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Anatomy and premalignant
conditions of oral cavity
sumeryadav2004@gmail.com
1. Oral Vestibule
- lies between the gums, teeth and
inner lips, inner cheek .
2. Oral Cavity Proper
- lies behind and wit...
Oral Vestibule
Boundaries:
1. Anteriorly by the lips,
2. Laterally by the
cheeks,
3. Superiorly by the
mucolabial and
muco...
Boundaries:
1. Anteriorly and laterally by
the teeth and gums,
2. Superiorly by the palate
(hard and soft),
3. Inferiorly ...
BLOOD SUPPLY
Mouth is supplied
by branches from
 Facial Artery
 Inferior Alveolar
Artery
 Maxillary Artery
 Infraorbit...
Lymphatic Supply
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PALATE
The palate forms the
superior wall or the
roof of the oral cavity
proper.
It is composed of the
hard palate which h...
SOFT PALATE
Tensor veli
palatini
Tenses the soft palate; opens
the pharyngotympanic tube
Levator veli
palatini
Only muscle...
Blood supply of Soft palate
sumeryadav2004@gmail.com
VENOUS DRAINAGE AND LYMPHATICS
sumeryadav2004@gmail.com
NERVE SUPPLY OF PALATE
• All muscles of soft palate are supplied by Vagus
nerve [X] via pharyngeal branch to pharyngeal
pl...
tongue
“A mobile mass of muscles lying on the floor of the
mouth and associated with the function of taste,
chewing, swall...
PAPILLAE
 Circumvallate papillae are arranged in a
row parallel to and in front of sulcus
terminalis
 Fungiform papillae...
Muscles of the tongue
INTRINSIC MUSCLES
MUSCLE FUNCTION
SUPERIOR Shortens tongue;
curls apex and sides
of tongue
INFERIOR ...
EXTRINSIC MUSCLES
GENIOGLOSSUS
Protrudes tongue;
depresses center of tongue
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HYOGLOSSUS
Depresses tongue
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STYLOGLOSSUS
Elevates and
retracts tongue
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PALATOGLOSSUS
Depresses palate;
Moves palatoglossal fold toward
midline;
Elevates back of the tongue
sumeryadav2004@gmail....
Arteries:
 Lingual artery
 Tonsillar branch of facial
artery
 Ascending pharyngeal artery
Veins:
 Lingual vein, ulti...
BLOOD AND NERVE SUPPLY
sumeryadav2004@gmail.com
Tip:
• Submental nodes
bilaterally & then
deep cervical nodes
Anterior two third:
• Submandibular
unilaterally & then
de...
NERVE SUPPLY OF TONGUE
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Precancerous
Lesions & Conditions
sumeryadav2004@gmail.com
Introduction
• Precancerous lesion
• “Morphologically altered tissue in which cancer is more
likely to occur, than in its ...
PREMALIGNANT LESIONS
• Leukoplakia
• Erythroplakia
• Carcinoma in situ
• Bowens disease
• Actinic keratosis & chelitis
• D...
PREMALIGNANT CONDITIONS
• Oral submucous fibrosis
• Oral lichen planus
• Syphilitic glossitis
• Sideropenic dysphagia
• Dy...
Leukoplakia
• The term LEUKOPLAKIA was first coined by a Hungarian
Dermatologist SCHWIMMER in 1877
• Originates from Greek...
Epidemiology
1. Prevalence
• Represents 85% of all oral precancers
2. Incidence
3 – 4 % of adult population
3. Age
Usually...
Classification of leukoplakia
(Axell & Pindborg et al 1983)
• Based on CLINICAL TYPE:
 Homogenous
 Non homogenous
• Base...
• Based on risk of MALIGNANT TRANSFORMATION
 High risk sites
Floor of mouth
Lateral/ventral surface of tongue
Soft palate...
Sharp’s staging of leukoplakia
• Stage I- Earliest lesion-non palpable, faintly translucent,
white discoloration
• Stage I...
