Hairy
Tongue: This is a relatively rare condition
whose appearance is due to the
elongation of filiform papillae. These papillae have a mechanical
abrasive function. These papillae do not contain
taste buds This condition can be caused by poor
oral hygiene, chronic oral irritation or smoking. The far right
picture shows a patient who was a heavy smoker and has been treated with radiation therapy
for head and neck cancer. Radiation therapy causes a dry mouth
with chronic oral inflammation. Treatment
involves good oral hygiene, brushing of the tongue, mouth rinses and
sometimes the trimming of the elongated papilla. The picture to
the left is the same patient two months later after improvement in his oral
hygiene.
Black Hairy
Tongue: This
patient has a black hairy tongue which was caused, at least in part, by significant
gastroesophageal reflux.
Control of her reflux along with the use of a topical anti-fungal medication
(Nystatin), cessation of smoking and bushing of her
tongue resulted in marked improvement. The
pre-treatment picture is the picture on the far right. The patient's
tongue two months post treatment is on the left.
Click on Pictures to Enlarge
A
third patient with a hairy tongue on the posterior midline portion of the tongue.
The patient was a non-smoker and was treated with brushing his tongue
three times a day and a two week course of a topical antifungal
medication, Nystatin.
The pictures to the right shows the pretreatment
appearance of the tongue with elongated filiform
papillae. The
picture on the left is two weeks after treatment with Nystatin and good
oral hygiene.
Click on Picture to Enlarge
The
fourth
patient, shown on the right, has a combination of a geographic and hairy
tongue. This condition does not produce any symptoms, and was not improved
with the use of oral antibiotics, Nystatin, steroids and good oral hygiene.
Click on Pictures to Enlarge
Leukoplakia
is a white patch which can occur in the oral cavity. It
is often caused by chronic irritation or infection but can also be a
cancerous or precancerous lesion.
In this patient the leukoplakia had areas of redness called erythroplakia.
Erythroplakia often represents a cancer. On biopsy, the patient
was found to have a fungal infection. Fungal infections of the oral
cavity may often mimic a cancer both on gross appearance and sometimes even histologically.
A condition called pseudoepitheliomatous hyperplasia can cause a similar appearance and
pathologically can be mistaken for cancer.
Click on Pictures to
Enlarge
The
picture on the right shows a large white lesion which mimics a T2 squamous
cell carcinoma on the upper gingival buccal sulcus and hard palate. The
leukoplakia extends anteriorly in the gingival buccal sulcus. The patient
was a 75 year old male with a 90 pack year history of smoking. The patient
quite smoking 15 years previously. The patient also used 1/3 of a pouch per
day of tobacco for the last 65 years. The lesion was biopsied which
revealed pseudoepithelial hyperplasia from candidiasis. Treatment with
smoking cessation, improved oral hygiene and a fungal medication (Nystatin)
resulted in marked improvement in the condition.
The picture on the right is from a 22 year old male who has used over one
can of snuff for the past 15 years. He has high blood pressure from
the
vasoconstrictive
(contraction of blood vessels) effect of nicotine and
gastroesophageal reflux
disease (stomach acid coming up from the stomach towards the mouth) which
is also made worse from using tobacco products. The picture on the
right shows extensive
leukoplakia
forming between his gums and lips. This is a pre-cancerous
condition and if it does not resolve with his cessation of using tobacco
products, it will need to be surgically removed.
Click
on Pictures to Enlarge
Apthosis
Ulcers: Apthosis ulcers are shallow small painful ulcers which
appear on mobile mucosa in the oral cavity. They are often found in
individuals that are under stress. The cause of these ulcers is
unknown. They can be treated by applying Amlexanox gel (a prescription
medication).
Click on Pictures to
Enlarge
Oral
Ulcers: This patient is a 80
year old, with a smoking history and very poor dentition. The
patient's lip ulcers mimic a cancer but are from erosion and infections
secondary to her poor dentition.
Cold
Sores: Cold sores are caused by the Herpes Simplex Virus.
Once infected, they plague the patient for life. Penciclovir cream is
a prescription medication which is approved by the Federal Drug Authority (FDA) for treatment.
Acyclovir ointment and oral anti-viral medications such as Valacyclovir and Famciclovir
may also be prescribed by a physician to treat Herpes Simplex infections. An over-the-counter
FDA approved medication for the treatment of cold sores is Abreva.
