dysplasia and potentially malignant disorders

Question 1

red flags for oral cancer

Answer 1

• > 3-week duration
• > 50 years old
• Smoking
• High alcohol consumption
• History of oral cancer
• Non-homogenous
• Non-healing ulceration (with no cause)
• Indurated
• Exophytic
• Tethering of tissue
• Tooth mobility
• Non-healing extraction sockets
• Difficulty speaking/swallowing
• Cervical lymphadenopathy
• Weight loss/appetite loss
• Numbness/altered sensation

Question 2

how to increase early oral cancer detection

Answer 2

• soft tissue examination for every patient every time
• patient education and empowerment
• recognition of complex social, cultural, publich health reasons behin risk behaviours, poor attendance, access to dental practices

Question 3

risk factors for oral cancer

Answer 3

• smoking
• poor OH
• alcohol
• chewing tobacco/betel/areca nut
• low fruit and veg
• HPV
• socio-economic background

Question 4

what is OED

Answer 4

• abnormal growth
• can only be diagnosed on histology
• it is not cancer or pre-cancer
• it carries higher risk of becoming cancer than normal tissue

Question 5

who gets OED

Answer 5

• people who smoke
• people who drink alcohol
• both
• HPV
• others ? - genetics

Question 6

what does OED look like

Answer 6

may be red or white or both

Question 7

how to describe lesions

Answer 7

site - higher risk sites include the ventolateral tongue and floor of mouth

size - larger lesions are more concerning

colour - white,red, mixed

texture - when palpating, can you feel it ? may feel thickened , rough, corrugated, firm, rubbery

Question 8

archiectural features of dysplasia from WHO

Answer 8

Question 9

cytological feature of dysplasia WHO

Answer 9

Question 10

molecular markers of dysplasia

Answer 10

• Signalling pathways - EGFR
• Cell cycle - Ki67, p53, pRB
• Immortalization - Telomerase
• Apoptosis - p53, p21
• Angiogenesis - VEGF
• COX-1&2 enzymes
• Proliferation and differentiation markers
• Viruses: HPV +, HPV-
• Loss of heterozygosity (LOH) 3p, 9p,13q ( retinoblastoma),17p

Question 11

histology of basal hyperplasia

Answer 11

• inreased basal cell numbers
• architecture
  
  • regular stratification
  • basal compartment is larger
• no cellular atypia

Question 12

histology in mild dysplasia

Answer 12

• architecture : changes in lower third
• cytology : mild atypia

Question 13

histology in moderate dysplasia

Answer 13

• architecture - change extends to middle third
• cytology - moderate atypia
• pleomorphism hyperchromatisim

Question 14

histology in severe dysplasia

Answer 14

• architecture - changes extend to upper third
• cytology - severe atypia and numerous mitosses, abnormally high

Question 15

what is carcinoma in situ

Answer 15

• theoretic concept
• malignant but not invasive
• abnormal architecture
• full thickness (or almost full) of viable cell layers
• pronounced ctylogical atypia
• mitotic abnormalities frequent

Question 16

what do we do with carcinoma in situ

Answer 16

• mild or low grade may be monitored. this should be for at least 5 years (liverpool algorithmn)
• moderate or severe high grade should be considered for removal by oral and maxillofacial surgery

Question 17

what is oral potentially malignant disorders

Answer 17

any mucosal abnormality that is associated with statistically increased risk of developing oral cancer

Question 18

types of OPMDS

Answer 18

• leukoplakia
• oral submucous fibrosis
• oral lichen planus
• oral lichenoid lesion
• oral graft vs host disease
• oral lupus erythematous
• dyskeratosis congenita
• palatal lesions in reverse smokers
• actinic chellitis/ keratosis
• PVL
• erythroplakia

Question 19

what is leukoplakia

Answer 19

Predominantly white patch not able to be attributedto another disorder (that does not have increased risk for cancer)

Question 20

how might leukoplakia be described

Answer 20

• Homogenous leukoplakia:
  
  • typically,well-demarcated
• Non-homogenous (mixed)
  
  • Diffuse borders
  • Red/nodular components (i.e. textural/colour abnormalities

Question 21

what else could leukoplakia be

Answer 21

• frictional keratosis - is there obvious cause ?
• biting habits
• OLP
• pseudomembranous candidiasis - can be scraped off, consider predisposing factors
• leukoedema - bilateral, disappears on stretching
• nicotinic stomatitis
• papilloma

Question 22

what is TXP for leukoplakia

Answer 22

• long term monitoring
• clinical correlation and biopsy report

Question 23

what is proliferative verrucous leukoplakia

Answer 23

• distinct form of multi-facial oral leukoplakia
• progressive
• highest risk of malignant change of all OPMDs
• “verrucous” “verricuform” = high risk words on biopsy reports
• 65% progression rate

Question 24

histology of proliferative verrucous leukoplakia

Answer 24

- acanthosis - well developed papillary archieecture with lichenoid immune response at early stage - broad expansion of rete process - flat rounded/ ends - elephants foot pattern -peaks of keratin

Question 25

what is erythroplakia

Answer 25

- predominantly fiery red patch that cannot be characterised clinically or pathologically as any other definable disease - solitary lesions, typically well demarcated - high risk of malignant change - solitary nature helps to distingush from widespread conditions eg OLP, blistering conditions

Question 26

what is oral sub mucous fibrosis

Answer 26

- progressive - loss of elasticity progresses to fibrosis of lamina proprietor - function limiting - burning, sensitive to spicy

Question 27

what is risk factor for oral sub mucous fibrosis

Answer 27

- Paan

Question 28

what is OLP

Answer 28

is an inflammatory condition of the oral mucosa that is usually idiopathic

Question 29

what are oral lichenoid lesions

Answer 29

- atypical OLP/unilateral lesions - lichenoid tissue reactions - lichenoid drug reactions

Question 30

what is the risk of removing restorations to composite

Answer 30

- potential for tooth to become symptomatic - requiring larger restorations - requiring crown - unrestorable - no resolution - can take up to 6-12 months to see improvement

Question 31

what is actinic cheilitis

Answer 31

- solar radiation exposure - enquire about sun history - diffuse, pathcy dryness and thickening - smoking cessation, UV protection year around

Question 32

what is palatal lesions in reverse smokers

Answer 32

- burning end of cigarette held in mouth - habit prevalent among certain ethnic backgrounds e.g. andhra pradesh india, carribean island, sardinia

Question 33

what is dyskeratosis congenita

Answer 33

- rare hereritary condition - leukoplkia ( often tongue dorsum) + hyperpigmentation of skin + nail dystrophy - arises early, should be excluded in children presenting with oral leukoplakia

Question 34

what is oral lupus erythematous

Answer 34

systemic lupus erythematosus is an autoimmune, inflammatory condition - similar to OLP - hard palate

Question 35

histology of chronic hyerplastic candidiasis

Answer 35

- collections of neutrophils in epithelium -mitotic figure - dysplasia