Oral Pathology Lecture Notes PDF

Website:www.samsonplab.co.uk, Email: [email protected] Telephone: +44(0)2089800039, Mobile: 00447436582971 TERMINOLOGIES: ORAL PATHOLOGY LECTURE NOTES Vesicles- is a sm...

Website:www.samsonplab.co.uk, Email: [email protected] Telephone: +44(0)2089800039, Mobile: 00447436582971 TERMINOLOGIES: ORAL PATHOLOGY LECTURE NOTES Vesicles- is a small blister a few millimetre in diameter. Bulla- is a larger blister. Contents: Ulcer- is a breach in the mucous membrane. 1. Terminologies Erosions- are shallower than ULCERS 2. Viral Infections Papule- is a circumscribed solid elevation of the s FLUID, varying 3. Recurrent apthous ulceration in size from pinhead to 1cm. 1 4. Fungal Infection: Oral Candiasis and Denture Stomatitis Macule- is change in surface colour without elevatio n DEPRESSION and — therefore non palpable, well or ill-defined! E 5. Vesicullo-Bullous Lesions h. — -_________ Cyst- is a epithelial lined cavity fluid with fluid, semi fluid or solid material. 6. White Lesions VIRAL INFECTIONS: 7. Salivary Gland Disorders 8. Salivary Gland Tu 9. Bacterial Infections Herpes si l (HHV-1) e A 10. Granulomatous Disorders He type II (HHV-2) 1 s of Tongue oster virus (VZV/HHV-3) 12. Facial Pain ein-Barr virus (EBV/HHV-4) 13. Cysts of Jaw Cytomegalovirus (CMV/HHV-5) 14. Granulomatous Diseases Human herpesvirus type 6 (HBLV/HHV-6) 15. Bullous Disorders Human herpesvirus type 7 (HHV-7) Copyrights reserved to Samsonplab Academy Itd. 2 Copyrights reserved to Samsonplab Academy Itd. 3  Kaposi’s sarcoma herpesvirus (KSHV/HHV-8) Treatment: Topical Acyclovir Herpetic Whitlow: vesicle formation on the fingers DNA virus transmitted through saliva and causes short lived 19 clinical, subclinical Herpes Simplex Virus Keratitis: corneal dendritic ulcer and remain latent afterward (Do NOT give steroid drops because it causes blindness) Seen in Children Herpes Simplex Virus Encephalitis: fever, fits, headaches, odd behaviour, Recurrence of disease in patient with suppressed immune system dysphasia, hemiparesis and spread centripetally Manifestations of primary HSV infection Systemic infection: eg, fever, sore throat, and lymphadenopathy. It often passes unnoticed. If immunocompromised, it may be life-threatening with fever, lymphadenopathy, pneumonitis, and hepatitis. 1.Herpes Simplex 1 (HSV) Gingivostomatitis: ulcers filled with yellow slough appear in the mouth. Herpetic whitlow: a breach in the skin allows the virus to enter the finger, causing Causes acute gingivostomatitis in anterior posteror of mouth a ( Y‘ Lymph node enlargement can be seen bilaterally vesicle to form. It frequently afflicts children's nurses. — a s -miasnian Resolves in 10 days without scar Remain latent in trigeminal ganglia Traumatic herpes (herpes gladiatorum): vesicles develop at any site where HSV is ground into the skin by brute force. Eczema herpeticum: HSV infection of eczematous skin; usually seen in children. #- --- Herpes simplex meningitis: this is uncommon and usually self-limiting; typically, HSV-2 , in women during a primary attack - see meningitis. Genital herpes: usually HSV-2. See the separate article on Herpes Simplex Genital. HSV keratitis: manifests with corneal dendritic ulcers. Avoid steroids. ’ a t. Herpes simplex encephalitis: usually HSV-1. It spreads centripetally - eg, from cranial nerve ganglia, to frontal and temporal lobes. Suspect in fever, fits, headaches, odd Clinical Presentation: behaviour, dysphasia, hemiparesis, or coma or subacute brainstem encephalitis, Gingivostomatitis - mouth ulcer meningitis, or myelitis. Herpes Labialis - cold sores Treatment Copyrights reserved to Samsonplab Academy Itd. 4 Copyrights reserved to Samsonplab Academy Itd. 5  Infectivity - 4 days before the rash until all lesions are scabbed (crust) Symptomatic relief (nutritious diet, plenty of fluids, bed rest. use of analgesics and Dormant - Remains dormant in the dorsal root ganglia —> reactivation due to illness or anti-microbial mouthwashes), chlorhexidine MW, 0.2% or hydrogen peroxide 6%. immunosuppression Shingles - pain in dermatosomal distribution which is unilateral and painful Acicylovir tablets, 200mg for 5 days or Aciclovir cream, 5% (2g) Treatment Apply to lesion every 4 hours (five times daily) for 5 days or Penciclovir cram, 1%. Seven day regimen of: Aciclovir Tablet, 800mg 1 tab five times daily. 