SIXTH EDITION ORAL PATHOLOGY CLINICAL PATHOLOGIC CORRELATIONS YOU’VE JUST PURCHASED MORE THAN A TEXTBOOK ACTIVATE THE COMPLETE LEARNING EXPERIENCE THAT COMES WITH YOUR BOOK BY REGISTERING AT http://evolve.elsevier.com/Regezi/oralpathology Evolve Student Learning Resources for Oral Pathology: Clinical Pathologic Correlations, sixth edition, OFFERS THE FOLLOWING FEATURES: • C ase studies demonstrating “unknown” cases. proper clinical identifcation of lesions and These cases provide excellent opportunities to conditions become more familiar with diagnosing lesions • 5 0 image-based questions provide an excellent and conditions based on clinical presentation way to test your skill at recognition and diagnosis • S elf-assessment exam (with 150 multiple choice questions created in the Board Review format) • A variety of weblinks are provided to pursue provides an excellent review for the NBDE further study • I nteractive Lecture Modules that walk you through decision-making practices and REGISTER TODAY! SIXTH EDITION ORAL PATHOLOGY CLINICAL PATHOLOGIC CORRELATIONS JOSEPH A. REGEZI, DDS, MS Professor Emeritus, Oral Pathology University of California San Francisco San Francisco, California JAMES J. SCIUBBA, DMD, PHD Professor (Ret), Otolaryngology, Pathology, Dermatology The Johns Hopkins School of Medicine Consultant, The Milton J. Dance Head & Neck Center The Greater Baltimore Medical Center Baltimore, Maryland RICHARD C.K. JORDAN, DDS, PHD, FRCPATH Professor of Oral Pathology & Pathology University of California San Francisco San Francisco, California with 960 illustrations 3251 Riverport Lane St. Louis, Missouri 63043 ORAL PATHOLOGY: CLINICAL PATHOLOGIC CORRELATIONS ISBN: 978-1-4557-0262-6 Copyright © 2012, 2008, 2003, 1999, 1993, 1989 by Saunders, an imprint of Elsevier Inc. 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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identifed, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data or Control Number Regezi, Joseph A. Oral pathology : clinical pathologic correlations / Joseph A. Regezi, James J. Sciubba, Richard C.K. Jordan. – 6th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4557-0262-6 (hardcover : alk. paper) 1. Mouth–Diseases. 2. Teeth–Diseases. I. Sciubba, James J. II. Jordan, Richard C. K. III. Title. [DNLM: 1. Mouth Diseases–pathology. 2. Jaw Diseases–pathology. 3. Tooth Diseases–pathology. WU 140] RC815.R39 2012 616.3′1–dc23 2011017827 Executive Editor: John Dolan Senior Developmental Editor: Courtney Sprehe Publishing Services Manager: Catherine Jackson Senior Project Manager: Rachel E. McMullen Design Direction: Kim Denando Working together to grow libraries in developing countries Printed in the United States of America www.elsevier.com | www.bookaid.org | www.sabre.org Last digit is the print number: 9 8 7 6 5 4 3 2 1 CONTRIBUTORS Eric R. Carlson DMD, MD, FACS Professor and Chairman Director of Oral and Maxillofacial Surgery Residency Program Director of Oral/Head and Neck Surgery Fellowship Program Department of Oral and Maxillofacial Surgery University of Tennessee Graduate School of Medicine and the University of Tennessee Cancer Institute Knoxville, Tennessee John Kim, MD, FRCP(C) Staf, Radiation Oncologist Princess Margaret Hospital/University Health Network Assistant Professor, Faculty of Medicine University of Toronto Toronto, Ontario, Canada Jefery C.B. Stewart, DDS, MS Associate Professor Department of Pathology School of Dentistry Oregon Health & Science University Portland, Oregon Richard J. Zarbo, DMD, MD Kathleen D. Ward Endowed Chair of Pathology Senior Vice President for Pathology and Laboratory Medicine Henry Ford Health System Detroit, Michigan v PREFACE Te sixth edition of Oral Pathology: Clinical Pathologic Cor- • Content is organized by clinical appearance of diseases relations carries on the practice of presenting oral pathology and conditions. in a clinically relevant format in which diseases and condi- • Clear, precise photomicrographs and clinical images show tions are classifed according to appearance and presenta- identifying details. tion. Tis practical approach to understanding oral diseases • Full-color illustrations explain concepts graphically. will assist the clinician in the recognition of specifc condi- • Boxes and tables throughout provide at-a-glance reference tions and in the development of diferential diagnoses and a material relating to specifc clinical conditions. rational treatment approach. Tis edition contains new information on disease etiology, pathogenesis, and treat- NEW TO THIS EDITION ment. Discussions on the molecular basis of cancers refect rapidly advancing knowledge in molecular medicine. Under- • Important new information is presented on bisphospho- standing this area of disease will help the clinician appreciate nate-related osteonecrosis of the jaws (BRONJ) and HPV- the current literature, and it will help in the further under- associated carcinoma of the oropharynx. standing of therapeutic strategies that are being developed. • Addition of new radiographic images, cone beam CTs Recent, pertinent references can be found at the end of the (CBCTs), regular CTs, and MRIs. chapter bibliographies. EVOLVE RESOURCES WHO WILL BENEFIT FROM THIS BOOK? Te Evolve website provides additional features for class- Students of dentistry, residents and clinicians alike will room review, board preparation, and