Oral medicine Lec 1

 The Normal color of the oral mucosa is Pink

 Some areas are reddish pink, due to :
1) Thin Mucosa or 2) High vascularity = Blood supply

‫ ال هو‬White ‫ لونه‬Oral mucosa‫ مكان واحد بس طبيعي أشوفه في ال‬

Dorsum of the tongue Papillae are heavily keratinized
White lesion ‫ تبدأ كـ‬oral mucosa ‫ ال بتطلع في ال‬Squamous cell carcinoma ‫معظم ال‬
Risk sites to develop oral malignancy : (IMPORTANT)

1) Floor of the mouth (: ‫أخطر مكان على األطالق‬

2) Ventral surface of the tongue.
3) Lateral borders of the tongue. ( Posterior lateral border especially)
4) Retromolar area.
5) Soft palate.
6) Palatal fauces.

‫ لونها يكون أبيض ؟؟‬Oral mucosa ‫ في ال‬area ‫إيه الي يخلي‬

 Hereditary. Reactive/inflammatory. Infectious.
 Oral lichen planus.  Idiopathic leukoplakia. Miscellaneous lesions.

: ‫ بيكون ألربعة أسباب‬White‫أي حاجه تتحول للون ال‬

1) Changes Occur below the epithelium.
2) Changes Occur within the epithelium.
3) Changes Occur above the epithelium = (Surface of the oral mucosa)
4) Changes Occur in the keratinization .
 The tissue thickness Be more white.
 Tissue thickness or Blood supply more reddish.
 Any necrotic tissue in oral mucosa is White.

Hyper-Keratinization :
:Hyper-Keratinization ‫أشهر سبب يعمل‬
1) Trauma of LOW magnitude for LONG duration
2) Secretion of tumor necrosis factor alpha “Lichen planus”.

Changes Occur above the epithelium :

Aspirin burn Change occurs at the Surface of the oral mucosa.
)Mucosa ‫(تغير فوق سطح ال‬
Changes Occur within the epithelium :
1) Acanthosis Hyperplasia of prickle cell layer.
2) Intracellular edema OR intercellular edema .

Changes Occur below the epithelium :

1) Fibrous deposition Increase the thickness Be white .
‫ ؟؟‬Fibrous deposition ‫إمتى يحصل‬
A. Low grade infection for long time
B. Immune system surrounds the prolonged infection by fibrous tissue
Limitation.
2) Scar due to trauma Deep in connective tissue.
. Scar ‫ عشان يحصل‬deep trauma ‫الزم تكون‬
 : ‫ حاجات‬3 ‫ أعمل‬White lesion ‫أول ما أشوف‬

1. Check the degree of whitish discoloration.

a. Obvious white color refers to Hyper-Keratinization.
Changes occur at high level of epithelium.
b. Faint diffuse white Changes in deep layers of epithelium.

2. Rubbing / stripping off test . ‫المسح بقطنه‬

: Lesion ‫ طلع معاك و انت بتمسح ال‬White lesion‫لو ال‬
Food debris OR necrotic layer ( aspirin layer ).
. ‫يبئى هو نتيجة أي سبب تاني‬ ‫ معاك‬white lesion‫لو مطلعش ال‬

3. Stretching ( If possible ) .
Buccal mucosa / Lip / Corner of the mouth.
 Some lesions disappear by stretching. These lesions involve intercellular
edema …. HOW???
By stretching Fluid distribution

Linea alba “ Normal anatomical variation ” disappear by stretching.

 Some lesions may be more obvious and get accentuated by stretching

Example : Lichen planus

. ‫ دون حدوث أي تغيير‬stretching ‫ تفضل زي ما هي مع ال‬Lesions ‫باقي ال‬

 Classification of white lesion according to cause of occurrence :

Hereditary White Lesions :

Properties:
i. Appear at young = (Pre-puberty) . / as a maximum during puberty.
ii. It is of benign nature .
iii. Hereditary white lesions are not restricted to one site but they are presented :
a. Bilateral.
b. Anywhere in oral mucosa.
c. They may present in the skin or mucous membrane than oral mucosa

iv. No treatment is required.

^_^‫ يجي في االمتحان و تكتب له األربع نقط ال فاتوا تاخد الدرجة‬hereditary lesion ‫أي‬

 1) Leukodema 
Features :
 Faint diffuse white lesion due to intercellular edema
 It disappears upon stretching the mucosa …. (‫)مهمه‬
 Bilateral .

Treatment :
 No treatment is indicated.  No malignant change.
 Pre-disposing factors:
1) Heavy smokers. 2) Dark skin.

 2) White Sponge Nevus 

Features :
 Bilateral Symmetrical white lesion.
 Spongy or velvety thick plaques.
 Almost appears on Buccal mucosa, OR involve anywhere in oral
mucosa ,OR mucous membrane of GIT
 Treatment:
 No symptoms.  No treatment. No potentiality for malignancy.

 3) Hereditary benign intraepithelial dyskeratosis 

: ‫ أعرف بس أنه ممكن يكون‬.... ‫مش حيجي عليه سؤال‬
1- Oral lesion 2- Eye lesion

 4) Darier’s disease 
: ‫ … بس إعرف انه ممكن يكون‬ ‫ده كمان مش بيجي عليه سؤال‬
Oral lesion – Skin lesion – Ear lesion – Nail lesion.