Etiopathogenesis
• Tobacco – most imp offending agent
• Alcohol
• Chronic irritation
• Syphilis
• Nutritional deficiency
•...
• Most studies have reported mortality ratios for smokers
versus never smokers of about 5:1, with several reporting
ratios...
Clinical presentation
• Any mucosal surface, solitary or multiple,
“White patches”
• Varies from a non-palpable faintly
tr...
SYMPTOMS
• Patients may report with a feeling of increased thickness of
mucosa
• Those with ulcerated or nodular type may ...
Clinical variants of leukoplakia
Homogeneous/ Leukoplakia Simplex Speckled/Nodular
Ulcerative
sumeryadav2004@gmail.com
Histopathological features
• Keratinization pattern
• Thickness of epithelium
• Changes in underlying
connective tissue
• ...
• Five clinical criteria for high risk of malignant change
– The nodular type
– Erosion or ulceration within lesion
– Pres...
Diferential diagnosis
• Leukoedema
• Lichen planus
• Chemical burn
• Morsicatio buccarum
• Lupus erythematosus
• White spo...
Conservative management
• Elimination of etiological factor
• Restraining from smoking or chewing tobacco
• To remove shar...
CHEMOPREVENTION
1) Isotrenitoin / 13- cis- retinoic acid –
2) Beta carotene -30mg TID
3) Topical Bleomycin – 0.5-1% soluti...
• Surgical Excision: entire lesion excised if it is >1cm in size,
following modalities used:
a) Scalpel – surgical strippi...
Erythroplakia
WHO DEFINITION:
“Any lesion of the oral mucosa that presents as a
bright red velvety patch or plaque, which ...
CLASSIFICATION
• Clinical variants
1. Homogenous erythroplakia
2. Erythroplakia interspersed with patches of leukoplakia
3...
• Etiology : Same as oral leukoplakia
• Age : Mainly middle age, peak 65-74 years
• Gender : Predilection for men
• Locati...
- Smooth and granular/nodular, well defined
- May have an irregular, red granular surface interspersed
with white or yello...
• Highest risk for malignant transformation - 14-50%
• Based on the fact that on histology 80-90% of cases
present as-
- C...
Management
• Biopsy should be performed
• Treatment guided by histopathologic diagnosis
• Recurrence , multifocality commo...
Intraepthelial carcinoma (Ca in Situ)
• Arises frequently on the skin, but also on mucous membranes,
including oral cavity...
• Histopathology
• Keratin may or may not be present on the surface, but if present it
is usually parakeratin
• Individual...
Precancerous conditions
sumeryadav2004@gmail.com
Oral lichen planus
• Named by E Wilson ( British physician) 1896
Lichen – latin for primitive plants (symbiotic algae & fu...
• Affects 0.5% to 1% of world's population
• Approx half patients with cutaneous LP have oral
involvement
• Mucosal involv...
• On skin-
• Flat-topped purple polygonal & pruritic papular rash
sumeryadav2004@gmail.com
Etiology & pathogenesis
• Both antigen-specific & non-specific mechanisms may be involved
in pathogenesis of OLP
• Antigen...
• These mechanisms may combine to cause
 T-cell accumulation in superficial lamina propria
 Basement membrane disruption...
Clinical features
• Lesions usually symmetrical
• Frequently affects buccal mucosa,
tongue, gingiva, lip and palate
• Extr...
Clinical variants
Reticular (92%) Atrophic (44%) Plaque (36%)
Erosive (9%) Bullous (1%)
sumeryadav2004@gmail.com
Clinical features
Asymptomatic
• Reticular – Wickham’s striae + discrete erythematous border
• Plaque-like – Resemble leuk...
Histology
 Shklar -3 classic microscopic
features of OLP
• Overlying hyperkeratinization
• A bandlike layer of chronic
in...
Diagnosis
• The characteristic clinical aspects of OLP - sufficient for
correct diagnosis
• An oral biopsy - to confirm cl...
