Oral Pathology

Oral Pathology
©Michael Finkelstein, D.D.S., M.S.

Addisons Disease
(c) Michael Finkelstein, D.D.S., M.S.

Adenoid Cystic Carcinoma
Adenoid cystic carcinoma of the left hard and soft palate. The lesion is
poorly circumscribed. It is fixed to both superficial and deep structures.

In this view we can appreciate the ductal spaces with their pink product
contrasting with the paler material in the others.

This is the typical cribriform pattern of tumor cells in adenoid cystic carcinoma.
There are small spaces lined by ductal cells and larger spaces containing
basement membrane-like material. The pattern overall resembles a slice of
Swiss cheese.

At Hi Mag, the duct lining cells are visible in small clusters with pink
cytoplasm. The stellate cells surrounding the ducts and the larger round
spaces are myoepithelial variants.

Aphthous Ulcers
Aphthous ulcers on the lower left labial mucosa. The ulcers are covered
by a tan-yellow fibrin clot.

Aphthous Ulcers
Aphthous ulcer on the left floor of the mouth.

Aphthous Ulcers
Aphthous ulcer on the right soft palate. Note the tan fibrin clot on the
surface of the ulcer and the surrounding zone of erythema.

Aphthous Ulcers
Large aphthous ulcer of the upper labial mucosa. This ulcer is much
larger and of longer duration than typical aphthae.

Aphthous Ulcers
Aphthous ulcers. Note the white areas of scarring on the labial mucosa.
Some clinicians would call this major aphthae.

Aphthous Ulcers
Aphthous ulcer of right lower labial mucosa. Ulcer is covered by a tan
fibrin clot.

Aphthous Ulcers
Aphthous ulcer on parotid papilla, where Stensen's duct enters the oral
cavity.

Aphthous Ulcers
Several aphthous ulcers on lower right labial mucosa. There are also
white areas of scarring closer to the midline. This patient has major
aphthae.

Aphthous Ulcers
Photomicrograph of aphthous ulcer. The surface is covered by stratified
squamous epithelium, with an ulcer in the center. There are no diagnostic
microscopic findings of apthous ulcers. The diagnosis is based on the clinical
findings and history.

Aphthous Ulcers
Aphthous ulcer. Note the ulcer on the nonkeratinized epithelium of the
buccal mucosa.

Aphthous Ulcers
Aphthous ulcer on the nonkeratinized epithelium of the buccal mucosa.

Basal Cell Carcinoma
This is an older patient with a slowly growing basal cell CA. The lesion is
raised with a central ulcer. The fine vascularity is quite typical. Such
tumors feel firm on palpation, and are usually asymptomatic.

At Hi Mag we see the tumor cells tend to palisade at the periphery of the
nests. Mitotic figures are usually easily found (arrow).

This is an older patient with a slowly growing basal cell CA. The lesion is
raised with a central ulcer. The fine vascularity is quite typical. Such
tumors feel firm on palpation, and are usually asymptomatic.

Candidosis
Candidosis. Note white plaques which will rub off on the left buccal
mucosa.

Candidosis
Candidosis. Note white plaques which will rub off on the ventral lateral
surface of the tongue.

Candidosis
Hyperplastic candidosis. A white rough plaque which will not rub off is located
on the right alveolar ridge. A biopsy specimen revealed hyperkeratosis with
numerous candidal hyphae present in the epithelium.

Candidosis
Median rhomboid glossitis appears as an erythematous region devoid of
papillae on the posterior dorsum of the tongue. It is a clinical
manifestation of candidosis.

Candidosis
Candidosis presenting as burning tongue in a patient taking systemic
corticosteroids. The dorsum of the tongue is erythematous without
white plaques.

Candidosis
Photomicrograph of candidal hyphae and spores. The hyphae are tubular
and the spores are pear-shaped. The presence of hyphae indicate
candidosis.

Carcinoma-in-situ (erythematous)
Carcinoma in situ of the left lateral surface of the tongue. The lesion is a
mixed erythematous and white plaque.

In this example there are disorderly, hyperchromatic squamous cells
throughout the thickness of the epithelium.

The arrows point to atypical, multipolar mitotic figures; these are commonly
seen in both CA-in-situ and invasive SqCA. We speak of CA-in-situ when the
dysplastic keratinocytes remain localized within the epithium.

Condyloma Acuminatum
Condyloma acuminatum presenting as multiple, rough, warty lesions on
the dorsum of the tongue.

Here is an image of a gingival growth in a young homosexual male who was
aware of the presence of genital warts in himself and in sex partners. The
growth was rapidly-enlarging and seemed papillary on the surface. It was
attached by a narrow base and was easily excised.

Here is a low-power microscopic image of a condyloma of the vulva, showing the
general features of such lesions. We observe epithelial hyperplasia, acanthosis and
papillomatosis without features of epithelial dysplasia. Virally-modified cells are seen
in the upper spinous layers as pale-looking dots at this power.

Here is a medium-power image from the vulvar condyloma shown previously.
The vacuolated cells in the upper spinous layer are called koilocytes, and
contain virus. There is nonspecific acute inflammation, also.

Congenital Epulis
Congenital epulis of the newborn. A well-circumscribed soft tissue
enlargement is present on the maxillary alveolar ridge of a newborn.

Congenital Keratosis Cyst
Congenital keratotic cyst, also known as dental lamina cyst. This lesion is
a white, smooth surface lesion which is present on the alveolar ridge of
neonates. It resolves spontaneously.

