Red & White Oral Lesions - Dent 880 Summer 2024 PDF

RED & WHITE LESIONS ANUPAMA GRANDHI, BDS, DDS Why does the mucosa appear white in color? Composition 1: Increased production of keratin...

RED & WHITE LESIONS ANUPAMA GRANDHI, BDS, DDS Why does the mucosa appear white in color? Composition 1: Increased production of keratin (hyperkeratosis) Composition 2: Abnormal but benign thickening of stratum spinosum (acanthosis) or dysplasia Composition 3: Intra and extracellular accumulation of fluid in the epithelium Composition 4: Fungi can produce white pseudomembranes Burket Oral Medicine, 12th Edition, 2015 Why does the mucosa appear red in color? Composition 5: Atrophy of the epithelium (decrease in the size of cells) Composition 6: Reduction in the number of epithelial cells Burket Oral Medicine, 12th Edition, 2015  Red & White Lesions Developmental Infectious Potentially /Hereditary/ Immune Malignant/ Reactive/Frictional/ Congenital Mediated/Allergic Malignant Factitial  Developmental/Hereditary/ Immune Mediated/Allergic Infectious Potentially Reactive/Frictional/Factitial Congenital Malignant/Malignant WHITE LESIONS White sponge nevus Lupus erythematosus Oral hairy leukoplakia Leukoplakia-benign Frictional keratosis Hereditary benign Graft-versus-host disease Syphilis (mucous keratosis, epithelial (alveolar ridge keratosis) intraepithelial dyskeratosis Oral lichen planus patches) dysplasia Morsicatio buccarum, Leukoedema Oral lichenoid contact Oral candidiasis Proliferative verrucous labiorum, linguarum lesions (pseudomembranous, leukoplakia Linea alba Dental restorative chronic hyperplastic) Actinic cheilitis Chemical burn material Oral submucous fibrosis Thermal burn Frequent use of Smokeless tobacco Contact desquamation agents like mint or keratosis with mouthwash cinnamon Squamous cell Nicotine stomatitis Drug induced lichenoid carcinoma Hairy tongue/Coated reactions tongue Antimalarials NSAIDs Diuretics Antihypertensives Oral hypoglycemics RED LESIONS Hemangioma Desquamative gingivitis Oral candidiasis Erythroplakia Thermal Burn Lupus erythematosus Median Epithelial Hematoma, Petechiae, Oral lichen planus rhomboid dysplasia Ecchymosis, Purpura Mucous membrane glossitis Carcinoma in situ pemphigoid Angular cheilitis Squamous cell Plasma Cell Gingivitis Denture carcinoma Erythema stomatitis Kaposi sarcoma migrans/Geographic tongue Oral lichenoid reactions RED & WHITE LESIONS Oral lichen planus Oral candidiasis Actinic cheilitis Burns Erythema Erythroleukoplakia Thermal migrans/Geographic (speckled leukoplakia) Chemical tongue Epithelial Nicotine stomatitis Oral lichenoid contact dysplasia lesions Squamous cell Frequent use of carcinoma agents like cinnamon Lupus erythematosus LINEA ALBA u Common lesion u Most likely associated with frictional irritation, pressure or sucking trauma from facial surfaces of the teeth u It presents as a linear white lesion u Usually, bilateral u Seen on buccal mucosa along occlusal plane LINEA ALBA u It is usually restricted to dentulous areas u No need for biopsy u No treatment is required u It may show spontaneous regression LINEA ALBA NDAB MORSICATIO MUCOSAE ORIS u Seen due to chronic chewing u Buccal mucosa - morsicatio buccarum u Labial mucosa - morsicatio labiorum u Lateral border of tongue - morsicatio linguarum u Presents as thick, shredded, white areas with irregular, ragged surface u May be interspersed with zones of erythema, erosion or focal traumatic ulceration u The periphery of the lesion blends with adjacent mucosa MORSICATIO MUCOSAE ORIS u Shows female predilection u Commonly affects anterior buccal mucosa (bilateral/may be unilateral) along the occlusal plane; lips; tongue u Most cases do not require biopsy and clinical presentation is sufficient to make a diagnosis u No treatment is needed. Lesion usually resolves upon habit cessation u In some patients, acrylic shields that separate the teeth from adjacent mucosa may provide quick resolution of the lesions MORSICATIO BUCCARUM RSJ NDAB MORSICATIO AT OTHER SITES RSJ – Morsicatio Labiorum NDAB – Morsicatio Linguarum THERMAL BURN u Common lesion u Seen due to ingestion of hot foods or beverages (especially microwave