diseases of oral cavity final

Diseases of oral cavity

Dr.Ramanujam.S M.S.,

Assistant professor,

General surgery.

CONTENTS

• ORAL CAVITY ANATOMY

• EXAMINATION OF ORAL CAVITY

• ORAL PATHOLOGY

• ORAL MANIFESTATION OF SYSTEMIC DISEASES

ORAL PATHOLOGY

– MUCOUSAL LESIONS– ULCERATIVE LESIONS– MALIGNANCY– DISEASES OF TEETH AND PULP,

GINGIVA– DISEASES OF BONES (MANDIBLE AND

MAXILLA)

Background

The mouth (buccal cavity) is the reservoir for the chewing and mixing of food with saliva.

It is the primary site of digestion and respiration as well as the primary communication structure.

It is the first part of the digestive tract and is exposed to various exogenous stimuli and exposure of longer duration can lead to reactive changes that need to be differentiated from malignancies

Anatomy of oral cavityAnatomy of oral cavity

Examination of Examination of the Oral Cavitythe Oral Cavity

Physical EvaluationPhysical Evaluation

Oral ExaminationOral Examination

Many diseases (systemic or local) Many diseases (systemic or local) have signs that appear on the have signs that appear on the face, head & neck or intra-orallyface, head & neck or intra-orally

Making a complete examination Making a complete examination can help you create a differential can help you create a differential diagnosis in cases of diagnosis in cases of abnormalities and make abnormalities and make treatment recommendations treatment recommendations based on accurate assessment of based on accurate assessment of the signs & symptoms of diseasethe signs & symptoms of disease

Oral ExaminationOral Examination

Each disease process may have Each disease process may have individual manifestations in an individual manifestations in an individual patientindividual patient

And there may be individual host And there may be individual host reaction to the diseasereaction to the disease

Careful assessment will guide the Careful assessment will guide the clinician to accurate diagnosisclinician to accurate diagnosis

Scope of responsibilityScope of responsibility

Diseases of the head & neckDiseases of the head & neck Diseases of the supporting hard Diseases of the supporting hard

& soft tissues& soft tissues Diseases of the lips, tongue, Diseases of the lips, tongue,

salivary glands, oral mucosasalivary glands, oral mucosa Diseases of the oral tissues which Diseases of the oral tissues which

are a component of systemic are a component of systemic diseasedisease

EquipmentEquipment

Assure that you have all the supplies Assure that you have all the supplies necessary to complete an oral necessary to complete an oral examinationexamination MirrorMirror Tissue retractor (tongue blade)Tissue retractor (tongue blade) Dry gauzeDry gauze

You must dry some of the tissues in You must dry some of the tissues in order to observe the nuances of any order to observe the nuances of any color changescolor changes

Exam of the Head & Neck; Exam of the Head & Neck; Oral CavityOral Cavity Be systematicBe systematic Consistently complete the exam Consistently complete the exam

in the same orderin the same order

Extra-oral examinationExtra-oral examination

Observe: color of skinObserve: color of skin Examination area of head & neckExamination area of head & neck

Determine: gross functioning of Determine: gross functioning of cranial nervescranial nerves Normal vs. abnormal Normal vs. abnormal

ParalysisParalysis Stroke, trauma, Bell’s PalsyStroke, trauma, Bell’s Palsy


TMJTMJ Palpate upon openingPalpate upon opening

What is the maximum intermaxillary What is the maximum intermaxillary space?space?

Is the opening symmetrical?Is the opening symmetrical? Is there popping, clicking, grinding?Is there popping, clicking, grinding?

What do these sounds tell you about the What do these sounds tell you about the anatomy of the joint?anatomy of the joint?

