3 Benign Inflammatory Lesions

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‫حممد البابلي‬.

‫د‬

Benign Inflammatory Lesions


- Aphthous stomatitis
- Traumatic ulcer
- Geographic tongue (benign migratory glossitis)/erythema migrans
- Lichen planus
- Inflammatory papillary hyperplasia
- Epulis fissuratum (inflammatory fibrous hyperplasia)
- Contact stomatitis from cinnamon/medication burn
- Dentifrice related sloughing

1. Aphthous stomatitis (canker sores):-


Recurrent aphthous stomatitis (RAS) is one of the most common and painful conditions in
the oral cavity. Although variable, the lesions typically begin in childhood or adolescence,
occur more frequently in females and tend to be seen less often in adults over 40.
Although no single causative agent has been identified, the accompanying mucosal
damage appears to be a T cell-mediated immunologic reaction.
Aphthous ulcers present in one of three forms: major, minor and herpetiform. Differences
in minor and major aphthous ulcers are generally dependent on size and healing. Minor
aphthous ulcerations range from 3-10 mm and generally heal within 1-2 weeks. The major
form measures more than 1 cm, may take up to 6 weeks to heal, and may scar. They are
both found on areas of unattached mucosa, such as the buccal and labial mucosa, as
opposed to recurrent herpetic lesions, which are limited to attached mucosa such as
gingiva. One to multiple ulcerations may present as shallow, round to oval, yellow-white
ulcerations with a red border. Herpetiform aphthae are less common, and while not
associated with the herpes virus, are named because of their clinical appearance.
Herpetiform aphthae are the least common form of RAS and are often found in a more
localized area, usually not on the lips, and consist of small individual lesions which can
combine to form larger ulcerations. Although the lesions usually heal within 7-10 days, the
outbreaks are often more frequent.
Etiology: The cause is not known, but is most likely multifactorial, and the following have
been reported as some of the possible causative factors. Food allergies, stress, trauma,
hormonal influences, smoking cessation, immunologic factors, GI disease such as Crohn’s
or Celiac Disease and nutritional deficiencies such as B12 may have possible causal
factors associated with RAS. Certain HLA types have been associated with aphthae.
Treatment: Review the patient’s medical history to rule out the need for medical referral
for detection of systemic disease. Aphthous ulcers are an immunologic condition and
treatment should be directed toward suppressing the immunologic reaction responsible for
the lesion. Many patients with mild or intermittent lesions may not require any treatment
or may use over-the-counter anesthetic or protective bioadhesive products. RAS is not
associated with herpes or any other viral infection and cannot be treated with anti-viral
medications. The chemical cautery agent, silver nitrate, can cause significant soft tissue
damage and should not be used in treatment.
‫حممد البابلي‬.‫د‬
Most patients who seek more aggressive treatment respond well to local high potency
topical corticosteroids, which carry a lower risk of adverse effects than systemic treatment
and should be considered the first line of treatment. Initiation of healing is usually noted

within 24-48 hours with 0.05% betamethasone or clobetasol gel. These gels should be
applied 4-5 times daily and are more effective intraorally than ointments or creams.
For patients with multiple lesions, or RAS in difficult to reach locations such as the soft
palate or tonsillar pillars, syrups or elixirs may be more practical. For example,
prednisolone is available in syrup form and can be used in a swish and spit regimen.
Another product for use in the fauces is beclomethasone dipropionate aerosol spray. In
cases resistant to these medi- cations, systemic steroids in tablet form may be considered
or else a swish and swallow steroid syrup can be used for both topical and systemic effects
Prognosis: Good, if the patient can gain relief from pain and sustain adequate nutrition
and hydration.
Differential Diagnosis: They are commonly confused with herpetic ulcerations. Possible
differential diagnoses include: trauma, soft tissue lesions due to inflammatory bowel
disease.