3. HHV-4 Glandular Fever 2.Varicella Zoster HHV- 3 EPSTEIN-BARR VIRUS is main causative agent Causes infectious mononucleosis Varicella zoster is a neurogenic DNA virus, which causes chicken pox as a 18 Seen mostly in children and young adults. infection, A )1 and is a contagious disease caused by air-bourne route. Clinical Features Seen below 10 years of age (chicken pox) commonly, shingles is seen in elderly ). : a-eyl l 4 ' aieer. ay" ‘ - Fever, generalised lymphadenopathy and often maculo-papular rash. w 2 T " aa.Eere.. ,_________ Y Sore throat with soft palate petchiae and whitish exudate on tonsils, pharyngeal oedema Itchy, vesicular, cutaneous, centripetal rash (from extremity to centre) which sometimes g. " 2 Petechial haemorrhages at the junction of hard and soft palate (pathogen microbe). affect the oral mucosa, diagnosis is by pre eruption pain followed by development of vesicles... 1 Jniny --- Serological changes Sometimes mouth ulcer can be seen Rash on trunk or face and passes macular papular, vesicular and pustular stages Monospot test before A y Paul- Bunnell test scarring. ly Ig M antibodies are seen first. Vericella zoster remains latent, with in dorsal root ganglia and do not cause any CMV associated ulcers are non specific but cells with typical owl-eye intranuclear problem inclusions can be seen in the inflammatory in the ulcer floor. as 4 c=cI ex ' her. but if reactivation occurs can lead to shingles. Shingles occur unilateral. * Ampicillin should not be given to patients with a sore throat who may have glandular Can cause Ramsay Hunt’s Syndrome (facial paralysis; vesicular eruptions in oral fever, may cause a rash to anaphylaxis. cavity). we Zoster of maxillary and mandibular division of trigeminal nerves cause facial rash Hairy Leukoplakia can be caused by the proliferation of HSV-4. Normally and associated with HIV-infection. sometimes toothache. Ophthalmic zoster ulcerate cornea, and needs to be treated urgently. Fever Crops of blisters starting at the back and to the chest Copyrights reserved to Samsonplab Academy Itd. 6 Copyrights reserved to Samsonplab Academy Itd. 7  Cytomegalovirus is a ubiquitous found in saliva and urine of infected person Primary infection is asymptomatic but can cause glandular fever like illness 6,Human Herpes Virus 7 CMV remains latent in oropharyngeal and epithelial cells and can be reactivated by immunosuppression. HHV-7 infects almost all children by the age of three years and persists lifelong, with Disseminated infection can lead to CMV retinitis in particular leading to blindness. the shedding of infectious virus in saliva. It is similar to human herpesvirus 6 (HHV-6) in its genetic content and many of its biological properties, including the ability to cause at least some cases of rosela infantum Primary mild flu-like illness 7.Human Herpes Virus 8 Encephalitis Transverse Myelitis It’s B-lymphotropic DNA-virus, transmitted through sexual contact Polyradiculitis Associated with KAPOSIS SARCOMA Retinitis Pneumonia Kaposis Sarcoma Hepatitis Colitis Flat-brown lesions initially and raised plaque and then seen as purple-red lesion, Uveitis seen Neuropathy on plalate, retromolar area and gingivae Purple swelling of hard palate that does not blanch on pressure. Most commonly seen in HIV patients 5.Human Heroes Virus 6 (Red Baby syndrome/exanthema subitum) Is a connective tissue cancer caused by Human herpes virus 8 (9.0 Jhbe = HIV Risk factors Va i5 — - t * - = $ = 5i= —=E i -Ul. i l l l ? — ‘0 sa ==—- - --====== y 75h, or e It's a T-cell lymphotropic herpes virus contracted with in first 2 years of life through Homosexual oropharyngeal secretions. IV Drug user " From endemic area (e.g: African countries) Clinical features — Y ‘ 1 Va". Febrile illness Macular or papular rash on face Pyrexia Diarrhoea Weight loss Cough Night sweats Lesions seen mostly on soft palate/ uvula Opportunistic infections as they are immunosuppresed Abrupt onset of high fever lasting 3-5days. Skin lesions may be nodular, papular or blotchy. Colour may be red, purple, Erythematous maculopapular rash brown or Rash is initially on the trunk, then spreads centrifugally to the face and limbs. black Copyrights reserved to Samsonplab Academy I td. 8 Copyrights reserved to Samsonplab Academy Itd. 9  Common sites include the mouth, nose and throat Highly infectious Usually painless but many become painful if inflamed or swollen Seen only in children Lesions may also involve internal organ. It is a viral illness which commonly causes lesions involving the mouth, hands and feet. It can also affect other areas such as genitalia and buttocks. Lungs: Dyspnea GIT: fatal bleeding Lymphatics: lymphedema Superimposed bacterial infection Lesions in esophagus or respiratory tract may lead to obstruction. Prodorme Low grade fever Malaise Loss of appetite Sore throat Cough Abdominal pain Mouth: II Coxsackie Virus (RNA Virus) Papular vesicular rash on extremities and oral mucosa, break down to leave painful ulcers, particularly on the palate. A)Herpangina (coxsackie virus A) Skin lesions: - Incubation period of 2-9 days " JeUhs 3. 