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IN BRIEF • Most red or hyperpigmented 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 (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. (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.

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Keypoints for patients: Table 1 Most common causes of red lesions Denture sore mouth (denture-related ) 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 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 ) • 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 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 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 (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.

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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 the night, or a dry • Denture related stomatitis is mouth, favour development of this infection. It • Antifungal therapy (eg topical or systemic) caused mainly by a yeast (Candida) is not caused by allergy to the dental material (if • If unresponsive to above, investigate for underlying but bacteria may also be involved it were, it would affect mucosae other than just predisposing factors • It may be precipitated by that beneath the appliance). prolonged wearing of a dental However, it is still not clear why only some dentures should be left out of the mouth at night, appliance, especially at night denture wearers develop denture-related stomati- and stored in an appropriate antiseptic which • It predisposes to tis, since most patients appear otherwise healthy. has activity against yeasts (Table 2). • It is best controlled by: Dentures can produce a number of ecological Cleansers containing alkaline hypochlorites, leaving out the appliance, changes; the oral flora may be altered and disinfectants, or yeast lytic enzymes are most allowing the mouth to heal plaque collects between the mucosal surface of effective against candida. Denture soak solution disinfecting the appliance the denture and the palate. containing benzoic acid is taken up into the using antifungal creams or gels (eg miconazole), The accumulation of microbial plaque (bacte- acrylic resin and can completely eradicate pastilles/lozenges (eg nystatin, ria and/or yeasts) on and attached to the fitting C.albicans from the denture surface. Chlorhexi- amphotericin) or capsules surface of the denture and the underlying mucosa dine gluconate can also eliminate C.albicans on (fluconazole) regularly for up to produces an inflammatory reaction. When candi- the denture surface and a mouthwash can reduce four weeks da is involved, the more common terms ‘candida- the palatal inflammation. • The appliance may require associated denture stomatitis’, ‘denture-induced The mucosal infection is eradicated by adjustment or changing candidosis’ or ‘chronic erythematous candidosis’ brushing the palate with chlorhexidine mouth- • Blood tests, microbiological studies or biopsy may be required if the are used. wash or gel, and using miconazole gel, nys- is unresponsive In addition, the saliva that is present between tatin pastilles, amphotericin lozenges or flu- the maxillary denture and the mucosa may have a conazole, administered concurrently with an lower pH than usual. Denture-related stomatitis is oral antiseptic such as chlorhexidine which sometimes associated also with various bacteria has antifungal activity. but is not exclusively associated with infection, and occasionally mechanical irritation is at play. Patient information and website http://www.emedicine.com/derm/topic642.htm Clinical features The characteristic presenting features of den- Neoplastic lesions; red neoplasms include: ture-related stomatitis are chronic erythema and • Peripheral giant cell tumours oedema of the mucosa that contacts the fitting • Angiosarcomas such as Kaposi’s sarcoma—a surface of the denture (Fig. 2). Uncommon com- common neoplasm in HIV/AIDS, appears in plications include: the mouth as red or purplish areas or nodules • Angular stomatitis especially seen in the palate • Papillary hyperplasia in the vault of the palate. • Squamous cell carcinomas • Wegener’s granulomatosis. Classification Denture-related stomatitis has been classified into Vascular anomalies (angiomas and three clinical types (Newton’s types), increasing in telangiectasia) include: severity: • Dilated lingual veins (varices) may be • A localised simple inflammation or a pinpoint conspicuous in normal elderly persons hyperaemia (Type I) • Haemangiomas are usually small isolated Keypoints for patients: • An erythematous or generalised simple type pre- developmental anomalies, or hamartomas Geographic tongue senting as more diffuse erythema involving part (Figs 7-9) • This is a common condition of or the entire, denture-covered mucosa (Type II) • Telangiectasias — dilated capillaries — may • The cause is unknown • A granular type (inflammatory papillary be seen after irradiation and in disorders • It may be inherited from parents hyperplasia) commonly involving the central such as hereditary haemorrhagic telangiec- • There may be an allergic part of the hard palate and the alveolar ridge tasia and systemic sclerosis (Fig. 10) component (Type III). • Angiomas are benign and usually congenital • It is not thought to be infectious (Figs 7-10). In general most do not require any • It is associated, rarely, with Diagnosis active treatment unless symptoms develop, in psoriasis Denture-related stomatitis is a clinical diagnosis which case they can be treated by injection of • It has no long-term consequences although it may be confirmed by microbiological sclerosing agents, cryosurgery, laser excision investigations. In addition haematological and or surgical excision. Keypoints for dentists: biochemical investigations may be appropriate to Geographic tongue identify any underlying predisposing factors such Vesiculobullous disorders • The cause is unknown but it may be as nutritional deficiencies, anaemia and diabetes , pemphigoid and pem- inherited mellitus in patients unresponsive to conventional phigus may present as red lesions (see article • It resembles, and is associated management. two), especially localised oral purpura, which rarely with, psoriasis presents with blood blisters (Fig. 11). Specialist • It has no long-term consequences Management referral is usually indicated. • There is no cure and treatment and The denture plaque and fitting surface is infested is therefore aimed at controlling with micro-organisms, most commonly Candida Reactive lesions symptoms and reassuring the albicans and therefore, to prevent recurrence, Reactive lesions that can be red are usually per- patient

