RECOGNIZING WHITE LESIONS PART I: Reactive, Idiopathic, Hereditary

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RECOGNIZING WHITE LESIONS PART I Reactive,
Idiopathic, Hereditary

• David E. Wojtowicz, DDS, MBA

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White Lesions

• A Lesion Appears WHITE Because Some Material Is
  Obscuring the Normal PINK or Racial Color.
• Is the WHITE Material Directly on the Surface?

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3 Mechanismsto Achieve White Appearance

• Epithelial Thickening
• Rough / Does NOT Rub Off
• Surface Material
• Rough / Does Rub Off
• Subepithelial Change
• Smooth / Does NOT Rub Off

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Six Common Etiologies for White Lesions

• Reactive (Snuff)
• Idiopathic (Hairy Tongue)
• Hereditary (Leukoedema)
• Auto-Immune (Lichen Planus)
• Infectious (Candidiasis)
• Neoplastic (SCC)

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1. Six Reactive White Hyperkeratotic
Lesions(These are HYPERKERATOTIC. They Do NOT
Rub Off.)

• a. Snuff Dippers Lesion
• b. Nicotinic Stomatitis
• c. Chemical Burn
• d. Linea Alba
• e. Actinic Cheilitis
• f. Denture Acanthosis

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1. Six Reactive White Hyperkeratotic Lesions(Do
They Rub Off?)a. Snuff Dippers Lesion

• Wrinkled, Velvety
• US Canada, Lower Carcinogenic Rate
• Asia Higher Rate Due to Added Carcinogens
• Treatment Quit Habit, Switch Site

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1. Six Reactive White Lesionsb. Nicotinic
Stomatitis

• Grey, White and Red on Hard Palate
• Pipe and Tobacco Smoking (Heat)
• Red Spots, Inflamed Minor Salivary Gland Orifices
• Treatment Quit Smoking

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1. Six Reactive White Hyperkeratotic Lesionsc.
Chemical Burn

• Caused by Aspirin
• Painful
• Usually in Molar Region
• Treatment Discontinue Aspirin Use

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1. Six Reactive White Hyperkeratotic Lesionsd.
Linea Alba

• Most Common White Lesion
• White Line _at_ Occlusal Plane
• Bilateral on the Buccal Mucosa
• No Treatment Needed

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1. Six Reactive White Hyperkeratotic Lesionse.
Actinic Cheilitis

• Sun Damage
• Lower Lip
• Obliteration of Border
• Treatment Avoid Sun, Use Sunblock

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1. Six Reactive White Hyperkeratotic Lesionsf.
Denture Acanthosis

• Caused by Irritants
• Clinical Appearance is Similar to Hyperkeratosis
• Thickened Intermediate Cell layer
• Elongation of Rete Pegs
• Treatment Avoid Irritants, ie. Ill-fitting
  Dentures

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2. Two Idiopathic White Hyperkeratotic Lesions

• Geographic Tongue
• Hairy Tongue

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Geographic Tongue(Benign Migratory Glossitis)

• White Borders (/-Hyperkeratotic)
• Red Patches of Denuded Filiform Papillae
• Common Disorder (1 - 2), Females, Young Adults
• Painfree or . . .
• Painful if inflamation is present
• Treatment None, or Topical Anesthetic

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Hairy Tongue

• Shaggy Matte of Filliform Papillae
• Candidiasis Stimulates the Hyperplasia
• Coffee, Tea, Tobacco Black
• Treatment Brush Tongue, Improve Oral Hygiene

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3. Two Hereditary White Hyperkeratotic Lesions

• Leukoedema
• White Sponge Nevus

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Leukoedema

• Milky Grey Film
• Bilateral Buccal Mucosa, Non-progressive
• Disappears When Stretched
• More Common in Black Population
• Treatment None Needed

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White Sponge Nevus

• Rough, Fissured Texture
• Symetric, Bilateral Buccal Mucosa
• Appears During Childhood, Non-progressive
• Autosomal Dominant Transmission

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RECOGNIZING WHITE LESIONS IIAuto-Immune,
Infectious, Neoplastic

• David E. Wojtowicz, DDS, MBA

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4. Two Auto-Immune White Hyperkeratotic Lesions

• Lichen Planus
• Lupus Erythematosus

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Lichen Planus

• Auto-immune Degeneration of Connective Tissue /
  Mucosa (Skin) Interface
• Middle Age (Rare Before 30)
• M F, Skin Lesions (33)

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Lichen Planus

• Reticular (Wickhams Striae)
• Annular
• Erosive
• Atrophic, Bullous

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Lichen Planus

• Stress Thiazide Drugs are Possible Triggers
• Differential Snuff (Stretch) White Sponge
  (Youth)
• Treatment None if Asymptomatic . . .

