Oral and maxillofacial pathology refers to the diseases of the mouth ("oral cavity" or "stoma"), jaws ("maxillae" or "gnath") and related structures such as salivary glands, temporomandibular joints, facial muscles and perioral skin (the skin around the mouth). The mouth is an important organ with many different functions. It is also prone to a variety of medical and dental disorders.Mouth Disease Information Retrieved on 2010-02-01
The specialty oral and maxillofacial pathology is concerned with diagnosis and study of the causes and effects of diseases affecting the oral and maxillofacial region. It is sometimes considered to be a specialty of dentistry and pathology. Sometimes the term head and neck pathology is used instead, which may indicate that the pathologist deals with otorhinolaryngologic disorders (i.e. ear, nose and throat) in addition to maxillofacial disorders. In this role there is some overlap between the expertise of head and neck pathologists and that of endocrine pathologists.
Diagnosis The key to any diagnosis is thorough medical, dental, social and psychological history as well as assessing certain lifestyle risk factors that may be involved in disease processes. Assessment of lifestyle risk factors may include tobacco use, alcohol consumption, and oral hygiene practices. This is followed by a thorough clinical investigation including extra-oral and intra-oral hard and soft tissues. Examination of these tissues during routine dental visits may facilitate early detection of oral and maxillofacial disease, particularly when lesions are asymptomatic or not readily visible to the patient. Early recognition during routine examinations may improve opportunities for earlier referral and management, which has been associated with improved clinical outcomes, particularly in conditions such as oral squamous cell carcinoma where delayed diagnosis is linked to more advanced disease at presentation.
It is sometimes the case that a diagnosis and treatment regime are possible to determine from history and examination, however it is good practice to compile a list of differential diagnoses. Differential diagnosis allows for decisions on what further investigations are needed in each case. Many oral lesions may present with subtle or overlapping clinical features, making definitive diagnosis challenging in some cases. Similar diagnostic challenges have been reported in cutaneous diseases such as pemphigus vulgaris, which is often misdiagnosed because its clinical presentation resembles other conditions.
There are many types of investigations in diagnosis of oral and maxillofacial diseases, including screening tests, imaging (radiographs, CBCT, CT, MRI, ultrasound) and histopathology (biopsy).
Screening investigations may include adjunctive diagnostic tools such as toluidine blue staining, autofluorescence imaging, and brush cytology, which can be used alongside conventional oral examination to help identify lesions requiring further investigation or biopsy. These techniques are non-invasive and have been increasingly studied for their potential to improve diagnostic accuracy and facilitate earlier detection of malignant and potentially malignant lesions. However, histopathological assessment remains the gold standard for definitive diagnosis.
Biopsy A biopsy is indicated when the patient's clinical presentation, past history or imaging studies do not allow a definitive diagnosis. A biopsy is a surgical procedure that involves the removal of a piece of tissue sample from the living organism for the purpose of microscopic examination. In most cases, biopsies are carried out under local anaesthesia. Some biopsies are carried out endoscopically, others under image guidance, for instance ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) in the radiology suite. Examples of the most common tissues examined by means of a biopsy include oral and sinus mucosa, bone, soft tissue, skin and lymph nodes.
Types of biopsies typically used for diagnosing oral and maxillofacial pathology are:
Excisional biopsy: A small lesion is totally excised. This method is preferred if the lesions are approximately 1 cm or less in diameter, clinically and seemingly benign and surgically accessible. Large lesions which are more diffused and dispersed in nature or those which are seemed to be more clinically malignant are not conducive to total removal.
Incisional biopsy: A small portion of the tissue is removed from an abnormal-looking area for examination. This method is useful in dealing with large lesions. If the abnormal region is easily accessed, the sample may be taken at the doctor's office. If the tumour is deeper inside the mouth or throat, the biopsy may need to be performed in an operating room. General anaesthesia is administered to eliminate any pain.
Exfoliative cytology: A suspected area is gently scraped to collect a sample of cells for examination. These cells are placed on a glass slide and stained with dye, so that they can be viewed under a microscope. If any cells appear abnormal, a deeper biopsy will be performed.
Diseases
Oral and maxillofacial pathology can involve many different types of tissues of the head. Different disease processes affect different tissues within this region with various outcomes. A great many diseases involve the mouth, jaws and orofacial skin. The following list is a general outline of pathologies that can affect oral and maxillofacial region; some are more common than others. This list is by no means exhaustive.