When do sounds occur?When do sounds occur? Use your stethoscope to listen to soundsUse your stethoscope to listen to sounds


Lymph node Lymph node palpationpalpation Refer to handoutRefer to handout

Thyroid Gland EvaluationThyroid Gland Evaluation


Thyroid Gland Thyroid Gland PalpationPalpation Place hands over Place hands over

the tracheathe trachea Have the patient Have the patient

swallowswallow The thyroid gland The thyroid gland

moves upwardmoves upward

Exam: LipsExam: Lips

Observe the color & its Observe the color & its consistency-intra-orally and consistency-intra-orally and externallyexternally

Is the vermillion border distinct?Is the vermillion border distinct? Bi-digitally palpate the tissue Bi-digitally palpate the tissue

around the lips. Check for around the lips. Check for nodules, bullae, abnormalities, nodules, bullae, abnormalities, mucocele, fibromamucocele, fibroma


Evert the lip and examine the tissueEvert the lip and examine the tissue Observe frenulum Observe frenulum

attachment/tissue tensionattachment/tissue tension Clear mucous filled pockets may be Clear mucous filled pockets may be

seen on the inner side of the lip seen on the inner side of the lip (mucocele). This is a frequent, (mucocele). This is a frequent, non-pathologic entity which non-pathologic entity which represents a blocked minor salivary represents a blocked minor salivary glandgland

Exam: Lips-palpationExam: Lips-palpation

Color, consistencyColor, consistency Area for blocked minor salivary Area for blocked minor salivary

glandsglands Lesions, ulcersLesions, ulcers


Frenum:Frenum: AttachmentAttachment Level of attached Level of attached

gingivagingiva

Exam: Lips-sun exposureExam: Lips-sun exposure


Palpate in the Palpate in the vestibule, vestibule, observe colorobserve color

Examination: Buccal Examination: Buccal MucosaMucosa Observe color, character of the mucosaObserve color, character of the mucosa

Normal variations in color among ethnic Normal variations in color among ethnic groupsgroups

Amalgam tattoo Amalgam tattoo Palpate tissuePalpate tissue Observe Stenson’s duct opening for Observe Stenson’s duct opening for

inflammation or signs of blockageinflammation or signs of blockage Visualize muscle attachments, hamular Visualize muscle attachments, hamular

notch, pterygomandibular foldsnotch, pterygomandibular folds

Examination: Buccal Examination: Buccal MucosaMucosa Linea albaLinea alba Stenson’s ductStenson’s duct

Examination: Buccal Examination: Buccal MucosaMucosa Lesions – white, red Lesions – white, red Lichen Planus, Leukedema Lichen Planus, Leukedema

GingivaGingiva

Note color, tone, Note color, tone, texture, texture, architecture & architecture & mucogingival mucogingival relationshipsrelationships

GingivaGingiva

How would you describe the gingiva?How would you describe the gingiva? Marginal vs. generalized?Marginal vs. generalized? Erythematous vs. fibrousErythematous vs. fibrous

Drug reactions: Anti-epileptic, Drug reactions: Anti-epileptic, calcium channel blockers, calcium channel blockers, immunosuppressant immunosuppressant

Exam: Hard palateExam: Hard palate

Minor salivary glands, attached Minor salivary glands, attached gingivagingiva

Note presence of tori: tx plan Note presence of tori: tx plan any pre-prosthetic surgery any pre-prosthetic surgery

Exam: Soft palateExam: Soft palate

How does soft palate raise upon How does soft palate raise upon “aah”?“aah”?

Vibrating line, tonsilar pillars, Vibrating line, tonsilar pillars, tonsils, oropharynxtonsils, oropharynx

Exam: OropharanyxExam: Oropharanyx

Color, consistency of tissueColor, consistency of tissue Look to the back, beyond the soft Look to the back, beyond the soft

palatepalate Note occasional small globlets of Note occasional small globlets of

transparent or pink opaque transparent or pink opaque tissue which are normal and may tissue which are normal and may include lymphoid tissueinclude lymphoid tissue

Exam: TonsilsExam: Tonsils

Tucked in at base of anterior & Tucked in at base of anterior & posterior tonsilar pillarsposterior tonsilar pillars

Globular tissue that has Globular tissue that has “punched out” appearing areas“punched out” appearing areas

Regresses after adulthoodRegresses after adulthood May see white “orzo rice like” or May see white “orzo rice like” or

“torpedo” shaped white “torpedo” shaped white concretions within the tissueconcretions within the tissue

Exam: TongueExam: Tongue

The tongue and the floor of the The tongue and the floor of the mouth are the most common mouth are the most common places for oral cancer to occurplaces for oral cancer to occur

It can occur other places; so It can occur other places; so visualize all areasvisualize all areas

You may observe:You may observe: Circumvalate papillae, epiglottisCircumvalate papillae, epiglottis


