Diseases of the oral cavity
Diseases of the oral cavity
Many diseases (systemic, genetic, localized, premalignant, malignant) manifest in the oral cavity. The role of a facial surgical team is to be able to diagnose, treat, or refer the patient to the appropriate specialists accordingly. The mouth and the associated perioral tissues have the great advantage of being an open cavity. This fact gives the opportunity to the clinician to observe any abnormalities during a routine examination. On the other hand, it is extremely important for the patients to seek medical advice whenever they notice something unusual in, or around the oral cavity. It is always better to ask for an expert’s opinion instead of making your own diagnosis or just wait for the lesion to disappear. In the majority of cases, the lesions are not worrisome, and most of them will require simple treatments. In some other cases, care must be taken from the physician to identify the cause of the lesion and refer the patient for a systemic evaluation. It is not rare that the first clinical signs of some systemic diseases may appear within the oral cavity. In those few cases, though, that we are truly dealing with a premalignant or a malignant lesion, early detection and treatment can be life-saving.
During the consultation, your physician will obtain a thorough medical history and a detailed clinical exam will be performed. Your doctor may ask for additional lab tests or radiographic imaging. Sometimes a biopsy must be implemented to the diagnostic workup. Please note that the biopsy is just an additional diagnostic modality and provides the histopathological confirmation of the investigated lesion’s nature. Unlike most people believe, biopsies are not only taken due to a high suspicion of malignancy.
They serve as a great tool in making the correct diagnosis and an evidence-based treatment plan.Making the correct diagnosis is critical. Depending on the type of the lesion the patient may be treated either by surgical intervention, medication, observation, or may be referred to the appropriate medical specialist, if the lesion presents as a manifestation of a systemic disease.
The list of the diseases that may appear in or around the mouth is endless; the detailed explanation of each one is beyond the scope of the information provided on this website.
The management of the benign and malignant conditions related to the oral cavity soft and hard tissues is analyzed at the “Head and Neck Surgical Oncology” chapter.
ORAL MANIFESTATIONS OF SYSTEMIC DISEASES
The presence of a lesion in the mouth may be a sign of a systemic illness. There are hundreds of diseases related to various human body systems that may also present in the oral cavity. The patient must be aware of the fact that sometimes an intraoral finding may not be of a local etiology. Many different entities may cause the same clinical sign. The physician will ask for an extended laboratory and radiographic workup if a systemic disease is suspected. A biopsy may also be performed. The early detection of a systemic disease from an intraoral clinical sign may offer significant benefit to the patient. In some other cases, the diagnosis of these lesions may be useful adjuncts to the clinical diagnosis of a syndrome or a systemic illness. Most of these cases will eventually be referred to a specialist for further individualized management.
