1. 1 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Chapter 1 Introduction to Preliminary Diagnosis of Oral Lesions

2. 2 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.  Outline  Vocabulary  The diagnostic process  Variants of normal  Benign conditions of unknown cause

3. 3 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Vocabulary  (pgs. 1-7)  Clinical Appearance of Soft Tissue Lesions  Soft Tissue Consistency  Color of Lesion  Size of Lesion  Surface Texture  Radiographic Terms Used to Describe Lesions in Bone

4. 4 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Appearance of Soft Tissue Lesions  (pgs. 1-2)  Bulla  A circumscribed, elevated lesion that is more than 5 mm in diameter, usually contains serous fluid, and looks like a blister  Lobule  A segment or lobe that is a part of the whole; these lobes sometimes appear fused together

5. 5 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Appearance of Soft Tissue Lesions (cont.)

6. 6 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Appearance of Soft Tissue Lesions (cont.)  (pgs. 1-2)  Macula  An area that is usually distinguished by a color different from that of the surrounding tissue; it is flat and does not protrude above the surface of the normal tissue. A freckle is an example of a macule.  Papule  A small, circumscribed lesion usually less than 1 cm in diameter that is elevated or protrudes above the surface of normal surrounding tissue.

7. 7 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Appearance of Soft Tissue Lesions (cont.)  (pg. 2)  Pedunculated  Attached by a stemlike or stalk base similar to that of a mushroom  Pustules  Variously sized circumscribed elevations containing pus

8. 8 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Appearance of Soft Tissue Lesions (cont.)

9. 9 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Appearance of Soft Tissue Lesions (cont.)  (pgs. 2-3)  Sessile  Describing the base of a lesion that is flat or broad instead of stemlike  Vesicle  A small, elevated lesion less than 1 cm in diameter that contains serous fluid

10. 10 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Appearance of Soft Tissue Lesions (cont.)

11. 11 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Soft Tissue Consistency  (pg. 2)  Nodule  A palpable solid lesion up to 1 cm in diameter found in soft tissue; it can occur above, level with, or beneath the skin surface.  Palpation  The evaluation of a lesion by feeling it with the fingers to determine the texture of the area; the descriptive terms for palpation are soft, firm, semifirm, and fluid filled; these terms also describe the consistency of a lesion.

12. 12 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Color of Lesion  (pg. 2)  Colors  Red, pink, salmon, white, blue-black, gray, brown, and black are the colors used most frequently to describe oral lesions; they can be used to identify specific lesions and may also be incorporated into general descriptions.  Erythema  An abnormal redness of the mucosa or gingiva  Pallor  Paleness of the skin or mucosal tissues

13. 13 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Size of Lesion  (pgs. 2-3)  Centimeter (cm)  One hundredth of a meter; equivalent to a little less than one-half inch  Millimeter (mm)  One thousandth of a meter; the periodontal probe is of great assistance in documenting the size or diameter of a lesion that can be measured in millimeters

14. 14 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Size of Lesion (cont.)

15. 15 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Surface Texture  (pg. 3)  Corrugated  Wrinkled  Fissure  A cleft or groove, normal or otherwise, showing prominent depth  Papillary  Resembling small, nipple-shaped projections or elevations found in clusters

16. 16 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Terms Used to Describe Lesions in Bone  (pgs. 3, 5)  Coalescence  The process by which parts of a whole join together, or fuse, to make one.  Diffuse  Describes a lesion with borders that are not well defined, making it impossible to detect the exact parameters of the lesion; this may make treatment more difficult and, depending on the biopsy results, more radical

17. 17 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Terms Used to Describe Lesions in Bone (cont.)

18. 18 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.  (pgs. 3, 5)  Multilocular  Describes a lesion that extends beyond the confines of one distinct area and is defined as many lobes or parts that are somewhat fused together, making up the entire lesion; a multilocular radiolucency is sometimes described as resembling soap bubbles; an odontogenic keratocyst often presents as a multilocular radiolucent lesion  Radiolucent  Describes the black or dark areas on a radiograph; radiant energy can pass through these structures; less dense tissue, such as pulp, is seen as a radiolucent structure Radiographic Terms Used to Describe Lesions in Bone (cont.)

19. 19 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Terms Used to Describe Lesions in Bone (cont.)

20. 20 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.  (pgs. 4, 6)  Radiolucent and radiopaque  Terms used to describe a mixture of light and dark areas within a lesion usually denoting a stage in the lesion’s development; for example, in a stage I periapical cemento-osseous dysplasia (cementoma), the lesion is radiolucent; in stage II it is radiolucent and radiopaque  Radiopaque  Describes the light or white area on a radiograph that results from the inability of radiant energy to pass through the structure; the more dense the structure, the more light or white it appears on the radiograph  (Note: Caries 4 MO, 5 DO, 28 DO ) Radiographic Terms Used to Describe Lesions in Bone (cont.)

