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Oral Medicine for the General Practitioner: Red, White and Coloured Lesions

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Oral Medicine for the General Practitioner: Red, White and Coloured Lesions Clinical Oral medicine for the general practitioner: red, white and coloured lesions Crispian Scully 1 This series of five papers summarises some of the most Table 1: Causes of red lesions important oral medicine problems likely to be Localised encountered by practitioners. Inflammatory Some are common, others rare. The practitioner cannot Candidosis be expected to diagnose all, but has been trained to Other mycoses recognise oral health and disease, and should be Lichen planus competent to recognise normal variants, and common Reiter’s disease orofacial disorders. In any case of doubt, the practitioner Graft versus host disease is advised to seek a second opinion from a colleague. The Drugs Epithelioid angiomatosis (Bartonella infection) series is not intended to be comprehensive in coverage Reactive lesions either of the conditions encountered, or all aspects of Pyogenic granulomas diagnosis or treatment: further details are available in Peripheral giant cell granulomas standard texts, in the further reading section, or from the Atrophic internet. The present article discusses aspects of red, Geographic tongue white and coloured lesions. Lichen planus Lupus erythematosus Red lesions Erythroplasia Red oral lesions are commonplace and usually associated Burns Avitaminosis B12 with inflammation in, for example, mucosal infections. Purpura However, red lesions can also be sinister by signifying Vascular severe dysplasia in erythroplasia, or malignant neoplasms Telangiectases (Hereditary haemorrhagic (Table 1). telangiectasia or scleroderma) Angiokeratomas (Fabry’s disease) Inflammatory lesions Angiomas Most red lesions are inflammatory, usually Neoplasms • Viral infections; (e.g. herpes simplex stomatitis) Giant cell tumour Squamous carcinoma • Fungal infections Kaposi’s sarcoma Wegener’s granulomatosis 1 Professor Crispian Scully CBE, MD, PhD, MDS, MRCS, BDS, BSc, Generalised MB.BS, FDSRCS, FDSRCSE, FDSRCPS, FFDRCSI, FRCPath, FMedSci, Candidosis FHEA, FUCL, DSc, DChD, DMed (HC), Dr HC. Emeritus Professor, Avitaminosis B complex (rarely) University College London (UCL); Professor of Oral Medicine, Irradiation or chemotherapy-induced mucositis University of Bristol; Visiting Professor at Universities of Athens, Polycythaemia Edinburgh, Granada, Helsinki and Peninsula 34 INTERNATIONAL DENTISTRY SA VOL. 13, NO. 2 Clinical 2 1 3 Figure 1: Median rhomboid glossitis. Figure 2: Pemphigus. Figure 3: Desquamative gingivitis. Candidosis angiomatosis, mimicking Kaposi’s sarcoma • Denture-related stomatitis; usually a form of mild • Cancer treatment-related mucositis; common after chronic atrophic candidosis consisting of inflammation irradiation of tumours of the head and neck, or beneath a denture or other appliance chemotherapy e.g. for leukaemia • Median rhomboid glossitis; a persistent red, rhomboidal • Immunological reactions; such as lichen planus, plasma depapillated area in the midline dorsum of tongue cell gingivostomatitis, granulomatous disorders (Figure 1) (sarcoidosis, Crohn’s disease, orofacial granulomatosis), • Acute oral candidosis; may cause widespread erythema amyloidosis, and graft versus host disease. and soreness sometimes with thrush, often a complication of corticosteroid or antibiotic therapy. Red Neoplastic lesions lesions of candidosis may also be seen in HIV disease, Red neoplasms include: typically in the palate • Peripheral giant cell tumours • Angiosarcomas such as Kaposi’s sarcoma - a common Deep mycoses - rare in the developed world, except in neoplasm in HIV/AIDS, appears in the mouth as red or HIV disease and other immunocompromised persons purplish areas or nodules especially seen in the palate • Histoplasmosis • Squamous cell carcinomas • Cryptococcosis • Wegener’s granulomatosis • Blastomycosis • Midline granulomas. • Paracoccidioidomycosis • Bacterial infections: these are rare causes of red lesions Vesiculobullous disorders but Bartonella infection may cause epithelioid These include erythema multiforme, pemphigoid and pemphigus (Figure 2). INTERNATIONAL DENTISTRY SA VOL. 13, NO. 2 35 Scully able 3: Types of leukoplakia with high Table 2: Causes of oral white lesions T malignant potential Local causes • In certain at-risk sites (floor of mouth/ventrum of tongue: • Materia alba (debris from poor lower lip; commissures) oral hygiene) • Associated with Candida species • Keratoses • Frictional keratosis (and cheek/lip biting) • Verrucous or nodular lesions • Smoker’s keratosis • Lesions mixed with red lesions (speckled, or • Snuff-dipper’s keratosis erythroleukoplakia) • Burns • Grafts • Scars • Furred or hairy tongue Neoplastic and possibly • Erythroplasia is one of the more important causes