Disorders of oral cavity
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Disorders of oral cavity. dr shabeel pn. Actinic cheilitis Premalignant condition due to chronic UVR exposure Affects lower lip, initially edematous & erythematous, later atrophic, white, scaly plaque, may obliterate vermillion border

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Disorders of oral cavity

Disorders of oral cavity

dr shabeel pn


Disorders of the lips

Actinic cheilitis

Premalignant condition due to chronic UVR exposure

Affects lower lip, initially edematous & erythematous, later atrophic, white, scaly plaque, may obliterate vermillion border

Ulceration or induration - biopsy to rule out malignant transformation

Disorders of the Lips


Disorders of the lips1

Angular cheilitis (perleche)

Inflammatory reaction- erythema and maceration at the angles of mouth, fissuring and crusting may be present

Predisposing factors- advanced age, ill-fitting dentures, thumb-sucking in children, oral Candidiasis, bacterial infections

Disorders of the Lips…


Disorders of the lips2

Disorders of the Lips…

  • Cheilitis glandularis

    • Inflammatory painless enlargement of lower lip, usually in elderly men

    • Triggered by actinic damage, bacterial infection, tobacco exposure, chronic irritation

  • Chelitis glandularis apostematosa

    • Painful enlargement, eversion of lip with erosions and recurrent bacterial infections or malignant transformation


Disorders of the lips3

Exfoliative cheilitis (factitious cheilitis)

Chronic superficial inflammation of vermilion borders of the lips

Characterized by persistent scaling

Attributed to repeated lip sucking, chewing or other manipulation of lips

Disorders of the Lips…


Granulomatous cheilitis cheilitis granulomatosa

Granulomatous inflammation, acute onset of asymmetric swelling of the upper lip or lower lip

Erythema, scaling, fissuring and erosions may develop

Prolonged and recurrent course with eventual fixed swelling

May be associated with constitutional symptoms, regional lymph node enlargement

Granulomatous cheilitis (cheilitis granulomatosa)


Granulomatous cheilitis

Granulomatous cheilitis

  • Melkersson-rosenthal syndrome- triad of lingua plicata ( fissured or furrowed tongue), facial paralysis and granulomatous cheilitis

  • Other cranial nerves (olfactory, auditory, glossopharyngeal, hypoglossal) may be involved

  • Biopsy- oedema, perivascular lymphocytic infiltrate, focal granulomas resembling sarcoidosis or Crohn’s disease


Disorders of tongue

Disorders of Tongue

  • Glossodynia (burning mouth syndrome)- spontaneous burning, discomfort, pain, irritation, or rawness of the tongue, has no identifiable etiology most of the time

  • Etiology-

    • Idiopathic, Infection, Allergic/contact hypersensitivity, Mechanical trauma

    • Xerostomia, Geographic tongue/ Fissured tongue

    • Vesiculobullous disease, temporomandibular dysfunction

    • Referred pain from teeth or tonsils

    • Drugs- Antibiotics, psychiatric medications, chemotherapy


Etiology of glossodynia

Neurologic

Peripheral nerve damage

Diabetic neuropathy

Trigeminal neuralgia

Acoustic neuroma

psychiatric

Depression

Anxiety

Cancerophobia

Somatoform disorder

OCD

Systemic disorders

Anemia (iron deficiency, pernicious)

Nutritional deficiency

Gastroesophageal reflux disease

Sjogren syndrome

Hypothyroidism

Acquired immunodeficiency syndrome

Etiology of Glossodynia


Disorders of tongue1

Disorders of Tongue…

  • Glossitis- presents as pain, irritation or burning, hypogeusia, or dysgeusia

  • Atrophic glossitis

    • Due to filiform de-papillation

    • Mild patchy erythema to a completely smooth, atrophic, beefy-red surface

    • Etiology - pernicious anemia, protein and other nutritional deficiencies, chemical irritants, drug reactions, amyloidosis, sarcoidosis, vesiculobullous diseases, oral candidiasis and systemic infections

    • Moeller or Hunter glossitis of pernicious anemia affects the lateral aspects and tip of the tongue respectively


Disorders of tongue2

Median rhomboid glossitis - atrophic disorder of the tongue secondary to chronic candidiasis

