OTO-ENT • OTORHINOLARYNGOLOGY

SHIFT
ORAL CAVITY DISEASES
1
Maria Karen Capuz, MD March 8, 2023 LEC #6a
● Hypoglossal Nerve (CN XII)
LECTURE OUTLINE ○ Tongue mobility, whether anterior or posterior tongue, is
I. Oral Cavity V. Masses and neoplasia innervated by CN XII
A. Oral vestibule A. Palatal or mandibular tori ○ In hypoglossal nerve palsy, the tongue will deviate towards the
B. Lips and cheeks B. Pyogenic granuloma affected side
C. Muscles of mastication C. Mucocele
II. Approach to the Diagnosis of D. Papilloma
Oral Cavity Lesions E. Hemangioma
III. Superficial Oral Lesions F. Minor salivary gland tumors
A. Oral candidiasis G. Oral cavity malignancy
B. Herpangina VI. Oral manifestations of systemic
C. Herpes labialis diseases
D. Recurrent aphthous A. Atrophic glossitis
stomatitis B. Koplik’s spots
E. Lichen planus VII. References Figure 2. Hypoglossal nerve palsy, lesion is on the left side.
IV. Premalignant lesions (oral VIII. Review Questions
potentially malignant disorders) IX. Freedom Wall ● Composed of various muscular systems
A. Leukoplakia ● Occupies much of the oral cavity
B. Erythroplakia ● Continuous anterolaterally with the floor of the mouth

👉
important/must know
📕
book
📑
previous trans
🩺
lecturer’s key points
● Mucosa of the tongue differs from the rest of the intraoral mucosa by
the presence of papillae
○ Project from the surface of the tongue

I. ORAL CAVITY
●
👉
○ Give the characteristic roughness of the tongue
Four main types: filiform, fungiform, vallate, and foliate
Taste Buds
● Divided into distinct sites that:
○ Allow formulation of treatment modalities and prognosis in a ○ Microscopic organs for taste reception
more defined fashion ○ Present in:

●
○ Enables a more accurate statistical collection and evaluation
7 subsites
○
👉■ Vallate, foliate, and fungiform (less) papillae
Note: NONE in the filiform papillae
Other sites: Soft palate, epiglottis, nodes on the posterior
1. Lips
2. Alveolar ridge tongue, and posterior wall of the oropharynx
3. Buccal mucosa
4. Oral tongue (anterior 2/3)
5. Floor of the mouth
■ C-shaped space beneath the tongue, behind the alveolar
ridge
6. Hard palate
7. Retromolar trigone
● Soft palate, uvula, palatine tonsils/fossal pillar and tongue base are
not part of the oral cavity → Part of the oropharynx already

Figure 1.The oral cavity.

● Boundaries of the Oral Cavity:

○ Anterolateral: Alveolar ridge and teeth Figure 3. Upper pic: body and base of the tongue, Lower pic: histology of the
○ Superior: Hard and soft palate tongue.
○ Posterior: Faucial isthmus
Retrieved from Probst Basic Otorhinolaryngology

📕
1. TONGUE AND ORAL FLOOR
A. ORAL VESTIBULE
Table 1. Innervation of the Tongue ● Boundaries:
Anterior 2/3 Posterior 1/3 ○ External: Lips and cheeks
Lingual n. (CN V3) ○ Internal: Alveolar process and teeth
Glossopharyngeal n. (CN IX) ● When the teeth are in occlusion, the oral vestibule communicates
Sensory touch, pain,
to nucleus solitarius with the oral cavity via a space behind the last molar
temperature
Chorda Tympani Glossopharyngeal n. ● The oral cavity opens → pharynx at the faucial isthmus
Taste
(CN VII) (CN IX)
Motor Hypoglossal (XII) Hypoglossal (XII)

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 B. LIPS AND CHEEKS 📕
● Morphologic framework is composed of the mimetic muscles
● Mucosal lining: Nonkeratinized squamous epithelium

