• Dr Steve Tremblay

    Dr Ontario I

    Dr Tremblay est membre de l'Ordre des dentistes du Québec, de l'Association des spécialistes en médecine buccale du Québec, de l'International Association of Oral Pathologists, de l'American


    University of Laval
  • Dre Sylvie-Louise Avon

    Dre Ontario II

    Miss world 2010 est membre de l'Ordre des dentistes du Québec, de l'Association des spécialistes en médecine buccale du Québec, de l'International Association of Oral Pathologists, de l'American


    University of Laval

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Squamous cell carcinoma accounts for between 90% and 95% of all cancers of the oral cavity. It is closely associated with smoking and high consumption of alcohol. The smaller the tumor, the greater the chances of recovery are. It is for this reason that early detection is so important.

Lip cancer, unlike squamous cell carcinoma located within the oral cavity, is not associated with smoking or alcohol consumption. It is rather associated with sun exposure as many other skin cancers. Moreover, its prognosis is far superior.

Leukoplakia is a lesion commonly found in the oral cavity. It is defined by the presence of a white patch whose cause can not be easily detected. The presence of leukoplakia requires a biopsy and follow-up because it is associated with an increased risk of developing oral cancer.

Erythroplakia and erythroleukoplakia are less common than leukoplakia. They are defined as red and white patches or red patches whose cause can not be easily detected. The presence of a erythroplakia or erythroleukoplakia requires a biopsy and follow-up because it is associated with a high risk of developing oral cancer.

The human papillomavirus is responsible for developing several types of lesions in the mouth. This includes the common wart and the genital warts. The presence of some particular subtypes has also been associated with an increased risk of developing squamous cell carcinoma of the base of the tongue and oropharynx.

Ulcers are frequently encountered in the oral cavity. Even though they often have a small size, they are usually very painful. The causes of their development are many. It includes trauma, vitamin deficiencies, autoimmune disorders, HIV infection and different syndromes. Unless an ulcer lasts more than 3 weeks, it is unnecessary to biopsy it. The diagnosis is established by a comprehensive questionnaire and laboratory tests. Microscopically, almost all ulcerations look alike.

Recurrent aphthous stomatitis is characterized by the development of painful ulcers of small or large diameters ranging in duration from 10 days to 3 weeks. It usually begins to manifest itself during adolescence. A thorough investigation is often necessary to ensure that no underlying systemic disorder is present.

When an oral ulcer lasts for more than 3 weeks, it becomes very important to do a biopsy to make sure we do not face a malignant tumor. Apart from the squamous cell carcinoma, chronic ulcers can represent a trauma, an infection or a TUGSE.

The traumatic ulcerative granuloma with stromal eosinophilia or TUGSE is a benign ulcer which can last for a long time and often requires ablation to cure. It is characterized by the presence of a significant number of eosinophils in the lamina propria and can be easily confused clinically with carcinoma of the tongue.

Lichen planus is a common disorder that can affect skin, mucosa and nails. In the mouth, in its atrophic and erosive forms, it appears as whitish streaks superimposed on a erythematous background. Clinically, this disorder can be confused with cicatricial pemphigoid, pemphigus vulgaris, lupus or lichenoid reactions. A histopathological examination can often help establishing the diagnosis.

Cicatricial pemphigoid manifests in the mouth mainly by the development of a desquamative gingivitis. This disorder, relatively uncommon, can also affect the skin, genital mucosa and eyes. A direct immunofluorescence examination in addition to regular histopathology helps establishing the diagnosis.

All forms of lupus can affect the oral cavity. This disorder manifests itself in the mouth in a manner similar to lichen planus. On the other hand, lupus lesions are not as likely to move around in the mouth as lichen planus lesions are. In addition to the standard evaluation in pathology, direct immunofluorescence and blood tests can help confirm the diagnosis.

Intra-oral syphilis in its itinial stage manifests by the development of a chancre. The differential diagnosis of the syphilitic chancre includes deep fungal infections, TUGSE, granulomatous disorders and cancer. Special stains can be used to identify the micro-organism that causes this disease.

