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8/7/2019 Diseases of the Oral Cavity
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DISEASES OF THE
ORAL CAVITYCSA Espina, MD, DPBO
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How to examine
the oral cavity
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What do you need for
a proper examination? a directed history and a good clinical eyea directed history and a good clinical eye
a good source of lighta good source of light
tongue depressor(s)tongue depressor(s) ± ± preferably 2preferably 2 clean gauzeclean gauze
clean examining glovesclean examining gloves
face maskface mask
measuring apparatusmeasuring apparatus
examining mirror (sometimes needed)examining mirror (sometimes needed)
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What do you need to perform?
InspectionInspection
PalpationPalpation ± ± bimanual palpationbimanual palpation
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ANDBIMANUAL
PALPATION OF
LESIONS THATMAY BE
TUMORS!!
EXAMINATION OF THE ORAL CAVITY
USING A TONGUE DEPRESSOR
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What do you need to watch out for?
Be conscious if you are causing any pain or Be conscious if you are causing any pain or discomfort when examining the patientdiscomfort when examining the patient
Protect yourself from infection (WEAR A MASK)Protect yourself from infection (WEAR A MASK)
When dealing with tumors, (especially malignantWhen dealing with tumors, (especially malignantones, or those for surgery), seek out the extent of ones, or those for surgery), seek out the extent of
the lesionthe lesion Always check the neck for enlarged nodes when Always check the neck for enlarged nodes when
dealing with tumors suspicious for malignancydealing with tumors suspicious for malignancy
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trigone
(anterior
2/3)
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BENIGN CONDITIONS
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APHTHOUS ULCERS
³singaw´
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APHTHOUS ULCERS A common and very painful affliction. A common and very painful affliction.
Often simply caused by trauma and heal quickly on their Often simply caused by trauma and heal quickly on their own.own.
The recurrent, bothersome form is known as recurrentThe recurrent, bothersome form is known as recurrentaphthous stomatitis.aphthous stomatitis.
Cause is unknown, though it is believed to be some sort of Cause is unknown, though it is believed to be some sort of immune mediated condition.immune mediated condition.
At this time it is believed that aphthous stomatitis is not At this time it is believed that aphthous stomatitis is notcaused by any infectious agent (viruses or bacteria) andcaused by any infectious agent (viruses or bacteria) andthese ulcers are not contagious.these ulcers are not contagious.
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APHTHOUS ULCERS
Almost always found on the "loose" tissues of the Almost always found on the "loose" tissues of the
mouth; i.e. the cheek, inner lip, tongue, soft palate,mouth; i.e. the cheek, inner lip, tongue, soft palate,
floor of mouth, and sometimes the throat.floor of mouth, and sometimes the throat.
A reddish halo usually surrounds them A reddish halo usually surrounds them
Usually small, less than one half centimeter inUsually small, less than one half centimeter in
diameter. A less common form, major aphthae, candiameter. A less common form, major aphthae, can
get quite large and take very long to heal.get quite large and take very long to heal.
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APHTHOUS ULCERS
Triggers are usually difficult to pin down.Triggers are usually difficult to pin down.
Stress, acidic foods, specific foods for theStress, acidic foods, specific foods for the
individual, trauma, chemical sensitivities all play aindividual, trauma, chemical sensitivities all play arole.role.
There is no cure for There is no cure for aphthousaphthous stomatitisstomatitis..
Usually, these are self Usually, these are self--limiting.limiting.
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APHTHOUS ULCERS Laser treatments are the most effective, giving immediateare the most effective, giving immediate
pain relief and causing the ulcer to heal in 24pain relief and causing the ulcer to heal in 24--72 hours.72 hours.Pain relief is immediate and lasting; the ulcers heal in twoPain relief is immediate and lasting; the ulcers heal in twoto four days.to four days.
Avoiding known triggers and reducing stress is helpful. Avoiding known triggers and reducing stress is helpful. A healthy diet with vitamin supplementation is A healthy diet with vitamin supplementation is
recommended.recommended.
