oral mucosal diseases 2010

WenWen--Chen WangChen Wang

Common Oral Mucosal Diseases

Assistant professor of Dept. of Oral Pathology, Faculty of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, TaiwanHead of Dental Dept., Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan E-mail: [email protected]

Wen-Chen Wang, DDS, MS, Ph.D


MUCOUS MEMBRANE

Definition:-Moist lining of the intestinal tract, nasal passages

and other body cavities that communicate with the exterior

Oral mucosa

Oral mucosa:Oral mucous membrane

Ref: Antonio Nanci: Ten Cate’s Oral Histology, Development, structure, and function 6th ed


STRUCTURE OF ORAL MUCOSA

Epithelium………………

..epidermis* Epithelial ridges, rete pegsLamina propria………...

..dermisSubmucosa……………...

..subcutaneous

Oral mucosa

--Similar to skinB.V. N.

Ref: BJ Orban:Orban’s oral histology and embryology,9th ed.


FUNCTIONAL CLASSIFICATION OF ORAL MUCOSA

Keratinized areas…Masticatory mucosa

hard palate & gingiva

vermilion border

Nonkeratinized areas…Lining or reflecting mucosa

lip, cheek, alveolar mucosa, vestibular fornix, mouth floor, soft palate, ventrum of tongue

Specialized mucosa

dorsum of tongue

Oral mucosa


FUNCTIONS OF ORAL MUCOSA

Protection

Sensation

Secretion

Thermal regulation

Oral mucosa


METHODS OF ORAL DIAGNOSIS

History taking

Inspection

Oral examination-Palpation-Percussion-Aspiration, -Auscultation

Radiographic examination

Laboratory examination


History Taking

What, where, when, how

Chief complaints

Present illness

Past medical historyFamily historySocial historyOccupational historyDental history

Review of symptoms by system


Chief Complaints

Pain

Soreness

Burning sensation

Bleeding

Loose teeth

Dry mouth

Swelling

Bad taste

Halitosis

Parthesia and anesthesia

Recent occlusal problem

Too much saliva

Delayed tooth eruption


1. Masses increase in size just before eating

ex. salivary retention phenomena, sialolithiasis

2. Slow-growing masses (duration of months to years)

1) Reactive hyperplasia 2) Chronic infection3) Cysts4) Benign tumors

Onset and Courses


3. Moderately rapid-growing masses (weeks to about 2 months)

1) Chronic infection2) Cysts 3) Malignant tumors


4. Rapidly growing masses (hrs to days)

1) Abscess (painful)2) Infected cyst (painful)3) Aneurysm4) Salivary retention phenomena 5) Hematomas

5. Masses with accompanying fever1) Infections2) lymphoma, leukemia


Inspection

Location

Contours

Color

Surfaces


ContoursNormal & variation

Masticatory mucosa vs lining mucosa

Color


Color

Normal: pinkish

Whitish ：Epithelial hyperplasia, Hyperkeratosis

or dense collagen bundle

Reddish：atrophic epithelium、vessels dilatation

or hyperplasia

Blackish：nevus, tattoo, melanosis

Yellowish:Yellowish: adipose tissue, glandsadipose tissue, glands

Translucent blue ：reflection of liquid

Leukoplakia


HemangiomaHemangioma

Peutz-Jegher’s syndrome

Fordyce’s granule

Mucocele

Betel nut chewer’s mucosa


Surfaces

Normal –smooth & glistening, except dorsal tongue, rugae & attached gingiva


Pathologic Mass May Be--

1) Smooth surface-arises beneath epi, originates from

mesenchyme

ex : benign & early maligant salivary gland tumors, benign & malig. mesenchymal T. ( fibroma, osteoma, hemangioma, myoma…), cellulitis, mucocele…

WenWen--Chen WangChen WangMixed tumor

irritation fibroma


2) Rough surface-except due to trauma, infection and maligancy, originates in the epithelium

ex: papilloma, VH V.ca, ulcerative & exophytic SCC

Ref: NK wood, PW Goaz: Differential diagnosis of oral and maxillofacial lesions 5th ed

