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Common Oral Lesions and Orofacial Pain: Guidelines for Assessment, Diagnosis,and Management
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- 1. Section I : Differential Diagnosis of Oral Lesions 1
- 2. 2 - Pseudomembranous candidiasis Chemical burn Food debris (materia alba) Detached keratin Dentifrice-associated epithelial slough White lesions that can be rubbed off Frictional keratosis Lichenoid contact reaction Idiopathic leukoplakia Oral squamous cell carcinoma White lesions associated with smokeless tobacco - Candidal leukoplakia - Single white lesions that cannot be rubbed off Generalized white plaque - Idiopathic leukoplakia - Lichen planus - Lupus erythematosus - Proliferative verrucous leukoplakia Bilateral white lesions - Linea alba buccalis - White sponge nevus - Hairy leukoplakia - Lichen planus - Lichenoid drug reaction - Leukoedema - Candidal leukoplakia Multiple white lesions that cannot be rubbed off White lesions that cannot be rubbed off White lesion Siribang-on Piboonniyom Khovidhunkit
- 3. 3 White lesions associated with smokeless tobacco White sponge nevus Proliferative verrucous leukoplakia Pseudomembranous candidiasis Linea alba buccalis Oral squamous cell carcinoma Lichenoid drug reaction Lichen planus Lichenoid contact reaction Leukoedema Idiopathic leukoplakia Dentifrice-associated slough Frictional keratosis Hairy leukoplakia Presents as asymptomatic folded bilateral lesions of buccal mucosa that tend to be thickened and have a sponge consistency White plaque cannot be rubbed off, usually presents bilaterally on the anterior buccal mucosa close to commissural area History of direct application of some medications such as aspirin or chemical agents to oral mucosa History of using dentifrice with strong detergent or flavoring compounds White plaque adjacent to contributing factors such as sharp tooth or poorly fitting dentures Asymptomatic white lesions cannot be rubbed off, usually located on lateral borders of the tongue in HIV-infected subjects or other immunocompromised patients, associated with Epstein-Barr virus (EBV) infection White plaque cannot be rubbed off in a patient with a history of smoking, alcohol consumption or betel nut chewing habit Diffuse, filmy surface, translucent white plaque on bilateral buccal mucosa with dissipation of white plaque upon stretching Presents with white striation (Wickham’s striae) on bilateral buccal mucosa Presents with white striation (Wickham’s striae) adjacent to metal containing products such as amalgam restoration or metal crown History of using medications such as antihypertensive drugs that can induce lichenoid lesion on bilateral buccal mucosa White lines on bilateral buccal mucosa adjacent to the occlusal plane of upper and lower teeth White plaque cannot be rubbed off in a patient with a history of smoking, tobacco use, alcohol consumption or betel nut chewing habit White plaque can be rubbed off leaning a red, raw, or bleeding surface. Usually presents with predisposing factors such as immunocompromising conditions, long-term use of steroids or antibiotics, or hyposalivation White plaque cannot be rubbed off on gingiva with cauliflower like surface, usually grows rapidly and can be trans formed to verrucous carcinoma White plaque cannot be rubbed off in a patient with a history of using smokeless tobacco Candidal leukoplakia Chemical burn Key characteristics of the lesions Lesions
- 4. 4 Denture-induced stomatitis - Erythematous lesion on denture bearing area - History of wearing denture at night or poor oral hygiene and poor denture condition - Immunocompromised patients - Patients with hyposivation Erythematous candidiasis - Red area with burning sensation to spicy food - History of using longterm antibiotics or corticosteroids - Patients with immunocompromised condition, e.g., HIV infection - Erosive area with burning sensation to spicy food - History of using medications for systemic diseases, e.g. hypertension, diabetes mellitus, gout, dyslipidemia - May present adjacent to dental restorations, e.g., amalgam, composite resin, or metal crown Erosive (atrophic) lichen planus or Lichenoid reaction - Generalized erosive area on attached gingiva - Can be seen in • Lichen planus • Pemphigus • Pemphigoid Desquamative gingivitis Red lesion - Depapillation on central posterior dorsum of the tongue - Associated with candidal infection Median rhomboid glossitis - Red-white lesion after exclusion of all other possible diagnoses - Premalignant lesion associated with history of smoking, tobacco use, betel nut chewing and/or alcohol abuse - Usually demonstrates dysplastic changes on the red area Erythroplakia - Malignant lesion associated with history of smoking, tobacco use, betel nut chewing and/or alcohol abuse Squamous cell carcinoma Siribang-on Piboonniyom Khovidhunkit
