Oral lesions and other dermatological conditions of the mouth

LAST UPDATED: Dec 12, 2021

Introduction

This chapter provides a brief introduction in to oral medicine, and signposts to those dermatological conditions that can be associated with oral lesions. The management of oral lesions generally falls outside the remit of this website as such conditions are often managed by Oral and Maxillofacial Surgeons.

This chapter is set out as follows:


History

The section on clinical findings, below, discusses the following:

  • An overview of oral lesions - a guide
  • Conditions affecting the lips - signposting
  • Common conditions affecting the tongue - an overview
  • Oral cancer - a brief description
  • White patches in the mouth - signposting
  • Mouth ulcers - a more detailed description including aphthous ulcers and Behçet syndrome

Clinical findings

Overview of oral lesions


Conditions affecting the lips


Common conditions of the tongue - an overview

Oral candidiasis
  • Signs of oral candida include white patches on the tongue and other mucosal surfaces that can often be wiped off, leaving behind red areas that may bleed slightly
  • For more information refer to the related chapter Candidal infection

Median rhomboid glossitis
  • Characterised by a smooth, shiny, erythematous, sharply circumscribed, asymptomatic, plaque-like lesion on the dorsal midline of the tongue. Other surfaces of the mouth are characteristically spared
  • Men are affected three times more often than women
  • Most persons with the condition are asymptomatic, but burning or itching is possible
  • Median rhomboid glossitis is commonly associated with candidal infection, which responds to antifungal therapy

Geographic tongue (syn. benign migratory glossitis)
  • Common, and of unknown aetiology. It has an association with fissured tongue and an inverse association with cigarette smoking
  • Characterised by irregularly shaped red, smooth, swollen patches on the tongue, often with a white border, giving rise to a map-like appearance
  • Usually self-limiting and does not require treatment, however, if symptomatic treatments can include topical anaesthetic preparations and/or soluble corticosteroids used as a 'mouth rinse'

Atrophic glossitis
  • Also known as 'smooth tongue' because of the smooth, glossy appearance with a red or pink background. The smooth quality is caused by the atrophy of filiform papillae
  • Primarily a manifestation of underlying conditions and warrants thorough diagnostic evaluation - nutritional deficiencies of iron, folic acid, vitamin B12, riboflavin, and niacin are common causes
  • Other aetiologies include candida, coeliac disease, xerostomia triggered by some medications and Sjögren's syndrome, and amyloidosis
  • Atrophic glossitis caused by nutritional deficiency often causes a painful sensation in the tongue
  • Treatment includes replacement of the missing nutrient or treatment of the underlying condition

Fissured tongue
  • In a fissured tongue, deep grooves develop due to physiologic deepening of normal tongue fissures
  • Typically occur with aging and require no treatment unless trapping of food and bacteria leads to inflammation of the fissures. Gentle brushing of the tongue is useful in persons with symptomatic inflammation
  • Associated with Down's syndrome, acromegaly, psoriasis, and Sjögren's syndrome

Hairy tongue
  • Accumulation of excess keratin on the filiform papillae of the dorsal tongue leads to the formation of elongated strands that resemble hair
  • The colour of the tongue can range from white or tan to black. Darker coloration results from the trapping of debris and bacteria in the elongated strands
  • Most commonly in smokers and in persons with poor oral hygiene, and has been associated with use of certain antibiotics
  • Most patients are asymptomatic, but some have halitosis or abnormal taste. No treatment is required, but gentle daily debridement with a tongue scraper or soft toothbrush can remove keratinised tissue

Oral cancer (including the lips)

Squamous cell carcinoma
  • Early lesions are often asymptomatic and appear as areas of erythroplakia (red patch) or leukoplakia (white patch - see below) and may be ulcerated or exophytic (growing outwards). As the lesion grows it becomes more symptomatic

Melanoma
  • The oral mucosa is primarily involved in less than 1% of melanomas
  • Lesions are largely macular, but nodular and even pedunculated lesions occur. The pigmentation varies from dark brown to blue-black; however, mucosa-coloured and white lesions are occasionally noted, and erythema is observed when the lesions are inflamed
  • The palate and maxillary gingiva are involved in approximately 80% of patients, but buccal mucosa, mandibular gingiva, and tongue lesions are also identified

An amalgam tattoo can sometimes be mistaken for melanoma. It is an iatrogenic lesion caused by traumatic implantation of dental amalgam into soft tissue. An amalgam tattoo is the most common localised pigmented lesion in the mouth,

Other malignancies that can present in the mouth include Kaposi's sarcoma (discoloured patches, and occasionally nodules, that are usually red or purple and look similar to bruises), and adenocarcinoma of a salivary gland.


