Diseases of oral cavity

Dr.Ramanujam.S M.S.,
Assistant professor,
General surgery.
 CONTENTS
• ORAL CAVITY ANATOMY
• EXAMINATION OF ORAL CAVITY
• ORAL PATHOLOGY
• ORAL MANIFESTATION OF
SYSTEMIC DISEASES
 ORAL PATHOLOGY
– MUCOUSAL LESIONS
– ULCERATIVE LESIONS
– MALIGNANCY
– DISEASES OF TEETH AND PULP,
GINGIVA
– DISEASES OF BONES (MANDIBLE AND
MAXILLA)
 Background
The mouth (buccal cavity) is the reservoir for
the chewing and mixing of food with saliva.
It is the primary site of digestion and respiration
as well as the primary communication
structure.
It is the first part of the digestive tract and is
exposed to various exogenous stimuli and
exposure of longer duration can lead to
reactive changes that need to be
differentiated from malignancies
Anatomy of oral cavity
Anatomy of oral cavity
Examination of the
Oral Cavity
Physical Evaluation
Oral Examination
 Many diseases (systemic or local) have signs
that appear on the face, head & neck or
intra-orally
 Making a complete examination can help
you create a differential diagnosis in cases
of abnormalities and make treatment
recommendations based on accurate
assessment of the signs & symptoms of
disease
Oral Examination
 Each disease process may have individual
manifestations in an individual patient
 And there may be individual host reaction
to the disease
 Careful assessment will guide the clinician
to accurate diagnosis
Scope of responsibility
 Diseases of the head & neck
 Diseases of the supporting hard & soft
tissues
 Diseases of the lips, tongue, salivary glands,
oral mucosa
 Diseases of the oral tissues which are a
component of systemic disease
Equipment
 Assure that you have all the supplies
necessary to complete an oral examination
 Mirror
 Tissue retractor (tongue blade)

 Dry gauze

 You must dry some of the tissues in order to

observe the nuances of any color changes
Exam of the Head & Neck; Oral
Cavity
 Be systematic
 Consistently complete the exam in the same
order
Extra-oral examination
 Observe: color of skin
 Examination area of head & neck

 Determine: gross functioning of cranial

nerves
 Normal vs. abnormal
 Paralysis
 Stroke, trauma, Bell’s Palsy
Extra-oral examination
 TMJ
 Palpate upon opening
 What is the maximum intermaxillary space?
 Is the opening symmetrical?

 Is there popping, clicking, grinding?

 What do these sounds tell you about the anatomy of
the joint?
 When do sounds occur?

 Use your stethoscope to listen to sounds

Extra-oral examination
 Lymph node palpation
 Refer to handout
Thyroid Gland Evaluation
Extra-oral examination
 Thyroid Gland
Palpation
 Place hands over the
trachea
 Have the patient
swallow
 The thyroid gland
moves upward
Exam: Lips
 Observe the color & its consistency-intra-
orally and externally
 Is the vermillion border distinct?
 Bi-digitally palpate the tissue around the
lips. Check for nodules, bullae,
abnormalities, mucocele, fibroma
Exam: Lips
Exam: Lips
 Evert the lip and examine the tissue
 Observe frenulum attachment/tissue tension
 Clear mucous filled pockets may be seen on
the inner side of the lip (mucocele). This is
a frequent, non-pathologic entity which
represents a blocked minor salivary gland
Exam: Lips-palpation
 Color, consistency
 Area for blocked minor salivary glands
 Lesions, ulcers
Exam: Lips
 Frenum:
 Attachment
 Level of attached gingiva
Exam: Lips-sun exposure
Exam: Lips
 Palpate in the
vestibule, observe
color
Examination: Buccal Mucosa

 Observe color, character of the mucosa

 Normal variations in color among ethnic groups
 Amalgam tattoo

 Palpate tissue
 Observe Stenson’s duct opening for
inflammation or signs of blockage
 Visualize muscle attachments, hamular
notch, pterygomandibular folds
Examination: Buccal Mucosa
 Linea alba
 Stenson’s duct
Examination: Buccal Mucosa
 Lesions – white, red
 Lichen Planus, Leukedema
Gingiva
 Note color, tone,
texture, architecture &
mucogingival
relationships
Gingiva
 How would you describe the gingiva?
 Marginal vs. generalized?
 Erythematous vs. fibrous
 Drug reactions: Anti-epileptic, calcium channel
blockers, immunosuppressant
Exam: Hard palate

