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    Patologie Orala PDF

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    COLOUR GUIDES ‘* ‘User-friendly3 format ideal for exam preparation ‘* Concise text clearly integrated with high-quality ‘= Unique approach allows review of a wide selection of cases during short clinical attachments '* An essential resource for students and health care ‘specialists in all fields of medicine Colour Guides ee ees emer ISBN 0-443-04803-—0 2 (Churchill Livingstone’ oliraosaslogaoy COLOUR GUIDE Oral Medicine C. Scully / R. A. Cawson ‘Churchill Livingstone i Yu WP rm yh i \ Wat it COLOUR GUIDE Oral Medicine C. Scully ap mps rap eDsRcPs FFDRSL MRCPath Profesor of Onl Meicn, Pathology and Mirbioles, Univer of rst nl Ue R.A. Cawson sip crs es Kors mets Poise af Ora Medicine and Pathology Inthe Uniesy af Landon, OK; Visti Pres, Bayar Univer Medial Cente and ala of Dents Dally Teas, USA Churchill Livingstone: wv hes, sitio Not an tons Group UK Lines eerie a ea 04 ISBN O-W43-O48o1-0 Peskin imine rd i He Kone 1 (eee —e-.”.hC SS Pretace ‘This book i intended a an sid to oral meine. The format chosen has ‘been i describe diseases initlly by site as this is how paca pretea. inevitably his leds to some overlap. Beeause ofits increasing importance, HIV disease ie given separate ston, ‘The text und illustrations are not fly comprehensive, particularly since otal of orl medicine ends tse to llstratve presentations too sty Patients have srmproms but no signs of dacuse. For reasons of space, Pictures of oral and perioral lsioss only have been included. Nevertheless, We have covered a wide range of material and trust that this Wil be ef 0 Undergraduates, postgraduates and practiioners, Some illusations show ungloved agers. These are usually not the linia’ fingers. Protective loves should always be worn by ncaa, Bristol and London, 1993 cs. Contents 1 Liptesions 2: Into eons: mon © Tonge leone 4. Ginga! eins 1 Ma sativa gland disease 8 Gemealipmptinade eclings 10, Reaolgies ai 1 / Lip lesions Herpes labialis Aatlgy Herpes simplex views (HSV), usually type 1. HSV lent in trigeminal grglion i restvaed as herpes labialis (old sores) fis precipitated by sun, sums, ‘menstruation, fre, HIV disease, immunostppresson, Incidence Comin, especialy in imaaunosompromise, Ginica femmes Prodromal paraesthesia or nition Exythemay then ‘esices avnear mucocutaneous junction flip. Hels in 710d (Figs 182) Trceigatons Viral damage can be confirmed by smear, Diagrors Differentiate from zoster, iopetigo, o carcinoma (arly. ig Hopital ge } Herpes zoster (‘shingles’) / AeiogyVariclls-zserveus (VZV) latent in sensory ganglion | (sev also p31) Tis reactivated fy, fr exuple, nmiuncrappresion, | Incidence Mainly affects eldeey ¢immunocompromised such 2 Hopes er sng, 4 in HIV nfecion (Ginica fates Pain nd rsh in wigeminal dernatome (Fig. 3. Unilateral vesces, then mouth ces, Pen in HIV infection, Incesigaions Clinical features. Thete 20 immunological test of Yale, Smears show viral damaged cell Dignos Pai: may simulate toothache. Rash; difercatiae frm FHISV infection. Mouth slers (ee p. 23). Thome Analgesics; cyelovir ointment rash and ables; ‘ntavenousaeyelove for mmunocompromised iy lethal Fig. Hones mer rst wth andreas old Ss Cracked lip Astolgy Chronic (elFinduce) trauma and maceration, and ‘mouth breathing Is aio found in Crohn's dbese and Down syneome Incidence Common during esl, windy, winter weather, ) (Gina fares Usually single persistenc painful vertical sure which bleeds on steiching the ipa opening the mouth wide ie. 19, “ooeigations Clinical features disgnostc, Diagnosis Ditlerenite fom angular soma s (occasionally), Treatment Bland tears (Boot 8S); rarely excision (curative) Actinic burns Acolgy Shortwave UV ight (Sunlight may als rigger herpes i Inbialis and Tupus erythematonu), Incidence Mainly frskinned individuals in sunny climes ora high aude, Cina fares Eyes, oedema, vesiculaton and occasionally hacmorthige (Fig. 17); late whitish lesion oe Inceigains History and clinica etures; biopsy may help, Diagnosis Ditferentiat fom other cases of burt (. frition and ea), Treument Prophylaxis: bland or barter creams (Uvista). Fn 6 Cacti ip. det syste, 1/ Uplsons Asigy Taide Clinical fate Incesigatins Diagnosis Trotmnt Aetiology Iecienes Cina fas Incesigaions Diagnrie Troiment Allergic angioedema "Type alergic response tallergen. ‘Uncommon: mainly in those with atop tendency Rapid development of oedematous sling of lit). (edema may inenve neck and haar the sinway ir) iscory of opie disease andr exposure to allergens allergy testing (pricks) Differetite fom hereditary angioedema and other ‘uses of dfs facia selling including: oedema Irom {catia infection or inset bite surgical emphysema; Crohn's disease, ches gemulomatosa and Medkersson-Roreathal syndrom chit glanduae Iymphangioma; haeroangiome ‘Mild angioedema: anthistrine, Severe angioedema {nteam cular alee, and corinserod Hereditary angioedema Genetic dees of inhibitor of activated st component of complement Cl (Cl esterase inhibitors autosomal ‘dominant inheritance, Rare Asin slleric angioedema (above) but precipitated by {eau eg: dentalireatment- There fhigh mortality ia some failies, Family history. Cl esterase fohiitor and CA serum levels se reduced Differeniete fom acute allergic angioedema and other uses of fecal selling Stanozolol (an androgenic stro), i. 18 det agonto soe a hed iy 1 / Upton Asia Incidence Clinical fee Diagnosis Asiolgy Incidence Cinia fare Iresigatons Diagss Tresment Oral Crohn's disease (orofacial granulomatosis) Unknown. A minority have gastrointestinal Cohn's, others a postulated reaction fo food or other enigens ce lwp. 4). ‘Uncommon but increasing, Mainly young adults Facil andr labial snlling (Fig. 19; angular stomatitis andlor cracked lips ulcers, rosa as andor obble-stoning; gingival hyperplasia, Somedmes ect of malabsorption (se pp 1,25 & 115) Misscher's is wher ip swelling is seein ioation, ston Rosenthal syndrome sfc swelling with fissured tongue