Non neoplastic Diseases of

the oral cavity

Dr. Krishna Koirala

2016/12/19

Oral Submucous Fibrosis

Aphthous Ulcers

Leukoplakia

Oral Candidiasis

Vincent’s Angina

Oral Submucous Fibrosis (OSMF)

• Definition :

–Chronic debilitating disease of oral mucosa characterized by inflammation and progressive fibrosis of lamina propria and deeper connective tissues followed by stiffening of an otherwise yielding mucosa resulting in difficulty in opening the mouth

• Sites : Any part of the oral cavity : Buccal mucosa -most common site

• Malignant potential !!!

Pathophysiology• Multifactorial

• Factors– Areca nut chewing− Ingestion of chilies − Genetic and immunologic processes− Nutritional deficiencies

• Areca nut (betel nut) chewing

− Arecoline (active alkaloid in betel nuts) - main

factor which leads to Submucous fibrosis by

– Stimulating fibrogenesis

− Increasing collagen synthesis by

fibroblasts

−Decreasing collagen degradation

• Ingestion of chilies

– Hypersensitivity reaction

• Genetic and immunologic processes

– Increased frequency of HLA - A10, B7 and DR3

• Nutritional deficiencies

– Iron deficiency anemia, vitamin B complex deficiency, malnutrition

Clinical features Symptoms

− Oral pain and burning sensation upon consumption of spicy foodstuffs

− Dryness of mouth /Change in gustatory sensation

− Impaired mouth movements (eating, blowing)

– Progressive inability to open the mouth (trismus)

– Hearing loss (stenosis of the Eustachian tubes)

– Nasal intonation of voice

Signs•Stomatitis (Stage 1) : erythematous mucosa, vesicles, mucosal ulcers / petechia

•Fibrosis (stage 2) :

− Blanched and leathery floor of the mouth

− Blanched rubbery soft palate with decreased mobility (stiffness, trismus)

– Blanched and atrophic tonsils ,shrunken budlike uvula

•Sequelae (stage 3) : Leukoplakia , Speech and hearing deficits

Treatment

Medical Treatment1) Steroids ( Short term improvement )

− Weekly submucosal intralesional injections for 6 - 8

wks (Dexamethasone 4 mg or Triamcenolone 40

mg )

–Topical application for 3 weeks ( Betamethasone

cream 0.05 % topically 6 hrly)

2) Hyaluronidase ( Topical/Intralesional ) −Lowers the viscosity of the intercellular cement

substance and decreases collagen formation

Steroids and topical hyaluronidase used together provide better long term results than either agent used alone

3) Submucosal administration of aqueous placental extract

–Anti-inflammatory , prevents and inhibits mucosal damage)

4) Intralesional injection of Interferon –gamma (? Role)

− Immunoregulatory effect

– Antifibrotic cytokine

5) Pentoxifylline : 400mg 3 times daily for 4-6 months

Surgical•Indications

– Patients with severe trismus

– Biopsy results revealing dysplastic or neoplastic changes

Procedures

1) Simple /laser excision of fibrous bands

2) Split thickness skin grafting following bilateral temporalis myotomy , coronoidectomy, or resection of the fibrous bands

3) Excision of fibrotic tissues and covering the defect with fresh human amnion, or buccal fat pad (BFP) grafts

4) Surgical excision of bands and

submucosal placement of fresh human

placental graft

5) Nasolabial flaps , lingual pedicle flaps,

platysma myocutaneous flap

Aphthous Ulcers

• Definition− Typically recurrent round or oval ulcers that occur inside the mouth on areas where the skin is not tightly bound to the underlying bone (e.g. on the inside of the lips and cheeks or underneath the tongue)

• Clinical types − Minor aphthous ulcers (80% ) − Major aphthous ulcers − Herpetiform ulcers

Predisposing factors• Hematinic deficiency (20% )

− Iron, folic acid, or vitamin B

• Malabsorption in gastrointestinal disorders

− Celiac disease, Crohn’s disease, pernicious anemia

• Stress

− Exacerbate during school or university examination times

• Trauma– Biting of the mucosa and wearing of

dental appliances • Endocrine factors

– Related to the progesterone level • Food allergies• Immune deficiencies:

