Red and White Oral Lesions (PDF)

Red and white lesions of the oral mucosa: RED AND WHITE TISSUE REACTION Red and white oral lesions are a group of conditions that affect the lining of the mouth. They can be caused by a variety of factors, including trauma, infection, inflammation, and cancer. White lesions of the oral mucosa can...

Red and white lesions of the oral mucosa: RED AND WHITE TISSUE REACTION Red and white oral lesions are a group of conditions that affect the lining of the mouth. They can be caused by a variety of factors, including trauma, infection, inflammation, and cancer. White lesions of the oral mucosa can be caused by: 1. Increased production of Keratin ( Hyperkeratosis ) 2. Abnormal but benign thickening of the stratum spinosum ( Acanthosis ) 3. Epithelial edema: intra- and extracellular accumulation of fluid in the epithelium may also result in clinical whitening 4. Microbes, particularly fungal infections (Fungi can produce whitish pseudomembranous) 5. Subepithelial superficial fibrosis, which with its decreased vascularity network causes a diffuse whitish appearance Red lesions of the oral mucosa can be caused by: 1. Decrease in thickness of epithelium ( Atrophy ) 2. loss of the superficial cell layers (superficial erosion) 3. Increased vascularization by dilatation of vessels and/or proliferation of vessels (inflammation) 4. cellular proliferation signifying a possible malignancy Consistency and texture are important to reach a diagnosis Palpation of white and red lesions is necessary in addition to inspection, as indurated lesions should draw additional suspicion for possible malignancy. Our clinical approach to differential diagnosis should include Age, presence of pain, single versus multiple lesions, distribution in specific areas, the borders toward the unaffected tissue, onset, duration, change in shape and size, whether it is raised in comparison to surrounding mucosa, its relapsing nature, and reasons for improvement or exacerbation. A patient’s specific systemic condition and associated medications are potentially very closely related to oral disease Infectious diseases: A. Oral Candiasis B. Hairy Leukoplakia A. ORAL CANDIDIASIS Oral candidiasis is the most prevalent opportunistic infection affecting the oral mucosa Caused by various candida species. Predominantly C. albicans, C. tropicalis, C. glabrata C. Albicans is one of the components of normal oral microflora More than 60% of people carry this organism. Candida is a dimorphic organism. It exist in two forms (hyphae and spores). Spores are nonpathogenic, hyphae are pathogenic. Candidal strains with better adhesion potential are more virulent than strains with poorer adhesion ability Its an opportunistic infection that usually happen to the very young, very old, and very sick. Candidiasis is when the candida cause lesion or symptoms. It’s usually superficial, can manifest as a red or a white lesion, and could be acute or chronic 1 of 20 Predisposing factors for oral candidiasis A. Local Poor oral hygiene Hyperkeratosis (lichen planus) Smoking Xerostomia (drugs, radiotherapy, Sjogren’s Atrophic constitution syndrome) Corticosteroids (topical/inhalers) Broad spectrum antibiotics - Imbalance of Prolonged denture wearing oral microflora High carbohydrate diet B. General Immunosuppressive disease (HIV) Impaired health status Immunosuppressive drug ( systemic corticosteroids, chemotherapy, biological agents) Hematological malignancies (leukemia and lymphomas) neutropenia Endocrine disturbances (diabetes mellitus, Addison’s disease, hypothyroidism, pregnancy) Nutritional deficiency (malnutrition and anemias) DIAGNOSIS Clinical examination Biopsy periodic acid Schiff (PAS) stained smear culture of the saliva (cytology) Further examination might be needed (endocrinology - glucose tests, WBC, hemoglobin folic acid, vitamin B12, serum ferritin) if predisposing factor not clear Treatment Correction the predisposing factor, together with antifungal medication Topical agents for mild cases Nystatin (cream or suspension) , and Miconazole gel Chlorhexidine has some anti candida activity Systemic antifungals for severe or refractory cases Fluconazole (drug interaction with warfarin) Examples: 1. PSEUDOMEMBRANOUS CANDIDIASIS (ORAL THRUSH) The acute form of pseudomembranous candidiasis (thrush) is most common candidal infection. The infection predominantly affects patients taking antibiotics, immunosuppressant drugs, or having a disease that suppresses the immune system. There is also a chronic form of pseudomembranous