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Module 10

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Abfraction

Dental Diseases

Definition

  • Non-carious cervical loss of tooth structure attributed to flexure and fatigue of enamel and dentin from eccentric occlusal loading.

Etiology

  • Occlusal stress (eccentric loading, bruxism)
  • Multifactorial (stress + erosion + abrasion)

Clinical features

  • Wedge/V-shaped notch at cervical area
  • Sharp margins
  • Typically on buccal surface
  • Commonly on premolars

Investigations

  • Occlusal analysis
  • Facet identification for bruxism

Management

  • Occlusal adjustment if indicated
  • Night guard for bruxism
  • GIC or composite restoration if symptomatic/progressive

Prognosis

  • Good with occlusal management.

Quick revision

  • Stress-induced flexure at cervical
  • Multifactorial aetiology
  • Night guard + restoration
Full atlas page →

Actinic Cheilitis

Premalignant Disorders

Definition

  • Premalignant degeneration of the lip vermilion caused by cumulative ultraviolet radiation exposure.

Etiology

  • Chronic UV-B exposure
  • Fair skin (Fitzpatrick I–II)
  • Outdoor occupation
  • Tobacco cofactor

Clinical features

  • Dry, scaly, atrophic lower lip
  • Loss of vermilion border definition
  • Pale/white patches with red erosions
  • Persistent crusting/fissuring
  • Focal ulcer or induration = suspect SCC

Investigations

  • Incisional biopsy of indurated/ulcerated area
  • Dermoscopy of lip
  • Toluidine-blue staining as adjunct

Management

  • Photoprotection: SPF 30+ lip balm, wide-brim hat
  • Topical 5-FU, imiquimod, or diclofenac for field change
  • Cryotherapy for focal lesions
  • CO₂ laser vaporisation or vermilionectomy (lip shave) for severe/dysplastic disease

Prognosis

  • Excellent with photoprotection; malignant transformation risk mandates biopsy of any indurated or non-healing area.

Quick revision

  • UV-induced PMD of lower lip
  • Solar elastosis on histology
  • Vermilionectomy for high-grade dysplasia
Full atlas page →

Adenomatoid Odontogenic Tumour

Odontogenic Tumors

Definition

  • A benign, slow-growing, well-encapsulated odontogenic tumour derived from odontogenic epithelium, characterised by duct-like structures and variable calcifications.

Etiology

  • Origin from reduced enamel epithelium or dental lamina remnants

Clinical features

  • Painless, slow-growing swelling in the anterior jaw
  • Unerupted tooth (usually maxillary canine)
  • Cortical expansion when large

Investigations

  • Clinical + radiographic + histopathological correlation
  • CBCT for surgical planning

Management

  • Conservative surgical enucleation with removal of capsule
  • Extract or orthodontically align associated impacted tooth

Prognosis

  • Excellent.

Quick revision

  • Two-thirds tumour
  • Encapsulated
  • Duct-like rosettes with dystrophic calcification
  • Enucleation is curative

Mnemonics

  • AOT = All 2/3 — female, maxilla, canine, teens, follicular, encapsulated

Clinical pearls

  • Adenomatoid ≠ adenocarcinoma — this is a benign encapsulated lesion.
  • Snowflake calcifications extending apically past the CEJ = AOT, not a dentigerous cyst.
Full atlas page →

Amalgam Tattoo

Pigmented Lesions

Clinical features

  • Painless flat blue-grey macule
  • Gingiva or alveolar mucosa adjacent to restorations

Management

  • No treatment; biopsy if diagnosis uncertain

Prognosis

  • Excellent, benign.
Full atlas page →

Ameloblastoma

Odontogenic Tumors

Definition

  • A slow-growing, locally invasive epithelial odontogenic neoplasm derived from odontogenic epithelium.

Clinical features

  • Painless bony expansion — 'egg-shell crackling'
  • Displaced teeth, root resorption
  • Facial asymmetry

Management

  • Conventional: segmental/marginal resection with 1–1.5 cm bony margins + immediate reconstruction
  • Unicystic (luminal/intraluminal): enucleation ± Carnoy's
  • Mural unicystic: resection
  • Peripheral: local excision

Prognosis

  • Excellent local control after resection; long-term follow-up 10+ years.

Mnemonics

  • A-B-C-D: Aggressive, Benign histology, Cystic-solid, Deforming

Clinical pearls

  • 'Soap-bubble' + 'knife-edge' root resorption + BRAF V600E = ameloblastoma.
Full atlas page →

Amelogenesis Imperfecta

Developmental Disorders

Definition

  • Genetically heterogeneous conditions with enamel abnormalities without systemic disease.

Etiology

  • Mutations in AMELX, ENAM, MMP20, KLK4, FAM83H genes
  • Autosomal dominant, AR, or X-linked inheritance

Clinical features

  • Thin, pitted or absent enamel (hypoplastic type)
  • Soft, cheese-like enamel (hypocalcified)
  • Opaque, mottled enamel (hypomature)
  • Anterior open bite common
  • Tooth sensitivity

Investigations

  • Clinical + family history
  • Genetic testing for confirmation

Management

  • Preventive fluoride varnish
  • Composite restorations / veneers
  • Full-coverage crowns for severe cases
  • Overdentures or implants long-term

Prognosis

  • Good with early restorative intervention; lifelong dental maintenance required.

Quick revision

  • AI = enamel only, DI = dentin only
  • Type III hypocalcified = soft, rapidly lost enamel
  • AMELX mutation = X-linked hypoplastic
Full atlas page →

Aneurysmal Bone Cyst

Non-odontogenic Cysts

Definition

  • A benign, locally aggressive, blood-filled, expansile lesion of bone characterised by cavernous vascular spaces separated by fibrous septa containing multinucleated giant cells; reclassified by WHO 2020/2022 as a true neoplasm with USP6 gene fusions.

Etiology

  • Primary ABC (~70%) — USP6 gene rearrangement (17p13) driving neoplastic proliferation
  • Secondary ABC (~30%) — arises within pre-existing lesion (fibrous dysplasia, ossifying fibroma, central giant cell granuloma, chondroblastoma, osteosarcoma) via altered haemodynamics

Clinical features

  • Rapidly enlarging, painful bony swelling
  • Facial asymmetry
  • Malocclusion / tooth displacement / mobility
  • Paraesthesia of the inferior alveolar nerve (uncommon)
  • Egg-shell crackling on palpation over ballooning cortex
  • Occasional pathological fracture

Investigations

  • OPG + CBCT for extent
  • MRI with contrast for fluid–fluid levels
  • Angiography selectively for pre-op embolisation of large lesions
  • Incisional biopsy (with caution — profuse bleeding) for histology
  • FISH for USP6 gene rearrangement to confirm primary ABC

Management

  • Enucleation + aggressive curettage with peripheral ostectomy is the standard treatment for most jaw ABCs
  • Adjuncts to reduce recurrence: cryotherapy with liquid nitrogen, Carnoy's solution, argon-beam coagulation, or phenol
  • En-bloc resection with immediate reconstruction for very large or recurrent lesions
  • Selective arterial embolisation as a pre-op adjunct or standalone therapy for surgically inaccessible sites
  • Sclerotherapy (percutaneous doxycycline / polidocanol) — emerging minimally invasive option, especially in growing children
  • Denosumab (anti-RANKL monoclonal antibody) — reported off-label use for refractory/recurrent cases
  • Radiotherapy — historically used, largely abandoned due to sarcomatous transformation risk

Prognosis

  • Good with complete excision; recurrence risk high without adjuvant therapy or in very young patients.

Quick revision

  • Blood-filled multilocular pseudocyst — reclassified as neoplasm (USP6)
  • Young patients, posterior mandible
  • Fluid–fluid levels on MRI
  • Aggressive curettage + adjuvant is standard
  • Recurrence 10–60% without adjuvant

Mnemonics

  • ABC = Angry Ballooning Cavity — Aggressive curettage, Blood-filled, Cortical thinning.

Clinical pearls

  • Rapidly expanding, blood-filled, multilocular jaw lesion in a young patient with fluid–fluid levels on MRI is ABC until proven otherwise.
  • Always request USP6 FISH — it changes diagnosis and, potentially, treatment.
  • Aggressive curettage + adjuvant beats simple curettage on recurrence.
Full atlas page →

Attrition

Dental Diseases

Definition

  • Mechanical wear of incisal/occlusal surfaces due to functional or parafunctional masticatory contact.

Etiology

  • Normal ageing
  • Bruxism
  • Coarse diet
  • Loss of posterior support
  • Malocclusion

Clinical features

  • Flat, shiny wear facets
  • Exposed dentin (yellow)
  • Cupping of cusp tips
  • Shortening of clinical crown
  • Matching facets on opposing teeth

Investigations

  • Clinical examination
  • Study models / photographs for monitoring

Management

  • Manage bruxism: occlusal splint
  • Restore lost structure: composite, crowns
  • Rehabilitate VDO if severe

Prognosis

  • Good if aetiology addressed and VDO restored.

Quick revision

  • Shiny, flat facets
  • Matching opposing wear
  • Occlusal guard for bruxism
Full atlas page →

Behçet Disease

Ulcerative Diseases

Definition

  • Chronic, relapsing multisystem inflammatory disorder characterised by recurrent oral ulcers, genital ulcers, and ocular inflammation.

Etiology

  • Unknown; autoimmune vasculitis
  • HLA-B51 association
  • Environmental triggers (infectious agents)

Clinical features

  • Recurrent oral aphthous-like ulcers (major criterion)
  • Genital ulcers (scarring)
  • Ocular: anterior/posterior uveitis, hypopyon
  • Skin: erythema nodosum, acneiform lesions, pathergy
  • Neurological, vascular, GI involvement

Investigations

  • Clinical diagnosis (ISG criteria)
  • Pathergy test (positive in ~50%)
  • HLA-B51
  • Ophthalmological exam

Management

  • Mild: topical steroids, colchicine
  • Moderate-severe: systemic steroids, azathioprine, cyclosporine
  • Severe: anti-TNF (infliximab), interferon-α
  • Anticoagulation if thrombosis

Prognosis

  • Variable; ocular and CNS involvement worsen prognosis.

Quick revision

  • Silk Road disease
  • Recurrent oral ulcers + genital + uveitis
  • Anti-TNF for severe
Full atlas page →

Burkitt Lymphoma

Malignant Tumors

Definition

  • Aggressive mature B-cell lymphoma defined by the t(8;14) MYC translocation (variants t(2;8), t(8;22)).

Etiology

  • Endemic form: EBV + Plasmodium falciparum co-infection
  • Sporadic: unknown
  • Immunodeficiency: HIV/AIDS-associated

Clinical features

  • Rapidly enlarging, painless jaw swelling (posterior maxilla most common)
  • Loose teeth, ill-fitting appliances
  • Facial deformity, proptosis
  • B symptoms uncommon
  • Extranodal: kidneys, ovaries, CNS

Investigations

  • Incisional biopsy with fresh tissue for FISH
  • CT/MRI head-neck, chest-abdomen-pelvis
  • Bone marrow biopsy
  • LDH, uric acid (tumour lysis risk)

Management

  • Intensive short-course chemotherapy (CODOX-M/IVAC, DA-EPOCH-R)
  • Rituximab
  • Intrathecal methotrexate for CNS prophylaxis
  • Aggressive tumour lysis prophylaxis (hydration, allopurinol, rasburicase)

Prognosis

  • Endemic: 80–90% cure with intensive chemo. Sporadic adult: 70–80%. HIV-associated: worse.

Quick revision

  • MYC t(8;14) · starry-sky · Ki-67 100% · CODOX-M/IVAC
Full atlas page →

Cemento-osseous Dysplasia

Fibro-osseous Lesions

Definition

  • Reactive/dysplastic fibro-osseous lesion of the jaws in which normal bone is replaced by cellular fibrous tissue with cementum-like and osseous calcifications.

Etiology

  • Unknown; reactive process of PDL origin

Clinical features

  • Asymptomatic incidental radiographic finding
  • Teeth vital (key differentiator from periapical granuloma/cyst)
  • Florid form may cause jaw expansion and secondary infection

Investigations

  • Vitality testing (positive)
  • OPG/CBCT to define extent
  • Biopsy avoided unless diagnosis unclear (risk of osteomyelitis in florid form)

Management

  • No treatment needed if asymptomatic — observation with periodic radiographs
  • Meticulous oral hygiene to prevent secondary infection
  • Debridement/saucerisation for infected florid COD
  • Avoid unnecessary extractions in involved areas

Prognosis

  • Excellent; not neoplastic; no malignant potential.

Quick revision

  • Vital teeth · anterior mandible (periapical) or multi-quadrant (florid) · observation
Full atlas page →

Cementoblastoma

Odontogenic Tumors

Definition

  • A benign odontogenic mesenchymal neoplasm characterised by proliferation of cementoblasts producing sheets of cementum-like tissue attached to the tooth root, with a peripheral radiolucent halo.

Etiology

  • Unknown; considered a true neoplasm arising from cementoblasts

Clinical features

  • Slow-growing painful swelling (pain unusual in odontogenic tumours — a distinguishing feature)
  • Associated tooth is vital
  • Cortical expansion when large

Investigations

  • Vitality tests (must be vital)
  • IOPA + OPG + CBCT
  • Histology after excision

Management

  • Extraction of associated tooth with attached tumour + curettage of socket
  • Selected small lesions — root amputation + endodontic therapy with preservation of tooth

Prognosis

  • Excellent after complete removal.

Quick revision

  • Painful, mandibular first molar, vital tooth, fused to root, radiolucent halo, extract tooth + tumour

Mnemonics

  • 4Fs = First molar, Fused to root, Fibrous halo, Fine pain

Clinical pearls

  • The only truly neoplastic cemental lesion; the rest are dysplasias.
Full atlas page →

Central Giant Cell Granuloma

Bone Diseases

Clinical features

  • Painless expansile swelling
  • May displace teeth or resorb roots

Management

  • Curettage; intralesional corticosteroids or calcitonin for aggressive lesions
  • Resection for recurrent aggressive lesions

Prognosis

  • Recurrence 15–20% after curettage.

