Oral Medicine — Update for the Dental Practitioner Red and Pigmented Lesions

10p639-645.qxd 03/11/2005 11:20 Page 639 IN BRIEF • Most red or hyperpigmented lesions in the mouth are inconsequential. • However, cancer and some systemic diseases may present in this way. • Most red lesions are inflammatory or atrophic but erthythroplasia is potentially malignant. • Most hyperpigmented lesions are racial or due to embedded material (eg amalgam tattoo) but malignant and systemic disease can present in this way. 6 • Biopsy may be indicated. Oral Medicine — Update for the dental practitioner Red and pigmented lesions C. Scully1 and D. H. Felix2 This series provides an overview of current thinking in the more relevant areas of oral medicine for primary care practitioners, written by the authors while they were holding the Presidencies of the European Association for Oral Medicine and the British Society for Oral Medicine, respectively. A book containing additional material will be published. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders, or discussion of disorders affecting the hard tissues. Approaching the subject mainly by the symptomatic approach — as it largely relates to the presenting complaint — was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made. Guidance on management and when to refer is also provided, along with relevant websites which offer further detail. ORAL MEDICINE RED AND PIGMENTED LESIONS 1. Aphthous and other This article covers red lesions followed by hyper- common ulcers pigmentation. 2. Mouth ulcers of more serious connotation RED ORAL LESIONS 3. Dry mouth and disorders Red oral lesions are commonplace and usually of salivation associated with inflammation in, for example, 4. Oral malodour mucosal infections. However, red lesions can also be sinister by signifying severe dysplasia in ery- 5. Oral white patches throplasia, or malignant neoplasms (Table 1). 6. Oral red and hyperpigmented patches Geographic tongue (erythema migrans) 7. Orofacial sensation and Geographic tongue (Fig. 1) is a very common con- Fig. 1 Geographic movement dition and cause of sore tongue, affecting at least tongue 8. Orofacial swellings and 1-2% of patients. There is a genetic background, lumps and often a family history. Many patients with a 9. Oral cancer fissured tongue (scrotal tongue) also have geo- 10. Orofacial pain graphic tongue. Erythema migrans is associated with psoriasis in 4% and the histological appear- ances of both conditions are similar. Some patients 1*Professor, Consultant, Dean, Eastman have atopic allergies such as hay fever and a few Dental Institute for Oral Health Care relate the symptoms to various foods. A few have Sciences, 256 Gray’s Inn Road, UCL, University of London, London WC1X 8LD; diabetes mellitus. 2Consultant, Senior Lecturer, Glasgow Dental Hospital and School, 378 Clinical features Sauchiehall Street, Glasgow G2 3JZ / Associate Dean for Postgraduate Dental Geographic tongue typically involves the Education, NHS Education for Scotland, dorsum of the tongue, sometimes the ventrum. It Figs 2 and 3 Geographic tongue 2nd Floor, Hanover Buildings, 66 Rose is often asymptomatic but a small minority of Street, Edinburgh EH2 2NN *Correspondence to: Professor Crispian patients complain of soreness; these patients are size, and spread or move to other areas sometimes Scully CBE virtually invariably middle-aged. If sore, this may within hours (Figs 2 and 3). Email: [email protected] be noted especially with acidic foods (for example The red areas are often surrounded by dis- tomatoes or citrus fruits) or cheese. tinct yellowish slightly raised margins. There is Refereed Paper © British Dental Journal 2005; 199: There are irregular, pink or red depapillated increased thickness of the intervening filiform 639–645 maplike areas, which change in shape, increase in papillae. BRITISH DENTAL JOURNAL VOLUME 199 NO. 10 NOV 26 2005 639 10p639-645.qxd 03/11/2005 11:37 Page 640 PRACTICE Keypoints for patients: Table 1 Most common causes of red lesions Denture sore mouth (denture-related stomatitis) Localised • Denture sore mouth is common, Inflammatory lesions but rarely sore Geographic tongue • It is caused mainly by a yeast Candidosis (Candida) that usually lives Lichen planus harmlessly in the mouth and elsewhere Drugs • It is not transmitted to others Reactive lesions • It may be precipitated by Pyogenic granulomas prolonged wearing of a dental Peripheral giant cell granulomas Fig. 4 Candida-associated denture stomatitis appliance, especially at night, Atrophic lesions which allows the yeast to grow Geographic tongue • It predisposes to sores at the