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1
White lesions Premalignant Lesions & Conditions
Oral Pathology
Dr. Sathya
2
Scope of the lecture
1. Why a lesion appears white?
2. Classification of white lesions
3. White lesions
4. Premalignant lesions & conditions
3
Based on Chapter Nineof Oral Pathology
by J.V. Soames and J.C. SouthamOxford :4th edition
4
Why a lesion appears white ?
1. Increased thickness of keratin layer
2. Increased thickness of epithelium eg Acanthosis
3. Pseudomembrane formation eg Candidiasis
“ White patch ” is a term used clinically to describe lesions presenting as white areas on the oral mucosa
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Increased thickness of keratin layer
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Increased thickness of epithelium eg Acanthosis
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Pseudomembrane formation eg Candidiasis
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Causes of oral white lesions
Normal variants : Fordyce’s spots, Leukoedema
Hereditary : White sponge naevus, Oral manifestation of genodermatoses
Traumatic : Mechanical (frictional keratosis) Chemical, Thermal
Infective : Candidosis Syphilitic leukoplakia Hairy leukoplakia
HPV infections
Dermatologic : Lichen planus Lupus erythematosus
Preneoplastic : Leukoplakia& Neoplastic Carcinoma in situ, Squamous cell carcinoma
9
????????........
Fordyce’s spots – heterotopic collection of sebaceous glands
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epithelium
sebaceous glands
11
Leukoedema
Diffuse greyish white lesion on the buccal mucosa
Absence of folding / thickening / loss of flexibility of mucosa
Whiteness disappears on stretching
Predisposing factors:
• Poor oral hygiene
• Tobacco usage
• Intake of spices
12
13
Hyperkeratosis and intracellular edema
“Spongiosis”
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• Hereditary disorder, autosomal dominant
• Mutations in genes coding for keratins 4 & 13 – keratin defects and abnormal desquamation process
C/F
• Affects any part of oral mucosa
• White patch of irregular borders, uneven thickness
• May be present from infancy / early childhood
White sponge naevus
15
Histopathology
• Epithelium shows acanthosis, with hyperparakeratosis
• Intra cellular edema of the prickle cell layer & parakeratinized cell layers
• Basket weave appearance
acanthosis
hyperkeratosis
16
Traumatic keratoses
Mechanical trauma – frictional keratosis
• Acute trauma leads to ulceration• Chronic frictional irritation leads to epithelial thickening & keratosis
• Chronic irritation – sharp tooth
cheek biting (morsicatio buccarum)
prolonged wearing of ill-fitting dentures
• Frictional keratosis – lesion resolves when source irritation is removed
Frictional keratosis
17Clinical implication………?
Sharp broken / ill-fitting denturesSharp tooth
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Linea alba – Frictional keratosis along the occlusal plane
Morsicatio buccarumMorsicatio labiorum
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Frictional keratosis - Improper tooth brushing
20
H/ P : Hyperkeratosis
Acanthosis (increase in thickness of spinous cell layer)
Hyperkeratosis
Acanthosis
Epithelium
Connective tissue
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Chemical trauma
Chemical insult to oral mucosa
1. Topical use of aspirin (aspirin burn)
2. Use of tobacco – smoked or chewed (tobacco pouch keratosis)
3. Chewing betel nut
H/ P : Epithelial thickening and hyperkeratosis
Aspirin burn
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Tobacco pouch keratosis
23
Chevron peaks / pattern of hyperkeratosis
Tobacco induced keratosis
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• Regular smokers of cigarettes, cigars & pipes often develop white plaques
• Usually on anterior aspect of buccal mucosa, tongue, palate & lips
• Produced by both thermal and chemical factors
Nicotinic Stomatitis / Stomatitis Nicotina / Pipe smokers palate
• Involves palatal mucosa
• Greyish-white area with scattered red spots
• Red spots are orifices of the minor salivary gland ducts
H/P :
• Hyperkeratosis
• Acanthosis
• Periductal chronic inflammation
Thermal trauma
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Stomatitis Nicotina – early lesion
Stomatitis Nicotina – advanced lesion
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keratosis acanthosis minor salivary gland duct
Minor salivary gland Periductal
chronic inflammatory infiltrate
Histopathology of Nicotinic stomatitis
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Infections – Oral thrush
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Infections – Syphilitic leukoplakia
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Infections – Oral hairy leukoplakia
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Infections – HPV associated Papilloma
31
EPITHELIAL DYSPLASIA
Abnormalities in proliferation, maturation and differentiation of
epithelial cells
32
Epithelial dysplasia
Abnormalities in proliferation, maturation and differentiation of epithelial cells
1. Increased / abnormal mitosis
2. Altered nuclear / cytoplasmic ratio
3. Abnormal keratinization : Intra epithelial keratin pearls / individual cell
keratinization
4. Irregular epithelial stratification
5. Loss of Polarity of basal cells
6. Loss of intercellular adhesion
7. Basal cell hyperplasia
8. Nuclear hyperchromatism
9. Enlarged and prominent nucleoli
10. Nuclear and cellular pleomorphism
11. Drop shaped retepegs
33
Intercellular adhesions - desmosomes
34
Altered nuclear cytoplasmic ratio
Loss of epithelial stratification, Loss of polarity of basal cells
Nuclear hyperchromatism, Nuclear and cellular pleomorphism
Drop shaped retepegs
35
Basal cell hyperplasia
Nuclear hyperchromatism
Altered nuclear cytoplasmic ratio
36Hyperkeratosis, acanthosis, drop shaped retepegs……???
