lesions of the oral cavity - entpa.org - common oral cavity and throat... · anatomy of the tongue....

3/19/2014

1

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PAFourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Jason C. Fowler, MPAS, PA‐C

Meadville ENT – Meadville, PA

Lesions of the Oral Cavity


Disclosures


Learning Objectives

• Identify common oral cavity infections, lesions and illnesses, as well as form a differential diagnosis

• Select appropriate testing based on the history and physical findings

• Develop a medical management plan including referral and follow up as necessary

3/19/2014

2

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Lesions of the Oral Cavity

Head and Neck Anatomy Oral Cavity:• Functions: respiration,

digestion, swallowing, taste • External components

(vestibule)– Lips,– vermillion border, / philtrum

• Internal components– Tongue– palate (hard / soft)– buccal mucosa, – Gingiva / alveolar ridges– major salivary ducts


Anterior view of the Oral Cavity

www.cancer.gov


Anatomy of the Tongue

3/19/2014

3


Clinical History• Important factors to consider

– Age and gender– Constitutional symptoms: e.g. Weight loss, fevers, night sweats– Duration of symptoms– Co-morbid medical conditions: e.g Immunocompromise– Environmental risk factors (ETOH / TOBACCO)– Dysphagia / Odynophagia / hemoptysis / Halitosis– Respiratory distress / Shortness of Breath

• Duration of symotoms– Acute: usually < 7 days – suggests inflammatory– Chronic: present for years, often asymptomatic – suggests congenital– Recurrent: multiple x per year, often painful – suggests infectious /

autoimmune / nutritional– Weeks: months, +/- painful – suggests possible neoplastic process

• Pain– Need to localize and quantify as accurately as possible. Malignancy may

often be masked by low degree of pain– REFERRED EAR PAIN – unilateral ear pain with a normal ear exam should

raise suspicion for oropharyngeal or laryngeal malignancy, especially in patients with social risk factors such as alcohol and tobacco


Oral cavity – Basic Anatomy


Normal Anatomy

RMT

Gingiva

Submandibular duct

Frenulum

Soft palate and uvula

Gingival‐labial fold

3/19/2014

4


Physical Exam of the Oral Cavity

• Extra‐oral exam

– Carefully exam the skin and symmetry of the head / neck

– Examination of lymphatic zones in the neck

– Palpation of parotid and submandibular glands

• Intra‐oral Exam *MUST REMOVE DENTURES!!!*

– Start with vestibule and upper / lower lips

– Buccal mucosa (including parotid ducts) and alveolar ridge

– Retromolar trigone

– Tongue – dorsal / ventral and lateral

– Floor or Mouth (incl. submandibular ducts) *BIMANUAL PALPATION*

– Hard / Soft Palate and uvula

– Palpate tonsillar fossae and base of tongue


Examination of the oral Cavity


Oral Cavity Exam cont.

Palpation of Left Base Of Tongue and Left tonsil

3/19/2014

5


Floor Of Mouth exam with bimanual palpation

Fowler 2014


Ulcerative Lesions of the Oral Cavity

Fowler 2014


Stomatitis – defined as inflammation of the mouth

with or without ulceration

• Oral Causes– Poor hygiene– Poor fitting dentures– Trauma (hot foods,

chemicals)– Ingested toxins

• Systemic Causes– Infection

• Viral• Fungal• Bacterial

– Drug reactions– Allergic reactions– Chemotherapy / Radiation– Nutritional deficiencies

Gingivostomatitis – when inflammation also affects the gingiva

Mucositis – not to be used interchangeably, as this refers to systemic mucosal pathology often as a result of chemo / RT

3/19/2014

6


Examples of Severe Stomatitis

Fowler 2014 Fowler 2014


Evaluating Stomatitis and Oral Ulcers

• Questions to Consider:– Acute or chronic process

– Single or multiple lesions

– Location of lesion(s)

– Duration of symptoms

– Associated pain or prodrome of pain?

– Systemic symptoms or mucocutaneous lesions elsewhere?

