Early detection of cancer lecture Flashcards
Describing all lesions- general overview of oral med
1
Q
Name some differential diagnosis of oral white patches
A
- Keratoses
- White patches of infective origin
- Candidosis
- Oral submucous fibrosis
- Lichen planus
- Lupus erythematosus
- Congenital lesions (eg, white sponge nevus, dyskeratosis
congenita, pachyonychia congenita) - Leukoplakias
- Frank carcinomas
2
Q
What can chronic mild irritation cause intraorally? For example from a sharp tooth or restoration
How does it look?
A
Frictional keratosis
Initially pale, -> then turns white & rough
Can involve tongue scalloping
3
Q
What’s the fancy name for severe cheek biting?
A
morsicatio buccarum
morusus (to bite)
bucca (cheek)
4
Q
What is white sponge naevus?
What age does it present?
Which areas does it affect, and how?
Extra: histology-wise? Mutation in which gene?
A
- Rare, benign, autosomal dominant
Presents during childhood - Affected mucosa corrugated, white, soft, irregularly
thickened - Anus, vagina, pharynx + oesophagus may also be
involved
Histology – epithelial hyperplasia with basket-weave
appearance
* No dysplasia or inflammation
* Mutation in the mucosal keratin K4 has been identified
5
Q
How common is lichen planus? And oral lichen planus?
A
A relatively common disorder (1-4% of population)
Oral lichen planus (OLP) affects 0.5-2% of the population
6
Q
Where can lichen planus present?
A
Oral, cutaneous and genital disease
Ocular, nasal, laryngeal, oesophageal
7
Q
By what system is lichen planus thought to mediate?
A
Immunologically mediated
Histology- cytotoxic T cells infiltrated into the base of the epithelium
8
Q
Why is lichen planus significant?
A
It is a potentially premalignant condition
Some debate: therefore good to biopsy
9
Q
Name the demographics which OLP affects
A
Occurs in 4th- 8th decades
* 60% women
* 2-3% children
* Europeans / Indians > Chinese / Malay
10
Q
How many skin LP pts have oral lesions?
A
70-77%
11
Q
How many OLP have skin lesions?
A
10-30%
May not be entirely accurate due to dental professionals not enquiring about skin lesions
12
Q
What are the risk factors for oral cancer?
A
- Tobacco
- Alcohol
- Betel nut
- Sunlight (lip)
- Mucosal disease – OLP,
Oral Submucous
Fibrosis, Dysplasia - Viral infections – HPV
- Malnutrition – Plummer
–Vinson Syndrome - Immunosuppression
- Genetic disorders –
Fanconi anaemia,
dyskeratosis congenita
13
Q
High risk lesions include:
A
- All red patches (erythroplakias)
- Non-homogenous leukoplakias i.e. speckled or
nodular appearance - All lesions showing dysplasia on biopsy
-indurated= invading other connective tissue= bad
14
Q
What is number 1
A
Circumvallate papillae
15
Q
What is number 2
A
Fungiform papillae
16
Q
What is number 3
A
Palatine tonsil
17
Q
What is number 4
A
Lingual tonsil
18
Q
What is number 5
A
Foliate papillae
19
Q
What is number 6
A
Filiform papillae
20
Q
Whats A?
Whats B?
A
A= lingual freenum
B= sublingual papillae/folds
21
Q
What is tongue scalloping?
Which condition has it been shown to be linked with?
A
Common
Relate to clenching
May be found in pt’s with OSA
22
Q
what is tonsiloliths?
what symptoms can it lead to
A
Associated with
repeated bouts
of tonsillitis
* Generally
asymptomatic
* Some larger
stones cause
multiple
symptoms
* Halitosis,
dysphagia:,
otalgia
23
Q
What are Fordyce’s spots?
What do they look like- where do they appear?
What is the tx?
A
- Common
- AKA Fordyce granules
- Sebaceous glands
- Creamy-yellow papules → may coalesce
- Buccal mucosa / Labial mucosa
- Appear in childhood
- Increase at puberty late + adult life
- Reassurance (or laser if major aesthetic concern)
24
Q
What are some alternate names for benign migratory glossitis?
A
‘Wandering rash’, ‘geographic tongue’, ‘lingua
geographica’, ‘erythema migrans’
25
How much of the population is affected by benign migratory glossitis?
1-2.5%
26
What is Waldeyer's ring?
What is it's purpose?
Incomplete ring of lymphoid tissue, situated in the naso-oropharynx
The ring acts as a first line of defense against microbes that enter the body via the nasal and oral routes.
27
What does the Waldeyer's ring consist of?
