Ulcerated Lesions
Recurrent Aphthous Stomatitis (RAS)
20% of the general population. Exact aetiology unknown, Trauma, Dysregulated salivary composition, xerostomia and stresses. Low levels of iron, zinc, folate, and vitamins B1, B2, B6 and B12, hypersensitivity to food. Incidence of RAS was lower in smokers because increase keratinisation of the oral mucosa. Underlying medical disorders, anaemia, Behcet’s syndrome, HIV, cyclic neutropenia and MAGIC syndrome, immunocompromised patients. Cyclic neutropenia- include RAS, mastoiditis, otitis and febrile episodes in infancy.
MINOR RAS Number of ulcers1-5 Size<10 mm Healing period10-14 days, no scarring
MAJOR RAS Number of ulcers1-10 Size>10 mm Healing period>6 weeks, high risk of scarring
HERPETIFORM RAS Number of ulcers10-100 Size2-3 mm Healing period<4 weeks, scarring uncommon
Treatment
Minor RAS: Topical corticosteroids; tetracycline mouth rinse
Major RAS: Topical, systemic, intralesional corticosteroids; immunosuppressants
Herpetiform RAS: Topical, systemic corticosteroids; tetracycline mouth rinse
Minor recurrent aphthous ulcer
Major recurrent aphthous ulcer
Treatment
Protective emollients Zilactin or Orabase, topical anaesthetics lidocaine or benzocaine, Tetracycline mouth rinses and NSAIDs. Topical corticosteroid, systemic corticosteroids prednisone in severe major RAS. Referral to an oral medicine specialist in severe cases of RAS.
Herpes Simplex Virus Infections (HSV)
Herpes simplex virus types 1 and 2 are highly prevalent, multiple sites of the body, including oral cavity. 40% under 20 yo had positive antibodies HSV-1, and 65% if over 70 yo
Clinical Features
Primary infections, childhood, asymptomatically or present with fever, headache and cervical lymphadenopathy, then eruption of vesicular lesions within the gingiva (primary herpetic gingivostomatitis), borders of the lips or perioral skin region as solitary lesions or clusters. The vesicles prone to rupture and may also appear crusted or as sores. Primary episodes often resolve within 10 to 14 days, then the virus lies dormant in trigeminal nerve ganglion
Secondary herpes labialis is recurrent crop of vesicles at vermillion border
Certain triggers, UV light trauma, stress, fatigue or menstruation, lead to shorter episodic outbreaks.
Primary herpetic stomatitis — upper and lower lip
Herpes labialis of the lower left lip (crusted lesion)
Treatment
Herpetic mouth lesions diagnosed clinically but confirmed by swab. self-resolve, mild cases treated supportively with fluid and analgesic. Systemic antivirals valaciclovir or famciclovir in neonates, pregnant, immunocompromised, early.
Recurrent lesion result in milder ‘cold sores’. Most infectious within first 24 hours, most mild and will self-resolve, larger lesions treated with topical acyclovir cream or famciclovir. Severe recurrences or immunocompromised with chronic lesions, daily prophylactic antivirals
Oral Squamous Cell Carcinoma
90% of oral cancers. adults older than 40 yo, most often on the lateral borders of the tongue, followed by gingiva and alveolar mucosa, floor of the mouth, ventral surface of the tongue. In areca nut chewing, tobacco-chewing, found on buccal mucosa.
