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ORAL CAVITY LESIONSORAL CAVITY LESIONS
Frederick Mars Untalan, MD
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mouthulcermouthulcery Latin ulcus and from Greek "" - elkos, "wound"[
y American English, cankersore
y open sore inside the mouth, or rarely a break in themucous membrane or the epithelium on the lips or
surrounding the mouth.y Causes: physical abrasion, acidic fruit, infection, other
medical conditions, medications, and cancerous andnonspecific processes.
y Two common types : aphthous ulcers
cold sores or fever blisters
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EpidemiologyEpidemiology
y Epidemiological studies show an average prevalence
between 15% and 30%.y women > men and < 45 years.
y >16-25 year olds, and
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ORAL CAVITYORAL CAVITY
y LIPS
y TEETH
y GINGIVA
y PALATE
y TONGUE
y ORAL MUCOUS MEMBRANES
y ORALLYMPHOID TISSUES
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Acute: small, recent onset, short duration,Acute: small, recent onset, short duration,recurrentrecurrent
y Trauma
y RecurrentAphthous Stomatitis
y
Behcetsy Herpesvirus Infection
y Herpangina
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Trauma:Trauma:
y Cheek Biting
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Trauma:Trauma:
y Ill-Fitting dentures
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Trauma:Trauma:
y Chemical Burns
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Trauma:Trauma:
y Abrasions from Teeth
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RecurrentAphthous Stomatitis(RAS)RecurrentAphthous Stomatitis(RAS)
yMostcommon ulcerative lesion of oralcavity
y Recurrent,painfululcers
y Confined to softmucosa
y Subdivided into three types:
Minor aphthae
Major aphthae
Herpetiform aphthae
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RecurrentAphthous Stomatitis(RAS)RecurrentAphthous 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
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RecurrentAphthous Stomatitis (RAS)RecurrentAphthous Stomatitis (RAS)
y Minor apthae
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RecurrentAphthous Stomatitis (RAS)RecurrentAphthous Stomatitis (RAS)
y MajorAphthae
Uncommon
Irregular, deep ulcers 1-3 cm in size
Raised borders
Heal in 4-6 weeks
Extensive scarring and distortion
BIOPSY!!
Steroids
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RecurrentAphthous Stomatitis (RAS)RecurrentAphthous Stomatitis (RAS)
y Major apthae
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Major aphthous ulcerMajor aphthous ulcer
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RecurrentAphthous Stomatitis (RAS)RecurrentAphthous Stomatitis (RAS)
y HerpetiformAphthae
Uncommon
Crops of up to 150 very small (
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RecurrentAphthous Stomatitis (RAS)RecurrentAphthous Stomatitis (RAS)
y Herpetiform aphthae
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BehcetsBehcets
y Symptom complex of:
Recurrent aphthous ulcers of the mouth
Painful genital ulcers
Uveitis or conjuctivitis
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BehcetsBehcets
y Affects persons ofMediterranean, Middle
Eastern, or Japanese decenty Easily confused with Stevens-Johnson syndrome or Reitersdisease
y Need referral for systemictreatment
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Acute UlcerativeAcute Ulcerative
Behcets Syndrome
recurrent oral and genital ulcersarthritis
inflammatory disease of eyes and GItract.
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Acute UlcerativeAcute Ulcerativeyy Reiters SyndromeReiters Syndromey mainly young men 20 to 30
y Classis triad Conjunctivitis
Arthritis
urethritis.
y Orallesions rangefromerythema topapules toulcerations involvingthe
buccal mucosa,gingiva,andlips.y Lesions on the tongue resemble
geographic tongue
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Herpesvirus InfectionHerpesvirus Infection
y HSV-1 and/orHSV-2
Primary Infection
Secondary Infection
y Varicella zoster virus (HHV-3)
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Herpesvirus InfectionHerpesvirus Infection
y Primary Infection
Herpetic gingivostomatitis
Youngerpatients
Often asymptomatic
May be associated with fever, chills, malaise
Vesicles-ulcers-crusting
Anywhere in the oral cavity
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Herpesvirus InfectionHerpesvirus Infection
y Primary Infection
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Herpesvirus InfectionHerpesvirus Infection
y Primary Infection
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Herpesvirus InfectionHerpesvirus Infection
y Secondary Infection
Reactivation of latent virus
Not associated with systemic symptoms
Small vesicles Occur only on the hardpalateand
gingiva
P
rodromal signs
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Herpesvirus InfectionHerpesvirus Infection
y Secondary infection
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Herpesvirus InfectionHerpesvirus Infection
y Varicella zoster virus (HHV-3)
Latent infection
Oral ulcers
Dermatomal distribution
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Herpesvirus InfectionHerpesvirus Infection
y Varicella zoster virus
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Herpesvirus InfectionHerpesvirus Infection
y Varicella zoster virus
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HerpanginaHerpangina
y NOT caused by Herpesvirus
y Coxsackie A virus
y Children < 10 years of agey Common in summer and fall
y Often subclinical presentation
y
Headache/A
bdominal pain 48hrs prior topapulovesicular lesions ontonsils & uvula.
