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Red lesions

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Introduction

Red lesions of the oral mucosa are produced by different pathogenetic mechanisms.
Underlying histological changes in red lesions
      Dilated blood vessels
    • Sprouting of newly developed blood vessels
    • Thin overlying epithelium
    • Bleeding under the surface
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Geographic tongue (lingua geographica)

Synonyms: erythema migrans, exfoliatio linguae areata, benign migratory glossitis

Definition and clinical features

Geographic tongue, also known as erythema migrans, is a common benign hereditary disorder of unknown aetiology that primarily affects the dorsal surface of the tongue. Rarely, other areas of the mucosa are also affected. Sometimes, it occurs in individuals with psoriasis. It may also affect children. Clinically it is often asymptomatic; patients may complain of tenderness or a burning sensation, particularly upon eating sour food. It manifests as scattered, flat, irregular red lesions that are often surrounded by a grey-yellowish (keratotic) ring. Red areas extend, heal and are then replaced by new lesions in other areas within a few hours. Geographic tongue sometimes affects patients with fissured tongue (lingua plicata).

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Diagnosis/Histopathological features

In the peripheral region of erythema migrans, characteristic histopathological features are: hyperkeratosis, spongiosis, acanthosis and elongation of the epithelial rete ridges. In the red portion of the lesion, localised loss of filiform papillae is seen with epithelial atrophy and mild subepithelial lymphocytic-plasmacellular infiltration. In addition, the epithelial surface is frequently necrotic, and collections of neutrophils with formation of microabscesses are observed within the epithelium. Because these features are reminiscent of psoriasis, this is called a psoriasiform mucositis.

Differential diagnosis

The histopathological appearance of mucosal lesions in psoriasis pustulosa generalisata and Reiter's syndrome cannot be distinguished from erythema migrans.
It may also be mistaken for lichen planus or lupus erythematosus.

Treatment and prognosis

Reassuring the patient

Teleangiectasias

Definition and clinical features

Persistent dilatation of small, superficial blood vessels; rarely inherited (e.g. Osler-Weber-Rendu syndrome; Bloom syndrome), primarily acquired, e.g. in scleroderma.

The uncommon Osler-Weber-Rendu syndrome (hereditary haemorrhagic teleangiectasia; HHT) is inherited via an autosomal dominant trait; however, family history can be negative. Clinically, oral and peri-oral telangiectasias are observed, as well as telangiectasias in teh nose, the gastro-intestinal tract and on the palms of the hands. They may bleed which may cause chronic iron-deficiency anaemia.

Scleroderma is a rare autoimmune disorder of blood vessels and connective tissue, which is divided into a progressive systemic (systemic sclerosis types I-III) and a localised form (circumscribed scleroderma). The disease most commonly affects adult middle-aged females. In later stages, development of a mask-like face with restricted mouth opening (microstomia), telangiectasias, smooth tongue surface and shortened lingual frenum. A relatively mild variant is characterised by subcutaneous calcification (CREST syndrome: calcinosis cutis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly and telangiectasia); frequent association with Sjögren's syndrome.

Diagnosis/Histopathological features

Osler-Weber-Rendu syndrome: clinical features, blood count.

Scleroderma: clinical features, serology: in 95% of cases, autoantibodies against centromeres, nucleoli, nuclear protein (Scl-70); histopathology: obliterative vasculopathy.

Differential diagnosis

  1. Oral lesions in Osler-Weber-Rendu syndrome: scleroderma, chronic liver diseases, post-irradiation state
  2. Oral lesions in scleroderma: Osler-Weber-Rendu syndrome, oral submucous fibrosis, secondary Sjögren's syndrome

Treatment and prognosis

Osler-Weber-Rendu syndrome: local haemostasis (cryo-surgery or laser), treatment of anaemia.

Scleroderma: management is difficult; enhancement of micro-circulation (calcium antagonists, acetylsalicylic acid), corticosteroids, in some cases immunosuppressants. Prognosis is dependent on type of disease; from favourable to poor and lethal.

