White Patches Flashcards
What is hyperkeratosis ?
This is the development of a keratinised layer at a site that is not normally keratinised
Or
it is a thickening of an existing keratinised layer
What is leukoplakia?
it is defined as a white patch or plaque that cannot be rubbed off and cannot be characterised clinically or histologically as any other disease
What is leukoedema?
white, grey or milky white edematous lesion of the buccal or labial mucosa
What are the main classes of white patches ?
- those that can be rubbed off
- those that are adherent to the oral mucosa
Give examples of causes of white patches that can be rubbed off
- candida albicans
- necrosed or dead mucosa that is sloughing from the underlying base
- collected food debris in patients with poor oral hygiene
Adherent white pathces can be divided into …
- developmental lesions
- acquired lesions
Give examples of developmental white patches
- fordyce granules
- geographic tongue
- white sponge naevus
- tylosis
- dariers disease
What are fordyce granules ?
these are slightly raised sebaceous glands (secrete sebum) that are found in hairless areas of the skin.
They are commonly found in the cheeks and the vermillion (borders of the lips)- labial and buccal mucosa
What is the potential significance of fordyce granules?
If they have not been previously noticed (by dentist or patient) then they give rise to concerns of oral cancer
What is the alternative name of geographic tongue? Why is is it given this name?
erythema migrans
this is due to the characteristic appearance and the variable parts of the tongue that are affected at different times
Briefly describe the appearance of white sponge naevus
white, shaggy, folded appearance
What is the pattern of inheritance for white sponge naevus?
autosomal dominant
White sponge naevus has a variable ________. What does this mean?
Penetrance
This refers to the proportion of people with a particular genetic variant who exhibit signs and symptoms of the genetic disorder.
(thus people with the genetic variant may not present with the white spinge naevus?)
What white patch can be seen in children?
white sponge naevus
What is tylosis?
it is a rare autosomal dominant disorder that affects the oral mucosa but more commonly the palms and soles of the feet.
What is Dariers disease?
Autosomal dominant disorder which is mucocutaneous.
mucocutaneous pertaining to where the mucosa and skin meet
The _____ mucosa accounts for 50% of Dariers disease.
oral mucosa
Where are lesions of the oral mucosa often found in Dariers disease?
the palate
Give examples of acquired white patches
- Traumatic
- infective
- viral
- idiopathic
What is the most common cause of acquired white patches?
mechanical trauma
Where is the most common site of mechanical trauma in the oral mucosa?
- buccal mucosa
- lateral margins of the tongue adjacent to the occlusal plane
Give instances where masticatory trauma occurs (leading to white patch development)
- edentulous ridges opposing natural dentition under an ill-fitting denture
- edentulous patients who do not wear dentures
When can chemical trauma of the mucosa lead to white patch development?
secondary to/following necrosis of the oral mucosa
Give an example of an instance that can lead to chemical trauma of the oral mucosa
Aspirin held in the mouth, typically against the cheek
Briefly describe the appearance of nicotinic stomatitis
white patches frequently speckled with red areas as a result of inflammatory changes to the salivary glands.
It is seen on the palate of pipe smokers as a result of heat in the mouth
Also known as smokers palate
What species of candida causes a wide distribution of white plaque that can be rubbed off leaving an underlying erythematous mucosa?
pseudomembranous candidiasis
What is the sole reason for the presence of white patches associated with pseudomebranous candidiasis ?
it is only present when there is an underlying cause that results in local or systemic compromise of the immune system
Briefly define how chronic hyperplastic candidiasis appears
an intraoral white patch present in the region of the commisures of the lips. Often present bilaterally.
Chronic hyperplastic candiadiasis can be rubbed off. True or false
False
How can chronic hyperplastic candidiasis be differentiated from other leukoplakias?
underlying candidal association is often revaled at a biopsy
However clinically they are similar to leukoplakias
What type of white patch has a higher risk of malignant transformation compared to others?