1. LIPS
● Longer upper lip, shorter lower lip
○ Connected to each other by the labial commissures at the
corners of the mouth
● Separated from the cheek by the nasolabial fold
○ Oblique sulcus that runs laterally and inferiorly from the nasal
alae
● Contains seromucous salivary glands
○ Drain into the oral vestibuli
● Orbicularis oris: Forms the muscular foundations of the lips
Figure 5. Approximate time schedule for teeth eruption
● Saliva production (mL): 1,500mL per day
○ 99.5% water, 0.5% organic/inorganic solids
○ Electrolyte composition (mEq/L):
■ Na: 10
■ K: 26

01. 👉 INFLAMMATORY LESIONS OF THE LIP ■

■
Cl: 10
HCO3: 30
● Blood supply of the lips: superior and inferior labial arteries
○ Origin: facial artery The following information is obtained from the quiz contest of the previous
● Venous drainage: facial vein batch.
○ Communicates with the orbital veins via the angular vein (above
the upper lip) II. APPROACH TO DIAGNOSIS OF ORAL CAVITY LESIONS
● Inflammatory lesions (e.g. furuncles)
○ Infection can spread → cranial cavity via connections between
the orbital veins and the cavernous plexus (may result in A. HISTORY
complications) ● Onset
● Duration
2. CHEEKS ● Triggering (aggravating) factors
● Personal history: To know the presence of risk factors, Give a clue
● Form the lateral boundaries of the oral vestibule
to potential causes of the oral cavity lesion and impact management
● Contain small salivary glands in their mucosa
○ Tobacco and alcohol use
● Buccinator: Mimetic muscle forming the muscular framework of the
○ Oral hygiene
cheek
○ Sexual history
○ Excretory duct of the parotid gland runs through the buccinator
○ Exposure to chemicals
muscle and opens → mucosa of the cheek opposite the upper
○ Diet
2nd molar
● Past medical history
● Bichat fat pad (buccal fat pad)
○ Immunocompromised status
○ Between buccinator and the masseter
○ Systemic diseases
○ Smoothens the cheek contour by filling the depression at the
○ Radiotherapy in the head and neck (Recent and past)
anterior border of the masseter
○ Chemotherapy

C. MUSCLES OF MASTICATION 📕 ●
○ Medications
Accompanying signs and symptoms
● Four major muscles of mastication: ○ Ex: skin lesions, swellings, or masses in other parts of the body
○ Temporalis other than the oral cavity as these may be manifestations of a
○ Masseter systemic disease
■ Posterior part of the cheek
○ Lateral pterygoid B. PHYSICAL EXAM
○ Medial pterygoid
● Perform a complete ENT physical examination
● Main innervation: Mandibular branch of the Trigeminal N. (V3)
● Inspect oral cavity and oropharyngeal area
● Note clinical characteristics of the oral cavity lesion such as:
○ Size (in cm)
○ Location (lips, gingiva, tongue, oropharynx)
■ How these lesions are spread out in the oral cavity
○ Surface morphology (e.g. whitish plaque, fungating)
○ Extent of induration especially in suspicious lesions
■ Induration: Soft tissue on bimanual palpation
○ Color (whitish, erythematous, etc.)
○ Pain
○ Other lesions in elsewhere in the body
● Bimanual Palpation
○ Palpation will help assess the extent, consistency, and depth of
suspicious oral cavity lesions

Figure 4. Muscles of mastication. (L-R, top to bottom): Temporalis, Masseter,

Lateral Pterygoid, Medial Pterygoid

📑 ADDITIONAL
●
INFORMATION ON THE ORAL CAVITY
Average # of permanent adult teeth: 32

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Figure 5. Proper Technique in Examining the Oral Cavity.

