DISEASES OF ORAL CAVITY. SYSTEMIC DISEASES - HIV (AIDS) - Leukaemia - Crohn’s disease - Diabetes mellitus - Down syndrome - Sarcoidosis - Chediak Higashi.

DISEASES OF ORAL CAVITY

SYSTEMIC DISEASES

- HIV (AIDS)- Leukaemia - Crohn’s disease- Diabetes mellitus- Down syndrome- Sarcoidosis

- Chediak Higashi syndrome

Normal defense Mechanisms of oral mucosa :

1. Competitive suppression ; by organisms of low virulence

2. Secretory Ig A

3. Other immunoglobulins ; sub mucosal collection of lymphocytes and plasma cells.

4. Antibacterial effect of saliva

5. Irrigation/Cleansing effect of food and drinks

Herpes simplex viral infection

- Type : HSV -1, HSV -2 (genital herpes)- Age : Children 2 -4 years of age - Presentation:

- Usually asymptomatic

- Gingivostomatitis ; abrupt onset of

vesicles/ ulcers

- Fever, anorexia, lymphadenopathy

Gross :- Vesicles ; few mm – large bullae- Filled with clear fluid - Ruptures to form shallow ulcer

Histology :- Intracellular and intercellular edema- Intranuclear inclusions- Multinucleated giant cells

Course of the disease :

- Spontaneous resolution in 3-4 weeks time.

- Remain dormant in the ganglion ; trigeminal

Reactivation:

- Trauma- Allergies- Exposure of UV light- URTI- Pregnancy

- Menstruation

- Extremes of temperature

COMMON SITES OF RECURRENT LESION :

Lips Nasal Orifices Buccal mucosa Gingiva Hard palate

Disorders of the Lips 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 Lips… Angular cheilitis (perleche)

Inflammatory reaction- erythema and maceration at the angles of mouth, fissuring and crusting may be present

Predisposing factors- advanced age, ill-fitting dentures, thumb-sucking in children, oral Candidiasis, bacterial infections

Disorders of the Lips… Cheilitis glandularis

Inflammatory painless enlargement of lower lip, usually in elderly men

Triggered by actinic damage, bacterial infection, tobacco exposure, chronic irritation

Cheilitis glandularis apostematosa Painful enlargement, eversion of lip with erosions

and recurrent bacterial infections or malignant transformation

Disorders of the Lips… Exfoliative cheilitis

(factitious 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

Granulomatous cheilitis (cheilitis granulomatosa) Granulomatous inflammation,

acute onset of asymmetric swelling of the upper lip or lower lip

Erythema, scaling, fissuring and erosions may develop

Prolonged and recurrent course with eventual fixed swelling

May be associated with constitutional symptoms, regional lymph node enlargement

Granulomatous cheilitis

Melkersson-rosenthal syndrome- triad of lingua plicata ( fissured or furrowed tongue), facial paralysis and granulomatous cheilitis

Other cranial nerves (olfactory, auditory, glossopharyngeal, hypoglossal) may be involved

Biopsy- oedema, perivascular lymphocytic infiltrate, focal granulomas resembling sarcoidosis or Crohn’s disease

Disorders of Tongue

Glossodynia (burning mouth syndrome)- spontaneous burning, discomfort, pain, irritation, or rawness of the tongue, has no identifiable etiology most of the time