1. Systemic Infectious Diseases.
1. Viral infections
1. Herpes Simplex Stomatitis
2. Herpes Zoster
4. Hand Foot Mouth Disease
5. Cytomegalovirus Infection
7. Infectious Mononucleosis
10. Verruca Vulgaris
11. Condyloma Acuminatum
12. Molluscum Contagiosum
13. Focal epithelial hyperplasia
2. Bacterial infections
1. Acute necrotizing gingivitis/stomatitis
2. Scarlet fever
3. Streptococcal stomatitis
3. Fungal infections
4. Protozoal infection
2. Connective tissue & Autoimmune Disorders
1. Sjogren’s Syndrome
2. Systemic Lupus Erythematous (SLE)
5. Behcet’s Syndrome
6. Reiter’s Syndrome
7. Rheumatoid arthritis
8. Polyarteritis Nodusa (PAN)
9. Ehlers-Danlos Syndrome
3. Granulomatous Diseases.
2. Wegner’s Granulomatosis
3. Sweet Syndrome
4. Midline Granuloma
4. Gastrointestinal Diseases.
1. Inflammatory Bowel Disease (Crohn’s & Ulcerative colitis)
2. Gastro-Esophageal Reflux Disease (GERD)
3. Peutz-Jegher’s Syndrome
4. Celiac Disease
5. Chronic Liver Disease
6. Malabsorption Diseases
5. Respiratory Diseases.
1. Chronic obstructive pulmonary Disease
2. Cystic fibrosis
4. Viral upper respiratory infections
7. Pharyngitis & Tonsillitis
6. Hematological Diseases.
1. Iron Deficiency Anaemia
2. Sickle Cell Anaemia
3. Pernicious Anaemia
3. Langerhans Cell Histiocytosis
4. Osler-Weber-Rendu Disease (HHT)
5. Plummer-Vinson Syndrome
8. Myelodysplastic Syndrome
9. Cyclic Neutropenia
10. Idiopathic Thrombocytopenic Purpura
11. Multiple Myeloma
7. Endocrine Diseases.
1. Diabetes Mellitus
2. Thyroid Disorders
3. Cushing’s Disease
4. Addison’s Disease
8. Neurological Diseases.
1. Paralysis of the hypoglossal nerve
2. Paralysis f the facial nerve
3. Melkersson-Rosenthal Syndrome
9. Nutritional Deficiencies.
1. Vitamin A deficiency
2. Vitamin B3 deficiency
3. Vitamin D deficiency
10. Dermatological Diseases.
1. Lichen Planus
2. Pemphigus Vulgaris
3. Mucous Membrane Pemphigoid
4. Erythema Multiforme
5. Stevens-Jhonson Syndrome
6. Toxic Epidermal Necrolysis
7. Dermatitis herpetiformis
9. Malignant acanthosis nigricans
10. Acrodermatitis enteropathica
11. Metabolic disorders.
2. Lipoid proteinosis
ORAL MANIFESTATIONS OF GENETIC DISEASES
A great variety of genetic disorders may manifest in the oral cavity. The physician must be aware of the different types of clinical signs related to a genetic disease. Most of the times, the clinical evaluation of the lesion corresponds with an already known genetic syndrome or disease. Differential diagnosis must be made though, as many similar clinical signs have different etiologies. The intraoral finding will be treated by the surgical team when necessary. Sometimes no specific treatment for conditions related to genetic diseases is necessary. The surgeon must be collaborating with the other medical specialists involved so that the best possible outcome is obtained for the patient.
1. White sponge nevus
2. Dyskeratosis congenita
3. Papillon-Lefevre syndrome
4. Dyskeratosis follicularis
5. Familial benign pemphigus
6. Epidermolysis bullosa
7. Chondroectodermal dysplasia
9. Osler-Weber-Rendu syndrome
10. Peutz-Jeghers syndrome
11. Tuberous sclerosis
12. Sturge- Weber syndrome
13. Cowen syndrome
14. Cleidocranial dysostosis
15. Jaddssohn-Lewandowski syndrome
16. Idiopathic gingival fibromatosis
17. Ectodermal dysplasia
18. Chondroectodermal dysplasia
19. Oral-facial-digital syndrome
ORAL LESIONS OF TRAUMATIC ORIGIN
Traumatic lesions may be manifested following the direct or chronic contact of a causative factor with the intraoral tissues. A very thorough clinical examination and medical history will aid in the correct diagnosis. Sometimes the traumatic origin of a lesion may not be clear so it may be confused with other similar looking entities. Self-inflicting (fictitious) insults or habitual causes have to be identified. The treatment in most cases is undertaken by the surgical team. It can vary from simple observation until healing, to the need for surgical correction of damaged tissues. It is also important to inform the patient about the mechanism of action of certain causative factors, to avoid similar episodes in the future.
1. Oral lesions caused by mechanical injury.
1. Traumatic ulcer
2. Chronic biting
3. Cotton roll stomatitis
4. Denture stomatitis
5. Palatal papillary hyperplasia
6. Negative pressure hyperplasia
7. Eosinophilic ulcer
8. Traumatic hematoma
9. Epulis fissuratum
10. Trauma due to sexual practices
11. Iatrogenic trauma
2. Oral lesions caused by chemical injuries.
1. Eugenol burn
2. Trichloroacetic acid burn
3. Aspirin burn
4. Alcohol burn
5. Acrylic resign burn
6. Hydrogen peroxide burn
7. Iatrogenic burn
3. Oral lesions caused by thermal injuries.
1. Hot food/liquid associated thermal burn
2. Nicotinic stomatitis
DRUG-INDUCED ORAL REACTIONS
All medications have potentially undesirable effects. Commonly or rarely used drugs for various conditions may be the cause of intraoral reactions. The patient must always be asked to provide the list of current or immediate past medications that were used. Most of the times, discontinuation of the drug will resolve the problems associated with its use. In few cases though, the side effects may be of a permanent nature. The physician has to treat accordingly if the unwanted effect is not reversed, or the medication cannot be stopped or replaced.
