mucosa colour changes Flashcards by niamh ritchie

oral white lesions can be due to

Hereditary

Smoking/frictional (keratosis)

Lichen planus
* Lupus erythematosus
* GVHD (graft vs host disease)

Candidal leukoplakia

Carcinoma

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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

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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)

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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)

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what are these

fordyce’s spots

ectopica sebacerous glands

benign, normal structures

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what is this

frictrional keratosis

usually traumatic source - parafunction clencher

causes reactive thickening of mucosa, reduced blood flow as well

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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)

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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

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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

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what is this

chemical burn – coagulation of proteins and damage to epithelial surface, acidic substance held on mucosa (aspirin, alendronic acid)

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what likely caused this

may relate to trauma, clear margin suggests more likely idiopathic

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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

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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

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what is this

red change/eythematous - denture covered tissues red due to prolonged contact with candida

chronic infective candidosis

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what caused this

herpes simplex

Intra epithelial vesicles – obstruct view of underlying blood vessels, appear white until vesicles burst

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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

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why are red lesions red

Blood flow increases
* Inflammation
* Dysplasia

Reduced thickness of the epithelium

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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

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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