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Eleana Stufi for their assistance in the prepa- I am also indebted to Associate Professor of ration of the first edition of the Atlas buy 15 gm ketoconazole cream visa. My sincere thanks are extended to the scientific I thank the following colleagues for permission staff of "A buy discount ketoconazole cream 15gm on-line. Karpathios (Greece) for ling and prompt help during the 23 years of our Figure 358 generic ketoconazole cream 15gm fast delivery, Dr purchase ketoconazole cream 15gm. Crispian Scully (England) for on the translation of the Greek edition of this Figure 278, Dr. My deepest gratitude is due to Professor Cris- Last, but by no means least, I can never fully pian Scully, Department of Oral Medicine and repay all that I owe my wife and three children for Surgery, University of Bristol, England, and Pro- their constant patience, support, and encourage- fessor Gerald Shklar, Department of Oral ment. Normal Anatomic Variants Linea Alba Leukoedema Linea alba is a normal linear elevation of the Leukoedema is a normal anatomic variant of the buccal mucosa extending from the corner of the oral mucosa due to increased thickness of the mouth to the third molars at the occlusal line. As a rule, it occurs bilaterally and with normal or slightly whitish color and normal involves most of the buccal mucosa and rarely the consistency on palpation (Fig. The oral opalescent or grayish-white color with slight mucosa is slightly compressed and adjusts to the wrinkling, which disappears if the mucosa is dis- shape of the occlusal line of the teeth. Leukoedema has normal consistency on palpation, and it should not be confused with leukoplakia or lichen planus. Normal Oral Pigmentation Melanin is a normal skin and oral mucosa pigment produced by melanocytes. However, areas of dark discoloration may often be a normal finding in black or dark- skinned persons. However, the degree of pigmen- tation of skin and oral mucosa is not necessarily significant. In healthy persons there may be clini- cally asymptomatic black or brown areas of vary- ing size and distribution in the oral cavity, usually on the gingiva, buccal mucosa, palate, and less often on the tongue, floor of the mouth, and lips (Fig. The pigmentation is more prominent in areas of pressure or friction and becomes more intense with aging. Clinically, there are many small, slightly raised whitish-yellow spots that are well circumscribed and rarely Congenital Lip Pits coalesce, forming plaques (Fig. They occur Congenital lip pits represent a rare developmental most often in the mucosal surface of the upper lip, malformation that may occur alone or in combina- commissures, and the buccal mucosa adjacent to tion with commissural pits, cleft lip, or cleft the molar teeth in a symmetrical bilateral pattern. Clinically, they present as bilateral or They are a frequent finding in about 80% of unilateral depressions at the vermilion border of persons of both sexes. There is no satisfactory explana- tion for the occurrence of oral hair although a developmental anomaly is the most likely possibil- ity. The presence of oral hair and hair follicles may offer an explana- tion for the rare occurrence of keratoacanthoma intraorally. The differential diagnosis should be made from traumatically implanted hair and the presence of hair in skin grafts after surgical procedures in the oral cavity. Ankyloglossia Cleft Palate Ankyloglossia, or tongue-tie, is a rare develop- Cleft palate is a developmental malformation due mental disturbance in which the lingual frenum is to failure of the two embryonic palatal processes short or is attached close to the tip of the tongue to fuse. Rarely, the condition may occur as a exhibit a defect at the midline of the palate that result of fusion between the tongue and the floor may vary in severity (Fig. The malfor- sents a minor expression of cleft palate and may mation may cause speech difficulties. Surgical clipping of the frenum cor- Cleft palate may occur alone or in combination rects the problem. Early surgical correction is recom- usually involves the upper lip and very rarely the mended. The incidence of cleft lip alone or in combination with cleft palate