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Oral White Lesions: an Updated Clinical Diagnostic Decision Tree dentistry journal Review Oral White Lesions: An Updated Clinical Diagnostic Decision Tree Hamed Mortazavi 1, Yaser Safi 2, Maryam Baharvand 1,*, Soudeh Jafari 1, Fahimeh Anbari 1 and Somayeh Rahmani 1 1 Oral Medicine Department, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran 1983969411, Iran; [email protected] (H.M.); [email protected] (S.J.); [email protected] (F.A.); [email protected] (S.R.) 2 Oral and Maxillofacial Radiology Department, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran 1983969411, Iran; Safi[email protected] * Correspondence: [email protected]; Tel.: +98-21-26708415 Received: 23 November 2018; Accepted: 18 January 2019; Published: 7 February 2019 Abstract: Diagnosis of oral white lesions might be quite challenging. This review article aimed to introduce a decision tree for oral white lesions according to their clinical features. General search engines and specialized databases including PubMed, PubMed Central, EBSCO, Science Direct, Scopus, Embase, and authenticated textbooks were used to find relevant topics by means of MeSH keywords such as “mouth disease”, “oral keratosis”, “oral leukokeratosis”, and “oral leukoplakia”. Related English-language articles published since 2000 to 2017, including reviews, meta-analyses, and original papers (randomized or nonrandomized clinical trials; prospective or retrospective cohort studies), case reports, and case series about oral diseases were appraised. Upon compilation of data, oral white lesions were categorized into two major groups according to their nature of development: Congenital or acquired lesions and four subgroups: Lesions which can be scraped off or not and lesions with the special pattern or not. In total, more than 20 entities were organized in the form of a decision tree in order to help clinicians establish a logical diagnosis by a stepwise progression method. Keywords: mouth disease; oral keratosis; oral leukokeratosis; oral leukoplakia 1. Introduction Diagnosis of oral white lesions might be quite challenging. These lesions represent a wide spectrum of lesions with different etiology and various prognoses. The diagnosis of white lesions varies from benign reactive lesions to more serious dysplastic and carcinomatous lesions. While there are some classic features that help distinguish these lesions, similar features may give rise to some complications in diagnosis. Efforts should be made to establish a definite diagnosis to prevent time elapse in treatment of patients with more serious lesions. A decision tree is a flowchart that organizes features of lesions in order to help clinicians to reach a logical conclusion. To use the decision tree, one should begin from the left side of the tree, makes the first decision, and proceeds to the far right of the tree where the definite diagnoses are listed [1]. Oral lesions can be classified into four groups comprising of ulcerations, pigmentations, exophytic lesions, and red-white lesions [2]. Although white lesions constitute only 5% of oral pathoses, some of these lesions such as leukoplakia, lichen planus, and proliferative verrucous leukoplakia have malignant potential as high as 0.5–100% [3]. Therefore, white lesions mandate an appropriate clinical diagnostic approach to exclude the possibility of malignancy. The onset of oral white lesions can be acquired or congenital, with a history of long-lasting existence in the latter form. Oral white lesions can be caused by a thickened keratotic layer or an accumulation Dent. J. 2019, 7, 15; doi:10.3390/dj7010015 www.mdpi.com/journal/dentistry Dent. J. 2019, 7, x FOR PEER REVIEW 2 of 24 The onset of oral white lesions can be acquired or congenital, with a history of long-lasting existence in the latter form. Oral white lesions can be caused by a thickened keratotic layer or an accumulation of non-keratotic material. Accordingly, when a clinician confronts a white area on the Dent. J. 2019, 7, 15 2 of 24 oral mucosa, the first issue to be elucidated is whether it can be scraped off by means of a piece of gauze or not. If so, a superficial non-keratotic layer such as pseudomembranes, most commonly causedof non-keratotic by fungal material.infections Accordingly,or caustic chemicals, when a clinicianshould be confronts suspected. a white Otherwise, area on white the orallesions mucosa, can bethe attributed first issue to beincreased elucidated thickness is whether of itkeratin can be layer, scraped which off by might means have of a piece been of induced gauze or by not. local If so, frictionala superficial irritation, non-keratotic immunologic layer such reactions, as pseudomembranes, or more crucial most processes commonly such caused as bypremalignant fungal infections or