Sandbox leucocytosis

Oral lesion	Differentiating feature	Location	Associated condition
White lesions
Benign migratory glossitis	Red patches with white distinct border Map like appearance	Dorsal/Lateral surface of the tongue	Psoriasis Diabetes Reiter's syndrome Medications such as oral contraceptive pills and lithium carbonate Pregnancy
Hairy tongue	Elongated filliform lingual papilae Carpet-like appearance	Dorsum of the tongue	Xerostomia
Leukoedema	White or whitish-gray edematous lesion Diffuse or patchy	Buccal and labial oral mucosa
White sponge nevus	White patches of tissue (nevi) Singular or multiple Thickened, velvety, sponge-like appearance	The moist lining of the oral mucosa buccal mucosa
Hairy leukoplakia	White patches Corrugated in appearance Hairy, hair-like growths Permanent	Lateral portions of the tongue Floor of the mouth Palate Buccal mucosa	EBV virus infection Immunosupression
Oral lichen planus	Reticular or papular lace like white lesions Multiple, Painful	Posterior buccal mucosa Gingival margin
Nicotinic stomatitis	Reddened area and slowly progresses to a white, thickened, and fissured White cobblestone appearance Red dot in the center Cannot be wiped off Painful	Palatal mucosa Posterior hard palate	Smokers
Oral frictional hyperkeratosis	White shaggy plaques Could be easily peeled without any pain leaving normal mucosa	Bilateral buccal mucosa Limited to the line of dental occlusion
Fordyce granules	White to yellow discrete papules, 1 to 2 mm	Symmetrically distributed Buccal mucosa Vermillion border of the lips	Hereditary non-polyposis colorectal cancer Muir-torre syndrome

Infectious oral Lesions
Disease	Differentiating feautures	Location	Image
Herpes simplex virus infections	Herpetic gingivostomatitis Painful ulcers covered by a yellowish pseudomembrane Ulcers that may coalesce to form bigger lesions Self limiting after 7 days	Keratinized and non-keratinized mucosa. Commonly seen on: Gums Palate Tongue Lips
Herpes zoster	Prodromal unilateral pain Clustered small ulcers with characteristic unilateral pattern Self limiting, heal within 10-14 days	Hard palate. Buccal mucosa Tongue Gingiva
Hand foot mouth disease	Oval-shaped, pale papules with a rim of erythema Small aphthae	Lesions spare the lips and gingiva, in contrast to HSV
Infectious mononucliosis	Pharyngitis Tonsillar exudates Appear white, gray-green, or even necrotic Palatal petechiae with streaky hemorrhages and blotchy red macules	Pharynx Tonsils
Erosive lichen planus	Ulcerative stomatitis	Buccal mucosa Sides of the tongue Gingiva Lips
Pseudomembranous candidiasis	Known as thrush. Usually asymptomatic. Confluent white wipeable plaques resembling curdled milk Superficially the plaques can be wiped off and the underlying mucosa often exhibits an erythematous appearance.	Oral mucosa, Tongue Buccal mucosa Hard palate
Histoplasmosis	Disease affect the lungs and cause acute or chronic respiratory problems in the immunocompromised population. Ulcerating erosive or nodular lesions in the oral mucous membrane. The oral lesions may also appear granulomatous and may be painful The ulcers may often resemble carcinoma or tuberculosis because of the raised and rolled borders, usually covered by a yellow or greyish membrane.	Oral mucosa Tongue Palate Lips	Ohio and Mississippi river valleys
Blastomycosis	Ulcerative mucosal lesions Sessile projections, granulomatous or verrucous lesions. Small ulcers are characteristic oral manifestation and may present as a primary lesion or secondary to disseminated disease. Oral lesions may resemble actinomycosis without the suppurative element		Mississippi, Missouri and Ohio River valleys and the Great lakes region.
