Common Oral Mucosal Diseases                         Wen-Chen Wang, DDS, MS, Ph.DAssistant professor of Dept. of Oral Path...
Oral mucosa        MUCOUS MEMBRANEDefinition: -Moist lining of the intestinal tract, nasal passagesand other body cavitie...
Oral mucosa          STRUCTURE OF ORAL               MUCOSA                                      B.V.                     ...
Oral mucosaFUNCTIONAL CLASSIFICATION    OF ORAL MUCOSA Keratinized areas …Masticatory mucosa  hard palate & gingiva  ver...
Oral mucosaFUNCTIONS OF ORAL MUCOSA     Protection     Sensation     Secretion     Thermal regulation                 ...
METHODS OF ORAL DIAGNOSIS       History taking       Inspection       Oral examination        -Palpation        -Percus...
History Taking   What, where, when, how   Chief complaints   Present illness   Past medical history    Family history ...
Chief Complaints   Pain                Bad taste   Soreness            Halitosis   Burning sensation   Parthesia and...
Onset and Courses1. Masses increase in size just before   eating     ex. salivary retention phenomena,         sialolithia...
3. Moderately rapid-growing masses   (weeks to about 2 months)    1) Chronic infection    2) Cysts    3) Malignant tumors ...
4. Rapidly growing masses (hrs to days)    1) Abscess (painful)    2) Infected cyst (painful)    3) Aneurysm    4) Salivar...
Inspection Location Contours Color Surfaces                 Wen-Chen Wang
Contours Normal & variationColor Masticatory mucosa vs lining  mucosa                            Wen-Chen Wang
Color   Normal: pinkish   Whitish :Epithelial hyperplasia, Hyperkeratosis             or dense collagen bundle   Reddi...
Leukoplakia
Hemangioma             Wen-Chen Wang
Peutz-Jegher’s syndrome
Fordyce’s granule
Mucocele
Betel nut chewer’s mucosa
SurfacesNormal – smooth & glistening, except dorsal tongue, rugae & attached gingiva                             Wen-Chen ...
Pathologic Mass May Be--1) Smooth surface -arises beneath epi, originates from mesenchyme ex : benign & early maligant sal...
irritation fibroma                     MixedWen-Chen Wang                          tumor
2) Rough surface-except due totrauma, infectionand maligancy,originates in theepithelium  ex: papilloma, VHV.ca, ulcerativ...
Wen-Chen Wang
3) Sessile or pedunculate Pyogenic granuloma
Palpation--A third eye of clinical examination   Anatomic regions & planes involved   Mobility   Extent   Consistency...
Anatomic Regions & Planes Involved   Locates a firm mass, superficial or deep   Difficult if swelling or painful        ...
Mobility1. free movable2. fixed to skin but not to the   underlying tissue3. free movable to the skin but   fixed to the u...
4. bound to both skin or mucosa   and to the underlying tissue1) fibrosis-after a previous inflammation.2) malignant- from...
Extent   Whether a mass has well defined,    M-D or P-D borders will depend    on :      -Border of the mass      -Consis...
Consistency   Fluctuation & emptiability: Fluid contented    lesion   Soft: vein, loose CT, glandular tissue   Cheesy: ...
Torus palatini           Wen-Chen Wang
Painless, Tender or PainfulPain1.inflammation-- mechanical trauma or  infection2.painful tumors--some neural tumors3.senso...
Unilateral or bilateral   Solitary or multiple•Solitary : A local benign or early            malignancy•Multiple : Systemi...
Erosive Lichen planus                        Wen-Chen Wang
Special Examination Radiographic exam Aspiration, smear cytological  exam., biopsy Laboratory exam…    (Suggested by at...
Common Oral Mucosal    Diseases                Wen-Chen Wang
Ulcerative Lesions   Ulcer-epithelium loss caused by any    reason   Trauma, burn, infection, oral cancer…   Most of tr...
Traumatic Ulcer A definite trauma history and clinicalfeatures can be tracedUsually occur at the soft tissue regionswhic...
BurnChemicals or drugs, thermalSuicide, psychiatric problems,Placement an aspirin tablet in oral to relievetoothachePh...
