Transcript Non-neoplastic diseases of oral cavity

Non-neoplastic
diseases of
oral cavity
Dr. Vishal Sharma
Common diseases
 Sub-mucous fibrosis
 Aphthous ulcer
 Leukoplakia
 Erythroplakia
 Oral candidiasis
 Oro-labial Herpes
 Vincent’s infection
 Infectious mononucleosis
 Tongue tie
 Geographic tongue
 Ranula
 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
• 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
• Term coined by S.G. Joshi in 1953
• 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
• Burning pain on consumption of spicy food
• Dryness of mouth
• Impaired mouth movements while eating & talking
• Progressive inability to open the mouth (trismus)
• Hearing loss (stenosis of Eustachian tubes)
• 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: betamethasone, tetracycline
5. Immuno-modulator: thalidomide 50 -100 mg daily
Behcet’s syndrome
• Uveitis + Aphthous
ulcer + Genital ulcer
• Oculo – Oro - Genital
syndrome
• 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
Etiology
1. Chronic smoking
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
• Leukoplakia
• Hyperkeratosis
• Hypertrophic candidiasis
• Hairy leukoplakia (Epstein-Barr virus infection)
• Lichen planus
• Oral sub-mucous fibrosis
• Lupus erythematosus
• White sponge nevus
• 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
• Chronic hyperplastic: white plaques, cannot be
removed by scraping (Candidal leukoplakia)
• Pseudo-membranous: loosely adherent white
lesions, can be scraped off leaving red patches
• Erythematous (atrophic): smooth, red patches
• 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:
• Poor general health
• Poor oro-dental hygiene
• Dental caries
Clinical Features
1. Painful, ulcerative lesions covered by necrotic
membrane present over:
• inter-dental papillae & spreading toward free gum
margins (acute necrotizing ulcerative gingivitis)
• 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 & H2O2 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
• Total count: leukocytosis
• Differential count: lymphocytosis + monocytosis
• Peripheral blood smear: atypical lymphocytes
• Paul Bunnel test (with sheep RBC): positive
• Monospot test (with horse RBC): positive
Sensitivity 85%, specificity 100%
Atypical lymphocytes
Treatment
• Symptomatic. Bed rest. Paracetamol for fever
• Steroids + tracheostomy for stridor
• Valacyclovir (1000 mg BD – TID X 7 d) is effective
• Avoid aspirin in children  Reye syndrome (fatty
liver + encephalopathy)
• Avoid antibiotics  ineffective
• Penicillin contraindicated  non-allergic rashes
• Avoid opioid analgesics  respiratory depression
Oro-labial Herpes
simplex infection
(cold sore)
Primary Herpes simplex
• Seen in children
• Oral cavity: multiple
vesicles  later ulcerate
• Fever + sore throat
• Neck node enlargement
• Tx: Acyclovir 15 mg/kg
PO 5 times/d for 7 days
Secondary Herpes simplex
• Reactivation of dormant virus in trigeminal
ganglion in adults by emotional stress, fatigue,
infection, pregnancy, immune-deficiency
• Vesicular & ulcerative lesions primarily affect
vermilion border of lip (Herpes labialis)
• Tongue, hard palate & gums also involved
• 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:
• Reticular: reticular white lines (Wickham’s striae)
• Erosive: reticular pattern with areas of ulceration
• Plaque: solid white lesion
Skin lesions: purple, polygonal, pruritic papules
Treatment:
• Reticular & plaque types: no treatment required
• Erosive type: topical or systemic steroids
Reticular lichen planus
Erosive lichen planus
Lichen planus plaque
Stevens – Johnson
syndrome
Stevens - Johnson syndrome
• Severe form of Erythema multiforme
• Minor form of Toxic Epidermal Necrolysis
involving < 10 % of body surface area
• Muco-cutaneous, immune-complex–mediated
hypersensitivity disorder causing separation of
epidermis from dermis
Etiology
• Idiopathic: 25 - 50 % cases
• Drug reaction: Penicillin, Sulfonamides, Macrolide,
Ciprofloxacin, Phenytoin, Carbamazepine,
Valproate, Lamotrigine, NSAIDs,
Valdecoxib, Allopurinol
• Viral infection: herpes simplex, HIV, influenza
• Malignancy: carcinoma, lymphoma
Hemorrhagic crusting of lips
Symptomatic Treatment
• Airway stability, fluid replacement, electrolyte
correction, wound cared as burns & pain control
• Underlying diseases & infections treated
• Offending drugs must be stopped
• Local anesthetics & mouthwashes for oral lesions
• Steroids use is controversial. Cyclophosphamide,
cyclosporine & I.V. immunoglobulin are used.
Nicotinic stomatitis
• Seen in pipe smokers
& reverse smokers
• Cobblestone mucosa
of postr hard palate,
with red dot in center
• Tx: smoking cessation
Geographic tongue
• Synonym: glossitis migrans
• burning sensation over tongue that worsens with
hot, spicy or acidic foods
• Red areas over tongue dorsum devoid of papillae
& surrounded by irregular keratotic white line
• Lesions keep changing their shape (map-like
appearance of tongue)
• 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
• Congenital anomaly with decreased mobility of
tongue tip caused by short, thick lingual frenulum
• Diagnosis: inability to protrude tongue tip beyond
lower central incisors
• Effects: speech problem (?), feeding difficulty, bad
oral hygiene
• 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
• Rana means frog (blue translucent swelling in
floor of mouth looks like underbelly of frog)
• Simple ranula: Bluish cyst located in floor of
mouth. Painless mass, does not change in size in
response to chewing, eating or swallowing
• Plunging ranula: Sub-mandibular neck swelling
with or without cyst in floor of mouth
Simple Ranula
Plunging ranula
Plunging ranula
Etiology
• Simple ranula: partial obstruction or severance of
sublingual duct leads to epithelial-lined retention
cyst. Commonly traumatic.
• 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:
complete removal of cyst + sublingual gland
Marsupialization
Intra-oral excision
Ranula specimen
Thank You