White Lesions

what is a Flat, solid, raised area of the skin or mucosa > 1 cm in diameter?

plaque

(> 1 cm in diameter)

plaque

what is a Solid mass of tissue > 1 cm in diameter?

tumor

(Solid mass of tissue > 1 cm in diameter)

tumor

what makes the oral mucosa look white?

could be due to:

• thick keratin

• alteration to keratinocytes

• thick epithelium

• fibrosis

what acronym can we use to remember etiologies/types of white lesions?

HIDE MAN

• hereditary

• infectious

• developmental

• environmental/reactive

• metabolic/medication-induced

• autoimmune/allergic/immune

• neoplastic

• White sponge nevus

• Hereditary benign intraepithelial dyskeratosis

• Darier disease/Warty dyskeratoma

• Dyskeratosis congenita

Are what category of white lesions?

hereditary

how is White Sponge Nevus (Cannon disease) passed down

rare autosomal dominant genodermatosis

White Sponge Nevus (Cannon disease) is caused by a mutation in…?

keratin 4 and 13

White Sponge Nevus (Cannon disease) is the defective _______ of oral mucosa

keratinization

the following are clinical features of:

• Appears at birth or early childhood

• Asymptomatic, bilateral and symmetrical, thickened, white, corrugated or velvety, diffuse plaques of the buccal mucosa

• Other oral mucosal sites

• Extra oral mucosal sites less common

White Sponge Nevus (Cannon disease)

what treatment is indicated for White Sponge Nevus (Cannon disease)?

• No treatment required

White Sponge Nevus (Cannon disease)

• white, symmetrical, waxy plaques

• could be mistaken for pseudomembranous candidiasis

White Sponge Nevus (Cannon disease) histopathologically presents with prominent __________ and marked acanthosis with clearing of the cytoplasm of the cells in the _______ layer

hyperparakeratosis; spinous

Perinuclear condensation of keratin tonofilaments found in White Sponge Nevus (Cannon disease)

how is Hereditary Benign Intraepithelial Dyskeratosis passed down?

• rare autosomal dominant genodermatosis

• Descendants of Native Americans who originally lived in North Carolina

Hereditary Benign Intraepithelial Dyskeratosis is caused by the duplication of chromosome _____

4q35

the following are clinical features of what white lesion?

• Develops during childhood

• Thick, corrugated white plaques, buccal and labial mucosa

• Other oral mucosal sites

• Ocular involvement → Thick, opaque, gelatinous plaques affecting the bulbar conjunctiva adjacent to the cornea

Hereditary Benign Intraepithelial Dyskeratosis

what treatment is indicated for Hereditary Benign Intraepithelial Dyskeratosis?

• No treatment required

Hereditary Benign Intraepithelial Dyskeratosis

how is Keratosis Follicularis (Darier disease) passed down?

Autosomal dominant disorder

Keratosis Follicularis (Darier disease) is caused by a mutation in ______ gene

ATP2A2 (alters normal function of desmosomes and keratin)

the following are clinical features of what white lesion?

• White, painless, keratotic papules or plaques, and cobblestoning of the oral mucosa

• 1/3 parotid or submandibular swelling

• Erythematous, papules on the skin of the trunk and the scalp

Keratosis Follicularis (Darier disease)

what treatment is indicated for Keratosis Follicularis (Darier disease)?

topical steroids

how is Dyskeratosis Congenita passed down?

Rare X-linked recessive genodermatosis

Dyskeratosis Congenita is caused by a mutation in _____ gene

DKC1 (other mutations have also been identified)

Dyskeratosis Congenita is caused by gene mutations that disrupt the normal maintenance of ________-

telomerase

Dyskeratosis Congenita presents an increased risk of …?

oral cancer and aplastic anemia

the following are clinical features of…?

• Apparent during first decade (super young patients)

• Nail dystrophy

• Oral leukoplakia

• Abnormal skin pigmentation

Dyskeratosis Congenita

Dyskeratosis Congenita

what category of white lesion are the following?

