Cheilitis (lip inflammation)

Cheilitis (lip inflammation)

🔍 1. Core Concept

• Cheilitis = inflammation ของ lips (vermilion ± skin ± oral mucosa)
• อาการหลัก:
• erythema, dryness, scaling, fissure, edema
• itching / burning
• สาเหตุหลัก:
• Irritant / allergic (พบบ่อยสุด)
• Atopy
• Infection (Candida, bacteria)
• Sun exposure (premalignant)
• Drug / systemic disease

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🧾 2. Approach (ใช้จริงในคลินิก)

🔹 Physical exam (สำคัญ)

• Diffuse vs localized
• Both lips vs unilateral
• Angular involvement?
• Ulcer / crust / exudate
• Extension beyond vermilion
• Oral mucosa involvement

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🔹 History (ต้องถาม)

• Onset / duration
• Lip licking / habits
• Cosmetics / toothpaste / food
• Denture / orthodontic appliance
• Sun exposure
• Smoking
• Drug (retinoid, chemo)
• Atopy / systemic disease

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🔬 Investigation (case-based)

• Patch test → allergic
• KOH / culture → infection
• Biopsy → suspicious lesion / malignancy
• Lab → nutritional deficiency

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🧩 3. Classification (high-yield)

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🟢 A. Eczematous cheilitis (MOST COMMON)

1. Irritant contact

• cause: lip licking, weather, irritants
• พบมากในเด็ก
  👉 clue: chronic lip licking

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2. Allergic contact

• delayed hypersensitivity
• cause:
• lipstick / balm / sunscreen
• toothpaste / mouthwash
• food (cinnamon, citrus)
  👉 Dx: patch test

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3. Atopic

• associated with AD
• indistinguishable clinically

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💊 Treatment (กลุ่มนี้)

• avoid trigger (สำคัญที่สุด)
• emollient (petrolatum)
• topical steroid (short course)
• tacrolimus (long-term option)

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💊 B. Drug-induced

• Retinoids (isotretinoin) → almost universal
  👉 Tx: supportive (moisturizer)

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☀️ C. Actinic cheilitis (IMPORTANT)

• chronic sun exposure
• lower lip
• premalignant → risk SCC
  👉 suspect if:
• chronic crusting, erosion
• blurred vermilion border

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🔴 D. Exfoliative cheilitis

• chronic scaling + crust
• diagnosis of exclusion
• often behavioral (licking/biting)

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🟡 E. Cheilitis glandularis

• swollen lower lip
• dilated salivary ducts → mucous secretion
• risk secondary infection ± SCC (rare)

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🟠 F. Cheilitis granulomatosa

• persistent lip swelling (angioedema-like)
• consider:
• Crohn disease
• sarcoidosis
  👉 Dx: biopsy
  👉 Tx: difficult (steroid ± immunomodulator)

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🔴 G. Angular cheilitis (VERY COMMON)

Cause

• saliva maceration + infection:
• Candida (most common)
• Staph

Risk factors

• dentures
• drooling
• lip licking (เด็ก)
• nutritional deficiency
• DM / immunosuppression

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Clinical

• fissure at mouth corner
• bilateral
• painful

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Treatment

• topical antifungal (azole) clotrimazole / miconazole ointment BID x 1-3 wk
• ± mupirocin (if bacterial)
• barrier cream (zinc / petrolatum)
• correct underlying cause

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🟣 H. Plasma cell cheilitis

• red indurated plaque
• mimic SCC → ต้อง biopsy

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🦠 I. Infectious / rare

• Leishmaniasis
• Syphilis
• TB
  👉 consider in atypical / non-response

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🚨 4. Red Flags (ต้อง biopsy / refer)

• Persistent focal lesion
• Induration / ulcer
• Actinic cheilitis suspicious
• Unilateral lesion
• Non-healing lesion
• Systemic symptoms

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🧠 5. Clinical Pattern Recognition

Finding	Likely Dx
Dry cracked lips + licking	Irritant
Diffuse erythema + cosmetic use	Allergic
Chronic sun-exposed lower lip	Actinic
Lip swelling recurrent	Granulomatous
Fissure at angle	Angular cheilitis
Severe scaling crust	Exfoliative

