1. Common Oral Mucosal Diseases
Wen-Chen Wang, DDS, MS, Ph.D
Assistant professor of Dept. of Oral Pathology, Faculty of Dentistry, College of
Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Head of Dental Dept., Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
E-mail: wcwang@kmu.edu.tw
Wen-Chen Wang

2. Oral mucosa
MUCOUS MEMBRANE
Definition:
-Moist lining of the intestinal tract, nasal passages
and other body cavities that communicate with the
exterior
Oral mucosa:

Oral mucous membrane
Wen-Chen Wang
Ref: Antonio Nanci: Ten Cate’s Oral Histology, Development, structure, and function 6th ed

3. Oral mucosa
STRUCTURE OF ORAL
MUCOSA
B.V.
N.
--Similar to skin
Epithelium………………
..epidermis
* Epithelial ridges, rete pegs
Lamina propria………...
..dermis
Submucosa……………...
..subcutaneous
Wen-Chen Wang
Ref: BJ Orban:Orban’s oral histology and embryology,9th ed.

4. Oral mucosa
FUNCTIONAL CLASSIFICATION
OF ORAL MUCOSA
Keratinized areas
…Masticatory mucosa
 hard palate & gingiva
 vermilion border
Nonkeratinized areas
…Lining or reflecting mucosa
 lip, cheek, alveolar mucosa, vestibular fornix,
mouth floor, soft palate, ventrum of tongue
Specialized mucosa
 dorsum of tongue
Wen-Chen Wang

5. Oral mucosa
FUNCTIONS OF ORAL MUCOSA
 Protection
 Sensation
 Secretion
 Thermal regulation
Wen-Chen Wang

6. METHODS OF ORAL DIAGNOSIS
 History taking
 Inspection
 Oral examination
-Palpation
-Percussion
-Aspiration,
-Auscultation
 Radiographic examination
 Laboratory examination Wen-Chen Wang

7. History Taking
 What, where, when, how
 Chief complaints
 Present illness
 Past medical history
Family history
Social history
Occupational history
Dental history
 Review of symptoms by system
Wen-Chen Wang

8. Chief Complaints
 Pain Bad taste
 Soreness Halitosis
 Burning sensation Parthesia and anesthesia
 Bleeding Recent occlusal problem
 Loose teeth Too much saliva
 Dry mouth Delayed tooth eruption
 Swelling
Wen-Chen Wang

9. Onset and Courses
1. Masses increase in size just before
eating
ex. salivary retention phenomena,
sialolithiasis
2. Slow-growing masses (duration of
months to years)
1) Reactive hyperplasia
2) Chronic infection
3) Cysts
4) Benign tumors Wen-Chen Wang

10. 3. Moderately rapid-growing masses
(weeks to about 2 months)
1) Chronic infection
2) Cysts
3) Malignant tumors
Wen-Chen Wang

11. 4. Rapidly growing masses (hrs to days)
1) Abscess (painful)
2) Infected cyst (painful)
3) Aneurysm
4) Salivary retention phenomena
5) Hematomas
5. Masses with accompanying fever
1) Infections
2) lymphoma, leukemia
Wen-Chen Wang

12. Inspection
 Location
 Contours
 Color
 Surfaces
Wen-Chen Wang

13. Contours
Normal & variation
Color
Masticatory mucosa vs lining
mucosa
Wen-Chen Wang

14. Color
 Normal: pinkish
 Whitish ：Epithelial hyperplasia, Hyperkeratosis
 or dense collagen bundle
 Reddish：atrophic epithelium、vessels dilatation
 or hyperplasia
 Blackish：nevus, tattoo, melanosis
 Yellowish: adipose tissue, glands
 Translucent blue ：reflection of liquid
Wen-Chen Wang

15. Leukoplakia

16. Hemangioma
Wen-Chen Wang

17. Peutz-Jegher’s syndrome

18. Fordyce’s granule

19. Mucocele

20. Betel nut chewer’s mucosa

21. Surfaces
Normal –
smooth & glistening, except dorsal
tongue, rugae & attached gingiva
Wen-Chen Wang

22. Pathologic Mass May Be--
1) Smooth surface
-arises beneath epi, originates from
mesenchyme
ex : benign & early maligant salivary gland tumors,
benign & malig. mesenchymal T.
( fibroma, osteoma, hemangioma,
myoma…), cellulitis, mucocele…
Wen-Chen Wang