● Examiner’s gloved hand grasps the oral cavity and fingers are used
to palpate the posterior aspect of the tongue. Topical anesthesia may
👉 Figure
●
6. Various presentations of oral candidiasis.
Pseudomembranous
be applied to prevent gagging. Important to delineate extent of the
○ Adherent white plaques that may be wiped off, leaves a raw
lesion. (Upper and lower left Image)
surface
● Examination including the lips, gingival, buccal gutter, buccal mucosa
● Median Rhomboid Glossitis
and opening of the Stensen’s duct. Ask the patient to lift the tongue
○ Red macular lesions, often with burning sensation
to see the floor of the mouth. (Right Image)
● Perleche (angular cheilitis)
○ Erythematous, scaling fissures at the corners of the mouth
III. SUPERFICIAL ORAL LESIONS
B. HERPANGINA
A. ORAL CANDIDIASIS ● “Vesicular pharyngitis”, “Ulcerative pharyngitis”
● Case: A 50 year old male came to the clinic with whitish firmly ● Caused by Group A Coxsackievirus
adherent plaques that can be scraped from the tongue and buccal ● Common in young, but also adults
mucosa leaving erythematous bleeding surfaces. ● Clinical Manifestation:
○ Fever, malaise, headache, muscle pain
1. DETAILS ELICITED TO DETERMINE PREDISPOSING FACTORS ● Vesicles in the oral cavity which rupture in a few days, leaving behind
shallow ulcerations
● Systemic Conditions
● Generally resolves in 14 days without complications
○ Endocrine disorders (DM), HIV infection, leukemia, malnutrition,
● Treatment:
reduced immunity based on age (but patient is just 50 y/0)
○ Symptomatic
● Factors leading to local overgrowth
○ Anti-inflammatory agents
○ Use of dentures
○ Mouth rinses
○ Use of a steroid inhaler, xerostomia
○ May add antibiotics if there is superimposed bacterial infection
● Exposures
○ Previous/recent radiation therapy, systemic chemotherapy, use
of broad-spectrum antibiotics or corticosteroids

01. ORAL CANDIDIASIS

● “Oral thrush”
● Caused by Candida sp.
● Risk factor: immunosuppression
● Diagnosis:
○ Oral exfoliative cytology → KOH stain
● Treatment:
○ Topical antifungals or systemic antifungals (e.g. nystatin,
fluconazole, ketoconazole [Nizoral], itraconazole [Sporanox])

👉 Figure 7. Physical exam findings of Herpangina.

● Lesions will appear as bullous eruptions surrounded by a red

● 👉
halo on the oral mucosa
Typically located at the anterior faucial pillars, uvula, and
palatine tonsils (more at the back of the throat)

C. HERPES LABIALIS
● Case: 6 y/o M, presenting with clustered vesicles and ulcers in
vermilion border and gingiva, noted for the past 2 days, with malaise
and low-grade fever

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Figure 8. Case of Herpes Labialis. Ask for other activities the patient is
engaged in before onset, family members with the same lesions.

1. POSSIBLE ETIOLOGY AND MANAGEMENT

● Herpes labialis, Herpetic gingivostomatitis or Cold sores
●
●
Caused by Herpes simplex virus Type 1
Usually young age
👉 Figure 10. Major recurrent aphthous ulcer (top), minor recurrent aphthous
ulcer (bottom.)
● Clinical Manifestation:
○ Asymptomatic or with cervical lymphadenopathy, fever, chills, ● Clinical Variants
anorexia
● Trigger:
○ Exposure to cold, sunlight, fatigue, stress
MAJOR APHTHAE
👉Table 2. Types of canker sores.
MINOR APHTHAE
●
○ 👉
Diagnosis:
Tzanck smears - shows multinucleated giant cells (not
necessarily done)
Larger (>10 mm)
Deeper ulcerations
Small (2-5 mm)
More superficial
● Treatment:
○ Immunocompetent patients do not usually need treatment Located in the anterior 1/3 of the oral
○ May give topical antivirals (e.g., acyclovir [Zovirax], famciclovir cavity
[Famvir]) ● Compared to Herpangina
■ Most effective if initiated during prodrome or as which are lesions located
prophylaxis more in the posterior part of
the oral cavity or in the
oropharynx
● In RAU, lesions are located
more anteriorly but inside
the oral cavity compared to
the Herpetic
Gingivostomatitis where
lesions are found on the
vermillion border of the lips