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💊 6. Management Principles

• Remove cause (สำคัญที่สุด)
• Restore barrier (emollient)
• Treat infection (antifungal ± antibiotic)
• Short course steroid (inflammatory)
• Investigate if atypical / refractory

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🔑 Key Takeaways

• Eczematous (irritant/allergic) = most common
• Angular cheilitis → think Candida
• Actinic cheilitis = premalignant
• Chronic lip licking = key cause ในเด็ก
• Lesion atypical → biopsy เสมอ

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Oral Soft Tissue Lesions in Children

Oral Soft Tissue Lesions in Children

🔍 1. Core Concept

• Oral lesions ในเด็กมี spectrum กว้าง:
• normal variant → infection → inflammatory → neoplasm → systemic disease
• ส่วนใหญ่ benign แต่บางกรณีเป็น early sign ของ systemic disease (เช่น leukemia, HIV)

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🧾 2. Approach (ใช้จริงในคลินิก)

🔹 Key step

1.       Age + tooth eruption stage

2.       Location (gum / tongue / lip / palate)

3.       Pain vs painless

4.       Acute vs chronic

5.       Systemic symptoms

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🦷 3. Lesions of Gums (high-yield)

🟢 Benign / developmental

• Eruption cyst / hematoma
• dome-shaped
• หายเองเมื่อฟันขึ้น
• Retrocuspid papillae
• papule หลัง canine
• bilateral, no treatment
• Physiologic pigmentation
• normal ในเด็กผิวคล้ำ

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🔴 Infection / dental origin

• Parulis (gum boil)
• abscess → draining fistula
• ต้องรักษา tooth (extract / pulpectomy)

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⚠️ Gingival overgrowth (ต้องคิด cause)

1. Inflammatory

• plaque / braces
• bleeding easily

2. Drug-induced

• phenytoin (most common)
• nifedipine, cyclosporine
  👉 management:
• oral hygiene + consider stop drug

3. Infiltrative (IMPORTANT)

• Leukemia
• edematous, hemorrhagic gingiva
• systemic symptoms

4. Hereditary

• gingival fibromatosis

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🦠 HIV gingivitis

• linear erythema
• pain + bleeding
• ไม่ตอบสนองต่อ hygiene
  👉 Tx: debridement + antibiotics ± antifungal

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👅 4. Tongue Lesions

🟢 Common benign

• Geographic tongue
• migratory red patch + white border
• no treatment
• Fissured tongue
• groove trapping debris

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🔴 Important conditions

• Ankyloglossia (tongue-tie)
• Mucocele (ventral tongue/lip)
• Thrush / HSV / HFMD

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👄 5. Lip Lesions

🔹 Infection

• Herpes labialis
• vesicle → ulcer → crust
• Angular cheilitis
• Candida-related fissure

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🔹 Others

• Freckling → consider genetic disease (Peutz-Jeghers)
• Labial frenulum abnormality → orthodontic issue

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🫧 6. Common Lesions Across Multiple Sites

🟢 Benign tumors

• Hemangioma
• Lymphangioma

🔴 Reactive lesions

• Irritation fibroma
• Pyogenic granuloma
• Peripheral giant cell granuloma

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🔥 Ulcers (VERY COMMON)

1. Traumatic ulcer (most common)

• heal <2 weeks

2. Aphthous ulcer

• painful, recurrent

3. Infection

• Candida (thrush)
• HSV (gingivostomatitis)
• HFMD

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🚨 7. Red Flags (ต้องคิด serious disease)

• Gingival enlargement + bleeding → leukemia
• Persistent ulcer >2 weeks
• Systemic symptoms (fever, weight loss)
• Severe mucositis → SJS / immunologic disease

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🧠 8. Clinical Pattern Recognition (ใช้เร็ว)

Finding	Likely Dx
Bluish dome over erupting tooth	Eruption cyst
Gum boil with pus	Parulis
Gingival hypertrophy + drug	Phenytoin effect
Gingiva bleeding + systemic	Leukemia
White wipeable plaque	Candida
Multiple ulcers + fever	HSV / HFMD
Single painful ulcer	Aphthous