• Oral candidiasis

• Oral Hairy leukoplakia

infectious

what are some causes of oral candidiasis?

Antibiotics, inhaled/topical steroids, immunosuppression, dry mouth, denture

t/f: oral candidiasis is an opportunistic fungal infection

true

the following are clinical features of what white lesion?

• Pseudomembraneous

• Erythematous

• Hyperplastic

oral candidiasis

what treatment is indicated for oral candidiasis?

• Nystatin suspension

• Clotrimazole troches

• Fluconazole

oral candidiasis

how is oral candidiasis diagnosed?

clinically and in laboratory

what causes oral hairy leukoplakia?

Epstein-Barr virus

t/f: oral hairy leukoplakia is a premalignant lesion

true

the following are clinical features of…?

• white, vertical, linear lesion or plaque on lateral border of tongue

oral hairy leukoplakia

what treatment is indicated for oral hairy leukoplakia?

• topical antivirals

• Adjustment of HIV medications and systemic immunosuppressants

what patients populations are affected by oral hairy leukoplakia?

• HIV/AIDS with low CD4 counts

• immunocompromised

• topical steroids

• healthy individuals

oral hairy leukoplakia

the following are what cateogory of white lesions?

• Leukoedema

• Contact desquamation

• Hairy tongue

• Frictional keratosis

• Benign alveolar ridge keratosis

• Nicotine stomatitis

• Smokeless tobacco keratosis

environmental/reactive

the following are clinical features of Leukoedema?

• Delicate lacy, gray-white lines on the buccal mucosa or ventral tongue

• Disappears on stretching the mucosa

• Very common

leukodema

what are causes of leukodema?

• Mildly irritating substances

  • Smoke from tobacco products or marijuana

  • caustic oral rinses, or toothpaste

• Traumatic, parafunctional habit such as mucosal sucking

what treatment is indicated for leukodema?

no treatment required

leukodema

the following are clinical features of what white lesion?

• Painless, thready white tissue on the mucosa, peels off leaving normal mucosa

Contact Desquamation

what causes Contact Desquamation?

• Caustic mouth washes high in alcohol content

• Strong toothpastes (whitening)

• Other contactants that are irritants to the mucosa

what treatment is indicated for Contact Desquamation?

Discontinuation of offending agent

Contact Desquamation

coated tongue is also known as…?

hairy tongue

the following are clinical features of what condition?

• Elongated filiform papillae on the dorsal surface of the tongue

• Yellowish white, can be discolored

coated tongue

what are some causes of coated tongue?

• heavy smoking

• poor PO intake

• dehydration

• poor oral hygiene

do not confuse hairy tongue with what other condition?

hairy leukoplakia

what treatment is indicated for coated tongue?

none (benign, esthetic concerns)

brushing tongue, improving oral hygiene

coated tongue

what treatment is inidcated for frictional keratosis?

none. biopsy is rarely indicated

frictional keratosis

• above = linea alba

• below = morsicatio mucosae oris

what are 2 types of frictional keratosis?

• linea alba (buccal mucosa)

• morsicatio mucosae oris (chronic chewing of oral mucosa)

Benign Alveolar Ridge Keratosis is oftren confused with ________

leukoplakia

what treatment is indicated for Benign Alveolar Ridge Keratosis?

none

what white lesion is a poorly demarcated, rought white plaque of keratinized mucosa caused by friction with food?

Benign Alveolar Ridge Keratosis

t/f; Benign Alveolar Ridge Keratosis is essentially a callous in the oral mucosa

`true

Benign Alveolar Ridge Keratosis

what condition is a leathery, white change of the hard palatal mucosa in long term smokers?