Disorders of Tongue…


Disorders of tongue3

Geographic tongue- benign inflammatory condition, due to Loss of filiform papillae

Erythematous plaques with an annular or serpiginous well demarcated white border

Etiology- psoriasis, Reiter syndrome, atopic dermatitis, diabetes mellitus, anemia, hormonal disturbances, Down syndrome, lithium therapy

Disorders of Tongue…


Disorders of tongue4

Fissured tongue (furrowed tongue, scrotal tongue, grooved tongue)

normal variant seen in 5-11% individuals

Numerous small irregular fissures oriented laterally on the dorsal tongue

Also seen in - Melkersson-Rosenthal syndrome, psoriasis, Down syndrome, acromegaly, Sjogren syndrome

Disorders of Tongue…


Disorders of tongue5

Herpetic geometric glossitis - rare cause of fissuring of tongue, presents with acute onset of pain and deep longitudinal grooves with smaller lateral fissures

Disorders of Tongue…


Disorders of tongue6

Hairy tongue (white or black hairy tongue) - hypertrophy of filiform papillae resembling hair-like projections

Associated with - heavy tobacco use, mouth breathing, antibiotic therapy, poor oral hygiene, general debilitation, radiation therapy, chronic use of bismuth containing antacids, lack of dietary roughage

White, yellow green, brown, or black color is due to chromogenic bacteria or staining from exogenous sources

Disorders of Tongue…


Disorders of tongue7

Orai hairy leukoplakia- caused by Epstein-Barr virus, presents as asymptomatic, corrugated, white plaques with accentuation of vertical folds along the lateral borders of tongue

Predominantly seen in HIV infection, organ transplant recipients and patients on chemotherapy

Disorders of Tongue…


Disorders of tongue8

Disorders of Tongue…

  • Macroglossia- congenital or acquired process, tongue is disproportionately large relative to the patient’s jaw size

  • Difficulty with mastication and speech and accidental tongue biting are common

  • Differential- Down syndrome, hypothyroidism, Beckwith-Wiedemann syndrome, neurofibromatosis, infection by mycobacteria, filamentous bacteria or fungus, amyloidosis


Disorders of salivary glands

Disorders of Salivary Glands

  • Xerostomia (dry mouth) - decreased saliva production

  • Women are twice as affected as men

  • Signs and symptoms - diminished or altered taste and smell, halitosis, heavy plaque accumulation, difficulty in wearing dentures, recurrent yeast infections, burning sensation, difficulty swallowing, dry or cracked lips, salivary calculi and increased thirst


Causes of xerostomia

Causes of xerostomia

  • Medications - Antidepressants, antihistamines, diuretics

  • Medical conditions - Parkinson disease, diabetes, anemia, cysticfibrosis, rheumatoid arthritis

  • granulomatous inflammation - tuberculosis, sarcoid, Sjögren syndrome, HIV, amyloid

  • Dehydration - Fever, excessive sweating, vomiting, diarrhea, blood loss, burns, smoking, consumption of tea, coffee

  • Radiation therapy of head and neck

  • Surgical removal of the salivary glands

  • Old Age


Disorders of salivary glands1

Mucocele (mucous retention cysts)- benign, painless, dome- shaped fluctuant papules, due to trauma or obstruction of minor salivary gland ducts

Multiple mucoceles - graft vs host disease, lichen planus, cicatricial pemphigoid

Ranula - large, bluish, translucent fluctuant mass in the floor of the mouth due to obstruction of the submandibular and or sublingual duct

Diffuse parotid gland enlargement - acute mononucleosis, HIV infection

Disorders of Salivary Glands


Disorders of gingiva periodontium

Disorders of Gingiva & Periodontium

  • Gingivitis - erythema, edema, and blunting of the interdental papillae, without bone loss

    • Predisposing factors - poor oral hygiene, tobacco use, diabetes

  • Periodontitis -chronic infection of connective tissue, periodontal ligament and alveolar bone

    • Long-term penodontitis is associated with increased risk of diabetes, heart disease, stroke and preterm birth

    • birth control pills, diabetes, steroids, Down syndrome, Langerhans cell histiocytosis, HIV predispose to periodontitis

