Oral Lesions You Can’t Afford to Miss

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

Continue for how to spot signs of common dental diseases >>

HOW TO SPOT SIGNS OF COMMON DENTAL DISEASES

In 2010 in the United States, close to 1.4 million emergency department visits and about $1 billion in hospital charges were due to dental problems.⁴ Approximately 40% of these visits were made by individuals without insurance.⁴ Due to a lack of dental insurance, patients may present to a medical professional rather than a dental professional. Additionally, uninsured individuals may neglect their dental problem until it becomes a medical emergency. Family practice clinicians need to recognize dental disease and be able to provide basic management of emergencies.⁵

Dental abscess.  A dental abscess can arise from pulpal infection (due to progression of caries) or periodontal infection (due to progression of periodontal disease). Pain symptoms are variable; however, intense, spontaneous cyclical pain is generally characteristic of a dental abscess of pulpal etiology, whereas a periodontal abscess can have less obvious symptoms. Swelling intraorally or extraorally indicates the spread of a localized infection (see Figure 5).

Severe infection and swelling can limit mouth opening and function and in extreme cases may obstruct swallowing and even breathing (eg, Ludwig’s angina). Affected teeth may or may not demonstrate obvious findings of advanced dental disease, such as gross caries, fracture, heavy calculus deposits, or marked periodontal attachment loss. Oral examination may reveal a parulis (focal erythematous swelling of the adjacent gingiva with a central draining sinus tract) (see Figure 6) and percussion of the affected tooth is generally painful.

Pericoronitis is infection and swelling of the gingival tissues that surround a tooth, typically in association with a partially erupted third molar. Signs and symptoms include pain, discomfort with eating and swallowing, and limited mouth opening. Examination demonstrates gingival inflammation around a tooth, with or without purulence (see Figure 7).

Acute necrotizing ulcerative gingivitis (ANUG) and periodontitis (ANUP) are severe conditions that are typically associated with psychological stress, severe malnutrition, and immunosuppression in patients with preexisting gingivitis or periodontitis.⁶ ANUG is associated with intense gingival pain, halitosis, generalized erythema, and destruction of the gingival papilla, often with bleeding.⁷ ANUP is a more advanced condition associated with damage and loss of the periodontium (including bone), often with loose teeth (see Figure 8).⁸

COMMON DENTAL DISEASES

Trauma. Dental trauma can be limited to the teeth and soft tissues, while more severe injuries can also affect the jaw bone.⁹ Accidental falls, assault, and motor vehicle traffic accidents are the most common causes of facial fractures in the United States and are often associated with dentoalveolar trauma (see Figure 9). The most commonly fractured facial bone is the mandible, characterized by painful opening and closing and an incomplete or altered bite.¹⁰

Continue for oral symptoms may be the first sign of systemic disease >>

ORAL SYMPTOMS MAY BE THE FIRST SIGN OF SYSTEMIC DISEASEInflammatory bowel disease. Crohn’s disease may affect the gastrointestinal tract anywhere from the mouth to the anus and may initially present with oral findings that may not correlate with abdominal symptoms. Oral Crohn’s disease may present as mucosal cobblestoning, mucosal tags, deep linear ulcerations, gingival hyperplasia, lip fissuring, aphthous ulcers, and angular cheilitis (see Figures 10 and 11). Other features may include diffuse, painless swelling of the lips and mucosal erythema.

Pyostomatitis vegetans is an uncommon condition typically associated with ulcerative colitis that is characterized by serpentine pustules that coalesce in a “snail track” pattern (see Figure 12).¹¹

Dermatologic/vesiculobullous diseases. Vesiculobullous lesions in the mouth may be seen in pemphigus vulgaris or bullous pemphigoid. Pemphigus vulgaris is an autoimmune intraepithelial blistering disease that often first presents in the oral cavity as flaccid bullae or painful ulcerations, prior to the onset of skin lesions (see Figure 13).

