White lesions:

1. Lichen planus - (LP) idiopathic inflammatory disease of skin & mucous membranes characterized by pruritic, violaceous papules that
favor extremities. Mucous membrane lesions are very common, occurring in 30 -70%. Lesions confined to the mouth or with minimal
accompanying skin involvement, are not uncommon, accounting for about 15% of all cases & may lead to great difficulty in diagnosis. They
are often referred first to dental surgeon. Buccal mucosa & tongue are most often involved. Oral LP can appear in at least seven forms:
atrophic, bullous, erosive, papular, pigmented, plaquelike & reticular. Most common & characteristic form of oral LP is reticular pattern,
characterized by bilaterally symmetrical, assymptomatic, slightly raised whitish linear lines in lace-like pattern or in rings with short
radiating spines on buccal mucosa. Gingival involvement is common & typically presents as chronic desquamative gingivitis. On tongue,
lesions are usually in form of fixed, white plaques, often slightly depressed below surrounding normal mucous membrane. Ulceration &
pigmentation of oral cavity are also seen.
2. Contact Stomatitis/ Contact Lichenoid reaction - Contact Stomatitis & cheilitis occurs due to numerous foods, food additives &
materials used in dentistry. Lipsticks & lipsalves are also implicated. Clinical features of contact stomatitis are localized to buccal mucosa or
lateral borders of tongue & appears shaggy white or erythematous keratotic areas with or without peripheral striae, & can resemble oral
lichen planus. Lipstick cheilitis may present as persistent irritation and scaling or a more acute reaction with oedema and vesiculation.
Lesions disappear within a week of discontinuing the offending product. When contact stomatitis secondary to amalgam is suspected, patch
testing is recommended and appropriate alternative dental materials, can be used to replace it.
3. Fordyce Granules - sebaceous glands found within oral mucosa, sebaceous choristomas (i.e., normal tissue in abnormal location); their
normal location is within upper layer of dermis (skin), asymptomatic granules consist of individual sebaceous glands that are 1 to 2 mm in
diameter, white, creamy white, or yellow slightly raised papules on buccal mucosa & vermilion of upper lip, usually occur in multiples,
forming clusters, plaques, or patches, enlarged clusters may feel rough to palpation & to patients tongue, sometimes isolated finding, less
commonly in labial mucosa, retromolar pad, attached gingiva, tongue, frenum; arise from sebaceous glands embryologically entrapped
during fusion of maxillary & mandibular processes, become more apparent after sexual maturity as sebaceous system develops, rarely,
intraoral hair may be seen in association with condition, occur in 80% of adults, density of granules per mucosal area is greater in men than
women, Histologically: rounded nests of clear cells, 10-30 per nest, in lamina propria & submucosa, cells have darkly staining, small,
centrally located nuclei, biopsy not required
4. Linea Alba - common intraoral finding that appears as raised white wavy line of variable length & prominence located at the level of
occlusion on buccal mucosa. Generally, this asymptomatic white line is 1 to 2 mm wide & extends horizontally from second molar to canine
region of buccal mucosa, ending at caliculus angularis; most often found bilaterally & cannot be rubbed off; develops in response to
frictional activity of teeth, which results in thickened (hyperkeratotic) epithelial changes; often associated with crenated tongue & may be
sign of pressure, bruxism, clenching, or sucking trauma. Clinical appearance is diagnostic. No treatment required.