malignantor caustic transformation chemicals, should [4,5]. be suspected. Otherwise, white lesions can be attributed to increased thicknessIn the ofnext keratin step, layer,any specific which mightclinical have pattern been of induced white lesions by local such frictional as papular, irritation, annular, immunologic reticular orreactions, erosive-ulcerative or more crucial patterns, processes or a combination such as premalignant of them (characteristic or malignant transformationfor lichenoid lesions) [4,5]. should be inspectedIn the next in order step, to any differentiate specific clinical whit patterne patterned of white lesions lesions from such non-patterned as papular, ones. annular, reticular or erosive-ulcerativeTherefore, this patterns,narrative or review a combination paper focuses of them on (characteristic three clinicalfor steps lichenoid to approach lesions) oral should white be lesions:inspected The in first order step to differentiateis to determine white whether patterned the lesionslesion is from congenital non-patterned or acquired; ones. the second and third stepsTherefore, are to this inspect narrative if it reviewcan be paper wiped focuses off or on not three and clinical if it has steps a tospecial approach pattern oral or white not. lesions: This diagnosticThe first step process is to determineis presented whether as an updated the lesion clin is congenitalical decision or tree. acquired; A decision the second tree andis a flowchart third steps usedare tofor inspect organizing if it can features be wiped of off lesions or not or and diseases if it has athat special help pattern clinicians or not. make This a diagnosticconstellation process of rationalis presented decisions as an rather updated than clinical haphazard decision ones tree.to reach A decision a conclusive tree is diagnosis a flowchart [1]. used for organizing features of lesions or diseases that help clinicians make a constellation of rational decisions rather than 2.haphazard Search Strategy ones to reach a conclusive diagnosis [1]. 2. SearchGeneral Strategy search engines and specialized databases including PubMed, PubMed Central, EBSCO, Science Direct, Scopus, Embase, and authenticated textbooks were used to find relevant topics by meansGeneral of MeSH search keywords engines such and specializedas “mouth databasesdisease,” “oral including keratosis,” PubMed, “oral PubMed leukokeratosis,” Central, EBSCO, and “oralScience leukoplakia”. Direct, Scopus, Related Embase, English-language and authenticated articles textbooks published were from used 2000 to findto 2017 relevant including topics reviews,by means meta-analyses, of MeSH keywords original papers such as (randomized “mouth disease,” or non-randomized “oral keratosis,” clinical “oral trials; leukokeratosis,” prospective orand retrospective “oral leukoplakia”. cohort studies), Related case English-language reports, and case articles series publishedwere reviewed. from 2000Out of to more 2017 includingthan 140 relevantreviews, articles meta-analyses, and textbooks, original five papers textbooks, (randomized and 45 or papers non-randomized were selected clinical including trials; reviews, prospective case or reportsretrospective or case cohort series, studies), and original case reports, articles. and We case described series were 20 reviewed. entities, with Out offocus more on than their 140 clinical relevant aspects.articles andFinally, textbooks, oral white five textbooks,lesions were and 45categorized papers were into selected two major including groups reviews, of congenital case reports and or acquiredcase series, origin and originaland four articles. subgroups: We described those that 20 entities,can be withscrapped focus onoff theiror not, clinical and aspects. patterned Finally, or non-patternoral white lesions lesions were (Figure categorized 1). into two major groups of congenital and acquired origin and four subgroups:Pictures thoseused that in canthis be review scrapped article off or were not, andcollected patterned from or non-patternthe archive lesionsof Oral (Figure Medicine1). DepartmentPictures of used Shahid in this Beheshti review articleDental were School collected under from permission the archive of the of Oral patients Medicine by signing Department the specialof Shahid consent Beheshti form. Dental School under permission of the patients by signing the special consent form. Figure 1. Figure 1. DecisionDecision tree tree of of oral oral white white lesions. lesions. Dent. J. 2019, 7, 15 3 of 24 Dent. J. 2019, 7, x FOR PEER REVIEW 3 of 24 3. Congenital/Genetically Lesions 3. Congenital/Genetically Lesions 3.1. Leukoedema 3.1. Leukoedema LeukoedemaLeukoedema is ais commona common normal normal variationvariation of of the the oral oral mucosa. mucosa.
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