White patches in the mouth and on the lips 

Lichen planus (LP)
  • The mouth is involved in up to 50% of all LP cases, and LP confined to the mouth accounts for about 15% of all cases
  • Characteristic findings are a white lacework pattern. In the mouth the buccal mucosa is the most commonly affected site. The tongue can also be involved, and less so the gums and lips
  • Linea alba (bite marks) arises as a white line on the buccal mucosa, and sometimes the side of the tongue, and can be confused with lichen planus
  • Occasionally lichenoid lesions arise as the result of contact allergic dermatitis to mercury in amalgam fillings on nearby teeth. Patch tests can confirm the diagnosis and if the fillings are replaced symptoms may improve
  • Refer to the chapter Lichen planus for more information

Materia alba
  • Materia alba is an accumulation of microorganisms, desquamated epithelial cells, leucocytes, and a mixture of salivary protein and lipids. It is a yellow or grey-white, soft, sticky deposit that is less adherent than plaque, and is most frequently seen at the dentogingival margin. Treatment is that of good oral hygiene

Oral leukoplakia (OL)
  • OL is a white (or white-red) patch or plaque of the oral mucosa that cannot be characterised clinically or pathologically as any other condition such as cheek biting, candidosis, lichen planus and materia alba
  • OL is pre-malignant and associated with squamous cell carcinoma (SCC)
  • Refer to the chapter Leukoplakia (and other white patches in the mouth) for more information 

Mouth ulcers

General notes 
  • There are many causes of oral ulcers, as highlighted in the 'overview of oral lesions' at the top of this section
  • Any solitary ulcer lasting more than three weeks needs to be referred urgently (two-week wait) as it could represent a squamous cell carcinoma
  • Drug reactions - oral ulcerations usually appear after a few weeks of the drug being commenced. In most cases the lesions resist conventional treatments, with a rapid healing following the suppression of the responsible drug. Oral ulcerations following symptoms of burning mouth, metallic taste, or loss of taste are strongly suggestive of a pharmacological origin. Most of the drugs able to induce oral ulceration are commonly prescribed in a) rheumatology: NSAID (diclofenac, indomethacin, naproxen), long-term rheumatoid arthritis therapy (azathioprine, methotrexate, penicillamine, and gold compounds); b) cardiology: ACEI (captopril, enalapril), angiotensin 2-receptor antagonists (losartan), and nicorandil, c) psychiatry: antidepressants (fluoxetine, lithium), d) HIV therapy (foscarnet, zalcitabine)
  • Recurrent mouth ulcers can be related to gastrointestinal conditions or various deficiencies, as such patients with recurrent ulcers should have the following blood tests - FBC, iron studies, red cell folate and B12, U+E, LFT and tissue transglutaminase antibodies 

Recurrent aphthous stomatitis (aphthous ulcers) 

Characterised by recurring episodes of ulcers, typically from childhood or adolescence, each lasting from 1-4 weeks before healing. Patients are otherwise apparently healthy. Ulcers typically are multiple, round or ovoid, with a circumscribed margin, a yellow or grey floor, and unlike other mouth ulcers they have surrounding erythema. Several types are described:

  • Minor aphthous ulcers - often cause minimal symptoms. Ulcers are usually 2–4 mm in diameter and found mainly on the mucosa of the lips, cheeks and floor of the mouth, sulci or ventrum of the tongue. They are uncommon on the gingiva, palate or dorsum of the tongue. Only a few ulcers (one to six) appear at a time; they heal in 7–10 days and recur at variable intervals. Ulcers heal with little or no evidence of scarring
  • Major aphthous ulcers - compared to the above, ulcers are larger, more painful, are slower to heal and recur more frequently. Lesions may occur on any area of the oral mucosa. Usually only a few ulcers (one to six) occur at one time; they heal slowly over 10–40 days, and may heal with scarring. Occasionally, inflammatory markers may be raised 
  • Herpetiform ulceration - tends to be found in slightly older patients, with a female predominance. The condition presents with many small, very painful ulcers at any oral site. The lesions increase in size and coalesce to leave large ragged ulcers that heal in 10 days or longer, but recur frequently. Despite of their name, there is no evidence of the Herpes simplex virus 