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💊 9. Management Principles

• ส่วนใหญ่ benign → reassurance
• Remove cause (trauma, plaque)
• Treat infection:
• antifungal (Candida)
• antiviral (HSV severe)
• Dental referral (abscess, eruption issue)
• Investigate systemic disease when suspected

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🔑 Key Takeaways

• เด็กส่วนใหญ่ = benign + self-limited
• Parulis → treat tooth, not lesion
• Gingival enlargement ต้อง rule out leukemia
• Ulcer >2 weeks → evaluate further
• ใช้ pattern recognition + age + location เป็นหลัก

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Oral Mucosal Lesions

Approach to Oral Mucosal Lesions

🔍 1. Core Concept

• Oral lesions มี differential diagnosis กว้างมาก (benign → premalignant → malignancy → infection → systemic disease)
• การวินิจฉัยต้องอาศัย:
• history + morphology + location
• อาจเป็น:
• isolated lesion
• หรือ manifestation ของ systemic disease

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🧾 2. Initial Evaluation (สำคัญที่สุด)

2.1 History (structured approach)

ให้ถามเป็น checklist:

🔹 Lesion characteristics

• Location (tongue only? diffuse?)
• Color → white / red / pigmented / ulcer / vesicle
• Morphology → macule, papule, plaque, ulcer
• Duration
• Change over time

🔹 Symptoms

• Pain, bleeding, discharge
• LN enlargement
• systemic symptoms (fever, weight loss, rash)

🔹 Risk factors

• Tobacco / alcohol / betel quid (สำคัญใน SEA)
• Drugs (especially new meds)
• Immunosuppression (HIV, chemo)
• Denture / trauma

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2.2 Physical Examination

🔹 Intraoral exam

• Inspect + palpate:
• location, size, color
• induration (→ malignancy)
• examine systematically:
• lips → buccal mucosa → gingiva → tongue → floor → palate

🔹 Extraoral exam

• facial asymmetry / mass
• cervical lymph nodes

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⚠️ 3. Red Flag for Malignancy (VERY IMPORTANT)

ใช้ mnemonic: RULE

• Red / red-white lesion
• Ulcer
• Lump
• Enduration

👉 lesion >3 weeks → ต้อง biopsy

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🧩 4. Classification by Morphology

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🔳 A. White / Red lesions

Benign

• Frictional keratosis
• Morsicatio (cheek biting)

Infection

• Candidiasis
• wipe off ได้ → pseudomembranous
• wipe off ไม่ได้ → hyperplastic

Premalignant (OPMD)

• Leukoplakia → malignant transformation ~10%
• Erythroplakia → high risk มาก
• Oral lichen planus

Malignant

• SCC (most common)
• ulcer + indurated margin
• tongue (lateral) common site

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⚫ B. Pigmented lesions

Benign

• Melanotic macule
• Smoker’s melanosis
• Drug-induced pigmentation
• Amalgam tattoo

Suspicious

• Melanoma
• asymmetry
• irregular border
• color variation
• rapid growth

👉 suspicious → biopsy

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🔴 C. Ulcerative / erosive lesions

Common

• Aphthous ulcer
• Recurrent aphthous stomatitis

Infection

• HSV (painful + prodrome)
• Coxsackie (HFMD)
• Syphilis (painless chancre)

Systemic disease

• Behçet (oral + genital ulcers)
• SLE
• IBD

Drug-related

• SJS/TEN
• mTOR inhibitor

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🫧 D. Vesiculobullous / autoimmune

• Pemphigus vulgaris → flaccid bullae → erosions
• Mucous membrane pemphigoid → desquamative gingivitis
• Erythema multiforme

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👅 5. Tongue lesions (high-yield)

Normal variants

• Fissured tongue
• Geographic tongue

Important conditions

• Atrophic glossitis → nutritional deficiency (Fe, B12, folate)
• Black hairy tongue → antibiotics / poor hygiene / smoking
• Median rhomboid glossitis → Candida

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🧠 6. Clinical Pattern Recognition (practical shortcut)

Finding	Likely Dx
White wipeable plaque	Candida
White non-wipeable plaque	Leukoplakia
Painful recurrent ulcers	Aphthous
Ulcer + induration	SCC
Pigmented irregular lesion	Melanoma
Multiple ulcers + genital	Behçet

