DENTAL ASPECTS OF MULTIPLE MYELOMA
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Transcript DENTAL ASPECTS OF MULTIPLE MYELOMA
RECOGNIZING WHITE
LESIONS
PART I: Reactive, Idiopathic,
Hereditary
David E. Wojtowicz, DDS, MBA
White Lesions
A Lesion Appears WHITE Because Some
Material Is Obscuring the Normal PINK or
Racial Color.
Is the WHITE Material Directly on the
Surface?
3 Mechanisms
to Achieve White Appearance
Epithelial Thickening
– Rough / Does NOT Rub Off
Surface Material
– Rough / Does Rub Off
Subepithelial Change
– Smooth / Does NOT Rub Off
Six Common Etiologies for
White Lesions
Reactive
(Snuff)
Idiopathic (Hairy Tongue)
Hereditary (Leukoedema)
Auto-Immune (Lichen Planus)
Infectious (Candidiasis)
Neoplastic (SCC)
1. Six Reactive White
Hyperkeratotic Lesions
(These are HYPERKERATOTIC. They Do
NOT Rub Off.)
a. Snuff Dipper’s Lesion
b. Nicotinic Stomatitis
c. Chemical Burn
d. Linea Alba
e. Actinic Cheilitis
f. Denture Acanthosis
1. Six Reactive White
Hyperkeratotic Lesions
(Do They Rub Off?)
a. Snuff
Dipper’s Lesion
Wrinkled, Velvety
US & Canada, Lower Carcinogenic Rate
Asia Higher Rate Due to Added Carcinogens
Treatment = Quit Habit, Switch Site
1. Six Reactive White Lesions
b. Nicotinic
Stomatitis
Grey, White and Red on Hard Palate
Pipe and Tobacco Smoking (Heat)
Red Spots, Inflamed Minor Salivary Gland
Orifices
Treatment = Quit Smoking
1. Six Reactive White
Hyperkeratotic Lesions
c. Chemical
Burn
Caused by Aspirin
Painful
Usually in Molar Region
Treatment = Discontinue Aspirin Use
1. Six Reactive White
Hyperkeratotic Lesions
d.
Linea Alba
Most Common White Lesion
White Line @ Occlusal Plane
Bilateral on the Buccal Mucosa
No Treatment Needed
1. Six Reactive White
Hyperkeratotic Lesions
e.
Actinic Cheilitis
Sun Damage
Lower Lip
Obliteration of Border
Treatment = Avoid Sun, Use Sunblock
1. Six Reactive White
Hyperkeratotic Lesions
f.
Denture Acanthosis
Caused by Irritants
Clinical Appearance is Similar to
Hyperkeratosis
Thickened Intermediate Cell layer
Elongation of Rete Pegs
Treatment = Avoid Irritants, ie. Ill-fitting
Dentures
2. Two Idiopathic White
Hyperkeratotic Lesions
Geographic
Tongue
Hairy Tongue
Geographic Tongue
(Benign Migratory Glossitis)
White Borders (+/-Hyperkeratotic)
Red Patches of Denuded Filiform Papillae
Common Disorder (1 - 2%), Females,
Young Adults
Painfree or . . .
Painful if inflamation is present
Treatment = None, or Topical Anesthetic
Hairy Tongue
Shaggy Matte of Filliform Papillae
Candidiasis Stimulates the Hyperplasia
Coffee, Tea, Tobacco = Black
Treatment = Brush Tongue, Improve Oral
Hygiene
3. Two Hereditary White
Hyperkeratotic Lesions
Leukoedema
White
Sponge Nevus
Leukoedema
Milky Grey Film
Bilateral Buccal Mucosa, Non-progressive
Disappears When Stretched
More Common in Black Population
Treatment = None Needed
White Sponge Nevus
Rough, Fissured Texture
Symetric, Bilateral Buccal Mucosa
Appears During Childhood, Nonprogressive
Autosomal Dominant Transmission
RECOGNIZING WHITE
LESIONS II:
Auto-Immune, Infectious,
Neoplastic
David E. Wojtowicz, DDS, MBA
4. Two Auto-Immune White
Hyperkeratotic Lesions
Lichen
Planus
Lupus Erythematosus
Lichen Planus
Auto-immune
Degeneration of
Connective Tissue / Mucosa (Skin)
Interface
Middle Age (Rare Before 30)
M = F, Skin Lesions (33%)
Lichen Planus
Reticular
(Wickham’s Striae)
Annular
Erosive
Atrophic,
Bullous
Lichen Planus
Stress
& Thiazide Drugs are
Possible Triggers
Differential: Snuff (Stretch)
White Sponge (Youth)
Treatment = None if
Asymptomatic . . .
