01/02: Complete Oral Exam Technique, Variants of Normal, and Common Oral Lesions

Transcribed by Christina Gory Date of the Lecture 7/2/2014
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[DOD] [1] [Extra-Oral and Intra-Oral Examination, Variants of Normal and
Common Oral Lesions] by [Dr. Shah]

[1] [Extra-Oral and Intra-Oral Examination, Variants of Normal and Common Oral
Lesions]
[Dr Allen] Okay before Dr. Shah gets stared I wanted to just come up with a couple
words of wisdom. I apologize for the mix-up of lectures. The administration had to
change some days on us. So your first lecture today is with Dr. Shah and Dr. Vogel is
giving a lecture that would have been on the 30
th
but as you know its gonna be on
Tuesday and Wednesday of next week at 11:00. It is spread over two days because
previously it was a two hour lecture but now its gonna be one two hours lectures.
I urge you to attend. This is part two of basically the lecture you had last year on Is
it Broken? And I think that is a great introduction to Diagnoses and Treatment of
Oral Diseases. Moving forward, this is a great course, everything about it should be
on the course syllabus, which is posted both on the intranet and on NYU classes. If
there is something that is not clear or there if is any confusion please send me an
email. I did try and make it clear but sometimes8 I know exactly what I meant to say
but sometimes it doesnt always come across that way. So if there is anything that is
confusing or seems to be contradictory please let me know and ill be sure to clear it
up for you. The last thing is I know that youre really excited about this but you are
going to be continuing in the peer and self assessment program throughout this year
with the same self assessment mentors and peer facilitators but following from your
feedback we have updated the website significantly. So its going to be easier to post
pictures, Its going to be just a button and weve moved ahead and tried to make
things easier. So again if you find that these things dont work correctly let me know
so we can fix it. We do really appreciate your feedback on things like this. Now this
will be the second year of the program and its the first year of second year students
participating in it and its really has I can sure along the way Dr. Wolff will share
some of this with you we can see real progression from the comments with people
and a lot of the things you have posted online. So welcome to DOD and I dont want
to take up anymore of Dr. Shahs time because I really think you will enjoy her
lecture. Thank you.

[Dr Shah]- Okay welcome. How is everyone? Guys all right? Okay. Alright well my
name is Dr.Shah and I wanna tell you guys a little bit about me. Im waiting for the
AV people to come and fix the lighting okay? Because I want it to be a little darker so
the slides and the pictures look better. But Id like to take a few minutes just to talk
about myself. Because for better or worse you guys are stuck with me in D3 NAD d4
and this d2 course. So just a few words about me. I have been at NYU. Okay theyre
working on he lighting good. I have been at NYU for 7 years since 2007. Okay and
just I am a southern gal. I grew up in Texas. I went to college in Austin I went to
dental school in Houston. And even though have been in NY for about 10 years now I
still identify as Texan. Although I dont have the southern drawl. I do say howdy and
yall a lot though. Well I dont say howdy but I do say yall. And I dont like bbq- Im
vegetarian and I hate country music. So I dont really know.. I guess I dont have a lot
of Texas roots but that is where I was born and raised. Okay so after finishing my

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dental school training I decided I wanted to pursue oral pathology because I was
always interested in diseases tumors cancers things like that so I went for umm ya
know I discovered the world of oral pathology when I was in dental school. I had a
good mentor. Uh then I went to a residency program, a three-year residency
program in oral pathology. There are only 10 programs in the entire country. And
the two best programs were in New York and therefore I left my world of comfort in
the South and came to NY, which was a really drastic drastic change. I dont know if
any of you are from the south. Are any of you from the south? Okay so a couple of
people. Were you shocked when you came here? Okay it was very different when I
came here. In the first week I was here I got into a fight, I had my car towed and I got
a ticket for talking on the cell phone. So it was really a rough time a big change. Okay
so um then I decided to come here. I did my three year residency in oral pathology
in Flushing and then I was going to go back to Texas but I winded up getting this job
at NYU and Ive been happy since and Ive been here for 7 years. Let me tell you a
little bit of what I do here okay. So besides teaching this class I am the course
coordinator for D3 OMPR Oral and Maxillofacial Pathology. Okay so I coordinate
that. Fourth year I run a rotation that all of you guys will be coming to the clinic on
the 8
th
floor for one week so you see what we do in the oral medicine clinic so Im
also in that clinic. Okay so I run a couple courses I see patients I want you all to
understand I am a clinician. Im not just someone who speaks here and looks at
microscope slides. Everything that you see, a lot of these pictures are my patients. I
see patients I treat patients I do my own biopsies. So Im very hands on. And I
actually spend more time in the clinic all day Monday and Wednesday than I do
looking at microscope slides and teaching so Im very much a clinician. I do some
clinical research, I teach these classes and in case you dont know what pathology
itself is- its looking at slides underneath the microscope. For any biopsies I do, any
biopsies done in the school, and any biopsies in the tri-state area we have dentists
surgeons head and neck surgeons MDs whoever dermatologists anyone that may
send us specimens and I look at things under the microscope and decide what the
microscope is and decide what the diagnosis is- whether its benign or malignant.
And then I often speak to clinicians about what to do next. Okay as I handle many of
these patients as well. Okay. So also you may occasionally see me in the admissions
clinic- 1A- Im also down there on Friday mornings to help teach students how to do
head and neck exams. Okay so that is a little bit about me. Ive been in NY for ya
know after my residency since then. I dont know if you guys got a chance to see the
picture I had- my screen saver- Im a very proud mother and I talk about my kids a
al ot so Im sorry I apologize in advance if I bore anyone. But I have a 6 year old
daughter and a 9 year old son who are currently in summer camp and I will often
post pictures of them. So just in case you looked at this lecture ahead of time you
might have seen a boy and a girl at the end- those are my kids- those are not random
people but my children. Okay other than that I dont think I have anything else to say
about myself so Im gonna go ahead and start this lecture.

So today what were talking about. Yes sir [Student asks question about microphone
and she repositions it and asks if it is better]. Okay so if at any point you guys have
questions feel free to interrupt and ask. This is a new topic for many of you and I

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have done this enough years to know what I am getting in to. So I am the
coordinator of this part- the oral pathology section. So any pathology questions, or
concern, or issue that you have please direct to me. And then if it has to do with the
course in general it goes to Dr. Allen who was just up here earlier. So um again part
of pathology that makes I t really hard for students is knowing the vocabulary okay
its a different language and terminology. And many times when I have taught this
course there are advance Placement students that have taken this type of course in
another country so they are way advance whereas the new students dont really
know what I am talking about and I have to be able to find a middle ground here.
And I know you guys have switched- all of everyone here is a fourth year dental
student. Am I right about that? Okay good. So again if there is anything you dont
understand feel free to interrupt. What I am talking about today is extra-oral and
intra-oral exams, variants of normal, and common oral lesions. Okay so first of all we
have to know how to do a proper head and neck and intraoral exam if you are even
going to find pathology. So I wanna go over the steps of doing an exam so in this I am
going over the steps and as I am going over the steps I am telling you in each area of
your mouth what are the things that are considered variants of normal. So variants
of normal are findings that you can find with some regularity in some percent f the
population. And they are things that you dont treat or biopsy. And then common
oral lesions in each area and what are some pathologies you can find. And please
note that this is a very introductory lecture and please note that I am only telling
you the most basic information and the most common lesions. Of course when you
get into my course next year you will get into a lot lot more detail and learn about a
lot more lesions. But I dont want to frighten you on the first day so Im gonna kind
of keep it low key here.

[2]- Extra-oral Exam: Head and Neck Exam
[Dr-Shah] Okay so extra oral exam- head and neck exam. When a patient first
comes in to see you or comes into the clinic you should take a look before they even
sit down at their general appearance. Take a look at their height and weight and
kind of assess their physical status and mental status once you start talking to them.
And then you should also look at facial symmetry. And then you should be taking a
glance at the skin as well. Looking at the skin, any exposed skin that you can see, um
you know you dont particularly have to ask a patient to roll up there pants or roll
up their sleeves. Just anything you can see. Look at their hair look at their nails. I
always take a quick glance at their hands from patients fingers ant nails you can tell
a lot about cardiovascular conditions and other issues and you guys will be learning
about this if you havent already. Okay so take a general look at the skin and then
youve taken a general look at physical and mental status. And then were also going
to be talking about neck masses and nodes. Okay so in the neck there are some
structures that are right on the midline and there are some that are on the side,
lateral neck. Well go over these.


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[3]-[Extraoral-Normal face symmetry]
[Dr Shah]- Okay so this is extra-oral finding of a normal face with symmetry.
Nothing too special about this face here. Okay so you notice its pretty symmetrical if
you were to draw a line down here everything is like it should be.

[4]-[ Facial Asymmetry]
[Dr Shah]- As opposed to this. This is facial asymmetry. Do you do you notice
anything abnormal about this face? Does it look longer or shorter on any side? Okay
so its a little longer on this [your left/pts right] side. So you notice there is some
asymmetry. So the mandible is actually a little longer on the right side of the
patients face. So you should notice things like this. This is something that is
obviously, that may be congenital. The patient may have been born this way. Or
there may be enlargement of the mandible or condylar hyperplasia or something
going on. But at this point you should notice that. That is all you need to do.

[5]-[ Pre-Malignant and Malignant Skin Findings]
[Dr Shah]- Okay alright so now I wanna talk about some skin findings. I wanna talk
about all of these findings that are listed right here. They are either premalignant
means they have the potential to develop into cancer or they actually are considered
fully cancerous. Okay so um this list of five things is in order of increasing severity.
So I start off with somethings that are precancerous and then I move to some things
that are really bad. Okay so why am I talking about skin findings? We are
responsible not for what is just in the mouth but for the entire maxillofacial area and
neck area. This is within the scope of our practice. And it is actually our
responsibility if you see something to ask the patient questions about it and to refer
the patient. Ya know obviously if the patient has a skin lesion or something you
think is a squamous cell carcinoma or a melanoma and it is not on the lips or the
mouth- it is outside something I am going to biopsy and treat although some oral
surgeons can do it. But I need to refer the patient to a dermatologist or to a head and
neck surgeon or someone. It is my responsibility and it becomes yours when you see
patients. Okay so one of the lower lesions on this scale is called a Solar or Actinic
Keratosis. Actinic means related to the sun. People who spend a lot of time in the
sun are more prone to developing skin cancers okay. So solar actinic keratosis is a
precancerous lesion. Im gonna show you pictures of each of these. So these are just
the the definitions. Then theres another skin finding called keratoacanthoma. This
thing has rapid growth and it is a low-grade malignancy but the interesting thing,
its a little controversial. Is it really a malignancy? Because many cases of
keratoacanthoma or KA, as its abbreviated, can resolve on their own. So if
something can resolve on its own should we really call it a cancer? This is kind of a
debatable point. Okay, basal cell carcinomas. Everyone here should have heard of a
basal cell carcinoma because its one of the most common human cancers. Okay its
really low-grade and slow growing and it rarely metastasizes. Okay and many
patients with fair skin that spend a lot of time in the sun can develop multiple basal
cell carcinomas and reoccurrences. Okay, then we have the squamous cell
carcinoma. The squamous cell carcinoma is the most common oral cancer. Um but
its uh also relatively common skin cancer but not as common as basal cell carcinoma

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though. And theres a variety of clinical presentations which ill show you these
pictures. And many of them are keratotic because squamous cells make keratin.
Okay? Then finally the worst and the least common fortunately, is melanoma.
Melanoma is one of the deadliest human cancers. Even just with the little bit of
invasion measured in millimeters um there can be metastasis and patients can die.
There used to be a really bad prognosis for melanoma but now there have been a lot
of advances and one of my fellow faculty members sister in law is a melanoma
expert here at NYU langone and she has told me there are quite a few treatments for
this so the prognosis has greatly improved or melanoma.