Crohn's disease is a granulomatous disorder that can affect the entire gastrointestinal tract. In the orofacial region, one can observe labial edema, fissures in the buccal mucosa and in the vestibular folds and signs of malabsorption disorder (atrophic glossitis, pale mucous membranes). On histopathologic examination, granulomas, which are the hallmark of this disorder, can often be observed.

Atrophic glossitis is characterized by the loss of the tongue filiform papillae and the development of a smooth surface. This is often accompanied by a burning sensation. The most common causes of atrophic glossitis are iron deficiency anemia, anemia by folic acid deficiency and pernicious anemia.

Migratory glossitis, more commonly known as geographic tongue, is a benign disorder that manifests itself by the presence of atrophic plaques that develop on the dorsal surface of the tongue and that are surrounded by a white edge. Occasionally, these plaques are associated with a burning sensation. When the disorder occurs in other mucous membranes, it is called migratory stomatitis.

Desquamative gingivitis is a clinical term describing a rather marked gingival erythema associated with a separation of the surface epithelium. Its differential diagnosis includes, among other things, lichen planus, cicatricial pemphigoid and pemphigus vulgaris. Direct immunofluorescence in addition to histopathological examination can helpt to establish the diagnosis.

Occasionally, one finds metastasis to the oral cavity and sometimes they represent the first known manifestation of cancer. Malignant tumors most often found to have metastasized to the oral cavity are malignant tumors from breast, prostate, kidney, thyroid and lung.

Melanotic macule is most of the time solitary and totally bening. Sometimes it may be associated with a syndrome, an underlying sytemic disorder or associated with use of certain drugs. It may also be confused with an amalgam tattoo, a neavus or a melanoma, hence the importance of evaluating this type of change in depth.

The amalgam tattoo is frequently encountered in the oral cavity. It is the result of the introduction of dental material in the chorion of soft tissue. To help confirm its presence and eliminate the possibility of a malignancy, one can take a radiograph of the tissue. In about half the cases, metallic pellets can be observed on the radiograph. Otherwise, a biopsy can be performed to determine the nature of the pigmented area.

The keratocyst recently changed its name. It is now called keratocystic odontogenic tumor. This reflects several aspects of the lesion. Among other things, its strong propensity to recur and the autonomous growth of its walls.

The removal of intra-bony cystic-like lesions always requires histopathological examination, even though most of the time the final diagnosis is radicular or follicular cyst. Lesions that can mimic these types of lesions include unicystic ameloblastomas, odontogenic keratocystic tumors (keratocysts) and glandular odontogenic cysts. These entities require a completely different clinical approach.

The ameloblastoma, apart from the odontoma, is the most frequenlty encountered odontogenic tumor. It is classified into three subtypes which all require different treatment approaches. The peripheral ameloblastoma develops in the form of a gingival mass that often resembles a traumatic fibroma. A simple excision is the best treatment. The unicystic ameloblastoma, which is found in bone, requires enucleation, like for a cyst. And finally the most common, multilocular ameloblastoma, requires an en bloc resection with margins of about 1cm

Traumatic fibroma is a very common lesion of the oral cavity. The term we should instead use to describe it is fibrous hyperplasia. The differential diagnosis of fibrous hyperplasia is broad and includes a variety of mesenchymal tumors, odontogenic tumors of the gingiva and salivary gland tumors. The histopathological examination helps to determine the nature of the mass.

Surgically removed lesions located at the apices of teeth must always be submitted for histopathological evaluation. Odontogenic tumors, fibro-osseous lesions or even tumors of hematopoietic origin can develop in lieu of a granuloma or apical cyst.

Surgicaly removed teeth often show lesions attached to the apex. Even though it is usually a cyst or an apical granuloma, it can represent another type of lesion such as an odontogenic tumor, a keratocysts or a lymphoma. It is therefore important to submit these lesions for histopathological examination.

Blue red masses of the gingiva can represent several different pathologic entities. The differential diagnosis includes amongst other things pyogenic granuloma and giant cell granuloma (central or peripheral). In both cases, removal should be done thoroughly with a curette as these types of lesions tend to recur.

Pyogenic granuloma is a benign reactive lesion that is characterized by the presence of a reddish ulcerated mass that tends to bleed easily. It is frequently found on the gingiva, but can grow elsewhere in the mouth. The pathologic examination allows to confirm the diagnosis and to eliminate the possibility that it could represent a giant cell granuloma or another type of vascular injury.

