Red/Pigmented Lesions

Question 1

What is Racial Pigmentation?

Answer 1

Diffuse intra-oral melanosis in dark-skinned races

Increased but normal melanin formation

Question 2

Clinical Findings of Racial Pigmentation

Answer 2

1. Buccal gingiva most common
2. Bilateral symmetrical
3. Does not alter surface morphology

Question 3

Clinical Findings of Smoking-associated Melanosis

Answer 3

1. Diffused melanin pigmentation on anterior facial gingiva
2. Diffused macular melanosis of buccal mucosa, gingiva, tongue

Question 4

Histopathologic Findings of Smoking-associated Melanosis

Answer 4

1. Increased melanin pigmentation of basal cell layer of surface epithelium
2. Basilar melanosis with pigmentary incontinence

Question 5

Differential Diagnosis of Smoking-associated Melanosis

Answer 5

1. Trauma
2. Neurofibromatosis
3. Peutz-Jegher’s syndrome
4. Drug-related pigmentation
5. Endocrine disturbances

Question 6

How long does related pigmentation take to disappear after cessation of smoking?

Answer 6

Gradually over 3 years

Question 7

What is Allergic Stomatitis?

Answer 7

Type IV hypersensitivity reaction to allergens in direct contact with oral mucosa

Question 8

Clinical Features of Allergic Stomatitis

Answer 8

1. HALLMARK: Erythema, edema, desquamation, ulcertation
2. Gingiva, tongue, lining or oral mucosa
3. Benign mixed white and red lesion

Question 9

Histhopathologic Findings of Allergic Stomatitis

Answer 9

1. Hyperkeratosis, no epithelial dysplasia
2. Lichenoid aspect

Question 10

Differential Diagnosis of Allergic Stomatitis

Answer 10

1. Oral lichenoid contact reaction
2. Leukoplakia
3. Focal trauma

Question 11

Management of Allergic Stomatitis

Answer 11

1. Removal of agent

2 In more severe cases, antihistamine therapy combined with topical anaesthetics

3. Chronic contact allergy usually respond well to removal of source and topical corticosteroid gel or oral suspension

Question 12

Define Erythroplakia

Answer 12

A red plaque that cannot be clinically or pathologically diagnosed as any other condition.

Greater malignant potential than leukoplakia

Question 13

Clinical Features of Erythroplakia

Answer 13

1. FOM, tongue, soft palate
2. Multiple lesions
3. Well demarcated erythematous patch with soft velvety texture
4. Asymptomatic

Question 14

Histopathologic Findings of Erythroplakia

Answer 14

1. Lack of keratin
2. Severe epithelial dysplasia, carcinoma in situ

Question 15

Investigations of Erythroplakia

Answer 15

Incisional Biopsy

Question 16

Differential Diagnosis of Erythroplakia

Answer 16

1. Mucositis
2. Candidiasis
3. Vascular lesions

Question 17

Management of Erythroplakia

Answer 17

Moderate to severe usually complete surgical excision

Long-term follow up due to recurrence

Question 18

What is an Oral Melanotic Macule?

Answer 18

Flat, brown mucosal discolouration produced by a focal increase in melanin deposition

Melanocytes normal numbers and morphology

Question 19

Clinical Features of Oral Melanotic Macule

Answer 19

1. Lower lip vermillion (Most common), buccal mucosa, gingiva, palate
2. Uniformly dark brown, round macule with diameter 7mm or less
3. Asymptomatic and does not enlarge further/become darker

Question 20

Histopathologic Findings of Oral Melanotic Macule

Answer 20

1. Increase in melanin in basal and parabasal layers of normal stratified squamous epithelium
2. Melanin incontinence (Melanin in the sub-epithelial CT)

Question 21

Differential Diagnosis

Answer 21

Malignant melanoma

Question 22

Investigations for Oral Melanotic Macule

Answer 22

Biopsy those on palate and maxillary alveolar mucosa for histopathological exam to rule out oral melanoma

Question 23

Management of Oral Melanotic Macule

Answer 23

For aesthetic areas : Excisional biopsy, electrocautery, laser ablation, cryosurgery

Question 24

What is an acquired melanocytic nevus (mole)?