Congenital Keratosis Cyst
In this image of gingiva from a newborn, we see numerous tiny keratotic cysts,
some of which are merging with surface epithelium. Presumably, most or all
such dental lamina remnants disappear this way without treatment

Denture Ulcer
Ulcer due to denture trauma. An ulcer is present on the anterior
mandibular alveolar ridge.

Dermoid/Epidermoid Cyst
Dermoid or epidermoid cyst. A large, compressible, well-circumscribed
soft tissue enlargement is present in the floor of the mouth. It is
elevating the tongue.

Dermoid/Epidermoid Cyst
Epidermoid cyst of the skin. A compressible, well-circumscribed soft
tissue enlargement is present in the skin inferior to the ear.

Ecchymosis
Ecchymosis (bruise) of the skin of the neck.

Ephelis
Ephelis, also known as freckle. A brown macule is present on the
vermilion zone of the lower lip.

Ephelis
Cafe au lait pigmentations of neurofibromatosis. The lesions are multiple
macules greater than 1.5 cm in diameter. These are examples of
generalized pigmented surface lesions.

Epidermolysis Bullosa
Epidermolysis bullosa. Multiple ruptured bullae (blisters) are present on
the lower extremities.

Epidermolysis bullosa. Closer view of a ruptured bulla.

Epidermolysis bullosa. Diffuse areas of skin are peeling off the lower
extremities of an infant.

Epidermolysis bullosa. The hands demonstrate ruptured bullae, severe
scarring and loss of nails.

Epidermolysis bullosa. Hands show scarring and contractures.

Epidermolysis bullosa. Multiple ulcers of the lips and perioral skin.

Epulis Fissuratum
Epulis fissuratum, also known as inflammatory fibrous hyperplasia.
Multiple soft tissue enlargements with a prominent fissure into which
the denture flange fits.

Epulis Fissuratum
Epulis fissuratum (inflammatory fibrous hyperplasia). Photomicrograph
demonstrating fibrous hyperplasia with a prominent fold or fissure.

Epulis Fissuratum
Epulis fissuratum (inflammatory fibrous hyperplasia). Note the dense
collagenous connective tissue.

Epulis Fissuratum
Epulis fissuratum. A lobulated soft tissue enlargement is present in the
maxillary left mucolabial fold. The flange of the denture would fit
between the rolls of tissue.

Erythema Multiforme
Erythema multiforme: Note the ulcers on the right buccal mucosa.

Erythema Multiforme
Erythema multiforme: Ulcers on the gingiva and lower labial mucosa.

Erythema Multiforme
Erythema multiforme: "Target lesions" on the hands.

Erythema Multiforme
Erythema multiforme: "Target lesions" on the feet.

Erythema Multiforme
Erythema multiforme: Vesicles on the lips.

Erythema Multiforme
Erythema multiforme: Close-up of vesicles on the lips. Some of the
vesicles have ruptured.

Familial Epithelial Hyperplasia
Familial epithelial hyperplasia (white sponge nevus): Epithelial thickening
of the right buccal mucosa and mandibular vestibule.

Familial epithelial hyperplasia (white sponge nevus): White epithelial
thickening of the left buccal mucosa and mandibular vestibule.

Familial epithelial hyperplasia (white sponge nevus): Diffuse white
epithelial thickening of the right buccal mucosa

Familial epithelial hyperplasia (white sponge nevus): Diffuse white
epithelial thickening of the left buccal mucosa.

Fibrin Clot
Fibrin clot: This patient has multiple ulcers associated with primary
herpes. Each ulcer is covered by a white to yellow fibrin clot.

Fordyce Granules
Fordyce granules: Note the yellow plaques with a smooth surface.
Fordyce granules represent sebaceous glands and are not pathologic.

Fordyce Granules
Here is another clinical example of Fordyce granules, with the arrow
pointing to one discrete lesion of many.

Fordyce Granules
Microscopically, Fordyce granules are collections of sebaceous glands similar
to those seen in association with hair follicles in the skin. Clusters of gland cells
drain their secretions through a short duct into the oral cavity.

Fordyce Granules
At higher power, the sebaceous lobule may be seen to exhibit holocrine
secretion, e.g. the cells degenerate and lyse in the central part of the lobule to
form the secretory product. The arrow points toward the duct orifice.

Gingival Cyst of Adult
Gingival cyst: A circumscribed soft tissue enlargement on the gingiva.

Gingival Cyst of Adult
The enlargement seen cinically is produced by a thin walled cyst. The
lining is one or a few cell layers thick. No surface corrugations,
parakeratosis or basilar hyperchromaticity is noted.

Granular Cell Tumor
Granular cell tumor: A soft tissue enlargement with an ulcer on the
dorsum of the tongue.

Granular Cell Tumor
Granular cell tumor: Microscopic image showing sheets of granular cells
infiltrating skeletal muscle.

Granular Cell Tumor
Granular cell tumor: Microscopic image showing granular cells.

Granular Cell Tumor
Granular cell tumor: Microscopic image showing pronounced hyperplasia
of the overlying stratified squamous epithelium. This appearance
resembles squamous cell carcinoma.

Hairy Tongue

Hairy Tongue
Hairy tongue stained black due to coffee and/or tobacco.

Hand Foot and Mouth Disease
Here is a young person with painful oral ulcers of sudden onset. Virus,
erythema multiforme / drug reaction, and major aphthae might all be
considerations. Accompanying skin lesions can help to establish the diagnosis
in such cases.

Similar, though less striking, papular lesions are seen on the sole of the
foot in this patient.

This illustration of palmar lesions from another case of Hand, Foot and
Mouth disease shows the grouped erythematous papules that are
typically seen.

