1. Non-neoplastic diseases of oral cavity
Dr. Vishal Sharma

2. Common diseases  Sub-mucous fibrosis  Aphthous ulcer
 Leukoplakia  Erythroplakia
 Oral candidiasis  Oro-labial Herpes
 Vincent’s infection  Infectious mononucleosis
 Tongue tie  Geographic tongue
 Ranula  Mucocoele

3. Oral pre-malignant conditions
Oral sub-mucous fibrosis
Leukoplakia & Erythroplakia
Oral candidiasis
Lichen planus
Nicotinic stomatitis (smoker’s palate)
Tertiary syphilis
Mucosal hyper-pigmentation (melanosis)

4. Ulcers of oral cavity

5. Infection: Herpes, Vincent’s infection, Candidiasis
Auto-immune: Aphthous ulcer, Behcet’s syndrome
Trauma: cheek bite, jagged tooth, ill-fitting denture chemical burn, thermal burn
Skin disorder: Lichen planus, erythema multiforme
Blood disorder: Leukemia, agranulocytosis, pancytopenia, sickle cell anemia
Drug allergy: mouth wash, toothpaste
Neoplasm: benign, malignant
Others: Radiation, chemotherapy, diabetes, uremia

6. Oral sub-mucous fibrosis

7. Definition Term coined by S.G. Joshi in 1953
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

8. 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
7. Excessive consumption of chilies (controversial)

9. Etiology

10. 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)
Hearing loss (stenosis of Eustachian tubes)
Nasal intonation (ed soft palate mobility)

11. Clinical Staging
Stage of stomatitis: red mucosa  vesicles  rupture to form mucosal ulcers
Stage of fibrosis (healing): blanching of mucosa, fibrous bands in oral mucosa, trismus, ed soft palate mobility
Stage of sequelae: difficult speech, hearing loss, leukoplakia, malignancy (3 - 8 %)

12. Blanched mucosa

13. Early fibrosis in lower lip

14. Early & advanced trismus

15. Medical Treatment
1. Bi-weekly submucosal intra-lesional injections of Dexamethasone 4 mg + Hyaluronidase 1500 IU for wks
2. Submucosal injection of human placental extract
3. Vitamin B complex + anti-oxidant supplement
4. Avoid consumption of mucosal irritants
5. Increased intake of fruits & vegetables

16. Dynamic splints for trismus

17. Surgical treatment for trismus
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

18. Aphthous ulcer (canker sore)

19. 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

20. Types
1. Minor aphthous ulcer: 2 – 10 mm in size, multiple, heal with no scar in weeks
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

21. Minor aphthous ulcer

22. Rule out HIV & malignancy
Major aphthous ulcer
Rule out HIV & malignancy

23. Herpetiform aphthous ulcers

24. Trigger factors for auto-immune injury
Deficiency: vitamin B complex, iron, folic acid, zinc
Stress: emotional & physical
Trauma: cheek bite, ill-fitting dentures
Hormonal imbalance: changing progesterone level
Allergy: sodium lauryl sulphate (mouth wash & paste)
Drugs: NSAIDs, cancer chemotherapy
Others: Behcet’s syndrome, HIV, Crohn’s disease
Infection: controversial

25. Treatment of aphthous ulcer

26. 1. Avoid trigger factors
2. Supplement: vitamin B complex + folic acid + iron
3. Topical gel combination: ZYTEE, QUADRAJEL 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 mg daily

27. Behcet’s syndrome Uveitis + Aphthous ulcer + Genital ulcer
Oculo – Oro - Genital syndrome
Tx: steroid

28. Leukoplakia

29. Introduction
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: % (average 5 %)
Sites: Buccal mucosa, tongue, lips, palate, floor of mouth, gingiva, alveolar mucosa

30. Etiology Chronic smoking Chronic tobacco chewing
Irritation from jagged teeth or ill-fitting dentures
Chronic alcohol consumption
Sun exposure to lips
Associated: submucous fibrosis, hyperplastic candidiasis, Plummer-Vinson syndrome, AIDS

31. Types of leukoplakia 1. Homogeneous leukoplakia: smooth, white
2. Nodular leukoplakia: nodular, white
3. Verrucous leukoplakia: warty, white
4. Speckled (erythro) leukoplakia: white + red
Malignant potential:
speckled >> nodular & verrucous >> homogenous

32. Homogenous Leukoplakia

33. Nodular Leukoplakia

34. Verrucous leukoplakia

35. Speckled (erythro) leukoplakia

36. Layers of epidermis

37. Pathological stages Hyperkeratosis: thickening of stratum corneum
Parakeratosis: keratinization with retention of nuclei in stratum corneum (homogeneous leukoplakia)
Acanthosis: thickening of stratum spinosum (verrucous & nodular leukoplakia)
Dyskeratosis: abnormal keratinization present below stratum granulosum (speckled leukoplakia)

38. Investigations 1. Supra-vital staining / Ora-screen: Toluidine
blue solution stains
areas of malignancy
2. Biopsy: to rule out
malignancy

39. D/D of oral white lesions
Leukoplakia
Hyperkeratosis
Hypertrophic candidiasis
Hairy leukoplakia (Epstein-Barr virus infection)
Lichen planus
Oral sub-mucous fibrosis
Lupus erythematosus
White sponge nevus
Carcinoma

40. 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

41. Cold knife excision
AFTER
BEFORE

42. Laser excision
AFTER
BEFORE

43. Erythroplakia (Erythroplasia)

44. 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
Red colour due to vascular submucosal tissue shining through under-keratinized mucosa
Malignant potential: 17 times > leukoplakia
Tx: excision biopsy