5. Leukoedema - opalescent, milky-white, or gray surface change of buccal mucosa, associated
with dark-pigmented persons, incidence increase with age; labial mucosa, soft palate & floor of the mouth are less common locations;
usually faint & bilateral; fine white lines & wrinkles, sometimes overlapping folds of tissue; prominence of lesion is related to degree of
underlying melanin pigmentation, level of oral hygiene & amount of smoking; borders of the lesion are wavy & diffuse; they fade into
adjacent tissue, which makes it difficult to determine
where the lesion begins & ends Diagnosis: by stretching mucosa, which causes white appearance to significantly diminish or disappear in
some cases; wiping the lesion fails to remove it. Cause: unknown, more severe in smokers & diminishes with smoking cessation. Histologic
examination of biopsy specimens shows increased epithelial thickness with prominent intracellular edema of spinous (middle) layer without
evidence of inflammation. No serious complications are associated with this lesion, and no treatment is required. Histologically: epithelium
is parakeratotic & acantothic, presence of thickening epithelium, intracellular oedema of spinous cells
6. Morsicatio Buccarum - from latin word morsus (bite), changes in oral mucosa due to cheek biting or cheek chewing. Initially, slightly
raised irregular white plaques appear in diffuse pattern that cover areas of trauma. Increased injury produces hyperplastic response that
increases size of the plaque. Linear or striated pattern is sometimes observed that contains thick corrugated areas & intervening zones of
erythema. Persistent injury leads to enlarging plaque with irregular zones
of traumatic erythema & ulceration. Chewing of oral mucosa is usually seen on anterior buccal mucosa & less frequently on labial mucosa,
lesions may be unilateral or bilateral & can occur at any age, Diagnosis requires visual or verbal confirmation of nervous habit. no
malignant potential,
Similar clinical appearance: speckled leukoplakia & candidiasis. Microscopic examination of biopsied tissue shows normal maturing
epithelial surface with a corrugated and thickened parakeratotic surface and minor subepithelial inflammation.
7. Leukoplakia - white plaque or patch that cannot be rubbed off & cannot be classified clinically as any other disease, protective reactions
against chronic irritants. Risk factors: men; 45 -65 years tobacco, alcohol, syphilis, vitamin deficiency, galvanism, chronic friction, UV
radiation, candidiasis. Site: lateral & ventral tongue, floor of mouth, alveolar mucosa, lip, soft palateretromolar trigone, mandibular attached
gingiva. Surface: smooth & homogeneous, thin & friable, fissured, corrugated, verrucoid, nodular, or speckled. Color: vary from faintly
translucent white, gray, or brown-white. WHO classification: 1) homogeneous, 2) nonhomogeneous: erythroleukoplakia (white lesion
with large red component), nodular (white lesion with raised & pebbly surface), speckled (white lesion with small red components), &
verrucoid (white lesion with raised corrugated surface). Epidemiology: 80% - benign; 20% dysplastic (premalignant) or cancerous; 1-4%
carcinoma in 20 years. High-risk sites: floor of mouth, lateral & ventral tongue, uvulopalatal complex & lips. Proliferative verrucous
leukoplakia persistent with a verrucoid (wartlike) appearance & high risk for malignant transformation; strong female predilection,
infrequent association with smoking, occasional association with HPV infection; <60 years. Appearance: multifocal lesions, with white,
corrugated or pebbly exophytic surface (pebbly outgrowths or wartlike outgrowths); spread slowly, rarely regress; recur after excision.
Epidemiology: 70% carcinoma. Speckled, nonhomogenous leukoplakia - epithelial dysplasia in 50%; highest rate of malignant
transformation among intraoral leukoplakias Risk factor: Candida albicans Treatment: eliminate any irritating & causative factors, then
observe for healing. Biopsy if: unexplained persistent oral leukoplakia.

8. Erythroplakia - persistent red patch that cannot be characterized clinically as any other condition; no histologic connotation; most
histologically diagnosed as epithelial dysplasia or worse; much higher propensity for progression to carcinoma than leukoplakia. Site:
mandibular mucobuccal fold, oropharynx, tongue, floor of the mouth Risk factors: <55 years, tobacco or alcohol use. Symptoms:
asymptomatic. Appeareance: redness of lesion as a result of atrophic mucosa overlying highly vascular (reddish) & inflamed submucosa;
border is often well demarcated.. Clinical variants: (1) homogeneous form - completely red; (2) erythroleukoplakia - mainly red patches
interspersed with occasional white areas; (3) speckled erythroplakia - contains white specks or granules scattered throughout red lesion.
