Transcribed by Christina GoryDate of the Lecture 7/2/2014

[DOD] [1] [Extra-Oral and Intra-Oral Examination, Variants of Normal and Common Oral Lesions] by [Dr. Shah]

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

[Dr Shah]- Okay welcome. How is everyone? Guys all right? Okay. Alright well my name is Dr.Shah and I wanna tell you guys a little bit about me. Im waiting for the AV people to come and fix the lighting okay? Because I want it to be a little darker so the slides and the pictures look better. But Id like to take a few minutes just to talk about myself. Because for better or worse you guys are stuck with me in D3 NAD d4 and this d2 course. So just a few words about me. I have been at NYU. Okay theyre working on he lighting good. I have been at NYU for 7 years since 2007. Okay and just I am a southern gal. I grew up in Texas. I went to college in Austin I went to dental school in Houston. And even though have been in NY for about 10 years now I still identify as Texan. Although I dont have the southern drawl. I do say howdy and yall a lot though. Well I dont say howdy but I do say yall. And I dont like bbq- Im vegetarian and I hate country music. So I dont really know.. I guess I dont have a lot of Texas roots but that is where I was born and raised. Okay so after finishing my dental school training I decided I wanted to pursue oral pathology because I was always interested in diseases tumors cancers things like that so I went for umm ya know I discovered the world of oral pathology when I was in dental school. I had a good mentor. Uh then I went to a residency program, a three-year residency program in oral pathology. There are only 10 programs in the entire country. And the two best programs were in New York and therefore I left my world of comfort in the South and came to NY, which was a really drastic drastic change. I dont know if any of you are from the south. Are any of you from the south? Okay so a couple of people. Were you shocked when you came here? Okay it was very different when I came here. In the first week I was here I got into a fight, I had my car towed and I got a ticket for talking on the cell phone. So it was really a rough time a big change. Okay so um then I decided to come here. I did my three year residency in oral pathology in Flushing and then I was going to go back to Texas but I winded up getting this job at NYU and Ive been happy since and Ive been here for 7 years. Let me tell you a little bit of what I do here okay. So besides teaching this class I am the course coordinator for D3 OMPR Oral and Maxillofacial Pathology. Okay so I coordinate that. Fourth year I run a rotation that all of you guys will be coming to the clinic on the 8th floor for one week so you see what we do in the oral medicine clinic so Im also in that clinic. Okay so I run a couple courses I see patients I want you all to understand I am a clinician. Im not just someone who speaks here and looks at microscope slides. Everything that you see, a lot of these pictures are my patients. I see patients I treat patients I do my own biopsies. So Im very hands on. And I actually spend more time in the clinic all day Monday and Wednesday than I do looking at microscope slides and teaching so Im very much a clinician. I do some clinical research, I teach these classes and in case you dont know what pathology itself is- its looking at slides underneath the microscope. For any biopsies I do, any biopsies done in the school, and any biopsies in the tri-state area we have dentists surgeons head and neck surgeons MDs whoever dermatologists anyone that may send us specimens and I look at things under the microscope and decide what the microscope is and decide what the diagnosis is- whether its benign or malignant. And then I often speak to clinicians about what to do next. Okay as I handle many of these patients as well. Okay. So also you may occasionally see me in the admissions clinic- 1A- Im also down there on Friday mornings to help teach students how to do head and neck exams. Okay so that is a little bit about me. Ive been in NY for ya know after my residency since then. I dont know if you guys got a chance to see the picture I had- my screen saver- Im a very proud mother and I talk about my kids a al ot so Im sorry I apologize in advance if I bore anyone. But I have a 6 year old daughter and a 9 year old son who are currently in summer camp and I will often post pictures of them. So just in case you looked at this lecture ahead of time you might have seen a boy and a girl at the end- those are my kids- those are not random people but my children. Okay other than that I dont think I have anything else to say about myself so Im gonna go ahead and start this lecture.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[16]- Examination of the Neck[Dr Shah]- Okay so enough about the skin. It is time to move on to the neck and eventually make it to the oral cavity. Okay so examination of the neck. One of the key things you need to do when you feel the neck is look for lymph nodes. Okay lymph nodes are these firm, freely movable, descried as rubbery nodules that you may find in the neck, and in the submental, and submandibular areas. And where else in the body can you find lymph nodes? Who knows? Axillary- the armpit. Those lymph nodes are very important for breast cancer patients. Because they take those lymph nodes to see if the cancer has drained and it gives you an idea of the prognosis and staging. Where else in the body do we have lymph nodes? Head and neck has the highest concentration. Then we have the axillary. Does anyone know where else we have lymph nodes? Behind the knee. Okay. We also have inguinal in the groin area. So those are where you have lymph nodes. Okay so you examine for any. Normally you dont feel lymph nodes. Okay, theyre kind of deep. But if you feel them its not a big deal as long as theyre freely movable, small, no rapid change. Okay it is when they are fixed or getting drastically bigger that you worry that a patient may have a hidden or metastatic cancer somewhere. Okay so were really concerned about neck lymph nodes and it is a major part of our examination. Because many patients can have hidden, oral, pharyngeal cancers, in the back of the throat, that they dont even know about. So finding a lymph node and diagnosing a lymph node can lead to a diagnosis so it is very important. Okay so here is a rule of thumb. Any neck mass in a patient over the age of 40 should be considered malignant until proven otherwise and that is the key that you go by. The most common. Okay then you have these other neck masses, not everything is a lymph node. Right? You have these other neck masses. Okay some neck masses the patient is born with. So the most common, congenital means present at birth, lateral neck mass is something called a branchial cleft cyst. And Im gonna show you what that looks like. The most common congenital midline neck mass is called a thyroglossal duct cyst. And again, ya know, do not panic, I will show you pictures of these things and well go over the a little bit more.