This medication is believed to protect the skin cells from viral damage and
promotes healing. Click on Pictures to
Enlarge
Chelitis:
Chelitis is crusting and cracking which occurs in the corners of the mouth.
It is caused by a fungus and anti-fungal creams are usually curative. Click on Pictures to
Enlarge
Shingles
(Herpes Zoster): Shingles are caused by the Herpes Zoster Virus.
They occur many years after an individual has had chicken pox. Once a
patient has had chicken pox, they will carry the virus for the rest of their life.
When the patient does not have symptoms, the virus is in a
dormant state residing cell bodies of nerve tissue. Over the years, a
patient's antibody levels fall and the dormant virus emerges. The
virus causes lesions to erupt on the skin in the regions that are innervated
by the infected nerve. In the right-hand picture, the lesions are seen on the patient's right jaw
and right half of his tongue. This corresponds to the lower division
of the trigeminal nerve (V cranial nerve) and the lingual nerve (XII cranial
nerve). This patient was treated with a seven day course of Valacyclovir
and had an uneventful recovery.
Click on Pictures to Enlarge
Stomatitis:
The pictures on the right show a 47 year old male with an intraoral viral
eruption which occurred 24 hours after exposure to caustic chemicals. This patient
was treated with Famvir (Famciclovir) and had rapid resolution of the
lesions.
The probable
cause of these lesions was herpes simplex.
Click on Pictures to Enlarge
The pictures on the right are from a 14 year old girl with punctuate viral
lesions on the hard palate and tongue. She was treated with Famvir (famciclovir).
The probable
cause of these lesions is herpes simplex.
Click on Pictures to Enlarge
Methicillin-resistant
Staphylococcus aureus (MRSA):
This patient had a two day history of a pimple on his right lower lip.
Over the last 24 hrs he had rapid increase in pain, swelling and redness.
The area was fluctuant and when lanced abundant puss was expressed.
Culture revealed MRSA. The wound was drained and the patient was
treated with Bactrum, a sulfa based antibiotic. MRSA is in the
group of bacteria referred to as Multi-Resistant Drug Organisms (MDROs).
Candidiasis
(Yeast Infection): The
pictures on the right show oral candidiasis caused by inhalation steroids.
The patients had asthma and used inhaled steroids on a daily basis.
These patients were treated with a topical anti-fungal medication, oral Nystatin.
Click on Pictures to Enlarge
Acute
Tonsillitis: This is a common condition which is usually caused by
gram positive bacteria. If the organism is Streptococcal
Pyrogenesis, there is a risk of developing Rheumatic
Fever. Which is a condition where the values of the heart are damaged
by the antibiotic response to bacteria. Tonsils normally have deep
crypts or holes that extend into the body of the tonsil. Often multiple different bacteria exist in the tonsillar
crypts. Treatment of tonsillitis with antibiotics
to prevent Rheumatic Fever or tonsillar abscess formation is usually
advisable.
Click on Pictures to
Enlarge
Learn More About Treatment
Options
for Chronic Tonsillitis
***
Tonsillectomy
***
The
picture to the right shows the appearance of acute tonsillitis due to
Infectious Mononucleosis. The patient was a 24 year old male with
bilateral 4 cm non-tender jugulo-digastric (upper neck) lymph nodes.
Because the infection was caused by a virus it was resistant to antibiotics.
Lip
Cancer: Cancer of the lip is a relatively common condition. When
caught early, it is treatable with surgery or radiation therapy.
Cancers of the lower lip have a better prognosis than those of the upper
lip. Chronic sun exposure is the most common cause, but smoking can
also be an etiology. The picture on the right shows a T2 N0 (tumor
size between 2 to 4 cm, with no lymph node spread) squamous cell carcinoma
of the lower lip. The patient was treated with surgical resection and
reconstruction using an Abby-Estlander Lip Flap.
Click on Pictures to Enlarge
The
patients shown in the pictures to the right have a basal cell carcinoma of
the upper (left picture) and lower (right picture) lips. Basal Cell
Carcinoma is a less aggressive tumor than squamous cell carcinoma. It
spreads and destroys tissues locally, but does not metastasize (spread by
blood or lymphatics). Treatment is surgical excision or radiation therapy.