[6] Actonic Keratosis
[Dr Shah]- okay now for some pictures. Um here we have some critical pictures of
patients with actinic keratosis. Often its going to be a rough, kind of a sandpaper
feel, kind of a gray-white type of a lesion. So you can see something here on this
patients cheek area. This patient has some of these on the temple area and this is on
the forehead of another patient. Kind of these rough, whitish, grayish areas on the
facial skin.

[7]- Keratoacanthoma
[Dr Shah]- Okay keratoacanthomas are these nodular lesions with a central
depression filled with a keratin plug okay. So you can see on this patients nose you
see this round nodule with a central depression. Heres another example on the
lower lips. Sometimes that depression kind of ulcerates and crusts. Okay and then
heres another example of a keratoacanthoma. Okay.

[8]- Basal Cell Carcinoma
[Dr Shah]- Then theres basal cell carcinomas. Maybe youve seen these before but
they can develop anywhere on the face but they kind of have a predilection for the
upper lip and the nose and the midface area. Okay basal cell carcinomas will often
be nodules, they may have a focal ulcer, theres an ulcer here, and then often they
have surface red blood vessels. Do you see these red blood vessels that are on the
surface of this lesion? And even here if you look at your computer and you look at it
closely youll see some surface red blood vessels. So these are very characteristic
clinical findings of basal cell carcinomas. And it is our job when you see something
like this to ask the patient well how long has this been here? Have you seen a
dermatologist? I think you should. Things like that are our responsibility.

[9]- Squamous Cell Carcinoma
[Dr Shah]- Then we move to squamous cell carcinomas. squamous cell carcinomas
can be red, white, ulcerated, exophytic, um a variety of different clinical
presentations. Here you can see, this is on the back of a patients ear, you can see
kind of a red-white ulcerated type lesion. This was a cancer, a squamous cell
carcinoma of the ear. This is an example on the midface, another squamous cell
carcinoma. This one is kind of white ulcerated and crusted here. So these are some
examples of SCC.


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[10]- Melanoma
[Dr Shah]- And then finally we have melanoma okay. And one thing I think I didnt
mention about melanoma, let me go back for a second here. Um I didnt mention that
it makes up about 5% of all skin cancers. And then also there is something called the
ABCD criteria for diagnosis of melanoma. Um many melanomas may develop from
pre-existing moles. So many times, ya know, if a patient has a mole, and it changing,
ya know, that could be a suspicious finding. But melanoma can also develop, what
we say, is de novo, not from a mole. Okay it may just develop as a pigmented are. So
we have this criteria for whether the pigmented lesion is suspicious or not and its
called the ABCD criteria. Has anybody every heart of this? Does anybody know what
ABCD stands for? Any clue? Anyone? And one other thing about me youll notice is
that I really like to involve the class. I like to ask a lot of questions. So do not be shy. I
find that this works a lot better if were more interactive. What do you know about
ABCD? [Student answers but cant hear]. Okay youre very close. Okay so the A is
actually asymmetry okay so very close, 3 our of 4 is not bad. So the A stands for
asymmetry. So many times moles are symmetrical. But if something is turning into
a melanoma, the borders, I hope you all know what a line of symmetry is, the lesion
will not be symmetrical. B stands for borders, and the borders are irregular and ill-
defined. C stands for color- variable color. Many times a mole will just be one color-
a dark brown, a light brown, a black. But if you have a lesion with multiple colors
that is a suspicious finding for melanoma. And then D is diameter. They usually say
diameter greater than 6 mm or the size of a pencil eraser. There is actually also an E,
ABCDE, E stands for evolving, the lesion is changing rapidly. Okay so we apply those
criteria to any pigmented lesion or mole and find out whether is might be suspicious
or melanoma or not. And then definitely a referral to a dermatologist, a biopsy to
look at it under a microscope. And then treat it. Okay so these are two examples of
facial melanomas. Look at this one here. And it has the ABCDE criteria. It has
variable, ill-defined borders the colors are variable, darker in some areas, lighter in
some areas. And then here is another lesion, which is sort of very asymmetrical.
Okay with variable colors.

[11] ? Image
[Dr Shah]- Okay who is this and why is there a picture of this person in my lecture?
Who is that? How many republicans are in the house here? Haha. This is John
McCain right? A republican senator from Arizona. So I just have a picture of him here
not because to tell you that Im republican but because this patient, this person, has
a disfigurement here. Have you ever? If you have ever seen him? If you have ever
seen him not only would you notice that he has the war injury with his hands but he
has something going on with the side of his face. Does anybody know what this
famous person had? Let me put it to you this way. [Goes back to the melanoma
image slide for a moment and asks- What is this?] Okay alright. So this patient John
McCain had a really nasty facial melanoma with very severe surgical treatment and
he has a lot of scars. And you can appreciate a scar here and some disfigurement
here. So that is why I have a picture of him.


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[12]- Benign Skin Finding: Seborrheic Keratosis
[Dr Shah]- Okay just to let you know pathology does happen in famous people too.
Benign skin finding. Now I wanna find benign skin findings. Seborrheic Keratosis or
SK. Okay this is a very common skin finding and they look like these brown and
black multiple tissue tags on patients faces. And youll see a lot of African American
and black patients will have SK. Okay common after age 40. These are actually not
linked to sun exposure. Okay and they have no risk for skin cancer. They have this
stuck on, waxy appearance, and theyre often multiple. Okay.

[13]- Seborrheic Keratoses
[Dr Shah]- Heres some examples. Im sure youve seen patients like this. Or you will
definitely see people like this. So heres an African American gentlemen with these
lesions here. You see these kind of dark, kind of waxy, stuck on multiple lesions.
These are called suborrheic keratosis. Okay you wouldnt expect any of those other
lesions to be multiple. Like your almost never going to have multiple melanomas on
one face. So the fact that these are multiple can kind of help with the diagnoses. Here
is a white patient with multiple of these SKs.

[14]- ? Image
[Dr Shah]- And again! Who is this famous person? See Im trying to keep it
interesting for you guys. Does anyone know who this is? Okay so Morgan Freedman.
Um and every year I give this lecture I guess Im getting older and this picture is
getting older and the students are still, ya know, pretty young. So maybe youre not
familiar with this guy. But Morgan Freedman, hes an actor, and why do I have a
picture of Morgan Freedman? For what reason? Because what are these black
bumps here? SK. Okay, so I just wanted to show you that.

[16]- Examination of the Neck
[Dr Shah]- Okay so enough about the skin. It is time to move on to the neck and
eventually make it to the oral cavity. Okay so examination of the neck. One of the key
things you need to do when you feel the neck is look for lymph nodes. Okay lymph
nodes are these firm, freely movable, descried as rubbery nodules that you may find
in the neck, and in the submental, and submandibular areas. And where else in the
body can you find lymph nodes? Who knows? Axillary- the armpit. Those lymph
nodes are very important for breast cancer patients. Because they take those lymph
nodes to see if the cancer has drained and it gives you an idea of the prognosis and
staging. Where else in the body do we have lymph nodes? Head and neck has the
highest concentration. Then we have the axillary. Does anyone know where else we
have lymph nodes? Behind the knee. Okay. We also have inguinal in the groin area.
So those are where you have lymph nodes. Okay so you examine for any. Normally
you dont feel lymph nodes. Okay, theyre kind of deep. But if you feel them its not a
big deal as long as theyre freely movable, small, no rapid change. Okay it is when
they are fixed or getting drastically bigger that you worry that a patient may have a
hidden or metastatic cancer somewhere. Okay so were really concerned about neck

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lymph nodes and it is a major part of our examination. Because many patients can
have hidden, oral, pharyngeal cancers, in the back of the throat, that they dont even
know about. So finding a lymph node and diagnosing a lymph node can lead to a
diagnosis so it is very important. Okay so here is a rule of thumb. Any neck mass in a
patient over the age of 40 should be considered malignant until proven otherwise
and that is the key that you go by. The most common. Okay then you have these
other neck masses, not everything is a lymph node. Right? You have these other
neck masses. Okay some neck masses the patient is born with. So the most common,
congenital means present at birth, lateral neck mass is something called a branchial
cleft cyst. And Im gonna show you what that looks like. The most common
congenital midline neck mass is called a thyroglossal duct cyst. And again, ya
know, do not panic, I will show you pictures of these things and well go over the a
little bit more.

[17] Head and Neck Lymph Note Distribution
[Dr Shah]- Okay now I wanna talk a little about the distribution of lymph nodes. You
guys have all had a gross anatomy course by this point right? How much lymph node
exposure did you get? Did yu get to find any neck lymph nodes or anything like that?
No? Okay. So maybe a lot of this is probably new for you but Im not going to go over
these diagrams exactly. Youll have to do that on your time but I want to point out
the important neck lymph nodes. So these little yellowish green bumps are lymph
nodes. Okay so we have some lymph notes in the parotid. The parotid gland is
located right here. It is a salivary gland. There are lymph nodes in front of the ear
and behind the ear, pre- and post-auricular. And then the two most important
group of lymph nodes for us as dentists and oral health care providers are
submental under the chin and you palpate those by rolling along the mandible and
you might even feel your own. Okay so you take your fingers and you go here and
you roll along the borer of your mandible and if you feel it great and you may not
feel it, theyre deep, its not a big deal. Submandibular s along the angle of the
mandible. And its the same thing, you take fingers and you roll along the mandible
and you see if you can feel a bump there, a movable bump. Those are submandibular
lymph nodes. Okay so the thing is, those two lymph nodes, theyre very important
for us. They actually drain a bunch of metastatic oral cancers. Oaky and, the thing is
is many times youll have these lymph nodes in patients and most of the time theyre
reactive and inflammatory. If a patient has a lot of dental decay or dental infections,
the infections will drain into these lymph nodes and theyll be enlarged and
palpable. So most of the time when you feel a lymph node it is a inflammatory or a
residual lymph node. It is not anything worrisome or metastatic cancer or anything
like that. But Im gonna go over some criteria to help you to decide what kind of
lymph node it is. And anytime it is suspicious, it is imaged with a CT scan and sent to
a head and neck surgeon to do a fine needle aspiration. They can stick a needle in
the node and drain cells to see if there is any metastatic cancer or lymphoma in it.
Okay so those are the important lymph nodes for us- pre and post auricular,
submental, submandibular. Theres also lymph nodes in the back of the neck called
occipital.


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[18]- Head and Neck Lymph Node Distribution
[Dr Shah]- Okay heres some more lymph nodes that we need to know. Um also
another major group of lymph nodes is near the sternocleidomastoid muscle. So
when were looking for lymph nodes in that area you always ask the patient to turn
their head. Because when they turn their head you can actually contract the SCM
muscle and you have a better feel along the anterior and posterior borders for
lymph nodes. Okay so youll have the patient turn their head, youll feel along the
borders, and its in a walking motion like this. You dont just go like this or strangle
them, but it is in a walking type of a motion. So those and a long the posterior border
and along the anterior border.

