Benign Mucosal Lesions of the Oral Cavity

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Benign Mucosal Lesions of the Oral Cavity

• Grand Rounds
• 3/2/2006

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Outline

• Case study
• Mucosal lesions
• Ulcerative lesions
• Conclusions

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Case Study

• 33 yo male admitted for throat pain, fever.
  Patient developed a vesiculopapular rash, fever
  as high as 103F, and thick coating on tongue, and
  penile ulcers following one week history of
  fevers and sore throat.
• Physical exam- Crusted lesions over face and
  neck,3 mm tender lesion on upper lip,
  tongue-tender, thick white coating with 2
  erythematous areas on tip, numerous white lesions
  across uvula, hard and soft palate, Neck- No
  lymphadenopathy
• ESR- 44

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Leukoedema
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Leukoedema

• Diffuse, filmy grayish surface with white
  streaks, wrinkles, or milky alteration
• Symmetric, usually involving the buccal mucosa,
  lesser extent labial mucosa
• Normal variation present in the majority of
  black adults, and half of black children
• At rest, opaque appearance. When stretched
  dissipates

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Oral Leukoplakia
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Oral Leukoplakia
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Oral Leukoplakia

• Clinically defined white patch or plaque that has
  been excluded from other disease entities
• Presence of dysplasia, carcinoma in situ, and
  invasive carcinoma from all sites 17-25 (Bouqot
  and Gorlin 1986)
• Etiology- associated with tobacco (smoking,
  smokeless tobacco), areca nut/betel preparations

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Oral Leukoplakia

• May be macular, slightly elevated, ulcerative,
  erosive, speckled, nodular, or verrucous
• Clinical shift in appearance from homogenous to
  heterogenous, speckled, or nodular, a rebiopsy is
  mandatory
• Correlation between increasing levels of
  dysplasia and increases in regional heterogeneity
  or speckled quality

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Proliferative Verrucous Leukoplakia
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Proliferative Verrucous Leukoplakia

• Uncommon variant of leukoplakia
• Multifocal, occurring more in women, and in those
  without the usual risk factors
• Evolution from a thin, flat white patch to
  leathery, then papillary to verrucous
• Development of squamous cell CA in over 70 of
  cases

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Site of Leukoplakia

• Risk of dysplasia/carcinoma higher with floor of
  mouth, ventrolateral tongue, retromolar trigone,
  soft palate than with other oral sites

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Epithelial Dysplasia
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Treatment

• Trial of cessation of offending agent, follow-up
• Guided by microscopic characterization
• Benign, minimally dysplastic- periodic
  observation or elective excision
• Complete excision can be performed with scalpel
  excision, laser ablation, electrocautery, or
  cryoablation
• Chemoprevention

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Oral Hairy Leukoplakia
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Oral hairy leukoplakia

• Asymptomatic, seen with systemic
  immunosuppression
• EBV
• Lateral tongue bilaterally subtle white
  keratotic vertical streaks to thick corrugated
  ridges
• Diagnosis by microscopy and in situ hybridization
• Management includes establishing diagnosis and
  treating immunosuppression

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Oral lichen planus
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Oral lichen planus

• 0.2- 2 population affected
• Usually asymptomatic, reticular from, white
  striaform symmetric lesions in the buccal mucosa
• T-cell lymphocytic reaction to antigenic
  components in the surface epithelial layer
• Other variants plaque, atrophic/erythematous,
  erosive

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Oral lichen planus

• Small risk of squamous cell carcinoma, more
  likely seen in the atrophic or erosive types
• Studies show that dysplasia with lichenoid
  features have significant degree of alleic loss.
  Recommendation is to remove these lesions/follow
  patient closely

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Candidiasis
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Candidiasis

• Opportunistic infection, Candida albicans
• Pseudomembranous (thrush), erythematous,
  atrophic, hyperplastic
• Risk factors Local- topical steroids,
  xerostomia, heavy smoking, denture appliances.
  Systemic- Poorly controlled diabetes mellitus,
  immunosuppression

