White Lesions of the White Lesions of the Oral MucosaOral Mucosa

Dr. Bushra Nasir

White LesionWhite Lesion

In order to discuss pathologic In order to discuss pathologic lesions that are white, the first lesions that are white, the first order is to eliminate the normal or order is to eliminate the normal or variants of normal that appear variants of normal that appear white.white.

Leukoedema: Clinical Leukoedema: Clinical FeaturesFeatures

Occurs in 50%+ Whites and over Occurs in 50%+ Whites and over 90% of African-Americans; uniform 90% of African-Americans; uniform opacification of buccal mucosa opacification of buccal mucosa bilaterally.bilaterally.

Leukoedema: CauseLeukoedema: Cause

The cause of leukoedema is The cause of leukoedema is unknown.unknown.

Leukoedema: TreatmentLeukoedema: Treatment

None necessary.None necessary.

Leukoedema: SignificanceLeukoedema: Significance

Need to recognize; remains Need to recognize; remains indefinitely; no ill effects.indefinitely; no ill effects.

White LesionsWhite Lesions

One way white lesions can be classified One way white lesions can be classified is to separate them into two categories is to separate them into two categories based upon whether the lesion can based upon whether the lesion can (pseudomembranesous or necrotic) or (pseudomembranesous or necrotic) or cannot (keratotic) be removed easily by cannot (keratotic) be removed easily by rubbing or scraping them:rubbing or scraping them:

1. 1. Pseudomembraneous or necrotic Pseudomembraneous or necrotic white white lesions.lesions.

2. 2. Keratotic white lesions.Keratotic white lesions.

Keratotic White Keratotic White LesionsLesions

LeukoplakiaLeukoplakia(leuko-white; plakia-patch)(leuko-white; plakia-patch)

Oral leukoplakia is defined by the WHO as “a Oral leukoplakia is defined by the WHO as “a white patch or plaque that white patch or plaque that cannotcannot be be characterized clinically or pathologically as any characterized clinically or pathologically as any other disease”. other disease”.

Thus a diagnosis by Thus a diagnosis by exclusionexclusion.. The term is strictly a The term is strictly a CLINICAL CLINICAL one and does one and does

notnot imply a specific histopathologic tissue imply a specific histopathologic tissue alteration.alteration.

Leukoplakia is the most common oral precancer.Leukoplakia is the most common oral precancer. How common is it according to Bouquot’s How common is it according to Bouquot’s

study???study???

The 15 Most Common Oral PathosesThe 15 Most Common Oral Pathoses(Based on examination of 23,616 U.S. adults; excludes caries & periodontitis)(Based on examination of 23,616 U.S. adults; excludes caries & periodontitis)

References: Bouquot JE. J Am Dent Assoc 1986; 112:50-57; www.oralpath.com

DiagnosisDiagnosis RankRank

Number of Lesions per 1,000 AdultsNumber of Lesions per 1,000 Adults

MalesMales FemalesFemales BothBoth

LeukoplakiaLeukoplakia 11 42.542.5 13.113.1 23.723.7

Torus palatinusTorus palatinus 22 13.213.2 21.721.7 18.718.7

Irritation fibromaIrritation fibroma 33 13.013.0 11.411.4 11.911.9

Fordyce granulesFordyce granules 44 17.717.7 5.25.2 9.79.7

Torus mandibularisTorus mandibularis 55 9.69.6 7.97.9 8.58.5

Leaf-shaped fibroma (under denture)Leaf-shaped fibroma (under denture) 66 0.40.4 12.912.9 6.76.7

HemangiomaHemangioma 77 8.48.4 4.14.1 5.65.6

Inflammatory ulcerInflammatory ulcer 88 5.45.4 5.15.1 5.25.2

Inflammatory erythemaInflammatory erythema 99 4.54.5 4.84.8 4.74.7

PapillomaPapilloma 1010 5.35.3 4.24.2 4.64.6

Epulis fissuratumEpulis fissuratum 1111 3.43.4 4.44.4 4.04.0

Lingual varicositiesLingual varicosities 1212 3.53.5 3.43.4 3.53.5

Fissured tongueFissured tongue 1313 3.53.5 3.13.1 3.33.3

Geographic tongueGeographic tongue 1414 3.43.4 3.03.0 3.13.1

Papillary hyperplasia of palatePapillary hyperplasia of palate 1515 1.71.7 3.83.8 3.03.0

Leukoplakia: Why is it Leukoplakia: Why is it White?White?

The clinical color (white) results The clinical color (white) results from a thickened surface keratin from a thickened surface keratin layer (which appears white when layer (which appears white when wet) and/or a thickened spinous wet) and/or a thickened spinous layer, which masks the normal layer, which masks the normal vascularity (redness) of the vascularity (redness) of the underlying connective tissue.underlying connective tissue.

Leukoplakia: A Premalignant Leukoplakia: A Premalignant or Precancerous Lesionor Precancerous Lesion

Although leukoplakia is not Although leukoplakia is not associated with a specific associated with a specific histopathologic diagnosis, it is histopathologic diagnosis, it is considered to be a premalignant considered to be a premalignant lesion for the risk of malignant lesion for the risk of malignant transformation is greater in a transformation is greater in a leukoplakic lesion than that leukoplakic lesion than that associated with normal or unaltered associated with normal or unaltered mucosa. mucosa.

LeukoplakiaLeukoplakia

Despite the fact that leukoplakia is a Despite the fact that leukoplakia is a premalignant lesion it should be noted premalignant lesion it should be noted that not every lesion shows that not every lesion shows histopathologic evidence of epithelial histopathologic evidence of epithelial dysplasia or frank malignancy dysplasia or frank malignancy (squamous cell carcinoma).(squamous cell carcinoma).

