Clinical Review

Oral Lesions You Can’t Afford to Miss

Being able to promptly recognize and diagnose oral lesions is critical to heading off several potentially serious conditions. This article and photo guide can help.

Clinician Reviews. 2015 September;25(9):44-47,50-53,56

Author(s):

William D. Anderson III, MD, DABFM, FAAFP

Nathaniel S. Treister, DMD, DMSc

E.J. Mayeaux Jr, MD, DABFM, FAAFP

DMD

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References

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Family practice clinicians can play an essential role in managing their patients’ oral health by promptly recognizing and diagnosing conditions that demand further medical attention, including nonodontogenic and odontogenic infections, primary oral mucosal diseases, oral manifestations of systemic disease, and malignancy. Many conditions are amenable to treatment by the primary care provider, while others will require referral to a specialist.

This article and accompanying photo guide describe the types of lesions you may encounter during examinations of the oral cavity and the corresponding diagnoses.

BE VIGILANT FOR NONODONTOGENIC CONDITIONS THAT MAY REQUIRE URGENT TREATMENT There are several uncommon, acute nonodontogenic conditions that affect the oral cavity; when severe, they may require urgent medical attention and possible hospitalization.

Primary herpes simplex virus 1 (HSV-1) infection is generally subclinical, but some patients develop significant oral disease—called primary herpetic gingivostomatitis—that is characterized by painful, diffuse, irregular, croplike ulcerations throughout the oral cavity and lips (see Figure 1).¹ The gingiva is nearly universally affected, which distinguishes this condition from erythema multiforme and aphthous stomatitis (described later in this article). The incidence is highest in children, followed by adolescents and young adults.²

Erythema multiforme. This mucocutaneous hypersensitivity reaction can be limited to the oral cavity and lips, without accompanying skin lesions. Flu-like symptoms, including fever and chills, are followed by acute onset of diffuse oral ulcerations that are generally limited to nonkeratinized mucosa and spare the gingiva (see Figure 2).³ Ulceration and crusting of the lips are common.

Aphthous stomatitis. Recurrent aphthous stomatitis (RAS) is a common immune mediated inflammatory condition characterized by “canker sores,” or small round/ovoid ulcers with a well-defined erythematous halo (see Figure 3). Lesions almost exclusively affect nonkeratinized mucosa (and never the lip vermilion) and heal within seven to 10 days, although “major” (> 0.5 cm) lesions may persist much longer (see Figure 4). A herpetiform pattern with multiple coalescing ulcers closely mimics HSV.

Small subsets of patients develop “complex” RAS, which is characterized by continuous and often multiple ulcerations that may extend into the esophagus, with associated chronic pain and compromised intake.² RAS associated with systemic conditions is reviewed below.

URGENT TREATMENT