Click on Pictures to Enlarge
Oral
Cancer: This patient is a 57
year old, with a 75 pack year history of smoking and alcohol intake.
He has an oral cancer involving the
uvula
(uvular cancer)
which has also spread onto the
nasopharynx
surface of the
soft palate.
He was also found to have a carcinoma in the upper portion of his right
lung.
Click on Pictures to Enlarge
Another
common oral cancer is tongue cancer. The picture on the right shows a cancer on the tongue in a 45 year old male who
never smoked. The most common cause of oral tumors is Human Papilloma
Virus which is found in 70% of oral tumors. This virus most commonly
causes tumors on the tonsil and base of tongue. Learn more about HPV
and oral cancer. Click on Pictures to
Enlarge
The
picture on the right shows a T1 squamous cell carcinoma of the oral
cavity in the region of the retromolar trigone. The patient had a 30 pack
year history of smoking an a two month history of feeling a lump in her
throat.
This
patient is a 87 year old who used to smoke 1 pack per day many years ago she
was not sure how long she smoked. This patient has a tumor on both her
tongue and right floor of the mouth. The tumor is over her
alveolus
and extends onto the anterior tonsillar pillar. These types of tumors
are often treated with a commando operation which consists of resection of
the
mandible,
floor of mouth and tongue; along with a radical neck dissection which
removes the muscles and lymph nodes in the neck.
Click on Pictures to
Enlarge
The
picture on the right shows a T1 squamous cell carcinoma on the floor of the
mouth. The patient was a 60 yr old male and had a 50 pack year history of
smoking. The cancer blocked the submaxillary salivary gland duct. The
gland swelled and presented as a mass in his upper neck.
This
patient is a 70 year old who smoked 1 pack per day for 50 years he also
drank alcohol heavily. He presented with severe
dysphagia
(trouble swallowing) and on examination was found to have a very small
airway. He underwent an emergency
tracheotomy
(breathing hole placed in the neck) under local anesthesia no IV sedation or
analgesia was given. The was then put to sleep with general anesthesia
and had his oral tumor debulked. The pictures on the right show a
large oral tumor in the
hypopharynx
with a very small airway under the
epiglottis.
Torus
palatinus
is a hard bony growth in the center of the roof of the mouth
(palate). It is not a tumor or neoplasm but a benign bony growth called
an exostosis. This growth commonly occurs in females over the age of
30 and rarely needs treatment. Occasionally it is removed for the
proper fitting of dentures.
Click on Pictures to
Enlarge
Torus
Mandibularis: This is a hard bony growth on each side of the
mandible (jaw
bone) -- see arrows. They are benign slow growing and seldom need
treatment. The prevalence in the United States is between 7% to 10%.
Occasionally they are is removed for the proper fitting
of dentures.
Click on Pictures to
Enlarge
This
photograph on the right shows a huge
nasalpolyp in a 10 year old white female extending
into the
oral pharynx.
In a young Caucasian patient cystic fibrosis should be ruled out.
The
picture on the right shows a large HPV papilloma extending from then
nasophayrnx into the oral pharynx. The patient was a 27 year old
female She had no recurrence after surgerical removal.
Picture
of an oral papilloma of the uvula. This is a common area for papilloma
to grow. These lesions are caused by the Human Papillomavirus or HPV. Click on Pictures to
Enlarge
Oral Fibroma:
Oral fibromas are benign lesions which can be removed as an office
procedure. The below left picture shows an oral fibroma in a young patient.
Click on Pictures to
Enlarge
Lingual Cavernous Hemangioma: This is a benign lesion but one
which is very hard to treat. Surgery is difficult. Angiography
is often needed to outline the feeding vessels and to embolize the
hemangioma.
Lingual Hemangioma:
The picture on the right is a small peduncular hemangioma on the tip of the
tongue of a ten year old male. It was removed under local anesthesia
in the surgeon's office.
Mass
on Base of Tongue: This mushroom like mass presented on a 40 yr
old female with a one month history of choking. It was treated with
surgical excision. The pathology report showed that the mass was a
benign vascular tumor.
Click on Pictures to
Enlarge
Sialocele:
A sialocele arises from the blockage of a salivary gland duct. The
duct enlarges and forms a sac of saliva. Treatment is with surgical
excision.