Treatment: biopsy mandatory, because 91% - severe dysplasia, carcinoma in situ, or SCC; inspection of entire oral cavity required because
10% to 20% - several erythroplakic areas - field cancerization.
9. Erythroleukoplakia & Speckled Erythroplakia (speckled leukoplakia) precancerous red & white lesions; asymptomatic; male
predilection; <50 years Site: lateral border of tongue, buccal mucosa, & soft palate. Risk factors: heavy smoking, alcoholism, poor oral
hygiene; fungal infections with mostly Candida albicans, Management: analysis for candida; erythroplakia with leukoplakic regions confers
high risk for typical cytologic changes and progression to carcinoma.
10. Squamous Cell Carcinoma - invasive malignancy of oral epithelium; 90% of all malignancies in oral cavity Epidemiology: <45 years
old age; men; Cause: mutations of genes on chromosomes 3 & 9 (p53, ras) - regulate cell proliferation & death (apoptosis). Risk factors:
tobacco & alcohol, HPV, Treponema pallidum, or C. albicans. aging, immune compromise, poor nutrition, oral neglect, chronic trauma, UV
radiation. Site: lateral border & ventral surface of tongue, oropharynx, floor of mouth, gingiva, buccal mucosa, lip & palate; buccal mucosa
-developing countries who chronically use quid (betel nut) tobacco. Epidemiology: <90% - erythroplakic; 60% leukoplakic component.
Color: red & white Surface: exophytic, infiltrative, or ulcerated instability of oral epithelium; suggest carcinoma. Symptoms: early lesions
- asymptomatic & slow growing, when develops, borders become diffuse & ragged, induration & fixation ensue; if mucosa ulcerated,
persistent sore or irritation that fails to heal Advancing: numbness, swelling, difficulty in speaking or swallowing; up to several centimeters
in diameter if treatment delayed & invade & destroy vital tissues; spreads by local extension or by way of lymphatic vessels; palpable
regional (submandibular or anterior cervical) LNs; LNs large, firm, rubbery & possibly fixed to underlying tissue. TNM Assessment system:
size (T), regional LNs (N) & distant metastases (M) Treatment: surgery & radiation therapy; prognosis depends, on site involved (posterior
tumors - worse prognosis), clinical stage at time of diagnosis & treatment, tumor diameter, patients access to adequate health care, patients
ability to cope & mount immunologic response; biopsy if neoplasia suspected; vital stains
11. Cigarette Keratosis - thickened patches on skin; specific reaction evident in persons who smoke nonfiltered or marijuana cigarettes to
very short length; involve upper & lower lips at location of cigarette placement; 7 mm in diameter; lateral to midline.; raised white papules
evident throughout patch, producing roughened texture & firmness to palpation; may extend onto labial mucosa, vermilion border is rarely
involved; Etiology: elderly men Treatment: smoking cessation - resolution; development of ulcer & crust formation should raise suspicion of
neoplastic transformation.
12. Snuff Dippers Patch (Tobacco Chewers Lesion, Snuff Keratosis) - wrinkled yellow-white area in mucobuccal fold - or mandibular
buccal or labial mucosa - persistent intraoral use of unburned tobacco. Site: hard palate, floor of the mouth, ventral tongue if tobacco placed
in maxillary vestibule or beneath tongue. Smokeless tobacco forms: snuff, dip, plug, or quid. Posterior sites commonly used for dip, plug, or
quid, anterior sites preferred for snuff. Risk factors: male teenagers are most frequently affected, southern & Appalachian states Symptoms:
Early - pale pink keratosis with corrugated or wrinkled surfaces; color progress from white & yellow-white to yellow-brown as
hyperkeratosis & exogenous staining occur; lesions asymptomatic, often <1 cm in diameter. Long-term: use of smokeless tobacco periodontal recession, caries, epidermal dysplastic changes, carcinoma; dysplastic changes after many years due to nitrosamines present in
tobacco. Treatment: cessation of use; if not normal appearance14 days after cessation, biopsy necessary.