Haemangiomas

Definition and clinical features

Developmental vascular malformation (hamartoma) or benign vascular tumour. Division into cavernous and capillary types. In the oral cavity, the most common mesenchymal tumour of infancy. Commonest localisation: tongue, lips, buccal mucosa. Reddish-purple, painless, soft and sometimes fluctuating nodular masses which typically blanch on pressure. Haemangiomatous vascular malformation of the face related to maxillary division of the trigeminal nerve (port wine stain) and involvement of the leptomeninges occur in Sturge-Weber syndrome. Complications: epilepsy, contralateral hemiplegia (rare), mental retardation (common).

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Diagnosis/Histopathological features

Histologically, sponge-like structure of variably dilated, blood-filled spaces with endothelial lining; in capillary type: highly cellular endothelial proliferation with often indistinct vascular lumina. Poorly defined boundary to surrounding fatty and connective tissue.

In Sturge-Weber syndrome: skull film (intracerebral calcification)

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Differential diagnosis

Telangiectasia, purpura, Kaposi's sarcoma. Rarely: haemangioendothelioma, Mafucci-Kast syndrome (multiple haemangiomas and enchondromas) and Fabry syndrome (lipidosis).

Treatment and prognosis

Haemangiomas: "watchful waiting" (in about 50% spontaneous involution), cryo-surgery, argon laser, sclerotherapy, or arterial embolisation (rarely).
Sturge-Weber syndrome: anticonvulsants, in-patient care frequently necessary.

Inflammations of the oral mucosa

Definition and clinical features

Inflammatory disorders of the oral mucosa are designated according to their localisation as:
  • Gingivitis (gums),
  • Cheilitis (lips),
  • Glossitis (tongue),
  • Pareiitis (bucca).
Only if larger parts of the oral mucosa are affected by inflammation, this is referred to as stomatitis. The term comprises numerous disease forms of various aetiology. Infections, particularly in immune deficiency and weakened general condition, poor oral hygiene, as well as reactions on physical effects, e.g. ill-fitting dentures, play a causative role. In this article, only inflammatory disorders causing intraoral red patches will be demonstrated.
  1. Radiation-induced mucositis
    A complication of external irradiation; clinical features: diffuse erythema (and ulceration), xerostomia which leads to dysphagia, loss of taste, candidiasis, sialadenitis and caries. Susceptibility to osteoradionecrosis. In children: mandibular hypoplasia, developmental alterations of teeth.
  2. Denture stomatitis
    primarily caused by Candida albicans, common in elderly patients who continuously wear their denture. Poor denture hygiene, carbohydrate-rich nutrition and HIV infection may play a causative role. Clinical features: diffuse erythema confined to the denture-bearing mucosa, sometimes with petechiae or candidiasis. Common association with angular cheilitis and palatal papillary hyperplasia.

Diagnosis/Histopathology

  1. Diagnosis is based unequivocally on case history; avoid biopsy!
  2. Unequivocal diagnosis: identification of Candida albicans in culture.

Differential diagnosis

  1. None, if history is known.
  2. Erythroplakia or trauma

Treatment

  1. Symptomatic: infection control, treatment with antibiotics effective against gram-negative organisms
  2. Denture hygiene (cleaning and soaking the denture over night in fungicide solution; e.g. hypochlorite, chlorhexidine), antimycotics

Relevant systemic infections

Clinical features

Measles (Rubeola)
  • End of the incubation period/begin of prodrome: maculopapular eruptions, sometimes with spot-like or striated bleeding on the buccal mucosa and on the soft palate.
  • Day 2-3 of the prodromal period: spot-like enanthema on the palate, uvula, tonsils and buccal mucosa with a tendency of confluence into multiple areas of erythema.
  • Koplik's spots: pinhead-sized grey-white papules on erythematous ground (grains of salt on a red background)
    #pic#
Scarlet fever
Beginning: dark red erythematous mucosa in the oropharynx, pharynx and on the tonsils. Tip and margins of the tongue are red, the dorsal surface of the tongue has a thick white coating. Later, the white coating desquamates to reveal an erythematous, swollen, dry tongue referred to as red strawberry tongue.
Rubella (German measles)
Sometimes small, discrete, dark red papules (enanthemas) on the soft palate and uvula.
Infectious mononucleosis
Numerous small petechiae on the soft palate.