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Erosive Lichen Planus

• Painful
• Risk Factor for SCC
• Treatment Biopsy, Steroids, Retinoic Acid

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Lupus Erythematosus

• Skin Lesions Butterfly Rash (Sun Exposed Area)
• Mucosal Lesions Rough White Patch
• Bordered by Striae, Ulcers, Erythema

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Lupus Erythematosus

• Systemic Arthritis, Vasculitis (Renal Failure)
• Antinuclear Antibodies (ANA)
• Differential Lichen Planus (Symmetrical
  Cutaneous), Leukoedema (Stretch) White Sponge
  (Youth)
• Treatment Corticosteroids

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5. Three Infectious White Lesions

• Candidiasis (DOES Does NOT Scrape Off) - FIVE
  Clinical Lesions
• Oral Hairy Leukoplakia (Does NOT Scrape Off)
• Syphilitic Mucous Patch (Does NOT Scrape Off)

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Candidiasis (Moniliasis)

• Acute
• Pseudomembraneous (Thrush) - White
• DOES Scrape Off
• Atrophic (Erythematous) - Red
• (Does NOT Scrape Off)
• Chronic
• Hyperplastic (Candidal Leukoplakia) - White
• (Does NOT Scrape Off)

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Candidiasis

• Commensal Organism - Normal Oral Flora
• Capable of Opportunistic Infections (Hyphae)
• Early Sign of Host Defense Breakdown
  (Neutropenia)
• Risk Factors Antibiotics, Imunosupression,
  Diabetes, HIV, Steroids, Nutritional Deficiency,
  Radiation/Chemo

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Candidiasis Acute Pseudomembraneous

• White, Scrapes Off
• Underlying Tissue Erythematous, Hemorrhagic,
  Pruritic
• Newborns RF (See Previous Item)
• Treatment a. Correct the Predisposing Factorb.
  Prescribe Nystatin Vaginal Tablets
• Disp 70
• Use One Tablet as a Lozenge 5 Times a Day

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Candidiasis Chronic Hyperplastic-Candidal
Leukoplakia

• Keratotic Plaques or Papules (?Scrape Off?)
  Against Erythematous Background With Acanthosis
• Sites Labial Commissure, Labial Buccal
  Vestibule
• Risk Factors Smoking, Poor Oral Hygiene
  (Dentures), Xerostomia - These Are Essentially
  All Chronic Irritants

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Candidiasis Chronic Hyperplastic-Candidal
Leukoplakia

• Cancer Risk Biopsy is Mandatory of All Speckled
  Erythroplakia or Erythroleuko-plakia Because of
  Increased SCC Risk
• Treatment a. Correct the Predisposing Factorb.
  Biopsy Lesionc. Prescribe Nystatin Vaginal
  Tablets
• Disp 70
• Use One Tablet as a Lozenge 5 Times a Day

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Candidiasis Three Red Chronic Oral Lesions

• Angular Cheilitis Perleche (Red)
• Median Rhomboid Glossitis (Red)
• Denture Sore Mouth Atrophic Candidiasis (Red)

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Oral Hairy Leukoplakia

• Rough, Hyperkeratotic, Patch
• Opportunistic E-B Virus
• HIV Immunocompromised
• Bilateral, Lateral Borders of the Tongue
• Treatment None or Acylovir
• Disp 60 Capsules
• One Cap q.4h. for 5 to 10 days

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Syphilitic Mucous Patch

• Painless, White, Mucosal Ulcers With . . .
• Nonpruritic Skin Rash, Lymphadenopathy
• Signs of Secondary Syphilis (T. pallidum)

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6. Four Neoplastic White Lesions

• Squamous Cell Carcinoma
• Verrucous Carcinoma
• Epithelial Dysplasia
• Carcinoma in Situ

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Squamous Cell Carcinoma (SCC)