Heavy Metal Ingestion - Lead Poisoning
Generalized pigmentation due to lead poisoning. The gingival margin is
pigmented.

Heavy Metal Ingestion - Bismuth Line
Generalized Pigmentation due to bismuth poisoning. The gingival margin
is pigmented bilaterally.

Hemangioma
Hemangioma: Diffuse compressible purple enlargement of the right
anterior tongue. The lesion blanches upon pressure.

Hemangioma
Hemangioma: Low power microscopic image showing an increased
number of blood vessels.

Hemangioma
Hemangioma: Purple compressible lesion of the left soft palate. The
lesion blanches upon pressure.

Hemangioma
Port-wine stain (nevus flammeus) of the hand.

Hemangioma
Port-wine stain (nevus flammeus) of the lower face and neck.

Hematoma
Hematoma. A purple thickened pigmented lesion which does not blanch
upon pressure is present on the left lateral border of the tongue. The
duration is three weeks.

Herpangina
This patient presented with dysphagia and mild constitutional symptoms such
as malaise and fatigue. The arrows point to some of the tiny ulcers seen to be
confined to the posterior oral cavity. The condition cleared within 10 days on
supportive measures only.

Herpes
Primary herpes: Note the multiple tender submandibular, submental and
anterior cervical lymph nodes.

Herpes
Primary herpes: Multiple ulcers on the lips, commissures, and gingiva.

Herpes
Primary herpes: Multiple ulcers on the labial mucosa, commissures and
gingiva.

Herpes
Primary herpes: Note the enlarged erythematous gingiva.

Herpes
Primary herpes: Multiple ulcers on the dorsum of the tongue and
commissures.

Herpes
Herpes simplex: Microscopic image of epithelial cells showing epithelial
necrosis and cells with giant and/or multiple nuclei.

Herpes
Recurrent herpes: A cluster of intact vesicles on the right vermilion zone
and skin.

Herpes
Primary herpes: Ulcers on the left mandibular gingiva and buccal mucosa.

Herpes
Primary herpes: Multiple ulcers on the dorsum of the tongue.

Herpes
Primary herpes: Close-up of ulcers on the dorsum of the tongue.

Herpes
Primary herpes: Gingival erythema and multiple ulcers of the gingiva,
tongue and labial mucosa.

Herpes
Primary herpes: Multiple ulcers on the lower labial mucosa.

Herpes
Primary herpes: An ulcer on the perioral skin.

Herpes
Herpes simplex: Microscopic image of epithelium showing epithelial
necrosis and cells with giant and/or multiple nuclei.

Herpetic whitlow
Herpetic whitlow: Early primary herpes infection of the fingertip. A
vesicle is surrounded by a zone of erythema.

Herpetic whitlow
Herpetic whitlow: 3rd day of lesion.

Herpetic whitlow
Herpetic whitlow: Vesicle is larger.

Herpetic whitlow
Herpetic whitlow: Vesicle has ruptured and "satellite" lesions are evident
proximal to the main lesion.

Herpetic whitlow
Herpetic whitlow: 2 weeks after lesion onset. The larger ulcers are
crusted.

Recurrent herpes
Recurrent herpes: A cluster of small ulcers is present on the right hard
palate and gingiva.

Herpes Zoster
Herpes zoster: Ulcers and erythema in a unilateral distribution on the
hard palate. These lesions represent maxillary involvement of the
trigeminal nerve.

Herpes Zoster
Herpes zoster: Vesicles, crusted ulcers and erythema of the upper lip
extending to the midline.

Herpes Zoster
Herpes zoster: Extensive ulceration of the hard palate extending to the
midline.

Hyperkeratosis
Hyperkeratosis: White rough epithelial thickening of left buccal mucosa.

Hyperkeratosis
Hyperkeratosis: Microscopic image showing thick layer of orthokeratin
on the surface.

Hyperkeratosis
Hyperkeratosis: Low-power microscopic image showing thick layer of
keratin on the surface.

Hyperkeratosis
Hyperkeratosis: White epithelial thickening of lower labial mucosa due to
placement of smokeless tobacco.

Hyperkeratosis
Hyperkeratosis. A rough white asymptomatic patch which does not rub
off is located on the mandibular left gingiva and alveolar mucosa.

Mononucleosis
Infectious mononucleosis: Note the edematous and erythematous
posterior soft palate and uvula, as well as painful ulcerated palatine
tonsils.

Mononucleosis
Infectious mononucleosis: The patient has tender enlarged lymph nodes
posterior to the ear.

Mononucleosis
Infectious mononucleosis: This young girl has a rash on her face.

Inflamatory Papillary Hyperplasia
Inflammatory papillary hyperplasia: Multiple small nodules are present
on the hard palate.

Inflammatory papillary hyperplasia: Microscopic image showing multiple
exophytic fingerlike projections of epithelium and connective tissue.

Inflammatory papillary hyperplasia: Erythematous velvety mucosa of the
anterior hard palate in the distribution of a temporary partial denture.

Inflammatory papillary hyperplasia: Low-power microscopic image
showing multiple exophytic fingerlike (papillary) projections of
epithelium and connective tissue.

Irritation Fibroma
Irritation fibroma (polypoid fibrous hyperplasia): A well-circumscribed
exophytic soft tissue enlargement on the right buccal mucosa.

Irritation Fibroma
Irritation fibroma (polypoid fibrous hyperplasia): Low-power microscopic
image showing a dome-shaped lesion consisting of an increased amount
of dense connective tissue.

