Oral Cavity Lesions

8/8/2019 Oral Cavity Lesions

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ORAL CAVITY LESIONSORAL CAVITY LESIONS

Frederick Mars Untalan, MD


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mouthulcermouthulcery Latin ulcus and from Greek "" - elkos, "wound"[

y American English, cankersore

y open sore inside the mouth, or rarely a break in themucous membrane or the epithelium on the lips or

surrounding the mouth.y Causes: physical abrasion, acidic fruit, infection, other

medical conditions, medications, and cancerous andnonspecific processes.

y Two common types : aphthous ulcers

cold sores or fever blisters


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EpidemiologyEpidemiology

y Epidemiological studies show an average prevalence

between 15% and 30%.y women > men and < 45 years.

y >16-25 year olds, and


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ORAL CAVITYORAL CAVITY

y LIPS

y TEETH

y GINGIVA

y PALATE

y TONGUE

y ORAL MUCOUS MEMBRANES

y ORALLYMPHOID TISSUES


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Acute: small, recent onset, short duration,Acute: small, recent onset, short duration,recurrentrecurrent

y Trauma

y RecurrentAphthous Stomatitis

y

Behcetsy Herpesvirus Infection

y Herpangina


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Trauma:Trauma:

y Cheek Biting


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Trauma:Trauma:

y Ill-Fitting dentures


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Trauma:Trauma:

y Chemical Burns


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Trauma:Trauma:

y Abrasions from Teeth


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RecurrentAphthous Stomatitis(RAS)RecurrentAphthous Stomatitis(RAS)

yMostcommon ulcerative lesion of oralcavity

y Recurrent,painfululcers

y Confined to softmucosa

y Subdivided into three types:

Minor aphthae

Major aphthae

Herpetiform aphthae


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RecurrentAphthous Stomatitis(RAS)RecurrentAphthous 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


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RecurrentAphthous Stomatitis (RAS)RecurrentAphthous Stomatitis (RAS)

y Minor apthae


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y MajorAphthae

Uncommon

Irregular, deep ulcers 1-3 cm in size

Raised borders

Heal in 4-6 weeks

Extensive scarring and distortion

BIOPSY!!

Steroids


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y Major apthae


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Major aphthous ulcerMajor aphthous ulcer


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y HerpetiformAphthae

Uncommon

Crops of up to 150 very small (


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y Herpetiform aphthae


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BehcetsBehcets

y Symptom complex of:

Recurrent aphthous ulcers of the mouth

Painful genital ulcers

Uveitis or conjuctivitis


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BehcetsBehcets

y Affects persons ofMediterranean, Middle

Eastern, or Japanese decenty Easily confused with Stevens-Johnson syndrome or Reitersdisease

y Need referral for systemictreatment


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Acute UlcerativeAcute Ulcerative

Behcets Syndrome

recurrent oral and genital ulcersarthritis

inflammatory disease of eyes and GItract.


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Acute UlcerativeAcute Ulcerativeyy Reiters SyndromeReiters Syndromey mainly young men 20 to 30

y Classis triad Conjunctivitis

Arthritis

urethritis.

y Orallesions rangefromerythema topapules toulcerations involvingthe

buccal mucosa,gingiva,andlips.y Lesions on the tongue resemble

geographic tongue


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Herpesvirus InfectionHerpesvirus Infection

y HSV-1 and/orHSV-2

Primary Infection

Secondary Infection

y Varicella zoster virus (HHV-3)


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y Primary Infection

Herpetic gingivostomatitis

Youngerpatients

Often asymptomatic

May be associated with fever, chills, malaise

Vesicles-ulcers-crusting

Anywhere in the oral cavity


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y Primary Infection


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y Primary Infection


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y Secondary Infection

Reactivation of latent virus

Not associated with systemic symptoms

Small vesicles Occur only on the hardpalateand

gingiva

P

rodromal signs


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y Secondary infection


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y Varicella zoster virus (HHV-3)

Latent infection

Oral ulcers

Dermatomal distribution


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y Varicella zoster virus


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y Varicella zoster virus


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HerpanginaHerpangina

y NOT caused by Herpesvirus

y Coxsackie A virus

y Children < 10 years of agey Common in summer and fall

y Often subclinical presentation

y

Headache/A

bdominal pain 48hrs prior topapulovesicular lesions ontonsils & uvula.

