View
224
Download
0
Category
Preview:
Citation preview
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
1/51
Benign Mucosal Lesions of theOral Cavity
Grand Rounds3/2/2006
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
2/51
Outline
C ase study
Mucosal lesionsUlcerative lesionsC onclusions
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
3/51
Case Study
33 yo male admitted for throat pain, fever. Patientdeveloped a vesiculopapular rash, fever as high as103F, and thick coating on tongue, and penile ulcersfollowing one week history of fevers and sore throat.Physical exam- C rusted lesions over face andneck,3 mm tender lesion on upper lip, tongue-tender,thick white coating with 2 erythematous areas on tip,
numerous white lesions across uvula, hard and softpalate, Neck- No lymphadenopathyESR- 44
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
4/51
Leukoedema
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
5/51
Leukoedema
D iffuse, filmy grayish surface with white
streaks, wrinkles, or milky alterationSymmetric, usually involving the buccalmucosa, lesser extent labial mucosaNormal variation; present in the majority of
black adults, and half of black children At rest, opaque appearance. When stretcheddissipates
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
6/51
Oral Leukoplakia
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
7/51
Oral Leukoplakia
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
8/51
Oral Leukoplakia
C linically defined white patch or plaque that
has been excluded from other diseaseentitiesPresence of dysplasia, carcinoma in situ, andinvasive carcinoma from all sites 17-25%
(Bouqot and Gorlin 1986)Etiology- associated with tobacco (smoking,smokeless tobacco), areca nut/betelpreparations
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
9/51
Oral Leukoplakia
May be macular, slightly elevated, ulcerative,
erosive, speckled, nodular, or verrucousC linical shift in appearance fromhomogenous to heterogenous, speckled, or nodular, a rebiopsy is mandatoryC orrelation between increasing levels of dysplasia and increases in regionalheterogeneity or speckled quality
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
10/51
P roliferative Verrucous Leukoplakia
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
11/51
P roliferative Verrucous Leukoplakia
Uncommon variant of leukoplakia
Multifocal, occurring more in women, and inthose without the usual risk factorsEvolution from a thin, flat white patch toleathery, then papillary to verrucousD evelopment of squamous cell C A in over 70% of cases
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
12/51
Site of Leukoplakia
Risk of dysplasia/carcinoma higher with floor
of mouth, ventrolateral tongue, retromolar trigone, soft palate than with other oral sites
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
13/51
E pithelial Dysplasia
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
14/51
T reatment
T rial of cessation of offending agent, follow-up
Guided by microscopic characterizationBenign, minimally dysplastic- periodic observation or elective excisionC omplete excision can be performed with scalpel
excision, laser ablation, electrocautery, or cryoablationC hemoprevention
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
15/51
Oral Hairy Leukoplakia
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
16/51
Oral hairy leukoplakia
Asymptomatic, seen with systemic
immunosuppressionEBVLateral tongue bilaterally; subtle white keratoticvertical streaks to thick corrugated ridgesD
iagnosis by microscopy and in situ hybridizationManagement includes establishing diagnosis andtreating immunosuppression
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
17/51
Oral lichen planus
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
18/51
Oral lichen planus
0.2%- 2% population affected
Usually asymptomatic, reticular from, whitestriaform symmetric lesions in the buccalmucosaT -cell lymphocytic reaction to antigenic
components in the surface epithelial layer Other variants: plaque,atrophic/erythematous, erosive
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
19/51
Oral lichen planus
Small risk of squamous cell carcinoma, more
likely seen in the atrophic or erosive typesStudies show that dysplasia with lichenoidfeatures have significant degree of alleicloss. Recommendation is to remove theselesions/follow patient closely
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
20/51
Candidiasis
