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White Lesions, Source: Burkhart, N.W., & DeLong, L. (2019). General…
White Lesions
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Infections
Acute Pseudomembranous Candidiasis (Candidosis, Moniliasis, Thrush)
- Etiology: Caused by species of Candida, usually albicans, which is a yeast-like fungus. Most patients harbor yeasts as part of their normal oral flora. Overgrowth of already present. Extremely low virulence. Factors include systemic broad-spectrum antibiotic therapy, systemic, topical, or aerosolized corticosteroid use, smoking, xerostomia, immune system disorders, diabetes.
- Method of Transmission: Not highly transmissible. It is considered an opportunistic infection.
- Characteristic:
1) Extraoral: Any epithelial surface of the body but is especially common in areas that are consistently warm and moist, such as the feet and areas where skin overlaps.
2) Perioral and Intraoral: Multiple, raised, whitish , cordlike plaques with variable surrounding erythema. The plaques are always multiple, and it is not unusual for large areas of the oral mucosa to be affected. Pain, discomfort, or burning. Can be scrapped off with a tongue blade or stiff instrument, hence the designation pseudomembranous.
3) Distinguishing: The ability to scrape the pseudomembranes off is a diagnostic feature of this form of candidiasis. Almost never sees bleeding base, since it would require scraping the tissues hard enough to remove the entire thickness of epithelium down into the underlying connective tissue.
- Dental Implications: Infection that needs to be diagnosed and treated. The tendency for this infection to occur in immunocompromised patients should prompt the dental professional to carefully review the patient's medical history for any sign of undiagnosed systemic problems.
- Treatment and Prognosis: Variety of effective antifungal medications are used for treatment. Many clinicians treat the infection with topical medications such as nystatin oral suspension or clotrimazole troches.
pg 339-340
Chronic Hyperplastic Candidiasis (Candidal Leukoplakia)
- Etiology: Hyperplastic candidiasis is also caused by a species of Candida, usually albicans.
- Method of Transmission: Chronic hyperplastic candidasis, like pseudomembranous candidiasis, is not considered to be highly transmissible.
- Characteristics:
1) Extraoral: Not applicable
2) Perioral and Intraoral: Chronic hyperplastic candidiasis manifests as a thickened, often raised, whitish plaque that does not rub off. Lesions commonly affect the tongue or commisure. Have no distinctive clinical features and are indistinguishable from leukoplakia.
3) Distinguishing: Hyperplastic candidiasis cannot be clinically distinguished from other white lesions that do not wipe off.
- Dental Implications: This lesion is rare, but it is considered premalignant. Chronic forms of candidiasis are also an indication that the person's immune system may be deficient.
- Treatment and Prognosis: Treatments include systemic antifungals, topical application of vitamin A/retinoids and B-carotenes, laser surgery, and conventional surgical excision. The treatment of these lesions is somewhat controversial, because treatment does not universally result in resolution of the lesion.
pgs. 340-341
Hairy Leukoplakia
- Etiology: Caused by an infection with Epstein-Barr virus (EBV) secondary to immunosuppression. HL is linked to the immunosuppression that results from infection with the human immunodeficiency virus (HIV). Well documented in other immunosuppressed patients.
- Method of Transmission: Not applicable
- Characteristics:
1) Extraoral: Not applicable
2) Perioral and Intraoral: HL produces whitish plaques that do not rub off. They usually affect the lateral borders of the tongue, often bilaterally, where they appear as vertical, raised ridges or sometimes as irregular flattened lesions. Rarely, will affect the tongue. Typically asymptomatic.
3) Distinguishing: White plaques, often with vertical raised ridges, bilaterally on the tongue in immunosuppressed patients.
- Dental implications: Significant diagnosis because it is a relatively accurate predictor of rapid progression from HIV latent infection to AIDS.
- Treatment and Prognosis: Antiviral therapy often produces improvement or resolution of the lesion. Recurrence is not uncommon. No evidence that it has the potential for malignant transformation.
pg. 341
Parulis
- Etiology:Draining sinus tract from an odontogenic infection of either periodontal or pupal origin.
- method of Transmission: N/A
- Characteristics: Swelling of gingiva; from purulent exudate (pus), which is more yellowish than white.
- Dental Implication: The source should be determined and treated.
- Treatment and Prognosis: Source determined and treated.
pgs. 341-342
Variations of Normal
Fordyce Granules
- Etiology: Normal sebaceous glands that are found in the oral mucosa. Sebaceous glands are also found in hair follicles of the skin, where they secrete an oily substance. (normal development)
- Method of Transmission: Not applicable
- Characteristics:
1) Extraoral: Not applicable
2) Perioral and Intraoral: Superficial yellowish-to-yellowish white, slightly elevated papules. Found most commonly on the buccal mucosa and are often bilaterally symmetrical. Asymptomatic.
3) Distinguishing: Very distinctive in their clinical presentation.
- Dental Implications: None
- Treatment and Prognosis: Normal anatomic findings that require no treatment.
pgs. 333-334
Leukoedema
- Etiology: Sufficiently common that most authorities consider it a variation of normal rather than a pathologic condition.
- Method of Transmission: Not applicable
- Characteristics:
1) Extraoral: Not applicable
2) Perioral and Intraoral: Produces a whitish opaqueness, sometimes with fine wrinkles, of the mucosa. Leukoedema is invariably found on the buccal mucosa and is often bilaterally symmetrical. Does not rub off and characteristically disappears when the mucosa is stretched.
3) Distinguishing: Manifests as thin whitish plaques on the buccal mucosa that will dissipate when the tissue is stretched.
- Dental Implications: None
- Treatment and prognosis: No treatment is indicated.
pg. 334
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Immune System Disorders
Lichen Planus
- Etiology: Chronic immune-mediated mucocutaneous disorder. T lymphocytes are recruited to the skin or oral mucosa where they are recruited to the skin or oral mucosa where they produce damage to the surface epithelium.
- method of Transmission: Not applicable
- Characteristics:
1) Extraoral: Purplish, raised papules with a keratotic white surface pattern of very fine interlacing lines called Wickham striae. All pruritic (itchy) and typically affect the legs and forearms.
2) Perioral and Intraoral: Another condition that appears in a variety of clinical patterns, including white lesions, red lesions, and ulcers. White lesions, which are the most distinctive clinically.
3) Distinuishing: Wickham striae observed bilaterally on the buccal mucosa and possibly on the gingiva are characteristic of this disorder.
- Dental implications: Often confused with other pathologic processses. Symptomatic patients require diagnosis and treatment. There is a controversy regarding the premalignant nature.
- Treatment and Prognosis: Reticular and plaque forms are generally asymptomatic, and patients usually do not require treatment unless the disease becomes erosive and symptomatic. Biopsy is usually not indicated unless a change occurs after a confirmed diagnosis is made. Erosive lesions are considered more suspicious, since they have been reported to become squamous cell carcinoma in some cases.
pg. 342
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Source: Burkhart, N.W., & DeLong, L. (2019). General and Oral Pathology for the Dental Hygienist (3rd). Philadelphia: Wolters Kluver. pp.332-348