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Principles of Oral Diagnosis: Gary C. Coleman
John F. Nelson
1st Ed (1993),page 295- 299
• I-White lesions of superficial materials
• Pseudomembranous candidiasis
• Hyperplastic candidiasis
•
(white lesion of epithelial thickning )
•
•
•
•
•
•
•
Angular chelitis
Chemical mucosal burns
Oral ulcers
II- White lesions of submucosal change
Fordyces granules
Scar
Submucous fibrosis
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I-WHITE LESIONS OF
SUPERFICIAL MATERIAL
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Opaque and rough or grainy. •
White material, soft or friable and •
rubbing  an ulcer or erythematous
Frequent burning & discomfort •
sensation.(food remnants, a dense
accumulation of materia alba, or plaque
 painless, mucosa appears normal.
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• The differential diagnosis is simple
after removal of the white material
• ( white surface coagulum ).therefore
the differential diagnosis shifts to the
ulcerative lesions category .
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1-Pseudomembranous
Candidiasis
Acute superficial mucosal infection. •
Infants & immune compromised. •
systemic corticosteroid therapy, •
chemotherapy, AIDS, or acute
debilitating illness.
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Clinical features
Diffuse, patchy, or globular white •
thickened plaques.
Tongue, soft palate & buccal •
mucosa.
Can be wiped off  erythematous, •
atrophic, or, ulcerated mucosa.
Mild burning pain  severe when •
coagulum scraped.
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Pseudomembranous
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Thrush
White patch and flecks that
rubbed off(patient complained of
a burning mouth )
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More extensive pseudomembranous
lesions associated with erythematous
base
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Differential diagnosis
C.F + resistance  diagnosis. •
Chemical burns (white fibrinoid •
surface thinner and delicate , more
focal + pt. HX. )
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Management
Culture or exfoliative cytology. •
Spread to orophayngeal and •
esophageal surfaces.
Medical referral. •
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2-Hyperplastic Candidiasis.
(White lesions of epithelial thickening )
• Superficial infection of the oral mucosa by the
fungus Candida albicans and less common species
of the same genus.
• * Predisposing factors,
• ( poor oral hygiene,xerostomia,recent antibiotic
treatment,dental appliance,)
* Compromised Immune system.
( early infancy,AIDS,corticosteroid,anemia,diabetes
mellitus,)
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Hyperplastic candidiasis
Epithelial thickening that do not rub •
off.
• Pseudomembranous candidiasis.
• Atrophic candidiasis.
Chronic infection,red patch thined→red
lesion
Angular chilitis: labial commissures •
(non healing fissures).
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Chronic Hyperplastic Candidosis
( candidal leukoplakia )
• It appears as a thick,white leathery plaque
of irregular thickness with rough surface
(identical leukoplakia clinically )
The white patch is seen as triangular •
patch on buccal mucosa , lip commissure
Bilateral distribution •
In some cases erythematous areas are •
located within the white patch ( producing
feature of speckled leukoplakia )
Candidal leukoplakia is often associated •
with angular cheilitis
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Candidal leukoplakia
a chronic form of candidiasis in which firm red white
plaques form
In the cheek
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In the palate opposite a tongue lesions (
kissing lesions
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Chronic
hyperplastic
candidasis.
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Chronic
hyperplastic
candidasis
presenting as
multiple wartilke
growths on the
patient’s lower 16
lip
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3-angular cheilitis
labial commissures •
characterized by nonhealing •
fissures
two, three, or even all four forms. •
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Clinical features
Hyperplastic candidiasis •
multiple or diffuse variably thick, •
patchy, do not rub off vague borders
tongue. •
Other forms •
Hyperplastic most resistance. •
vaginal itching and discharge •
indicative of vaginal candidiasis.
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Differential diagnosis
The combination and underlying •
condition (resistance).
Lichen planus-striae & skin •
lesions.
Hairy leukoplakia treatment  no •
response  ?? other lesion.
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Management decisions
A working diagnosis •
exolifative cytology •
culture. •
Topical antifungal -1 week. •
Resistant  systemic antimycotic. •
Clean mucosa  brush or scrap •
Dentures  1/2 teaspoon of bleach in 1 •
cup or in topical antimycotic
Medical referral. •
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4-chemical Mucosal Burns
corrosive chemicals( aspirin tablet. Iatrogenic •
chemical injury )
Wiped away  painful central ulceration. •
Thin, membranous appearance Adherent patches on
periphery.
The lesions may be categorized as ulcerative rather
than white if the superficial white material has
been abraded away before examination
Pt. HX.
Differential diagnosis
Diffuse & multifocal  candidiasis.
Treatment :- remove the cause
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5-Oral Ulcers
white  superficial fibrinoid •
coagulum.
Bulla( separation of the epithelium •
from the connective tissue )
Wiped away •
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Differential diagnosis
Epithelial thickening. •
Candidiasis. •
Chemical burn. •
Clinically :- -------- •
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II-WHITE LESIONS OF
SUBMUCOSAL CHANGE
It appear pale because the normally
vascular mucosal connective tissue
has been replaced by less vascular
tissue .
Smooth, translucent, don't rub off
Non painful
Fordyce granules,
scarring,submucous
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fibrosis
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1-Fordyce Granules
Ectopic Sebaceous glands located •
within the oral mucosa ( variation of
normal ).
Increase in prominence with age. •
Buccal, labial mucosa •
Treatment , no treatment or follow •
up.
Clinically ,,,,,,,,,,,, •
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Fordyce’s granules on the buccal mucosa
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Clinical features.
Small (1 to 2 mm) •
ovoid yellowish-white •
Bilaterally symmetric distribution . •
Differential diagnosis
Characteristic appearance •
Management:
No treatment or observation. •
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2-Scar
Healing and repair of soft tissue •
injuries with dense collagenous
connective tissue or scar often
produces a pale appearance as
compared with adjacent, normal
tissues.
( ?The hard palate and gingiva).
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Clinical features.
Focal, homogeneous, pale, smooth and •
sharply delineated borders.
No pain, or other symptoms. •
Pit or fissure depressions ( if the injury or •
surgical procedure resulted in poor
tissue apposition )
Stellate pattern of pale lines radiating •
from the depression between the tonsillar
pillars that represent healing follwing a
tonsillectomy .
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Differential diagnosis.
Submucous fibrosis •
Management
None or observation. •
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3-Submucous Fibrosis
Generalized fibrosis of the •
connective tissue of the oral mucosa
in response to habitual chewing of
betal nut & spices
India & southeast Asia . •
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Clinical features.
Generalized yellow- to white •
discoloration.
Smooth surface •
Intensity of the color vary. •
Loss of elasticity & firmness. •
Soft palate and buccal mucosa. •
Severe  trismus •
HX.  oral habits.
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Generalized oral mucosal fibrosis and history
of the oral habit confirm the diagnosis
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Differential diagnosis.
systemic sclerosis, •
Radiotherapy. •
Management
Discontinue habit, •
Fibrosis is irreversible. •
Stretching exercises +corticosteroid •
clinical reexamination.( is mandatory because approximately
one third eventually develop squamous cell carcinoma )
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