IMMUNOFLUORESCENCE
• Direct immunofluorescence – shaggy band of fibrinogen
in the basement membrane, IgM stained cytoid bo...
Management
• Reticular type is asymptomatic & treatment often
unnecessary
• Erosive type presents significant management p...
• In symptomatic patients with apparent contact dental
factor, patch test with replacement of amalgam
• In those with no a...
Lichenoid reaction
• The oral lichenoid eruption is a less specific entity compared with
LP of the skin.
• Best considered ...
Oral submucous fibrosis
DEFINITION -
“It is a slowly progressing chronic fibrotic disease of the
oral cavity & oropharynx,...
Clinical features
Age
• Range wide & regional; even prevalent among teenagers in India
Ranges from 11-60 years
Sex
• From ...
Mortality/morbidity
• High rate of morbidity - progressive
inability to open mouth, resulting in
difficulty eating & conse...
Etiology
• Initially classified as idiopathic, now
• Betel quid & it’s components (Arecoline, an active
alkaloid found in ...
Clinical presentation
• Common site – buccal mucosa, retromolar area, uvula,
palate, etc
• Initially, pain and a burning s...
• Depapillation & atrophy of tongue and uvula
• Depigmented & loss of stippling over gingiva
• Nasal tone in the voice
• D...
Clinical stages
Three stages (Pindborg, 1989) based on physical findings:
• Stage 1: Stomatitis includes erythematous muco...
• Stage 3: Sequelae of OSF
– Leukoplakia is found in more than 25% of
individuals with OSF
– Speech and hearing deficits m...
RANGANATHAN K (2001)
• Group I : Only Symptoms, No mouth opening
• Group II : Mouth opening > 20mm
• Group III : Mouth ope...
Histopathology
• Hyperkeratinized, atrophic epithelium with flattening
& shortening of rete pegs
• Nuclear pleomorphism & ...
• Advanced stage shows “homogenization” and
“hyalinization” of collagen fibers (important feature)
• Degeneration of muscl...
Management
1. Behavioral therapy
- Patient counseling, stoppage of habit
2. Medicinal therapy
-Hyaluronidase: Topically, s...
Thank You
sumeryadav2004@gmail.com
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Oral precancerous lesions and anatomy of oral cavity

  1. 1. Anatomy and premalignant conditions of oral cavity sumeryadav2004@gmail.com
  2. 2. 1. Oral Vestibule - lies between the gums, teeth and inner lips, inner cheek . 2. Oral Cavity Proper - lies behind and within the arch of teeth. sumeryadav2004@gmail.com
  3. 3. Oral Vestibule Boundaries: 1. Anteriorly by the lips, 2. Laterally by the cheeks, 3. Superiorly by the mucolabial and mucobuccal folds, and 4. Posteriorly and medially by the teeth and gums. sumeryadav2004@gmail.com
  4. 4. Boundaries: 1. Anteriorly and laterally by the teeth and gums, 2. Superiorly by the palate (hard and soft), 3. Inferiorly by the tongue and the floor of the mouth, and 4. Posteriorly by the opening into the pharynx. sumeryadav2004@gmail.com
  5. 5. BLOOD SUPPLY Mouth is supplied by branches from  Facial Artery  Inferior Alveolar Artery  Maxillary Artery  Infraorbital Artery  Postero superior sumeryadav2004@gmail.com
  6. 6. Lymphatic Supply sumeryadav2004@gmail.com
  7. 7. PALATE The palate forms the superior wall or the roof of the oral cavity proper. It is composed of the hard palate which has an osseous base, and behind, a soft palate composed of fibrous tissue. sumeryadav2004@gmail.com
  8. 8. SOFT PALATE Tensor veli palatini Tenses the soft palate; opens the pharyngotympanic tube Levator veli palatini Only muscle to elevate the soft palate above the neutral position Palatopharyngeus Depresses soft palate; moves palatopharyngeal arch toward midline; elevates pharynx Palatoglossus Depresses palate; moves palatoglossal arch toward midline; elevates back of the tongue Musculus uvulae Elevates and retracts uvula; thickens central region of soft palate MUSLE FUNCTION A. Tensor veli palatini muscles and the palatine aponeurosis. B. Levator veli palatini muscles. C. Palatopharyngeus sumeryadav2004@gmail.com
