Oral Diagnosis II Forth Year

1. Dr Wael M Swelam 11/15/2008
1
By
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Saturday, November 15, 2008
Diagnostic Sequence
History
Physical Examination
Chief Complaint of the present Condition
Radiographic Exam
Differential Diagnosis
Working Diagnosis
15 November 2008 2Differential Diagnosis of White oral lesions
Examination set
Li h i / i i “i i ”Lighting/vision “inspection”
Palpation
Wooden blade
Therapeutic response
Toluidine blue, Cytology &/or Biopsy, y gy / p y
15 November 2008 3Differential Diagnosis of White oral lesions
15 November 2008 Differential Diagnosis of White oral lesions 4

2. Dr Wael M Swelam 11/15/2008
2
Any history of trauma?
Painful?
Smoking / drinking habits
Site, high risk area of mouth
Removable +/-
Note mucosal ulceration and erythema
Homogeneous or not?g
Skin conditions associated
Palpate regional lymph nodes
If palpable, fixed+/-
15 November 2008 5Differential Diagnosis of White oral lesions
15 November 2008 6Differential Diagnosis of White oral lesions
Bilateral symmetry
Asymptomatic
Independent finding
Remains unchanged
VariationVariation
of Healthyof Healthy
ii
Abnormality
Remains unchanged
Older patient
tissuetissue
By location &
tissue affected
White color of mucosa Dark color of mucosa Ulcers, Vesicles, or Bullae Tissue enlargement
15 November 2008
7Differential Diagnosis of White oral lesions
No enlargement
No loss of surface integrity
No radiographic finding
No enlargement
No loss of surface integrity
No radiographic finding
, ,
Pain
No enlargement
No radiographic finding
g
Mucosal changes are
mainly secondary
No radiographic finding
KERATOTIC
NECROTIC
VESICLES/BULLAE
15 November 2008 8Differential Diagnosis of White oral lesions

3. Dr Wael M Swelam 11/15/2008
3
•• ChemicalChemical
– Tobacco products
Eth n l– Ethanol
– Alcohol-based mouth rinses
– Acidic foods and beverages
•• ThermalThermal
– Smoking
– Hot & cold foods and beverages
•• MechanicalMechanical
– Occlusal trauma
Sharp edges of prostheses or teeth– Sharp edges of prostheses or teeth
•• Actinic radiation & Ultraviolet lightActinic radiation & Ultraviolet light
•• Microorganism relatedMicroorganism related
– Syphilis
– Presence of Candida albicans
– Presence of viruses
15 November 2008 9Differential Diagnosis of White oral lesions
S f S b i h li l
15 November 2008 Differential Diagnosis of White oral lesions 10
Epithelial
Thickening
Surface
Material
Subepithelial
Change
Oral White lesions
(cannot be rubbed off)
* Leukodema
* Linea Alba
* Leukoplakia
*Nicotine Stomatitis
* Lichen Planus
(Can scrape off with Tongue blade or
gauze)
• Surface debris (food accretion)
• Necrosis (sloughing)
Lichen Planus
*White hairy tongue
*Candidiasis
*White Sponge Nevus
* Papilloma
*Squamous Cell Carcinoma
*Verrucous carcinoma
• Thrush (Acute Pseudomembranous Candidiasis)
15 November 2008 11Differential Diagnosis of White oral lesions
• Homogeneous type
• Speckled type
• White and red patches
• Verrucous typeSpeckled type Verrucous type
15 November 2008 12Differential Diagnosis of White oral lesions

4. Dr Wael M Swelam 11/15/2008
4
Homogenous
Sharp borders
Area of friction
Apparent cause
Heterogenous
Vague borders
Any Location
May enlarge
Tobacco
Rough, shaggy
Vague borders
Midline of tongue
Symmetrical
Often stained
Homogenous
Sharp borders
Lower lip
Older age
Loss of vermilion border
Dimished host
resistance
15 November 2008 13
Improve with
cause removal
Older age
Cofactors
Homogenous gray
Red spots
Palate
Pipe smoking
Wrinkled
velvety
Mucobuccal Fold
Smokeless tobacco
Some material rubs off
Poor oral hygiene
improves
Sun exposure
Static/progressive
Chronic Bilateral
Buccal mucosa
Dimished host
resistance
Chronic Bilateral
Buccal mucosa
Poor hygiene
Areas atrophic/rub off
Painful
R i h
At risk AIDS/HIV +ve
Rough, thickened patches Lacy striae +/-Disappear when
15 November 2008
Regress with treatment
Often
coexist
g , p
Bilateral,
Lateral surface of tongue
Asymptomatic
Persists/progress
y
erosions
+/- skin lesions
Changes but
seldome regress
stretched
Mildly wrinkeled
Milky appearance
Congenital/Familial
Dramatic appearance
14
Raised component Red component
T b d l h h l• Tobacco and alchohol use
• Nonsmoker and unknown etiology of lesion
• Microscopic atypia
AIDS related15 November 2008 15Differential Diagnosis of White oral lesions
Curdy, white, diffuse
Vague borders
Poor oral hygiene
Diminished host resistance
Progress with treatment
Ragged, delicate
Focal
Sharp borders
Cause effect
Heals
Chemical Burn
Pseudomembranous
candidiasis
Delicate, Grainy
Pseudo-membranous
May be cause related
Ulcer
Buccal mucosa
Multiple
Bilateral
Asymptomatic
Static
Adults
•Hx of trauma
•Asymptomatic
•Static
• Hx Betel
nut
• Limitation
of tissue
movement
• Progress
Fordyce’s
granules
Scar
Submucous
fibrosis
15 November 2008 16

