“enign and Malignant Epithelial Oral Pathology” Edward ... · “enign and Malignant Epithelial Oral Pathology” Edward Halusic, Jr., DMD POMA District VIII 32nd Annual Educational

“Benign and Malignant Epithelial Oral Pathology”Edward Halusic, Jr., DMD

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 1

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Benign and Malignant Epithelial Oral Pathology

Edward J. Halusic, DMD

Diplomate, American Board of Oral and Maxillofacial Surgery

Private Practice, Greensburg, Pa.

POMA District VIII 32nd Annual Educational Winter SeminarSunday, February 3, 2019

Nemacolin Woodlands

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Disclosures

None

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Course Objectives

Upon Completion of the course, participants will be familiar with:

Differential diagnosis of some common reactive processes and soft tissue lesions in the oral cavity

Management strategies for these lesions

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Outline

Epithelial Pathology

Normal anatomic variants

Inflammatory

Infectious

Reactive/Traumatic

Premalignant

Malignant

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Geographic TongueBenign Migratory Glossitis

Erythema Migrans

• Harmless Condition

• Well defined, reddened areas on the dorsal and lateral tongue with slightly white or yellow-white, raised lines around the edges

• Condition usually waxes ad wanes in severity persisting for a period of time (days to weeks to months)

• Process repeats itself in a different area or areas after a few more days, weeks or months

• When the condition is “active”, the tongue is often sensitive and can feel like it has been scalded to hot, spicy, or acidic foods.

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Burning Mouth Syndrome

• Chronic Pain Condition

• Intraoral burning recurring for more than 2 hours per day for more than 3 months without clinically evident causative lesions

• Women 7:1.

• Usually perimenopausal or menopausal age group.

• 0.7 to 15 % of the population

• Anterior two thirds of the tongue

• Taste alterations

• Oral Dryness

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Burning Mouth Syndrome

• Complex disease without a clear etiology

• Not well understood or well managed by medicine or dentistry

• Neuropathic.

• Gustatory

• Primary BMS: No local or systemic causes can be identified

• Secondary BMS: Local or systemic caused can be identified

• Prognosis is poor. Spontaneous remission in only about 3% of patients in 5 years.

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Burning Mouth Syndrome Symptoms

• Burning of Oral Mucosa

• Alteration in taste such as bitter or metallic tastes

• Oral Dryness (Xerostomia) in spite of normal salivary flow

• Roughness, sandiness texture

• All of these symptoms can significantly affect quality of life

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Burning Mouth Syndrome Diagnosis

Fungal Infections

Mechanical Trauma

Thermal Trauma

Chemical Injury

Xerostomia

Parafunctional Habits

Oral Pathology

Allergic Contact Stomatitis

Must rule out Secondary BMS

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Burning Mouth Syndrome DiagnosisSubstance List for Allergic

Contact StomatitisChemicals Where found

Zinc, Cobalt, Mercury, Gold, Palladium Dental Materials

Nickel Sulfate Dental Materials, Stainless Steel, Food (e.g., shrimp and chocolate milk)

Sodium Lauryl Sulfate Toothpaste

Fragrance Mix Oral Care Products

Balsam of Peru Oral Care Products, Citrus Fruits, Spices, Cough Medicines and Lozenges

Cinnamic Alcohol Cinnamon and products with cinnamon flavor

Nasri-Heir et al, J Indian Prosthodontic Society, 2015 Oct-Dec; 15)4): 300-307

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Endocrine Disorders

Immunological Disorders (Sjogren’s)

GERD


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Basic Metabolic Panel

Iron Serum levels/ferritin

Vitamin B12 and folate levels to rule out associated anemias

ANA, Anti/SS-A, Anti/SS-B, Rheumatoid Factor to rule out Sjogren’s

CBC

Cytological smears if candidiasis is suspected

Salivary Flow Rates if xerostomia is suspected

Skin Patch Tests if allergic reactions are suspected


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Medications (Augment/Induce Burning(ACE), Xerostomia)


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Medications related to Hyposalivation/Xerostomia


Medications Examples

Tricyclic Antidepressants Amitriptyline, nortriptyline

Antipsychotic Carbidopa/levodopa,chlorpromazine

Antihistaminic Phenergan

Bronchodilator (anticholinergic and B-2 agonist)

Tiotropium, formoterol

Decongestant Oxymetazoline

Antidepressant Venlafaxine

Skeletal muscle relaxant Tizanidine

Antihypertensives Furosemide, clonidine, lisinopril, verapamil

Chemotherapy Cyclophosamide

Protease inhibitor for HIV Reyataz, Norvir, Kaletra

Opioid Hydrocodone, oxycodone

Benzodiazepine Diazepam

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Treatment of Burning Mouth Syndrome


Benzodiazepenes:

• Clonazepam. GABA agonist.