37Epithelial dysplasia - Drop shaped rete pegs & basal cell hyperplasia
38
Epithelial dysplasia involving lower third of the epithelium cellular & nuclear pleomorphism, suprabasal mitosis, loss of ordered
stratification
Mitotic figure
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Moderate epithelial dysplasia – involving lower 2/3rds of the epithelium
Severe epithelial dysplasia – involving the entire epithelium
also called Carcinoma in situ
40
Leukoplakia
Definition : “A white patch or plaque that cannot be characterized clinically or histopathologically as any other disease”
Leukoplakia is a clinical diagnosis arrived at by exclusion.
41
Prevalence : varies from 1 – 10%
Non Homogenous :
Speckled / Nodular :
• irregular nodular / thickened surface
• areas of redness or ulceration producing speckled appearance
Verrucous : warty appearance
Clinical features :
Homogenous :
• Flat, uniform white plaques
• may show shallow cracks / fissures
42
Predisposing factors :
• Tobacco – Smoked / chewed
• Betel Chewing
• Snuff
• Alcohol
• Candida
• Viruses – HPV
• Oral epithelial atrophy - Iron deficeiency, Vitamin deficiency, Tertiary syphilis, Sideropenic dysphagia
• Mutation of tumor suppressor genes
43
H/P :
Leukoplakia is a clinical term, diagnosis not based on specific H/P features
• Varying degrees of Keratosis - Hyperkeratosis
• Varying degrees of epithelial thickness - Acanthosis
• Chronic inflammatory infiltration in lamina propria
• Features of epithelial dysplasia
Hyperkeratosis Acanthosis
44
Epithelial dysplasia
Abnormalities in proliferation, maturation and differentiation of epithelial cells
1. Increased / abnormal mitosis
2. Altered nuclear / cytoplasmic ratio
3. Abnormal keratinization : Intra epithelial keratin pearls / individual cell
keratinization
4. Irregular epithelial stratification
5. Loss of Polarity of basal cells
6. Loss of intercellular adhesion
7. Basal cell hyperplasia
8. Nuclear hyperchromatism
9. Enlarged and prominent nucleoli
10. Nuclear and cellular pleomorphism
11. Drop shaped retepegs
45
Epithelial dysplasia involving lower third of the epithelium cellular & nuclear pleomorphism, suprabasal mitosis, loss of ordered
stratification
Mitotic figure
46Epithelial dysplasia - Drop shaped rete pegs & basal cell hyperplasia
47
Moderate epithelial dysplasia – involving lower 2/3rds of the epithelium
Severe epithelial dysplasia – involving the entire epithelium
also called Carcinoma in situ
48
Prognosis :
Epithelial dysplasia
• Homogenous leukoplakia – epithelial dysplasia in 10%
• Non homogenous leukoplakia – are more dysplastic 50%
• Speckled leukoplakia – Epithelial dysplasia in 100%
Malignant transformation (Oral squamous cell carcinoma)
• 0.3 – 18%
• Ventral surface of tongue, floor of mouth, lingual aspect of lower alveolar mucosa show higher risk of malignant transformation
• Leukoplakia with epithelial dysplasia are more likely to become malignant
• Speckled & non homogenous leukoplakia – increased rate of malignant transformation
49
• Defined as a bright red velvety plaque on the oral mucosa which cannot be categorized clinically or pathologically as any other condition.
