Handbook of Oral Pathology and Oral

Medicine S. R. Prabhu
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Handbook of Oral Pathology and
Oral Medicine
Handbook of Oral Pathology and Oral Medicine

S. R. Prabhu BDS; MDS (Oral Path); FFDRCS (Oral Med); FDSRCS(Edin); FDSRCPS
(Glas); FDSRCS (Eng), FFGDPRCS(UK); MOMed RCS (Edin); FICD.

Honorary Associate Professor

School of Dentistry
University of Queensland
Brisbane, Australia
This edition first published 2022
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Library of Congress Cataloging-­in-­Publication Data applied for

[ISBN: 9781119781127]

Cover Design: Wiley

Cover Images: Courtesy of S. R. Prabhu

Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India

10 9 8 7 6 5 4 3 2 1
To the victims of COVID-­19 infection and all those frontline healthcare workers who are engaged in
the fight against the disease with utmost courage and dedication.
 vii

Contents

Foreword xvii
Preface xix
Acknowledgements xxi
About the Companion Website xxiii
Nomenclature Used in The Study of Human Disease xxv
Standard Abbreviations for Prescribers xxviii

Part I Pathology of Teeth and Supporting Structures 1

1 Disorders of Tooth Development and Eruption 3

1.1 ­Anodontia, Hypodontia and Oligodontia 3
1.2 ­Hyperdontia (Supernumerary Teeth) 5
1.3 ­Microdontia and Macrodontia 6
1.4 ­Gemination, Fusion and Concrescence 7
1.5 ­Taurodontism and Dilaceration 9
1.6 ­Amelogenesis Imperfecta 11
1.7 ­Dentinogenesis Imperfecta 13
1.8 ­Dentinal Dysplasia (Dentin Dysplasia) 14
1.9 ­Regional Odontodysplasia (Ghost Teeth) 16
1.10 ­Delayed Tooth Eruption 17
1.11 ­Tooth Impaction (Impacted Teeth) 18
1.12 ­Dens Invaginatus and Dens Evaginatus 20
1.13 ­Fluorosis (Mottled Enamel) 22
1.14 ­Tetracycline-­Induced Discoloration of Teeth: Key Features 24
1.15 ­Enamel Pearl: Key Features 24
1.16 ­Talon Cusp: Key Features 25
1.17 ­Hutchinson’s Incisors and Mulberry Molars: Key Features 26
1.18 ­Tooth Ankylosis: Key Features 26
1.19 ­Supernumerary Roots: Key Features 27

2 Dental caries 29
2.1 ­Definition/Description 29
2.2 Frequency 29
viii Contents

2.3 ­ etiology/Risk Factors/Pathogenesis 29

A
2.4 ­Classification of Caries 30
2.5 ­Clinical Features 30
2.6 ­Differential Diagnosis 33
2.7 ­Diagnosis 33
2.8 ­Microsopic Features 33
2.9 ­Management 35
2.10 ­Prevention 36

3 Diseases of the Pulp and Apical Periodontal Tissues 37

3.1 ­Classification of Diseases of the Pulp and Apical Periodontal Tissues 37
3.2 ­Pulpitis 38
3.3 ­Apical Periodontitis and Periapical Granuloma 40
3.4 ­Apical Abscess (Dentoalveolar Abscess) 43
3.5 ­Condensing Osteitis 44

4 Tooth Wear, Pathological Resorption of Teeth, Hypercementosis and Cracked Tooth

Syndrome 47
4.1 ­Tooth wear: Attrition, Abrasion, Erosion, and Abfraction 47
4.2 ­Pathological Resorption of Teeth 50
4.3 ­Hypercementosis 52
4.4 ­Cracked Tooth Syndrome 53

5 Gingival and Periodontal Diseases 57

5.1 ­Classification of Gingival and Periodontal Diseases 58
5.2 ­Chronic Gingivitis 58
5.3 ­Necrotizing Periodontal Diseases 60
5.4 ­Plasma Cell Gingivitis 63
5.5 ­Foreign Body Gingivitis 64
5.6 ­Desquamative Gingivitis 65
5.7 ­Chronic Periodontitis 67
5.8 ­Aggressive Periodontitis 70
5.9 ­Fibrous Epulis (Peripheral Fibroma) 73
5.10 ­Peripheral Ossifying/Cementifying Fibroma 74
5.11 ­Peripheral Giant Cell Granuloma (Giant Cell Epulis) 76
5.12 Angiogranuloma (Pyogenic granuloma/pregnancy epulis) 77
5.13 ­Inflammatory Gingival Hyperplasia (Inflammatory Gingival Enlargement) 79
5.14 ­Generalized Gingival Hyperplasia in Pregnancy 81
5.15 ­Drug-­Induced Gingival Hyperplasia 82
5.16 ­Familial Gingival Hyperplasia 84
5.17 ­Gingival and Periodontal Abscesses 86
5.18 ­Pericoronitis/Pericoronal Abscess 89
5.19 ­Gingival Enlargement in Granulomatosis with Polyangiitis (Wegener’s
granulomatosis) 91
5.20 ­Gingival Enlargement in Leukaemia 93
5.21 ­Gingival Enlargement in Ascorbic Acid Deficiency 95
 Contents ix

Part II Pathology of Jaw Bones 99

6 Infections and Necrosis of the Jaw 101

6.1 ­Acute Suppurative Osteomyelitis 101
6.2 ­Chronic Suppurative Osteomyelitis 104
6.3 ­Sclerosing Osteomyelitis 106
6.4 ­Proliferative Periostitis (Garre’s Osteomyelitis) 108
6.5 ­Actinomycosis of the Jaw 109
6.6 ­Cervicofacial Cellulitis (Cervicofacial Fascial Space Infection) 111
6.7 ­Osteoradionecrosis of the Jaw 112
6.8 ­Medication-­Related Osteonecrosis of the Jaw 114

7 Cysts of the Jaw 117

7.1 ­Radicular, Lateral Radicular, and Residual Radicular Cysts 117
7.2 ­Dentigerous Cyst 120
7.3 ­Eruption Cyst 122
7.4 ­Odontogenic Keratocyst (Keratocystic Odontogenic Tumour) 123
7.5 ­Lateral Periodontal Cyst 126
7.6 ­Calcifying Odontogenic Cyst 127
7.7 ­Orthokeratinized Odontogenic Cyst: Key Features 130
7.8 ­Glandular Odontogenic Cyst: Key Features 130
7.9 ­Nasopalatine Duct Cyst (Incisive Canal Cyst) 130
7.10 ­Pseudocysts of the Jaw: Solitary Bone Cyst, Aneurysmal
Bone Cyst and Stafne’s bone Cyst 132
7.11 ­Nasolabial Cyst: Key Features 135

8 Odontogenic Tumours 137

8.1 ­World Health Organization Classification of Odontogenic Tumours (2017) 137
8.2 ­Ameloblastoma 138
8.3 ­Unicystic Ameloblastoma 141
8.4 ­Squamous Odontogenic Tumour 144
8.5 ­Calcifying Epithelial Odontogenic Tumour (Pindborg Tumour) 145
8.6 ­Adenomatoid Odontogenic Tumour 147
8.7 ­Ameloblastic Fibroma 149
8.8 ­Ameloblastic Fibrodentinoma and Ameloblastic Fibro-­Odontome 151
8.9 ­Odontome (Odontoma) 153
8.10 ­Dentinogenic Ghost Cell Tumour 155
8.11 ­Odontogenic Myxoma 157
8.12 ­Odontogenic Fibroma (Central Odontogenic Fibroma) 159
8.13 ­Cementoblastoma 161