2. Traumatic ulcer:-
An ulcer is a localized area of discontinuity in surface epithelium. Traumatic ulcers are
frequently observed in the oral cavity and can be of such varying size and shape that they
are difficult to characterize. Simple traumatic ulcers are most often found on the buccal
mucosa, tongue, and lips, but may also occur anywhere in the mouth. They appear as areas
of erythema covered by a yellowish membrane of variable thickness. A rolled
hyperkeratotic border may develop adjacent to the ulcer.
Etiology: In many cases of traumatic ulceration, there is a corresponding source of
irritation. They may be due to mechanical damage from food, self-inflicted injury (such as
biting), occur due to mastication, a result of toothbrushing injury, malocclusion, broken
down or sharp teeth, placement of restorations, prosthesis irritation or injury during sleep.
Ulcerations can also be caused by thermal, chemical or electrical burns.
A histologically specific type of ulcer with elevated and indurated margins called
traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) resembles squamous
cell carcinoma. It most often affects the tongue and exhibits deep inflammation that
resolves more slowly and typically requires biopsy. An unusual occurrence is that
incisional biopsy often appears to initiate healing.
‫حممد البابلي‬.‫د‬
Treatment: Relieving an obvious source of irritation or toxic agent should result in
resolution of an ulcer. Symptomatic relief can be provided by over-the-counter
bioadhesive preparations. In some cases clinicians advocate application of corticosteroids
to speed healing, while others claim this will delay healing.
Prognosis: When the source of the trauma is removed, the ulcer should resolve. If healing
does not occur in 2-3 weeks, a biopsy must be performed.
Differential Diagnosis: Squamous cell carcinoma, Riga-Fede disease, TUGSE, ulcerative
mucosal disease such as lichen planus.

3. Geographic tongue (benign migratory glossitis) / erythema migrans:-


Benign migratory glossitis (BMG) is a common benign lesion that most often affects the
tongue and sometimes other oral mucosal surfaces (erythema migrans). It is an
inflammatory disorder characterized by multiple erythematous areas representing loss of
filiform papillae surrounded by a yellow-white irregular border. The map-like areas of red
and white, (hence the name geographic tongue), usually resolve within a few days, but
may quickly develop in another area. Patients with fissured tongue often have geographic
tongue as an accompanying condition. When the patient is asymptomatic, BMG is often
noted on a routine dental exam or a patient/parent may seek consultation when they notice
the appear- ance of the tongue or experience symptoms.
Etiology: Widely considered to be unknown, although some authors propose an
association with psoriasis.
Treatment: In the great majority of cases, no treatment is required other than reassuring
the patient that BMG is a benign entity. If a patient complains of burning or sensitivity that
affects daily life, topical corticosteroids such as betamethasone gel applied in a thin layer
may provide symptomatic relief. In a recent study of long standing, symptomatic BMG,
cyclosporine rinses or topical 0.1% tacrolimus ointment have been used with success.
Prognosis: Typically, BMG is a chronic condition with periods of exacerbation and
remission. According to a recent study, taste is not affected by BMG.
Differential Diagnosis: The lesions of geographic tongue are characteristic of the
condition, however, it may be misdiagnosed as candidiasis.
‫حممد البابلي‬.‫د‬