1. Gingival hyperplasia (Phenytoin, Nifedipine)
2. Xerostomia (Antiparkinson, Antineoplastics)
3. Dysgeusia-Taste Disorders (Captopril, Penicillamine)
4. Stomatitis (Sulphonamides, Barbiturates)
5. Oral allergic reactions (Ampicillin, Chlorhexidine)
6. Buring mouth syndrome (ACE inhibitors, Penicillin)
7. Aphthous-like ulcers (NSAIDS, B-Blockers)
8. Oral ulceration (Ibuprofen, Tetracycline)
9. Glossitis (Tricyclic antidepressants, NSAIDS)
10. Erythema Multiforte (Sulphonamides, Aspirin)
11. Vesiculo–Bullous Lesions (Naproxen, Penicillamine)
12. Oral Lichenoid Reactions (B-Blockers, Thiazides)
13. Mucosal Pigmentation (Minocycline, Chlorpromazine)
14. Teeth Discoloration (Tetracycline, Minocycline)
15. Black Hairy Tongue (Cephalosporins, Corticosteroids)
16. Oral Mucositis (Cisplatin, 5-fluorouracil)
17. Sialorrhoea (Clozapine, Rivastigmine)
18. Damage to the teeth structure (Phenytoin, Theophylline)
19. Oral Motor Disorders (Fluvoxamine, Promethazine)
20. Halitosis (Nitrates, Cytotoxic Drugs)
21. Oral Infections (Antibiotics, Antineoplastics)
22. Alveolar osteitis (Oral Contraceptives)
23. Angioedema (Penicillin, ACE inhibitors)
22. Cheilitis (Simvastatin, Streptomycin)
24. Osteonecrosis of the jaws (Bisphosphonates, Avastin)
GINGIVAL AND PERIODONTAL DISEASES
In the great majority of cases, the treatment of gum diseases is undertaken by our Dental colleagues. A complete clinical examination of the oral cavity, though, must include the mucosa overlying the jaw bones, as sometimes surgical diseases may also be manifested. When periodontal or gum disease is diagnosed, and the patients are not under routine dental care, we will refer them for a dental consultation to one of our external dental associates.
1. Dental plaque induced gingival diseases
2. Nonplaque induced gingival lesions
3. Chronic Periodontitis
4. Aggressive Periodontitis
5. Necrotizing Periodontal diseases
6. Periodontal abscesses
7. Periodontitis as a manifestation of systemic diseases
8. Periodontitis associated with endodontic lesions
9. Developmental or acquired deformities and conditions
DISEASES OF THE TONGUE
A variety of congenital, developmental or acquired diseases may present on the tongue. The clinician has to evaluate every finding accordingly. It is important to obtain a detailed medical history and perform a thorough clinical examination. As malignancies can be developed on the tongue, each abnormality has to be very carefully evaluated by the surgeon. In cases of functional issues due to its size or mobility, surgical intervention may be able to improve the problem. In other cases, findings may be subject solely to only periodic checks and observation. When systemic diseases manifest on the tongue, collaboration with other specialists is essential.
1. Congenital/Developmental abnormalities of the tongue
9. Lingual thyroid
10. Cleft tongue
11. Median rhomboid glossitis
2. Infectious diseases of the tongue
3. Cystic lesions of the tongue
7. Anterior median
4. Red and white lesions of the tongue
3. Lichen Planus
8. Focal epithelial hyperplasia
5. Fissured tongue
1. Traumatic bite
6. Neoplastic diseases of the tongue
1. Benign Lesions
2. Malignant Lesions
3. Metastatic Lesions
7. Neurologic diseases of the tongue
3. Trigeminal neuralgia
4. Glossopharyngeal neuralgia
7. Tongue thrusting
8. Papillary Changes of the tongue
1. Median rhomboid glossitis
2. Geographic tongue
3. Pernicious anemia
4. Protein deficiency
5. Lichen planus
7. Hairy tongue
8. After antibiotic treatment
9. After steroid treatment
10. Hydrogen peroxide mouthwash
11. Immunosuppressive drugs
13. High fever
DISEASES OF THE LIPS
Alterations of the lip’s color, shape, size and texture, or an observation of any growth should alert the patient to seek medical advice. As it is easy for the patients to notice changes in the lip morphology, early detection of more serious conditions is feasible. Lips’ pathological conditions may be a part of a systemic disease or a localized entity. In any case, the surgical team will undertake all necessary diagnostic and therapeutic actions to solve the problem.
