ORAL DERMATOLOGICAL CONDITIONS

ORAL DERMATOLOGICAL CONDITIONSMODERATOR:Dr.MOHANTYPRESENTER:RAVINDRA.DAnatomy: Oral cavityOral cavity

LipsTongueFloor of MouthBuccal mucosaPalateRetromolar trigone

Sub-mucous fibrosis Aphthous ulcer Leukoplakia Erythroplakia Oral candidiasis Oro-labial Herpes Vincents infection Infectious mononucleosis Tongue tie Geographic tongue Ranula Mucocoele Common diseases of oral cavity3INTRODUCTIONRecurrent, superficial ulcers, with necrotic centre + red margin, involving movable mucosa of inner surface of lips, cheeks, tongue & soft palate Differences from viral ulcer 1. Frequent recurrence2. Selective involvement of movable mucosa3. Absence of fever, malaise, lymph node enlargement 1.Aphthous ulcer4

Minor aphthous ulcer: 2 10 mm in size, multiple, heal with no scar in 1 - 2 weeks 5

Rule out HIV & malignancy2. Major aphthous ulcer: 20 40 mm in size, usually single, heal with scar over months

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3. Herpetiform aphthous ulcer: < 1 mm in size, multiple, heal with no scar in 1 week

72.Behcets syndromeUveitis + Aphthous ulcer + Genital ulcer Oculo Oro - Genital syndromeTreatment : steroid

93.Oral candidiasisEtiology: Infection with Candida albicansPredisposing factors:Chronic ill-health Uncontrolled diabetes mellitusAcquired immune deficiency syndrome Prolonged use of steroids Prolonged antibiotic therapy Immuno-suppressant therapy (cyclosporine)Anti-cancer chemotherapy10

1.Chronic hyperplastic: white plaques, cannot be removed by scraping (Candidal leukoplakia)

TYPES11

2.Pseudo-membranous: loosely adherent white lesions, can be scraped off leaving red patches

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3.Erythematous (atrophic): smooth, red patches

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4.Cheilitis: white lesions on angle of mouth

14DIAGNOSIS1. Microscopic exam of wet smear on KOH mount: look for pseudo-hyphae2. Culture (Sabouraud dextrose agar): white colonyTREATMENT1. Clotrimazole paint, Nystatin mouthwash2. Systemic Fluconazole: for chronic cases3. Excision of hyperplastic plaque4. Correction of underlying cause

154.Vincents infection (Acute Necrotizing Ulcerative Gingivitis or Trench mouth)Etiology: infection with spirochete Borrelia vincenti & Gram ve anaerobe Bacillus fusiformisPredisposing factors: Poor general healthPoor oro-dental hygieneDental caries CLINICAL FEATURESPainful, ulcerative lesions covered by necrotic membrane present over: inter-dental papillae & spreading toward free gum margins (acute necrotizing ulcerative gingivitis) tonsils (Vincents angina) Halitosis, neck lymph node enlargement & fever

16STAGES

DiagnosisSmear stained with Gentian violet to identify Borrelia vincenti & Bacillus fusiformisTreatment1. Systemic Benzylpenicillin / Erythromycin2. Systemic Metronidazole / Clindamycin3. Betadine mouthwash & H2O2 gargle4. Dental care & bed rest18Primary Herpes simplexSeen in children Oral cavity: multiple vesicles which later ulcerate Fever + sore throat Neck node enlargementTreatment: Acyclovir 15 mg/kg PO 5 times/d for 7 days

5.Oro-labial Herpes simplex infection (cold sore)19Secondary Herpes simplexReactivation of dormant virus in trigeminal ganglion in adults by emotional stress, fatigue, infection, pregnancy, immune-deficiencyVesicular & ulcerative lesions primarily affect vermilion border of lip (Herpes labialis)Tongue, hard palate & gums also involvedTreatment: Acyclovir 200 mg PO 5 times / day X 7 days

20Other Bacterial Infections

A-Ulcerated chancreB-Ulcerated mucous patches (snail track ulcers)C-Gummatous ulcerTuberculosis of The Tongue

Syphilis6.Trauma:CHEEK BITING ILL-FITTING DENTURES

CHEMICAL BURNS

ABRASIONS FROM TEETH

7.Infectious mononucleosis (glandular fever)Caused by Epstein Barr virusSpreads only by intimate contact (kissing disease)C/F: 1. fever, fatigue, malaise2. pharyngitis, palatal petechiae 3. ulcer-membranous lesions over tonsils4. neck lymph node enlargement5. hepatomegaly & splenomegaly

23INVESTIGATIONSTotal count: leukocytosisDifferential count: lymphocytosis + monocytosisPeripheral blood smear: atypical lymphocytesPaul Bunnel test (with sheep RBC): positiveMonospot test (with horse RBC): positive Sensitivity 85%, specificity 100% TREATMENTSymptomatic:Bed rest. Paracetamol for feverSteroids + tracheostomy for stridorValacyclovir (1000 mg BD TID X 7 d) is effectiveAvoid aspirin in children - Reye syndrome (fattY liver + encephalopathy)

