oral lesions with diagrams,,,with journal included discussing common oral lesions in india

1. ORAL
DERMATOLOGICAL
CONDITIONS
MODERATOR:Dr.MOHANTY
PRESENTER:RAVINDRA.D

2. Anatomy: Oral cavity
• Oral cavity
o Lips
o Tongue
o Floor of Mouth
o Buccal mucosa
o Palate
o Retromolar
trigone

3. Common diseases of oral cavity
Sub-mucous fibrosis
Aphthous ulcer
Leukoplakia
Erythroplakia
Oral candidiasis
Oro-labial Herpes
Vincent’s infection
Infectious mononucleosis
Tongue tie
Geographic tongue
Ranula
Mucocoele

4. 1.Aphthous ulcer
INTRODUCTION
• 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

5. 1. Minor aphthous ulcer: 2 – 10 mm in size, multiple,
heal with no scar in 1 - 2 weeks

6. 2. Major aphthous ulcer: 20 – 40 mm in size, usually single,
heal with scar over months
Rule out HIV & malignancy

7. 3. Herpetiform aphthous ulcer: < 1 mm in size, multiple,
heal with no scar in 1 week

8. TREATMENT
1. Avoid trigger factors
2. Supplement: vitamin B complex + folic acid + iron
3. Topical gel combination:
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

9. 2.Behcet’s syndrome
• Uveitis + Aphthous ulcer +
Genital ulcer
• Oculo – Oro - Genital
syndrome
• Treatment : steroid

10. 3.Oral candidiasis
• 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

11. TYPES
1.Chronic hyperplastic: white plaques, cannot be
removed by scraping (Candidal leukoplakia)

12. 2.Pseudo-membranous: loosely adherent white lesions,
can be scraped off leaving red patches

13. 3.Erythematous (atrophic): smooth, red patches

14. 4.Cheilitis: white lesions on angle of mouth

15. DIAGNOSIS
1. Microscopic exam of wet smear
on KOH mount: look for pseudohyphae
2. Culture (Sabouraud dextrose
agar): white colony
TREATMENT
1. Clotrimazole paint, Nystatin
mouthwash
2. Systemic
chronic cases
Fluconazole:
for
3. Excision of hyperplastic plaque
4. Correction of underlying cause

16. 4.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
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

17. STAGES

18.  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

19. 5.Oro-labial Herpes simplex infection
(cold sore)
Primary Herpes simplex
• Seen in children
• Oral cavity: multiple vesicles
which later ulcerate
• Fever + sore throat
• Neck node enlargement
• Treatment: Acyclovir 15
mg/kg PO 5 times/d for 7
days

20. Secondary Herpes simplex
• Reactivation of dormant virus in
trigeminal ganglion in adults by
emotional stress, fatigue,
infection, pregnancy, immunedeficiency
• Vesicular & ulcerative lesions
primarily affect vermilion border
of lip (Herpes labialis)
• Tongue, hard palate & gums also
involved
• Treatment: Acyclovir 200 mg PO 5
times / day X 7 days

21. Other Bacterial Infections
Syphilis
A-Ulcerated chancre
B-Ulcerated mucous
patches (snail track ulcers)
Tuberculosis of
The Tongue
C-Gummatous ulcer

22. 6.Trauma:
CHEEK BITING
ILL-FITTING DENTURES
CHEMICAL BURNS
ABRASIONS FROM TEETH

23. 7.Infectious mononucleosis
(glandular fever)
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

24. •
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%
•
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)

25. 8.Submucosal fibrosis
• 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
• ETIOLOGY (MULTI-FACTORIAL)
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

26. PRESENTING SYMPTOMS
•
Burning pain on consumption of spicy food
• Dryness of mouth
• Impaired mouth movements while eating & talking
• Progressive inability to open the mouth (trismus)
•This patient has so much of limitation in opening of mouth
that it is difficult to put even 2 fingers in the mouth
• Hearing loss (stenosis of Eustachian tubes)
• Nasal intonation ( ed soft palate mobility)
•STAGES
1.
Stage of stomatitis: red mucosa
vesicles
2.
Stage
blanching
of
fibrosis
(healing):
rupture to form mucosal ulcers
of
mucosafibrous
bands
in
trismus, deceased soft palate mobility
3.
Stage of sequelae: difficult speech, hearing loss,leukoplakia, malignancy (3 - 8 %)
oral
mucosa,