  9. 9. Blood supply of Soft palate sumeryadav2004@gmail.com
  10. 10. VENOUS DRAINAGE AND LYMPHATICS sumeryadav2004@gmail.com
  11. 11. NERVE SUPPLY OF PALATE • All muscles of soft palate are supplied by Vagus nerve [X] via pharyngeal branch to pharyngeal plexus • Except Tensor palatini muscle which is supplied by Mandibular nerve. • Sensory supply is derived from lesser palatine branches of the sphenopalatine ganaglion and from the branches of glossopharyngeal nerve. • Secretomotor from Suprior salivary N. through greater petrosal nervesumeryadav2004@gmail.com
  12. 12. tongue “A mobile mass of muscles lying on the floor of the mouth and associated with the function of taste, chewing, swallowing, and speaking”. TONGUE CONSISTS OF • Mucous membrane • Mucous glands • Lymphoid tissue • Fat • Striated muscle fibres • Fibrous tissue sumeryadav2004@gmail.com
  13. 13. PAPILLAE  Circumvallate papillae are arranged in a row parallel to and in front of sulcus terminalis  Fungiform papillae are numerous at the tip and margin of the tongue.  Filliform papillae are prevalent on the dorsum of the tongue arranged in rows parallel to sulcus terminalis sumeryadav2004@gmail.com
  14. 14. Muscles of the tongue INTRINSIC MUSCLES MUSCLE FUNCTION SUPERIOR Shortens tongue; curls apex and sides of tongue INFERIOR Shortens tongue; uncurls apex and turns it downward TRANSVERSE Narrows and elongates tongue VERTICAL Flattens and widens tongue All intrinsic muscles are supplied by Hypoglossal nerve sumeryadav2004@gmail.com
  15. 15. EXTRINSIC MUSCLES GENIOGLOSSUS Protrudes tongue; depresses center of tongue sumeryadav2004@gmail.com
  16. 16. HYOGLOSSUS Depresses tongue sumeryadav2004@gmail.com
  17. 17. STYLOGLOSSUS Elevates and retracts tongue sumeryadav2004@gmail.com
  18. 18. PALATOGLOSSUS Depresses palate; Moves palatoglossal fold toward midline; Elevates back of the tongue sumeryadav2004@gmail.com
  19. 19. Arteries:  Lingual artery  Tonsillar branch of facial artery  Ascending pharyngeal artery Veins:  Lingual vein, ultimately drains into the internal jugular vein Hypoglos sal nerve Lingual artery & vein Deep lingual vein Dorsal lingual artery & vein sumeryadav2004@gmail.com
  20. 20. BLOOD AND NERVE SUPPLY sumeryadav2004@gmail.com
  21. 21. Tip: • Submental nodes bilaterally & then deep cervical nodes Anterior two third: • Submandibular unilaterally & then deep cervical nodes Posterior third: • Deep cervical nodes (jugulodigastric mainly) sumeryadav2004@gmail.com
  22. 22. NERVE SUPPLY OF TONGUE sumeryadav2004@gmail.com
  23. 23. Precancerous Lesions & Conditions sumeryadav2004@gmail.com
  24. 24. Introduction • Precancerous lesion • “Morphologically altered tissue in which cancer is more likely to occur, than in its apparently normal counterpart” • Precancerous condition • “Generalized state of the body, which is associated with a significantly increased risk of cancer” sumeryadav2004@gmail.com
  25. 25. PREMALIGNANT LESIONS • Leukoplakia • Erythroplakia • Carcinoma in situ • Bowens disease • Actinic keratosis & chelitis • Dyskeratosis follicularis sumeryadav2004@gmail.com
  26. 26. PREMALIGNANT CONDITIONS • Oral submucous fibrosis • Oral lichen planus • Syphilitic glossitis • Sideropenic dysphagia • Dyskeratosis congenita sumeryadav2004@gmail.com