– Medications

– Timing of symptoms – i.e., triggers

Aphthous ulcer of hard palate

Fowler 2014


Systemic disease associated with oral ulcers

Preeti et al. J Oral Maxillofac Pathol. 2011 Sep‐Dec; 15(3): 252–256 – with permission

Fowler 2014

3/19/2014

7


Common Forms of Stomatitis

• Aphthous

• Viral– Herpetic

– Herpangina

– Zoster

• Fungal– Angular Chelitis

– Diffuse oral candidiasis (“Thrush”)


Recurrent Aphthous Stomatitis• A.k.a. Canker Sores• Affect 30‐35% of the population Equal age / gender distribution• Last 10‐30 days on average• Vary in size and shape

– Minor: 80% <1cm heal without scarring– Major: >1cm often associated with delayed healing and scarring

• Clinical features– White‐gray ulceration with erythematous halo, occasionally with

fibrinopurulent exudate– Buccal, labial, soft palate, FOM, lateral / ventral tongue

• Treatment aimed at pain reduction and promoting healing– Topical/ systemic corticosteroids (Kenalog in Orabase, prednisolone liquid)– Topical pain relief (2% viscous lidocaine)– Identifying systemic triggers (e.g., nutritional deficiency or systemic disease)


Treatment of Aphthous Stomatitis

Preeti et al. J Oral Maxillofac Pathol. 2011 Sep‐Dec; 15(3): 252–256 – with permission

3/19/2014

8


Many types of “Magic Mouthwash”

• 80ml each:– Nystatin 100,000U suspension– Prednisolone 15mg / 5ml

solution– Benadryl 12.5mg / 5ml elixir– Maalox– 2% viscous lidocaine– Distilled H2O

• Sig: 10ml swish, gargle, spit q 6hr as needed.

• BMX – variant with only lidocaine, Maalox and benadryl

• Other preparations may include: Sucralfate (coating agent), erythromycin or tetracycline

• Need to be aware of potential drug interactions / side effects


Aphthous Stomatitis• Work‐up for recurrent

ulcerative stomatitis may include– CBC– ESR / CRP– Iron studies– B12 titiers– SS‐A / SS‐B, autoimmune

studies– Glucose levels– Thyroid function– HSV titers– HIV


Oro‐labial Herpes Simplex (HSV‐1)

• DNA virus transmitted via saliva

• Up to 90% of adults are have antibodies to HSV‐1

• Increase prevalence with age• Associated with lower

socioeconomic status• Clinical: may have fever,

lymphadenopathy, fatigue with multiple painful mucosal ulcers

• May have prodrome of pain / burning

• Treatment with topical / systemic antivirals

Fowler 2014

3/19/2014

9


Oro‐labial HSV1

• Ulcerated vesicles often in groups

• Typically found on keratinized mucosa

– Lips

– Gingiva

– Hard palate


Treatment of Primary HSV‐1

Acyclovir 400 mg

Sig: 400mg PO TID x 7‐10 days

Famvir 250 mg

Sig: 250mg PO TID x 7‐10 days (recurrence = 1000mg PO x 1d)

Treat early; meds are no help after day 5 or 6.


Treatment of recurrent oro‐labial HSV‐1

Topical Therapy:

• Acyclovir 5%ointment (Zovirax)

Disp: 15 gm

Sig: Apply hourly at sxonset

• Pencyclovir 1% cream (Denavir) Disp: 2 gm

Sig: Apply every 2 hrs for 4 days

Systemic Therapy:

• RX: Valacyclovir 1 gm (Valtrex)

• RX: Famciclovir 500 mg (Famvir)

• RX: Acyclovir 400mg (Zovirax)

• Give multiple refills

3/19/2014

10


Herpangina

• Not as common as Herpetic lesions of the oral cavity

• Coxsackie A virus

• Typically multiple small ulcers on palate

• May have single larger ulcerations or bullae

• Hand‐Foot‐Mouth Disease if similar eruptions on hand and feet

• Usually self‐limited within 10 days


Herpes Zoster / Shingles

• May present as clusters of vesicular ulcers in a dermatomal‐like distribution

• Varizella‐Zoster virus (Human Herpes Virus HHV‐3)

• May have prodrome of burning or itching mimicking tooth pain

• Post‐herpetic neuralgia may linger for a month or more after resolution of oral ulcerations

• Antiviral tx within 48‐72 hours of treatment

• Vaccination booster over 60 yrs if not contraindicated


Oral Candidiasis

• Most common fungal infection of oral cavity. Detected in 55% of healthy individuals – Very young / elderly common