Erosive Lichen Planus
Painful
Risk
Factor for SCC
Treatment = Biopsy, Steroids,
Retinoic Acid
Lupus Erythematosus
Skin
Lesions: Butterfly Rash (Sun
Exposed Area)
Mucosal Lesions: Rough White
Patch
Bordered by Striae, Ulcers,
Erythema
Lupus Erythematosus
Systemic: Arthritis,
Vasculitis (Renal
Failure)
Antinuclear Antibodies (ANA)
Differential: Lichen Planus
(Symmetrical
& Cutaneous), Leukoedema (Stretch)
White Sponge (Youth)
Treatment = Corticosteroids
5. Three Infectious White
Lesions
Candidiasis
(DOES & Does NOT
Scrape Off) - FIVE Clinical
Lesions
Oral Hairy Leukoplakia (Does NOT
Scrape Off)
Syphilitic Mucous Patch (Does NOT
Scrape Off)
Candidiasis (Moniliasis)
Acute
– Pseudomembraneous (“Thrush”) - White
DOES Scrape Off
– Atrophic (“Erythematous”) - Red
(Does NOT Scrape Off)
Chronic
– Hyperplastic (“Candidal Leukoplakia”) - White
(Does NOT Scrape Off)
Candidiasis
Commensal Organism - Normal Oral Flora
Capable of Opportunistic Infections
(Hyphae)
Early Sign of Host Defense Breakdown
(Neutropenia)
Risk Factors: Antibiotics, Imunosupression,
Diabetes, HIV, Steroids,
Nutritional Deficiency, Radiation/Chemo
Candidiasis: Acute
Pseudomembraneous
White, Scrapes Off
Underlying Tissue: Erythematous,
Hemorrhagic, Pruritic
Newborns & RF (See Previous Item)
Treatment = a. Correct the Predisposing
Factor
b. Prescribe: Nystatin Vaginal Tablets
– Disp: 70
– Use: One Tablet as a Lozenge 5 Times a Day
Candidiasis: Chronic Hyperplastic
-Candidal Leukoplakia
Keratotic Plaques or Papules (?Scrape Off?)
Against Erythematous Background
With Acanthosis
Sites: Labial Commissure, Labial &
Buccal Vestibule
Risk Factors: Smoking, Poor Oral Hygiene
(Dentures), Xerostomia
- These Are Essentially All Chronic Irritants
Candidiasis: Chronic Hyperplastic
-Candidal Leukoplakia
Cancer Risk: Biopsy is Mandatory of All
Speckled Erythroplakia or Erythroleukoplakia Because of Increased SCC Risk
Treatment = a. Correct the Predisposing
Factor
b. Biopsy Lesion
c. Prescribe: Nystatin Vaginal Tablets
– Disp: 70
– Use: One Tablet as a Lozenge 5 Times a Day
Candidiasis: Three Red
Chronic Oral Lesions
Angular
Cheilitis = Perleche (Red)
Median Rhomboid Glossitis (Red)
Denture Sore Mouth = Atrophic
Candidiasis (Red)
Oral Hairy Leukoplakia
Rough, Hyperkeratotic, Patch
Opportunistic E-B Virus
HIV & Immunocompromised
Bilateral, Lateral Borders of the Tongue
Treatment: None or Acylovir
– Disp: 60 Capsules
– One Cap q.4h. for 5 to 10 days
Syphilitic Mucous Patch
Painless,
White, Mucosal Ulcers
With . . .