Have the patient stick out their Have the patient stick out their tonguetongue

Wrap the tongue in a dry gauze Wrap the tongue in a dry gauze and gently pull it from side to and gently pull it from side to side to observe the lateral side to observe the lateral bordersborders

Retract the tongue to view the Retract the tongue to view the inferior tissuesinferior tissues


You may observe You may observe lingual lingual varicosities varicosities


You may observe geographic You may observe geographic tongue (erythema migrans)tongue (erythema migrans)


You may observe drug reactionYou may observe drug reaction


Observe signs of nutritional Observe signs of nutritional deficiencies, immune dysfunctiondeficiencies, immune dysfunction


You may observe You may observe oral canceroral cancer

Exam: Floor of mouthExam: Floor of mouth

Visualize, palpate - bimanuallyVisualize, palpate - bimanually Wharton’s duct Wharton’s duct Must dry to observeMust dry to observe

Does “lesion” wipe off?Does “lesion” wipe off? Where are the two mostWhere are the two most

likely areas for oral cancer?likely areas for oral cancer? lateral border of the tonguelateral border of the tongue Floor of mouthFloor of mouth

Palpation of the floor of the Palpation of the floor of the mouthmouth


Squamous Cell CarcinomaSquamous Cell Carcinoma

Exam: Leukoplakic area Exam: Leukoplakic area

Edentulous Mandibular Ridge


Oral Cancer:Oral Cancer: RedRed WhiteWhite Red and WhiteRed and White

Does the patient have important Does the patient have important risk factors for oral cancer?risk factors for oral cancer? Counseling for smoking and alcoholCounseling for smoking and alcohol

Cessation Cessation

Squamous Cell Squamous Cell CarcinomaCarcinoma

Triaging Lesions Triaging Lesions **

Describe it’s characteristicsDescribe it’s characteristics Size, shape, color, consistency, locationSize, shape, color, consistency, location

How long has it been present?How long has it been present? Is it related to a trauma?Is it related to a trauma?

Fractured cusp, occlusal traumaFractured cusp, occlusal trauma Has it occurred before?Has it occurred before? Can you wipe it off? Can you wipe it off? Does the patient have specific risk Does the patient have specific risk

factors for neoplastic lesions?factors for neoplastic lesions?

Triaging Lesions Triaging Lesions **

Any lesion that is suspicious Any lesion that is suspicious should be re-evaluated in 2 should be re-evaluated in 2 weeksweeks Lesions due to infectious processes Lesions due to infectious processes

would have healed in that time would have healed in that time frameframe

If it remains, the lesions should be If it remains, the lesions should be biopsiedbiopsied

Exam: Maxilla & Exam: Maxilla & MandibleMandible• size, shape, contour

• pre-prosthetic treatment

•Tori removal

• tuberosity reduction

•Soft or hard tissue or both

Exam: Maxilla & Exam: Maxilla & MandibleMandible

Exam: Maxilla & Exam: Maxilla & MandibleMandible Evaluate for Evaluate for

Epulis fissuratumEpulis fissuratum

If you make a If you make a new denture will new denture will the excess tissue the excess tissue resolve?resolve?

OcclusionOcclusion

Orthodontic Orthodontic classificationclassification

InterferencesInterferences

OcclusionOcclusion

Systematic Oral Systematic Oral ExaminationExamination Done at initial exam & at recalls Done at initial exam & at recalls

unless patient history requires soonerunless patient history requires sooner You must visualize all areas of the You must visualize all areas of the

oral cavityoral cavity Oral cancer can occur in other places Oral cancer can occur in other places

than the lateral borders of the tongue than the lateral borders of the tongue & the floor of the mouth& the floor of the mouth

Be completeBe complete Do good, do no harm, do justice, Do good, do no harm, do justice,

respect autonomyrespect autonomy

Visualize all areasVisualize all areas

BreathBreath

Oral odors can indicate:Oral odors can indicate: Infection: caries, periodontal dxInfection: caries, periodontal dx URT infectionsURT infections Chronic G.I. disturbancesChronic G.I. disturbances Lung abscessLung abscess Diabetic acidosisDiabetic acidosis Uremia, kidney problemUremia, kidney problem Liver failure: mousy, musty odorLiver failure: mousy, musty odor Self-medication with alcoholSelf-medication with alcohol

Example of Dental Example of Dental ChartingCharting

ORAL PATHOLOGYORAL PATHOLOGY

DEFINITION—THE STUDY OF DISEASES IN THE ORAL CAVITY.