Irritation Fibroma
Irritation fibroma (polypoid fibrous hyperplasia): Medium power
microscopic image demonstrating dense connective tissue with a surface
of keratinized stratified squamous epithelium.

Irritation Fibroma
Irritation fibroma (polypoid fibrous hyperplasia): High power microscopic
image showing dense connective tissue with collagen bundles and
relatively few blood vessels and fibroblasts.

Irritation Fibroma
Irritation fibroma (polypoid fibrous hyperplasia): A well-circumscribed
dome-shaped soft tissue enlargement of the left buccal mucosa.

Irritation Fibroma
Irritation fibroma. Low-power photomicrograph showing a dome-shaped
lesion with a surface of keratinized stratified squamous epithelium. Most of
the lesion consists of dense irregular connective tissue. Hematoxylin and eosin
stain.

Irritation Fibroma
Irritation fibroma (polypoid fibrous hyperplasia): Microscopic image
showing dense connective tissue and a surface of keratinized stratified
squamous epithelium.

Irritation Fibroma
Irritation fibroma (polypoid fibrous hyperplasia): Microscopic image
showing dense connective tissue.

Kaposis Sarcoma
Kaposi's sarcoma: A circumscribed purple compressible surface lesion on
the hard palate. The lesion blanches on pressure.

Kaposis Sarcoma
Kaposi's sarcoma: A red to blue surface lesion of the retromolar pad
area.

Kaposis Sarcoma
Kaposi's sarcoma: Bilateral erythematous lesions of the retromolar pads.

Kaposis Sarcoma
Kaposi's sarcoma: Purple surface lesion on skin of temple region.

Kaposis Sarcoma
Kaposi's sarcoma: A purple to brown surface lesion of the hard palate.

Kaposis Sarcoma
Kaposi's sarcoma. Purple exophytic nodular soft tissue enlargements
which blanch upon pressure are present on the dorsum of the tongue in
an elderly patient.

Kaposis Sarcoma
Kaposi's sarcoma. Purple exophytic nodular soft tissue enlargements
which blanch upon pressure are present in the antecubital fossa in an
elderly patient.

Kaposis Sarcoma
Kaposi's sarcoma. Microscopic image demonstrating slit-like vascular
spaces filled with erythrocytes.

Keratoacanthoma
Keratoacanthoma: An indurated soft tissue enlargement of the right
commissure area. The lesion is fixed to the surface and to underlying
muscle. The center of the lesion is filled with keratin.

Keratoacanthoma
Keratoacanthoma: Low power microscopic image showing squamous
epithelium proliferating outward and downward into the connective
tissue.

Lichen planus (white)
Lichen planus: White striae of right buccal muocsa.

Lichen planus: White striations showing the classic network
arrangement, with erythematous mucosa, on the right buccal mucosa.

Lichen planus: White striations on the attached gingiva.

Lichen planus: White striations on the left buccal mucosa.

Lichen planus: White striations on the dorsum of the tongue.

Lichen planus: White striations of the attached gingiva.

Lichen planus: White patch of epithelial thickening adjacent to an ulcer
on the left buccal mucosa.

Lichen planus: Diffuse white epithelial thickening of ventral and lateral
tongue.

Lichen planus: White patches of epithelial thickening on dorsum of
tongue.

Lichen planus, erosive: Painful ulcers and erythematous mucosa of the
hard palate.

Lichen planus: Microscopic image showing hyperkeratosis, irregular
epithelial proliferation in a "saw-tooth" pattern, and a dense band-like
infiltrate of lymphocytes underneath the epithelium.

Lichen planus: Striations and erythematous mucosa on the left alveolar
ridge and hard palate.

Lichen planus: Microscopic image showing hyperkeratosis, elongation of
the rete ridges, and a dense infiltrate of lymphocytes underneath the
epithelium.

Lichen planus: Microscopic image demonstrating hyperkeratosis,
elongation of the rete ridges and a dense band of lymphocytes
underneath the epithelium.

Lichen planus: High power microscopic image demonstrating necrosis of
keratinocytes in the basal cell layer and the dense infiltrate of
lymphocytes underneath the epithelium.

Lichen planus: Microscopic image showing hyperkeratosis, irregular
elongation of rete ridges producing a "sawtooth pattern," and a dense
lymphocytic infiltrate underneath the epithelium.

Lichen planus: Epithelium-connective tissue interface showing necrosis of
basal cells and replacement by an eosinophilic band.

Lichen planus: Striations and erythematous mucosa on the right buccal
mucosa.

Lichen planus: Striations and erythematous mucosa on the right buccal
mucosa.

Lichen planus: Striations, white plaques, and erythematous mucosa on
the left buccal mucosa.

Lichen planus. White rough lesions forming a network or striated pattern
with an underlying red mucosal base, present on the buccal mucosa.


Lichen planus. White rough lesions forming a striated pattern on the
buccal mucosa and dorsum of tongue.

Lichen planus. Lichen planus. White rough lesions forming a striated
pattern on the buccal mucosa.


Lichen planus (erythematous)
Lichen planus: Erythema and white epithelial thickening of right lateral
border of tongue.

Lichen planus: Large painful ulcer of left lateral border of tongue.

Lichen planus: Erythema and white epithelial thickening of left lateral
border of tongue.

Lichen planus: Large painful ulcer of dorsum of tongue.

Lichen planus: Ulcers of the maxillary anterior gingiva.

Lichen planus: White striations and ulcer on left buccal mucosa.

Lichen planus: Large ulcer surrounded by white striations on left buccal
mucosa.

Lichen planus: Erythema and ulcers of maxillary gingiva.