Clinical pearls

  • Always check serum calcium & PTH to rule out brown tumour.
Full atlas page →

Cervicofacial Actinomycosis

Maxillofacial Infections

Definition

  • Chronic bacterial infection caused by filamentous Gram-positive anaerobic Actinomyces species, most commonly A. israelii.

Etiology

  • Actinomyces israelii (most common)
  • A. naeslundii, A. viscosus, A. odontolyticus
  • Polymicrobial with Aggregatibacter, Fusobacterium

Clinical features

  • Slowly enlarging, indurated, painless mass at the angle of the mandible
  • Multiple discharging sinuses through skin
  • Yellow 'sulphur granules' in pus
  • Trismus, low-grade fever
  • Crosses tissue planes (unlike malignancy following fascia)

Investigations

  • Gram stain and anaerobic culture of pus (needs 5–14 days)
  • Histopathology: sulphur granules with radiating filaments
  • CT/MRI: soft-tissue mass with cortical erosion
  • 16S rRNA PCR

Management

  • High-dose IV penicillin G 18–24 MU/day × 4–6 weeks, then oral penicillin/amoxicillin 6–12 months
  • Alternatives: doxycycline, clindamycin, erythromycin (penicillin allergy)
  • Surgical drainage and excision of sinuses/necrotic bone

Prognosis

  • Excellent with prolonged antibiotics; recurrence common if therapy <6 months.

Quick revision

  • A. israelii · sulphur granules · long-course penicillin
Full atlas page →

Cervicofacial Necrotising Fasciitis

Maxillofacial Infections

Definition

  • Life-threatening soft-tissue infection producing widespread fascial necrosis, often with relative sparing of underlying muscle and overlying skin early in the disease.

Clinical features

  • Rapidly spreading painful cellulitis disproportionate to skin findings
  • Skin: erythema → dusky discolouration → haemorrhagic bullae → necrosis
  • Crepitus (gas)
  • Systemic toxicity: fever, tachycardia, hypotension, altered mentation (SIRS/sepsis)

Investigations

  • Do NOT delay surgery for imaging in obvious cases
  • LRINEC score
  • CT/MRI: gas in fascial planes, fascial thickening
  • Blood cultures, wound cultures
  • Frozen section: fascial necrosis

Management

  • Immediate aggressive surgical debridement — the mainstay; repeat every 24 h until clean
  • Empirical broad-spectrum: piperacillin–tazobactam + clindamycin + vancomycin/linezolid
  • Clindamycin suppresses exotoxin production
  • IVIG for streptococcal toxic shock
  • ICU support: fluids, vasopressors, ventilation
  • Hyperbaric oxygen adjunctive
  • Reconstruction after infection controlled

Prognosis

  • Mortality 20–40% (higher with mediastinitis, delayed surgery, comorbidity).

Quick revision

  • Polymicrobial · early aggressive debridement · clindamycin + β-lactam · high mortality
Full atlas page →

Chondrosarcoma of the Jaws

Malignant Tumors

Definition

  • Malignant tumour of mesenchymal cells producing a cartilaginous matrix.

Etiology

  • Primary (de novo)
  • Secondary: from enchondroma, osteochondroma, Ollier / Maffucci syndromes
  • Post-irradiation

Clinical features

  • Painless swelling of anterior maxilla or condyle
  • Loose teeth, nasal obstruction, proptosis
  • Slow but relentless growth

Investigations

  • CT (matrix calcification) and MRI (soft-tissue extent)
  • Incisional biopsy
  • Chest CT for metastases

Management

  • Wide surgical resection with clear margins (mainstay)
  • Radiotherapy — limited efficacy; used for unresectable/positive margins (proton beam)
  • Chemotherapy generally ineffective except mesenchymal variant

Prognosis

  • 5-yr survival: Grade I ≈ 80%, Grade III ≈ 30%. Jaw location worse than long bones due to resection limits.

Quick revision

  • Cartilage-producing malignancy · wide excision · radioresistant
Full atlas page →

Cleft Lip & Palate Repair

Maxillofacial Surgery

Definition

  • Surgical protocol for correction of cleft lip and/or palate deformities, delivered by a coordinated cleft team from infancy to skeletal maturity.

Prognosis

  • Excellent functional and aesthetic outcomes with multidisciplinary team care; lifelong follow-up required.

Quick revision

  • Rule of 10s · lip 3mo · palate 9-12mo · alveolar graft 8-11y · orthognathic at 18y
Full atlas page →

Cleft Lip and Palate

Developmental Disorders

Definition

  • Non-syndromic or syndromic oro-facial cleft due to incomplete fusion of maxillary and medial nasal processes (lip) or palatal shelves (palate) during embryogenesis.

Etiology

  • Multifactorial (genetic + environmental)
  • Genes: IRF6, MSX1, TGFβ3
  • Teratogens: alcohol, smoking, anticonvulsants

Clinical features

  • Unilateral or bilateral cleft lip ± alveolus
  • Cleft of hard/soft palate
  • Nasal deformity
  • Feeding difficulties
  • Speech problems (VPI)
  • Dental anomalies (missing/supernumerary teeth)

Investigations

  • Antenatal USG (lip visible 18 wks)
  • Genetic testing for syndromic cases
  • Speech/hearing assessment

Management

  • Multidisciplinary cleft team
  • Lip repair: 10 weeks (rule of 10s)
  • Palate repair: 9–12 months
  • Alveolar bone graft: 9–11 years (mixed dentition)
  • Secondary rhinoplasty, orthognathic surgery as needed

Prognosis

  • Excellent aesthetic and functional outcomes with early comprehensive care.

Quick revision

  • CL+P: male > female
  • Isolated CP: female > male
  • IRF6 gene — Van der Woude syndrome
Full atlas page →

Cleidocranial Dysplasia

Developmental Disorders

Definition

  • A rare autosomal dominant skeletal disorder caused by RUNX2 (CBFA1) mutation, affecting membranous and endochondral bone.

Etiology

  • Heterozygous mutation of RUNX2 gene on chromosome 6p21
  • Impaired osteoblast differentiation

Clinical features

  • Hypoplastic/aplastic clavicles — shoulders approximate in midline
  • Delayed closure of fontanelles and sutures
  • Frontal, parietal and occipital bossing
  • Maxillary hypoplasia with relative mandibular prognathism
  • High arched narrow palate ± cleft palate
  • Prolonged retention of deciduous teeth
  • Multiple unerupted permanent and supernumerary teeth

Investigations

  • Clinical + radiographic diagnosis
  • Genetic testing (RUNX2)

Management

  • Multidisciplinary — pediatric dentist, orthodontist, oral surgeon, prosthodontist
  • Belfast/Toronto/Jerusalem protocols: extract deciduous + supernumerary, expose and orthodontically align permanents
  • Implants and prostheses when growth complete

Prognosis

  • Excellent for lifespan. Dental rehabilitation is lifelong.

Mnemonics

  • CCD = Clavicles, Cranium, Dentition

Clinical pearls

  • Suspect CCD in any child with multiple supernumeraries and delayed eruption.
Full atlas page →

Condylar Hyperplasia

TMJ Disorders

Definition

  • Persistent, self-limiting enlargement of the condyle, condylar neck and/or ramus caused by aberrant endochondral proliferation.

Clinical features

  • Progressive facial asymmetry with chin deviation to the unaffected side (Type II) or ipsilateral (Type I)
  • Unilateral posterior open bite / crossbite
  • Occlusal cant
  • Preserved TMJ function

Investigations

  • OPG, PA cephalogram, 3D CT
  • Bone scintigraphy (99mTc-MDP): >10% uptake asymmetry = active
  • SPECT for improved localisation

Management

  • Active disease: high condylectomy (5 mm) to arrest growth ± orthognathic correction
  • Burnt-out disease: orthognathic surgery alone (bimaxillary + genioplasty)
  • Orthodontic decompensation before surgery

Prognosis

  • Excellent with correct timing; monitor with serial cephalometrics and bone scans.

Quick revision

  • Obwegeser I/II/III · bone scan for activity · condylectomy if active
Full atlas page →

Deep Neck Space Infections

Maxillofacial Infections

Definition

  • Infections that spread from the tooth/jaw into the potential spaces bounded by the deep cervical fascia, following predictable anatomical routes.

Etiology

  • Odontogenic (>60%) — most often mandibular molars
  • Tonsillar, salivary, traumatic, iatrogenic

Clinical features

  • Swelling, pain, trismus, dysphagia, drooling
  • Airway compromise (retro-/parapharyngeal)
  • Fever, malaise, elevated WCC/CRP
  • Torticollis (deep spread)

Investigations

  • Contrast-enhanced CT head-neck (gold standard)
  • Aspirate for culture
  • FBC, CRP, glucose, coagulation
  • Chest imaging to exclude mediastinitis

Management

  • Airway assessment — secure early (awake fibre-optic if compromised)
  • IV empirical antibiotics: amoxicillin-clavulanate or ampicillin-sulbactam + metronidazole; add clindamycin/vancomycin if MRSA suspected
  • Surgical: extract source tooth + incision & drainage of involved spaces via appropriate approaches, dependent drainage, corrugated/Penrose drain
  • ICU support if septic
  • Reassess and re-image if no improvement in 48–72 h

Prognosis

  • Good with early surgical drainage and antibiotics; delayed presentation carries high morbidity/mortality.

Quick revision

  • Odontogenic source · early I&D + antibiotics · watch for mediastinitis
Full atlas page →

Dental Caries

Dental Diseases

Definition

  • A dynamic disease process in which cariogenic biofilms produce organic acids that demineralise enamel, dentin and cementum.

Etiology

  • Streptococcus mutans, S. sobrinus, Lactobacillus, Actinomyces
  • Fermentable carbohydrates

Clinical features

  • White spot lesion → brown discolouration → cavitation
  • Sensitivity to sweet/cold
  • Pain in advanced lesions

Management

  • Non-cavitated: fluoride varnish, SDF, resin infiltration
  • Cavitated: minimally invasive restoration (composite, GIC)
  • Pulpally involved: RCT or extraction

Prognosis

  • Excellent when managed early; progressive without intervention.

Clinical pearls

  • Silver diamine fluoride arrests caries but stains lesions black.
Full atlas page →

Dental Erosion

Dental Diseases

Definition

  • Irreversible loss of dental hard tissues caused by extrinsic or intrinsic acid exposure without bacterial involvement.

Etiology

  • Extrinsic: dietary acids (citrus, carbonated drinks, wine)
  • Intrinsic: GERD, bulimia, chronic vomiting

Clinical features

  • Smooth, silky-shiny enamel surface
  • Cupping of cusps and incisal edges
  • Palatal erosion of upper anteriors (intrinsic)
  • Facial erosion (extrinsic)
  • Restorations standing proud ('amalgam islands')

Investigations

  • Dietary history
  • Medical history (GERD, bulimia)
  • BEWE (Basic Erosive Wear Examination)

Management

  • Identify and reduce acid source
  • Dietary counselling
  • Fluoride/CPP-ACP remineralisation
  • Restore with composite/crowns if severe

Prognosis

  • Good if behaviour modified early; irreversible once lost.

Quick revision

  • Non-bacterial acid = erosion
  • Intrinsic = palatal maxillary anteriors
  • BEWE scoring system
Full atlas page →

Dental Implantology

Maxillofacial Surgery

Definition

  • Restoration of missing teeth using alloplastic root-form implants that osseointegrate with alveolar bone to support prosthetic crowns, bridges or dentures.

Prognosis

  • 10-year survival ≈ 95% in healthy non-smokers; reduced by smoking, uncontrolled diabetes, radiotherapy, poor hygiene and bruxism.

Quick revision

  • Osseointegration (Brånemark) · CBCT planning · 2 mm from IAN · torque ≥30 Ncm for immediate loading
Full atlas page →

Dentigerous Cyst

Odontogenic Cysts

Clinical features

  • Often asymptomatic — incidental finding
  • Painless bony expansion when large
  • Displacement / resorption of adjacent teeth

Management

  • Enucleation + extraction of associated tooth
  • Marsupialisation for very large cysts / young patients to preserve tooth

Prognosis

  • Excellent after complete enucleation.

Clinical pearls

  • Follicular space > 4 mm on OPG is suspicious for dentigerous cyst.
Full atlas page →

Dentinogenesis Imperfecta

Developmental Disorders

Definition

  • Heritable dentin defect due to DSPP gene mutation affecting both dentitions.

Etiology

  • Mutation in DSPP gene (chromosome 4q21)
  • Autosomal dominant

Clinical features

  • Opalescent blue-grey or amber teeth
  • Bulbous crowns, cervical constriction
  • Rapid attrition with flat occlusal surfaces
  • Primary teeth more affected than permanent

Investigations

  • Clinical + radiographic
  • Family history
  • Genetic testing

Management

  • Stainless steel crowns (deciduous)
  • Full-coverage restorations
  • Overdentures
  • Implants after growth

Prognosis

  • Good with early intervention; lifelong restorative needs.

Quick revision

  • DSPP mutation
  • Bulbous crown, cervical constriction
  • Obliterated pulp on OPG
Full atlas page →

Dento-alveolar Trauma

Trauma

Definition

  • Injury to the teeth, supporting tissues, and alveolar bone caused by acute mechanical trauma.

Clinical features

  • Fractured, displaced, or missing teeth
  • Mobility, occlusal interference
  • Gingival laceration, alveolar step
  • Vitality changes on follow-up

Investigations

  • Multiple periapical radiographs (parallel, occlusal, 45°)
  • CBCT for root/alveolar fractures
  • Vitality testing (baseline and follow-up)
  • Photographs; document per IADT chart

Management

  • Enamel fracture: smooth or composite restoration
  • Enamel-dentin: composite; monitor vitality
  • Complicated crown fracture: pulp cap / partial pulpotomy (Cvek) if <24 h; RCT if mature
  • Root fracture: reposition, flexible splint 4 wk (cervical: 4 mo)
  • Extrusion: reposition, flexible splint 2 wk
  • Lateral luxation: reposition, flexible splint 4 wk
  • Intrusion: monitor if immature/<3mm; orthodontic/surgical repositioning if mature/severe
  • Avulsion: replant ASAP; storage in HBSS/milk/saliva; flexible splint 2 wk; systemic doxycycline; tetanus check; RCT within 7–10 days for mature apex
  • Alveolar fracture: reposition, rigid splint 4 wk

Prognosis

  • Depends on extra-alveolar time, storage medium, root maturity and periodontal ligament vitality — best outcome if avulsed tooth replanted within 5 min.

