White lesions

University Of AdenUniversity Of AdenFaculty of DentistryFaculty of Dentistry

Department of Oral SurgeryDepartment of Oral Surgery2012-20132012-2013

Oral MedicineOral MedicineAssociate Prof. Dr. Muhgat AbdoAssociate Prof. Dr. Muhgat Abdo

Oral& Dentofacial SurgeonOral& Dentofacial Surgeon

muhgatabdo@hotmail.dedewww.adendent-faculty.netwww.adendent-faculty.net

White Lesions of White Lesions of The Oral The Oral

MucosaMucosa

Oral MedicineOral MedicineIntroductionIntroduction

White lesions White lesions of the oral mucosa are aof the oral mucosa are a

multifactorial group of disorders, the color ofmultifactorial group of disorders, the color of

which is produced by the scattering of the lightwhich is produced by the scattering of the light

through an altered epithelial surface.through an altered epithelial surface.

The diagnosis and differential diagnosis of oralThe diagnosis and differential diagnosis of oral

white lesions should be made on the basis of thewhite lesions should be made on the basis of the

medical history, clinical features, and laboratorymedical history, clinical features, and laboratory

tests.tests.

Oral MedicineOral MedicineIntroductionIntroduction

Leukoplakia Leukoplakia

1. Hairy leukoplakia1. Hairy leukoplakia

2.2. Lichen planusLichen planus

3.3. Lichenoid reactionsLichenoid reactions

4.4. Linea albaLinea alba

5.5. Nicotinic stomatitisNicotinic stomatitis

6.6. Uremic stomatitis Uremic stomatitis

7.7. Cinnamon contact stomatitisCinnamon contact stomatitis

8.8. Chemical burnChemical burn

9.9. Candidiasis Candidiasis

10.10. Chronic bitingChronic biting

11.11. Geographic tongue Geographic tongue

12.12. Hairy tongue Hairy tongue

13.13. Furred tongueFurred tongue

Oral MedicineOral MedicineWhite LesionsWhite Lesions

Leukoplakia Leukoplakia

14.14. Materia alba of the gingivaMateria alba of the gingiva

15.15. Fordyce’s granulesFordyce’s granules

16.16. LeukoedemaLeukoedema

17.17. White sponge nevusWhite sponge nevus

18.18. Dyskeratosis congenitaDyskeratosis congenita

19.19. Pachyonychia congenitaPachyonychia congenita

20.20. Focal palmoplantar and oralFocal palmoplantar and oral

21.21. mucosa hyperkeratosis syndromemucosa hyperkeratosis syndrome

22.22. PapillomaPapilloma

23.23. Verrucous carcinomaVerrucous carcinoma

24.24. Squamous-cell carcinomaSquamous-cell carcinoma

25.25. Skin and mucosal graftsSkin and mucosal grafts

26.26. Epithelial peelingEpithelial peeling


LeukoplakiaLeukoplakiaDefinition and EtiologyDefinition and Etiology

Leukoplakia is a clinical term, and the lesion is Leukoplakia is a clinical term, and the lesion is defined as a white patch or plaque, firmly defined as a white patch or plaque, firmly attached to the oral mucosa, that cannot be attached to the oral mucosa, that cannot be classified as any otherclassified as any other disease entity. disease entity. It is a precancerous lesionIt is a precancerous lesion..

The exact The exact etiologyetiology remains unknown. remains unknown. TobaccoTobacco, , alcoholalcohol, , chronic local frictionchronic local friction, and, and CandidaCandida albicansalbicans are important predisposing factors. are important predisposing factors. Human papilloma virus (HPV) may also be Human papilloma virus (HPV) may also be involved in the pathogenesis of oral leukoplakiainvolved in the pathogenesis of oral leukoplakia..

LeukoplakiaLeukoplakiaThe Clinical FeatuersThe Clinical Featuers

Three clinical varieties are recognized:Three clinical varieties are recognized:

1.1.HomogeneousHomogeneous (common). (common).

1.1.SpeckledSpeckled (less common). (less common).

2.2.VerrucousVerrucous (rare). (rare).

Speckled and verrucous leukoplakia have a greaterSpeckled and verrucous leukoplakia have a greaterrisk for malignant transformation than therisk for malignant transformation than thehomogeneous form. homogeneous form.

HomogeneousHomogeneous

LeukoplakiaLeukoplakiaThe Clinical FeatuersThe Clinical Featuers

Three clinical varieties are recognized:Three clinical varieties are recognized:

The buccal mucosa, tongue, floor of the mouth, The buccal mucosa, tongue, floor of the mouth, gingiva, and lower lip are the most commonly gingiva, and lower lip are the most commonly affected sites.affected sites.

