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White Lesions of the Oral Cavity and Derive a Differential Diagnosis Four for Various White Lesions

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White Lesions of the Oral Cavity and Derive a Differential Diagnosis Four for Various White Lesions 2014 self-study course four course The Ohio State University College of Dentistry is a recognized provider for ADA, CERP, and AGD Fellowship, Mastership and Maintenance credit. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp. The Ohio State University College of Dentistry is approved by the Ohio State Dental Board as a permanent sponsor of continuing dental education ABOUT this FREQUENTLY asked COURSE… QUESTIONS… Q: Who can earn FREE CE credits? . READ the MATERIALS. Read and review the course materials. A: EVERYONE - All dental professionals in your office may earn free CE contact . COMPLETE the TEST. Answer the credits. Each person must read the eight question test. A total of 6/8 course materials and submit an questions must be answered correctly online answer form independently. for credit. us . SUBMIT the ANSWER FORM Q: What if I did not receive a ONLINE. You MUST submit your confirmation ID? answers ONLINE at: A: Once you have fully completed your p h o n e http://dent.osu.edu/sterilization/ce answer form and click “submit” you will be directed to a page with a . RECORD or PRINT THE 614-292-6737 unique confirmation ID. CONFIRMATION ID This unique ID is displayed upon successful submission Q: Where can I find my SMS number? of your answer form. A: Your SMS number can be found in t o l l f r e e the upper right hand corner of your 1-888-476-7678 monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for ABOUT your your office only, and is the same for f a x FREE CE… everyone in the office. 614-292-8752 Q: How often are these courses available? . TWO CREDIT HOURS are issued for successful completion of this self- A: FOUR TIMES PER YEAR (8 CE credits). e - m a i l study course for the OSDB 2014-2015 biennium totals. [email protected] . CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. w e b . ALLOW 2 WEEKS for processing and www.dent.osu.edu/ mailing of your certificate. sterilization Page 1 WHITE LESIONS OF THE ORAL 2014 CAVITY course This course will help dental professionals familiarize themselves with common white lesions of the oral cavity and derive a differential diagnosis four for various white lesions. INTRODUCTION White lesions of the oral cavity are one of the leading reasons for which patients seek professional treatment. These lesions can have a wide spectrum of diagnoses including infectious, reactive, immune-mediated, premalignant, and malignant conditions. Patient Pseudomembranous Dr. Carl Allen, The Ohio State Candidiasis University College of Dentistry history, clinical presentation, and location can be very helpful in immunocompetent individuals to narrowing down the differential disseminated infection in diagnosis of these various white immunosuppressed patients. A lesions. variety of clinical forms of oral candidiasis exist, including: INFECTIOUS WHITE LESIONS Pseudomembranous Erythematous Hyperplastic CANDIDIASIS Mucocutaneous Candidiasis is the most prevalent Among these, the two clinical oral fungal infection in humans. forms which appear white are Candida Albicans, part of the normal pseudomembranous and oral micro flora, is the causative hyperplastic candidiasis. organism. A complex interaction of immune status and mucosal Pseudomembranous candidiasis environment of the host and strain appears clinically as creamy, white of C. Albicans controls the presence plaque (similar to cottage cheese or curdled milk) and is usually written by of candidal infection. Various predisposing factors for oral present on the buccal mucosa, neetha santosh, dds candidiasis include use of dentures, tongue, and palate. This plaque xerostomia, recent broad-spectrum can be removed by scraping or antibiotic therapy, corticosteroid use wiping, which leaves an intact edited by (aerosolized inhalants or topical normal or reddened underlying mucosa. Diagnosis of alternative rachel a. flad, bs creams/gel), and immunodeficiency (HIV infection or leukemia). white lesions such as lichen planus karen k. daw, mba, cecm should be considered if the evan miller Clinical Features: mucosa bleeds while scraping the plaque. The patients with pseudomembranous candidiasis The clinical features of candidiasis usually complain of mild burning c a n v a r y f r o m superficial involvement of oral mucosa in sensation or bad taste. The diagnosis is usually established by Page 2 the relevant history of predisposing factors and treatment regimen of patients with dentures. If typical clinical appearance. there is no improvement post-treatment, biopsy of the area is recommended to exclude other Isolation and identification of candidal hyphae or possible conditions. A referral to the physician is yeasts by exfoliative cytology (smear), or, culture also prudent to rule out underlying systemic on Sabouraud’s agar slant (swab) can