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🧪 7. When to Investigate

Biopsy (key decision)

• lesion >3 weeks
• suspicious features (RULE)
• unclear diagnosis
• pigmented lesion suspicious melanoma

Lab (case-by-case)

• HIV (recurrent candidiasis / hairy leukoplakia)
• CBC, iron, B12 (atrophic glossitis)
• autoimmune panel (SLE, pemphigus)

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💊 8. Management Principles

• Treat underlying cause
• remove irritants (trauma, dentures)
• antifungal (Candida)
• topical steroids (aphthous, lichen planus)
• urgent referral + biopsy (suspected cancer)

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🔑 Key Takeaways (สำหรับใช้จริง)

• Oral lesion = pattern recognition + red flag detection
• ทุก lesion ที่ >3 สัปดาห์ → biopsy
• RULE mnemonic ใช้คัดกรอง cancer
• Candida vs leukoplakia → wipe test
• SEA context → ต้องถาม betel quid

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Sialolithiasis (salivary gland stones)

Sialolithiasis (salivary gland stones)

🔎 1. Overview (High-yield)

• Sialolithiasis = stone ใน salivary gland/duct
• พบบ่อยที่สุดใน submandibular gland (80–90%)
• อันดับรอง: parotid (6–20%)

👉 กลไกหลัก

• salivary stasis + ↑Ca → stone formation

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⚠️ 2. Risk factors (จำง่าย)

• dehydration / hypovolemia
• anticholinergic drugs
• smoking
• gout
• trauma
• history of kidney stones

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📌 3. Clinical presentation (classic exam question)

🟢 Classic triad

• pain + swelling + worse with eating

อื่น ๆ

• episodic swelling
• painless swelling (พบได้ ~30%)
• fever / erythema → คิดถึง infection

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🩺 4. Physical exam (สำคัญมาก)

Submandibular

• คลำ Wharton’s duct (floor of mouth)
• stone อาจคลำได้ใกล้ frenulum

Parotid

• คลำ Stensen’s duct (opposite upper 2nd molar)

Key findings

• ไม่มี saliva flow → obstruction
• pus → bacterial infection
• stone → hard, mobile

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🚨 5. Complications (ต้องระวัง)

• secondary infection → abscess → airway risk
• chronic sialadenitis → gland atrophy

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🧪 6. Diagnosis (practical)

🟢 Clinical diagnosis เป็นหลัก

• pain หลังอาหาร + palpate stone

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Imaging (เลือกให้ถูก)

Modality	Use
CT non-contrast = best	gold standard
Ultrasound	screening (>2 mm)
MRI	ไม่ดีสำหรับ stone
Sialography	rarely used

👉 CT sensitivity ~98%

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🔍 7. Differential (สำคัญ)

• bacterial sialadenitis
• viral (mumps)
• Sjögren
• tumor (painless, no meal relation)

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💊 8. Management (stepwise)

🔹 First-line (Primary care)

• hydration
• massage gland
• warm compress
• sialagogues (lemon candy)
• NSAIDs

👉 stop anticholinergic drugs

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🔹 Antibiotics (ถ้ามี infection)

• amoxicillin-clavulanate first line

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🔹 Indications refer ENT

• ไม่ดีขึ้นใน few days
• recurrent
• severe infection
• suspicion tumor

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🛠️ 9. Definitive treatment (specialist)

🟢 Minimally invasive (first choice)

• sialoendoscopy (success ~86%)

👉 success ดีถ้า

• size เล็ก
• distal
• mobile

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🔹 Other options

• laser lithotripsy
• extracorporeal lithotripsy
• wire basket

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🔴 Surgery (last resort)

• transoral removal
• gland excision (sialoadenectomy)

⚠️ risk:

• facial nerve injury
• lingual / hypoglossal nerve

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🚩 10. Red flags → คิด malignancy

• painless mass
• no relation to eating
• firm, fixed
• facial nerve palsy

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🧠 Key takeaway (จำสั้น)

• Pain after eating = stone จนกว่าจะพิสูจน์ว่าไม่ใช่
• CT non-contrast = best test
• รักษาเริ่ม conservative ก่อน
• failure → sialoendoscopy

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