Transcript Non-neoplastic diseases of oral cavity
Non-neoplastic diseases of oral cavity
Dr. Vishal Sharma
Common diseases
Sub-mucous fibrosis
Aphthous ulcer
Leukoplakia
Oral candidiasis
Vincent’s infection
Tongue tie
Ranula
Erythroplakia
Oro-labial Herpes
Infectious mononucleosis
Geographic tongue
Mucocoele
Oral pre-malignant conditions 1. Oral sub-mucous fibrosis 2. Leukoplakia & Erythroplakia 3. Oral candidiasis 4. Lichen planus 5.
Nicotinic stomatitis (smoker’s palate) 6. Tertiary syphilis 7. Mucosal hyper-pigmentation (melanosis)
Ulcers of oral cavity
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Infection:
Herpes, Vincent’s infection, Candidiasis •
Auto-immune:
Aphthous ulcer, Behcet’s syndrome •
Trauma:
cheek bite, jagged tooth, ill-fitting denture chemical burn, thermal burn •
Skin disorder:
Lichen planus, erythema multiforme •
Blood disorder:
Leukemia, agranulocytosis, pancytopenia, sickle cell anemia •
Drug allergy:
mouth wash, toothpaste •
Neoplasm:
benign, malignant •
Others:
Radiation, chemotherapy, diabetes, uremia
Oral sub-mucous fibrosis
Definition
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Term coined by S.G. Joshi in 1953
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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 7.
Excessive consumption of chilies (controversial)
Etiology
Presenting symptoms
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Burning pain on consumption of spicy food
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Dryness of mouth
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Impaired mouth movements while eating & talking
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Progressive inability to open the mouth (trismus)
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Hearing loss (stenosis of Eustachian tubes)
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Nasal intonation (
ed soft palate mobility)
Clinical Staging Stage of stomatitis: red mucosa
vesicles
rupture to form mucosal ulcers Stage of fibrosis (healing): blanching of mucosa, fibrous bands in oral mucosa, trismus,
ed soft palate mobility Stage of sequelae: difficult speech, hearing loss, leukoplakia, malignancy (3 - 8 %)
Blanched mucosa
Early fibrosis in lower lip
Early & advanced trismus
Medical Treatment 1. Bi-weekly submucosal intra-lesional injections of Dexamethasone 4 mg + Hyaluronidase 1500 IU for 6- 8 wks 2. Submucosal injection of human placental extract 3. Vitamin B complex + anti-oxidant supplement 4. Avoid consumption of mucosal irritants 5. Increased intake of fruits & vegetables
Dynamic splints for trismus
Surgical treatment for trismus 1. Simple release of fibrous bands + skin grafting 2. Laser-assisted release of fibrous bands 3. Excision of lesions & reconstruction with: buccal fat pad, naso-labial flap, lingual flap, palatal muco-periosteal flap, radial forearm flap 4. Temporalis muscle myotomy + mandibular coronoidectomy
Aphthous ulcer (canker sore)
Introduction Recurrent, 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 recurrence 2. Selective involvement of movable mucosa 3. Absence of fever, malaise, lymph node enlargement
Types 1. Minor aphthous ulcer: 2 – 10 mm in size, multiple, heal with no scar in 1 - 2 weeks 2. Major aphthous ulcer: 20 – 40 mm in size, usually single, heal with scar over months 3. Herpetiform aphthous ulcer: < 1 mm in size, multiple, heal with no scar in 1 week
Minor aphthous ulcer
Major aphthous ulcer Rule out HIV & malignancy
Herpetiform aphthous ulcers
Trigger factors for auto-immune injury Deficiency:
vitamin B complex, iron, folic acid, zinc
Stress:
emotional & physical
Trauma:
cheek bite, ill-fitting dentures
Hormonal imbalance:
changing progesterone level
Allergy:
sodium lauryl sulphate (mouth wash & paste)
Drugs:
NSAIDs, cancer chemotherapy
Others:
Behcet’s syndrome, HIV, Crohn’s disease
Infection:
controversial
Treatment of aphthous ulcer
1. Avoid trigger factors 2. Supplement:
vitamin B complex + folic acid + iron
3. Topical gel combination: ZYTEE, QUADRAJEL a. steroid:
triamcinolone
b. antibiotic:
chlorhexidine, metronidazole, benzalkonium, cetalkonium, tannic acid
c. analgesic:
benzydamine, choline salicylate
d. anesthetic:
lignocaine, benzocaine
4. Mouth rinse: b
etamethasone, tetracycline
5. Immuno-modulator:
thalidomide 50 -100 mg daily
Behcet’s syndrome
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Uveitis + Aphthous ulcer + Genital ulcer Oculo – Oro - Genital syndrome
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Tx: steroid
Leukoplakia
Introduction Definition: 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 disease Malignant transformation: 1 - 20% (average 5 %) Sites: Buccal mucosa, tongue, lips, palate, floor of mouth, gingiva, alveolar mucosa