In fact, dysplastic epithelium or invasive In fact, dysplastic epithelium or invasive carcinoma is found in only 5 to 25 % of carcinoma is found in only 5 to 25 % of the biopsy samples of leukoplakia.the biopsy samples of leukoplakia.

Leukoplakia: Malignant Leukoplakia: Malignant Transformation PotentialTransformation Potential

Overall, the malignant Overall, the malignant transformation potential of transformation potential of leukoplakia is 4 % (estimated leukoplakia is 4 % (estimated lifetime risk).lifetime risk).

However, specific clinical subtypes However, specific clinical subtypes are associated with much high are associated with much high potential malignant transformation potential malignant transformation rates (as high as 47 %).rates (as high as 47 %).

Leukoplakia: How Common Leukoplakia: How Common Is It?Is It?

Leukoplakia is by far the most common oral Leukoplakia is by far the most common oral precancer, accounting for 85 % of such lesions. precancer, accounting for 85 % of such lesions. ((Note:Note: this statement is not saying that this statement is not saying that leukoplakia has the highest malignant leukoplakia has the highest malignant transformation risk of the premalignant group of transformation risk of the premalignant group of lesions for erythroplakia [erythroplasia] does).lesions for erythroplakia [erythroplasia] does).

Leukoplakia is also a relatively common lesion Leukoplakia is also a relatively common lesion for it is estimated that approximately 3 % of all for it is estimated that approximately 3 % of all white adults will be affected at some time. white adults will be affected at some time. Additionally, Bouquot in his study of oral mucosal Additionally, Bouquot in his study of oral mucosal lesions found it to be the most common of all.lesions found it to be the most common of all.

Leukoplakia: Who Leukoplakia: Who Develops It?Develops It? There is a strong male predilection There is a strong male predilection

(70%), except in parts of the country (70%), except in parts of the country where females use tobacco products where females use tobacco products more than males.more than males.

Overall, there has been a slight decrease Overall, there has been a slight decrease in the proportion of males affected over in the proportion of males affected over the past few decades.the past few decades.

In general, leukoplakia is diagnosed more In general, leukoplakia is diagnosed more frequently now than in the past, probably frequently now than in the past, probably because of enhance awareness.because of enhance awareness.

Leukoplakia: EtiologyLeukoplakia: Etiology

The cause of leukoplakia remains The cause of leukoplakia remains unknownunknown..

Over the years the following have Over the years the following have been considered: tobacco, alcohol, been considered: tobacco, alcohol, sanguinaria, ultraviolet radiation, sanguinaria, ultraviolet radiation, microorganisms and trauma.microorganisms and trauma.

Etiology of Leukoplakia: The Etiology of Leukoplakia: The Role of TobaccoRole of Tobacco

The habit of tobacco smoking appears most The habit of tobacco smoking appears most closely associated with leukoplakia closely associated with leukoplakia development.development.

80 % of patients with leukoplakia are smokers.80 % of patients with leukoplakia are smokers. Smokers are much more likely to have Smokers are much more likely to have

leukoplakia than non-smokers.leukoplakia than non-smokers. Heavier smokers have greater numbers of and Heavier smokers have greater numbers of and

larger lesions than light smokers.larger lesions than light smokers. A large proportion of leukoplakias in persons A large proportion of leukoplakias in persons

who stop smoking either disappear or become who stop smoking either disappear or become smaller soon after discontinuing the habit.smaller soon after discontinuing the habit.

Etiology of Leukoplakia: The Etiology of Leukoplakia: The Role of Alcohol and Role of Alcohol and SanguinariaSanguinaria Alcohol, which seems to have a strong Alcohol, which seems to have a strong

synergistic effect with tobacco in oral cancer synergistic effect with tobacco in oral cancer development, has development, has notnot been associated with been associated with leukoplakia.leukoplakia.

Sanguinaria (blood root) is a herbal extract that Sanguinaria (blood root) is a herbal extract that has been used in toothpaste and mouthwash.has been used in toothpaste and mouthwash.

Over 80 % of the patients with Over 80 % of the patients with vestibular/maxillary alveolar leukoplakias have vestibular/maxillary alveolar leukoplakias have a history of using a sanguinaria containing a history of using a sanguinaria containing product as compared to 3 % of the “normal” product as compared to 3 % of the “normal” population; some lesions have persisted after population; some lesions have persisted after the patient stopped using the product.the patient stopped using the product.

Etiology of Leukoplakia: The Etiology of Leukoplakia: The Role of Ultraviolet RadiationRole of Ultraviolet Radiation

Ultraviolet radiation has been Ultraviolet radiation has been associated with leukoplakia of the associated with leukoplakia of the vermilion of the lower lip.vermilion of the lower lip.

This leukoplakia is usually This leukoplakia is usually associated with actinic cheilosis.associated with actinic cheilosis.

Etiology of Leukoplakia: The Etiology of Leukoplakia: The Role of MicroorganismsRole of Microorganisms

Treponema pallidum Treponema pallidum has been has been implicated in leukoplakia of the dorsal implicated in leukoplakia of the dorsal surface of the tongue in patients with surface of the tongue in patients with syphilis.syphilis.

Candida albicansCandida albicans has been has been demonstrated histologically in the demonstrated histologically in the hyperplastic/dysplastic epithelium of hyperplastic/dysplastic epithelium of lesions termed candidal leukoplakia lesions termed candidal leukoplakia and candidal hyperplasia.and candidal hyperplasia.

Etiology of Leukoplakia: The Etiology of Leukoplakia: The Role of Microorganisms Role of Microorganisms ContinuedContinued Human papillomavirus (HPV), Human papillomavirus (HPV),

particularly subtypes 16 and 18, particularly subtypes 16 and 18, have been identified in some oral have been identified in some oral leukoplakias.leukoplakias.