Etiology- Idiopathic, Infection, Allergic/contact

hypersensitivity, Mechanical trauma Xerostomia, Geographic tongue/ Fissured tongue Vesiculobullous disease, temporomandibular

dysfunction Referred pain from teeth or tonsils Drugs- Antibiotics, psychiatric medications,

chemotherapy

Etiology of Glossodynia

Neurologic Peripheral nerve

damage Diabetic neuropathy Trigeminal neuralgia Acoustic neuroma

Psychiatric Depression Anxiety Cancerophobia Somatoform disorder

Systemic disorders Anemia (iron

deficiency, pernicious) Nutritional deficiency Gastroesophageal

reflux disease Sjogren syndrome Hypothyroidism Acquired

immunodeficiency syndrome

GLOSSITIS: Definition: Inflammation of the tongue Causes: - Vitamin B12 deficiency (Pernicious anemia) - Deficiency of riboflavin, niacin, pyridoxine - Sprue-----Vitamin B deficiency - Iron deficiency anaemia -----Vitamin B

deficiency - Plummer Vinson syndrome; Combination of iron deficiency anemia,

Glossitis and Esophageal dysphagia

OTHER CAUSES:- Carious tooth- Ill - fitting dentures- Syphilis - Inhalation burns- Ingestion of corrosive chemicals

Disorders of Tongue… Glossitis- presents as pain, irritation or burning,

hypogeusia, or dysgeusia Atrophic glossitis

Due to filiform de-papillation Mild patchy erythema to a completely smooth,

atrophic, beefy-red surface Etiology - pernicious anemia, protein and other

nutritional deficiencies, chemical irritants, drug reactions, amyloidosis, sarcoidosis, vesiculobullous diseases, oral candidiasis and systemic infections

Moeller or Hunter glossitis of pernicious anemia affects the lateral aspects and tip of the tongue respectively

- Presentation :

Large beefy tongue- Mechanism:

Atrophy of papillae ----- Thinning of mucosa ---- Exposure of underlying blood vessels.

Disorders of Tongue…

Median rhomboid glossitis - atrophic disorder of the tongue secondary to chronic candidiasis

Disorders of 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

Disorders of Tongue…

Fissured tongue (furrowed tongue, scrotal tongue, grooved tongue)

normal variant seen in 5-11% individuals

Numerous small irregular fissures oriented laterally on the dorsal tongue

Also seen in - Melkersson-Rosenthal syndrome, Psoriasis, Down syndrome, Acromegaly, Sjogren syndrome

Disorders of Tongue…

Herpetic geometric glossitis - rare cause of fissuring of tongue, presents with acute onset of pain and deep longitudinal grooves with smaller lateral fissures

Disorders of 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 exog source

Disorders of Tongue…

Oral hairy leukoplakia- caused by Epstein-Barr virus, presents as asymptomatic, corrugated, white plaques with accentuation of vertical folds along the lateral borders

.Predominantly seen in HIV infection, organ transplant recipients and patients on chemotherapy

Disorders of Tongue…

Macroglossia- congenital or acquired process, tongue is disproportionately large relative to the patient’s jaw size

Difficulty with mastication and speech and accidental tongue biting are common

Differential- Down syndrome, hypothyroidism, Beckwith-Wiedemann syndrome, neurofibromatosis, infection by mycobacteria, filamentous bacteria or fungus, amyloidosis

Disorders of Salivary Glands

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

Causes of xerostomia

Medications - Antidepressants, antihistamines, diuretics Medical conditions - Parkinson disease, diabetes,

anemia, cystic fibrosis, 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

Disorders of Salivary Glands

Mucocele (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

Disorders of Salivary Glands

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

Disorders of Gingiva & Periodontium

Gingivitis - erythema, edema, and blunting of the interdental papillae, without bone loss Predisposing factors - poor oral hygiene, tobacco use,

diabetes Periodontitis -chronic infection of connective tissue,

periodontal ligament and alveolar bone Long-term periodontitis is associated with increased

risk of diabetes, heart disease, stroke and preterm birth

birth control pills, diabetes, steroids, Down syndrome, Langerhans cell histiocytosis, HIV predispose to periodontitis

Juvenile periodontitis is associated with genetic defects in leukocyte chemotaxis

Papillon-Lefevre syndrome - severe and destructive periodontal disease, teeth exfoliation

Disorders of Gingiva & Periodontium

Erosive gingivostomatitis (desquamative gingivitis)- inflammation and erythema of the gingiva, nonspecific reaction pattern, may be due to viral infection, autoimmune, inflammatory and blistering disorders

Lichen planus - painful or asymptomatic lacy white patches, plaques or papules, often with erosions and ulcerations

Lichenoid mucositis - NSAIDS, antihypertensive medications, contact allergy, graft-versus-host disease

GINGIVITIS

- Gingiva: Soft tissue mucosal lining in between the teeth comprising of stratified squamous epithelium.