Recurrent Aphthous Ulcer   Commonest oral mucosal disease         Herpetiform RAU    Wen-Chen Wang
Patients Can Be Grossly ClassifiedAs :1.Primary immune dysregulation -genetic, stress, congenital or acquired immunal dise...
Treatment of RAU   Topical steroid or NSAID therapy, local    cauterization   Underline diseases or any possible    etio...
Tuberculosis (TB)   Worldwide, chronic infectious disease,    airborne droplets   Crowded or unsanitary environment   O...
Oral Tuberculosis   Primary and secondary   Exposure to infected sputum or    hematogeneous spread   Indurated, chronic...
Herpes Simplex Virus      Infection (HSV type 1)   Airborne droplets or direct contact   Primary and recurrent   Most p...
Clinical Characters of HSV Infection    Primary-upper respiratory tract infection     oral symptoms,small vesicles/tiny  ...
Secondary HSV Infection   A discrete collection of vesicular    swellings rupture erosion crusted   The commonest recurr...
Recurrent HSV infection             Wen-Chen Wang
Oral White Lesions and Betel     Nut Related Lesions                       Wen-Chen Wang
Lichen Planus   Reticular type (lace-like network of white lines,    Wickham’s striae)   Erosive type   Asymptomatic or...
Lichen planus
Oral Candidiasis   Oral normal flora   Local irritation( ill-fitting or improper    denture hygiene)   Antibiotics   I...
Oral Candidiasis   Oral manifestation:    Pseudomembranous type--creamy white    Atrophytic type-- reddish   Symptoms:...
Oral candidiasis
Oral Cancer and Precancerous Lesions  -Related to Betel Quid Chewing Habits                                 Wen-Chen Wang
What isoral cancer?               Wen-Chen Wang
Oral Cancer is-   Any cancer found in oral cavity   A cancer of the oral epithelial    origin, ex. squamous cell    carc...
Who is in high risk ?Contributingfactors of oralcancer?                                 Wen-Chen Wang
Contributing Factors              of Oral Cancer--In betel nut (betel quid) consumption areas Betel nut chewing habit ( 8...
Oral Cancer   Early: may be a leukoplakia or    erythroplakia   Tumor cells invade into connective    tissue or grow exo...
Oral CancerLocations: In Taiwan : buccal mucosa is the most  common, followed by lateral border of  tongue, retromolar, l...
Oral Cancer              Wen-Chen Wang
Oral Cancer              Wen-Chen Wang
Visit your dentist as soon aspossible if any oral ulcerdoesn’t heal within 2 weeks !                       Wen-Chen Wang
What areOral Precancerous Lesions ?                              Wen-Chen Wang
Oral Precancerous Lesions   Leukoplakia   Erythroleukoplakia   Erythroplakia   Oral submucous fibrosis   Verrucous hy...
Leukoplakia   White lesions which cannot be characterized by lichen    planus, oral candidosis etc.   Malignant change 4...
Erythroleukoplakia                     Wen-Chen Wang
Verrucous Hyperplasia   Exophytic, papillary or    cauliflower-like    appearance   White, or pink to    reddish, result...
Oral Submucous Fibrosis                (OSF)   20-40 y/o, male   Sites: oral mucosa, oropharynx, esophagus   Clinical c...
Oral submucous fibrosis                          Wen-Chen Wang
Oral submucous fibrosis             Wen-Chen Wang
Managements of OSF   Mouth opening exercise   Local cortical steroid injection   Surgical treatment combined with skin ...
Oral Manifestationsof Systemic Diseases                Wen-Chen Wang
Burning Mouth Syndrome         (BMS) Bacterial or fungal infection Dry mouth Nutritional abnormality Anemia Endocrine...
Clinical Features of BMS   Middle aged female or elder male   Burning sensation, esp. tongue and    tongue tip; taste ch...
Vitamin Deficiency Vit. A: keratosis Vit. B: glossitis, angular cheilitis,  burning mouth Vit. C: generalized gingival ...
