FOCUS | CLINICAL Common benign and malignant oral mucosal disease Timothy Wong, Tami Yap, ORAL AND MAXILLOFACIAL pathology this structure, the authors have chosen David Wiesenfeld encompasses a multitude of diverse to highlight the common benign and conditions and presentations that can malignant mucosal disease and jaw be daunting when one is confronted by pathology by grouping them according Background Mucosal diseases of the oral cavity the exhaustive list and classification of to their clinical presentation. It is hoped are relatively common, and patients diagnostic possibilities. The structured and that this will provide the reader with a often seek initial assessment from comprehensive list of benign and malignant narrow list of differential diagnoses and their general practitioner. mucosal disease and jaw pathology has assist with stratifying urgency of referral to more than one hundred different diagnostic either an oral and maxillofacial surgeon or Objective The aim of this article is to provide possibilities. Listing all these possibilities oral medicine specialist. Broadly speaking, an overview of common oral mucosal is potentially more of a hindrance than a oral pathology can present as a mucosal diseases to help with formulating a benefit for the general practitioner (GP) surface lesion (white, red, brown, blistered differential diagnosis and stratifying when a patient opens their mouth to or verruciform), swelling present at an oral the urgency of referral. demonstrate their clinical problem. subsite (lips/buccal mucosa, tongue, floor Discussion The oral cavity is home to multiple of mouth, palate and jaws; discussed in an Pathological mucosal conditions of the types of tissue. Pathological conditions accompanying article by these authors)1 or oral cavity and jaws commonly present can originate from any of these, including symptoms related to teeth (pain, mobility). as a mucosal ulcer or a white, red or mucosa, minor and major salivary glands, The last of these presentations has been pigmented lesion. In this review, the muscle, nerves, vessels, bone, teeth and excluded from this article as it is assumed authors outline the most common periodontal structures. The ‘surgical that a patient with symptoms related to conditions organised according to their clinical presentation and describe their sieve’ is as helpful for the clinician for teeth is more likely to present to their typical appearance and management. formulating a list of differential diagnoses dentist than their GP. in the oral cavity as it is elsewhere in the The most commonly encountered body. The diagnosis may be congenital or mucosal surface lesions are those of an acquired. Acquired oral cavity conditions epithelial break (ulcer) or an alteration in may be traumatic, infective/inflammatory, thickness, texture or colour (white, red or neoplastic, cystic, autoimmune/allergic, pigmented lesion). vascular, endocrine, degenerative, idiopathic or nutritional. The starting letter of each of these acquired causes The ulcerated lesion forms the mnemonic ‘TIN CAVED IN’. An ulcerated lesion is most commonly Rather than presenting oral traumatic or immunological (aphthous) pathological conditions according to in origin; however, the most important 568 | REPRINTED FROM AJGP VOL. 49, NO. 9, SEPTEMBER 2020 © The Royal Australian College of General Practitioners 2020 COMMON BENIGN AND MALIGNANT ORAL MUCOSAL DISEASE FOCUS | CLINICAL lesion to exclude is an oral malignancy. [RAS]) affects 20–50% of the population3 Oral squamous cell carcinoma Other, less common, possible causes of an and presents as painful, recurrent ulcers There were approximately 3800 newly ulcer are infective (bacterial or fungal) and that almost always affect non-keratinised diagnosed cases of head and neck immune-related causes (eg inflammatory oral mucosa (buccal mucosa, floor of cancers in Australia in 2019, with oral bowel disease). The ‘ulcer’ could also mouth, vestibule of the lips, soft palate cancer comprising just over half of these represent the residual appearance of the and tongue). The aetiology of RAS is cases.6 More than 90% of oral cancers mucosa in an autoimmune vesiculobullous unknown but is thought most likely to be are oral squamous cell carcinoma (SCC); or blistering condition after the blister immunologically mediated.4 There are other tumours are minor salivary gland has ruptured. Persistence, as opposed three recognised clinical subtypes based carcinomas, sarcomas and odontogenic to episodic recurrence, of an ulcer is an on their clinical presentation: minor malignancies.7 Oral cavity (as distinct importance feature. Mucosal turnover (most common), major and herpetiform. from the oropharynx) subsites are defined should occur in <10 days;2 therefore, any Minor