Nonpruritic Skin Rash,
Lymphadenopathy
Signs of Secondary Syphilis
(T. pallidum)
6. Four Neoplastic White
Lesions
Squamous
Cell Carcinoma
Verrucous Carcinoma
Epithelial Dysplasia
Carcinoma in Situ
Squamous Cell Carcinoma
(SCC)
90%
of All Oral Malignancies = SCC
Mixed Red & White is
Most Likely Presentation
Age: Elderly (40+)
Gender: Males (2:1)
Location: Lower Lip, Floor of Mouth,
Lateral & Ventral Tongue, Soft Palate
Squamous Cell Carcinoma
(SCC)
Uncontrolled
Growth
“Up Regulation” of Oncogenes
– Kinases & Cyclines
Become Overactive
Deactivation
of Suppresser Genes
(Antioncogenes)
Verrucous Carcinoma
Hyperkeratotic,
Exophytic,
Papillary
Age: Elderly (60+)
Gender: Males (2:1)
Location: Gingiva, Alveolar Ridge,
Buccal Mucosa
Epithelial Dysplasia
Premalignanat
Changes of
Cell & Architecture
Mixed Red & White is
Most Likely Presentation
Cell Alterations: Nuclear Changes
Architecture Alterations:
Bulbous Rete Pegs
Carcinoma in Situ (CIS)
Entire
Thickness
(Top to Bottom Change)
Basement Membrane Intact
No Invasion or Change of
Connective Tissue
Geriatrics
Proliferative
Verrucous Leukoplakia (PVL)
– Hyperkeratotic Lesions
Mixed Smooth and Warty
– Mainly on Edentulous Alveoloar Ridge
Cancer
Risk: May Progress to
SCC or VC
Risk Factors / Predisposing
Factors
Demographic (Age,Gender,Race)
Social (Alcohol, Tobacco,
Oral Habits)
Recent History (*Trauma, *Infection,
Surgery)
(*Especially Chronic)
Medical History (Chronic Disease, Acute
Illness, Medications,Treatments)
(Especially: Diabetes, Organ Cancer,
Antibiotics, Chemo)
3 Mechanisms:
Surface Material
– Rough / Does Rub Off
Epithelial Thickening
– Rough / Does NOT Rub Off
Subepithelial
Change
– Smooth / Does NOT Rub Off
– Two Examples:
Fordyce Granules = Ectopic Sebaceous
Glands
Scar: Surgical, Traumatic
Clues to Normal
Bilateral Symmetry
Predictable Locations
Asymptomatic
Independent Finding (no Secondary
Features such as redness, swelling)
Increase with Age
Remains Unchanged w/ Treatment
Glossary of Terms
Acanthosis: excessively thickened
intermediate cell layer with broad and long
rete pegs
Hyperkeratosis: excessively thickened
keratin in stratum corneum
Leukoplakia: a white patch on the oral
mucosa that cannot be scraped off and
cannot be classified as any other disease
Review: Which of the Following
Choices Demonstrate Concepts
of Differential Diagnosis:
a List of Diseases With Similar Manifestations (Yes)
b Oral Ulcer (No, monomorphic presentation)
c Zinc Deficiency, Trauma, Herpes, Aphthous Lesion as
Potential Etiologies for a Single Monomorphic
Presentation. (Yes)
d Rely Primarily on the Clinical Appearance (No, must
include history, risk factors, visual inspection)
List the Seven Primary
Clinical Manifestations of
Non-dental Lesions
–
–
–
–
–
–
–
Normal Variation
White
Red (Pigmented or Dark)
Ulceration
Exophytic
Radiographic
Syndrome
•List Four Techniques
Employed to Investigate the
Secondary Clinical Features
of Oral Lesions:
Visual Inspection
Palpation
Probing
Patient Awareness
Name at Least Four Visual
Features to Inspect for When
Examining an Oral Lesion:
Location
Shape & Contours
Size
Solitary/Multiple
Borders
Homogenous/Heterogeneous
Surface Color/Texture
Displacement (of Teeth?)
During Palpation One Can
Check For:
Compressible
Tender
Color Change (Blanching)
Mobile / Bound Down
Induration
Probing, Exudate
During the Interview, Inquire
if Patient is Aware of:
Pain or Altered Function
Duration (Acute, Chronic)
Progressive Course or Remission
Response to Stress/ Foods
List Four Risk or
Contributory Factors:
Demographic (Age,Gender,Race)
Social (Alcohol, Tobacco, Oral Habits)
Recent History (Trauma, Infection,
Surgery)
Medical History (Chronic Disease,
Acute Illness, Medications,Treatments)
Differential Diagnosis
List
of Diseases With Similar
Manifestations
Rule Out (R/O) on the Basis
of Contradictions
Example: Oral Ulcer