The
torus to the right has a chronic non-healing ulceration exposing a focus of
dead bone. This patient had been
on Fosamax for five years. Fosamax is a bisphosphonate, a medication
used to treat osteoporosis. This patient
also had ear surgery (mastoidectomy) three years previously, while on
Fosamax for two years, without any problems. A year later and off of
Fosamax the bony sequestra fell off and the palate healed without surgery.
Fosamax inhibits bone resorption by
suppressing the activity of the cells which remodel bone, osteoclasts.
Some patients taking Fosamax have been found to form dead bone in their jaws
( mandibular necrosis ). This is especially true if the patient has
infected teeth or trauma to the overlying mucosa. Less frequently,
this complication has been found to occur in the upper jaw bone or palate
(maxilla). Treatment is difficult since any trauma or surgery to the
area may expand the bone loss.
For more information:
Marx RE 2005
Farrugia MC 2006
Merigo E 2006
Severe
necrosis of the
mandible
from use of bisphosphonates in a 68 year old
who was undergoing treatment for cancer. The picture on the right
shows an oral-cutaneous fistula with exposure of mandibular bone.
Intra oral examination reveals necrosis and exposure of the entire left body
of the
mandible.
The patient did not have any pain. Reconstruction had to be postponed
for many months after the drug was discontinued.
View Abstract
Click on Pictures to
Enlarge
Oral
Pharynx Necrosis:
The picture on the right shows necrosis of the
posterior
oral pharynx
from
intranasal
narcotic usage. Click on Pictures to
Enlarge
Stevens Johnson Syndrome:
Shown in the photographs below is a severe mucositis with epidermal
sloughing in a 17 year of female. Symptoms started 24 hours after
taking tetracycline for a cough. Blisters first formed with sloughing
of the mucosa. The lips, buccal mucosa and soft palate were the main
areas of involvement. A working diagnosis of Stevens Johnson Syndrome
was made and the patient was transferred to a major University Medical
Center.
Stevens Johnson Syndrome is a rare but serious
disorder caused by a wide range of drugs and infections: Including
antibiotics, non-steroidal anti-inflammatory agents, anticonvulsants and a
variety of infections (flu, hepatitis, herpes, typhoid and HIV).
Lesion may involve large portions of the skin. Prognosis is generally
good with a 1-5% fatality rate with sloughing involves less than 10% of the
skin. However, mortality rate can be greater than 25% when sloughing
involves more than 30% of the skin surface.
Stevens Johnson Syndrome Support Page
Click on Pictures to
Enlarge
Lichen
Planus: This condition presents as a white lace like pattern on the
inside of the cheeks. It can be confused with many other conditions and
evaluation by a physician is mandatory to make sure other serious problems
are not present. Often the condition is caused by a reaction to
medications. Beta Blockers and oral hypoglycemics are the most common
offending medications. Lichen Planus can also be associated with
other conditions such as Hepatitis C. Treatment is with oral
steroid rinses, and if possible identifying and removing the causative
agent.
Click on Pictures to
Enlarge
The pictures below are from a 37
year old patient with biopsy proven lichen planus which occurred during a
stressful time in the patient's life. Her tongue had scarred plaques, her cheeks
were inflamed. She also had multiple dental caries. The patient
was treated with a liquid steroid taken by mouth and a topical steroid cream. Two
years later she was asymptomatic without a recurrence. One might
wonder if this patient is abusing methamphetamine, however, this abuse produces gingivitis and
caries next to the gum line of the teeth.
Lichenoid
Reaction:
The patient shown in the pictures to the right is a 61 year old female who
presented with a four month history of mildly painful white tongue lesions
which slowly healed and became asymptomatic. After healing, her tongue had
persistent smooth plaques surrounded by a whitish ring. No other lesions
were identified.
Click on Pictures to
Enlarge
Phemphigoid:
Bullous phemphigoid is an auto-immune disease which causes blistering of
the skin. It can involve the mucous membranes in 10% to 25% of
patients. Blisters form when antibodies attack proteins in the basement
membrane of the skin (between the dermis and epidermis). Many cases
are self limited and go into remission in five years or less. However,
severe cases may require treatment with corticosteroids and immunosupressive
agents. Phemphigoid should not be confused with Phemphigus Vulgaris
which is a much more aggressive disease. In Phemphigus Vulgaris
antibodies attack proteins called
desmogleins. Desmogleins are the
proteins which hold the skin together. Diagnosis of Phemphigoid and
Phemphigus requires biopsy. For more information go to
http://www.pemphigus.org .
