4th year mucosal disease Flashcards
Define leukoplakia
A white patch plaque of questionable risk with no other histological diagnosis
What is the prevalence of leukoplakia?
1-2%
In smokers, how much does the prevalence of leukoplakia increase?
x6
DELETE
Speckled
Verrucous
Define erythroplakia
Red patch that cannot be classified as any other disease and is associated with an increased risk of malignancy
What is the malignant transformation rate of erythroplakia?
Greater than 80%
List the 8 risk factors for progression of red/white patches
Female gender
Long duration of leukoplakia
Leukoplakia in non-smokers/drinkers
Location on the tongue and/or floor of the mouth
Greater than 200 mm²
Non-homogeneous type
Presence of Candida
Presence of epithelial dysplasia
Define an ulcer
A break in the oral mucosa
What should be done if an ulcer is not healing?
Create red flag referral to be seen within 2 weeks
What are the 2 common locations for ulcers?
Edge of tongue
Buccal mucosa
Name the 4 classifications of ulcers based on size
Minor (<1cm)
Major (>1cm)
Herpetiform (pin point ulcers)
Large erosive areas
List 5 topical treatments for ulcers
Corsydyl
Difflam
Topical steroids
Antibiotics
Triple mouthwash
What are features of suspicious oro-mucosal lesions? (8)
Solitary ulcer present for longer than 3 weeks
Unintended weight loss
Rolled margins
Bleeding on light touch
Firm or fixed lesions
Numbness
Red or speckled lesions
Severe or extensive ulceration
What are 6 potential causes of oral ulceration?
Neoplasia (SCC)
Trauma
Recurrent aphthous stomatitis
Oral infection
Drugs
Systemic disease
What is recurrent aphthous stomatitis (RAS)?
A condition characterized by recurrent, painful ulcers in the oral cavity
Give 3 epidemiological features of oral lichen planus
Affects 2% of the population
More common in females
More common in older adults
What are the 6 clinical forms of lichen planus?
Reticular
Papular
Plaque-like
Atrophic
Erosive
Bullous
Describe the appearance of reticular oral lichen planus
Fine net-like lines
Describe the appearance of papular oral lichen planus
Small elevated nodules
Describe the appearance of plaque oral lichen planus
Broad area of mucosal thickening
Describe the appearance of atrophic oral lichen planus
Reddened/hypervascular mucosa
Describe the appearance of bullous oral lichen planus
Sub-epithelial fluid-filled blisters
Describe the appearance of erosive oral lichen planus
Broad shallow ulcers covered by fibrinous slough
What percentage of oral lichen planus cases transform to become malignant
1%
What are the 4 treatment options for oral lichen planus?
No active treatment
Remove trigger
Topical/intralesional/systemic steroids
Other immunomodulatory agents
What are 6 risk factors for OSCC?
Tobacco
Alcohol
UV-light/sun exposure
Malnutrition
Infections: syphilis, candida, HPV
Immunosuppression
What are 3 clinical features of OSCC?
Firm, not very mobile lump
Thickened warty white plaque
Ulcer with raised, rolled, everted edge
What is the survival rate for early-stage and late-stage OSCC?
Early: 80% three-year survival
Late: 50% three-year survival
What are 7 important features requiring referral?
Ulcer with granular floor
Traumatic ulcer unhealed after 3 weeks
Indurated swelling
Thickened white patch esp. if speckled
Spontaneously loosed teeth
Non-healing socket
Neurological symptoms
Define potentially malignant oral lesions
Lesions that are not malignant but have a risk of developing into OSCC
What are the 2 classifications of leukoplakia?
Homogeneous leukoplakia: lowest risk of OSCC
Non-homogeneous leukoplakia: higher risk of OSCC
What are 3 causes of white patches in the oral cavity?
Thicker keratin (hyperkeratosis)
Thicker epithelium (hyperplasia)
Fibrosis in the lamina propria
What is dysplasia?
Architectural and cytological changes in epithelium resembling cancer without invasion
What is frictional keratosis?
A condition characterised by a thickening of the epithelium due to chronic friction or irritation
Often seen in areas of the oral cavity subjected to repeated trauma.
What is a candidal infection?
An infection caused by the overgrowth of Candida species, most commonly Candida albicans
It can affect various mucosal surfaces, including the oral cavity.
Describe the appearance of homogeneous leukoplakia
Flat, possibly fissured
Describe the appearance of non-homogeneous leukoplakia
Nodular, speckled or both
What are 3 types of laboratory investigations for oral lesions?
Microbiological
Haematological
Histopathological
These investigations help in diagnosing infections and abnormalities.
