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1. What are the oral mucosal diseases? 2. What is oral medicine? 1. Any disease that occurred on oral mucosa, such as oral cancers, oral mucosal ulcers, white lesions, tongue disorders can be called the oral mucosal disease. 2. Oral Medicine is a special discipline in dentistry, which concerns oral mucosal diseases and their management with systemic and topical medicines. Oral Mucosal HistologyThe oral mucosa has both epithelial and connective tissue structural modifications in the different regions of the oral cavity, providing three recognizable histological types. These types of epithelia correspond to the function of the tissues: masticatory (tough) mucosa in the gingivae and hard palate; lining (flexible) mucosa in the lips, cheeks, vestibule, alveolar mucosa, soft palate, floor of mouth, and inferior surface of the tongue; and specialized (mix of masticatory and lining) mucosa on the dorsum of the tongue (see next).Masticatory (keratinizing)LiningSpecialized(f) Anterior two-thirds of dorsal surface of tongue; (xiii) filiform papillae, which cover the majority of the anterior part of the tongue; fungiform papillae (arrows), which are dotted between the filiform papillae. (g) Posterior aspect of anterior two-thirds of tongue where a line of circumvallate papillae (circled) are located.Relating Clinical Appearance to Histological StructureColor of Oral Mucosa The pink/red color of oral mucosa is derived from extensive blood supply to these tissues. The distribution of blood vessels is also important in imparting the level of rednessfor example, while the epithelium of the vermilion border of the lip is keratinized, it is thin, like interfollicular skin. Lingual Papillae Filiform papillae , fungiform papillae, circumvallate papillae, foliate papillae.Gingivae In health, the attached gingiva has a stippled appearance (small superficial depressions) due to collagen fiber bundles that attach the gingival connective tissues to the tooth root and bone. Located between the teeth are the interdental papillae consisting of keratinized epithelium on the facial/lingual aspects overlying connective tissue . Salivary Gland Ducts The oral mucosa differs from skin in that it is continually bathed with saliva, secreted by salivary glands of the oral submucosa. The minor salivary glands in the lip submucosa are notable as they contribute a lumpy texture to these tissues. Concluding Remarks In summary, within the confined regions of the oral cavity, the oral mucosa displays a range of regional differences that relate to its development and functional demands. The oral mucosa represents some features that are specific to the oral environment, including the constantly moist surroundings, the presence of teeth protruding through the oral epithelium, and the ubiquitous presence of inflammation in this region, along with the consistent functional demands of eating and communicating. General Features of Oral Mucosal Diseases AetiologyIn general, the aetiology of oral mucosal diseases is complicated (like OLP, RAU), and the host immunities are usually involved in most cases although in some cases, the causes are quite simple (like oral mucosal trauma). And females might be more susceptible to oral mucosal diseases. SymptomsFor one disease (eg, OLP, Oral Candidiasis), there may be varieties of clinical appearances depending on the lesions on different oral mucosal sites and disease course. Likewise, different diseases may be featured as the same lesions (eg. ulceration). DiagnosisIn clinics, the diagnosis of oral mucosal disease is basically depending on the clinical appearances and history, and most likely, the pathological confirmation is essential. And also, the examinations of hosts immunological functions and haematology are needed nowadays. Treatment General speaking, the treatment of oral mucosal diseases is relatively difficult because of the complicated aetiology and pathogenesis. Prognosis Fortunately, the prognosis of oral mucosal diseases is relatively positive, optimistic in spite of the factors mentioned above such as obscured aetiology, complicated clinical appearances and difficulties of treatment. Oral Medicine and PathologyUsually, discipline of oral medicine is very much depended on oral pathology, and these two disciplines are one family now abroad, which means you cannot be a specialist of oral medicine without a degree of oral pathology. Role of Oral Medicine in DentistryThe incidence of oral mucosal diseases is much lower than the other dental diseases such as caries, periodontal disease. And the demand of specialists of oral medicine, in turn, is much less than general dentist in conservative dentistry and the economic profit from the practice of oral medicine is quite lower too in China, but not abroad, and a Chinese specialist of oral medicine has to do the other dental practices. However, the researches on oral medicine are very important and achievable in the science of dentistry as its obvious elements mentioned above. Oral Medicine: We bring medicine to dentistry-The American Academy of Oral Medicine Basic description of oral mucosal lesions Macule & PatchMaculesmall, circular, flat spot 2 cm can be seen but not feltvariety of shapesdifferent color from nearby skin (usually