MANY SYSTEMIC AS WELL AS INFECTIOUS DISEASES HAVE ORAL MANIFESTATIONS.

If mucosal lesions are evident:If mucosal lesions are evident:

• Try to remove local factors that could have contributed to the lesion

• commence anti-inflammatory treatment for two weeks, if lesion remains: biopsy

• a diagnosis based on clinical appearance alone is usually not sufficient to determine the histological nature of the tissue

• Try to remove local factors that could have contributed to the lesion

• commence anti-inflammatory treatment for two weeks, if lesion remains: biopsy

• a diagnosis based on clinical appearance alone is usually not sufficient to determine the histological nature of the tissue

Oral LesionsOral Lesions

By colour change• White lesions• Red lesions• Red and white

lesions• pigmented lesions

By colour change• White lesions• Red lesions• Red and white

lesions• pigmented lesions

By surface change• nodules• vesiculobullous

lesions• ulcerative lesions

By surface change• nodules• vesiculobullous

lesions• ulcerative lesions

Oral lesionsOral lesions

White lesions:• Leukoplakia• Lichen• Leukoedema• Morsicatio

buccarum• White Sponge

Neavus• Fordyce’s Granules

White lesions:• Leukoplakia• Lichen• Leukoedema• Morsicatio

buccarum• White Sponge

Neavus• Fordyce’s Granules

Red lesions:• Erythroplakia• Varicosity• Hemangioma• Purpura (Petechiae,

Ecchymosis)• Sturge-Weber

Angiomatosis• Hereditary

Hemorrhagic Teleangiectasia

Red lesions:• Erythroplakia• Varicosity• Hemangioma• Purpura (Petechiae,

Ecchymosis)• Sturge-Weber

Angiomatosis• Hereditary

Hemorrhagic Teleangiectasia

Oral lesionsOral lesions

Red-white lesions

• speckled Erythroplakia

• Squamous Cell Carcinoma

• Lichen planus

• Lupus Erythematodes

• Lichenoid Drug Reactions

• Candidiasis (Candidal Leukoplakia, Anti-biotic Sore Mouth, Denture Stomatitis)

Red-white lesions

• speckled Erythroplakia

• Squamous Cell Carcinoma

• Lichen planus

• Lupus Erythematodes

• Lichenoid Drug Reactions

• Candidiasis (Candidal Leukoplakia, Anti-biotic Sore Mouth, Denture Stomatitis)

Pigmented lesions• Melanoplakia• Tobacco associated

Pigmentation (Smokers Melanosis)

• Nevus• Malignant Melanoma• Peutz-Jeghers

Syndrome• Addisons’s Disease• Amalgam Tattoo

Pigmented lesions• Melanoplakia• Tobacco associated

Pigmentation (Smokers Melanosis)

• Nevus• Malignant Melanoma• Peutz-Jeghers

Syndrome• Addisons’s Disease• Amalgam Tattoo

Background Definitions

Gingivitis-inflammation of the gumsXerostomia-abnormal dryness of the mouth due

to insufficient secretions Mucositis-inflammation of a mucous membrane Stomatitis-inflammation of the mouth having

various causes (as mechanical trauma, allergy, vitamin deficiency, or infection)

Cheilitis-inflammation of the lipGlossitis-inflammation of the tongue

LeukoplakiaLeukoplakia

White lesions on the mucosa which will not rub of and can not be classified as any other

disease (WHO 1978)

• is a clinical descriptive term, not a histological diagnosis

White lesions on the mucosa which will not rub of and can not be classified as any other

disease (WHO 1978)

• is a clinical descriptive term, not a histological diagnosis

Leukoplakia

EtiologyEtiology

• Combination of extrinsic local factors and intrinsic predisposing factors

• Initiation through chemical or mechanical irritation: – chemical: alcohol, tobacco– mechanical: sharp tooth or crown

margins, irritating denture clasps

• Combination of extrinsic local factors and intrinsic predisposing factors

• Initiation through chemical or mechanical irritation: – chemical: alcohol, tobacco– mechanical: sharp tooth or crown

margins, irritating denture clasps

Histologic FeaturesHistologic Features

• Leukoplakia usually shows hyperkeratosis or acanthosis with or without dysplasia (20% show dysplasia)

