2 Cheilitis Exfoliativa Desquamative, recurrent, fissures if severe.MC upper lip if cause is unknown.MC lower lip if it is a reaction to other disease states, ie SD, AD, PV, Plummer-Vinson syndrome.Irritation: lipsticks, dentrifices, mouthwashes, shaving/aftershave, nail enamel, lip licking, UVTx: Remove cause, topical steroids, ointments
5 Actinic Cheilitis Lower lip MC, UV induced Ulceration is rare unless SCC is presentHereditary PMLE may resembleTreatment: Biopsy if thickened or ulceratedCyro, 5-FU, CO2 laser, Vermilionectomy,Photodynamic Therapy with 5-ALAH&E same as AK
7 Cheilitis Glandularis Swelling and eversion of lower lip with patulous openings of the ducts of the mucous glands - Chronic, inflammatory.Mucous exudes freely to form a glue-like film, lips stick together, palpation feels like pebbles beneath the surface.Apostematosa variant has abcess formation.Etiology: irritation, atopic, factitious, actinic
8 H&E – infiltration of lymphocytes, histiocytes and plasma cells in and around the ectatic glands.
9 Cheilitis Glandularis “STICKY LIPS” TX SAME AS ACTINIC CHEILITIS
10 Angular Cheilitis (Perleche) MC Candida albicansLabial commisures, moist fissuresElderly – facial and dental architectureYouth – thumbsucking, lollipops,Thrush in DM II or HIV, Tumoral calcinosis, Deficiency of Iron, Riboflavin, Vitamin A, E, etc.
11 Treatment: Dental consultation - dentures Topical nystatin with iodochlorhydroxyquin (Vioform) in hydrocortisone ointment.Injection of dermal filler substances, excision, flap.
12 Plasma Cell CheilitisSharply outlined, infiltrated, dark red plaque with a laquer-like glazing of the surface of the lower lipSimilar to Zoon’s balanitis plasmacellularisBand-like infiltrate of plasma cellsReaction pattern to any number of stimuliClobetasol propionate bid, Griseofulvin 500mg qd.
13 BAND-LIKE INFILTRATE OF PLASMA CELLS CHARACTERISTIC KERATINOCYTES ARE DIAMOND-SHAPED OR LOZENGE SHAPED
14 Plasmoacanthoma Advanced version of Plasma Cell Cheilitis Verrucous tumor with plasma cell infiltrateCandida albicans may be found in the lesionsUsually grows along the angles of the mouth
15 Drug-Induced Ulcer of the Lip May be confused with ulcers of DLE or SCCPhenylbutazoneChlorpromazinePhenobarbitalMethyldopaThiazide diureticsFixed-Drug/Photo?
16 Other forms of Cheilitis Lichen PlanusSLEPsoriasisLip Biting
17 Oral Crohn’s Disease 10-20% of Crohn’s patients 90% have granulomas on biopsyInflammatory hyperplasia of oral mucosa, cobblestoning, fissuring,Metallic dysgeusiaGingival bleedingMetastatic Crohn’s – non-caseating granulomatous skin lesions in patients with Crohn’s.
19 Pyostomatitis Vegetans Inflammatory stomatitis in setting of UC.Edema and erythema with deep folding of the buccal mucosa as well as pustules, small vegetating projections, erosions, ulcers and fibrinopurulent exudate.Pustules fuse into shallow ulcers resulting in characteristic “SNAIL TRACK” ulcersSkin lesions favor axilla, groin, scalp, crusted erythematous papulopustules that coalesce into asymmetrical annular plaques.
20 Red – edemaBlack – perivascular infiltrateBlue – abcess formation with eosinophilsTX – Systemic Steroids
21 Cheilitis Granulomatosa Sudden onset of lip swelling that progresses to permanent lip enlargmentUpper lip usually swells firstCause unknownHistology shows tuberculoid granulomas and an inflammatory reaction patternTX- IL steroids.
22 Pathology – tuberculoid granulomas with epithelioid and Langerhan’s giant cells
23 Melkersson-Rosenthal Syndrome Classic Triad starts in adolescenceLip enlargement (other areas may swell too)Scrotal TongueRecurring facial paralysisPathology similar to Cheilitis GranulomatosaR/O Ascher Syndrome – lip swelling, edema of eyelids (blepharochalasis)IL Steroids, Surgical nerve decompression, cosmetic surgery for lip reduction, Clofazimine, Thalidomide
25 Fordyce’s Disease (Spots) Ectopically located sebaceous glandsMinute orange or yellowish pinhead sized macules in mucosa of lipsTx: Isotretinoin
26 Stomatitis Nicotina “Smokers keratosis” “Smokers patches” Ostia of the mucous ducts appear as red pinpoints surrounded by milky white, slightly umbilicated papules on the palateMaceration, ulceration and aphthae.Heat may be causative event.Tx: Stop smoking, stop drinking hot liquids.
