Table of Contents
Introduction
The oral cavity is an overlapping area among different medical specialties, such as otolaryngology (ENT), maxillofacial surgery, dentistry, and oncology. The oral cavity overlaps so many specialties because of its role as a shared pathway for food, liquids, and even air in some cases. The oral cavity is the door to the gastrointestinal system. Any oral lesion, even a small one, can affect the ability to eat, speak, and appear. All oral cavity diseases cannot be covered in a single article because a single oral disease can be discussed from multiple points of view according to the writer's specialty. This article discusses white oral lesions from an otolaryngology point of view.
What Is the Classification for Oral Lesions?
Clinically, oral lesions can be classified according to their color into:
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White lesions.
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Pigmented lesions.
Discussing white oral lesions is important due to their rate and susceptibility to malignant transformation of some lesions, such as lichen planus and leukoplakia. Oral white lesions can also be classified into:
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Congenital lesions.
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Acquired lesions.
What Are Congenital Lesions?
Congenital lesions are present at birth and may be noticed later in life, such as leukoderma, white sponge nevus, dyskeratosis congenita, and hereditary benign intraepithelial dyskeratosis.
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Leukoderma: It presents as a grey or white patch, most commonly on the oral cavity mucosa. The wrinkles of the white patch disappear while stretching the oral mucosa. The most affected oral part is the buccal mucosa.
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White Sponge Nevus: It is present after birth, early childhood, and adolescence. It takes the shape of raised, corrugated, white, spongy plaques, most commonly affecting the oral mucosa bilaterally. It can also affect the soft palate, the floor of the mouth, and alveolar mucosa. White sponge nevus can cause difficulty in swallowing when it involves the esophagus.
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Dyskeratosis Congenita: It is a bone marrow failure syndrome that affects many body systems. The most important oral manifestation is bullae formation, followed by eruptions. Dyskeratosis congenita is also characterized by developmental delay, liver failure, hypothyroidism, microcephaly, and many other manifestations.
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Hereditary Benign Intraepithelial Dyskeratosis: It is presented in childhood by the same manifestation of white sponge nevus described before. It has raised corrugated white plaques and, in addition to an ocular involvement in the form of thick white opaque gelatinous plaques on the mucous membrane lining the inner surface of the eyelids and the eyeball adjacent to the cornea. The lesion can also affect the cornea, producing blindness that needs an ophthalmology intervention.
All the above-mentioned congenital lesions do not require any medical interference and are not premalignant except dyskeratosis congenita, which requires a bone marrow transplantation. Moreover, it has a thirty percent potential of malignant transformation into leukoplakia.
What Are Acquired Lesions?
The acquired white oral lesions are classified into two groups:
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Acquired lesions that can be scraped off.
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Acquired lesions that cannot be scraped off.
What Are the Acquired Lesions That Can Be Scraped Off?
They are superficial oral burn, candidiasis, materia alba, and morsicatio.
1. Superficial Oral Burn - These can be thermal or chemical.
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Thermal Burns: These are caused by hot food, liquids, and iatrogenic from hot dental instruments. The most affected oral parts are the tip of the tongue, posterior buccal mucosa, and palatal mucosa. Superficial thermal burns are increased after using microwave ovens in our homes.
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Chemical Burns: These are caused by chemical materials, such as Aspirin, hydrogen peroxide, and battery acid. Superficial oral burns present mostly as small areas of the yellowish-white necrotic epithelium. All the superficial oral burns are not dangerous and improve without treatment. In some severe cases, medical treatment with antibiotics, analgesics, and anti-inflammatory drugs is needed.
2. Oral Candidiasis: This is the most common lesion of the oral lesions. The causative organism is Candida Albicans, usually in the oral cavity. Candida Albicans, an opportunistic fungus, becomes a pathological agent when the patient’s immunity falls. Oral candidiasis is commonly seen in infants because of their underdeveloped immune system, elderly patients who have chronic diseases that affect their immunity, such as diabetes mellitus, patients under severe psychological stress, and patients taking broad-spectrum antibiotics for a long period. Oral candidiasis appears as creamy white plaques that can be removed, leaving a blood-oozing surface. Although oral candidiasis treatment is just local antifungal drops or gel, the chronicity of oral candidiasis can be an important sign of human immunodeficiency virus (HIV) infection.
3. Materia Alba: This is not a pathological condition but an accumulation of food remnants in the form of white or grey patches on the oral mucosa and tongue that can be easily removed. Materia alba is a matter of lack of oral hygiene. The treatment is mainly mouth gargling and brushing.
4. Morsicatio: This Latin word means “bite.” Many people can subconsciously bite their oral mucosa, leaving a white bite lesion on their inner buccal mucosa. The difficulty in diagnosing morsicatio is the denial of the patient himself. Most of the cases are under severe psychological stress or have a mental illness. The most affected parts are the sides of the tongue, buccal mucosa, and the inner surface of the lips. The diagnosis would be easy if the patient confessed that he bites his oral mucosa. If the patient denies this, a biopsy should be taken from the lesion to be histologically examined to exclude malignancy.
What Are Acquired White Oral Lesions That Cannot Be Scraped Off?
They can be classified into two groups:
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The first group acquired lesions with a specific pattern.
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The second group is acquired lesions that do not have a specific pattern.
Conclusion:
The clinical presentation of white lesions, oral epithelial dysplasia, and squamous cell carcinoma can vary, so it is essential to establish a clear and definitive diagnosis. Throughout the individual’s lifetime, regular check-ups and long-term follow-ups are required. Biopsies are performed in case of suspicion of malignancy, and it becomes crucial to consult an oral pathologist for evaluation.
