1. White lesions of the oral mucosa 2. Solitary oral ulcer and fissures

1. Differential Diagnosis of Oral and Maxillofacial lesions 1. White lesions of the oral mucosa 2. Solitary oral ulcer and fissures 3. Yellow conditions of the oral mucosa 王文岑 高雄醫學大學 牙醫學系 高醫大附設醫院S 棟 2 樓 口腔病理影像診斷科 07-3208284; wcwang@kmu.edu.tw

2. White lesions of the oral mucosa Keratotic Lesions 1. Leukoedema2. Linea alba buccalis3. Leukoplakia4. Nicotinic stomatitis, snuff-dipper’s lesion5. Benign migratory glossitis and mucositis6. Lichen planus7. Papilloma, verrucous vulgaris8. white exophytic squamous cell carcinoma, Verrucous carcinoma9. Hypertrophic candidiasis10. White sponge nevus

3. Sloughing, pseudomembranous, necrotic lesions • Plaque • Traumatic ulcer • Pyogenic granuloma • Chemical burns • ANUG • Candidasis

4. Ulcers Short-term ulcers • Traumatic ulcers (most) • Recurrent aphthous ulcers (minor) • Recurrent intraoral herpes simplex lesions • Ulcers as result of odontogenic infection • Ulcers with generalized mucositis or vesiculobullous disease • Ulcers secondary to systemic disease

5. Persistent ulcers • Traumatic ulcers (occasional) • Ulcers from odontogenic infection • Squamous cell carcinoma • Chancre • Gumma • Ulcer secondary to systemic disease • Low-grade mucoepidermoid tumor • Metastatic tumor

6. Normal Color of Oral Mucosa 1). dark pink (reddish) to very pale (almost white). 2). thickness of epithelium, degree of keratinization A). thicker epithelium: more keratinized, more fibrous and less vascular subepithelial connective tissue--color is whiter; hard palate, fixed gingival, dorsal surface of the tongue. B). darker pink or more reddish in color: less keratin, more vascular tissues; vestibule, floor of the mouth, ventral surface of the tongue, retromolar regions. C). normal variations pigmentations. D). substances in the blood, i.e. hemoglobin level polycythemia (red, cherry red) anemia (pale).

7. Healthy oral mucosa

8. Healthy oral mucosa

9. Leukoedema • non-malignant variation of normal mucosa. • most often at buccal mucosa, but also other sites (labial mucosa, soft palate). • most often seen adults > 40 yrs. • clinical features: • early stage: firmly opalescence; • later stage: definite grayish white cast with coarsely wrinkle surface which cannot be removed with a tongue blade, but will disappear on stretching. • (if injury: red eroded area, mimic cheek biting).

10. Leukoedema

11. Leukoedema

12. Leukoedema microscopic findings: • increased thickness of epithelium. • marked intracellular edema (ballooning) • acanthosis: abnormal thickening of the spinous layer (may be severe with elongation, thickening, blunting, and confluence of the rete pegs or may consist only of their elongation). • parakeratosis: hyperkeratosis with retention of nuclei.

13. Leukoedema

14. Leukoedema D.D. • leukoplakia, cheek-biting lesion, white sponge nevus. Treatment: • no treatment is required

15. Linea alba buccalis • usually on buccal mucosa near the occlusal plane. • usually bilateral, may be related with occlusal trauma, therefore more prominent if patient has little overjet of molars and premolars. • Microscopic findings: increased thickness of epithelium, or hyperorthokeratosis (hyperkeratosis without retention of nuclei). • Treatment: no special treatment, to avoid bite injury, change the relationship of upper and lower teeth (new denture or orthodontic treatment)

16. Linear alba

17. Leukoplakia • White patch • keratotic change occurring on mucous membranes. • usually caused by chronic irritation. important etiologic factors including: smoking, cold temperature, hot and/or spicy foods, alcohol, betel nut and /or tabacoo chewing, occlusal trauma, sharp edges of prostheses or teeth, actinic radiation.

18. Leukoplakia Clinical features: asymptomatic, old age group (40–70 yrs). most happened at: tongue, floor of the mouth, lower lip, commissures, palate, mucobuccal fold, alveolar ridge, retromolar area, buccal mucosa. D.D. first R/O lesions of sloughing pseudomembranous types. easy to scrap off or not? if not, lesions are keratotic and need to D.D. with many white lesions.

