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Competing Interests: Disclosures Drs. Glass and Howell did not report any disclosures.

Background: The aim of this prospective study was to evaluate the efficacy of a new form of autofluorescence imaging and tissue reflectance spectroscopy (Identafi, DentalEZ) in examining patients with oral mucosal lesions., Methods: The authors examined 88 patients with 231 oral mucosal lesions by conventional oral examination (COE) using white-light illumination and ×2.5 magnification loupes, followed by examination using Identafi. The authors noted fluorescence visualization loss, the presence of blanching, and diffuseness of vasculature. They performed incisional biopsies to provide definitive histopathologic diagnosis., Results: Identafi's white light produced lesion visibility and border distinctness equivalent to COE. Identafi's violet light displayed a sensitivity of 12.5% and specificity of 85.4% for detection of oral epithelial dysplasia (OED). The authors noted visible vasculature using the green-amber light in 40.9% of lesions., Conclusions: Identafi's intraoral white light provided detailed visualization of oral mucosal lesions comparable with examination using an extraoral white-light source with magnification. A high level of clinical experience is required to interpret the results of autofluorescence examination as the violet light displayed low sensitivity for detection of OED. The green-amber light provided additional clinical information in relation to underlying vasculature and inflammation of lesions., Practical Implications: Examination using Identafi can provide clinicians with more clinical data than a standard COE with yellow incandescent light, but the clinical and optical findings should be interpreted as a whole and not in isolation. Clinicians should use the light features of Identafi in a sequential and differential manner., (Copyright © 2016 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Background: Few studies have compared patient and anatomic characteristics across the broad scope of oral and maxillofacial disease seen in dental clinics. The authors conducted a study to make these comparisons by surveying a large sample of histologically diagnosed oral and maxillofacial lesions in a US adult population., Methods: A total of 51,781 specimens biopsied from 51,781 adult patients were received by an oral pathology service over 13 years (2001-2015) and analyzed. A description of patients' sex and age at diagnosis, as well as the anatomic site of biopsy was given for diagnoses of 10 oral disease types, including malignant neoplasm, benign neoplasm, infectious, reactive, potentially malignant, developmental, healthy tissue, immune dysfunction, physical trauma, and other., Results: The authors reported reactive lesions were the most prevalent disease type found in the sample (74.9%). Malignant diagnoses comprised 1.97% of all biopsies. The 3 most prevalent diagnoses in this study included benign keratosis, chronic apical periodontitis, and radicular cyst. Different anatomic sites, patient age groups, and sexes show different distributions of disease., Conclusions: Certain disease types and diagnoses were found to have a higher prevalence by sex, among particular age groups, and in certain anatomic sites., Practical Implications: This information provides clinicians with a detailed and broad scope of the variety of oral and maxillofacial lesions processed at an oral pathology service and may assist practitioners in forming clinical impressions and differential diagnoses., (Copyright © 2016 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Background: Solid organ transplantation no longer is considered a rare procedure. After undergoing transplants, patients will require both routine and emergent oral health care, and it can be provided safely in private dental offices. Transplant recipients are immunosuppressed, and for this reason clinicians should be alert for oral abnormalities in such patients., Case Description: A 53-year-old man with a history of cardiac transplant and multiple medical comorbidities had unusual mucosal plaques, oral discomfort and skin lesions. As a result of his compromised immune system, the clinical presentation of his condition-which proved to be herpes zoster (HZ) virus, also called "shingles"-was atypical, resulting in a delay of the definitive diagnosis., Conclusions: and, Clinical Implications: HZ is a serious infection in the immunocompromised population. Timely diagnosis and treatment of this condition is necessary to prevent treatment delay and medication errors.

