COLOUR

GIUIIDIE'

Oral
RI'I'

Pathology
A.
to

C'8WSIOni I E.

WI Odelll

Churchllll1v1ngs,tone,

I

Or81 P,athol,ogy
l

COl.OUR

GIUIIDE

,R. A.

CaWSOD MD FRCPII(l'i FDS Emerims IProfi;~Of ofOrill .• Medlcine and PathgJ.g,sy. UlliversilY a.f Lomlol:l, UK Vi~itillg ProCessor, IlIlj'lJlJiI' UnivlIlrsitlll\i.edJe91 Ce!fuer end D~n;t'i!~ CoUeg~. Dallas, T'CKII!5, USA

E. W. Odell
London, UK

I't1ID Ems FDS MSc L&1urtzo in OF<ll.Medi~iite ,ji:[lJCa:tIlQLO<!!y. P Unit,ed Medic91 and Dent>ll Sclio!)ls of Guy'~ 1I1lI:! St Thomas's Hospitills., U !1h'eni~ of

Churcbn~.Livingstone
EDINBURGH LONDON ,"rI.ADlHI) MELBOURNE NEW YORK AND TOK ¥O 199.3

Pref.ace
CHURCHll.L
Mcdi.c:ll Division

LlVING5TONll
of ?~w;III ['r~"n~1

r Jml! .....

Distrnmtcll illJ the U]],ilei! SEates of .'\m~IJ;a b:;r (bn.rchlU Li\TiLl{gi!«IJl~ lnc., 650< AVl:O!lII: of m~lIm~ril!.:wiil, 'N e w y ••rk. N .y_ 1001 !, jlJ)d hy j!i!i5;OC~am:i.OO[OII3!cics" t1o-",,~h.,;j ".nol.e:r,rei;t"l:llri~~ l.bro~~LJ[ [lie' W!J!rid.

To underssand pamoJogy, c]ear illustraticns oftb.e mieroseopic cn:IU18le8 are esseatial, To uy to- understand :!lind!emember the feamresef most di~ei!ses r without seeing bow they appear under tile m~cro5lOO]u~ ~iI!ie<Ii non-muslca! is pel:Som rryi.ng UJ' imagine the s(!1,1nd '01a, piece of music me.relly by readiug the score, It is OIJlt: tb!][Ig to. liLe:scribeill 'wrd:l; alone the LI1lV'9.'lli.tUI of tissues. by l:1ioopl.asms, hilt ]t is .inflnutely In(lre ililfornlaJtii\l'll to s<ee these c:h:lUlge8. Co~our adds ilIl[(J£:1lcsl!lr.lbly to clarifyilllg: IDCli'C C'Jtanges. but Iln~i:~

!ill ~i;g;Ill!~ reserved, 'No.paxu:,f!bi5 publicaaion maybe .l:ejlMCWCC<i •• l;[QKid in a n:uiic:va!! ~m, or tI'llosmrliCd, iII ,m~' ~Jrrm 'IT lIy' 'my ,ne:.1!I$, eliB"U1.1;;;<:, '''i!!i:Il:t~ie:am. phClmeo,pyInc.

~mK

QU

Olhe:rwi~C',....ilhoo.n cilb'=i" the

pr1{lo-",·,.i ll~

pNmi~ioD,

the publishers (OImrnbil!l lLi'!'illg!lODC. RUbcrl S«''i.etlsou. House, 1-3 Bi!!Xti£r'sl'1act,kith Walk, £dinburgb EAl ~l'iF},.Qr a lia:n« pcr,mLuill;!! irCll;W<lWdoop}"wg.in the UllillCt'i Killgililltl Ol.-weilll'ly Til! f'~!!hT Li,juniOl!lg A~il:"CY l'~.1,.00 T"II !:lI1~~J1] CI,J~UC~, lomdom WIT' 9f1E_
0'

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as CoIQur 1.Iirl~~Ot"I '1'."!,,,.I~·:, [QS,1'

.d:lu~vdyralCI!ldy, histopathology atlases in ooieu have been fa!: I:leyolld the price rnnge of mos1·swdeliits. By centrast, Ule present Colour Guide, dlOU.gh incJqJensive. provides more than two bundred and sixty iUUSlnlllUliIS TO cever all the irapnrtant lesious ofuhc eraland peoiioral tissues> as wdl as rare but impaetant diseasea S!\lichrul.Wcgcners gr<liIJlIllI(lrna.fQSts ;md (be charaeteristie les}loosassoeisted with MDS. The tal. is cempressed fet reasens of space but covers all the ilill.ponnt points liliI.lllt. 3. student sbcutd he aware of fur degree OO"~ fM lilicu ma uer, many higher ,~ml!.tiolJJre~.1ilirem~Oit:l •. Howcref, this boo1\:;mouM be used in CUJl:juncJti~!nwith ::I. fullef' [exl :su·clIt as Essemials o/~ISW1Jery awJ

1995;

Pa.tlwwgjil. Loll don i993

ISBN D-443-0~800-2
Cataloguing m, PDililicariQn DM3 /I. !;lltaID.gtl,C record fur IIlhL~ book i:s a"Vai'lalJle fro'<1 1110,: rilidi B

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Priated In H(ln~ KoolJ LTI'lOl

loW1cr'~ IlIlil:'fil 111 1I'..e _mBn~

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1. EIIe~dupm~!lilt~ill d!~£~ct5 ,oheetbJ
~. De:ntailearies

3. PWpitti.s
4. ~jcal

.

1 37
II

16." Beill!igo. oo.lIliI.eCt~vetissue
~1.!m:fI~

:pe:liod!D:ntimi~

·S- R~!;O'i"lii"".n:l11ld
Hw~rc>l::em~ntlltsi.sB >6, Pe~od.olltal dJi:;,e~S1e 7'. eyst5 ,of ~!IlG~!"W5 8" 'Otl'fl:iUil,~mi.C lumilUl'5 9",iN,~o[mt_lIg~[~ tumeurs !1>F
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15
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baue
10, No.n-4:le.1J'p.1a.8!1ffieoolle, Glisease8,

U. l:n£l:cri"~5~l)m;niti~, 12. :r\:roiil;.Jmie~1i'vt:s,t.omal!Jl:is 113. K.en!iW.s.:e5i (We;dQ:pIrtiM:
·w:hill~!: .I!I:~i!l!!Il!!ii) 11.4. S;wuamou!j, eelilc~a

'536l ,~, 83 97 Hli

1.7. S~il\m.as ~8. Lympho.Mas 1l9'.Pi~lIl:ed leSii.lm5 10.. .lI.li.s.ctiJla:n.eoull twnom.lil!Je l~iQXli5i 2],. Sa.I!iy,1li'}' jlmd ~wnl!llrn> g ZZ. S<!1Iiv:uy gJ;undleystsmd C£umlili~~o[!;'Jiili:!dt'ie :!i~ailla.d'C!Il!i.ti.s !:J. Gr.l!DIU~QJIl.IrtQu;s >clJise~se:>
24 •. .Mi!So~[l:m~lIb;rrg.iji~:

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HI
115

111 nl

U9

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2,.H!1IV in.f~tiO:Il ~!_I!d JDB A

141

143

AS. Hypt.'<rpi.aslic

~~i'DJI5

At!tiaJ.ogy

~. " AmeJ!uginel>i'!>im]lle:r[e;,;'L.a-lly~pl;a8dc brYiPOcaJ!c:mcdtYPt:~ • Deatinegenesis [m!p~[fa;HI.
ACll.uirnJ:
" Rl:cli;:ct~

0,

,. Fluorosis .. Tetracycline
Min'f!$Cojly

.' Severt: mcilloolic

dllitu:[b!::lElc~

]l:igmC[JJUlrUU>]!l"

Ame~'l:gel1£i!'rll imper/e.r;tQ,: '•. kypi1).ltmic .!ype-d.efecti.ve maul:.:fol!'Il!l:iJtiJcm-emtmel irneg1!l.l:air"!l)ve!!'al] tbi][I.f>omertime'll nodiul:JHJr piucdllJ~l~ welh:a'lcifieic4 .fuLa.lJdlldi lLf3!F1sliuaBIIlL(Fig, 1) • a • }l~d/i:fJi,gd ,rypt! -.n~r:lilJ!al rnat:l"ii!!(Qrm~.tioFl and

mo:tpDology
away.

liMJt

oo:Liit: chalky, ad rClldily chilpped an,d
Fig.~ Am9log~asi~ ilfnper!~Ii!: hypopl:as.lk

Dmtmvgmum imperfe'e;kI! mantle (5IiPCrol::iaO dentine with re.,gtlmr mlbule:s, remainder-a few ine.gl.llLar u!lb:u!~e8" :in.cll!liS](i:n of smaJ!l blood! vessels {Fig, 2), Enam.el did:ec~
are also sometimes fresilm.t .
can. ,t:l:IlJ!5e

~

.R1ickm~ if ~\!en~
(Fr,g.3).

b1""~t1!I,;ak]!fil.'adon wlth awide
spa~es

area ofll[lOOe:ntID[]Jc iliEHI m::IillY i:n~ug~Qbll13r

Sl!'PeIIl!!' me~!U:Jr:srullbilOCe.f:

lypicaJ]yaEecl

enamel

malirix JIlI~cl.l!lemg linear ~][Iling enarael dd:eClS COEH::s]JO:ndiin,g to degrcc ·01"reoth futtIillllion ,a~ time ~f illEless,

Tet:mryclilie pi,gmmta,iml: teeth uMlaUy OF!l(!rmal
~lU

furm

s.:ec:uio:n®iih~w yd~~w(I1.l1O<resoence along liaes lQ,nde:rUV ]]ght (F'l,g- 4).

stained yd[ow, degradruitlg ro grey or browlil_ Hsed
i~cre.me[lti3l1

2: I Dental IlIlries
Ai!\ri£iIoD .. Ba:cttl'.i.a,-PE~billllily m:lIli[Jly acidegeaie and ihlcanor aCl:inomyce:s Elll.}' contri.l!JI]iI£,possibly at dif:IDrmt, ::It:agl:s . • rJ!aqlle-adl!,en;ilJit m.eshw'~lr],\;, f bacteria ,m o po.lysaocfla!l'irles"t:hrekcs[ [[I, stagnation areas, oone:entl":lJt:~ 1!Ja.c~eI'i3i~eidpreduetioa a end dclay,!;; buffeeing by saliva (Hg~ 5)., .' Sllsoep[ib]e~!MIt!b ~ulfa.oe alild!(~oo,s,iibly) ]ml[]!l[ne ]lilI'mUl,Elsmains ofS~p" s,ncprtocoeci, Iaetebacilli
mm\am" O'th~vi:r~daDs

responses. '" Frequent supply of'bs:cre'riS!1 subc-stralu~-m,:;ruI1Fy
(Sl!I,CI'Ol!,e).

sUWllr

IElnalllir1!i~~ 'Qiluie's,
P'qJhoJr)f:Y

he-~mwll
leads

$llIibIlilJ.cOOSOO]:)J.c

jiicr,eas~q size ilIiil1d1 :il'l.!mbe:;s of poteS m emSimel. UQ]n mic:roscQ!P¥ &b.cnws oni.cal area of dlllilige whlil a]Jex deeply ('Fig_ 6,)" c oompri.s;i,n:g: .dei:ise sulfate lOOThf: (more tadiopiiqule) wlli1 en halll:cem striae of RelZiius " milrn. hodiy of lesien ,. diafk Zulli!;
'. ~phm~ ltalli:s]iJiee:illl zO[lt:. Degrees 0:[ dt:mlEeraiiCdtJio.[]J :in di.f[t:U:ilU :l!ion.es are assessed iby :pol<llriudl ]]gl!u ~t!ildiCli and mi£r,uradiogtapby .. Pro~iV!C demiaesalizatiea 'CVCEL~WI[ly aUQWs entry 10'

~Oprodill,C(~O'ill of

$mge (su:bwicrosoopic}:

ooc~ma~~h!l ~

.. J

J

~

1bacl~.R..
aJNlg

S'Ui!!indary

rbe

ilillI:lIelQ'lit:lilli:na:ljuJiil<cI:io[l (i~ig. ) 7

,tma_mld' CIi~ieS,: 1:J9t;lenil Fe::!ch ~~Ilidspreadi

Dd, snack

be:Jj]e;t~JiI.®<'rIe,r.1 w:itklllIQl. The: [ernl : ~J:Id,,1)' (!fl,UmJ c~ [s Ili~® used fur C;ttrl-esreclIlmng bessderesrerarieas. enamel
f['(Jill

3:

lPiac~erill S'preada.'.Iolll.!J the amcloot::[Iunal. junetioa (Fig, '1> p, 4) illilllll'l dow~ d:e:lu~lliailll!lbuks. So.f~C1II[n.g of 1Ih~matrix by fuacte'l'ial adds 'C8!L1SeSdistt::ll!s]on OF nlfu1!l!l£:s, (Fi~ 8, p.., 4). Jm,y dent~llie aposed by enamel aestruc,ti(J(Il!' is eolonized by plaqll:~ w.biic[bextends destruction over 11.

wide ,~
Mi~$QiIpj'

(Fig. '9'),

Delil(~m:is
Wa][sof

demwc:ra]]jzed by lilacte!l'IDa] ad~ fr(lrn nacteri'l s:piiead!iE.,g al.on;g the ame~!1!Id.elJJcillal! jUl'lIctiAlIll oo.Qj inv,ades via thetubules, a COIJJi.e;ali F~~il1ll!be~l:li& fO:l'meit '

by Iillllcwri..[,fule:l"V\f':l1ling
IJiqlJlcfac1Ii.oJ!lfeei Wig.

tubales

in9L1fie:ned

d1i,.~u~gwmi1'8.

dent~liI.e liIeco.me dislend,.edi dearlne ib['dliks down [(I fnrm UIII)a.l'l.d! tile rissueprogl:essiv¢J1y
I1Ig\'1018arnlillia deslKJ~in9 dilfIn, (h1i~hpcrwerJ .

Dell1tiilaI mad!iolfls
J[);eal!ll tm'iai.clLS Odmlrolil~asil$ are ~U!egjj I:lJ acure cmICS and puilpal -rooules sealed 01' l6'y ~a:ldtiedi:lfi.3~r.rial. "iI)aululOeof( ~tle~,

cnilsof

~]),ve,ry ehrnnie canes or anritiea, tJl]bw.e WalliS, fueoome p1'n-gressirvcly uddifiedl (pe,Fimbll.LaF ,mcmi!I!l.e) uatil rn'lill!lles

are obli1i:e ..ated

f'

(F'If!. H).

SeCQdafj' (re,l3Imtive:) delilJ'l:me R~l!I]~.r tdl.1il.:a1t dett!uil1c f)lJlEls I.I:llldl::.Febrenic lesions, Irr.eg1il]a;r (:!'eilldilewi:lh Few ,irIT,gula:r. tubules.farms Ibene~th marea-eun: ]eMOEIS (Fii~I2).

3, I Pulp'ilis
Aetio~.
CariC5 (most commonly]. '.' Traumatic exposure (cavity prepannioDl, fracture er cracked toothsvudreme). ., The[tlilJ:l.l or chemical irritati(l~. Of both, from
:reSIOrntlo[lS.

leiused pu'l[pitis
AcolDe dl1lSedi pnlphis Typical. [infiammarory reactinns arc initially Iocalized [l!'I a minl!lte area (F' g_ 13) bu1!.:'1'Jlicalii;f lead te necrosls of t pulp due to resr.r.i.cdos ofbhlOm sllpplly by the a;p.ical f{lramf"]I~ompression of VC5s£b by oerlema in the c ro:n:!finedi&j)ace and. thnnnhoses,
P'alholo;E!J)'

AU degrees of selllerhy ])lay be encountered, ~l.am,eJy: .. aente byper,~milaalid {.'Il::clcm.a (Fjjg.M) .. ]ll'!il:gresliiLv.enlilnalion by neutrophils i .. destruction of &pelCudiud pi~ oeJls .. abscess~Clrrmatiol;l (:Fig. IS} .. ,ceUl!Il.i.d (Hg'- 'UlI) .. .. necresls. (There W little 'co:rrdsli.ou between SymptOllllS and billtomogiC!!~picnue bua acute pulp pain ]S u~llally indicative' of jrtleve:r!i,jbly !ilCVCI).'iil pulpitis.) Cb~ic c~!lXSed.pul(pitis .. P!r'OOOllillilli8iJll[Y mlll'l!ID[lllcleal."'inflarnmatory cells (IY.!IiiIl'1toCll(es.,plasma cells 1lJudirnl.a.croplug.es,). .~n itiaUy l~cdl pulp allamage._ Destl!:'lIcTiom. of pulp, is often rd2luvc:ly '$~OW. • Ofren il!Di iw;QHllpktc caikiific barrier- a/round iIlil'lai1:'iilllitm:yCtlcUis. '. US.lIIa!]y) neeresis (If pilip evenmally res!.!hs,

P(lI}wlogy

iiig. '1& CeaJiilis of pt!llp.

1

Open pu I:pitiis.
Wiide'=]lollull'eof die pulp by caricus destruceion of the crown rna, :JJ1]ow it t,o, sliJ'fvive by' relieving the JllIreSSJ.IT:e of,eXl!ll.illI.re:. Sl!Ilfvi'l\id of p:u~p ][l these cireumetanccs :mary hie more likel,y ,i!1 teed] wh.h OPC[l~ inenmplete apices, I!Ilflammation Pl'l.flw!ngy ,ext,ends rnr,uughm.u: the [11.]1 which p,
bYgF.limdat.ion tissue ~ernll!l.e-Sreplaced

(Fig-~ 11).

'Gtl'l:l!.ul.ll.tion (iSSUe maypmli.fe.ra;te

Mod become ooloni.zcd! by epithelial cella Prolnerarkm

throUigh !.he expo:s:ure

of

the q:Ihb.e.I~llim may Iead to die formaulJ}nuf ;.'I!1 a]mosl comptete o!i)ivc[i(]g,allowing subsidence of lDl:ilamm.:.ujem. beneath (exCl~t at the marg!ins in eontaet wi.th tbe edges

M nbc earieus
IIIwide

dentineand

fihros~8 ofrJ]c mass, The pu~p po]yrn:;(Fig, l.8}mUls fo,rmed, appears as ~ i1Ji[]k or red :n.Qdwc]lrotn~d ing f:nlim

pl.aque)

iID.dlprogressive

eQOO'!.I:ttt:.Ocs1!ruCUO:Il of nerveus tissue in the mass renders it imiCllsiltiv,e.,

Oth,er p ul p ,changes Ca1ci.1i~:

()Qlmp'].elce h,e:alillig of We Wldcf~y][Ig JluLp. '. DiffU~ gl'lmulur ~kffication. Fine calcifi:caticm;s. ma¥

• .3'"m:oHiimy to pnlpilU_ Calcifleatiens may format tb.c borda onoca]~zed lew-grade pnl]jl,it:ill.1l!ndi coalesce to Sl!IT'01:mdl it comple:rcly (dentine bridge], However, the bridge is, permeable sod. inflammatioll ext:emul!s beneath ~t(jFi,g. 19). Dentine bridges, soon OII! X.·.ray· after pulp treatment, d!ll, 110t ne(leSSllri~J therefore indicate
fmgr-essi:rve:ly extend diIoug'b normal plll~s and fuse form ]1I!l'ge ma'l'."!<es Pig .. 10). Th;t>y ,are of 111:1 clinical ( signifiaal!l.oe. -PIlip. s.~_!Larg,e calciti.etll masses Il,f nibll.lar dcatine may fm:m :in the pulp, S0mc 3/t Ieasr as excrcscenees

(.0

fiomilie wallIs. They are nOL necessarily age-roiaocd, and an seen in young persoos with dli.e dental
abnormahties '!i!flElider:rr-DaJillos, ~yndl!r'Ome~Pulp
SOO[]Je&

are .asympl;gmatic; I:!b.e'irchjef signmc:mClll:' is pessible ,oooti!1i!:c:lio:n l[JI 1OI]I,t c;mal! tl\EaUnelill Inti.m:Jal :fltw:rp#(itJl:;' (:sec p. 13 and Hgs 2. 5-2:1, p. 14)_

Iii;> 19 Catdf]!;::dioo ['dellfliIll9 brld;;!!tl um.def

l!dp~i5..

4 , A!piiica,~p e'riiod!onfitiiis
AJll!tiD,~ • Seoond.ny 11(1aries and! pulp necrosis in most cases, c '. Trauma (j_1; tooth severing apiCiIJvessels, '. Roell CaI!l:ll1I:rea!lmen.t (immim mediC3[1]clJlts 01
ove[\exa.emjOlll).

P,rJ,tltnlomrt.l!c~ii'e.; iL'ttlln:mlatio[l (If acute ~lilIhmmB!I'OE)'odls (oeulluphib.) md fi!lIia exudate i.1i! putcutial space belwtt!ll lLfJJ'CK and periapkai bone (Fi;g. 21). If neglected, [heft: is ~1!IPp'llr.ltif.m reserption, usually of buecal and plate oHJOne. and sinus formation (lin the gam ovedyjl1g 'the apex of die t()otll. 10 dc;ciidm:JUsmalars, ][I.£l:mmiaticm, often iO'lrerrailicula:r. i.e, '!ll'vfil'l.ying: peemaaenr Slllcces&ol", devclops. Cbmnic.:' low gnde' i.niiam.matiion" Granulation tissue (ftb~ blasts and capi Ilary loops) pro]iifer::J!tes with \I,il1jl.ing densi.ty 'Iiltt inffammatory il"llfi]niilile. A rounded nodule (If granWalD.OIJI tissae (,a:p.iciJ ~,lIWOm<l) f'mm.s, ~itb, l'eS(i['ptio[l of 'p!.'lriarpical bene te iliccu.mmmlmt:c iit (FlW! .22

s 23), .~pil'di41 ,~o.mern:: rests 'ill Malg,,~:z are often dc:stroyro b:yinfia:mIlliliU,(lD.. If not, they linay pr,oliferau; (Fig., 24) in ,apical ;gtan'Uloma:s te fOnD mkwcyslS. The cp'inhc~iaJ liiniJl;g is va:riablc in th~ck:m~ss, Eve:nmaUy" a pC!rim1oD.t:Jl cyst may dIU!> form"
Pusftn'ma~imr.: neutrophil infiltradOfJI and lOIifN grade suppuration ~,u;dLy leads eventually re d~sdtaFgc villi sinus on gum or occasionally en ~ki[lover apex.

Fii~~:MApica1 gr,Bnu'iomfl w~h epitlhelal proJi~iI1iII:l'L

Reso~lltiioliil
Aei'Wrogy N~t7IWh in de(idJ~(i!.ll$ [tedl bclo:re shedding.
Pat1wlljgir:al~ '.' ]d~npamic-:i.l1l.t~r.n;al! or exremaJ .' secondary floc9i1 ~!]:Ilam,11Ulit~O:Il,].1Ire:;s,tlre iirOilil 1Il!a]~sed -moth Of UlimOUf" Ol1.hoaoilld,c move:me:ml, .r.epla[lb~tion.1il1!!:rh~dteeth). lbUlI!i\UJ,fD!' Idi(fpathic;: P.'.ro~.v,e resorption ]yy gi,;i[[JJ~ eells, maiJJJ!y of d!e'fui.me. There issamerimes il1lli:::rIEljj~rrcm. I1qplilldtillvc: ~ti"h:y m f®filiL ill cootlplex f'3ttcm of ];Cl;QEPt~lJ[I aad oome-I.j}te rei'iaru~jjv('! 'Il,i;S!I1.I.t:.RcsQFjJiti'j}n {~ElEm1l!1or ex~ei.iIil:d)~1lJ t:.Xi]lIWC pllllljp (F~gll 2S, 26 :& D)..!P'ulf[tis
]J)UOWS.

SeCVI1:~~ l!!sl!aUyi()wi2ed gimu cell aenvirs. Variable :rep<lfative a-c'tivizy livhlt ib.arolissu.(': depooitiull is Stem.

Hr,p,ereer:mllii'WtiOs<iiS:
A!e'ID~ .' Age~l1ig~

• Chr~;t)k ,apk:al penMoEltitiis .. .cementomas

• Ewied!(ee{ib.P.~e~·s Ui[$t':ll5C.

(3dJi3(!cEl~ttl IeSIjJE:ption).

(p. 5~.). .

P!ldwlog!i

on1l!~ of of FOIJl. Ra!!1~]Y (Pagel\s er CC1IIl£UlOCDhwitm!l:lll), 1t1lli~l!'eis <1!1II ~rttgJiJ~llFj~gsaw-]Illl!zzJlc{'mosale') pattens of .inte<rmi.ttent de~i:ni.uIil!Dd F'@Qrp1t~OEl {Fig ..2:8,). ,ce.memmm formill[lgsmo'M:h.lhid.';;e!Ji~[]!g

UsuaUy b.md~ltr-!icql[Cl!ltim di.epooit:io!llJ

m~

l'ig, 201·IFlI~rnal ~~iomi

shQ"",-.g gi~n! oalls,

IiiS>'ZB IHrpefllJ;fllf:li1toois<: laJlle!lirr ~m!!l ive;gIlIBf.

NOIWmI:lJl1i~i1til'J

m$Mn,. ('~n;giv.gi~~~id:l_eHl!1'1I1!l
i"U,cltlliIlilIl.llD

c(J.::iilL]jItiises:

.. oral ~~lIm,-e:xtetlds. foom lInl!e!l)gingiiv~. crest ofgiJlilgiv.a] ma_rgiilo~an~bas rete ridges ep:hhdl!ilI
.. jum:twwl,@idreimm.-te:llids

• .mku~r tpilhai:r.lm-iQ~iDS tbe Qj',a] d j!!1lJJctianal ~

a union WIth lllilc[oo:1:b ~iIJ.riae ephl:lclilll,8ittaC':hm:ent c:xtCllldiE:g l~ the am.tlloo.e.[I;u.t!Lal jUIil,cl'i(m in ~wr~!!1 l!I!NIltiUlI!'e~l[Ie, deep, towlliUch :ismt~ooO'.illla1

te be fl!aue:ned!QI'Id! furm.~

]i.gam.e:1Il1:. C!llIDN!Btllve tiseue gitlgi'Nift~ support ~iv,a] wUg;ln as a. cuft!: 3!'ol!md the !Mm. :rM1~ml~' ]01111 :adjaee!D.t !teeth m:ul"mo:md:llC[p1lf. A~6nd jilwts fom ~oo1Ihi!lll' the SOC~1 wan. (f~gs 29 &310 :mdl Fiig. 3~p. l8~

me

me

,AGll:lte:IIIllmeif,atilve gilglilviti:S,
A.wioio,[ll'
Othe-.rw:ise beall.l!hY)'OlIJII,g: adlLllJUl Aerii:®i'!llIg}' l!IRm®'WIl bll.t ]S,associarliCd wilm:

wrn:rl.

.30 *rmaJ !'I~n adul inlEt',denlil ~Iil!!i'o'<l'

"poor oral bycgiene
,I SittH~StS!~

.

smoki:mg '.' I!Ippeil:' ['esp~ratlilrytract inf:e~III:s
!IiiI1

Micr.ob:i~l~

ov.embelm~[lg proLifulailion of Grnm:..m~g:at:ivc 3IIaatllilic fuaoteri;i! ttra:cili.tlol1atlly termed Fflj()~ iIlUdtllUiWn and B:om:Jia (:r~il'Wma) ~rn;em:i. Other ;ma€il'!lnb~ma'Y 31:00 be llJ!\i'Dlv.ed. Asm:efl!f SilDWS :fmj]Sp~OOCib2etraTI. Q!llImp]e:x.{Fig" 31) .dJ p1lyrnorjlh,~ Gingiva]. neerosis andl!l!lllI!l~SJ!'ocifiicWce:r:atiOl!l 'oovucd ~y sl!01ilP containing filsifunl!lSalIildi sIPKodJJ!letts. Tissue is inv ..i:lc!li1 by ~]!Jjj[OCilliCN:~,wiilil progrc&rsive desrructien of margill!ai[ gmlf,iV';u; (~'I:,g.~2) aad dlell. ef de~er S!JIppm:1l:ingtissues, 11lere isne geil1era~izeil 8toJ1i~a!tit~-

Pu$he,furo:o

Fiig.3:11Arute, ulcerative gqivitiSi: ruscbaereriah::cm~1 n !Ome~.