Risk Factors
alcohol use, tobacco use, betel quid, areca nut chewing, and HPV infection. Nutritional deficiencies, immunosuppression. Solar radiation- lower lip
Clinical Features
Early-stage often painless, asymptomatic, from non-healing ulcers, lumps or swellings, ill-fitting prostheses, erythroplakia, leukoplakia, pain or numbness, ulcers with fissures or raised exophytic margins, non-healing extraction sockets, induration (increased tissue density) and fixation (lack of tissue mobility). Any suspicious lesion in the oral cavity that does not resolve after 3 weeks should be investigated
Squamous cell carcinoma right pterygomandibular region
Squamous cell carcinoma of the left ventral surface of the tongue
Treatment
Surgical excision. Metastatic cases involve cervical lymph nodes 80% of the time, lymph node resection. Radiotherapy and/or chemotherapy. In advanced squamous cell carcinoma cases. 5-year survival rate for oral cancer remains around 50%, so early detection
White Or Mixed White-Red Lesions
Oral Candidosis
Oral candidosis, opportunistic infection from changes in the oral microflora
Risk Factors
Broad-spectrum antibiotic use, dentures, inhaled corticosteroids without rinsing the mouth, smoking, diabetes and immunosuppression (e.g. AIDS, haematological malignancies, chemotherapy). Dry mouth
Pseudomembranous- white coating on mucosa, can be wiped away, underlying erythem. Topical antifungal therapy
Erythematous (atrophic)- painful (burning) and smooth (due to depapillation), Topical antifungal therapy
Hyperplastic-Often chronic; white patches, cannot be removed. Resemble leukoplakia, biopsy
Denture-induced stomatitis- 60% of denture wearers; erythematous areas at denture-bearing areas. Assess fit of dentures and denture hygiene, topical antifungal therapy to mouth and dentures
Diagnosis by clinical appearance, but oral swab or smear can be helpful
First-line treatment topical antifungal nystatin liquid, amphotericin lozenges or miconazole gel. Refractory cases investigated for underlying cause. This may also include the use of fluconazole or ketoconazole.
Pseudomembranous candidosis
Pseudomembranous candidosis
Erythematous candidosis
Median rhomboid glossitis (a form of erythematous candidiasis): a roughly symmetric, asymptomatic red lesion involving the midline of the posterior dorsal tongue.
Hyperplastic candidosis associated within edentulous ridge 47-48-retromolar region in a diabetic with poor denture hygiene. Biopsy to R/O Cancer
Denture-induced stomatitis
Oral Lichen Planus (OLP)
chronic inflammatory oral mucosa, a subtype of lichen planus, cell-mediated immunological dysfunction epithelial damage. Prevalence of 1–2%, usually adults, exact etiology unknown
Clinical Features
The most common sites are gingiva, tongue and buccal mucosa, followed by vermillion border of the lip and the labial mucosa; floor of the mouth and the palate are rare. Buccal mucosa is 73%–95.5%, and bilateral in 82%. Six types
Reticular- small, white keratotic papules connected by a white, lacy network known as Wickham’s striae; asymptomatic, can cause taste alteration and burning sensation if on the tongue. Incidence 64.8%. Generally, treatment not required
Plaque-like- White, smooth keratotic lesions, sometimes with striations. If asymptomatic, no treatment; if symptomatic, topical corticosteroids
Papular- Small keratotic lesions of approximately 1 mm in diameter, Topical corticosteroids e.g. dexamethasone, triamcinolone; systemic corticosteroids e.g. prednisolone if topical therapy ineffective
Atrophic/erythematous- Regions of muscle atrophy with thinned epithelium in conjunction with previous reticular lesions, Txt Same as above
Erosive- Red or erythematous areas with central ulceration of varying degrees and bordered by fine white striae; characterised by lesions, ulcers and sometimes bullae. Incidence- 22.9%. Txt Same as above
Bullous- Severe erosions resulting in rupture of epithelium and bullae formation. Txt Same as above
Two thirds of individuals affected by OLP experience symptoms. Most are atrophic and erosive (ulcerative) forms. mucosal roughness, burning sensation, irritation, xerostomia, bleeding and dysgeusia.
OLP has the potential for squamous cell carcinoma from 0% to 5.8%.
Diagnosis by biopsy.
Reticular form of oral lichen planus on buccal mucosa
Reticular oral lichen planus. White, lace-like striations on the buccal mucosa are known as Wickham's striae.
