Red and white patches

Question 1

what is a problem with the oral mucosa?

Answer 1

that it can only react in so many ways -> u tend to get ulcers, white patches, red patches, lumps, blisters, erosions (shallow ulcer)&raquo_space; there is a whole host of different conditions that can cause oral soft tissue lesions but there is a limited way in which the oral soft tissues can present (limited way in which they can change).
= This means that just by looking at a lesion its quite often the case that u won’t able to tell
what exactly it is, it also means that u can get a variety of presentations in the same lesion

• So when talking about WP, RP, blisters, lumps, ulcers -> u may well sometimes get a lesion which is just WP, u may as well sometimes get a lesion which is just a lump, but very often things will change.

Question 2

slide 7 Top RHS

Answer 2

Top RHS=an ulcer but that ulcer is on top of a lump so both a lump and an ulcer

Question 3

slide 7 top middle

Answer 3

fairly benign looking aphthous ulcers (they are white in the middle but around the edge they are red)

Question 4

slide 7 top LHS

Answer 4

bigger nastier more “chronic looking” ulcer with irregular edges and it is white in the middle but red around the edges

Question 5

slide 7 second row middle

Answer 5

reticular lichen planus
which is typically both white and red

Question 6

slide 7 bottom LHS

Answer 6

desquamative gingivitis with a mixture of white and red

Question 7

slide 7 bottom RHS

Answer 7

some erosions or some blisters which are red in the middle
but also have an element of white around them

Question 8

what can happen to lesions as time goes?

Answer 8

they can change
for ex slide 7 top RHS
that lesion probably started as a lump then got bigger then turned into a lump with an ulcer on top

bottom RHS- was probably a blister that then bursted to leave a shallow ulcer or erosion

Question 9

how can we categorise oral soft tissue lesions?

Answer 9

1) appearance (what we will deal with)
2)causes

Question 10

what are some descriptions of appearances of oral soft tissue lesions?

Answer 10

1- white patches
2- red/purple patches
3- mixed white + red/purple patches
4- pigmented lesions
5- blisters

Question 11

what are some causes of oral soft tissue lesions?

Answer 11

1- infections
2-trauma
3- granulomatous disease (post-grad level)
4- immune-mediated diseases (oral lichen planus , pemphigoid, pemphigus)
5- oral epithelial dysplasia (v. important)

Question 12

what is oral epithelial dysplasia ?

Answer 12

harmful changes in the cells that make up the epithelium (lining) of the mouth

earliest form of precancerous lesion

Question 13

slide 9 basic histology pf the epithelium
explain basal membrane and basal cell of layers

Answer 13

the wavy blue line = basement membrane
that separates the epithelium from the underlying oral soft tissues

on top of the basement membrane

we’ve got the basal cell of layers-
these basal cells replicate, they replicate on a continuous basis and as they replicate they pile up on top of each other.

Question 14

slide 10
what cells replicate in the epithelium?

Answer 14

Only the basal cells in health are replication
therefore that is the only place you would expect to see cellular evidence of cell replication

Question 15

slide 11
what would the cells on top be doing in health?

Answer 15

maturing

not replicating
they mature and stack on top of each other

they go from squamous (rounded appearance) > to a more flat appearance

Question 16

slide 12
what do these layers of old mature cells do for the epithelium?

Answer 16

they give the epithelium its robustness

(there may be some keratin production depending on the type of epithelium but not always)

Question 17

slide 13
what is underneath the basement membrane?

slide 14

Answer 17

Stroma
and in it there are blood vessels arteries and veins

and then fat

Question 18

slide 15 what else is there

Answer 18

Glands - minor salivary glands
depending on the tissue there can be sebaceous glands (glands that produce more oily thick secretions)

Question 19

slide 16
what are melanocytes ?

Answer 19

the epithelium we also have melanocytes that are producing melanin= pigment.
* We all have the same number of melanocytes and if there is any difference in skin tones between us it’s bec of the way our skin handles that melanin, not a difference in number of melanocytes

• Melanocytes will also be subject to local stimulating, trauma, & hormones -> so one of the signs of untreated Addison’s disease is darkening of the skin related to production of hormones that are supposed to stimulate the adrenal glands but also stimulate melanocytes or melanin production. (important to notice in pt examination)

Question 20

when do you a thinner epithelium ?