1ii~>:12 Aeuce uleerllwe gin:!lMti!;: glngi'Olal
ne::rQOO;:,

15

6 I P'erioduJlMii disease

Ohro,nicC gingivitis
AerW,log]i' ,brliamml'LIOF}' response to 1;:D~~ri!!l, plaque acclllmuiaLln:g aL the: gl,liJglvilil margi:n. The b~CWii!l!1popnlatinn is wi:~ no speeilic pa:m®geil'ls, idemtified a!tdbomgll" ilIliti::tUy, bacteria om: Grum-pos~tj.,-e' and ,S,ei!:'obk-A[li]],o!'~.sii!Dg bulk of pla.l:Jlllc (UDO-300 cells d]j' cl) W associared with mO]i\easiing promiillt:nC>e ()fIGiI'a!fljHl~tiive bacteria, snch as veilloncNac. fusobaeteriaand cam.pylobacte:r .. "[he process is pIiOb;rb[yinitia~cd by leaka!}e (lfbacte!l'iiaJi
anl:lii~lls :&omp]:a~u:c in

moo

':hcgillgival

sulcus,

MicrQ.sco:I!:Yli"]aque iUI '~ooth surface with i.nfl.amm;ui.GilI sha_lJlliy Localized to Vici_D~1ty of !plaque., Then: is an ~[litiatl hyperaelllk stage (F[g. 33)wirtt rdative4y scanty ,i~_fl~:matol'y CleJ[~in die coriam, B.y deli[i~rio-n.,the per,iolio[lol, Eig:ame-nt is :not ~D,'i"Ohl'odillii),dtlte ep!udl,eliaJI anachmeatta enamel prnisus d;es:p~telll:llammatory eells eXIlmdililg bensath it (Fig ..34). 11'1e hlllammatJliry in1!i]trnrte becomes jucrcasiillgly dense but is sharply confined to the margin.at gingiva (Fig, 35~.It ~is
Jll'edomiimmtly

Fiilj. 33 Marginal !illlgiWtis: eil'ly ~l'3m'1ic, stage,

Fii:g. 'M ,Jlin.IiIBI e,p~eliJm ~mll~,pitliieTllIl
!till cbJnimt on Ilnamal.

antiJlImdy response

l)ml!phuplasmaCYlk

is :;nUlCWR by arnibooy .production

and the preteetive

in

[pLasma cells (Fig, '36) ..

F1ig>~ Marginal ~'I1gi'iili9: d'em8e rctilrnllliit i'lliammlltofll' ~llIfillratfic

11

Chrunb; pedodoliliitis
AeJillloDrmlsklJl.©!:
of'bacterial IJmaq;Iffi.Pro~e8.'lioE of wiitiliJ. itlis~l]~destructionis :I. (J®,mmon blJ!t DOli: mvaF:iabli> seqmd tn ehrenic gi:ngWYlilills:; mae is widi> ][Irl!ividWJTI.v,ma'ulD']l fIll' WlJii::l!lown rea<Si!lIJJs.
iJ!L1l!aJj]J]J]J.3[[~I1

M~~
fRtd i:mmmwJ6llY

M:my

]lJlI~e;nt paili!Dg€cJ!l.'!l (e.g.. P~l!}'I'OmaM~ siPec~res, ca]DlJ!oc:ympb:ag:a" closmdilia, fusQiFlacte!l']i3!, elL.) ,C3]jJ be isoJla~ed :from ~erlodi1ln1l,ti31 pocke,rs. 'but Ilild!ividlilaill1lll~es i.1l tissue ,d'eStructi{k1l are uacertale, Sume <e.g-AI:~mvmJ?I:~ species) prodllWe bQlIl;e' .[\e:wrbi:n:g fuCWil'S- Pi deife~ive ~mm1,m;ereS'j)(lrn.@e (ii!!ltibody prodl!Jcliol:ll md ~hd!U'

irn:m:wtit:y) ooplaq!.!:e bacteria is deIectable. 'Evi.dence of iI!IUIWUin;O~ogica:U.y m.edjarted !tissue destrlJl,cdo.ll ~s sFclllla~ve 0:tl]y :a:~llid cQluisteH!t with bi'Swlogioo not Ilmllililgs. PeoriiOO.QlJltaJl destmctiQ!J!is acooie~~ed in

i:mml!lllo!ilieficI~m,t patlenes but h,(li~fa.cw:!109._ff~ti.lil.g progooois ofperroo.Qntal disease have [lot been .id.elJll:!J!filedi ~1Ji o1ihemse beru:t!h:y peoEWnS.
,

Fi!il.lli' Chromi!;lperioOO~. Note
inflarnli'!'l;!tol)'

inmllT2l.\!i llooa~d ~ ",kjtl!y (iI'I

Rg.:iS PeriocIo:nt!il Pcdet: pl.~ue "'!lid
ca'k:ubs,. andl ep1!ha!la! lirninS'

IIJI~e.

Micm.llClilPJ'

L PLaq.Il'f' ud! o.filO'IB: !ZalrulUO,I1I, tood! Sl!J:rla.ce eM1t.e[ldiilIlg into 'p~k~ll> (F.i;gfl;l7& 3-8).2. ~edom:i![l"Dd!i' ~ymphO])]a8rnacytk imfihl's,re of giI!l.gI'<llII !I]~ugi!]j 8!tld JI'OCke,t w;a:]ls} not 'e:!!~e:Il!dingm:o:!',e deeply md aer i[JIvolvim.ga1IveGbrl' bone (Figs 38& 3,9)3-~:t:\1;'1!1NI m~~tion of,ep~me:]~al~,u:atl!II::ll~[lI(Fig; 40). 'i. Destruction. (If peJri.odJ)lii[m H~a.m:e:i!JJ{ fi:Mesud

alv,e;(dslI'ilone; bl.:l[ oS(OOClaM,!l r.att:ly seen, S- :fol'mati®1l of epithe1ium~lined poocke{s wiililil. e[pWle1l1a[ a[uchm.ent ill. floor, Gmd'lla[ooo'UWln'di :p:r'O~S o[ desl:mtOlio.i:li. [dids ,evenmal1y to, ~MSeliLin.g Or~ee{llil. 'fi:ss;u.e desl:fllcrr:imt is U'SlIahlyuniforta :aJ)ong[be arch (bn:rI2irlfiraJ bone loss) btu ~io~f~C!l:OO:S·li!ila:Y ~romol>emo.r,e c(Ilmplex paUetllS of indjridua:i reeih (vtil"'tica1boa,e ]os.s.)m~y dev:e:lop (iii) ~iQ:rl);ldly:, the[\€:~s9! more rnpid destruetlen of perIodl:!II1J!JaJ. Hgam.€ont itha:n i3!1'I'\~t~ ~Q!le w:it:.h ext~~i(l1Jl
ilf poC.ket:iDg berweif,l!I. teffi:h amid bo:me (lDua!h'lUII!i' pochtill[JJg),.

desUJ'il!!Clion.!L.ocaLizedi

d1esU'UCUOfi

(in OOfie

3l1'o®UlIl.d

fr~, Zl!lIl8 l!!e~ilIfloar
Of'~

fill!,:all '(bra period.oo1itiS: in~amrTT!ilillll1''o~' oorJ!t.;tOO oony p

Iiig,4Q Mig~tl~Gr~p:ithe.1ia1 I;!IOn'lll !;eml;fltmD.

~cbmenI

Adv,an4l:ed ehr'Oni,c: pe:riodonti1:is
De.s1:mctlio]! may progr'-C:liS uorilteoth Sllip]Jj!JiJ1: beeemes inadiequate and mon: oomplelt parrerns efbone ]o:ss d.ey:elup' (Fig. ..~ I), lntr,a,'I:m,nypoc.keb ,cx~enllill eep t'fli' th~,crest 00' tbe d ,iiI)vwlu bone aod lire difficlil1t ttl ma:n~ge_ lks.pit,e the di!ep'esrension (If ill!fla:mmatte!l it may remain clear ,of ,a]veo.iiITbone cLose]}' adjacent, which may :abo lad any Slgn of osteoclastic :acuvity l:dstologU.caJ]yFig, 42). (

me

Periodontall tla1tera,l, absce.ss,
Ae~
USmlI1y a complicatioiil of advanced penedanritis, It :M9:Y be due :0 ~niila.r_y110t~e ~ockel Hom (?food.jpacking) or
m~re vuuHeDit.Ud~UO'fi.

P",drology

• Rapid
'I 'I 'I'

Wides:pl'ead 0!'4ooclast~cresorptiou 'IlIf bone (F~g. 44) inciliOOlSi:lil,g wid!di and de:pm oi:ptl!dc.t to form ,deep inttabiill1Y pocket• flus may esnde ilrom pock.e,t liIi.llUitlit OJ[ point: 011

Destmetian of ephl1eLi:9~pocket Dense nell!tto~l:liI il'lililtn'ue iIIIldi

a.[li:ele~IIli'0:!l <(If:pe:tiOOo[]t;d

destnaction, (fig. 43),

Fiigl_ 41 La!e twariJ)dlonmi.w~h~ntr;tbni:lV
p!l>C~

fIIg~4:2 iFltJI;h~r p!I'I'i!rr view cri ill1JilOOny
p!Xilel;.

]][]]ng.
511PPUTilitiOIl.

anashedginglva.

IF~.'. Giiilllt cells re.sodiIil'lQI booy llOor of IPeI'iodontal ebseess, -

'GingN,allllec:ession
Aerrolo,5' • and! tear ('senile") fEo:m Qvtr-vigoRlu:s UJotbb:fIIlls:ing_ '. SL>V'm'"e 1[mco:ntr~~led ulceearive g1li1givi1i:C;.,
WPMiE'

'. Some cases of

ehronle pmo

dQDljjt~S.

M:iuv.5"t:opy

Gradual destructlon of g~l:ligiv~dl:i,lj.!j1J!l.e,pcriij!jdo:ntil ligament and bone, all ail aimilar E31~C1l. No pocket is fu,rm.ed. There is lo,w grade minimal chronic inflammation (Pig;. 45).

IGi,ngival swelling
..ik'rao!'COj)y

AootieiiDiYeklmonm I:ytie lel!lbem:ia ·baggemned. n::>pOl1!se to plaque, Wirth gwS's inliJmt~(Dn of g!!l.,!l~vat:by 1.ellikacmic cells, gI[lgi.v.a[ s\'i\em~~" aad aceeleeated petiio.d.Q(Jt31. destruetion (fi,g. 46)

H~dir:my type; ~~eii'd[w:dI smooth gi.n,gil\laJwelling s
may ove:rgro.w and conceal erupting
~g-m"£jj~-qfed

Fi'bnmil ihyperpl3isiaJ

Filg~i46 Acute FllI'I'fm.oocl;1liib 1e-1JI~: 9ill!lMI~!~il.

teeth.
sw.e]Ungs

hyperplru:M~' iPil"'{Jiduo~,bulbous

ofinmJ'df'lIitaJ f'a.pillae: .. CaUSCl;. inelude p,b.mtytO]~, cyclOSpo:rilll) uit:edipiile and its analogues (caJciu:m c~almellll(lckers). 801ili soow 'hype:rpLasja of gingi v:il coUag'L:1nwi.th "sttetdl.l.lJJ!f (If elongated m't:: nd!g:cs (F~g.47). Pat/wwm'
C@TIS~SW

Flfe~amI.q ,epollis, (p~tGifi.ani:.1I' tWil!l~u:r} of dilated, [.1tim..:wa]]c~~ls jill! loose tmeideIIla![6U8 8lfoma ,0·fL(:I1 wil!l::l. supeeimpnsed infliamm!ltIi(!D {fig. 48). I'he conditiou is not

dli.s.lliIlguishable £rom a pyQgcnic

granulama

exaept 'by the

pn'lgnaIl1t state,

23

P~'ri:Dd!(udalll~ra,Ol;(:iUll;ar~ c,sts
A.etioJ(plO' F'lllji de~.uh, ,a,pkaJ pei'iooCl.i:ldds •.piX!Lifetui(lu of epjdldial rests of MalSlflse2 cYMk cha:n.~eill epithel iUrnI.;, ,expalilsiom ©f evsr by h,.i.1rosuuic press YEe; "eM~£])(io!Ji (If SUHl)ulI.diin:g hone,
j,

In,~id~m:e'

65 - 15% of jaw cy!>ti>.Pe:riod0ll1.tal cyst, :m: ~hJ;:mOS[ 1.1~mm.UEl ause of d:mlmLic !;well]iulPi' of tlil!!:: jaw~. c
CiomlPom:;[I;t;s cOHl!p'r~c:

PatM,iogy

.. epit!hdi;a[ liming '!II! ehM[I~c imJUammarory i[lfi.]t!'al~ .' fiifur~J.IDlw,alJ[ .. b(JIIl.Yshe!] l!l:Ild.ergoi.l1lg: poo.gJrefW~i.v~ [\eJ'l[hlJtion. The epithe.hl. !i.l!I;in~i~ strailiifiedl s'iJ,l!I.amm.ls in type and V>fry variable ill! tli.iC.l\;ThBSS; sometimes w.itb:;rncadm:ll. configueation {Fig,. 49),iITegil!lladyac<Ll!I.t!hoti.c (Fig" :50) or, rar1ll1!!i",. tbiek (Fig. 51). Insome areas, tn:e ~it!he~i.al. limLm,g llllJa!y be destroyed (lFig. 53, p, 2:8:). T!he IlmJ:l:,:F:lyiaginficammamry infi]ua!i(l: is also of vlu:ialble density. The filbro'litS,waJ!1aIJ~ows enucleation of me cyst bo:w ~tll fuljJny' ~_j~t Oric S!bOl.!l'S pr-og:reSSl'l"C;OCSOIptilll'El B 'O!llJ tliJeiIlR£raspe::taJ!!ld :lllpos:itio:l!l. extreomal]y (Fig, 52), but reserptinn typicaUy outpaces ::rpposiinoo. 00 tbat !:!be b,teral wan ~8 desttoyoo..

""'1]'

fig, SO Wli!D\ed ~ll!NiIh iliJegll\lirqlitheli:ll IliniIl,~

btie siJIa:g~cysts D.~!lte.I!I:!l~(mf ey.st leads to th~nl1li.l1i.gof tlli,e'epithelial o lining and, if ~[I]ection is [IolI SIl[}e'.I"urnl.~dI, 1I1u.~ in:fiammail]lTyil1l·f.iJ[ru-ate ilal[lcrnl.ffi ,atrVJf:'Ill!lai~d (F~g~ :52), Residua!!. ~ysls The ,c:alili~ltjj'l,i'e WI1ltl!i. is extracted, leaeinga resldiu:d eyst. They arc typLcaUyfou]1d late in [ile.aIlliol. show l<I!~C-1IyjJc
Ka.tl!lF.Cll.

L.3tc~3rn. rad:klll:u cys®S These till: nne ~EJ.d are occm;..ionaUy related HJ'~.l!iilQal ~{lOl 'Cliinalof;) I1LOJl-VLlOiil. ~myth. Otnci['S are ~k:".d{l!pm,eI1~.al ::I111l@ fiC!!imbeside:a vimllooll:i. IFIg, 51 TIiiCik ,e;plflia11l!intlliJtIilll ~r,iiD.d'oota'J
q'St

11Tii,512:QUDp!ew qJitbl1fiaL fiilf,cU$. ill1.d hKJny .cys~wd,

" J Cy!>ts: 01' (he jl'il'Mi,

Peri,odonta'l (ra.diicularl
O¢ll;s,

cysts

~oontdl

M:~n

CholeMefol fr.om tille b:re"kooWII of bloed (leUs is m,q:!!I.elidy Seal ln c!i'Smss l1ee.cRe-ibia]lied dI.dts. aeIJj~S, rypi.caIi1y fmtiri in d'le cyst wall~ ltIut extend [RID the C~,[ C3V~ty (figs )3 and 58,), C1efil~a~e $1,J![,OOIlllld!ed by g,i.m[ cells wlho5C cytoplasm becomes s·trelc.rlj~d 1l!Il1lli atrenuated,
but the clusters of nuclei may 'be seen near one end
(Fig.. 54),

.&piimtiou of cys[.BUii~'lypi~y abo sibows choTestorol as l!Ia:l, :rhomboid, notched c:rys'[:a]sPig. 55) 'often with ( mooiy iillHammatmy cells,

Mimncopy

Hy;attine l1Iodies Hyalill€ (Bmli:trolil)bod.we5 ;W; Ih~iil:reffaCdk f,l;Id-nl .. or ee hair-pin '®T otlicr ~hiij}ts(IF~. 56). StSrillllr:l!g is ·","®riaMe. Their nature is; ullknown. They may be D 'eJlitHre[l:J[ prO!ilJw;;~ haematogeaeus in origin, nr Gohlet celllls Mucous mempmStll can proo.uce macie-filled goblet cells m the 'GJiliiithdild 1iniag ofperiooDital cysts but ,ronside[;;ilily W'Ol"C fn:qllU:ndy ill d.elrli~rou:s cysts (Fi,g. S9,p. 30).

F1:'!J.[$A Clefts with gianl· il:ellS.EIDIi dep;l!lltSit9, 01· memlilSidetiin,

.~.licro:l\OOpy

21'

Dent~gerlOl!!ls cys1ts
Cystic. cbang.e
~Il

romp'le~ionof

ensoael formation. d~f00t ohiitikw;nl,lli. came.

remains ofenam,d Q.l'g:m afk,r Tb~s .is :I ,devdo-pment:ll

15,- ]8% ur jarw cysts. The male W fenlaJie: ratio is more

than 2 Ug i,

Microscopy

Thecyst wal is srtached

10

nesr theamelocemenral junction (1"'ig5 57 & 58). The liining uf [he cyst (probiJ-ibly ,urigio!l!till.g fr-om

the neekef'the tooth at.or

~teT'nail en3lmd epithelium) t:ylli.rolly ~ippear.s. !b!i a tlltiro Hat b.yer of squaraeus cells without 3. defined by.err of basal cells. The ][]]lett:'enamel epi1thclim:n cover.i!!lg rue Ol}W!Il of the toIlm is QJsu:;Il'Iy last, The :libii"0U~ w,aU is typk9JL]y wirlrolU intla!fI'Imato!l:rymfiltnue, unless set::CJiJ!l.darily mfecxedL MIl(l(lilllSo~ls arerelatilllehy eomraon (fig.5'9). Eropti!lloD cysts An eruption cyS(

fig ..Sl Derrligetous qrsIwill1 eRBmel ~]fI1~iull1 OOMBl!n enamellSI(Ia.;e'left]1 illild [

