Oral Cavity Lesions

ORAL CAVITY LESIONS ORAL CAVITY LESIONS
Frederick Mars Untalan, MD

mouth ulcer mouth ulcer
y Latin ulcus and from Greek "" - elkos, "wound"
[
y American English, canker sore
y open sore inside the mouth, or rarely a break in the
mucous membrane or the epithelium on the lips or
surrounding the mouth.
y Causes: physical abrasion, acidic fruit, infection, other
medical conditions, medications, and cancerous and
nonspecific processes.
y Two common types :
aphthous ulcers
cold sores or fever blisters
Epidemiology Epidemiology
y Epidemiological studies show an average prevalence
between 15% and 30%.
y women > men and < 45 years.
y >16-25 year olds, and <over 55.
y 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
ORAL CAVITY ORAL CAVITY
y LIPS
y TEETH
y GINGIVA
y PALATE
y TONGUE
y ORAL MUCOUS MEMBRANES
y ORAL LYMPHOID TISSUES
Acute: small, recent onset, short duration, Acute: small, recent onset, short duration,
recurrent recurrent
y Trauma
y Recurrent Aphthous Stomatitis
y Behcets
y Herpesvirus Infection
y Herpangina
Trauma: Trauma:
y Cheek Biting
Trauma: Trauma:
y Ill-Fitting dentures
Trauma: Trauma:
y Chemical Burns
Trauma: Trauma:
y Abrasions from Teeth
Recurrent Aphthous Stomatitis(RAS) Recurrent Aphthous Stomatitis(RAS)
y Most common ulcerative lesion of oral
cavity
y Recurrent, painful ulcers
y Confined to soft mucosa
y Subdivided into three types:
Minor aphthae
Major aphthae
Herpetiform aphthae
Recurrent Aphthous Stomatitis(RAS) Recurrent Aphthous 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
Recurrent Aphthous Stomatitis (RAS) Recurrent Aphthous Stomatitis (RAS)
y Minor apthae
y Major Aphthae
Uncommon
Irregular, deep ulcers
1-3 cm in size
Raised borders
Heal in 4-6 weeks
Extensive scarring and distortion
BIOPSY!!
Steroids
y Major apthae
Major aphthous ulcer Major aphthous ulcer
y Herpetiform Aphthae
Uncommon
Crops of up to 150 very small (<3mm) ulcers
Heal completely in 7-10 days
COMPLETELY UNRELATED TO
HERPESVIRUS
y Herpetiform aphthae
Behcets Behcets
y Symptom complex of:
Recurrent aphthous ulcers of the mouth
Painful genital ulcers
Uveitis or conjuctivitis
Behcets Behcets
y Affects persons of
Mediterranean, Middle
Eastern, or Japanese decent
y Easily confused with Stevens-
Johnson syndrome or Reiters
disease
y Need referral for systemic
treatment
Acute Ulcerative Acute Ulcerative
Behcets Syndrome
recurrent oral and genital ulcers
arthritis
inflammatory disease of eyes and GI
tract.
Acute Ulcerative Acute Ulcerative
y y Reiters Syndrome Reiters Syndrome
y mainly young men 20 to 30
y Classis triad
Conjunctivitis
Arthritis
urethritis.
y Oral lesions range from erythema to
papules to ulcerations involving the
buccal mucosa, gingiva, and lips.
y Lesions on the tongue resemble
geographic tongue
Herpesvirus Infection Herpesvirus Infection
y HSV-1 and/or HSV-2
Primary Infection
Secondary Infection
y Varicella zoster virus (HHV-3)
y Primary Infection
Herpetic gingivostomatitis
Younger patients
Often asymptomatic
May be associated with fever, chills, malaise
Vesicles-ulcers-crusting
Anywhere in the oral cavity
y Primary Infection
y Primary Infection
y Secondary Infection
Reactivation of latent virus
Not associated with systemic symptoms
Small vesicles
Occur only on the hard palate and
gingiva
Prodromal signs
y Secondary infection
y Varicella zoster virus (HHV-3)
Latent infection
Oral ulcers
Dermatomal distribution
y Varicella zoster virus
y Varicella zoster virus
Herpangina Herpangina
y NOT caused by Herpesvirus
y Coxsackie A virus
y Children < 10 years of age
y Common in summer and fall
y Often subclinical presentation