Define dysplasia
Architectural and cytological changes in epithelium resembling cancer but without invasion of tissues
It indicates a tissue disturbance that looks like cancer but does not behave like it.
What are the features of epithelial dysplasia? (8)
Distorted rete peg architecture
Dyskeratosis
Basal cell hyperplasia
Loss of adherence
Loss of polarity
Hyperchromatism
Pleomorphism
Abnormal mitotic figures
N:C refers to the nuclear-to-cytoplasmic ratio.
What is the risk factor increase for OSCC with the presence of dysplasia?
Increases the risk by a factor of 10
OSCC stands for oral squamous cell carcinoma.
What are the grades of dysplasia and their associated risks of OSCC?
Mild: less than 5%
Moderate: 10-20%
Severe: 15-50%
Higher grades of dysplasia correlate with increased risk for cancer.
What are the 5 types of surgical treatments for dysplasia?
Scalpel excision
Laser excision
CO2 laser ablation
Photodynamic therapy
Cryotherapy
These methods aim to remove or destroy abnormal tissues.
1 advantage of surgical treatment approaches for dysplasia?
The most abnormal-looking tissue can be removed or destroyed
What are 3 advantages of medical treatment approaches for dysplasia?
Topical drugs can be directed at abnormal tissues
Less overall destruction
Systemic medications may help manage other sites
Medical treatments may include retinoids and EGFR inhibitors.
What are 4 medical treatments for dysplasia?
Retinoids
EGFR inhibitors/antagonists
COX2 antagonists
p53 modulators
What are the 3 disadvantages of treatment for dysplasia?
Local side effects: pain, infection, slow healing
Systemic side effects
None of the therapies prevent new lesions or OSCC
Ongoing monitoring is essential.
Define fibrous hyperplastic nodules
Overgrowth of tissue
They are often caused by chronic minor trauma or low-grade infection.
2 potential causes of fibrous hyperplastic nodules?
Chronic minor trauma
Chronic low-grade infection
These factors contribute to the development of these lesions.
3 common presentations of fibrous hyperplastic nodules
Fibroepithelial polyp (FEP)
Fibrous epulis at gingiva
Denture induced hyperplasia
What are the 5 clinical features of papilloma?
Usually painless
Single or multiple
Occur at any oral site
Outwards growth
Cauliflower-like appearance due to keratin
Caused by HPV types 6 and 11.
2 managements of papilloma
Excision
Cryotherapy
What are the 3 clinical features of pyogenic granuloma?
Painless
Pedunculated lesion
Red and inflamed
Often associated with pregnancy gingivitis.
Common site of pyogenic granuloma
Gingiva
3 causes of pyogenic granuloma
Local low-grade irritation
Hormonal changes
Trauma
3 managements of pyogenic granuloma
Excision
Remove causative factors
Improve oral hygiene as often calculus/plaque causative
Define giant cell granuloma
Uncommon benign lesion commonly at tooth bearing areas of unknown aetiology
2 classifications of giant cell granulomas and where they are found
Central: within bone
Peripheral: on gingiva
What are the 6 clinical features of central giant cell granuloma?
May be asymptomatic
Bony swelling
Can erode through cortical plate
Loosening of teeth
Purple gingival swelling
Ulceration/inflammation of overlying mucosa
This condition can be diagnosed through radiographic imaging.
What are the 5 radiographic features of central giant cell granuloma?
May be large/rounded
Radiolucent, may have areas of trabeculation
Soap bubble appearance
Localised but often ill defined edges
May perforate alveolar bone, extend into the mouth and resorb/displace adjacent roots
3 management strategies for giant cell granuloma
Excision of soft tissue lesion and curettage underlying bone
Resection may be required in larger lesions
Corticosteroids, calcitonin, interferon alpha and bisphosphonates in children and patients unable to carry out surgery
Define hyperparathyroidism
Parathyroid hormone overproduction
3 epidemiological features of hyperparathyroidism
Uncommon
More common in females
Usually elderly
What is the management for hyperparathyroidism-related lesions?
Correction of the underlying lesion
May involve surgical resection and management of calcium levels.
Define vascular malformation
An abnormal growth and development of a single type of vessel or a combination of vessels
What are the 5 clinical features of vascular malformations?
Raised or flat
Soft but can become firm
Deep red/bluish color
Size varies
Usually blanch with pressure
They can be congenital and may impact movement if located on the tongue.
5 management strategies for vascular malformations
Excision if small
Laser surgery
Cryotherapy
Radiation therapy
Corticosteroids
Define haemangioma
A benign vascular tumour that usually presents in the first few months of life
3 management strategies for haemangioma
Leave as can regress with time
Cryotherapy
Excision
Define purpura
Small blood vessels bleeding into skin or mucous membranes
Causes of purpura
Underlying platelet or vascular disorders
Define herpes group viruses
DNA viruses characterised by latency
Herpes simplex viruses include HHV-1 and HHV-2.