IiIg. lSI

I}en~i9;erous ~

shG'fi'irQ attaehlD!lDi

gingiva ovedyiJilJg 811'11 unerupted

is..smetly,

~~~l,

.

at neck CiflfloJliL

a soft tissue cyst ill the

tooth. Iii: is

pr®alb~y 3

~1!l,perficialdeneigerous
M,iCwSflJjry'

cyst.

Thin nliJI'mILS WilU wilh thin ~qWllIROui;epithel.iaA ]itnillg dee,ply aad oral mucosal epithelium sllpei!'lkiaLly (Fig,. 60). Thereis variable iJlflammatc('lryinliluare :i!!lthe walt

!iii, 100 ElitJlltlcli'I~w~h eyttwalll

ImuOOSllI~

'Odonto,ge:n le kleratocyst
A,ei'W~
Ilaknown. P[~lllDi.ab]}' dte qs.~ ,j)riginares f[\~m primoTdi::lil .odmllro~i]h:epilhe]jum (:mypan of dC:I]tllil ]amiiU3 '!;IT remnants 'thereof) or enlam,e.] organ ~:n;;fgn::ile t start of amelogenesis, ,f!. ieeth JS sometimes missing, A~ont ~O% edontogenic cYSts. Tile msle to rem.a[e of mtio is alilmlt LS. to L Tbey N!rm most frequently in young adults or <It age 50-00, poss.-ibty [bien. asa result of slIow growth and late detection,

lnc.id~e

F;o.rJwromr

Albout 75% in oodly espaasicn of bcae. Olilll[',acteristic

011' fawn ofmaodi.ble. TypkaUy. illlfilmlllV!e growitb iI.litO eancellous bene io:r.ms aiD e:2:teDSlv,e pseudolocU:laited. area .0:1 udi.ohl.'CCIlCY 'with Un1e

M~

l.ini.[J]g 'll! 'eJlii1ili.elLiilJ1m 'l1lIfeven rhid\::ness, 5-$ cells thk.k~ and :fila!t ~1lI5CDilC;.[]tme:llil!br;a:lle-, Thereis 3 ml!, J.l!!I.isad\edbasa] cell [aycr and thin eo:sinopbilk layer of ,~kerntiD (Fig. 61). ()rrlwk.eratiniZatWt, i!il ~CC[l in 3 minewty (alnont 3ffl!O), oocasi.(U1aUy wi1tb. keratin forming se.rusollhl! cyst conteers (Fig. ,6,2). Pai¥!'ktr:aftltm-fd o/S'.ts have a stronger lendoe,nqT toreeur lhrao..n o:l1hokera.ti[]iz,cd variaDl:. Tii.e epidilei:imn is die lYpka[Jy milch fulded. and tends W '&oplmlte from the fibrou$ w~1 (Fig. 63). Danghttr cySl:S HIIeoccasio[lal]),

~16,1 i~1 1lI1n9L

pafaker;atLi!l!i;.ed~r~r~n

seen. in die cyst waH ,aniillm3iY 300umU ror oome recurrences (F:ig.. 65, p, 34). An iinfli!lJllru:fiarozy t[liUtl'<l1t.e is
lypi,cS!llly aib~lIItlmt infection and ~]J.ilammard.Ol!l came the lining: to resemble dla!! '1ll!:II periodootal 'C}'S1 (Pig, 64)-

IFitm. 3 ~eratoc'i'Sl; IlBllli:el1i~inil!ad ~ 6 showingl~k:lllt:.aollrrnentto ~SlW.lln,

Ing.lS4, 11(:eI'ilI~tsh~ less of~~ struOlJUre II!! a I!SlIJJt cfiinft:!l1II1III'tDoo.

NlaSOlPa~aliine~~IiJ:isivle calHa.!; led~alillpilla~ilnlilll D
Icyst
A,e~l~[PirO\Hft'r.alti{lilli.
1IJJ~j)a~;atifie

nf epithelialremneots
d!1lliC"L

of lining 0:1'
6fsIl[LI.lI!moH

MkrouOH

:il!ndlor clliared oohunl1i;a:rr€iPit'hd~tim (Hg_ 66), Chara"n~l'ffi'l:icaU:y~ neul\o:va8c!.I.]ar ~lmd~e (alseftora a
incisive ca_n;ali) FiEl~ ( 67) :3!lJ!dI SQmelilli~e.. sa]~vary acini.
l1tliay

Mjdlim~ c:yllI of anwrior

m.9Xi.lb with! lifl:ing

be

fCUUidi

in tile

CYSt

wiLL

G~o!bl.!fl~em!axiiUary eyst,
AaWiogy
ParMlo.gy Dc¥clopm.cmaJ. -m.OSt cases .aPl!'e3r ~()lbe devt'lop~eirltal.
]illCW

pe.ri.o!iQon.a[

cySts.

JB;y dehitio.n" me Cy8~ fbnns ~Ili the afueri(lr!I!IaN:il~a between hueit's] incisor and CIIltliae, b()d~ ofwhkh. sre V~[a1~ibu( these crheria ~e ofle'Jl not oompiete:,~yfulfilled, It has a fibrous wllill with iii ]h~ifig thaill'llay be sql}!lamou.s., OOhlmlliaf 0. od,l!mna.r ,dliau:ld ephhe!~irl1m_

1ii9ll~ Ollia!eclepilhelru:mllinin~1n~opal ..tire
qmt.

A~fWIoDlfi[]lkIlO'MIl"

TI:Ji8 ]:l,aEl G;Koct:di.llgjy lli['e$():l'~([S'S1lIe CYST

cxrorllailrolhe mvrola!!"ridge IlIrneanh the ala, ,1l~L~I probehlyarises fmm remnants o.ftltc lower eillt!of (he El300rncrima] duet, A Ill:ll5ublbilil!c~t may be '~eil!l ,a:l. 3lm®st allY age fuimtIl:JJc pClIkiEcidc[loci:;, at 40'-5'0 yeim!~ Microscopy 'JIj'ihclinillg classically (bat often IlOI}i:;. I!Iulil<:ilia[ed columaar C1J~rlJj::]il]m m~y he lOt{!!I3iJilom; or ci~i,aled but wim. a fibrous wal!l(F~!!~ 68),

(lr.

l!'i'g,61 rlkwc"'iill~l!llar blIrndle 11Th nOI::iI;l~I~I1i",e c'fS'Iwodl. .

CJstswi~hinl tl!lmOll.HS
Cysts within lU!moU!fS an be m1l!.1aik,en lor :simpLe '}'SI[S dimica:]~y9ilii:di radjoEJnipbi:caUy l1I~u their predse nsture is c®:nft.r.!ll!OO :mkrosooPlI. Tilley are ttl00 [ common Un ~y ameIQb.la.smma (f~. (9), A ctI~dfyillg ooo1iltlD<~e:mk ,cyst can be a cyM. or ill soiidl
ru:.mOllil'.

'Cys'lii::amdo:brnastoma.
M~~~ El>l[enS~Ve ¢yui.c
[IWliJiOlllt.

Cii::lli1llgt: (see PI 42) CD overgrow !:he The ]i!IliIflS' oooom.esll3l3!Ucnoo and!. ]j[J;lJyb e ]il:u:l[s[rn,~\I[is.h!l'bk i[]J ]J3!ft from. iI1baJtofa s]mp~e~ysrr,

E1~he[,e, ameleblastcraa cellsare mOore~bVjjOil!s in ilic cysr ~ww,g 3[JId. a. typi.cal WililillilI fu[J]l:SlElllJ!rallthickcll~Dlg"

I(':allciifyling odoliJtogellilic cyst
'Thollg<a often cystic,

Iiig.1O

C!ik:ifr!(ing ooon~;elE~with

gilost

msy bea beoiga

mis lesinn eaa also be solid 1II1d
tlIIIl]I[i'llIl'.

~ell$~

0001Ilu},gc.IIic

bu:idmre

R.iix, Jiw:y age ean ,,~ aHa:locl. bat t:llre lesi.oIl :ism.ost dtcDl de[edtil ]III. the :sooo[ldl decade. w;ail;lwith lining ]J'n::d.om]!JImlliy of S(jjUill!iIOlliS ma~ !;De ~crdl[mn<l[" mill. am.e.lobla!ll.-~ikc:. All:m.lIl1lI!I.aTI. b'ratiniZ3n~Il OF8pi!nous cel~s padl!lccs. poor cells COIiI:i>~stlii[]!g d:iSMDiI.ed ,oosjn~phiilic 'i!if ,~iilicl'i:lll. ccl]S cilJbc[" 3!II.l!lChO:3lF orr ooC;lls~mllllUyeonraining IlU'd.ClIlF 1CCJij[JJ[]ml5. (fig:; 1~. li & J2).ra.1IC.hy ,~illficatiOJIl 7 m;JIYd!cvcili!ill ]ulillc.m. A.s5oci:1ll~ed or indueed od.olJJoo;gmric
e.v.iithelill.lJ!lEl but m'e ba:sm [ayer
ttnm.ll!Lrnl or ha!l!llMliilElila:sare

Mi'a'wopyfihoolJis

[]jol1i:n:freqll!li!D.t. d!eveJo]ljjn1jl

ll:d.jacCl[tly In tl!.cl]b[\i!ill.]s wan.

lfim, 7~1Cal~lf\!iDdI odol1lID~ 'Shoi>tcells.

cyst willii

Ag. lii: C:llcifyil)g OOontogeni.:: 1;)151 wilh ghO$l

~ls.

35

Cysts, without 'eipitheUa,1 ~iinilng '(lo:n,·od!allil~ogell1liepsel!!ldocysts,~
J~r;,idem'!)tlnd
fft!tiology

R.:il'€. bur w.udl pealk a,!:l~ ~oddleJlJ.ce iII. tibt; :5!:lOOJ!ldi decade. The ,aedolo.gy is speelllbnive. S'IJI!l:bi yns wt::['It: c ttaditinrli;i!.lJ~.y:hOl!!glH (0 be traumatic (c;n]]C[ terms: ~ liIae.morlrl:i!a:gh; (If U1ilW1Iil3dc boae cyst), but tliK:[,C is [10 supro:rti ng evidence,
Almoo"l:it'lvalllllbiy

Soli~<I~ bene ,e:Y$l

Ptlllwlogy

ill mandihle,

The c:ll,'lity and!

rndioJuoelil.cye.l!1CiIiI.d. rtlFo!llg!b c1I!noe'Jlol!lll I!Jl[)illlif: .mdl arch 1111' boemreen (be roots 'Oflteetib. but nl!r€Jly {;J'iP<i!md bone, the The CYSl ma,}, 'COIl:~][). serosaagniooas iu:id. 0[' be' empty '~K"e,p[ for. all. The waiU. is u;sll::d~y rough, b,:I1)~ bOlle" SQI'Ilelrume5 whh u:ao~, of conneetive tissue lI!S iIllJ®lIIijll.et.e lu.l1I.i!!:g "Hg~ oflelll willi!. evidenee of :sma]~ 73),
bia!f'mi.orrrhages_ Unlfke u:iI,]e grS(S} sc[hary bOR!:: C~t1;, ]Jro0!l11b]y .heal llponta[le(II!1~;'Jy_.TI 'e cavily:ihouhJI be 'tliPOClIl!cd OIlJ~YtIlJ'

oo[]JHrm. l[le d~~g!lio~;;is, KSU~ti:[lg Tile b~et:ti[ll!!iE:rotbe cavity csuses h tl) ~eSi1l~ [bes~ Cysl:s arenet ..Nmm lly l.e, lill.eeoli.n:g illto dlebol:l;e .
•"-el.uysilUal

Ai!\titllogj\'

bl)o¢ cysi1 SiI?et::;uhrtive_ P,rn;sjbiy dais is [l,(k:".dt!lpme.m.ail

~dct:l

or

a :resl!L]t (If ~.~eed:ulllg !:Ji~Q.)o<r ~ VllIscu.il.Hl".izalio[l of, :II pu.~mi:n:g les ion. such asa gialiH ecll granuloma, Pilthdlogy GrossEy,the ,cyst re.o:;¢nib!¢> a ~kloo.-fillcJI
~pUDg!::. I:inCt~hy

Mi.ol'!Dsoop!C'9JI]:i',
cenncetive m:.m.}"g!inlI tissue

it oolli)~isvsof MO(IJd-fiiLleod. S')JH=
~y higilll¥' vascular

:lliJlbt£Il:ed o~]ls and ~pamred

~e']l!s (F.i;gs 7'4 & 7S)- Soraerlmes t~.e solid .lI['~sm)3Y' calci:fr and I1ffie'.I1Ilbleossifyiibgliibro'inJiSi_

septa (and S inJ!iLllir &oJI~dIliif,eacs f~.eR wirh o

8

I OdontogenictJUlmours

Most cerumen nwplasm of jaws .. It ma.inly affe~ meles aged. ova <til' ye:us. with about 80% of rumOllil"liibe~l~g St:CU.in tlire l!'3ml!!S 'l)lr pi)S~eri.O[ booy of the: m:llJid~i)]e_ AmcIoh]a'S<to.ma [y'p:icaUy appt:llliS as a mnlti[(lcula:1i cyst On a radiograph: eccasionally it.:is mcnolocular and! ean mimic aperindontal or dentigerous cyst. It: is.slow growing: ;mdllocaJ]y iili"'3~]\lC but OOfS not metastasize: IIw.elilMastic earcinema is c1«l~dli.ng'ty rare,

Microscopy

Several! suillity[)eS,are recognized. Appearances may alsc vary within IlI1i indivhll~l tumoue, F9lliculall' ,tytw: tslaads ·Ot traIDoc-uJ)aeoJfoClSe ;lUlggJar cells, :resembling steUa;[e retIcllllum, snm:m.nded by a single layer of tail" celuraasr, Il!J]IdIJMast·]~kie cells with. iliu.dc~ at the opposite pole [0 tlb.c baseeaeut membrane (Figs 7'5-78). CyS[ fo:rm.atioD is, common V3fying from microcyst!! within a so]iidlltUJDOllf to a preilomi.lJIlI!Dtly C;'1'lOC tumour (Fig.®O,.p, 42).. C,'sts ~ev.e:lop either within epithelial islends U~i:gs 76 & Ill' n-O.Jl[l ys u.c dc,gcncr3lilll[l of c ccnaective tissue stroma-only the: ghests otbloed vessels may remain (Fi,g. 79),. ln 0'IltU;: atl1rlollolas.toma. the niiliiilg is ~§ltCD:flIaru.ened, ~:mibliq aJ non-neoplsstic ~"¢ (Pig .. tim, p, 42): l!Jiiopsy (If this alene :mary lead to mis.diap.osis:. PlexiflJl'm ,I)'pg: thin trabecelae o['opiith.cli.:d l1Cnll in COtlfie¢n.ii",'C tissue :sb'll'mi3L Amnlhomal'OU!s ,type: sliljuamnus m.ela]J1as:ia of central C8'~ Qif'ep~lIl.eliU!llJl, bun otherwise resembles the mOF"C comm!0f1 f6J]i:cu13£ 1iJ']loC; (Fig;. sr, p.. 42). Basal !Cell~ype.l·small; dHkly SOitiDitlg ~lls, pmdl]mimmtly in a u.a:bet:ular pattern bUT wirh Un1e pllllisadillg ail:the p.eriphczy,. Rare'. e1!trafl$Sffll!S. basal cell ameloblastomas have been mistaken I~T basal.,odl

111i."". Amilllllbli3s"l:ama: tallicuiar 1lB.l!BJIlil. U

m

Cilircinomas.

,Gfdi';iil.W",!(;eU. type: rue, uSRilly feS'tm'blt'l; the folliealar ty(If'~ bill tumour iis~a:ndlB centaln I~ui'{i:e eusinupbilic grannlar e_phh,elia,l c.cill.:s (Fig, 82, 11.42).

.&!~

JIHD[l·liI.COp~ast]C cysts 0[' other :radii.oI.l!lCern:llesions "y md!iogr:a'P,by alene i,s 1.]!EI:ndiab~e" Am:~]9b!;il:lJljOllllars are i:([\i'~;i.\l'e ~CiI! fecU!l" unless w.i,del.yelI!d5edi- Their ooharvl!D1][' is ant de;t:emlin~ by hlis[l);logiO!I .P~u:ie<1i'!lb:ut itliJegw;a:l!llilar cd~ type is twmMy more 1ikeiy (I) recur. The mol!ll!l]ocl:lJl~,wl.11gr$dc ~ril!lm :1liI.aryespoollid m tia9Nt1(g!iJ r el'l!ude!l!ti&ll_ 'b_re maxiUary :amd(!JMa~Li(lmil!S liiia.y p:restrm .m;lI.j.o:1" s!l.1'gical.~rob!lem$ if die.)' inv!lde tk craaial cavity.

Hio~sy is esseatial, -prum:iicub:dy fOE cystic ame]o'd:i,]aMomas wben:: 3. F:001jJ:gn~Zl:Ib~cumour may be :p]'es.ent only as 3. t limiillli!1 area ef muralllliicJli::ening. Di:ff.el'eJilliuion From

A!Illte'll}b~Mmml!i& :&])l'ea~: ~oo ~i;ffiC1!!]~ le'm:Ollll,lge.

illiwsoi:

tissues (Fig, i!B)

ale

T~~.tId.eaJly, U'eal!.rneJU is by c()mp[eue e:lOci~ijJo~prdentbly wIlll. up ll) 3.2 CJlIJ! !:l!laJrgilJeil' l:1iotmal b(Ji.lil.'~However, spread Is .mari.l11lyth.ro~.~h eancelleus tJqneand h :is some1timJes ptJIss!ible~o, preserve dl.e [&wer OOn1eJlof.me: maIldiibl.e'. ijf iI~~ ci!Jll1!O<lI!:i-free)re aivo±dI oo:It!J.pJeu! resectlcn of the jaw_ BO!:ll}, repair canre-form mu;cil 0:[ jaw. Any ~h;h.l!al tlU!mour is, S]~YW gt'{!IwiillJg a1lL~ .ltlliy

me

reoo!rll'~ncel'JhO'u]d 1bederectsble hY['C8!J1]ruradiograpbic r roI.]OW~l!Iitl~ !l!lIowj:ll~mrth!e:r ~rumJn:dle.x.~;i!;i]JlJI.Iil nW!:SsMY. if

41

\-_.
,Ca.lcifyingl odontogen'it 'CYI,!·
Solid variant (Fig. 8.4)ofteslon ,de8cr~bcd earliee (p, 35}.

C'aJleilJi n 91 epitlilJeI ial odonlDgelilh: ,(Pinmlborg]' tumolU'r ~'CE01]1 This ~s iii rare but impommt blm,oll[' because of its re8efll'ltlla:nce W, and risk. of Donfusiom whh poorly differenrieted carcinoma, Age and! site d]slriltmlio]lare
5~mj]~ to 'I1h:lt '0'{ alllil,eloblasil1Jm:ll,

Radliograpbic:: ap;pe,a:ralD('es Sire. var.iahle:: there may be circumscribed ,0. diffn:se ra.d~o]lioenc)"oftenwith scauered snow-sbower opacities, Trabeculation i~aLSQ varialble-muhiLoeWar. :h(ltleyoomD' or mD!lolnCllIa[' IIp]_')es.tlllntX:s may beseen.

Mia-'MCOpy

Sheets ofvllrillfu]e~sized squamous cells, typ,icaUy with
well-defned cell mewbr.mefi IIDd prominenc ililIerceUwar bridges (iFig. :850).The anclei lire ,often pleomorphic, IQil'ge and hypercmoriiatic l.'e&enlbliQ' C3JtCi.n,oma (JFiig. 8:6). or smaller and more uniform (Flg. 87). VariatioD!] in ,~p'e.mlIll~ do not: appear te affecrrJb.chalVi.Ol]f The conneeti ...e n:iliss:nes:w(!Jml3!,nudik,r; eareinemas, hdl::s an in:Hamm:awF:}' iofi]ttarle. The [iU!lDOllU may ,a:iso cc:tnairll cak:ifi.catuons (Fig. 87) ~IIJ~ c.haril.c~er.is1ticaJlIy. deposils of amylnld (Fig. 86). A Few clC3!l' ce]ls may bepresent bur the 'cUel'!r ~U edonrcgenic nmlOnrfcarl'cil:10ilIH~ is 3 diiff:ere[lf enTity" wiiliUfU'[ Oiwyloid (]I]" calcificstiens, aod may metasissize.
0

F.is~ifW
Iype,

Cakili(il1g ooDrrlagfini~ ";C'ji~f. $(ilid

Fii9':8'5 CaIJ::ifydf!l9&plilelial odomlogenic !ui'l1Ourr{CEO'1I'l.

MIn.wu,.

Behaviour ~f eliOT :isprobably :rarlhe:rf>im~le:r to d:nu 01
amd~b]asli:oma., w:idi. stow btu .inv3JsiV'e growth aada telJid)e:n.cy to [CClill if mot. m. Iy excised.

Ifi!J, 86 crOf: ,a:mylof(ddef)tlslls ::md nucfear placrnoilhi5m.

1i!i,87 tEOr with calcifil:a1:iDIIS,

8 I (J(J,ORlogenic

tllll'lQ)I!JJ~

Ad eml1mart(lid (u:lontogleni:c 'tUIl owr Alainly round io t'CCllS or m. the third decade
maJ!ma. ~s u8uaJlyaffcCloo.. The mmOilF slJi[[",mulds. m is

and has a higher lncldenee in women thanin men, Theamerior

c'IilDtigul)u:s w:id~ a tooth" predu.cin,g 3.:radiograpl'dc awealilm~c silmilar to tharof flI dmtaJI or denti.gerous CYM ..

M~py

Censisrs ,~f lmrls or sheets ,of '&mmJ!> d:1iIIk cp:iilie]~a](lens. w (!Fig .. IUI),fr"Cqu~ndy with amorphous or orystaUine csJcmcatiolils andmiCI'(II;;j"$u, Iiaed by am.etoblasit-~ike CO]Uimnaa.'· eipi,tl:ie]iulJ) (Fig. 8,9). T!iJ.cieirs, 1l! fibreus 'Ci'ijJ:SlIih::. The: twn.illlr ~s readi'~y enacleated wiUmnt ri:;;k [)if reeurrenee,

Progrwris

Me~anD'tlic:neuroect1odermall jaw tlJlmour ,of iinf,ancy [progonolll1lC!l) ,
.

Fig. ®!II Ad'en(lrna~oiclQdontt1geaH;: lPnWI': ml;:;rocys-n;: alll)llkJbl~st<lih cell~ slid

This IDB mre mm~O'uI mil!l is [lot ,Mio'IJJt:ogenk bill[ a orig:iRaJte~ from tile n'olillll erest, It ~s Ill'luaUy deteeted as <II ragged area m mdiiolllcclilCY ia the maxiJ]a SI[ a:Ml1IU3 mcorhs; the iIllaill,diblclillE" ether sltes are' ra;eiy an::~~ed. Micrmwi\!)l
C4!lIlIS[8tS

p:ig!lllie:n:ted (melhmio-oontaini I!Ifl) cells (Fig. 90} with. pale ll!U'dei~ SlJ]1'iOl!lliJJdm,g sliIilaU 8:pa~s or defrs, w,g'Cther wim

,of s. cO.ilDtctivc tissue stroma c(n:iltairung fueii of

groU'ps of fio:[])~p~p.oo.1ted c:e<~~" !!i1.Qlle sljju~l!IJildcdl by or pjgment cells (Fig, '~n).

lklrmJiour

There [S aJ variable rare of gl1owtb" but most a]!Jpcar to be ben~g.nand wim lrail'(l esceptians re I1I!Ot recur after

ex,c:i~ioo.

if1ll.9'1 Mai2lllotic n~~!t1denn;d'llimour: pigmlliltcelliS. 6{lgh power,!

Ame~olblasti:c fiib:roma
ExceediDglIy rare and lj'Il.ically .affects teensgees, There is a. ~sl(lw-grO"wingJ' p'.aiin]es;s sweUiingw1:th II c!i'st:-li~e: area of
'l'"adjo~tlooDCY_

Mic:rosrnpy

Processes of epithelium llesemb1ing amel.oblastll surround. edls n:scmh:ijng ncUaite redcwillm. (Figs 92 .& 93)_ The S{lIOm<I. l"es.eilllMe~ de-Jwille ~apil!lll (Fig, 93), Thi.s is thought ill) 'be a true l!l1~ndlrumnur and ill soraettmes associated with 3. developl.D!g oomjlliil'Sj:r:c iIldOillitoma. The
tu:mil!)ll!r

Pr(}~

iilS rcadi:ly enucleated tnn. may recur,

Squill mo uiS,odioRtogenic:wnilo11lll1l'
.Rare unnour OOI:!!~jS~~Dg of multiple islands of weU·d't1en:ntia!ted sq!LJamo~ cells in oom~ecri'I'Ctissue :ottoma (Figs 94 & 95), It Ilac& w:ide a~ d:is~riblllio[Jjand a ao ,a:ppuem:u. seE .(llr she ~1l1"edilecri"'Il.

TrMWt.i.m~ fJ1Id
.fJI'Og1W$is

There is p]"iIlba~ly minin:l3~risk ef recuerence itf me 1D1lm01.!f ill, ooE.s.emii~i",·e1y e·!l'.cised .

fijI> 95 :;:qua-mils, odlllOWjlcl'lic mm:JIW ..

IHi!lJl ~err_}

47

Odonril:og,eliiG
fTD'rilably
rood!!. germ"

myxDI111I8

like mifser:lehiy.ma[ romf"f.I.ment of 'FIu,f!' lumOl]!l"' Is liI11illaU}, (I~tl~d 1.[1the second 0:; tll.Irn. decade, s[ig!lllLly :m.'l11"e freqUf!'.aJi.dy .in the mandible, ;1'$ a ~lii~-iib I)f ~~il]}b1l!.~b~,~ ,~r~of radi(l.~lloe'ricy wuth ~p:u'sio:!l of bene (Fig. '96,)..
a!I.'~es fl1(lm

Mi~vp'y

Leese, muooidfibriillac¥ rissue centains spiluUe (I~ stellare cells with 1Mg, d!e1jca,~e,iIrt~enw:iilidmgpI;'OCell8es and, f9rdi",reMs ,(ri.,,,dO'n[o,ge.ill:Lc eiPiilieliium seettered thlroupolu tibe Ulmollt. Soonelimd mere is ezrensive
OOIliIi: ~1Ji'o'Ilis:itl[l (Fig, '97) ..

:l'rmmretu «!W

prognosis

l!.i.lill1'u:ghbot::[]]p, this trWill.U'W: is difficl!I]t. ['0 umovc oom]Jh:~cly amI wide cxcisiea is [)(lCCSS~zy. l!I.owe"o'er, 'tB.t:: rumoU[ canpersist for yean OI dic>cadcs;lifn:r'i'o'ani~ lI:lough whhmlJl nectSMiri~y (lIlI;sillig symi!UilllI:iJS.

Odli):niiolitl as
Mo~[ ill\C mllllfurm~lim!I:s uf dcy,t:lo:pilIl,g; dc:nlalli:ssues (~amaltll.IYmas). OcCasiUlJll'lUy, 81[1.oU;tmlmna is asseeiaied w][lil:a UlmOill£ such as ameJiob]llif>ticfilb:r,uIIi3.
(;~)]DPQsill¢,od.~ntD1ll3S Com~lrd type: li!DJnhijJ']c:sma]] l'O~ID-likc struetares (de:lIl[~;ks)winh~Il! Iibrous :roUid~ (Fig. 98).

GlimphJt.rype: completely iDegum[ mass of delliull []@Sll€S (fig. 9~'). !it may Jila".e ill ca.1.d]llowtr form wim de:lua]

tissues &lu:roundillig a rauchbranebed pll1p cbiilimber. Though fuci::l[lg Ililliymorpho]ugicill resemblaaee (ILl a [oolh" oomp]ex Qdol:limmas ha:ve lib.!;: in(]iYidU3~den[aJ
Vj88UItS hlll@']];fia]

whelnJ C!lIkifiC1lllWn i8 o®mpJe[e and lhe .mG, €trU.p.t lind f:re~1!!emJy dle;n becomes 1:llIlfh:tea

relatioa

W

eae amnher, Growth ceases
U;I:lid!Sro

Ceme"t(ll~irJ!a$ !andl,oell1lleliilta~d,$plla;sia$
CelD!e!li1!@'Mas!~l!!:iIiSi

The

twliI.OIll

<l!P]JJC<m 111$II

uslllaUy afliecc.s males; IiI1lu;et 15 yems .. It mdiop;3q]ut: <iJ]J~£1IiI ][I~. wiili rodii.O.hI.Oe:lH Wlil tiu:.
liDI~]il![ ~·egiQliI"

:wngilil!,.llcsli<l!lly
.MJ!w.,Si!i(l!pjI

A.:rmID[JJdod O[ ]FR>gUlm m:assmlf·DC:m.CliIttLm CD be seem on ilic.["~[ Qftiln: itOOtli!. (Fi.gS UIO SiUU). The eemeatum is ia 3. p.agetoid (,mosaic!')patwn!l wi.m many eementeblasrs (!Fig,. 1(2)• aperiphera] zone OF :pe!!"~cemeDJrumaE.cl.a zone oflm.caile:illiem eement mLa1trix (p]'eoemell.mm) 1I!nd!:liib['(!ills pericementum, This ~!1 probaMy ;11. beni:gn t1lml!jl]][,
Ce:memify.ing

fOlIDm:i in me miidille-aged 3!lJJd!]1} themolar region, A HJllliIJJrloo. area ef radiolw:lt.: lIlcYI'e:se:mlblcs apicail gI3lJi1ll~~m:3I but 1ili.c~ootilJ.s vital i Evc[l.miill.y it becoaies a Most
OlIooill
c

