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FINALS - Oral Medicine > Oral Mucosal Disease > Flashcards

Oral Mucosal Disease Flashcards

1
Q

When should a mucosal lesion be refered to oral med for an opinion?

A

Anything the dentist thinks might be cancer.

Any symptomatic lesion that has not responded to standard treatment.

Any benign lesion that the patient can’t be persuaded is not cancer.

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2
Q

What pathways are there for suspected oral cancers?

A

2 week cancer referal pathway

NICE nad SIGN head and neck cancer guidelines

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3
Q

Describe the histology of oral mucosa.

A

Stratified squamous epithelium

Lamina propria

Can be keratinised or non-keratinised

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4
Q

How does keratinised tissue present?

A

Pale white, as the tissue has been thickened. It will typically not have an inflamed border.

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5
Q

In what ways can the mucosa react to damage?

A

Atrophy (reduction in layers)
Erosion (partial thickness loss)
Ulceration (fibrin on surface)
Oedema (intra/inter-cellular)
Blister (vesicle or bulla)

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6
Q

How does ulceration present?

A

White center of keratinised tissue with clear margin of inflammation surrounding it.

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7
Q

List the common tongue lesions that can be considered benign?

A

Geographic tongue
Black hairy tongue
Fissured tongue

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8
Q

What is geographic tongue?

A

Desquamation of the tongue, leading to intermittant patchy lesions.

It is often sensitive to acidic/spicy food.

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9
Q

What are the symptoms of geographic tongue?

A

Possible sensitivity to acidic/spicy food.

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10
Q

What are the potential causes of geographic tongue?

A

Haemanitic deficiency (B12, folate, ferratin)

Parafunctional trauma

Dysaesthesia

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11
Q

What is black hairy tongue?

A

Hyperplasia of the papillae, leading to pigmented bacterial build up.

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12
Q

What is glossitis?

A

Inflammation of the tongue, which can often lead to a shiny smoothed appearance.

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13
Q

When should you refer a swelling to oral med?

A

Symptomatic
Abnormal mucosa
Increasing in size
Rubbery consistancy
Trauma from teeth
Unsightly

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14
Q

What mucosal lesions do not normally need referal?

A

Tori
Small polyps
Mucoceles

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15
Q

What are the main causes of white lesions?

A

Hereditary

Smoking/frictional

Lichen planus
- Lupus Erthematosus
- GVHD

Candidal leukoplakia

Carcinoma

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16
Q

What is leukoplakia?

A

White patches on the oral mucosa or tongue.

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17
Q

What % of leukoplakia becomes malignant?

A

1-5%

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18
Q

When should you refer a white lesion?

A

If the lesion is becoming more raised and thickened

If the lesion is without obvious cause

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19
Q

Why are red lesions red?

A

Reduced thickness of the epithelium, caused by increased bloodflow from inflammation and dysplasia.

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20
Q

What is erthroplakia?

A

A red patch that cannot be attributed to any other cause. More of a concern for malignancy than leukoplakia.

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21
Q

Why are red/blue lesions red/blue in colour?

A

Fluid build up in the connective tissue. Typically darker blue will indicate slow moving blood, and lighter will indicate saliva or lymph.

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22
Q

What is the cause of mucosal pigmentation?

A

Exogenous stain of tea/coffee/chlorhexadine/bacteria.

Intrinsic pigmentation - relative melanosism, melanoma, systemic disease.

Intrinsic foreign body such as amalgam or arsenic.

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23
Q

What are the causes of localised brown/black lesions?

A

Amalgam
Melanoitc macule
Melanotic naevus
Malignant melanoma

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24
Q

What are the causes of more generalised brown/black lesions?

A

Racial/familial
Smoking
Drugs
Addison’s disease

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25
Q

What is a general rule when considering a red, white, or pigmented patch for biopsy?

A

If it is unexplained, send for biopsy.

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26
Q

If you think a mucosal lesion might be cancer or dysplasia what guidelines can you consult for what to do next?

A
  • NICE and SIGN Head and Neck cancer guidance
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27
Q

What epithelium is this diagram and is it keratinised or non-keratinised?

A
  • Buccal mucosa
  • Non-keratinised
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28
Q

What epithelium is this and is it keratinised or non keratinised?

