RECOGNIZING WHITE LESIONS PART I: Reactive, Idiopathic, Hereditary David E. Wojtowicz, DDS, MBA 1 1

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 3

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 4

Six Common Etiologies for White Lesions Reactive (Snuff) Idiopathic (Hairy Tongue) Hereditary (Leukoedema) Auto-Immune (Lichen Planus) Infectious (Candidiasis) Neoplastic (SCC) 5 5

1. Six Reactive White Hyperkeratotic Lesions (These are HYPERKERATOTIC 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 6

1. Six Reactive White Hyperkeratotic Lesions (Do They Rub Off. ) a 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 7

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 8

1. Six Reactive White Hyperkeratotic Lesions c. Chemical Burn Caused by Aspirin Painful Usually in Molar Region Treatment = Discontinue Aspirin Use 9

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 10

1. Six Reactive White Hyperkeratotic Lesions e. Actinic Cheilitis Sun Damage Lower Lip Obliteration of Border Treatment = Avoid Sun, Use Sunblock 11

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 12

2. Two Idiopathic White Hyperkeratotic Lesions Geographic Tongue Hairy Tongue 13

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 15

Hairy Tongue Shaggy Matte of Filliform Papillae Candidiasis Stimulates the Hyperplasia Coffee, Tea, Tobacco = Black Treatment = Brush Tongue, Improve Oral Hygiene 14

3. Two Hereditary White Hyperkeratotic Lesions Leukoedema White Sponge Nevus 16

Leukoedema Milky Grey Film Bilateral Buccal Mucosa, Non-progressive Disappears When Stretched More Common in Black Population Treatment = None Needed 17

White Sponge Nevus Rough, Fissured Texture Symetric, Bilateral Buccal Mucosa Appears During Childhood, Non-progressive Autosomal Dominant Transmission 18

RECOGNIZING WHITE LESIONS II: Auto-Immune, Infectious, Neoplastic David E. Wojtowicz, DDS, MBA 1

4. Two Auto-Immune White Hyperkeratotic Lesions Lichen Planus Lupus Erythematosus 4

Lichen Planus Auto-immune Degeneration of Connective Tissue / Mucosa (Skin) Interface Middle Age (Rare Before 30) M = F, Skin Lesions (33%) 5

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 . . . 6

Erosive Lichen Planus Painful Risk Factor for SCC Treatment = Biopsy, Steroids, Retinoic Acid 7

Lupus Erythematosus Skin Lesions: Butterfly Rash (Sun Exposed Area) Mucosal Lesions: Rough White Patch Bordered by Striae, Ulcers, Erythema 8

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) 10

Candidiasis (Moniliasis) Acute Pseudomembraneous (“Thrush”) - White DOES Scrape Off Atrophic (“Erythematous”) - Red (Does NOT Scrape Off) Chronic Hyperplastic (“Candidal Leukoplakia”) - White 11

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 Erythroleuko-plakia 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 12

Syphilitic Mucous Patch Painless, White, Mucosal Ulcers With . . . Nonpruritic Skin Rash, Lymphadenopathy Signs of Secondary Syphilis (T. pallidum) 13

6. Four Neoplastic White Lesions Squamous Cell Carcinoma Verrucous Carcinoma Epithelial Dysplasia Carcinoma in Situ 14

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 15

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 16

Carcinoma in Situ (CIS) Entire Thickness (Top to Bottom Change) Basement Membrane Intact No Invasion or Change of Connective Tissue 17

Geriatrics Cancer Risk: May Progress to SCC or VC 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) 18

3 Mechanisms: Subepithelial Change 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 2

Clues to Normal Bilateral Symmetry Predictable Locations Asymptomatic Independent Finding (no Secondary Features such as redness, swelling) Increase with Age Remains Unchanged w/ Treatment 19 19

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 19 20

Review: Which of the Following Choices Demonstrate Concepts of Differential Diagnosis: List of Diseases With Similar Manifestations (Yes) Oral Ulcer (No, monomorphic presentation) Zinc Deficiency, Trauma, Herpes, Aphthous Lesion as Potential Etiologies for a Single Monomorphic Presentation. (Yes) Rely Primarily on the Clinical Appearance (No, must include history, risk factors, visual inspection) 20 21

List the Seven Primary Clinical Manifestations of Non-dental Lesions Normal Variation White Red (Pigmented or Dark) Ulceration Exophytic Radiographic Syndrome 24 22

List Four Techniques Employed to Investigate the Secondary Clinical Features of Oral Lesions: Visual Inspection Palpation Probing Patient Awareness 25 23

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?) 27 24

During Palpation One Can Check For: Compressible Tender Color Change (Blanching) Mobile / Bound Down Induration Probing, Exudate 28 25

During the Interview, Inquire if Patient is Aware of: Pain or Altered Function Duration (Acute, Chronic) Progressive Course or Remission Response to Stress/ Foods 29 26

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) 30 27

Differential Diagnosis List of Diseases With Similar Manifestations Rule Out (R/O) on the Basis of Contradictions Example: Oral Ulcer