recognizing white lesions part i: reactive, idiopathic, hereditary david e. wojtowicz, dds, mba

RECOGNIZING WHITE RECOGNIZING WHITE LESIONS LESIONS

PART I: Reactive, Idiopathic, PART I: Reactive, Idiopathic, Hereditary Hereditary

RECOGNIZING WHITE RECOGNIZING WHITE LESIONS LESIONS

PART I: Reactive, Idiopathic, PART I: Reactive, Idiopathic, Hereditary Hereditary

David E. Wojtowicz, DDS, MBADavid E. Wojtowicz, DDS, MBA

White Lesions White Lesions White Lesions 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?

A Lesion Appears WHITE Because Some Material Is Obscuring the Normal PINK or Racial Color.

Is the WHITE Material Directly on the Surface?

3 Mechanisms3 Mechanismsto Achieve White Appearance to Achieve White Appearance

Epithelial Thickening– Rough / Does NOT Rub Off

Surface Material– Rough / Does Rub Off

Subepithelial Change– Smooth / Does NOT Rub Off

SixSix Common Etiologies for Common Etiologies for White LesionsWhite Lesions

Reactive (Snuff) Idiopathic (Hairy Tongue)Hereditary (Leukoedema)Auto-Immune (Lichen Planus) Infectious (Candidiasis)Neoplastic (SCC)

1. 1. SixSix Reactive White Reactive White Hyperkeratotic LesionsHyperkeratotic Lesions

(These are (These are HYPERKERATOTICHYPERKERATOTIC. They Do . They Do NOTNOT Rub Off.) Rub Off.)

a. Snuff Dipper’s Lesion

b. Nicotinic Stomatitis

c. Chemical Burn

d. Linea Alba

e. Actinic Cheilitis

f. Denture Acanthosis

a. Snuff Dipper’s Lesion

b. Nicotinic Stomatitis

c. Chemical Burn

d. Linea Alba

e. Actinic Cheilitis

f. Denture Acanthosis

(Do They Rub Off?)(Do They Rub Off?)

a.a. Snuff Dipper’s LesionSnuff Dipper’s Lesion

(Do They Rub Off?)(Do They Rub Off?)

a.a. Snuff Dipper’s LesionSnuff Dipper’s Lesion

Wrinkled, Velvety US & Canada, Lower Carcinogenic Rate Asia Higher Rate Due to Added Carcinogens Treatment = Quit Habit, Switch Site

1. 1. SixSix Reactive White Lesions Reactive White Lesions

b.b. Nicotinic StomatitisNicotinic Stomatitis

1. 1. SixSix Reactive White Lesions Reactive White Lesions

b.b. Nicotinic StomatitisNicotinic Stomatitis

Grey, White and Red on Hard Palate Pipe and Tobacco Smoking (Heat) Red Spots, Inflamed Minor Salivary Gland

Orifices Treatment = Quit Smoking

Grey, White and Red on Hard Palate Pipe and Tobacco Smoking (Heat) Red Spots, Inflamed Minor Salivary Gland

Orifices Treatment = Quit Smoking

1. 1. Six Six Reactive White Reactive White Hyperkeratotic LesionsHyperkeratotic Lesions

c.c. Chemical BurnChemical Burn

c.c. Chemical BurnChemical Burn Caused by Aspirin Painful Usually in Molar Region Treatment = Discontinue Aspirin Use

Caused by Aspirin Painful Usually in Molar Region Treatment = Discontinue Aspirin Use

dd.. Linea AlbaLinea Alba

dd.. Linea AlbaLinea Alba Most Common White Lesion White Line @ Occlusal Plane Bilateral on the Buccal Mucosa No Treatment Needed

Most Common White Lesion White Line @ Occlusal Plane Bilateral on the Buccal Mucosa No Treatment Needed

ee.. Actinic CheilitisActinic Cheilitis

ee.. Actinic CheilitisActinic Cheilitis Sun Damage Lower Lip Obliteration of Border Treatment = Avoid Sun, Use Sunblock

