ORAL MEDICINسوزان دمحم .د

In Oral Cavity lesions &Red White

White lesions are described as abnormal areas of the mucosa that appear whiter than the

surrounding tissue .Any condition that increases the thickness of the epithelium causes it

to appear white. Lesions most often appear white because of a thickening of the keratin

layer, or hyperkeratosis. Other common causes of a white appearance include a

canthosis (a thickening of the spinous cell layer), an increase in the amount of edema

fluid in the epithelium (i.e leukoedema), and reduced vascularity in the underlying

lamina propria. Surface ulcerations covered by a fibrin cap can also appear white, as

would collapse bullae. Many white lesions involving the oral mucosa are benign and do

not require treatment. These white lesions include congenital or developmental

conditions such as white sponge nevus, keratosis follicularis, hereditary benign

pachyonychia congenita, and Fordyce granules. Other benign conditions that do not

require intervention include skin and mucosal grafts, materia alba associated with the

gingiva or tongue, and keratotic lesions such as hairy tongue. In contrast, many diseases

that may require dental intervention can cause whitening of the oral mucosa, depending

on symptoms and potential morbidity or mortality. Oral white lesions can be caused by a

thickened keratotic layer or an accumulation of non-keratotic material, the non keratotic

can be scraped off by means of a piece of gauze, a superficial non-keratotic layer such as

pseudomembranes, most commonly caused by fungal infections or caustic chemicals,

should be suspected. Otherwise, white lesions can be attributed to increased thickness of

keratin layer, which might have been induced by local frictional irritation, immunologic

reactions, or more crucial processes such as premalignant or malignant transformation.

NORMAL&HEREDITARY WHITE LESIONS

Leukoedema

of variation a represents that alteration mucosal common a is Leukoedema :Definition

blacks in usually occurs it ,changes pathologic true a than rather condition normal the

people.

Etiology: It is due to increased thickness of the epithelium and intracellular edema of

the prickle-cell layer.

Clinical features: clinically, it is characterized by a grayish-white, opalescent pattern of

the buccal mucosa bilaterally and a slightly wrinkled surface, which characteristically

disappear when the mucosa is averted and stretched. It usually occurs bilaterally on the

buccal mucosa, and rarely on the tongue and lips, leukodema diagnosed only clinically.

Differential diagnosis : Leukoplakia, candidiasis, white sponge navus, lichen plannus

Treatment: No treatment is required, reassurance.

WhiteSpongeNevus

Definition: white sponge nevus, or Cannon disease, is relatively rare developmental

inherited autosomal dominant disorder.

Etiology: It is inherited as an autosomal dominant trait.

Multiple furrows and a spongy texture, the lesions may appear at birth, or more

commonly in early childhood, the buccal mucosa and the ventral surface of the tongue

are the sites of predilection.

Differential diagnosis: leukoedema,lichenplanus,leukoplakia

Treatment :No treatment is required for this benign and asymptomatic condition.

Granules Fordyce’s.

Definition: fordyce's granules are ectopic sebaceous glands of the oral mucosa of

vermilion portion of the lips

Etiology: It is a normal anatomical variation

Fordyce spots are visible sebaceous glands that are present in most individuals. which

are seen in the oral cavity as a multiple, asymptomatic small, painless, raised, yellowish

or white spots of 1 to 3 mm in diameter. The common site for occurrence of Fordyce’s

granules has been suggested as vermillion border and lips. On the other hand buccal

mucosa particularly inside the commissures and retro molar region has also been

suggested as common site, They occur in about 80% adults of both sexes. The diagnosis

is based on the clinical, feature, alone.

Differential diagnosis: Lichen planus, candidiasis.

Treatment: No treatment is required, reassurance.

REACTIVE/INFLAMMATORY WHITE LESIONS

Linea alba

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

Clinical features: It presents as an asymptomatic, bilateral, linear elevation with a

slightly whitish color at the level of the occlusal line of the teeth. It has a normal

consistency on palpation. It is a very common finding and is most likely associated with

pressure, frictional irritation, or sucking trauma from the facial surfaces of the teeth. The

diagnosis is based on clinical grounds alone.

Treatment: No treatment is required, the white streak may disappear spontaneously in

some people.