Chronic hyperplastic candidiasis
Chronic hyperplastic candidiasis can always be resolved with antifungals. True or false
False
Why do chronic hyperplastic candidiasis white patches warrant excision?
due to their increased risk of malignant transformation
Briefly describe the appearance of viral papillomas
polypoid lesions that often have an irregular surface and a white hyperkeratotic appearance
Large viral papillomas are difficult to distinguish from what kind of lesions?
veruccous papillomatous lesions
How do veruccous papillomatous lesions differ from large viral papilloma lesions
they often have areas of neoplastic change within them
What condition associated with HIV can present as a white patch?
hairy leukoplakia
By definition, all leukoplakias are …
idiopathic
Lichen planus is a mucocutaneous condition. What are the subtypes of lichen planus?
- purely cutaneous lesion
- purely mucosal
- affects skin and mucous membranes
What is the most common form of lichen planus?
- striated or reticular lichen planus
What is the most concerning form of lichen planus?
the erosive form
Briefly describe the appearance of reticular/striated lichen planus
lace like pattern of striae on buccal mucous membranes or lateral borders of the tongue. It is frequently bilateral
Reticular lichen planus is often asymptomatic. True or false
True
How does erosive lichen planus appear ?
there are areas of erosive ulcerations within the area of the mucosa that is affected by the hyperkeratosis
ulcers present in the area of hyperkeratosis
Erosive lichen planus is often symptomatic. Give examples of some triggers that can cause symptoms in people with erosive lichen planus
- hot and spicy foods
It is uncommon for patients who have reticular-like lichen planus to have erosive episodes periodically. True or false
False
This has been known to occur.
What form of lichen planus likely has the potential for malignant transformation?
erosive forms of lichen planus
What seperates lichen planus from a lichenoid reaction?
the presence of a causative agent
they, however, appear the same clinically and histologically
Give examples of causative agents of lichenoid reactions
- amalgam restorations
- a number of pharmaceutical drugs
When is it acceptable to not refer management of a white patch to a specialist?
if there is clear evidence of a local traumatic cause which can be removed and its removal resolves the white patch
What information should be collected when taking a history from patient with a white patch ?
- if patient is aware of it, duration and any associated symptoms
- if lesion is associated with a traumatic event that patient can recall /change in medication
- any changes in appearance or location of the lesion
- whethere or not the lesion comes and goes
- any new skin lesions along side problems intra-orally
- new medications
- family history of similar oral symptoms
- SH: smoking and drinking habits, tobacco use
What important features should be noted down following the discovery of a white patch in an exam?
- site of lesion
- isolated lesion or several sites
- homogenous or non-homogenous
- whether non-white elements of the patch are normal looking or erythematous
- following palpation, does it rub off or does it remain adherent
- presence of ulceration or erosion
- any association with hard tissue- trauma
*
What areas of the oral mucosa are associated with increase risk of malignant transformation?
- sublingual sites
- lateral/ventral surface of the tongue
- retromolar/soft palate area
What kinds of lesions have a greater incidence of dysplastic or neoplastic change?
heterogenous lesions with an ertythematous or speckled looking mucosa
White patches that arise in non smokers are of great concern (increased malignancy risk) to what sector of the population?
- increased age
- female sex
Briefly describe an “ideal” biopsy
- under local anaesthetic
- biopsy should be taken from the most clinically concerning part of the white patch (e.g. ulceration)
- unless the patch is very small, biopsy should be incisional and not excisional
- take care to not damage salivary duct orifices
- if lesion is heterogenous, multiple biopsies can be taken
What are the objectives of a biopsy if a definitive diagnosis cannot be obtained?
- assess if any dysplasia or neoplasia is present
- assess degree of dysplasia
Following histological results, what treatment options are available for white patches?
- removal of cause e.g traumatic lesions, replacement of amalgam in lichenoid reactions
- monitoring with repeat biopsy in the event of change
- excision; best done with laser
- medical treatment with retinoids currently being investigated but not yet mainstream
Smoking cessation
What kinds of white patches should be excised?
- where there is evidence of dysplasia
- if histology indicates pre-malignant diagnosis e.g. chronic hyperplastic candidiasis
Most newly diagnosed oral SCCs present in patients who previously have had a white patch. True or false
false
they often arise de novo as an area of ulceration
What is the generally acceptable consensus for the referral of an oral ulcer?
an oral uncer that has not resolved or improved significantly within 3 weeks of onset should be regarded as suspicious and referred for urgent specialist assessment.
What is the treatment plan for a white patch that is not expected to resolve?
monitor at regular check-ups
in the event of any change in appearance or symptoms, consideration should be given for further investigation
