9 – Orofacial Lesions

9

Orofacial Lesions

George M. Taybos, DDS, MEd

Pain in the oral cavity is not an unusual complaint of dental patients, and most of the time, that pain can be attributed to obvious disease processes that directly affect the dentition (eg, caries, pulpal pathosis) and/or the periodontium. However, the pain may not always be associated with the teeth or the periodontium but may be due to oral lesions that are affecting other oral tissues. Sometimes these orofacial lesions can cause severe pain and compromise the patient’s ability to masticate, swallow, and even sleep; in other instances, these lesions may be a source of great concern, especially for the cancerphobic individual. Therefore, the dentist must make every effort to accurately diagnose the patient’s problem and either provide a cure or symptomatic relief.

Diagnostic Approach

Although making a specific diagnosis based on the etiology, course, and symptoms is an important step in the overall management of the patient’s orofacial lesion(s), a thorough review of the patient’s medical and dental history is as significant as the history and pathogenesis of the patient’s chief complaint. The clinician must know the patient’s past and present illnesses, medications (prescription and over-the-counter), and social history (alcohol and/or tobacco use) and habits. The clinical signs and symptoms of the orofacial lesion may be pathognomonic; however, the dentist must evaluate the character, progression, and duration of the lesion and relate these findings to those of the head and neck examination before arriving at a working diagnosis.

Therapeutic Approach

Ideally the management and treatment of any orofacial lesion should be dictated by the etiology of the lesion, such as trauma, infections (bacterial, viral, or fungal), autoimmune diseases, or a component of a systemic disease. If a specific etiologic factor can be identified, then in addition to instituting a specific treatment for the current lesion, future painful episodes may possibly be preventable. For the lesions of unknown etiology and certain viral infections, management and treatment will be limited to supportive and palliative measures.

Squamous Cell Carcinoma

Squamous cell carcinoma (SCC) of the oral cavity is an invasive malignant neoplasm of the epithelium of the mouth and oropharynx. It is predominantly found in males aged 50 to 70 and females aged 60 to 80 years, with a very strong relationship to alcohol and tobacco use/abuse. The incidence of SCC is twice as high for males as females. Ninety-seven percent of all intraoral SCCs are found in three high risk areas of the oral cavity: floor of the mouth (50%; Fig 9-1), soft palate complex (32%), and ventrolateral surface of the tongue (18%). On the floor of the mouth, over 70% of the lesions found there are located in the anterior portion.

e9780867155297_i0269.jpg

Fig 9-1 Stage III squamous cell carcinoma on the anterior floor of the mouth in a 48-year-old male with a history of tobacco and alcohol abuse.

Signs and Symptoms

Early SCC, leukoplakia, and/or erythroplasia is usually asymptomatic (Fig 9-2). If the carcinoma does cause signs and symptoms, the patient will complain of pain, bleeding, ulceration, a mass, or difficulty in swallowing. Unfortunately, the lesion at this point is at least a stage II disease, often with associated lymph node involvement.

e9780867155297_i0270.jpg

Fig 9-2 Stage I squamous cell carcinoma on the anterior floor of the mouth in a 51-year-old male with a history of alcohol abuse.

Diagnosis

Erythematous lesions in the high-risk locations should be suspect. As an adjunct to clinical suspicion, exfoliative cytology may be useful; however, a biopsy of the lesions is an absolute requirement before a diagnosis can be made and therapy can be initiated.

Treatment

Exfoliative Cytology

Exfoliative cytology may be used as a screening technique and as an adjunct to biopsy. It may be defined as the microscopic examination of cells scraped from the surface of a lesion (as opposed to theexamination of tissue blocks in biopsies), and therein lies its limitations. When properly used, oral exfoliative cytology may be most useful in diagnosing viral infections and candidiasis, and, in rare instances, may indicate changes suggesting dysplasia or squamous cell carcinoma. The procedure is inexpensive, qui ckand easy, and painless. It must be stressed that in most instances oral exfoliative cytology is not an alternativeto biopsy.

