common oral lesions by ravindra daggupati
DESCRIPTION
oral lesions with diagrams,,,with journal included discussing common oral lesions in indiaTRANSCRIPT
ORAL DERMATOLOGICAL
CONDITIONS
MODERATOR:Dr.MOHANTYPRESENTER:RAVINDRA.D
Anatomy: Oral cavity
• Oral cavity
o Lipso Tongueo Floor of MouthoBuccal mucosao PalateoRetromolar
trigone
Sub-mucous fibrosis Aphthous ulcer
Leukoplakia Erythroplakia
Oral candidiasis Oro-labial Herpes
Vincent’s infection Infectious mononucleosis
Tongue tie Geographic tongue
Ranula Mucocoele
Common diseases of oral cavity
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
1.Aphthous ulcer
1. Minor aphthous ulcer: 2 – 10 mm in size, multiple, heal with no scar in 1 - 2 weeks
Rule out HIV & malignancy
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
TREATMENT
1. Avoid trigger factors
2. Supplement: vitamin B complex + folic acid + iron
3. Topical gel combination:
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
2.Behcet’s syndrome• Uveitis + Aphthous ulcer
+ Genital ulcer
• Oculo – Oro - Genital syndrome
• Treatment : steroid
3.Oral candidiasis• 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
1.Chronic hyperplastic: white plaques, cannot be removed by scraping (Candidal leukoplakia)
TYPES
2.Pseudo-membranous: loosely adherent white lesions, can be scraped off leaving red patches
3.Erythematous (atrophic): smooth, red patches
4.Cheilitis: white lesions on angle of mouth
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
4.Vincent’s infection (Acute
Necrotizing Ulcerative Gingivitis or
Trench mouth)
Etiology: infection with
spirochete Borrelia vincenti
& Gram –ve anaerobe
Bacillus fusiformis
Predisposing factors:
• Poor general health
• Poor oro-dental hygiene
• Dental caries
CLINICAL FEATURES1. 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
STAGES
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
Primary Herpes simplex• Seen in children
• Oral cavity: multiple
vesicles which later
ulcerate
• Fever + sore throat
• Neck node enlargement
• Treatment: Acyclovir 15
mg/kg PO 5 times/d for 7
days
5.Oro-labial Herpes simplex infection (cold sore)
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
• Treatment: Acyclovir 200 mg PO 5
times / day X 7 days
Other Bacterial Infections
A-Ulcerated chancre B-Ulcerated mucous patches (snail track ulcers)
C-Gummatous ulcer
Tuberculosis of The Tongue
Syphilis
6.Trauma:CHEEK BITING ILL-FITTING DENTURES
CHEMICAL BURNS ABRASIONS FROM TEETH
7.Infectious mononucleosis (glandular fever)
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
• 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%
• 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)
8.Submucosal fibrosis • 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
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)
•This patient has so much of limitation in opening of mouth
that it is difficult to put even 2 fingers in the mouth
• Hearing loss (stenosis of Eustachian tubes)
• Nasal intonation (ed soft palate mobility)
•STAGES
1. Stage of stomatitis: red mucosa vesicles rupture to form mucosal ulcers
2. Stage of fibrosis (healing): blanching of mucosafibrous bands in oral mucosa,
trismus, deceased soft palate mobility
3. Stage of sequelae: difficult speech, hearing loss,leukoplakia, malignancy (3 - 8 %)
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. Increased intake of fruits &
vegetables
SURGICAL TREATMENT
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
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 with: submucous fibrosis, hyperplastic candidiasis, Plummer-Vinson
syndrome, AIDS
9.Leukoplakia
TYPES
1. Homogeneous leukoplakia: smooth,white
2. Nodular leukoplakia: nodular, white
3. Verrucous leukoplakia: warty, white4. Speckled (erythro) leukoplakia: white + red
Malignant potential: speckled >> nodular & verrucous >> homogenous
INVESTIGATIONS
1. Supra-vital staining /
Ora-screen: Toluidine
blue solution stains
areas of malignancy
2. Biopsy: to rule out
malignancy
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
10.Erythroplakia 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
o Red colour due to vascular
submucosal tissue shining through
under-keratinized mucosa
o Malignant potential: 17 times >
leukoplakia
o Treatment : excision biopsy
11.Oral lichen planusEtiology: unknown (? hypersensitivity reaction)
Types of oral lichen planus:
SKIN LESIONS: purple, polygonal, pruritic papules
TREATMENT: Reticular & plaque types: no treatment required Erosive type: topical or systemic steroids
12.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
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.
14.Nicotinic
stomatitis• Seen in pipe smokers & reverse
smokers
• Cobblestone mucosa of postr hard
palate, with red dot in center
• treatment: smoking cessation
Elongated filiform papillae on tongue due to excess keratin formation. Become infected with chromogenic bacteria & look like hairs.
• Etiology: smoking
• Treatment : scraping of tongue
13.Black hairy tongue
15.ORAL CANCER Squamous Cell Carcinoma constitutes 95% of oral cancers
Common in Old Men (50-60 years)
COMMON SITES :
1. Lip (lower lip)2. Tongue (anterior ⅔) 3. Mouth floor4. Tonsil and Fauces AETIOLOGY:1. Tobacco and alcohol are the most common associations: Smokers can have 15-fold greater risk ( than nonsmokers ) of malignancy. Chewing tobacco and betel nuts are important causes in India and parts of Asia 2. Leukoplakia and Erythroplakia 3. Human papilloma virus (HPV) (type16) 4, Genetic factors may also play a role (deletions in chromosomes 18q, 8p, and 3p are implicated). 5. Exposure to ultra-violet light (cancer of the lip).