varies from 0. Plastic surgery as early as possible corrects the esthetic and functional problems. Developmental Anomalies Bifid Tongue Torus Palatinus Bifid tongue is a rare developmental malforma- Torus palatinus is a developmental malformation tion that may appear in complete or incomplete of unknown cause. The inci- deep furrow along the midline of the dorsum of dence of torus palatinus is about 20% and appears the tongue or as a double ending of the tip of the in the third decade of life, but it also may occur at tongue (Fig. It may coexist with shape may be spindlelike, lobular, nodular, or the oro-facial digital syndrome. The exostosis is benign and consists of bony tissue covered with normal mucosa, although it may become ulcerated if traumatized. Because of its slow growth, the Double Lip lesion causes no symptoms, and it is usually an Double lip is a malformation characterized by a incidental finding during physical examination. It may be congenital, but it may be anticipated if a total or partial denture is can also occur as a result of trauma. Developmental Anomalies Torus Mandibularis Fibrous Developmental Malformation Torus mandibularis is an exostosis covered with Fibrous developmental malformation is a rare normal mucosa that appears on the lingual sur- developmental disorder consisting of fibrous over- faces of the mandible, usually in the area adjacent growth that usually occurs on the maxillary alveo- to the bicuspids (Fig. Bilateral exostoses cal painless mass with a smooth surface, firm to occur in 80% of the cases. Clinically, it is an asymptomatic growth that Commonly, the malformation develops during the varies in size and shape. Surgical excision is required if Multiple exostoses are rare and may occur on the mechanical problems exist. Clinically, they appear as multiple asymptomatic small nodular, bony elevations below the mucco- labial fold covered with normal mucosa (Fig. Developmental Anomalies Facial Hemiatrophy Masseteric Hypertrophy Facial hemiatrophy, or Parry-Romberg syndrome, Masseteric hypertrophy may be either congenital is a developmental disorder of unknown cause or functional as a result of an increased muscle characterized by unilateral atrophy of the facial function, bruxism, or habitual overuse of the mas- tissues. Clinically, masseteric The disorder becomes apparent in childhood and hypertrophy appears as a swelling over the girls are affected more frequently than boys in a ascending ramus of the mandible, which charac- ratio of 3:2. In addition to facial hemiatrophy, teristically becomes more prominent and firm epilepsy, trigeminal neuralgia, eye, hair, and when the patient clenches the teeth (Fig. Hemiatrophy of the tongue and the lips are the most common oral manifestations (Fig. The differential diagnosis includes true lipodystro- phy, atrophy secondary to facial paralysis, facial hemihypertrophy, unilateral masseteric hypertro- phy, and scleroderma. It is progressive until The differential diagnosis includes white sponge early adulthood, remaining stable thereafter. Histopathologic examination they are found in the buccal mucosa and the establishes the diagnosis. Gingival Fibromatosis The differential diagnosis includes leukoplakia, lichen planus, leukoedema, pachyonychia con- Gingival fibromatosis is transmitted as an auto- genita, congenital dyskeratosis, hereditary benign somal dominant trait. It usually appears by the intraepithelial dyskeratosis, and mechanical tenth year of life in both sexes. Histopathologic examination is with minimal or no inflammation and normal or helpful in establishing the diagnosis. The upper gingiva are more severely affected Hereditary Benign Intraepithelial and may prevent the eruption of the teeth. Dyskeratosis The differential diagnosis should include gingival hyperplasia due to phenytoin, nifedipine, and cy- Hereditary benign intraepithelial dyskeratosis is a closporine, and gingival fibromatosis, which may genetic disorder inherited as an autosomal domi- occur as part of other genetic syndromes. The ocular lesion pre- sents as a gelatinous plaque covering the pupil partially or totally and may cause temporary 3. Hereditary benign intraepithelial dyskeratosis, white lesions on the buccal mucosa.

