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Oral Pathology > LO 3 > Flashcards

LO 3 Flashcards

1
Q

Define injury

A

The result of an alteration in the environment that causes tissue damage or necrosis

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2
Q

Describe inflammation

A

Allows the body to eliminate injurious agents, contain injuries, and heal defects

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3
Q

List the body’s innate defenses

A
  1. Physical barrier - Intact skin or mucosa
  2. Mechanical defense - Respiratory system’s cilia and mucus
  3. Antibacterial activity - Enzymes in saliva
  4. Removal of foreign substances - Flushing action of tears, saliva, urine, and diarrhea
  5. Inflammation process - White blood cells
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4
Q

Describe inflammation

A
  1. Nonspecific response
  2. Extent and duration of injury - extent and duration of inflammatory response
  3. Local or systemic
  4. Acute, chronic, or combination
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5
Q

What are the 5 localized signs of inflammation?

A
  1. Redness
  2. Heat
  3. Swelling
  4. Pain
  5. Loss of normal tissue function
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6
Q

What are the 3 systemic signs of inflammation?

A
  1. Pyrexia (fever)
  2. Leukocytosis (high WBC)
  3. Lymphadenopathy - swelling of lymph nodes
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7
Q

List the sequence of microscopic events in order during inflammation

A
  1. Injury to tissue
  2. Constriction of microcirculation - Less blood loss (vasoconstriction)
  3. Hyperemia - Dilation of blood vessels
  4. Increase in permeability of fluid + cells emigrating creating exudate (fluid that leaks out of cells into nearby tissues)
  5. Increased blood viscosity (due to added cells/WBCs/clotting factors)
  6. Results in decreased blood flow
  7. Margination of WBCs (WBCs migrate to vessel walls) - Means chemotaxis (alert to immune system for increase action)
  8. WBCs enter tissue - emigration - exudate and edema (fluid retention)
  9. WBCs ingest foreign material - phagocytosis
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8
Q

Describe hyperemia

A
  1. Increased blood flow in capillary beds of injured tissue
  2. Will produce erythema (redness) and heat
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9
Q

Describe exudate

A
  1. Increased blood plasma and proteins in injured tissue - Helps dilute injurious agents but results in excess fluid in tissues: Edema
  2. Serous (watery) exudate - Mainly plasma fluids and proteins, a few WBCs
  3. Purulent exudate (suppuration) - Contains plasma fluids and proteins, tissue debris, and many WBCs
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10
Q

Describe emigration

A

The process by which WBCs escape from blood vessels through gaps in endothelial cells

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11
Q

Describe chemotaxis

A

Directed movement of WBCs toward the site of injury

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12
Q

Describe phagocytosis

A
  1. The process by which WBCs ingest and then digest foreign substances
  2. May include pathogenic organisms and tissue debris
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13
Q

Describe white blood cells in the inflammatory response

A
  1. Neutrophils: Polymorphonuclear leukocytes (PMNs)
  2. Monocytes circulating in blood - transform into macrophages when in tissue
  3. Lymphocytes and plasma cells - Seen in chronic inflammation and the immune response
  4. Eosinophils and mast cells - Seen in both inflammation and the immune response, related to histamine production
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14
Q

Describe neutrophils (Polymorphonuclear
Leukocytes/PMNs)

A
  1. Function - phagocytosis
  2. Multilobed nucleus and granular cytoplasm that contains lysosomal enzymes
  3. Constitute 60% to 70% of WBC population
  4. Derived from stem cells in bone marrow
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15
Q

Describe macrophages

A
  1. Function - Phagocytosis; play a role in immune system
  2. Single round nucleus and do not have granular cytoplasm
  3. Constitute 3% to 8% of WBC population
  4. Derived from stem cells in bone marrow
  5. Monocytes can transform into macrophages when necessary
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16
Q

Describe biochemical mediators

A
  1. Cause many of the events in the inflammatory response - Basic mediators can recruit other mediators and immune mechanisms- alarm system
  2. May be derived from - blood, endothelial cells, WBCs and platelets, pathogenic organisms as they injure the tissue
  3. Three interrelated systems - Kinin system; Clotting mechanism; Complement system
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17
Q

Describe the Kinin system

A
  1. Active in early phases of inflammation
  2. Activated by substances in plasma and injured tissue
  3. Causes increased - Dilation of blood vessels at the site of injury; Permeability of local blood vessels
  4. Induces pain
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18
Q