Reactive & inflammatory white lesions:

a. Frictional keratosis. b. cheek chewing.
c. Chemical injuries. d. Actinic keratosis.
e. Smoking keratosis. f. Nicotine stomatitis.
g. Smokless tobacco induced keratosis.
Oral Keratosis:
Definition: White lesion that is caused by Hyperkeratinization
This lesion is of keratotic nature and can’t be rubbed off
The lesion has a definite etiological factor.

Some lesions ’re reversible after identification & removal of

the lesion.
 Other lesions ’re irreversible 
Irreversible lesions are classified as premalignant lesion ,due to
epithelial dysplasia
malignant ‫ ممكن يتحول إلى‬, ‫ لفترة طويلة‬Stimulus ‫لو إتعرض إلى‬

 1) Frictional Keratosis 

White lesion in oral

mucosa due to
hyperkeratosis
keratotic nature. The
etiological factor is the
friction with low
magnitude and
extended duration. It
can’t be rubbed off.

.etiology ‫ مع تحديد ال‬oral keratosis‫ ال‬Definition ‫الحظ انه نفس‬

 Frictional keratosis is reversible lesion &

Benign lesion.
 Causes:
1- Rough or maladjusted denture.
2- Sharp cusps or edges of broken
teeth.
3- Mastication forces applied on
edentulous area.
4- Orthodontic appliance.

 2) Cheek chewing 
Definition:
White lesion which is caused by
chronic irritation due to
involuntary habit.

It is considered as
frictional keratosis variant.
How to differentiate it by clinical appearance ???
Frictional keratosis Cheek chewing
Localized restricted Diffuse
to the area of the friction

Treatment :
1- Stop the chewing habit.
2- Tranquilizer may be prescribed.
3- Night guard with smooth rounded edges.

Cheek chewing keratosis has not the potentiality for malignant transformation

 3) Chemical burn
“Chemical injury of oral mucosa”
Definition :
It is a transient non-
keratotic white lesions
of the oral mucosa

Chemicals Strong acids “Phenol” Cause red lesions

Weak acids “acetyl salicylic acid”= “Aspirin” White lesion
 ‫ الي عنده يخف؟؟‬pain‫ ال‬, mucosa‫ على ال‬aspirin ‫ و حط‬Pulpitis‫ من ال‬pain ‫ ليه لو حد عنده‬
Aspirin is dissolved by saliva Acetyl salicylic acid release (leach out)
burns the superfacial layer of mucosa that is in contact with aspirin.

There’re two pain impulses :

Pain impulses from pulpitis & pain impulses from mucosa.
The brain interpret the most superfacial impulses.

Aspirin burns leads to superfacial necrotic tissue that can be rubbed off .
After rubbing The underlying mucosa is reddish.

 4) Actinic keratosis 
Definition :
“Actinic or solar keratosis is
premalignant epithelial lesion that
is directly related to long term
sun.”
It’s found on :
The back of the neck .
 The dorsum of the hand.
 Vermillion border of the lip
( especially lower lip ).

 It is a premalignant irreversible lesion that has to be

surgically removed.
Clinical features :
It appear as white plaque with hyperkeratosis
{‫ كرد دفاعي‬sun rays‫ بتحاول تحمي نفسها من ال‬lip‫ علشان ال‬Keratosis ‫}بيحصل‬
Hyper pigmented melanotic area

Sun exposure melanin pigmentation .

 5) Smoker’s keratosis 

 Etiology :
Due to low magnitude stimulation with extended duration leads to
hyperkeratosis.
Causes ( Forms ) of stimulation :
 Irritation by nicotine of tobacco.
 Releasing irritant by-product during smoking.
 Low heat production.
: ‫ حاجات‬3 ‫ المدخن عنده‬
 White smoker’s patch may be surrounded by red area,
due to direct contact with burning part of cigarette .

 Diffuse white keratotic lesion Bilateral on buccal mucosa and

tapered .. WHY ??
 Because that the heat production is more effective on mucosa
which is closed to cigarette than the mucosa that is far away from
the heat.
‫ الي قريبه من مصدر الحراره غير ال‬mucosa ‫} ألن تأثير الحرار الناتج عن التدخين بيأثر أكتر على ال‬
{.‫ الي بعيده عن الحراره‬mucosa
 Stomatitis nicotina.
 6) Stomatitis nicotina 
Definition :

Specific white lesion that develops

on hard & soft palate heavy
smoking.
Clinical features :

Whitish discoloration (more than the normal white color of the

palate) due to irritation.
‫ الي في الصفحة الي فاتت‬3causes‫الي هما ال‬

Numerous elevated papules with punctuate red centers representing

an inflamed & metaplastically altered minor salivary gland ducts.

metaplasia ‫ يحصل‬ductal epithelium ‫ لل‬irritation‫ هنا بيحصل‬

occlusion ‫ يحصله‬duct ‫ (يتنفخ) و بالتالي ال‬epithelium increase in size ‫ و بالتالي‬
‫ فحيحصل الحاجه التالته و االخيرة‬accumulation of salivary secretion ‫ و بالتالي‬

Yellowish areas around the red centers

Stomatitis nicotina is NOT a premalignant lesion.

Reversible .
Treatment :
Stop smoking
Acrylic plate is constructed to cover
the palate.
Water drinking after smoking to
reduce the harmful effects.

