White patches, red patches and pigmented lesions Flashcards
Reasons why oral lesions may appear white?
epithelium has thickened
organic material
- Candida
- food debris
physiological
- tongue coating
- desquamation
- leukoedema
White patches - potential causes (CLINK)
congenital
lichen planus
infections
neoplastic/potentially neoplastic
keratosis
Give examples of neoplastic and potentially malignant white patches
squamous cell carcinoma
leukoplakia
sub mucous fibrosis
actinic chelitis
Squamous cell carcinoma red flags
> 3 week duration
50 years old
smoking
high alcohol consumption
history of oral cancer
non-homogenous
non-healing ulceration
tooth mobility
non-healing extraction sockets
difficulty speaking or/and swallowing
weight loss
fatigue
appetite loss
cervical lymphadenopathy
numbness/altered sensation
squamous cell carcinoma management
urgent suspected cancer referral to oral and maxillofacial surgery
be honest with patient and explain concern
explain that they will need to get a biopsy/sample promptly
Leukoplakia - define
a white patch or plaque that cannot be characterised clinically or pathologically
- can’t be rubbed away
Leukoplakia - significance
2-5% become malignant in 10 years
5-20% are dysplastic
10-35% of leukoplakias showing dysplasia proceed to carcinoma in 10 years
Clinical risk factors for malignant transformation
strong association
size >200mm2
non homogenous texture
red or speckled colour
tongue or floor of mouth
medium association
female sex
>50 years
Histological risk factors for malignant transformation
strong association
severe dysplasia
high risk dysplasia
medium association
HPV-16 +
many genes involved
disorders that should be excluded for a diagnosis of leukoplakia
leukoedema
white sponge naeuvus
frictional keratosis
chemical injury
acute pseudomembranous candidosis
hairy leukoplakia
lichen planus (Plaque like variant)
lichenoid reaction
Discoid lupus erythematous
proliferative verrucous leukoplakia features
up to 85% undergo malignant transformation
warty surface with white/yellow appearance
common sites palate and gingiva
will enlarge over time
often very extensive and impractical to remove
oral submucous fibrosis features
related to paan use
pale in colour
firm to palpate
fibrous bands develop
typically affects buccal mucosa and soft palate
mouth opening over time diminishes
oral sub mucous fibrosis malignant transformation rate
5%
what is keratosis - name the different types/causes
a response to trauma
frictional
- sharp teeth/restorations/denture/occlusion
thermal
- smoking/hot foods/drink
chemical
- aspirin/acid/bleach/chlorhexixidne
Leukoedema features
not a mucosal disease
normal physiology
faint white lines, typically on buccal mucosa
more common in people of African heritage
White sponge naevus features
inherited autosomal dominant
mutation of genes that codes for keratins 4 and 13
affects any part of mucosa
- most commonly buccal mucosa
poorly defined border
benign
White sponge naeuvus histology
hyperkeratosis
intra-cellular oedema in stratum spinosum and parakeratined layers
thickening of epithelium, especially stratum spinosum - acanthosis
no inflammatory changes
White patches general management strategies
exclude red flags
does it wipe away
get photos
assess for obvious cause
refer if unsure or no improvement
biopsy?
review
reasons why oral lesions may appear red
inflammation
mucosal atrophy
increased vascularisation
mucosal/submucosal bleeding
red patches differential diagnoses and causes
viral infection
candida infection
iatrogenic
- mucositis secondary to chemo or radiotherapy
granulomatous disease
blistering diseases
allergy
psoriasis
geographic tongue
trauma
deficiency states
erythroplakia
erythroplakia features
atrophic lesion
localised
well defined borders
can have speckled appearance - erythroleukoplakia
strong association with tobacco use
50% malignant transformation rate
erythroplakia common sites
soft palate
buccal mucosa
floor or mouth
erythroleukoplakia features
speckled red/white patches
heterogenous appearance
exists on a spectrum with red and white patches
highly suspicious for SSC or severe dysplasia
red patches management
thorough history and examination
exclude red flags
obvious cause? correct and review
red patches have high malignant potential
biopsy if can’t be attributed to a cause
why do lesions in the mouth appear pigmented?
extrinsic
- amalgam - blue grey appearance
- chlorhexidine
- tobacco
- heavy metals
intrinsic
- melanin
peutz-jeghers syndrome features
developmental hypermelanosis
autosomal dominant disorder
resembled freckles - eyes mouth and nostrils
muco-cutanous pigmentation
buccal mucosa and lips affected
typically presents in infancy
- fades throughout life
GI polyposis
- gi polyps have malignancy risk
Peutz-Jeghers syndrome investigations and management
FBC/endoscopy/STK11 gene
management
- manage polyps
- regular MRI/CT
endogenous/intrinsic oral pigmentation - cause
inflammation
- stimulates melanocyte activity
- can be seen in lichen planus and areas of other inflammatory disease
how does Addison’s disease lead to oral pigmentation?
oral pigmentation is an early presentation of Addison’s
adrenal glands no longer produce enough steroid
- adrenal insufficiency leads to increase ACTH
- ACTH causes pigmentation seen by stimulating melanocytes
- patchy hyperpigmentation can be seen
medication associated with oral pigmentation
antimalarials
zidovudine
gold
heavy metals
minocycline - antibiotics
busulphan - chemotherapy
melanotic macule features
single brown lesion
- comprised of a collection of melanin containing cells
flat
non raised
typically <1cm diameter
no rapid change
painless
common on vermillion border
melanotic macule management
consider excisional biopsy to exclude melanoma
melanocytic naevi features
medical term for a mole
blue/black lesions
focal proliferation of melanocytes
typically appear during childhood
papular appearance
typically >1cm in diameter
no rapid change
clinically resembles melanoma
- rarely progresses to melanoma
melanoma features
rare
may arise from a pigmented naeuvus
palate or maxillary gingiva most common
refer if suspected melanoma
melanoma - warning signs (ABCDE)
asymmetry
border irregularity
colour irregularity
diameter >6mm
evolving
- shape, size, colour, elevation
What is a naevus?
a benign growth on skin caused by a cluster of melanocytes
melanoma incidence and prevelence
1.2 cases per 10 million per year
1-2% of oral malignancies
average age of presentation is 60
more common in populations with higher skin pigmentation
5 year survival rate 25.5%
Kaposi’s sarcoma features
vascular neoplasm/tumour
human herpes virus 8 associated
disorganised epithelial cell growth
mainly presents in immunocompromised
Reddish-blue or brown foci
can present on skin, oral mucosa or GI tract
Kaposi’s sarcoma management
surgery
radiotherapy
chemotherapy
immunotherapy
managing underlying immunodeficiency