Frictional (Traumatic) Keratosis

Frictional (traumatic) keratosis is defined as a white plaque with a rough and frayed

surface that is clearly related to an identifiable source of mechanical irritation and that

will usually resolve on elimination of the irritant, these lesions may occasionally mimic

dysplastic leukoplakia, therefore, careful examination and sometimes a biopsy are

required to rule out any atypical changes. Lesions belonging to this category of keratosis

include linea alba and cheek, lip, and tongue chewing, frictional keratosis is frequently

associated with rough or maladjusted dentures and with sharp cusps and edges of broken

teeth.

Treatment: Upon removal of the offending agent, the lesion should resolve within 2

weeks, biopsies should be performed on lesions that do not heal to rule out a dysplastic

lesion.

Chronic(cheek) Biting

Definition and etiology : Mild chronic biting of the oral mucosa is relatively common in

nervous individuals these patients consciously bite the buccal mucosa, lips, and tongue

Clinical features: the lesions are characterized by a diffuse irregular white area of small

furrows and desquamation of the epithelium.

Differential diagnosis :Candidiasis, leukodema, lichen planus, leukoplakia,

Treatment :recommendation to stop the habit.

Chemical Burn

Definition: Transient nonkeratotic white lesions of the oral mucosa it is an injury to the

oral mucosa caused by topical application of caustic agents.

Etiology: causative agents include aspirin, hydrogen peroxide, phenol, alcohol, , silver

nitrate, , acid etching liquid, and varnishes of tooth cavities.

Clinical features: clinically, the affected mucosa is covered with a white membrane due

to necrosis. The necrotic epithelium can easily be scraped off, leaving a red, bleeding

surface. The lesions are painful. The diagnosis should be made on the basis of the

clinical features and history.

Differential diagnosis: necrotizing ulcerative gingivitis and stomatitis, candidiasis,

mechanical trauma, bullous diseases.

Treatment is symptomatic.

Nicotinic Stomatitis (stomatitis nicotina palatini, smoker’s palate)

Definition: nicotinic stomatitis, or smoker’s palate, is a common tobacco- related type of

keratosis that occurs exclusively on the hard palate, and is classically associated with

heavy pipe and cigar smoking.

Etiology: the elevated temperature, rather than the tobacco chemicals, is responsible for

this lesion.

Clinical features: clinically, the palatal mucosa initially responds to the high temperature

with redness. Later, it become wrinkled and takes on a diffusely grayish-white color,

with numerous micro nodules with characteristic punctate red centers , which represent

the inflamed and dilated orifices of the minor salivary gland ducts. The lesions are not

premalignant, in contrast to the “reverse smoker’s palate” lesion, which is associated

with reverse smoking.

Differential diagnosis: reverse smoker’s palate, discoid lupus erythematous, candidiasis,

lichen planus. leukoplakia( speckled).

Treatment cessation of smoking.

Smokeless Tobacco Keratosis (Snuff Pouch)

Etiology: Persistent habit of holding ground tobacco within the mucobuccal vestibule.

Clinical Presentation usually in men in western countries, white, fissured, appearance

surface may be like verrucous leathery surface due to chronic tobacco use over many

years. Diagnosis by clinical appearance- biopsy.

Differential Diagnosis: Leukoplakia (idiopathic), Mucosal burn (chemical/thermal)

Treatment: discontinuation of habit, If dysplasia is present, stripping of mucosal site.

Prognosis: Generally good with tobacco cessation, malignant transformation to

squamous cell carcinoma or verrucous carcinoma occurs but less frequently than does

smoking related carcinoma.

Immunologic causes

Lichen Planus

Definition: Lichen planus is a relatively common chronic inflammatory immunologic

mucocutaneous disorder of the oral mucosa and skin.

induced immunologically mediated-cell a involves planus lichen of etiology The

disease). (autoimmuneepithelium the of layer cell basal the of degeneration

Clinical features: OLP is classified as reticular consists of slightly elevated fine whitish

lines Wickham’s striae (lacelike keratotic mucosal configurations) most frequently

observed in buccal mucosa bilaterally, atrophic or erosive (keratotic changes combined

with mucosal erythema, and burning pain ) considered premalignant condition with

increased risk of malignant transformation , bullous vesiculobullous presentation

combined with reticular or erosive patterns). plaque type associated with well-defined

white plaque that some times surrounded by stria ,it is highly resemblance with

homogenous leukoplakia, the difference between two lesions the presence of papular or

reticular structures in plaque like OLP and

Reticular popular and plaque OLP is quite frequently painless lesion that is usually

asymptomatic before it is identified during a routine oral examination.

