University Of Aden

Faculty of Dentistry
Department of Oral Surgery
2012-2013

Oral Medicine
Associate Prof. Dr. Muhgat Abdo
Oral& Dentofacial Surgeon

muhgatabdo@hotmail.de
www.adendent-faculty.net
 Oral Medicine
Introduction

White Lesions of The

Oral Mucosa
 Oral Medicine
Introduction

White lesions of the oral mucosa are a

multifactorial group of disorders, the color of
which is produced by the scattering of the light
through an altered epithelial surface.
The diagnosis and differential diagnosis of oral
white lesions should be made on the basis of the
medical history, clinical features, and laboratory
tests.
 Oral Medicine
White Lesions
Leukoplakia
1. Hairy leukoplakia
2. Lichen planus

3. Lichenoid reactions

4. Linea alba
5. Nicotinic stomatitis

6. Uremic stomatitis

7. Cinnamon contact stomatitis

8. Chemical burn

9. Candidiasis

10. Chronic biting

11. Geographic tongue

12. Hairy tongue

13. Furred tongue

 Oral Medicine
White Lesions
Leukoplakia
14. Materia alba of the gingiva
15. Fordyces granules
16. Leukoedema
17. White sponge nevus
18. Dyskeratosis congenita
19. Pachyonychia congenita
20. Focal palmoplantar and oral
21. mucosa hyperkeratosis syndrome
22. Papilloma
23. Verrucous carcinoma
24. Squamous-cell carcinoma
25. Skin and mucosal grafts
26. Epithelial peeling
 Leukoplakia
Definition and Etiology

Leukoplakia is a clinical term, and the lesion is

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 precancerous lesion
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
 Leukoplakia
The Clinical Featuers

Three clinical varieties are recognized:

1.Homogeneous (common).
1.Speckled (less common).
Homogeneous
2.Verrucous (rare).

Speckled and verrucous leukoplakia have a greater

risk for malignant transformation than the
homogeneous form.
 Leukoplakia
The Clinical Featuers

Three clinical varieties are recognized:

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

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

Leukoodema White Sopngy Nevus Lichen Planus

 Leukoplakia
Treatment

1. Elimination or discontinuation of predisposing

factors, systemic retinoid compounds.
2. Photo Documentation.
3. Surgical excision is the treatment of choice after
Biopsy result.
Therapy:
A. Good Oral Hygiene.
B. Vitamin A+E Tab. 1xBDx4 Weeks.
C. Vitamin B Complex 1xBDx4 Weeks.
D. Mouth Wash.
 White Lesion
Hairy Leukoplakia
Definition : 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

Etiology : EpsteinBarr virus seems to play an

.important role in the pathogenesis
 White Lesion
Hairy Leukoplakia
: Clinical 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 precancerous
 White Lesion
Hairy Leukoplakia

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

some cases aciclovir or valaciclovir can be used with
.success. antiviral medication products
 White Lesion
Hairy Leukoplakia
1. Elimination or discontinuation of predisposing
factors, systemic retinoid compounds.
2. Photo Documentation.
3. Surgical excision is the treatment of choice after
Biopsy result.
Therapy:
A. Good Oral Hygiene.
B. Vitamin A+E Tab. 1xBDx4 Weeks.
C. Vitamin B Complex 1xBDx4 Weeks.
D. Mouth Wash.
E. Control every Weeks.
 White Lesion
Lichen Planus

Definition: Lichen planus is a relatively common

chronic inflammatory disease of the oral mucosa
.and skin
Etiology: Although the cause is not well known, T
cell-mediated autoimmune phenomena are
.involved in the pathogenesis of lichen planus
 White Lesion
Lichen Planus (Etiology)

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
 White Lesion
Lichen Planus

Clinical features: White papules that usually

coalesce, forming a network of lines (Wickmans
striae), are the characteristic oral lesions of the
disease. Six forms of the disease are recognized in
:the oral mucosa, classified according to frequency
1.The common (reticular, erosive).
2.The less common (atrophic,
hypertrophic).
1.The rare (bullous, pigmented).

The prognosis of lichen planus is usually good.

 White Lesion
Lichen Planus

1.Lichen Planus (reticular,

erosive).

1.Lichen Planus (atrophic, )reticular(

hypertrophic).

)Hypertrophic(
1.Lichen Planus (bullous,
pigmented).
)Pigmented(
 White Lesion
Lichen Planus

: Differential 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
 White Lesion
Treatment of Lichen Planus

Treatment: Not required; however, in some cases

aciclovir or valaciclovir can be used with success.

