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white lesions part 2 (PMD) Flashcards

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1
Q

3 types of potentially malignant disorders

A

1) leukoplakia
2) oral lichen planus
3) lichenoid reactions

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2
Q

characteristics of leukoplakia
- what it looks like
- female/male
- cause
- predisposing factors

A
  • is a white plaque that cannot be characterised clinically/ pathologically as another disease
  • male predomincance, >40 yo, increase with age
  • is uncommon, but the most common premalignant lesion
  • unknown cause
  • predisposing factors are the 6S:
    sunlight, sex, syphilis, smoking, spirits (alcohol), spices (betel nut)
    same factors as SCC and erythroplakia
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3
Q

6 types of clinical presentation of leukoplakia

A

1) early/ mild/ thin
2) nodular/ granular
3) homogenous/ thick
4) speckled/ erythroleukoplakia
5) verruciform
6) proliferative verrucous

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4
Q

what does early/ mild leukoplakia look like

A
  • grey/ white plaque
  • flat to slightly elevated
  • soft with sharply demarcated borders
  • may be translucent, fissured, wrinkled
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5
Q

clinical presentation of nodular/ granular leukoplakia

A

increase surface irregularities

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6
Q

clinical presentation of homogenous/ thick leukoplakia

A
  • distinctly white plaque
  • thickened/ leathery
  • deepened fissures
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7
Q

clinical presentation of speckled/ erythroleukoplakia

A
  • white plaque with scattered patches of redness
  • epithelial cells so immature and atrophic that they cant produce keratin
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8
Q

clinical presentation of verruciform

A

sharp/ blunt wart-like projections

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9
Q

clinical presentation of proliferative verrucous

A
  • multiple, slowly spreading, keratotic plaques
  • rough surface projections
  • exhibit persistent growth, eventually become exophytic and verrucous (wart-like)
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10
Q

location of leukoplakia

A
  • lip vermillion, buccal mucosa and gingiva ( more common)
  • lip vermillion, tongue, floor of mouth (accounts for >90% of those that show dysplasia/ carcinoma)
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11
Q

how to diagnose leukoplakia

A

clinical + histo (must take biopsy) + elimination of other lesions that appear as white plaque

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12
Q

histopatho findings of leukoplakia
- hyperkeratosis and ____
- variable number of ____ cells in subjacent _____
- keratin layer will have ____
- no/ got dysplasia?

A
  • may have acanthosis
  • chronic inflammatory cells, in aubjacent CT
  • hyperorthokeratosis/ hyperparakeratosis or both
  • may have dysplasia
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13
Q

management of leukoplakia that exhibit moderate dysplasia or worse

A
  • complete removal
  • recurrence rate 10-35%
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14
Q

mx of leukoplakia with no/minimal dysplasia

A
  • mx should be guided by lesion size and response to tobacco cessation
  • may diminish in size after smoking cessation
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15
Q

ddx of leukoplakia

A

white lesions:
- leukoedema
- BARK, frictional keratosis (linea alba, morsicato buccarum)
- nicotinic stomatitis, smokeless tobacco lesions
- OLP, lichenoid reactions
- pseudomembranous candidiasis
- OHL

not white lesions:
- syphilis (secondary mucous patches)
- squamous papilloma, condyloma acuminatum

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16
Q

what layers of epithelium are affected and what histo is observed in MILD epithelial dysplasia in leukoplakia

A
  • basal and parabasal layers
  • nuclear hypochromatism and slight pleomorphism
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17
Q

what layers of epithelium are affected and what histo is observed in MODERATE epithelial dysplasia in leukoplakia

A
  • basal layer to mid portion of spinous layer
  • nuclear hypochromatism and pleomorphism
  • cellular crowding
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18
Q

what layers of epithelium are affected and what histo is observed in SEVERE epithelial dysplasia in leukoplakia

A
  • basal layer to a level above midpoint of epithelium
  • marked nuclear hyPER chromatism and pleomorphism
  • scattered mitotic figures
  • atypical cells involve most of epithelial thickness
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19
Q

what layers of epithelium are affected and what histo is observed in carcinoma in situ epithelial dysplasia in leukoplakia

A

whole thickness of epithelium

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20
Q

what is the cause of oral lichen planus

A

chronic t cell mediated disorder of stratified squamous epithelium (SSE), unknown cause

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21
Q

which demographic is more affected by OLP

A

middle aged adults, females

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22
Q

predisposing factors for OLP

A

drugs, restorative materials, microbes (hep C), systemic disorders, stress

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23
Q

pathogenesis of OLP

A
  • antigen specific cd8+ cytotoxic t cells trigger keratinocyte apoptosis, destroy the basal keratinocytes above basement membrane
  • mast cell granulation and MMP activation -> prolongs antiinflam reaction
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24
Q

7 forms of OLP

A

PAPERBD

papular: raised
atrophic: red, thin
plaque: white, flat
erosive: break in epithelium
reticular: striated
bullous: bubble appearance (less common)
desquamative gingivitis: red, painful, involve free gingi margin to mucogingival fold

