• Most white lesions in the mouth are inconsequential and caused by friction or trauma. • However, cancer and some systemic diseases such as lichen planus and candidosis may present in this way. • Biopsy may be indicated.
Oral Medicine — Update for the dental practitioner
Oral white patches
C. Scully1 and D. H. Felix2
This series provides an overview of current thinking inthe more relevant areas of oral medicine for primary care practitioners, written by the authors while they were holding the Presidencies of the European Association for Oral Medicine and the British Society for Oral Medicine, respectively. A book containing additional material will be published. The series gives the detail necessary to assist the primary dental clinical team caring for patientswith oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders, or discussion of disorders affecting the hard tissues. Approaching the subject mainly by the symptomatic approach — as it largely relates to the presenting complaint — was considered to be a more helpful approach for GDPs rather than taking a diagnostic categoryapproach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made. Guidance on management and when to refer is also provided, along with relevant websites which offer further detail.
ORAL MEDICINE 1. Aphthous and other common ulcers 2. Mouth ulcers of more serious connotation 3. Drymouth and disorders of salivation 4. Oral malodour 5. Oral white patches 6. Oral red and hyperpigmented patches 7. Orofacial sensation and movement 8. Orofacial swellings and lumps 9. Oral cancer 10. Orofacial pain
WHITE LESIONS Truly white oral lesions may consist of collections of debris (materia alba), or necrotic epithelium (such as after a burn), or fungi – such as candidosis. These cantypically be wiped off the mucosa with a gauze. Other lesions which cannot be wiped off, appear white usually because they are composed of thickened keratin, which looks white when wet (Fig. 1). A few rare conditions that are congenital, such as white sponge naevus (Fig. 2) present in this way but most such white lesions are acquired and many were formerly known as ‘leukoplakia’, a term causingmisunderstanding and confusion. The World Health Organisation originally defined leukoplakia as a ‘white patch or plaque that cannot be characterised clinically or pathologically as any other disease’, therefore specifically excluding defined clinicopathologic entities such as can-
didosis, lichen planus (LP) and white sponge naevus, but still incorporating white lesions caused by friction or othertrauma, and offering no comment on the presence of dysplasia. A subsequent seminar defined leukoplakia more precisely, as ‘a whitish patch or plaque that cannot be characterised clinically or pathologically as any other disease and which is not associated with any physical or chemical causative agent except the use of tobacco’. There are a range of causes of white lesions (Table 1). Morphologicalfeatures may give a guide to the diagnosis. For example, focal lesions are often caused by keratoses. Multifocal lesions are common in thrush (pseudomembranous candidosis) and in LP. Striated lesions are typical of LP, and diffuse white areas are seen in the buccal mucosa in leukoedema and some LP, in the palate in stomatitis nicotina and at any site in keratoses. White lesions are usually pain-1*Professor, Consultant, Dean, Eastman
Dental Institute for Oral Health Care Sciences, 256 Gray’s Inn Road, UCL, University of London, London WC1X 8LD; 2Consultant, Senior Lecturer, Glasgow Dental Hospital and School, 378 Sauchiehall Street, Glasgow G2 3JZ / Associate Dean for Postgraduate Dental Education, NHS Education for Scotland, 2nd Floor, Hanover Buildings, 66 Rose Street, Edinburgh...