The middle-aged individuals are more commonly affected (the ratio of women to men

ratio is 3 : 2), the buccal mucosa, tongue, and gingiva are the sites of predilection, the

skin lesions characteristically the flexor surfaces of the extremities.. the lesions are

typically present as flat papules with fine scaling on the surface of hand or and leg or a

purple to brown in color, raised rash that can be very itchy .In addition to the oral

mucosa. The disease can usually be diagnosed on clinical grounds alone. The prognosis

of lichen planus is usually good, erosive form show malignant transformation.

Differential diagnosis: Discoid LE, candidiasis, leukoplakia, erythroplakia, bullous

pemphigoid.

Treatment: no treatment is needed in asymptomatic lesions, topical steroids (ointment in

Orabase, intraregional injection) may be helpful. Systemic steroids in low doses can be

used in severe and extensive cases 30-60 mg for ten days, the topical use of antiseptic

mouthwashes should be avoided.

reactions Lichenoid

Lichenoid reactions are instances of mucosal disease that resemble lichen planus both

clinically and microscopically, but are due to an allergic response ,these agents is

extensive and includes medications, oral hygiene products and occasionally, metallic

filling materials placed by the dentist, responsible drugs are antihypertensive , none

steroidal anti-inflammatory drugs ,gold therapy , diuretics , and oral hypoglycemic

agents. Identifying the underlying cause of a lichenoid reaction is often challenging, but

when successful leads to lesion resolution.

Lupus erythmatosis

Definition: Lupus erythematosus is a chronic immunologically mediated disease there

are two forms of lupus, DLE affecting the skin and mucous membranes, and SLE which

may also affect joints, visceral organs, and other tissues.

Autoimmune :Etiology

This is immune related, multi-organ disease, affecting females more than males.

Clinical features oral lesions develop in 15–25% of cases in DLE and in 30–45% of

cases in SLE, usually in association with skin lesions, the oral lesions are characterized

by a well-defined central atrophic red area surrounded by a sharp elevated border of

irradiating whitish striae and hyperkeratotic plaques may be seen, lesions particularly

affects the palate, DLE characterized with butter fly rash at the malar area, it may

predispose to oral carcinoma.

Histopathological test is very helpful, direct immunofluorescence can be used .

Differential diagnosis: Lichen planus, geographic glossitis, speckled leukoplakia, ,

cicatricial pemphigoid.

.doses high in required often steroids, with essentially is SLE of Treatment :Treatment

Treatment of DLE is often symptomatic with the use of potent topical steroids to

suppress the lesions.

INFECTIOUS WHITE LESIONS

Candidiasis

Definition: Candidiasis is the most common oral fungal infection. Over the last two

decades, the disease has taken on major importance.

Etiology: It is usually caused by Candida albicans, and less frequently by other fungal

species ,predisposing factors are local (poor oral hygiene, xerostomia, mucosal damage,

dentures, antibiotic mouthwashes) and systemic (broad spectrum antibiotics, steroids,

immunosuppressive drugs, radiation, HIV infection, hematological malignancies, iron-

deficiency anemia, cellular immunodeficiency, endocrine disorders)

Clinical features: Oral candidiasis is classified as primary, consisting of lesions

exclusively on the oral and perioral area, and secondary, consisting of oral lesions of

mucocutaneous disease. Primary candidiasis includes five clinical varieties

pseudomembranous, erythematous, nodular, papillary hyperplasia of the palate, and

Candida-associated lesions (angular cheilitis, median rhomboid glossitis, denture

stomatitis). The main forms/types of candidiasis that produce white lesions are the

following:

Acute atrophic psuedommebranous candidiasis (THRUSH) which is white, slightly

elevated, removable spots or plaques, the lesions may be localized or generalized, and

appear more frequently on the buccal mucosa, soft palate, tongue, and lips, xerostomia a

burning sensation, and an unpleasant taste are the most common symptoms.

