Non-neoplastic diseases of

oral cavityDr. Vishal Sharma

Sub-mucous fibrosis Aphthous ulcer

Leukoplakia Erythroplakia

Oral candidiasis Oro-labial Herpes

Vincent’s infection Infectious

mononucleosis

Tongue tie Geographic tongue

Ranula Mucocoele

Common diseases

Oral pre-malignant conditions1. Oral sub-mucous fibrosis

2. Leukoplakia & Erythroplakia

3. Oral candidiasis

4. Lichen planus

5. Nicotinic stomatitis (smoker’s palate)

6. Tertiary syphilis

7. Mucosal hyper-pigmentation (melanosis)

Ulcers of oral cavity

• Infection: Herpes, Vincent’s infection, Candidiasis

• Auto-immune: Aphthous ulcer, Behcet’s syndrome

• Trauma: cheek bite, jagged tooth, ill-fitting denture

chemical burn, thermal burn

• Skin disorder: Lichen planus, erythema multiforme

• Blood disorder: Leukemia, agranulocytosis,

pancytopenia, sickle cell anemia

• Drug allergy: mouth wash, toothpaste

• Neoplasm: benign, malignant

• Others: Radiation, chemotherapy, diabetes, uremia

Oral sub-mucous

fibrosis

• Term coined by S.G. Joshi in 1953

• Chronic pre-malignant disease of oral cavity,

characterized by juxta-epithelial inflammation +

progressive fibrosis of lamina propria & deeper

connective tissues, followed by stiffening of

mucosa resulting in difficulty in mouth opening

Definition

1. Areca nut (betel nut) chewing

2. Tobacco & Paan masala chewing

3. Genetic predisposition

4. Auto-immune injury

5. Nutritional deficiency of vitamins, iron, anti-oxidants

6. Excessive alcohol consumption

7. Excessive consumption of chilies (controversial)

Etiology (multi-factorial)

Etiology

• Burning pain on consumption of spicy food

• Dryness of mouth

• Impaired mouth movements while eating & talking

• Progressive inability to open the mouth (trismus)

• Hearing loss (stenosis of Eustachian tubes)

• Nasal intonation (ed soft palate mobility)

Presenting symptoms

Stage of stomatitis: red mucosa vesicles

rupture to form mucosal ulcers

Stage of fibrosis (healing): blanching of mucosa,

fibrous bands in oral mucosa,

trismus, ed soft palate

mobility

Stage of sequelae: difficult speech, hearing loss,

leukoplakia, malignancy (3 - 8 %)

Clinical Staging

Blanched mucosa

Early fibrosis in lower lip

Early & advanced trismus

Medical Treatment

1. Bi-weekly submucosal intra-lesional injections of

Dexamethasone 4 mg + Hyaluronidase 1500 IU

for 6- 8 wks

2. Submucosal injection of human placental extract

3. Vitamin B complex + anti-oxidant supplement

4. Avoid consumption of mucosal irritants

5. Increased intake of fruits & vegetables

Dynamic splints for trismus

1. Simple release of fibrous bands + skin grafting

2. Laser-assisted release of fibrous bands

3. Excision of lesions & reconstruction with:

buccal fat pad, naso-labial flap, lingual flap,

palatal muco-periosteal flap, radial forearm flap

4. Temporalis muscle myotomy + mandibular

coronoidectomy

Surgical treatment for trismus

Aphthous ulcer (canker sore)

Recurrent, superficial ulcers, with necrotic centre +

red margin, involving movable mucosa of inner

surface of lips, cheeks, tongue & soft palate

Differences from viral ulcer

1. Frequent recurrence

2. Selective involvement of movable mucosa

3. Absence of fever, malaise, lymph node enlargement

Introduction

Types

1. Minor aphthous ulcer: 2 – 10 mm in size, multiple,

heal with no scar in 1 - 2

weeks

2. Major aphthous ulcer: 20 – 40 mm in size, usually

single, heal with scar over

months

3. Herpetiform aphthous ulcer: < 1 mm in size,

multiple, heal with no scar in 1

week

Minor aphthous ulcer

Major aphthous ulcer

Rule out HIV & malignancy

Herpetiform aphthous ulcers

Deficiency: vitamin B complex, iron, folic acid, zinc

Stress: emotional & physical

Trauma: cheek bite, ill-fitting dentures

Hormonal imbalance: changing progesterone level

Allergy: sodium lauryl sulphate (mouth wash & paste)

