Oral Cavity/Salivary Gland Diseases Flashcards
Oral Cavity
- Disorders of the Lip
- Disorders of the Tongue
- Disorders of Buccal and Tongue
Oral Cavity - Disorders of the Lip
- Exfloiatice Cheilitis
- Angular Chelitis
- Actinic Cheilitis
Exfoliative Cheilitis
•facititious cheilitis
– Chronic superficial inflammation of vermilion borders of the lips
– Characterized by persistent scaling
– Attributed to repeated lip sucking, chewing or other manipulation of lips
Angular Cheilitis
– Environmental
– B2 (Riboflavin) deficiency
Actinic Cheilitis
– Premalignant condition due to chronic UVR exposure
– Affects lower lip, initially edematous & erythematous, later atrophic, white, scaly plaque, may obliterate vermillion border
– Ulceration or induration
- biopsy to rule out malignant transformation
Disorders of the Tongue
- Geographic Tingue
- Hairy Tongue
- Oral Chancre (Syphilis)
Geographic Tongue
- Geographic tongue- benign inflammatory condition, due to loss of filiform papillae
- Erythematous plaques with an annular or serpiginous well demarcated white border
- Etiology- psoriasis, Reiter syndrome, atopic dermatitis, diabetes mellitus, anemia, hormonal disturbances, Down syndrome, lithium therapy
Hairy Tongue
- Hairy tongue (white or black hairy tongue) - hypertrophy of filiform papillae resembling hair-like projections
- Associated with - heavy tobacco use, mouth breathing, antibiotic therapy, poor oral hygiene, general debilitation, radiation therapy, chronic use of bismuth containing antacids, lack of dietary roughage
- White, yellow green, brown, or black color is due to chromogenic bacteria or staining from exogenous sources
Oral Chancre: Trepenoma pallidum
- Painless ulceration in primary syphilis
- Highly Contagious
- Represents the site of infection
Disorders of Buccal Tisue and Tongue
- Aphthous Ulcers
- Herpes Simplex Virus
- Oral Candidiasis
Aphthous Ulcers
• Etiology unknown
- runs in the family, starts in childhood/adolescence
- typically resolves in the third decade of life.
- up to 40% affected
• Exclude systemic conditions
- may be associated with immunological disorders [Crohn’s; ulcerative colitis]
- exclude cause due HIV/AIDS, vitamin deficiency states, or drugs [e.g. NSAIDS]
Herpes Simplex Virus
•Primary infection:
- usually caused by HSV-1
- widespread gingivostomatitis
- entire oral mucos red/ blistering
- Concomitant systemic viral symptoms
•Recurrent infection after latency period
- Localized cold sore
- Localized herpetic stomatitis
Oral Candidiasis
- most common oral fungal infection
- Predisposing factors- dry mouth, antimicrobials, corticosteroids, leukemia, HIV inf, tobacco smoking, denture wearing, endocrinopathy
- caused by Candida albicans
- acute pseudomembranous, erythematous, chronic hyperplastic
Oral Candidiasis - Pseudomembranous
- Most common of the 3 forms
- Also called thrush
- Superficial gray – to – white inflammatory membrane
- Scrape off exudate
- underlying erythematous inflammatory base
Oral Candidiasis - Erythematous
- Also known as atrophic form
- Red raw-looking lesion
- Associated with inhaled steroids
- Appears on palate or dorsum of tongue
Oral Candidiasis - Hyperplastic
- Nodular or plaque-like
- White plaque persistent
- Generally involves buccal mucosa on both sides of mouth
Oral Candidiasis Treatment
•Nystatin
-topical use only
•Fluconazole
- azole drug family
- decrease sterol synthesis - inhibit cytochrome P-450 [lanosterol –. ergosterol]
- adverse effect - liver dysfunction
*caspofungin
- echinocandin drugs
- decrease cell wall synthesis - block formation of Beta glycan
- adverse effect - GI upset, flushing due to histamine release
Gingivitis and Periodontal Disease
- Inflammation of the gums
- Manifestations – Redness – Swelling – Bleeding
- Results from bacterial colonization at gum margin
- necrotizing ulcerative gingivitis
- coxsackievirus infections
- herpangina
- hand foot and mouth disease
- acute lymphonodular pharyngitis
Risk Factors for Gingivitis and Periodontal Disease
– Smoking
– Diabetes
– Medications
– Poor nutrition
– Stress
– Illness
– Genetic susceptibility
Necrotizing Ulcerative Gingivitis
• A painful, erythematous gingivitis with necrosis of interdental papillae
– Most likely caused by both a fusiform bacillus and a spirochete (Borrelia vincentii)
– Associated with decreased resistance to infection
• Diagnosis
– Necrosis results in cratering of the interdental papillae.