1. Angular cheilitis
2. Actinic cheilitis
3. Exfoliative cheilitis
4. Cheilitis glandularis
5. Cheilitis granulomatosa
6. Contact cheilitis
7. Plasma cell cheilitis
8. Melanotic macule
9. Pyogenic granuloma
10. Herpes labialis
11. Aphthous ulcers
12. Squamous cell carcinoma
SOFT TISSUE ORAL CYSTS
Many cystic lesions of different origin can appear within the oral cavity. The patient may experience a sudden or gradual, localized enlargement within the mouth. In the great majority of cases, these conditions are benign, but they will require some form of surgical treatment. Cystic lesions can be excised under local anesthesia or sedation/general anesthesia, depending on the lesion’s location and size.
3. Lymphoepithelial cyst
4. Dermoid cyst
5. Epidermoid cyst
6. Eruption cyst
7. Nasopalatine duct cyst
8. Gingival cyst
9. Thyroglossal duct cyst
10. Salivary duct cyst
11. Macrocystic lymphatic malformation
12. Anterior medial lingual cyst
ORAL ODONTOGENIC INFECTIONS
A very common problem of the general public is an infection within the oral cavity originating from the teeth. Although most of the times these conditions are treated successfully by our dental colleagues, in some cases the infection can spread to the adjacent tissues and spaces. Furthermore, elderly patients, medically compromised patients, pediatric patients need special consideration when dealing with an infection, as the host response may place a severe load to the body. In our clinic, we treat conditions that have been evaluated as moderate or severe infections requiring surgical intervention and/or hospitalization.
Cases of odontogenic infections which may require surgical management, present with the following signs and symptoms ranging from less important to extremely serious:
Signs of inflammation (swelling, redness, pain, heat) Fever Chills Fatigue Lymphadenopathy Headache Presence of fistulae Difficulty in opening of the mouth Difficulty in breathing Difficulty in swallowing Changes in phonation Salivation Lethargy Decreased level of consciousness Agitation Impaired eye movement Stiff neck Increased rate of respiration
Many factors can contribute to the severity, the clinical appearance and the rapid spread of an odontogenic infection. These factors include the patient's overall health and immune response, the type of the bacteria involved, the failure of the initial antibiotic treatment or dental management and the delay in seeking medical assistance.
The infection can spread to the adjacent anatomic tissues and spaces of the head and neck relative to the site of the initial cause.
The lips The nasolabial fold The lower eyelid The cheek The palate The pterygomandibular space The submasseteric space The infratemporal space The parotid space The submandibular space The submental space The sublingual space The pharyngeal space The retropharyngeal space
Special consideration must be given to a condition called Ludwig’s angina, which is a type of severe, diffuse cellulitis, involving the spaces on the floor of the mouth, the submandibular, submental, and sublingual spaces bilaterally. This condition has an acute onset and develops rapidly, over a short course of hours. The infection spreads involving planes of connective tissue through tissue spaces, normally with virulent and invasive organisms being the causative agents. The majority of cases follow an inadequately managed or neglected odontogenic infection. This condition is a surgical emergency.
Patients with moderate or severe oral infections will require a thorough evaluation and appropriate treatment.
A complete patient history, physical examination, laboratory investigation, radiological investigation, and accurate and appropriate interpretation of findings must be made.
CT scanning is the advanced imaging modality most widely used in the evaluation of facial infections.
When a decision is made to treat an odontogenic infection surgically, the primary goal is to perform surgical drainage, as well as to remove the cause of the infection. Surgical management may range from a simple tooth removal to treatment as complex as a wide incision of the soft tissues overlying the involved spaces. Drainage of accumulated pus and necrotic debris is established with the placement of a surgical drain. Surgical incision and drainage help to decompress the swollen tissues, to remove the toxic purulent material, to facilitate the perfusion of blood, to increase the concentration and effectiveness of the antibiotics and defense factors, and to increase oxygenation of the infected area thus eliminating the population of the bacteria which develop under anaerobic conditions.
A culture of the purulent material is mandatory, as the antibiotic treatment is targeted according to its findings.
The patient is closely monitored to ensure that the clinical signs and symptoms are improving.
The drain is slowly advanced and removed after several days when the purulent material is not evident.
As a general rule, we advise the patients, who have signs and symptoms of an odontogenic infection, to consult their dental professionals initially. Most of the times, the management of a dental infection is achieved with the appropriate dental treatment. In more complicated cases, the dentist decides to treat or refer the patient to a surgical facility for further evaluation and treatment.
In cases where serious clinical signs and symptoms are already present, it is prudent to seek medical advice immediately.
