation and submission of the material of this book. Clinical slides were also kindly provided by Dr Barbara Chadwick, Professor Graham Ogden, Mr Will McLaughlin, Mr Mike Cassidy, Professor Phil Lamey, Mr Mike Fardy, and Mr Andrew Cronin. Acknowledgements Preface such as infection, neoplasia, or developmental anomaly, rather than on the patient’s sympto- matic complaint of ulceration, erythema, white patch, or pain. It is hoped that the reader will find that the symptom-based approach em- ployed in this book will be one of practical value in the clinical diagnosis and management of patients with oral diseases. Michael A.O. Lewis Richard C.K. Jordan The primary aim of this book is to provide the clinician with a well-illustrated text that may be used firstly to assist the diagnosis of those conditions that fall into the specialty of oral medicine and secondly to provide a guide to initial treatment. A number of excellent atlas- type texts or reference works that comprehen- sively cover oral diseases are available. However, these books may be of limited value in the clinical setting since the material is usually presented according to the underlying etiology, ABBREVIATIONS 9 ABH Angina bullosa hemorrhagica ACE Angiotensin-converting enzyme ACTH Adrenocorticotropic hormone AIDS Acquired immune deficiency syndrome ANUG Acute necrotizing ulcerative gingivitis AZT Azidothymidine BCG Bacille Calmette–Guérin BMS Burning mouth syndrome BMT Bone marrow transplantation CREST Subcutaneous calcinosis, Raynaud’s phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia CRP C-reactive protein CT Computerized tomography DLE Discoid lupus erythematosis DNA Deoxyribonucleic acid EBV Epstein–Barr virus ESR Erythrocyte sedimentation rate FBC Full blood count FIGlu Formimino glutamic acid FTA abs Fluorescent treponema/antibody absorbed GVHD Graft versus host disease HAD Hospital Anxiety and Depression HHV Human herpesvirus HIV Human immunodeficiency virus HLA Human leukocyte antigen HPV Human papillomavirus HSV Herpes simplex virus IF Immunofluorescence ITP Idiopathic thrombocytopenia KSHV Kaposi’s sarcoma herpesvirus LFTs Liver function tests MaRAS Major recurrent aphthous stomatitis MCV Mean corpuscular volume MiRAS Minor recurrent aphthous stomatitis MMP Mucous membrane pemphigoid MRI Magnetic resonance imaging MVD Microvascular decompression PSA Pleomorphic salivary adenoma PUVA Psoralen and ultra-violet A RAS Recurrent aphthous stomatitis RAS (HU) Herpetiform recurrent aphthous stomatitis RAST Radio-allergen sorbent test REAL Revised European American lymphoma SCC Squamous cell carcinoma SLE Systemic lupus erythematosis SS Sjögren’s syndrome SSRI Serotin re-uptake inhibitor TENS Transcutaneous electric nerve stimulation TMJ Temporomandibular joint dysfunction TPHA Treponema pallidum hemagglutination VDRL Venereal Diseases Reference Laboratory VZV Varicella zoster virus WHO World Health Organization Abbreviations