oven associated). May be iatrogenic u Presents as sloughing white lesion/red-white lesion/red lesion u May show zones of erythema and ulceration u May show remnants of necrotic epithelium at periphery THERMAL BURN u Commonly affects palate or posterior buccal mucosa (depends on heat source) u Swallowing of hot beverages may cause swelling of upper airway and dyspnea several hours after the injury u Most cases resolve without treatment u Corticosteroids and antibiotics are used when there is involvement of upper airway with breathing difficulties ELECTRONIC CIGARETTE BURNS u The risk of thermal burns is associated with use of electronic cigarettes u Overheated Lithium battery u Overheating of the vaporizing system u In some cases, overheating may cause a blast that results in both physical and thermal injury u Chemical alkali burns from the electrolyte solution ELECTRONIC CIGARETTE BURNS u Most commonly affect the thigh, hands, face, and thorax u The burn area should be tested for pH with pH paper u If alkaline, then the area should be covered with mineral oil u If acidic, the area should be irrigated with water u The necrotic tissue would require debridement and be treated like a traditional burn u Oral burns are treated with saline rinses, systemic analgesics, and soft diet u Oral lacerations require surgical repair u Imaging is necessary to determine the extent of damage and to look for any foreign bodies THERMAL BURN NDAB – Thermal burn was the result of Internet – “Pizza palate” attempted ingestion of a hot pizza roll CHEMICAL BURN u Etiopathogenesis u Aspirin-tablets, powder u Bisphosphonates u Psychoactive drugs: chlorpromazine, promazine u Hydrogen peroxide u Toothwhitening products (contain hydrogen peroxide or carbamide peroxidase) u May show epithelial necrosis at dilutions as low as 1% u Recreational drugs like cocaine, MDMA, amphetamine CHEMICAL BURN u Iatrogenic u Silver nitrate: used to treat aphthous ulcerations u Endodontic irrigants: formocresol and sodium hypochlorite u Calcium hydroxide: used in the debridement of root canals and shows antimicrobial activity. u Dental cavity varnish u Acid etch materials u Cotton roll – chemical absorbed by cotton u Cotton roll burn/cotton roll stomatitis – is seen when the oral mucosa adheres to the dry cotton rolls, and rapid removal can cause epithelial stripping CHEMICAL BURN u May affect any oral mucosal site u Upon short exposure, the mucosa appears to exhibit superficial white, wrinkled plaque u Upon long exposure u There appears to be separation of surface epithelium from underlying tissue u A necrotic red, bleeding connective tissue is seen upon loss of necrotic epithelium u This is eventually covered by a yellow gray fibrinopurulent membrane u Best treatment is prevention of exposure to caustic materials u When prescribing caustic drugs, the clinician must instruct patient to swallow medication CHEMICAL BURN u The following can decrease the chance of tissue damage when irrigated with sodium hypochlorite u Using a rubber dam u Avoiding excessive pressure during application u Keeping the syringe needle away from the apex u Superficial damage resolves in 10-14 days without scarring after discontinuation of offending agent; temporary pain relief is obtained with topical anesthetics u Larger, deeper damage is treated with surgical debridement and antibiotic coverage to promote healing and prevent spread of necrosis u If calcium hydroxide overfill into the mandibular canal is associated with pain, numbness, or dysesthesia, refer the patient to an endodontist or oral surgeon to surgery with debridement. It’s likely to be successful if the intervention is performed within 72 hours after injury CHEMICAL BURN NDAB – Phenol burn NDAB – Aspirin burn CHEMICAL BURN RSJ- Mucosal burn (necrosis) caused by prolonged aspirin contact.  