ORAL CAVITY LESIONS

Frederick Mars Untalan, MD

mouth ulcer
y y y

y

y

Latin ulcus and from Greek " " - elkos, "wound"[ American English, canker sore open sore inside the mouth, or rarely a break in the mucous membrane or the epithelium on the lips or surrounding the mouth. Causes: physical abrasion, acidic fruit, infection, other medical conditions, medications, and cancerous and nonspecific processes. Two common types :
aphthous ulcers cold sores or fever blisters

Epidemiology

Epidemiological studies show an average prevalence between 15% and 30%. y women > men and < 45 years. y >16-25 year olds, and <over 55. y The frequency of mouth ulcers varies from fewer than 4 episodes per year (85% of all cases) to more than one episode per month (10% of all cases) including people suffering from continuous RAS
y

ORAL CAVITY
LIPS y TEETH y GINGIVA y PALATE y TONGUE y ORAL MUCOUS MEMBRANES y ORAL LYMPHOID TISSUES
y

Acute: small, recent onset, short duration, recurrent
Trauma y Recurrent Aphthous Stomatitis y Behcet·s y Herpesvirus Infection y Herpangina
y

Trauma:
y

Cheek Biting

Trauma:
y

Ill-Fitting dentures

Trauma:
y

Chemical Burns

Trauma:
y

Abrasions from Teeth

Recurrent Aphthous Stomatitis(RAS)
Most common ulcerative lesion of oral cavity y Recurrent, painful ulcers y Confined to soft mucosa y Subdivided into three types:
y

Minor aphthae Major aphthae Herpetiform aphthae

Recurrent Aphthous Stomatitis(RAS)
y

Minor aphthae:
Less than 1 cm Heal completely in 7-10 days without scarring Painful Prodromal stage Shallow and round to oval Gray to yellow membrane Clusters of up to 5 ulcers Steroids

Recurrent Aphthous Stomatitis (RAS)
y

Minor apthae

Recurrent Aphthous Stomatitis (RAS)
Major Aphthae
Uncommon Irregular, deep ulcers 1-3 cm in size Raised borders Heal in 4-6 weeks Extensive scarring and distortion BIOPSY!! Steroids

y

Recurrent Aphthous Stomatitis (RAS)
y

Major apthae

Major aphthous ulcer

Recurrent Aphthous Stomatitis (RAS)
y

Herpetiform Aphthae
Uncommon Crops of up to 150 very small (<3mm) ulcers Heal completely in 7-10 days COMPLETELY UNRELATED TO HERPESVIRUS

Recurrent Aphthous Stomatitis (RAS)
y

Herpetiform aphthae

Behcet·s
y

Symptom complex of:
Recurrent aphthous ulcers of the mouth Painful genital ulcers Uveitis or conjuctivitis

Behcet·s
y

y

y

Affects persons of Mediterranean, Middle Eastern, or Japanese decent Easily confused with StevensJohnson syndrome or Reiter·s disease Need referral for systemic treatment

Acute Ulcerative
Behcet·s Syndrome recurrent oral and genital ulcers arthritis inflammatory disease of eyes and GI tract.

Acute Ulcerative
y

Reiter·s Syndrome y mainly young men 20 to 30 y Classis triad
Conjunctivitis Arthritis urethritis.

Oral lesions range from erythema to papules to ulcerations involving the buccal mucosa, gingiva, and lips. y Lesions on the tongue resemble geographic tongue
y

Herpesvirus Infection
y

HSV-1 and/or HSV-2
Primary Infection Secondary Infection

y

Varicella zoster virus (HHV-3)

Herpesvirus Infection
y

Primary Infection
Herpetic gingivostomatitis Younger patients Often asymptomatic May be associated with fever, chills, malaise Vesicles-ulcers-crusting Anywhere in the oral cavity

Herpesvirus Infection
y

Primary Infection

Herpesvirus Infection
y

Primary Infection

Herpesvirus Infection
y

Secondary Infection
Reactivation of latent virus Not associated with systemic symptoms Small vesicles Occur only on the hard palate and gingiva Prodromal signs

Herpesvirus Infection
y

Secondary infection

Herpesvirus Infection
y

Varicella zoster virus (HHV-3)
Latent infection Oral ulcers Dermatomal distribution

Herpesvirus Infection
y

Varicella zoster virus

Herpesvirus Infection
y

Varicella zoster virus

Herpangina
y y y y y y y

NOT caused by Herpesvirus Coxsackie A virus Children < 10 years of age Common in summer and fall Often subclinical presentation Headache/Abdominal pain 48hrs prior to papulovesicular lesions on tonsils & uvula. Sore throat

