oral cavity by joyjitdas7

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									Disorders of oral cavity
            Disorders of the Lips
• Actinic cheilitis
   – Premalignant condition due
     to chronic UVR exposure
   – Affects lower lip, initially
     edematous & erythematous,
     later atrophic, white, scaly
     plaque, may obliterate
     vermillion border
   – Ulceration or induration -
     biopsy to rule out malignant
         Disorders of the Lips…
• Angular cheilitis (perleche)
   – Inflammatory reaction-
     erythema and maceration at
     the angles of mouth,
     fissuring and crusting may
     be present
   – Predisposing factors-
     advanced age, ill-fitting
     dentures, thumb-sucking in
     children, oral Candidiasis,
     bacterial infections
        Disorders of the Lips…
• Cheilitis glandularis
   – Inflammatory painless enlargement of lower lip,
     usually in elderly men
   – Triggered by actinic damage, bacterial infection,
     tobacco exposure, chronic irritation
• Chelitis glandularis apostematosa
   – Painful enlargement, eversion of lip with erosions and
     recurrent bacterial infections or malignant
        Disorders of the Lips…
• Exfoliative cheilitis
  (factitious cheilitis)
   – Chronic superficial
     inflammation of
     vermilion borders of
     the lips
   – Characterized by
     persistent scaling
   – Attributed to repeated
     lip sucking, chewing or
     other manipulation of
   Granulomatous cheilitis (cheilitis
• Granulomatous inflammation,
  acute onset of asymmetric
  swelling of the upper lip or lower
• Erythema, scaling, fissuring and
  erosions may develop
• Prolonged and recurrent course
  with eventual fixed swelling
• May be associated with
  constitutional symptoms,
  regional lymph node
        Granulomatous cheilitis
• Melkersson-rosenthal syndrome- triad of lingua plicata
  ( fissured or furrowed tongue), facial paralysis and
  granulomatous cheilitis
• Other cranial nerves (olfactory, auditory,
  glossopharyngeal, hypoglossal) may be involved
• Biopsy- oedema, perivascular lymphocytic infiltrate, focal
  granulomas resembling sarcoidosis or Crohn’s disease
           Disorders of Tongue
• Glossodynia (burning mouth syndrome)- spontaneous
  burning, discomfort, pain, irritation, or rawness of the
  tongue, has no identifiable etiology most of the time
• Etiology-
   – Idiopathic, Infection, Allergic/contact hypersensitivity,
     Mechanical trauma
   – Xerostomia, Geographic tongue/ Fissured tongue
   – Vesiculobullous disease, temporomandibular dysfunction
   – Referred pain from teeth or tonsils
   – Drugs- Antibiotics, psychiatric medications, chemotherapy
            Etiology of Glossodynia
• Neurologic                     • Systemic disorders
   –   Peripheral nerve damage     – Anemia (iron deficiency,
   –   Diabetic neuropathy           pernicious)
   –   Trigeminal neuralgia        – Nutritional deficiency
   –   Acoustic neuroma            – Gastroesophageal reflux
                                   – Sjogren syndrome
• psychiatric
                                   – Hypothyroidism
   –   Depression
                                   – Acquired immunodeficiency
   –   Anxiety                       syndrome
   –   Cancerophobia
   –   Somatoform disorder
   –   OCD
         Disorders of Tongue…
• Glossitis- presents as pain, irritation or burning,
  hypogeusia, or dysgeusia
• Atrophic glossitis
   – Due to filiform de-papillation
   – Mild patchy erythema to a completely smooth,
     atrophic, beefy-red surface
   – Etiology - pernicious anemia, protein and other
     nutritional deficiencies, chemical irritants, drug
     reactions, amyloidosis, sarcoidosis, vesiculobullous
     diseases, oral candidiasis and systemic infections
   – Moeller or Hunter glossitis of pernicious anemia
     affects the lateral aspects and tip of the tongue
        Disorders of Tongue…
• Median rhomboid
  glossitis - atrophic
  disorder of the tongue
  secondary to chronic
        Disorders of Tongue…
• Geographic tongue- benign
  inflammatory condition, due to
  Loss of filiform papillae
• Erythematous plaques with an
  annular or serpiginous well
  demarcated white border
• Etiology- psoriasis, Reiter
  syndrome, atopic dermatitis,
  diabetes mellitus, anemia,
  hormonal disturbances, Down
  syndrome, lithium therapy
        Disorders of Tongue…
• Fissured tongue (furrowed
  tongue, scrotal tongue,
  grooved tongue)
• normal variant seen in 5-11%
• Numerous small irregular
  fissures oriented laterally on
  the dorsal tongue
• Also seen in - Melkersson-
  Rosenthal syndrome,
  psoriasis, Down syndrome,
  acromegaly, Sjogren
        Disorders of Tongue…
• Herpetic geometric
  glossitis - rare cause of
  fissuring of tongue,
  presents with acute onset
  of pain and deep
