MetLife designates this activity for 2.0 continuing education credit for the review of this Quality Resource Guide and successful Quality Resource Guide completion of the post test. FIRST EDITION White Lesions of the Oral Cavity change, while potentially overlapping with several of Author Acknowledgements Educational Objectives the conditions covered in this document, should be Paul Edwards, MSc DDS FRCD(C) considered under their respective categories2 and are not Following this unit of instruction, the practitioner Professor - should be able to: included in this discussion. Oral Pathology, Medicine & Radiology Indiana University 1. Outline the range of common and clinically Oral mucosa may present with a white appearance for School of Dentistry important white lesions affecting the oral a number of reasons, ranging from hyperkeratosis (an Indianapolis, Indiana cavity. increase in the thickness of the keratin surface layer) to Dr. Edwards has no relevant financial 2. Describe the steps involved in the initial epithelial hyperplasia (an increase in the thickness of the relationships to disclose. assessment of a white lesion of indeterminate epithelial layer itself). White mucosal change may likewise The following commentary highlights etiology. result from intracellular edema (a buildup of fluid between fundamental and commonly accepted 3. Categorize white lesions of the oral cavity by epithelial cells, as seen in leukoedema), reduced sub- practices on the subject matter. The category of disease process (INERTIA). surface vascularity (increased collagen deposition seen information is intended as a general overview and is for educational purposes only. This with the use of certain brands of smokeless tobacco) and 4. Describe the rationale for developing a information does not constitute legal advice, extrinsic surface changes such as debris accumulation differential diagnosis for all white lesions of which can only be provided by an attorney. the oral cavity. (materia alba, candidiasis) or chemical or thermal cautery © Metropolitan Life Insurance Company, (dentifrice-associated sloughing, cinnamon reaction). New York, NY. All materials subject to this copyright may be photocopied for the 5. Define and explain the etiology, significance, This latter group of conditions is characterized by the and management of “idiopathic leukoplakias” noncommercial purpose of scientific or ability to remove the white material with vigorous wiping, educational advancement. in the oral cavity. or resolution of the lesion within several days following Originally published September 2014. 6. Appreciate the challenges involved in the removal of the offending agent(s). Expiration date: December 2017. The management of potentially preneoplastic white content of this Guide is subject to change as new scientific information becomes lesions of the oral cavity. The initial step in assessing any lesion of indeterminate available. etiology is to carefully evaluate it with respect to duration, size, location, surface texture, borders, and distribution. Background Commonly, chronic lesions involving multiple quadrants are associated with systemic mucocutaneous conditions hite lesions of the oral cavity comprise a MetLife is an ADA CERP Recognized Provider. such as lichen planus. group of lesions of diverse etiology, ranging ADA CERP is a service of the American Dental Association to assist dental professionals from reactive lesions to squamous cell With these findings in mind, it is critical that the clinician W in identifying quality providers of continuing carcinoma (Table 1). The lesions in this disparate group then formulate a thorough differential diagnosis, dental education. ADA CERP does not approve of conditions often overlap in appearance, potentially representing a list of both the most likely and the or endorse individual courses or instructors, leading to under-diagnosis. A thorough knowledge nor does it imply acceptance of credit hours by most clinically significant diagnostic possibilities, for boards of dentistry. of their clinical presentations and significance allows the lesion in question. The differential diagnosis will Concerns or complaints about a CE provider management of these lesions as a critical part of the guide patient management by directing what additional may be directed to the provider or to ADA 1 practice of dentistry. This Quality Resource Guide will investigation, if any, is needed in order to arrive at a CERP at www.ada.org/goto/cerp. discuss the most common and/or clinically significant definitive diagnosis. The use of a mnemonic that prompts Accepted Program Provider FAGD/MAGD white lesions that may appear in the oral cavity. Credit 11/01/12 - 12/31/16. the clinician to consider all general etiologic causes