ORAL

DERMATOLOGICAL
CONDITIONS

MODERATOR:Dr.MOHANTY
PRESENTER:RAVINDRA.D

Anatomy: Oral cavity

Oral cavity
o Lips
o Tongue
o Floor of Mouth
o Buccal mucosa
o Palate
o Retromolar
trigone

Common diseases of oral cavity

Sub-mucous fibrosis
Leukoplakia

Aphthous ulcer
Erythroplakia

Oral candidiasis

Oro-labial Herpes

Vincents infection

Infectious mononucleosis

Tongue tie
Ranula

Geographic tongue
Mucocoele

1.Aphthous ulcer

INTRODUCTION

Recurrent, superficial ulcers, with necrotic centre +

red margin, involving movable mucosa of inner
surface of lips, cheeks, tongue & soft palate
Differences from viral ulcer
1. Frequent recurrence
2. Selective involvement of movable mucosa
3. Absence of fever, malaise, lymph node enlargement

1. Minor aphthous ulcer: 2 10 mm in size, multiple,

heal with no scar in 1 - 2 weeks

2. Major aphthous ulcer: 20 40 mm in size, usually single,

heal with scar over months

Rule out HIV & malignancy

3. Herpetiform aphthous ulcer: < 1 mm in size, multiple,

heal with no scar in 1 week

TREATMENT
1. Avoid trigger factors
2. Supplement: vitamin B complex + folic acid + iron
3. Topical gel combination:
a. steroid: triamcinolone
b. antibiotic: chlorhexidine, metronidazole,
benzalkonium, cetalkonium, tannic acid
c. analgesic: benzydamine, choline salicylate
d. anesthetic: lignocaine, benzocaine
4. Mouth rinse: betamethasone, tetracycline
5. Immuno-modulator: thalidomide 50 -100 mg daily

2.Behcets syndrome

Uveitis + Aphthous ulcer + Genital ulcer

Oculo Oro - Genital syndrome

Treatment : steroid

3.Oral candidiasis
Etiology: Infection with Candida albicans
Predisposing factors:
1. Chronic ill-health
2. Uncontrolled diabetes mellitus
3. Acquired immune deficiency syndrome
4. Prolonged use of steroids
5. Prolonged antibiotic therapy
6. Immuno-suppressant therapy (cyclosporine)
7. Anti-cancer chemotherapy

TYPES
1.Chronic hyperplastic: white plaques, cannot be
removed by scraping (Candidal leukoplakia)

2.Pseudo-membranous: loosely adherent white lesions,

can be scraped off leaving red patches

3.Erythematous (atrophic): smooth, red patches

4.Cheilitis: white lesions on angle of mouth

DIAGNOSIS
1. Microscopic exam of wet
smear on KOH mount: look for
pseudo-hyphae
2.

Culture

(Sabouraud

dextrose agar): white colony

TREATMENT
1. Clotrimazole paint, Nystatin
mouthwash
2. Systemic Fluconazole: for
chronic cases
3.

Excision

of

hyperplastic

plaque
4.

Correction

cause

of

underlying

4.Vincents infection (Acute Necrotizing

Ulcerative Gingivitis or Trench mouth)
CLINICAL FEATURES
1. Painful, ulcerative lesions
spirochete Borrelia vincenti
covered by necrotic
membrane present over:
& Gram ve anaerobe
.inter-dental papillae &
spreading toward free gum
Bacillus fusiformis
margins (acute necrotizing
ulcerative gingivitis)
Predisposing factors:
.tonsils (Vincents angina)
Poor general health
2. Halitosis, neck lymph node
enlargement & fever

Etiology: infection with

Poor oro-dental hygiene

Dental caries

STAGES

 Diagnosis
Smear stained with Gentian violet to identify Borrelia
vincenti & Bacillus fusiformis
Treatment
1. Systemic Benzylpenicillin / Erythromycin
2. Systemic Metronidazole / Clindamycin
3. Betadine mouthwash & H2O2 gargle
4. Dental care & bed rest

5.Oro-labial Herpes simplex infection

(cold sore)
Primary Herpes simplex

Seen in children

Oral cavity: multiple vesicles

which later ulcerate
Fever + sore throat
Neck node enlargement
Treatment: Acyclovir 15
mg/kg PO 5 times/d for 7
days

