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WHITE LESIONSPrepared by:Dr. Rea Corpuz

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lesions of the oral mucosa,

which are white results from a

thickened layer of keratin

epithelial hyperplasia

intracellular epithelial

edema

reduced vascularity of subjacent connective

tissue

White Lesions

white or yellow lesions

may also be due to fibrous exudate covering an:

ulcer submucosal deposit surface debris fungal colonies

White Lesions

(1) Leukoedema

(2) Leukoplakia

(3) Lichen Planus

(4) Candidiasis

(5) White Sponge Nevus

(6) Nicotine Stomatitis

White Lesions

(7) Geographic Tongue

(8) Hairy Tongue

(9) Dental Lamina Cyst

(10) Fordyces Disease

(11) Perleche

White Lesions

generalized opacification

of buccal mucosa that is regarded as a variation of normal

can be identified in majority

of population

(1) Leukoedema

Etiology & Pathogenesis

to date, cause has not

been established

smoking chewing tobacco none alcoholo ingestion are bacterial infection proven salivary condition cause electrochemical interactions

have been implicated

(1) Leukoedema

Clinical Features

usual discovered as

incidental finding

asymptomatic

symmetrically distributed

in buccal mucosa

(1) Leukoedema

Clinical Features

appear as gray-white,

diffuse, filmy or milky surface

more exaggerated cases,

whitish cast with surface textural changes

wrinkling or corrugations

(1) Leukoedema

Clinical Features

with stretching of buccal

mucosa, opaque changes dissipate

more apparent in non-whites,

especially African-American

(1) Leukoedema

Treatment

NO treatment is necessary

since there is no malignant

potential

if there is any doubt about

diagnosis, a biopsy can be performed

(1) Leukoedema

also known as Leukokeratosis;

Erythroplakia

Leuko= white

Plakia = patch

defined by World Health Organization

(WHO) as a white patch or plaque that cannot be characterized clinically or pathologically as any other disease

(2) Leukoplakia

clinical term indicating a

white patch or plaque of oral mucosa

cannot be rubbed off

cannot be characterized clinically

as any other disease

biopsy is mandatory to

establish a definitive diagnosis

Leukoplakia

(2) Leukoplakia

Mild or Thin Leukoplakia

Homogenous or

Thick Leukoplakia

Granular or Nodular

Leukoplakia

Verrucous or Verruciform

Leukoplakia

(2) Leukoplakia

Proliferative Verrucous

Leukoplakia (PVL)

Erythroleukoplakia or

Speckled Leukoplakia

(2) Leukoplakia

(2) Leukoplakia

Mild or Thin Leukoplakia

seldom shows dysplasia

on biopsy

may disappear or continue

unchanged

(2) Leukoplakia

Homogenous or Thick Leukoplakia

for tobacco smokers who do

not reduce their habit

2/3 of such lesions slowly

extend laterally, become thicker + acquire distinctly white appearance

(2) Leukoplakia


affected mucosa may become

leathery to palpation

fissures may deepen

become more numerous

most thick, smooth lesions

remain indefinitely at this stage

(2) Leukoplakia


some, perhaps as many

as 1/3, regress or disappear

(2) Leukoplakia

Granular or Nodular Leukoplakia

few become even more

severe

develop increased surface

irregularities

(2) Leukoplakia

Verrucous or Verruciform

Leukoplakia

lesions that demonstrate

sharp or blunt projections

(2) Leukoplakia


Leukoplakia (PVL)

high risk form of

leukoplakia

development of multiple

keratotic plaques

with roughened

surface projections

(2) Leukoplakia


Leukoplakia (PVL)

tend to slowly spread

involve additional oral

mucosal sites

gingiva is frequently involved

although other sites may be

affected as well

(2) Leukoplakia


Leukoplakia (PVL)

as lesions progress, there

may go through a stage indistinguishable

transform into full-fledged

squamous cell carcinoma (usually within 8 years of initial PVL diagnosis)