and iil ply Dilfereniste from saroid ubervlose and foreign body Tnuraesional corticosteroids cssioallysuphasalazine; tliminat food allergens Sarcoidosis Unknown: chronic granulomatous reaction ‘Uncommon: prevalence highest in lick females Cervical ymphadenoputhy; enlarged slivacy glands and ‘crostomis; mucosal nodules; gingival hyperplasia bal soveling (Fig. 203 rarely, Heefordssyndsome(alivary and acrinal swelling facial palsy and elt) Biopsy chest radiograph; gallium sean; Kveim test ose, raised serum angiotensin converting enryme tnd adenosine deaminase Differentiate frum Crohn's disease, eaberulosis and foreign hody reactions Tntealesonal corticosteroids; systemic steroids ifling or je involved. ia 19 Cos ee aan cin ane i280 Srl retin sin Fe 1. Atos Idee Gina ats Ixsigations Diagross Troament Aeslogy Ieidorce Cina fate nceigations Trsamont Naevi (Congenital lesions derived from melanobass (soe aso pe, Rare, Usually affect lips, palate, gingiva, or buccal ‘Usually asymptomatic smooth pigmented macule <1 cin indiamete (Fig. 21). biopsy, showing naevus cells seen fo exclude malighant melanoma, Differentiate fom racial pigmentation, amalgam tatoo, ‘malignant melanoma and Pevz-eghers syndrome et Psb, Excision biopsy. Peuta-Jeghers syndrome ) Autosomal dominant disorder (ee also p. 3). Rare ‘Hyperpigmented cules periorally and on labial andlor cea mucosa (Pig. 2) rarely on tank or eaten Gassrintestinal polyps usualy benign and in sll intestine, predisposing wo intussusception, tinicalfecares pathognomonic Ditfeceninie fom racial pigmentation and freckles (epelides) (sep. 8b, Reastue or excise fr histological confirmation ig. 2 Pours: lia 11 Unless Aton, Incidence Clinical fares vsigatons Diagros Prsament Asibogy Incidence Clinical features Diagnosis Trstment Mucocele Usually extravasation of mucus from damaged salivary sland duct; rarely receation of mucus within salivary Bland or dct (Ge also. 101, Common: mostly on ower lip snd in young. sdullcildren, particularly ales It sometines fects tongue buccal mucoss of floor of mouth, Dome-shaped blu rantucent,futuant painless sellings usally = om in diameter (Fig, 23) These rupture easily oreleae viscid salty mucus, bat ‘Requendiy ecu, Microscopic fetures Diagnosis is clearcut bu a slivary gland neoplasm mast be cexclued, particulary in ey swellings i pe lip. asymptomatic and small observe; otherwise, we ‘syonrgery or excision Sturge-Weber syndrome (encephalotrigeminal angiomatosis) Congenital angioma Chamartom) that affects fee, mous and ipsilateral leptmeninges (te also p79) Rare ‘Hacmangioms (portwine naevus) in trigeminal region involving face (naers ammens), orl rucoss (Fi 2) and underlying bone (with hemityperrophy of bone and scelerated eruption of sociated eth) eplepsy and ‘itraezeral eleiieaions; gingival yperplata ttn Phenytoin-indueed}; mental handicay, Diflremit fom huemengioaa and various rare syndromes, Anticonvulsants fr eplepys observation of angioma, or ‘weatment as for haemangoma (sep. 75). i 28 Sureetr yon: mito nim stig spt te i 2 / Intraoral lesions: mucosal ulcers Uleers of local aetiology Aciology Trauma, including sel induced lesions due a cheek Dising(@ neurotic habit) and in same rare syndeomes (Figs 25 & 26) Orthodoniie appliances, dentures or faterdenal wiring are comm iatrogenic cute, Ores types include prerypoid uses of palate in neonates (Bednar aphthae) end ees du to burns (om levtica injury, het or cold chemise or irradiation). Rare causes include ulceration of lingual faenum caused by tepasted coughing Ircidone Connon, Ginicatfanoer Usually single leer closely elated to cause denture Range). Chronic ition may esate hyperplasia ‘oriyperkerstons. Diagnosis Differeniate fom mouth ulcers which can be caused by # Malignant neoplasms. # Recurrent sphthae (and Hebets syndrome), Systemic diodes 8) Haematological: bematnic (ron, fot, vitamin 1B) decency, white ell and other immune defects including HIV iafction, ad leukemia iy Gauraecinat colic disease, Croha’sdivease and ucertve cas Gi) Muccatneou (dermatological): ee plans, emmphigus pemphigoid and localized oral Purpura, erthema multiforme, dermaris lhexpeifrmis nd near Iga csest) pidermalysis bulls, lps erythen Relur's sadrome io) Infections: herpes views, Consslde viruses syphilis tuberculosis and deep msm, (9) Drags: eytotonc agen and any others Treament Remove etiological tors. Loca treatment chlorhexidine 0.2% southrash, os and a8 Teste ow enuey drt rs, 2 / rales: mucosal Ailey Incidene Clie feats % Irceizatons Diagnosis Trsmont ‘Aphthae (recurrent aphthous stomatitis - RAS) Unclear: immunological changes are decectale but ther iso reliable evidence ofautoimmine dseise ot any asia immunological actions. It maybe due to ‘anges in cll mediated immune responses and sossereatviy with Sreptencus angus. Underiying Predisposing factors are Seen Ina minority: emtinic ‘Gro, folate or vitamin By) deficeney in. 106, felationship with luteal phase of mesercation (arly, “stress oo allergies (possibly) and AIDS (major sphae), 25% of population, mostly non-smokers. Onset is ‘sully in childhood or adolescence. Later onset may signify haenatinie defcency or AIDS. ‘Typically early onset with recurtent ulcers usualy lasting I eck to 1 mouth There may be multiple ore ters ethervise normal health, There are three ditinet linia pater of aba: © Minoy~ small ulcers (<4 mm) on mabile mucosse, healing within 14.4, noscacing (Fig. 2) Major large ulcers ey > 1 em, any sit incading ‘dorsum of tongue and hard palit, healing within 13m, with searing (Fi, 28). + Herpnform aks ~ mule minute ulcers that soalesceo produce ragged ulcers Fig. 29). History of recurrences and daca festure. Tete it n0 immunotogial est of value blood picture useful fer possible deficiencies (Fig 30, p. 28), Differentiate fom other causes of mouth weer (se 1.23) especially Beets syndrome, ‘Treat any undevying predisposing factors. Test apse vith chlorhexidine 0.5 aqueous touthorash or topical Sorticsterads (hydrocortione hemisuccinte 25 me pallets or 0.1% triamcinolone