03-02-06 Benign Mucosal Lesions of the Oral Cavity1

8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1

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Benign Mucosal Lesions of theOral Cavity

Grand Rounds3/2/2006


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Outline

C ase study

Mucosal lesionsUlcerative lesionsC onclusions


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Case Study

33 yo male admitted for throat pain, fever. Patientdeveloped a vesiculopapular rash, fever as high as103F, and thick coating on tongue, and penile ulcersfollowing one week history of fevers and sore throat.Physical exam- C rusted lesions over face andneck,3 mm tender lesion on upper lip, tongue-tender,thick white coating with 2 erythematous areas on tip,

numerous white lesions across uvula, hard and softpalate, Neck- No lymphadenopathyESR- 44


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Leukoedema


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Leukoedema

D iffuse, filmy grayish surface with white

streaks, wrinkles, or milky alterationSymmetric, usually involving the buccalmucosa, lesser extent labial mucosaNormal variation; present in the majority of

black adults, and half of black children At rest, opaque appearance. When stretcheddissipates


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Oral Leukoplakia


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Oral Leukoplakia


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Oral Leukoplakia

C linically defined white patch or plaque that

has been excluded from other diseaseentitiesPresence of dysplasia, carcinoma in situ, andinvasive carcinoma from all sites 17-25%

(Bouqot and Gorlin 1986)Etiology- associated with tobacco (smoking,smokeless tobacco), areca nut/betelpreparations


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Oral Leukoplakia

May be macular, slightly elevated, ulcerative,

erosive, speckled, nodular, or verrucousC linical shift in appearance fromhomogenous to heterogenous, speckled, or nodular, a rebiopsy is mandatoryC orrelation between increasing levels of dysplasia and increases in regionalheterogeneity or speckled quality


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P roliferative Verrucous Leukoplakia


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P roliferative Verrucous Leukoplakia

Uncommon variant of leukoplakia

Multifocal, occurring more in women, and inthose without the usual risk factorsEvolution from a thin, flat white patch toleathery, then papillary to verrucousD evelopment of squamous cell C A in over 70% of cases


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Site of Leukoplakia

Risk of dysplasia/carcinoma higher with floor

of mouth, ventrolateral tongue, retromolar trigone, soft palate than with other oral sites


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E pithelial Dysplasia


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T reatment

T rial of cessation of offending agent, follow-up

Guided by microscopic characterizationBenign, minimally dysplastic- periodic observation or elective excisionC omplete excision can be performed with scalpel

excision, laser ablation, electrocautery, or cryoablationC hemoprevention


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Oral Hairy Leukoplakia


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Oral hairy leukoplakia

Asymptomatic, seen with systemic

immunosuppressionEBVLateral tongue bilaterally; subtle white keratoticvertical streaks to thick corrugated ridgesD

iagnosis by microscopy and in situ hybridizationManagement includes establishing diagnosis andtreating immunosuppression


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Oral lichen planus


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Oral lichen planus

0.2%- 2% population affected

Usually asymptomatic, reticular from, whitestriaform symmetric lesions in the buccalmucosaT -cell lymphocytic reaction to antigenic

components in the surface epithelial layer Other variants: plaque,atrophic/erythematous, erosive


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Oral lichen planus

Small risk of squamous cell carcinoma, more

likely seen in the atrophic or erosive typesStudies show that dysplasia with lichenoidfeatures have significant degree of alleicloss. Recommendation is to remove theselesions/follow patient closely


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Candidiasis


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Candidiasis

Opportunistic infection, C andida albicans

Pseudomembranous (thrush), erythematous,atrophic, hyperplasticRisk factors: Local- topical steroids,xerostomia, heavy smoking, dentureappliances. Systemic- Poorly controlleddiabetes mellitus, immunosuppression


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Candidiasis

Symptoms: burning, dysgeusia, sensitivity,

generalized discomfort Angular cheilitis, coinfection with staph maybe present

Acutely- atrophic red patches or white curd-like surface colonies C hronic- denturerelated form confined to area of appliance


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Candidiasis

C onfirmation with KOH smear, tissue PAS or

silver stainsT reatment- topical or systemic,polyene,azoles


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Oral ulcerative lesions

Acute

C hronicRecurrent


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A cute ulcerative

Bacterial Acute necrotizing ulcerative gingivostomatitis

Poor oral hygiene, Punched-out ulcer atinterdental papillae, seen in young adultswith poor nutrition, heavy smoking

Streptococcal gingivostomatitisB hemolytic strep, bright red gingivae

Oral tuberculosisGonococcal stomatitis


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Syphilis


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A cute ulcerative

SyphilisC ongenital syphilis- Hutchinsons incisors, moons molars

Primary-painless, indurated, ulcerated, usually involving the lips,tongueSecondary- mucous patches, split papulesT ertiary- Gummas, can involve palate, tongueFungalOral C andidiasisHistoplasmosis- disseminated form, oropharyngeal lesions maypresent as ulcerative, nodular, or vegetative. Biopsy will provide thediagnosis


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P rimary Herpetic Gingivostomatitis


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A cute ulcerative

Viral InfectionsHerpes simplex- 600,000 new cases annually,prodrome followed by small vesicles that ulcerate,primary infection involves the gingiva, and caninvolve the entire oral cavityRecurrent herpes simplex- prodrome present,herpes labialis, limited to keratinized epithelium andcan involve the gingiva and hard palateVaricella zoster virus- distribution of trigeminal nerveC oxsackie- prodrome, vesicular, pharynx,tonsils, softpalate


