Differencial diagnosis – part I White lesions MUDr. Hana Poskerová Ph.D. Stomatologická klinika FN u svaté Anny a LF MU v Brně C:\Users\ing. Radomil Novak\Desktop\ICRC\propagace a marketing\PPT prezentace\Background\budovajpeg.jpg C:\Users\ing. Radomil Novak\Desktop\ICRC\propagace a marketing\loga\FNUSA - NEW!!\FNUSA_logo.jpg Disruption of the mucosal surface •Blisters •Erosion •Ulcer Differencial diagnosis Change of color •White lesions •Red lesions •Pigmented lesions Change in mucosal thickness •Papillary lesions •Soft tissue enlargement •Atrophy - etiology is diverse - clinical picture is often very similar - various lesions with various prognosis • 1 - overproduction of keratin on the epithelium surface - keratosis, hyperkeratosis 2 - thickening of the epithelium - acanthosis 3 - accumulation of debris, colonies of microbes White lesions •keratosis, hyperkeratosis • • •acanthosis • • •colonies of microbes White lesions White lesion •Is it accumulation of debris ? Materia alba - amorphous structure, epithelia, leukocytes, rests of food, removing by spray is possible Is it really a "white surface" or it is erosion or ulceration covered by fibrin pseudomembrane? nik50638 Is it really a "white surface" or it is the multiplied coating of the tongue? D:\pac.Janoušková Zdeňka 1958 foto.4.8.011\nik50757.JPG •Can you wipe it away ? - colonies of microorganisms • •Is it localized or diffused lesion ? • •Is their symmetry ? - oral lichen planus / leukoplakia • •Subjective complaints ? - candidiasis, lichen • •Smoking ? - leukoplakia Differencial diagnosis of white lesions •Leukoedema •White sponge nevus congenital/developmental •Fordyce‘s granules •Linea alba •Morsicatio buccarum at labiorum chronic irritation •Frictional keratosis of low intensity White lesions - etiology White lesions - etiology •Leukoplakia •Nicotinic stomatitis external factors •Toxic - allergic reaction •Actinic cheilitis •Lichen planus – reticular and plaque type •Lupus erytematodes •Psoriasis immunopathological reactions •Pseudomembranous candidiasis •Chronic hyperplastic candidiasis •Hairy leukoplakia •HPV infections •Syphilis Leukoedema White sponge nevus Fordyce‘s granules White lesions congenital/developmental disorders Leukoedema • anatomical variant of oral mucosa • thickening of the epithelium, intracellular oedema • occurs bilaterally on buccal mucosa White spongious nevus •inherited, congenital benign lesion, familial occurence •appears at birth or in infancy •thickening of the oral mucosa, multiple furrows •asymptomatic, occurs bilaterally on buccal mucosa,... nik63863 nik63864 nik63862 Morbus Fordyce – Fordyce granules • developmental anomaly • frequent finding • heterotopic sebaceous glands • men are affected more often Linea alba Morsicatio buccarum at labiorum Frictional keratosis White lesions chronic mechanical irritation of low intensity that stimulates thickeninig of the epitelium Linea alba - bilateral linear elevation of oral mucosa at occlusal line (compression) Cheek-lip bite stomatitis Morsicatio buccarum at labiorum •Morsicatio buccarum/labiorum nik60164 Frictional keratosis •benign hyperkeratosis •chronic irritation of low intensity that stimulates thickeninig of the epitelium (inadequate OH, ill-fitting dentures) •history of chronic trauma •gingiva, alveolus, hard palate •painless, persistent •removing of irritation •observation - biopsy Leukoplakia Nicotinic stomatitis Actinic cheilitis Toxic - allergic reaction White lesions external factors Leukoplakia •Clinical description - white patch or plaque, firmly attached to the oral mucosa, that cannot be classified in any other disease entity nik59897 Leukoplakia - clinical appearance •Homogenous •Non-homogenous Leukoplakia plana - verrucous - erytroplakia Leukolpakie Leuko nehomo Leukopl - simplex Homogenous leukoplakia •Circumscribed adherent white homogenous plaque with a smooth or wrinkled surface •Asymptomatic, painless, persistent Leuko homo2 Non - Homogenous •Is not uniform (colour, surface, textura) •Changing of white/red patches, multiple small white nodules, proliferation Non - Homogenous nik50499 Non - Homogenous •Verrucous leukoplakia Dysplastic changes of the epithelium - Ca in situ Higher probability of malignancy nik50482 •Erytroplakia Tongue erythroplakia malignize in 96% Matte appearance Leukoplakie nearby Leuko nehomo Trauma jazyk Histological examination WHO classification 2017 Binary classification Mild dysplasia Low-grade dysplasia Moderate dysplasia High-grade dysplasia Severe dysplasia Risk of malignant transformation Type: non-homogeneous (redness, bleeding, induration) Localization - root (up to 70%), base and edges of the tongue, oral base, retromolar area Size - idiopathic leukoplakia, (non) smoking women - the accumulation of factors is risky - epithelial dysplasia - candida colonization (15 % leukoplakia) Leukoplakia - treatment Elimination of irritating effects - radices, caries, teeth in supraocclusion - prosthetic dentures - SMOKING, hard alcohol Surgery (histological examination) 1 / small - excision of the whole lesion, control 2 / extensive without dysplasia - dg. excision, than regular observation 3 / epithelial dysplasia - radical surgary Nicotinic stomatitis – Smoker‘s palate - chronic exposure to the thermal and chemical irritation at smokers (regression is possible) -redness on the palate, grayish – white multinodular appearance (keratinization) -multiple red dots (minor salivary glands) Toxic - allergic reaction Acylpyrin burns Acid burns - white plaques at the site of contact Actinic/abrasive cheilitis -in older persons as a result of long-standing exposure to sunlight -lower lip, mild oedema, slight erythema, dryness, fine scaling, athropic area, erosions Actinic/abrasive cheilitis Diff. dg .: oral lichen planus, lupus erythematosus OLP - inflammatory changes dominate ACH - degenerative to dysplastic changes lupus ery ret nik56126 nik56127 Man, 69 years old White lesions •Lichen planus – reticular and plaque type •Lupus erytematodes •Psoriasis immunopathological reactions Annularni LP OLP jazyk5 LICHENPLANUS20 Oral lichen planus •Chronic inflammatory disease •Etiology - probably immune mechanisms •2% of the population; 40 - 60 years; more common in women Reticular type of OLP - white adherent striations Plaque type of OLP- white adherent circumscribed plaques Annular type of OLP - white adherent rings Oral lichen planus atrophic erosive bullous nik34578 lichen 9 OPLjazyk4 OLP jazyk5 nik34574 nik50762 nik46000 OLP patro OPL-gingiva OLPgingiva2 Desqamative gingivitis •Sensitivity to soreness, burning •More common in women •10 % OLP only desquamative gingivitis nik44132 nik44130 Lichenoid reaction to amalgam nik00015 nik00001 Lichenoid reaction to amalgam nik58025 nik58023 Lichenoid reaction to amalgam Oral lichenoid lesion / lichenoid reaction contact allergy to gold nik68921 nik71240 nik71241 Diff. Dg. Lichenoid reaction Leukoplakia White lesions •Pseudomembranous candidiasis •Chronic hyperplastic candidiasis •HPV •Hairy leukoplakia •Syphilis infections Acute pseudomembranous candidiasis - C. albicans primarily grows on the epitelial surface - multiple nonadherent plaques - removal of the plaques reveals erythematous surface Chronic hyperplastic candidiasis - circumscribed, adherent white plaque - infected epithelium becomes hyperplastic with formation of excess surface keratin HPV infection - exophytic - well circumscribed - pedunculated or sessile growth - solitary or multiple lesions - white or grayish colour Hairy leukoplakia - hyperplasia of oral epithelium with production of excess keratin - caused by EB virus infection - the surface of the lesion is frequently infeceted with C. albicans - in individuals with compromised immunity Syphilis – 2. stage White lesions White lesions - differecial dignosis