White lesions

White lesions
Classification (aetiological):
1. hereditary
2. traumatic
3. infective
4. idiopathic - leukoplakia
5. dermatological - lichen planus
- lupus erythematosus
6. neoplastic - carcinoma in-situ
- squamous cell carcinoma
 White lesions
Classification (aetiological):
1. hereditary - leukoedema
- white sponge naevus
- hereditary benign intraepithelial
dyskeratosis
- follicular keratosis (Darier’s
disease)
 White lesions
Classification (aetiological):
1. hereditary
2. traumatic - frictional keratosis
- chemical
- thermal
3. infective - candidosis
- syphilitic leukoplakia
- hairy leukoplakia
 White lesions
Classification (aetiological):
1. hereditary
2. traumatic
3. infective
4. idiopathic - leukoplakia
5. dermatological - lichen planus
- lupus erythematosus
6. neoplastic - carcinoma in-situ
- squamous cell carcinoma
IDIOPATHIC LEUCOPLAKIA
 IDIOPATHIC LEUCOPLAKIA

- relatively rare disease - estimated prevalence of less than

1%;
- men and women are more or less equally affected;
- rarely occurs in the first two decades of life and is much
more common in tobacco users than in non-tobacco users;
- may occur everywhere in the oral cavity and is often
asymptomatic otherwise
 IDIOPATHIC LEUCOPLAKIA
LEUCOPLAKIA
► firmly attached, predominantly white patch or plaque of the oral mucos;
► which cannot be wiped off;
► cannot be characterized clinically or pathologically as any other disease;
► and is not associated with any
physical or chemical agent except
the use of tobacco.
IDIOPATHIC LEUCOPLAKIA
IDIOPATHIC LEUCOPLAKIA
Classification

homogenous leukoplakia
non-homogenous leukoplakia
erythroleukoplakia
nodular leukoplakia
verrucous leukoplakia
 LEUCOPLAKIA – CLINICAL FEATURES
patch or plaque, white or predominantly
white,
tough and adherent, with
slightly raised surface above the surrounding
mucosa
most frequently at the
posterior buccal mucosa,
retromolar region,
floor of mouth and
tongue. May occur everywhere in the oral
cavity!
Homogenous leukoplakia :
- the lesion is uniformly white and the surface is flat or
slightly wrinkled
-Homogeneous plaques are
predominantly white, of
uniform flat, thin appearance
with shallow cracks of
surface keratin, and have a
smooth, wrinkled, or
corrugated surface with a
consistent texture throughout.
Non-homogeneous leukoplakia

1. Erythroleukoplakia : there is a mixed white-and-red color;

the surface may be flat, speckled or nodular.
 1. Erythroleukoplakia - mixed, white and red
(erythroleukoplakia), but retaining predominantly white
character;
1. Erythroleukoplakia

Increased risk of
malignant
transformation !
2. Nodularleukoplakia:small polypoid outgrowths, rounded red
or white excrescences;
2. Nodular leukoplakia
3. Verrucous leukoplakia - wrinkled or corrugated
surface appearance.
 Proliferative verrucous leukoplakia - is a subtype of verrucous
leukoplakia
- involves multiple mucosal areas (multifocal) with confuent, exophytic and
proliferative features.
- is characterised by:
- an aggressive evolution,
- resistance to treatment, and
- high rate of malignant
transformation.
 Leukoplakia - Symptoms

Homogenous leukoplakia:
usually asymptomatic;

Non-homogenous leukoplakia :
pain or itching may occur
 Leukoplakia - diagnosis
clinical examination;
histopatological findings:
As a general rule each leukoplakia should be
biopsied irrespective of the presence or absence
of symptoms, the clinical subtype (homogeneous
or non-homogeneous), the seize and the oral
subsite.
In extensive leukoplakias the taking of multiple
biopsies (“mapping”) may be considered.
 Leukoplakia - differential diagnosis
Lichen planus
- sometimes associated with cutaneous lesions and mucosal lesions outside the oral cavity (only
oral lesions);
- almost always bilateral presentation (usually asymmetrical);
- several clinical subtypes of lichen planus may occur
simultaneously
- usually reticular lesions (white plaques); the erosive
erythematous type and the plaque type may morphologi-
cally be indistinguishable from leukoplakia;
- heavy use of tobacco is in favor of a diagnosis of
leukoplakia!
 Leukoplakia - differential diagnosis

