1. 1
Section I :
Differential Diagnosis of Oral Lesions

2. 2
Whitelesion
Siribang-onPiboonniyomKhovidhunkit
-Pseudomembranouscandidiasis
-Chemicalburn
-Fooddebris(materiaalba)
-Detachedkeratin
-Dentifrice-associatedepithelialslough
SinglewhitelesionsthatcannotberubbedoffMultiplewhitelesionsthatcannotberubbedoff
-Frictionalkeratosis
-Lichenoidcontactreaction
-Idiopathicleukoplakia
-Oralsquamouscellcarcinoma
-Whitelesionsassociatedwith
smokelesstobacco
-Candidalleukoplakia
Bilateralwhitelesions
-Lineaalbabuccalis
-Whitespongenevus
-Hairyleukoplakia
-Lichenplanus
-Lichenoiddrugreaction
-Leukoedema
-Candidalleukoplakia
Generalizedwhiteplaque
-Idiopathicleukoplakia
-Lichenplanus
-Lupuserythematosus
-Proliferativeverrucousleukoplakia
WhitelesionsthatcanberubbedoffWhitelesionsthatcannotberubbedoff

3. 3
CandidalleukoplakiaWhiteplaquecannotberubbedoff,usuallypresentsbilaterallyontheanteriorbuccalmucosa
closetocommissuralarea
ChemicalburnHistoryofdirectapplicationofsomemedicationssuchasaspirinorchemicalagentstooral
mucosa
Dentifrice-associatedsloughHistoryofusingdentifricewithstrongdetergentorflavoringcompounds
FrictionalkeratosisWhiteplaqueadjacenttocontributingfactorssuchassharptoothorpoorlyfittingdentures
HairyleukoplakiaAsymptomaticwhitelesionscannotberubbedoff,usuallylocatedonlateralbordersofthetongue
inHIV-infectedsubjectsorotherimmunocompromisedpatients,associatedwithEpstein-Barr
virus(EBV)infection
IdiopathicleukoplakiaWhiteplaquecannotberubbedoffinapatientwithahistoryofsmoking,alcoholconsumptionor
betelnutchewinghabit
LeukoedemaDiffuse,filmysurface,translucentwhiteplaqueonbilateralbuccalmucosawithdissipationof
whiteplaqueuponstretching
LichenplanusPresentswithwhitestriation(Wickham’sstriae)onbilateralbuccalmucosa
LichenoidcontactreactionPresentswithwhitestriation(Wickham’sstriae)adjacenttometalcontainingproductssuchas
amalgamrestorationormetalcrown
LichenoiddrugreactionHistoryofusingmedicationssuchasantihypertensivedrugsthatcaninducelichenoidlesionon
bilateralbuccalmucosa
LineaalbabuccalisWhitelinesonbilateralbuccalmucosaadjacenttotheocclusalplaneofupperandlowerteeth
OralsquamouscellcarcinomaWhiteplaquecannotberubbedoffinapatientwithahistoryofsmoking,tobaccouse,alcohol
consumptionorbetelnutchewinghabit
PseudomembranouscandidiasisWhiteplaquecanberubbedoffleaningared,raw,orbleedingsurface.Usuallypresentswith
predisposingfactorssuchasimmunocompromisingconditions,long-termuseofsteroidsor
antibiotics,orhyposalivation
ProliferativeverrucousleukoplakiaWhiteplaquecannotberubbedoffongingivawithcauliflowerlikesurface,usuallygrowsrapidly
andcanbetransformedtoverrucouscarcinoma
WhitelesionsassociatedwithWhiteplaquecannotberubbedoffinapatientwithahistoryofusingsmokelesstobacco
smokelesstobacco
WhitespongenevusPresentsasasymptomaticfoldedbilaterallesionsofbuccalmucosathattendtobethickened
andhaveaspongeconsistency
LesionsKeycharacteristicsofthelesions