Background: Many textbooks and articles are available to assist dentists in examining patients, establishing diagnoses for oral lesions and understanding the techniques of biopsy. There is little guidance in the literature, however, on when and how to follow up lesions that have a low index of clinical suspicion, or for which the pathological diagnosis does not demonstrate any overt signs of malignancy or premalignancy., Types of Studies Reviewed: The authors reviewed the literature, talked to numerous clinicians and sought legal opinions regarding how a reasonable and prudent dentist should manage patients with clinically evident oral lesions that do not suggest any adverse long-term effects on the health and safety of the patient., Results: The few guidelines available in the literature, coupled with the observations of the authors and others, allow logical and reasonable interim recommendations to be proposed regarding the frequency of examinations, the timing of invasive procedures and medicolegally prudent documentation guidelines. Future studies are needed to refine these recommendations., Clinical Implications: Some dentists have been sued for alleged failure to monitor patients, document cases or refer patients with oral lesions. The recommendations provided here can help dentists manage these patients, but they should not be construed as being rigid guidelines or legal standards that apply to all clinical situations. In some cases, the judgment and experience of clinicians may indicate the need to deviate from these recommendations. Refinements of these guidelines may emerge on the basis of future studies.

The authors describe an innovative method for teaching dental professionals to differentially diagnose and treat HIV-related oral lesions. The method included a half day of didactic presentations and a half day of clinical grand rounds. The clinical grand rounds featured clinical stations where small groups of practitioners observed HIV oral manifestations and interacted with patients. Their observations were discussed with two dentists expert in diagnosing and managing oral complications of HIV. Videotapes of the patients' oral lesions augmented the discussions.

The authors examined the effect of smokeless tobacco use on the athletic performance of major league baseball players during the 1988 season. They evaluated performance records of 158 players on seven major league teams who played or pitched at least 10 games or innings during the 1988 season. ST use, they concluded, is not related to player performance in major league baseball but does place players at significantly increased risk for mucosal lesions and other oral pathology.

Dental patients who smoke crack cocaine are at higher risk for HIV infection and other medical concerns including stroke, heart failure and pulmonary hemorrhage. Four cases are reported which illustrate oral ulcers caused by crack cocaine usage.

The indications for advantages and disadvantages of the punch biopsy technique in the diagnosis of oral mucosal disease are discussed. The punch biopsy is recommended for use by the general practitioner as a simple, fast, inexpensive, and safe procedure for the diagnosis of oral mucosal lesions.

The risk for oral mucosal lesions associated with use of smokeless tobacco among 1,109 professional baseball players during spring training in 1988 was investigated. Leukoplakia was very strongly associated with use of smokeless tobacco in this population of healthy young men. Of the 423 current smokeless tobacco users, 196 had leukoplakia compared to seven of the 493 nonusers (OR = 60.0, 95% CI = 40.5-88.8). The amount of smokeless tobacco used (in hours per day that smokeless tobacco was held in the mouth), recency of smokeless tobacco use (hours since last use), type (snuff versus chewing tobacco), and brand of snuff used were significantly associated with risk for leukoplakic lesions among smokeless tobacco users. Ninety-eight leukoplakic areas in 92 subjects were biopsied and examined microscopically. All lesions were benign, but one specimen had mild epithelial dysplasia. The long-term significance of leukoplakia in smokeless tobacco users and their relation to oral cancer is not clear.

Herpes zoster is considered a disease of elderly or immunocompromised patients. These cases are unusual since clinical signs of the disease occurred in two healthy, young adults. Various diagnostic and treatment considerations for herpes zoster infections are presented.

The treatment of gingival lichen planus, involving cryosurgery, is discussed in a case report. An overview of the clinical and histological changes occurring after this treatment also is presented.

The increasing use of smokeless tobacco and the accumulating list of associated health hazards including cancer and cardiovascular effects should be of concern to the dentist. This study documents both concern from patients' perceptions and clinical examinations of their smokeless tobacco-associated lesions. Implications for the dentists' practice among adolescents and young adults are discussed.

Bulimia is an eating disorder disease that presents difficulties in its diagnosis, primarily because of the secretive nature of the person with the disease. The disease is most common in young females, and there is an average of a 4-year delay between the onset of the disease and the patient's self-referral for treatment. Objective oral signs and symptoms of bulimia do exist and their presence can facilitate a diagnosis of bulimia during routine examination. The realization that five oral signs and symptoms of bulimia--enamel erosion, salivary gland enlargement, xerostomia, oral mucosal erythema, and cheilosis--are associated with the disease can eliminate some laboratory tests as well as facilitate an earlier diagnosis of bulimia.