CHEMICAL BURN NDAB – Mucosal Burn from Tooth-whitening Strips. Sharply demarcated zone of epithelial necrosis on NDAB – Hydrogen peroxide applied with cotton the maxillary facial gingiva, which developed swab interproximally. from the use of tooth-whitening strips. Less severe involvement also is present on the mandibular gingiva. CHEMICAL BURN NDAB - Cotton Roll Burn (Zone of white epithelial necrosis and erythema of the maxillary alveolar mucosa). CHEMICAL BURN NDAB – Iatrogenic formocresol burn due to endodontic material between rubber dam clamp and tooth. Iatrogenic silver nitrate burn – dentist applied silver nitrate to cauterize tissue at sites of pericoronitis LEUKOEDEMA u Common oral mucosal condition u Seen in 70% to 90% of black adults u Seen in 50% of black children u The prevalence in Caucasians is less (ranges anywhere from 10% to more than 90%) uThe difference in racial predilection may be due to presence of background mucosal pigmentation in blacks u It’s a variation of normal rather than a disease u Unknown cause. It appears to be developmental in nature u However, it is more common and severe in smokers and becomes less pronounced with smoking cessation LEUKOEDEMA u Presents as a diffuse gray-white, milky and opalescent lesion; appears folded resulting in wrinkles or streaks u Seen bilaterally on the buccal mucosa; may extend onto the labial mucosa; rarely floor of mouth u The lesions do not rub off u White appearance diminishes or disappears when the cheek is everted and stretched u No treatment is required NDAC: Leukoedema. RSJ: Leukoedema. A thin ‘milky’ white coloration of the buccal mucosa. Note that White, wrinkled appearance of the the patient also has gingivitis. buccal mucosa. NDAC: Leukoedema. A, Diffuse white appearance of the buccal mucosa. B, Whiteness disappears when the cheek is stretched.  CANDIDIASIS Candidiasis is the most common oral fungal infection in humans Local General Denture wearing Immunosuppressive diseases Smoking Impaired health status Atopic constitution Immunosuppressive drugs Inhalation steroids Chemotherapy Topical steroids Endocrine disorders Hyperkeratosis Diabetes mellitus Imbalance of the oral microflora Hypoparathyroidism Quality and quantity of saliva (xerostomia) Hypoadrenalism Hematinic deficiencies Immunologic immaturity of infancy Systemic antibiotic therapy Pregnancy PSEUDOMEMBRANOUS CANDIDIASIS u Pseudomembranous candidiasis u Presents as adherent white plaques that resemble cottage cheese u Composed of tangled masses of hyphae, yeasts, desquamated epithelial cells, and debris u Scraping plaques can remove them; underlying mucosa may be normal or erythematous u Commonly affects buccal mucosa, palate, and dorsal tongue u Symptoms may not be present or mild burning sensation/unpleasant taste in the mouth (salty or bitter) NDAC: Pseudomembranous Candidiasis. NDAC: Pseudomembranous Candidiasis. A, White plaques on an erythematous base, characteristic of pseudomembranous candidiasis Multiple white plaques overlying B, Removal of several of the pseudomembranous plaques erythematous mucosal change on the reveals a mildly erythematous mucosal surface but no soft palate. evidence of bleeding. RSJ: Candidiasis, pseudomembranous type. COATED TONGUE u Coated tongue: caused by accumulation of bacteria and desquamated epithelial cells on the dorsal tongue without hair like filiform projections (may be a source of halitosis) (mistaken for candidiasis) u Patients who use bismuth subsalicylate for upset stomach may show transient black staining of the dorsal tongue without elongation of the filiform papillae; rapidly resolves after discontinuation of the medication NDAC: Coated Tongue. The dorsal tongue appears white and mildly thickened from the accumulation of keratin and bacteria on the surface. NDAC: Bismuth Staining. Transitory staining of the posterior dorsal tongue after using bismuth subsalicylate for an upset stomach. HAIRY TONGUE u Seen in 0.5% to 11.3% of adults u Seen due to marked accumulation of keratin on filiform papillae of the dorsal tongue resulting in hair like appearance u Due to increase in keratin production or decrease in normal keratin desquamation u Cause is uncertain u Possible associated factors u Smoking u General debilitation u Poor oral hygiene u Oxidizing mouthwashes u Drugs that induce xerostomia u History of radiation therapy to head and neck HAIRY TONGUE u Commonly affects midline tongue anterior to the circumvallate papillae, spares the lateral and anterior borders