oral mucosal diseases Flashcards
referral to oral med when
ANYTHING the dentist thinks might be cancer or dysplasia
* 2 week Cancer referral pathway for actual malignancies (all potential seen in 14days)
* NICE and SIGN Head & Neck cancers guidelines
Any SYMPTOMATIC lesion that has not responded to standard treatment
* Hospital referral criteria
* SDCEP guidance tx not work
E.g. lichen planus management not worked, pt not experiencing relief, can refer in to hospital
Any BENIGN lesion that the patient can’t be persuaded is not cancer…..
* Oral medicine can see them, as dentist doesn’t think it is cancer (so not cancer department)
Photo sent with referral or emailed when call specialist
oral mucosa epithelium type
stratified squamous epithelium
lamina propria
gross types
* lining, masticatory, gustatory (depend on function)
microscopic
* non-keratinised
* keratinised
orthokeratosis (gingival or palate) or parakeratosis (keratin change due to alteration to standard mucosal type e.g. lichen planus)
strata and components of oral mucosa epithelium
Lamina propria – blood vessels
Basement membrane (basal) – with epithelial progenitor cells
Cells mature and progress up through epithelium, loosing purple staining
Cell well left at surface - keratinised
cell division where
Cell division in basal and suprabasal cells ONLY
* Any mitosis that is not in the basal or suprabasal layers – possible malignancy
3 reactive changes of oral epith
keratosis
* nonkeratined site (parakeratosis)
acanthosis
elongated rete ridges
acanthosis
hyperplasia of stratum spinosum (reactive change - trauma, immunological)
or in response to disease (lichen planus)
elongated rete ridges
hyperplasia of basal cells
5 possible oral mucosa reactions
atrophy
erosion
ulceration
oedema
blister
atrophy
reduction in viable layers (opposite of acanthosis)
erosion
partial thickness loss (due to disease)
ulceration
fibrin on surface, loss of epithelium completely
oedema
intracellular (cells get bigger due to fluid)
intercellular (spongiosis, areas of fluid between epithelial cells)
blister
vesible or bulla (collections of fluid, within or below epithelium)
name depends on size of lesion
age effect on mucsoa
progressive mucosal atrophy
appearance should be normal still (only slightly thinner, like skin)
nutrional def effect on mucosa
iron or B group vitamins
* atrophy
* predisposes to infection
geographic tongue
benign
1-2% of population (less in children)
desquamation- varied pattern and timing
alteration to maturation and replacement of epithelium of tongue
Something else is causing the trouble
* Haematinic deficiency (B12, folate, ferritin)
* Parafunctional trauma
* Dysaesthesia
symptoms of geographic tongue
none
sensitive with acidic/spicy food - intermittent, worse in young
management georgraphic tongue
Eat things that are comfortable for them
* Symptomatic for week than usually settle for a period
Assess whether symptoms occur all of the time (when tongue is normal too) or only when tongue abnormal – get pt to take photo of their tongue when they experience symptoms
black hairy tongue
Hyperplasia of papillae (elongation)
* become stained with food stuffs and Bacterial pigment
* benign, management – remove elongated surface
tongue scraper or peach stone (suck around the mouth for hour a day to gradually wear the surface)
fissured tongue
Unknown cause, changes randomly
Asymptomatic, usually appearance issue
* Deep fissures could trap food/bacteria and cause local inflammation
* Clean fissures with soft brush
Is there another disease process there causing symptoms in fissures?
* Candida
* Lichen planus
glossitis
Inflammation of the tongue
* Does not look normal, so needs further investigation
What investigations are needed?
* Haematinics
* Deficiency - iron
* Fungal cultures
* Biopsy (assess mucosa could be lichen planus)
when to refer swellings
6
- Symptomatic (pain is a feature of salivary gland malignancy! Or area of function)
- Abnormal overlying and surrounding mucosa
- Increasing in size
- ‘rubbery’ consistency
- Trauma from teeth
- Unsightly
when to not refer swellings
3
- Tori (bony)
- Small polyps (more damage to remove than justified)
- Mucoceles – unless they become fixed in size
describe this
tx?
Multiple small swellings in vault of palate, same mucosal covering and colour as rest
Multiple fibrous enlargement due to wearing denture for many years (papillary hyperplasia)
No tx, modify denture impression and construction to prevent problems occurring
describe this
tx?
Fibrous polyp – leaf fibroma (not round protrusive, squashed under denture so thin and elongated)
Remove and allow to heal before new denture to prevent rub and increase in size
describe this
tx?
Fibroepithelial polyp
Mucosal covering same as surrounding, no inflammation around base of lesion (no concern)
Could be left but looks like at size that it would be caught between U+L teeth, trauma will cause enlargement and more trouble
describe this
Small mucocele on palate
Clear, visible but if burst wont be able to see gland which caused it so surgical removal of it not advisable (doesn’t appear fixed?)
describe this
tx?
Parafunctional habit of tongue thrust through teeth cause polyp development on tongue edge
Blocking gap between teeth (happen naturally or use of appliance) will cause area on tongue tip to settle
describe this
tx?
Fixed mucocele, increasing in size and filled with saliva
Remove both extravagated mucosa and associated gland
descirbe this
tx?
Tori – benign, bony swellings
* Associated with parafunctional clenching habits (e.g. TMD pts)
* Can also be asym
Mandibular tori covered by thin mucosa, generally asym,
Bisphosphonate pts more likely to get avascular necrosis of the mucosa over the tori compared to other areas of mandible because blood supply is derived from bone and periosteum rather than arterial supplies of head and neck
* Tori is a risk factor before pt start bisphosphonates
**Removal of tori is not recommended unless specific circumstance **
what is this
pyogenic granuloma
granulation tissue – mixed inflammatory infiltrate on fibro-vascular background
* No epithelial covering
* Appearance - Fibrous yellow or red lesion
* any mucosal site
response to trauma
if Not a granuloma, not pyogenic - other names
* gingiva – aka vascular epulis (most frequent site)
* gingiva, during pregnancy (pregnancy epulis)
