Dr. Saleem Shaikh
Oral mucosa is lined by stratified squamous
epithelium, which is further of two types keratinized and non keratinized.
Due to some stimulus like friction, infection,
chemicals etc some of these non keratinized
areas may get keratinized or in some cases the
keratinized areas become hyperkeratinized.
When normally nonkeratinized tissue turns into
keratinized it is known as ‘keratosis’
Such lesions are known as ‘Keratotic lesions’.
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This group involves a number of various lesions and most of them
commonly present as white coloured lesions, Due to excess of
keratin production.
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Leukoplakia
Lichen planus
White sponge nevus
Keratoacanthoma
Hairy tongue
Linea alba
Smoker’s palate
Verrucous carcinoma
Oral hairy leukoplakia
Hyperplastic candidiasis
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(leuko = white; plakia = patch)
is the most common potentially malignant lesion of the
oral mucosa.
“a predominently white non scrappable plaque or patch
of the oral mucosa that cannot be characterised as any
other definable lesion”.
Etiology: tobacco is the most important etiology, both
smoking and smokeless forms of tobacco can cause
leukoplakia. Sometimes leukoplakia is also seen in non
tobacco users, i.e. without any known causative factor
such cases have been referred to as ‘Idiopathic
leukoplakia’.
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Clinical features:
• It is seen usually unilaterally on the buccal mucosa
or the vestibule or any other part of the oral mucosa
where tobacco is placed for chewing. It appears as a
white patch which cannot be scrapped (wiped) off
with a gauze piece or spatula.
• Based on its appearance it can be further classified
into
 Homogenous: when it is uniformly white in colour
 Non Homogenous: when it is mixed with red areas
such lesions are also referred as speckeled
leukoplakia, nodular leukoplakia or
erythroleukoplakia.
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Usually non homogenous variant have poor prognosis
and are associated with pain and discomfort as
compared to the homogenous variant.
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Proliferative verrucous leukoplakia (PVL) is an
aggressive variant of leukoplakia, which clinically
presents as a fingerlike warty lesion and invariably
progresses onto malignancy.
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Histological features: Histologic features of this lesion
are not specific, hyperkeratosis and epithelial
hyperplasia are typically seen. Dysplasia ranging from
mild to severe is also seen in 10-20% of the cases.
Leukoplakia is a clinical diagnosis and histology is used
to only rule out other definable lesions. Hence it is also
said that it is a negative diagnosis.
Treatment: If it is a small patch and is not causing any
problem then ask the patient to stop tobacco use and
put him under observation. If it is otherwise or shows
dysplastic features than excision is the treatment of
choice.
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Hairy tongue caused by defective desquamation of the
filiform papillae, due to various factors.
Etiology: hypertrophy of filliform papillae due to
lack of mechanical friction.
It is usually seen in individuals with poor oral hygiene
(eg, lack of tooth brushing), eating a soft diet,
chronically ill patients etc.
Although it should be white due to excess keratin,
hairy tongue usually is black in color or of any other
color depending on the diet.
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Clinical features: filliform
papillae which are usually
1mm in size may extend
upto 15 mm, this causes
tickling sensation on the
soft palate, Gagging and
Halitosis
Treatment: use of a simple
tongue cleaner is sufficient
to remove the excess
keratin, in severe cases
scissors or lasers can be
used. Prognosis is
excellent.
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This is a hereditary condition which is inherited by
autosomal pattern
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it does not appear at birth it is gradually noticed
around 9-10 yrs and by 18-25 yrs is at its peak.
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Oral lesions are widespread seen on the cheeks,
palate, floor of the mouth etc. mucosa appears thick
sponge like and corrugated and is of white color.
It is asymptomatic and only complaint here is the
aesthetics and the patient may be uncomfortable due
to thick mucosa
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Histologic features:
Hyperkeratosis and
acanthosis,
Intracellular edema
with perinuclear
orange bands are also
seen.
Treatment: usually no
treatment if
asymptomatic, but if
excised prognosis is
excellent.
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(Leukokeratosis nicotina palate) this is a lesion seen
on the palate of smokers; specially pipe, cigar and
beedi smokers.
Clinical features: the lesion is seen on Hard
palate as a reaction to heat due to smoking. Palate
shows a grayish white coating which is due to
hyperkeratosis and tiny red spots are also noticed
these are the inflamed orifices of the minor salivary
gland ducts.
Reverse smokers palate – this is a condition resulting
from a peculiar habit of keeping the lighted end of
the cigarette in the oral cavity. The resulting lesion
looks similar to smokers palate but it usually is
premalignant in nature.