Lichen planus (graft versus host disease)
Lichen planus in patient with graft versus host disease: White striations on left
buccal mucosa. Lichen planus-like lesions are a common oral manifestation in
graft versus host disease. This phenomenon supports the idea that lichen
planus is an autoimmune disease.

Lichen planus in patient with graft versus host disease: White rough
plaques on the dorsum of the tongue.

Lichen planus in patient with graft versus host disease: White rough
plaques and elongated filiform papillae on dorsum of tongue.

Lichen planus (skin)
Lichen planus of the skin: White striations with an erythematous base.

Lichen planus of the skin: Faint, white striations overlying an
erythematous base.

Lichen planus of the skin: White striations. These lesions are often
pruritic.

Lichen planus of the skin: White striations on an erythematous base.

Lichen planus of the skin: White striations and plaques on an
erythematous base.

Lupus Erythematous
Lupus erythematosus, skin: Slightly elevated erythematous rash of malar
region.

Lupus Erythematous
Lupus erythematosus, skin: Scaly hyperkeratotic lesion on nose.

Lupus Erythematous
Lupus erythematosus, skin: Lesion of long duration on nose
demonstrates scarring and hyperpigmentation.

Lupus Erythematous
Lupus erythematosus, skin: Lesion on temple shows elevated
hyperkeratotic periphery.

Lupus Erythematous
Lupus erythematosus, skin: Lesion on skin and vermilion of upper lip
shows scaly hyperkeratotic center and erythematous periphery.

Lupus Erythematous
Lupus erythematosus on skin and vermilion of upper lip: Lesion has scaly
hyperkeratotic areas with a thin rim of erythema at the periphery. A
crusted ulcer is present on the vermilion border.

Lupus Erythematous
Lupus erythematosus: Ulcers are present on the vermilion zone.

Lupus Erythematous
Lupus erythematosus: Ulcers with white hyperkeratotic periphery are
present on the right buccal mucosa.

Lupus Erythematous
Atrophic candidosis (candidiasis) in patient with systemic lupus erythematosus:
Note the erythematous dorsal surface of the tongue. The patient reports pain
and burning. She takes prednisone for systemic lupus.

Lymphoepithelial Cyst
Lymphoepithelial cyst: Well circumscribed tan enlargement on the left
posterior lateral border of the tongue. The lateral-ventral tongue and
floor of the mouth are common locations for this lesion.

Lymphoma
Non-Hodgkin's lymphoma: Enlarged lymph nodes in the right axilla.

Lymphoma
Non-Hodgkin's lymphoma: Close-up of enlarged lymph nodes.

Lymphoma
Non-Hodgkin's lymphoma: Note the soft tissue enlargement of the uvula
and right soft palate.

Lymphoma
Lymphoma. An erythematous firm soft tissue enlargement partially
covering the external auditory canal.

Lymphoma
Lymphoma. An erythematous firm soft tissue enlargement of the hard
palate.

Medication (Atabrine)
Generalized pigmentation due to Atabrine (quinacrine) hydrochloride:
This drug is used to treat protozoal and helmintic infections. It can cause
diffuse pigmentation, as seen on the hard palate in this patient.

Medication (Atabrine)
Generalized pigmentation due to Atabrine (quinacrine) hydrochloride:
Note the pigmentation of the nail beds.

Melanoma
Melanoma: Multiple irregularly shaped pigmented lesions are present on
the right hard and soft palate. Some of the lesions are flat, while others
are thickened.

Melanoma
Melanoma. A diffuse thickened darkly pigmented lesion of the
mandibular right gingiva and alveolar mucosa.

Melanoma
Melanoma. Microscopic image showing nests of melanoma cells
demonstrating nuclear pleomorphism and hyperchromatism and
deposits of melanin pigment.

Melanoma
Melanoma. Microscopic image showing melanoma cells with
pleomorphic, hyperchromatic nuclei, prominent nucleoli, and deposits of
melanin pigment.

Melanoma
Melanoma. Microscopic image showing nests of melanoma cells in the
connective tissue and within the epithelium. The cells demonstrate nuclear
pleomorphism and hyperchromatism and deposits of melanin pigment.

Oral Melanotic Macule
Oral melanotic macule. A persistent nonthickened brown asymptomatic
macule on the left soft palate.

Oral Melanotic Macule
Oral melanotic macule. Microscopic image showing increased melanin
pigmentation in the basal cell layer of the stratified squamous
epithelium.

Malignant Mucoepidermoid Carcinoma
Mucoepidermoid carcinoma, right parotid gland: Note the enlargement
inferior to the ear.

Mucous Membrane Pemphigoid
Mucous membrane pemphigoid. Note the erythema and ulcerations on
the gingiva.

Mucous membrane pemphigoid. Ulcers are present on the left buccal
mucosa.

Mucous membrane pemphigoid.Note the ulcers in the right buccal
mucosa.

Mucous membrane pemphigoid.Note the gingival ulceration and
bleeding.

Mucous membrane pemphigoid.Low-power photomicrograph showing
separation of the epithelium and connective tissue, resulting in a subepithelial
blister. This is the result of autoantibodies formed against antigens in the basal
lamina.

Photomicrograph of mucous membrane pemphigoid showing separation of the
epithelium from the connective tissue in the basement membrane region. This
results in a subepithelial blister. The separation is the result of autoantibodies
directed against antigens in the basal lamina.

Mucous membrane pemphigoid. Note the erythematous gingiva.

Mucous membrane pemphigoid demonstrating gingival erythema.

Mucous membrane pemphigoid demonstrating gingival erythema and
ulceration.