Erosive oral lichen planus
Gingival oral lichen planus areas of desquamation or loss of the epithelial surface appearing intensely red — desquamative gingivitis
Erosive lichen planus. (A) Central ulceration with peripheral radiating Wickham's striae on the buccal mucosa. (B) Generalized gingival erythema and erosions (desquamative gingivitis).
Treatment
Etiology of OLP unknown, no cure exists. Symptomatic lesions such as erosive or erythematous OLP are painful. Topical corticosteroids dexamethasone or triamcinolone. Systemic corticosteroids prednisolone for acute exacerbations, where topical ineffective
Geographic Tongue
Benign, incidence of 2%–3%, smooth red areas depapillation dorsum and lateral tongue, recurrent, migrate
Erythema migrans, benign migratory glossitis
Clinical Features
erythematous surrounded by white margins of regeneration of papilla and keratin, etiology unknown, usually painless, some may burn and sensitive to acidic & spicy foods.
Geographic tongue on dorsal and lateral surfaces of the tongue
Treatment
Biopsy not required but can to rule out malignant. Resolve spontaneously, no treatment. Any burning sensation- use topical steroids and anesthetics.
Pre-Malignant Disorders
Include leukoplakia, erythroplakia, oral submucous fibrosis, actinic cheilitis and OLP. Early identification and treatment.
Leukoplakia- white plaques oral mucosa with unknown cause. Risk of malignancy, should be differentiated from benign candidiasis, hairy leukoplakia, lupus erythematous and morsication. Smokers six times more likely to develop leukoplakia, 1% annual risk of malignant transformation. Leukoplakia has two types - homogenous white.
Non-homogenous, red and white lesion, erythroleukoplakia or speckled leukoplakia, high risk of malignant transformation, these lesions may require surgical excision.
Leukoplakia (biopsied with diagnosis of oral lichen planus and secondary oral candidosis)
Erythroplakia
Oral submucous fibrosis, chronic inflammation and fibrosis, difficulty opening jaw, intolerance to spicy food, a burning sensation, mucosal stiffening and fibrosis, 10-year malignancy risk 7.6%.
Submucosal fibrosis, used betel leaf frequently (pallor of soft palate is extensive fibrous change within the submucosa)
Actinic cheilitis- lip, caused by solar UV radiation, elastosis, chronic inflammatory infiltrate, vasodilation and hyperkeratosis. Can progress to squamous cell carcinoma. lip dryness, atrophy, scaly lesions, ulcerations and loss of vermilion border. Incidence 31%, multifocal on the lower lip of typically fair-skinned, above 40 yo, history of significant sun exposure
Dry and fissured lips (called cheilitis) secondary to oral candidosis with solar elastosis (actinic cheilitis)
Biopsy to assess dysplasia from other inflammatory and atrophic lesions.
Lumps And Bumps
Mucocele
Cavities filled with mucus, benign soft-tissue masses, usually asymptomatic, minor salivary glands, single or multiple, round, smooth, raised, smooth fluctuant nodules, mucous extravasation cyst (MEC) or mucous retention cyst (MRC) depending on histology. Ranula is mucocele floor of the mouth. Most prevalent between 10 and 19 yo. May experience discomfort and problems with speech, swallowing and mastication depending on the size of the lesion and the location.