Heal with scarring in 2-4 weeks Heal without scarring in 1 week

E. LICHEN PLANUS
● Chronic waxing and waning inflammatory condition
● Predominantly > 40 y/o
● Etiology suggests immune-mediated causes, medications
(anti-malarial/anti-TB drugs, gold salts), viral hepatitis A/B, stress
○ Psychosomatic mechanisms are also implicated (i.e. after
👉 Figure 9. Herpes Labialis that manifests as clustered vesicles along severe emotional trauma or stressful situations).
vermillion border with shallow ulcers and crusting typically always involves
the gingiva. 👉
RETICULAR
Table 3. Types of lichen planus.
EROSIVE
● Bilateral, white, lacy striae ● Erythematous and ulcerated
D. RECURRENT APHTHOUS STOMATITIS
gingiva with peripheral radiating
● “Canker sores” striae
● Etiology is unknown (associated with viruses, vitamin deficiency), ● Asymptomatic

👉
●
associated with precipitating factors
Most common inflammatory condition in oral cavity
Occur in second and third decades
● Precipitating factors:
○ Minor trauma, hormonal changes, GI disease, “emotional
stress”
○ iron, folic-acid or vitamin B12 deficiency
● Clinical Manifestation:
○ Recurring painful, solitary or multiple ulcers
○ Covered by white-to-yellow pseudomembrane, surrounded by
erythematous halo involving nonkeratinizing mucosa (e.g.,
labial, buccal, ventral tongue)
● Treatment:
○ Symptomatic (mouthwash, gurgles, lidocaine)
○ Vitamin B12
○ Topical steroid gel

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 Figure 12. Oral hairy leukoplakia.

● Etiology: Epstein-Barr virus (EBV) infection | G

● Associated with HIV or immunocompromised state
● Treatment
○ Antivirals: Acyclovir (Zovirax) or Ganciclovir

B. ERYTHROPLAKIA
● Similar lesion to leukoplakia, EXCEPT that it is RED in appearance
Figure 11. Lichen planus manifestation. Top: Recurrent; Bottom: Erosive. ● Red area: Level with mucosal surface or slightly depressed
● Marked epithelial dysplasia
● Clinical Manifestations: ○ Indicative of a high malignant potential (50%)
○ Affects the skin and mucosae concomitantly
○ Typically appear as reticular white markings on the mucosa of
the cheek and tongue (Wickham’s phenomenon)
■ Differentiate from leukoplakia
○ Painful ulcerations may occur in erosive LP
■ Differentiate from pemphigus vulgaris, SLE, or syphilis
● Diagnosis:
○ Classic presentations clinically recognizable BUT lesions that
do not exhibit classic features may require biopsy
● Treatment:
○ Asymptomatic: do not require treatment
○ Symptomatic (there’s a bit of discomfort or pain): topical
corticosteroid gels (fluocinonide), corticosteroids, and mouth
rinses
■ Aromatic retinoid and isotretinoin combined with steroids – Figure 13. Erythroplakia.
recommended for mucosal lesions
■ Oral rinses with anti-inflammatory and local anesthetic ● Treatment
solutions – for very painful, erosive lesions ○ Tissue biopsy to rule out malignancy
■ Especially for non-healing erythroplakia
✓ NOTE: may be associated with an increased risk of oral cancer. Periodic ○ Microscopic analysis recommended.
follow-up is advised.
V. MASSES AND NEOPLASIA
IV. PREMALIGNANT LESIONS
(ORAL POTENTIALLY MALIGNANT DISORDERS [OPMD])
A. PALATAL OR MANDIBULAR TORI