Two cases of focal epithelial hyperplasia were observed in Tehran, Iran. No cases had been reported previously in the literature in Iran. The patients whose cases are presented were both white females. Multiple nodular lesions were seen on the upper and lower labial and buccal mucosa. The lesions were clinically and histologically consistent with focal epithelial hyperplasia (Heck's disease). No further treatment was undertaken as the lesions usually regress spontaneously.

A patient with Munchausen's syndrome received treatment from at least 25 dental practitioners in the New York metropolitan area. The patient and the syndrome are described to alert the dental community about this patient who is still presumed to be living in the New York area.

A typical example of irritation fibrosis arising in the buccal mucosa has been presented. Clinicians are cautioned that although this common oral lesion generally appears clinically in a fairly characteristic manner, to rule out a more serious, similar appearing disease, these lesions should be surgically excised and examined microscopically.

Considerable controversy exists regarding the malignant potential of lichen planus. Although a number of cases of malignant transformation have been reported, many have lacked adequate documentation. A histologically well-documented case of squamous cell carcinoma on the dorsum of the tongue arising in a long-standing lesion of erosive lichen planus is presented.

A case of hereditary intestinal polyposis and orofacial pigmentation is presented. Recognition of the characteristic pigmentation by dentists may lead to early diagnosis of associated hamartomatous polyps or neoplastic disease that may be life-threatening.

Tissue specimens submitted to an oral pathology biopsy service during a 17 1/2-year period were studied to determine the types of diagnoses rendered, the general types of pathological processes represented, and the epidemiologic distribution of patients. A total of 15,783 cases were studied. Normal structures were observed in 480 cases, mostly dental follicles, and were eliminated from the study. The remaining 15,303 cases had been diagnosed as pathological entities. A majority of the oral biopsies were taken from either infectious or reactive conditions. Fibromas, periapical granulomas, periodontitis, mucoceles, and radicular cysts were the most frequently encountered lesions. Neoplasms constituted nearly 15% of all the specimens, with approximately 18% of these being malignant. An additional 360 lesions (2.4% of the total number of specimens) harbored dysplasia and might be considered premalignant. The peak age groups represented in these patients were the third through sixth decades of life. More oral biopsies were performed on females than males. A majority of the patients were white. The purpose of this study was to determine the relative frequency of oral lesions that were considered to be of sufficient clinical significance to merit a biopsy. Although this data might be used as a guide for forming clinical impressions about oral lesions, the clinician must always be aware of the possible occurrence of more rare lesions.

Oral exfoliative cytology can be a powerful tool for early detection of malignant and premalignant lesions as well as for some viral and fungal infections, if the limitations of the method are thoroughly understood and appreciated by the dental clinician. The rationale for oral cytology is developed and documented, and interpretations of the results are explained. Advantages and disadvantages of this technique are given and indications and contraindications for this diagnostic adjunct are discussed. A simple method involving the use of inexpensive equipment in the office is suggested.

A case of oral lichen planus has been discussed. The causes, associated conditions, laboratory tests, and treatment were addressed. The use of cyanoacrylate "super glue" may have acted as a contactant and promoted the patient's localized lichenoid process. No additional treatment was provided other than confirmation of clinical suspicions. The most important factor was ruling out the possibility of a dysplastic or a malignant process. Should the patient become symptomatic, the treatment would probably start out with kaolin and pectin (Kaopectate) lidocaine/benadryl rinses. Should supportive therapy fail, alternative regimens including topical to systemic corticosteroids would be considered.

Dental practitioners should be familiar with Darier's disease because oral lesions of the disease may resemble other diseases. Differential diagnosis should include papillary hyperplasia of the palate, acanthosis nigricans, Cowden's disease, nicotine stomatitis, and condyloma acuminatum. Careful observation of the oral and skin lesions and consideration of the medical and family history should assist in diagnosis. Vitamin A, given in high doses, has been used with variable success in the treatment of Darier's disease. Systemic corticosteroids have been used with good results, but these require prolonged use as they are not curative. Secondary infection is a common complication for which topical corticosteroids are helpful.