9 Non-­odontogenic Benign and Malignant Tumours of the Jaw 165

9.1 ­Osteoma 165
9.2 ­Multiple Osteomas in Gardner’s Syndrome 167
9.3 ­Central Haemangioma (Intraosseous Haemangioma) 169
9.4 ­Melanotic Neuroectodermal Tumour of Infancy 171
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9.5 ­ steosarcoma 172

O
9.6 ­Chondrosarcoma: Key Features 174
9.7 ­Ewing’s Sarcoma 175
9.8 ­Myeloma (Multiple Myeloma) 177
9.9 ­Solitary Plasmacytoma 179
9.10 ­Burkitt’s Lymphoma 181

10 Fibro-­Osseous and Related Lesions of the Jaw 185

10.1 ­Ossifying Fibroma/Cemento-­Ossifying Fibroma 185
10.2 ­Cemento-­Osseous Dysplasias 187
10.3 ­Familial Gigantiform Cementoma: Key Features 190
10.4 ­Central Giant Cell Granuloma 191

11 Genetic, Metabolic, and Other Non-­neoplastic Bone Diseases 195

11.1 ­Osteogenesis Imperfecta 195
11.2 ­Cleidocranial Dysplasia 197
11.3 ­Cherubism 199
11.4 ­Gigantism and Acromegaly 201
11.5 ­Brown Tumour of Hyperparathyroidism 203
11.6 ­Paget’s Disease of Bone (Osteitis Deformans) 205
11.7 ­Fibrous Dysplasia and McCune–Albright Syndrome 207
11.8 ­Mandibular and Palatine Tori: Key Features 210
11.9 ­Focal Osteoporotic Bone Marrow Defect: Key Features 210

Part III Pathology of the Oral Mucosa 213

12 Developmental Anomalies and Anatomical Variants of Oral Soft Tissues 215

12.1 ­Fordyce Granules: Key Features 215
12.2 ­Double Lip: Key Features 215
12.3 ­Leukoedema: Key Features 216
12.4 ­Ankyloglossia: Key Features 216
12.5 ­Geographic Tongue: Key Features 217
12.6 ­Hairy Tongue: Key Features 218
12.7 ­Fissured Tongue: Key Features 218
12.8 ­Lingual Thyroid: Key Features 218
12.9 ­Microglossia and Macroglossia: Key Features 219
12.10 ­Bifid Tongue: Key Features 220
12.11 ­Bifid Uvula: Key Features 220
12.12 ­Cleft Lip: Key Features 221
12.13 ­Calibre Persistent Labial Artery: Key Features 221
12.14 ­Epstein’s Pearl and Bohn’s Nodules: Key Features 223
12.15 ­Dermoid and Epidermoid Cysts: Key Features 223
12.16 ­Oral Varicosities: Key Features 224
12.17 ­Lymphoid Aggregates: Key Features 224
12.18 ­Parotid Papilla: Key Features 225
12.19 ­Circumvallate Papillae: Key Features 226
12.20 ­Physiological Pigmentation: Key Features 226
 Contents xi

13 Bacterial Infections of the Oral Mucosa 229

13.1 ­Scarlet Fever: Key Features 229
13.2 ­Syphilis 229
13.3 ­Gonorrhoea: Key Features 232
13.4 ­Tuberculosis 233

14 Fungal Infections of the Oral Mucosa 237

14.1 ­Candidosis (Candidiasis) 237
14.2 ­Histoplasmosis 244
14.3 ­Blastomycosis: Key Features 246

15 Viral Infections of the Oral Mucosa 247

15.1 ­Primary Herpetic Gingivostomatitis (Primary Herpes) 247
15.2 ­Herpes Labialis 250
15.3 ­Varicella (Chickenpox) 252
15.4 ­Herpes Zoster (Shingles) 253
15.5 ­Infectious Mononucleosis (Glandular Fever) 255
15.6 ­Oral Hairy Leukoplakia: Key Features 257
15.7 ­Cytomegalovirus Infection: Key Features 258
15.8 ­Herpangina: Key Features 258
15.9 ­Hand, Foot, and Mouth Disease 258
15.10 ­Squamous Papilloma 260
15.11 ­Condyloma Acuminatum: Key Features 261
15.12 ­Multifocal Epithelial Hyperplasia: Key Features 262
15.13 ­Verruca Vulgaris: Key Features 262
15.14 ­Measles: Key Features 263

16 Non-­infective Inflammatory Disorders of the Oral Mucosa 265

16.1 ­Recurrent Aphthous Stomatitis 265
16.2 ­Oral Lichen Planus 269
16.3 ­Oral Lichenoid Lesions 272
16.4 ­Pemphigus Vulgaris 273
16.5 ­Mucous Membrane Pemphigoid 276
16.6 ­Erythema Multiforme 279
16.7 ­Lupus Erythematosus: Key Features 281
16.8 ­Traumatic Ulcer: Key Features 281
16.9 ­Oral Lesions in Behcet’s Disease/Syndrome 282
16.10 ­Oral Lesions in Crohn’s Disease 283
16.11 ­Oral Lesions in Reactive Arthritis: Key Features 285
16.12 ­Uremic Stomatitis: Key Features 285
16.13 ­Chronic Ulcerative Stomatitis: Key Features 285
16.14 ­Radiation-­Induced Mucositis: Key Features 286
16.15 ­Medication-­Induced Oral Ulceration: Key Features 287
16.16 ­Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis 287

17 Non-­neoplastic Mucosal Swellings 291

17.1 ­Irritation Fibroma (Traumatic Fibroma) 291
17.2 ­Denture-­Induced Granuloma (Epulis Fissuratum) 293
xii Contents

17.3 ­ ibrous Epulis (Peripheral Fibroma): key features 294

F
17.4 ­Pyogenic Granuloma: key features 295
17.5 ­Peripheral Giant Cell Granuloma: key features 295
17.6 ­Peripheral Ossifying Fibroma: key features 295
17.7 ­Traumatic Neuroma 295
17.8 ­Squamous Papilloma: Key Features 296
17.9 ­Congenital Epulis: Key Features 297

18 Benign Neoplasms of the Oral Mucosa 299

18.1 ­Lipoma 299
18.2 ­Schwannoma (Neurilemmoma) 301
18.3 ­Granular Cell Tumour 302
18.4 ­Haemangioma 304
18.5 ­Lymphangioma 306
18.6 ­Leiomyoma (Vascular Leiomyomas): Key Features 307
18.7 ­Rhabdomyoma: Key Features 307

19 Oral Potentially Malignant Disorders 309

19.1 ­Erythroplakia 309
19.2 ­Leukoplakia 311
19.3 ­Chronic Hyperplastic Candidosis (Candidal Leukoplakia) 315
19.4 ­Palatal Lesions in Reverse Smokers 317
19.5 ­Oral Lichen Planus: Key Features 319
19.6 ­Oral Submucous Fibrosis 320
19.7 ­Oral Lichenoid Lesion 322
19.8 ­Lupus Erythematosus 324
19.9 ­Actinic Keratosis of the Lip (Actinic Cheilitis) 326
19.10 ­Graft-­Versus-­Host Disease 328
19.11 ­Dyskeratosis Congenita 330
19.12 ­Sublingual Keratosis: Key Features 331
19.13 ­Syphilitic Leukoplakia: Key Features 332
19.14 ­Darier’s Disease: Key Features 332

