Oral pathology lec# 2 Web viewWhen stage increases in #, the risk of dysplasia to progress to cancer increases. Dermatological white lesion: Its skin disease & this disease has oral

Sun 22\9\2014Oral pathology Lec #2

White lesion

White patch: term used clinically to describe the appearance of lesions presenting as white area on oral mucosa.

Aetiological classification of white patch:HereditaryTraumaticInfectiveIdiopathicDermatologicalNeoplastic

Leukoplakia:

Defined as: #a predominantly white lesion of the oral mucosa

that can't be characterized as any other definable lesion.

#White lesion whithout known couse.

So diagnosis of these lesion by excluding the other cause of white lesion.

Prevalence: Less than 1% of people

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Gender:Male > FemalUsually in elderly pt. or in middle age pt.

Site:Affect any site on oral mucosa but the floor of the mouth & buccal mucosa are being the most common site to be affected.

*leukoplakias involving the ventral tongue and\or floor of the mouth have high risk of malignant transformation than lesion at other site.

Size:Vary from a quite small and circumscribed plaque to an extensive lesion involving a large area of oral mucosa.

Color: maybe: # white # whitish-yallow

# gray

Characteristic of leukoplakia: Has high chance to change to malignant.

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clinical classification of leukoplakia: there are 2 types of leukoplakia:

Homogeneous 2\non-homogeneous 1\

Non-homogeneous HomogeneousIf we see one of these things:

1-not flat surface, irregular nodular. (thickening surface) some case may take a warty appearance.

2-variation in color , show areas of redness producing a speckled appearance.

3-ulcer.Non-homogeneous lesion have a worse prognosis

50% of cases have dysplasia.

1-plaque-like,flat,uniform2-predominantly white

plaque.3 -may show shallow

cracks\fissures on surface.

Only 10% of cases have dysplasia.

# Non-homogenous is more dangerous than homogenous .

Erythroplakia:

Is a bright-red patch on the oral mucosa which can't be categorized clinically or pathologically as being due to any other condition.

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Erythroplakia lesion may be homogeneous with well-defined outline. Or . may be intermingled with patch of leukoplakia which called speckled leukoplakias or erythroleukoplakia.

Histologically Erythroplakia may represent carcinoma in situ or even invasive carcinoma.

Etiology : is Unknown similar to leukoplakia , but in some pt. predisposing factor can idintifie.

The Incriminated factors are:

# tobacco

#Alcohol

#candida

#viruses: HPV 16 + 18

#Epithelial atrophy

In atrophic area there are High chance to develop leukoplakia and oral cancer.

Causes of atrophy in oral mucosa:

1\Iron deficiency as : Sideropenic dysphagia, Patterson Kelly, plummer-vinson syndrome.

Iron deficiency epi. Atrophy appear of cancer and leukoplakia.

2\ Vit. deficiency (vit. A&B).3\submucous fibrosis.. especially in chewing habit area.

4\tertiary syphilis.

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Histopathological features of leukoplakia:

No specific histological feature..there is a wide range in histological appearances which reflect present of:

*Ortho or parakeratosis or mixture in the same area.In case of speckled there is an atrophy*.Hyperplasia of epithelium*.

*Chronic cell infiltrate in lamina properia.

But the most imp. Feature for pathologist is present of Dysplasia or not. cause leukoplakia has a potential change to cancer. So we should take a biopsy to decide if there is a dysplasia or not.

in diagnose of leukoplakia case the case should follow-up and management cause these lesion may be a cancer.

Pathologist classification of dysplasia according to its severity :

1-basal cell hyperplasia.2 -Milddysplasia in lowe1\3 of thickness epi.

3 -Moderatdysplasia up to 1\2 of thickness epi.4-severedysplasia more than 1\2

5 -carcinoma in situfull thickness of epi.

An increased in severity of dysplasia increase the risk of oral cancer.

Prognosis:

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-unpredictable(-0.3-18% )of case could be change to cancer.

Risk factor of leukoplakia:* Family history: if the pt. have family history for

oral cancer this will increase the susceptiblitiy in changing the leukoplakia to cancer.

