Original Article Brunei Int Med J. 2013; 9 (5): 290-301 Yellow lesions of the oral cavity: diagnostic appraisal and management strategies Faraz MOHAMMED 1, Arishiya THAPASUM 2, Shamaz MOHAMED 3, Halima SHAMAZ 4, Ramesh KUMARASAN 5 1 Department of Oral & Maxillofacial Pathology, Dr Syamala Reddy Dental College Hospital & Research Centre, Bangalore, India 2 Department of Oral Medicine & Radiology, Dr Syamala Reddy Dental College Hospital & Research Centre, Bangalore, India 3 Department of Community & Public Health Dentistry, Faculty of Dentistry, Amrita University, Cochin, India 4 Amrita center of Nanosciences, Amrita University, Cochin, India 5 Oral and Maxillofacial Surgery, Faculty of Dentistry, AIMST University, Kedah, Malaysia ABSTRACT Yellow lesions of the oral cavity constitute a rather common group of lesions that are encountered during routine clinical dental practice. The process of clinical diagnosis and treatment planning is of great concern to the patient as it determines the nature of future follow up care. There is a strong need for a rational and functional classification which will enable better understanding of the basic disease process, as well as in formulating a differential diagnosis. Clinical diagnostic skills and good judgment forms the key to successful management of yellow lesions of the oral cavity. Keywords: Yellow lesions, oral cavity, diagnosis, management INTRODUCTION INTRODUCTI Changes in colour have been traditionally low lesions have a varied prognostic spec- used to register and classify mucosal and soft trum. The yellowish colouration may be tissue pathology of the oral cavity. Thus, the- caused by lipofuscin (the pigment of fat). It se lesions have been categorised as white, may also be the result of other causes such red, white and red, blue and/or purple, as accumulation of pus, aggregation of lym- brown, grey and/or black and yellow. 1-5 Yel- phoid tissue, exudation of serum, degenera- tion of blood pigments, lipid containing struc- tures, neoplasms and extrinsic stains. Most Correspondence: Faraz Mohammed # 471, 14 th Cross, 8 th Main Wilson Garden, are harmless and do not require any treat- Bangalore – 560030 ment other than reassurance. But still a mi- Karnataka, India. E mail: [email protected] nority of these lesions are potentially danger- MOHAMMED et al. Brunei Int Med J. 2013; 9 (5): 291 ous if left untreated. Thus there is a need for a rational and functional classification which Table 1: Classification of lesions in the oral cavity with yellow colour. will enable better understanding of the basic disease process as well as in formulating a Nature of the Pathology disease differential diagnosis on a clinical basis. Such a classification will go a long way in improving Neoplasias Lipoma/liposarcoma the diagnostic acumen of the general dentist, Dermoid and epidermoid cysts Cysts and at the same time providing care for the Lymphoepithelial cyst Hyperplastic general population at large. The classification Verruciform xanthoma reactions for lesions/conditions in the oral mucosa dis- Infectious Pyostomatitis vegetans playing a ‘yellow colour’ is based upon nature Jaundice 5 Pigmental is as shown in Table 1. This article review deposits Carotenemia the various yellow lesions encountered in the Amyloidosis Metabolic oral cavity. disorders Hyalinosis cutis et mucosae Accessory lymphoid Lipoma aggregates Developmental Fordyce spots Lipomas are the most common soft tissue alterations Yellow hairy tongue benign tumours that are composed chiefly of adipose tissue. 6 Approximately 20% occur in the head and neck region and oral lipomas or with histology. However, it can resemble account for only between 1 and 4% of all cas- other conditions such submucous cysts es. 7 In the oral cavity, it is most commonly (lymphoid and lymphoepithelial cysts). Histol- located in the cheeks, floor of the mouth and ogy typically shows the presence of mature the tongue (Figure 1a). The first description adipose tissue. 10-12 of such lesion was provided by Roux in 1848 in a review of alveolar masses which he re- Irrespective of location, the treatment ferred to it as a "yellow epulis". 8 When locat- is simple surgical excision, including a cuff of ed in the superficial plane, there is a yellow surrounding tissue to prevent local recurrenc- surface discolouration. The tumour has a less es. Advantages of suction-assisted lipectomy dense and more uniform appearance than for medium sized (4 to 10 cm) or large lipo- surrounding fibrovascular tissues when it is mas (>10 cm) have been reported. An infil- transilluminated. 9 Magnetic resonance imag- trating lipoma must be ‘de-bulked’ where a ing (MRI) scans are very useful in diagnosis portion of the infiltrating fat is deliberately left whereas computed tomography (CT) and ul- untouched in order to preserve as much nor- trasound scans are less reliable. mal tissue as possible. 