20 Malignant Neoplasms of the Oral Mucosa 335

20.1 ­Squamous Cell Carcinoma and Verrucous Carcinoma 335
20.2 ­Melanoma (Malignant Melanoma) 340
20.3 ­Kaposi’s Sarcoma 342
20.4 ­Fibrosarcoma: Key Features 343
20.5 ­Rhabdomyosarcoma: Key Features 344
20.6 ­Leiomyosarcoma: Key Features 344

Part IV Pathology of the Salivary Glands 347

21 Non-­neoplastic Salivary Gland Diseases 349

21.1 ­Salivary Calculi: Key Features 349
21.2 ­Mucoceles (Mucous Extravasation Cysts, Mucous Retention
Cysts and Ranula) 350
 Contents xiii

21.3 ­ jögren’s Syndrome 352

S
21.4 ­Sialadenitis: Key Features 354
21.5 ­Necrotizing Sialometaplasia: Key Features 355

22 Salivary Gland Neoplasms 357

22.1 ­World Health Organization Histological Classification of Salivary
Gland tumours (2017) 357
22.2 ­Pleomorphic Adenoma 358
22.3 ­Warthin’s Tumour (Papillary Cystadenoma Lymphomatosum) 360
22.4 ­Mucoepidermoid Carcinoma 362
22.5 ­Adenoid Cystic Carcinoma 364

Part V Clinical Presentation of Mucosal Disease 367

23 White Lesions of the Oral Mucosa 369

23.1 ­Actinic Cheilitis: Key Features 369
23.2 ­Chemical Burn: Key Features 370
23.3 ­Chronic Hyperplastic Candidosis: Key Features 370
23.4 ­Darier’s Disease: Key Features 371
23.5 ­Dyskeratosis Congenita: Key Features 371
23.6 ­Fordyce granules: Key Features 372
23.7 ­Frictional Keratosis: Key Features 372
23.8 ­Hereditary Benign Intraepithelial Dyskeratosis: Key Features 373
23.9 ­Leukoedema: Key Features 373
23.10 ­Leukoplakia: Key Features 373
23.11 ­Oral Hairy Leukoplakia: Key Features 374
23.12 ­Oral Lichen Planus: Key Features 374
23.13 ­Oral Squamous Cell Carcinoma: Key Features 375
23.14 ­Pseudomembranous Candidosis: Key Features 375
23.15 ­Smokeless Tobacco-­Induced Keratosis: Key Features 376
23.16 ­Smoker’s Keratosis: Key Features 376
23.17 ­Sublingual Keratosis: Key Features 377
23.18 ­Syphilitic Leukoplakia: Key Features 377
23.19 ­Verrucous Carcinoma: Key Features 377
23.20 ­White Hairy Tongue: Key Features 378
23.21 ­White Sponge Nevus: Key Features 378

24 Red and Purple Lesions of the Oral Mucosa 381

24.1 ­Contact Stomatitis: Key Features 381
24.2 ­Desquamative Gingivitis: Key Features 382
24.3 ­Erythema Migrans: key features 382
24.4 ­Erythema Multiforme: Key Features 382
24.5 ­Erythematous Candidosis: Key Features 383
24.6 ­Erythroplakia: Key Features 383
24.7 ­Haemangioma: Key Features 384
24.8 ­Hereditary Haemorrhagic Telangiectasia: Key Features 384
24.9 ­Infectious Mononucleosis: Key Features 385
xiv Contents

24.10 ­ aposi’s Sarcoma: Key Features 385

K
24.11 ­Linear Gingival Erythema: Key Features 385
24.12 ­Lupus Erythematosus: Key Features 386
24.13 ­Median Rhomboid Glossitis: Key Features 386
24.14 ­Mucosal Ecchymosis, Haematoma, and Petechiae: Key Features 386
24.15 ­Plasma Cell Gingivitis: Key Features 387
24.16 ­Port-­Wine Nevus: Key Features 387
24.17 ­Radiation Mucositis: Key Features 387
24.18 ­Thermal Burn: Key Features 388

25 Blue, Black, and Brown Lesions of the Oral Mucosa 389

25.1 ­Addison’s Disease: Key Features 389
25.2 ­Amalgam Tattoo: Key Features 389
25.3 ­Black/Brown Hairy Tongue: Key Features 390
25.4 ­Drug-­Induced Pigmentation: Key Features 391
25.5 ­Heavy Metal Pigmentation: Key Features 392
25.6 ­Laugier–Hunziker Syndrome: Key Features 392
25.7 ­Melanoma: Key Features 393
25.8 ­Melanotic Macule: Key Features 393
25.9 ­Peutz–Jeghers Syndrome: Key Features 393
25.10 ­Physiological Pigmentation: Key Features 394
25.11 ­Mucosal Nevi: Key Features 394
25.12 ­Smoker’s Melanosis: Key Features 395

26 Vesiculobullous Lesions of the Oral Mucosa 397

26.1 ­Angina Bullosa Haemorrhagica: Key Features 397
26.2 ­Bullous Lichen Planus: Key Features 397
26.3 ­Dermatitis Herpetiformis: Key Features 398
26.4 ­Erythema Multiforme: Key Features 398
26.5 ­Hand, Foot and Mouth Disease: Key Features 398
26.6 ­Herpes Zoster (Shingles): Key Features 399
26.7 ­Mucous Membrane Pemphigoid: Key Features 399
26.8 ­Pemphigus Vulgaris: Key Features 400
26.9 ­Primary Herpetic Gingivostomatitis: Key Features 400
26.10 ­Herpes Labialis: Key Features 400

27 Ulcerative Lesions of the Oral Mucosa 403

27.1 ­Oral Ulcers in Agranulocytosis: Key Features 403
27.2 ­Oral Ulcers in Behçet’s Disease: Key Features 404
27.3 ­Oral Ulcers in Coeliac Disease: Key Features 404
27.4 ­Chronic Ulcerative Stomatitis: Key Features 405
27.5 ­Oral Ulcers in Crohn’s Disease: Key Features 405
27.6 ­Oral Ulcers in Cyclic Neutropenia: Key Features 406
27.7 ­Cytomegalovirus Ulcers: Key Features 406
27.8 ­Eosinophilic Ulcer: Key Features 406
27.9 ­Gangrenous Stomatitis: Key Features 406
27.10 ­Necrotizing Sialometaplasia: Key Features 407
 Contents xv

27.11 ­ ecrotizing Ulcerative Gingivitis: Key Features 407

N
27.12 ­Oral Ulcers in Reactive Arthritis: Key Features 408
27.13 ­Recurrent Aphthous Ulcers: Key Features 408
27.14 ­Squamous Cell Carcinoma Presenting as an Ulcer: Key Features 409
27.15 ­Syphilitic Ulcers: Key Features 409
27.16 ­Traumatic Ulcer: Key Features 410
27.17 ­Tuberculous Ulcer: Key Features 410
27.18 ­Oral Ulcer in Ulcerative Colitis: Key Features 411