Leukoedema
- veil-like aspect of the buccal mucosa,
- bilaterally (usually white plaques, shallow cracks, unilaterally) ;
- disappear when stretched (no);
- occurs almost exclusively in
middle-aged, dark-skinned people
 Leukoplakia - differential diagnosis
Lupus erythematosus
- almost always cutaneous involvement as well;
- bilaterally (usually unilaterally);
- erythematous plaques, erosions, or ulcers with radiating delicate white striae
(usually white plaques, shallow cracks )
 Leukoplakia - differential diagnosis

Candidiasis, hyperplastic
- some refer to this lesion as candida-associated leukoplakia;
- mainly located in the commissurers and the dorsum
and the lateral borders of the tongue;
- some use the results of antifungal treatment for
establishing the diagnosis;
- otherwise clinically
indistinguishable from leukoplakia!
 Leukoplakia - differential diagnosis

Candidiasis, pseudomembranous
- can be easily wipped off
 Leukoplakia - differential diagnosis

Morsicatio
- history of habitual chewing or biting;
- clinical aspect of irregular whitish-
yellowish flakes, often bilateral
 Leukoplakia – Risk of malignant transformation
No aetiologic factors – idiopathic leukoplakia (patients who do
not smoke and are over 60 years of age)
Location in high-risk sites for development of oral carcinoma-
floor of the mouth, lateral borders of the tongue, soft palate and
retromolar areas
Speckled leukoplakias and Long duration of leukoplakia
Presence of epithelial dysplasia
(histopathologically confirmed
epithelial dysplasia)
Female gender
 Leukoplakia - Management
• Low risk leukoplakia:
• The main aim of oral leukoplakia • lesions having no dysplastic features or
management is to avoid malignant having mild dysplasia associated with
transformation. following features: site not in high risk
• Proper clinical examination should be area; homogenous clinical form
done and type, size and location of • High risk leukoplakia:
lesion should be recorded
• lesions shows dysplasia associated with
• A consideration of leukoplakia risk following features: site in high risk area;
potential (low risk leukoplakia and high non homogenous clinical form
risk leukoplakia) should be done.
 Leukoplakia – Management
• Low risk leukoplakia
• habit cessation
1. if there is regression in size of leukoplakia after 2-3 weeks of habit
cessation, than follow up is done initially every three months
followed by every 6-12 months
2. if there is not regressing in size biopsy is mandatory
a. no signs of dysplasia - conservative treatment
b. mild, moderate or severe dysplasia - both conservative and
surgical treatment
 Leukoplakia – Management
• High risk leukoplakia
• habit cesation
• after 2-3 weeks of habit cessation, biopsy is
mandatory
a. no signs of dysplasia - conservative treatment
b.mild, moderate or severe dysplasia - both conservative
and surgical treatment
 Leukoplakia – Management
a. no signs of dysplasia - conservative treatment
b. mild, moderate or severe dysplasia - both conservative and surgical
treatment
- low to moderate malignant risk may be either completely removed or
not, and the decision should consider other factors such as location, size and,
in the case of smokers, the patient’s engagement in smoking cessation.
- moderate or severe epithelial dysplasia, surgical treatment is
recommended.
 Leukoplakia – Management
Treatment options:
- elimination of risk factors (tobacco abuse, betel chewing, alcohol abuse, superimposed
candida infection over the lesion etc.);
- conservative treatment includes - use of chemopreventive agents: vitamins (vitamins A,
C, E), fenretinide (Vitamin A analogue), carotenoids (beta-carotene, lycopene), bleomycin,
protease inhibitor, anti-inflammatory drugs, green tea, curcuma etc.
- photodynamic therapy
- follow-up - in case of no improvement, treatment should become more invasive
- surgical treatment (should be the method of choice in OL with histologically diagnosed
epithelial dysplasia) - conventional surgery, electrocoagulation, cryosurgery, and laser
surgery (excision or evaporation).
LICHEN PLANUS
 Lichen planus