• white colour change is the sign of hyperkeratosis

• Leukoplakia usually shows hyperkeratosis or acanthosis with or without dysplasia (20% show dysplasia)

• white colour change is the sign of hyperkeratosis

Clinical appearance - homogeneous and non-

homogeneous Leukoplakia

Clinical appearance - homogeneous and non-

homogeneous Leukoplakia

• Homogeneous: non-palpable, faintly translucent white discoloration

• non-homogeneous: – verrucous or nodular– speckled: hyperkeratotic white areas

and red areas– errosive: fissuring and ulcer formation

• Homogeneous: non-palpable, faintly translucent white discoloration

• non-homogeneous: – verrucous or nodular– speckled: hyperkeratotic white areas

and red areas– errosive: fissuring and ulcer formation

Site of Leukoplakia

• Risk of dysplasia/carcinoma higher with floor of mouth, ventrolateral tongue, retromolar trigone, soft palate than with other oral sites

• Clinical shift in appearance from homogenous to heterogenous, speckled, or nodular, a rebiopsy is mandatory

• Correlation between increasing levels of dysplasia and increases in regional heterogeneity or speckled quality

Sites of predilectionSites of predilection

• Lateral and ventral tongue

• floor of the mouth

• alveolar ridge mucosa

• corner of the mouth

• less frequently:– soft palate – lip

• Lateral and ventral tongue

• floor of the mouth

• alveolar ridge mucosa

• corner of the mouth

• less frequently:– soft palate – lip

High risk sitesHigh risk sites

• 4-6% of leukoplakias progress to squamous cell carcinoma within 5 years

• high risk sites of malignancy:– floor of the mouth– lateral and ventral tongue– lips

• 4-6% of leukoplakias progress to squamous cell carcinoma within 5 years

• high risk sites of malignancy:– floor of the mouth– lateral and ventral tongue– lips

Differential diagnosisDifferential diagnosis

Nicotine Stomatitis

Candidiasis

Hairy Leukoplakia

Leukoedema

White sponge naevus

Fordyce granules

Nicotine Stomatitis

Candidiasis

Hairy Leukoplakia

Leukoedema

White sponge naevus

Fordyce granules

Treatment

• Trial of cessation of offending agent, follow-up• Guided by microscopic characterization• Benign, minimally dysplastic- periodic

observation or elective excision• Complete excision can be performed with

scalpel excision, laser ablation, electrocautery, or cryoablation

• Chemoprevention

Erosions and ulceration are a clinical sign of malignant

transformation

Erosions and ulceration are a clinical sign of malignant

transformation

DysplasiaDysplasia

• mild: affects only basal 1/3 of epithelium

• moderate: affects half of epithelial layer

• severe: more than 2/3 of epithelium affected

• Carcinoma in situ (CIS): the whole thickness of epithelium is involved but the basement membrane is intact

• mild: affects only basal 1/3 of epithelium

• moderate: affects half of epithelial layer

• severe: more than 2/3 of epithelium affected

• Carcinoma in situ (CIS): the whole thickness of epithelium is involved but the basement membrane is intact

Treatment

• Trial of cessation of offending agent, follow-up• Guided by microscopic characterization• Benign, minimally dysplastic- periodic

observation or elective excision• Complete excision can be performed with

scalpel excision, laser ablation, electrocautery, or cryoablation

• Chemoprevention

Hairy leukoplakiaHairy leukoplakia

• Oral sign of HIV infection

• viral origin likely (Epstein-Barr virus)

• frequently associated with Candida albicans

• Oral sign of HIV infection

• viral origin likely (Epstein-Barr virus)

• frequently associated with Candida albicans

Lichen planusLichen planus

• Common skin disease with oral manifestation (ca 30% of cases) or oral lesions without cutaneous signs

• most likely immunologic disorder in which T lymphocytes destroy the basal cell layer of the affected epithelium

• Common skin disease with oral manifestation (ca 30% of cases) or oral lesions without cutaneous signs

• most likely immunologic disorder in which T lymphocytes destroy the basal cell layer of the affected epithelium