Chronic hyperplastic candidiasis,( chronic plaque type, nodular candidiasis) /candida

leukoplakia: The lesion characterized by appearance of white plaque or patches that

cannot peeled off such lesion usually located on the anterior buccal mucosa &cannot

clinically be distinguish from leukoplakia only by biopsy.

Mucocutaneous candidiasis: is a heterogeneous and rare group of clinical syndromes,

characterized by chronic lesions of the skin, nails, and mucosae, and usually associated

with immunological defects, clinically, the oral lesions appear as white and usually

multiple plaques, which cannot be removed.

Diagnosis: microscopic evaluation of lesion smears, Potassium hydroxide preparation to

demonstrate hypha, Periodic acid–Schiff (PAS) stain culture on proper medium

(Sabouraud’s, corn meal, or potato agar)

Differential diagnosis: leukoplakia, hairy leukoplakia, lichen planus, syphilitic

mucous patches, white sponge nevus, chemical and traumatic lesions, lupus

erythematosus.

Treatment: Topical antifungal agents (nystatin, azole derivatives, amphotericin B).

Systemic azoles (ketoconazole, fluconazole, itraconazole).

Hairy Leukoplakia

Definition: Hairy leukoplakia is one of the most common and characteristic lesions of

human immunodeficiency virus (HIV) infection, it has been used as a marker of disease

activity as it is associated with low CD4+T lymphocyte count, rarely, it can also appear

in immunosuppressed patients after organ transplantation, and immunosuppressive

drugs and chemotherapy.

.pathogenesis the in role important an play ot seems virus Barr–Epstein :Etiology

elevated often asymptomatic, white a as presents leukoplakia Hairy :features Clinical

lateral the on bilaterally found always almost is lesion The patch. removable un and

surface. ventral the and dorsum the to spread may and tongue, the of margins

orientation. vertical a with corrugated is lesion the of surface the Characteristically,

…ousprecancer not is lesion The seen. be also may lesions flat and othsmo However,

Differential diagnosis: Chronic biting, lichen planus, frictional keratosis, uremic

stomatitis, hyperplastic candidiasis.

Treatment: Not required, however, in some cases acyclovir or valacyclovir can be used

with success.

Mucous patches:

A superficial grayish area of mucosal necrosis is seen in secondary syphilis, this lesion

is termed a mucous patch.

Secondary syphilis usually develops within 6 weeks after the primary lesion and is

characterized by diffuse maculo papular eruptions of the skin and mucous membranes,

on the skin, these lesions may present as macules or papules, in the oral cavity, the

lesions are usually multiple painless grayish white plaques overlying an ulcerated

necrotic surface. The lesions occur on the tongue, gingiva, palate, and buccal mucosa.

Associated systemic signs and symptoms(including fever, sore throat, general malaise,

and headache) may also be present. The mucous patches of the secondary stage of

syphilis resolve within a few weeks but are highly infective because they contain large

numbers of spirochetes

Systemic diseases

Uremic Stomatitis

Definition: Uremic stomatitis is a rare disorder that may occur in patients with acute or

chronic renal failure.

Etiology: increased concentration of urea and its products in the blood and saliva, the

pathogenesis of oral lesions is not clear. It usually appears when blood concentration of

urea exceeds 30 m mole/1. The degradation of oral urea by the enzyme urease forms free

ammonia, which may damage the oral mucosa.

Clinical features: Four forms of uremic stomatitis are recognized: (a) the ulcerative

form, (b) the hemorrhagic form, (c) the no ulcerative, pseudomembranous form, and (d)

the hyperkeratotic form. The last two forms appear as white lesions. The ulcerative,

pseudomembranous form presents as painful diffuse erythema covered by a thick

whitish-gray pseudomembrane, the hyperkeratotic form presents as multiple painful

white hyperkeratotic lesions with thin projections, the tongue, and the floor of the mouth

are more frequently affected, xerostomia, uriniferous breath odor, unpleasant taste, and a

burning sensation are common symptoms. Candidiasis and viral and bacterial infections

are common oral complications, The diagnosis is based on the history, the clinical

features, urinalysis and blood urea level determination.