– HIV and other immune defects • Drugs eg NSAIDs

Minor aphthae

Major aphthae

Herpetiform ulcers

Age of onset

Childhood/adolescent

Childhood/adolescent

Young adults

Ulcer size 2-4 mm >10mm Tiny, coalesce

Number Up to six Mainly solitary 10-100

Sites affected

Vestibule, labial ,buccal mucosa, FOM

Any site Any site but often ventrum of tongue

Duration of each ulcer

Up to ten days Up to one month Up to one month

Others ------------ May heal with scarring

Affect mainly women

• Features

– Single or multiple ulcers ranging

from 2-10 mm diameter lasting

for a few weeks

– Yellow base and circumscribed

erythematous margins without induration

– Ulcers heal in about 10 days , frequency

variable

Diagnosis • History and clinical features

• Exclude systemic disorders

– Complete blood count

– Iron studies (usually an assay of serum ferritin )

– Red blood cell folate assay

– Serum vitamin B -12 measurements

– Rarely biopsy

Treatment• Goal

−Relief of pain and reduction of ulcer duration

• General measures

− Identify and correct predisposing factors

− Avoid eating particularly hard or sharp food

− Correct iron or vitamin deficiency

• Topical corticosteroids : Mainstay of treatment

– Reduce painful symptoms but not the rate of ulcer recurrence 

– Hydrocortisone, triamcenolone, prednisolone

– Betamethasone, fluticasone, clobetasol – more potent and effective

– Betamethasone (0.5 mg tablet) dissolved in 15 ml of water as mouth rinse, used 4 times daily

• Systemic corticosteroids

• Topical antibiotics

– Reduce the severity of ulceration

– Doxycycline 100 mg or tetracycline 500 mg in 10 ml of water as a mouth rinse for 3 minutes, 4 times daily

– Chlorhexidine gluconate mouth rinses

• Anti-inflammatory agents

• Benzydamine - transient pain relief

• Systemic immunomodulators

−Thalidomide 50-100 mg daily

• Other medications

− Sucralfate, diclofenac, aspirin

−Transfer factor, gamma-globulin

therapy, dapsone, colchicine,

pentoxifylline, prednisolone

Leukoplakia

• Definition− Oral white lesions that cannot be clinically or

pathologically attributed to any specific disease

− Propensity for malignant transformation (10 -20% )

• Sites

− Buccal mucosa (occlusal lines), alveolar mucosa, tongue, lips, palate, floor of mouth, gingiva

• Causes

– Irritation from rough teeth, fillings, or crowns, or ill-fitting dentures that rub against the cheek or gum

– Chronic smoking, pipe smoking, or other tobacco use

– Sun exposure to the lips

– Oral cancer (rare)

– HIV or AIDS

• Symptoms :

− White or gray colored patches on abovementioned areas. Usually painless, but may be sensitive to touch, heat, spicy foods, or other irritation

• Investigations:– Orascreen - helps to identify

malignancy from areas of dysplasia

– Biopsy from most active part

Treatment• Supplementation with 150,000 IU of beta-

carotene twice a week for six months

• Vitamin E (alpha - tocopherol ) and C

• Retinoids — derivatives of vitamin A

• Bleomycin

• Complete surgical removal – if epithelial dysplasia

• Other treatment modalities

− Cryosurgery, laser surgery, photodynamic therapy

Oral Candidiasis

• Infection of oral cavity with Candida albicans

• Commensal in mouth of many patients

• Pathogenesis− General debilitating diseases ( DM, AIDS )

− Prolonged antibiotic therapy

− Anticancer chemotherapy

− Prolonged use of steroids

Types• Acute

– Multiple small white patches on the oral mucosa which when wiped off leave erythematous patches

– Quite painful, seen particularly in buccal mucosa and soft palate

• Chronic− White lesion, cannot be rubbed off, widespread− Common in buccal mucosa just inside the

corner of mouth

• Diagnosis− KOH mount− Staining with PAS− Fungal culture

• Treatment− Local application of nystatin,

clotrimazole, amphotericin− Systemic antifungals e.g. Ketoconazole

( chronic)− Excision of patch− Correction of underlying cause

Vincent’s Angina ( acute necrotizing ulcerative

gingivitis)• Infection of oral cavity with spirochete (Borrelia

vincenti) and anaerobic organism (Bacillus fusiformis)

• Occurs in debilitated individuals and those with poor dental hygiene

• Gingivitis affecting interdental papillae producing ulceration and necrotic membrane

• Tonsils and oropharynx may also be involved

• Painful lesions associated with fetor, cervical lymphadenopathy and fever

• Diagnosis

• Smear stained with Gentian violet to

identify the spirochete and Fusiform bacilli

• Treatment

• Local : Antiseptic mouthwashes

• Systemic: Benzyl penicillin and

metronidazole (oral or parenteral)