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, Beh├žet 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 

Oral Cancer

Oral cancer is associated with significant morbidity and mortality. Early presentations of oral cancer are usually asymptomatic, whereas late presentations include pain, discomfort, reduced mobility of the tongue, increased mobility of the teeth or an inability to wear dentures. Oral cancer varies in appearance and can mimic many other oral mucosal diseases.

Squamous cell carcinoma of the left anterior ventral surface of the tongue
Squamous cell carcinoma of the left mandibular alveolus

Oral cancer can mimic many other oral mucosal diseases, so early specialist referral is required for investigation and biopsy of any suspicious lesion. 

Any suspicious lesion needs early specialist referral for investigation and biopsy.

Squamous cell carcinoma is the most common oral malignancy, which arises from the epithelium of the oral cavity. Oral squamous cell carcinoma can affect any part of the oral mucosa; however, it most commonly occurs on the lateral surfaces of the tongue, the floor of the mouth or the gingivae. 


Risk factors for oral squamous cell carcinoma  

  1. advanced age 
  2. male gender 
  3. smoking or tobacco use 
  4. alcohol use 
  5. infection by oncogenic viruses (eg human papillomavirus) 
  6. personal or family history of squamous cell carcinoma of the head and neck 
  7. history of cancer therapy 
  8. prolonged immunosuppression 
  9. areca nut (betel quid) chewing. 
  10. Genetic susceptibility, environment, occupation and diet may also contribute to the development of oral squamous cell carcinoma. 

Cancers originating from the salivary glands and supporting nonepithelial tissues are less common than squamous cell carcinoma. Metastatic cancers to the oral soft tissues and jawbones commonly originate from primary malignancies in the breast, prostate, kidneys or lungs. Leukaemia and lymphoma may also present in the oral cavity. 

 

The treating specialist should perform the biopsy of an oral mucosal lesion. In rural or remote areas where a delay in specialist review is expected, seek expert advice on biopsy technique. A punch biopsy is not appropriate.




 

References:

  1. Therapeutic guidelines (Oral & Dental) 2019 

Oral Leukoplakia

Oral leukoplakia

Oral leukoplakia (OL) is a clinical term for a nonremovable white lesion that is not easily recognisable as any particular condition and therefore requires further investigation.

Oral leukoplakia manifests as patches that are bright white and sharply defined. The surfaces of the patches are slightly raised above the surrounding mucosa.

Oral leukoplakia may be homogenous (uniform lesion often with a fissured surface), or nonhomogeneous (with surface irregularity and textural or colour variation for example speckled-see below given photograph.

Oral Lichen Planus

Oral Lichen Planus on left mucosa [1]


Question: What is oral lichen planus?

Answer: It is a chronic inflammatory condition that affects the skin, nails, hair, and mucous membranes, characterised by purplish, itchy, flat eruptions.


Question: How common is the condition?

Answer: It is a common condition in India. Its cases are reported more than 10 lakh per year in India. 


Question: How much time does it need for recovery?

Answer: It can last several years or remains lifelong.



Question: Is the condition treatable? 

Answer: Treatments can help manage conditions. There is no known cure present. 

 

Question: Does diagnosis require lab tests or imaging? 

Answer: Its diagnosis rarely requires lab tests or imaging. 

 

 

 

Condition Highlights 

  1. It commonly occurs for ages 35-50. 
  2. It is more common in females. 
  3. Family history may increase likelihood to occur.