Download DENTAL ASPECTS OF MULTIPLE MYELOMA

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