seetonide in orbase) or Tetrcyeline rinses, Rarely, ore potent topical seoide (eg: beumethasone or heslomethnrons) ny be neded Fig. Mer phtae a> donascerng md don i. Hapa a: mute douse caestofrm Inbiran. Aetiology Incidence tinal fares Incesgtions Diagwoss Treumont Behget’s syndrome Unclear immunological changes like thse in apbehae are reported. Immune complexes, possibly with berpes Sroplex virus, ey be implicated in persons wth specie ‘but wenk HCA associations, Rare: most common in Japan and Turkey. eis ‘predominantly a disease of adult male. “Maltisyrem disorder in which orl lesions ace indstinguiahable for types athe 1 Ora aplhar almost invariably (Fi, 3) 1 Becitene seduced visual acy, uvetiy etinal vasculitis, 4 Shi divas: rypicalyerytvema nodosum, 1 Yoon diese: atv of lrg ous 1 Neuologcal dau: various syndromes, 1 nk tromboses, cli real dicate, ee ‘lineal feats. Thre no immunological est of valu Differentiate om other oculomucocutaneos disorders, ‘spec ulcerative coli, eryiema multzorme, ‘phils and Reiter's syndrome, 15 Onatuier: eats fr aphae above) { Syme immunosuppresion using colchicine, ‘miostroids, azathioprine, eylosparins dapsone forthalidomie (ot there fany possibility of resnancy) Fin. Bees ions pte nso een pt, 2 J ncaoaesoes: muse les Avioli Incidence (Cini fears Ircesigtion Diagnosis Tisenone Herpetic stomatitis, Herpes simplex virus (11S¥, usually 1ype I. (See also pL) (Common cause of mouth ulcers in poor areas with fever in children. [es also seen in adult, especialy in more ' affluent commits, Incubation peeiod 37 . Some S0% of infections are Sucinical. Cini features of primary iaacion Fnclude 1 Mout des: multiple vesicles and ound scattered loots (Figs 32 & 3) vith yellow slough and ‘rythematous halos ulcers fine to produce regular ‘isons 1 Ging: disse erythema std oedema, oeesionally crnorbagic Cereal Imphadeiis Esser Malai, arab and anaes Rarely skin lesions o ala involvement, Dental sal may acouires herpetic whitlow if not varing surgical glover Recurrences usually present 1 herpes labialis (seep 1) but incor lees in ‘ Immunocompromised (Fig. 3) Infection may rarely precipice erythema multorme, Smear fr viral damaged cells, Vea cultre or section Inieroseopy is used osatonaly A risng ie ‘of atibogies i onfmaory Difleresiat from othe cases of mouth ulcers (cep. 23) especially hand fom and moth disease, ‘hickenpos and shingles, herpangi, erythema ‘ouliforme and leukaemin Soft diet nd adequate uid intakes antipyretics \ lgescspurtcetamal elite local antnepis (0.2% ‘queous chlorine mouthwashes)s sector orally or parenterally in immuaccompromised patents 9.2 Horie somes useing nm po lone Fi. Hepes pate opt wth Hen 2 nora sons: mucosal es Actoloy and eons (tial fares Inception: Diagnosis Travinent Aetiology ant ‘acon tinal ares Ircenigatns Diagnose Troamont Chickenpox (varicella) ‘Herpes varicella-zoster veus (VZV); common childhood cxamthem Incubation period 14-21 4. Some 50% of infections are stbelisieal. Cine features include + Ulers:ndisingushable from HSV, but no associated singiviie (Fig 35, 1» Rask: mainly face and tronk; papules then vesicles, ster and sci crops 1 Caiea bonpladenie Five. Malia, rita, anni, 1 Rev: pneumonia or encephalitis, (Giniel Rising antibody ire i confirmatory. Differentite om other mouth woes, expecially herpes simplex and other viral infections (seep. 23) Symptomatic (sep. 29; immune globulin or acyclovir in immunocompromaise Shingles (zoster) Reactivation of VZV latent in sensory ganglia. Immune «ects predispose to reactivation; unconen. 4 Moor horace: 30% trigeminal region 1 Pate bole, with end air rash ‘Rash unilateral vesiulating then scbbing in deematome, 1 Mouth uke: manda snr ~ipsiltera on buses! nd lingual mess may —ipailteral on palate and vestbule (Fg. 36, «¢ Rony: geniculate zoster (rash nea, facial palsy and ters on ipsilateral soft palate} ~ Ratsay-Hunt syndrome (Clinical features and smear fom fresh lesion Differeaine fom toothache und other causes of uct especially herpes simplex (sep. 2). Analgesis; acyclovir (high dose orally or parenterally, ‘specially inthe immasnocompromised; sympromatie teeaument of ulcers Ophrhalmi zoster, ‘ophthalmological opinion, F35 crelooe F362 conron ed ton lite 2 /Intacralasens: nso ers Asiatgy idence trical fares Iesigatons Aatoogy Ineidone Gina farane Issigations Piste Hand, foot and mouth disease Conscke viruses (usually Al6; rarely AS or 10, Very common. It usually ccursin small epidemic, in hilren, bu is raely see in dental practice, Incubation period 2-6 .lafetions may be subclinical lineal features include: oral uot esembling herpetic ‘Momatts But afesing labial and bce! mucoe (Fig 37); no gingivitis; mila fer, alse and anoveas; fash red papules that evalve to saperial vesicles in @ few days, found mainly on plas and sols, nical features. Serology i confirmatory but rarely required Differentiate rom herpetic stomatitis, chickenpox. Symptomatic (se herpes simple, p29, Herpangina Gonsckewrses asl (47,9, 16 B23, 4,075} echovinises (07 acommon, Sell utes ar sen antong young chiles Incubation period 2-9 Many infections are subclinical Clinal feats inte: phryagcl ulcers sualyresrbling herpetic ulcers bu etc posto: tm alone of pal and ura andes ore throat Fig 38; gins ceri Iymphatents (moder ever, mls, sabi, soon vomiting linia feracs. Serology (theoredcally) confirmatory Differentiate fom herpetic stomatitis, chickenpox, ‘Symptomatic 6 herpes simples, p. 29. 28 Hern: mle es tate and py Infectious mononucleosis. | Atoogy Epstein Bare virus EBV) Incideet Common: predomiaunly a divease of adolescents (Gina fares Incubation period probably 5-21 d. Many infections we | sthelinical, The spectzum of manifestations ineiuds ‘ore thot, fail swelling and ulceration with ceamny uate and palatal petchis; ocesional mouth ulcers Figs 39 &40);iymph node enlargement ~ generalized tender ymphadenopathy fever, malaise, anovesa and lositace ig 29 tcos enon ose ann clad sits eseigaions Clinical features; blood pictures Pa-Bunnel ts for ‘eterophil antibodies, Diagnosis Ditlerentite tom other plandala. Like fever syndromes ‘specially early HIV infection, eptotsegalovirs Infection, Texpleme god ifertion and diphberia Troament Sympromaic (ee hemes stnplexsp. 