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Benign Mucosal Lesions of the Oral Cavity

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33 yo male admitted for throat pain, fever. Patient developed a vesiculopapular rash, fever as high as 103F, ... Oral Hairy Leukoplakia. Oral hairy leukoplakia ... – PowerPoint PPT presentation

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Title: Benign Mucosal Lesions of the Oral Cavity


1
Benign Mucosal Lesions of the Oral Cavity
  • Grand Rounds
  • 3/2/2006

2
Outline
  • Case study
  • Mucosal lesions
  • Ulcerative lesions
  • Conclusions

3
Case Study
  • 33 yo male admitted for throat pain, fever.
    Patient developed a vesiculopapular rash, fever
    as high as 103F, and thick coating on tongue, and
    penile ulcers following one week history of
    fevers and sore throat.
  • Physical exam- Crusted lesions over face and
    neck,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 soft palate, Neck- No
    lymphadenopathy
  • ESR- 44

4
Leukoedema
5
Leukoedema
  • Diffuse, filmy grayish surface with white
    streaks, wrinkles, or milky alteration
  • Symmetric, usually involving the buccal mucosa,
    lesser extent labial mucosa
  • Normal variation present in the majority of
    black adults, and half of black children
  • At rest, opaque appearance. When stretched
    dissipates

6
Oral Leukoplakia
7
Oral Leukoplakia
8
Oral Leukoplakia
  • Clinically defined white patch or plaque that has
    been excluded from other disease entities
  • Presence of dysplasia, carcinoma in situ, and
    invasive carcinoma from all sites 17-25 (Bouqot
    and Gorlin 1986)
  • Etiology- associated with tobacco (smoking,
    smokeless tobacco), areca nut/betel preparations

9
Oral Leukoplakia
  • May be macular, slightly elevated, ulcerative,
    erosive, speckled, nodular, or verrucous
  • Clinical shift in appearance from homogenous to
    heterogenous, speckled, or nodular, a rebiopsy is
    mandatory
  • Correlation between increasing levels of
    dysplasia and increases in regional heterogeneity
    or speckled quality

10
Proliferative Verrucous Leukoplakia
11
Proliferative Verrucous Leukoplakia
  • Uncommon variant of leukoplakia
  • Multifocal, occurring more in women, and in those
    without the usual risk factors
  • Evolution from a thin, flat white patch to
    leathery, then papillary to verrucous
  • Development of squamous cell CA in over 70 of
    cases

12
Site of Leukoplakia
  • Risk of dysplasia/carcinoma higher with floor of
    mouth, ventrolateral tongue, retromolar trigone,
    soft palate than with other oral sites

13
Epithelial Dysplasia
14
Treatment
  • Trial of cessation of offending agent, follow-up
  • Guided by microscopic characterization
  • Benign, minimally dysplastic- periodic
    observation or elective excision
  • Complete excision can be performed with scalpel
    excision, laser ablation, electrocautery, or
    cryoablation
  • Chemoprevention

15
Oral Hairy Leukoplakia
16
Oral hairy leukoplakia
  • Asymptomatic, seen with systemic
    immunosuppression
  • EBV
  • Lateral tongue bilaterally subtle white
    keratotic vertical streaks to thick corrugated
    ridges
  • Diagnosis by microscopy and in situ hybridization
  • Management includes establishing diagnosis and
    treating immunosuppression

17
Oral lichen planus
18
Oral lichen planus
  • 0.2- 2 population affected
  • Usually asymptomatic, reticular from, white
    striaform symmetric lesions in the buccal mucosa
  • T-cell lymphocytic reaction to antigenic
    components in the surface epithelial layer
  • Other variants plaque, atrophic/erythematous,
    erosive

19
Oral lichen planus
  • Small risk of squamous cell carcinoma, more
    likely seen in the atrophic or erosive types
  • Studies show that dysplasia with lichenoid
    features have significant degree of alleic loss.
    Recommendation is to remove these lesions/follow
    patient closely

20
Candidiasis
21
Candidiasis
  • Opportunistic infection, Candida albicans
  • Pseudomembranous (thrush), erythematous,
    atrophic, hyperplastic
  • Risk factors Local- topical steroids,
    xerostomia, heavy smoking, denture appliances.
    Systemic- Poorly controlled diabetes mellitus,
    immunosuppression