- Its inflammation is called gingivitis- Pathogenesis :lack of oral hygiene----dental plaque beneath the gumline----mineralisation---- calculus (Tartar)----Release of acidic end product----Inflammation.

Prevalence :Higher in AdolescenceTreatment :

Aimed at prevention of the disease and reducing the accumulation of plaque/ calculus formation :1. Brushing 2. Flossing 3. Regular dental visits4. Maintenance of good oral hygiene

PERIODONTITIS :

- Inflammation of the supporting structures of the teeth

(Periodontal ligament, alveolar bone)

- Severe persistent infection----loss of tooth.

PATHOGENESIS

Poor oral hygiene Shift in bacterial flora; 300 different org Facultative gram positive organism – Healthy

site Anaerobic gram negative microaerophilic

organisms – Diseased site. Actinobacillus, Porphyromonas gingivalis,

Provotella intermedia

Disorders of Gingiva & Periodontium

Acute necrotizing ulcerative gingivitis (trench mouth, vincent disease)

Punched- out ulcers of the interdental papillae, gingival hemorrhage, severe pain, foul odor

Fever and lymphadenopathy are common

Disorders of Gingiva & Periodontium

Precipitating factors- poor oral hygiene, nutritional deficiency, alcohol and tobacco use, Immunosuppression

Etiologic agents- Treponema, Selenomonas, Bacteroides, Prevotella and Borrelia vincentii

Aphthous ulceration

Acute, recurrent, painful ulcers on nonkeratinized mucosa

Most common cause of oral ulcerations Effect up to 40-50 % of the population Ulcers with a gray or yellow pseudomembrane and

erythematous margin Potential triggers - heredity, food and medication allergy,

decreased mucosal barrier integrity, hematologic and immunologic disorders, emotional stress, and trauma

Aphthous Ulcers…..

- Superficial ulceration of oral mucosa - Age : First two decades- Presentation: Extremely painful recurrent

lesion- Gross: single or multiple ,shallow ulcer

surrounded by hyperaemia

HISTOLOGY: - Predominant monuclear cells, scattered

neutrophils

CLINICAL COURSE :- Spontaneous resolution (7-10days)- Persists for weeks

ETIOLOGY : Unknown

TREATMENT : Symptomatic

Aphthous ulcerationMinor aphthae (90 -95 %)

Major aphthae

(5-10%)

Herpetiform ulcers

(1-5%)

Age of onset Childhood or adolescence

Childhood or adolescence

Young adult

Ulcer size 2–4 mm 10 mm or larger Initially tiny, but

ulcers coalesce

Number of ulcers Up to about 6 Up to about 6 10–100

Sites affected Mainly vestibule,

labial, buccal

mucosa &

floor of mouth

Any site Any site but often on ventrum of tongue

Duration of each ulcer

Up to 10 days Up to 1 month Up to 1 month

Aphthous ulceration

Systemic Conditions Associated Hematinic deficiency (up to 20%)- iron, folic acid

or vitamin B12 deficiency Gastrointestinal malabsorption (3%) - Celiac

disease, dermatitis herpetiformis, gluten-sensitive enteropathy, Crohn disease, pernicious anemia

Systemic lupus erythematosus, reactive arthritis HIV Behcet disease PFAPA (periodic fever, aphthous stomatitis,

pharyngitis, and cervical adenitis) MAGIC(mouth and genital ulcers inflam cartil)