 Minor salivary glands, attached gingiva

 Note presence of tori: tx plan any pre-
prosthetic surgery
Exam: Soft palate
 How does soft palate raise upon “aah”?
 Vibrating line, tonsilar pillars, tonsils,
oropharynx
Exam: Oropharanyx
 Color, consistency of tissue
 Look to the back, beyond the soft palate
 Note occasional small globlets of
transparent or pink opaque tissue which are
normal and may include lymphoid tissue
Exam: Tonsils
 Tucked in at base of anterior & posterior
tonsilar pillars
 Globular tissue that has “punched out”
appearing areas
 Regresses after adulthood
 May see white “orzo rice like” or “torpedo”
shaped white concretions within the tissue
Exam: Tongue
 The tongue and the floor of the mouth are
the most common places for oral cancer to
occur
 It can occur other places; so visualize all
areas
 You may observe:
 Circumvalate papillae, epiglottis
Exam: Tongue
 Have the patient stick out their tongue
 Wrap the tongue in a dry gauze and gently
pull it from side to side to observe the
lateral borders
 Retract the tongue to view the inferior
tissues
Exam: Tongue
Exam: Tongue
 You may observe
lingual varicosities
Exam: Tongue
 You may observe geographic tongue
(erythema migrans)
Exam: Tongue
 You may observe drug reaction
Exam: Tongue
 Observe signs of nutritional deficiencies,
immune dysfunction
Exam: Tongue
 You may observe oral
cancer
Exam: Floor of mouth
 Visualize, palpate - bimanually
 Wharton’s duct
 Must dry to observe
 Does “lesion” wipe off?
 Where are the two most
likely areas for oral cancer?
 lateral border of the tongue
 Floor of mouth
Palpation of the floor of the mouth
Exam: Floor of mouth
Exam: Floor of mouth
 Squamous Cell Carcinoma
Exam: Floor of mouth
 Squamous Cell Carcinoma
Exam: Leukoplakic area
Edentulous Mandibular Ridge
Exam: Floor of mouth
 Oral Cancer:
 Red
 White

 Red and White

 Does the patient have important risk factors

for oral cancer?
 Counseling for smoking and alcohol
 Cessation
Squamous Cell Carcinoma
Triaging Lesions *
 Describe it’s characteristics
 Size, shape, color, consistency, location
 How long has it been present?
 Is it related to a trauma?
 Fractured cusp, occlusal trauma
 Has it occurred before?
 Can you wipe it off?
 Does the patient have specific risk factors for
neoplastic lesions?
Triaging Lesions *
 Any lesion that is suspicious should be re-
evaluated in 2 weeks
 Lesions due to infectious processes would have
healed in that time frame
 If it remains, the lesions should be biopsied
Exam: Maxilla & Mandible
• size, shape, contour
• pre-prosthetic treatment
•Tori removal
• tuberosity reduction
•Soft or hard tissue or both
Exam: Maxilla & Mandible
Exam: Maxilla & Mandible
Exam: Maxilla & Mandible
 Evaluate for Epulis
fissuratum