133 Mainly on palms, soles and between fingers and toes. ye."d 12s.ge *4.UL Clinical features Lesions start as erythematous macule but rapidly progress to grey vesicles with erythematous base. Hemorrhagic Conjunctivitis Y Lesions may also appear on trunk, thighs, buttocks & genitalia. Herpangia y Lesions are usually asymptomatic but can be itchy or painful. Mild pyrexia V 1. Sore throat Headache C ) Ill Paramyxovirus Dysphagia Vomiting RNA virus. Abdominal pain re D/D - teething, herpetic stomatitis measles Acute infection of measles transmitted by droplet infection. Incubation period 10-14 days. B)Hand, Foot and Mouth Disease Caused by COXSACKIE Virus usually A16, rarely type 5 and 10. Copyrights reserved to Samsonplab Academy Itd. Copyrights reserved to Samsonplab Academy Itd. Il  Ulceration is defined as a break in the continuity of an epithelial lining. Coryza Conjunctivitis Recurrent Apthous Stomatitis Non productive cough Lymphadenopathy Common oral condition affecting 20% of the population High fever Koplik's spots - in mouth Rash is first seen on the forehead and neck and then it spreads to the trunk a finally to the limbs. Rash lasts for 3 days Swelling around the eyes and photophobia may be present Aetiology Factors Genetic Nutritional deficiencies Pneumonia Systemic diseases Encephalitis Endocrine Stress Trauma Allergy Infection Also known as German Measles Smoking cessation rst s Caused by RNA virus - Togaviridae Transmitted as airborne deposits. CLINICAL FEATURES In children, it causes macular rash starting from face and behind ears Fever ( \ g h... “Co a Headache ‘.CS Mild conjunctivitis Runny nose Viral Illness Associated lymphadenopathy (suboccipital, post-auricular, cervical lymph n @6des) MINOR APTHOUS RECURRENT APTHOUS ULCERATION Recurrent Oral ulceration Copyrights reserved to Samsonplab Academy Itd. 12 Copyrights reserved to Samsonplab Academy Itd. 13. Benzydamine mouthwash, 0.15%. Rinse or gargle using 15 ml every 1% hour as required Sex ratio M=F M=F= Lignocaine ointment 5% or spray 10% Age of onset 10-19 10-19 20-29 Hydrocortisone oromucosal tablets 2.5mg No. Of ulcers k 10 30 days to > 30 days Traumatic Ulceration Recurrence 1-4 months < monthly < monthly Sites affected Labial and buccal Labial, buccal Labial and buccal Often seen in buccal or lingual sulcus, lateral tongue Mostly tender, yellowish- floor, red-margins and no induration mucosa, tongue mucosa, tongue, mucosa, soft Should eliminate in 7 - 10 days. palate and palate, floor of pharynx mouth Scarring Uncommon common Possible if ulcer colease Antimicrobial mouthwash Chlorhexidine mouthwash, 0.2% Aetiology Hydrogen Peroxide mouthwash, 6% Mechanical LocalAnalgesics Chemical Thermal Copyrights reserved to Samsonplab Academy Itd. 14 Copyrights reserved to Samsonplab Academy Itd. 15  Factitious injury Commonly seen in HIV patients. Radiation FUNGAL INFECTIONS Oral Candidiasis Candida Albicans and Candida Dubliniensis are the Candidial species causing Oral Candidosis. Acute candidiasis Chronic candidiasis Denture-Induced Stomatitis Pseudomembranous Candidosis (Thrush) Chronic atrophic candidosis/ Denture stomatitis Erythematous candidosis ( formerly calledAngular chelitis denture sore mouth) Chronic hyperplastic candidosis(candidal leukoplakia) Median rhomboid glossitis Predisposing Factors Immunodeficiency Prompted by ill fitting dentures, poor denture hygiene, wearing of dentures at night Anaemia _ me 2. lev , s. “I"s Enclosed mucosa is cut from protective action of saliva —zc - Antiba ing taken over a long time Mucosal erythema restricted to area cover by denture Xero ia Smo Acute Antibiotic Stomatitis Hig drate diet “7 ie ---me itional deficiency (Iron, folate, and vitamin B12) - Overuse of antibiotics especially tetracycline suppressing normal oral mucosa Steroid inhaler —Whole mucosa is red and sore Thrush/ Acute PseudomembranousCandidiasis Erythematous Candidiosis Red, shiny, atrophicappearance Creamy light adherent plaque or erythematous oral mucosa (usually cheek, palate or oropharynx) Can be easily wiped off Copyrights reserved to Samsonplab Academy ltd. 16 Copyrights reserved to Samsonplab Academy ltd. 17. If dysplasia fount then the lesion may be clinically classified as candida leukoplakia TREATMENT Miconazole, 2% 20g tube for Candida gram positive bacteria - apply to angle of mouth twice daily. Advice patient to continue use for 10 days after lesions have healed OR Sodium fusidate ointment, 2% 15 g tube - apply to angles of mouth four tim bacterial).. For unresponsive cases: Miconazole 2% and Hydrocortisone 1% crea Local measures to be used in the first instance Advice patients to who use corticosteroid inhaler to rinse th with water or brush Angular Chelitis teeth immediately after using the inhaler Fluconazole capsule, 50 mg 1 capsule for 7 days." ’ In denture wearing patients, it is caused by infection with candida species. DO NOT PRESCRIBE azoles for patients taking Warfarinor Statins Iron deficiency is a significant etiology in angular chelitis. OR Without denture, it is more likely to be cause by infection with streptococcus species or Miconazole oro-mucosa gel, 24mg/ mt.8 staphylococcus species. - * E a-s Yy Apply pea-size amount after food four time; ily. Advice patient to continue use for Unless the classic golden crust associated with S.aureus are present, treatment 48hours after lesion have healed 7 should " ".7 if azole's are contraindicate ral suspension. 