c. white lesions - dental.pacific.edudental.pacific.edu/documents/departments/alumni/eversole/c....
TRANSCRIPT
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WHITE LESIONS OF THE UPPER AIRWAY
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WHITE LESION CONFIGURATIONS
• Solitary vrs Multifocal• Flat Plaque• Verrucous/rippled• Lacey• White with red component• Papular (curdled milk plaques)• Pseudomembranous
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PLAQUES• FRICTIONAL KERATOSES
– DENTURE, CHRONIC BITING• LEUKOPLAKIA
– IDIOPATHIC– SMOKELESS TOBACCO– SANGUINARIA– ACTINIC CHEILITIS
• WARTY DYSKERATOMA & GROVER’S DISEASE
• LICHEN PLANUS (HYPERPLASTIC)• DYSKERATOSIS CONGENTIA
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Frictional Keratosis• Cause/Effect• Edentulous ridge crest, especially
retromolar pad• Ill Fitting prostheses• Broken cusps and restorations• Habitual tongue and Cheek biting• Risk for cancer is low, perhaps
nonexistant• If smoking is a factor, biopsy should be
undertaken
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Cheek Bite Keratosis (Morsicasio Bucarum)
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Frictional Keratosis
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Leukoplakia
An upper aerodigestive tract white lesion that:
cannot be rubbed awaydoes not have a cause (tobacco excluded)does not represent another clincially and microscopically defined disease
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Leukoplakia• 20% precancerous change histologically• Floor of the Mouth – 40% dysplastic• 6% of all leukoplakias will progress to
carcinoma within 5-7 years• Biopsy: no dysplasia > periodic follow up or
excision (laser ablation)• Postive for dysplasia > excision with
assessment of margins • Ploidy assessment: aneuploid leukoplakias
carry highest risk for progression to carcinoma
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LEUKOPLAKIA
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LEUKOPLAKIA
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LEUKOPLAKIA
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FOCAL LEUKOPLAKIA
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Smokeless Tobacco Keratosis
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SANGUINARIA LEUKOPLAKIA
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Actinic Cheilitis• Solar irradiation to lower lip• Diffuse leukoplakia across vermilion• Light complected most prone• Prolonged outdoor jobs or recreation• Microscopically ranges from benign
keratosis to dysplasia to carcinoma. Connective tissues show elastic degeneration.
• Tx: lip stripping or 5-fluorouracil cream
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Actinic Keratosis of the Lip
Proposed Excision areas inked
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VOCAL CORD LEUKOPLAKIA
DYSPLASIA
SQUAMOUS CELL CA
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Proliferative Verrucous Leukoplakia• A specific subtype of leukoplakia characterized
by verrucous white lesions that tend to spread laterally and recur following excision
• Elderly females• Gingiva and vestibule• Smoking habit seen in less than 50%• Microscopically, the lesions range from
verrucous keratosis to atypical verrucous hyperplasia that may progress to either verrucous carcinoma or invasive squamous cancer
• Tx: aggressive excision by scalpel or laser with close periodic followup and re-excision when recurrences develope
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PVL
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Leukoplakia Histology• Benign Keratosis
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Leukoplakia Histology
• Dysplasia
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Leukoplakia Histology• Squamous Cell Carcinoma, invasive islands of tumor
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WARTY DYSKERATOMA• Rare white lesion, often with an irregular, pebbly
surface• A benign keratosis with specific histologic
features:– Keratosis– Individual cell keratinization– Villous rete pegs– Suprabasilar acantholysis (desmosome defect)
• Multiple lesions are termed Grover’s disease (focal acantholytic dyskeratosis)
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WARTY DYSKERATOMA
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Lichen Planus
• Reticular, Erosive, Hyperplastic• The Hyperplastic or Hypertrophic form
resembles leukopakia clinically• Tongue and Buccal Mucosa• There may be marginal or adjacent stria• Histology: marked hyperkeratosis,
lichenoid mucositis
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LICHEN PLANUS, Reticular
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Lichen Planus Histology• Keratosis, basal cell damage, thickening of the
basement membrane, T lymphocyte infiltrate (chronic interface mucositis)
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LICHEN PLANUS, HYPERPLASTIC
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EROSIVE LICHEN PLANUS
desquamation
Anti-fibrinogen
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Lichen Planus
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IS LICHEN PLANUS PRECANCEROUS?