VerrucousVerrucous SpeckeldSpeckeld

LeukoplakiaLeukoplakiaDifferential DiagnosisDifferential Diagnosis

Lichen planus, Cinnamon contact stomatitis.Lichen planus, Cinnamon contact stomatitis.Candidiasis, Hairy leukoplakia.Candidiasis, Hairy leukoplakia.Lichen planus reactions, Chronic biting.Lichen planus reactions, Chronic biting.Tobacco pouch keratosis, Leukoedema.Tobacco pouch keratosis, Leukoedema.Chemical burn, Uremic stomatitis.Chemical burn, Uremic stomatitis.Skin graft, Some genodermatoses. Skin graft, Some genodermatoses. Discoid lupus erythematosus.Discoid lupus erythematosus.

LeukoodemaLeukoodema

Hairy LeukHairy Leuk..

Lichen PlanusLichen PlanusWhite Sopngy NevusWhite Sopngy Nevus

LeukoplakiaLeukoplakiaTreatmentTreatment

1.1. Elimination or discontinuation of predisposing Elimination or discontinuation of predisposing factors, systemic retinoid compounds.factors, systemic retinoid compounds.

2.2. Photo Documentation. Photo Documentation. 3. Surgical excision is the treatment of choice after 3. Surgical excision is the treatment of choice after

Biopsy resultBiopsy result..

Therapy:Therapy:A.A. Good Oral Hygiene.Good Oral Hygiene.B.B. Vitamin A+E Tab. 1xBDx4 Weeks.Vitamin A+E Tab. 1xBDx4 Weeks.C.C. Vitamin B Complex 1xBDx4 Weeks.Vitamin B Complex 1xBDx4 Weeks.D.D. Mouth Wash.Mouth Wash.E.E. Control every 2 WeeksControl every 2 Weeks..

White LesionWhite LesionHairy LeukoplakiaHairy Leukoplakia

DefinitionDefinition : is an unusual form of leukoplakia that is seen only in people who are infected with HIV, have AIDS, or AIDS-related complex. It consists of fuzzy, hence the name "hairy," white patches on the tongue and less frequently elsewhere in the mouth. It may resemble thrush, an infection caused by the fungus Candida which, in adults, usually occurs if your immune system is not working properly, and may be one of the first signs of infection with the HIV virus.

EtiologyEtiology : Epstein–Barr virus seems to play an Epstein–Barr virus seems to play an important role in the pathogenesisimportant role in the pathogenesis..


Clinical featuresClinical features :The presence of white or gray colored patches on your tongue, gums, roof of your mouth, or the inside of the cheeks of your mouth may be a sign of leukoplakia. The patch may have developed slowly over weeks to months and be thick, slightly raised, and may eventually take on a hardened and rough texture. It usually is painless, but may be sensitive to touch, heat, spicy foods, or other irritation.The lesion is not precancerousThe lesion is not precancerous..

Differential diagnosisDifferential diagnosis::Oral candidiasisSquamous cell carcinomaGeographic tongueLichen planusSmoker's leukoplakiaEpithelial dysplasiaWhite sponge nevusIrritation leukoplakiaHairy tongue

White LesionWhite Lesion Hairy LeukoplakiaHairy Leukoplakia


Treatment, if needed, involves removing the source of irritation. For example, if leukoplakia is caused by a rough tooth or an irregular surface on a denture or filling the tooth will be smoothed and dental appliances repaired .

If leukoplakia is caused by smoking, you will be asked to minimize or stop smoking or using other tobacco products. Hairy leukoplakia requires treatment with an in in some cases aciclovir or valaciclovir can be used with some cases aciclovir or valaciclovir can be used with success. success. antiviral medication products.


1.1. Elimination or discontinuation of predisposing Elimination or discontinuation of predisposing factors, systemic retinoid compounds.factors, systemic retinoid compounds.

2.2. Photo Documentation. Photo Documentation. 3. Surgical excision is the treatment of choice after 3. Surgical excision is the treatment of choice after

Biopsy resultBiopsy result..

Therapy:Therapy:A.A. Good Oral Hygiene.Good Oral Hygiene.B.B. Vitamin A+E Tab. 1xBDx4 Weeks.Vitamin A+E Tab. 1xBDx4 Weeks.C.C. Vitamin B Complex 1xBDx4 Weeks.Vitamin B Complex 1xBDx4 Weeks.D.D. Mouth Wash.Mouth Wash.E.E. Control every WeeksControl every Weeks..