4. 4
Redlesion
Siribang-onPiboonniyomKhovidhunkit
Erythematous
candidiasis
Denture-induced
stomatitis
Erosive(atrophic)
lichenplanusor
Lichenoidreaction
Desquamative
gingivitis
Median
rhomboid
glossitis
Erythroplakia
Squamouscell
carcinoma
-Redarea
withburning
sensationto
spicyfood
-Historyof
usinglong-
term
antibioticsor
corticosteroids
-Patientswith
immuno-
compromised
condition,
e.g.,HIV
infection
-Erythematous
lesionon
denture
bearingarea
-Historyof
wearing
dentureatnight
orpoororal
hygieneand
poordenture
condition
-Immunocom-
promised
patients
-Patientswith
hyposivation
-Erosivearea
withburning
sensation
tospicyfood
-Historyofusing
medications
forsystemic
diseases,e.g.
hypertension,
diabetes
mellitus,gout,
dyslipidemia
-Maypresent
adjacentto
dental
restorations,
e.g.,amalgam,
compositeresin,
ormetalcrown
-Generalized
erosivearea
onattached
gingiva
-Canbeseenin
•Lichenplanus
•Pemphigus
•Pemphigoid
-Depapillation
oncentral
posterior
dorsum
ofthetongue
-Associated
withcandidal
infection
-Red-white
lesionafter
exclusionof
allother
possible
diagnoses
-Premalignant
lesion
associatedwith
historyof
smoking,
tobaccouse,
betelnut
chewingand/or
alcoholabuse
-Usually
demonstrates
dysplastic
changesonthe
redarea
-Malignant
lesion
associated
withhistory
ofsmoking,
tobaccouse,
betelnut
chewing
and/or
alcohol
abuse

5. 5
Redandwhitelesion
Siribang-onPiboonniyomKhovidhunkit
Oralcandidiasis
ofmixed
pseudomembra-
nousanderythema-
toustypes
Lichenplanusor
Lichenoidreaction
Cheekortongue
bitinghabit
Geographic
tongue
Nicotinicstomatitis
(Stomatitis
nicotina)
Erythroleukoplakia
Squamouscell
carcinoma
-Whiteplaque
canberubbed
off,leavingred
areaor
bleeding
-Historyofusing
long-term
antibioticsor
corticosteroids
-Patientswith
immunocom-
promised
conditions,e.g.,
HIVinfectionor
usingimmuno-
suppressants
-Patientswith
hyposalivation
fromradio-
therapyoforal
cancer
-Erosiveareawith
whitestriation
(Wickham’s
striae)
-Burningsensa-
tiontospicyfood
-Historyofusing
medicationsfor
systemic
diseases,e.g.
hypertension,
DM,gout,
dyslipidemia
-Maypresent
adjacentto
dentalrestora-
tion,e.g.,
amalgam,
compositeresin,
orcrown
-Redareaswith
whiteshredded
surfaceon
lateralsurface
ofthetongueor
buccalmucosa
-Historyofcheek
ortonguebiting
habit
-Reductionofthe
lesioncanbe
obtainedafter
theabstinence
ofsuchhabit
-Redor
depapillated
areawith
whiterimon
thetongue
-Burning
sensationif
candidal
superinfection
-Morecommon
inindividuals
withallergic
diseases;e.g.
atopy,
asthma,and
contactallergy
-Redpapule
onwhite
plaquethat
cannotbe
rubbedoff
-Presentson
theposterior
palatein
individuals
withhistoryof
heavysmoking
-Red-white
lesionsafter
exclusionofall
otherpossible
diagnoses
-Premalignant
lesionasso-
ciatedwith
smoking,
tobaccouse,
betelnut
chewing
and/orheavy
consumption
ofalcohol
-Usually
demonstrate
dysplastic
changesonthe
redarea
-Malignant
lesion
associated
withhistory
ofsmoking,
tobaccouse,
betelnut
chewing
and/or
alcohol
abuse