  longitudinal grooves with
  smaller lateral fissures
           Disorders of Tongue…
• Hairy tongue (white or black hairy
  tongue) - hypertrophy of filiform papillae
  resembling hair-like projections
• Associated with - heavy tobacco use,
  mouth breathing, antibiotic therapy,
  poor oral hygiene, general debilitation,
  radiation therapy, chronic use of
  bismuth containing antacids, lack of
  dietary roughage
• White, yellow green, brown, or black
  color is due to chromogenic bacteria or
  staining from exogenous sources
        Disorders of Tongue…
• Orai hairy leukoplakia-
  caused by Epstein-Barr
  virus, presents as
  corrugated, white plaques
  with accentuation of
  vertical folds along the
  lateral borders of tongue
• Predominantly seen in
  HIV infection, organ
  transplant recipients and
  patients on chemotherapy
         Disorders of Tongue…
• Macroglossia- congenital or acquired process, tongue is
  disproportionately large relative to the patient’s jaw size
• Difficulty with mastication and speech and accidental
  tongue biting are common
• Differential- Down syndrome, hypothyroidism, Beckwith-
  Wiedemann syndrome, neurofibromatosis, infection by
  mycobacteria, filamentous bacteria or fungus,
   Disorders of Salivary Glands
• Xerostomia (dry mouth) - decreased saliva production
• Women are twice as affected as men
• Signs and symptoms - diminished or altered taste and
  smell, halitosis, heavy plaque accumulation, difficulty in
  wearing dentures, recurrent yeast infections, burning
  sensation, difficulty swallowing, dry or cracked lips,
  salivary calculi and increased thirst
         Causes of xerostomia
• Medications - Antidepressants, antihistamines, diuretics
• Medical conditions - Parkinson disease, diabetes,
  anemia, cysticfibrosis, rheumatoid arthritis
• granulomatous inflammation - tuberculosis, sarcoid,
  Sjögren syndrome, HIV, amyloid
• Dehydration - Fever, excessive sweating, vomiting,
  diarrhea, blood loss, burns, smoking, consumption of
  tea, coffee
• Radiation therapy of head and neck
• Surgical removal of the salivary glands
• Old Age
     Disorders of Salivary Glands
• Mucocele (mucous retention cysts)-
  benign, painless, dome- shaped
  fluctuant papules, due to trauma or
  obstruction of minor salivary gland
• Multiple mucoceles - graft vs host
  disease, lichen planus, cicatricial
• Ranula - large, bluish, translucent
  fluctuant mass in the floor of the mouth
  due to obstruction of the submandibular
  and or sublingual duct
• Diffuse parotid gland enlargement -
  acute mononucleosis, HIV infection
Disorders of Gingiva & Periodontium
• Gingivitis - erythema, edema, and blunting of the
  interdental papillae, without bone loss
   – Predisposing factors - poor oral hygiene, tobacco use, diabetes
• Periodontitis -chronic infection of connective tissue,
  periodontal ligament and alveolar bone
   – Long-term penodontitis is associated with increased risk of
     diabetes, heart disease, stroke and preterm birth
   – birth control pills, diabetes, steroids, Down syndrome,
     Langerhans cell histiocytosis, HIV predispose to periodontitis
   – Juvenile periodontitis is associated with genetic defects in
     leukocyte chemotaxis
• Papillon-Lefevre syndrome - severe and destructive
  periodontal disease, with exfoliation of the deciduous
  and permanent teeth
Disorders of Gingiva & Periodontium
• Erosive gingivostomatitis (desquamative gingivitis)-
  inflammation and erythema of the gingiva, nonspecific
  reaction pattern, may be due to viral infection,
  autoimmune, inflammatory and blistering disorders
• Lichen planus - painful or asymptomatic lacy white
  patches, plaques or papules, often with erosions and
• Lichenoid mucositis - NSAIDS, antihypertensive
  medications, contact allergy, graft-versus-host disease
 Disorders of Gingiva & Periodontium
• Acute necrotizing ulcerative
  gingivitis (trench mouth, vincent
• Punched- out ulcers of the
  interdental papillae, gingival
  hemorrhage, severe pain, foul odor
• Fever and lymphadenopathy are
• Precipitating factors- poor oral
  hygiene, nutritional deficiency,
  alcohol and tobacco use,
• Etiologic agents- Treponema,
  Selenomonas, Bacteroides,
  Prevotella and Borrelia vincentii
           Aphthous ulceration
• Acute, recurrent, painful ulcers on nonkeratinized
• Most common cause of oral ulcerations
• Effect up to 30 % of the population
• Ulcers with a gray or yellow pseudomembrane and
  erythematous margin
• Potential triggers - heredity, food and medication allergy,
  decreased mucosal barrier integrity, hematologic and
  immunologic disorders, emotional stress, and trauma
                 Aphthous ulceration
                   Minor aphthae       Major aphthae     Herpetiform ulcers
                   (90 -95 %)          (5-10%)           (1-5%)