Erythematous candidosis

Definition and clinical features

Candidosis of the oral mucosa may exhibit a variety of clinical patterns, the extension of which depends primarily on the immune status of the host. It can manifest in form of reddened, sore mucosal lesions, particularly in patients treated with broad-spectrum antibiotics. Primarily, palate and tongue are affected; it can also be a symptom of HIV infection. A specific form of clinically localised erythematous candidosis is median rhomboid glossitis affecting the midline, posterior dorsal tongue. Clinically, well-demarcated erythematous area, sometimes raised lesion. Prevalence: up to 1% of adults. Infection with Candida albicans is consistently detectable.

Diagnosis/Histopathological features

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Histopathological features: acanthosis and marked papillomatosis of squamous epithelium with elongated rete ridges. Parakeratosis or necrosis on the surface, lack of filiform papillae. At the dermo-epidermal junction, chronic inflammatory infiltrate of lymphocytes, plasma cells and neutrophilic granulocytes, sometimes spreading to the epithelium. Formation of intraepithelial microabscesses by neutrophilic granulocytes. In the PAS stain, tubular hyphae of candida albicans embedded in the parakeratin layer. Rete ridges are sometimes cut incompletely giving the impression of discontinuous epithelial proliferations. They are sometimes accompanied by expressed pseudoepitheliomatous hyperplasia and reactive cellular atypia. (CAVEAT: no carcinoma!)

Differential diagnosis

  • Atrophic form of lichen planus: saw-toothed rete ridges, band-like infiltrate of lymphocytes without granulocytes, no Candida albicans
  • Leukoplakia with epithelial dysplasia: persistent cellular atypia despite antifungal therapy
  • Granular cell tumour of the tongue (clinically)
  • Ectopic thyroid tissue (clinically)
  • Highly differentiated invasive squamous cell carcinoma

Treatment and prognosis

Involution of erythematous mucosal lesion and regeneration of filiform papillae after antifungal therapy.

Mucosal bleeding

Definition and clinical features

Red or brown, small, pinpoint sized bleeding (petechiae), larger exanthemas (purpura) or more extended splotchy (ecchymosis), spontaneous haemorrhages on the oral mucosa have various causes. Thrombocytopenias - idiopathic (autoimmune) (ITP, Werlhof's disease), sometimes with AIDS; defective platelet functions; less frequently vascular defects, chronic myelogenic leukaemia, local oral purpura (angina bullosa haemorrhagica). Petechiae on the soft palate are characteristical features of infectious mononucleosis, but they may also occur in HIV infection, rubella or secondary to forced vomitus in bulimia. Accidental small petechiae on the buccal mucosa at the occlusal level are frequent in otherwise healthy individuals. Otherwise, petechiae of the oral mucosa are rare and always require rapid diagnosis.

Diagnosis/Histopathological findings

Clinically: differential blood count and blood coagulation tests

Differential diagnosis

Haemangiomas (petechiae will not blanch on pressure), telangiectasias and Kaposi's sarcoma. Thrombocytopenia also occurs in AIDS.

Treatment and prognosis

Depending on underlying cause.

Erythroplakia

Synonyms: erythroplasia; erythroplasia of Queyrat

Definition and clinical features

Erythroplakia is a rounded, well-demarcated, shiny, dark-red flat or slightly depressed focus with a soft, velvety texture and usually occurs on the soft palate or floor of the mouth, predominantly in older men. It is a rare condition with unknown aetiology, but the causes are presumed to be the same as those associated with oral cancer. The term has originally been used by the French dermatologist Queyrat to describe a red pre-cancerous lesion of the glans penis. Clinically and histopathologically, oral erythroplakia corresponds to the genital lesion. Histopathologically, almost all erythroplakias represent either severe epithelial dysplasia or in situ squamous cell carcinoma (Morbus Bowen). Early invasive carcinoma may also appear with erythroplakia symptoms. The red colour is caused by an intense capillarisation below the focal narrowed atypical epithelium. Erythroplakia is commonly associated with leukoplakia (erythroleukoplakia).