u Elongated papillae are brown, yellow or black (due to growth of pigment-producing bacteria or staining from tobacco and food u Asymptomatic u Patients may complain of gagging sensation or a bad taste in the mouth u No biopsy is necessary u Eliminate predisposing factors, encourage excellent oral hygiene u NDAC: Hairy Tongue. NDAC: Hairy Tongue. Elongated, yellowish white Marked elongation and brown filiform papillae on the dorsal staining of the filiform papillae, surface of the tongue. resulting in a hair like appearance. RSJ: Hairy tongue. MEDIAN RHOMBOID GLOSSITIS u Presents as a well demarcated erythematous zone that affects midline of posterior dorsal tongue u Erythema is seen due to loss of filiform papillae u It is often asymmetric; surface is smooth or lobulated u It is often asymptomatic NDAC: Erythematous Candidiasis. A, Severe presentation of central papillary atrophy. In this patient, the lesion was asymptomatic. B, Marked regeneration of the dorsal tongue papillae occurred 2 weeks after antifungal therapy with fluconazole. DENTURE STOMATITIS/CHRONIC ATROPHIC CANDIDIASIS u Most common form of candidiasis in denture patients and is usually asymptomatic u Localized to denture bearing areas of maxillary removable denture u Seen when patient wears denture continuously (however must rule out other causes such as improper denture design, allergy to denture base or inadequate curing of the denture acrylic) u Presents with varying degrees of erythema, sometimes accompanied by petechial hemorrhage u Chronic atrophic candidiasis can also be associated and concomitant with inflammatory papillary hyperplasia. This is often secondary to poorly fitting dentures NDAC: Denture Stomatitis. A, Maxillary denture with incomplete palatal vault associated with midline tissue hyperplasia. B, Mucositis corresponds to the outline of the prosthesis. C, Resolution of mucositis after antifungal therapy and appropriate denture cleansing. ANGULAR CHEILITIS u Presents with erythema, fissuring and scaling of the angles of the mouth u Commonly seen in older patients with decreased vertical dimension of occlusion and accentuated folds at the corners of the mouth, with pooling of saliva in the corners of the mouth u The severity of the lesions’ waxes and wanes u Cause: 20% of cases by Candida albicans, 60% of cases by Candida albicans & Staphylococcus aureus, 20% of cases by Staphylococcus aureus NDAC: Angular Cheilitis. Characteristic lesions appear RSJ: Candidiasis, angular cheilitis form. as fissured, erythematous alterations of the skin at the corners of the mouth. ORAL CANDIDIASIS u Diagnosis u Clinical signs in conjunction with exfoliative cytology uCytologicalfindings should demonstrate hyphal phase of the organism uCytology is simple, non-invasive and cost effective u Culture ORAL CANDIDIASIS u Imidazole agents u Clotrimazole 1% cream u Clotrimazole troches 10 mg u Disp: 15 gm (Mycelex) u Sig:Apply thin film to inner u Disp: #70 surface of denture and/ u Sig:Dissolve, in mouth, 1 or angles of mouth four troche as a lozenge five times a day (after each times daily for 14 meal and at bedtime) consecutive days. u Note: Do not eat or drink u Note: Do not eat or drink for 30 minutes following for 30 minutes following use. Continue for at least 3 days after apparent use clinical resolution ORAL CANDIDIASIS u Polyene agents u Nystatin oral suspension 100,000 units/ml u Disp: 240 ml u Sig: Swish and spit out (or swallow) 10 ml five times a day for 7-14 days u Nystatin pastilles 200,000 units/pastille u Sig: Dissolve 1-2 pastilles in mouth 3-4 times a day for 7-10 days u Nystatin ointment u Sig: Apply to affected area 3-4 times a day ORAL CANDIDIASIS u Triazoles u Fluconazole u Good systemic absorption u Long half-life allows for once-a-day dosing u Rare liver toxicity u Resistance to drug seems to develop in some instances u Drug interactions with phenytoin, warfarin, and sulfonylureas u Other agents u Iodoquinol u Has antifungal and antibacterial properties ORAL CANDIDIASIS u Angular cheilitis u Iodoquinol and hydrocortisone cream u Disp: 1 oz tube u Sig: Apply a thin film to the corners of the mouth three times a day u Clotrimazole 