22
Candidiasis
  • Symptoms burning, dysgeusia, sensitivity,
    generalized discomfort
  • Angular cheilitis, coinfection with staph may be
    present
  • Acutely- atrophic red patches or white curd-like
    surface colonies Chronic- denture related form
    confined to area of appliance

23
Candidiasis
  • Confirmation with KOH smear, tissue PAS or silver
    stains
  • Treatment- topical or systemic, polyene,azoles

24
Oral ulcerative lesions
  • Acute
  • Chronic
  • Recurrent

25
Acute ulcerative
  • Bacterial
  • Acute necrotizing ulcerative gingivostomatitis
  • Poor oral hygiene, Punched-out ulcer
    at interdental papillae, seen in young adults
    with poor nutrition, heavy smoking
  • Streptococcal gingivostomatitis
  • B hemolytic strep, bright red gingivae
  • Oral tuberculosis
  • Gonococcal stomatitis

26
Syphilis
27
Acute ulcerative
  • Syphilis
  • Congenital syphilis- Hutchinsons incisors,
    moons molars
  • Primary-painless, indurated, ulcerated, usually
    involving the lips, tongue
  • Secondary- mucous patches, split papules
  • Tertiary- Gummas, can involve palate, tongue
  • Fungal
  • Oral Candidiasis
  • Histoplasmosis- disseminated form, oropharyngeal
    lesions may
  • present as ulcerative, nodular, or vegetative.
    Biopsy will provide the diagnosis

28
Primary Herpetic Gingivostomatitis
29
Acute ulcerative
  • Viral Infections
  • Herpes simplex- 600,000 new cases annually,
    prodrome followed by small vesicles that
    ulcerate, primary infection involves the gingiva,
    and can involve the entire oral cavity
  • Recurrent herpes simplex- prodrome present,
  • herpes labialis, limited to keratinized
    epithelium and can involve the gingiva and hard
    palate
  • Varicella zoster virus- distribution of
    trigeminal nerve
  • Coxsackie- prodrome, vesicular, pharynx,tonsils,
    soft palate

30
Recurrent herpes simplex
31
Erythema Multiforme
32
Acute ulcerative
  • Erythema multiforme
  • Mucocutaneous hypersensitivity reaction
  • Etiology- infectious (strong association with
    HHV-1, viral, mycoplasma), drugs (antiseizure
    medications, sulfonamides)
  • Clinically- target lesions develop over the skin
    with erythematous periphery and central area that
    can develop bullae, vesicles.

33
Erythema Multiforme
  • Clinically- Oral 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 buccal mucosa
  • Mucosal ulcers are irregular in size and shape,
    tender and covered with fibrinous exudate
  • Sialorrhea, pain, odynophagia, dysathria
  • Severe EM are associated with involvement of
    other mucosal sites- eyes, genitalia, and less
    common esophagus and lungs

34
Erythema Multiforme
  • Histopathology- 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

35
Acute ulcerative
  • Lupus erythematosus- chronic discoid and systemic
    lupus erythematosus (SLE) forms
  • Discoid type- lip, intraoral lesions, most
    common site is buccal mucosa central depressed,
    red atrophic area surrounded by slightly, raised
    keratotic border
  • SLE form- common site posterior hard palate,
    superficial ulcerations that vary in size without
    keratinization of the oral mucosa
  • Immunofluorescence shows staining of the
    basement membrane with immunoglobulin, and
    complement

36
Acute Ulcerative
  • Reiters Syndrome- mainly young men 20 to 30.
    Classis triad of conjunctivitis, arthritis, and
    urethritis. Oral lesions range from erythema to
    papules to ulcerations involving the buccal
    mucosa, gingiva, and lips. Lesions on the tongue
    resemble geographic tongue
  • Behcets Syndrome- recurrent oral and genital
    ulcers, athritis, and inflammatory disease of
    eyes and GI tract.