candidiasis, often associated with immunodeficiency. Clinical: Thick creamy-white friable (loosely attached) plaques Can be wiped off with gentle scarping, which leaves an erythematous base underneath Symptomatic/metallic taste and burning sensation Main Predisposing Factors: - Dry mouth - Corticosteroids - Antimicrobials - Immune defect. Treatment: - Correcting predisposing factors + antifungal medication 2 of 20 2. ERYTHEMATOUS CANDIDIASIS ACUTE ATROPHIC CANDIDIASIS (ANTIBIOTIC SORE MOUTH) Clinical: o Generalized mucosal redness o Often painful (burning sensation) o Lesions of erythematous candidiasis have a diffuse border, which helps distinguish them from erythroplakia, which usually has a sharper demarcation and often appears as a slightly submerged o The infection is also seen in the palate and the dorsum of the tongue of patients who are using inhalation steroids Main Predisposing Factors - Smoking - Corticosteroids - Antibiotics - Dry mouth Treatment: Address the underlying predisposing factors o e.g., stop causative antibiotic if possible o change to a narrower spectrum drug o rinse mouth after using steroid inhaler Topical antifungal therapy 3. CHRONIC ATROPHIC CANDIDIASIS (DENTURE-RELATED STOMATITIS) The most prevalent site for denture stomatitis is the denture-bearing palatal mucosa Denture stomatitis and angular cheilitis are referred to as Candida associated infections, as they are always associated with raised counts of intraoral Candida and since bacteria may cause these infections Nearly every patient will report wearing dentures overnight. Thus, denture stomatitis is the consequence of continuous irritation, both microbial and mechanical from the denture, on the underlying mucosal surface Cause: Candida +/- bacteria (BOTH) Clinical: Red area outlined by the shape of the maxillary denture Usually, asymptomatic Predisposes to angular cheilitis and inflammatory papillary hyperplasia Main Predisposing Factors: Continuous denture wearing Denture stomatitis is classified into three different types: Type I is localized erythematous sites caused by trauma from the denture Type II affects a major part of the denture covered mucosa. Type III – inflammatory papillary hyperplasia Diagnosis: Mainly clinical and history smear of mucosa or denture can be done 3 of 20 3. CHRONIC ATROPHIC CANDIDIASIS (DENTURE-RELATED STOMATITIS) (continues…..) Treatment: 1) Cease denture night wear 2) Improve denture hygiene 3) Store denture in an antiseptic at night e.g., commercial denture cleanser, chlorhexidine or diluted sodium hypochlorite solution 4) 1 teaspoon of sodium hypochlorite in a denture cup of water; keep for 15 minutes or at night; rinse for 2 minutes; can turn chrome cobalt dentures black 5) Apply miconazole gel B+F to the fitting surface of denture 6) If recurrent, the most likely reason is failure to comply with treatment regime 4. ANGULAR CHEILITIS - Candida associated infections, as they are always associated with raised counts of intraoral Candida and since bacteria may cause these infections - Presents as infected fissures of the commissures of the mouth, surrounded by erythema. - The lesions are frequently infected with both candida albicans and Staphylococcus aureus. Cause: Candida +/- bacteria (Staph. aureus) (BOTH) Clinical: Red fissures at the corners of mouth Main Predisposing Factors: - Over closure of the mouth (loss of vertical dimension) - lip licking - intraoral candidiasis - anemia - drooling - denture wearing - (vit. B12 and iron def.) Treatment: 1. Miconazole gel (B+F) or fusidic acid cream 2. Treat intra-oral infection 3. Check for underlying causes (e.g. anemia) if recurrent or resistant to treatment Must treat intraoral infection simultaneously. This is always present even if not evident. 5. MEDIAN RHOMBOID GLOSSITIS (CENTRAL PAPILLARY ATROPHY) Clinical: Asymptomatic red rhomboid area on the midline dorsum of tongue Anterior to the circumvallate papillae Result from a trophy of the filiform papillae Often with a matching "kissing" lesion on the palate Main Predisposing Factors: Tongue rests against the soft palate not a self-cleansing area Tobacco smoking, denture wearing, inhalation steroids, immune defect Treatment: Reassurance Anti-fungal treatment 4 of 20 6. CHRONIC HYPERPLASTIC CANDIDIASIS (CANDIDAL LEUKOPLAKIA, CHRONIC PLAQUE TYPE, AND NODULAR CANDIDIASIS) Clinical: Leukoplakia-like lesion asymptomatic white plaque that cannot be rubbed off usually on anterior buccal mucosa Considered as a potentially malignant lesion A histologic feature is the