(2) Leukoplakia


Leukoplakia (PVL)

lesions rarely regress

despite therapy

strong female predilection

minimal association with

tobacco use

(2) Leukoplakia

Erythroplakia

leukoplakia may become

dysplastic

even invasive, with no change

in its clinical appearance

however, some lesions eventually

demonstrate scattered patches of redness called erythroplakia

(2) Leukoplakia



such areas usually represent

sites in which epithelial cells are so immature or atrophic that they can no longer produce keratin

(2) Leukoplakia



intermixed red-and-white

lesion

pattern of leukoplakia

that frequently reveals advanced dysplasia on biopsy

(2) Leukoplakia

Etiology & Prognosis

many cases are etiologically

related to use of tobacco in smoked or smokeless forms and may regress after discontinuation of tobacco use

(2) Leukoplakia


other factors, such as

alcohol abuse may have trauma a role in C. albicans infection etiology

(2) Leukoplakia


nutritional factors have

been cited as important, especially iron deficiency anemia

(2) Leukoplakia

Clinical Features

associated with middle-aged

+ older population

vast majority of cases occur

after age of 40 years

(2) Leukoplakia

Site of Occurence

Vestibule Buccal Palate Alveolar Ridge Lip Tongue Floor

(2) Leukoplakia

leukoplakia of lips + tongue

also exhibits relative high percentage of dysplastic or neoplastic change

(2) Leukoplakia

Treatment & Prognosis

absence of dysplastic or

atypical epithelial changes

periodic examinations +

rebiopsy of new suspicious areas are recommended

(2) Leukoplakia

Treatment & Prognosis

if diagnosis as moderate to

severe dysplasia

excision is obligatory

for large lesions, grafting

procedures may be necessary after surgery

may recur after complete removal

(2) Leukoplakia

chronic mucocutaneous

disease of unknown cause

relatively common

typically presents as bilateral

white lesions

occasionally with associated

ulcers

(3) Lichen Planus

Pathogenesis

although cause is unknown

generally considered to be

a immunologically mediated process

resembles hypersensitivity

reaction

(3) Lichen Planus

Clinical Features

disease of middle age

affects men + women in

nearly equal numbers

children rarely affected

(3) Lichen Planus

Clinical Features

Types:

Reticular Erosive (ulcerative) Plaque Papular Erythematous (atrophic)

(3) Lichen Planus

Clinical Features

Reticular Form

most common type

numerous interlacing white

keratotic lines or striae (Wickhams striae)

produces anular or lacy

pattern

(3) Lichen Planus

Clinical Features

Reticular Form

buccal mucosa is the site

most commonly involved

may also be noted on:

tongue gingiva less common lips

(3) Lichen Planus

Clinical Features

Plaque Form

resembles leukoplakia

but has multifocal distribution

range from slightly elevated

to smooth and flat

(3) Lichen Planus

Clinical Features

Plaque Form

primary sites are

dorsum of tongue buccal mucosa

(3) Lichen Planus

Clinical Features

Erythematous Form

red patches

with very fine white

striae

attached gingiva commonly

involved

(3) Lichen Planus

Clinical Features

Erythematous Form

patchy distribution often

in four quadrants

patient may complain of

burning sensitivity generalized discomfort

(3) Lichen Planus

Clinical Features

Erosive Form

central area of lesion is

ulcerated

fibrinous plaque or

pseudomembrane covers ulcer

changing patterns of involvement

from week to week

(3) Lichen Planus

Treatment

although it cannot be

generally cured

some drugs can provide

satisfactory control

corticosteroids are the single

most useful group of drugs in the management of lichen planus

(3) Lichen Planus

Treatment

corticosteroid

ability to modulate

inflammation + immune response

(3) Lichen Planus

Treatment

topical application +

local injection of steroids have been used successfully in controlling but not curing this disease

(3) Lichen Planus

common oppurtunistic

oral mycotic infection

develops in the presence of

one of several predisposing factors

immunodeficiency endocrine disturbances hypoparathyroidism diabetes mellitus poor oral hygiene xerostomia

(4) Candidiasis

caused by Candida albicans

infection with this organism

is usually superficial, affecting the outer aspects of involved oral mucosa or skin