[19]- Head and Neck Lymph Node Distribution
[Dr Shah]- Okay this diagram shows you some of the major lymph node groups and
what structures drain into each area. So here again, this is the submandibular lymph
node area. This will often if theres a metastasis from the tongue, floor of mouth,
gums, mucosa of cheek many of the oral cancers that are starting to spread will
cause enlargement in the submandibular area. The next area is the submental here-
lip cancers and some floor of mouth cancers will lead to enlargement of the
submental lymph nodes. Okay and then these are some other things that drain some
other cancers.

[20]- Criteria for Evaluation of Palpable Lymph Nodes
[Dr Shah]- All right so if you find a lymph node now what? Now what are you going
to do? Well you need to decide whether if its inflammatory- where the vast majority
are- or whether its neoplastic. Neoplastic means it um has a metastatic cancer in it
or possibly a lymphoma, okay? So these are some of the factors you look at. This is a
really nice chart. From the history, if the patient tells you that when you touch the
lymph node it is painful that is actually a good sign. That points towards an
inflammatory lymph node. Usually pain is bad but when it comes to lymph nodes if
the patient tells you its a little painful or tender when you touch it that is actually a
good sign and it points toward an inflammatory lymph node. Neoplastic lymph
nodes are not usually painful. Okay also if the patient has an infection or fever that
also points to an inflammatory lymph node. Ya know, many times when a patient
gets a bad cold, or flu, or a bad sore throat or something you also have enlargement
of lymph nodes, lymphadenopathy. And sometimes its reversible, most of the times
it is reversible, but sometimes its not and you are left with a large lymph node. Also,
if a patient has weight loss or high risk factors, that might point to a neoplastic
lymph node. If a patient suddenly has a rapid, ya know, weight loss they might have
a cancer somewhere in their body so it points to a neoplastic lymph node. Also if you
just look at age as a factor, if you find a lymph node in a younger patient its more
likely to be inflammatory and a lymph node in an older patient has a better chance
of being neoplastic or malignant. Okay then this is all based on history but you also
have to actually feel the lymph node and make some determinations So again, if it
feels tender to the patient good sign, it points toward inflammatory. Rubbery is a
good sign. Rock hard is a bad sign. If it is fixed and really really really firm or rock

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hard that might indicate um that theres a metastatic cancer or a lymphoma and that
is a malignancy in the lymph node. Okay mobility is important. If its movable that is
a good thing, if its fixed it might point towards a neoplastic lymph node. And finally
size is also a factor. Most benign lymph nodes are very small. Theyre under 2 cm in
size. So if you have a really big lymph node, there is a chance that it could be
neoplastic or have a metastasis or a lymphoma. Okay.

[21]- Lymphoma
[Dr Shah]- Okay so this is some examples of lymph nodes that um did show
malignancies, either lymphoma or a metastatic cancer. So lymphoma is split into
two kinds. Hodgkins and Non-Hodgkins. Im not gonna go over the details of this
right now, you dont need to know. The only thing is that Hodgkins is better than
non-Hodgkins because it stays confined to the lymph nodes. Look at this patients
neck [left image], youll see some enlargement here, right? So this is on several
lymph nodes along the sternocleidomastoid muscle and supraclavicular, above the
clavicle we also have a bunch of lymph nodes, have enlarged and caused this mass
here. And if you feel this it feels firm and fixed. Okay so which is a bad sign and upon
aspiration and blood work this patient did have a lymphoma. Heres another
example [right image], you see this bump over here, you feel it it feels hard to
extremely firm, its fixed and not movable, it may be growing in size at a rapid rate,
and then upon fine needle aspiration or biopsy this patient was found to have a non-
Hodgkins lymphoma.

[22]- Metastatic Carcinoma
[Dr Shah]- Okay here are examples of metastatic carcinomas. Okay so here you have
um two patients with enlarged neck nodes that actually were found to have
metastatic cancer. Heres an example right here okay and heres another example
right here [points to both images]. And again you feel this, its very firm to rock hard,
its fixed, it doesnt move around and feel rubbery like benign inflammatory lymph
nodes. Alright now but before I move on to the next part does everyone understand
where the major lymph node groups are and sort of how to distinguish between
whats benign inflammatory and what might be malignant or um neoplastic? You
sort of have an idea?

[23]- Branchial Cleft Cyst
[Dr Shah]- Okay, again, dont be shy if you have any questions. Okay because the
knowledge just keeps building you have to have a good foundation here. Okay so
some more neck masses that you should be paying attention to. So I talked about a
few slides ago the most common congenital lateral neck mass, its called branchial
cleft cyst. So if you look on the side of the neck of this patient you can appreciate this
bump here. Okay and if you feel this its going to feel cystic. So cysts have a lumen
lining and a wall. And many cysts are filled with fluid and are compressible and soft,
right? So youll actually feel that in this patient and then youll know that this is not
like a lymph node or something metastatic or along those lines. And then the patient
certainly will have imaging CT and will need to have this removed. And um ya know,
I like this picture because I like these hair accessories. I should probably get some.

11

[24] Thryoglossal Duct Cyst
[Dr Shah]- Okay thyroglossal duct cyst is another congenital neck lesion that I d like
to mention. This is in the midline, its the only midline structure. You dont normally
have lymph node enlargement or branchial cleft cysts in the middle of the neck. So
anytime you have something going on tin the middle of the neck you have to think
about thyroid issues. Okay? So these are patients. You can appreciate these large
bums in the midline of the neck and theyre cystic. If you feel them they feel sort of
soft and compressible. And what this is, this has to do with the descent of the
thyroid during embryology. So I dont know what you remember from anatomy but
the thyroid starts in the back of the uh the tongue behind the circumvallate papillae
in the foramen cecum area and it slowly drops during development through a tract.
It does all the way down to under the hyoid bone and theres a tract there, a tract or
a duct, and it is supposed to degenerate before birth. But if it doesnt, then anywhere
along that duct or tract can give rise to the formation of this cyst. Okay so that is
what a thryoglossal duct cyst is. So clinically one of the important clinical features in
diagnosing this, besides the fact that it is midline and that it is soft and compressible,
is many times if you ask the patient to stick out their tongue or swallow the cyst will
move up and down because the tract is still connected to the back of the tongue. You
all understand that? Okay so thats a one of the key clinical features that helps in
diagnosing a thyroglossal duct cyst. Okay and I want to point out one more thing, its
a little harder to identify in males right? Because they have the Adams apple or the
prominence of the laryngeal prominence but even makes can have thyroglossal duct
cysts but its obviously easier to diagnose in a female. And both of these patients are
female patients so ya know they really shouldnt have this pathology here. Okay.
[Student asks a question- probably if its movable or fixed.] It does move when they
stick out their tongue or when they swallow. It moves up and down because the
tract is still connected to the back of the tongue so any motion of the tongue is gonna
cause movement of the tract and the cyst.

[25] Thryoid mass
[Dr Shah]- Alright another thyroid issue, beside the thyroid it self having a tumor or
having cancer, we also palpate the thyroid itself during an extra-oral exam. Its part
of the beck structures. So the thyroid is under the prominence. It sits low in the neck
here. A lot of students feel up here, this is not where the thyroid is. The thyroid is
down here. Okay so that is part of looking and doing an extra-oral exam, feeling the
thyroid. So a patient can obviously have a thyroid cancer or tumor or adenoma as
well. And another thyroid condition is something called goiter, which is a diffuse
enlargement of the thyroid with functional thyroid tissue. And these people have
really diffuse enlargement or the neck. Almost they look like for example um ya
know you guys have seen these football players that have these really big strong
necks but this guy was not a football player and you can appreciate how large his
neck was. Right? And it is kind of bumpy and irregular and if you feel it its functional
thyroid tissue so it has a firm feel throughout the neck. Okay and heres a female
patient that has a thyroid mass goiter and it doesnt always have to be symmetrical.
Okay one side of the thyroid can be more enlargement.

12

[25] Lips: Vermillion Border and Labial Mucosa
[Dr Shah]- Okay so that was enough of really the head and neck exam. Im gonna
start slowly to move to the lips and intraoral. Does anyone have any questions about
the thyroid or neck masses or lymph nodes? So okay. Yes sir? [student asks
questions]. Okay so you dont really have to know much about it, I just want you to
know that if you are going to have a lymphoma Hodgkins is better than non-
Hodgkins, it has a better prognosis just thats all you need to know for now.
Anything else? Okay. Im gonna move on. Okay so now lets talk about the lips. Okay
the lips have an extra-oral and an intra-oral component, right? Okay so you start by
looing on the outside of the lip.

[26]- The Vermillion Borders of the Lips
[Dr Shah]- Okay so first of all I wanna tell you. Who knows what a vermillion border
is? Do you guys all know what a vermillion border of you lip is? Okay so the
vermillion border is the interface between the skin and the lip, okay? So um most
patients have a distinct interface, a normal vermillion border. Some variants of
normal that you can see on the lips are something called Fordyce granules. Theyre
like these little yellow, granular bumps you might see on some patients lips. And
they are really ectopic sebaceous glands that, you have Fordyce granules that can
occur in the skin but they can occur in the oral cavity and lips too and its considered
a variant of normal completely. Okay and then melanin pigmentation, just like a
patient can have pigmentation on their skin, you can have pigmentation on your lips
and in your mouth as well. So dark skinned individuals may have diffuse
pigmentation in their oral cavity and on their lips as well.

Now I also wanna talk about what are some common oral lesions that you can
see on the lips? Okay something called actinic chelitis, um this is the counterpart of
actinic keratosis, the skin lesion that I talked about earlier. And its a pre-malignant
lesion of the lips in people that spend too much time in the sun and dont out any lip
balm, or sunscreen, or protection. I think a lot of people may not know that if you
spend a lot of time in the sun you might remember to put a lot of sunscreen or
suntan lotion but you have got to protect your lips too because theyre prone to
developing cancers as well. Okay then Im gonna talk about angular cheileisis which
is actually a fungal infection of the corner of the mouth Herpes Labialsis which Im
sure, hopefully none of you suffer from that, but Im sure you will see patients with
herpes labialis. Okay who knows some of the common terms that patients use to
describe herpes labialis. Cold sores. Whats the other one? Fever blisters. Right.
Okay so no one in this class should ever use those words. Those are the publics
words. We use the term herpes labialis. But that is the same thing. And then finally,
squamous carcinoma, or a cancer of the lip. So now lets show you pictures of each of
these things.

[27] Normal Vermillion Borders
[Dr Shah]-This is a patients lips with a normal vermilion borer or interface between
the skin or the lip. Even if you look closely at this patient you can see these little

13
yellow bumps here. Do you guys see these little yellow bumps here? This is a
variant of normal, the Fordyce granules the ectopic sebaceous glands.