Squamous cell ca. of lip Squamous Cell carcinoma of the Tongue
Uncommon Malignant Tumors of The Oral Cavity
• Malignant melanoma• Lymphomas• Leukemic infiltration• Adenocarcinoma of
minor salivary glands• Sarcomas
Acute Leukemia: gum involvement
JOURNAL PROPER
INTRODUCTION
• Very often the oral dermatological conditions involving oral cavity are misdiagnosed and proper attention and care is not given.
• This study is to sensitize the clinicians to the prevailing situation of oral dermatological conditions.
MATERIALS & METHODS• A total of 150 cases were
taken up for the study irrespective of age,sex,duration of lesions attending dermatology/ENT dept. during 1 year period.
• The following areas were taken into consideration:
1. Site of lesion2. Morphology3. Extent of lesion4. Discharge if any5. Margins of lesion6. Floor and base of lesion7. Regional lymphnodes if any
• Investigations done are:
1. Routine blood,urine and stool tests
2. Scrapings,KOH mount3. Tzank test4. Gram stains5. Biopsy for certain
cases.6. Special tests were
done for systemic diseases if indicated
OBSERVATIONS AGE(yr.) MALE FEMALE TOTAL % (out of
150)
0-10 4 4 8 5.33%
11-20 12 20 32 21.33%
21-30 13 22 35 23.34%
31-40 13 24 37 24.67%
41-50 9 14 23 15.33%
>50 9 6 15 10.00%
TOTAL 60 90 150
AGE DISTRIBUTION
0--10 11--20 21--30 31--40 41--50 >500
5
10
15
20
25
30
4
1213 13
9 9
4
2022
24
14
6
MALEfemale
AGE IN YEARS
NO
.
OF
PA
TIE
NTS
AGE AND SEX DISTRIBUTION
DISEASES WITH ORAL MANIFESTATIONSDISEASES NO.OF PATIENTS % OUT OF 150
Aphthous ulcer 16 28.57%
Oral candidiasis 9 16.07%
Angular chelitis 6 10.71%
Oral leukoplakia 4 7.14%
Fixed drug eruption 4 7.14%
Squamous cell ca. 3 5.36%
Fordyce spot 2 3.57%
Herpes simplex stomatitis 2 3.57%
Oral sub mucosal fibrosis 6 10.71%
Mucocele 2 3.57%
Leukemia 1 1.79%
Warts 1 1.79%
Scrotal tongue 1 1.79%
DISCUSSION• Pt.s having oral diseases
presents with different signs and symptoms like
Oral pain,soreness,burning, xerostomia,bleeding, swelling, change ofcolour,erosion,crusting,Ulcers,fissuring• The study has recorded 25 pt.s of
pemphigus vulgaris having both cutaneous manifestations, revealing that this is the common lesion.
• The study shows that buccal mucosa was the most commonly affected site(68%),followed by palates(56%),lips(44%),tongue(40%),labial mucosa(16%).
pemphigus vulgaris
• Collagen diseases form the next common group. Among this systemic lupus erythematosus is major one, and most of the lesions are confined to palate.
• The study recorded 13 cases of discoid lupus erythematosus,with lips being the commonest site.
• Among the specific cutaneous disorders,16 cases of recurrent aphthous stomatits have been recorded,with labial mucosa being common site.,and most common one was minor type.
• 12 pts of lichen planus were recorded with lip&cheek being common sites, and common in age group of 20-40.
• Infective disorders constitute 10% of study with candidiasis being common one.common site of involvement is dorsal tongue.
• The study also recorded 6 cases of oral submucosal fibrosis with cheeks(buccal mucosa) being common site.
• 4 pts of oral leukoplakia have been recorded with buccal mucosa being common site of involvement.
• 6 pts of angular stomatitis have been recorded with lesions on lips and buccal mucosa..
Diseases with oral and cutaneous
manifestationsDISEASES NO.OF PTS. % OUT OF 94
Pemphigus vulgaris 25 26.60%
Pemphigus vegetans 2 2.13%
Stevens Johnson's syndrome 8 8.15%
Toxix epidermal necrosis 4 4.26%
Erythema multiforme 1 1.06%
Discoid lupus erythematosus 13 13.83%
Systemic lupus erythematosus
16 17.02%
Systemic sclerosis 6 6.38%
Lichen planus 12 12.77%
Vitiligo 6 6.38%
Pie diagram showing distribution of
lesions
37.33
62.67
ORAL LESIONS
ORAL&CUTANEOUS LESIONS
CONCLUSIONS• Oral mucous membrane alone may be involved in
some disesases,but it is often missed by clinician.
• This can be taken care of by primary health care providers without going through much sophisticated investigations and thus early intervention for patients.
BIBLIOGRAPHY• INDIAN JOURNAL OF OTOLARYNGOLOGY AND
HEAD &NECK SURGERY(apr-june 2013)• SCOTT&BROWN 6TH EDITION• TEXT BOOK OF DERMATOLOGY BY NEENA KHANNA
• Next academic session:
18-11-13-MONDAY
CASE PRESENTATION BY
Dr.SUSRUTHA
Thank you