Embed Size (px)
Citation preview
Dent 355Dent 355Keratoses and Related Keratoses and Related
Disorders of Oral Mucosa IDisorders of Oral Mucosa I
Dr. Huda HammadDr. Huda Hammad
Keratoses and Related Keratoses and Related Disorders of Oral MucosaDisorders of Oral Mucosa
IntroductionIntroductionClassificationClassificationDefinition of histopathologic termsDefinition of histopathologic termsHereditary conditionsHereditary conditionsTraumatic keratosesTraumatic keratosesLeukoplakiaLeukoplakiaDermatological causes of white patchesDermatological causes of white patches
Introduction: Normal Oral MucosaIntroduction: Normal Oral Mucosa
Color of normal Color of normal oral mucosa: oral mucosa: vascularity, vascularity, melanin, epithelial melanin, epithelial thickness, thickness, keratinization.keratinization.
Introduction: Normal Oral MucosaIntroduction: Normal Oral MucosaNon-keratinized partsNon-keratinized parts
Introduction: Normal Oral MucosaIntroduction: Normal Oral MucosaNon-keratinized partsNon-keratinized parts
Introduction: Normal Oral MucosaIntroduction: Normal Oral MucosaKKeratinized Partseratinized Parts
Introduction: White PatchesIntroduction: White Patches
White patches White patches may be may be due to increased or due to increased or abnormal production of abnormal production of keratin keratin which appears which appears white in the wet oral white in the wet oral environment: they environment: they cannot cannot be scraped off.be scraped off.
Accumulation of Accumulation of debrisdebris and desquamated cells on and desquamated cells on oral mucosa may also oral mucosa may also result in white areas: result in white areas: can can be scraped off.be scraped off. Lack of mechanical Lack of mechanical
stimulationstimulation Dcreased salivary flow Dcreased salivary flow
Definition of Histopathological Definition of Histopathological TermsTerms
Orthokeratosis:Orthokeratosis: superficial keratinized superficial keratinized squames are flattened, squames are flattened, anucleateanucleate, with , with homogeneous, homogeneous, acidophilic cytoplasm.acidophilic cytoplasm.
Parakeratosis: Parakeratosis: superficial keratinized superficial keratinized squames are flattened, squames are flattened, with homogeneous, with homogeneous, acidophilic cytoplasm, acidophilic cytoplasm, but contain but contain pyknotic pyknotic nucleinuclei..
Definition of Histopathological Definition of Histopathological TermsTerms
Hyperkeratosis: Hyperkeratosis: increased thickness of increased thickness of keratin layer.keratin layer.
Hyperparakeratosis: Hyperparakeratosis: increased thickness of increased thickness of parakeratin layer.parakeratin layer.
Keratosis: keratinization Keratosis: keratinization of epithelium that is not of epithelium that is not normally keratinized. normally keratinized.
Definition of Histopathological Definition of Histopathological TermsTerms
AcanthosisAcanthosis: : hyperplasia hyperplasia of prickle of prickle cell cell layer which results layer which results in overall increased in overall increased thickness of thickness of epithelium, with epithelium, with broadened, elongated broadened, elongated rete ridgesrete ridges..
Epithelial atrophyEpithelial atrophy: : decreased epithelial decreased epithelial thickness usually thickness usually associated with loss of associated with loss of rete ridges.rete ridges.
Definition of Histopathological Definition of Histopathological TermsTerms
Cellular atypiaCellular atypia: : a group of a group of cellularcellular changes which changes which cytologically characterize cytologically characterize dysplasia and which are dysplasia and which are typically seen in typically seen in premalignant lesions.premalignant lesions.
Epithelial dysplasia: a term Epithelial dysplasia: a term describing describing epitheliumepithelium when features of cellular when features of cellular atypia are present.atypia are present.
* Atypia refers to cells, * Atypia refers to cells, while dysplasia refers to while dysplasia refers to the tissue as a whole.the tissue as a whole.
