Mucosal Colour Changes

Question 1

why are lesions white

Answer 1

thickening of keratin layer obstructs view to the blood vessels which are responsible for providing pink colour of mucosa

thickening of mucosa / keratin = less visibility of blood and if less blood in tissues = vasoconstrictor hence why we can see blanching on admin of LA

Question 2

causes of oral white lesions (5)

Answer 2

1. hereditary
2. smoking / frictional
3. lichen planus (GVHD / lupus erythematosus)
4. candidal leukoplakia
5. carcinoma

Question 3

leukoplakia

Answer 3

a white patch which cannot be scraped off or attributed to any other cause
no histopathological connotation (it is a clinical description)
diagnosis of exclusion
1-5% become malignant but no association with malignancy at the beginning

Question 4

fordyce’s spots

Answer 4

ectopic sebaceous glands
seen mostly on buccal mucosa but can be seen on the lips
benign normal structures

Question 5

frictional keratosis

Answer 5

often has obvious trauma i.e. parafunctional clenching (linea alba)

Question 6

smoker’s keratosis

Answer 6

smokers 6x more likely to have leukoplakia
low malignant potential of the lesion but higher oral cancer risk overall
trauma from thermal gases

Question 7

hereditary keratosis

Answer 7

white sponge naevus
not traumatic as it is right down in the sulcus
often starts in childhood spreading anteriorly and down into sulcus
if 1 family member has it other most likely will have it too
shown as fluid filled areas in superficial epithelium histologically

Question 8

thickening on tuberosity

Answer 8

thickening as it has clear cut edge and normal surrounding mucosa so there is no reaction to the white lesion

If malignant there would be inflammatory process around the lesion. Appears as a keratosis. As there is no obvious cause it is termed idiopathic keratosis

Question 9

whitening around gingiva of tooth

Answer 9

Could be idiopathic or trauma or desquamative gingivitis
Biopsy is necessary but would take slighter higher up as to not disrupt dento-gingival junction

Question 10

chemical burn

Answer 10

usually from aspirin
Acidic substance in contact with mucosa has caused protein coagulation and damage to epithelial surface. Aspirin normally cause but can also be seen with alendronic acid which is taken for osteoporosis tx / prevention. Often seen in nursing homes with ptx who don’t have full cognitive function as they may not swallow tablet but hold it in their mouths for a prolonged period

Question 11

side of tongue lesion

Answer 11

side of tongue can have hair leukoplakia which is elongation of the papilla due to incorporation of EBV but may simply be a traumatic keratosis

Question 12

defined margin

Answer 12

this is good. undefined margins indicate uncontrolled cell division & spread i.e. malignancy

Question 13

infective white lesions candidiasis

Answer 13

1. pseudomembranous acute i.e. thrush - can be scraped off their pseudomembrane as it is not firmly attached to mucosa
2. denture associated chronic - erythematous due to being in contact with candida for a prolonged period of time

Question 14

infective white lesion

Answer 14

herpes simplex
intraepithelial vesicles that disrupt view of connective tissue blood vessels

Question 15

when to refer a white lesion

Answer 15

• most are benign
• if red and white, concentrate on red part
• refer if lesion is becoming more raised & thickened
• if lesion is ‘without cause’ on lateral tongue, anterior floor of mouth or soft palate area

Question 16

why are red lesions red

Answer 16

blood flow increases due to inflammation / dysplasia leading to reduced thickness of epithelium

Question 17

if red lesion has bite margin & erythematous ridge

Answer 17

observe for a short period as it may resolve in a few weeks but if not take biopsy

Question 18

erythroplakia

Answer 18

atrophic or non keratotic end of spectrum
a red patch which cannot be attributed to any other cause
more of a concern for malignancy than leukoplakia as it is unexplained

Question 19

red / blue lesions

Answer 19

fluid in connective tissue:
dark = slow moving blood - varicosities; veins or cavernous haemangioma
light blue = clear fluid - saliva in mucocele or lymph in lymphangioma

Question 20

vascular hamartomas

Answer 20

can have capillary or cavernous (related to blood) haemangioma
appears quite friable and then very red, increasing in size
take a biopsy
will increase then reduce in size suggesting it is vascular rather than a malignancy which would only tend to increase in size

Question 21

lymphangioma

Answer 21

most are cavernous and found on tongue
takes lymph fluid from tissues back into circulation
proliferation of fluid spaces
can be indistinguishable from cavernous haemangioma until biopsy carried out

Question 22

connective tissue diseases i.e. vasculitic diseases

Answer 22

1. large vessel disease - giant cell (temporal) arteritis
2. medium vessel disease - polyarteritis nodosa/ kawasaki disease
3. small vessel disease - granulomatosis with polyangitis

Question 23

causes of mucosal pigmentation

Answer 23

1. exogenous stain of tea / coffee / CHX / bacterial overgrowth
2. intrinsic pigmentation:
   - reactive melanosis / melanotic macule (normal number of melanocytes but increased amount of melanin)
   - melanocytic naevus (increased no of melanocytes all producing same amount of melanin)
   - melanoma (cancer producing pigment)
   - effect of systemic disease, paraneoplastic phenomenon
3. intrinsic foreign body i.e. amalgam, arsenic

Question 24

brown / black lesions

Answer 24

localised = amalgam, melanotic macule, melanotic naevus, malignant melanoma
generalised = racial/familial, smoking, drugs, addison’s disease (raised ACTH conditions)

Question 25

mucosal inflammation

Answer 25

can be acute / chronic
aetiology = trauma, infection, immunological, physical / chemical, viral / bacterial / fungal

Question 26

signs & symptoms of melanoma

Answer 26

variable pigmentation
irregular outline
raised surface
symptomatic - itch / bleed

Question 27

purpose of biopsy (3)

Answer 27

1. identifies or excludes malignancy
2. identifies dysplasia
3. identifies other disease i.e. lichen planus

Question 28

if you have an unexplained white red or pigmented patch

Answer 28

must biopsy

Question 29

what should be referred to OM

Answer 29

• pt with abnormal and / or unexplained changes to oral mucosa
• if there is concern about dysplasia risk i.e. appearance of lesion, risk site, risk behaviour, family hx

Question 30

what should not be referred to OM

Answer 30

asymptomatic variations of normal mucosa
benign conditions that the practitioner has diagnosed as asymptomatic, no potential of malignant risk, for which there is no tx
if unsure consider clinical photography to monitor area until next check up / send to specialist for opinion