Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
1
White & Red Lesions of The Oral Mucosa
Useful dermatological, clinical and pathological terms:
Macule: A macule is a change in the surface color of skin or mucosa
without elevation or depression, non-palpable, well or ill-defined
variously sized, but generally less than 5-10mm (or less than 1cm) in
diameter. These are lesions that are flush with the adjacent. They may
be red due to increased vascularity or inflammation, or pigmented due
to the presence of melanin, hemosiderin, and foreign materials
(including the breakdown products of medications). A good example in
the oral cavity is the melanotic macule.
Patch: A patch is a large macule equal to or larger than 5-10mm (or
larger than 1cm) in diameter. Patch may have some surface change such
as fine scale or wrinkling, however, the lesion itself still not palpable.
Papule: Is a circumscribed solid elevation (slightly domed or flat-topped)
of the skin or mucosa with no visible fluid, varying in size from pinhead
to less than 5-10mm (or less than 1cm) in diameter.
Plaque: Described as either a broad papule or confluence of papules
equal to or greater than 10mm (or larger than 1cm). Or alternatively as
an elevated, plateau-like lesion that is greater in its diameter than its
depth.
Nodule: A nodule is morphologically similar to a papule that it is also a
palpable spherical or dome shaped lesion less than 10mm (or less than
1cm) in diameter. However, it is differentiated by being centered deeper
in the dermis or subcutaneous tissue (Endophytic) or sub-mucosa
(Exophytic). A good example of an oral mucosal nodule is a fibroma.
Tumor: similar to nodule but larger than 10mm (or larger than 1cm) in
diameter.
Blister: Is a small skin or mucosal elevation containing body fluid (serous,
lymph, serum, plasma, blood or pus).
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
2
Vesicle: A vesicle is small blister, a circumscribed, fluid-containing,
epidermal or mucosal elevation generally less than either 5-10 mm in
diameter (less than 1cm). The fluid content is clear serous fluid.
Bulla: A bulla is a large blister, rounded or irregularly shaped containing
clear serous or purulent fluid. Its size is larger than 5-10mm (greater
than 1cm).
Pustule: A pustule is a small elevation (blister) of the skin or mucosa
containing cloudy or purulent material (pus) usually consisting of
necrotic inflammatory cells. They appear yellow, white or red.
Telangiectasia: Represents an enlargement of superficial blood vessels
to the point of being visible.
Purpura: These are reddish to purple discolorations caused by blood
from vessels leaking into the connective tissue. These lesions do not
blanch when pressure is applied and are classified by size as petechiae
(less than 0.3 cm), purpura (0.4–0.9 cm), or ecchymoses (greater than 1
cm).
Scale: Dry or greasy laminated masses of keratin that represent
thickened stratum corneum.
Crust: Dried sebum (sebaceous secretion), pus, or blood usually mixed
with epithelial and sometimes bacterial debris.
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
3
The oral cavity is lined by oral mucosa which is composed of Oral
Epithelium & Sub-mucosa
its function, the oral mucosa is divided into:
to
According
1.
Masticatory mucosa 2. Lining mucosa
3. Specialized mucosa
Why lesions appear white?
Mucosal lesions appear white due to:
1. Increased thickness of epithelial covering
2. Abnormal keratinization of non-keratinized epithelial surfaces
(metaplasia) such as keratinization of non-masticatory (lining) mucous
membrane of the oral cavity
3. Hyperkeratosis which is increased or excessive production of keratin
4. Imbibition of fluid (water, saliva) by the upper layer of mucosa
5. Tissue necrosis
Why lesions appear red?
Mucosal lesions appear red due to:
1. Thinning of epithelial covering (erosion, atrophy)
2. Reduced epithelial keratinization
3. Abnormal cell turnover during healing
4. Blood leakage into surrounding tissue due to trauma
5. Vasodilation during inflammation and vascular proliferation in tumor
(neoplasm)
6. As part of dysplasia (premalignant and malignant)
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
4
of White and Red lesions
Classification
1. Normal variation: I. Leukodema II. Fordyce’s granules
III. Linea alba IV. Morsicatio
2. Developmental: I. White spongy nevus II. Median rhomboid glossitis
3. Traumatic: I. Traumatic keratosis
II. Nicotinic stomatitis (Stomatitis nicotina)
III. Papillary hyperplasia of the palate
4. Infective: I. Candidiasis (Candidosis) II. Syphilis III. Measles or Rubeola
5. Blood dyscrasias: I. Anemia II. Plummer Vinson syndrome
III. Vitamin A deficiency
6. Drugs: I. Chemical burn (Aspirin & other medications)
II. Drug reactions: a. Lichenoid drug reaction b. Stomatitis venenata
c. Stomatitis medicamentosa
7. Dermatological: I. Lichen planus II. Lupus erythematosus III. Psoriasis
8. Premalignant: I. Leukoplakia II. Erythroplakia
III. Submucous fibrosis
9. Malignant: Squamous cell carcinoma
10. Miscellaneous: I. Oral skin graft II. Geographic tongue
III. Coated tongue
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
5
Leukodema
It’s a common variation of the normal oral mucosa. Appears as a
greyish-white milky film on the buccal mucosa and soft palate, especially
in dark skinned people (Negros) and heavy smokers. It represents a
normal anatomical variation that can be accentuated by smoking. It’s
asymptomatic & found on routine oral examination. It can’t be removed
with tongue blade.
