Non neoplastic diseases of oral cavity

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Non neoplastic Diseases of the oral cavity

• Dr. Krishna Koirala, MBBS, MS ( ENT-HNS)
• Associate Professor
• Dept. of ENT
• MCOMS, Pokhara, Nepal

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• Oral Submucous fibrosis
• Aphthous Ulcers
• Leukoplakia
• Oral Candidiasis
• Vincents Angina

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• Oral Submucous Fibrosis (OSMF)

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• Definition Chronic debilitating disease of oral
  mucosa characterized by inflammation and
  progressive fibrosis of lamina propria and deeper
  connective tissues followed by stiffening of an
  otherwise yielding mucosa resulting in difficulty
  in opening the mouth
• Sites Any part of the oral cavity Buccal
  mucosa -most common site
• Malignant potential !!!

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• Pathophysiology
• Multifactorial
• Factors
• Areca nut chewing
• Ingestion of chilies
• Genetic and immunologic processes
• Nutritional deficiencies
• Juxtaepithelial inflammatory reaction in the oral
  mucosa

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• Areca nut (betel nut) chewing
• Arecoline (active alkaloid in betel nuts) - main
  factor which leads to Submucous fibrosis by
• Stimulating fibrogenesis
• Increasing collagen synthesis by fibroblasts
• Decreasing collagen degradation

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• Ingestion of chilies
• Hypersensitivity reaction
• Genetic and immunologic processes
• Increased frequency of HLA - A10, B7 and DR3
• Nutritional deficiencies
• Iron deficiency anemia, vitamin B complex
  deficiency, malnutrition

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• Clinical features
• Symptoms
• Oral pain and burning sensation upon consumption
  of spicy foodstuffs
• Dryness of mouth /Change in gustatory sensation
• Impaired mouth movements (eating, blowing)
• Progressive inability to open the mouth (trismus)
  
• Hearing loss (stenosis of the eustachian tubes)
• Nasal intonation of voice

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• Signs
• Stomatitis (Stage 1) erythematous mucosa,
  vesicles, mucosal ulcers / petechia
• Fibrosis (stage 2)
• Blanched rubbery soft palate with decreased
  mobility (stiffness, trismus)
• Blanched and leathery floor of the mouth
  ,blanched and atrophic tonsils ,shrunken budlike
  uvula
• Sequelae (stage 3) Leukoplakia , Speech and
  hearing deficits

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• Treatment

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• Medical Treatment
• 1) Steroids ( Short term improvement )
• Weekly submucosal intralesional injections
  (dexamethasone 4 mg or triamcenolone 40 mg ) for
  6 - 8 wks
• Topical application ( betamethasone cream 0.05
  topically 6 hrly for 3 weeks)
• 2) Hyaluronidase ( Topical/Intralesional)
• Lowers the viscocity of the intercellular cement
  substance and decreases collagen formation
• Steroids and topical hyaluronidase together
  provide better long term results than either
  agent used alone

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• 3) Submucosal administration of aqueous placental
  extract
• Anti-inflammatory , prevents and inhibits
  mucosal damage)
• 4) Intralesional injection of Interferon gamma
  (? Role)
• Immunoregulatory effect
• Antifibrotic cytokine
• 5) Pentoxifylline 400mg 3 times daily for 4-6
  months

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• Surgical
• Indications
• Patients with severe trismus
• Biopsy results revealing dysplastic or neoplastic
  changes

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Procedures

• 1) Simple /laser excision of fibrous bands
• 2) Split thickness skin grafting following
  bilateral temporalis myotomy ,coronoidectomy, or
  resection of the fibrous bands
• 3) Excision of fibrotic tissues and covering the
  defect with fresh human amnion, or buccal fat
  pad (BFP) grafts

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• 4) Surgical excision of bands and submucosal
  placement of fresh human placental graft
• 5) Nasolabial flaps , lingual pedicle flaps,
  platysma myocutaneous flap

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• Aphthous Ulcers

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• Definition
• Typically recurrent round or oval ulcers that
  occur inside the mouth on areas where the skin is
  not tightly bound to the underlying bone (e.g. on
  the inside of the lips and cheeks or underneath
  the tongue)
• Clinical types
• Minor aphthous ulcers (80 )
• Major aphthous ulcers
• Herpetiform ulcers

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Predisposing factors

• Hematinic deficiency (20 )
• Iron, folic acid, or vitamin B
• Malabsorption in gastrointestinal disorders
• Celiac disease, Crohns disease, pernicious
  anemia
• Stress (Exacerbate during school or university
  examination times)

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• Trauma
• Biting of the mucosa and wearing of dental
  appliances
• Endocrine factors
• Related to the progesterone level
• Food allergies
• Immune deficiencies
• HIV and other immune defects
• Drugs eg NSAIDs

