mucosa colour changes Flashcards
oral white lesions can be due to
5
Hereditary
Smoking/frictional (keratosis)
Lichen planus
* Lupus erythematosus
* GVHD (graft vs host disease)
Candidal leukoplakia
Carcinoma
why are white lesions white
Pink colour comes from connective tissue underneath – where BV are, diluted by epithelium on top
thickening decreases visibility even more
2 reasons why white lesions are white (histologically)
Thickening of the mucosa or keratin
* Less visibility of blood
Less blood in the tissues
* Vasoconstrictor (e.g. blanching when LA delivered)
leukoplakia is
a white patch which cannot be scraped off or attributed to any other cause
No histopathological connotation - it is a clinical description
* if a biopsy is done and comes back as hyperkeratosis – than use this term
Diagnosis of exclusion
1 - 5% become malignant (higher chance if white lesion due to carcinogen exposure e.g. betel nut chewing compared to trauma)
what are these
fordyce’s spots
ectopica sebacerous glands
benign, normal structures
what is this
frictrional keratosis
usually traumatic source - parafunction clencher
causes reactive thickening of mucosa, reduced blood flow as well
what is this
Smoker’s keratosis
Trauma from thermal gases causing keratosis
Smokers are six times more likely to have “leukoplakia”
* Low malignant potential of the lesion
But higher oral cancer risk overall
Underlying mucosa normal, bar overproducing melanocytes in response to smoking exposure/ trauma (not sufficient to make lesion appear pigmented)
what is this
Hereditary Keratosis
* Areas not subject to trauma
* Often start posteriorly in childhood before spreading anteriorly and superiorly
* Familial members have it
fluid flilled areas – increase opacity of epithelium, white appearance
what is this
describe lesion
clear cut edge, mucosa around it appears normal (no reaction to it – malignancy will have inflammatory reaction around it)
* thickening
no obvious reason for keratosis – idiopathic keratosis
could be idiopathic, trauma, desquamative gingivitis
biopsy to confirm cause – careful around dental gingival margin
what is this
chemical burn – coagulation of proteins and damage to epithelial surface, acidic substance held on mucosa (aspirin, alendronic acid)
what likely caused this
may relate to trauma, clear margin suggests more likely idiopathic
what likely cuased this
suggestive of black hairy tongue, elongation of papillae and thickening of surface due to incorporation of EBV (quicker replication),
or parafunction tongue thrusting and rubbing against molars
what is this
white pseudomembranous – can be scraped off, not adhered to mucosa, when swabbed off leaves an inflammatory change/red bleeding area underneath the lesion
infective pseudomembranous candidosis (thrush, acute)
red and white lesionos
what is this
red change/eythematous - denture covered tissues red due to prolonged contact with candida
chronic infective candidosis
what caused this
herpes simplex
Intra epithelial vesicles – obstruct view of underlying blood vessels, appear white until vesicles burst
when to refer a white lesion
Most are benign
* Keep under review at dentist
If RED and WHITE concentrate on the RED part
If the lesion is becoming more raised and thickened or has inflammatory margin (red tissue around edge of lesion, not normal underlying/surrounding mucosa)
If the lesion is ‘without cause’
* Lateral tongue
* Anterior floor of mouth
* Soft palate area
No parafunctional habits or trauma
Refer with photo
why are red lesions red
Blood flow increases
* Inflammation
* Dysplasia
Reduced thickness of the epithelium
concerning or not?
Concern as no obvious cause for the red lesion on lateral of tongue
Could be capillary haemangioma present from birth
If new lesion could be dysplasia causing inc vascularity
concern or no?