Mucous membrane pemphigoid. Note the ginvial erythema and
ulceration.

Mucous membrane pemphigoid. Note the gingival erythema and
ulceration.

Mucous membrane pemphigoid. Note the gingival erythema.

Mucous membrane pemphigoid. A blast of air is causing formation of a blister. This is
known as a Nikolsky sign. A Nikolsky sign is not always present in patients with
mucous membrane pemphigoid. Other diseases, including pemphigus vulgaris, lichen
planus, and lupus erythematosus can sometimes demonstrate a Nikolsky sign.

Mucous membrane pemphigoid. Note the ulcers on the left buccal
mucosa.

Mucous membrane pemphigoid. Note the large palatal ulcer.

Mucous membrane pemphigoid. There is a large ulcer on the buccal
mucosa.

Mucous membrane pemphigoid. Note the extensive ulceration of the
soft palate. The ulcers are covered by a light yellow fibrin clot.

Mucous membrane pemphigoid demonstrating an ulcer of the hard
palate.

Mucous membrane pemphigoid with extensive ulceration of the
edentulous alveolar ridge.

Mucous membrane pemphigoid. A blast of air is causing the formation of a
blister. This is called a Nikolsky sign. It is sometimes present in mucous
membrane pemphigoid, pemphigus, lichen planus and lupus erythematosus.

Mucous membrane pemphigoid. Note the intense erythema of the
attached gingiva.

Mucous membrane pemphigoid. A blast of air is causing the formation of a
blister. This is known as a Nikolsky sign. It is sometimes, but not always,
present in mucous membrane pemphigoid, pemphigus vulgaris, lichen planus
and lupus erythematosus.

Mucous membrane pemphigoid. High-power photomicrograph showing
separation of the epithelium and the connective tissue in the basement
membrane region.

Mucous membrane pemphigoid.This is a photomicrograph of a direct
immunofluoresence preparation. The white irregular line indicates
deposition of autoantibodies in the basement membrane region.

Mucous membrane pemphigoid. This is a high-power photomicrograph
demonstrating separation of the epithelium and the connective tissue in
the basement membrane region.

Mucus Retention Phenomenon
Salivary extravasation phenomenon (mucous retention phenomenon;
mucocele): A well circumscribed blue compressible enlargement of the
commissure area. The lesion does not blanch upon pressure.

Mucous retention (salivary extravasation) phenomenon. Low-power
photomicrograph showing a lobule of normal salivary gland tissue
adjacent to a circumscribed pool of mucus. Hematoxylin and eosin stain.

Mucous retention (salivary extravasation) phenomenon. Medium-power
photomicrograph showing a pool of mucus containing a cellular infiltrate. A
wall of fibrovascular connective tissue is adjacent to the mucous pool.
Hematoxylin and eosin stain.

Mucous retention (salivary extravasation) phenomenon. High-power
photomicrograph showing a pool of mucus containing neutrophils and
macrophages with phagocytized mucus. A wall of fibrovascular connective
tissue is adjacent to the mucous pool. Hematoxylin and eosin stain.

Mucous retention (salivary extravasation) phenomenon. A compressible
soft tissue enlargement on the lower left lip.

Mucous retention (salivary extravasation) phenomenon. Medium-power
photomicrograph showing a pool of mucus containing a cellular infiltrate. A
wall of fibrovascular connective tissue is adjacent to the mucous pool.

Mucous retention (salivary extravasation) phenomenon. High-power
photomicrograph showing a pool of mucus containing neutrophils and
macrophages with phagocytized mucus. A wall of fibrovascular connective
tissue is adjacent to the mucous pool. Hematoxylin and eosin stain.

Ranula
Ranula (salivary extravasation phenomenon; mucous retention
phenomenon; mucocele): A large compressible bluish soft tissue
enlargement of the floor of the mouth.

Necrotizing Sialo Metaplasia
Necrotizing sialometaplasia. A punctate ulcer on the posterior lateral
portion of the hard palate.

Neuroma
Neuroma. A soft tissue enlargement is present in the mandibular right mental
foramen area. The surface of the lesion demonstrates epithelial thickening,
probably secondary to trauma from a denture. The lesion is tender to
palpation.

Neuroma
Neuroma. Medium power photomicrograph showing multiple peripheral
nerve bundles in a disorganized pattern separated by dense irregular
connective tissue. Hematoxylin and eosin stain.

Neuroma
Neuroma. High power photomicrograph showing multiple peripheral
nerve bundles in a disorganized pattern separated by dense irregular
connective tissue. Hematoxylin and eosin stain.

Nevus
Nevus. Medium power photomicrograph showing nests of nevus cells in the
connective tissue subjacent to the stratified squamous epithelium. Melanin
pigment is present in some of the cells. Hematoxylin and eosin stain.

Nevus
Nevus. A thickened, firm, nontender, well circumscribed, dark brown
surface lesion on the right hard palate.

Nevus
Nevus. High power photomicrograph showing nests of nevus cells subjacent to
the stratified squamous epithelium. The nevus cells demonstrate nuclei that
are uniform in size, shape and staining. Some of the cells contain melanin
pigment. Hematoxylin and eosin staining.

Nicotinic Stomatitis
Nicotinic stomatitis. The hard palate is white, rough and nontender. The white
lesion does not rub off. Red dots, representing dilated salivary gland duct
orifices, are present in the white plaque. Nicotinic stomatitis is associated with
pipe, cigar and cigarette smoking.