 If you make a new

denture will the excess
tissue resolve?
Occlusion
 Orthodontic
classification
 Interferences
Occlusion
Systematic Oral Examination
 Done at initial exam & at recalls unless
patient history requires sooner
 You must visualize all areas of the oral cavity
 Oral cancer can occur in other places than
the lateral borders of the tongue & the floor
of the mouth
 Be complete
 Do good, do no harm, do justice, respect
autonomy
Visualize all areas
Breath
 Oral odors can indicate:
 Infection: caries, periodontal dx
 URT infections
 Chronic G.I. disturbances
 Lung abscess
 Diabetic acidosis
 Uremia, kidney problem
 Liver failure: mousy, musty odor
 Self-medication with alcohol
Example of Dental Charting
 ORAL PATHOLOGY
 DEFINITION—THE STUDY OF DISEASES
IN THE ORAL CAVITY.
 MANY SYSTEMIC AS WELL AS
INFECTIOUS DISEASES HAVE ORAL
MANIFESTATIONS.
 If mucosal lesions are evident:
• Try to remove local factors that could
have contributed to the lesion
• commence anti-inflammatory treatment
for two weeks, if lesion remains: biopsy
• a diagnosis based on clinical appearance
alone is usually not sufficient to determine
the histological nature of the tissue
 Oral Lesions
By colour change By surface change
• White lesions • nodules
• Red lesions • vesiculobullous
• Red and white lesions
lesions • ulcerative lesions
• pigmented lesions
 Oral lesions
White lesions: Red lesions:
• Leukoplakia • Erythroplakia
• Lichen • Varicosity
• Leukoedema • Hemangioma
• Morsicatio buccarum• Purpura (Petechiae,
• White Sponge Ecchymosis)
Neavus • Sturge-Weber
Angiomatosis
• Fordyce’s Granules
• Hereditary
Hemorrhagic
Teleangiectasia
 Oral lesions
Red-white lesions Pigmented lesions
• speckled Erythroplakia • Melanoplakia
• Squamous Cell • Tobacco associated
Carcinoma Pigmentation (Smokers
• Lichen planus Melanosis)
• Lupus Erythematodes
Erythematodes • Nevus
• Lichenoid Drug Reactions • Malignant Melanoma
• Candidiasis (Candidal • Peutz-Jeghers Syndrome
Leukoplakia,
Leukoplakia, Anti-biotic
Anti-biotic • Addisons’s Disease
Sore
Sore Mouth,
Mouth, Denture
• Amalgam Tattoo
Stomatitis)
Stomatitis)
 Background Definitions
Gingivitis-inflammation of the gums
Xerostomia-abnormal dryness of the mouth due
to insufficient secretions
Mucositis-inflammation of a mucous membrane
Stomatitis-inflammation of the mouth having
various causes (as mechanical trauma,
allergy, vitamin deficiency, or infection)
Cheilitis-inflammation of the lip
Glossitis-inflammation of the tongue
 Leukoplakia
White lesions on the mucosa
which will not rub of and can
not be classified as any other
disease (WHO 1978)

• is a clinical descriptive term,

not a histological diagnosis
Leukoplakia
 Etiology
• Combination of extrinsic local
factors and intrinsic predisposing
factors
• Initiation through chemical or
mechanical irritation:
– chemical: alcohol, tobacco
– mechanical: sharp tooth or crown
margins, irritating denture clasps
 Histologic Features

• Leukoplakia usually shows

hyperkeratosis or acanthosis with or
without dysplasia (20% show
dysplasia)
• white colour change is the sign of
hyperkeratosis
 Clinical appearance -
homogeneous and non-
homogeneous Leukoplakia
• Homogeneous: non-palpable, faintly
translucent white discoloration
• non-homogeneous:
– verrucous or nodular
– speckled: hyperkeratotic white areas
and red areas
– errosive: fissuring and ulcer formation
 Site of Leukoplakia
• Risk of dysplasia/carcinoma higher with
floor of mouth, ventrolateral tongue,
retromolar trigone, soft palate than with
other oral sites
• 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
 Sites of predilection
• Lateral and ventral tongue
• floor of the mouth
• alveolar ridge mucosa
• corner of the mouth
• less frequently:
– soft palate
– lip
 High risk sites
• 4-6% of leukoplakias progress to
squamous cell carcinoma within 5
years
• high risk sites of malignancy:
– floor of the mouth
– lateral and ventral tongue
– lips
Differential diagnosis

Nicotine Stomatitis
Candidiasis
Hairy Leukoplakia
Leukoedema
White sponge naevus
Fordyce granules
 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
Erosions and ulceration are a
clinical sign of malignant
transformation
 Dysplasia
• mild: affects only basal 1/3 of epithelium
• moderate: affects half of epithelial layer
• severe: more than 2/3 of epithelium
affected
• Carcinoma in situ (CIS): the whole
thickness of epithelium is involved but
the basement membrane is intact
 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
 Hairy leukoplakia

• Oral sign of HIV infection

• viral origin likely (Epstein-Barr virus)
• frequently associated with Candida
albicans
 Lichen planus
• Common skin disease with oral
manifestation (ca 30% of cases) or
oral lesions without cutaneous signs
• most likely immunologic disorder in
which T lymphocytes destroy the
basal cell layer of the affected
epithelium
 Lichen planus
• Frequently affected sites:
– buccal mucosa
– dorsal tongue
• less frequently affected:
– lips
– palate
– gingiva
– floor of mouth
 Lichen planus