Lichen planus:
the typical age of
presentation is between
30-60 years;
more frequently seen
in women.
 Lichen planus
Lichen planus:
chronic inflammatory disease;
etiology - is not known clearly, but
at present it has been linked to
autoimmune disorder (is a type IV
hypersensitivity reaction )
characteristic cutaneous ± mucous
(oral, vulvovaginal, esophageal,
laryngeal, conjunctival) lesions;
 Lichen planus
• oral lichen planus (OLP) presents in a wide range of clinical forms
• six clinical forms of OLP have been described
• white forms:
• reticular,
• papular,
• plaque-like and
• red forms:
• erosive (ulcerated),
• atrophic (erythematous) and
• bullous.
 • reticular type lichen planus–on the
Lichen planus lips and mucosa of the cheek
• present as fine white striae, Wickham’s
striae.
Lichen planus

• Papular type lichen

planus
Lichen planus
Plaque type lichen planus
Lichen planus Lichen planus

• Erosive type lichen planus–

ulcerated lesion in the buccal
mucosa with erythematous
borders
Lichen planus

Atrophic type lichen planus

–sometimes representing as
desquamative gingivitis
Lichen planus

Bullous type lichen

planus–lesion on upper
buccal mucosa
• the clinical presentation is usually Lichen planus
bilateral, more or less symmetrical,
• located at buccal mucosa, tongue, lips
and gingiva.
• the reticular, erosive, papular and
plaque-type are the most common
ones;
• the atrophic and bullous types are rare.
• clinical types of OLP may occur alone
or in various combinations;
• lesions persist for many years with
perios of exacerbation and quiescence.
 Lichen planus
• the cutaneous lesions of LP are
characterized by 5 ps: purple,
polygonal, pruritic papules and plaque

• can occur anywhere on the skin surface

(often on the flexor surfaces of limbs,
inner aspects of knees and thighs and
trunk and also may appear on lines of
trauma, reflecting the Köbner
phenomenon.
 Lichen planus

• may appear on lines of

trauma, reflecting the Köbner
phenomenon.
 Lichen planus
• Some patients report
• genital involvement with
features similar to skin lesions;
• scalp involvement (lichen
planopilaris), and
• nail beds.
• laryngeal, esophageal and
conjunctival involvement.
 Lichen planus / oral lichenoid lesions
• Lichen planus (LP) is idiopathic • Oral lichenoid lesions (OLL) may be caused by
• drugs,
• exogenous agents:
• food,
• flavorings,
• dental restorative materials,
• allogeneic bone marrow, or
• systemic disease (chronic liver disease,
hypertension, diabetes mellitus).
Oral lichenoid lesions are similar clinically and histopathological to those of
OLP, but have identifiable etiology.
 Oral lichenoid lesions
• white plaques or erythema, uni- or bilateral,
• topographic in relationship - adjacent or in Oral lichenoid
direct contact - to dental restoration or lesions at flavoring
agents
flavoring agents, and
• the onset of lesions is correlated with the
restorative treatment or use of trigger
(flavoring agent);
• after removal of the restoration, or
identification and discontinuation of the
offending agent lesions generally resolve.
• lesions are located more often on the lateral
border of the tongue and / or buccal mucosa.
 Oral lichenoid lesions
• white plaques or erythema, uni- or bilateral,
• topographic in relationship - adjacent or in
direct contact - to dental restoration or
flavoring agents, and
• the onset of lesions is correlated with the
restorative treatment or use of trigger
(flavoring agent);
• after removal of the restoration, or
identification and discontinuation of the
offending agent lesions generally resolve.
• lesions are located more often on the lateral
border of the tongue and / or buccal mucosa. Oral lichenoid lesions at dental restoration (amalgam
filling)
 Lichen planus
• Symptoms:
• striae alone may be
asymptomatic, or cause
roughness of the mocusa;