1,00 ,000 unit/ml be commenced with azole's. 1 ml after food four times daily for MEDIAN RHOMBOID GLOSSITIS VESICULO-BULLOUS LESIONS Seen in patients using inhaled steroids and smokers A)Anqina Bullosa Haemorrhagica Lesions are in centre of dorsum of tongue and palate (kissing lesion) Lozenge shaped erythematous patch on the midline dorsal tongue Clinical features H/P epithelial hyperplasia with neutrophils in the parakeratin layer. The t 2t Appearance of recurrent blood blisters in oral mucosa. Most commonly seen in posterior hard and soft palate. Blisters ruptures to leave a superficial ulcer, which is entirely self-limiting. CHRONIC HYPERPLASTIC CANDIDOSIS White patch on the oral commissural buccal mucosa bilaterally or dorsum of tongue Increased risk of malignant change Check clotting screen and full blood count to ensure normal haemostats components. Histopathology candida hyphae can be seen in the superficial layers of the epidermis. Blunt rate pegs. Neutrophils form microabscesses in the parakeratin. Analgesics, mouthwash such as benztdamine hydrochloride. Copyrights reserved to Samsonplab Academy Itd. 18 Copyrights reserved to Samsonplab Academy Itd. 19  Benign Mucous Membrane P e m p hi giod/ CIC ATRICIA L PEMPHIGOID B) Pemphigus Autoimmune disorder Characterised by blisters ad erythematouslesionsaffectingtheoralmucosa, Rare autoimmune skin disease with several different variants: conjunctiva and vulvovaginalregion Pemphigus vulgaris. May also be present as desquamative gingivitis Pemphigus vegetans May lead to blindness if conjunctiva is involved Pemphigus foliaceous. odies commonly Ig G. Autoantit0,010 l Pemphigus erythematous. Diagnosis is based on direct immunofluorescence testing on a fresh biopsy of perilesional mucosa. " y It’s a group of disorders in which autoantibodies directed against component of desmosomes that enable kertinocytes to adhere one to another. P. vulgaris is most common variant. Separation of connective tissue epithelial from connective tissue at basement Age: 40-60 years old, commonly in females membrane Hemidesmosomes are seen intact Vulgaris: Heals with scarring Thin walled bullae- easily breakable and prone to infections. - i. 7 Seen in young patients “ ). y Bullous Pemphigoid The blisters are flaccid (loose) and fragile, so they easily burst. Lesions are typically painful but not itchy. Skin lesions on limbs and trunk begin as non-specific urticarial rash. Lesion often first in mouth but spread to skin widely Autoimmune condition causing sub epidermal blistering of the skin Nikolsky's sign may be positive (gentle stroking the mucosa can cause a vesicle or Common in elder patients bulla —y to appear).. Clinical presentation: Autoantibodies most commonly Ig G, react with a component of desmosomes called —etedrs.emes R : , j T | desmogleins in particularly desmoglein 3 and 1. “Itchy tense blisters typically around flexors Diagnosis is made by direct immunofluorescence on fresh biopsy or cytological Blisters “do. e V usually heal without scarring a 3 r ‘ to: ,. aee; % L ' material. Mouth is usually spared %i a.ws. TVerr.., Histopathology Intra-epithelial clefting above basal cell layer. Cells have tombstone appearance (desmosomes). Acantholysis is seen (loss of intercellular adherence of suprabasal spinous cells.) C) Pemphigoid: Copyrights reserved to Samsonplab Academy ltd. 20 Copyrights reserved to Samsonplab Academy ltd. 21  Hyperkeratosis Different diagnosis (TINNED VIM) 1) Trauma Frictional keratosis Friction Keratosis - - sites -= Caused by 10% of drug reactions % )7 LJ -7. — Sudden onset of erythematous lesions affecting skin and mucous membranes Associated with fever, malaise and sore throat “Acral” sites are often involved with target or necrotic lesions. Investigations and Diagnosis Diagnosis usually based on clinical picture but can be confirmed with biopsy. Chemical burns s Skin grafts Treatment: Scars recipitating factors ev "dehydration c steroid (+/- azathioprine) 2) Infective White Lesions Candidosis (acute, chronic, mucocutaneous, chronic hyperplastic leukoplakia) Hairy Leukoplakia White Lesions are white due to : Condyloma Acuminata Papilloma and other HPV lesions Hyperplasia of epithelium Pailloma