[28]- Variant of Normal Vermillion With Melanin Pigmentation
[Dr Shah]- Okay this is another variant of normal on the lips. All Im showing you
here is melanin pigmentation. You obviously have a dark-skinned male patient here
and so he has got some pigmentation on the lip ya know. Alright

[29]- Abnormal Finding-Actinic Cheilitis
[Dr Shah]- Then abnormal findings. Actinic Cheilitis. This comes from spending too
much time in the sun and not protecting the lips. What starts to happen is the lips
starts to become a little discolored, it becomes grayish white, the vermillion border
interface is lost, and this is a premalignant condition that increases the risk for
squamous cell carcinoma. So if you look at this picture the patients, theres a
blurring of the interface of the vermillion border, this is a little bit of glare artifact
obviously, and then you start to develop white patches that may ulcerate and crust.
There was an ulcer here, which means, when you see something ulcerates that
means the epithelium is gone and you have a yellow white fibrin coating. And
sometimes a scab or crust forms on top of that and so this is an actinic cheilitis that
really increases the chances and can progress to a squamous cell carcinoma. Also
when you feel the patients lip you also not only is it a enough to look at the lips you
are supposed to actually be feeling the lips. Palpation is a bog deal when doing an
extra-oral exam. So when you actually feel the lips youll actually feel that its not soft
and smooth throughout. Youll actually feel a firmness or change and youll really
feel that in a lip cancer and youll start to feel that um in one of these actinic
cheitisisis that might be starting to progress.

[30]- Abnormal Finding- Angular Cheilitis
[Dr Shah]- Alright heres angular cheilitis. This is at the commisures or angles or
corners of the mouth. And you get this red area or ulceration or a fissure here.
Heres an example and heres another example. And its usually bilateral but it can be
unilateral and just on one side. And most of the time this is due to a fungal infection,
candidiasis. And youll see this often in patients that where complete dentures that
have loss of vertical dimension because saliva can pool in corners of the mouth and
five rise to a fugnal infection. Okay so this is angular cheilitis. Erythema, fissuring,
superficial erosion and the etiology often is candidiasis or a fungal infection. There
may also be a superimposed bacterial infection and this needs to be treated. And
were gonna talk more about this when I talk about fungal infections in a couple
lectures from now. Im just giving you a little intro to seeing this and finding this.

[31]- Abnormal Finding: Herpes Labialis
[Dr Shah]- Okay herpes labialis, alright so these cold sores or fever blisters as they
are also known as, they start off as vesicles or blisters right? And this is the most
contagious stage. This is the time when you dont really wanna kiss someone that
has these bumps on their lip. This is the time when you dont wanna take an
ungloved hand and go like this and rub it on your skin or rub it in your eye because

14
this is the time that you could, that the patient is contagious and you could spread
this. When its in the blister form. When ultimately this thing will rupture okay and
itll ulcerate and crust. Okay so theres an ulcer and then it starts to scab over and at
that stage its not considered contagious but you should still exercise universal
precaution. But at that point it is not contagious. Now this is an example when you
see one blister and one kind of ruptured blister that is ulcerated and crusted [left
image]. And this example you see a bunch of these fluid filled blisters also known as
vesicles, these small fluid filled blisters [right image]. And many times we talk about
herpes labialis or herpetic lesions we use the word crop. Crop is a small group. So I
would describe this as a crop of vesicles, a small group of vesicles. Okay herpes
labialis can be on, ya know, on either side of the lip, usually its the lower lip, but you
can also have it on the upper lip as well. Okay. All right.

[32]- Abnormal Finding: Squamous Cell Carcinoma of the Lip
[Dr Shah]- Okay this is another abnormal finding is squamous cell carcinoma of the
lip. This is the worst finding that you can have on the lip right? And it may have
come from an actinic keratosis or it may not have. This is kind of relatively low
grade [left image] lip cancer. Theres a big ulcer here and theres an enlargement
and if you feel the patients lip it feel very firm and not soft like the rest of the lip.
And this is kind of a higher grade squamous cell carcinoma [right image] of the lip
and if you feel this its going to feel firm and its not going to feel like the rest of the lip
and probably when you have a cancer like this youll probably be able to feel several
submental lymph nodes as well because this drains in that area. Okay?

[33] Labial Mucosa
[Dr Shah]- Okay alright so that was the outside of the lip, now we have to move to
the inside of the lip, the labial mucosa. The mucosal part of your lip, upper and
lower.

What are some normal findings? Minor salivary glands. Okay if you feel your lower
lip and you dont exactly have to do this now unless you want to, youre gonna feel
these bumps, everyone should feel these bumps on your lower lip. Um maybe you
knew this before maybe you didnt but those are minor salivary glands that help
make saliva in your mouth. You have minor salivary glands almost everywhere in
your mouth except the top of your tongue, in the middle of the palate and the
gingiva. Otherwise there are minor salivary glands everywhere. Theyre most
palpable on the lower lip. Some patients have more prominent minor salivary
glands than others, they may have a really bumpy lip, but its normal, its a variant of
normal. In some patients you may not even feel these bumps but theyre there
whether you feel them or not.

Whats a common oral lesion that youre gonna find in the labial mucosa. Well its
related to trauma t the minor salivary glands and their ducts that carry saliva into
the mouth. These ducts, think of a pipe, if theres some kind of trauma like a patient
bites their lip too hard or something or maybe they get I dont know into a fight and
they get punched or something happen um one of these ducts can break and then

15
the saliva leaks into the tissue and causes a bump. Okay? And show you a picture of
what that looks like.

[34]- Labial Mucosa: Minor Salivary Glands
[Dr Shah]- Okay this is um minor salivary glands. If you were to look at someones
lip and dab dry with gauze and then just stare at it for a minute youll actually see
the saliva coming from from these glands, It should be a clear saliva. Completely
clear drops. If a patient has infections of the salivary glands then its purulent and
has a yellow white color to it. Okay but you should see a clear salivary gland
secretion.

[35] Abnormal Finding-Mucocele
[Dr Shah]- Okay this is an example of the mucocele that I was talking about. You see
this bump over here? Sometimes its very exophytic and sticks out like this and other
times its kind of deeper and more diffuse and Ill show you another picture. But at all
times its filled with saliva and mucus so its going to be soft and compressible and its
going to often have a bluish color to it. Sometimes when its really deep in the lip
then you have a thicker surface on it and you wont see that bluish color. But heres
an example so again a mucocele is a lesion formed where the salivary gland duct is
severed and the mucus spills into the connective tissue and then sort of a cyst like
structure forms around it but its not a true cyst with an epithelial lining. Okay so
theres the bump. This is what it looks like under the microscope and I jut want t tell
you at this level youre not going to Im not going to give you any microscope slides
on an exam or anything like that so this is really more for your knowledge. But there
could always be a case on your exam where if I have gone over important
microscopic findings and I show you a picture like this and I saw the biopsy showed
this this and this you should be able to make the diagnosis but you dont have to be
able to read the histology as of yet. Okay but this is what a mucocele, if this is
removed, as it should be, this is what it looks like under the microscope. This is the
surface, these are mucus glands, this is the um actual lesion (the clear area in the
middle), with mucus washed out during the processing and this is the surrounding
tissue. Okay thats what that would look like.

[36]- Mucoceles
[Dr Shah]- Okay these are some more examples of mucoceles. This one is a little
deeper and more diffuse [left image] but you see the bump on the lower lip here,
labial mucosa. Heres another example okay. So again, you feel these, theyre soft
and compressible. And some patients may tell you that they fluctuate in size. Okay
like there are times when like near meal time when youre hungry and youre
salivating more, more saliva leaks and the bump may get a little bigger and then it
may gradually come down in size. So fluctuating size may also be a clinical feature of
a mucocele but it doesnt have to be okay. And at any rate, these are going to need to
be surgically treated. A lot of patients, when they get bumps like this, they just, ya
know, they themselves stick a pin or needle in it and just, ya know, drain it and
believe that theyre cured but ultimately it comes right back okay.


16
[37]- Labial and Buccal Vestibules
[Dr Shah]- Alright now weve done the lops and the labial mucosa, were ging to moe
to the vestibules. The labial and buccal vestibules.

[38]- Common Oral Lesion:
[Dr Shah]- Okay a common oral lesion in these areas is um tobacco pouch keratosis.
And this is for people that use snuff, smokeless tobacco, or chewing tobacco. So are
these things dangerous? Can you get cancer from these or is it just cigarettes? Can
you get cancer? Theres a conception out there right and I have so many patients oh
I dont do cigarettes, I just do that thing What is that thing? Camel snuff or
whatever. Um ya know, I cant get cancer from that. Is that true? No its not true. You
can get cancer from smokeless tobacco and chewing tobacco. Although, between us,
you dont have to tell your patient, it does have a lower chance for cancer than
smoking cigarettes does. But I dont tell my patients that because I want them to
stop. Alright so depending on where the patient puts the pouch they can get um this
this lesion here. So many patients will put the pouch of smokeless of chewing
tobacco in the mandibular vestibule and many people will put it towards the back,
some people will put it towards the front. Wherever the patient places the pouch,
they usually place it in that area. The mucosa develops this white rough changes.
This patient put the pouch in the anterior mandibular vestibule. You see these tough
white changes here? Okay this is a slightly premalignant. This does have the
potential to become dysplastic and cancer but I have to tell you its a relatively low
rate. Okay. Then heres an example [left image] that put their chewing tobacco in the
posterior mandibular vestibule and you can see the rough white changes here. So
mainly if I see a patient like this I tell them that it does have the potential to become
something and they really should try to stop the habit. And then I put this patient on
recall. And how do we know if this is becoming cancer or not? Well I dont originally
do a biopsy but when I call the patient, I see them every 3 months or so, you look for
any red spots or any non-healing sores or any pain and then I would biopsy those
areas. Okay so that is generally how I manage how patients with tobacco pouch
keratosis are managed.

[39]- Abnormal finding: Linear Ulcer
[Dr Shah]- Alright another finding that you can have in the vestibule and this is
another abnormal finding and youll rarely see this but occasionally. A patient may
have a linear ulcer or sore right in the vestibule. And this is actually a manifestation
of systemic diseases. There are many systemic diseases in the body that have
manifestations in the mouth. And two of these are GI diseases, Crohns and
Ulcerative Cheilitis. Okay you can actually get these linear ulcers in the mouth in
the vestibule so thats what this is here. This is in a patient with Crohns disease.
And this is a fibrous adhesion from the times that this healed and scarred and
formed again. Okay so thats a finding.

[40]- Buccal Mucosa
[Dr Shah]- Alright now we move to the buccal mucosa, the inside of the cheeks is
what the buccal mucosa is. Theres a normal structure there called the parotid

17
papilla and this is the opening of the parotid salivary gland and that duct is called
stensons duct. Some people will just have a tiny little bump and if you feel your own
mouth at your own convenience you might feel a little bump, its usually in the area
of the maxillary first molar. Where your cheek hits the maxillary first molar you
might feel a little bump. And some patients have big flaps of tissue, thats called the
parotid papilla. Okay and if you are ever in doubt that thats what that is you can dry
it, you can feel, you can kind of palpate the patients parotid gland and see if saliva
comes out from it and then youll know that thats what youre dealing with. Ive
gotten so many referrals oh theres some unusual pathology on this patients cheek
and really its just the parotid papilla and the last thing you want to do its biopsy and
cut that off and then that patient doesnt have a salivary gland duct so you sort of
have to know what youre doing okay.