248.Submucosal fibrosis Chronic pre-malignant disease of oral cavity, characterized by juxta-epithelial inflammation + progressive fibrosis of lamina propria & deeper connective tissues, followed by stiffening of mucosa resulting in difficulty in mouth opening

ETIOLOGY (MULTI-FACTORIAL) 1. Areca nut (betel nut) chewing 2. Tobacco & Paan masala chewing 3. Genetic predisposition 4. Auto-immune injury 5. Nutritional deficiency of vitamins, iron, anti-oxidants 6. Excessive alcohol consumption

PRESENTING SYMPTOMSBurning pain on consumption of spicy food Dryness of mouth Impaired mouth movements while eating & talking Progressive inability to open the mouth (trismus) This patient has so much of limitation in opening of mouth that it is difficult to put even 2 fingers in the mouth Hearing loss (stenosis of Eustachian tubes) Nasal intonation (ed soft palate mobility)STAGESStage of stomatitis: red mucosa vesicles rupture to form mucosal ulcersStage of fibrosis (healing): blanching of mucosafibrous bands in oral mucosa, trismus, deceased soft palate mobilityStage of sequelae: difficult speech, hearing loss,leukoplakia, malignancy (3 - 8 %)

26MEDICAL TREATMENTBi-weekly submucosal intra- lesional injections of Dexamethasone 4 mg + Hyaluronidase 1500 IU for 6- 8 wks Submucosal injection of human placental extractVitamin B complex + anti-oxidant supplementIncreased intake of fruits & vegetablesSURGICAL TREATMENT Simple release of fibrous bands + skin graftingLaser-assisted release of fibrous bandsExcision of lesions & reconstruction with:buccal fat pad, naso-labial flap,lingual flap, palatal muco-periosteal flap, radial forearm flapTemporalis muscle myotomy + mandibular coronoidectomy

27Definition: pre-malignant condition with white patch or plaque that cannot be rubbed off with gauze swab & cannot be characterized clinically or pathologically as any other diseaseMalignant transformation: 1 - 20% (average 5 %)Sites: Buccal mucosa, tongue, lips, palate, floor of mouth, gingiva, alveolar mucosa ETIOLOGYChronic smoking Chronic tobacco chewingIrritation from jagged teeth or ill-fitting denturesChronic alcohol consumptionSun exposure to lips Associated with: submucous fibrosis, hyperplastic candidiasis, Plummer-Vinson syndrome, AIDS

9.Leukoplakia 28

TYPESHomogeneous leukoplakia: smooth,white2. Nodular leukoplakia: nodular, white

3. Verrucous leukoplakia: warty, white4. Speckled (erythro) leukoplakia: white + redMalignant potential: speckled >> nodular & verrucous >> homogenousINVESTIGATIONS1. Supra-vital staining / Ora-screen: Toluidine blue solution stains areas of malignancy2. Biopsy: to rule out malignancyTREATMENT

Removal of causative agent

Supplement: Vitamin A (beta-carotene), C, E, B12, folic acid.

Surgical excision: if HPE shows dysplasia.Surgical excision modalities: cold knife, cryosurgery, laser surgery

3110.Erythroplakia Definition: pre-malignant condition with red patch or plaque that cannot be rubbed off with gauze swab & cannot be characterized clinically or pathologically as any other diseaseRed colour due to vascular submucosal tissue shining through under-keratinized mucosaMalignant potential: 17 times > leukoplakiaTreatment : excision biopsy

3211.Oral lichen planusEtiology: unknown (? hypersensitivity reaction)Types of oral lichen planus:

SKIN LESIONS: purple, polygonal, pruritic papulesTREATMENT: Reticular & plaque types: no treatment required Erosive type: topical or systemic steroids 3312.Stevens - Johnson syndromeSevere form of Erythema multiformeMinor form of Toxic Epidermal Necrolysis involving < 10 % of body surface areaMuco-cutaneous, immune-complexmediated hypersensitivity disorder causing separation of epidermis from dermis ETIOLOGY

Idiopathic: 25 - 50 % cases

Drug reaction: Penicillin, Sulfonamides, Macrolide, Ciprofloxacin, Phenytoin, Carbamazepine, Valproate, Lamotrigine, NSAIDs, Valdecoxib, Allopurinol

Viral infection: herpes simplex, HIV, influenza

Malignancy: carcinoma, lymphoma

34Symptomatic TreatmentAirway stability, fluid replacement, electrolyte correction, wound cared as burns & pain controlUnderlying diseases & infections treated Offending drugs must be stoppedLocal anesthetics & mouthwashes for oral lesionsSteroids use is controversial. Cyclophosphamide, cyclosporine & I.V. immunoglobulin are used.

3514.Nicotinic stomatitis

Seen in pipe smokers & reverse smokersCobblestone mucosa of postr hard palate, with red dot in centertreatment: smoking cessationElongated filiform papillae on tongue due to excess keratin formation. Become infected with chromogenic bacteria & look like hairs.