29}; metronidazole may improve sore throat Measles Autiaogy — Measles vias \ Incidnce Common childhood exanthen, Gina fares Incubation period 7-14 . Maay infections a 40 beri morontos paren ei subetnial. Features include: Koplik's spots small setae. ‘white spot on buccal mucosa dusingprodeome (Fi. 4); ‘asi maculopapulr;confunctiits ny nose coughs fever, malls and anorena Ircesigatons Clinical features; sing antibody ttre confirmatory. Diagocs Differentiate from thrash, Fordyce spots (ot in nize TresamentSympromatic Ge herpes simple, 9.2, 5 a4 Medes: Kopp bc i, 2) near kon: ncn Asolo Incidence Cnc Inception: Diagnosis Troament Artology Incidence Cla fone respons Diagnosis Trament Acute ulcerative gingivitis (acute necrotizing gingivitis) Anaerobic fusiform bacteria and spiuchacies (ce also ». 131, Predisposing factors include por oa hygiene, Stnoking, rately) immune detets and HIV infestion Uncoenmon in UK. Iis seem mainly in towee socioeconomic groups, among young aul ices at ips ofinterdenal papilla ectsonally spread slong margins (Fig 42); soreness gingival blessing, haltosis; arly eer, malts, anorexia and eerie lymph node enlargement (Clinical features; sea. Ditierentiate fom leuksemis, herpetic tomatic ‘Ora debridement and hysiene instruction {Peroxide or perborate mouthwash, 4 Metronidazole (penicilin in pregnant females) * Periodontal opizion, Tuberculosis Mycobactera: usually M. ebeafors, but ely atypical mycobacteria, ew MC ain snmacilre, Mi rroplaceam,.M. hawai, especialy in HIV infection Uncommon. I i seen mainly in slobolics, diabetes, pivents with immune defects including HIV infection) fd certain rail groups fe. Asia) Ueeration: usualy single chronie leer on dorsum of tongue asocated with postpemary pulmonary infection ig. 4, Biopsy; spurum culture; ches radiogrepy. Ditlrentite fom other cases of mouth ulcers, ‘pecially syphilis sd carcinoma Combination chemotherspy Fi. atest gah: esol rae pega ig. Tue pl pe alt un doi store Aso Incidene Cina fares Iroetigations Trament Trsponona polo sexually transmitted. Other treponematoses, including Fass, bejel and pint, are rare inthe UK. Uncommon. Ii predominantly a infection ofthe scrully promiscunus (prostitutes, male homasesuas, tewellers armed forces). Incubation period 9-9 a. Congenital syphilis © Head ond nit: frontal bossing, sade nose, Hutchinsosian incisors, Moon's or mulberry molars nd rhagades (ep. 19) + Others nena haadica, iterstial hers, deafness, sre bie and Cluton's jin Acquired ephilic. Sages: © Prinary np (seep-3). Chance: hard psiless fpupule of nodule tha may ulcerate, and heals in 66-8, Tes highly infecuous, and usually on genitals ‘or perianal, but rately on lip or tongue. Thee is ‘gional lymph node enlargement 1 Secondary sph. Oral lesions: mucous patches, split Depules or anaibcrack ulcers (Pi 4) These a Fighly infectious Rash (copperyeoloured rypically on pals and soles, condyomata lata and generalized Iymph node enlargement ean also be presen. Tatars spl, Orl lesions: lositislevkoplakia) ind gums (asully midline in palate or tongue, Fig, 45), These ae non-iafectous, and maybe asscited with cardiovascular complications (arte aneurysm or neuroayphilis (bes doralis; gener paralysis or the fosane; Aravll-Robiason pupils). Direct smear of primary and secondary stage lesions Setology becomes pose late in primary sage Penicillin by injection (or erythromycin or tetracycline). Fatt Siphie scendeyophishonng mousse 546 Gonna ey 30. reer Aetiology Inside iia arr Inceigations Trotment 4 Drugs causing mouth ulcers, [Awide spectrum of drugs can occasionally cause mouth lets By various mechanisms. The more common ‘Rumples inelud: ote agents particularly methotrexate, ents rerrplanuTie (ichenoid) lesions, such as antihypertensive, antidabets, gold salts, non-steroidal sntbinfammstry asa, Antimalarials and otter drugs (Figs 46 & 4), 1 Agents causing lea! chemieal burns (spec spin hneldin the mouth, ‘Uleets are common in those on eyrotxic drugs. Other Gui agen induced ulcer: non speci choo lene ese lichen plants clinlly and istotosealy + Chena rs: wuly itary Lesion wih slouabing Drug history: est effect of withdrawal Stop causative dug; symptomatic: Fi e8 Og rein dutometivecs, Fis 7 Oper: pela ive esr Aatoogy Ircidnce Gina fears Irsesigatons Diagnosis Troan Aesology Incidence ‘Cina fares ecesigatons Diagnosis Trsament Leukopenia Viral infections (specially HIV infection) drugs, srraistion,sopatic Uncommon: but lmphopenia due to HIV infection i {creasingly common. Predisposition: + infstins~ mucosa, systemic or post-operative, ‘mont ers ~charactristaly persistent ulcers [aching sflammatory halo (Fig 8) ul blood picture; bone marow biopsy if appropri. Differentiate fom ocher causes of mouth ulcers (ee 23h cepecially leukaemia, Inmprove oral hygiene; antsicrobials as necessary Leukaemia eiopathi radiation, some chromosomal disorders, shemcal, viruses (ste also pp. 7 & 127. Uncommon Generalized lymph node enlargements Iepstsplenomegals purpura: oval weer (Fig 48) cervical fymph node eolagement;petechie ad stoi brcrorehuges infections ~ candidosis or herpetic subers~ gingival swelling (acute myeloid eaksemin, [abil anaesthesia and fll psy Cael). Se also age. Poll blood piewre and bone marrow biopsy: Differentiate fol her causes of mouth ulcers ee >. 