Difference between revisions of "Oral pathology"

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'''Oral pathology''' is a domain of dentistry.  In the context of [[anatomical pathology]], it can be lumped with [[head and neck pathology]].
'''Oral pathology''' is a domain of dentistry.  In the context of [[anatomical pathology]], it can be lumped with [[head and neck pathology]].  '''''Oral lesions''''' and '''''oral cavity''''' redirect here.
 
=Normal=
==Normal oral mucosa==
:''Buccal mucosa'' redirect here.
===Microscopic===
*Non-keratinized squamous mucosa.
*No pigmentation.
*No inflammation.
 
=Reactive=
==Benign leukoplakia==
{{Main|Leukoplakia}}
===General===
*Very common finding.
*Biopsied as it may be malignant.
 
===Microscopic===
Features:
*Hyperkeratosis.
*Parakeratosis.
*No nuclear atypia.
*No pigmentation.
*No significant inflammation.
 
DDx:
*Dysplasia.
*[[Squamous cell carcinoma of the head and neck|Squamous cell carcinoma]].
*[[Benign alveolar ridge keratosis]].
 
===Sign out===
<pre>
BUCCAL MUCOSA, RIGHT, BIOPSY:
- SQUAMOUS MUCOSA WITH A COMPACT KERATIN LAYER AND PARAKERATOSIS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>
 
====Micro====
The sections show a squamous mucosa with a layer of compact keratin, parakeratosis, and
focal hypergranulosis. There is no inflammation at the interface. Epidermal intercellular
bridges are easily seen. There is no significant nuclear atypia. Mitoses are not evident.
 
==Oral contact mucositis==
===General===
*Inflammatory reaction of irritative agent, e.g. cinnamon-flavoured chewing gum.<ref name=pmid19862397 >{{Cite journal  | last1 = Siqueira | first1 = AS. | last2 = Santos | first2 = CC. | last3 = Cristino | first3 = MR. | last4 = Silva | first4 = DC. | last5 = Pinheiro | first5 = Md. | last6 = Pinheiro | first6 = JJ. | title = Intraoral contact mucositis induced by cinnamon-flavored chewing gum--a case report. | journal = Quintessence Int | volume = 40 | issue = 9 | pages = 719-21 | month = Oct | year = 2009 | doi =  | PMID = 19862397 }}</ref>
*Similar to [[contact dermatitis]].<ref name=pmid2234878/>
 
Note:
*''Oral mucositis'' be seen in the context of radiation treatment.<ref name=pmid21537592>{{Cite journal  | last1 = Lino | first1 = MD. | last2 = Carvalho | first2 = FB. | last3 = Oliveira | first3 = LR. | last4 = Magalhães | first4 = EB. | last5 = Pinheiro | first5 = AL. | last6 = Ramalho | first6 = LM. | title = Laser phototherapy as a treatment for radiotherapy-induced oral mucositis. | journal = Braz Dent J | volume = 22 | issue = 2 | pages = 162-5 | month =  | year = 2011 | doi =  | PMID = 21537592 }}</ref>
 
===Microscopic===
Features:
*+/-Ulceration.<ref name=pmid2234878>{{Cite journal  | last1 = Hay | first1 = KD. | last2 = Greig | first2 = DE. | title = Propolis allergy: a cause of oral mucositis with ulceration. | journal = Oral Surg Oral Med Oral Pathol | volume = 70 | issue = 5 | pages = 584-6 | month = Nov | year = 1990 | doi =  | PMID = 2234878 }}</ref>
 
Image:
*[http://lupusimages.com/browser/detail/2488/histopathology-hyperparakeratosis-with-interface-mucositis Interface mucositis with parakeratosis in lupus (lupusimages.com)].


