Keratotic White Lesions of Oral Mucosa An Oral ... White Lesions of Oral Mucosa: An Oral...

Bhasin M, Saini RS, Laller S, Malik M. keratotic white lesions of oral mucosa: an oral

stomatologist perspective. J Periodontal Med Clin Pract 2016;03: 33-40

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1, 2 3 4Dr. Meenakshi Bhasin Dr. Ravinder S Saini , Dr.Sanjeev Laller , Dr.Mamta Malik

Keratotic White Lesions of Oral Mucosa: An Oral Stomatologist Perspective

Review Article

Affiliation

1. Senior Lecturer, Department of Oral Medicine & Radiology,

Hitkarini Dental College,Jabalpur, M.P,India.

2. Department of Dental Technology COAMS, KKU, Saudi Arabia

3. Reader, PDM Dental college & Research Institute Bahadurgarh, Haryana, India.

4. Reader,PDM Dental college & Research Institute Bahadurgarh, Haryana, India.

Corresponding Author:

Dr. Meenakshi Bhasin

Senior Lecturer, Department of Oral Medicine & Radiology,

Hitkarini Dental College,

Jabalpur, M.P,India

Conflict of Interest – Nil

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Abstract

White lesions are common findings in the oral cavity

and may affect any surface such lesions are often an

incidental finding on routine examination. The

process of clinical diagnosis and treatment planning

is of great concern to the patient as it determines the

nature of future follow up care.White lesions of the

oral mucosa represent a diagnostic challenge for

dental practitioners, because similar appearances

are the final common manifestation of a wide

spectrum of conditions. The lesions represent

diagnoses of varying seriousness, ranging

fromtraumatic keratosis to dysplasia and squamous

cell carcinoma. Some clinical features are classical

and others overlap between different diagnoses,

they should be correlated with patient

history.Clinicaldiagnostic skills and good judgment

forms the key to successful management of white

lesions of theoral cavity.�Key words: Keratotic, white lesions, leukoplakia,

mucosa

Introduction

Oral white lesions are a common clinical finding in a

recent study of more than 17 000 people in the 1

United States, these lesions were found in 27.9% .

The lesions represent a wide spectrum of diagnoses

of varying seriousness, ranging from traumatic

keratosis to dysplasia and squamous cell 3

carcinoma . White patches may be isolated or

involve multiple areas and have variable

presentations including linear patterns, plaque like

lesions, diffuse patches and mixed white and

Vol-III, Issue - 1, Jan-Apr 2016


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4erythematous areas . Most of the oral diseases have

pathognomic & characteristic clinical features which

can serve as pathfinder in the diagnosis. White lesions

appear white due to increased thickness of surface 5epithelium and reduced vascularity . It is important to

investigate the lesion with a thorough history,

examination and the appropriate investigations. This

article briefly reviews common lesions which may

present as a white patch in the oral cavity and their

management.

thWhite Lesions (Acc to Burket's Oral Medicine 9

Edition)

Ø Lichen Planus

Ø Nicotine Stomatitis

Ø Leukoedema

Ø Leukoplakia

Ø Hairy tongue

Ø Geographic Tongue

Ø HairyLeukoplakia

Ø Hyperplastic Candidiasis

Ø White Sponge Nevus

Ø Frictional Keratosis

Ø Chemical Burn

Ø Linea Alba Buccalis

L ic he n P la nus A sym p to m a tic , c o m m o nly b ila te ra l, w hite p la q ue a rra nge d in

s tria te d p a tte rn a sso c ia te d w ith e rythe m a , a ffe c ting

p re d o m ina ntly the b uc c a l m uc o sa , to ngue a nd

gingiva e ,7 w hic k a m s tria e , fla t le s io ns a nd a sso c ia te d w ith the

his to ry o f s tre ss . C o rtic o s te ro id s a re the m a ins ta y o f O L P

the ra p y b e c a use o f the ir a c tivity in d a m p e ning c e ll m e d ia te d

im m une a c tivity a nd a re a d m inis te re d to p ic a lly,

intra le s io na llyo r sys te m ic a lly. T he c o m b ina tio n o f sys te m ic

a nd to p ic a l s te ro id the ra p y is o fte n ve ry e ffe c tive . L o c a lize d

o ra l le s io ns a re tre a te d w ith to p ic a l o intm e nt,a p p lie d tw o to

fo ur tim e s d a ily a fte r m e a ls a nd ge ne ra lize d o ra l le s io ns a re

o fte n tre a te d e ffe c tive ly w ith a s te ro id m o uth rinse tw ic e d a ily

a fte r m e a ls .8 T re a tm e nt o f O L P w ith c yc lo sp o rin,

a za thio p rine ,le va m iso le , grise o fulvin, re tino id s ,

hyd ro xyc hlo ro q uine sulp ha te , d a p so ne a nd p so ra le n/U V A ha s

b e e n re p o rte d .9 ,1 0 (F ig 1 )