brown, red, or black)Patch a large macule 2cm in diameter Papule & PlaquePapulea circumscribed, solid elevation of mucosa with no visible fluidvarying in size from a pinhead to 1cmcan be either white, pink or red Plaquea broad papule, or confluence of papules 1cmVesiclea circumscribed, fluid-containing, epidermal elevation1-10mm in sizeBullaplural bullaea rounded or irregularly shaped blister containing serous or seropurulent fluid 1cmTwo different types of bullaPustulea small elevation of the skin containing purulent material usually consisting of necrotic inflammatory cells (ie.neutrophils)rarely in oral cavityUlcera discontinuity of the mucosa exhibiting COMPLETE loss of the epitheliumErosiona discontinuity of the skin exhibiting INCOMPLETE loss of the epitheliumNodulemorphologically similar to a papule 1cm, usually 5 cmvarying colors from pink to deep purple Tumora swelling or lesion formed by an abnormal growth of cells (termed neoplastic) cancer, can be benign, pre-malignant or malignant (whereas cancer is by definition malignant)Atrophydecrease in size or wasting away of a body part or tissueRhagadeslinear scars at the surface of mucosaPseudomemranea layer of coagulated fibrin, leukocytes and bacteria overlying a badly damaged mucous membrane called also false membraneCrustsdried serum, pus, or blood usually mixed with epithelial and sometimes bacterial debrisScalesdry or greasy laminated masses of keratinComplicated clinical featuresDifferent diseases have similar lesionDifferent lesions appear in one diseaseDifferent lesions appear sequently in different stage of one disease Different diseases have similar lesionDifferent lesions appear in one diseaseDifferent lesions appear sequently in different stage of one diseaseDiagnosis ProceduresClinical diagnosisHistorical diagnosisLaboratory diagnosisMicroscopical diagnosis (histopathology &Microbiology)Clinical Examination Procedures1、Etiology & Mechanism several possible causesGenetic predisposition/ Hematologic deficency/ Immunologic abnormality/ Hormonal influences/ Infectious agents/ Smoking cessation/psychological stress/ Trauma .The remaining patients have herpetiform aphthous ulcerations. Herpetiform aphthous ulcerations are considered a distinct clinical entity that manifests as recurrent crops of dozens of small ulcers throughout the oral mucosa. RAU(minor)The RAU lesions are confined to the oral mucosa and begin with prodromal symptoms of burning, itching or stinging any time from 2 to 48 hours before an ulcer appears. During this initial period, a localized area of erythema develops.Within hours, a small white papule forms, ulcerates, and gradually enlarges over the next 48 to 72 hours.The ulceration demonstrates a yellow-white, removable fibrinopurulent membrane that is encircled by an erythematous halo. Classically, the ulcerations measure between 2 and 10 mm in diameter and heal without scarring in 7 to 14 days. From one to five lesions typically are present during each episode. The buccal and labial mucosa are affected most frequently, followed by the ventral surface of the tongue, floor of the mouth, and soft palate. Involvement of keratinized mucosa, (e.g., hard palate, gingiva) is rare and usually represents extension from adjacent nonkeratinized epithelium. The recurrence rate is highly variable, ranging from one ulceration every few years to more than two episodes per month.RAU(major)RAU(major)Major aphthous ulcerations are larger than minor aphthae and demonstrate the longest duration per episode. The number of lesions usually is intermediate between that seen in the minor and herpetiform variatnts. The ulcerations are deeper than the minor variant, measure from 1 to 3 cm in diameter, take from 2 to 6 weeks to heal, and may cause scarring. The number of lesions varies from 1 to 10. Any oral surface area may be affected but the labial mucosa, soft palate, and tonsillar fauces are involved most commonly. The onset of major aphthae might begin after puberty, and recurrent episodes may continue to develop for up to 20 year or more. With time, the associated scarring can become significant, and in rare instances may lead to a restricted mouth opening. RAU(major)RAU(Herpetiform)Herpetiform aphthous ulcerations demonstrate the greatest number of lesions and most frequent recurrences. The individual lesions are mall, averaging 1 to 3 mm in diameter, with as many as 100 ulcers present in a single recurrence. Because of their mall size and large number, the lesions bear a superficial resemblance to primary HSV (herpes simplex virus) infection, leading to the confusing designation, Herpetiform. It is common for individual lesions to coalesce into larger irregular ulcerations. The ulcerations heal within 7 to 10 days, but the recurrences tend to be closely spaced. Many patients are affected almost constantly for periods as long as 3 years. Although the nonkeratinized, movable mucosa is affected most frequently, any oral mucosal surface may be involved. There is a female predominance, and typically the onset is in adulthood.4 Differential Diagnosis Major RAU Malignant tumor TB-ulcer recurrent & self-limited YesNoNo UlcerCrater-form Crater-form & indent-form cauliflower-form InfiltrationNoYesNo Pathology InflammationMalignancy TB nodule5 TreatmentThe patients medical history should be reviewed for signs and symptoms of any systemic disorder that may be associated with aphthouslike ulceration. Based on lesion state to adjust the therapy protocol .