Red and White Lesions in Oral Mucosa

Red and White Lesions

• Causes of white mucosa:
  • Hyperkeratosis (increased keratin production)
  • Acanthosis (abnormal thickening of stratum spinosum)
  • Intra- and extracellular fluid accumulation in epithelium
  • Fungal pseudomembranes
• Causes of red mucosa:
  • Atrophy of epithelium (decrease in cell size)
  • Reduction in number of epithelial cells

Developmental, Hereditary, and Congenital Lesions

• White lesions:
  • White sponge nevus
  • Leukoedema
  • Hereditary benign intraepithelial dyskeratosis
• Red lesions:
  • Hemangioma
• Red and white lesions:
  • Oral lichen planus
  • Erythema migrans/geographic tongue

Linea Alba

• Common lesion
• Caused by frictional irritation, pressure or sucking trauma
• Presents as a linear white lesion, usually bilateral on buccal mucosa along occlusal plane
• No need for biopsy or treatment, may show spontaneous regression

Morsicatio Mucosae Oris

• Caused by chronic chewing
• Presents as thick, shredded, white areas with irregular surface
• May have zones of erythema, erosion, or focal traumatic ulceration
• Common in females, affecting anterior buccal mucosa, lips, and tongue
• No treatment needed, resolves upon habit cessation

Thermal Burn

• Caused by ingestion of hot foods or beverages
• Presents as sloughing white lesion, red-white lesion, or red lesion
• May show zones of erythema and ulceration
• Commonly affects palate or posterior buccal mucosa
• Most cases resolve without treatment, corticosteroids and antibiotics used in severe cases

Chemical Burn

• Caused by:
  • Aspirin-tablets, powder
  • Bisphosphonates
  • Psychoactive drugs
  • Hydrogen peroxide
  • Recreational drugs
• Presents as white, wrinkled plaque or necrotic red, bleeding connective tissue
• May affect any oral mucosal site
• Treatment involves prevention of exposure, sodium hypochlorite irrigation, and debridement

Leukoedema

• Common oral mucosal condition
• Seen in 70-90% of black adults and 50% of black children
• Presents as diffuse gray-white, milky, or opalescent lesion
• Unknown cause, may be developmental in nature
• No treatment required

Candidiasis

• Most common oral fungal infection
• Caused by:
  • Local factors (denture wearing, smoking, inhalation steroids)
  • General factors (immunosuppressive diseases, impaired health status)
• Presents as:
  • Pseudomembranous candidiasis (adherent white plaques)
  • Coated tongue (accumulation of bacteria and desquamated epithelial cells)
  • Hairy tongue (marked accumulation of keratin on filiform papillae)

Hairy Tongue

• Seen in 0.5-11.3% of adults
• Caused by increase in keratin production or decrease in normal keratin desquamation
• Presents as elongated, yellowish-white or brown filiform papillae on dorsal tongue
• Asymptomatic, eliminate predisposing factors, encourage excellent oral hygiene

Median Rhomboid Glossitis

• Presents as well-demarcated erythematous zone on midline of posterior dorsal tongue
• Erythema due to loss of filiform papillae, often asymmetric and smooth or lobulated
• Often asymptomatic### Denture Stomatitis/Chronic Atrophic Candidiasis
• Most common form of candidiasis in denture patients, usually asymptomatic
• Localized to denture-bearing areas of maxillary removable denture
• Seen when patient wears denture continuously, but must rule out other causes such as improper denture design, allergy to denture base, or inadequate curing of denture acrylic
• Presents with varying degrees of erythema, sometimes accompanied by petechial hemorrhage
• Can be associated with concomitant inflammatory papillary hyperplasia, often secondary to poorly fitting dentures

Angular Cheilitis

• Presents with erythema, fissuring, and scaling of the angles of the mouth
• Commonly seen in older patients with decreased vertical dimension of occlusion and accentuated folds at the corners of the mouth, with pooling of saliva in the corners of the mouth
• The severity of the lesions waxes and wanes
• Caused by 20% Candida albicans, 60% Candida albicans & Staphylococcus aureus, and 20% Staphylococcus aureus

Oral Candidiasis

• Diagnosis involves clinical signs in conjunction with exfoliative cytology
• Cytological findings should demonstrate hyphal phase of the organism
• Cytology is simple, non-invasive, and cost-effective
• Treatment options include:
  • Imidazole agents (clotrimazole 1% cream, clotrimazole troches 10 mg)
  • Polyene agents (nystatin oral suspension 100,000 units/ml, nystatin pastilles 200,000 units/pastille, nystatin ointment)
  • Triazoles (fluconazole)
  • Other agents (iodoquinol)

Geographic Tongue (Erythema Migrans, Benign Migratory Glossitis)

• Seen in 1-3% of the population, with unknown etiopathogenesis and female predilection
• Presents as multiple, well-demarcated zones of erythema (atrophy of filiform papillae) surrounded by slightly raised yellow-white serpentine or scalloped border on the dorsal tongue (anterior 2/3rd) and ventrolateral tongue
• Lesions develop quickly, heal in days to weeks, and then develop in a different area; continually changing pattern
• Often associated with fissured tongue (1/3rd of patients)
• May demonstrate burning sensation or sensitivity to hot or spicy foods
• Treatment is not usually indicated, but topical steroids may be used for symptomatic patients

Submucosal Hemorrhage

• Seen when a traumatic event results in hemorrhage and entrapment of blood within tissues
• Terminology depends on the size of hemorrhage:
  • Petechiae: minute hemorrhages into skin, mucosa, or serosa
  • Purpura: slightly larger area affected (5 mm – 2 cm)
  • Ecchymosis: any accumulation greater than 2 cm
  • Hematoma: accumulation of blood within tissue producing a mass
• Causes include:
  • Trauma (blunt trauma, oral trauma from sexual practices)
  • Increased intrathoracic pressure (repeated or prolonged coughing, vomiting, convulsion, or giving birth)
  • Non-traumatic causes (anticoagulation therapy, thrombocytopenia, disseminated intravascular coagulation, viral infections)
• Presents as non-blanching lesion, usually flat, except for hematoma (elevated lesion)
• Commonly seen on labial mucosa or buccal mucosa
• No treatment if not associated with morbidity or related to systemic disease, as areas resolve spontaneously