Etiological Classification of White Oral Etiological Classification of White Oral LesionsLesions
HereditaryHereditary Oral epithelial nevusOral epithelial nevus
Oral manifestations of other Oral manifestations of other rare genodermatosesrare genodermatoses
LeukoedemaLeukoedema
TraumaticTraumatic Mechanical (frictional Mechanical (frictional keratosis)keratosis)
Chemical Chemical
ThermalThermal
InfectiveInfective Candidosis:Candidosis:
- acute psuedomembranous- acute psuedomembranous
- chronic hyperplastic- chronic hyperplastic
- chronic mucocutaneous- chronic mucocutaneous
Syphilitic leukoplakiaSyphilitic leukoplakia
Hairy leukoplakiaHairy leukoplakia
IdiopathicIdiopathic LeukoplakiaLeukoplakia
DermatologicalDermatological Lichen planusLichen planus
Lupus erythematosusLupus erythematosus
NeoplasticNeoplastic Carcinoma Carcinoma in situin situ
Squamous cell carcinomaSquamous cell carcinoma
Hereditary Conditions Hereditary Conditions (Genodermatoses): Oral Epithelial (Genodermatoses): Oral Epithelial Nevus (White Sponge Nevus)Nevus (White Sponge Nevus) Autosomal dominant Autosomal dominant with with
incomplete penetrance and incomplete penetrance and variable expressivity.variable expressivity.
Causes:Causes: Mutations in genes coding for Mutations in genes coding for
keratins 4 & 13.keratins 4 & 13.
? Abnormality in ? Abnormality in desquamation.desquamation.
Benign condition with no Benign condition with no consequences other than consequences other than altered appearance of mucosa.altered appearance of mucosa.
Hereditary Conditions Hereditary Conditions (Genodermatoses): Oral Epithelial (Genodermatoses): Oral Epithelial Nevus (White Sponge Nevus)Nevus (White Sponge Nevus) Any part Any part of oral mucosa of oral mucosa
may be affected, as well may be affected, as well as other mucosal as other mucosal surfaces in the body.surfaces in the body.
Edges not well-defined.Edges not well-defined.
Shaggy or folded Shaggy or folded appearance.appearance.
May appear in infancy, May appear in infancy, childhood, or childhood, or adolescence.adolescence.
Hereditary Conditions Hereditary Conditions (Genodermatoses): Oral Epithelial (Genodermatoses): Oral Epithelial
Nevus (White Sponge Nevus)Nevus (White Sponge Nevus)
Histopathology:Histopathology:- Acanthosis.Acanthosis.- Hyperparakeratosis.Hyperparakeratosis.- Intracellular edema of Intracellular edema of
prickle and prickle and parakeratinized cell parakeratinized cell layers.layers.
- Pyknotic nuclei impart Pyknotic nuclei impart basketweave appearance.basketweave appearance.
H. Keratosis
Acanthosis and edema
Hereditary Conditions Hereditary Conditions (Genodermatoses): Leukoedema(Genodermatoses): Leukoedema
Particularly evident in persons with Particularly evident in persons with racial pigmentation of oral mucosa.racial pigmentation of oral mucosa.
Ethnic and racial clustering suggest Ethnic and racial clustering suggest hereditary factors.hereditary factors.
Regarded as a variant of normal.Regarded as a variant of normal.
Presents as a translucent, milky Presents as a translucent, milky whiteness of the surface of the whiteness of the surface of the mucosa with a slightly folded mucosa with a slightly folded appearance.appearance.
It tends to disappear on stretching.It tends to disappear on stretching.
Hereditary Conditions:Hereditary Conditions:LeukoedemaLeukoedema
Histology:Histology:- Acanthosis with Acanthosis with
broadened rete broadened rete ridges.ridges.
- Superficial prickle Superficial prickle cells appear cells appear vacuolated and vacuolated and contain glycogen.contain glycogen.
Traumatic Keratoses: Traumatic Keratoses: Mechanical Trauma-Frictional Mechanical Trauma-Frictional
KeratosisKeratosis Acute friction may lead to Acute friction may lead to
blistering and ulceration.blistering and ulceration.
Chronic friction leads to Chronic friction leads to epithelial thickening and epithelial thickening and hyperkeratinization known as hyperkeratinization known as frictional keratosis.frictional keratosis.
Frictional keratosisFrictional keratosis may result may result from: sharp tooth, chronic from: sharp tooth, chronic cheek biting, prolonged wear cheek biting, prolonged wear of ill-fitting dentures.of ill-fitting dentures.
Traumatic Keratoses: Traumatic Keratoses: Mechanical Trauma-Frictional Mechanical Trauma-Frictional
KeratosisKeratosis To diagnose frictional To diagnose frictional
keratosis a source of keratosis a source of chronic irritation that chronic irritation that fits the size and shape fits the size and shape of the lesion must be of the lesion must be identified. Lesion must identified. Lesion must resolve upon removal resolve upon removal of the source.of the source.