confirm the disorders. diagnosis. Hyperplastic candidiasis presents as a white plaque ORAL HAIRY LEUKOPLAKIA that cannot be removed by scraping or wiping. It is most often present on the anterior buccal Oral hairy leukoplakia is a lesion that occurs mucosa near the commissures, as well as on the mainly in immunocompromised individuals, tongue and lips. Hyperplastic candidiasis cannot especially in AIDS patients. This lesion has also be clinically distinguished from routine been described in patients experiencing extended corticosteroid therapy after organ leukoplakia. The diagnosis is established by the transplantation or other systemic conditions. identification of candida by a cytologic smear or Epstein-Barr virus is the main causative organism culture and by total disappearance of plaque of oral hairy leukoplakia. following antifungal treatment. A biopsy of the area will be prudent if any white plaque has Clinical Features: remained in order to rule out the presence of true leukoplakia. Oral hairy leukoplakia typically presents as white vertical streaks or corrugated plaques on the Care should be taken to avoid confusing lateral border of the tongue. This lesion is usually coated/hairy tongue with candidiasis. Coated bilateral and can extend to the dorsal and lateral tongue is due to accumulation of keratin and surfaces of the tongue, and can also rarely involve bacteria on the dorsal surface of the tongue, the buccal mucosa, soft palate, pharynx, and resulting in a white and thickened appearance. esophagus. Oral hairy leukoplakia does not rub Hairy tongue has a typical hair-like appearance off; differential diagnoses include hyperplastic due to elongation of and the keratin accumulation candidiasis, true leukoplakia, proliferative on the filiform papillae of the dorsal tongue. The verrucous leukoplakia, morsicatio linguarum diagnosis of coated/hairy tongue is distinguished (tongue chewing), and lichen planus. A definite by its characteristic clinical appearance. Scraping diagnosis can be established by identification of the tongue and improving oral hygiene is the Epstein-Barr virus within the lesion using in situ recommended treatment. hybridization or by histopathological examination of the biopsied area. Treatment: Treatment: A variety of topical and systemic antifungal agents are available to treat oral candidiasis. Most of the Usually, it is not necessary to treat oral hairy patients respond well to the topical treatment leukoplakia. There can be resolution of the lesion which include Nystatin and Clotrimazole. The if the patient is on Highly Active Antiretroviral systemic drugs available are Ketoconazole, Therapy (HAART) for HIV infection. HIV patients Fluconazole, and Itraconazole and are used usually diagnosed with oral hairy leukoplakia have higher for chronic or disseminated candidiasis. The chances of disease progression to AIDS. Since recommended dosage of Clotrimazole is to oral hairy leukoplakia is mostly seen in dissolve 1 troche (10 mg) slowly in the mouth 5 immunocompromised individuals, its occurrence times per day for 10 days. Nystatin oral in the absence of a known reason of suspension can be used by swishing 2-5 mL for immunosuppression warrants referral to a two minutes and swallowing thereafter. physician for a complete physical evaluation. Disinfection of dentures by soaking them in 10% household bleach (complete dentures) or in Nystatin oral suspension (removable dentures with metal parts) should be included in the Page 3 REACTIVE WHITE LESIONS appearance. Isolated lesions on the lateral border of the tongue without history of tongue chewing LINEA ALBA should be thoroughly evaluated to rule out HIV- associated oral hairy leukoplakia. Linea alba means “white line” in Latin and is one of the most common variations of the buccal No treatment is usually required for morsicatio mucosa. Pressure, frictional irritation, or sucking lesions. An oral acrylic shield may be fabricated to trauma from adjacent facial surfaces of the teeth protect buccal and labial mucosa from chewing are usually linked to this alteration. habits. Clinical Features: CHEMICAL INJURIES OF THE ORAL MUCOSA Linea alba typically presents as a bilateral white Prolonged periods of contact between various line on the buccal mucosa at the level of the drugs and chemicals and the oral mucosa can occlusal plane. It can have a scalloped appearance cause temporary white lesions. Aspirin, hydrogen and extend from the commissure to the posterior peroxide, silver nitrate, phenol, eugenol, teeth. formacresol, sodium hypochlorite, dental cavity varnishes, and acid etch materials are some of the Treatment: most common drugs and chemicals that cause oral mucosa. These white lesions are due to Diagnosis of linea alba is made by the epithelial necrosis and fibrinopurulent exudate characteristic clinical location and appearance, from the chemical injury. with biopsy not usually being necessary. Linea alba requires no treatment and it may disappear Clinical Features: on its own in some individuals.
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