• Dependent on host immune status– DM, HIV, pregnancy, chemo /

RT– Pulmonary inhalers (eg Advair)

• Usually mild‐self limiting with recurrent infections necessitating underlying disease

• Treat with topical / systemic antifungal therapy

3/19/2014

11


Oral Candidiasis

Severe ulcerative candidiasis due to inhaled corticosteroid use

Diffuse candidiasis after extended antibiotic therapy for pneumonia



Angular Cheilitis / Candidiasis

• Oral candidal infection of the corner of the mouth often seen in denture wearers

• Can also be seen with s. aureusinfection, nutritional deficiency, contact dermatitis, Sjogrens, and Crohnsdisease

• Treatment usually directed topically at fungal source:

– Nystatin– Clotrimazole– Ketaconazole– Amphoteracin B

• Culture if failure to resolve• Search for systemic source


Median Rhomboid Glossitis• Candidal infection that

generally manifests as a denuded area of erythematous mucosa on the dorsal tongue usually anterior to the circumvallate papillae

• Often an incidental finding• Treatment if symptomatic is

with topical anti‐fungals– Nystatin– Clotrimazole

• Patients with pain, dysphagia or otalgia would warrant a biopsy

Fowler 2014

3/19/2014

12


Geographic Tongue• Benign inflammatory

condition of unknown etiology.

• Characterized by areas of atrophic erythematous mucosa

• Up to 15% of adults F>M 2:1

• Often asymptomatic and self‐limited

• Treatment directed at symptomatic relief and judicious use of topical corticosteroids


Geographic Tonguea.k.a. Benign Migratory Glossitis

Images courtesy of Jose Mercado, PA‐C 2011


Hairy Tongue• Results from failure of the

filiform papillae to desquamate • Precipitating factors:

– poor oral hygiene– Medications– xerostomia (head / neck RT,

Sjogrens)

• Roughly 0.5% of adult population

• Treatment is scraping or brushing of the tongue in order to denude the papillae

Fowler 2014

3/19/2014

13


Torus Mandibularis

• Dense bony outgrowth usually along the inner table of the mandible

• Most often near premolars• 90% bilateral• More common in Asians• Etiology not clearly understand• Can be susceptible for overlying

ulcers• Can be problematic with denture

fitting• Excision not often helpful, although

laser excision a possibility

Rocca et al. YAG Laser: A New Technical Approach to Remove Torus Palatinus and Torus Mandibularis. Case Rep Dent. June 2012; online.

Fowler 2014


Torus Palatinus

• Bony protrusion of the palate

• Usually less than 2cm, but can fluctuate in size

• Almost always midline• More common in Asians

/ Inuits– 20‐35% incidence in US

• 2x more common in females

• Denture fitting can be problematic and necessitate excision

Fowler 2014

Fowler 2014


Ankyloglossia “tongue tie”• Tethering of the anterior

tongue tip due to thickened frenulum

• Incidence ranges from <1% to 10%, depending on criteria for diagnosis*

• Associated with: – breast feeding difficulties (up

to 25%)** – speech / language difficulty– Tongue mobility issues

• Treatment: Frenotomy, speech

*Mueller DT, Callanan VP. Congenital malformations of the oral cavity. Otolaryngol Clin North Am. 2007;40(1):141.

**Messner, (2000). "Ankyloglossia: Incidence and associated feeding difficulties". Archives of otolaryngology—head & neck surgery 126 (1): 36–9

Fowler 2014

3/19/2014

14


Oral Cavity Fibroma• Most common “tumor” or

oral mucosa• Localized growth of fibrous

tissue in response to chronic trauma / irritation– Buccal mucosa, lateral tongue

• F>M 2:1 30‐50 years• Often painless /

asymptomatic• Local excision• May recur if persistent

trauma– i.e., poorly fitting dentures

Fowler 2014


Pyogenic granuloma(lobular capillary hemangioma)

• Benign hemangioma of the oral cavity characterized by histologic arrangement of vessels (lobular)

