ORAL CAVITY

 The oral cavity represents the first part of the digestive tube.
 Its primary function is to serve as the entrance of the alimentary tract and
to initiate the digestive process by salivation and propulsion of the
alimentary bolus into the pharynx.
 It's lined by mucous membrane which is pink in color non-keratinizing
stratified squamous epithelia contain taste buds and minor salivary
glands.

 Posteriorly:
Separated from the oropharynx by anterior Pillar of the tonsil
laterally
The junction of the hard and soft palate above.
And the line of the circumvallate papillae bellow.
 Anteriorly:
the junction of the mucosa & vermillion border with the skin
of the lips.
 Inferiorly:
the junction of the ant. 2/3 and the posterior 1/3 of the
tongue.
 Superiorly: the junction of the hard palate and soft palate.
Anatomy of the oral cavity
ANATOMY

1. Sensory nerve supply
• Anterior 2/3 tongue:
• General sensation: lingual nerve from mandibular branch of trigeminal
nerve.
• Special sensation (Taste): facial nerve via chorda tympani
• Posterior 1/3: general sensation + taste by Hypoglossal nerve .
• Roof: general sensation via the maxillary branch of trigeminal nerve.
2. Motor nerve supply:
• The hard and soft palates are innervated by the greater palatine and
nasopalatine nerves.They are both derived from the maxillary branch (V2)
of the trigeminal nerve.
• Muscle in the cheek and the lip are supplied by the branches of the facial
nerve
• The muscles of the tongue supplied by Hypoglossal nerve

A. Cleft lip and palate.
B. Congenital abnormalities of the jaws such as Pierre
Robin syndrome which is a congenital condition of
facial abnormalities in humans it is a chain of certain
developmental malformations.
The three main features are cleft palate,
retrognathia and glossoptosis.

1. Dyskeratosis congenita: (DKC), also known as Zinsser-
Engman-Cole syndrome it's a rare congenital abnormality
resulting in dyskeratotic white patches in the mouth also
associated with abnormalities of the skin pigmentation,
leukoplakia, cornea.
2. Fordyce’s spots: are small raised, pale red, yellowish or skin-
colored spots that appear on the the labia, scrotum, or the
vermilion border of the lips of a person's face these lesions
are of no significance.

3. White sponge naevus:
• Is an autosomal dominant condition of the oral mucosa.
• It is caused by a defect in the normal process of keratinization of
the mucosa.
• This results in lesions which are thick, white on the inside of the
cheeks within the mouth.
• Usually, these lesions are present from birth or develop during
childhood.
• The condition is entirely harmless, and no treatment is required
4. Hereditary hemorrhagic telangiectasia ( osler-Weber disease):
• Is a rare autosomal dominant genetic disorder that leads to
abnormal blood vessel formation in the skin, mucous membranes,
and often in organs such as the lungs, liver, and brain.

1. Macroglossia:
• Is the medical term for an unusually large tongue
• Occurs in congenital diseases e.g. /Down syndrome, cretinism
• Or NON- congenital like lymphangioma, acromegaly
2. Ankyloglossia:
• Also known as tongue-tie.
• Is a congenital oral anomaly that decrease mobility of the tongue tip
• Caused by an unusually short, thick lingual frenulum.
• It is rarely severe enough to affect suckling or later speech.
• Treated by horizontal incision and vertical repair.

3. Median rhomboid glossitis:
• It's of no significance.
• Flat pink area on the dorsum of the tongue anterior to the
circumvallate papillae
4. Lingual thyroid:
• Part or the whole the thyroid tissue will stay in the foramen
cecum (in the midline of the posterior 1/3 of the tongue( as
soft tissue mass.
• It's important to remember that it may be the only thyroid
tissue in the body and may be a site of a thyroid neoplasm.

1. Hematological diseases:
A. Agranulocytosis: it is an acute condition involving a severe and dangerous
leukopenia.
It causes acute ulcers and sloughing in the oral cavity.
B. Acute leukemia:
leukemia depend on the general status of patients include gingival swelling,
oral ulceration, spontaneous gingival bleeding, petechiae, mucosal pallor,
herpetic infections and candidiasis.
C. AIDs: causes hairy leukoplakia, oral candidiasis, herpetic stomatitis, and
Kaposi sarcoma.