28 Papillary Lesions of the Oral Mucosa 413

28.1 ­Condyloma Acuminatum: Key Features 413
28.2 ­Multifocal Epithelial Hyperplasia (Heck’s Disease): Key Features 413
28.3 ­Oral Proliferative Verrucous Leukoplakia: Key Features 414
28.4 ­Squamous Papilloma: Key Features 414
28.5 ­Squamous Cell Carcinoma: Key Features 414
28.6 ­Verruca Vulgaris (Oral Warts): Key Features 414
28.7 ­Verrucous Carcinoma: Key Features 415

Part VI Orofacial Pain 417

29 Orofacial Pain 419

29.1 ­Odontogenic Orofacial Pain 419
29.2 ­Neuropathic Orofacial Pain 421
29.3 ­Other Conditions with Orofacial Pain 423

Part VII Miscellaneous Topics of Clinical Relevance 427

30 Oral Manifestations of Systemic Disorders 429

30.1 ­Gastrointestinal and Liver Disorders 429
30.2 ­Cardiovascular Disease 431
30.3 ­Respiratory Disease 431
30.4 ­Kidney Diseases 432
30.5 ­Endocrine and Metabolic Disorders 434
30.6 Nervous System Disorders 435
30.7 ­Haematological Disorders 437
30.8 ­Immune System Disorders 439

31 Systemic Diseases Associated with Periodontal Infections 441

31.1 ­Cardiovascular Disease 441
31.2 ­Coronary Heart Disease (Atherosclerosis and Myocardial Infarction) 441
31.3 ­Stroke 442
31.4 ­Infective Endocarditis 442
31.5 ­Bacterial Pneumonia 442
31.6 ­Low Birth Weight 443
31.7 ­Diabetes Mellitus 443
xvi Contents

32 Other Signs and Symptoms Related to the Oral Environment 445

32.1 ­Halitosis 445
32.2 ­Taste Disorders 446
32.3 ­Dry Mouth (Xerostomia) 447
32.4 ­Sialorrhea 448
32.5 ­Trismus 449
32.6 ­COVID-­19 Infection 449

33 Outline of Diagnostic Steps and Procedures Employed in

Oral Pathology and Oral Medicine 453
33.1 ­History 453
33.2 ­Clinical Examination 454
33.3 ­Clinical Differential Diagnosis 455
33.4 ­Diagnosis 456

Index 459
 xvii

Foreword

This is an amazing work. Professor SR Prabhu has touched constructively on almost every “issue”,
every decision required, in the day-to-day practice of oral medicine and to a considerable extent,
oral/maxillofacial pathology. He has laid out the material in a very logical set of chapters. The
extensive illustrations are of uniformly high quality: many of these have been donated by col-
leagues around the world and I join in thanking them for their generosity: many have become
personal friends to us both.
I initially was hesitant to contribute this Foreword. As a quantitative scientist, I always wish to
see the evidence base for every diagnosis, test and treatment presented. This is deliberately not the
intention here - indeed it is the opposite of Prof Prabhu’s intent. As he put it in response to my
challenge “My intention is not to compete with great authors of international repute. The material
presented is truly a compilation of what is known in the scientific papers, books and case reports
that are (I might interpolate with much hard work) available. This is a humble attempt to provide
students and busy practitioners with a source that provides quick access to information”. I see the
value of this: indeed, I wish my current undergraduate and postgraduate students came to clinics
with a copy in their pockets!
Professor SR Prabhu is a remarkable professional in the autumn of a remarkable career. This has
impacted the dental profession, and particularly dental students, across the globe, for decades,
beginning with his first teaching appointment in India in 1971. We first met when he was
Commonwealth Medical Scholar in my department in London in 1974. Chronologically since then
he has taught and led teaching [including from positions as Head of Department or Dean in several
institutions] in universities in India, Kenya, Sudan, Australia, Papua New Guinea, West Indies,
Malaysia, Saudi Arabia, West Indies (again), United Arab Emirates, and several Australian univer-
sities, again. His vast knowledge reflects this.
I have learned much from his global experience and it was particularly educative for me to work
with him, as co-editor and co-author of his largest work Oral Diseases in the Tropics (Oxford University
Press 1992; Revised reprint, Jaypee Bros. 2017). Beyond that his
bibliography is extensive.
We are fortunate that he has maintained the drive and passion
to give us this valuable work at this time: one positive outcome of
Covid-2019.

Newell W Johnson, CMG

Emeritus Professor of Oral Health Sciences,
Kings’ College London, &
Dean Emeritus and Honorary Professor of Dental Research,
Griffith University, Queensland, Australia
Brisbane, June 2021
 xix

Preface

The Handbook of Oral Pathology and Oral Medicine is primarily targeted at undergraduate dental
students and practitioners. Dental students find the available prescribed textbooks of oral pathol-
ogy and oral medicine loaded with information and are not user friendly, particularly at the time
of preparation for examinations. Teachers and students alike feel that there is a need for a book
that offers information in a concise manner for quick reference. This handbook aims to fill this
need by providing a highly illustrated succinct guide presented as bulleted lists for easy reference.
Text style used in this handbook allows the reader to quickly gather essential information relevant
to the disease without scanning through lengthy paragraphs. For further information, a recom-
mended reading list is provided at the end of each chapter.
Topics included in this book are in accordance with the universally followed curricula in oral
pathology and oral medicine. The text is divided in seven parts: pathology of teeth, pulp, and sup-
porting structures, pathology of jawbones, pathology of the oral mucosa, pathology of the salivary
glands, clinical presentation of mucosal disease, orofacial pain, and miscellaneous topics of clini-
cal relevance. Many international clinicians and teachers have generously contributed clinical,
radiographical and photomicrographic images to this handbook.
The author and the publishers feel that the format, design, style, and content of the text used in
this handbook will assist dental students and clinicians in dentistry and other healthcare profes-
sions. Accompanying this handbook is a website containing case scenarios and MCQs especially
designed for dental students preparing for examinations.
S. R. Prabhu
Brisbane
June 2021
 xxi

Acknowledgements

I wish to thank Professor Newell Johnson for the Foreword and his inspirational role in shaping
my academic career in oral pathology and oral medicine.
I also wish to express my grateful thanks to many colleagues who have shared their teaching
material to this book. Every effort has been made to trace and acknowledge copyright material for
the images used. If someone’s name has been inadvertently missed or infringement of copyright
has occurred accidentally, I tender my sincere apologies.
My great appreciation goes to guidance provided by Associate Commissioning Editor for
Veterinary and Dentistry books Miss Loan Nguyen and Managing Editor for Health and Life
Sciences Miss Tanya McMullin of John Wiley & Sons (UK). Others at Wiley publishing who deserve
my grateful thanks include Adalfin Jayasingh, Fathima Shaheen, and Susan Engelken.
Finally, I am indebted to my wife Uma Prabhu for her unconditional support during the
COVID-­19 stay-­at-­home period when the preparation of manuscripts for this handbook was started
and completed.
S. R. Prabhu
Brisbane
June 2021
 xxiii

­About the Companion Website

Don’t forget to visit the companion web site for this book:

www.wiley.com/go/prabhu/oral_pathology

There you will find valuable materials, including:

●● 240 multiple choice questions
●● 36 clinical case scenarios
●● Images from the book as downloadable PowerPoint slides

Scan this QR code to visit the companion website

 xxv

­Nomenclature Used in The Study of Human Disease

Nomenclature of diseases:
●● Disease: impairment of normal physiological function affecting all or part of an organism mani-
fested by signs and symptoms.
●● Disorder: deviation from the usual way the body functions.
●● Condition: an abnormal state of health that interferes with the usual activities or feeling of
wellbeing.
●● Risk factor: something that increases a person’s chances of developing a disease.
●● Aetiology: the study of the underlying cause of the disease/disorder.
●● Pathogenesis: the development and chain of events leading to a disease.
●● Epidemiology: a branch of medical science that deals with the incidence, distribution, and
control of disease in a population.
●● Incidence: the measure of the probability of occurrence of new cases of a disease over a cer-
tain period.
●● Prevalence: total number of individuals in a population who have a disease or health condition
at a specific period, usually expressed as a percentage of the population.
●● Prognosis: prediction of the likely course and outcome of a disease.
●● Morbidity: the extent to which a patient’s overall health is affected by a disease.
●● Mortality: the likelihood of death from a particular disease.
●● Acute and chronic illnesses:
–– Acute illnesses are of rapid onset.
–– Chronic conditions usually have a gradual onset and are more likely to have a pro-
longed course.
●● Syndrome refers to a collection or set of signs and symptoms that characterize or suggest a par-
ticular disease.
Clinical nomenclature of oral mucosal lesions:
●● Lesion: clinically detectable surface changes in the skin or mucous membranes can be termed
‘lesions’. They include the following:
–– Macule: a macule is a change in surface colour, without elevation or depression and therefore
nonpalpable, well-­or ill-­defined, but generally considered less than 1.5 cm in diameter at the
widest point.
–– Patch: a patch is a large macule equal to or greater than 1.5 cm across. Patches may have some
subtle surface change, such as a fine scale or wrinkling but although the consistency of the
surface is changed, the lesion itself is not palpable.
–– Papule: a papule is a circumscribed, solid, palpable elevation of skin/mucous membrane with
no visible fluid, varying in size from a pinhead to less than 1.5 cm in diameter at the wid-
est point.
xxvi ­Nomenclature Used in The Study of Human Diseas

–– Plaque: a plaque is a broad, flat-­topped papule, or confluence of papules, equal to or greater

than 1.5 cm in diameter, or alternatively as an elevated, plateau-­like lesion that is often greater
in its diameter than in its depth.
–– Nodule: a nodule is morphologically similar to a papule and is a palpable spherical lesion in
all three directions: length, width, and depth. A nodule is usually a solid lesion of 1.5 cm or
less in diameter. It may be sessile (attached directly by the base) or pedunculated (attached by
a peduncle – a stem).
–– Tumour: similar to a nodule but larger than 1.5 cm in diameter.
–– Vesicle: a vesicle is a small blister; a circumscribed, fluid-­filled, epithelial elevation generally
less than 1.5 cm in diameter at the widest point. The fluid is a clear serous fluid.
–– Bulla: a bulla is a large, rounded or irregularly shaped blister of the skin or mucous mem-
brane containing serous or seropurulent fluid. Bullae are greater than 1.5 cm in diameter.
–– Pustule: a pustule is a small elevation of the skin or mucous membrane containing cloudy or
purulent material (pus) usually consisting of necrotic inflammatory cells. When haemor-
rhagic, the colour of the pustule may be red or blue.
–– Cyst: a cyst is an epithelial-­lined pathological cavity containing liquid, semisolid, or solid
material.
–– Pseudocyst: a cyst-­like lesion that is not lined by epithelium.
–– Fissure: a fissure is a crack in the skin or mucous membrane that is usually narrow
and deep.
–– Erosion: an erosion is a lesion that lacks the full thickness of the overlying epithelium and is
moist, circumscribed, and usually depressed.
–– Ulcer: an ulcer is a discontinuity of the skin or mucous membrane exhibiting complete loss
of the epidermis or epithelium, with some amount of destruction of the subepithelial connec-
tive tissue.
–– Telangiectasia: a telangiectasia represents an enlargement of superficial blood vessels in the
skin or mucous membrane to the point of being visible.
–– Scale: a skin lesion that consists of dry or greasy laminated masses of keratin.
–– Crust: a skin lesion that is dried sebum, pus, or blood, usually mixed with epithelial and
sometimes bacterial debris. Can occur on the vermilion as well.
–– Lichenification: epidermal thickening of the skin characterized by visible and palpable
thickening with accentuated skin markings.
–– Excoriation: a punctate or linear abrasion of the skin produced by mechanical means (often
scratching), usually involving only the epidermis, but commonly reaching the papillary dermis.
–– Induration: dermal or mucosal thickening causing the cutaneous or mucosal surface to feel
thicker and firmer.
–– Atrophy: a loss of epithelial or submucous tissue. With epithelial atrophy, the mucous mem-
brane appears thin, translucent, and wrinkled. Atrophy should be differentiated from erosion.
–– Maceration: in maceration, the skin softens and turns white, due to being consistently wet.
–– Umbilication: formation of a depression at the top of a papule, vesicle, or pustule.
–– Rash: presence of multiple non-­vesicular skin eruptions.
–– Sinus/fistula: a sinus or fistula is a tract connecting cavities to each other or to the surface.
–– Sessile lesion: a lesion attached to the underlying tissues with a broad base.
–– Pedunculated lesion: a lesion attached to the underlying tissues with a narrow base, such as
a stalk or pedicle.
–– Serpiginous lesion: a lesion with a wavy border.
–– Discoid lesion: a round or disc-­shaped lesion.
–– Annular or circinate lesion: a ring-­shaped lesion.
–– Herpetiform lesions: lesions resembling those of herpes.
 ­Nomenclature Used in The Study of Human Diseas xxvii

–– Reticular or reticulated lesion: a lesion resembling a net or lace.