Vit. B12 deficiency                    Wen-Chen WangAfter treatment
Blood Diseases Anemia- pale mucosa Hemophilia- hematoma or petechiae   Coagulation problems    associated with impaired...
Leukemia   Bleeding tendency   Idiopathic oral ulcers, necrotic gingival    margin   Gingival swelling (chloroma)   Or...
Go for an oral anddental examinationevery 6 months!          Wen-Chen Wang
Kaohsiung Medical UniversityReferences1. Antonio Nanci: Ten Cate's Oral Histology,    Development, structure, and function...
oral mucosal diseases 2010
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  1. 1. Common Oral Mucosal Diseases Wen-Chen Wang, DDS, MS, Ph.DAssistant professor of Dept. of Oral Pathology, Faculty of Dentistry, College ofDental Medicine, Kaohsiung Medical University, Kaohsiung, TaiwanHead of Dental Dept., Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, TaiwanE-mail: wcwang@kmu.edu.tw Wen-Chen Wang
  2. 2. Oral mucosa MUCOUS MEMBRANEDefinition: -Moist lining of the intestinal tract, nasal passagesand other body cavities that communicate with theexteriorOral mucosa: Oral mucous membrane Wen-Chen Wang Ref: Antonio Nanci: Ten Cate’s Oral Histology, Development, structure, and function 6th ed
  3. 3. Oral mucosa STRUCTURE OF ORAL MUCOSA B.V. N. --Similar to skinEpithelium……………… ..epidermis* Epithelial ridges, rete pegsLamina propria………... ..dermisSubmucosa……………... ..subcutaneous Wen-Chen Wang Ref: BJ Orban:Orban’s oral histology and embryology,9th ed.
  4. 4. Oral mucosaFUNCTIONAL CLASSIFICATION OF ORAL MUCOSA Keratinized areas …Masticatory mucosa  hard palate & gingiva  vermilion border Nonkeratinized areas …Lining or reflecting mucosa  lip, cheek, alveolar mucosa, vestibular fornix, mouth floor, soft palate, ventrum of tongue Specialized mucosa  dorsum of tongue Wen-Chen Wang
  5. 5. Oral mucosaFUNCTIONS OF ORAL MUCOSA  Protection  Sensation  Secretion  Thermal regulation Wen-Chen Wang
  6. 6. METHODS OF ORAL DIAGNOSIS  History taking  Inspection  Oral examination -Palpation -Percussion -Aspiration, -Auscultation  Radiographic examination  Laboratory examination Wen-Chen Wang
  7. 7. History Taking What, where, when, how Chief complaints Present illness Past medical history Family history Social history Occupational history Dental history Review of symptoms by system Wen-Chen Wang
  8. 8. Chief Complaints Pain Bad taste Soreness Halitosis Burning sensation Parthesia and anesthesia Bleeding Recent occlusal problem Loose teeth Too much saliva Dry mouth Delayed tooth eruption Swelling Wen-Chen Wang
  9. 9. Onset and Courses1. Masses increase in size just before eating ex. salivary retention phenomena, sialolithiasis2. Slow-growing masses (duration of months to years) 1) Reactive hyperplasia 2) Chronic infection 3) Cysts 4) Benign tumors Wen-Chen Wang
  10. 10. 3. Moderately rapid-growing masses (weeks to about 2 months) 1) Chronic infection 2) Cysts 3) Malignant tumors Wen-Chen Wang
  11. 11. 4. Rapidly growing masses (hrs to days) 1) Abscess (painful) 2) Infected cyst (painful) 3) Aneurysm 4) Salivary retention phenomena 5) Hematomas5. Masses with accompanying fever 1) Infections 2) lymphoma, leukemia Wen-Chen Wang
  12. 12. Inspection Location Contours Color Surfaces Wen-Chen Wang
  13. 13. Contours Normal & variationColor Masticatory mucosa vs lining mucosa Wen-Chen Wang
  14. 14. Color Normal: pinkish Whitish :Epithelial hyperplasia, Hyperkeratosis or dense collagen bundle Reddish:atrophic epithelium、vessels dilatation or hyperplasia Blackish:nevus, tattoo, melanosis Yellowish: adipose tissue, glands Translucent blue :reflection of liquid Wen-Chen Wang