– Sloughing of necrotic tissue causes a pseudomembrane over the tissue.
• Treatment
– Gentle debridement
– Antibiotics if fever is present
Coxsackievirus Infections
• Causes several different infectious diseases
– May be transmitted by fecal-oral contamination, saliva, and respiratory droplets
• Three have distinctive oral lesions
– Herpangina
– Hand-foot-and-mouth disease
– Acute lymphonodular pharyngitis
Coxsackievirus Infections - Herpangina
• Characterized by fever, malaise, sore throat (odynophagia), and difficult swallowing (dysphagia)
– Includes vesicles on the soft palate
– Erythematous pharyngitis
• Resolves in less than 1 week without treatment
Coxsackievirus Infections - Hand Foot and Mouth Disease
• Usually occurs in epidemics in children less than 5 years old
– Multiple macules or papules occur on the skin, typically on feet, toes, hands, and fingers.
– Oral lesions are painful vesicles that can occur anywhere in the mouth.
• Resolves within 2 weeks
Oral Cancer
- Occurs most often in people over age 45
- Symptoms
– Sore that does not heal
– Lump on lip or mouth
– White or red patch on gum, tongue, or buccal mucosa
– Unusual bleeding, numbness, or pain
•pre-malignant epithelial lesions
- leukoplakia
- erythroplakia
- oral hairy leukoplakia
•SCC
- traditiona;
- HPV
Oral Cancer Symptoms
– Feeling of something caught in the throat
– Difficulty or pain with chewing or swallowing
– Swelling in jaw
– Voice changes
– Pain in ear
Oral Cancer Risk Factors
– Tobacco use
– Chronic and heavy alcohol use
– Sun exposure to lips
– History of leukoplakia
– Erythroplakia: is a clinical term used to describe patches of keratosis. It is visible as adherent white patches on the mucous membranes of the oral cavity
Leukoplakia
- Definition: a whitish patch or plaque that cannot be characterized clinically or pathologically as any other disease, and is not associated with any physical or chemical causative agent, except the use of tobacco.
- Annual transformation rate to SCC of 1%
- Between 5% and 25% of these lesions are premalignant
- Cannot be scraped off
- Can occur anywhere in mouth
- Epidemiology: 40 – 70 years; 2:1 male:female
- 5-25% can progress to squamous cell carcinoma [SCC]
- Use of tobacco a risk factor
Erythroplakia
- Less common than leukoplakia but more serious
- Red velvety lesion level or slightly depressed vs mucosa
- Atypical dysplastic lesion
- Highly prone to progress to SCC
- >90% have dysplasia, carcinoma-in-situ or invasive carcinoma
Oral Hairy Leukoplakia
- Whittish corrugated thickening of mucosa on lateral tongue border
- Occurs almost exclusively in HIV-infected patients
– Probability of developing AIDS is 50% at 16 months and 80% at 30 months in patients with hairy leukoplakia
- EBV present in tissue
- Usually on lateral portion of tongue
- Associated with immuno-compromised patients
- Caused by Epstein-Barr virus [EBV]
- Lesion cannot be scraped off
- Hyperparakeratosis and acanthosis
Squamous Cell Carcinoma
- 95% of head and neck malignancies
- Etiologic factors: smoking alcohol, betel nut chewing, HPV-16/18 infection
- Usually smokers in 60s
- Oral lesion infiltrates locally before metastasizing – cervical lymph node
- 5-year survival <50%
SCC Progression
- Normal
- Hyperplasia/Hyperkeratosis
- Mild/Moderate Dysplasia
- Severe Dysplasia/CIS
- SCC
SCC Risks
- High risk oncogenic HPV 16 and 18
- <50 years
- Cervical lymph node metastasis
- Primary in the oropharynx
- Pathogenesis similar to cervical HPV infection
– Viral inactivation of tumor suppressor genes
Salivary Gland Diseases
- xerostomia
- mucocele
- multiple mucocele
- ranula
- diffuse parotid gland enlargement
- sialadenitis
- Sjogren’s Syndrome
- neoplasms
- pleomorphic adenoma
- Warthin tumor
- mucoeperimoid carcinoma
Xerostomia
- Xerostomia (dry mouth) - decreased saliva production
- Women are twice as affected as men
- Signs and symptoms