6. 6
Erosion
(apartiallossofepithelium
presentingasasingleormultiple
redpatches)
Siribang-onPiboonniyomKhovidhunkit
Multipleunilateralerosions
orclusterofsmallpainfulerosionson
thehardpalateorattachedgingiva
Generalized
widespread
erosions
Singleormultiplelocalizederosion
Recurrent
herpessimplex
virusinfection
Recurrent
herpeszoster
virusinfection
AcuteonsetChroniconset
-Primaryherpetic
gingivostomatitis
-Erythema
multiforme,e.g.,
afterusingsome
medicationsor
afterherpesvirus
infection
-Lichenplanus
(usuallypresents
withwhitestriations,
i.e.,Wickham’s
striae)
-Pemphigus/pem
phigoid/other
vesiculobullous
diseases
-Lichenplanus/Lichenoidreaction
-Traumaorburnofaknowncause
-Precancerouslesionsuchas
erythroplakia
-Carcinoma
-Bullousdiseasessuchas
pemphigus,pemphigoid

7. 7
Ulcerativelesion
Siribang-onPiboonniyomKhovidhunkit
UlcerswithspontaneoushealingRecurrentulcersPersistentulcers
Unilateralmultiple
ulcers
Generalizedmultiple
ulcers
SingleulcerMultipleulcers
-Traumaticulcer
(checkthecause
andeliminateit.If
noresponse,
performabiopsy)
-Recurrent
aphthousulcers
(RAU)
•MinorRAU
•MajorRAU
•Herpetiform
RAU
-Recurrentaphthous
ulcers(RAU)
•MinorRAU
•MajorRAU
•HerpetiformRAU
-Recurrentintraoral
herpessimplex
virusinfection
-Recurrentherpes
labialis
-Recurrentherpes
zostervirus
infection
SingleulcerMultipleulcers
-Traumaticulcer
-Infections
-Tuberculosis
-Deepfungal
infection
-Viralinfection
-Squamouscell
carcinoma
-Salivarygland
neoplasm
•Benign
•Malignant
-Vesiculobullous
diseases
•Pemphigus
•Pemphigoid
•LinearIgA
disease
-Lichenplanus
-Lichenoidreaction
-Lupuserythemato-
sus(LE)
•Systemiclupus
erythematosus
(SLE)
•Discoidlupus
erythematosus
(DLE)
-Erythema
multiforme(EM)
-Recurrentintraoral
herpessimplex
virusinfection
-Recurrentherpes
labialis
-Recurrentherpes
zostervirus
infection
-Primaryherpes
simplexvirus
infection
-Primaryherpes
zostervirus
infection
-Hand-foot-mouth
disease
-Herpangina
-Catscratchdisease
-Rubella

8. 8
Nonwhitelesion
Siribang-onPiboonniyomKhovidhunkit
ExtrinsicfactorsIntrinsicfactors
Generalizeddiffuseorpatchy
pigmentation
-Racialpigmentation
-Inflammatorypigmentation
-Addison’sdisease
-Peutz-Jegherssyndrome
-Drug-inducedpigmentation,e.g.,
minocline,tetracycline
-Smoker’smelanosis
-Melanoacanthoma
MelaninpigmentationBloodandblood-derivedpigmentation
-Amalgamtattoo
-Decorativetattoo
-Chlorhexidinestaining
-Heavymetalsulphides
(checkforoccupationalexposure)
-Blackhairytongue
Blanchesonpressure(discoloration
isduetobloodinvessels)
-Hemangioma/vascular
malformation
-Varix(varicosity)
Noblanchingonpressure
Red,blue,brown,yellow,oryellow
brownpigmentation
-Hemorrhage
-Kaposi’ssarcoma
-Pyogenicgranuloma
-Benignandmalignantvascular
neoplasms
Discreteflatpigmentationpatches
-Benignmelanoticmacule
-Pigmentednevus
-Melanoma/melanomainsitu
Associatedwithtumormass
-Pigmentedneuroectodermaltumor
ofinfancy
-Melanoma

