This document discusses various lesions that can occur in the oral cavity. It begins by defining mouth ulcers and listing common causes such as physical abrasion, infection, and cancer. It then covers specific conditions like recurrent aphthous stomatitis, lichen planus, pemphigus vulgaris, and necrotizing sialometaplasia. It provides details on symptoms, appearance, epidemiology, treatment and pathogenesis for each condition. In general, the document provides a comprehensive overview of acute and chronic ulcerative lesions that can present in the oral cavity.

1. ORAL CAVITY LESIONS Frederick Mars Untalan, MD

3. mouth ulcerLatin ulcus and from Greek "ἕλκος" - elkos, "wound"[American English, canker soreopen sore inside the mouth, or rarely a break in the mucous membrane or the epithelium on the lips or surrounding the mouth. Causes: physical abrasion, acidic fruit, infection, other medical conditions, medications, and cancerous and nonspecific processes. Two common types :aphthous ulcerscold sores or fever blisters

4. EpidemiologyEpidemiological studies show an average prevalence between 15% and 30%.women > men and < 45 years. >16-25 year olds, and <over 55.The frequency of mouth ulcers varies from fewer than 4 episodes per year (85% of all cases) to more than one episode per month (10% of all cases) including people suffering from continuous RAS

5. ORAL CAVITYLIPSTEETHGINGIVAPALATETONGUEORAL MUCOUS MEMBRANESORAL LYMPHOID TISSUES

6. Acute: small, recent onset, short duration, recurrentTraumaRecurrent Aphthous StomatitisBehcet’sHerpesvirus InfectionHerpangina

7. Trauma:Cheek Biting

9. Trauma:Ill-Fitting dentures

11. Trauma:Chemical Burns

12. Trauma:Abrasions from Teeth

13. Recurrent Aphthous Stomatitis(RAS)Most common ulcerative lesion of oral cavityRecurrent, painful ulcersConfined to soft mucosaSubdivided into three types:Minor aphthaeMajor aphthaeHerpetiformaphthae

14. Recurrent Aphthous Stomatitis(RAS)Minor aphthae:Less than 1 cmHeal completely in 7-10 days without scarringPainful Prodromal stageShallow and round to ovalGray to yellow membraneClusters of up to 5 ulcersSteroids

15. Recurrent Aphthous Stomatitis (RAS)Minor apthae

16. Recurrent Aphthous Stomatitis (RAS)Major AphthaeUncommonIrregular, deep ulcers1-3 cm in sizeRaised bordersHeal in 4-6 weeksExtensive scarring and distortionBIOPSY!!Steroids

19. Recurrent Aphthous Stomatitis (RAS)Major apthae

20. Major aphthous ulcer

21. Recurrent Aphthous Stomatitis (RAS)Herpetiform AphthaeUncommonCrops of up to 150 very small (<3mm) ulcersHeal completely in 7-10 daysCOMPLETELY UNRELATED TO HERPESVIRUS

22. Recurrent Aphthous Stomatitis (RAS)Herpetiform aphthae

23. Behcet’sSymptom complex of:Recurrent aphthous ulcers of the mouthPainful genital ulcersUveitis or conjuctivitis

24. Behcet’sAffects persons of Mediterranean, Middle Eastern, or Japanese decentEasily confused with Stevens-Johnson syndrome or Reiter’s diseaseNeed referral for systemic treatment

27. Acute UlcerativeBehcet’s Syndrome recurrent oral and genital ulcers arthritis inflammatory disease of eyes and GI tract.

28. Acute UlcerativeReiter’s Syndromemainly young men 20 to 30Classis triad ConjunctivitisArthritisurethritis. Oral lesions range from erythema to papules to ulcerations involving the buccal mucosa, gingiva, and lips. Lesions on the tongue resemble geographic tongue

29. Herpesvirus InfectionHSV-1 and/or HSV-2Primary InfectionSecondary InfectionVaricella zoster virus (HHV-3)

30. Herpesvirus InfectionPrimary InfectionHerpetic gingivostomatitisYounger patientsOften asymptomaticMay be associated with fever, chills, malaiseVesicles-ulcers-crustingAnywhere in the oral cavity

31. Herpesvirus InfectionPrimary Infection

32. Herpesvirus InfectionPrimary Infection

33. Herpesvirus InfectionSecondary InfectionReactivation of latent virusNot associated with systemic symptomsSmall vesicles Occur only on the hard palate and gingivaProdromal signs