Age of onset       Childhood or        Childhood or      Young adult
                   adolescence         adolescence
Ulcer size         2–4 mm              10 mm or larger   Initially tiny, but
                                                         ulcers coalesce
Number of ulcers   Up to about 6       Up to about 6     10–100
Sites affected     Mainly vestibule,   Any site          Any site but often
                   labial, buccal                        on ventrum of
                   mucosa &                              tongue
                   floor of mouth
Duration of each   Up to 10 days       Up to 1 month     Up to 1 month
          Aphthous ulceration
• Systemic Conditions Associated
  – Hematinic deficiency (up to 20%)- iron, folic acid or
    vitamin B12 deficiency
  – Gastrointestinal malabsorption (3%) - Celiac disease,
    dermatitis herpetiformis, gluten-sensitive enteropathy,
    Crohn disease, pernicious anemia
  – Systemic lupus erythematosus, reactive arthritis
  – HIV
  – Behcet disease
  – PFAPA (periodic fever, aphthous stomatitis,
    pharyngitis, and cervical adenitis)
  – MAGIC (mouth and genital ulcers with inflamed
                 Behcet’s disease
• Major criteria                          • Minor criteria
   – Oral Aphthae                            – Proteinuria and
   – Genital Ulcers                            haematuria
• Ocular- Iridocyclitis, Retinal             – Thrombophlebitis
  vasculitis,Optic atrophy                   – Aneurysms
• CNS lesions-                               – Arthralgias
   Meningoencephalitis, cerebral
   infarction, psychosis, cranial nerve
   palsies, cerebellar and spinal cord
• Dermatological
    – Pustules
    – Erythema nodosum
    – Pathergy
Non-aphthous erosions & ulcers
• Pemphigus vulgaris, paraneoplastic pemphigus, bullous
  pemphigoid, cicatricial pemphigoid, EB acquisita
• Epidermolysis bullosa simplex, junctional EB &
  dystrophic EB demonstrate the most severe
• Discoid and SLE- oral discoid lupus is characterized by
  ―sunburst‖ erythematous plaques surrounded by white
  radiating striations
• Erythema multiforme and stevens-johnson
  syndrome/toxic epidermonecrolysis
 Non-aphthous erosions & ulcers…
• Chronic ulcerative stomatitis - autoimmune mucosal
  erosive disorder
• Resemble erosive LP
• Direct immunofluorescence- IgG bound to nuclei of
  keratinocytes of basal and lower epithelial layers
• Responsive to Hydroxychloroquine
           Iatrogenic mucositis
• Complications of systemic chemotherapy and head and
  neck radiation, occurs due to direct tissue injury of the
  mucosal epithelium
            Disorders of mucosal
• Localized                     • Generalized
•   Amalgam, tattoo             • Racial
•   Ephelis / Naevus            • Localized irritation, e.g.
•   Malignant melanoma            smoking
•   Kaposi’s sarcoma            • Drugs, e.g. phenothiazines,
•   Peutz–Jegher syndrome         antimalarials, minocycline,
                                  contraceptives, mephenytoin
•   Laugier–Hunziker syndrome   • Addison’s disease/ Nelson’s
•   Melanotic macules             syndrome
                                • Ectopic adrenocorticotrophic
                                  hormone (e.g. bronchogenic
                                • Albright’s syndrome
                                • Haemochromatosis
                                • Neurofibromatosis,
                                  incontinentia pigmenti
                                • Malignant acanthosis nigricans
                  Disorders of Teeth
DISORDER                   FINDINGS
Bulimia                    Erosion of enamel and loss of dentin