C. Measles ➡ Kopliks spots.
A. Chicken pox ➡ Vesicles
B. Acute
streptococcal
tonsillitis ➡
strawberry tongue.
D. Glandular fever
➡ petechial rash on
the hard palate
2. Acute exanthematous manifestation of viral infection

3. Drugs side effects:
A. Penicillin, sulphonamides, and barbiturates ➡ oral thrush and
erythema multiform.
B. Phenytoin, nifidipine, cyclosporine ➡ Gingival hyperplasia .
C. Gold salts ➡ ulcerations of the mouth

4.Vitamin deficiency:
A. Vitamin c ➡ gingivitis.
B. Iron, folate, B12 ➡ glossitis
C. B2 (riboflavin) and nicotinic acid ➡ angular cheilitis
and glossitis.

5. Auto-immune diseases:
A. Chronic lupus and SLE causes
vesicular and ulcerative lesions.
B. Scleroderma.
D. Sjögren syndrome:
• Xerostomia, dry, red, wrinkled
mucosa
• Dysphagia
• Disturbance in taste.
• Increase risk of infections.
C. behcet's disease

• Black people have darker color of gums.
• Hemochromatosis.
McCune-Albright syndrome
Mercury
chronic lead-poisoning (plumbism)

Peutz- Jegher syndromeMelanoma
Addison's diseaseBismuth

A.Viral:
1. Primary herpetic gingivostomatitis:
• Caused by herpes simplex virus 1
• Frequently affecting children and adults not exposed to the
virus before.
• Clinically the patient have fever, malaise vesicular lesions
2-4 mm in size which breaks forming ulcers with yellowish
base.
• Last's 1-2 weeks.
• Recurrent oral herpes is unusual while herpes labials (cold
sore) is very common.

2. Herpes zoster :
• Affects the trigeminal nerve causing painful unilateral lesions may be
associated with cervical lymph node and facial nerve palsy.
3. Hand foot mouth disease:
• Mild, contagious viral infection caused by Group A coxsacki virus.
• Mostly in children.
• The incubation period is 1 week and it last about 1 week.
• The patient has fever, malaise, with vesicles on the hand, feet, buttocks,
and mouth and later ulcers
4. Herpangina:
Occurs mainly in children and caused by different viruses (Coxsackie,
echovirus) It's similar to herpes simplex but the lesions are more in the
oropharynx than the oral cavity.

B. Bacterial infections:
1. Acute necrotizing gingivitis:
• Caused by borrelia vincentii and anaerobic bacillus fusiformis.
• Affect the inter dental papillae in debilitated adults with poor
dental hygiene.
• The patient had pain, fever, enlarged lymph nodes, ulceration,
and necrotic membrane which may spread to the tonsil and
nasopharynx.
• Treatment is by local mouth wash and systemic penicillin and
flagyl (IV).

2. Gangrenous stomatitis (cancrum oris)
• Severe disfiguring infection of the mouth and face that starts as a gingival
ulcer and spreads rapidly through the tissues of the mouth and face.
• The exact cause is unknown, but may be due to bacteria called
Fusobacterium necrophorum.
• Often following other illness such as measles or tuberculosis.
• This disorder most often occurs in young, severely malnourished children
between the ages of 2 and 5 and is mostly found in African children.
• Treatment: antibiotics and proper nutrition helps stop the disease from
getting worse.
• Plastic surgery may be necessary to remove destroyed tissues.

C. Fungal infections:
1. Candidiasis:
 Fungal infection due to any type of candida . when it affects the
mouth, it is commonly called thrush
 Acute type:
• Multiple small white patches when wiped off leaving painful
erythematous patch
• Treated by local nystatin or amphotericin.
 Chronic type:
• White lesion cannot be rubbed off (candidal leukoplakia) mainly
inside the corner of the mouth.
• Treated by ketoconazole.

2. Histoplasmosis
• Systemic fungal disease caused by histoplasma capsulatum
that takes various clinical forms among which oral lesions
are rare.
• The disseminated form of the disease that usually occurs in
association with HIV.
• Histoplasmosis causing granular looking ulcers usually in
wide spread.
• Treatment is by ketoconazole.

 Traumatic injuries to oral mucosa are quite common.
 Traumatic ulcers are most commonly affecting the
tongue, lips, and buccal mucosa .
 These lesions may persist for a few days or even
several weeks .

Traumatic injury can occur by one of the following means :
 Mechanical .
 Thermal .
 Chemical.
 Factitious injury .
 Radiation .
 Eosinophilic ulcer s (Traumatic Granuloma ) .