Secondary Herpes simplex

Reactivation of dormant virus in
trigeminal ganglion in adults by
emotional stress, fatigue, infection,
pregnancy, immune-deficiency
Vesicular & ulcerative lesions
primarily affect vermilion border of
lip (Herpes labialis)
Tongue, hard palate & gums also
involved
Treatment: Acyclovir 200 mg PO 5
times / day X 7 days

Other Bacterial Infections

Syphilis

A-Ulcerated chancre

B-Ulcerated mucous
patches (snail track ulcers)

Tuberculosis of
The Tongue

C-Gummatous ulcer

6.Trauma:
CHEEK BITING

ILL-FITTING DENTURES

CHEMICAL BURNS

ABRASIONS FROM TEETH

7.Infectious mononucleosis
(glandular fever)
Caused by Epstein Barr virus
Spreads only by intimate contact
(kissing disease)
C/F: 1. fever, fatigue, malaise
2. pharyngitis, palatal petechiae
3. ulcer-membranous lesions
over tonsils
4. neck lymph node enlargement
5. hepatomegaly & splenomegaly

 INVESTIGATIONS
Total count: leukocytosis
Differential count: lymphocytosis + monocytosis
Peripheral blood smear: atypical lymphocytes
Paul Bunnel test (with sheep RBC): positive
Monospot test (with horse RBC): positive Sensitivity 85%,
specificity 100%
TREATMENT
Symptomatic:Bed rest. Paracetamol for fever
Steroids + tracheostomy for stridor
Valacyclovir (1000 mg BD TID X 7 d) is effective
Avoid aspirin in children - Reye syndrome (fattY liver +
encephalopathy)

8.Submucosal fibrosis
Chronic pre-malignant disease of oral cavity, characterized
by juxta-epithelial inflammation + progressive fibrosis of
lamina propria & deeper connective tissues, followed by
stiffening of mucosa resulting in difficulty in mouth opening
ETIOLOGY (MULTI-FACTORIAL)
1. Areca nut (betel nut) chewing
2. Tobacco & Paan masala chewing
3. Genetic predisposition
4. Auto-immune injury
5. Nutritional deficiency of vitamins,
iron, anti-oxidants
6. Excessive alcohol consumption

PRESENTING SYMPTOMS
Burning pain on consumption of spicy food
Dryness of mouth
Impaired mouth movements while eating & talking
Progressive inability to open the mouth (trismus)
This patient has so much of limitation in opening of mouth
that it is difficult to put even 2 fingers in the mouth
Hearing loss (stenosis of Eustachian tubes)
Nasal intonation (ed soft palate mobility)
STAGES
1. Stage of stomatitis: red mucosa

vesicles rupture to form mucosal ulcers

2. Stage of fibrosis (healing): blanching of mucosafibrous bands in oral mucosa,

trismus, deceased soft palate mobility
3. Stage of sequelae: difficult speech, hearing loss,leukoplakia, malignancy (3 - 8 %)

MEDICAL TREATMENT

SURGICAL TREATMENT

1.

1.

Bi-weekly submucosal intra-

bands + skin grafting

lesional injections of

2. Laser-assisted

Dexamethasone 4 mg +
Hyaluronidase 1500 IU

for

6- 8 wks
2.

Simple release of fibrous

release

of

fibrous bands
3. Excision

of

lesions

&

Submucosal injection of human

reconstruction with:buccal fat

placental extract

pad,

3. Vitamin B complex + anti-oxidant

supplement
4. Increased intake of fruits &
vegetables

naso-labial

flap,lingual

flap, palatal muco-periosteal

flap, radial forearm flap
4. Temporalis muscle myotomy +
mandibular coronoidectomy

9.Leukoplakia
Definition: pre-malignant condition with white patch or plaque that cannot be
rubbed off with gauze swab & cannot be characterized clinically or pathologically
as any other disease
Malignant transformation: 1 - 20% (average 5 %)
Sites: Buccal mucosa, tongue, lips, palate, floor of mouth, gingiva, alveolar mucosa
ETIOLOGY
1. Chronic smoking
2. Chronic tobacco chewing
3. Irritation from jagged teeth or ill-fitting dentures
4. Chronic alcohol consumption
5. Sun exposure to lips
6. Associated with: submucous fibrosis, hyperplastic candidiasis, Plummer-Vinson

syndrome, AIDS

TYPES
1. Homogeneous leukoplakia:
smooth,white

2. Nodular leukoplakia: nodular, white

3. Verrucous leukoplakia: warty, white

Malignant potential:

4. Speckled (erythro) leukoplakia:

white + red

speckled >> nodular & verrucous >> homogenous

TREATMENT

INVESTIGATIONS
1. Supra-vital staining /
Ora-screen: Toluidine
blue solution stains
areas of malignancy
2. Biopsy: to rule out
malignancy

1.