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Keypoints for dentists: Single hyperpigmented lesions • If the lesion could be an amalgam tattoo, take a radiograph • If the lesion is radio-opaque, it is probably a tattoo and should be left alone • If the lesion is not radio-opaque, or if it was not initially considered likely to be an amalgam tattoo, biopsy it

Fig. 7 Vascular hamartoma (haemangioma) tongue Fig. 12 , lower

Fig. 8 Vascular hamartoma (haemangioma, palate) Fig. 13 Pyogenic

sistent soft lumps (Figs 12 and 13) which include: • Pyogenic granulomas • Peripheral giant cell granulomas

Specialist referral is usually indicated.

Atrophic lesions The most important red lesion is erythroplasia, since it is often dysplastic (see below). Geographic tongue also causes red lesions (see above), desquamative is a frequent cause of red Fig. 9 Haemangioma in floor of mouth gingivae, almost invariably caused by lichen planus or pemphigoid, and iron or vitamin defi- ciency states may cause glossitis (Fig. 14) or other red lesions.

ERYTHROPLAKIA (ERYTHROPLASIA) Erythroplasia is a rare condition defined as ‘any lesion of the that presents as bright red velvety plaques which cannot be charac- terised clinically or pathologically as any other recognisable condition’. Mainly seen in elderly males, it is far less com- mon than , but far more likely to be dysplastic or undergo malignant transformation. Fig. 10 Telangiectasia, and tongue Clinical features is seen most commonly on the soft palate, floor or mouth or buccal mucosa. Some erythroplakias are associated with white patches, and are then termed speckled leukoplakia (Fig. 15).

Diagnosis Biopsy to assess the degree of epithelial dysplasia and exclude a diagnosis of carcinoma.

Prognosis Erythroplasia has areas of dysplasia, carcinoma Fig. 11 Angina bullosa haemorrhagica in situ, or invasive carcinoma in most cases.

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deficiencies. Other investigations needed may include other haematological tests and/or biop- sy or imaging.

Management Treatment is usually of the underlying cause, or surgery.

HYPERPIGMENTATION Oral mucosal discolouration may be superficial (extrinsic) or due to deep (intrinsic — in or Fig. 14 beneath mucosa) causes and ranges from brown Atrophic glossitis to black. Extrinsic discolouration is rarely of conse- quence and is usually caused by: • Habits such as tobacco or betel use • Coloured foods or drinks, (such as liquorice, beetroot, red wine, coffee, tea) • Drugs (such as chlorhexidine, iron salts, crack cocaine, minocycline, bismuth subsalicylate, and lansoprazole).

Fig. 15 Erythroplasia in soft palate complex

Carcinomas are seen 17 times more often in erythroplakia than in leukoplakia and these are therefore the most potentially malignant of all oral mucosal lesions.

Management Erythroplastic lesions are usually (at least 85%) Fig. 16 severely dysplastic or frankly malignant. Any causal factor such as tobacco use should be Black hairy tongue stopped, and lesions removed. There is no hard This is one extrinsic type of discolouration seen evidence as to the ideal frequency of follow-up, especially in patients on a soft diet, smokers, and but it has been suggested that patients with those with dry mouth or poor oral hygiene (Fig. mucosal potentially malignant lesions be re- 16). examined within one month, at three months, at The best that can usually be done is to avoid six months, at 12 months and annually thereafter. the cause where known, and to advise the patient to brush the tongue or use a tongue-scraper. PURPURA This presents as bleeding into the skin and Intrinsic discolouration mucosa and is usually caused by trauma. Occa- This may have much more significance (Table 3). sional small petechiae are seen at the occlusal Localised areas of pigmentation may be caused line in perfectly healthy people. mainly by: Thrombocytopenia can result in red or • Amalgam tattoo (embedded amalgam). Typi- brown pinpoint lesions (petechiae) or diffuse cally this is a single blue-black macule in the bruising (ecchymoses) at sites of trauma, such as the palate. Suction (eg fellatio) may produce Table 3 Main causes of intrinsic mucosal hyperpigmentation bruising in the soft palate). Localised oral pur- pura or angina bullosa haemorrhagica is an Localised idiopathic, fairly common cause of blood blis- • Amalgam or other tattoo ters, often in the soft palate, in older persons • Naevus (Fig. 11). Sometimes the use of a corticosteroid • Melanotic macule inhaler precipitates this. • Neoplasms (eg malignant or Kaposi’s sarcoma) • Pigmentary incontinence Diagnosis of red lesions • Peutz-Jegher’s syndrome Diagnosis of red lesions is mainly clinical but Generalised lesions should also be sought elsewhere, espe- • Racial pigmentation cially on the skin or other mucosae. • Localised irritation, eg tobacco or betel It may be necessary to take a blood picture • Drugs, eg antimalarials • Pregnancy/oral contraceptive pill (including blood and platelet count), and assess • Addison’s disease (hypoadrenocorticism) haemostatic function or exclude haematinic