An example of pemphigus vulgaris with initial clinical manifestations confined to the mouth has been presented. Clinicians must recognize this serious disease and understand that probably more than half of the patients with pemphigus vulgaris will first experience oral lesions, and almost all will, at some time, have oral vesiculoulcerative lesions.

Patients with renal failure have characteristic systemic and oral conditions that require special precautions during dental treatment. Drugs must be administered with caution and patients undergoing hemodialysis must receive special consideration. Both hemodialysis and transplant patients must be protected against infection. This is achieved by early, aggressive, and thorough dental treatment. Use of antibiotics during dental treatment is essential in transplant patients and is often necessary in hemodialysis patients to protect them against bacteremia. Bacterial endocarditis is a concern in patients with renal failure and with heart disease and, in these patients, antibiotic prophylaxis is essential. Hepatitis is often present in patients with renal failure, and precautions should be taken against its spread. Before dental treatment of patients with renal failure is begun, the dentist should consult the patient's physician regarding specific precautions. A treatment plan should be constructed which best restores the patient's dentition and protects from potentially severe infection of dental origin.

Although rare, oral pemphigus vulgaris must be considered in those patients who have a prolonged history of oral lesions. The fact that chronic oral lesions characteristically precede skin changes in pemphigus emphasizes the importance of this disease to the dental profession. Patients with long-term and recurrent vesiculoulcerative oral lesions should undergo biopsy examination to establish the diagnosis. The dentist and the physician must collaborate to establish an appropriate diagnostic and therapeutic plan for the management of these patients.

Four days before a routine dental examination, the patient had been stung on the left side of the soft palate by a yellow jacket. The lesion was well demarcated, with a prominent area of deep red erythema approximately 1.5 cm in diameter. inside of which was a coral pink ring approximately 0.5 cm in diameter. The patient was not experiencing discomfort at the time of examination. Reactions to Hymenoptera stings usually include pain, erythema, and swelling, but, in more severe instances, extensive swelling and systemic reactions in the form of anaphylaxis or delayed allergic responses may be seen. The patient should be referred immediately to a physician or medical treatment facility for observation and treatment if necessary. If the stinger is located either periorally or intraorally, it should be carefully removed by flicking so that additional venom from the sac is not injected into the patient.

The frequent occurrence of the oral lesions of histoplasmosis in combination with disseminated infection necessitates prompt recognition and diagnosis. The possibility of such an infection occurring in an immunocompromised patient should be considered high on the list of differential diagnoses, and treatment should be planned accordingly. The varied clinical presentations of histoplasmosis, ranging from shallow ulcers to nodular or vegetative masses, can be confusing and may lead to inaccurate diagnosis with resultant delay in treatment or inappropriate treatment. Submission of adequate tissue sections for microbiological and histopathological assessments is crucial.

Histiocytosis X, a term comprising three well-known disease complexes, may have dental mobility as a prodromal or major symptom. In each of three patients described, an oral finding predated the other symptoms. The earliest symptom in one patient was loosened teeth; in another, periodontosis-like symptoms were documented ten years before the patient's report of pelvic pain which led to a diagnosis of eosinophilic granuloma; in the third patient, premature eruption of the primary teeth the gingival bleeding was the prodromal symptom. The clinician should understand the significance of each finding and investigate them until a confirmatory diagnosis is made.

An atypical presentation of a verruciform xanthoma is discussed. Usually the surface of the lesion is rougher and more warty, and the lesions generally are larger. The foregoing case, however, serves to illustrate that all lesions, regardless of how small or innocuous, should be examined microscopically to determine a diagnosis and to develop a proper treatment plan. Rarely can a definitive diagnosis be made entirely on the basis of the clinical characteristics of the lesion.