=Odontogenic tumours and cysts=
=Odontogenic tumours and cysts=
{{Main|Odontogenic tumours and cysts}}
{{Main|Odontogenic tumours and cysts}}
=Oral infections=
==Oral candidiasis==
===General===
*Due to [[candida]] - a [[fungus]].
*May be associated with immunodeficiency, e.g. [[AIDS]], organ transplant/immunosuppression.
Forms:<ref name=Ref_PBoD777>{{Ref PBoD|777}}</ref>
#Pseudomembranous (thrush).
#Erythematous.
#Hyperplastic.
===Microscopic===
:See ''[[candidiasis]]''.
==Hairy leukoplakia==
===General===
Features:<ref name=Ref_PBoD777>{{Ref PBoD|777}}</ref>
*Oral lesion.
**Often on [[tongue]].
*Caused by [[EBV]].<ref name=pmid2169222>{{Cite journal  | last1 = Kanitakis | first1 = J. | last2 = Zambruno | first2 = G. | last3 = Marchand | first3 = C. | last4 = Perret-Liaudet | first4 = P. | last5 = Hermier | first5 = C. | last6 = Thivolet | first6 = J. | title = [Oral hairy leukoplakia in AIDS. Histologic and ultrastructural study of 8 cases]. | journal = Ann Dermatol Venereol | volume = 117 | issue = 5 | pages = 345-53 | month =  | year = 1990 | doi =  | PMID = 2169222 }}</ref>
**May be seen in the context of a [[HIV]]-infection.<ref>{{Cite journal  | last1 = Itin | first1 = PH. | last2 = Lautenschlager | first2 = S. | title = Viral lesions of the mouth in HIV-infected patients. | journal = Dermatology | volume = 194 | issue = 1 | pages = 1-7 | month =  | year = 1997 | doi =  | PMID = 9031782 }}</ref>
===Gross===
*White confluent patches (icing sugar) - usu. tongue.
DDx:
*See ''[[leukoplakia]]''.
Images:
*[http://hardinmd.lib.uiowa.edu/cdc/6061.html Hairy leukoplakia (uiowa.edu)].
===Microscopic===
Features:<ref>URL: [http://www.pathologyoutlines.com/oralcavity.html#hairyleukoplakia http://www.pathologyoutlines.com/oralcavity.html#hairyleukoplakia].</ref>
*Hyperkeratosis (thicker stratum corneum).<ref>URL: [http://www.emedicine.com/asp/dictionary.asp?keyword=hyperkeratosis http://www.emedicine.com/asp/dictionary.asp?keyword=hyperkeratosis].</ref>
*Acanthosis (thicker stratum spinosum).<ref>URL: [http://www.emedicine.com/asp/dictionary.asp?keyword=acanthosis http://www.emedicine.com/asp/dictionary.asp?keyword=acanthosis].</ref>
*"Balloon cells" in upper stratum spinosum - perinuclear clearing.
==Oral condyloma==
===General===
*Benign.
*Sexually transmitted.<ref name=Ref_HaNP246>{{Ref HaNP|246}}</ref>
*Typically seen in young adults.
===Gross===
*Polypoid projection with a broad base.
*Usually palate or labia.<ref name=Ref_HaNP246>{{Ref HaNP|246}}</ref>
===Microscopic===
Features:
*Broad papillary projections with rounded contours.
*No hyperkeratosis.
DDx:<ref name=Ref_HaNP246>{{Ref HaNP|246}}</ref>
*[[Squamous papilloma]] - thinner papillary projections, often branch.
*[[Verruca vulgaris]] - church spire-like projections, hyperkeratosis and parakeratosis.
*Squamous cell carcinoma.
Image:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020353/figure/f4-cln_65p1383/ Condyloma acuminatum (nih.gov)].<ref name=pmid21340231>{{Cite journal  | last1 = Reis | first1 = HL. | last2 = Ferreira | first2 = DC. | last3 = Forattini | first3 = AG. | last4 = Souza | first4 = PG. | last5 = Curvelo | first5 = JA. | last6 = Passos | first6 = MR. | title = Genital and oral human papillomavirus infection in a patient from the group of women who have sex with women. | journal = Clinics (Sao Paulo) | volume = 65 | issue = 12 | pages = 1383-5 | month =  | year = 2010 | doi =  | PMID = 21340231 | PMC = 3020353 }}</ref>
===Sign out===
<pre>
LESION, PALATE, EXCISION:
- ORAL CONDYLOMA.
</pre>
=Oral neoplasms=
==Peripheral fibroma==
*[[AKA]] ''focal fibrous hyperplasia'', [[AKA]] ''peripheral ossifying fibroma, [[AKA]] ''fibroid epulis'' (old term), [[AKA]] ''fibroepithelial polyp''.<ref name=Ref_Sternberg5_775>{{Ref Sternberg5|775}}</ref>
*[[AKA]] ''oral fibroma''.<ref>URL: [http://emedicine.medscape.com/article/1080948-overview#aw2aab6b3 http://emedicine.medscape.com/article/1080948-overview#aw2aab6b3]. Accessed on: 20 August 2012.</ref><ref name=Ref_HaNP240>{{Ref HaNP|240}}</ref>
{{Main|Oral fibroma}}