Sun Damage Lower Lip Obliteration of Border Treatment = Avoid Sun, Use Sunblock

ff.. Denture AcanthosisDenture Acanthosis

ff.. Denture AcanthosisDenture 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

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. 2. TwoTwo Idiopathic White Idiopathic White Hyperkeratotic LesionsHyperkeratotic Lesions2. 2. TwoTwo Idiopathic White Idiopathic White Hyperkeratotic LesionsHyperkeratotic Lesions

Geographic TongueHairy Tongue

Geographic TongueGeographic Tongue(Benign Migratory Glossitis)(Benign Migratory Glossitis)

Geographic TongueGeographic Tongue(Benign Migratory Glossitis)(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

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 TongueHairy TongueHairy TongueHairy Tongue

Shaggy Matte of Filliform Papillae Candidiasis Stimulates the Hyperplasia Coffee, Tea, Tobacco = Black Treatment = Brush Tongue, Improve Oral

Hygiene

Shaggy Matte of Filliform Papillae Candidiasis Stimulates the Hyperplasia Coffee, Tea, Tobacco = Black Treatment = Brush Tongue, Improve Oral

Hygiene

3. 3. TwoTwo Hereditary White Hereditary White Hyperkeratotic LesionsHyperkeratotic Lesions3. 3. TwoTwo Hereditary White Hereditary White Hyperkeratotic LesionsHyperkeratotic Lesions

LeukoedemaWhite Sponge Nevus

LeukoedemaLeukoedemaLeukoedemaLeukoedema

Milky Grey Film Bilateral Buccal Mucosa, Non-progressive Disappears When Stretched More Common in Black Population Treatment = None Needed

White Sponge NevusWhite Sponge NevusWhite Sponge NevusWhite Sponge Nevus

Rough, Fissured Texture Symetric, Bilateral Buccal Mucosa Appears During Childhood, Non-

progressive Autosomal Dominant Transmission

Rough, Fissured Texture Symetric, Bilateral Buccal Mucosa Appears During Childhood, Non-

progressive Autosomal Dominant Transmission

RECOGNIZING WHITE RECOGNIZING WHITE LESIONS II:LESIONS II:

Auto-Immune, Infectious, Auto-Immune, Infectious, Neoplastic Neoplastic

RECOGNIZING WHITE RECOGNIZING WHITE LESIONS II:LESIONS II:

Auto-Immune, Infectious, Auto-Immune, Infectious, Neoplastic Neoplastic

David E. Wojtowicz, DDS, MBADavid E. Wojtowicz, DDS, MBA

4. 4. Two Two Auto-Immune White Auto-Immune White Hyperkeratotic LesionsHyperkeratotic Lesions

Lichen PlanusLupus Erythematosus

Lichen PlanusLichen PlanusLichen PlanusLichen Planus

Auto-immune Degeneration of Connective Tissue / Mucosa (Skin) Interface

Middle Age (Rare Before 30) M = F, Skin Lesions (33%)

Auto-immune Degeneration of Connective Tissue / Mucosa (Skin) Interface

Middle Age (Rare Before 30) M = F, Skin Lesions (33%)

Reticular (Wickham’s Striae)AnnularErosive Atrophic, Bullous

Stress & Thiazide Drugs are Possible Triggers

Differential: Snuff (Stretch) White Sponge (Youth)

Treatment = None if Asymptomatic . . .

Stress & Thiazide Drugs are Possible Triggers

Differential: Snuff (Stretch) White Sponge (Youth)

Treatment = None if Asymptomatic . . .

