Soft Tissue Pathology

• What order do you examine in?

  • Examine in systematic order:

  - Lips

  - Tongue

  - Palate

  - Throat

  - Oral mucosa

  
  

  • Note:

  - Colour changes

  - Ulceration

  - Swelling
• How to document condition/present complaint?

  • Photograph if possible

  
  

  • Presenting complaint

  - caution

  - Location

  - Symptoms and duration

  - Triggers

  - Relieving factors

  - Recurrence

  - Consider any relevant medical conditions
• What is recorded for a lesion?

  - Site

  - Size

  - Colour

  - Consistency

  - Surface

  - Surrounding mucosa

  - Attachment
• how do you screen for perio in children?

  
• What are examples of gingival conditions?


  • Necrotising ulcerative gingivitis

  
  

  • Chronic gingivitis

  
  

  • Drug induced enlargement

  
  

  • Gingivitis artefacta

  
  

  • Chronic periodontitis

  
  

  • Aggressive periodontitis
• What is Necrotising Ulcerative gingivitis (NUG)?

  • Common acute infection – bacterial / viral?

  • No loss of connective tissue attachment

  • Seen in teenagers and young adults

  • Necrosis and ulceration

  • Ulcers are– “punched out”– yellow-grey sloughing– painful
• What are characteristics of NUG?

  • Often pre-existing gingivitis due to poor OH

  • Profuse bleeding on probing

  • Distinctive halitosis

  • Acute phase 5-7 days

  • Followed by chronic remission

  • Will recur if not treated

  • Treatment:–Mechanical debridement– Intensive OHI– Children over 10 - metronidazole

  
• What is Chronic Gingivitis?

  • Directly related to poor OH

  • Incidence increases between 5 – 12 yrs

  • Linked to the onset of puberty

  • Precursor to chronic perio

  • Treatment:–Intensive prevention in line with DBOH
• What is drug induced gingival enlargement?

  • Well recognised side effect of several drugs

  • Most common in children:– Phenytoin• Epilpesy• Enlargement seen in 50%–Ciclosporin•Immunosuppressant (organ transplant pts)• Enlargement seen in 30%– Nifedipine• Post-transplant pts to reduce nephrotoxic effect of ciclosporin• Enlargement seen in 15%
• How is drug induced gingival enlargement managed?

  Management:

  – Change drug therapy if possible– Strict oral home care regime in line with DBOH– Regular PMPR– Severe cases- surgery
• What is gingivitis artefacta?

  •Self-inflicted trauma to the gingiva

  • Minor /major(anywhere else on body?)

  • Resolve when cause is removed

  • Common in children with additional needs– Autism– Self-injurious behaviour
• What is Chronic Periodontitis?

  • Begins and progresses during earlyteenage years(attachment loss uncommon below age 9)

  • Related to presence of subgingival calculus

  • Loss of connective tissue attachment

  • Risk factors same as for adults: diabetes?

  • Treatment same as for adults
• What is Aggressive Periodontitis?

  • Rare• Can affect primary / permanent dentition• May lead to premature tooth loss• Can be localised / generalised• Bacterial infection with immunological defects

  • Treatment:– Intensive OHI– PMPR and RSD– Antibiotics (tetracycline, metronidazole, amoxicillin)
• What is oral ulceration and what must be considered when dealing with it?

  RAU - recurrent Aphthous Ulceration

  • Most common oral mucosal lesion

  • More frequent in younger age groups

  • Affects males and females equally

  • Multiple aetiological factors– genetic + environmental

  • Can be associated with systemic disease

  • Advise blood tests

  • Is it painful?• How many ulcers are there?• How long has this been a problem for?• Which sites of the mouth are affected?
• For recurrent ulcers what should be asked?

  • How long is the healing period?

  
  

  • Are there ulcers anywhere else on the body?

  
  

  • Predisposing factors?

  
  

  • Any known allergies?

  
  

  • Any recent new medications?
• What is a

  traumatic ulcer?• Usually singular

  • Patient may recall the incident

  • Causes:– Toothbrushing– Biting (epilepsy, following LA)– Thermal / chemical burn– Orthodontic appliance

  • Treatment:– Remove cause– Monitor, should heal in 2-3 wks

  
• What is minoraphthous ulceration?• Account for 80% of cases

  
  

  • One to five

  
  

  • Less than 10mm in diameter

  
  

  • At frequent intervals

  
  

  • Non-keratinised mucosa, anterior region

  
  

  • Heal within 2 weeks, no scarring

  
• What is Major aphthous ulceration?

  • Account for 10% of cases

  
  

  • Cause more disability

  
  

  • More than 10mm in diameter

  
  

  • Any mucosa, posterior region

  
  

  • Healing can take up to 8 weeks

  
  

  • Cause scarring

  
  

  • Common in HIV infection

  
• What is Herpetiform Aphthous ulceration?

  • Account for 10% of cases

  
  

  • Multiple small lesions (up to 100)

  
  

  • 1-2mm

  
  

  • Coalesce into larger lesion

  
  

  • Any mucosa

  
  

  • More common in females

  
  

  • Heal within 2 weeks, no scarring

  
• What is orofacial granulomatosis?

  • Rarely seen in children

  • Affects males + females equally

  • Characteristics:

  - Recurrent / persistent swelling of lips and face

  - Angular cheilitis

  - Multiple mucosal tags

  - Cobblestoning of the buccal mucosa

  • May be related to dietary triggers

  • May go on to develop Crohn's disease➢ refer to GP

  
• What are types of viral infections?

  • Herpetic infections (HHV1-HHV4)

  
  

  • Mumps

  
  

  • Measles

  
  

  • Rubella

  
  

  • Herpangina

  
  

  • Hand, foot and mouth disease
• What is primary herpes simplex infection and how is it managed?