y Headache/Abdominal pain 48hrs prior to
papulovesicular lesions on tonsils & uvula.
y Sore throat
Herpangina Herpangina
Primary Herpetic Gingivostomatitis Primary Herpetic Gingivostomatitis
Acute ulcerative Acute ulcerative
y 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
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
Recurrent herpes simplex Recurrent herpes simplex
Chronic: longer duration, well Chronic: longer duration, well
circumscribed, raised borders, circumscribed, raised borders,
indurated base with crater indurated base with crater
y Trauma
y Infection
y Neoplasm
y Necrotizing sialometaplasia
Trauma: Trauma:
y Ill-Fitting dentures
Infection Infection
y Rare
y HIV/AIDS patients
y Bacterial
y Deep mycotic infection
y Candida
Infection Infection
y Bacterial
Usually secondary infection
Primary infection: syphilis, tuberculous, or
actinomycosis
Infection Infection
y Bacterial-Syphilis
Syphilis Syphilis
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
Infection Infection
y Bacterial-Syphilis
Infection Infection
y Mycotic
Blastomycosis
Histoplasmosis
Infection Infection
y Histoplasmosis
y Histoplasmosis
y disseminated form, oropharyngeal lesions may
present as ulcerative, nodular, or vegetative
Biopsy will provide the diagnosis
Infection Infection
y Candida
Candida albicans
Most common
Normal flora
Predisposing factors
White creamy patches
KOH prep
Nystatin oral suspension
Infection Infection
y Candida
Candidiasis Candidiasis
y Opportunistic infection, Candida albicans
y Pseudomembranous (thrush),
erythematous, atrophic, hyperplastic
y Risk factors: Local- topical steroids,
xerostomia, heavy smoking, denture
appliances. Systemic- Poorly controlled
diabetes mellitus, immunosuppression
y Symptoms: burning, dysgeusia, sensitivity,
generalized discomfort
y Angular cheilitis, coinfection with staph
may be present
y Acutely- atrophic red patches or white
curd-like surface colonies Chronic-
denture related form confined to area of
appliance
y Confirmation with KOH smear, tissue PAS
or silver stains
y Treatment- topical or systemic,
polyene,azoles
Leukoedema Leukoedema
y Diffuse, filmy grayish surface with
white streaks, wrinkles, or milky
alteration
y Symmetric, usually involving the buccal
mucosa, lesser extent labial mucosa
y Normal variation
present in the majority of black adults, and
half of black children
y At rest, opaque appearance.
When stretched dissipates
Leukoedema Leukoedema
Oral Leukoplakia Oral Leukoplakia
y Clinically defined white patch or
plaque that has been excluded from
other 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
y May be macular, slightly elevated, ulcerative, erosive,
speckled, nodular, or verrucous
y Clinical shift in appearance from homogenous to
heterogenous, speckled, or nodular, a rebiopsy is
mandatory
y Correlation between increasing levels of dysplasia
and increases in regional heterogeneity or speckled
quality
Proliferative Verrucous Leukoplakia Proliferative Verrucous Leukoplakia
y Uncommon variant of leukoplakia
y Multifocal, occurring more in women, and
in those without the usual risk factors
y Evolution from a thin, flat white patch to
leathery, then papillary to verrucous
y Development of squamous cell CA in
over 70% of cases
Proliferative Verrucous Leukoplakia Proliferative Verrucous Leukoplakia
Site of Leukoplakia Site of Leukoplakia
y Risk of dysplasia/carcinoma higher with
floor of mouth, ventrolateral tongue,
retromolar trigone, soft palate than with
other oral sites
Epithelial Dysplasia Epithelial Dysplasia
Treatment Treatment
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