Coccidiodomycosis	Asymptomatic Pulmonary or extrapulmonary disease Oral lesions are uncommon Described as ulcerated granulomatous nodules Ulcers appear nonspecific and usually heal by hyalinization and scar	No specific location

Pigmented lesions
Oral lesion		Differentiating feature	Location	Associated Condition
Physiologic		Multifocal, symmetric, persistent and race inherited Dark-brown band	Gingival margins
Intravascular	Hemangioma	Red or bluish-red, slightly raised lesions Rapidly during infancy and regress slowly during childhood	Lip Dorsum of the tongue Gingiva Buccal mucosa	Rendu-Osler-Weber syndrome Sturge-Weber syndrome Kasabach-Merritt syndrome Maffucci syndrome Klippel-Trenaunay-Weber syndrome PHACE(S)
	Kaposi sarcoma	Purplish, reddish blue or dark brown macules Plaques and nodules that may ulcerate	Skin	Immunosuppression HIV AIDS
Extra-vascular	Hematoma
	Ecchymosis	Nonpalpable purpuric spots	Palate Tongue Lips	Aging Chronic usage of Nonsteroidal anti-inflammatory drugs (NSAIDs) Corticosteroids Anticoagulants Deficiency of zinc Liver diseases
	Petechiae
Melanocytic	Oral melanocytic macule	Focal pigmented brown lesions similar to ephelides Flat and mostly smaller than 1 cm Characterised by a focal increase in melanin production	Vermillion border of the lips
	Oral melanoacanthoma	Rapidly enlarging, asymptomatic, pigmented macule.	Buccal mucosa	Local trauma or chronic irritation
	Ephelis	Flat red or light brown spots 3–10 mm in diameter Poorly defined and may merge into large patches	Outer lips	Exposure to ultraviolet radiation
Diffuse
Addison's disease		Mucosal hyperpigmentation	Brown patches of Gingival Vermillion border of the lips Buccal mucosa, palate and tongue
Peutz-Jeghers syndrome		Inherited, autosomal dominant Flat, painless brown pigmented patches Microscopically mild acanthosis with elongation of the rete pegs with increased pigmentation in the melanocytes and adjacent keratinocytes	Perioral Freckling of the skin around lips and vermillion zone of the lips. Intraorally Buccal mucosa Tongue Labial mucosa	Hemartomatous polyposis of the gastrointestinal tract Pancreatic cancer gastrointestinal tract cancer
Neurofibromatosis		Nodular neurofibroma Macroglossia Enlargement of filiform papillae	Tongue Lips Palate Buccal mucosa Gingiva Floor of the mouth or the pharynx	Cafe au lait macules Freckling in the axillary or inguinal regions (Crowe´s sign) Optic glioma Lisch nodules (iris hamartomas) Sphenoid dysplasia A first-degree relative
Polyostotic fibrous dysplasia		Orofacial deformity Dental disorders Bone pains Compromised oral health		McCune-Albright syndrome
Smoker's melanosis		Irregular macular hyperpigmentation of the oral mucosa. Brown patches	Mandibular anterior gingiva in cigarette smokers Buccal mucosa in pipe smokers. Hard palate in those who engage in reverse smoking	Smoking
Amalgam Tattoo		Blue-black macules	Gingival margin or proximal buccal mucosa near amalgam dental fillings	Dental Implant surgery

Vesicular/Ulcerative/Erythematous lesions
Oral lesion			Differentiating feature	Location	Associated Condition
Hereditary	Epidermolysis bullosa	Epidermolysis bullosa simplex	Autosomal dominant Intradermal blistering Skin lesions usually disappear without scarring		Pyloric atresia Other congenital abnormalities of the gastrointestinal and genitourinary tract
		Junctional epidermolysis bullosa	Autosomal recessive Separation of lamina lucida at the dermo-epidermal junction Involvement of oral mucosa, Alopecia and anonychia are frequent
