Oral and maxillofacial pathology
Other namesOral pathology, stomatognathic disease, dental disease, mouth disease
SpecialtyDentistry

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).[1][2] The mouth is an important organ with many different functions. It is also prone to a variety of medical and dental disorders.[3]

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.[4] 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. This is followed by a thorough clinical investigation including extra-oral and intra-oral hard and soft tissues.[5]

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.[5]

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).[5]

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.[6]

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.[7]

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 your 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.[7]

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.[7]

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

Malocclusion

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.[8][9][10] The most common form is combined cleft lip and palate and it accounts for approximately 50% of the cases whereas isolated cleft lip concerns 20% of the patients.[11]

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.[12][13] 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.[10]

The palates 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.[10]

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.[10]

Macroglossia

Is a rare condition, categorised by tongue enlargement which will eventually create a crenated border in relation to the embrasures between the teeth.[14]

Hereditary Cause
Acquired Causes
Consequences
Treatments

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.[14]

Ankyloglossia

Stafne defect

Torus palatinus

Torus mandibularis

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.[15]

Acquired

Vascular

Infective

X-ray of advanced bone loss due to periodontitis
X-ray of advanced bone loss due to periodontitis

Bacterial

Viral

Fungal

Pseudomembranous candidiasis of the posterior mouth and oropharynx
Pseudomembranous candidiasis of the posterior mouth and oropharynx

Traumatic

Autoimmune

This article may benefit from being shortened by the use of summary style. Summary style may involve the moving of large sections to sub-articles that are then summarized in the main article.

Sjögren syndrome is an autoimmune chronic inflammatory disorder characterised by some of the body's own immune cells infiltrating and destroying lacrimal and salivary glands (and other exocrine glands). There are two types of Sjögren's syndrome: primary and secondary. In primary Sjögren's syndrome (pSS) individuals have dry eyes (keratoconjunctivitis sicca) and a dry mouth (xerostomia). Based on a meta-analysis, the prevalence of pSS worldwide is estimated to 0.06%, with 90% of the patients being female.[23] In secondary Sjögren's syndrome (sSS), individuals have a dry mouth, dry eyes and a connective tissue disorder such as rheumatoid arthritis (prevalence 7% in the UK), systemic lupus erythematosus (prevalence 6.5%–19%) and systemic sclerosis (prevalence 14%–20.5%).[24] Additional features and symptoms include:

Tests used to diagnose Sjögren's syndrome include:

There is no cure for Sjogren's syndromeis disease however there are treatments used to help with the associated symptoms.

Complications of Sjogren's syndrome include ulcers that can develop on the surface of the eyes if the dryness is not treated. These ulcers can then cause more worrying issues such as loss of eye sight and life long damage. Individuals with Sjögren's syndrome have a slightly increased risk of developing non-Hodgkin Lymphoma, a type of cancer. Other conditions such as peripheral neuropathy, Raynaud's phenomenon, kidney problems, underactive thyroid gland and irritable bowel syndrome have been linked to Sjogren's syndrome[25]

Metabolic

Inflammatory

Neurological

Neoplastic

Oral cancer on the tongue.
Oral cancer on the tongue.

Degenerative

Environmental

Unknown

There are many oral and maxillofacial pathologies which are not fully understood.

2 minor aphthae on the lower labial mucosa
2 minor aphthae on the lower labial mucosa
Geographic tongue
Geographic tongue

Specialty

Occupation
NamesOral and Maxillofacial Pathologist, Oral Pathologist
Occupation type
Specialty
Activity sectors
Pathology, Dentistry, Medicine
Specialtygastroenterology
Description
Education required
Varies. Typically dental degree followed by specialist training

Oral and maxillofacial pathology, previously termed oral pathology, is a speciality involved with the diagnosis and study of the causes and effects of diseases affecting the oral and maxillofacial regions (i.e. the mouth, the jaws and the face). It can be considered a speciality of dentistry and pathology.[4] Oral pathology is a closely allied speciality with oral and maxillofacial surgery and oral medicine.

The clinical evaluation and diagnosis of oral mucosal diseases are in the scope of oral & maxillofacial pathology specialists and oral medicine practitioners,[30] both disciplines of dentistry. When a microscopic evaluation is needed, a biopsy is taken, and microscopically observed by a pathologist. The American Dental Association uses the term oral and maxillofacial pathology, and describes it as "the specialty of dentistry and pathology which deals with 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."[31]

In some parts of the world, oral and maxillofacial pathologists take on responsibilities in forensic odontology.

Geographic variation

United Kingdom

There are approximately 30 consultant oral and maxillofacial pathologists in the UK. A dental degree is mandatory, but a medical degree is not. The shortest pathway to becoming an oral pathologist in the UK is completion of 2 years' general professional training and then 5 years in a diagnostic histopathology training course. After passing the required Royal College of Pathologists exams and gaining a Certificate of Completion of Specialist Training, the trainee is entitled to apply for registration as a specialist.[32] Many oral and maxillofacial pathologists in the UK are clinical academics, having undertaken a PhD either prior to or during training. Generally, oral and maxillofacial pathologists in the UK are employed by dental or medical schools and undertake their clinical work at university hospital departments.

New Zealand

There are 5 practising Oral Pathologists in New Zealand (as of May 2013).[33] Oral pathologists in New Zealand also take part in forensic evaluations.[33]

See also

References

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Further reading