Describe Clotting mechanism system

A
  1. Clots blood and mediates inflammation
  2. Some of the clotting mechanism products that are activated during tissue injury cause local vascular dilation and permeability by activating kinin
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19
Q

Describe the complement system

A
  1. Involves the production of a sequential cascade of plasma proteins - They are present in blood in an inactive form; A trigger (usually an antibody-antigen complex) initiates the sequence of steps; These plasma proteins function in inflammation and immunity
  2. Some components cause WBCs known as mast cells to release histamine - Histamine causes an increase in vascular permeability and vasodilation-classic signs of allergies
  3. Other components cause cell death, form chemotactic factors for WBCs, and enhance phagocytosis
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20
Q

Describe prostaglandins (released by the body)

A
  1. Cause increased vascular dilation and permeability, tissue pain and redness, and changes in connective tissue (CT)
  2. Results in slow down of body for healing
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21
Q

Describe lysosomal enzymes (released by the body)

A
  1. Act as chemotactic factors-activate/attract other parts of immune response promoting healing
  2. May cause damage to connective tissue and to the clot
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22
Q

Describe endotoxins (released by pathogenic microorganisms)

A
  1. Produced by cell walls of gram-negative bacteria
  2. Serves as chemotactic factor; can activate complement, function as an antigen, and damage bone and tissue
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23
Q

Describe lysosomal enzymes (released by pathogenic microorganisms)

A

Have a similar chemical composition and action as those released by WBCs

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24
Q

Describe how fevers occur

A
  1. Controlled by the hypothalamus
  2. Pyrogens - Fever-producing substances produced by WBCs and pathogens (act on hypothalamus)
  3. The hypothalamus increases body temperature by way of prostaglandins
  4. Elevated body temperature an attempt to kill temperature sensitive bacteria/virus
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25
Q

Describe Leukocytosis

A
  1. Increased WBC count
  2. It is the body’s attempt to provide more cells for phagocytosis
  3. The type of WBC that is increasing in number can aid in differential diagnosis - Viral infection: Increase in lymphocytes; Bacterial infection: Increase in neutrophils; Allergic reaction: Increase in eosinophils
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26
Q

Describe Lymphadenopathy

A
  1. Enlarged and palpable superficial lymph nodes
  2. The enlarged nodes occur because of changes in lymphocytes, which are the primary cells of the immune response
  3. Hyperplasia: An increase in the number of cells
  4. Hypertrophy: Enlargement of individual cells
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27
Q

Describe chronic inflammation

A
  1. Caused by persistent injuries
  2. Repair cannot be completed until source of injury is removed
  3. Cells involved include - Macrophages, Lymphocytes, Plasma cells, Neutrophils, Monocytes, Fibroblasts
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28
Q

Describe Granulomatous Inflammation

A
  1. Formation of granuloma: Microscopic groupings of macrophages surrounded by lymphocytes and plasma cells
  2. These macrophages group together to form multinucleated giant cells
  3. Associated with foreign body reactions and some infections such as tuberculosis
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29
Q

Describe hyperplasia

A
  1. An increase in the number of cells, often in response to chronic irritation or abrasion
  2. May return to normal if the insult subsides, or may persist after removal of the irritant
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30
Q

Describe hypertrophy

A
  1. An increase in the size of cells
  2. May be seen in cardiac muscle as a response to hypertension
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31
Q

Describe atrophy

A

A decrease in size or function of a cell, tissue, organ, or entire body

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32
Q

Describe regeneration

A

The process by which injured tissue is replaced with tissue identical to that present before the injury

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33
Q

Describe repair

A

The restoration of damaged or diseased tissues

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34
Q

What microscopic events take place the day of injury?

A
  1. Blood flows into injured tissue to produce a clot
  2. The clot contains fibrin, clumped red blood cells (RBCs), and platelets
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35
Q

What microscopic events take place the day AFTER injury?

A
  1. Neutrophils emigrate from the microcirculation into injured tissue in an acute inflammatory response
  2. Phagocytosis occurs
36
Q

What microscopic events take place TWO DAYS AFTER injury?