• Lichen planus occurs in .5% of the population (1/200) and is therefore common. So CA could be coincidental
• 1-2% of patients with LP end up with an oral cancer (1/2000)
• Conclusion: LP is a risk factor for oral cancer in a subpopulation of patients
• Tumors reported to arise in an LP lesion as well as on nonlesional mucosa among LP patients
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LICHEN PLANUS, CARCINOMA
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DIFFUSE BILATERAL BUCCAL MUCOSAL WHITE LESIONS
• LEUKOEDEMA
• WHITE SPONGE NEVUS
• RARE GENOKERATOSES
• CHEEK BITE KERATOSIS
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Leukoedema
• Normal variation• Diffuse sheetlike silky white sheen of
buccal mucosa• Dark skin populations• Whiteness disappears or minimizes when
the tissue is stretched• It is not precancerous
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Leukoedema
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WHITE SPONGE NEVUS
• Thick curtain like folded white lesions, entire buccal mucosa bilaterally
• Similar lesions involve the genitourinary tract
• Hereditary: Autosomal dominant • Parakeratosis with parakeratin chevrons
and individual cell keratinization• Tx: none
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White Sponge Nevus
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WSN Histology• Parakeratosis, individual cell keratinization
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Pachonychia Congenita• Patchy diffuse white lesions of buccal
mucosa bilaterally• Lesions may occur on other mucosal
areas• Massive thickening of toenails and
fingernails• Hereditary: Autosomal Dominant defect in
keratinization• Hyperparakeratosis, acanthosis• Tx: none
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Pachonychia Congenita
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Hereditary Benign Intraepithelial Dyskeratosis (HBID, Red Eye)
• Hereditary defect in keratinization• Racial isolate group in North Carolina• Bilateral patchy lesions of buccal mucosa• Scleral erythema• Seasonal fluctuation in lesional severity• Parakeratosis, acanthosis, individual cell
keratinization• Tx: none
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Incontinentia Pigmenti
• Heritable disease• Manifestations evolve during infancy
– Slate grey or brown diffuse cutaneous macular pigmentations
– Verrucoid crusty cutaneous lesions– Oral white lesions
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Incontinentia Pigmenti
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Dyskeratosis Congenita
• Heritable disease• Clinical manifestations evolve during
infancy– Oral white lesions, dysplastic, progress to
carcinoma– Multiple other anomalies
• Progression to carcinoma may occur during childhood
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Dyskeratosis Congenita
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LACEY/FRINGE BORDERS
• LICHEN PLANUS• LICHENOID MUCOSITIS• LUPUS ERYTHEMATOSUS• ORAL HAIRY LEUKOPLAKIA
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Reticular Lichen Planus
• Stria of Wickham, lacey, spiderweb, fringe borders
• Asymptomatic • May progress to erosive form over time• Adult onset• Buccal mucosa, vestibule, gingiva• Chronic lymphocytic interface mucositis
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Reticular Lichen Planus
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Lupus Erythematosus• Females>Males• Systemic and cutaneous (discoid) forms• Oral lesions usually do not exist in the absence
of skin lesions (classic discoid lesions and butterfly rash)
• White, lacey, finge borders• Hyperkeratosis, acanthosis, chronic lymphocytic
interface mucositis• DIF: basement membrane IgM• Serologic: ANA, anti-DNA antibodies• Tx: topical and systemic steroids
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LUPUS ERYTHEMATOSUS
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Oral Hairy Leukoplakia• Epstein Barr virus etiology• EBV receptors present on oropharyngeal
keratinocytes• HIV infected patients, appears when CD4 count
is less than 500• Males• Lateral tongue lesions with fringe (hairy) borders• Often with superimposed Candida • Tx: Acyclovir related drugs
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ORAL HAIRY LEUKOPLAKIA
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ORAL HAIRY LEUKOPLAKIA
EBV DNA
Candida
EBV receptors
EBV virions
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VERRUCOUS/CORRUGATED/RIPPLED
• VERRUCIFORM BENIGN KERATOSIS– RETROMOLAR FRICTIONAL KERATOSIS– IDIOPATHIC
• VERRUCIFORM XANTHOMA• SMOKELESS TOBACCO KERATOSIS• FLAT WARTS (SESSILE PAPILLOMA)• PROLIFERATIVE VERRUCOUS LEUKOPLAKIA
– ATYPICAL VERRUCOUS HYPERPLASIA– VERRUCOUS CARCINOMA– EXOPHYTIC, PAPILLARY SQUAMOUS CELL
CARCINOMA
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PROLIFERATIVE VERRUCOUS LEUKOPLAKIA• A clinical term that defines a group of histologically
distinct diagnoses ranging from atypical verrucous hyperplasia to verrucous carcinoma to invasive squamous cell carcinoma
