REACTIVE & INFLAMMATORY WHITE LESIONS

LINEA ALBA (WHITE LINE)
Horizontal streak on the buccal mucosa at the level of the occlusal plane extending from the commissure to the posterior teeth
Common finding
Most likely associated with pressure, frictional irritation, or sucking trauma from the facial surfaces of the teeth
Present in about 13% of the population in one study.

Clinical features:
Usually present bilaterally
May be pronounced in some individuals
Prominent with reduced overjet of the posterior teeth
Often scalloped and restricted to dentulous areas
Treatment:
No treatment indicated, may disappear spontaneously

FRICTIONAL (TRAUMATIC) KERATOSIS
Defined as “White plaque with a rough and frayed surface that is clearly related to an identifiable source of mechanical irritation and that will usually resolve on elimination of the irritant”
Occasionally mimics dysplastic leukoplakia, hence biopsy may be necessary
Prevalence rate of 5.5% reported
Similar to calluses on the skin
Never been shown to undergo malignant transformation
Lesions belonging to this category include linea alba and cheek, lip, and tongue chewing
Frictional keratosis is frequently associated with rough or maladjusted dentures and with sharp cusps and edges of broken teeth

CHEEK CHEWING
May result from chronic irritation due to repeated sucking, nibbling, or chewing
Area becomes thickened, scarred, and paler than the surrounding tissues
Usually seen in people who are under stress, or in psychological situation in which cheek and lip biting become habitual
Chronic chewing of the labial mucosa (morsicatio labiorum) and the lateral border of the tongue (morsicatio linguarum) may be seen with cheek chewing or may cause isolated lesions
Clinical features:
Most frequently found bilaterally on the posterior buccal mucosa along the plane of occlusion
May be seen in combination with traumatic lesions of the lips or tongue
Patients often complain of roughness or small tags of tissue that they actually tear free from the surface. This produces a distinctive frayed clinical presentation
Lesions are poorly outlined whitish patches that may be intermixed with areas of erythema or ulceration
Twice as prevalent in females and 3 times more common after the age of 35 years

Treatment:
Since the lesions occur from unconscious and/or nervous habit, no treatment is required
Occlusal night guard may be fabricated for those desiring treatment
Differential diagnosis:
Oral hairy leukoplakia (when isolated lesion present on the tongue & appropriate risk factors for HIV present)
White sponge nevus
Chemical burns
Candidiasis

CHEMICAL INJURIES OF THE ORAL MUCOSA
Transient nonkeratotic white lesions of the oral mucosa are often a result of chemical injuries caused by a variety of agents that are caustic when retained in the mouth for long periods of time
White lesions are attributable to the formation of a superficial pseudomembrane composed of a necrotic surface tissue and an inflammatory exudate

Specific causative agents are:
Aspirin
Silver nitrate
Formocresol
Sodium hypochlorite
Paraformaldehyde
Dental cavity varnishes
Acid-etching materials
Hydrogen peroxide

Aspirin burn:
Acetyl salicylic acid is a common source of burns of the oral cavity and is usually held in the mucobuccal fold area for prolonged periods of time for the relief of common dental pain

Silver nitrate:
Commonly used as a chemical cautery agent for the treatment of aphthous ulcers
It brings about almost instantaneous relief of symptoms by burning the nerve endings at the site of the ulcer
Often destroys tissue around the immediate area of application and may result in delayed healing or severe necrosis at the application site

Hydrogen peroxide:
Often used as an intraoral rinse for the prevention of periodontal disease. At concentrations greater than 3 %, it is associated with epithelial necrosis.
Sodium hypochlorite:
It is a dental bleach and is also used as a root canal irrigant. It may cause serious ulcerations due to accidental contact with oral soft tissues.

Dentifrices and mouthwashes:
Unusual sensitivity reaction with severe ulcerations and sloughing of the mucosa has been reported to have been caused by a cinnamon-flavoured dentifrice
However, they probably represent a sensitivity or allergic reaction to the cinnamon aldehyde in the toothpaste
Caustic burns of the lips, mouth, and tongue have been seen in patients who use mouthwashes containing alcohol and chlorhexidine
A case of chemical burn confined to the masticatory mucosa and produced by abusive ingestion of fresh fruit and by the concomitant excessive use of mouthwash has also been reported

Typical features:
Usually located on the mucobuccal fold area & gingiva
Injured area is irregular in shape, white, covered with a pseudomembrane, and very painful
Area of involvement may be extensive
Brief contact: superficial white and wrinkled appearance without resultant necrosis is usually seen
Long term contact: can cause severe damage and sloughing of the necrotic mucosa.
Unattached nonkeratinized mucosa commonly affected

Treatment:
Best is prevention
– Supervise children taking aspirin tablets
-Use a rubber dam during endodontic procedures
Most superficial burns heal within 1 or 2 weeks.
A protective emollient agent such as a film of methyl cellulose may provide relief