White Lesions Flashcards
White - Wipable
Hairy Tongue / Coated Tongue
Pseudomembranous Candidiasis
Morsicatio Buccarum
Chemical Burn
Cotton Roll Stomatitis
Toothpaste / Mouthwash Reaction
Coated Tongue
Combination of bacteria and sloughing epithelial cells on dorsal tongue only
Contributing factors include mouth breathing, xerostomia, open mouth
posture, sinusitis, dehydration, poor oral hygiene, febrile/acute illness
Can be cause of halitosis
Cream colored to tan film that is wipeable
Can occur in anterior part of tongue or cover posterior aspect as well
RX: Improve hydration, increase OH (especially brushing tongue), r/o
ankyloglossia
White Hairy Tongue
Caused by accumulation of keratin on FILIFORM papillae
Occurs on dorsal aspect of tongue
Unknown cause, but may be associated with xerostomia, poor oral hygiene and tobacco
exposure in adolescent
Appear as cream to brown colored projections on the tongue. May appear thick and matted.
Also see brown hairy tongue for related clinical presentation
Adherent to tongue, but can the discoloration can be removed
Prevalence is unknown in children
TX: Increase hygiene, brush or scrap tongue, discontinue tobacco usage, 1% or 2% hydrogen
peroxide can decrease clinical presentation
Pseudomembranous Candidiasis (Thrush)
Common oral infection in neonates
◦ Increased incidence with antibiotics/steriods being taken by neonate or mother
(when breastfeeding is occurring)
◦ Premature and immunocompromised patients have higher incidence
Caused by Candida albicans
Presentation: White, wipeable, non-adherent papules and plaques. Red
underlying mucosa that may burn.
Concurrent conditions: Diaper rash, perioral rash
NOT only on dorsal aspect of tongue, found throughout oral cavity
RX: Nystatin or Fluconazole (May need to treat both mother and child)
◦ Try to maintain bacterial balance when on antibiotics
◦ Rx probiotic to help maintain balance in GI and minimize fungal/opportunistic
overgrowth
◦ 1000mg troche is 900mg sugar!
Rule out coated tongue, materia alba, mucosal sloughing
Morsicatio’s Buccarum
Chronic irritation to the internal buccal mucosa
Subset of frictional keratosis
Caused by biting, chewing or chronic irritation to the area
Can be a result of narrow maxilla, excessive buccal fat
Typically bilateral and parallel to the occlusal plane
Hyperparakeratosis, acanthosis and vacuolated cells
Chemical / Mucosal Burn
Typically a result of thermal burn from pizza, soup, hot beverage
Palate and tongue are most common locations
Chemical burn can result from formocresol, acid etch, ferric sulfate
Typically occurs on skin (perioral), gingiva, buccal or labial mucosa
Appears as irregular shaped necrotic patch that wipes off and reveals
red erosive area
RX: Palliative, allow it to heal and typically resolves in a few days:
Neosporin for perioral/skin lesion
Possibly due to cinnamon or dentifrice, but more diffuse
Cotton Roll / Triangle Stomatitis
Caused by inadvertent removal of cotton roll or cheek
triangle causing superficial mucosal removal
Superficial layer of mucosa has sloughed off
Self-limiting and will heal in the days following the dental
appointment
Moisture is absorbed from the mucosa into the cotton roll
or triangle
Toothpaste or Mouthwash Associated
Mucosal Sloughing
Etching of superficial oral mucosa from contact allergy/irritation
Toothpaste (esp. new brand/flavor) and mouthwash are most common causes
Pyrophosphates in Crest Pro Health and other dentifrices can lead to sloughing
Floor of mouth, buccal and labial mucosa are most common
Burning sensation with thin peeling white film
◦ Underlying erythema, ulcers or smaller vesicles
RX: Discontinue causative agent, palliative TX
White – Non-Wipable
Symmetrical
◦ Linea alba / Frictional Keratosis
◦ Leukoedema
◦ Reticular Lichen Planus
◦ White Sponge Nevus
◦ Hereditary Benign Intraepithelial Dyskeratosis (HBID)
White – Non-Wipable
Solitary/Multiple
◦ Leukoplakia
◦ Tobacco Keratosis
◦ Actinic Cheliosis
◦ Hairy Leukoplakia
◦ Hyperplastic Candidiasis
Linea Alba
Buccal mucosa presentation and can span from commissure to
posterior aspect of molars
Present as distinct linear white line, adjacent to the occlusal plane and
may be slightly raised
Can be associated with frictional keratosis on lateral border of tongue
Prevalence of 1.5% in children, up to 5.3% in adolescents
NO treatment is needed
Frictional Keratosis/Cheek & Tongue Biting