Papilloma
Papilloma. A firm, white, rough, exophytic, pedunculated, nontender soft
tissue enlargement is present on the right ventral tongue. The enlargement is
fixed to the surface mucosa but not to underlying structures.

Papilloma
Papilloma. Low-power photomicrograph of an exophytic, pedunculated
proliferation consisting of multiple fingerlike epithelial projections. Each
epithelial proliferation contains a central core of connective tissue.

Papilloma
Papilloma. Medium power photomicrograph showing acanthosis and
hyperkeratosis with underlying loose connective tissue. Hematoxylin and
eosin stain.

Papilloma
Papilloma. Low-power photomicrograph of an exophytic, pedunculated
proliferation consisting of multiple fingerlike epithelial projections. Each
epithelial proliferation contains a central core of connective tissue.
Hematoxylin and eosin stain

Papilloma
Papilloma. A firm, white, rough, exophytic, pedunculated, nontender soft
tissue enlargement is present on the left soft palate. The enlargement is
fixed to the surface mucosa but not to underlying structures.

Papilloma

Pemphigus
Pemphigus. Collapsed vesicles and bullae and crusted ulcers are present
on the face.

Pemphigus
Pemphigus. Low-power photomicrograph shows a vesicle within the
stratified squamous epithelium. Epithelial cells are present along the
base of the vesicle. Hematoxylin and eosin stain.

Pemphigus
Pemphigus. Medium power photomicrograph shows loss of cohesion between
the epithelial cells (acantholysis). Epithelial cells are floating free within the
vesicle. Several layers of epithelial cells are present along the base of the
vesicle. Hematoxylin and eosin stain.

Pemphigus
Pemphigus. Medium power photomicrograph of direct immunofluorescence
preparation. There is staining for antibodies in the intercellular spaces of the
stratified squamous epithelium. This indicates that antibody is being produced
against the intercellular material of the epithelium.

Pemphigus

Pemphigus

Periodontal Abscess
Gingival abscess: A tender erythematous fluctuant gingival enlargement
is present facial to the maxillary first and second molars.

Periodontal Abscess
Gingival abscess: Microscopic image showing a dense infiltrate of
neutrophils.

Periodontal Abscess
Gingival abscess: A microscopic image showing a dense infiltrate of
neutrophils, some of which are undergoing liquefaction necrosis.

Periodontal Abscess
Periodontal abscess. A tender erythematous fluctuant soft tissue
enlargement of recent onset.

Peripheral Fibroma
Peripheral ossifying fibroma: A well circumscribed firm nontender soft
tissue enlargement is present on the gingiva facial to the mandibular
right canine.

Peripheral Fibroma
Peripheral ossifying fibroma: Low power microscopic image
demonstrating numerous fibroblasts, collagen and basophilic mineralized
material.

Peripheral Fibroma
Peripheral ossifying fibroma: Low power microscopic image
demonstrating numerous fibroblasts, collagen and basophilic mineralized
material.

Peripheral Fibroma
Peripheral ossifying fibroma: High-power microscopic image
demonstrating numerous fibroblasts, sparse collagen and basophilic
mineralized material.

Peripheral Fibroma
Peripheral ossifying fibroma: A well circumscribed firm soft tissue enlargement
is present on the interdental papilla between the mandibular right lateral
incisor and canine. The lesion has an erythematous surface, probably due to
trauma.

Peripheral Giant Cell Granuloma
Peripheral giant cell granuloma: A well circumscribed erythematous soft tissue
enlargement is present on the facial gingiva between the maxillary left canine
and first premolar. The lesion blanches upon pressure. A small ulceration,
probably due to trauma, is present on the surface.

Peripheral giant cell granuloma: A low power microscopic image
demonstrating numerous blood vessels and multinucleated giant cells.

Peripheral giant cell granuloma: A well circumscribed blue and red soft
tissue enlargement of the gingiva distal to the maxillary right central
incisor. The lesion blanches upon pressure.

Pyogenic granuloma: A microscopic image showing numerous small and
medium sized blood vessels. The prominent vascularity explains why the
lesion clinically is red to purple in color and blanches upon pressure.

Peripheral giant cell granuloma: High power microscopic image showing
numerous blood vessels and multinucleated giant cells.

Petechiae
Petechiae: Numerous red pinpoint sized macules in the maxillary
vestibule area. These petechiae are due to trauma.

Petechiae
Petechiae. Petechiae of the soft palate associated with infectious
mononucleosis.

Pleomorphic Adenoma
Pleomorphic adenoma (mixed tumor): A well circumscribed firm soft tissue
enlargement of the posterior lateral hard palate. The posterior lateral hard
palate is the most common location for intraoral salivary gland tumors.

Pleomorphic Adenoma
Pleomorphic adenoma (mixed tumor): A microscopic image showing
ducts lined by cuboidal cells, islands of epithelium, and loose connective
tissue staining basophilic (myoid).

Pleomorphic Adenoma
Pleomorphic adenoma (mixed tumor): High power microscopic image
showing ducts lined by cuboidal epithelial cells. Note the loose myxoid
(containing abundant ground substance) connective tissue.

Pleomorphic Adenoma
Pleomorphic adenoma (mixed tumor): A firm well circumscribed soft
tissue enlargement fills up the palatal vault. The lesion has a blue color
but it does not blanch upon pressure. This means it is not vascular.

Pleomorphic Adenoma
Pleomorphic adenoma (mixed tumor): A Waters sinus radiograph of the
previous patient. Note that the lesion has invaded the left maxillary sinus. The
invasion of the sinus does not indicate malignancy in this case, but rather a
very long duration of persistent growth.

