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RECOGNIZING WHITE LESIONS PART I: Reactive, Idiopathic, Hereditary

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Idiopathic (Hairy Tongue) Hereditary (Leukoedema) Auto-Immune (Lichen Planus) ... Hairy Tongue. Shaggy Matte of Filliform Papillae. Candidiasis Stimulates the ... – PowerPoint PPT presentation

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Title: RECOGNIZING WHITE LESIONS PART I: Reactive, Idiopathic, Hereditary


1
RECOGNIZING WHITE LESIONS PART I Reactive,
Idiopathic, Hereditary
  • David E. Wojtowicz, DDS, MBA

2
White Lesions
  • A Lesion Appears WHITE Because Some Material Is
    Obscuring the Normal PINK or Racial Color.
  • Is the WHITE Material Directly on the Surface?

3
3 Mechanismsto Achieve White Appearance
  • Epithelial Thickening
  • Rough / Does NOT Rub Off
  • Surface Material
  • Rough / Does Rub Off
  • Subepithelial Change
  • Smooth / Does NOT Rub Off

4
Six Common Etiologies for White Lesions
  • Reactive (Snuff)
  • Idiopathic (Hairy Tongue)
  • Hereditary (Leukoedema)
  • Auto-Immune (Lichen Planus)
  • Infectious (Candidiasis)
  • Neoplastic (SCC)

5
1. Six Reactive White Hyperkeratotic
Lesions(These are HYPERKERATOTIC. They Do NOT
Rub Off.)
  • a. Snuff Dippers Lesion
  • b. Nicotinic Stomatitis
  • c. Chemical Burn
  • d. Linea Alba
  • e. Actinic Cheilitis
  • f. Denture Acanthosis

6
1. Six Reactive White Hyperkeratotic Lesions(Do
They Rub Off?)a. Snuff Dippers Lesion
  • Wrinkled, Velvety
  • US Canada, Lower Carcinogenic Rate
  • Asia Higher Rate Due to Added Carcinogens
  • Treatment Quit Habit, Switch Site

7
1. Six Reactive White Lesionsb. Nicotinic
Stomatitis
  • Grey, White and Red on Hard Palate
  • Pipe and Tobacco Smoking (Heat)
  • Red Spots, Inflamed Minor Salivary Gland Orifices
  • Treatment Quit Smoking

8
1. Six Reactive White Hyperkeratotic Lesionsc.
Chemical Burn
  • Caused by Aspirin
  • Painful
  • Usually in Molar Region
  • Treatment Discontinue Aspirin Use

9
1. Six Reactive White Hyperkeratotic Lesionsd.
Linea Alba
  • Most Common White Lesion
  • White Line _at_ Occlusal Plane
  • Bilateral on the Buccal Mucosa
  • No Treatment Needed

10
1. Six Reactive White Hyperkeratotic Lesionse.
Actinic Cheilitis
  • Sun Damage
  • Lower Lip
  • Obliteration of Border
  • Treatment Avoid Sun, Use Sunblock

11
1. Six Reactive White Hyperkeratotic Lesionsf.
Denture Acanthosis
  • Caused by Irritants
  • Clinical Appearance is Similar to Hyperkeratosis
  • Thickened Intermediate Cell layer
  • Elongation of Rete Pegs
  • Treatment Avoid Irritants, ie. Ill-fitting
    Dentures

12
2. Two Idiopathic White Hyperkeratotic Lesions
  • Geographic Tongue
  • Hairy Tongue

13
Geographic Tongue(Benign Migratory Glossitis)
  • White Borders (/-Hyperkeratotic)
  • Red Patches of Denuded Filiform Papillae
  • Common Disorder (1 - 2), Females, Young Adults
  • Painfree or . . .
  • Painful if inflamation is present
  • Treatment None, or Topical Anesthetic

14
Hairy Tongue
  • Shaggy Matte of Filliform Papillae
  • Candidiasis Stimulates the Hyperplasia
  • Coffee, Tea, Tobacco Black
  • Treatment Brush Tongue, Improve Oral Hygiene

15
3. Two Hereditary White Hyperkeratotic Lesions
  • Leukoedema
  • White Sponge Nevus

16
Leukoedema
  • Milky Grey Film
  • Bilateral Buccal Mucosa, Non-progressive
  • Disappears When Stretched
  • More Common in Black Population
  • Treatment None Needed

17
White Sponge Nevus
  • Rough, Fissured Texture
  • Symetric, Bilateral Buccal Mucosa
  • Appears During Childhood, Non-progressive
  • Autosomal Dominant Transmission

18
RECOGNIZING WHITE LESIONS IIAuto-Immune,
Infectious, Neoplastic
  • David E. Wojtowicz, DDS, MBA

19
4. Two Auto-Immune White Hyperkeratotic Lesions
  • Lichen Planus
  • Lupus Erythematosus

20
Lichen Planus
  • Auto-immune Degeneration of Connective Tissue /
    Mucosa (Skin) Interface
  • Middle Age (Rare Before 30)
  • M F, Skin Lesions (33)

21
Lichen Planus
  • Reticular (Wickhams Striae)
  • Annular
  • Erosive
  • Atrophic, Bullous

22
Lichen Planus
  • Stress Thiazide Drugs are Possible Triggers
  • Differential Snuff (Stretch) White Sponge
    (Youth)
  • Treatment None if Asymptomatic . . .