4. Lichen planus:-
Lichen planus is a relatively common chronic, inflammatory, mucocutaneous disease seen
most often in middle-aged females. Cutaneous lesions appear as multiple pruritic, purplish,
polygonal papules. On close examination, the skin lesions, which occur mostly on
extensor surfaces of the extremities, will show a fine lace-like pattern of lines known as
Wickham’s striae. Oral lichen planus (OLP) occurs most often in the absence of skin
lesions. There are basically two main forms of OLP, reticular and erosive. The reticular
form is more common and usually appears as multiple lesions with a bilateral symmetrical
pattern. It begins as small white lesions which join to form an annular or plaque-like
pattern. The plaque-like form may be difficult to distinguish from leukoplakia. A typical
appearance shows slender white-gray lines radiating from the oral papules (Wickham’s
striae). Instead of the reticular pattern, the dorsal tongue may exhibit more of a keratotic
plaque-like lesion.
Erosive lichen planus lesions are usually symptomatic to patients and therefore the patient
is more likely to seek professional advice. Atrophic, erythematous lesions with central
ulceration and fine white striae on the periphery of the erosions are seen clinically. If
confined to the gingival mucosa in a pattern scalloping the teeth, this is termed
desquamative gingivitis.
Etiology: The cause is unknown, but appears to be multifactorial and is characterized by a
T- cell medicated chronic immune response and abnormal epithelial keratinization..
Treatment: The reticular and plaque-like lesions are usually asymptomatic and treatment
is not necessary. For symptomatic OLP, topical steroids, such as triamcinolone mouthwash
or mixed with orabase, clobetasol or fluocinonide are used first in treatment. If the OLP is
severe or affects large areas of the oral mucosa, systemic corticosteroids should be
prescribed. Patients should be advised that the lesions will most likely recur and the
possibility of candidiasis associated with corticosteroid use may occur. No therapy
currently cures OLP; the goal of treatment for symptomatic lesions is palliation.
Prognosis: There is still controversy whether OLP is associated with an increased risk of
malignancy. Excessive tobacco and alcohol use should be discouraged and it is
recommended that lesions are observed at least yearly. Isolated erosive lichenoid lesions
should also be biopsied to rule out premalignant or malignant lesions.
Differential Diagnosis: The clinical features may be diagnostic of the typical reticular
form of OLP. However, biopsy is necessary if the form is atypical or if clinical features
suggest the possibility of dysplasia or malignancy. There are many oral lichen planus-like
‫حممد البابلي‬.‫د‬
or “lichenoid” lesions which can confuse the diagnosis of OLP. Drug reactions, graft-
versus-host disease, and oral contact stomatitis related to dental materials, most often
amalgam, may be indistinguish- able from OLP. In diagnosing erosive lichen planus, other
ulcerative or erosive diseases such as lupus erythematosis and chronic ulcerative stomatitis
should be ruled out by biopsy and immunofluorescent studies. Gingival lesions of erosive
lichen planus may also resemble pemphigoid or pemphigus vulgaris with biopsy and
immunofluorescence required.

5. Inflammatory papillary hyperplasia:-


Inflammatory papillary hyperplasia (IPH) is a reactive tissue response that is usually found
in the hard palate underneath an ill-fitting dental prosthesis, or even one who exhibits
parafunctional habits. It may also occur infrequently in a patient who does not wear
prosthesis, such as a mouth breather. Less frequently, this lesion may occur on the
mandibular edentulous ridge or the surface of an epulis fissuratum. It is usually
asymptomatic and the mucosa is erythematous, with a pebbly appearance. Some believe
this lesion is part of a spectrum that involves denture stomatitis as the earliest form.
Etiology: Poorly fitting prostheses, poor prosthesis hygiene and wearing a prosthesis con-
stantly without removal, appear to be the major reasons for occurrence of this lesion.
Candida has also been suggested to have a causal relationship.
Treatment: In cases of early IPH, denture removal for extended periods of time may allow
the tissue to resume a more normal appearance. Often antifungal therapy involving the
mucosa and denture must accompany daily removal of the prosthesis to provide complete
resolution. Meticulous hygiene of the prosthesis and oral cavity should be practiced. In
more advanced cases, the excess tissue should be excised prior to fabrication of a new
prosthesis. Techniques used may include surgical blade incision, laser surgery and
electrosurgery.
Prognosis: Since the condition is benign, the prognosis is good. Once the lesions are
resolved, if the patient continues to practice good oral hygiene and allow the tissue to rest
daily, IPH should not recur.
Differential Diagnosis: Although the appearance of the lesions is characteristic, keratosis
follicularis (Darier’s disease) may be considered in unusual cases.
‫حممد البابلي‬.‫د‬