Quick revision

  • IADT 2020 · replant ASAP · HBSS best medium · 2 wk flexible splint for avulsion
Full atlas page →

Distraction Osteogenesis

Maxillofacial Surgery

Definition

  • Biological process of new bone formation between vascularised bone segments gradually separated by traction (Ilizarov principle applied to craniofacial skeleton).

Prognosis

  • Excellent for large advancements (>10 mm) with lower relapse than conventional osteotomy; especially useful in growing patients and syndromic hypoplasia.

Quick revision

  • Latency 5–7 d · rate 1 mm/d · consolidation 2× · Ilizarov principle
Full atlas page →

Epulis Fissuratum

Soft Tissue Lesions

Definition

  • Reactive tissue overgrowth secondary to chronic irritation from a denture flange.

Etiology

  • Ill-fitting denture flange
  • Chronic mechanical irritation

Clinical features

  • Single or multiple soft tissue folds in vestibule
  • Firm, fibrous consistency
  • Denture flange sits within groove between folds
  • Usually painless

Investigations

  • Clinical exam + biopsy if atypical

Management

  • Relieve denture flange
  • Surgical excision of redundant tissue
  • Reline or new denture

Prognosis

  • Excellent after excision and denture correction.

Quick revision

  • Denture flange irritation
  • Firm folds in vestibule
  • Excision + new denture
Full atlas page →

Erythema Multiforme

Vesiculobullous Diseases

Definition

  • Immune-mediated reaction pattern causing mucocutaneous blistering, often recurrent.

Etiology

  • HSV (>70% of recurrent EM)
  • Mycoplasma pneumoniae
  • Drugs (sulfonamides, NSAIDs, anticonvulsants)

Clinical features

  • Oral: haemorrhagic crusting of lips, erosions on buccal/labial mucosa
  • Skin: target (iris) lesions — central vesicle, pale ring, erythematous halo
  • Acute onset, self-limiting 2–6 weeks
  • Recurrences common if HSV-associated

Investigations

  • Clinical diagnosis
  • Skin biopsy if atypical
  • HSV PCR if recurrent

Management

  • Supportive: hydration, soft diet, analgesics
  • Topical steroids for oral lesions
  • Aciclovir prophylaxis for HSV-associated recurrent EM
  • Systemic steroids controversial

Prognosis

  • Excellent; self-limiting but may recur.

Quick revision

  • HSV trigger > drugs
  • Target lesions
  • Self-limiting 2-6 weeks
Full atlas page →

Erythematous (Atrophic) Candidiasis

Red Lesions

Definition

  • A form of oral candidosis in which mucosa appears red and atrophic due to loss of filiform papillae or thinned epithelium, secondary to Candida infection.

Etiology

  • Candida albicans (majority)
  • Predisposing local (denture, xerostomia) or systemic (antibiotics, steroids, HIV, diabetes) factors

Clinical features

  • Diffuse erythema of palate under maxillary denture (denture stomatitis — Newton's II/III)
  • Depapillated red patch on dorsum of tongue (central papillary atrophy → median rhomboid glossitis)
  • Diffuse red painful mucosa after broad-spectrum antibiotics
  • Kissing lesions: opposing palatal erythema mirrored on tongue
  • Painful, burning sensation, sensitivity to acid/spice

Investigations

  • KOH mount / oral rinse culture
  • HbA1c, HIV screen, haematinics in recurrent cases
  • Biopsy if not responding to antifungals

Management

  • Nystatin oral suspension 100,000 IU/ml QID × 14 days
  • Miconazole oral gel or clotrimazole troches
  • Fluconazole 100–200 mg/day systemically for refractory / immunocompromised
  • Denture stomatitis: soak denture in chlorhexidine 0.2% overnight; replace ill-fitting dentures
  • Reduce/change inhaled steroid; rinse mouth after use

Prognosis

  • Excellent with treatment and control of predisposing factors.

Quick revision

  • Red painful mucosa
  • Antibiotic or denture history
  • KOH positive for hyphae
  • Topical nystatin + hygiene
  • Investigate systemic disease if recurrent

Mnemonics

  • Red mouth after Rx (antibiotic) — think Candida

Clinical pearls

  • Red + painful under denture = candidal denture stomatitis until proven otherwise.
  • Treat patient AND denture — dentures are the reservoir.
Full atlas page →

Erythroplakia

Red Lesions

Definition

  • WHO: 'A fiery red patch that cannot be characterised clinically or pathologically as any other definable disease.' Considered an oral potentially malignant disorder (OPMD).

Etiology

  • Heavy tobacco use
  • Alcohol (synergistic)
  • Areca nut
  • Chronic Candida infection
  • HPV (subset)

Clinical features

  • Bright red, velvety, well-demarcated plaque
  • Flat or slightly depressed, soft on palpation
  • Common sites: floor of mouth, ventral/lateral tongue, soft palate, retromolar area
  • May be mixed with white areas (erythroleukoplakia)
  • Usually asymptomatic; mild soreness or metallic taste

Investigations

  • Toluidine blue (strongly positive)
  • Autofluorescence loss
  • Incisional/excisional biopsy — GOLD STANDARD
  • HPV testing if history suggestive

Management

  • Habit cessation
  • Complete surgical excision with 5 mm margin
  • CO2 laser excision acceptable for superficial lesions
  • Definitive oncologic management if invasive SCC

Prognosis

  • Highest malignant potential of all OPMDs — up to 50% harbour or progress to invasive SCC within 5 years.

Quick revision

  • Red > white in risk
  • > 90% dysplasia / CIS / SCC at first biopsy
  • Excision mandatory regardless of grade
  • Lifelong follow-up

Mnemonics

  • RED = Really Every Dysplastic — biopsy every red patch

Clinical pearls

  • Red > white — erythroplakia is more ominous than leukoplakia.
  • Any red patch not diagnosable as candidiasis or lichen planus must be biopsied.
  • Toluidine blue helps localise most dysplastic zones.
Full atlas page →

Fibrous Dysplasia

Fibro-osseous Lesions

Etiology

  • Post-zygotic activating mutation of GNAS gene (Gsα)

Clinical features

  • Slow painless unilateral swelling
  • Facial asymmetry
  • Ill-defined margins on imaging

Management

  • Observation for stable lesions
  • Bisphosphonates for pain/rapid progression
  • Cosmetic contouring after growth quiescence

Prognosis

  • Usually stabilises after skeletal maturity.
Full atlas page →

Geographic Tongue

Red Lesions

Definition

  • A benign inflammatory disorder of unknown aetiology presenting as circular or irregular areas of filiform papillae atrophy with raised keratotic borders that migrate over time on the dorsum and lateral tongue.

Etiology

  • Idiopathic; possible associations with psoriasis, atopy, stress, hormonal factors, nutritional deficiencies, and juvenile diabetes

Clinical features

  • Multiple, well-demarcated, smooth red patches on dorsum and lateral tongue
  • Raised, yellow-white, serpiginous or arcuate keratotic borders
  • Lesions migrate — change in shape and location over days to weeks
  • Usually asymptomatic; some report burning with hot/spicy/acidic foods
  • Often coexists with fissured tongue
  • Rare extra-lingual sites (ectopic geographic stomatitis): buccal mucosa, palate, gingiva

Investigations

  • Clinical diagnosis is sufficient
  • Screen haematinics if burning symptoms
  • Biopsy only if atypical or fixed lesion

Management

  • Reassurance — no treatment required in asymptomatic cases
  • Avoid triggers: hot, spicy, acidic foods; alcohol-containing mouthwashes
  • Topical anaesthetic (2% lidocaine viscous) for symptomatic relief
  • Topical corticosteroid (triamcinolone in orabase) for symptomatic lesions
  • Zinc supplementation — some reports of benefit
  • Address any co-existent nutritional deficiency

Prognosis

  • Excellent — benign, no malignant potential.

Quick revision

  • Migrating red patches + white borders
  • Psoriasiform histology
  • Benign, no treatment
  • Associated with fissured tongue

Mnemonics

  • GEO = Grows, Erases, Reappears Over time

Clinical pearls

  • Migration is diagnostic — ask patient to photograph over 1–2 weeks.
  • Reassurance is the treatment; no biopsy needed if classical.
  • Screen for haematinics if burning persists.
Full atlas page →

Haemangioma

Benign Tumors

Definition

  • Benign neoplasm of vascular endothelium characterised by GLUT-1 positivity (infantile type), rapid proliferation then spontaneous involution.

Clinical features

  • Bright red 'strawberry' cutaneous lesion or bluish deep swelling
  • Blanches on pressure
  • Head & neck in 60%
  • Beard distribution → airway involvement
  • PHACES syndrome (Posterior fossa, Haemangioma, Arterial, Cardiac, Eye, Sternal)

Investigations

  • Clinical diagnosis usually sufficient
  • USG with Doppler: high-flow lesion
  • MRI for deep/segmental lesions
  • Biopsy rarely required; GLUT-1 IHC differentiates from malformation

Management

  • Observation for uncomplicated lesions (spontaneous involution)
  • First-line pharmacotherapy: oral propranolol 2–3 mg/kg/day
  • Topical timolol for superficial
  • Systemic steroids (historical, second-line)
  • Pulsed-dye laser for residual telangiectasia
  • Surgical excision for functional/aesthetic residuum after involution

Prognosis

  • Excellent; 50% resolve by age 5, 90% by 9 years.

Quick revision

  • GLUT-1+ · propranolol first line · 90% involute by age 9
Full atlas page →

Hemifacial Microsomia

Developmental Disorders

Definition

  • Congenital asymmetric hypoplasia of structures derived from the first and second branchial arches, most commonly affecting the mandible, ear, and facial soft tissues.

Etiology

  • Sporadic vascular disruption of stapedial artery
  • Possible genetic component (14q32)
  • Environmental teratogens

Clinical features

  • Mandibular hypoplasia (Pruzansky grades)
  • Microtia/anotia
  • Facial nerve weakness
  • Soft tissue deficiency
  • Macrostomia
  • Preauricular tags
  • Vertebral anomalies (Goldenhar)

Investigations

  • Clinical + 3D CT
  • Audiometry
  • Spine X-ray if Goldenhar suspected

Management

  • Multidisciplinary craniofacial team
  • Distraction osteogenesis (mandible)
  • Costochondral graft for TMJ reconstruction
  • Orthognathic surgery at skeletal maturity
  • Ear reconstruction

Prognosis

  • Good functional and aesthetic outcomes with staged surgical management.

Quick revision

  • 1st + 2nd arch derivative hypoplasia
  • OMENS: Orbit, Mandible, Ear, Nerve, Soft tissue
  • Stapedial artery haemorrhage theory
Full atlas page →

HPV-associated Oropharyngeal SCC

Oral Cancer

Definition

  • Squamous cell carcinoma of the oropharynx associated with transcriptionally active high-risk human papillomavirus (predominantly HPV-16).

Etiology

  • HPV-16 (>90% of HPV-OPSCC), HPV-18/33 less commonly
  • Oral–oral and oral–genital sexual transmission

Clinical features

  • Painless neck lump (cystic level II lymphadenopathy) often presenting feature
  • Sore throat, dysphagia, referred otalgia
  • Tonsillar asymmetry or base-of-tongue mass

Investigations

  • p16 IHC (surrogate; block staining >70% cells positive)
  • HPV DNA PCR / RNA in situ hybridisation (confirmatory)
  • MRI head-neck
  • PET-CT for staging and unknown primary
  • EUA with biopsy of tonsil / tongue base

Management

  • Concurrent chemoradiation (cisplatin) — standard for locally advanced disease
  • Transoral robotic surgery (TORS) with neck dissection for selected T1-T2 lesions ± adjuvant therapy
  • De-escalation trials ongoing (reduced-dose RT)

Prognosis

  • 5-year overall survival ≈ 75–85% (vs 40–50% for p16-negative OPSCC).

Quick revision

  • HPV-16 · p16+ · better prognosis · AJCC 8 separate staging · TORS or chemoRT
Full atlas page →

Kaposi Sarcoma

Malignant Tumors

Definition

  • HHV-8-driven mesenchymal malignancy of endothelial origin producing multifocal vascular lesions of skin and mucosa.

Etiology

  • HHV-8 (KSHV) infection
  • Cofactor: immunosuppression (HIV, transplant)

Clinical features

  • Flat red-purple macule → plaque → nodule
  • Hard palate most common oral site, then gingiva, tongue
  • Multifocal, painless initially → ulceration and bleeding
  • Cutaneous, GI, pulmonary involvement in advanced disease

Investigations

  • Biopsy with HHV-8 IHC
  • HIV testing and CD4 count
  • CT chest/abdomen for staging
  • Endoscopy if GI symptoms

Management

  • Optimise ART (mainstay for AIDS-KS)
  • Local: intralesional vinblastine, radiotherapy, cryotherapy, sclerotherapy
  • Systemic: liposomal doxorubicin, paclitaxel for advanced disease
  • Reduce immunosuppression in transplant-related KS

Prognosis

  • AIDS-KS: dramatically improved with ART. Classic KS: indolent, elderly-appropriate care.

Quick revision

  • HHV-8 · palate · LANA-1+ · ART + local/systemic therapy
Full atlas page →

Lateral Periodontal Cyst

Odontogenic Cysts

Definition

  • A developmental odontogenic cyst arising from rests of dental lamina, located on the lateral aspect of a vital tooth root, characterised by a thin non-keratinised epithelial lining with focal plaque-like thickenings.