13 Malignant transfor- mations or recurrences in the oral and maxil- Lipoma is composed predominantly of lofacial regions are rare. 14 Intramuscular li- mature adipocytes, possibly admixed with pomas have a higher recurrence rate because collagenic streaks, and is often well demar- of their infiltrative growth pattern, but this cated from the surrounding connective tis- variant is rare in oral and maxillofacial region. sues. It can be easily distinguished clinically Cao et al . reported recurrences in young pa- MOHAMMED et al. Brunei Int Med J. 2013; 9 (5): 292 tients (under 18 years old) and development They constitute between 1.6% and 6.9% of all of liposarcoma after several recurrences. cystic in the head and neck region. 30 The epi- Therefore, long-term follow-up is necessary in dermoid cyst, often mistakenly referred to as patients under 18 years old. 15 a sebaceous cyst or wen, is a very common skin lesion which arises from traumatic en- Liposarcoma trapment of surface epithelium. The epider- Liposarcoma, the malignancy of adipocytes, moid cyst of the oral mucosa is usually locat- was first described by Virchow in the 1860s. 16 ed on the attached gingiva, where it has tradi- It is a bulky yellow tumour (Figure 1b)similar tionally been called gingival cyst of adult. 30, 31 to a lipoma, but generally more complex and The oral dermoid cysts tend to be simple with contains areas of prominent sclerosis. 17 It is skin adnexa in the wall. In most cases, these the most common soft tissue sarcoma, com- cysts are treated by enucleation. 32 Akao and prising approximately 17% of all sarcomas, colleagues believed that intraoral approach and 3% of all liposarcomas occurring in the must be attempted first, even when dealing head and neck region. Early diagnosis and with a large cyst. This approach leads to good complete resection plays a key role in the cosmetic and functional results. 33, 34 Marsupi- treatment of liposarcoma. Liposarcoma alisation has also been proposed as an alter- demonstrates considerable microscopic varia- native treatment especially for giant cysts. 32 bility and the biological behaviour of the tu- When intraoral access is complicated, a com- mour is greatly dependent on the exact histo- bined intraoral and extraoral approach should pathologic appearance. In fact, Enzinger and be considered. Surgical excision is normally Weiss have stated that a diagnosis of liposar- achieved without major complications and coma without further qualification as to the prognosis is very good. 33, 34 exact histological type is meaningless. 18 Lymphoepithelial cyst The treatment of choice for liposarco- Oral lymphoepithelial cyst (so-called branchi- mas is surgical excision 19, 20 and the frequent al) is a rare lesion, which manifests as a pink- presence of satellite nodules means that wide ish to yellowish, small, asymptomatic, submu- surgical excision is necessary for adequate cosal mass (Figure 1c). Most cases occur in removal of the tumour. Despite aggressive regions of the oral cavity presenting lymphoid surgery, between 50 and 70% of tumours aggregates, such as the floor of the mouth recur locally. 21, 22 It has also been reported (65.3%) and the lateral and ventral surfaces that non-surgical treatments have limited val- of the tongue (13.7%). 35 However, they may ue, 23-25 but the role of radiotherapy have occur in the parotid gland. 36 Histologically, been report to reduce local recurrence after lymphoepithelial cysts exhibit a cystic cavity surgery. 26-28 Adjuvant chemotherapy has not lined by a parakeratinised stratified squamous been shown to be of value. 29 epithelium. The luminal space is filled with sloughed epithelial cells and the epithelial lin- Dermoid and Epidermoid cysts ing is devoid of rete ridges. Characteristically, Dermoid and epidermoid cysts are cystic mal- the fibrous capsule shows a dense lymphoid formations lined with squamous epithelium. tissue, with germinal centres. No treatment is MOHAMMED et al. Brunei Int Med J. 2013; 9 (5): 293 a b c d e f g h Figs. 1: a) Giant intramuscular lipoma of the tongue, b) Liposarcoma of the tongue, c) Lymphoepithelial cyst in buccal mucosa, d) Verruciform xanthoma, e) Pyostomatitis vegetans with gingival edema and pustules, f) Gingival enlargement in amyloidosis, g) Hyalinosis cutis et mucosae - Yellowish white papular deposits near the frenum, h) Fordyce spots, and i i) Yellow hairy tongue MOHAMMED et al. Brunei Int Med J. 2013; 9 (5): 294 usually required for oral lymphoepithelial cyst proximately 37 cases have been documented unless its location results in it frequently trau- in the literature. 43 Subsequently McCarthy matised leading to symptoms. However, in considered that this disorder to be a variant of most cases, the lesions are removed by con- pyodermatitis with oral location. This condi- servative surgical excision in order to arrive at tion is an unusual oral expression of inflam- a definitive diagnosis. 35 There is no malignant matory bowel disease. 44 It is a highly specific potential but the lymphoid stroma, as with all marker for inflammatory bowel disease and its lymphoid tissues, can become involved with correct recognition may lead to the diagnosis an extra nodal lymphoma.