A. LEUKOPLAKIA ● A lesion most commonly seen in the oral cavity

● Aka Torus palatinus, Torus mandibularis
● Most commonly encountered lesion ● Bony exostoses seen on palate or medial aspect of the anterior
● Most common precancerous lesion of the lips and oral cavity mandible
● White patch or plaque that cannot be characterized clinically or
pathologically as any other disease (WHO, 1978, 2001)
● Clinical manifestations
○ White adherent patch or plaque, cannot be wiped off
○ Strongly associated with tobacco and alcohol use
■ Higher malignant potential when occurring in never
smokers
■ Inverted smoking, betel nut chewing
● Treatment
○ Close observation
○ Tissue biopsy to rule out malignancy
■ d/t its resemblance to a carcinoma in situ and invasive Figure 14. Left: Torus palatinus; Right: Torus mandibularis.
carcinoma, and their potential for malignant degeneration.
● Benign, non-neoplastic, arising from the cortical plate
ORAL HAIRY LEUKOPLAKIA ● Considered a developmental anomaly appearing in adulthood
● Unilateral or bilateral ○ Usually px will go to the dentist first or they will have trouble
○ Lateral tongue location differentiates this condition from hairy with their fitting of dentures or may cause problems when eating
tongue ● Treatment
○ Removal require only if:
■ It interferes with function or denture fabrication
■ It is subject to recurrent traumatic surface ulceration

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 B. PYOGENIC GRANULOMA
● Rapidly growing lesion
○ Develops as a response to local irritation, trauma, or increased
hormone level (pregnancy)
■ Traumatic use of toothpick, toothbrush

Figure 17. Papilloma.

E. HEMANGIOMA 📑
● Benign, self-involuting tumor of the endothelial cells that line the
blood vessels
Figure 15. Pyogenic granuloma. ● Clinical manifestations:
○ Usually appears in the first week of life, grows most rapidly over
● Clinical manifestations first 6 months
○ Erythematous ○ Growth is complete and involution has commenced by 12 mos
○ Non-painful ○ Half of all infantile hemangiomas have:
○ Smooth or lobulated ■ Completed involution by age 5
○ Bleeds easily when touched ■ 70% by age 7
● Sites: gingiva, lip, tongue, buccal mucosa ■ Most by age 1
● Treatment: ● Treatment:
○ Surgical excision ○ Conventional surgical treatment or laser surgery
■ Recurrence uncommon ■ Advised only if the tumor persists beyond period of
○ Observation (in pregnant women) involution, provided the patient does not present

○
■ Resolves after birth
Biopsy may be done for histological analysis, if unsure of the
etiology.
👉
symptoms: Dyspnea, dysphagia
Symptomatic: Prompt early surgical intervention

C. MUCOCELE
● Area of mucin spillage in soft tissue resulting from the rupture of a
salivary gland duct
● Associated with local trauma (e.g. patients with braces and biting)
● Clinical manifestations:
○ Recurrent swelling with periodic rupture
○ Bluish, dome-shaped, fluctuant mucosal swelling most
commonly located at the lower labial mucosa
● Treatment:
○ Surgical excision, including the removal of adjacent minor
salivary glands

Figure 18. Hemangioma.

F. MINOR SALIVARY GLAND TUMORS

● Clinical manifestations:
○ May present as painless, smooth, firm mass in any part of the

🩺 oral cavity
Most common in the hard palate due to the numerous minor
salivary glands in the area
● Biopsy is performed to rule out malignancy
● Treatment: surgical excision
Figure 16. Mucocele.

D. PAPILLOMA

🩺
● Associated with human papilloma virus (HPV) 6 or 11 infection
If suspected, ask the sexual history because this is a sexually
transmitted disease
● Clinical manifestations:
○ Single, isolated pedunculated lesion with finger-like projections
● Treatment:
○ Surgical excision or laser ablation

Figure 19. Minor salivary gland tumor.

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 G. ORAL CAVITY MALIGNANCY

1. STAGING AND DIAGNOSIS

● 2.9% of all new cancer cases (National Cancer Institute SEER,

🩺
●

🩺
2020)
Most common type: Squamous Cell Carcinoma (SCCA)

🩺 Most commonly affect lower lip (90%)

