Name that Oral Lesion! by Seena Patel

General dentists are first in the line of practitioners that patients see for an oral lesion evaluation; therefore, a sound understanding of oral mucosal diseases and their clinical presentation is paramount. Accurate diagnosis not only leads to early intervention or specialist referral, but also avoids unnecessary office visits and inappropriate treatments. So, let’s see if you can name that lesion!

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  1 Here’s an image of the hard palate. A 70-year-old woman presents with a growth that ‘falls down’ unless she keeps her maxillary denture in place to ‘hold it in.’ This growth has been present for one year. She wears her denture, which does not fit well, all day and night and is waiting for her dentist to make a new one. Note the diffuse erythema with slight papillary hyperplasia at the midline of the palate.

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  2 An 82-year-old man presents with an ulceration in the vestibule of the mandibular anterior region (#24/25 area). It has been present for six months without healing. The maxilla and mandible are edentulous. The patient wears only a maxillary denture and does not have a history of tobacco use, and there are no other lesions present in the oral cavity. A clinical exam reveals that the maxillary teeth fit into the ulceration as the patient closes his mouth.

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  3 A 32-year-old woman presents for evaluation of recurring ulcerations on the tongue. She’s had them for years, but they became more frequent in the past year. They last 10–14 days and are moderately painful, with spicy or acidic foods worsening the pain. She has tried topical anesthetics and ‘miracle mouthwash’ without relief.

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  4 A 52-year-old woman presents with ‘rough areas’ on the right and left buccal mucosa. They appear white from self-inspection, but are not painful. She noticed them about a month ago. Pictured above is the right buccal mucosa; the left appears identical. The white lesions cannot be wiped off with gauze.

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  5 A 72-year-old woman with a history of medication-induced xerostomia presents with burning of the oral mucosa and an unpleasant taste that began two weeks ago. Clinical exam reveals diffuse, white curdlike lesions surrounded by mild erythema. These lesions wipe off with gauze and leave an erythematous base.

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  6 A 42-year-old woman presents for evaluation of a growth on the lower lip. It was noted two months ago, she reports, after accidentally biting her lip severely while eating a sandwich. The lesion sometimes decreases in size, but then returns to its current size. It is not painful, but she finds herself biting on it frequently because of its size.

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  7 A 66-year-old man presents for evaluation of a white lesion on the left side of the tongue, which was noticed at his dentist’s office. He is not sure how long it’s been there, and it does not cause pain. All adjacent teeth are smooth. He does not report biting the tongue recently and discloses a history of smoking cigarettes—one pack per day for 25 years.

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  8 A 63-year-old man presents for evaluation of the left buccal mucosa. He would like to have new dentures made, but his dentist referred him for evaluation before this. The patient says that his current denture impinges on the lesion, causing pain. The lesion has been present for eight months and has increased in size. It is severely painful, and he cannot open his mouth as wide as he used to. He smokes 1½ packs of cigarettes per day, and has done so for the past 40 years.

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  9 A 35-year-old woman presents with a lesion on her lip that began shortly after a dental procedure. She has had these before. They generally last for a week.

1 Leaflike denture fibroma (fibroepithelial polyp) and inflammatory papillary hyperplasia
The leaflike denture fibroma is a type of fibrous hyperplasia caused by wearing an ill-fitting denture. The photo is characteristic, with a flattened, pink growth attached to the palate by a narrow stalk. This usually sits in a cupped-out depression on the palate. The above lesion also shows characteristics of inflammatory papillary hyperplasia, which is a reactive growth of tissue that develops under a denture. It can also be associated with Candida organisms. Risk factors for developing this are an ill-fitting denture, poor denture hygiene and wearing the denture 24 hours a day.

2 Traumatic ulcer
Traumatic etiology must be considered in areas that show a clear relation to a local injury. While these lesions generally heal in two weeks, they will not heal appropriately if the source of trauma is not removed. In this patient’s case, he needed to stop using the maxillary denture until the site healed, after which a mandibular denture will need to be fabricated.

3 Recurrent aphthous stomatitis (RAS)
RAS is an immune-mediated reaction that’s triggered by many factors, including medications, certain foods, trauma, stress, hormonal changes, infections and hematologic ab- normalities. RAS may also be associated with systemic conditions like Behçet syndrome, celiac disease and cyclic neutropenia. These ulcerations commonly occur on nonkeratinized tissue and generally last 7–14 days. They are usually 3–10mm in diameter and heal without scarring. Children and young adults are the most affected.

Common mistakes:
Aphthous ulcerations are often misdiagnosed as recurrent herpes simplex infections.

4 Oral lichen planus, reticular type
Oral lichen planus, reticular type
Lichen planus is an immune-mediated mucocutaneous disease that occurs through a T-cell-mediated process. It is more common in women and may affect the skin, presenting as purple, pruritic, polygonal papules.

There are four forms: reticular, erosive, plaque-type and bullous. The reticular form is most common, presenting with characteristic, interlacing white striae (Wickham striae), usually on the posterior buccal mucosae. Reticular lichen planus is not symptomatic, but the erosive form usually presents with painful lesions.

Common mistakes:
Lichen planus is often misdiagnosed as oral candidiasis.

5 Pseudomembranous candidiasis
This is the most common form of candidal infection, often referred to as “thrush.” Symptoms are generally mild. Presence of infection is dependent on several factors, including host immune status and the oral mucosal environment.

6 Mucocele
A mucocele is a common oral lesion caused by a ruptured salivary gland duct. The mucin then spills into the surrounding soft tissues, forming a dome-shaped, fluctuant swelling. It may increase or decrease in size. Mucoceles are often caused by trauma to the site and, as such, the lower lip is a common site of involvement. While some may rupture and resolve on their own, most require local surgical excision.

7 Leukoplakia
A leukoplakia is a descriptive term for a white plaque or patch that cannot be classified clinically or pathologically as any other disease. It is, therefore, a diagnosis of exclusion. Other disorders that cause white lesions must be excluded before declaring a lesion as leukoplakic.

This type of lesion may be premalignant. Therefore, a biopsy is necessary to rule out other causes of keratosis and to assess for the presence of epithelial dysplasia. Leukoplakia can be characterized as thin, thick, homogenous, nonhomogenous, granular, nodular or verrucous. This particular lesion is a homogenous leukoplakia.

8 Traumatic ulcer
Squamous cell carcinoma Squamous cell carcinoma is the most common type of oral malignancy. While a single causative agent has not been identified, risk factors include tobacco and alcohol use.

Squamous cell carcinoma may also be preceded by a precancerous lesion, such as leukoplakia. High-risk sites are the tongue and floor of mouth.

Early detection is paramount. Prompt referral to a head and neck surgeon is necessary for a comprehensive diagnostic work-up and treatment.

9 Recurrent herpes simplex infection
his lesion is a result of reactivation of the herpes simplex virus (HSV-1), which is spread through infected saliva or active perioral lesions. Various triggers can cause recurrent HSV, such as ultraviolet light, stress, dental treatment, pregnancy, allergy, trauma and menstruation. Prodromal signs (e.g., burning, tingling, erythema, itching) may occur before the lesion develops.

The vermilion border of the lip and adjacent skin is a common site of involvement. Intraoral mucosa can also be affected, which involves the keratinized mucosa (hard palate and attached gingiva).