under a denture - could be related to denture hygiene and candida
but why only part of ridge? Needs investigation, biopsy
explain this lesion
Geographic tongue – review in couple of weeks, will likely change or disappear
explain this pattern of lesion
Here only part of denture bearing area red due to denture being old and resorption of ridge and no change to palatal bone – takes all the force and rubbing and candida
possible causes of this
Erythematous changes on gingiva
dysplasia, inflammation or thinning of epithelium (desquamative gingivitis – here)
Refer red lesions more readily than white lesions
erythoplakia
Atrophic or non-keratotic end of the spectrum
a red patch which cannot be attributed to any other cause
More of a concern for malignancy than leukoplakia
* Requires investigation - biopsy
red/blue lesion causes
Fluid in the connective tissue
* Dark – slow moving blood – varicosities
* Veins or cavernous haemangioma
Light Blue – clear fluid
* saliva (mucocele), Lymph (Lymphangioma)
vascular harmartomas can be
capillary haemangiomas or cavernous haemangiomas
inc and dec in size – suggest vascular lesion
malignancy will only inc
what is this
cavernous haemangioma
what is this
Inc in size, friable, technically erythoplakia till proven otherwise - biopsy
likely capiallary haemangioma
histological difference between capiallary and cavernous haemangiomas
capillary – red lesion, lots of little vessels
cavernous – larger blood areas, slow moving blood, rapid deoxy, blue lesions
histological difference between capiallary and cavernous haemangiomas
capillary – red lesion, lots of little vessels
cavernous – larger blood areas, slow moving blood, rapid deoxy, blue lesions
lymphangiomas
Most are cavernous (Tongue pic)
cystic hygroma
proliferation of fluid spaces when lymph getting taken back to circulation from tissues
cannot diff from cavernous haemangioma until biopsy
vasculititis
alteration to blood flow to human tissues
vasculitis diseases that can appear in mouth
3 classes
Large vessel Disease
* Giant cell (temporal) arteritis
Medium Vessel Disease
* Polyarteritis nodosa
* Kawasaki disease
Small vessel Disease
* Granulomatosis with Polyangiitis
rare conditions
types/cause of pigmented lesions
External pigment or internal pigmentation (melanocytes)
Why are some pigmented?
* racial pigmentation – melanosis histologically
* cavernous haemangioma – proliferation of blood space
brown lesions - differentiation between number of melanocytes and amount of melanin produced
mucosal pigmentation
exogenous stain of
4 examples
tea, coffee, CHX
bacterial overgrowth
mucosal intrinsic pigmentation due to
4
Reactive Melanosis/melanotic macule (freckle) (normal number melanocyte but producing too much melanin)
Melanocytic naevus (too many melanocytes in one area, producing number amount of melanin each)
Melanoma – cancer producing pigment
Effect of systemic disease, paraneoplastic phenomenon
mucosal pigmentation due to intrinsic foreign body
metal - amalgam, arsenic
brown or black lesion
1st step in assessment
if localised focal lesion or generalised
possible causes of localised focal pigmented lesion
7
Amalgam
Melanotic Macule
Melanotic naevus
Malignant Melanoma
Peutz-Jehger’s syndrome
Pigmentary incontinence
Kaposi’s sarcoma
Single focus on melanin production in tissue creating single pigmented l
possible causes of generalised focal pigmented lesion
4
Racial/familial
Smoking
Drugs
Addison’s disease (example image)
* Raised ACTH conditions – stimulates melanocytes
effect on all mucosa
when to refer mucosal pigmentation?
Is it easily explained?
* Racial
* Smoking
* Medicines - Contraceptive pill, tetracycline, new biologic drugs
Is it increasing in size, colour or quantity?
Any NEW systemic problem?
Do I have an EXISTING radiograph showing it to be amalgam?
mucosa inflammation
conisder
acute or chronic?
aetiology
* trauma - physical/chemical
* infection - bacterial/viral/fungal
* immunological
characteristics of melanoma
Variable pigmentation (high and low areas)
Irregular outline
Raised surface
Symptomatic
* Itch
* bleed
3 reasons to biopsy
identifies or excludes malignancy
identifies dysplasia (step towards malignancy)
identifies other disease, e.g. lichen planus
White, Red or Pigmented Patch, MUST biopsy if unexplained (e.g. clear traumatic keratosis, monitor)
what should be referred to oral med
6 cosiderations
Patients with abnormal and/or unexplained changes to the oral mucosa
* Practitioner threshold will vary with experience
If there is concern about dysplasia risk (erythematous change more than white)
Appearance of lesion
Risk site (FOM, soft palate, lateral tongue)
Risk behavior (smoking etc)
Family history (oral cancer in family)
If unsure – consider clinical photography to
* Monitor area until next check up
* Send to specialist for an opinion
what should not be reffered to oral med
Asymptomatic VARIATIONS of NORMAL mucosa
Benign conditions the practitioner has diagnosed that:
* Are asymptomatic
* Do not have potentially malignant risk
* For which there is no treatment
If unsure – consider clinical photography to
* Monitor area until next check up
* Send to specialist for an opinion