instructor resources. beneft from the clear pathologic images and consistent format of this text. Te supplemental study resources allow For the Student additional exploration within the feld of oral pathology by way of PowerPoint modules, an assessment quiz, and more. • Case studies—30 case studies demonstrate "unknown" cases. Tese cases provide excellent opportunities to become more familiar with diagnosing lesions and condi- ORGANIZATION tions based on clinical presentation. Oral Pathology: Clinical Pathologic Correlations provides the • Self-assessment exam—150 multiple choice questions basis of comprehensive study of oral and maxillofacial (created in the Board Review format) provide an excellent pathology. Te sixth edition maintains a clinical approach to review for the NBDE. the identifcation of oral and maxillofacial diseases. At the • Interactive lecture modules—Each chapter features an beginning of each chapter is a list of diseases or conditions accompanying module which walks you through decision- that present as indicated by the chapter title. Found within making practices and proper clinical identifcation of the chapter are detailed descriptions of etiology, pathogen- lesions and conditions. Each module contains case esis, clinical features, histopathology, diferential diagnosis, unknowns in which there are correlations of clinical and and treatment and prognosis of the listed diseases. radiographic features with histopathology. Also included Te Clinical Overview remains at the beginning of the in each module are summary slides and additional exam- book as a distillation of the clinical aspects found in the main ples of the diseases presented. To further assist in retaining text. Tis section is intended to be a quick reference for this information, a self-assessment quiz is included at the review of topics before exams or whenever a refresher is end of each module. needed. • Image-based questions—50 image-based questions provide an excellent way to test your skill at recognition and diagnosis. An answer key is provided for the DISTINCTIVE FEATURES OF THIS BOOK instructor. • Te Clinical Overview section includes a quick summary • Weblinks—A variety of weblinks are provided for the of key diseases in a table format. reader to pursue further study. vii viii PREFACE For the instructor ACKNOWLEDGMENTS Access to all the student material, plus … Te authors gratefully acknowledge the contributions made • Image collection—An electronic image collection includes by the talented and professional staf at Elsevier. In particu- all the images from the text. Tese images are downloadable lar, we ofer special thank yous to Courtney Sprehe, Senior in various formats to create lectures and class exercises. Developmental Editor; Rachel McMullen, Senior Project • Chapter specifc testbank—Over 500 multiple choice Manager; and John Dolan, Executive Editor who were questions are provided can be used to create quizzes or instrumental in making the production of this book fnal exams. Te questions follow the Board Review format. possible. • Answer key for image-based questions C H A P T E R 1 Vesiculobullous Diseases VIRAL DISEASE VIRAL DISEASE Herpes Simplex Infection Oral mucous membranes may be infected by one of several Varicella-Zoster Infection diferent viruses, each producing a relatively distinct clinical Hand-Foot-and-Mouth Disease pathologic picture (Table 1-1). Herpangina Te herpesviruses are a large family of viruses character- Measles (Rubeola) ized by a DNA core surrounded by a capsid and an envelope. IMMUNOLOGIC DISEASE Seven types of herpesviruses are known to be pathogenic for humans, with six of these linked to diseases in the head and Pemphigus Vulgaris neck area. Mucous Membrane Pemphigoid Bullous Pemphigoid Dermatitis Herpetiformis Herpes Simplex Infection Linear Immunoglobulin A Disease (LAD) Herpes simplex virus (HSVs) infections are common vesicu- HEREDITARY DISEASE lar eruptions of the skin and mucosa. Tey occur in two Epidermolysis Bullosa forms—primary (systemic) and secondary (localized)—and may be localized or secondary in nature. Both forms are self-limited, but recurrences of the secondary form are common because the virus can be sequestered within gan- glionic tissue in a latent state. Control of symptoms rather than cure is the usual goal of treatment. Pathogenesis.  Physical contact with an infected individ- ual or with body fuids is the typical route of HSV inocula- tion and transmission for a seronegative individual who has not been previously exposed to the virus, or possibly for someone with a low titer of protective antibody to HSV (Figure 1-1). Te virus binds to the cell surface epithelium via heparan sulfate, which leads to transmembrane cytoplas- mic insertion, followed by sequential activation of specifc genes during the lytic phase of infection. Tese genes include immediate early (IE) and early (E) genes, coding for regula- tory proteins and for DNA replication, and late (L) genes, coding for structural proteins. Documentation of the spread of infection through airborne droplets, contaminated water, or contact with inanimate objects is generally lacking. During the primary infection, only a small percentage of individuals show clinical signs and symptoms of infectious systemic disease, whereas a vast majority experience only subclinical disease. Tis latter group, now seropositive, can be identifed 1