Excellent oral hygiene, including use of antibacterialExcellent oral hygiene, including use of antibacterial
rinses has been shown to reduce frequency of attacks.rinses has been shown to reduce frequency of attacks. Topical steroid treatments (Kenalog, Lidex gel, DecadronTopical steroid treatments (Kenalog, Lidex gel, Decadron
rinses) are quite useful, reducing the pain and duration of rinses) are quite useful, reducing the pain and duration of the lesions.the lesions.
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SYSTEMIC DISEASE
PRESENTING AS ULCERS
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SYSTEMIC DISEASE
PRESENTING AS ULCERS Aphthae can also be manifestations of various Aphthae can also be manifestations of various
systemic diseases such as Behcet's syndrome, HIV,systemic diseases such as Behcet's syndrome, HIV,autoimmune disorders, Crohn's disease, and theautoimmune disorders, Crohn's disease, and the
like.like.
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CANDIDIASIS OR ORAL THRUSH
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CANDIDIASIS OR ORAL THRUSH
An overgrowth of yeast fungus, An overgrowth of yeast fungus, Candida albicansCandida albicans in thein themucous membranes of the mouth.mucous membranes of the mouth.
Oral thrushOral thrush refers to temporary candidiasis in the mouths of refers to temporary candidiasis in the mouths of babies, whilst if occurring in the mouth or throat of adults itbabies, whilst if occurring in the mouth or throat of adults itmay also be termedmay also be termed candidosiscandidosis or or moniliasismoniliasis..
Appear as thick white or cream Appear as thick white or cream--colour deposits. Underlyingcolour deposits. Underlyingthe deposits the mucosa of the mouth may appear inflamedthe deposits the mucosa of the mouth may appear inflamed(red and possibly slightly raised).(red and possibly slightly raised).
In babies the condition is termed thrush and is usuallyIn babies the condition is termed thrush and is usuallypainless and causes no discomfort. Adults may experiencepainless and causes no discomfort. Adults may experiencediscomfort or burning.discomfort or burning.
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CANDIDIASIS OR ORAL THRUSH
THOSE AT RISK:THOSE AT RISK:
NeonatesNeonates
Denture usersDenture users
Poorly controlled diabeticsPoorly controlled diabetics Those taking strong antibioticsThose taking strong antibiotics
or inhaled steroids for or inhaled steroids for
treatment of lung conditionstreatment of lung conditions
(may be reduced by regularly(may be reduced by regularlyrinsing the mouth with water rinsing the mouth with water
after taking the medication)after taking the medication)
Those undergoingThose undergoing
chemotherapychemotherapy
ImmunocompromisedImmunocompromised peoplepeople
Poorly nourished patientsPoorly nourished patients(specifically those with vitamin(specifically those with vitamin
A, iron and A, iron and folatefolate deficiencies)deficiencies)
Women undergoing hormonalWomen undergoing hormonal
changes, like pregnancy or changes, like pregnancy or
those on birth control pillsthose on birth control pills
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CANDIDIASIS OR ORAL THRUSH
Any underlying cause should be addressed. Any underlying cause should be addressed.
Treatment with topical antifungal drugs, such asTreatment with topical antifungal drugs, such as
NystatinNystatin ((MycostatinMycostatin),), MiconazoleMiconazole.. Patients who arePatients who are immunocompromisedimmunocompromised, either with, either with
HIV/AIDS or as a result of chemotherapy, mayHIV/AIDS or as a result of chemotherapy, may
require systemic treatment with oral or intravenousrequire systemic treatment with oral or intravenous
administered antiadministered anti--fungalsfungals, like, like Amphotericin Amphotericin B.B.
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DENTAL INFECTIONS
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DENTAL INFECTIONS
Not a lifeNot a life--threatening disease; however, if anthreatening disease; however, if an
odontogenic infection spreads through fascialodontogenic infection spreads through fascial
planes, patients are at risk for sepsis and airwayplanes, patients are at risk for sepsis and airway
compromise.compromise.
Neutropenic patients undergoing chemotherapy areNeutropenic patients undergoing chemotherapy are
at risk for certain pathogenic oral microorganismsat risk for certain pathogenic oral microorganisms
causing bloodstream infections, which increase thecausing bloodstream infections, which increase thechance of morbidity and mortality.chance of morbidity and mortality.