3) Sessile or pedunculate

Pyogenic granuloma


Palpation

--A third eye of clinical examination

Anatomic regions & planes involved

Mobility

Extent

Consistency

Painless, tender or painful

Unilateral or bilateral

Solitary or multiple


Anatomic Regions & Planes Involved

Locates a firm mass, superficial or deep

Difficult if swelling or painful


Mobility

1. free movable2. fixed to skin but not to the

underlying tissue 3. free movable to the skin but

fixed to the underlying tissue


4. bound to both skin or mucosa and to the underlying tissue

1) fibrosis-after a previous inflammation.2) malignant- from skin or mucosa invade

to underlying tissue 3) malignant- from deeper tissue invade to

surface epithelium4) malignant- from loose CT to both the

superficial & the deeper layers


Extent

Whether a mass has well defined, M-D or P-D borders will depend on :

-Border of the mass -Consistency of surrounding tissue -Thickness of overlying tissue -Sturdiness of underlying tissue


Fluctuation & emptiability: Fluid contented lesion

Soft: vein, loose CT, glandular tissue

Cheesy: sebaceous cyst, epidermoid cyst

Rubbery: relaxed muscle, glandular tissue with capsule, arteries

Firm: fibrous tissue, tensed muscle, large nerve

Bony hard: bone, cartilage, tooth structure

Consistency


Torus palatini


Painless, Tender or Painful

Pain1.inflammation-- mechanical trauma or

infection2.painful tumors--some neural tumors3.sensory nerve encroachmentTendernessLow-grade inflammation & internal pressure, chronic infection


Unilateral or bilateral

Solitary or multiple

•Solitary : A local benign or early malignancy

•Multiple : Systemic, disseminated diseases or syndrome


Erosive Lichen planus


Special Examination

Radiographic exam

Aspiration, smear cytological exam., biopsy

Laboratory exam…

(Suggested by attending drs.)


Common Oral Mucosal Diseases


Ulcerative Lesions

Ulcer－epithelium loss caused by any reason

Trauma, burn, infection, oral cancer…

Most of traumatic ulcers would be healed within 2 weeks spontaneously, otherwise, a further evaluation should be necessary.


Traumatic Ulcer

A definite trauma history and clinical

features can be traced

Usually occur at the soft tissue regions

which can be bitted or hit by teeth , ex. Lower lip, tongue and buccal area

Ill-fitted dentures

Improper oral habits, ex,

lip biting, tongue biting etc.

A traumatic ulcer of the author


Burn

Chemicals or drugs, thermal

Suicide, psychiatric problems,

Placement an aspirin tablet in oral to relieve

toothache

Phenol, H2 O2 , NaHOCl used in dental practice


Recurrent Aphthous Ulcer

Commonest oral mucosal disease

Herpetiform RAU


Patients Can Be Grossly Classified As : 1.Primary immune dysregulation

-genetic, stress, congenital or acquired immunal disease (leukopenia, AIDS, endocrine etc. )

2.Decreased mucosal barrier-Trauma, blood diseases, nutritional

defficiency(Vit.B12、follic acid, iron)3. Increased antigenic expose-Bacteria, virus, etc.


Treatment of RAU

Topical steroid or NSAID therapy, local cauterization

Underline diseases or any possible etiology should be evaluated if suffered severely and recurred very often


Tuberculosis (TB)

Worldwide, chronic infectious disease, airborne droplets

Crowded or unsanitary environment

Opportunity infection, 5-10% progress into active disease

Immunocompromised patients, ex. DM, HIV infection


Oral Tuberculosis

Primary and secondary

Exposure to infected sputum or hematogeneous spread

Indurated, chronic painless ulcer

Enlarged regional lymph nodes


Herpes Simplex Virus Infection (HSV type 1)

Airborne droplets or direct contact

Primary and recurrent

Most primary HSV infections are asymptomatic, some suffered from primary herpetic gingivostomatitis

Usually in children and young adults


Clinical Characters of HSV Infection

Primary-upper respiratory tract infection oral symptoms，small vesicles/tiny ulcers Latency

Secondary- reactivation of latent virus after trauma, menstruation, systemic upsets, etc.


A discrete collection of vesicular swellings rupture erosion crusted

The commonest recurrent lesion is herpes labialis.

Attached gingiva, hard palate

Heal within 1-2 weeks without scarring

Secondary HSV Infection


Recurrent HSV infection


Oral White Lesions and Betel Nut Related Lesions


Lichen Planus

Reticular type (lace-like network of white lines, Wickham’s striae)

Erosive type

Asymptomatic or burning irritation in reticular type, symptomatic in erosive type

Middle-aged, F:M=3:2

Idiopathic, stress

Topical or systemic steroid therapy

Malignant potential is controversial

Lichen planus


Oral Candidiasis

Oral normal flora

Local irritation（ ill-fitting or improper denture hygiene）

Antibiotics

Immuno-compromised, systemic disease patients

Complete denture of upper jaw


Oral Candidiasis

Oral manifestation:

Pseudomembranous type--creamy white

Atrophytic type-- reddish

Symptoms: varied, from mild to burning sensation, pain and dysphagia

Oral candidiasis


Oral Cancer and Precancerous Lesions -Related to Betel Quid Chewing Habits


What is oral cancer?


