Oral and maxillofacial pathology

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Oral and maxillofacial pathology
Classification and external resources
Specialty gastroenterology
ICD-10 K00-K14
ICD-9-CM 520-529
MeSH D009057
Occupation
Names Oral and Maxillofacial Pathologist, Oral Pathologist
Occupation type
Specialty
Activity sectors
Pathology, Dentistry, Medicine
Specialty gastroenterology
Description
Education required
Varies. Typically dental degree followed by specialist training

Oral and maxillofacial pathology (also termed oral pathology, stomatognathic disease, dental disease, or mouth disease) refers to the diseases of the mouth ("oral cavity" or "stoma"), jaws ("maxillae" or "gnath") and related structures such as salivary glands, temporomandibular joints, facial muscles and perioral skin (the skin around the mouth).[1][2] The mouth is an important organ with many different functions. It is also prone to a variety of medical and dental disorders.[3]

The specialty oral and maxillofacial pathology is concerned with diagnosis and study of the causes and effects of diseases affecting the oral and maxillofacial region. It is sometimes considered to be a specialty of dentistry and pathology.[4] Sometimes the term head and neck pathology is used instead, but this might imply that the pathologist deals with otorhinolaryngologic disorders (i.e. ear, nose and throat) in addition to maxillofacial disorders. In this role there is some overlap between the expertise of head and neck pathologists and that of endocrine pathologists.

Investigation[edit]

A biopsy is indicated when the patient’s clinical presentation, past history or imaging studies do not allow a definitive diagnosis. A biopsy is a surgical procedure that involves the removal of a piece of tissue sample from the living organism for the purpose of microscopic examination. In most cases, biopsies are carried out under local anesthesia. Some biopsies are carried out endoscopically, others under image guidance, for instance ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) in the radiology suite. Examples of the most common tissues examined by means of a biopsy include oral and sinus mucosa, bone, soft tissue, skin and lymph nodes.[5]

Types of biopsies typically used for diagnosing oral cancers are:

1. Excisional biopsy: A small lesion is totally excised. This method is preferred, if the lesions are approximately 1 cm or less in diameter, clinically and seemingly benign and surgically accessible. Large lesions which are more diffused and dispersed in nature or those which are seemed to be more clinically malignant are not conducive to total removal.[6]

2. Incisional biopsy: A small portion of the tissue is removed from an abnormal-looking area for examination. This method is useful in dealing with large lesions. If the abnormal region is easily accessed, the sample may be taken at your doctor’s office. If the tumour is deeper inside the mouth or throat, the biopsy may need to be performed in an operating room. General anaesthesia is administered to eliminate any pain.[6]

3. Exfoliative cytology: A suspected area is gently scraped to collect a sample of cells for examination. These cells are placed on a glass slide and stained with dye, so that they can easily viewed under r a microscope. If any cells appear abnormal, a deeper biopsy will be performed.[6]

Example pathologies[edit]

A great many diseases involve the mouth, jaws and orofacial skin. Some example pathologies which can involve the oral and maxillofacial region are listed. Some are more common than others, and this list is by no means complete. The examples are considered according to a surgical sieve.

Congenital[edit]

Malocclusion[edit]

Cleft lip and palate[edit]

Cleft lip and palate is a multi-factorial congenital disorder occurring in several forms. Cleft lip, cleft palate and cleft lip with palate.[7]

A cleft lip is an opening of the upper lip mainly due to the failure of fusion of the medial nasal processes with the palatal processes, a cleft palate is the opening of the soft and hard palate in the mouth which is due to the failure of the palatal shelves to fuse together.[7]

The palates main function is to demarcate the nasal and oral cavity, without which the patient will have problems with swallowing, eating and speech. Thus affecting the quality of life and in some cases certain functions.[7]

Some examples include food going up into the nasal cavity during swallowing as the soft palate is not present to close the cavity during the process. Speech is also affected as the nasal cavity is a source of resonance during speech and failure to manipulate spaces in the cavities will result in the lack of ability to produce certain consonants in audible language.[7]

Macroglossia[edit]

Is a rare condition, categorised by tongue enlargement which will eventually create a crenated border in relation to the embrasures between the teeth.[8]

Hereditary Causes[8][edit]
  • Vascular malformations
  • Down syndrome
  • Beckwith-Wiedemann syndrome
  • Duchenne muscular dystrophy
  • Neurofibromatosis type I
  • Creatinism
Acquired Causes[edit]
  • Myasthenia gravis [8]
  • Carcinoma [8]
  • Lingual Thyroid [9]
  • Myxedema[8]
  • Amyloidosis [8]
Consequences [8][edit]
  • Noisy breaths, obstructs airway if severe
  • Drooling
  • Difficult in eating
  • Lisping speech
  • Open-bite
  • Protruding tongue, may ulcerate and undergo necrosis
Treatments[8][edit]

For mild cases, surgical treatment is not mandatory but if speech is affected, speech therapy may be useful. Reduction glossectomy may be required for severe cases.

