Radiographic presentation
None.
Differential diagnosis
Painful, red oral mucosal lesions suggest pemphigus, erosive lichen planus, and pemphigoid as the most serious considerations. However, a premalignant field dysplasia or field cancer should also be considered.
Microscopic features
There will be a diffuse sub-basement membrane inflammation composed of a mixture of lymphocytes and plasma cells with plasma cells predominating. The basement membrane will be intact and normal.
Suggested course of action
Potential etiologic agents should be reviewed with the patient. If a topical agent is responsible, discontinuation is recommended. If an oral drug is thought to be responsible, a letter of explanation with a referral of the patient to the prescribing physician is recommended.
Treatment
Identification and discontinuation of the offending drug, or use of an alternate drug or dose of the same drug with a different dye coloring in the tablet, as many of these are caused by a specific dye color. Refractory cases are treated with prednisone.
Hairy Leukoplakia
Nature of disease
An opportunistic infection caused by the Epstein-Barr virus producing focal epithelial proliferation and hyperkeratosis.
Predilections
Seen mostly in adults with some immune compromise. Once thought to be an early sign of HIV/AIDS, it is now known to occur in other immune-compromised patients as well. No sex or racial predilection is known.
Clinical features
Asymptomatic, white hairlike proliferations are mostly seen on the dorsum and/or lateral border of the tongue. There is noted lack of redness and paresthesia.
Radiographic presentation
None.
Differential diagnosis
Although the short hairlike strands and a history of immune compromise will strongly suggest hairy leukoplakia, candidiasis and lichen planus may appear similar, as might condyloma acuminata.
Microscopic features
Exophytic epithelial proliferations with prominent acanthosis and hyperparakeratosis. A noted lack of subjacent inflammation is usually present. Below the parakeratin layers, pale-staining epithelial cells with pyknotic nuclei are prominent.
Suggested course of action
Confirm a history of immune compromise and refer to either an immunologist or an infectious disease specialist. If uncertain, an incisional biopsy will confirm the diagnosis.
Treatment
Occasionally, the areas of hairy leukoplakia are excised. Otherwise, there is no treatment other than treatment of the underlying immune compromise.
Dental Lamina Rests/Epithelial Inclusions (Bohn’s Nodules and Epstein Pearls)
Nature of disease
Bohn’s nodules are white elevations in the edentulous ridge of newborns representing true residual dental lamina remnants or a developing gingival cyst. Epstein pearls are epithelial rests also seen in newborns as white nodules but that arise in the midline of the palate from the fusion of the palatal and nasal processes. Small cysts may develop from these as well.
Predilections
Exclusively newborns less than 1 year of age. No sex or racial predilection is known.
Clinical features
Small, white, asymptomatic expansions of the oral surface in newborns, seen on either the edentulous ridge or the palatal midline.
Radiographic presentation
None.
Differential diagnosis
Other than the early eruption of an expected primary tooth, Bohn’s nodules are distinctive. Other than hypertrophy or mucocele development in the palate, Epstein pearls are also quite distinctive.
Microscopic features
If the nodule represents residual rests, it will appear as a collection of odontogenic epithelial cells in a rounded fashion. If the nodule has progressed to a gingival or palatal cyst, there will be a lumen lined by a thin layer of epithelium with focal thickened areas.
Suggested course of action
Reassure parents of the natural involution of the cyst as it erupts into the oral cavity and becomes confluent with the oral epithelium.
Treatment
None required.
Nicotine Stomatitis
Nature of disease
A nonmalignant, nonpremalignant change in the palatal mucosa producing white patches of hyperkeratosis due to the heat from pipe smoking or, more rarely, cigar smoking.
Predilections
Mostly adult men who frequently smoke pipes or, more rarely, adults who smoke cigars. There is no racial predilection.
Clinical features
White patches of thickened epithelium of the palatal mucosa creating a cobblestone appearance with central small red dots representing inflammation at the openings of minor salivary gland ducts.
Radiographic presentation
None.
Differential diagnosis
Nicotine stomatitis is clinically distinctive. However, some cases of candidiasis may appear quite similar.