CLINICAL ORAL PATHOLOGY for Dentist

PATHOLOGY AND ORAL DISEASE


I. CLINICAL ORAL PATHOLOGY:

The structures of the jaws, mouth, tongue and throat reflect the disease conditions manifested by

the systemic human whole: Be aware that the mouth and tongue are windows, indicators to the

status of systemic function of the human body.

a. Anemia is often heralded by “Burning Tongue Syndrome”

b. Aphthous ulcers “canker sores” are the first signs of the onset of female hormones and

menses in 10-11-12 year old girls.

c. Liver dysfunction will manifest clinically as a buccal mucosa “lichenoid” reaction mimicking

Oral Lichen Planus (OLP).

d. Cyclosporin, Procardia, Cardizem and Dilantin medications will cause the development of

gingival first sign of the hyperplasia (which may result in a recurring $5000.00 periodontal

surgery bill.)

e. The first clinical signs of AIDS are oral thrush, oral herpes and White hairy leukoplakia.

(a CBC would reveal a CD4 count of 200 to 500).

f. Systemic fevers will lead to “fever blisters” and viral colds will lead to “cold sores”

g. Oral ulcerations are the onset of Chron’s Disease, ulcerative colitis, and irritable

bowel syndromes.

There are over three hundred different disease entities of the oral cavity. Regardless of etiology,

the mouth manifests clinical pathology in consistent sets of clinical patterns: ulcers, keratosis,

swelling, vesicles or combinations of the listed. Radiographic manifestations will be fractures,

radioluecencies and radiopacities.

KEY POINTS:

a. A patient with significant (and potentially live threatening) oral infections will often have a

normal CBC.

b. The most important radiograph an MD can request to assist the DDS/BDS is a panorex

radiograph. Labs are: CBC, SMAC, INR, and Vitamins.

c. The panorex will show all sinus, maxillary bones, mandibular bones, zygoma, and part of

the cervical vertebral column.

Dentistry is a system of health care with 10 specialties. BDS/DDS doctors provide care through oral

and maxillofacial surgery, periodontal surgery, oral medicine, hospital dentistry, oral and

maxillofacial pathology, maxillofacial prosthodontics for craniofacial defects, root canal care

(endodontics), public health, and general dentistry. If you remain on hospital staff and or enter

private practice get to know the dental staff and several dental doctors.

II. CURRENT TRENDS:

The American Academy of Periodontology has reclassified the disease entities in the Oral Cavity

(see Armitage paper). Be aware that the BDS/DDS will be treating over 300 types of disease

conditions and may need to consult with you to the medical ramifications of some of the

conditions.

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FUNDAMENTALLY, the two primary factors that contribute to oral disease are SMOKING AND

DIABETES followed by medications, stress and genetics.


III. DISEASES GROUPINGS:

A. VIRAL: (“fever blisters, cold sores”),

Acute Herpetic Gingivostomatitis: acute herpetic gingivostomatitis with oral mucosal ulcers.

MICRO: HSV1 or HSV2 virus

TX: Anti-viral medications.

Chicken pox- This facial view shows a child with chicken pox, which is caused by the varicella

virus.

HX: usually self-limiting in children, forms Herpes Zoster in adult (shingles).

MICRO: VZV (Varicella zoster virus) causes chicken pox and is related to Herpes.

TX: Anti-virals PRN.

Condyloma- This slide shows a condyloma in a 6-year-old child.

MICRO: HPV (human papilloma virus).

TX: anti-viral creams, chryotherapy. Do not use lasers.

Coxsackie viruses Infection (Herpangina)-Vesicles arepresent on the soft palate.

MICRO: a Picornovirus (not Herpes) called Coxsackie virus

TX: Supportive

Hairy leukoplakia- This is a condition that characteristically involves the lateral borders of the

tongue. It is seen almost exclusively in human immunodeficiency disease (HIV)-seropositive

patients.

MICRO: Epstein-Barr virus was found in the lesion.

TX: Antiviral therapy. HIV.

Mononucleosis- This disease is caused by the Epstein-Barr virus. Oral mucosal petechiae

are sometimes seen in patients with mononucleosis.

MICRO: EBV

TX: supportive

B. HORMONAL

Necrotizing Periodontal Diseases

Clinical picture showing punched out papillae, which are characteristic of this gingival condition.

HX: Smoking, elevated cortico-steroids from physical/mental stress, poor oral hygiene.

MICRO: Spirochetes, bacteroides

TX: RP and S, antibiotics, smoking cessation, stress reduction, life style changes.

ANUG-Clinical picture of the posterior area.

Pregnancy tumor-A tumor that is histologically the same as a pyogenic granuloma and is a

reactive inflammatory lesion. This patient exhibits a pregnancy tumor on the tongue.