		Dystrophic epidermolysis bullosa	Autosomal dominant or recessive Defective anchoring fibrils resulting in separation of sub-basal lamina Blisters results in dystrophic lesions Millium formation due to damaged hair follicles
Autoimmune	Pemphigus vulgaris	Superficial ulcers to small vesicles or blisters. In the oral cavity, the bubbles rapidly break, leaving a painful erosion producing burning sensation. The size of the ulcers is extremely variable. Nikolsky's sign		Buccal mucosa Soft palate Lower lip Tongue Less frequently, at the gingiva	Inflammatory bowel disease Rheumatoid arthritis
	Mucous membrane pemphigoid (Cicatricial pemphigoid)	Desquamative gingivitis The lesions show as simple erythema or true ulcerations affecting both the fixed gingiva and the adherent gingiva. The symptoms associated with these conditions go from burning sensation and bleeding to mastication impairment Pemphigoid blisters are less brittle than those seen in pemphigus Remain intact in the oral cavity for up to 48 hours		Gingiva Buccal mucosa Palate	Hypothyroidism
	Lupus erythematosus	Classical clinical manifestation is represented by a regular: Round or slightly red irregular area Atrophy or the presence of ulceration The red area is characterized by typical white radiating striae and telangiectasia. Lack of symmetry Petechial lesion Gingival bleeding such as desquamative gingivitis, marginal gingivitis, or erosive mucosal
	Aphthous ulcer	Shallow, round to oval ulcer with white or yellow pseudomembrane surrounded by erythematous halo In chronic ulcer grey membrane may replace the yellow pseudomembrane		Non-keratinized oral mucosa along the labial or buccal surfaces, soft palate, floor of the mouth, ventral or lateral surface of the tongue and oropharynx
	Erythema multiforme	Prodromal skin target lesions, bullae and ulcerations with irregular borders and inflammatory halos, bloody encrustations on the lips		Lips Buccal mucosa Tongue
	Sjogren's Syndrome	Affects salivary and lacrimal glands Dryness in the mouth (xerostomia) Deficiency of tears causes xerophthalmia Lack of saliva predisposes patients to develop tooth cavities. Accumulation of plaque Edema and inflammations of the gingiva are frequent clinical signs. Moreover, a salivary flow decrease can develop opportunistic infections.		Gingiva Parotid gland Tooth
	Bullous pemphigoid	Discrete vesicle formation with Multiple ulcers Desquamative gingivitis as the most common presentation		Gingiva
Idiopathic	Erythroplakia
	Contact stomatitis	Irritant contact stomatitis	Microscopic features: Oral mucosa may appear acanthotic, hyperkeratotic with elongated rete ridges Lamina propria infiltrated by lymphocytes, plasma cells, histiocytes and eosinophils Hallmark of ICD is perturbation of the skin barrier and epidermal regenerative hyperproliferation Hallmark of ACD is spongiosis Clinical manifestations may incude Erythema, vesicle formation, erosion, ulcer formation and shaggy hyperkeratosis	Oral cavity: commonly sides of the tongue, gums, hard palate and buccal mucosa
		Allergic contact stomatitis
	Medication induced stomatitis

Type of cancer	Subtype	Epidemiology	Localization	Clinical features	Diagnostic procedures