=Pigmented lesions of the oral cavity=
=Pigmented lesions of the oral cavity=
Line 9: Line 136:
**[[Peutz-Jeghers syndrome]].
**[[Peutz-Jeghers syndrome]].
**[[Addison's disease]].
**[[Addison's disease]].
**Drug-induced.
**Drug-induced - typically [[OCP]] or tetracycline, usu. has an irregular distribution.<ref name=pmid22956033>{{Cite journal  | last1 = Beck-Mannagetta | first1 = J. | last2 = Hutarew | first2 = G. | title = [Pigmented lesions of the oral mucosa]. | journal = Hautarzt | volume = 63 | issue = 9 | pages = 704-9 | month = Sep | year = 2012 | doi = 10.1007/s00105-012-2351-x | PMID = 22956033 }}</ref>
**Smoker's melanosis.
**[[Smoker's melanosis]].
*Focal:
*Focal:
**Vascular lesions.
**Vascular lesions.
**Amalgam tattoo.
**[[Amalgam tattoo]].
**[[Melanocytic lesions]].
**[[Melanocytic lesions]].
***Melanotic macule.
***[[Melanotic macule]].
***[[Blue nevus]].
***[[Blue nevus]].
***[[Malignant melanoma]].
***[[Malignant melanoma]] - classically hard palate.<ref name=pmid22956033/>
 
==Melanotic macule==
===General===
*Benign.
*Clinically apparent lesion.
 
===Gross===
*Flat pigmented lesion less than 10 mm in size ([[macule]]).
*Usually solitary.<ref name=pmid289929>{{Cite journal  | last1 = Buchner | first1 = A. | last2 = Hansen | first2 = LS. | title = Melanotic macule of the oral mucosa. A clinicopathologic study of 105 cases. | journal = Oral Surg Oral Med Oral Pathol | volume = 48 | issue = 3 | pages = 244-9 | month = Sep | year = 1979 | doi =  | PMID = 289929 }}</ref>
 
Image:
*[http://ocw.tufts.edu/Content/51/lecturenotes/551831/552087 Melanotic macule - labia (tufts.edu)].
 
===Microscopic===
Features - either or both of the following:<ref name=pmid289929/>
#Pigmented basal cell layer.
#Pigment incontinence - (dermal) macrophages with pigment (melanin).
 
DDx:
*Focal melanosis - ''not'' clinically apparent, i.e. history does not say ''pigmented lesion''.
 
Image:
*[http://ocw.tufts.edu/Content/51/lecturenotes/551831/552086 Melanotic macule - labia (tufts.edu)].
 
===Stains===
*[[Fontana-Masson stain]] +ve.
*[[Prussian blue stain]] -ve.
 
===Sign out===
<pre>
LESION, BUCCAL MUCOSA (LEFT), BIOPSY:
- MELANOTIC MACUOLE.
- NEGATIVE FOR DYSPLASIA.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Micro====
The sections show a non-keratinized squamous mucosa. The squamous epithelium has no
significant pathology and does not have noticeable pigmentation. The subepithelial tissue
has pigmented macrophages (melanophages) and is otherwise unremarkable.
 
A Fontana-Masson stain marks the pigment (confirming it is melanin).  A Prussian blue
stain is negative.


==Smoker's melanosis==
==Smoker's melanosis==
Line 36: Line 206:
*[http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1077501-1654.jpg Basal melanosis (medscape.com)].
*[http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1077501-1654.jpg Basal melanosis (medscape.com)].


==See also==
==Intramucosal melanocytic nevus==
*Abbreviated ''IMN''.
*[[AKA]] ''intramucosal melanocytic nevus''.
===General===
*Most common oral nevus.<ref>URL: [http://emedicine.medscape.com/article/1079272-overview http://emedicine.medscape.com/article/1079272-overview]. Accessed on: 10 December 2012.</ref>
**Second most common is the [[blue nevus]].
*Essentially an ''[[intradermal melanocytic nevus]]''.
 
