ORAL MEDICINE An Overview

Gus Permana Subita, Drg, SpPM, PhD Department of Oral Medicine Faculty of Dentistry University of Indonesia Jakarta, 4 April 2007

Oral Medicine
Oral Medicine may be defined as the specialty of dentistry concerned with the health care of patients with acute or chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and medical management. It is also concerned with the investigation of the aetiology and pathogenesis of these disorders leading to understanding which may be translated into clinical practice.

Oral Medicine
Oral medicine is a clinical and academic specialty that is dedicated to the investigation, diagnosis, management and research into medically related oral diseases, and the oral and facial manifestations of systemic diseases. These include diseases of the gastrointestinal, dermatological, rheumatological, and haematological systems, autoimmune and immunodeficiency disorders, and the manifestations of neurological or psychiatric diseases Oral medicine is in fact the bridge between medicine and dentistry, if these discipline should be separated at all.

Penyakit Primer vs Penyakit Sekunder

International of Classification of Diseases of the Oral-maxillofacial region Spectrum of oral mucosal diseases.

Lesi Primer vs Lesi Sekunder

Papules Plaque Vesicle Bulla Ulcer Erosion Pustule Nodule Tumor Atrophy Crustae

Histopathology of mucosal lesions

Epithelial alterations
Hyperkeratosis Parakeratosis Acanthosis Spongiosis Hydrophic degeneration Acantholysis Extension of Rete Pegs Pseudoepitheiomatous hyperplasia Dyskeratosis Necrosis Ulceration Dysplasia Connective tissue alterations Inflammatory infiltration Hyperplasia Collagen degeneration Vascularity Mucous gland alterations

These basic forms will be referred to continuously throughout this module.

Classification
Based on Main Clinical Features:
White or white and red spots and plaques Red lesions Erosions Ulcers Blisters and vesicles Papillary-verrucous lesions Swelling (facial, salivary glands) Bleeding Peeling and crusting Tumour

Classification
Based on causative: Microbial (viral, fungal,bacterial) Chemical Physical (thermal, mechanical, ultraviolet) Infective stomatitis Non-infective stomatitis Tongue disorders Oral premalignancy Oral cancer Neoplastic and non-neoplastic diseases of salivary glands Soft tissue (mesenchymal) neoplasmas and lymphomas Melanoma and other pigmented lesions

 Main signs and symptoms:

Halitosis Facial swelling Swelling of the salivary glands Dry mouth/xerostomia Burning mouth syndrome Pain Facial palsy Pigmentation Purpura Sialorrhoea Trismus

Successful dental-oral therapy is based upon scientifically-based decisions involving

The diseases process, The identification of all etiologic factors, A correct diagnosis, Controlling the etiologic, predisposing, trigger factors, And correcting deformities produced by diseases.

Treatment plan for oral ulceration Patient presents with complaints

No

DIAGNOSIS Caused by underlying treatable disorder? FOLLOW-UP

Yes

TREAT UNDERLYING DISORDER

TREATMENT

Improvement in symptoms?

No

TREATMENT

Yes
CONTINUE TREATMENT

Yes

FOLLOW-UP

Improvement in symptoms?

No
SPECIALIST REFERRAL

The purpose of making a diagnosis

To be able to offer the most: Effective and safe treatment Accurate prognostication

Common complaints
Cervical lymphadenopathy Dry mouth (xerostomia) Halitosis (oral malodour) Lumps and swellings Pain Red, white and pigmented lesions Sensory and motor changes Soreness and ulcers

Chief complaint
When a patient uses the term sore or a sore to describe a complaint, this may indicate the presence of mucosal inflammation or ulcers from any cause except early ulcerative malignancies (which are usually painless)

History taking
General information Presenting complaint History of the present complaint Past medical history Dental history Family history Social history

Presenting complaint
Any history should begin by allowing the patient to explain the nature of the problem or reason for attendance What is the problem? Why have you come to see us today? Please tell me about the problem

History of Presenting symptoms

Timing:
When did this start? Is it constant, or occasional? If occasional
when does it occur? What makes it worse? What makes it better? ( including self-medications, e.g. analgesics.) Have you had this before? If so, did you attend a doctor/have tests/have treatment?

History of Presenting symptoms (cont)

Severity, duration and disability
What does it stop you doing? Does it interfere with your work/sleep/family or social life/recreation?

History of Presenting symptoms (cont)

Questions on pain or discomfort:
Site
where do you feel it most? Can you point to the site? Do you feel it anywhere else?

Character
What does it feel like?

History of Presenting symptoms (cont)

What is the location of the problem What did you notice first? Did you have any problem worse or symptoms related to this? What makes the problem worse or better? Have the symptoms gotten better or worse at any time? Have any tests been performed to diagnose this complaint? Have you consulted other dentists, physicians, or anyone else related to this problem? What have you done to treat these symptoms?