21. 21 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Terms Used to Describe Lesions in Bone (cont.)

22. 22 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.  (pgs. 4-6)  Root resorption  Observe radiographically when the apex of the tooth appears shortened or blunted and irregularly shaped; it occurs as a response to stimuli, which can include a cyst, tumor, or trauma  External resorption arises from tissue outside the tooth, such as the periodontal ligament, whereas internal resorption is triggered by pulpal tissue reaction from within the tooth; in the latter the pulpal area can be seen as a diffuse radiolucency beyond the confines of the normal pulp area. Radiographic Terms Used to Describe Lesions in Bone (cont.)

23. 23 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Terms Used to Describe Lesions in Bone (cont.)

24. 24 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.  (pgs. 5, 7)  Scalloping around the root  A radiolucent lesion that extends between the roots, as seen in a traumatic bone cyst; this lesion appears to extend up the periodontal ligament  Unilocular  Having one compartment or unit that is well defined or outlined as in a simple radicular cyst  Well circumscribed  Term used to describe a lesion with borders that are specifically designed and in which one can clearly see the exact margins and extent Radiographic Terms Used to Describe Lesions in Bone (cont.)

25. 25 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Terms Used to Describe Lesions in Bone (cont.)

26. 26 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. The Diagnostic Process  (pg. 8)  Making a Diagnosis  The process of diagnosis requires gathering information that is relevant to the patient and the lesion being evaluated; this information comes from various sources  There are eight distinct diagnostic categories that contribute segments of information leading to a definitive or final diagnosis

27. 27 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. The Diagnostic Process (cont.)  (pgs. 8-23)  Clinical diagnosis  Radiographic diagnosis  Historical diagnosis  Laboratory diagnosis  Microscopic diagnosis  Surgical diagnosis  Therapeutic diagnosis  Differential diagnosis

28. 28 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Diagnosis  (pgs. 8-10)  The strength of the diagnosis comes from the clinical appearance of the lesion.  The clinician can establish a diagnosis for some lesions based on color, shape, location, and history of the lesion.

29. 29 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Diagnosis (cont.)  (pgs. 8-10)  Examples of lesions that may be clinically diagnosed include Fordyce granules, torus palatinus, mandibular tori, melanin pigmentation, retrocuspid papillae, and lingual varicosities.  Other benign conditions of unknown cause that are recognized by their distinct clinical appearance include fissured tongue, median rhomboid glossitis, geographic tongue, and hairy tongue.

30. 30 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Diagnosis (cont.)

31. 31 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Diagnosis (cont.)

32. 32 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Diagnosis (cont.)

33. 33 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Diagnosis (cont.)

34. 34 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Diagnosis (cont.)  (pgs. 8, 10)  The diagnostic process may require historical information in addition to the clinical findings.  An example is an amalgam tattoo.  Any history in the area can be very helpful in confirming the clinical impression.

35. 35 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Diagnosis (cont.)

36. 36 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Diagnosis  (pgs. 10-14)  In a radiographic diagnosis, the radiograph provides sufficient information to establish the diagnosis.  Examples of conditions for which the radiograph provides the most significant information include periapical pathosis, internal resorption, external resorption, heavy interproximal calculus, dental caries, compound odontoma, complex odontoma, supernumerary teeth, impacted or unerupted teeth, and calcified pulp

37. 37 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Diagnosis (cont.)

38. 38 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Diagnosis (cont.)

39. 39 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Diagnosis (cont.)

40. 40 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Diagnosis (cont.)

41. 41 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Diagnosis (cont.)  (pgs. 10, 14, 15-17)  Normal anatomic landmarks are also easily observed radiographically.  In some cases, the radiograph may show very distinct and well-defined structures, such as nutrient canals and mixed dentition.  Unusual radiographic findings are illustrated  These include cubic zirconia, amalgam fragment, eyeglasses, amalgam overhang, instruments from root canal procedures, curette, retained primary tooth, shotgun pellet, and nose ring.

42. 42 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Diagnosis (cont.)

43. 43 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiographic Diagnosis (cont.)

44. 44 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Historical Diagnosis  (pgs. 14-18)  Personal history, family history, past and present medical and dental histories, history of drug ingestion, and history of the presenting disease or lesion can provide information necessary for the final diagnosis.  Pathologic conditions in which the family history contributes a significant role in diagnosis include amelogenesis imperfecta, dentinogenesis imperfecta, and other genetic disorders.