(4) Candidiasis

in severely debilitated +

immunocompromised patients such as patients with AIDS

infection may extend into

alimentary tract (candidal esophagitis

bronchopulmonary tract

and other organ system

(4) Candidiasis

Clinical Features

most common form is

acute pseudomembranous also known, as thrush

young infants + elderly

are commonly affected

(4) Candidiasis

Clinical Features

oral lesion of acute

candidiasis (thrush)

white soft plaques that sometime

grow centrifugally + merge wiping plaques with gauze

sponge leaves a painful, eroded, eryhtematous or ulcerated surface

(4) Candidiasis

Clinical Features

Chronic Erythematous

Candidiasis

commonly seen on

geriatric individuals

who wear complete

maxillary denture

(4) Candidiasis

Clinical Features


Candidiasis

distinct predilection for

palatal mucosa as compared with mandibular alveolar arch

(4) Candidiasis

Clinical Features


Candidiasis

chronic low-grade

resulting from poor prosthesis fit

failure to remove

appliance at night

(4) Candidiasis

Clinical Features


Candidiasis

bright red

relative little

keratinization

(4) Candidiasis

Clinical Features

Hyperplastic Candidiasis

may involve dorsum of

tongue

pattern referred to as

median rhomboid glossitis

(4) Candidiasis

Clinical Features


usually asymptomatic

usually discovered on

routine oral examination

(4) Candidiasis

Clinical Features


found anterior to

circumvallate papillae

oval or rhomboid

outline

(4) Candidiasis

Clinical Features


may have smooth,

nodular or fissured surface

range in color from

white to more red

(4) Candidiasis

Clinical Features

Mucocutaneous Candidiasis

long standing

persistent candidiasis of

oral mucosa skin vaginal mucosa

(4) Candidiasis

Clinical Features

Mucocutaneous Candidiasis

often resistant to treatment

begins as a pseudomembranous

type of candidiasis

soon followed by nail +

cutaneous involvement

(4) Candidiasis

Treatment

majority of infections may

be simply treated with topical applications of nystatin suspension

nystatin cream or

ointment often effective when applied directly to denture-bearing surface itself

(4) Candidiasis

Treatment

topical applications of either

nystatin or clotrimazole should be continued for at least 1 week beyond disappearance of clinical manifestations of disease

(4) Candidiasis

Treatment


topical + systemic antifungal

agents may not be effective at completely removing lesions

surgical management

may be necessary

(4) Candidiasis

Treatment

Chronic Mucocutaneous

Candidiasis associated with immunosuppression

topical agents may not

be effective

(4) Candidiasis

Treatment

Chronic Mucocutaneous

Candidiasis associated with immunosuppression

systemic administration

of medications:

Ketoconazole Fluconazole Itraconazole

(4) Candidiasis

autosomal-dominant condition

due to point mutations for

genes coding for keratin 4 and/or 13.

affects oral mucosa bilaterally

NO treatment is required


Clinical Features

asymptomatic

folded white lesions

may affect several mucosal

sites

lesions tend to be thickened

+ spongy consitency


Clinical Features

presentation intraorally

is almost always bilateral + symmetric

usually appears early in

life, typically before puberty


Clinical Features

usually observed in buccal

mucosa

tongue + vestibular mucosa

may be involved


Treatment

NO treatment necessary

since it is asymptomatic + benign


common tobacco-related

form of keratosis

typically associated with pipe

+ cigar smoking

with positive correlation

between intensity of smoking + severity of condition


combination of tobacco

carcinogens + heat is markedly intensified in reverse smoking (lit end positioned inside the mouth)

