Name That Oral Lesion! by Dr. Seena Patel

Name That Oral Lesion! 

by Dr. Seena Patel

Diagnosing oral lesions is a vital part of the oral health care provider’s practice. Oral mucosal lesions can be caused by many etiologies, ranging from a simple traumatic lesion to an oral cancer. A thorough knowledge of common oral mucosal lesions helps providers better understand these etiologies, which treatments are necessary and when to refer patients to a specialist. Naturally, early diagnosis and intervention can save lives and drastically impact the patient’s quality of life. So, let’s see if you can name that lesion!

Question 1
A 19-year-old woman presented to the oral medicine clinic complaining about swollen gingiva—and five years earlier, she had visited the clinic with the same complaint. Lesions (Figs. 1a and 1b) were localized to the gingiva only. Biopsies done at both times showed the diagnosis of nonnecrotizing granulomatous inflammation and mild fibrosis. After her initial diagnosis in 2018, she had seen a gastroenterologist and was treated for Crohn’s disease. However, this treatment did not resolve the lesions. Recently, she saw another GI specialist, who did not find any evidence of Crohn’s disease.
Name That Oral Lesion!
Fig. 1a: 2018
Name That Oral Lesion!
Fig. 1b: 2023

Answer: Orofacial granulomatosis.
Orofacial granulomatosis is an immune-mediated reaction with no known cause. Other factors can present with similar oral manifestations. Underlying systemic granulomatous diseases such as Crohn’s disease, sarcoidosis and tuberculosis need to be ruled out, as do as other local factors including periodontal disease, foreign body gingivitis, plasma cell gingivitis and contact stomatitis. Certain medications—including checkpoint inhibitors, antiretroviral therapy, interferons, and tumor necrosis factor-alpha antagonists—also may cause this reaction. Furthermore, patients may be reacting to any other substance introduced into the body, and therefore an allergy consult may be sought.

The clinical presentation is varied and often involves swelling of the lips. Other features include intraoral swelling, ulcers and papules; gingival edema, erythema, erosion and pain; cobblestone appearance of the buccal mucosae; fissures in the tongue; linear ulcerations and hyperplasia in the buccal vestibule; and palatal papules or hyperplasia. Treatment is focused on identifying the cause or trigger for the lesions, but often, this is difficult to determine. Topical, intralesional or systemic immunomodulatory agents such as corticosteroids can be administered for symptomatic treatment.

Question 2

A 62-year-old woman presented with severe pain on the tongue and a bad taste. She had started dexamethasone elixir a few days before these symptoms. The examimation revealed diffuse, white plaques that could be wiped off with gauze (Figs. 2a–2d).

The patient’s relevant medical history includes a diagnosis of chronic lymphocytic leukemia that is stable and not being medically treated.
Name That Oral Lesion!
Fig. 2a
Name That Oral Lesion!
Fig. 2b
Name That Oral Lesion!
Fig. 2c
Name That Oral Lesion!
Fig. 2d

Answer: Pseudomembranous candidiasis, secondary to topical corticosteroid use.
Candidiasis is the most common fungal infection to infect the oropharyngeal region. Primarily caused by Candida albicans, this is an opportunistic infection that occurs when the oral flora is altered or when the patient is experiencing systemic immunosuppression. Contributing factors include dry mouth; smoking; current or recent antibiotic use; poor oral hygiene; inhaled, topical or systemic corticosteroids; immunosuppressive medications; and improper denture use or hygiene.

There are several types, including: pseudomembranous, erythematous, central papillary atrophy, chronic multifocal, angular cheilitis, denture stomatitis and chronic hyperplastic. Pseudomembranous candidiasis is the most common form. The white plaques can be wiped or scraped off, which is a notable feature of this lesion. Antifungal medication is the treatment of choice. Addressing the underlying contributing factor is also necessary to prevent recurrence.