of For the purpose of this Guide, a white lesion is defined disease (idiopathic, neoplastic, etc.) should be considered Address comments to: [email protected] as a readily identifiable distinct white color change (when when developing the differential diagnosis (Table 1). In MetLife Dental compared to the adjacent unaffected mucosa), localized addition to helping assure that all possible etiologies Quality Initiatives Program or generalized on the oral mucosal surface, which does are considered in the differential diagnosis, mnemonics 501 US Highway 22 Bridgewater, NJ 08807 not readily rub off. Lesions with ulceration or red color may also reduce the likelihood of a “rush to diagnosis”. www.metdental.com Quality Resource Guide – White Lesions of the Oral Cavity Table 1 Common and Clinically Important White Lesions of the Oral Cavity Grouped by Category of Disease Process (Mnemonic: INERTIA) Prevalence Category Specific Clinical Clinical In General of Disease Condition/ Specific Etiology Management Comments Presentation Significance Dental Diagnosis Process Practice Normal More common in developmental Bilateral buccal None; clinical black patients, I Leukoedema variant associated mucosa; diffuse presentation is No treatment needed but also seen in Idiopathic with intraepithelial subtle white change pathognomonic lighter skinned edema individuals Idiopathic leukoplakia; Exposure to epithelial dysplasia; carcinogens modified Biopsy and definitive treatment Can also be Varies depending on by host susceptibility Potentially based on histopathologic categorized proliferative condition. Generally Varies N (Tobacco, alcohol, preneoplastic diagnosis. Indefinite recall (q6 under verrucous single site. leukoplakia; rarely immuno- months) in absence of dysplasia “Idiopathic” Neoplastic oral submucous suppression) (includes fibrosis preneoplastic, benign and Confirmatory biopsy followed malignant) squamous cell Tobacco, alcohol, Varies; evidence of by definite surgical excision, carcinoma; rarely immuno- Malignant neoplasm Uncommon surface change and/or radiation therapy and/or supression verrucous carcinoma chemotherapy Rare. Included as Ammonia production Abrupt onset of example of E from degradation of white [plaques in Underlying renal failure Most likely to Uremic stomatitis Address underlying renal failure “Endocrine/ elevated serum urea patient with acute or is life-threatening see in severely Endocrine/ Metabolic” by oral flora? chronic renal failure ill hospitalized metabolic patient etiology May be mistaken for Chemical burn; White sloughing of other white lesions and Somewhat R Direct tissue damage thermal burn exposed oral tissues possibly bullous lesions common Reactive such as pemphigoid If frictional etiology not clearly Frictional May be Retromolar pad; evident and/or if thick, papillary or hyperkeratosis; linea indistinguishable T Repetitive friction buccal mucosa; verrucous in appearance and/or if Common alba; Morsicatio clinically from lateral tongue other changes, incisional biopsy to Traumatic linguarum idiopathic leukoplakia rule out dysplasia is mandatory. Biopsy to confirm; investigation May signify to rule out HIV-related Corrugated white undiagnosed HIV immunosuppression if no clinical I Oral hairy EBV infection of patch(es) lateral disease. Often history of medication-induced Rare leukoplakia superficial epithelium tongue; often misdiagnosed clinically immuno-suppression. May be Inflammatory bilateral as “tongue chewing” or seen in patients on high potency or Infectious “idiopathic leukoplakia” corticosteroid inhalers for COPD or asthma. Biopsy required if unilateral Varies: “classic” Immune-mediated Many other processes presentation, or in presence of bilateral white striae Somewhat Lichen planus mucocutaneous present with similar erythema, ulceration or other on buccal mucosa to common disease clinical appearance “non-classical” appearance widespread erosions A (see text). Autoimmune Associated with chronic Rare in overall (immune- Resembles lichen GVHD. Most patients on Biopsy if atypical presentation population. mediated) Graft versus host Allogeneic bone planus. Dorsal immuno-suppressive (thick, granular, persistent Common after disease marrow transplant tongue often therapy, increasing risk ulceration). bone marrow involved. of oral cancer. transplant. www.metdental.com Page 2 Quality Resource Guide – White Lesions of the Oral Cavity Specific Lesions Thick, corrugated or verrucous appearing white Histologically, idiopathic leukoplakias represent patches, lesions with irregular borders or variations a spectrum (Figures 3A-C) ranging from simple Frictional Hyperkeratosis in the degree or intensity of whiteness should be hyperkeratosis to SCC, with upwards of 15% of oral Repetitive friction