of a pre-neoplastic localised red lesion, since it is often dysplastic (see below). • Leukoplakia • Erythema migrans (geographic tongue) manifests with • Keratoses irregular depapillated red areas, which change in size • Carcinoma and shape, usually on the dorsum of the tongue Inflammatory • Desquamative gingivitis is a frequent cause of red Infective gingivae, almost invariably caused by lichen planus or • Candidosis pemphigoid (Figure 3). • Hairy leukoplakia • Iron or vitamin deficiency states may cause glossitis or • Syphilitic mucous patches and keratosis other red lesions. • Koplik’s spots (measles) • Some papillomas Purpura • Reiter’s disease Bleeding into the skin and mucosa is usually caused by: • Koilocytic dysplasia • Trauma, occasional small petechiae are seen at the (papillomavirus) occlusal line in perfectly healthy people Non-infective • Suction (e.g. fellatio may produce bruising in the soft • Lichen planus palate) • Lupus erythematosus • Platelet disorders such as thrombocytopenia can result in red or brown pinpoint lesions (petechiae) or diffuse Congenital • Leukoedema bruising (ecchymoses) at sites of trauma, such as the • Fordyce spots palate. • Inherited dyskeratoses • Localised oral purpura or angina bullosa haemorrhagica • White sponge naevus is an idiopathic, fairly common cause of blood blisters, • Focal palmoplantar and oral mucosa often in the soft palate, in older persons. hyperkeratosis syndrome • Darier’s disease Vascular anomalies • Pachyonychia congenita • Dyskeratosis congenita Also known as angiomas and telangiectasia, these include: • Dilated lingual veins (varices) may be conspicuous in normal elderly persons Reactive lesions • Haemangiomas are usually small isolated developmental These include: anomalies, or hamartomas. Rarely, they may be part of • Pyogenic granulomas the Sturge-Weber syndrome (haemangioma with • Peripheral giant cell granulomas epilepsy and hemiplegia) or other rare conditions • Telangiectasias - dilated capillaries - may be seen after Burns irradiation and in disorders such as hereditary Atrophic lesions: haemorrhagic telangiectasia and systemic sclerosis. 36 INTERNATIONAL DENTISTRY SA VOL. 13, NO. 2 Scully Inherited disorders of keratin Inherited dyskeratoses are rare but include: • White sponge naevus • Focal palmoplantar and oral mucosa hyperkeratosis syndrome • Darier’s disease • Pachyonychia congenita • Dyskeratosis congenita. There may be a family history or other features associated, Figure 4: Keratosis. such as lesions on other mucosae, or skin appendages such as the nails. Specialist care is indicated. Local causes of white lesions Diagnosis Debris, burns (from heat, chemicals such as Diagnosis of red lesions is mainly clinical but lesions mouthwashes), grafts and scars may appear pale or white. should also be sought elsewhere, especially on the skin or Materia alba can usually easily be wiped off with a gauze. other mucosae. It may be necessary to take a blood picture (including blood and platelet count), and assess Keratoses and leukoplakias haemostatic function or exclude vitamin deficiencies. Leukoplakia is nowadays defined as ‘a whitish patch or Investigations needed may include other haematological plaque that cannot be characterised clinically or tests and/or biopsy or imaging. pathologically as any other disease and which is not Management associated with any physical or chemical causative agent Treatment is usually of the underlying cause, or excision. except the use of tobacco’. Thus frictional keratosis and specific tobacco-induced White lesions lesions such as smoker’s keratosis are now termed Some common whitish conditions, notably Fordyce keratoses (not leukoplakias). Keratotic lesions, being granules are really yellowish, but may cause diagnostic inherent in the mucosa, will not wipe away with a gauze confusion. swab (Figure 4). Truly white oral lesions appear white usually because they Leukoplakia is in fact not a single entity, rather it is a are keratotic (composed of thickened keratin, which looks heterogeneous group of lesions of different aetiologies white when wet) or may consist of collections of debris and of different potential for malignant change. Most (necrotic epithelium or materia alba), or fungi - such as leukoplakias - up to 70% in large series - are benign candidosis. without evidence of dysplasia, but clearly biopsy is White lesions have a range of causes (Table 2) but are indicated to define the remaining 10 to 30% that are usually painless. The morphological features may give a either dysplastic or already invasive carcinomas. Overall guide to the diagnosis. For example, focal lesions; are the rate of malignant transformation is of some 3 to 6% often caused by keratoses; multifocal lesions; are common over 10 years but rates up to 30% have been reported, in thrush (pseudomembranous candidosis) and lichen especially
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