ORAL DERMATOLOGICAL

CONDITIONS

MODERATOR:Dr.MOHANTYPRESENTER:RAVINDRA.D

Anatomy: Oral cavity

• Oral cavity

o Lipso Tongueo Floor of MouthoBuccal mucosao PalateoRetromolar

trigone

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 of oral cavity

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

1.Aphthous ulcer

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

Rule out HIV & malignancy

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

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

2.Behcet’s syndrome• Uveitis + Aphthous ulcer

+ Genital ulcer

• Oculo – Oro - Genital syndrome

• Treatment : steroid

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

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

TYPES

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

3.Erythematous (atrophic): smooth, red patches

4.Cheilitis: white lesions on angle of mouth

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

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 FEATURES1. 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

STAGES

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

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

5.Oro-labial Herpes simplex infection (cold sore)

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

• Treatment: Acyclovir 200 mg PO 5

times / day X 7 days

Other Bacterial Infections

A-Ulcerated chancre B-Ulcerated mucous patches (snail track ulcers)

C-Gummatous ulcer

Tuberculosis of The Tongue

Syphilis

6.Trauma:CHEEK BITING ILL-FITTING DENTURES

CHEMICAL BURNS ABRASIONS FROM TEETH

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

• 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)

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

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 rupture to form mucosal ulcers

2. Stage of fibrosis (healing): blanching of mucosafibrous bands in oral mucosa,

trismus, deceased soft palate mobility

3. Stage of sequelae: difficult speech, hearing loss,leukoplakia, malignancy (3 - 8 %)

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. Increased intake of fruits &

vegetables

SURGICAL TREATMENT

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

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

9.Leukoplakia

TYPES

1. Homogeneous leukoplakia: smooth,white

2. Nodular leukoplakia: nodular, white

3. Verrucous leukoplakia: warty, white4. Speckled (erythro) leukoplakia: white + red

Malignant potential: speckled >> nodular & verrucous >> homogenous

INVESTIGATIONS

1. Supra-vital staining /

Ora-screen: Toluidine

blue solution stains

areas of malignancy

2. Biopsy: to rule out

malignancy

TREATMENT

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

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

11.Oral lichen planusEtiology: 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

12.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

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.

14.Nicotinic

stomatitis• Seen in pipe smokers & reverse

smokers

• Cobblestone mucosa of postr hard

palate, with red dot in center

• treatment: smoking cessation

Elongated filiform papillae on tongue due to excess keratin formation. Become infected with chromogenic bacteria & look like hairs.

• Etiology: smoking

• Treatment : scraping of tongue

13.Black hairy tongue

15.ORAL CANCER Squamous Cell Carcinoma constitutes 95% of oral cancers

Common in Old Men (50-60 years)

COMMON SITES :

1. Lip (lower lip)2. Tongue (anterior ⅔) 3. Mouth floor4. Tonsil and Fauces AETIOLOGY:1. 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 2. Leukoplakia and Erythroplakia 3. Human papilloma virus (HPV) (type16) 4, Genetic factors may also play a role (deletions in chromosomes 18q, 8p, and 3p are implicated). 5. Exposure to ultra-violet light (cancer of the lip).

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

Uncommon Malignant Tumors of The Oral Cavity

• Malignant melanoma• Lymphomas• Leukemic infiltration• Adenocarcinoma of

minor salivary glands• Sarcomas

Acute Leukemia: gum involvement

JOURNAL PROPER

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.

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 lesion2. Morphology3. Extent of lesion4. Discharge if any5. Margins of lesion6. Floor and base of lesion7. Regional lymphnodes if any

• Investigations done are:

1. Routine blood,urine and stool tests

2. Scrapings,KOH mount3. Tzank test4. Gram stains5. Biopsy for certain

cases.6. Special tests were

done for systemic diseases if indicated

OBSERVATIONS 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

AGE DISTRIBUTION

0--10 11--20 21--30 31--40 41--50 >500

5

10

15

20

25

30

4

1213 13

9 9

4

2022

24

14

6

MALEfemale

AGE IN YEARS

NO

.

OF

PA

TIE

NTS

AGE AND SEX DISTRIBUTION

DISEASES WITH ORAL MANIFESTATIONSDISEASES 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%

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

• 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..

Diseases with oral and cutaneous

manifestationsDISEASES 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%

Pie diagram showing distribution of

lesions

37.33

62.67

ORAL LESIONS

ORAL&CUTANEOUS LESIONS

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.

BIBLIOGRAPHY• INDIAN JOURNAL OF OTOLARYNGOLOGY AND

HEAD &NECK SURGERY(apr-june 2013)• SCOTT&BROWN 6TH EDITION• TEXT BOOK OF DERMATOLOGY BY NEENA KHANNA

• Next academic session:

18-11-13-MONDAY

CASE PRESENTATION BY

Dr.SUSRUTHA

Thank you