y Sore throat


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HerpanginaHerpangina


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Primary Herpetic GingivostomatitisPrimary Herpetic Gingivostomatitis


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Recurrent herpes simplexRecurrent herpes simplex


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Chronic: longerduration, wellChronic: longerduration, well

circumscribed,raised borders,circumscribed,raised borders,

indurated base withcraterindurated base withcrater

y Trauma

y Infection

y Neoplasm

y Necrotizing sialometaplasia


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Trauma:Trauma:

y Ill-Fitting dentures


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InfectionInfection

y Rare

y HIV/AIDS patients

y Bacterial

y Deep mycotic infection

y Candida


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InfectionInfection

y Bacterial

Usually secondary infection

Primary infection: syphilis, tuberculous, or

actinomycosis


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InfectionInfection

y Bacterial-Syphilis


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SyphilisSyphilis


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Acute ulcerativeAcute ulcerative

y Syphilis

y Congenital syphilis

Hutchinsons incisors, moons molars

Primary

painless, indurated, ulcerated, usually involving the lips, tongue

Secondary- mucous patches, split papules

Tertiary- Gummas, can involve palate, tongue


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InfectionInfection

y Bacterial-Syphilis


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InfectionInfection

y Mycotic

Blastomycosis

Histoplasmosis


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InfectionInfection

y Histoplasmosis


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yHistoplasmosis

y disseminated form, oropharyngeal lesions maypresent as ulcerative, nodular, or vegetativeBiopsy will provide the diagnosis


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InfectionInfection

y Candida Candida albicans

Most common

Normal flora Predisposing factors

White creamy patches

KOH prep

Nystatin oral suspension


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CandidiasisCandidiasis


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y Opportunistic infection, Candida albicans

y Pseudomembranous (thrush),

erythematous, atrophic, hyperplasticy Risk factors: Local- topical steroids,

xerostomia, heavy smoking, dentureappliances. Systemic- Poorly controlled

diabetes mellitus, immunosuppression


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y Symptoms: burning, dysgeusia, sensitivity,generalized discomfort

y Angular cheilitis, coinfection with staphmay be present

y Acutely- atrophic red patches or white

curd-like surface colonies Chronic-denture related form confined to area ofappliance


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y Confirmation with KOH smear, tissue PASor silver stains

y Treatment- topical or systemic,

polyene,azoles


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LeukoedemaLeukoedema

y Diffuse,filmy grayish surface withwhite streaks, wrinkles,ormilkyalteration

y S

ymmetric, usually involving the buccalmucosa, lesser extent labial mucosa

y Normal variation present in the majority of black adults, and

half of black childreny At rest, opaque appearance.

When stretched dissipates


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LeukoedemaLeukoedema


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Oral LeukoplakiaOral Leukoplakia

y Clinically definedwhitepatchorplaque that has been excluded fromother disease entities

y Presence of dysplasia, carcinoma in situ,and invasive carcinoma from all sites 17-25% (Bouqot and Gorlin 1986)

y Etiology associated with tobacco (smoking, smokeless

tobacco), areca nut/betel preparations


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Oral LeukoplakiaOral Leukoplakia


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ProliferativeVerrucous LeukoplakiaProliferativeVerrucous Leukoplakia

y Uncommon variant of leukoplakia

y Multifocal, occurring more in women, andin those without the usual risk factors

y Evolution from a thin, flat white patch toleathery, then papillary to verrucous

y Development of squamous cell CA in

over 70% of cases


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ProliferativeVerrucous LeukoplakiaProliferativeVerrucous Leukoplakia


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Site ofLeukoplakiaSite ofLeukoplakia

y Risk of dysplasia/carcinoma higher withfloor of mouth, ventrolateral tongue,retromolar trigone, soft palate than with

other oral sites


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Epithelial DysplasiaEpithelial Dysplasia


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TreatmentTreatment

y Trial of cessation of offending agent, follow-up

y Guided by microscopic characterization

y Benign, minimally dysplastic- periodic observation

or elective excision

y Complete excision

scalpel excision

laser ablation

electrocautery,

cryoablation

y Chemoprevention


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Oral Hairy LeukoplakiaOral Hairy Leukoplakia