  27. 27. Leukoplakia • The term LEUKOPLAKIA was first coined by a Hungarian Dermatologist SCHWIMMER in 1877 • Originates from Greek words – “leucos” - white and “plakia” - patch • WHO 1978 • “A white patch or plaque in the oral cavity which cannot be scrapped off or stripped off easily & more over, which cannot be characterized clinically or pathologically as any other disease” sumeryadav2004@gmail.com
  28. 28. Epidemiology 1. Prevalence • Represents 85% of all oral precancers 2. Incidence 3 – 4 % of adult population 3. Age Usually in the 4th – 6th decades of life 4. Sex Males have the highest incidence, with the trend changing gradually sumeryadav2004@gmail.com
  29. 29. Classification of leukoplakia (Axell & Pindborg et al 1983) • Based on CLINICAL TYPE:  Homogenous  Non homogenous • Based on ETIOLOGY:  Tobacco associated  Idiopathic • Based on EXTENT:  Localized  Diffuse sumeryadav2004@gmail.com
  30. 30. • Based on risk of MALIGNANT TRANSFORMATION  High risk sites Floor of mouth Lateral/ventral surface of tongue Soft palate  Low risk sites Dorsum of tongue Hard palate • Based on HISTOLOGY:  Dysplastic  Non dysplastic sumeryadav2004@gmail.com
  31. 31. Sharp’s staging of leukoplakia • Stage I- Earliest lesion-non palpable, faintly translucent, white discoloration • Stage II- Localized or diffuse, slightly elevated plaque of irregular outline. It is opaque white & may have a fine granular texture • Stage III- Thickened white lesion showing induration and fissuring sumeryadav2004@gmail.com
  32. 32. Etiopathogenesis • Tobacco – most imp offending agent • Alcohol • Chronic irritation • Syphilis • Nutritional deficiency • Actinic radiation sumeryadav2004@gmail.com
  33. 33. • Most studies have reported mortality ratios for smokers versus never smokers of about 5:1, with several reporting ratios in excess of 10:1. Furthermore, the risk for death from oral cancer is consumption related • Male cigarette smokers had a relative risk for oral cancer 27.7 times greater than that of a male never smoker • These studies have found that after 3 to 5 years of smoking abstinence, oral cancer risk decreased by about 50% sumeryadav2004@gmail.com
  34. 34. Clinical presentation • Any mucosal surface, solitary or multiple, “White patches” • Varies from a non-palpable faintly translucent white area to a thick fissured, papillomatous or indurated lesion • Colour varies from white, grey or yellowish white, sometimes brownish-yellow • 70% in buccal mucosa, commissural areas, followed by lower lip, floor of the mouth, palate & gingivasumeryadav2004@gmail.com
  35. 35. SYMPTOMS • Patients may report with a feeling of increased thickness of mucosa • Those with ulcerated or nodular type may complain of burning sensation • Enlarged cervical lymph nodes may signal occurrence of metastasis sumeryadav2004@gmail.com
  36. 36. Clinical variants of leukoplakia Homogeneous/ Leukoplakia Simplex Speckled/Nodular Ulcerative sumeryadav2004@gmail.com
  37. 37. Histopathological features • Keratinization pattern • Thickness of epithelium • Changes in underlying connective tissue • Waldron & Shafer (1975) 80% lesions show benign hyperkeratosis with/without acanthosis & 17% represent CIS Dysplastic changes typically begin in basal & parabasal zones of epithelium sumeryadav2004@gmail.com
  38. 38. • Five clinical criteria for high risk of malignant change – The nodular type – Erosion or ulceration within lesion – Presence of a nodule indicates malignant potential – A lesion that is hard in its periphery – Lesion of anterior floor of mouth & undersurface of tongue • In all cases, relative risk of malignant potential is determined by presence of epithelial dysplasia upon histological examination sumeryadav2004@gmail.com