(Minor, Major)Evaluate drug effectiveness and adverse effect.In patients with mild disease, the mainstay of therapy is the use of topical treatment. Major aphthous ulcerations are more resistant to therapy and often warrant more potent corticosteroids. In this way the ulcerations will receive both topical and systemic therapy. Non-specific immune inhibitor Thalidomide (反应停) is reported effectiveness in minimize the frequency and severity of the attacks.Numerous alternatives to corticosteroid agents have been used to treat patients suffering from aphthous ulcerations. Caution should be exercised, however, because some of these treatments may have significant side effects. The success of these therapies is highly variable. Treatments do not resolve the underlying problem and are merely an attempt to “beat back brush fire.” Recurrences often continue, although breaking up the cycle may induce longer disease-free intervals between attacks. Lichen Planus is a common chronic immunologic inflammatory mucocutaneous disease. About 28% of patients who have OLP also have skin lesions .Unlike oral lesions, skin lesions are usually self-limiting, lasting only 1 year or less. OLP varies in appearance from keratotic (reticular or plaquelike) to erythematous and ulcerative.Immunology: cell-mediated immunologic reactionInfection: hepatitis CPsychopathic-psychological factors: Stress Others:diabetes, trauma, and hypersensitivity to drugs, chemicals and metals 3.1 Oral Lesionsclassified according to clinical features: non-erosive (reticular) erosiveErosive vs. non-erosiveBased on: signs symptoms lesion transformationSignificance: guide for treatmentNon-erosive (reticular) OLPThe reticular form consists of (a) slightly elevated fine whitish lines (Wickhams striae) that produce either a lacelike pattern or a patern of fine radiating lines or annular lesions. The white lesions may appear as papules in some instances. The reticular form usually causes no symptoms and involves the posterior buccal mucosa bilaterally. Other oral mucosal surfaces may also be involved concurrently, such as the lateral and dorsal tongue, the gingivae, the palate, and vermilion border. The reticular pattern may not be as evident in some sites, such as the dorsal tongue, where the lesions appear more as keratontic plaques with atrophy of the papillae. OLP (2 years-old boy)OLP (non-erosive)OLP (non-erosive)Typical lesion of OLP (non-erosive)Erosive OLPErosive lichen plan, although not as common as the reticular form, is more significant for the patient because the lesions are usually symptomatic. Clinically, there are atrophic, erythematous areas with central ulceration of varying degrees. The periphery of the atrophic regions is usually bordered by fine, white radiating striae. If the erosive component is severe, epithelial separation from the underlying connective tissue may occur. These results in the relatively rare presentation of bullous lichen planus.The lesions are usually present for weeks to months. Erosive OLPOLPOLP (lip)Skin lesion： flat violaceous papules BiopsyIf the typical radiating white striae and erythematous, atrophic mucosa are present at the periphery of well-demarcated ulceration on the posterior buccal mucosa bilaterally, then the diagnosis can sometimes be rendered without the support of histopathologic findings. However, a biopsy is often necessary to rule out other ulcerative or erosive diseases .Undefinable diagnosisMalignant transformation in clinicLong course of diseaseSuspected co-occur with other diseases5 TreatmentReticular lichen planus typically produces no symptoms, and no treatment is needed. Occasionally, affected patients may have superimposed candidiasis, in which case they may complain of a burning sensation of the oral mucosa. Antifungal therapy is necessary in such a case. Some investigators recommend annual reevaluation of the reticular lesion of oral lichen planus. Erosive lichen planus is often bothersome because of the open sores in the mouth. Because it is an immunologically mediated condition, corticosteroids are recommended. The lesions respond to systemic corticosteroids, but such drastic therapy is usually not necessary. One of the stronger topical corticosteroids applied several times per day to the most symptomatic areas is usually sufficient to induce healing with 1 or 2 weeks. The patients should be warned that the condition will undoubtedly flare up again, in which case the corticosteroids should be reapplied.Malignant transfer rate: 1-10%In general: 1%A kind of precancerous conditionA generalized state associated with significantly increased risk of cancerDiseases Involving Lip and Tongue-specific clinical and pathological presentationsActinic cheilitis (acute)Actinic cheilitis (chronic)Cheilitis of benign lympholasis Cheilitis granulomatosaChronic cheilitisChronic cheilitisAngular cheilitisAngular cheilitisAngular cheilitisAngular cheilitis Allergic stomatitis vesicle, erythema, ulceration, white pseudomembraneAngioneurotic edemaErythema multiformeErythema multiformeErythema multiforme
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