===Microscopic===
Features:
*Symmetrical lesion.
*"Matures" with depth
**Less cellular with depth
**Less nuclear atypia with depth.
**Smaller cells with depth.
**Smaller nests with depth.
**Rare mitoses (superficial).
***No deep mitoses.
*No destruction of surrounding structures.
*No [[nucleoli]].
 
===Sign out===
<pre>
PALATE LESION, PUNCH BIOPSY:
- INTRAMUCOSAL MELANOCYTIC NEVUS.
</pre>
 
==Amalgam tattoo==
===General===
*Benign and common.
*Material from a dental filling.<ref name=Ref_HaNP215>{{Ref HaNP|215}}</ref>
*May be confused with a [[melanocytic lesion]].
 
===Gross===
*Pigmented lesion.
 
Image:
*[http://www.surgical-dentistry.info/AmalgamTattoo.html Amalgam tattoo (surgical-dentistry.info)].
===Microscopic===
Features:<ref name=Ref_HaNP216>{{Ref HaNP|216}}</ref>
*Fine powdery black material in the subepithelial tissue - '''key feature'''.
**May be clumped.
**Found between collagen fibres.
*+/-Foreign body-type [[giant cells]] - uncommon.
 
DDx:
*[[Melanocytic lesions]].
*Other [[pigmented material]].
 
====Images====
<gallery>
File:Amalgam_tattoo-1.jpg | Amalgam tattoo. (WC/Bernhard138)
File:Amalgam_tattoo-2.jpg | Amalgam tattoo. (WC/Bernhard138)
File:Amalgam_tattoo-3.jpg | Amalgam tattoo. (WC/Bernhard138)
</gallery>
 
www:
*[http://dermatlas.med.jhmi.edu/image/amalgam_tattoo_1_090401 Amalgam tattoo (jhmi.edu)].
 
===Sign out===
<pre>
MOUTH, BIOPSY:
- AMALGAM TATTOO.
- SQUAMOUS MUCOSA WITH PARAKERATOSIS.
- SUBEPITHELIAL CALCIFICATIONS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
=See also=
*[[Head and neck cytopathology]].
*[[Head and neck cytopathology]].
*[[Odontogenic tumours and cysts]].
*[[Tongue]].
*[[Tonsil]].


==References==
=References=
{{Reflist|1}}
{{Reflist|2}}


[[Category:Head and neck pathology]]
[[Category:Head and neck pathology]]

Latest revision as of 18:17, 2 May 2017

Oral pathology is a domain of dentistry. In the context of anatomical pathology, it can be lumped with head and neck pathology. Oral lesions and oral cavity redirect here.

Normal

Normal oral mucosa

Buccal mucosa redirect here.

Microscopic

  • Non-keratinized squamous mucosa.
  • No pigmentation.
  • No inflammation.

Reactive

Benign leukoplakia

Main article: Leukoplakia

General

  • Very common finding.
  • Biopsied as it may be malignant.

Microscopic

Features:

  • Hyperkeratosis.
  • Parakeratosis.
  • No nuclear atypia.
  • No pigmentation.
  • No significant inflammation.

DDx:

Sign out

BUCCAL MUCOSA, RIGHT, BIOPSY:
- SQUAMOUS MUCOSA WITH A COMPACT KERATIN LAYER AND PARAKERATOSIS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Micro

The sections show a squamous mucosa with a layer of compact keratin, parakeratosis, and focal hypergranulosis. There is no inflammation at the interface. Epidermal intercellular bridges are easily seen. There is no significant nuclear atypia. Mitoses are not evident.

Oral contact mucositis

General

Note:

  • Oral mucositis be seen in the context of radiation treatment.[3]

Microscopic

Features:

  • +/-Ulceration.[2]

Image:

Odontogenic tumours and cysts

Main article: Odontogenic tumours and cysts

Oral infections

Oral candidiasis

General

  • Due to candida - a fungus.
  • May be associated with immunodeficiency, e.g. AIDS, organ transplant/immunosuppression.