However, HPV has also been However, HPV has also been demonstrated in normal oral demonstrated in normal oral epithelial cells.epithelial cells.

Etiology of Leukoplakia: The Etiology of Leukoplakia: The Role of TraumaRole of Trauma

Several keratotic lesions, which until Several keratotic lesions, which until recently have been viewed as variants of recently have been viewed as variants of leukoplakia, are now considered leukoplakia, are now considered notnot to be to be premalignant.premalignant.

Included in this group are lesions termed Included in this group are lesions termed nicotine stomatitis and frictional keratosis.nicotine stomatitis and frictional keratosis.

These keratoses are readily reversible These keratoses are readily reversible after the elimination of the trauma or after the elimination of the trauma or chronic irritation.chronic irritation.

Leukoplakia: Clinical Leukoplakia: Clinical FeaturesFeatures

Leukoplakia usually affects people Leukoplakia usually affects people over the age of 40 years (average over the age of 40 years (average age is 60 years).age is 60 years).

Prevalence increases rapidly with Prevalence increases rapidly with age particularly in males.age particularly in males.

Approximately 8 % of the males Approximately 8 % of the males over the age of 70 years are over the age of 70 years are reportedly affected.reportedly affected.

Leukoplakia: Clinical Leukoplakia: Clinical Features ContinuedFeatures Continued

Approximately 70 % of the oral Approximately 70 % of the oral leukoplakias are found on the lip leukoplakias are found on the lip vermilion, buccal mucosa and vermilion, buccal mucosa and gingiva.gingiva.

NoteNote: Lesions of the tongue, lip : Lesions of the tongue, lip vermilion and floor of the mouth vermilion and floor of the mouth account for more than 90 % of those account for more than 90 % of those that show dysplasia or carcinoma that show dysplasia or carcinoma upon histologic examination.upon histologic examination.

Leukoplakia: Clinical Leukoplakia: Clinical Features ContinuedFeatures Continued

Individual lesions vary in clinical Individual lesions vary in clinical appearance and tend to change over time.appearance and tend to change over time.

Early/mild lesions usually appear as Early/mild lesions usually appear as slightly elevated gray or gray-white slightly elevated gray or gray-white plaques, which may appear translucent, plaques, which may appear translucent, fissured or wrinkled and are typically soft fissured or wrinkled and are typically soft and flat.and flat.

Early/mild lesions are usually well Early/mild lesions are usually well demarcated but may blend into the demarcated but may blend into the surrounding normal mucosa.surrounding normal mucosa.

Leukoplakia: Clinical Leukoplakia: Clinical Features ContinuedFeatures Continued

Early/mild thin leukoplakia, which Early/mild thin leukoplakia, which seldom shows dysplasia on biopsy, may seldom shows dysplasia on biopsy, may disappear or continue unchanged.disappear or continue unchanged.

If the cause (s) of the lesion are not If the cause (s) of the lesion are not removed, many lesions will gradually removed, many lesions will gradually become thicker and larger.become thicker and larger.

The clinical appearance (s) of The clinical appearance (s) of leukoplakia and the anticipated leukoplakia and the anticipated underlying histopathologic changes are underlying histopathologic changes are presented in the following diagram. presented in the following diagram.

Proliferative Verrucous Proliferative Verrucous Leukoplakia (PVL)Leukoplakia (PVL)

PVL is a special high risk form of leukoplakia.PVL is a special high risk form of leukoplakia. It is characterized by multiple keratotic plaques It is characterized by multiple keratotic plaques

with rough surface projections although initially with rough surface projections although initially beginning as a simple flat hyperkeratosis.beginning as a simple flat hyperkeratosis.

PVL plaques tend to spread slowly, yet PVL plaques tend to spread slowly, yet progressively.progressively.

PVL usually transforms into a squamous cell PVL usually transforms into a squamous cell carcinoma within about 8 years.carcinoma within about 8 years.

PVL has a strong female predilection (1:4 male PVL has a strong female predilection (1:4 male to female) and minimal association with tobacco to female) and minimal association with tobacco usage. usage.

Leukoplakia: Histopathologic Leukoplakia: Histopathologic FeaturesFeatures

Leukoplakia is characterized by a Leukoplakia is characterized by a thickened keratin layer (hyperkeratosis) thickened keratin layer (hyperkeratosis) with or without a thickened spinous with or without a thickened spinous layer (acanthosis).layer (acanthosis).

Some leukoplakias show surface Some leukoplakias show surface hyperkeratosis but with atrophy or hyperkeratosis but with atrophy or thinning of the underlying epithelium.thinning of the underlying epithelium.

Variable numbers of chronic Variable numbers of chronic inflammatory cells are typically noted inflammatory cells are typically noted within the underlying connective tissue.within the underlying connective tissue.

Leukoplakia: Histopathologic Leukoplakia: Histopathologic Features ContinuedFeatures Continued

While most leukoplakias show no While most leukoplakias show no dysplasia on biopsy, some 5 to 25 dysplasia on biopsy, some 5 to 25 % of the cases do show evidence % of the cases do show evidence of epithelial dysplasia (or of epithelial dysplasia (or squamous cell carcinoma).squamous cell carcinoma).

The histopathologic alterations of The histopathologic alterations of dysplastic epithelial cells are dysplastic epithelial cells are outlined in the next slide.outlined in the next slide.