23
Erosive Lichen Planus
  • Painful
  • Risk Factor for SCC
  • Treatment Biopsy, Steroids, Retinoic Acid

24
Lupus Erythematosus
  • Skin Lesions Butterfly Rash (Sun Exposed Area)
  • Mucosal Lesions Rough White Patch
  • Bordered by Striae, Ulcers, Erythema

25
Lupus Erythematosus
  • Systemic Arthritis, Vasculitis (Renal Failure)
  • Antinuclear Antibodies (ANA)
  • Differential Lichen Planus (Symmetrical
    Cutaneous), Leukoedema (Stretch) White Sponge
    (Youth)
  • Treatment Corticosteroids

26
5. Three Infectious White Lesions
  • Candidiasis (DOES Does NOT Scrape Off) - FIVE
    Clinical Lesions
  • Oral Hairy Leukoplakia (Does NOT Scrape Off)
  • Syphilitic Mucous Patch (Does NOT Scrape Off)

27
Candidiasis (Moniliasis)
  • Acute
  • Pseudomembraneous (Thrush) - White
  • DOES Scrape Off
  • Atrophic (Erythematous) - Red
  • (Does NOT Scrape Off)
  • Chronic
  • Hyperplastic (Candidal Leukoplakia) - White
  • (Does NOT Scrape Off)

28
Candidiasis
  • Commensal Organism - Normal Oral Flora
  • Capable of Opportunistic Infections (Hyphae)
  • Early Sign of Host Defense Breakdown
    (Neutropenia)
  • Risk Factors Antibiotics, Imunosupression,
    Diabetes, HIV, Steroids, Nutritional Deficiency,
    Radiation/Chemo

29
Candidiasis Acute Pseudomembraneous
  • White, Scrapes Off
  • Underlying Tissue Erythematous, Hemorrhagic,
    Pruritic
  • Newborns RF (See Previous Item)
  • Treatment a. Correct the Predisposing Factorb.
    Prescribe Nystatin Vaginal Tablets
  • Disp 70
  • Use One Tablet as a Lozenge 5 Times a Day

30
Candidiasis Chronic Hyperplastic-Candidal
Leukoplakia
  • Keratotic Plaques or Papules (?Scrape Off?)
    Against Erythematous Background With Acanthosis
  • Sites Labial Commissure, Labial Buccal
    Vestibule
  • Risk Factors Smoking, Poor Oral Hygiene
    (Dentures), Xerostomia - These Are Essentially
    All Chronic Irritants

31
Candidiasis Chronic Hyperplastic-Candidal
Leukoplakia
  • Cancer Risk Biopsy is Mandatory of All Speckled
    Erythroplakia or Erythroleuko-plakia Because of
    Increased SCC Risk
  • Treatment a. Correct the Predisposing Factorb.
    Biopsy Lesionc. Prescribe Nystatin Vaginal
    Tablets
  • Disp 70
  • Use One Tablet as a Lozenge 5 Times a Day

32
Candidiasis Three Red Chronic Oral Lesions
  • Angular Cheilitis Perleche (Red)
  • Median Rhomboid Glossitis (Red)
  • Denture Sore Mouth Atrophic Candidiasis (Red)

33
Oral Hairy Leukoplakia
  • Rough, Hyperkeratotic, Patch
  • Opportunistic E-B Virus
  • HIV Immunocompromised
  • Bilateral, Lateral Borders of the Tongue
  • Treatment None or Acylovir
  • Disp 60 Capsules
  • One Cap q.4h. for 5 to 10 days

34
Syphilitic Mucous Patch
  • Painless, White, Mucosal Ulcers With . . .
  • Nonpruritic Skin Rash, Lymphadenopathy
  • Signs of Secondary Syphilis (T. pallidum)

35
6. Four Neoplastic White Lesions
  • Squamous Cell Carcinoma
  • Verrucous Carcinoma
  • Epithelial Dysplasia
  • Carcinoma in Situ