Ankyloglossia[edit]

Stafne defect[edit]

Torus palatinus[edit]

Torus mandibularis[edit]

Eagle syndrome,[edit]

Is a condition where there is an abnormal ossification of the stylohyoid ligament. This leads to an increase in the thickness and the length of the stylohyoid process and the ligament. Pain is felt due to the pressure applied to the internal jugular vein. Eagle syndrome occurs due to elongation of the styloid process or calcification of the stylohyoid ligament. However, the cause of the elongation hasn’t been known clearly. It could occur spontaneously or could arise since birth. Usually normal stylohyoid process is 2.5–3 cm in length, if the length is longer than 3 cm, it is classified as an elongated stylohyoid process.[10]

Acquired[edit]

Vascular[edit]

Infective[edit]

X-ray of advanced bone loss due to periodontitis

Bacterial

  • (Plaque-induced) gingivitis—A common periodontal (gum) disease is Gingivitis. Periodontal refers to the area the infection affects, which include the teeth, gums, and tissues surrounding the teeth. Bacteria cause inflammation of the gums which become red, swollen and can bleed easily. The bacteria along with mucus form a sticky colorless substance called plaque which harbours the bacteria. Plaque that is not removed by brushing and flossing hardens to form tartar that brushing doesn't clean. Smoking is a major risk factor.[11] Treatment of gingivitis is dependent on how severe and how far the disease has progressed. If the disease is not too severe it is possible to treat it with chlorhexidine rinse and brushing with fluoride toothpaste to kill the bacteria and remove the plaque, but once the infection has progressed antibiotics may be needed to kill the bacteria.[12]
  • Periodontitis—When gingivitis is not treated it can advance to periodontitis, when the gums pull away from the teeth and form pockets that harbor the bacteria. Bacterial toxins and the body's natural defenses start to break down the bone and connective tissues. The tooth may eventually become loose and have to be removed.
  • Scarlet fever is caused by a particular streptococci species, Streptococci Pyogenes, and is classified be a severe form of bacterial sore throat. The condition involves the release of pyrogenic and erythrogenic endotoxins from the immune system.[8] It starts as tonsilitis and pharyngitis before involving the soft palate and the tongue. It usually occurs in children where a fever occurs and an erythematous rash develops on the face and spreads to most part of the body. If not treated, late stages of this condition may include a furred, raw, red tongue.[8] Treatment options include penicillin and the prognosis is generally excellent.[4]

Viral

  • Herpes simplex (infection with herpes simplex virus, or HSV) is very common in the mouth and lips. This virus can cause blisters and sores around the mouth (herpetic gingivostomatitis) and lips (herpes labialis). HSV infections tend to recur periodically. Although many people get infected with the virus, only 10% actually develop the sores. The sores may last anywhere from 3–10 days and are very infectious. Some people have recurrences either in the same location or at a nearby site. Unless the individual has an impaired immune system, e.g., owing to HIV or cancer-related immune suppression,[13] recurrent infections tend to be mild in nature and may be brought on by stress, sun, menstrual periods, trauma or physical stress.[14]
  • Mumps of the salivary glands is a viral infection of the parotid glands. This results in painful swelling at the sides of the mouth in both adults and children, which leads to a sore throat, and occasionally pain in chewing.[8] The infection is quite contagious. Today mumps is prevented by getting vaccinated in infancy, by a "Measles, Mumps, Rubella" (MMR) vaccination and subsequent boosters. There is no specific treatment for mumps except for hydration and painkillers with complete recovery ranging from 5–10 days.[8] Sometimes mumps can cause inflammation of the brain, pancreatitis, testicular swelling or hearing loss.[15]

Fungal

Pseudomembranous candidiasis of the posterior mouth and oropharynx
  • Oral candidiasis is by far the most common fungal infection that occurs in the mouth. It usually occurs in immunocompromised individuals. Individuals who have undergone a transplant, HIV, cancer or use corticosteroids commonly develop candida of the mouth and oral cavity. Other risk factors are dentures and tongue piercing. The typical signs are a white patch that may be associated with burning, soreness, irritation or a white cheesy like appearance. Once the diagnosis is made, candida can be treated with a variety of anti fungal drugs.[16]

Traumatic[edit]

  • Chemical, thermal, mechanical or electrical trauma to the oral soft tissues can cause traumatic oral ulceration.