and other HPV lesions Loss of normal vascularity Syphilitic Leukoplakia Kopliks spots (measles) Copyrights reserved to Samsonplab Academy Itd. 22 Copyrights reserved to Samsonplab Academy Itd. 23  Disturbance of differentiation in epithelium in a premalignant way- ranges 3) Neoplastic from mild atypic to severe dysplasia Carcinoma (Squamous cell) Abnormal and increased mitoses Loss of basal cell polarity 4) Endocrine Cell pleomorphism Drop shaped rete processes Deep cell cohesion SE-te 5) Developmental Irregular hyperplasia/atrophy Irregular stratification Fordyces spots Loss of differentiation White sponge Naevus Nuclear hyperchromatism Dyskeratosis Congentita Tylosis B)Carcinoma in situ:Neoplasm that shows all the features os a carcinoma but Dariers Disease hasn't invaded the basement membrane. 6) Vascular Risk Factors 7) Immunological History- Betel Quid Usage, Tobacco smoking Lichenoid - High alcohol intake Lichen Planus Genetic Disorders Lichen Sclerosis Large persistent lesions Lupus erythematosus Change in existing lesion Pyostomatitis vegetans Xanthomatosis Site 1) Posterolateral tongue a " th. Dermatomyositis. 2) Floor of mouth -y s*tee. effheel I 3) Retromolar region 8) Idiopathic ( ) 4) Anterior pillar of fauces Leukoplakia C)Fordyce EN0t)) dw ,he.r ti-. (Mlle, ) Sublingual Keratoses Y s ' s... ‘y - t 9) Medication Tobacco related keratoses Oral submucous Fibrosis (betel quid) 10) Metabolic A)Dysplasia Copyrights reserved to Samsonplab Academy Itd 25 Copyrights reserved to Samsonplab Academy Itd. 24  5 Appear after the age of 3 Sebacous glands seen as creamy yellow dots along border between vermillion and oral mucosa Histology D)White Sponge Naevus Typical basket weave appearance Incidence: rare, Consistent presence of acanthosis with parakeratosis and intracellular Age: 2nd decade oedema Clinical Features E)Dyskeratosis Congenital Shaggy spongy folded white lesion at several mucosal sites Inherited syndrome in which patient undergoes premature aging and prediposition to Asymptomatic diffuse bilateral lesions malignancy Mostly seen on buccal mucosa No malignant potential therefore reassurance is only tx needed Clinical features Hyperkeratosis of all mucous membrances Dysplastic white/red lesions of oral mucosa Dystrophic nails Abnormal pigmentations of skin Haematological abnormalities Periodontal manifestations reported Causes of death include cancer of the mouth/ other sites, GI or cerebral bleeding or opportunistic infections (50%) Copyrights reserved to Samsonplab Academy ltd. 26 Copyrights reserved to Samsonplab Academy ltd. 27  low. Tylosis Is the association of oral white lesions with an oesophageal carcinoma. Hyperkeratosis of palms and soles also present. G)Chronic Mucocutaneous Candidosis Syndrome F)Chronic Hyperplastic Candidosis / Candidial Leukoplakia Clinical Features: Tough adherent plaque distinguishable only by biopsy from other leukoplakias Persistant Candidosis associated with mouth, nails and skin.. Can be associated with disorders of parathyroid, adrenals and haematological Incidence: disorders. ‘%. Initially thrush like but develops resemblance more to chronic hyper plastic lesions. Age: Middle aged adults Long term systemic anti fungal Fluconazole. Sex: Males Aetiology: risk factors similar to thrush Incidence: 20-25% of HIV patients. Aetiology: Variable thickness white plaques that do not rub off. Opportunistic infection by the Epstein- Barr Virus EBV which infects keratinocytes in Rough or irregular in texture or nodular and speckled. mucosa. Angular Stomatitis may be associated. ) Found in immunosuppresed patients eg HIV and organ transplant. Frequently at commisures of mouth/ dorsum of tongue/ post commissural buccal A1 v Clinical Features mucosa. Occassionally include elements of epithelial dysplasia therefore refer. Acanthotic parakeratinized epithelium with finger-like projections of parakeratin producing hairy or corrugated clinical appearance. Histology Swollen/ balloon cells (keratinocytes) containing EBV. Presence of candida! hypae seen on Gram or Periodic Acid Shift (PAS) staining. Mangement Parakeratotic epithelium which is more coherent as it has only slight chronic inflammatory cell infiltrate. No need for treatment unless it is an aesthetic problem. Regression frequently occurs with treatment of immunosuppression, t. " 5 5i Treatment with topical Acyclovir. Stop smoking. Prolonged topical polyene for 3 months. Systemic anti-fungals Fluconazole general resolution in 2-3 weeks, but may Incidence: almost extinct go on for months. Treat iron deficiency if present. Surgical excision if persistent and signs of dysplasia. Levels of malignant No distinctive features but affects the dorsum of the tongue and spares the change risk is margins. Copyrights reserved to