–– Verrucous lesion: a wart-­like lesion.
–– Stellate lesion: a star-­shaped lesion.
–– Target lesion or ‘bull’s eye lesion: named for its resemblance to the bullseye of a shooting
target. Also referred to as an ‘iris’ lesion.
–– Purpura: haemorrhage into the surface of the skin or mucous membrane. Purpura measure
3–10 mm whereas petechiae measure less than 3 mm, and ecchymoses greater than 10 mm.
The appearance of an individual area of purpura varies with the duration of the lesions. Early
purpura is red and becomes darker, purple, and brown, yellow as it fades. Purpuric spots do
not blanch on pressure.
–– Petechiae: petechiae are small sharply outlined and slightly elevated red-­or purple-­coloured
purpuric macules of about 1–3 mm in diameter. They contain extravasated blood.
–– Ecchymoses: ecchymoses are larger purpuric lesions that are macular and deeper in origin
than petechiae. They are to be distinguished from hematoma caused by extravasation of blood.
–– Hematoma: a localized swelling that is filled with blood caused by a break in the wall of a
blood vessel.
–– Hamartoma: a benign (non-­neoplastic) tumour-­like growth consisting of a disorganized
mixture of cells and tissues normally found in the body where the growth occurs.
–– Epulis: a nonspecific exophytic gingival mass.
Histological nomenclature of oral mucosal lesions:
●● Hyperplasia: an increase in the amount of organic tissue that results from cell proliferation.
●● Parakeratosis: a mode of keratinization characterized by the retention of nuclei in the stratum
corneum.
●● Hyperkeratosis: thickening of the stratum corneum associated with the presence of an abnor-
mal quantity of keratin.
●● Orthokeratosis: hyperkeratosis without parakeratosis. No nucleus is seen in the cells as in the
normal epidermis (skin) or epithelium (mucous membrane).
●● Acanthosis: a benign abnormal thickening (hyperplasia) of the stratum spinosum, or prickle
cell layer of the epidermis (skin) or epithelium (mucous membrane).
●● Acantholysis: the loss of intercellular connections (desmosomes), resulting in loss of cohesion
between keratinocytes in the skin or mucous membrane.
●● Spongiosis: intercellular oedema (abnormal accumulation of fluid) in the epidermis in the skin
or the epithelium in the mucous membrane.
●● Dyskeratosis: abnormal keratinization occurring prematurely within individual cells or groups
of cells below the stratum granulosum.
●● Vacuolization: the formation of vacuoles within or adjacent to cells and often confined to the
basal cell-­basement membrane zone area.
●● Cellular or epithelial dysplasia: an epithelial anomaly of growth and differentiation often
indicative of an early neoplastic process.
●● Metaplasia: cells of one mature, differentiated type are replaced by cells of another mature,
­differentiated type.
●● Atypia: deviation from normal or a state of being not typical. Atypical cells are not necessarily
cancerous.
●● Colloid bodies (also called Civatte bodies): these apoptotic keratinocytes are oval or round,
immediately above or below the epidermal or epithelial basement membrane.
●● Hydropic (liquefaction) degeneration: basal cells become vacuolated, separated, and
disorganized.
●● Hyaline bodies: necrotic keratocytes; also termed colloid bodies, Civatte bodies, and apop-
totic bodies.
Another random document with
no related content on Scribd:
 Fig. 67

Fig. 68

Fig. 69
 Fig. 70

The seeds of the pine tree are hidden away in the pine cone (Fig.
69) you know so well, and those of the hemlock in the hemlock cone
(Fig. 61). When they are quite ripe, they break away from these
cones. In so doing, each one carries with it a little piece of the cone,
which acts as a wing to the seed (Fig. 70).
Nearly all of these seeds you can find for yourselves when you
wander about the country. Indeed, if you have eyes that are good for
anything, many of them you cannot help seeing. It is all very well to
read about these plants and trees, and to look at pictures of their
flowers and fruits, and to have your teacher bring into the
schoolroom specimens for examination. If this is all the city children
can do (although even in the city one can do more than this), why,
surely it is far better than nothing.
But best of all is it to go right into the woods and fields where
these strange, interesting creatures are living, and to see for
yourselves their manners and customs.
 SHOOTING SEEDS

Fig. 71

D OWN by the brook and along the sides of the mountain grows a
tall shrub which is called the witch-hazel. I hope some of you
know it by sight. I am sure that many of you know its name on
account of the extract which is applied so often to bruises and burns.
This picture (Fig. 71) shows you a witch-hazel branch bearing both
flowers and fruit; for, unlike any other plant I know, the flower of the
witch-hazel appears late in the fall, when its little nuts are almost
ripe. These nuts come from the flowers of the previous year.
It is always to me a fresh surprise and delight to come upon these
golden blossoms when wandering through the fall woods.
Often the shrub has lost all its leaves before these appear. You
almost feel as if the yellow flowers had made a mistake, and had
come out six months ahead of time, fancying it to be April instead of
October. In each little cluster grow several blossoms, with flower
leaves so long and narrow that they look like waving yellow ribbons.
But to-day we wish chiefly to notice the fruit or nut of the witch-
hazel.
Now, the question is, how does the witch-hazel manage to send
the seeds which lie inside this nut out into the world? I think you will
be surprised to learn just how it does this.
If you have a nut before you, you see for yourselves that this fruit
is not bright-colored and juicy-looking, or apparently good to eat, and
thus likely to tempt either boy or bird to carry it off; you see that it is
not covered with hooks that can lay hold of your clothing, and so
steal a ride; and you see that it has no silky sails to float it through
the air, nor any wings to carry it upon the wind.
And so the witch-hazel, knowing that neither boy nor girl, nor bird
nor beast nor wind, will come to the rescue of its little ones, is
obliged to take matters into its own hands; and this is what it does. It
forces open the ripe nut with such violence, that its little black seeds
are sent rattling off into the air, and do not fall to the ground till they
have traveled some distance from home. Really they are shot out
into the world (Fig. 72).
If you wish to make sure that this is actually so, gather some of
these nuts, and take them home with you. It will not be long before
they begin to pop open, and shoot out their little seeds.
Did you ever hear of Thoreau? He was a man who left his friends
and family to live by himself in the woods he so dearly loved. Here
he grew to know each bird and beast, each flower and tree, almost
as if they were his brothers and sisters. One day he took home with
him some of these nuts, and later he wrote about them in his journal,
—
“Heard in the night a snapping sound, and the fall of some small
body on the floor from time to time. In the morning I found it was
produced by the witch-hazel nuts on my desk springing open and
casting their seeds quite across my chamber.”

Fig. 72

Now, I do not want any of you children to go off by yourselves to

live in the woods; but I should like to think that you could learn to
love these woods and their inmates with something of the love that
Thoreau felt. And if you watch their ways with half the care that he
did, some such love is sure to come.
Although the witch-hazel’s rough way of dealing with its young is
not very common among the plants, we find much the same thing
done by the wild geranium, or crane’s bill, and by the touch-me-not.
The wild geranium is the pretty purplish, or at times pink flower
which blossoms along the roads and in the woods in May and early
June.
Its seedbox has five divisions. In fruit this seedbox tapers above
into a long beak, which gives the plant its name of “crane’s bill.”
When the fruit is quite ripe, it splits away from the central part of this
beak in five separate pieces, which spring upward so suddenly that
the seeds are jerked out of the five cells, and flung upon the earth at
a distance of several feet. The picture (Fig. 73) shows you how this
is done. But a little search through the summer woods will bring you
to the plant itself; and if you are patient, perhaps you will see how
the wild geranium gets rid of its children. But though this habit may at
first seem to you somewhat unmotherly, if you stop to think about it
you will see that really the parent plant is doing its best for its little
ones. If they should fall directly upon the ground beneath, their
chances in life would be few. About plants, as about people, you
must not make up your minds too quickly.

Fig. 73
 Fig. 74

Another plant that all of you country children ought to know, is the
touch-me-not, or jewelweed. Sometimes this is called “lady’s
eardrop,” because its pretty, red-gold, jewel-like flowers remind us of
the drops that once upon a time ladies wore in their ears. These
flowers we find in summer in wet, woody places. In the fall the fruit
appears. This fruit is a little pod (Fig. 74) which holds several seeds.
When this pod is ripe, it bursts open and coils up with an elastic
spring which sends these seeds also far from home (Fig. 75).

Fig. 75

This performance of the touch-me-not you can easily see; for its
name “touch-me-not” comes from the fact that if you touch too
roughly one of its well-grown pods, this will spring open and jerk out
its seeds in the way I have just described.