13. Verrucous Carcinoma (of Ackerman): warty, exophytic, white-and-red mass that is firm to palpation; cauliflowerlike or papulonodular
tumor; low-grade, nonmetastasizing, variant of SCC, 25x less common Risk factor: long-term smokeless tobacco use, at the site of chronic
placement; 30% - HPV associated; Sites: buccal mucosa, vestibule, mandibular gingiva, palate, men <60 years Appearance: white-gray,
undulating keratotic surface with pink-red pebbly papules throughout; lateral growth, usually exceeds vertical growth, leads to increase in
mass & diameters of several centimeters; large lesions locally destructive; by invading & eroding underlying alveolar bone. Similarappearing lesions: verrucous epithelial hyperplasia, pyostomatitis vegetans & proliferative verrucous leukoplakia Treatment: wide surgical
excision; after surgery, long-term prognosis of affected patients is better than SCC & improves when the use of smokeless tobacco is
discontinue
14. Nicotine Stomatitis (Smokers Palate) - direct response of oral mucosa to prolonged pipe & cigar smoking; severity correlated with
intensity & duration of smoke exposure; usually found in middle-aged & elderly men, in unprotected palatal regions (not covered by
maxillary denture) that contain minor salivary glands, that is, posterior to palatal rugae, on soft palate & sometimes extending onto buccal
mucosa. Rarely, dorsum of tongue affected (glossitis stomatitis nicotina); progressive changes with time; irritation initially causes palate to
become diffusely erythematous; palate eventually becomes grayish white secondary to hyperkeratosis; multiple discrete keratotic papules
with depressed red centers develop that correspond to dilated & inflamed excretory duct openings of minor salivary glands; papules enlarge
as irritation persists but fail to coalesce, producing characteristic cobblestone (parboiled) appearance of the palate. Isolated but prominent
red-centered papules are common. Brown staining of lingual surface of posterior teeth commonly associated with this condition.
15. White Sponge Nevus (Familial White Folded Dysplasia) - inherited condition characterized by appearance of asymptomatic, white,
folded, spongy plaques; lesions often exhibit symmetric wavy pattern; Cause: autosomal dominant genetic - point mutations in genes
regulating keratin 4 & 13 production - epithelial maturation & exfoliation altered; appears at birth or early childhood, persists throughout life,
Location: mostly buccal mucosa bilaterally, labial mucosa, alveolar ridge, floor of the mouth; may involve entire oral mucosa or be
distributed unilaterally as discrete white patches, gingival margin & dorsal tongue almost never affected, soft palate & ventrolateral tongue
commonly involved, size vary; extraoral mucosal sites may involve nasal cavity, esophagus, larynx, vagina & rectum Similar to: hereditary
benign intraepithelial dyskeratosis. Histology: prominent parakeratosis, thickening & clearing of spinous layer, perinuclear tangles of keratin
tonofilaments. No treatment required.
16. Traumatic White Lesions Cause: physical & chemical irritants: frictional trauma, heat, topical use of aspirin, excessive use of
mouthwash, caustic liquids, toothpastes. Frictional trauma is often noted on attached gingiva; excessive toothbrushing, movement of oral
prostheses, chewing on edentulous ridge, with time, mucosa becomes thickened & develops roughened white surface that does not wipe off,
pain is absent. Histology: hyperkeratosis.
Picture: white peeling or corrugated lesion if superficial layers of mucosa are damaged; white patches with diffuse irregular borders,
underneath raw, red, or bleeding surface, moveable mucosa is more susceptible to trauma than is attached mucosa, pain relief & healing
occur within days of removing cause, another white lesion caused by trauma is a scar - fibrous healing response of dermis. Scars - often
asymptomatic, linear, whitish pink, sharply delineated. A thorough history may reveal previous injury, recurrent ulcerative disease, seizure
disorder, or previous surgery.