 They are clinically diverse, but usually appear as a
single , painful ulcer with a smooth red or whitish-
yellow surface and a thin erythematous halo.
 They are usually soft on palpation, and heal without
scarring within 6–10 days, spontaneously or after
removal of the cause.

1. Removing factors, caused trauma.
2. Good hygiene of oral cavity.
3. Antiseptic for 7-10 days.
4. Analgetics if it is necessary.
5. Topical steroids may be used for a short time.
6. Biopsy.

1- Aphthous ulceration
 It is very common ulcers with unknown etiology
(hypersestivity reaction ,hormonal , vit defeciency, stress).
There are basically 3 types of aphthous ulcers:
 Recurrent minor aphthous ulcers, which occur in up to 80% of
aphthous ulcer cases.They are usually less than 5mm in diameter and heal
within 1-2 weeks.
 Major aphthous ulcers, which are large ulcers (more than 10mm) that take
weeks or months to heal and do so with scarring.
 Herpetiform ulcers, which are multiple pinpoint ulcers that heal within a
month.These are most commonly on the tongue.

 It is of unknown eitology clinicaly the
patient had relapsing oral and genital
ulceration associted with uvitis , vasculitis
of the skin ,synovitis and
meningoencephalitis .
 treatment by oral steroid .

Is a rare chronic blistering skin disease.
It classfied as type 2 hypersensitivity reaction.
 it affect late middle age and elderly patients.
 Pemphigus vulgaris most commonly presents
with oral blisters (buccal and palatine mucosa,
especially), but also includes cutaneous blisters.

 Blisters commonly erode and leave
ulcerated lesions and erosions.A positive Nikolsky
sign (induction of blistering in normal skin or at the
edge of a blister) is indicative of the disease.
 Severe pain with chewing can lead to weight loss and
malnutrition.

Is a group of rare chronic autoimmune disorders
characterized by blistering lesions that primarily
affect the various mucous membranes of the
body.The mucous membranes of the mouth
and eyes are most often affected. usually results
in permanent scarring of the affected area,
particularly the conjunctiva .

 Gum involvement is common, and as with lichen planus the gums are bright red
 Compared to other conditions affecting the mouth, vesicles or small bullae may
remain intact for some time. When erosions form they are slow to heal

 Affecting young patient 10-13y
 Secondary to herps and mycoplasma infection , or caused by
drugs like pencillian.
Most commonly lips, inside the cheeks, tongue
Less commonly floor of the mouth, palate, gums.
 Treatment is supporative and Systemic steroid .

Uncommon benign ulaceration of the hard palate or oropharynx.
It is thought to be caused by ischemic necrosis of minor salivary
glands in response to trauma.
 painless, self-limiting, heals within several weeks and most
frequently develops in the palates ( unilateral ,bilateral or midline in
location ) .

 It’s an autoimmune disease .
 In most cases the cause is idiopathic ,
other causes include drugs , mechanical
trauma and viral infection.
 It is uncommon disease with 2 types :
1. Reticular : slightly raised lesion with
white bluish tinge and reticular striae .
2. Erosive: erythematous painful
ulcerated lesion.

Is defined as a predominantly white lesion
on the mucous membrane with an
increased risk of cancer with histological
changes like : Keratosis, Hyperkeratosis,
Parakeratosis ,Acanthosis .
 Diagnosis is by biopsy .
 Treatment is not needed in
asymptomatic patient .
 Antiviral (aciclovir/ valacyclovir).

Mucosal abnormality which cause erythematous due to dysplasia
without keratosis .The dysplasia is sever with high malignant
potential.
 These may appear as a bright red, smooth, velvety, granular or
nodular lesions often with a well-defined margins adjacent to
normal looking mucosa and are usually asymptomatic.
 The soft palate, the floor of mouth, the ventral surface of
tongue and the retro-molar area are the most common
sites of involvement.

 Called migratory glossitis or erythema migrans .
 It’s bengin condition of unknown eaitology .
 Clinically the patient is asymptomatic with map like appearance
tongue due to loss of filiform papillae.
No treatment is required .

 Coated tongue due to elongation and accumulation of keratin
assocaited with filiform paplliae it usually appear white in color
and become black in smoker .
 It’s of unknown eitology .
 Treatment by scraping off the keratin with a brush.