Behcet’s disease Major criteria

Oral Aphthae Genital Ulcers

Ocular- Iridocyclitis, Retinal vasculitis,Optic atrophy

CNS lesions- Meningoencephalitis, cerebral infarction, psychosis, cranial nerve palsies, cerebellar and spinal cord lesions

Dermatological Pustules Erythema nodosum

Minor criteria Proteinuria and

haematuria Thrombophlebitis Aneurysms Arthralgias

Non-aphthous erosions & ulcers

Pemphigus vulgaris, paraneoplastic pemphigus, bullous pemphigoid, cicatricial pemphigoid, EB acquisita

Epidermolysis bullosa simplex, junctional EB & dystrophic EB demonstrate the most severe

Discoid and SLE- oral discoid lupus is characterized by “sunburst” erythematous plaques surrounded by white radiating striations

Erythema multiforme and stevens-johnson syndrome/toxic epidermonecrolysis

Non-aphthous erosions & ulcers…

Chronic ulcerative stomatitis - autoimmune mucosal erosive disorder

Resemble erosive LP Direct immunofluorescence- IgG bound to nuclei of

keratinocytes of basal and lower epithelial layers Responsive to Hydroxychloroquine

Iatrogenic mucositis

Complications of systemic chemotherapy and head and neck radiation, occurs due to direct tissue injury of the mucosal epithelium

Disorders of mucosal pigmentation Localized Amalgam, tattoo Ephelis / Naevus Malignant melanoma Kaposi’s sarcoma Peutz–Jegher syndrome Laugier–Hunziker syndrome Melanotic macules

Generalized Racial Localized irritation, e.g. smoking Drugs, e.g. phenothiazines,

antimalarials, minocycline, contraceptives, mephenytoin

Addison’s disease/ Nelson’s syndrome

Ectopic adrenocorticotrophic hormone (e.g. bronchogenic carcinoma)

Albright’s syndrome Haemochromatosis Neurofibromatosis, incontinentia

pigmenti Malignant acanthosis nigricans

DISORDERS OF TEETH

A – INFLAMMATORY LESIONS

CARIES (TOOTH DECAY) : Commonest cause of loss of tooth Focal degradation of tooth structure Pathogenesis :

Impaction of food Bacteria in the oral cavity Fermentation of sugars Acidic metabolic end products Degradation of tooth structure

Processed food containing large amounts of carbohydrates

Incidence declined in most countries; Improved oral hygiene Fluoridation of drinking water

(Flouride + enamel structure flouro apatite resistance to degradation)

Disorders of Teeth

DISORDER FINDINGS

Bulimia Erosion of enamel and loss of dentin

Congenital cytomegalovirus

Yellow dentin and hypoplastic pitted enamel

Congenital erythropoietic porphyria

Erythrodontia of canine teeth and molars and brown discoloration of incisors

Congenital syphilis Hutchinson teeth, mulberry molars

Ectodermal dysplasia Hypodontia/anodontia/microdontia, peg-shaped teeth, supernumerary teeth, enamel defects

Gardner syndrome Supernumerary teeth

Goltz syndrome Anodontia and enamel defects

Disorders of Teeth…

Incontinentia pigmenti Hypodontia, conical-shaped teeth

Lepromatous leprosy Reddening of upper teeth (pink spots) due to infection of dentin

Primary biliary cirrhosis

Green pigment deposits

Sjogren syndrome Caries, increased plaque accumulation, poor oral hygiene

Reflux Erosion of enamel due to repeated exposure to gastric acid

Tetracycline staining Permanent gray discoloration

Tuberous sclerosis Pitted enamel of the permanent teeth

Benign Tumors

Pyogenic granuloma (pregnancy tumor) - an exaggerated, reactive proliferation of granulation and vascular tissue triggered by minor trauma or medication, classically during pregnancy

Pulp polyp- exaggerated reactive proliferation of the dental pulp (neurovascular bundle), results when gross caries destroys the enamel crown