adding a significant risk for

malignant conversion


Clinical Features

palatal mucosa initially

responds with an erythematous change follwed by keratinization


Clinical Features

subsequent to opacification

or keratinization of palate

red dots surrounded by

white keratotic rings appear

dot represent inflammation

of salivary gland excretory duct


Treatment

condition rarely evolves into

malignancy

except in individuals who

reverse smoke

discontinuation of tobacco

habit


also known as erythema migrans,

benign migratory glossitis

prevalent among whites +

blacks

strongly associated with fissure

tongue

inversely associated with cigarette

smoking


emotional stress may enhance

the process


Clinical Features

affects women slightly more

than men

children occasionally may

be affected

characterized initially by

presence of atrophic patches surrounded by elevated keratotic margins


Clinical Features

desquamated areas appear

red + may be slightly tender

followed over a period of

days or weeks, pattern changes

appearing to move across

dorsum of tongue


Clinical Features

most patients are asymptomatic

occasionally patients complain

of irritation or tenderness

especially in relation to

consumption of spicy foods + alcoholic beverages


Clinical Features

lesions periodically disappear

recur for no apparent reason


Treatment

NO treatment is required

because of self-limiting + usually asymptomatic nature of this condition


Treatment

when symptoms occur,

topical steroids especially

ones containing antifungal agent

helpful in reducing symptoms


Treatment

mouth clean using mouthrinse

composed of sodium bicarbonate in water

reassure patients that condition

is totally benign


clinical term referring to a

condition of filiform papillae overgrowth on dorsal surface of tongue

there are numerous initiating

or predisposing factors for hairy tongue

(8) Hairy Tongue

broad spectrum antibiotics

such as penicillin + systemic cortiocosteroids are often identified in clinical history of patients with this condition

(8) Hairy Tongue

oxygenating mouthrinses

containing:

hydrogen peroxide sodium perborate carbamide peroxide

have been cited as

possible etiologic agents

(8) Hairy Tongue

Clinical Features

clinical alteration translates

to hyperplasia of filiform papillae; result is

thick serves to trap matted surface bacteria, fungi,

foreign materials

(8) Hairy Tongue

Clinical Features

extensive elongation of

papillae occurs,

gagging may be tickiling sensation felt

(8) Hairy Tongue

Clinical Features

color may range from white

to tan to deep brown depending on:

diet oral hygiene composition of bacteria

inhabiting papillary surface

(8) Hairy Tongue

Treatment

brush/scrape tongue with

baking soda

maintain good oral hygiene

emphasize to patients that

this process is entirely benign

(8) Hairy Tongue

Treatment

self-limiting

tongue should return to

normal after institution of physical debridement + proper oral hygiene

(8) Hairy Tongue

also known as Gingival Cyst of

New Born or Bohns nodules

appear as multiple nodules

along alveolar ridge in neonates


similar epithelial inclusion

cysts may occur along midline of palate (palatine cyst of new born or Epsteins pearls)

developmental origin derived from epithelium included in fusion line

between palatal shelves + nasal processes no treatment; resolve spontaneously


Treatment

not necessary because nearly

all spontaneously rupture before patient is 3 months of age


represents ectopic sebaceous

glands or sebaceous choristomas

normal tissue in abnormal

location

regarded as developmental

considered a variation of normal

(10) Fordyces Granules

multiple

often seen in aggregates

sites of predilection include

buccal mucosa vermillion of upper lip


lesions generally are symmetrical

distributed

tend to become obvious after

puberty

maximal expression occurring

between 20-30 years of age


lesions are asymptomatic

discovered during routine

oral examination


Treatment

No treatment is indicated

glands are normal in

character

do not cause any untoward

effects


also known as Angular

Cheilitis

inflammation + atrophy

of skin of folds at angles of mouth

(11) Perleche

may be due to:

excessive lip licking

thumb sucking

sagging of facial skin

in edentulous or elderly persons

(11) Perleche

may be due to:

prolonged contact with

saliva results in maceration with possible secondary

infection by Candida or staphylococci

(11) Perleche

Clinical Features

skin at angles of mouth

has erythematous fissures

often with exudate + crust

further licking to moisten

inflamed area exacerbates the problem

(11) Perleche

Treatment

applying antimicrobial

creams

followed by low-potency

steroid creams until symptoms resolve

protective lip balm may help

prevent recurrence

(11) Perleche

References:

Books

Cawson, R.A: Cawsons Essentials of Oral

Oral Pathology and Oral Medicine, 8th Edition (page 165-167 ) Neville, et. al: Oral and Maxillofacial Pathology

3rd Edition (pages 388- 397; 590-592; 819-820) Regezi, et. al: Oral Pathology: Clinical Pathologic

Correlations, 5th Edition (pages 73-105; 241-242; 296-299; 394)

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