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Pathology of the Oral Cavity


oral manifestation of systemic dz: scarlet fever (fiery or white coated tongue w/ hyperemic papillae), measles (spotty exanthema, koplik's spots, ulcerations on buccal mucosa), infectious mononucleosis (pharyngitis/tonsilitis), diptheria (pseudomembrane), HIV (predisposition), pancytopenia, leukemia (like agranulocytosis), monocytic leukemia (enlarged gingiva), melanotic pigmentation (Addisons dz, hemochromatosis, Albright syndrome, Peutz-Jeghers syndrome), dilantin ingestion (fibrous enlargement of gingiva), pregnancy (pyogenic fibroma)

vermillion border = where epidermis meets mucosa, ie the edge of the lip

apthous stomatitis = canker sores of lips & gums, pale w/ red (hyperemic) border, thin exudate, more with celiac, sometimes triggered by hypersentitivity, stress, lauryl sulfate in toothpaste, menstrual cycle hormones, hypochlorhydria, foods such as tomatoes and oranges. NOT HSV.

Behcet's syndrome is an uncommon condition that has painful ulcers resembling apthous ulcers as intial manifestations, later: genital ulcers, iridocyclitis, arthritis, GI problems, males 20-30 more, more in the Mediterranean and Asian pops esp Japan

iridocyclitis = inflam of iris and ciliary body causing pain, photophobia and hazy vision

herpetic stomatitis = cold sores, fever blisters, red-rimmed painful vesicles & ulcers @ vermillion border, etio: HSV 1 & 2, dz of children and young adults, Tzanck test for multinucleated giant cells from fused eosinophilic intranuclear viral inclusions. Lesions accompanied by lymphadenopathy, fever, anorexia, irritability. Reactivated by: injury/trauma, fever, stress, allergies, hormones, UV, heat/cold, URI's, immunosuppression, high arginine/lysine diet, vitamin B deficiencies. Tx: laser light to decrease duration of lesions. Lesions heal in 7-14 days, primary outbreak is worst, keep it away from cornea and fingertips.

herpangina = NOT a herpes infx, rather a vesicular eruption on anterior tonsillar pillars dt coxsackie A virus (hand, foot and mouth dz), self limiting, 7 day course

diptheria = corynebacterium diptheriae, pseudomembrane, gray, removal may cause bleeding, may cause myocardial and neural tissue damage by exotoxin

candida = thrush, superficial curdy white-gray patches that invade, exudate can be scraped off, confirm with KOH, gram stain or culture, normal component of oral flora, overgrows dt abx, chemo, steroids, high sugar intake, common in babies, diabetics and immunosuppressed.

dental caries = cavities, major cause of loss of teeth in persons under 35, mixed bacterial flora (esp strep mutans) -> acidification -> proteolysis -> decalcification of enamel and dentin, risks: acidic saliva, high sucrose/carb diet, xerostomia, heredity. protective: good oral hygienene, good mineral nutrition and fluoride.

dental plaque = polysaccharide matrix derived from foodstuffs (notoriously sucrose) and microbes

calculus = calcified plaque

pulpitis - infx and suppuration inside the tooth, throbbing toothache

gingivitis = inflam of soft tissues around the teeth

chronic gingivitis = edema, redness, change of contours (recession), bleeding, loss of soft tissue adaptation to teeth, deep crevices between gums and teeth (pockets), occurs at any age but most prevalent and severe in adolescence, reversible, progresses to loss of supporting bone (periodonatal dz)

periodontal disease = inflam of periodontal ligaments, alveolar bone, cementum, friable gums, major cause of tooth loss after 35. etio: shift in types and proportions of bacteria along gums, plaques containing anaerobic and microaerophilic gram-negative flora-> calculus ->inflam ->periodentitis. Sequelae: destruction of periodontal ligament and alveolar bone, loosening and loss of teeth. Risk factors: folic acid deficiency, leukemia, DM, scurvy, hyperparathyroidism, endocrine abnormalities, AIDS, Crohns dz, pregnancy, smoking, stress, poor oral hygiene.