Behçet syndrome

Behçet syndrome is a rare condition characterised by the association of recurrent aphthous stomatitis with genital ulceration and eye disease, ulcers are painful and tend to scar. There may be a number of other systemic, especially neurological, or cutaneous manifestations. Behçet syndrome usually starts in the third and fourth decade, the cause is unknown. The international criteria for classification of Behçet syndrome defines the condition as at least 3 episodes of recurrent oral ulcers in a 12-month period plus at least two or more of the following:

  • ​Genital ulcers
  • Eye involvement - uveitis or retinal damage
  • Skin lesions - erythema nodosum, papulopustular lesions and acneform nodules
  • Pathergy - the pathergy cutaneous test is a pricking of the skin made by the doctor with a sterile needle. The results are read after 24-48 hours. In patients with Behçet syndrome the test is often positive with formation of a pustule at the test site 

Unlike recurrent aphthous stomatitis, Behçet syndrome is not self‐limiting. It causes morbidity (especially in terms of ocular and neurological disease) and occasional mortality. Most patients present with oral and ocular disease but there follows a relapsing and remitting but variable course. CNS involvement, thromboses of major vessels and gastrointestinal perforation result in a poor prognosis. Patients with suspected Behçet syndrome require prompt referral to a specialist.


Dermatological (and other) conditions associated with mouth ulcers (and occasionally blisters)

  • Lichen planus - in addition to ulcers, there is loss of tongue papillae except at front of tongue. In the mouth lichen planus can also be papular or plaque-like. There is a risk of squamous cell carcinoma development, especially if there are many white, thick, 'stuck-on' gingival lesions
  • Erythema multiforme ​- can cause intermittent mucosal eruptions, often with sparing of the gingiva. Lots of small lesions arise, which then coalesce
  • Mucous membrane pemphigoid - gum involvement is common, and as with lichen planus the gums are bright red. Compared to other conditions affecting the mouth, vesicles or small bullae may remain intact for some time. When erosions form they are slow to heal. Lesions can be persistent and extensive in the buccal mucosa, especially the hard palate
  • Pemphigus vulgaris - mucosal lesions may precede cutaneous lesions by months, or may be the only manifestation of the condition. Bullae are rarely seen, instead, ill-defined, painful erosions mainly involving the lips, buccal mucosa and palate, which are slow to heal. Lesions on the border of the soft and hard palate are almost pathognomonic. There is significant whitening of the mucosa. Erosions can be seen on the gingival tips. The mucosa returns to normal when the condition is in remission
  • Linear IgA disease - ​mucosal involvement, which can precede cutaneous signs, is common with bullae and ulceration on the lips and inside the mouth in approximately 50% of cases. Lesions may spread to the pharynx
  • Reactive arthritis (syn. Reiters syndrome) - the classical clinical presentation comprises the triad of an asymmetrical large joint oligoarthritis with or without dactylitis, urethritis and ocular inflammation manifesting 1–6 weeks after the acute infection. Mouth erosions, geographic tongue and circinate balanitis are common features
  • Inflammatory bowel disease

Images

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Management

General measures

  • Good oral hygiene should be maintained with the use of an antiseptic mouthwash eg chlorhexidine
     
  • Topical analgesia is available as 5% lidocaine ointment, or a mouthwash and spray eg Difflam ®
     
  • A number of topical anti-inflammatories can be used as a gargle for 2-4 minutes, 3-4 times a day
    • Betamethasone 500 microgram soluble tablet dissolved in 10 ml of water 
    • Flixonase Nasule ® drop 400 micrograms dissolved in 10 ml of water 
    • Doxycycline 100 mg dispersible tablets have both anti-inflammatory and antibacterial properties 
  • If local treatments are not adequate add in a trial of colchicine 500 mcg tablets OD, then increase to BD, occasionally TDS is used if the patient it able to tolerate it, however, it can take 4-6 months for colchicine to take effect 

Condition specific treatments 

  • Geographic tongue - 125 mg of Solvazinc dissolved in 10 mls of water and gargled for 2 minutes, 2-3 times a day
  • Dependant on the cause other treatments that may be used in Secondary Care include azathioprine, prednisolone, and thalidomide

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