Samsonplab Academy Itd. 28 Copyrights reserved to Samsonplab Academy Itd. 29  Cracks, small erosions or nodules may prove to be invasive carcinoma. Irregular outline and surface. Histology reveals hyperkeratosis, acanthosis, dysplasia, chronic inflammatory changes with plasma cells predominating. Giant cells and rarely granulomas may be present. Endarteritis of small arteries is characteristics. Tx with antibiotics and refer to specialist as there is a high risk for malignant change. _ 1 ) HPV Lesions.. ‘ Presentation: Verrucae. Prevalence higher in STD's and immunocompromised. Network of raised white lines or straie (reticular pattern), often produce a Usually seen on lips on children with warty fingers warty or smooth typical 'lace like' surfaced papule. ( \ 1 pattern against an erythematous base. A tiny white elevated dot like structure is frequently present at the point of intersection of the white lines, which is known as "striae of Wickham Types of lichen planus; reticular type, erosive type, plaque type, atrophic type, bulls type. J) Lichen Planus Cutaneous lesions clinically appear as clusters or diffuse areas of raised, purplish or veo * reddish papules, which are covered bya white glistening scale. z ( They classically on flexor surfaces, especially on the trunk f -EEiSTTP. “hrseg Posteriorly in Buccal Mucosa, lateral aspects of tongue, floor of mouth or Fingernails may be ridged or atrophied.. gingivae may Scalp may be involved, leading to hair loss show desquamative gingivitis. As the skin lesions produce itching sensation, patients often produce linear -... 9 % 5. to —e --Uesen’.wtorml _ \ Palatal mucosa is usually spared. (x Y excoriations. “ " Koebner phenomen : it refers to the development of skin lesions of lichen " planus, which are extending along the areas of injury or irritation. Copyrights reserved to Samsonplab Academy Itd. 30 Copyrights reserved to Samsonplab Academy Itd. 31  Early stage patches are pale and translucent. Become dense and white with rough surface most commonly seen on buccal Histopathology: or labial mucosa along occlusal. Surface epithelium shows hyperorthokeratinizaton or hyperparakeratinization Acanthosis or thickening of spinus cell layer is seen Saw tooth rete pegs are seen O)Chemical Burns One of the most important histologic features of lichen planus is the presence of necrosis or liquefaction degeneration of the basal cell layer of the epithelium. k 1 Various chemicals or drugs, notably aspirin put in buccal sulcus to try and In lichen planus few round or ovoid , amorphous, eosinophilic bodies are sometimes relieve 7. % present within the epithelium , known a "civatte bodies". y toothache may cause burns. 1. Mouth washes or accidental ingestions of corrosive fluids may cause Treatment: Topical steroids widespread lesions. White lesions with sloughing mucosa. * Lichen planus can be associated with Hepatitis C. Stop exposure and self-healing occurs. “Erosive lichen planus is considered as a premalignant condition. Skin grafts scars and other normal temperature burns K)Papilloma: Benign neoplasm of epithelium caused by HPV P) Immunological Cauliflower like lesion with whitish colour Most common at the junction of the hard and soft palate --------- - -’ a - — - --- Lichen Planus and Licheoid Run Together Most common at the junction of the hard and soft palate treatment is by total Chronic inflammatory immunologically mediated disease which can affect stratified 1 Sen — ! mn ----============ ma _fme i s ’ - at — - - —- excision.17 squamous epithelium of the skin, oral mucosa and genitalia l)Condyloma Acuminata ‘ y Incidence: Warty smooth surfaced papules seen on tongue or palate fauces in sexually Common 1% of population active ) Age:30-65 persons 1= Sex: Female Management same as verrucae Geography: worldwide Malignancy potential 3 months) Hemoptysis Occurs mostly after radiotherapy, particularly when given for head, neck cancers. Homeless^ ", :-L. ass yy —r Travel to endemic areas like Asia/ Africa, Eastern Europe - ‘ t, ttlm, “Gs.) a 3 2 ’ (1(7373 -is52t 2275 i 1 ri 17522 5 - Salivary Calculi —Rere. are. z 7h —=rens. 4 ih 47 YI ‘ * satt : a.zmp TB may be extrapulmonary like TB meningitis. Miliary TB, Abdominal TB 80% Submandibular. ) 6% Parotid Histopathology : Necrotising granuloma with Langhan’s Giant’s cells, acul t.s nt “aneagcad”. —22 5 :.1 —9—1 - 2% Sublingual and minor salivary glands 3-Syphilis ) Mostly unilateral "Aaaosin All phases (primary, secondary, tertiary ) effects the mouth. * I.J Calculi usually form by deposition of Ca salts and have a layered structure. ACTERIAL INFECTION Primary Lesions 1.Scarlet Fever A chance (painless nodule) develops usually lips or tongue. Trepenma pallaidium is the causative agent. Delayed hypersensitivity to streptococcal