This document summarizes red and white lesions of the oral mucosa according to Burkett's 12th edition classification. It describes various infectious diseases including different types of oral candidiasis characterized by white or red patches. It also discusses premalignant disorders such as oral leukoplakia, erythroplakia, and oral submucous fibrosis. Finally, it covers immunopathologic diseases including oral lichen planus and its clinical presentations like reticular, papular, plaque-like, bullous and erythematous forms. Images are included to illustrate key lesions.

1. Red and White Lesions of the
Oral Mucosa
Dr.haidar mahdi oral medicine
Prepared by :-
Yunus faisal

2. CLASSFICATION ACCORDING TO
BURKET’S 12th edition

3. RED AND WHITE TISSUE REACTIONS
• A white appearance of the oral mucosa may be caused by a variety of
factors.
1- Hyperkeratosis .
2- Acanthosis.
3-Intra and extracellular accumulation of fluid in the epithelium (i.e
leukoedema).
4-Necrosis of the oral epithelium.
5-Microbes, particularly fungi, can produce whitish
pseudomembranes.
6- Reduced vascularity in the underlying lamina propria.

5. Why abnormally red ?
• atrophic epithelium
• reduction in the number of epithelial cells
• or increased vascularization that is dilatation of vessels and/ or
proliferation of vessels.
• Blood vessel enlargement.
• Presence of blood in the tissue.
• Increace hemoconcentration.
• Burket’s oral medicine 12th end.

7. INFECTIOUS DISEASES
• Oral Candidiasis:-
Oral candidiasis is the most prevalent opportunistic
infection affecting the oral mucosa. In the vast
majority of cases, the lesions are caused by Candida
albicans. The pathogenesis is not fully understood,
but a number of predisposing factors have been
shown to convert C. albicans from the normal
commensal flora (saprophytic stage) to a pathogenic
organism (parasitic stage)

10. Pseudomembranous Candidiasis
• The acute form of pseudomembranous candidiasis
(thrush) and is recognized as the classic candidal
infection (Figure-1).
• The infection predominantly affects patients taking:-
• 1-antibiotics,
• 2-immunosuppressant drugs,
• 3-or having a disease that suppresses the immune
system.

11. Figure -1 Pseudomembranous candidiasis during the immunosuppressive phase
following heart transplantation.

12. Erythematous Candidiasis
• The erythematous form of candidiasis was previously
referred to as atrophic oral candidiasis
• explained by increased vascularization .
• The lesion has a diffuse border (Figure -2), which helps distinguish it
from erythroplakia, which usually has a sharper
demarcation and often appears as a slightly submerged
lesion.
• The infection is predominantly seen in the palate and the
dorsum of the tongue of patients who are using inhalation steroids.
Other predisposing factors that can cause erythematous candidiasis
are smoking and treatment with broad-spectrum antibiotics

13. Figure -2 Erythematous candidasis caused by inhalation steroids.

14. Chronic Plaque-Type and Nodular
Candidiasis
• The chronic plaque type of oral candidiasis replaces the
older term, candidal leukoplakia. A white irremovable
plaque characterizes the typical clinical presentation,
which may be indistinguishable from oral leukoplakia
(Figure-3).

15. both the chronic plaque-type and the nodular type of oral
candidiasis (Figure -4) have been associated with malignant
transformation, but the possible role of yeasts in oral
carcinogenesis is unclear.

16. Denture Stomatitis
• The most prevalent site for denture stomatitis is the
denture-bearing palatal mucosa (Figure -5).
• is classifed into three different types :-
• Type I is limited to minor erythematous sites caused by
trauma from the denture.
• Type II affects a major part of the denture-covered
mucosa .
• In addition to the features of type II, type III has a
granular mucosa.

17. Figure -5 Denture stomatitis type III with a granular mucosa in the central
part of the palate.

18. Angular Cheilitis
• Angular cheilitis presents as infected fissures of the
commissures of the mouth, often surrounded by
erythema (Figure -6).
• The lesions are frequently coinfected with both
Candida albicans and Staphylococcus aureus.
VitaminB12 defciency, iron defciencies, and loss of
vertical dimension have been associated with this
disorder.

19. Figure -6 Angular cheilitis

20. Median Rhomboid Glossitis
• is clinically characterized by an erythematous lesion in
the center of the posterior part of the dorsum of the
tongue (Figure -7).As the name indicates, the lesion has
an oval confguration. Tis area of erythema results from
atrophy of the fliform papillae and the surface may be
lobulated.
• Smokers and denture-wearers have an increased
risk of developing median rhomboid glossitis as well as
patients using inhalation steroids.

21. Figure -7 Median rhomboid glossitis.

22. Oral Candidiasis Associated with HIV
• More than 90% of acquired immune defciency syndrome
(AIDS) patients have had oral candidiasis during the
course of their HIV infection, and the infection is
considered a portent of AIDS development (Figure -8).
• The most common types of oral candidiasis in
conjunction with HIV are;-
• pseudomembranous candidiasis, erythematous
candidiasis, angular cheilitis, and chronic plaque-like
candidiasis.
• As a result of the highly active antiretroviral therapy
(HAART), the prevalence of oral candidiasis has
decreased substantially.