- 5. 5 - White plaque can be rubbed off, leaving red area or bleeding - History of using long-term antibiotics or corticosteroids - Patients with immunocompromised conditions, e.g., HIV infection or using immunosuppressants - Patients with hyposalivation from radiotherapy of oral cancer Oral candidiasis of mixed pseudomembranous and erythematous types Geographic tongue - Red or depapillated area with white rim on the tongue - Burning sensation if candidal superinfection - More common in individuals with allergic diseases; e.g. atopy, asthma, and contact allergy Cheek or tongue biting habit - Red areas with white shredded surface on lateral surface of the tongue or buccal mucosa - History of cheek or tongue biting habit - Reduction of the lesion can be obtained after the abstinence of such habit Lichen planus or Lichenoid reaction Red and white lesion - Erosive area with white striation (Wickham’s striae) - Burning sensation to spicy food - History of using medications for systemic diseases, e.g. hypertension, DM, gout, dyslipidemia - May present adjacent to dental restoration, e.g., amalgam, composite resin, or crown - Red papule on white plaque that cannot be rubbed off - Presents on the posterior palate in individuals with history of heavy smoking Nicotinic stomatitis (Stomatitis nicotina) - Red-white lesions after exclusion of all other possible diagnoses - Premalignant lesion associated with smoking, tobacco use, betel nut chewing and/or heavy consumption of alcohol - Usually demonstrate dysplastic changes on the red area Erythroleukoplakia - Malignant lesion associated with history of smoking, tobacco use, betel nut chewing and/or alcohol abuse Squamous cell carcinoma Siribang-on Piboonniyom Khovidhunkit
- 6. 6 Recurrent herpes simplex virus infection Recurrent herpes zoster virus infection Multiple unilateral erosions or cluster of small painful erosions on the hard palate or attached gingiva Chronic onset - Lichen planus (usually presents with white striations, i.e., Wickham’s striae) - Pemphigus/pem phigoid/other vesiculobullous diseases Acute onset Generalized widespread erosions Erosion (a partial loss of epithelium presenting as a single or multiple red patches) - Primary herpetic gingivostomatitis - Erythema multiforme, e.g., after using some medications or after herpes virus infection - Lichen planus/Lichenoid reaction - Trauma or burn of a known cause - Precancerous lesion such as erythroplakia - Carcinoma - Bullous diseases such as pemphigus, pemphigoid Single or multiple localized erosion Siribang-on Piboonniyom Khovidhunkit
- 7. 7 Generalized multiple ulcers - Primary herpes simplex virus infection - Primary herpes zoster virus infection - Hand-foot-mouth disease - Herpangina - Cat scratch disease - Rubella Unilateral multiple ulcers - Recurrent intraoral herpes simplex virus infection - Recurrent herpes labialis - Recurrent herpes zoster virus infection Ulcers with spontaneous healing Multiple ulcers - Recurrent aphthous ulcers (RAU) • Minor RAU • Major RAU • Herpetiform RAU - Recurrent intraoral herpes simplex virus infection - Recurrent herpes labialis - Recurrent herpes zoster virus infection Single ulcer - Traumatic ulcer (check the cause and eliminate it. If no response, perform a biopsy) - Recurrent aphthous ulcers (RAU) • Minor RAU • Major RAU • Herpetiform RAU Recurrent ulcers Ulcerative lesion - Traumatic ulcer - Infections - Tuberculosis - Deep fungal infection - Viral infection - Squamous cell carcinoma - Salivary gland neoplasm • Benign • Malignant Single ulcer - Vesiculobullous diseases • Pemphigus • Pemphigoid • Linear IgA disease - Lichen planus - Lichenoid reaction - Lupus erythematosus (LE) • Systemic lupus erythematosus (SLE) • Discoid lupus erythematosus (DLE) - Erythema multiforme (EM) Multiple ulcers Persistent ulcers Siribang-on Piboonniyom Khovidhunkit