Drugs: NSAIDs, cancer chemotherapy

Others: Behcet’s syndrome, HIV, Crohn’s disease

Infection: controversial

Trigger factors for auto-immune injury

Treatment of aphthous ulcer

1. Avoid trigger factors

2. Supplement: vitamin B complex + folic acid + iron

3. Topical gel combination: ZYTEE, QUADRAJEL

a. steroid: triamcinolone

b. antibiotic: chlorhexidine, metronidazole,

benzalkonium, cetalkonium, tannic

acid

c. analgesic: benzydamine, choline salicylate

d. anesthetic: lignocaine, benzocaine

4. Mouth rinse: betamethasone, tetracycline

5. Immuno-modulator: thalidomide 50 -100 mg daily

Behcet’s syndrome

• Uveitis + Aphthous ulcer + Genital ulcer

• Oculo – Oro - Genital syndrome

• Tx: steroid

Leukoplakia

Definition: pre-malignant condition with white

patch or plaque that cannot be rubbed off with

gauze swab & cannot be characterized clinically

or pathologically as any other disease

Malignant transformation: 1 - 20% (average 5 %)

Sites: Buccal mucosa, tongue, lips, palate, floor

of mouth, gingiva, alveolar mucosa

Introduction

1. Chronic smoking

2. Chronic tobacco chewing

3. Irritation from jagged teeth or ill-fitting dentures

4. Chronic alcohol consumption

5. Sun exposure to lips

6. Associated: submucous fibrosis, hyperplastic

candidiasis, Plummer-Vinson syndrome, AIDS

Etiology

Types of leukoplakia

1. Homogeneous leukoplakia: smooth, white

2. Nodular leukoplakia: nodular, white

3. Verrucous leukoplakia: warty, white

4. Speckled (erythro) leukoplakia: white + red

Malignant potential:

speckled >> nodular & verrucous >> homogenous

Homogenous Leukoplakia

Nodular Leukoplakia

Verrucous leukoplakia

Speckled (erythro) leukoplakia

Layers of epidermis

1.Hyperkeratosis: thickening of stratum corneum

2.Parakeratosis: keratinization with retention of nuclei

in stratum corneum (homogeneous leukoplakia)

3.Acanthosis: thickening of stratum spinosum

(verrucous & nodular leukoplakia)

4.Dyskeratosis: abnormal keratinization present

below stratum granulosum (speckled leukoplakia)

Pathological stages

Investigations

1. Supra-vital staining /

Ora-screen: Toluidine

blue solution stains

areas of malignancy

2. Biopsy: to rule out

malignancy

D/D of oral white lesions• Leukoplakia

• Hyperkeratosis

• Hypertrophic candidiasis

• Hairy leukoplakia (Epstein-Barr virus infection)

• Lichen planus

• Oral sub-mucous fibrosis

• Lupus erythematosus

• White sponge nevus

• Carcinoma

1. Removal of causative agent

2. Supplement: Vitamin A (beta-carotene), C, E,

B12, folic acid

3. Surgical excision: if HPE shows dysplasia

Surgical excision modalities:

cold knife, cryosurgery, laser

surgery

Treatment

Cold knife excision

BEFORE AFTER

Laser excision

BEFORE AFTER

Erythroplakia (Erythroplasia)

Definition: pre-malignant condition with red patch

or plaque that cannot be rubbed off with gauze

swab & cannot be characterized clinically or

pathologically as any other disease

Red colour due to vascular submucosal tissue

shining through under-keratinized mucosa

Malignant potential: 17 times > leukoplakia

Tx: excision biopsy

Erythroplakia

Oral candidiasis (Moniliasis)

Etiology: Infection with Candida albicans

Predisposing factors:

1. Chronic ill-health

2. Uncontrolled diabetes mellitus

3. Acquired immune deficiency syndrome

4. Prolonged use of steroids

5. Prolonged antibiotic therapy

6. Immuno-suppressant therapy (cyclosporine)

7. Anti-cancer chemotherapy

Types of oral candidiasis• Chronic hyperplastic: white plaques, cannot be

removed by scraping (Candidal leukoplakia)