• Frequently affected sites: – buccal mucosa– dorsal tongue

• less frequently affected:– lips– palate– gingiva– floor of mouth

• Frequently affected sites: – buccal mucosa– dorsal tongue

• less frequently affected:– lips– palate– gingiva– floor of mouth


• Four appearances of oral lichen planus:– striated (reticular)– atrophic– erosive– plaquelike

• Four appearances of oral lichen planus:– striated (reticular)– atrophic– erosive– plaquelike

ErythroplakiaErythroplakia

• Def: persistent red patch that cannot be characterized clinically as any other condition

• redness of the lesion is a result of atrophic mucosa overlying highly vascular submucosa

Erythroplakia

Area of Squamous Cell Carcinoma Surrounded by Erythroplakia

ErythroplakiaErythroplakia

• Most erythroplakia are histologically diagnosed epithelial dysplasia or worse

• much higher chance of progression to carcinoma

• biopsy is mandantory

• Most erythroplakia are histologically diagnosed epithelial dysplasia or worse

• much higher chance of progression to carcinoma

• biopsy is mandantory

CONDITIONS OF THE TONGUE

• GLOSSITIS

– General term used to describe inflammation and changes to the tongue.

– FOUR MAIN TYPES

• BLACK HAIRY TONGUE• GEOGRAPHIC TONGUE• FISSURED TONGUE• PERNICIOUS ANEMIA

BLACK HAIRY TONGUE

– caused by an oral flora imbalance after the administration of antibiotics– the filiform papillae become elongated so that they resemble hairs, they then become stained by food,

• GEOGRAPHIC TONGUE

• the surface of the tongue loses areas of the filiform papillae in irregularly shaped patterns

• the smooth areas resemble a map.

• over days or weeks the smooth areas and the whitish margins seem to change locations across the surface of the tongue

• affects 1-3% of the population

• occurs at all ages

• women have it twice as much as males

– FISSURED TONGUE

• considered a variation of normal

• etiology is unknown

• theories include a vitamin deficiency or chronic trauma over a long period

• dorsum of tongue appears to have deep fissures or grooves that become irritated if debris collects in them

• patient is advised to brush tongue with a soft toothbrush

– PERNICIOUS ANEMIA• a condition in which the body does not absorb vitamin b 12• oral manifestation of pernicious anemia include angular cheilitis • ulceration and redness at the corners of the lips• loss of papillae of the tongue• a burning and painful tongue

Ulcerative Lesion

Things to Consider

Most Likely: Aphthous ulcer, HSV, Trauma, Malignancy

Less Likely: Varicella Zoster, Autoimmune disease, Fungal infection, Malnourishment

Must Rule Out: Malignancy, Immunosuppresion, Bacterial/Fungal disease, Some of the autoimmune diseases

Differential Diagnosis• Infection

– HSV, Actinomycosis, CMV, Varicella Zoster, Coxsackievirus, Syphilis, Candidiasis, Cryptosporidium, Histoplasma (fungal typically seen in immunocompromised)

• Autoimmune

– Behçet's syndrome, Lupus, Crhon’s Disease, Pemphigoid, Lichen Planus, Aphthous ulceration, Erythema multiforme

• Neoplasm

• Trauma Induced (necrotizing sialometaplasia)

• Malnourishment: Vitamin B deficiencies, Vitamin C deficiency, Iron deficiency, Folic acid deficiency

What to Do Next?

-Work from most common to least common, and rule out the things that will cause the most morbidity or mortality

1. Biopsy the lesion

2. Check labs (ensure not immunocomprimised) – finger stick glucose in office, CBC, CMP, A1c

3. Rule out infection: Send swab and biopsy for HSV testing (smear, PCR) as well as gram stain and possible culture (viral/bacterial)

Final Diagnosis: Major Aphthous Ulcer

Aphthous Ulcers

• Most common cause of non-traumatic ulcerations of the oral cavity

• Etiology unclear• 10-20% of general population• Diagnosis of exclusion

Aphthous Ulcers

• Classifications– Minor aphthous ulcer

» < 1cm in diameter» Located on freely mobile oral mucosa» Appears as a well-delineated white

lesion with an erythematous halo» Prodrome of burning or tingling in

area prior to ulcer’s appearance» Resolve in 7-10 days» Never scars

Aphthous Ulcers– Major aphthous ulcer

» > 1cm in diameter» Involves freely mobile mucosa,

tongue, and palate» Last much longer – 6 weeks or

more» Typically scar upon healing

Aphthous Ulcers

– Herpetiform ulcers» Small, 1-3mm in diameter ulcerations

appearing in crops of 20-200 ulcers» Typically located on mobile oral mucosa,

tongue, and palate» Last 1-2 weeks» Called herpetiform because ulcerations

resemble those of HSV, but there is no vesicular phase

Aphthous Ulcers Cont.