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
21/51
Candidiasis
Opportunistic infection, C andida albicans
Pseudomembranous (thrush), erythematous,atrophic, hyperplasticRisk factors: Local- topical steroids,xerostomia, heavy smoking, dentureappliances. Systemic- Poorly controlleddiabetes mellitus, immunosuppression
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
22/51
Candidiasis
Symptoms: burning, dysgeusia, sensitivity,
generalized discomfort Angular cheilitis, coinfection with staph maybe present
Acutely- atrophic red patches or white curd-like surface colonies C hronic- denturerelated form confined to area of appliance
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
23/51
Candidiasis
C onfirmation with KOH smear, tissue PAS or
silver stainsT reatment- topical or systemic,polyene,azoles
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
24/51
Oral ulcerative lesions
Acute
C hronicRecurrent
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
25/51
A cute ulcerative
Bacterial Acute necrotizing ulcerative gingivostomatitis
Poor oral hygiene, Punched-out ulcer atinterdental papillae, seen in young adultswith poor nutrition, heavy smoking
Streptococcal gingivostomatitisB hemolytic strep, bright red gingivae
Oral tuberculosisGonococcal stomatitis
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
26/51
Syphilis
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
27/51
A cute ulcerative
SyphilisC ongenital syphilis- Hutchinsons incisors, moons molars
Primary-painless, indurated, ulcerated, usually involving the lips,tongueSecondary- mucous patches, split papulesT ertiary- Gummas, can involve palate, tongueFungalOral C andidiasisHistoplasmosis- disseminated form, oropharyngeal lesions maypresent as ulcerative, nodular, or vegetative. Biopsy will provide thediagnosis
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
28/51
P rimary Herpetic Gingivostomatitis
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
29/51
A cute ulcerative
Viral InfectionsHerpes simplex- 600,000 new cases annually,prodrome followed by small vesicles that ulcerate,primary infection involves the gingiva, and caninvolve the entire oral cavityRecurrent herpes simplex- prodrome present,herpes labialis, limited to keratinized epithelium andcan involve the gingiva and hard palateVaricella zoster virus- distribution of trigeminal nerveC oxsackie- prodrome, vesicular, pharynx,tonsils, softpalate
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
30/51
R ecurrent herpes simplex
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
31/51
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
32/51
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
33/51
E rythema Multiforme
C linically- Oral mucosa and lips demonstrateaphthous like ulcers and occasionally vesicles or bullae may be present. Gingiva rarely involved;common sites include labial mucosa, palate, tongue,and buccal mucosaMucosal ulcers are irregular in size and shape,tender and covered with fibrinous exudate
Sialorrhea, pain, odynophagia, dysathriaSevere EM are associated with involvement of other mucosal sites- eyes, genitalia, and less commonesophagus and lungs
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
34/51
E rythema Multiforme
Histopathology- Intense lymphocytic
infiltration in a perivascular distribution andedema from submucosa into the laminapropria, epithelium lack antibodies, bloodvessels contain fibrin, C 3, IgM
T reatment- with oral involvement only cantreat symptomatically/short course of corticosteroids
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
35/51
A cute ulcerative
Lupus erythematosus- chronic discoid and systemiclupus erythematosus (SLE) formsD iscoid type- lip, intraoral lesions, most common siteis buccal mucosa; central depressed, red atrophicarea surrounded by slightly, raised keratotic border SLE form- common site posterior hard palate,superficial ulcerations that vary in size without
keratinization of the oral mucosaImmunofluorescence shows staining of thebasement membrane with immunoglobulin, andcomplement
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
36/51
A cute Ulcerative
Reiters Syndrome- mainly young men 20 to
30.C
lassis triad of conjunctivitis, arthritis,and urethritis. Oral lesions range fromerythema to papules to ulcerations involvingthe buccal mucosa, gingiva, and lips. Lesionson the tongue resemble geographic tongueBehcets Syndrome- recurrent oral andgenital ulcers, athritis, and inflammatorydisease of eyes and GI tract.