• Four appearances of oral lichen

planus:
– striated (reticular)
– atrophic
– erosive
– plaquelike
 Erythroplakia

• Def: persistent red patch that cannot

be characterized clinically as any
other condition
• redness of the lesion is a result of
atrophic mucosa overlying highly
vascular submucosa
 Erythroplakia

Area of Squamous Cell Carcinoma Surrounded

by Erythroplakia
 Erythroplakia
• Most erythroplakia are histologically
diagnosed epithelial dysplasia or
worse
• much higher chance of progression
to carcinoma
• biopsy is mandantory
CONDITIONS OF THE TONGUE
• GLOSSITIS
– General term used to describe inflammation and
changes to the tongue.
– FOUR MAIN TYPES
• BLACK HAIRY TONGUE
• GEOGRAPHIC TONGUE
• FISSURED TONGUE
• PERNICIOUS ANEMIA
 BLACK HAIRY TONGUE
– caused by an oral flora imbalance after the
administration of antibiotics
– the filiform papillae become elongated so
that they resemble hairs, they then become
stained by food,
• GEOGRAPHIC TONGUE
• the surface of the tongue loses areas of the
filiform papillae in irregularly shaped patterns
• the smooth areas resemble a map.
• over days or weeks the smooth areas and the
whitish margins seem to change locations across
the surface of the tongue
• affects 1-3% of the population
• occurs at all ages
• women have it twice as much as males
– FISSURED TONGUE
• considered a variation of normal
• etiology is unknown
• theories include a vitamin deficiency or
chronic trauma over a long period
• dorsum of tongue appears to have deep
fissures or grooves that become irritated if
debris collects in them
• patient is advised to brush tongue with a
soft toothbrush
– PERNICIOUS ANEMIA
• a condition in which the body does not
absorb vitamin b 12
• oral manifestation of pernicious anemia
include angular cheilitis
• ulceration and redness at the corners of the
lips
• loss of papillae of the tongue
• a burning and painful tongue
Ulcerative Lesion
 Things to Consider
Most Likely: Aphthous ulcer, HSV, Trauma,
Malignancy
Less Likely: Varicella Zoster, Autoimmune
disease, Fungal infection, Malnourishment
Must Rule Out: Malignancy,
Immunosuppresion, Bacterial/Fungal
disease, Some of the autoimmune
diseases
 Differential Diagnosis
• Infection
– HSV, Actinomycosis, CMV, Varicella Zoster, Coxsackievirus,
Syphilis, Candidiasis, Cryptosporidium, Histoplasma (fungal
typically seen in immunocompromised)
• Autoimmune
– Behçet's syndrome, Lupus, Crhon’s Disease, Pemphigoid,
Lichen Planus, Aphthous ulceration, Erythema multiforme
• Neoplasm
• Trauma Induced (necrotizing sialometaplasia)
• Malnourishment: Vitamin B deficiencies, Vitamin C deficiency,
Iron deficiency, Folic acid deficiency
 What to Do Next?
-Work from most common to least common, and rule out the
things that will cause the most morbidity or mortality
1. Biopsy the lesion
2. Check labs (ensure not immunocomprimised) – finger
stick glucose in office, CBC, CMP, A1c
3. Rule out infection: Send swab and biopsy for HSV testing
(smear, PCR) as well as gram stain and possible culture
(viral/bacterial)

Final Diagnosis: Major Aphthous Ulcer

 Aphthous Ulcers
• Most common cause of non-traumatic
ulcerations of the oral cavity
• Etiology unclear
• 10-20% of general population
• Diagnosis of exclusion
 Aphthous Ulcers

• Classifications
– Minor aphthous ulcer
» < 1cm in diameter
» Located on freely mobile oral mucosa
» Appears as a well-delineated white
lesion with an erythematous halo
» Prodrome of burning or tingling in
area prior to ulcer’s appearance
» Resolve in 7-10 days
» Never scars
Aphthous Ulcers
– Major aphthous ulcer
» > 1cm in diameter
» Involves freely mobile mucosa,
tongue, and palate
» Last much longer – 6 weeks or
more
» Typically scar upon healing
 Aphthous Ulcers

