WHITE LESION in oral mucosa
WHITE LESION in oral mucosa
def.
WHITE LESION is a non specific term used to
describe any abnormal area of the oral
mucosa that on clinical examination appears
whiter than the surrounding tissue and
usually slightly raised ,roughened or
otherwise of a different texture form the
adjacent normal tissue.
CLASSIFICATION
ACCORDING TO THE ETIOLOGY.
1- Normal Variation.
2- Traumatic.
3- Auto immunologic.
4- Metabolic.
5- Congenital.
6- Multifactorial.
WHITE LESION is a non specific term used to
describe any abnormal area of the oral
mucosa that on clinical examination appears
whiter than the surrounding tissue and
usually slightly raised ,roughened or
otherwise of a different texture form the
adjacent normal tissue.
CLASSIFICATION
ACCORDING TO THE ETIOLOGY.
1- Normal Variation.
2- Traumatic.
3- Auto immunologic.
4- Metabolic.
5- Congenital.
6- Multifactorial.
ACCORDING TO CLINICAL FEATURES:
1- Keratotic. These lesions can resist rubbing and scraping involve thickening of mucosal epithelium as a result of hyperkeratosis.
2- Non keratotic. These lesions can be dislodged easily
and often leave a slight redness or raw patch of the mucosa.
3- Others.
2- Non keratotic. These lesions can be dislodged easily
and often leave a slight redness or raw patch of the mucosa.
3- Others.
KEY TERMS
KERATOSIS: Any horny growth, such as a wart or callosity.
HYPERKERATOSIS: Excessively thickened layer of the stratum corneum composed of orthokeratin (hyperorthokeratosis) or
parakeratin (hyperparakeratosis).
ACANTHOSIS: Excessive thickening of the spinous layer of squamous epithelium, resulting in broadening and elongation of the rete pegs.
EPITHELIAL ATROPHY: Reduction in the normal thickness of epithelium that involves less than the entire thickness of the epithelium.
EPITHELIAL DYSPLASIA: A premalignant change in epithelium characterized by a combination of cellular and architectural alterations.
KERATOTIC WHITE LESIONS
LINEA ALBA
It is white line that extend anterioposteriorly on buccal mucosa parallel to the line of occlusion.
Is consider as normal frictional cornification, may be bilateral ,and more prominent in patients who have clinching or bruxism habit.
TREATMENT : No treatment is indicated ,just reassurance the patient,as it's normal variant.
STOMATITIS NICOTINA (Smoker’s Keratosis)
It is specific lesion that develops on palate in heavy, long term cigarette, pipe and cigar smokers.
CLINICAL FEATURES : White thickening of palatal mucosa associated with small implicated swelling and red centers ,if the patient is denture wearer, the lesion appear on soft palate.
HISTOPATHOLOGICAL FEATURES: White areas show hyperkeratosis and inflammatory swelling of minor salivary glands.
TREATMENTT: Stop smoking, the lesion resolves within weeks.
FRICTIONAL KERATOSIS
It is a protective response to prolonged mild abrasion of the mucous membrane. By such irritants as sharp tooth, cheek- biting or denture.
CLINICAL FEATURES: First, the patches are pale and translucent, but later become dense and white.
TREATMENT: Removal of the irritant causes the patch disappear in 7- 14 days.
Review appointment, if the patch persist, biopsy is necessary.
Angular cheilitis
It is a premalignant lesion,associated with long term exposure to solar radiation.
CLINICAL FEATURES : May be found on the vermillion of lower
lip as well as other sun exposed skin surface, it is
pale in color ,pinkish and mottled, it is found more in white peoples.
HISTOPATHOLOGICAL FEATURES :
ELASTOSIS : Degeneration of elastic tissues, degenerative changes in the dermal connective tissues with increased amounts of elastotic material, any disturbance of the dermal c.t.
CHEILITIS : Inflammation of the lips, with alteration of the epithelium.
TREATMENT: Avoid sun exposure ,Topically 5- fluorouracil,
Surgical removal (shaving)
Lupus erythematous
autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs.
Diagnosis: It is a connective tissue disease, which has two mains forms:
Systemic and Discoid . Either can give rise to
oral lesion which appear similar to oral lichen
planus.
Systemic : Has varied effects, artharlgias and rashes are most common, but any organ system can be affected. A great variety of most antinuclear antibodies is produced.
Discoid : A chronic skin disease with mucocutaneous lesion. It may be associated with Arthralgia, but rarely significant auto antibodies production.
Clinical Features :
- Typical lesions are white striate areas with irregular atrophic areas or shallow erosions.
- Typically are less sharply defined than in lichen planus.
Histopathological features:
- Irregular pattern at epithelial atrophy and
acanthosis.
Investigations: Biopsy, immunofluorescent and hematological test are required to definitive diagnosis.
Treatment: Corticosteroid therapy.
Lichen Planus
It is a common immunological chronic inflammatory disease of skin and membranes (so, called mucocutaneous disease) and it’s cause is unknown but may be referred to some drugs or irritant materials.
DIAGNOSIS: Lichen planus has characteristic appearance and distribution which help in making the diagnosis.
CLINICAL FEATURES:
- Females account for at least 65% of patients.
- Patients usually over 40 years old.
- Untreated disease can persist for 10 or more years.
- Lesion usually bilateral and symmetrical.
- Cutaneous lesion only occasionally.
- Buccal mucosa, dorsum of tongue, Gingiva.
Forms:
- Striae (Reticular).
- Atrophic.
- Erosive.
- Plaques.
- Bullous.
Histology:
- Degeneration of the basal cell layer.
- Saw teeth profile of the rete ridge.
- Inflammatory cells in relation to the epithelium.
Investigations: Biopsy, immunofluorescent.