Congenital                 Yellow dentin and hypoplastic pitted enamel
Congenital                 Erythrodontia of canine teeth and molars and brown
erythropoietic porphyria   discoloration of incisors

Congenital syphilis        Hutchinson teeth, mulberry molars

Ectodermal dysplasia       Hypodontia/anodontia/microdontia, peg-shaped teeth,
                           supernumerary teeth, enamel defects

Gardner syndrome           Supernumerary teeth

Goltz syndrome             Anodontia and enamel defects
             Disorders of Teeth…
Incontinentia pigmenti   Hypodontia, conical-shaped teeth

Lepromatous leprosy      Reddening of upper teeth (pink spots) due to
                         infection of dentin
Primary biliary          Green pigment deposits
Sjogren syndrome         Caries, increased plaque accumulation, poor
                         oral hygiene
Reflux                   Erosion of enamel due to repeated exposure to
                         gastric acid
Tetracycline staining    Permanent gray discoloration
Tuberous sclerosis       Pitted enamel of the permanent teeth
               Benign Tumors
• Pyogenic granuloma (pregnancy tumor) - an
  exaggerated, reactive proliferation of granulation and
  vascular tissue triggered by minor trauma or medication,
  classically during pregnancy
• Pulp polyp- exaggerated reactive proliferation of the
  dental pulp (neurovascular bundle), results when gross
  caries destroys the enamel crown
• Verruciform xanthoma - minute white or yellow
  verrucous papules on the gingiva, alveolar mucosa, or
  hard palate. Foamy, lipid-laden macrophages in biopsy
• Mucosal lipomas - present as asymptomatic, soft,
  yellow nodules on the buccal or vestibular mucosa,
  tongue, floor of the mouth or lips of middle-aged adults
             Benign Tumors…
• Traumatic neuroma - occur around mental foramen,
  alveolar ridge, lip or tongue
• Neurofibromas and schwannomas (neurilemmoma) -
  on the tongue or buccal mucosa
• Sipple syndrome - multiple mucosal neuromas,
  associated with pheochromocytoma, parafollicular
  thyroid cysts secreting calcitonin, medullaiy thyroid
  carcinoma and opaque nerve fibers on the cornea
• Granular cell tumor (Abrikosov tumor) - reactive
  process of Schwann cell origin, appears on the dorsal
  tongue as single or multiple asymptomatic firm, ill-
  defined papule
          Pre-Malignant Lesions
• Leukoplakia - chronic, white, verrucous plaque with
  histologic atypia
   – Severity linked to the duration and quantity of tobacco and
     alcohol use
   – Occur anywhere in the oral cavity
   – Lip, tongue, or floor of the mouth lesions are prone for
     progression to SCC
• Erythroplakia - non-inflammatory erythematous plaque
   – Analagous to intra-oral erythroplasia of Queyrat or SCC in situ
   – Biopsies - severe dysplasia and areas of frank invasion
     Pre-Malignant Lesions…
• Submucous fibrosis
  – generalized white discoloration of oral mucosa with
    progressive fibrosis, painful mucosal atrophy and
    restrictive fibrotic bands
  – individuals who chew betel quid, a concoction of
    tobacco, lime, areca nut and betel leaves
  – Ultimately leads to trismus, dysphagia and severe
  – 5 - 10 % progress to SCC
            Malignant Lesions
• Squamous cell carcinoma - present as leukoplakia,
  erythroplakia, erythroleukoplakia, irregular endophytic
  masses with ulceration or exophytic nodules
• High-risk anatomic sites - ventrolateral tongue, floor of
  the mouth, and the vermillion border of the lip
• Verrucous carcinoma - locally aggressive SCC in older
  adults presents as a hyperkeratotic, verrucous, exophytic
  white mass on the vestibules or mandibular gingiva, floor
  of the mouth, palate, and lip. Risk factors - smokeless
  tobacco and infections with HPV( 16 and 18)
           Malignant Lesions…
• Proliferative verrucous leukoplakia - rare progressive
  multifocal leukoplakia, with white, hyperkeratotic,
  verrucous plaques involve large areas of mucosa
   – Women are affected four times as men
   – More than 90 % undergo malignant transformation
   – Smoking is not associated, HPV may be etiologic factor
• Melanoma - irregular pigmented macule, patch or
  papule on the hard palate or maxillary gingiva
   – in older than 50 years
   – advanced lesions may ulcerate or bleed
   – Breslow depth - most important prognostic factor
          Malignant Lesions…
• Hodgkin, non-Hodgkin, cutaneous Tcell, and Burkitt
  lymphoma - non-specific, indurated, painless masses
• Burkitt lymphoma is associated with alveolar bone
• Langerhans cell histiocytosis - ulcerative gingivitis,
  periodontitis, ulceration and bony destruction, may be
  initial or sole manifestation of disease
• multicentric reticulohistiocytosis - flesh-colored to
  reddish-brown nodules on oral or nasal mucosa, in
  addition to classic cutaneous lesions and associated
• Kaposi sarcoma - single or multiple hemorrhagic
  patches or exophytic nodules, most often on gingiva or
• Asymptomatic, blue, soft nodules on the lips and
  ventrolateral tongue
• Not associated with any known systemic disease
• Caliber-persistent labial artery - raised pulsatile
  tortuous, blue rubbery bleb appreciation of lateral
  pulsation is diagnostic
• Mucosal hemangiomas - benign vascular tumors of
  infancy, erythematous or bluish vascular nodules,
  sometimes with associated thromboses and phleboliths,
  spontaneous regression usual
• Petechiae, ecchymoses, hematomas, and spontaneous
  gingival hemorrhage in thrombocytopenia, coagulation,
  hemolytic anemia, von willebrand disease, anticoagulant
        Salivary Gland Tumors
• Occur most commonly on the palate and on the
  retromolar pad distal to the third molar
• Erythematous papules or ulcerated papules and nodules
 Medication-Related Oral Changes
Teeth Discoloration   Tetracyclines, Chlorhexidine