A
  1. Monocytes change to macrophages in tissue
  2. Macrophages continue phagocytosis and secrete growth factors that stimulate growth of new blood vessels in a process called angiogenesis
  3. Neutrophils are reduced in number
  4. Fibroblasts increase in number and produce new collagen fibers in a process called fibroplasia
  5. Granulation tissue (CT) is formed
  6. Epithelialization, the process by which new surface tissue is created, occurs
  7. Blood clot acts as a scaffold for new connective tissue
  8. Lymphocytes and plasma cells migrate to the area as chronic inflammation and the immune response begins
37
Q

What microscopic events take place SEVEN DAYS AFTER injury?

A
  1. Inflammatory and immune responses are completed, if the source of injury is removed
  2. Fibrin is digested by tissue enzymes - It sloughs off and the initial repair is complete
  3. The new tissue is relatively red - New epithelium is thin, New connective tissue is highly vascularized
  4. Immature collagen fibers are present and fragile
  5. Fibroblasts differentiate into myofibroblasts
38
Q

What microscopic events take place TWO WEEKS AFTER injury?

A
  1. Initial granulation tissue and its fibers have been remodeled
  2. Matured, fibrous connective tissue is called scar tissue - It is whiter and paler because of increased collagen and decreased vascularity
39
Q

What factors affect the amount of scar tissue produced?

A
  1. Heredity
  2. Strength and flexibility needed in the tissue
  3. Tissue type
  4. Type of repair - Healing by primary intention; Healing by secondary intention; Healing by tertiary intention
40
Q

Describe healing by primary intention

A
  1. Healing of an injury in which there is little loss of tissue
  2. The margins are close together and very little granulation tissue forms
  3. Example- surgical incision
41
Q

Describe healing by secondary intention

A
  1. The edges of the injury cannot be joined during healing
  2. A large clot forms, resulting in increased granulation tissue, often from traumatic injury
  3. May result in excess scar tissue: A keloid
42
Q

Describe healing by tertiary intention

A
  1. Delaying surgical tissue repair until infection is resolved
  2. An injured area may become infected, especially with puncture wounds
  3. In some situations, an infected injury is left open until infection is controlled
43
Q

List local factors that impair healing

A
  1. Bacterial infection
  2. Tissue destruction and necrosis
  3. Hematoma
  4. Excessive movement of injured tissue
  5. Poor blood supply
44
Q

List systemic factors that impair healing

A
  1. Malnutrition
  2. Immunosuppression
  3. Genetic connective tissue disorders
  4. Metabolic disorders
45
Q

List common injuries to the oral soft tissues

A
  1. Aspirin burn
  2. Phenol burns
  3. Electric burns
  4. Other burns
  5. Lesions associated with cocaine use
  6. Lesions from self-induced injuries
  7. Hematoma
  8. Traumatic ulcer
  9. Frictional keratosis
  10. Linea alba
  11. Nicotinic stomatitis
  12. Tobacco pouch keratosis
  13. Traumatic neuroma
  14. Amalgam tattoo
  15. Melanosis
  16. Solar cheilitis
  17. Mucocele
  18. Necrotizing sialometaplasia
  19. Sialolith
  20. Acute and chronic sialadenitis
46
Q

List dental materials that can cause burns

A
  1. Phenol
  2. Sodium hypochlorite
  3. Ferric sulfate
  4. Formocresol
  5. Eugenol
47
Q

Describe aspirin burns

A
  1. Topical application is a common misuse of this product
  2. The tissue becomes necrotic and white
  3. The surface may slough off, leaving a painful ulcer
  4. The ulcer usually heals in 7 to 21 days
48
Q

Describe electric burns

A
  1. May be seen in infants or young children who have chewed an electrical cord
  2. May be quite extensive, damaging oral tissue and even tooth buds
  3. May cause permanent disfigurement and scarring
  4. Treatment - Plastic surgery, Oral surgery, Orthodontic therapy
49
Q

Describe thermal burns

A
  1. Hot food burns - From soup or cheese on pizza
  2. Products containing hydrogen peroxide or eugenol
50
Q

Describe lesions associated with cocaine use

A
  1. Lesions located at the midline of the hard palate may vary from ulcers to keratotic lesions to exophytic reactive lesions as a result of smoking crack cocaine
  2. Necrotic ulcers of the tongue and epiglottis have been reported as a result of freebasing cocaine
51
Q