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Influenza virus and tuberculosis bacteria are spread by secretions that are coughed or sneezed into the air by an infected person discount ketoconazole cream 15gm overnight delivery. Human or animal wastes in watersheds cheap 15 gm ketoconazole cream visa, failing septic systems buy ketoconazole cream 15gm line, failing sewage treatment plants purchase ketoconazole cream 15 gm on line, or cross-connections of water lines with sewage lines provide the potential for contaminating water with pathogens. The water may not appear to be contaminated because the feces has been broken up, dispersed, and diluted into microscopic particles. These particles containing pathogens, may remain in the water and be passed to humans or animals unless adequately treated. In addition to water, other methods exist for spreading pathogens by the fecal-oral route. A frequent source is a food handler who does not wash his hands after a bowel movement and then handles food with unclean hands. It is interesting to note the majority of foodborne diseases occur in the home, not restaurants. Day care centers are another common source for spreading pathogens by the fecal-oral route. Here, infected children in diapers may get feces on their fingers, then put their fingers in a friend’s mouth or handle toys that other children put into their mouths. The general public and some of the medical community usually refer to diarrhea symptoms as stomach flu. Technically, influenza is an upper respiratory illness and rarely has diarrhea associated with it; therefore, stomach flu is a misleading description for foodborne or waterborne illnesses, yet is accepted by the general public. So the next time you get the stomach flu, you may want to think twice about what you’ve digested within the past few days. Chain of Transmission When water is contaminated with feces, this contamination may be of human or animal origin. If the human or animal source is not infected with a pathogen disease-causing bacteria, viruses or protozoa, no disease will result. This depends on the temperature of the water and the length of time the pathogens are in the water. The pathogens in the water must enter the water system’s intake and in numbers sufficient to infect people. The water is either not treated or inadequately treated for the pathogens present. A susceptible person must drink the water that contains the pathogen in order for illness (disease) to occur. This chain lists the events that must occur for the transmission of disease via drinking water. By breaking the chain at any point, the transmission of disease will be prevented. Bacterial Diseases (More detailed information in the next chapters) Campylobacteriosis is the most common diarrheal illness caused by bacteria. The illness is frequently over within two to five days and usually lasts no more than 10 days. Campylobacteriosis outbreaks have most often been associated with food, especially chicken and unpasteurized milk, as well as unchlorinated water. Medical treatment generally is not prescribed for campylobacteriosis because recovery is usually rapid. Cholera, Legionellosis, salmonellosis, shigellosis, yersiniosis, are other bacterial diseases that can be transmitted through water. All bacteria in water are readily killed or inactivated with chlorine or other disinfectants. Viral Diseases or Viruses Hepatitis A is a common example of a viral disease that may be transmitted through water. The onset is usually abrupt with fever, malaise, loss of appetite, nausea, and abdominal discomfort, followed within a few days by jaundice. The disease varies in severity from a mild illness lasting one to two weeks, to a severely disabling disease lasting several months (rare). Hepatitis A outbreaks have been related to fecally contaminated water; food contaminated by infected food handlers, including sandwiches and salads that are not cooked or are handled after cooking; and raw or undercooked mollusks harvested from contaminated waters. Aseptic meningitis, polio, and viral gastroenteritis (Norwalk agent) are other viral diseases that can be transmitted through water. Most viruses in drinking water can be inactivated by chlorine or other disinfectants. Terrorism Recent investigations have shown proof the terrorist organizations have been able to reproduce most of these pathogens and have the technology and funding to attack our public water supply system. Even diseases that we have not seen in years are easily and readily available for a terrorist to backflow into our distribution system, or pour into a wellhead or clearwell. Most of the following information may be simple or instruction that you already know. History of Research By the last half of the 19th century, the microbial world was known to consist of protozoa, fungi, and bacteria, all visible with a light microscope. In the 1840s, the German scientist Jacob Henle suggested that there were infectious agents too small to be seen with a light microscope, but for the lack of direct proof, his hypothesis was not accepted. Although the French scientist Louis Pasteur was working to develop a vaccine for rabies in the 1880s, he did not understand the concept of a virus. During the last half of the 19th century, several key discoveries were made that set the stage for the discovery of viruses. Pasteur is usually credited for dispelling the notion of spontaneous generation and proving that organisms reproduce new organisms. The German scientist Robert Koch, a student of Jacob Henle, and the British surgeon Joseph Lister developed techniques for growing cultures of single organisms that allowed