Squamous cell carcinoma Basaloid squamous cell carcinoma Papillary squamous cell carcinoma Spindle cell carcinoma Acantholytic squamous cell carcinoma Adenosquamous carcinoma	Verrucous carcinoma	Older males 5th and 6th decades of life Males are affected more often than females	Lip SCC arise almost exclusively on the lower lip Buccal mucosa Upper and lower gingiva Hard palate Anterior two-thirds of the tongue, including dorsal, ventral and lateral surfaces, and the floor of mouth	Often asymptomatic or may present with vague symptoms and minimal physical finding	Biopsy shows: Thickened club-shaped papillae and blunt stromal invaginations of well-differentiated squamous epithelium with marked keratinization
Lymphoepithelial carcinoma		0.8-2% of all oral or oropharyngeal cancers	Tonsil and tongue(90%) Palate and buccal mucosa(others)	Intraoral mass, which may be ulcerated. Some tumors can be bilateral	Biopsy chows: Syncytial sheets and clusters of carcinoma cells with vesicular nuclei Prominent nucleoli and ill-defined cell borders A rich lymphoplasmacytic infiltrate is present
Epithelial precursor lesions	---	---	Seen in the entire digestive tract	White patches (leukoplakia) Red patches (erythroplasia/erythroplakia) Mixed red and white lesions	Biopsy shows: Hyperplasia Dysplasia, / squamous intraepithelial neoplasia / atypical hyperplasia Carcinoma in-situ
Proliferative verrucous leukoplakia and precancerous conditions	---	Average age at diagnosis is 62 years Women are more commonly afflicted (ratio, 4:1)	Buccal mucosa in women Tongue in men.	An aggressive form of oral leukoplakia with considerable morbidity and strong predilection to malignant transformation	Biopsy shows: Extensive, thick, white plaques Hyperplasia and dense hyperkeratosis Verrucous surface with hyperkeratosis, hypergranulosis and a dense inflammatory infiltrate in the corium
Papillomas	Squamous cell papilloma and verruca vulgaris	Common in children and in adults in the 3rd to 5th decades Almost equal sex incidence with a slight male predominance	Any oral site may be affected mostly: Hard and soft palate Labial mucosa Tongue Gingiva	Soft, pedunculated lesions formed by a cluster of finger-like fronds or a sessile, dome-shaped lesion with a nodular, papillary or verrucous surface	Biopsy shows: Exophytic and comprise folds of hyperplastic stratified epithelium Cluster of finger-like projections
	Condyloma acuminatum	2nd and 5th decade with a peak in teenagers and young adults	Labial mucosa Tongue Palate	Painless, rounded, dome-shaped exophytic nodules 15 mm in diameter Have a broad base and a nodular or mulberry-like surface that is slightly red, pink or of normal mucosal color. Lesions may be multiple and are then usually clustered	Biopsy shows: Several sessile, cauliflower-like swellings forming a cluster
	Focal epithelial hyperplasia	Disease of children, adolescents and young adults	All areas of the oral cavity Labia Buccal mucosa Tongue	Multiple asymptomatic lesions Soft rounded or flat plaque-like sessile swelling. Usually pink or white in color 2-10mm in diameter	Biopsy shows: Rounded sessile swelling formed by a sharply demarcated zone of epithelial acanthosis Koilocytes similar to those of squamous papilloma are usually present “Mitosoid bodies”, which are nuclei with coarse clumped heterochromatin resembling a mitotic figure
Granular cell tumor	---	Arise in all age groups, with a peak between 40 and 60 years Females are affected more often than males with an M/F ratio of 2:1	Tongue is the most common single site Buccal mucosa Floor of oral cavity Palate Salivary gland	Lesion presents as a smooth, sessile mucosal swelling 1-2 cm in diameter with a firm texture. The overlying epithelium is of normal color or may be slightly pale	Biopsy shows: Plump eosinophilic cells with central small dark nuclei and abundant granular cytoplasm
