APPENDIX
Differential Diagnosis of Oral
and Maxillofacial Diseases
The most important aspect of patient care is the accurate
diagnosis of the patient’s disease. Unfortunately, the clinical
presentation of many disease processes can be strikingly
similar, despite their vast differences in etiology and patho-
genesis. Because treatment and, ultimately, prognosis are
based on the diagnosis, the diagnostic process is critical in
optimal patient management. This appendix provides some
guidelines for expediting and facilitating the diagnostic
process from a clinical perspective.
The first step in gathering information is the acquisition
of a thorough history of the disease process. This step typi-
cally includes items such as the onset, severity, location,
duration, character, and course of the signs and symptoms
being experienced by the patient. Additional information
regarding medical, social, and family history may be neces-
sary. With this information, the clinician can often start the
process of formulating a list of possible diagnoses, even
before performing an examination.
The information obtained during the clinical examina-
tion is also important because many lesions have character-
istic appearances. By evaluating these characteristics in
conjunction with the patient’s history, often the clinician
can narrow the list of diagnostic possibilities. This list,
known as a differential diagnosis, essentially includes possible
pathologic entities, usually ranked in order from most likely
to least likely.
DEFINITIONS
To better describe the appearances of lesions and commu-
nicate these features to colleagues, the clinician should be
familiar with the following terms:
Macule. Focal area of color change that is not elevated
or depressed in relation to its surroundings.
Papule. Solid, raised lesion that is less than 5 mm in
diameter.
Nodule. Solid, raised lesion that is greater than 5 mm
in diameter.
Sessile. Describing a tumor or growth whose base is the
widest part of the lesion.
Pedunculated. Describing a tumor or growth whose
base is narrower than the widest part of the lesion.
Papillary. Describing a tumor or growth exhibiting
numerous surface projections.
Verrucous. Describing a tumor or growth exhibiting a
rough, warty surface.
Vesicle. Superficial blister, 5 mm or less in diameter,
usually filled with clear fluid.
Bulla. Large blister, greater than 5 mm in diameter.
Pustule. Blister filled with purulent exudate.
Ulcer. Lesion characterized by loss of the surface epithe-
lium and frequently some of the underlying connective
tissue. It often appears depressed or excavated.
Erosion. Superficial lesion, often arising secondary to
rupture of a vesicle or bulla, that is characterized by partial
or total loss of the surface epithelium.
Fissure. Narrow, slitlike ulceration or groove.
Plaque. Lesion that is slightly elevated and is flat on its
surface.
Petechia. Round, pinpoint area of hemorrhage.
Ecchymosis. Nonelevated area of hemorrhage, larger
than a petechia.
Telangiectasia. Vascular lesion caused by dilatation of a
small, superficial blood vessel.
Cyst. Pathologic epithelium-lined cavity, often filled
with liquid or semi-solid contents.
Unilocular. Describing a radiolucent lesion having a
single compartment.
Multilocular. Describing a radiolucent lesion having
several or many compartments.
By using these terms, the clinician can describe the char-
acteristics of lesions efficiently and uniformly. Applying
these clinical descriptors to the lesions also can help catego-
rize them with respect to the differential diagnosis. By
adding additional characteristics such as prevalence, patient
race or nationality, patient age at diagnosis, patient sex, and
sites of predilection, the clinician can hone the differential
diagnosis list considerably.
HOW TO USE THIS APPENDIX
This appendix is designed to help the clinician formulate a
differential diagnosis by organizing and categorizing disease
entities according to their most prominent or identifiable
849
850 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

clinical features. Under each “clinical feature” heading is a
list of lesions with that clinical feature as a prominent com-
ponent. Diseases are listed according to estimated frequency
relative to similar diseases or lesions.
The most common lesions are marked with triple aster-
isks (***), less common lesions are marked with double
asterisks (**), and rare lesions are marked with a single
asterisk (*). Such estimated frequency indicators should not
be compared between lists; they are intended only for the
single differential diagnosis list in which they occur.
Clinical features that most readily distinguish the lesions
are listed with each disease process to help focus the clini-
cian’s search for the most accurate diagnosis. Finally, the
corresponding page number in the book is provided for
each disease entity so that the reader can refer to the text
for a more detailed discussion.
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 851

INDEX TO THE APPENDIX: DIFFERENTIAL DIAGNOSIS LISTS

Part 1: Mucosal and Soft Tissue Pathology: Part 4: Radiographic Pathology
Color Changes
A. Unilocular Radiolucencies:
A. White Lesions: Can Be Scraped Off 852 Pericoronal Location 862
B. White Lesions: Cannot Be Scraped Off 852 B. Unilocular Radiolucencies:
C. White and Red Lesions 853 Periapical Location 862
D. Red Lesions 853 C. Unilocular Radiolucencies:
E. Petechial, Ecchymotic, and Telangiectatic Lesions 853 Other Locations 862
F. Blue and/or Purple Lesions 854 D. Multilocular Radiolucencies 863
G. Brown, Gray, and/or Black Lesions 854 E. Radiolucencies: Poorly Defined or
H. Yellow Lesions 855 Ragged Borders 863
F. Radiolucencies: Multifocal or Generalized 864
Part 2: Mucosal and Soft Tissue Pathology: G. Radiopacities: Well-Demarcated Borders 864
Surface Alterations H. Radiopacities: Poorly Demarcated Borders 865
I. Radiopacities: Multifocal or Generalized 865
A. Vesiculoerosive and Ulcerative Lesions: J. Mixed Radiolucent/Radiopaque Lesions:
Acute (Short Duration and Sudden Onset) 856
Well-Demarcated Borders 865
B. Vesiculoerosive and Ulcerative Lesions: K. Mixed Radiolucent/Radiopaque Lesions:
Chronic (Long Duration) 856
Poorly Demarcated Borders 866
C. Papillary Growths: Focal or Diffuse 857
L. Mixed Radiolucent/Radiopaque Lesions:
Multifocal or Generalized 866
Part 3: Mucosal and Soft Tissue Pathology: M. Unique Radiographic Appearances:
Masses or Enlargements “Ground Glass” (Frosted Glass) Radiopacities 866
A. Soft Tissue Masses (Lumps and Bumps): N. Unique Radiographic Appearances:
Lower Lip 858 “Cotton Wool” Radiopacities 866
B. Soft Tissue Masses (Lumps and Bumps): O. Unique Radiographic Appearances:
Upper Lip 858 “Sunburst” Radiopacities 866
C. Soft Tissue Masses (Lumps and Bumps): P. Unique Radiographic Appearances:
Buccal Mucosa 858 “Onion-Skin” Radiopacities 867
D. Soft Tissue Masses (Lumps and Bumps): Q. Soft Tissue Radiopacities 867
Gingiva/Alveolar Mucosa 858
E. Soft Tissue Masses (Lumps and Bumps): Part 5: Pathology of Teeth
Floor of Mouth 859
A. Hyperdontia (Extra Teeth) 868
F. Soft Tissue Masses (Lumps and Bumps): B. Hypodontia (Missing Teeth) 868
Tongue 859
C. Macrodontia (Larger Than Normal Teeth) 868
G. Soft Tissue Masses (Lumps and Bumps): D. Microdontia (Smaller Than Normal Teeth) 868
Hard or Soft Palate 859
E. Malformed Crown 868
H. Soft Tissue Masses (Lumps and Bumps): F. Enamel Loss After Tooth Formation 869
Multiple Lesions 860
G. Extrinsic Staining of Teeth 869
I. Soft Tissue Masses (Lumps and Bumps): H. Intrinsic Discoloration (“Staining”) of Teeth 869
Midline Neck Lesions 860
I. Abnormally Shaped Roots 870
J. Soft Tissue Masses (Lumps and Bumps): J. Enlarged Pulp Chamber or Canal 870
Lateral Neck Lesions 860
K. Pulpal Calcification 870
K. Generalized Gingival Enlargement 861
L. Thickened Periodontal Ligament 871
M. Generalized Loss of Lamina Dura 871
N. Premature Exfoliation of Teeth 871
852 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 1: MUCOSAL AND SOFT TISSUE PATHOLOGY: COLOR CHANGES