Removal of causative
agent

2. Supplement: Vitamin A
(beta-carotene), C, E, B12,
folic acid.
3. Surgical excision: if HPE
shows dysplasia.
Surgical excision modalities:
cold knife,
cryosurgery, laser surgery

10.Erythroplakia
Definition: pre-malignant condition
with red patch or plaque that cannot
be rubbed off with gauze swab &
cannot be characterized clinically or
pathologically as any other disease
o Red

colour

due

to

vascular

submucosal tissue shining through

under-keratinized mucosa
o Malignant potential: 17 times >
leukoplakia
o Treatment : excision biopsy

11.Oral lichen planus

Etiology: unknown (? hypersensitivity reaction)

Types of oral lichen planus:

SKIN LESIONS: purple, polygonal, pruritic papules

TREATMENT: Reticular & plaque types: no treatment required
Erosive type: topical or systemic steroids

12.Stevens - Johnson
syndrome
ETIOLOGY

Severe form of Erythema

multiforme

Minor form of Toxic Epidermal

Necrolysis involving < 10 % of
body surface area

Idiopathic: 25 - 50 % cases
Drug reaction: Penicillin,
Sulfonamides, Macrolide,
Ciprofloxacin, Phenytoin,
Carbamazepine, Valproate,
Lamotrigine, NSAIDs,
Valdecoxib, Allopurinol

Muco-cutaneous, immune-

Viral infection: herpes simplex,

complexmediated hypersensitivity
HIV, influenza
disorder causing separation of
epidermis from dermis

Malignancy: carcinoma,
lymphoma

Symptomatic Treatment
Airway stability, fluid replacement,
electrolyte correction, wound cared
as burns & pain control
Underlying diseases & infections
treated
Offending drugs must be stopped
Local anesthetics & mouthwashes
for oral lesions
Steroids use is controversial.
Cyclophosphamide, cyclosporine &
I.V. immunoglobulin are used.

13.Black hairy
tongue

Elongated filiform papillae

on tongue due to excess
keratin formation.
Become infected with chromogenic
bacteria & look like hairs.

14.Nicotinic stomatitis

smokers

Etiology: smoking
Treatment : scraping of tongue

Seen in pipe smokers & reverse

Cobblestone mucosa of postr hard

palate, with red dot in center

treatment: smoking cessation

15.ORAL CANCER

Squamous Cell Carcinoma constitutes 95% of oral cancers

Common in Old Men

(50-60 years)

COMMON SITES :

1. Lip (lower lip)

2. Tongue (anterior )
3. Mouth floor
4. Tonsil and Fauces
. AETIOLOGY:
1.

2.
3.
4,
5.

Tobacco and alcohol are the most common associations:

Smokers can have 15-fold greater risk ( than nonsmokers ) of malignancy.
Chewing tobacco and betel nuts are important causes in India and parts of Asia
Leukoplakia and Erythroplakia
Human papilloma virus (HPV) (type16)
Genetic factors may also play a role
(deletions in chromosomes 18q, 8p, and 3p are implicated).
Exposure to ultra-violet light (cancer of the lip).

Squamous cell ca. of lip

Squamous Cell carcinoma of the

Tongue

Uncommon Malignant Tumors of

The Oral Cavity
Malignant melanoma
Lymphomas
Leukemic infiltration
Adenocarcinoma of minor
salivary glands
Sarcomas

Acute Leukemia: gum involvement

JOURNAL PROPER

INTRODUCTION
Very often the oral dermatological conditions
involving oral cavity are misdiagnosed and proper
attention and care is not given.
This study is to sensitize the clinicians to the
prevailing situation of oral dermatological conditions.