A. cyst of the mouth
1- Developmental cyst : the may be midline
or lateral where the maxillary and
premaxillary fuse.
2-Cyst associatd with the teeth .
3-Nasopalatine cyst
4-Cyst and tumors of the jaws.
5-Dermoid cyst : it may be submental or in
the floor of the mouth and tongue.

6- Retention cyst or ranula : it is uni or multilocular mucous
filled cyst in the floor of the mouth and classified into :-
A.Simple ranula which an epithelial lining and confined to the
floor of the mouth .
B.Plunging ranula which is lined by connective tissue confined to
the floor of the mouth or extend through mylohyoid muscle into
the neck .

Associted with the teeth ,dental caries , and gingivitis
are predisposing factors .
 These cyst may lead to destuction of the enamel and
dentine and dental abscess formation leading to chronic
inflammatory disease of the gum .
 Traetment is by removal of swelling and treatment of
causative infection .

ORAL CAVITY

squamous papilloma arise from the stratified squamous
epithelia of the oral cavity. It has little malignant
transformation
appears as :-
1- exophytic growth made up of
numerous small finger like
projections.
2- either single or multiple growth.
3- cauliflower or wart like
appearance in the mucosa of the
oral cavity, most frequently on the
tongue.

Papilloma of the tongue, appears as small, cauliflower elevations.

Most common oral benign soft tissue tumor.
Most of these lesions are infact hyperplasis or reactive
poliferation of the fibrouse tissue due to irritation of trauma
Appears as
• round-to-ovoid, asymptomatic,
smooth-surfaced, pedunculated mass.
• The surface is usually similar in color to
the surrounding mucosa but may be
ulcerated, owing to repeated trauma.
• Most often in the buccal mucosa where
it is frequently bitten by the patient.

Fibroma of the
buccal mucosa
Treatment is simple excision

Most common benign salivary gland tumor in the oral cavity and it’s
the most common tumor of the parotid gland.
Appears as
1. soft, irregular, bluish or purple in color.
2. The tumor is usually solitary and
presents as a slow growing, painless,
firm single nodular mass.
3. Majority in the hard palate, also the
tongue, floor of the mouth.
4. complete excision which should be as
conservative as possible.

Neurilemmoma is rarely seen.
Neurofibroma is sometimes seen as part of Von-
Recklinghausen’s disease.
Neurofibromaneurilemmoma

rarely seen as leiomyoma, rhabdomyoma and lipoma.
Rhabdomyomaleiomyomalipoma

 pseudoepitheliomatous hyperplasia
 firm non ulcerated nodule
 mass of large cells with granular eosinophilic
cytoplasm.

High risk lesions
• Erythroplakia
• Chronic
hyperplasitic
candidiasis
Medium risk
lesion
• Oral submucous
fibrosis
• Syphlitic
glossitis
Low risk lesion
• Oral lichen
planus
• Discoid lupus
erthromatosus
Conditions associated with malignant transformation

90 % of oral cancers are primary squamous cell carcinoma arising
from the oral mucous membrane
The incidence
In India and parts of Asia western countries
Highest rated 3 % of all
40% of all cancers cancers
Tumors who tend to have a good prognosis are
1. Small , slow growing lesions.
2. Detected early.
3. Present in the front of the mouth.
Tumors who tend to have the worst prognosis are
1. Rapid growing lesions.
2. Invade the bone.
3. Posteriorly sited.

Mutagenic
agents
• Tobacco
• alcohol
Previous
cancer
• Oral
• Esophagus
• Lung
• Throat
Immuncompromized
patients
• AIDS
• Post
transplant
patients
Postulated
agents
• Chronic
Candida
infections
• Vitamin
deficiencies

1) area of ulceration, often Surrounded by leukoplakic or
erythroplakic patches.
2) commonest sites involved are floor of the mouth, ventro-
lateral tongue and the soft palate.
Ulcerated lesionof an oral
squamous cell carcinoma
arising on the lateral border of
the tongue

3) Symptoms of early lesions: Asymptomatic, Irritation,
Discomfort
4) Symptoms of late lesions: non-specific symptoms Pain ,
swelling, Parasthesia , Dysarthia , Dysphagia .
5) Signs of oral cancer:
Non-healing ulcer
Induration and fixation of tissues
Exophytic growth
White/red mucosal patches
Unexplained localized tooth mobility
Non-healing tooth socket
SQUAMOUS CELL CARCINOMA

Oral cancer has the
Ability to invade and destroy local structures
Spread via lymphatic into the neck.
Pattern of spread is essential for effective treatment .
Local invasion
Can infiltrate widely into
adjacent connective tissue within (muscle bundles, perineural
spaces)
local blood vessels.
Direct extension via odontal membrane or cortical deficiencies in
edentulous ridges allows invasion of alveolar bone.

