Oral Lesions and Tobacco Effects Quiz

Oral Pathology Final Exam Review

• Macule:

  • Definition: A flat area of change that isn't elevated or depressed.
  • Important: If there's a change in texture when feeling the lesion, it's not a macule.
  • Common use: Freckles
  • Well-defined borders are less worrisome for a malignant process than fuzzy ones.

• Papule vs. Nodule:

  • Papule: Solid, raised lesion less than 5 mm in diameter.
  • Nodule: Solid, raised lesion greater than 5 mm in diameter.
  • Typically well-circumscribed.
  • "Bump" is a general term for both.

• Plaque:

  • Definition: A slightly elevated, flat lesion on the surface.
  • Unlike a macule, has some surface texture when palpated.
  • Associated with dysplasia (potentially malignant).
  • Well or ill-defined borders are important for prognosis.

• Sessile vs. Pedunculated:

  • Sessile: A tumor or growth whose base is the widest part of the lesion.
  • Pedunculated: A tumor or growth whose base is narrower than the widest part of the lesion.
  • Lesions cannot be both.

• Papillary:

  • Surface projections are typically more rounded or "cauliflower-like".
  • Often pedunculated
  • Fibrovascular cores support the exophytic growth

• Verrucous:

  • Rough or warty surface
  • Can be "church-spire"-like or spikier than papillomas
  • Overlying epithelium often "cups" toward the center

• Vesicle, Bulla, Pustule:

  • Vesicle: Small blister (≤5 mm), usually with clear fluid.
  • Bulla: Large blister (>5 mm), often filled with blood.
  • Pustule: Blister filled with purulent exudate (pus).
  • Lesions may be single or multiple depending on healing stage.
  • May occur in clusters.

• Erosion and Ulceration:

  • Erosion: Partial/full loss of superficial epithelium.
  • Ulcer: Loss of epithelium (and often some underlying connective tissue), depressed/excavated.
  • All ulcers are erosions, but not all erosions are ulcers.

• Petechiae vs. Ecchymosis:

  • Petechiae: Small, pinpoint hemorrhages.
  • Ecchymosis: Larger, non-elevated hemorrhages ("bruises").

• Telangiectasia:

  • Dilation of small, superficial blood vessels.
  • Overlying a swelling in the oral cavity, particularly salivary glands, can be an ominous sign.

• White Coated Tongue:

  • A form of hairy tongue
  • Do not confuse with hairy leukoplakia

• Oral Hairy Leukoplakia:

  • Lateral tongue aspect
  • Caused by Epstein-Barr virus (EBV) in immunocompromised patients (e.g., HIV/AIDS).
  • White plaque that doesn't wipe off.

• Pseudomembranous Candidiasis ("Thrush"):

  • Caused by Candida Albicans, the most common oral fungal infection.
  • Exists in yeast (fairly innocuous) and hyphal (invasive) forms
  • Diagnosis requires microscopic visualization of the hyphal form.
  • White plaques that resemble cottage cheese or curdled milk
  • Often seen in infants with underdeveloped immune systems or patients on broad-spectrum antibiotics.

• Morsicatio:

  • Chronic mucosal chewing
  • Higher prevalence in stressed individuals (e.g., dental students) or those with psychological conditions.

• Toothpaste or Mouthwash Reaction:

  • Filmy whiteness that disappears when rubbed off.
  • Sodium Lauryl Sulfate is a surfactant that may cause a reaction.
  • Allergic contact stomatitis
  • Superficial epithelial desquamation / sloughing

• Secondary Syphilis:

  • Mucous patch lesion that may only be partially scraped off.
  • Approximately 4-6 weeks after initial infection with Treponema pallidum.

• Just a Little More Syphilis...

  • Primary: Chancre
  • Secondary: Mucous patches, condyloma lata
  • Tertiary/Latent: Gumma

• Congenital Syphilis:

  • Hutchinson's triad
    • Hutchinson's teeth
    • Mulberry molars and Hutchinson's incisors
    • Ocular interstitial keratitis
  • VIIIth nerve deafness

• Leukodema:

  • Common oral condition of unknown cause
  • More common in people of African descent
  • Diffuse, gray-white, milky opalescent appearing mucosa
  • Usually more prominent in smokers
  • Easily diagnosed clinically by everting and stretching the mucosa.
  • The white appearance greatly diminishes.

