Red and White Lesions of the Oral Mucosa l Oral medicine MCQs for dental students

Red and White Lesions of the Oral Mucosa l Oral medicine MCQs (multiple choice question) for dental students 

 

Hereditary white lesions

Leukoedema

• Normal variation , more in black
• Hyperplastic epithelium with parakeratinzation
• Symmetrical on both cheeks and asymptomatic
• Diffuse white/grey opacification on the buccal mucosa – disappears when you stretch the cheek
• Treatment: no treatment – this is a normal variation

 

white spongy neavus

• Mutations in genes producing keratin type 4 and/or 13
• Hyper plastic epithelium with parakeratinization
• Symmetrical and asymptomatic
• Thickened irregular white patch [ affects any mucosal tissue – buccal, GIT, genital mucosa]
• Tratment : no treatment

 

Reactive white lesions

• traumatic induced white lesions trauma will cause hyper keratosis – cause and effect relationship is seen
• hyperkeratosis is reversible if the cause is removed Traumatic induced white lesions have an irregular border, because the patient bites down in different directions and the forces will be applied differently → irregular border
• Habitual cheek biting [ specially if combined with loss of space b/w the teeth] → regular borders [ because the patient will always bit in the same way

Tobacco induced white lesions

                        A. Smoking:

• Nicotine stomatitis - heat and toxins from smoking will cause the palate to become white with diffused red spots [ red spots are the inflmmaed minor salivary glands]
• Low malignancy potential because it is wide spread , but indicates heaviness of smoking
• Treatment : no specific treatment , just pt education regarding smoking and regular follow ups

       Q: why do you see red spots on the palate in nicotine stomatits ?

• the red spotsare the openings of the minor salivary glands and they appear red because the the palate becomes more whitish because of the keratosis → better contrast that’s why you notice them + they are red because they are inflammed

                         

                        B. Smokeless tobacco [ neswar, snuff , pan etc.]

• A wrinkled white patch in the buccal mucosa- where the tobacco is kept
• Usually you will see gingival recession, teeth attrition, and staining close to the lesion
• Has malignanat potential to become squamous cell carcinoma or verrucous carcinoma

          Q:why do smokelss tobacco lesions has differnet variable apperances?

• Because their contents and the percentage of tobacco are not the same , some people will buy them ready made and others will make them themselves and add nuts, spices etc.

 

Infectious white lesions

Fungal white lesions :

• difficult to diagnose but treated easily
• Most common oral fungal infection : candidosis caused by candida albicans
• Usually when you take a swab from the lesions, you collect only the spores. [ the hyphae remain in the tissue]
• Candida is identified under microscope using PAS [ per iodic acid Schiff stain or KOH stain ]
• Candida is a part of the normal flora but becomes pathogenic under local and systemic factors:

 

Local factors

1. Xerostomia
2. Reduced OVD
3. Poor oral hygiene

Systemic factors

1. Extremities of age [ very old or very young patients]
2. Blood dyscrasis [ leukemia , lymphoma etc. ]
3. Broad spectrum ABX **
4. Immune suppression **

TYPES OF CANDIDAL INFECTIONS:

ACUTE:

• Acute atrophic candidiasis : red inflamed mucosa – associated with dentures and ABX use

                    Treatment: correct diagnosis + denture and oral Hygiene + antifungal agents

• Acute pseudomembranous candidiasis [ oral thrush]: white/ yellow plaques that can be easily

                                   wiped off , once wiped off you will see areas of erosion.

• Treatment:

1. simple cases [ associated with ABX use ] → OH + topical antifungals
2. Complicated cases [ immunocompromised pt ] → medical consult + topical/ systemic antifungals

 

CHRONIC:

•  Chronic atrophic candidiasis: Includes the following:

1.      median rhomboid glossitis [ affects both tongue and palate]
2.      papillary hyperplasia of the palate
3.      angular cheilitis [ due to decrease in OVD → the corners of the mouth will be folded and kept warm and moist hidden away from cleaning → angular chelitis]
4.      non-specific red areas in mouth
5.      chronic denture stomatitis
6. Treatment : determine predisposing factors → antifungal agents

 

• chronic hyperplastic candidiasis: [ the one that really appears as white also called candida leukoplakia ]