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R ecurrent herpes simplex


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E rythema Multiforme

C linically- Oral mucosa and lips demonstrateaphthous like ulcers and occasionally vesicles or bullae may be present. Gingiva rarely involved;common sites include labial mucosa, palate, tongue,and buccal mucosaMucosal ulcers are irregular in size and shape,tender and covered with fibrinous exudate

Sialorrhea, pain, odynophagia, dysathriaSevere EM are associated with involvement of other mucosal sites- eyes, genitalia, and less commonesophagus and lungs


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E rythema Multiforme

Histopathology- Intense lymphocytic

infiltration in a perivascular distribution andedema from submucosa into the laminapropria, epithelium lack antibodies, bloodvessels contain fibrin, C 3, IgM

T reatment- with oral involvement only cantreat symptomatically/short course of corticosteroids


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A cute ulcerative

Lupus erythematosus- chronic discoid and systemiclupus erythematosus (SLE) formsD iscoid type- lip, intraoral lesions, most common siteis buccal mucosa; central depressed, red atrophicarea surrounded by slightly, raised keratotic border SLE form- common site posterior hard palate,superficial ulcerations that vary in size without

keratinization of the oral mucosaImmunofluorescence shows staining of thebasement membrane with immunoglobulin, andcomplement


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A cute Ulcerative

Reiters Syndrome- mainly young men 20 to

30.C

lassis triad of conjunctivitis, arthritis,and urethritis. Oral lesions range fromerythema to papules to ulcerations involvingthe buccal mucosa, gingiva, and lips. Lesionson the tongue resemble geographic tongueBehcets Syndrome- recurrent oral andgenital ulcers, athritis, and inflammatorydisease of eyes and GI tract.


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A cute ulcerative

D rug reactions

Barbiturates, salicylates, phenolphthalein,quinine, digitalis, griseofulvin, and dilantin


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Chronic Ulcerative


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Chronic ulcerative

Pemphigus vulgaris- 0.1 to 0.5

patients/100,000; 70% present with upper aerodigestive lesionsD esmoglein 3 is the pemphigus antigenIgG, IgA

D eposition of antibodies in the intracellular spaces produces direct damage to thedesmosomes


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P emphigus vulgaris

C linical presentation- ulceration and pain withcollapse of vesicles

Lesions extend from gingival margin to alveolar marginOropharyngeal lesions favor lateral aspects of softpalate to lateral pharyngeal wallLesions heal quickly without scarringT reatment- immunosuppression with steroidssupplemented with azathioprine5% mortality with immunosuppression


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Chronic Ulcerative

Mucous Membrane ( C icatricial) Pemphigoid

Autoantibodies directed at molecular components of the basement membraneMost common Head and Neck sites-oral, followed by ocular, nasal, and

nasopharynx sitesOcular scarring- symblepharon, cornealopacification, entropion


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Mucous Membrane P emphigoid

D iagnosis is with immunofluorescence

showing linear immune deposits along thebasement membraneSite directed therapy. Oral cavity- topical vs.systemic steroids.


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Chronic Ulcerative

T raumatic (Eosinophilic) Granuloma-self-limiting, relatively long duration, deep mucosal injury, origin

unknownC linical presentation- 5 th to 7 th decade, painful rapid onset, 1 to2 cm in diameter with crater center and firm periphery that iswhite in appearancePathology- deep ulceration extending into skeletal muscle,intense, diffuse inflammatory infiltrate of histiocytes, endothelialcells, and eosinophilsT reatment- observation, topical or intralesional corticosteroids,excision if clinical presentation in question


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Major aphthous ulcer


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R ecurrent ulcerative

Recurrent aphthous stomatitis (RAS)

Frequency range of 20-40% of population,most common non-traumatic form of oralulcerationD ata indicates a greater prevalence among

those in professional groups, higher socioeconomic status, and non-smokers


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RA S

Seen in a variety of conditionsC rohns disease, Behcets syndrome, gluten-sensitive

enteropathy, food hypersensitivity (nuts, spices, chocolate)C ertain medications- NSAI D S, B-blockers, K+channel blockersSweets syndrome- acute febrile neutrophilic dermatosisPFAPA- Periodic fever, aphthous ulcers, pharyngitis,

and adenitis

Familial variety


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PA S

Pathogenesis- No sign of vesicle or blistering

formationLesions over non-keratinizing mucosalsurfaces (labial, buccal, ventral, and lateraltongue, floor of mouth, soft palate, tonsillar

pillars)


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RA S

C lassification-Minor 1.0 cm deeper, more painful, posterior aspect of oralcavity, 6 weeks or longer in immunocompromisedHerpetiform- multiple pinhead-sized, pain greater than size of lesionT reatment- symptomatic, topical steroids, for larger lesionsintralesional steroids. Severe- short term systemic steroids.


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Case Study

Prodrome

Rash present, major aphthous ulcers, genitalfindingsNo eye findingsNo prior history


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Conclusions

Must rule out dysplasia, squamous cell

carcinoma with leukoplakiaD uration of lesion, as well as location help tonarrow your differential diagnosisBiopsy of persistent lesions can help guidemanagement


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R eferences

C ohen, Lawrence. Ulcerative Lesions of the

OralC

avity. International Journal of D ermatology Sept 1980, 362-373.Sciubba, James. Oral Mucosal Lesions.

C ummings Otolaryngology Head and

Neck Surgery. Philadelphia, 2005, 1448-91.

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03-02-06 Benign Mucosal Lesions of the Oral Cavity1