– Herpetiform ulcers
» Small, 1-3mm in diameter ulcerations
appearing in crops of 20-200 ulcers
» Typically located on mobile oral mucosa,
tongue, and palate
» Last 1-2 weeks
» Called herpetiform because ulcerations
resemble those of HSV, but there is no
vesicular phase
 Aphthous Ulcers Cont.
– Treatment
»Topical tetracycline solution for 5-7 days has
shown good results
»Topical steroids shown to shorten disease
duration
»Sucralfate suspension shown to improve pain as
well as shorten disease duration
»Major aphthous ulcers or more severe forms of
disease require 2 week course of systemic
steroids
• KEY TO DIAGNOSIS: Diagnosis of exclusion;
clinical appearance/course
– Any ulceration that fails to heal in 1-2
weeks should be biopsied

– Associated Premalignant lesions

• Leukoplakia
• Erythroplakia
 Oral Malignancy
– Malignancy
• 30% of all head and neck cancer occur in the oral
cavity (most common site of head and neck cancer)
• Symptoms/findings – non-healing ulcerations, pain,
expansile lesion, trismus, dysphagia, odonyphagia,
halitosis, numbness in lower teeth (inferior alveolar
nerve involvement)
• Indicators of more aggressive tumors – require more
aggressive treatment
– 4mm of invasion
– > 1cm in size
– Perineural, lymphatic, or vascular invasion
 Types of Oral Cancer
– Squamous cell carcinoma – most common (90% of
cases)
– Basal cell carcinoma – more common on upper lip
– Verrucous carcinoma
» Variant of squamous cell carcinoma
» Less aggressive (rare metastasis or deep invasion)
» Most common site is on buccal mucosa
» Warty lesion
– Salivary gland malignancy
» Most common in oral cavity is adenoid cystic carcinoma
» Mucoepidermoid carcinoma
» Adenocarcinoma
– Lymphoma – both Hodgkin’s and non-Hodgkin’s types
– Sarcomas – most commonly rhabdomyosarcoma and
liposarcoma; look for Kaposi’s sarcoma in AIDS patients
– Melanoma
 Oral manifestation of systemic
diseases.
• Drug Reactions
• Fungal infections
• Viral infections
• Leukemia
• Behcet’s Disease
• Diabetes Mellitus
• Nutritional Deficiencies
• Amyloidosis
 Behcet’s Disease
• Behcet’s disease is a rare disorder mainly affecting
young men.
• While the disease affects multiple organ systems, oral
ulcerations resembling canker sores present in 99% of
patients.
• The oral lesions are the herald of this disease and are
usually 6mm or smaller and resolve within 1-3 weeks.
• Treatment is symptomatic and supportive. Medication
may be prescribed to reduce inflammation and/or
regulate the immune system. Immunosuppressive
therapy may be considered.
Behcet’s Disease
 Sjögren’s Syndrome
• Sjögren’s syndrome is the 2nd most common
autoimmune disease with women in their mid-60’s
being the primarily afflicted.
• Initial symptoms include dry eyes and dry mouth due
to gradual glandular dysfunction.
• In some cases, dysphagia, increased dental caries,
increased susceptibility to oral candidiasis, and
difficulty wearing dental prostheses will develop.
• Treatment is generally symptomatic and supportive.
Moisture replacement therapies may ease the
symptoms of dryness. Nonsteroidal anti-inflammatory
drugs may be used to treat musculoskeletal
symptoms. Corticosteroids or immunosuppressive
drugs may be considered in severe cases.
Sjögren’s Syndrome
 Drug Reactions- SJS and TEN
• Stevens-Johnson syndrome and toxic epidermal
necrolysis are rare, life-threatening, drug induced
reactions.
• 7 to 21 days after exposure purpuric and
erythematous macules evolve to skin necrosis and
epidermal detachment.
• Oral mucous membrane involvement occurs in up
to 50% of cases and may impair ingestion of
nutrition.
• Most commonly implicated in these reactions are
sulfonamides, penicillins, phenytoin, and
phylbutazone.
Erythema Multiforme
 Carry home messages
• Thorough examination is vital in
diagnosis and management of diseases
of oral cavity.
• Any suspicious lesion should be
biopsied.