Oral Mucosal Colour Changes

Question 1

What are the causes of white oral lesions?

Answer 1

 Hereditary- oral white sponge Naevus (genetic changes to cytokeratins)
 Frictional- thickening of keratin layer, obstructs view to blood vessels giving more white appearance
 Lichen planus- acanthosis (reduces visibility of vessels)
 Candidal leukoplakia- inflammation within epithelium and connective tissue, thickness and fluid builds up reducing visibility of vessel
 Carcinoma- thickening of cells

Question 2

What conditions is lichen planus associated with

Answer 2

Lupus erythematosus

Graft versus host disease

Question 3

What causes lesions to appear white?

Answer 3

Thickening of the mucosa or keratin
-> Less visibility of blood/vessels

Less blood in the tissues
-> vasoconstrictor effect- slowing of blood passage through connective tissue

Question 4

What is leukoplakia?

Answer 4

A white patch which cannot be scraped off or attributed to any other cause

-> descriptor/diagnosis of exclusion

Question 5

What is the risk of leukoplakia becoming malignant?

Answer 5

1-5%

-> risk is based on aetiology of white patch

Question 6

What are fordyce’s spots?

Answer 6

Ectopic sebaceous glands
-> Benign and normal

Question 7

What habit is associated with frictional keratosis?

Answer 7

Parafunctional clenching- pulling buccal mucosa in which rubs against cusps of teeth causing keratotic thickening and lack of view of blood flow (white appearance)

Question 8

What causes smokers keratosis, what are its features?

Answer 8

Trauma caused by thermal gases
 Thickening of tissues
 mucosa remains normal but sometimes as a result of trauma, melanocytes over produce melanin (pigmentation changed- melanosis)
 Malignant conversion potential is low (but general risk is higher due to smoking)

Question 9

What are the features of White Sponge Naevus?

Answer 9

 Starts in childhood in posterior of mouth then spreads forward
 Familial
 Not caused by trauma

Question 10

What causes the appearance of WSN?

Answer 10

Fluid accumulates between epithelial cells in the superficial layers- increases opacity of tissue and disrupts visualisation of blood vessels

Question 11

What would be the general features of a non-worrying oral lesion?

Answer 11

White lesions

Well defined (no inflammation surrounding)

Covering normal mucosa

Question 12

What is idiopathic keratosis?

Answer 12

Occurs without obvious cause (genetic programming switches to produce more keratin)

-> still biopsy to confirm

Question 13

How does desquamative gingivitis present?

Answer 13

Lichen planus areas- white, with areas of thinning- red vascular appearance

Question 14

Why is biopsy of the gingival margin an issue?

Answer 14

Difficult- chance of ischaemia and tissue death (done by specialist)

Question 15

What occurs as a result of a chemical burn in the oral cavity?

Answer 15

Coagulation of protein and damage to epithelial surface

Question 16

What medications are associated with causing chemical burns?

Answer 16

Can happen with aspirin or alendronic acid (can be seen if patient has reduced cognitive function and does not swallow tablets)

Question 17

Which habit is associated with traumatic keratosis?

Answer 17

Tongue thrusting

Question 18

What happens as a result of hairy leukoplakia, what causes this?

Answer 18

Elongation on papillae on side of tongue and thickening of surface
-> Due to incorporation of Epstein bar virus into genetic code of the cell causing them to reproduce at faster rate and produce more keratin rich appearance

Question 19

What are the types of lesions associated with candida?

Answer 19

Pseudomembranous Acute (thrush)

Denture Associated - Chronic due to prolonged contact (erythematous)

Question 20

What does pseudomebraneous mean?

Answer 20

Not part of or adhering to mucosa (can be rubbed off)

Question 21

How do lesions caused by HSV present in the mouth?

Answer 21

As intra-epithelial vesicles (disrupt view of BVs)
-> Loses white appearance on bursting

Question 22

When should a white lesion be referred by a dentist?

Answer 22

If RED and WHITE- concentrate on the RED part

If the lesion is becoming more raised and thickened

If the lesion is ‘without cause’- esp in lateral tongue, anterior floor of mouth, soft palate area

-> most are benign and kept under review by dentist only

Question 23

What are the caused of the red appearance of some lesions?