• atrofic lesions are sore;

• erosive lesions usually cause
more severe symptoms
 Lichen planus
• Complications: • Diagnosis of OLP is established by:
• clinical examination
• Candidiasis infection
• with histopathologic confirmation.
(because of corticosteroids
Direct immunofluorescence examination is
used in treatment) used as an adjunct to the above method of
• Malignant transformation diagnosis and to rule out specific autoimmune
diseases such as pemphigus and pemphigoid.
• Ulcerative lesions
• Smokers, alcohol consumers
• lesions to more than 5 years old
 Differential diagnosis
• Oral lichenoid lesions
• clinical history: dental restorations, habits of using
cinnamon- containing foods or oral hygiene products
• Oral lichen planus (toothpaste, mouthwashes), drug therapy, systemic or
• clinical history: violent topical application, systemic diseases (especially
hepatitis C, hepatitis B, and / or other liver diseases), etc.
emotions
• there is a temporal relationship between above
mentioned elements from clinical history and the onset of
oral lesions
• clinical presentation: atypical sites for OLP such as the
palate, unilaterality, erosion;
• histopathologic evaluation
• therapeutic probation: resolution of the lesions after
trigger identification and elimination (in months or even
longer).
 Treatment
• There is currently no cure for OLP !
• Excellent oral hygiene is believed to
reduce the severity of the symptoms.
• Asymptomatic reticular and plaque
forms of OLP do not require
pharmacologic intervention.
• In symptomatic lesions treatment is
aimed primarily at reducing the length
and severity of symptomatic outbreaks.
• mild to moderately symptomatic lesions
- topical corticosteroids (0.05%
clobetasol propionate gel,26 0.1% or
0.05% betamethasone valerate gel,6
0.05% fluocinonide gel, etc.) up to 3
times a day, after meals and at bedtime,
applied directly or mixed with equal
parts Orabase to facilitate adhesion to
the gingival tissues
 Treatment
• in patients with widespread • if lesions are recalcitrant to topical
symptomatic lesions - aqueous steroid management - systemic steroid
triamcinolone acetonide or therapy
dexamethasone elixir for gargle after • OLL - identification and elimination
meals; and at night. After rinsing, the of causative agent.
solution should be expectorated, and
nothing should be taken by mouth for • patients with OLP and OLL should be
one hour re-evaluated every 3–6 months!
• recalcitrant or extensive lesions -
intralesional injection of
corticosteroid (subcutaneous injection
of triamcinolone acetonide)
 Oral lichenoid contact hypersensitivity - amalgam restorations

