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 for the gastrointestinal system. Any oral lesion, even a small lesion, can affect our ability to eat, speak, and our appearance. All the diseases of the oral cavity cannot be covered in a single article because a single oral disease can be discussed from multiple points of view according to the specialty of the writer himself. In this article, I have discussed white oral lesions from an otolaryngology point of view.
What is The Classification For Oral Lesions?
Clinically, oral lesions can be classified according to the color into:
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White lesions.
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Pigmented lesions.
The importance of discussing white oral lesions is not only due to its rate but also the susceptibility for 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 lesions that are present at birth and may be noticed later during life like leucoderma, white sponge nevus, dyskeratosis congenita, and hereditary benign intraepithelial dyskeratosis.
1) Leucoderma - It presents as a grey or white patch most commonly on the oral cavity mucosa. Wrinkles of the white patch disappear while stretching the oral mucosa. The most affected oral part is the buccal mucosa.
2) White Sponge Nevus - It is presented after birth or in early childhood and even in adolescence. It takes the shape of raised, corrugated, white spongy plaques, which affect most commonly 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 affects the esophagus.
3) Dyskeratosis Congenita - It is a bone marrow failure syndrome. So, it is a disease that affects many systems of the body. The most important oral manifestation here is bullae formation, followed by eruptions. Dyskeratosis congenita is also presented by developmental delay, liver failure, hypothyroidism, microcephaly, and many other manifestations.
4) Hereditary Benign Intraepithelial Dyskeratosis - It is presented in childhood by the same manifestation of white sponge nevus, which is described before. It has raised corrugated white plaques and in addition to an ocular involvement in the form of white thick 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 which needs an ophthalmology interference.
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.
Acquired Lesions That Can Be Scraped Off:
They are superficial oral burn, oral candidiasis, materia alba, and morsicatio.
1) Superficial Oral Burn - can be thermal or chemical.
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Thermal Burns - 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 the use of microwave ovens in our homes.
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Chemical Burns - 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 - is the most common lesion of the oral lesions that we are discussing now. The causative organism is Candida Albicans, which are normally present in the oral cavity. Candida Albicans, an opportunistic fungus in nature, turns into a pathological agent when the patient’s immunity falls. Oral candidiasis are commonly seen in infants because of their underdeveloped immune system, elderly patients who have chronic diseases that affect the 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 - 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 - is a Latin word that means “bite.” A lot of people can bite their own oral mucosa subconsciously, 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. If the patient confesses that he actually bites his own oral mucosa, the diagnosis would be easy. If the patient denies, a biopsy should be taken from the lesion to be histologically examined to exclude any malignancy.
Acquired White Oral Lesions That Cannot Be Scraped off:
They can be classified into two groups:
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The first group is acquired lesions with a specific pattern.
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The second group is acquired lesions that do not have a specific pattern.
I will be addressing acquired white oral lesions in my next article.