•More frequent in the later stages
•May not be clinically apparent
• but metastatic deposits have been found in the
lungs, liver and bones in approximately 50% of
post-mortem examinations carried out in patients
dying with oral cancer.

o Effective exposure and complete removal of oral tumors.
o Surgical approach should be easy to repair and produce minimal
scarring and deformity.
o Splitting of the lip, division of the mandible(mandibulotomy) .

o Fully displays the posterior tongue, retromolar and soft palate
regions and facilitates tumour excision .

o Facial cheek flaps and maxillary osteotomies allow similar
access to the posterior palate and retro maxillary regions.

Resection of the primary tumor
o The principal objective of surgical treatment is to excise the
entire primary tumor with a margin (ideally about 1cm) of
adjacent normal tissue in anticipation of microscopic
spread, and to remove channels of metastasis such as
nerves, vessels and lymphatics.
o Anterior tongue tumors may require partial, hemi or
subtotal glossectomy depending on the size and position.

o Lower lip cancers may
be treated by wedge
excision alone or
combined with a lip
shave procedure
(removal of the entire
vermilion).

o small buccal mucosal cancers can be excised intraorally, more
advanced lesions may require excision of buccinator muscle
and overlying skin.
o Tumors of the floor of mouth, retromolar region and lower
alveolus usually involve the underlying mandible and require
mandibular resection.
The inferior dental nerve canal, should be included in
mandibular body resections due to the likelihood of perineural
spread.
o Mucosal excision, alveolar resection, palatal fenestration or
maxillectomy may be required for tumours arising from the
palatal mucosa and maxillary alveolus depending on their size
and position.

Management of the neck
o Neck dissection
o It is indicated after clinical examination or imaging
techniques confirm enlarged lymph nodes.
FNA may be carried out to confirm cytologically the
presence of carcinoma deposits within enlarged nodes.
o In oral cancer management. Levels I to III or IV are the
most often dissected

o post-operative radiotherapy advised if multiple nodes prove positive or there is
extra capsular tumor spread.
o Neck dissection contraindicated in extensive disease where involved lymph
nodes may be fixed by tumour extension into vital structures such as the carotid
artery or skull base. A complete surgical excision is either not possible or may
produce significant morbidity or even mortality.

Reconstruction
o Important aims of reconstruction is :-
 prevent facial deformity.
 Maintain bone continuity. and facilitate masticatory,
swallowing and speech functions.
 Reduction of psychological morbidity.
 Acceptable quality of life outcome.
o By tissue transfer and micro vascular surgery, in which free
flaps (often comprising skin, muscle and bone) are
transferred from distant sites and their dependent arteries
and veins connected to vessels in the neck.

o The radial forearm osseofasciocutaneous flap, a groin flap, or
the fibula flap, may be used to reconstruct the mandible.
o Maxillary defects result in direct communications between oral
and nasal cavities or the paranasal sinuses, with the inevitable
production of nasal speech and swallowing difficulties.

Radiotherapy
o Radiotherapy is the treatment of tumors with ionizing
radiation and is potentially curative in oral cancer treatment.
o X-ray, gamma ray and less
commonly particulate radiation
is delivered either as external
beams from outside
the patient (teletherapy)

o or radioactive materials such as iridium wires can be implanted
within or in close proximity to the tumor (brachytherapy).

o Chemotherapy has provided a major advance in the
management of certain malignancies. chemotherapeutic
agents have markedly improved the long-term survival rates
of patients. In general, chemotherapy is less effective in
treating solid tumours in adults and is rarely of curative
value in oral cancer treatment, but may have a role in trying
to prevent secondary tumours developing from metastatic
deposits.

o Chemotherapy Drugs like Cisplatin , 5-fluorouracil
o Targets of Chemotherapy actively dividing cells to eliminate
tumours .
o Side effects of chemotherapy are nausea and vomiting,
bone marrow suppression, alopecia and oral mucositis.
To reduce the severity of mucositis, a high standard of oral
hygiene and careful attention to preventive and restorative
dental care is essential .