1. mostly tongue and buccal mucosa
2. don’t always have easily determined predisposing factors
3. Correct diagnosis important because lesion has malignant potential and can resemble other pathology including lichen planus and early squamous cell carcinoma [Requires biopsy ( to R/o dysplasia and carcinoma) because cytology smear not always reliable]
4. Treatment : treat predisposing factors + anti fungal agents

Viral white lesions

Epstein – Barr virus :

•       type of herpes viruses

Oral hairy leukoplakia:

• White lesion on the lateral border of the tongue with irregular surface and prominent ridges or folds , extends onto the ventral surface of the tongue
• Associated with HIV infections because it is:   

1.       A marker for HIV progression
2.    Marker for viral load
3.    Indication of the effectiveness of the HIV medication

• Characteristic microscopical feature of OHL = koliocytes in the prickle cell layer [cells that have inclusion bodies where viral proteins are being assembled]

 

Immune mediated white lesions

 

1- Oral Lichen Planus :

• Mucocutaneous [ appears on mucosa and skin]
• Oral common sites = [ buccal mucosa, dorsum of the tongue , gingiva]
• Lesions include: [ normally appear together]

1.      Striae [most common] – sharply defined with lacy , starry or anular patterns
2.    Atrophic areas
3.    Erosions
4.    Plaques

• If Oral Lichen Planus appears on the tongue you will not see striations , it will mostly be plaque
• CAUTION: the appearance of OLP on the tongue occurs on the lateral borders of the tongue [ opposite to median rhomboid glossitis which appears on the central region]
• Oral lichen planus also has skin lesions that appear mostly on the flexor surfaces of the wrists [ but can also occur on knees, elbows, ankles ]
• Characterized by 4 P:

1.     Purple
2.     Pruritic
3.     Polygonal
4.     Papules

• Mostly have superficial fine white striations called Wickman’s striae

 

MS appearance of Oral Lichen Planus :

• Saw tooth appearance of rete pegs
• Band like lymphocytic infiltrate adjacent to the basement membrane
• Liquefactive necrosis [ basal cells degeneration]
• Immune fluorescence = fibrinogen deposits on the basement membrane
• Civette bodies [ formed by apoptosis] – normally seen in normal tissue but seen in large numbers in cases of Oral Lichen Planus

Important point of Oral Lichen Planus:

1.     Symptomatic [ pain + burning mouth]
2.     Resembles more serious conditions like cancer
3.     Might have malignant potential
4.     Might have a relation with Hepatitis C

 

Q: what should you examine in patients when you suspect OLP?

•       Ask about any medications the patients is taking [ the lichenoid reaction might be due to the medication]
•       Look for any metallic restorations close to the lesion [ the metal might be causing an allergic reaction]

 

Other lesions with lichenoid appearance :

•             Lichenoid contact lesions : allergic contact stomatitis - mostly due to metallic restorations
•             Lichenoid drug reactions : [ NSAIDs, tetracyclines, thiazides etc ]

 

Treatment of Oral Lichen Planus :

• [ most important is keep the atrophic lesions clean, dehydration and candidial or bacterial infection will make the condition worse]

1.      Control of symptoms [ proper OH + Chlorhexidine + hydration]
2.      Corticosteroids to modulate inflammation and immune response
3.      Antifungal therapy to treat secondary candidal infection

• sometimes the pain goes away with proper OH and hydration only and you don’t need to give corticosteroids [ corticosteroids are not given right away , you need to make sure that the patient is complaint to be able to have frequent visits to monitor for adverse effects]

• Topical corticosteroid should only be given for a short duration to prevent candida infections 

2- lupus erythematous :

• looks like OLP but not only mucocutaneous , but might involve multiple systems in the body
• mostly in females
• has 2 types :

1.                          systemic : involves multiple systems
2.                          discoid: only muco cutaneous [ but can become  systemic later on]

 

DISCOID  lupus erythematous:

• skin lesions on sun exposed areas – hair follicle involvement [ perm hair loss] – arthralgia
• oral lesions similar to OLP but with less striations and less pain
• Treatment: topical corticosteroids

 

SYSTEMIC  lupus erythematous:

• caused by immune reaction to the antigen antibody complexes
• Rynaud’s phenomena , butterfly skin rash [ rash over the zygomatic process and the bridge of the nose]
• Oral lesions are similar to discoid but involve the palate more
• Treatment: systemic corticosteroids / immunosuppressive agents and organ specific treatment.