So some variants of normal that you can get on the cheek, linea alba, each of us
when we put our teeth together we may have a line on our cheek from front to back
according to how our bite is and that is considered a variant of normal. Alright.
Leukoedema is a condition where you have these white swollen changes on the
inside of the cheek and it is a variant of normal and I will show you. Its seen a lot
more in dark skinned patients, usually African American male patients. Fordyce
granules Ive already talked about, you can get on the lip, and the next most common
location is the buccal mucosa. And of course melanin pigmentation which you can
get anywhere in the mouth.

Common oral lesions that you can find on the cheek. One of the most common oral
lesions at all is called the fibroma and it has to do with a bump where a patient bites
or chews their cheek or lip or tongue, theyll get this firm bump, okay. And do you
guys know what the words what sessile and pedunculated mean? Any idea? So when
you have these bumps in the mouth, the way they attach to the underlying skin is
described as sessile or pedunculated. Sessile means it has a broad base. Okay its like
a dome like this and pedunculated means its narrower at the bottom, it has a stem
or stalk. So for example, if you have a bump that has a stem or a stalk and is
pedunculated its so much easier to remove that, I just pick it up and you can cut it
like this. But if you have something that is sessile, it is a lot broader of an area to
remove. You guys get these terms? Okay I just really wanna make sure because this
forms really the foundation of this, knowing these terms. Okay another common oral
lesion that you can find on the inside of the cheeks or buccal mucosa is called lichen
planus and this is actually a autoimmune type of a skin disease too. And were going
to talk a lot more about this in one of my upcoming lectures on mucus membrane
diseases.

[41] Parotid Papilla
[Dr Shah]- Okay so some pictures of the parotid papilla. Okay this is what it
normally looks like, youre on the cheek, your on the higher part of the cheek, where
the maxillary molars are, you have this little bump, and its usually bilaterally
symmetrical. So if you see something and youre like I dont know what this is you
should look at the other side and see if its on there. So a lot of determining

18
pathology involves comparing for symmetry. Okay so youll see this bump here and
lets see if you really have no idea, is this a fibroma? What is this? I can dab it dry
with a 2x2 and go like this and see if spit comes out from that bump and then I know
that thats what Im dealing with. Some patients have this [left image] instead of a
little bump like this [right image]. They actually have a triangular flap like this, a flap
of tissue. And this is called also a parotid papilla. A triangular flap of tissue and
either under that is where the duct opens or it could actually be at the tip or the
corners of this triangle. Alright? So when it doubt try to express the saliva or look at
the other side. Alright. And then you know one thing I didnt mention and I want to
go back to, when you do an intra-oral exam, what are the two most important things
you need to have on your table? Thing about some things, instruments, equipment,
things you need to have. So there are three things. Somebody said gauze. Youre
gonna need gauze because you have to dry things because some things that are dry
look different than things that are wet. And then youre going to need what else? A
mirror. You absolutely need to have a mirror. You did not do a proper exam if you
did not use a mirror. And this is something I have to tell you so many students will
not use a mirror and thats not a proper exam so you must use a mirror. So what is
the third thing? Its not really an instrument but its really important. How are you
gonna see? Light. We need light right? And of course we need our eyes right. Okay
but you need you need um some source of light okay. You need a mirror and you
need gauze. If you dont have these things you did not do a proper intraoral exam
period. Okay so here we are with the parotid papilla.

[42]- Linea Alba
[Dr Shah]- Linea Alba is another um variant of normal on the cheeks. You see this
white line here [right image]? Linea means line and then alba means white. Okay
this is along the occlusal plane. When the patient closes, youll see that the line
corresponds to that. So if you have a patient whose bite is off or who has really
sharp teeth, the line might be a little more prominent than someone who doesnt.
And it could be on one side, its often bilateral, but it could just be unilateral Maybe
the patient doesnt have teeth on one side and is biting more on one side so then
theyll just have more of a linea alba on one side. Okay and it doesnt have to be a
beautiful straight line. Sometimes theres an incomplete line or something like that.
So you can see a little bit here and you can see a more prominent linea alba here.
And when the patient closes youll see its along the occlusal plane. So if this was
biopsied, which it should never be, no one should ever biopsy this, um It winds up
on under the microscope just being what we call hyperplastic and hyperkeratotic.
And again well go over these things later if you dont get those terms.

[43] Leukoedema
[Dr Shah]- Okay another variant of normal that can occur on the cheeks is called
keukoedema. Leukoedema is sort of a white, swelling of the buccal mucosa. So if you
look at this patient you see this kind of grayish whiteish kind of color of the buccal
mucosa. And an interesting this about leukoedema is that when you stretch the
tissue and flatten it out it either disappears or lessens. Okay that is a really nice
clinical test you can do. So this is the same patient and this is a gloved hand [right

19
image] that is retracting the cheek. And you can see it lessens a little. It doesnt have
to completely go away but it is a little less than this, its a little less white and gray,
and a little flatter. Okay so generalized white opalescent appearance disappears or
lessens when the tissue is stretched.

[44] Leukoedema
[Dr Shah]- Heres some more examples of leukoedema. Okay most of the time its a
lot more common in African American or black males and females. But you can see it
in any race. Okay alright so heres an example of leukoedema on the buccal mucosa
[left image]. And then when it is looked at under the microscope, if its amber
biopsied, you just see thick tissue with these white swollen epithelial cells. Okay?

[45] Fordyces Granules
[Dr Shah]- Okay Fordyce granules, I already went over. Ectopic sebaceous glands.
These rough, yellowish kind of cluster of small nodules. See the buccal mucosa See
these nodules here? Look over here [left image], this patient has a lot. And they have
like a big group here. You can have that. You may not see anything. You may see
scattered yellow bumps or you may see just like big big clusters of them. Okay and
then if this is ever biopsied, which it shouldnt, under the microscope, this is what a
sebaceous gland looks like. And this is the surface mucosa. Okay so most commonly
found on the buccal mucosa and lips.

[46] Normal Melanin Pigmentation
[Dr Shah]- Okay and then this is normal melanin pigmentation that you can have on
the buccal mucosa.

[47] Abnormal Finding- Fibroma
[Dr Shah]- Abnormal findings. Fibroma is a bump on the cheek. Okay so here is a
bump. If you feel this it feels really firm. Firm. Okay. And if the patient may be biting
on it a lot. Usually theres a history- yeah I bite on my cheek. Usually theres a
sharper, broken tooth that keeps rubbing and irritating the tissue and that is why its
proliferating. But sometimes theres an ulcer on top of it where theyre biting it.
Okay when theyre eating or what other oral habits. So these are two fibromas. So
when you look at a fibroma you should be bale to say whether it is sessile or
pedunculated. So this one okay so this one if you look at it closely I can stick a probe
under this and sort of pick it up a little which it looks like it is a little narrower here
than here so then I would call this pedunculated. And its much easier to do an
excisional biopsy and remove something that is narrower on the bottom than the
top because you can pick it up and sort of undermine it.

[48] Abnormal Finding- Lichens Planus
[Dr Shah] Alright so an abnormal finding on the cheeks. Okay so so far weve
talked about variants of normal, um and common .. yeah variants of normal yeah.
Abnormal finding here is lichen planus. And as I said to you Im going to talk more
detail about this in upcoming lectures. All I want to say right now is that you see
these radiating white lines You see this kind of linear kind of its described as

20
reticular or fishnet pattern here. You have these radiating white lines. Heres
another example right here. Its usually bilateral but it can be unilateral. Okay and
that is all you need to know about it at this point and we will talk a lot more about it
more in depth later. But this is a common finding on the buccal mucosa. But its an
abnormal finding. It is not a variant of normal to have lichen planus.

[49]- Dorsal Tongue
[Dr Shah]- Okay so now Im going to move to the tongue. Okay so does anyone have
any questions on the findings on the buccal mucosa? You really have to ya know
categorize this in your head. Theres a lot of information in this course and I want to
give you guys some advice. Those people that really want to do well you have to
understand and not just memorize. And you have to find a way to categorize this in
your head. Whats normal? Whats abnormal? Ya know, what are the most common
lesions that occur in each spot? What are the key microscopic findings and clinical
features? Does it feel firm? Does it feel soft? Should it have a blue color? You have to
really find a way to organize this information if you want to do well. Not just in this
course but especially next year.

Okay. Now Im gonna move to the tongue. So the tongue has several surfaces. And
each of these surfaces can have different findings and lesions. Right? So you all
know that the top of the tongue is the dorsal surface then you have the ventral
tongue, and then you have the sides or the lateral border of the tongue. Okay so
what are some things that can happen on the dorsal tongue?

Well one of the main findings are your papillae, or your taste buds, and there are
four types of taste buds on the tongue. The filiform, the fungifiorm, the
circumvallate, and whats the last one thats not on this list? The foliate. And its not
on this list because its not really on the dorsal surface of the tongue, Its more on the
lateral surfaces of the tongue, the foliate. Okay so these are normal findings. which
of these is the most common papillae? The filliform. Okay those cover the bulk of
your dorsal tongue. And then fungiform is more towards the front, the bigger
papillae near the front, and the circumvallate that form kind of the V shaped
structure in the very back of your tongue.

Okay variants of normal- um in patients that are of color, you can have pigmented
papillae. Just like you can have um ya know pigmentation anywhere on your mucosa
all of these papillae can also have pigmentation. Another variant of normal also is
having a fissured tongue. Most patients have a smooth tongue but you can also have
these grooves and lines and indentations um in your tongue and that is a variant of
normal called fissured tongue.

Okay and then theres some other conditions that happen on the tongue and are of
unclear etiology that means no one really knows what causes them. Okay and
theres no real treatment for these to tell you the truth. Hairy tongue, theres
something called hair tongue, and no theres not really hair growing from your
tongue but well talk about what it is soon. Geographic tongue is another condition.

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And then median rhomboid glossitis. So these are some benign conditions that can
occur on the dorsal tongue.

[50] Normal Dorsal Tongue
[Dr Shah]- Normal dorsal tongue. Take a look at this tongue. Youve got filiform.
These are all filliform and these are all fungiform papillae. And then you have
circumvallate. Look at the very back of the tongue. You see these large um sort of
they form a V shaped structure. Those are the circumvallate papillae. And what I
want to say, theres variations. Some people have tiny circumvallate papillae and
other ones have really big ones like this patient might have and they can get even
bigger! Its all within the range of normal.

[51]- Pigmented Fungiform Papillae
[Dr Shah]- Alright heres a variant of normal. Heres a patient with pigmented
papillae. Okay so the fungiform papillae in the front dorsal of the tongue, you see
this brownish color to them? Thats okay, thats just pigmentations. This is a patient
with dark skin color. You can also get papillae that are colored.

[52] Fissured Tongue
[Dr Shah]- Okay fissured tongue. Here you have tongues that have these kind of lines
and grooves in them and some people have a very mild fissured tongue and some
people have a really wrinkled prominent fissured tongue And its not a big deal, its a
variant of normal. The only problems is is that when sometimes when some people
have a really deep fissured tongue its uh theres more likelihood hat ya know they
dont keep their tongue clean, that debris can accumulate and lead to some bacterial
infections. Okay and pain on the fissures of the tongue okay. So these are examples
of fissured tongue. And the cause is unknown. Its the way the tongue was formed.

