Oral Lesions: Malignancy & OPMDs

Malignancy & OPMDs

• Leukoplakia is a white, non-wipeable patch that carries a 5-25% risk of cancer
• Leukoplakia is Commonly found on the buccal mucosa, ventral tongue, floor of the mouth, and soft palate
• Homogeneous leukoplakia indicates low risk, while non-homogeneous (red-white, nodular, verrucous) leukoplakia indicates high risk
• Erythroplakia presents as a red, velvety lesion and carries a 90%+ risk of showing dysplasia or SCC, necessitating a biopsy
• Erythroplakia is More dangerous than leukoplakia and usually occurs on the floor of the mouth, ventral tongue, and soft palate
• Proliferative Verrucous Leukoplakia (PVL) manifests as multifocal white patches, grows slowly but aggressively
• PVL has a high risk of transforming into SCC (>70%) and recurs even after treatment

Differentials for Oral Lesions

• Frictional keratosis resolves upon trauma removal
• Hyperplastic candidiasis does not wipe off but improves with antifungals
• Lichen planus is bilateral and reticulated in appearance
• PVL presents as persistent, spreading white patches
• Malignant risk varies with dysplasia severity, with severe dysplasia at ~45%, moderate at ~20%, and mild at ~10%
• Any persistent lesion in high-risk sites (ventral tongue, floor of mouth) should be biopsied even with no dysplasia
• Actinic cheilitis is sun damage to the lower lip, presenting as crusted and ulcerated
• Actinic cheilitis requires biopsy if it persists
• Actinic cheilitis is treated with SPF, 5-FU, imiquimod, diclofenac, or surgery
• Oral SCC accounts for 90% of oral cancers and commonly appears on the lateral tongue, floor of the mouth, soft palate, lower lip, and gingiva
• Oral SCC presents Symptoms include non-healing ulcers, induration, rolled borders, red/white patches, pain, dysphagia, and speech changes
• Oral SCC risk factors include tobacco, alcohol, HPV-16/18, betel nut, chronic trauma, and immunosuppression
• Oral Submucous Fibrosis (OSF) presents with fibrosis, pallor, trismus, and burning sensations, indicating a high cancer risk
• Nicotine stomatitis presents as a white palate due to heat and turns premalignant only if dysplasia is present
• Deep fungal infections (histoplasmosis, blastomycosis) can mimic SCC and present with rolled border ulcers and systemic signs
• Treatment involves itraconazole for mild cases and amphotericin B for severe cases
• Ulcers are differentiated through biopsy when chronic trauma, major aphthae, deep fungal infections, or tumors are suspected
• HPV-related SCC has a better prognosis and typically occurs in the oropharynx
• HPV-SCC is treated with surgery, chemo, and radiation and can be prevented with Gardasil 9
• Toluidine blue helps identify high-risk lesions and is valuable for guiding biopsy or surgery, but not for general dentist screening

Tobacco Cessation

• The 5 A's for tobacco cessation include Ask, Advise, Assess, Assist, and Arrange
• SPIKES protocol includes Setting, Perception, Invitation, Knowledge, Emotion, Summarize, which are cancer bad news delivery steps
• A combination of patch and gum with support offers the best treatment
• NRT patch dosages: 21 mg/day for 4 weeks, 14 mg/day for 2 weeks, and 7mg/day for 2 weeks
• Nicotine gum is administered as 4mg every 1-2 hours as needed (PRN)
• Varenicline should be started 1 week before quitting and not combined with nicotine patches or other NRT
• Bupropion is initiated at 150mg QD for 3 days, then BID and is compatible with NRT
• Bupropion is contraindicated in patients with bulimia, anorexia, seizure disorders, or those taking buprenorphine or MAO inhibitors
• Combo therapy is the most effective approach

Alcohol and Cancer Risk

• A standard drink contains 12oz of beer, 5oz of wine, or 1.5oz of liquor
• Heavy drinking is defined as ≥14 drinks/week for men and ≥7 drinks/week for women

Cancer Staging

• T1 tumors are <2cm and ≤5mm in depth
• T2 tumors are 2-4cm or 5-10mm
• T3 tumors are >4cm or >10mm
• T4 indicates invasion
• N0 signifies no nodes
• N1 signifies 1 small ipsilateral node
• N2/3 indicates multiple/large nodes
• ENE+ means aggressive
• M0 indicates no spread
• M1 indicates distant spread