Step 1 Rub a moist tongue depressor gently over the entire surface of the lesion.
Step 2 Spread the scraping evenly on a glass slide.
Step 3 Immediately spray the slide with an alcohol fixative.
Step 4 Submit the specimen to the pathologist, along with an adequate history, a clinical description, a photograph, and an exact location of the lesion.

Biopsy

Excisional biopsy is the technique of choice when a lesion is relatively small and is believed to be benign. The lesion is excised in its entirety. Incisional biopsy is indicated when a lesion is large or a malignancy is suspected. A pie-shaped wedge is removed to include both normal and abnormal tissue. In some instances several specimens may have to be taken for adequate microscopic evaluation.

Step 1 Anesthetize the area, but do not inject directly into the specimen.
Step 2 Ensure that there are wide margins around the abnormal area and that the specimen is deep enough to evaluate the integrity of the basement membrane. Do not crush or macerate the tissue.
Step 3 Orient the specimen properly and immediately place it in preservative (formaldehyde).
Step 4 Provide the pathologist with an adequate history, clinical description , photographs, radiographs, and an exact location of the lesion.
Step 5 If the initial biopsy fails to confirm or is inconsistent with the clinical impression, repeat biopsies and clinical monitoring are necessary.

Traumatic Ulcers

The traumatic ulcer is an oral ulcer that is the direct result of an injurious event. Some common sources of trauma are sharp restorations, fractured teeth, orthodontic wires, ill-fitting dentures, thermal injury (hot or cold), chemical injury, and factitious injury (self-inflicted).

Signs and Symptoms

The border of the ulcer is irregular with an erythematous halo of variable width surrounding a gray-yellow crater (Fig 9-3). The ulcer can occur on any mucosal tissue, but is more commonly found on the buccal mucosa, tongue, floor of the mouth, and palate. The ulcer may or may not be painful or may only be painful while eating. The ulcer will heal in 7 to 14 days without scarring.

e9780867155297_i0273.jpg

Fig 9-3 Traumatic ulcer. Lesion of unknown traumatic origin located on the left floor of the mouth adjacent to the mandibular left premolars. Note the irregular margin and the narrow, distinct erythematous halo.

Diagnosis

Often the patient will relate a traumatic event that correlates with the oral ulcer, and a thorough intraoral examination may reveal sharp or defective restorations or prostheses. In other instances, careful questioning of the patient may elicit the source of the trauma.

Treatment

Step 1 If the source of the trauma can be identified (such as sharp restorations, fractured teeth, ill-fitting prostheses, etc), remove or repair the source of the irritant.
Step 2 If the ulcer is painful, a topical corticosteroid will eliminate the pain and promote healing.
Rx: Triamcinolone acetonide in Orobase, 0.1%
Disp: 5 g
Sig: Apply a thin film to the lesion after meals and at bedtime
or
Rx: Fluocinonide ointment (Lidex), 0.05%; mix with equal parts of Orobase
Disp: 10 g
Sig: Apply a thin film to the lesion after meals and at bedtime
or
Rx: Clobetasol propionate ointment (Temovate), 0.05%; mix with equal parts of Orobase
Disp: 10 g
Sig: Apply a thin film to the lesion after meals and at bedtime
Step 3 Even if the etiology of the traumatic oral ulcer is obvious, observe the lesion until it is completely healed.
Note: Oral candidiasis may occur in patients using topical steroid therapy . Monitor the oral cavity for the presence of a fungal infection. If the patient has a history of fungal infections while using steroids, initiate prophylactic antifungal therapy.

Recurrent Aphthous Stomatitis (Oral Ulcers)

Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease of the oral mucosa. The etiology is unknown; however, suspected predisposing factors include (1) local trauma, (2) microbial infections (eg, streptococci, varicella, and cytomegalovirus), (3) systemic conditions (eg, nutritional deficiencies and/or malabsorption syndrome resulting in decreased serum levels of folic acid, iron, and B-complex vitamins), systemic illnesses resulting in decreased immune status (HIV), (4) genetic factors (RAS may occur along family lines), and (5) immunologic factors (increased serum immunoglobulins; possible cell-mediated immune response).