D.D: Lichen planus, Leukoplakia, Cheek biting & White spongy nevus
Diagnosis: 1. Clinical appearance 2. Histopathology
3. Stretching test (disappears by stretching)
Treatment: Reassurance
Fordyce’s granules
They are common congenital lesions seen mostly in elder patients.
Represent ectopic sebaceous glands. Mostly found on the buccal
mucosa and the lips (labial mucosa). Commonly, they are soft,
asymptomatic, and symmetrically distributed yellowish creamy spots
with few millimeters in diameter. Sometimes appear as clumps of spots
or small white-yellowish sub-mucosal patches.
Diagnosis: 1. Clinical appearance 2. Biopsy
Treatment: Reassurance
Linea alba
Is a horizontal white line on the buccal mucosa at the level of the
occlusal plane extending from the mouth commissure to the posterior
teeth. It is a very common finding and is most likely associated with
pressure or frictional irritation (as in bruxism), or sucking trauma from
the facial (labial, buccal) surfaces of the teeth (negative pressure such as
during sucking or heavy shisha/ pipe smoking).
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
6
Clinical features:
1. Linea alba buccalis usually present bilaterally and may be pronounced
in some individuals.
2. It is more prominent in individuals with reduced overjet of posterior
teeth.
3. It is often scalloped and restricted to dentulous areas.
Treatment:
1. No treatment (Reassurance). It may disappear spontaneously
2. If not disappear, then apply Keratolytic agent
3. Remove the cause (example Bite plate in bruxism)
Morsicatio
Morsicatio (also known as “morsicatio mucosae oris”) refers to biting or
nibbling of the oral mucosa. Common sites for this habitual nibbling
include the tongue (morsicatio linguarum), buccal mucosa (morsicatio
buccarum), and labial mucosa (morsicatio labiorum). The patient may or
may not be aware of the habit (asymptomatic), and some investigators
have suggested an association with stress or psychological disorders.
The chronically traumatized mucosa develops a white to red-white
plaque/patch with a rough, ragged, or macerated appearance.
Sometimes the patient can remove thread-like shreds of keratin from
the surface. Accompanying ulceration or erosion also is possible on
continuous biting/nibbling.
Diagnosis:
The characteristic clinical presentation is sufficient for the diagnosis,
although biopsy may be performed if there is uncertainty. Microscopic
examination shows a thickened, shredded keratin layer.
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
7
Treatment:
1. No treatment (Reassurance)
2. Stop or abstain the habit and the lesion will disappear spontaneously
3. To remove the cause, Bite plate or habit breaker may be constructed
4. If not disappear, then apply Keratolytic agent
White sponge nevus
White sponge nevus (Cannon's disease) is a developmental keratotic
lesion inherited as an autosomal dominant trait (mutation in the keratin
genes), it affects the mouth and other mucosal surfaces. It appears from
infancy to adolescence. Affected mucosa appears white thickened,
folded or corrugated lesions with spongy soft texture. WSN is
asymptomatic, in the oral cavity it involves the buccal mucosa and floor
of the mouth usually bilaterally. Other mucosal surfaces may be affected
such as vagina, anus and nasal cavity.
Diagnosis:
1. Clinical appearance
2. Positive family history
3. When confused with leukoplakia, biopsy is indicated to confirm the
diagnosis
Treatment: Reassure the patient that the condition is benign. If it is
causes extreme discomfort, surgical excision and grafting can be
performed.