Most common malignant type according to histologic lining:
non-keratinizing stratified squamous epithelium
● Staging: assess the extent of tumor spread
○ Standardized to TMN System
■ Tumor (size, extent, adjacent structures and depth)
■ Node (size, number, laterality)
■ Metastasis (distant spread)
● Diagnosis: Figure 21. Atrophic Glossitis. Papillae of the tongue are atrophied. Tongue
○ H&P (History & Physical Exam) seems to be hyperemic.
○ Fiberoptic exam as indicated
○ Gold standard to confirm diagnosis: histopathology B. KOPLIK’S SPOTS
○
🩺CT, MRI as appropriate
Best modality to assess extent: MRI with Gadolinium
contrast
●
●
Associated with Rubeola/Measles
Clinical manifestations
● Multidisciplinary consultation ○ High fever (40c)
○ e.g. nutrition specialists, oncologist, radio-oncologist, dental, ○ Classic 3Cs: conjunctivitis, cough, coryza
medical ○ Appearance of erythematous maculopapular rash from head
○ Prepare the patient of the disease and treatment complications going down 2 weeks after exposure
● Dental, prosthodontic evaluation ○ Oral lesion (Koplik’s spot): pale round spots with erythematous
● Nutrition, speech, and swallowing evaluation/therapy base seen on buccal and lingual mucosa
● Smoking cessation (and other risk factors) and psychological
counseling

2. MANAGEMENT
● Goal: To maximize survival with preservation of form and function →
surgical procedure planned to remove tumor with adequate margins
and reconstructive plan to restore form and function
● Prognosis:
○ Early stage (Stage I and II)
■ Good prognosis
■ Single modality treatment: surgery or radiotherapy alone
– Surgery is preferred
○ Late stage (Stage III and IV)
■ Poorer prognosis Figure 22. Koplik’s Spots
●

●
Multimodality treatment: Surgery and radiotherapy and/or
chemotherapy
Develop prospective surveillance plan
👉 IN●SUMMARY
Good history
● Provide comprehensive rehabilitation: dental, nutrition, health and ○ Temporal evolution of lesions
behavior modification ○ Possible exposure/triggers
○ Accompanying symptoms
○ Pertinent past/personal/medical history
● Physical examination
○ Characteristic appearance
○ Location of lesions
○ Extent
○ Other lesions in other parts of the body
● Ancillary as necessary
● Rational management

VII. REFERENCES
● Batch 2023 Oral cavity/Oropharyngeal diseases Transcript
● Capuz, K.C., (2022). Oral cavity diseases [Recorded lecture
presentation]. Manila, Philippines: Faculty of Medicine and Surgery,
Figure 20. Example of reconstruction of lip defect using local flap technique. University of Santo Tomas, DEPARTMENT OF
OTORHINOLARYNGOLOGY
VI. ORAL MANIFESTATIONS OF SYSTEMIC DISEASES

A. ATROPHIC GLOSSITIS
● aka Hunter’s glossitis
● Associated with diseases such as:
○ Pernicious anemia (Vit B12 deficiency)
○ Iron Deficiency anemia
○ Other nutritional deficiencies: folic acid, niacin, riboflavin (Vit B9,
B3, B2, respectively)
● Atrophic inflammatory condition of the tongue base
● Clinical manifestations:
○ Common symptoms: burning of the tongue, dry mouth,
altered sense of taste
○ Tongue presents a typical smooth, shiny appearance with
partial atrophy of the filiform papillae

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 VIII. REVIEW QUESTIONS
1. Epstein Barr virus infection is associated with which of the ff? :
a. Oral hairy leukoplakia
b. Lichen planus
c. Atrophic glossitis
d. Papilloma
2. The most common type of malignancy in the oral cavity is?
a. Adenocarcinoma
b. Squamous cell carcinoma
c. Lymphoma
d. Sarcoma
3. What is the management of salivary gland mucocele
a. Aspiration
b. Excision
c. Curettage
d. Irrigation and drainage
4. Which of the following is a form of fungal infection in the oral cavity?
a. Median rhomboid glossitis
b. Herpangina
c. Atrophic glossitis
d. Erosive lichen planus
5. Sensation of taste at the tongue base is served by which nerve?
a. Lingual
b. Chorda tympani
c. Glossopharyngeal
d. Hypoglossal
A, B, B, A, C

IX. FREEDOM WALL

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