No treatment is needed in asymptomatic lesions.

Topical steroids (ointment in Orabase, intralesional
injection), may be helpful.

Systemic steroids in low doses can be used in severe

and extensive cases.

The topical use of antiseptic mouthwashes should be

avoided.
 White Lesion
Lichenoid Reactions
Definition : 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
Etiology : 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
 White Lesion
Lichenoid Reactions
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 diagnosis:
diagnosis is usually made clinically
 White Lesion
Lichenoid Reactions
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: Replacement of the restorative material,

polishing and smoothing, and good oral hygiene are
recommended. Topical steroid treatment for a short
.time is also helpful
 White Lesion
Lichenoid Reactions
Lichenoid reaction to dental
amalgam and cold: white and
erythematous lesions on the
.buccal mucosa

Lichenoid drug reaction to

allopurinol: white
hyperkeratotic lesions and
superficial erosions on the
.sides of the tongue
 White Lesion
Linea Alba
Definition: Linea alba is a relatively common
.alteration of the buccal mucosa

Etiology: Pressure, sucking

.from the buccal surface of the teeth
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. The diagnosis
.is based on clinical grounds alone

.Treatment: No treatment is required

 White Lesion
Nicotinic Stomatitis
Definition : Nicotinic stomatitis, or smokers 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
 White Lesion
Nicotinic Stomatitis
Clinical features: Clinically, the palatal mucosa
initially responds to the high temperature with
redness. Later, it becomes wrinkled and takes on a
diffusely grayish-white color, with numerous
micronodules 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 smokers palate lesion, which is associated
.with reverse smoking
.The diagnosis:
diagnosis is usually made clinically
 White Lesion
Nicotinic Stomatitis
Laboratory tests: Usually not required. However, a
.histopathological examination is useful

.Differential diagnosis: Reverse smokers palate

.Leukoplakia. Discoid lupus erythematosus
.Candidiasis. Lichen planus

.Treatment: Cessation of smoking

 White Lesion
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 (C.
.glabrata, C. krusei, C. tropicalis, C. parapsilosis)
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, neutropenia, iron-deficiency anemia,
.cellular immunodeficiency, endocrine disorders)
 White Lesion
Candidiasis
: Clinical features: Oral Candidiasis is classified as
Primary: consisting of lesions exclusively on the
.oral and perioral area
Secondary: consisting of oral lesions of
.mucocutaneous disease
:Primary Candidiasis
: includes five clinical varieties
Pseudomembranous.
Erythematous.
Nodular.
Papillary hyperplasia of the palate.
Candida-associated lesions. (angular cheilitis,
 White Lesion
Candidiasis
The main forms of candidiasis that
produce white
: lesions are the following
:Pseudomembranous Candidiasis
Is the most common form of the
disease, and is clinically characterized
by creamy-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
 White Lesion
Candidiasis

: Nodular Candidiasis
Is a chronic form of the disease; it
, appears clinically as a white, firm
and raised plaque that usually
.does not detach
: Mucocutaneous Candidiasis
Is a heterogeneous and rare group of
clinical syndromes, characterized by
chronic lesions of the skin, nails, and
mucosa, and usually associated with
immunological defects. Clinically, the
oral lesions appear as white and
usually multiple plaques, which cannot
.be removed
 Oral Medicine
White Lesions
1. Leukoplakia
2. Hairy leukoplakia
3. Lichen planus
4. Lichenoid reactions
5. Linea alba
6. Nicotinic stomatitis
7. Candidiasis
8. Uremic stomatitis
9. Cinnamon contact stomatitis
10. Chemical burn
11. Chronic biting
12. Geographic tongue
13. Hairy tongue
14. Furred tongueMateria alba of the gingiva
 Oral Medicine
White Lesions
15 White sponge nevus
16 Dyskeratosis congenita
17 Pachyonychia congenita
18 Focal palmoplantar and oral mucosa hyperkeratosis syndrome
19 Papilloma
20 Verrucous carcinoma
21 Squamous-cell carcinoma
22 Skin and mucosal grafts
23 Epithelial peeling
 References
M.D., D.D.S., Ph.D. G. Laskaris, Pocket Atlas of Oral
Diseases 2006 Thieme. Second Edition.

Dr. Pramod John R, Textbook of Oral Medicine. 2nd

Edition. (2005).

Dr Larry J. Peterson and others, Contemporary Oral

and Maxillofacial Surgery. Fourth Edition. (2004).