Any cancer found in oral cavity

A cancer of the oral epithelial origin, ex. squamous cell carcinoma, verrucous carcinoma

Oral Cancer is-


Contributing factors of oral cancer?

Who is in high risk ?


Contributing Factors of Oral Cancer

--In betel nut (betel quid) consumption areas

Betel nut chewing habit ( 80% in Taiwan)

Others are:1. smoking 2. alcoholism3. radiation exposure 4. improper nutrition5. syphilis 6. candidiasis7. mutation of gene 8. immunodeficiency 9. improper denture


Oral Cancer

Early: may be a leukoplakia or erythroplakia

Tumor cells invade into connective tissue or grow exophytically

Clinical features: reddish or whitish ulcerative surfaces with induration, delayed healing process


Oral Cancer

Locations:

In Taiwan : buccal mucosa is the most common, followed by lateral border of tongue, retromolar, lower lip, palate and gingiva

In the world: lateral border of tongue is the most common


Oral Cancer


Visit your dentist as soon as possible if any oral ulcer doesn’t heal within 2 weeks !


What are Oral Precancerous Lesions ?


Oral Precancerous Lesions

Leukoplakia

Erythroleukoplakia

Erythroplakia

Oral submucous fibrosis

Verrucous hyperplasia

Erosive lichen planus*

*precancerous condition


Leukoplakia

White lesions which cannot be characterized by lichen planus, oral candidosis etc.

Malignant change 4~5%

Homogeneous leukoplakia and non-homogeneous leukoplakia


Erythroleukoplakia


Verrucous Hyperplasia

Exophytic, papillary or cauliflower-like appearance

White, or pink to reddish, resulted from varied keratosis


20-40 y/o, male

Sites: oral mucosa, oropharynx, esophagus

Clinical characteristics:

-Dense collagen bundles, decreased vascularity, epithelium atrophy, whitening of the mucosa

-Trismus-Epithelium atrophy→ decreased protection,

sensitive to spicy foods

Oral Submucous Fibrosis (OSF)


Oral submucous fibrosis


Managements of OSF

Mouth opening exercise

Local cortical steroid injection

Surgical treatment combined with skin graft

Prognosis is not good in the severe OSF

patients


Oral Manifestations of Systemic Diseases


Burning Mouth Syndrome (BMS)

Bacterial or fungal infection

Dry mouth

Nutritional abnormality

Anemia

Endocrine disturbance, DM

Improper denture

Idiopathic


Clinical Features of BMS

Middle aged female or elder male

Burning sensation, esp. tongue and tongue tip; taste change

Normal appearance and color

Diagnosis and treatment depend on the etiology


Vitamin Deficiency

Vit. A: keratosis

Vit. B: glossitis, angular cheilitis, burning mouth

Vit. C: generalized gingival swelling, bleeding tendency and ulcers, periodontitis


Vit. B12 deficiency

After treatment


Blood Diseases

Anemia－pale mucosa

Hemophilia－hematoma or petechiae

Coagulation problems associated with impaired liver function


Leukemia

Bleeding tendency

Idiopathic oral ulcers, necrotic gingival margin

Gingival swelling (chloroma)

Oral candidosis


Go for an oral and

dental examination

every 6 months!


References1. Antonio Nanci: Ten Cate＇s Oral Histology,

Development, structure, and function 6th ed. 2. BJ Orban:Orban＇s oral histology and

embryology,9th ed.3. NK wood, PW Goaz: Differential diagnosis of oral

and maxillofacial lesions 5th ed.4. BW Neville, DD Damm, CM Allen,JE Bouquot: Oral &

Maxillofacial pathology. 2nd ed.

Acknowledgement Clinical pictures were fully supported by Dept. of Oral Pathology, Kaohsinug Medical University

http://www.kmu.edu.tw/media/photos/001.jpg

Kaohsiung Medical University

oral mucosal diseases 2010

Health & Medicine

Transcript of oral mucosal diseases 2010