Mucosal Disease

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Lecture presented 2004 to Dentists

Text of Mucosal Disease

  • 1.

2. Oral Pathology Reading List

  • Pindborg:Atlas of diseases of the oral Mucosa
  • Shafer:A textbook of oral pathology
  • Batsakis:Tumors of the head and neck
  • Bhaskar:Synopsis of oral pathology
  • Neville:Oral and Maxillofacial pathology
  • Millard:2nd world workshop on oral medicine

3. State of the Research

  • Few studies assessing mucosal disease in native populations (Canada and US)
  • Mucosal lesions potentially increasing in prevalence *
  • Problems identified in school children included**:
  • **Oral mucosa lesions in Mazahua Indian adolescents; Banderas et al: Acta Odontol Latinoam, 1999
  • * Dental health findings in a Native American settlement; Staley et al: Iowa Dent J, 1993

4. State of the Research

  • Pigmented lesions47.6%
  • Lingual anomalies17.4%
  • Developmental tooth alter6.9%
  • Gingival inflammatory
  • hyperplasia, ankilosis of tongue, lichen planus, focal epithelial hyperplasia and double lip24 %

5. Mucosal Diseases

  • White Lesions
  • Vesiculobullous and Desquamative Lesions
  • Viral Disorders
  • Allergic Disorders
  • Immunopathologic Disorders
  • Dermatologic Disorders
  • Inflammatory Hyperplasias
  • Minor Salivary Gland Tumors

6. White Lesions

  • Dermatoses
  • Inflammatory/infectious
  • Keratotic lesions

7. Dermatoses

  • Lichen Planus
  • Lupus Erythematosus
  • Areata Migrans
  • Solar Cheilosis (Actinic Keratosis)

8. Lichen Planus

  • .1 4% of population
  • Clinical types: reticular, erosive, ulcerative
  • Erosive lesions less common (.16-.56 of LP lesions

9. Lichen Planus

  • .3-3% with neoplastic conversion
  • Fluctuation over time
  • Generally seen in older adults but may occur in children

10. Lichen Planus

  • Erosive lesions and systemic disorders
    • Malignancies
    • Gastrointestinal disease
    • Primary biliary cirrhosis
    • Chronic active hepatitis (Hepatitis C)
    • Ulceratiave colitis
    • Diabetes mellitus
    • Autoimmune disease
    • Drug reactions
    • GVHD

11. Lichen Planus

  • Clinical presentation
    • Symptoms
    • Location
      • Buccal mucosa, dorsal tongue, gingiva, lips, floor of the mouth, soft palate, lateral tongue
    • Tissue quality
      • Keratotic (papular, plaque-like, linear, reticular, annular
      • Vesiculo-bullous (atrophic, erosive )

12. Lichen Planus 13. Lichen Planus 14. Lichen Planus 15. Lichen Planus 16. Lichen Planus 17. Lichen Planus 18. Dermatoses

  • Areata Migrans (Geographic tongue, benign migratory glossitis

Prevalence 1-2% Multiple painless circinate erythematous patch with whitened border 19. Inflammatory/Infectious

  • Acute Pseudomembranous Candidiasis
  • Chemical injuries
  • Verruca Vulgaris:Condyloma Accuminatum
  • Syphilitic mucous patch

20. Patient CM Lesions Associated with Whiteners 21. Keratotic Lesions

  • Papilloma
  • Benign Keratosis: Verruciform Hyperkeratosis; Linea alba; Cheek biting; Hairy tongue
  • Epithelial Atypia;Carcinoma-in-Situ; And Squamous cell carcinoma
  • Nicotinic Stomatitis; Tobacco Keratosis; Verrucous carcinoma

22. Sensitivity and specificity of OraScan toluidine blue mouthrinse in the detection of oral cancer and precancer. J Oral Pathol Med 1996

  • N = 145 Asian patients
  • Ready to use kit: OroScan
  • Oral carcinomas = 100% sensitivity
  • Oral dysplasias 79% sensitivity
  • Specificity 62%