 Histologic
features: hyperkeratosis of the
epithelium and melanin deposits and
inflammatory cells in the laminapropria are
seen. Reverse smokers palate also shows
dysplastic features in the epithelium.
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Hairy leukoplakia is a white patch on the side of
the tongue with a corrugated or hairy
appearance.
This condition is seen commonly as an oral
manifestation of HIV infection and considered by
many clinicians as an oral marker for AIDS.
Etiology: It results from an opportunistic
infection by Epstein Barr virus (EBV) and Human
Pappiloma virus (HPV)
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Clinical features: Patients with oral hairy leukoplakia
may report a nonpainful white plaque along the
lateral tongue borders.
Lesions may frequently appear and disappear
spontaneously.
Hairy leukoplakia is often asymptomatic, some
patients with hairy leukoplakia do experience
symptoms including mild pain, alteration of taste.
Size ranges from small lesions to irregular "hairy" or
"feathery" lesions with prominent folds or
projections.
Treatment: Usually subsides in its own as the
immunity is restored and does not increase in size
rapidly hence no specific treatment is required.
However for large lesions antiviral medications such
as acyclovir can be administered.
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Oral lichen planus (OLP) is a common
mucocutaneous disease.
bilateral white striations, papules, or plaques on
the buccal mucosa, tongue, and gingivae.
Erythema, erosions, and blisters may or may not
be present.
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oral involvement is almost always seen
sometimes even without skin lesions.
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Etiology: oral lichen planus is a T-cell–mediated
autoimmune disease
 lichen
planus antigen may be induced by
• drugs (lichenoid drug reaction),
• contact allergens in dental restorative materials
or toothpastes (contact hypersensitivity reaction)
• mechanical trauma (Koebner phenomenon),
• viral infection, or unidentified agents.
• It is interesting to note that the disease seldom
is seen in carefree persons; the nervous, highstrung person is almost invariably the one in
whom the condition develops.
 lichen
planus, diabetes mellitus and
vascular hypertension - the triad being
described as Grinspan’s syndrome.
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lesions are characterized by lesions
consisting of radiating white or gray,
velvety, threadlike reticular patches,
rings and streaks
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Depending on the predominant clinical pattern oral
lesions are classified into
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Reticular
Erosive
Hypertrophic / Plaque
Papular
Atrophic
Vessiculo bullous
Reticular pattern is the most common pattern and
atropic and erosive pattern are more likely to be
symptomatic and may turn malignant.
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Histologic Features:
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hyperparakeratosis or hyperorthokeratosis
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acanthosis with intracellular edema
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a “saw tooth” appearance of the rete pegs.
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Band like subepithelial mononuclear infiltrate
consisting of T cells
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degenerating basal keratinocytes that form
colloid (Civatte, hyaline, cytoid) bodies,
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. histologic clefts (ie, Max-Joseph spaces) may
be seen between the basal layer and basement
membrane.
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Treatment: Due to its minimal potential for
malignant transformation, these patients need to
be kept on long- term follow up.
 Medical treatment of OLP is essential for the
management of painful, erythematous, erosive, or
bullous lesions. The principal aims of current OLP
therapy are the resolution of painful symptoms, the
resolution of oral mucosal lesions, the reduction of
the risk of oral cancer, and the maintenance of
good oral hygiene. As it is an autoimmune
mediated
condition
corticosteroids
are
recommended.
Linea alba literally means ‘white line’.
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It is used to describe a horizontal streak on the
inner surface of the cheek, level with the biting
plane.
It usually extends from the commissure to the
posterior teeth. likely associated with pressure,
frictional irritation, or sucking trauma from the
facial surfaces of the teeth.
May be also seen when the posterior over jet is
insufficient.
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It is a low grade variant of squamous cell carcinoma
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It differs in its clinical appearance, peculiar
Histologic features and its clinical behavior.
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The lesions commonly have rugaelike folds with
deep clefts between them,
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it is exophytic and appears to be fixed to the
underlying structures.
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Usually asymptomatic when it is small the patient
reports to the clinic because of the exophytic nature
of the growth.
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Histologic features: histologically these lesions
appear orderly and harmless,
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the epithelium is well differentiated and shows very
less dysplastic features,
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it is hyperplastic and grows downwards into the
connective tissue without break in the basement
membrane.
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Typically cleftlike spaces filled with parakeratin are
seen, this is known as parakeratin plugging.
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The parakeratin lining the clefts with the parakeratin
plugging is the hallmark of verrucous carcinoma.
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Chronic inflammatory cells are seen in the
connectivetissue.