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

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

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

[20]- Criteria for Evaluation of Palpable Lymph Nodes[Dr Shah]- All right so if you find a lymph node now what? Now what are you going to do? Well you need to decide whether if its inflammatory- where the vast majority are- or whether its neoplastic. Neoplastic means it um has a metastatic cancer in it or possibly a lymphoma, okay? So these are some of the factors you look at. This is a really nice chart. From the history, if the patient tells you that when you touch the lymph node it is painful that is actually a good sign. That points towards an inflammatory lymph node. Usually pain is bad but when it comes to lymph nodes if the patient tells you its a little painful or tender when you touch it that is actually a good sign and it points toward an inflammatory lymph node. Neoplastic lymph nodes are not usually painful. Okay also if the patient has an infection or fever that also points to an inflammatory lymph node. Ya know, many times when a patient gets a bad cold, or flu, or a bad sore throat or something you also have enlargement of lymph nodes, lymphadenopathy. And sometimes its reversible, most of the times it is reversible, but sometimes its not and you are left with a large lymph node. Also, if a patient has weight loss or high risk factors, that might point to a neoplastic lymph node. If a patient suddenly has a rapid, ya know, weight loss they might have a cancer somewhere in their body so it points to a neoplastic lymph node. Also if you just look at age as a factor, if you find a lymph node in a younger patient its more likely to be inflammatory and a lymph node in an older patient has a better chance of being neoplastic or malignant. Okay then this is all based on history but you also have to actually feel the lymph node and make some determinations So again, if it feels tender to the patient good sign, it points toward inflammatory. Rubbery is a good sign. Rock hard is a bad sign. If it is fixed and really really really firm or rock hard that might indicate um that theres a metastatic cancer or a lymphoma and that is a malignancy in the lymph node. Okay mobility is important. If its movable that is a good thing, if its fixed it might point towards a neoplastic lymph node. And finally size is also a factor. Most benign lymph nodes are very small. Theyre under 2 cm in size. So if you have a really big lymph node, there is a chance that it could be neoplastic or have a metastasis or a lymphoma. Okay.

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

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

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

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

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

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

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

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

[27] Normal Vermillion Borders[Dr Shah]-This is a patients lips with a normal vermilion borer or interface between the skin or the lip. Even if you look closely at this patient you can see these little yellow bumps here. Do you guys see these little yellow bumps here? This is a variant of normal, the Fordyce granules the ectopic sebaceous glands.

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

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

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

[31]- Abnormal Finding: Herpes Labialis[Dr Shah]- Okay herpes labialis, alright so these cold sores or fever blisters as they are also known as, they start off as vesicles or blisters right? And this is the most contagious stage. This is the time when you dont really wanna kiss someone that has these bumps on their lip. This is the time when you dont wanna take an ungloved hand and go like this and rub it on your skin or rub it in your eye because this is the time that you could, that the patient is contagious and you could spread this. When its in the blister form. When ultimately this thing will rupture okay and itll ulcerate and crust. Okay so theres an ulcer and then it starts to scab over and at that stage its not considered contagious but you should still exercise universal precaution. But at that point it is not contagious. Now this is an example when you see one blister and one kind of ruptured blister that is ulcerated and crusted [left image]. And this example you see a bunch of these fluid filled blisters also known as vesicles, these small fluid filled blisters [right image]. And many times we talk about herpes labialis or herpetic lesions we use the word crop. Crop is a small group. So I would describe this as a crop of vesicles, a small group of vesicles. Okay herpes labialis can be on, ya know, on either side of the lip, usually its the lower lip, but you can also have it on the upper lip as well. Okay. All right.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[43] Leukoedema[Dr Shah]- Okay another variant of normal that can occur on the cheeks is called keukoedema. Leukoedema is sort of a white, swelling of the buccal mucosa. So if you look at this patient you see this kind of grayish whiteish kind of color of the buccal mucosa. And an interesting this about leukoedema is that when you stretch the tissue and flatten it out it either disappears or lessens. Okay that is a really nice clinical test you can do. So this is the same patient and this is a gloved hand [right image] that is retracting the cheek. And you can see it lessens a little. It doesnt have to completely go away but it is a little less than this, its a little less white and gray, and a little flatter. Okay so generalized white opalescent appearance disappears or lessens when the tissue is stretched.