corners of the mouth (angular Lichen planus cheilitis) Lupus erythematosus • It has no serious long-term Erythroplasia consequences Avitaminosis B12 • Blood tests, microbiological studies Purpura or biopsy may be required Trauma • It is best controlled by: Thrombocytopenia leaving out the appliance, allowing the mouth to heal Vascular cleaning the appliance (as below) Telangiectases (Hereditary haemorrhagic telangiectasia or scleroderma or post-irradiation ngiomas) Fig. 5 disinfecting the appliance (as per Median rhomboid glossitis additional instructions) Neoplasms using antifungal creams or gels Squamous carcinoma regularly for up to four weeks Kaposi’s sarcoma • The appliance may require Giant cell tumour adjustment or changing Wegener’s granulomatosis • Keep the appliance as clean as Generalised natural teeth. Clean both surfaces (inside and outside) after meals Inflammatory lesions and at night. Use washing-up Most red lesions are inflammatory, usually geographic liquid and a toothbrush and tongue (erythema migrans) (Figs 1 to 3) lukewarm water and hold it over a Viral infections (eg herpes simplex stomatitis) basin containing water, in case you drop it, which could cause it to Fungal infections break. Never use hot water, as it Candidosis Fig. 6 Erythematous candidosis may alter the colour. A disclosing denture-related stomatitis, discussed below, is agent, for example Rayners Blue or usually a form of mild chronic erythematous Red food colouring (available at candidosis consisting of inflammation beneath essary to exclude diabetes, or anaemia if there most supermarkets) can be applied a denture,orthodontic or other appliance (Fig. 4) is confusion with a depapillated tongue of with cotton buds, to help see median rhomboid glossitis; a persistent red, whether you are cleaning the glossitis. rhomboidal depapillated area in the midline appliance thoroughly enough. If dorsum of tongue (Fig. 5) stains or calculus deposits are Management difficult to remove, try an acute oral candidosis; may cause widespread Reassurance remains the best that can be given. erythema and soreness sometimes with thrush, overnight immersion (eg Dentural, Zinc sulphate 200mg three times daily for three Milton or Steradent), or an often a complication of corticosteroid or application of Denclen antibiotic therapy. Red lesions of candidosis months or a topical rinse with 7% salicylic acid in may also be seen in HIV disease, typically in the • Dentures should be left out 70% alcohol are advocated by some and may palate (Fig. 6) overnight, so that your mouth has a occasionally help. rest. It is not natural for your palate Bacterial infections: to be covered all the time and the Cancer treatment-related mucositis; common Patient information and websites chances of getting an infection are after irradiation of tumours of the head and http://www.usc.edu/hsc/dental/opath/Cards/Ge increased if the dentures are worn neck, or chemotherapy eg for leukaemia 24 hours a day. Ensure you leave the ographicTongue.html Immunological reactions such as lichen planus, dentures out for at least some time http://www.worlddent.com/2001/05/series/ncut- plasma cell gingivostomatitis, granulomatous and keep them in Dentural or disorders (sarcoidosis, Crohn’s disease, orofacial tic1_2.xml Steradent, as they may distort if granulomatosis), amyloidosis, and graft versus allowed to dry out host disease DENTURE-RELATED STOMATITIS (DENTURE- • Special precautions for dentures A vitaminosis B or iron deficiency or folate INDUCED STOMATITIS; DENTURE SORE with metal parts: Denclen, deficiency Dentural and Milton may discolour MOUTH; CHRONIC ERYTHEMATOUS metal, so use with care. Brush CANDIDOSIS) briefly to remove stains and Denture-related stomatitis consists of mild deposits, rinse well with lukewarm Diagnosis inflammation of the mucosa beneath a water and do not soak overnight The diagnosis of geographic tongue is clinical denture — usually a complete upper denture. • Before re-use, wash in water and mainly from the history of a migrating pat- This is a common condition, mainly of the brush the appliance to remove tern and the characteristic clinical appear- middle-aged or elderly, more prevalent in loosened deposits ance. Blood examination may rarely be nec- women than men. 640 BRITISH DENTAL JOURNAL VOLUME 199 NO. 10 NOV 26 2005 10p639-645.qxd 03/11/2005 11:38 Page 641 PRACTICE Aetiopathogenesis Table 2 Management of denture-related stomatitis Keypoints for dentists: Dental appliances (mainly dentures) especially Denture-related stomatitis • Denture hygiene measures when worn throughout

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