the assignment of specific bacteria to specific diseases. Because Mayer was unable to isolate a bacterium or fungus from the tobacco leaf extracts, he considered the idea that tobacco mosaic disease might be caused by a soluble agent, but he concluded incorrectly that a new type of bacteria was likely to be the cause. The Russian scientist Dimitri Ivanofsky extended Mayer’s observation and reported in 1892 that the tobacco mosaic agent was small enough to pass through a porcelain filter known to block the passage of bacteria. But Ivanofsky, like Mayer, was bound by the dogma of his times and concluded in 1903 that the filter might be defective or that the disease agent was a toxin rather than a reproducing organism. Unaware of Ivanofsky’s results, the Dutch scientist Martinus Beijerinck, who collaborated with Mayer, repeated the filter experiment but extended this finding by demonstrating that the filtered material was not a toxin because it could grow and reproduce in the cells of the plant tissues. In his 1898 publication, Beijerinck referred to this new disease agent as a contagious living liquid—contagium vivum fluid—initiating a 20-year controversy over whether viruses were liquids or particles. The conclusion that viruses are particles came from several important observations. Because each hole, or plaque, developed from a single bacteriophage, this experiment provided the first method for counting infectious viruses (the plaque assay).

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But when by the destruction of this original cutaneous eruption order ketoconazole cream 15 gm with mastercard, which acts vicariously for the internal malady cheap 15 gm ketoconazole cream fast delivery, it has been robbed then the psora is put in the unnatural position of dominating in a merely one-sided manner the internal finer parts of the whole organism buy ketoconazole cream 15 gm overnight delivery, and thus of being compelled to develop its secondary symptoms order 15 gm ketoconazole cream. How important and necessary the cutaneous eruption is for the original psora, and how carefully in the only thorough cure of itch, that is, the internal cure, every external removal of the eruption must be avoided, we may see from the fact that the most severe chronic ailments have followed as secondary symptoms of the internal psora after the original itch-eruption has been driven out, and that when, in consequence of a great revolution in the organism, this itching eruption re-appears on the skin, the secondary symptoms are so suddenly removed, that these grievous ailments, often of many yearsÕ standing, are wont to disappear, at least temporarily, as if by a miracle. But let no one suppose that an internal psora, which, after the external destruction of the original cutaneous eruption, has broken out into secondary chronic ailments, can, through the re-appearance of such an itch-like eruption on the skin, come into just as normal a state as before, or that it can be cured just as easily as if it were still the original eruption and as if this had not been as yet removed. Even the eruption following immediately after the infection has no such unchanging constancy and pertinacity on the skin as the chancre and the figwarts show on the spots where they first appear,* but not infrequently disappears from the skin also from other causes than from artificial remedies used purposely for its destruction, and so also from other causes unknown. Such a respite can be expected still less in this secondary eruption, which has been brought out on the skin by any cause after the local extirpation of the eruption; for the second eruption is wont to be far more inconstant and changeable, so that it often passes away on much slighter provocation in a few days - a proof that it lacks much of the complete quality of the primitive itch-eruption, so that the physician cannot count on it in the thorough cure of the psora. This proneness to change, in the itch-like eruption which has been called a second time to the skin, seems evidently to be caused by the fact that the internal psora, after the destruction of the original itch-eruption is unable to give to the secondary eruption the full qualities belonging to the primary eruption, and is already much more inclined to unfold itself in a variety of other chronic diseases; wherefore a thorough cure is now much more difficult, and is simply to be conducted as if directed against the internal psora. The cure is not, therefore, advanced by producing such a secondary eruption through internal remedies, as has sometimes been effectually attempted (see Nos. Such a secondary eruption is always very transitory, and so unreliable and rare that we cannot build our hope of cure on it, nor expect from it the advancement of any thorough cure. From this it again appears how unconscionable it is of the allopathic physicians, to destroy the primitive itch eruption through local applications instead of completely eradicating this grave disease from the whole living organism by a cure from within, which at that stage is as yet very easy, and by thus choking off in advance all the wretched consequences that we must expect from this malady if uncured; i. For this purpose I found most serviceable the wearing of a plaster mostly on the back (but where practicable also on other portions of the skin); the plaster was prepared by gently heating six ounces of Burgundy pitch, into which, after removing it from the fire, an ounce of turpentine produced from the larch-tree (called Venetian turpentine) was stirred until it was perfectly mixed. A portion of this was spread on a chamois skin (as