Answer 20

when do you get cells produced at a slower rate
or an increased rate of loss

= that is why you get white patches

Question 20

when do we get a thicker epithelium?

Answer 20

• when squamous cells heap up and the cells and are not being lost.
  -when cells are produced at a faster rate

Question 21

why do white patches form?

Answer 21

heaped up epithelium which isn’t being scrapped away- either bc cells being produced at an increased rate or being lost at a decreased rate then that thickened epithelium soaked in saliva will turn white

Question 22

what does VITAMINS CDS allow you to do?

Answer 22

allows you to talk about any presentation or any sign or symptom or any kind of pathology & breaks down it possible causes

-not in the order of the likely-hood (just help u remember).

-there’s a reasonable argument for including VITAMINS CDE in our deferential diagnostic list for oral soft tissues.

Question 22

what is VITAMINS CDS

Answer 22

• Vascular
  -Infective/inflammatory
  -trauma (most common)
  -Auto-immune\Metabolic
  -Idiopathic/iatrogenic
  -Neoplastic (related to cancer)
  -Social (smoking/ alcohol, non accidental injuries ig trauma in mouth)
  -congenital
  -Degenerative
  -endocrine

Question 23

what are the 2 types of trauma ?

Answer 23

• chronic= trauma sustained break in epithelium
  -acute=overrides mechanical strength of epithelium

Question 24

what is a blister?

Answer 24

result of trauma
fluid filled lumps under the skin
tend to be delicate/burst easily
intact epithelium no break in continuity
in the mouth the mucosa is not keratinised therefore we rarely see them there
usually evidence of a burst blister would be seen
(shallow erosion with some ragged edges

Question 25

slide 22
bottom LHS
what is this lesion?

Answer 25

blood blister on tongue

Question 26

what is an ulcer?

Answer 26

if the trauma is more sustained and causes a break in the continuity of the epithelium

Question 27

slide 23
what is this lesion?

Answer 27

Ulcer
breaking the continuity of the epithelium with a white area around it suggesting the area is a bit thicker

Question 27

what is frictional keratosis? (white patch)
give an example

Answer 27

when there is chronic trauma
keeps up with the epithelium (could be from denture/position of teeth) slide 24
(heaping up of epithelium)

ex
linear alba -
occlusal line on buccal mucosa (or side of tongue)
area that is frequently caught between the teeth

chronic trauma dein broken teeth
broken restorations
denture clasp (slide 28)

Question 28

what is smokers keratosis?
slide 27

Answer 28

WP in the palate
caused by inhaling hot cigarette smoke

thermal damage

(staining of teeth will also be seen from nicotine)

Question 29

what white patches are from “normal anatomy”

Answer 29

-Fordcyce’s spots (little suits underneath the mucosa in the mouth slide 30)
-sebaceous glands (can be on the lips slide 29)

they will be smooth with no ulceration

Question 30

what is Mid-line rhomboid glossitis ?
slide 31+32+33

Answer 30

normal red patch lesion

middle of tongue RP
rhomboid shape

loss of papilla

if biopsied - candidal hyphae could be seen

no clear cause - could be developmental

Question 31

what is geographic tongue ?
slide 34+35+36

Answer 31

Normal mixed red and white patch
asymptomatic (can be tender)
common
depopulation can be seen in red areas

Question 32

what are vascular lesions?

Answer 32

caused by changes underneath the epithelium (not in the epithelium/mucosa)

mucosa over the top - looks normal

common in the floor of the mouth - dilated vessels (normal)

vascular malformation/ haemangioma - developmental abnormality

(slide 37)
slide 38- red arterial blood - haemangioma
slide 39 normal vascular malformation lower lip (common)

they can be inherited or congenital (kids are more likely to develop them) slide 40

old people can get them in the lower lip as well - no need tx but can bleed if traumatised

Question 33

what is a pyogenic granuloma (vascular epulis)
slide 42+43

Answer 33

RP
reactive vascular lesion commonly in gingiva

reactive lesion - related to local inflammation (plaque trap?)

Question 34

what is desquamative gingivitis ?

Answer 34

-erosion of gingiva around the margins of teeth
intact but inflamed epithelium
not related to OH (not marginal gingivitis)

common in oral lichen planus

responds to topical steroids

Question 35

what is angular cheilitis (stomatitis)?
slide 46

Answer 35

RP
bilateral lesion
saliva trapping in corner of mouth