BENIGN NEOPLASMS OF THE ORAL CAVITY
A variety of benign tumors may present in the oral cavity. Most of these tumors are rare and are classified by the tissue of origin. Routine management includes biopsy and histopathological examination of the specimen, followed by surgical excision. If the lesion is small, an excisional biopsy will be performed. These lesions are benign and not life-threatening, but their surgical treatment can sometimes result in loss of soft tissue and/or bone structures, requiring some form of reconstruction.
1. Condyloma acuminatum
2. Eosinophilic granuloma
4. Peripheral ossifying fibroma
10. Traumatic neuroma
11. Verruciform xanthoma
12. Granular cell tumor
13. Fibrous histiocytoma
14. Venous malformation
15. Lymphatic malformation
18. Intradermal nevus
19. Junctional nevus
20. Blue nevus
21. Pleomorphic adenoma
23. Odontogenic tumors
24. Giant cell lesions
25. Fibro osseous lesions
26. Bening nonodontogenic tumors
28. Pyogenic granuloma
31. Verrucous hyperplasia
32. Pregnancy related granuloma
33. Peripheral granuloma
MALIGNANT NEOPLASMS OF THE ORAL CAVITY
Malignant lesions may present within the oral cavity, as in all other parts of the human body. These lesions are the most important entities to be detected, because early intervention plays a key role not only in the overall outcome but also to the effort necessary for their eventual treatment. When a lesion is observed early enough and the treatment process is initiated immediately, then the outcome has a much greater chance to be positive. Additionally, there may be a lesser need for extended excisional procedures, combined with reconstructive surgeries and further additional treatment modalities.
Each case is very carefully evaluated and individualized. All updated treatment protocols regarding head and neck malignancies are implemented. The surgeons will follow what is best accepted by the medical community worldwide for the treatment of each case.
It is the patient’s responsibility, though, to seek medical advice for any abnormal finding within the oral cavity. This will facilitate the overall effort if the finding is proved to be worrisome. It is of paramount importance not to ignore anything that may appear in the mouth without signs of healing after two weeks. A non healing ulcer, any weird looking growth, a swelling that is not subsiding, a whitish or reddish plaque, a lump or a patch, rough spots or crusts, an unexplained bleeding or numbness, a change in the color or the texture of the mucosa, loose teeth with no obvious dental cause, should alert the patient to ask for an expert’s opinion.
The benefit of the fact that the oral cavity is open to observation must be emphasized. Prevention has always been the best approach to fight malignant diseases. Everyone should perform a self-check of the oral cavity once a month, apart from the need of routine dental checks every six months.
1. Malignant epithelial tumors
1. Squamous cell carcinoma
2. Verrucous carcinoma
3. Basaloid squamous cell carcinoma
4. Papillary squamous cell carcinoma
5. Spindle cell carcinoma
6. Acantholytic squamous cell carcinoma
7. Adenosquamous carcinoma
8. Carcinoma cuniculatum
9. Lymphoepithelial carcinoma
2. Malignant salivary gland tumors
1. Acinic cell carcinoma
2. Mucoepidermoid carcinoma
3. Adenoid cystic carcinoma
4. Polymorphous low-grade adenocarcinoma
5. Basal cell adenocarcinoma
6. Epithelial-myoepithelial carcinoma
7. Clear cell carcinoma, not otherwise specified
9. Mucinous adenocarcinoma
10. Oncocytic carcinoma
11. Salivary duct carcinoma
12. Myoepithelial carcinoma
13. Carcinoma ex-pleomorphic adenoma
3. Malignant soft tissue tumors
1. Diffuse large B-cell lymphoma (DLBCL)
2. Mantle cell lymphoma
3. Follicular lymphoma
4. Extranodal marginal zone B-cell lymphoma of MALT type
5. Burkitt lymphoma
6. T-cell lymphoma (including anaplastic large cell lymphoma
7. Extramedullary plasmacytoma
8. Langerhans cell histiocytosis
9. Extramedullary myeloid sarcoma
10. Follicular dendritic cell sarcoma/tumor
11. Mucosal malignant melanoma
12. Metastatic tumors
4. Malignant bone (jaw) tumors
1. Malignant ameloblastoma
2. Ameloblastic carcinoma
3. Peripheral primary intraosseous squamous cell carcinoma
4. Malignant epithelial odontogenic ghost cell tumor
5. Clear cell odontogenic carcinoma
6. Ameloblastic fibrosarcoma
7. Odontogenic Sarcoma
11. Malignant fibrous histiocytoma
15. Secondary (metastatic) bone tumors