• Leukoplakia:

  • White plaque that cannot be identified as any other disease
  • Typically a clinical description
  • A clinical sign of a pre-malignant condition, though not all leukoplakia is cancerous.
  • Caused by several factors: Tobacco, alcohol, radiation, etc.

• Leukoplakia causes:

  • Tobacco (80% of patients)
  • Alcohol
  • Sanguinaria (antibacterial additive in toothpaste)
  • UV radiation
  • Immunocompromised individuals
  • Microorganisms
  • Trauma

• Leukoplakia Cytologic and Architectural features:

  • Normal variations in nuclear size (anisonucleosis)
  • Abnormal variation in nuclear shape (nuclear pleomorphism)
  • Abnormal variation in cell size (anisocytosis)
  • Abnormal variation in cell shape (cellular pleomorphism)
  • Irregular epithelial stratification
  • Loss of basal cell polarity
  • Drop-shaped rete ridges
  • Increased number of mitotic figures
  • Premature keratinization (dyskeratosis)
  • Keratin pearls within rete ridges
  • Loss of epithelial cell cohesion

• Leukoplakia Biopsy and Treatment:

  • Biopsy to confirm diagnosis.
  • Treatment: Removal or excision of most severe areas

• Tobacco Pouch Keratosis:

  • White plaques that resemble cottage cheese or curdled milk
  • Often initiated by broad-spectrum antibiotics or immune impairment (HIV/AIDS, leukemia).
  • Characterized by a rough, warty surface and “church-spire"-like or spikier projections compared to papillomas where epithelium often "cups" toward the center.

• Lichen Planus:

  • Relatively common, chronic dermatologic disease

• Lichen Planus—Reticular: -A clinical description showing a reticular pattern of white lines on oral mucosa

• Lichen Planus—Erosive:

  • Oral ulcers may be involved -This form can be painful and can easily be mistaken for other conditions

• Actinic Cheilosis/Cheilitis:

  • Pre-malignant alteration of lower lip vermillion from chronic UV exposure
  • Common in fair-skinned adults.
  • Early findings include atrophy, dryness, and fissures. Lesions may further thicken to form leukoplakic or cancerous lesions.
  • Always examine any lesion that is not resolving.

• Submucous Fibrosis:

  • Characterized by juxtaepithelial and submucosal collagenized tissue with inflammatory cells
  • No treatment to reverse.
  • 10-15% of biopsies show dysplasia, and 6% show squamous cell carcinoma. Patients are 19 times more likely to get oral cancer.

• Nicotine Stomatitis:

  • A response to heat (from pipes or hot beverages) and not the chemicals in tobacco
  • Characterized by hyperkeratosis and acanthosis of the epithelium
  • Usually seen in oral areas most likely exposed to heat (such as soft palate or buccal mucosa.)

• Oral Hairy Leukoplakia:

  • Predominantly on lateral tongue borders with presentation of white mucosal plaque. -Associated with severe immunosuppression (such as in people with HIV/AIDS) and is associated with EBV

• Hyperplastic Candidiasis:

  • A form of candidiasis that can be difficult to remove by scraping
  • Most often found on the anterior buccal mucosa.

• Lupus Erythematosus (SLE):

  • An immunologic condition
  • Can present with varying degrees of ulceration, pain, erythema, and hyperkeratosis

• White Sponge Nevus:

  • Oral lesions clinically appear as symmetrical, thick, white, corrugated or velvety diffuse plaques
  • Primarily bilateral in buccal mucosa
  • Usually asymptomatic

• Hereditary Benign Intraepithelial Dyskeratosis:

  • Is a very rare autosomal dominant genodermatosis.
  • Typically it presents in childhood
  • Affects both oral and conjunctival mucosa

• Pachyonychia Congenita: • A group of rare autosomal, dominant, genodermatoses characterized by keratin mutations • Characterized by thick, callous-like, hyperkeratotic lesions on palms and soles of feet • Affects nails, especially toenails, dramatically.