17. Hairy tongue (lingua vilosa, coated tongue) abnormal filiform papilla elongation, hair-like appearance, increased keratin deposition,
delayed shedding of cornified layer, Cause: lack of tongue cleanse, cancer therapy, Candida albicans infection, irradiation, poor oral hygiene,
change in oral pH, smoking, antibiotics, oxidizing mouthwashes, Clinical picture: white, yellow, green, brown, black, begins in midline of
tongue, near foramen caecum, mostly in men older than 30 y, may be several mm length, asymptomatic, Treatment: abrasive paste tongue
brushing, elimination of predisposing factors: dry mouth or diabetes mellitus; effervescent & mucus-solvent mouthwashes, chemical
cauterization with trichloaoacetic acid,
18. Hairy leukoplakia raised, white, corrugated lesions on lateral tongue border, caused by EBV in patients with HIV or
immunosuppressive patients for transplantation/systemic disease, may extend to dorsal & ventral surfaces & palate & buccal mucosa, histo:
hair-like peeling of parakeratotic surface layer, Candida infection often associated, early weak white folds, adjacent pink troughs, vertical
white-banded washboard appearance, bands coalesce to form discrete white plaques or extensive thick white corrugated patches, large
lesions asymptomatic, poorly demarcated borders, do not rub off, mostly bilateral, treatment: antivital agents, immunotherapy
19. Median rhomboid glossitis asymptomatic rhomboid or ovoid shaped red, white or yellow area on tongue depapillation from C.
albicans chronic infection, mostly in midline of dorsum, anteriorly to circumvallate papillae, well defined, 1-2,5cm red lesion with irregular
but rounded borders, in middle aged people, rare in children, higher in diabetes, immunosuppression, HIV, broad spectrum antibiotics
treatment, Early manifestation: smooth, denuded, beefy red patch, devoid of filiform papillae, granular/lobular with time globular &
lobular, sometimes: erythematous palatal candida lesion directly over tongue chronic multifocal candidiasis; asymptomatic; Treatment:
antifungal nystatin, fluconazole
20. Granular cell tumor rare, benign soft tissue tumor, composed of polygonal cells, extremely granular cytoplasm, may occur in
cutaneous, mucosal & visceral sites, 50% in dorsal-lateral tongue, beingn proliferation of neural/endocrine cells; asymptomatic, solitary,
dome shaped, submucosal nodule covered with normal/yellow/white tissue; smooth surface, may be ulceratedif traumatized, tumor sessile,
well circumscribed, firm to compression, very slow growth, painless,up to few cm, larger with slightly depressed central area, rarely on
ventral tongue or buccal mucosa, multiple lesions, pseudoepitheliomatous hyperplasia, overlying granular neoplastic cells, may resemble
epidermoid carcinoma, treatment: conservative local excision
21. Lingual thyroid nodule of thyroid tissue, posteriorly to foramen caecum, on posterior third of tongue, when thyroid tissue fails to
migrate to anterolateral surface of trachea, raised, asymptomatic mass of 2 cm diameter, increased vascularity, symptoms: dysphagia,
dysphonia, hypothyroidism during puberty, pregnancy or menopause, posteriorly to circumvallate papillae, in 50% - only active thyroid
tissue present; if becomes cystic thyroglossal duct cyst
22. Actinic cheilosis (actinic cheilitis, solar keratosis) premalignant lesion of vermilion part of lower lip caused by excessive exposure to
sunlight, early stages: lower lip is red, atrophic with subtle blotchy intervening pale areas & loss of vermilion border of lip, with increased
sun exposure, irregular scaly areas develop, that may thicken & contain focal white patches than can be peeled off, lip becomes firm, slightly
swollen, fissured, everted, ulceration with thin yellow surface crust appears, ulcers causes: trauma, loss of elasticity, early sign of dysplasia
or carcinoma, histo: epithelial atrophy, subepithelial basophilic degeneration of collagen, increased elastin fibers, Treatment: biopsy, 10%
develop into cancer, use of sunscreen, dysplasia surgery/topical 5-fluorouracil, excision of vermillion area lip shave operation or laser
treatment if significant dysplasia on biopsy; chemical exfoliants