(oss:ify.iog) Ilbmma

related too nil.

"'9.11)11 Oemenlnbl!lS'toolfi: r~mj]ooi'l
1

~j

ramopll.qJU.c mass,

M!ict~

ED!~q IJ:OOll1~C!j. df cemeatum (cr:[]uluticlcs) {Fig.HH) d'c.vc[op iD! 3. lll:bmlllSmilIss.,. wlin:i£lbl]ually beeames ,d.'I::[]scly cail.cilicclJal!I!d poog~ess=ses. um'Bl!I.tifyilIl,g IillnilJma. Th

lilOtrdi:alhdy'msliingms1iL;rb]e ]lip. 53-54)

Etc(l]![l.ossifyili\g mlbooma {sec

fi:m. ~ 02 [ellll~tobl~a:
3nd giant ~ ...

!;ementa!Jl3sU:

51

Typkal]y seen in liliIemid·30~ .age. :group, W!OOThe:!il bdog trw.~ce [!l1eqlle']!.ti.y affa:tJed .:as me::ll, The maadible is as

ne, clinicsl .and :radii,ogr>!!pl]1c felu~u'es ,of Q:ssitYing liilbmrna are tne same as for oenu;l:Idfy]ilg lfib['''~ma.and it is not a. ~pa:ri3!~e: 'e:rui.(y. h bas a silln~la["$e.if-]imi.~ ,OOUl!"Se. The [iI,U:ll(UU' rtypicaUy shows hon:ytFabt::(:w3e {Fig. ] 04} bUl~uuaUy ~hett .atr>~ alse (I:!F :iJn:dom:ilil:~]II:ly) eemendcle-like ceacretieas ][l .fibrous stroma (Fl;g. 103, P. S2). I( pf>oducts a ci:mllID.'8mhom, rounded area of radlo]Ulccncy w~lb i.rrqw:.fr caleifieatione, but jit]cre~m.gly widesprOlu:li r,adi®pac,l!1y. Remova] is justified, ]Ilru1:iCl!l]1I!rly if tbe rumol][isl:i!rge BllId diSliO[[]ug ti:u; jaw.,

lII11na]ly affected,

~de

ODe of liliie run:iSt jaw tumoues, It coosists of hpline Qlifli1age ,ooIl!~3lini[j;g small ChllJIilW:>Ocytesin eharaeteeistic lacunae. CRo.n(lr,uma is dilIic1!Jlt 1IOdistingisish from .Iow

C:hoDdrlJ'S;:!n.loIml.

This. is :I lbO]1l;!r O\i'CfgOOl;!;'t]j. with a. cartilag.ulJJow: ~p .. 9~% of eases arise from lIhe oo:oolJioid ,~1" CDIii.dytoi,cl.pl!I()LeS8.

H~liH.c c;aniilagc,®flIeu with re§l!tbdy .21ii,gned c,e:.n~ and! res=bliIlg :aJ!I.cpiiJ)lilysls, ov~J']ies sl:(l'w~.ypro~.ifJt'rati.llIg bone, m;;u.3Uycmce]]0l.!lS ~n type (Hg. UDS). In 1ti.m:e"tile []GIj~bot::OO[EJ.cs!l['c:domi]la]l1tly I::ml1lY w.ith a. 1thinnul.lg eartilage cap,

May be e[]Jdt'liSt:eal~r more of;te:n f~r.im'(,f!a[but ~el!l. itt is of~e.m dilli!;~dl to dj;s~jjngll:rnb from. eK_~1IOs:es. Mj'a't).!ClJ'/'Y (::l!Im~~ ~~r~mu: lamcl]a'C ,~fd.cmcoo[EJiJ)a:ot bone with .re~ative!.yfew esteocytes (¥i..g~UI6). 'C"tlce.lfm.lS~\§:~:wiid!e_~y spaced bonyjrabeculae wi tiel oonex oH~men:ned Done (Fig, lOn

53

The most. Olilmlllonprimal)" tumour ofitu.1Jle. ~t ~S:lJrare O>mphcatiu.n of IlIdi.oiliCI3PY or Pagel's disease of the axiial~kdetliln. OS'I:e'05a:ocoma 'lIstl:aUy affec1tSynung persons, psrnicldaFIly males

Micrascob'

and [he tumoar is e.h.her pE,cdo:mii.llantly ()I.S;trolytic. ('1!I~!!djf[eil"CliI.ti,ated~ or plf~duetiv.e, and then may 'lbepr,edom]nallJJtil:y osreodl0mtilrob13shc illl"fiboo'bias;Iic.~t OOIl~ists: of abnonnal t1.IimOUI esteoblasts, which. are tylplOliUy 31I1p.TIaf) Illiypc;riil['iill,mi!tk and lW:]g'eFt~:;I!'II lIlor-ma]; often in large Dlimibus in some arC3.S {Figs, U)8 & l09}. Tllmour (J;$[roi.di(Fig. 108) and bone arf,eoften formed and predeminate in me osteoblastic Efpe- AmOtlU~, m.lIIy be SIDarl'lin n:he d:lODdrl)-(!1' i'iJrolbl<l>'Stk \!,iUia:ms. Sumeiimesilic tumouris biighly vascular or "telangiectatic' . .5imHlmlding nermal bone is desouy;oo
A.ppcK;m,()~, 9:1'e vlIIrialilie

Fig)- 1&3' O~QIIla: ooteoblastt;,

1m'l1igf1I3Ilt

(Fjg:. I,rn Oi)"
weI]

Histo~ogica] chaeacrerlstics dillnet with pro.gIl!osis.

fieelD [() I.l(lIIcla~e

Radio,graplJi.c features ::«e' highly vall'iab~e cun~]iJon.di.ng wid:! the variable hi...wpaLbology but there i:sl:ypi.caHy ,EI. rapidJy growilItg and peiiiful! soft tissue mass rogethe.r W]di:l a rugged :Jil"€iiI ofradiol1l1ce:n~ SInd Vllrial:J~e radiopacity without ddIDaib]£ panern. Mc:tastaolliisis, mai:n'l}' lQtbc hm;gs (F'Ig. 11 n p:rodilldin:g Cl([)IIIon.·bil] radiopacities. Truatmem and prvgnrui!> enrren~ ueannenr consists of wjde excision and cnetllOlhmtp.y: tile tumnar is nor :radiiosCl!lsi1ti.ve. Th..e S.yea;r $l!Iirvi at rate of maodibu]artumollni, is about v 40%_

I1g. 1110 Os[oosarl;(IIil<!: ililV.a.sioll 01 oomlll'l
~,

'55

Centr,all'Qli,anrt oell~ gr,arnIUiI:cuna,Orf ~hl: jiaws,
Ae~io,fugy
Mla lJeO]:)laMn aad lW~ 3111Sleodia5mm.a.h o was :miistake:t:dy tenned <~3mri'V,eg)J:m.l cdlgram.Ji.I.omlll' in thepas[ (bu~ it is :more des~rut:ri'Ve tlita[JJ r,ep3fa:live). 11'I,ere isne evidence ,of [fawnlnic~ctiioio:gy mdillhme <In: 1:]0 cbid,ges, ~1I iJlo(ldi ChC11iI]S'I!Iy" Acl.\g~C:SCCllltli m YiULlDg ad.w.rs Me m:tinly ll!1lIoc:~cd" espceianr kmmes, the usual

Unk:!D:(!Iwtli;

IIiI.3[1diibk. The rummlll.' p[\!ild!m:es 11[1:aF~ 0:£ li1idi.o]IIlCODCyofk:1Il vri:til::J. fainttrsbecelation and ~Ilid!.efi[litt hillrdr::rs or 11soap blllbl!J,je ap;pear.nJlce:.

sire 1!IIt:i:m.g·fue

Micrmoopy

Loose,l.!llll!l;:illy bighly oe]]ular and vascular eanneetive U5ISU.estroma cO]1ta:i]]lingml!1]timlil!l.cI~a!~e gii91lu. cdl:!l Ilf

vm1.,itiJ,1e size (IF:igs ] 1.2 &: ~ I3l "fhe lesior!s 91ft riot IiIjjsl[do~ica]~y wsthl:gW!S.halill]e ~!Il,m ~Qin}e'le~i:(!Jns of
nypapll!f3ltl!Jyr-oidii&m.

B~haviow

Occ<Wi,O'.I!la]~y ttllme is !rapid!. growth diBJiI:l!. oQT!!'e.s.:pei.IiJ.din:g e.~t.l:IJi5.iml ofboae destzuetien, I:JlHdtIe tllin(J;U[' :isiJe[JJ:ign.

Fii~>111:3 i:'lillt ceIIgramulonls: lypiea'l G '!(I$~las~.'_

and =]JOlIlcl.s ·~o OO[]llSITvll!tive i'esecl~(ln.R.e-lli.dm'll. areas mary resolve siPOli!l:tanoonsly.

Mullitiip'e! mrye~omal n II .soliill:aliV IPiasmac,yltol11ll a
M~e'](kmi3.is ;Q 1'Il~1 igllam UJmQl!I:r of: p']tli~ma ce:1~s iCi3.11S~lJigmuITi:plep!.l1ltcbed,·~:u~ of ibwt: desrruerioe, foci Snl.!Jtlll)l" lasmacytOOllias are rare Ilind!maybe in SOif:~ p tis8Iu.~M(lSt ll~tim:luely beeeme mUihi:pl~" Micto.>t:opy
'The' tumeur eonsists of ltle()piall;nkpi.a8m;a,,eBs (Fig. 114} whk!h rrnr:hJ~ tlf!Q!1odom:al imm1illil<lgiClt!t(Iin-usu;aUy

Mye]l](rnl1l is u~1:!.<Illi~y .reoo.g!lli:1J~iiI acsaf'~'lI~( of pajnftd~ ]JiIl!m::.hed-ml1i!bone leskms Ql" fa~II'l(lI,Q,gical hA;(I,~iI\esCklc:asi,ol!laUy.the cmtditi.otll i,~ idIet~ted ,~jl~'. by oh;mccliJodi[]g OE mOl!locilO'.nan ~l)'reirgammll.gllobw][];J.'C.I!ll!i:a dUriil!l:g 'I'01!lUrn:e .hlIemi3.mitlg;ic:a[ ~1lJ'\Ie:>liganiQlil.

I,gG. Amy[.oiri (1)rm9!(iJ(![l (Fig. ] IS,) h®tlil wi[hiill [he lillIm.m.!Lr:md.im: other s:u~e&, slJch asjhe ~®ngue, ma,:yresutr.

Iji!!l> lU M,yelaliT1~:lrmiloidl deposilf> In soft ! lissues.

9

I N'onodoFitogenic: larnnurs of bone

ILa flJgledla ns' ee I~hislioeytosis (h1sflio~¥tosis, X; eosi nophi liie 'glralnu 10m a~
A. rare mmour
O( tumour-like disease of lh'e Langc:rhans" cells (dendritic, arrtigen-presenting oe.1[s) iCS,1Jsii[lg~oLi1iair}.' or :1l11ll!Ijple areas of desITlIlctio[]J of bO:lle 801d som.etimes of peri(l~uillUlI tissues, e.xjpoo:in,gthe roms, oK ~"C(;th. Eof;ift(lpbilic ,grallll~l)ma. may be sCillha:ty er mUl~1tiple_.

M irfoscoPY

The mass eansfsts

eosiuopbsls in dense clusters or u:hiuly scattered (Fig. lUi). Histiecytes an; typically large and! pale and variable in ::;]zcanJ. shape (Ftg. ~17). S{l~iltary el)Sinopi:lillic gnlm;dom.a Ilf tile jaw often u:l>]lonlfus,weU to wide ,ex,ds~l)nfo]1ow~d by
clbcmoiliera:p'Y, but the prognosis

of pkomo:liPll]c

Iii

Lioc:ytcs and

l"rmtmtmi' anil prog11b;is

U[lp[,cd:iC-laM,e_

is somewhar

fig. ni' EosioopIWliI: 91'llnulomib [l'iJgn powtf_1

IhDd.-Sehi1lillte~ris~u

d.isease

SU·icl1.y,tbis is a triad of osteolyuc les:ions. of the skull, exupb1th:dmosanta diabetes Dm:u,idl1~ but rhename is Ofl't:lil aiPplied re .anytype of muhifocail,oos,inopltiLi.c gTIIIIllllti}rnaL II is, a rare v:IT19.m. l.dtel!',er=Siw(; diii:!lease
il.

Tbis atfrects infants I'l:l"Y01Ul,g cbildren, Typ~,~Uy, involves soft 1115SUC;S. (r.a1l:hes; ]ymph:iu::ienopflillly,
splenomegaly> kvcr and anaemia). The proguosis

abo
1>001'.

is

Secondary tumours
Caxei~om3l,ii)l!IS meta.!"i.~~~ an: '0\!eral1'the most coramon t1!IlTIOll rs (If bone bur ecasidceable less cemmon in dle jawll_ Secnadaeies can come J1::nUCl!IllIrly from earcinomas ofthe breast, ]lIDg, prostate, tnyr,o.idl or ki~mcy mull are recOigoi zable by their ~mb]a[lCie rothepnmary rumoll r (Figs I [S & 11'9). A diep<lsil.llI the jaw is, lIIery r.JfI~ty the first :!'.jgn of 111!istant ffi':.ymplOmaric ~lrimary. d

Ilfig. 111:11ecQlldary S

C;81cinOlR!l in mandible.

IFiIl..1Itti9 5eocomiary ~sit t'<IrciaQrmEl in jaw.

m bFOllIthial

Thil~ is <II oolJislleciil1~ term ,encuuq::mS1&.ing diseases ~:mging roomfrihmlll<S dlysplas~.a to the w,cll·c,i:rcu.mscribc!!l lesions of QssUyiD,g fibroma and uncommon, apparemly u!lrermccliiate, types. II: .is 9! oo;t]'tro'llers,iaL area, with dli~p'0$is ,depelldem on cl):ll:$itlcmlli.mll (i1f clinical and m4:ilug;rap:hi.c:feaaaes, mj~~Ij}:py alll.d behaviour,

lFiibri(illUs dysplasia I[monostm,tte)
TypiicaUy seen ~[]ynung adiullfl ef cimer sell as IDlillIJ.dcd!, painless, smooth bo!l.YswcUi.ng of tltc· mmilJa. Thc sweUing IDay disturb Inaction OJi occlusien, R1!j(Uog;ra:phy shows a rounded area of relad'il: radiolucency 0]1ten w:hh tine orange pee[ or gtO!IlUld,g~ass IIp.p;e-aralDitej lImitl.esiollS vail)' fmm prcd.omi.ll(l.ndy nbmus Wid:! !p$~gdQcy5ticappeanmce to p8u:hily sclerorie, and dc:.lJjsel~' (tssiJied. T!:Ie borders 1lI1e;rge :im'G)el'cepdb]y wim slllrrol!lllld~ilgnannal bene, M~WJ!Y Rm:mderd, .JDmi:S of loose, cellular fibH!lllS tissue, typicaUy oolltain~ng evc:n~;'dis'lIibu:ted s]efidc:r ttabeouJ!ae of \!<'\lJ\le1tl bone (Figs 1201 &: 12]) with !Jsffi(JIbl~[8 wiitllriJll them (Fi.g. 122). blending impercepobly whh lilOmlru bone traoocu]ae ai margins, Tile IIIIIlOlliIl (If oom.: is 1::!]g]lly v,walde. S(r.ml:t~mes8mal] foci of s.caUloFCdi ,gii9!Iil.t ceUs (F'i.g. 123) or myxoid! tissue C3[I be seen, Fhere alie ItO s:igniifili:<illt cluange.;. till b:~Qod chc:mi.stry_ Typical]y,lh'eR is ,(I SPOllta.neQUS arrest of ll':rogrcss with skE[elld marturity_ Resroti(m is only .required fur iilisfigu:re[J]O]lt or dist.IJJrib0m f;uncl~e'm.

Fig, 1 ro FibrolllS, 1fIrs.plasi~ inrolving pflriooo11ltalli!sue.

n~_1121FibniI1II5,d~l~i<l; tJebecu'l<le of wUvefllbone_

Troo~m.ent

Onset ~s ofltCn.ill ch:ildhooo~ predomi:na:ndy ill romales. Theee are mul1tiJ!;!I,e: lesions with marnJar skin ~igmentar]um. ,endocrine distuebances and preeecious PlI.ocrty illl {emile!> in Mbrigihr sYllldrume_ MiCf(lS.Copy Simib.r ~n,m0nos~Q,ti.c(ypc.

"I). UZ
~

FiIJr'Dusd'(splasfa: do~OIil ofwDwm

161

.

___

CherllIbism (I.amiiliiall mbroll~ dfysllilasia)
~cmlblCi!l fibrous. dysplasia in iv. ~~~aJdon of progress afla: iil.ckItl!lm:rW!r3UO'J!l but ,differs WI:]: I; .m:i~5COJl]!l: fCWltJiJll''es I; symmetr:i.cai ~n'li"ilmve[llellt·of j~.w.~ (mil!JJ~ilil]c:, ramus an~ adiaeem b~dy;. maxi lla aJloo in S¢fCL'C C3lit:li) • lcsiens awem' multicystic Oll radio<,gtapih.:s
• typicallyregresse8witlll ,I autJl:lSIJlma.!ldominaDt

iaheraaaee b'lll'~oor pencteation p of the mit in females and maliiY Spm-ailic C351l:S..
RadiollllC'efU:ies precede sweJ.J.iDg and] may persist fur

skeletal truIItlH'ity

same years. after d~l:dcat re~ol!lil.1!ion. Microat'i:lpy

Replacement oflbooe by loose Y35cWar eonneetive tissue o!llD1tai:lJJi!lg~.y giant cells usuellyresembling giant eell ~ullJlma (Hg~ ~24). H~M~dl(jlogy 0'£ d:u1:rufu]sm and. Jib:l\ulE dYSJ;llwl:ill'8 is lIlot in ~I:S!eLf diiquootic. Cm:lliinnafLion de-Iellds on; • ml'licaJ. picture • rnmograpbic feablres
,I

bchaviiOlU' of lesion.

HyPeqlar,alhryr,o:idislm
Aetio~ ..
]P!l!'i.mary hwerpam(l:'Iyrot~lrsm-hY!ilu:sccretiion of parra.1tD.(Ifm10ne rtly para~hYFO]d llllI!Dlow: bur hone lesiens
nlll!i!j"~C\ledjJl1gJy rare.. .. Seooa~da.ry h:ypetpamrnymidHm results from ~eJij;al tfailiiur-e ] ea.d~llg to ['.eacl~\I'c ~;naJt1lJ.}!Hljjdlh}1) e:rp.nas ia,

Mkr~

1'll![niJIur~like foci of osteoelasts (figs U.S &: ~26) iJiIl.'oduce ,C:yst~]]k:,elIeas (sometimes ifilil]lllillla][ar) OD rndi.ogFa:pb a (!llsleitis :fibrosa 'c:y&tica). MiqyscopicaUy, 1i:hccoumtiOlil :is inilisrilllgu:iS:hahl.¢ from gjiant (eU gnmul,om.3 ef tile jaws. Diagnosis depe.n.dlli Oill serum ,cliemtslIy Changes, IlruIldy, raiis~~ cslcinm (up' to )(2 norn');!l.]),. norma] or 10... phesphate 1IInd. raised alkaline flhoo])hl!itasc~

63,

10 I Nom-lteopi!lstio; l:Ktne diseasss

P,ag,efs disease
AelibloID' tmd
pr.etJa~

'm bone

I(,ostei~is de,formans)

i\<\ay be miliooogkaUy detectable ill 5% of 1those~:wel' S5 in same areas of Bri.tain, hu l !;;yJD()(D)<mal:ic defUlnnin,g disease i.s 1lJ!1lOOmmon. The Il:ctioJo,gy:i:;, IID.d~r 'but there iii; evidence of weak genetic HDd! pl)lSS]b~yvi.!;Ill C<lIIlpon,eD.lS. The (();nd]ti(l'I~ i~ IIISl!I.a!ly ]Jolf'i1~tl)ti.c and :nlOsll Jjn::quemdyaffeel:StE pe~"'h. c;a['!;'a.riuJiD. limbs. The and mmri.lla is ocea:dOlla]~y affect.ed g,R~ the Matldiblef!lll~Y ral."ely.. Lesiensare ]lFedoIDlimlllltny o:stoolytjc initia:n~ybut.
there

i.s increasi.ii(g

sder'OSEs, eften

witD.grnss

gcneT\l.li~cd

lhi.oketlmg of btlJliu::. I kaLinc phospharase ]ev'cls are A grea.tly raised (urp to :;.:20 normel], Rad,i,Q~ap!Jica1E~I'> there is ~"<lIrii.aib]cad.ioh.locncy of the r bone ef the jaws, widJlo$-$ of trabeculation andlamina dl!ln, fo;ntlwoo by ccnon-wool areas of mdi.iOP'3city and gross, cram' Ilyperccmen,(oo:is. III the maxiUa, gross. Lhi,cll::ellli.ng rihe :a~ of voo]ar ridges causes tIle m.iddJIe th ird of rille ]fiCl;; to bulge forward.

Mi(roscoPJl'

Anaocnk mOl.'ganizatiol] ofnli'mma] bone .rern.od'dling is characrerisuc witll .alrenlatin:g reserpnen an dIdcp'os~rjOn (FijJ;. ] 27): malil.Y Q"SII.OQlblasl.S 'I)ncudast!l line the hone and! m:ngi.f18 (Fi.,g, l2:H). An irf\e:gu.l:a!l' ~gnem of f\e:>'crsa1 lines Jili'uduoe8 III ~jgsall'i'-pU!U'le ('m~k') pattem (Ifba'liOphiHc li[JJCS< .i n (tu::: 1J000e~ lY];l]ca_l~y with predonnaant (}st0~clI!"Slic activity initially, but then witl:! [l!iOgrcsSi.Viely increasing rn;tool:llasli:c acdv~'ty e.ausl!ng banes to beceme tibiic.iwr and 11I!r{le:rimtI weak/cr. Decreasing 'Y3scw:ariry ofbol!l~ lin the late :stages makes them sllsCf:p'tiiMe UI inflCCtillll_ InvohremCIlu of tbe ceJllelli[iUlill preduees craggy hypc.t1cern.enwsis, which also lih(!lW8 3 'm'Qlsa.i,' W1llUern m:icl1OsOJpical.ly (Fig. 129). The disease is. typi caUl' aetlve for 3.-5 yean become'lrirwaiUy static,
bUll Dl.3!(

PnJ.,gHruis

then

1"11 ..1l~ 1"a5le1t's diseBiSe of booe: 'mo5Ulc' [i\9'>'arsaO liI'LJ.l$_

!Fig, 11Z9~9~r~ di5ea5e: i!l'e9lJl;¥ hJipercemenlosis o"l"toIl-th.

Ra di~ation iill'dury I[ o'$,teorad~o:n,e¢rosi.sl
Irradliadon far cancer C1IIIi1 cause desth of bane cells klal\l'D Rg empty ]am.liI£!.e (Fi..g, 130) ,a:l1d ,obHr'crnJuve 'lmdarte:rii'lis (Fig. 131)~Ieavingseverely i.scl13crni.c are$ ,of bene, rukmIlts to ~Ilra~ this dead tissue by 'OS1ieodas:ISpreduee moth-eaten areas but this activity is rise to ex'lC[lsive chronic uiSwomyeJilis.

limitedlYy 'me PO(lT' bJood supply •. Il'I!fecu:o.n, usually from teeth" readiily spI1f':1d~in II.ftc iscbaemlc bone a!IiI.dI give can

!Ostleomyelitiis;
Aetiology I~feclion of the iaw can [caDe]yre5llih from severe dental
~1'IJ(ectio:ml fremfracmees O Sec<ldldrury itO, irradialiml" Mt~
~o thrombosis

open

{O

lite: skin, orir may lim
IfIg, 131 Irradial:ioo-iimdu~ed o:blita;rme

Inf«d,oti. s\Pl.'ood!siu.ou.P the ,C\ancdlOhis spaoes ..I.ead:ing t
of bleed vessels iill bollY Clmalicu1ae and OO:Jle'~ecros:ili" ecsotleboce S;b.0WiSi empty lacunae, ~~ N typ'icaRy ~nIi1mn:edlby inflammatory cells (rig:;, B2 & EB} <lfJ.d may :show ma8~, gnacteriia,. OSlcoola:s;J!S. fMIll healthyperipharal. ~!HI e resorb the iInn,c:rio:ll w~th..infected l:mlJlewhi,ch becoenes ;liiep~raJlal. a'S ~ sell!l1lJeS[fu:m.

,eroa:rteritiis in bone-

111(1. Atulr: ostr:OIl'IY17:litis: dood bone and! '1~

inll,!!nmaWiy cells.

Rig, '131 Ature litSteoonyelitE: ilICule mftami1ilatGljI cells in doo d IrIOI _

HerlPetic: :stoll1natitms:
Ail:fmlom;' A ]Jrimary .infecllo:n of 9J [I01il-~:lllmUl:l!e ~mdhl]dUiaJ by HSV (~liaUy) type L There is: a::o~ead~1y eclining lrlddence d En d1eve1!ilped countries but increased 'pl\e¥ilILence][] jjmmlm.odefiC'.ie.ITl~, e_g, AWns. V[[a] ][IfeC1tio.m. epith.e:Ij8!~ of cells prodm;es intraepitn.e]i.al ve~ilde:s (fig- 131) with ".irl!l:.;-dillm~cd cells in the floor (Fig ..l 35) lesdililg 10 epiilid]m destnreticn (Fig, B6), ulcers 811din(lilim:matioD" Sl'nea!'8 fr'i)IIIIli early lesinns :!ihow ba]looll~ng ikgel:l!ennioll of epirliu;::~rul cell nuelei (v.irOllproliferarion [msbillg ciLro:m.3[][l w fUFI!ll pcriphernl rimfa[ld e,pi.itheli;al.

FwhaJogy

!l:iajucells (Fig~ 137). There is, a S'yslmJic fehriLe illness, lyrn.:pbadecnop:nfu.y,
and a !l'blJ:n.gtitre of antibodies.

Herpel!< 1aJbjaJ~s,
Vim'S m~y perslsl ]0 tbe l[]ge:m:in::d g::IJIl,giLion. eriodic P rea(~:ir\1s!lhm leads [0 vesicles ;mol erusting ulcers 0i1il bo:r,d~lf."8 Ups ]r.~bQlil 300'i! 'U.{p;.ltienitll~f (!f priwuy !ill!fe(:lt1:011_ Mk:roswp~t: flClltl!Jl[Cll :air!::lu, same as for t
!pri lIi'lla:ry

11i9,l35 !ferp~~c '~lflma1im: viruiHbrnaged liiells,in nOOf 01 vesil1:le,

.'

11a(eclioIl,

IHle:rpes zester .of ~liIe t1ri'9lemill1l,all ,arl'le!l
Aaitl.r~ .Rz::ietiV<I.tiOJllOF vaeicella-zester illfecli.oIl1 11$i1aUyin the dd'l:E~Yhmg .Wl" theunhi~~ jllfec:(j,Q[J (dLid.'.!CIiljJQ.X).

TID:: oo.Eldiiti(!JI!I.is eS[leeiSlliy oommon and ':>C:'!"eF~ in i:mml!tllodf!jfj.c~e'.IlJCies;lfe-tbreateaing l ]!il .81I!JS" A.t:1'd~}vir i~3D. cffiI:ctive- .mti-herpe]jc dmg, [jut mustbe given in heavy dosage, espec.uaJ~y ~Q ~rnm~[]OO,>;!fil;iCRl :~'Ut:[HS,
:lind!pre(~b]y
TEigcrnljj]J;:I~
IIllIU::otJiS3.

i[ltta!veI1f1l!l&~y_

the sl!mS'o])' ares of sliD and d!i li'.is.tol'i, ~811 a]~y ilIilibnerol1y i:III1ld lyp]Ctilllywilh aehing pam.
",,{feels

zoster

ohb:e

affeeted

Mi~ftV

Yes.i0i.1L~l1imtRFI.d I]h:cnl!l~oj]. die same as: fur lIerj)es 's:impkx,
Mg_ 136 tIcI]pe1ic :swino!'ili:;;; €;piihelfum,
I~Pil>'!ijS. 0f

Fng.liJIl' 1Il;[!IiOOilimgde!iJeIlIer.alioo of ep~helia1 ~llIls.irl SIl'IBIIf,

NOD-IO]!Iccific ulcerarioa canresult from 'lJi3tUitUllor lJll!idlm.tili,ed. eanses as in reru:r.remt apbdlae.

Beeurrent a'plrrllha,e
Aaio1~ abncnnalrties, bill their aeuologica] significaoee is dulltlinful.Tills ~SI!J(lt :iIDJ auteimmunc disease-> it :dfectIO otherwise 1iJJeahlhypersons, ..nd is not <L-s,roaleJ. with
:rerogn~:z;ed response Unknown in most cases,

M.any

reperted

:immI!l!JlQlogii,cal

imm1ilDologi.ClIlI.diagnos[iic tests and there Isno
to i'mIDlJInOsllippyesllii"e treatment. 5-10').'& O:l'CIIS€:S:! ulcers 3I£1L': p:redJl,j~~ed.

auwifnmuile

diseases,

There

are no usefu'l

re-ii.alb~e