Histopathologic Alterations of Histopathologic Alterations of Dysplastic Epithelial CellsDysplastic Epithelial Cells

Enlarged nuclei and cells.Enlarged nuclei and cells. Large and prominent nucleoli.Large and prominent nucleoli. Increased nuclear-cytoplasmic ratio.Increased nuclear-cytoplasmic ratio. Hyperchromatic (dark-staining) nuclei.Hyperchromatic (dark-staining) nuclei. Pleomorphic (abnormally shaped) nuclei Pleomorphic (abnormally shaped) nuclei

and cells.and cells. Dyskeratosis (premature keratinization)Dyskeratosis (premature keratinization) Increased mitotic activity and abnormal Increased mitotic activity and abnormal

mitotic figuresmitotic figures

Histopathologic Alterations of Histopathologic Alterations of Dysplastic Epithelium Dysplastic Epithelium ContinuedContinued Bulbous or teardrop-shaped rete Bulbous or teardrop-shaped rete

ridges.ridges. Loss of polarity (lack of progressive Loss of polarity (lack of progressive

maturation toward the surface).maturation toward the surface). Keratin or epithelial pearls.Keratin or epithelial pearls. Loss of typical epithelial cell Loss of typical epithelial cell

cohesiveness.cohesiveness.

Leukoplakia: Treatment and Leukoplakia: Treatment and PrognosisPrognosis

Leukoplakia represents a clinical diagnosis Leukoplakia represents a clinical diagnosis and therefore the first step in treatment is to and therefore the first step in treatment is to arrive at a definitive diagnosis via biopsy and arrive at a definitive diagnosis via biopsy and histologic examination of the tissue.histologic examination of the tissue.

Treatment depends upon the diagnosis and Treatment depends upon the diagnosis and any leukoplakia exhibiting moderate epithelial any leukoplakia exhibiting moderate epithelial dysplasia or worse warrants complete dysplasia or worse warrants complete removal if possible. Treatment of lesions removal if possible. Treatment of lesions exhibiting less severe changes is guided by exhibiting less severe changes is guided by the size of the lesion and its response to more the size of the lesion and its response to more conservative measures such as eliminating conservative measures such as eliminating tobacco use.tobacco use.

Leukoplakia: Treatment and Leukoplakia: Treatment and Prognosis ContinuedPrognosis Continued

Leukoplakia not exhibiting dysplasia often is Leukoplakia not exhibiting dysplasia often is not excised but clinical evaluation every 6 not excised but clinical evaluation every 6 months is recommended.months is recommended.

Additional biopsies are recommended if Additional biopsies are recommended if smoking continues or if clinical changes smoking continues or if clinical changes increase in severity.increase in severity.

The following diagram represents the The following diagram represents the various clinical appearance of oral various clinical appearance of oral leukoplakia and the anticipated underlying leukoplakia and the anticipated underlying associated histopathologic changes.associated histopathologic changes.

Leukoplakia: Treatment and Leukoplakia: Treatment and Prognosis ContinuedPrognosis Continued

Complete removal of oral leukoplakia can be Complete removal of oral leukoplakia can be accomplished with equal effectiveness by accomplished with equal effectiveness by surgical excision, electrocautery, surgical excision, electrocautery, cryosurgery or laser ablation.cryosurgery or laser ablation.

Long-term follow-up after removal is Long-term follow-up after removal is mandatory because of recurrence potential mandatory because of recurrence potential and because new leukoplakias may occur.and because new leukoplakias may occur.

Malignant transformation potential is related Malignant transformation potential is related to clinical appearance and the degree of to clinical appearance and the degree of dysplasia present. dysplasia present.

Nicotine StomatitisNicotine Stomatitis

Nicotine Stomatitis: Clinical Nicotine Stomatitis: Clinical FeaturesFeatures

Asymptomatic generalized Asymptomatic generalized opacification of palate with red opacification of palate with red dots representing inflamed salivary dots representing inflamed salivary gland orifices scattered gland orifices scattered throughout.throughout.

Nicotine Stomatitis: CauseNicotine Stomatitis: Cause

Heat and smoke associated with Heat and smoke associated with combustion of tobacco; typically combustion of tobacco; typically seen in pipe smokers.seen in pipe smokers.

Nicotine Stomatitis: Nicotine Stomatitis: TreatmentTreatment

Discontinue smoking; lesion Discontinue smoking; lesion typically regresses.typically regresses.

Nicotine Stomatitis: Nicotine Stomatitis: SignificanceSignificance

Rarely develops into palatal Rarely develops into palatal cancer; malignant transformation cancer; malignant transformation risk no greater than for “normal” risk no greater than for “normal” palatal mucosa.palatal mucosa.

Smokeless Tobacco Smokeless Tobacco Users LesionUsers Lesion

Snuff Dipper’s LesionSnuff Dipper’s Lesion

Tobacco Chewer’s LesionTobacco Chewer’s Lesion

White Lesions Associated White Lesions Associated with Smokeless with Smokeless Tobacco:Clinical FeaturesTobacco:Clinical Features Asymptomatic white folds Asymptomatic white folds

surrounding area where tobacco is surrounding area where tobacco is held; usually found in labial and held; usually found in labial and buccal vestibules; a common oral buccal vestibules; a common oral lesion.lesion.

White Lesions Associated White Lesions Associated with Smokeless Tobacco: with Smokeless Tobacco: CauseCause Chronic irritation from snuff or Chronic irritation from snuff or

chewing tobacco.chewing tobacco.

White Lesions Associated White Lesions Associated with Smokeless Tobacco: with Smokeless Tobacco: TreatmentTreatment Discontinue habit; biopsy Discontinue habit; biopsy

suspicious areassuspicious areas

White Lesions Associated White Lesions Associated with Smokeless Tobacco: with Smokeless Tobacco: SignificanceSignificance Increased risk for development of Increased risk for development of

verrucous and squamous cell verrucous and squamous cell carcinoma after many years.carcinoma after many years.