Median rhomboid glossitis
Described as rhomboid, diamond or rounded area of depapillation in the
midline of the dorsum of the tongue at the junction of the ant. 2/3 and
post. 1/3 anterior to the v-shaped circumvallate papillae. The lesion is
asymptomatic and seen in adults. Mostly appear as a red depapillated
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
8
area, alternatively it may be white. It may have a nodular appearance, or
flat/slightly depressed area. In some cases, it may appear nodular
fibrous with epithelial hyperplasia. MRG location on the tongue suggests
that it may be developmental represents a remnant of the tuberculum
impar, however, as it is not commonly seen in children this suggestion is
no longer accepted. It has now been recognized that MRG is often
associated with candida.
Diagnosis:
1. Clinical appearance
2. Swab and culture to demonstrate candidal hyphae (Gram stain)
3. Biopsy is indicated to rule out carcinoma
Treatment:
1. Reassurance
2. When candidal hyphae detected, the lesion treated with topical
antifungal drug
3. If the lesion remains, follow up for any enlargement or change is
indicated
Keratosis)
Traumatic keratosis (Frictional
It refers to an isolated area of thickened whitish oral mucosa that is
related to an identifiable local irritant and resolves following elimination
of the irritant. It's usually found in association with denture clasps,
rough edges of denture, sharp edges of restorations, broken teeth, lips
of heavy cigarette smokers and buccal mucosa opposite the molar teeth.
Early cases appear grayish white, later becomes dense, firm and white.
Diagnosis: Demonstrate the irritant factor & Biopsy (if suspected)
Treatment: Reassurance & Remove the irritant (cause)
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
9
Nicotinic stomatitis (stomatitis nicotina)
It's a specific lesion that develops on the palate of heavy cigarette, pipe
and cigar smokers. Palatal mucosa appears as grayish white, thickened
and/or fissured. Focal thickening occurs around the orifices of the
palatal minor S. Gs which appears as white, umbilicated nodules with
red centers (orifices of the S. Gs) which may be stained brown by
deposits of tar.
Diagnosis: History & Clinical examination & Biopsy (if suspected)
Treatment:
1. Stop smoking & lesion resolves within weeks
2. Follow up of the patient
Papillary hyperplasia of the palate
Appears in denture wearers especially those wearing ill-fitting denture
or rocking denture. The lesion is asymptomatic, discovered by clinical
examination (sometimes painful), the palatal mucosal lesion appears as
polypoid, granulated erythematous elevations.
Diagnosis: history and clinical appearance. Biopsy if suspected.
Treatment:
1. Reassure the patient that the lesion is benign
2. In early cases the lesion will resolve with relief of the denture or
construction of new well-fitting denture
3. In advanced cases surgical excision may be required (and biopsied).
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
10
Candidiasis (Candidosis)
It's most the common oral fungal infection in humans. Represent classic
opportunistic infections caused by Candida albicans. C.A is a component
of the normal oral flora with as many as 30-50% of people carrying the
organism in their mouths without clinical manifestations.
The commensal C.A becomes pathogenic when appropriate
predisposing factors exist such as:
1. Acidic saliva
2. Xerostomia
3. Nocturnal denture wearing
4. Heavy smokers
5. Mal-nutrition & mal-absorption syndrome
6. Prolonged use of antibiotics
7. Steroid therapy
8. Radiotherapy (7, 8, 9, 10 & 11 considered Immune-compromised)
9. Chemotherapy
10. HIV infection
11. Endocrine abnormalities
12. Diabetes mellitus
13. Vitamins deficiencies
14. Age (elders & infants)
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
11
Antifungal drugs
I. According to mode or site of action:
1. Polyenes: Nystatin (Mycostatin, Nystat), Amphotericin B (Fungizone)
2. Azoles: Imidazole derivatives
Topical: Clotrimazole...Mycelex
Miconazole..Micogel
Econazole
Systemic: Ketoconazole..Nizoral
3. Triazole: Systemic
Fluconazole. Diflucan
Itraconazole. Sporanox
4. Others: Gentian violet 1% (Crystal violet) (Triarylmethane antiseptic
dye)
II. According to route of administration:
1. Topical (local): Amphotericin B (Fungizone),
Clotrimazole (Mycelex), Econazole (Spectazole),
Itraconazole (Sporanox), Miconazole (Monistat, Micatin),
Nystatin (Mycostatin)
2. Systemic: Fluconazole (Diflucan), Itraconazole (Sporanox)
Ketoconazole (Monistat, Micatin)
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
12
Nystatin: 100000. IU, 200000. IU, & 500000. IU 1×4...daily
Pastilles, Drops
Amphotericin B: 100mg/20ml suspension
50mg... powder for injection
1×4 daily
Clotrimazole: Gel, Lotion, Solution
Troche.100mg..200mg..500mg
Ketoconazole: 200mg. tab..once daily
50mg, 100mg, 150mg, 200mg tab... IV.