Etiology

  • Developmental — from rests of dental lamina (Serres) or reduced enamel epithelium along lateral root

Clinical features

  • Usually asymptomatic — incidental radiographic finding
  • Occasional painless swelling on facial gingiva
  • Associated teeth are vital and non-carious

Investigations

  • Vitality tests of adjacent teeth (must be vital)
  • Periapical radiograph
  • CBCT for surgical planning
  • Histology after enucleation

Management

  • Conservative enucleation with preservation of adjacent teeth
  • Botryoid variant may require enucleation with careful curettage due to multilocularity

Prognosis

  • Excellent for classical LPC; guarded for botryoid due to recurrence.

Quick revision

  • Vital tooth, interradicular, small unilocular radiolucency, glycogen-rich clear cells, mandibular premolar region

Mnemonics

  • LPC = Lateral, Premolar, Clear cells

Clinical pearls

  • Vital tooth + tiny interradicular radiolucency = LPC.
  • Botryoid variant recurs — treat like a mini-OKC.
Full atlas page →

Le Fort Fractures

Trauma

Definition

  • Transverse fractures of the maxilla that separate all or part of the maxilla from the skull base along lines of structural weakness.

Etiology

  • High-energy blunt trauma: RTA, assault, fall from height

Clinical features

  • Facial oedema, ecchymosis
  • Malocclusion, anterior open bite
  • Mobile midface on rocking maxilla (I) or nasofrontal complex (II/III)
  • CSF rhinorrhoea (II/III)
  • Battle sign, raccoon eyes (III)
  • Elongated (donkey) face
  • Numbness in V2 distribution

Investigations

  • ATLS primary survey
  • CT face with 3D reconstruction (gold standard)
  • Beta-2 transferrin for CSF rhinorrhoea

Management

  • Airway priority (may need surgical airway)
  • Cervical spine clearance
  • Reduction and rigid internal fixation via facial buttress reconstruction
  • Access: sublabial (I), subciliary/transconjunctival + sublabial (II), coronal + additional approaches (III)
  • IMF or MMF as required
  • Post-op: elemental diet, oral hygiene, IMF release protocol

Prognosis

  • Good with early anatomical reduction; delayed treatment leads to permanent facial elongation and malocclusion.

Quick revision

  • I floating palate · II pyramidal · III craniofacial disjunction · buttress reconstruction
Full atlas page →

Leukoedema

White Lesions

Definition

  • A common, asymptomatic mucosal variation characterised by intracellular oedema of the spinous layer of the buccal epithelium, producing a diffuse milky-white appearance that resolves on stretching.

Etiology

  • Considered a normal anatomical variation; possibly exacerbated by chronic irritation (smoking, alcohol, poor oral hygiene)

Clinical features

  • Bilateral, symmetrical, diffuse grey-white to milky opalescence of buccal mucosa
  • Extends onto labial mucosa and occasionally floor of mouth
  • Wrinkled or folded surface texture
  • Diagnostic sign: appearance disappears on stretching the cheek — pathognomonic
  • Asymptomatic; no pain or functional issues

Investigations

  • Clinical examination sufficient
  • Biopsy only if diagnosis uncertain or lesion does not disappear on stretch

Management

  • No treatment necessary
  • Habit cessation (tobacco, alcohol) may reduce prominence

Prognosis

  • Excellent — no malignant potential.

Quick revision

  • Bilateral, diffuse, milky
  • Disappears on stretch
  • Intracellular oedema of spinous layer
  • Benign, no treatment

Mnemonics

  • Leukoedema Leaves on stretch

Clinical pearls

  • When you stretch the cheek and the whiteness vanishes, it is leukoedema.
  • Very common in Black adults — do not misdiagnose as leukoplakia.
Full atlas page →

Leukoplakia

White Lesions

Definition

  • WHO 2005: 'A white plaque of questionable risk having excluded other known diseases or disorders that carry no increased risk for cancer.'

Etiology

  • Tobacco (smoking and smokeless)
  • Areca nut / pan / gutka
  • Alcohol (synergistic)
  • Candida albicans (co-factor in nodular type)
  • HPV 16/18 (subset)
  • Chronic mechanical / galvanic irritation (contested)
  • Idiopathic (~10–30%)

Clinical features

  • Homogeneous — thin, flat, uniform white plaque with sharp margins
  • Non-homogeneous — nodular, verrucous, speckled (erythroleukoplakia) — significantly higher malignant risk
  • Proliferative verrucous leukoplakia (PVL) — multifocal, persistent, recurrent, elderly women, gingiva
  • Cannot be scraped off (differentiates from candidiasis)
  • Common sites: buccal mucosa, lateral/ventral tongue, floor of mouth, retromolar area

Investigations

  • Toluidine blue vital staining (adjunct, false positives)
  • Autofluorescence (VELscope) screening
  • Brush cytology + DNA image cytometry
  • Incisional biopsy of most suspicious area — GOLD STANDARD
  • Molecular markers: LOH panel, TP53 IHC in research settings

Management

  • Habit cessation (tobacco, areca, alcohol) — MANDATORY first step
  • Small homogeneous, no dysplasia: observation + 3-monthly review
  • Dysplastic or non-homogeneous: complete excision
  • Topical/systemic retinoids, β-carotene, lycopene — adjuncts only, high recurrence on withdrawal

Prognosis

  • Overall malignant transformation ≈ 1% per year (range 0.1–17%). Risk factors: non-homogeneous type, size > 200 mm², floor of mouth / ventral tongue, high-grade dysplasia, female non-smoker, PVL (up to 70% lifetime).

Quick revision

  • Diagnosis of exclusion — clinical + histological
  • Non-homogeneous >> homogeneous risk
  • Habit cessation is treatment step 1
  • Biopsy is mandatory
  • Lifelong follow-up for high-risk lesions

Mnemonics

  • Non-homogeneous = Nasty (higher risk)
  • PVL — Persistent, Verrucous, Lethal

Clinical pearls

  • Any leukoplakia that fails to regress 2–4 weeks after removing irritants must be biopsied.
  • Red > white — a speckled lesion is more ominous than a homogeneous plaque.
  • PVL is a clinical, not histological, diagnosis — established retrospectively.
Full atlas page →

Ludwig's Angina

Maxillofacial Infections

Etiology

  • Odontogenic infection from mandibular molars (most common)
  • Polymicrobial: streptococci, staphylococci, anaerobes

Clinical features

  • Brawny bilateral submandibular swelling
  • Raised, protruding, oedematous tongue ('woody floor of mouth')
  • Trismus, dysphagia, drooling
  • Stridor — impending airway obstruction
  • Fever, toxicity

Investigations

  • CBC, CRP, blood culture
  • CECT neck — extent and mediastinal spread
  • Airway assessment

Management

  • Airway management is priority — fibre-optic intubation or elective tracheostomy
  • IV broad-spectrum antibiotics (Amoxi-clav + metronidazole; add clindamycin/vancomycin for MRSA suspicion)
  • Incision & drainage of all involved spaces
  • Removal of causative tooth

Prognosis

  • Mortality < 10% with prompt airway control and IV antibiotics.

Clinical pearls

  • Airway first, antibiotics second, drainage third.
Full atlas page →

Mandibular Fracture

Trauma

Clinical features

  • Malocclusion
  • Step deformity, mobility, crepitus
  • Sublingual haematoma (Coleman's sign)
  • Numbness in mental nerve distribution
  • Deviation of chin on opening (condylar #)

Management

  • Closed reduction: MMF / IMF for minimally displaced, condylar, paediatric
  • Open reduction & internal fixation (ORIF): displaced, unfavourable, condylar with malocclusion, edentulous
  • AO/Champy's principles of osteosynthesis

Prognosis

  • Excellent with anatomical reduction and stable fixation.
Full atlas page →

Median Rhomboid Glossitis

Red Lesions

Definition

  • A localised area of atrophic filiform papillae on the midline posterior dorsum of the tongue, chronically associated with Candida infection rather than the previously proposed developmental origin.

Etiology

  • Chronic Candida albicans infection (currently accepted view)
  • Historically considered developmental — persistence of the tuberculum impar — now largely rejected

Clinical features

  • Well-demarcated, oval or rhomboidal red or pink patch
  • Located in the midline of the posterior dorsum of the tongue, immediately anterior to the circumvallate papillae
  • Smooth or slightly nodular / lobulated surface
  • Usually asymptomatic; occasionally burning or altered taste
  • Kissing lesion on palate in HIV / immunocompromised

Investigations

  • Clinical + KOH mount / culture for Candida
  • HbA1c, HIV screen in extensive / non-responding cases
  • Biopsy if clinical suspicion of neoplasm — but interpret cautiously due to pseudo-epitheliomatous hyperplasia

Management

  • Systemic fluconazole 100–200 mg once daily × 14 days (extensive/nodular)
  • Topical nystatin or miconazole gel for milder cases
  • Smoking cessation
  • Address underlying immunosuppression / diabetes
  • Surgical excision reserved for persistent nodular lesion or when malignancy cannot be excluded

Prognosis

  • Excellent — benign; not premalignant.

Quick revision

  • Midline posterior dorsum tongue
  • Rhomboidal red patch
  • Candida-associated
  • Fluconazole responds
  • Beware pseudo-epitheliomatous hyperplasia

Mnemonics

  • MRG = Midline Rhomboid, Grows on Candida

Clinical pearls

  • Any midline red patch of the tongue in a smoker / diabetic — think MRG.
  • Palatal kissing lesion — screen for HIV.
  • Do not diagnose SCC from a superficial biopsy of MRG — beware pseudo-epitheliomatous hyperplasia.
Full atlas page →

Medication-Related Osteonecrosis of the Jaws

Bone Diseases

Definition

  • AAOMS 2022: exposed bone or bone probed through a fistula in the maxillofacial region persisting >8 weeks in a patient with current or previous antiresorptive/antiangiogenic drug exposure and no history of jaw radiation or obvious metastatic disease.

Etiology

  • Bisphosphonates (zoledronate, alendronate, pamidronate)
  • Denosumab
  • Antiangiogenics: bevacizumab, sunitinib
  • mTOR inhibitors

Clinical features

  • Exposed necrotic bone
  • Pain, swelling, halitosis, purulence
  • Loose teeth, sinus tracts
  • Mandible > maxilla (posterior)

Investigations

  • OPG, CBCT for extent
  • MRI/CT for advanced staging
  • Cultures for superadded infection

Management

  • Prevention key: dental screening BEFORE therapy; complete extractions with 4–6 wk healing
  • Stage 0/1: chlorhexidine mouthwash, analgesia, careful monitoring
  • Stage 2: antibiotics (amoxicillin/metronidazole), superficial debridement
  • Stage 3: sequestrectomy/resection with reconstruction
  • Drug holiday controversial — coordinate with oncologist; not evidence-based for denosumab
  • Adjuncts: PRF, teriparatide (non-oncology), ozone, hyperbaric oxygen (limited evidence)

Prognosis

  • Difficult; prevention >> treatment. Stage 3 often requires major resection.

Quick revision

  • AAOMS 2022 · exposed bone >8 wk · prevention with pre-treatment dental clearance
Full atlas page →

Mucocele

Soft Tissue Lesions

Definition

  • Cystic or pseudocystic accumulation of mucin following rupture of a salivary duct (extravasation) or obstruction (retention).

Etiology

  • Trauma to minor salivary gland duct (extravasation)
  • Duct obstruction (retention)

Clinical features

  • Painless, dome-shaped, bluish-translucent swelling
  • Fluctuant
  • History of trauma/lip biting
  • May rupture and recur

Investigations

  • Clinical diagnosis; excisional biopsy confirms

Management

  • Excision with associated minor salivary gland
  • Marsupialization (ranula)

Prognosis

  • Excellent with complete excision.

Quick revision

  • Bluish fluctuant lower lip swelling
  • Extravasation = pseudocyst
  • Excise with gland
Full atlas page →

Mucoepidermoid Carcinoma

Salivary Gland Disorders

Definition

  • Malignant epithelial salivary gland neoplasm characterised by variable proportions of mucous, intermediate and squamoid cells.

Etiology

  • Sporadic; ionising radiation increases risk
  • CRTC1(MECT1)-MAML2 fusion in ≈50–70%

Clinical features

  • Painless slow-growing swelling (low grade) — may mimic mucocele on palate
  • Rapidly growing painful mass with fixation, facial nerve palsy (high grade)
  • Fluctuant bluish palatal swelling common

Investigations

  • MRI (soft-tissue detail, perineural spread)
  • FNAC / core biopsy
  • CT chest for staging

Management

  • Wide local excision with clear margins
  • Parotid: superficial or total parotidectomy with facial nerve preservation
  • Neck dissection for high-grade / cN+
  • Adjuvant radiotherapy for high-grade, positive margins, perineural or vascular invasion
  • Chemotherapy for palliation

Prognosis

  • 5-year survival: low grade >90%, intermediate ~70%, high grade 30–50%.

Quick revision

  • MAML2 fusion · commonest paediatric salivary malignancy · grade determines prognosis
Full atlas page →

Mucous Membrane Pemphigoid

Vesiculobullous Diseases

Definition

  • Autoimmune disease with autoantibodies against basement membrane zone proteins causing subepithelial blisters.

Etiology

  • Autoantibodies against BP180, BP230, laminin-332, laminin-311, type VII collagen

Clinical features

  • Intact blisters (more common than pemphigus due to thicker roof)
  • Desquamative gingivitis
  • Positive Nikolsky sign (may be negative)
  • Ocular: symblepharon, entropion, blindness
  • Other sites: nose, pharynx, larynx, genitalia

Investigations

  • Perilesional biopsy for DIF
  • Serum ELISA/IIF for circulating antibodies

Management

  • Mild oral: topical corticosteroids, tacrolimus
  • Moderate: dapsone, tetracycline + niacinamide
  • Severe/ocular: systemic steroids, azathioprine, mycophenolate, rituximab

Prognosis

  • Chronic; ocular scarring is major morbidity.