  • HHV1 and HHV2 (Human herpes virus)

  • Usually under 5s

  • Characteristics:– Widespread oral ulceration, gingival inflammation– Blood encrusted lips– High temperature, enlarged lymph nodes

  • Management:– Self-limiting (10-14 days)– Soft diet, high fluid intake– Discourage touching infected area– Chlorhexidine m/wash (swab)- child can end up in hospital

  CONTAGIOUS

  
• What is recurrent herpes simplex infection?

  • HHV1 and HHV2 remain latent after primary infection

  • Reactivated by triggers

  • Preceded by a tingling sensation

  • “Coldsore”

  • Small cluster of vesicles on the vermillion border

  • Enlarge, coalesce, scab, heal (10 days)

  • Aciclovir cream

  
• What is the varicella zoster virus?

  • HHV3

  • Primary infection = chicken pox

  – Highly contagious

  – Initial spots present on trunk

  – Rapid proliferation including in mouth

  – Rupture into itchy vesicles

  – Systemic illness, general malaise, high temp

  • Latent reactivation = shingles

  
• What is Epstein - Barr virus? (Glandular fever) (Mono)

  • HHV4

  
  

  • Infectious mononucleosis (glandular fever)

  
  

  • Teenagers

  
  

  • Salivary transmission (kissing disease)

  
  

  • Resembles primary herpetic gingivostomatitis

  
  

  Lymphadenopathy, fever, fatigue - persists
• What is Measles, Mumps, Rubella?

  • Vaccinated against in the UK (MMR)

  • All self-limiting (within 14 days)

  •Measles– current outbreak in West Midlands, vaccination rate low– Fever, cough, Koplik’s spots, rash

  •Mumps– Bilateral swollen parotid glands, fever

  • Rubella– Rare, red/pink rash, fever, limited oral symptoms

  
• What is Herpangina?


  • Coxsackie A virus

  
  

  • Vesicles on tonsils, soft palate, pharyngealregions

  
  

  • Differentiated from primary herpes by location

  
  

  • General malaise

  
  

  • Short lived (3-5 days)
• What is hand, foot and mouth disease?

  • Coxsackie A virus

  
  

  • Maculopapular rash on hands and feet

  
  

  • Intra-oral vesicles => painful ulcers

  
  

  • Highly contagious

  
  

  • Outbreaks common in primary schools

  
  

  • Self-limiting (7-10 days)

  
• What are some bacterial infections?

  • Staphylococcus

  • Streptococcus

  • Congenital syphilis

  • Tuberculosis

  • Actinomycosis
• What are Staphylococcal & Streptococcal infection?

  • Impetigo• Crusting vesicles• Angles of mouth + lips• Vesicles coalesce• Highly contagious• Self-limiting

  
• What is congenital syphilis?

  • Rare (7 cases in England + Wales 2016/17)

  • Caused by aspirochaete – Treponema pallidum

  • Transmitted in utero / during birth from infected mother

  • Oral effects:– Rhagades (fissuring at angles of mouth)– Hutchinson’s incisors (– Mulberry molars

  
• What is Tuberculosis?


  • Oral lesions are rare (chronic ulcer)

  
  

  • Can see tuberculous lymphadenitis affecting submandibular and cervical lymph nodes

  
  

  • Seen in children cared for by family members from TB endemic areas

  
  

  • BCG vaccination now offered at birth to "at risk" children

  
• What is Actinomycosis?


  • Rare

  
  

  • Actinomyces israelii

  
  

  • Can follow intra-oral trauma (eg: extraction)

  
  

  • Abscess formation, spreads, may rupture on to skin

  
  

  • Long-term penicillin
• What is Candida Albicans?

  • Acute pseudomembranous candidiasis– Easily removed white patches on a red base– Neonatal thrush is common– Seen with inhaler use in asthma /immunocompromised

  • Chronic atrophic candidiasis– Associated with removable ortho appliances (poor hygiene practices)

  • Chronic mucocutaneous candidiasis– Rare, inherited condition
• What are types of cysts?

  • Mucocoele

  • Ranula

  • Haemangioma

  • Bohn's nodules

  • Epstein's pearls

  • Eruption cyst

  • Epidermolysis bullosa

  • Erythema multiformed
• What is a Mucocoele?

  • 2 types–Mucous extravasation• More common–Mucous retention• Mostly seen inside lower lip• Fluctuant, bluish cyst, up to 1cm in diameter• Caused by low level recurrent trauma• Rupture spontaneously• Recurrence is common• Surgical excision rarely indicated

  
• What is a Ranula?

  • Type of mucocoele

  - Extravasation

  
  

  • Arises from sublingual / submandibular glands

  • Large, painless, bluish swelling

  • Floor of mouth

  • Usually unilateral

  • Requires surgical removal

  
• What is a Haemangioma?

  •Overgrowth of small blood vessels forming a lump under the skin

  • AKA strawberry naevus / strawberry mark

  • Prevalence:– 1 in 10 babies– More common in girls, premature babies, multiple births

  • Common on cheeks, lips

  • Intra-oral involvement – caution! BLEEDING!!

  – Prevention is key

  
• What are Bohn's nodules?

  • Seen in neonates

  
  

  • Developmental• Smooth, white, solid ginigval cysts

  
  

  • Remnants of dental lamina

  
  

  • Filled with keratin

  
  

  • Can be mistaken for natal teeth

  
  

  • Resolve spontaneously

  
• What are Epstein's pearls?

  • Similar to Bohn's nodules

  • Located along palatal midline

  • White / yellowish, less than 3mm

  • Seen in neonates

  • Resolve spontaneously