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I D E N T I F I C AT I O N A N D S C R E E N I N G

Oral Pathology:
Techniques for
Detection and
Differential
Diagnosis
Cynthia Blendermann Perone, DDS

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Oral Pathology: Techniques for
Detection and Differential Diagnosis
Cynthia Blendermann Perone, DDS
ABSTRACT
Oral pathology includes diseases of
the mouth, jaw, and related structures.
This article provides information to help
identify, screen, and diagnose common
oral pathologies and oral abnormalities.
A variety of diagnostic mechanisms are
available for use, including screening
methods and tools to aid in the
detection of oral pathologies. The article
will focus on key areas to explore when
making a differential diagnosis, which
may involve referring to a specialist in
some situations.
LEARNING OBJECTIVES
• Describe how to identify and
differentiate between common
abnormalities of the mouth and
surrounding areas.
• Define screening methods and
tools to aid in the detection of oral
pathologies.
• Discuss how to confidently make a
differential diagnosis.
VOLUME 5 • NUMBER 107
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O
ral pathology encompasses diseases of the mouth, jaw,
and related structures, such as the temporomandibular
joint (TMJ), salivary glands, periorbital skin, and facial
muscles. There are hundreds of oral pathologies. When patients
have a suspicious growth or condition of the mouth, it is essential
to determine the cause, accurately diagnose, and speedily give
any necessary care.
Every year, there are about 500,000 new cases of oral cancer
worldwide, accounting for approximately 3% of all malignancies.1
Oral cancer has a tendency to be detected at a late stage, which is
detrimental to patients.2 Although the oral cavity is a potentially
accessible site for examination, up to 50% of oral cancers are not
detected until the disease is well advanced.3 The most common
form of oral cancer is squamous cell carcinoma, which accounts
for 96% of all cancers of the oral cavity.4 Despite significant
advances in cancer treatment, early detection of oral cancer and its
curable precursors remains the best way to ensure patient survival
and improved quality of life.5,6 Clinicians can improve patients’
survival rates if a cancerous lesion is detected at an early stage or
if a precursor lesion (dysplasia) is discovered and treated before
malignant progression.7 As the emphasis shifts from damage
mitigation to disease prevention or reversal of early disease in
the oral cavity, the need for sensitive and accurate detection and
diagnostic tools becomes more important.8
The goal of this article is to build confidence and competence
in the identification, screening, and differential diagnoses of com-
mon oral pathologies as well as the detection of oral abnormalities.
Building this knowledge will take collaboration between dental
providers, physicians, and specialists, including oral and maxil-
lofacial surgeons, radiologists, and pathologists.
IDENTIFYING AND DIFFERENTIATING BETWEEN COMMON
ABNORMALITIES
The development of a reasonable differential diagnosis is of prime
importance in determining whether biopsy is indicated. The dif-
ferential diagnosis aids the clinician in selecting the appropriate
CDEWORLD.COM 3
 1
Fig 1. A radiographic assessment may include a panoramic image.
technique if a biopsy is neces-
sary.9 There are three steps to
achieving the first learning ob-
jective of this article, identify-
ing and differentiating between
common abnormalities of the
mouth and surrounding area.
One is to take a comprehensive
medical history. Another is to
understand the anatomy of the
oral cavity and surrounding
structures. The third is to be
familiar with the terminology
associated with what is being
visualized or palpated.
Medical History
Medical history should be col-
lected at every appointment.
Patients should be asked about
their social history, including dietary habits,
oral hygiene habits, smoking, and alcohol and
drug use. A comprehensive understanding of
each patient’s medical history enables dentists
to understand the psychosocial components
and general habits of a patient, thus enabling
4 CDEWORLD.COM
An intraoral
an accurate assessment of risk
factors and pathologies.
assessment in- Physical Assessment
A physical assessment of the
cludes visual- oral cavity and surrounding
landmarks has three compo-
izing all land- nents: the extraoral assess-
ment, the intraoral assess-
marks in the ment, and radiographs. The
extraoral assessment involves
oral cavity and palpation of the submandibu-
lar and sublingual glands, cer-
gingival and vical lymph nodes, pre- and
post-auricular lymph nodes,
buccal mucosa. TMJ, any asymmetries, lips,
skin and facial structures,
thyroid gland, and muscles of
mastication. An intraoral as-
sessment includes visualizing
all landmarks in the oral cavity and gingival
and buccal mucosa, along with the dentition.
Radiographic assessments may involve a pan-
oramic image (Figure 1) or cone-beam com-
puted tomography (CBCT) as required, which
must be read by someone trained to do so.
MARCH 2018
 TABLE 1. COMMON TERMINOLOGY IN DIAGNOSIS
TERM DEFINITION
benign noncancerous
bulla large blister greater than 5 mm
endophytic burrowing
erythroplakia red patch
exophytic mass-forming
hyperkeratosis thickening of stratum corneum (keratinized layer) of the mucosa
leukoplakia white patch
macule small circumscribed changes in the color—not depressed or raised
malignant diseases in which abnormal cells uncontrollably divide and can invade nearby tissues
multilocular radiolucent lesion with several compartments
neoplasm an abnormal growth of tissue
nodule solid raised lesion (greater than 5 mm)
papillary tumor growth with multiple projections
papule solid raised lesion (less than 5 mm)
pedunculated raised on a stalk (base is smaller than the largest part of lesion)
radiolucent dark (does not block radiation, therefore appears dark)
radiopaque light white (blocks radiation, therefore appears white)
sessile attached directly by the base
unilocular radiolucent lesion with a single compartment
vesicle superficial blisters 5 mm or less; may be filled with clear fluid

