Non-neoplastic diseases of oral cavity Dr. Vishal Sharma

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

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)

Ulcers of oral cavity

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

Oral sub-mucous fibrosis

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

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)

Etiology

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)

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 %)

Blanched mucosa

Early fibrosis in lower lip

Early & advanced trismus

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

Dynamic splints for trismus

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

Aphthous ulcer (canker sore)

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

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

Minor aphthous ulcer

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

Herpetiform aphthous ulcers

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

Treatment of aphthous ulcer

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 50 -100 mg daily

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

Leukoplakia

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: 1 - 20% (average 5 %) Sites: Buccal mucosa, tongue, lips, palate, floor of mouth, gingiva, alveolar mucosa

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

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

Homogenous Leukoplakia

Nodular Leukoplakia

Verrucous leukoplakia

Speckled (erythro) leukoplakia

Layers of epidermis

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)

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

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

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

Cold knife excision AFTER BEFORE

Laser excision AFTER BEFORE

Erythroplakia (Erythroplasia)

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

Erythroplakia

Oral candidiasis (Moniliasis)

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

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

Hyperplastic

Pseudo-membranous (thrush)

Erythematous

Candidal Cheilitis

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

Microscopic examination

Sabouraud dextrose agar

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

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

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

Early acute necrotizing ulcerative gingivitis

Advanced acute necrotizing ulcerative gingivitis

Vicent’s angina

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

Infectious mononucleosis (glandular fever)

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

Clinical Features

White patch on tonsil

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%

Atypical lymphocytes

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

Oro-labial Herpes simplex infection (cold sore)

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

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

Herpes simplex labialis

Herpes simplex of tongue

Oral Lichen planus

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

Reticular lichen planus

Erosive lichen planus

Lichen planus plaque

Stevens – Johnson syndrome

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

Hemorrhagic crusting of lips

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.

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

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.

Geographic tongue

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

Fissured tongue & hyperkeratosis

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

Tongue-tie or Ankyloglossia

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

Pre-operative

Horizontal incision planned

Horizontal incision made

Vertical suturing done

Post-operative

Lip mucocoele

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

Complete surgical excision

Ranula

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

Simple Ranula

Plunging ranula

Plunging ranula

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

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

Marsupialization

Intra-oral excision

Ranula specimen

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