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Candidiasis

• Symptoms burning, dysgeusia, sensitivity,
  generalized discomfort
• Angular cheilitis, coinfection with staph may be
  present
• Acutely- atrophic red patches or white curd-like
  surface colonies Chronic- denture related form
  confined to area of appliance

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Candidiasis

• Confirmation with KOH smear, tissue PAS or silver
  stains
• Treatment- topical or systemic, polyene,azoles

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Oral ulcerative lesions

• Acute
• Chronic
• Recurrent

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Acute ulcerative

• Bacterial
• Acute necrotizing ulcerative gingivostomatitis
• Poor oral hygiene, Punched-out ulcer
  at interdental papillae, seen in young adults
  with poor nutrition, heavy smoking
• Streptococcal gingivostomatitis
• B hemolytic strep, bright red gingivae
• Oral tuberculosis
• Gonococcal stomatitis

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Syphilis
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Acute ulcerative

• Syphilis
• Congenital syphilis- Hutchinsons incisors,
  moons molars
• Primary-painless, indurated, ulcerated, usually
  involving the lips, tongue
• Secondary- mucous patches, split papules
• Tertiary- Gummas, can involve palate, tongue
• Fungal
• Oral Candidiasis
• Histoplasmosis- disseminated form, oropharyngeal
  lesions may
• present as ulcerative, nodular, or vegetative.
  Biopsy will provide the diagnosis

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Primary Herpetic Gingivostomatitis
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Acute ulcerative

• Viral Infections
• Herpes simplex- 600,000 new cases annually,
  prodrome followed by small vesicles that
  ulcerate, primary infection involves the gingiva,
  and can involve the entire oral cavity
• Recurrent herpes simplex- prodrome present,
• herpes labialis, limited to keratinized
  epithelium and can involve the gingiva and hard
  palate
• Varicella zoster virus- distribution of
  trigeminal nerve
• Coxsackie- prodrome, vesicular, pharynx,tonsils,
  soft palate

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Recurrent herpes simplex
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Erythema Multiforme
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Acute ulcerative

• Erythema multiforme
• Mucocutaneous hypersensitivity reaction
• Etiology- infectious (strong association with
  HHV-1, viral, mycoplasma), drugs (antiseizure
  medications, sulfonamides)
• Clinically- target lesions develop over the skin
  with erythematous periphery and central area that
  can develop bullae, vesicles.

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Erythema Multiforme

• Clinically- Oral mucosa and lips demonstrate
  aphthous like ulcers and occasionally vesicles or
  bullae may be present. Gingiva rarely involved
  common sites include labial mucosa, palate,
  tongue, and buccal mucosa
• Mucosal ulcers are irregular in size and shape,
  tender and covered with fibrinous exudate
• Sialorrhea, pain, odynophagia, dysathria
• Severe EM are associated with involvement of
  other mucosal sites- eyes, genitalia, and less
  common esophagus and lungs

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Erythema Multiforme

• Histopathology- Intense lymphocytic infiltration
  in a perivascular distribution and edema from
  submucosa into the lamina propria, epithelium
  lack antibodies, blood vessels contain fibrin,
  C3, IgM
• Treatment- with oral involvement only can treat
  symptomatically/short course of corticosteroids

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Acute ulcerative

• Lupus erythematosus- chronic discoid and systemic
  lupus erythematosus (SLE) forms
• Discoid type- lip, intraoral lesions, most
  common site is buccal mucosa central depressed,
  red atrophic area surrounded by slightly, raised
  keratotic border
• SLE form- common site posterior hard palate,
  superficial ulcerations that vary in size without
  keratinization of the oral mucosa
• Immunofluorescence shows staining of the
  basement membrane with immunoglobulin, and
  complement

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Acute Ulcerative

• Reiters Syndrome- mainly young men 20 to 30.
  Classis triad of conjunctivitis, arthritis, and
  urethritis. Oral lesions range from erythema to
  papules to ulcerations involving the buccal
  mucosa, gingiva, and lips. Lesions on the tongue
  resemble geographic tongue
• Behcets Syndrome- recurrent oral and genital
  ulcers, athritis, and inflammatory disease of
  eyes and GI tract.

