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

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Presentation on theme: "Non-neoplastic diseases of oral cavity Dr. Vishal Sharma."— Presentation transcript:

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

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

3 Oral pre-malignant conditions 1.Oral sub-mucous fibrosis 2.Leukoplakia & Erythroplakia 3.Oral candidiasis 4.Lichen planus 5.Nicotinic stomatitis (smokers palate) 6.Tertiary syphilis 7.Mucosal hyper-pigmentation (melanosis)

4 Ulcers of oral cavity

5 Infection: Herpes, Vincents infection, Candidiasis Auto-immune: Aphthous ulcer, Behcets 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 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 Definition

8 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) Etiology (multi-factorial)

9 Etiology

10 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) Presenting symptoms

11 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 %) Clinical Staging

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 6- 8 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 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 Surgical treatment for trismus

18 Aphthous ulcer (canker sore)

19 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 Introduction

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 Major aphthous ulcer Rule out HIV & malignancy

23 Herpetiform aphthous ulcers

24 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: Behcets syndrome, HIV, Crohns disease Infection: controversial Trigger factors for auto-immune injury

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 Behcets syndrome Uveitis + Aphthous ulcer + Genital ulcer Oculo – Oro - Genital syndrome Tx: steroid

28 Leukoplakia

29 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 Introduction

30 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: submucous fibrosis, hyperplastic candidiasis, Plummer-Vinson syndrome, AIDS Etiology

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 1.Hyperkeratosis: thickening of stratum corneum 2.Parakeratosis: keratinization with retention of nuclei in stratum corneum (homogeneous leukoplakia) 3.Acanthosis: thickening of stratum spinosum (verrucous & nodular leukoplakia) 4.Dyskeratosis: abnormal keratinization present below stratum granulosum (speckled leukoplakia) Pathological stages

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 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 Treatment

41 Cold knife excision BEFORE AFTER

42 Laser excision BEFORE AFTER

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 Vincents infection (Acute Necrotizing Ulcerative Gingivitis or Trench mouth)

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

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 (Vincents angina) 2. Halitosis, neck lymph node enlargement & fever

59 Early acute necrotizing ulcerative gingivitis

60 Advanced acute necrotizing ulcerative gingivitis

61 Vicents 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 & H 2 O 2 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 (Wickhams 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: % 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


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

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