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Oral Pathology - 04 - Mucosal Immunologic Diseases

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Oral Pathology

Introduction to Oral Pathology1

Oral pathology is the specialty of dentistry and discipline of pathology that addresses 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.

Oral pathology includes immunologic diseases affecting the oral mucosa. These conditions are categorized based on the immune system’s response:

  • Autoimmune: The immune system attacks the body's own tissues.
  • Hyperimmune: The immune system overreacts to known or unknown stimuli.

Clinical Manifestations and Diagnosis

The practice of oral pathology involves the clinical examination, radiographic interpretation, and microscopic analysis of tissues to reach a definitive diagnosis. Key areas of focus include:

  • Developmental Anomalies: Structural defects occurring during the formation of oral tissues.
  • Infectious Diseases: Bacterial, viral, and fungal infections manifesting in the oral cavity.
  • Neoplasms: Benign and malignant tumors of the soft tissues and jawbones.
  • Immune-Mediated Disorders: Conditions where the immune system affects the mucosal lining.

Role of the Pathologist

Pathologists work closely with clinicians to provide essential diagnostic information that guides patient treatment plans. This collaborative approach ensures that both common and rare conditions are managed effectively through evidence-based practices.

Table Of Contents

Disease Categories and Classifications2

  • Developmental Conditions
  • Mucosal Lesions—Reactive
  • Mucosal Lesions—Infections
  • Mucosal Lesions—Immunologic Diseases
  • Mucosal Lesions—Premalignant
  • Mucosal Lesions—Malignant
  • CT Tumors—Benign
  • CT Tumors—Malignant
  • Salivary Gland Diseases—Reactive
  • Salivary Gland Diseases—Benign
  • Salivary Gland Diseases—Malignant
  • Lymphoid Neoplasms
  • Odontogenic Cysts
  • Odontogenic Tumors
  • Bone Lesions—Fibro-Osseous
  • Bone Lesions—Giant Cell
  • Bone Lesions—Inflammatory
  • Bone Lesions—Malignant
  • Hereditary Conditions

Mucosal Lesions and Immunologic Diseases

Commonly referred to as a “canker sore,” these ulcers occur on nonkeratinized mucosa.

Clinical Presentation

Aphthous ulcers are the most common immunologic mucosal conditions. They affect non-keratinized (unattached) tissue 99% of the time, including the labial, buccal, and alveolar mucosa, floor of the mouth, soft palate, and ventral tongue.

Clinical Classifications3

  • Minor: Heal without scarring.
  • Major: Heal with scarring; also known as Sutton Disease.
  • Differential Diagnosis: Unlike recurrent herpes simplex virus (which affects keratinized tissues like the hard palate or attached gingiva), aphthous ulcers are found only on non-keratinized surfaces.

Aphthous Ulcers

Associated Conditions

  • Behcet’s Syndrome: A multisystem vasculitis characterized by aphthous-type ulcers of the oral and genital mucosa, along with inflammation of the eye.

Treatment

  • Corticosteroids are utilized for the management of Behcet’s Syndrome.

Erythema Multiforme

These lesions often appear on the lips but can occur anywhere on the skin and mucosa.

Clinical Variations4

  • Minor: Associated with herpes simplex hypersensitivity.
  • Major: Associated with drug sensitivity; also known as Stevens-Johnson Syndrome.

Angioedema

Clinical Presentation5

  • Characterized by diffuse swelling of the lips, neck, or face.
  • Result of an allergic reaction to drug or food contact.

Pathophysiology

  • Mediated by mast cell release of IgE and histamines.

Treatment

  • Antihistamines.

Wegener Granulomatosis

Etiology and Presentation6

  • Result of an allergic reaction to an inhaled antigen.
  • Clinically presents as strawberry gingivitis.
    • The gingiva appears bright red and stippled, resembling the surface of a strawberry.

Treatment

  • Corticosteroids (prednisone) and cyclophosphamide.

Lichen Planus

Pathophysiology and Histology7

  • T lymphocytes target and destroy basal keratinocytes.
  • Histological observations include basal zone vacuolization and sawtooth rete pegs secondary to keratinocyte destruction.

Clinical Forms

  • Reticular: Characterized by Wickham striae; this is the more common form.
    • Wickham striae are described as white, lacy, ribbon-like stripes.
  • Erosive: Characterized by Wickham striae accompanied by red ulceration.
    • This is the second most common form of Lichen Planus.

Treatment

  • Corticosteroids.

Lupus Erythematosus

Discoid Chronic Type8

  • Features disc-like lesions on facial skin.
  • Oral lesions mimic the appearance of erosive lichen planus.

Systemic Acute Type

  • Involves multiple organs.
  • Characterized by a butterfly rash over the bridge of the nose.
  • Diagnosed via autoantibodies (ANA test).

Treatment

  • Corticosteroids.

Scleroderma

Clinical Features9

  • Characterized by the hardening of skin and connective tissue.
  • Oral manifestations include restricted opening and uniform widening of the PDL (periodontal ligament) space.
  • The name Scleroderma literally translates to "hard skin."

Pemphigus Vulgaris

Pathophysiology10

  • Suprabasilar involvement.
  • Autoantibodies target desmosomes.

Clinical Presentation

  • Multiple painful ulcers preceded by bullae.
  • Positive Nikolsky’s sign.
    • Nikolsky’s sign is a phenomenon where slight rubbing of the mucosa or skin (or blowing air) causes the outermost layer to exfoliate or shed.

Treatment

  • Corticosteroids.

Mucous Membrane Pemphigoid

  • Pathophysiology: Sub-basilar (below the epithelium) where autoantibodies attack the basement membrane.
  • Clinical Comparison: Clinically similar to pemphigus vulgaris but differs in the depth of tissue attachment loss.
  • Mnemonic: "Pemphigus is above; Pemphigoid is 'biloy' (below)."

Footnotes

  1. Original PDF page 1: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.1 ↩

  2. Original PDF page 2: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.2 ↩

  3. Original PDF page 3: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.3 ↩

  4. Original PDF page 4: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.4 ↩

  5. Original PDF page 5: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.5 ↩

  6. Original PDF page 6: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.6 ↩

  7. Original PDF page 7: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.7 ↩

  8. Original PDF page 8: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.8 ↩

  9. Original PDF page 9: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.9 ↩

  10. Original PDF page 10: Oral Pathology - 04 - Mucosal Immunologic Diseases, p.10 ↩

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