 7) Smokless tobacco induced keratosis 

Definition :
Habitually chewing
tobacco leaves or
dipping snuff leads to
development of a well-
recognized mucosal
lesion.

 Irritant is directly placed opposing the oral mucosa for

long time in a definite site.
Clinical features :
Changes ’re seen in the area where contacting the tobacco.

The most common site : 1) Anterior mandibular vestibule.

2) Posterior vestibule.
The change in the tissue nature Premalignant lesion
Irreversible

There ’re gingival recession & periodontal destruction in

immediate area of contact.

Treatment : Surgical incision

 7) Glass blower keratosis 

 It is a combination of white lesions with erythematous “red” spots

due to burns.
 “Irreversible” & “premalignant” lesion.

NOTE : Chemical burn isn’t an oral keratosis

 Lecture (2) (Idiopathic leukoplakia)

 Definition :
“ White lesion due to hyper-keratinization which can’t be
attributed to any other form of local disease or systemic
disease is called idiopathic leukoplakia ”
, ‫مطلعش معاك‬ rubbing off ‫ لونه أبيض و جيت تعمله‬lesion ‫عندك‬
!!! ‫وال يوجد له سبب‬
***************************
Premalignant lesion is consist of : epithelial dysplasia &
atypical cells.
 If the dysplasia involve the FULL thickness of the epithelium
,it is called “Carcinoma in situ”
 If the basement membrane is disturbed and the malignant cells
divide in the connect tissue It indicate “Malignancy”.

 ALL clinical forms of idiopathic leukoplakia are premalignant

***************************
 Predisposing factor :
1. Smoking (tobacco) 2. Alcoholic
3. Oral candidiasis. 4. Electro galvanic reaction.
  60% of idiopathic leukoplakia lesions ’re candidal leukoplakia
Tobacco + Alcoholism = Synergism.

‫ لكن أكثر مكانين‬oral mucosa‫ بتطلع في أي مكان في ال‬Leukoplakia ‫ال‬

1. Buccal mucosa. :‫بيظهر فيهم‬
2. gingiva ( gingival margin )
***************************
Clinical forms :
1) Homogenous Leukoplakia : “Most common”
Well defined white patch that is slightly
elevated.
It has fissured, wrinkled & corrugated surface.
Dry cracked mud-like appearance.
‫األرض المشققة‬

2)Speckled leukoplakia : "‫ "المنقرشه‬

It is also known as “Nodular leukoplakia”
Mixed red-white lesion.
Keratotic white nodules are
distributed over an atrophic
erythematous base.
‫( عليه‬atrophy) ‫أرضية حمراء‬
. hyper-keratinized ‫ أبيض‬nodule
 High potentiality for malignant transformation.
.‫ ظهر فيه اللون األحمر‬lesion ‫علشان هذا ال‬

3) Verrucous leukoplakia :
Thick white lesions with papillary surface.
Heavily keratinized.

4) Proliferative Verrucous leukoplakia : “the most dangerous”

Excessive papillary or verrucoid
white plaques.

tend to involve multiple mucosal

site in oral cavity.

Transform into squamous cell

carcinoma over period of many years.

***************************

‫ إزاي أفرق اذا‬white lesion ‫لو جالك في العياده حالة عندها‬

‫ ؟؟؟؟؟‬frictional keratosis ‫ وال‬Homogenous leukoplakia ‫كانت‬
 frictional keratosis
‫العيان حيقولك ان فيه حاجة بتحك في‬
History
. ‫مكان محدد لمدة طووووويلة‬
Definite object cause the
friction in definite area for
long time
1) It has a definite
Etiological factor .
2) On Palpation :
Same as the normal tissue
examination
lesion‫يعني ساعت ما تمسك ال‬
Clincal
normal tissue ‫حتحس انك ماسك‬
3) The shape of the lesion
differ than the shape of
leukoplakia keratosis .
With biopsy :
investigation
Special
No dysplasia
& &
Reversible
Homogenous leukoplakia
‫العيان حيقولك ان عنده واحده من ال‬
‫ ال قولناهم‬Predisposing factors
Lecture 2 ‫في أول صفحه في‬
1) No definite etiological
factor.
2) Palpation :
Loss of tissue elasticity &
pliability.
‫ لل‬stretching ‫يعني مثال لو جيت تعمل‬
‫ كلها‬mucosa ‫ حتالقي ال‬Buccal mucosa
resistance‫طلعت معاك ماعدا حته معينه بتعمل‬
‫ تالقي الحته ده‬bending ‫و كذلك لو بتعمل‬
resistance ‫بردوه بتعمل‬
3) different shape.
With biopsy :
dysplasia
Irreversible
Treatment :
Idiopathic leukoplakia is premalignant
 Surgical removal The first treatment of choice.
‫ هنا الجراحة حتكون صعبة‬floor of the mouth ‫ ظهرت في ال‬Leukoplakia ‫ طيب إفرض ال‬
!!!‫ أعمل إيه ؟‬.....
 Cryosurgery ‫الكي بالتبريد‬ OR  Laser ablation. ‫استئصال‬
‫ أعمل إيه ؟؟؟‬... ‫ طيب إفرض لو واحد رفض الجراحة بكل أنواعها‬
lesion ‫“ أشوف ساعتها هل ال‬Toluidine blue test” ‫ و أعمل‬Biopsy ‫أول حاجه أخد‬
‫ ؟؟؟؟‬Malignant ‫ وال‬Premalignant ‫ده‬
‫ و المريض رافض الجراحة‬Premalignant ‫ و إنها‬Dysplasia ‫لو طلعت عندك‬
Malignant changes‫هنا ننصح العيان و أقوله بتابع معايا و كل زياره أشوف أي حاجه لل‬
. Close follow up program ‫وده بنسميه‬
One visit each 3 months ‫ شهور فيه زياره‬3 ‫بقول للعيان ان كل‬