Lichen PlanusLichen Planus

Lichen PlanusLichen Planus

Lichen planus is a relatively common, Lichen planus is a relatively common, chronic dermatologic disease, often chronic dermatologic disease, often affecting the oral mucosa.affecting the oral mucosa.

Current evidence indicates it is an Current evidence indicates it is an immunologically mediated disorder.immunologically mediated disorder.

Its relationship to stress is Its relationship to stress is controversial.controversial.

A variety of drugs are known to induce A variety of drugs are known to induce similar appearing lesions for which the similar appearing lesions for which the term lichenoid mucositis is used.term lichenoid mucositis is used.

Lichen Planus: Clinical Lichen Planus: Clinical FeaturesFeatures From 1 to 2 % of the population has cutaneous From 1 to 2 % of the population has cutaneous

lichen planus.lichen planus. The majority of patients are middle-aged or The majority of patients are middle-aged or

older and there is a female gender predilection older and there is a female gender predilection (3:2).(3:2).

Skin lesions appear as pruritic, purple, Skin lesions appear as pruritic, purple, polygonal papules with a fine, lace-like network polygonal papules with a fine, lace-like network of white lines known as Wickham striaeof white lines known as Wickham striae

Oral and other mucous membranes may be Oral and other mucous membranes may be involved as well as the nails.involved as well as the nails.

Lichen PlanusLichen Planus

While many forms are recognized by While many forms are recognized by some authors, there are essentially some authors, there are essentially two forms of oral lesions:two forms of oral lesions:

1. Reticular lichen planus1. Reticular lichen planus 2. Erosive lichen planus2. Erosive lichen planus The white, keratotic lesion of the The white, keratotic lesion of the

reticular form is what we are reticular form is what we are discussing today.discussing today.

Reticular Lichen PlanusReticular Lichen Planus

This is the more common form of the disorder.This is the more common form of the disorder. Usually it is asymptomatic and occurs most Usually it is asymptomatic and occurs most

frequently on the buccal mucosae bilaterally.frequently on the buccal mucosae bilaterally. It may also affect the tongue, gingiva and It may also affect the tongue, gingiva and

palate as well as other areas.palate as well as other areas. Reticular lichen planus was so named because Reticular lichen planus was so named because

of the interlacing white lines. However, the of the interlacing white lines. However, the lesion may have a plaque like appearance.lesion may have a plaque like appearance.

Lesions typically wax and wane over weeks to Lesions typically wax and wane over weeks to months.months.

Erosive Lichen PlanusErosive Lichen Planus

This form is usually symptomatic due to This form is usually symptomatic due to ulceration.ulceration.

The lesions appear atrophic, erythematous The lesions appear atrophic, erythematous with central areas of ulceration.with central areas of ulceration.

Usually the fine, white, radiating striae can Usually the fine, white, radiating striae can be seen at the edge of the lesion.be seen at the edge of the lesion.

With gingival involvement, this form is part With gingival involvement, this form is part of a group of specific disease entities, of a group of specific disease entities, which produce a reaction pattern called which produce a reaction pattern called desquamative gingivitis.desquamative gingivitis.

Lichenoid MucositisLichenoid Mucositis

Lichenoid Drug ReactionLichenoid Drug Reaction

Lichenoid ReactionLichenoid Reaction

Lichen Planus: Histologic Lichen Planus: Histologic FeaturesFeatures

The histologic features are characteristic The histologic features are characteristic but not pathognomonic because lichenoid but not pathognomonic because lichenoid mucositis and other lesions can appear mucositis and other lesions can appear similar.similar.

Orthokeratosis or parakeratosis is seen Orthokeratosis or parakeratosis is seen with the reticular form.with the reticular form.

The spinous layer may be atrophic or The spinous layer may be atrophic or hyperplastic with “saw-toothed” rete hyperplastic with “saw-toothed” rete ridges.ridges.

The basal layer may show hydropic The basal layer may show hydropic degeneration.degeneration.

Lichen Planus: Histologic Lichen Planus: Histologic Features ContinuedFeatures Continued

A band-like infiltrate of predominantly T-A band-like infiltrate of predominantly T-lymphocytes adjacent to the epithelium is lymphocytes adjacent to the epithelium is usually present.usually present.

Degenerating keratinocytes (colloid, cytoid, Degenerating keratinocytes (colloid, cytoid, hyaline or Civatte bodies) may be seen at hyaline or Civatte bodies) may be seen at the interface of the epithelium and the interface of the epithelium and connective tissue.connective tissue.

Immunopathologic features are non-specific. Immunopathologic features are non-specific. Most lesions show a band of fibrinogen at Most lesions show a band of fibrinogen at the basement membrane zone.the basement membrane zone.

Lichen Planus: DiagnosisLichen Planus: Diagnosis

The diagnosis of the reticular form The diagnosis of the reticular form can often be made on clinical can often be made on clinical findings alone.findings alone.

Biopsy is often necessary to rule Biopsy is often necessary to rule out other vesiculoerosive disease out other vesiculoerosive disease in cases of the erosive type.in cases of the erosive type.

Lichen Planus: Treatment Lichen Planus: Treatment and Prognosisand Prognosis

The reticular form typically produces no The reticular form typically produces no symptoms and requires no treatment.symptoms and requires no treatment.

The erosive form is usually treated by The erosive form is usually treated by topical (or systemic if necessary) topical (or systemic if necessary) corticosteroids.corticosteroids.

With steroid treatment, the patient should With steroid treatment, the patient should be monitored for candidal infection.be monitored for candidal infection.

Potential malignant transformation, Potential malignant transformation, associated mainly with the erosive form, is associated mainly with the erosive form, is small.small.