• Thick white lesions with a rough, cauliflower, verrucous surface
• Females > Males• Typically over age 50• < 50% with a history of tobacco use• Gingival/Sulcus predilection• Progressive lateral proliferation, increasing the area of
involvement• High recurrence after excision• HPV association• Tx: wide local excision with margin assessment, three
month followup
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PROLIFERATIVE VERRUCOUS LEUKOPLAKIA (PVL)
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VERRUCOUS CARCINOMA
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PVL HISTOLOGY
ATYPICAL VERRUCOUS HYPERPLASIAVERRUCOUS CARCINOMA
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VERRUCOUS CARCINOMA
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Smokeless Tobacco Keratosis
• White lesions in mandibular vestibule• Contact lesion: occurs at site of tobacco or
snuff placement• Subtle to overt white appearance with a
wrinkled, corrugated appearance• Reversible if habit is curtailed• Gingival recession• Cancer progression is extremely low
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SMOKELESS TOBACCO KERATOSIS
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Flat Warts
Inked to show excisional margins
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Verruciform Xanthoma• White to yellow plaque with a rough surface• Usually on the gingiva, yet can occur anywhere• Skin counterpart is xanthalasma of the eyelids• Benign keratosis with elongated rete ridges
between which are found submucosal papilla with foam “xanthoma” cell infiltration
• Not known to be associated with hyperlipoproteinemia
• Tx: local excision
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VERRUCIFORM XANTHOMA
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MIXED RED AND WHITE LESIONS
• BENIGN MIGRATORY GLOSSITIS• IRRITATIONAL KERATOSIS• CANDIDIASIS• LEUKOERYTHROPLAKIA (SPECKLED
LEUKOPLAKIA)• EROSIVE LICHEN PLANUS
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Benign Migratory Glossitis•Geographic tongue•Circinate white lesions with a red
denuded surface (depapillation)•Lesions spontaneous resolve then
reappear at other tongue sites•Primarily on dorsum, yet can have lesions
on ventral aspect or even lips and buccal mucosa (Erythema migrans)
•Parakeratosis with subacute mucositis•Tx: none, brush tongue
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Benign Migratory Glossitis
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Candidiasis• Infection with various Candida species• Usually asymptomatic yet can experience mild
burning• Red appeance with white speckling• White lesions can be rubbed away• Denture sore mouth of the palate, angular
cheilitis, other mucosal sites• Smear positive for PAS mycelia• Tx: topical or systemic specific antifungals
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Candidiasis
HIV
DiabetesPost antibiotic
PAS
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Leukoerythroplakia• Speckled leukoplakia• Mixed red and white foci in which the white
component cannot be rubbed away• Soft palate, ventral tongue, floor of mouth• Toluidine blue positivity in red areas:
suspect dysplasia, biopsy should include a red focus
• Over 60% show dysplasia or carcinoma• Wide excision evaluation of margins
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LEUKOERYTHROPLAKIA
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EROSIVE LICHEN PLANUS
• White stria often seen• White lesions overlayed on an
erythematous backgroung• Desquation without bulla formation• Painful, burning aggrevated by acidic
foods• Emotional upset, stress• Tx: Topical and systemic steroids
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EROSIVE LICHEN PLANUS
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Erosive Lichen Planus
Sub-basilar desquamation,Lymphocytic infiltration
Direct Immunofluorescence positiveFor basement membrane fibrinogen
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PAPULAR
• CANDIDIASIS
• DARIER WHITE DISEASE
• LICHEN PLANUS
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CANDIDIASIS
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CANDIDIASIS
PAS STAINING
MYCELIA
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Keratosis Follicularis (Darier-White Disease)
• Autosomal dominant defect in keratinization• Multiple orange papules and verrucoid keratoses
of the skin• Multiple white lesions, bilateral buccal mucosa
and other mucosal sites• Same histology as warty dyskeratoma with
villous rete pegs, individual cell keratinization and suprabasilar clefting
• Tx: Vitamin A and retinoids
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Keratosis Follicularis
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PSEUDOMEMBRANOUS
• CANDIDIASIS• ASPIRIN BURN• BULLOUS DISEASES• ULCERATIVE DISEASES• VESICULAR DISEASES
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ASPIRIN BURN
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PSEUDOMEMBRANOUS VESICULO-BULLOUS
PEMPHIGUS
PYOSTOMATITIS VEGETANS PRIMARY HERPES
APHTHOUS STOMATITIS