• All ages with = gender distribution

– Increase incidence in pregnancy

• Lips, gingiva, cheek and tongue

• Non‐painful but may bleed easily

• Conservative local excision curative

– Pregnancy‐induced tend to regress following delivery

Fowler 2014

Fowler 2014


Squamous Papilloma

• Wart‐like growth consisting of squamous mucosa in an exophytic pattern

• Most common benign “neoplasm” in the oral cavity

• Strong assoc with HPV 6‐11• Benign with little potential

to progress to malignancy• M>F (slight), W>AA (slight)

30‐50 yrs• Local excision or laser

usually curativeFowler 2014

3/19/2014

15


Squamous Papilloma – Soft Palate

Fowler 2014


Pharyngitis

• Defined as infection and or irritation of pharynx and tonsils

• Majority of cases are viral and self –limited, however most bacterial cases are due to Group A streptococci . Candida also a possibility

• Delayed use of antibiotics is encouraged.– Judicious use of antibiotic treatment reduces risk of complications and need for re‐evaluation / retreatment *

– Most cases will resolve spontaneously* Little P et al. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis. Jan 16 2014


Pharyngitis Pearls• Group A strep (GAS) most

common in 4‐7 yo age range– 14‐30% of pharyngitis in school‐

aged children*– Only 10% of adult pharyngitis is

GAS*

• Sudden onset more likely GAS• Cough generally NOT assoc with

GAS• Headache and vomiting are

more consistent with GAS than a viral etiology

• Recent orogenital contact may suggest gonococcal source

*Alcaide AL, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am. 2006

3/19/2014

16


CENTOR Criteria for GAS Pharyngitis

• 4 catergories worth 1 point each

– Fever– Absence of cough– Tonsillar exudate– Tender cervical adenopathy

• 0‐1 makes diagnosis likely, with 4 being likely

• Positive predictive values of 40% and 50% for scores of 3 and 4, respectively

• Validity is often conflicting

Roggen et al. Centor criteria in children in a paediatric emergency department: for what it is worth. BMJ Open.2013 Apr 22;3(4).

Fine et al. Large Scale Validation of the Centor and McIssac scores to predict group A streptococcus. Arch Intern Med. 2012 June 11, 172 (11): 847‐52.


Treatment of GAS Pharyngitis• Most cases resolve within 3‐

4 days without antibiotics, although prompt treatment may shorten the duration by 1 day.

• Antibiotics are mainly given to prevent acute rheumatic fever, despite an already low incidence in the US

• Supportive therapy and analgesics increase patient comfort levels– NSAIDS, acetaminophen,

steroids

• Antibiotic therapy:– Penicillin G– Penicillin VK– Amoxicillin– Cephalexin– Azithromycin– Erythromycin (resist

rates up to 30%)– Clindamycin

• Good for patients with multiple recurrent episodes / carriers

– Ceftriaxone

Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (Review). The Cochrane Collaboration. 2007;(1):1‐41.


Complications of Strep Pharyngitis

• Cervical Adenitis

• Otitis Media / Acute sinusitis

• Peritonsillar abscess

• Retropharyngeal abscess

• Rheumatic fever / rheumatic heart disease– <1 case per 1 million*

• Post‐streptococcal glomerulonephritis

*Centers for Disease Control and Prevention. Summary of notifiable diseases, United States, 1997. MMWR Morb Mortal Wkly Rep. Nov 20 1998;46(54):ii‐vii, 3‐87

R peritonsillar abscess w/ displaced tonsil

CT demonstrating R PTA fluid collection (arrow)

3/19/2014

17

Mononucleosis Pharyngitis

• Epstein‐Barr infection

• Pharyngitis is most common finding in an otherwise syndromic entity

• 45 cases per 100,000

• No sex or ethnic predilection

• Highest incidence in 15‐25 yo

• Splenomegaly with rupture more often cause of fatal events, albeit rare.

• Prodrome of fatigue, low‐grade fever, malaise and myalgias over 1‐2 weeks are common

• Pharyngeal and tonsil symptoms often severe and exudative

• Lymphadenopathy in almost all cases, anterior and posterior

• May have rash or jaundice


Infectious Mononucleosis

Large swollen tonsils with significant edema and exudate

Large posterior triangle node in a Monospot positive 12 yo with 2 weeks of fatigue and adenopathy

Fowler 2014

Diagnosis and Treatment of Mono

• Work‐up may include Monospot test for diagnosis– 85% sensitive

– May have false + in other viral illness (kids especially)

• Elevated WBC may be useful– Moderate increase in total

WBC, with significant increase in lymphocytes on differential (>50%)

– Usually > 10% atypical lymphs

• LFTs are often elevated

• Treatment– Supportive

• Analgesics

• Antipyretics

• Limit physical contact if evidence of splenomegaly

– Corticosteroids• Use with caution

• Some limited data to suggest improved recovery time in mono pharyngitis

Omori and Dyne. Mononucleosis in Emergency Medicine. Emedicine May 2012.