• 70% reduction in pain levels with oral dose of 0.5-1.5 mg/day to maximum of 3 mg. (Grushka et al.)

• Significant reduction in pain at dose of 0.5 mg/day after 9 weeks of treatment when compared to control group. (Heckman et al.)

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Anticonvulsants such as gabapentin at 300 mg/day showed some favorable results in one study which could not be confirmed in another study.

Tricyclic antidepressants at 10-40 mg/day have shown to be beneficial in relieving pain although side effect of xerostomia may be unfavorable.

SSRI’s: Paroxetine with initial dose of 10-20 mg/day to maximum of 30 mg/day revealed 80% of patients experienced pain reduction with 12 weeks.

Serotonin noradrenaline reuptake inhibitors: significant decrease in pain levels after 12 weeks of treatment with minalcipran 15 mg/day to 100 mg/day.

Histamine H2 receptor antagonist: significant improvement in pain levels using lafutidine(India) 10 mg twice daily for 12 weeks. It has a sensitive effect on capsaicin-sensitive afferent neurons improvement in pain levels using lafutidine 10 mg twice daily for 12 weeks. In US, equivalent would be famotidine or ranitidine.

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Alpha Lipoic Acid: Potent antioxidant. One study showed efficacy while another did not confirm the results.

Topical: Capsaicin. Hot component of chili peppers.

Topical Treatment: Clonazepam. 1.0 mg dissolved. 3 times per day. Hold for 3 minutes and expectorate. 66% of patients reported resolution of symptoms and 29% reported partial reduction of symptoms after 6 months.

Psychologic/Psychiatric Intervention: Individual or small group cognitive-behavior therapy has been shown to reduce the intensity of the pain of BMS. Some authors feel this is a critical component of treating patients with BMS as 50% of patients presented with psychiatric disorders including anxiety, depression, obsessive or psychosomatic symptoms.

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• Foods that cause burning or exacerbate symptoms should be avoided. ( Pineapple, tomato orange, lemon,etc.)

• Smoking, alcohol, and mouth rinses with alcohol should be avoided

• Toothpastes with abrasive substances should be avoided.

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Lichen PlanusCommon chronic mucocutaneousautoimmune mediated disease– 1.27% prevalence

• Most common in women 30‐60 yrs– 3:2 to female to male

• Associated with cell‐mediated immunologicdysfunction

Erosive

Skin Lesions • 4P’s- Purple- Pruritic- Polygonal- Papules

- Most commonly seen on the flexor surfaces

Reticular

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Lichen Planus TreatmentTopical SteroidsSystemic SteroidsSystemic Steroid Sparing Agents (Calcineurin Inhibitors)

-Tacrolimnus (topical)

-Cyclosporine (topical)

Erosive

Skin Lesions • 4P’s- Purple- Pruritic- Polygonal- Papules

- Most commonly seen on the flexor surfaces

Reticular

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Lichen Planus Treatment

Topical Steroids

Lidex Gel (Fluocinonide) 0.05%• Disp: 30 g tube• Coat the lesion with a thin film after

each meal and at bedtime

* Can be compounded with Orabase(methylcellulose base)

Dexamethasone Elixir (.5mg/ml)

• Disp: 250cc• Sig: Rinse with 1 teaspoon (5ml) 4

times a day and spit

• Do not eat or drink for 30 minutes after using the elixir

• Advantages- covers large area of oral cavity

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Calcineurin Inhibitor

Tacrolimus 0.1%• Disp: 30 g tube• Sig: Apply to affected site twice daily

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Systemic Steroids

Prednisone• 8 week regimen. 10 mg. x 105 tablets. • 20 mg four times per day every other day for two

weeks.• 20 mg twice per day every other day for two weeks.• 20 mg once per day every other day for two week.• 10 mg once per day every other day for two weeks.

