1. Diseases of the Oral Cavity
Presented by:
Bastaninejad, Shahin, MD, ORL-HNS, TUMS, Amir’Alam Hospital

2. Anatomy: Oral cavity Oral cavity Lips Tongue Floor of Mouth
Buccal mucosa
Palate
Retromolar trigone

3. Diseases of the oral cavity
Reactive lesions
Inflammatory lesions
Oral cancer
Precancerous lesions (Leukoplakia & erythroplakia)
Benign Tumors of Oral Cavity

4. Reactive lesions 1-Irritation fibroma : Most common
61 % of all the reactive lesions
Can occur throughout the oral cavity
Most common along the "bite line."
Microscopically: fibrous tissue covered by squamous mucosa.

6. Reactive lesions Giant cell epulis 2-Pyogenic granulomas 12 %
Highly vascular lesions similar to granulation tissue.
3-Peripheral giant cell granuloma (giant cell epulis) 5%
Aggregation of multinucleated foreign body-like giant cells
Separated by fibroangiomatous stroma.
Giant cell epulis

7. Epulis
Epulis is a clinical term applied to swellings at the gum margin.
Most of them are granulomas associated with chronic gingivitis
A few are true neoplasms

8. Diseases of the oral cavity
Reactive lesions
Inflammatory lesions
Oral cancer
Precancerous lesions (Leukoplakia & erythroplakia)
Benign Tumors of Oral Cavity

9. Inflammatory lesions Viral infection Fungal infection
Bacterial infection
A - Vincent’s angina
B - Syphilis
C - Oral tuberculosis
4. Aphthous ulcers (aphthous stomatitis)
5. Dermatoses

10. Inflammatory Lesions Inflammation of the mouth (Stomatitis)
Inflammation of the Lips (Cheilitis)
Inflammation of the soft tissues around teeth typically resulting from inadequate oral hygiene (Gingivitis)
Inflammmation of the tongue (Glossitis).
Glossitis more commonly applied to the "beefy-red" tongues of certain deficiency states (e.g.; vitamin B12, and iron, deficiencies).
Other causes of glossitis: hot and spicy foods, chronic irritation by excessive smoking, ragged tooth or syphilitic inflammation

11. 1-Viral Infection Herpes Simplex Virus (HSV) Infections (Cold Sores)
Herpes simplex virus (usually type 1) infection causes "cold sores"
The virus infects the mouth in children.
Most adults have had HSV1 infection, but it remains latent and produces this small sore:
During periods of stress
From local trauma
Environmental changes
Cold sores consist of numerous vesicles and shallow ulcerations.
Cold sore of lower lip (herpes labialis)
Sore = abraded or painful area of the body

13. HSV Cont. Antipyretics, analgesics, hydration
Treatment
Antipyretics, analgesics, hydration
Valacyclovir and famciclovir inhibit viral DNA polymerase – help to suppress and control symptoms, but does not cure (given for 1 week)
If catch in the prodrome - 5% acyclovir cream for 1 week has shown to shorten course or completely abort reactivation altogether
KEY TO DIAGNOSIS – Clinical + Fluid analysis (PCR) and/or serology (Elisa, Western Blot)

14. Coxackie virus & measles
Coxackie A virus causes herpangia
Acute vesiculo-ulcertaive mucosal lesion
Occurs in epidemics
Affects children
Begins in tonsils, soft palate & uvula
Painful
Heal spontaneously within few days
Koplik’s spots are a feature of measles
Herpangia
Koplik’s spots

16. Herpangina

17. Oral Candidiasis ( Thrush, Monaliasis )
Candida albicans is an oral commensal in 20-40% of population.
Infection occurs in:
Infants
Patients on broad spectrum antibiotics, steriod or cytotoxic therapy
Diabetes
Neutropenia
Immunodeficiency (AIDS)
Presents as superficial gray-white inflammatory membranes comprising fungus in a fibrinosuppurative exudate.
White exudate can be removed by scraping
Exudate bleeds on removal ?

18. Erythematous Candidiasis

19. Candidiasis Cont. Treatment Mild, acute forms – topical Nystatin
Mild, chronic – topical Nystatin + Clotrimazole troches (troche=lozenge)
Refractory or immunocomprimised WITHOUT systemic involvement – add oral Fluconazole
Severe forms (systemic) – IV Amphotericin B with or without Fluconazole
KEY TO DIAGNOSIS: Clinical + KOH Prep; culture and serum (1,3)β-D-glucan detection assay if unclear

20. Bacterial Infection A - Vincent’s angina (Trench muoth, Acute ulcerative gingivitis)
Caused by Borellia vincenti and fusiform bacilli
Both are normal inhabitants of oral cavity
Decreased resistance (inadequate nutrition, immunofeciency) is a predisposing factor to infection
Punched out erosions → ulceration → spreads → invovles all gingival margin, which become covered by a necrotic pseudomembrane

22. Bacterial Infection B - Syphilitis
A-Ulcerated chancre
B-Ulcerated mucous
patches (snail track ulcers)
C-Gummatous ulcer
C - Tuberculosis of
The Tongue