Click on Pictures to Enlarge
Ankyloglossia
or a persistent lingual frenulum is a congenital persistence of tissue
which binds the tongue to the floor of the mouth. When severe, the
frenulum should be cut to mobilize the tongue. Click on Pictures to
Enlarge
Salivary
Gland Stone:
This patient had a stone which formed in the Submandibular
(Submaxillary) Gland Duct. The picture on the far right shows the
duct's papilla in the floor of the mouth, underneath the patient's tongue.
This duct drains uphill, is wide and has a mucoid or viscous secretion.
Thus, when salivary gland stones occur, they usually occur in this duct.
Treatment consists of excising the stone. Prevention is with
hydration, gland massage and using a few drop of sour lemon juice several
times a day to increase salivary flow.
Click on Pictures
to Enlarge
The
picture on the right is from a patient who has a small salivary gland stone
in its duct. Note the dilatation of the salivary gland duct.
Click on Pictures
to Enlarge
The
X-Ray on the right shows a giant salivary gland stone (Larger than 1.5 cm)
just under the
mandible.
For more information on the management of giant salivary gland stones, go to
the World Articles in Ear Nose and Throat. Note the size of the stone
next to the penny.
Click on Pictures
to Enlarge
The
picture below shows a stone in the left submandibular (submaxillary)
salivary gland duct. The submandibular salivary gland is the most common
salivary gland to form stones. This is because it has a wide duct and mucoid saliva which flows uphill. Prevention of stone formation includes
plenty of fluids and sialogues, such as a few drops of lemon juice or a dill
pickle. Notice the normal orifice of the right submandibular gland (Warthin's)
duct.
Click on Pictures
to Enlarge
The
picture to the right shows a stone in the left Parotid salivary gland duct (Stensen's
Duct). The submandibular salivary gland is the most common salivary gland
to form stones. This is because it has a wide duct and a mucoid saliva
which flows up hill. Stones are rare in the parotid gland since the saliva
is serous and the duct flows down hill. Prevention of stone formation
includes plenty of fluids and sialogues, such as a few drops of lemon juice
or a dill pickle.
Click on Pictures
to Enlarge
The
pictures on the right show a patient with severe sialothiasis (salivary
gland stones). One of the stones has eroded through the floor of the
mouth. Two stones were recovered with a third still in the duct.
This patient had a long history of recurrent salivary gland swelling and
infection. Treatment will probably require excision of the
submandibular salivary gland.
Click on Pictures
to Enlarge
Geographic
Tongue:
This is a benign non-painful condition caused
by the absence of lingual papilla. The glassy patches move around
the tongue and change shape. The cause of this condition is unknown
and treatments are not reliable. The left hand picture is from a 20
year old male who is at the beginning stages of a bout of acute tonsillitis.
He stated the condition worsens during the acute episodes.
Click on Pictures to
Enlarge
The picture to the
right is an 18 year old with a combination of a hairy and geographic tongue.
Click on Pictures to
Enlarge
Oral-Maxillary
Fistula: In this condition, a hole (fistula) develops between the
mouth and the large sinus cavity above the palate (roof of the mouth).
This condition can be caused by dental infections or a complication of
surgery. Treatment is with a two layer surgical closure.
An incision is made around the periphery of the fistula. The mucosa of
the fistula is elevated and inverted. It is then sewn together,
forming an inner layer. The cheek mucosa is then advanced over
the inner closure and sewn over the defect.
Click on Pictures to
Enlarge
The
patient shown on the right has a small hole in the middle of a tooth socket.
A tooth had been pulled and a hole was made into the maxillary sinus.
The hole did not fully heal and a small fistula was left in the middle of
the upper alveolar ridge.
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The
picture on the right shows a T1 squamous cell carcinoma on the floor of the
mouth. The patient was a 60 yr old male and had a 50 pack year history of
smoking. The cancer blocked the submaxillary salivary gland duct. The
gland swelled and presented as a mass in his upper neck. 
