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Oral cavity lesions

  1. 1. ORAL CAVITY LESIONS <br />Frederick Mars Untalan, MD<br />
  2. 2.
  3. 3. mouth ulcer<br />Latin ulcus and from Greek "ἕλκος" - elkos, "wound"[<br />American English, canker sore<br />open sore inside the mouth, or rarely a break in the mucous membrane or the epithelium on the lips or surrounding the mouth. <br />Causes: physical abrasion, acidic fruit, infection, other medical conditions, medications, and cancerous and nonspecific processes. <br /> Two common types :<br />aphthous ulcers<br />cold sores or fever blisters<br />
  4. 4. Epidemiology<br />Epidemiological studies show an average prevalence between 15% and 30%.<br />women > men and < 45 years. <br />>16-25 year olds, and <over 55.<br />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<br />
  6. 6. Acute: small, recent onset, short duration, recurrent<br />Trauma<br />Recurrent Aphthous Stomatitis<br />Behcet’s<br />Herpesvirus Infection<br />Herpangina<br />
  7. 7. Trauma:<br />Cheek Biting<br />
  8. 8.
  9. 9. Trauma:<br />Ill-Fitting dentures<br />
  10. 10.
  11. 11. Trauma:<br />Chemical Burns<br />
  12. 12. Trauma:<br />Abrasions from Teeth<br />
  13. 13. Recurrent Aphthous Stomatitis(RAS)<br />Most common ulcerative lesion of oral cavity<br />Recurrent, painful ulcers<br />Confined to soft mucosa<br />Subdivided into three types:<br />Minor aphthae<br />Major aphthae<br />Herpetiformaphthae<br />
  14. 14. Recurrent Aphthous Stomatitis(RAS)<br />Minor aphthae:<br />Less than 1 cm<br />Heal completely in 7-10 days without scarring<br />Painful <br />Prodromal stage<br />Shallow and round to oval<br />Gray to yellow membrane<br />Clusters of up to 5 ulcers<br />Steroids<br />
  15. 15. Recurrent Aphthous Stomatitis (RAS)<br />Minor apthae<br />
  16. 16. Recurrent Aphthous Stomatitis (RAS)<br />Major Aphthae<br />Uncommon<br />Irregular, deep ulcers<br />1-3 cm in size<br />Raised borders<br />Heal in 4-6 weeks<br />Extensive scarring and distortion<br />BIOPSY!!<br />Steroids<br />
  17. 17.
  18. 18.
  19. 19. Recurrent Aphthous Stomatitis (RAS)<br />Major apthae<br />
  20. 20. Major aphthous ulcer<br />
  21. 21. Recurrent Aphthous Stomatitis (RAS)<br />Herpetiform Aphthae<br />Uncommon<br />Crops of up to 150 very small (<3mm) ulcers<br />Heal completely in 7-10 days<br />COMPLETELY UNRELATED TO HERPESVIRUS<br />
  22. 22. Recurrent Aphthous Stomatitis (RAS)<br />Herpetiform aphthae<br />
  23. 23. Behcet’s<br />Symptom complex of:<br />Recurrent aphthous ulcers of the mouth<br />Painful genital ulcers<br />Uveitis or conjuctivitis<br />
  24. 24. Behcet’s<br />Affects persons of Mediterranean, Middle Eastern, or Japanese decent<br />Easily confused with Stevens-Johnson syndrome or Reiter’s disease<br />Need referral for systemic treatment<br />
  25. 25.
  26. 26.