***************************
 Malignant changes :
1- Change in color / Ex. White >> Red
2- Ulceration / Ex. Intact surface>> ulcerated
3- Bleeding
4- Induration & fixation of underlying tissue.
5- Lymphadenopathy :
 Involvement of the regional lymph node.
 lymph node be matted, indurated and fixed.
6- Increase in size  ‫أضعف عالمة‬.
 : ‫ تيجي في ستة أشكال‬Oral cavity ‫ لو جات في ال‬squamous cell carcinoma ‫ ال‬
1- White lesion. 4- Ulcer.
2- Red lesion. 5- Swelling.
3- Mixed white and red lesion 6- Crust. ‫متحصلش جوا البوء‬
in lower lip ‫تحصل في‬

Lecture (3)
Infectious White Lesions
 Infectious agents:
1- Bacteria
2- Virus  Example :Oral hairy leukoplakia.
3- Fungus.

***************************
 Oral hairy leukoplakia 
Corrugated white lesion.
Specific to lateral borders of the
tongue.
Epstein-Barr virus (EBV)  The causative
agent in oral hairy leukoplakia.
 . HIV infection ‫ زي عند ال‬T cells ‫ عمره ما يشاغل إال في حالة تعطيل ال‬EBV ‫ ال‬
Oral hairy leukoplakia ‫ هي ال‬Bilaterally ‫ الوحيدة الي ممكن أشوفها في البوء‬Leukoplakia ‫ ال‬

‫ ؟؟؟‬Why...
 As it caused by virus (Systemic) Bilateral appearance.
Treatment:
Antiviral medications ( Drugs ).
***************************
 Oral candidiasis 

‫ ليه ؟؟‬Candidal infection ‫ إال إحنا معندناش‬, ‫ عندنا كلنا‬candida fungus ‫ على الرغم ان ال‬
: survive ‫ حاجات عشان ي‬3 ‫ محتاج‬micro-organism ‫ أي‬
Stabilization Nutrition Reproduction

‫ عشان مش قادرة‬infection ‫ متقدرش تعمل‬candida ‫ال‬

within epithelium “ Hyphae ” ‫تغرس رجلها‬
WHY …????
 Local Causes:
1- Presence Lactobacillus acidophilus that are responsible for acid production
This acid Limit the candidal infection .
2- The integrity of the oral epithelium.
Healthy intact epithelium = No gaps within epithelium.
3- Mechanical flow of saliva.

4- Oral mucosa is continuously renewed = (Shedding mechanism)

 : systemic ‫ بس المرة دي‬candidal infection ‫ فيه أسباب أخرى تمنع ظهور ال‬
Systemic Causes:
1- Integrity of the immune system.
2- Iron (Fe) component  Especially in the ferritin.
3- Vitamin B12 And folic acid .

***************************
Predisposing factors for Oral candidosis :

 Local factors 
1- Smoking ... Why ?
The nicotine and the other components of tobacco cause the occlusion
of peripheral blood vessels
 Decrease resistance to the infection.
 Decrease nutrition to epithelium.
 Decrease healing.
 Decrease immune cell infiltration.
 Decrease shedding mechanism.
2- Chronic trauma
 Trauma to definite site in oral mucosa for long time
The integrity of the oral epithelium be compromised 
It may change the tissue nature.
3- Excessive use of the antiseptic mouth wash.
Excessive use leads to decrease the bacteria in the oral cavity involving the
“Lactobacillus acidophilus ”
4- Poor oral hygiene.
 Systemic factors
1. Age
 Newly born infants :
There isn’t enough strong immune system
 Old age :
Exhausted immune system.
2. Drugs
 Antibiotics:
Use a broad spectrum , use the antibiotic for long time in high dose.
 Immunosuppressive drugs:
1- Organ transplantation. 2- auto-immune disease.
3. Diabetes mellitus:
.Uncontrolled diabetes mellitus ‫الزم يكون‬
Diabetes mellitus cause the followings:
1- Occlusion of the peripheral blood vessels.
2- Increased Ketone bodies Which affect the efficiency of the immune cells.
4. Post-operative:
 Major surgery & Hospitalization for long time.
Why ?
1) Increased stress leads to decreased immunity.

2) Increased the possibility of the infection transmission.

3) The patient with major surgery :
 He doesn’t perform good oral hygiene measures.
 No proper diet.
 Decreased salivary flow
 Massive doses of antibiotics.
5. Xerostomia :
 diminished salivary flow.
 Saliva  responsible for the mechanical wash out.
6. Immunodeficiency & Immunosuppression.

Diabetes mellitus & AIDS Steroid inhaler , Cancer chemotherapy & radiotherapy

***************************

Acute forms of the diseases respond quicker and

 ‫هامة‬ ‫قواعد‬
much better to the treatment.
Acute candidal infections need superficial firm of
the treatment ‫فقط ال غير‬
Systemic antifungal drugs are
Severely hepatotoxic & severely toxic to the kidneys.

