Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
1
White & Red Lesions of The Oral Mucosa
Measles or Rubeola
It's an acute highly contagious viral disease affecting children. Symptoms
develops 10-12 days after exposure & last for 7-10 days.
Measles starts with prodromal symptoms: fever, lymphadenopathy,
headache, nausea, cough, conjunctivitis, photophobia, lacrimation &
nasal discharge, followed by the oral & skin Rash.
Oral lesions form 2-3 days after the start of the prodromal symptoms
(before the rash begins), they appear as small spots (bluish-white) with
red erythematous borders on the buccal mucosa & soft palate known as
Koplik's spots which are pathognomonic in 97% of cases. Rash appears
first on face, hair line, behind ear, neck, chest, back and extremities.
Diagnosis: Clinically & laboratory
Treatment: Bed rest, good diet, & symptomatic treatment
Anemia
Anemia is associated with pallor of the oral mucosa and atrophic
glossitis due to erythema and atrophy of papillae in addition to other
features of anemia.
Depapillation of the tongue
Localized:
1. Geographic tongue
2. Median rhomboid glossitis
3. Chronic atrophic candidiasis
4. Depapillation of elderly
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
2
Complete:
1. Anemia: Iron, B12, Foliate
2. Atrophic lichen planus
3. Discoid lupus erythematosus
4. Tertiary syphilis atrophic glossitis
lation with oral lesions
and its re
Vitamin A (Retinol)
Normal functions of vitamin A:
1. Vitamin A helps in maintaining the integrity of epithelial tissue
2. Accelerates the normal formation of bones and teeth
3. Vitamin A has a specific role in the physiological mechanism of vision
4. Prevents premature ageing
5. It’s also required for somatic growth
Note: Vitamin A (Retinol) and/its derivatives is used as a keratolytic
agent Tretinoin (Retin A®)
Vitamin A deficiency, it's characterized by:
1. Night blindness
2. Dry conjunctiva
3. Corneal ulceration and xerophthalmia
keratinized epithelial cells which
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Keratinizing metaplasia of the non
4.
usually results in white lesion such as leukoplakia of the oral mucosa,
and dryness of the skin
5. Also it is characterized by defective formation of the enamel, dentin &
pulp
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
3
Chemical burn (Aspirin burn)
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Drugs
It occurs when an Aspirin tablet (acetyl salicylic acid) is placed in the
muco-buccal fold or sulcus to relief pain of pulpitis, periostitis, P.A
abscess
Characterized by irregularly shaped whitish pseudo-membranous
painful lesion (due to necrosis and sloughing of epithelium) develops
where the medicament touches the oral mucosa and the gingival
tissues. The entire mucosa may be diffusely involved. Case resolves
following removal of the cause.
Chemical burn (Medications)
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Drugs
Many of medicaments used in dental practice may cause painful burn
and white lesion of the gingivae and oral mucosa when they accidentally
contact any oral mucosa.
Examples of materials: Eugenol, Silver nitrate, Phenol, Mouth rinses,
and Sodium hypochlorite
Lichenoid drug reaction
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Drug reactions
This term is given to lichen planus like lesions. It represents
hypersensitivity reaction to certain drugs.
Patients may come with skin/and or oral mucosal lesions which are
indistinguishable clinically and histologically from lichen planus.
Lesions may appear as white striae, or with sever atrophy /or ulceration,
therefore, complete drug history is mandatory in all lichen planus
patients to detect the possible causative drug.