A
  • Palate
  • Thick Keratinised layer sitting on surface
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29
Q

Label this diagram and explain

A
  • Lamina propria with blood vessles
  • Basal layer with epithelial progenitor cells (essentially stem cells)
  • As you go up through spinosum the cells are undergoing maturation , become less purple staining suggesting they are losing their cell organelles
  • Eventually becomes stratum corneum where cells have lost all organelles except cell wall and becomes the flattened keratin of the surface
  • Mitosis should only occur in basal membrane layer, any other mitosis occurring could be dysplastic
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30
Q

How is the oral mucosa histologically set up?

A
  • Stratified squamous epithelium
  • Lamina propria
  • 3 gross types depending on function so can be lining, masticatory, gustatory
  • Keratinised or non keratinised
  • Keratinised can be orthokeratosis or parakeratosis
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31
Q

What are some reactive changes that can occur in the oral epithelium?

A
  • Keratosis on nonkeratinsed site called parakeratosis
  • Acanthosis (hyperplasia of stratum spinosum)
  • Elongated rete ridges (hyperplasia of basal cells)
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32
Q

What is ulceration mucosal reaction?

A
  • Fibrin on surface
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33
Q

What is blister mucosal reaction?

A
  • Vesicle or bulla depending on size of lesion
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34
Q

What is commonly seen with age in regard to mucosa?

A
  • Progressive mucosal atrophy
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35
Q

What does this picture show and what can cause this?

A
  • Smooth tongue
  • Mucosal atrophy on dorsal of tongue
  • Nutritional deficiency of iron or B group vitamins
  • Predisposed to infection
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36
Q

What does this image show?

A
  • Geographic tongue
  • Alteration to maturation and replacement of normal epithelial tissues at different rates
  • Makes some areas appear redder due to closer proximity to lamina dura (blood vessels)
  • Will resolve as epithelium is then replaced
  • pt may complain to sensitivity from spicy or very flavoured foods
  • Requires no txt and can be started at any age (feels worse in children)
  • BENIGN with no symptoms
37
Q

What does this image show? Describe the condition

A
  • Brown/black hairy tongue
  • Can be due to bacterial colonisation but most commonly due to elongation of surface papilla - then becoming stained with food or drink or chlorhexidine
  • Benign
38
Q

What is the management of black/brown hairy tongue?

A
  • Can be done with tongue scraper
  • Can also be done with nectarine or peach stone (suck the stone for an hour a day) improve appearance
39
Q

What does this image show? Describe the condition

A
  • Fissured tongue
  • Unsure as to why it is fissured
  • Fissures aren’t usually painful but if deep food can become trapped and cause local inflammation - use a soft brush to clean daily
  • If fissures are painful consider another disease like LP or Candida which is causing the symptoms
40
Q

What does this picture show? Describe the condition

A
  • Glossitis
  • Inflammation of the tongue
  • Investigate with haematinics and small biopsy to diagnose whether due to deficiencies or other disease like LP
41
Q

Describe this picture

A
  • Multiple Small swellings in vault of palate
  • Same coloured tissue as surrounding
  • Multiple fibrous enlargement caused by ill fitting denture wearing
  • Papillary hyperplasia of palate and usually get better fitting denture
42
Q

Describe this picture

A
  • Leaf fibroma
  • Polyp instead of becoming round lesion has been squashed by denture wear
  • Now have thin and elongated lesion
  • Remove and give time to not wearing a denture to allow site to heal
43
Q

Describe this picture

A
  • Simple fibre epithelial polyp
  • Mucosal covering is same as surrounding mucosa
  • No signs of inflammation
  • Could be left alone but due to size of this it may cause difficulty in closing teeth together causing more trauma
  • remove
44
Q

Describe this picture

A
  • Parafunctional habit of child sticking tongue between teeth has caused polyp to grow on apex of tongue
  • Use appliance to stop tongue or close the gap with ortho with stop the polyp
45
Q

Describe this picture

A
  • Small mucocele in palate
46
Q

Describe this picture

A
  • Large fixed mucocele that has filled with saliva
  • Possible to remove the extravasated mucous and associated gland
47
Q

Describe what you see in these pictures

A
  • Tori which are bony swellings
  • Benign
  • Common with pts with parafunctional clenching habits - present with TMD pain
48
Q

For pts taking bisphonates what do you need to consider in regard to Tori?