1% mixed with mupirocin 2% (1:1) u Disp: 15 g tube u Sig: Apply a thin film of this mixture on the affected areas 2-3 times a day until resolved u Very effective and predictable results u Nystatin 100,000 units/g and triamcinolone acetonide 0.1% ointment (Mycolog II, Mytrex) u Disp: 15 g (30 g, 60 g) tube u Sig: Apply a thin film to the corners of the mouth three times a day u Clotrimazole 1% and betamethasone cream (Lotrisone) u Disp: 15 g tube u Sig: Apply a thin amount to the affected area twice daily GEOGRAPHIC TONGUE u Other names: erythema migrans, benign migratory glossitis u Seen in 1-3% of population u Unknown etiopathogenesis u Female predilection u Presents as multiple, well demarcated zones of erythema (atrophy of filiform papillae) surrounded by slightly raised yellow-white serpentine or scalloped border (complete or partial) on the dorsal tongue (anterior 2/3rd) (tip and lateral borders), also ventrolateral tongue u Lesions develop in one area quickly, heal in days to weeks; then develop in a different area; continually changing pattern GEOGRAPHIC TONGUE u The lesions are usually asymptomatic; however, they may demonstrate burning sensation or sensitivity to hot or spicy foods u Often associated with fissured tongue (1/3rd of patients) u If seen involving buccal mucosa, labial mucosa, floor of mouth and soft palate- it is referred to as erythema migrans (don’t get confused with candidiasis or erythroplakia) u Symptomatic patients may need treatment with topical steroids (patient with burning sensation or tenderness) u Otherwise, no treatment is indicated NDAC: The erythematous, well- demarcated areas of papillary NDAC: The lateral distribution of the atrophy are characteristic of lesions is shown erythema migrans affecting the tongue. Note the asymmetrical distribution and the tendency to involve the lateral aspects of the tongue NDAC: Striking involvement of the NDAC: Lesions of the lower labial dorsal and lateral surfaces of the mucosa tongue NDAC: These palatal lesions show well- demarcated erythematous areas surrounded by a white border, similar to the process involving the tongue RSJ: Geographic tongue. RSJ: Geographic tongue. SUBMUCOSAL HEMORRHAGE u Seen when a traumatic event results in hemorrhage and entrapment of blood within tissues u Terminology depends on the size of hemorrhage u Minute hemorrhages into skin, mucosa, or serosa: petechiae u If a slightly larger area is affected: purpura (5 mm – 2 cm) u Any accumulation greater than 2 cm: ecchymosis u If the accumulation of blood within tissue produces a mass: hematoma SUBMUCOSAL HEMORRHAGE u Causes u Hematoma formation is usually seen secondary to blunt trauma u Petechiae and purpura formation may be seen secondary to repeated or prolonged increased intrathoracic pressure (Valsalva maneuver) associated with activities like repeated coughing, vomiting, convulsion, or giving birth. Also seen secondary to oral trauma from sexual practices u May also see hemorrhage from nontraumatic causes such as u Anticoagulation therapy u Thrombocytopenia u Disseminated intravascular coagulation u Viral infections (infectious mononucleosis, measles) SUBMUCOSAL HEMORRHAGE u Commonly presents as non-blanching lesion. Usually they are flat lesions, except hematoma (elevated lesion) u They can be red/purple to blue/blue-black u Commonly seen on labial mucosa or buccal mucosa u Hemorrhage associated with increased intrathoracic pressure may be seen as soft palate petechiae or purpura u No treatment if it’s not associated with morbidity or related to systemic disease. The areas resolve spontaneously u If hemorrhage is seen secondary to an underlying disorder, then treatment should be directed to control the associated disease u Large hematoma may require several weeks to resolve SUBMUCOSAL HEMORRHAGE RSJ – Petechiae associated with idiopathic RSJ – Traumatic ecchymosis. thrombocytopenic purpura (spontaneous hemorrhages). SUBMUCOSAL HEMORRHAGE NDAB – Petechia from violent NDAB – Hematoma from blunt trauma. coughing.  SUBMUCOSAL HEMORRHAGE Internet – Hematoma in child with aplastic anemia and very low platelet count. Internet – Ecchymosis following tooth extraction.