Aberdein and Singer. Clinical Review: A systematic review of corticosteroid use in infections. Crit Care. 2006; 10(1):203 pub online Nov 2005.

3/19/2014

18


Sebaceous Tonsillitis and Tonsilloliths

**Darrow DH, Siemens C (August 2002). "Indications for tonsillectomy and adenoidectomy". Laryngoscope 112 (8 Pt 2 Suppl 100): 6–10

• Frequently encountered

• High association of halitosis*

• Frequent source of discomfort and occasionally chronic tonsillitis

• Treatment:– Irrigation

– Oral lavage

– Laser

– Tonsillectomy **

*Rio AC et al. Relationship betweenthe presence of tonsilloliths and halitosis in chronic caseous tonsillitis. Br J Dent. 2008 Jan 26; 204(2)

Fowler 2014


Sebaceous tonsillitis / Tonsilloliths

Fowler 2014Fowler 2014


Pre‐malignant Conditions of the Oral Cavity

2 main categories:‐Generalized state with an

associated with signs of increased risk of oral cavity Ca *

• Lichen planus• Discoid lupus erythematosus• Submucosal fibrosis

‐Morphologically altered tissue in which oral cavity cancer is more likely to occur

• Leukoplakia• Erythroplakia

* Warnakulasuriya S et al.. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral PatholMed. Nov 2007;36(10):575‐80

Fowler 2014

3/19/2014

19


Oral Lichen Planus

• Chronic inflammatory state • “frond‐like” white plaques

– Most often bilateral– Buccal mucosa, lateral tongue,

gingiva

• +/‐ erythema / ulceration• T‐cell mediated autoimmune

disease *• 1‐2% of population**• F =M Usually > age 40• No racial predilection

*Sugerman P, et al. The pathogenesis of oral lichen planus. CritRev Oral Biol Med. 2002;13(4):350‐65

**Axéll T, Rundquist L. Oral lichen planus‐‐a demographic study. Community Dent Oral Epidemiol. Feb 1987;15(1):52‐6

Fowler 2014


Oral Lichen Planus

• Roughly 2/3 will have symptoms• Associated with medication use

– NSAIDs, Beta‐B, ACE, anti‐malarials

• Association w/ sensitivity to dental amalgam (mercury)*

– Patch testing

• Up to a 5% incidence of malignant transformation**

• High incidence of systemic mucosal involvement

– female genital > male

* Koch P, Bahmer FA. Oral lesions and symptoms related to metals used in dental restorations: a clinical, allergological, and histologic study. J Am Acad Dermatol. Sep 1999;41(3 Pt 1):422‐30

**Silverman S Jr. Oral lichen planus: a potentially premalignant lesion. J Oral MaxillofacSurg. Nov 2000;58(11):1286‐8


Oral Lichen Planus• Dif Dx:

– Autoimmune / bullous diseases affecting oral mucosa

– Pre‐malignant leukoplakia / erythroplakia

– SCCa

• Work‐up:

– Biopsy most useful

• Treatment

– Topical steroids (kenalog in Orabase)

– Topical tacrolimus

– Systemic corticosteroids (selective)

– Hydrochloroquine, azathioprine, dapsone, retenoids may have potential

*N Lavnya, et al. Oral lichen planus: An update on pathogenesis and treatments. J Oral Maxillofac Pathol. 2011 May‐Aug; 15(2): 127–132

3/19/2014

20


Oral Leukoplakia• General descriptive term used to

describe a white patch on the oral mucosa of uncertain etiology, that cannot be characterized as any other definable lesion.*

• Increased risk of transformation to Squamous cell carcinoma (SCCa), albeit low.– Annual malignant transformation rate

rarely exceeds 1%*

• Etiology:– Tobacco, ETOH, trauma, inflammation– HIV / AIDS (hairy leukoplakia)

Left RMT leukoplakia with central ulcerative changes secondary to trauma (dental filling)* Lodi G, et al. Interventions for treating oral leukoplakia.