Lymph Nodes

• Reactive lymph nodes are soft, tender, mobile, and <2cm
• Neoplastic lymph nodes are firm, fixed, and >2cm
• Hodgkin's lymph nodes are rubbery and persistent

Biopsy Guidelines

• Biopsy any red, white, indurated, ulcerated, or persistent lesions, especially in high-risk areas
• Biopsies are crucial, and early detection can save lives

MMP/PV

• H&E samples are taken at the lesion site
• DIF samples are taken 1 cm away from the lesion

OLP

• OLP affects non-keratinized mucosa in white areas accompanied by striations

Malignancy

• If an indurated (hardened) area is present, suspect malignancy, but if there is no induration, consider a red area
• An incisional biopsy should be performed first, and an excisional biopsy can follow if the histology confirms SCC and the margins are determined

Leukoplakia

• For small leukoplakia, an excisional biopsy is appropriate, while for large lesions, an incisional biopsy is preferred

Autoimmune & Desquamative Gingivitis Conditions

• Pemphigus vulgaris starts in the mouth with chicken wire IgG on DIF and necessitates systemic steroids
• DIF shows Supra-basilar, intra-epithelial patterns
• Mucous membrane pemphigoid (MMP) involves gingival sloughing with linear IgG/C3 at hemidesmosomes
• MMP DIF shows linear or sub-basilar deposition in the basement membrane
• Oral lichen planus involves reticular (asymptomatic) or erosive (painful) lesions with Wickham's striae and may be associated with Hepatitis C history
• Oral lichenoid lesions are linked to medication or restorative material history
• Lupus erythematosus oral ulcers mimic erosive LP and present with systemic signs like malar rash, joint pain, and fatigue
• Desquamative gingivitis requires biopsy + DIF, and is a clinical pattern seen in PV, MMP, erosive LP, and related conditions noted above
• Necrotizing Ulcerative Gingivitis (NUG) presents with painful gingiva, interdental papilla necrosis, bleeding, halitosis, stress, and immunosuppression
• Necrotizing Ulcerative Periodontitis (NUP) features bone loss, deep interdental necrosis, minimal pocketing, and is commonly seen in HIV+ or immunocompromised patients
• Localized juvenile spongiotic gingival hyperplasia presents as a red papillary gingival lesion in kids and teens with normal hygiene and does not respond to typical hygiene practices

Infectious & Fungal Diseases

• Candidiasis appears pseudomembranous (wipes off), erythematous (burning), or hyperplastic (white, does not wipe off)
• Denture stomatitis presents as red mucosa under a denture base and is Candida-related
• Denture stomatitis is Driven by dentures, dry mouth, diabetes, steroids, and antibiotics
• Manage Denture Stomatitis With Nystatin, clotrimazole, and fluconazole
• With Mucormycosis expect rapid necrosis, black eschar, diabetes/ketoacidosis, and nasal/palatal tissue loss
• Coccidioidomycosis involves inhaled spores, lung disease, and chronic oral ulcers in the southwestern U.S. (“Valley Fever”)
• Aspergillosis presents as fungal sinusitis, immunocompromised status, and necrotic palatal or sinus lesions with septate hyphae
• Histoplasmosis leads to chronic non-healing ulcers, lung infection, and is caused by inhaled spores found primarily in Ohio & Mississippi

Bacterial & Granulomatous Diseases

• Periapical abscess leads to local swelling, non-vital tooth, pain, and possible sinus tract
• Tuberculosis presents as granulomas with caseating necrosis and may cause ulcers or nodules
• Leprosy cases present Rare oral involvement due to granulomas with foamy macrophages
• Crohn’s disease presents Cobblestone mucosa, tags, linear ulcers, lip swelling and requires confirmation with colonoscopy/endoscopy and is described as "most common GI disorder with characteristic oral lesions"
• Cat Scratch Disease: Bartonella henselae infection from kitten scratches in kids/young adults
• Cat Scratch oral clues include tender cervical/parotid nodes mimicking salivary swelling, diagnosis is clinical or via Bartonella serology and treatment involves self-limiting measures but may require azithromycin for severe cases