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Acute ulcerative

• Drug reactions
• Barbiturates, salicylates, phenolphthalein,
  quinine, digitalis, griseofulvin, and dilantin

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Chronic Ulcerative
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Chronic ulcerative

• Pemphigus vulgaris- 0.1 to 0.5 patients/100,000
  70 present with upper aerodigestive lesions
• Desmoglein 3 is the pemphigus antigen
• IgG, IgA
• Deposition of antibodies in the intracellular
  spaces produces direct damage to the desmosomes

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Pemphigus vulgaris

• Clinical presentation- ulceration and pain with
  collapse of vesicles
• Lesions extend from gingival margin to alveolar
  margin
• Oropharyngeal lesions favor lateral aspects of
  soft palate to lateral pharyngeal wall
• Lesions heal quickly without scarring
• Treatment- immunosuppression with steroids
  supplemented with azathioprine
• 5 mortality with immunosuppression

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Chronic Ulcerative

• Mucous Membrane (Cicatricial) Pemphigoid
• Autoantibodies directed at molecular components
  of the basement membrane
• Most common Head and Neck sites-
• oral, followed by ocular, nasal, and
  nasopharynx sites
• Ocular scarring- symblepharon, corneal
  opacification, entropion

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Mucous Membrane Pemphigoid

• Diagnosis is with immunofluorescence showing
  linear immune deposits along the basement
  membrane
• Site directed therapy. Oral cavity- topical vs.
  systemic steroids.

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Chronic Ulcerative

• Traumatic (Eosinophilic) Granuloma-
• self-limiting, relatively long duration, deep
  mucosal injury, origin unknown
• Clinical presentation- 5th to 7th decade,
  painful rapid onset, 1 to 2 cm in diameter with
  crater center and firm periphery that is white in
  appearance
• Pathology- deep ulceration extending into
  skeletal muscle, intense, diffuse inflammatory
  infiltrate of histiocytes, endothelial cells, and
  eosinophils
• Treatment- observation, topical or intralesional
  corticosteroids,
• excision if clinical presentation in question

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Major aphthous ulcer
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Recurrent ulcerative

• Recurrent aphthous stomatitis (RAS)
• Frequency range of 20-40 of population,
• most common non-traumatic form of oral
  ulceration
• Data indicates a greater prevalence among those
  in professional groups, higher socioeconomic
  status, and non-smokers

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RAS

• Seen in a variety of conditions
• Crohns disease, Behcets syndrome,
  gluten-sensitive enteropathy, food
  hypersensitivity (nuts, spices, chocolate)
• Certain medications- NSAIDS, B-blockers,
  Kchannel blockers
• Sweets syndrome- acute febrile neutrophilic
  dermatosis
• PFAPA- Periodic fever, aphthous ulcers,
  pharyngitis,
• and adenitis
• Familial variety

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PAS

• Pathogenesis- No sign of vesicle or blistering
  formation
• Lesions over non-keratinizing mucosal surfaces
  (labial, buccal, ventral, and lateral tongue,
  floor of mouth, soft palate, tonsillar pillars)

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RAS

• Classification-
• Minor
• usually anterior portion of oral cavity,
  ulcerative episode 7 to 10 days, no scarring
• Major 1.0 cm deeper, more painful,
  posterior aspect of oral cavity, 6 weeks or
  longer in immunocompromised
• Herpetiform- multiple pinhead-sized, pain
  greater than size of lesion
• Treatment- symptomatic, topical steroids, for
  larger lesions intralesional steroids. Severe-
  short term systemic steroids.

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Case Study

• Prodrome
• Rash present, major aphthous ulcers, genital
  findings
• No eye findings
• No prior history

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Conclusions

• Must rule out dysplasia, squamous cell carcinoma
  with leukoplakia
• Duration of lesion, as well as location help to
  narrow your differential diagnosis
• Biopsy of persistent lesions can help guide
  management

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References

• Cohen, Lawrence. Ulcerative Lesions of the Oral
  Cavity. International Journal of Dermatology
  Sept 1980, 362-373.
• Sciubba, James. Oral Mucosal Lesions. Cummings
  Otolaryngology Head and Neck Surgery.
  Philadelphia, 2005, 1448- 91.