being the softest), and laid on while still warm. Instead of this, there might also be used so-called tree-wax (made of yellow wax and common turpentine), or also taffeta covered with elastic resin; showing that the itching eruption evolved is not due to any irritation caused by the substance applied; nor does the psora first mentioned cause either eruption or itching on the skin of a person who is not psoric. I discovered that this method is the most effective to cause such an activity of the skin. Yet despite of all the patience of the sick persons (no matter how much they might internally be affected with the psora), I never could evolve a complete eruption of itch, least of all one that would remain for a time on the skin. What could be effected was only that some itching pustules appeared, which soon vanished again, when the plaster was left off. More frequently there ensued a moist soreness of the skin, or at best a more or less violent, itching of the skin, which in rare cases extended also to the other parts not covered by the plaster. This, indeed, would cause for a time a striking alleviation of even the most severe chronic diseases flowing from a psoric source; e. But this much could not be attained on the skin of many patients (frequently all that could be attained was a moderate or small amount of itching), or again, if I could produce a violent itching, this frequently became too unbearable for the patient to sustain it for a time sufficient to produce an internal cure. When the plaster then was removed in order to relieve him, even the most violent itching, together with the eruption present, disappeared very soon, and the cure had not been essentially advanced by it; this confirms the observation made above, that the eruption if evolved a second time (and so also the itching reproduced) had not by any means the full characteristics of the eruption of the itch which had originally been repressed, and was therefore of little assistance in the real advancement of a thorough cure of the psora through internal remedies, while the little aid afforded loses all value owing to the often unbearable infliction of the artificially produced eruption and itching of the skin, and the weakening of the whole body which is inseparable from the titillating pain. He will say, indeed: Ò If it is not known - and hardly ever does it become demonstrably known - where, when, at what occasion and from what person avowedly suffering from itch the infection has been derived, then he could not discover from the present, and often insignificant little eruption whether it was real itch; so he was not to be blamed for the evil consequences, if he supposed it to be something else and endeavored to remove it from the skin as soon as possible by a lotion of lead solution, or an ointment of cadmia, or white precipitate of mercury, according to the wishes of the aristocratic parents. For, first of all, no cutaneous eruption of whatever kind it may be, ought to be expelled through external means by any physician who wishes to act conscientiously and rationally. In every case there is at the bottom a disorderly state of the whole internal living organism, which state must first be considered; and therefore the eruption is only to be removed by internal healing and curative remedies which change the state of the whole; then also the eruption which is based on the internal disease will be cured and healed of itself, without the help of any external remedy, and frequently more quickly than it could be done by external remedies. Secondly, even if the physician should not have presented to him the original, undestroyed form of the eruption, - i. In such a case we can never doubt as to the infection with itch, though in genteel and wealthy families we can seldom secure the information and the certainty as to how, where and from whom the infection has been derived; for there are innumerable imperceptible occasions whereby this infection may be received, as taught above. The homoeopathic physician in his private practice seldom gets to see and to treat an eruption of itch spread over a considerable part of the skin and coming from a fresh infection. The patients on account of the intolerable itching either apply to some old woman, or to the druggist or the barber, who, one and all, come to their aid with a remedy which, as they suppose, is immediately effective (e. Only in the practice of the barracks, of prisons, hospitals, penitentiaries and orphan asylums those infected have to apply to the resident physician, if the surgeon of the house does not anticipate him. Even in the most ancient times when itch occurred, for it did not everywhere degenerate into leprosy, it was acknowledged that there was a sort of specific virtue against itch in sulphur; but they knew of no other way of applying it, but to destroy the itch through an external application of it, even as is done now by the greater part of the modem physicians of the old school. So also the most ancient physicians, like the moderns, prescribed for their itch patients baths of warm sulphurous mineral water. Such patients are usually also delivered from their eruption by these external sulphur remedies. But that their patients were not really cured thereby, became manifest, even to them, from the more severe ailments that followed, such as general dropsy, with which an Athenian was afflicted when he drove out his severe eruption of itch by bathing in the warm sulphur baths of the island of Melos (now called Milo), and of which he died. Epidemion, which has been received among the writings of Hippocrates (some three hundred years before Celsus). Internally the