25dand inh node enlargement (we 9. M3) Chemotherapy for leukaemia; supportive care ~ oral lygiene and topical analgesia; ayclovie for herpetic infections antfangals oe cancdos Fig. 4 Nesp destinies, Laveen uontn cred yee eat ute Abtology Clinica fares «6 Iroeigains Trtment Malignant tumours ‘Most malignant orl lers are aguas cll carcinomas the incidence maybe esing in some Sntres, Other primary rumours can Pe anal early), traf salivary glands, ot oer, eg lymphoma, Kepon's ‘savoma or metastases, (Seals pp. 5 & 63.) ‘The etiology of orl earinorais uncle, Tabasco tr alcoha ia some countries) and premalignant fondions (ysplast leukoplakas,canidess,terary typhi, lichen planus, orl submucous bes ana Paterson-Kelly syndrome) may predispse to careiaoms, Carcinomas presen as ulcer, red or white lesions, lumps cor fissare, and usully form chronic indurated lets typically with eased rolled edge and granting oor (Figs $0 & 31) Lymphomas are uncommon (Fg. 52) but ‘increasingly seen in HIV Biopsy. Differesiate fom other causes of mouth ulcers (ee 25), especially myjoraptha or, rarely chronic Infections eg, tuberculosis Oral carcinoma is weated by one or more of he following: surgery radiation and, occasionally, shemotherapy. The prognosis of intapral carcinoma is ‘Poor about 30% Spr survival rat. Tiss because ‘ofthe high proportion of ate stage eases Fi 82 Lymph ate detonator net Pome 21 Insalleson: muna les Atl Incidence Cisia fares Inceigains Dingnss Troemene Autolog, | Incidence Cina fates Inoetigations Diagnosis Trauma a Crohn's disease (orofacial granulomatosis) Unknow, Mouth ulcers canbe due wo Croa's disease isel secondary t folate or other deficiency, or coincidenally sociated ‘Ulers,ypically solitary persistent and ragged with Ihyperplstic margins (Fig 53); there may be other features (seep. ‘Biopsy ul blood piu; gastrointestinal cui i nessa. Dilfrcniae fom orher causes of mouth ulcers (ee 1.23) especially mlignont lesions ox chrone bacterial Infection ‘Topical or intalsional conicostericss steric or possibly topical suphasaarne Ulcerative colitis Unknown, Uncommon, Aphthae can be asccated with ulerative «oii, ut direct cause and fic elationshi, or may be ‘sccondary to anaemia dus to chronic howel hcrorrage. General persistent iavhoeas requently pales with pstage of blood and mucus ia severe eas iron tleficiensy anaemia; weight Loe, Ora: mucosal pustules (pyosomaiis vegetans) oF feregular chrome ulcer (Fig. 8). Biopsy fal blood piture; sigmoidoscopy barium, Differentiate fom other causes of mouth ulcers (see 23) partcalarly Croha's disease “Haematiaies for any secondary deficiencies opeal comiosteroids may be helpful sulphaalazine; Somiosteroid enemas Fiat Ooh dco moles Ft Util mas pus pyetonais eet 2 ntecralasens: mucous Aetiology Incidence ina fame Irrigations Diagrose Prsamene Pemphigus Actoimmune: sicultingsutoanebodits to epithelial intercelilar substance, I i eure cused by das Aenicilanine) or ther agen Rare. It is aly a disease of middle-aged women, ‘specially fom around the Mediterranean, ‘Ora lesion ae most common in pemphigu vulgaris and often precede skin lesions. Blisters aywhere om the tacos uptue rapidly to eave ragged ulcers (Figs 55 & 56) Nikolshy’ sig s postive Skin lesions: lege acid blisters especialy where here is rauma. Lesions may siet other mucosa, 4 Biopsy to show acanthosis including.” Immunofiurescene to show TgG and C3 binging wo intercellular stachment of epithelial cells, 1 Serology antibodies a epithelial intercellular substance), Diflerentiat from other causes of mouth ulcers sce p-23), especially mucous membrane pemphigoid, Immunosuppression with corticosteroids ps uathiopeine os gol Fuss Ponchisvare Fn s6Fereinswiote 2 J uations: rusosl ues Actos Incidence (hina fares Ioeigatons Diagoss Treatment Aaisagy Taide (tical fares Icesigaions Diagoss Trsxment 8 Mucous membrane pempt His some autoimmune features [Not uncommon. Its seen mainly in middle-aged oe lier females. (Ora blisters (sometimes bloo-filed) can present anywhere uc especially at sites of waums. Niolsky’s fign may be posit, Ulcers may bel with scarring (Fags 57 8 58)" Desquamative gingivitis common, (see. 133). (ters: conjunctival exons ~ leaing 1a Snpaired sight {enuopion or symblepharon} laryngeal lesions may lead stenosis skin lesions blisters rarely (unlike bulls pemphigoid which arly aes the mouth) Biopsy —subepichelal split including immunostaining (C3land IgG a basement membrane Diffreiate fom cher causes of mouth wees (ee 23), especially pemphigus and loclized oral purpur ‘Potent topical corticosteroids or, rarely, systemic corticosteroids or dapyone. Localised oral purpura Uncles. Notuncommon; seen mainly in the eldery Blood blisters in mouth and pharynas mainly on the oft palate Sometines termed snginabulloca haemorrhage) ial occasionally on the Intel border of the tongue Pig 59), Thee is rapid onset, with breakdown in day or vo to leer. No bleeding tendency. Contes hasmostss noeral biopsy (arly exclude pemphigoid Differentiate kom pemphiguid and other vesculbullous lisorders, aun, purpura (ez also p 8) Reassure, Topica analgesics, Fi 7 Meo entrap Fi 58 uns nob pemphi pd wsm, a 8 Lost puma bls oer Pay sed da ee =<. ee ‘i a Ina srs: mucosal ues Erythema multiforme Ginica foraes Usually a top?) Oral: cracked bleeding, crsted, swollen lips and ulcers (see Figs 9 & 10) Orders: conjunctival andor genial usr; rashes {yplelly "target oi lesions, o bulla om extemites; ‘Ever and malaise | Mucocutancous lesions and systemic itiness 1s for 10-14 once or twice per yea (see (Stevens Johnson syndrome) bullous and other rashes, ‘reumonta ais, nephnitis or myocarditis vouigaions Biopsy ifneded exclude other disorders Diognis Diflerentnt from other oeulomucocutaneous syndromes, especially pemphigoid and Benger's syndrome Treument See age? Epidermolysis bullosa Aology Genetic monly, including various aurosomal dominant (telativly benign) and recessive (ore sever) forms Defect of epithelial basement membrane proiein is seen Jn some sub-ypes, Am acquired form has so been described, Iidece Rare | Gina fotnee Autoromal dominant forme: skin Wistrs afer wana, | ‘hich eal without aces, Oral lesions ze rate, | ‘Recessive form skin ad mouth lla in neonates (Figs 60 & 6), which bal oly and sear, Some de; others Improve slowly (se ls p. 149) | roigtos—Exmiy isos py 0 xls te sero i 61 Epo a aig ends depiaton iagncs Differentiate fom other vesiulobullous disorders Tremont Avoid sauroa.Phenytoin may benef some. Coriostrois re posibly lp Incidence inica fares Jrceigatons Tremont Lupus erythematosus ‘Unknown. Connective