Differential diagnosis of Oral White Lesions DEPARTMENT OF

Differential diagnosis of Oral White Lesions DEPARTMENT OF ORAL MEDICINE & RADIOLOGY Dentistry Explorer

White lesions of the oral mucosa may be conveniently divided into two groups: 1. Those that cannot be scrapped off with tongue blade (most are keratotic) 2. Those that can be scrapped off with tongue blade (sloughing, pseudomembranous necrotic types) 3. A third type, vesiculobullous lesions, have a white or grayishwhite appearance during a stage of their presentation; such lesions have a significant white component when the blisters are intact and for few days after they rupture. Dentistry Explorer

KERATOTIC WHITE LESIONS LEUKOEDEMA LINEA ALBA BUCCALIS LEUKOPLAKIA NICOTINE STOMATITIS CIGARETTE SMOKER'S LIP LESION SMOKELESS TOBACCO LESION MIGRATORY GLOSSITIS PERIPHERAL SCAR TISSUE (NONKERATOTIC) • LICHEN PLANUS • LICHENOID REACTIONS • • • • • HAIRY LEUKOPLAKIA PAPILLOMA, VERRUCA VULGARIS, CONDYLOMA ACUMINATUM WHITE EXOPHYTIC SQUAMOUS CELL CARCINOMA VERRUCOUS CARCINOMA HYPERPLASTIC OR HYPERTROPHIC CANDIDIASIS WHITE SPONGE NEVUS SKIN GRAFTS ELECTROGALVANIC OR MERCURY CONTACT ALLERGY Dentistry Explorer

Leukoedema Ø Caused due to mastication and poor oral hygiene Ø smoking can intensify the condition Ø Commonly seen in blacks adults Ø most frequent site: buccal mucosa bilaterally also on the labial mucosa and soft palate. Ø Has folded or wrinkled pattern which become less prominent or disappears altogether when the tissue is stretched Dentistry Explorer

Ø Histopathologically, increased thickness of epithelium with marked intracellular edema(ballooning) in the prickle cell layer hyperparakerat osis Dentistry Explorer

Differential Diagnosis • Leukoplakia(do not disappear on stretching and present not only on buccal mucosa) • Cheek-biting lesion(buccal mucosa is roughened with ragged or eroded surface) • Lichen planus (Wickham’s striae present, do not disappear on stretching) • White sponge nevus(occurs in childhood) Dentistry Explorer

Linea Alba buccalis • White line on the buccal mucosa at the level of the occlusal plane extending horizontally from the commissure to the most posterior teeth. • most likely associated with pressure, frictional irritation, or sucking trauma from the facial surfaces of the teeth Dentistry Explorer

Leukoplakia q Potentially malignant lesion of oral mucosa q Generally denotes negative diagnosis based on exclusion criteria q Definitive diagnosis made when histopathologically examined Clinical Features • Mostly occur between 40 and 70 years of age • more common in men. • Frequent sites: lip vermilion, buccal mucosa, gingiva, tongue, oral floor, hard palate, lip mucosa, and soft palate. Dentistry Explorer

Four basic clinical appearances: I. Homogeneous white plaques 2. Speckled leukoplakias 3. Combination white and red patches 4. Verrucous leukoplakias Histopathology q. Epithelial dysplasia and surface hyperkeratosis q. BM is intact Dentistry Explorer

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DIFFERENTIAL DIAGNOSIS OF HOMOGENEOUS LEUKOPLAKIA • Lichen planus • Leukoedema • Cheek-biting lesion • Smokeless tobacco lesion • Hyperplastic or hypertrophic candidiasis • Hairy leukoplakia • Electrogalvanic or mercury contact allergy • Verrucous or squamous cell carcinoma • Verruca vulgaris • White sponge nevus Dentistry Explorer

Nicotine Stomatitis • • smoker's palate seen in pipe smokers Etiology: Heat from pipe smoke Site: whole mucosal surface of the hard palate Dentistry Explorer

• Classically described as having a parboiled appearance because of its many transecting fissures, dividing the white mucosal surface into small, flat-topped, nodular areas with red dot in middle of each nodule representing inflamed orifice of minor salivary gland duct Dentistry Explorer