Quick revision

  • Subepithelial blisters
  • Linear IgG BMZ
  • Ocular scarring risk
Full atlas page →

Mumps (Epidemic Parotitis)

Salivary Gland Disorders

Definition

  • Acute systemic viral infection of paramyxovirus (Rubulavirus) with tropism for glandular and nervous tissues.

Etiology

  • Mumps virus (paramyxovirus)

Clinical features

  • Prodrome: fever, malaise, myalgia, headache
  • Painful bilateral parotid swelling (70%) with elevated earlobe
  • Trismus, pain on chewing acidic foods
  • Redness around Stensen duct opening without pus
  • Orchitis, oophoritis, meningo-encephalitis, deafness

Investigations

  • Clinical diagnosis
  • Serology: IgM to mumps virus
  • RT-PCR of saliva/buccal swab
  • Serum amylase elevated (salivary isoenzyme)

Management

  • Supportive: hydration, analgesia, antipyretics, bed rest
  • Isolation for 5 days after swelling onset
  • No antivirals of proven benefit

Prognosis

  • Self-limiting; resolves in 7–10 days; lifelong immunity.

Quick revision

  • Paramyxovirus · bilateral parotitis · MMR vaccine
Full atlas page →

Nasolabial Cyst

Non-odontogenic Cysts

Definition

  • A soft-tissue, non-odontogenic developmental cyst located in the nasolabial fold, external to the maxillary bone, arising from epithelial remnants along the embryonic fusion of the medial nasal, lateral nasal and maxillary processes — or, per current theory, from misplaced nasolacrimal duct epithelium.

Etiology

  • Developmental — misplaced epithelium of the inferior nasolacrimal duct (currently favoured theory)
  • Historical: entrapped ectoderm at fusion of medial nasal, lateral nasal and maxillary embryonic processes
  • Occasional trauma or infection as triggers for enlargement

Clinical features

  • Slowly enlarging, painless swelling of the upper lip lateral to the midline
  • Obliteration of the nasolabial fold
  • Elevation of the ala nasi and lifting of the nasal tip
  • Bulging into the floor of the nasal vestibule
  • Fluctuant on palpation
  • Nasal obstruction if large

Investigations

  • Vitality testing of adjacent maxillary teeth (must be vital)
  • MRI or CT to confirm soft-tissue location
  • USG for a first pass
  • Aspiration — mucoid fluid
  • Excisional biopsy definitive

Management

  • Complete surgical excision via sublabial approach is the gold standard
  • Endoscopic transnasal marsupialisation is a minimally invasive alternative with low morbidity and comparable recurrence
  • Aspiration alone is not curative

Prognosis

  • Excellent with complete excision. No malignant potential documented.

Quick revision

  • Extra-osseous non-odontogenic cyst
  • Female middle-aged predominance
  • 10% bilateral
  • Respiratory epithelium with goblet cells
  • MRI diagnostic
  • Sublabial excision curative

Mnemonics

  • Klestadt = Klean out from Klestadt approach (sublabial)

Clinical pearls

  • A soft-tissue swelling that lifts the ala nasi with vital adjacent teeth is a nasolabial cyst.
  • Endoscopic marsupialisation is faster with less morbidity — offer as an option to modern patients.
Full atlas page →

Nasopalatine Duct Cyst

Non-odontogenic Cysts

Definition

  • A developmental, non-odontogenic, intra-osseous cyst arising from proliferation of epithelial residues of the paired embryonic nasopalatine ducts within the incisive canal of the anterior maxilla.

Etiology

  • Spontaneous proliferation of nasopalatine duct epithelial remnants
  • Trauma from ill-fitting denture
  • Local inflammation
  • Bacterial infection
  • Mucus retention within duct remnants

Clinical features

  • Often asymptomatic, incidental radiographic finding
  • Palatal swelling in the midline behind the maxillary central incisors
  • Labial vestibular swelling in larger lesions
  • Salty or mucoid discharge if fistulised into the mouth
  • Vital adjacent incisors — pathognomonic distinguisher from radicular cyst

Investigations

  • Vitality testing of both central incisors (must be vital)
  • Periapical + occlusal + panoramic radiographs
  • CBCT for pre-surgical planning
  • Fine-needle aspiration — mucoid straw-coloured fluid
  • Excisional biopsy for definitive diagnosis

Management

  • Surgical enucleation is the treatment of choice
  • Palatal approach for palatally located cysts
  • Labial (sulcular) approach for buccally expanded lesions
  • Marsupialisation reserved for very large cysts abutting the nasal floor

Prognosis

  • Excellent. Complete cure expected after enucleation.

Quick revision

  • Most common non-odontogenic oral cyst
  • From nasopalatine duct remnants
  • Heart-shaped radiolucency in anterior maxillary midline
  • Vital adjacent teeth
  • Neurovascular bundle in cyst wall is pathognomonic
  • Enucleation is curative

Mnemonics

  • NASO-PALATINE: Neurovascular bundle, Anterior maxilla, Salty discharge, Oval/heart-shape, Painless, Adults 4th–6th decade, Localised, Adjacent teeth vital, Treatment enucleation, Incisive canal, Non-odontogenic, Excellent prognosis.

Clinical pearls

  • Vital teeth + midline anterior maxilla + heart-shape = nasopalatine cyst.
  • Counsel every patient about transient palatal numbness before surgery.
Full atlas page →

Odontogenic Keratocyst

Odontogenic Cysts

Definition

  • A benign but locally aggressive developmental odontogenic cyst characterised by a distinctive parakeratinised stratified squamous epithelial lining and marked propensity for recurrence. WHO 2022 reclassified it once again as an odontogenic cyst.

Etiology

  • Developmental — arises from remnants of dental lamina (rests of Serres)
  • PTCH1 tumour-suppressor gene mutation (Sonic Hedgehog pathway)

Clinical features

  • Often asymptomatic, discovered incidentally on OPG
  • Painless swelling only when very large
  • Grows anteroposteriorly along medullary bone — minimal buccolingual expansion
  • Displacement of teeth, occasional paraesthesia
  • May be associated with unerupted tooth (mimics dentigerous)

Investigations

  • Aspiration — thick cheesy fluid, keratin flakes, protein < 4 g/dL
  • Incisional biopsy for histopathological confirmation
  • Genetic testing for PTCH1 in suspected Gorlin syndrome
  • Skin examination for BCCs, palmar pits
  • Chest X-ray, brain imaging in Gorlin

Management

  • Enucleation alone — recurrence 25–60%
  • Enucleation + Carnoy's solution (modified, without CHCl3) — recurrence 8–10%
  • Enucleation + peripheral ostectomy — recurrence 10–20%
  • Enucleation + cryotherapy (liquid N2) — recurrence 11%
  • Marsupialisation — reduces size, decreases recurrence when followed by enucleation
  • Resection (segmental/marginal) for aggressive/recurrent OKCs — recurrence < 2% but greatest morbidity
  • Vismodegib (SMO inhibitor) — experimental for Gorlin syndrome

Prognosis

  • Excellent for lifespan; recurrence and morbidity are the main issues. Syndromic OKCs require long-term surveillance.

Quick revision

  • From rests of Serres, PTCH1 mutation
  • Posterior mandible
  • Grows anteroposteriorly, little expansion
  • Parakeratinised, palisaded basal, flat CT junction
  • High recurrence — enucleation + adjunct
  • Multiple/young → screen Gorlin

Mnemonics

  • OKC = Only Kids Come (young age); PARA-K, PALI-sade, FLAT junction, SATELLITES = 4 histologic pillars

Clinical pearls

  • 'Empty' looking lesion on OPG in the mandibular ramus of a young patient — think OKC.
  • Always screen for skin BCCs and palmar pits.
  • Marsupialise big lesions, enucleate later — safer and lower recurrence.
Full atlas page →

Odontogenic Myxoma

Odontogenic Tumors

Definition

  • A benign, locally infiltrative odontogenic tumour of ectomesenchymal origin, composed of loosely arranged stellate and spindle cells in an abundant myxoid extracellular matrix.

Etiology

  • Origin from odontogenic ectomesenchyme (dental follicle, papilla, periodontal ligament)

Clinical features

  • Slow, painless swelling
  • Loosening or displacement of teeth
  • Cortical expansion and thinning
  • Facial asymmetry

Investigations

  • Incisional biopsy (aspiration first to exclude vascular lesion)
  • CBCT + MRI for surgical planning

Management

  • Small lesions: aggressive curettage + peripheral ostectomy ± chemical adjunct (Carnoy's)
  • Medium/large: marginal or segmental resection with 1–1.5 cm bony margin
  • Immediate or delayed reconstruction (fibula free flap)

Prognosis

  • Excellent for lifespan; morbidity from recurrence and reconstruction.

Quick revision

  • Ectomesenchymal
  • Mandible > maxilla
  • Tennis-racket / step-ladder / soap-bubble
  • Stellate cells + myxoid stroma
  • No capsule → recurs; resect with margin

Mnemonics

  • Myxoma = Mucin, Mesenchyme, Mandible, Multilocular, Must resect with Margin

Clinical pearls

  • Multilocular + straight fine septa + stringy aspirate = myxoma until proven otherwise.
  • Never curette a multilocular radiolucency without aspirating first.
Full atlas page →

Odontoma

Odontogenic Tumors

Definition

  • A benign mixed odontogenic tumour (currently considered a hamartoma) composed of enamel, dentin, cementum and pulp tissue in variable degrees of organisation.

Etiology

  • Local trauma or infection during odontogenesis
  • Genetic predisposition (Gardner syndrome — multiple odontomas)
  • Familial cases reported

Clinical features

  • Usually asymptomatic — detected on OPG for failure of eruption
  • Small painless bony swelling
  • Retained deciduous teeth / unerupted permanent teeth
  • Rare eruption ('erupted odontoma') with local infection

Investigations

  • Clinical + radiographic diagnosis usually sufficient
  • CBCT for planning
  • Histology after excision
  • Colonoscopy + APC gene testing if multiple odontomas

Management

  • Surgical enucleation with removal of surrounding fibrous capsule
  • Orthodontic traction of associated unerupted tooth after odontoma removal
  • Multiple odontomas → investigate for Gardner syndrome

Prognosis

  • Excellent.

Quick revision

  • Hamartoma
  • Most common odontogenic tumour
  • Compound (anterior maxilla) vs complex (posterior mandible)
  • Radiopacity + halo
  • Gardner if multiple

Mnemonics

  • Compound = Cluster (of denticles), Complex = Chaos

Clinical pearls

  • Any impacted tooth in an unusual position — look for an overlying odontoma.
  • Multiple odontomas + colonic polyps = Gardner — refer for colonoscopy.
Full atlas page →

Oral Candidiasis

White Lesions

Definition

  • Superficial infection of oral mucosa by Candida species (mainly C. albicans), occurring when host defences or oral flora are disrupted.

Etiology

  • Candida albicans (85%)
  • C. glabrata, C. tropicalis, C. krusei (increasingly, especially in immunocompromised and after azole use)

Clinical features

  • Pseudomembranous (thrush): creamy white curd-like plaques that wipe off leaving erythematous or bleeding base — palate, buccal mucosa, tongue
  • Erythematous (atrophic): red, painful mucosa; central papillary atrophy of dorsal tongue (median rhomboid glossitis is a form)
  • Chronic hyperplastic (candidal leukoplakia): white plaque that does NOT wipe off — commissures of buccal mucosa, potentially malignant
  • Denture stomatitis (Newton's types I–III): erythema of denture-bearing palate
  • Angular cheilitis: cracked, erythematous fissures at oral commissures
  • Chronic mucocutaneous candidiasis: persistent skin, nail and mucosal involvement in immunodeficient patients

Investigations

  • KOH 10% wet mount — budding yeast and pseudohyphae
  • Sabouraud dextrose agar culture with germ-tube test (C. albicans)
  • Oral rinse / imprint culture (quantitative)
  • Biopsy for chronic hyperplastic candidiasis
  • Screen underlying disease: HIV, diabetes, immunodeficiency, haematinics

Management

  • Topical: nystatin oral suspension 100,000 IU/ml — swish & swallow 4× daily for 7–14 days
  • Topical: miconazole oral gel 2% or clotrimazole troches 10 mg 5×/day
  • Systemic: fluconazole 100–200 mg once daily 7–14 days (recurrent/immunocompromised)
  • Itraconazole 200 mg/day or voriconazole for azole-resistant strains
  • Denture stomatitis: soak denture in chlorhexidine 0.2% or sodium hypochlorite overnight, replace worn dentures
  • Angular cheilitis: miconazole cream + hydrocortisone (Daktacort) to commissures

Prognosis

  • Excellent for acute forms in immunocompetent hosts; poorer for chronic mucocutaneous and hyperplastic types. ≈ 10% of chronic hyperplastic candidiasis develops dysplasia/SCC.

Quick revision

  • 4 primary + 3 Candida-associated types
  • Pseudomembranous wipes off; hyperplastic does not
  • PAS stain shows hyphae
  • Topical nystatin first line; fluconazole for refractory
  • Always investigate underlying disease in recurrent cases

Mnemonics

  • Predisposing = ABCDE: Antibiotics, Broad immunosuppression, Corticosteroids, Diabetes, Extremes of age

Clinical pearls

  • Wipes off = candidiasis; doesn't wipe off = biopsy.
  • Chronic hyperplastic candidiasis on commissures — 10% risk of dysplasia.
  • Recurrent candidiasis in an adult — screen for HIV and diabetes.
Full atlas page →

Oral Lichen Planus

White Lesions

Definition

  • A chronic, immunologically mediated mucocutaneous disease characterised by CD8+ T-cell-directed apoptosis of basal keratinocytes, presenting with bilateral, symmetrical white striae and/or erosions of oral mucosa.