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DENTAL INFECTIONS Local infectionsLocal infections
Grossly decayed tooth that are tender to percussion andGrossly decayed tooth that are tender to percussion andtemperature.temperature.
Swollen erythematous or hemorrhagic gingiva.Swollen erythematous or hemorrhagic gingiva.
Dentoalveolar ridge edema is evidenced by a periodontal,Dentoalveolar ridge edema is evidenced by a periodontal,periapical, and subperiosteal abscess.periapical, and subperiosteal abscess.
With further invasion, the infection may elevate the periosteumWith further invasion, the infection may elevate the periosteumand penetrate adjacent tissues.and penetrate adjacent tissues.
An abscess may form and require incision and drainage. An abscess may form and require incision and drainage.
Deeper infections or abscesses that have spread along theDeeper infections or abscesses that have spread along thefascial planes may complain of fever and difficultyfascial planes may complain of fever and difficultyswallowing, breathing, and opening the mouth.swallowing, breathing, and opening the mouth.
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DENTAL INFECTIONS Mandibular infectionsMandibular infections
Infections from the mandibular teeth may result in spread to several spaces of Infections from the mandibular teeth may result in spread to several spaces of the neck including the submental space, sublingual space, submandibular the neck including the submental space, sublingual space, submandibular space and retropharyngeal spacespace and retropharyngeal space
Submental space infection is characterized by a firm midline swelling beneathSubmental space infection is characterized by a firm midline swelling beneaththe chinthe chin
Sublingual space infection is indicated by swelling of the mouth's floor withSublingual space infection is indicated by swelling of the mouth's floor withpossible tongue elevation, pain, and dysphagiapossible tongue elevation, pain, and dysphagia
Submandibular space infection is identified by swelling of the submandibular Submandibular space infection is identified by swelling of the submandibular triangle of the neck around the angle of the jaw.triangle of the neck around the angle of the jaw.
Retropharyngeal space infection is identified by stiff neck, sore throat,Retropharyngeal space infection is identified by stiff neck, sore throat,dysphagia, hot potato voice, and stridor with possible spread to thedysphagia, hot potato voice, and stridor with possible spread to themediastinum.mediastinum.
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DENTAL INFECTIONS Ludwig¶s anginaLudwig¶s angina is characterized by brawnyis characterized by brawny boardlikeboardlike
swelling from a rapidly spreadingswelling from a rapidly spreading cellulitiscellulitis of theof thesublingual,sublingual, submentalsubmental, and, and submandibular submandibular spaces withspaces with
elevation and edema of the tongue, drooling, and airwayelevation and edema of the tongue, drooling, and airwayobstruction.obstruction.
The condition isThe condition is odontogenicodontogenic in 90% of cases and arisesin 90% of cases and arisesfrom the second and thirdfrom the second and third mandibular mandibular molars in 75% of molars in 75% of cases.cases.
Potential exists for adjacent retropharyngeal andPotential exists for adjacent retropharyngeal andmediastinalmediastinal infection.infection.
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DENTAL INFECTIONS
Ludwig¶s angina ± watch out for
Aiway Obstruction!
nasopharyngeal airway tube
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DENTAL INFECTIONS
Causes:Causes:
Infections through theInfections through the fascialfascial planes usually areplanes usually are
polymicrobialpolymicrobial (average 4(average 4--6 organisms).6 organisms).
Dominant isolates are anaerobic bacteria.Dominant isolates are anaerobic bacteria.
Anaerobes (75%) Anaerobes (75%) -- PeptostreptococciPeptostreptococci,, BacteroidesBacteroides
andand PrevotellaPrevotella organisms, andorganisms, and FusobacteriumFusobacterium
nucleatumnucleatum Aerobes (25%) Aerobes (25%) -- Alpha Alpha--hemolytic streptococcihemolytic streptococci
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ANKYLOGLOSSIA
Also known as Persistent Lingual Frenulum
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ANKYLOGLOSSIA
Persistent lingualPersistent lingual frenulumfrenulum is ais a congenitalcongenital
persistence of tissue which binds the tongue to thepersistence of tissue which binds the tongue to the
floor of the mouth.floor of the mouth.