Differential diagnosis: Candidiasis, cinnamon contact stomatitis, hairy leukoplakia,

white sponge nevus, drug reactions.

Treatment: the oral lesions usually improve after hemodialysis, a high level of oral

hygiene, mouthwashes with oxygen release agents, and artificial saliva are suggested.

antiviral, and antimicrobial agents if necessary.

Premalignant and malignant condition

Carcinoma Verrucous

carcinoma cell squamous of variant grade-low a is carcinoma errucousv : Definition

pathogenesis. the in involved presumably is papillomavirus Human :Etiology

Clinical features: Clinically it presents as an epiphytic white mass with a verrucous or

pebbly surface, the size varies from 1 cm in the early stages to very extensive lesions.

The buccal mucosa, palate, and alveolar mucosa are the most common sites of

involvement, Verrucous carcinoma mainly develops in smokers over 60 years of age

Differential diagnosis: Verrucous leukoplakia, papilloma, white sponge nevus,

squamous-cell carcinoma.

Treatment: Surgical excision

Squamous-Cell Carcinoma

Squamous-cell carcinoma has a wide spectrum of clinical features. In about 5–8% of

cases, it appears in the early stages as a white asymptomatic plaque identical to

leukoplakia or atypical red patch . Biopsy histopathological examination are important

for the diagnosis in these cases.

suspicious clinical features: unexplained ulceration, Induration Persistent, Proliferative

growth, Change in texture and color.

Fixation to underlying tissues, Sudden loosening of teeth, Lymph node involvement,

Pain often a late feature .

Treatment: The treatment of oral carcinoma is clearly a complex matter, which in the

majority of cases involves surgery (with reconstruction), radiotherapy, or a combination

of both.

IDIOPATHIC “TRUE” LEUKOPLAKIA

Definition: Leukoplakia is a clinical term, and the lesion defined as a white patch or

plaque, firmly attached to the oral mucosa, that cannot be classified as any other disease

entity. It is a pre- cancerous lesion.

Etiology: The exact etiology remains unknown. Tobacco, alcohol, chronic local friction,

and candida albicans are important. predisposing factors. Human papilloma virus (HPV)

may also be involved in the pathogenesis of oral leukoplakia.

Clinical features: Three clinical varieties are recognized homogeneous (common),

speckled (less common), an verrucous (rare). Speckled and verrucous leukoplakia have a

greater risk for malignant transformation than the homogeneous form. The average

percentage of malignant transformation for leukoplakia varies between 4% and 6%. The

buccal mucosa, tongue, floor of the mouth, gingiva, and lower lip are the most

commonly affected sites.

Subtypes: Many varieties of leukoplakia have been identified.

Homogeneous leukoplakia refers to a usually well-defined white patch, localized or

extensive, that is flat or slightly elevated and that has a fissured, wrinkled, or corrugated

surface on palpation, these lesions may feel leathery to “dry, or cracked mud-like. It is

usually asymptomatic.

Non-homogeneous leukoplakia's are often symptomatic. It include speckled mixed,

white and red (erythroleukoplakia) Nodular (speckled) leukoplakia is granular or

nonhomogeneous. The name refers to a mixed red-and-white lesion in which keratotic

white nodules or patches are distributed over an atrophic erythematous background .This

type of leukoplakia is associated with a higher malignant transformation rate, with up to

two-thirds of the cases in some series showing epithelial dysplasia or carcinoma.

“Verrucous leukoplakia” is a term used to describe the presence of thick white lesions

with papillary surfaces in the oral cavity. These lesions are usually heavily keratinized

and are most often seen in older adults in the sixth to eighth decades of life. Some of

these lesions may exhibit an epiphytic growth pattern. Proliferative verrucous

leukoplakia (PVL) ,the lesions of this special type of leukoplakia have been described as

extensive papillary or verrucoid white plaques that tend to slowly involve multiple

mucosal sites in the oral cavity and to exhibit transform into squamous cell carcinomas

over a period of many years. PVL has a very high risk for transformation to dysplasia,

squamous cell carcinoma .Verrucous carcinomais almost always show a slow growing

and well-differentiated lesion that seldom metastasizes.