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Oral hairy leukoplakiaOral hairy leukoplakia

y Asymptomatic, seen with systemicimmunosuppression

y EBV

y Lateraltongue bilaterally; subtle white keratoticvertical streaks to thick corrugated ridges

y Diagnosis by microscopy and in situ hybridization

y Management includes establishing diagnosis and treating

immunosuppression


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NeoplasmNeoplasm

y Squamous cellcarcinoma(SCC)

Mostcommon

Irregular ulcers with raised margins

May be exophytic, infiltrative or verrucoid Mimic benign lesions grossly


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NeoplasmNeoplasm

y Squamous cell carcinoma


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NeoplasmNeoplasm



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NeoplasmNeoplasm



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Necrotizing SialometaplasiaNecrotizing Sialometaplasia

y Inflammatory condition

y Ischemia to minor salivary glands

y Deep ulcers of the hardpalate

y Resolves in 6 weeks


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SialometaplasiaSialometaplasia


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Generalized: broadclassificationGeneralized: broadclassification

encompassinga widevariety ofencompassinga widevariety of

causativeagents orconditionscausativeagents orconditionsy Contact stomatitis

y Radiation mucositis

y Cancer chemotherapy


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Dermatologic Disorders: cutaneous andDermatologic Disorders: cutaneous and

oralmanifestationsoralmanifestations

y Erythema multiforme

y Lichen planus

y Benign mucous membrane pemphigoid

y Bullous pemphigoid

y Pemphigus vulgaris


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Dermatologic DisordersDermatologic Disorders


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


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y Mucocutaneous hypersensitivity reaction

y Etiology

infectious (strong association with HHV-1, viral,mycoplasma)

drugs (antiseizure medications, sulfonamides)

y Clinically

target lesions develop over the skin with erythematousperiphery

central area that can develop bullae, vesicles.


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Erythema MultiformeErythema Multiforme


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y Clinically Oral mucosa and lips

demonstrate aphthous likeulcers and occasionallyvesicles or bullae may be

present. Gingiva rarely involved;

common sites includelabial mucosa, palate,tongue, and buccal mucosa

Mucosal ulcers are irregularin size and shape, tenderand covered with fibrinousexudate.

Sialorrhea, pain,odynophagia, dysathria.

Severe EM are associatedwith involvement of other

mucosal sites- eyes,genitalia, and less commonesophagus and lungs


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y Histopathology]

Intense lymphocytic infiltration in a perivasculardistribution and edema from submucosa into the

lamina propria, epithelium lack antibodies, bloodvessels contain fibrin, C3, IgM

y Treatment- with oral involvement only can

treat symptomatically/short course ofcorticosteroids


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y Lichen planus

Chronic disease of skin and mucousmembranes

Destruction of basal cell layer by activatedlymphocytes

Reticular: fine, lacy appearance on buccalmucosa (Wickmans striae)

Hypertrophic: resembles leukoplakia

Atrophic or erosive: painful


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Oral lichen planusOral lichen planus


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y Lichen planus


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Oral lichen planusOral lichen planus

y Small risk of squamous cell carcinoma,more likely seen in the atrophic orerosive types

y Studies show that dysplasia withlichenoid features have significantdegree of alleic loss.

y

Recommendation is to remove theselesions/follow patient closely


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y Lichen planus


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y Lichen planus


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Tense subepithelial bullae of skin and mucousmembranes

Rupture, large erosions, heal without scarring

Sloughing (Nikolsky sign)

y Bullous pemphigoid

Cutaneous lesions more common

y Both show subepithelial clefting with dissolution

of the basement membrane IgG in basement membrane


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y Pemphigus vulgaris Severe, potentially fatal

Jewish andI

talians Intraepithelial bullae and acantholysis

Nikolskys sign

Loss of intracellular bridges

Autoimmune response to desmoglein 3 Intraepithelial clefting


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D l D dD l D d


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ORAL CAVITY LESIONSORAL CAVITY LESIONS

Frederick Mars Untalan, MD

Oral Cavity Lesions

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