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

A. White Lesions: Can Be Scraped Off

*** White coated tongue May be scraped off slightly, with difficulty 12
*** Pseudomembranous “Milk curd” or “cottage cheese” appearance; may leave red base 191
candidiasis when rubbed off
*** Morsicatio Surface may appear to be peeling off 259
*** Toothpaste or mouthwash Filmy whiteness; leaves normal appearing mucosa when rubbed off 320
reaction
** Thermal burn Example: pizza burn 262
** Sloughing traumatic lesion Example: cotton roll “burn” 266
** Chemical burn Example: aspirin burn secondary to direct application for toothache 264
* Secondary syphilis Mucous patch; may be only partially scraped off 171
* Diphtheria Gray-white pseudomembrane of oropharynx 168
B. White Lesions: Cannot Be Scraped Off
*** Linea alba Buccal mucosa along occlusal plane 259
*** Leukoedema Primarily in blacks; milky white alteration of buccal mucosa 7
bilaterally; disappears when stretched
*** Leukoplakia May show benign hyperkeratosis, epithelial dysplasia, or invasive 355
carcinoma
*** Tobacco pouch keratosis Usually in mandibular vestibule; associated with use of snuff or 364
chewing tobacco
*** White coated tongue Diffuse involvement of dorsal tongue 12
** Lichen planus Wickham’s striae; typically bilateral on buccal mucosa 729
** Morsicatio Most common on anterior buccal mucosa, labial mucosa, and 259
lateral border of tongue; exhibits ragged surface
** Actinic cheilosis Pale, gray-white, scaly alteration of lower lip; usually in older men 370
with history of chronic sun exposure; precancerous
* Nicotine stomatitis Usually associated with pipe smoking; occurs on hard palate 368
* Hairy leukoplakia Usually lateral border of tongue; rough surface with vertical 242
fissures; usually associated with HIV infection
* Hyperplastic candidiasis Most commonly affects anterior buccal mucosa 195
* Lupus erythematosus Most common on buccal mucosa; may mimic lichen planus or 740
leukoplakia; associated skin lesions usually present
* Skin graft History of previous surgery —
* Submucous fibrosis More common in South Asia; associated with betel quid chewing 366
* White sponge nevus Hereditary; onset in childhood; generalized lesions, especially 691
buccal mucosa
* Hereditary benign Hereditary; onset in childhood; generalized lesions, especially 692
intraepithelial buccal mucosa; ocular involvement possible
dyskeratosis
* Pachyonychia congenita Hereditary; onset in childhood; most common on dorsal tongue 693
and areas of trauma; nail, palmar, and plantar changes also
present
* Dyskeratosis congenita Hereditary; onset in childhood; dystrophic nail changes 695
* Uremic stomatitis Renal failure 793
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 853

PART 1: MUCOSAL AND SOFT TISSUE PATHOLOGY: COLOR CHANGES—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

C. White and Red Lesions

*** Erythema migrans Geographic tongue; continually changing pattern; rarely involves 726
other oral mucosal sites
*** Candidiasis White component may be rubbed off 191
** Lichen planus Atrophic or erosive forms; Wickham’s striae; typically bilateral on 729
buccal mucosa
** Burns Examples: pizza burn, aspirin burn, other chemical burns; white 262
component may be rubbed off
** Actinic cheilosis Pale, gray-white and red alteration to lower lip; usually in older men 370
with history of chronic sun exposure
** Erythroleukoplakia Usually shows epithelial dysplasia or carcinoma 359
** Cinnamon reaction Related to cinnamon flavored gum; typically on buccal mucosa 322
and lateral tongue
* Nicotine stomatitis Usually associated with pipe smoking; occurs on hard palate 368
* Lupus erythematosus Most common on buccal mucosa; may mimic lichen planus or 740
leukoplakia; associated skin lesions usually present
* Scarlet fever Secondary to β-hemolytic streptococcal infection; strawberry/ 167
raspberry tongue
* Verruciform xanthoma Most common on gingiva and hard palate; surface may be 341
papillary
D. Red Lesions
*** Pharyngitis Examples: strep throat, viral pharyngitis 166
*** Traumatic erythema Caused by local irritation —
*** Denture stomatitis Denture-bearing palatal mucosa 194
*** Erythematous candidiasis Example: central papillary atrophy (median rhomboid glossitis) 192
*** Erythema migrans Geographic tongue (cases with absence of white borders); 726
continually changing pattern; rarely involves other mucosal sites
*** Angular cheilitis Erythema and cracking at labial commissures 194
** Thermal burns Example: caused by hot liquids 262
** Erythroplakia Usually shows epithelial dysplasia or carcinoma 363
* Anemia Atrophic, red tongue; can be due to pernicious anemia, iron- 771
deficiency anemia, hypovitaminosis B
* Hemangioma Develops in younger patients; may blanch; may show bluish hue 504
* Lupus erythematosus Usually with associated skin lesions 740
* Scarlet fever Secondary to β-hemolytic streptococcal infection; strawberry/ 167
raspberry tongue
* Plasma cell gingivitis Allergic reaction usually related to flavoring agents 145
* Radiation mucositis Patient currently undergoing radiotherapy 266
E. Petechial, Ecchymotic, and Telangiectatic Lesions
*** Nonspecific trauma History of injury to lesional site 279
** Upper respiratory Soft palate petechiae 280
infections

Continued
854 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 1: MUCOSAL AND SOFT TISSUE PATHOLOGY: COLOR CHANGES—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