White Hairy TongueWhite Hairy Tongue

Hairy Tongue: Clinical Hairy Tongue: Clinical FeaturesFeatures

Elongation of filiform papillae; Elongation of filiform papillae; asymptomatic.asymptomatic.

Hairy Tongue: CauseHairy Tongue: Cause

Unknown; may follow antibiotic or Unknown; may follow antibiotic or corticosteroid usecorticosteroid use

Hairy Tongue: TreatmentHairy Tongue: Treatment

Improve oral hygiene and identify Improve oral hygiene and identify contributing factorscontributing factors

Hairy TongueHairy Tongue

Benign process; may be Benign process; may be cosmetically objectionable. cosmetically objectionable.

(Squamous, (Squamous, Squamous Cell) Squamous Cell) PapillomaPapilloma

Squamous Papilloma: Squamous Papilloma: Clinical FeaturesClinical Features

Painless, exophytic, granular to cauliflower-like Painless, exophytic, granular to cauliflower-like lesion; predilection for tongue, floor of mouth, lesion; predilection for tongue, floor of mouth, palate, uvula, lips, faucial pillars; generally palate, uvula, lips, faucial pillars; generally solitary; soft in texture; color is white or same solitary; soft in texture; color is white or same as surrounding tissue; young adults and as surrounding tissue; young adults and adults; is a common oral lesion.adults; is a common oral lesion.

The squamous papilloma occurs in 1 in every The squamous papilloma occurs in 1 in every 250 adults and makes up about 3% of the 250 adults and makes up about 3% of the lesions sent for biopsy. We did about a 5 yr. lesions sent for biopsy. We did about a 5 yr. study at MCV and had 464 lesions in our study at MCV and had 464 lesions in our sample.sample.

Squamous Papilloma: Squamous Papilloma: CauseCause

Most due to HPV; viral subtypes 6 Most due to HPV; viral subtypes 6 and 11 have been detected in up and 11 have been detected in up to 50% of the oral papillomas.to 50% of the oral papillomas.

Squamous Papilloma: Squamous Papilloma: TreatmentTreatment

ExcisionExcision

Squamous Papilloma: Squamous Papilloma: SignificanceSignificance

Lesion has no known malignant Lesion has no known malignant potential; recurrences are rare if potential; recurrences are rare if properly excised. properly excised.

Verruca VulgarisVerruca Vulgaris

(Oral) Verruca Vulgaris: (Oral) Verruca Vulgaris: Clinical FeaturesClinical Features

Painless, papillary, exophytic Painless, papillary, exophytic lesion usually with a white surface lesion usually with a white surface because of keratin production; because of keratin production; may be regarded as a type of may be regarded as a type of papilloma (Regezi, Sciubba and papilloma (Regezi, Sciubba and Jordan); children and young adults Jordan); children and young adults most effected; common on skin most effected; common on skin while uncommon intraorally.while uncommon intraorally.

Verruca Vulgaris: CauseVerruca Vulgaris: Cause

HPV with common subtypes being HPV with common subtypes being 2,4,6, and 40. 2,4,6, and 40.

Verruca Vulgaris: Verruca Vulgaris: TreatmentTreatment

Oral lesions are treated by excision Oral lesions are treated by excision or obliterated with laser, or obliterated with laser, cryotherapy, etc.cryotherapy, etc.

Without treatment about 2/3 of the Without treatment about 2/3 of the cases spontaneously regress with cases spontaneously regress with a couple of years.a couple of years.

Verruca Vulgaris: Verruca Vulgaris: SignificanceSignificance

Of little significance; may be Of little significance; may be multiple and a cosmetic problem.multiple and a cosmetic problem.

Verrucous Verrucous CarcinomaCarcinoma

Verrucous Carcinoma: Verrucous Carcinoma: Clinical FeaturesClinical Features

Broad-based, exophytic, indurated Broad-based, exophytic, indurated lesion; usually found on buccal lesion; usually found on buccal mucosa or in vestibule; adult mucosa or in vestibule; adult males are most frequently affectedmales are most frequently affected

Verrucous Carcinoma: Verrucous Carcinoma: CauseCause

May be associated with use of May be associated with use of tobacco, especially smokeless tobacco, especially smokeless tobacco; HPV present in some tobacco; HPV present in some lesions.lesions.

Verrucous Carcinoma: Verrucous Carcinoma: TreatmentTreatment

Excision is treatment of choice; Excision is treatment of choice; radiation may have a role in radiation may have a role in therapy today.therapy today.

Verrucous Carcinoma: Verrucous Carcinoma: SignificanceSignificance

Slow-growing malignancy; well-Slow-growing malignancy; well-differentiated with better prognosis differentiated with better prognosis than usual squamous cell than usual squamous cell carcinoma; growth pattern is more carcinoma; growth pattern is more expansile than invasive; expansile than invasive; metastases are uncommon.metastases are uncommon.

Hyperplastic Hyperplastic CandidasisCandidasis

White Sponge White Sponge NevusNevus

Cannon’s DiseaseCannon’s Disease

Familial White Folded Familial White Folded DysplasiaDysplasia

White Sponge Nevus: Clinical White Sponge Nevus: Clinical FeaturesFeatures

Asymptomatic, bilateral, dense, Asymptomatic, bilateral, dense, shaggy, white or gray, generalized shaggy, white or gray, generalized opacification; primarily buccal opacification; primarily buccal mucosa affected, but other mucosa affected, but other membranes may be involved; rare membranes may be involved; rare entity.entity.

White Sponge Nevus: White Sponge Nevus: CauseCause

Hereditary entity; autosomal Hereditary entity; autosomal dominant with high degree of dominant with high degree of penetrance and variable penetrance and variable expressivity; keratin 4 and/or 13 expressivity; keratin 4 and/or 13 affected (genes are mutated).affected (genes are mutated).