ancient physicians gave no sulphur in itch, because they, like the moderns, did not see that this miasmatic disease was, at the same time and especially, an internal disease. They only gave it in connection with the external means of driving away the itch, and, indeed, in doses which would act as purgatives, - ten, twenty and thirty grains at a dose, frequently repeated, - so that it never became manifest how useful or how injurious this internal application of such large doses, in connection with the external application, had been; at least the whole itch-disease (psora) could never be thoroughly healed thereby. The external driving out of the eruption was simply advanced by it as by any other purgative, and with the same injurious effects as if no sulphur at all had been used internally. For even if sulphur is used only internally, but in the above described large doses, without any external destructive means, it can never thoroughly heal a psora; partly because in order to cure as an antipsoric and homoeopathic medicine, it must be given only in the smallest doses of a potentized preparation, while in larger and more frequent doses the crude sulphur* in some cases increases the malady or at least adds a new malady; partly because the vital force expels it as a violently aggressive remedy through purging stools or by means of vomiting, without having put its healing power to any use. After assuming that a drug, which in a normal state of health causes the symptoms a, b, g, - in analogy with other physiological phenomena, produces the symptoms x, y, z, which appear in an abnormal state of health - can act upon this abnormal state in such a way that the disease-symptoms x, y, z, are transformed into the drug symptoms a, b, g, which latter have the peculiar characteristic of temporariness or transitoriness; he then continues: Ò This transitory character belongs to the group of symptoms of the medicine a, b, g, which is substituted for the group of symptoms belonging to the disease, merely because the medicine is used in an extraordinarily small dose. Should the homoeopathic physician give the patient too large a dose of the homoeopathic remedy indicated, the disease x, y, z may indeed be transformed into the other, i. If a very large dose is given, then a new often very dangerous disease is produced, or the organism does its utmost to free itself very quickly from the poison (through diarrhoea, vomiting, etc. This in time passes away, when the psora again lifts its head, either with the same morbid symptoms as before, or with others similar but gradually more troublesome than the first, or with symptoms developing in nobler parts of the organism. Ignorant persons will rejoice in the latter case, that their former disease at least has passed away, and they hope that the new disease also may be removed by another journey to the same baths. They do not know, that their changed morbid state is merely a transformation of the same psora; but they always find out by experience, that their second tour to the baths causes even less alleviation, or, indeed, if the sulphur-baths are used in still greater number, that the second trial causes aggravation. Thus we see that either the excessive use of sulphur in all its forms, or the frequent repetition of its use by allopathic physicians in the treatment of a multitude of chronic diseases (the secondary psoric ailments) have taken away from it all value and use; and we may well assert that, to this day, hardly anything but injury has been done by allopathic physicians through the use of sulphur. I know a physician in Saxony who gained a great reputation by merely adding to his prescriptions in nearly all chronic diseases flowers of sulphur, and this without knowing a reason for it. This in the beginning of such treatments is wont to produce a strikingly beneficent effect, but of course only in the beginning, and therefore after that his help was at an end. Even when, owing to its undeniable anti-psoric effects, sulphur may be able of itself to make the beginning of a cure, after the external expulsion of the eruption, either with the still hidden and latent psora or when this has more or less developed and broken out into its varied chronic diseases, it can nevertheless be but rarely made use of for this purpose, because its powers have usually been already exhausted, because it has been given to the patient already before by allopathic physicians for one purpose or another, perhaps has been given already repeatedly; but sulphur, like most of the antipsoric remedies in the treatment of a developed psora that has become chronic, can hardly be used three or four times (even after the intervening use of other antipsoric remedies) without causing the cure to retrograde. The cure of an old psora that has been deprived of its eruption, whether it may be latent and quiescent, or already broken out into chronic diseases, can never be accomplished with sulphur alone, nor with sulphur-baths either natural or artificial. Here I may mention the curious circumstance that in general with the exception of the recent itch-disease still attended with its unrepressed cutaneous eruption, and which is so easily cured from within* - every other psoric diathesis, i. It is, therefore, not strange, that one single and only medicine is insufficient to heal the entire psora and all its forms, and that it requires several medicines in order to respond, by the artificial morbid effects peculiar to each, to the unnumbered host of psora symptoms, and thus to those of all chronic (non venereal) diseases, and to the entire psora, and to do this in a curative homoeopathic manner.

