Assessment of Oral Mucosal Diseases

Palatal perforation

Assessment of Oral Mucosal Diseases


Oral mucosal lesions are common. They can be due to physiological changes, local disease, an oral manifestation of a skin condition, an adverse drug reaction or systemic disease, for example, gastrointestinal disease. Successful management of an oral mucosal disease requires an accurate diagnosis. 

Assessing an oral mucosal lesion involves taking a full patient history that should include a medication history, performing a thorough extraoral and intraoral examination and using diagnostic investigations where suitable. If you have a high suspicion for oral cancer, then you must note down the risk factors for oral cancer. If any 'red flag' features are present, the diagnosis is not clear, or the patient has not responded to initial treatment, early referral to an appropriate specialist is required. 

Failure to respond to initial treatment, an unclear diagnosis or the presence of any suspicious features could indicate malignancy and warrant early referral. 


‘Red flag’ features of oral mucosal diseases  

  1. oral ulcers that have lasted for more than 2 weeks 
  2. orals ulcers that recur 
  3. nontraumatic oral ulcers in children 
  4. pigmented lesions on the oral mucosa 
  5. red, white or mixed red and white lesions on the oral mucosa of unknown origin or with features 
  6. of potentially malignant disease, such as induration, ulceration with rolled margins, fixation to underlying tissues, lesions in high-risk sites, for example, lateral tongue, floor of mouth 
  7. facial or oral paraesthesia 
  8. persistent oral mucosal discomfort with no obvious cause 
  9. lumps or swellings, including lymphadenopathy 
  10. swelling, pain or blockage of a salivary gland, suggestive of salivary gland disease 
  11. suspected allergy or adverse reaction to dental materials for example, oral lichenoid lesion 
  12. dry mouth that is not adequately relieved with artificial salivary products and nonpharmacological methods 
  13. dry mouth caused by systemic disease 
  14. suspected oral manifestations of systemic diseases, for example, syphilis, Behçet syndrome, HIV, inflammatory bowel disease, lichen planus, pemphigoid
  15. lesions occurring in immunocompromised patients, for example, patients with neutropenia or HIV infection


Potentially Malignant Disorders of Oral Cavity


Some oral mucosal diseases are associated with significant morbidity and mortality, particularly oral potentially malignant disorders and oral cancer. Oral potentially malignant disorders include: 
  1. oral leukoplakia 
  2. oral erythroplakia 
  3. chronic hyperplastic candidiasis 
  4. actinic cheilitis 
  5. oral lichen planus 
  6. oral submucous fibrosis 
  7. discoid lupus erythematosus 
  8. dyskeratosis congenita 
  9. epidermolysis bullosa. 

Oral potentially malignant disorders can become malignant at the site of the lesion, but also predict an increased risk of cancer at other sites in the mouth, even in clinically normal appearing oral mucosa. 


Conditions that can be managed by a GP

 

The following conditions can be managed in general practice, provided there are no 'red flag' features present that would warrant referral: 

  1. recurrent aphthous ulcerative disease 
  2. traumatic oral ulcers 
  3. oral candidiasis 
  4. angular cheilitis 
  5. oral mucocutaneous herpes simplex virus 
  6. dry mouth 
  7. oral mucositis 
  8. amalgam tattoo 
  9. geographic tongue 
  10. hairy tongue. 

There are physiological causes of oral mucosal discolourations, for example, Fordyce spots also known as ectopic sebaceous glands, leukoedema, which do not require active management. 

An oral medicine specialist is the most appropriate specialist to diagnose and manage oral mucosal disease, but may not be accessible; an oral surgeon, dermatologist or otorhinolaryngologist are other options. 

 

Ref: 

  1. Therapeutic Guidelines Oral & Dental 2019