Describe traumatic ulcers

A
  1. Cheek, lip, or tongue biting
  2. Denture irritation
  3. Mucosal injury
  4. Overzealous brushing
  5. Treatment
  6. Usually heals within 7 to 14 days unless the trauma persists
  7. May require a biopsy
52
Q

Describe traumatic granulomas

A
  1. The result of persistent trauma. Ex. dentures
  2. Appearance: Hard (indurated), raised lesion
  3. Heals rapidly after biopsy
53
Q

Describe hematomas

A
  1. Accumulation of blood within tissue as a result of trauma (bruise)
  2. Appears as a red to purple to bluish-gray mass
  3. Frequently seen on labial or buccal mucosa
54
Q

Describe Frictional Keratosis

A
  1. A form of hyperkeratosis
  2. Cause: Chronic rubbing or friction against an oral mucosal surface; resembles a callus on skin
  3. Appearance: Opaque white
55
Q

Describe linea alba

A
  1. A white, raised line most commonly on the buccal mucosa at the occlusal plane
  2. May be the result of a teeth-clenching habit
  3. Sometimes the pattern of the teeth can be seen in the lesion
  4. Microscopic appearance: Epithelial hyperplasia and hyperkeratosis
  5. No treatment necessary
56
Q

Describe nicotine stomatitis

A
  1. A benign lesion typically associated with pipe and/or cigar smoking; may also occur with cigarette smoking
  2. Initial appearance: Erythema
  3. Increased opacity as keratinization occurs
  4. Raised red areas occur at the openings of ducts of inflamed minor salivary glands
57
Q

Describe Smokeless Tobacco Keratosis

A
  1. A white lesion located where chewing tobacco is placed, most often in the mucobuccal fold
  2. Early lesions may have a granular or wrinkled appearance
  3. Long-standing lesions may be more opaquely white and have a corrugated surface
58
Q

Describe the danger of e-cigarettes

A
  1. Can be damaging to oral tissues as regular cigarette smoking
  2. Produce an aerosol or vapor to bring nicotine to the lungs
  3. Vapor contains toxic chemicals and heavy metals
59
Q

Describe Traumatic Neuroma

A
  1. A lesion caused by injury to a peripheral nerve
  2. Often from a local anesthetic injection
  3. Painful, ranging from pain on palpation to severe, intractable pain, lightning like sensation
  4. Treatment - Often resolves in 1-3 days, surgical excision if not resolved
60
Q

Describe amalgam tattoos

A
  1. A flat, bluish-gray lesion of the oral mucosa, caused by the introduction of amalgam into tissue
  2. May occur during placement or removal of an amalgam restoration or during an extraction
  3. May be seen in any location in the oral cavity, most commonly on the gingiva or alveolar ridge
  4. Amalgam particles may be seen on radiograph, aiding in diagnosis
  5. Patient history may help
  6. Must be differentiated from malignant melanoma
  7. Treatment - None, providing melanoma has been ruled out
61
Q

Describe Melanosis (Smoker’s Melanosis)

A
  1. Normal physiologic pigmentation of oral mucosa
  2. May be genetic
  3. May occur as a result of inflammation: Smoker’s melanosis
  4. Results from heat/chemical exposure
62
Q

Describe Solar Cheilitis (Actinic Cheilitis)

A
  1. A degeneration of the tissue of the lips, caused by exposure to the sun
  2. Lips appear dry and cracked
  3. The vermilion appears pale pink and mottled
  4. The interface between lips and skin is indistinct
  5. Microscopically: Epithelium is thinner than normal; degenerative CT changes
  6. Smoking and alcohol use increase risk of squamous cell carcinoma
  7. Biopsy may be indicated for persistent scaling or ulceration
  8. Prevention - Avoid sun exposure; Use sun-blocking agents
63
Q

Describe Mucous Retention Lesions: Mucocele or Mucous Retention Cyst

A
  1. A lesion formed when a salivary gland duct is severed and the mucous salivary gland secretion spills into the adjacent connective tissue
  2. Not a true cyst because it is not lined with epithelium
  3. Dilated salivary gland ducts that developed as a result of duct obstruction
  4. Treatment - Removal of affected minor salivary gland
64
Q

Describe Mucous Retention Lesion: Ranula

A
  1. A unilateral mucocele-like lesion that forms on the floor of the mouth
  2. Associated with the ducts of submandibular and sublingual glands
  3. Also known as a “Frog’s Belly”
  4. Can result from a salivary stone
65
Q