Itraconazole: 100mg, 200mg cap
Pseudomembranous candidiasis (Thrush):
It's an acute candidal infection, characterized by:
1. Development of soft friable adherent creamy white plaques (pseudo-
membranes) on the oral mucosa
2. Distinctive feature of these plaques is that they can be wiped off
easily by scrapping them with a tongue blade leaving an erythematous
(bleeding raw mucosal) areas
3. Most commonly occur on the palate (soft & hard), buccal mucosa,
labial mucosa & tongue. Angle of the mouth may be associated (angular
stomatitis)
4. Symptoms: Burning sensation & abnormal taste (metallic taste)
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
13
Diagnosis:
1. History: If patients not infants or elderly, any adult male/female who
develops thrush without apparent cause HIV infection or other
immunological disturbances should be suspected. However, any form of
candidiasis can be secondary to HIV infections
2. Clinically: Presence of the lesions which could be removed by
scrapping
3. Laboratory:
a) +ve swab and culture on Sabouraud's dextrose agar to see the
colonies
b) PAS stain (periodic acid schiff reagents) and Gram-stain demonstrate
the candidal hyphae
Neonatal thrush: Due to
Milk fermentation
Immaturity of the immune response
Acquired during passage through birth canal
Treatment of Thrush:
Correction of systemic background &/ antifungal therapy
1. Nystatin (Mycostatin ®): Tablets 500000 U
Suspension 100000 U in 60 ml & 473 ml units
Topical cream (or ointment) 100000 U/g in 15 g & 60 g units
Lozenges 200000 U
2. Mycostatin drops
3. Miconazole: Topical Oral Gel (Daktarin ®) Each gram of the gel
contains 20 mg of miconazole
Other forms (cream & ointment)
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
14
4. Amphotericin B (Fungizone ®): Topical or oral suspension 100 mg/ml
in 24 ml (1ml q.i.d)
5. Gentian violet
idiasis:
Erythematous cand
I. Acute atrophic candidiasis or antibiotic sore mouth
Mostly follows a course of broad-spectrum antibiotics.
Could be found in:
1. AIDS & immunocompromised patients
2. Prolonged use of systemic and local steroids
3. Iron deficiency anemia
4. Misdiagnosed with the raw areas of thrush after the white patches
have been scraped off
Clinically characterized by:
1. Burning sensation
2. The affected mucosa appears red
For instance, when the tongue is affected, it may be associated with
diffuse loss of the filiform papillae resulting in a reddened
(erythematous) bald tongue
Treatment:
1. Treat the underlying condition (Ex. Stop or change the antibiotic)
& if not respond systemic)
topical
(
2. Antifungal
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
15
II. Central papillary atrophy of the tongue or Median rhomboid
glossitis
MRG are usually asymptomatic and chronic. It presents as a well
demarcated erythematous zone with smooth or populated surface.
Treatment: Topical Antifungal
III. Chronic multifocal candidiasis
This is a form of chronic candidal infection involving multiple areas in
the mouth.
Areas involved: Tongue (MRG), angle of the mouth, in addition to
junction of the hard & soft palate. Palatal lesions appear red
(erythematous)
Treatment: Antifungal (systemic)
IV. Angular cheilitis or Perleche
Angular cheilitis (Angular stomatitis, Cheilosis, Perleche). It's a bilateral
chronic inflammation of the corner (commissure) of the mouth
Characterized by erythema, fissuring and scaling. Typically seen in elders
with reduced vertical dimension, however, may occur in other age
groups
Microbiological studies revealed that the lesion is caused by both
Candida albicans and Staphylococcus aureus
Treatment:
1. Identify the predisposing factors
2. Topical antifungal &/ antibiotic such as fusidic acid cream (Fucidin®)
3. Increase the vertical dimension if needed
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
16
V. Chronic atrophic candidiasis or Denture associated stomatitis
It occurs in denture wearing patients, especially those wearing a well-
fitting denture overnight. The denture isolates the underlying or bearing
mucosa from the protective/washing action of saliva.
Its characterized by varying degrees of asymptomatic erythema
localized to the denture bearing areas of a maxillary removable dental
prosthesis. Smoking increase the susceptibility of this infection. Angular
cheilitis maybe associated and may represent the chief complain.