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Etiology It is a reactive generic ketoconazole cream 15gm line, rather fibrous hyperplasia in response to local irritation or trauma purchase ketoconazole cream 15 gm otc, than a true neoplasm generic ketoconazole cream 15gm with mastercard. Clinical features The lesion typically presents as an asymptomatic purchase 15 gm ketoconazole cream overnight delivery, well-defined, firm, sessile or pedunculated tumor with a smooth surface of normal epithelium (Figs. Differential diagnosis Neurofibroma, peripheral ossifying fibroma, lipoma, myxoma, schwannoma, pleomorphic adenoma. Usage subject to terms and conditions of license 256 Soft-Tissue Tumors Papilloma See pp. Lipoma Definition Lipoma is a benign tumor of fat tissue, and is relatively rare in the oral cavity. Clinical features It appears as an asymptomatic, well-defined tumor, sessile or pedunculated, varying in size from0. The buccal mucosa, buccal vestibule, floor of the mouth, and tongue are the most common sites affected. Usage subject to terms and conditions of license 258 Soft-Tissue Tumors Soft-Tissue Osteoma Definition Osteoma is a benign tumor that represents a proliferation of mature cancellous or compact bone. Clinical features Osteoma is rare in the jaws and extremely rare on the oral soft tissue. The latter formhas been described in the palate, buccal mucosa, tongue, and alveolar process. Clinically, soft-tissue osteoma presents as an asymptomatic, well-defined, hard tumor, covered by thin and smooth epithelium (Fig. Traumatic Neuroma Definition Traumatic neuroma or amputation neuroma is a reactive proliferation of nerve fibers and surrounding tissues. Clinical features It appears as a small, usually mobile, tumor covered by normal mucosa (Fig. The lesion is usually painful, particularly on palpation, and is often located in the mental foramen area, lower lip, and tongue. Usage subject to terms and conditions of license 260 Soft-Tissue Tumors Neurofibroma Definition Neurofibroma is a relatively rare benign neoplasm of the oral mucosa, originating in Schwann cells or perineural cells. Clinical features It appears as a painless, well-defined, pedunculated and firm tumor, covered by normal epithelium (Figs. Multiple skin and oral neurofibromas are a common finding with neurofibromatosis (Fig. Differential diagnosis Fibroma, schwannoma, traumatic neuroma, and granular-cell tumor. Usage subject to terms and conditions of license 262 Soft-Tissue Tumors Schwannoma Definition Schwannoma or neurilemoma is a rare benign tumor of Schwann-cell origin. Clinical features It presents as an asymptomatic, well-defined, firm and sessile tumor, usually covered by normal epithelium (Fig. Differential diagnosis Neurofibroma, fibroma, granular-cell tumor, leiomyoma, pleomorphic adenoma, and other salivary gland tumors. Leiomyoma Definition Leiomyoma is a rare benign tumor deriving from smooth muscle. In the oral cavity it derives from the smooth muscles of blood vessels and fromthe circumvallate papillae of the tongue. Clinical features It presents as a slow-growing, painless, firm, and well-defined tumor with a normal or reddish color (Fig. Differential diagnosis Hemangioma, granular-cell tumor, hemangio- pericytoma, myofibroma, schwannoma. Usage subject to terms and conditions of license 264 Soft-Tissue Tumors Granular-Cell Tumor Definition Granular-cell tumor, or granular-cell myoblastoma, is a rel- atively rare, benign tumor, probably originating in Schwann cells or undifferentiated cells. Clinical features It presents as an asymptomatic, firm, well-defined