  27. 27. Acute Ulcerative<br />Behcet’s Syndrome<br /> recurrent oral and genital ulcers<br /> arthritis<br /> inflammatory disease of eyes and GI tract.<br />
  28. 28. Acute Ulcerative<br />Reiter’s Syndrome<br />mainly young men 20 to 30<br />Classis triad <br />Conjunctivitis<br />Arthritis<br />urethritis. <br />Oral lesions range from erythema to papules to ulcerations involving the buccal mucosa, gingiva, and lips. <br />Lesions on the tongue resemble geographic tongue<br />
  29. 29. Herpesvirus Infection<br />HSV-1 and/or HSV-2<br />Primary Infection<br />Secondary Infection<br />Varicella zoster virus (HHV-3)<br />
  30. 30. Herpesvirus Infection<br />Primary Infection<br />Herpetic gingivostomatitis<br />Younger patients<br />Often asymptomatic<br />May be associated with fever, chills, malaise<br />Vesicles-ulcers-crusting<br />Anywhere in the oral cavity<br />
  31. 31. Herpesvirus Infection<br />Primary Infection<br />
  32. 32. Herpesvirus Infection<br />Primary Infection<br />
  33. 33. Herpesvirus Infection<br />Secondary Infection<br />Reactivation of latent virus<br />Not associated with systemic symptoms<br />Small vesicles <br />Occur only on the hard palate and gingiva<br />Prodromal signs<br />
  34. 34. Herpesvirus Infection<br />Secondary infection<br />
  35. 35. Herpesvirus Infection<br />Varicella zoster virus (HHV-3)<br />Latent infection<br />Oral ulcers<br />Dermatomal distribution<br />
  36. 36.
  37. 37. Herpesvirus Infection<br />Varicella zoster virus<br />
  38. 38. Herpesvirus Infection<br />Varicella zoster virus<br />
  39. 39. Herpangina<br />NOT caused by Herpesvirus<br />Coxsackie A virus<br />Children < 10 years of age<br />Common in summer and fall<br />Often subclinical presentation<br />Headache/Abdominal pain 48hrs prior to papulovesicular lesions on tonsils & uvula.<br />Sore throat<br />
  40. 40. Herpangina<br />
  41. 41. Primary Herpetic Gingivostomatitis<br />
  42. 42. Acute ulcerative<br />Varicella zoster virus- distribution of trigeminal nerve<br />Coxsackie- prodrome, vesicular, pharynx,tonsils, soft palate<br />Recurrent herpes simplex- prodrome present,<br /> herpes labialis, limited to keratinized epithelium and can involve the gingiva and hard <br />Viral Infections<br />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<br />palate<br />
  43. 43. Recurrent herpes simplex<br />
  44. 44. Chronic: longer duration, well circumscribed, raised borders, indurated base with crater<br />Trauma<br />Infection<br />Neoplasm<br />Necrotizing sialometaplasia<br />
  45. 45. Trauma:<br />Ill-Fitting dentures<br />
  46. 46. Infection<br />Rare<br />HIV/AIDS patients<br />Bacterial<br />Deep mycotic infection<br />Candida<br />
  47. 47. Infection<br />Bacterial<br />Usually secondary infection<br />Primary infection: syphilis, tuberculous, or actinomycosis<br />
  48. 48. Infection<br />Bacterial-Syphilis<br />
  49. 49. Syphilis<br />
  50. 50. Acute ulcerative <br />Syphilis<br />Congenital syphilis<br />Hutchinson’s incisors, “moon’s molars”<br /> Primary<br /> painless, indurated, ulcerated, usually involving the lips, tongue<br /> Secondary- mucous patches, split papules<br /> Tertiary- Gummas, can involve palate, tongue<br />
  51. 51.
  52. 52.
  53. 53.