Oral Hairy Leukoplakia Oral Hairy Leukoplakia
Oral hairy leukoplakia Oral hairy leukoplakia
y Asymptomatic, seen with systemic
immunosuppression
y EBV
y Lateral tongue bilaterally; subtle white keratotic
vertical streaks to thick corrugated ridges
y Diagnosis by microscopy and in situ hybridization
y Management includes establishing diagnosis and treating
immunosuppression
Neoplasm Neoplasm
y Squamous cell carcinoma (SCC)
Most common
Irregular ulcers with raised margins
May be exophytic, infiltrative or verrucoid
Mimic benign lesions grossly
Neoplasm Neoplasm
y Squamous cell carcinoma
Neoplasm Neoplasm
Neoplasm Neoplasm
Necrotizing Sialometaplasia Necrotizing Sialometaplasia
y Inflammatory condition
y Ischemia to minor salivary glands
y Deep ulcers of the hard palate
y Resolves in 6 weeks
Sialometaplasia Sialometaplasia
Sialometaplasia Sialometaplasia
Generalized: broad classification Generalized: broad classification
encompassing a wide variety of encompassing a wide variety of
causative agents or conditions causative agents or conditions
y Contact stomatitis
y Radiation mucositis
y Cancer chemotherapy
Dermatologic Disorders: cutaneous and Dermatologic Disorders: cutaneous and
oral manifestations oral manifestations
y Erythema multiforme
y Lichen planus
y Benign mucous membrane pemphigoid
y Bullous pemphigoid
y Pemphigus vulgaris
Dermatologic Disorders Dermatologic 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
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 erythematous
periphery
central area that can develop bullae, vesicles.
Erythema Multiforme Erythema Multiforme
y 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 buccal mucosa
Mucosal ulcers are irregular
in size and shape, tender
and covered with fibrinous
exudate.
Sialorrhea, pain,
odynophagia, dysathria.
Severe EM are associated
with involvement of other
mucosal sites- eyes,
genitalia, and less common
esophagus and lungs
y 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
y Treatment- with oral involvement only can
treat symptomatically/short course of
corticosteroids
y Lichen planus
Chronic disease of skin and mucous
membranes
Destruction of basal cell layer by activated
lymphocytes
Reticular: fine, lacy appearance on buccal
mucosa (Wickmans striae)
Hypertrophic: resembles leukoplakia
Atrophic or erosive: painful
Oral lichen planus Oral lichen planus
y 0.2%- 2% population affected
y Usually asymptomatic, reticular from,
white striaform symmetric lesions in
the buccal mucosa
y T-cell lymphocytic reaction to antigenic
components in the surface epithelial
layer
y Other variants: plaque,
atrophic/erythematous, erosive
y Lichen planus
y Small risk of squamous cell carcinoma,
more likely seen in the atrophic or
erosive types
y Studies show that dysplasia with
lichenoid features have significant
degree of alleic loss.
y Recommendation is to remove these
lesions/follow patient closely
y Lichen planus
y Lichen planus
Tense subepithelial bullae of skin and mucous
membranes
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
Severe, potentially fatal
Jewish and Italians
Intraepithelial bullae and acantholysis
Nikolskys sign
Loss of intracellular bridges
Autoimmune response to desmoglein 3
Intraepithelial clefting
Quinns Rule Quinns Rule for Stomatitis: for Stomatitis:
Call it aphthous stomatitis.
Treat it for two weeks.
If it is still there,
biopsy it.
ORAL CAVITY LESIONS ORAL CAVITY LESIONS
Frederick Mars Untalan, MD

Oral Cavity Lesions

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ORAL CAVITY LESIONS ORAL CAVITY LESIONS

Frederick Mars Untalan, MD

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