9. 9
Addison’sdiseaseAssociatedwithsignsandsymptomsofAddison’sdisease,e.g.,weakness,fatigue,perioraland
cutaneouspigmentation.Serumcortisollevelsshouldbeinvestigated.
AmalgamtattooUsuallypresentsadjacenttoalargeamalgamfillingorcrown;mostcommononedentulous
ridge
BenignmelanoticmaculeUsuallyexistssincechildhoodasbrownflatlesionwithnochangeinsizeorlocation
Canbesolitaryormultipleandmostcommonlypresentsonupperorlowerliporpalate
BlackhairytongueBlackordarkbrownpigmentlocalizedtothedorsumofthetonguewithorwithoutovergrowthof
filiformpapillae
Usuallypresentsinpatientswithhyposalivation,andahistoryofusingantibioticmedicationor
otherherballozenges
DecorativetattooHistoryoftattooapplication
Drug-inducedpigmentationHistoryofusinglong-termmedication,e.g.,minocycline,tetracycline,anti-retroviralmedications
HeavymetalsulphidesHistoryofoccupationalexposure,e.g.,workinginafactorywithchemicalsubstancethat
containsheavymetal
Hemangioma/vascularmalformationPresentssincechildhood,ifthelesionislarge,pulsationcanbeobtained
HemorrhageHistoryoftraumaortakinganticoagulantmedication
InflammatorypigmentationHistoryofchronicinflammation,e.g.,patientwithlichenplanus
Kaposi’ssarcomaIrregularmassassociatedwithimmunocompromisedcondition,e.g.,HIVinfection,patientswho
areonimmunosuppressivemedication
MelanoacanthomaAcuteonsetwithgeneralizedpigmentationoftheoralcavity
MorecommoninAfrican-AmericanorIndianpopulation
Melanoma/melanomainsituMostfrequentlyseenonpalateorgingivaasbrowntoblackmaculeormasswithirregular
borders
Peutz-JegherssyndromeAssociatedwithintestinalpolyposisorpresentswithgastrointestinalproblems
PigmentednevusUsuallyexistssincechildhoodassolitarysmallbrown,blackorblueelevatedpapuleornodule
PigmentedneuroectodermaltumorPresentsininfantlessthan6monthsofageandoccurstypicallyinmaxilla
ofinfancy
PyogenicgranulomaHistoryoftraumaorirritation,mostcommonongingiva,canbeassociatedwithpregnancyora
useofcontraceptivemedication
RacialpigmentationGeneralizedhomogeneouspigmentationontheattachedgingiva;bilaterallysymmetry,
commonindark-skinnedpatients
Smoker’smelanosisHistoryofsmoking,presentsaspigmentationmostoftenfoundonanteriorgingiva
Varix(varicosity)Morecommoninelderlypatients,mostcommononupperorlowerlip,ventralsurfaceofthe
tongue
LesionsKeycharacteristicsofthelesions

10. 10
Softtissueswelling/mass
Siribang-onPiboonniyomKhovidhunkit
Reactivehyperplasia
Diseasesofsalivary
gland
Benignsofttissue
lesions
Malignantsofttissue
lesions
Acuteinflammatory
enlargement
Papillaryenlarge-
mentofsurface
epithelium
-Pyogenic
granuloma
-Irritationfibroma
-Peripheralossifying
fibroma
-Peripheralgiantcell
granuloma
-Mucocele
-Ranula
-Benignsalivary
glandtumor
•Mixedtumor
-Malignantsalivary
glandtumor
•Mucoepidermoid
carcinoma
•Adenoidcystic
carcinoma
-Lipoma
-Granularcelltumor
-Neuroma
-Squamouscell
carcinoma
-Non-Hodgkin’s
lymphoma
-Abscessfrom
dentalorigin
-Pericoronitis
-Squamous
papilloma
-Verruciform
xanthoma