DefinitionDefinition: Lichen planus is a relatively common : Lichen planus is a relatively common chronic inflammatory disease of the oral mucosa chronic inflammatory disease of the oral mucosa and skinand skin..EtiologyEtiology: Although the cause is not well known, T : Although the cause is not well known, T cell-mediated autoimmune phenomena are cell-mediated autoimmune phenomena are involved in the pathogenesis of lichen planusinvolved in the pathogenesis of lichen planus..

White LesionWhite LesionLichen PlanusLichen Planus

A minority of patients may have disease that closely mimics lichen planus, both clinically and histologically, and are described as ‘lichenoid lesions’. Examples include lichenoid drug reactions

[anti-hypertensive agents including beta blockers,thiazide diuretics, angiotensin converting enzyme inhibitors5 and calcium channel blockers, sulphonylureas, anti-malarials, gold, penicillamine, allopurinol6 and nonsteroidal anti-inflammatory agents[, lichenoid reactions seen in close proximity toamalgam restorations [and other metallic and also non-metallic dental restorations[

White LesionWhite Lesion Lichen Planus (Etiology)Lichen Planus (Etiology)

Clinical featuresClinical features: White papules that usually : White papules that usually coalesce, forming a network of lines (Wickman’s coalesce, forming a network of lines (Wickman’s striae), are the characteristic oral lesions of the striae), are the characteristic oral lesions of the disease. Six forms of the disease are recognized in disease. Six forms of the disease are recognized in the oral mucosa, classified according to the oral mucosa, classified according to

frequencyfrequency : :1.1.The common (reticular, erosive). The common (reticular, erosive). 2.2.The less common (atrophic, The less common (atrophic, hypertrophic).hypertrophic).1.1.The rare (bullous, pigmented).The rare (bullous, pigmented).

The prognosis of lichen planus is usually good.


1.1.Lichen Planus Lichen Planus (reticular, (reticular, erosive). erosive).

1.1.Lichen Planus Lichen Planus (atrophic, (atrophic, hypertrophic).hypertrophic).

1.1.Lichen Planus Lichen Planus (bullous, (bullous, pigmented). pigmented).


))PigmentedPigmented((

))reticularreticular((

))HypertrophicHypertrophic((

White LesionWhite Lesion Lichen PlanusLichen Planus

Differential diagnosisDifferential diagnosis : :Drug induced "lichenoid" reactionsDiscoid / Systemic lupus erythematosusNon specific ulcerationCandidosisLeukoplakiaHairy LeukoplakiaMucous Membrane PemphigoidPemphigusWhite sponge naevus and other genodermatosesCheek biting

TreatmentTreatment: Not required; however, in some cases : Not required; however, in some cases aciclovir or valaciclovir can be used with success.aciclovir or valaciclovir can be used with success.

No treatment No treatment is needed in asymptomatic lesions. is needed in asymptomatic lesions. Topical steroids (ointment in Orabase, intralesional Topical steroids (ointment in Orabase, intralesional injection), may be helpful.injection), may be helpful.

Systemic steroids in low doses can be used in severe Systemic steroids in low doses can be used in severe and extensive cases.and extensive cases.

The topical use of antiseptic mouthwashes The topical use of antiseptic mouthwashes should be should be avoided.avoided.

White LesionWhite LesionTreatment of Treatment of Lichen PlanusLichen Planus

White LesionWhite LesionLichenoid ReactionsLichenoid Reactions

DefinitionDefinition : Lichenoid or lichen planus reactions are a heterogeneous group of lesions of the oral mucosa that show clinical and histopathological similarities to lichen planus, but have a different course.EtiologyEtiology : Hypersensitivity to dental restorative materials, amalgam, composite resins and dental plaque accumulation are the most common causative factors. Rarely, a reaction to drugs may be

responsible .


Clinical features:Clinical features: Clinically, they appear as white and/or erythematous lesions, usually associated with

peripheral delicate white striae. Erosions are also common. The lesions mimic erosive

lichen planus.Characteristically, the lesions are strictly confined to the mucosa directly in contact with the restorative

materials, and do not migrate to other sites .The lesions disappear after removal of the adjacent

material.The diagnosisThe diagnosis: is usually made clinically.


Laboratory tests: Laboratory tests: A skin punch test may be helpful in some cases.Differential diagnosis: Lichen planus, fixed drug eruption, discoid lupus erythematosus, cicatricial pemphigoid, cinnamon contact stomatitis.

