The most common and important causes of white lesions in the mouth include the normal bite line, lichen planus, lupus erythematosus, secondary syphilis (lues), leukoplakia, candidiasis, and human papilloma virus infection. All of these diseases except candidiasis occur because of the development of a byperkeratotic surface in an area normally lacking the ability to form a stratum corneum. This cornified layer is white while wet for the same reason that one’s fingertips become white after prolonged exposure to water. The whiteness in candidiasis represents the actual yeast organisms present in a thick mycelial plaque.Bite line is the most common white lesion in the mouth. This lesion is characterized both by its linearity and by its location at the dental occlusion line. Often the bite line has several irregular extensions that correspond to grooves between the teeth. It is asymptomatic. The bite line probably arises as a type of “callus” formation secondary to the presence of chronic, biting trauma. The condition has no pathologic significance and requires no treatment.
Lichen Planus is the most common pathologic explanation for white plaques on the oral mucous membranes. In milder lesions the plaques are made up of a network of crisscrossed, gray-white lines, whereas in more severe cases the plaques are thicker and are less reticulated. Central erosions may be present in these latter lesions.
The mucosal lesions of lichen planus are most commonly located on the buccal surfaces, but involvement of the gingivae, lips, and tongue is occasionally seen. Patients with mild oral lichen planus are asymptomatic, but in more severe, erosive cases the lesions can be very painful. The diagnosis is easily made when typical cutaneous lesions are found elsewhere on the body. Lichen planus does sometimes exist solely within the mouth, however, and in such instances biopsy will be necessary to confirm the diagnosis.
The mucosal lesions of lichen planus are chronic in nature; buccal plaques in particular may remain for years. Very rarely, squamous cell carcinoma has arisen in older lesions of erosive lichen planus.
Asymptomatic plaques require no treatment. Painful, eroded lesions are partially responsive to topically applied steroids (Kenalog in Orabase, Temovate Ointment, or Steroid Aerosol sprays) and to topically applied tretinoin (Retin-A). In some cases, orally administered retinoids or intralesionally injected triamcinolone will be required, Topically applied cyclosporine has recently been suggested in spite of its very high cost.
About 20% of patients with either discoid or acute systemic lupus erythematosus may have mucosal lesions. The gray-white plaques seen with either type of lupus erythematosus are clinically similar to those found in lichen planus, though they do tend to be less reticulated. They most often occur on the buccal surface, lips, and palate. Erosions are possible but are uncommon. Diagnosis depends on the presence of typical lesions of lupus erythematosus elsewhere on the skin. Biopsy is distinctive but not pathognomonic. Treatment of the mucosal lesions is generally not necessary.
Secondary Syphilis is frequently accompanied by the presence of white plaques in the mouth. These plaques are whiter, thicker, and more sharply marginated than the otherwise similar lesions of lupus erythematosus and lichen planus. They are generally asymptomatic. The mucosal lesions of syphilis are teeming with treponemas and thus are very contagious.
These lesions occur during the secondary stage of syphilis, and thus serologic tests will always be positive.
Dark-field examinations may be of help, but care must be taken to differentiate Treponema pallidum from the Borrelia sp. that are normal inhabitants of the mouth. Typical cutaneous lesions of secondary syphilis will nearly always be found. Treatment of the patient with penicillin results in resolution of mucosal lesions.
The word leukoplakia is derived from the Greek word for “white plaque.” By dermatologic convention, use of the word is restricted to lesions that show evidence of dysplasia on biopsy. Intraoral lesions are particularly likely to be seen in patients who have chronically used intraoral tobacco products, whereas lip lesions are usually due to chronic sunlight exposure.
Diagnosis is established by way of biopsy. Most often only mild atypia is present, but in more chronic cases the picture may be that of carcinoma in situ. Such lesions should be treated with excision, electrosurgical destruction, or laser ablation. Lesions confined to the outer lip (”actinic cheilitis”) may also be treated with topically applied fluorouracil.
Candidiasis (moniliasis, thrush) represents infection with Candida sp., most often Candida albicans. The white plaques formed as the result of such yeast infection are thick and soft. They are loosely adherent, and pieces of the plaque can be dislodged with the edge of a scalpel blade. Material removed in this manner will reveal dense mats of hyphae on potassium hydroxide (KOH) examination.
Lesions of candidiasis can occur anywhere in the mouth but are particularly common on the buccal surfaces. Oral candidiasis may be found in infants and in immunosuppressed or debilitated adults. Patients with Acquired Immuno Deficiency Syndrome (AIDS) are almost universally affected. Treatment is carried out by the application of an oral solution of nystatin (Mycostatin oral suspension) or through the use of clotrimazole (Mycelex) troches.
Human papilloma virus infection may result either in the appearance of flat-topped individual or coalescent white warts (Heck’s disease) or, in patients with AIDS, shaggy white plaques on the tongue known as oral hairy leukoplakia. Treatment generally necessitates local destruction.
Tags:AIDS, borrelia, Dermatology Diagnosis, diagnosis, diseases, treatment virus infection
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