23. Figure -8 Erythematous candidiasis at the central part of the tongue in an AIDS
patient. Hairy leukoplakia can be seen at the right lateral border.

24. Oral Hairy Leukoplakia
• is the second most common HIV-associated oral
mucosal lesion.
• OHL has been used as a marker of disease activity since
the lesion is associated with low T-lymphocyte counts.
The lesion is not pathognomonic for HIV disease since
other states of immune defciencies, such as caused by
immunosuppressive drugs and cancer chemotherapy,
have also been associated with OHL .

25. Figure -9 Hairy leukoplakia at the left lateral border of the tongue in an AIDS
patient.

26. PREMALIGNANT
DISORDERS
• Oral Leukoplakia
• Erythroplakia
• Oral Submucous Fibrosis

27. PREMALIGNANT DISORDERS
• Oral Leukoplakia
• -A keratotic plaque occurring on mucous
membranes.
• -conidered a premalignant lesion .
• Definition
WHO defined leukoplakia as ‘’a white patch or plaque
that cannot be characterised clinically or pathologically as
any other disease”

28. This disorder can be further divided into a homogeneous and
a nonhomogeneous type.
The typical homogeneous leukoplakia is clinically
characterized as a white, often well-demarcated plaque with
an identical reaction pattern throughout the entire lesion
(Figure -10).
Figure -10 A homogeneous leukoplakia at the left buccal mucosa.

29. The nonhomogeneous type of oral leukoplakia
may have white patches or plaques intermingled with red
elements (Figure -11).
Due to the combined appearance of white and red areas, the
nonhomogeneous oral leukoplakia has also been called
erythroleukoplakia and speckled leukoplakia.
The clinical manifestation of the white component
may vary from large white verrucous areas to small nodular
structures.
If the surface texture is homogeneous but contains
verrucous, papillary (nodular), or exophytic components,
the leukoplakia is also regarded as nonhomogeneous.

30. Figure -11, A nonhomogeneous leukoplakia in a heavy smoker.

31. Erythroplakia
• is defned as a red lesion of the oral mucosa that excludes
other known pathologies (Figure -12) .
• Prevalence : 0.02-0.83%
• Female:male =1:1.04
• Erythroplakia is usually asymptomatic, although some
patients may experience a burning sensation in
conjunction with food intake.
• Ulcerations and depigmented areas may also be a part of
this particular form of oral lesion.

32. Figure -12 Erythroplakia at the alveolar ridge. The patient later developed a
squamous cell carcinoma.

33. Oral Submucous Fibrosis
• is a chronic disease affecting the oral mucosa, as well as
the pharynx and the upper two-thirds of the esophagus .
• An international consensus has been reached where at
least one of the following characteristics should be
present :-
• Palpable fibrous bands
• Mucosal texture feels tough
• Blanching of mucosa together with histopathologic
features consistent with oral submucous fibrosis

34. Figure -13 A patient with submucous fibrosis with restricted ability to open her
mouth. The buccal mucosa has a marbling appearance.

35. IMMUNOPATHOLOGIC
DISEASES
• • Oral lichen planus
• Lichenoid contact reactions
• Lichenoid drug eruptions
• Lichenoid reactions of graft-versus-host disease
(GVHD

36. Oral Lichen Planus
• Introduction:
• Chronic inflammatory disease that affects the
skin and the mucous memnrane.
• Prevalence is 0.5-2.2%
• Commonly seen in women than male.
• Classic appearance of skin lesion consists of
pruritic erythematous to violaceous papules
which are flat topped ,small,angular only a few
millimeters in diameter.

37. The white and red components of the lesion can be a part of the
following clinical types :-
• Reticular
• Papular
• Plaque-like
• Bullous
• Erythematou
• Ulcerative
RETICULAR FORM
Figure -14 A reticular form of oral lichen planus.
1-characterized by fine ,white lines or striae .
2-striae form a network also show annular
patterns
3-most frequently observed bilaterally in the
buccal mucosa.

38. Figure -15 Papular
oral lichen planus with
dense cover of
papules.
PAPULAR FORM
1. present in the initial phase of the disease .
2.Characterized by small white dots.

39. Erythematous oral lichen planus
Figure -16 A,
Erythematous oral
lichen planus.
1. characterized by homogeneous red area.
2. present in the buccal mucosa or palate.
3. affecting attached gingiva present as
desquamative gingivitis .

40. Figure -17 A,
Ulcerative oral lichen
planus.
1. disabling form of OLP
2. surrounded by an erythematous zone frequently
radiating white striae.
3. complains of smarting sensation.
Ulcerative oral lichen planus

41. Figure -18bullous
lichen planus
1. unusual
2. clinically resemble erosive lichen planus
BULLOUS LICHEN PLANUS

42. Fig -19 A plaque-like oral lichen
planus with a plaque in the anterior
part
PLAQUE FORM
1- homogeneous well-demarcated white plaque
,surrounded by striae.
2- similar to homogeneous oral leukoplakias.
3-most often encountered in smokers.

43. THE END…………
Thank you
Bu
rke
t’s
12th
2015