Wide range of drugs can cause lichenoid drug reaction, such as:
1. Antimicrobial agents: Such as Tetracycline, Streptomycin, and
Dapsone
2. Antiarthritics such as Gold salts
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
4
3. Oral hypoglycemic agents: Such as Chlorpropamide (Diabinese®),
Tolbutamide (Orinase®)
4. Thiazide diuretics
5. Anti-hypertensive: Such as Captopril (Capoten ®), Methyldopa
(Aldomet ®)
6. Beta blockers
7. Non-steroidal anti-inflammatory drugs: such as Indomethacin and
Ibuprofen
8. Some tricyclic anti-depressants
9. Antimalarials
10. Others: Iodide, Pencillamine, Copper in dental alloys, and Amalgam
restorations
Diagnosis:
1. History (useful) & clinical examination (not enough)
2. Biopsy: It’s hard to differentiate LDR from L.P, however, LDR lesions
epithelium
-
present with eosinophils infiltration of the sub
may
3. Withdrawal of the possible causative drug may also confirm the
diagnosis (the drug is known from history)
Treatment: Cessation or substitution of the possible causative drug &
treatment of the oral lesions which is similar to that of L.P
allergic
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Stomatitis venenata or contact stomatitis
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Drug reactions
stomatitis
It's a condition that may be found following the placement or contact
with a variety of substances into or surrounding the mouth, including:
1. Chrome cobalt denture 2. Gold crowns
3. Denture soft lining 4. Chewing gums
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
5
5. Amalgam 6. Acrylic denture
7. Tooth paste 8. Temporary bridge
9. Lip stick 10. Face cream
11. Sulphonamide ointments
Treatment: In mild cases remove the cause and relief pain. In severe
cases topical corticosteroid is used
Stomatitis medicamentosa
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Drug reactions
It's a condition that may be found following systemic administration of
certain drugs or agents. The reaction occurs quickly, usually within 24hrs
after contact with the offending antigen.
It's characterized by inflammation, ulceration or vesicles similar to the
lesion of erythema multiforme
Treatment: same as the local allergic stomatitis
Lichen planus
LP is a common chronic inflammatory disease of the skin and mucous
membranes. It mostly affects male and female patients of middle age or
older. Its prevalence is approximately 1% of the population (variable).
Oral lesions may precede the skin lesions or follow them or they may be
seen simultaneously. The mouth is a common site of involvement and
the lesions may show great variation in clinical appearance.
There is no clear etiology for the disease, however, the t-lymphocytes
infiltration of the epithelium suggests that LP is a cell-mediated
immunological disorder. Other possible causes could be reaction to drug
or amalgam restorations (see drug reactions), an early sign of graft
versus host diseases, psychological factors, and recent studies reported
that LP might be associated with hepatitis C infection.
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
6
LP & OLP has several clinical forms or patterns such as:
1. Reticular (Striate) form
2. Linear
3. Annular
4. Papular
5. Bullous
6. Atrophic
7. Atrophic glossitis
8. Erosive or ulcerative
9. Plaque or leukoplakia like
10. Desquamative gingivitis
Common sites of OLP include:
1. Buccal mucosa which is the most common site, and the lesion may
spread to the commissures
most common affected site, on which the lesions
nd
2. Tongue, the 2
found on the dorsum and lateral sides
3. Gingivae and lips are occasionally affected
4. Then comes the floor of the mouth and palate
Though OLP may be asymptomatic, however, it may present with the
following symptoms:
1. Roughness
2. Burning sensation
3. Metallic taste
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
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4. Difficulty in eating and drinking
Typical OLP lesion may show characteristic clinical features (or forms)
either isolated or combined which aid in its diagnosis
Striate (reticular) form
Striae are the most common & shows the typical features of OLP. They
appear as sharply-defined snowy white, lacy, starry or annual patterns.
Occasionally the striae may be interspersed with minute, white papules.
Striae may be smooth (not palpable) or may be firmer than the
surrounding mucosa causing roughness of the mucosa.
Atrophic form: In which there are red (erythematous) areas of mucosal
thinning and often combined with the striae.
Erosive form: The erosions appear as shallow irregular areas of
epithelial destruction. They can be very persistent and may be covered
with a smooth slightly raised yellowish layer of fibrin. The margins may
be slightly depressed due to fibrosis and gradual healing of the
peripheries. Striae may radiate from the margins of the erosions.
Plaque (leukoplakia like) form: In which plaques are occasionally seen
in early stages of OLP especially on the dorsum of the tongue.