Previously Denture stomatitis was thought to be attributed to allergy to
denture base material or sensitivity to remnants of methylmetharylate
monomer.
is
Type I
Denture stomatitis is classified into three different types.
limited to minor erythematous sites caused by trauma from the
ed mucosa. In
cover
-
affects a major part of the denture
Type II
denture.
has a granular mucosa.
Type III
,
type II
addition to the features of
The denture serves as a vehicle that accumulates sloughed epithelial
cells and protects the microorganisms from physical influences such as
mastication & salivary flow. The microflora is complex and may, in
addition to C. albicans (main causative MO) contain bacteria from
several genera, such as Streptococcus-, Veillonella-, Lactobacillus-,
Prevotella- (formerly Bacteroides), and Actinomyces-strains. It is not
known to what extent these bacteria participate in the pathogenesis of
denture stomatitis.
Diagnosis: Smear from denture base. Swab and culture
Treatment:
1. Instruct the patient to stop wearing the denture for 1-2 weeks,
meanwhile, soak the denture in 0.1 hypochlorite or chlorhexidine
overnight, to eliminate C.albicans from the denture base
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
17
2. Topical antifungal: Coat the denture with miconazole gel and wear it,
then remove it, clean & scrub the base, and apply the gel again, this is
done t.i.d for 1-2 weeks till the fungi eliminated
3. In resistant cases, itraconazole or fluconazole may be given orally,
however, topical treatment is safer
4. When there is no response, underlying conditions should be inspected
and treated such as iron deficiency anemia the chief complain
Chronic hyperplastic candidiasis or Candidal leukoplakia
This type of chronic candidiasis affects adults of middle age or older.
CHP characterized by a white patch (plaque) that can’t be removed by
scraping. The plaque has variable thickness & often rough or irregular in
texture.
The lesion may also be nodular with an erythematous background
(mixed red and white areas) resulting in a speckled leukoplakia. Such
lesions may have an increased frequency of epithelial dysplasia.
It's most commonly found on:
a. The buccal mucosa & may extend to the commissural mucosa
b. Dorsum & laterodorsal surfaces of the tongue
c. Labial mucosa (less)
Diagnosis:
1. Clinically: Appearance & non scraped-off lesion
2. Biopsy: To confirm and differentiate the lesion from idiopathic
leukoplakia &/ erythron-leukoplakia or erythroplakia
Treatment:
1. Systemic antifungal such as fluconazole for several months
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
18
2. Unresponsive lesions need surgical excision and grafting with
antifungal treatment to prevent recurrence if there are any remnants
Mucocutaneous Candidiasis MCC
Chronic mucocutaneous candidiasis syndromes are group of rare
candidiasis which are difficult to manage. They are considered as a rare
group of immunological disorders
There are 4 main types of MCC:
1. Familial (limited) type
2. Diffused type (Candidal granuloma)
3. Endocrine candidiasis syndrome
4. Late-onset (Thymoma syndrome)
Generally characterized by candidiasis of the mouth, nails, skin and
other mucosal surfaces. Oral lesions appear as thick white plaques
which can’t be scraped off.
Syphilis
The oral mucosa may be involved in primary, secondary, and tertiary
syphilis. Each stage of syphilis has its own clinically distinct oral lesion.
The characteristic oral lesion of primary syphilis known as chancre. It
may occur on the lip, tip of the tongue, & rarely other oral sites. Chancre
initially appear as a firm nodule about 1cm in diameter. It is typically
painless; however, the regional lymph nodes are enlarged & rubbery in
texture. Few days later, chancre breaks into a rounded ulcer with raised
indurated edges (which may resemble carcinoma when occur on the lip).
Chancre is highly infectious.
Secondary syphilis. The characteristic oral lesion of 2ndry syphilis is
known as Snail’s track ulcer. Oral lesions rarely appear without the skin
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
19
rash, the oral lesions mainly affect the tonsils, lateral borders of the
tongue and lips. The ulcers are usually flat, covered by greyish
membrane and may be irregularly linear. The ulcers may coalesce to
form well-defined yellowish-white mucous patches. The ulcers discharge
contains syphilis spirochetes therefore saliva is highly infective
Tertiary syphilis. Gumma is the characteristic lesion of 3ry syphilis
which may affect the palate, tongue or tonsils. Its size may vary from
few to several cms. Gumma begins as swelling with yellowish center
which undergoes necrosis leaving a painless deep ulcer. Syphilitic
leukoplakia of the tongue may also develop during 3ry syphilis, which is
a premalignant lesion. Atrophic glossitis may occur as well.
Treatment of syphilis: Antibiotics, particularly penicillin, tetracycline and
erythromycin are also effective.