Medrol Dose Pack• Disp: One pack• Sig: Use as directed

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• Susceptibility to infection- Oral candidiasis

• Insomnia- Dose oral steroids in the morning

• Hyperglycemia• Poor wound healing• Capillary fragility• Hypertension• Glaucoma• Adrenal suppression• Mood swings• Peptic ulceration

- Care with ASA/NSAIDS, consider PPI

• Cushing syndrome

Complications of Steroid Therapy

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• Reported 0.04 to 1.74% of oral lichen planus has malignant transformation to squamous cell carcinoma

- Mainly erosive & atrophic forms, poorly controlled

• Must see classic LP i.e. bilateral, symmetric, reticulated, at the usual sites

• Repeat biopsy if change in the character of the lesions

Squamous cell carcinoma arising in Lichen Planus

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Differential Diagnoses

• Lichenoid Drug Reaction

• Lichenoid Contact Stomatitis

• Chronic Ulcerative Stomatitis

• Vesiculobullous disease

• Lupus Erythematosus

Case

• 54 year old female presents with a 13 month history of “oral sores”

• She has seen numerous providers- Past diagnoses and treatment include: shingles,

thrush, and herpes• PMHx: Hx MI, Hx pericardial effusion, gout• Meds: Aspirin, Carvedilol, Citalopram, Furosemide,

Docusate Sodium, Eliquis, Atorvastatin, Allopurinol, Albuterol, Maalox, Ambien, Magic Swizzle, Zofran (prn)

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• Lupus Erythematosusallopurinol

Case

• 54 year old female presents with a 13 month history of “oral sores”

• She has seen numerous providers- Past diagnoses and treatment include: shingles,

thrush, and herpes• PMHx: Hx MI, Hx pericardial effusion, gout• Meds: Aspirin, Carvedilol, Citalopram, Furosemide,

Docusate Sodium, Eliquis, Atorvastatin, Allopurinol, Albuterol, Maalox, Ambien, Magic Swizzle, Zofran (prn)

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Medications associated with lichenoid reactions

- Antihypertension agents- Diurectics (e.g. HCTZ), beta blockers, ACE

inhibitors- Sulfonylureas- Levothyroxine- Sulfasalazine- Allopurinol- NSAIDs- Carbamazepine- Some statins- Biologics such as TNF alpha inhibitor

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Lichenoid Reaction to Gold

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New Case

• 66 yo female presents with CC of “my gums hurt bad”• PMHx: Hypertension, thyroid disease, and arthritis

• She is being worked up for autoimmune disease • Arthritis vs connective tissue disorder

associated with a rash on her chest and arms for years

• Meds: Prednisone 5 mg/day, Citalopram, Bupropion, Lisonopril, Levothyroxine, Methotrexate, Folic Acid, and Vitamin C, B12 injections

Exam

• Posterior left lateral border of the tongue, there is a 1cm ulcer

• Maxillary left alveolar crestal mucosa tooth area 13: There is erythema and a 0.3 cm small ulceration

• Right mandibular alveolar crest, #30 area: ulcer with a pseudomembrane 0.5 to 0.7 cm

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Biopsy of tongue: Ulcer and Epithelial Dysplasia

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Methotrexate

New Case

• 66 yo female presents with CC of “my gums hurt bad”• PmHx: Hypertension, thyroid disease, and arthritis

• She is being worked up for autoimmune disease • Arthritis vs connective tissue disorder

associated with a rash on her chest and arms for years

• Meds: Prednisone 5 mg/day, Citalopram, Bupropion, Lisonopril, Levothyroxine, Methotrexate, Folic Acid, and Vitamin C, B12 injections

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Potential etiologies for oral ulceration

• Trauma• Factitious

• Chemical• Idiopathic

• Recurrent Aphthous Stomatitis• Medication-Related Ulceration• Infectious Ulceration

• Viral• Herpes simplex virus• Varicella zoster (Shingles)• Epstein-Barr virus

• Fungal

• Mucocutaneous Disease• Lichen planus• Erythema Multiforme• Benign mucous membrane pemphigoid• Pemphigus vulgaris

• Autoimmune/Systemic Diseases• Celiac disease• Crohn’s • Bechet’s disease• Lupus erythematous

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Clinical History

• Patient Presents with non-healing ulcer of several weeks duration

• CC: “My tongue hurts”

• History reveals patient was biting his tongue during the night and was waking up in pain. Ulcer seem to be secondary to repetitive trauma.