[53] Hairy Tongue
[Dr Shah]- This is what we call hairy tongue. Okay so what hairy tongue is its
elongated filiform papillae. What happens is the actually papillae on the dorsal
surface of the tongue, they elongate, they become hyperplastic and they keratinize.
Alright so what can happen is that tone these papillae enlarge they get his white
color to them, its sort of like what we call a white hairy tongue, but depending on
the patients food habits. If you have a patient that drinks a lot of wine or smokes or
has some other habit, those papillae, those elongated papillae can become colored.
And so now your white hairy tongue becomes a different colored tongue- theres a
brown hairy tongue, theres a black hairy tongue, theres a green hairy tongue. And
Ill show you pictures of this . Okay and what happens is that these foods can deposit
or if the tongue papillae are so elongated and the patient is not scraping or cleaning,
bacteria can sort of set up camp there and chromogenic bacteria release pigments
and can cause the coloration. Okay so here you have examples of white hairy tongue.
And I want to point out to you that this is not the same thing as a coated tongue .a lot
of people have a coated tongue, debris on your tongue, maybe even you dont scrape
your tongue, maybe you dont brush your tongue, a lot of people can have that. But
its different and how do you know the difference? Because when you, if you take

22
your gloved hand and feel these papillae they actually move back and forth. Like
think of a rug, one of those rugs that has a really furry rug or whatever. Or maybe
even a dog, I dont know. If you go like this and you go like this the papillae move
back and forth. Thats called a hairy tongue and thats not the same as a coated
tongue. A lot of students have a misconception of that so I wanted to try and explain
that to you all. But see if you look here, you see this elongation here, if you you can
actually go with your finger and kind of move these a little bit. Alright and heres
another example of a white hairy tongue. And this picture, its a good thing you guys
have already had lunch right? I havent eaten yet but yeah? [Student asks question].
These are both hairy tongues. This one [right image] almost looks like a coated
tongue, I would give that to you, its not as prominent as this [left image]. But even
then if you again you put your finger on it it will move and this is a hairy tongue
okay?

[54] Black and green hairy Tongue images
[Dr Shah]- Alright, here you have a black hairy tongue. Look at this. And again its
called hairy tongue because it looks like hair but again its the elongated papillae
and it has nothing to do with hair. Okay and this is a green hairy tongue. Green hairy
tongue. Caused by some chromogenic bacteria. Alright and these are so hard to
treat. Theres almost no treatment for this. And about a number of years ago, when I
first came to New York, I read a story that a patient had a black hairy tongue that
looked something like this and you can imagine that you know, its not aesthetically
pleasing right? So you can imagine that this patient wanted to have it fixed or
removed and it uh it wasnt its not really treatable and the tongue was very vascular,
it has lots of blood vessels, so you dont just wanna go in there and take a scalpel and
go like this because the patient will bleed to death. Unfortunately, thats what
happened with one patient. They went, nobody would do anything because they
couldnt and they were competent so they didnt, so this patient went to one of these
undercover dentists from other countries that kind offset up camp in their office, in
the basement of somebodys building, and this this person took a scalpel and just
sliced the top of the tongue off and the patient bleed to death and died. Died because
of the black hairy tongue. And this was a case in the New York Times. You can
probably Google it and look it up, I think it was like 8 or 9 years ago. Okay so if you
see a patient like this please dont do that. Okay so the only thing you can do
nowadays really is some laser treatment might work to try and work with this.
Some people can, an oral surgeon might be able to slowly remove pieces. But
unfortunately hairy tongue is really a problem and is hard to do anything about.
Okay?

[55] Geographic Tongue
[Dr Shah]- Alright another condition that you can see on the dorsal surface of the
tongue is called geographic tongue. Geographic tongue. Okay and this is where you
get um these red spot on the tongue which white borders. Okay and these spots,
they can move around. So what this patient tongue looks like today, in a couple of
days it might not look like this. It may be completely gone or it may be in different
areas. So theyre red patches. And this can happen on the lateral tongue as well, and

23
it can actually happen theres something called ectopic geographic tongue, where
these spots can occur in other areas of the mouth, these red spots with these white
borders. Nobody really knows what causes it and theres no real treatment for this.
Most of the time its asymptomatic although the red spots are areas of thin
epithelium and the patient might report a burning or a sensitivity when they eat
something hot, spicy, or acidic. And I can tell you unfortunately I have a geographic
tongue. And theres some association with pregnancy. I dont think I ever had it until
after I had my children and I think I developed it then. But it can come and go t
anytime. Anytime. And Im Indian and I like spicy food so I still eat it but my tongue
burns a lot after I eat. Um but there are some treatments you can do for it but
theyre only temporary solutions, theres no permanent cure. So the cause is
unknown but there has been some association of psoriasis of the skin so its said that
his might be some type of some autoimmune type of condition. Alright okay so you
can see it here. And this is another presentation, usually its red with these elevated
yellowish white borders, and heres another example of broader areas.

[56]- Geographic Tongue
[Dr Shah]- This is another example of geographic tongue. See here, this red spot?
With the elevated yellowish white border? And heres some more. And with
geographic tongue youre going to have multiple spots. You might have one but
there are usually multiple spots. Okay? So should not be biopsied no treatment or
cure. All you can do its treat the symptoms.

[57] Median Rhomboid Glossitis
[Dr Shah]- Heres another condition that you can see on the dorsal surface of the
tongue, its called median rhomboid glossitis. Median means middle right? Rhomboid
has to do with the shape. And then glossitis has to do, glossitis has to do with
inflammation of the tongue. So this is right in the middle of he tongue, towards the
back dorsal surface, you get this red patch, which can be flat or a little raised, and
nobody knows what causes this, usually its asymptomatic. Occasionally a patient
may say I have a burning sensation there because sometimes candidiasis occurs on
top of it, a fungal infection occurs on top of it. And you can treat the fungal infection
but usually the red patch is still there. Um but at least it wont be symptomatic. Okay.

[58]Lateral Tongue
[Dr Shah]- So that was the dorsal tongue, now Im gonna move to the lateral tongue.
What can happen on the sides of the tongue? Normal structures- foliate papillae
and the lingual tonsils. The lingual tonsils are in the very back of your tongue, the
posterior, behind the foliate papillae. And some people have very small lingual
tonsils and other people have these big bumps, and if youre ever in doubt, look at
the other side of the tongue and compare it. Usually its symmetrical.

Variants of normal- lingual tonsillitis. Just like the tonsils in the back of your mouth
when your throat, when your sick, can enlarge and become red, your lingual tonsils
can also enlarge and become red.


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Abnormal finding- a patient can develop a traumatic ulcer from biting or from a
sharp or broken tooth on the sides of the tongue..

Unclear etiology- also a patient can have geographic tongue on the sides of the
tongue.

And then one other things I want to point out is that the lateral tongue is one of the
highest risk areas in the mouth for squamous cell carcinoma. Okay so if you are
going to have a n oral cancer in your mouth the most common locations by far are
the sides and the bottom of your tongue and the floor of the mouth. Okay?

[59]- Foliate Papillae and Lingual Tonsil
[Dr Shah]- Okay so here are some pictures of foliate papillae and the lingual tonsil.
These are the foliate papillae, these kind of um of vertically striated depressed areas
here, and this is part of the lingual tonsil here, were at the very back of the tongue.
And I want to tell you one thing, when you are looking at he lateral borders of the
tongue, when you s do your intraoral exam, you need to use gauze and you grab the
tip of the tongue and you really pull it to the side and you feel and see the sides of
the tongue. You dont just ask your patient to stick out their tongue and wag it from
side to side, you literally take gauze and you hold it and move it from side to side.
Somebody is laughing and I have seen it all I think in my 7 years. So definitely use
gausze and pull it to the side and look at feel, move it to the other side, look, and feel.
So heres another example, these are the foliate papillae and these are the lingual
tonsils. This is lymphoid tissue in the back of the tongue.

[60] Lingual Tonsillitis
[Dr. Shah]- This is an example of lingual tonsillitis. Look here- foliate papillae,
lingual tonsils, theyre a little bit enlarged, a little bit erythemetis. And the patient
might say yeah Ive got some, I feel some pain or something there. And then you look
at the other side and it may or may not be symmetrical. And theres no real
treatment for lingual tonsillitis. You just sort of wait and it will resolve on its own.
Okay?

[61]Abnormal Finding- Traumatic Ulcer
[Dr. Shah]- Alright abnormal finding traumatic ulcer. If a patient bites their tongue,
or if a patient has sharp or broken teeth, or a broken tooth, or a restoration, their
tongue may be hitting that area. You can develop an ulcer or a sore. And many times
a traumatic ulcer, if theyre chronic which means theyve been there for a little
while, they can develop a white border around them. So heres a great example of a
traumatic ulcer, were sort of at the lateral ventral part of the tongue. An ulcer is
where you are missing epithelium and you have this yellow white coating and heres
a white border around it [right image]. So perhaps this patient, one of these teeth
were sharp, or maybe they have a biting habit or who knows. Okay but this is very
characteristic of a traumatic ulcer and they tend to have an irregular shape many
times. Theyre not perfectly round or oval like other types of ulcers in the mouth.
Atlas ulcers and canker sores and herpetic ulcers will be. Okay so heres another

25
example [left image], you can see the kind of linear ulcer of an irregular shape and
you can see a little bit of a white border around this traumatic ulcer.

[62] Chronic Traumatic Ulcer
[Dr. Shah]- Heres another example of a chronic traumatic ulcer on the lateral
border of the tongue, the white boarder around it. Okay.

[63] Geographic Tongue
[Dr Shah]- Geographic tongue. I already showed you pictures of this I just wanted to
show you again that it can occur on the sides o f the tongue. Same thing I just said,
you get these red patches and these elevated red-white borders. Theres a word to
describe this, its called serpigenous . Serpent like. Many times these borders are
kind of these curved linear kind of structures.

[64] Squamous Cell Carcinoma
[Dr. Shah]- Okay squamous cell carcinomas. I told you this is the most common site.
One of the most common sites in the mouth, the sides of the tongue. Okay and now
as I mentioned earlier when I was talking about squamous cell carcinomas of the
skin, you have variable presentations. Sometimes its red, sometimes its white,
sometimes its exophytic meaning it sticks out, sometimes its ulcerated, sometimes
its just a firm are. We use the word indurated. Indurated, that means firm and thats
suspicious for a cancer. So this example, were in the back o the tongue, its exophytic,
its sticking out. This is not a lingual tonsil guys. This is a cancer. Its red and white
and you have a big ulcer in this area. This is a cancer.

[Dr. Shah]- Heres some more examples. Look at this one. this one was just an ulcer
that has a white border around it. Okay heres another example of a lateral tongue
squamous cell carcinoma.

[Dr. Shah]- And heres a final example here, look at this. Lateral border, you have
some white areas. Okay and then you have this area here thats got some redness to
it too. Alright and were gonna be talking about this when I talk about biopsy
technique but red areas are a lot worse than white areas when it comes to the
premalignant lesions and cancers. So this whole red area, out of this whole thing,
probably this is the worst area here.

