Leukoplakia, SCC, lichenoid reaction, candidiasis, GVHD,self-inflicted trauma
Im sorry for correcting/bringing up the facts, but I don't think that candidiasis nor lichenoid reaction is strictly unilateral nor it is always white (lichenoid reaction can be pink in some stage I think) also as for leukoplakia, if you take in consideration the tongue and bottom of the oral cavity it can be on both sides simultaneously.
Don't be sorry Nikola. I suggested the white lesions that are "most probably" unilateral, and that "most commonly" appear white. Take lichenoid reaction , for instance. What differentiates it from lichen planus is the unilateral distribution, but this does not mean that all cases of lichenoid are unilateral, because this depends upon the etiology. It is always unilateral unless it is related to drugs for example. I have seen two cases of lichenoid that were spread widely on the oral mucosa, including the palate, one in an old lady on antihypertensive drugs and one in a young lad with multiple amalgam fillings. In the case of leukoplakia; this is usually a solitary white lesion, however some types are known to be bilateral like candidal leukoplakia and sublingual keratosis.
Oh well im student and currently learning/learned dermatology and its stated that lichenoid reaction is most commonly bilateral in our textbook :)
For Nikola, As per my knowledge no text book gives lichenoid reaction as a bilateral. Most commonly lichenoid reaction is unilateral.
Please can u provide me the name of the txt book from which u have studied, so that I can review it.
For Najla, If u don't mind can u please provide me with the references for ur answers agora each of your commented lesions please.
If I were you Nicola, I would write to the author (s) of this book asking them to correct this data. It is important for physicians like you, who take care of patients with oral lesions, to recognize lesions early. So if the white lesion can be wiped off, it may be thrush in an un-diagnosed HIV-positive patient. And if the lesion is adherent, it may be SCC in the form of a white patch. In the later case, you will achieve early diagnosis of cancer and save a patient's life.
Kindly follow the link below; it is written by Crispian Scully and it is a nice paper on the differential diagnosis of white lesions.
http://www.nature.com/bdj/journal/v199/n9/full/4812901a.html
Oh well i tried to find it on internet but without any luck...and only copy i have is printed version and not official, and as I sad its written in Serbian.
Dear Nicola,
If your textbook is of good quality it provides references as basis for the information it provides. However if it doesn´t, you should look elsewhere for evidence based medicine. Besides, early 2000s may already be 10 years in the past and oral medicine is still a somewhat rapidly advancing field so many points in the book might be outdated by now, if you are unlucky!
As for the OLP and OLL (oral lichen planus and -lichenoid lesions): There are still difficulties in differentiating between certain cases of these two histopathologically and clinically. This was worse before: In 2003, van der Waal and van der Meij published the modifications for WHO criteria for OLP (http://www.ncbi.nlm.nih.gov/pubmed/12969224), which were proven to be of better quality in 2009 by Rad et al. (http://www.ncbi.nlm.nih.gov/pubmed/19464654).
As already stated above, OLP presents mostly in a bilateral pattern and OLL in more localised patterns. However: OLP has been reported to present in an unilateral form (http://www.ncbi.nlm.nih.gov/pubmed/10228636) and OLL in bilateral forms (http://www.ncbi.nlm.nih.gov/pubmed/8233426).
We must keep in mind, that lichenoid lesions represent a hypersensitivity reaction to a factor we can usually identify, such as amalgam restorations, certain medications or underlying diseases (HIV[or medications used to treat it] or HCV for example), whereas lichen planus is a disorder where (as far as is known currently) the underlying causative factor mostly cannot be identified, if there is any at all (autoimmunity perhaps). This explains the distribution, for ex. a lichenoid reaction next to (and in this case caused by) a corroded amalgam filling would be unilateral.
These can also both present in white form but most often they are not 100% white, having reddening around the lesion.
Dr. Mohammed,
Is there a reason you specifically ask for "any four purely unilaterally occurring oral white lesions"? Why four?
You may be better informed than I, but if I had to list white-only lesions, the first that spring to my mind (these are my patients that presented with unilateral white lesions) are:
-Leukoplakia diagnosed as Verruca vulgaris (presented as a white thickening at the border of lingual alveolar mucosa and gingiva, no reddening and uniform in apperance, somewhat rough at the surface)
-Leukoplakia that was biopsy-confirmed as a SCC (this was a homogenous leukoplakia of the left side of floor of the mouth, but presented with a palpable "hardness" at the edge of the lesion which was actually SCC at the border of the otherwise only dysplastic epithelium/leukoplakia-area).
-Leukoplakia (upper retromolar area, left side) that was biopsy-confirmed as a hyperkeratosis with no dysplasia - likely caused by smoking in this case.
-Morsicatio buccorum: For some reason there was no reddening or bilateral presentation due to asymmetric dental arches.
-FEH that was first clinically diagnosed as leukoplakia (HPV13 or 32-caused hyperplasia of the oral epithelium).
All of those looked clinically like a "leukoplakia" but only in the case of morsicatio I could arrive at a diagnosis without resorting to surgery (it regressed after trimming sharp tooth edges).
When discussing white lesions of uncertain diagnosis, or "predominantly white lesions of the oral mucosa than cannot be characterized as any other definable lesions" i.e. leukoplakias (van der Waal & Axéll 2002), we most likely need biopsies anyway since many of these do not regress after elimination of likely causative factors.
As you probably all know, leukoplakia is not a definite diagnosis, only a clinical one. For some more reading about the matter, I recommend the following few articles in addition to the good one posted above by Dr. Dar-Odeh:
http://www.ncbi.nlm.nih.gov/pubmed/12167428
and
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3548640/
Hope this somewhat digressing comment is of use to you.
Regards,
Aaro Turunen
Dr. Faraz M:
It is a really interesting question. Based on my knowledge, the data on Predominantly Unilateral White lesions of the Oral Cavity is really Limbotic.
Here are few suggestions:
1. Lichenoid reaction
2. Frictional Keratosis.
3.Mucosal/Asprin/Chemical burns
4. Lupus Erythematosus (Systemic/Discoid)
Explanations:
1. Lichenoid reaction is one most commonly differential diagnosis in Lichen planus and it is commonly excluded with one of the criteria as unilateral involvement.
2. Frictional Keratosis are mostly unilateral as, it cannot occur bilaterally unless there is similar injury over the contrary side.
3. Mucosal burns are generally related to the mode/involvement of the injury.
4.Lupus Erythematosus does manifests orally as a white lines, however it was neither mentioned as unilateral/bilateral.
Please accept my apologies for not including the references as you requested. Hoping the explanations may help in justifying the answer.
Dr. Faraz Mohammed, Share your answer when you find/conclude the question with precise answer with reference.
For sure Lichens planus is NOT an unilateral white lesion, it is Lichenoid reaction which is purely a unilateral white lesion
Many neoplasms could present this way, as may non-neoplastic epulides.
One neoplasm would be verrucous carcinoma. We recently had a case that presented as an all-white thickening of the tongue mucosa. What made it interesting was that it looked like a leukoplakia but recurred in a few weeks after excisional biopsy. The pathology report arrived at the diagnosis only after it had been repeatedly removed for examination. The lesion did not recur after removal with a wide margin.
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