When severe, theWhen severe, the frenulumfrenulum should be cut toshould be cut to
mobilize the tongue to prevent articulation problemsmobilize the tongue to prevent articulation problems
for the child.for the child.
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GEOGRAPHIC TONGUE
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GEOGRAPHIC TONGUE Also known as Also known as Benign MigratoryBenign Migratory GlossitisGlossitis
Benign, nonBenign, non--painful, and fairlypainful, and fairly--common condition of common condition of unknown etiology.unknown etiology.
Caused by the absence of taste bud papilla manifesting asCaused by the absence of taste bud papilla manifesting asmultiple, irregular, flat red and white lesions of the dorsummultiple, irregular, flat red and white lesions of the dorsumof the tongue.of the tongue.
Glassy patches move around the tongue and changeGlassy patches move around the tongue and changeshape.shape.
Cause of this condition is unknown and does not requireCause of this condition is unknown and does not requiretreatment.treatment.
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BLACK HAIRY TONGUE
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BLACK HAIRY TONGUE Also known as Also known as LinguaLingua VillosaVillosa NigraNigra
Commonly observed condition of defectiveCommonly observed condition of defectivedesquamation of thedesquamation of the filiformfiliform papillae or elongationpapillae or elongation
of the taste buds.of the taste buds.
Results from a variety of precipitating factors: poor Results from a variety of precipitating factors: poor oral hygiene, chronic oral irritation or smoking.oral hygiene, chronic oral irritation or smoking.
Treatment involves good oral hygiene, brushing of Treatment involves good oral hygiene, brushing of the tongue, mouth rinses and sometimes thethe tongue, mouth rinses and sometimes thetrimming of the elongated papilla.trimming of the elongated papilla.
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SCROTAL TONGUE
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SCROTAL TONGUE Also called Also called Fissured Tongue or LinguaFissured Tongue or Lingua PlicataPlicata..
Harmless and asymptomatic condition in which fissuresHarmless and asymptomatic condition in which fissuresdevelop in the tongue, making it look wrinkled.develop in the tongue, making it look wrinkled.
Familial, but not always a congenital condition.Familial, but not always a congenital condition. Asymptomatic condition, unless food particles and debris Asymptomatic condition, unless food particles and debris
lodging in the depths of the fissures cause a mildlodging in the depths of the fissures cause a mild glossitisglossitis..Deep fissures may harbor colonies of bacteria or debrisDeep fissures may harbor colonies of bacteria or debrisfrom food, leading to bad breath or fungal infections of thefrom food, leading to bad breath or fungal infections of the
tongue.tongue. There is no treatment for scrotal tongue, except for goodThere is no treatment for scrotal tongue, except for good
oral hygiene if the above condition occurs.oral hygiene if the above condition occurs.
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BENIGN GROWTHS
SIMPLE RANULATONGUE HEMANGIOMA
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BENIGN GROWTHS
ORAL FIBROMA
SIALOCOELE
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BENIGN GROWTHS
TORUS PALATINUSTORUS MANDIBULARIS
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BENIGN GROWTHS
Hard bony growth or Hard bony growth or exostosisexostosis in the center of thein the center of the
roof of the mouth or on the floor of mouth.roof of the mouth or on the floor of mouth.
NotNot a tumor or neoplasm.a tumor or neoplasm. Commonly occurs in females over the age of 30Commonly occurs in females over the age of 30
and rarely needs treatment.and rarely needs treatment.
Occasionally these bony growths are removed for Occasionally these bony growths are removed for the proper fitting of dentures.the proper fitting of dentures.
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PRE-MALIGNANTLESIONS
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LEUKOPLAKIADEFINITION:DEFINITION:
A condition of the mouth A condition of the mouththat involves the formationthat involves the formation
of of white leathery patcheswhite leathery patchesor spotsor spots on the mucouson the mucousmembranes of the oralmembranes of the oralcavity.cavity.