 Spectrum of oral candidosis :

 1) Acute candidosis :
 Oral thrush ( Acute pseudomembranous candidosis ) . ‫لونها أبيض‬
 Acute antibiotic stomatitis ( acute atrophic / erythematous ) ‫لونها أحمر‬
: ‫قاعدة عامة‬

‫ لونه أبيض أو يميل إلى البياض‬candidal infection ‫من ال‬form ‫ أي‬

Due to the covering by pseudo-membrane or the over-proliferation of mucosa
due to atrophy of mucosa ‫ لكن الي لونه أحمر‬
2) Chronic candidosis .

***************************
1) Acute candidosis 
 Acute pseudomembranous candidosis :
 Clinical features :
 Soft, friable and creamy colored
plaques.
 Anywhere in the oral cavity.
 The distinctive feature :
It can be easily wiped off , to
expose an erythematous mucosa
or shallow ulceration
Why ?
Due to the inflammation of the epithelium and the connective tissue.
  By magnification :
There are Pin sized bleeding point ..WHY ?
It represent the hyphae of the candida that
was embedded in the epithelium.

Treatment ‫ و أسهل واحد في ال‬, Candidal infection ‫ في ال‬Form ‫ هو أشهر‬Oral thrush ‫ال‬

 Acute antibiotic Stomatitis :

It is a red lesion , Due to atrophy of the surface of mucosa.
Cause :
antibiotic :
(Broad spectrum - High doses - For long time.)
leads to Imbalance between the bacteria &
the candida.

The mucosa is glazed reddish in color

and sometimes , there are flecks of thrush.  Lesion ‫ طبقة بيضاء على ال‬.

Another cause :
The oral thrush exists for long time  then excessive proliferation occur.
So, the thickness of the oral thrush is increased.
By movements that occur in the oral environment  the oral thrush will fall
down , resulting in reddish inflamed area.
Acute atrophic candidosis ‫لذلك االسم التاني هو‬

***************************
  2) Chronic candidosis 
Denture induced stomatitis :
It is also called :
Denture associated stomatitis OR denture associated candidiasis.
 Causes :
1) Very well fitting denture ( especially in upper denture ) cuts off the underlying
mucosa from protective action of saliva.
2) ill-fitting denture leads to( food (accumulation + candidal cells accumulation. )

By the inspection of fitting surface

of the denture :
Presence of white pseudo-membrane
oral thrush …. WHY ?
As the hyphae of candidal cells able
to penetrate the pores of acrylic
resin .
 Denture induced stomatitis doesn’t be seen under the lower denture .. WHY ?
Because of the relatively free flow of saliva beneath it.
Treatment :
1- local antifungal. 2- denture sealing 3- denture scrapping

Denture may need relining or complete rebasing . 

candida infection in corners of the mouth ‫ بيكون عنده‬denture induced stomatitis ‫في األغلب الي عنده‬

Angular stomatitis : ( Angular cheilitis )

 Definition :

Fungal infection at the corners of the mouth.

Angular stomatitis is in association with any other form of candidal
infection.
Other candida infection ‫ تيجي لوحدها أو مصحوبة مع‬angular stomatitis ‫يا إما ال‬
Bilateral appearance.
Caused by : Leakage of candida infected saliva at the
angles of the mouth.
predisposing factors :
Low vertical dimension . Vitamin B12 deficiency.
 : ‫ يا إما‬Corner of mouth ‫ الي عند ال‬Lesion ‫ أحيانا بيكون ال‬
Mixed (fungal & bacterial infection) OR pure fungal infection
secondary bacterial infection‫وبعدين حصل‬Fungal infection ‫يعني كان األول فيه‬ 
.
CBC appearance (Crusting Bleeding Cracking appearance)‫المنظر ده يسمى‬
‫قشرة‬ ‫دم‬ ‫تشققات‬
CBC appearance indicate secondary bacterial infection.
. Treatment ‫الموضوع ده يفرق معايا في ال‬

Pure fungal infection Pure local antifungal drugs.

CBC appearance Anti-fungal + Anti-bacterial drugs.
Median rhomboid glossitis :
very resistant form of chronic candidal infection.
. Uncontrolled diabetes ‫ باألخص الناس ال عندهم‬
One of the most resistant form to the antifungal drugs .
Erythematous patches of atrophic papillae located in the central
area of the dorsum of the tongue.
 Chronic mucocutaneous candidiasis : ‫ملغي مش علينا‬
 Candidal infection in : 1- Oral mucosa 2- skin
With the patients who are Severely immunocompromised.
 Chronic hyperplastic candidiasis : “ Candidal leukoplakia ”
: ‫عندنا حالتين منه‬
1- Candidal infection at first, cause tissue hyperplasia and
keratinization leads to leukoplakia incidence.
. Candida albicans then leukoplakia : ‫إذن في الحالة األوالنية عندي‬
2- At first, Leukoplakia tissue alterations occur lead to
compromised integrity of epithelium .
Finally, Candidal infection occur.
: ‫ و لكن في كال الحالتين‬
Management of candidal leukoplakia :
Treatment of leukoplakia + Topical antifungal drugs.
) ‫( الشابتر الي فات‬
 Erythematous candidiasis :
Acute erythematous candidiasis Chronic erythematous candidiasis
(Acute antibiotic stomatitis )
Shiny and glazed Dull reddish
It can diffuse Localized circumscribed
Anywhere in oral mucosa Dorsum of the tongue
Hard palate
Soft palate
Associated with HIV patient
  Treatment of oral candidosis 
1- Correct the underlying predisposing factor (s)
2- Antifungal drugs.
3- Supplements [ improve the diet / Improve the physiologic
state ].