1. Chronic smoking Etiology 2. Chronic tobacco chewing 3. Irritation from jagged teeth or ill-fitting dentures 4. Chronic alcohol consumption 5. Sun exposure to lips 6. Associated: submucous fibrosis, hyperplastic candidiasis, Plummer-Vinson syndrome, AIDS
Types of leukoplakia 1. Homogeneous leukoplakia: smooth, white 2. Nodular leukoplakia: nodular, white 3. Verrucous leukoplakia: warty, white 4. Speckled (erythro) leukoplakia: white + red Malignant potential: speckled >> nodular & verrucous >> homogenous
Homogenous Leukoplakia
Nodular Leukoplakia
Verrucous leukoplakia
Speckled (erythro) leukoplakia
Layers of epidermis
Pathological stages 1. Hyperkeratosis:
thickening of stratum corneum
2. Parakeratosis:
keratinization with retention of nuclei in stratum corneum (homogeneous leukoplakia)
3. Acanthosis:
thickening of stratum spinosum (verrucous & nodular leukoplakia)
4. Dyskeratosis:
abnormal keratinization present below stratum granulosum (speckled leukoplakia)
Investigations 1. Supra-vital staining / Ora-screen: Toluidine blue solution stains areas of malignancy 2. Biopsy: to rule out malignancy
D/D of oral white lesions
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Leukoplakia
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Hyperkeratosis
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Hypertrophic candidiasis
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Hairy leukoplakia (Epstein-Barr virus infection)
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Lichen planus
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Oral sub-mucous fibrosis
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Lupus erythematosus
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White sponge nevus
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Carcinoma
Treatment 1. Removal of causative agent 2. Supplement: Vitamin A (beta-carotene), C, E, B12, folic acid 3. Surgical excision: if HPE shows dysplasia Surgical excision modalities: cold knife, cryosurgery, laser surgery
Cold knife excision BEFORE AFTER
Laser excision BEFORE AFTER
Erythroplakia (Erythroplasia)
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 disease Red colour due to vascular submucosal tissue shining through under-keratinized mucosa Malignant potential: 17 times > leukoplakia Tx: excision biopsy
Erythroplakia
Oral candidiasis (Moniliasis)
Etiology: Infection with Candida albicans Predisposing factors: 1. Chronic ill-health 2. Uncontrolled diabetes mellitus 3. Acquired immune deficiency syndrome 4. Prolonged use of steroids 5. Prolonged antibiotic therapy 6. Immuno-suppressant therapy (cyclosporine) 7. Anti-cancer chemotherapy
Types of oral candidiasis
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Chronic hyperplastic: white plaques, cannot be removed by scraping (Candidal leukoplakia)
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Pseudo-membranous: loosely adherent white lesions, can be scraped off leaving red patches
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Erythematous (atrophic): smooth, red patches
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Cheilitis: white lesions on angle of mouth
Hyperplastic
Pseudo-membranous (thrush)
Erythematous
Candidal Cheilitis
Diagnosis 1. Microscopic exam of wet smear on KOH mount:
look for pseudo-hyphae
2. Culture (Sabouraud dextrose agar):
white colony
Treatment 1. Clotrimazole paint, Nystatin mouthwash 2. Systemic Fluconazole: for chronic cases 3. Excision of hyperplastic plaque 4. Correction of underlying cause
Microscopic examination
Sabouraud dextrose agar
Vincent’s infection (Acute Necrotizing Ulcerative Gingivitis or Trench mouth)
Introduction Etiology: infection with spirochete Borrelia vincenti & Gram –ve anaerobe Bacillus fusiformis Predisposing factors:
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Poor general health
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Poor oro-dental hygiene
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Dental caries
Clinical Features 1. Painful, ulcerative lesions covered by necrotic membrane present over:
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inter-dental papillae & spreading toward free gum margins (acute necrotizing ulcerative gingivitis)
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tonsils (Vincent’s angina) 2. Halitosis, neck lymph node enlargement & fever
Early acute necrotizing ulcerative gingivitis
Advanced acute necrotizing ulcerative gingivitis
Vicent’s angina
Diagnosis Smear stained with Gentian violet to identify Borrelia vincenti & Bacillus fusiformis Treatment 1. Systemic Benzylpenicillin / Erythromycin 2. Systemic Metronidazole / Clindamycin 3. Betadine mouthwash & H 2 O 2 gargle 4. Dental care & bed rest
Infectious mononucleosis (glandular fever)