Define HHV-1
A herpes simplex virus that causes primary herpetic gingivostomatitis and may become latent and recur as a cold sore
Define HHV-3
Varicella-zoster virus that causes the primary infection chickenpox and the secondary reactivation herpes zoster
Define HHV-4
Epstein-Barr virus that causes infectious mononucleosis and is implicated in various diseases, such as oral hairy leukoplakia
What are the 3 clinical features of herpes simplex virus infections?
Variable, usually ulcers effecting any mucosal site
Cervical lymphadenopathy
Pyrexia
Severity can vary, especially in immunocompromised individuals.
What is the 4 managements for herpes simplex virus infections?
Maintain fluid intake
Analgesic therapy
Systemic acyclovir for severe cases
Mouthwash therapy
Preventive measures are crucial to limit spread.
4 clinical features of herpes labialis
Initial prodrome
Clusters of tiny blisters, which ulcerate
Crusting and healing
Usually effects function vermillion border lip
3 management strategies for herpes labialis
Preventive measures
Warn patients of infectivity of the lesion
Topical 5% acyclovir cream in prodromal phase
Clinical features of shingles
Unilateral painful vesicular eruption localised to a single dermatome
Management of shingles
High dose systemic acyclovir for 7-10 days, 800mg x5 day
What are the 5 clinical features of measles virus infections?
Respiratory symptoms: cough, runny nose
Inflamed eyes
Pyrexia
Rash
Koplik spots: intra-oral may form before skin rash
What are the 2 clinical features of mumps virus infections?
Enlarged salivary glands
Flu-like symptoms
Complications can include meningitis and deafness.
Define hand foot and mouth disease
A common infection that usually effects children causes mouth ulcers plus spots and blisters on the hands and feet
What are the 3 transmission methods for herpes simplex virus
Direct contact with infective lesion
Contact with infected saliva from individual shedding the virus
Transfer via inanimate objects
Define actinomycosis
A rare, chronic suppurative granulomatous disease caused by filamentous anaerobic Gram-positive bacilli
It is often linked to poor oral hygiene and trauma.
What are 6 predisposing factors for Actinomycosis?
Poor oral hygiene
Trauma
Poorly controlled diabetes mellitus
Immunosuppressed
Alcoholism
Malnutrition
What are 4 common clinical presentation of Actinomycosis?
Cervicofacial slow growing painless, indurated swelling
Abscesses with sinus discharge to oral mucosa or skin
Discharge contains visible sulphur like granules
Pain and trismus in advanced stages
What are 3 diagnostic methods for Actinomycosis?
Imaging
Aspiration and culture
Histopathology
3 management strategies for Actinomycosis
Removal of dental focus
Antimicrobials
Surgical debridement
Define Cat Scratch Disease
Regional lymphadenopathy and fever resulting from the scratch or bite of an infected cat caused by Bartonella henselae
What are 4 clinical features of Cat Scratch Disease?
Papule/pustule at site of inoculation
Regional lymphadenopathy
Surrounding tissue changes
Suppuration
Define impetigo
Common contagious superficial bacterial skin infection caused by Staphylococcus aureus, Streptococcus pyogenes
What is the most common form of impetigo?
Non-bullous impetigo
4 clinical features of non-bullous impetigo
Erythematous macule/papule
Becomes pustuler before rupture
“Honey-coloured” yellow crust on skin after rupture
Lesions expand and coalesce
4 clinical features of bullous impetigo
Vesicles or bullae
Blister formation
Rupture and shed to produce an erythematous moist base that oozes serum
Systemic symptoms
Management of impetigo
Spontaneous resolution
Antimicrobial agents
Define Lyme disease
Bacterial infection caused by Borrelia burgdorferi
What is the characteristic rash of Lyme disease called?
Erythema migrans, a red rash that increases in size may have a central clearing and presents at site of bite
Define Syphilis
Common sexually transmitted infection caused by Treponema pallidum
What are the four main clinical stages of Syphilis?
Primary syphilis
Secondary syphilis
Latent syphilis
Tertiary syphilis
What is a common manifestation of primary syphilis?
Solitary chancre that develops at site of inoculation, usually lips which heals within 8 weeks
What are the symptoms of secondary syphilis?
‘Flu-like’ constitutional symptoms
Mucocutaneous manifestations: skin rash, mucous patches
Generalised lymphadenopathy
What is a common manifestation of tertiary syphilis?