Congenital
Cleft lip and palate Cleft lip and palate is one of the most common occurring multi-factorial congenital disorder occurring in 1 in 500–1000 live births in several forms. The most common form is combined cleft lip and palate and it accounts for approximately 50% of cases, whereas isolated cleft lip concerns 20% of the patients.Young G. Cleft Lip and Palate. Available at http://www2.utmb.edu/otoref/Grnds/Cleft-lip-palate-9801.htm.
People with cleft lip and palate malformation tend to be less social and report lower self-esteem, anxiety and depression related to their facial malformation. One of the major goals in the treatment of patients with cleft is to enhance social acceptance by surgical reconstruction.
A cleft lip is an opening of the upper lip, mainly due to the failure of fusion of the medial nasal processes with the palatal processes; a cleft palate is the opening of the soft and hard palate in the mouth, which is due to the failure of the palatal shelves to fuse together.
The palate's main function is to demarcate the nasal and oral cavity, without which the patient will have problems with swallowing, eating and speech, thus affecting the quality of life and in some cases certain functions.
Some examples include food going up into the nasal cavity during swallowing as the soft palate is not present to close the cavity during the process. Speech is also affected as the nasal cavity is a source of resonance during speech and failure to manipulate spaces in the cavities will result in the lack of ability to produce certain consonants in audible language.
Macroglossia Macroglossia is a rare condition, categorised by tongue enlargement which will eventually create a crenated border in relation to the embrasures between the teeth.
Hereditary causes include vascular malformations, Down syndrome, Beckwith–Wiedemann syndrome, Duchenne muscular dystrophy, and Neurofibromatosis type I.
Acquired causes include carcinoma, lingual thyroid, myxedema, and amyloidosis.
Consequences may include noisy breaths – airway obstruction in severe cases, drooling, difficulty eating, lisping speech, open bite, and protruding tongue, which may ulcerate and undergo necrosis.
For mild cases, surgical treatment is not mandatory but if speech is affected, speech therapy may be useful. Reduction glossectomy may be required for severe cases.
Ankyloglossia Ankyloglossia (also known as tongue-tie) may decrease the mobility of the tongue tip and is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth.
Stafne defect Stafne defect, or lingual mandibular cortical defect, is a depression of the mandible, most commonly located on the lingual surface (the inside of the jawbone, near the tongue).
Torus palatinus Torus palatinus is a bony protrusion on the palate, usually present on the midline of the hard palate.
Torus mandibularis Torus mandibularis is a bony growth in the mandible along the surface nearest to the tongue. Mandibular tori usually are present near the premolars and above the location on the mandible of the mylohyoid muscle attachment.
Eagle syndrome Eagle syndrome is a condition where there is an abnormal ossification of the stylohyoid ligament. This leads to an increase in the thickness and the length of the stylohyoid process and the ligament. Pain is felt due to the pressure applied to the internal jugular vein. Eagle syndrome occurs due to elongation of the styloid process or calcification of the stylohyoid ligament. However, the cause of the elongation has not been known clearly. It could occur spontaneously or could arise since birth. Usually normal stylohyoid process is 2.5–3 cm in length, if the length is longer than 3 cm, it is classified as an elongated stylohyoid process.
Acquired Infective
Bacterial (Plaque-induced) gingivitis—A common periodontal (gum) disease is gingivitis. Periodontal refers to the area the infection affects, which include the teeth, gums, and tissues surrounding the teeth. Bacteria cause inflammation of the gums which become red, swollen and can bleed easily. The bacteria along with mucus form a sticky colorless substance called plaque which harbours the bacteria. Plaque that is not removed by brushing and flossing hardens to form tartar that brushing does not clean. Smoking is a major risk factor. Treatment of gingivitis is dependent on how severe and how far the disease has progressed. If the disease is not too severe it is possible to treat it with chlorhexidine rinse and brushing with fluoride toothpaste to kill the bacteria and remove the plaque, but once the infection has progressed antibiotics may be needed to kill the bacteria. Periodontitis—When gingivitis is not treated it can advance to periodontitis, when the gums pull away from the teeth and form pockets that harbor the bacteria. Bacterial toxins and the body's natural defenses start to break down the bone and connective tissues. The tooth may eventually become loose and have to be removed. Scarlet fever is caused by a particular streptococci species, Streptococci Pyogenes, and is classified be a severe form of bacterial sore throat. The condition involves the release of pyrogenic and erythrogenic endotoxins from the immune system. It starts as tonsillitis and pharyngitis before involving the soft palate and the tongue. It usually occurs in children where a fever occurs and an erythematous rash develops on the face and spreads to most part of the body. If not treated, late stages of this condition may include a furred, raw, red tongue. Treatment options include penicillin and the prognosis is generally excellent.
Viral