Introduction Caused by Epstein Barr virus Spreads only by intimate contact ( kissing disease ) C/F: 1. fever, fatigue, malaise 2. pharyngitis, palatal petechiae 3. ulcer-membranous lesions over tonsils 4. neck lymph node enlargement 5. hepatomegaly & splenomegaly
Clinical Features
White patch on tonsil
Investigations
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Total count: leukocytosis
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Differential count: lymphocytosis + monocytosis
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Peripheral blood smear: atypical lymphocytes
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Paul Bunnel test (with sheep RBC): positive
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Monospot test (with horse RBC): positive Sensitivity 85%, specificity 100%
Atypical lymphocytes
Treatment
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Symptomatic. Bed rest. Paracetamol for fever
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Steroids + tracheostomy for stridor
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Valacyclovir (1000 mg BD – TID X 7 d) is effective
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Avoid aspirin in children
Reye syndrome (fatty liver + encephalopathy)
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Avoid antibiotics
ineffective
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Penicillin contraindicated
non-allergic rashes
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Avoid opioid analgesics
respiratory depression
Oro-labial Herpes simplex infection (cold sore)
Primary Herpes simplex
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Seen in children
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Oral cavity: multiple vesicles
later ulcerate
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Fever + sore throat
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Neck node enlargement
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Tx: Acyclovir 15 mg/kg PO 5 times/d for 7 days
Secondary Herpes simplex
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Reactivation of dormant virus in trigeminal ganglion in adults by emotional stress, fatigue, infection, pregnancy, immune-deficiency
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Vesicular & ulcerative lesions primarily affect vermilion border of lip ( Herpes labialis )
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Tongue, hard palate & gums also involved
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Tx: Acyclovir 200 mg PO 5 times / day X 7 days
Herpes simplex labialis
Herpes simplex of tongue
Oral Lichen planus
Etiology: unknown (? hypersensitivity reaction) Types of oral lichen planus:
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Reticular: reticular white lines (Wickham’s striae)
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Erosive: reticular pattern with areas of ulceration
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Plaque: solid white lesion Skin lesions: purple, polygonal, pruritic papules Treatment:
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Reticular & plaque types: no treatment required
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Erosive type: topical or systemic steroids
Reticular lichen planus
Erosive lichen planus
Lichen planus plaque
Stevens – Johnson syndrome
Stevens - Johnson syndrome
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Severe form of Erythema multiforme
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Minor form of Toxic Epidermal Necrolysis involving < 10 % of body surface area
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Muco-cutaneous, immune-complex –mediated hypersensitivity disorder causing separation of epidermis from dermis
Etiology
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Idiopathic: 25 - 50 % cases
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Drug reaction: Penicillin, Sulfonamides, Macrolide, Ciprofloxacin, Phenytoin, Carbamazepine, Valproate, Lamotrigine, NSAIDs, Valdecoxib, Allopurinol
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Viral infection: herpes simplex, HIV, influenza
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Malignancy: carcinoma, lymphoma
Hemorrhagic crusting of lips
Symptomatic Treatment
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Airway stability, fluid replacement, electrolyte correction, wound cared as burns & pain control
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Underlying diseases & infections treated
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Offending drugs must be stopped
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Local anesthetics & mouthwashes for oral lesions
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Steroids use is controversial. Cyclophosphamide, cyclosporine & I.V. immunoglobulin are used.