Erosive Lichen PlanusErosive Lichen PlanusErosive Lichen PlanusErosive Lichen Planus

PainfulRisk Factor for SCCTreatment = Biopsy, Steroids,

Retinoic Acid

PainfulRisk Factor for SCCTreatment = Biopsy, Steroids,

Retinoic Acid

Lupus ErythematosusLupus ErythematosusLupus ErythematosusLupus Erythematosus

Skin Lesions: Butterfly Rash (Sun Exposed Area)

Mucosal Lesions: Rough White Patch

Bordered by Striae, Ulcers, Erythema

Skin Lesions: Butterfly Rash (Sun Exposed Area)

Mucosal Lesions: Rough White Patch

Bordered by Striae, Ulcers, Erythema

Lupus ErythematosusLupus ErythematosusLupus ErythematosusLupus Erythematosus

Systemic: Arthritis, Vasculitis (Renal Failure)

Antinuclear Antibodies (ANA) Differential: Lichen Planus (Symmetrical

& Cutaneous), Leukoedema (Stretch) White Sponge (Youth)

Treatment = Corticosteroids

Systemic: Arthritis, Vasculitis (Renal Failure)

Antinuclear Antibodies (ANA) Differential: Lichen Planus (Symmetrical

& Cutaneous), Leukoedema (Stretch) White Sponge (Youth)

Treatment = Corticosteroids

5. 5. Three Three Infectious White Infectious White LesionsLesions

Candidiasis (DOES & Does NOT Scrape Off) - FIVE Clinical Lesions

Oral Hairy Leukoplakia (Does NOT Scrape Off)

Syphilitic Mucous Patch (Does NOT Scrape Off)

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)Candidiasis (Moniliasis)Candidiasis (Moniliasis)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)

Acute– Pseudomembraneous (“Thrush”) - White

DOES Scrape Off

– Atrophic (“Erythematous”) - Red (Does NOT Scrape Off)

Chronic– Hyperplastic (“Candidal Leukoplakia”) - White

(Does NOT Scrape Off)

CandidiasisCandidiasisCandidiasisCandidiasis

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

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 Candidiasis: Acute PseudomembraneousPseudomembraneous

White, Scrapes Off Underlying Tissue: Erythematous,

Hemorrhagic, Pruritic Newborns & RF (See Previous Item) Treatment = a. Correct the Predisposing

Factorb. Prescribe: Nystatin Vaginal Tablets– Disp: 70– Use: One Tablet as a Lozenge 5 Times a Day

White, Scrapes Off Underlying Tissue: Erythematous,

Hemorrhagic, Pruritic Newborns & RF (See Previous Item) Treatment = a. Correct the Predisposing

Factorb. Prescribe: Nystatin Vaginal Tablets– Disp: 70– Use: One Tablet as a Lozenge 5 Times a Day

Candidiasis: Chronic HyperplasticCandidiasis: Chronic Hyperplastic-Candidal Leukoplakia-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

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 HyperplasticCandidiasis: Chronic Hyperplastic

-Candidal Leukoplakia-Candidal LeukoplakiaCandidiasis: Chronic HyperplasticCandidiasis: Chronic Hyperplastic

-Candidal Leukoplakia-Candidal Leukoplakia Cancer Risk: Biopsy is Mandatory of All

Speckled Erythroplakia or Erythroleuko-plakia Because of Increased SCC Risk

Treatment = a. Correct the Predisposing Factorb. Biopsy Lesionc. Prescribe: Nystatin Vaginal Tablets– Disp: 70– Use: One Tablet as a Lozenge 5 Times a Day

Cancer Risk: Biopsy is Mandatory of All Speckled Erythroplakia or Erythroleuko-plakia Because of Increased SCC Risk

Treatment = a. Correct the Predisposing Factorb. Biopsy Lesionc. Prescribe: Nystatin Vaginal Tablets– Disp: 70– Use: One Tablet as a Lozenge 5 Times a Day

Candidiasis: Candidiasis: Three Three RedRed Chronic Oral LesionsChronic Oral Lesions

Angular Cheilitis = Perleche (Red) Median Rhomboid Glossitis (Red) Denture Sore Mouth = Atrophic

Candidiasis (Red)

Angular Cheilitis = Perleche (Red) Median Rhomboid Glossitis (Red) Denture Sore Mouth = Atrophic

Candidiasis (Red)

Oral Hairy LeukoplakiaOral Hairy LeukoplakiaOral Hairy LeukoplakiaOral 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

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 PatchSyphilitic Mucous PatchSyphilitic Mucous PatchSyphilitic Mucous Patch

Painless, White, Mucosal UlcersWith . . .