In by de:fideiicy ~]. and I'l$]:ll)md [Q IJ.dm~tra1ti.on of;. fo1ate" ,...jtS!m~n h 12 or occasionally KOfi. FrlOOD ] 0% to 2(1% of the populatio» are sffected in same degree, TY~1caUy l!i.lccration starts mi]d.lyi:ll
I1Jsua][yassoclaled with a haemarinic defic-iency state. Major apbrtftlae, S!pliitI:l8-]~ikJc ulcers 'Ill:!:ragged! :infecricm_

childhood ,or adl)]esceilce; ml'cn peaks in early adu:lt ]~fe and! then grad'uaUy declines. Rare easet late i.n life is necrotizing mlioo~a1 ulcers are sometimes a feawre

HW

In ulcers

associated

wi,t!hHIV infecrion,
]t

or

cytomega]ovinn
''II'IIl1S,

rna.}' be f~u:nd!. but

may be a ]'l88&e:R.ger

.,

Mktvswpy

mceratioll

,ap;perurs to be preceded hy ~e1/!cocYlic i:n:filtrat:ioUJof [lie epitheliusn and! uoderlying coFilIm and inrereellujar (!ledema leadiag to (lii,~ir:ltegr.adO:f1I(Jlr.lht:

qIlitheLiulI_1 (Fij;'. B8~. UICC>FShave no specific fearures but CO:llsi:st oE 8 break in the epiillen~m willi.an iilltCIl!SC ilJiiHamm.atory infiJtr.J/IC extending: deeply (Pig. B~'). Diagn.{l8is therefere d.qpcllIds ]arge~yen rhe ibistory (IIf :n:egWar eecurrences ;mdl clinical reattJre-8_

71

IUich{i'li~ phm us
Ag.jioloED/

m.M.ialled but it twi.caUy aHcru othe1Wi.~ healthy persons and is no~.associated with other such diseases.

UIJik:flOWfi.TheOOlldidon

ispossihly imsmanclogieally

'bi a
the

:mdmalarialS. .metlhyldupa." cte.], It is
SRt

m1lllJrilty it r'eSYlhs (rom ,drug treatment (gold" most common {ltter

mO-8R JJrcq;I!le[l[ d1~(li~l mannestarienis 3. bey panern ,of n.J1iu miae ,~)11tbe buccal macosa, typirnUy
symmc~trically_ Othe:r sires: indl1li'CIDe

of ,45 and

ShOUH

65% ,of cases are in :fernales. The

mar.-glms and dUr.l>mn of tile w'J!I,gue or. infrequently. the g;!llglv.ae (Wildly atrophic areas, rardY5tri:Je)_ Almphi, .l~.ionc are' red and sraoorh, Erosions ryp-ic3Uy have depressed ~i (IS sad are (l0¥e'Eedi by araised Li!!:f'ef of ydlhlWiish fibrin.Wihiile plaques maiJil]Y resalr from IOligstmdiin,g dli.:se.ase_Cutai1loous lkh.e:n plOOlll.S is lil'eCl_uendy not
asseciated,

ltfi.ero,uOjly Omil lesiOIlS are of theee ty~e:s., often al] assClclallCd.

Stria.e'

(while le.s:famJ.Hyper-cr parakeratosis is as;smiateOi wir.b pointed, someLlmes saw~~(!)om rete ridges, liqucfaetiou a.egt:uCFartltOlI of the basal (jell ]ay,er. and a oon(Mik~ mOillonl.l.dear (predouumnltly T iympliloc}"1e) infiiuate. with a wclU~defi_fi,elW .low;er border in the mriulll (Figs I40 & HI)" These 'classi.ca]' dlQtlges IUC: not oneil all iou[ldj m[l:elhu.

AfmPJiic (reel)<luWns ..The epitheliam is libill and l1il!n~!eilwhhilJut .ke'--ml~is, Ibe infllalUlllaJlO'F)' rafiltrate is more densebut stiiU 'hilmd--lik.c (F.ig_ 142), Bro-ri:m:ts. The '~ithcli:IiLm is destrcjed by priogn::ss:iOilOf

Il.lrophy (oat by rupture af'!ilu][ac:)\ &emnd:iU:Y infection lncreascs the i.l'il1ammar'flry response oodl produces a nen-

specific picture apart from any changes of [i chen planus a.I [he .margins_
TrMlii'i'U;i'll

£rnill pmpwm

Lidii!:u pJa!DIuSl. tl1l)~ 1!I_S,l!LaUy a seJIf-l:imiti.n,g disease, can persist fur many yelllfS iifllllilu,ea[ea_ FrnqlIlenl:il:y. there is a ~~ respcnse to to]l:lcaJ COI'tD.cosl'eroids: :systEmic
corticootec,uids are l!Is\ulilly effective ulQPi.ci1 treatment

f:rills.
The riik of'mllil:ignamt chauge· may be .approxiJm:arely [ % over a HI ..year ~c:riod fbi spoc:cdile sltes,

IBuUous lelry~henullIiiI1:Ulli~'Ol1mel

I(S1:evels..Joihlso n syndml1e)
Unknown,

but {lcC3JliolILa]~yfO]~I[I'w:sdrug rrea:lI!l'leltli[ (e:s(I}e'Cwld~y illng",acun.g Stl!l]iP'~:I(m;ami.d:c:s)'li[ he~elk Q<l my~oplasmLid ~llfectia[JJ (pr.ima:;ry atypical! ]JD'ctimo:nia). However" 1'1:0 triggering factor ]S idle:lII:lilll1ablc]umos[ cases No irnmlJnol,ogkal mechanism has kiOC'Il idl:::mlmoo. The d~sea$e ty'pkaUy aJilecls Yoll!Dig: dlll.ts, alld! tt:Il.d:>[Q a recur :2 '0;[ 3 times a. }'\e'ar a:rlldtfuen 8flilintalMlOu:s~yrdij}1ve:>

aR.e:ra (~m.e.

l~aithofcl!!J!'

'This isa mlllo®cu:ta:neQ~ vesk~IQb1dllIl:t]sdisease bat QRiWbia11esions alone ~...N!(:QmDr!Qlr!."~el.y, l!'oce:ll!illy wpturedI:1l11]a/f are seen on th~ Ii,s bl!lJt llt in t:lire m
,a,~icru
Iltl(D!Jllll. Clinicail]y,

s.!.';(!I]Le:!II"b]et;d.iJ[lg "ulIa cusoocl. llii]J(Slltt

feawre- O1ral 1]~C'e'l'i3.<t~(ln often WjdZS]llR!ld. linn is. ilh!e'!J!~~d .Il(JIll4esc:riplI i.n eharacter. Tm'~e[ks~cms and 00" bu[~ae'af:focttftle s.k:in, 1I!ndi. ceaiuneti v:i,ti)S or lridsttlay

Fii~> 143,Bulou5:.errnallD!,lltif~ I
stag~..

!larl",

W:n 5if;::vere'cases (8~:e\!!e;Il'S... o[bmso:n syndro:mc) ~l!JI;';Fe i:s J ~j:::i~~ :1[lig.cQc~n !llJJd.IDl1ltisysrem d!iseaSlll:w]Jmm.ililaise do' rever_ ]que~j'.bllndaesser, exeepri!i!lmal!ly nuly, deamh

be $S1oe!ated"

ma~~es1)lk

.

Mi~~y

Viaria'ble p'iCWfe whh degeueeation ofspincus lead~itlg to subel])iti'ldruai
R~:pmre

Cc]]:S 3[]1(1 !i'i'ilde&predin~en;Jel]lJbr!i}fd.emi3.L, semetimes trndli[]lg to i:nllNi.-e])ktiJeHa[!,les!ic:l[J]:IIci~Ln orene:nsiveva{!ul[llarr ,druDge
ye:;;iJcl!1]atlolJl (Figs 14t3, &. 1014). ]ea¥e'-ll:eOOSlQ![IS •. Tb.eu ]5 a mon.on1.!!.dea!" infi!ammatory ilJJfi~~atf' ~mbepilthcl]aiI]y and

(If ve~id.es

9JrQ'l!I:r!dl!l;perfiC'.i9J1 S b~j](id vessels (F~g. 145).

IPlem:lJ!hi!gus vl~g,a.,is "

A,etWlilgyllnil
jM#wlogj!

Pi 'uypicali' al,ltoimmnm: dli::>e!lise wii:h, docultu]og a1lJLllIiIllrlb&dles gainst epitheUal iIlterceHul:u: ceme:m a subsmnoe:, wb:icb can be clemOi1Hrated in situ by :immWlo:lluoresOfElce. Destructicn of ilne'rml!lul;u adherenoe :JeaAliso disiiliUcgratioi:li of e'pith"elia and intrat CJlilheliial veslenlation, oft!:lJi first in the mouth. Clinically" WOlneR M'C more frequently affected, 'lIll!ua]~y li<elWee'.fI dJ,e ages 0[40 8Jm:]$~ sometimes with oral ksionsas the first s~gilll.Vesicles are fiagi]e, r<mt:ly SIlCD.mllleu in me mouth. but th.cy typi<:aUy !eaV\esmajl, pairnnd irregular eresioos .. Occa:sio:naDy;vesicles are ]1I[lodm:cd! ~r slro1i::iHg til,e' mucesa (Ni:kJO]sky's sign). b ~U]lae are obvious on slin and can spread g}l,Ierhe wiho]c t body.R.upttln: leaves crusted Iesions; .fluid and. electrolyte less or in(ecti~n may be ruti'll if l.U'ltl'eatedi. lmmu:m(!Jsuppressiv,e treatmeat ]SI.II.8!UaJ])' life-s!!vi.Dg but hC3VY dmes of~ fOir example, prndnisolJOne plus azatkioprine are needed. Scp:aru'llon (If epithelial oclJ.s :from one 3i1l0tller (3C3utlIo1y:sis) i:!'!iti,ii1]y forming snpJtabal>l!I~ defu then inl:r3-cpil!.hdiLa~ vesicles. Basal cells atlliere tOo fine aeother and. 00 underlying i;on.nocnvc tissue eo form tne floor of vcs:i.cle:s btU 'they ,evenmaUy gq;I3JI3U iIlfleCrI!!pture of
vesicles (l~ig .. l4!6) to leave

rn{]~,wim infiammaul1ry

infiltrarem the fl!oor_ Prickle eeils afICI;lCIUlthlnlys~s Dooomc :WI.lIl(£ed) tloa~ (Iff in vesicle il!lid (Fig- 147) and an: seen in smears. (T?:IIudk eells), Th.cu v., posirive irnn.nmoflil!lllU:SCC[loc (If immuaeglobulin (usually [gG) along intcwcllular jUDcti.o.DlS and !.vllJling detached acantholytic cdls_
Abroll1.te o(mfi;ma[i(ll~ of me: diia,guoo]s is l;,u)Ssihle by irrunulmdil!lOIescellce of i.mmllnogl!()IJU~ili! (Pig- J4S). but :histololn'is Ireq.uendy adeqaate,

Iii;> 14rJ Rf~phiQus vUlgaris: IlClln1holjitic Ci~Is, ~j!laratjllg r~ ,aaolir01I'I9f- aaily'
stage"

I~, Nil Pempl!ig~ \!ldjJalis~ lmmllBOfll!lOliescellli.ie 5hcwringI!!G Iiloog inl!lf'reIHlaI IbtlJder'S of ,~irllelil,!m_

'n

12 I Non--irrfective sl:OliTiiItitis

Mlueous, nme,mlbrue pe,mphigo,id
Actw~.!i!i'"mI patJwlvgy
There Vii, ~m:lieevidenee fU'F immlulop;:liliog!:aes,is w,ith fiumati.o'lil of Ililu:iblildil'=li against the basement membrane

zone (8MZ). Wnmen

<1Ft: m<limly

affected

I:U;;lW'eell

the

ages of 50-70' yean. Bullae and vesicles l"esuJt frO:ilil loss of attachment of epithelium ~1'I' the I.mder~yi.Dg iioDneclille t~,IJIJ:. ,BIlJlae result fmm mm.,or traumaj : iil.oIsly's sign IDa}, be pooitrve; rlllpllUed veslcles Ieave iadoteot erosiens;

lesions on gingivae' IDay be called '(fesqmrm.a1tive gimgivitis'" Scarr.ing (a:nd damage U), sigfu) ,ill comenen the ocular variant but rare ill the mUl.nb.
Auroantibouics to liJa6ell]ent membrane zone materia]

in

(il!f:ui-~MZ ab) are :run reutinely ddeoC[~lJ1.'lle:11'1 erum: s im:mUI1i'Ilfl.1!IORsce:nce 10' tim:mlIDog(ob'1I1.'liIs along me' BMZ is !i€EIl. in ilOOlil 40% but the coJ]lplern1:nt component (GJ ~sseen in about 8(1'%..There is a poor cerrelation between auti-BMZ ab drre~ and tile severity ofthe disease as assessed by rcurine rne'EilHJIis. There is flO. ~ecogDi.z.~d association willi olh,er meee ty]l]!,;a]
autoimsaune d~sel'll8e:s.

ldicro,s.copy

"Sllhep]dc:m:t~l bIlU8!F>~palCat:iq ful[ (b id::m.':s.s, f o ep~[!he~i.um frem ~anIU[la propria . • ' No. acantholysis, • Mixed, d1l0nll!; iofiaJ!l!lmalOE)' ][I.lilU1I(e in ~amirm~ ()l"Olu-ia (Figs 14'9' &: ] 50). FJectton miicro!>ooP!I' slTtnws the Ievel of separation of the epitheuum to be along the lamins lucida (between rhe pLasma membrane of die ba.sal cells and the electron dense basal ]amil!lla).. ImllJunOglll'ltndi.o or eomplemem mary lie dcteetable

:along, the bJ3i~tmejH (Fig .. [51). Tr'Wtme'm

1D'1emb[',;rn.c 'hil' ilirifll11n.'!Jfh:IOK!!ic;eil1~e

There ~soI~n a good response U) [opicai certicesterolds. :Syst:ernie wn:icflStero.ids arc ilildicalled forc::m:I1ruve' disease ~pecia][y if it: involves dle eyes.

Fig.'150 MOC(]l!JS rmelll'brane pemphig~,
(High jl!Iliwar.'

FiIlJ. 151 !M.'ucOIlJ:ii membrane pt;:rTlP~I~id~ irnmmliftuOl'll&1lence' of CMIP\OOll!llli {CJ alClI18IJ~t IDtlltl!!ranelIllle.

ILupus erythemat'l)sus
Anw!~lfjf tmd pathology

Bime~'~1"s;1cmni.cor discoid hl.rpllls eryiliematoS1!!s (SLE Of OLE) can cause oral! Iesions. SU ~s <I CO:lllltttive ~,uc: disease (:amoimf:lll.l!ne),
thought
ttl

be imml!l..ne-complo:

medillll,ed, Wilth mlll]d'ple

Omunolil dIed:S are I'a!lliles a.nd arthritis but i!lIm,o-:s{ 9111' iSl"ne-JDi be jn'll'olivedi and Sjijgren's s:yildco:me is em present iin :about: 3111% of casesnus: i.osmucoeutaneous whh Iesions IliPPea:J';]Dg t]u:' :5l1!!'lfle as thos-e (Dr SLE. but minimal. systtmic e£reds 0["
a1!lmanrilDody prod.1!lotiml.
0["

1!QIll'IilF'gm-,s,pecific al!ltO!uuibooie.s, panicula:rliy atIrillUcl.eaI Jactors and ,often cbewn3wid (actor.

Wome,n aged 20--40yea:m are mainJj' affucl!~. Oiral, lesions eonstst of :streaky white 0'( e.ryt lemalnUS areas, erosions fre~l1en:tly similar to these of Helben planus.
MufOSiUj{Jy

fig, 153 LllI~

errtl1U!:l!I\IIlOSI!IS~

adjaceJl

Highly llamble pic(llJl1ewim wildly kl!'f',gu.1ru'patt.ern.s of acanthosis or epithelial an:ophy, UqlJefactioIl dtegeneratilil,n of bas:d cell layer <i.lildiwidely scattered ill]lawm.arory i.iiillrate :in.the e:O:l'il1J:rn(F]gS 152 & ~~B). 1bicl!::'~I!in:g (nf me b9iSeIIHmt me:mlbmne. 1iIJRe is show!] by PAS staining (Fig. 154). :Iiiirlm.ulJl1ghibu1:in aod oompl~meu:t ..n: also d.erectabl,c there ~y

Ilpillrieli:al atropily lind

ilii:iirrtho$i$.

me

immU.!llIil,.fll!lores",-,e,nce_

Diagn.osi;gof SLE should be confirraed by allltoa!ltift:mdy studies, which wifere!'!dare il. ffUm .oLE"

.Treatment

tmt sysremiic conioos4:eooidsan:

,Lesi(ln,~ often

SlR

respond. poody to liopkal corticosteroids, ~lI.stifi:!Jbk fur extelilsi'l'c

:EI1

[-e!,fli;opl:;dlia{;o ehrouie white (k:el'a:lIllt:ie.) mueosal are p~.aqu!f$ which are [lot due tn aDY idenfifiahle disease. Tge term i'f'; p1!Ire~yc1i[liem and has nf.l histelogical
implications, 1m1I ~j~ro~ogy lis Il:ecessny lOCI eJ<dlJd.c .m;;rli.g[l3[1cyor oilier diseases, MO!ll, ~ooko'Piall;~as arenot ~r€!I:Il;afti;gl]iHTli: but red :lesl,ons (el)filuop!la~ias. p. 95-96) p are' F~eqU!el1i.dy~l1'ec-aI'lOe'ffiU:~ or :ul1vasi:\leearcmoma.

:r~'i1l!)l~

Oral wI11~epl~.qr~!~$ share

aad ~d~Qpa~h.i, forms are Qf¥ei!lu;ot d iSIi!lg~i~h!!ble l'Ii:nologically frmn these wh:h derined causes !lll,lch as frkliiolila] kierulOSiJS, linn may sl1.Q'W ~iysplilisia w,cHII$wpi£w]y.l'dIIllI[',es of ma] whik lesions
include rhe
r)jJ]hJiW~n:,g

1:PS!UY iliswlo:gkal

fearures,

in ¥<IIry~n:g 'OO:lrlbi:lltlliQ[l!s;

Micr~py

• flypl!!r{l!l'nio)ker!atosis-::lJ sl]pcTnc]a!icos:mt}philiJ.: ]ay,er U/§ dead c~inJn,c.[ja~~QlIi,I]m::S ~lJrlcr ""fii,cit tht::rcis a ]:w~et
oolllt.8]niq: ~lIIropi::liLlC~lIUiLe8 (If preke:r,atin (Pig. I5S) . • ' P!liIllkeruWSiS'- (he surfsce c@mtSJSI.S of e:l1ele epi lheliS!1 cells oomillil:lJ~Oigshrul:l1:::en,pykitloli,c, b:aoophHk nuclei widll1l()' Ilnaerly:ing grum,dOllr ceil layer (Figs 156 &:

01 e!pimellli;al ,~Hs

'. A!camlwt.is-tlyper.;plasia of tnt: ]JT.idde cdl Uiyei!' 1l!8uaJIUy with L()~8of dlellormai]yregul;u prolliJe of rbe rete rid!ges (fig. lS6),
• Epi~'hdialC;I~y-ILb:iRIJJ~[Ig

157).

• Dy$1.duria

reteridges ofthe 'cwi'lndiillm Wig. 1)8). ken~o$l$but
(see lPP.93-94)
li:II::]1;

usually wiill ~t}5!S[ rbe o [ckiilltlnsh:ip'.

is no

rnllY be 3J5~m;i<I'Ll;1d with

Crulli[MCmU

Fiigl.'158HvIll6r,cr1l\riNiaIOOis,and~l:a~ e !Jtmph'p'"

lJ

Whit,e '!i'ponge nae'vu:s
AarotoID' ,flOO ~tlwlcgy Hereditazy (;:!.ul:OSom3ldom:inant) @iwrtiel" ProdlildDg '.lo£'I.,wlriU:: ttii.e::k.el'lruDg the (lira] m1!.C0.'!>3. ,t:: COl'lmt101l of n is,3i~J'm]J[OPlati.c (wa.y [I0~ be notioea uodl adu]th(lloo), bill ta.g~ ,(jifpmliIuding ,eoph:be1i.nm may be chewed off (II: dclac1bedi" [p'oou!llldug :lID irreg~hllr s~:r:fu_ct:.The wh.ole: of the ornl mucesa may be ,a.ife(:{ed to vaJFiabie degree,
TYilicaJ!~)' re~3r acanthosls wilh widespread int:roceUulll!f oedema. eXl:enilililg paniculaEiy jn the polaqu.c where promili[lImt cdl mc::mbdnes, gjve a '"baskel:"we:ave:' appc3._rnnct: f~igs 1:59,& 11)(11).The sW'f~l.'ce is WPicaJ1y

ir'e;guLar ..:blfi~mmalOry illfilu91e is a:bsem. from the
Co(lri.1UlJJ

{Fig. ]61).

The di,agnoSi'll' shotUid. 'be 'C(lIlJill'nted if me: fEWli~ly h.lsmry is uninformative. then be !!;i",eo-

iD,' 'biopSY" espoeci.aJly
ltfilll5SlI:rance 'C3]]

fig. '160 Wil.ne~~e E\pitholial ~e'II!j.

n;aB'!i1J~~

oed eIiT1~tOLIS

:a5

miorog(Je~kaUy (Fig. U'il) i'ltiid is distin,guisitJabl.e OIilly by clinical ,evjdeo,cx ,I)[ mech:mll:aillnluma, 3IId :resIeill!lI'(uJJ ith, w

This. shows non-s:pccil!fic keratosis removm of 'me
:in:iIDa]ll.

SIlil1,o~ers Iker,atosis
This F~u!llB hom heavy ~G)f1g..:tetmpipe sID.okin,g;, is, therefore seen maiI!.:!y in men) and affects the palate,

Par1w,logy

The l!ierams,isi!1j !'!oD-spedfic Ibutwcn: is C:~isricilJly iillftammadon and swelliBg efthe pWaJmJ n)!uoous ,!:lands I,nocblc[ug[\ro umbIliC3ited s-we:m!llgs, (rij!- U'i3).
fl9, 1163, SIllIlIrer'S :s.ahar'l''Jj~w~c

lreratosis: SlN!'][11l!1I1l!11~t!l1

0;1' the [eniary S[-3i!l"C syph:ili.:s but ,rMeLy seen of It l).'JlkaJJy aff~[S [he dlOoHllm. of r!b.e tongueand theee Is ,9. b~g!b risk of mflilignmt OD.lIngC. A~eatulle
ID1W.

Microscopy

Features 'Iilf q)hbelial kereL<l!.li]Sare not specific bur dysplasia or m,aiig;lla'o[ cbimg,t:ma!y be ,eVident (Fig~ 164). .A charn.creristic syphiliti.c !.l[]llam:matmyrespouse ('~ritis (Fig,. 165), plasma cell. infiltr,ate and 'GCCall,ion!lJly gflI!DUiloumll .fmmarti.oo) ,may be seen deeply, but diagnos:is is ,essentially !iC[\I!I]ogocait

Fiig, 164 SWltiliitk 1oo'kri~1:lkNi II.Ii'Ihmildl ~si"_

fig. 1'65, Endarrertli> beneath $¥phililit ~eu'liD~ak:ia.

ACUitle 'CIJl1u!lidosilS I[OJrlsh; 'p!selllldol1lelin blrllolUs' cald~dosi!S11
Aetio1cgy Thrush ~~itlliietypical acute infection of muoo1!lJS, m.eI'll.l:i1mlW8S by CfmWtill athirum ..n implies Il[lderly.m;g immWl.!1ldelfic.iency, e.g.. [IflO!rlareS,; tiN ilJ!fectioIil, rT~]o:n:g;oo. broadspectnsm 3!D1).i:rn.I!c:'rnhial, imml!lIloM!l:p.press:uve :;JJrndi cytotoxic tlle'.lirnent 0[' d\eibni~'!Jt:ullg iL~I'Ies,.'k Clru]}kall[y, ~h.J"li!sb forms· SOH friable, crealnyftJoclks.

or ;plaquetl, th~i:[ w~pe oft easily re¥~LiIlig; LII:w.~t ~t b eifyd}ema.wUisepi'f.b.d~l1im.. A G'ilIm-s[ilIiiilleds.me~H' ShOWll, l1tlianyGill1lm-iPCIIsli(]ve bwl:'lf!:e !of C. a/h.icwlS and
i:nfiamm.aHJF)' cells (Ag. ]66). The plaque of thrush is aile m q'li[il:u:li.a] liinerplasia.-it lSI:Ii.!lIt ::I psendu1il:liemhnllie (::I~lI::Ier,enlsLough}. 'flae epjtlldial oo1~s00' (illeplaque ere sepm[ed, by in~m:mai[>OiiY exudi;;ne (hence h is &jllib~e) ~]}d~din;g maRY I:!!eu.l!rol)hilsThe mflamrn~I(Iry intih!i'S!te is maS[ dern:S<e,,~ormi:n;g miCI"I!}9,~sces8~ at the 8iJi1mce ,():i' vbJeprickle IJd~bye:r 3!IJJdI pmv:id!es, ~he ])]a!:'le of cleavage tlHU aUI:m'S l3]e [l13llJil!lettl he wi[~ off- PAS staining will demeestrare ~Wj)H1I;~.e c.. o.f IfrbkaM growm.[: dOWlliWlIJI'dis dtIOQgih the e,phbelial cdl)!: 00 the 8!U1cfaoe of the 8jplllJYI!Iscdllayeif (1Fi;g.~68). Deej)l.y" there is 3C311[ihlQ$~s w]lh loag, slender dOWlilg;lXlwths (If ephl:'leLhJID1L, _ imlamm:ato[y :i.n6hran: i!ilI the Lamina and propria (Fig, .~ 67).

M'it=M;!1py

Fiig, 166 Thrm'll:I~lecl tGra!li1 51alnJ!

h'l1P~e

Ii'll $maar_

l'n:trlmem

Tbrush j[cqm:JIll~yrcspul!1ili; wcl] Ill]Jto:iJ~ca] iIInnlfuiI1gal'$ Mlch as Jtl!ySl8JlilJ! r lIIm.pho1:A:iricin !but in severe o imllftimotie!fide!m:=y (e:.g. UIV ~[Ifc(;lliu[]J} .l1uOOfiazolemay be neetled,

Unrommon. persistent candidalinfection u:;;ua]lyof OT ,over hut may QCQlS"iIllIlilLly be SCCIJi ill. parieats with HW i.llIfecltij)t}~ who may dlcvdlilljp :my ty;pe of oE3!l,c.llIJidlid'osh ,(Ii llIicall!i"~ •. ehmnic caadidal plaques []GIIY lmmogeueom be ,or spedkd ]0 character. .
middle-age

MicroSto.iP..V

Productien

of ~anikera.[(!IT:ic plaque, Hyphae

grow

tlJrough plaque TOjhe spinlllus layer {Figs Hi'9' & 17,1'1). Plaqne is :il1fihrated by moderate IlilImibers 'Clflellkocyites. an.d beads (If oedema. Jrhc deeper epithel.imn .is acanthotic; sometimes grossly 50 (Fig, 171), snd sOOlil,~i:m.e8 dY1iplauic.

ChrOli1Ji:c mu eocata n,eol!ls candido,s~iSsYIm:t'r'Omes
AU are rare bur ,rom;priise 1.e.u.l(o])I]a1kia-lilte oral aDidl.~do5i.!i associated ....<i.m ','.u·iiable skwll ,aniluaiJ i.lilvolvemem:, and wme(imes sys·tcmic dliSlDroers. There lis a, limiln:-d. defect of cellular i:woillIoirtyin about 60% of i;.1iuien'lS bur .110
;S'peciaL&\I~ccplibi.lity to syS'~en]k caadidosis. Om; "Mint i;~~hn:ed with! eadoerine defideiDcies, pa:nlculadr primary h}'JlopW'al.I:I)'l!Oi.di.<mlan.d Adldlis.on's disease (calldida c:mj)lOC:[inopa.tihy syndrome). M'icrosl!)ll'py

fV. 1&9 Chrgtiiccallilid~5; ~r~e

ililV<ldilg 1P:,f[,U eratntie pfaque. [fAs..j

Fig, 17(11 OIlIrcmic ea iildldllisls: IiiYlPnae' .allilJ WlammlliIDry in iltJrarein plaque.