23. irritation fibroma
MixedWen-Chen Wang
tumor

24. 2) Rough surface
-except due to
trauma, infection
and maligancy,
originates in the
epithelium
ex: papilloma, VH
V.ca, ulcerative &
exophytic SCC
Ref: NK wood, PW Goaz: Differential diagnosis of oral and maxillofacial lesions 5th ed
Wen-Chen Wang

25. Wen-Chen Wang

26. 3) Sessile or pedunculate
Pyogenic granuloma

27. Palpation
--A third eye of clinical examination
 Anatomic regions & planes involved
 Mobility
 Extent
 Consistency
 Painless, tender or painful
 Unilateral or bilateral
 Solitary or multiple
Wen-Chen Wang

28. Anatomic Regions & Planes Involved
 Locates a firm mass, superficial or deep
 Difficult if swelling or painful
Wen-Chen Wang

29. Mobility
1. free movable
2. fixed to skin but not to the
underlying tissue
3. free movable to the skin but
fixed to the underlying tissue
Wen-Chen Wang

30. 4. bound to both skin or mucosa
and to the underlying tissue
1) fibrosis-after a previous inflammation.
2) malignant- from skin or mucosa invade
to underlying tissue
3) malignant- from deeper tissue invade to
surface epithelium
4) malignant- from loose CT to both the
superficial & the deeper layers
Wen-Chen Wang

31. Extent
 Whether a mass has well defined,
M-D or P-D borders will depend
on :
-Border of the mass
-Consistency of surrounding tissue
-Thickness of overlying tissue
-Sturdiness of underlying tissue
Wen-Chen Wang

32. Consistency
 Fluctuation & emptiability: Fluid contented
lesion
 Soft: vein, loose CT, glandular tissue
 Cheesy: sebaceous cyst, epidermoid cyst
 Rubbery: relaxed muscle, glandular tissue
with capsule, arteries
 Firm: fibrous tissue, tensed muscle, large
nerve
 Bony hard: bone, cartilage, tooth structure
Wen-Chen Wang

33. Torus palatini
Wen-Chen Wang

34. Painless, Tender or Painful
Pain
1.inflammation-- mechanical trauma or
infection
2.painful tumors--some neural tumors
3.sensory nerve encroachment
Tenderness
Low-grade inflammation & internal
pressure, chronic infection
Wen-Chen Wang

35. Unilateral or bilateral
Solitary or multiple
•Solitary : A local benign or early
malignancy
•Multiple : Systemic, disseminated
diseases or syndrome
Wen-Chen Wang

36. Erosive Lichen planus
Wen-Chen Wang

37. Special Examination
 Radiographic exam
 Aspiration, smear cytological
exam., biopsy
 Laboratory exam…
(Suggested by attending drs.)
Wen-Chen Wang

38. Common Oral Mucosal
Diseases
Wen-Chen Wang

39. Ulcerative Lesions
 Ulcer－epithelium loss caused by any
reason
 Trauma, burn, infection, oral cancer…
 Most of traumatic ulcers would be healed
within 2 weeks spontaneously, otherwise,
a further evaluation should be necessary.
Wen-Chen Wang

40. Traumatic Ulcer
 A definite trauma history and clinical
features can be traced
Usually occur at the soft tissue regions
which can be bitted or hit by teeth , ex.
Lower lip, tongue and buccal area
Ill-fitted dentures
Improper oral habits, ex,
lip biting, tongue biting etc.
Wen-Chen Wang
A traumatic ulcer of the author

41. Burn
Chemicals or drugs, thermal
Suicide, psychiatric problems,
Placement an aspirin tablet in oral to relieve
toothache
Phenol, H2O2, NaHOCl used in dental practice
Wen-Chen Wang

