White Lesions of oral cavity

Presented by :

Sushant Pandey

653

Resource faculty :

Dr. ashish Shrestha

Dr. Shashi Keshwar

Dept. of oral pathology

Objectives :

• To know about common white lesions of oral cavity

• To differentiate them clinically

Colour of oral mucosa depends on

Amount and dilatation of blood vessels in the underlying connective tissue

Degree of keratinisation

Amount of melanin pigment in epithelium

Thickness of epithelium

Presence of keratin in a normally nonkeratinized site.

Hyperparakeratosis or hyperorthokeratosis in a normally keratinized site.

Abnormal keratin formation or aggregation in epithelial cells.

Acanthosis.

Intra and extracellular accumulation of fluid in the epithelium.

Nonepithelial changes such as underlying scarring and fibrosis.

Microbes, particularly fungi, produce whitish pseudomembranes.

Why abnormally white?

Leukoedema

Leukoedema is a generalized mild opacification of the buccal mucosa that is regarded as a variation of normal.

Etiology : Unknown

More common in black population.

Clinical features :Characterized by diffuse, gray white, milky appearance of mucosa.The surface appears folded, resulting in wrinkles or whitish streaks.Typically occurs bilaterally on the buccal mucosa.Asymptomatic.Disappears when cheek is stretched.

White sponge nevus (Cannon disease)

Etiology = point mutations for genes coding for keratin 4 and keratin 13 which leads to defective keratinization of the normal oral mucosa.

Clinical features :Usually appear at birth or in early childhood.Symmetrical, thickened, white, corrugated or velvety, diffuse plaques affect the buccalmucosa bilaterally.May affect ventral tongue, labial mucosa, soft palate, alveolar mucosa, and floor of the mouth as well as extra-oral mucosa.Does not disappear when cheek is stretched.Asymptomatic.

Hereditary benign intraepithelial dyskeratosis

Frictional hyperkeratosis

related to chronic rubbing or friction against an oral mucosal surface.

occur in areas that are commonly traumatized, such as the lips, lateral margins of the tongue, buccal mucosa along the occlusal line, and edentulous alveolar ridges

Edentulous ridges and vestibules may be affected in denture wearers.

Morsicatio Mucosae Oris (chronic mucosal chewing)

Morsicatio = Bite

located most frequently on thebuccal mucosa = morsicatio buccarumlabial mucosa = morsicatio labiorumlateral border of the tongue = morsicatio linguarum

A higher prevalence of classic morsicatio mucosae oris has been found in people who are under stress or who exhibit psychologic conditions.

Thickened, shredded, white areas may be combined with intervening zones of erythema, erosion, or focal traumatic ulceration.

Smokeless tobacco keratosis (snuff pouch, tobacco pouch keratosis)

represents a characteristic white or gray plaque involving the mucosa in direct contact chewing tobacco

The mucosa appears fissured or rippled.

Nicotine Stomatitis (Smoker’s Palate)

develops in response to heat rather than the chemicals.

“reverse smoking” habit produces a pronounced palatal keratosis.

With long-term exposure to heat, the palatal mucosa becomes diffusely gray or white; numerous slightly elevated papules are noted, usually with punctate red centers. Such papules represent inflamed minor salivary glands and their ductal orifices.

Leukoplakia

“a white patch or plaque that cannot be characterized clinically or pathologically as any other disease”Non-scrapable.Always associated with a habit.Premalignant lesion.

Etiology :TobaccoAlcoholSanguinariaCandida HPV 16 and 18

Forms of leukoplakia

1) Homogeneous

2) Non homogenous

Proliferative Verrucous Leukoplakia

1. Squamous papilloma2. Verruca vulgaris3. Verrucous carcinoma4. SCC

Some white exophytic growths

Etiology – EBV

Presents as white mucosal plaque that do not rub off.

Most commonly occur on lateral border of tongue.

Sign of severe immunosuppression.

Histology : Balloon cells

Hairy leukoplakia

Characterized by marked accumulation of keratin on filiform, resulting in a hair like appearance.

Commonly affects midline just anterior to circumvallate papillae.

The papillae may become brown, black due to growth of pigment producing bacteria or staining from food.

Hairy tongue

Candidiasis

Oral Submucous Fibrosis

Oral Lichen Planus

Chemical Injuries Of The Oral Mucosa

Bilateral lesions Unilateral lesions

LeukoedemaWhite sponge nevusHBIDLichen PlanusCheek chewingCandidiasis

Frictional keratosisBurnHairy leukoplakiaLeukoplakia

Photo Quiz !!

10/M presented with bilateral folded velvety white buccal mucosal changes.How will you approach this case ?

28/M IV drug user, presented with unscrapable white plaques on lateral border of tongue since 6 months.

Most likely diagnosis ??

55/M presented with white, lacy, plaques over the anterior buccal mucosa bilaterally but could not recall since when. No ulcerations were present. Earlier he was prescribed Fluconazoleby a clinician but the lesion didn’t resolve.

Most likely diagnosis ??

60/F who was given Amoxycillin+Clavulanate for dental abscess after drainage, presented with white plaques on soft palate after 2 weeks. The plaques were easily scrapable with a dry gauze.

Likely diagnosis ??

70/M who had been wearing complete denture since 3 months developed bilateral unscrapable white plaque on the mandibular alveolar ridge.

DD ??

Identify the lesion

References :

1. Neville, Damm, Allen Oral and Maxillofacial pathology

2. Regezi, Sciubba Oral pathology clinical pathologic correlation

3. Wood, Goaz Differential diagnosis of oral and maxillofacial lesions

Thank you

You are awesome !!

Questions ??