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

2. 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. 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

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

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

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

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

9. 1. Six Reactive White Hyperkeratotic Lesions d. Linea Alba
Most Common White Lesion
White Occlusal Plane
Bilateral on the Buccal Mucosa
No Treatment Needed 10

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

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

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

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

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

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

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

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

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

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

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

21. Lichen Planus Reticular (Wickham’s Striae) Annular Erosive
Atrophic, Bullous

22. Lichen Planus Stress & Thiazide Drugs are Possible Triggers
Differential: Snuff (Stretch) White Sponge (Youth)
Treatment = None if Asymptomatic . . . 6

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

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

25. Lupus Erythematosus Systemic: Arthritis, Vasculitis (Renal Failure)
Antinuclear Antibodies (ANA)
Differential: Lichen Planus (Symmetrical & Cutaneous), Leukoedema (Stretch) White Sponge (Youth)
Treatment = Corticosteroids

26. 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

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

28. 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

29. 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

30. 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

31. 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

32. Candidiasis: Three Red Chronic Oral Lesions
Angular Cheilitis = Perleche (Red)
Median Rhomboid Glossitis (Red)
Denture Sore Mouth = Atrophic Candidiasis (Red)

33. 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

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

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

36. 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

37. Squamous Cell Carcinoma (SCC)
Uncontrolled Growth
“Up Regulation” of Oncogenes
Kinases & Cyclines Become Overactive
Deactivation of Suppresser Genes (Antioncogenes)

38. Verrucous Carcinoma Hyperkeratotic, Exophytic, Papillary
Age: Elderly (60+) Gender: Males (2:1)
Location: Gingiva, Alveolar Ridge, Buccal Mucosa

39. Epithelial Dysplasia Premalignanat Changes of Cell & Architecture
Mixed Red & White is Most Likely Presentation
Cell Alterations: Nuclear Changes
Architecture Alterations: Bulbous Rete Pegs 16

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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

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

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

49. 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

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

51. 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

52. 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

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