  15. 15. Leukoplakia
  16. 16. Hemangioma Wen-Chen Wang
  17. 17. Peutz-Jegher’s syndrome
  18. 18. Fordyce’s granule
  19. 19. Mucocele
  20. 20. Betel nut chewer’s mucosa
  21. 21. SurfacesNormal – smooth & glistening, except dorsal tongue, rugae & attached gingiva Wen-Chen Wang
  22. 22. Pathologic Mass May Be--1) Smooth surface -arises beneath epi, originates from mesenchyme ex : benign & early maligant salivary gland tumors, benign & malig. mesenchymal T. ( fibroma, osteoma, hemangioma, myoma…), cellulitis, mucocele… Wen-Chen Wang
  23. 23. irritation fibroma MixedWen-Chen Wang tumor
  24. 24. 2) Rough surface-except due totrauma, infectionand maligancy,originates in theepithelium ex: papilloma, VHV.ca, ulcerative &exophytic SCC Ref: NK wood, PW Goaz: Differential diagnosis of oral and maxillofacial lesions 5th ed Wen-Chen Wang
  25. 25. Wen-Chen Wang
  26. 26. 3) Sessile or pedunculate Pyogenic granuloma
  27. 27. Palpation--A third eye of clinical examination Anatomic regions & planes involved Mobility Extent Consistency Painless, tender or painful Unilateral or bilateral Solitary or multiple Wen-Chen Wang
  28. 28. Anatomic Regions & Planes Involved Locates a firm mass, superficial or deep Difficult if swelling or painful Wen-Chen Wang
  29. 29. Mobility1. free movable2. fixed to skin but not to the underlying tissue3. free movable to the skin but fixed to the underlying tissue Wen-Chen Wang
  30. 30. 4. bound to both skin or mucosa and to the underlying tissue1) fibrosis-after a previous inflammation.2) malignant- from skin or mucosa invade to underlying tissue3) malignant- from deeper tissue invade to surface epithelium4) malignant- from loose CT to both the superficial & the deeper layers Wen-Chen Wang
  31. 31. Extent Whether a mass has well defined, M-D or P-D borders will depend on : -Border of the mass -Consistency of surrounding tissue -Thickness of overlying tissue -Sturdiness of underlying tissue Wen-Chen Wang
  32. 32. Consistency Fluctuation & emptiability: Fluid contented lesion Soft: vein, loose CT, glandular tissue Cheesy: sebaceous cyst, epidermoid cyst Rubbery: relaxed muscle, glandular tissue with capsule, arteries Firm: fibrous tissue, tensed muscle, large nerve Bony hard: bone, cartilage, tooth structure Wen-Chen Wang
  33. 33. Torus palatini Wen-Chen Wang
  34. 34. Painless, Tender or PainfulPain1.inflammation-- mechanical trauma or infection2.painful tumors--some neural tumors3.sensory nerve encroachmentTenderness Low-grade inflammation & internal pressure, chronic infection Wen-Chen Wang
  35. 35. Unilateral or bilateral Solitary or multiple•Solitary : A local benign or early malignancy•Multiple : Systemic, disseminated diseases or syndrome Wen-Chen Wang
  36. 36. Erosive Lichen planus Wen-Chen Wang
  37. 37. Special Examination Radiographic exam Aspiration, smear cytological exam., biopsy Laboratory exam… (Suggested by attending drs.) Wen-Chen Wang
  38. 38. Common Oral Mucosal Diseases Wen-Chen Wang
  39. 39. Ulcerative Lesions Ulcer-epithelium loss caused by any reason Trauma, burn, infection, oral cancer… Most of traumatic ulcers would be healed within 2 weeks spontaneously, otherwise, a further evaluation should be necessary. Wen-Chen Wang
  40. 40. Traumatic Ulcer A definite trauma history and clinicalfeatures can be tracedUsually occur at the soft tissue regionswhich can be bitted or hit by teeth , ex.Lower lip, tongue and buccal areaIll-fitted denturesImproper oral habits, ex,lip biting, tongue biting etc. Wen-Chen Wang A traumatic ulcer of the author