 Antifungal drugs :
Systemic Local.
 Local antifungal drugs :
It should be in contact in with yeast cells for suitable duration.
***************************
 Mechanism :
Local antifungal drugs cause pores within yeast cells ‘fluid
balance’ of the cell will be disturbed External fluids get inside
the yeast cells .
Yeast cells swells and finally burst
***************************
 Different forms of topical antifungal drugs :
Cream ,  Gel ,  lozenges ,  Drops.
denture ‫( باألخص في حالة ال‬Gel)  Sticky ‫ الي هو‬form ‫أحسن‬
.‫ و حتلبس العيان نفس الطقم بتاعه‬induced stomatitis
[Angular cheilitis] Cream
[Buccal mucosa or tongue infection] Drops.
***************************
 Patient’s instructions : ‫ده الكالم ال حتقوله للعيان‬
 After [1 2] weeks fungal infection manifestation
will disappear.
: patient ‫ أشهر األعراض ال عند ال‬
Slight burning sensation .
Slight loss of taste sensation.

‫ ان حتى لو األعراض لو اختفت بعد أسبوع أو اسبوعين‬patient ‫ الزم تقول لل‬

‫الزم يستمر على الدواء‬

 Stop drugs uptake after 3 weeks … WHY ?

 As, the candidal hyphae is still embedded within the tissue.
 to ensure the complete removal of candidal infection.
***************************
 Cortisone ‫ زي مثال ال‬immunosuppressive drugs ‫العيانين ال بياخدوا‬
. ‫ كإجراء وقائي‬topical antifungal drugs ‫ دول بنديهم‬,

 Each 3 weeks of immunosuppressors drugs prescribe

topical antifungal drugs for 1 week.
‫ فيه أسبوع واحد‬, immunosuppressors ‫ أسابيع من عالجه من ال‬3 ‫ كل‬
.antifungal ‫بياخد معاه دواء‬
***************************

: ‫ أفرق إزاي لو عيان بيلبس إنه عنده‬/‫س‬

Denture induced stomatitis OR allergy to acrylic resin.

‫؟؟؟؟؟؟‬
 Denture induced stomatitis allergy to acrylic resin
1) History
‫العيان بيكون البس الطقم‬
‫من فترة طويلة و حتالقيه مش مهتم‬ ‫العيان لسه البس الطقم من فترة قصيره‬
oral hygiene‫بال‬
2) Clinical examination
Inflamed reddish ‫كالهما حتالقيهم‬
All oral mucosa that come in
Reddish area is restricted to the
contact with acrylic resin is
denture bearing area.
reddish
(Even the buccal mucosa is
. ‫ زانق فيها‬denture ‫المكان ال‬
reddish in color.)
By inspection of the fitting surface of the denture :

denture‫حتالقي الطقم لسه جديد و ال‬

*_* ‫حاجه مش نظيفة خالص‬
‫نظيف‬

3) Special investigation
Swap from ( Palate or the fitting surface of the denture).
By PAS stain ..[ PAS = “ Periodic acid Schiff ” ] :

Presence of hyphae. No hyphae.

4) Trial of treatment line :

it is resolved by local antifungal
No resolve.
drug.
‫واحد عنده ‪ Candidal infection‬على ال ‪ tongue‬زي ال ) ‪( Acute antibiotic stomatitis‬‬

‫كيف العالج ؟؟؟؟؟؟‬

‫‪‬الزم أعالجه بالخطوات التالية ‪:‬‬
‫‪ -1‬أخليه يستعمل ‪ Tongue scraper‬أو معلقة شاي صغيرة ‪,‬‬
‫يشد لسانه لبره و يعمل ‪ scrapping‬لل ‪Dorsum of the tongue‬‬
‫‪ -2‬يرج ال ‪ suspension‬كويس قبل االستعمال عشان المكونات بتترسيب ‪Shake ...‬‬
‫‪well‬‬
‫‪ -3‬ينقط ال ‪ drops‬بتاعت ال ‪ suspension‬على ال ‪. tongue‬‬
‫‪ -4‬الكالم ده يتعمل بتكرار كالتالي ‪ 5 :‬نقط ‪ 5 ‬مرات ‪ 3 ‬أسابيع‬
‫(‪ 5‬نقط لكل مرة ‪ 5 ...‬مرات لكل يوم)‬
‫‪ -5‬يخلي ال ‪ suspension‬في بوئه أكبر مدة ممكنة و بعدين يبلعه علشان لو فيه‬
‫‪ infectional extension‬في ال ‪ GIT‬أو ال ‪.pharynx‬‬
‫‪‬الزم أتأكد ان العيان معندهوش ‪:‬‬
‫‪Severe Xerostomia‬‬
‫‪Uncontrolled diabetes mellitus.‬‬
‫‪Nutritional deficiency (Vitamin B12 & Iron “Fe” ).‬‬

‫***************************‬
  Lec 4 : Lichen planus 

Definition :
Chronic inflammatory disease of the skin and mucous membrane.
Chronic inflammatory dermatosis.
Mucocutanous disorder.
 The mucous membrane that is affected by the lichen planus :
1. Oral mucous membrane. 2. Genital mucous membrane.