- diminished or altered taste and smell, halitosis, heavy plaque accumulation, difficulty in wearing dentures, recurrent yeast infections, burning sensation, difficulty swallowing, dry or cracked lips, salivary calculi and increased thirst
Xerostomia Causes
• Medications
- Antidepressants, antihistamines, diuretics
• Medical conditions
- Parkinson disease, diabetes, anemia, cysticfibrosis, rheumatoid arthritis
• granulomatous inflammation
- tuberculosis, sarcoid, Sjögren syndrome, HIV, amyloid
• Dehydration
- Fever, excessive sweating, vomiting, diarrhea, blood loss, burns, smoking, consumption of tea, coffee
- Radiation therapy of head and neck
- Surgical removal of the salivary glands
- Old Age
Mucocele
e (mucous retention cysts)- benign, painless, dome- shaped fluctuant papules, due to trauma or obstruction of minor salivary gland ducts
Multiple Mucoceles
- graft vs host disease, lichen planus, cicatricial pemphigoid
Ranula
large, bluish, translucent fluctuant mass in the floor of the mouth due to obstruction of the submandibular and or sublingual duct
Diffuse Parotid Gland Enlargement
- acute mononucleosis, HIV infection
Sialadenitis
- Usually affects parotid – parotitis
- From duct obstruction
- From bacterial infection: [staphylococcus or streptococcus]
- From viral infection – mumps; parainfluenza; influenza; coxsackie; EBV; CMV; adenovirus
Submandibular Calculi
• majority of salivary calculi (80% to 95%) occur in the submandibular gland
Sjogren’s Syndrome
- Autoimmune
- Associated with other autoimmune diseases: rheumatoid arthritis; systemic lupus; primary biliary cirrhosis secondary to SS
- Destruction of salivary and lacrimal [tear ducts] glands
- Typical: women 50-60 [women more frequently exhibit immune disorders]
- Glands infiltrated by CD4 T lymphocytes
Sjogren’s Syndrome - Clinical
- Inflammatory joint pain [RA link]
- Keratoconjunctivitis sicca [decrease tears = dry eyes]; with corneal damage
- Xerostomia [decrease saliva = dry mouth
- Symptoms outside glands: arthritis; skin rash; tubule interstitial nephritis
- Complications: tooth decay; mucosa-associated lymphoma [MALT]
- Histopathologic image of focal lymphoid infiltration in the minor salivary gland associated with Sjögren’s syndrome, lip biopsy, H & E stain.
Sjogren’s Syndrome - Pathogenesis
- Glandular cells express high levels of HLA-DR [human leukocyte antigen]
- Antigens present to T-cells
- Cytokines produced
- B-cells also activated
- predispose to lymphoma
- characteristic antibodies: anti-SSA [anti Ro][most specific]; anti-SSB [antiLa]
- Other diagnostic features: tear production and salivary flow rate
Pleomorphic Adenoma
- Benign mixed tumor
- Most common of salivary
- Painless, slow-growing
- Radiation ↑ risk
- Excise due to risk of malignancy over time
- Histologically heterogeneous appearance
- Epithelial [E] components = cells with moderate amount of cytoplasm
- Stromal component [S] = myoepithelial cells
Warthin Tumor
- [papillary cystadenoma lymphomatosum]
- Benign cystic tumor
- Second most common
- Largely parotid location [characteristic]
- Round or oval encapsulated masses
- Mucinous or serous secretions
- Oncocytic cells: abundance of structurally abnormal mitochondria with decreased metabolic function
- Smoking may damage mitochondrial DNA –> abnormalities
A) Low power view with epithelial and lymphoid elements. A follicular germinal center lies beneath the epithelium.
B) Cystic spaces separate lobules of neoplastic epithelium containing a double layer of epithelial cells on a reactive lymphoid stroma.
Mucoepidermoid Carcinoma
- Most common salivary malignancy in adults and children
- Adults most common 35-65
- Radiation = risk factor
- Histology: mucous, epidermoid and intermediate cells [progenitors]
- Low grade:
- Predominantly mucous cells
- Rarely metastasize
- 5-yr survival 90%
•High grade:
- Predominantly epidermoid cells
- Aggressive
- High recurrence
- Metastasize to distant sites
- 5-yr survival 50%
•Translocation of MECT1-MAM2 [11q21; 19p13] >50%