y Sore throat
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HerpanginaHerpangina
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Primary Herpetic GingivostomatitisPrimary Herpetic Gingivostomatitis
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Recurrent herpes simplexRecurrent herpes simplex
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Chronic: longerduration, wellChronic: longerduration, well
circumscribed,raised borders,circumscribed,raised borders,
indurated base withcraterindurated base withcrater
y Trauma
y Infection
y Neoplasm
y Necrotizing sialometaplasia
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Trauma:Trauma:
y Ill-Fitting dentures
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InfectionInfection
y Rare
y HIV/AIDS patients
y Bacterial
y Deep mycotic infection
y Candida
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InfectionInfection
y Bacterial
Usually secondary infection
Primary infection: syphilis, tuberculous, or
actinomycosis
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InfectionInfection
y Bacterial-Syphilis
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SyphilisSyphilis
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Acute ulcerativeAcute ulcerative
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
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InfectionInfection
y Bacterial-Syphilis
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InfectionInfection
y Mycotic
Blastomycosis
Histoplasmosis
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InfectionInfection
y Histoplasmosis
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Acute ulcerativeAcute ulcerative
yHistoplasmosis
y disseminated form, oropharyngeal lesions maypresent as ulcerative, nodular, or vegetativeBiopsy will provide the diagnosis
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InfectionInfection
y Candida Candida albicans
Most common
Normal flora Predisposing factors
White creamy patches
KOH prep
Nystatin oral suspension
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CandidiasisCandidiasis
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CandidiasisCandidiasis
y Opportunistic infection, Candida albicans
y Pseudomembranous (thrush),
erythematous, atrophic, hyperplasticy Risk factors: Local- topical steroids,
xerostomia, heavy smoking, dentureappliances. Systemic- Poorly controlled
diabetes mellitus, immunosuppression
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CandidiasisCandidiasis
y Symptoms: burning, dysgeusia, sensitivity,generalized discomfort
y Angular cheilitis, coinfection with staphmay be present
y Acutely- atrophic red patches or white
curd-like surface colonies Chronic-denture related form confined to area ofappliance
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CandidiasisCandidiasis
y Confirmation with KOH smear, tissue PASor silver stains
y Treatment- topical or systemic,
polyene,azoles
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LeukoedemaLeukoedema
y Diffuse,filmy grayish surface withwhite streaks, wrinkles,ormilkyalteration
y S
ymmetric, usually involving the buccalmucosa, lesser extent labial mucosa
y Normal variation present in the majority of black adults, and
half of black childreny At rest, opaque appearance.
