Red, white & pigmented lesions

Question 1

White/red patches: normal/reactionary/acquired/traumatic

Answer 1

• Keratosis/hyperkeratosis
• Smokers keratosis/stomatitis nicotina
• Chemical burns
• Fordyce spots
• Geographic tongue
• Submucous fibrosis
• Leukoedema

Question 2

Keratosis/hyperkeratosis - frictional keratosis

Answer 2

White patches can be caused by prolonged mild abrasion of the mucous membrane by such irritants such as a sharp tooth, cheek biting or dentures.
Clinical features: At first the patches are pale and translucent but later become dense and white, sometimes with a rough surface. Habitual cheek biting causes an area of buccal mucosa to appear patchily red and white with a rough surface.
Pathology: the epithelium is moderately hyperplastic with a prominent granular cell layer and thick hyperkeratosis but no dysplasia. There are often scattered chronic inflammatory cells in the corium,
Management: Removal of the irritant causes the white patch to disappear, biopsy necessary if white patch persists, completely benign

Question 3

Smokers keratosis/Stomatitis Nicotina

Answer 3

Seen in heavy, long-term pipe smokers and some cigar smokers.
Clinical features: Palate is affected but any part protected by the denture is spared.. Changes then are only on the soft palate. The lesion has 2 components: hyperkeratosis and inflammatory swelling of the minor mucous glands. White thickening of palatal mucosa is associated with small umbilicated swellings with red centres. The white plaque is sometimes distinctly tesselated (pavement-like).
Management: Smoking cessation, the lesion resolves within weeks of not smoking.

Question 4

Chemical burns

Answer 4

• Topical application of aspirin (Aspirin burn) adjacent to symptomatci tooth will produce epithelial necrosis, sloughing and ulceration
• Low grade insult such as excessive CHX mouthwash may result in hyperkeratosis (make sure CHX is less than 1 min in mouth)
• Chronic chemical insult seen in pts who use tobacco

Question 5

Fordyce spots/granules

Answer 5

Sebaceous glands are present in the oral mucosa in at least 80% of adults, particularly the elderly. They grow in size with age and appear in the oral mucosa as soft symmetrically distributed, creamy spots a few mm in diameter, particularly in older people. The buccal mucosa is the main site but sometimes the lips and rarely even the tongue is involved. Pts can be reassured that they are of no significance.

Question 6

Geographic tongue/Benign migratory glossitis

Answer 6

• Prevalence of 1% in the population and there is often an FH
• Unknown aetiology
• Reported in pts with psoriasis and it is possible that these disorders share the same underlying genetic predisposing actors.
• Clinically: irregular, partially depapillated and red areas on the anterior 2/3 of the dorsal surface of the tongue and is associated with loss of filiform and fungiform papillae remaining as shiny and dark red eminences. The margins of the lesions are often outlined by a thin, white line or band. The affected areas ay begin as small lesions only a few mm in diameter, which, after gradually enlarging, heal and then reappear in another location. The condition may regress for a period and then recur. It is usually symptomless but there may be some irritation associated with acidic/spicy foods.
• In most cases there is no need for treatment, mainly reassurance. Ocasionally geographic tongue may cause a burning sensation of the tongue. In this situation, topical anaesthetics can be used for surface numbing. Anti-inflammatory drugs like cortisonelike drugs may also be prescribed to help control discomfort. Zinc sulphate 200mg three times daily for three months or a topical mouth rinse with 7% salicylic acid in 70% alcohol may help

Question 7

Submucous fibrosis

Answer 7

• Premalignant condition caused by betel nut chewing. Common in south-east Asia but has started to spread to Europe and North America. It can lead to squamous cell carcinoma.
• Clinical features: hypovascularity leading to blanching of the oral mucosa, staining of the teeth and trismus
• No treatment can be given, prevention is best.

Question 8

Leukoedema

Answer 8

Bilateral diffuse, translucent, milky white- greyish thickening particularly of the buccal mucosa with a slightly folded appearance. It is a variation of normal, present in 90% of black people and variable numbers of white people.

Question 9

White/red patches: infections

Answer 9

Candida + Viral

Question 10

White/red patches: hypersensitivity reactions

Answer 10

Lichen planus + Lichenoid