* Non-homogenous: leukoplakia has highest chance to change to cancer.

if the pt. have Homogenous lesion changing with time to non-homogenous(speckle or nodularity or ulcer or redness) he will have higher tendency to change into cancer.

* Size: increasing in size more than 2cm more susceptible to cancer.

* Duration: increase the durationincrease the chance to change to cancer

* Site: present leukoplakia on the floor of the mouth has more susceptibility to change to cancer.

**The Risk of developing malignancy at lesion site is 5 times greater in pt. with leukoplakia than with normal person.

Dysplasia:- In * Homogenous leukoplakia 10% Non-homogenous 50%

Erythroplakia 80-90% either sever or carcinoma in situ or cancer (mild invasive)

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we have another thing to predict the prognoss rather than Biopsy which is a Molecular marker staining the tissue ether by immunohistochemistry or other.

Classification and Staging:This staging is used to predict the risk.

1-Size: L1 (less than 2cm) L2 ( 2-4 cm)

L3 ( more than 4 cm)

We use the size to predict the prognosis.

2-presence of dysplasia (D): D0: no dysplasia

D1: mild to moderate dysplasia D2: severe dysplasia

Stages:Stage1: L1D0Stage2: L2D0Stage3: large or small size and D1Stage4: L3D1 or any size with D2

When stage increases in #, the risk of dysplasia to progress to cancer increases.

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Dermatological white lesion:Its skin disease & this disease has oral manifestation as white lesion.

Lichen planus: (easier in Dx.)-the most common disease that we can see in pt.

who visit our clinic.

-totally benign.

-chronic inflammatory disorder affecting skin and mucous membranesmost diseas affecting mucosa.

-affecting 1% of population.

-most predisposes females 30-60%

-affect middle age 30-50 years.

-40% of pt. have skin+oral lesion both areas are affected.

-35% of pt. have just skin lesion without oral manifestation.

-25% of pt. have just oral manifestation without skin lesion.. in this case we may have problem in diagnosis coz in lichen planus we depend on presence of skin lesion in diagnosis.Feature of skin lesion :

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*Purplish, itchy, small papules (2-3mm)in diameter, has white striation on its surface called Wickham's striae.these striae help in Dx.

*Almost any area in sikn can affect but mostly in flexon surface of the wrist.

* Nail are involved in up to 10% of pt.they have atrophy and vertical ridges.

Skin lesion is not permenant they can disappear after one or two years and come back again in another place of the body… this is v.imp. when take history.

-we have to distinguish between lichen planus

and Psoriasis which is red or white lesion on

skin and it doesn't has Wickham's striae.

Oral lichen planus:-most frequent site is Buccal mucosa.-can affect other site as tongue, gingiva,

lip ,vestibule. -least frequent (rarely seen) on the floor of the

mouth & palate.

Distribution of L.P is bilaterally and symmetrical this will help in diagnosis.

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Types of lichen planus:1-Reticular type:

-the most common type.-Asymptomatic

-Site : appears on buccal mucosa bilaterallook like white spongy naevus.

-has wickham's striae has lace-like striae

-it seems like leukoedema, so we have to do stretch test for diagnosis.

2-Plaque-like:-less frequent.-Asymptomatic.

-white plaques resembling leukoplakia.-Site: appear on buccal mucosa and on tongue or

other sites.

3-Papular type:-rare not common

-Asymptomatic.-small white papules that may coalesce give

plaque-lesion.

4-Atrophy type:-more frequent than popular and plaque-like

and the 2nd most type after reticular.-atrophyred in color look like Erythroplakia..

so to differentiate between them we look for wickham's striae.

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-Symptomatic… it cause pain because atrophy means loss of epi. That protects nerves, without

epi. The tissue becomes so Sensitive .-most common Site is Gingiva.. it look like

gingivitis.**How to differentiate btn atrophy type &

gingivitis??

Gingivitis: is the inflammation of marginal gingiva.

Atrophy type: redness is on the whole thickness of gingiva (marginal gingiva & attached gingiva) and this called desquamative gingivitis.