Keratoacanthoma	---	Occurs more often in whites Twice as frequent in men as in women	Skin of the face,including the lips Mucocutaneous linings may also be involved	Verrucous, speckled or ulcerated lesions Deep projections, which extend through minor salivary glands and underlying bone	Biopsy shows: Verrucous surface, keratinized clefts and penetrating squamous rete processes Minimal atypia seen
Papillary hyperplasia	---	Affects all age groups	Palate	Asymptomatic nodular or papillary mucosal lesion	Biopsy shows: Parakeratinisation or less frequently orthokeratinisation
Median rhomboid glossitis	---	---	Dorsum of the tongue at the junction of the anterior two thirds and posterior third	Forms a patch of papillary atrophy in the region of the embryological foramen caecum	Biopsy shows: Psoriasiform hyperplasia Areas of pseudoepitheliomatous hyperplasia Atypia may be present
Salivary gland tumors	Acinic cell carcinoma	2-6.5% of all intraoral salivary gland tumors Age range from 11-77 years, with a mean of 45 years Male to female ratio of 1.5:1	Buccal mucosa Upper lip and Palate	Tumors usually form non-descript swellings	Biopsy shows: Solid sheets of epithelium with secretory material Ductal differentiation in tumors
	Mucoepidermoid carcinoma	9.5-23% of all minor gland tumors	Palate (most common site) Buccal mucosa Lips: upper>lower Floor of oral cavity Retromolar pad	Asymptomatic Bluish, domed swellings that resemble mucoceles or haemangiomas High-grade tumors result in ulceration, loosening of teeth, paraesthesia or anaesthesia	Low power microscopy shows low-grade tumor with both cystic and solid areas and an inflamed, fibrous stroma
	Adenoid cystic carcinoma	42.5% of minor gland tumors	Tongue Tonsil Oropharynx Cheek Lips Retromolar pad and gingiva	Slow growing submucosal masses and ulceration may be seen, particularly in the palate Pain, or evidence of nerve involvement, is usually only present in advanced tumors	Predominantly solid variant shows peri- and intraneural invasion
	Epithelial-myoepithelial carcinoma	---	---	---	---
	Clear cell carcinoma, NOS		---	---	---
	Basal cell adenocarcinoma	Rare in minor glands	Palate Buccal mucosa Lip	Asymptomatic, smooth or lobulated sub-mucosal masses	Microscopically similar to basal cell adenocarcinomas of the major gland
	Cystadenocarcinoma	32% developed in the minor glands	Palate Lips Buccal mucosa Tongue and retromolar regions	Slow growing and painless but some palatal tumors may erode the underlying bone causing sinonasal complex	---
	Salivary duct carcinoma	Rare in minor salivary glands Age range was 23-80 years (mean 56 years)	Palate (65%) Buccal mucosa and vestibule (19%) Tongue (8%) Retromolar pad (4%) and upper lip (4%)	Tumors formed painless swellings but many in the palate can be painful and ulcerated or fungated with metastases to regional lymph nodes	The range of microscopical appearances is similar to that seen in the major glands
Salivary gland adenomas	Pleomorphic adenoma	40-70% of minor gland tumors	Palate Lips and Buccal mucosa	Painless, slow growing, submucosal masses, but when traumatized may bleed or ulcerate	Biopsy shows cellular, and hyaline or plasmacytoid cell
	Myoepithelioma	42% of minor gland tumors	Palate of younger individuals	---	---
	Basal cell adenoma	20% of minor gland tumors	Upper lip Buccal mucosa	---	They are histologically similar to those in major glands.
