Oral Pathology - White Lesions

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White Lesions: What Causes Them?

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* Hyperkeratosis

- Thickening of the horny layer of the epidermis or mucosa by increased keratin production which turns white when hydrated by saliva.

* Necrosis of epithelial cells

- Usually caused by an injury

* Ischemia

- Defective blood supply to the tissue

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Variations of Normal:

Fordyce Granules

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* Normal Sebaceous glands found in the oral mucosa

* Found in 80% of the population

* Not found in children - sebaceous glands form at puberty.

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Variations of Normal:

Leukoedema

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* Intracellular edema and tissue whiteness.

* More common in African Americans.

* Buccal Mucosa appears wrinkled

* Does not rub off - disappears when stretched.

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Traumatic and Inflammatory:

Geographic Tongue

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* aka Benign Migratory Glossitis

* Rarely seen i nchildren.

* More common in females in early to mid-adulthood

* Cause of inflammation unknown

* Appears as de-papillated area

* Treated w/ corticosteroids

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Traumatic and Inflammatory:

Frictional Keratosis

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* Physical irritation of oral mucosa produces keratin as protection against injury.

* White plaque that does NOT rub off.

* Not considered Leukoplakia because cause is known and does not become malignant lesion

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Traumatic and Inflammatory:

Check Chewing

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* aka morsicatio buccarum and morsicatio labiorum

* Location on lip or at the occlusal plane helps w/ diagnosis

* Can be found on the tongue

* Pt should be discouraged from habit

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Traumatic and Inflammatory:

Nicotine Stomatitis

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* Keratotic change of palate mucosa by heat from smoking or chronically drinking hot fluids

* Heat and irritation produce keratosis and irritation of minor salivary gland ducts on palate (red ducts) and edema (white/raised rings)

* May lead to carcinoma

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Traumatic and Inflammatory:

Hairy tongue

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* Etiology Unknown

* Can be white, black or brown

* Elongation of filiform papillae w/ hair-like appearance

* Brush tongue or use rinse (i.e. chlorhexidine)

* Risk Factors: Antibiotics, Therapeutic radiation, Smoking, Oxygenated Mouthrinse, Overgrowth of oral flora

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Infections:

Candidiasis.

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* Not in healthy people

* Predisposing Factors: Systemic broad-spectrum antibiotic therapy, Corticosteroids, Smoking, Xerostomia, Systemic Disorders, Diabetes, Immune Function Disorders.

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Infections:

Acute Pseudomembranous Candidiasis

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Candidiasis, Thrush

* White plaque that CAN BE RUBBED OFF

* Treatment: Nystatin oral suspension or glotrimazole croches or systemic fluconazole

* Organisms grow on mucosa and produce necrosis of superficial keratinocytes - dead cells lie on surface as white plaque due to hyphae (elongated form) of organism*

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Infections:

Chronic Hyperplastic Candidiasis

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* Rarest form

* very low risk of malignant transformation

* Thickened, raised, Whitish plaque that does NOT rub off

* Affects tongue, commissures, mucosa

* INDISTINGUISHABLE FROM LEUKOPLAKIA

* Systemic anti-fungals to treat

* Only candidiasis that shows malignant potential.

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Infections:

Hairy Leukoplakia

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* Infection of Ebstein Barr virus secondary to immunosuppression

* Predictor of rapid progression - Latent HIV to AIDS

* Whitish plaques of raised vertical ridges that do NOT rub off, usually on lateral borders of tongue.

* Biopsy to diagnose

* Antifungal to treat

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Infections:

Parulis

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* Swelling of the gingiva

* Caused by draining of sinus tract from an odontogenic infection of periodontal or pulpal origin.

Listed as white because purulent exudate is seen clinically as yellow or white.

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Immune System Disorders:

Lichen Planus

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* Immune-mediated mucocutaneous disorder

* T-lymphocytes recruited to skin damage epithelium

* Wickham striae (lacy pattern) on buccal mucosa, usually bilaterally; gingiva (Koebner phenomenon), or tongue

* No treatment needed unless change/growth

* Suspicious for malignancy if erosive

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Koebner Phenomenon

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* aka isomorphic reaction (in same form)

* Most widely known phenomena in dermatology

* First described by Heinrich Koebner (1872)

* Some patients had developed psoriasis at site of excoriation (abrasion from scratching), a horse bite, or a tattoo.

* usually describes response where new lesions develop on healthy skin that has suffered trauma in patients with skin conditions

* Pt w/ psoriasis + trauma to healthy skin = new lesion resembling psoriasis lesions

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Immune System Disorders:

White Sponge Nervus (WSN)

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* RARE - inherited mutation of certain keratin genes

* usually apparent in childhood

* widespread keratinization of buccal and labial mucosa

* Lesions do NOT rub off

* affect buccal mucosa folds - help in diagnosis since you can not bite buccal folds

* no treatment needed

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Immune System Disorders:

Leukoplakia

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* Most common form of premalignant lesion

* " White patch or plaque... does NOT rub off... can not be diagnosed clinically or pathologically as any specific disease"

* Diagnosis by exlusion of other conditions

* Frictional keratosis should not be mistaken for leukoplakia because leukoplakia is premalignant and frictional keratosis is not.

* Highly variable in size, shape, and location (any mucosal surface)

* Usually single and soft when palpated, some may feel leathery (degree of keratinization)

* Firm indurated mass indicates malignancy

* ventral tongue and floor of mouth (HIGHEST RISK AREAS) show more microscopic evidence of premalignancy or malignancy

* arises from microscopic mutations of epithelial cells following exposure to carcinogens

* 20% likely to become invasive

* Treatment includes eliminating risk factors (smoke/smokeless tobacco cessation), or surgical/laser removal w/ follow up observations

*other risk areas influde: lateral tongue, retromolar trigone, lateral soft palate, and lower lip from sun exposure (actinic cheilitis)

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Immune System Disorders:

Speckled Leukoplakia

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* Exhibits both red and white components

* May have redness, ulceration or pebbly appearance

* appears on lateral borders of tongue

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Immune System Disorders:

Proliverative Verrucous Leukoplakia

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* Aggressive

* High incidence of oral canver

* progressive

* Tendency to form on gingiva where associated w/ greatest potential for malignant transformation.

* biopsy should be performed to look for epithelial dysplasia, representing malignant change

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Immune System Disorders:

Smoking-Related Leukoplakia

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* Most important etiologic factor is tabacco (smoked and smokeless)

* 50% of leukoplakias in smokers will resolve with smoking cessation and over 95% of smokeless tobacco will will resolve

* Lesions are painless and persistant

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Immune System Disorders:

Leukoplakia of the Lower Lip

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* aka actinic chelitis

* Related to chronic sun damage

* Atrophy of vermillion border

* erosion and crusted appearance

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Immune System Disorders:

Oral Submucosal Fibrosis

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* Areca nut or betel nut chewing

* Genetic predisposition and genetic mutation

* Generalized stomatitis that develops numerous vesicles and ulcers

* Second tissue develops white thickening of tissue

* Third stage is formation of premalignant leukoplakia lesions in about 25% of cases

* NO treatment. Pt should stop chewing betel nut.