Describe Sialolith

A
  1. A salivary gland stone
  2. May be found in both minor and major salivary glands
  3. Formed by precipitation of calcium salts around a central core
  4. May often be seen on radiographs
  5. Treatment - Sometimes the calcification can be “milked” from the duct; It may require surgical removal - this may damage the duct
66
Q

Describe Necrotizing Sialometaplasia

A
  1. A benign condition of salivary glands
  2. Moderately painful swelling and ulceration
  3. Thought to result from blockage of blood supply to affected area, resulting in salivary gland necrosis
  4. Salivary gland epithelium is replaced by squamous epithelium
  5. The ulcer usually heals by secondary intention
67
Q

Describe and list the types of Reactive Connective Tissue Hyperplasia

A
  1. Pyogenic granuloma
  2. Giant cell granuloma
  3. Irritation fibroma
  4. Denture-induced fibrous hyperplasia
  5. Papillary hyperplasia of the palate
  6. Gingival enlargement
  7. Chronic hyperplastic pulpitis
  8. Proliferating, exuberant granulation tissue and dense fibrous connective tissue resulting from overzealous repair
  9. May be a response to a single event or chronic low-grade injury
68
Q

Describe Pyogenic Granuloma

A
  1. A proliferation of connective tissue containing numerous blood vessels and inflammatory cells occurring as a response to injury
  2. Ulcerated
  3. Soft to palpation
  4. Bleeds easily
  5. Deep red to purple
  6. Generally elevated, may be sessile or pedunculated
  7. Most commonly observed on the gingiva, it may be seen on other intraoral areas
  8. May vary in size from a few millimeters to several centimeters
  9. Usually develops rapidly and then remains static
  10. Most common in teenagers and young adults, but may occur at any age
  11. If seen in a pregnant person, it is called a pregnancy tumor
  12. Treatment - Surgically excised if it does not regress spontaneously
69
Q

Describe a pregnancy tumour

A
  1. A pyogenic granuloma seen in a pregnant person
  2. The lesions are identical to those seen in men and nonpregnant women
  3. May be caused by hormonal changes and increased response to plaque
  4. They often regress after delivery
70
Q

Describe Peripheral Giant Cell Granuloma

A
  1. A lesion that contains many multinucleated giant cells, well-vascularized connective tissue, RBCs, and chronic inflammatory cells
  2. Reactive lesion
  3. Clinical appearance resembles that of pyogenic granuloma
  4. Treatment: Surgical excision
71
Q

Describe a Peripheral Ossifying Fibroma

A
  1. Exophytic, usually well-demarcated sessile or pedunculated gingival lesion
  2. Clinically it appears to emanate from the interdental papilla on the gingiva
  3. Has been reported in both children and adults
  4. Composed of cellular fibrous connective tissue
  5. Treatment consists of complete surgical excision with thorough scaling of the adjacent teeth
  6. Related often to subgingival calculus
72
Q

Describe Fibroma, Irritation Fibroma, Traumatic Fibroma, and Focal Fibrous Hyperplasia

A
  1. The most common mass on the gingiva
  2. Caused by trauma
  3. Appearance: A broad-based, persistent exophytic lesion composed of dense, scar like connective tissue with few blood vessels. Usually a small lesion, less than 1 cm in diameter
73
Q

Describe Denture Induced Fibrous Hyperplasia

A
  1. Cause: Ill-fitting denture
  2. Location: In elongated folds of tissue adjacent to denture flange
  3. Composed of dense, fibrous CT surfaced with stratified squamous epithelium
  4. Treatment - Surgical removal, Relining of prosthesis, New denture
  5. Commonly associated with candida albicans - creates perfect environment
74
Q

Describe Inflammatory Papillary Hyperplasia of the Palate

A
  1. Denture-induced hyperplasia
  2. Appearance: Palatal mucosa covered by multiple erythematous papillary projections; “cobblestone” appearance
  3. Can results in Candida albicans infection
75
Q

Describe Gingival Enlargement

A
  1. An increase in the bulk of free and attached gingiva, especially the interdental papillae
  2. Gingival margins are rounded
  3. Color may vary from normal pink to pale or erythematous depending on the degree of inflammation and vascularity
  4. May be generalized or localized
  5. Reactive response to Local irritants, Hormonal changes, Medications (calcium channel blockers, phenytoin, cyclosporin), Hereditary conditions, Idiopathic factors, Leukemia
76
Q

