Oral Medicine 2 Notes PDF

Doctor: Yazan Hassouneh Writer: Abdalrahman Ghanim+ Mohammad Jehad Corrector:  ﷽ Slides are in black, Dr notes in orange Management of common oral mucosal diseases 1 So in this lecture we will get an overview about some common oral mucosal dise...

Doctor: Yazan Hassouneh Writer: Abdalrahman Ghanim+ Mohammad Jehad Corrector:  ﷽ Slides are in black, Dr notes in orange Management of common oral mucosal diseases 1 So in this lecture we will get an overview about some common oral mucosal diseases and how to manage them in the clinic ❖ Oral mucosal diseases ▪ Oral mucosal diseases are conditions that affect the mucosa of the oral cavity ▪ Common especially —> 1. infectious: candida and viruses (herpes) 2. Reactive lesions caused by chronic irritation: fibrous epulis, vascular epulis, and pyogenic granuloma. We should be familiar with those lesions and know how to manage them correctly ▪ These diseases can be of different etiologies: infectious, inflammatory, reactive, neoplastic, genetic, or it could be idiopathic ▪ Several diseases can have the same clinical presentation, which makes clinical diagnosis more challenging we should follow a systematic approach in diagnosing those diseases to reach the correct one ▪ Management protocols vary based on the specific oral mucosal disease our aim is to provide safe and efficient management ❖ Reactive/inflammatory and traumatic diseases ▪ The cause is chronic mild to moderate irritation causing inflammatory response in the mucosa ▪ May lead to tissue hyperplasia overextended denture flanges, keratosis frictional keratosis which is a white patch close to irritation site, ulceration traumatic ulcer, fibrosis fibroepithelial polyp  ▪ Benign cant transform into malignant. But may cause some symptoms: pain and discomfort upon eating, speech, etc… ▪ Biopsy may be needed in some diseases to confirm the diagnosis ❖ Denture induced hyperplasia (fissuratum) The accurate name is denture induced hyperplasia, prosthodontist used to name it denture fissuratum. ▪ The source of chronic irritation is the denture at the periphery (over extended) at level of vestibule ▪ Painful in severe irritation, but in mild irritation it’s asymptomatic (painless) ▪ Can be associated with ulceration if the denture is overextended ‫كثيير‬ Management Always confirm the diagnosis (site of irritation should coincide with the site if overgrowth) Always give the patient instructions: 1. Not to wear dentures while sleeping 2. How to clean dentures ✓ Denture modification (treating the cause to prevent recurrence) either by trimming the overextended flange or by relining poor fitting dentures ✓ Surgical excision ✓ Send for histopathology lab biopsy As role any surgical excision is followed by biopsy to confirm diagnosis  ❖ Fibroepithelial Polyp Other misnomer is fibroma, fibroma is benign tumor so fibroepithelial polyp is the correct name. ▪ The source of chronic irritation might be continuous biting (at tongue or buccal and labial mucosae) at level of occlusal line caused by : cheek biting, lip biting from teeth or rough restorations, and spacing between teeth ▪ Nodule localized mass (sessile without stalk vs pedunclated with stalk (mushroom)) ▪ Smooth surface. However, might be keratotic ▪ Pinkish ▪ Asymptomatic but when it increases in size it will cause interference with occlusion, eating, and speech ▪ Recurrence is rare if excised completely always start with removal of the cause of irritation Management ✓ Remove and any identified cause or habit ✓ Surgical excision ✓ Send to histopathology lab In early stage (immature formation of fibrous tissue): once you remove the cause the polyp will disappear spontaneously without need for surgical excision (reversible) In late stage (mature formation of fibrous tissue): we should excise the polyp and send it to the lab  ❖ Pyogenic granuloma It’s a common lesion that can affect any site orally, if it arise in the gingiva its called vascular epulis, incase during pregnancy its called pregnancy epulis or tumor. The classical name os pyogenic granuloma but it’s not an accurate name/misnomer, pyogenic means it produces pus and granuloma