Due to low grade, chronic irritation that is fairly obvious
Gingiva, buccal mucosa and lateral aspect of tongue is most common
White, adherent patches that appear smooth or can have roughed,
corrugated surface appearance
Non-tender to touch or pull of cheek
May be associated with prominent linea alba on buccal mucosa
NO treatment needed, will reverse with change in habit
Mimics smokeless tobacco keratosis, leukoplakia, chronic hyperplastic
candidiasis
Prevalence is 0.26-1.89% in children
Leukoedema
Variation of normal oral mucosa
Increased incidence in African-American patients
◦ Can occur in over 50% of these children
Buccal mucosa is most common intraoral site
Uni or bilateral, diffuse, white film, adherent, wrinkled mucosa
Stretching of mucosa will cause lesion to fade or disappear
Increased thickening of oral mucosa, intracellular edema of
spinous layer
NO treatment needed
Mimic white sponge nevus and cheek-biting keratosis
Lichen Planus
Chronic mucocutaneous disease (Rare in children)
Caused by T-Cell mediated autoimmune disease, may be due to
contact allergy (lichenoid reaction)
Affects SKIN (Especially extremities) AND ORAL MUCOSA
◦ Buccal mucosa, gingiva and tongue and most common locations
Appear as white lacy lines with a red background; Bilateral and
symmetrical presentation
Burning sensation and will come and go over time
May have secondary candida infection on top of lichen planus
TX: Incisional biopsy to confirm and topical steroids
◦ Topical antifungals if candida is suspected
White Sponge Nevus
Inherited in autosomal dominant manner
◦ Mutation is gene coding for Keratin 4 and 13 proteins
Result in asymptomatic benign, white lesions of the buccal mucosa
Deeply folded white lesion of buccal mucosa, other sites too
Symmetrical, appear earlier in life
Do not disappear when pulled upon
Spongiosis, acanthosis, parakeratosis, clear cells in prickle layer
Perinuclear condensation of keratin
Prevalence of 1.54%
Treatment: None needed, no malignant potential → only remove if
causing problem with speech and /or feeding
Hereditary Benign Intraepithelial
Dyskeratosis
Autosomal dominant mucocutaneous disease
Also known as Witkop’s disease or Witkop-Von Sallmann Syndrome
Very rare and effects individuals of mixed white, American Indian and
black ancestry living in North Carolina (Triracial)
Closely resembles white sponge nevus, BUT also affects EYES
◦ Can lead to visual impairment
Leukoplakia
White patch or plaque of 5mm or greater
Cannot be wiped off
Non-specific, more generalized term
Floor of the mouth and or buccal vestibule
Usually due to local irritant or ill-fitting device/appliance
Determine possible cause and cease to see if it resolves
If not, biopsy to confirm
Smokeless Tobacco Keratosis
Commonly caused by chewing tobacco, snuff or dip
Vestibular mucosa is common location
White, wrinkled, adherent plaque. Associated gingival
recession, stained teeth, tooth sensitivity and halitosis
TX: Stop habit immediately, consider biopsy if keratosis
does not resolve after stopping habit
◦ Can become malignant, but rarely occurs in younger patient
Actinic Cheilosis
Referred to as Solar cheilitis or actinic cheilitis
Occur after years or prolonged exposure to ultraviolet light
(UV) that is mainly UVB in nature, like sunlight
This is a pre-malignant condition and needs to be closely
monitored
Most common is adults and with increasing age/exposure
Lower lips are most frequently impacted
Early signs show color changes at vermillion border and loss of
distinct border
Lips appears cracked, ulcerated and may not heal
Hairy Leukoplakia
Latent infection of Epstein-Barr Virus
Common with immunocompromised, especially HIV patient
Ventral-lateral surface of tongue
White, shaggy adherent plaques; may be tender
Candida infections can occur concurrently
Tx: Incisional biopsy if cause is unknown, Rx antiviral and
antifungal
Diff Dx: Cinnamon reaction, tongue-biting reaction, lichen
planus
Chronic Hyperplastic Candidiasis
Chronic mucocutaneous disease
May be associated with endocrine and/or autoimmune disorders
Commonly seen in anterior buccal mucosa and tongue
◦ May have nail involvement
White, wrinkled adherent plaques that may be tender to touch
TX: Incisional biopsy and antifungal agents
Differential Dx: Cinnamon reaction, cheek or tongue biting keratosis,
lichen planus, hairy leukoplakia