- 8. 8 Amalgam tattoo Decorative tattoo Chlorhexidine staining Heavy metal sulphides (check for occupational exposure) - Black hairy tongue - Extrinsic factors Intrinsic factors No blanching on pressure Red, blue, brown, yellow, or yellow brown pigmentation - Hemorrhage - Kaposi’s sarcoma - Pyogenic granuloma - Benign and malignant vascular neoplasms Blanches on pressure (discoloration is due to blood in vessels) - Hemangioma/vascular malformation - Varix (varicosity) Blood and blood-derived pigmentation Nonwhite lesion Associated with tumor mass - Pigmented neuroectodermal tumor of infancy - Melanoma Discrete flat pigmentation patches - Benign melanotic macule - Pigmented nevus - Melanoma/melanoma in situ Generalized diffuse or patchy pigmentation - Racial pigmentation - Inflammatory pigmentation - Addison’s disease - Peutz-Jeghers syndrome - Drug-induced pigmentation, e.g., minocline, tetracycline - Smoker’s melanosis - Melanoacanthoma Melanin pigmentation Siribang-on Piboonniyom Khovidhunkit
- 9. 9 Smoker’s melanosis Varix (varicosity) Racial pigmentation Peutz-Jeghers syndrome Pigmented nevus Pigmented neuroectodermal tumor of infancy Pyogenic granuloma Melanoma/melanoma in situ Melanoacanthoma Hemangioma/vascular malformation Hemorrhage Inflammatory pigmentation Kaposi’s sarcoma Decorative tattoo Drug-induced pigmentation Heavy metal sulphides Black hairy tongue Benign melanotic macule History of trauma or irritation, most common on gingiva, can be associated with pregnancy or a use of contraceptive medication Generalized homogeneous pigmentation on the attached gingiva; bilaterally symmetry, common in dark-skinned patients History of smoking, presents as pigmentation most often found on anterior gingiva More common in elderly patients, most common on upper or lower lip, ventral surface of the tongue Associated with signs and symptoms of Addison’s disease, e.g., weakness, fatigue, perioral and cutaneous pigmentation. Serum cortisol levels should be investigated. Usually presents adjacent to a large amalgam filling or crown; most common on edentulous ridge Usually exists since childhood as brown flat lesion with no change in size or location Can be solitary or multiple and most commonly presents on upper or lower lip or palate Black or dark brown pigment localized to the dorsum of the tongue with or without overgrowth of filiform papillae Usually presents in patients with hyposalivation, and a history of using antibiotic medication or other herbal lozenges History of tattoo application History of using long-term medication, e.g., minocycline, tetracycline, anti-retroviral medications History of occupational exposure, e.g., working in a factory with chemical substance that contains heavy metal Presents since childhood, if the lesion is large, pulsation can be obtained History of trauma or taking anticoagulant medication History of chronic inflammation, e.g., patient with lichen planus Irregular mass associated with immunocompromised condition, e.g., HIV infection, patients who are on immunosuppressive medication Acute onset with generalized pigmentation of the oral cavity More common in African-American or Indian population Most frequently seen on palate or gingiva as brown to black macule or mass with irregular borders Associated with intestinal polyposis or presents with gastrointestinal problems Usually exists since childhood as solitary small brown, black or blue elevated papule or nodule Presents in infant less than 6 months of age and occurs typically in maxilla Addison’s disease Amalgam tattoo Key characteristics of the lesions Lesions
- 10. 10 - Abscess from dental origin - Pericoronitis Acute inflammatory enlargement - Squamous papilloma - Verruciform xanthoma Papillary enlargement of surface epithelium - Pyogenic granuloma - Irritation fibroma - Peripheral ossifying fibroma - Peripheral giant cell granuloma Reactive hyperplasia Benign soft tissue lesions - Lipoma - Granular cell tumor - Neuroma Diseases of salivary gland Soft tissue swelling/mass - Mucocele - Ranula - Benign salivary gland tumor • Mixed tumor - Malignant salivary gland tumor • Mucoepidermoid carcinoma • Adenoid cystic carcinoma - Squamous cell carcinoma - Non-Hodgkin’s lymphoma Malignant soft tissue lesions Siribang-on Piboonniyom Khovidhunkit