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Minor aphthae Major aphthae Herpetiform ulcers
Age of onset Childhood/adolescent Childhood/adolescent Young adults
Ulcer size 2-4 mm gt10mm Tiny, coalesce
Number Up to six Mainly solitary 10-100
Sites affected Vestibule, labial ,buccal mucosa, FOM Any site Any site but often ventrum of tongue
Duration of each ulcer Up to ten days Up to one month Up to one month
Others ------------ May heal with scarring Affect mainly women
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• Features
• Single or multiple ulcers
• ( 2-10 mm diameter) lasting for
• a few weeks
• Yellow base and circumscribed erythematous
  margins without induration
• Each ulcer heals in about 10 days - frequency
  variable

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• Diagnosis
• History and clinical features
• Exclude systemic disorders
• Complete blood count
• Iron studies (usually an assay of serum ferritin
  levels)
• Red blood cell folate assay
• Serum vitamin B -12 measurements
• Rarely biopsy

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• Treatment
• Goal
• -Relief of pain and reduction of ulcer duration
• General measures
• - Identify and correct predisposing factors
• - Avoid eating particularly hard or sharp food
• - Correct iron or vitamin deficiency

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• Topical corticosteroids Mainstay of treatment
• Reduce painful symptoms but not the rate of ulcer
  recurrence 
• Hydrocortisone, triamcenolone, prednisolone
• Betamethasone, fluticasone, clobetasol - more
  potent and effective
• Betamethasone (0.5 mg tablet) dissolved in 15 ml
  of water as mouth rinse, used 4 times daily
• Systemic corticosteroids

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• Topical antibiotics
• Reduce the severity of ulceration
• Doxycycline 100 mg or tetracycline 500 mg in 10
  ml of water as a mouth rinse for 3 minutes 4
  times daily
• Chlorhexidine gluconate mouth rinses
• Anti-inflammatory agents
• Benzydamine - transient pain relief

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• Systemic immunomodulators
• Thalidomide 50-100 mg daily
• Other medications
• Sucralfate, diclofenac, aspirin
• Transfer factor, gamma-globulin therapy, dapsone,
  colchicine, pentoxifylline, prednisolone

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• Leukoplakia

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• Definition
• Oral white lesions that cannot be clinically or
  pathologically characterized by any specific
  disease
• Propensity for malignant transformation (10 -20
  )
• Sites
• Buccal mucosa ( occlusal lines), alveolar mucosa,
  tongue, lips, palate, floor of mouth, gingiva

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• Causes
• Irritation from rough teeth, fillings, or crowns,
  or ill-fitting dentures that rub against the
  cheek or gum
• Chronic smoking, pipe smoking, or other tobacco
  use
• Sun exposure to the lips
• Oral cancer (rare)
• HIV or AIDS

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• Symptoms White or gray colored patches on
  abovementioned areas. Usually painless, but may
  be sensitive to touch, heat, spicy foods, or
  other irritation
• Investigations
• Orascreen - helps to identify malignancy from
  areas of dysplasia
• Biopsy from most active part

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• Treatment
• Supplementation with 150,000 IU of beta-carotene
  twice per week for six months
• Vitamin E (alpha - tocopherol ) and C
• Retinoids derivatives of vitamin A
• Bleomycin
• Complete surgical removal if epithelial
  dysplasia
• Other treatment modalities
• Cryosurgery, laser surgery, photodynamic therapy

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• Oral Candidiasis

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• Infection of oral cavity with Candida albicans
• Commensal in mouth of many patients
• Pathogenesis
• General debilitating diseases ( DM, AIDS )
• Prolonged antibiotic therapy
• Anticancer chemotherapy
• Prolonged use of steroids

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Types

• Acute
• Multiple small white patches on the oral mucosa
  which when wiped off leave erythematous patches
• Quite painful, seen particularly in buccal mucosa
  and soft palate
• Chronic
• White lesion, cannot be rubbed off, widespread
• Buccal mucosa just inside the corner of mouth

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• Diagnosis
• KOH mount
• Staining with PAS
• Fungal culture
• Treatment
• Local application of nystatin, clotrimazole,
  amphotericin
• Systemic antifungals eg. Ketoconazole ( chronic)
• Excision of patch
• Correction of underlying cause

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• Vincents Angina

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• Infection of oral cavity with
• spirochete (Borrelia vincenti) and
• anaerobic organism ( Bacillus fusiformis)
• Occurs in debilitated individuals and those with
  poor dental hygiene
• Gingivitis affecting interdental papillae
  producing ulceration and necrotic membrane,
  tonsils and oropharynx may also be involved
• Painful lesions associated with fetor, cervical
  lymphadenopathy and fever

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• Diagnosis
• Smear stained with Gentian violet to identify the
  spirochete and Fusiform bacilli
• Treatment
• Local Antiseptic mouthwashes
• Systemic Benzyl penicillin and metronidazole
  ( oral or parenteral)