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

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

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

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.

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

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

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

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

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

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

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)

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

Herpangina

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 ?

Erythematous Candidiasis

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

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

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

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

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

Aphthous Ulcers Cont. Herpetiform ulcers Small, 1-3mm in diameter ulcerations appearing in crops of 20-200 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

Dermatoses Lichen planus White plaques

whitish linear lesions in lacy pattern

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

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

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).

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

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.

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

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 ).

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

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

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

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

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.

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

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

Bastaninejad, Shahin, MD