Verruciform xanthoma - minute white or yellow verrucous papules on the gingiva, alveolar mucosa, or hard palate. Foamy, lipid-laden macrophages in biopsy

Mucosal lipomas - present as asymptomatic, soft, yellow nodules on the buccal or vestibular mucosa, tongue, floor of the mouth or lips of middle-aged adults

Benign Tumors…

Traumatic neuroma - occur around mental foramen, alveolar ridge, lip or tongue

Neurofibromas and Schwannomas (neurilemmoma) - on the tongue or buccal mucosa

Sipple syndrome - multiple mucosal neuromas, associated with pheochromocytoma, parafollicular thyroid cysts secreting calcitonin, medullary thyroid carcinoma and opaque nerve fibers on the cornea

Granular cell tumor (Abrikosov tumor) - reactive process of Schwann cell origin, appears on the dorsal tongue as single or multiple asymptomatic firm, ill-defined papule

REACTIVE / TUMOR –LIKE LESIONS:

FIBROUS PROLIFERATIVE LESION1. Irritation Fibroma:- Site: buccal mucosa, gingivo-dental margin- Gross: smooth pink exophytic nodule - Histology: Fibrous tissue nodule covered by squamous

epithelium Few inflammatory cells - Treatment: Surgical excision

Pyogenic granuloma:

Site : Gingiva Age/Sex :Children/young adult; esp pregnant

women (Pregnancy tumor) Gross: Erythematous, haemorrhagic,

exophytic mass showing surface ulceration. Histology :

Highly vascular tissue resembling granulation tissue (? Capillary Hemangioma)

Course of disease:

- Regress completely (especially after pregnancy)

- Fibrous maturation- Peripheral ossifying fibroma

Peripheral ossifying fibroma

- Common reactive lesion - Etiology : unknown ; pyogenic granuloma- Age/Sex : young teenage females - Gross:

Red, ulcerated nodule (like pyogenic granuloma)

- Treatment :- Complete surgical excision upto the

periosteum ; high recurrence rate.

Peripheral giant cell granuloma

- Common lesion - Site : Gingival mucosa- Gross: Bluish purple ulcerated nodule - Histology :

. Numerous multinucleated foreign body type giant cells

. Fibrovascular stroma - Differential diagnosis :

.Central giant cell granuloma

.Brown tumours

Varicosities Asymptomatic, blue, soft nodules on the lips and

ventrolateral tongue Not associated with any known systemic disease Caliber-persistent labial artery - raised pulsatile

tortuous, blue rubbery bleb, appreciation of lateral pulsation is diagnostic

Mucosal hemangiomas - benign vascular tumors of infancy, erythematous or bluish vascular nodules, sometimes with associated thromboses and phleboliths, spontaneous regression usual

Petechiae, ecchymoses, hematomas, and spontaneous gingival hemorrhage in thrombocytopenia, hemolytic anemia, von willebrand disease, anticoagulant therapy

Pre-Malignant Lesions

Leukoplakia - chronic, white, verrucous plaque with histologic atypia Severity linked to the duration and quantity of

tobacco and alcohol use Occur anywhere in the oral cavity; Lip, tongue, or

floor of the mouth Lesions are prone for progression to SCC

Erythroplakia - non-inflammatory erythematous plaque Analagous to intra-oral erythroplasia of Queyrat

or SCC in situ Histology: - severe dysplasia and areas of frank

invasion

Pre-Malignant Lesions…

Submucous fibrosis Generalized white discoloration of oral mucosa with

progressive fibrosis, painful mucosal atrophy and restrictive fibrotic bands

Individuals who chew betel quid, a concoction of tobacco, lime, areca nut and betel leaves

Ultimately leads to trismus, dysphagia and severe xerostomia

5 - 10 % progress to SCC

Malignant Lesions

Squamous cell carcinoma - present as leukoplakia, erythroplakia, erythroleukoplakia, irregular endophytic masses with ulceration or exophytic nodules

