Differential Diagnosis of White Patches Flashcards
What are the possible categories to classify white lesions?
- Normal
(e.g. lingual tonsils and retroplastic papilla are common things mistaken as pathological) - Developmental
- Traumatic
(e.g. cheek, tongue biting producing keratosis) - Infectious
(hairy leukoplakia (infection of Epstein Barr virus) and candida) - Lichen planus and similar conditions
(white striae associated with lichen planus (present in 2-3% of population)) - Idiopathic
How to approach history and examination?
- Is the lesion a carcinoma? (feel induration of lesion)
- is it normal?
- Evidence for developmental condition? (look for changes in other tissues such as hair/nails and ask for family history)
- Habits and cause of friction (sharp teeth/restorations, cheek biting etc.)
- Does site help?
1. Chronic hyperplasia candidosis (occurs behind commissure of buccal mucosa)
2. Oral hairy leukoplakia (lateral border of tongue and sometimes on buccal mucosa)
3. Stomatitis nicotina (diffusely white across whole palate, opening of salivary glands often inflamed) - Any striae or atrophic pattern?
- Risk features for dysplasia and malignancy?
- Smear it/ biopsy it
How can Fordyce spots be classified and what are the clinical features?
- Normal anatomy
- Small, raised, pale red, yellow-white or skin-coloured bumps or spots that can appear on vermillion border of lips, buccal or labial mucosa
- When numerous and confluent they can make creamy yellow plaque
- Sometimes seen on retromylohyoid area
- 80% adults
- Sebaceous glands in oral mucosa
How can leukoedema be classified and what are the clinical features?
- Normal anatomy
- Often seen on afro-caribbean pts
- Would disappear on stretching on tissue
- Bilateral, diffuse, translucent, white thickening of surface layers of epithelium with an increase in thickness of parakeratin at the surface
- Buccal and labial mucosa
- Hx: irregular parakeratinisation and upper prickle cells show an enhanced ‘blanket weave’ pattern
- Tx unnecessary
How can geographic tongue (erythema migrans) be classified and what are the clinical features?
- Irregular smooth, red areas on dorsal tongue
- Caused by loss of filiform papillae
How can white sponge naevus (Cannon’s syndrome) be classified and what are the clinical features?
- Developmental
- Important as often with pt’s without family history
- Not dysplastic, often presents as irregular layers of keratin
- Genetic autosomal dominant trait
- Bilateral buccal mucosa
- White thickening can involve all lining mucosa. White areas lack sharp borders
- Hx: epithelial thickening
- Defective parakeratinisation
- No tx - reassure - benign
What are other developmental differential diagnoses for white patches?
- Dyskeratosis congenita (bone marrow failure)
- Pachyonychia congenita (nails and skin)
- Tylosis (hyperkeratosis of the palms and soles)
What white patches can physical trauma cause?
- Frictional keratosis
- Completely benign
- White patch caused by prolonged mild abrasion of the mucosal membrane by insults e.g. sharp tooth or dentures
- At first: pale and translucent
- With prolonged friction: Dense and white and smooth
- Common sites: BM and edentulous alveolar ridge
- Excessive trauma will cause an ulcer, and the margins of a traumatic ulcer are often surrounded by a zone of frictional keratosis - cheek/tongue biting
- Biting produces indentations and shredded tags
- Background epithelium undergoes keratosis in response
- Causes an area of mucosa to appear red and white with a rough surface
- Damage is superficial
What can cause white patches due to chemical trauma?
- Aspirin/caustic/iatrogenic
- Mouthwashes
- Snuff Dippers’ Keratosis
What three types of candela infection can cause white patches?
- Thrush (acute candida)
- Sore, often pts immunosuppressed, medication, diabetes?
- Red background with fluffy, white areas
- Able to be rubbed off - Chronic hyperplastic candidosis
- Generally behind commissure for smokers
- Unable to be rubbed off (as lower organism count)
- Irregular outline with tessellated pattern
- Discrete white plaque - Mucocutaneous type
- Chronic mucocutaneous candidiasis
- Discrete white plaque
What bacterial conditions can cause white patches in the mouth?
- Syphilitic leukoplakia
What viral condition can cause a white patch in the mouth?
- Hairy leukoplakia
- Sign of HIV infection (occasionally occurs in normal individuals)
- Sof tt corrugated painless plaques on lateral borders of tongue
- Dx: biopsy
- EBV antigens detectable in epithelial nuclei
- Not premalignant - no tx required
- May regress spontaneously or with HIV antiretroviral tx
How can idiopathic white patches be classified clinically?
- Clinically white patches are leukoplakia
- Histologically all are keratosis with or without dysplasia
- Other ways to classify:
1. Clinical presentation: Homogenous, Verrucous, Nodular
2. By site: Sublingual keratosis
3. Presumed aetiology: Smoker’s keratosis, actinic keratosis - Occasionally one with be squamous cell carcinoma
By principle, what should happen to all white patches
- Should have biopsy sample removed
- Only the very experienced or unwise do not biopsy and both can be caught out by an unexpected malignancy or dysplasia
Look at papers for differential diagnosis flow charts of common red and white patches
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