  54. 54. Infection<br />Bacterial-Syphilis<br />
  55. 55. Infection<br />Mycotic<br />Blastomycosis<br />Histoplasmosis<br />
  56. 56. Infection<br />Histoplasmosis<br />
  57. 57. Acute ulcerative <br />Histoplasmosis<br />disseminated form, oropharyngeal lesions may present as ulcerative, nodular, or vegetative <br /> Biopsy will provide the diagnosis<br />
  58. 58. Infection<br />Candida<br />Candida albicans<br />Most common<br />Normal flora<br />Predisposing factors<br />White creamy patches <br />KOH prep <br />Nystatin oral suspension<br />
  59. 59. Infection<br />Candida<br />
  60. 60. Candidiasis<br />
  61. 61. Candidiasis<br />Opportunistic infection, Candida albicans <br />Pseudomembranous (thrush), erythematous, atrophic, hyperplastic<br />Risk factors: Local- topical steroids, xerostomia, heavy smoking, denture appliances. Systemic- Poorly controlled diabetes mellitus, immunosuppression<br />
  62. 62. Candidiasis<br />Symptoms: burning, dysgeusia, sensitivity, generalized discomfort<br />Angular cheilitis, coinfection with staph may be present<br />Acutely- atrophic red patches or white curd-like surface colonies Chronic- denture related form confined to area of appliance<br />
  63. 63. Candidiasis<br />Confirmation with KOH smear, tissue PAS or silver stains<br />Treatment- topical or systemic, polyene,azoles<br />
  64. 64. Leukoedema<br />Diffuse, filmy grayish surface with white streaks, wrinkles, or milky alteration<br />Symmetric, usually involving the buccal mucosa, lesser extent labial mucosa<br />Normal variation<br />present in the majority of black adults, and half of black children<br />At rest, opaque appearance. <br />When stretched dissipates<br />
  65. 65. Leukoedema<br />
  66. 66. Oral Leukoplakia<br />Clinically defined white patch or plaque that has been excluded from other disease entities<br />Presence of dysplasia, carcinoma in situ, and invasive carcinoma from all sites 17-25% (Bouqot and Gorlin 1986)<br />Etiology<br />associated with tobacco (smoking, smokeless tobacco), areca nut/betel preparations<br />
  67. 67. Oral Leukoplakia<br />
  68. 68. Oral Leukoplakia<br />
  69. 69. Oral Leukoplakia<br />May be macular, slightly elevated, ulcerative, erosive, speckled, nodular, or verrucous<br />Clinical shift in appearance from homogenous to heterogenous, speckled, or nodular, a rebiopsy is mandatory<br />Correlation between increasing levels of dysplasia and increases in regional heterogeneity or speckled quality <br />
  70. 70. Proliferative Verrucous Leukoplakia<br />Uncommon variant of leukoplakia <br />Multifocal, occurring more in women, and in those without the usual risk factors<br />Evolution from a thin, flat white patch to leathery, then papillary to verrucous<br />Development of squamous cell CA in over 70% of cases<br />
  71. 71. Proliferative Verrucous Leukoplakia<br />
  72. 72. Site of Leukoplakia <br />Risk of dysplasia/carcinoma higher with floor of mouth, ventrolateral tongue, retromolar trigone, soft palate than with other oral sites<br />
  73. 73. Epithelial Dysplasia<br />
  74. 74. Treatment <br />Trial of cessation of offending agent, follow-up<br />Guided by microscopic characterization<br />Benign, minimally dysplastic- periodic observation or elective excision<br />Complete excision <br />scalpel excision<br />laser ablation<br />electrocautery, <br />cryoablation<br />Chemoprevention<br />
  75. 75. Oral Hairy Leukoplakia<br />
  76. 76. Oral hairy leukoplakia<br />Asymptomatic, seen with systemic immunosuppression<br />EBV<br />Lateral tongue bilaterally; subtle white keratotic vertical streaks to thick corrugated ridges<br />Diagnosis by microscopy and in situ hybridization<br />Management includes establishing diagnosis and treating immunosuppression<br />
  77. 77. Neoplasm<br />Squamous cell carcinoma (SCC)<br />Most common<br />Irregular ulcers with raised margins<br />May be exophytic, infiltrative or verrucoid<br />Mimic benign lesions grossly<br />
  78. 78. Neoplasm<br />Squamous cell carcinoma<br />
  79. 79. Neoplasm<br />Squamous cell carcinoma<br />
  80. 80. Neoplasm<br />Squamous cell carcinoma<br />
  81. 81. Necrotizing Sialometaplasia<br />Inflammatory condition<br />Ischemia to minor salivary glands<br />Deep ulcers of the hard palate<br />Resolves in 6 weeks<br />
  82. 82. Sialometaplasia<br />
  83. 83. Sialometaplasia<br />