As fOii iselated caronic candidosis (see Figs 169-171).

Dentt!!lI'Ie~induce.dI e,tJ'Vl1hermaiolis. san di:dosJis
M.osl.oo:mm'iJDl. Wldjer al] 'Upper deature wnCI'e bypnae of C. albiaJm ll,rolirera(,e il'l the m.nlerf:r~ ibetween denture hasl: end ml!l.OOsa, wflidl is cut off lfiro:mlecal defenses. DiFIu:>!:: camlfida[ el1''it'hema &.8 i'Illiu soon in X'cIDst!JImia. !In 1IIV infeetinn C. l1l1;i.crlll:s. can cause rod ml!l.tl(!lsal macules (eryilicmatoIDl easdldosis),
.iMiaasroP.)' HyphaelITC liuiP~rficial. to the 'elP~dldil.llDl and not l>CCIJi ]IIi sections. The epithelium iiSSpoflgiodc, ;'lC3Il'lhulic and ill.filtr~Med,b1y ehrenic .imiflammarory cells.

!Flail., lleukopllak!ia
:K:c ]J'lI.ges ]43-]44, 91

1D,.spl!asia~Iepii.helila~iJll.vp'ial; dys~elra~(lsi$'
DYflplasia. ~I'i a~mW ma[!!Jmti(!lli1~d ·dii:J]'eremiad@l.l1l ~f !Ei~.~ph!l!eJ~~m~ as seen in C~dillQm<liS !IIlIiJ.dlIlsQ in i ~l1lkopl*ias~ when il isusu:aMy il!DJ l.firuCi'lltOO uf prernaliglilallCY_ 'fll!:e fo:llowilt:.g feaHm:s are seen in li'mJI'i:n:g oornlb~n:!!!ti®I!lIJs: M:ic:m.%~py .. "ype~c.b!oomald8itBa:mdi Iliher.uh~fiof the nuelear

cyttl'J)If!.~miclu~o. he nuclei IiiU: :u'iYnurmaUy ]qe in r T relarien [l) the att3 of Cj![{ij)bljiilill and 3l[C m.O[\C lIi!c:lIvily baoophHic. Nucleoli! may be mou pmD]JC[li!
(]IF .

..

• ., ,.

numerom,. N'u.de:aF p]oo:mt'!qJlhism (iinegu.1Mly s.hapeOi. Iliudei) is. ofrren 3.~tK::i:n.od(Fig.l 12.) mdiv~dlll:d,dt:epcdlli;;c:ra:tmi.iaJlilj}lIl {dysk;era/~@Il:is). hulividlll.ru o:i1swil:b]ulibc friick]ece[l .layer de'l!i~Jo:p' ll:lit~lJ)p]ajS]lllic .kiernti!lIl a!I!ldllJecomeoos.rn.opb/~h!:: (Hg~173). Loss Oifpolaili~ .. The 1'JIliSW. celllayer lases iiIS[lo:rmOil! o:rdei.ly ~~J1tIe.memudln1IDeI;tUs ]jjc ~[[\cp.]:nly at ang1!es to Q!leS!..fi®meil' (Figs 173 &~74)" MI~D&es:.Th.ese·!m!_Y be seen 8I.lrpei!'Jid.al!~y ::IrnmJlg the SJ,iuou. o~il:8 '1m:! are of ·Si:l!lJi8U:f i:mporrr;p,anicw.arly ~f iblil~J:'mat O;tj]iJerfealwJ:'es. Loss of in[.e:rcdluJ!:nadliu::[Cl!lce with
v •

Fig, 172 M'1Id to iOOder;B.te ~la~illwilh iT.ypere:l!iromati~l'fI.and L'l.v~~r~loois.

r73 D'I'$OO~ 1MT!h deep (lell hvJpeil:lilrofllla1i1m.:me foss of Ilclarilv_ ~
~erilm~iQn:

cells (Fig- ]74) :alil.ddloop-sll:ll!J'OO a'8llO'C'!9!rerl_

Iliw,ciI:·f:lI]ed S:PilCCS :aWeaFi,iIiI:gbetweCliil tililJl:: cprithdli;al! ~lImlool.l.:S) [\C1Ic ridges aresLTm~itW:me:8 a88.odill~edwilE d)'}iJlIaiSia.

EI)I'f!er.ker.aw.osi:6 .ruuilru-3;ca[lmQ~i'li mayo!' may .[]Jotbe
. . SlW,~re {ilysrbsia with iCe1]u~ar .aJbfio.rmali:lies cx~tndi. it1l::J[CIj]l.]gliL the :fu!1lth~ckl'l!ess of the ephhdU!l1ili (llJp!-'t.Qbottom 'cnange) ~'S sOIl'l1etimes ttil'me:d C(l£CiWJm(l-in-~ilU (F~i!l. 1is), ilf. the ce~~IJ!I;1!:I" ~hIF.lQr;m~djdes C;.'Icdliloma are of present batthere liS ]1)1) illl.v.a.s.iol'l_

111;,. ~laiSia: U'4
ailltar,em~.

~

or 1n00000sliularr

Fi!l~ ~ere 115
(;ha..

dysp1ii51i1 O~W;-OOtl.mn ~Ftim0rl\9-im.-ritu]_

EJ'ftlhfiOphJiS1ia 11,'elryUl'ropl akilal'~
·his .isa dilllcal term for chrenic red lesions (iI.e,. h)']J'El:'kcr.llloo.is is absent), They do not forlll raised, ,1,B.que.sbur are typiodly .Ievelwith, 0[" depressed below,
(be *lmnll!lfidhlg mucosa a:ndltypkaUy lioh()w severe dy~pla.s;i.a (fig- ]76) lIX early ClIICiMma.

Ealrir¥ lr:a'rrl~:i,",C!lma
'EDadditien to dys:p~a'S1ic lelllkllp]3kias. some earlly C31rcimlrnas, bcforeuJicf'[liung" produce ~e:ra}ti[)lOJ!.the
susface a:nd ;:qJpciirf as innuttllt white Iesions,

Mi~Si)oW

There ~s~nvashfe :sguamoIDS oeU eaecinoma replacing the m,o![m_3lepithelial sU!rfa~ and an OWdYlOg parakerannieed plaque (Fig. 177),

SquiI,mo lI]S, ceil~IP,apillll'omlil'
.A. OOIll.IDOll. benign lesion cbl'ilrn~terned by fine, fing.er-I:i.ke papillae, giving 1t a ebaracteelstic WiU'It)' appearanc« dj]]icli~l1_ HPV (par'licnl;ar!ly l1"pBS, ,6 and II) may be i_mpliicned, hut cyw:logkaIJ signs of viral iafecnen are not ev:idcm his,toJQgi.C<IIiiy_ O,aI ",inll warts resemble tlapiUOlJilfiS ,~~i!l:licalIly~ show "'i'ml changes and but inclusion bodii.e:s, Micro.scopy
.A.central branclil:i:n;g OOIfe of vascular cenneedve tissue estends 111m l'h-e 'jJap:iUllt'_. The lanerare covered by

~h}'P~]as'lic stratified SIJ.mamo'l!Is '~)litlu:IiIJDlwhich may 'be keratinized (Fig. U8)- Thepaplllcma then appears ·wili..,. Tmmnent F..xcisi.(ln is eueative.

fig_'17l Carcinoma wilEJdrefi!.(]ni~ surtese,

95

A~trc~I!'M
{1(ll~

f1!l}Wever, ~1Ji Britaia, ora] cancer incidence in roe:n. hss ~~ad:uly ded.tn~d w!b]lc:; c~i!!a!oon'CIi!I1diw~®:hloJ 'c{I!'I!~llm~ti!il1rl

~dfi]ogicalfaCiiflll u>S;l1:any l.!U!Ii.dCJ!lti.llabie aJtr.hollgl!. wide I.}' l1f'g:m:lledas 11iihlttdl. 110toDiiI.etO Hod atcnb(!ll]!le. has ]~(::r~oo. 1"here, is

!II d05'cr[diltlo.mip with ~i.pe smoikii<lg"The !:Iigll.~ncidim.re ~f. orsl CilInceil:' ~~huilia Is possi'l.dy related ill dli:H:e;r1lilltlIyPCli, aDd. fiOITllS of tiOhacco ~&age_ Ilf'V 16 and. .re'1a~ed slllia!im>hill'i't:been illil!pU~~e;d. ])i)l>sibly by U'i.~!I'~lJig mutation. of '!he p53 gene. SQ!llai}lO'u;s eil earelnoma ll!sll!aHy d~ll!)iPs afl,er age 5'0 c

aadiheincideace i:!D!c:rea.~ with 3ge" bp Clll1o€:] :18,associateriwitfu. ,eKCesiS;

:Sll!ll$b~ne, ,~pe(hlil1y lomir '~!d.[I![1edm.:des. h lS 1I:S5l'1c[an~d vcitb ~01Jdl;;j):p]il:kiill iiil. o:lllily II mi.r:t~ir.ity.

expooSIllC

['{II

M1a'ascopy

[cgiJ)(llLa1l'ymp'b nodes, M.ost afi!' we]~ di:ffcl)~ltiatedl O,IJJVi61J8 S~WlImoU,~ psttem aadfeemarion of whorls of 1:le:r8t~1:li deeply (cell nests) (f~g. 119). Th.e basement membrane leJildos tn d!i;5,lJp~<tr awdlthe tummJlfa]:Dpe'.!ln as i:I1I.'Ii'ading •. ir.oop]ar epithelial :PfO'Cesses M sheets (If cells witlt i~l-dmodorutlii!lie!> ~k~l]y s,mrounded by ehronic [IJJH3mmamry cel!B (f']g.

lMsc[]Jtillil features are epilbelialli ahlJJonnal:ities (dJy~p]acs:iJill) Wild inV<:l5iu]l, L~uer, mem[$&e~ develop, ,anK:lJ!l!iFry in

w~m

liigl_ '1791S,quaI'nOllJScartinOl11a: 'ctllll~l

Ibrm;nlon.

foig."llill S(JIIIITIOO~ c:elII c~rdinoma: well.;(j~l~~~~dl

180). fuva:sion is, chnc~e;ri~eoiJl n,y d!estru.ctlOIil.lIDhi:;;:;II.t:$ in. me p!:l~l ,~f.lhe mmolllr (Fig- 1:81), NeQ]llias,llc ,epri:uhdiim cdls S!!I'e leOI[l~l'[lh!ic,S:h(lJw p

v.ru:laliJ]y I:d;uw::Ui" often hYiPeocl!rolnatii.c, mnclej m vCliil;;ular IlJucl!c:i wh .. bp:romineJlU or ml!l]dp!!e' nucleoli (F~!!. 182). Milt~ (F)g. 183., .p_ 10@) ma;y!be .lJ!ll!meHHlll :mdi.azypiieal Witb. iiOicrefLCsiog de:djffe[le.p.tbllti;~ilIl,rlIe IILCO;p~tic cells m3,' koomeprogre&!livdy mare

bypc:rcllromadc aad 1'>egl!I]a/rl[l Si7Jf (Fig. 1&4, m[l,Y become d~f]icll!lt toreeagnize as e:m;:o]nu[lllllS by Ug!ll'l ie.ooc~y iii] elllJl!le.me (aIJJ:l]J,]astic} m
p, 1O@} liOm~:t they a::Uillrp]eS.

wtOrmly

Fi~, l:lJi1l$qui!moU!> caliCi~!Jlij de~n;..y[mml
rnusdec

14

I

SquarnOO$ tlBll cwelnr;mllil

TMatme'tu

and

progwW

The Plaln for.1mlof I.te~uneiltt !!.Ir\e' wiic:lLe ~.cisiOin often. with r:!Idi(ld!e:rap)'> 'Ort i!',adjothe~aJlY alone..6(100 'f>luvivaJ .ares ,de!pe:nd IjJo]J. ~]y dliJagn.0S'~s. treatment, Sl/U'vivaD. aodl also deeerlorares wilth lIge. AV~Jlie 5-ycoarsurvivld rares for carm!rlQma of U:teruilgu,e ore 37% :£01' males and 46% lim!'femaJes. Most oiliolt sites wit'him dIe, mO'llJ.'rn hove a
];luher betliet progno:s:is,,, earcin0ma of d:te Iip has a. :muclb better pl'®gILlosis ::IJDd a :5~YallfSlmI'hrii rate o£9'4% fm meles ht (incol'.l.p]icably) onlly:&4% for- femal,es.

Verrucollis ear,ciino'ma
An uneommen variaar wbkb ,appears as apromiinelllt wbhe warty ]da-qw::.It may result from. the proWllgerli U:iI'C of &!ul)kelesstob!3~ (snuff <tippIl1g) but mquel]dy no, cau.s.e is a"PllM1CU'!:. 2a-e may be :i.mrpli.ca,red-

mv

Fis- 183
IlTiillJses.

Squamous carcinQm!'i;..a.'bnOlll1al

There' ~sgross hyperkeratosis mdipapillary epjihe]~al Qve_rgrl(Jwtb prodllc:in,g a. folded arppeaIiulce w.ith i:mtel!"lren~.[]g d'm-like spaces. The uDii!fom Level of dUWD,gmwitb of the tumOllr gives 3. well-defined deep :mar:gin in tbcPN:-inva8.ive smg:e(H,g. 1851 but can transferm l®, inva:sive aJ:'cmilm.a .. E,ilhdial ,azypiaJis minimal (i:n the cady stages), ibl!l! tib.el1t:: is typical,ly a c'brolilk .iniliam:maitoty inlihr.ate in dt.e conl.OO. Trmtnte'JJt and

liig, 1M f'I[)OIty-difeTeTT~i~el :!iqIll6rnDu~ e ~i!Kinlllllia_

prqgnosU

Spread 1ItId. metastasis is slower than SI!liIlMIlOIlS cell ca_rd!i!oma andi. the response ttl :i\deql!laJte ~ci:;,]Oiil is better.

Ve'rmoous hype~plasial
JIm. essefilriaUy simi1.a!lr IdiO<D '[0 'Ierru.crm.8 cuciuomill but differillg .hj,'Stological!~!I'm '!hal I(:he·mass does Dill!push down in!:{/!1the Iamineprepria WIld the baum.e.lIi.'D. rue'.m'lu~a.IJJe n.1! l!l Ievel with that '!LIf the surrounding m normali epirlhdium.

99

1

fibrous n(ldu~es,(fibrous le'pu~ides,. pol,yprs(lInd de,nturn g,ran ulloma,s)
Aaindogy and
pddm~ ]--I1:I!!se a~ ~m_e oflh~Il1IOO( iG,ommon oral

MHeiliogs are hype:rplas;tic in nalil1\e, f,esu_kiog :fi'-om fibr,ous pru>]jfer~tio,lll in ]"{1!l;p!:J[lse[0 chmnicirritatien eften _ IntliaJl!lfllaiOo]"feomponent.

IiIUl

m,tm

These lesions are dJistinS1U:ishaible'only by their she of origin and consist of irrt:l!lJl.llll1fbUfld]es;of collagenous
ooDJl1ccllivetif>8;l!I.e wi,1th varying ,Iliumbersof ibrolda sts covered by stratified sljiU;iill1UIJS, ephl1el,i,l!ml Fj,~ ( U6-188), oflen with mild sribcpiilieliid Il![Iflammal(l[), infiltrate, Osteoid or bone may form within ,:1,iiibrolliS epulis (Fig. li89J- Mo[\e 'S'eVe:FC and deeply extending :inhmmation -r'e8-'lI1tsfram nJ:OCF"".IItlon.

PyoglE!liIic granuloma
eliililica]ly, pyo~enk granulomas ,appei!r assoft, red nodules, uSlla:Uy on the giJ]gl'i'Olilllfifgins- Despite their name, these 3Ie VlIisculerr prolife,ralliolllls" hurt ilnflamIDllitWn :is &-equcnl1y superimposed.

M~swpy

Lie In 11 h:iOSC tissue srrema but typicailly; int!le.rnmawr:y cd[sfiiU the vcs&d.s aad irnllh:rnrtce the stroma (F]g. t90. fl- 104). 11nc- m(lidtule is oovel'ed by s'IDI(~fied'f¥qml!Illom. epi_theliuJiIil of V<lnilib]e thi.cbe:s.s and, ]Jrilnic1l,ll[Brly in dn: irlli'l:a!lued typ~ :I]]3J be ulcerated,
OO[l[lOOtiVC

M<1!ny ilibltCd 'lhin-waUe.d bloodvessels

Tmumenl

&<:'~sijln

is, OIJ!!1',:11iiv~"

15 I ~perpllaistic IlesioRS.

IP"egnancy epulis
Ollri[]g pregnancy, ll.o:rrmomal.facters fu.vollr gi.ll,gi.val hypc;rplasillmd formation of pyog,erlk gr,!!1I1II1(l.mas (pu,g[l!l[]cy ~Il!Li.s). CLinically and 11i.:s.-m~og.ki:!:n.y tne$e

d'o not di:frGr from pyoge:ni,e g[~:llld(Ulll9.'!i een ill. s non-pregnant ~m.[:SI[II.lIS - C1uly tile' pregnant :Sfate di.fferenn1lJl:es dJ.em. (iFi,g. 19'1)_ Treatmam Ii1'Id

~ru

(I'I.1egnan.cy epulis is I.i.ke~yto regress afierpanuridon oral. bygiel!leis good, btu may have 1!.0 be excised,

if

This lDypc:[]lIias,ticIesion is believed itO result from ,a [proii.remtio[] of esteoclasts hom the sites of s~eddi.ll.g of deciduous teeth as it is OIl]Y flJl!Indi..1l! this area of jhe i ah!',w13I ridgeand m1Iii]dy in }I'!JIl![Igpeople. E!<''()e'ptio:rud'I.y rul'eiy., hYPOrp.aEOl!lbyroidiism gives rise to 3. giant cell. ,epufu, diistii[lgl!liisbablc only by abnormal Mood chemisliIy 3IId bone lesions, if present,

Fi~.1001 Pyogenic gnmuloo'la,

Microscopy

The lliUl;SS ~!'i bJighly (ic]~ll!lar nd crowded with osteoclasta like giant cells of variable size in a. oeUll!la:r and V3SC'1!Ilar Siroma and co\'Cud iby stratified squamous epithelillm (Figs l'!U &: 193), If neglected. it mil}' ur:lile:rgo gradual fibros.is wiit!b a 8.brillkillg m:re of ,gi.ant cellis;surrounded by .6hmus tissue,
Eseision is rnrariive'_

l'rwtrnenr

103

MCl1!l'ofiibE'iH!IlLaJ5 :life UtlOOmrn.oill rumours ,aris4ug: from
uerve sheatb :!iffill'ulbbiSlS.

.Mio:QsroPJ

They eonsist of wavy 1il1!lEdlc:s of oolhgelli and ffi)'Nblas.'ts wIDth elongaJt:oo[JJlI.]clci(f"i;g;~'94). Vui.ab!e am,!)u:lIl:S(if IDI!lC'.iinO'l.1ll grm.l:IIldJ substaneeare presentand mlli}'prodl!ce ,9. :mp!Gltid apjle1J.I'a[).oe. 'll:'IIre tumour IEI:ay conl~:ilil nerve fibres 0:1" lle QmJ:n.ti:llIIlIfrUS with lihesheaftib.oill.llI!cne.

NemilemmOi:'iUi8 srlse from Sd]W~HU"l ells wbJlch form. c

the axQJlLalJ sheadl,

Micrruwpy

• A.tIl!!irii A !isms - OOIllSlSIS ofregJuia;riy a~:r:a:~ed ,eh~Ji'lg.a[edpjndle oens with d@sel.yalignedl (paJi:53dicd) s
[ludei whlch an dJair.k:l.y basopbilic aad dO]Jg'!lt.cd (F~g~ 195). .. Almon; 8' ~O$-(lo.msi.$t of sherter spindle-shaped m (lV,a] eells m :!! !'Il1]ci.I1H)l!!S mart!.'!.}!. ad wavy delieare l:)QJodles (If 'oo~]~genfilb[1e&.

TItc-ycllmacn;riMicllIUy

cOlllllprffile

.tw(l

types 'IilE tissue:

lriJ:ulm a~ie hllD1lPlllJIt;a~i'QIiJ]1 lelliOnil,iiI
Prolife[a:niO:I1I '0\1:flb:re-s from vke
jllro}l~I:I"!al. SlUm]! OF 3.

sevt.[',ed fic[,,,,t: can .pr,OO~JOeSi ulimolu-Lili::e '!Iollll!l]e of []e:rve ~i:cJles surrounded b~ :likous tissue (Fig. 1%).

Plexiform neulofiiiD'ronlla
This consists (If a umg]ed mass (If nerve lli.lnes cut in vario~ planes (l''lQ~ 1'91]), It. eaa be a soLi1Ia!ry lesion or a characteristic ka,ul!f,e ,oJ' ol!!urofibLOIDlI.ID8lS(von iR.OOktm,gibOlfmcn':s, diseese), Whe~ found. in the laIDCTIIl bordereftbe tengue, partiealarly, this ]esio[l is likely ro be one of the Ieaturea ,of muldpJe endocrine adenomatosis and associated with. phaeochrnmocyroma and! medullary C'al'CimUD.3 of the iliyrotd,

Hae'tlilatfilgiomas
These il!fe 1J8UaUy hamartomas rarber than true Uirn()Uf'S il:nd are some'rrlmespa:n of a w~despread. d!ev!C[epmema! defect (mucocllInmeous al'lgiOm8!lclj)JslS"lo:rfi'irim: slain), ] Mjatl:f~'

,c:a"ri1IIat}" haem~~ma!l' Thefle OOJitsiiS'tof a mass, of fine capiUaric:!i, ]m~erf()rQ~e' rese'Hes, of ellidovneUa1 cells (!Fig. ~9(8), covered by
(II'

s.q;uamol,l,s epithelium. Cavemo'Uc">

These

of dilated, thin-walled, bloed-fllled vessels or 8i1nlsoiih covered by squamous epithelium (Fig. 1'99). If a haemangioma needs m be remnved, oryuth,crap:y ]$ proba.My dien the treatment ,OF choice because of til!: risk
CJ)n.SiM

lb!!Iemang~Glma!l

of serieus h:::ie:mon'llsg,e_

101

ILymphiul1lgiOI1as
Ge:!leooty w~-emi!de CaV>enlQ1JSi ha,em.ailllglo:mais bllH COilllSl:s[ of d!i lated lYffiph:il!tk vessels which dClnot cl)f1(ain.blood!
cel]s ~n~es.stnl'l!!m;a]:i2ed (Pig. 200),

M;it;:~{;rJpy

These

IID::; FIIFC"b~lIli:g[]l tl1!mOIJ![8 of

smooth

IDI]8Ck

of

yeS1il!;;~ a][s. w

They consiet prcd.!i:Uill<m:lil.y

OEfiWOOth

muscle odb w!bjjrn Me oOElCe[]trical!~r

1I!f.ranged 3!l'o1!llldi

smallvessels but spread our wllin.Olilll :I!Di)' IJfWllarpattern moo the main tumour 1I!l1el1S. 1"be ;50IlIIOOlll:! muscle eeflsase [lO;! dbv.iom, ill H &. E stainedseetion but are made C'O.fipicll.OUS witllt sfec]al stains such :IS PTA" (fig. 2{H),

Lipomas are bfni;g[lrurnOLl.l'S uft3!t oe,IJ.~s most and oo.mm(DIl~Ysrise from. dIe buocal fart pad, M;i~opy
The; []CJJ51S eensists of bt cells (a,dipocy;res) neeld!. ID,~eilie1' lJy ~~; areolar rissl!I£'and cove'red! by :mJ]lI00~ (fi:,g. 201). is, cueative.

1~tm;m:mojjsi~Il
These are

Li~osaJfOIIImas

[OC&gIIIiz.OO 'but

~C(ledli:lIlgill~' 'rn!fC' ora] li][IDOl!l!l'S.

As, a result of the wo,T~d.w~d!espl.1Baid of HIV iofee'lion, the ~iUtlilJy rare KajlQ.si's sarcoma has become (j),nc the of mOSI ,commO[l types, <If ~m<li and i:s [he most cennaon
IiDr<lJ IlThlmollll" .in

.AIDS.h HIV

ilJ!fe£ti~

K.ap@si's

&aI,coma.:reqlUendy f p]s,<lUc m!' nsdele,
The
WDlQUf

SD'COma.[S m~ilt fr,eqm::1J!1: in male homOiSexlLials • .h ean aJlso<compJIDcare deep' iimmuIIIOlin])~r,~sion bllt l1l3i[]]y in. Ihost who ;a:re "LA M. Inthese oolld~doos, Kapos~'s

appears in the mooili asa

pJI:I'P]i;sh

,directly or s«ooda<ry

~filhoug.b:t to. be of ",inlilllJ.r.l,gililil. ~i!tber i~the i!.llKlrl.wo'ikficlcOCY state.

Mi:c:tosropy

Kapoisi.·S sareema is a t1lImll)UII"of endolthdi:a] cells (as :sibJoWD. ~y the lIliurr1l:.e:r fur [9,(:lOOr VID) but these Jargely ~111.1!m.e <Ii spindle 'sharpe(Fig, 2m). Early Lesions consist afpro~ilferatiilllg capilhu.ries, uSI1,]~Uy id! mlIO.y w iafilatiIil:lIatory ,oeUs.. and dos.e[Yf\~el:ii1bl,e gcundatioll tissue, La~t:Jr there are trilbnJ&1I!l''OlilmBi-like jnteclilci:n.g bands of s.;pindl:e..sbrupedl mm.o:tJr cslls SUlrf(lWllIding, sl.i:t-]jJ;evessel lum_.ens or' ml,[lUlte romd lumens whem cut nil. cr·1lISlS.· se~tion(Fig, 2(4). Tbciolhmmartory element pj,1i)~5ive~y djsappcan~ U:J.e' tumou:r cells IiIcoome more fIlI~,oomo:rpbi.c mitosesbecome Dum.,erol.a.:s (.fig. 205). and In;temp!ll'Sedi :iI!r'c a:cman,giomaA.ik..e areas 'ilritih mOF:e b o]wi<lutS ·vasCl.lhr spaces, KaplOOi's s.a:I"I;(Ima has a

fig, 21M Kllposifs sarmma:. spildJe oililis al'1d1
IJi!InSl>'jj~J~
O!.Jt 1;'<!!O(:ui'ar pace9. ~

~

usuaUy fu1!:aA witkilfL 1 years

pOOIr' P[ogn(lS~S ]o.l\1DS
l!]If

and is dia,gn08~~ iirn::s,pooti.ve of

Oral

fihroSaHlOIIDI.5

are

~X.i.iCiPOO[l.illny

rare, Thepeek Ilige

itlddem~e is probably between 35 <lind 55..They form Jirm 8;wdli:Qg5 wi.libJl1'IU di!!>l~llii;li."'t:: d[[I~l;;;lIl ft':~.u.lFC$.
Mi'Cl'O.scoj:!y

MaJjgD.aJiHtlbrob];J.ts~s form

d)el]l'S~ i.[Itc:r1<11~in.gb!ll]].'dlesof

mor'c iHCgWM, miNliS-Cll tleoomcme're freqoeat me. less coilagc[]J is preduced (~g. 2M). Mrusm~ may diev.d0;P IIHillY yClll's afit.c:r dliagmlis.:is and ug,ully fo:rmiIiltbi.e hm:g~..

Wlifl)rtIfi~ dOElg:::tt.edJ sp]m1]c-sl:JJa:pa"l cells with occ~£iorud m.][~8.IIld SOElIH: ollagen fi:mm.:ll1i:iOlIl.W'im ~ncH:a'l>in:g c dedi,i'"c:rc[lJti"!~!)[1 me 3!rr<lRg,cm:em of oelb becomes,

me

Rhabrlomy@s"rcom~~ are the most
sareoma found
~IlJ

CO!!ll!:llOIli

type

IllF

the lIIHmth8 of childlre.lll_ s!tJows elongatedl spindle-sbaped spaees

flig> ,007'

RlhaOOOI'l!tij\tllllal'OOI!l\31:

M:icwswpy

The m.'I'eoli3!1' ~e

l¥iPe.

,a.moor (jeU

frem tID:: wa[ls, ef wm.c-h h1l!fig oolIDJdI. r pear-shaped, o ~[kly staiaiag oeJl~ (Fi;g .. 2®,'f). EmhEyonmii i:b.ahdbmyoo.mm:as 3F:ll h]ghly
p]oomo[JIliLi.c
Wl~CS,"

cells wiimol1!t obv.wll'S<ly
cress-striatiens

ancl! (lOIIl:Sls,t of 3. ~OO8e"l!lIHl['guimdi

m.:Jss of

]denrttifiable features
;;aR

(JF.]g" Ill&)

fur mll~Dk oel[m.aFikier:s.

seen; :imm.wuu:ymelIL'emistty

lis be~p:ful

nc main
tOlilgue;

S~(:ef!llil" tbis ell.oee()ji.llIglliy rn:re mmom ,em:i.IJJ~~i:lkceUs

is: the

Mkt~

3II[I.ounwef: gLyco;gen andi,. fl1&jUEfI.dy, fart spaces, ,f.![1@IlS~JtIDJiatimlll ay be seen (Hg, 2)09)'lilT' ma!y be demonstrable m Q.IIlly specialstaias, .. by

urge. ffilffiJd, g!l'allJular

CQllIl9.in ta!l'ge

fig"2OOI RkiM~iTComa:

pleomcnphic

~

