Intra-Oral lesions

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Outline

Traumatic
   -Cheek biting/ dentures/ burns/ chemicals 

Infective
 -Viral -HSVI, HSVII, V Zoster, Coxsakie V, 
 -Bacterial- seconadry, Syphillis,
 -Fungi- Candida 

Inflammatory
-Immune-Behcets, Erythema multiforme, Lichen planus, Benign mucous membrane  pemphigoid, Bullous pemphigoid,Pemphigus vulgaris , E Multiforme
-Granulomatous-wegners 

Neoplastic

Idiopathic
-Apthous 

Systemic
  -Chron’s/ vitamine lack, coeliac

I  INFECTIVE

Candida

Definition

Candia infection usually by Candida albicans-yeast like organism 


Aetiology 
Candida Albicans 

Pathophysiology
Local factors-dehydration, sjogrens, XRT, dentures Systemic-reasons for immune suppression, antibiotics, diabetes etc


Clinical
I Acute Thrush (psedo membraneos Candidasis) 
Easily wiped off
Leaves a raw bed
White plaque on mucosal surface

II Acute Atrophic Candidasis 
Acute burning sensation Red patch or diffuse patch Painful
De keratinisation-de papillation-hence atrophic

III Chronic Hyperplastic candidasis 
Resembles leukoplakia ie Cant be rubbed off

IV Angular cheilitis

V Median Rhomboid Glossitis

Treatment

-If non responsive will require biopsy and PAS stain. Need to exclude dysplasia. -Chronic candida infection may lead to cancer development. 

-Remove offending reason ie stop smoking/ stop antibiotic use/ check immune   status etc
-If acute form Nylstatin topically- lozenges/ drops
-If Chronic form Myconazole gel until lesion disappears
-If non responsive try oral fluconazole or itraconazole for at least 2 weeks


-Dentures soak in Chlorexidine

HSV types I and II

Definition
-Primary Infection By a DNA virus 

Aetiology
Herpes -DNA virus types I and II 

Epidemiology
Common, Young
Clinical
Primary
Herpetic gingivostomatitis
Often asymptomatic ie non painful
May be associated with fever, chills, malaise Vesicles-ulcers-crusting
Anywhere in the oral cavity
Diagnosis, clinical, smears, rising titre of antibodies

Secondary Infection
Reactivation of latent virus in 20 – 30% Not associated with systemic symptoms Small vesicles

Treatment
Aciclovir, peniciclovir cream, analgesia

II  INFLAMMATORY/ IMMUNE

Lichen Planus

Definition
Lichen planus is an inflammatory muco-cutaneous condition

Epidemiology
Can occur in the buccal mucosa also finger nails Higher in older ager >40 yrs
F>M 



Aetiology
Inflammatory disorder
T cells attacking the basal layer= autoimmune origin likely 
Papular Plaque-like Atrophic/erosive 

Clinical
Usually asymptomatic
Some ulcerate
If buccal may have restricted mouth opening Bilaterally symmetrical-buccal, lateral tongue Gingiva may have ulceration
Palate-unlikely 

erosive risk of Cancer

Reticula -Common form

Papular

Plaque like- rare

Treatment
Asymptomatic non erosive forms (Reticular)-No treatment 

Symptomatic
If Symptomatic 
Medium potency - Topical corticosteroids Triamcinalone acetonide (0.1% Kenalog in Orabase) Betamethasone valerate (0,05% Betnovate cream) Systemic corticosteroids???? Not usually necessary Prednisone tablets (5mg) 
Erosive- Malignant potential- Excise






III  IDIOPATHIC


Geographic Tongue

Aetiology
unknown
uneven de keratinisation of tongue
may get secondary infection with candida
Hereditary ie allergic cause

Clinical
can be red and painful

Treatment
avoid irritants
miconazole / nylstatin if candida



Apthous Ulcers

Definition-Idiopathic painful reccurent ulcers in the oral cavity

Epidemiology V common (most common ulcer) 

Aetiology
Unknown
Possibilities- Exaggerated response to trauma Infections
Immunologic Gastrointestinal disorders

Haematologic deficiencies 
Hormonal disturbance Stress

Clinical 

• Minor aphthous ulcers
most common, small, round, or oval, and are less than 10 mm across. They look pale yellow, but the area around them may look swollen and red. Only one ulcer may develop, but up to five may appear at the same time. Each ulcer lasts 7-10 days, and then goes without leaving a scar. They are not usually very painful.

• Major aphthous ulcers
 occur in about 1 in 10 cases. They tend to be 10 mm or larger across. Usually only one or two appear at a time. Each ulcer lasts from two weeks to several months, but will heal leaving a scar. They can be very painful and eating may become difficult.

• Herpetiform ulcers
occur in about 1 in 10 cases. These are tiny pinhead-sized ulcers, about 1-2 mm across. Multiple ulcers occur at the same time, but some may join together and form irregular shapes. Each ulcer lasts one week to two months. Despite the name, they have nothing to do with herpes or the herpes virus

Treatment
Analgesia- systemic and topicas Steroids-topical/ systemic Topic tetracycline