- High-risk anatomic sites ; ventrolateral tongue, floor of the mouth, and the vermillion border of the lip

Verrucous carcinoma - locally aggressive SCC in older adults presents as a hyperkeratotic, verrucous, exophytic white mass on the vestibules or mandibular gingiva, floor of the mouth, palate, and lip. Risk factors - smokeless tobacco and infections with HPV( 16 and 18)

Malignant Lesions…

Proliferative verrucous leukoplakia - rare progressive multifocal leukoplakia, with white, hyperkeratotic, verrucous plaques involve large areas of mucosa Women are affected four times as men More than 90 % undergo malignant transformation Smoking is not associated, HPV may be etiologic

factor

Melanoma - irregular pigmented macule, patch or papule on the hard palate or maxillary gingiva in older than 50 years advanced lesions may ulcerate or bleed Breslow depth - most important prognostic factor

Malignant Lesions… Lymphoma : Hodgkin, Non-Hodgkin Lymphoma

(Cutaneous T Cell, and Burkitt lymphoma) - Non-specific, indurated, painless masses

- Burkitt lymphoma is associated with alveolar bone destruction

Langerhans cell histiocytosis - ulcerative gingivitis, periodontitis, ulceration and bony destruction, may be initial or sole manifestation of disease

Multicentric reticulohistiocytosis - flesh-colored to reddish-brown nodules on oral or nasal mucosa, in addition to classic cutaneous lesions and associated arthropathy

Kaposi sarcoma - single or multiple hemorrhagic patches or exophytic nodules, most often on gingiva or palate

Salivary Gland Tumors

Occur most commonly on the palate and on the retromolar pad distal to the third molar

Erythematous papules or ulcerated papules and nodules

Medication-Related Oral Changes

Teeth Discoloration Tetracyclines, Chlorhexidine

Gingiva Swelling Phenytoin, Ciclosporin, Nifedipine, Diltiazem

Dry mouth Tricyclic antidepressants, Phenothiazines,

Antihypertensives, Lithium

Disturbed Taste Metronidazole, Penicillamine

Ulcers Cytotoxic drugs, Non-steroidal anti-inflammatory agents

Lichenoid lesions Non-steroidal anti-inflammatory agents

Mucosa Thrush Broad-spectrum antimicrobials, Corticosteroids

Cytotoxic drugs

Hyper pigmentation Minocydine, antimalarials, clofazimine,

amiodarone, ketoconazole, and zidovudine

Physical and Chemical Trauma

Chronic biting and manipulation of lips in and buccal mucosa in nervous habit- ragged, irregular, white plaque at the site of trauma

Frictional keratosis - thickened white plaque (sharp tooth or overextended denture)

Irritation fibroma - sessile nodule at site of chronic mucosal irritation

Smoker’s palate or nicotine stomatitis - thermal injury to the hard palate of pipe smokers

Appears as a diffusely white palate studded with 2-5mm erythematous umbilicated papules

Physical and Chemical Trauma Epulis fissuratum

Develops beneath poorly fitting dentures, painless, elongated ridges of hypertrophic mucosa along the anterior labial alveolar ridge

Giant cell epulis A reactive hyperplastic proliferation, appears as a deep

red papule on the interdental papillae Many multinucleated giant cells are seen histologically is a

vascular proliferation

Chemical burn

Aspirin burns Mucosa in direct contact with aspirin becomes necrotic

and painful, also with Medications containing phenol Contact stomatitis

Intra-oral erythema, ulceration or a lichenoid mucositis Dental amalgams, Cinnamate, flavorings, food

additives, spices, toothpaste, mouthwash, dental epoxy resins, cosmetic lip products

Oral Manifestations of Viral Infections

Herpes (HHV-l and HHV-2)

Lip edema with erythematous, grouped vesicles, erosions, intra-oral hemorrhagic ulcers. Tongue involvement in immunocompromised patients