28 Torus PalatinusBony protuberance in the midline of the hard palate, asymtomatic
29 Scrotal Tongue May be congenital or familial. Large tongue with plicate superficial or deep grooves, longitudinal along the median rapheAssociations: Melkersson-Rosenthal Syndrome, Down’s Syndrome, Pachyonychia Congenita, Pemphigus Vegetans, Cowden’s Syndrome
30 Geographic TongueIsolated finding or associated with Atopic Dermatitis or PsoriasisAnnular atrophic areas looks like outlines of countries on a map, locations of lesions change weekly.Asymptomatic usuallyTopical 0.1% Tretinoin solution may clear in 4-6 days
31 Histology: epidermal hyperkeratosis and marked transepidermal migration of neutrophils (aka munro’s microabcesses). Cannot be differentiated histologically from pustular psoriasis or Reiter’s syndrome.
32 Black Hairy TongueBenign hyperplasia of the filiform papillae of the anterior 2/3 of the tongueEtio: smoking, oral antibiotics, CandidaHisto: elongated and stratified filaments composed of ortho and parakeratotic cells.TX: toothbrush, tretinoin, 40% urea, stop predisposing factors.
35 Moller’s Glossitis Painful, chronic, makes eating difficult Tip and lateral tongueIntensely red, well defined irregular patches in which the filiform papillae are absent and thinned and the fungiform papillae are swollen.Check for macrocytic anemia, if present Pernicious Anemia is likelyHypersegmented neutrophil
36 Glossitis of PellagraSides & tip of tongue are erythematous and edematous with imprints of teeth, “Beefy red” with smooth “glazed” appearance.Niacin, Tryptophan (Niacin precursor), Alcoholism.
37 4 D’s of Pellagra: diarrhea, dermatitis, dementia, death.
38 Median Rhomboid Glossitis Shiny oval or diamond shaped elevation, midline, directly in front of the circumvallate papillae.Candida species may be presentHisto: Chronic inflammation with fibrosis with occas. hyphae in areas of parakeratosisItraconazole helpful.
40 Eosinophilic Ulcer of the Tongue Ulcer with elevated borders usually covered by a pseudomembrane.MC posterior aspect of tongueRapid onset, spontaneously resolves in a few weeks. Benign, self-limited.Histo: Predominantly eosinophilic infiltrate with histiocytes and neutrophilsIf multifocal and recurrent CD30 positive lymphoproliferative disease may be present.
42 Caviar Tongue Small round purplish capillary telangiectasias Commonly found on underside of tongue after age 50Etio: elastic tissue deterioration
43 Dental SinusTooth abcess forms a sinus tract that opens on the skin as an inflammed noduleMC chin or jawlineMay palpate a cord-like tract beneath the lesionDental X-Ray diagnosticOther fistulas: SCC, Actinomycosis, osteomyelitis, deep fungal, foreign body
46 Leukoplakia Once regarded as precancerous Whitish patches or plaques of the mucous membranes.May or may not reveal cellular atypiaDiscussed in SCC lecture
47 ErythroplakiaLeukoplakia that has lost the thick macerated keratin layer.MC in mucocutaneous junctionsHistologically cellular atypia, pleomorphism, hyperchromatism, increased mitotic figures90% are SCC in situ or invasive.Moral: biopsy red areas in the setting of leukoplakia
49 Proliferative Verrucous Leukoplakia 70% become SCCF>M 4 to 1.Flat white areas on mucous membranes that thicken and become exophyticAssoc with HPV 16Aggressive early therapy is best.
50 SCC Lower lip has high metastatic rate. Intraoral lesions more likely in those who consume: Cigarettes, Chewing Tobacco, Betel Nuts, Alcohol.May complicate DEB, Erosive LP, XP, Dyskeratosis CongenitaIntraoral SCC has only 30% survival rate.
51 Aquired Dyskeratotic Leukoplakia 1 patientWhite plaques on palate, gingiva, lips and genitaliaUnique finding of clusters of dyskeratotic cells in the prickle cell layerLaser, Etretinate
52 Melanocytic Oral Lesions Intramucosal MC > Compound > JunctionalLabial melanotic macule – vermillion border of lower lip, sharply demarcated, young womenBlue nevus – dendritic cells in submucosaOral melanoacanthoma, young blacks, buccal mucosa after trauma, resolves in 40%Melanoma rare, mostly in elderly patients
54 Melanoacanthoma, variant of pigmented SK, melanocytes not restricted to basal layer
55 Oral Melanosis MC African Americans Things to keep in mind: McCune Albright Syndrome (dimple over 4th knuckle, Coast of Maine border, unilateral café au lait macule with bony abnormalities below it)Peutz-Jeghers (polyposis, colon cancer)Addison’s DiseaseTar, Heavy metal poisoning, dental amalgamsCis-platinum – gingival platinum line
56 Osseous Choristoma of the Tongue Nodule on dorsum of tongue.Contains mature lamellar bone or cartilageDoes not recur after excision.