Forms:[4]

  1. Pseudomembranous (thrush).
  2. Erythematous.
  3. Hyperplastic.

Microscopic

See candidiasis.

Hairy leukoplakia

General

Features:[4]

  • Oral lesion.
  • Caused by EBV.[5]
    • May be seen in the context of a HIV-infection.[6]

Gross

  • White confluent patches (icing sugar) - usu. tongue.

DDx:

Images:

Microscopic

Features:[7]

  • Hyperkeratosis (thicker stratum corneum).[8]
  • Acanthosis (thicker stratum spinosum).[9]
  • "Balloon cells" in upper stratum spinosum - perinuclear clearing.

Oral condyloma

General

  • Benign.
  • Sexually transmitted.[10]
  • Typically seen in young adults.

Gross

  • Polypoid projection with a broad base.
  • Usually palate or labia.[10]

Microscopic

Features:

  • Broad papillary projections with rounded contours.
  • No hyperkeratosis.

DDx:[10]

  • Squamous papilloma - thinner papillary projections, often branch.
  • Verruca vulgaris - church spire-like projections, hyperkeratosis and parakeratosis.
  • Squamous cell carcinoma.

Image:

Sign out

LESION, PALATE, EXCISION:
- ORAL CONDYLOMA.

Oral neoplasms

Peripheral fibroma

  • AKA focal fibrous hyperplasia, AKA peripheral ossifying fibroma, AKA fibroid epulis (old term), AKA fibroepithelial polyp.[12]
  • AKA oral fibroma.[13][14]
Main article: Oral fibroma

Pigmented lesions of the oral cavity

A brief DDx of pigmented lesions:[15]

Melanotic macule

General

  • Benign.
  • Clinically apparent lesion.

Gross

  • Flat pigmented lesion less than 10 mm in size (macule).
  • Usually solitary.[17]

Image:

Microscopic

Features - either or both of the following:[17]

  1. Pigmented basal cell layer.
  2. Pigment incontinence - (dermal) macrophages with pigment (melanin).

DDx:

  • Focal melanosis - not clinically apparent, i.e. history does not say pigmented lesion.

Image:

Stains

Sign out

LESION, BUCCAL MUCOSA (LEFT), BIOPSY:
- MELANOTIC MACUOLE.
- NEGATIVE FOR DYSPLASIA.
- NEGATIVE FOR MALIGNANCY.

Micro

The sections show a non-keratinized squamous mucosa. The squamous epithelium has no significant pathology and does not have noticeable pigmentation. The subepithelial tissue has pigmented macrophages (melanophages) and is otherwise unremarkable.

A Fontana-Masson stain marks the pigment (confirming it is melanin). A Prussian blue stain is negative.

Smoker's melanosis

General

  • Benign.
  • Seen in ~20% of smokers.[15]
  • Presence of find (smoking) dose-dependent, i.e. longer heavier smokers are more likely to have it.

Gross

  • Typically labial gingvia or buccal mucosa.[15]

Microscopic

Features:

  • Basal melanosis.
  • +/-Melanin incontinence.

Image:

Intramucosal melanocytic nevus

  • Abbreviated IMN.
  • AKA intramucosal melanocytic nevus.

General

Microscopic

Features:

  • Symmetrical lesion.
  • "Matures" with depth
    • Less cellular with depth
    • Less nuclear atypia with depth.
    • Smaller cells with depth.
    • Smaller nests with depth.
    • Rare mitoses (superficial).
      • No deep mitoses.
  • No destruction of surrounding structures.
  • No nucleoli.

Sign out

PALATE LESION, PUNCH BIOPSY:
- INTRAMUCOSAL MELANOCYTIC NEVUS.

Amalgam tattoo

General

Gross

  • Pigmented lesion.

Image:

Microscopic

Features:[20]

  • Fine powdery black material in the subepithelial tissue - key feature.
    • May be clumped.
    • Found between collagen fibres.
  • +/-Foreign body-type giant cells - uncommon.

DDx:

Images

  • Amalgam tattoo. (WC/Bernhard138)

  • Amalgam tattoo. (WC/Bernhard138)

  • Amalgam tattoo. (WC/Bernhard138)

www:

Sign out

MOUTH, BIOPSY:
- AMALGAM TATTOO.
- SQUAMOUS MUCOSA WITH PARAKERATOSIS.
- SUBEPITHELIAL CALCIFICATIONS.
- NEGATIVE FOR MALIGNANCY.