	Cystadenoma	7% of benign minor gland tumors	Lips Cheek Palate	---	---
Kaposi sarcoma	---	Classic (elderly men of Mediterranean/EastEuropean descent) Endemic ( middle-aged adults and children in Equatorial Africa who are not HIV infected) Iatrogenic (Immunosuppressed, post-transplant) AIDS associated (HIV-1 infected individuals)	Skin ( most common) Mucosal membranes such as oral mucosa, lymph nodes and visceral organs	Purplish, reddish blue or dark brown macules Plaques and nodules that may ulcerate	Biopsy of all 4 types show: Vascular slits and sparsely distributed lymphocytes
Lymphangioma	---	Pediatric lesions Present at birth or during the first years of life Appear mostly in the head and neck area but may be found in any other part of the body	Tongue	Circumscribed painless swelling Soft and fluctuant on palpation Irregular nodularity of the dorsum of the tongue	Biopsy shows: Thin-walled, dilated lymphatic vessels of different size, which are lined by a flattened endothelium
Ectomesenchymal chondromyxoid tumour of the anterior tongue	---	Age range varies from 9-78 years No distinct sex predilection.	---	Asymptomatic, slow growing solitary nodule in the anterior dorsal tongue	Biopsy shows: Round, cup-shaped, fusiform, or polygonal cells with uniform small nuclei and moderate amounts of faintly basophilic cytoplasm Some tumors may show nuclear pleomorphism, hyperchromatism, and multinucleation
Focal oral mucinosis (FOM)	---	The lesion affects all ages Rare in children There is no distinct sex predilection.	Gingiva( most common site) Palate Cheek mucosa and Tongue	Asymptomatic fibrous or cystic-like lesion	Histopathology is characterized by: Well-circumscribed area of myxomatous tissue Fusiform or stellate fibroblasts Absent or sparse reticular fibers Mucinous material shows alcianophilia at pH 2.5
Congenital granular cell epuli	---	Affects newborns Females are affected ten times more often than males	Maxilla Mandible	Solitary, somewhat pedunculated fibroma-like lesion attached to the alveolar ridge near the midline	Ultrasound for prenatal diagnosis Immuno histochemically, the tumor cells are positive for vimentin and neuron specific enolase No reactivity with cytokeratin, CEA, desmin, hormone receptors or S-100
Hematolymphoid tumors	Non-Hodgkin lymphoma	Second most common cancer of the oral cavity	Palate Tongue Floor of mouth Gingiva Buccal mucosa Lips Palatine tonsils Lingual tonsils or Oropharynx	NHL of the lip presents with: Ulcer Swelling Discoloration Pain Paraesthesia Anaesthesia, or Loose teeth	Biopsy shows: Large cells with predominantly round nuclei and membrane-bound nucleoli, consistent with centroblastic morphology. Predominantly medium-sized cells with abundant pale cytoplasm. Large cells with round or multilobated nuclei
	Langerhans cell histiocytosis	---	Jaw bone Intraoral soft tissues Gingiva Palate Floor of mouth Buccal mucosa and Tonsil	Common oral symptoms include: Swelling Pain Gingivitis Loose teeth and Ulceration	Biopsy shows ovoid Langerhans cells with deeply grooved nuclei, thin nuclear membranes and abundant eosinophilic cytoplasm
	Hodgkin lymphoma	---	Waldeyer ring, particularly the palatine tonsil Oropharynx Alveolar crest of mandible Maxillary gingiva	Most patients present with localized disease (stage I/II), with Chronic tonsillitis or tonsillar enlargement with or without enlarged cervical lymph nodes	---
	Extramedullary myeloid sarcoma	---	Palate Gingiva	Isolated tumor-forming intraoral mass	Biopsy shows an Indian-file pattern of infiltration
	Follicular dendritic cell sarcoma / tumour	Tumor of adulthood Affects wide age range	Tonsil Palate or Oropharynx.	The patients usually present with a painless mass	Biopsy usually exhibits borders and comprises: Fascicles Whorls Nodules Storiform arrays or Diffuse sheets of spindly to ovoid tumor cells sprinkled with small lymphocytes
Mucosal malignant melanoma	---	0.5% of oral malignancies Incidence 0.02 per 100,000	80% arise: Palate Maxillary alveolus or gingivae Mandibular gingiva Others: Buccal mucosa Floor of mouth Tongue	Asymmetric with irregular outlines Macular pigmentation Nodular growth Ulceration Melanosis	Biopsy: S100 positive Negative for cytokeratins More specific markers include: HMB45, Melan-A or anti-tyrosinase
Hypopharyngeal Cancer		Tobacco use. Abuse of alcohol consumption 7% of all cancers of head and neck 1 per 100,000 individuals Males are commonly affected with a hypopharyngeal cancer compared to females.