• Dx: Nocturnal Tongue Biting

• Rx: Occlusal Night Guard to protect tongue from trauma of biting.

Pre Occlusal GuardPre Occlusal Guard

Post Occlusal Guard

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Aphthous Ulcers

• 10-20% of the general population• 40+% of college-age pop during exams• Idiopathic• Immune dysregulation• Tan-gray surface coat with fiery red-halo• Origin on loose, NON-keratinized mucosa• Unlikely to develop AFTER ~40yrs

3 Forms

• Minor• 80%, 4-6mm diameter, round to oval, 7-

10 day duration• Major

• More rare, >1 cm, irregular outline, 4-6 week duration, heals with scaring

• Clusterform• Punctate 2-3 mm, 10-100 lesions, • Extend onto keratinized tissue

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Clinician’s Guide Treatment of Common Oral Lesions. Siegel, Silverman, and Collection 6th Ed. BC Decker.

MBX for palliative treatment.

Equal part of:- 2% Viscous Xylocaine- Maalox-Benadryl Elixir (2.5 mg/ml)

Treatment-Aphthous Ulcers

• Rx: Triamcinolone acetonide (Kenalog) in Orabase 0.1%Disp: 5gm tubeSig: Apply to affected area t.i.d. for no more than 2 weeks(DO NOT RUB IN)

• Rx: Dexamethasone elixir (0.5mg/5ml)Disp:200ccSig: Swish with 1 tsp for 2 min then spit out, q.i.d.

Treatment is usually only for major or multiple, symptomatic aphthae.

Do no eat or brush 30 minutes after application.

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• Aphthous stomatitis

• No vesicles• Begins as an ulcer• Disproportionate pain• Loose, non-keratinized

mucosa• Round, oval red halo

• Herpes stomatitis

• Mult. Small vesicles• Merge to form ulcers• Painful• Keratinized mucosa• Irrregular

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Herpes Simplex Virus

• Retrograde travels to sensory ganglia• Virus remains dormant in

ganglia until reactivation • Viral latency• Recurrence is heralded by itching,

tingling, burning sensation• Virus then travels down

sensory nerve • Reinfecting epithelium

• Fragile vesicles form in clusters on keratinized epithelium

• Scratching vesicles can lead to autoinoculation of other sites

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Treatment – Recurrent HSV

• Rx: Docansol (Abreva) cream (OTC)Disp: 2gm tubeDab on lesion 5 times daily during waking hours, for 4 days beginning when symptoms first appear. (NOT for use intraorally. On lips only.)

• Rx: Valacyclovir (Valtrex) caplets 500 mg Disp: 8 capsTake 4 caps as soon as prodromal symptoms are recognized and then 4 caps twelve hours later

• Lysine 1000 mg; 500 mg twice per day.

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Suggested Drug Therapies for Oral Candidiasis

Rx: Mycelex (clotrimazole) troches 10mg or Nystatin pastilles• Disp: 70 troches (or pastilles)• Sig: 1 troche (or pastille) dissolved slowly in mouth 5 times a

day for 14 days

Rx: Fluconazole (Diflucan) tablets 100mg • Disp.: 15 tabs• Sig: Take 2 tabs stat, then 1 tablet daily until gone

Patients with denture stomatitis (with candidiasis)Rx: Nystatin ointment• Disp: 30 gram tube • Sig: Apply to denture base and insert denture t.i.d. (Note: The patient should also be instructed to clean denture and soak. If the patient wears a partial denture with metal connectors, avoid bleach solutions– Use OTC soaking product or Nystatin suspension)

Clinician’s Guide Treatment of Common Oral Lesions . Siegel, Silverman, & Sollecito. 6th Ed. BC