37
Acute ulcerative
  • Drug reactions
  • Barbiturates, salicylates, phenolphthalein,
    quinine, digitalis, griseofulvin, and dilantin

38
Chronic Ulcerative
39
Chronic ulcerative
  • Pemphigus vulgaris- 0.1 to 0.5 patients/100,000
    70 present with upper aerodigestive lesions
  • Desmoglein 3 is the pemphigus antigen
  • IgG, IgA
  • Deposition of antibodies in the intracellular
    spaces produces direct damage to the desmosomes

40
Pemphigus vulgaris
  • Clinical presentation- ulceration and pain with
    collapse of vesicles
  • Lesions extend from gingival margin to alveolar
    margin
  • Oropharyngeal lesions favor lateral aspects of
    soft palate to lateral pharyngeal wall
  • Lesions heal quickly without scarring
  • Treatment- immunosuppression with steroids
    supplemented with azathioprine
  • 5 mortality with immunosuppression

41
Chronic Ulcerative
  • Mucous Membrane (Cicatricial) Pemphigoid
  • Autoantibodies directed at molecular components
    of the basement membrane
  • Most common Head and Neck sites-
  • oral, followed by ocular, nasal, and
    nasopharynx sites
  • Ocular scarring- symblepharon, corneal
    opacification, entropion

42
Mucous Membrane Pemphigoid
  • Diagnosis is with immunofluorescence showing
    linear immune deposits along the basement
    membrane
  • Site directed therapy. Oral cavity- topical vs.
    systemic steroids.

43
Chronic Ulcerative
  • Traumatic (Eosinophilic) Granuloma-
  • self-limiting, relatively long duration, deep
    mucosal injury, origin unknown
  • Clinical presentation- 5th to 7th decade,
    painful rapid onset, 1 to 2 cm in diameter with
    crater center and firm periphery that is white in
    appearance
  • Pathology- deep ulceration extending into
    skeletal muscle, intense, diffuse inflammatory
    infiltrate of histiocytes, endothelial cells, and
    eosinophils
  • Treatment- observation, topical or intralesional
    corticosteroids,
  • excision if clinical presentation in question

44
Major aphthous ulcer
45
Recurrent ulcerative
  • Recurrent aphthous stomatitis (RAS)
  • Frequency range of 20-40 of population,
  • most common non-traumatic form of oral
    ulceration
  • Data indicates a greater prevalence among those
    in professional groups, higher socioeconomic
    status, and non-smokers

46
RAS
  • Seen in a variety of conditions
  • Crohns disease, Behcets syndrome,
    gluten-sensitive enteropathy, food
    hypersensitivity (nuts, spices, chocolate)
  • Certain medications- NSAIDS, B-blockers,
    Kchannel blockers
  • Sweets syndrome- acute febrile neutrophilic
    dermatosis
  • PFAPA- Periodic fever, aphthous ulcers,
    pharyngitis,
  • and adenitis
  • Familial variety

47
PAS
  • Pathogenesis- No sign of vesicle or blistering
    formation
  • Lesions over non-keratinizing mucosal surfaces
    (labial, buccal, ventral, and lateral tongue,
    floor of mouth, soft palate, tonsillar pillars)

48
RAS
  • Classification-
  • Minor
  • usually anterior portion of oral cavity,
    ulcerative episode 7 to 10 days, no scarring
  • Major 1.0 cm deeper, more painful,
    posterior aspect of oral cavity, 6 weeks or
    longer in immunocompromised
  • Herpetiform- multiple pinhead-sized, pain
    greater than size of lesion
  • Treatment- symptomatic, topical steroids, for
    larger lesions intralesional steroids. Severe-
    short term systemic steroids.

49
Case Study
  • Prodrome
  • Rash present, major aphthous ulcers, genital
    findings
  • No eye findings
  • No prior history

50
Conclusions
  • Must rule out dysplasia, squamous cell carcinoma
    with leukoplakia
  • Duration of lesion, as well as location help to
    narrow your differential diagnosis
  • Biopsy of persistent lesions can help guide
    management

51
References
  • Cohen, Lawrence. Ulcerative Lesions of the Oral
    Cavity. International Journal of Dermatology
    Sept 1980, 362-373.
  • Sciubba, James. Oral Mucosal Lesions. Cummings
    Otolaryngology Head and Neck Surgery.
    Philadelphia, 2005, 1448- 91.
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