tsue disease (auto-immune) (Geealso 9.9) ‘Ugcommon, Both discoid (DLE) and systemic (SLE) can fet the mouth, and onl esons ean precede other ‘ual fetations in a minority of patients DLE: characvsti features of iztzoal lesions inch ‘ental erythems whic sot or papules, radiating wt ‘Stic at margins tnd peripheral felangiectasis, SEBS lesions like thot ip DLE but usually more severe Uleraion Fig, 62) SLE may also te asociated with Sjogren’ syndrome (e p 138) and aely, TMI rhe Biopoy; blood picture; eutoantbodies especially ‘ritidial Gloublestanded DNA), Antitelea factors fr prseat in SLE, aot DLE. (DLE: dtereasiate rom other cases of mouth ulcers (seep. 23) and especialy Kom SLE, lichen plans and Tenkoplakis. SLE: dierenviate from other causes of mouth slcers especially DLE (sep. 23). DLE: topical corticonterids (arly systemic) SLE: sstemie steroids, azathioprine, chloroquine or old, Lichen planus “This well casos whit lesions and is therefore lisussedon page 57. However, ican present with ‘rosons Fig. 6). Fg 6 hepa oir wot ergo 3 / Intraoral white lesions Avtlogy Incidence nica arse 9 Iroeigatons Diagwois Truman Lichen planus ‘sully no atilogcal fats is denifiable, A minority are due drug lckenoid lesions, seep. 4), ‘raft vesus-hon dies, iver disorder (pomsiby) and ‘eations to amalgam oF gold (posi) Commons mainly middle-aged or elderly females (ce alsop. Lesions may be asymptomatic, White strate lesions are common (Figs 64 865; erosions are es common Tesions tend wo be bilateral ‘Retiularlesions ae mest afen found on bucal ‘mucosa sometimes on te tongue, Pupul lesions allect Similar sites PlagueIike lesions sualyafese posterior ‘bce! mucost, Red lstons of trophic LP may siulate enybroplasia Sep, 79) LP can cause desguamatie [agit (se p15), Onl lesions are osensionlly Fyperpiamented. Rash: rustic, polysonal,pseplish papules predominantly on fect surfaces of wees and ‘Shins rarely on the ace Trauma may ince lesions (Kosbner phesomenon) Alopecia oil deformities are seen oceisionally Erosions are irregular, prs vlowish slough, and are often Fesons (se Pig 635.56) They have asl premalignant pote (1% after ten years. Drag history; biopsy. Ditferearite fom other cases of white lesions (sce pan less ee p23) epecilly DLE and 1 Sympiomare: corticosteroids topically and rarely, intlesionaly or systemically. Other drags such 25 retinoid griseofulvin or eSlosporia have not proved ‘elishly superior, or may have adverse fects a i. hepa bt tn pop | Fi 8 Len pur: pte spelt, SS ee 2 tacit sions Asie and ‘aeliee Cina fares Irons Diagnosis Potent Asisog and ‘ne trical ares Irian: Diagnosis Traament Aaiolgy and Teen Cina fares vegans Diagnose Treament Ca ‘Thrush ‘Neonatal oe cstrbed oral microflora by antibotes ‘orlcsteruds or aerostomi; immune dees expecially {nH infection, immuaosuppresive westment, Teuktemiss and lymphomas and diabetes. Rare in Ina patient White or creamy plagues that cas be wiped off leave 8 red hase (Fis 68) Gram stain smear (hyphae) blood picts Differentiate from Koplit's or Fordyce’ spots and tichen planus sis ‘Treat predisposing cae. Ancfungals: nptatin orl Sinpension or pale or amphotericin lozenges or talgonaale el ot tablets or uconale tablet Chronic mucocutaneous candidosis luamune defects sometimes; occasionally gonetics FV ‘infection, Iisa zare contin. (Ovals persistent widespread leukoplakia (ig 67) ‘Gutancons: nil end skin candidosis. (rer: etc fail multiple eadorinopathies, ron (ficensy oF yom Family history biopsy Blood pictures autoantibody and fdocrine studies. Differentiate fom other white lesions (te p69), ‘Antifungals os above) including systemic Ketoconazole CCandidal leukoplakia (limited type) Unclear making predisposes. The condition is uncommon, but considerably more common than ‘onic macoeuaneous endidoss ‘Leukoploki is ypically found at commissure often speched, Thee sa bigher premalignant potential than any etkoplakas (sc also Fig. 739.69) Biopsy Differentiate from other orl white lesions (sep. 6) ‘Antifungals; stop smoking; remove (excision ot eryourgery) ar observe, a i. Oven: nucsestenu codon ieee aie 3 / volte leone Aig Incidnce Cinia fares Iraeigatons Diagross Trament Actioly Iidece Clinica fares Irceigations Diagacs Tremont Chemical burns Various chemicals or drugs notably axptin put in sulcus touy relieve wothache Unknow, White lesion with sloaghing mucosa localized wu to buccal sulcus and adjacent buceal mucos, offen longridecaion tooth Fig 68) History. Dire fom other white lesions (ep. 6 Trea orhache as appropriate, Sop the Rai son seitcalog Cheek biting Anxious personality or anxiety neurosis (8 aso Eletional keratosis p65), ‘Gomon: most prevlen in anslous females, expecially ‘ove wth other psjehologically related! dearer og \emporonndibula pain-dyfunction syndrome Rarely (Gelemutlaion) seen in psychiatric disorders, mental handicap of some rare drome, Abrasion of superficial epithelium leaves whit lingments on reddish background (Fi, 69. Lesions ace invariably restricted to lower labial mcesa andor bel smucosa nea oscil line (lisicl Fests Differentiate fom other causes of whit lesions ee p63), partially white sponge nacris. Stop the hab if posible, Fi. 8 Bune phinpiel nods ato ee rote anurtoh ee EE eee a 3 sarin eons Keratoses ‘Leukoplakia is the term utd fr hypeskeraote white ‘coal lesions af unknown caine Thete ate no specie histopatblogical connotations Aaiolog” Causes of leukoplakia and othe keratoses include the fallosing Hiopatic: most cases Fis 10 Friction (Fig. 70, Tobacco: pipe smoking cn case “icine stomatii' of plate especialy, smokeless vobaco or berel-chewing can ‘rut keratin of buccal sults (Fig 725.60, Micoorgenions| 1 Condi ican. Candalleakoplakisfreguertty Fig 1 Hoops fappest speckle often afectcommissues and have fay high premalignant posential (Fig. 7, p60), ‘© Supls: Spc leukoplakia especiy ale ‘Sormum of tongue and have fly high remalignane potential Fig 74, p68) Hay tatoplats le virally pathognomonic of HIV infection, Epstein-Barr virus maybe detected, I i ot premalignant (Fig. 