‫ ؟‬Skin and mucous membrane manifestation ‫هل كل العيانين عندهم‬

. ‫ فقط‬Skin manifestations ‫ممكن يكون عنده‬
. ‫ فقط‬mucous membrane manifestations ‫ممكن يكون عنده‬
. ‫ممكن يكون عنده االثنين مع بعض‬

Pathogenesis :
 Autoimmune reaction .
The immune system of the body produce antibodies which attack
against the body cells. ‫الجسم بيهاجم نفسه‬
Cell mediated immunological destruction .
The immune system attack against the basal cells (stratum
germinativum) epithelium ‫ في‬layer ‫ده أهم‬
 : ‫ كالتالي‬epithelium ‫ مع ال‬connective tissue ‫ عندنا عالقة ال‬
The papillary projections of connective tissue within epithelium.
WHY ??
To increases the surface area for the diffusion of the nutrition
from the connective tissue to epithelium.

 The immune system consists of White Blood Cells.

Granulocytes Agranulocytes
Neutrophils T cells
Basophiles B cells
Eosinophils

‫ و بعدين‬Plasma cells ‫ بتموت أي حاجه غريبة و تحول نفسها ل‬ B cells 

antibodies ‫تطلع ال‬
T helper cell  ‫ فيه منها نوعين‬ T cells 

T cytotoxic cell = T killer cell 

‫ ؟‬How ... perforation ‫ يعمل‬perforin ‫ أسمه‬protein ‫يطلع‬
By Osmotic pressure disturbance.
The tissue destruction mainly occurs at the basal cell layer.
Any tissue destruction mainly is accompanied with
fibrinogen deposition.
Immunofluorescent test :

Shaggy band of
fibrinogen at B.M zone

IgM in dermal papilla in

peribasal area

***************************

affected skin biopsy : ‫لما ناخد عينة من الجلد المصاب‬

: ‫ اسمه‬Fluorescent material ‫ متصنع في المعمل عليها‬IgM ‫يحطوا عليها‬
Multiple IgM staining cytoid bodies.
Basement membrane‫ وجدوا إنها واخده شكل ال‬fibrinogen ‫ ده تمسك في ال‬IgM‫ال‬

***************************

‫ بحيث تكون‬basement membrane ‫ الي بتموت و تقع تحت ال‬basal cells ‫ال‬
.Civatte bodies ‫ اسمها‬Connective tissue ‫جوا ال‬
 ‫ الجسم يعاملها كأنها‬ ‫( ده ماتت بطريقة غريبة‬basal cells) ‫بما ان الخاليا‬
IgM ‫ الجسم يبعت‬ foreign bodies
Coating of Civatte bodies .
.colloid bodies ‫) تسمى‬IgM ‫ (ال اتغطت بال‬Civatte bodies ‫في هذه الحالة‬
***************************
Basement ‫ بيمسك في الخاليا الي واقعة تحت ال‬Fluorescent IgM ‫ال‬
.‫ عشان كده بشوف نقط متفرقة مضيئة‬ membrane

: ‫ يحصل مع‬Fluorescence ‫ ال‬Immunofluorescent test ‫ في ال‬

1) At the basement membrane ( Fibrinogen ).
2) Beneath a basement membrane.

***************************
Q/what are the triggers of this immune reaction ?
“Unknown cause ”‫ده األصل‬
Idiopathic lichen planus ‫علشان كده بيسموها‬
1) Emotional stress OR
2) Cell mediated response of T cells to any other stimulus.
  lichenoid reaction With a known cause .. ‫لها سبب‬
 Affect the oral mucosa membrane
especially ?
 Because of increased continuous
stimulation .
It may be reaction to :
 Restorative material
 Drugs.
 Galvanic recurrent

Lichenoid reaction lichen planus

Clinically: almost be bilateral and
It is always unilateral symmetrical
“ Mirror like image ”

History: ‫حتالقي العيان غير الدوا مؤخرا‬

‫ أو‬RESTRATIVE ‫مثال يكون حط‬
‫ جديده‬MATERIAL
‫ا المهم ان فيه حاجه غريبه حصلت‬
 ‫‪ ‬عندنا هنا حاجتين ‪:‬‬

‫‪Graft versus host disease  host versus graft disease‬‬

‫عكس بعض‬
‫‪Host = recipient.‬‬

‫‪ ‬زي واحد جه يزرع كليه ‪ Kidney‬هذه ال ‪ Kidney‬جاية بال ‪immune cells‬‬

‫بتاعتها ] من ال‪ [ Donor‬ألنها من جسم تاني ‪.‬‬
‫و المريض ال هو ال ‪ recipient‬عنده ال ‪ immune cells‬بتاعته‬
‫‪ ‬سبب اختالف ‪ immune cells‬ده عن ده ‪:‬‬
‫ألن كل ‪ body‬ال ‪ cells‬بتاعته عندها ‪ MHC‬خاص بيها‬
‫)‪MHC = (Major histocompatibility complex‬‬
‫‪ ‬فيه احتمالين ‪:‬‬
‫‪‬ال ‪ kidney‬تهاجم جسم ال ‪ host‬ساعتها بنسمي الحالة ده ‪graft versus host disease:‬‬