5. Dr Wael M Swelam 11/15/2008
5
• Epithelial or food debris
• Chemical trauma (aspirin can ca se epithelial necrosis• Chemical trauma (aspirin can cause epithelial necrosis,
sloughing, ulceration)
• Pseudomembranous Candidiasis
15 November 2008 17Differential Diagnosis of White oral lesions
15 November 2008 18Differential Diagnosis of White oral lesions
15 November 2008 19Differential Diagnosis of White oral lesions
15 November 2008 20Differential Diagnosis of White oral lesions

6. Dr Wael M Swelam 11/15/2008
6
•Chemical burns•Chemical burns
•Gangrenous stomatitis
•Superficial bacterial infections
•Traumatic ulcers
•Necrotic lcers of s stemic dise se•Necrotic ulcers of systemic disease
•Mucous patch of Treponema infections
15 November 2008 21Differential Diagnosis of White oral lesions
1. Patient history
– If there are similar lesion in other members of the
family and the patient is young aged (suggestive of
hereditary lesion ex. WSN)
– If this lesion is related to certain injurious agent
(Traumatic, Thermal, Chemical ex. Frictional Keratosis )
– If the lesion appear after certain drug intake (like
antibiotic for long period ex. Candidiasis)
– If the lesion was related in site to certain habit (like
check biting ex. Linea Alba Buccalis)
15 November 2008 22Differential Diagnosis of White oral lesions
2. Clinical manifestations
– If the lesion is associated with skin lesion
– The lesion is either unilateral or bilateral (bilateral lesion associated
i h ki l i i i f Li h l )with skin lesion is suggestive of Lichen planus)
– If this lesion have characteristic clinical shape (anatomizing striae
“Wickham's striae” are characteristic for Lichen planus)
– If the oral lesion is restricted to certain site (hairy Leukoplakia of
HIV infection usually appear at lateral side of tongue)
– Whether this site is changing or not (Geographic tongue is
)migratory)
– If the lesion disappear on its stretching (characteristic for
leukodema)
– Sponge texture with wrinkled morphology is suggestive of
WSN15 November 2008 23Differential Diagnosis of White oral lesions
1. Congenital1. Congenital
2. Acquired
3. Infective
4. Dermatological
15 November 2008 24Differential Diagnosis of White oral lesions

7. Dr Wael M Swelam 11/15/2008
7
1. Congenital
a. Fordyce Spots (ectopic sebaceous glands)
b. White sponge naevus (defect of keratin - thickened,
bilateral, often affect buccal mucosa)
c. Dyskeratosis congenita (rare, potentially malignant)
Differential Diagnosis of
White oral lesions
15 November 2008 25
2. Acquired
a)Traumatic
b)Frictional keratosis
cheek biting, sharp tooth, ill-fitting denture (often
seen along occlusal line)
c)Smoker’s keratosis (Nicotinic stomatitis)
diffusely white palate with red dots showing dilated
minor salivary glands
d)Submucous fibrosisd)Submucous fibrosis
Differential Diagnosis of
White oral lesions
15 November 2008 26
3. Infective
i. Candidal leukoplakia
may be associated with an increased risk of malignant
changechange
ii. Syphilitic leukoplakia
malignant potential high, rarely seen now – feature of
tertiary syphilis, commonly dorsum of tongue
iii. Oral hairy leukoplakia
EBV causes, corrugated surface, almost always margins of
tongue, often immunocompromised patients – especially HIV
Differential Diagnosis of
White oral lesions
15 November 2008 27
4. Dermatological
a. Systemic lupus erythematosis
- 20% of patients with SLE;
- Symmetrically distributed erythematous areas, or white patches,
- Difficult to distinguish from lichen planus, palate a common site
b. Discoid lupus erythematosus
Mostly affects buccal mucosa, alveolar ridge and vermillion of lip;
central atrophic area with white striae radiating perpendicular to
edge of lesion; can be indistinguishable from SLE
c. Lichen planus and lichenoid drug reactions
Very difficult to differentiate
Differential Diagnosis of
White oral lesions
15 November 2008
28

8. Dr Wael M Swelam 11/15/2008
8
15 November 2008 29Differential Diagnosis of White oral lesions
15 November 2008 30Differential Diagnosis of White oral lesions
15 November 2008 31Differential Diagnosis of White oral lesions
15 November 2008 32Differential Diagnosis of White oral lesions

9. Dr Wael M Swelam 11/15/2008
9
15 November 2008 33Differential Diagnosis of White oral lesions