White Sponge Nevus: White Sponge Nevus: TreatmentTreatment

None required.None required.

White Sponge Nevus: White Sponge Nevus: SignificanceSignificance

Remains indefinitely; no ill effects.Remains indefinitely; no ill effects.

Hairy LeukoplakiaHairy Leukoplakia

Hairy Leukoplakia: Clinical Hairy Leukoplakia: Clinical FeaturesFeatures

Filiform to flat patch on lateral Filiform to flat patch on lateral tongue; often bilateral; tongue; often bilateral; occasionally on buccal mucosa; occasionally on buccal mucosa; typically asymptomatic.typically asymptomatic.

Hairy Leukoplakia: CauseHairy Leukoplakia: Cause

Opportunistic Epstein-Barr virus Opportunistic Epstein-Barr virus (EBV) infection.(EBV) infection.

Hairy Leukoplakia: Hairy Leukoplakia: TreatmentTreatment

No specific treatment; patient No specific treatment; patient should be evaluated for AIDS; may should be evaluated for AIDS; may improve with AIDS therapy.improve with AIDS therapy.

Hairy Leukoplakia: Hairy Leukoplakia: SignificanceSignificance

Seen in 20% of HIV-infected Seen in 20% of HIV-infected patients; marked increase in AIDS; patients; marked increase in AIDS; may occur in non-AIDS-affected may occur in non-AIDS-affected immunosuppressed patients and immunosuppressed patients and rarely in immunocompetent rarely in immunocompetent patients.patients.

HEREDITARY BENIGN HEREDITARY BENIGN INTRAEPITHELIAL INTRAEPITHELIAL DYSKERATOSIS (HBID)DYSKERATOSIS (HBID)

● Synonym: Witkop-Von Sallmann SyndromeSynonym: Witkop-Von Sallmann Syndrome● HBID is rare genodermatosis seen primarily in HBID is rare genodermatosis seen primarily in triracial isolate (African-American, White and triracial isolate (African-American, White and Native American) originally discovered in NC.Native American) originally discovered in NC.● Autosomal dominant trait.Autosomal dominant trait.

HBID: Clinical FeaturesHBID: Clinical Features● Clinical Features: Usually appears during Clinical Features: Usually appears during childhood.childhood.● Oral and conjunctival lesions; oral lesions similar Oral and conjunctival lesions; oral lesions similar to to white sponge nevus in appearance and location; white sponge nevus in appearance and location; milder cases resemble leukoedema.milder cases resemble leukoedema.● Ocular lesions appear as thick, opaque, gelatinous Ocular lesions appear as thick, opaque, gelatinous plaques affecting conjunctiva and sometimes plaques affecting conjunctiva and sometimes cornea.cornea.

HBID: Clinical Features HBID: Clinical Features ContinuedContinued

Eyes may tear, itch and patient Eyes may tear, itch and patient may have photophobia. may have photophobia.

Plaques (eye) most prominent in spring and Plaques (eye) most prominent in spring and tend to regress in the fall.tend to regress in the fall.

Blindness may occur from vascularity of Blindness may occur from vascularity of cornea secondary to shedding of the plaque.cornea secondary to shedding of the plaque.

HBID: Histologic HBID: Histologic FeaturesFeatures

● Histologic Features: Hyperparakeratosis with Histologic Features: Hyperparakeratosis with acanthosis; upper spinous layers show a acanthosis; upper spinous layers show a dyskeratotic process with epithelial cells appearing dyskeratotic process with epithelial cells appearing to be surrounded or engulfed by adjacent cells to be surrounded or engulfed by adjacent cells resulting in “cell-within-a-cell” phenomenon.resulting in “cell-within-a-cell” phenomenon.

HBIDHBID

HBID: Treatment and HBID: Treatment and PrognosisPrognosis

● No treatment is usually necessary for oral lesions.No treatment is usually necessary for oral lesions.● Patients with ocular lesions should see the Patients with ocular lesions should see the ophthalmologist; plaques obscuring vision require ophthalmologist; plaques obscuring vision require surgery but they ultimately recur. surgery but they ultimately recur.

DARIER’S DISEASEDARIER’S DISEASE● Synonyms: Keratosis Follicularis; Dyskeratosis Synonyms: Keratosis Follicularis; Dyskeratosis Follicularis, Darier-White Disease.Follicularis, Darier-White Disease.● Uncommon autosomal dominant trait with high Uncommon autosomal dominant trait with high penetrance and variable expressivity.penetrance and variable expressivity.● A lack of cohesion among surface epithelial cells A lack of cohesion among surface epithelial cells characterizes the disease.characterizes the disease.● A mutant gene that encodes an intracellular calcium A mutant gene that encodes an intracellular calcium

pump has been identified as the cause for the pump has been identified as the cause for the abnormal desmosomal organization.abnormal desmosomal organization.

DARIER’S DISEASE: DARIER’S DISEASE: Clinical FeaturesClinical Features

● Numerous erythematous, pruritic papules on trunk Numerous erythematous, pruritic papules on trunk and scalp develop during and scalp develop during second decade; lesions second decade; lesions are rough and degradation of the accumulated are rough and degradation of the accumulated keratin gives a foul odor.keratin gives a foul odor.● Palms and soles may exhibit pits and keratosis.Palms and soles may exhibit pits and keratosis.● The nails may show lines, ridges or painful splits.The nails may show lines, ridges or painful splits.