    • Juvenile periodontitis is associated with genetic defects in leukocyte chemotaxis

  • Papillon-Lefevre syndrome - severe and destructive periodontal disease, with exfoliation of the deciduous and permanent teeth


Disorders of gingiva periodontium1

Disorders of Gingiva & Periodontium

  • Erosive gingivostomatitis (desquamative gingivitis)- inflammation and erythema of the gingiva, nonspecific reaction pattern, may be due to viral infection, autoimmune, inflammatory and blistering disorders

  • Lichen planus - painful or asymptomatic lacy white patches, plaques or papules, often with erosions and ulcerations

  • Lichenoid mucositis - NSAIDS, antihypertensive medications, contact allergy, graft-versus-host disease


Disorders of gingiva periodontium2

Acute necrotizing ulcerative gingivitis (trench mouth, vincent disease)

Punched- out ulcers of the interdental papillae, gingival hemorrhage, severe pain, foul odor

Fever and lymphadenopathy are common

Precipitating factors- poor oral hygiene, nutritional deficiency, alcohol and tobacco use, Immunosuppression

Etiologic agents- Treponema, Selenomonas, Bacteroides, Prevotella and Borrelia vincentii

Disorders of Gingiva & Periodontium


Aphthous ulceration

Aphthous ulceration

  • Acute, recurrent, painful ulcers on nonkeratinized mucosa

  • Most common cause of oral ulcerations

  • Effect up to 30 % of the population

  • Ulcers with a gray or yellow pseudomembrane and erythematous margin

  • Potential triggers - heredity, food and medication allergy, decreased mucosal barrier integrity, hematologic and immunologic disorders, emotional stress, and trauma


Aphthous ulceration1

Aphthous ulceration


Aphthous ulceration2

Aphthous ulceration

  • Systemic Conditions Associated

    • Hematinic deficiency (up to 20%)- iron, folic acid or vitamin B12 deficiency

    • Gastrointestinal malabsorption (3%) - Celiac disease, dermatitis herpetiformis, gluten-sensitive enteropathy, Crohn disease, pernicious anemia

    • Systemic lupus erythematosus, reactive arthritis

    • HIV

    • Behcet disease

    • PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis)

    • MAGIC (mouth and genital ulcers with inflamed cartilage)


Behcet s disease

Major criteria

Oral Aphthae

Genital Ulcers

Ocular- Iridocyclitis, Retinal vasculitis,Optic atrophy

CNS lesions- Meningoencephalitis, cerebral infarction, psychosis, cranial nerve palsies, cerebellar and spinal cord lesions

Dermatological

Pustules

Erythema nodosum

Pathergy

Minor criteria

Proteinuria and haematuria

Thrombophlebitis

Aneurysms

Arthralgias

Behcet’s disease


Non aphthous erosions ulcers

Non-aphthous erosions & ulcers

  • Pemphigus vulgaris, paraneoplastic pemphigus, bullous pemphigoid, cicatricial pemphigoid, EB acquisita

  • Epidermolysis bullosa simplex, junctional EB & dystrophic EB demonstrate the most severe

  • Discoid and SLE- oral discoid lupus is characterized by “sunburst” erythematous plaques surrounded by white radiating striations

  • Erythema multiforme and stevens-johnson syndrome/toxic epidermonecrolysis


Non aphthous erosions ulcers1

Non-aphthous erosions & ulcers…

  • Chronic ulcerative stomatitis - autoimmune mucosal erosive disorder

  • Resemble erosive LP

  • Direct immunofluorescence- IgG bound to nuclei of keratinocytes of basal and lower epithelial layers

  • Responsive to Hydroxychloroquine


Iatrogenic mucositis

Iatrogenic mucositis

  • Complications of systemic chemotherapy and head and neck radiation, occurs due to direct tissue injury of the mucosal epithelium


Disorders of mucosal pigmentation

Localized

Amalgam, tattoo

Ephelis / Naevus

Malignant melanoma

Kaposi’s sarcoma

Peutz–Jegher syndrome

Laugier–Hunziker syndrome

Melanotic macules

Generalized

Racial

Localized irritation, e.g. smoking

Drugs, e.g. phenothiazines, antimalarials, minocycline, contraceptives, mephenytoin