Past medical history

Previous episodes of similar or related problems, including medical consultations, tests and treatments including hospitalizations and operations Other previous illnesses, injuries or operations

Past medical history(Scully)

General symptoms, such as fever or weight loss Relevant symptoms related to body systems Medical or surgical consultations, investigations and treatments, including radiotherapy Current prescribed drugs (including alternative medicines Self-medications Complementary medicine Allergies Previous illnesses Hospitalizations Operations Anaesthetics Specific medical problems

Penyakit yang pernah diderita

Jantung Tekanan darah tinggi Tekanan darah rendah Kencing manis Kelainan darah Sakit kuning HIV Alergi Penyakit lain . Ya Ya Ya Ya Ya Ya Ya Ya Tdk Tdk Tdk Tdk Tdk Tdk Tdk Tdk

Tanda tangan pasien

Drug and allergy history

Current practitioner-prescribed drugs Self-medications Allergies

Dental history
Regularity of attendance for dental care Attitude to dental treatment Recent relevant dental problems Recent restorative treatment

Family history
A history of the same problem in blood relatives, which may indicate either a genetic disorder or predisposition, or common exposure to an environmental factor Family members, age, cause of death if premature and major illnesses

Social history
Occupation Social and family life Residence Recreations Habits:
Diet Smoking Alcohol and other recreational drugs

Clinical examination
General examination
Vital signs Other signs

Extraoral head and neck examination Intraoral examination

Intraoral examination

Assessment of important characteristics of ulcers

How long have you had the ulcer(s)? How many are there? Where is the ulcer located? Is it painful Do you know of anything that may have caused the ulcer e.g. taruma, eating hot or heavily spiced food? Have you ever had any ulcers before? If yes, when? How many? How often? How long do they last Are there any associated problems, e.g. pain, bleeding, halitosis? Is it getting bigger, smaller or staying the same size? Do you get tingling or itching before the ulcers appear? Do the ulcers start as blisters? Do you get ulcers at other body sites, e.g. skin, eyes, genital regions?

Assessment of important characteristics of ulcers

Site Single/multiple Size Shape Base of the ulcer Edge Pain Time period

Site
Adjacent to a sharp tooth edge ---- ulcus traumatic Interdental papilla ----ANUG

Shape
Round Crescentic Irregular Coalescing Angular Stellate Punched out

General investigations
Urinalysis Blood testing Skin testing Biopsy Imaging

Treatment Plan for Oral Ulceration

Patient presents with complaints

EVALUATION

ALTERNATIVE DIAGNOSIS

DIAGNOSIS

TREATMENT :
Nonpharmacological Pharmacotherapy

PREVENTION :
Follow-up Nonpharmacological

Treatment Plan for Oral Ulceration

TREATMENT OF ORAL ULCERATION : Nonpharmacological PREVENTION OF ORAL ULCERATION : Nonpharmacological

Pharmacotherapy

Pharmacotherapy

FOLLOW-UP
Yes No

CONTINUE TREATMENT

CHANGE TREATMENT

All lesions of the oral cavity can be placed in one of three broad morphologic categories: (1) Elevated (2) Depressed (3) Flat.

DESCRIBING ORAL SOFT TISSUE LESIONS MORPHOLOGY

As you encounter various oral lesions, you should be able to answer questions such as: Is the lesion elevated, depressed or flat? Is it generalized or localized? Is it single or multiple? Is it fluid filled or not? What is the character of the fluid, if present? What is the approximate size (use millimeters and centimeters) of the lesion? Is it larger at the base or on the top? If multiple lesions are present, are they separate or coalescing?

ELEVATED LESIONS
An elevated lesion is one in which the surface is above the normal plane of the mucosa. All elevated lesions are not necessarily symmetrical but may have irregular contours. Clinically, it is quite easy to determine that a lesion is elevated by looking at the lesion at different angles and relying on stereoscopic vision. Perspective is helpful since an elevated lesion may hide or cover any normal structures.

Elevated lesions may be localized or generalized.

A localized elevated lesion is limited to a small, focal area. A generalized elevated lesion involves most or all of an area or site. Some generalized lesions may involve more than one site. It is usually easier to determine the limits of involvement of localized lesions than of generalized lesions. Localized lesions may be single or multiple. The number of lesions are often characteristic for a particular disease. A single lesion is one lesion of a particular morphology. Where more than one lesion of a particular morphology is present, they are considered as multiple lesions.

Elevated lesions may be further divided into blisterform or nonblisterform lesions.

Blisterform lesions are those which contain a body fluid, usually identified by their characteristic translucent appearance. Tactile examination of a blisterform lesion will reveal a soft rebounding sensation. Blisterform lesions are given descriptive names, depending on their size and the material contained within the blister. A blisterform lesion is either a vesicle, pustule, or bulla.