N ic o tine S to m a tit is N ic o tinic s to m a titis o c c urs a lm o st e xc lus ive ly in he a vy

p ip e sm o k e rs a nd ra re ly in c iga re tte o r c iga r sm o k e rs . It

c ha ra c te ris tic a llyo c c urs p o s te rio r to the ruga e a s re d ne ss o n the

p a la te , w hic hla te r a ssum e s a gra yish- w hite a nd no d ula r

a p p e a ra nc e d ue to p e rid uc ta l k e ra tiniza tio n o f the m ino r

sa liva ry gla nd s . A c ha ra c te ris tic find ing is the a p p e a ra nc e o f

m ultip le re d d o ts ,w hic h re p re se nt the d ila te d a nd infla m e d d uc t

o p e nings o f the m ino r sa liva ry gla nd s . T he rm a l a nd c he m ic a l

a ge nts a c tinglo c a lly a re re sp o ns ib le fo r the o c c urre nc e o f this

c o nd itio n. T he tre a tm e nt o f c ho ic e is sm o k ing c e ssa tio n.1 1


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3. Leukoedema Located Bilaterally on buccal mucosa, gray-white, diffuse,

wrinkled surface, disappears on stretching mucosa and it has

milky surface with an opalescent quality. No treatment is

required6.

4. Leukoplakia White patch, Localised or extensive, slightly elevated,

wrinkled surface. On palpation these lesions may feel leathery

to “dry or cracked mud like6.” Treatment requires cessation of

habit. The use of beta-carotene has potentialbenefits and

protective effects against cancer are possiblyrelated to its

antioxidizing action.12The supplementation of lycopene (8

mg/day and 4 mg/day) reduced hyperkeratosis.13Recommended

daily allowance for ascorbic acid ranges between 100–120

mg/per day for adults.13 The recommended daily limit rates for

α-Tocoferol (Vitamin E) are 10 mg/day for adult men and 8

mg/day for adult women.14 In the systemic use with dosage of

300000 IU of retinoic acid (Vitamin A) and in topical use with

dosage range from 0.05% to 1%.13 Topical bleomycin was

used in dosages of 0.5%/day for 12 to 15 days or 1%/day for

14 days.13 (Fig 2)

5. Hairy tongue Abnormal coating on the dorsum of tongue occur due to

neglected oral hygiene, use of antibiotics and

immunosuppressive drugs, oral candidiasis, excessive alcohol

consumption and smoking. Desquamation of the filliform

papilla leads to hair like appearance. Treatment focused on

elimination of predisposing factors and removal of filiform

papilla.15

6. Geographic tongue It is a benign, inflammatory disorder, circumferentially

migrating and leaves an erythematous area behind, atrophy of

filiform papilla and occurring most commonly on the dorsum

of the tongue and on the lateral borders.16 For painful BMG,

recommended supportive and symptomatic management would

include a bland diet, plenty of fluids, acetaminophen for

systemic pain relief, and a topical anesthetic agent such as



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3. Leukoedema Located Bilaterally on buccal mucosa, gray-white, diffuse,

wrinkled surface, disappears on stretching mucosa and it has

milky surface with an opalescent quality. No treatment is

required6.

4. Leukoplakia White patch, Localised or extensive, slightly elevated,

wrinkled surface. On palpation these lesions may feel leathery

to “dry or cracked mud like6.” Treatment requires cessation of

habit. The use of beta-carotene has potentialbenefits and

protective effects against cancer are possiblyrelated to its

antioxidizing action.12The supplementation of lycopene (8

mg/day and 4 mg/day) reduced hyperkeratosis.13Recommended

daily allowance for ascorbic acid ranges between 100–120

mg/per day for adults.13 The recommended daily limit rates for

α-Tocoferol (Vitamin E) are 10 mg/day for adult men and 8

mg/day for adult women.14 In the systemic use with dosage of

300000 IU of retinoic acid (Vitamin A) and in topical use with

dosage range from 0.05% to 1%.13 Topical bleomycin was

used in dosages of 0.5%/day for 12 to 15 days or 1%/day for

14 days.13 (Fig 2)