75.68) 1 + Focal stil perl (Hels diene) ie rare. I predominantly alfes Eskimos and Ameriean Indians nd ir cased by oman papiliomsvinas Incidence Fae common, Most keratoses are sen mainly in mmiddle-agelelderty adults, but hairy leukoplakia seen ‘mally in young adult males Fi 71 Oe is uty eon 7 2 / incr te eons Cie fares 6 nical ype Keratoses (contd) [Most eratosss are benign but overall 1-394 are Dremalignant. Keraons in particular ite o of appearance fend to have higher premalignant tot epithelial dysplasia, microscopically ist le guide ‘Sites: most fequentiy in the buccal mucos, Appearance: mest sre smooth plagues (homogencous Teakoplakis, Fg 70, p. 64); some warty (vereucous leskoplakiay some mived white andre lesions (Gpeckled feskepakis). In general, homogenous Teakoplakis are beniga, Premalignant poteatil is higher in verrucousleukoplakiss and is highest in speckled Leskoplskise Some studies show malignast "Bunsformetion in over 20% of pecked leukoplakis Frictional Rraross. Usually sen at sites of trauma fom teeth, also along buccal occlusal lie (Pig. 71.64) and aly beside outstanding tooth, of on elencilns is homogeneous and clears up when ieiaion ‘Smokers heats (stomatitis nicoina). Pipe smoking isthe usual cause The palate, particularly the sot palate is affected. Red orifices ofswollen minor salivary lands ot palate within widespread white lesion give suking appearance of red spots on white background (Fig. 72), ‘Tis lesion ts beniga i sl, but eeeinoma say Aevelop neath (Other tobaccoslatd habits. Tbacco-chewing, sll. dipping or chewing of betel quis may lend to leraoses which an be premalignant. Soul pp Is aseclated predominanly with verrucousRertoses Which can progress fo verrucouscarcinome, Smokeless obacco Is kel o ave the sume eet Tobacco-tlaed Rersose yplealy resolve a sopping the habit Fo.) Seeded ope can ch 41a sions a Cina pes (eon) Ivseigations Keratoses (contd) Candida leukoplakia C albicans can cause oe colnice suher keratoses purculaly ia smokers and is expecially likely to form speckled leukoplakia eommisure (se Fig. 78,p. 72) lemay be dysplastic and have higher ‘remalignant potential than some other keratoses, imdida leukopakiss my respond to anifungale and stopping smoking. ‘Syphiltclukoplakias, Leukopakis, especialy ofthe dorsum of tongues isa feature of tertiary spl ts rare seen now (Fig. 74, Prealinant pote i high “Hairy lekoplahia. Usually hus a coerugited surface and ‘mainly afets mains of the tongue lon excusiely (Fg. 75), Ics een inthe immunceompnomised and isa fomplcation af HIV infection and. predictor of hose ‘who will progress fallow AIDS. eis sen in all groups atrisk of HIV infection. The condition spe to ‘be benign, and selimiting or may respond to aelovie Leuhoplakia in chronic renal feilre. Symmectica ft ‘eratonis may complete chronic ena alse, but ‘solves after ueattent by renal transplantation dialysis. ‘Sublingual keratosis. Kertoes ithe oor ofthe ‘mouthiventrum of tongue were frmesy thought io be ‘seri (Congenital) but although of weno setilogys now reporced to have premalignant penta get than other leukoplakia. A few sties suggest that > 20% undergo malignant rasformaton, Often hoinogencous, there may be speckled areas. The surface has aang lige’ appearance (se ig 76. 70). Opinions arya 0 Ivhether the lesion shouldbe left undisturbed or removed surgically or by cryoprobe, ‘Most white lesions ned oe biopsied for possible \ysplasa or early malignant change ig 75 ADS. rycen tog era cannon ‘orugedopsoce a Trsament 2 nao tie lesions Keratoses (contd) Ditfereniate fom other orl white lesions ‘Desetopmental. White sponge naevus; other rate syndromes. Acquired ‘¢ Transient burns, check-biting, Thrush 1 Persistent— keratosis (icional, dapat smokers ‘candida yphiite); thrash in LY. 1s Lichen planus Lupus erythematous, ‘See above but in general: eat predisposing factors 1 surgically remove smal discrete lesions < 2em ddatmeter 1 observe regularly large lesions ing carcinomas may appear a ora white lesions (Fig 77) ab aor may occasionally aie in ‘ier oral white lesions, notably in seme Keates, “yskeraosiscongenta, orl submmicousSbsoas oe rarely inlichen planus. se also pp 5 & 49). 4.7 Saunas encom nh agra eal vhs pao 3 Flac hte ons Actlogy Iidence tinea eae respons Diagnosis Troament Atisogy Iridoce linia fares Iresigations Diagross Tisaiment ‘White sponge naevus Genetic: autosomal dominant, but family history say be negative. Rae: fen reengnized ete in life Oral fesions predominate: asymptomatic, diss, bilateral white Iesons with shagay or spongy, wrinkled surface (Fg. 78) They mainly present on the buccal ‘mucosa, but sometimes on the tongue, Aor of mouth, or ‘lecwherey anda ose ge Clinica eaares; biopsy is consrmatry Disiretite fom other white lesions (sce p69), cespectlly cheek biting Reassurance Oral submucous fibrosis (OSMF) Possibly slated to the us of areca mts or chillies Rarein UK virally ony disease of adults from Indian sub-continent ‘Tight vertical bands in buccal mucosa (Fig. 79 that may progress to severly rastrct oral opening. lean aso, ‘fect the palate or tongue. Often anaemia i present Premalgnaat potential ~carcinottaposily in up 0 25% Clinical features; biopsy; haematology. Dilfeceniate from scleroderma sep. 73). Stop use ofaesa nut chillis. Asymptomatic observe nly. Sympromati wih rerrcted opening exereen, intralesional comiosteroids snpery. Possibly penillamine 978 espe rae, ig.7# Orlabmucas tes toning vecltnd od ilo musa 7" 4 / Intraoral pigmented lesions cielo Isdoe Chia ares resigns Diagwois Treanent | Arig Incidence Cinica anes Irseigations Trsoment Scleroderma Unknown, ‘Vacommon: mainly midleg female. (Ova opening restricted with microsoma snd pale ‘boc thicker congue; widened perodoatal pace on adhography in ev, But ech not mobile Occasionally: islangiccsi (Fis 80) secon ‘Sjseren's syndromes bore lesions. (Other features: skin tight and way Rayna syndrome; dysphagia Rare variant: CRST syndrome (calcinosis, Reyncu’s syndrome, slerodacrly,telangecasa. (Gina features; histopathology; auto