Oral Mucosal Diseases

Question 1

referral of mucosal lesion to OM for opinion

Answer 1

1. anything the dentist thinks might be cancer / dysplasia; 2wk cancer referral pathway for actual malignancies, NICE & SIGN H&N cancer guidelines
2. any symptomatic lesion that has not responded to standard tx; hospital referral criteria & SDCEP
3. any benign lesion that the pt can’t persuaded is not cancer
   should take photos to send with referral if possible

Question 2

the oral mucosa

Answer 2

stratified squamous epithelium
lamina propria
gross types - lining, masticatory, gustatory
microscopic - non keratinised / keratinised

Question 3

layers of strata between lamina propria & keratin

Answer 3

outer -> inner
stratum corneum
stratum granulosum
stratum spinosum
basal layer
lamina propria
lamina propria with blood vessels then basement membrane with the epithelial progenitor cells (effectively stem cells) which continue & grow up the epithelium in a fairly ordered manner gradually losing purple staining suggesting loss of cell organelles as you move towards cell wall which is becomes flattened keratin layer

Question 4

sign of dysplastic cell division

Answer 4

any cell mitosis seen other than near the lamina propria is an indication of dysplastic cell division

Question 5

reactive changes of the oral mucosa

Answer 5

1. keratosis - non keratinised site (parakeratosis)
2. acanthosis - hyperplasia of stratum spinosum
3. elongated rete ridges - hyperplasia of basal cells
   if you traumatise the surface at a low level it will react & increase thickness of the epithelium, increase surface protection (i.e. keratin) so the above happens

Question 6

mucosal reactions

Answer 6

atrophy - reduction in viable layers
erosion - partial thickness loss
ulceration - fibrin on surface & loss of epithelium
oedema - intracellular (inside cell itself which will appear bigger) or intercellular (space between cells)
blister - vesicle or bulla

Question 7

how age & nutrition impacts mucosa

Answer 7

age - progressive mucosal atrophy
nutritional deficiency - Fe / B group vitamins causes atrophy & predisposes to infection

Question 8

benign mucosal conditions

Answer 8

appear unusual but often no further investigation required

Question 9

3 main types of tongue lesions

Answer 9

1. geographic tongue - 1-2% of population; less in children, desquamation; varied pattern & timing
2. black hairy tongue - hyperplasia of papillae, bacterial pigment
3. fissured tongue

Question 10

geographic tongue symptoms

Answer 10

sensitive with acidic/spicy food
intermittent
much worse in young children
can have none
something else usually causing the problem; haematinic deficiency (B12, folate, ferritin), parafunctional trauma, dysaesthesia

Question 11

geographic tongue

Answer 11

Alteration to the maturation & replacement of the normal epithelial surface. Happens in random areas and so goes unnoticed as the epithelium is replaced
Whole areas of epithelial surface are replaced at a single occasion, starts with halting epithelial replication so that the continuing loss of surface cells from the tongue without replacement results in thinning of the epithelial layer. The thinning makes the tongue appear redder as there is less of a barrier to the blood vessels underneath. More sensitive as the red areas are closer to the nerve in the connective tissue and pt will complain about spicy / citrus foods. After a few days the epithelial reproduction restarts so thickness starts to increase and appearance starts to return to normal so sensitivity decreases

Question 12

hair tongue

Answer 12

Can be due to bacterial colonisation but in many cases it is simply elongation of the surface papillae which are then becoming stained with pigments from food etc
Can be improved by removing the elongated surface from the tongue with a tongue scraper or with a peach/nectarine stone which is more natural

Question 13

fissured tongue

Answer 13

Not constantly present. Don’t really know why. Clean fissures of tongue with soft brush if food et begins to get stuck in it.

Question 14

glossitis

Answer 14

inflammation of the tongue
tongue atrophy plus angular cheilitis indicates pt may have Fe deficiency as well as smooth tongue
could also be caused by lichen planus so good to look into haematinics / fungal cultures also

Question 15

when to refer swellings

Answer 15

1. symptomatic (pain is feature of salivary gland malignancy)
2. abnormal overlying & surrounding mucosa
3. increasing in size
4. ‘rubbery’ consistency
5. trauma from teeth
6. unsightly

Question 16

when not to refer swellings

Answer 16

1. tori - usually in midline or palate or lingual aspect of the mandible
2. small polyps - will cause more damage being removed
3. mucoceles - from minor salivary glands are very difficult to find surgically; only remove if they become fixed in size

Question 17

fibrous leaf polyp

Answer 17

instead of swelling out and round it has been squashed beneath the denture making it thin & elongated
should be removed before new denture is constructed

Question 18

simple fibre epithelial polyp

Answer 18

if covering mucosa is same as surrounding mucosa there is no inflammation around the base of the lesion which would cause concern if there was
can be left alone but if it gets to a reasonable size it can be removed

Question 19

polyp on tongue edge

Answer 19

due to parafunctional habit of pushing tongue through gap in teeth; block area with ortho / small appliance which will cause this to settle

Question 20

mucocele

Answer 20

1. clear & visible on palate but if it bursts it will not be possible to find during surgery so just leave alone
2. fixed mucocele on RHS which has become larger & larger & filled with saliva so would remove this and associated gland

Question 21

what are tori

Answer 21

benign bony swellings associated with parafunctional clenching habit , often with TMD pain

Question 22

lower arch tori

Answer 22

Lower arch tori are covered with a thin mucosa that is not keratinised; if on bisphosphonates the pt is more likely to get avascular necrosis on the mucosa over the tori. This is due to the blood supply to the mucosa being largely derived from the bone & periosteum rather than directly from arterial supplies in the head & neck. Removal is not recommended in these pt unless there are very unusual circumstances

Question 23

pyogenic granuloma

Answer 23

mixed inflammatory infiltrate
any mucosal site
response to trauma
if not a granuloma not pyogenic (pus related)
other names inc:
on gingiva = vascular epulis (most common)
on gingiva in pregnancy = pregnancy epulis

Different as it does not have an epithelial surface; this is an inflammatory lesion with inflamed granulation tissue but with no patchy epithelial covering so it has a fibrinous yellow appearance or is just a red lesion