The giant cell granuloma manifests as a gingival blue-red mass or as a radiolucent lesion in its central type. Such a diagnosis requires eliminating the presence of hyperparathyroidism in which case, one can see the development of a brown tumor that is completely identical histopathologically to the giant cell granuloma.

Lipoma is a benign mesenchymal tumor that manifests clinically as a yellowish mass covered by pink mucosa. An interesting feature of the lipoma is that it floats in formaldehyde. Histopathological examination eliminates the possibility of it being a liposarcoma.

Masses of the anterior two-thirds of the tongue include mainly two different diagnoses: fibrous hyperplasia and granular cell tumor. The latter is characterized by proliferation of multiple granular cells in the lamina propria. On histopathological examination, pseudo-epitheliomatous hyperplasia, which strongly resembles oral cancer can be observed. These two entities must however be differentiated as the granular cell tumor is totally benign.

Mucoceles occur mostly on the lower labial mucosa. However, it can also be found on the palate, the buccal mucosa and the floor of mouth. When it is removed, one should ensure to remove underlying minor salivary glands to avoid a recurrence of the lesion.

Pleomorphic adenoma is one of the most common benign tumors of the salivary glands. Although its removal is usually curative, one must always ensure to have disease free margins to prevent recurrence. Occasionally, long-standing pleomorphic adenomas can transform into malignant tumors called carcinoma ex-pleomorphic adenoma.

Mucoepidermoid carcinoma is the most frequent malignant tumor of the salivary glands most. Intra-orally, it it most commonly found on the palate. Clinically, as it may look slightly blue, it can be confused with a mucocele or a lesion of vascular origin. The low-grade lesions have an excellent prognosis, while those of high grade are much more difficult to treat.

Oral candidiasis can take several forms. It can manifest by the presence of an asymptomatic or painful reddish area (erythematous candidiasis), removable white lesions (pseudomembranous candidiasis) or adherent white patches (hyperplastic candidiasis). In more difficult cases to diagnose, a biopsy can help identifying the presence of hyphae and confirm the diagnosis.

Direct immunofluorescence is a laboratory technique used to detect the presence of autoantibodies in a biopsy specimen. This technique is particularly useful for the diagnosis of a vesicular-bullous disorder. Unlike traditional stains, tissue taken for a test of direct immunoflorescence must be kept in Michel's solution and not in formalin. It must be prepared within a period of 7 days.

Squamous cell carcinoma of the lip is especially seen among the people who have been long exposed to sunlight. It is more akin to skin cancer than cancer of the oral cavity. Before its development, there is often the presence of actinic cheilitis manifested by the presence of hypopigmented patches, crusts and loss of definition of the vermilion-skin junction. To prevent lip cancer, the use a lip balm with sunscreen is excellent.

The two main risk factors for development of oral cancer are alcohol and tobacco. Actually, nearly 90% of people developing this type of tumor are smokers. To prevent it, alcohol consumption should be limited, mouthwash containing alcohol must be avoided and all smoking habits must be stopped.

Fibro-osseous lesions are a group of disorders characterized by replacement of normal bone by fibrous tissue into which metaplastic bony areas. This group of disorders includes cemento-osseous dysplasias (apical, focal, florid), fibrous dysplasia and ossifying fibroma. Histopathologically, all these entities are similar. The final diagnosis therefore relies on the histopathological appearance, but also on the radiologic appearance of lesions.

Cutaneous melanoma is usually characterized by the presence of a pigmented lesion that meets four criteria: asymmetry, border irregularity, color variation and diameter of more than 6mm. Patients may also mention an itch. The most significant risk factor for this type of tumor is the presence of sunburns early in life. If removed early, when the lesion does not penetrate deeply into soft tissues, the long-term prognosis is excellent.

Melanoma of the oral cavity manifests by the development of a pigmented lesion that initially may look rather benign. That's why it is recommended to biopsy any pigmented lesions of the mouth. Unlike cutaneous melanoma, melanoma of the mouth may grow very fast and has a poor prognosis. /p>