means collection of lymphocytes and histiocytes. In pyogenic granuloma theres no pus/ cells mentioned above ▪ Local irritation factors (inadequate OH, malocclusion, appliances,) or hormonal changes (pregnancy epulis) ▪ Vascular proliferation instead of fibrous tissue formation (reddish- blue color) ▪ Nodule(sessile vs pedunculated) same thing as in fibroepithelial polyp ▪ Smooth surface. However might be ulcerated in acute trauma ▪ Asymptomatic, may cause bleeding ▪ High recurrence rate especially if excised during pregnancy (3-15)% up to 20% Management ✓ Remove any identifiable cause of habit ✓ Surgical excision ✓ Send to histopathology lab ✓ If the pt is pregnant women: same management but we prefer to wait until delivery. Best time to excise is after delivery—> spontaneous resolution without surgical excision when the lesion is small with mild symptoms only, after the delivery the number of blood vessels will decrease then the rate of recurrence will decrease as well  Once the lesions is large with severe symptoms we can remove it during pregnancy by surgical excision (but here the number of blood vessel is high and recurrence rate is high) ❖ Peripheral Giant Cell Granuloma PGCG Its cause is unknown, some theories suggested that it arises from periosteum or may form osteoclast. It’s different than central giant cell granuloma which is associated with hyperparathyroidism and arise from the bone ▪ Local irritation factors (inadequate OH, Calculus, Malocclusion, Appliances) overhang restoration ▪ Vascular proliferation instead of fibrous tissue formation, more bluish than pyogenic granuloma, may get very large) giant cells give it brown to bluish color ▪ Nodule (sessile VS pedunculated) anterior part of the jaw (anterior to 6s) as shown in the picture below with the special hourglass ⌛️ appearance ▪ Smooth surface, might be ulcerated ▪ Asymptomatic, may cause bleeding and mild bone resorption ▪ High recurrence rate 10-36 % up to 40% Management ✓ Remove any identifiable cause of habit ✓ Surgical excision down to the bone with debridement of underlying bone ✓ Send to histopathology lab  ❖ Traumatic Ulcers Its very common, some of them are caused by acute trauma in oral mucosa (lip cheek biting) ‫عارفين سببها وإنها بتختفي بعد‬- ‫ما براجعوا العيادة مشانها‬ - ‫كم يوم‬ ▪ Local irritation factors (orthodontic brackets, sharp edges, remaining roots…) the shape, size, and site of the ulcer are consistent with the cause -pic of orthodontic brackets-. the ulcer of our concern is the one caused by chronic mild local irritation ▪ Sit in size/site of the source of trauma (topographic) ▪ Heals by removal of the cause ▪ Symptomatic (painful) because of the loss of epithelium and exposure of underlying connective tissue Management ✓ Remove any identifiable cause ✓ Wait for 10-14 days for complete healing ✓ Topical covering agents (solcoseryl dental paste) or topical anesthetic (lidocaine gel 2% benzocaine can be used as well or benzydamine mouth wash may be used for symptoms relief In the follow up period we should observe the signs of healing (symptoms subside, become smaller in size, change of color -instead of ulceration it becomes epithelialized- For patients with low pain threshold, we can prescribe systemic analgesics for them.  ❖ Linea Alba Considered as normal variation cause it’s common, asymptomatic. Associated with clinching (bruxism) ▪ Well known and famous lesion ▪ Mild chronic irritation to the buccal mucosa at the level of occlusal line bilateral ▪ Slight keratosis will develop giving the white line ▪ Totally benign ▪ Should be differentiated from frictional keratosis due to habitual cheek biting which has to be treated Frictional keratosis: if its extended beyond a white line, then give the pt instructions how to manage stress because there’s underlying cause of stress when the the pt frequently clenches on his teeth/ biting his cheek. Oral appliance therapy ( night guard or occlusal splint in order to stop the habit and to protect the mucosa) Theres no medication to be prescribed, we do behavioral management/ mechanical management to stop the habit Management ✓ Linea alba doesn’t need to be treated ✓ Frictional keratosis can be treated by breaking the habits: stress coping mechanisms, appliances maybe used  ❖ Thermal burns Thermal or chemical burn are similar. Could be caused by any high temperature material ( food , impression) Or by certain chemicals such as topically applied aspirin/ NSAIDs on site of pain ▪ May happen by electric current or high temperature during food ingestion ▪ Painful ▪ If burns happen at the lips, contracture occurs making oral hygiene and dental treatment hard for the patient Management ✓ For large and extensive necrosis and destruction to the oral tissues, tetanus immunization should be taken antibiotics should be prescribed (amoxicillin 625mg) to prevent systemic infection and septicemia ✓ CHX mouth wash Some pts can’t brush their teeth properly, putting them at risk of secondary bacterial infection so we prescribe CHX mouthwash ✓ Covering agent (solcoseryl dental paste) ✓ Topical anesthetic agents (lidocaine gel 2%) benzocaine can be used also ❖ Idiopathic diseases ▪ No clear/known etiology ▪ May have predisposing factors: females, family history, stress, allergy.. ▪ Example: Recurrent aphthous stomatitis, oral lichen planus Very common in practice so we have to be familiar with their clinical presentation, diagnostic approach and initial management ❖ Recurrent aphthous stomatitis The etiology of aphthous ulcer is unknown, but they link it to stress as underlying cause ( seen in pts with stressful life style, at finals etc…) trauma also linked to it ▪ Common condition affects 10-20% of population during their lifetime ▪ Multiple, recurrent, round or ovoid ulcers with red halo and yellow floor  ▪ Associated with smoking cessation ▪ Three types: major less common than minor type it has protracted course (minor one heals within 7-10 days meanwhile major takes 4-6 or even 8 weeks to heal, sometimes it heals with scarring, minor 2-10 small ulcers few mm in size heals without scarring, herpetiform least common variant usually affect older females, appear as small ulcers that look like herpetic gingivostomatitis, those small ulcers may collecise into one large ulcer ▪ Specific to the oral mucosa ▪ Female predisposition ▪ Aphthous like ulcers is associated with systemic diseases: celiac disease, crohn’s disease, anemia and bechet’s disease ▪ Painful Management Look for other suggestions/ symptoms Suggest the presence of systemic disease. Especially if the pt has GI symptoms or signs of anemia. If its related to stress we may prescribe anti-anxiety medications ✓ Stress coping mechanism ✓ If ulcer is 1-3 in number, or if they have low recurrence rate, they can be covered with a covering agent, topical anesthetic can be used ✓ For more than 5 ulcers, or high recurrence rate: topical corticosteroid can be used (medium potency: dexamethasone and betamethasone) low potency can be used also  ❖ Oral lichen planus Listed with immune mediated conditions. But still with unknown etiology ▪ Chronic inflammatory disease with unknown etiology ▪ Bilateral white striation ▪ Types: reticular white patches, papular, erosive painful and need management, erythematous painful also, atrophic, bolus and plaque like type ▪ You should be able to differentiate between lichen planus and lichenoid rxn ▪ Lichen planus is bilateral and symmetrical with associated skin lesions / history of skin rash. Lichenoid rxn is localized next to amalgam filling or in pts who take anti hypertensive, anti diabetic and some NSAIDs ▪ Risk of malignant change 1% erosive type about 5% is accepted Management ✓ If asymptomatic, no treatment is needed reticular type. Reassurance and pt education are sufficient theres no risk of malignant transformation ✓ For symptomatic lichen planus topical corticosteroids are commonly used. Covering agents, topical NSAIDs such as benzdyamine mouth wash is used. If theres no improvement we move to topical Corticosteroids from low / moderate potency (hydrocortisone Betamethasone or dexamethasone) to high potency, if still no improvement we can use intralesional steroid injections (triamcinolone), our last choice of treatment is systemic immune suppressants THE END Keep GAZA in your prayers