Etiology: smoking

Treatment : scraping of tongue

13.Black hairy tongue3615.ORAL CANCERSquamous Cell Carcinoma constitutes 95% of oral cancers

Common in Old Men (50-60 years)

COMMON SITES : Lip (lower lip)Tongue (anterior ) Mouth floorTonsil and FaucesAETIOLOGY:Tobacco and alcohol are the most common associations: Smokers can have 15-fold greater risk ( than nonsmokers ) of malignancy. Chewing tobacco and betel nuts are important causes in India and parts of Asia 2. Leukoplakia and Erythroplakia 3. Human papilloma virus (HPV) (type16) 4, Genetic factors may also play a role (deletions in chromosomes 18q, 8p, and 3p are implicated). 5. Exposure to ultra-violet light (cancer of the lip).

Squamous cell ca. of lip

Squamous Cell carcinoma of the TongueUncommon Malignant Tumors of The Oral CavityMalignant melanomaLymphomasLeukemic infiltrationAdenocarcinoma of minor salivary glandsSarcomas

Acute Leukemia: gum involvementJOURNAL PROPERINTRODUCTION Very often the oral dermatological conditions involving oral cavity are misdiagnosed and proper attention and care is not given.This study is to sensitize the clinicians to the prevailing situation of oral dermatological conditions.MATERIALS & METHODSA total of 150 cases were taken up for the study irrespective of age,sex,duration of lesions attending dermatology/ENT dept. during 1 year period.The following areas were taken into consideration:Site of lesionMorphologyExtent of lesionDischarge if anyMargins of lesionFloor and base of lesionRegional lymphnodes if any

Investigations done are:Routine blood,urine and stool testsScrapings,KOH mountTzank testGram stainsBiopsy for certain cases.Special tests were done for systemic diseases if indicatedOBSERVATIONS AGE(yr.)MALEFEMALETOTAL% (out of 150)0-104485.33%11-2012203221.33%21-3013223523.34%31-4013243724.67%41-509142315.33%>50961510.00%TOTAL6090150AGE DISTRIBUTIONAGE IN YEARSNO. OF PATIENTSAGE AND SEX DISTRIBUTIONDISEASES WITH ORAL MANIFESTATIONSDISEASESNO.OF PATIENTS% OUT OF 150Aphthous ulcer1628.57%Oral candidiasis916.07%Angular chelitis610.71%Oral leukoplakia47.14%Fixed drug eruption47.14%Squamous cell ca.35.36%Fordyce spot23.57%Herpes simplex stomatitis23.57%Oral sub mucosal fibrosis610.71%Mucocele 23.57%Leukemia 11.79%Warts 11.79%Scrotal tongue 11.79%DISCUSSIONPt.s having oral diseases presents with different signs and symptoms like Oral pain,soreness,burning, xerostomia,bleeding, swelling, change ofcolour,erosion,crusting,Ulcers,fissuringThe study has recorded 25 pt.s of pemphigus vulgaris having both cutaneous manifestations, revealing that this is the common lesion.The study shows that buccal mucosa was the most commonly affected site(68%),followed by palates(56%),lips(44%),tongue(40%),labial mucosa(16%).

pemphigus vulgarisCollagen diseases form the next common group. Among this systemic lupus erythematosus is major one, and most of the lesions are confined to palate.The study recorded 13 cases of discoid lupus erythematosus,with lips being the commonest site.Among the specific cutaneous disorders,16 cases of recurrent aphthous stomatits have been recorded,with labial mucosa being common site.,and most common one was minor type.12 pts of lichen planus were recorded with lip&cheek being common sites, and common in age group of 20-40.Infective disorders constitute 10% of study with candidiasis being common one.common site of involvement is dorsal tongue.The study also recorded 6 cases of oral submucosal fibrosis with cheeks(buccal mucosa) being common site.4 pts of oral leukoplakia have been recorded with buccal mucosa being common site of involvement.6 pts of angular stomatitis have been recorded with lesions on lips and buccal mucosa..

Diseases with oral and cutaneous manifestationsDISEASESNO.OF PTS.% OUT OF 94Pemphigus vulgaris2526.60%Pemphigus vegetans22.13%Stevens Johnson's syndrome88.15%Toxix epidermal necrosis44.26%Erythema multiforme11.06%Discoid lupus erythematosus1313.83%Systemic lupus erythematosus1617.02%Systemic sclerosis66.38%Lichen planus1212.77%Vitiligo 66.38%Pie diagram showing distribution of lesionsCONCLUSIONSOral mucous membrane alone may be involved in some disesases,but it is often missed by clinician.

This can be taken care of by primary health care providers without going through much sophisticated investigations and thus early intervention for patients.BIBLIOGRAPHYINDIAN JOURNAL OF OTOLARYNGOLOGY AND HEAD &NECK SURGERY(apr-june 2013)SCOTT&BROWN 6TH EDITIONTEXT BOOK OF DERMATOLOGY BY NEENA KHANNA

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