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is not radio-opaque, it is best biopsied to exclude naevi or melanoma. Similar lesions can be caused by other foreign bodies (eg graphite tattoo), local irritation or inflamma- tion.

• Naevi are blue-black often papular lesions formed from increased melanin-containing cells (naevus cells) seen particularly on the palate. They are best removed to exclude Fig. 17 Amalgam tattoo melanoma.

• Pigmentary incontinence may be seen in some inflammatory lesions such as lichen planus, especially in smokers (Fig. 20).

• Melanotic macules are usually flat single brown, collections of melanin-containing cells, seen particularly on the vermilion bor- der of the lip and on the palate (Fig. 19). They are best removed to exclude Fig. 18 Amalgam tattoo melanoma.

• Malignant melanoma is rare, seen usually in the palate or maxillary gingivae. Features suggestive of malignancy include a rapid increase in size, change in colour, ulcera- tion, pain, the occurrence of satellite pig- mented spots or regional lymph node enlargement. Incisional biopsy to confirm the diagnosis followed by radical excision is indicated. Fig. 19 Melanotic macule, lower labial mucosa • Kaposi’s sarcoma is usually a purple lesion seen mainly in the palate or gingival of HIV-infected and other immunocompromised persons.

Generalised pigmentation, often mainly affecting the gingivae, is common in persons of colour, and is racial and due to melanin. Seen mainly in black and ethnic minority groups it can also be noted in some fairly light-skinned people (Fig. 21). Such pigmenta- tion may be first noted by the patient in adult Fig. 20 Smoking-induced melanosis, buccal mucosa life and then incorrectly assumed to be acquired. In all other patients with widespread intrinsic pigmentation, systemic causes should be exclud- ed. These may include: • Tobacco, which can also cause intrinsic hyper- pigmentation (smoker’s melanosis) • Antimalarials, oral contraceptive pill, anticon- vulsants, minocycline, phenothiazines, gold, busulphan and other drugs • Heavy metals (such as mercury, lead and bis- muth) not used therapeutically now, rarely Fig. 21 Racial pigmentation cause industrial exposure etc • Pregnancy mandibular gingiva close to the scar of an • Hypoadrenalism (Addison’s disease). Hyper- apicectomy (Figs 17 and 18) or where amal- pigmentation in this is generalised but most gam has accidentally been introduced into a obvious in normally pigmented areas (eg wound, is painless, and does not change in the nipples, genitalia), skin flexures, and size or colour. A lesion suspected to be an sites of trauma. The mouth may show amalgam tattoo is best radiographed first to patchy hyperpigmentation. Patients also see if there is radio-opaque material present, typically have weakness, weight loss, and though not all are radio-opaque. If the lesion hypotension.

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Diagnosis is to be achieved, all pigmented Patients to refer The nature of oral hyperpigmentation can oral cavity lesions should be viewed with sometimes only be established after further suspicion. The consensus of opinion is that Erythroplasia/erythroplakia — in view of high risk of malignant investigation. a lesion with clinical features as above transformation In patients with localised hyperpigmenta- seriously suggestive of malignant melanoma, Squamous carcinoma tion, in order to exclude melanoma, are best biopsied at the time of definitive Isolated brown or black lesions of radiographs may be helpful (they can some- operation. suspect aetiology times show a foreign body) and biopsy may be In patients with generalised or multiple Generalised or multiple indicated, particularly where there is a hyperpigmentation, specialist referral is hyperpigmentation solitary raised lesion, a rapid increase in size, indicated. Kaposi’s sarcoma change in colour, ulceration, pain, evidence of Wegener’s granulomatosis in view satellite pigmented spots or regional lymph Management of associated systemic disease node enlargement. If early detection of oral Management is of the underlying condition.

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