25. Apthous Ulcers (Canker Sores)
Apthous ulcers are extremely common lesions (up to 20% of population)
They are painful, multiple, small, shallow, recurrent ulcerations
Presented clinically as white lesions (1<,1> CM)
Etiology is unknown
Aphtha = Whitish spot

26. Aphthous Ulcers Cont.
Most common cause of non-traumatic ulcerations of the oral cavity
Etiology unclear
10-20% of general population
Diagnosis of exclusion
Classifications
Minor aphthous ulcer
< 1cm in diameter
Located on freely mobile oral mucosa
Appears as a well-delineated white lesion with an erythematous halo
Prodrome of burning or tingling in area prior to ulcer’s appearance
Resolve in 7-10 days
Never scars
Major aphthous ulcer
> 1cm in diameter
Involves freely mobile mucosa, tongue, and palate
Last much longer – 6 weeks or more
Typically scar upon healing

27. Aphthous Ulcers Cont.
Herpetiform ulcers
Small, 1-3mm in diameter ulcerations appearing in crops of ulcers
Typically located on mobile oral mucosa, tongue, and palate
Last 1-2 weeks
Called herpetiform because ulcerations resemble those of HSV, but there is no vesicular phase
Treatment
Topical tetracycline solution for 5-7 days has shown good results
Topical steroids shown to shorten disease duration
Sucralfate suspension shown to improve pain as well as shorten disease duration
Major aphthous ulcers or more severe forms of disease require 2 week course of systemic steroids
KEY TO DIAGNOSIS: Diagnosis of exclusion; clinical appearance/course

29. Dermatoses
Lichen planus
White plaques

30. whitish linear lesions in lacy pattern

31. Diseases of the oral cavity
Reactive lesions
Inflammatory lesions
Oral cancer
Precancerous lesions (Leukoplakia & erythroplakia)
Benign Tumors of Oral Cavity

32. Squamous Cell Carcinoma constitutes 95% of oral cancers
Incidence:
Geographic variation:
Accounts for 2% of cancers in UK
Commoner in S. East Asia
Ages & sex :
Old Men (50-60 years)
Site :
Lip (lower lip)
Tongue (anterior ⅔)
Mouth floor
Tonsil and Fauces

33. Oral Cancer 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, lap, 8p, and 3p are implicated).
5- Exposure to ultra-violet light (cancer of the lip).

34. Squamous cell carcinoma of lip
Gross:
Ulcerated nodule with raised everted edges
Often on lower lip
Histologically:
Well differentiated squamous carcinomas
Spread:
Growth is relatively slow
Submandibular nodes
Deeper cervical lymph nodes

35. Squamous cell carcinoma of Tongue & Floor of the mouth
More aggressive than tumors of the lips
Grossly starts as a nodule → malignant ulcer
Spread:
1-Local
Local infiltration to floor of the mouth, facuces and pharynx leads to fixation the tongue, interfering with speech and swallowing.
Local spreads into the medullary cavity of the mandible.
2-lymphatic spread (occurs early) → deep cervical lymph nodes.

36. Squamous Cell carcinoma of the Tongue
Perform incisional Bx in any oral lesion persist for more than 2wks

37. Relationship between location& prognosis of squamous cell carcinoma of oral cavity
Prognosis is best with lip lesions
Poorest with mouth floor and tongue base lesions (20%-30% 5-year survival rate ).

38. Uncommon Malignant Tumors of The Oral Cavity
Malignant melanoma
Lymphomas
Leukemic infiltration
Adenocarcinoma of minor salivary glands
Sarcomas
Acute Leukemia: gum involvement

39. Diseases of the oral cavity
Reactive lesions
Inflammatory lesions
Oral cancer
Precancerous lesions (Leukoplakia & erythroplakia)
Benign Tumors of Oral Cavity

40. Oral Premalignant Lesions
Leukoplakia
Whitish plaque that cannot be scrapped off
5-20% malignant potential
Microscopic examination reveals hyperkeratosis and atypia
Lesions on lateral tongue, lower lip, and floor of mouth more likely to progress to malignancy
Erythroplakia
Red patch or macule with soft, velvety texture
Much higher chance of harboring malignancy – 60-90% of untreated cases
Treatment is surgical excision or laser ablation

41. Precancerous Lesions Leukoplakia and Erythroplakia
Causes include:
1- Chronic tobacco use (pipe - smoking).
2- Chronic irritation (e.g.; dentures).
2- Alcohol abuse.

42. Hairy Leukoplakia An oral lesion seen in HIV infected, AIDS patients
Caused by Epstein-Barr virus (EBV) infection, often with superimposed candida
Lesions are white patches of fluffy ("hairy") hyperkeratosis on tongue lateral borders.

43. Diseases of the oral cavity
Reactive lesions
Inflammatory lesions
Oral cancer
Precancerous lesions (Leukoplakia & erythroplakia)
Benign Tumors of Oral Cavity

44. Benign Tumors of Oral Cavity
Cavernous hemangioma
1-Squamous cell papilloma.**** 2-Capillary hemangioma 3-Cavernous hemangioma & lymphangioma → macrochelia & macroglossia 4-leiomyoma 5-Schwannoma

45. Bastaninejad, Shahin, MD