Etiology

  • Idiopathic — T-cell autoimmune reaction against basal keratinocytes
  • Hepatitis C virus association (particularly in Mediterranean populations)
  • Drug reactions (lichenoid): ACE inhibitors, NSAIDs, β-blockers, antimalarials, sulphonylureas
  • Dental materials (amalgam, gold, composites — lichenoid contact reaction)
  • Stress and anxiety (exacerbating factor)

Clinical features

  • Bilateral, symmetrical distribution — hallmark feature
  • Reticular — interlacing white Wickham striae (most common, asymptomatic)
  • Papular — small white papules
  • Plaque-like — homogeneous white plaque mimicking leukoplakia
  • Atrophic — red, thinned mucosa with striae at margins
  • Erosive — painful ulcers with peripheral striae
  • Bullous — rare, fluid-filled blisters that rupture
  • Common sites: posterior buccal mucosa (bilaterally), tongue, gingiva (desquamative gingivitis)
  • Skin: purple, pruritic, polygonal, planar papules (6 Ps) on flexor surfaces
  • Nails, scalp (lichen planopilaris), genital mucosa may be involved

Investigations

  • Incisional biopsy including intact epithelium and lamina propria
  • Direct immunofluorescence: shaggy fibrinogen deposition at BMZ, Civatte bodies stain for IgM
  • Hepatitis C serology (endemic areas)
  • Patch testing if contact lichenoid reaction suspected

Management

  • Reticular / asymptomatic: reassurance, oral hygiene, observation
  • Symptomatic (atrophic/erosive): topical high-potency corticosteroids (clobetasol 0.05%, fluocinonide) as gel or in orabase
  • Intralesional triamcinolone for localised persistent erosions
  • Systemic corticosteroids (prednisolone 40–60 mg/day tapering) for severe widespread disease
  • Topical calcineurin inhibitors (tacrolimus 0.1%, pimecrolimus) — steroid-sparing
  • Systemic immunomodulators: azathioprine, mycophenolate, hydroxychloroquine, methotrexate, retinoids for refractory cases
  • Chlorhexidine mouthwash; antifungals to cover steroid-induced candidiasis

Prognosis

  • Chronic disease; malignant transformation ≈ 1% over 5 years (higher for erosive/atrophic types).

Quick revision

  • 6 Andreasen types
  • 6 Ps of cutaneous LP: Purple, Pruritic, Polygonal, Planar, Papules
  • Basal cell degeneration + saw-tooth rete + band-like infiltrate
  • Topical clobetasol = first line
  • 1% MT over 5 years

Mnemonics

  • 6 Ps of LP: Purple, Pruritic, Polygonal, Planar, Papules, (+ Plaque)

Clinical pearls

  • Bilateral, symmetric, reticular — think OLP first.
  • Steroid + antifungal together — steroids provoke candidiasis.
  • Re-biopsy any long-standing lesion that changes character.
Full atlas page →

Oral Lipoma

Benign Tumors

Definition

  • Benign neoplasm composed of mature adipose tissue enclosed by a thin fibrous capsule.

Clinical features

  • Soft, yellow, dome-shaped, freely mobile submucosal mass
  • Painless, slow-growing
  • Positive 'slip sign'

Investigations

  • Clinical diagnosis usually; USG or MRI for deep lesions (fat-signal hyperintense on T1)

Management

  • Conservative surgical excision with capsule — curative

Prognosis

  • Excellent; malignant transformation to liposarcoma exceedingly rare (except atypical lipomatous variants).

Quick revision

  • Adipocyte tumour · buccal mucosa · excision curative
Full atlas page →

Oral Manifestations of CKD

Systemic Diseases

Definition

  • Oral changes associated with chronic kidney disease and end-stage renal disease, secondary to uraemia, mineral-bone disorder and medications.

Clinical features

  • Uraemic fetor (ammoniacal breath)
  • Metallic taste
  • Mucosal pallor from anaemia
  • Xerostomia and enlarged salivary glands
  • Uraemic stomatitis: white plaques/pseudomembranes
  • Gingival bleeding, petechiae
  • Delayed eruption, enamel hypoplasia in children
  • Cyclosporine/nifedipine-induced gingival overgrowth in transplant recipients

Investigations

  • FBC, urea, creatinine, eGFR
  • Calcium, phosphate, PTH, vitamin D
  • Coagulation profile before invasive dental treatment

Management

  • Coordinate care with nephrologist; treat on non-dialysis day, morning after dialysis
  • Avoid nephrotoxic drugs (NSAIDs, tetracycline, aminoglycosides)
  • Adjust doses (amoxicillin, aciclovir) per eGFR
  • Use LA with epinephrine cautiously if hypertensive
  • Manage bleeding with local haemostatics; consider DDAVP
  • Endocarditis prophylaxis if indicated (AV fistula not itself an indication)

Prognosis

  • Depends on underlying renal function; oral changes improve with dialysis/transplantation.

Quick revision

  • Uraemic fetor · lamina dura loss · treat morning after dialysis · avoid NSAIDs
Full atlas page →

Oral Manifestations of Diabetes Mellitus

Systemic Diseases

Clinical features

  • Periodontitis — the 'sixth complication' of diabetes
  • Xerostomia, sialosis
  • Candidiasis (especially denture stomatitis, angular cheilitis)
  • Delayed wound healing, altered taste
  • Recurrent oral abscesses
  • Burning mouth sensation

Investigations

  • HbA1c, fasting/random blood glucose

Management

  • Glycaemic control (multidisciplinary)
  • Aggressive periodontal therapy
  • Antifungal therapy for candidiasis
  • Saliva substitutes and stimulants

Clinical pearls

  • Non-surgical periodontal therapy can reduce HbA1c by ~0.4%.
Full atlas page →

Oral Manifestations of HIV/AIDS

Systemic Diseases

Definition

  • Spectrum of opportunistic infections, neoplasms and idiopathic conditions of the oral cavity associated with HIV infection and immunosuppression.

Clinical features

  • Pseudomembranous or erythematous candidiasis, angular cheilitis
  • Oral hairy leukoplakia (EBV) — corrugated white patch on lateral tongue, cannot be wiped off
  • Kaposi sarcoma — HHV-8, purple palatal macules/nodules
  • Non-Hodgkin lymphoma
  • Linear gingival erythema, necrotising ulcerative gingivitis/periodontitis/stomatitis
  • Aphthous-like ulcers (major)
  • Salivary gland disease with xerostomia and parotid enlargement
  • HPV-associated warts

Investigations

  • HIV serology and CD4 count
  • Biopsy of persistent lesions (KS, NHL, OHL)
  • Fungal smear/culture

Management

  • Initiate/optimise antiretroviral therapy (mainstay)
  • Candidiasis: topical nystatin/miconazole; systemic fluconazole for refractory
  • OHL: aciclovir; recurs on stopping
  • KS: ART ± intralesional vinblastine, radiotherapy, chemotherapy
  • NUP: debridement + metronidazole + chlorhexidine + amoxicillin
  • Standard universal infection control

Prognosis

  • Excellent when ART maintains CD4 and viral suppression; lesions often regress.

Quick revision

  • Candidiasis · OHL · KS · NUP · ART is definitive treatment
Full atlas page →

Oral Manifestations of Leukaemia

Systemic Diseases

Definition

  • Oral changes secondary to leukaemic infiltration, marrow failure (anaemia, thrombocytopenia, neutropenia) and treatment effects.

Clinical features

  • Diffuse boggy gingival enlargement covering crowns (esp AML M4/M5)
  • Spontaneous gingival bleeding, petechiae, ecchymoses (thrombocytopenia)
  • Mucosal pallor (anaemia)
  • Oral ulcers, opportunistic infections (candidiasis, HSV) from neutropenia
  • Odontogenic infections that fail to resolve
  • Chloroma (granulocytic sarcoma)

Investigations

  • FBC with peripheral smear (blasts)
  • Bone marrow aspiration/biopsy
  • Flow cytometry, cytogenetics
  • Coagulation profile before dental procedures

Management

  • Refer to haematology-oncology urgently
  • Delay elective dental treatment until remission
  • Dental screening BEFORE chemotherapy: eliminate infection foci
  • Chlorhexidine mouthwash, cryotherapy for mucositis
  • Platelet cover (≥ 50 × 10⁹/L) for extractions
  • Antibiotic prophylaxis if neutropenic

Prognosis

  • Depends on subtype, cytogenetics and response to therapy.

Quick revision

  • AML M4/M5 · gingival hyperplasia · FBC + BM aspirate
Full atlas page →

Oral Melanoma

Pigmented Lesions

Definition

  • Malignant neoplasm of melanocytes arising from oral mucosa, most commonly on palate or gingiva.

Etiology

  • Unknown; no UV association unlike cutaneous melanoma
  • Possible role of chronic irritation, melanosis

Clinical features

  • Brown-black macule/nodule
  • Irregular borders, variegated colour
  • May be amelanotic (pink/red)
  • Palate and maxillary gingiva most common
  • Late: ulceration, satellite lesions, bone invasion

Management

  • Wide surgical excision (margins 1–2 cm when possible)
  • Neck dissection if nodal disease
  • Adjuvant immunotherapy (pembrolizumab, nivolumab)
  • Radiotherapy (adjuvant/palliative)

Prognosis

  • Poor; 5-year survival 15–25%. Late presentation and rich lymphatics contribute.

Quick revision

  • Poor prognosis unlike cutaneous
  • Palate most common site
  • Wide excision + immunotherapy
Full atlas page →

Oral Melanotic Macule

Pigmented Lesions

Definition

  • Focal area of increased melanin deposition in basal layer without increase in melanocyte number.

Etiology

  • Idiopathic
  • Post-inflammatory
  • Chronic irritation

Clinical features

  • Flat, brown to black macule
  • Well-defined borders
  • Usually <1 cm
  • Non-elevated, non-palpable

Investigations

  • Biopsy if atypical features (irregular borders, rapid growth)

Management

  • Observation if clinical diagnosis confident
  • Excisional biopsy if doubt

Prognosis

  • Excellent; no malignant potential.

Quick revision

  • Most common oral pigmented lesion
  • Increased melanin, not melanocytes
  • Biopsy if suspicious
Full atlas page →

Oral Nevus

Pigmented Lesions

Definition

  • Benign proliferation of nevus cells (modified melanocytes) in oral mucosa.

Etiology

  • Unknown; possibly from neural crest migration

Clinical features

  • Well-circumscribed, brown to blue-black macule or papule
  • Commonly on hard palate
  • Usually <6 mm

Investigations

  • Excisional biopsy

Management

  • Excisional biopsy for diagnosis
  • No further treatment if benign

Prognosis

  • Excellent; malignant transformation rare.

Quick revision

  • Intramucosal most common type in mouth
  • Palate/gingiva sites
  • Excise for diagnosis
Full atlas page →

Oral Schwannoma

Benign Tumors

Definition

  • Benign, encapsulated peripheral nerve sheath tumour composed exclusively of well-differentiated Schwann cells.

Clinical features

  • Slow-growing, painless, firm, submucosal nodule
  • Usually solitary
  • May cause paraesthesia if involving lingual/IAN

Investigations

  • MRI: 'target sign' (central low, peripheral high T2)
  • Fine-needle aspiration unreliable

Management

  • Complete surgical excision with preservation of parent nerve fascicles
  • Malignant transformation extremely rare

Prognosis

  • Excellent; malignant peripheral nerve sheath tumour only in NF1 setting.

Quick revision

  • Antoni A/B · Verocay bodies · S-100+ · excision curative
Full atlas page →

Oral Squamous Cell Carcinoma

Oral Cancer

Etiology

  • Tobacco (smoked & smokeless)
  • Alcohol (synergistic with tobacco)
  • Areca nut
  • HPV 16 (oropharyngeal)
  • Chronic trauma
  • Immunosuppression

Clinical features

  • Non-healing ulcer > 3 weeks
  • Indurated margins, everted edges
  • Fixed to underlying tissues
  • Cervical lymphadenopathy
  • Common sites: lateral tongue, floor of mouth, gingiva

Investigations

  • Incisional biopsy — gold standard
  • CECT / MRI — local extent
  • USG neck + FNAC — nodal disease
  • PET-CT — distant metastasis / recurrence
  • Chest imaging

Management

  • Stage I–II: single-modality — surgery OR radiotherapy
  • Stage III–IV: composite resection + neck dissection + adjuvant CRT
  • Neck: elective SND for cN0 with DOI > 3 mm
  • Targeted / immunotherapy: cetuximab, pembrolizumab, nivolumab for recurrent/metastatic

Prognosis

  • 5-year survival: Stage I 80%, Stage IV < 30%.

Mnemonics

  • FEAR — Fixed, Everted, Anaesthetic, Rolled edges

Clinical pearls

  • Any oral ulcer that fails to heal within 3 weeks must be biopsied.
Full atlas page →

Oral Submucous Fibrosis

Premalignant Disorders

Etiology

  • Areca nut (arecoline)
  • Capsaicin
  • Nutritional deficiencies
  • Genetic predisposition (HLA-A10, DR3, DR7)

Clinical features

  • Burning sensation, especially with spicy food
  • Blanched marble-like mucosa
  • Palpable vertical fibrous bands
  • Progressive trismus
  • Depapillation of tongue

Management

  • Habit cessation (mandatory)
  • Intralesional steroids ± hyaluronidase
  • Placental extract injection, pentoxifylline, lycopene
  • Surgical release of fibrous bands + reconstruction (buccal fat pad, nasolabial flap) for severe trismus
  • Physiotherapy — mouth-opening exercises

Prognosis

  • Malignant transformation 7–13%.

Clinical pearls

  • OSMF is irreversible — early diagnosis is critical.
Full atlas page →

Oral Tuberculosis

Ulcerative Diseases

Definition

  • Oral lesion caused by Mycobacterium tuberculosis, usually secondary to pulmonary TB.

Etiology

  • Mycobacterium tuberculosis
  • Secondary (sputum inoculation) > primary

Clinical features

  • Chronic, painful, irregular ulcer
  • Undermined edges
  • Granular floor
  • Tongue > palate > gingiva
  • Regional lymphadenopathy

Investigations

  • Chest X-ray
  • Sputum AFB/culture
  • Biopsy with ZN stain / TB PCR
  • Mantoux test / IGRA

Management

  • Standard ATT (RIPE regimen): Rifampicin, Isoniazid, Pyrazinamide, Ethambutol × 2 months, then RI × 4 months

Prognosis

  • Good with ATT.

