White Patches - What are they ?

White patches develop within the oral mucosa. The reasons can be trauma, infection, immune related disease or neoplasia. White patches usually manifest as painless, but discomfort can occur due to erosion or ulceration, particularly in lichen planus. They are pre-malignant and therefore biopsy is indicated routinely. White patches may be localized or widespread throughout the mouth. Localized white patches can have a traumatic or neoplastic etiology, while widespread involvement suggests a systemic, immunologic, or hereditary condition. 

White Patches often Associated With Pain

• Lichen planus 
• Lichenoid reaction 
• Lupus erythematosus 
• Chemical burn 

White Patches that are Rarely Associated with Pain

• Candidiasis 
• Chronic hyperplastic candidosis (candidiasis) 
• White sponge nevus 
• Dyskeratosis congenital 
• Frictional keratosis 
• Nicotinic stomatitis 
• Leukoplakia 
• Squamous cell carcinoma

Here are some details on some of the white lesions of oral cavity:

• Lichen planus is one of the mucocutaneous disorders. The cause of lichen planus is not known, but  is said to be immunologically mediated. It presents as white patches or striae that may affect any oral site, typically with a symmetric and bilateral distribution. Clinical diagnosis of oral lichen planus is aided by the presence of cutaneous lesions. 
• Lichenoid reactions are named so because both clinically and histologically they resemble to lichen planus. Systemic drugs like antihypertensives, hypoglycemics, and non-steroid anti-inflammatory agents have been implicated in lichenoid reactions. 

• Pseudomembraneous candidosis (candidiasis) is characterized by soft creamy-yellow patches that affect large areas of the oral mucosa, in particular the junction of the hard and soft palate.  
• Chronic hyperplastic candidosis (candidiasis) are similar to pseudomembraneous candidosis (candidiasis), but this form is particularly related to tobacco use. 
• Chronic irritation of the oral mucosa leads to Frictional keratosis. Any site in the mouth can be affected, the most common sites being the lips, lateral borders of the tongue, buccal mucosa at the occlusal line and an edentulous ridge. 
• Nicotinic stomatitis is tobacco-related keratosis in the mouth. It can be associated with pipe, cigar, or cigarette smoking. 
• Leukoplakia is a clinical term used to describe orthe definition goes as follows -  ‘a white patch or plaque on the oral mucosa that cannot be rubbed off and cannot be characterized clinically as any specific disease’ 
• Oral submucous fibrosis (OSMF) condition is characterized by the development of fibrous tissue in the buccal mucosa and palate. The primary causative factor is chewing of the areca nut. Chronic exposure to chilli peppers or prolonged deficiency of iron and vitamin B complexes, particularly folic acid also causes OSMF.  

Management

Management of white patches / white lesions involves correct diagnosis, taking biopsy where required and taking up special investigations when in need. Counselling patients to quit habits i.e. the causative factors is important too. When in initial stages, these conditions are easy to treat with conservative approach but on turning malignant surgical intervention becomes necessary. 

Article by Dr. Siri P.B.