• Dyskeratosis Congenita: • Is a rare X-linked recessive genodermatosis. • The diagnosis can be made early in life (by the time they are 10 years of age). • Includes triad of reticulated skin pigmentation, nail dysplasia, and oral leukoplakia • Has an extremely high rate of mortality. Often diagnosed in the first 10 years of life, but in the best case scenario, the patients will live into their 30s.

• Erythema Migrans: • Common, benign, migratory glossitis.

• Fissured Tongue (Scrotal Tongue): • Approximately 2-5% of the population • May be connected to a hereditary component, such as Melkersson-Rosenthal syndrome.

• Erosive Lichen Planus: • A desquamative gingivitis pattern of mucosal inflammation when ELP occurs within the gingiva • Often associated with other conditions such as mucous membrane pemphigoid and pemphigus vulgaris

• Lichenoid Lesions: • Appear clinically similar to lichen planus, but have different etiologies. Usually have a higher presentation of plasma cells in the inflammatory infiltrate compared to lichen planus

• Erythroleukoplakia: • Leukoplakia becoming dysplastic with scattered red patches (erythroplakia). • Epithelial cells are immature or atrophic, leading to loss of keratin production.

• Sialolithiasis (Salivary Stones): • Are calcified structures • Usually occur in submandibular salivary glands • Can cause pain, swelling • May be treated conservatively or surgically.

• Xerostomia: • A reduction in salivary secretion. Causes: medications, radiation, autoimmune diseases, Sjogren's Syndrome, etc. Causes: medications, radiation, autoimmune diseases, Sjogren's Syndrome, etc.

• Median Rhomboid Glossitis: • A well-defined erythematous zone affecting the midline of the posterior dorsal tongue. • Usually asymptomatic.

• Anemia (various types): • A general term for a decrease in red blood cell volume or hemoglobin concentration. • Causes include iron deficiency, (due to blood or GI issues), or vitamin B12 deficiencies (pernicious anemia) •

• Plummer-Vinson Syndrome: • A clinical condition characterized by a triad of signs: Iron-deficiency anemia, glossitis (tongue inflammation), and dysphagia.

• Kaposi's Sarcoma:

  • Vascular neoplasm most commonly associated with HIV infection
  • Oral lesions are highly variable (ranging from macules to purplish or red plaques).

• Rhabdomyosarcoma:

  • A malignant neoplasm that originates from skeletal muscle.
  • A high frequency form of cancer in the head and neck area.

• Synovial Sarcoma:

  • An uncommon soft tissue sarcoma.
  • Frequently seen in the extremities (long bones).

• Metastases to the Jaws:

  • Can occur to bone tissue or oral soft tissue.
  • A widely disseminated disease

• Dentigerous Cysts:

• Cysts formed during tooth development (eruption)

• Most often occur in the mandibular third molars but can occur in other sites

• Usually asymptomatic

• Odontogenic Keratocyst:

• A cyst that arises from cells in the dental lamina

  • Usually in the posterior mandible
  • Considered a "high recurrence" rate of lesions.

• Orthokeratinized Odontogenic Cysts: Uncommon, but predominantly in young adults with a male predilection. Diagnostic feature: Orthokeratinized lining. Histologically similar to OKC, but differs with the lining being orthokeratin.

• Nevoid Basal Cell Carcinoma (Gorlin) Syndrome:

  • Involves several types of cancer.
  • Is caused by the PTCH gene on chromosome 9
  • Usually appears as multiple basal cell carcinomas around puberty

• Lateral Periodontal Cyst (LPC):

  • A developmental odontogenic cyst, and is fairly common, and occurring most frequently in the mandibular premolar/canine/lateral incisor area.