A thorough understanding of anatomy includes Table 1. It is also important to take medication

an awareness of nerves and vasculature. This
knowledge will enable a more comprehensive as-
sessment of complex pathologies. Furthermore,
when taking a biopsy of an area of the mouth,
an understanding of the vital structures in those
areas is crucial in order to prevent damage to the
vasculature and nerves.
Terminology
When describing a lesion, terminology is key.
Critical components in the description of a le-
sion include, but are not limited to, location,
size, shape, color, consistency, mobility, and
radiographic properties. A history of the lesion,
including whether it causes pain and any other
curiosities, is also important. Some of the most
common terminology in diagnosis is listed in
histories, not only to prevent prescription errors
and consequent risks to patients but also to detect
drug-related clinical or pathologic changes.10
SCREENING METHODS
After the medical history and physical assess-
ment, anatomy, landmarks, and descriptive ter-
minology are understood, the next objective is
to define screening methods and tools to help
detect oral pathologies. Screening methods fall
into four categories: visual, tools, laboratory
studies, and biopsy.
Visual Examination
Visual examination involves what was covered in
the previous section of this article: radiographic
interpretation, along with extraoral and intraoral

VOLUME 5 • NUMBER 107 CDEWORLD.COM 5

 2 3
Fig 2. Biopsy punches.
An oral
assessments. Some oral pa-
thologies are easily diagnosed
biopsy is
based on history and appear-
ance; however, others are not.
In addition, although diagnosis
may appear to be self-evident essential for
by visual inspection alone,
coexisting diseases could be a definitive
present that may go undetected
and untreated.11 Nevertheless, diagnosis of
a thorough history-taking en-
sures a good doctor-patient re-
lationship and can prevent the
the diseases
need for expensive laboratory
procedures in some cases.12
that occur
Tools
in the oral
A variety of screening tools
can be implemented to detect
mucosa.
oral pathologies. Some use
fluorescent visualization to
detect oral disease. Others
use three wavelengths of light to reveal mucosal
abnormalities. Still others use light-emitting di-
ode (LED) beam technology and a high-contract
fluorescence viewer to enable both intraoral and
extraoral access. Depending on the type of light
and the imaging approaches used, optical imag-
ing of the oral tissues can detect slight changes
within the tissues, such as alterations in tissue
architecture and composition; expression of
specific biomarkers, vascularity/angiogenesis,
and perfusion; and microanatomy and tissue
boundary integrity.13,14 These tools can be used to
6 CDEWORLD.COM
Fig 3. Brush biopsy.
identify oral cancer, but when
abnormalities are found, it is
important to remember that
not all abnormal tissue will
be cancer. Each tool has its
individual benefits; choosing
a tool ultimately comes down
to personal preference.
Laboratory Studies
The next set of diagnostics
involves collection of cultures
or tissues for laboratory stud-
ies. Cultures can be taken to
assess bacterial, fungal, and
viral infections that may be
contributory to the patholo-
gies. Bacterial and fungal
culturing is not routinely per-
formed for oral lesions. The
cultures can be obtained by
swabbing a patient’s draining
abscess to determine which type of bacteria or
fungus is present in order to best treat with anti-
biotics or antifungal therapy. Viral cultures can
be obtained similarly. Other tests include direct
fluorescence, an antibody test, and polymerase
chain reaction.
Biopsy
To diagnose oral lesions, a tissue biopsy is consid-
ered the gold standard.15 An oral biopsy is essential
for a definitive diagnosis of the diseases that oc-
cur in the oral mucosa.16 Initially, the accuracy of
MARCH 2018