Answer 23

Blood flow increases
-> Inflammation
-> Dysplasia causing increased vascularity (can become malignant)

Reduced thickness of the epithelium

Question 24

What are the features of geographic tongue?

Answer 24

White margins with areas of erythema
-> Changes in a few weeks or may resolve

Question 25

What causes red lesions to present under dentures?

Answer 25

If candida present due to poor denture hygiene -> Can appear in certain areas only in older dentures if bone has resorbed in certain sections meaning only certain parts of mucosa are in contact

Question 26

What is erythroplakia?

Answer 26

A red patch which cannot be attributed to any other cause -> Atrophic or non-keratotic end of the spectrum -> More of a concern for malignancy than leukoplakia

Question 27

What are the causes of red/blue lesions?

Answer 27

Fluid in the connective tissue: Dark – slow moving blood in large vessels -> varicosities, veins or cavernous haemangioma Light Blue – clear fluid -> presence of saliva (mucocele)/lymph (Lymphangioma) within

Question 28

How do normal haemangiomas look?

Answer 28

More red due to presence of more capillaries

Question 29

How can vascular lesions be distinguished from malignancy?

Answer 29

Vascular- tend to fluctuate in size Malignancy- only increases

Question 30

What cause lymphangioma?

Answer 30

Proliferation of fluid filled spaces -> common in tongue -> most are cavernous and appear like cavernous haemagiomas

Question 31

What does vasculitis cause?

Answer 31

Alteration of blood flow to tissues

Question 32

What are the different types of vasculitic disease?

Answer 32

Large vessel Disease: Giant cell (temporal) arteritis Medium Vessel Disease: Polyarteritis nodosa Kawasaki disease Small vessel Disease: Granulomatosis with Polyangiitis

Question 33

What are the causes of pigmented lesions?

Answer 33

Exogenous- -> Stain from tea, coffee, chlorhexidine -> Bacterial overgrowth Intrinsic Pigmentation -> Reactive Melanosis/melanotic macule- freckles -> Melanocytic naevus -> Melanoma -> Effect of systemic disease, paraneoplastic phenomenon Intrinsic foreign body -> metals – amalgam, arsenic

Question 34

What is melanoma?

Answer 34

Malignant change within melanocyte -> can be pigment free -> may be on face, hands or neck rather than the mouth

Question 35

What are the causes of localised black/brown lesions?

Answer 35

Amalgam tattoos Melanotic Macule Melanotic naevus Malignant Melanoma Peutz-Jehger’s syndrome Pigmentary incontinence Kaposi’s sarcoma

Question 36

What are the causes of localised black/brown lesions?

Answer 36

Racial/familial Smoking Drugs- Contraceptive pill/tetracycline/newer biologics Addison’s disease -> Raised ACTH conditions

Question 37

What does ACTH do to cause generalised black/brown lesions?

Answer 37

More stimulation of melanocytes, more melanin and pigmentation of skin and mucosa

Question 38

What should be done if patient suspected to have raised ACTH as result of Addison's?

Answer 38

Check BP and electrolytes

Question 39

When should oral pigmentation be referred?

Answer 39

If increasing in size, colour or quantity If related to new systemic disorder

Question 40

What are the signs of Melanoma?

Answer 40

Variable pigmentation Irregular outline Raised surface Symptomatic- Itch/bleed

Question 41

What are the causes of mucosal inflammation

Answer 41

trauma- physical or chemical infection- viral, bacterial or fungal immunological

Question 42

What are biopsies used for?

Answer 42

Identifying/excluding malignancy Identifying dysplasia Identify other disease- lichen planus -> All unexplained white, red, pigmented patches

Question 43

What cases should be referred to oral med?

Answer 43

Patients with abnormal and/or unexplained changes to the oral mucosa -> Practitioner threshold will vary with experience  If there is concern about dysplasia risk: Appearance of lesion Risk site Risk behavior Family history

Question 44

What should not be referred to OM?

Answer 44

Asymptomatic VARIATIONS of NORMAL mucosa Benign conditions the practitioner has diagnosed that: Are asymptomatic Do not have potentially malignant risk For which there is no treatment

Question 45

What should you do if you are unsure whether to refer to OM?

Answer 45

Monitor area until next check up Send photos to OM and discuss with specialist