[67] Ventral Tongue: Normal Structure
[Dr. Shah]- Okay so moving on to the bottom of the tongue. We talked about the top
of the tongue, we talked about the sides of the tongue, so lets talk about the bottom
of the tongue. Okay so the bottom of the tongue you can also get squamous cell
carcinomas. Most of the time its coming from the lateral and going toward the
ventral. Okay but there is a normal structure on the bottom of the tongue that you

26
should be familiar with. And these are called lingual varicosities. Theyre veins that
are dilated. And with age, these veins will dilate more and become more prominent
.So here sane example of the lingual varicosities and heres another example. Okay
and sometimes you have this reddish color, this reddish enlargement as well with tis
bluish purplish enlargement. Prominent enlarged lingual veins.

[68] Floor of the Mouth
[Dr. Shah] Okay now we move to the floor of the mouth, this is the area that forms
the floor the bottom of the mouth under the tongue.
What are some normal findings? The lingual frenum and you can also find some
openings to any salivary gland ducts, youll note that you make saliva that pools in
the floor of the mouth so you have the openings for the submandibular and
sublingual salivary glands. You can actually see the openings n in the floor of the
mouth

And a variant of normal can be the mandibular tori. Now I want to point out that
the mandibular torus is a bump of bone on the inside of the mandible. Its not really a
floor of the mouth structure, but thats the, when you are looking at the floor of the
mouth is when you see this structure. Okay that is why its on this list.

What are some common oral lesions that you can have on the floor of the mouth?
Something called ranula. Ranula is the equivalent of a mucocoele where the salivary
gland duct is ruptured and the saliva accumulates and you have a bump. Okay and
then you can also get something called sialolithiasis. Who knows what a lithe is? The
word lith. Maybe you have heard of a tonsillolith, phlebolith, whatever. Lithe is a
stone. You can get stones in salivary gland ducts as well as many other areas of your
body. So sialolithes, salivary gland stones, can be found in the floor of the mouth and
other areas as well. What else can you have in the floor of the mouth? Leukoplakia.
This means white patch that doesnt wipe off, a pre-cancer. And you can get cancer
in the floor of the mouth. I told you thats another, a high risk site, in the mouth.

[69] Lingual Frenum
[Dr. Shah]- Okay and here are some findings. Lingual frenum is the frenum that
connects the tongue to the midline floor of the mouth. And in some patients they
have a really short frenum or a high attachment and then they get a condition called
ankyloglossia, which is tongue tied right? And these are patients that cant move
their tongue a lot, its hard to work on these patients or to do an exam because they
cant move their tongue much. Theres a simple surgical procedure called a
frenectomy where you can just kind of do a releasing incision here that can be done
in these patients if they want it.

[70] Caruncle/Orifice of Whartons duct
[Dr. Shah]- Okay these are some openings of salivary gland ducts, the
submandibular gland is the big gland you can feel when you feel your neck here,

27
thats the salivary gland here. It is these openings in the floor of the mouth, it has a
major duct called Whartons duct. And if you look at a patients floor of the mouth
youll see this kind of v-shaped structure here and then youll see these two bumps
towards to front, and those are the openings. This word caruncle of the same as
orifice or openings of the Whartons duct. These are normal structures. Okay and
this picture shows the bumps to you too. Do you see them there? These openings?
Again if you dab dry and rub here youll see the saliva coming out if you are ever in
doubt.
[71] Mandibular Tori
[Dr Shah]- Mandibular tori. Remember I told you this isnt really a floor of mouth
structure but you see it best when you are looking at the floor of the mouth. Okay so
you can see these bumps of bone, these are variants of normal. Firm, hard, boney
structures. Often bilaterally symmetrical but dont have to be. Could be unilateral.
Sometimes theyre just one little bump and sometimes theyre quite big and theyre
even touching. And its never a big deal unless the patient needs a denture and these
are getting in the way and then these are surgically remove. But otherwise these are
never biopsied and treated. And on radiograph you can actually see a radiopacity if
you are unsure or unclear.

[72] Abnormal Finding: Ranula
[Dr Shah]- Okay now for some abnormal findings in the floor of the mouth. And
more thing I wanted to point out to you guys, is when you do the examination of the
floor of the mouth, I told you for the tongue you have to use gauze, you look at the
tip, you hold the gauze, you move it to the side, palpate, you move it to the other
side, palpate means feel right, sometimes you may miss seeing something but you
may actually feel something unusual and that may draw your eye to it so palpation
is very important. When you are doing an intraoral or extra-oral exam okay. Use
those use your fingertips, you have a lot of um of receptors on the tips so fingertips
are very sensitive. Okay but um so when you palate, when you feel, when you are
doing your floor of the mouth exam, you are supposed to do something called
bimanual palpation. Its where you stick one finger in, one finger out, and run your
finger all the way along the floor of the mouth. And you are feeling the
submandibular, the salivary gland, and youre feeling for stones or salivary gland
tumors or anything unusual on the floor of the mouth. Okay its called bimanual
palpation, two fingers, all the way around.

Okay so heres an abnormal finding, its called a ranula. Okay ranula is essentially a
mucocoele located in the floor of the mouth. So as I told you, a salivary gland duct
ruptured and saliva came out and made this kind of this bubble or swelling. All
right? So it has it often has a bluish hue to it and if you feel it its fluid filled, its
compressible, and we use this word called fluctuant. Fluctuant means fluid filled. Its
filled with saliva and mucus. Heres another example okay? Its not as exophytic or
sticking out as much as this one, its a little deeper, and you can sort of appreciate a
bluish hue to this. This is another example of a ranula. Okay.

[73] Abnormal Findings- Sialolithiasis

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[Dr. Shah]- Alright you can also find salivary gland stones. What is that gonna look
like? Well youre going to see this yellowish white hard stone like bump. And it can
block salivary flow. It blocks the duct so the patient may tell you they have pain in
the area, especially when theyre salivating and the duct is blocked by the stone.
Lets say you had know this was a stone, I dont know what this is. You can take an
occlusal radiograph. Okay an occlusal size 4 film and you see this radiopacity here,
this is a stone. And that helps with the diagnosis of this. Its not always as um as easy
to diagnose as this. Sometimes these are a lot deeper in the gland and you dont
always see this hard whit structure beautiful here thats easy to remove. Sometimes
theyre a lot deeper. But they need to come out because they are blocking a salivary
gland duct and can lead to infection.

[74] Abnormal Finding: Leukoplakia
[Dr. Shah]- Okay another abnormal finding in the floor of the mouth is leukoplakia.
What is leukoplakia? Its a white, plaque like lesion in the floor of the mouth that
cannot be wiped off and cannot be diagnosed as anything else. So a leukoplakia can
occur anywhere in the mouth and its a flat white lesion that doesnt wipe off. Okay
so anytime you see a white lesion, you should be taking the gauze and trying to wipe
it first to see if its a fungal infection or some debris or some peeling mucosa or some
other thing. And then if it still stays there and you have no idea what it is then its
called a leukoplakia. And a leukoplakia has a pre-malignant potential and could be a
pre-cancer. Most of them are not. 4/5 out of every white lesion ends up being just
benign and what we call hyperkeratosis. But we have 1/5 that can be early, ya know,
early pre-cancer or an early cancer. So how do you know whether your patients
white spot is one of those 5 or not, well you dont. Thats why biopsies have to be
done and a pathologist has to look at it. Okay so heres an example if leukoplakia. Ad
you worry about some sites more than other. So if I saw these white patches on the
cheek, I would be ya know as worried as I would be if I saw these white patches
on the floor of the mouth, which is a higher risk site. Okay so heres an example.

[75] Leukoplakia Images
[Dr Shah]- Heres some more examples. Heres a leukoplakia in the floor of the
mouth, and heres another leukoplakia in the floor of the mouth. So this thing
definitely needs to be biopsied to see whether theres any pre-cancerous or
cancerous changes in it.

[76]- Squamous Cell Carcinoma of Floor of the Mouth
[Dr Shah]- All right now I show you some cancers that did and do occur in the floor
of the mouth. Heres an area. Look. This is an edentulous patient, were in the
anterior floor of mouth, this is a rough red and white area here. This was indeed a
squamous cell carcinoma. Heres another example here, indurated, ulcerated. When
you feel this when you do the bimanual palpation you will feel a firm to really hard
change in the tissue that um is ya know and we refer to that as indurated.

[77] Hard Palate

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[Dr. Shah]- All right so now we move to the hard palate. Hang in there with me for
another 15 minutes. Were getting there. Um now we move to the hard palate. Keep
in mind all of this is continuous. Ive just broke this up into steps for you guys to
point out the common lesions and normal findings. But any time you do an oral
exam youve got to be systematic, youve got to cover everything. Okay?

So hard palate. Whats a normal structure on the hard palate? The incisive papilla
and rugae. So the incisive papillae is this, this little swelling you have in the back of
the central incisors. And some people have it more prominent than others. Than you
can also have these like bumps or bone or shelves of bone on your palate. Again,
some patients barely there, in other patients huge shelves or bumps of bone,
projections of bone, and those are called rugae.

Alright variant of normal just like you can get mandibular tori, you can get a palatal
torus. A torus is a growth of bone, its a variant of normal. Um a maxillary or a
palatal torus will be right in the midline, it has to be right in the middle, and its
gonna feel bony hard when you feel it. And the patient will tell you its painless and
its been there forever.

Examples of abnormal findings um on the hard palate. Nicotinic Stomatitis. If you
have a patient who is a smoker, youll see these red dots and white change so the
palate. Denture stomatitis. If a patient wears dentures and doesnt remove them and
clean them like they should. If were talking about an upper complete or even a
partial denture you can get a fungal infection or changes on the palate. Okay of
course the palate is exposed to hot foods or drinks so if you are drinking hot coffee
or eating hot pizza or soup, you can get a burn, or an ulcerated area or a change on
the palate. And then the worst possible scenario is a salivary gland tumor. Your
palate has a lot of salivary glands and a bump of the sides of your salivary glands
could be a tumor.

[78] Palatal Rugae and Incisive Papilla
[Dr Shah]- All right so this is normal structures. Heres the incisive papilla right
here. And then these are the rugae, or shelves of bone here. So this is all normal,
nothing abnormal here.

[79] Maxillary Torus (Torus Palatinus)
[Dr Shah]- Okay here we have a variant of normal. Palatal torus or maxillary torus
or torus palatinus, whatever you want to call it. Midline, okay. Many times its
symmetrical [left image]. Its bony hard. Its just a growth, a bump of bone. But many
times it is asymmetrical and kind of multinodular [right image]. But you should
always be able to tell by feeling it what it is. And if you are unsure a radiograph,
youll see a radiopacity. Okay but it should never come to that. Midline structure,
hard, painless, palatal torus. Thats really all you have to look at. And I want to point
out one thing. Tori, mandibular and palatal, have a genetic component and are many
times inherited, autosomal dominant inheritance. So youre parents or siblings
might have it but it doesnt have to be inherited.