34. Herpesvirus InfectionSecondary infection

35. Herpesvirus InfectionVaricella zoster virus (HHV-3)Latent infectionOral ulcersDermatomal distribution

37. Herpesvirus InfectionVaricella zoster virus

38. Herpesvirus InfectionVaricella zoster virus

39. HerpanginaNOT caused by HerpesvirusCoxsackie A virusChildren < 10 years of ageCommon in summer and fallOften subclinical presentationHeadache/Abdominal pain 48hrs prior to papulovesicular lesions on tonsils & uvula.Sore throat

40. Herpangina

41. Primary Herpetic Gingivostomatitis

42. Acute ulcerativeVaricella zoster virus- distribution of trigeminal nerveCoxsackie- prodrome, vesicular, pharynx,tonsils, soft palateRecurrent herpes simplex- prodrome present, herpes labialis, limited to keratinized epithelium and can involve the gingiva and hard Viral InfectionsHerpes simplex- 600,000 new cases annually, prodrome followed by small vesicles that ulcerate, primary infection involves the gingiva, and can involve the entire oral cavitypalate

43. Recurrent herpes simplex

44. Chronic: longer duration, well circumscribed, raised borders, indurated base with craterTraumaInfectionNeoplasmNecrotizing sialometaplasia

45. Trauma:Ill-Fitting dentures

46. InfectionRareHIV/AIDS patientsBacterialDeep mycotic infectionCandida

47. InfectionBacterialUsually secondary infectionPrimary infection: syphilis, tuberculous, or actinomycosis

48. InfectionBacterial-Syphilis

49. Syphilis

50. Acute ulcerative SyphilisCongenital syphilisHutchinson’s incisors, “moon’s molars” Primary painless, indurated, ulcerated, usually involving the lips, tongue Secondary- mucous patches, split papules Tertiary- Gummas, can involve palate, tongue

54. InfectionBacterial-Syphilis

55. InfectionMycoticBlastomycosisHistoplasmosis

56. InfectionHistoplasmosis

57. Acute ulcerative Histoplasmosisdisseminated form, oropharyngeal lesions may present as ulcerative, nodular, or vegetative Biopsy will provide the diagnosis

58. InfectionCandidaCandida albicansMost commonNormal floraPredisposing factorsWhite creamy patches KOH prep Nystatin oral suspension

59. InfectionCandida

60. Candidiasis

61. CandidiasisOpportunistic infection, Candida albicans Pseudomembranous (thrush), erythematous, atrophic, hyperplasticRisk factors: Local- topical steroids, xerostomia, heavy smoking, denture appliances. Systemic- Poorly controlled diabetes mellitus, immunosuppression

62. CandidiasisSymptoms: burning, dysgeusia, sensitivity, generalized discomfortAngular cheilitis, coinfection with staph may be presentAcutely- atrophic red patches or white curd-like surface colonies Chronic- denture related form confined to area of appliance

63. CandidiasisConfirmation with KOH smear, tissue PAS or silver stainsTreatment- topical or systemic, polyene,azoles

64. LeukoedemaDiffuse, filmy grayish surface with white streaks, wrinkles, or milky alterationSymmetric, usually involving the buccal mucosa, lesser extent labial mucosaNormal variationpresent in the majority of black adults, and half of black childrenAt rest, opaque appearance. When stretched dissipates

65. Leukoedema

66. Oral LeukoplakiaClinically defined white patch or plaque that has been excluded from other disease entitiesPresence of dysplasia, carcinoma in situ, and invasive carcinoma from all sites 17-25% (Bouqot and Gorlin 1986)Etiologyassociated with tobacco (smoking, smokeless tobacco), areca nut/betel preparations

67. Oral Leukoplakia

68. Oral Leukoplakia

69. Oral LeukoplakiaMay be macular, slightly elevated, ulcerative, erosive, speckled, nodular, or verrucousClinical shift in appearance from homogenous to heterogenous, speckled, or nodular, a rebiopsy is mandatoryCorrelation between increasing levels of dysplasia and increases in regional heterogeneity or speckled quality

70. Proliferative Verrucous LeukoplakiaUncommon variant of leukoplakia Multifocal, occurring more in women, and in those without the usual risk factorsEvolution from a thin, flat white patch to leathery, then papillary to verrucousDevelopment of squamous cell CA in over 70% of cases

71. Proliferative Verrucous Leukoplakia

72. Site of Leukoplakia Risk of dysplasia/carcinoma higher with floor of mouth, ventrolateral tongue, retromolar trigone, soft palate than with other oral sites

73. Epithelial Dysplasia

74. Treatment Trial of cessation of offending agent, follow-upGuided by microscopic characterizationBenign, minimally dysplastic- periodic observation or elective excisionComplete excision scalpel excisionlaser ablationelectrocautery, cryoablationChemoprevention