Gingiva Swelling      Phenytoin, Ciclosporin, Nifedipine, Diltiazem
Dry mouth             Tricyclic antidepressants, Phenothiazines,
                      Antihypertensives, Lithium
Disturbed Taste       Metronidazole, Penicillamine
Ulcers                Cytotoxic drugs, Non-steroidal anti-inflammatory
Lichenoid lesions     Non-steroidal anti-inflammatory agents
Mucosa Thrush         Broad-spectrum antimicrobials, Corticosteroids
                      Cytotoxic drugs

Hyper pigmentation    Minocydine, antimalarials, clofazimine,
                      amiodarone, ketoconazole, and zidovudine
 Physical and Chemical Trauma
• Chronic biting and manipulation of lips in and buccal
  mucosa in nervous habit- ragged, irregular, white plaque
  at the site of trauma
• Frictional keratosis - thickened white plaque (sharp
  tooth or overextended denture)
• Irritation fibroma - sessile nodule at site of chronic
  mucosal irritation
• Smoker’s palate or nicotine stomatitis - thermal injury
  to the hard palate of pipe smokers
• Appears as a diffusely white palate studded with 2-5mm
  erythematous umbilicated papules
 Physical and Chemical Trauma
• Epulis fissuratum-
   – Develops beneath poorly fitting dentures, painless,
     elongated ridges of hypertrophic mucosa along the
     anterior labial alveolar ridge
• Giant cell epulis
   – A reactive hyperplastic proliferation, appears as a
     deep red papule on the interdental papillae
   – Many multinucleated giant cells are seen
     histologically in a vascular proliferation
               Chemical burn
• Aspirin burns
  – Mucosa in direct contact with aspirin becomes
    necrotic and painful, also with Medications containing
• Contact stomatitis
  – Intra-oral erythema, ulceration or a lichenoid
  – Dental amalgams, Cinnamate, flavorings, food
    additives, spices, toothpaste, mouthwash, dental
    epoxy resins, cosmetic lip products
           Oral Manifestations of Viral
 Herpes                      Lip edema with erythematous, grouped vesicles,
(HHV-l and HHV-2)            erosions, intra-oral hemorrhagic ulcers. Tongue
                             involvement in immunocompromised patients
Chickenpox (HHV-3)           Oral ulcers on palate or buccal mucosa

