Lesions of oral cavity

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Lesions of oral cavity

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Lesions of oral cavity

  1. 1. LESIONS OF ORAL CAVITY DR JOEL G. MATHEW
  2. 2. ULCERS OF ORAL CAVITY  INFECTIONS  VIRAL-HERPANGINA, HERPES SIMPLEX  BACTERIAL-Vincent’s infection, TB, syphilis  Fungal: Candidiasis  Immune disorders: Aphthous ulcer, Behcet’s syndrome  Trauma  ill-fitting denture, phenol, aspirin burns, Hot food  Neoplasms  Skin disorders: Erythema multiforme, lichen planus, BMMP, bullous pemphigoid, lupus erythematosus
  3. 3.  Blood disorders: Leukaemia, agranulocytosis, pancytopenia  Drug allergy: Mouth washes, tooth paste, etc. Reactions to systemic drugs  Vitamin deficiencies  Miscellaneous: Radiation mucositis, cancer chemotherapy, diabetes mellitus, uraemia
  4. 4. INFECTIONS
  5. 5. HERPANGINA  SYN: Vesicular stomatitis , Acute lymphonodular pharyngitis  Cause: Enteroviruses-Coxsackie A, EV 71  Characteristic vesicular rash on tonsillar pillars, soft palate, uvula, tonsils, posterior pharyngeal wall  Discrete 1- to 2-mm vesicles and ulcers  Enlarge over 2-3 days to 3-4 mm and are surrounded by erythematous rings up to 10 mm  1-15 lesions are present, usually around 5  Usually resolve without complications  Rarely, meningitis
  6. 6. Herpetic gingivostomatitis  Syn: orolabial herpes  Cause: HSV  Primary  Children  Clusters of multiple vesicles -> ulcers  Fever, malaise and headache , sore throat and lymphadenopathy.  Secondary  Adults, mild  Vermilion border of the lip > hard palate and gingiva  Reactivation of dormant virus in trigeminal ganglion  Acyclovir, 200 mg, five times a day for 5 days to reduce viral load
  7. 7. Hand, foot and mouth disease  Cause: Coxsackievirus A16 and enterovirus 71 (EV71)  spread via the fecal-oral and perhaps respiratory routes  primarily in children  vesicular palmoplantar eruption and erosive stomatitis.  Cloudy vesicles with a red halo are highly characteristic of this disease.
  8. 8. Vincent’s infection  Syn: acute necrotising ulcerative gingivitis, trench mouth  Causative organisms include a fusiform bacillus and a spirochaete –borrelia vincentii  Affects young adults and middle-aged persons  Starts at the interdental papillae -> free margins of the gingivae  Lesions covered with necrotic slough.  Gingivae become red and oedematous.  Similar ulcer and necrotic membrane may also form over the tonsil (vincent’s angina).  Diagnosis: smear from the affected area.  Treatment is  Systemic antibiotics (penicillin or erythromycin and metronidazole),  Frequent mouth washes (with sodium bicarbonate solution) and attention to dental hygiene.
  9. 9. Moniliasis (candidiasis)  caused by Candida albicans  Thrush  white grey patches on the oral mucosa and tongue.  infants and children  systemic malignancy and diabetes or taking broad spectrum antibiotics, cytotoxic drugs, steroids or radiation.  Thrush can be treated by topical application of nystatin or clotrimazole.
  10. 10.  Chronic hypertrophic candidiasis. Also called candidal leukoplakia.  White patch which cannot be wiped off.  Mostly affects anterior buccal mucosa just behind the angle of mouth.  Hypertrophic form usually requires excisional surgery.
  11. 11. IMMUNE DISORDERS
  12. 12. Aphthous ulcers  Recurrent and superficial  Aetiology: Unknown. Autoimmune, Nutritional (Folate, B12, Iron), Viral, Bacterial, Food allergies, Hormonal, Stress  usually involving movable mucosa, i.e. inner surfaces of lips, buccal mucosa, tongue, floor of mouth and soft palate, sparing mucosa of the hard palate and gingivae.  Minor form  more common,  ulcers are 2–10 mm in size and multiple with a central necrotic area and a red  They heal in about 2 weeks without leaving a scar.  Major form, ulcer is very big, 2–4 cm in size, and heals with a scar but is soon followed by another ulcer.
