Oral Mucosal Disease Flashcards
When should a mucosal lesion be refered to oral med for an opinion?
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.
What pathways are there for suspected oral cancers?
2 week cancer referal pathway
NICE nad SIGN head and neck cancer guidelines
Describe the histology of oral mucosa.
Stratified squamous epithelium
Lamina propria
Can be keratinised or non-keratinised
How does keratinised tissue present?
Pale white, as the tissue has been thickened. It will typically not have an inflamed border.
In what ways can the mucosa react to damage?
Atrophy (reduction in layers)
Erosion (partial thickness loss)
Ulceration (fibrin on surface)
Oedema (intra/inter-cellular)
Blister (vesicle or bulla)
How does ulceration present?
White center of keratinised tissue with clear margin of inflammation surrounding it.
List the common tongue lesions that can be considered benign?
Geographic tongue
Black hairy tongue
Fissured tongue
What is geographic tongue?
Desquamation of the tongue, leading to intermittant patchy lesions.
It is often sensitive to acidic/spicy food.
What are the symptoms of geographic tongue?
Possible sensitivity to acidic/spicy food.
What are the potential causes of geographic tongue?
Haemanitic deficiency (B12, folate, ferratin)
Parafunctional trauma
Dysaesthesia
What is black hairy tongue?
Hyperplasia of the papillae, leading to pigmented bacterial build up.
What is glossitis?
Inflammation of the tongue, which can often lead to a shiny smoothed appearance.
When should you refer a swelling to oral med?
Symptomatic
Abnormal mucosa
Increasing in size
Rubbery consistancy
Trauma from teeth
Unsightly
What mucosal lesions do not normally need referal?
Tori
Small polyps
Mucoceles
What are the main causes of white lesions?
Hereditary
Smoking/frictional
Lichen planus
- Lupus Erthematosus
- GVHD
Candidal leukoplakia
Carcinoma
What is leukoplakia?
White patches on the oral mucosa or tongue.
What % of leukoplakia becomes malignant?
1-5%
When should you refer a white lesion?
If the lesion is becoming more raised and thickened
If the lesion is without obvious cause
Why are red lesions red?
Reduced thickness of the epithelium, caused by increased bloodflow from inflammation and dysplasia.
What is erthroplakia?
A red patch that cannot be attributed to any other cause. More of a concern for malignancy than leukoplakia.
Why are red/blue lesions red/blue in colour?
Fluid build up in the connective tissue. Typically darker blue will indicate slow moving blood, and lighter will indicate saliva or lymph.
What is the cause of mucosal pigmentation?
Exogenous stain of tea/coffee/chlorhexadine/bacteria.
Intrinsic pigmentation - relative melanosism, melanoma, systemic disease.
Intrinsic foreign body such as amalgam or arsenic.
What are the causes of localised brown/black lesions?
Amalgam
Melanoitc macule
Melanotic naevus
Malignant melanoma
What are the causes of more generalised brown/black lesions?
Racial/familial
Smoking
Drugs
Addison’s disease
What is a general rule when considering a red, white, or pigmented patch for biopsy?
If it is unexplained, send for biopsy.
If you think a mucosal lesion might be cancer or dysplasia what guidelines can you consult for what to do next?
- NICE and SIGN Head and Neck cancer guidance
What epithelium is this diagram and is it keratinised or non-keratinised?
- Buccal mucosa
- Non-keratinised
What epithelium is this and is it keratinised or non keratinised?
- Palate
- Thick Keratinised layer sitting on surface
Label this diagram and explain
- 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
How is the oral mucosa histologically set up?
- 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
What are some reactive changes that can occur in the oral epithelium?
- Keratosis on nonkeratinsed site called parakeratosis
- Acanthosis (hyperplasia of stratum spinosum)
- Elongated rete ridges (hyperplasia of basal cells)
What is ulceration mucosal reaction?
- Fibrin on surface
What is blister mucosal reaction?
- Vesicle or bulla depending on size of lesion
What is commonly seen with age in regard to mucosa?
- Progressive mucosal atrophy
What does this picture show and what can cause this?
- Smooth tongue
- Mucosal atrophy on dorsal of tongue
- Nutritional deficiency of iron or B group vitamins
- Predisposed to infection
What does this image show?
- 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
What does this image show? Describe the condition
- 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
What is the management of black/brown hairy tongue?