necrotizing gingivitis = necrosis of gingival margins and inter-dental papillae, membrane appears grayish, non-contagious, responds to penicillin, etio: weakened immune system or immunocompromise, mitral valve prolapse, strep viridans, common in stressed homeless & alcoholic pops, "trench mouth" in wartime.

bacterial infx of mouth: gonorrhea, syphilis, tuberculosis, actinomycosis, strep viridans

geographic tongue = red areas denuded of papillae (smooth) maplike patterns, etio: unknown

glossitis = beefy red tongue with atrophy of papillae & thinning mucosa, ulcerative lesions usu on lateral borders of tongue, etio: deficiencies of B2, 3, 6, 12, iron, celiac dz, dentures, jagged teeth, Plummer-Vinson or Paterson-Kelly syndrome (Fe deficiency glossitis, webs and esophageal dysphagia), rarely: syphilis, inhalation burns, ingestion of corrosive chems

fissured tongue = cracks in tongue dt inflam, more w/ age, tx: vitamins, CoQ10, tongue brushing

hairy tongue = elongated papillae on dorsum of tongue, colors range yellow to brown to black, may follow abx, "harmless"

hairy leukoplakia = whitish keratotic thickening anywhere in oral mucosa, oft on lateral border of tongue, raised areas that have a feathery of corrugated pattern, cannot be scraped off, may be first sign of HIV, immune compromise, EBV is the cause but Candida may be present

fibrous hyperplasia = irritation fibroma - quasi-tumor at site of repeated injury, fibroblastic defense where you bite yourself, buccal mucosa at bite line or gingival-dental margin, risk: dentures, scrambled teeth

pyogenic granuloma = highly vascular peduncular lesoin usu in gingiva, commonest among pregnant women but also in kids and young adults, red to purple in color, rapid growth, friable, similar to granulation tissue, may regress or undergo fibrous maturation, turning into a peripheral ossifying fibroma

peripheral ossifying fibroma = common growth of the gingiva, red, ulcerated, nodular lesions, may be mistaken for pyogenic granuloma, recurrence rate 15-20%, etio: unknown, peak incidence among young & teen females

peripheral giant cell granuloma = giant cell epulis = common lesion of oral cavity, protrudes from gingiva at sites of chronic inflam, covered by intact mucosa but may be ulcerated, more purplish-blue in color than a pyogenic granuloma, "a striking aggregation of multinucleated foreign body-like giant cells separated by a fibroangiomatous stroma", not encapsulated, readily excised

leukoplakia = white plaque that is not candida or other dz, variable appearance, indistinct or sharp borders, solitary or multiple, slightly thickened or smooth or wrinkled, sometimes corrugated, verrucous, any hyperkeratotic lesion, may look like lichen planus, consider precancerous until proven otherwise, 50% rate of malignant transformation, etio: tobacco esp dip, alco, ill fitting dentures, persistent irritation, HPV, ominous: speckled look on floor of mouth, ventral tongue

erythroplakia = red version of above, less common, red, velvety, poss eroded, becomes SCC, etio: smoking, drinking, etc.

squamous cell carcinoma = most common mouth cancer (95%, adenocarcinoma 5%), EARLY: raised, firm, pearly plaques or irreg rough thickening, LATER can erode to shaggy ulcer with rolled border, may be mixed with leuko/erythroplakia, occurs most at ages 50-70, pts with this at high risk for esophageal, pharyngeal and lung cancers, 90% 5 year survival for (best) lip lesions, 80% for tongue and floor cancers, 19% for late stage, the farther posterior the lesion is, the more aggressive it is likely to be, risks: HSV, HPV, tobacco, marijuana, alcohol, combo of alc and smoking increases risk 100x in women, 38x in men. Sunlight and pipe smoking risk for lower lip. 50% of oropharyngeal cancers harbor oncogenic variants of HPV in base of tongue/tonsils. Infiltrates local LN before metast, then mediastinal LN's, lungs, liver, bones.

oral lichen planus = chornic dz of skin and oral mucosa, white, lacy patches, type IV immune injury to basal cells, on skin: purple pruritic polygonal papules and p...

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