Clinical features and treatment of mucoceles
MEC (mucous extravasation cyst)- No epithelial lining. Granulation tissue. Rupture of minor salivary gland duct and mucin spilling into surrounding soft tissue. cheek or lip biting. Buccal and labial mucosa less than 1.5 cm
MRC (mucous retention cyst)- True cyst due to presence of epithelial lining. Mucin and inflammatory debris are present. Similar appearance to MEC but pain present and mucus or pus may be expressed. Due to mucous retention in the duct, ductal opening is blocked, causing swelling and irritation. Floor of the mouth, upper lip, hard palate, maxillary sinus
Ranula- Blue dome-shaped fluctuant swelling that can elevate the tongue and is present lateral to the midline. Larger than other mucoceles, sometimes reaching several centimetres in size. Arises from leaking of saliva from sublingual gland, Wharton’s duct or ducts of Rivini. Floor of the mouth
Treatment- Marsupialisation, dissection, carbon dioxide lasers or complete excision including total removal of feeder gland to minimise recurrence
Mucocele on lower lip
Squamous Cell Papilloma (SCP)
Benign and asymptomatic exophytic mass, HPV types 6 and 11. Risk factors smoking, dietary deficiencies, hormonal changes and other infections. Two types- Isolated-solitary in adults, multiple-recurring in children. HPV can transmit via skin-to-skin, oral or sexual contact with an infectious person, or from mother to child.
Localised proliferation cauliflower-like from soft tissue. Grows to reach a maximum of 1 cm. Common sites palate (37.84%), tongue (29.73%), lips and gingiva. Most commonly 30 to 50 yo.
Squamous papilloma of the lingual frenum
Treatment
Surgical excision including some surrounding tissue. Laser such as CO2 and ER,Cr:YSGG, electrocautery and cryosurgery. Recurrence is uncommon, except in HIV.
Pyogenic Granuloma
Non-neoplastic rapidly growing vascular lesion on the skin or mucous membranes. Etiology is unclear, possibly from inflammatory hyperplasia secondary to trauma, chronic irritation, medications or hormone factor such a pregnancy.
Localised red papule, smooth or lobulated, on a pedunculated or sessile base. From a few millimetres, can bleed easily, may ulcerate. Majority on the gingiva, particularly maxillary gingiva, may also affect the lips, mucosa and tongue
Pyogenic granuloma
Treatment
Excision, especially during pregnancy, carries a high recurrence rate. Observation for small, asymptomatic lesions to surgical excision.
Pigmented Lesions
Oral Melanoma
Primary oral melanomas are rare, less than 1% of melanomas occur on mucosal surfaces. Incidence increases with age. Etiology is unknown, risk factors include pre-existing pigmented naevi, infection, trauma from ill-fitting prostheses and tobacco consumption.
Clinical Features
Most black, brown, white, grey, purple or red lesions, third amelanocytic. May include ulceration, central nodules and satellite lesions. Most commonly on hard palate (40%) or gingival surfaces (28%). Most (85%) are invasive at diagnosis, 5-year survival 15%. Diagnosis by biopsy.
Oral melanoma
Treatment
Surgery to excise the tumor, radiotherapy, chemotherapy and immunotherapy.
Amalgam Tattoo
Displacement of amalgam particles in soft tissues, grey—blue or black pigmentation on the oral mucosa. Usually round and uniformly pigmented and can be present on the buccal mucosa, lips, tongue, floor of the mouth, palate and gingiva
Amalgam tattoo biopsied of left buccal mucosa
Treatment
No treatment is required, but excision using laser in aesthetic regions
Hairy Tongue
Benign and painless, elongated filiform papilla of the tongue. Incidence0.5%
Clinical Features
Defective desquamation and hypertrophy of central filiform papillae, leading to bacteria. discoloration: white, yellow, green, brown or black. Etiological factors poor oral hygiene, antibiotic and psychotropic agents, xerostomia, mouthwashes, and smoking and alcohol, coffee, tea and food.
Hairy tongue on dorsal surface of tongue
Treatment
Minimising smoking and coffee. Regular tongue brushing, tongue scraper or toothbrush. In rare cases, surgical removal of papillae.
Conclusion
Any lesion not resolving after 3 weeks for specialist review. Additional red flags include non-healing ulcers, ill-fitting prostheses, erythroplakia, leukoplakia, ulceration with fissures, and lesions with induration and fixation. Particular attention in oral examination for patients with smoking, betel nut or areca nut consumption, solar radiation, HPV infection and immunocompromised state.