• 90 of All Oral Malignancies SCC
• Mixed Red White is Most Likely Presentation
• Age Elderly (40) Gender Males (21)
• Location Lower Lip, Floor of Mouth, Lateral
  Ventral Tongue, Soft Palate

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Squamous Cell Carcinoma (SCC)

• Uncontrolled Growth
• Up Regulation of Oncogenes
• Kinases Cyclines Become Overactive
• Deactivation of Suppresser Genes
  (Antioncogenes)

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Verrucous Carcinoma

• Hyperkeratotic, Exophytic, Papillary
• Age Elderly (60) Gender Males (21)
• Location Gingiva, Alveolar Ridge, Buccal Mucosa

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Epithelial Dysplasia

• Premalignanat Changes of Cell Architecture
• Mixed Red White is Most Likely Presentation
• Cell Alterations Nuclear Changes
• Architecture Alterations Bulbous Rete Pegs

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Carcinoma in Situ (CIS)

• Entire Thickness (Top to Bottom Change)
• Basement Membrane Intact
• No Invasion or Change of Connective Tissue

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Geriatrics

• Proliferative Verrucous Leukoplakia (PVL)
• Hyperkeratotic Lesions Mixed Smooth and Warty
• Mainly on Edentulous Alveoloar Ridge
• Cancer Risk May Progress to SCC or VC

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Risk Factors / Predisposing Factors

• Demographic (Age,Gender,Race)
• Social (Alcohol, Tobacco, Oral Habits)
• Recent History (Trauma, Infection, Surgery)
  (Especially Chronic)
• Medical History (Chronic Disease, Acute Illness,
  Medications,Treatments) (Especially Diabetes,
  Organ Cancer, Antibiotics, Chemo)

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3 Mechanisms

• Surface Material
• Rough / Does Rub Off
• Epithelial Thickening
• Rough / Does NOT Rub Off
• Subepithelial Change
• Smooth / Does NOT Rub Off
• Two Examples
• Fordyce Granules Ectopic Sebaceous Glands
• Scar Surgical, Traumatic

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Clues to Normal

• Bilateral Symmetry
• Predictable Locations
• Asymptomatic
• Independent Finding (no Secondary Features such
  as redness, swelling)
• Increase with Age
• Remains Unchanged w/ Treatment

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Glossary of Terms

• Acanthosis excessively thickened intermediate
  cell layer with broad and long rete pegs
• Hyperkeratosis excessively thickened keratin in
  stratum corneum
• Leukoplakia a white patch on the oral mucosa
  that cannot be scraped off and cannot be
  classified as any other disease

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Review Which of the Following Choices
Demonstrate Concepts of Differential Diagnosis

• List of Diseases With Similar Manifestations
  (Yes)
• Oral Ulcer (No, monomorphic presentation)
• Zinc Deficiency, Trauma, Herpes, Aphthous Lesion
  as Potential Etiologies for a Single Monomorphic
  Presentation. (Yes)
• Rely Primarily on the Clinical Appearance (No,
  must include history, risk factors, visual
  inspection)

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List the Seven Primary Clinical Manifestations of
Non-dental Lesions

• Normal Variation
• White
• Red (Pigmented or Dark)
• Ulceration
• Exophytic
• Radiographic
• Syndrome

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List Four Techniques Employed to Investigate the
Secondary Clinical Features of Oral Lesions

• Visual Inspection
• Palpation
• Probing
• Patient Awareness

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Name at Least Four Visual Features to Inspect for
When Examining an Oral Lesion

• Location
• Shape Contours
• Size
• Solitary/Multiple
• Borders
• Homogenous/Heterogeneous
• Surface Color/Texture
• Displacement (of Teeth?)

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During Palpation One Can Check For

• Compressible
• Tender
• Color Change (Blanching)
• Mobile / Bound Down
• Induration
• Probing, Exudate

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During the Interview, Inquire if Patient is Aware
of

• Pain or Altered Function
• Duration (Acute, Chronic)
• Progressive Course or Remission
• Response to Stress/ Foods

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List Four Risk or Contributory Factors

• Demographic (Age,Gender,Race)
• Social (Alcohol, Tobacco, Oral Habits)
• Recent History (Trauma, Infection, Surgery)
• Medical History (Chronic Disease, Acute Illness,
  Medications,Treatments)

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Differential Diagnosis

• List of Diseases With Similar Manifestations
• Rule Out (R/O) on the Basis of Contradictions
• Example Oral Ulcer