Differential diagnosis: Lichen planus, contact stomatitis, candidiasis, hairy leukoplakia,

lichnoid reactions, chronic biting, tobacco pouch keratosis, leukoedema, chemical burn,

uremic stomatitis, and discoid lupus erythematosus.

Treatment: elimination or discontinuation of predisposing factors, systemic retinoid

compounds surgical excision is the treatment of choice.

MISCELLANEOUS LESIONS

Hairy Tongue

Definition: hairy tongue is a relatively common disorder that is due to marked

accumulation of keratin on the filiform papillae of the tongue, resulting in a hair like

pattern.

Etiology: Unknown. Predisposing factors are poor oral hygiene, oxidizing mouthwashes,

antibiotics, excessive smoking, radiation therapy, emotional stress, and bacterial and

Candida species infections.

Clinical features: Clinically, it is characterized by an asymptomatic elongation

of the filiform papillae of the dorsum of the tongue, sometimes extending over

Several millimeters, the color range from whitish to brown or black, the

diagnosis is made clinically.

Treatment: elimination of predisposing factors, brushing of the tongue,

maintain good oral hygiene

Furred Tongue

Definition: Furred tongue is a relatively uncommon disorder, usually appearing during

febrile illnesses.

Etiology: The cause is not clear. Predisposing factors are febrile painful oral lesions,

poor oral hygiene, dehydration, and soft diet.

Clinical features: Clinically, it appears as a white or whitish-yellow thick coating on the

dorsal surface of the tongue . The lesion is due to lengthening of the filiform papillae, by

up to 3-4 mm, and accumulation of debris and bacteria, characteristically, furred tongue

appears and disappears within a short period. The diagnosis is made clinically.

Differential diagnosis Hairy tongue, hairy leukoplakia, candidiasis.

Treatment: Therapy of the underlying illnesses and improvement of oral hygiene

Materia Alba of the Gingiva

Definition and etiology: Materia alba results from the accumulation of food debris, dead

epithelial cells, and bacteria. It is common at the dentogingival margin. rarely, materia

alba may be seen along the vestibular surface of the attached gingiva in patients with

poor oral hygiene.

Clinical features: It presents as a soft, whitish plaque that is easily detached after slight

pressure.

Differential diagnosis: Candidiasis, chemical burn, leukoplakia.

Treatment good oral hygiene..

Geographic Tongue(geographic stomatitis, migratory glossitis)

Definition: Geographic tongue, or erythema migrans , is a relatively common benign

condition, primarily affecting the tongue and rarely other oral mucosa sites

Etiology :The exact etiology remains unknown. It may be genetic. Small percentage

associated with cutaneous psoriasis

Clinical features :Clinically, the condition is characterized by multiple, well-demarcated,

erythematous, depapillated patches, typically surrounded by a slightly elevated whitish

border ,and usually restricted to the dorsum of the tongue. Characteristically, the lesions

persist for a short time in one area, then disappear completely and reappear in another

area. The condition is usually asymptomatic, and often coexists with fissured tongue.

The diagnosis is made clinically.( Location and appearance).

Differential diagnosis: Candidiasis, lichen planus, psoriasis, Reiter syndrome, syphilitic

mucous patches.

Treatment: reassurance of the patient, avoidance soreness and spicy food.

Oral Submucous Fibrosis

Etiology: results from direct mucosal contact with a quid containing areca (betel) nut,

tobacco, and other ingredients alkaloids tannin in the areca nut are liberated by action of

slaked lime within the quid, which is wrapped with the betel leaf.it is chronic disease

that effect oral mucosa as well as pharynx and the upper two third of esophagus, risk of

oral squamous cell carcinoma is increased several-fold.

Clinical Presentation: Early phase tenderness, vesicles, erythema, burning, melanosis or

paler mucosa which may comprise white marbling appearance

Later phase: mucosal rigidity, trismus , Sites most often affected buccal mucosa, soft

palate ,deep scarring, epithelial atrophy in cheeks, soft palate

diagnosis depend on the clinical appearance& history of habit of betel quid chewing

Differential Diagnosis: lichen planus, leukoplakia, frictional keratosis.

Treatment: intraregional corticosteroid placement, Surgical release of scar bands in latter

stages, Careful follow-up and vigilance for development of squamous cell carcinoma.