Treatment: Treatment: Replacement of the restorative material, polishing and smoothing, and good oral hygiene are recommended. Topical steroid treatment for a short time is also helpful.


Lichenoid reaction to dental Lichenoid reaction to dental amalgam and cold: white and amalgam and cold: white and erythematous lesions on the erythematous lesions on the buccal mucosabuccal mucosa..

Lichenoid drug reaction to Lichenoid drug reaction to allopurinol: white allopurinol: white hyperkeratotic lesions and hyperkeratotic lesions and superficial erosions on the superficial erosions on the sides of the tonguesides of the tongue.

White LesionWhite LesionLinea AlbaLinea Alba

Definition:Definition: Linea alba is a relatively common Linea alba is a relatively common alteration of the buccal mucosaalteration of the buccal mucosa..

Etiology: Etiology: Pressure, suckingPressure, sucking from the buccal surface of the teethfrom the buccal surface of the teeth..

Clinical features: It presents as an It presents as an asymptomatic, bilateral, linear elevation with a asymptomatic, bilateral, linear elevation with a slightly whitish color at the level of the occlusal slightly whitish color at the level of the occlusal line of the teeth . It has a normal consistency on line of the teeth . It has a normal consistency on palpation. The diagnosispalpation. The diagnosis is based on clinical grounds aloneis based on clinical grounds alone..

Treatment: No treatment is requiredNo treatment is required..

White LesionWhite LesionNicotinic StomatitisNicotinic Stomatitis

DefinitionDefinition : Nicotinic stomatitis, or smoker’s palate, Nicotinic stomatitis, or smoker’s palate, is a common tobacco- related type of keratosis that is a common tobacco- related type of keratosis that occurs exclusively on the hard palate, and is occurs exclusively on the hard palate, and is classically associated with heavy pipe and cigar classically associated with heavy pipe and cigar smokingsmoking . .

EtiologyEtiology : The elevated temperature, rather than the The elevated temperature, rather than the tobacco chemicals, is responsible for this lesiontobacco chemicals, is responsible for this lesion..

White LesionWhite Lesion Nicotinic Stomatitis Nicotinic Stomatitis

Clinical features:Clinical features: Clinically, the palatal mucosa Clinically, the palatal mucosa initially responds to the high temperature with initially responds to the high temperature with redness. Later, it becomes wrinkled and takes on a redness. Later, it becomes wrinkled and takes on a diffusely grayish-white color, with numerous diffusely grayish-white color, with numerous micronodules with characteristic punctate red micronodules with characteristic punctate red centers, which represent the inflamed and dilated centers, which represent the inflamed and dilated

orifices of the minor salivary gland ductsorifices of the minor salivary gland ducts . . The lesions are not premalignant, in contrast to the The lesions are not premalignant, in contrast to the “reverse smoker’s palate” lesion, which is associated“reverse smoker’s palate” lesion, which is associated with reverse smokingwith reverse smoking..

The diagnosisThe diagnosis: is usually made clinically.

White LesionWhite Lesion Nicotinic Stomatitis Nicotinic Stomatitis

Laboratory tests: Laboratory tests: Usually not required. However, a histopathological examination is useful.

Differential diagnosis: Reverse smoker’s palate.Leukoplakia. Discoid lupus erythematosus.Candidiasis. Lichen planus.

Treatment: Cessation of smokingCessation of smoking..

White LesionWhite LesionCandidiasisCandidiasis

DefinitionDefinition : Candidiasis is the most common oral Candidiasis is the most common oral fungal infection. Over the last two decades, the fungal infection. Over the last two decades, the disease has taken on major importancedisease has taken on major importance..Etiology : Etiology : It is usually caused by It is usually caused by Candida albicansCandida albicans, , and less frequently by other fungal species (C. and less frequently by other fungal species (C. glabrata, C. krusei, C. tropicalis, C. parapsilosis)glabrata, C. krusei, C. tropicalis, C. parapsilosis)..

Predisposing factors are local (poor oral hygiene, Predisposing factors are local (poor oral hygiene, xerostomia, mucosal damage, dentures, antibiotic xerostomia, mucosal damage, dentures, antibiotic mouthwashes) and systemic (broad-spectrum mouthwashes) and systemic (broad-spectrum antibiotics, steroids, immunosuppressive drugs, antibiotics, steroids, immunosuppressive drugs, radiation, HIV infection, hematological radiation, HIV infection, hematological malignancies, neutropenia, iron-deficiency anemia, malignancies, neutropenia, iron-deficiency anemia, cellular immunodeficiency, endocrine disorders)cellular immunodeficiency, endocrine disorders)..