A
  • Tori considered risk factor for necrosis due to limited blood supply from periosteum in pts taking bisphophonates
  • Removal of Tori is not recommended though
49
Q

What does this picture show?

A
  • Pyogenic granuloma
  • Inflamed granulation tissues with no epithelial covering
  • Has fibrinous yellow appearance or red lesion
  • Can occur on any mucosal site and is a response to trauma
    Not a granuloma and not pyogenic
50
Q

What are some reasons Oral white lesions can form?

A
  • Hereditary
  • Smoking/frictional
  • Lichen Planus
    • Lupus eryhtematosus
    • GVHD
  • Candidal leukoplakia
  • Carcinoma
51
Q

How can candidal leukoplakia cause white lesions?

A
  • Candida can cause inflammation in the epithelium and surrounding tissues
  • Inflammation will allow fluid and thickness in the epithelium , reducing blood flow to epithelium , causing whiteness
52
Q

How does smoking/frictional cause oral white lesions?

A
  • Cause irritation to mucosal surface
  • Thicken keratin layer (acanthosis)
  • Keratin layer obstructs blood flow to keratin layer causing whiteness
53
Q

How does a carcinoma cause oral white lesion?

A
  • Associated with thickening of cells as they are proliferating at uncontrollable manor
  • Acanthosis - whiteness
54
Q

Why are white lesions white?

A
  • In normal mucosa lamina dura exists beneath spinosum and stratum cornea layer
  • Cells become less dense as you move up to surface allows blood vessels to be seen
  • In keratinsed tissues, the cells are denser as thickening of the mucosa or keratin occurs , tissue is less opaque therefore can’t see the blood vessels as clearly, showing whiteness instead
  • Or shows white lesions as there is less blood in the tissues due to vasoconstrictors (blanching)
55
Q

What is meant by the term Leukoplakia?

A
  • A white patch which cannot be scraped off or attributed to any other cause
  • No histopatholgical connotation
  • Does not mean malignant (around 1% in UK)
56
Q

What is shown in these pictures? Describe the condition

A
  • Fordyce’s spots
  • Ectopic sebaceous glands
  • Mucosa forms from the skin therefore normal for sebaceous glands to be produced in mucosa
  • Seen mostly on buccal mucosa and also can be seen on lips
57
Q

What does this picture show?

A
  • Frictional keratosis
  • Rubbing is causing the reactive thickening of the mucosa
  • Keratotic thickening occurs meaning less opacity to blood vessels in lamina dura , there fore white appearance
58
Q

What does this picture show?

A
  • Smoker’s keratosis
  • Trauma from thermal gases
  • Reactive change of keratin
  • Thickening of keratin , less able to see BV so white appearance
59
Q

What does this picture show?

A
  • The histology of Smoker’s/traumatic
  • Shows thick layer of keratin formed on the palate
  • Mucosa is normal
  • Melanocytes have overproduced melanin commonly seen with trauma so see an increase in melanin pigment
60
Q

Does smokers keratosis increase chance of malignant risk?

A
  • Smokers more likely to have leukoplakia
  • Low malignant potential of the lesion
  • BUT higher oral cancer risk due to smoking
61
Q

What does this picture show?

A
  • White sponge naevus
  • Hereditary keratosis
  • Often starts in childhood and if one person in fam has it , likely others will to
62
Q

What does this image show?

A
  • White sponge naevus wtih areas of spongiosis
  • Spongiosis causing fluid filled areas within the epithelium
  • Making it less opaque so can’t see the BV as clearly and lesion appears white
63
Q

Describe this white lesion

A
  • White lesion on the maxillary tuberosity
  • It has clear cut edge
  • Appears thickened
  • No erythema surrounding so inflammation has not occurred
  • If lesion is malignant then will show inflammation surrounding the edge
  • This lesion has no trauma related aspects therefore deemed Idiopathic keratosis
64
Q

What is this picture showing?

A
  • Chemical (aspirin) burn
  • Acidic substance held in contact with mucosa
  • Caused coagulation of proteins and thickening of the mucosa
65
Q

What is this picture showing?