Mucous membrane pemphigoid is an autoimmune subepithelial disease that affects mucous membranes and the skin. Characteristic oral mucosal blisters quickly rupture and form ulcerations, which may occur in the absence of other mucosal involvement (eg, anus, genitalia, nose or throat) (see Figure 14).¹² 

Painful aphthous ulcers are common. When oral ulcerations are diffuse and recurrent, they may be the first sign of Behçet’s disease, a multisystem autoimmune vasculitis.¹³

Oral lichen planus is a chronic immune-mediated mucocutaneous disease that is often limited to the oral cavity. It presents with characteristic radiating white striations of the buccal mucosa and tongue, often with associated erythema and ulcerations (see Figure 15).¹⁴

SIGNS OF SYSTEMIC DISEASE

Continue for rheumatologic conditions >>

Rheumatologic conditions. Systemic or discoid lupus erythematosus may present with oral findings that largely resemble those of oral lichen planus (see Figure 16).¹⁵ Sjögren’s syndrome is an autoimmune disease with characteristic xerostomia, which can lead to oral discomfort, dysphagia, recurrent candidiasis, and rampant dental caries.

Other conditions to watch for. Erosion of the enamel on the lingual surface of the teeth may be a sign of gastroesophageal reflux disease or bulimia (see Figure 17). Examination of the oral mucosa can reveal typical white plaques of oral candidiasis (see Figure 18), which may be associated with systemic immune suppression as well as salivary gland dysfunction.

SIGNS OF SYSTEMIC DISEASE (cont'd)

Oral conditions that have been associated with HIV infection include ANUG/ANUP, recurrent candidiasis, and oral hairy leukoplakia (see Figure 19). In the absence of known HIV infection, patients who present with any of these oral conditions should be evaluated for HIV infection.¹³

Atrophic glossitis may indicate a vitamin B deficiency. Thrombocytopenia and leukemia may pre­sent with oral petechiae, purpura, oral hematomas, or hemorrhagic bullae (see Figure 20).¹³ Painless pseudomembranous mucosal erosions may be a presentation for secondary syphilis.¹⁶

SIGNS OF SYSTEMIC DISEASE (cont'd)

Continue for signs that suggest malignancy >>

LOOK FOR SIGNS THAT SUGGEST MALIGNANCYIn the United States, oral and pharyngeal cancers account for approximately 40,000 cases of cancer and 8,000 deaths each year.¹⁷ More than 90% of these are squamous cell carcinomas (SCCs); the remainder are mainly salivary gland tumors, lymphoma, and other infrequent cancers.¹⁸

SCC of the oral cavity most commonly occurs on the tongue but can develop in any site, presenting as mucosal ulcers, plaques, or masses that do not heal (see Figure 21). Tobacco and alcohol use are associated with up to 80% of cases of SCC of the head and neck.¹⁸ Some oropharyngeal SCCs are associated with human papillomavirus infection type 16.¹⁹

Potentially malignant oral lesions include leukoplakia and erythroplakia. Leukoplakia is a white patch or plaque of the oral mucosa that can’t be explained by any other clinical diagnosis (see Figure 22). These lesions are at risk for malignant transformation and may demonstrate dysplasia or frank SCC on biopsy.²⁰ Proliferative verrucous leukoplakia is a unique form of leukoplakia that is characterized by a wrinkled appearance that is often multifocal; the condition is associated with a higher risk for malignant transformation.

Erythroplakia is a red patch that similarly can’t be explained by another diagnosis. It has a very high risk for malignant transformation over time. All potentially malignant oral lesions, including leukoplakia and erythroplakia, require biopsy and careful monitoring.

Non-SCC cancers. Salivary gland tumors are rare and most commonly occur in patients ages 55 to 65. Most neoplasms (70%-85%) occur in the parotid gland, while 8% to 15% develop in the submandibular salivary gland and less than 1% involve the sublingual gland.²¹ Minor salivary gland tissue, especially in the lips and palate, may also be affected (see Figure 23). Patients present with circumscribed, fixed or movable, painless, soft or firm masses in a salivary gland.

Melanoma should be included in the differential diagnosis of oral pigmented lesions that have any features of cutaneous melanoma, such as asymmetry, irregular borders, or variable or changing color.²²

Hematologic malignancies may initially pre­sent (or demonstrate evidence of relapse) in the oral cavity. Leukemia typically presents with sheet-like overgrowth and swelling of the gingiva, with associated erythema and bleeding (see Figure 24), whereas lymphoma typically presents as a solitary mass or ulceration. Solid tumors that metastasize to the oral cavity may present with localized unexplained soft or hard tissue growths, with or without associated neurologic symptoms (eg, paresthesia).