Herpes zoster (HHV-3)        Painful, unilateral, aphthous-like ulcers in second and
                             third trigeminal nerve branch
Infectious mononucleosis     Exudative tonsillitis, uvular edema, palatal petechiae,
Epstein-Barr virus (HHV-4)   and, uncommonly, necrotizing ulcerative gingivitis
Oral hairy leukoplakia       White plaques with prominent vertical folds on lateral
Epstein-Barr virus (HHV-4)   tongue> dorsal tongue > buccal mucosa and
                             vestibule in immunocompromised individuals

Congenital Cytomegalovirus   Yellow dentin and hypoplastic puffed enamel of the
(HHV-5)                      teeth, Aphthous-like ulcers
Roseola infantum (HHV-6)     Erythematous macules on soff palate
(exanthem subitum)
           Oral Manifestations of Viral
Kaposi sarcoma HHV-8       Erythematous to violaceous macules on palate,
                           gingiva, tongue. Evolve into painful, ulcerated nodules
Herpangina                 Acute onset, 1- to 2-mm erythematous macules on
Group A coxsackievirus     palate and uvula. Lesions vesiculate and ulcerate,
                           leaving painful superficial erosions
Hand-foot-and- mouth       Many small, painful ulcers with surrounding erythema
disease (Coxsackie A-l6)   on the tongue, buccal mucosa, palate
Acute lymphonodular        White or yellow papules with an erythematous base on
pharyngitis (Gp A Cox)     uvula, tonsils, oropharynx
Measles (rubeola)          Koplik spots - brightly erythematous macules with white
                           centers on buccal mucosa adjacent to posterior teeth
Rubella (German            Forschheimer spots—small erythematous macules on
measles)                   palate
Acute sero-conversion of   Erythema, ulcerations, and secondary candidiasis
         Oral Manifestations of Viral
Squamous papilloma       Solitary, exophytic, pedunculated, mucosa
(HPV)                    colored papule, occurs on the palate or tongue
Verruca vulgaris (HPV)   Solitary or clusters of verruciform papules on the
                         Buccal mucosa, lips, or perioral skin
Condyloma                Resemble verruca vulgaris but are larger. Oral
acuminatum (HPV)         Involvement of the labia, lingual frenum, soft
                         palate, and gingiva
Focal epithelial         Benign, soft, painless 1- to 4-mm papules on the
hyperplasia (Heck        labial, buccal, or lingual mucosae
disease) (HPV)
Kawasaki disease         Beefy red oropharynx, strawberry tongue
                         (inflammation and papillary enlargement),
                         severe hemorrhagic cheilits
     Oral Manifestations of bacterial
Scarlet fever (Group B   Erythema of hard palate and a white-coated
Streptococcus)           Tongue with erythematous, edematous,
                         fungiform papillae. Later the tongue becomes
                         beefy red (strawberry tongue)
Diphtheria               Thick, gray pseudomembrane with erythematous
(Corynebacterium         Halo on tonsils, pharynx, gingiva, tongue,
Diphtheriae)             buccal mucosa
Tularemia (Francisella   Painful, necrotic oral ulcers or diffuse stomatitis
Lepromatous leprosy      Firm yellow-pink ulcerative nodules (lepromas)
                         on the palate or tongue. Macroglossia due to
                         tongue infiltration, Reddening of upper teeth
                         (pink spots) due to infection of dental pulp
Granuloma inguinale      Painful hemorrhagic ulcers or vegetative
                         nodules, Severe scarring
     Oral Manifestations of bacterial
Primary syphilis    Chancre—painless ulceration with indurated borders
                    on the lip, tongue, buccal mucosa, or oropharynx with
Secondary           Mucous patches—oval plaques on the tongue with a
syphilis            white or gray pseudomembrane. Split papules, macer-
                    ated, flat-topped papules at the oral commissures
                    (condyloma lata). chronic oral ulcerations
Tertiary syphilis   Interstitial glossitis with atrophy of filiform
                    and fungiform papillae and fissuring of the tongue,
                    Pre-malignant leukoplakia, gummas involve palate