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25
histopatho findings for OLP - varying degree of ___ and ___ on surface epithelium - thickness of ___ layer varies - ___, ____ rete ridges - degeneration of ___ cell layer of epithelium - degenerating ___ (Civatte bodies) between epithelium and ___ - intense, band like infiltrate of predominantly ____ in lamina propria - got/ no dysplasia?
- varying degree of orthokeratosis and parakeratosis - thickness of spinous layer - pointed, saw toothed rete ridges - degen of basal cell layer - degenerating keratinocytes, between epithelium and CT - infiltrate of predominantly t lymphocytes - no dysplasia
26
forms and characteristics of erosive LP
AEBD forms: - atrophic - erythematous - bullous (only if erosive component is severe and there is epithelial separation from the underlying CT) - desquamative gingivitis (if the atrophy and ulceration is confined to gingiva mucosa) characteristics: - got central ulceration of varying degrees - periphery bordered by fine, white radiating striae
27
2 types of OLP
1) erosive LP (AEBD forms) 2) reticular LP (PPR forms)
28
forms and characteristics of reticular LP
PPR: papules, keratotic plaques on tongue, reticular (striated) characteristics: - lace like network, striated pattern of slightly raised grey white lines (wickham striae) - usually asymptomatic
29
symptoms of erosive LP
- erythematous and desquamative gingiva - ulceration - bleeding and irritation with tooth brushing - oral pain and soreness, worse with acidic and spicy food - sensitivity to hot, acidic, spicy food - altered/ blunted taste sensation (if the tongue is affected)
30
location of OLP
- bilateral, mostly symmetrical - posterior buccal mucosa > dorsal and lateral border of tongue > gingiva and alveolar ridge > lower lip - floor of mouth, palate, upper lip (uncommon) - skin, genital mucosa, scalp, nails (uncommon)
31
what are the 3 key histo points impt for the dx of OLP
- degeneration of basal cell layer of epithelium - intense, band like infiltrate of predom t lymphocytes in lamina propria - no dysplaisa
32
comparing leukoplakia and OLP
leukoplakia: single, well demarcated and non striated OLP: bilateral, diffuse, striated
33
ddx of OLP
lichenoid reactions (have identical clinical and histo findings)
34
3 types of therapy that can be done under management of OLP
1) Symptomatic therapy 2) adjunctive therapy 3) maintenance therapy
35
symptomatic therapy for OLP
- control inflammation, decrease pain with minimal side effects - change erosive OLP to non erosive - 1st line: topical corticosteroids - 2nd line: systemic corticosteroids for severe/ recalcitrant lesions resistant to topical. OR topical calcineurin inhibitors to block activation and prolif of t lymphocytes
36
example of topical calcineurin inhibitor
tacrolimus
37
adjunctive therapy for OLP
- control candida using topical anti fungals eg nystatin, miconazole - maintain good OH - manage salivary gland hypofunction if present
38
maintenance therapy for OLP
- low potency topical corticosteroids - long term follow up
39
ddx for OLP
lichenoid reactions
40
what are lichenoid reactions
antigen fixation in epithelial cells causing these cells to be destroyed by immune system these lesions resemble OLP clinically and histologically but have identifiable aetiology
41
4 types of lichenoid reactions that we learn
1) oral lichenoid drug reaction/ eruption 2) oral lichenoid contact lesions 3) oral lichenoid lesions of GVHD 4) systemic lupus erythematous
42
what are some drugs causing OLDR (oral lichenoid drug rxn)
methyldopa, anti malarias, NSAIDs, diuretics, ACE inhibitors, B blockers
43
what is the clinical presentation of OLDR
- unilateral lesions of reticular striae - erosive lesions - e/o lesions
44
location of OLDR in mouth
- palate - labial mucosa - floor of mouth
45
how do we dx OLDR
- need to establish when the lesion onset and when the offending drug was used - see whether there is resolution of symptoms upon withdrawal of the agent
46
what are the histopatho findings of OLDR
- variable, non diagnostic - lymphocytic infiltrate is mixed, more diffuse. this extends deeper into lamina propria, got perivascular distribution
47
mx for OLDR?
1) substitute drug after consulting physician 2) decrease dose of offending drug 3) topical corticosteroids (+/- anti fungals) do these in order
48
ddx of OLDR and oral lichenoid contact lesions
OLDR: erosive OLP OLCL: reticular OLP
49
where are oral lichenoid contact lesions found?
adjacent to dental materials possible materials are Ni, composite, gic usually buccal mucosa, ventral and lateral borders of tongue
50
clinical presentation of oral lichenoid contact lesions
- white or erythematous - peripheral striae
51
histopatho findings of oral lichenoid contact lesions and oral lichenoid lesions of GVHD
- similar to OLP aka varying degree of ortho and parakeratosis on surface epithelium. pointed saw toothed rete ridges, degen of basal cell layer of epithelium, infiltrate of predom t lymphocytes in lamina propria - lymphocytic infiltrated mixed
52
how do oral lichenoid lesions of GVHD come about
- hx of bone marrow transplant - immunocompetent t cells from donor (graft) attack tissue in immunocompromised host (recipient) - increased risk of developing solid tumours (eg SCC)
53
clinical presentation of oral lichenoid lesions of GVHD
- fine, reticular network of white striae - may have atrophy of mucosa - burning sensation of oral mucosa
54
where will oral lichenoid lesions of GVHD be located in mouth
- buccal and labial mucosa - tongue
55
mx of oral lichenoid lesions of GVHD
- systemic therapy since it is a multi organ disease 1) give high dose systemic corticosteroids 2) supplement w cyclosporin, tacrolimus - topical corticosteroids (+/- anti fungals) - long term follow up
56
ddx of oral lichenoid lesions of GVHD
reticular OLP
57
which are the lichenoid reactions that have ddx of reticular OLP and which have ddx of erosive OLP
reticular OLP: 1) oral lichenoid contact lesions 2) oral lichenoid lesions of GVHD erosive OLP: 1) OLDR 2) SLE
58
clinical presentation of SLE
- central atrophic area with radiating white striae - erythematous lesions on palate - slit like gingival ulcerations
59
location of SLE in oral cavity
- palate (most common, 80%) - buccal mucosa, lips, gingiva vs OLP on palate is uncomon
60
how to dx SLE
must be by histo
61
histopatho findings of SLE
similar to OLP may have deep perivascular distribution

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