* Infectious mononucleosis Soft palate petechiae; tonsillitis and/or pharyngitis may be present 229
* Idiopathic Areas of trauma; gingival bleeding possibly present 545
thrombocytopenic
purpura
* Trauma from fellatio Posterior palatal petechiae or ecchymosis 280
* Hemophilia Hereditary; childhood onset; gingival bleeding may be present 534
* Leukemia Caused by secondary thrombocytopenia; gingival bleeding may be 547
present
* Hereditary hemorrhagic Multiple, pinhead-sized telangiectasias; possible history of 702
telangiectasia nosebleeds or gastrointestinal bleeding
* CREST syndrome Multiple, pinhead-sized telangiectasias; Calcinosis cutis, Raynaud’s 747
phenomenon, Esophageal motility defect, Sclerodactyly,
Telangiectasias
F. Blue and/or Purple Lesions
*** Varicosities Especially after 45 years of age; most common on ventral tongue 13
and lips
*** Submucosal hemorrhage Also see Appendix List, Part 1, E. (previous topic) 279
Petechial, Ecchymotic, and Telangiectatic Lesions
*** Amalgam tattoo Most common on gingiva; blue-gray; radiopaque amalgam 281
particles sometimes discovered on radiographs
*** Mucocele Especially on lower labial mucosa; typically pale blue; cyclic 422
swelling and rupturing often exhibited
** Eruption cyst Overlying an erupting tooth 635
** Salivary duct cyst Usually pale blue 425
** Hemangioma Usually red-purple; may blanch under pressure; onset in younger 504
patients
** Ranula Pale blue, fluctuant swelling of lateral floor of mouth 424
* Kaposi sarcoma Especially in AIDS patients; usually purple; most common on 244
palate and maxillary gingiva
* Nasopalatine duct cyst Midline of anterior palate 26
* Salivary gland tumors Especially mucoepidermoid carcinoma and pleomorphic adenoma; Chapter 11
usually pale blue; most common on posterior lateral palate
* Gingival cyst of the adult Most common in mandibular bicuspid-cuspid region 644
* Blue nevus Most common on hard palate 354
* Melanoma Most common on hard palate and maxillary gingiva; may show 401
mixture of deep blue, brown, black, and other colors
G. Brown, Gray, and/or Black Lesions
*** Racial pigmentation Most common on attached gingiva in darker complexioned —
patients
*** Amalgam tattoo Most common on gingiva; usually slate-gray to black; opaque 281
amalgam particles may be found on radiographs
*** Black/brown hairy tongue Discoloration and elongation of filiform papillae 12
*** Melanotic macule Brown; most common on lower lip 348
** Smoker’s melanosis Most common on anterior facial gingiva 289
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 855

PART 1: MUCOSAL AND SOFT TISSUE PATHOLOGY: COLOR CHANGES—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

** Non-amalgam tattoos Example: graphite from pencil 281

* Melanocytic nevus Most common on hard palate; can be flat or raised 350
* Melanoma Most common on hard palate and maxillary gingiva; may show 401
mixture of deep blue, brown, black, and other colors
* Oral melanoacanthoma Rapidly enlarging pigmented lesion; usually occurs in blacks 349
* Drug ingestion Examples: chloroquine, chlorpromazine, minocycline; especially on 290
hard palate
* Peutz-Jeghers syndrome Freckle-like lesions of vermilion and perioral skin; intestinal polyps; 701
hereditary
* Addison disease Chronic adrenal insufficiency; associated with bronzing of skin 784
* Neurofibromatosis type I Café au lait pigmentation; cutaneous neurofibromas 495
* McCune-Albright Café au lait pigmentation; polyostotic fibrous dysplasia; endocrine 593
syndrome disorders
* Heavy metal poisoning Typically along marginal gingiva (e.g., lead, bismuth, silver) 286
* Melanotic Anterior maxilla; destroys underlying bone 499
neuroectodermal tumor
of infancy
H. Yellow Lesions
*** Fordyce granules Sebaceous glands; usually multiple submucosal papules on buccal 6
mucosa or upper lip vermilion
** Superficial abscess Example: parulis from nonvital tooth 123
** Accessory lymphoid Most common in oropharynx and floor of mouth; may exhibit 533
aggregate orange hue
** Lymphoepithelial cyst Most common on lingual and palatine tonsils, and floor of mouth; 34
may be yellow-white
** Lipoma Most common on buccal mucosa; soft to palpation 488
* Jaundice Generalized discoloration, especially involving soft palate and floor 765
of mouth; sclera usually affected also
* Verruciform xanthoma Most common on gingiva and hard palate; surface may be rough 341
or papillary
* Pyostomatitis vegetans “Snail-track” pustules; associated with inflammatory bowel disease 792
856 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 2: MUCOSAL AND SOFT TISSUE PATHOLOGY: SURFACE ALTERATIONS

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

A. Vesiculoerosive and Ulcerative Lesions: Acute (Short Duration and Sudden Onset)
*** Traumatic ulcer Mild-to-moderate pain; history of local trauma 260
*** Aphthous stomatitis Extremely painful; may be single or multiple; nonkeratinized 303
movable mucosa; often recurs
*** Recurrent herpes labialis Vermilion and labial skin; begins as multiple vesicles; often recurs 220
** Primary herpetic Fever and malaise; children and young adults; multiple vesicles; 219
gingivostomatitis gingiva consistently affected
** Necrotizing ulcerative Painful destruction of gingival papillae; fetid odor; mostly in 143
gingivitis (NUG) teenagers and young adults
** Mucosal burns Chemical or thermal 262
** Recurrent intraoral herpes Gingiva or hard palate (except in immunocompromised); focal 220
simplex cluster of vesicles and shallow ulcers
** Allergic reactions Example: Caused by topical medications or dental materials; 320
erythema and vesicles
** Erythema multiforme / Predominantly in children and young adults; multiple blisters and 723
Stevens-Johnson ulcers; often crusting, hemorrhagic lip lesions; may have
syndrome associated “target” skin lesions or involvement of ocular and
genital mucosa
** Herpangina Especially in children; multiple small ulcers on soft palate and 233
tonsillar pillars
* Varicella (chickenpox) Associated with skin eruption; few oral vesicles and ulcers; usually 224
in children
* Herpes zoster Unilateral involvement along nerve distribution; usually middle-aged 227
and older adults; painful vesicles and ulcers
* Hand-foot-and-mouth Especially in children; multiple vesicles and ulcers; associated 233
disease vesicles on hands and feet
* Necrotizing Usually posterior lateral hard palate; prior swelling may be present; 439
sialometaplasia deep crater-like ulcer; may be only minimal pain
* Anesthetic necrosis Usually at site of palatal injection 277
* Primary syphilis Chancre at site of inoculation; usually painless with clean ulcer bed 170
* Behçet syndrome Aphthous-like ulcers; genital ulcers and ocular inflammation 308
B. Vesiculoerosive and Ulcerative Lesions: Chronic (Long Duration)
*** Erosive lichen planus Associated with white striae; usually in middle-aged and older 729
adults; most common on buccal mucosa and gingiva
(“desquamative gingivitis”)
** Traumatic granuloma Solitary, non-healing ulcer 260
** Squamous cell carcinoma Usually in middle-aged and older adults; usually indurated and may 374
have rolled border; may be painless
** Mucous membrane Most common in middle-aged and older women; most commonly 718
pemphigoid presents as a “desquamative gingivitis”; may involve ocular and
genital mucosa
* Lupus erythematosus May have associated red and white change; usually with skin 740
involvement
* Pemphigus vulgaris Usually in middle-aged and older patients; multiple oral blisters and 712
ulcers usually precede skin lesions
* Deep fungal infections Examples: histoplasmosis, blastomycosis; may be painless Chapter 6
* Tuberculosis Associated mass may be present; may be painless 176
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 857