Signs and Symptoms

Minor aphthae are usually less than 5 mm in diameter and are located on the labial and buccal mucosa, soft palate, and tongue and heal without scarring (Fig 9-4). Major aphthae are greater than 5 mm in diameter, are present for up to 6 weeks, and often heal with scarring. The lesions most often occur on the lips, soft palate, and tonsillar fauces resulting in severe difficulty in chewing and swallowing. Herpetiform ulcers usually begin in the third decade of life and are characterized by multiple ulcers (2 x 3 mm in diameter) that can occur anywhere in the oral cavity. These ulcers may coalesce to produce larger ulcers with irregular borders.

e9780867155297_i0275.jpg

Fig 9-4 Recurrent aphthous ulcer. A classic representation of the minor aphthous variant, this lesion is located on nonkeratized alveolar mucosa and has a regular margin with a diffuse erythematous halo.

Diagnosis

Diagnosis is based on the patient’s history and clinical findings.

Treatment

No medications have shown any consistent benefit in preventing recurrences of RAS. Corticosteroids have demonstrated some benefit in treating the existing lesions and decreasing the pain; antiseptic mouthrinses have been shown to decrease the intensity of pain, increase the rate of healing, and decrease the number of episodes of the ulcerations.

Step 1 Topical steroid agents
Rx: Triamcinolone acetonide in Orabase, 0.1%
Disp: 5g
Sig: Apply a thin layer to the lesion after meals and at bedtime
or
Rx: Fluocinonide ointment (Lidex), 0.05%; mix with equal parts of Orabase
Disp: 10 g
Sig: Apply a thin layer to the lesion after meals and at bedtime
or
Rx: Clobetasol propionate ointment (Temovate), 0.05%; mix with equal parts of Orabase
Disp: 10 g
Sig: Apply a thin layer to the lesion after meals and at bedtime
or
Rx: Dexamethasone elixir (Decadron), 0.5 mg/5 mL
Disp: 100 mL
Sig: Rinse with 1 teaspoonful (4.9 mL) for 2 minutes 4 times a day; do not swallow
Step 2 Antimicrobial mouthrinse
Rx: Chlorhexidine gluconate, 0.12%
Disp: 16 oz (473.2 mL)
Sig: Rinse with 0.5 oz (14.8 mL) 2 times a day for 30 seconds; do not swallow
Note: Oral candidiasis may occur in patients using topical steroids. Monitor the oral cavity for the presence of a fungal infection. If the patient has a history of fungal infections while using steroids, prescribe prophylactic antifungal therapy.

Xerostomia (Dry Mouth)

Xerostomia is the subjective complaint of dryness in the mouth. The most common causes of xerostomia are medications, head and neck radiation therapy, and Sjögren’s syndrome.

Signs and Symptoms

In addition to the patient’s complaint of dryness, the oral tissues may be dry and pale or red and atrophic. The tongue may display a decreased or total loss of filiform papillae resulting in a fissured and inflamed appearance. There can be an overgrowth of Candida albicans (under removable prostheses and at the commissures). The patient may complain of a burning sensation due to the loss of papillae on the tongue and/or a superimposed carididal infection. Another common complaint is an altered taste and smell. Also, the decreased salivary flow may predispose the patient to an increased caries rate especially at the gingival margins and exposed root surfaces.

Diagnosis

The diagnosis of xerostomia is based on the patient’s subjective complaint of a dry mouth, a thorough medical/dental history, and an objective assessment of signs of dryness. If the patient is suspected of having Sjögren’s syndrome, a labial salivary gland biopsy is helpful.

Treatment

Step 1 Salivary gland stimulation
Rx: Pilocarpine hydrochloride tablets (Salagen), />

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Related posts:

  1. 1 – The Diagnostic Process
  2. 5 – Traumatology (Adult)
  3. 8 – Prosthodontics
  4. 6 – Traumatology (Child)
  5. 2 – Medical Emergencies
  6. 3 – Periodontics

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Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 9 – Orofacial Lesions

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