36
Squamous Cell Carcinoma (SCC)
  • 90 of All Oral Malignancies SCC
  • Mixed Red White is Most Likely Presentation
  • Age Elderly (40) Gender Males (21)
  • Location Lower Lip, Floor of Mouth, Lateral
    Ventral Tongue, Soft Palate

37
Squamous Cell Carcinoma (SCC)
  • Uncontrolled Growth
  • Up Regulation of Oncogenes
  • Kinases Cyclines Become Overactive
  • Deactivation of Suppresser Genes
    (Antioncogenes)

38
Verrucous Carcinoma
  • Hyperkeratotic, Exophytic, Papillary
  • Age Elderly (60) Gender Males (21)
  • Location Gingiva, Alveolar Ridge, Buccal Mucosa

39
Epithelial Dysplasia
  • Premalignanat Changes of Cell Architecture
  • Mixed Red White is Most Likely Presentation
  • Cell Alterations Nuclear Changes
  • Architecture Alterations Bulbous Rete Pegs

40
Carcinoma in Situ (CIS)
  • Entire Thickness (Top to Bottom Change)
  • Basement Membrane Intact
  • No Invasion or Change of Connective Tissue

41
Geriatrics
  • Proliferative Verrucous Leukoplakia (PVL)
  • Hyperkeratotic Lesions Mixed Smooth and Warty
  • Mainly on Edentulous Alveoloar Ridge
  • Cancer Risk May Progress to SCC or VC

42
Risk Factors / Predisposing Factors
  • Demographic (Age,Gender,Race)
  • Social (Alcohol, Tobacco, Oral Habits)
  • Recent History (Trauma, Infection, Surgery)
    (Especially Chronic)
  • Medical History (Chronic Disease, Acute Illness,
    Medications,Treatments) (Especially Diabetes,
    Organ Cancer, Antibiotics, Chemo)

43
3 Mechanisms
  • Surface Material
  • Rough / Does Rub Off
  • Epithelial Thickening
  • Rough / Does NOT Rub Off
  • Subepithelial Change
  • Smooth / Does NOT Rub Off
  • Two Examples
  • Fordyce Granules Ectopic Sebaceous Glands
  • Scar Surgical, Traumatic

44
Clues to Normal
  • Bilateral Symmetry
  • Predictable Locations
  • Asymptomatic
  • Independent Finding (no Secondary Features such
    as redness, swelling)
  • Increase with Age
  • Remains Unchanged w/ Treatment

45
Glossary of Terms
  • Acanthosis excessively thickened intermediate
    cell layer with broad and long rete pegs
  • Hyperkeratosis excessively thickened keratin in
    stratum corneum
  • Leukoplakia a white patch on the oral mucosa
    that cannot be scraped off and cannot be
    classified as any other disease

46
Review Which of the Following Choices
Demonstrate Concepts of Differential Diagnosis
  • List of Diseases With Similar Manifestations
    (Yes)
  • Oral Ulcer (No, monomorphic presentation)
  • Zinc Deficiency, Trauma, Herpes, Aphthous Lesion
    as Potential Etiologies for a Single Monomorphic
    Presentation. (Yes)
  • Rely Primarily on the Clinical Appearance (No,
    must include history, risk factors, visual
    inspection)

47
List the Seven Primary Clinical Manifestations of
Non-dental Lesions
  • Normal Variation
  • White
  • Red (Pigmented or Dark)
  • Ulceration
  • Exophytic
  • Radiographic
  • Syndrome

48
List Four Techniques Employed to Investigate the
Secondary Clinical Features of Oral Lesions
  • Visual Inspection
  • Palpation
  • Probing
  • Patient Awareness

49
Name at Least Four Visual Features to Inspect for
When Examining an Oral Lesion
  • Location
  • Shape Contours
  • Size
  • Solitary/Multiple
  • Borders
  • Homogenous/Heterogeneous
  • Surface Color/Texture
  • Displacement (of Teeth?)

50
During Palpation One Can Check For
  • Compressible
  • Tender
  • Color Change (Blanching)
  • Mobile / Bound Down
  • Induration
  • Probing, Exudate

51
During the Interview, Inquire if Patient is Aware
of
  • Pain or Altered Function
  • Duration (Acute, Chronic)
  • Progressive Course or Remission
  • Response to Stress/ Foods

52
List Four Risk or Contributory Factors
  • Demographic (Age,Gender,Race)
  • Social (Alcohol, Tobacco, Oral Habits)
  • Recent History (Trauma, Infection, Surgery)
  • Medical History (Chronic Disease, Acute Illness,
    Medications,Treatments)

53
Differential Diagnosis
  • List of Diseases With Similar Manifestations
  • Rule Out (R/O) on the Basis of Contradictions
  • Example Oral Ulcer
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