variaars r'~'LIh from the M:age of dev,e]opme'JlL( of die lympoocyte Ilmde:l'gOiiOg ilill!O,p]ilif>llc c!l!lalil;g.e. The cell of origio of Hodgkin"s disease ]S i.I:I1ct!!'lain ~llJ( may berne monocyte Or 'f lympll.oC)!'te. Lymp1ri,om:asWillnl~uJtlidyHoogkilil'~ J][M:as.>e) an: ran: in memi'IIIm, fmr more oommQ'Bly 3fft'i~1li:o:g Il:e,rvica]
lympillLude!.', but are oom;iik[afuly :mo,u: n~ul::lJJ~ili:!!, seen ill p;lIriCIIllS with. Al0S. In the ID_OUlI:!b they maybe the pDlIIIl3ill'Y lesion or tirepre:seutil[J:g feature of ~'l:miIm_rod

il:ympllilOmall coraprise Hodlgll;;]ll'~,dcUi!Cli&e and lilQiOMod,giki:m's lym~hjJm::t. NoOtI-Hoogkin's ]~(ln]Jliiomlli U81l1a]]y.8im(;s firuJ1Il.1B:lympl:iocyn:s and the di.lIe:rem

~.

Mmo.wll'jiY

l.ym.Jll!lOm.acs are one oflllile mest di:ffic:llit:neas of hillwJ<I!libo]ogy" <ItS ]'ell!ecwed by tile mllny classlfieations. The esseudal iffl'2lU!re_:isproli.f,eil"1liti~n. of ]Yn1p.hl:!!cyIe~ ciillihe:r diEfusely (F:ii:g.2:HII') 0]" with a fnUi.C1!Il1Erp-attcHlJ. Al::oonlilil:g~o the type. liliIe1-ymphocyiles r:J!ng:efrom large [mm.aItl:l[1C lympbolb1asw tn sma]l mature eells OF ~IJlWlWlobla5ls. {Hg" 212), .M.oIl.ooloEa]im[]!ll!WO.i!!~ebwilil
prodillCllionlIDay' be detected, Sl!llTOWldi:ng: tis.sl]csm.ay be illvmj):cd (f:ig" iU).lli:Iodgkin's disease is retIl3lrlruhk:fur me \'<f![loty ,of cellspresens, ilIlclmuli!lllg ly.mplilocytc~> 1rLil;1li.o~yIICll, osi:nQ]:!i]i1:i]s <lEd. Rood-Soo[!llIberg cells, The o Iatrer 3l"ebFge cel]s w:im aJ symm.e1Jl:;1ca] (:m]!l'[1o[.jjmag,c)

parr 'of ]n:ge\l\esicll]~a1tedlJJl]cle,].

fl'WJ~I:,(UM

pm~

The JlFll'g[lJooisof non·,Uo dgkin's ]y.mp:hom<l. 'iaFie.s ;rcoord!il!lg to the lirill-Mlogical type and plliniclliladr~o the ~'UI,geof de¥e]ill[pmentwfum dI.e1ected,.Hod:gk:i!!l·;~ dI~ooase if
rca501ILaJhly-~oC'.a]~zedi respeads .olileIl!Ioiherapy. to iradiot!I:JJerapy <l!ndll'or

l~igrnel1rtednaevil
The!Jt:,~~[ as a![i:-35 which rn:Cl;g.~fmm bfaish-beewn maeales >e$embling amalgam tauo.ns to esrensive b]ac'k plaq)ll,eSO, u;suaJ!ly OD. the liDailliuehfmsooj'lY Tille ,i:gme!llt cells {mc]aD!Xyr~) C3;!llile ]DtmaJe:;m.a] (Will he g.ubmuoosm OOlllilo::(~ .. e tissue] {Fig. 2]3)~or ( )ilfidiooal. {clusters of melanocytes projecting fr,em tll.e cpiitliteliiomesemC"Hyma] j uncuen into the lllBdc,dyil'ig; corium) (Filll- 2[4), IIp,cari:ng [(I, dl'Ql).,00w.1lI fEamrne cpimelium-ln adults juneticna] activi.ty is suggesdve of dcvclopmei!'lt of m:d~gmamt melanoma. ('..ampoulild naevi show::i combinatioo ofilmtb festuees,

MlaUgnant

liI1,elal(I'IDI

Ora] mail.~gtImliJ[ melanomas:m:: mit and we ofreJil. L~ befo",l: being netieed, Amcl.3inoti.e me!mlol]lll1s appear :as [l00di<S:h areas '01" [I00U]es. Oral melaaomes a!£C lllSIJjiilly ],OCliJpittd late and the prognosis ~s,therefol!c ~m. Tbe ~ mcidem~e is at age 40-6.0 }'eru:8,.

AI~

The £cam!¢> can ,indu.de: • intracpitheHaI me:iallocytC!l, l}'PicaUy wIth deat halos muod!mem '. i1WCiIion:ala~tjovi1y with mclan(l(;.}'TeG in br~ clear areas widtin aad dmpp'in,g :from the b_ ~ayc:J[ .. pr;ij}]ife:£'lItio,n,of meLanoc:y;tcs ~u tile '&uifuJ muco~
'OOI[!lJiwt]VC

ti ssue, and

be. ~[]solid sheers, rounded, clrclJ!llil&C.ri!bedCillo,u!p!l0[" in fascieles (Fig- lIS}. f'igmelu spilil!i!lJ]~s:ba~d
CIlIi!

Maliglil:n:l~. mellacl'locytes.:range ~o sli:a:pe from

110Il1Ud.

W

may be dense or be !nvi:s~b,lc willtnollll S@ecia] staining,

Amalgam tattoo
CLiiniclill]y. tattoos are by fiff the mills!: commO[l ~esia[ls HistOlogicaUy~ dlel amalgam is ... SOCD as bLadJ: particles or lar,gt:!"masses lying in the cOWl~dve tissue, Ereijjucntiy with ~Q f'iJln:e:ignbody [ICllCt~0ln (Fi.g:. 2~6), Biopsy is 'l!I$uaHy reqllired! 'lO esclnde Ml alIrly melanoma. alilil!gam

oraI ~]gmc[ued

I~. :215 Malignalid rnIlJatllllim: pigiiimtoo !Spi~d1Mh~mdiln~. -

117'

Cl.iim~ ~pr.em."am:;e$are variablle; tme l"llunO'ilf :is u!>'illal~y S~1l. oa the darsum ef the 10i:lig1!U!_ Adul(s between {he ages, of 3()-6{J years are afftiCled_ iW'iictamifljJ'

Two clllu'acterilitic {eamrcsare:

.' ]lI&¢Udioep:i.tfu::]iomal{lI.]S hypeltllas~a ~f. {he 0veEilying 'epimeljum (Fig. 217) '. gIattulac ,ceUllr,cplad!llg muscle fibres (fi;s 2]8, &: 2]9)_ Th.c ep~t!hel:iWiJI may dosely rese!l:lble. Ciii'd!l(Mlil3l btU lacks ciUU]:il/r,atyp:i:a. Cel1s with eearse eosinophiJ!ic graElu]cs appe!ll' to merge wiili. musde fibres, Positive staining for $... l}{l! protein and neurone ®]lIccij,c enelase l S1Uggesta lleurQ~ o:rigill.
r

.,

Tret!ffl:Ilc'fl~ Oimplcl.t: ex.cisiQIJi s curati!ie. i

G~anularrce.II'e'pu~i,sof '~hel ewborn n

l[roongeli(tall,eIPldis,

Thi.s soft.•rounded swcUin:g may mtdy be found 011 the aJ.v>eoiar ridge of W1flOWl.res,_The lilpJile:r ia:w is uS'IlaUy afl'ecled and most ,arc in femaLemf:anm_

M:icrosoop_v

C1:o$e-'p13ili~ .gt:all.nlm: cells lul'.v€ Jlrom'il!lEmt cell membranes. Thegranu.w cel.lssltll!inwith myogenic markers ~I>.g" myos~D.and actin) btu Hot fur S-IOO pro~ein;, 1h~ aze probably Qifm.esc:m:hymal origin._ The surrol,md.ing epidlildiwn is lat aicdl.acks pseudoopiili.elioonS:iflll.S hyperplasia.

IiIg.,21!1' rillJlllajf~lIllm100J: G
pseoo~lDIJtgu;: I'JllS'tollOO

~Iasi!l

wilh !Celli

!!rilli] _r 'tUmourteIl51b~alh.

lfig. 119 Grll1iA!lar oeI tllllJl()ur~ graill.l'.:lf t_r ¢'elll> 1llef!J1ng ..mn flllJ51i1e fibre>.

,211 I Sailliva,ryglandl tumoars
PI eo:mIQI~p-hi:cade!nolin a
This is me mo:!it cemmnn type of 8a1.i.v:~ry mmOli.lf tiUt forms '1),llly "DOil.l 40% of iEua-Ol!'alsa]iv9!ry g18iilld tumeurs, Typicilll sires Me pa]a!ie~li])o aadbeccal glands, l'tficl'~PlIenl]"!orphic .a.de[ltml.3isform frem epithelial and myoepi.the1ial eells, My,m:pitlielial. (lells U:Ilfi(P'm he

['ieli.aJblyr,ecagn:i.a:d by light microscopy btu may 'be seen a.. !)l_;Ii!1dle~dl3pcd. byal.ine (p~a.slil]acytoid) or dear cells .. s Th,e:y csn be idlenuified by imml!!nQ~u!dnillig poo;ilivcJly with. both c@itl:Jidia[ andmuscle cell mark.ei:S. MYOe]Jiin.li.'diid cd.~s preduee t:l:le C~JIiLIiIW1.i!i'C bSSIIl!L': stru.ClLllJrCl; i:n p1.eo.mo:rpn ic adeaomas a~ a result of their mlilJupotcmiaJ ~)fopertie;§i.. Higib[y wr.iable panemsare seen even within
ind~v[diWlI
tUID.OIml

., duei-Iike structures (Fi.g_ .221) • sheers 'Olf ~maU. ciLaJ'll:: ifj?itlleUiI cdis

CFig- 2:2Ilr), CommQIlI

features

include:

"9- 220 Flleornofi]j!hi!;adeooma; typical mixild pOinem,

Fig, Hli

evrno!pllic adeoolrnJ;tubul<!T

M(;tur8S ..

• 'SQ_Ua:lnClUS mc:~arplasia and lrerrnin !"Of:ilIi~llO[l

(Fig, 212)

• basophUk macoid areas, sometimes furming the bllU<; 'Ilhhe tumour (Fig. 223) e cartilage (F~g.224.•p. i24) and, IXl;tItdiomalil.y;bOOlC • fibrob.last-like ElIYrep.itb elial s:piod le ce lils. e 'pla®llilllC}rlQi.dJ'!hY3~i.[le HllYOe'pi.tl'lel.i~dc.e]ls (Fig. 225,

r-.li-t).

IFig. 2:2:2. IPleolillOrplni;:aden(lfJla: 5qUi!mGU!i
fI1IIltiipl:asia,.

fig. W IPleomo~·
ll'f'lli!!.

ade1l0mli: myxOm(!ltous.

'lil11

There is a lfibr-ous capn1e,

th rough dle capsule tissues (Fig, ,226). Phl~

w:iiiliOllU

but the [JUID(llllI 0ftelJl eNtt[lds lllvadi[l!g Sl!!frolIlHlii I]g

Pleemorphle adeaosaa Is slO1ill'-glr'l)w:ing and ibenign bUl can uudergo malig;n:mt dla[l~e (see p, ] 29, Care:'noma in pleomorphic adeneme), 1I.!>llal1'y afte'r DiiWy y:eQjiS., Cal"cimlma em then be f>'een,adjacentl!) 'typical l:I~eo<milrpbi.t:a_dieIllJlma I:GmpGllIenl;:; :in the same tumour, ('.omplete eacision is essei:'itia!.:ltld Cl]fQti IIC. hCOiiqIlkt.e excision t'YJ:i,:icaUy leads IO mwltinmllllla:r gr,\1lwtlI IliDd i!lJCiF.easedfisk oil'ma!.igm!iDlt ,cJUI:Jil.,gc. ecurrence R of plevmo.rphic adenoraas 00!i1l!~1:l! f£o(lim:

T:rmtm'!!1iI

• :smgjea]

diffic"Ulllli,esof iI'mlrnJ'8!l;

cspecimUy from

the

P!l!COtil!!l [md g • ' tx~,e:ns:iOili, the rom(!UI(' ilirolllgb the capsule of .. sccdJin,g of spill 'tWillflUr cc'][s ~tmothe lncision (due m aUl:ilIIilp,wd enucleauon), Je!l'ding tu .mIlL[~nodlutgr recunell('e:!i (Fi8.Z2.1). Pi.eomo,rphi,c 9Idienomas are flOt ,i.Q iDially 1ll'lIll.tinodUllar.

FigJ.Z24. fi'toomDiphtc a!leliiomllJ: cartilage 'tIitItl1!t"~aOOli .

fig> ,ZZ6 P1eOOiO!lPbie iildenomal infiitr,aIDg IhecapruJe.,

fi'g. 227 ~rphlt:
rl!(UliIlllltll"S_

adenoma: trillJl1ioodular

Mo:nolflorp hie acie'lurm(ll!5
These haw; :I. l!In:i:iurmp<tuenJl 'ofIen (~f U'al~ecl.lJla!1' 011' dh!IClul.arpatteru (FigS z~:s&:: i:29) and ]ad;:: the
oo.lJJ[]Jooti!vc
U55iLC

Co.rn4l0.D!el!I.($ of pieornorp.n
~'IJib'typ.i:$.

ic adeneme,

There

3![C'

se..eral

W'arithhiJ'stununu ~Arilelolymphlo.;a)1
Aden!lll}f.l[]!phomas [)Urn) abo.1!l1i:ijJ}D of :S3~iv.azy glaad l runlOl!I:fS but ¥.i:llOUilIilly all are in lih,e ]JI'.lIHltiirli gJatldi f1im~

about 5% are hllate[;al InrnNJ.l'3J glands M'C ]Joo~bab]y .Iii!ever a.ffernd!. This (I]mOI.]!f is, mootlY!.iClt.':D in m1.dd~e-Qge
and typicall}' fmms
ill 50h

or cyst.]i[kjc mass ][1 'the Jower

po]e of the paretid,

Mkmu"'PY

The two oom~O'lIiBiits am gland!lJ!l:3]' e:lJ(i~cl]l!I.m and. Iymphoiid tiSSIIL> (F]g,. ;nO). "f.a]~,.c(]I]lJlI]]mt" e@~;il1oph.i~i:c fip]!tlldial eells {Fig. ;Un 51l1IIDlI![I(1 iIIn(~prouude into, cystic spaces and {lO"'~[ l}'mrp.iI:J!)~d tissue 'l);Il~~sdrigf a s.mail.llympbJocy~t":l> and, uSIl,a]ly"ge:rmi .. ~1centres, "{heHI.l!!IIl®:wr.is lJCJ![i;gIJJ.

n~. 29 2
lip..

liubhlbr rnooornOfphie ,ll.dmDmIIIl of

"Q.~1 Adil:mj)lyl1'lph~; ool1llponern.

~irlle!io;;l

125

M ucoeipider.,oi:d Icarl1ci.li1Ioma
M1lI.(locpiili::[lEIuid. card~om!!! is fd!l!d.vel.ybf'n:ign in wme cases IilIut '~[1 ~dlilli'l'e like IltypiC'-[ ~il'l!ll\ma, It f®HJ[:S co:mmOIILly ~n the :prua[.e. Putielll[s· lire usu.aftl.ymiddleagcrlJor older . .M£CI:O~py

1!J:e:lLr]y 10% l1iintn'li"oiiilil saliv,azy gland.

tuJll'!Qllrs; most

The two eamponents are 1i:t1rge, pale, mucu,s"Se.'Cr>e1ing iJe]~s,wil:i,eJIt t~icailly S1lIliR1i!l.lIilO! ]m'ge Or small cysd.e ®IacBS (figs 132 &: 233),:llTIld slu:cts of qJ~(Ie1"m®~d Oe'~18Less we']l d!iff~rel'lualfld tumaues tend ~uKf>emble ~lI!:l.lIiHiI1lIl1JS eareiuemas but :f~rthe pu:l>CIlce ·o!l" ()~~l oo~i(!l'Ial .MUC01!.S ee']ls (:F.i.:g.234.),l3ehavj,ull!r is not reUalm]yret1lcted ~Q m.icrm;co:po:icappearancesand oC)'ilo:Jiogic;lli)' fu~IILi:g1Ji tumoues ClIlJJ fue lU'f3S_lVC (l~ig~ .B~).
Wide
,~dSllllll

T:r.ealmetli

is re'llil!li:red.

fig, 29:9,IMilocoe~errnQidl cardncliT1~ In ...al!fng , tJelle.

forms Mia"osc~

mtJy al:l®l!H 1% ofUn1tra·o~alJ salivary gl!aJllclJ

mlQI(lI,[lf\'l,_

TY'pi~l.y a more or less uniform pa:trem of]M,ge,d:![.ikly ~~)hiLk: oe]~~ w>idlgmll!ll!~arc:yllIlr[as.m (Fig, 23:5) resemblingserous ac.in;a:; cells, Ohe.1!l nnnour eells are in ~:he~w,w~t:hl(ll!~o'b""jCl'lliS orgall!~za!d~1!lbut OCe<lsi.QEJ;lIUy ][]I
:m acil1:!!1f Il!rm!t]Jgeir:ne'~t_

TI'ea;(;mcn~ and

Wid.e

'el!dSiOI!

SI]Ql!Iid

'he' oOO:rnt!i'l1e, but

the

be.[b;1ll\l'~oll![15 ]

.Prognom

llIf.1Tl"eliably .P"'ed:uCtsi1~e fiml'll h~sitD.]ogical ,~~ncc:; and e~!'IJ ~lhl:uffelllelTl.tratted rnrnlllU's. em. be ]El'l'asl!vc,

fii5l.:B4 MllI:oeglidE'llT1loidl areirncrna: ~rtv c !!frffarantiaLOO.

Am'9l1l1o:idleystic ear'Ciin Ol1nal
Fmms U% Oil mU':a-<Onll $~jVMY[llMd. Miel'PSe~py
l:umOllUlJ,

Colls:isvs of 8m2~1,_, dadr; cells wid!. duc~.-li~e 'l1Io1eg' in :;'I
cribriool:'llil (SwillS8 eheese) (Pi!,: •.2:3>6) )[ La~e-]]1\)e ~aiD:e[,lil~ I o:fu:i!l wlrlib byaliRJe ,orm~dDlo1Jls. ,C'haltlg>e in [lil.t 81:OO:1lll8. It hasa strOOlg tendency tnperine1dm1 I:llilO';i;fi;lGIl (F~g. 137) and sprelid. T1IDeUImOlll! isslow-gruww,!! fum ,w:f!iciLlh 10 CN:.c:iu: as

tbe borders IIDCiU-dt:!IllIlCd. Mc.t3SIa:ses. radical acision is aeeded,

dmrdoiP

late

and

form a:liJOUlt [2% OE :iJilb'9:-@:!'9J[ sal~lr.Iry gla[Jj(l tl!IlTIJ:(lurs,. 3[](11ilIl3~[JJIy affeLCt~e over ,{!j0s..

Mkr~Wcl['-G1i:ffi::ul!lliatcd (F'I:g. 238) o:r

:fmm gll~[Id1ul.ar ,a'U.e:m cyl>[:!; wiirtib. papi!Um'Y :i:m~o.wt:bJs" Less-welld!l:IJ:e["elillL:illCdi tumoars :sliJow greater ClIl[h.I];)![
WEIlQ1!IF.S.

1IFi!ll.Z3JMEflDid ~·1iccan::inolm; pEfineuril1
in ...asien,

[pleomo:rphl:im.
eaninOlJillil

U[lJdJiffen:ilJJl[l1l·od
M'C.

ca:rci!I!lO'l!l!t:ll5aJ!lcl.s~u3moliSce:n
:lLilJJd.

rare

~en mostil:ym

t:litee]di&r.J!y ..

.Pl!oomorpbic i3.dealQma U!1l l,I:.!Hi~go maJilgruMu dlu:!!Il!ge} usually a.t1ter ~'~~rs (!If :sl(l'W~wdrt,. in WC1!.lrrt:l1IceS and! if! o/]d!.fihrotluc "sC"~ed) W:ll101.!ln!. (Fige 1'9'~ Cfl£ditlnm:lll ~il ~I.e~m,(lrphk !l!de:.n(lID;aC(I~ri8es :IlIoom 7% of sa1iwry 1illmOIil[S >of rnrn.®:r ,gll.a:llU.i;~but up 10 3O'JiO (lif s!lIblin[lU!a]
gl9!lJi(l.turn(ll.!:i$.

Mia:-rusoopy

MaJ!~gliLa:n.t dl::llI.'Igt is u;s'UJaUy :9,denocS!E:innm:lll (Flg~ 239) .en!!'IillIldi.fr.errellliliia~d C9Jrdl'l(a]'lla with :i:mV.a,sjOll and fieslulmctiOlJl o.1f~l.I.r.roll!ndling St:~'1I;u':l\!!m, bl!!,[ ebewbe;!)€: fearhl[1e;s. of or.iginail. rJelIIl1'l1l.olflh~~ !I!~e:!l(lln!!.l)er~~~l.

Ji:29

22 I Salivalry giand cyst.s lind

Ch reale non"ispecilfic silillhllden lfls
SaUv81ry'glland ~cysts,
MncoU!i 'e:ldrnv,asardOIl cy.51JB '~ml[ll:illOceJ]e5) .M.ml! o©mmo:n '[ype of soft iti:ssue ~ysts. M.iiI1ot gU:lHis, ,espe-ciaJ1~Y'l1'f the t~p,are affected.

Ae-l~

Probably mainly result from i.njll.ry to the diu.cil;~e8dillg to leakag'e and fOnDilillOft of J;l(I(l~s sa1iva in Qveriyj ng of oofi tl..SSHeS witb. ilJlfilamm8(00'),' reaetien (Fig'. 1-40'). Coolesc-e!iloe of peolsef 'sali a Jeads WI ilifi' fonnatiea of 8 cyst with ~~nj_[Ig of6ibrobiasls and 'OOIJ![l.'I'e>8edi (ibm us tissue (FiGS 241 & 242).

Sab-VliiiY f!ete~ri;jilR cysbi Rare ."ada-iu of ml!lC&ele produccd by duct '(lbstmttlolil., feIDIllilrlg a, diokaUy similar lesion btu the cyst is Lined! ib-y &u.e.ned duct epithelium (Fig. 2:43).

1iISl-,24!(1el:~~,oo-~ mutlO!:deal'ldl .macbed :s@liwll'j' _U!!.

Fi$,,2,4'1 E.idJ!:l'IIesaiiDnmwcoc:de: Collnew,.e
msue WrII ~3bo1;\i!i]; lliiI~ciIi- aiitllijlIld-lade:fI h'laCl(lph<l9e.9, in contelllli.

'Clhlr,omie In,ono\S,pe ciificsi a1ladeliilitiis
A!l1wJbgy' Commonly a consequence ef ,oIilSlH.lcLlOIii to sal ivary secretien, sometimes :ill ,iilSiSOClaJt]OOIJi wilth calculus formatien, Scattered, 1llli~i1~Y perlidlnctaJ infilltratio:[JJ by eheonlc i[][fLammalmy oCelli!> diILatatio[lof duets, degenerafion of 3.cioi ;mtll ]m::r't3sing fibe,01ll8 replacement (f':ig. 244:, Jl' 13.4) 11£";; the q,;:bi8lnlc{'e.ris:ti,cfeatures.

Micn;m:,t)/':l'

131

RS-:242 Extr~r'l'iifSII1ioorflU!!lf!alI!!:: lihmus "'Ia'JI.

Fi®-,Z41 Saliwry muooU:H~ioo~: epi1ReliBlllming>

Sanva'ry Icalcll!Ili
OdatJi [onn uSlIaUyby ceacretien of calcium salls mu.nd!a nidus of Q~llic: matter, p<81licuhrl.y ][1 the $ubmandiitniLarg[al!.d_ Calculi may be mu!.tipiL:lwitbi.llilhe gland! OF oolil!.3ry and ln t:b€ dnct, Sj_~ad!elli1i.i5 willi dll.c~ ddatatiion is typically associated. Mm.5:wpj' C:;!J1c1.l!1i appear ciu.b~ ail, lamellared MIU£:(Ures or m.ultip~t:. COl:}cretio:ns which fu&e to furm 3 single: mass, The sUK<Dul'ldiLng duct epirhelium rna:y und.crll;u, squamous me[,aplas'ia(F~g.24)):m~ the 5W".rOl!llding tissue may be.

iio.f1ii1med.-

Sj,ogrreni':s syndlml1ile
mIlD.CC"lhl,e; Ii8Sl1e

H,ld

mia,ted diismders,

Sjogren's, syndrome comprises dr-y moudl.

dry cy,cs and dli.selIsc-w.uaJ[]Y rheuraaaoid anbiiids. SilCC8 svndlrome bas II.O associaeed connective (issue dliseas~ and differs i:lJJlhc .immuf:ll:llogi.cal findiil(l;tL The bej;]jgn IYRlphoopiilicl.i.al lesioa h. ttiJ.e same b.:imliogkalLy as SjOgren's. sYlldmmc" These c'ollditioml mainly affect women, U&-ua[J.y OV'CE )0.

Micm5j)~py

Infihra·~iorn:,@f s.alirvary tissue by Iym:pl:mcyres iiild p:lli~m:J.
cells is il:li~ti'!ny periidu.ctad (fij]_ 246). The infiltrate sprt3dis mnws:ros and lcarls to progreclisi.v,edestruedon of acini \:)l!H d.I!,l£.ts are mereresisram (Fig. 2..41). H"elilmally. unli}' Jymrphllll'las:m.acytic cells and islalJillls: of ibypeJpbstic duet e!pi[he]~QiIrn ('epLm},ocpilhdial islands') mlllY il"t:il'llli:!I.

The ]ympllOp]a<&ma.c:ytic infihrate remai.ns ccalined withiu rhe s~l:ivaJry Lobules and does not penetrate (he glllm.cl septa, Labi=d saJivary glands sibow clese OOJ;l'dlJ[ti.ilD.wi(b~he pmolidi changes. b1!leC]J,jm!l'uepidle~,i,ali .ishl]1~ an: rare-

I~II, :!;'u SjOgJI.,1"9, i!IiI1idriJnul: _tru~tiurn Ii'JI g1il1llcl ,ii.'tin~ 8nd c.pimVO£l'.Pihelial - lii!Ild5.

133

lI:ifi~O~~CilUy. gm!ll.~~Mli~ ~re £o.i::m, ['UlI.1,i[i,dedo.11ect:iom> c oIhi.s~iocyt.es. often wilh giant cells a'Sin ruberol]llilsiis. Cliiirlwly" howell£:r, "gramuloma' indl!ldes many clImll!ic infiammatllry' condiliom.s (e.g, 3fiicaID granuloma,. Wegener's gl'amw.oma, e1:~_)w!hicblad. granul,o.mas. hls[~ogkil]y.

luberel!lliosis
A!tt~

Tl.I.bC:H~u1ous O'.ralllftooFaul}B; seool'lda.ry m chcst infection, occasi.an.a]flysao in AIDS, patients, qylhe;rwl,s:e 'll'IT)' I3£'e" .M}'CQt:laetena 3I['C rarely fO'ulild wn '!!1m] lesions but 3[1C preSeJlit i:l'lspl!litll!llil."
DBEl[! Wcc:r wlrh o'lt"erbmg;iin,g edges (u1i"ID!!lly on dUISum ofnm:gu..c:) wiith tiUbe:rc,ulom, ,gnw.worn~ and Langih1lfni' glliant cells (!Figs 248 ,&, 24'!lI'j,

M,it;~

IFungal1 in~ections I[deep Imycoses)
Immllll[]OOllppliessedi and AIDS pat.iiemts De ~l!I!Soep[ilbLe' such as histtlp]a<SllDosis or ali:per:gill.o:!i,:ii~. Otlbelr 8ucb io1oo1liO[iS are common in Sood! .America. Man._ f1r'~:Hi1iloe al ]csiollis all.rome srnge.. m
to momy fungal h)fecti.ons

IJ!I:~ ..

Iig.249 T'ubi:rtulbuJii griil.., orna barneGlh
1

M~

SeveraJi of the mycq~es (ntil candidosis) prolinec granulomatous i1e8.ctiliUls more or less ~mbling 1tl!Iben:u.losis (Fig. 25(111). T~s:SUR: utms of the fulllguSj; f USllaJ]y spore forms or bypbae:, millY :sometimes be detec1t3bl£, blu iiJ$uS!Jly only wiith '~-pec:ial stains. Histoplamw capsul(!'.iwn lsunnsual in dllU: thespores, with cba:raCWl'irsti.c ha11)-1il\:e capiSu]c,. may be seen in H &: E sta~ned seeriens (Fig- 15 I),

IRI, 2iD H"l!ito.plasmcs['!i the roni:lll~~ or

langhans' 135

9itm cell and granuJomilL

Am.2S,1 Hkl_Wphmtc1' ~psulattIm: 5I.!liQllnded by halD-llle' capi!.!1e.

.~f:3

"N"e:iilfue:r :mYCI.'I$i.s a
hisloiogicllJ!Ly.

affumilie SI.'IFl tissues aathe angle of the i:~w> it ollly bm e:xreprioDlail]y mc{~Jy hrvQ!:ve.<i. diJe' ia'lYS.The eausarive orgamsm il; lli5uaUy At-rinm!J[YC!tt isN't!lii, a, filamentous
bacterium found

C1itlk,an!i', actinomyoosis mosr

nCf a

gtmulomatous

disease frei\l!Ient1r;'

in I1iCfm.a~ mouths.

The reason for ~lS