23. Concomitant Leukoplakia in patients with oral squamous cell carcinoma. Oral diseases. 1999

  • N = 100 patients with oral squamous cell carcinoma
  • 47% with concomitant leukoplakia
  • 36% with leukoplakia adjacent to site
  • 11% with leukoplakia distant to site
  • Conclusion: early detection and management of oral leukoplakia may be preventative

24. Leukoplakia 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. Vesiculobullous Lesions

  • Viral disorders
  • Allergic disorders
  • Immunopathologic disorders
  • Dermatologic disorders

35. Viral Disorders

  • Primary Herpetic Gingivostomatitis
  • Recurrent Herpes Labialis
  • Intraoral Recurrent Herpes Simplex
  • Primary V-Z Disease
  • Secondary V-Z Disease
  • Herpangina

36. Primary Herpetic Gingivostomatitis

  • Fever and lymphadenopathy
  • Multiple painful erythematous ulcerations
  • Localized to the cheek, tongue, lips, palate, and importantly attached gingiva
  • Bilateral
  • Confirm with viral culture
  • Acyclovir elixir, famcyclovir* and valacyclovir (*may reduce latent infection with simplex 1)

37. A prospective study of new infections with herpes simplex virus Type 1 and 2. Chiron HSV Vaccine Study Group. N Engl J Med 1999 4;341(19):1432

  • 2393 sexually active HSV-2 seronegative persons monitored for evidence of new HSV infection
  • 40% of new HSV-2 and 2/3 of new HSV-1 are asymptomatic.
  • In sexually active adults new HSV-1genital infections as common as oropharyngeal HSV-1 infections

38. Primary Herpetic Gingivostomatitis 39. Primary Herpetic Gingivostomatitis 40. Viral Disorders

  • Intraoral Recurrent Herpes Simplex
    • Clinical Characteristics
      • Initial burning sensation
      • Multiple punctate ulcers which coalesce
      • Localized to the attached gingiva in a well defined area
      • Moderate to severe pain
      • 10-14 day duration with complete resolution/recrudesemce

41. 42. 43. The probability of in vivo reactivation of herpes simplex virus type 1 increases with the number of latently infected neurons in the ganglia; J virol 1998

  • Animal study: mice
  • The number of animals that experienced virus reactivation was positively correlated with the number of latently infected neurons in the ganglia

44. Patient M S Severe right face pain and cold sores 45. 46. 47. 48. Vericella Zoster (Shingles )

  • Unilateral
  • Clusters of vesicles
  • Dyesthesia initially then severe pain
  • 7-10 day course with scarring lesions persisting for up to 5 weeks
  • Concern re osteonecrosis and tooth devitalization
  • Post-herpetic neuralgia

49. Allergic Disorders

  • Stomatitis Venenata (contact)
  • Stomatitis Medicamentosa (drug)
    • Erythema multiforme
    • Anaphylactic stomatitis
    • Intraoral fixed drug reactions
    • Lichenoid drug reactions
    • Lupus erythematosus like reactions
    • Pemphigus-like drug reactions
    • Non-specific vesiculoulcerative lesions

50. Allergic Disorders

  • Treatment
    • Discontinuation / removal of offending drug
      • Risks/benefits
      • Consult with physician
    • Topical corticosteroids
    • For anaphylactic epinephrine, corticosteroids, antihistamines

51. ImmunopathologicDisorders

  • Recurrent Aphthous Stomatitis
  • Behcets Syndrome
  • Pemphigus Vulgaris
  • Bullous Pemphigold
  • Benign Mucous Membrane Pemphigoid (Circitricial Pemphigoid)

52. Aphthous Stomatitis

  • Clinical characteristics
    • Minor, major, Herpetiform
    • Simple versus complex
  • Causes
    • Trauma, smoking cessation, emotional stress, hormones, heredity, food hypersensitivity, immune dysregulation, infec