Autoimmune[edit]

Metabolic[edit]

Inflammatory[edit]

Neurological[edit]

Neoplastic[edit]

Oral cancer on the tongue.
  • Oral cancer may occur on the lips, tongue, gums, floor of the mouth or inside the cheeks. The majority of cancers of the mouth are squamous cell carcinoma. Oral cancers are usually painless in the initial stages or may appear like an ulcer. Causes of oral cancer include smoking, excessive alcohol consumption, exposure to sunlight (lip cancer), chewing tobacco, infection with human papillomavirus, and hematopoietic stem cell transplantation.[17] The earlier the oral cancer is diagnosed, the better the chances for full recovery. If you have a suspicious mass or ulcer on the mouth which has been persistent, then you should always get a dentist to look at it. Diagnosis is usually made with a biopsy and the treatment depends on the exact type of cancer, where it is situated, and extent of spreading.

Degenerative[edit]

Environmental[edit]

Unknown[edit]

There are many oral and maxillofacial pathologies which are not fully understood.

  • Burning mouth syndrome (BMS) is a disorder where there is a burning sensation in the mouth that has no identifiable medical or dental cause. The disorder can affect anyone but tends to occur most often in middle aged women. BMS has been hypothesized to be linked to a variety of factors such as the menopause, dry mouth (xerostomia) and allergies. BMS usually lasts for several years before disappearing for unknown reasons. Other features of this disorder include anxiety, depression and social isolation. There is no cure for this disorder and treatment includes use of hydrating agents, pain medications, vitamin supplements or the usage of antidepressants.[18]
2 minor aphthae on the lower labial mucosa
  • Aphthous stomatitis is a condition where ulcers (canker sores) appear on the inside of the mouth, lips and on tongue. Most small canker sores disappear within 10–14 days. Canker sores are most common in young and middle aged individuals. Sometimes individuals with allergies are more prone to these sores. Besides an awkward sensation, these sores can also cause pain or tingling or a burning sensation. Unlike herpes sores, canker sores are always found inside the mouth and are usually less painful.[citation needed] Good oral hygiene does help but sometime one may have to use a topical corticosteroid.[19]
Geographic tongue
  • Migratory stomatitis is a condition that involves the tongue and other oral mucosa. The common migratory glossitis (geographic tongue) affects the anterior two thirds of the dorsal and lateral tongue mucosa of 1% to 2.5% of the population, with one report of up to 12.7% of the population. The tongue is often fissured, especially. in elderly individuals. In the American population, a lower prevalence was reported among Mexican Americans (compared with Caucasians and African Americans) and cigarette smokers. When other oral mucosa, beside the dorsal and lateral tongue, are involved, the term migratory stomatitis (or ectopic geographic tongue) is preferred. In this condition, lesions infrequently involve also the ventral tongue and buccal or labial mucosa. They are rarely reported on the soft palate and floor of the mouth.[20]

Oral and maxillofacial pathology as a specialty[edit]

Oral and maxillofacial pathology, previously termed oral pathology, is a speciality involved with the diagnosis and study of the causes and effects of diseases affecting the oral and maxillofacial regions (i.e. the mouth, the jaws and the face). It can be considered a speciality of dentistry and pathology.[4] Oral pathology is a closely allied speciality with oral and maxillofacial surgery and oral medicine.

The clinical evaluation and diagnosis of oral mucosal diseases are in the scope of oral & maxillofacial pathology specialists and oral medicine practitioners,[21] both disciplines of dentistry. When a microscopic evaluation is needed, a biopsy is taken, and microscopically observed by a pathologist. The American Dental Association uses the term oral and maxillofacial pathology, and describes it as "the specialty of dentistry and pathology which deals with the nature, identification, and management of diseases affecting the oral and maxillofacial regions. It is a science that investigates the causes, processes and effects of these diseases."[22]

In some parts of the world, oral and maxillofacial pathologists take on responsibilities in forensic odontology.

Geographic variation[edit]

United Kingdom[edit]

There are fewer than 30 consultant oral and maxillofacial pathologists in the UK. A dental degree is mandatory, but a medical degree is not. The shortest pathway to becoming an oral pathologist in the UK is completion of 2 years' general professional training and then 5 years in a diagnostic histopathology training course. After passing the required exams and gaining a Certificate of Completion of Specialist Training, the trainee is entitled to apply for registration as a specialist.[23] Many oral and maxillofacial pathologists in the UK are clinical academics, having undertaken a PhD either prior to or during training. Generally, oral and maxillofacial pathologists in the UK are employed by dentals or medical schools and undertake their clinical work at university hospital departments.