Nicotine Stomatitis

what treatment is indicated for Nicotine Stomatitis?

none (reversible after smoking cessation)

Nicotine Stomatitis is a mucosal response to ______

heat

Nicotine Stomatitis

Smokeless Tobacco Keratosis is caused by contact with caustic agents within ______

tobacco

how does early stage of Smokeless Tobacco Keratosis present?

grayish-white wrinkles and parallel ridges and fissures in the area where tobacco is placed

*reversible

how does advanced stage of Smokeless Tobacco Keratosis present?

well-demarcated keratotic plaques

• must biopsy for evaluation of dysplasia

• regular follow up

smokeless tobacco keratosis

what category of white lesions are the following?

• Oral lichen planus

• Lupus erythematosus

• Oral graft-versus-host disease

autoimmune/immune-mediated/allergic

the following are clinical features of what condition?

• Typically, bilateral and symmetrical

• Reticular/keratotic (Wickham striae)

• Ulcerative

• Erythematous/erosive

Oral Lichen Planus (OLP)

smokeless tobacco lesion

what treatment is indicated for oral lichen planus (OLP)?

• Topical and systemic steroids or steroid-sparing agents

• Replacing amalgam restorations

what demographics are affected by oral lichen planus?

1-2% of middle-aged patients

2/3 : 1 female predominance

what are some causes of oral lichen planus (OLP)?

• idiopathic

• medication-induced

• hepatitis C virus

what is the MOA of oral lichen planus (OLP)?

T cell destruction of basal cells

oral lichen planus (OLP) can occur as contact lichenoid reactions to dental _________

amalgams

oral lichen planus (OLP) show malignant transformation potential of %

0.1-1% of cases

Lichenoid reaction associated with amalgam restoration

the following are clinical features of what condition?

• Autoimmune disease, unknown etiology

• Affects multiple organs

• Oral lesions resemble oral lichen planus (Not always bilateral and symmetrical)

• characteristic butterfly rash, scarring, and post inflammatory hyperpigmentation

Lupus Erythematosus

what & of patients with DLE and SLE, respectively, have oral lesions?

20% and 45%

what are some circulating anitbodies in systemic lupus erythematosus?

ANA, anti-Smith, anti–doublestranded DNA, and antiribonucleoprotein

what are 2 forms of lupus erythematosus?

sytemic and discoid

what is a complication that can occur following hematopoietic stem cell transplant for treatment of hematologic malignancies that commonly affects the moutth?

Oral Graft-versus-Host Disease (GvHD)

Oral Graft-versus-Host Disease (GvHD) oral mucosal lesions essentailly resemble ___

OLP (and therefore treated similarly)

the following conditions are what category of white lesions?

• Oral leukoplakia

• Oral submucousfibrosis

• Oral squamous cell carcinoma

neoplastic

what is a White plaque of questionable risk having excluded other known diseases or disorders that carry no increased risk for cancer?

oral leukoplakia

oral leukoplakia is highly associated with _______ and development of ______.

dysplasia; cancer

what are some high risk sites of oral leukoplakia?

Ventral tongue, floor of mouth, buccal mucosa, soft palate, and gingiva

what % of oral leukoplakia represent dysplasia, carcinoma-in-situ, or invasive SCC?

43% to 47%

what are the 3 types of oral leukoplakia?

• homogenous (16%)

• non-homogenous

• proliferative leukoplakia (70-100%)

what are some risk factors for oral leukoplakia?

• Smoking

• Excessive alcohol consumption

• H/o cancer and cancer therapy

• Family h/o cancer

• H/o autoimmune disorder or prolonged immunosuppression

• Areca nut chewing

• Older age

• Human Papilloma Virus

How many of these leukoplakias become/are dysplasia/SCC?

25-47%

• Variable malignant transformation

  • Homogenous: 16%

  • Proliferative leukoplakia: 70-100%

what treatment is indicated for leukoplakias?

• Surgical excision of small lesions

• Laser ablation

• Novell off label use of topical chemotherapy

• Monitoring

• Clinical trial of immune checkpoint inhibitor (nivolumab) for proliferative leukoplakia