Traumatic Keratoses: Traumatic Keratoses: Mechanical Trauma-Frictional Mechanical Trauma-Frictional
KeratosisKeratosis Histopathology: Histopathology: - Hyperkeratosis +/- Hyperkeratosis +/-
acanthosis.acanthosis.- There is There is nono dysplasia. dysplasia.
Traumatic Keratoses: Traumatic Keratoses: ChemicalChemical
Severe chemical Severe chemical insult insult to oral mucosa to oral mucosa produces epithelial produces epithelial necrosis, sloughing & necrosis, sloughing & ulceration, e. g. ulceration, e. g. Aspirin burn.Aspirin burn.
Traumatic Keratoses: Traumatic Keratoses: ChemicalChemical
Low grade, chronic Low grade, chronic insult insult is seen in is seen in tobacco users, tobacco users, whether it is smoked, whether it is smoked, chewed, or used as chewed, or used as snuff. Also in other snuff. Also in other chewing habits such chewing habits such as betel nut.as betel nut.
Traumatic Keratoses: Traumatic Keratoses: ThermalThermal
Generalized Generalized hyperkeratosis hyperkeratosis is seen is is seen is smokers of cigarettes, cigars, and pipes, smokers of cigarettes, cigars, and pipes, particularly anterior buccal mucosa, tongue particularly anterior buccal mucosa, tongue & palate.& palate.
Combination of thermal and chemical factors Combination of thermal and chemical factors likely.likely.
Localized keratosis on lips Localized keratosis on lips at site of cigarette at site of cigarette may be seen with constant use, also on may be seen with constant use, also on palate and dorsal tongue in pipe smokers.palate and dorsal tongue in pipe smokers.
Traumatic Keratoses: Thermal Traumatic Keratoses: Thermal Nicotinic Stomatitis Nicotinic Stomatitis
A characteristic palatal A characteristic palatal condition seen in condition seen in smokers, particularly in smokers, particularly in pipe smokers.pipe smokers.
Characterized by Characterized by hyperkeratinized palatal hyperkeratinized palatal mucosa with a mucosa with a cobblestone cobblestone appearanceappearance, with , with inflamed orifices of inflamed orifices of minor salivary gland minor salivary gland ducts showing as ducts showing as red red dots dots centrally.centrally.
Traumatic Keratoses: Thermal Traumatic Keratoses: Thermal Nicotinic Stomatitis Nicotinic Stomatitis
Condition is rCondition is reversibleeversible upon cessation of upon cessation of smoking and is smoking and is not not considered premalignant.considered premalignant.
However, in smokers, the However, in smokers, the presence of these presence of these conditions indicates the conditions indicates the potential for abnormal potential for abnormal changeschanges that may be that may be premalignant, therefore premalignant, therefore the whole mouth should the whole mouth should be examined carefully for be examined carefully for other lesions.other lesions.
Traumatic Keratoses: Thermal Traumatic Keratoses: Thermal Nicotinic Stomatitis Nicotinic Stomatitis
Histopathologic Histopathologic Features:Features:
- Hyperkaratinized Hyperkaratinized and acanthotic and acanthotic squamous squamous epithelium.epithelium.
- Mild chronic Mild chronic inflammation of inflammation of subepithelial subepithelial connective tissue connective tissue and mucous glands.and mucous glands.
LeukoplakiaLeukoplakia Leukoplakia = white patch.Leukoplakia = white patch.
WHO original definition: "a WHO original definition: "a white patch which cannot be white patch which cannot be characterized clinically or characterized clinically or histopathologically as any histopathologically as any other disease".other disease".
Definition slightly modified in Definition slightly modified in 1994 to: "a predominantly 1994 to: "a predominantly white lesion of the oral mucosa white lesion of the oral mucosa that cannot be characterized that cannot be characterized as any other as any other definable lesiondefinable lesion". ".
LeukoplakiaLeukoplakia
Leukoplakia is Leukoplakia is a clinical diagnosis a clinical diagnosis arrived at by arrived at by exclusionexclusion of of other white lesions.other white lesions.
It It implies implies nono particular histopathologic change or behavior. particular histopathologic change or behavior.