  41. 41. BurnChemicals or drugs, thermalSuicide, psychiatric problems,Placement an aspirin tablet in oral to relievetoothachePhenol, H2O2, NaHOCl used in dental practice Wen-Chen Wang
  42. 42. Recurrent Aphthous Ulcer Commonest oral mucosal disease Herpetiform RAU Wen-Chen Wang
  43. 43. Patients Can Be Grossly ClassifiedAs :1.Primary immune dysregulation -genetic, stress, congenital or acquired immunal disease (leukopenia, AIDS, endocrine etc. )2.Decreased mucosal barrier-Trauma, blood diseases, nutritional defficiency(Vit.B12、follic acid, iron)3. Increased antigenic expose-Bacteria, virus, etc. Wen-Chen Wang
  44. 44. Treatment of RAU Topical steroid or NSAID therapy, local cauterization Underline diseases or any possible etiology should be evaluated if suffered severely and recurred very often Wen-Chen Wang
  45. 45. Tuberculosis (TB) Worldwide, chronic infectious disease, airborne droplets Crowded or unsanitary environment Opportunity infection, 5-10% progress into active disease Immunocompromised patients, ex. DM, HIV infection Wen-Chen Wang
  46. 46. Oral Tuberculosis Primary and secondary Exposure to infected sputum or hematogeneous spread Indurated, chronic painless ulcer Enlarged regional lymph nodes Wen-Chen Wang
  47. 47. Herpes Simplex Virus Infection (HSV type 1) Airborne droplets or direct contact Primary and recurrent Most primary HSV infections are asymptomatic, some suffered from primary herpetic gingivostomatitis Usually in children and young adults Wen-Chen Wang
  48. 48. Clinical Characters of HSV Infection  Primary-upper respiratory tract infection oral symptoms,small vesicles/tiny ulcers Latency  Secondary- reactivation of latent virus after trauma, menstruation, systemic upsets, etc. Wen-Chen Wang
  49. 49. Secondary HSV Infection A discrete collection of vesicular swellings rupture erosion crusted The commonest recurrent lesion is herpes labialis. Attached gingiva, hard palate Heal within 1-2 weeks without scarring Wen-Chen Wang
  50. 50. Recurrent HSV infection Wen-Chen Wang
  51. 51. Oral White Lesions and Betel Nut Related Lesions Wen-Chen Wang
  52. 52. Lichen Planus Reticular type (lace-like network of white lines, Wickham’s striae) Erosive type Asymptomatic or burning irritation in reticular type, symptomatic in erosive type Middle-aged, F:M=3:2 Idiopathic, stress Topical or systemic steroid therapy Malignant potential is controversial Wen-Chen Wang
  53. 53. Lichen planus
  54. 54. Oral Candidiasis Oral normal flora Local irritation( ill-fitting or improper denture hygiene) Antibiotics Immuno-compromised, systemic disease patients Complete denture of upper jaw Wen-Chen Wang
  55. 55. Oral Candidiasis Oral manifestation: Pseudomembranous type--creamy white Atrophytic type-- reddish Symptoms: varied, from mild to burning sensation, pain and dysphagia Wen-Chen Wang
  56. 56. Oral candidiasis
  57. 57. Oral Cancer and Precancerous Lesions -Related to Betel Quid Chewing Habits Wen-Chen Wang
  58. 58. What isoral cancer? Wen-Chen Wang
  59. 59. Oral Cancer is- Any cancer found in oral cavity A cancer of the oral epithelial origin, ex. squamous cell carcinoma, verrucous carcinoma Wen-Chen Wang
  60. 60. Who is in high risk ?Contributingfactors of oralcancer? Wen-Chen Wang
  61. 61. Contributing Factors of Oral Cancer--In betel nut (betel quid) consumption areas Betel nut chewing habit ( 80% in Taiwan) Others are: 1. smoking 2. alcoholism 3. radiation exposure 4. improper nutrition 5. syphilis 6. candidiasis 7. mutation of gene 8. immunodeficiency 9. improper denture Wen-Chen Wang