Nonpruritic Skin Rash,Lymphadenopathy

Signs of Secondary Syphilis (T. pallidum)

Painless, White, Mucosal UlcersWith . . .

Nonpruritic Skin Rash,Lymphadenopathy

Signs of Secondary Syphilis (T. pallidum)

6. 6. Four Four Neoplastic White Neoplastic White LesionsLesions

Squamous Cell CarcinomaVerrucous CarcinomaEpithelial DysplasiaCarcinoma in Situ

Squamous Cell Carcinoma Squamous Cell Carcinoma (SCC)(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

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 Squamous Cell Carcinoma (SCC)(SCC)

Uncontrolled Growth“Up Regulation” of Oncogenes

– Kinases & Cyclines Become Overactive

Deactivation of Suppresser Genes (Antioncogenes)

Uncontrolled Growth“Up Regulation” of Oncogenes

– Kinases & Cyclines Become Overactive

Deactivation of Suppresser Genes (Antioncogenes)

Verrucous CarcinomaVerrucous CarcinomaVerrucous CarcinomaVerrucous Carcinoma

Hyperkeratotic, Exophytic,Papillary

Age: Elderly (60+)Gender: Males (2:1)

Location: Gingiva, Alveolar Ridge,Buccal Mucosa

Hyperkeratotic, Exophytic,Papillary

Age: Elderly (60+)Gender: Males (2:1)

Location: Gingiva, Alveolar Ridge,Buccal Mucosa

Epithelial DysplasiaEpithelial DysplasiaEpithelial DysplasiaEpithelial Dysplasia

Premalignanat Changes ofCell & Architecture

Mixed Red & White is Most Likely Presentation

Cell Alterations: Nuclear Changes Architecture Alterations:

Bulbous Rete Pegs

Premalignanat Changes ofCell & Architecture

Mixed Red & White is Most Likely Presentation

Cell Alterations: Nuclear Changes Architecture Alterations:

Bulbous Rete Pegs

Carcinoma in Situ (CIS)Carcinoma in Situ (CIS)Carcinoma in Situ (CIS)Carcinoma in Situ (CIS)

Entire Thickness (Top to Bottom Change)

Basement Membrane IntactNo Invasion or Change of

Connective Tissue

Entire Thickness (Top to Bottom Change)

Basement Membrane IntactNo Invasion or Change of

Connective Tissue

GeriatricsGeriatricsGeriatricsGeriatrics

Proliferative Verrucous Leukoplakia (PVL)

– Hyperkeratotic Lesions Mixed Smooth and Warty

– Mainly on Edentulous Alveoloar RidgeCancer Risk: May Progress to

SCC or VC

Proliferative Verrucous Leukoplakia (PVL)

– Hyperkeratotic Lesions Mixed Smooth and Warty

– Mainly on Edentulous Alveoloar RidgeCancer Risk: May Progress to

SCC or VC

Risk Factors / Predisposing Risk Factors / Predisposing FactorsFactors

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)

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:3 Mechanisms:3 Mechanisms:3 Mechanisms: Surface Material

– Rough / Does Rub Off Epithelial Thickening

– Rough / Does NOT Rub Off

– Two Examples: Fordyce Granules = Ectopic Sebaceous

Glands Scar: Surgical, Traumatic

– Two Examples: Fordyce Granules = Ectopic Sebaceous

Glands Scar: Surgical, Traumatic

Clues to NormalClues to NormalClues to NormalClues to Normal

Bilateral Symmetry Predictable Locations Asymptomatic Independent Finding (no Secondary

Features such as redness, swelling) Increase with Age Remains Unchanged w/ Treatment

Bilateral Symmetry Predictable Locations Asymptomatic Independent Finding (no Secondary

Features such as redness, swelling) Increase with Age Remains Unchanged w/ Treatment

Glossary of TermsGlossary of TermsGlossary of TermsGlossary 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

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 Review: Which of the Following Choices Demonstrate Concepts Choices Demonstrate Concepts

of Differential Diagnosis:of Differential Diagnosis:

Review: Which of the Following Review: Which of the Following Choices Demonstrate Concepts Choices Demonstrate Concepts

of Differential Diagnosis: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)

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 List the Seven Seven Primary Primary Clinical Manifestations of Clinical Manifestations of

Non-dental LesionsNon-dental Lesions

List the List the Seven Seven Primary Primary Clinical Manifestations of Clinical Manifestations of

Non-dental LesionsNon-dental Lesions

– Normal Variation– White– Red (Pigmented or Dark)– Ulceration– Exophytic– Radiographic– Syndrome

•List List Four Four Techniques Techniques Employed to Investigate the Employed to Investigate the Secondary Clinical Features Secondary Clinical Features

of Oral Lesions:of Oral Lesions:

•List List Four Four Techniques Techniques Employed to Investigate the Employed to Investigate the Secondary Clinical Features Secondary Clinical Features

of Oral Lesions:of Oral Lesions: Visual Inspection Palpation Probing Patient Awareness

Visual Inspection Palpation Probing Patient Awareness

Name at Least Name at Least Four Four Visual Visual Features to Inspect for When Features to Inspect for When

Examining an Oral Lesion:Examining an Oral Lesion:

Name at Least Name at Least Four Four Visual Visual Features to Inspect for When Features to Inspect for When

Examining an Oral Lesion:Examining an Oral Lesion: Location Shape & Contours Size Solitary/Multiple Borders Homogenous/Heterogeneous Surface Color/Texture Displacement (of Teeth?)

Location Shape & Contours Size Solitary/Multiple Borders Homogenous/Heterogeneous Surface Color/Texture Displacement (of Teeth?)

During Palpation One Can During Palpation One Can Check For:Check For:

Compressible Tender Color Change (Blanching) Mobile / Bound Down Induration Probing, Exudate

During the Interview, Inquire During the Interview, Inquire if Patient is Aware of:if Patient is Aware of:

Pain or Altered Function Duration (Acute, Chronic) Progressive Course or Remission Response to Stress/ Foods

List List Four Four Risk or Risk or Contributory Factors:Contributory Factors:

Demographic (Age,Gender,Race) Social (Alcohol, Tobacco, Oral Habits) Recent History (Trauma, Infection,

Surgery) Medical History (Chronic Disease,

Acute Illness, Medications,Treatments)

Demographic (Age,Gender,Race) Social (Alcohol, Tobacco, Oral Habits) Recent History (Trauma, Infection,

Surgery) Medical History (Chronic Disease,

Acute Illness, Medications,Treatments)

Differential DiagnosisDifferential DiagnosisDifferential DiagnosisDifferential Diagnosis

List of Diseases With Similar Manifestations

Rule Out (R/O) on the Basis of Contradictions

Example: Oral Ulcer

List of Diseases With Similar Manifestations

Rule Out (R/O) on the Basis of Contradictions

Example: Oral Ulcer

recognizing white lesions part i: reactive, idiopathic, hereditary david e. wojtowicz, dds, mba

reactive white lesions

white material

white line

white appearance

recognizing white lesions

common white lesion

quit smoking slide

aspirin use slide

Documents

hereditary pancreatitis

module hereditary

classification of seizure idiopathic epilepsy...

free time activities iza kruczek joanna duszkiewicz olga...

wojtowicz tomasz big data project far cry’s ranking system

hereditary gingival...

hereditary angioedema

primaryidiopathicosteolysis: descriptionof family ·...

hereditary diseases

slater mill jonathan wojtowicz 10-29-13 mgt336 dr.einstein

hereditary spherocytosis

evaluation nationalataxiafoundation ataxic disorders · •...

list of publications tomasz wojtowicz · march 16, 2017 ....

australian product information zan-extra · and section 4.5...

hereditary hemochromatosis

quasi-hereditary algebras, exact borel subalgebras, a...

radcomms 2012, session three: monitoring developments -...

adolescent idiopathic scoliosis - welcome to …...

idiopathic hydronephrosis

hereditary traits