• disappears rapidly after the habit is discontinued. • Papillary hyperplasia and nicotine stomatitis are the only entities that have a marked predilection for the palate. • The small, centrally placed dots and flat nodules of nicotine stomatitis differentiate this condition from papillary hyperplasia, which occurs under an acrylic denture Dentistry Explorer

Cigarette smoker’s lip lesion q Corresponds to the area where the patients hold the cigarette • confined to the mucosal aspect of lip and never cross the vermilion border • Usually seen in neuropsychiatric patient as their pain threshold is increased due to medication Dentistry Explorer

Smokeless Tobacco mucosal lesion • mucosal lesion corresponds to the area of placement of smokeless tobacco product • Earlier stages are white • Mild leukoedema like lesion • The lesion is regressed after discontinuation of use of tobacco Dentistry Explorer

Migratory Glossitis q. Psoriasiform mucositis of dorsum of tongue • Constant changing pattern of serpenginous white lines sorrounding the areas of smooth depailated mucosa • Changes pattern within few days • Prominent during psychological stress Dentistry Explorer

• Clinical features Ø burning sensation made worse by spicy or citrus fruits q Histopathology Ø Filiform papilla lost Ø Margin-hyperparakeratosis, acanthosis Ø Central area-desquamated parakeratin Ø Thin and elongated rete ridges Dentistry Explorer

• Differential diagnosis Ø Psoriasis(silvery white scales, also present in skin) Ø Lichenoid reaction(liquefactive degeneration of basal cells) Ø Reiter’s Syndrome(rete ridges are not elongated) Dentistry Explorer

Peripheral Scar lesion q. Nonkeratotic lesion involves subepithelium, epithelium or both • Healing of surgical wounds, large traumatic ulcers and giant apthae in Sutton’s disease produce scarring. • Is not as white as other white lesion • Proper history is useful in differentiating scar lesion from other white lesion Dentistry Explorer

Lichen Planus • Complex mucocutaneous disease • May be due to an immunologic disturbance • Associated with Grinspan’s Syndrome(triad of DM, vascular HTN and Lichen Planus) • OLP has wax and wane ability Dentistry Explorer

Clinical features • About 50% of people with cutaneous LP have oral involvement as well • Age: 30 to 60 years • Sex: F>M(1. 4: 1) • Site: buccal mucosa(most common), vestibule, tongue, lip and gingiva • Seldom solitary and frequently bilateral Dentistry Explorer

Histopathology Hyper para/orthokeratosis Saw toothed rete ridges Acanthosis Basal layer vacuolization Lymphocytic infiltration between Epithelium and connective tissue interface • Apoptotic keratinocytes(colloid/civatte/hyaline bodies) • Max joshep spaces • • • Dentistry Explorer

Differential Diagnosis • Leukoplakia • Cheek biting lesion • Lichenoid drug reaction • Lichenoid reaction • Candidiasis Dentistry Explorer

Lichenoid Reaction q Observed in habitual betel quid chewers q Consist of white, wavy, parallel and non elevated striae that do not crisscross q Seen on buccal mucosa and mandibular groove(area of intimate contact with betel quid) Dentistry Explorer

Lichen Planus Lichenoid Reaction Smaller lesion Bilateral involvement Wickham’s striae present Seen in flexor and extremities Mucous membrane involvement more • Alopecia uncommon • • • Larger lesion Unilateral Wickham’s striae absent Seen in sun exposed area like trunk • Mucous membrane involvement less • Alopecia common Dentistry Explorer

Electrogalvanic and Mercury contact Allergy • Occur on attached gingiva and adjacent mucosa by contact of two dissimilar metal restoration or due to amalgam restoration • disappear either after dissimilarity of metal is corrected or after that tooth is extracted Dentistry Explorer

Hairy Leukoplakia • Patch on side of tongue with corrugated or white appearance • Caused by EBV • Occurs in immunocompromised person especially with HIV Dentistry Explorer

Papilloma, verruca vulgaris and condyloma acuminatum • Oral papilloma, verruca vulgaris(common wart) and condyloma acuminatum are similar exophytic lesion • They appear white if surface keratin is thick enough • Otherwise they appear pink exophytic mass Dentistry Explorer

White exophytic SCC • Firm nodular lesion • Surface is rough, pebbled and in some cases may be multicolored or partly ulcerated • Usually in lateral border of tongue Dentistry Explorer