erythrogenic toxin. Marked cervical lymphadenopathy which resolves in 1-2 months. Causes upper respiratory tract infection. Syphilitic glossitis is atropic due to tongue involvement by treponema. Copyrights reserved to Samsonplab Academy ltd 46 Copyrights reserved to Samsonplab Academy ltd. 47  Caused by Corynebacterium diphtheriae 2-4 months after 10 lesion with cutaneous rash, condylomata and ulceration of Symptoms: polyneuritis oral mucosa. myocarditis bradycardia Mucous patches or snake track ulcers could be seen. dysphagia brassy cough Marked with Gumma formation.. \ \/ Pigmented Lesions pe ’ 3 A mo, 1. (I ” Necrotic granulomatous reaction affecting palate or tongue perforation of palate. It can be extrinsic or intrinsic. Extrinsic Pigmentation is usually recognised and common causes are regular. CHX rinsing i? Paan chewing which produces an orange-brown discoloration Congenital Syphilis Due to treponema palladium crossing placental barrier leading to classical appearance of saddle nose, frontal bossing, Hutchinson incisors (peg shaped with notch), mulberry "5 a -ti t ! 0 s anst "lE alen -e=edee"teed - (moon) molars, 8th cranial nerve deafness, interstitial keratitis. Black Hairy Tongue 4.Gonorrhoea It is caused by overgrowth of filliform papillae accompanied by bacterial a rr. E. L —g. pigmentation. 15 x more common than syphilis. It is often brown in colour. Result of orogenital contact with infected partner. Increasing friction to dorsal mucosa by gentle rubbing with a tooth brush or.. ) —0.111 f , N | I ’ | I.... Stomatitis or pharyngitis with ulcers and purulent gingivitis by Nesseria n sucking a gonorrhoea. peach stone can be effective remedies. Gram -ve intercellular diplococcic. Amalgam Tattos 5.Diptheria Presents as a grey-black discolouration of mucosa. Grey collar pseudomembrane. It is caused by entry of dental amalgam into mucosa at the time of placement Oral manifestations includes ‘diptheric membrane’ begins on tonsils. of Patient have peculiar nasal twang and exhibit nasal regurgitation of liquids. amalgam restorations or during dental extractions. Temporary paralysis of soft palate during 3rd and 5th week of disease. R/G will usually reveal amalgam particles in tissue. Copyrights reserved to Samsonplab Academy Itd. 48 Copyrights reserved to Samsonplab Academy Itd. 49  Head and neck Melanotic Lesions Gastrointestinal Genitourinary Can be focal or diffuse. Melanoma of unknown primary site Discrete Melonin-Pigmented Lesions Treatment Intra-oral pigmented naevi or oral focal melanosis and discrete I Multiple pigmented oral and circumoral macules can be a manifestation Radical excision. Peutz-Jeghers Overall prognosis is pc: syndrome. Navei Malignant Melonoma Blue black often papulae lesion formed from increase cells seen on palate. Diffuse lesion. Present mostly on palate or gingivae as a spreading area of pigmentation Causes of Oral Mucosal Pigmentation which evolve ( XY 41 in v into nodulated ulcerated tumour. 1 )‘..(.97 Exogenous Endogenous Bone involvement is often a prominent feature. Progressively increases in size although growth may be very rapid Superficial mucosal staining Developmental racia This is a skin cancer of black or brown. Pigmented naevi Peutz-Jeghers syndrome Black hairy tongue Acquired Endocrine Assessment - Addison's disease - Ectopic ACTH production Associated with: Chronic irritation Drug induced Associated with HIV infection Melanotic macules I 2. 1. Typical presentation of oral malignant melanoma Foreign bodies Neoplastic Note the surrounding areas of pign taton. Amalgam tattoo 518 Malignant melonoma Darkly pigmented mole or ulcers which grows rapidly usually on the shin or back. Graphite It is usually located on the sun exposed areas. Heavy metal salts - Lead - Mercury Various types; - Bismuth Melanoma of CNS Mucosal Melanomas:- Copyrights reserved to Samsonplab Academy Itd. Copyrights reserved to Samsonplab Academy Itd. Oral Cancer It is Important to be suspicious of oral lesions particularly patients with high risk such as: Most common malignant epithelia neoplasm affecting the mouth Use of tobacco More than 90% is oral squamous cell carcinoma. It is among 10 most common Alcohol or Betel cancers History of previous OSCC worldwide mortality rate in UK is just over 50% despite treatment, it accounts for about Clinicians should be aware that single ulcers, lumps, red or white patches if any 1700 deaths per year, due to late detection ae persisting for more than 3 weeks may be a manifestations of malignancy — g Number of oral and orophyrangeal cancers is currently estimated to 300,000 cases Whole oral mucosa should be examined as there may be widespread dysplastic. ". J 1 H 14159 , 5 A %. e - W 4% world-wide, amounting 3% of total cancers. mucosa Urgent referrals should be made out of incisional biopsy must be taken if practitioner is competent. aP - as f ).. “aim. %.. " I Management —ren — Most oral cancers is carcinoma on the lower lip where it may be proceeded i X a -L-sd -- s.5 th. —-euei IS. "ae ask9, e 710 by Actinic. y Cancer treatment involves a team approach involving a range of specialities Chelitis induced by chronic exposure to sunlight present as a swelling. including. y The other main site is intra-orally, especially on the postero-lateral border/ventrum surgeons, anaesthetics etc. of.. \ 5 “c —efe * ' — =-i OSCC is treated with surgery and radiotherapy to control 10 tumour and tongue." metastases in ato-. 