DARIER’S DISEASE: DARIER’S DISEASE: Clinical Features Clinical Features ContinuedContinued

● Between 15% and 50% of patients have Between 15% and 50% of patients have oral oral lesions, which are often multiple, lesions, which are often multiple, normal-colored normal-colored

to white, flat-to white, flat- topped papules.topped papules.● If clustered together, the papules present a If clustered together, the papules present a cobblestone appearance.cobblestone appearance.● The hard palate and alveolar mucosa are most The hard palate and alveolar mucosa are most commonly involved. commonly involved. ● Parotid swelling occurs in some patients.Parotid swelling occurs in some patients.

DARIER’S DISEASE: DARIER’S DISEASE: Histologic FeaturesHistologic Features

● This is a dyskeratotic process characterized This is a dyskeratotic process characterized by a by a central keratin plug which overlies epithelium central keratin plug which overlies epithelium exhibiting a suprabasilar cleftexhibiting a suprabasilar cleft● The intraepithelial clefting is known as The intraepithelial clefting is known as acantholysis and is acantholysis and is not unique to Darier’s disease.not unique to Darier’s disease.● The rete pegs are long, narrow and “test-tube The rete pegs are long, narrow and “test-tube shaped”.shaped”.● Dyskeratotic cells (corps ronds or grains) are Dyskeratotic cells (corps ronds or grains) are observed.observed.

Darier’s DiseaseDarier’s Disease

DARIER’S DISEASE: DARIER’S DISEASE: Treatment and PrognosisTreatment and Prognosis

● Photosensitive patients should avoid heat and sun Photosensitive patients should avoid heat and sun exposure and use sunscreens.exposure and use sunscreens.● Systemic retinoids may be beneficial in severe Systemic retinoids may be beneficial in severe cases.cases.● The condition is not premalignant.The condition is not premalignant.

Actinic CheilosisActinic Cheilosis

A slowly developing, premalignant lesion of the lower lip A slowly developing, premalignant lesion of the lower lip that results from chronic or excessive UV light that results from chronic or excessive UV light exposure.exposure.

Much more common in light-complexioned persons who Much more common in light-complexioned persons who sunburn easily, this lesion is associated with those who sunburn easily, this lesion is associated with those who have an outdoor occupation or hobby (therefore have an outdoor occupation or hobby (therefore farmer’s/sailor’s lip).farmer’s/sailor’s lip).

It has a similar pathophysiological and biological It has a similar pathophysiological and biological behavior as actinic keratosis.behavior as actinic keratosis.

Patients are typically over the age of 40 and there is a Patients are typically over the age of 40 and there is a strong male gender predilection.strong male gender predilection.

The earliest clinical changes include atrophy at the The earliest clinical changes include atrophy at the vermilion border characterized by a smooth surface vermilion border characterized by a smooth surface with blotchy pale areas.with blotchy pale areas.

Actinic CheilosisActinic Cheilosis

As the lesion progresses it becomes rough, scaly, As the lesion progresses it becomes rough, scaly, thickened and may appear leukoplakic. Patient may thickened and may appear leukoplakic. Patient may indicate he can peel off the scale only to have it reform.indicate he can peel off the scale only to have it reform.

With further progression, ulcers may develop and last With further progression, ulcers may develop and last several months. several months.

Many such changes may be irreversible but patient Many such changes may be irreversible but patient should be instructed to use lip balms with sunscreens to should be instructed to use lip balms with sunscreens to prevent further damage. prevent further damage.

Areas of thickening, ulceration, induration and Areas of thickening, ulceration, induration and leukoplakia should be biopsies.leukoplakia should be biopsies.

Vermilionectomy (lip shave) is the most popular method Vermilionectomy (lip shave) is the most popular method of treatment in those severe cases not showing of treatment in those severe cases not showing malignant change.malignant change.

Since from 5-10 % of the cases undergo malignant Since from 5-10 % of the cases undergo malignant change over time, long-term follow-up is necessary.change over time, long-term follow-up is necessary.

Actinic CheilosisActinic Cheilosis

Actinic CheilosisActinic Cheilosis

Sloughing, Sloughing, Pseudomembranous, Pseudomembranous, Necrotic White Necrotic White LesionsLesions

Materia albaMateria alba

Traumatic UlcerTraumatic Ulcer

Chemical BurnsChemical Burns

Acute Necrotizing Acute Necrotizing Ulcerative Ulcerative Gingivostomatitis Gingivostomatitis (ANUG)(ANUG)

PseudomembranouPseudomembranous Candidiasiss Candidiasis

Pseudomembranous Pseudomembranous CandidiasisCandidiasis

Painful, elevated plaques (fungus) can Painful, elevated plaques (fungus) can be wiped off leaving an eroded, be wiped off leaving an eroded, bleeding surface; associated with poor bleeding surface; associated with poor oral hygiene, systemic antibiotic oral hygiene, systemic antibiotic therapy, systemic diseases, therapy, systemic diseases, debilitation, reduced immune response; debilitation, reduced immune response; chronic infections may result in chronic infections may result in erythematous mucosa without obvious erythematous mucosa without obvious white colonies; common disease entity.white colonies; common disease entity.

Pseudomembranous Pseudomembranous Candidiasis: CauseCandidiasis: Cause

Opportunistic fungus-Opportunistic fungus-Candida Candida albicansalbicans; rarely caused by other ; rarely caused by other Candida species.Candida species.

Pseudomembranous Pseudomembranous Candidiasis: TreatmentCandidiasis: Treatment

Clotrimazole troches or nystatin Clotrimazole troches or nystatin suspension and treatment of the suspension and treatment of the underlying cause.underlying cause.

Pseudomembranous Pseudomembranous Candidiasis: SignificanceCandidiasis: Significance

Usually disappears in 1 to 2 weeks Usually disappears in 1 to 2 weeks after treatment; some chronic after treatment; some chronic cases require long-term therapy.cases require long-term therapy.