• Differential diagnosis Ø Large papilloma and condyloma acuminatum (surface pattern is quite uniform, multiple, softer in palpation than SCC) Ø Pyogenic granuloma (softer in palpation, bleeds easily, overall contour is smooth) Ø Verruca vulgaris (uncommon oral lesion, small size, horny appearance) Ø Verrucous carcinoma (not common, flat wide based lesion, uniform surface pebbling) Dentistry Explorer

Verrucous carcinoma • Slow growing, superficial, low grade carcinoma of oral cavity and upper aerodigestive tract • Usually occurs in person who smoke or use snuff or chew tobacco • Clinical Features • occurs in elderly patient • the surface is rough, pebbly, and warty with deep crevices Dentistry Explorer

characteristically show a rim of slightly elevated normal mucosa where the tumor has pushed under the edge of the normal tissue and has undermined it slightly. Dentistry Explorer

Histopathology Ø Marked epithelial proliferation with downward growth of epithelium without pattern of true invasion Ø Bulbous rete ridges Ø Parakeratin plugging into epithelium(hallmark) Ø BM intact Dentistry Explorer

White sponge nevus • White sponge nevus is a hereditary condition • white lesions occur on various mucous membranes of the body • has an autosomal dominant inheritance pattern, • may be present at birth or may begin or become more intense at puberty. Dentistry Explorer

q Symmetrical, thickened, white, corrugated or velvety, diffuse plaques affecting the buccal mucosa mostly Microscopically • Marked intracellular edema occurs throughout the prickle cell layer. Dentistry Explorer

• Differential diagnosis • Cheek chewing lesion(rough buccal mucosa) • Leukoedema(disappear on stretching) • Leukoplakia • LP(wickham’s striae present, bilateral) Dentistry Explorer

Skin Grafts q may be misdiagnosed as leukoplakic lesions • This is especially true with white patients because the skin graft appears white and, after some months, its borders may become vague • Careful history helps to identify skin grafts. Dentistry Explorer

White Sponge Nevus • Occurs soon after birth or at least by puberty • Widely distributed over oral mucous membrane • Shows familial pattern • Intracellular edema in prickle cell layer Leukoplakia • Seen in patients mostly above 40 years of age • Not disseminated throughout the oral cavity • No familial pattern • No edema Dentistry Explorer

Verruca vulgaris Verrucous Leukoplakia • Small, raised, white lesion seldom more than 0. 5 cm in diameter • Larger lesion usually circumscribed by border of inflamed mucosa • Chronic trauma to the area favour this diagnosis • Area of chronic trauma is not seen Dentistry Explorer

Electrogalvanic or mercury contact allergy • Keratotic plaquelike lesion on gingiva, tongue or buccal mucosa adjacent to tooth restored. • Disappears after metals are replaced or teeth are extracted Leukoplakia • Not due to dissimilar metal restoration or amalgam restoration • Do not disappear even after removal of metal or tooth extraction Dentistry Explorer

• Hairy leukoplakia is differentiated from other lesion by Biopsy of lesion and microscopic study showing keratin hairs and EBV. • Seen in patient with immunodeficiency(HIV) usually on lateral border of tongue and has corrugated appearance Dentistry Explorer

Lichen Planus Leukoplakia • Wickham’s striae present • Borders of LP lesions are often feathered shows reticular or annular pattern • Mostly affect female • Chronic irritant is present • Absent • No such borders are seen • Mostly affects male Dentistry Explorer

SLOUGHING, PSEUDOMEMBRANOUS NECROTIC WHITE LESIONS qin contrast to the keratotic lesions, these lesions may be scrapped off the mucosa with a tongue blade, leaving a raw, bleeding surface. • The white material may be a necrotic or coagulated surface epithelium or a mixture of necrotic epithelium, plasma proteins, blood cells, and microorganisms Dentistry Explorer

SLOUGHING, PSEUDOMEMBRANOUS, NECROTIC WHITE LESIONS • PLAQUE • TRAUMATIC ULCER • PYOGENIC GRANULOMA • CHEMICAL BURNS • ACUTE NECROTIZING ULCERATIVE GINGIVITIS • CANDIDIASIS • NECROTIC ULCERS OF SYSTEMIC DISEASE • DIFFUSE GANGRENOUS STOMATITIS Dentistry Explorer