Chickenpox (HHV-3) Oral ulcers on palate or buccal mucosa

Herpes zoster (HHV-3) Painful, unilateral, aphthous-like ulcers in second and

third trigeminal nerve branch

Infectious mononucleosis

Epstein-Barr virus (HHV-4)

Exudative tonsillitis, uvular edema, palatal petechiae, and, uncommonly, necrotizing ulcerative gingivitis

Oral hairy leukoplakia

Epstein-Barr virus (HHV-4)

White plaques with prominent vertical folds on lateral tongue> dorsal tongue > buccal mucosa and vestibule in immunocompromised individuals

Congenital Cytomegalovirus

(HHV-5)

Yellow dentin and hypoplastic puffed enamel of the teeth, Aphthous-like ulcers

Roseola infantum (HHV-6)

(exanthem subitum)

Erythematous macules on soft palate

Oral Manifestations of Viral Infections

Kaposi sarcoma HHV-8 Erythematous to violaceous macules on palate,

gingiva, tongue. Evolve into painful, ulcerated nodules

Herpangina

Group A coxsackievirus

Acute onset, 1- to 2-mm erythematous macules on palate and uvula. Lesions vesiculate and ulcerate, leaving painful superficial erosions

Hand-foot-and- mouth

disease (Coxsackie A-l6)

Many small, painful ulcers with surrounding erythema

on the tongue, buccal mucosa, palate

Acute lymphonodular

pharyngitis (Gp A Cox)

White or yellow papules with an erythematous base on uvula, tonsils, oropharynx

Measles (rubeola) Koplik spots - brightly erythematous macules with white

centers on buccal mucosa adjacent to posterior teeth

Rubella (German

measles)

Forschheimer spots—small erythematous macules on

palate

Acute sero-conversion of

HIV

Erythema, ulcerations, and secondary candidiasis

Oral Manifestations of Viral Infections

Squamous papilloma (HPV) Solitary, exophytic, pedunculated, mucosa

colored papule, occurs on the palate or tongue

Verruca vulgaris (HPV) Solitary or clusters of verruciform papules on the

Buccal mucosa, lips, or perioral skin

Condyloma

acuminatum (HPV)

Resemble verruca vulgaris but are larger. Oral

Involvement of the labia, lingual frenum, soft

palate, and gingiva

Focal epithelial

hyperplasia (Heck

disease) (HPV)

Benign, soft, painless 1- to 4-mm papules on the

labial, buccal, or lingual mucosae

Kawasaki disease Beefy red oropharynx, strawberry tongue

(inflammation and papillary enlargement),

severe hemorrhagic cheilitis

Oral Manifestations of bacterial Infections

Scarlet fever (Group B

Streptococcus)

Erythema of hard palate and a white-coated

Tongue with erythematous, edematous,

fungiform papillae. Later the tongue becomes

beefy red (strawberry tongue)

Diphtheria (Corynebacterium

diphtheriae)

Thick, gray pseudomembrane with erythematous

Halo on tonsils, pharynx, gingiva, tongue,

buccal mucosa

Tularemia (Francisella

tularensis)

Painful, necrotic oral ulcers or diffuse stomatitis

Lepromatous leprosy Firm yellow-pink ulcerative nodules (lepromas)

on the palate or tongue. Macroglossia due to

tongue infiltration, Reddening of upper teeth

(pink spots) due to infection of dental pulp

Granuloma inguinale Painful hemorrhagic ulcers or vegetative nodules, Severe scarring

Oral Manifestations of bacterial Infections

Primary syphilis Chancre—painless ulceration with indurated borders

on the lip, tongue, buccal mucosa, or oropharynx with

lymphadenopathy

Secondary

syphilis

Mucous patches—oval plaques on the tongue with a

white or gray pseudomembrane. Split papules, macer-

ated, flat-topped papules at the oral commissures

(condyloma lata). chronic oral ulcerations

Tertiary syphilis Interstitial glossitis with atrophy of filiform

and fungiform papillae and fissuring of the tongue, Pre-malignant leukoplakia, gummas involve palate