Addison’s disease/ Nelson’s syndrome

Ectopic adrenocorticotrophic hormone (e.g. bronchogenic carcinoma)

Albright’s syndrome

Haemochromatosis

Neurofibromatosis, incontinentia pigmenti

Malignant acanthosis nigricans

Disorders of mucosal pigmentation


Disorders of teeth

Disorders of Teeth


Disorders of teeth1

Disorders of Teeth…


Benign tumors

Benign Tumors

  • Pyogenic granuloma (pregnancy tumor) - an exaggerated, reactive proliferation of granulation and vascular tissue triggered by minor trauma or medication, classically during pregnancy

  • Pulp polyp- exaggerated reactive proliferation of the dental pulp (neurovascular bundle), results when gross caries destroys the enamel crown

  • Verruciform xanthoma - minute white or yellow verrucous papules on the gingiva, alveolar mucosa, or hard palate. Foamy, lipid-laden macrophages in biopsy

  • Mucosal lipomas - present as asymptomatic, soft, yellow nodules on the buccal or vestibular mucosa, tongue, floor of the mouth or lips of middle-aged adults


Benign tumors1

Benign Tumors…

  • Traumatic neuroma - occur around mental foramen, alveolar ridge, lip or tongue

  • Neurofibromas and schwannomas (neurilemmoma) - on the tongue or buccal mucosa

  • Sipple syndrome - multiple mucosal neuromas, associated with pheochromocytoma, parafollicular thyroid cysts secreting calcitonin, medullaiy thyroid carcinoma and opaque nerve fibers on the cornea

  • Granular cell tumor (Abrikosov tumor) - reactive process of Schwann cell origin, appears on the dorsal tongue as single or multiple asymptomatic firm, ill-defined papule


Pre malignant lesions

Pre-Malignant Lesions

  • Leukoplakia - chronic, white, verrucous plaque with histologic atypia

    • Severity linked to the duration and quantity of tobacco and alcohol use

    • Occur anywhere in the oral cavity

    • Lip, tongue, or floor of the mouth lesions are prone for progression to SCC

  • Erythroplakia - non-inflammatory erythematous plaque

    • Analagous to intra-oral erythroplasia of Queyrat or SCC in situ

    • Biopsies - severe dysplasia and areas of frank invasion


Pre malignant lesions1

Pre-Malignant Lesions…

  • Submucous fibrosis

    • generalized white discoloration of oral mucosa with progressive fibrosis, painful mucosal atrophy and restrictive fibrotic bands

    • individuals who chew betel quid, a concoction of tobacco, lime, areca nut and betel leaves

    • Ultimately leads to trismus, dysphagia and severe xerostomia

    • 5 - 10 % progress to SCC


Malignant lesions

Malignant Lesions

  • Squamous cell carcinoma - present as leukoplakia, erythroplakia, erythroleukoplakia, irregular endophytic masses with ulceration or exophytic nodules

  • High-risk anatomic sites - ventrolateral tongue, floor of the mouth, and the vermillion border of the lip

  • Verrucous carcinoma - locally aggressive SCC in older adults presents as a hyperkeratotic, verrucous, exophytic white mass on the vestibules or mandibular gingiva, floor of the mouth, palate, and lip. Risk factors - smokeless tobacco and infections with HPV( 16 and 18)


Malignant lesions1

Malignant Lesions…

  • Proliferative verrucous leukoplakia - rare progressive multifocal leukoplakia, with white, hyperkeratotic, verrucous plaques involve large areas of mucosa

    • Women are affected four times as men

    • More than 90 % undergo malignant transformation

    • Smoking is not associated, HPV may be etiologic factor

  • Melanoma - irregular pigmented macule, patch or papule on the hard palate or maxillary gingiva

    • in older than 50 years

    • advanced lesions may ulcerate or bleed

    • Breslow depth - most important prognostic factor


Malignant lesions2

Malignant Lesions…

  • Hodgkin, non-Hodgkin, cutaneous Tcell, and Burkitt lymphoma - non-specific, indurated, painless masses