Caries or trauma may result in _________

A
  1. Inflammation
  2. Infection
  3. Chronic hyperplastic pulpitis
  4. Necrosis of the pulp

*The inflammatory process begins in pulp and then extends to the periapical area - Accessory canals may lead to areas of inflammation on the lateral portion of the root

77
Q

Describe Periapical Abscess

A
  1. Acute periapical abscess: Purulent exudate surrounded by connective tissue containing neutrophils and lymphocytes
  2. Inflammation produces severe pain
  3. Tooth may slightly extrude from tooth socket
  4. May or may not test positive with electric pulp testing
  5. May develop directly from inflammation in the pulp
  6. More commonly develops in an area of previously existing chronic inflammation
  7. Treatment - Drainage and endodontic therapy; Extraction
78
Q

List the stages of periapical abscess

A
  1. Fistula
  2. Fistulous tract
  3. Channel of least resistance
  4. Presence of fistula warrants a radiographic evaluation
79
Q

Describe Periapical Granuloma

A
  1. A localized mass of chronically inflamed granulation tissue that forms at the opening of the pulp canal, generally at the apex of a nonvital tooth root
  2. Chronic process
  3. Most cases are asymptomatic
  4. Tooth may be sensitive to pressure and percussion
  5. Tooth may be slightly extruded from the socket
  6. Treatment - Endodontic therapy, Extraction
  7. Composed of granulation tissue containing lymphocytes, plasma cells, and macrophages
  8. May also contain neutrophils, areas of dense fibrous connective tissue, or epithelial rests of Malassez
80
Q

Describe Radicular Cyst (Periapical Cyst)

A
  1. A true epithelium-lined cyst
  2. Associated with the root of a nonvital tooth
  3. The most commonly occurring cyst in the oral region
  4. A result of proliferation of the rests of Malassez
  5. Usually asymptomatic and discovered on radiograph
  6. Radiographic appearance - Radiolucent, Well circumscribed, Same as periapical granuloma
  7. Treatment - Endodontic therapy, Apicoectomy, Extraction and curettage of periapical tissue
81
Q

Describe Residual Cyst

A
  1. Forms after tooth extraction and all or part of radicular cyst is left behind
  2. Treatment - Surgical removal
82
Q

Describe external tooth resorption

A
  1. External resorption: Nonreversible resorption of the tooth structure, beginning at the outside of the tooth
  2. Causes - Inflammation, Pressure, Reimplantation, Idiopathic
83
Q

Describe internal tooth resorption

A
  1. Internal tooth or root resorption: Resorption often associated with an inflammatory response in the pulp or an idiopathic reason
  2. Clinically: A pinkish area in the crown resulting from the vascular, inflamed connective tissue - Pink tooth of Mummery
  3. Radiographically: Radiolucent
  4. Treatment - If the root is not perforated, calcium hydroxide is placed and endodontic treatment is performed in an attempt to save the tooth - If the tooth is perforated, it must be removed
84
Q

Describe Focal Sclerosing Osteomyelitis (Condensing Osteitis)

A
  1. A change in the bone near the apices of teeth - Thought to be a reaction to low-grade infection
  2. Generally asymptomatic
  3. If painful, may be associated with pulpal inflammatory disease
  4. Radiopaque - Borders may be diffuse or well defined; Body lays down more bone to wall off infection spread
  5. Commonly associated with the mandibular first molar
  6. No treatment usually necessary
  7. Biopsy to rule out other radiopaque lesions such as osteoma, complex odontoma, or ossifying fibroma
85
Q

Describe Alveolar Osteitis (“Dry Socket”)

A
  1. A postoperative complication following tooth removal in which the blood clot is lost before healing can take place, leaving raw, exposed nerve endings
  2. Most often occurring in mandibular third molar areas
  3. Patient may complain of pain, bad odor, and bad taste
  4. Risk factors - Dissolution of the clot at the surgical site, Traumatic extraction, Presence of infection before extraction, Tobacco smoking after extraction
  5. Treatment - Gentle irrigation, Daily application of Dry Socket Paste containing eucalyptol until symptoms are relieved

Oral Pathology (11 decks)

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