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Diagnosis/Histopathological features

Microscopically, erythroplakia is characterised by a thickened spinous layer (acanthosis) and slight hyper-parakeratosis. Rete ridges are broadened, papillae thinned. The epithelial structure is entirely replaced by enlarged atypical epithelial cells with enlarged, pleomorphic, hyperchromatic nuclei containing large and prominent nucleoli. Numerous mitotic figures and dyskeratotic single cells are observed in each epithelial layer. The cells vary with regard to size and form. Large, atypical keratinocytes may also occur in small groups within the epithelium (pagetoid growth pattern; differential diagnosis: malignant melanoma!). Intact basement membrane, no invasion. Varying degree of uncharacteristic inflammatory infiltration of subepithelial connective tissue. All erythroplakias must be submitted for microscopic examination in order to exclude an invasive carcinoma.

#pic#

Differential diagnosis

Focal inflammatory or atrophic lesions, e.g. deficiency anaemia, geographic tongue (clinically), erosive lichen planus, in situ malignant melanoma (histologically).

Treatment and prognosis

Complete excision; frequent transition into invasive squamous cell carcinoma with poor prognosis.

Kaposi's sarcoma

Definition and clinical features

Kaposi's sarcoma is a malignant, virus-associated, spindle cell tumour. Four clinical presentations are recognised:
  1. Classic, chronic (especially in elder men on feet and hands; first described in 1872 by Moritz Kaposi)
  2. Endemic, lymphadenopathic (in Africa)
  3. Iatrogenic immunosuppression-associated (in immunocompromised patients with other malignant tumours, and after organ transplantation)
  4. AIDS-related (frequently disseminated with involvement of the oral cavity).
Current evidence suggests that Kaposi's sarcoma is caused by human herpes virus 8 (HHV 8). In the past, it was a rare disease but nowadays it increasingly occurs as a symptom in HIV with oral lesions often being the first signs of AIDS. Since the introduction of anti-retroviral therapy in 1995, its prevalence has significantly decreased. Oral lesions involve most frequently the palate and the gingiva but may also occur in any other oral region. Early lesions present as reddish, purple or brown patches. In later stages they become nodular, extend and become ulcerated.

Diagnosis/Histopathological features

#pic# #pic# #pic#

In an early stage (patch stage), proliferation of miniature blood vessels around larger, dilated vessels resulting in an irregular, vascular network with increased cellularity. The lesional endothelial cells have a normal appearance without signs of atypia. In the plaque stage, further proliferation of vessels along with the development of a significant spindle cell component which is immunohistochemically CD34 and CD31 positive. Additionally, inflammatory infiltration with lymphocytes and plasma cells, hemosiderin deposition (iron stain), occasional PAS-positive intra- and extra-cellular hyalin globuli. Spindle cells surround poorly defined vascular slits partially containing erythrocytes. Increased cellular and nuclear polymorphism. In the nodular stage, the spindle cells predominate the nodular tumour; extra-vasal erythrocytes and slit-like vascular spaces may be observed.

Differential diagnosis

Histologically:
  1. Epulis granulomatosa: lobularly arranged capillary proliferations, scattered spindle-shaped fibroblasts
  2. Angiosarcoma: vessel forming tumour with atypical, partially epitheloid endothelium, strong cellular polymorphism, no actin-positive pericytes
  3. Other spindle cell sarcomas such as fibrosarcoma, leiomyosarcoma
Clinically:

Other pigmented lesions, especially epithelioid angiomatosis, haemangiomas and purpura

Treatment and prognosis

Systemic combined chemotherapy is used for treating the underlying disease. AIDS patients with oral Kaposi's sarcoma have a poorer prognosis than those with cutaneous manifestation.


sources

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  • Kuffer R, Lombardi T (2003), Premalignant lesions of the oral mucosa. A discussion about the place of oral intraepithelial neoplasia (OIN), Oral Oncol. 2002 Feb;38(2):125-30, Comment in: Oral Oncol. 2002 Dec;38(8):809-10; author reply 811-2
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  • Van Doorne L, De Maeseneer M, Stricker C, Vanrensbergen R, Stricker M (2002), Diagnosis and treatment of vascular lesions of the lip, Br J Oral Maxillofac Surg. 2002 Dec;40(6):497-503
  • Vissink A, Burlage FR, Spijkervet FK, Jansma J, Coppes RP (2003), Prevention and treatment of the consequences of head and neck radiotherapy, Crit Rev Oral Biol Med. 2003;14(3):213-25
  • Voros-Balog T, Vincze N, Banoczy J (2003), Prevalence of tongue lesions in Hungarian children, Oral Dis. 2003 Mar;9(2):84-7