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[80] Abnormal Finding- Nicotinic Stomatitis
[Dr Shah]- Okay abnormal findings on the hard palate. In a patient who is a
smoker, depending on how much they smoke, and how many cigarettes they smoke,
and how long they have been smoking, they can get changes in the top of their
mouth. And what they get are these diffuse kind of white change, or keratosis, and
these red dots. And the red dots are inflamed salivary gland duct openings, that is
what they are. Okay so this correlates strongly with how much and how long they
have been smoking. And interestingly this is not a pre-malignant condition. This will
not turn into cancer, okay? However, ya know, I dont.. youre patient will ask you
that, so the way I answer that is by saying yeah this may not turn into cancer but you
can easily develop a white spot somewhere else that could so ya know please work
on smoking cessation. And then we talk about our patches and lozenges and things
that we have. Okay but if a patient stops smoking, this will gradually disappear. But
sometimes it takes many, many, many years and I have seen people stop smoking
15-20 years ago and they still have a few red spots and white changes. Okay so just
know that this is not malignant or pre-malignant or cancerous. Heavy smoking. And
under the microscope I see keratosis and inflammation of the salivary glands.

[81] Nicotine Stomatitis
[Dr Shah]- Heres another example of nicotine stomatitis.

[82] Abnormal Finding: Denture Stomatitis
[Dr Shah]- Another abnormal finding of the hard palate is something called
denture stomatitis from either a partial or a complete upper denture. If the patient
is not taking them off at night and keeping them clean they can get this redness, this
extensive redness here. This is from a partial denture, and this is from a complete
denture in the denture bearing area. And many times this is um a fungal infection
okay? Erythematous candidiasis, which well be talking about in an upcoming
lecture.

[83] Abnormal Finding: Thermal Burn
[Dr. Shah]- Another abnormal finding on the palate is a burn. Remember I told
you from pizza or hot coffee or a hot drink. You can actually lose um ya know some
tissue from the palate. So this is an ulcerated area here. And this is an area sort of
like a bruise here that was from a healing thermal burn here.

[84] Abnormal Finding: Salivary Gland Tumor
[Dr. Shah]- Okay and this is the worst, one of the worst possible findings, compared
to all of the other things. Salivary gland tumors, which can be benign or malignant.
Its half and half on the palate. So heres a bump on the palate which is a salivary
gland tumor and here is another example. This one was probably benign [left image]
and this one was probably malignant [right image]. Okay? And when you feel this
they feel firm. Okay so it doesnt feel like a torus, which is bony hard. And it is not in
the midline so you should not get confused. But occasionally, these get big enough
and they cross into he midline. But even then, by feeling it and by taking a good

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history, and then if worst comes to worst, a radiograph you should be able to know
the difference.

[85] Soft Palate
[Dr. Shah]- Now we move to the soft palate. We covered the palate and now we are
going towards the back of the the mouth. Soft Palate has a lot of lymphoid tissue and
tonsilar tissue.

Okay what is a variant of normal? Pigmentation. Racial pigmentation. What is
another variant of normal? Youre uvula, or the ball of lymphoid tissue that hangs in
the back of your mouth is there. Some people have a very small uvula, some people
have a really long or big uvula. Okay. And some patients that had a tonsillectomy,
the remove the uvula too so your patient may not have a uvula. Okay uh but there is
one interesting variant called a bifid uvula. Its where the uvula didnt fuse
completely and its sort of got like two parts to it and this is the mildest presentation
of cleft palate. Cleft palate. Incomplete fusion of the palatal shelves.

And then a common oral lesion in the soft palate area is a papilloma, which is a
wart. A viral wart caused by HPV. Okay?

[86] Normal Lymphoid Tissue
[Dr Shah]- All right normal lymphoid tissue. Here we are, you can see some
lymphoid tissue, it may have a yellowish color. You have some increased vasculature
back there as well.

[87] Physiologic Melanosis
[Dr Shah]- Melanosis you see in a dark skinned patient. You have pigmentation on
the palate that goes into the soft palate area.

[88] Bifid Uvula
[Dr Shah] Okay this is a bifid uvula. You see how theres kind of a cleft and you have
two parts to this uvula. I think its kind of interesting looking. You dont see it too
much but you do every now and then. Okay but this next slide is a good one.

[89] Bifid Uvula and Hyperplastic Tonsils
[Dr. Shah]- Okay bifid uvula and hyperplastic tonsils. Check out this uvula okay. And
look at these tonsils, really enlarged as well. And many times. Let me tell you one
more then, when you are looking at the soft palate and uvula, you should depress
the patients tongue and have them say ah. The act of them saying ah causes the
soft palate to vibrate and gives you a lot better vision of the soft palate and
oropharynx. Okay so you should always do that- depress the tongue and have the
patient say ahh when you look at the patients soft palate and oropharynx. Okay
and many patients will have enlarged tonsils and some of them will have little
stones in this, tonsilloliths. And some people will have some exudate in this and
sometimes it will be really red and inflamed if they have been sick lately or if they
are sick.

32

[90] Common Oral lesion: Papilloma
[Dr. Shah]- Okay common oral lesion, a viral wart can be back there, HPV related.
Most of the time this may have long fingerlike projections like this [bottom left
image]. Sometimes its kind of a rough surface type of a bump [upper left image]. And
heres a high power view showing you, if you look at this is looks almost cauliflower
like [right image]. Okay which um I really hate to describe pathology as food
although a lot of people do that. And see now I dont eat cauliflower anymore
because I think of this. But there are a lot of um food references in pathology and
you are going to hear me say them over the course of my lectures. But anyway, so
these are viral lesions that should be removed.

[91]- Final Steps of Intra-Oral Examination
[Dr. Shah]- Okay we are really near the end here. So you are not done yet, you still
have some things to look at. The final steps of the intra-oral exam. Okay so we
basically covered, before I do this, we did our extra-oral, we looked at the face, we
looked at the neck and nodes, we looked for symmetry, then we looked at the lips,
labial mucosa, buccal mucosa, vestibules, we went to the tongue, the sides, the top
and the bottom, floor of mouth, hard palate, soft palate, and then when the patient
says ahhh you can actually try to look down the oropharynx as far down as you
can cause um patients can develop cancers in the oropharynx that are linked to HPV.
Dr Ker who is one of my colleagues will be talking about that when he lectures to
you all shortly. But um you are not done, we still have to look at the gingiva, the
teeth, and the occlusion. And I have to say this is what dental students and dentists
spend the most of their time looking at. Okay but remember, and I say this a lot,
there is a person attached to those teeth. You have to look at everything and think of
the person as a whole. Okay so make sure you look at these structures.

[92] Buccal Exostoses- Variant of Normal
[Dr. Shah]- Okay so I want to point out that there are some just so like you can have
tori in the midline palate and along the lingual surface of the mandible, you can have
other bumps of bone in your mouth as well, and these are called exostoses.
Exostoses are projections of bone. Okay so all tori are exostoses but not all
exostoses are called tori. Okay so tori is a very specific term for the palatal torus and
the mandibular tori. Any other bump of bone is just called an exostoses and not a
torus. You guys get that? Okay. So um here many times on the buccal surface of the
gingiva youll have these prominent bumps of bone, it may just be in the back, it may
be all along, it may just be the top, it may just be the bottom, it could be both. So here
this patient has these little bumps of bone on the posterior maxilla and these are
exostoses. You touch these and they are bony hard projections of bone. No need for
biopsy or treatment, dont do anything, Look at this patient. They have um buccal
exostoses mainly in the mandible. You see these bumps of bone? And in some people
its so prominent that they actually look like little shelves that you can put
something on. And you are going to see patients like this with these exostoses and
thats considered a variant of normal.


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[93] Common Gingival Lesions- The 3 Ps
[Dr. Shah]- Okay gingival lesions. When you look at the gums, you can get bumps on
your gums. Okay Im not talking about gingivitis, or inflammation, or calculus, or
plaque. These are lesions that can be caused by that but okay you can get a bump
and these often originate from the interdental papilla, between teeth. And 90% of
the bumps that you get on the gums are going to be one of these things called the 3
Ps. The 3 Ps and we are going to spend a lot more time on this later. But just as an
overview, the 3 Ps, and you have to know the names, Pyogenic granuloma, okay this
is also called pregnancy tumor, because it is seen with more frequency in pregnant
women but please, I dont like that, because you can see it in women that are not
pregnant and you can see it in men. Okay? So it is basically, its a gingival lesion,
usually its very red, soft, spongy, and bleeds easily. Bleeds easily. Then you can also
get something called the peripheral ossifying fibroma, you have a bump, if youve its
making bone or calcifications so when you feel it it feels firm and a lot harder than
this feels [points to pyogenic granuloma image]. And sometimes this can have an
ulcer or some keratosis on top. And then the final gingival lesion P is called a
peripheral giant cell granuloma. And many times this has a bluish color to it and it is
sort of in between these two lesions. It is not as soft and spongy as this one
[pyogenic granuloma] but it is not as hard as this [peripheral ossifying fibroma].
Okay so clinically, you can see one of these bumps and say you know what, I think it
is one of the 3 P lesions. But you may not you cannot always tell just by looking at it
exactly which one it is. And these need to be surgically removed and looked at under
the microscope and then we come up with a diagnosis. And these are reactive
lesions so theres pockets in here and plaque and calculus in there. So when this
lesion is surgically removed, part of the treatment is scaling and root planning the
adjacent teeth. So at the time the bump is removed you scale and plane the adjacent
teeth other wise this can come right back and it is like you never did anything. Ive
seen things where a bump like this is removed and when scaling and root planning
is not done the patient comes back in 2-3 weeks and it comes right back like you
never did anything or like it was a figment of your imagination but it was really done
so youve got to scale and root plane those teeth. So excisional biopsy and SRP.

[94] Teeth
[Dr. Shah]- Okay so then finally we should take a glance at the teeth. When we are
doing our extra-oral and intra-oral exam it is not about diagnosing caries or seeing
which teeth need root canals and crowns. Um so you focus on the soft tissue but you
take a general glance at the teeth to see if the patient has any systemic diseases or
genetic diseases. Okay so both of these are genetic diseases that affect the teeth.
Amelogenesis Imperfecta affects enamel formation and then Dentinogenesis
Imperfect affects dentin formation. Okay amelogeneisis imperfect theres multiple
types where you dont have enough enamel, or the enamel is not calcified or
matured, those are the three types- hypoplastic, hypocalified, and hypomaturation
and then theres a mixed type. Okay so if you look at this ptient they dont have
enough enamel and the yellow is actually the dentin and there are all open contacts
here. Okay so this is amelogeneisis imperfect. In dentinogensis imperfect you have
kind of a graying, brownish, to bluish kind of a shiny look to the teeth and that is

34
called dentinogenesis imperfect. Okay and one last thing I want to say about
dentinogenesis imperfect is if you see a patient with teeth like this, also the
radiograph is gonna show findings, youre not going t have um pulp chambers and
pulp cannals in patients that have dentinogenesis imperfect. Out of these two this
one is much worse [DI], you would think this one is worse [AI] but this one is much
worse [DI]. And the reason being because many cases of DI are associated with a
condition called OI, which is osteogeneisis imperfect, a defect in type IV collagen.
And that leads to malformed bones and multiple fractures throughout the body.
[95] THE END!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
[Dr Shah] Okay so alright! That is the end but before does anyone have any
questions on anything? Did I overwhelm you? Did I scare you? Did I frighten you?
Youll come back? Okay. All right guys I just want to show you this is a picture of my
kids. My daughter does ballet and my son does karate okay so Im a quite the proud
mother there. Alright guys thank you!

01/02: Complete Oral Exam Technique, Variants of Normal, and Common Oral Lesions

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Transcribed by Christina Gory Date of the Lecture 7/2/2014

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