Answer 24

Benign, localised proliferation of nevus cells derived from neural crest → Migrate to epidermis shortly after birth

Question 25

What is a Nevus?

Answer 25

Derived from melanocytes, cluster and migrate down into CT

Question 26

Clinical Features of Melanocytic Nevus

Answer 26

1. Painless, raised or flat <1cm 2. Palate, mucobuccal fold, gingiva 3. Solitary lesion

Question 27

Classification of Melanocytic Nevustion

Answer 27

Junctional nevus: Cluster at epithelial basement membrane junction to form localised pigmentation Compound nevus: Some clusters migrate into lamina propria while some left at junction Intramucosal nevus: Eventually all migrate into lamina propria. Brown-black colour Blue nevus: Remain deep in lamina propria

Question 28

Histopathological Findings od Melanocytic Nevus

Answer 28

**Superficial nevus cells** - Organised into small aggregates, appearing round - Abundant cytoplasm - Intracellular melanin **Deeper nevus cells** - Less cytoplasm - Seldom pigmented

Question 29

Differential Diagnosis of Melanocytic Nevus

Answer 29

1. Melanoma 2. Other pigmented lesions

Question 30

Management of Melanocytic Nevus

Answer 30

Conservative surgical excision for aesthetics

Question 31

What is Post-inflammatory Induced Pigmentation?

Answer 31

Inflammation interferes with both melanin synthesis and its transfer to keratinocytes Damaged epithelial layer decreases shielding of UV light → Induce melanocytes to produce more melanin for basal cell protection Accumulation of subepithelial melanin

Question 32

Post-inflammatory Induced Pigmentation occurs in which condition?

Answer 32

Reticular lichen planus due to constant damage and healing

Question 33

Aetiology of a Melanoma

Answer 33

UV radiation exposure from sunlight

Question 34

Risk Factors of Melanoma

Answer 34

1. Fair complexion 2. History of sunburns in childhood

Question 35

What is Melanoma?

Answer 35

Malignancy of melanocytic origin Aggressive lesion that metastasizes early → Poor prognosis

Question 36

Demographics of Oral Melanoma

Answer 36

Rare, middle-aged to elderly

Question 37

Clinical Presentation of Melanoma

Answer 37

1. Brown macule with irregular borders 2. Nodular, may be flat 3. Most common on hard palate and maxillary gingiva

Question 38

Histopathology of Melanoma

Answer 38

1. Atypical melanocytes in epithelial and CT junction 2. Enlarged varying degrees of pleomorphism and hyperchromatism 3. Radial spread → More superficial Vertical spread → Deeper infiltration

Question 39

Investigation of Melanoma

Answer 39

Early diagnosis by biopsy → Surgical excision before metastasis Diagnosis is helped greatly by immunohistochemistry (S-100, MelanA, SOX10)

Question 40

Management of Melanoma

Answer 40

Radical excision with or without neck dissection, radiotherapy, immunotherapy

Question 41

Prognosis of Melanoma

Answer 41

Poor prognosis due to high level of reccurence, rapid growth and metastasis

Question 42

What is an Amalgam Tattoo?

Answer 42

Implantation of dental amalgam within oral mucosa, resulting in pigmentation

Question 42

Clinical appearance of Amalgam Tattoo

Answer 42

1. Black, blue, grey macules 2. Well-defined, irregular or diffuse 3. Lateral spread may occur for several months 4. Gingiva, alveolar mucosa and buccal mucosa

Question 43

Radiographic Findings of Amalgam Tattoo

Answer 43

Fragments area densely radiopaque

Question 44

Investigation of Amalgam Tattoo

Answer 44

If no metallic fragments found on DPT, biopsy should be obtained to rule out melanocytic neoplasia