Sometimes they may be seen on the buccal mucosa in persistent OLP
cases.
LP- Skin lesions and nail lesions:
The typical skin lesions are purplish papules, their size may range from
2-5mm with a glistening surface marked by minute fine white lines or
striae known as Wickham's striae, the lesions are usually itchy (pruritis
symptom).
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
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Typical site of skin lesions is the flexor surface of the wrists, then comes
the shins, ankles and lumber regions.
Though skin lesions are not always found in patients with OLP, but their
presence may help to confirm the diagnosis.
Nail lesions are rare; however, LP may affect one or more nails,
sometimes without involving the surrounding skin surface.
When all nails are affected and LP not seen elsewhere it’s known as
twenty-nail dystrophy.
The affected nail shows a thin nail plate, which will become grooved and
ridged. In some cases, there may be complete destruction of the nails
and they will eventually disappear (anonchyia).
LP Genital lesions:
Vulva and vagina may also be involved in LP but may be asymptomatic.
The vulvo-vaginal-gingival syndrome is a rare and severe variant of L.P
which is difficult to manage. Characterized by erosions or desquamation
of vulval, vaginal, and gingival mucosae with a tendency for scarring and
stricture formation.
LP in relation to systemic diseases:
1. Diabetes mellitus
2. Vascular hypertension
3. Hepatitis type C
4. Lupus erythematosus
5. Grinspan's syndrome: Diabetes mellitus + Vascular hypertension +
OLP
OLP lesions thought to be a result of the drugs used for treatment of
hypertension and diabetes mellitus.
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
9
LP Histopathology:
Typical histological features (white lesion or reticular form):
1. Hyperkeratosis or parakeratosis
2. Thickening of the granular cell layer
3. Acanthosis
4. Liquefactive degeneration of the basal cell layer
5. Saw-tooth appearance of the rete ridges
6. Well defined band like zone of cellular infiltration (predominantly t-
lymphocytes) that is confined to the lamina propria
Atrophic lesions show: Severe thinning of the epithelium, destruction of
basal cell layer and band like subepithelial inflammatory cells infiltrate.
Erosive lesions show: Destruction of the epithelium, leaving only the
fibrin covered granulating connective tissue floor of the lesion.
LP Diagnosis:
1. History
2. Clinical examination (appearance)
3. Biopsy
4. Immunofluorescence (IF) reveals: Shaggy band of fibrinogen and
colloid (cytoid) bodies in the dermal papillae and/or basement
membrane zone. These cytoid bodies can stain for IgM (shows IgM less
frequently IgA and IgG).
Treatment of lichen planus: There is no known cure for OLP, treatment
include:
1. Reassurance
Dr. Ahmed Salih Khudhur
BDS, M.Sc., PhD. Newcastle University/UK
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2. Elimination of drugs and chemicals (cause)
3. Antihistamine
4. Steroids (topical, systemic & intra-lesional injection)
5. Vitamin A and vitamin A derivatives such as Tretinoin (Retin A®) &
Isotretinoin
6. Cryotherapy
7. Surgical excision
8. CO
2
and infra-red Laser
9. Cyclosporine, it’s selective inhibitor of CD4 (Topical &/ systemic. Dose
8mg/kg/day)
10.Tazarotene third generation topical retinoid
11. Tacrolimus (immunosuppressive) mouth wash is likely to be effective
in resistant cases (0.1 mg per 100 mL of distilled water, 4 times daily for
6 months)
Potent topical steroids can be used to treat LP, however, they require
monitoring because of their side effects
Such drugs:
1. Fluocinonide (Lidex) 0.05%
2. Clobetasol (Temovate) 0.05%
3. Possible steroid alternatives such as Beclomethasone found in aerosol
inhalers for asthma, 6 puffs/day will deliver enough corticosteroid to the
lesion.
4. Triamcinolone is less effective but can be useful in desquamative
gingivitis LP.
Note: Patients on steroids should be monitored for the development of
Thrush.