  13. 13.  Topical application of steroids  Cauterisation with 10% silver nitrate.  In severe cases, 250 mg of tetracycline dissolved in 50 ml of water is given as mouth rinse and then to be swallowed, four times a day.  Local pain can be relieved with lignocaine viscous.
  14. 14. Behcet’s syndrome (Oculo-oro- genital syndrome)  Behçet's disease is a complex multisystem disease characterized by oral and genital ulcers and other systemic features.  Diagnosis is based on the International Criteria for Behçet's Disease including:  oral aphthae,  genital aphthae,  ocular lesions,  cutaneous lesions,  and a positive pathergy test.  Cutaneous lesions should display a neutrophilic vascular reaction on histopathologic examination.
  15. 15.  Seen worldwide, with the highest prevalence reported in Turkey and Japan  prevalence and often the severity is increased in the Middle East and the Mediterranean  predominantly affect males  Cause and Pathogenesis  Heredity, immunologic factors, infectious agents, inflammatory mediators, and clotting factors likely contribute.
  16. 16.  Oral aphthae, or Canker sores are often the initial feature of Behçet's disease and constitute a requisite diagnostic feature  usually occur in crops of more than 3 to 10s  painful and shallow, and they heal without scarring over 1 to 3 weeks  Genital ulcers typically occur on the scrotum and penis in males and on the vulva or vaginal mucosa in females.  These aphthae are similar in appearance to oral lesions, but they have a greater tendency to scar and may recur less frequently.[
  17. 17.  Cutaneous-  erythema nodosum–like lesions,  pyoderma gangrenosum–like lesions,  Sweet's syndrome–like lesions,  cutaneous small vessel vasculitis, and pustular vasculitic lesions including lesions induced by trauma—the so-called pathergy lesion.  Pathergy signifies the development of erythematous pustules or papules 24 to 48 hours following puncture of the skin with a 20- to 21-gauge sterile needle.  Specimens from all these lesions demonstrate a neutrophilic vascular reaction on histopathologic analysis.  Ophthalmic (83% to 95% of men and 67% to 73% of women)  anterior and posterior uveitis,  retinal vasculitis, and hypopyon, with secondary glaucoma,  cataract formation, decreased visual acuity, and synechiae formation
  18. 18.  Arthritis of Behçet's disease is typically a nonerosive, inflammatory, symmetric, or asymmetric oligoarthritis  Central nervous system (CNS) involvement is most commonly characterized by  brain stem or corticospinal tract syndromes (neuro-Behçet's syndrome),  venous sinus thrombosis,  increased intracranial pressure  isolated headache.  Cardiac complications include  myocardial infarction,  pericarditis,  arterial and venous thromboses, and  aneurysm formation.
  19. 19. Miscellaneous lesions of oral cavity and tongue  Median rhomboid glossitis  red rhomboid area, devoid of papillae, seen on the dorsum of tongue in front of foramen caecum.  Due to chronic oral candidiasis
  20. 20. TRAUMATIC ULCER  lateral border of tongue -jagged tooth or ill-fitting denture;  buccal mucosa -cheek bite;  palate - injury with a foreign object such as pencil or tooth brush  acute ulcerative lesions of oral and oropharyngeal mucosa - ingestion of acids or alkalies or hot fluids.  Aspirin burn - buccal sulcus
  21. 21. SKIN DISORDERS
  22. 22. Erythema multiforme  Acute, self-limited, polymorphous eruption  Symmetrically distributed macules, papules, and bullae, with an edematous, petechial, vesicular, or bullous dusky violet center.  It is probably due to cell-mediated hypersensitivity reaction to certain drugs or infections, particularly in genetically predisposed individuals, those immunocompromised or with autoimmune disease.  Mucosal lesions are ocular (conjunctivitis, keratitis), oral (stomatitis, cheilitis), nasal, pharyngeal, tracheal, and genital (balanitis and valvulitis).  Dull red, flat or slightly raised maculopapules, which may remain small or may increase in size to reach a diameter of 1- 3 cm in 48 h. Typical cases show at least some target (or iris) lesions.  The disease is self-limiting and management is mainly supportive. Steroids are used to treat the severe form.