  84. 84. Generalized: broad classification encompassing a wide variety of causative agents or conditions<br />Contact stomatitis<br />Radiation mucositis<br />Cancer chemotherapy<br />
  85. 85. Dermatologic Disorders: cutaneous and oral manifestations<br />Erythema multiforme<br />Lichen planus<br />Benign mucous membrane pemphigoid<br />Bullous pemphigoid<br />Pemphigus vulgaris<br />
  86. 86. Dermatologic Disorders<br />Erythema multiforme<br />Rapidly progressive<br />Antigen-antibody complex deposition in vessels of the dermis<br />Target lesions of the skin<br />Diffuse ulceration, crusting of lips, tongue, buccal mucosa<br />Self-limited, heal without scarring<br />
  87. 87. Acute ulcerative <br />Erythema multiforme <br />Mucocutaneous hypersensitivity reaction<br />Etiology<br />infectious (strong association with HHV-1, viral, mycoplasma)<br />drugs (antiseizure medications, sulfonamides)<br />Clinically<br />target lesions develop over the skin with erythematous periphery <br />central area that can develop bullae, vesicles.<br />
  88. 88. Dermatologic Disorders<br />Erythema multiforme<br />
  89. 89. Erythema Multiforme<br />
  90. 90. Erythema Multiforme<br />Clinically<br />Oral mucosa and lips demonstrate aphthous like ulcers and occasionally vesicles or bullae may be present.<br />Gingiva rarely involved; common sites include labial mucosa, palate, tongue, and buccalmucosa<br />Mucosal ulcers are irregular in size and shape, tender and covered with fibrinousexudate.<br />Sialorrhea, pain, odynophagia, dysathria. <br />Severe EM are associated with involvement of other mucosal sites- eyes, genitalia, and less common esophagus and lungs<br />
  91. 91. Erythema Multiforme<br />Histopathology]<br />Intense lymphocytic infiltration in a perivascular distribution and edema from submucosa into the lamina propria, epithelium lack antibodies, blood vessels contain fibrin, C3, IgM <br />Treatment- with oral involvement only can treat symptomatically/short course of corticosteroids<br />
  92. 92. Dermatologic Disorders<br />Lichen planus<br />Chronic disease of skin and mucous membranes<br />Destruction of basal cell layer by activated lymphocytes<br />Reticular: fine, lacy appearance on buccal mucosa (Wickman’s striae)<br />Hypertrophic: resembles leukoplakia<br />Atrophic or erosive: painful<br />
  93. 93. Oral lichen planus<br />
  94. 94. Oral lichen planus<br />0.2%- 2% population affected<br />Usually asymptomatic, reticular from, white striaform symmetric lesions in the buccal mucosa<br />T-cell lymphocytic reaction to antigenic components in the surface epithelial layer<br />Other variants: plaque, atrophic/erythematous, erosive<br />
  95. 95. Dermatologic Disorders<br />Lichen planus<br />
  96. 96. Oral lichen planus<br />Small risk of squamous cell carcinoma, more likely seen in the atrophic or erosive types<br />Studies show that dysplasia with lichenoid features have significant degree of alleic loss. <br />Recommendation is to remove these lesions/follow patient closely<br />
  97. 97. Dermatologic Disorders<br />Lichen planus<br />
  98. 98. Dermatologic Disorders<br />Lichen planus<br />
  99. 99. Dermatologic Disorders<br />Benign mucous membrane pemphigoid<br />Tense subepithelial bullae of skin and mucous membranes<br />Rupture, large erosions, heal without scarring<br />Sloughing (Nikolsky sign)<br />Bullous pemphigoid<br />Cutaneous lesions more common<br />Both show subepithelial clefting with dissolution of the basement membrane<br />IgG in basement membrane<br />
  100. 100. Dermatologic Disorders<br />Benign mucous membrane pemphigoid<br />
  101. 101. Dermatologic Disorders<br />Benign mucous membrane pemphigoid<br />
  102. 102. Dermatologic Disorders<br />Pemphigus vulgaris<br />Severe, potentially fatal<br />Jewish and Italians<br />Intraepithelial bullae and acantholysis<br />Nikolsky’s sign<br />Loss of intracellular bridges<br />Autoimmune response to desmoglein 3<br />Intraepithelial clefting<br />
  103. 103. Dermatologic Disorders<br />Pemphigus vulgaris<br />
  104. 104. Dermatologic Disorders<br />Pemphigus vulgaris<br />
  105. 105. Quinn’s Rule for Stomatitis:<br />“Call it aphthous stomatitis. <br />Treat it for two weeks. <br />If it is still there, <br />biopsy it.”<br />
  106. 106. ORAL CAVITY LESIONS <br />Frederick Mars Untalan, MD<br />