MATERIALS & METHODS

A total of 150 cases were

taken up for the study
irrespective of
age,sex,duration of lesions
attending dermatology/ENT
dept. during 1 year period.
The following areas were
taken into consideration:
1. Site of lesion
2. Morphology
3. Extent of lesion
4. Discharge if any
5. Margins of lesion
6. Floor and base of lesion
7. Regional lymphnodes if any

Investigations done are:

1. Routine blood,urine and
stool tests
2. Scrapings,KOH mount
3. Tzank test
4. Gram stains
5. Biopsy for certain
cases.
6. Special tests were
done for systemic
diseases if indicated

OBSERVATIONS

AGE DISTRIBUTION

AGE(yr.)

MALE

FEMALE

TOTAL

% (out of
150)

0-10

5.33%

11-20

12

20

32

21.33%

21-30

13

22

35

23.34%

31-40

13

24

37

24.67%

41-50

14

23

15.33%

>50

15

10.00%

TOTAL

60

90

150

AGE AND SEX DISTRIBUTION

30

NO.

OF

PATIENTS

25
20

20

15
12

10
5

22

13

24

13

MALE

14
9

female
9
6

0
0--10

11--20

AGE IN YEARS

21--30

31--40

41--50

>50

DISEASES WITH ORAL MANIFESTATIONS

DISEASES

NO.OF PATIENTS

% OUT OF 150

Aphthous ulcer

16

28.57%

Oral candidiasis

16.07%

Angular chelitis

10.71%

Oral leukoplakia

7.14%

Fixed drug eruption

7.14%

Squamous cell ca.

5.36%

Fordyce spot

3.57%

Herpes simplex stomatitis

3.57%

Oral sub mucosal fibrosis

10.71%

Mucocele

3.57%

Leukemia

1.79%

Warts

1.79%

Scrotal tongue

1.79%

DISCUSSION

Pt.s having oral diseases presents

with different signs and symptoms
like
Oral pain,soreness,burning,
xerostomia,bleeding, swelling,
change
ofcolour,erosion,crusting,
Ulcers,fissuring
The study has recorded 25 pt.s of
pemphigus vulgaris having both
cutaneous manifestations,
revealing that this is the common
lesion.
The study shows that buccal
mucosa was the most commonly
affected site(68%),followed by
palates(56%),lips(44%),tongue(40
%),labial mucosa(16%).

pemphigus vulgaris

 Collagen diseases form the next common group. Among this

systemic lupus erythematosus is major one, and most of the
lesions are confined to palate.
The study recorded 13 cases of discoid lupus erythematosus,with
lips being the commonest site.
Among the specific cutaneous disorders,16 cases of recurrent
aphthous stomatits have been recorded,with labial mucosa being
common site.,and most common one was minor type.
12 pts of lichen planus were recorded with lip&cheek being
common sites, and common in age group of 20-40.
Infective disorders constitute 10% of study with candidiasis
being common one.common site of involvement is dorsal tongue.
The study also recorded 6 cases of oral submucosal fibrosis with
cheeks(buccal mucosa) being common site.
4 pts of oral leukoplakia have been recorded with buccal mucosa
being common site of involvement.
6 pts of angular stomatitis have been recorded with lesions on
lips and buccal mucosa..

Diseases with oral and cutaneous

manifestations

DISEASES

NO.OF PTS.

% OUT OF 94

Pemphigus vulgaris

25

26.60%

Pemphigus vegetans

2.13%

Stevens Johnson's syndrome

8.15%

Toxix epidermal necrosis

4.26%

Erythema multiforme

1.06%

Discoid lupus erythematosus

13

13.83%

Systemic lupus erythematosus

16

17.02%

Systemic sclerosis

6.38%

Lichen planus

12

12.77%

Vitiligo

6.38%

Pie diagram showing distribution of

lesions

37.33
62.67

ORAL LESIONS
ORAL&CUTANEOUS
LESIONS

CONCLUSIONS
Oral mucous membrane alone may be involved in some
disesases,but it is often missed by clinician.
This can be taken care of by primary health care
providers without going through much sophisticated
investigations and thus early intervention for
patients.

BIBLIOGRAPHY

INDIAN JOURNAL OF OTOLARYNGOLOGY AND

HEAD &NECK SURGERY(apr-june 2013)
SCOTT&BROWN 6TH EDITION
TEXT BOOK OF DERMATOLOGY BY NEENA
KHANNA

 Next academic session:

18-11-13-MONDAY
CASE PRESENTATION BY
Dr.SUSRUTHA

Thank you