Hereditary

1. Leukoedema

Incidental finding in non Caucasians

• Clinical: Generalized opacification on buccal mucosa, symmetrical

• Histology:
  • Parakeratosis
  • Acanthosis
  • Basket weave appearance – intracellular edema of stratum spinosum
  • Enlarged cells + pyknotic nuclei

• Management: No intervention needed

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2. White sponge naevus

• Etiology: AD, Keratin 4 and 13 point mutations

• Clinical:
  • White areas, lack sharp borders
  • Spongy white lesion
  • Other mucosal surfaces
  • Symmetrical

• Histology:
  • Parakeratosis
  • Acanthosis
  • Basket weave appearance
  • Hyperkeratosis
  • Marked spongiosis

• Management: No intervention needed

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Reactive

1. Frictional keratosis

• Etiology:
  • Chronic rubbing or friction against a mucosal surface
  • Ill fitting dentures or prosthesis, line of occlusion – Linea alba

• Histology:
  • Hyperkeratosis
  • Chronic inflammatory cells in epithelium

• Management: Observe for any clinical change that may suggest neoplastic change

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2. Nicotine stomatitis

• Etiology: Smoking

• Clinical:
  • Keratin opacification of palate
  • Inflamed minor salivary glands (reddened and enlarged)

• Histology:
  • Hyperkeratosis
  • Inflamed minor glands
  • Epithelial hyperplasia

• Management:
  • Encorage patient to quit
  • Observe for neoplastic changes

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3. Hairy leukoplakia

• Etiology:
  • EBV
  • HIV, Immunosuppression

• Clinical:
  • Lateral surface of tongue in male homosexuals
  • Flat plaque like of filiform (corrugated)

• Histology:
  • Hyperkeratosis
  • Viral cytopathy – Inclusion bodies in superficial cells of epithelium
  • Ballooning degeneration of cells
  • Scanty subepithelial infiltrate and Langerhans cells

• Management:
  • Acyclovir, ganciclovir
  • Tretinoin
  • Podophyllum

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4. Burns

• Etiology:
  • Thermal burns
    • Dorsum of tongue, palate – Hot food/drink
    • Erosive lesion – erythematous border surrounding white damaged mucosa
  • Chemical burns:
    • Dorsum of tongue, palate – toxic chemical/ suicide
    • Muccobuccal fold: Etching process, aspirin placed near decayed tooth
    • Mild white filmy desquamation in oral mucosa

• Clinical:
  • Transient non keratotic appearance
  • Superficial membrane composed on coagulated tissue within inflammatory exudate

• Histology:
  • Inflammatory infiltrate
  • Coagulative necrosis of epithelium

• Management:
  • Heal without scarring in 7-10 days
  • Palliative care
  • Topical anesthetics (benzocaine gel)
  • Topical corticosteroids (triamcinolone ointments)
  • Bonjela
  • Sodium bicarbonate mouthwash

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Preneoplastic and neoplastic

1. Actinic cheilitis

• Etiology: Chronic exposure to the sun (UVB rays)

• Clinical: Accelerated tissue degeneration of vermillion of lips

• Histology:
  • Hyperkeratotic epithelium
  • Atrophic epithelium
  • Basophilic change of collagen
  • Telangiectasia

• Management: PABA lip balm (para-aminobenzoic acid)

Types of chelitis

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2. Leukoplakia

• Etiology:
  • Tobacco
  • Alcohol
  • Nutrition deficiency
  • Idiopathic
  • Age: 40+

• Clinical:
  • White patch on oral mucosa that cannot be scraped off
  • Vestibule buccal > palate, alveolar ridge, lip, tongue, floor of mouth

• Histology:
  • Hyperkeratosis
  • Dysplasia
  • Carcinoma in situ

• Management: 10 – 15% turn malignant

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3. Lichen planus

• Etiology:
  • Chronic mucocutaneous disease
  • Abnormal cellular adhesion molecules (CAM) – bind to T-lymphocyte receptors (LFA) – which destroy skin and mucosal tissue
  • Therefore lymphocytic destruction of basal keratinocytes

• Subtypes:
  • Reticular
  • Plaque like
  • Atrophic
  • Erosive/ulcerative
  • Bullous

• Histology:
  • Orthokeratosis/ parakeratosis
  • Acanthosis
  • Epithelial atrophy
  • Missing rete-ridges/ saw tooth appearance