DIAGNOSIS: Lichen planus has characteristic appearance and distribution which help in making the diagnosis.
CLINICAL FEATURES:
- Females account for at least 65% of patients.
- Patients usually over 40 years old.
- Untreated disease can persist for 10 or more years.
- Lesion usually bilateral and symmetrical.
- Cutaneous lesion only occasionally.
- Buccal mucosa, dorsum of tongue, Gingiva.
Forms:
- Striae (Reticular).
- Atrophic.
- Erosive.
- Plaques.
- Bullous.
Histology:
- Degeneration of the basal cell layer.
- Saw teeth profile of the rete ridge.
- Inflammatory cells in relation to the epithelium.
Investigations: Biopsy, immunofluorescent.
Treatment : Reassurance of the patient.
Corticosteroid.
Cyclosporine. Monitoring of lesion.
Corticosteroid.
Cyclosporine. Monitoring of lesion.
Uremic Stomatitis
are seen in patients whit long standing renal failure.
It explained as chemical burn resulting from increasing ammonia level in saliva.
Diagnosis:
- Positive history of renal failure.
- Soft plaques symmetrically distributed with crenate surface.
Histopathology: Irregular acanthosis with mild atrophic of epithelial cells.
Investigation: Serology (Blood Urea Nitrogen)
BUN Level in excess of 50 mg/ dl.
Treatment: Dialysis or renal transplantation.
No local treatment.
White Sponge Nevus
Also called Cannon’s disease, is a developmental anomaly, inherited as autosomal dominant trait.
It’s first noted in infancy or early childhood.
Diagnosis: Is Based on the age of the patient, family history and clinical features.
History: Positive familiar history.
Clinically: Affected mucosa is white, soft and irregular thickened.
It is usually bilateral, most often involving the buccal mucosa and tongue.
There are no defined borders.
It is asymptomatic without clinical consequence.
Histopathology: Shaggy hyperparakeratosis and intracellular edema abnormally cell membrane (basket- waves appearance) . No treatment.
It’s first noted in infancy or early childhood.
Diagnosis: Is Based on the age of the patient, family history and clinical features.
History: Positive familiar history.
Clinically: Affected mucosa is white, soft and irregular thickened.
It is usually bilateral, most often involving the buccal mucosa and tongue.
There are no defined borders.
It is asymptomatic without clinical consequence.
Histopathology: Shaggy hyperparakeratosis and intracellular edema abnormally cell membrane (basket- waves appearance) . No treatment.
Leukoplakia
Leukoplakia is defined by WHO in 1983 as “white patch which can not wiped off the mucosa or ascribed to any specific disease process”.
CLINICAL FEATURES: It has 3 main forms.
Homogeneous Leukoplakia:
Refer to localized lesion or extensive white patch that presents a consistent pattern throughout, even though the
surface of the lesion may described variously as corrugated, wrinkled or papillomatous, it is painless.
Nodular, granular or non homogeneous Leukoplakia:
Refers to a mixed red and white lesion in which small keratotic nodules are scattered over an atrophic patch of mucosa. This clinical form is the most dangerous one because of its extremity high rate of malignant transformation.
Verrucous Leukoplakia:
In Which the surface is broken up by multiple papillary projection that may also be heavily keratinized producing lesion that show some resemblance to the dorsum of the tongue.
Etiology :
Tobacco, Alcohol, Candidiasis, Electro galvanic reactions, Mechanical, and Chemical irritation, Herpes simplex virus, Papilloma viruses.
Diagnosis: Cellular or epithelial dysplasia by microscopy.
Hyperkeratosis, and chronic inflammatory cell infiltration in the corium ,but any degree of dysplasia and cellular atypia is significant of premalignant change.
Differential diagnosis:
Lichen planus is probably the most important lesion. But other white lesions of the oral mucosa should be differentiated from Leukoplakia.
TREATMENT:
1- Eliminating all possible local irritants and any identified systemic predisposing factors.
2- Administration of vit A, B complex, iron, and estrogen.
3- Topical antifungal treatment for 1- 3 weeks.
4- Follow up, is the resolution of the lesion has not occurred, biopsy is necessary.
5- Laser therapy.
6- Surgical excision and topical chemotherapy in aggressive cases.
CLINICAL FEATURES: It has 3 main forms.
Homogeneous Leukoplakia:
Refer to localized lesion or extensive white patch that presents a consistent pattern throughout, even though the
surface of the lesion may described variously as corrugated, wrinkled or papillomatous, it is painless.
Nodular, granular or non homogeneous Leukoplakia:
Refers to a mixed red and white lesion in which small keratotic nodules are scattered over an atrophic patch of mucosa. This clinical form is the most dangerous one because of its extremity high rate of malignant transformation.
Verrucous Leukoplakia:
In Which the surface is broken up by multiple papillary projection that may also be heavily keratinized producing lesion that show some resemblance to the dorsum of the tongue.
Etiology :
Tobacco, Alcohol, Candidiasis, Electro galvanic reactions, Mechanical, and Chemical irritation, Herpes simplex virus, Papilloma viruses.
Diagnosis: Cellular or epithelial dysplasia by microscopy.
Hyperkeratosis, and chronic inflammatory cell infiltration in the corium ,but any degree of dysplasia and cellular atypia is significant of premalignant change.
Differential diagnosis:
Lichen planus is probably the most important lesion. But other white lesions of the oral mucosa should be differentiated from Leukoplakia.
TREATMENT:
1- Eliminating all possible local irritants and any identified systemic predisposing factors.
2- Administration of vit A, B complex, iron, and estrogen.
3- Topical antifungal treatment for 1- 3 weeks.
4- Follow up, is the resolution of the lesion has not occurred, biopsy is necessary.
5- Laser therapy.
6- Surgical excision and topical chemotherapy in aggressive cases.
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