Fig. 76

In Europe grows a curious plant called the “squirting cucumber”

(Fig. 76). Its fruit is a small cucumber, which becomes much inflated
with water. When this is detached from its stalk, its contents are
“squirted” out as if from a fountain, and the seeds are thus thrown to
a distance of many feet.
 THE CHESTNUT AND OTHER SEEDS

Fig. 77

A T the head of this chapter you see the fruit of the chestnut tree
(Fig. 77).
What fine October days this picture brings to mind,—clear, cold
mornings when we arm ourselves with baskets and a club, and go
chestnuting.
Usually the boys climb the tree, and shake the branches till the
open burrs rattle out their contents. But sometimes a teasing cluster
refuses to set loose its treasure. Then the club comes into play. If it
strikes the great burrs, and raps out their fat chestnuts, a shout of joy
follows.
What a delight it is to hunt in the long grass for the glossy brown
beauties just after a sudden shower from above! No one speaks. All
are bent low in breathless search.
I know of nothing much more perfect in its way than an open
chestnut burr, still holding its two or three fine nuts. Its green, prickly
outer covering makes a fine contrast to the velvety brown lining; and
within this beautiful case the plump, shining nuts are laid with the
daintiest care.
 Perhaps the chestnut burr is even safer as a seed case than the
apple. While its seeds (the chestnuts) are young and unripe, it does
not stop to plead, “Pray; don’t destroy my baby nuts!” but it seems to
call out sternly, “Hands off!” and promptly punishes the boy or girl
who disobeys this rough command.
But when the chestnut seeds are quite ripe, then it opens as wide
as it knows how; and very tempting it looks as it unfolds its contents.
A chestnut tree in October looks like one great invitation.
The acorn (Fig. 78), the seed of the oak tree, is pretty enough as a
plaything, but less pleasing than the chestnut. Only the squirrel
seems to find it fair eating.

Fig. 78

The trees which hide their seeds in nutshells contrive in different

ways to send them abroad.
Many of these nuts are hoarded as winter food by the squirrels.
Often in a moment of fright these little creatures drop them by the
way. Again, they forget just where they deposited their hoard, or for
some other reason they leave it untouched. Thus many nuts are
scattered, and live to change into trees.
Others may fall into the water, and float to distant shores. The
cocoanut, for example, has been carried in this way for hundreds of
miles. Its outer covering protects the seed from being soaked or hurt
by water; and when at last it is washed upon some distant shore, it
sends up a tall cocoanut tree.
 SOME STRANGE STORIES

W HEN I began to tell you children about the different ways in

which plants send their young out into the world, I had no idea
that I should take so much time, and cover so many pages with the
subject. And now I realize that I have not told you one half, or one
quarter, of all there is to tell.
You have learned that seeds are scattered abroad by animals that
eat the bright cases in which they are packed, and by animals into
whose hair or clothing they manage to fasten themselves.
You know that sometimes seeds are blown through the air by
means of silky sails to which they are fastened, or else by their little
wings.
You discovered that certain plants actually pushed their young
from their cozy homes in no gentle fashion, much as a mother bird
shoves her timid little ones from the edge of the nest.
And in the last chapter you read that occasionally seeds were
floated by water to distant shores.
Now, these are the chief ways in which plants contrive to dispose
of their seeds; but they are not the only ways. Before leaving the
subject altogether, I will mention a few plants which use other
contrivances.
 Fig. 79

This picture (Fig. 79) shows you the fruit of the poppy. Many of you
know it well. In the fall you find in the garden these pretty seedboxes.
They answer famously as pepper pots, if one chances to be playing
house in the orchard.
Just below the top of the poppy seedbox the picture shows you a
circle of little openings; and inside the seedbox are many poppy
seeds (Fig. 80).
But how can seeds get out of these openings, do you suppose?
If they were lower down, it would be an easy matter for the seeds
to drop out, right on the ground. But perhaps it is well that this cannot
happen. Did such a quantity of seeds fall upon one small bit of earth,
they would have a poor chance for life.
Well, then, you ask, must they wait patiently in the seedbox till
some child comes along and pulls it off for a pepper pot?

Fig. 80
 No, they are not obliged to wait always for you children. This is
fortunate for the poppy plants that are so unlucky as to live in lonely
gardens where no children ever play.
Then what does happen?
If you will go out into the garden the next windy fall day, you will
see for yourselves. You will see the tall poppy plants swaying to and
fro with every gust of wind; and you will see how the seedboxes are
tossed from side to side, and that every now and then a very violent
toss sends the little seeds tumbling head over heels out of the little
openings just as effectively as if the wind too were playing house
and using them as pepper pots.
When the seeds are let loose in this way, the tall poppy plants are
swayed so far to one side, and the wind is blowing so hard, that they
land upon the ground much farther from home than would have been
the case had they fallen through openings cut in the lower part of the
seedbox.
In the East grows a strange plant called the “rose of Jericho.” Its
fruit is a pod. When this plant is nearly ready to get rid of its seeds,
what do you think it does? It lets go its hold upon the earth, curls
itself up into a little ball, and is driven here and there by the wind.
When it finds a nice damp place, it stops and uncurls itself; and the
little pods split open, and drop their seeds on the earth.
Some plants bear fruit that look very much like insects. It is
believed that sometimes these are taken for such, and snapped up
by birds, and thus succeed in getting away from home.
 Fig. 81

This picture (Fig. 81) shows you a pod which, as it lies upon the
ground, looks like a centiped.
Here you have a seed which is shaped and marked like a beetle
(Fig. 82).
The next picture (Fig. 83) shows you a seed from the castor-oil
plant. You can see that it might easily be mistaken for some insect.

Fig. 82

Think how disappointed the bird must be, after having greedily
snapped up and carried off one of these little objects, to discover that
for all his pains he has secured nothing but a dry, tough pod or seed.

Fig. 83
 But if the mother plant really does any thinking at all, cannot you
fancy how she chuckles with delight over the trick she has played,
and the clever way in which she has started her young on its travels?
There is still another way in which birds help to scatter seeds.
They alight in wet places, covering their little feet with mud. Now, a
clot of mud may contain many different seeds; and for days this clot
may stick to the bird’s foot, and thus cause the seeds it holds to be
carried for hundreds of miles.
Have you ever heard of Darwin? He was a great man who spent
most of his life in studying plants and animals.
How many years do you suppose he was interested in the study of
those long, brown worms which you find in quantities in the lawn and
after heavy rains along the sidewalk? At intervals for forty-four years
he studied these little creatures which you girls think ugly and
uninteresting enough, although the boys know they make fine fish
bait.
Well, Darwin once raised eighty-two plants from seeds contained
in a clot of earth which was clinging to the leg of a partridge. So you
can see that when a bird gets his feet wet, he may really be doing
the world a service. And it is not likely that he takes cold himself.
Now, I want you children to see how many different ways you can
recall in which plants scatter abroad their little seeds; and later I want
you to go out into the garden, or into the woods, and see if you
cannot discover many of the seeds about which you have been
reading. But better still it would be if you could find others of which I
have told you nothing.
I should like you to make a list of the different plants which you
find in fruit, putting after each name a slight description of the way in
which it gets rid of its seeds. This will not be a stupid task at all if you
set your mind to it. It will give your walks a new pleasure, and it will
bring to your school work something of the freshness and joy which
belong to the woods.
 Part II—Young Plants

HOW THE BABY PLANT LIVES

W HEN these little seeds at last find a good resting place, what
do you think happens to them? They grow into new plants, of
course. But how does this come about? How does a seed turn into a
plant?
I could hardly expect you to guess this, any more than I could
have expected you to guess how the apple flower changes into the
apple fruit. I will tell you a little about it; and then I hope your teacher
will show you real seeds and real plants, and prove to you that what I
have said is really so.
Of course, you believe already that I try to tell you the exact truth
about all these things. But people far wiser than I have been
mistaken in what they thought was true; and so it will be well for you
to make sure, with your own eyes, that I am right in what I say.

