course of action
Reassure the patient of the nonpremalignant nature of benign migratory glossitis and that it does not represent any known systemic disease.
Treatment
None required.
Acute and Chronic Radiation Mucositis
Nature of disease
An initial inflammatory condition of the oral mucosa resulting from the cellular injury created by high-dose radiation energy. While the initial phase, usually beginning 3 weeks into a radiotherapy treatment protocol, comprises acute inflammation and hyperemia, this usually subsides about 3 to 4 weeks after completion of radiotherapy into a fibrotic chronic phase.
Predilections
Adults and, more rarely, children who undergo greater than 6,000 cGy of radiotherapy. There is no sex or racial predilection.
Clinical features
In the acute phase, a painful red-white mucosa often with a weeping serous or fibrinous exudate or slough appears. Frequently dysphagia and tender lymphadenopathy are also present. The chronic phase will present as a dry white surface that may have superficial Candida infection and may be somewhat firm and contracted.
Radiographic presentation
None.
Differential diagnosis
The acute phase may be identical to a drug-induced mucositis from chemotherapy, which may have been used concomitant with the radiotherapy. Otherwise, consider secondary mucositis from HIV, leukemia, or multiple myeloma. The chronic phase will resemble a chemical burn such as lye ingestion or progressive systemic sclerosis (scleroderma).
Microscopic features
The acute phase will show hyperemia and sludging in most vessels as well as interstitial edema and acute inflammatory cells. The chronic phase will be poorly vascular and poorly cellular with collagen replacing most cellular elements as seen in a scar.
Suggested course of action
During the acute phase, advise the patient to avoid alcohol or acid-containing medicaments and foods. Prescribe “magic mouthwash”—ie, Kaopectate (Chattem) 5 mL, Benadryl (McNeil) 12.5 mg, and dexamethasone 12 mg swish and spit—and/or 2% lidocaine gel to be applied topically before meals and as needed. If secondary infection is suspected (eg, tender lymphadenopathy, significant mucosal pain), also treat with antibiotics: amoxicillin 500 mg three times daily or doxycycline 100 mg daily.
Treatment
No specific curative treatment is known. However, the palliative care discussed above is useful.
Field Cancerization
Nature of disease
Although smoking and certain human papillomaviruses (HPV) have been linked to oral squamous cell carcinoma, a significant number occur without any apparent carcinogen exposure. One of these is the field cancerization phenomenon in which the normal oral mucosa transforms into squamous cell carcinoma over a wide area and with new lesions developing over time.
Predilections
Adults over 30 years of age, with a slight female predilection. No racial predilection is known.
Clinical features
Pebble-like leukoplakia or erythroplakia over a wide surface area, mostly seen on the gingiva, at the lateral border of the tongue, and on the buccal mucosa. This condition is often painful and does not develop ulcerations or regional lymph node spread until it has been present for some time.
Radiographic presentation
Radiographs are usually normal until late in its course, when bony invasion results in osteolysis.
Differential diagnosis
Proliferative verrucous leukoplakia bears a very close resemblance to field cancerization and is actually another form of it, but one that goes through a verrucous phase (while field cancerization does not). Additionally, lichen planus, candidiasis, and a large isolated T3 squamous cell carcinoma may be considered.
Microscopic features
Field cancerization histopathology is no different than that of isolated dysplasia, carcinoma in situ, and invasive squamous cell carcinoma that represent focal disease, in which atypical epithelial cells with pleomorphic nuclei and mitotic figures occur above an intact basement membrane and then invade through the basement membrane to the subjacent connective tissue, sometimes forming keratin pearls and other times more anaplastic features.
Suggested course of action
Suspicious cases should be photographed for documentation and biopsied. If this cannot be accomplished by the initial examining practitioner, the patient should be referred to an oral and maxillofacial surgeon or a regional cancer center.
Treatment
The lesions present at the time are excised with 1.5-cm margins with frozen section control, and the defect is skin grafted or reconstructed with a tissue flap. A prophylactic neck lymphadenectomy is also usually accomplished. If lymphadenopathy is present, a treatment neck dissection is performed. Close follow-up is observed every 2 to 3 months, with retreatment of new lesions as they arise.
Scarlet Fever
Nature of disease
Today, a rare bacterial infection caused by group A beta-hemolytic streptococci (Streptococcus scarlatina or Streptococcus pyogenes) that produces a unique red macular skin rash and a red swollen tongue by virtue of its erythrotoxin elaboration.
Predilections
Mostly children and young adults. No sex or racial predilection is known.
Clinical features
The child or young adult will present with fever,