• Pseudo-membranous: loosely adherent white

lesions, can be scraped off leaving red patches

• Erythematous (atrophic): smooth, red patches

• Cheilitis: white lesions on angle of mouth

Hyperplastic

Pseudo-membranous (thrush)

Erythematous

Candidal Cheilitis

Diagnosis

1. Microscopic exam of wet smear on KOH mount:

look for pseudo-hyphae

2. Culture (Sabouraud dextrose agar): white colony

Treatment

1. Clotrimazole paint, Nystatin mouthwash

2. Systemic Fluconazole: for chronic cases

3. Excision of hyperplastic plaque

4. Correction of underlying cause

Microscopic examination

Sabouraud dextrose agar

Vincent’s infection

(Acute Necrotizing

Ulcerative Gingivitis

or Trench mouth)

Etiology: infection with spirochete Borrelia vincenti

& Gram –ve anaerobe Bacillus fusiformis

Predisposing factors:

• Poor general health

• Poor oro-dental hygiene

• Dental caries

Introduction

Clinical Features

1. Painful, ulcerative lesions covered by necrotic

membrane present over:

• inter-dental papillae & spreading toward free gum

margins (acute necrotizing ulcerative gingivitis)

• tonsils (Vincent’s angina)

2. Halitosis, neck lymph node enlargement & fever

Early acute necrotizing ulcerative gingivitis

Advanced acute necrotizing ulcerative gingivitis

Vicent’s angina

Diagnosis

Smear stained with Gentian violet to identify

Borrelia vincenti & Bacillus fusiformis

Treatment

1. Systemic Benzylpenicillin / Erythromycin

2. Systemic Metronidazole / Clindamycin

3. Betadine mouthwash & H2O2 gargle

4. Dental care & bed rest

Infectious mononucleosis (glandular fever)

Introduction

Caused by Epstein Barr virus

Spreads only by intimate contact (kissing disease)

C/F: 1. fever, fatigue, malaise

2. pharyngitis, palatal petechiae

3. ulcer-membranous lesions over tonsils

4. neck lymph node enlargement

5. hepatomegaly & splenomegaly

Clinical Features

White patch on tonsil

Investigations

• Total count: leukocytosis

• Differential count: lymphocytosis + monocytosis

• Peripheral blood smear: atypical lymphocytes

• Paul Bunnel test (with sheep RBC): positive

• Monospot test (with horse RBC): positive

Sensitivity 85%, specificity 100%

Atypical lymphocytes

Treatment• Symptomatic. Bed rest. Paracetamol for fever

• Steroids + tracheostomy for stridor

• Valacyclovir (1000 mg BD – TID X 7 d) is effective

• Avoid aspirin in children Reye syndrome (fatty

liver + encephalopathy)

• Avoid antibiotics ineffective

• Penicillin contraindicated non-allergic rashes

• Avoid opioid analgesics respiratory depression

Oro-labial Herpes simplex infection

(cold sore)

Primary Herpes simplex

• Seen in children

• Oral cavity: multiple

vesicles later ulcerate

• Fever + sore throat

• Neck node enlargement

• Tx: Acyclovir 15 mg/kg

PO 5 times/d for 7 days

Secondary Herpes simplex

• Reactivation of dormant virus in trigeminal

ganglion in adults by emotional stress, fatigue,

infection, pregnancy, immune-deficiency

• Vesicular & ulcerative lesions primarily affect

vermilion border of lip (Herpes labialis)

• Tongue, hard palate & gums also involved

• Tx: Acyclovir 200 mg PO 5 times / day X 7 days

Herpes simplex labialis

Herpes simplex of tongue

Oral Lichen planus

Etiology: unknown (? hypersensitivity reaction)

Types of oral lichen planus:

• Reticular: reticular white lines (Wickham’s striae)

• Erosive: reticular pattern with areas of ulceration

• Plaque: solid white lesion

Skin lesions: purple, polygonal, pruritic papules

Treatment:

• Reticular & plaque types: no treatment required

• Erosive type: topical or systemic steroids

Reticular lichen planus

Erosive lichen planus

Lichen planus plaque

Stevens – Johnson syndrome

Stevens - Johnson syndrome

• Severe form of Erythema multiforme

• Minor form of Toxic Epidermal Necrolysis

involving < 10 % of body surface area

• Muco-cutaneous, immune-complex–mediated

hypersensitivity disorder causing separation of

epidermis from dermis

Etiology

• Idiopathic: 25 - 50 % cases

• Drug reaction: Penicillin, Sulfonamides, Macrolide,

Ciprofloxacin, Phenytoin,

Carbamazepine, Valproate, Lamotrigine,

NSAIDs, Valdecoxib, Allopurinol

• Viral infection: herpes simplex, HIV, influenza

• Malignancy: carcinoma, lymphoma

Hemorrhagic crusting of lips

Symptomatic Treatment

• Airway stability, fluid replacement, electrolyte

correction, wound cared as burns & pain control

• Underlying diseases & infections treated

• Offending drugs must be stopped

• Local anesthetics & mouthwashes for oral lesions

• Steroids use is controversial. Cyclophosphamide,

cyclosporine & I.V. immunoglobulin are used.

Nicotinic stomatitis

• Seen in pipe smokers

& reverse smokers

• Cobblestone mucosa

of postr hard palate,

with red dot in center

• Tx: smoking cessation

Geographic tongue• Synonym: glossitis migrans

• burning sensation over tongue that worsens with

hot, spicy or acidic foods

• Red areas over tongue dorsum devoid of papillae

& surrounded by irregular keratotic white line

• Lesions keep changing their shape (map-like

appearance of tongue)

• Tx: Avoid irritant food. Vitamin B + Zinc.

Geographic tongue

Black hairy tongue

Elongated filiform papillae

on tongue due to excess

keratin formation. Become

infected with chromogenic

bacteria & look like hairs.

Etiology: smoking

Tx: scraping of tongue

Fissured tongue & hyperkeratosis

Median rhomboid glossitis

Red rhomboid area on

lingual dorsum anterior to

foramen caecum

Due to persistence

(invagination failure) of

tuberculum impar or

chronic candidal infection

No tx required

Tongue-tie or Ankyloglossia

• Congenital anomaly with decreased mobility of

tongue tip caused by short, thick lingual frenulum

• Diagnosis: inability to protrude tongue tip beyond

lower central incisors

• Effects: speech problem (?), feeding difficulty, bad

oral hygiene

• Tx: horizontal incision + vertical closure of

frenulum

Pre-operative

Horizontal incision planned

Horizontal incision made

Vertical suturing done

Post-operative

Lip mucocoele

Etiology: Lip trauma injures its tiny salivary ducts

extravasation of mucus & saliva in surrounding

tissues with lining of granulation or connective

tissue smooth, soft round fluid-filled mucocoele

Commonly affects lower lip

Tx: Lip mucocoeles usually resolve spontaneously

If they recur frequently or become problematic:

a. marsupialization of mucocoele

b. complete surgical excision of mucocoele with

adjacent minor salivary glands

Complete surgical excision

Ranula

Introduction

• Rana means frog (blue translucent swelling in

floor of mouth looks like underbelly of frog)

• Simple ranula: Bluish cyst located in floor of

mouth. Painless mass, does not change in size in

response to chewing, eating or swallowing

• Plunging ranula: Sub-mandibular neck swelling

with or without cyst in floor of mouth

Simple Ranula

Plunging ranula

Plunging ranula

Etiology• Simple ranula: partial obstruction or severance of

sublingual duct leads to epithelial-lined retention

cyst. Commonly traumatic.

• Plunging ranula: 1. sublingual gland projects

through or behind mylohyoid muscle

2. ectopic sublingual gland on

cervical side of mylohyoid muscle

TreatmentMarsupialization: un-roofing of cyst & suturing of

cyst margin to adjacent tissue. Failure = 60-90%

Sclerosing agents: intra-lesional injection of

Bleomycin or OK-432

Intra-oral excision: of ranula alone (failure = 60%)

or ranula + sublingual gland (failure = 2 %)

Trans-cervical approach for plunging ranula:

complete removal of cyst + sublingual gland

Marsupialization

Intra-oral excision

Ranula specimen

Thank You