aphthous ulcers are oval shaped as the lips, tongue, floor of mouth, buccal persistent ulcer that has been present for and <10 mm in size, frequently last mucosa, retromolar trigone, maxillary ≥2 weeks should be referred to an oral and 5–10 days and heal without scarring and mandibular alveolus and hard palate. maxillofacial surgeon or oral medicine (Figure 2). The major risk factors for oral cavity SCC specialist for biopsy. Major aphthous ulcers are variably are smoking,8 alcohol consumption of shaped and >10 mm in size, can last up to six >3 standard drinks per day9 and betel quid Traumatic ulcer weeks and can heal with scarring. They can (paan) consumption. The most common oral ulcer is one resemble an ulcer of an early malignancy. Oral SCC most commonly presents as a caused by trauma. This trauma is most Herpetiform aphthous ulcers are non-healing ulcer, which can be indurated/ often mechanical (eg biting) but may also numerous 1–2 mm diameter ulcerations firm and have irregular margins and raised, be from thermal, radiation or chemical that may coalesce and are not restricted to rolled edges (Figures 3–6). As SCC invades means. The characteristic symptoms of non-keratinised oral mucosa. They heal in adjacent structures in the oral cavity, it may inflammation, pain, redness and swelling 1–2 weeks. result in neurosensory change (paraesthesia are often present, and the central part Aphthous-like ulceration can be or anaesthesia) and tooth mobility. In late of the ulcer may be covered by a yellow- associated with haematinic deficiency stages, it may cause alteration of speech and white fibrinous exudate (Figure 1). or gastrointestinal or rheumatological swallowing. It is important to note that oral The cause must be addressed if possible, disease. Vitamin B12, folic acid or iron SCC may not necessarily be painful, and and review to ensure mucosal healing deficiency can also be associated with RAS pain is not used to differentiate between within two weeks is recommended. If the in a small proportion of patients, and these a potentially malignant or benign cause ulcer persists beyond this period, referral nutritional markers should be checked and of an ulcer. In addition, oral SCC is found to an oral and maxillofacial surgeon should corrected in this subgroup. across virtually all age groups (including be undertaken. Topical corticosteroids, such as paediatric, although rarely), and up to 10% hydrocortisone 1% cream or ointment 2–3 of SCCs are diagnosed in patients who do Aphthous ulcer times daily after meals, commenced within not smoke or drink alcohol.10 Therefore, the Recurrent aphthous ulceration (otherwise 24 hours of onset of the aphthous episode absence of risk factors does not rule out the known as recurrent aphthous stomatitis can shorten the duration of the symptoms.5 possibility of malignancy. Figure 1. Symptomatic traumatic ulceration Figure 2. Minor aphthous ulceration of Figure 3. Left lateral tongue squamous of the left mid-ventral tongue associated with the lower right labial mucosa with typical cell carcinoma with irregular margins, a sharp left lower molar. The ulcer has flat erythematous hallow and yellow base heterogeneous appearance and raised, rolled edges and is surrounded by an area of frictional edges. The cancer was palpably firm and keratosis. The ulcer was soft on palpation. indurated, unlike normal tongue tissue. © The Royal Australian College of General Practitioners 2020 REPRINTED FROM AJGP VOL. 49, NO. 9, SEPTEMBER 2020 | 569 FOCUS | CLINICAL COMMON BENIGN AND MALIGNANT ORAL MUCOSAL DISEASE If an ulcer is suspected to have any of white and/or red lesions. Causes of contact with the ridge) are common sites. suspicious malignant features, then these presentations include variations The lesion is often slightly textured and immediate referral to an oral and of normal, frictional causes, infectious white, and takes on the shape or outline of maxillofacial surgeon or specialist causes, immune-mediated causes and the traumatic cause (Figure 9). unit in a tertiary hospital is indicated. pre-malignant and malignant changes. A tissue diagnosis is established, followed The presence or absence of symptoms Oral candidiasis by completion of staging (computed does not necessarily correlate with the Oral candidiasis is an opportunistic fungal tomography [CT], magnetic resonance malignant potential of a lesion. In this infection usually caused by Candida imaging [MRI], ultrasonography +/– article, the authors outline a short list of albicans that arises in a patient with one positron emission tomography [PET]). more commonly occurring conditions or more local or systemic predisposing Patients should be managed by a that can present as non-ulcerative factors. Local factors include poor multidisciplinary