• *Calcifying Odontogenic Cysts:

  • Is part of a spectrum of lesions including odontogenic epithelium containing "ghost cells" which may undergo calcification. Other variants include: dentinogenic ghost cell tumor and ghost cell odontogenic carcinoma (malignant)

• Glandular Odontogenic Cysts:

  • More common in middle-aged adults.
  • Typically unilateral and involves the mandibular region
  • Usually painless.

• Conventional Ameloblastoma:

  • A benign tumor of the jaw, often present as a painless, slowly growing mass. -Commonly seen on the hard palate and molar region

• Unicyctic Ameloblastoma:

  • Usually found to be in the mandible
  • Often found to be posterior in the mandible.

• Adenomatoid Odontogenic Tumor (AOT):

  • A relatively common benign tumor, that can be located in the jaw and other sites like the mandible and hard palate
  • Typically is a single lesion, and is frequently found unerupted teeth.

• Calcifying Epithelial Odontogenic Tumor:

  • Uncommon lesions (<1% of odontogenic tumors)
  • Typically seen in patients 30-50 years and is most often located in the posterior mandible
  • Commonly appear as a radiolucent lesion with unilocular or multilocular appearance.

• Ameloblastic Fibroma:

  • Is a benign odontogenic tumor.
  • Most cases arise in the first or second decade of life with posterior mandibular locations being most common.

• Odontoma:

  • This is a common congenital tumor.
  • Most commonly in anterior maxilla and molar region.

• Odontogenic Myxoma:

  • A benign odontogenic tumor.
  • Usually solitary, painless lesion that is primarily seen in the mandible. Often, the lesion expands buccally during its growing process.

• Oral Complications of Neoplastic Therapy

  • The most affected tissues are those affected via rapid turnover, e.g., mucosa, and those related to bone turnover
  • Outcomes include xerostomia (dry mouth), loss of taste, osteoradionecrosis, trismus (difficulty closing jaw), and dermatitis.

• Osteoradionecrosis

  • Development of bone necrosis due to treatment related to radiation therapy.
  • More common in the mandible.

• Ehlers-Danlos Syndrome: • A group of inherited disorders that affect connective tissues

• Tuberous Sclerosis: • Is a rare disorder characterized by the presence of numerous benign tumors of the skin and nerves

• Multiple Endocrine Neoplasia (MEN):

  • Is a rare group of hereditary disorders that are characterized by multiple tumors involving the endocrine glands

• Chronic Nonbacterial Osteomyelitis (CNO):

  • A condition characterized by recurrent episodes of pain, inflammation, enlargement of the soft tissue and bone.
  • More commonly seen in females in the first two decades of life

• Condenshing Osteitis: • Localized areas of bone sclerosis near the root tips of teeth, characterized by an increased radiodensity.

  • Usually located in the posterior mandible.

• Simple Bone Cysts: • A well-defined unilocular radiolucency that is typically asymptomatic • Can be found in the jaw bone • A lesion is typically well-defined in the jaw bone and has smooth borders

• Aneurysmal Bone Cysts: • Rare benign bone tumors, and involve both spongy and compact bone. • Occurs in the mandible in around 20% of cases

• Fibrous Dysplasia (FD): • A benign condition affecting a bone • Symptoms are mild and include a slight expansion of bone

• Cemento-osseous Dysplasia (CCD): • A benign lesion appearing as a radiolucent area which most often affects the anterior mandible of women. • Is often asymptomatic. • Not associated with pain or bleeding, though it does involve certain areas where the tooth has lost its bone

• Gardner's Syndrome: • An inherited condition that causes various abnormalities involving the gastrointestinal tract.

• COVID-19 • Affects the oral cavity • Common symptoms include taste disturbances, olfactory dysfunction, and mucosal lesions.

• Other:

  • Most oral complications of the listed conditions should be evaluated based on their clinical findings and/or the findings of the medical history of individual patients.
  • There are several other conditions not listed above that are important to learn for the exam.

Test your knowledge about oral lesions, specifically focusing on conditions like tobacco pouch keratosis and lichen planus. This quiz covers key features, demographics, and treatment methods related to these conditions. Ideal for those studying oral pathology or dental health.