White lesions

White lesions

1. University Of AdenUniversity Of Aden
Faculty of DentistryFaculty of Dentistry
Department of Oral SurgeryDepartment of Oral Surgery
2012-20132012-2013
Oral MedicineOral Medicine
Associate Prof. Dr. Muhgat AbdoAssociate Prof. Dr. Muhgat Abdo
Oral& Dentofacial SurgeonOral& Dentofacial Surgeon
[email protected]@hotmail.dede
www.adendent-faculty.netwww.adendent-faculty.net

2. White Lesions of White Lesions of
The Oral MucosaThe Oral Mucosa
Oral MedicineOral Medicine
IntroductionIntroduction

3. 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 Medicine
IntroductionIntroduction

4. 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 Medicine
White LesionsWhite Lesions

5. 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
Oral MedicineOral Medicine
White LesionsWhite Lesions

6. LeukoplakiaLeukoplakia
Definition 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..

7. LeukoplakiaLeukoplakia
The 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 greater
risk for malignant transformation than therisk for malignant transformation than the
homogeneous form. homogeneous form.

HomogeneousHomogeneous

8. LeukoplakiaLeukoplakia
The 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

9. LeukoplakiaLeukoplakia
Differential 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

10. LeukoplakiaLeukoplakia
TreatmentTreatment
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..

11. White LesionWhite Lesion
Hairy 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..

12. White LesionWhite Lesion
Hairy LeukoplakiaHairy Leukoplakia
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..

13. Differential diagnosisDifferential diagnosis::
Oral candidiasis
Squamous cell carcinoma
Geographic tongue
Lichen planus
Smoker's leukoplakia
Epithelial dysplasia
White sponge nevus
Irritation leukoplakia
Hairy tongue
White LesionWhite Lesion
Hairy LeukoplakiaHairy Leukoplakia

14. 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.

15. White LesionWhite Lesion
Hairy LeukoplakiaHairy Leukoplakia
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..

16. 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 Lesion
Lichen PlanusLichen Planus

17. 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 to
amalgam restorations ]and other metallic and also
non-metallic dental restorations]
White LesionWhite Lesion
Lichen Planus (Etiology)Lichen Planus (Etiology)

18. 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.

White LesionWhite Lesion
Lichen PlanusLichen Planus

19. 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).
White LesionWhite Lesion
Lichen PlanusLichen Planus
((PigmentedPigmented))
((reticularreticular))
((HypertrophicHypertrophic))

20. White LesionWhite Lesion
Lichen PlanusLichen Planus
Differential diagnosisDifferential diagnosis: :
Drug induced "lichenoid" reactions
Discoid / Systemic lupus erythematosus
Non specific ulceration
Candidosis
Leukoplakia
Hairy Leukoplakia
Mucous Membrane Pemphigoid
Pemphigus
White sponge naevus and other
genodermatoses
Cheek biting

21. 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 Lesion
Treatment of Treatment of Lichen PlanusLichen Planus

22. White LesionWhite Lesion
Lichenoid 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.

23. White LesionWhite Lesion
Lichenoid ReactionsLichenoid Reactions
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.

24. White LesionWhite Lesion
Lichenoid ReactionsLichenoid Reactions
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.

25. White LesionWhite Lesion
Lichenoid ReactionsLichenoid Reactions
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.

26. White LesionWhite Lesion
Linea 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..

27. White LesionWhite Lesion
Nicotinic 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..

28. 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.

29. 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..

30. White LesionWhite Lesion
CandidiasisCandidiasis
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. parapsilosisglabrata, 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 disorderscellular immunodeficiency, endocrine disorders(.(.

31. White LesionWhite Lesion
CandidiasisCandidiasis
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 of
mucocutaneous 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(.

32. White LesionWhite Lesion
CandidiasisCandidiasis
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 Is the most common form of the
disease, and is clinically characterized disease, and is clinically characterized
by creamy-white, slightly elevated, by 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..

33. White LesionWhite Lesion
CandidiasisCandidiasis
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 and
usually multiple plaques, which cannot usually multiple plaques, which cannot
be removedbe removed . .

34. 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
Oral MedicineOral Medicine
White LesionsWhite Lesions

35. 1515White sponge nevusWhite sponge nevus
1616Dyskeratosis congenitaDyskeratosis congenita
1717Pachyonychia congenitaPachyonychia congenita
1818Focal palmoplantar and oral Focal palmoplantar and oral mucosa hyperkeratosis syndromemucosa hyperkeratosis syndrome
1919PapillomaPapilloma
2020Verrucous carcinomaVerrucous carcinoma
2121Squamous-cell carcinomaSquamous-cell carcinoma
2222Skin and mucosal graftsSkin and mucosal grafts
2323Epithelial peelingEpithelial peeling
Oral MedicineOral Medicine
White LesionsWhite Lesions

36. 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 Textbook of Oral
MedicineMedicine. 2. 2
ndnd
Edition. (2005(. Edition. (2005(.
 Dr Larry J. Peterson and othersDr Larry J. Peterson and others, ,
Contemporary Oral and Maxillofacial SurgeryContemporary Oral and Maxillofacial Surgery. .
Fourth Edition. (2004(.Fourth Edition. (2004(.