 A vesicle is a blisterform lesion which is less than 5 mm in its greatest diameter and contains serum or mucin. The serum or mucin gives the vesicle a clear or translucent, slightly white appearance. Vesicles in the oral cavity are often collapsed due to trauma, creating a collapsed vesicle which appears white or cream colored. A pustule is a blisterform lesion that contains pus which imparts a yellowish coloration. It may be greater or less than 5 mm. A bulla is a blisterform lesion larger than 5 mm in its greatest diameter which may contain serum or mucin. It may occasionally contain extravasated blood. The color may appear clear, red or blue, depending upon the fluid content. Similar to vesicles, bullae often collapse due to trauma in the oral cavity and are termed collapsed bullae which are white or red in color.

Non-blisterform lesions are solid and contain no fluid. They are recognized by their opaque appearance. On palpation, they feel firm and solid. Non-blisterform lesions are also given descriptive names, depending on their size and pattern. A non-blisterform lesion is either a papule, nodule, tumor or plaque.

 A papule is a lesion which consists of tissue and is less than 5 mm in its greatest diameter. A nodule is similar to a papule in that it consists of tissue, but it is greater than 5 mm and less than 2 cm in its greatest diameter. A tumor is similar to a nodule in that it consists of tissue, but it is greater than 2 cm in its greatest diameter. A plaque is a slightly raised non-blisterform lesion which has a broad flat top like a plateau. It has a "pasted on" or "stuck on" appearance and is usually greater than 5 mm in diameter. The elevation and density of plaques vary. When the plaque is not as obviously raised above the plane of the normal mucosa, or not as dense, it will be more difficult to interpret as a "plaque".

A papule, nodule, and tumor may be classified as sessile or pedunculated according to their base or attachment to the mucosa.

A sessile lesion is a papule, nodule, or tumor whose base or attachment to the normal mucosa is the greatest diameter of the lesion.

A pedunculated lesion is a papule, nodule, or tumor that has an attachment to the normal oral mucosa which is smaller than the greatest diameter of the lesion. In other words, the lesion is attached by a stalk or pedicle.

 The size of a lesion is often a clue to its diagnosis. It is not necessary to measure exactly the size of a lesion. Only a reasonably accurate estimate of the lesion's size is expected. Size of lesions is best estimated by comparing the lesion with familiar landmarks of known size immediately adjacent to it. These landmarks include teeth, parotid papillae, lingual papillae, incisive papillae, etc.

 For example, lower incisor teeth are approximately 5 mm in their greatest width and upper central incisors, 8-9 mm in their greatest width. Molars are approximately 10 mm or 1 cm in their mesiodistal aspect. The lingual filiform and fungiform papillae are less than 1 mm in diameter.

 You will recall that more than one lesion of a particular morphology is considered multiple. Multiple lesions with any of the morphologic characteristics so far described can be separate or coalescing. However, in the oral cavity, small lesions coalesce more frequently than large ones.

 Separate lesions are usually few in number and relatively widely spaced, but not always. They usually remain individual, distinct lesions, even if they tend to enlarge after their initial appearance. Coalescing lesions are numerous and in proximity to one another. Their margins may merge and leave a single lesion, even if they enlarge only slightly after their initial appearance. With multiple lesions that vary in size, the morphology of peripheral lesions becomes important in deciding whether the lesions should be classified as separate or coalescing. Whenever both separate and coalescing lesions are present, the predominant type of lesion determines the correct morphologic classification. If neither separate nor coalescing lesions is predominant, it may be described as either.

DEPRESSED LESIONS
A depressed lesion is one in which the surface is below the normal plane of the mucosa. Most depressed lesions are ulcers. An ulcer is a loss in continuity of the oral epithelium. Clinically, the center of the ulcer is often yellow to grey with a red periphery. Occasionally, a red center may be observed. Ulcers often result from the rupture of elevated lesions such as vesicle, bullae, pustules, and papules. Some depressed lesions are the result of atrophy or scarring and have an intact epithelial surface. Other depressed lesions may.be pits or blind "pouches" caused by a failure of complete filling out during embryologic development. Clinically, it is quite easy to determine if a lesion is depressed by looking at the lesion from different angles and relying on stereoscopic vision. Depressed lesions may be single or multiple.

 A single depressed lesion is one lesion of a particular morphology. Where more than one lesion of a particular morphology is present, they are multiple. Since descriptors of single and multiple lesions vary slightly, single lesions will be considered first.

 Single depressed lesions Outline

regular - if the border is a continuous linear outline and resembles a circle or an oval. irregular - if the border has numerous deviations from a circular or oval pattern

Margin
Raised - margin is above the plane of the normal mucosa. Smooth - margin is on the same plane as the normal mucosa.