TX: Treat, as needed, ideal therapy after lactation has ceased.

Recurrent Aphthous Ulcers (RUA)- These ulcerations are characteristic of recurrent aphthous

stomatitis.

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C. FUNGAL

Angular chelitis- This condition is most often bilateral. The ulcerated, crusted, erythematous

area of the right commissure is most often caused by Candid.

MICRO: Candidiasis

TX: Anti-fungal , Diflucan, Nystantin,

Black Hairy Tongue- This condition is characterized by the elongation of the filiform papillae,

which affects the dorsal surface of the tongue anterior to the circumvallate papillae. This clinical

picture shows the black to brown discoloration caused by chromogenic bacteria.

MICRO: often fungus overgrowth.

TX: Tongue brushing, increased oral hygiene, anti-fungal prn.

Papillary hyperplasia- This condition is also referred to as pseudopapillomatosis. It results from

irritation to the palate from an ill-fitting denture. This clinical view shows glistening red papillary

projections.

MICRO: Usually Candida

TX: new denture (?), anti-fungals. Thrush

D. BACTERIAL:

Chancre- The lesion of primary syphilis of the tongue and secondary syphilis of the hands and

palate.

HX: Syphilis remains a significant infectious disease.

MICRO: Treponema pallidum

TX: Antibiotics

FISTULA- (also parulis or sinus tract):-GingivitisPeriodontitisTB-Solitary painless ulcer on top of tongue.

HX: Bacterium

TX: Antibiotics

E. DERMATOLOGICAL:

Allergy- This condition consists of a hypersensitive reaction acquired through exposure to a

particular allergen. This series shows edema of the gingival ( do to toothpastes), eyelids

(associated with an allergic reactions to a cat and clinical picture of the lips showing edema that

resulted from penicillin allergy.

Chemical burns- This condition occurs when an exogenous chemical (aspirin, Clorox,

nitroglycerin) is placed again on the mucosal tissues. The chemical causes sloughing and

necrosis of the epithelial tissue. In this clinical picture, the white area on the buccal mucosa

resulted from an aspirin that was placed in the area.

TX: remove aspirin.

Erythema multiforme- This condition affects the skin and oral tissues. Skin lesions have a

characteristic "bull's-eye" or target appearance. This clinical view shows erythema multiforme on

the hand. Oral clinical characteristics of this condition include crusting and ulceration of the lips

and ulceration and erythema to varying degrees on the mucosal tissues involved. This clinical

picture shows erythema multiforme affecting the lips and buccal mucosa.

Geographic tongue(migratory glossitis, oral psoriasis)-In this patient, the dorsal and lateral

borders of the tongue are affected. Red patches are seen as a result of a lack of filiform papillae,

and these patches are surrounded by a yellow or white border. When the filiform papillae

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regenerate, the area returns to normal. However, another area will begin to break down, and the

filiform papillae will be destroyed.

HX: some authors feel a varient of psoriasis.

TX: palliative.

Lichen planus- This condition commonly affects the mucous membranes (as well as other

tissues! of the oral cavity, and oral lesions can appear prior to the skin eruptions. There are

several forms or types of lichen planus. This patient's buccal mucosa showed a white plaque-like

pattern. The characteristic white, lace-Iike pattern is seen on the buccal mucosa of this patient

with lichen planus is known as Wickham's striae. This patient exhibited erosive lichen affecting

the buccal mucosa and lateral border of the tongue. Low-power microscopic examination reveals

orthokeratotic stratified squamous epithelium covering fibrous connective tissue. The epithelium

exhibits elongated rete ridges, and the inflammatory cells in the connective tissue are located

near the epithelium.

HX: always rule out Hepatitis and liver disease first.

TX: topical steroids

Pemphigoid(benign mucous membrane Pemphigoid- This condition is an autoimmune disease

characterized by sub epithelial bullae formation that affects mucous membranes, including the

oral cavity. It is also referred to as cicatricial pemphigoid, since scarring can result during the

healing process. The appearance of the gingiva here is called desquamative

gingivitis.

TX: Biopsy and steroids.

Pemphigus vulgaris- This is another autoimmune disease; however, in this condition, the

lesions are intraepithelial. Note the ulceration on the mucosa and the inflamed gingiva.

HX; very serious, potentially fatal skin disease.

TX: Biopsy and Oral Medicine or Dermatology.

Recurrent Aphthous Ulcers (RUA)- These ulcerations are characteristic of recurrent aphthous

stomatitis.

F. PHARMACEUTICAL: all pharmaceuticals have oral side

effects in some manner ranging from xerostomia to lichenoid

reactions to hyperplasias.


thanks to

Michael Colvard, DDS, MTS, MS

ASSISTANT PROFESSOR