Clinical features: Clinical features: Oral Candidiasis is classified asOral Candidiasis is classified as : :

• Primary: Primary: consisting of lesions exclusively on the consisting of lesions exclusively on the oral and perioral areaoral and perioral area..Secondary: Secondary: consisting of oral lesions ofconsisting of oral lesions ofmucocutaneous diseasemucocutaneous disease..

Primary CandidiasisPrimary Candidiasis::includes five clinical varietiesincludes five clinical varieties : :•Pseudomembranous.Pseudomembranous.•Erythematous.Erythematous.•Nodular.Nodular.•Papillary hyperplasia of the palate.Papillary hyperplasia of the palate.•Candida-associated lesions. (angular cheilitis, Candida-associated lesions. (angular cheilitis, median rhomboid glossitis, denture stomatitis). median rhomboid glossitis, denture stomatitis).


The main forms of candidiasis that The main forms of candidiasis that produce whiteproduce white lesions are the followinglesions are the following : :Pseudomembranous CandidiasisPseudomembranous Candidiasis::

Is the most common form of the disease, Is the most common form of the disease, and is clinically characterized by and is clinically characterized by creamy-white, slightly elevated, creamy-white, slightly elevated, removable spots or plaques . The removable spots or plaques . The lesions may be localized or generalized, lesions may be localized or generalized, and appear more frequently on the and appear more frequently on the buccal mucosa, soft palate, tongue, and buccal mucosa, soft palate, tongue, and lips. Xerostomia, a burning sensation, lips. Xerostomia, a burning sensation, and an unpleasant taste are the most and an unpleasant taste are the most common symptomscommon symptoms..


Nodular CandidiasisNodular Candidiasis : :Is a chronic form of the disease; it Is a chronic form of the disease; it appears clinically as a white, firmappears clinically as a white, firm , ,and raised plaque that usuallyand raised plaque that usually does not detachdoes not detach..Mucocutaneous CandidiasisMucocutaneous Candidiasis : :

Is a heterogeneous and rare group of Is a heterogeneous and rare group of clinical syndromes, characterized by clinical syndromes, characterized by chronic lesions of the skin, nails, and chronic lesions of the skin, nails, and mucosa, and usually associated with mucosa, and usually associated with immunological defects. Clinically, the immunological defects. Clinically, the oral lesions appear as white andoral lesions appear as white andusually multiple plaques, which cannot usually multiple plaques, which cannot be removedbe removed. .

1. Leukoplakia 1. Leukoplakia

2.2. Hairy leukoplakiaHairy leukoplakia

3.3. Lichen planusLichen planus

4.4. Lichenoid reactionsLichenoid reactions

5.5. Linea albaLinea alba

6.6. Nicotinic stomatitisNicotinic stomatitis

7.7. Candidiasis Candidiasis

8.8. Uremic stomatitis Uremic stomatitis

9.9. Cinnamon contact stomatitisCinnamon contact stomatitis

10.10. Chemical burnChemical burn

11.11. Chronic bitingChronic biting

12.12. Geographic tongue Geographic tongue

13.13. Hairy tongue Hairy tongue

14.14. Furred tongueMateria alba of the gingivaFurred tongueMateria alba of the gingiva


1515 White sponge nevusWhite sponge nevus

1616 Dyskeratosis congenitaDyskeratosis congenita

1717 Pachyonychia congenitaPachyonychia congenita

1818 Focal palmoplantar and oral Focal palmoplantar and oral mucosa hyperkeratosis syndromemucosa hyperkeratosis syndrome

1919 PapillomaPapilloma

2020 Verrucous carcinomaVerrucous carcinoma

2121 Squamous-cell carcinomaSquamous-cell carcinoma

2222 Skin and mucosal graftsSkin and mucosal grafts

2323 Epithelial peelingEpithelial peeling


ReferencesReferences

M.D., D.D.S., Ph.D. M.D., D.D.S., Ph.D. G. LaskarisG. Laskaris, Pocket Atlas of , Pocket Atlas of Oral Diseases © 2006 Thieme. Second Edition.Oral Diseases © 2006 Thieme. Second Edition.

Dr. Pramod John RDr. Pramod John R, , Textbook of Oral MedicineTextbook of Oral Medicine. 2. 2ndnd Edition. (2005).Edition. (2005).

Dr Larry J. Peterson and othersDr Larry J. Peterson and others, , Contemporary Contemporary Oral and Maxillofacial SurgeryOral and Maxillofacial Surgery. Fourth Edition. . Fourth Edition. (2004).(2004).

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White lesions