Viral Diseases

• Primary HSV in children presents with painful widespread vesicles and systemic signs like fever and malaise
• Recurrent intraoral herpes presents coalescing ulcers on keratinized mucosa of hard palate and attached gingiva
• Herpes Zoster/Shingles presents unilateral ulcers along CN V dermatomes, skin lesions, and is treated with antivirals and palliative care and is referred if CN V1 (eye) is involved
• Erythema Multiforme is often HSV-triggered, causing oral ulcers, hemorrhagic lip crusts, and skin target lesions that are self-limiting
• Stevens-Johnson Syndrome (SJS) is drug-triggered and presents severe mucosal ulceration and skin detachment
• Toxic Epidermal Necrolysis (TEN) is a severe drug reaction with skin detachment and high mortality rates

HPV-Related Papillomas

• Squamous Papilloma presents pedunculated, finger-like lesions found more often on the palate
• HPV 6/11
• Verruca Vulgaris presents Pedunculated lesions commonly on anterior mouth in children
• HPV 1/2/4/6/7
• Condyloma Acuminatum-sessile,clustered,larger,HPV6/11
• Heck's disease features Flat-topped, multiple lesions in children, HPV 13/32
• Oral Florid Papillomatosis features Multiple, stippled/verrucous lesions in HIV+ patients and multiple HPV types

Parotid & Bilateral Swelling in Clinical Practice

• Mumps presents bilateral painful parotid swelling, fever, elevated serum amylase and results from Paramyxovirus
• Sjogren's syndrome presents dry mouth + dry eyes + parotid enlargement and autoantibodies SSA/SSB
• Obstructive sialadenitis typically affects the submandibular gland and displays sialoliths visible on occlusal film
• Sarcoidosis leads to a parotid swelling With non-caseating granulomas

Lumps and Bumps (Reactive & Gingival Masses)

• Irritation fibroma is Most common firm,trauma-related soft tissue growth
• Pyogenic granuloma presents Any age red and ulcerated common in pregnancy that bleeds easily
• Peripheral ossifying fibroma presents Reactive calcifications on gingiva and in young patients
• Peripheral giant cell granuloma presents Purple-blue gingival only In older patients and resorbs underlying bone.
• Traumatic neuroma presents A painful nerve injury after (mechanical allondynia) most commonly mental freeman area and tongue.
• Neurofibroma presents Soft tissue NF1 may appear orange
• Mucocele presents Minor salivary trauma lower labial can be minor salivary
• Ranula presents Midline floor of mouth May plunge sublingual glands
• Dermoid Cyst presents Dougy midline floor of moth May have all skin appendages
• Lipoma ONLY orange/yellow buccal mucosa
• Epidermoid Cyst presents Subcutaneous without skin appendages
• Epulis fissuratum presents a folded fibrous tissue usually due to denture flange That must be ruled out for malignancy
• Eruption Cyst presents erupting tooth in First first molars. Will need an incision that may resolve
• Gingival Cyst of Newborn: Soft tissue limited, Alveolar is keratin ridge.

Systemic & Ulcerative Conditions

• Aphthous Ulcers is a type of inflammatory
• • MinorAphthous Ulcers are cm shallow 7-10 days . 
• • Major Aphthous Ulcers are cm, and be slow to heal and have cars.
• Herpetiform Aphthous Ulcers is a type of inflammatory with multiple and no herpes.
• Crohn like symptoms
• Iron deficiency anemia. Pale glossitis is most common
• Ulcerative Colitis with bloody cancer risk.
• Pyostomatitis Vegetans snails rare on ulcerative

Tobacco Cessation Management

• Nicotine gum, patch lozenge may cause side effects such as NRT.
• Antidepressant (Zyban) is an antidepressant and Bupropion side effects:
• Varenicline(Chantix)side effects:
• Counseling meds will be successful.

Normal Anatomy

• Geographic tongue: Has depapillarion may cause issues
• Lingual tissue is to look for the Waldeyers
• Free are common posterior
• Fordyce yellow
• Fissured: Grooved
• Harmless pigmentation.
• Filiform: Question for atrophy.
• Fungiform: Mushroom shaped contains to Anterior
• Lingual back lymphoid is for ring.
• Circumvallate: All way back of the tongue

Palate

• Add differeintal.

Adenoid & Pleomorphic

• Slowly
• Rapid: aggressive/Caused neurologie
• Painful
• Is mainly in to the partoid and platal