Gummata, an indurated, nodular or ulcerated lesion that may produce tissue destruction, often found at multiple sites
Common site of tertiary syphilis
Hard palate
What are common complications of tertiary syphilis?
Cardiovascular syphilis
Neurosyphilis
What are 3 dental manifestations in the primary dentition associated with Congenital Syphilis?
Mulberry molars
Hutchinson’s incisors
Anterior open bite
Define Tuberculosis
Chronic communicable infectious disease caused by Mycobacterium tuberculosis
What is the oral manifestations of Tuberculosis?
Single, painful ulcers on the dorsum of the tongue
Describe the management of tuberculosis
Quadruple antimicrobial therapy
Define oral candidosis
Infection of the oral/perioral tissue with candida fungal species
What is the most common species causing oral candidosis?
C. albicans
4 local predisposing factors to oral candidosis
Xerostomia
Broad spectrum antimicrobials
Corticosteroids
Dental appliances
Classification of oral candidosis
Primary: confirmed to oral and perioral tissues
Secondary: distributed in other parts of the body as well as the oral cavity
What is the clinical presentation of Pseudomembranous candidosis?
Semi adherent white/creamy patches, wiped off to reveal an erythematous base, with a tendency to recur
3 common sites of acute pseudomembranous candidosis
Palate
Dorsum of tongue
Buccal mucosa
What is the clinical presentation of erythematous candidosis?
Painful, localised erythematous areas
What is the clinical presentation of Candidal leukoplakia?
Persistent, adherent white/speckled lesions
What is the clinical presentation of Angular cheilitis?
Inflammation, fissuring and pain of the skin at commissure caused by candida or staph
What is the clinical presentation of median rhomboid glossitis
Elliptical or rhomboid papillary atrophy at midline of tongue
What is the clinical presentation of denture associated erythematous candidosis?
Erythema and oedema of oral mucosa in contact with a dental prosthesis
Define chronic mucocutaneous candidosis
Rare, heterogeneous group of syndromes causing persistent, severe, and diffuse mucocutaneous candidal infections affecting skin, nails and mucous membranes
5 diagnostic investigations for oral candidosis
Swabs
Oral rinse
Smear
Tissue biopsy
Blood tests
What is the management for oral candidosis?
Anti-fungal therapy
Topical: Nystatin, Chlorohexidine
Systemic: Fluconazole, Miconazole
What are the two forms of Candida as a dimorphic yeast-like fungus?
Blastospore
Hyphae
What is the risk associated with Azole antifungal drugs like Miconazole and Fluconazole?
Significant drug interactions
Define white sponge naevus
Hereditary condition present from birth/early childhood causing thick bilateral symmetrical white plaques mainly on the buccal mucosa
Define lichen planus
A clinically distinctive maculopapular mucocutaneous rash with a characteristic distribution that eventually heals without scar but may leave hyperpigmented macules with a tendency to develop at sites of trauma
Define lichenoid reaction
Something that resembles lichen planus clinically and histologically but is caused by an identifiable agent, e.g. a drug
Describe the pathogenesis of lichen planus
1.Something alters the protein signature of the basal keratinocyte
2.Langerhans’ cells detect the new antigen(s)
3.Antigen(s) presented by Langerhans’ cells to T-cells
4.Cell mediated immunity develops
5.Activated T-cells infiltrate back to the altered epithelium and kill individual basal cells
6.The epithelium reacts by proliferating
5 conditions that mimic oral lichen planus/lichenoid reaction
Frictional keratosis
Lupus erythematosus
Tobacco-related keratosis
Potentially malignant oral lesion
Chronic graft-versus-host disease
3 common sites for OSCC
Tongue: lateral border and ventral surface
Floor of mouth
Lower gum including retromolar pad
3 treatment options for OSCC
Surgery: remove all tumour with a 5mm periphery of non-tumour tissue
Radiotherapy
Chemotherapy
Define leukoplakia
White patch that cannot be classified as any other disease and is associated with an increased risk of malignancy
What are 3 causes of red patches
Thinner keratin
Thinner epithelium (atrophy)
Vascularity in the lamina propria
3 classifications of potentially malignant oral lesions
Homogeneous leukoplakia: lowest risk of OSCC
Non-homogeneous leukoplakia: higher risk of OSCC
Erythroplakia: highest risk of OSCC
What are the 3 clinical features of fibrous hyperplastic nodules
Usually well circumscribed
Solid and raised
Can form on mucosa close to line of occlusion
2 management strategies for fibrous hyperplastic nodules
Remove stimulus
Excisional biopsy under LA, can recur if causative factor not removed
3 epidemiological features OSCC
1-2% of all cancers worldwide
80% of patients aged 40+ years
2M:1F
