white patches and red patches and pigmented lesions

Question 1

why do lesions appear white

Answer 1

• thickened epithelium
  -organic - candida, food
  physiological - tongue coating, leukodema , desquamation

Question 2

what is CLINK

Answer 2

• congenital
• lichen planus
• infections
• neoplastic/potentially neoplastic
• keratosis

Question 3

what is this

Answer 3

leukoedema

Question 4

what is leukoedema

Answer 4

• not a mucosal disease
• normal physiology
• gaint white lines , typically on buccal mucosa
• fade or disappear on starching mucosa
• more common in people of african heritage

Question 5

what is white sponge navus

Answer 5

-inherited autosomal dominant
-mutation of genes that code for keratin 4 and 13
-most common buccal mucosa
- children/teen
-poorly defined border
-benign

Question 6

what is this

Answer 6

white sponge navus

Question 7

histology of white sponge navus

Answer 7

• acanthotic - thickening of epithelium, especially stratum spinosum
• hyperkeratosis
• intra-cellular oedema in stratum spinosum and parakeratinised layers
• no inflammatory changes

Question 8

what is darier disease

Answer 8

congenital
autosomal dominant
hyperkeratosis papule affecting sebhorric areas on head/neck
asymptomatic

Question 9

what is focal palmoplanter and oral mucosa hyperkeratosis syndrome

Answer 9

• autosomal dominant
• soles, palms and oral mucosa - keratinised tissue

Question 10

some infectious causes of white patches

Answer 10

• pseudomembranous candidiasis
  -chronic hyperplastic candidiasis

Question 11

what is hairy leukoplakia

Answer 11

• white patch
• lateral aspect of tongue
  -often bilateral
  -often result of EBV infection and presents in immunocompromised

Question 12

some examples of neoplastic and potentially malignant white patches

Answer 12

• SCC
  -leukoplakia
  -submucous fibrosis
• actinic cheilitis

Question 13

SCC red flags

Answer 13

• > 3-week duration
• > 50 years old
• Smoking
• High alcohol consumption
• History of oral cancer
• Non-homogenous
• Non-healing ulceration
• Induration
• Exophytic
• Tethering of tissue
• Tooth mobility
• Non-healing extraction sockets
• Difficulty speaking/swallowing
• Cervical Lymphadenopathy
• Weight loss/appetite loss/fatigue
• Numbness/altered sensation

Question 14

management of SCC

Answer 14

• urgent suspected cancer referral to Max fax
• local guidelines
  -honesty with patient and explain concern
• biopsy

Question 15

what is leukoplakia

Answer 15

• a white patch or plaque that cannot be characterised clinically or pathologically
• diagnosis of exclusion
• cant be rubbed away

Question 16

how may homogenous leukoplakia present

Answer 16

uniformly white, flat and thin, smooth surface, may exhibit shallow plaque

Question 17

how may verrucous leukoplakia present

Answer 17

• surface raised, exophytic, wrinked or corrugated
• warty surface with white yellow appearance
• palate and gingive common sites
• enlarges over time
• often very extensive and impractical to remove
• up to 85% undergo malignant transformation

Question 18

how many leukoplakia turn malignant

Answer 18

• 2-5% in 10 years

Question 19

risk factors for malignant leukoplakia transformation

Answer 19

• larger
  -non homogenous
  -red
  -tongue and FOM
• severe dysplasia
  >50 years old

Question 20

disorders that should be excluded for leukoplakia diagnosis

Answer 20

• leukoedema
• white sponge nevus
• frictional keratosis
• chemical injurt
• acute pseudomembranous candidosis
• hairy leukoplakia
• lichen planus (plaque like varient)
• lichenoid reaction (local factors and medications)
• discoid lupus erythematosus

Question 21

management of leukoplakia

Answer 21

• if confirmed leukoplakia
• if dysplasia present - remove
  -if no dysplasia - remove if feasible

Question 22

what is oral sub mucous fibrosis

Answer 22

• paan use
  -pale and firm to palate
  -fibrous bands
  -soft palate common
• prevention is best

Question 23

management of OPMD

Answer 23

• little can be done minus modifying risk factors like smoking cessation
• take clinical photos for observation
• if dysplasia then consider excision

Question 24

what is keratoses and types

Answer 24

• responce to trauma
• frictional - sharp teeth/restorations/dentures/occlusions
• thermal - smoking/hot food /drink
• chemical - aspirin/acid/bleach/chlorhexidine

Question 25

why do lesions look red

Answer 25

- inflammation - mucosal atrophy - increased vascularisation - mucosal/submucosal bleeding

Question 26

differential diagnosis for red patches

Answer 26

- viral -candidal -iatrogenic -lichen plants -blistering diseases -allergies -trauma -erythroplakia - leukemia

Question 27

what is erythroplakia

Answer 27

- atrophic lesion -fiery red patch that cannot be characterised clinically or pathologically as any other definable lesion

Question 28

how may erythroplakia present

Answer 28

- localised -well defined borders -red texture -can be speckled -soft palate and buccal mucosa and FOM -associated with tobacco use

Question 29

what Is erythro-leukoplakia

Answer 29

- red and white patches -heterogenous appearance -highly suspicious for SCC or severe dysplasia

Question 30

how do pigmented lesions occur

Answer 30

extrinsic - amalgam -chlorhexidine -tobacco -heavy metal intrinsic -melanin

Question 31

melanins role in pigmentation

Answer 31

- produced by melanocytes - important for photo protection

Question 32

what is peutz jeghers syndrome

Answer 32

- developmental hypermelanosis -autosomal dominant -STK11 - tumour suppressor gene mutation - freckles on mouths and eyes -and GI polyps these GI polyps have to be managed

Question 33

inflammation and melanin

Answer 33

- inflammation stimulates melanocyte activity - can often see increased melanin in areas of other inflammatory disease like lichen plants

Question 34

pigmentation in Addisons disease

Answer 34

- oral pigmentation an early presentation - adrenal glands no longer produce enough steroid - adrenal insufficiency leads to increased adrenocorticotrophic hormone (ACTH) by the pituitary gland - ACTH causes pigmentation seen by stimulating melanocytes - patchy hyperpigmentation can be seen

Question 35

medications which are associated with pigmentation

Answer 35

- antimalarials -zidovuidine -busulphan -gold -minocycline -heavy metals

Question 36

what is melantonic macule

Answer 36

- single brown lesion -compromised of a collection of melanin-containing cells

Question 37

how may melantonic macule present

Answer 37

- flat - non raised - typically <1cm - no rapid change - painless - common on vermillion border

Question 38

what is melanocytic naevi

Answer 38

- blue/black lesions -focal proliferation of melanocytes

Question 39

how do melanocytic naevi appear

Answer 39

- some are congenital - typically appear during childhood - <1cm - papular appearance - no rapid change - clinically resemble melanoma

Question 40

what is melanoma

Answer 40

- rare - may arise from pigmented naevus - palate or maxillary gingivae most common

Question 41

suspect melanoma

Answer 41

Question 42

what is kaposi sarcoma

Answer 42

- vascular neoplasm - human herpes virus 8 (HHV8) associated - disorganised epithelial cell growth - results in clefts containing erythrocytes - mainly presents in immunocomprimised - people with AIDS

Question 43

management of kaposi sarcoma

Answer 43

- surgery - radiotherapy - chemotherapy - immunotherapy - manage underlying immunodeficiency - HAART