Neoplastic and Non-neoplastic Rodent Thyroid Lesions and Their Relevance
Non-neoplastic diseases of oral cavity Dr. Vishal Sharma.
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Transcript of Non-neoplastic diseases of oral cavity Dr. Vishal Sharma.
![Page 1: Non-neoplastic diseases of oral cavity Dr. Vishal Sharma.](https://reader038.fdocuments.in/reader038/viewer/2022102518/55163a81550346b2068b5078/html5/thumbnails/1.jpg)
Non-neoplastic diseases of
oral cavityDr. Vishal Sharma
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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
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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)
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Ulcers of oral cavity
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• 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
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Oral sub-mucous
fibrosis
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• 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
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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)
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Etiology
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• 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
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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
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Blanched mucosa
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Early fibrosis in lower lip
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Early & advanced trismus
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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
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Dynamic splints for trismus
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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
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Aphthous ulcer (canker sore)
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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
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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
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Major aphthous ulcer
Rule out HIV & malignancy
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Herpetiform aphthous ulcers
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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
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Treatment of aphthous ulcer
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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
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Behcet’s syndrome
• Uveitis + Aphthous ulcer + Genital ulcer
• Oculo – Oro - Genital syndrome
• Tx: steroid
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Leukoplakia
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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
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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
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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
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Homogenous Leukoplakia
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Nodular Leukoplakia
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Verrucous leukoplakia
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Speckled (erythro) leukoplakia
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Layers of epidermis
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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
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Investigations
1. Supra-vital staining /
Ora-screen: Toluidine
blue solution stains
areas of malignancy
2. Biopsy: to rule out
malignancy
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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
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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
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Cold knife excision
BEFORE AFTER
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Laser excision
BEFORE AFTER
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Erythroplakia (Erythroplasia)
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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
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Erythroplakia
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Oral candidiasis (Moniliasis)
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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
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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
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Hyperplastic
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Pseudo-membranous (thrush)
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Erythematous
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Candidal Cheilitis
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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
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Microscopic examination
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Sabouraud dextrose agar
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Vincent’s infection
(Acute Necrotizing
Ulcerative Gingivitis
or Trench mouth)
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Etiology: infection with spirochete Borrelia vincenti
& Gram –ve anaerobe Bacillus fusiformis
Predisposing factors:
• Poor general health
• Poor oro-dental hygiene
• Dental caries
Introduction
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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
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Early acute necrotizing ulcerative gingivitis
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Advanced acute necrotizing ulcerative gingivitis
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Vicent’s angina
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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
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Infectious mononucleosis (glandular fever)
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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
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Clinical Features
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White patch on tonsil
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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%
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Atypical lymphocytes
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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
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Oro-labial Herpes simplex infection
(cold sore)
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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
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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
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Herpes simplex labialis
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Herpes simplex of tongue
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Oral Lichen planus
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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
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Reticular lichen planus
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Erosive lichen planus
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Lichen planus plaque
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Stevens – Johnson syndrome
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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
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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
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Hemorrhagic crusting of lips
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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.
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Nicotinic stomatitis
• Seen in pipe smokers
& reverse smokers
• Cobblestone mucosa
of postr hard palate,
with red dot in center
• Tx: smoking cessation
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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.
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Geographic tongue
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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
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Fissured tongue & hyperkeratosis
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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
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Tongue-tie or Ankyloglossia
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• 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
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Pre-operative
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Horizontal incision planned
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Horizontal incision made
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Vertical suturing done
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Post-operative
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Lip mucocoele
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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
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Complete surgical excision
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Ranula
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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
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Simple Ranula
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Plunging ranula
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Plunging ranula
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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
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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
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Marsupialization
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Intra-oral excision
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Ranula specimen
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Thank You