1. ORAL CAVITY LESIONS Frederick Mars Untalan, MD

3. mouth ulcer Latin ulcus and from Greek "ἕλκος" - 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

4. Epidemiology Epidemiological studies show an average prevalence between 15% and 30%. women > men and < 45 years. >16-25 year olds, and <over 55. 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

5. ORAL CAVITY LIPS TEETH GINGIVA PALATE TONGUE ORAL MUCOUS MEMBRANES ORAL LYMPHOID TISSUES

6. Acute: small, recent onset, short duration, recurrent Trauma Recurrent Aphthous Stomatitis Behcet’s Herpesvirus Infection Herpangina

7. Trauma: Cheek Biting

9. Trauma: Ill-Fitting dentures

11. Trauma: Chemical Burns

12. Trauma: Abrasions from Teeth

13. Recurrent Aphthous Stomatitis(RAS) Most common ulcerative lesion of oral cavity Recurrent, painful ulcers Confined to soft mucosa Subdivided into three types: Minor aphthae Major aphthae Herpetiformaphthae

14. Recurrent Aphthous Stomatitis(RAS) 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

15. Recurrent Aphthous Stomatitis (RAS) Minor apthae

16. 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

19. Recurrent Aphthous Stomatitis (RAS) Major apthae

20. Major aphthous ulcer

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

22. Recurrent Aphthous Stomatitis (RAS) Herpetiform aphthae

23. Behcet’s Symptom complex of: Recurrent aphthous ulcers of the mouth Painful genital ulcers Uveitis or conjuctivitis

24. Behcet’s Affects persons of Mediterranean, Middle Eastern, or Japanese decent Easily confused with Stevens-Johnson syndrome or Reiter’s disease Need referral for systemic treatment

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

28. Acute Ulcerative Reiter’s Syndrome mainly young men 20 to 30 Classis triad Conjunctivitis Arthritis urethritis. Oral lesions range from erythema to papules to ulcerations involving the buccal mucosa, gingiva, and lips. Lesions on the tongue resemble geographic tongue

29. Herpesvirus Infection HSV-1 and/or HSV-2 Primary Infection Secondary Infection Varicella zoster virus (HHV-3)

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

31. Herpesvirus Infection Primary Infection

32. Herpesvirus Infection Primary Infection

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

34. Herpesvirus Infection Secondary infection

35. Herpesvirus Infection Varicella zoster virus (HHV-3) Latent infection Oral ulcers Dermatomal distribution

37. Herpesvirus Infection Varicella zoster virus

38. Herpesvirus Infection Varicella zoster virus

39. Herpangina 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

40. Herpangina

41. Primary Herpetic Gingivostomatitis

42. Acute ulcerative Varicella zoster virus- distribution of trigeminal nerve Coxsackie- prodrome, vesicular, pharynx,tonsils, soft palate Recurrent herpes simplex- prodrome present, herpes labialis, limited to keratinized epithelium and can involve the gingiva and hard Viral Infections Herpes simplex- 600,000 new cases annually, prodrome followed by small vesicles that ulcerate, primary infection involves the gingiva, and can involve the entire oral cavity palate

43. Recurrent herpes simplex

44. Chronic: longer duration, well circumscribed, raised borders, indurated base with crater Trauma Infection Neoplasm Necrotizing sialometaplasia

45. Trauma: Ill-Fitting dentures

46. Infection Rare HIV/AIDS patients Bacterial Deep mycotic infection Candida

47. Infection Bacterial Usually secondary infection Primary infection: syphilis, tuberculous, or actinomycosis

48. Infection Bacterial-Syphilis

49. Syphilis

50. Acute ulcerative Syphilis Congenital syphilis Hutchinson’s incisors, “moon’s molars” Primary painless, indurated, ulcerated, usually involving the lips, tongue Secondary- mucous patches, split papules Tertiary- Gummas, can involve palate, tongue

54. Infection Bacterial-Syphilis

55. Infection Mycotic Blastomycosis Histoplasmosis

56. Infection Histoplasmosis

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

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

59. Infection Candida

60. Candidiasis

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

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

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

64. Leukoedema Diffuse, filmy grayish surface with white streaks, wrinkles, or milky alteration Symmetric, usually involving the buccal mucosa, lesser extent labial mucosa Normal variation present in the majority of black adults, and half of black children At rest, opaque appearance. When stretched dissipates

65. Leukoedema

66. Oral Leukoplakia Clinically defined white patch or plaque that has been excluded from other disease entities Presence of dysplasia, carcinoma in situ, and invasive carcinoma from all sites 17-25% (Bouqot and Gorlin 1986) Etiology associated with tobacco (smoking, smokeless tobacco), areca nut/betel preparations

67. Oral Leukoplakia

68. Oral Leukoplakia

69. Oral Leukoplakia 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

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

71. Proliferative Verrucous Leukoplakia

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

73. Epithelial Dysplasia

74. Treatment 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 Chemoprevention

75. Oral Hairy Leukoplakia

76. Oral hairy leukoplakia 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

77. Neoplasm Squamous cell carcinoma (SCC) Most common Irregular ulcers with raised margins May be exophytic, infiltrative or verrucoid Mimic benign lesions grossly

78. Neoplasm Squamous cell carcinoma

79. Neoplasm Squamous cell carcinoma

80. Neoplasm Squamous cell carcinoma

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

82. Sialometaplasia

83. Sialometaplasia

84. Generalized: broad classification encompassing a wide variety of causative agents or conditions Contact stomatitis Radiation mucositis Cancer chemotherapy

85. Dermatologic Disorders: cutaneous and oral manifestations Erythema multiforme Lichen planus Benign mucous membrane pemphigoid Bullous pemphigoid Pemphigus vulgaris

86. Dermatologic Disorders 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

87. Acute ulcerative Erythema multiforme Mucocutaneous hypersensitivity reaction Etiology infectious (strong association with HHV-1, viral, mycoplasma) drugs (antiseizure medications, sulfonamides) Clinically target lesions develop over the skin with erythematous periphery central area that can develop bullae, vesicles.

88. Dermatologic Disorders Erythema multiforme

89. Erythema Multiforme

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

91. Erythema Multiforme 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 Treatment- with oral involvement only can treat symptomatically/short course of corticosteroids

92. Dermatologic Disorders 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

93. Oral lichen planus

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

95. Dermatologic Disorders Lichen planus

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

97. Dermatologic Disorders Lichen planus

98. Dermatologic Disorders Lichen planus

99. Dermatologic Disorders Benign mucous membrane pemphigoid Tense subepithelial bullae of skin and mucous membranes Rupture, large erosions, heal without scarring Sloughing (Nikolsky sign) Bullous pemphigoid Cutaneous lesions more common Both show subepithelial clefting with dissolution of the basement membrane IgG in basement membrane

100. Dermatologic Disorders Benign mucous membrane pemphigoid

101. Dermatologic Disorders Benign mucous membrane pemphigoid

102. Dermatologic Disorders 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

103. Dermatologic Disorders Pemphigus vulgaris

104. Dermatologic Disorders Pemphigus vulgaris

105. Quinn’s Rule for Stomatitis: “Call it aphthous stomatitis. Treat it for two weeks. If it is still there, biopsy it.”

106. ORAL CAVITY LESIONS Frederick Mars Untalan, MD