– Treatment»Topical tetracycline solution for 5-7 days has

shown good results»Topical steroids shown to shorten disease

duration»Sucralfate suspension shown to improve pain

as well as shorten disease duration»Major aphthous ulcers or more severe forms of

disease require 2 week course of systemic steroids

• KEY TO DIAGNOSIS: Diagnosis of exclusion; clinical appearance/course

– Any ulceration that fails to heal in 1-2 weeks should be biopsied

– Associated Premalignant lesions• Leukoplakia• Erythroplakia

Oral Malignancy

– Malignancy• 30% of all head and neck cancer occur in the oral

cavity (most common site of head and neck cancer)• Symptoms/findings – non-healing ulcerations, pain,

expansile lesion, trismus, dysphagia, odonyphagia, halitosis, numbness in lower teeth (inferior alveolar nerve involvement)

• Indicators of more aggressive tumors – require more aggressive treatment– 4mm of invasion– > 1cm in size– Perineural, lymphatic, or vascular invasion

Types of Oral Cancer– Squamous cell carcinoma – most common (90% of

cases)– Basal cell carcinoma – more common on upper lip– Verrucous carcinoma

» Variant of squamous cell carcinoma» Less aggressive (rare metastasis or deep invasion)» Most common site is on buccal mucosa» Warty lesion

– Salivary gland malignancy» Most common in oral cavity is adenoid cystic carcinoma» Mucoepidermoid carcinoma» Adenocarcinoma

– Lymphoma – both Hodgkin’s and non-Hodgkin’s types– Sarcomas – most commonly rhabdomyosarcoma and

liposarcoma; look for Kaposi’s sarcoma in AIDS patients– Melanoma

Oral manifestation of systemic diseases.

• Drug Reactions• Fungal infections• Viral infections• Leukemia• Behcet’s Disease• Diabetes Mellitus• Nutritional Deficiencies• Amyloidosis

Behcet’s Disease

• Behcet’s disease is a rare disorder mainly affecting young men.

• While the disease affects multiple organ systems, oral ulcerations resembling canker sores present in 99% of patients.

• The oral lesions are the herald of this disease and are usually 6mm or smaller and resolve within 1-3 weeks.

• Treatment is symptomatic and supportive. Medication may be prescribed to reduce inflammation and/or regulate the immune system. Immunosuppressive therapy may be considered.

Behcet’s Disease

Sjögren’s Syndrome• Sjögren’s syndrome is the 2nd most common

autoimmune disease with women in their mid-60’s being the primarily afflicted.

• Initial symptoms include dry eyes and dry mouth due to gradual glandular dysfunction.

• In some cases, dysphagia, increased dental caries, increased susceptibility to oral candidiasis, and difficulty wearing dental prostheses will develop.

• Treatment is generally symptomatic and supportive. Moisture replacement therapies may ease the symptoms of dryness. Nonsteroidal anti-inflammatory drugs may be used to treat musculoskeletal symptoms. Corticosteroids or immunosuppressive drugs may be considered in severe cases.

Sjögren’s Syndrome

Drug Reactions- SJS and TEN• Stevens-Johnson syndrome and toxic epidermal

necrolysis are rare, life-threatening, drug induced reactions.

• 7 to 21 days after exposure purpuric and erythematous macules evolve to skin necrosis and epidermal detachment.

• Oral mucous membrane involvement occurs in up to 50% of cases and may impair ingestion of nutrition.

• Most commonly implicated in these reactions are sulfonamides, penicillins, phenytoin, and phylbutazone.

Erythema Multiforme

Carry home messages

• Thorough examination is vital in diagnosis and management of diseases of oral cavity.

• Any suspicious lesion should be biopsied.

diseases of oral cavity final

Documents