penetration of candidal hyphae through the epithelial cells and the associated subepithelial chronic inflammatory response Main Predisposing factors: Smoking or immune defect Treatment: 1. Smoking cessation 2. Topical or systemic antifungal 3. Consider biopsy to assess for dysplasia 4. Consider excision/follow-up if persistent or dysplasia present 7. ORAL CANDIDIASIS ASSOCIATED WITH HIV More than 90% of AIDS patients have had oral candidiasis Oropharyngeal candidiasis is related to the degree of immunosuppression and is most often observed in patients with CD4 counts Difficult to eradicate Close follow-up is recommended 8 of 20 B. ERYTHROPLAKIA Definition: is a fiery red patch or plaque that cannot be characterized clinically or pathologically as any other definable disease or condition It’s a clinical diagnosis that require exclusion of other oral red conditions Tobacco, and alcohol use are risk factors Higher risk of malignant transformation 80% Less common than leukoplakia, but more serious prevalence in adults has been estimated to be in the range of 0.02% to 0.1% Clinically: well demarcated, red patch with a soft to velvety granular texture Usually, asymptomatic * Any red mucosal lesion without an apparent local cause or not fitting into other known red lesions, and not regressing following removal of possible cause or two weeks of treatment, should be considered a cancer unless histologically proven otherwise Diagnosis and microscopic features : Exclusion of other oral red lesions DDx(non-specific mucositis, erythematous candidiasis, erosive lichen planus LP, lupus erythematous) Histological evaluation of a biopsy specimen - Atrophic and non keratinized epithelium Almost all >90% of cases show dysplasia, carcinoma in situ, or carcinoma at initial presentation Treatment : Guided by histopathological changes Biopsy, complete excision for dysplastic lesion Aggressive treatment for SCCa Tobacco cessation Follow up BIOPSY Excisional biopsy is generally recommended if the leukoplakia diameter is less than 30 mm and the location allows Otherwise, in larger or suspicious lesions incisional biopsies should be undertaken, sometimes from several sites. Selecting the appropriate site that will best represent the most severe aspect is of paramount importance Following five years of no relapse, self-examination may be a reasonable approach 9 of 20 Examples: 1. CHRONIC HYPERPLASTIC CANDIDIASIS (CANDIDAL LEUKOPLAKIA) Etiology A white or red-white fixed lesion caused by chronic C. albicans infection A form of chronic oral candidiasis The malignant potential is controversial and considered low Candida can induce hyperkeratosis and can produce chemical carcinogens (nitrosamines) Can be difficult to separate from oral leukoplakia secondarily superimposed with Candida (opportunistic infection) Clinical Well-demarcated white or red-white plaque Common on the labial commissure Leukoplakia- or speckled leukoplakia-like lesion Usually painless Cannot be rubbed off More common in smokers Microscopic Hyperkeratosis Candidal hyphae in the keratin layer (PAS stain) Epithelial dysplasia in rare, called 'leukoplakia' superimposed with candida Mild connective tissue chronic inflammation Diagnosis Biopsy is required to confirm candidal presence and to assess dysplastic changes if any The presence of candidial hyphae on biopsy, and the resolution of the lesion after antifungal therapy support the diagnosis Treatment Topical or systemic antifungal medications Smoking cessation Consider excision/follow-up if persistent or if dysplasia present treat as leukoplakia Prognosis: The risk of malignant transformation is controversial but low 2. ACTINIC CHEILITIS (ACTINIC CHEILOSIS; SOLAR CHEILOSIS) A premalignant alteration of the lower lip vermilion caused by chronic ultraviolet light exposure Etiology Chronic sun exposure Common among fair-skinned outdoor occupations Clinical Early lesions appear as blotchy, pale areas Indistinct mucocutaneous junction Rough plaques, scales, and crusts may develop later Persistent ulceration and nodularity may indicate malignancy Microscopic Hyperkeratosis Epithelial dysplasia in some cases Atrophic or acanthotic epithelium Signs of solar elastosis in the submucosa Diagnosis Treatment History of outdoor/chronic sun exposure Preventive measures Biopsy to rule out dysplastic changes (lip balm, sunscreen Indurated, thickened, or ulcered areas should be biopsied wide-brimmed hat when outdoors) 6-10% transformation rate Lip shave (vermilionectomy) for dysplastic 10 of 20 cases Long-term follow-up