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Squamous Papilloma

• Caused by HPV 2, 6, 11, 57 (low risk types)• Immunosuppressed patients at a higher risk• Painless exophytic pedunculated or sessile masses

with a cauliflower-like surface• Most frequent sites: soft palate, tongue, lip• Less than 0.5 cm in diameter• Differential: Verruca, condyloma, Heck’s• Treatment: Surgical excision

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• Patient presents with an exophytic white lesion lower lip

• Previous excision in 2008Verruca Vulgaris (common wart)

• HPV 2, 4, 6, 40 (low risk types)• Can spread by autoinoculation• Most common in children• Most frequent intraoral sites are lip, labial

mucosa, and anterior tongue • Single or multiple, white, pedunculated or

sessile, papillary or pebbly lesion(s)

Treatment• Excision• CO2 Laser: High rate of efficacy

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Diagnosis

• Papillary keratosis• Mild epithelial dysplasia

• PVL? Proliferative Veruccous Leukoplakia

Clinical History- 74 yo female

• Patient presents with a rough white patch of the maxillary molar area (#2-3) of 3 years duration.

• A smaller patch is present on the contralateral side in the area of #13-14.

• PMHx: Hypothyroidism, Hx rheumatic fever• SH: 1/2ppd (15 pack years)• Ddx: Hyperkeratosis, verrucous carcinoma

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Case History

• 71 yo female• Greater than 1 year history of multiple tongue lesions.• “Fibrotic tissue at the lateral border of the tongue and

papillary growths present adjacent to the fibrotic tissue.”

• PMHx-hypertension, osteoporosis, hyperlipidemia and Sjogren’s syndrome.

• Previous pathology report from the right buccal mucosa interpreted as a benign squamous papilloma from an outside institution.

Verrucous CA Papillary keratosis with dysplasia

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Proliferative Verrucous Leukoplakia:

• Condition characterized by the development of multiple, persistent, leukoplakias

• Not associated with tobacco use• Many will develop a verrucous carcinoma

and/or a squamous cell carcinoma• Long term follow-up warranted

MAJOR CRITERIA MINOR CRITERIA

A. A leukoplakic lesion with more than two different oral sites.B. The existence of a verrucousarea.C. The lesions have spread or enlarged during developmentof the disease.D. There has been a recurrence in a previously-treated area.E. Histopathologically, there can be from keratosis to verrucous hyperplasia,verrucous carcinoma or OSCC, whetherin situ or infiltrating.

A. An oral leukoplakic lesion that occupies at least 3 cfm when adding all the affected areas.B. The patient is a female. C. The patient (male or female) is a non-smoker. D. A disease evolution higher than 5 years.

In order to make the diagnosis of PVL, it was suggested that one of the two following combinations of the criteria mentioned before were met,

1. Three major criteria (Criterion E must be fulfilled) or 2. Two major criteria (Criterion E must be fulfilled) + two minor criteria.

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History

• 59 year old male • Social Hx: -Tobacco, ETOH Socially• Irregular dental care intervals• Previousy Biopsies 4 & 2 yrs ago• Lesion is spreading to adjacent teeth• Previous Pathology: Focal keratosis

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Malignant Epithelial Pathology

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Clinical History

• 66 yo male with history of SSC R neck 10 years ago treated with chemoradiation

• Now with induration of the left alveolar ridge under denture and with rapid growth

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Verrucous carcinoma

Treatment and prognosis• Surgical excision without neck dissection• Very low change of metastasis• Recurrence depends on ability to excise• 90% disease-free after 5 years

Verrucous carcinoma- Clinical features

• Low-grade variant of SC• Mostly men >55 years old (appears a decade sooner

than regular SCC)• Usually large lesion when diagnosed• Painless, slow-growing• Papillary or verrucous surface• Usually white in color, depending on amount of

keratin• Mary arise in proliferative verrucous leukoplakia

(PVL)

Verrucous carcinoma

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A word about bisphosphonates…..

Complete Dental Exam

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Thank you!!

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Documents

“enign and Malignant Epithelial Oral Pathology” Edward ... · “enign and Malignant Epithelial Oral Pathology” Edward Halusic, Jr., DMD POMA District VIII 32nd Annual Educational