• In OLL it is recommended to replace the amalgam filling if the following

conditions are met:
• single, isolated lesions;
• the onset of lichenoid lesions is correlated with the restorative treatment;
• the lesion / lesions is / are limited to area with direct contact / adjacent
with dental restoration (lichenoid lesions topographic in relationship -
adjacent or in direct contact - to dental restoration);
• the patient has only oral lesions (there are not associated cutaneous,
genital, laryngeal, esophageal, etc. lesions)
 Self-evaluation test
• A 45 years old male, smoker, alcohol • Precancerous lesion frequently found in
consumer. Clinical intraoral examination people that chew tobacco:
points out white plaques, well marked, • a. carcinoma
crossed by fine moats that offer the aspect
of split land, localized on the lower lip • b. leukoplakia
mucosal membrane. Specify the most • c. lichen planus
probable diagnostic:
a. reticular oral lichen planus
• d. leukemia
b. erythematous lupus • e. lymphoma
c. leukoplakia
d. leukoedema
e. nicotinic stomatitis
 Self-evaluation test
• Omogenous leukoplakia • Define leukoplakia.
interests:
• a. lateral margins of the tongue
• b. dorsal face of the tongue
• c. any area in the oral cavity
• d. only keratinised mucosal
membrane
• e. only not keratinised mucosal
membrane
 Self-evaluation test
• Define leukoplakia.
► white patch or plaque of the oral mucos, which cannot be wiped
off, cannot be characterized clinically or pathologically as any other
disease and is not associated with any physical or chemical agent
except the use of tobacco.
• Classification of oral leukoplasia. - homogenous leukoplakia
- non-homogenous leukoplakia
- erythroleukoplakia
- nodular leukoplakia
- verrucous leukoplakia
• Differencial diagnosis between leukoplakia and lupus erythematous is made on the
following elements:
a. unilateral / mostly bilateral
b. does not disappear at the stretching of the mucous membrane / disappers at the
stretching of the mucous membrane
c. can not be removed through whiping / can be removed through whiping
d. history in the family / no history in the family
e. white plaques / the presence of smooth, white, radiar strips
• Differential diagnostic between leukoplakia and leucoedema is made on the
following elements:
a. history in the family / no history in the family
b. does not disappear at the stretching of the mucous membrane / disappers at the
stretching of the mucous membrane
c. asimetrical lesions / bilateral, simetrical
d. most frequently localised on the jugal mucos membrane / interests any area of oral
mucous membrane
e. white plaque / white reticular lesions
• Differential diagnostic between leukoplakia and oral lichen planus is made on the
following elements:
a. asymmetrical lesions / frequent bilateral lesions
b. white plaques / reticular white lesions
c. asymetrical lesions / bilateral, symetric
d. frequently localised on the jugal mucous membrane / interests any area of the oral
mucous membrane
e. white plaque / reticular white lesions
• A 50 years old female patient. Objective clinical examination emphasizes on the
jugal mucous membrane, asymmetrical erythematous lesions, with irregular
margins, surrounded with fine keratosic branches with radial arrangement. Specify
the most probable clinical diagnostic:
a. pemphigus mucous membrane
b. lupus erythematous
c. leukoplakia
d. oral lichen planus
e. erythema multiforme
• Specify the elements that allow the differential diagnostic between oral lichen
planus lesions and oral lichenoid reactions
 • clinical history: dental restorations, habits of using
cinnamon- containing foods or oral hygiene
products (toothpaste, mouthwashes), drug therapy,
systemic or topical application, systemic diseases
• Oral lichen planus (especially hepatitis C, hepatitis B, and / or other
- clinical history: violent emotions; liver diseases), etc.

- usually bilateral; • there is a temporal relationship between above

mentioned elements from clinical history and the
- ± cutaneous lesions onset of oral lesions
• clinical presentation: atypical sites for OLP such as
the palate, unilaterality, erosion;
• therapeutic probation: resolution of the lesions after
trigger identification and elimination (in months or
even longer);
• without cutaneous lesions
• In oral lichenoid reactions it is recommended the replacement of the amalgam fillings
if the following conditions are met . . . . . . . . .
• In OLL it is recommended to replace the amalgam filling if the following conditions
are met:
• single, isolated lesions;
• the onset of lichenoid lesions is correlated with the restorative treatment;
• the lesion / lesions is / are limited to area with direct contact / adjacent with
dental restoration (lichenoid lesions topographic in relationship - adjacent or in
direct contact - to dental restoration);
• the patient has only oral lesions (there are not associated cutaneous, genital,
laryngeal, esophageal, etc. lesions)
• Specify the situations in which the • recalcitrant or extensive lesions -
administration of corticosteroids is
recommended through intralesional
injections as a therapeutic alternative to
oral lichen planus.
 • Oral lichen planus is characterized through: • Select the correct answers. Oral lichen
planus:
a. satellite lymphadenopathy
a. is a papulo-squamous disease
b. white lesions that can be wiped off
b. has cutaneous manifestations and/or
c. plaque-type keratosis lesions
characteristic mucous membranes
d. reticular lesions (lace-like network)
c. is an infectious disease
e. erosive lesions
d. is an hereditary disease
e. is a type IV hypersensitivity reaction
Specify the complications that can occur • Oral lichen planus is a disease:
in oral lichen planus: a. infectious
a. becomes chronic b. contagious
b. candida infection c. hereditary
c. submucosal fibrosis d. acute
d. nicotinic stomatitis e. papulo-squamous
e. xerostomia