Question 3

A 73-year-old man was referred for an evaluation of nonpainful white lesions on the right and left ventrolateral surfaces of the tongue, occurring with no known cause. They had been present for about one year. His clinical exam showed bilateral, diffuse and illdefined white plaques that could not be wiped or scraped off (Figs. 3a–3c).
Name That Oral Lesion!
Fig. 3a
Name That Oral Lesion!
Fig. 3b
Name That Oral Lesion!
Fig. 3c

Answer: Oral hairy leukoplakia.
Oral hairy leukoplakia (OHL) is caused by Epstein-Barr virus and occurs in the setting of immunosuppression. Clinical features of this lesion will show an ill-defined white lesion occurring bilaterally, typically on the lateral borders of the tongue. It cannot be wiped off with gauze. There may be vertical, linear keratoses as well as a shaggy surface texture.

These lesions are commonly known to occur in persons with AIDS and are indicative of severe immunosuppression. Other immunosuppressive conditions such as organ transplants can also cause OHL and older patients who are immunocompetent, as in this case, have also exhibited OHL. In these cases, OHL likely develops because of immunosenescence that occurs with age, but patients should be referred for a medical evaluation to assess for causes of immunosuppression if they didn’t already have such a diagnosis. In this case, the patient confirmed that he’d tested negative for HIV in the past, but he was referred to his physician to potentially retest and assess for any other causes of immunosuppression. OHL does not require any treatment; the underlying cause, if present, must be addressed.

Common mistake: This lesion in the current presentation could be misdiagnosed as lichen planus.

Question 4
A 79-year-old woman presented to the clinic about a nonpainful leukoplakia on the right buccal mucosa with no known cause. She was a smoker but did not drink alcohol. The clinical examination revealed multiple well-defined, white plaques involving the right buccal mucosa, the buccal gingiva by Teeth #3, 4, 12, 13, 20 and 21, and the buccal gingiva and vestibular muscosa from Teeth #23–26 (Figs. 4a–4d). Biopsies were performed for each site
Name That Oral Lesion!
Fig. 4a: Right buccal mucosa (mild to focally moderate epithelial dysplasia).
Name That Oral Lesion!
Fig. 4b: Buccal gingiva on Teeth #3 and #4 (mild to focally moderate dysplasia.
Name That Oral Lesion!
Fig. 4c: Buccal gingiva and vestibular mucosa from #23–26.
Name That Oral Lesion!
Fig. 4d: Buccal gingiva on Teeth #20 and #21 (mild dysplasia).

Answer: Proliferative leukoplakia.
Leukoplakia is a potentially malignant disorder defined as a white plaque that is not caused by trauma, allergy, fungal infection or immune-related disease. Therefore, it is a diagnosis of exclusion. Lesions must be biopsied to evaluate for dysplasia or malignancy. Dysplasia of the epithelium involves cellular alterations encompassing portions of the epithelium, and it is graded mild/low, moderate/medium or severe/high based on the amount of the epithelium affected. The presence of dysplasia indicates a higher risk for malignant transformation.

“Leukoplakia” is a clinical term only, referring to an isolated lesion. Proliferative leukoplakia (PL) means there are multiple leukoplakias at different sites of the oral mucosa. PL has a much higher malignant transformation rate (~50%) than isolated leukoplakia.

The traditional risk factors of tobacco use, alcohol intake and betel quid use are associated with leukoplakia, but these risk factors are not often seen in those with PL. PL affects women much more often than men. Age is a risk factor, because PL is often seen after the age of 60. These lesions are also less responsive to surgical excision, and often recur.

Clinical features of PL will show multiple white plaques involving the oral mucosa; the gingiva is a common site to be affected. The lesions are usually well demarcated and typically have a nonhomogenous surface texture. Over time, the lesions may develop projections, making it appear verrucous.

Treatment depends on the severity of dysplasia, as well as a consideration for the number of lesions present, sites involved, and age and medical history of the patient. Surgical excision or CO2 laser ablation may be a potential therapy. Careful observation every three months is necessary. Any new lesions or change to existing lesions must undergo another biopsy.