  • Burkitt lymphoma is associated with alveolar bone destruction

  • Langerhans cell histiocytosis - ulcerative gingivitis, periodontitis, ulceration and bony destruction, may be initial or sole manifestation of disease

  • multicentric reticulohistiocytosis - flesh-colored to reddish-brown nodules on oral or nasal mucosa, in addition to classic cutaneous lesions and associated arthropathy

  • Kaposi sarcoma - single or multiple hemorrhagic patches or exophytic nodules, most often on gingiva or palate


Varicosities

Varicosities

  • Asymptomatic, blue, soft nodules on the lips and ventrolateral tongue

  • Not associated with any known systemic disease

  • Caliber-persistent labial artery - raised pulsatile tortuous, blue rubbery bleb appreciation of lateral pulsation is diagnostic

  • Mucosal hemangiomas - benign vascular tumors of infancy, erythematous or bluish vascular nodules, sometimes with associated thromboses and phleboliths, spontaneous regression usual

  • Petechiae, ecchymoses, hematomas, and spontaneous gingival hemorrhage in thrombocytopenia, coagulation, hemolytic anemia, von willebrand disease, anticoagulant therapy


Salivary gland tumors

Salivary Gland Tumors

  • Occur most commonly on the palate and on the retromolar pad distal to the third molar

  • Erythematous papules or ulcerated papules and nodules


Medication related oral changes

Medication-Related Oral Changes


Physical and chemical trauma

Physical and Chemical Trauma

  • Chronic biting and manipulation of lips in and buccal mucosa in nervous habit- ragged, irregular, white plaque at the site of trauma

  • Frictional keratosis - thickened white plaque (sharp tooth or overextended denture)

  • Irritation fibroma - sessile nodule at site of chronic mucosal irritation

  • Smoker’s palate or nicotine stomatitis - thermal injury to the hard palate of pipe smokers

  • Appears as a diffusely white palate studded with 2-5mm erythematous umbilicated papules


Physical and chemical trauma1

Physical and Chemical Trauma

  • Epulis fissuratum-

    • Develops beneath poorly fitting dentures, painless, elongated ridges of hypertrophic mucosa along the anterior labial alveolar ridge

  • Giant cell epulis

    • A reactive hyperplastic proliferation, appears as a deep red papule on the interdental papillae

    • Many multinucleated giant cells are seen histologically in a vascular proliferation


Chemical burn

Chemical burn

  • Aspirin burns

    • Mucosa in direct contact with aspirin becomes necrotic and painful, also with Medications containing phenol

  • Contact stomatitis

    • Intra-oral erythema, ulceration or a lichenoid mucositis

    • Dental amalgams, Cinnamate, flavorings, food additives, spices, toothpaste, mouthwash, dental epoxy resins, cosmetic lip products


Oral manifestations of viral infections

Oral Manifestations of Viral Infections


Oral manifestations of viral infections1

Oral Manifestations of Viral Infections


Oral manifestations of viral infections2

Oral Manifestations of Viral Infections


Oral manifestations of bacterial infections

Oral Manifestations of bacterial Infections


Oral manifestations of bacterial infections1

Oral Manifestations of bacterial Infections


Oral manifestations of fungal infections

Oral Manifestations of fungal Infections


Oral manifestations of fungal infections1

Oral Manifestations of fungal Infections

  • Oral candidiasis

  • Acute pseudomembranous, Acute atrophic, Chronic atrophic, Chronic hyperplastic, Median rhomboid glossitis

  • Predisposing factors- dry mouth, antimicrobials, corticosteroids, leukaemia, HIV inf, tobacco smoking, denture wearing, endocrinopathy


Oral manifestations of endocrine disorders

Oral manifestations of Endocrine disorders


Oral manifestations of liver diseases

Oral manifestations of Liver diseases


Oral manifestations of gastrointestinal diseases

Oral manifestations of Gastrointestinal diseases


Oral manifestations of renal diseases

Oral manifestations of Renal diseases


Oral manifestations haematological diseases

Oral manifestations Haematological diseases


References

References

  • Fitzpatrick,s dermatology in general medicine 7th edition

  • Rook’s text book of dermatology 7th edition


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