snodies (ANF and $2170 especial), (Ora lesion: diferente rom OSME (se 70) telangiectasia eg: HHT, se below] and secondary Shomen's syndrome ee py. 119 & 13), Pesiciersine. ” Hereditary haemorrhagic telangiectasia (HHT; Osler-Rendu-Weber syndrome) Autosomal dominant ieritance bu fail history may benegave. Rac ‘Telangiectaes are present only and perorally (Fig. 81) ‘atalino, gatrointstinal act and oscasionally ‘on palms. Telangectses may bled sung teiency anaemia. ‘Clinical festares; blood picture Differentiate from other causes of elangietsia: scleroderma chron ver diteae nd post radiation ‘Cayosugery or ltr if bleeding is troublesome; treat Acsooey Iridence hina fares Inesigtions Diagass Treat Auto Icidonce (incl eae Inceigations Diagnois Tremont 4 nsscrlpgmeredesons Haemangioma Hamartoms or benign tomour. ‘Most common on tongue, vrmilion border of lip, ot ‘paced mca Red ob, poles, soft and sometimes fucuant lesions that wuslly blanch on pressure (Figs 82,83 & 122). Most appear in inane: Aspiration; biopsy (excision if feasible for confirmation, rarely. Ditlereatiate rom telangiectass, purpura Kapos’s sarcomis and epitheiold angiomatoss Rarely Fhesmangioeadatbelionas, Mafucels syndrome (muldple Ineemangiomas and enchondsomas) and Fabry disease Glipidsis) Observation Some 50% regress spontaneoisy), xyostrgery seg late sseroant oe (acl) arterial embolization oly if bleeding is eoublesome ‘Sturge-Weber syndrome Congenital. (See also page 21) Rare “Hacmangint within rigeminal sensory area extending into lepiomeninges; epilepeys hemiplegia (sometimes) ‘mental handicap (common. (incl features shal sadiograph intracerebral calcification) Dilfereniate from buemangioms and other rare symdromes. Anticonvulsants for epilepsy. Institutional cae often eves. Fu 2 Hoenn, a 4 ota sige ens Autsogy Gini forares Digs Treat Astolosy Incidence Cini fares Incesigations Trosmant Radiation-induced lesions Tnvarableifteletherpy (external beam tentment) involves oral mucosa and salivary alands Mucosits ise erythems end ulceration (Fig, 8. ‘Xerosomia: leading to dysphagi,dintrbed at, fanuidosis laden, radiation caries. Libis to tstcoradionectois, Others: ja ypopasa; hypoplasia and retarded eruption ‘of developing tceth rss telangictasa (ate) Diagnosis lar from history; avoid biopsy, Symptomatic; contro infections Trestment with mtimicrobias ete aghast Gras negative bail may ‘prevent mucositis, Denture-induced stomatitis, ‘Usually C albicans, Constant denture weating predisposes, but other factors may include poor denture Fygiene, high arbobydate det and HIV infection, (Common: msinlyeldery patients, Difse erythema of denture hearing area only (Fig 85), ‘vith oetasonalpetechine or thrush Ts almost always Asymptomatic The only known complications are angular stomatitis (ep. 1) and aggravation of palatal pupillary hyperplasia Diagnosis is ceareuts smear for hyphae Differentiate fom ersehfplasia or eraums Leave dentures out at night in anti-fungal Anypochlorite,ehlohexidine) antifungals; enon 19 ature, Erythematous candidosis (Capdidosis may ease sore rd mouth especially ig patients on broad spectrum noticias, Fnythematouscandideis especially onthe palate or rogue, ay alo be a estare of HV disease Fl 8 Ogre ried oat 4 Inter pigmented eins Avtology Incidence tinal fara Iosigatons Diagoss Trent Arig, Incidence Clinica anes Inssigations Diagnosis Proto ® Erythroplasia (erythroplakia) Unksowa. ‘Uncommon mainly son in eldely males Its much less common than leukoplakia, bu far more likely be ‘ysplatc oF malignant Red velvey ptch of variable confgurstion commonly ‘on soft palate ot for of mouth es usually level with oF ‘pressed belo sucounding mucoss (Fig. 55) Biopsy for epithelial dysplasia nd carcinom, from inflammatory and atopic lesions, icy anaemia, geographic rong, licked Bis, bu the prognosis is often poor. Kaposi's sarcoma ‘Unclea: a malignant neoplasm of endochelial cell Iti Sequendly assisted wih HIV infecon. ‘Once rare, now increasing as feaure of HIV infection. Ie ie vierely unknown in the moath except in AIDS and related syndromes (commonly), or omunotuppreses ‘nga transplant patient (ere) Early lesions ae ed purple or brown macule. Later ‘hese become nodular, extend disseminate and ay bcerate: Kaposi's sarcoma typically involves the plate, bouteanafee anyother oral site (Fig 87) Biopsy i confiemarory Differentiate from other pigmented lesions (see p81), specially epithelioid angiomatuis,aemangionis nd purpura. ‘Treatment of underying predisposing condition if possible; radiotherapy vines allo Fp Kap ssacana aod wt rsh — 4 nara omen estas Asiolgy Ircidnce Cia fares Insesigaions Diagnosis Truster Absilogy Ircidence Clie fanoes voetigations Diagnosis 8 Purpura Platelet deficiency -iiopatic(auorinenune), sometimes i AIDS; plat defect; vascular defect ately ocalized oral purpura angina bullosa Heemorthagis’sce p81). Palatal peechine area feature ‘of infetious monomcetsis hut ay be een in HV Sisease or vubela or where there Is vocing fo bulimia. ‘Occasional small aumatic peteciae athe occlusal line ae common in otbervse healthy patents. Otherwise, oral purpura is uncommon, Resor brown pinpoint lesions petechise or eschymoses rainy at ster of rauma (Fig 8), Lesions do noc bane tu pressure (ef baereangiomal, ‘Blood picture (including blood count) and beemostatic function Differentiate fom haemangiomas, telangiectasia and Kaposi's sarcoma. Thrombocytopenia faleo seen in HIV tater "Treat the underlying case. Racial pigmentation Racial pigmentation is sen not only in coloured patients Putas in some white, especialy tose tom Mediveranennlitra, ‘Common =the main cee. Browa (carey Mack pigmentation especially of the ingiva ig 89) Niluless to exclude Addison's disease (sep. $3 Differentiate fom other causes of pigmentation (especially Adson's disease), namely: Lovaied: amalgam too, eplis, nevi, PeutzJeghers syndrome, melanoma and Kapes's 1 Gone: ail, Addison's disease, drugs ad ator ‘ee eases including AIDS, Fa fh pant,

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