Plaque • Plaque, or materia alba may be mistaken for a lesion • In some mouths with poor hygiene a mixture of food debris and bacteria may be seen as white plaques on the gingivae, alveolar mucosa, and teeth Dentistry Explorer

Traumatic ulcer • Oral mucosa that has been crushed by mechanical trauma appears as a sloughing white lesion on the gingivae or other oral sites • A history of such a traumatic event is diagnostic • If the severity of a traumatic lesion seems to be out of proportion to the intensity of the precipitating trauma, underlying systemic disease should be suspected Dentistry Explorer

Chemical burns • Results from patient applying analgesics, such as aspirin or acetaminophen to the mucosa adjacent to the aching tooth • Addicts applying drugs such as cocaine in oral mucosa also have these lesions • Chronic mild burns usually produce keratotic white lesions which can be scrapped leaving bleeding surface Dentistry Explorer

Pseudomembranous Candidiasis • Called as oral thrush • Characterised by presence of adherent white plaques which resemble cottage cheese or curdled milk on mucosa • Whitish plaques contain tangled mass of hyphae, yeast, desquamated epithelial cells and debris • Can be removed with tongue blade, rubbing with dry gauze piece Dentistry Explorer

Acute Necrotizing Ulcerative Gingivitis • Vincent's infection, trench mouth • moderately uncommon, infectious, necrotic, and ulcerative disorder of gingivae • Can occur at any age but majority in 17 to 35 years of age • Often in whites • Stress and poor oral hygiene major factor • Patients complains of tenderness, discomfort, increasingly intense pain in gingiva, fever, fetid odor, bad taste Dentistry Explorer

• Ulcerative and necrotic process commences at the tip of papilla and expands around gingival crest • Ulcerative lesion is covered by necrotic grayish white pseudomembrane • Punched out defect of interdental papilla Dentistry Explorer

Necrotic ulcers in systemic disease • may occur in debilitating systemic diseases such as leukemia, sickle cell anemia, and uremia. • The ulcers are usually deep craters with a white necrotic surface • commence as small mucosal injuries that become chronically infected because of the decreased resistance of the patient Dentistry Explorer

Diffuse Gangrenous Stomatitis • pseudomembrane is formed • occurs in extremely debilitated patients • must be differentiated from localized gangrenous stomatitis (cancrum oris or noma), a single localized and very destructive lesion Dentistry Explorer

Clinical Features • found in patients with severe debilitating diseases, such as advanced diabetes, uremia, leukemia, malnutritional states, or heavy metal poisoning. • painful oral lesions and a very unpleasant odor. • multiple, affecting several mucosal surfaces, and are surrounded by a thin, inflamed margin. • The lesions are covered by a dirty gray to yellow pseudomembrane that can be readily removed leaving raw, bleeding, painful surface. Dentistry Explorer

Summary • Lesions that cant be scrapped off • Leukoedema: primarily in blacks; milky white alteration of buccal mucosa bilaterally; disappears when stretched • Linea Alba: Buccal mucosa along the occlusal plane • Leukoplakia: epithelial dysplasia, benign hyperkeratosis • Nicotine Stomatitis: flat and fissured white nodules in palate with red dot in pipe smokers • Migratory Glossitis: wandering rash of tongue • Lichen Planus: Wickham’s striae; typically bilateral on buccal mucosa, seldom solitary Dentistry Explorer

• Hairy Leukoplakia: usually lateral border of tongue: rough with vertical fissures: usually associated with HIV infection • Hyperplastic candidiasis: mostly affects anterior buccal mucosa • Lupus Erythematous: most common in buccal mucosa; associated skin lesion usually present • Skin Graft: History of previous surgery • White sponge nevus: hereditary; onset in childhood; generalised lesion; especially buccal mucosa Dentistry Explorer

• Lesions that can be scrapped • Plaque: mostly seen around teeth • Pseudomembranous Candidiasis: Milk curd or cottage cheese appearance; may leave red base when rubbed off • Traumatic Ulcer: history of trauma is present • Chemical burn: e. g aspirin burn secondary to direct application for toothache • ANUG: uncommon necrotic ulcerative lesion of gingiva; painful; fetid odor Dentistry Explorer

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