See also

References

  1. ↑ Siqueira, AS.; Santos, CC.; Cristino, MR.; Silva, DC.; Pinheiro, Md.; Pinheiro, JJ. (Oct 2009). "Intraoral contact mucositis induced by cinnamon-flavored chewing gum--a case report.". Quintessence Int 40 (9): 719-21. PMID 19862397.
  2. ↑ 2.0 2.1 Hay, KD.; Greig, DE. (Nov 1990). "Propolis allergy: a cause of oral mucositis with ulceration.". Oral Surg Oral Med Oral Pathol 70 (5): 584-6. PMID 2234878.
  3. ↑ Lino, MD.; Carvalho, FB.; Oliveira, LR.; Magalhães, EB.; Pinheiro, AL.; Ramalho, LM. (2011). "Laser phototherapy as a treatment for radiotherapy-induced oral mucositis.". Braz Dent J 22 (2): 162-5. PMID 21537592.
  4. ↑ 4.0 4.1 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 777. ISBN 0-7216-0187-1.
  5. ↑ Kanitakis, J.; Zambruno, G.; Marchand, C.; Perret-Liaudet, P.; Hermier, C.; Thivolet, J. (1990). "[Oral hairy leukoplakia in AIDS. Histologic and ultrastructural study of 8 cases].". Ann Dermatol Venereol 117 (5): 345-53. PMID 2169222.
  6. ↑ Itin, PH.; Lautenschlager, S. (1997). "Viral lesions of the mouth in HIV-infected patients.". Dermatology 194 (1): 1-7. PMID 9031782.
  7. ↑ URL: http://www.pathologyoutlines.com/oralcavity.html#hairyleukoplakia.
  8. ↑ URL: http://www.emedicine.com/asp/dictionary.asp?keyword=hyperkeratosis.
  9. ↑ URL: http://www.emedicine.com/asp/dictionary.asp?keyword=acanthosis.
  10. ↑ 10.0 10.1 10.2 Thompson, Lester D. R. (2006). Head and Neck Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 246. ISBN 978-0443069604.
  11. ↑ Reis, HL.; Ferreira, DC.; Forattini, AG.; Souza, PG.; Curvelo, JA.; Passos, MR. (2010). "Genital and oral human papillomavirus infection in a patient from the group of women who have sex with women.". Clinics (Sao Paulo) 65 (12): 1383-5. PMC 3020353. PMID 21340231. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020353/.
  12. ↑ Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Reuter, Victor E; Stoler, Mark H (2009). Sternberg's Diagnostic Surgical Pathology (5th ed.). Lippincott Williams & Wilkins. pp. 775. ISBN 978-0781779425.
  13. ↑ URL: http://emedicine.medscape.com/article/1080948-overview#aw2aab6b3. Accessed on: 20 August 2012.
  14. ↑ Thompson, Lester D. R. (2006). Head and Neck Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 240. ISBN 978-0443069604.
  15. ↑ 15.0 15.1 15.2 Kauzman, A.; Pavone, M.; Blanas, N.; Bradley, G. (Nov 2004). "Pigmented lesions of the oral cavity: review, differential diagnosis, and case presentations.". J Can Dent Assoc 70 (10): 682-3. PMID 15530266.
  16. ↑ 16.0 16.1 Beck-Mannagetta, J.; Hutarew, G. (Sep 2012). "[Pigmented lesions of the oral mucosa].". Hautarzt 63 (9): 704-9. doi:10.1007/s00105-012-2351-x. PMID 22956033.
  17. ↑ 17.0 17.1 Buchner, A.; Hansen, LS. (Sep 1979). "Melanotic macule of the oral mucosa. A clinicopathologic study of 105 cases.". Oral Surg Oral Med Oral Pathol 48 (3): 244-9. PMID 289929.
  18. ↑ URL: http://emedicine.medscape.com/article/1079272-overview. Accessed on: 10 December 2012.
  19. ↑ Thompson, Lester D. R. (2006). Head and Neck Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 215. ISBN 978-0443069604.
  20. ↑ Thompson, Lester D. R. (2006). Head and Neck Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 216. ISBN 978-0443069604.
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