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Grand Rounds
3/2/2006


= áase study
= Mucosal lesions
= Ulcerative lesions
= áonclusions



= 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- árusted 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
   

   

= Ñiffuse, 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

 



 



 


= álinically 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

 


= May be macular, slightly elevated, ulcerative,

erosive, speckled, nodular, or verrucous
= álinical shift in appearance from
homogenous to heterogenous, speckled, or
nodular, a rebiopsy is mandatory
= áorrelation between increasing levels of
dysplasia and increases in regional
heterogeneity or speckled quality
ë 
    


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= 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
= Ñevelopment of squamous cell áA in over
70% of cases
   


= Risk of dysplasia/carcinoma higher with floor

of mouth, ventrolateral tongue, retromolar
trigone, soft palate than with other oral sites
£ 
 


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= *rial of cessation of offending agent, follow-up

= Guided by microscopic characterization
= Benign, minimally dysplastic- periodic observation or
elective excision
= áomplete excision can be performed with scalpel
excision, laser ablation, electrocautery, or
cryoablation
= áhemoprevention


 




 


= Asymptomatic, seen with systemic

immunosuppression
= EBV
= Lateral tongue bilaterally; subtle white keratotic
vertical streaks to thick corrugated ridges
= Ñiagnosis by microscopy and in situ hybridization
= Management includes establishing diagnosis and
treating immunosuppression











= 0.2%- 2% population affected

= Usually asymptomatic, reticular from, white
striaform symmetric lesions in the buccal
mucosa
= *-cell lymphocytic reaction to antigenic
components in the surface epithelial layer
= Other variants: plaque,
atrophic/erythematous, erosive






= 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









= Opportunistic infection, áandida albicans

= Pseudomembranous (thrush), erythematous,
atrophic, hyperplastic
= Risk factors: Local- topical steroids,
xerostomia, heavy smoking, denture
appliances. Systemic- Poorly controlled
diabetes mellitus, immunosuppression





= Symptoms: burning, dysgeusia, sensitivity,

generalized discomfort
= Angular cheilitis, coinfection with staph may
be present
= Acutely- atrophic red patches or white curd-
like surface colonies áhronic- denture
related form confined to area of appliance





= áonfirmation with KOH smear, tissue PAS or

silver stains
= *reatment- topical or systemic,
polyene,azoles

 
  

= Acute
= áhronic
= Recurrent
-  


= 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

-  

= Syphilis
áongenital syphilis- Hutchinson¶s incisors, ³moon¶s molars´
Primary-painless, indurated, ulcerated, usually involving the lips,
tongue
Secondary- mucous patches, split papules
*ertiary- Gummas, can involve palate, tongue
= Fungal
Oral áandidiasis
Histoplasmosis- disseminated form, oropharyngeal lesions may
present as ulcerative, nodular, or vegetative. Biopsy will provide the
diagnosis
ë
  
 

-  


= 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
áoxsackie- prodrome, vesicular, pharynx,tonsils, soft
palate
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£ 
 
-  
 

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

= álinically- 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
£ 
 

= Histopathology- Intense lymphocytic

infiltration in a perivascular distribution and
edema from submucosa into the lamina
propria, epithelium lack antibodies, blood
vessels contain fibrin, á3, IgM
= *reatment- with oral involvement only can
treat symptomatically/short course of
corticosteroids
-  


= Lupus erythematosus- chronic discoid and systemic

lupus erythematosus (SLE) forms
Ñiscoid 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
-  


= Reiter¶s Syndrome- mainly young men 20 to

30. álassis 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
= Behcet¶s Syndrome- recurrent oral and
genital ulcers, athritis, and inflammatory
disease of eyes and GI tract.
-  


= Ñrug reactions
Barbiturates, salicylates, phenolphthalein,
quinine, digitalis, griseofulvin, and dilantin

 


 


= Pemphigus vulgaris- 0.1 to 0.5

patients/100,000; 70% present with upper
aerodigestive lesions
= Ñesmoglein 3 is the pemphigus antigen
= IgG, IgA
= Ñeposition of antibodies in the intracellular
spaces produces direct damage to the
desmosomes
ë  


= álinical 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
= *reatment- immunosuppression with steroids
supplemented with azathioprine
5% mortality with immunosuppression

 


= Mucous Membrane (áicatricial) 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
   

ë 

= Ñiagnosis is with immunofluorescence

showing linear immune deposits along the
basement membrane
= Site directed therapy. Oral cavity- topical vs.
systemic steroids.

 

= *raumatic (Eosinophilic) Granuloma-
self-limiting, relatively long duration, deep mucosal injury, origin
unknown
álinical 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
*reatment- observation, topical or intralesional corticosteroids,
excision if clinical presentation in question

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= Recurrent aphthous stomatitis (RAS)

Frequency range of 20-40% of population,
most common non-traumatic form of oral
ulceration
Ñata indicates a greater prevalence among
those in professional groups, higher
socioeconomic status, and non-smokers
O-

= Seen in a variety of conditions

árohn¶s disease, Behcet¶s syndrome, gluten-sensitive
enteropathy, food hypersensitivity (nuts, spices, chocolate)
áertain medications- NSAIÑS, B-blockers, K+channel blockers
Sweet¶s syndrome- acute febrile neutrophilic dermatosis
PFAPA- Periodic fever, aphthous ulcers, pharyngitis,
and adenitis
Familial variety
ë-

= 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)
O-

= álassification-
Minor <1.0cm, comprise 85% of all ulcers
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
*reatment- symptomatic, topical steroids, for larger lesions
intralesional steroids. Severe- short term systemic steroids.



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

= Must rule out dysplasia, squamous cell

carcinoma with leukoplakia
= Ñuration of lesion, as well as location help to
narrow your differential diagnosis
= Biopsy of persistent lesions can help guide
management
O 


= áohen, Lawrence. Ulcerative Lesions of the

Oral áavity. International Journal of
Ñermatology Sept 1980, 362-373.
Sciubba, James. Oral Mucosal Lesions.
áummings Otolaryngology Head and
Neck Surgery. Philadelphia, 2005, 1448-
91.