MALIGNANCIES

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

Continue for how to spot signs of common dental diseases >>

HOW TO SPOT SIGNS OF COMMON DENTAL DISEASES

In 2010 in the United States, close to 1.4 million emergency department visits and about $1 billion in hospital charges were due to dental problems.⁴ Approximately 40% of these visits were made by individuals without insurance.⁴ Due to a lack of dental insurance, patients may present to a medical professional rather than a dental professional. Additionally, uninsured individuals may neglect their dental problem until it becomes a medical emergency. Family practice clinicians need to recognize dental disease and be able to provide basic management of emergencies.⁵

Dental abscess.  A dental abscess can arise from pulpal infection (due to progression of caries) or periodontal infection (due to progression of periodontal disease). Pain symptoms are variable; however, intense, spontaneous cyclical pain is generally characteristic of a dental abscess of pulpal etiology, whereas a periodontal abscess can have less obvious symptoms. Swelling intraorally or extraorally indicates the spread of a localized infection (see Figure 5).

Severe infection and swelling can limit mouth opening and function and in extreme cases may obstruct swallowing and even breathing (eg, Ludwig’s angina). Affected teeth may or may not demonstrate obvious findings of advanced dental disease, such as gross caries, fracture, heavy calculus deposits, or marked periodontal attachment loss. Oral examination may reveal a parulis (focal erythematous swelling of the adjacent gingiva with a central draining sinus tract) (see Figure 6) and percussion of the affected tooth is generally painful.

Pericoronitis is infection and swelling of the gingival tissues that surround a tooth, typically in association with a partially erupted third molar. Signs and symptoms include pain, discomfort with eating and swallowing, and limited mouth opening. Examination demonstrates gingival inflammation around a tooth, with or without purulence (see Figure 7).

Acute necrotizing ulcerative gingivitis (ANUG) and periodontitis (ANUP) are severe conditions that are typically associated with psychological stress, severe malnutrition, and immunosuppression in patients with preexisting gingivitis or periodontitis.⁶ ANUG is associated with intense gingival pain, halitosis, generalized erythema, and destruction of the gingival papilla, often with bleeding.⁷ ANUP is a more advanced condition associated with damage and loss of the periodontium (including bone), often with loose teeth (see Figure 8).⁸

COMMON DENTAL DISEASES

Trauma. Dental trauma can be limited to the teeth and soft tissues, while more severe injuries can also affect the jaw bone.⁹ Accidental falls, assault, and motor vehicle traffic accidents are the most common causes of facial fractures in the United States and are often associated with dentoalveolar trauma (see Figure 9). The most commonly fractured facial bone is the mandible, characterized by painful opening and closing and an incomplete or altered bite.¹⁰

Continue for oral symptoms may be the first sign of systemic disease >>

ORAL SYMPTOMS MAY BE THE FIRST SIGN OF SYSTEMIC DISEASEInflammatory bowel disease. Crohn’s disease may affect the gastrointestinal tract anywhere from the mouth to the anus and may initially present with oral findings that may not correlate with abdominal symptoms. Oral Crohn’s disease may present as mucosal cobblestoning, mucosal tags, deep linear ulcerations, gingival hyperplasia, lip fissuring, aphthous ulcers, and angular cheilitis (see Figures 10 and 11). Other features may include diffuse, painless swelling of the lips and mucosal erythema.

Pyostomatitis vegetans is an uncommon condition typically associated with ulcerative colitis that is characterized by serpentine pustules that coalesce in a “snail track” pattern (see Figure 12).¹¹

Dermatologic/vesiculobullous diseases. Vesiculobullous lesions in the mouth may be seen in pemphigus vulgaris or bullous pemphigoid. Pemphigus vulgaris is an autoimmune intraepithelial blistering disease that often first presents in the oral cavity as flaccid bullae or painful ulcerations, prior to the onset of skin lesions (see Figure 13).

