differentiate between different white lesions

4. Diagnosis of white lesion may be reached via one,
two or all of the following:
• History of the lesion.
• Clinical examination.
• Laboratory investigations.

5. 1-HISTORY OF THE LESION
A- History of chief complaint:
The Patient May Complain of:
1- Color Change of oral mucosa particularly of the lips (e.g.
papular lichen planus).
2- Roughness and/or stiffness of oral tissue (e.g. verrocus
leukoplakia, oral submucous fibrosis).

6. 3- Pain, discomfort, dysphagia or altered taste sensation: e.g.
• Atrophic & erosive lichen planus.
• Discoid lupus erythematosis.
• Oral submucous fibrosis.
• Carcinoma in situ.
• Squamous cell carcinoma.
• Acute Candidiasis.
• Thermal and chemical bums.
4.The patient may have no complaint: e.g
• Leukoedema. •White spongy nevus. •Hereditary benign
intraepithelial dyskeratosis.

7. B -History of causative factors:
•History of physical agents: e.g. local use of aspirin (chemical bum), hot drinks
(thermal bum) and radiation (radiation mucositis) and trauma.
•History of intraoral surgery for skin graft.
•History of Drug Administration:
White lesions developing in persons on antibiotics, steroids and antimitotics
may be an indication of candidiasis.
Mucosal and skin lesion may follow drug administration e.g. Lichenoid lesion

8. •History of Excessive Smoking and tobacco:
History of excessive smoking e.g. cigar, pipe, cigarette and chewing
tobacco may be related to stomatitis nicotina, leukoplakia lesions. In
addition chewing tobacco and holding snuff in labial sulcus may be a
causative local factor.
- Smoking may be implicated in the following conditions:
• Smokers patch on lower lip.
• Stomatitis nicotina on palate.
• Tobacco chewer keratosis on the cheeks and tongue.
• Oral snuff keratosis on labial and buccal sulcus.

9. C-History of white lesions in new born or young children:
1. Thrush
2. White folded gingivostomatitis
3. Hereditary benign intraepithelial dyskeratosis
D-Psychiatric History may reveal some white lesion that occur due to
cheek and lip biting and sucking (frictional keratosis) as well as lichen
planus.

10. • History of skin lesion may reveal its oral manifestation as LP, LE,
psoriasis & Darrier’ s disease.
• History of remission & exacerbation of the lesion e.g. LP, LE, BMMP,
BP.
• History of itching accompanied by development of new lesion at the
scratching site e.g. LP, and psoriasis.
• History of photosensitization e.g. SLE.

11. 2- CLINICAL EXAMINATION:
The following information should be obtained during clinical examination:
A. Wiping off or scrapping of the Lesion:
1. Easily wiped off (thermal-chemical bum, syphilitic mucous patches).
2. Wiped off with some difficulty (thrush).
3. Cannot be wiped off (lukoplakia, papular lichen planus).
4. Some cells can be scraped off (white sponge nevus).

12. B. White lesion may or may not interfere with physical properties of involved
tissue:
1. Leukoplakia, candidal leukoplakia, oral submucous fibrosis and carcinoma
interfere with the normal pliability (elasticity)&flexibility of the affected
tissue.
2. The physical characteristic of the tissue, is not interfered with normal
pliability of the affected site e.g. thermal & chemical bum, white folded
gingivostomatitis, & thrush.
C. White Lesion May Disappear Following Stretching of the Oral Mucosa:
e.g. Leukoedema which is contrast to lichen planus as the lines
accentuates upon stretching and ?.
D. The Presence of Wickham’s Stria: radiating from the white lesion is
pathognomonic for lichen planus and ?.

13. E- White lesion may be accompanied by extra oral lesions e.g:
• Mucous patches of syphilis accompanied by generalized lymphadenopathy
and generalized skin eruption.
• Eye lesion (congested conjunctiva or white plaque over the cornea) in
hereditary benign intraepithelial dyskeratosis.
• Spongy white lesions on nasal mucosa, vaginal mucosa, labia, anus and
rectum occur in white sponge nevus.
• Butterfly skin lesion on the face in the form of red macules covered by yellow
scales may be diagnostic of lupus erytheromatosis.
• Flat-topped polygonal lesion on the flexor aspect of the extremities with purple
glistering appearance accompanied by pruritus is diagnostic for lichen planus.
• Oral and cutaneous candidosis and dystrophic changes in fingernails, as well
as excessive melanin formation is a feature of candidosis endocrinopathy
syndrome.
• Pitting of the ridges and V-shaped defects in the fingernails is characteristic
for Darier’s disease.

14. F-White lesions may or may not interfere with the physical properties of
the involved tissue:
1. Leukoplakia, candidal leukoplakia, submucous fibrosis & carcinoma
(they all interfere with the normal elasticity & flexibility of the affected
tissue).
2. White folded gingivostomatitis, papular LP & DLE (not interfered with
the physical charecteristics of the tissues).

15. G-The presence of some criteria with white lesions:
• Wickham’s striae radiating from the lesion (LP & LE).
• Atrophic oral mucosa + keratotic margin (LP & Discoid LE).
• Crusting of the lip surrounded by keratotic margin (Discoid LE).
• Frictional keratosis (look for the cause) …. Nicotine stomatitis (clinical
picture & history of smoking).
• Soft spongy white lesion with or without folds (hereditary benign
intraepithelial dyskeratosis or WSN).
• Keratotic lesion on vermillion border of the lower lip (smoker’s keratosis) or
may be large to involve the whole vermillion border (actinic keratosis).

16. White lesion that are accompanied by extra oral lesions:
1. Syphilitic mucous patch + generalized skin eruptions &
lymphadenopathy.
2. Eye lesions (congested conjuctiva & white plaque over the cornea) in
hereditary benign intraepithelial dyskeratosis.
3. Butterfly skin lesion on the face (red macules covered by yellow scales
in DLE).
4. Skin pruritic lesions (LP).
5. Oral + skin + finger nail defects (candidosis endocrinopathy syndrome,
LP & Darrier’ s disease).

17. 3-LABORATORY INVESTIGATIONS
1. Bacterial smear and culture give positive results in the following lesions
(moniliasis and syphilis) i.e. they reveal Candida albican, treponema
palladium).
2. Exfoliative cytology (white spongy nevus).
3. Blood picture: in systemic lupus erythematosis the blood picture reveals
leukopenia, anemia, thrombcytopenia and increased E.S.R. Immunologic
tests e.g. anti DNA and others LE tests is important for diagnosis of LE.
4. Biopsy is one of the most important diagnostic tools in diagnosis of white
lesions.
5. Immunofluorescent Testing: Incubating a biopsy specimen of the lesion
with a flourescein-conjugated antiglobulin performs direct immunofluorescent
technique, the slide will be examined by UV microscope. e.g. lupus
erythematosis

18. Patients with SLE have excessive bleeding tendency (Why?), oral
surgical procedures should be avoided for them as much as you can.
In addition, prophylactic antibiotics are indicated, as they are
susceptible to develop endocarditis.
Penicillin, sulfonamide and NSAID may precipitate the lesions, so avoid
their use.
Avoid tetracycline as it may cause photosesitivity.