75. Oral Hairy Leukoplakia

76. Oral hairy leukoplakiaAsymptomatic, seen with systemic immunosuppressionEBVLateral tongue bilaterally; subtle white keratotic vertical streaks to thick corrugated ridgesDiagnosis by microscopy and in situ hybridizationManagement includes establishing diagnosis and treating immunosuppression

77. NeoplasmSquamous cell carcinoma (SCC)Most commonIrregular ulcers with raised marginsMay be exophytic, infiltrative or verrucoidMimic benign lesions grossly

78. NeoplasmSquamous cell carcinoma

79. NeoplasmSquamous cell carcinoma

80. NeoplasmSquamous cell carcinoma

81. Necrotizing SialometaplasiaInflammatory conditionIschemia to minor salivary glandsDeep ulcers of the hard palateResolves in 6 weeks

82. Sialometaplasia

83. Sialometaplasia

84. Generalized: broad classification encompassing a wide variety of causative agents or conditionsContact stomatitisRadiation mucositisCancer chemotherapy

85. Dermatologic Disorders: cutaneous and oral manifestationsErythema multiformeLichen planusBenign mucous membrane pemphigoidBullous pemphigoidPemphigus vulgaris

86. Dermatologic DisordersErythema multiformeRapidly progressiveAntigen-antibody complex deposition in vessels of the dermisTarget lesions of the skinDiffuse ulceration, crusting of lips, tongue, buccal mucosaSelf-limited, heal without scarring

87. Acute ulcerative Erythema multiforme Mucocutaneous hypersensitivity reactionEtiologyinfectious (strong association with HHV-1, viral, mycoplasma)drugs (antiseizure medications, sulfonamides)Clinicallytarget lesions develop over the skin with erythematous periphery central area that can develop bullae, vesicles.

88. Dermatologic DisordersErythema multiforme

89. Erythema Multiforme

90. Erythema MultiformeClinicallyOral mucosa and lips demonstrate aphthous like ulcers and occasionally vesicles or bullae may be present.Gingiva rarely involved; common sites include labial mucosa, palate, tongue, and buccalmucosaMucosal ulcers are irregular in size and shape, tender and covered with fibrinousexudate.Sialorrhea, pain, odynophagia, dysathria. Severe EM are associated with involvement of other mucosal sites- eyes, genitalia, and less common esophagus and lungs

91. Erythema MultiformeHistopathology]Intense lymphocytic infiltration in a perivascular distribution and edema from submucosa into the lamina propria, epithelium lack antibodies, blood vessels contain fibrin, C3, IgM Treatment- with oral involvement only can treat symptomatically/short course of corticosteroids

92. Dermatologic DisordersLichen planusChronic disease of skin and mucous membranesDestruction of basal cell layer by activated lymphocytesReticular: fine, lacy appearance on buccal mucosa (Wickman’s striae)Hypertrophic: resembles leukoplakiaAtrophic or erosive: painful

93. Oral lichen planus

94. Oral lichen planus0.2%- 2% population affectedUsually asymptomatic, reticular from, white striaform symmetric lesions in the buccal mucosaT-cell lymphocytic reaction to antigenic components in the surface epithelial layerOther variants: plaque, atrophic/erythematous, erosive

95. Dermatologic DisordersLichen planus

96. Oral lichen planusSmall risk of squamous cell carcinoma, more likely seen in the atrophic or erosive typesStudies show that dysplasia with lichenoid features have significant degree of alleic loss. Recommendation is to remove these lesions/follow patient closely

97. Dermatologic DisordersLichen planus

98. Dermatologic DisordersLichen planus

99. Dermatologic DisordersBenign mucous membrane pemphigoidTense subepithelial bullae of skin and mucous membranesRupture, large erosions, heal without scarringSloughing (Nikolsky sign)Bullous pemphigoidCutaneous lesions more commonBoth show subepithelial clefting with dissolution of the basement membraneIgG in basement membrane

100. Dermatologic DisordersBenign mucous membrane pemphigoid

101. Dermatologic DisordersBenign mucous membrane pemphigoid

102. Dermatologic DisordersPemphigus vulgarisSevere, potentially fatalJewish and ItaliansIntraepithelial bullae and acantholysisNikolsky’s signLoss of intracellular bridgesAutoimmune response to desmoglein 3Intraepithelial clefting

103. Dermatologic DisordersPemphigus vulgaris

104. Dermatologic DisordersPemphigus vulgaris

105. Quinn’s Rule for Stomatitis:“Call it aphthous stomatitis. Treat it for two weeks. If it is still there, biopsy it.”

106. ORAL CAVITY LESIONS Frederick Mars Untalan, MD