• Premalignant lesion, may develop in a previously white lesion
Erythroplakia
C/F :
Homogenous red lesion with irregular outline
Erythroleukoplakia : Intermingled with patches of leukoplakia (speckled leukoplakia)
50
H/P :
• Epithelial atrophy, severe epithelial dysplasia
• Basement membrane is intact, no connective tissue invasion
• 50% may represent Carcinoma in situ or even invasive carcinoma
Prognosis :
• Nearly 100 % of lesions show malignant transformation
• Ulceration, induration, fixation, lymphadenopathy are clinical features that indicate malignancy
51
Prevalence :
0.5 – 2% in general population
Lichen planus
C/F :
• 60% affects women
• Age : 30 – 50 yrs more common
• Skin lesion with oral manifestations in 50% of cases
• Only oral manifestations – Oral lichen planus
• Skin lesions – purple, pruritic, papules
• Distinctive white streaks on the surface – Wickham’s striae
• Skin lesions may be discrete, linear, annular or wide spread
52
Oral lesions :
• Buccal mucosa, tongue, gingiva, palate, lips may be affected
• Usually bilateral
• Clinical types : Reticular – lace like striae
Papular – small white raised lesions <5mm
Plaques – white raised lesions >5mm
Atrophic / Erosive – red areas / shallow ulceration
Bullous – subepithelial bullae
• Wickham’s striae evident
• Pain & discomfort (burning sensation) vary from mild to severe
53Bullous Erosive / atrophic
Reticular Papular
54
Pathogenesis
• Cell mediated immune response to antigenic changes in epithelial cells
Antigens in epithelial cells
Cytokine release from Langerhans cells & keratinocytes
Activates T cells (CD4, CD8 cells)
T cells migrate to the basal cell region
Cytotoxic CD8 cells damage the basal cells
55
Lichenoid Reactions :
• Hypersensitivity to drugs / dental materials produces lichen planus like lesions.
• Lesions usually resolve on withdrawal of offending drug
Lichenoid reaction resulting from hypersensitivity to amalgam restoration
56
H/P:
• Ortho / parakeratinization
• Epithelium may be atrophic / acanthotic
• Rete pegs show saw tooth pattern
• Subepithelial band of chronic inflammatory cell infiltrate (T lymphocytes)
• Basal cell degeneration – liquefactive degeneration
• Civatte bodies – degenerating basal cells undergoing apoptosis
appear as hyaline, shrunken / condensed bodies
• Bullous lichen planus - subepithelial bulla
Prognosis :
Premalignant condition, 1 - 4 % malignant transformation
57
Saw tooth rete pegs and dense subepithelial inflammatory infiltrate evident
Lichen planus
58
59
Premalignant Lesions and Conditions
Premalignant lesion is defined as a morphologically altered tissue in which cancer is more likely to occur than its normal counterpart. The lesion itself undergoes malignant transformation.
Premalignant condition is a generalized disorder associated with a significantly increased risk of cancer development some where in the mouth.
60
Premalignant lesions
1. Leukoplakia – Homogenous, non-homogenous, nodular, speckled,
Verrucous leukoplakia, Candidal Leukoplakia
2. Erythroplakia
3. Carcinoma in Situ
Premalignant conditions
1. Oral submucous fibrosis
2. Lichen planus
3. Actinic keratosis
4. Conditions associated with epithelial atrophy – sideropenic dysphagia
61
Oral submucous fibrosis
Chronic disease may affect any part of oral mucosa
Increased stiffening with progressive fibrosis
Etiology
Areca-nut chewing habits
Genetic predisposition
Nutritional factors
C/F
Burning sensation in mouth when consuming spicy food
Reduced mouth opening & tongue protrusion
Mucosa is blanched with marble-like appearance
Palpable bands of fibrous tissue
62
blanched appearance of mucosa
fibrosis with resultant atrophy of the papillae
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H/P
1. Atrophic and thin stratified squamous epithelium, absence of rete ridges
2. Hyalinization of subepithelial connective tissue
3. Very few fibroblasts, blood vessels obliterated by dense fibrosis
4. Inflammatory infiltrate (lymphocytes and plasma cells)
Epithelial dysplasia may be seen in 10 – 15 % of cases
Premalignant condition : 5 - 8% malignant transformation
64
Actinic keratosis / actinic cheilitis
Exposure to UV component of the sun
Disease of outdoor workers – farmers and fisherman
Risk of developing lip cancer
65
Also called as Plummer-Vinson syndrome / Paterson-Brown-Kelly syndrome
Triad of dysphagia (due to esophageal webs) glossitis iron deficiency anemia.
Sideropenic dysphagia
Blood picture Bald tongue, glossitis
66
Principles of management of dysplastic lesions
1. Stop any associated habits
2. Treat candidial infection / iron def
3. Biopsy to assess dysplasia
4. Assess risk of malignant change on clinical & H/P findings
5. Consider ablation of individual lesions
6. Regular observation
67
Options for management of premalignant lesions
1. Early detection of cancer
2. Surgical excision with grafting
3. Laser excision
4. Topical chemotherapy
5. Retinoids