27. MEDICAL TREATMENT
1.
SURGICAL TREATMENT
Bi-weekly submucosal intralesional injections of
for 6-
8 wks
2.
Submucosal injection of human
placental extract
3. Vitamin B complex + anti-oxidant
supplement
4. Increased intake of fruits &
vegetables
Simple
release
of
fibrous
bands + skin grafting
Dexamethasone 4 mg +
Hyaluronidase 1500 IU
1.
2. Laser-assisted
release
of
fibrous bands
3. Excision
of
lesions
&
reconstruction with:buccal fat
pad,
naso-labial
flap,
palatal
flap,lingual
muco-periosteal
flap, radial forearm flap
4. Temporalis muscle myotomy +
mandibular coronoidectomy

28. 9.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
ETIOLOGY
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 with: submucous fibrosis, hyperplastic candidiasis, Plummer-Vinson
syndrome, AIDS

29. TYPES
1. Homogeneous leukoplakia:
smooth,white
2. Nodular leukoplakia: nodular, white

30. 3. Verrucous leukoplakia: warty, white
Malignant potential:
4. Speckled (erythro) leukoplakia:
white + red
speckled >> nodular & verrucous >> homogenous

31. INVESTIGATIONS
TREATMENT
1. Supra-vital staining /
1.
Ora-screen: Toluidine
blue solution stains
areas of malignancy
2. Biopsy: to rule out
malignancy
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

32. 10.Erythroplakia
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
o Red
colour
due
to
vascular
submucosal tissue shining through
under-keratinized mucosa
o Malignant potential: 17 times >
leukoplakia
o Treatment : excision biopsy

33. 11.Oral lichen planus
Etiology: unknown (? hypersensitivity reaction)
Types of oral lichen planus:
SKIN LESIONS: purple, polygonal, pruritic papules
TREATMENT: Reticular & plaque types: no treatment required
Erosive type: topical or systemic steroids

34. 12.Stevens - Johnson
syndrome
ETIOLOGY
• 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
• 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

35. 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.

36. 13.Black hairy
tongue
Elongated filiform papillae
on tongue due to excess
keratin formation.
Become infected with chromogenic
bacteria & look like hairs.
• Etiology: smoking
• Treatment : scraping of tongue
14.Nicotinic stomatitis
•
Seen in pipe smokers & reverse
smokers
•
Cobblestone mucosa of postr hard
palate, with red dot in center
•
treatment: smoking cessation

37. 15.ORAL CANCER
 Squamous Cell Carcinoma constitutes 95% of oral cancers
 Common in Old Men (50-60 years)
 COMMON SITES :
1.
2.
3.
4.

1.
2.
3.
4,
5.
Lip (lower lip)
Tongue (anterior ⅔)
Mouth floor
Tonsil and Fauces
AETIOLOGY:
Tobacco and alcohol are the most common associations:
Smokers can have 15-fold greater risk ( than nonsmokers ) of malignancy.
Chewing tobacco and betel nuts are important causes in India and parts of Asia
Leukoplakia and Erythroplakia
Human papilloma virus (HPV) (type16)
Genetic factors may also play a role
(deletions in chromosomes 18q, 8p, and 3p are implicated).
Exposure to ultra-violet light (cancer of the lip).

38. Squamous cell ca. of lip
Squamous Cell carcinoma of the
Tongue

39. Uncommon Malignant Tumors of
The Oral Cavity
Malignant melanoma
Lymphomas
Leukemic infiltration
Adenocarcinoma of minor
salivary glands
• Sarcomas
•
•
•
•
Acute Leukemia: gum involvement

40. JOURNAL PROPER

41. INTRODUCTION
• Very often the oral dermatological conditions
involving oral cavity are misdiagnosed and proper
attention and care is not given.
• This study is to sensitize the clinicians to the
prevailing situation of oral dermatological conditions.