6. Epulis fissuratum (inflammatory fibrous hyperplasia):-


This lesion consists of folds of hyperplastic tissue into which the flange of a complete or
partial denture rest, most often in the maxillary anterior vestibule, although sometimes it
can be seen lingual to the mandibular ridge. The excess tissue is usually firm and fibrous,
but can be inflamed and ulcerated, similar to that of a pyogenic granuloma. The size of an
epulis varies greatly, from less than 1 cm to the length of the vestibule. This lesion is seen
more often in older individuals, as expected with a denture-related conditions and is more
frequently observed in females.
Etiology: Hyperplasia of the oral mucosa in reaction to an ill-fitting complete or partial
denture is the usual causative factor.
Treatment: Surgical removal and microscopic examination of the tissue is the definitive
treatment for epulis fissuratum. This should be accompanied by some form of correction to
the prosthesis or remake of the prosthesis in order to prevent recurrence.
Prognosis: Good with definitive treatment and proper prosthesis fit.
Differential Diagnosis: The characteristic appearance of epulis fissuratum is generally
diagnostic.

7. Contact stomatitis from cinnamon/medication burn:-


Products flavored with artificial cinnamon are fairly common. Some of the most
frequently found cinnamon flavored products are foods such as ice cream and candy, gum,
mints, toothpaste, mouthwashes and floss. In susceptible individuals, the use of toothpaste
results more in diffuse gingival involvement with enlargement, edema and erythema.
Sloughing of superficial epithelium is common.
The reaction to gum and candy is more localized, with most lesions occurring on the
buccal mucosa and lateral tongue. The lesions have an erythematous base, but are often
white due to a covering of hyperkeratosis of the surface epithelium and can progress to the
dorsum of the tongue.
‫حممد البابلي‬.‫د‬
Etiology: Reactions to cinnamon flavoring are found most commonly in products that are
associated with prolonged or frequent contact with the oral mucosa, for example, candy,
gum, and toothpaste. Tartar control toothpastes contain bitter pyrophosphates which
require extensive flavoring to mask and therefore may cause oral lesions. Although less
common, there are reports that the spice form of cinnamon may also cause mucosal
reactions. Cinnamon contact stomatitis is believed to be a form of intra-oral contact
allergy.
Treatment: Discontinuation of the cinnamon-flavoring containing product usually results
in resolution of the lesions within a week. If the lesions last longer, a topical corticosteroid
may be used for a short time.
Prognosis: Good, with discontinuation of the offending product.
Differential Diagnosis: History of the use of cinnamon flavored products, clinical
appearance and resolution of the lesions upon cessation of product use are adequate to
diagnose contact stomatitis from cinnamon. Leukoplakia, hairy leukoplakia, and lichenoid
reaction may also be considered.

8. Dentifrice Related Sloughing:-


Dentifrice related sloughing of the oral mucosa is an increasingly common finding and
may be caused by a variety of additives found in many dentifrices. While typi- cally
asymptomatic, erythema or a burning sensation is sometimes seen. It is characterized by
areas of white, “stringy” sloughing of the superficial keratin layer. Among the associated
additives, flavoring agents, abrasives, detergents (i.e. sodium lauryl sulphate), “tartar con-
trol” agents (i.e.tetrasodium and/or tetrapotassium pyrophosphate), and fluorides may re-
sult in reactive changes of the oral mucosa. Manufacturers are aware of the problem of
dentifrice related sloughing and have sometimes removed a product from availability, ad-
justed a product’s formulation or recommended alternate products for susceptible persons.
Etiology: Hypersensitivity to dentifrice detergent and tartar control agents may result in
dentifrice related sloughing. Higher concentrations of detergents are required to solubilize
pyrophosphates in a tartar control dentifrice and can lead to reactions to the detergent. Py-
rophosphates have also been shown to increase alkalinity which can irritate oral mucosa. A
person’s adverse reaction to a tartar control dentifrice may also be exacerbated by dry
mouth, which is a common finding in the United States’ growing elderly population and
concomitant increased use of medications.
Treatment: Treatment consists of discontinuation of the offending product.
Prognosis: Prognosis is good, with discontinuation of the offending product.
‫حممد البابلي‬.‫د‬
Differential Diagnosis: Intraoral reaction to other chemical agents.

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