PART 2: MUCOSAL AND SOFT TISSUE PATHOLOGY: SURFACE ALTERATIONS—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

* Sarcoidosis May be associated with erythematous macules or plaques; may be 310

painless
* Epidermolysis bullosa Hereditary (except epidermolysis bullosa acquisita); onset in infancy 708
and childhood; multiple skin and oral blisters or ulcers in areas
of trauma; may result in extensive scarring
* Pyostomatitis vegetans Yellowish “snail-track” pustules; associated with inflammatory 792
bowel disease
* Wegener granulomatosis Usually palatal ulceration and destruction; associated lung and 315
kidney involvement may be present; may show “strawberry
gingivitis”
* Extranodal NK/T-cell Palatal lymphoma with ulceration and destruction of underlying 562
lymphoma, nasal-type bone; may be painless
(midline lethal
granuloma)
* Noma Gangrenous necrosis secondary to necrotizing ulcerative gingivitis; 181
usually in malnourished children or immunocompromised
individuals
* Tertiary syphilis Gumma; associated mass may be present; may be painless; may 172
perforate palate
C. Papillary Growths: Focal or Diffuse
*** Hairy tongue Usually brown or black discoloration; hyperkeratotic elongation of 12
filiform papillae on posterior dorsal tongue
*** Papilloma Can be white or pink; most common on soft palate and tongue; 332
usually pedunculated
*** Inflammatory papillary Usually involves midportion of hard palate beneath denture 478
hyperplasia
** Leukoplakia (some Examples: proliferative verrucous leukoplakia, granular or nodular 355
variants) leukoplakia
** Squamous cell carcinoma Examples with papillary surface changes 374
** Giant cell fibroma Usually in children and young adults; most common on gingiva 473
* Verruca vulgaris Common wart; especially in younger patients; most common on 334
labial mucosa
* Hairy leukoplakia Usually lateral border of tongue; rough surface with vertical 242
fissures; usually associated with HIV infection
* Verruciform xanthoma Most common on gingiva and hard palate 341
* Verrucous carcinoma Especially in older patients with long history of snuff or chewing 389
tobacco use; especially in mandibular vestibule and buccal
mucosa; may be white or red
* Condyloma acuminatum Venereal wart; broad-based lesions with blunted projections; 335
frequently multiple
* Multifocal epithelial Usually multiple, flat-topped papular lesions; usually in children; 336
hyperplasia most common in Native Americans and Inuit; color may vary
from normal to white
* Darier’s disease Most commonly appears as pebbly appearance of hard palate; 699
associated crusty, greasy skin lesions; hereditary
* Acanthosis nigricans Most commonly appears as generalized pebbly alteration of upper 748
(malignant type) lip; pigmented, pebbly skin changes in flexural areas; associated
gastrointestinal malignancy
858 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 3: MUCOSAL AND SOFT TISSUE PATHOLOGY: MASSES OR ENLARGEMENTS

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

A. Soft Tissue Masses (Lumps and Bumps): Lower Lip

*** Mucocele Typically pale blue; often exhibits cyclic swelling and rupturing; 422
labial mucosa only
*** Fibroma Usually normal in color 473
** Pyogenic granuloma Red, ulcerated, bleeds easily; usually on vermilion border 483
** Squamous cell carcinoma Tumor with rough, granular, irregular surface; usually on vermilion 374
border
* Other mesenchymal Examples: hemangioma, neurofibroma, lipoma Chapter 12
tumors
* Salivary duct cyst May be bluish; labial mucosa only 425
* Salivary gland tumor Usually mucoepidermoid carcinoma Chapter 11
* Keratoacanthoma Volcano-shaped mass with central keratin plug; rapid development; 372
vermilion border only
B. Soft Tissue Masses (Lumps and Bumps): Upper Lip
** Fibroma Usually normal in color 473
** Minor gland sialolith Small, hard submucosal mass: may be tender 427
** Salivary gland tumor Usually canalicular adenoma (older than age 40) or pleomorphic Chapter 11
adenoma (younger than age 40)
* Salivary duct cyst May be bluish 425
* Other mesenchymal Examples: hemangioma, neurofibroma, schwannoma Chapter 12
tumors
* Nasolabial cyst Fluctuant swelling of lateral labial vestibule 24
C. Soft Tissue Masses (Lumps and Bumps): Buccal Mucosa
*** Fibroma Usually normal in color; along occlusal plane 473
** Lipoma May be yellow; soft to palpation 488
** Mucocele Typically pale blue; often exhibits cyclic swelling and rupturing 422
* Hyperplastic lymph node Usually buccinator node; movable submucosal mass 533
* Other mesenchymal Examples: hemangioma, neurofibroma Chapter 12
tumors
* Squamous cell carcinoma Tumor with rough, granular, irregular surface 374
* Salivary gland tumor Pleomorphic adenoma and mucoepidermoid carcinoma most Chapter 11
common
D. Soft Tissue Masses (Lumps and Bumps): Gingiva/Alveolar Mucosa
*** Parulis Fistula from nonvital tooth 124
*** Epulis fissuratum Ill-fitting denture 475
*** Pyogenic granuloma Usually red, ulcerated, easily bleeding; increased frequency in 483
pregnant women
*** Peripheral ossifying May be red or normal in color; may be ulcerated 487
fibroma
*** Fibroma Usually normal in color 473
** Peripheral giant cell Reddish purple; frequently ulcerated 485
granuloma
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 859