  39. 39. Diferential diagnosis • Leukoedema • Lichen planus • Chemical burn • Morsicatio buccarum • Lupus erythematosus • White sponge nevus sumeryadav2004@gmail.com
  40. 40. Conservative management • Elimination of etiological factor • Restraining from smoking or chewing tobacco • To remove sharp broken down teeth • Correction & replacement of overhanging or faulty metal restorations with a metal bridge sumeryadav2004@gmail.com
  41. 41. CHEMOPREVENTION 1) Isotrenitoin / 13- cis- retinoic acid – 2) Beta carotene -30mg TID 3) Topical Bleomycin – 0.5-1% solution/2wks 4) 5-Fluorouracil & Cisplatin sumeryadav2004@gmail.com
  42. 42. • Surgical Excision: entire lesion excised if it is >1cm in size, following modalities used: a) Scalpel – surgical stripping b) Cryosurgery – with liquid nitrogen c) Electrocautery d) Laser ablation sumeryadav2004@gmail.com
  43. 43. Erythroplakia WHO DEFINITION: “Any lesion of the oral mucosa that presents as a bright red velvety patch or plaque, which cannot be characterized clinically or pathologically as any other recognizable condition” Reported by Querat in 1911 sumeryadav2004@gmail.com
  44. 44. CLASSIFICATION • Clinical variants 1. Homogenous erythroplakia 2. Erythroplakia interspersed with patches of leukoplakia 3. Granular or Speckled erythroplakia sumeryadav2004@gmail.com
  45. 45. • Etiology : Same as oral leukoplakia • Age : Mainly middle age, peak 65-74 years • Gender : Predilection for men • Location/size - Soft palate, floor of the mouth & buccal mucosa & tongue - Typical lesion < 1.5 cm in diameter but >4cm also observed sumeryadav2004@gmail.com
  46. 46. - Smooth and granular/nodular, well defined - May have an irregular, red granular surface interspersed with white or yellow foci - Soft on palpation sumeryadav2004@gmail.com
  47. 47. • Highest risk for malignant transformation - 14-50% • Based on the fact that on histology 80-90% of cases present as- - Carcinoma In Situ - Severe epithelial dysplasia - Microinvasive carcinoma sumeryadav2004@gmail.com
  48. 48. Management • Biopsy should be performed • Treatment guided by histopathologic diagnosis • Recurrence , multifocality common • Careful long term follow up sumeryadav2004@gmail.com
  49. 49. Intraepthelial carcinoma (Ca in Situ) • Arises frequently on the skin, but also on mucous membranes, including oral cavity • Most severe stage of epithelial dysplasia • Striking feature – dysplastic epithelial cells donot invade into connective tissue • Common among elderly, with a male prdiliction • Present as white plaques or ulcerated, & reddened areas • Site – floor of the mouth, tongue, lips • Has combined features of leuko & erythroplakiasumeryadav2004@gmail.com
  50. 50. • Histopathology • Keratin may or may not be present on the surface, but if present it is usually parakeratin • Individual cell keratinization or keratin pearl formation are rare • Consistent finding – loss of orientation & normal polarity of cells • Treatment • No accepted treatment • Surgical excision, irradiation & cauterization sumeryadav2004@gmail.com
  51. 51. Precancerous conditions sumeryadav2004@gmail.com
  52. 52. Oral lichen planus • Named by E Wilson ( British physician) 1896 Lichen – latin for primitive plants (symbiotic algae & fungi) Planus – latin for flat • Definition • “A common chronic immunologic inflammatory mucocutaneous disorder that varies in appearance from keratotic (reticular or plaque like) to erythematous and ulcerative, affecting the stratified squamous epithelium” sumeryadav2004@gmail.com