45. 45 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Historical Diagnosis (cont.)

46. 46 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Historical Diagnosis (cont.)  (pgs. 18-19)  A patient’s medical or dental status, including drug history, can also contribute significant information to a diagnosis.

47. 47 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Historical Diagnosis (cont.)

48. 48 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Historical Diagnosis (cont.)  Examples include  A history of ulcerative colitis may contribute to the diagnosis of oral ulcers.  Gingival enlargement due to treatment with a calcium channel blocker  A history of a skin graft from the hip to the ridge and mucobuccal fold area can provide significant information relevant to the diagnosis of a white- or brown-pigmented area on the mandibular ridge and vestibule.  Periapical cemento-osseous dysplasia, which is found most frequently in black women in the third decade.

49. 49 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Laboratory Diagnosis  (pgs. 18, 20)  Clinical laboratory tests, including blood chemistries and urinalysis, can provide information that contributes to a diagnosis.  An example is an elevated serum alkaline phosphatase level, significant in the diagnosis of Paget’s disease.  Laboratory cultures are helpful in determining the diagnosis of oral infections.

50. 50 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Laboratory Diagnosis (cont.)

51. 51 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Microscopic Diagnosis  (pgs. 18-20)  The microscopic examination of the biopsy specimen taken from the lesion in question contributes significant information.  It is most important that an adequate tissue sample be removed for microscopic evaluation.

52. 52 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Microscopic Diagnosis (cont.)  (pg. 19)  Brush test can be used to obtain information from oral mucosal epithelium.  A circular brush is used to obtain cells from the full thickness of epithelium.  The results of this test may help determine if a scalpel biopsy is needed to establish a definitive diagnosis.

53. 53 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Microscopic Diagnosis (cont.)  (pgs. 19-20)  A white lesion cannot be diagnosed based on clinical appearance alone.  The microscopic appearance of this type of white lesion can vary from a thickening of epithelium to epithelial dysplasia, which can be premalignant.

54. 54 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Microscopic Diagnosis (cont.)

55. 55 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Surgical Diagnosis  (pgs. 20-21)  Diagnosis is made using the information gained during the surgical procedure.  Examples include  Traumatic bone cyst May appear as a radiolucency that scallops around the roots May appear as a radiolucency that scallops around the roots When the lesion is opened surgically, an empty void is found. When the lesion is opened surgically, an empty void is found.  Lingual mandibular bone cavity Surgical examination of the well-circumscribed, radiolucent area reveals salivary gland tissue entrapped during development. Surgical examination of the well-circumscribed, radiolucent area reveals salivary gland tissue entrapped during development.

56. 56 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Surgical Diagnosis (cont.)

57. 57 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Therapeutic Diagnosis  (pgs. 20-21)  Nutritional deficiencies are common conditions to be diagnosed by therapeutic means.  Examples include  Angular cheilitis May be associated with a deficiency of B-complex vitamins May be associated with a deficiency of B-complex vitamins Most commonly a fungal condition and responds to topical application of an antifungal cream or ointment such as Nystatin Most commonly a fungal condition and responds to topical application of an antifungal cream or ointment such as Nystatin  ANUG Responds to hydrogen peroxide Responds to hydrogen peroxide

58. 58 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Therapeutic Diagnosis (cont.)

59. 59 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Differential Diagnosis  (pgs. 21-23)  That point in the diagnostic process when the practitioner decides which test or procedure is required to rule out the conditions originally suspected and establish the definitive or final diagnosis  See Box 1-1: Case study illustrating how the diagnostic processes work together and how differential diagnosis is used.

60. 60 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Variants of Normal  (pgs. 23-25)  Fordyce Granules  Torus Palatinus  Mandibular Tori  Melanin Pigmentation  Retrocuspid Papilla  Lingual Varicosities  Linea Alba  Leukoedema

61. 61 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Fordyce Granules  (pgs. 22-23)  Clusters of ectopic sebaceous glands  Most commonly observed on lips and buccal mucosa  Appear as yellow lobules in clusters and are usually distributed over the buccal mucosa or vermilion border of the involved lips  Considered a variant of normal  Treatment  None

62. 62 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Fordyce Granules (cont.)

63. 63 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Torus Palatinus  (pg. 23)  An exophytic growth of normal compact bone  Inherited and occurs more commonly in women  Asymptomatic, develop gradually, and are observed clinically in the midline of the hard palate  May take on various shapes and sizes, may be lobulated, and are covered by normal soft tissue  Treatment  None, unless they interfere with speech, swallowing, or a prosthetic appliance

64. 64 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Torus Palatinus (cont.)