PART 3: MUCOSAL AND SOFT TISSUE PATHOLOGY: MASSES OR ENLARGEMENTS—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

* Squamous cell carcinoma Tumor with rough, granular, irregular surface 374
* Metastatic tumors May be painful and destroy bone 525
* Gingival cyst of the adult Most common in mandibular bicuspid-cuspid region; may be blue 644
* Traumatic neuroma Edentulous mandible in mental foramen area; often painful to 489
palpation
* Kaposi sarcoma Especially in AIDS patients; usually purple 244
* Peripheral odontogenic Example: peripheral ameloblastoma 660
tumors
* Congenital epulis Usually in females; especially anterior maxilla 503
* Melanotic Anterior maxilla; destroys underlying bone; may be pigmented 499
neuroectodermal tumor
of infancy
* Other mesenchymal Examples: hemangioma, neurofibroma Chapter 12
tumors
E. Soft Tissue Masses (Lumps and Bumps): Floor of Mouth
*** Ranula/mucocele Typically a pale blue, fluctuant swelling 424
** Sialolith Usually hard mass in submandibular duct; may be associated with 427
tender swelling of affected gland; radiopaque mass
** Lymphoepithelial cyst Small, yellow-white submucosal lesion 34
** Squamous cell carcinoma Tumor with rough, granular, irregular surface 374
* Epidermoid or dermoid Midline yellow-white submucosal lesion 30
cyst
* Salivary gland tumors Especially mucoepidermoid carcinoma Chapter 11
* Mesenchymal tumors Examples: lipoma, neurofibroma, hemangioma Chapter 12
F. Soft Tissue Masses (Lumps and Bumps): Tongue
*** Fibroma Usually normal in color; most common on margins of tongue 473
** Squamous cell carcinoma Tumor with rough, granular, irregular surface; usually lateral or 374
ventral border
** Mucocele Usually anterior ventral surface; usually bluish or clear color 422
** Pyogenic granuloma Usually red, ulcerated, easily bleeding 483
* Granular cell tumor Dome-shaped; usually on dorsum of tongue 502
* Other mesenchymal Examples: lymphangioma, hemangioma, neurofibroma, osseous Chapter 12
tumors choristoma
* Salivary gland tumors Especially mucoepidermoid carcinoma and adenoid cystic Chapter 11
carcinoma
* Lingual thyroid Usually posterior midline of dorsal surface; usually in women 10
G. Soft Tissue Masses (Lumps and Bumps): Hard or Soft Palate
*** Palatal abscess Associated with nonvital tooth 123
*** Leaf-like denture fibroma Pedunculated hyperplastic growth beneath ill-fitting denture 477
** Salivary gland tumors Especially pleomorphic adenoma, mucoepidermoid carcinoma, Chapter 11
adenoid cystic carcinoma, polymorphous low-grade
adenocarcinoma; may have bluish hue

Continued
860 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 3: MUCOSAL AND SOFT TISSUE PATHOLOGY: MASSES OR ENLARGEMENTS—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

** Nasopalatine duct cyst Fluctuant swelling of anterior midline palate 26

* Lymphoma Often boggy and edematous; may have bluish hue; may be 555
bilateral
* Kaposi sarcoma Usually purple; may be multiple; usually associated with AIDS 244
* Other mesenchymal Examples: fibroma, hemangioma, neurofibroma Chapter 12
tumors
* Squamous cell carcinoma Tumor with rough, granular, irregular surface; occasionally arises 374
from maxillary sinus
* Mucocele/salivary duct Usually has bluish hue 422
cyst
* Melanocytic nevus/ Usually pigmented 350, 401
melanoma
* Necrotizing Early stage lesion; often associated with pain or paresthesia 439
sialometaplasia
* Adenomatoid hyperplasia Asymptomatic, painless mass 438
of minor salivary glands
H. Soft Tissue Masses (Lumps and Bumps): Multiple Lesions
** Multiple fibromas Some patients may develop more than one fibroma on the oral 473
mucosa
* Kaposi sarcoma Usually purple lesions of palate and maxillary gingiva; usually 244
associated with AIDS
* Neurofibromatosis type I Oral and skin neurofibromas; café au lait skin pigmentation 495
* Multifocal epithelial Usually flat-topped papular lesions; usually in children; most 336
hyperplasia common in Native Americans and Inuit; color may vary from
normal to white
* Amyloidosis Pale, firm deposits, especially in tongue; periocular cutaneous 766
lesions frequently present; most often associated with multiple
myeloma
* Granulomatous diseases Examples: sarcoidosis, Crohn disease, leprosy 310
* Multiple endocrine Mucosal neuromas of lips and tongue; adrenal 497
neoplasia type 2B pheochromocytomas; medullary thyroid carcinoma; marfanoid
body build
* Tuberous sclerosis Small fibroma-like growths on gingiva; angiofibromas of face; 705
epilepsy; intellectual disability
* Multiple hamartoma Cowden syndrome; small fibroma-like growths on gingiva; multiple 707
syndrome hamartomas of various tissues; breast cancer in affected women
I. Soft Tissue Masses (Lumps and Bumps): Midline Neck Lesions
** Thyroid gland enlargement Examples: goiter, thyroid tumor —
* Thyroglossal duct cyst May move up and down with tongue motion 32
* Dermoid cyst Soft and fluctuant 30
* Plunging ranula Soft and compressible 424
J. Soft Tissue Masses (Lumps and Bumps): Lateral Neck Lesions
*** Reactive Secondary to oral and maxillofacial infection; often tender to 533
lymphadenopathy palpation
** Epidermoid cyst Soft and movable 29
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 861

PART 3: MUCOSAL AND SOFT TISSUE PATHOLOGY: MASSES OR ENLARGEMENTS—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

** Lipoma Soft mass 488

** Metastatic carcinoma Deposits from oral and pharyngeal carcinomas; usually indurated 383
and painless; may be fixed
** Lymphoma May be unilateral or bilateral; usually painless; Hodgkin and 553
non-Hodgkin types
* Infectious mononucleosis Fatigue; sore throat; tender lymph nodes 229
* Salivary gland tumors Arising from submandibular gland or tail of parotid gland Chapter 11
* Submandibular sialadenitis Example: secondary to sialolithiasis 429
* Branchial cleft cyst Soft and fluctuant; most common in young adults 33
* Granulomatous diseases Examples: tuberculosis, sarcoidosis 176, 310
* Cat-scratch disease History of exposure to cat 184
* Cystic hygroma Infants; soft and fluctuant 510
* Plunging ranula Soft and compressible 424
* Other mesenchymal Examples: neurofibroma, carotid body tumor Chapter 12
tumors
K. Generalized Gingival Enlargement
*** Hyperplastic gingivitis Examples: associated with puberty, pregnancy, diabetes 140
** Drug-related gingival Examples: phenytoin, calcium-channel blockers, cyclosporine; may 148
hyperplasia be fibrotic
* Gingival fibromatosis May be hereditary; onset in childhood 151
* Leukemic infiltrate Usually boggy and hemorrhagic 547
* Wegener granulomatosis “Strawberry” gingivitis; may have palatal ulceration and destruction; 315
lung and kidney involvement
* Scurvy Vitamin C deficiency 770
862 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 4: RADIOGRAPHIC PATHOLOGY