5-Bollous type:-rare to see

- up to 2cm , mostly seen in skin not intraorally coz its easy to ruptures and produce an ulcers.

- Site: on posterior buccal mucosa.

6-Erosive type:-Dangerouse.

-most painfull to the pt., difficulty in mastication,bleeding, suffering during swallowing.

-extensive areas of shallow irregular areas of epithelial loss (ulceration)

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So its not red in color.. its yellowish membrane duo to fibriline deposition.

-can occure in any area, its very persistant (chronic duration of ulceration)

-Diagnosis of erosive type by recognize white area around the lesion

Histological feature of lichen planus:1.Focal acanthosis—the epi. Is ortho or

parakeratinized.2 .sawtooth rete pegs: this appearance results

from acanthosis which make irregular elongation and widening of the rete processes.

3.Adense, well-defined band of T-lymphocyte in the superficial layer of epi.

4 .Inflammation extending to basal and parabasal cell layer.

5 .liquefactive degeneration of the basal cells: which is the degeneration of the basal cells associated with oedema and lymphocytic infiltration.

6.Civatte bodies: the degenerating cells appear as hyaline condensed bodies and represent basal cells under going apoptosis.

The etiology of lichen planus: Unknown!!

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But May be associated with some condition like:1 \infective agents such as bacteria.

2 \systemic diseases: DM, hypertension, ulcerative colitis, liver disease such as hepatitis C and graft-versus-host disease (GVHD).

3 \Psychiatric disorders: stress, depression.4\Tobacco.

5\Decrease in vitamins.6 \Lichenoid reaction: results from drugs

antimalarial,gold,methyldopa,NSAID)and amalgam restoration .

The pathogenesis:

1-Type IV hyper sensitivity reaction will appear, caused by the well-defined band of T-lymphocyte that will excite the immune cells to come and fight the cells in the region.

2- lichenoid reaction is similar to lichen planus clinically. (in Certain patients who take certain drugs (antimalarial, methyldopa and NSAID) lesions will appear similar to lichenplanus.

And next to an old amalgam restoration a red lesion with whitish striated border will appear.

Histologically we can differentiate btw these lesions and lichen planus but not clinically.

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3- A certain infective unknown agents come to the epithelium and its similar to the antigen of the keratinocytes, processed by langerhan's cells and presented activate production of CD8.

So the treatment is by suppressing the immune reaction.

Lupus erythromatosus:Two main forms of this disease are recognized:

1\Chronic discoid lupus erythematosus.2 \Systemic lupus erythematosus.

1\ Chronic discoid lupus erythematosus : * which is (Localized) disease.

* its restricted to the skin of the face, scalp & ears

*present as Scaly red patches and butterfly pattern ( lesion has symmetrical distribution over the nose & cheeks).

*Oral lesion are present in 50% of the cases.*can affect any part of the oral mucosa

(cheeks,vermillion zone), there will be a discoid area of erythema surrounded by a white keratotic border with radiating striae like sun.

The histological appearance : 1\ Ortho- or parakeratinized.

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2\ Hyperplasia or atrophy.3\ Keratin plugging.

4\ subepithelium and deep perivascular lymphocytes (this is the difference btw chronic discoid and lichen planus).

5\ liquefactive degeneration in the basal cell layer.

6\ Directimmuneflurocence test will be +ve for IGg , C3 and fibrinogen (coz they will be deposit as a granular linear in the basement membrane).

Systemic lupus erythematosus:*which is disseminated disease involving

almost every organ of the body.*the lesion in sys. LE. Include skin rashes that

occur on cheeks.*Oral lesion occur in 20% of the cases

described as superficial erosions & erythematous patches on the buccal mucosa.

*there is systemic symptoms: fatige, malaise, fever psychosis and lymphadenopathy.

Good Luck any correction are more than welcome

Done by.. Lama Jaber .

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Documents

Oral pathology lec# 2 Web viewWhen stage increases in #, the risk of dysplasia to progress to cancer increases. Dermatological white lesion: Its skin disease & this disease has oral