42. Recurrent Aphthous Ulcer
 Commonest oral mucosal disease
Herpetiform RAU Wen-Chen Wang

43. Patients Can Be Grossly Classified
As :
1.Primary immune dysregulation
-genetic, stress, congenital or acquired
immunal disease (leukopenia, AIDS, endocrine
etc. )
2.Decreased mucosal barrier
-Trauma, blood diseases, nutritional
defficiency(Vit.B12、follic acid, iron)
3. Increased antigenic expose
-Bacteria, virus, etc.
Wen-Chen Wang

44. Treatment of RAU
 Topical steroid or NSAID therapy, local
cauterization
 Underline diseases or any possible
etiology should be evaluated if suffered
severely and recurred very often
Wen-Chen Wang

45. Tuberculosis (TB)
 Worldwide, chronic infectious disease,
airborne droplets
 Crowded or unsanitary environment
 Opportunity infection, 5-10% progress
into active disease
 Immunocompromised patients, ex. DM,
HIV infection
Wen-Chen Wang

46. Oral Tuberculosis
 Primary and secondary
 Exposure to infected sputum or
hematogeneous spread
 Indurated, chronic painless ulcer
 Enlarged regional lymph nodes
Wen-Chen Wang

47. Herpes Simplex Virus
Infection (HSV type 1)
 Airborne droplets or direct contact
 Primary and recurrent
 Most primary HSV infections are
asymptomatic, some suffered from
primary herpetic gingivostomatitis
 Usually in children and young adults
Wen-Chen Wang

48. Clinical Characters of HSV Infection
 Primary-upper respiratory tract infection
oral symptoms，small vesicles/tiny
ulcers Latency
 Secondary- reactivation of latent virus
after trauma, menstruation, systemic
upsets, etc.
Wen-Chen Wang

49. Secondary HSV Infection
 A discrete collection of vesicular
swellings rupture erosion crusted
 The commonest recurrent lesion is herpes
labialis.
 Attached gingiva, hard palate
 Heal within 1-2 weeks without scarring
Wen-Chen Wang

50. Recurrent HSV infection
Wen-Chen Wang

51. Oral White Lesions and Betel
Nut Related Lesions
Wen-Chen Wang

52. Lichen Planus
 Reticular type (lace-like network of white lines,
Wickham’s striae)
 Erosive type
 Asymptomatic or burning irritation in reticular type,
symptomatic in erosive type
 Middle-aged, F:M=3:2
 Idiopathic, stress
 Topical or systemic steroid therapy
 Malignant potential is controversial
Wen-Chen Wang

53. Lichen planus

54. Oral Candidiasis
 Oral normal flora
 Local irritation（ ill-fitting or improper
denture hygiene）
 Antibiotics
 Immuno-compromised, systemic disease
patients
 Complete denture of upper jaw
Wen-Chen Wang

55. Oral Candidiasis
 Oral manifestation:
 Pseudomembranous type--creamy white
 Atrophytic type-- reddish
 Symptoms: varied, from mild to burning
sensation, pain and dysphagia
Wen-Chen Wang

56. Oral candidiasis

57. Oral Cancer and Precancerous Lesions
-Related to Betel Quid Chewing Habits
Wen-Chen Wang

58. What is
oral cancer?
Wen-Chen Wang

59. Oral Cancer is-
 Any cancer found in oral cavity
 A cancer of the oral epithelial
origin, ex. squamous cell
carcinoma, verrucous carcinoma
Wen-Chen Wang

60. Who is in high risk ?
Contributing
factors of oral
cancer?
Wen-Chen Wang

61. Contributing Factors
of Oral Cancer
--In betel nut (betel quid) consumption areas
 Betel nut chewing habit ( 80% in Taiwan)
 Others are:
1. smoking 2. alcoholism
3. radiation exposure 4. improper nutrition
5. syphilis 6. candidiasis
7. mutation of gene 8. immunodeficiency
9. improper denture
Wen-Chen Wang

62. Oral Cancer
 Early: may be a leukoplakia or
erythroplakia
 Tumor cells invade into connective
tissue or grow exophytically
 Clinical features: reddish or whitish
ulcerative surfaces with induration,
delayed healing process
Wen-Chen Wang