65. 65 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Mandibular Tori  (pgs. 23-24)  Outgrowths of normal, dense bone found on the lingual aspect of the mandible in the area of the premolars above the mylohyoid ridge  Usually bilateral, often lobulated or nodular, can appear fused together, and have no predilection for either sex  Treatment  None, unless they interfere with fabrication and placement of a prosthetic appliance

66. 66 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Mandibular Tori (cont.)

67. 67 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Melanin Pigmentation  (pgs. 9, 23-24)  The pigment that gives color to skin, eyes, hair, mucosa, and gingiva  Most commonly observed in dark-skinned individuals

68. 68 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Melanin Pigmentation (cont.)

69. 69 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Retrocuspid Papilla  (pgs. 9, 23)  A sessile nodule on the gingival margin of the lingual aspect of the mandibular cuspids

70. 70 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Retrocuspid Papilla (cont.)

71. 71 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Lingual Varicosities  (pg. 24)  Usually observed on the ventral and lateral surfaces of the tongue  Clinically, red-to-purple enlarged vessels or clusters are seen.  Most commonly observed in individuals older than 60 years of age; thought to be related to the aging process

72. 72 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Lingual Varicosities (cont.)

73. 73 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Linea Alba  (pg. 25)  A “white line” that extends anteroposteriorly on the buccal mucosa along the occlusal plane  May be bilateral  May be more prominent in patients who have a clenching or bruxing habit

74. 74 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Linea Alba (cont.)

75. 75 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Leukoedema  (pg. 25)  A generalized opalescence on buccal mucosa  Most commonly observed in black adults  If the mucosa is stretched, the opalescence becomes less prominent.  Treatment  None

76. 76 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Leukoedema (cont.)

77. 77 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Benign Conditions of Unknown Cause  (pgs. 25-26)  Lingual Thyroid Nodule  Median Rhomboid Glossitis  Geographic Tongue  Fissured Tongue  Hairy Tongue

78. 78 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Lingual Thyroid Nodule  (pg. 25)  When thyroid tissue does not descend or remnants become trapped  A high predilection for females  Emergence linked with hormonal changes

79. 79 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Lingual Thyroid Nodule (cont.)  Clinically, a mass in the midline of the dorsal surface of the tongue posterior to the circumvallate papillae in the area of the foramen cecum  Usually has a sessile base and is 2 to 3 cm in width  Upon histological examination, normal thyroid tissue is found.  Treatment  Evaluation of the patient to determine whether the thyroid gland is present in its normal location

80. 80 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Median Rhomboid Glossitis  (pgs. 25-26)  Cause is not clear.  May be associated with a chronic infection of Candida albicans  Clinically, appears as a flat or slightly raised oval or rectangular erythematous area in the midline of the dorsal surface of the tongue, beginning at the junction of the anterior and middle thirds and extending posterior to the circumvallate papillae.

81. 81 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Median Rhomboid Glossitis (cont.)

82. 82 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.  Treatment  No specific treatment exists.  An antifungal treatment works sometimes.  May resolve spontaneously Median Rhomboid Glossitis (cont.)

83. 83 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Geographic Tongue  (pgs. 25-26)  The cause is not clear.  Genetic factors may play a role.  May be exacerbated by stress  Clinically, involves dorsal and lateral areas of the tongue  Diffuse areas devoid of filiform papillae may be observed  There appears to be remission and changes in the depapillated areas

84. 84 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Geographic Tongue (cont.)

85. 85 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Geographic Tongue (cont.)  (pg. 26)  Treatment  Usually none indicated  Occasionally, the patient may complain of a burning discomfort.  Ectopic geographic tongue  It may be found on areas other than the tongue.

86. 86 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Fissured Tongue  (pgs. 9, 26)  The cause is unknown.  Seen in about 5% of the population  Probably involves genetic factors  Clinically, the dorsal surface of the tongue appears to have deep fissures or grooves.  Treatment  None

87. 87 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Fissured Tongue (cont.)

88. 88 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hairy Tongue  (pgs. 26-27)  An increased accumulation of keratin on the filiform papillae resulting in a white, “hairy” appearance  The elongated filiform papillae are white.  In black hairy tongue, the papillae are black due to chromogenic bacteria.  Treatment  Directing the patient to brush the tongue gently with a toothbrush to remove debris

89. 89 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hairy Tongue (cont.)

90. 90 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Discussion Questions  What is the difference between a macule and a papule?  What are the elements of the diagnostic process?  What variants of normal may be found within the oral cavity?