However, However, a small percentage a small percentage are premalignant and some are premalignant and some may be invasive carcinomas at presentation.may be invasive carcinomas at presentation.
It is impossible to predict which lesions are likely to become It is impossible to predict which lesions are likely to become malignant, but certain clinical and histopathological malignant, but certain clinical and histopathological features are recognized as being features are recognized as being associatedassociated with an with an increased risk.increased risk.
Leukoplakia: IncidenceLeukoplakia: Incidence
Worldwide variation from Worldwide variation from <1%->10%.<1%->10%.
Problems in comparison due to difficulties in Problems in comparison due to difficulties in standardization of diagnostic criteria.standardization of diagnostic criteria.
Marked variation in incidence, sex, site, and age Marked variation in incidence, sex, site, and age groups affected between groups affected between different cultural and different cultural and ethnic groupsethnic groups, reflecting variations in possible , reflecting variations in possible etiological factors.etiological factors.
Leukoplakias involving Leukoplakias involving ventral tongue and/or FOM ventral tongue and/or FOM (sublingual keratosis) have a (sublingual keratosis) have a higher risk higher risk of of malignant transformation. malignant transformation.
Leukoplakia: IncidenceLeukoplakia: Incidence
Previous studies in Previous studies in Western Europe & Western Europe & North America: North America:
- - predominance in males predominance in males - generally described as - generally described as
affecting affecting older peopleolder people- FOM & buccal mucosa - FOM & buccal mucosa
mostly affected.mostly affected.
Recent studies in the Recent studies in the same areas indicate same areas indicate that:that:
- - M:F ratio is becoming M:F ratio is becoming almost equalalmost equal
- incidence in younger - incidence in younger adults adults is increasingis increasing
- this possibly reflects - this possibly reflects changes in smoking changes in smoking habits.habits.
Leukoplakia: Clinical Leukoplakia: Clinical FeaturesFeatures
HomogeneousHomogeneous- flat, uniform, - flat, uniform,
predominantly white predominantly white plaquesplaques
- may show shallow - may show shallow cracks/fissurescracks/fissures
Leukoplakia: Clinical Leukoplakia: Clinical FeaturesFeatures
Non-homogeneous Non-homogeneous (including speckled)(including speckled)
- irregular - irregular nodular/thickened, nodular/thickened, sometimes verrucous sometimes verrucous surface.surface.
- often speckled with often speckled with areas of erythroplakia.areas of erythroplakia.
Non-homogeneous Non-homogeneous lesions have a lesions have a worse worse prognosis.prognosis.
Leukoplakia: Clinical Leukoplakia: Clinical FeaturesFeatures
Erythroplakia: "a bright red velvety plaque Erythroplakia: "a bright red velvety plaque on the oral mucosa which cannot be on the oral mucosa which cannot be categorized clinically or pathologically as categorized clinically or pathologically as being due to any other condition".being due to any other condition".
Leukoplakia: Clinical Leukoplakia: Clinical FeaturesFeatures
Erythroplakia: Erythroplakia: - may be - may be homogeneoushomogeneous with a well-defined but irregular outline with a well-defined but irregular outline- or may be intermingled with patches of leukoplakia - or may be intermingled with patches of leukoplakia (speckled (speckled
leukoplakia)leukoplakia)- histopathologically, erythroplakia may represent carcinoma-in-situ or - histopathologically, erythroplakia may represent carcinoma-in-situ or
invasive carcinoma.invasive carcinoma.- its development in a previously uniform white lesion is an important - its development in a previously uniform white lesion is an important
clinical sign which may indicate sinister change.clinical sign which may indicate sinister change.
Leukoplakia: Clinical Leukoplakia: Clinical FeaturesFeatures
Clinical features that may indicate Clinical features that may indicate malignant change in malignant change in leukoplakia/erythroplakia:leukoplakia/erythroplakia:
1.1. development of erythroplakia in a previously development of erythroplakia in a previously uniform white lesionuniform white lesion
2.2. fixationfixation3.3. indurationinduration4.4. ulcerationulceration5.5. lymphadenopathylymphadenopathy6.6. bone destruction if it overlies bonebone destruction if it overlies bone7.7. other clinical features of malignancy.other clinical features of malignancy.
Leukoplakia: Etiological Leukoplakia: Etiological FactorsFactors
Leukoplakia is by definition idiopathic, Leukoplakia is by definition idiopathic, but in some patients, predisposing but in some patients, predisposing factors can be identified. factors can be identified. (but they are (but they are nor causative)nor causative)
Etiology is likely to be multifactorialEtiology is likely to be multifactorial
Tobacco use is a major factor.Tobacco use is a major factor.