4
Fig 4. Fine-needle aspiration.
the history-taking and clinical examination can
have an influence on the accuracy of a biopsy.
Thereafter, the biopsy’s accuracy is dependent on
the administration of local anesthesia, the method
adopted to remove the tissue, adequate size and
depth of the tissue from the representative site, and
the subsequent fixation method.17
The four biopsy techniques that can be used
orally include a punch biopsy, a brush or exfolia-
tive cytology, an incisional or excisional biopsy,
or an aspiration. An incisional biopsy is typically
obtained to get a small representative sample, while
an excisional biopsy is usually used to surgically
remove and evaluate an entire lesion. The area
can be numbed with topical or local anesthetic, or
a block may be used instead in an effort to reduce
the risk of distorting the lesion.
Biopsy punches come in a variety of sizes and
in both reusable and disposable forms (Figure 2).
Disposable biopsy punches are lighter and more
easily manipulated than their metal counterparts.
Most incisional intraoral biopsies can be performed
with a 3- or 4-mm punch, whereas larger punches
can be used for small excisional biopsies.
An excisional biopsy removes the entire lesion
and a border around the lesion. An incisional
biopsy removes part of the lesion for diagnostic
purposes. In a brush biopsy (Figure 3), a small
brush is used on the lesion to collect material for
the biopsy that may provide helpful information
on infectious and noninfectious oral diseases.
VOLUME 5 • NUMBER 107
Fine-needle aspiration biopsy technique (Figure
4) is used on salivary gland masses and enlarged
lymph nodes. Fine-needle aspiration involves a thin
hollow needle being inserted into a mass to extract
cells or fluids. The patient rinses the mouth with
chlorhexidine for about 60 seconds, and the area
is then numbed with local anesthetic. A 22-gauge
needle is normally used to collect a sample, which
is then fixated to a slide for examination by an oral
pathologist.
To safely store and transport samples, tissue
removed from the mouth must typically be placed
in a fixative solution. For routine biopsies, 10%
neutral buffered formalin is the fixative of choice.
The pathology laboratory should be consulted for
any anticipated special procedures to ensure that
the tissue is handled properly. Sending a biopsy
out for analysis should adhere to a standard pro-
tocol that includes follow-up with the patient and
documentation.
Results can be referred to a specialist: an oral
and maxillofacial surgeon, oral pathologist, or
periodontist. Referral of these lesions to a special-
ist will result in an early definitive diagnosis and
treatment if needed. Lesions may require special
attention and particular management strategies
depending on the site, grade of dysplasia, and
patient risk.5
CONCLUSION
Oral pathology is a complex topic that involves
continuous education. Determining how to make
a differential diagnosis falls into the overall knowl-
edge of oral pathology and describing what is seen.
To make a differential diagnosis with confidence,
one needs to gather the correct information, in-
cluding medical history, anatomy, terminology,
samples, and images.
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Quiz TO TAKE THE QUIZ, VISIT
CDEWORLD.COM/EBOOKS/CE/107
10. Macedo RG, Robinson JP, Verhaagen B, Walmsley
Versluis M, Cooper PR, and van der Sluis LM. A novel
methodology providing new insights into the ultrasonic
Oral Pathology: Techniques for Detection and Differential
removal of a biofilm-mimicking hydrogel from lateral
Diagnosis
morphological features of the root canal. Int Endod J. 2014;
47: 1040–1051.
Cynthia Blendermann Perone, DDS
11. Vandrangi P, Basrani B. Multisonic ultracleaning in molars
1.
withEvery year there are
the GentleWave about
system. howHealth.
Oral many 2015;May:72-86.
new cases of oral 6. When abnormalities are found, what is important to
cancer worldwide? remember?
A. 15,000 B. 50,000 A. all abnormalities are cancerous
C. 500,000 D. 5,000,000 B. not all abnormal tissue will be cancer
C. abnormalities are unrelated to cancerous tissue
2. What is the most common form of oral cancer? D. abnormalities are always a sign of poor dental hygiene
A. squamous cell carcinoma
B. verrucous carcinoma 7. Cultures can be taken to assess which types of
C. minor salivary gland carcinoma infections?
D. lymphoma A. bacterial B. fungal
C. viral D. all of the above
3. How often should medical history be collected?
A. only for new patients 8. What is considered the gold standard for diagnosing
B. only when a patient arrives with pain oral lesions?
C. at every appointment A. a tissue biopsy
D. depends on the patient’s age B. a radiograph
C. an extraoral assessment
4. A physical assessment of the oral cavity and surrounding D. none of the above
landmarks has three components. What are they?
A. the extraoral assessment, the intraoral assessment, and a 9. Which of the following biopsy techniques can be
biopsy used orally?
B. the extraoral assessment, the intraoral assessment, and A. a punch biopsy
radiographs B. a brush biopsy
C. a biopsy, analysis, and treatment plan C. an excisional biopsy
D. radiographs, a biopsy, and laboratory analysis D. all of the above

5. Which of the following are included in the variety of screening 10. Which biopsy technique is usually used to surgically
tools that can be implemented? remove and evaluate an entire lesion?
A. fl uorescent visualization A. excisional
B. three wavelengths of light B. incisional
C. LED beam technology and a high-contract fluorescence C. punch
viewer D. brush
D. all of the above

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