tumor that may be slightly elevated, with a normal or whitish color, and 2 cmin size or smaller (Figs. The dorsumand lateral borders of the tongue are the sites of predilection, followed by the buccal mucosa. The tumor most frequently occurs between 30 and 60 years of age and is more common in women. Differential diagnosis Rhabdomyoma, schwannoma, neurofibroma, pleomorphic adenoma, leiomyoma, granular-cell tumor of the newborn. Usage subject to terms and conditions of license 266 Soft-Tissue Tumors Melanotic Neuroectodermal Tumor of Infancy Definition Melanotic neuroectodermal tumor of infancy is a rare be- nign tumor of neural crest origin, which usually occurs in tooth-bearing areas. Clinical features It presents as a rapidly expanding, painless tumor covered by normal epithelium of a normal or reddish-brown color (Fig. It occurs mostly in the anterior region of the maxilla (79%), and rarely in the mandible, skull, shoulder, skin, brain, and epididymis. Laboratory tests Histopathological examination, radiography, high urinary level of vanillylmandelic acid. Differential diagnosis Granular-cell tumor of the newborn, odonto- genic tumors, melanoma, neuroblastoma, schwannoma, sarcomas. Usage subject to terms and conditions of license 268 Soft-Tissue Tumors Myxoma Definition Myxoma is a very rare benign tumor of the oral cavity, of mesenchymal origin. Clinical features It is a well-defined, soft tumor covered by normal epithelium(Fig. It can appear at any age, and is most frequent on the buccal mucosa, the floor of the mouth, and the palate. Benign Fibrous Histiocytoma Definition Benign fibrous histiocytoma is a rare tumor, primarily com- posed of histiocytes and fibroblasts. Clinical features It presents as a painless, firmtumor, covered by normal epithelium, which may be ulcerated (Fig. Differential diagnosis Fibroma, neurofibroma, schwannoma, lipoma, granular-cell tumor, leiomyoma, malignant fibrous histiocytoma. Usage subject to terms and conditions of license 270 Soft-Tissue Tumors Pleomorphic Adenoma Definition Pleomorphic adenoma is the most common benign tumor of the salivary glands, and originates fromductal and myoepithelial elements. Clinical features Pleomorphic adenoma in the minor salivary glands presents as an asymptomatic, slow-growing, firm swelling, 2–3cmin size (Figs. The posterior palate is the most common intraoral site, followed by the upper lip and buccal mucosa. Differential diagnosis Other benign and malignant salivary gland tu- mors, necrotizing sialadenometaplasia, lipoma. Usage subject to terms and conditions of license 272 Soft-Tissue Tumors Keratoacanthoma Definition Keratoacanthoma is a fairly common benign tumor that originates fromhair follicles. Clinical features It appears as a rapidly growing, painless, well-cir- cumscribed dome- or bud-shaped tumor, 1–2 cmin diameter, with a keratin crater at the center (Fig. The tumor reaches its full size within 4–8 weeks, persists for a period of one or two months, and may then undergo spontaneous regression. Almost 10% of keratoacanthomas are located on the lips, and only a few cases have been reported intra- orally. Differential diagnosis Basal-cell carcinoma, squamous-cell carcinoma, warty dyskeratoma, papillary syringadenoma, cutaneous horn. Squamous-Cell Carcinoma Squamous-cell carcinoma of the oral cavity has a varied clinical presen- tation and may mimic a variety of diseases, leading to diagnostic dilem- mas. A relatively common clinical pattern for the disease is an exophytic irregular mass or tumor (Figs.

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