When stretched dissipates
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LeukoedemaLeukoedema
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Oral LeukoplakiaOral Leukoplakia
y Clinically definedwhitepatchorplaque that has been excluded fromother 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
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Oral LeukoplakiaOral Leukoplakia
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ProliferativeVerrucous LeukoplakiaProliferativeVerrucous Leukoplakia
y Uncommon variant of leukoplakia
y Multifocal, occurring more in women, andin those without the usual risk factors
y Evolution from a thin, flat white patch toleathery, then papillary to verrucous
y Development of squamous cell CA in
over 70% of cases
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ProliferativeVerrucous LeukoplakiaProliferativeVerrucous Leukoplakia
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Site ofLeukoplakiaSite ofLeukoplakia
y Risk of dysplasia/carcinoma higher withfloor of mouth, ventrolateral tongue,retromolar trigone, soft palate than with
other oral sites
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Epithelial DysplasiaEpithelial Dysplasia
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TreatmentTreatment
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
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Oral Hairy LeukoplakiaOral Hairy Leukoplakia
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Oral hairy leukoplakiaOral hairy leukoplakia
y Asymptomatic, seen with systemicimmunosuppression
y EBV
y Lateraltongue bilaterally; subtle white keratoticvertical streaks to thick corrugated ridges
y Diagnosis by microscopy and in situ hybridization
y Management includes establishing diagnosis and treating
immunosuppression
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NeoplasmNeoplasm
y Squamous cellcarcinoma(SCC)
Mostcommon
Irregular ulcers with raised margins
May be exophytic, infiltrative or verrucoid Mimic benign lesions grossly
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NeoplasmNeoplasm
y Squamous cell carcinoma
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NeoplasmNeoplasm
y Squamous cell carcinoma
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NeoplasmNeoplasm
y Squamous cell carcinoma
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Necrotizing SialometaplasiaNecrotizing Sialometaplasia
y Inflammatory condition
y Ischemia to minor salivary glands
y Deep ulcers of the hardpalate
y Resolves in 6 weeks
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SialometaplasiaSialometaplasia
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Generalized: broadclassificationGeneralized: broadclassification
encompassinga widevariety ofencompassinga widevariety of
causativeagents orconditionscausativeagents orconditionsy Contact stomatitis
y Radiation mucositis
y Cancer chemotherapy
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Dermatologic Disorders: cutaneous andDermatologic Disorders: cutaneous and
oralmanifestationsoralmanifestations
y Erythema multiforme
y Lichen planus
y Benign mucous membrane pemphigoid
y Bullous pemphigoid
y Pemphigus vulgaris
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Dermatologic DisordersDermatologic Disorders
y Erythema multiforme
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
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Acute ulcerativeAcute ulcerative
y Erythema multiforme
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 erythematousperiphery
central area that can develop bullae, vesicles.
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Dermatologic DisordersDermatologic Disorders
y Erythema multiforme
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Erythema MultiformeErythema Multiforme
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Erythema MultiformeErythema Multiforme
y Clinically Oral mucosa and lips
demonstrate aphthous likeulcers and occasionallyvesicles or bullae may be
present. Gingiva rarely involved;
common sites includelabial mucosa, palate,tongue, and buccal mucosa
Mucosal ulcers are irregularin size and shape, tenderand covered with fibrinousexudate.
Sialorrhea, pain,odynophagia, dysathria.
Severe EM are associatedwith involvement of other
mucosal sites- eyes,genitalia, and less commonesophagus and lungs
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Erythema MultiformeErythema Multiforme
y Histopathology]
Intense lymphocytic infiltration in a perivasculardistribution and edema from submucosa into the
lamina propria, epithelium lack antibodies, bloodvessels contain fibrin, C3, IgM
y Treatment- with oral involvement only can
treat symptomatically/short course ofcorticosteroids
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Dermatologic DisordersDermatologic Disorders
y Lichen planus
Chronic disease of skin and mucousmembranes
Destruction of basal cell layer by activatedlymphocytes
Reticular: fine, lacy appearance on buccalmucosa (Wickmans striae)
Hypertrophic: resembles leukoplakia
Atrophic or erosive: painful
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Oral lichen planusOral lichen planus
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Dermatologic DisordersDermatologic Disorders
y Lichen planus
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Oral lichen planusOral lichen planus
y Small risk of squamous cell carcinoma,more likely seen in the atrophic orerosive types
y Studies show that dysplasia withlichenoid features have significantdegree of alleic loss.
y
Recommendation is to remove theselesions/follow patient closely
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Dermatologic DisordersDermatologic Disorders
y Lichen planus
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Dermatologic DisordersDermatologic Disorders
y Lichen planus
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Dermatologic DisordersDermatologic Disorders
y Benign mucous membrane pemphigoid
Tense subepithelial bullae of skin and mucousmembranes
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
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Dermatologic DisordersDermatologic Disorders
y Benign mucous membrane pemphigoid
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Dermatologic DisordersDermatologic Disorders
y Benign mucous membrane pemphigoid
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Dermatologic DisordersDermatologic Disorders
y Pemphigus vulgaris Severe, potentially fatal
Jewish andI
talians Intraepithelial bullae and acantholysis
Nikolskys sign
Loss of intracellular bridges
Autoimmune response to desmoglein 3 Intraepithelial clefting
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Dermatologic DisordersDermatologic Disorders
y Pemphigus vulgaris
D l D dD l D d
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Dermatologic DisordersDermatologic Disorders
y Pemphigus vulgaris
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ORAL CAVITY LESIONSORAL CAVITY LESIONS
Frederick Mars Untalan, MD