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RECOGNIZING WHITE LESIONS PART I: Reactive, Idiopathic, Hereditary David E. Wojtowicz, DDS, MBA 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? 3 Mechanisms to Achieve White Appearance Epithelial Thickening – Rough / Does NOT Rub Off Surface Material – Rough / Does Rub Off Subepithelial Change – Smooth / Does NOT Rub Off Six Common Etiologies for White Lesions Reactive (Snuff) Idiopathic (Hairy Tongue) Hereditary (Leukoedema) Auto-Immune (Lichen Planus) Infectious (Candidiasis) Neoplastic (SCC) 1. Six Reactive White Hyperkeratotic Lesions (These are HYPERKERATOTIC. They Do NOT Rub Off.) a. Snuff Dipper’s Lesion b. Nicotinic Stomatitis c. Chemical Burn d. Linea Alba e. Actinic Cheilitis f. Denture Acanthosis 1. Six Reactive White Hyperkeratotic Lesions (Do They Rub Off?) a. Snuff Dipper’s Lesion Wrinkled, Velvety US & Canada, Lower Carcinogenic Rate Asia Higher Rate Due to Added Carcinogens Treatment = Quit Habit, Switch Site 1. Six Reactive White Lesions b. Nicotinic Stomatitis Grey, White and Red on Hard Palate Pipe and Tobacco Smoking (Heat) Red Spots, Inflamed Minor Salivary Gland Orifices Treatment = Quit Smoking 1. Six Reactive White Hyperkeratotic Lesions c. Chemical Burn Caused by Aspirin Painful Usually in Molar Region Treatment = Discontinue Aspirin Use 1. Six Reactive White Hyperkeratotic Lesions d. Linea Alba Most Common White Lesion White Line @ Occlusal Plane Bilateral on the Buccal Mucosa No Treatment Needed 1. Six Reactive White Hyperkeratotic Lesions e. Actinic Cheilitis Sun Damage Lower Lip Obliteration of Border Treatment = Avoid Sun, Use Sunblock 1. Six Reactive White Hyperkeratotic Lesions f. 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 2. Two Idiopathic White Hyperkeratotic Lesions Geographic Tongue Hairy Tongue 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 Hairy Tongue Shaggy Matte of Filliform Papillae Candidiasis Stimulates the Hyperplasia Coffee, Tea, Tobacco = Black Treatment = Brush Tongue, Improve Oral Hygiene 3. Two Hereditary White Hyperkeratotic Lesions Leukoedema White Sponge Nevus Leukoedema Milky Grey Film Bilateral Buccal Mucosa, Non-progressive Disappears When Stretched More Common in Black Population Treatment = None Needed White Sponge Nevus Rough, Fissured Texture Symetric, Bilateral Buccal Mucosa Appears During Childhood, Nonprogressive Autosomal Dominant Transmission RECOGNIZING WHITE LESIONS II: Auto-Immune, Infectious, Neoplastic David E. Wojtowicz, DDS, MBA 4. Two Auto-Immune White Hyperkeratotic Lesions Lichen Planus Lupus Erythematosus Lichen Planus Auto-immune Degeneration of Connective Tissue / Mucosa (Skin) Interface Middle Age (Rare Before 30) M = F, Skin Lesions (33%) Lichen Planus Reticular (Wickham’s Striae) Annular Erosive Atrophic, Bullous Lichen Planus Stress & Thiazide Drugs are Possible Triggers Differential: Snuff (Stretch) White Sponge (Youth) Treatment = None if Asymptomatic . . . Erosive Lichen Planus Painful Risk Factor for SCC Treatment = Biopsy, Steroids, Retinoic Acid Lupus Erythematosus Skin Lesions: Butterfly Rash (Sun Exposed Area) Mucosal Lesions: Rough White Patch Bordered by Striae, Ulcers, Erythema Lupus Erythematosus Systemic: Arthritis, Vasculitis (Renal Failure) Antinuclear Antibodies (ANA) Differential: Lichen Planus (Symmetrical & Cutaneous), Leukoedema (Stretch) White Sponge (Youth) Treatment = Corticosteroids 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) 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) 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 Candidiasis: Acute Pseudomembraneous White, Scrapes Off Underlying Tissue: Erythematous, Hemorrhagic, Pruritic