Cochrane Database Syst Rev. 2004;(3)

Fowler 2014


Leukoplakia

Homogeneous R buccal plaque w/ h.o chewing tobacco use

Irregular R buccal plaque c/w dental trauma


Oral Erythroplakia• Red patch on the oral

mucosa that cannot be attributed to any other definable pathology

• Floor of mouth, tongue and soft palate most common

• Usually > 50 yrs M>F 3:1• EtOH and tobacco =

synergistic • 40%‐85% incidence of

sever dysplasia, Carcinoma in‐situ and SCCa in biopsy specimens*

* Hashibe M et al. Chewing tobacco, alcohol and the risk of erythroplakia. Cancer Epidemiol Biomarkers Prev. 2000 Jul;9(7):639‐45

* Shafer WG, Waldron CA. Erythroplakia of the oral cavity. Cancer. 1975Sep;36(3):1021‐8.

Fowler 2014

Left buccal erythro‐leukoplakia in a 65 yo wm w/ 50+ pack years

3/19/2014

21

Squamous Cell Carcinoma

• Accounts for ~90% of all oral cavity malignancy

• Older men AA > W

• Lip and lateral tongue most common

• Tobacco, EtOH, betel nut, radiation, diet

• HPV – 16 (oropharyngeal)*

• Presentation can range from a painless ulcer or lump to cervical metastases

• Tobacco = 20x increase

• Alcohol = 5x increase

• Alcohol + tobacco = 50x increase!

*Campisi G, et al. Human papillomavirus: its identity and controversial role in oral oncogenesis, premalignant and malignant lesions (review). Int J Oncol. Apr 2007;30(4):813‐23


Squamous Cell Carcinoma of the Lip




SCCA of the Tongue


3/19/2014

22


SCCA of the Palate

81 yo WF with 35# weight loss and mouth pain. Tx for thrush x 3 in 4 month period. ***Must remove dentures for exam!!

26 yo WM with no social risk factors and 6 weeks of severe right mouth pain. Pancytopenic on work‐up. Work up for Fanconi anemia

Fowler 2014

Fowler 2014


PET‐CT of 81 yo WF with left palate SCCa (previous slide)

Fowler 2014


Alveolar Ridge SCCa

At presentation Post‐radiation therapy


3/19/2014

23


Floor of Mouth SCCa

Fowler 2014


Left Buccal Mucosa SCCa

Fowler 2014


Oral Cavity SCCa

• Work‐up– Biopsy or exfoliative

cytology• FNA for neck masses

– CT, MRI, PET‐CT

– Pan‐endoscopy to r/o second primary

– CXR

– Bone scan in select cases

– Labs – LFTs, CBC, Ca++

• Treatment Options:

• Surgery– Primary or salvage

– Conservative vs radical

• Radiation therapy

• Chemotherapy

• Brachytherapy – rare w/ improvements in IMRT

• Gene Therapy / targeted therapy – new and on the horizon

3/19/2014

24


Surgical Specimens ‐ SCCa

SCCa of anterior maxillar gingival‐labial sulcus and subsequent anterior maxillectomy




Left primary palate SCCa Left orbital exenteration and hemimaxillectomy

Fowler 2014

Fowler 2014



R lateral hemiglossectomyR hemimandibulectomy for RMT SCCa (arrow)

Fowler 2014

Fowler 2014

3/19/2014

25


Questions?

Fowler 2014

Red arrow = Uvula

Green arrow = frenulum


References

• www.cancer.gov• Head and Neck Pathology: A vol of Foundations in Diagnostic Pathology. Lester D.R Thomson MD, ed. Elsevier. 2006

• www.entusa.com Kevin Kavanagh MD• www.emedicine.Medscape.com/article/1079920‐overview#aw2aab6b3 Viral Infections of the Mouth. Gordon et al.

• Tyldesley W. Color Atlas of Oral Medicine‐ 2nd ed. Moseby‐Wolfe. 1994

lesions of the oral cavity - entpa.org - common oral cavity and throat... · anatomy of the tongue....

Documents