Often caused by chronicOften caused by chronicirritation, tobacco use or irritation, tobacco use or infection.infection.
It is not a specific disease entityIt is not a specific disease entityand is diagnosed by theand is diagnosed by theexclusion of diseases that mayexclusion of diseases that maycause similar white lesions.cause similar white lesions.
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LEUKOPLAKIADEFINITION:DEFINITION:
Leukoplakia affects less than one percent of the population,Leukoplakia affects less than one percent of the population,and is most common in adults within the 50and is most common in adults within the 50--70 years age70 years agegroup.group.
A small proportion of cases is associated with a risk of A small proportion of cases is associated with a risk of cancer.cancer.
Treatment of leukoplakia mainly involves avoidance of Treatment of leukoplakia mainly involves avoidance of predisposing factors like smoking, tobacco and betel nutpredisposing factors like smoking, tobacco and betel nut
chewing, alcohol, and removal of chronic irritants like sharpchewing, alcohol, and removal of chronic irritants like sharpedges of teeth.edges of teeth.
In suspicious cases, a biopsy is warranted.In suspicious cases, a biopsy is warranted.
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ERYTHROPLAKIADEFINITION:DEFINITION:
Flat red patch or lesion in theFlat red patch or lesion in themouth with a soft and velvetymouth with a soft and velvetytexturetexture that cannot bethat cannot be
attributed to any other attributed to any other pathology.pathology.
Many other conditions that areMany other conditions that aresimilar in appearance and mustsimilar in appearance and mustbe ruled out before a diagnosisbe ruled out before a diagnosisof of erythroplakiaerythroplakia is made.is made.
ErythroplakiaErythroplakia is moreis morefrequently is associated withfrequently is associated withdysplasia, and is thus a predysplasia, and is thus a pre--cancerous lesion.cancerous lesion.
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ERYTHROPLAKIADEFINITION:DEFINITION:
Mostly found in elderly men around the ages of 65Mostly found in elderly men around the ages of 65 -- 74.74.
Commonly associated with smoking.Commonly associated with smoking.
Microscopically, the tissue exhibits severe epithelialMicroscopically, the tissue exhibits severe epithelialdysplasia, carcinomadysplasia, carcinoma--inin--situ, or invasive squamous cellsitu, or invasive squamous cellcarcinoma in 90% of cases.carcinoma in 90% of cases.
Treatment involves biopsy and complete excision of theTreatment involves biopsy and complete excision of the
lesion is sometimes advised.lesion is sometimes advised. Recurrence of the erythroplakia is common and longRecurrence of the erythroplakia is common and long--termterm
monitoring is needed.monitoring is needed.
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MALIGNANT
TUMORS
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SQUAMOUS CELL
CARCINOMA
W ARTY OR EXOPHYTIC TYPE
ULCERATIVE TYPE
INVASIVE TYPE
SCCA OF THE LOWER LIP
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SQUAMOUS CELL
CARCINOMA Smoking and other tobacco use are associated withSmoking and other tobacco use are associated with
about 75 percent of oral cancer cases, caused byabout 75 percent of oral cancer cases, caused byirritation of the mucous membranes of the mouthirritation of the mucous membranes of the mouth
from smoke and heat of cigarettes, cigars, andfrom smoke and heat of cigarettes, cigars, and
pipes.pipes.
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SQUAMOUS CELL
CARCINOMA
Tobacco containsTobacco containsover 19 knownover 19 known
carcinogens.carcinogens.
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SQUAMOUS CELL
CARCINOMA In many Asian culturesIn many Asian cultures
chewing betel nut is knownchewing betel nut is known
to be a strong risk factor to be a strong risk factor
for developing oral cancer.for developing oral cancer. In India where suchIn India where such
practices are common,practices are common,
oral cancer represents uporal cancer represents up
to 40% of all cancers,to 40% of all cancers,compared to just 4% in thecompared to just 4% in the
UK.UK.
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SQUAMOUS CELL
CARCINOMA HumanHuman papillomaviruspapillomavirus (HPV) types 16 and 18(HPV) types 16 and 18
exposureexposure is a known risk factor and independentis a known risk factor and independent
causative factor for oral cancer.causative factor for oral cancer.