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

A. Unilocular Radiolucencies: Pericoronal Location

*** Hyperplastic dental follicle <5 mm in thickness 633
*** Dentigerous cyst >5 mm in thickness 632
** Eruption cyst Bluish swelling overlying erupting tooth 635
** Odontogenic keratocyst — 636
* Orthokeratinized — 639
odontogenic cyst
* Ameloblastoma Especially unicystic type 653
* Ameloblastic fibroma Usually in younger patients 669
* Adenomatoid odontogenic Usually in anterior region of jaws; most often with maxillary canine; 664
tumor usually in teenagers
* Calcifying odontogenic Gorlin cyst 647
cyst
* Carcinoma arising in Mostly in older adults 651
dentigerous cyst
* Intraosseous muco- Mostly in posterior mandible 457
epidermoid carcinoma
* Other odontogenic lesions Examples: calcifying epithelial odontogenic tumor, odontogenic Chapter 15
myxoma, central odontogenic fibroma
B. Unilocular Radiolucencies: Periapical Location
*** Periapical granuloma Nonvital tooth 117
*** Periapical cyst Nonvital tooth 119
** Periapical cemento- Especially in black females; usually apical to mandibular anteriors; 597
osseous dysplasia teeth are vital
(early)
* Periapical scar Usually endodontically treated tooth with destruction of cortical 119
plate
* Dentin dysplasia type I Multiple periapical granulomas or cysts; shortened, malformed 102
roots
C. Unilocular Radiolucencies: Other Locations
*** Developing tooth bud Within alveolar bone —
** Lateral radicular cyst Nonvital tooth; lateral canal 120
** Nasopalatine duct cyst Between and apical to maxillary central incisors; palatal swelling 26
may occur
** Lateral periodontal cyst Especially in mandibular bicuspid-cuspid region 645
** Residual (periapical) cyst Edentulous area 121
** Odontogenic keratocyst — 636
** Central giant cell Especially in anterior mandible 584
granuloma
** Stafne bone defect Angle of mandible below mandibular canal 22
* Cemento-osseous Early stage; usually in young adult and middle-aged black women; 596
dysplasia usually in mandible
* Central ossifying fibroma Early-stage lesion 602
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 863

PART 4: RADIOGRAPHIC PATHOLOGY—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

* Ameloblastoma Especially unicystic type 653

* Buccal bifurcation cyst Buccal aspect of erupting mandibular first or second molar 650
* Other odontogenic cysts Examples: ameloblastic fibroma, central odontogenic fibroma, Chapter 15
and tumors calcifying odontogenic cyst
* Langerhans cell “Histiocytosis X”; usually in children or young adults 550
histiocytosis
* Melanotic Anterior maxilla; may be pigmented 499
neuroectodermal tumor
of infancy
* Median palatal cyst Clinical midline swelling of hard palate 28
* Schwannoma/ Usually associated with mandibular nerve 494
neurofibroma
D. Multilocular Radiolucencies
*** Odontogenic keratocyst — 636
*** Ameloblastoma Especially in posterior mandible; often associated with impacted 653
tooth
** Central giant cell Especially in anterior mandible 584
granuloma
* Ameloblastic fibroma Especially in young patients 669
* Odontogenic myxoma “Cobweb” trabeculation 679
* Central odontogenic — 676
fibroma
* Calcifying epithelial Often associated with impacted tooth 666
odontogenic tumor
* Orthokeratinized Often associated with impacted tooth 639
odontogenic cyst
* Lateral periodontal cyst Especially in mandibular bicuspid-cuspid region 645
(botryoid type)
* Calcifying odontogenic Especially in cases with minimal or no calcifications; often 647
cyst associated with impacted tooth
* Central hemangioma/ Especially in younger patients; may have honeycombed 506
arteriovenous radiographic appearance; may pulsate
malformation
* Aneurysmal bone cyst Especially in younger patients 591
* Cherubism Hereditary; onset in childhood; multiple quadrants involved 587
* Hyperparathyroidism Usually elevated serum calcium levels 781
(brown tumor)
* Intraosseous muco- Usually in posterior mandible 457
epidermoid carcinoma
* Fibrous dysplasia Very rarely on panoramic films of mandibular lesions 592
E. Radiolucencies: Poorly Defined or Ragged Borders
*** Periapical granuloma or Nonvital tooth 117
cyst
*** Focal osteoporotic Especially edentulous areas in posterior mandible; more common 579
marrow defect in females

Continued
864 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 4: RADIOGRAPHIC PATHOLOGY—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

** Osteomyelitis Usually painful or tender 128

** Medication-related Exposed necrotic bone; most often associated with 271
osteonecrosis of the bisphosphonate drugs
jaw
* Simple bone cyst Mandibular lesion that scallops up between roots of teeth; usually 589
in younger patients
* Metastatic tumors Painful; paresthesia; usually in older adults 622
* Osteoradionecrosis History of radiation therapy; painful 269
* Multiple myeloma May be painful; in older adults 563
* Primary intraosseous Odontogenic or salivary origin 661
carcinomas
* Osteosarcoma Often painful; usually in young adults 614
* Chondrosarcoma — 618
* Ewing sarcoma Usually in children 621
* Other primary bone Examples: fibrosarcoma, lymphoma —
malignancies
* Desmoplastic fibroma of Especially in younger patients 613
bone
* Massive osteolysis Phantom (vanishing) bone disease 581
F. Radiolucencies: Multifocal or Generalized
*** Cemento-osseous Early stage lesions; usually in black females; usually in mandible 596
dysplasia
** Nevoid basal cell Odontogenic keratocysts 640
carcinoma syndrome
** Multiple myeloma Painful; in older adults; “punched-out” lesions 563
* Cherubism Usually multilocular; onset in childhood; hereditary 587
* Hyperparathyroidism Multiple brown tumors 781
* Langerhans cell “Histiocytosis X”; in children and young adults; teeth “floating in air” 550
histiocytosis
G. Radiopacities: Well-Demarcated Borders
*** Torus or exostosis Associated with bony surface mass 18
*** Retained root tip Remnants of periodontal ligament usually seen —
*** Idiopathic osteosclerosis Most commonly associated with roots of posterior teeth; no 579
apparent inflammatory etiology
*** Pseudocyst of the Homogeneous, dome-shaped relative opacity rising above bony 293
maxillary sinus floor of maxillary sinus
** Condensing osteitis Usually at apex of nonvital tooth 134
** Odontoma, compound Toothlike structures with thin, radiolucent rim at junction with 674
surrounding bone; may prevent eruption of teeth; more common
in anterior segments of jaws
** Odontoma, complex Amorphous mass with thin, radiolucent rim at junction with 674
surrounding bone; may prevent eruption of teeth; more common
in posterior segments of jaws
** Cemento-osseous Late-stage lesions; especially in middle-aged and older black 596
dysplasia women; usually in mandible
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 865

PART 4: RADIOGRAPHIC PATHOLOGY—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