Mucous membrane pemphigoid is an autoimmune subepithelial disease that affects mucous membranes and the skin. Characteristic oral mucosal blisters quickly rupture and form ulcerations, which may occur in the absence of other mucosal involvement (eg, anus, genitalia, nose or throat) (see Figure 14).¹² 

Painful aphthous ulcers are common. When oral ulcerations are diffuse and recurrent, they may be the first sign of Behçet’s disease, a multisystem autoimmune vasculitis.¹³

Oral lichen planus is a chronic immune-mediated mucocutaneous disease that is often limited to the oral cavity. It presents with characteristic radiating white striations of the buccal mucosa and tongue, often with associated erythema and ulcerations (see Figure 15).¹⁴

SIGNS OF SYSTEMIC DISEASE

Continue for rheumatologic conditions >>

Rheumatologic conditions. Systemic or discoid lupus erythematosus may present with oral findings that largely resemble those of oral lichen planus (see Figure 16).¹⁵ Sjögren’s syndrome is an autoimmune disease with characteristic xerostomia, which can lead to oral discomfort, dysphagia, recurrent candidiasis, and rampant dental caries.

Other conditions to watch for. Erosion of the enamel on the lingual surface of the teeth may be a sign of gastroesophageal reflux disease or bulimia (see Figure 17). Examination of the oral mucosa can reveal typical white plaques of oral candidiasis (see Figure 18), which may be associated with systemic immune suppression as well as salivary gland dysfunction.

SIGNS OF SYSTEMIC DISEASE (cont'd)

Oral conditions that have been associated with HIV infection include ANUG/ANUP, recurrent candidiasis, and oral hairy leukoplakia (see Figure 19). In the absence of known HIV infection, patients who present with any of these oral conditions should be evaluated for HIV infection.¹³

Atrophic glossitis may indicate a vitamin B deficiency. Thrombocytopenia and leukemia may pre­sent with oral petechiae, purpura, oral hematomas, or hemorrhagic bullae (see Figure 20).¹³ Painless pseudomembranous mucosal erosions may be a presentation for secondary syphilis.¹⁶

SIGNS OF SYSTEMIC DISEASE (cont'd)

Continue for signs that suggest malignancy >>

LOOK FOR SIGNS THAT SUGGEST MALIGNANCYIn the United States, oral and pharyngeal cancers account for approximately 40,000 cases of cancer and 8,000 deaths each year.¹⁷ More than 90% of these are squamous cell carcinomas (SCCs); the remainder are mainly salivary gland tumors, lymphoma, and other infrequent cancers.¹⁸

SCC of the oral cavity most commonly occurs on the tongue but can develop in any site, presenting as mucosal ulcers, plaques, or masses that do not heal (see Figure 21). Tobacco and alcohol use are associated with up to 80% of cases of SCC of the head and neck.¹⁸ Some oropharyngeal SCCs are associated with human papillomavirus infection type 16.¹⁹

Potentially malignant oral lesions include leukoplakia and erythroplakia. Leukoplakia is a white patch or plaque of the oral mucosa that can’t be explained by any other clinical diagnosis (see Figure 22). These lesions are at risk for malignant transformation and may demonstrate dysplasia or frank SCC on biopsy.²⁰ Proliferative verrucous leukoplakia is a unique form of leukoplakia that is characterized by a wrinkled appearance that is often multifocal; the condition is associated with a higher risk for malignant transformation.

Erythroplakia is a red patch that similarly can’t be explained by another diagnosis. It has a very high risk for malignant transformation over time. All potentially malignant oral lesions, including leukoplakia and erythroplakia, require biopsy and careful monitoring.

Non-SCC cancers. Salivary gland tumors are rare and most commonly occur in patients ages 55 to 65. Most neoplasms (70%-85%) occur in the parotid gland, while 8% to 15% develop in the submandibular salivary gland and less than 1% involve the sublingual gland.²¹ Minor salivary gland tissue, especially in the lips and palate, may also be affected (see Figure 23). Patients present with circumscribed, fixed or movable, painless, soft or firm masses in a salivary gland.

Melanoma should be included in the differential diagnosis of oral pigmented lesions that have any features of cutaneous melanoma, such as asymmetry, irregular borders, or variable or changing color.²²

Hematologic malignancies may initially pre­sent (or demonstrate evidence of relapse) in the oral cavity. Leukemia typically presents with sheet-like overgrowth and swelling of the gingiva, with associated erythema and bleeding (see Figure 24), whereas lymphoma typically presents as a solitary mass or ulceration. Solid tumors that metastasize to the oral cavity may present with localized unexplained soft or hard tissue growths, with or without associated neurologic symptoms (eg, paresthesia).