57 Peripheral Ameloblastoma Rare invasive neoplasm of gingivaMC lower jawProbably BCC of oral mucosa per Lever
61 Low power shows a well circumscribed nodule with lobules of dilated and congested capillaries High power shows myxoid stroma and bland endothelial cells
62 Granuloma Fissuratum Discoid, folded “like a bent coin”, Chronic inflammatory fibrous hyperplasia
63 Angina Bullosa Haemorrhagica Sudden appearance of one or more blood blisters in the oral mucosaNo associated skin or systemic diseaseMay be recurrentMC on soft palate of middle-aged or elderly patientsNo treatment is necessary
64 Angina Bullosa Haemorrhagica Subepidermal bullaeKEY: bulla is filled with red blood cells.
65 MucoceleResult of trauma or obstruction of salivary ducts, usually on the lower lipSoft rounded translucent projection often with a bluish tint.
66 Acute Necrotizing Ulcerative Gingivostomatitis (Trench Mouth, Vincent’s Disease) “Punched out” ulcerations, rapid onset, painful, foul, fetid odorBacteroides fusiformis & Borrelia vincentiiTX: PCN, 3% H2O2 mouthwash, debridementR/O herpes infectionNOMA: severe variant in children with poor nutrition, gangrenous spread to bone may result in death.
67 NOMA, means “to devour” gangrenous, starts in the mouth as a benign oral lesion and rapidly destroys tissues of the mouth and face. MC under six years of age.Fatal in 70% and 90% of cases, survivors disfigured for lifeFlourishes where poverty is greatest, nutrition is poorest and hygiene is neglected.“Face of poverty”
68 Acatalasemia AKA “Takahara’s disease” AR, Rare, Japan Deficiency of Catalase enzyme in liver muscles, bone marrow, erythrocytes and skin.Recurrent alveolar ulcerations may progress to gangrene, tooth loss, resolves in puberty.Add H2O2 to blood: it turns blackish brown and the peroxide does not foamTX: Antibiotics and dental extractions.
69 Cyclic Neutropenia Decrease of circulating neutrophils Every 21 days neutropenia, mouth ulcerations, fever, malaise, arthralgias.Ulcers irregularly outlined and covered with grayish white sloughTX: Recombinant Colony Stimulating Factor, Cyclosporine, Antibiotics for infections, good dental hygiene.
71 Approach to Recurrent Apthous Stomatitis CBC – Anemia, B-12, Folate, Iron, NeutropeniaGI symptoms or surgeries ? – UC, Crohn’s, Celiac Dz, Malabsorption (B1, B2, B6)Genital or Ocular lesions? – think Behcet’s, or Reiter’s.Risk factors for HIV, AIDS ???Tzanck to R/O Herpes, RPR to R/O SyphillisBiopsy to rule out pemphigus, LP
72 RAS - Treatment Viscous Lidocaine 2% solution Dyclonine HCl, 0.5% 50/50 mix of Benadryl and MaaloxFluocinonide or Triamcinolone in Orabase.Beconase nasal SprayTCN 250mg dissolved in 5ml solution gargled for 2 minutes then swallowedApthasol paste (Amlexanox)Dapsone, Colchicine, Thalidomide
73 Recurrent Intraoral Herpes Simplex Infection Numerous small vesicles in clustersRupture abruptly to form punctate erosions with a red base.Tzanck smear shows multinucleated epithelial cells.MC Palate (Pearl: Herpangina and Apthous ulcers occur on non-attached mucosa, whereas recurrent Herpes simplex occurs on mucosa fixed to bone)
74 Periadenitis Mucosa Necrotica Recurrens (Major Apthous Ulcer) Sutton’s DzSharply circumscribed ulcer with deeply punched out and depressed craterHeals with scarTx: IL steroids
75 Behcet’s Syndrome (Oculo-Oral-Genital Syndrome) Oral ulcers that recur at least 3 times per year in the presence of any 2 of the following:1) Recurrent genital ulceration2) Retinal vasculitis, Ant./Post. Uveitis3) EN, Folliculitis, Papulopustular, Acneiform4) Positive pathergy test
76 Behcet’s DiseaseUlcers are 2-10mm, sharply circumscribed, with a dirty grayish base and a surrounding bright red halo.Eating may be painfulGenital lesions are similarOcular lesions start with intense periorbital pain and photophobia, conjunctivitisCNS – multiple sclerosis-likeGI symptoms due to intestinal ulcerations.Thrombophlebitis, Vasculitis, Arthralgia
79 Pathergy test – pustule forms 3-4 days after needle-stick Helpful for diagnosis, but usually negative even in the presence of Behcets’ Syndrome
80 HISTOLOGY OF BEHCET’S = LCV - A neutrophilic infiltrate surrounds the superficial capillary plexus in the papillary dermis, with destruction of small venules. There is fibrin deposition in the blood vessel walls, transmural migration of PMNs, extravasated RBCs and nuclear dust
82 Behcet’s Treatment Ulcerations usually heal spontaneously Oral hygiene – mild toothpastesSucralfate suspensionColchicine 0.6mg bidDapsone 100mg dailyThalidomide 200mg bid x 5 days then 100mg bid x daysMethotrexate for severe refractory cases