Congenital

syphilis

Hutchinson teeth in 50%—peg shaped with crescentic

notches along incisal edge of incisors. Mulberry or Moon’s molars—rounded or crenated occlusal cusps of first molars

Oral Manifestations of fungal Infections

Primary oral Aspergillus

aspergillosis

Necrotic, violaceous ulcerations with black eschar on gingiva and palate

Maxillary sinus Aspergilus aspergillosis

Untreated maxillary infection can progress to necrotic palatal perforation with a yellow and black palatal ulcer and facial edema

Zygomycosis, Mucor and

Rhizopus

black, necrotic palatal ulceration

Histoplasmosis

Blastomycosis

Cryptococcus

Coccidioidomycosis

Para coccidioidomycosis

Chronic verrucous or necrotic mucosal ulceration

Oral Manifestations of fungal Infections Oral candidiasis Acute pseudomembranous, Acute atrophic, Chronic

atrophic, Chronic hyperplastic, Median rhomboid glossitis

Predisposing factors- dry mouth, antimicrobials, corticosteroids, leukaemia, HIV inf, tobacco smoking, denture wearing, endocrinopathy

Oral manifestations of Endocrine disordersPituitary dwarfism Microdontia, Retarded tooth eruption

Congenital hypothyroidism

Macroglossia, Retarded tooth eruption

Gigantism/acromegaly

Spaced teeth, Mandibular prognathism,

Macroglossia, Megadontia

Hyperparathyroidism Bone rarefaction, Brown tumours

Addison’s disease Mucosal hyperpigmentation

Diabetes mellitus Periodontal disease, Xerostomia, Candidiasis,

Sialosis, Lichen planus

Pregnancy Gingivitis, Epulis

Oral manifestations of Liver diseases

Alcoholic cirrhosis Bleeding tendency, Sialosis

Chronic active hepatitis

Lichen planus

Primary biliary cirrhosis

Sjögren’s syndrome, Lichen planus

Hepatitis C Lichen planus, Sjogren’s syndrome

Oral manifestations of Gastrointestinal diseases

Pernicious anaemia Ulcers, Glossitis, Angular stomatitis, Erythema

Any malabsorption Ulcers, Glossitis, Angular stomatitis

Chronic regurgitation Tooth erosion, Halitosis

Crohn’s disease Mucosal tags, Gingival hyperplasia, Cobblestoning

of mucosa, Ulcers, Glossitis, Angular stomatitis

Coeliac disease Ulcers, Glossitis, Angular stomatitis, Dental hypoplasia

Chronic pancreatitis Sialosis

Cystic fibrosis Salivary gland swelling

Gardner’s syndrome

(familial colonic polyposis)

Osteomas

Oral manifestations of Renal diseases

Chronic renal failure

Xerostomia, Halitosis/taste disturbance, Leukoplakia

Dental hypoplasia, Bleeding tendency

Post renal transplant

Infections( herpetic, candidal), Bleeding tendency,

Gingival hyperplasia, Kaposi’s sarcoma

Hairy leukoplakia

Renal rickets

(vitamin D resistant)

Delayed tooth eruption, Dental hypoplasia, Enlarged

pulp

NephroticSyndro Dental hypoplasia

Oral manifestations Haematological diseases

Deficiency of haematinics

(iron, folic acid or vitamin B12)

Burning sensation, Ulcers, Glossitis, Angular stomatitis

Sickle-cell anaemia Jaw deformities, Osteomyelitis

Aplastic anaemia Ulcers, Bleeding tendency

Leukaemia/lymphoma Infections, Ulcers, Bleeding tendency,

purpura, Gingival swelling

Multiple myeloma Bone pain, Tooth mobility, Amyloidosis

Amyloid disease Enlarged tongue, Purpura