** Soft tissue radiopacity Examples: sialoliths, calcified nodes, phleboliths, bullet fragments, —
superimposed on bone shotgun pellets, amalgam tattoos (See also Appendix List, Part
4, Q, page 867)
* Intraosseous foreign body — —
* Osteoma Associated with bony surface mass 605
* Enamel pearl Furcation area of molar tooth 85
* Osteoblastoma/osteoid Late-stage lesions 608
osteoma/
cementoblastoma
H. Radiopacities: Poorly Demarcated Borders
** Cemento-osseous Late stage lesions; especially in middle-aged and older black 596
dysplasia women; usually in mandible
** Medication-related Sclerosis of alveolar crestal bone; exposed necrotic bone; most 271
osteonecrosis of the often associated with bisphosphonate drugs
jaw
** Condensing osteitis Usually at apex of nonvital tooth 134
** Sclerosing osteomyelitis May be painful 131
* Fibrous dysplasia “Ground glass” appearance; onset usually in younger patients 592
* Paget disease of bone “Cotton wool” appearance; late-stage lesions; in older patients 582
* Proliferative periostitis “Onion-skin” cortical change; in younger patients; often associated 134
with nonvital tooth
* Osteosarcoma May have “sunburst” cortical change; frequently painful; usually in 614
young adults
* Chondrosarcoma — 618
I. Radiopacities: Multifocal or Generalized
** Florid cemento-osseous Late-stage lesions; especially in middle-aged and older black 598
dysplasia women; usually in mandible
** Medication-related Multifocal sites of involvement; sclerosis of alveolar crestal bone; 271
osteonecrosis of the exposed necrotic bone; most often associated with
jaw bisphosphonate drugs
* Idiopathic osteosclerosis Occasionally may be multifocal 579
* Paget disease of bone “Cotton wool” appearance; late-stage lesions; in older patients; 582
more common in maxilla
* Gardner syndrome Multiple osteomas; epidermoid cysts; gastrointestinal polyps with 606
high tendency toward malignant transformation; hereditary
* Polyostotic fibrous “Ground glass” appearance; onset usually in younger patients; may 593
dysplasia be associated with café au lait skin pigmentation and endocrine
abnormalities (McCune-Albright syndrome)
* Osteopetrosis Hereditary; recessive form may be associated with secondary 574
osteomyelitis, visual and hearing impairment
J. Mixed Radiolucent/Radiopaque Lesions: Well-Demarcated Borders
*** Developing tooth — —
*** Cemento-osseous Intermediate-stage lesions; especially in middle-aged black 596
dysplasia women; usually in mandible

Continued
866 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 4: RADIOGRAPHIC PATHOLOGY—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

** Odontoma Compound or complex type; in younger patients; may prevent 674

eruption of teeth
* Central ossifying fibroma — 602
* Ameloblastic fibro- Usually in children 671
odontoma
* Adenomatoid odontogenic Usually in anterior region of jaws; most often with maxillary canine; 664
tumor usually in teenagers
* Calcifying epithelial Pindborg tumor; often associated with impacted tooth; may show 666
odontogenic tumor “driven snow” opacities
* Calcifying odontogenic Gorlin cyst; may be associated with odontoma 647
cyst
* Osteoblastoma/osteoid Intermediate-stage lesion; usually in younger patients; often painful 608
osteoma
* Cementoblastoma Intermediate-stage lesion; attached to tooth root 610
K. Mixed Radiolucent/Radiopaque Lesions: Poorly Demarcated borders
** Medication-related Exposed necrotic bone; most often associated with 271
osteonecrosis of the bisphosphonate drugs
jaw
** Osteomyelitis With sequestrum formation or with sclerosing type; often painful 128
* Metastatic carcinoma Especially prostate and breast carcinomas; may be painful 622
* Osteosarcoma/ May be painful 614
chondrosarcoma
L. Mixed Radiolucent/Radiopaque Lesions: Multifocal or Generalized
** Florid cemento-osseous Intermediate-stage lesions; especially in middle-aged black 598
dysplasia women; usually in mandible
** Medication-related Exposed necrotic bone; most often associated with 271
osteonecrosis of the bisphosphonate drugs
jaw
* Paget disease of bone In older patients; more common in maxilla 582
M. Unique Radiographic Appearances: “Ground Glass” (Frosted Glass) Radiopacities
* Fibrous dysplasia Onset usually in younger patients 592
* Hyperparathyroidism May cause loss of lamina dura 781
N. Unique Radiographic Appearances: “Cotton Wool” Radiopacities
** Cemento-osseous Especially in middle-aged black women; usually in mandible 596
dysplasia
* Paget disease of bone In older patients; more common in maxilla 582
* Gardner syndrome Multiple osteomas; epidermoid cysts; gastrointestinal polyps with 606
high tendency toward malignant transformation; hereditary
* Gigantiform cementoma Hereditary; facial enlargement may be present 601
O. Unique Radiographic Appearances: “Sunburst” Radiopacities
* Osteosarcoma Often painful; usually in young adults 614
* Intraosseous hemangioma Especially in younger patients 506
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 867

PART 4: RADIOGRAPHIC PATHOLOGY—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

P. Unique Radiographic Appearances: “Onion-Skin” Radiopacities

* Proliferative periostitis In younger patients; often associated with nonvital tooth; best seen 134
with occlusal radiograph
* Ewing sarcoma In young children 621
* Langerhans cell “Histiocytosis X”; usually in children or young adults 550
histiocytosis
Q. Soft Tissue Radiopacities
*** Amalgam tattoo Markedly radiopaque; associated with surface discoloration 281

** Other foreign bodies Examples: bullet fragments, shotgun pellets —

** Sialolith Glandular pain may be present while patient is eating 427
** Tonsilloliths Superimposed on mandibular ramus 168
* Phlebolith May occur in varicosities or hemangiomas 14
* Calcified lymph nodes Example: tuberculosis 178
* Osseous and cartilaginous Most common on tongue 515
choristomas
* Calcinosis cutis May be seen with systemic sclerosis (especially CREST syndrome) 747
* Myositis ossificans Reactive calcification in muscle —
868 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 5: PATHOLOGY OF TEETH

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

A. Hyperdontia (Extra Teeth)

*** Idiopathic supernumerary Mesiodens, paramolar, distomolar 70
teeth
** Cleft lip and palate Extra lateral incisor or canine 1
* Gardner syndrome Osteomas and gastrointestinal polyps 606
* Cleidocranial dysplasia Hypoplastic or missing clavicles; failure of tooth eruption 576
B. Hypodontia (Missing Teeth)
*** Idiopathic hypodontia Missing third molars, lateral incisors 70
** Cleft lip and palate Missing lateral incisor or canine 1
* Hereditary hypohidrotic Cone-shaped teeth 690
ectodermal dysplasia
* Incontinentia pigmenti Cone-shaped teeth 698
* Radiotherapy during Stunted tooth development 52
childhood
C. Macrodontia (Larger Than Normal Teeth)
** Fusion Joining of two tooth germs 77
** Gemination Incomplete splitting of a tooth germ 77
* Idiopathic macrodontia — 76
* Facial hemihyperplasia Affected side only; nondental tissues also enlarged 35
* Gigantism Abnormally tall stature 775
D. Microdontia (Smaller Than Normal Teeth)
*** Supernumerary teeth Mesiodens; fourth molars 70
*** Peg-shaped lateral incisors Cone-shaped teeth 76
** Dens invaginatus Cone-shaped teeth; tendency for pulpal death and periapical 82
pathosis
* Idiopathic microdontia Usually generalized 76
* Hereditary hypohidrotic Cone-shaped teeth; sparse, blond hair; diminished sweating 690
ectodermal dysplasia
* Radiotherapy during Stunted tooth development 52
childhood
* Congenital syphilis Hutchinson’s incisors 172
* Hypopituitarism Associated dwarfism 774
E. Malformed Crown
*** Mesiodens and other Cone-shaped teeth or microdont 70
supernumeraries
** Environmental enamel Example: high fever during tooth development 49
hypoplasia
** Peg-shaped lateral incisors Cone-shaped teeth 76
** Dens invaginatus Cone-shaped teeth; tendency toward pulpal death and periapical 82
pathosis
** Turner tooth Infection or trauma to associated primary tooth 50
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 869