oecasional invasiun of (~S8!Je8 ~bl the immunocempetent peirllOEl s, unknown, but h is O(l'wincreasioglly rarely seen i in this group. MicrolUlW

Acti11vmycl1S imldii, ifit [ny;ules the [issues,

Pl'OdUCCl;

muhipie abscesses, There is :;up~:m:r,aIi(lI1, watl:! a central ooIQBY of Ilb,me:nIOUl! bacteria surrounded ~l'libmsis, iUidi 'Si1HI."Jell develop (Figs 15.2 & 1:53)_lnfla.mmaloiry reacticn aod fillroiis qrp]caUy fw lO Iocsl ize the illJectiolJl" w'h.ich, if llIum:.a~'cd, sp[le'.ad 8 dU'Ol!Igh rlIc t~~l,l~p:roducilJJg ml,dtiplt: sinuses. LyI1l1Ph. nodes arc liiO'1 ~1]!,10]ved!exiCept y d:iUI::Lextension of the mfection, b The diagnosis is cOllfinlledi by culture of pus, but is
un]ikelly to be
JM)S]l]VC

fibrotma'bste~ walll•

litlg,2!5ZAclinllllIl't~~i5; IQt;lIII!J~ wrth ~~r.l1 a:IIonv sUFromndedl hy OOi!llfl!lkiis. and

l!illh 2.53 ~Iim(llltly~i$:

di!lail ai oocterilll

oo\Dnv·

unless 'Sl!I'lpl:ll]fgranules"

(eclenies

of Actinomyces) arepresem,

Ae!iaf()D

UI1IUlOiWn_

,~s()dared- e8[pec1",lly m;gati .... reaction to tuberculin, c
H:lbr ~ynup'h.nedes 3l!l!m semetimes ~n~hel"l!ft ~nn~ arc ol'temsin sltes but almost 3.0.y tissue ean be affected, There is a predilection also for .~j~"'luy Tis~ue, es.-pCcllill.}f labial glands. Gingivai cn]3£grnu:m deve1fl['lS in some

,M~[Io:riimmmlOlogic311 d'e1'ei.."VS may be

I~lJrqkt!fJJ

cases.

MiCroscopy

Compact

h:istiocyric

ID.1! Iti~lleami. with

granulomas wi~hol.litcaseation, oflen giant cells Wig,. 2:54)-

DiaglWm

[)i~gl:loJii8is n®mdly dependesu Oil oorn1~i[l)ed Lalbordlm)' and clinical fl!Dmngl>, in p:artlou]ar,. evidence of
[pl!ilmonary involsemem,

biopsy

of affected

tMUC;

lP(Jf:lit~\!\eKvnm
converting

ra:ised! serum angiotc:n::>in cm:ym.e (AleE) levels,
I'iiQ_l!!i4 Sar~oh:l(lSis~ ~'I,gramul\!1ma MIiI
9i~n1~,

lc8~ or

Granulomaa are frequently of UlJik[]OWE 'otll se raroia,c:i:all ~mlldoma~osis') hut some may be reactians ~t:l,fum!
eompeneots.

A!I' ~

isOOIP,

1~l,

Claim':\! dimse of oral mw::lJOSiI

23 I Graolillomal1ll115: ,- ISeases

Ae'lioliogy \!1li~llI)wn. The disease (yp~C<!lIy causes g:ral:l;u](IIDa~l[lusin·l)ammartion of dle ilenm but ean in.vOlve· ma:rly otll,er sites including ~hemOlldl_, 0131
les-ioJ1~ in:dll(le ,oobD'le5t~mcp[()lif~ti():n and $rnn.mmeswCcr'3t:iO:IlI. ef the mucosa

Miau.!1iopy

S1!!l:lep'ithe1liali oedema. minor ebronici nffammanen and I.JslI.idl.y 8mail1.1ooiSc scattered ;granu1oma'!> eirdIer SJIJ~i'idal!ly Or' deeply (Fig. lSS) j)'. 13S~ &: Fig. 2.56).

NoJe:

MeU::e!l'SsoD.~ose:lJJtlmI s.yndlrome (facial or l:ilbla1

sweml'lg{, reeurrenc facial palsies and ~ssured tnngue) and cheilitis, grlrn.l!I~omailmmshow similar hlsroillgy. -

Nli(mne g,r,anul:oma s,yndro'me IUetha,lllrni:dUne
granll!cnn:a}1
These rare syndromes havre initial ntU1OJihiuy:nge-al. sympE(lmll ~eading;to midfacial destrueden 'of tissues and! a fa:l.id il'erm-inatloll.. The tw'OI m.ain causes are' W'egellcr's gr:an!.:domaros:is and -peripheraI T ceU Lylll)~homas.

Wq:eller's gfallluJil!lmatDsili
TypkaJ~y co'm:p.rIses ~1!1]o:m3W1jS nasa! il:l!ll::unmation, pu1monary alia renal Invelvemeat, p,]us"eccasianally, aJ cibuacreili:iistk ]ll!'o.lirera1tivcgi:ngiviills ("srrawbel:ry gums') or m.!Jcofjalll!l~ceratiilln. Microsoopicllil1y, tbere .is Ilecrot~zing artelFirtis wilIh giant cells {Fig- 257),wbich are sesnered '0:1' related 1IO the indlamed vessels, Gj[lgivllil biopsy shd)W~['Iggiaat cells may ;aUow eru-iJiy su.occssfw

cywr.oxic treatment,

lPe:ripbe;ral T ,~e.1Il ympibom'- S ~ Nasopb::ll1'I1geaJ T cell ~ymphomas

can produce mitial SyPIJptoms ~[Irusti[]gwsJit:ab~eH-om Wege![le:n gr:a.I]l]lnmatm:ls but, ocQis.iona1lly. enensro,n of tissue destructien

Mic,oos,OO]!liCllUy, (he cellulae picture' is h~bIy ploolllOl]llhicbl.u !.:eUs may be angioeemrie !Uli,l an,giodC:SU1lcdv,e WIld mimic ]Dfiamm_3tllF)' arteeltls, Ulttima'~eay" 8!1'stel:U_ic s~l'e::IJdis ]ik!c 'ID~H of ot'!!er jymp:bl)ma;,~_

peoduces

pahu9I1 ~le'rfuratiolJJ

andulceration,

me

139

24 I Miscellaneous, fiibroti,c conditions
lPirogr:essiive :systle:mie :$Cil'e:f\i)sis (selerodennaJ,
AetroJom.
A eenneetive tissue (.alll'lO~mm:lIiI:ne) disease procil1c:ing; p]'(!;:g:reS's~veibrosi~ IliDd s[ifte.ning of dre ~1I;iLD and vis-cera. f Limiil~aoniO:Ili opening ef the [lu:lIl!dband movc:nttlU of of the ~OQ;ul.e: nd Sjtiw'cn":s :SYBdronil~'may devclup. a i\n(Jllil.'ilI,dear'bodies an: present. Death :is 1!I!!ua]1yfoom renal 01' cardiae faihire,

MilTGlt:'opy'

Progressive fibrous 1i.hickeliljng of Sll!bmucosa cKl!.Cliding wttl and d,esrro,y:ing slIIptrficl,a] JI!!u~]e fihres. There is I)
peri ... soo[u ~ymphocy!.ic inliLttate (Fi.g~25M). a

iQnil~ sulbmucous filbrosis
Aetiolol.'Y Mlieets tbose from dIe Indian slIIbc-onru.ent and may be ]\clililro ItO Ar'CC1 nnt C:ht:Wing. btu [he aedO:logr is I!I.[Iccrtai:n.Ir is [lot 3IIJJ lliulloimnU.llle ,oonaitlo[l. Then: is inlettlSe,symmerri.c:i1.; 'nh.kk oo9ir,d"·]~l\i.e stiHim.i[lg of shes such ss til(: ~::d3tC:;cheeks. or lip, hut net ef the v~scefa er o1hcc pam (If tli.eootliy. Similar to scleeederma 'bu]:mnreintenseand pedv!lSro]9ir i.l!IifUmue (Fig- 2SiIJ). Sometimes
p.Ill'l!li:futy

Fiig> ,ZSlI Sc:lerodennJiii;$UOOl 1IC05a I fitJrosls wilh
p!lfMSOillar IvmphOt::l!'lie;nlLa!a. i

IIMcle

de5tru~on in the ron9~e' <I~d

MU1"J!JI.rcopy

'epitllelial dyspias:La; which is

iPFClDailignsm.

lacking there is

IFig.299 Oral rubm1!loous fibrosis: deeper cxt~lIIsioo s~nOOerrnil.

oHibK!!lis

aod rn~le

OO:!i1JrUClOOIlthan in

1411

25 I IHIV iinfeltio,n ,an d AJIDS
Hrun!!!!:'!!imnn.I.Doo.elicicnt;l' virus (UI\f) vartimL:l.Ii'Iy
jillfecrs and destroys T hc'lpc:r (CD4) lympbocytes. Ieading (iIiISua.1~y)top:mg;rc:sslve1y mOl\e ~I)e defects. p~l1iO!lli!rly of ce!l-mcrlri:u.od imml.!lilility aad e\relJJrua11y. gross lmmunedefieieney, Dea'w :I_S lIsuLly due to o,v]}Ortl,lIfJ.i.stk inJ6crioD but lymp:ho:mas, aJnd K~po-s:i'~, 5arooma (see p, ]11) 3!I'C also O~1D![]jJoili. eNS oens ,il.1!e ail:.io

dili',t;(dy ~nVQI\l\ed cranial neave lesions may result, and

'iHa iiry" ~e~iko'pl!a'kjal
swfam:llong ~anenill:il)rders of the toll!gHC. Hailr-Wke protrusions of keratin an: iI1!r'cly seen .. M:ic:rosc9PY
Hyperke:ratos:is with ridged S'IU'-mce (Fig. 160); oftm Ql1Il{D![l]zOOby C. a.ib.iwm orbacteria . .Pi. zone ofko:ilocYla (ltacllolatecl!omd ba11oo:ned, [:Iric-lie cells willi ~yl\;noli(: [IudL:j)~, ~CC:IJI ill ~he priC:kle -cell Iayer (fig, .216])..
Epstein-Barr lig. ~ Hally lau.tia,
i'nfi:lIl1mBIDIy

USillIIUY painless, sof~ wb~te' pbql1e with OOllU!PUed

inrfillr.E.te ~h,

iI Hill nmil'lttioo:M~E>lI. ypilu,alIllie h

:l>lJIrfde~.

~~nll;~

andsc:all1y

",im'usc:a:psid

Srl'lJitig:ellJis identifiable .

iii] the

niill:::lcil (Fig. 216,2).

~gn.om

Th.CJi''il

is, nil evidence gO%of these patieeus

{Ii prernatigl131Dtpotential but dev,elop AIDS. withiilJJ .3 yearS,

over

Other fyjpiical onlll mani,.estations,
'" 'O!!nd~dmis(:my 1typc), '. HW g,ingi!<.itis pcriodountis, ,mr
'. Necro[i:d[lg
l!I]oerollVC gingiv:itis. .. Ka,]!losjj'sf09JOCo:mll 1l!1lJdl.lymW~IOI!I:nl:S.

Less [!I!\,eq_llent ce: a

'. atypit:aiI.1idccraLiQJils, '.' llympiooopitlu:llia] lesions, (If 8aHv;ary glands .. infeeticns by he:q;les si,1I1lple~(If varicella-zoster, ,c}rtomcg>tJoVlrIlS orHlmll3fl papillomsvirus .. deep liJyt{'S~,. See pretedlin.!:l ~3g:es for die patl:lO]ogy of these lesions,
Fij9.,~S'1Hiliil"j'I!eljJkopl~kiiil:; h~rpril~~ ~'IMl]ijm with blilClit'l(lIis Ihamootn,lbli, surfilli!le, lfig,. 2$.~ ~iIy lelJlkQpiam ~IpGs;iti!.re51!1inilg for I!:pstEfi-Ban !{,jms ,c:ap;sid i!n'i~n.

Iindex
l'I!boo=

p;:.rioooomol (l"Il~r'i!1),;l i,.t\!
39, 4~

];lull'> 1,.~ l\C:llIl,tbflll.Y!li~. Tl, Ii!! AGlJl!ltlJ.oo:n~ amclj!iblasbo:[])II,

lI.Ql1ntb.~ ~3, :::4 Ao;.i:n.lo.: ~,11 1,J'",";.n",.,~,1 n, 128 A"rilLi.'I'~yoMi~, 1:11,B8 J'I...k.nClCruCi_ma, 129, Ull A.,ji~.Il.ai.dI ).liie ~!DQma, C ]151, 130 Aikm~hmn~ ~;lS,IZl'l Arn-,nmna, U~-~, 12~ mon'3mo!-,;1l"io:, h25, 126
iJliOII!~~~i']j~j~, L21-4 ,l:l:Imooma ..ie, 1,2:9 IIdc!l}Q[l!Iataid OOo:Otogt'llir l.IEIin'lrul,4:S, 40,

Cf~IN

C!h~bi~ru,6~, ,64 m~ndrol1il!3 • .53 ostro-,.53 Cldl'li, pi;!~i,,.J~"I"1 o::ySI, 17, 13: ('''''':~tl t[iLI .::p[J]jd~,1 ]9 ('..<1nll.0ct:i~e: rds,smA:: tumours, H,5 -10 CrIlII!O.·~ diseaae, i351, 1<W
~j I, B2 Cy!'i[K: ClIrdl!lO!l1llIl"~;i'tnoid.ll~,

Fi.h .. _"""",,!, H 3, 114
FiJb~ll:Sis, 141.-.2.

.FililwLL:I. d.VSpLasia, 61.,61 familia.'l, 63, 64 l;ibroo.sl!lOdal~ 101 , Wi:
fQjli~liIr·lImo:>Ml~toma. 3'9, ~ Friel io",~1 ~J;""~[J<Ii~, Sl,.1j8 Fut:l:g::ll.,01fi!cI:L"'~!i., ..,0 M~~

]a';l,'-",se« .a.1'ro llolli~' ~.~~,l5-38. _. ~D~ ~1;!1I1 ~IIU~"IJ .... r> c:tmr3l, }1, 'S!! W 11,,,1,, eu'-'1';':; M~,...,c;,::DIOdCllrul:ll mrnDuroJ!lf. io. iI'IJim~',4~t4(j.
K"pio.:lii~~ilI~

j,;,yw, ~S 3~,<l2 :""Ui.-:llry t1.:ti'ldl,

:1:lAj

G~nl o;<;!lU t;!i1'!til;, 103. U~ Gi;,,,r Dell gr.,m,"L.,onq ...J i"-,t:~1J1i:B1, .57,58
Girl&i.~a .IlorDul, 15',.16 :==iQIl.23,24·

Keratlaizadon, orrhe-, 3], 32 K=[I)~'!it.do:Iiw~):'lIi" H-~ a .limItD51:li,IH..:9f,
La!J;g<:rhans" 'i:dllli~uCl!Z)"t0:5i5, 5>9,.00 L!:iODl)'O:IlIIll. vascutar, 1.00

111-11

D!'nu~ caries, 3-~ H!l1.T~I!i!I,
D=~rUY~~"i'l>l!<' [Jo:,iLLl[1<;'; ~ ~

.;:aries, ~; 5, ,6
~t'f,!~iO:lII!,.B

~"''$~'c:., 36, A~ 3:5. "'Till"l(jg~c,;!~ ..lDlpNf«tll:, 1.2Al'lllpl1'[:artiOJ!l.n~[mna, HIS. 1,06 AO.c:W:YOIilJRll:>I:I~ ~~~, :17, 38 fJ;pb~h~,=> TCLJli.fiI'1!!IU; 71.-2
I\p,ieal ~¥riodlooIlli&. U-ll Atroplili: (mill) kii(lM, n,74 IImroplhy,~iI!h~al,83 ,\ttFi!li~liI, ~, (j

AIDS 3lldl HEV iD!:eclloo, U 1,143-4 AmIII!;Bm latloo, U7,. 118 iI:J:mi1.ohlu~i~6~WJIl<!,47', 4~ ~ool~~~()rn~ 3:5,36, .3&-42

Dcmino.~nJ:!;~~
IXm=

imp!!d~1I,

.1, Z

'~I:ID.~IUII~

ilr..l"1l!~ma associated M.th. 10~ IDi~ooLd.l,llpllS ~l'llihl.~tl)l;'II~ n l)mg-;ll~iat>cdl ~I'PI~~", .2:3,2,4 ~tJ:ir.!twi~ (cl~~pfui~1;B,.9'3-4 Dys"l!:!si:l, S~, 9~-4, '97 :Eiirroo:'!I •. f~l1 F!Lbroo.'5dyGpl~ia &.iBml:! ~nli:'>, ~. Eo.osi.. ~,plililiL: r;!r.![l1lV~ma,:59',00 E:i,)'lho::!jatQ!!ilMlqC'Jli~ wmmJ[, gj;;i{)'i:!!!;;!, 4:!.44 .EpiJt!l!~IiII1D. in !iPi~IJ':ri,Jd"'i1,~is, 11, I:;! ~~!'< .• ~l.y, 3. & ~IYrI,i;ll (.:I~J:lla~i3), 9~-<l; 9'1 in cliIllIllk[llcrtodllIlltltiG, is, ;lID qrs~ 'MUlW[ liini:og 'l>J. 17-

91

o,:;mdiJlo ...i~ "!lllocia:[.Cdi VI'.~[1l,

1,I11;I;r.J1.i¥~ L5, 16 clirn<1io::, ~.. - i:P; GLOOuloruaocLllary q~[.~~ Gob1£[ cells, c~r, 17, 1=0 Grmula:r eakiEk'illjll!ll 'ilifplJlp.diifu5.::, Granular ~d1J1IJne&!)MII~~UiDllJ,}9', 42 Gr.l"lJhr c..ll ~!,llil: IJf ~t;!"'oom,i]9 'Grcanu~a:r 001 rurnau" H ~', Drn
';'~I'tl:

G-m~i'lit~s, 1:5 -·1

~~lliDg. B. 2:4
II

'}

GrnnlJlama,135

:(;8j,n,

r J~ 61:1111 i.a, 'I]YI:~h.IoJI1!1.rllllCYlj~~ lA:~.1~~~bk~a, ss 2~eaudidal, 9 U,92 hmp.f, 14,3, 144 5tPfuilitit:, ~7. ss Lichen planus, 73-~· LilitmlJ"", ~(19 Li:p=~com31, 109 Lupus 'Cf},h~ma[MIl!i, 7:1-4 l;,1lIP~' 100', II!!!
Lf'11Ph_-\!IIJ!~

Leuerer-Si .... di~=,!;I ,~ ~

acute, .23~.24

iliamc~]j, c~;JUI'3I,ofj~ kthaill!Didlic.e,. 13~. 140

U .l:!nl""i'I',1OJ ~inQ.phi:L;':, W.fi.I!I

adeno-, !2~ ~26 T-ttUqlltri¢u~;'iI,
ll"l1"Ll~

n S-I

~

139,140

57, Soil Mail ignam
(~.l

Ibru:ria
B35al~U

"..rri~. ,,;,<1,

1" 4·, :S, is il€rIlIodomii i~fi:cIiDl1, ]5- 1:9
ami!'kiIi1-J:li;5.tI!iJ!Ila.~g,

~.k,l®l,]i1)4 Gr.m;~IiJI!l<lL'.m~ &i=im, U:>-40

Hu:mQ<.ImII.I!I1, lO8 H.jry I~,-,~~~.i<l" 14~, '~44
Hand-s.::b1lI[l(!i'-4]lri~,i;lli:i !'I~ ro:iICl' of II'1I!;)nimal
]J~ GiD:JirulJ~iiB,

0') jj;J~il~h:lr;U {Oir:tlti'lt.!'· M~lLDolilJ!!, mali,gDlID,t,. ll7, II,~
MI'II;loo!;~<iJi~"'r'b;m"""", 11,2

n-. 'FLloT,CI!IIlr.'lund:lp«qi.t

Bo= di~=~ H--6I!,U !!!IiRJ· ffJ

4;~
W'1!a,69
cdl

S~

~Lio,;:,37,3S

.E«oiIlmJ5 ~,tlDSJ

tll~'fopI!aSI;t> Sa-,f;(1 .ilfll}-<IIc:;-opla!i[~, 6]-:!:

mulriforme, lS-6
ruIl1l0U!I\ 4,3,

m ~;;:M~h,II.,lll
"r
""n ... 1 :gi.iJ8j~ii!,·

.

e

]m~osi~

fl9,70

Mc:I::iI!:[a.~cs,::lro;"£i<ilaJl1'us. ~,60 I "I;.\l'J.(jOCumru::ollS oCaJIdidll.!ls a.~'lLdrl!lJll~. chrollic, '91
M,,,,,,;i!J3 p.'''II,il:i;i;'lliid, 7~'-,M M~ (fui!i~U i11f~lioo:!;), &':1-91,. ,}l deep, 135,13(, .L'rtJ'dallllll:, EuJ1filll~,5'1, 58 I M!'doiIlUillllr.-Ylk kID;Il<'[1Ii., ","~'I'",2.1:, :N,

X,(bDg;~rh3l!s'

Oik;jjJj~lj~lII, PY1v,. 9, 1(1 C;;!1L:if}",,:!: o!j'kilh;;l iail, ,,.j!,)j!lll,gulic

·414 CakiIyio;g ,odontD,~tmc cr-:s<t. 35, 31l,43. eM· Cakuli. ;salinI)'. BJ,.l~ WOI:f .•m' Tumm!r,;_~{l):.JId{Jf) _1~j!W"""F
('".ai'ldjdMi~. S')-'.l'U,.9'1

C.1!pilla:ryb.3l:mEgio:ms, 'ICain::ioolIlJ.aJ 9=OOary,.5;;1,6ilJ'

Ul]" 1.08

·~i~d£:l. eongeaital, 119' fibroo_'5.10], W2 ~IIIL ~I, 1<i:'I, ~00 i'l"i'8f'a.,I:}', B., ,24,. 103;" 1'IM EDooirlm,B EruprioorJ. cf~r~.&9, 30 EzyLh",m<IJ ml'lili rum" e , t.lIlt.-..u'!;. 75--6 E'J'1h~al"'lJ~ c:mdido;;i5, d(::l!lru~~~iDoo~ .1!i11"tfi:roplasia(':~ylllIr'JPIi!~·i~), 95, %
fulr.-..-IIUIlI <'1""'" mlll!i1lB,H~ 91

!~

H[;;:"·~~I~am".",,·i~, I,~5, ~3(j HLV .iO:fool:i"il~ and A][)S, ~ ~ 1,10113 .. []:r.sJ!iDi: 00iiic;s, 11, 21!: 1'lI.~l'=miSJ ol'I?u]p, 7. ill HU:Mi'=iIl&:OI<Al!S, 13. i4! H~'flI'''keJr.'l'.or:;i:;., 83. 64 ]:L~fplll::nhYll'Qidisi1:l, 6~. ,6-4. HYp<\~Jc!l5iac,1.O1-~ cl'ru:K~a:t>c¢, ;!l. M
,!{CliTiJ.~.u;.I~, ~

hhUQoJ;),IUSLc5),59',6O

Muo;oy~

1>-'I.u!1~mnQidI

GIIK.ia'CI[]llJ, 1,27, I.ll! ",,;1;lrIliVIIiGllLII!in ~y,;U; (rotoo;,;":>;I",,,),Bj

".,,,,,1,,,,,,,,

My:«',"',", '"'''~ll'oge,,;<;. <19, :sm,
Nia".-i

'~r.ly, ~3,g~ ~iLlh;.:t;:y :gl~m.t •. 12.7-30

~9,UIlIiIJ~,~.w-~'(!O Ci!rti~ dlSl'liIl, ~-<Iio C.avu~Jru!, Il3C'mangiimoa.

Fibromll
1(1.],

1~

OlluJil:\S,~ulJ'~ 7, ~

(;CIJl!~I~"1! i'o"rt11~;r" 51, S·2 C";:'illll:ilOOibliil5[rI!IIai,S.I" 5!2;

48 S~ nru!rO-,.~ N~llro~",," ll~b'il!illO !'i~,S4 Fi,bru-MSOOIlS It!l['O.D~ ,M

:;Ull,;:I ... M""liL:. H, Cl!1~lClI[i~.j11@,.51,

ho;ii;sfi.\'c canal ;y.ll, .3c3, .H [roifmq,r, mCUIlllO~~ ncuroeerodermel jaw ILmDOIJI oJ. 4.5,. '16, 5U.r1ro Nruoor.l!l fofuctii"",. .1!:£8[l,llll:HllallOO1l1 d;s_ ;;;s.;. .. i.il",d.",i,~~, 1.315-7 rnj]~ =mml:m~,8,9'-91. 'Sl~ pajoo(j~'L"I,i~t'.I S{OIIlat~, 61)- 7lJl !·O;!I.Jii'!li(!ll iniil!!:Y, 'rH, 118

pigruC,DIN:d, .1.U7,.1 HI 'l'rih:it~spacge,. 85-6 N!lW1!!;biuJ ...t"l, 33, J4 ' N .... ~"'I;j'fi,"o; ..1'1!1,,;i.'113-o11 Neonates, gl';jj1JuI~C!i:.U ,e;puli~ of. 11 9', .S2e
]n:f,3I!l('\"

~I.!;O'

N~j~'rnl 'Jfumoon N "-m:;ll:'mrn~'m~, 1C~ i([ifj, NCllIl'OOCIoolcrrnal i;:lvr mlllrlW of no.fmq. ·D!f~~llD.atic. S, 4e, 4 N!:~_roJli~ 1~, 1.06

1l'1(!:[qif"'F.~",I 00, H~1

Neuroma,

rraulll8'd'C/II!IIlJl1lUl[ID!II,.

lWI), 100

Index

113, U4 'RJh.;jhdrnnyoBSJIOO:m>'!, 1U, WI· :Ri~I!II~,l,2
'Rhs.bdOIll.}1QI!l;]!,

Udom:08.l!nio,: ,~I., mcilyi~8. :105, %,430,44OE.onI~)::!'Ik Od.)nloona. ~ifl8:

Odrnll~:eDi~

~eJ:iItl)!;)'lil. 3] -1
[]JJI11ILJrn.

l~-5l!

Onhuk~oltiln:izsiion, ~], 32 o!'t~t~ dcfufi11l:llDS,. 6.S-6 Ostco;;"b.alldMl!l"",~3, S4. Cl$tetllD3, .53, :5<1. Os1:~~ti'&, 67,68 O:5.mol;ijdi'IIII!lC[osi~ 67, 6R
O:5.tOO!W'ei)ma,

49, 50'

Iibrema, 53<"S-t

.IlllllBlllltlalioJm/utha coaditions 131.-4 ru~'t~',m;, -30 SarcmdiC6ci.s, 1;7, 138 .$a[lCOlJla, ] II - i4 lipo-. 109 osteo-, 55-6
:SClt5rmis, pr~iVE L"I, ,1~2 :S:Wari1.'cni[~,drnmi.c SmWim"~ t:cr:IJf~~ ~'~l!:ml~ (~cl!::[Dduma), !Ilo.n-~JI~ilil!;, 13], HZ

Sali.'YU}' sl3.n.ch, 121-.34

S5-~

Sj;Jgrell'uyndromc,

~L'~ W~=ofoo",;, ~:s,-6 I'ala:[ii\e ~1IiII q&li, medqn, 34 1'IIpill.r.t!!~, ¥quamotl!l cel" 95, % .

n.

lB. B~ 87, lUI, :5<t!lllmOllS 001 ,;:;aj\ciDo;:omil, 97 -]00 :!iqUilmI!<1I5 oo.~ p;all'iilil ....l~ 9"5, ~, l Sq1l3fi1f)!IS o(.dmntogr:llic tum ....'f, 47,48 :'ikv.em-J.Amoon ~drmne jS.~6
lil'omaiiris.,

P:;II:dJrrari.ci~,
hmphigu
~.!j

~1i5.

hl1lk'§1IJt>oo:is. 83" ,~ :&!lI'IpljiElJid.m~, ..~is_.

3], 31

Pcriodnmaldd~_
~ruf'o;!!l)ilnilil,

Illern'brll~, 7'il-~O 11-:8 15-1'4

] [-12. 1,9'-2:[,.22 3p.i..:al~ 11-11 d1umtt.; 1,9-:U,,1l adVacood, 21. U li'igm~tro lr:siaM, 117-1.8 Pi!lldb'ml IJJJnOIII',43, ~ ~ll.I(1l~" 1q~.ri;aI. 3,4 J:"ilMm~'iI, ~Q.ti~, :5,1, ~i8

infa:tioo~> 69~ 1(1 ll[l!JoinrC!:tl'ol.ls, 1]-,&2 SIlJIlIC!l,fI!lIlp,51,m Siriu~ 73 Su"'mlil.ooU5lib~osi~,o;o",l, 4i, 141 1 S~'Pt.ilili~rruJrop!:rl!:ia, S:)" 8 Syncm.i.:: I~plu ~£fI.h=jjlfl~m; 1;1 139, l40

69-1l::l.

flr:.Dfmm arn~loJbJlI!lroma" 19
I't1ln' 1i~10],10rl: pilip, 9, 10
ho:udlX)'!iiB,

.

T;!,•• h, dcvdopmltlll;a]l do:fl!of,:l~ J -l., see .ahfJ Di!lI'!&i!l, auiC'!!' O~IlUI~;!; Ulmo~ T(1r~l,l]!!: pilPJ].mtati.orl, I, :1: Thru~<Ii.:i'JL'g>(I11"mml.UCl:ll![. ~l.l~l!$, So 6 Tr.oymatloc nrumma, !O,~, lOii<

T -ceil Lj-mpOOIIII:II%peripbcm!,

T"lI'"minai Tnkrm~ J~.:UI3) I(J-I

al1~

herpes 1~]36

:a.>liU,~1' 69 of.

~n:mC)' !:'i;lIjJjj~.".:t~ ["rogoIl.o.mll, 45, ~

Tnmoo.lI\(~) (be:o~ IIliLdlo:r mllJligna.n.), 3;9-60, 95, 9'7 -lOO, ](15-16, 12:1-:J;(I, JiI'I1 a§:.o, .tpedfit (o/I!§ f)j) tl;!1IICotIN

niti'l-o:od<m'tog~.n.k" ~1- 8 I'loelidlJmmtbrmmls 12nilidosis, 89-90 Pulp

bon"", 53-00
Sf:C0IIlI.!!!.t)',

m.IiIam.lO.a.ion,

1'1I1piliis..7-]I]! cl.-d, i,~ opoeD, 9, 10 Pm; fonnslio!ll ii!l,~

JiM Pn.Tpi[i~ iD1:lJ.C',J[ ,~b3.Dgl!S; ., 10 9

eonaecnve .i~lII.c, 105-·10 o;ym wi.llbin. ;J.o:.

>9

.m:lllD~ 45, <W

3s:.

MIll'I!Io!JC1II·oifmIl!!.i

jaw,oficfarl;::y

-

r~mic:

!lf3.llLJI..,:ma,

Jot. ] 04,

pcrioatoo:i.ilh,

11

ooi!lmo,~ri~, J!P-52 wllivary gland, i~I-31) TIJ.t'i .....!l'-JIiIIdr:sion-s. 019' 21:1 l]I(:(\ran\'c: 8ifQlii vi.k;, .Bru[c:, ls., ]6

Jt.'ltilLtion ~ion,

,iDjwy, 6.1,~S Radk1ll\!r ~ts, 1:5
giI'!Jri~~odlr>:i:!l~lI,Z3, 2~

Va!iCILh.lo:iDmyoma. .lf1\1 t:mIlli:IW; caremema, 99, 100 V!!:lirul;OJu~.hyptqll""~ 99 Wl!Iitli.m~ ·rumoo.>~~.:5, ] 2~ WcgmC-.li·-l' gr.B.lI1lilol!luno~ii, 11'9, l4:0 W.lliIe 1!c!<'"l:1s,73, 113-96

R~ l=ems, nrop~l~, 73, 74 ~;'m,H,14 im.tmlaJ,9 13\H

147

COLQUR

GUI[)IES

• "Usarlolfri-ndly' tDrmalldeallor ,examl prepar: lion '. Concise lext cleal1l¥ inlegrated will1lhj'ghi"qualiily colour clinical photogr phs '. UA~ClU' PIPl'Qle'lIiIlaillows review of a,wide salactj'onl Of cas- - durlng_ t1!ortclinical atI- chmems, • An 'essential resource lor studenls and h- 111'111 ,care ~aelalist- in all'ft -Id of medicin.
J

Ii -olil.nt: liMI •• r... qo' M!ldliilln. ;!J,a. Ft.~umnlD,J. ForfdM
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J-.M,~M@ IurelCIII J!Wl!Jo!vUJ

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A.P~ ~J-~,

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M!ldldnl! lind .111""'" fOf DiMitil'lry ,S:.R. IIWfifffJ. SwIlyIP.W."'ityJ
I'of.a;(!!i!i~rt Mlcrollklllli'llliJj'

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