Quick revision

  • Secondary TB > primary
  • Caseating granulomas + AFB
  • RIPE regimen
Full atlas page →

Orthognathic Surgery

Maxillofacial Surgery

Clinical features

  • Skeletal Class II/III
  • Facial asymmetry
  • Vertical maxillary excess/deficiency
  • Obstructive sleep apnoea

Investigations

  • Cephalometrics
  • 3D CBCT + virtual surgical planning
  • Dental models / digital splints

Management

  • Pre-surgical orthodontics (decompensation)
  • Surgery — osteotomies with rigid fixation
  • Post-surgical orthodontics + retention

Prognosis

  • Stable long-term when proper planning + orthodontic detailing.
Full atlas page →

Ossifying Fibroma

Fibro-osseous Lesions

Definition

  • Benign encapsulated fibro-osseous neoplasm composed of cellular fibrous tissue with variable bone/cementum-like mineralisation.

Clinical features

  • Slow-growing painless jaw swelling with bucco-lingual expansion
  • Displacement of teeth
  • Well-defined lesion — key distinction from fibrous dysplasia

Investigations

  • OPG, CBCT to define margins
  • Incisional biopsy for diagnosis

Management

  • Complete surgical enucleation with curettage of the bony cavity — curative
  • Segmental resection for large or recurrent juvenile variants

Prognosis

  • Excellent for classical OF; juvenile variants more aggressive with higher recurrence.

Quick revision

  • Encapsulated · enucleation curative · JOF more aggressive
Full atlas page →

Osteomyelitis of the Jaws

Bone Diseases

Definition

  • Inflammatory condition of bone that begins as an infection of the medullary cavity and Haversian systems, extending to the periosteum.

Etiology

  • Odontogenic infection (majority)
  • Trauma, fracture
  • Radiation (ORN), MRONJ overlap
  • Haematogenous (rare in adults)

Clinical features

  • Acute: deep throbbing pain, swelling, fever, trismus, tender teeth, Vincent sign (paraesthesia of lower lip)
  • Chronic: recurrent swelling, sinuses, sequestra extruding through mucosa/skin

Investigations

  • CT for cortical detail
  • MRI/bone scan for early marrow oedema
  • Bone biopsy and culture (aerobic + anaerobic)

Management

  • Culture-directed IV antibiotics — empirical: penicillin + metronidazole or clindamycin; continue 4–6 wk (longer for chronic)
  • Surgical: drainage, sequestrectomy, saucerisation, decortication
  • Resection with reconstruction for refractory cases
  • Hyperbaric oxygen for refractory/ORN
  • Control comorbidities (diabetes)

Prognosis

  • Good for acute with prompt treatment; chronic forms may require multiple surgeries.

Quick revision

  • Sequestrum + involucrum · long IV antibiotics + surgical debridement
Full atlas page →

Osteosarcoma of the Jaw

Malignant Tumors

Clinical features

  • Rapidly growing swelling
  • Paraesthesia (numb chin syndrome — mandibular)
  • Loose teeth

Management

  • Radical resection with wide margins + neoadjuvant / adjuvant chemotherapy
  • Post-op radiotherapy for positive margins

Prognosis

  • 5-year survival 40–60% for jaw osteosarcoma.
Full atlas page →

Paget Disease of Bone

Bone Diseases

Definition

  • Focal or multifocal disorder of bone remodelling characterised by increased and disorganised osteoclastic resorption followed by exuberant, disorganised osteoblastic bone formation.

Etiology

  • Multifactorial: genetic (SQSTM1 mutation), possible paramyxovirus trigger
  • First-degree relatives 7× risk

Clinical features

  • Progressive bone pain, deformity
  • Enlarging cranial vault (hat size increases)
  • Bilateral symmetrical jaw enlargement, spacing of teeth, denture becomes tight
  • Deafness (cranial nerve VIII compression)
  • High-output cardiac failure (rare)

Management

  • Asymptomatic: monitor
  • Symptomatic: bisphosphonates (single-dose IV zoledronate preferred) — normalises ALP
  • Calcitonin (second line)
  • Analgesia, orthopaedic surgery for fractures
  • Dental: extractions difficult (dense bone, hypercementosis, bleeding); avoid elective surgery in active phase

Prognosis

  • Generally good with bisphosphonate therapy; new hearing loss or increased pain warrants imaging to exclude sarcoma.

Quick revision

  • Cotton-wool skull · isolated ALP · zoledronate
Full atlas page →

Pemphigus Vulgaris

Vesiculobullous Diseases

Etiology

  • Autoantibodies against desmoglein-3
  • HLA-DR4 association

Clinical features

  • Oral lesions precede skin in 50–70%
  • Flaccid bullae that rupture to painful erosions
  • Positive Nikolsky sign

Investigations

  • Direct immunofluorescence — intercellular IgG/C3 ('fish-net' pattern)
  • Indirect IF — circulating antibodies
  • ELISA — anti-desmoglein-3 titres

Management

  • Systemic corticosteroids (prednisolone 1 mg/kg/day)
  • Steroid-sparing: azathioprine, mycophenolate mofetil
  • Rituximab (first-line in moderate-severe disease per current guidelines)

Prognosis

  • Untreated 80% mortality; with therapy 5–10%.

Mnemonics

  • Pemphigus = 'PV kills Deep' (Desmoglein-3, suprabasal)

Clinical pearls

  • Rituximab has revolutionised management — early referral is essential.
Full atlas page →

Periapical Abscess

Dental Diseases

Definition

  • Acute or chronic suppurative process at the periapex secondary to non-vital pulp.

Etiology

  • Sequela of untreated caries/pulpitis
  • Trauma
  • Failed RCT

Clinical features

  • Acute: severe throbbing pain, tooth elevation ('high tooth'), swelling, fever
  • Chronic: sinus tract (parulis), mild discomfort or asymptomatic

Investigations

  • Vitality tests (negative)
  • PA radiograph
  • Aspiration if fluctuant

Management

  • Establish drainage: access opening or I&D
  • RCT or extraction
  • Antibiotics if spreading infection / systemic signs

Prognosis

  • Excellent with drainage and definitive treatment.

Quick revision

  • Incision and drainage principle
  • Parulis = chronic sinus tract
  • Antibiotics adjunctive, not primary
Full atlas page →

Peripheral Giant Cell Granuloma

Soft Tissue Lesions

Definition

  • Non-neoplastic reactive lesion of the gingiva/edentulous ridge characterised by multinucleated osteoclast-like giant cells.

Etiology

  • Reactive to local irritation (calculus, trauma, extraction)
  • Possibly from periosteum or PDL

Clinical features

  • Dark red-purple nodule on gingiva/alveolar ridge
  • Sessile or pedunculated
  • May cause superficial bone resorption ('cupping')
  • Bleeds easily

Investigations

  • Excisional biopsy
  • Serum calcium/PTH if recurrent (to exclude hyperparathyroidism)

Management

  • Excision to periosteum
  • Remove local irritants
  • Curettage of underlying bone

Prognosis

  • Excellent; low recurrence with complete excision.

Quick revision

  • Purple-red gingival nodule
  • Giant cells + haemosiderin
  • Excise to periosteum
Full atlas page →

Pleomorphic Adenoma

Salivary Gland Disorders

Definition

  • Benign salivary gland neoplasm composed of variable mixtures of epithelial and myoepithelial cells within a chondromyxoid stroma.

Etiology

  • PLAG1 or HMGA2 gene rearrangements in most cases

Clinical features

  • Painless, slow-growing, mobile, firm swelling
  • Parotid: preauricular mass without facial nerve involvement
  • Palatal: firm submucosal swelling posterolateral hard palate
  • Long history (years)

Investigations

  • USG-guided FNAC (85–90% accurate)
  • MRI (T2 hyperintense with capsule)
  • Core biopsy avoided in parotid (seeding risk)

Management

  • Parotid: superficial parotidectomy with facial nerve preservation (deep lobe → total parotidectomy)
  • Submandibular: gland excision
  • Palate/minor gland: wide local excision including periosteum/bone
  • Enucleation → 25–45% recurrence — obsolete

Prognosis

  • Excellent with appropriate surgery; recurrence risk correlates with capsular disruption at first operation.

Quick revision

  • Commonest salivary tumour · superficial parotidectomy · avoid enucleation · beware carcinoma ex PA
Full atlas page →

Primary Herpetic Gingivostomatitis

Vesiculobullous Diseases

Definition

  • Primary infection with herpes simplex virus type 1 presenting as acute vesicular and ulcerative stomatitis with systemic symptoms.

Etiology

  • HSV-1 (>90%); HSV-2 in genital-oral transmission

Clinical features

  • Prodrome: fever, malaise, irritability
  • Oral: vesicles on keratinised and non-keratinised mucosa → shallow painful ulcers
  • Fiery red, swollen, bleeding gingiva
  • Cervical lymphadenopathy
  • Resolves 10–14 days

Investigations

  • Clinical diagnosis
  • Tzanck smear (multinucleated giant cells)
  • Viral culture/PCR if atypical

Management

  • Supportive: hydration, soft diet, antipyretics
  • Aciclovir (if within 72h onset): 15 mg/kg 5×/day × 7 days (children)
  • Topical benzocaine, lidocaine gel for pain

Prognosis

  • Excellent; self-limiting but virus persists latent.

Quick revision

  • HSV-1 primary infection
  • Children 6mo-5yr
  • Aciclovir within 72h
Full atlas page →

Pulpitis

Dental Diseases

Definition

  • Inflammatory response of dental pulp to bacterial, mechanical, thermal, or chemical irritants.

Etiology

  • Deep caries
  • Cracked/fractured tooth
  • Dental procedures
  • Trauma
  • Attrition/erosion

Clinical features

  • Reversible: sharp, transient pain to cold/sweet, relieved on stimulus removal
  • Irreversible: spontaneous, lingering pain, nocturnal exacerbation, poorly localised

Investigations

  • Thermal testing (cold)
  • Electric pulp test
  • Percussion test
  • Periapical radiograph

Management

  • Reversible: remove irritant, sedative restoration
  • Irreversible: root canal therapy or extraction
  • Pulpotomy in young permanent teeth (MTA)

Prognosis

  • Reversible pulpitis: excellent. Irreversible: good with RCT.

Quick revision

  • Reversible = transient; Irreversible = lingering/spontaneous
  • Increased pulpal pressure causes pain
  • MTA pulpotomy for immature apex
Full atlas page →

Pyogenic Granuloma

Benign Tumors

Clinical features

  • Rapidly growing red-purple pedunculated mass
  • Bleeds easily
  • Interdental papilla commonly affected

Management

  • Excision with removal of local irritants
  • Recurrence 15%

Clinical pearls

  • Pregnancy tumour is a hormonally influenced pyogenic granuloma.
Full atlas page →

Radicular Cyst

Odontogenic Cysts

Definition

  • An inflammatory odontogenic cyst arising from the epithelial cell rests of Malassez in the periodontal ligament, triggered by pulpal necrosis and periapical inflammation.

Etiology

  • Pulp necrosis from dental caries
  • Traumatic pulp injury
  • Failed root canal treatment
  • Deep restorations reaching pulp

Clinical features

  • Usually asymptomatic — incidental radiographic finding
  • Non-vital associated tooth (negative to EPT and cold)
  • Slow painless bony swelling as cyst enlarges
  • Egg-shell crackling when cortex thins
  • Occasional discharging sinus

Investigations

  • Vitality testing (EPT + thermal) — pathognomonic negative response of causative tooth
  • Percussion & palpation
  • Aspiration — straw-coloured fluid, cholesterol crystals shimmer
  • Biopsy for histopathologic confirmation after enucleation

Management

  • Non-surgical root canal treatment for small lesions — up to 85% heal without surgery
  • Apicoectomy + retrograde MTA seal for persistent apical pathosis
  • Enucleation ± peripheral ostectomy for lesions > 2 cm
  • Marsupialisation (Partsch I) for very large cysts adjacent to vital structures, followed by staged enucleation
  • Extraction of hopeless tooth with enucleation of cyst

Prognosis

  • Excellent. Endodontic success rate 85–90%; surgical enucleation > 95% cure.

Quick revision

  • Most common odontogenic cyst
  • From cell rests of Malassez
  • Always non-vital tooth
  • Non-keratinised stratified squamous lining
  • Rushton bodies pathognomonic when present
  • Enucleation is curative

Mnemonics

  • Radicular = Rest of Malassez, Rushton bodies, Root apex, Rotten (non-vital) tooth

Clinical pearls

  • Not every periapical radiolucency is a cyst — histology is the arbiter.
  • Failed RCT + persistent radiolucency at 6 months → surgical exploration.
Full atlas page →

Ranula

Soft Tissue Lesions

Definition

  • Mucous extravasation (or rarely retention) cyst of the floor of mouth originating from the sublingual gland or minor salivary glands.

Etiology

  • Trauma/obstruction of sublingual or submandibular duct

Clinical features

  • Unilateral, bluish, translucent swelling floor of mouth
  • Soft, fluctuant
  • May deviate tongue
  • Plunging ranula: submandibular swelling with floor of mouth component

Investigations

  • MRI (plunging ranula)
  • Clinical + ultrasound

Management

  • Marsupialization (simple ranula)
  • Excision of sublingual gland (recurrent/plunging)
  • Transcervical approach for plunging ranula

Prognosis

  • Good; gland excision prevents recurrence.