PART 5: PATHOLOGY OF TEETH—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

** Fusion or gemination “Double” tooth 77

* Talon cusp Extra cusp on lingual of anterior tooth 80
* Dens evaginatus Extra cusp on occlusal of premolar tooth 81
* Amelogenesis imperfecta Hereditary defect in enamel formation 92
* Dentinogenesis imperfecta Fracturing away of enamel due to hereditary defect in dentin 98
formation; gray-yellow opalescent teeth; calcified pulp chambers
* Regional odontodysplasia Poor tooth formation in a focal area; “ghost teeth” 104
* Congenital syphilis Hutchinson’s incisors; mulberry molars 172
* Vitamin D–resistant rickets Hereditary condition; high pulp horns 789
* Renal osteodystrophy Abnormal calcium and phosphate metabolism 782
* Hypoparathyroidism Possible associated endocrine-candidiasis syndrome 780
* Pseudohypoparathyroidism — 781
* Epidermolysis bullosa Hereditary blistering skin disease 708
* Radiotherapy during Stunted tooth development 52
childhood
* Globodontia Associated with otodental syndrome 91
* Lobodontia Cusp anatomy resembles teeth of carnivores 91
F. Enamel Loss After Tooth Formation
*** Caries — —
*** Trauma Fractured tooth —
*** Attrition Physiologic loss of tooth structure 55
*** Abrasion Pathologic loss of tooth structure 56
** Erosion Chemical loss of tooth structure 56
* Dentinogenesis imperfecta Hereditary defect in dentin formation; poor junction between 98
enamel and dentin
* Amelogenesis imperfecta Hereditary defect in enamel formation; especially hypocalcified 92
types
G. Extrinsic Staining of Teeth
*** Tobacco Black or brown 63
*** Coffee, tea, and cola Brown or black 63
drinks
** Chromogenic bacteria Brown, black, green, or orange 63
** Chlorhexidine Yellow-brown 63
H. Intrinsic Discoloration (“Staining”) of Teeth
*** Aging Yellow-brown; less translucency —
*** Death of pulp Gray-black; less translucency 64
** Fluorosis White; yellow-brown; brown; mottled 52
** Tetracycline Yellow-brown; yellow fluorescence 65
** Internal resorption “Pink tooth of Mummery” 58

Continued
870 APPENDIX Differential Diagnosis of Oral and Maxillofacial Diseases

PART 5: PATHOLOGY OF TEETH—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

* Calcific metamorphosis Yellow 114

* Dentinogenesis imperfecta Blue-gray; translucent 98
* Amelogenesis imperfecta Yellow-brown 92
* Congenital erythropoietic Yellow; brown-red; red fluorescence 64
porphyria
* Erythroblastosis fetalis Yellow; green 64
I. Abnormally Shaped Roots
*** External root resorption Secondary to infection, cyst, tumor 58
*** Dilaceration Abnormal curvature 89
** Hypercementosis Excessive cementum production 88
** Supernumerary roots — 90
** Concrescence Joining of teeth by cementum 77
** Taurodontism Enlarged pulp chambers; shortened roots 86
** Enamel pearl Ectopic enamel in furcation 85
* Benign cementoblastoma Tumor attached to root 610
* Radiotherapy during Stunted root development 52
childhood
* Dentinogenesis imperfecta Shortened roots; obliterated pulps 98
* Dentin dysplasia type I Shortened, pointed roots (“rootless teeth”); obliterated pulps; 102
periapical pathosis
J. Enlarged Pulp Chamber or Canal
** Internal resorption Secondary to caries or trauma 58
** Taurodontism Enlarged pulp chambers; shortened roots 86
* Dentinogenesis imperfecta “Shell teeth” 98
* Regional odontodysplasia “Ghost teeth” 104
* Vitamin D–resistant rickets High pulp horns 789
* Hypophosphatasia — 788
* Dentin dysplasia type II “Thistle-tube” pulps; pulp stone formation 101
K. Pulpal Calcification
*** Pulp stones Asymptomatic radiographic finding 115
*** Secondary dentin Response to caries 113
** Calcific metamorphosis Pulpal obliteration secondary to aging or trauma 114
* Dentinogenesis imperfecta Pulpal obliteration by excess dentin 98
* Dentin dysplasia type I Pulpal obliteration by excess dentin; “chevron”-shaped pulp 102
chambers
* Dentin dysplasia type II Pulpal obliteration of primary teeth; pulp stones in permanent teeth 101
 APPENDIXDifferential Diagnosis of Oral and Maxillofacial Diseases 871

PART 5: PATHOLOGY OF TEETH—cont’d

Frequency of
Occurrence Lesion or Condition Comments or Special Characteristics Page

L. Thickened Periodontal Ligament

*** Periapical abscess Focal thickening at apex of nonvital tooth; painful, especially on 123
percussion of involved tooth
*** Current orthodontic — —
therapy
** Increased occlusal function — —
* Systemic sclerosis Generalized widening 744
(scleroderma)
* Sarcoma or carcinoma Especially osteosarcoma; localized to teeth in area of tumor 616, 623
infiltration
M. Generalized Loss of Lamina Dura
* Hyperparathyroidism Calcium removed from bones; bone may have “ground glass” 781
appearance
* Osteomalacia Vitamin D deficiency in adults 771
* Paget disease of bone “Cotton wool” change hides lamina dura 582
* Fibrous dysplasia “Ground glass” change hides lamina dura 592
N. Premature Exfoliation of Teeth
*** Trauma Avulsed tooth —
** Aggressive periodontitis Premature alveolar bone loss 157
** Immunocompromised AIDS, leukemia, chemotherapy 246
states
** Diabetes mellitus Increased susceptibility to infection and severity of periodontitis 785
* Osteomyelitis Bone destruction loosening teeth 128
* Cyclic or chronic Increased susceptibility to infection; premature alveolar bone loss 544
neutropenia
* Langerhans cell “Histiocytosis X”; eosinophilic granuloma; premature alveolar bone 550
histiocytosis loss
* Dentin dysplasia type I “Rootless teeth” 102
* Regional odontodysplasia “Ghost teeth” 104
* Papillon-Lefèvre syndrome Palmar and plantar hyperkeratosis; premature periodontitis 159
* Down syndrome Premature periodontitis —
* Hypophosphatasia Lack of cementum production in primary teeth 788
* Scurvy Vitamin C deficiency 770