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
37/51
A cute ulcerative
D rug reactions
Barbiturates, salicylates, phenolphthalein,quinine, digitalis, griseofulvin, and dilantin
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
38/51
Chronic Ulcerative
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
39/51
Chronic ulcerative
Pemphigus vulgaris- 0.1 to 0.5
patients/100,000; 70% present with upper aerodigestive lesionsD esmoglein 3 is the pemphigus antigenIgG, IgA
D eposition of antibodies in the intracellular spaces produces direct damage to thedesmosomes
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
40/51
P emphigus vulgaris
C linical presentation- ulceration and pain withcollapse of vesicles
Lesions extend from gingival margin to alveolar marginOropharyngeal lesions favor lateral aspects of softpalate to lateral pharyngeal wallLesions heal quickly without scarringT reatment- immunosuppression with steroidssupplemented with azathioprine5% mortality with immunosuppression
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
41/51
Chronic Ulcerative
Mucous Membrane ( C icatricial) Pemphigoid
Autoantibodies directed at molecular components of the basement membraneMost common Head and Neck sites-oral, followed by ocular, nasal, and
nasopharynx sitesOcular scarring- symblepharon, cornealopacification, entropion
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
42/51
Mucous Membrane P emphigoid
D iagnosis is with immunofluorescence
showing linear immune deposits along thebasement membraneSite directed therapy. Oral cavity- topical vs.systemic steroids.
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
43/51
Chronic Ulcerative
T raumatic (Eosinophilic) Granuloma-self-limiting, relatively long duration, deep mucosal injury, origin
unknownC linical presentation- 5 th to 7 th decade, painful rapid onset, 1 to2 cm in diameter with crater center and firm periphery that iswhite in appearancePathology- deep ulceration extending into skeletal muscle,intense, diffuse inflammatory infiltrate of histiocytes, endothelialcells, and eosinophilsT reatment- observation, topical or intralesional corticosteroids,excision if clinical presentation in question
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
44/51
Major aphthous ulcer
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
45/51
R ecurrent ulcerative
Recurrent aphthous stomatitis (RAS)
Frequency range of 20-40% of population,most common non-traumatic form of oralulcerationD ata indicates a greater prevalence among
those in professional groups, higher socioeconomic status, and non-smokers
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
46/51
RA S
Seen in a variety of conditionsC rohns disease, Behcets syndrome, gluten-sensitive
enteropathy, food hypersensitivity (nuts, spices, chocolate)C ertain medications- NSAI D S, B-blockers, K+channel blockersSweets syndrome- acute febrile neutrophilic dermatosisPFAPA- Periodic fever, aphthous ulcers, pharyngitis,
and adenitis
Familial variety
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
47/51
PA S
Pathogenesis- No sign of vesicle or blistering
formationLesions over non-keratinizing mucosalsurfaces (labial, buccal, ventral, and lateraltongue, floor of mouth, soft palate, tonsillar
pillars)
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
48/51
RA S
C lassification-Minor 1.0 cm deeper, more painful, posterior aspect of oralcavity, 6 weeks or longer in immunocompromisedHerpetiform- multiple pinhead-sized, pain greater than size of lesionT reatment- symptomatic, topical steroids, for larger lesionsintralesional steroids. Severe- short term systemic steroids.
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
49/51
Case Study
Prodrome
Rash present, major aphthous ulcers, genitalfindingsNo eye findingsNo prior history
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
50/51
Conclusions
Must rule out dysplasia, squamous cell
carcinoma with leukoplakiaD uration of lesion, as well as location help tonarrow your differential diagnosisBiopsy of persistent lesions can help guidemanagement
8/7/2019 03-02-06 Benign Mucosal Lesions of the Oral Cavity1
51/51
R eferences
C ohen, Lawrence. Ulcerative Lesions of the
OralC
avity. International Journal of D ermatology Sept 1980, 362-373.Sciubba, James. Oral Mucosal Lesions.
C ummings Otolaryngology Head and
Neck Surgery. Philadelphia, 2005, 1448-91.
Recommended