Quick revision

  • Blue, frog belly swelling
  • Plunging = submandibular extension
  • Excise sublingual gland for recurrence
Full atlas page →

Recurrent Aphthous Stomatitis

Ulcerative Diseases

Etiology

  • Genetic predisposition
  • Stress
  • Trauma
  • Nutritional deficiency (B12, folate, iron)
  • Hormonal changes
  • Sensitivity to SLS

Clinical features

  • Prodrome of tingling
  • Round ulcer, yellow-grey floor, erythematous halo
  • Non-keratinised mucosa

Management

  • Topical corticosteroids (triamcinolone in Orabase)
  • Chlorhexidine mouthwash
  • Topical anaesthetics for symptom control
  • Systemic steroids / colchicine for major RAS

Prognosis

  • Self-limiting; recurrent throughout life for many patients.
Full atlas page →

Sialolithiasis

Salivary Gland Disorders

Etiology

  • Salivary stasis + calcium precipitation around organic nidus

Clinical features

  • Meal-time swelling and pain ('sialoadenitis alimentaria')
  • Palpable stone in duct
  • Purulent discharge if infected

Management

  • Distal stones — intra-oral duct slitting (sialodochoplasty)
  • Small stones (< 4 mm) — sialendoscopy ± lithotripsy
  • Chronic hilar/parenchymal stones — gland excision

Prognosis

  • Excellent with appropriate management.
Full atlas page →

Sjögren Syndrome

Salivary Gland Disorders

Definition

  • Systemic autoimmune disease characterised by lymphocytic infiltration and progressive destruction of exocrine glands, principally salivary and lacrimal.

Clinical features

  • Xerostomia: burning mouth, difficulty swallowing dry food, rampant caries
  • Xerophthalmia: gritty eyes, keratoconjunctivitis sicca
  • Bilateral parotid enlargement
  • Fissured/depapillated tongue
  • Extra-glandular: arthralgia, Raynaud, interstitial lung disease, neuropathy

Investigations

  • ACR/EULAR 2016 criteria (score ≥ 4): Focus score ≥ 1 on labial gland biopsy (3), anti-SSA/Ro (3), ocular staining score ≥ 5 (1), Schirmer ≤ 5 mm/5 min (1), unstimulated whole salivary flow ≤ 0.1 mL/min (1)
  • Anti-Ro/SSA (60–70%), anti-La/SSB (40%)
  • Elevated ESR, hypergammaglobulinaemia
  • Sialography (fruit-laden branchless tree), sialoscintigraphy, US of parotid

Management

  • Symptomatic sicca: artificial tears, saliva substitutes, sugar-free gum
  • Muscarinic agonists (pilocarpine 5 mg qid, cevimeline)
  • Systemic: hydroxychloroquine for arthralgia/fatigue; immunosuppression (methotrexate, rituximab) for severe extra-glandular disease
  • Aggressive caries prevention: fluoride, chlorhexidine, sialogogues

Prognosis

  • Chronic; excellent with symptom control. Life expectancy near normal unless lymphoma develops.

Quick revision

  • Focus score ≥1 · anti-Ro/SSA · pilocarpine · watch for MALT lymphoma
Full atlas page →

Smoker's Melanosis

Pigmented Lesions

Definition

  • Benign melanin hyperpigmentation of oral mucosa induced by tobacco smoke components.

Etiology

  • Tobacco smoke components stimulate melanin production

Clinical features

  • Diffuse brown pigmentation
  • Anterior labial gingiva, lips, buccal mucosa
  • Intensity correlates with smoking duration
  • Usually bilateral

Investigations

  • Clinical + smoking history
  • Biopsy if atypical

Management

  • Smoking cessation (pigmentation fades over months to years)

Prognosis

  • Excellent; reversible with cessation.

Quick revision

  • Tobacco-induced melanin
  • Anterior gingiva
  • Fades with cessation
Full atlas page →

Solitary Bone Cyst

Non-odontogenic Cysts

Definition

  • A solitary intra-osseous cavity, devoid of epithelial lining (hence a pseudocyst), usually containing air, serosanguineous fluid or blood, occurring predominantly in the mandible of children and adolescents.

Etiology

  • Trauma-haemorrhage theory (most accepted) — intramedullary bleed fails to organise → bone lysis
  • Ischaemic marrow necrosis
  • Altered bone metabolism / venous drainage abnormality
  • Association with cemento-osseous dysplasia (florid COD)

Clinical features

  • Asymptomatic in > 60% — discovered on routine radiographs
  • Occasional painless mandibular swelling
  • Adjacent teeth are vital
  • No paraesthesia
  • Rare pathological fracture in very large cysts

Investigations

  • Vitality tests of adjacent teeth (must be vital)
  • OPG and periapical radiographs
  • CBCT for extent
  • Surgical exploration is diagnostic and therapeutic — 'empty cavity' finding

Management

  • Surgical exploration with curettage of the bony walls to induce bleeding is both diagnostic and therapeutic — the induced haematoma organises into bone
  • Very rarely bone graft required for very large defects
  • Serial radiographic follow-up to confirm bony infill

Prognosis

  • Excellent. Complete bony healing expected after simple curettage.

Quick revision

  • Pseudocyst — no epithelial lining
  • Adolescent posterior mandible
  • Scalloping between vital tooth roots
  • Empty cavity on exploration
  • Curettage curative
  • Rapid bony infill

Mnemonics

  • EMPTY: Empty cavity, Mandible posterior, Pseudocyst, Teenagers, Yields to curettage.

Clinical pearls

  • A scalloped mandibular radiolucency in a teenager with vital teeth and no expansion is a solitary bone cyst until proven otherwise.
  • Exploration IS the treatment — no lining to remove.
Full atlas page →

Temporomandibular Disorders

TMJ Disorders

Clinical features

  • Preauricular pain
  • Clicking / crepitus
  • Restricted mouth opening
  • Deviation on opening

Investigations

  • Clinical DC/TMD criteria
  • MRI — disc position and effusion
  • CBCT — bony changes

Management

  • Conservative: patient education, soft diet, NSAIDs, occlusal splints, physiotherapy
  • Minimally invasive: arthrocentesis, intra-articular steroids/hyaluronate
  • Surgical: arthroscopy, discoplasty, condylectomy, total joint replacement for end-stage disease

Prognosis

  • 70–80% respond to conservative therapy.
Full atlas page →

TMJ Ankylosis

TMJ Disorders

Definition

  • Restriction of jaw movement caused by fusion of the mandibular condyle to the temporal bone through fibrous, bony or fibro-osseous tissue.

Etiology

  • Trauma (most common — 50%)
  • Infection (otitis media, osteomyelitis)
  • Systemic (ankylosing spondylitis, rheumatoid)
  • Radiotherapy
  • Congenital

Clinical features

  • Reduced or absent mouth opening
  • Micrognathia (unilateral: chin deviation to affected side; bilateral: bird-face)
  • Sleep-disordered breathing/OSA
  • Poor oral hygiene, dental crowding

Investigations

  • OPG, PA cephalogram
  • CT / 3D CT (gold standard for bony architecture)
  • MRI to assess disc

Management

  • Aggressive early release to prevent deformity and OSA
  • Kaban protocol: (1) aggressive gap arthroplasty ≥1.5 cm, (2) ipsilateral coronoidectomy, (3) contralateral coronoidectomy if opening <35 mm, (4) interpositional material (temporalis flap or alloplastic), (5) rigid fixation with early mobilisation, (6) aggressive physiotherapy for ≥6 months
  • Costochondral graft in growing children; TMJ prosthesis in adults

Prognosis

  • Good with strict adherence to Kaban protocol and physiotherapy; re-ankylosis if immobilised.

Quick revision

  • Sawhney classification · Kaban protocol · aggressive physio
Full atlas page →

Torus Palatinus & Mandibularis

Benign Tumors

Definition

  • Localised bony overgrowth of the maxillary or mandibular alveolar cortical plate — a normal anatomical variant.

Etiology

  • Multifactorial: genetic (autosomal dominant with variable penetrance), functional (heavy occlusal forces, bruxism), environmental

Clinical features

  • Slow-growing, painless, bony-hard midline palatal or bilateral lingual mandibular swellings
  • Thin overlying mucosa prone to trauma ulceration
  • May interfere with denture seating or speech

Investigations

  • Clinical diagnosis; occlusal radiograph for extent if surgery planned

Management

  • No treatment required unless: interferes with prosthesis, causes speech problems, chronic mucosal trauma, or patient concern
  • Surgical removal: elevate mucoperiosteal flap, section with bur/osteotome, smooth with file, tension-free closure

Prognosis

  • Excellent; no recurrence after complete removal.

Quick revision

  • Anatomical variant · surgery only if functional problem
Full atlas page →

Traumatic Fibroma

Soft Tissue Lesions

Definition

  • A focal reactive hyperplasia of fibrous connective tissue in response to persistent local irritation.

Etiology

  • Cheek biting
  • Denture trauma
  • Sharp restoration margins

Clinical features

  • Smooth, dome-shaped, firm, pink nodule
  • Usually < 1.5 cm
  • Buccal mucosa along occlusal plane most common

Management

  • Conservative surgical excision with removal of irritant

Prognosis

  • Excellent; recurrence rare if irritant removed.

Clinical pearls

  • Firm, painless, and non-blanching — clinical diagnosis, histology confirms.
Full atlas page →

Traumatic Ulcer

Ulcerative Diseases

Definition

  • Break in oral mucosa due to extrinsic injury.

Etiology

  • Sharp tooth/restoration
  • Denture irritation
  • Accidental biting
  • Burns (hot food)
  • Chemical injury (aspirin burn)

Clinical features

  • Painful ulcer with erythematous halo
  • Yellow-white fibrin base
  • Adjacent to identifiable traumatic source
  • Heals within 10–14 days after cause removal

Investigations

  • Clinical + removal of cause
  • Biopsy if no healing in 2 weeks

Management

  • Remove traumatic agent
  • Smooth sharp edges
  • Topical analgesics/steroids
  • Chlorhexidine rinse

Prognosis

  • Excellent; heals rapidly after cause removed.

Quick revision

  • Cause-related ulcer
  • Remove cause = healing
  • Biopsy if >2 weeks
Full atlas page →

Verrucous Carcinoma

Oral Cancer

Definition

  • A non-metastasising well-differentiated variant of squamous cell carcinoma composed of thick, club-shaped keratotic papillae with pushing margins.

Etiology

  • Chronic tobacco use (particularly smokeless: paan, snuff)
  • HPV-16/18 detected in some cases
  • Chronic irritation

Clinical features

  • Slow-growing exophytic, cauliflower-like, white-warty painless lesion
  • May cover a large area and cause bone erosion (pressure-type)
  • Rarely metastasises to lymph nodes

Investigations

  • Deep incisional biopsy including epithelial–connective tissue interface (superficial biopsy misleading)
  • MRI/CT for bone involvement

Management

  • Wide surgical excision with 1 cm margin — treatment of choice
  • Neck dissection generally NOT required (nodes rare)
  • Radiotherapy avoided historically due to reported anaplastic transformation; contemporary evidence limited
  • Cryotherapy or laser for small lesions

Prognosis

  • 5-year survival >80% with adequate excision; better than conventional SCC due to absence of metastases.

Quick revision

  • Ackerman tumour · pushing margins · excision only · avoid RT
Full atlas page →

White Sponge Nevus

White Lesions

Definition

  • An inherited disorder of mucosal keratinisation caused by mutations in mucosal keratins KRT4 or KRT13, producing bilateral spongy white plaques from infancy or early childhood.

Etiology

  • Autosomal dominant mutation in KRT4 (12q13) or KRT13 (17q21) genes encoding mucosa-specific keratins

Clinical features

  • Bilateral, symmetrical, thick, spongy, folded, corrugated white plaques
  • Buccal mucosa most affected; also labial mucosa, ventral tongue, floor of mouth, soft palate
  • Does NOT disappear on stretching (distinguishes from leukoedema)
  • May affect nasal, oesophageal, laryngeal, anogenital mucosa
  • Asymptomatic; no malignant potential

Investigations

  • Clinical + family history + biopsy
  • Genetic testing (KRT4/13) confirms diagnosis

Management

  • No treatment required (benign, asymptomatic)
  • Anecdotal: topical / systemic tetracycline mouth rinse — reduces plaque thickness in some reports
  • Chlorhexidine mouthwash for oral hygiene

Prognosis

  • Excellent — benign, no malignant potential.

Quick revision

  • AD, KRT4/KRT13 mutation
  • Childhood onset, bilateral spongy plaques
  • Perinuclear keratin condensation on histology
  • No treatment; benign

Mnemonics

  • WSN = White Since Newborn

Clinical pearls

  • WSN plaques are spongy and remain white on stretching — leukoedema does not.
  • Ask about family history — nearly always positive.
  • Extra-oral mucosae may be involved — examine nasal and genital sites.
Full atlas page →

Zygomatic Complex Fracture

Trauma

Definition

  • Fracture of the zygomatic bone involving disruption at its articulations with the frontal, temporal, maxillary, and sphenoid bones (hence 'quadripod' rather than 'tripod').

Etiology

  • Assault, RTA, sports (esp cricket/hockey)

Clinical features

  • Flattening of malar prominence (masked by early oedema)
  • Periorbital ecchymosis, subconjunctival haemorrhage extending posteriorly
  • Infraorbital paraesthesia (V2)
  • Diplopia, enophthalmos, hypoglobus
  • Trismus (impingement on coronoid)
  • Step deformity at infraorbital rim, zygomatic buttress, frontozygomatic suture

Investigations

  • CT face with coronal and 3D reconstruction (gold standard)
  • Ophthalmology assessment: visual acuity, pupils, motility, fundus
  • Occipitomental views if CT unavailable

Management

  • Undisplaced/minimally displaced without functional deficit: conservative + soft diet 4–6 wk + avoid sleep on affected side
  • Displaced: open reduction with internal fixation via combined approaches: (1) frontozygomatic (upper eyelid or lateral brow), (2) infraorbital rim (subciliary/transconjunctival), (3) zygomaticomaxillary buttress (sublabial)
  • Fix at 2–3 points depending on stability; Gillies temporal approach for pure arch fractures
  • Orbital floor reconstruction if defect > 2 cm² or entrapment

Prognosis

  • Good with anatomical reduction; delayed treatment produces malunion requiring osteotomy.

Quick revision

  • Quadripod fracture · CT gold standard · ORIF at 2–3 points · watch V2 and eye
Full atlas page →