Newborns & RF (See Previous Item) Treatment = a. Correct the Predisposing Factor b. Prescribe: Nystatin Vaginal Tablets – Disp: 70 – Use: One Tablet as a Lozenge 5 Times a Day 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 Candidiasis: Chronic Hyperplastic -Candidal Leukoplakia Cancer Risk: Biopsy is Mandatory of All Speckled Erythroplakia or Erythroleukoplakia Because of Increased SCC Risk Treatment = a. Correct the Predisposing Factor b. Biopsy Lesion c. Prescribe: Nystatin Vaginal Tablets – Disp: 70 – Use: One Tablet as a Lozenge 5 Times a Day Candidiasis: Three Red Chronic Oral Lesions Angular Cheilitis = Perleche (Red) Median Rhomboid Glossitis (Red) Denture Sore Mouth = Atrophic Candidiasis (Red) 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 Syphilitic Mucous Patch Painless, White, Mucosal Ulcers With . . . Nonpruritic Skin Rash, Lymphadenopathy Signs of Secondary Syphilis (T. pallidum) 6. Four Neoplastic White Lesions Squamous Cell Carcinoma Verrucous Carcinoma Epithelial Dysplasia Carcinoma in Situ Squamous Cell Carcinoma (SCC) 90% of All Oral Malignancies = SCC Mixed Red & White is Most Likely Presentation Age: Elderly (40+) Gender: Males (2:1) Location: Lower Lip, Floor of Mouth, Lateral & Ventral Tongue, Soft Palate Squamous Cell Carcinoma (SCC) Uncontrolled Growth “Up Regulation” of Oncogenes – Kinases & Cyclines Become Overactive Deactivation of Suppresser Genes (Antioncogenes) Verrucous Carcinoma Hyperkeratotic, Exophytic, Papillary Age: Elderly (60+) Gender: Males (2:1) Location: Gingiva, Alveolar Ridge, Buccal Mucosa Epithelial Dysplasia Premalignanat Changes of Cell & Architecture Mixed Red & White is Most Likely Presentation Cell Alterations: Nuclear Changes Architecture Alterations: Bulbous Rete Pegs Carcinoma in Situ (CIS) Entire Thickness (Top to Bottom Change) Basement Membrane Intact No Invasion or Change of Connective Tissue Geriatrics Proliferative Verrucous Leukoplakia (PVL) – Hyperkeratotic Lesions Mixed Smooth and Warty – Mainly on Edentulous Alveoloar Ridge Cancer Risk: May Progress to SCC or VC 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) 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 Clues to Normal Bilateral Symmetry Predictable Locations Asymptomatic Independent Finding (no Secondary Features such as redness, swelling) Increase with Age Remains Unchanged w/ Treatment 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 Review: Which of the Following Choices Demonstrate Concepts of Differential Diagnosis: a List of Diseases With Similar Manifestations (Yes) b Oral Ulcer (No, monomorphic presentation) c Zinc Deficiency, Trauma, Herpes, Aphthous Lesion as Potential Etiologies for a Single Monomorphic Presentation. (Yes) d Rely Primarily on the Clinical Appearance (No, must include history, risk factors, visual inspection) List the Seven Primary Clinical Manifestations of Non-dental Lesions – – – – – – – Normal Variation White Red (Pigmented or Dark) Ulceration Exophytic Radiographic Syndrome •List Four Techniques Employed to Investigate the Secondary Clinical Features of Oral Lesions: Visual Inspection Palpation Probing Patient Awareness 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?) During Palpation One Can Check For: Compressible Tender Color Change (Blanching) Mobile / Bound Down Induration Probing, Exudate During the Interview, Inquire if Patient is Aware of: Pain or Altered Function Duration (Acute, Chronic) Progressive Course or Remission Response to Stress/ Foods 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) Differential Diagnosis List of Diseases With Similar Manifestations Rule Out (R/O) on the Basis of Contradictions Example: Oral Ulcer