19. Homogeneous thick leukoplakia

20. Leukoplakia

21. Speckled leukoplakia

22. Non-homogeneous thick leukoplakia

23. Verrucous leukoplakia

24. Verrucous leukoplakia

25. Verrucous leukoplakia

26. Hairy leukoplakia • Special types of Leukoplakia • Hairy leukoplakia • AIDS patient: irregular surface like hair. • acanthosis with marked hyperparakeratosis with formation of ridged and keratin projections, areas of ballooning cells and little or no inflammation in the connective tissue. • Ballooning changes = koilocytes: enlarged cells, some with enlarged nuclei with perinuclear halos, others are pyknotic nuclei. • (papilloma-like virus) ,(EM: EB virus), (Immunofluorescence staining for EB virus capsid antigens).

27. 毛狀白斑(Hairy leukoplakia) EB病毒感染引起

28. Hairy Leukoplakia on margin of tongue in a homosexual man

29. Koilocytes: Hairy leukoplakia

30. Lesion due to corroded amalgam fillings lingually in mandibular molars, similar with hairy leukoplakia

31. D.D. of hairy leukoplakia in AIDS 1. lesions due to restorative materials: corroded amalgam fillings, white lesions will disappear within a few weeks after fillings are replaced by plastic material. 2. leukoplakia: a. idiopathic leukoplakia: often located on tongue (inferior surface), usually middle-aged women, extensive and smooth surface. b. tobacco-associated leukoplakia: border of tongue, well-defined, smooth surface, regress after stop smoking.

32. D.D. of hairy leukoplakia in AIDS 3. lichen planus: border of the tongue, rare (reticular type). 4. chronic hyperplastic candidiasis: labial commissures extending to the buccal mucosa, disappear after fungi-static treatment.

33. White Sponge Nevus young, usually can be seen before puberty wide spread, usually whole oral cavity has familial pattern

34. Lichen planus usually involve several lesions, leukoplakia is more often a solitary lesion. may have Wickham’s striae: fine grayish white lines arranged in a lace-like pattern may have skin lesion (leukoplakia : no skin lesion) D.D with lichen planus

35. Lichen planus

36. Nicotinic stomatitis or smoker’s palate • Nicotinic stomatitis or smoker’s palate, smoker’s keratosis • man, pipe smokers. • usually whole hard palate. • reddish stomatitis changed to slightly opalescent then white. • usually “red/pink dots/spots” as the centers of lesion indication inflammation of minor salivary glands. • usually disappear after stopping pipe smoking.

37. Stomatitis nicotina palati

38. Snuff dipper’s lesion, Tobacco chewer’s lesion • parboiled appearance of the white lesion, some are thick white plaque • lesion depends on where the tobacco was contact with the mucosa. • usually on the mandibular vestibule (both the incisors and the molar regions). • if change the habit, then most lesions will completely disappear.

39. Tobacco chewer’s lesion

40. Hairy Tongue

41. White hairy tongue 1.elongation of the filiform papillae: increased retention of keratin. 2.male more than female. 3.depends on foods, the color can be different. 4.treated by tongue brushing.

42. Black Hairy Tongue

43. Black hairy tongue • Caused by elongated filiform papillae. • Other causes: (i) antibiotics (penicillin or tetracycline) (ii) mouthwashes (sodium perborate or chlorhexidine) (iii) iron preparations (iv) smoking (iv) some foodstuffs (v) herbs

44. Geographic Tongue

45. Geographic tongue • Benign migratory glossitis and mucositis (Geographic tongue) 1.psychological influences and suspected. 2.irregularly shaped red patches and white patterns like map, on the dorsal , ventral and lateral surfaces of tongue. 3.red patches: desquamated filiform papillae: enlarge and regressive:change every week then completely disappear.

46. Geographic tongue 4.generally asymptomatic, sometimes burning sensation, tenderness and pain. 5. treated with : a. bland diet; b. coating the lesion with triamcinolone in Orabase, if symptoms occur

47. Median rhomboid glossitis

48. Median rhomboid glossitis • May be congenital ( persistence of the tuberculum impair) or may be associated with candidal infection. Smoking may predispose to the candidosis. • There is: (i) absence of filiform papillae. (ii) epithelial hyperplasia and acanthosis. (iii) chronic inflammatory infiltrate in the lamina propria.

49. Lichen planus 1. Affecting 0.5-2.0% of the population 2. Mean age at onset: 30-50 years 3. A mild predilection for females 4. Six forms: reticular, papular, plaque, atrophic, erosive, bullous 5. Malignant transformation -- <1% 6. Etiology: emotional stress or aberrant cellular immunity

50. Lichen planus 7. sites: mostly at buccal mucosa (85%), others including gingiva, tongue, palate, floor of the mouth, vermillion border, (skin: small flat papules/ulceration may fuse together).