63. Oral Cancer
Locations:
 In Taiwan : buccal mucosa is the most
common, followed by lateral border of
tongue, retromolar, lower lip, palate and
gingiva
 In the world: lateral border of tongue is
the most common
Wen-Chen Wang

64. Oral Cancer
Wen-Chen Wang

65. Oral Cancer
Wen-Chen Wang

66. Visit your dentist as soon as
possible if any oral ulcer
doesn’t heal within 2 weeks !
Wen-Chen Wang

67. What are
Oral Precancerous Lesions ?
Wen-Chen Wang

68. Oral Precancerous Lesions
 Leukoplakia
 Erythroleukoplakia
 Erythroplakia
 Oral submucous fibrosis
 Verrucous hyperplasia
 Erosive lichen planus*
*precancerous condition
Wen-Chen Wang

69. Leukoplakia
 White lesions which cannot be characterized by lichen
planus, oral candidosis etc.
 Malignant change 4~5%
 Homogeneous leukoplakia and non-homogeneous
leukoplakia
Wen-Chen Wang

70. Erythroleukoplakia
Wen-Chen Wang

71. Verrucous Hyperplasia
 Exophytic, papillary or
cauliflower-like
appearance
 White, or pink to
reddish, resulted from
varied keratosis
Wen-Chen Wang

72. Oral Submucous Fibrosis
(OSF)
 20-40 y/o, male
 Sites: oral mucosa, oropharynx, esophagus
 Clinical characteristics:
-Dense collagen bundles, decreased vascularity,
epithelium atrophy, whitening of the mucosa
-Trismus
-Epithelium atrophy→ decreased protection,
sensitive to spicy foods
Wen-Chen Wang

73. Oral submucous fibrosis
Wen-Chen Wang

74. Oral submucous fibrosis
Wen-Chen Wang

75. Managements of OSF
 Mouth opening exercise
 Local cortical steroid injection
 Surgical treatment combined with skin
graft
 Prognosis is not good in the severe OSF
patients
Wen-Chen Wang

76. Oral Manifestations
of Systemic Diseases
Wen-Chen Wang

77. Burning Mouth Syndrome
(BMS)
 Bacterial or fungal infection
 Dry mouth
 Nutritional abnormality
 Anemia
 Endocrine disturbance, DM
 Improper denture
 Idiopathic
Wen-Chen Wang

78. Clinical Features of BMS
 Middle aged female or elder male
 Burning sensation, esp. tongue and
tongue tip; taste change
 Normal appearance and color
 Diagnosis and treatment depend on
the etiology
Wen-Chen Wang

79. Vitamin Deficiency
 Vit. A: keratosis
 Vit. B: glossitis, angular cheilitis,
burning mouth
 Vit. C: generalized gingival swelling,
bleeding tendency and ulcers,
periodontitis
Wen-Chen Wang

80. Vit. B12 deficiency
Wen-Chen Wang
After treatment

81. Blood Diseases
 Anemia－
pale mucosa
 Hemophilia－
hematoma or petechiae
 Coagulation problems
associated with impaired liver function
Wen-Chen Wang

82. Leukemia
 Bleeding tendency
 Idiopathic oral ulcers, necrotic gingival
margin
 Gingival swelling (chloroma)
 Oral candidosis
Wen-Chen Wang

84. Go for an oral and
dental examination
every 6 months!
Wen-Chen Wang

85. Kaohsiung Medical University
References
1. Antonio Nanci: Ten Cate＇s Oral Histology,
Development, structure, and function 6th ed.
2. BJ Orban:Orban＇s oral histology and
embryology,9th ed.
3. NK wood, PW Goaz: Differential diagnosis of oral
and maxillofacial lesions 5th ed.
4. BW Neville, DD Damm, CM Allen,JE Bouquot: Oral &
Maxillofacial pathology. 2nd ed.
Acknowledgement
Clinical pictures were fully supported by Dept. of
Oral Pathology, Kaohsinug Medical University
http://www.kmu.edu.tw/media/photos/001.jpg
Wen-Chen Wang