23. Georgaphic tongue (benign migratory glossitis, erythema migrans) benign inflammation, irregular patches on dorsum of tongue, 1%
of population, mostly women, young adults, Cause: unknown, stress, nutritional deficiencies, hormonal, hereditary factors, only filiform
papilla on dorsal & lateral tongue, Manifestation: red patches surrounded by white borders 1) patchy areas of desquamated filiform papilla,
2) patchy desquamated areas delineated by raised, white, circinate (ring shaped) borders, 3) patchy areas of desquamated filiform papillae
bordered by erythematous band of inflammation, 1&2 asymptomatic, 3 - red inflammatory band triggered by spicy food burning
sensation, may appear suddenly & last for years, typical spontaneous remission, some patients: tenderness when eating highly flavored food,
possible association with psoriasis Treatment: none, analgesic mouthwash for pain relief, avoid food that irritate tongue, zinc supplements
24. Systemic lupus erythematosus (SLE) - autoimmune disorder, Forms: (1) chronic discoid
LE (chronic cutaneous LE) only involves skin, (2) systemic LE - multiple
organ systems involved; (3) subacute cutaneous LE - nonscarring skin lesions, mild musculoskeletal (arthritis) symptoms, limited or no
organ disease. Cause: unknown
Chronic cutaneous or discoid LE benign, purely mucocutaneous disorder, mostly in woman after 40s; red butterfly rash distributed
symmetrically on cheeks across bridge of nose & other sun exposed areas of face: malar areas, forehead, scalp, ears; lesions are chronic, with
periods of exacerbation & remission. Oral lesions 20-40%, may develop before or after skin lesions, lip lesions - red with white to silvery,
scaly margin; sun-exposed lower lip at vermilion border is a common site, upper lip is usually involved as a result of direct extension of
dermal lesions. Intraoral lesions are frequently diffuse erythematosus plaques, with erosive, ulcerative & white components; sometimes
appears as isolated red-white plaques on buccal mucosa mostly, but also tongue, palate & gingiva; central, red atrophic area sometimes
covered by fine stippling of white dots. Peripheral margins irregular, composed of alternating red & keratotic white lines extending for
short length up to about 1 cm in radial pattern. Similar to lichen planus, but concurrent ear involvement helps to exclude diagnosis of lichen
planus. Ulcerative lesions are painful & require treatment. Treatment: sunscreens, topical steroids, systemic steroids, antimalarial &
immunosuppressants, avoidance of emotional stress, cold, sunlight & hot spicy foods is necessary.
25. Lichenoid & Lupuslike Drug Eruption (Stomatitis Medicamentosa) - oral hypersensitivity reaction to a drug that results in oral lesions.
Clinical picture: reticular or erosive lesions, white linear plaques with red margins, lesions may erupt immediately or after prolonged use of
drug, persistent inflammatory changes may result in large erythematous areas, mucosal ulceration & pain. Drug-induced LE often associated
with arthritis, fever & renal disease. Causes of LE: hydralazine & procainamide, gold, griseofulvin, isoniazid, methyldopa, penicillin,
phenytoin, procainamide, streptomycin & trimethadione. Causes of Lichenoid: chloroquine, dapsone, furosemide, gold, mercury,
methyldopa, palladium, penicillamine, phenothiazines, quinidine, thiazides, certain antibiotics & heavy metals.
26. Pseudomembranous Candidiasis (Thrush) Cause: Candida Albicans, antibiotics, steorids, diabetes, immunodeficiency, chemotherapy,
steroid inhaler in asthma, Clinical picture: diffuse, velvety, white mucosal plaques that are nonpainful until they are wiped off, leaving red,
raw, or bleeding surface. Place: oral cavity, GIT, vagina Oral place: buccal mucosa, tongue, soft palate, circular or oval reddish white patch at
site of aerosol contact on palate. Diagnosis: clinical examination, fungal culture, direct microscopic examination of tissue scrapings;
cytologic smear treated with KOH, Gram, or periodic acidSchiff (PAS) stain will reveal budding organisms with branching pseudohyphae.
Treatment: topical or systemic antifungal medication for 2 weeks usually produces resolution. Fluconazole, Nystatin, Amphotericin B