  23. 23. Pemphigus vulgaris  autoimmune disorder affecting older age group (50–70) [AMBD]  Oral ulcerations are superficial and involve palate, buccal mucosa and tongue.  Jagged intraoral erosions->Blisters  Treatment consists of systemic steroids and cytotoxic drugs.
  24. 24. Benign mucous membrane pemphigoid (BMMP)  Most common AMBD  autoimmune disorder.  Mucosal lesions involve cheek, gingivae and palate > Conjunctiva  Bulla filled with clear or haemorrhagic fluid -> ruptures to form superficial ulceration covered with shaggy collapsed mucosa.  Skin lesions may be absent.  Treatment consists of steroids.
  25. 25. Lichen planus  Oral lichen planus (OLP) can occur without cutaneous disease.  Onset before middle age is rare; the mean age of onset is in the sixth decade.  Women outnumber men by more than 2:1.  Mucous membrane involvement is observed in more than 50% of patients with cutaneous lichen planus  The most common location of OLP is the buccal mucosa (80% to 90%) followed by the tongue (30% to 50%) Lavy white lesions on buccal mucosa
  26. 26. Geographic tongue  Also called benign migratory glossitis,  Well-defined areas of atrophied filiform papillae bordered by arcs of normal or hyperplastic filiform papillae and by gradual changes in the location of these lesions over time
  27. 27. Submucous Fibrosis  Definition:  Submucous fibrosis represents a multifactorial disorder;  with the considered chief etiologic factor being the consistent and habitual use of areca (betel) nut, either in the form of chewing or simply placing a quid of material (paan masala) in the buccal or labial sulcus several time per day, or in a packaged powdered form with other components (guthka), over many years.  premalignant condition with transformation rates as high as 7.6%  Etiology and pathogenesis:  failure of collagen remodeling  altered epithelial-mesenchymal interactions ->formation of collagenous bands and aggregates within the submucosa and lamina propria.  diminished level of functional collagenase levels
  28. 28.  Clinical Features  Changes of submucous fibrosis are most marked over soft palate, faucial pillars and buccal mucosa  Initial mucosal alterations: erythema with or without vesiculation.  Later: slow diminishment of erythema and a progressive decrease in the degree of oral opening and tongue mobility  Pallor of the normally pink mucosa becomes evident as the underlying chronic inflammation recedes and fibrosis and hyalinization progress.  Scar bands may become evident deep within the buccal soft tissues, further limiting jaw opening and function.  Development of squamous cell carcinoma is characterized by a gradual thickening of the epithelial surface with hyperplastic to verrucous surface qualities becoming evident.
  29. 29.  Histology:  juxtaposition of atrophic epithelium surfacing a subjacent fibrosis.  Early connective tissue alterations are characterized by delicate and loosely arranged collagen fibers with progressive degrees of hyalinization  In the late stages:  complete hyalinization of the supportive connective tissue.  Variable degrees of chronic inflammation occur in the form of lymphocytes and plasma cells.  Variable levels of dysplasia have been noted.
  30. 30.  Management of oral submucous fibrosis is problematic, particularly in advanced cases and when the use of areca-containing products remains in place.  Medical:  Avoid irritant factors  Topical injection of steroids-Dexamethasone  Treat existent anaemia or vitamin deficiencies  Encourage jaw opening exercises.  Surgical  Surgical release procedures of scar bands have been only modestly successful.  More recently collagenase and pentoxifylline administration in separate studies has been proposed

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