  53. 53. • Affects 0.5% to 1% of world's population • Approx half patients with cutaneous LP have oral involvement • Mucosal involvement, sole manifestation in up to 25% cases • Peak incidence - middle age, F:M- 2:1 • Characteristically associated with persistent clinical course & resistance to most conventional treatments sumeryadav2004@gmail.com
  54. 54. • On skin- • Flat-topped purple polygonal & pruritic papular rash sumeryadav2004@gmail.com
  55. 55. Etiology & pathogenesis • Both antigen-specific & non-specific mechanisms may be involved in pathogenesis of OLP • Antigen-specific mechanisms: – antigen presentation by basal keratinocytes and – antigen-specific keratinocyte killing by CD8+ cytotoxic T-cells • Non-specific mechanisms: – mast cell degranulation and – matrix metalloproteinase (MMP) activation sumeryadav2004@gmail.com
  56. 56. • These mechanisms may combine to cause  T-cell accumulation in superficial lamina propria  Basement membrane disruption  Intra-epithelial T-cell migration &  Keratinocyte apoptosis sumeryadav2004@gmail.com
  57. 57. Clinical features • Lesions usually symmetrical • Frequently affects buccal mucosa, tongue, gingiva, lip and palate • Extra-oral mucosal involvements - anogenital area, conjunctivae, oesophagus/larynx • Approx 1.2% - 5.3% lesions undergo malignant changes • Hence regular follow up mandatorysumeryadav2004@gmail.com
  58. 58. Clinical variants Reticular (92%) Atrophic (44%) Plaque (36%) Erosive (9%) Bullous (1%) sumeryadav2004@gmail.com
  59. 59. Clinical features Asymptomatic • Reticular – Wickham’s striae + discrete erythematous border • Plaque-like – Resemble leukoplakia, common in smokers Symptomatic • Atrophic – Diffuse red patch, peripheral radiating white striae • Erosive – Irregular erosion covered with a pseudomembrane • Bullous – Small bullae / vesicles that may rupture easily sumeryadav2004@gmail.com
  60. 60. Histology  Shklar -3 classic microscopic features of OLP • Overlying hyperkeratinization • A bandlike layer of chronic inflammatory cells within underlying connective tissue • Liquefaction degeneration of basal cell zone sumeryadav2004@gmail.com
  61. 61. Diagnosis • The characteristic clinical aspects of OLP - sufficient for correct diagnosis • An oral biopsy - to confirm clinical diagnosis (exclude dysplasia & malignancy) • Gingival LP more difficult to diagnose, direct immunofluorescence of perilesional mucosa for diagnosis sumeryadav2004@gmail.com
  62. 62. IMMUNOFLUORESCENCE • Direct immunofluorescence – shaggy band of fibrinogen in the basement membrane, IgM stained cytoid bodies are also seen in dermal papilla or peribasilar area sumeryadav2004@gmail.com
  63. 63. Management • Reticular type is asymptomatic & treatment often unnecessary • Erosive type presents significant management problems • All patients should optimize oral hygiene • Oral candidiasis should be excluded/treated • Cortico steroids, is the treatment of choice eg – Fluocinonide or Clobetasol gel for 2 weeks, with 3mnths follow-up sumeryadav2004@gmail.com
  64. 64. • In symptomatic patients with apparent contact dental factor, patch test with replacement of amalgam • In those with no apparent contact factor, topical or intralesional steroid - first line treatment. A short course of systemic steroid for more rapid control sumeryadav2004@gmail.com
  65. 65. Lichenoid reaction • The oral lichenoid eruption is a less specific entity compared with LP of the skin. • Best considered as a reaction pattern of oral mucosa to a variety of insults, including – OLP itself – Contact allergy – Trauma and – Other inflammatory dermatoses (e.g. oral lupus erythematosus may look very lichenoid)sumeryadav2004@gmail.com