MALIGNANCIES

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

Continue for how to spot signs of common dental diseases >>

HOW TO SPOT SIGNS OF COMMON DENTAL DISEASES

In 2010 in the United States, close to 1.4 million emergency department visits and about $1 billion in hospital charges were due to dental problems.⁴ Approximately 40% of these visits were made by individuals without insurance.⁴ Due to a lack of dental insurance, patients may present to a medical professional rather than a dental professional. Additionally, uninsured individuals may neglect their dental problem until it becomes a medical emergency. Family practice clinicians need to recognize dental disease and be able to provide basic management of emergencies.⁵

Dental abscess.  A dental abscess can arise from pulpal infection (due to progression of caries) or periodontal infection (due to progression of periodontal disease). Pain symptoms are variable; however, intense, spontaneous cyclical pain is generally characteristic of a dental abscess of pulpal etiology, whereas a periodontal abscess can have less obvious symptoms. Swelling intraorally or extraorally indicates the spread of a localized infection (see Figure 5).

Severe infection and swelling can limit mouth opening and function and in extreme cases may obstruct swallowing and even breathing (eg, Ludwig’s angina). Affected teeth may or may not demonstrate obvious findings of advanced dental disease, such as gross caries, fracture, heavy calculus deposits, or marked periodontal attachment loss. Oral examination may reveal a parulis (focal erythematous swelling of the adjacent gingiva with a central draining sinus tract) (see Figure 6) and percussion of the affected tooth is generally painful.

Pericoronitis is infection and swelling of the gingival tissues that surround a tooth, typically in association with a partially erupted third molar. Signs and symptoms include pain, discomfort with eating and swallowing, and limited mouth opening. Examination demonstrates gingival inflammation around a tooth, with or without purulence (see Figure 7).

Acute necrotizing ulcerative gingivitis (ANUG) and periodontitis (ANUP) are severe conditions that are typically associated with psychological stress, severe malnutrition, and immunosuppression in patients with preexisting gingivitis or periodontitis.⁶ ANUG is associated with intense gingival pain, halitosis, generalized erythema, and destruction of the gingival papilla, often with bleeding.⁷ ANUP is a more advanced condition associated with damage and loss of the periodontium (including bone), often with loose teeth (see Figure 8).⁸

COMMON DENTAL DISEASES

Trauma. Dental trauma can be limited to the teeth and soft tissues, while more severe injuries can also affect the jaw bone.⁹ Accidental falls, assault, and motor vehicle traffic accidents are the most common causes of facial fractures in the United States and are often associated with dentoalveolar trauma (see Figure 9). The most commonly fractured facial bone is the mandible, characterized by painful opening and closing and an incomplete or altered bite.¹⁰

Continue for oral symptoms may be the first sign of systemic disease >>

ORAL SYMPTOMS MAY BE THE FIRST SIGN OF SYSTEMIC DISEASEInflammatory bowel disease. Crohn’s disease may affect the gastrointestinal tract anywhere from the mouth to the anus and may initially present with oral findings that may not correlate with abdominal symptoms. Oral Crohn’s disease may present as mucosal cobblestoning, mucosal tags, deep linear ulcerations, gingival hyperplasia, lip fissuring, aphthous ulcers, and angular cheilitis (see Figures 10 and 11). Other features may include diffuse, painless swelling of the lips and mucosal erythema.

Pyostomatitis vegetans is an uncommon condition typically associated with ulcerative colitis that is characterized by serpentine pustules that coalesce in a “snail track” pattern (see Figure 12).¹¹

Dermatologic/vesiculobullous diseases. Vesiculobullous lesions in the mouth may be seen in pemphigus vulgaris or bullous pemphigoid. Pemphigus vulgaris is an autoimmune intraepithelial blistering disease that often first presents in the oral cavity as flaccid bullae or painful ulcerations, prior to the onset of skin lesions (see Figure 13).