Fig. 84

If you should cut in two the seed of that beautiful flower the garden
peony, and should look at it very closely through a good magnifying
glass, you would find a tiny object such as you see in the half seed
shown in this picture (Fig. 84). Both your eyes and your glass need
to be very good to show you that this little object is a baby peony
plant. Fig. 85 gives the little plant as it would look if taken out of the
seed.
Every ripe seed holds a baby plant; and to become a grown-up
plant, it needs just what boy and girl babies need,—food and drink
and air.
But shut up so tight in its seed shell, how can it get these?
Well, in this peony seed its food is close at hand. It is packed away
inside the seed, all about the little plant. In the picture (Fig. 84),
everything except the little white spot, which shows the plant, is baby
food,—food that is all prepared to be eaten by a delicate little plant,
and that is suited to its needs just as milk is suited to the needs of
your little sister or brother.

Fig. 85

The little leaves of the baby plant take in the food that is needed to
make it grow fat and strong.
Now, how does the baby plant get water to drink?
I have asked your teacher to soak over night some peas that have
been dried for planting, and to bring to school to-day a handful of
these, and also a handful which have not been soaked. She will pass
these about, and you can see how different the soaked ones are
from the others. Those that have not been in the water look dried
and wrinkled and old, almost dead in fact; while those which have
been soaked are nearly twice as large. They look fat, and fresh, and
full of life. Now, what has happened to them?
Why, all night long they have been sucking in water through tiny
openings in the seed shell; and this water has so refreshed them,
and so filled the wrinkled coats and swelled them out, that they look
almost ready to burst.
 So you see, do you not, how the water manages to get inside the
seed so as to give the baby plant a drink?
Usually it is rather late in the year when seeds fall to the earth.
During the winter the baby plant does not do any drinking; for then
the ground is frozen hard, and the water cannot reach it. But when
the warm spring days come, the ice melts, and the ground is full of
moisture. Then the seed swells with all the water it sucks in, and the
baby plant drinks, drinks, drinks, all day long.
You scarcely need ask how it keeps warm, this little plant. It is
packed away so snugly in the seed shell, and the seed shell is so
covered by the earth, and the earth much of the time is so tucked
away beneath a blanket of snow, that usually there is no trouble at all
about keeping warm.

Fig. 86

But how, then, does it get air?

Well, of course, the air it gets would not keep alive a human baby.
But a plant baby needs only a little air; and usually enough to keep it
in good condition makes its way down through the snow and earth to
the tiny openings in the seed shell. To be sure, if the earth above is
kept light and loose, the plant grows more quickly, for then the air
reaches it with greater ease.
So now you see how the little plant inside the peony seed gets the
food and drink and air it needs for its growth.
In the picture above (Fig. 86) you get a side view of the baby plant
of the morning-glory, its unripe seed being cut in two. As you look at
it here, its queer shape reminds you of an eel. But if instead of
cutting through the seed, you roll it carefully between your fingers,
and manage to slip off its coat, and if then you take a pin and
carefully pick away the whitish, jelly-like stuff which has been stored
as baby food, you will find a tiny green object which through a
magnifying glass looks like the next picture (Fig. 87). The narrow
piece pointing downward is the stem from which grows the root.
Above this are two leaves.

Fig. 87

This baby plant is a very fascinating thing to look at. I never seem
to tire of picking apart a young seed for the sake of examining
through a glass these delicate bright-green leaves. It seems so
wonderful that the vine which twines far above our heads, covered
with glorious flowers, should come from this green speck.
As this morning-glory is a vine which lives at many of your
doorsteps, I hope you will not fail to collect its seeds, and look at
their baby plants. When these are very young, still surrounded by a
quantity of baby food, you will not be able to make them out unless
you carry them to your teacher and borrow her glass; but when the
seed is ripe, and the little plant has eaten away most of the
surrounding food, it grows so big that you can see it quite plainly with
your own eyes.
 A SCHOOLROOM GARDEN

I WANT you children to do a little gardening in the schoolroom. You

will enjoy this, I am sure.
When I was a child, I took great delight in the experiments that I
am going to suggest to you; and now that I am grown up, I find they
please me even more than they did years ago.
During the past week I have been doing this sort of gardening; and
I have become so interested in the plant babies which I have helped
into the world, that I have not been at all ready to stop playing with
them, even for the sake of sitting down to tell you about them.
To start my garden, I had first to get some seeds. So I put on my
hat and went down to the little shop in the village, half of which is
given up to tailor work, while the other half is devoted to flower
raising. The gray-bearded florist tailor who runs this queer little place
was greatly interested when he heard that I wanted the seeds so that
I might tell you children something of their strange ways.
“Seeds air mighty interestin’ things,” he said. “Be you young or be
you old, there’s nothin’ sets you thinkin’ like a seed.”
Perhaps the florist tailor had been fortunate in his friends; for I
have known both grown-up people and children who year after year
could see the wonder of seed and baby plant, of flower and fruit,
without once stopping to say, “What brings about these changes?”
To “set thinking” some people would take an earthquake or an
avalanche; but when this sort of thing is needed to start their brains
working, the “thinking” is not likely to be good for much.
But I hope that some of you will find plenty to think about in the
seeds which your teacher is going to show you; and I hope that
these thoughts may be the beginning of an interest and curiosity that
will last as long as you live.
 The seeds which I got that morning were those of the bean,
squash, pea, and corn; and your teacher has been good enough to
get for you these same seeds, and she will show you how to do with
them just what I have been doing this past week.
First, I filled a pot with finely sifted earth, and planted the different
seeds; then I filled a glass with water, floated some cotton wool upon
its surface, and in this wool laid some beans; and then my garden
planting was done.
During the following days I kept the earth in the pot slightly moist.
The cotton wool in the glass of water did this for itself.
And how carefully I watched my two little gardens!
For three days the pot of earth kept its secret. Nothing happened
there, so far as I could see. But the beans that were laid upon the
cotton wool grew fat and big by the second day, just like those that
your teacher soaked over night; and by the third day their seed coats
had ripped open a little way, just as your coat would rip open if it
were tightly buttoned up and suddenly you grew very fat; and out of
the rip in the seed coat peeped a tiny white thing, looking like the bill
of a chick that is pecking its way out of the eggshell which has
become too small to hold it.
Very quickly this little white tip grew longer. It curved over and bent
downward, piercing its way through the cotton wool into the water.

Fig. 88

About this time the pot garden began to show signs of a

disturbance. Here and there I saw what looked like the top of a thick
green hoop (Fig. 88).
What had happened, do you think?
Why, first this bean had sucked in from the damp earth so much
water that it had grown too fat and big for the seed coat; and it had