- 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
What does this image show? Describe the condition
- 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
What does this picture show? Describe the condition
- Glossitis
- Inflammation of the tongue
- Investigate with haematinics and small biopsy to diagnose whether due to deficiencies or other disease like LP
Describe this picture
- 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
Describe this picture
- 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
Describe this picture
- 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
Describe this picture
- 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
Describe this picture
- Small mucocele in palate
Describe this picture
- Large fixed mucocele that has filled with saliva
- Possible to remove the extravasated mucous and associated gland
Describe what you see in these pictures
- Tori which are bony swellings
- Benign
- Common with pts with parafunctional clenching habits - present with TMD pain
For pts taking bisphonates what do you need to consider in regard to Tori?
- Tori considered risk factor for necrosis due to limited blood supply from periosteum in pts taking bisphophonates
- Removal of Tori is not recommended though
What does this picture show?
- 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
What are some reasons Oral white lesions can form?
- Hereditary
- Smoking/frictional
- Lichen Planus
- Lupus eryhtematosus
- GVHD
- Candidal leukoplakia
- Carcinoma
How can candidal leukoplakia cause white lesions?
- 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
How does smoking/frictional cause oral white lesions?
- Cause irritation to mucosal surface
- Thicken keratin layer (acanthosis)
- Keratin layer obstructs blood flow to keratin layer causing whiteness
How does a carcinoma cause oral white lesion?
- Associated with thickening of cells as they are proliferating at uncontrollable manor
- Acanthosis - whiteness
Why are white lesions white?
- 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)
What is meant by the term Leukoplakia?
- 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)
What is shown in these pictures? Describe the condition
- 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
What does this picture show?
- 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
What does this picture show?
- Smoker’s keratosis
- Trauma from thermal gases
- Reactive change of keratin
- Thickening of keratin , less able to see BV so white appearance
What does this picture show?
- 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
Does smokers keratosis increase chance of malignant risk?
- Smokers more likely to have leukoplakia
- Low malignant potential of the lesion
- BUT higher oral cancer risk due to smoking
What does this picture show?
- White sponge naevus
- Hereditary keratosis
- Often starts in childhood and if one person in fam has it , likely others will to
What does this image show?
- 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
Describe this white lesion
- 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
What is this picture showing?
- Chemical (aspirin) burn
- Acidic substance held in contact with mucosa
- Caused coagulation of proteins and thickening of the mucosa
What is this picture showing?
- Pseudomembranous acute candidosis (acute)
- Can be scraped of as not adherent to mucosa due to pseudomembranous
- Will leave inflammatory area underneath the lesion
What is this picture showing?
- Denture associated erythemous candidosis (Chronic)
- Denture covered tissues are erythematous due to poor denture hygiene
What are these pictures showing?
- Herpes simplex virus
- Gives intraepithelial vesicles that disrupt the view of the connective tissue blood vessels
- Once the vesicle bursts you lose the whiteness
When do you refer a white lesion?
- 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
Why are red lesions red?
- Blood flow increases due to inflammation or dysplasia
- Or due to reduced thickness of epithelium which is making connective tissue redness more visible
What does this picture show?
- ## Desquamative gingivitis due to thinning of epithelium
What is Eruthroplakia?
- Area of redness which can’t be attributed to any other cause
- Higher concern than leukoplakia and require biopsy
What are blue lesions?
- 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)
What does this picture show?
- Vascular haemangioma
- Can be capillary or cavernous
What is this picture?
- Cavernous haemangioma
What is the difference between these two pics?
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)
What is a Lymphangioma?
- Takes lymph fluid from the tissues back into circulation
What are some exogenous causes mucosal pigementation?
- Tea , Coffee , Chlorhexidine
- Bacterial overgrowth
What are some intrinsic causes of mucosal pigmentation?
- Reactive melanosis/melanotic macule
- Melanocytic naevus
- Melanoma
- Effect of systemic disease, paraneoplastic phenomenon
What are some intrinsic foreign body cause of mucosal pigmentation?
- Amalgam, arsenic
What is a melanocytic naevus?
- Melanocyte is becoming abnormal and produces too much melanin (proliferation increases)
- Produces benign skin lesion
What is a melanotic macule?
- Normal amount of melanocytes with increased amount of melanin
- Benign mucosal pigmentation
What is a melanoma?
- Cancer producing pigment
What are the causes of brown or black lesions?
- 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
What does this image show?
- Melanotic macule
What do these pictures show?
- 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
What disease do these pictures show
- Addisons / Cushing disease
- ACTH hormone is increased
- Increased ACTH increases melonocyte production of melanin
- Lead to pigmented mucosa
What are the characteristics of melanoma?
- Variable pigmentation within single lesion
- Irregular outline
- Raised surface
- Symptomatic - May itch or bleed
- Refer
Why are biopsys important?
- Identify or exclude malignancy
- Identify dysplasia
- identify other disease like LP
What is the general rule in regard to biopsy?
- Any white, red or pigmented patch that can’t be explained must be biopsied