Herpangina

Primary Herpetic Gingivostomatitis

Acute ulcerative
y

Viral Infections

Varicella zoster virusdistribution of trigeminal nerve

Herpes simplex- 600,000 Coxsackie- prodrome, new cases annually, vesicular, pharynx,tonsils, prodrome followed by soft palate small vesicles that ulcerate, primary Recurrent herpes simplexinfection involves the prodrome present, gingiva, and can involve the entire oral cavity herpes labialis, limited to keratinized epithelium palate
and can involve the gingiva and hard

Recurrent herpes simplex

Chronic: longer duration, well circumscribed, raised borders, indurated base with crater

Trauma y Infection y Neoplasm y Necrotizing sialometaplasia
y

Trauma:
y

Ill-Fitting dentures

Infection
Rare y HIV/AIDS patients y Bacterial y Deep mycotic infection y Candida
y

Infection
y

Bacterial
Usually secondary infection Primary infection: syphilis, tuberculous, or actinomycosis

Infection
y

Bacterial-Syphilis

Syphilis

Acute ulcerative
y Syphilis
y

Congenital syphilis

Hutchinson·s incisors, ´moon·s molarsµ
Primary painless, indurated, ulcerated, usually involving the lips, tongue Secondary- mucous patches, split papules Tertiary- Gummas, can involve palate, tongue

Infection
y

Bacterial-Syphilis

Infection
y

Mycotic
Blastomycosis Histoplasmosis

Infection
y

Histoplasmosis

Acute ulcerative
y Histoplasmosis
y

disseminated form, oropharyngeal lesions may present as ulcerative, nodular, or vegetative Biopsy will provide the diagnosis

Infection
y

Candida
Candida albicans Most common Normal flora Predisposing factors White creamy patches KOH prep Nystatin oral suspension

Infection
y

Candida

Candidiasis

Candidiasis
Opportunistic infection, Candida albicans y Pseudomembranous (thrush), erythematous, atrophic, hyperplastic y Risk factors: Local- topical steroids, xerostomia, heavy smoking, denture appliances. Systemic- Poorly controlled diabetes mellitus, immunosuppression
y

Candidiasis
Symptoms: burning, dysgeusia, sensitivity, generalized discomfort y Angular cheilitis, coinfection with staph may be present y Acutely- atrophic red patches or white curd-like surface colonies Chronicdenture related form confined to area of appliance
y

Candidiasis
Confirmation with KOH smear, tissue PAS or silver stains y Treatment- topical or systemic, polyene,azoles
y

Leukoedema
Diffuse, filmy grayish surface with white streaks, wrinkles, or milky alteration y Symmetric, usually involving the buccal mucosa, lesser extent labial mucosa y Normal variation
y

present in the majority of black adults, and half of black children
y

At rest, opaque appearance.
When stretched dissipates

Leukoedema

Oral Leukoplakia
Clinically defined white patch or plaque that has been excluded from other disease entities y Presence of dysplasia, carcinoma in situ, and invasive carcinoma from all sites 1725% (Bouqot and Gorlin 1986) y Etiology
y

associated with tobacco (smoking, smokeless tobacco), areca nut/betel preparations

Oral Leukoplakia

Oral Leukoplakia

Oral Leukoplakia
y y

y

May be macular, slightly elevated, ulcerative, erosive, speckled, nodular, or verrucous 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

Proliferative Verrucous Leukoplakia
Uncommon variant of leukoplakia y Multifocal, occurring more in women, and in those without the usual risk factors y Evolution from a thin, flat white patch to leathery, then papillary to verrucous y Development of squamous cell CA in over 70% of cases
y

Proliferative Verrucous Leukoplakia

Site of Leukoplakia
y

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

Epithelial Dysplasia

Treatment
y y y y

Trial of cessation of offending agent, follow-up Guided by microscopic characterization Benign, minimally dysplastic- periodic observation or elective excision Complete excision
scalpel excision laser ablation electrocautery, cryoablation

y

Chemoprevention

Oral Hairy Leukoplakia

Oral hairy leukoplakia
y y y y y

Asymptomatic, seen with systemic immunosuppression EBV Lateral tongue bilaterally; subtle white keratotic vertical streaks to thick corrugated ridges Diagnosis by microscopy and in situ hybridization Management includes establishing diagnosis and treating immunosuppression

