White Lesions

Question 1

White surface lesions are divided into 3 groups based on their clinical features:

Answer 1

• Epithelial thickening
  
  • Asymptomatic, rough, do not rub off
• Surface debris
  
  • Symptomatic, rub off, underlying erythema
• Subepithelial lesions
  
  • Asymptomatic, smooth palpation, translucent

Question 2

Keratinized tissues

Answer 2

• Tongue
• Hard palate
• Attached gingiva
• Outer lip (past vermillion border)

Question 3

Non-keratinized tissues

Answer 3

• Everywhere else that isn’t the tongue, hard palate, attached gingiva, or outer lip (past vermillion border)
• Buccal mucosa
• Labial mucosa
• Soft palate
• Floor of the mouth

Question 4

What gives white lesions their color?

Answer 4

Excessive keratin build up

Question 5

White Sponge Nevus

Answer 5

Familial Epithelial Hyperplasia

• Autosomal Dominant inheritance
• Mutation of keratin genes
  
  • Abnormal keratin production
• Presents as multiple white rough surface lesions throughout the oral cavity
• May involve anal and genital mucosa
• Appears in early childhood
• Not malignant
• Tx: None

Question 6

Frictional Keratosis

Answer 6

• Related to chronic rubbing or friction
• Anywhere in the oral cavity
• Careful history taking and examination sufficient for dx
• Tx: Lesion should resolve or reduce after removal of causative agent. Otherwise, no tx needed

Question 7

Hairy Tongue

Answer 7

• Represents elongation of filiform papillae due to accumulation of keratin on the dorsum of the tongue
• Associated with lack of mechanical abrasion to tongue
• Tx: Brush/scrape tongue
• Px: Good

Question 8

Hairy Leukoplakia

Answer 8

• Epithelial thickening of the lateral surfaces of the tongue
• Present in immunocompromised patients i.e. HIV, AIDS, transplant patients, etc
• Tx: None, other than to determine the immune status of the patient
• Px: Indicates poorly functioning immune system

Question 9

Lichen Planus

Answer 9

• Common dermatologic disease that often affect oral mucosa
• Oversensitivity rxn of T lymphocytes
• Most patients are middle-aged adults; 3:2 F:M
• Skin features sometimes present:
  
  • Planar
  • Purple
  • Pruritic
  • Polygonal
  • Plaque
  • Papule
• Oral features
  
  • Lesions are multifocal; typically bilateral on the buccal mucosa
    
    • Reticular Pattern
    • Erosive Pattern

Question 10

Lichen Planus: Reticular Pattern

Answer 10

• Wickham’s Striae: white lacy pattern with underlying erythema
• White plaques sometimes present
  
  • Asymptomatic and are not tx’d
• More common form
• Multifocal lesions; usually bilateral
• Wax and wane over wks/mos
• Tx: If burning, rx topical corticosteroid

Question 11

Lichen Planus: Erosive Pattern

Answer 11

• Central area of ulceration that is painful
• Areas of pseudomembrane centrally may be present
• Multifocal; usually bilateral
• Wickham’s striae may be present
• Less common, but more significant and painful
• Central erosion/pseudomembrane w/ erythema and possibly Wickham’s striae
• May present as desquamative gingivitis
• Tx: Topical corticosteroids. Flare-ups require reapplication of drugs or prophy tx. Severe cases rx systemic corticoid tx

Question 12

Leukoedema

Answer 12

• Common, asymptomatic, variation of normal
• White, opalescent, filmy, folded surface, does not rub off, rough
• Distribution: bilateral buccal mucosa
• More common in AA vs. more easily recognized in AA population
• Dx clinically: white appearance decreases when tissue is stretched
• Tx: None

Question 13

Erythema Migrans

Answer 13

• AKA geographic tongue, benign migratory glossitis
• Commonly seen on anterior 2/3 of tongue and ventral and lateral surfaces
• Red patches with white border
• Due to atrophy of filiform papillae w/ elevated white border
• Presents as multiple, well-demarcated, irregular red patches with sharply defined, tortuous, yellow-white border
• Lesions resolve in some areas and appear in other areas = migratory
• Usually asymptomatic
• Can be associated with burning sensation
• Cause is unknown
• Tx: None. Topical steroids for symptomatic lesions

Question 14

Lichenoid Mucositis/Rxn

Answer 14

• Looks like lichen planus bc of inflammation in the mucosa
  
  • Clinical and microscopic findings are similar
• Causes
  
  • Rxn to flavoring agents (cinnamon, mint, etc)
  • Rxn to medicine
  • Graft vs. Host Disease
    