Depth - distance from the base of the ulcer to the plane of margin
superficial - less than 3 mm in depth. deep - greater than 3 mm in depth.

 Multiple depressed lesions have the same morphologic descriptors as discussed for single lesions: Outline, margin, depth, and diameter.In addition, multiple lesions may be either separate or coalescing. Separate lesions - few in number or widely spaced, not likely to merge or blend into one another, even if they enlarge. They remain distinct. Coalescing lesions - numerous and in proximity, may merge or blend into one another after minor enlargement. When this occurs, a single lesion is formed. The original outline of the initial lesions may or may not still be detectable. If both separate and coalescing lesions are present, the predominant type of lesion determines the correct morphologic classification. In this case, the lesions are best described as coalescing. If neither separate nor coalescing lesions are predominant, it may be described as either.

FLAT LESIONS
A flat lesion is one in which the surface is on the same plane as the normal oral mucosa. Because of this, any lesion of normal mucosal coloring would be undetectable (except on the dorsum of the tongue). Therefore, the only way most flat lesions can be detected is through a change in color.

 A flat lesion with an abnormal color is called a macule. Although color is a primary characteristic of macules, color will be the subject of another unit. Since the tongue is anatomically unique, special considerations must be given to flat lesions occurring on the dorsal and lateral borders of the tongue. Loss of papillae results in an apparent depressed lesion, but since the mucosal surface is intact, it is in fact a flat lesion. Since it does not involve an abnormality of color, however, it is not a macule. What you have to understand is that lesions of the tongue that involve loss of papillae are exceptions, the only flat lesions that are not macules. Lesions resulting from a loss of papillae may be single or multiple. Single and multiple lesions may be regular or irregular in outline.

Lesions of geographic tongue in full bloom are apparently depressed but they are just areas where the papillae have atrophied.

This is a scar from a severe burn. Mucosa doesn't scar easily, but it will scar. This lesion is depressed.

A blisterform lesion. Note: it is an unruptured blister. This is an unusual find in the oral cavity. Most blisters rupture before you see them.

A bulla is like a large blister.

This lesion has quite clearly coalesced. You are correct if you say this is very close to a plaque. There is overlap and nothing is pure. Best thing to do is see if you can find areas toward the periphery where small separate lesions are joining to form a coalesced lesion. This is a definite gray area.

A collapsed vesicle. Most of the vesicles you will see will have collapsed. This does not mean the lesion ceases to be a vesicular lesion. It just means the vesicles have collapsed.

Remember this one? Among other things, it is a good example of a deep, depressed lesion.

Depressed lesions are clearly sunk below the surface. This is hard to see in 2 dimensions.

Flat is even with the surface Depressed is deep to the surface Elevated is higher that the surface

Can you guess the width of the lesion at the arrow by comparing it to the central incisior?

Generalized over the right palate.

Note the irregular border of this ulcer.

Note these macules are on the same plane as the normal mucosa.

A localized lesion

Multiple elevated lesions of the buccal mucosa.

Sometimes depressed lesions come in groups called multiple.

Both the single and the multiple Lesions in this picture are irregular in outline.

A familiar picture. This lesion is also a nodule.

Nonblisterform is a solid lesion containing no fluid.

A papule - This is hard to demonstrate in a picture, but it is a small elevation. Review the drawing in "basic forms" and try to combine it in your mind with this picture.

Pedunculated is hard to show in a picture, but you can get the idea by combining these two pictures in your mind.

Leukoplakia is not the only lesion that can present as a plaque, but these are good examples.

A pustule. Pustules can be the abscess itself or they can be just the opening area where an abscess is burrowing through bone.

These borders are raised and also rolled. But all rolled borders are raised.

Same lesion as before, but note the regular border.

These lesions are clearly separate, and will probably never coalesce.

Sessile is broader at the base than at any other part of the lesion.

A single lesion

This is a Single Depressed lesion.

Note the single lesion on the right border of the tongue. Its borders are regular in outline, however the two single lesions toward the posterior are clearly irregular in outline.

Smooth borders of depressed lesions are simply not raised above the plane of the mucosa.

This is a superficial ulcer of the buccal mucosa.

A blisterform lesion is often translucent. Life is better than a picture. Translucent shows up better in life. Translucent means permitting the passage of light. Translucent lesions can be filled with clear fluid or fluid of some color, but the key is they transmit light.

A tumor - essentially a large nodule.

This lesion is not so obviously depressed as the previous one, but the red center is below the surface level.

Here is a histologic picture to make the point a little clearer.

This is yellowish gray, but you can have a bright red center too as in the previous example.

This is a translucent vesicle. It contains fluid.

Selamat belajar