Common mistake: This lesion could be confused with plaque-type lichen planus, because it is widespread throughout the mouth.

Question 5

A 39-year-old man presented to the oral medicine clinic for an evaluation of a lower lip lesion (Fig. 5) that had been noted six months earlier. He reported constantly biting it, but it did not cause pain. The patient was a daily smoker, consumed 12 alcoholic drinks per week and had a history of recreational drug use.
Name That Oral Lesion!
Fig. 5

Answer: Giant cell fibroma.
A giant cell fibroma is a benign connective-tissue growth, not caused by trauma or irritation. Despite the name, it is a small lesion, typically less than 1 cm in size. Giant cell fibromas are often seen in younger individuals (< 30 years old) and usually occur on the gingiva. The lesion will appear sessile or pedunculated, and frequently with a papillary surface texture. It does not cause the patient any symptoms. Conservative, surgical excision is the treatment modality. Lesion recurrence is very low.

Common mistake: This lesion looks like an irritation fibroma, which would be caused by trauma.

Question 6
A 77-year-old woman presented with a complaint of spontaneous, bright, red gingiva that bled easily (Figs. 6a–6d). This had begun two months before the visit, with no known cause. The patient reported mild difficulty tolerating acidic foods and her medical history was remarkable for rheumatoid arthritis, for which she took methotrexate. Her social history was unremarkable, and she had used the same toothpaste for years.

Name That Oral Lesion!
Fig. 6a: Maxillary gingiva (before).
Name That Oral Lesion!
Fig. 6b: Left buccal mucosa (before).
Name That Oral Lesion!
Fig. 6c: Lower labial musosa (before).
Name That Oral Lesion!
Fig. 6d: Mandibular gingiva (before).

Answer: Plasma cell gingivitis.
Initially, the patient was prescribed topical corticosteroids and also instructed to stop using her toothpaste and instead brush twice a day with a diluted baking soda solution and rinse with ACT fluoride rinse. Over time, she was told to stop the topical corticosteroid. After approximately seven months, the symptoms had resolved.

Plasma cell gingivitis is a hypersensitivity reaction that usually affects the gingiva. Typical offenders include flavoring agents (e.g., in chewing gum or candy), certain products in toothpaste, and spices such as pepper or cardamom. However, in some cases the lesions are idiopathic.

The characteristic clinical features of plasma cell gingivitis are bright, erythematous, smooth and enlarged gingiva involving both keratinized and nonkeratinized gingiva. Lesions occur with a rapid onset of action and can cause soreness. Patients will report irritation with toothpastes and spicy foods. The histology will show a plasma cell infiltrate. This histologic appearance can also occur in gingivitis because of mouth breathing, plaque and chronic periodontitis; therefore, such local causes should be ruled out. In addition, a similar presentation can occur in lymphoproliferative disorders, and therefore attention to a systemic contribution is necessary.

Treatment involves identification of the offending agent, when possible. Patients should keep a comprehensive log of anything that comes into contact with the oral mucosa. Serial elimination of each item can help identify the cause. In some cases, the patient may need to see an allergist. Symptomatic treatment with topical or systemic immunomodulatory agents can be helpful.

Common mistake: This could be mistaken as a local gingival or periodontal condition. Remember that patients can develop an allergy at any time in their life, even if they’ve been using the same product for many years.

Question 7
A 43-year-old woman presented to the clinic for an evaluation of a hard mass on the gingiva that had occurred about two months earlier (Figs. 7a–7d). Over time, the lesion had increased in size. The patient denied trauma had occurred at the site, but reported the lesion caused mild pain and difficulty with eating. She had never smoked or used other tobacco products, and drank alcohol very occasionally.
Name That Oral Lesion!
Fig. 7a: Initial consultation.
Name That Oral Lesion!
Fig. 7b: Initial consultation.
Name That Oral Lesion!
Fig. 7c: : Recurrence two months later, after a biopsy.
Name That Oral Lesion!
Fig. 7d: : Recurrence two months later, after a biopsy.