    • Immune system is attacking the host
  • Can be focal or multifocal

Question 15

Nicotinic Stomatitis

Answer 15

• Present on hard palate of smokers - mainly pipe or cigar
• Almost no potential (on hard palate) for transformation to squamous cell carcinoma
  
  • Response to heat rather than chemicals
• Tx: None needed
• Reverse Smoker’s Palate = pronounced nicotinic stomatitis
  
  • Significant risk of dysplasia or carcinoma

Question 16

Linea Alba

Answer 16

• Common alteration of buccal mucosa
• Pressure, frictional irritation, sucking trauma from facial surfaces of the teeth
• Usually bilateral
• Tx: N/A

Question 17

Morsicatio Buccarum

Answer 17

• Chronic cheek chewing
  
  • Labial mucosa = morsicatio labiorum
  • Tongue = morsicatio linguarum
• Usually bilateral
• Tx: N/A
  
  • Lateral acrylic shields connected by steel wire

Question 18

Leukoplakia

Answer 18

• Strictly a clinical term and is NOT a dx. Cannot be characterized clinically or pathologically as any other disease
• You must be able to exclude all the above white lesion conditions before using “leukoplakia”
• Typically considered precancerous or premalignant because of the frequency of the leukoplakia to become malignant is greater than the risk associated with normal mucosa
• Most leukoplakias are hyperkeratosis w/o dysplasia or cancer
• Definitive dx by microscopic dx of a biopsy may show one of the following:
  
  • Hyperkeratosis: Callous
    
    • Not pre-malignant; does not need to be removed
  • Epithelial dysplasia: Atypical cells confined to the cells of the epithelium
    
    • Enlarged nuclei/cells
    • Increased nuclear-to-cytoplasmic ratio
    • Hyperchromatic nuclei
    • Pleomorphic cells
    • Increased/abnormal mitotic activity
  • Pre-malignant
    
    • Mild = usually not removed
    • Moderate = may be removed
    • Severe = must be removed
  • Carcinoma-in-situ: Cancer confined to the epithelium
    
    • Will eventually invade
    • Must be removed
  • Superficial squamous cell carcinoma
    
    • Must be removed

Question 19

Two types of candidosis

Answer 19

• Oral thrush - pseudomembranous candidosis
• Erythematous candidosis

Question 20

Oral thrush - Pseudomembranous Candidosis

Answer 20

• White plaques rub off, leaving an erythematous base
• Best recognized form
• Pain or burning sensation
• Often associated w/ xerostomia, abx, and/or decreased host resistance
• Common opportunistic oral mycotic infection
  
  • Most common oral fungal infection in humans
• Component of normal oral microflora
• Predisposing factors
  
  • Immunodeficiency; acquired immunosuppression; endocrine disturbances; diabetes mellitus; corticosteroid tx; systemic abx tx; xerostomia; poor OH

Question 21

Erythematous Candidosis

Answer 21

• More common than white
• Red variations
  
  • Acute erythematous candidosis
  • Chronic erythematous candidosis
  • Angular chelitis
  • Median rhomboid glossitis
• Tx: Cytology smear confirms dx
  
  • Topical (nystatin, clotrimazole) and systemic (ketoconazole, fluconazole) antifungal meds

Question 22

Burn

Answer 22

• Heat, cold, chemicals
• Area of yellow-white epithelial necrosis
• Supporting hx

Question 23

Chemical Injury

Answer 23

• Chemicals/drugs in prolonged contact w/ oral tissues
• Pain in area of application
• Children/psychiatric pts may hold meds in their mouth
• Topicals for pain can compound the problem

Question 24

Dentrifice-Associated Slough

Answer 24

• Painless, gray-white gelatinous membranes on gingiva, vestibule, floor of mouth and lips
  
  • Most obvious in the morning
  • Associated w/ SLS and pyrophosphates found in some dentrifices and mouth rinses
  • May cause burning sensation

Question 25

Subepithelial lesions - Congenital Cysts

Answer 25

* Palatal cysts * Gingival cysts

Question 26

What are the two types of congenital palatal cysts?

Answer 26

* **Bohn's Nodules:** Epithelial remnants from minor salivary glands of palate entrapped below the surface * **Epstein's Pearls:** Palatal shelves fusing at the midline entrap small islands of epithelium

Question 27

Subepithelial gingival cysts

Answer 27

* Entrapment of dental lamina * Appearance similar to palatal variant * Dental lamina cyst & congenital keratotic cyst

Question 28

Subepithelial Fibrosis (Scar)

Answer 28

* Usually poorly defined * H/o injury or surgery * Tx: N/A

Question 29

Fordyce Granules

Answer 29

* Represent ectopic sebaceous glands * **Yellow-granular plaques and nodules present in clusters** * Most commonly located on the buccal mucosa & lip * Dx based on clinical basis * Tx: N/A