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

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

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

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

[48] Abnormal Finding- Lichens Planus[Dr Shah] Alright so an abnormal finding on the cheeks. Okay so so far weve talked about variants of normal, um and common .. yeah variants of normal yeah. Abnormal finding here is lichen planus. And as I said to you Im going to talk more detail about this in upcoming lectures. All I want to say right now is that you see these radiating white lines You see this kind of linear kind of its described as reticular or fishnet pattern here. You have these radiating white lines. Heres another example right here. Its usually bilateral but it can be unilateral. Okay and that is all you need to know about it at this point and we will talk a lot more about it more in depth later. But this is a common finding on the buccal mucosa. But its an abnormal finding. It is not a variant of normal to have lichen planus.

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

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

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

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

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

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

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

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

[53] Hairy Tongue[Dr Shah]- This is what we call hairy tongue. Okay so what hairy tongue is its elongated filiform papillae. What happens is the actually papillae on the dorsal surface of the tongue, they elongate, they become hyperplastic and they keratinize. Alright so what can happen is that tone these papillae enlarge they get his white color to them, its sort of like what we call a white hairy tongue, but depending on the patients food habits. If you have a patient that drinks a lot of wine or smokes or has some other habit, those papillae, those elongated papillae can become colored. And so now your white hairy tongue becomes a different colored tongue- theres a brown hairy tongue, theres a black hairy tongue, theres a green hairy tongue. And Ill show you pictures of this . Okay and what happens is that these foods can deposit or if the tongue papillae are so elongated and the patient is not scraping or cleaning, bacteria can sort of set up camp there and chromogenic bacteria release pigments and can cause the coloration. Okay so here you have examples of white hairy tongue. And I want to point out to you that this is not the same thing as a coated tongue .a lot of people have a coated tongue, debris on your tongue, maybe even you dont scrape your tongue, maybe you dont brush your tongue, a lot of people can have that. But its different and how do you know the difference? Because when you, if you take your gloved hand and feel these papillae they actually move back and forth. Like think of a rug, one of those rugs that has a really furry rug or whatever. Or maybe even a dog, I dont know. If you go like this and you go like this the papillae move back and forth. Thats called a hairy tongue and thats not the same as a coated tongue. A lot of students have a misconception of that so I wanted to try and explain that to you all. But see if you look here, you see this elongation here, if you you can actually go with your finger and kind of move these a little bit. Alright and heres another example of a white hairy tongue. And this picture, its a good thing you guys have already had lunch right? I havent eaten yet but yeah? [Student asks question]. These are both hairy tongues. This one [right image] almost looks like a coated tongue, I would give that to you, its not as prominent as this [left image]. But even then if you again you put your finger on it it will move and this is a hairy tongue okay?

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

[55] Geographic Tongue[Dr Shah]- Alright another condition that you can see on the dorsal surface of the tongue is called geographic tongue. Geographic tongue. Okay and this is where you get um these red spot on the tongue which white borders. Okay and these spots, they can move around. So what this patient tongue looks like today, in a couple of days it might not look like this. It may be completely gone or it may be in different areas. So theyre red patches. And this can happen on the lateral tongue as well, and it can actually happen theres something called ectopic geographic tongue, where these spots can occur in other areas of the mouth, these red spots with these white borders. Nobody really knows what causes it and theres no real treatment for this. Most of the time its asymptomatic although the red spots are areas of thin epithelium and the patient might report a burning or a sensitivity when they eat something hot, spicy, or acidic. And I can tell you unfortunately I have a geographic tongue. And theres some association with pregnancy. I dont think I ever had it until after I had my children and I think I developed it then. But it can come and go t anytime. Anytime. And Im Indian and I like spicy food so I still eat it but my tongue burns a lot after I eat. Um but there are some treatments you can do for it but theyre only temporary solutions, theres no permanent cure. So the cause is unknown but there has been some association of psoriasis of the skin so its said that his might be some type of some autoimmune type of condition. Alright okay so you can see it here. And this is another presentation, usually its red with these elevated yellowish white borders, and heres another example of broader areas.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[67] Ventral Tongue: Normal Structure[Dr. Shah]- Okay so moving on to the bottom of the tongue. We talked about the top of the tongue, we talked about the sides of the tongue, so lets talk about the bottom of the tongue. Okay so the bottom of the tongue you can also get squamous cell carcinomas. Most of the time its coming from the lateral and going toward the ventral. Okay but there is a normal structure on the bottom of the tongue that you should be familiar with. And these are called lingual varicosities. Theyre veins that are dilated. And with age, these veins will dilate more and become more prominent .So here sane example of the lingual varicosities and heres another example. Okay and sometimes you have this reddish color, this reddish enlargement as well with tis bluish purplish enlargement. Prominent enlarged lingual veins.

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

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

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

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

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

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

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

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

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

[75] Leukoplakia Images[Dr Shah]- Heres some more examples. Heres a leukoplakia in the floor of the mouth, and heres another leukoplakia in the floor of the m