Pemphigus vulgaris is a rare, potentially fatal skin disease with lesions usually first appearing in the mouth. Histologic examination is the only reliable mechanism with which to establish an accurate diagnosis. An elderly patient with multiple oral and skin lesions was diagnosed, referred to the dermatology service, and successfully treated with corticosteroid therapy.

A unusual type of oral desquamation appeared as grayish-white gelatinous membranes on the floor of the mouth, lips, vestibules, and gingiva in a 50-year-old woman. The painless desquamation was caused by synthetic dentifrice detergents (foaming agents) and was exacerbated by the patient's use of drugs with antisialic action.

Herpes zoster is an acute viral infection that principally affects the skin. It occasionally may involve the oral region with patients sometimes initially complaining of toothache. Generalized skin involvement by the disease should alert the clinician to the possibility of an underlying malignancy. Dentists should also be aware that the disease is infectious and can be transmitted, especially to susceptible individuals.

Rhinocerebral mucormycosis is a fungal diseases that has a 50% mortality. Its occurrence has increased, possibly because of greater use of chemotherapeutic agents that mya compromise the immunologic defenses of the host or alter the normal flora. The earliest signs, ulceration and pain, may appear in the mouth. In the patient described in this report, the autopsy showed that mucormycosis had entered the brain cells.

A man with chronic granulomatous disease had severe gingivitis and ulcerous lesions in the buccal mucosa and palatal plate. After the use of good hygiene procedures, his condition improved greatly. It is possible that oral symptoms reported in this disease are due in part to accumulations of plaque. A review of the literature on chronic granulomatous disease is included.

A survey was taken of a selected group of 4,793 oral lesions submitted to the oral pathology biopsy service between 1950 and 1970. About two thirds of all the specimens examined microscopically were classified as inflammatory, infectious, or reactive hyperplasia. Of the 12.6% of the sample classified as neoplasms, one of every five was malignant. Three of every four of the malignant neoplasms were microscopically diagnosed as squamous cell carcinomas. Benign neoplasms were most common in ages 40 to 60, whereas premalignancies and malignancies were most commonly discovered in the slightly older age group of 50 to 70. Although malignant neoplasms were found more often in men than women, there was a striking increase in the incidence of malignancies in women in the second ten-year period of the study. There were unexplainably few malignant neoplasms found in blacks. Patients should be taught to recognize the early signs of oral premalignancy and malignancy through the use of a simple method of self-examination at home. They should be discouraged from the frequent use of tobacco and alcohol, which have long been known to be predisposing factors in the production of oral squamous cell carcinomas.

Clinical diagnosis among the vesiculobullous diseases is difficult. Benign mucous membrane pemphigoid is a chronic condition, whereas bullous pemphigoid and erythema multiforme are self-limiting. Oral lesions can be the initial appearing feature of the disease. Therefore, routine histological examination with immunofluorescent studies and a good medical history will aid in differentiating among them. The case report described here shows a benign mucous membrane (cicatricial) pemphigoid in a 52-year-old female whose initial symptoms involved the oral mucosa with subsequent skin lesions. There is no other apparent mucosal involvement at this time. The symptoms are palliated with use of topical fluocinonide, but continued follow-up care is indicated.

The foregoing case is an example of amyloidosis in which biopsy of a hemorrhagic vesicle on the buccal mucosa established the diagnosis. Once the diagnosis was made, the patient's cardiomyopathy, nephrotic syndrome, hepatomegaly, GI hemorrhage, hematuria, and oral lesions readily were explained.

As the dental profession moves toward additional emphasis in detection of disease and sophistication in diagnosis, biopsy is being used with increasing frequency as a diagnostic tool. This article states and elucidates simple ground rules that govern the rationale of surgical sampling of pathologic tissue. The three most common deficiencies that hamper interpretation (tissue artifact, inadequate clinical information, and inappropriate tissue sampling) are discussed, and the biopsy approach to various types of clinical lesions is reviewed.

Oral ulcerative lesions may strongly resemble one another which can lead to erroneous assumptions in diagnosis. The importance of assembling all the pertinent facts including, at times, microscopic examination and bacterial cultures before instituting treatment is illustrated by this case report of an oral gonococcal infection.