Waldeyer’s ring consists of four tonsillar structures:
1: The pharyngeal
The tubal
The (2) palatine: back of throat & visible
The lingual tonsils)
As well as small collections of lymphatic tissue disbursed throughout the mucosal lining of the pharynx (mucosa-associated lymphoid tissue, ie MALT).
28
What is benign migratory glossitis associated with?
Autosomal dominant condition, frequently
associated with fissured tongue
29
What kinds of demographic is benign migratory glossitis?
* Reduced prevalence in smokers
* Probably equal gender distribution
* ? Link with psoriasis or atopy
30
What does the histology of benign migratory glossitis look like?
Acanthotic epithelium at edges,
neutrophil infiltration, chronic inflammation
31
How does benign migratory glossitis present?
* Most frequently involves dorsum of tongue but can
be found on most oral mucosal surfaces
* Usually asymptomatic, 1% symptomatic (discomfort when having spicy food ect)
* ? More common in early childhood
* Loss of superficial keratin and filiform papillae
* Irregularly shaped patches of erythematous
depapillation surrounded by raised ‘serpinginous’
white or yellow borders
32
Which conditions are possibly associated with BMG?
* Allergy/atopy
* Low zinc
* Juvenile diabetes
mellitus
* Seborrhoeic
dermatitis
* Spasmodic bronchitis
of childhood
* Gastrointestinal
disorders
* Pustular psoriasis
* Down syndrome
* Lithium
* Pregnancy
33
If a patient has persistent symptomatic BMG, what would we test for?
Zinc deficiencies
Additional hematinics like iron/vitaminB12/folate
These will cause depapillation of the tongue
34
How do we manage BMG?
* Reassurance, benign condition, most asymptomatic
* Exclude other causes of tongue soreness (candidiasis, reduced hematinic levels, refer to oral med)
* 0.15% benzydamine oral rinse (Difflam- dilute to reduce sting)
* May be associated with candidal secondary infection -
Topical antifungals
* Topical corticosteroids, zinc supplements or
mouthwash
35
What is tongue coating?
* Often erroneously assumed to represent a candidal
infection (thrush) of the dorsum of tongue
* Overgrowth of filiform papillae
* Food debris and bacteria
* Encouraged by soft diets, reduced fluid intake
* Smoking alcohol intake may also be contributory
factors
* ? Oral malodour
36
What is the management of tongue coating?
* Reassurance and information
* Improved oral hygiene
* Tongue brushing - avoid excessive tongue brushing
which often tends to make prominent filiform
papillae worse
* Oxidizing mouthwashes (Peroxyl) may be helpful
* Smoking cessation
* Fibrous diet
* Increased fluid intake
37
What is strawberry tongue? What other associated symptoms could be expected
Associated with
scarlet fever (rare)
Streptococcus group A infection in children
Sore throat, pyrexia,
red rash with
‘sandpaper’ feel –
initially neck
underarm and groin
then rest of body
38
What is black/brown hairy tongue?
What can it be associated with?
* Elongation of filiform papillae
* Extrinsic staining
* May be associated with heavy smoking, XS antiseptic
m/wes, antibiotics, stouts
* Overgrowth of pigment producing bacteria or fungi
* May alternate with areas of white hairy tongue
39
How do we manage black/brown hairy tongue?
* Reassurance and information
* Improved oral hygiene, more fibrous diet,
hydration
* Tongue brushing - avoid excessive tongue
brushing which often tends to make
prominent filiform papillae worse
* Oxidizing mouthwashes (Peroxyl) may be
helpful
* Smoking cessation
40
Name some generalised causes of oral pigmentation
Developmental
Habits
Post-inflam
Medication
Associated with systemic disease
41
Name some developmental causes of oral pigmentation
Racial pigmentation
Pigmented naevi (freckles)
Peutz-Jeghers
42
Name some habitual causes of oral pigmentation
Smoking
Betel use
43
Name some general causes of oral pigmentation, when associated with systemic disease
Endocrine
Metabolic
Infective
44
Which drugs can induce a blue-grey kind of hyperpigmentation?
Chloroquine (anti malarial)
Minocycline (derm)
Fluoxetine (antidepressant)
Amiodarone (arrythmia's)
45
Which drugs can induce a brown kind of hyperpigmentation?
Busulphan (cancer)
Bleomycin (cancer)
Cyclophosphamide (cancer)
Minocycline
Doxycycline
AZT (HRT)
Propranolol
46
Which is more a more common colour of drug- induced hyperpigmentation, blue grey or brown?
Brown
47
Name 3 white patches of an infective origin
Candidal
Syphilitic
Oral hairy leukoplakia
48
What is leukoplakia?
