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الدكتورسعد يونس سليمان

Anatomy of The Oral Cavity
The oral cavity extends from the vermilion border of the lips( i.e. the junction between the skin which is keratinizing and the mucus membrane which is non- keratinizing and pink) to the oropharyngeal isthmus, i.e. up to the anterior pillar of tonsils.

Common disorders of oral cavity

Ulcers of oral cavity Miscellaneous lesions of tongue and oral cavity Tumours of Oral Cavity

Ulcers of oral cavity

Causes: 1- Infection: (a) viral
Herpes Simplix


(b) Bacterial infection:Vincent’s infection ( acute necrotizing ulcerative gingivitis)Highly infectious ulcerative lesions affecting the gingivae and tonsils Fusiform bacillus and a Spirochaete . It was common during the First World War due to lack of hygiene in cleaning of eating and drinking utensils. Diagnosis: swab from the affected areaTreatment:Systemic antibiotic: Penicillin or Erythromycin and metronidazole.Frequent mouth washes ( with sodium bicarbonate mouth solution).Attention to dental hygiene.

Chronic bacterial infection

Tuberculous Ulcer (undermined edge)
Syphilitic ulcer Deep with punched out edge
the Snail track ulcer is seen secondary Syphilis

Infection ( cont.)

(c) Fungal ulcers ( moniliasis or thrush) Predisposing factorprolonged antibiotic therapy. poorly nourished children debilitating illness. Diagnosis: creamy-white plaque ..easily removed with slight bleeding.Treatment: …Topical application of: Nystatin Clotrimazole 1% of aqueous solution of Gentian Violet after each feed.

2-Immune disorders: (1) Aphthus ulcer: (Recurrent Aphthus Ulcer RAU, Recurrent Aphthus Stomatitis RAS, Recurrent Oral Ulcer ROU): Benign, recurrent ulceration of the oral mucosa, which appear as painful white or yellow ulcer surrounded by bright red area.

INCIDENCE: common form of mouth ulcer SEX: women > men. AGE: any, but usually first appear between the age of 10 and 40.AETIOLOGY: unknown. The following factors may be suggested:Autoimmune process ( attack of mucous membrane by the own body’s immune system).Hereditary. The patient often have positive family history.Nutritional deficiency (vitamin B 12, folic acid and iron).Physical or emotional stress.Viral or bacterial infection.Food allergies.Hormonal changes related to menstrual cycles.

CLASSIFICATION: They are of two types:

Minor aphthus ulceration: More common 2-10mm in size Multiple Painful They heal in about 7-10 days without leaving a scar.
Major aphthus ulceration: Less common 2-4 cm in size Usually single Painful They heal in about 3-6 weeks with a scar.

Treatment of aphthus stomatitis Minor aphthus: treatment is symptomatic as most ulcers heal spontaneously. Avoid oral trauma Topical analgesics (such as lidocaine) Topical steroids Antimicrobial mouth washes to prevent secondary infection Major aphthus: Treatment is more aggressive. Steroid and antibiotic mouthwashes Short course of systemic steroid : 30 to 60mg of oral prednisolone. Any persistent ulcer should be biopsied to exclude malignancy.

Behcet’s Syndrome (occulo-oro-genital syndrome)

is characterized by triad of (1) aphthus-like ulcers in the oral cavity (2) genital ulceration (3) uveitis. There may also be vasculitis of the skin, synovitis and meningoencephalitis. It is a relapsing condition of unknown aetiology.

3- Traumatic ulcer

Physical: cheek bite, ill-fitting denture. Chemical: silver nitrate, phenol, aspirin burn. Thermal: hot food or fluid



4- Neoplasms: Squamous cell CA Minor salivary glands’ CA5-Skin disorders: Erythema multiforme Lichen planus Erythema multiforme
Lichen planus

6- Blood disorders:Leukaemia, agranulocytosis.7- Drug allergy: Systemic administration penicillin, tetracycline, sulpha …etc. contact stomatitis due to local reaction to mouth washes, tooth paste, prosthetic dental materials …etc.8- Vitamin deficiencies.9- Miscellaneous: radiation mucositis, cancer chemotherapy, diabetes mellitus, uraemia.

Agranulocytosis

Leukaemia
Mucositis

Miscellaneous lesions of tongue 

Median rhomboid tongue

Geographical tongue (migratory glossitis)

Hairy tongue:

Fissured tongue:

Ankyloglossia (Tongue tie): Fordyce’s spots: Normal frenulum


Cystic : Mucoele: retention cyst of minor salivary glands. Ranula Dermoid

Ranula

It is a cystic translucent lesion seen in the floor of mouth on one side of the frenulum and pushing the tongue up. It arises from the sublingual salivary gland due to obstruction of its duct. Treatment is complete surgical excision if small, or marsupialisation, if large.

2- Premalignant lesions: (a) Leucoplakia: Diagnosed clinically. White patches on the oral mucosa are abnormal; if they can be removed by spatula the diagnosis is usually candida. Aetiology is unknown. Treatment is by excision by using the KTP laser.

(b) Erythroplakia is a red patch on the mucosal surface and has a high malignant potential. It should always be widely removed and a split-thickness graft applied. (c) Melanosis and mucosal hyperpigmentation: Benign pigmented lesions of oral mucosa may transform into malignant melanomas.