45. Erythroplakia

46. Oral candidiasis (Moniliasis)

47. 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

48. Types of oral candidiasis
Chronic hyperplastic: white plaques, cannot be removed by scraping (Candidal leukoplakia)
Pseudo-membranous: loosely adherent white lesions, can be scraped off leaving red patches
Erythematous (atrophic): smooth, red patches
Cheilitis: white lesions on angle of mouth

49. Hyperplastic

50. Pseudo-membranous (thrush)

51. Erythematous

52. Candidal Cheilitis

53. 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

54. Microscopic examination

55. Sabouraud dextrose agar

56. Vincent’s infection (Acute Necrotizing Ulcerative Gingivitis or Trench mouth)

57. Introduction Etiology: infection with spirochete Borrelia vincenti
& Gram –ve anaerobe Bacillus fusiformis
Predisposing factors:
Poor general health
Poor oro-dental hygiene
Dental caries

58. Clinical Features
1. 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

59. Early acute necrotizing ulcerative gingivitis

60. Advanced acute necrotizing ulcerative gingivitis

61. Vicent’s angina

62. 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

63. Infectious mononucleosis (glandular fever)

64. Introduction 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

65. Clinical Features

66. White patch on tonsil

67. 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%

68. Atypical lymphocytes

69. 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)
Avoid antibiotics  ineffective
Penicillin contraindicated  non-allergic rashes
Avoid opioid analgesics  respiratory depression

70. Oro-labial Herpes simplex infection (cold sore)

71. Primary Herpes simplex
Seen in children
Oral cavity: multiple vesicles  later ulcerate
Fever + sore throat
Neck node enlargement
Tx: Acyclovir 15 mg/kg PO 5 times/d for 7 days

72. 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
Tx: Acyclovir 200 mg PO 5 times / day X 7 days

73. Herpes simplex labialis

74. Herpes simplex of tongue

75. Oral Lichen planus

76. Etiology: unknown (? hypersensitivity reaction)
Types of oral lichen planus:
Reticular: reticular white lines (Wickham’s striae)
Erosive: reticular pattern with areas of ulceration
Plaque: solid white lesion
Skin lesions: purple, polygonal, pruritic papules
Treatment:
Reticular & plaque types: no treatment required
Erosive type: topical or systemic steroids

77. Reticular lichen planus

78. Erosive lichen planus

79. Lichen planus plaque

80. Stevens – Johnson syndrome

81. 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

82. 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

83. Hemorrhagic crusting of lips

84. 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.

85. Nicotinic stomatitis Seen in pipe smokers & reverse smokers
Cobblestone mucosa of postr hard palate, with red dot in center
Tx: smoking cessation

86. Geographic tongue Synonym: glossitis migrans
burning sensation over tongue that worsens with hot, spicy or acidic foods
Red areas over tongue dorsum devoid of papillae & surrounded by irregular keratotic white line
Lesions keep changing their shape (map-like appearance of tongue)
Tx: Avoid irritant food. Vitamin B + Zinc.

87. Geographic tongue

88. Black hairy tongue Elongated filiform papillae on tongue due to excess
keratin formation. Become
infected with chromogenic
bacteria & look like hairs.
Etiology: smoking
Tx: scraping of tongue

89. Fissured tongue & hyperkeratosis

90. Median rhomboid glossitis
Red rhomboid area on
lingual dorsum anterior to
foramen caecum
Due to persistence
(invagination failure) of
tuberculum impar or
chronic candidal infection
No tx required

91. Tongue-tie or Ankyloglossia

92. Congenital anomaly with decreased mobility of tongue tip caused by short, thick lingual frenulum
Diagnosis: inability to protrude tongue tip beyond lower central incisors
Effects: speech problem (?), feeding difficulty, bad oral hygiene
Tx: horizontal incision + vertical closure of frenulum

93. Pre-operative

94. Horizontal incision planned

95. Horizontal incision made

96. Vertical suturing done

97. Post-operative

98. Lip mucocoele

99. Etiology: Lip trauma injures its tiny salivary ducts
 extravasation of mucus & saliva in surrounding
tissues with lining of granulation or connective
tissue  smooth, soft round fluid-filled mucocoele
Commonly affects lower lip
Tx: Lip mucocoeles usually resolve spontaneously
If they recur frequently or become problematic:
a. marsupialization of mucocoele
b. complete surgical excision of mucocoele with adjacent minor salivary glands

100. Complete surgical excision

101. Ranula

102. Introduction
Rana means frog (blue translucent swelling in floor of mouth looks like underbelly of frog)
Simple ranula: Bluish cyst located in floor of mouth. Painless mass, does not change in size in response to chewing, eating or swallowing
Plunging ranula: Sub-mandibular neck swelling with or without cyst in floor of mouth

103. Simple Ranula

104. Plunging ranula

105. Plunging ranula

106. Etiology
Simple ranula: partial obstruction or severance of sublingual duct leads to epithelial-lined retention cyst. Commonly traumatic.
Plunging ranula: 1. sublingual gland projects
through or behind mylohyoid muscle
2. ectopic sublingual gland on
cervical side of mylohyoid muscle

107. Treatment
Marsupialization: un-roofing of cyst & suturing of cyst margin to adjacent tissue. Failure = 60-90%
Sclerosing agents: intra-lesional injection of Bleomycin or OK-432
Intra-oral excision: of ranula alone (failure = 60%) or ranula + sublingual gland (failure = 2 %)
Trans-cervical approach for plunging ranula: complete removal of cyst + sublingual gland

108. Marsupialization

109. Intra-oral excision

110. Ranula specimen

111. Thank You