Oral cancer in this group tends to occur on theOral cancer in this group tends to occur on the
tonsil andtonsil and tonsillar tonsillar pillars, base of the tongue, andpillars, base of the tongue, and
thethe oropharynxoropharynx..
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SQUAMOUS CELL
CARCINOMASYMPTOMSSYMPTOMS
Lesion, lump, or ulcer onLesion, lump, or ulcer onthe tongue, lip, or other the tongue, lip, or other
areasareas Usually painless initiallyUsually painless initially
May develop poor nutritionMay develop poor nutritionand poor oral hygienceand poor oral hygience
due to feeding problemsdue to feeding problemswhen the tumor iswhen the tumor isadvancedadvanced
Additional symptoms that Additional symptoms thatmay be associated withmay be associated with
this disease:this disease: Tongue mobility problemsTongue mobility problems
Problems with mouthProblems with mouth--opening (opening (trismustrismus))
Swallowing difficultiesSwallowing difficulties
Articulation problems Articulation problems
Pain andPain and paresthesiaparesthesia arearelate symptomslate symptoms
SQ O S C
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SQUAMOUS CELL
CARCINOMA While a dentist, physician or other medicalWhile a dentist, physician or other medical
professional may suspect a particular lesion isprofessional may suspect a particular lesion is
malignant, the only definitive method for malignant, the only definitive method for
determining this is throughdetermining this is through BIOPSYBIOPSY andand
microscopic evaluation of the cells.microscopic evaluation of the cells.
SQUAMOUS CELL
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SQUAMOUS CELL
CARCINOMA Surgical excision of the tumor is usually recommended.Surgical excision of the tumor is usually recommended.
Radiation therapy is often used in conjunction with surgery,Radiation therapy is often used in conjunction with surgery,
or as the definitive radical treatment, especially if theor as the definitive radical treatment, especially if the
tumour is inoperable.tumour is inoperable. Owing to the vital nature of the structures in the head andOwing to the vital nature of the structures in the head and
neck area, surgery for larger cancers is technicallyneck area, surgery for larger cancers is technically
demanding.demanding.
Reconstructive surgery may be required to give anReconstructive surgery may be required to give an
acceptable cosmetic and functional result.acceptable cosmetic and functional result.
SQUAMOUS CELL
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SQUAMOUS CELL
CARCINOMA Survival rates for oral cancer depend on the precise site,Survival rates for oral cancer depend on the precise site,
and the stage of the cancer at diagnosis.and the stage of the cancer at diagnosis.
Overall, survival is around 50% at five years when allOverall, survival is around 50% at five years when allstages of initial diagnosis are considered. Survival rates for stages of initial diagnosis are considered. Survival rates for
stage 1 cancers are 90%, hence the emphasis on earlystage 1 cancers are 90%, hence the emphasis on early
detection to increase survival outcome for patients.detection to increase survival outcome for patients.
Following treatment, rehabilitation may be necessary toFollowing treatment, rehabilitation may be necessary to
improve movement, chewing, swallowing, and speech.improve movement, chewing, swallowing, and speech.
SQUAMOUS CELL
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SQUAMOUS CELL
CARCINOMA Chemotherapy is useful in oral cancers when used inChemotherapy is useful in oral cancers when used in
combination with radiation therapy.When cure is unlikely itcombination with radiation therapy.When cure is unlikely it
can also be used to extend life and can be consider can also be used to extend life and can be consider
palliative but not curative care.palliative but not curative care. Treatment of oral cancer will usually be by be aTreatment of oral cancer will usually be by be a
multidisciplinary team, with treatment professionals frommultidisciplinary team, with treatment professionals from
the realms of radiation, surgery, chemotherapy, nutrition,the realms of radiation, surgery, chemotherapy, nutrition,
dental professionals, and even psychologydental professionals, and even psychology all possiblyall possiblyinvolved with diagnosis, treatment, rehabilitation, andinvolved with diagnosis, treatment, rehabilitation, and
patient care.patient care.
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