(3) Malignant lesions Carcinoma of oral cavity Non-squamous malignant lesions Minor salivary gland tumours Melanomas Lymphomas

Symptoms of Pharyngeal Disease

1. Sore throat 2. Dysphagia 3. Difficulty in speech 4. Difficulty in breathing 5. Cervical lymphadenopathy

Infections of The Pharynx

In the pharynx the most common site involved in an infection is the oropharynx. In the oropharynx the area involved are: The lateral wall ( tonsillitis ). the posterior wall (Pharyngitis). the floor( Lingual tonsillitis). The roof ( the soft palate) is rarely infected.

Acute Pharyngitis

Most common cause of sore throat in adults. occurring primarily during the winter months and less often in autumn and spring. 40-60 % viral origin. It precedes the common cold, and may accompany influenza, measles, infectious mononucleosis, scarlet fever, typhoid fever or small pox



Symptoms: Sore throat Feeling of coldness Slight pyrexia Headache Backache and joint pain. The throat feels dry, or painful especially on swallowing. Some hoarseness. These symptoms last for a day or two .

O/E Redness.Swelling of the mucosa. Tender cervical LAP. In children the mouth should be examined for Koplik’s spots in case the pharyngitis is the precursors of measles.

Treatment Self-limiting disease (3-4 days ); so treatment is only symptomatic Bed rest. Analgesic (paracetamol) Warm fluids by mouth. If the attack is prolonged or the constitutional symptoms are severe antibiotics are prescribed: Penicillin or erythromycin.

Membranous Pharyngitis

What is a pharyngeal Membrane? What is a True Membrane? What is a False Membrane?
Inflammatory reaction mucoid or purulent Exudate  coverthe pharyngeal mucosa and form a true MembraneThe underlying mucosa is intact So removal does not leavebleeding surface Certain Inflammatory reaction Necrosis of surface epithelium The subepithelial tissue produce FIBRINOGEN change to fibrin form the false membrane (with the necrotic epithelium)The membrane covers the submucosa because the epithelium is destroyed  removal leaves bleeding surface Covering the pharyngeal mucosa by an exudate


1- Acute simple pharyngitis 2- Acute tonsillitis 3- Moniliasis 4-diphtheria 5- Vincent Angina 6- Infectious Mononucleosis 7- Agranulocytosis 8- Acute leukemia
The ulcer is covered by a FALSE MEMBRANE Usually Unilateral - Exceeds the limit of the tonsil to the pillars - Dirty grayish with offensive odor - Adherent to the underlying tissue - Removal leaves bleeding surface - Reforms rapidly after removal
False membrane Unilateral Not limited to the tonsil Adherent and reforms rapidly after removal Leave bleeding surface on removal
False membrane similar to diphtheria but bilateral
True membrane covering the ulcers Diffuse hyperemia of Ph mucosa Multiple small white patches on the oral & ph mucosa Removal of these patches reveals superficial small ulcerations
Extensive necrotic ulceration Covered by False membrane Surrounded by LITTLE REACTION You need to do Blood Picture Bone Marrow aspirate
Extensive necrotic ulceration Covered by False membrane Multiple hemorrhagic petachiae You need to do Blood Picture Bone Marrow aspirate
A true membrane Limited to the tonsil Usually bilateral Easily removed Removal does not leave bleeding surface

Diphtheria‘Bull-neck’ Diphtheria

Chronic pharyngitis
Non specific Chronic simple pharyngitis
Specific -Tuberculosis - Syphilis

Nonspecific chronic pharyngitis Chronic infection of the aggregates of submucosal lymphatics in the posterior pharyngeal wall leading to what is called" granular pharyngitis". A frequent finding is a thick vertical bands of lymphoid tissue on the posterolateral wall of the pharynx behind the posterior pillar of the fauces- the so-called lateral pharyngeal band.

Etiology : 1-Recurrent acute pharyngitis 2-Chronic sinusitis with post-nasal drip 3- Mouth breathing 4- Industrial fumes, Smoking & spirits 5- GERD


Symptoms : - History of repeated attacks of sore throatThroat irritation & FB sensation due to postnasal drip (hemming نحنحه&hawking تنخيم)-Tiring of voice( not hoarseness)- Fear of cancer may be dominant in patient's mind.Signs: - Catarrhal, mild hyperaemia of the pharyngeal mucosa- Hypertrophic, scattered nodules on the posterior pharyngeal wallTreatment: of the cause

Treatment: Cessation of smoking. Appropriate treatment of postnasal drip and acid reflux. Reassurance by the exclusion of malignancy. Soothing gargles.

(أَمَّنْ خَلَقَ السَّمَاوَاتِ وَالْأَرْضَ وَأَنْزَلَ لَكُمْ مِنَ السَّمَاءِ مَاءً فَأَنْبَتْنَا بِهِ حَدَائِقَ ذَاتَ بَهْجَةٍ مَا كَانَ لَكُمْ أَنْ تُنْبِتُوا شَجَرَهَا أَئِلَهٌ مَعَ اللَّهِ بَلْ هُمْ قَوْمٌ يَعْدِلُونَ) [النمل: 60]