Neoplasm
y Squamous

cell carcinoma (SCC)

Most common Irregular ulcers with raised margins May be exophytic, infiltrative or verrucoid Mimic benign lesions grossly

Neoplasm
y

Squamous cell carcinoma

Neoplasm
y

Squamous cell carcinoma

Neoplasm
y

Squamous cell carcinoma

Necrotizing Sialometaplasia
Inflammatory condition y Ischemia to minor salivary glands y Deep ulcers of the hard palate y Resolves in 6 weeks
y

Sialometaplasia

Sialometaplasia

Contact stomatitis y Radiation mucositis y Cancer chemotherapy
y

Generalized: broad classification encompassing a wide variety of causative agents or conditions

Dermatologic Disorders: cutaneous and oral manifestations

Erythema multiforme y Lichen planus y Benign mucous membrane pemphigoid y Bullous pemphigoid y Pemphigus vulgaris
y

Dermatologic Disorders
y

Erythema multiforme
Rapidly progressive Antigen-antibody complex deposition in vessels of the dermis Target lesions of the skin Diffuse ulceration, crusting of lips, tongue, buccal mucosa Self-limited, heal without scarring

Acute ulcerative
y y y

Erythema multiforme Mucocutaneous hypersensitivity reaction Etiology
infectious (strong association with HHV-1, viral, mycoplasma) drugs (antiseizure medications, sulfonamides)

y

Clinically
target lesions develop over the skin with erythematous periphery central area that can develop bullae, vesicles.

Dermatologic Disorders
y

Erythema multiforme

Erythema Multiforme

Erythema Multiforme
y

Clinically
Oral mucosa and lips demonstrate aphthous like ulcers and occasionally vesicles or bullae may be present. Gingiva rarely involved; common sites include labial mucosa, palate, tongue, and buccal mucosa

Mucosal ulcers are irregular in size and shape, tender and covered with fibrinous exudate. Sialorrhea, pain, odynophagia, dysathria. Severe EM are associated with involvement of other mucosal sites- eyes, genitalia, and less common esophagus and lungs

Erythema Multiforme
y

Histopathology]
Intense lymphocytic infiltration in a perivascular distribution and edema from submucosa into the lamina propria, epithelium lack antibodies, blood vessels contain fibrin, C3, IgM

y

Treatment- with oral involvement only can treat symptomatically/short course of corticosteroids

Dermatologic Disorders
y

Lichen planus
Chronic disease of skin and mucous membranes Destruction of basal cell layer by activated lymphocytes Reticular: fine, lacy appearance on buccal mucosa (Wickman·s striae) Hypertrophic: resembles leukoplakia Atrophic or erosive: painful

Oral lichen planus

Oral lichen planus
0.2%- 2% population affected y Usually asymptomatic, reticular from, white striaform symmetric lesions in the buccal mucosa y T-cell lymphocytic reaction to antigenic components in the surface epithelial layer y Other variants: plaque, atrophic/erythematous, erosive
y

Dermatologic Disorders
y

Lichen planus

Oral lichen planus
Small risk of squamous cell carcinoma, more likely seen in the atrophic or erosive types y Studies show that dysplasia with lichenoid features have significant degree of alleic loss. y Recommendation is to remove these lesions/follow patient closely
y

Dermatologic Disorders
y

Lichen planus

Dermatologic Disorders
y

Lichen planus

Dermatologic Disorders
y

Benign mucous membrane pemphigoid
Tense subepithelial bullae of skin and mucous membranes Rupture, large erosions, heal without scarring Sloughing (Nikolsky sign)

y y

Bullous pemphigoid
Cutaneous lesions more common

Both show subepithelial clefting with dissolution of the basement membrane
IgG in basement membrane

Dermatologic Disorders
y

Benign mucous membrane pemphigoid

Dermatologic Disorders
y

Benign mucous membrane pemphigoid

Dermatologic Disorders
y

Pemphigus vulgaris
Severe, potentially fatal Jewish and Italians Intraepithelial bullae and acantholysis Nikolsky·s sign Loss of intracellular bridges Autoimmune response to desmoglein 3 Intraepithelial clefting

Dermatologic Disorders
y

Pemphigus vulgaris

Dermatologic Disorders
y

Pemphigus vulgaris

Quinn·s Rule for Stomatitis:
´Call it aphthous stomatitis. Treat it for two weeks. If it is still there, biopsy it.µ

ORAL CAVITY LESIONS

Frederick Mars Untalan, MD

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