Mucous membrane pemphigoid is an autoimmune subepithelial disease that affects mucous membranes and the skin. Characteristic oral mucosal blisters quickly rupture and form ulcerations, which may occur in the absence of other mucosal involvement (eg, anus, genitalia, nose or throat) (see Figure 14).¹² 

Painful aphthous ulcers are common. When oral ulcerations are diffuse and recurrent, they may be the first sign of Behçet’s disease, a multisystem autoimmune vasculitis.¹³

Oral lichen planus is a chronic immune-mediated mucocutaneous disease that is often limited to the oral cavity. It presents with characteristic radiating white striations of the buccal mucosa and tongue, often with associated erythema and ulcerations (see Figure 15).¹⁴

SIGNS OF SYSTEMIC DISEASE

Continue for rheumatologic conditions >>

Rheumatologic conditions. Systemic or discoid lupus erythematosus may present with oral findings that largely resemble those of oral lichen planus (see Figure 16).¹⁵ Sjögren’s syndrome is an autoimmune disease with characteristic xerostomia, which can lead to oral discomfort, dysphagia, recurrent candidiasis, and rampant dental caries.

Other conditions to watch for. Erosion of the enamel on the lingual surface of the teeth may be a sign of gastroesophageal reflux disease or bulimia (see Figure 17). Examination of the oral mucosa can reveal typical white plaques of oral candidiasis (see Figure 18), which may be associated with systemic immune suppression as well as salivary gland dysfunction.

SIGNS OF SYSTEMIC DISEASE (cont'd)

Oral conditions that have been associated with HIV infection include ANUG/ANUP, recurrent candidiasis, and oral hairy leukoplakia (see Figure 19). In the absence of known HIV infection, patients who present with any of these oral conditions should be evaluated for HIV infection.¹³

Atrophic glossitis may indicate a vitamin B deficiency. Thrombocytopenia and leukemia may pre­sent with oral petechiae, purpura, oral hematomas, or hemorrhagic bullae (see Figure 20).¹³ Painless pseudomembranous mucosal erosions may be a presentation for secondary syphilis.¹⁶

SIGNS OF SYSTEMIC DISEASE (cont'd)

Continue for signs that suggest malignancy >>

LOOK FOR SIGNS THAT SUGGEST MALIGNANCYIn the United States, oral and pharyngeal cancers account for approximately 40,000 cases of cancer and 8,000 deaths each year.¹⁷ More than 90% of these are squamous cell carcinomas (SCCs); the remainder are mainly salivary gland tumors, lymphoma, and other infrequent cancers.¹⁸

SCC of the oral cavity most commonly occurs on the tongue but can develop in any site, presenting as mucosal ulcers, plaques, or masses that do not heal (see Figure 21). Tobacco and alcohol use are associated with up to 80% of cases of SCC of the head and neck.¹⁸ Some oropharyngeal SCCs are associated with human papillomavirus infection type 16.¹⁹

Potentially malignant oral lesions include leukoplakia and erythroplakia. Leukoplakia is a white patch or plaque of the oral mucosa that can’t be explained by any other clinical diagnosis (see Figure 22). These lesions are at risk for malignant transformation and may demonstrate dysplasia or frank SCC on biopsy.²⁰ Proliferative verrucous leukoplakia is a unique form of leukoplakia that is characterized by a wrinkled appearance that is often multifocal; the condition is associated with a higher risk for malignant transformation.

Erythroplakia is a red patch that similarly can’t be explained by another diagnosis. It has a very high risk for malignant transformation over time. All potentially malignant oral lesions, including leukoplakia and erythroplakia, require biopsy and careful monitoring.

Non-SCC cancers. Salivary gland tumors are rare and most commonly occur in patients ages 55 to 65. Most neoplasms (70%-85%) occur in the parotid gland, while 8% to 15% develop in the submandibular salivary gland and less than 1% involve the sublingual gland.²¹ Minor salivary gland tissue, especially in the lips and palate, may also be affected (see Figure 23). Patients present with circumscribed, fixed or movable, painless, soft or firm masses in a salivary gland.

Melanoma should be included in the differential diagnosis of oral pigmented lesions that have any features of cutaneous melanoma, such as asymmetry, irregular borders, or variable or changing color.²²

Hematologic malignancies may initially pre­sent (or demonstrate evidence of relapse) in the oral cavity. Leukemia typically presents with sheet-like overgrowth and swelling of the gingiva, with associated erythema and bleeding (see Figure 24), whereas lymphoma typically presents as a solitary mass or ulceration. Solid tumors that metastasize to the oral cavity may present with localized unexplained soft or hard tissue growths, with or without associated neurologic symptoms (eg, paresthesia).

MALIGNANCIES