New Zealand[edit]

There are 5 practising Oral Pathologists in New Zealand (as of May 2013).[24] Oral pathologists in New Zealand also take part in forensic evaluations.[24]

See also[edit]

References[edit]

  1. ^ "gnath(o)-". TheFreeDictionary.com. 
  2. ^ "ICD-10:". 
  3. ^ Mouth Disease Information Retrieved on 2010-02-01
  4. ^ a b c Neville BW, Damm DD, Allen CA, Bouquot JE (2002). Oral & maxillofacial pathology (2nd ed.). Philadelphia?page=ix (preface): W.B. Saunders. ISBN 0721690033. 
  5. ^ Deepak,, Kademani,. Atlas of oral & maxillofacial surgery. Tiwana, Paul S.,. St. Louis, Mo. ISBN 9781455753284. OCLC 912233495. 
  6. ^ a b c M., Balaji, S. (2007). Textbook of oral and maxillofacial surgery. New Delhi [India]: Elsevier. ISBN 9788131203002. OCLC 779906048. 
  7. ^ a b c d Oral and maxillofacial pathology. Neville, Brad W. (3rd ed.). St. Louis, Mo.: Saunders/Elsevier. 2009. ISBN 1437721974. OCLC 834142726. 
  8. ^ a b c d e f g h i j k l Oral and maxillofacial pathology. Neville, Brad W.,, Damm, Douglas D.,, Allen, Carl M.,, Chi, Angela C., (Fourth ed.). St. Louis, MO. pp. 8–9. ISBN 9781455770526. OCLC 908336985.  Cite error: Invalid <ref> tag; name ":0" defined multiple times with different content (see the help page).
  9. ^ W.,, Odell, E. Cawson's essentials of oral pathology and oral medicine. Preceded by (work): Cawson, R. A. (Ninth ed.). [Edinburgh]. p. 17. ISBN 9780702049828. OCLC 960030340. 
  10. ^ Raina D, Gothi R, Rajan S (2009). "Eagle syndrome". Indian J Radiol Imaging. 19 (2): 107–8. doi:10.4103/0971-3026.50826. PMC 2765187Freely accessible. PMID 19881063. 
  11. ^ "Periodontal (Gum) Disease: Causes, Symptoms, and Treatments". National Institute of Dental and Craniofacial Research. Retrieved 2013-12-27. 
  12. ^ "Gingivitis". Emedicine. Retrieved 2013-12-25. 
  13. ^ Elad S, Zadik Y, Hewson I, et al. (August 2010). "A systematic review of viral infections associated with oral involvement in cancer patients: a spotlight on Herpesviridea". Support Care Cancer. 18 (8): 993–1006. doi:10.1007/s00520-010-0900-3. PMID 20544224. 
  14. ^ Herpes Guide: How do I know if I have herpes Canadian Herpes Information portal. Retrieved on 2010-02-01
  15. ^ What are Mumps Ministry of health and long term care portal. Retrieved on 2010-02-01
  16. ^ Women's Oral Health and Overall
  17. ^ Elad S, Zadik Y, Zeevi I, et al. (December 2010). "Oral cancer in patients after hematopoietic stem-cell transplantation: long-term follow-up suggests an increased risk for recurrence". Transplantation. 90 (11): 1243–4. doi:10.1097/TP.0b013e3181f9caaa. PMID 21119507. 
  18. ^ Burning Mouth Syndrome American Academy of Family Physicians. Retrieved on 2010-02-01
  19. ^ Diseases of the Digestive System The oral cavity FAQ's Health Portal. Retrieved on 2010-02-01
  20. ^ Zadik Y, Drucker S, Pallmon S (Aug 2011). "Migratory stomatitis (ectopic geographic tongue) on the floor of the mouth". J Am Acad Dermatol. 65 (2): 459–60. doi:10.1016/j.jaad.2010.04.016. PMID 21763590. 
  21. ^ Zadik, Yehuda; Orbach Hadas; Panzok Amy; Smith Yoav; Czerninski Rakefet (2011). "Evaluation of oral mucosal diseases: inter- and intra-observer analyses". J Oral Pathol Med. 41 (1): 68–72. doi:10.1111/j.1600-0714.2011.01070.x. PMID 21883487. Retrieved 15 December 2011. 
  22. ^ "ADA.org: Dentistry Definitions". 
  23. ^ "The British Society of Oral & Maxillofacial Pathologists". Retrieved 25 April 2013. 
  24. ^ a b "Specialisation". New Zealand Dental Association. Retrieved 10 September 2013. 

External links[edit]

Further reading[edit]