Polymorphous Low-Grade Adenocarcinoma
Polymorphous low-grade adenocarcinoma: A soft tissue enlargement is
present at the junction of the left hard and soft palate.

Pyogenic Granuloma
Full face image of patient with pyogenic granuloma.

Pyogenic Granuloma
Pyogenic granuloma: A red compressible rapidly growing well circumscribed
soft tissue enlargement of the right anterior tongue. The lesion blanches upon
pressure. The white areas on the surface of the lesion are fibrin clots covering
ulcerations.

Pyogenic Granuloma
Pyogenic granuloma: Microscopic image of a fibrin clot covering an
ulceration on the surface of the lesion. The red granular material is fibrin.

Pyogenic Granuloma
Pyogenic granuloma. A circumscribed erythematous nontender easily
bleeding compressible soft tissue enlargement of the interdental papilla.
The lesion blanches upon pressure.

Pyogenic Granuloma
Pyogenic granuloma. A circumscribed erythematous nontender easily
bleeding compressible soft tissue enlargement of the gingiva. The lesion
blanches upon pressure.

Racial Pigment
Racial pigmentation. An example of generalized pigmentation.

Salivary Gland Adenocarcinoma
Adenocarcinoma of right hard and soft palate. Note the ulcerated
surface. Lesion was fixed to surrounding structures on both the hard and
soft palate.

Adenocarcinoma of right hard and soft palate. This is after surgical excision of
the lesion. There is continuity between the nasal cavity and oral cavity. An
obturator (partial denture-like appliance) was made to cover the defect.

Adenocarcinoma of right hard and soft palate. This shows surgical defect
covered by a temporary obturator.

Adenocarcinoma of right hard and soft palate. The surgical defect is
covered by an obturator that also serves as a partial denture.

Schwannoma
Schwannoma: A well circumscribed firm nontender soft tissue
enlargement is present on the gingiva facial to the maxillary left first
molar.

Sjogrens Syndrome
Sjogren's syndrome: The patient has diffuse firm nontender enlargement
of the left parotid gland, accompanied by xerostomia and xerophthalmia.

Squamous cell carcinoma (erythematous)
Superficially invasive squamous cell carcinoma: A nontender erythematous pebbly plaque is present on
the left soft palate and tonsillar pillar area. The patient was unaware of the lesion. An asymptomatic
erythematous surface lesion of the soft palate, tonsillar pillar, lateral and ventral tongue and floor of the
mouth is the most common presentation of carcinoma in situ and EARLY squamous cell carcinoma.

Superficially invasive squamous cell carcinoma: High power microscopic
image showing atypical squamous epithelium. The cells demonstrate
variation in nuclear size, shape and staining and loss of maturation.

Superficially invasive squamous cell carcinoma: An asymptomatic red
patch with white rough areas is present on the left soft palate.

Squamous cell carcinoma: High power microscopic image showing
marked variation in nuclear size, shape and staining. An atypical mitosis
is present in the lower center of the field.

Squamous cell carcinoma (white)
Squamous cell carcinoma. An indurated ulcer with white epithelial
thickening along the border of the ulcer.

Squamous cell carcinoma (white)
Squamous cell carcinoma, closer view. An indurated ulcer with white
epithelial thickening along the border of the ulcer.

Tattoo
Tattoo: A nonthickened nontender black surface lesion is present on the
facial gingiva in the mandibular canine incisor region.

Tattoo
Tattoo: Same patient as previous image. The periapical radiograph
demonstrates small radiopaque particles consistent with amalgam.

Tattoo
Tattoo: Medium power microscopic image showing black amalgam
particles surrounded by an infiltrate of chronic inflammatory cells.

Tattoo
Tattoo: Low power microscopic image showing black amalgam particles
in the lamina propria.

Tattoo
Tattoo: Medium power microscopic image showing black amalgam
particles and chronic inflammatory cells in the lamina propria.

Tattoo
Tattoo: A thickened nontender black surface lesion on the left buccal
mucosa. A tattoo can sometimes be thickened due to fibrosis.

Tattoo
Tattoo: A thickened gray-black nontender surface lesion is present on the
right posterior hard palate. This is a tattoo due to graphite from a pencil
implanted in the tissue.

Toxic Mucositis
Toxic mucositis (idiosyncratic drug reaction): A chronic ulcer is present on the right
alveolar ridge. Some drugs which may cause toxic mucositis include nonsteroidal
anti-inflammatory drugs, colloidal gold and tricyclic antidepressants. The ulcer is a
side-effect of the drug and not an allergic reaction.

Varicella
Varicella (chickenpox). Ulcers and papules on the skin of the face.

Varicella
Varicella (chickenpox). Ulcers and papules on the skin of the trunk.

Varicella
Varicella (chickenpox). An ulcer on the postauricular skin.

Varicella
Varicella (chickenpox). An erythematous papule on the skin.

Varicella
Varicella (chickenpox). An erythematous papule on the skin of the palm.

Varix
Varix: A well circumscribed raised compressible surface lesion is present
on the vermilion zone of the lower lip. The lesion blanches upon
pressure. A thrombosed varix does NOT blanch upon pressure.

Verruca Vulgaris
Verruca vulgaris: A tan rough sessile nontender enlargement is present
on the palmar skin.

Reference
http://www.uiowa.edu/~oprm/Atlas
WIN/AtlasFrame.html

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©Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

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(c) Michael Finkelstein, D.D.S., M.S.

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(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

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(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

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(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

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(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.

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(c) Michael Finkelstein, D.D.S., M.S.

(c) Michael Finkelstein, D.D.S., M.S.