‫‪‬جسم ال ‪ host‬يهاجم ال ‪ kidney‬ساعتها بنسمي الحالة ده ‪Host versus graft disease :‬‬
‫أيهما أخطر ؟؟‬
‫‪Answer : Graft versus host disease‬‬
‫ألن في هذه الحالة ال‪ Kidney‬حتهاجم جسم المريض كله و بدل ما كانت ال‪ Kidney‬بس ال عنده بايظه ‪ ..‬فيه ‪Organ‬‬
‫تاني حيبوظ‬
‫لكن لو ‪ Host versus graft disease‬ممكن ساعتها نشيل ال‪ Kidney‬من المريض و كأن شيئا لم يحدث‬

‫‪By immuno depressants.‬‬ ‫‪‬‬ ‫‪ ‬إزاي نتجنب الكالم ده ؟‬

 basal ‫ ال اتزرع يهاجم ال‬Organ ‫ احتمال ان ال‬graft versus host disease ‫في حالة ال‬
) Lichenoid reaction( ‫ تعمل لي‬epithelium  cells
***************************

Grinspan’s syndrome :
Uncontrolled diabetes mellitus + hypertension + reaction similar to
lichen planus
‫ حاجات دول مع بعض يعملوا لي‬3 ‫ال‬Grinspan’s syndrome

***************************
Treatment :
1) Asymptomatic lesion ( no pain )  require no treatment.
 Patient instructions : ‫أعرف العيان الحقيقة ال ُمره‬
The nature of disease.
The disease stays for long time.
The disease is combined by remission & exacerbation.
‫يختفي األلم‬ ‫يزداد األلم‬
Uptake the drugs for long time. As the drug is not curative.
The Patient should stick to follow up program as the lichen planus is a
premalignant disease.
preparation ‫ و أبدأ من ال‬... ‫ ال عندي أبدأ أدي العالج‬symptoms ‫ علي حسب ال‬
‫األضعف إلى األقوى‬
2) Symptomatic lichen planus :
 At first, Topical corticosteroids
) No affect ( ‫لو منفعش العالج‬
 [Topical + Systemic] corticosteroid 40 – 80 mg per day
‫ حندي العيان نفس األدوية و نزود عليهم‬, ) No affect ( ‫لو منفعش العالج و ملهوش تأثير‬

 + add anti-inflammatory drugs , but non-steroidal in nature [NSAIDs]

‫نوقف كل ال فات و نبدأ ندي المريض التالي‬‫لو لسه ملهوش تأثير‬
Intra-lesion injection of corticosteroid :
Very painful
Once per a week ‫مره كل أسبوع‬
‫ خالص‬Corticosteroid ‫ مش حندي‬ ‫لو برضه ملهوش تأثير‬
: ‫نبدأ ندي المريض‬
 Immunosuppressors .
Example : Dapson Azathioprine.
‫ أسابيع‬3 ‫ لمدة‬systemic corticosteroid ‫لو طولت في‬
Topical antifungal ‫ يكون فيه أسبوع واحد‬Corticosteroid ‫ أسابيع من ال‬3 ‫الزم كل‬
As a prophylaxis measure

***************************
  Lichen planus 
1) Skin Lesion :

planar plaque with violaceous color.

Symmetrically distributed.
On the flexor surfaces.
(wrists / legs / Trunk)
During acute phase, face is involved.
 Koebner’s phenomenon
New papule may appear at sites of minor
skin lesions

Change over time becoming hyper-

pigmented and hyper-keratotic.
2) Nail Lesion :

Lateral thinning and complete loss of nail matrix.

3) Oral Lesion : 

Hallmark of oral lichen planus  Wickham’s striae.

Reticulated linear lesions especially on buccal mucosa.
Oral Lichen planus “OLP” classified as :
1- Reticular 2- Atrophic 3-Bullous 4-Erosive
 1- Reticular form
Consists of :
Elevated fine whitish lines
[Wickham’s striae] pattern of
radiating lines.
Annular lesions white elevated
lesion.
These lesions are
asymptomatic. just
change in color

2- Atrophic
Inflamed area of oral mucosa
Covered by thinned red epithelium.
 3- Erosive
Develop as a complication of the atrophic, when the epithelium ulcerated
Symptomatic…. mild burning  severe pain

4- Bullous
Severe destruction of basal cell
layer which leads to :
Separation of the overlying layers
 forms “vesicles” or “bullae"

 Rupture forming  “ulcer”

 Severe pain.

*************************

White lines can’t be eliminated by either :

1) Stretching the mucosa. Or 2) rubbing off its surface
 Histopathology features
Areas of hyper keratosis.
 Necrosis of basal cell layer.
 A dense sub-epithelial band of lymphocytes.
This sub-basilar lymphatic infiltration is composed largely of T cells
 Civatte bodies :
 Isolated epithelial cells shrunken with eosinophilic cytoplasm and
one or more pyknotic nuclear fragment
 Scattered within epithelium and superficial lamina propria
 These cells are undergone apoptosis.

Females ‫ هم ال‬Lichen planus (LP) ‫ أكتر ناس عندهم‬

 Orabase (gel) :
 sodium carboxymethyl cellulose
 used as a treatment
 Very stick
 Resist fluid-flow