Congenital          Hutchinson teeth in 50%—peg shaped with crescentic
syphilis            notches along incisal edge of incisors. Mulberry or
                    Moon’s molars—rounded or crenated occlusal cusps of
                    first molars
       Oral Manifestations of fungal
Primary oral Aspergillus    Necrotic, violaceous ulcerations with black eschar
aspergillosis               on gingiva and palate

Maxillary sinus Aspergilus Untreated maxillary infection can progress to
aspergillosis              necrotic palatal perforation with a yellow and black
                           palatal ulcer and facial edema

Zygomycosis, Mucor and      black, necrotic palatal ulceration

Histoplasmosis              Chronic verrucous or necrotic mucosal ulceration
Para coccidioidomycosis
     Oral Manifestations of fungal
• Oral candidiasis
• Acute pseudomembranous, Acute atrophic, Chronic
  atrophic, Chronic hyperplastic, Median rhomboid
• Predisposing factors- dry mouth, antimicrobials,
  corticosteroids, leukaemia, HIV inf, tobacco smoking,
  denture wearing, endocrinopathy
   Oral manifestations of Endocrine
Pituitary dwarfism     Microdontia, Retarded tooth eruption

Congenital             Macroglossia, Retarded tooth eruption
Gigantism/acromegaly   Spaced teeth, Mandibular prognathism,
                       Macroglossia, Megadontia
Hyperparathyroidism    Bone rarefaction, Brown tumours

Addison’s disease      Mucosal hyperpigmentation
Diabetes mellitus      Periodontal disease, Xerostomia, Candidiasis,
                       Sialosis, Lichen planus
Pregnancy              Gingivitis, Epulis
         Oral manifestations of Liver
Alcoholic cirrhosis         Bleeding tendency, Sialosis

Chronic active hepatitis    Lichen planus

Primary biliary cirrhosis   Sjögren’s syndrome, Lichen planus

Hepatitis C                 Lichen planus, Sjogren’s syndrome
                   Oral manifestations of
                  Gastrointestinal diseases
Pernicious anaemia             Ulcers, Glossitis, Angular stomatitis, Erythema

Any malabsorption              Ulcers, Glossitis, Angular stomatitis

Chronic regurgitation          Tooth erosion, Halitosis

Crohn’s disease                Mucosal tags, Gingival hyperplasia, Cobblestoning
                               of mucosa, Ulcers, Glossitis, Angular stomatitis
Coeliac disease                Ulcers, Glossitis, Angular stomatitis, Dental hypoplasia

Chronic pancreatitis           Sialosis

Cystic fibrosis                Salivary gland swelling

Gardner’s syndrome             Osteomas
(familial colonic polyposis)
        Oral manifestations of Renal
Chronic renal failure   Xerostomia, Halitosis/taste disturbance, Leukoplakia
                        Dental hypoplasia, Bleeding tendency
Post renal transplant   Infections( herpetic, candidal), Bleeding tendency,
                        Gingival hyperplasia, Kaposi’s sarcoma
                        Hairy leukoplakia

Renal rickets           Delayed tooth eruption, Dental hypoplasia, Enlarged
(vitamin D resistant)   pulp
Nephrotic syndrome      Dental hypoplasia
Oral manifestations Haematological
Deficiency of haematinics           Burning sensation, Ulcers, Glossitis, Angular
(iron, folic acid or vitamin B12)   stomatitis

Sickle-cell anaemia                 Jaw deformities, Osteomyelitis

Aplastic anaemia                    Ulcers, Bleeding tendency

Leukaemia/lymphoma                  Infections, Ulcers, Bleeding tendency,
                                    purpura, Gingival swelling
Multiple myeloma                    Bone pain, Tooth mobility, Amyloidosis

Amyloid disease                     Enlarged tongue, Purpura
• Fitzpatrick,s dermatology in general
  medicine 7th edition
• Rook’s text book of dermatology 7th edition

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