Nicotinic stomatitis
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Seen in pipe smokers & reverse smokers
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Cobblestone mucosa of postr hard palate, with red dot in center
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Tx: smoking cessation
Geographic tongue
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Synonym: glossitis migrans
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burning sensation over tongue that worsens with hot, spicy or acidic foods
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Red areas over tongue dorsum devoid of papillae & surrounded by irregular keratotic white line
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Lesions keep changing their shape (map-like appearance of tongue)
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Tx: Avoid irritant food. Vitamin B + Zinc.
Geographic tongue
Black hairy tongue
Elongated filiform papillae on tongue due to excess keratin formation. Become infected with chromogenic bacteria & look like hairs.
Etiology: smoking Tx: scraping of tongue
Fissured tongue & hyperkeratosis
Median rhomboid glossitis Red rhomboid area on lingual dorsum anterior to foramen caecum Due to persistence (invagination failure) of tuberculum impar or chronic candidal infection No tx required
Tongue-tie or Ankyloglossia
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Congenital anomaly with decreased mobility of tongue tip caused by short, thick lingual frenulum
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Diagnosis: inability to protrude tongue tip beyond lower central incisors
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Effects: speech problem (?), feeding difficulty, bad oral hygiene
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Tx: horizontal incision + vertical closure of frenulum
Pre-operative
Horizontal incision planned
Horizontal incision made
Vertical suturing done
Post-operative
Lip mucocoele
Etiology: Lip trauma injures its tiny salivary ducts
extravasation of mucus & saliva in surrounding tissues with lining of granulation or connective tissue
smooth, soft round fluid-filled mucocoele Commonly affects lower lip Tx: Lip mucocoeles usually resolve spontaneously If they recur frequently or become problematic: a. marsupialization of mucocoele b. complete surgical excision of mucocoele with adjacent minor salivary glands
Complete surgical excision
Ranula
Introduction
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Rana means frog (blue translucent swelling in floor of mouth looks like underbelly of frog)
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Simple ranula: Bluish cyst located in floor of mouth. Painless mass, does not change in size in response to chewing, eating or swallowing
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Plunging ranula: Sub-mandibular neck swelling with or without cyst in floor of mouth
Simple Ranula
Plunging ranula
Plunging ranula
Etiology
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Simple ranula: partial obstruction or severance of sublingual duct leads to epithelial-lined retention cyst. Commonly traumatic.
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Plunging ranula: 1. sublingual gland projects through or behind mylohyoid muscle 2. ectopic sublingual gland on cervical side of mylohyoid muscle
Treatment Marsupialization: un-roofing of cyst & suturing of cyst margin to adjacent tissue. Failure = 60-90% Sclerosing agents: intra-lesional injection of Bleomycin or OK-432 Intra-oral excision: of ranula alone (failure = 60%) or ranula + sublingual gland (failure = 2 %) Trans-cervical approach for plunging ranula: c omplete removal of cyst + sublingual gland
Marsupialization
Intra-oral excision
Ranula specimen
Thank You