A
  • Pseudomembranous acute candidosis (acute)
  • Can be scraped of as not adherent to mucosa due to pseudomembranous
  • Will leave inflammatory area underneath the lesion
66
Q

What is this picture showing?

A
  • Denture associated erythemous candidosis (Chronic)
  • Denture covered tissues are erythematous due to poor denture hygiene
67
Q

What are these pictures showing?

A
  • Herpes simplex virus
  • Gives intraepithelial vesicles that disrupt the view of the connective tissue blood vessels
  • Once the vesicle bursts you lose the whiteness
68
Q

When do you refer a white lesion?

A
  • Most are benign
  • If red and white parts concentrate on red part
  • If lesion is becoming more raised and thickened
  • If lesion is whitou cause i.e. lateral tongue / anterior floor of mouth / soft palate area
69
Q

Why are red lesions red?

A
  • Blood flow increases due to inflammation or dysplasia
  • Or due to reduced thickness of epithelium which is making connective tissue redness more visible
70
Q

What does this picture show?

A
  • ## Desquamative gingivitis due to thinning of epithelium
71
Q

What is Eruthroplakia?

A
  • Area of redness which can’t be attributed to any other cause
  • Higher concern than leukoplakia and require biopsy
72
Q

What are blue lesions?

A
  • Due to fluid in the connective tissue
  • Can be dark which show slow moving blood like varicosities - are going to be veins or cavernous haemangioma
  • Can be light blue and contain clear fluid - most likely saliva (mucocele) or lymph (lymphangioma)
73
Q

What does this picture show?

A
  • Vascular haemangioma
  • Can be capillary or cavernous
74
Q

What is this picture?

A
  • Cavernous haemangioma
75
Q

What is the difference between these two pics?

A

First one shows capillarious haemangioma - red lesion

Second one shows cavernous haemangioma - slow moving blood , rapid deoxygenation giving blue appearance (can see the larger areas)

76
Q

What is a Lymphangioma?

A
  • Takes lymph fluid from the tissues back into circulation
77
Q

What are some exogenous causes mucosal pigementation?

A
  • Tea , Coffee , Chlorhexidine
  • Bacterial overgrowth
78
Q

What are some intrinsic causes of mucosal pigmentation?

A
  • Reactive melanosis/melanotic macule
  • Melanocytic naevus
  • Melanoma
  • Effect of systemic disease, paraneoplastic phenomenon
79
Q

What are some intrinsic foreign body cause of mucosal pigmentation?

A
  • Amalgam, arsenic
80
Q

What is a melanocytic naevus?

A
  • Melanocyte is becoming abnormal and produces too much melanin (proliferation increases)
  • Produces benign skin lesion
81
Q

What is a melanotic macule?

A
  • Normal amount of melanocytes with increased amount of melanin
  • Benign mucosal pigmentation
82
Q

What is a melanoma?

A
  • Cancer producing pigment
83
Q

What are the causes of brown or black lesions?

A
  • Racial/familial
  • Smoking
  • Drugs like contraceptive pill or tetracyclines as this stimulates production of melanin by melanocytes
  • Addisons disease caused by raised ACTH conditions so stim of melanocytes increases
84
Q

What does this image show?

A
  • Melanotic macule
85
Q

What do these pictures show?

A
  • Amalgam tattoo
  • Metal is a foreign body and is being phagocytosed by giant cells to be removed in mucosa
  • Dont take radiograph it is not justified, take biopsy
86
Q

What disease do these pictures show

A
  • Addisons / Cushing disease
  • ACTH hormone is increased
  • Increased ACTH increases melonocyte production of melanin
  • Lead to pigmented mucosa
87
Q

What are the characteristics of melanoma?

A
  • Variable pigmentation within single lesion
  • Irregular outline
  • Raised surface
  • Symptomatic - May itch or bleed
  • Refer
88
Q

Why are biopsys important?

A
  • Identify or exclude malignancy
  • Identify dysplasia
  • identify other disease like LP
89
Q

What is the general rule in regard to biopsy?

A
  • Any white, red or pigmented patch that can’t be explained must be biopsied

FINALS - Oral Medicine (13 decks)

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