Answer: Peripheral ossifying fibroma.
Peripheral ossifying fibroma is a common, benign and reactive lesion that affects the gingiva. The usual clinical features involve a pedunculated or sessile mass that is smaller than 2 cm, often seen in the interproximal papilla. It can appear pink or red with a smooth or ulcerated surface. These are often seen in teenagers or young adults, and mostly females. The histology will show mineralized characteristics, such as bone, cementum or other calcified material.

There is potential for recurrence after surgical excision (8%–16%), and therefore, periodontal surgery may be needed to completely remove the fibroma.

In this patient’s case, the initial excision was not sufficient, but she had complete relief after periodontal surgery. The differential diagnoses for this lesion also include pyogenic granuloma and peripheral giant cell granuloma.

Question 8
A 39-year-old man presented to the clinic for evaluation of a palatal ulcer that had begun about 1½ weeks earlier. It was mildly tender at that point and seemed to have improved over time. He reported that it “drained” a week ago and he thought it was an abscess. Other pertinent symptoms included a numbness sensation in the maxillary anterior palatal region and right-sided jaw pain. In addition, he reported fatigue and flu-like symptoms about 11 days before his visit and described an unintentional weight loss of approximately 40 pounds within the previous two months.

The clinical exam showed a palatal ulcer (Fig. 8). Pertinent CNV exam findings were a reduced sensation to light touch on the anterior aspect of the hard palate; all other CNV sensations were normal. The patient’s medical history was otherwise unremarkable. He had smoked two or three cigars per day for 16 years.
Name That Oral Lesion!
Fig. 8

Answer: Necrotizing sialometaplasia.
Necrotizing sialometaplasia is a rare condition that affects the salivary glands. Ischemia of this tissue causes necrosis. While the exact cause is unknown, contributing factors may include trauma, local injection, upper respiratory infection, previous surgeries, and eating disorders that involve binging and purging. The most common site is the posterior hard palate, and it often occurs unilaterally and more often affects males.

The usual clinical presentation will involve a swelling with pain or paresthesia that undergoes tissue sloughing and forms a necrotic ulcer. The main concern is that this lesion appears similar to a malignancy, and therefore a biopsy is recommended to rule this out. Otherwise, necrotizing sialometaplasia does not require any treatment. Resolution occurs on its own and takes five or six weeks. In this case, the lesion resolved itself with no treatment.

Common mistake: This lesion could be thought of as a malignancy.

Diagnostic pearls
  • Always follow up on a new lesion after two weeks. If the lesion persists, a referral to a specialist and a biopsy should be considered. When in doubt, always refer.
  • Use a systematic approach when diagnosing an oral lesion. Oral lesions fall under three major categories: developmental, neoplastic and reactive. Developmental lesions are congenital and hereditary. Neoplasms are abnormal growths of tissue and these may be benign or malignant. Reactive lesions may occur as a result of trauma, infection, inflammation or autoimmunity.
  • A helpful way to determine the type of oral lesion is to know the types of tissue that the oral lesion involves (for example, epithelium versus connective tissue). This can help you assess what kind of lesion it is.
  • Remember that oral dysplasia must be followed long-term. Oral cancers can develop in that patient at any time, and therefore, they must be seen every three to six months for a follow-up for the rest of their lives. Early detection and treatment of oral cancers allows for a much better prognosis.

Author Bio
Seena Patel, DMD, MPH Seena Patel, DMD, MPH, is the director of oral medicine and an associate professor at A.T. Still University’s Arizona School of Dentistry & Oral Health (ATSU-ASDOH). She is also an associate at Southwest Orofacial Group in Phoenix, practicing orofacial pain, oral medicine and dental sleep medicine since 2012. She is a diplomate of the American Board of Orofacial Pain and the American Board of Oral Medicine. Patel earned her DMD and MPH degrees from ATSU-ASDOH and completed her residency in orofacial pain and oral medicine at the Herman Ostrow School of Dentistry at the University of Southern California.

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