42. MATERIALS & METHODS
• A total of 150 cases were
taken up for the study
irrespective of
age,sex,duration of lesions
attending dermatology/ENT
dept. during 1 year period.
• The following areas were
taken into consideration:
1. Site of lesion
2. Morphology
3. Extent of lesion
4. Discharge if any
5. Margins of lesion
6. Floor and base of lesion
7. Regional lymphnodes if any
• Investigations done are:
1. Routine blood,urine and
stool tests
2. Scrapings,KOH mount
3. Tzank test
4. Gram stains
5. Biopsy for certain
cases.
6. Special tests were done
for systemic diseases
if indicated

43. OBSERVATIONS
AGE DISTRIBUTION
AGE(yr.)
MALE
FEMALE
TOTAL
% (out of
150)
0-10
4
4
8
5.33%
11-20
12
20
32
21.33%
21-30
13
22
35
23.34%
31-40
13
24
37
24.67%
41-50
9
14
23
15.33%
>50
9
6
15
10.00%
TOTAL
60
90
150

44. AGE AND SEX DISTRIBUTION
30
PATIENTS
25
20
20
15
12
NO.
OF
10
5
22
13
24
13
MALE
14
9
female
9
6
4
0
0--10
11--20
AGE IN YEARS
21--30
31--40
41--50
>50

45. DISEASES WITH ORAL MANIFESTATIONS
DISEASES
NO.OF PATIENTS
% OUT OF 150
Aphthous ulcer
16
28.57%
Oral candidiasis
9
16.07%
Angular chelitis
6
10.71%
Oral leukoplakia
4
7.14%
Fixed drug eruption
4
7.14%
Squamous cell ca.
3
5.36%
Fordyce spot
2
3.57%
Herpes simplex stomatitis
2
3.57%
Oral sub mucosal fibrosis
6
10.71%
Mucocele
2
3.57%
Leukemia
1
1.79%
Warts
1
1.79%
Scrotal tongue
1
1.79%

46. DISCUSSION
• Pt.s having oral diseases
presents with different signs
and symptoms like
Oral pain,soreness,burning,
xerostomia,bleeding, swelling,
change ofcolour,erosion,crusting,
Ulcers,fissuring
• The study has recorded 25 pt.s
of pemphigus vulgaris having
both cutaneous manifestations,
revealing that this is the
common lesion.
• The study shows that buccal
mucosa was the most commonly
affected site(68%),followed by
palates(56%),lips(44%),tongue(
40%),labial mucosa(16%).
pemphigus vulgaris

47. • Collagen diseases form the next common group. Among this
systemic lupus erythematosus is major one, and most of the
lesions are confined to palate.
• The study recorded 13 cases of discoid lupus
erythematosus,with lips being the commonest site.
• Among the specific cutaneous disorders,16 cases of recurrent
aphthous stomatits have been recorded,with labial mucosa
being common site.,and most common one was minor type.
• 12 pts of lichen planus were recorded with lip&cheek being
common sites, and common in age group of 20-40.
• Infective disorders constitute 10% of study with candidiasis
being common one.common site of involvement is dorsal tongue.
• The study also recorded 6 cases of oral submucosal fibrosis
with cheeks(buccal mucosa) being common site.
• 4 pts of oral leukoplakia have been recorded with buccal
mucosa being common site of involvement.
• 6 pts of angular stomatitis have been recorded with lesions on
lips and buccal mucosa..

48. Diseases with oral and cutaneous
manifestations
DISEASES
NO.OF PTS.
% OUT OF 94
Pemphigus vulgaris
25
26.60%
Pemphigus vegetans
2
2.13%
Stevens Johnson's syndrome
8
8.15%
Toxix epidermal necrosis
4
4.26%
Erythema multiforme
1
1.06%
Discoid lupus erythematosus
13
13.83%
Systemic lupus erythematosus
16
17.02%
Systemic sclerosis
6
6.38%
Lichen planus
12
12.77%
Vitiligo
6
6.38%

49. Pie diagram showing distribution of
lesions
37.33
62.67
ORAL LESIONS
ORAL&CUTANEOUS
LESIONS

50. CONCLUSIONS
• Oral mucous membrane alone may be involved in some
disesases,but it is often missed by clinician.
• This can be taken care of by primary health care
providers without going through much sophisticated
investigations and thus early intervention for
patients.

51. BIBLIOGRAPHY
• INDIAN JOURNAL OF OTOLARYNGOLOGY AND
HEAD &NECK SURGERY(apr-june 2013)
• SCOTT&BROWN 6TH EDITION
• TEXT BOOK OF DERMATOLOGY BY NEENA
KHANNA

52. • Next academic session:
18-11-13-MONDAY
CASE PRESENTATION BY
Dr.SUSRUTHA

53. Thank you