  66. 66. Oral submucous fibrosis DEFINITION - “It is a slowly progressing chronic fibrotic disease of the oral cavity & oropharynx, characterized by fibroelastic change and inflammation leading to a progressive inability to open the mouth, swallow or speak” sumeryadav2004@gmail.com
  67. 67. Clinical features Age • Range wide & regional; even prevalent among teenagers in India Ranges from 11-60 years Sex • From 0.2 - 2.3% in males to 1.2 - 4.5% in females in Indian communities Race • South-East Asian countries, in Indian immigrants to other countries sumeryadav2004@gmail.com
  68. 68. Mortality/morbidity • High rate of morbidity - progressive inability to open mouth, resulting in difficulty eating & consequent nutritional deficiencies • Significant mortality rate - can transform into oral cancer, particularly Squamous cell carcinoma 7.6% sumeryadav2004@gmail.com
  69. 69. Etiology • Initially classified as idiopathic, now • Betel quid & it’s components (Arecoline, an active alkaloid found in betel nuts, stimulates fibroblasts to increase production of collagen by 150%) • Capsaicin – Chillies (hypersensitivity reaction) • Nutritional factors • Immunological factors sumeryadav2004@gmail.com
  70. 70. Clinical presentation • Common site – buccal mucosa, retromolar area, uvula, palate, etc • Initially, pain and a burning sensation upon consumption of hot & spicy foods • Vesicle & ulcers • Excessive or reduced salivation & defective gustation • Hearing loss sumeryadav2004@gmail.com
  71. 71. • Depapillation & atrophy of tongue and uvula • Depigmented & loss of stippling over gingiva • Nasal tone in the voice • Difficulty in deglutition • Impaired mouth movements (eg, eating, whistling, blowing, sucking) sumeryadav2004@gmail.com
  72. 72. Clinical stages Three stages (Pindborg, 1989) based on physical findings: • Stage 1: Stomatitis includes erythematous mucosa, vesicles, mucosal ulcers, melanotic mucosal pigmentation & mucosal petechiae • Stage 2: Fibrosis occurs in ruptured vesicles & ulcers when they heal, hallmark of this stage sumeryadav2004@gmail.com
  73. 73. • Stage 3: Sequelae of OSF – Leukoplakia is found in more than 25% of individuals with OSF – Speech and hearing deficits may occur because of involvement of the tongue and the eustachian tubes sumeryadav2004@gmail.com
  74. 74. RANGANATHAN K (2001) • Group I : Only Symptoms, No mouth opening • Group II : Mouth opening > 20mm • Group III : Mouth opening < 20mm • Group IV: Limited mouth opening, precancerous & cancerous changes throughout mucosa sumeryadav2004@gmail.com
  75. 75. Histopathology • Hyperkeratinized, atrophic epithelium with flattening & shortening of rete pegs • Nuclear pleomorphism & severe inter-cellular edema • Finely fibrilar collagen & increased fibroblastic activity in early stage showing dilated & congested blood vessels with areas of hemorrhage sumeryadav2004@gmail.com
  76. 76. • Advanced stage shows “homogenization” and “hyalinization” of collagen fibers (important feature) • Degeneration of muscle fibers and chronic inflammatory cell infiltration in the connective tissue sumeryadav2004@gmail.com
  77. 77. Management 1. Behavioral therapy - Patient counseling, stoppage of habit 2. Medicinal therapy -Hyaluronidase: Topically, shown to improve symptoms more quickly than steroids alone - Mild cases – intralesional inj Dexamethasone 4 mg to reduce symptoms & surgical splitting / excision of fibrous bands - Recent study – intralesional inj of gamma interferon 3 times a week, improves mouth opening significantly sumeryadav2004@gmail.com
  78. 78. Thank You sumeryadav2004@gmail.com
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Oral precancerous lesions and anatomy of oral cavity

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