White patches, red patches and pigmented lesions Flashcards by Steven Anjorin

Reasons why oral lesions may appear white?

epithelium has thickened
organic material
- Candida
- food debris
physiological
- tongue coating
- desquamation
- leukoedema

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White patches - potential causes (CLINK)

congenital
lichen planus
infections
neoplastic/potentially neoplastic
keratosis

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Give examples of neoplastic and potentially malignant white patches

squamous cell carcinoma
leukoplakia
sub mucous fibrosis
actinic chelitis

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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

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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

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Leukoplakia - define

a white patch or plaque that cannot be characterised clinically or pathologically
- can’t be rubbed away

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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

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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

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Histological risk factors for malignant transformation

strong association
severe dysplasia
high risk dysplasia

medium association
HPV-16 +
many genes involved

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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

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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

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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

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oral sub mucous fibrosis malignant transformation rate

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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

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Leukoedema features

not a mucosal disease
normal physiology
faint white lines, typically on buccal mucosa
more common in people of African heritage

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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