Leukoplakia: Etiological Leukoplakia: Etiological Factors, TobaccoFactors, Tobacco
The most common factor in patients with leukoplakia.The most common factor in patients with leukoplakia.
Higher prevalence of leukoplakia among smokers.Higher prevalence of leukoplakia among smokers.
Prevalence increases with Prevalence increases with amountamount of tobacco. of tobacco.
Distribution of lesions Distribution of lesions may vary with particular type of may vary with particular type of habit: cigarettes, bidis, reverse smoking, tobacco habit: cigarettes, bidis, reverse smoking, tobacco chewing, pans, snuff dipping.chewing, pans, snuff dipping.
In those patients whose tobacco-associated keratosis In those patients whose tobacco-associated keratosis regresses on cessation of the habit the lesion should regresses on cessation of the habit the lesion should not be classified as leukoplakia.not be classified as leukoplakia.
Leukoplakia: Etiological Factors, Leukoplakia: Etiological Factors, TobaccoTobacco
Smoked tobaccoSmoked tobacco
Leukoplakia: Etiological Factors, Leukoplakia: Etiological Factors, TobaccoTobacco
Smokeless Smokeless tobacco: areca nut tobacco: areca nut (betel nut)(betel nut)
Leukoplakia: Etiological Factors, Leukoplakia: Etiological Factors, TobaccoTobacco
Smokeless Smokeless tobacco: chewing tobacco: chewing tobacco and snufftobacco and snuff
Leukoplakia: Etiological Factors, Leukoplakia: Etiological Factors, AlcoholAlcohol
No clear evidence No clear evidence for importance as a for importance as a factor.factor.
Many heavy Many heavy smokers however smokers however are also heavy are also heavy drinkers.drinkers.
Leukoplakia: Etiological Factors, Leukoplakia: Etiological Factors, CandidaCandida
Candidal Candidal leukoplakia leukoplakia (chronic (chronic hyperplastic hyperplastic candidosis).candidosis).
May be associated May be associated with idiopathic with idiopathic leukoplakia.leukoplakia.
Leukoplakia: Etiological Factors, Leukoplakia: Etiological Factors, VirusesViruses
HPV: type 16 & 18, HPV: type 16 & 18, uncertain role.uncertain role.
EBV: hairy EBV: hairy leukoplakia, leukoplakia, completely completely different lesion, no different lesion, no premalignant premalignant potential.potential.
Leukoplakia: Etiological Factors, Leukoplakia: Etiological Factors, Oral Epithelial AtrophyOral Epithelial Atrophy
Iron deficiency.Iron deficiency.
Submucous fibrosis.Submucous fibrosis.
Tertiary syphilis.Tertiary syphilis.
Some vitamin deficiencies.Some vitamin deficiencies.
Sideropenic dysphagia Sideropenic dysphagia (Plummer-Vinson (Plummer-Vinson syndrome).syndrome).
Leukoplakia: Etiological Factors, Leukoplakia: Etiological Factors, Tumor-Suppressor GenesTumor-Suppressor Genes
Mutations in tumor Mutations in tumor suppressor genes, suppressor genes, mainly p53.mainly p53.
Leukoplakia: Etiological Factors, Leukoplakia: Etiological Factors, Sanguinaria canadensisSanguinaria canadensis
The common bloodroot plant The common bloodroot plant Sanguinaria canadensisSanguinaria canadensis has been has been used since 1982 and found to be used since 1982 and found to be effective effective against plaque build up against plaque build up and gingivitis.and gingivitis.
Sanguinaria-associated Sanguinaria-associated leukoplakia leukoplakia is a unique form of oral is a unique form of oral leukoplakia attributed to the chronic leukoplakia attributed to the chronic use of oral rinses and toothpastes use of oral rinses and toothpastes containing the extract of the plant.containing the extract of the plant.
It is usually located on It is usually located on the attached the attached gingiva and the alveolar mucosa gingiva and the alveolar mucosa of the maxillary vestibule.of the maxillary vestibule.
Preparations containing Preparations containing Sanguinaria Sanguinaria should be avoided until the risk for should be avoided until the risk for malignant transformation is malignant transformation is determined.determined.