5. Hairy tongue Abnormal coating on the dorsum of tongue occur due to

neglected oral hygiene, use of antibiotics and

immunosuppressive drugs, oral candidiasis, excessive alcohol

consumption and smoking. Desquamation of the filliform

papilla leads to hair like appearance. Treatment focused on

elimination of predisposing factors and removal of filiform

papilla.15

6. Geographic tongue It is a benign, inflammatory disorder, circumferentially

migrating and leaves an erythematous area behind, atrophy of

filiform papilla and occurring most commonly on the dorsum

of the tongue and on the lateral borders.16 For painful BMG,

recommended supportive and symptomatic management would

include a bland diet, plenty of fluids, acetaminophen for

systemic pain relief, and a topical anesthetic agent such as



7. Hairy Leukoplakia Usually in an immunocompromised or immunosuppressed

host. May serve as a pre-AIDS sign. Located on Lateral border

of tongue. Early lesions are fine, white, vertical streaks with

corrugated surface or vertical folds and later lesions are plaque

like.16OHL is usually asymptomatic. Topical retinoids (e.g.

0.1% vitamin A may improve the appearance of OHL-affected

oral surfaces through their dekeratinizing and

immunomodulating effects. Topical podophyllin has also been

reported to induce resolution of OHL.Hairy leukoplakia can be

treated successfully with antiviral drugs.Antiviral agents such

as acyclovir, zidovudine, desciclovir ganciclovir.Lesions recur

soon after discontinuation of therapy.17

8. Candidiasis Oral candidiasis is a common opportunistic infection ofthe oral

cavity caused by an overgrowth of Candidaspecies, the

commonest being Candida albicans.18Associatedwith

predisposing factors include immunosuppression, diabetes

mellitus, antibiotic therapy, xerostomia and use of dentures.

There are a number of different types of oropharyngeal

candidiasis including acute pseudomembranous, acute

atrophic, chronic hyperplastic, chronic atrophic, median

rhomboid glossitis, and angular cheilitis.18Pseudomembranous

candidiasis (thrush) is characterised by extensive white

pseudomembranes consisting of desquamated epithelial cells,

fibrin, and fungal hyphae. These white patches occur on the

surface of the labial and buccal mucosa, hard and soft palate,

tongue, periodontal tissues, and oropharynx. The membrane

can usually be scraped off with a swab to expose an underlying

erythematous mucosa.18Acute atrophic candidiasis is usually

associatedwith a burning sensation in the mouth or on the

tongue. The tongue may be bright red similar to that seen with

a low serum B12, low folate, and low ferritin.18Chronic

hyperplastic candidiasis characteristically occurs on the buccal

mucosa or lateral border of the tongue as speckled or



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9. White Sponge Nevus White sponge nevus (WSN) is a rare hereditary dyskeratotic

hyperplasia of mucous membranes21.Present at birth, or in

early childhood, located on buccal mucosa, The lesions consist

of symmetric, thickened, white, corrugated or velvety, diffuse

plaque21 with an elevated and irregular surface comprising

fissure or plaque formations.21,15 No treatment is required.

10. Frictional Keratosis Seen in edentulous areas of the alveolar ridge. Reducing

predisposing factors are sufficient. No surgical intervention is

required.15

12. Chemical Burn Result from applying analgesics such as aspirin or

acetaminophen, to the mucosa adjacent to an aching tooth,

mild white filmy desquamation seen in oral mucosa.Areas of

necrosis typically heal without scarring in 7-10 days after

discontinuation of the drug.22Simultaneously palliative and

symptomatic treatment such as topical anaesthetics

(benzocaine gel) and topical corticosteroids(Triamcinolone

ointment)may be helpful.

13 Linea Alba Buccalis White line, seen bilaterally, streak on buccal mucosa at the

level of occlusal plane extending horizontally from

commissure to most posterior teeth.

Fig. 1 Fig. 2



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Fig. 3 Fig. 4

Conclusion

Oral white lesions are not uncommon and a

significant number of patients are asymptomatic.

The dental professionals should be familiarize with

their pattern and presentation to effect early

diagnosis and management.

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Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript.Source of support: NIL

Copyright © 2014 JPMCP. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



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