7 2 -- es , 3t : q -9= -- Intra-oral SCC may be present as an indurated lump/ulcer. cervical lymph nodes. 4 1. y ----- Pa 1.1 7Ls. J ’ is ’ 7j 5".st -4 V s 1 > > f > - ey -5) Squamous cell Carcinoma Possible Aetiological Factor For Oral Cancers Carcinogens. Tobacco Alcohol Areca nut Sunlight "" wg,.mrmmm — Im “ ---- 2 ‘TT Jaspes, a FPa. e rs — — — — - 1 ( 7 —77 Infections 1 - r Syphilis Candidiasis Viruses Mucosal Disease Role of Dental Practitioner in Cancer Preventi n and Diagnosis Copyrights reserved to Samsonplab Academy Itd. 52 Copyrights reserved to Samsonplab Academy Itd. 53  Oral epithelia dysplasia the clinical diagnosis, in order to prioritise the waiting list. Lichen planus Patient s details including current telephone number so the patient can be contacted OSMF to attend a clinic at short notice Complications of Radiotherapy Could Be Short medical history including name and address of patient’s general medical practitioner Osteonecrosis 8 Relevant social history including smoking and drinking status Pathological fracture Detailed description of the lesion including duration, site, size, colour, texture and Dry mouth findings upon palpation \ Radiation scar Clinical diagnosis (or diagnoses) in order to categories the urgency of the referral Chronic ulceration Non urgent referral Mouth Cancer Referral Guidelines for Dentists Assessing patients for mouth cancer Patients should be examined for potential malignancy at every dental examination “I5 ijnpee h th -- 1 ' E Assessing patients for mouth cancer symptoms requires a high level of suspicion, but. rat—1 ‘c) 2 --TT FS ‘ * Frit many other conditions may present with similar changes. On the right are examples of malignant and potentially malignant lesions. The level of suspicion should be higher if the patient is a smoker or heavy alcohol drinker, chews betel nut (areca nut) or tobacco, or is over 40 years. PmeT n he ?% Ta 18 Y% , The referral process for oral soft tissue lesions Urgent referral If an abnormal area has been detected in the mouth, a biopsy is the only way to know for certain whether or not it is malignant. This should be carried out in a specialist referral centre of either oral medicine, oral and maxillofacial surgery or plastic surgery. Referrals should be divided into three categories (non-urgent, prompt and urgent) according to the urgency of the referral. The table opposite provides more detail on referral classification. Referral details It is essential for the consultant to know certain details about the patient, the lesion, and Copyrights reserved to Samsonplab Academy Itd. 54 Copyrights reserved to Samsonplab Academy Itd. 55  ype of Referral Example Referral Urgent (within 2 weeks)* Unexplained oral The local maxillofacial ulceration or mass surgery, oral medicine, oral persisting for more than 3 surgery or plastic surgery weeks unit. Unexplained red, or red Referrals can be done by and white patches that are telephone or fax, or by filling painful, swollen or bleeding out a 2WW (2 week wait) If patches are not painful, referral form, depending on swollen or bleeding, arrangements with local referral can be made non­ specialist units. urgently. Unexplained one-sided pain in the head and neck area for more than 4 weeks, associated with ear ache, but with a normal otoscopy Unexplained recent lump in the neck, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks Unexplained persistent sore or painful throat Signs and symptoms in the oral cavity persisting for more than 6 weeks, that PROMPT REFERRAL cannot be definitively diagnosed as a benign lesion Relevant social history including smoking and drinking status Unexplained tooth mobility Detailed description of the lesion including duration, site, size, colour, texture and persisting for more than 3 findings upon palpation weeks, that cannot be Clinical diagnosis (or diagnoses) in order to categories the urgency of thereferral attributed to a dental cause Hoarseness persisting for A chest X-ray. If positive, more than 3 weeks, refer urgently to a team especially in smokers aged specialising in lung cancer. 0 If negative, refer urgently to