  62. 62. Oral Cancer Early: may be a leukoplakia or erythroplakia Tumor cells invade into connective tissue or grow exophytically Clinical features: reddish or whitish ulcerative surfaces with induration, delayed healing process Wen-Chen Wang
  63. 63. Oral CancerLocations: In Taiwan : buccal mucosa is the most common, followed by lateral border of tongue, retromolar, lower lip, palate and gingiva In the world: lateral border of tongue is the most common Wen-Chen Wang
  64. 64. Oral Cancer Wen-Chen Wang
  65. 65. Oral Cancer Wen-Chen Wang
  66. 66. Visit your dentist as soon aspossible if any oral ulcerdoesn’t heal within 2 weeks ! Wen-Chen Wang
  67. 67. What areOral Precancerous Lesions ? Wen-Chen Wang
  68. 68. Oral Precancerous Lesions  Leukoplakia  Erythroleukoplakia  Erythroplakia  Oral submucous fibrosis  Verrucous hyperplasia  Erosive lichen planus* *precancerous condition Wen-Chen Wang
  69. 69. Leukoplakia White lesions which cannot be characterized by lichen planus, oral candidosis etc. Malignant change 4~5% Homogeneous leukoplakia and non-homogeneous leukoplakia Wen-Chen Wang
  70. 70. Erythroleukoplakia Wen-Chen Wang
  71. 71. Verrucous Hyperplasia Exophytic, papillary or cauliflower-like appearance White, or pink to reddish, resulted from varied keratosis Wen-Chen Wang
  72. 72. Oral Submucous Fibrosis (OSF) 20-40 y/o, male Sites: oral mucosa, oropharynx, esophagus Clinical characteristics: -Dense collagen bundles, decreased vascularity, epithelium atrophy, whitening of the mucosa -Trismus -Epithelium atrophy→ decreased protection, sensitive to spicy foods Wen-Chen Wang
  73. 73. Oral submucous fibrosis Wen-Chen Wang
  74. 74. Oral submucous fibrosis Wen-Chen Wang
  75. 75. Managements of OSF Mouth opening exercise Local cortical steroid injection Surgical treatment combined with skin graft Prognosis is not good in the severe OSF patients Wen-Chen Wang
  76. 76. Oral Manifestationsof Systemic Diseases Wen-Chen Wang
  77. 77. Burning Mouth Syndrome (BMS) Bacterial or fungal infection Dry mouth Nutritional abnormality Anemia Endocrine disturbance, DM Improper denture Idiopathic Wen-Chen Wang
  78. 78. Clinical Features of BMS Middle aged female or elder male Burning sensation, esp. tongue and tongue tip; taste change Normal appearance and color Diagnosis and treatment depend on the etiology Wen-Chen Wang
  79. 79. Vitamin Deficiency Vit. A: keratosis Vit. B: glossitis, angular cheilitis, burning mouth Vit. C: generalized gingival swelling, bleeding tendency and ulcers, periodontitis Wen-Chen Wang
  80. 80. Vit. B12 deficiency Wen-Chen WangAfter treatment
  81. 81. Blood Diseases Anemia- pale mucosa Hemophilia- hematoma or petechiae Coagulation problems associated with impaired liver function Wen-Chen Wang
  82. 82. Leukemia Bleeding tendency Idiopathic oral ulcers, necrotic gingival margin Gingival swelling (chloroma) Oral candidosis Wen-Chen Wang
  83. 83. Go for an oral anddental examinationevery 6 months! Wen-Chen Wang
  84. 84. Kaohsiung Medical UniversityReferences1. Antonio Nanci: Ten Cate's Oral Histology, Development, structure, and function 6th ed. 2. BJ Orban:Orban's oral histology and embryology,9th ed. 3. NK wood, PW Goaz: Differential diagnosis of oral and maxillofacial lesions 5th ed. 4. BW Neville, DD Damm, CM Allen,JE Bouquot: Oral & Maxillofacial pathology. 2nd ed.Acknowledgement Clinical pictures were fully supported by Dept. of Oral Pathology, Kaohsinug Medical University http://www.kmu.edu.tw/media/photos/001.jpg Wen-Chen Wang

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