A predominantly white lesion of the oral mucosa that cannot be characterised as any other definable lesion (disease) and which is not associated with any physical or chemical causative agent, except tobacco
49
What is erythroplakia/ erythroplasia?
A bright red velvety plaque which cannot be characterised as any other definable lesion/disease
50
What is an alternate term for premalignant that is now recommended?
Potentially malignant
51
What is leucodema?
Variation of normal
Bilateral, diffuse, translucent, greyish appearance to oral mucosa
Disappears on spreading affected mucosa
Typically present in more pigmented skin
52
Skin LP lesions are very responsive to...?
Topical corticosteroids
53
What do cytotoxic T cells target in lichen planus?
Basal keratinocytes
54
What may lichen planus be exacerbated/associated by?
Stress
Spiced food
Acidic food and drink
Diabetes mellitus
Liver disease
55
What are OLP symptoms?
Can be asymptomatic
Pain & discomfort esp when eating spicy/citrus food
Pt's concerned about appearance- esp when desquamative gingivitis involved
56
How does oral lichen planus typically present?
Symmetrical
Can have several forms at one time
Buccal/labial mucosa, tongue, gingiva
Very rarely on the palate or lingual
57
What are the morphological variants of lichen planus?
Papular
Reticular
Plaque-like
Atrophic
Erosive (ulcerative)
Bullous
58
What is Koebner's
phenomenon?
Lesions often in areas
of increased friction
e.g. occlusal line
Keratotic more
common then
ulcerative forms
59
If someone is presenting with desquamative gingivitis LP, what is key in their management to aid their symptoms?
Plaque control
OHI
60
What do cutaneous LP lesions present as?
Purple polygonal pruritic papules, wrists and shins mostly
Dystrophic (abnormal) nails
61
Name the percentage of females with genital LP
20%
62
Name the percentage of males with genital LP
5%
63
What does lichen planopilaris lead to?
Scarring alopecia
64
Name the anatomical sites at an increased risk of malignant transformation
FoM
Lateral border of tongue
Retromolar reigon
Buccal sulcus (paan chewers)
Labial commissure (candidal leukoplakia and smokers)
65
Which gender is at an increased risk of malignant transformation for leukoplakia's?
Female gender
66
Name some Oral Potentially Malignant Disorders
(OPMDs)
* Leukoplakia
* Erythroplakia
* Oral submucous fibrosis
* Oral lichen planus
* Actinic cheilitis
* Palatal lesions of reverse smoking
* Discoid lupus erythematosus
* Inherited disorders: Fanconi anaemia,
Dyskeratosis congenita
67
Which condition presents with SCC on the dorsum of the tongue?
Syphilis tertiary stage
Squamous cell carcinoma is rarely found on the dorsum of the tongue.
68
What are the malignant transformation rates of OLP?
0.9-1.09%
69
What are the malignant transformation rates of oral lichenoid lesions?
1.3-5%
70
How do we screen for oral premalignant lesions and
cancer?
Current adjunctive methods include toluidine blue,
brush biopsy and fluorescence imaging
Biopsy remains gold standard
71
What does toluidine blue stain which is not helpful in diagnosis?
Cancer, dysplasia, inflammation is stained.
Therefore lichen planus is stained too
Good guide to biopsy
72
Which ulcers need urgent referral?
*First appearance
*Rolled edges
*Necrotic centre. maybe exudate present
*Indurrated into tissue
*Irregular shape
*Failed to heal
*High risk area
*Risk factors present
eg. tobacco, alcohol,
paan
73
How do we manage suspected cancer lesions in practice?
* Do not biopsy in practice
* Refer to local Oral and Maxillofacial /Oral Surgery
Unit aiming for 2-week target
* Explain to patient that you have found an oral lesion
which you are concerned about and that Specialist
assessment is indicated
* Do not tell the patient that they cancer
74
What are the clinical features suggestive of potentially malignant disease of head and neck, according to NICE criteria?
* Ulceration of oral mucosa persisting for more than three
weeks
* Oral swellings that persist for more than three weeks
* All red and white patches of oral mucosa
* Unexplained tooth mobility not associated with periodontal
disease
* Unresolved neck masses for more than three weeks
* Cranial neuropathies
* Orbital masses
* Hoarseness persisting for more than six weeks
75
What is median rhomboid glossitis caused by?
Deep seated candidal infection
Response to length anti fungal tx
Diabetes mellitus
Use of steroids inhaler
76
With CHC, what is key to do prior to biopsy?
Give antifungal agents
77
What is stomatitis nicotina? What are the clinical presentations
Thick keratinisation of surface of palate with red spots in centre= inflammed minor salivary glands
Tesilated=pavement like
Associated with smoking
78
What is this?
verrucous carcinoma