• Diagnosis: +ve for fibrinogen immune fluorescence

• Management: Long term follow up

• NB: Koebner phenomenon – occurs in lichen planus, warts and vitiligo

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4. Oral submucous fibrosis

• Etiology: Areca nut chewing, genetic trait

• Clinical:
  • Stiffnes in oral mucosa – limits mouth opening
  • Epithelial atrophy
  • Fibrosis of subepithelial connective tissue

• Histology:
  • Severe epithelial atrophy and dysplasia
  • Hyperkeratosis, no retepegs

• Management: Can transform to malignancy, long term follow up

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5. Lupus erythematosus

• Etiology: Autoimmune disease, affects humoral and cell mediated immunity

• Subtypes:
  • Acute/ Systemic (SLE)
  • Subacute (intermediate features)
  • Chronic/ Discoid

• Histology:
  • Keratosis
  • Epithelial atrophy
  • Basal cell loss
  • Subepithelial + perivascular lymphocyte infiltrate

• Direct immunofluorescence (DIF): Granular/ linear basal membrane deposits of IgG, IgM, IgA, C3 and fibrinogen

	Discoid/ Chronic	Systemic/ Acute
Organs affected	Skin Oral lesions	Skin Oral Heart Kidney Joints
Symptoms	Local only	Fever Malaise Weight loss
Serology	No detectable antibodies	+ve antinuclear antigen (ANA) Anti DNA antibodies
Management	NSAIDS Topical cortiosteroids	NSAIDS Systemic corticosteroids

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Infective

1. Candidiasis

• Etiology: Normal flora C. albicans turns pathogenic

• Pathology:
  • Adhesion using molecules – lectins, integrins, mannose containing proteins – bind to lectin like molecules on epithelial cells
  • Produce toxins – aspartyl proteases
  • Enhance survival by transitioning between: Yeast blastospore form ↔ Hyphae form

• Diagnosis:
  • Histology: Basic PAS (Periodic acid–Schiff) – shows candidal hyphae/ blastospores
  • Germ test tube – Culture at 37°C in serum for 3 hours – hyphae growth

• Management:
  • Topical: Nystatin, clotrimazole
  • Systemic – Fluconazole, ketoconazole

• Predisposing factors:

1. Systemic antibiotics
2. Immunodeficiency – infancy/ acquired
3. Xerostomia
4. Poor oral hygiene
5. Endocrine disturbance – DM, pregnancy, hypoadrenalism, hypoparathyroidism
6. Corticosteroids

Mnemonic: SIXPEC

• Types:

1. Acute: Pseudomembranous (yellow/white) or erythematous lesion (red and painful)

• Extreme age
• Immunosuppressed
• Cancer therapy

2. Chronic: Erythematous or hyperplastic lesions

• Denture sore mouth in 65% geriatric denture wearers

3. Mucocutaneous: Underlying systemic disease

• 1. Localized
• 2. Familial
• 3. Syndrome associated

4. HIV associated

5. Others:

• Angular chelitis
• Median rhomboid glossitis Picture

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2. Hairy leukoplakia

3. Koplik spots

• Etiology: Complication of measles (paramyxoviridae)

• Clinical:
  • White spot < 1cm in diameter in children
  • Precedes maculopapular rash of measles

• Histology: Superficial necrosis + neutrophilic inflammatory infiltrate

• Management: Supportive, antipyretics

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4. Syphilis

• Etiology: 2ry syphilis can turn malignant

• Clinical:
  • Atrophic epithelium
  • Glossitis

• Histology: Atrophic epithelium

More notes

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Others

1. Ectopic lymphoid tissue/ fordyce granules

• Etiology: Ectopic sebaceous glands

• Clinical:
  • Yellow white elevations on:
    • Post-lat aspect of tongue
    • Buccal mucosa
    • Upper lip vermillion

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2. Geographic tongue

AKA Migratory glossitis, erythema migrans

• Etiology:
  • Aggravated by stress
  • Irritated by spicy food

• Clinical: Keratosis on dorsum of tongue ± fissuring

• Histology:
  • Atrophic filiform papillae
  • Hyperkeratosis
  • Dense inflammatory infiltrate
  • Acanthosis

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3. Hairy tongue

• Etiology:
  • Chronic smoking
  • Broad spectrum antibiotics

• Clinical:
  • Overgrowth of filiform papillae on tongue
  • Colonization by chromogenic bacteria – change in colour of papillae

• Management:
  • OHI
  • Sodium bicarbonate

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