Part IV: Summary of Clinical Features of Oral Mucosal Lesions

Table 1. White Surface Lesions of Oral Mucosa
EPITHELIAL THICKENING WHITE LESIONS
Asymptomatic; rough to palpation; fixed to the surface (won’t rub off)
Lichen planus Multiple areas of mucosa involved; bilateral distribution; white plaques arranged in striated pattern associated with erythema; ulcers may be present; skin lesions may be present.
Nicotine (nicotinic) stomatitis Hard palate; mainly in pipe or cigar smokers.
Hairy tongue Dorsum of tongue.
Hairy leukoplakia Lateral surface of tongue; patient is immunocompromised, e.g. AIDS.
White sponge nevus Multiple lesions affecting broad areas of mucosa; familial history; present from early age; genital & rectal mucosa may be affected.
Leukoedema Bilateral on buccal mucosa. Disappears when tissue is stretched.
Erythema migrans (geographic tongue, benign migratory glossitis) Multiple red patches with irregular yellow-white border; dorsal lateral tongue; lesions migrate; usually asymptomatic.
Hyperkeratosis May resolve spontaneously.
Epithelial dysplasia
Carcinoma-in-situ
Superficially invasive squamous cell carcinoma
Persistent; usually asymptomatic; more common as red lesion or mixed red and white lesion.
SURFACE DEBRIS WHITE LESIONS
Pain or burning; rubs off; submucosal erythema
Candidosis History of antibiotic therapy, immunosuppression; xerostomia; nail and/or vaginal lesions may be present
Burn (thermal or chemical) History of burn.
Dried, thick saliva Removed with wet gauze.
SUBEPITHELIAL WHITE LESIONS
Asymptomatic; smooth to palpation; surface is translucent.
Cysts Small cysts of oral mucosa can appear white. Examples are congenital keratotic cyst and lymphoepithelial cyst.
Fordyce granules (ectopic sebaceous glands) Yellow, circumscribed, in clusters; most commonly located on buccal mucosa and upper lip.
Mucosal scarring History of injury or surgery; usually poorly defined.
Table 2. Localized Pigmented Surface Lesions of Oral Mucosa
INTRAVASCULAR BLOOD LESIONS
Usually blanch on pressure and compressible
Varix Blue; thickened; sometimes does not blanch due to thrombosis.
Hemangioma Congenital; thickened; red or blue
Kaposi sarcoma Patient is immunocompromised; may be thickened or flat.
EXTRAVASCULAR BLOOD LESIONS
Do not blanch; present for less than 1 month; may have history of injury or bleeding problem.
Hematoma Thickened; firm to palpation.
Ecchymosis Not thickened
Petechiae Focal and pinpoint size; red; multiple; not thickened
MELANOCYTIC LESIONS
Persistent; do not blanch
Ephelis (freckle) Not thickened; located on sun-exposed surfaces.
Oral melanotic macule Not thickened; located on mucosa not exposed to sun
Nevus Thickened; may be flat early in development
Melanoma Thickened; may be flat early in development
TATTOO
Do not blanch; may be history of injury; radiopaque object sometimes seen on radiograph; may be thickened or flat.
Table 3. Vesicular-Ulcerated-Erythematous Surface Lesions of Oral Mucosa
HEREDITARY – EPIDERMOLYSIS BULLOSA
Skin lesions are always present; Nikolsky’s sign often present; mouth opening may be restricted due to scarring. Lesions are congenital or begin at an early age; patient frequently has a familial history.
MYCOTIC – CANDIDOSISv(CANDIDIASIS)
Diffuse mucosal erythema; burning or pain may be present; ulcers are rarely present; lymphadenopathy is rare. Patient often has predisposing factors: antibiotics, immunosuppression.
AUTOIMMUNE
Slow onset; chronic lesions; exacerbations & partial remissions; lesions do not heal in a predictable period of time; lymphadenopathy is rare.
Mucous membrane pemphigoid (cicatricial pemphigoid; benign mucous membrane pemphigoid) Erythematous attached gingiva; vesicles sometimes observed; Nikolsky sign may be present; skin vesicles & ulcers may be present.
Bullous pemphigoid Skin vesicles, bullae & ulcers are always present; occasional oral vesicles & ulcers.
Pemphigus Mucosal vesicles & ulcers in any location usually precede skin lesions; Nikolsky sign may be present.
Lupus erythematosus Nonspecific mucositis & ulcers are sometimes present but are associated with skin lesions.
Oral lesions: white epithelial striae with submucosal erythema (lichenoid lesions).
Multiple organ system disorders: erythematous skin
rash, photosensitivity, arthritis, nephritis, neurologic disease; anemia, leukopenia, thrombocytopenia.
VIRAL
Acute onset; multiple lesions; systemic manifestations (malaise, fever, diarrhea, lymphadenopathy, lymphocytosis) often present; vesicle stage is present in all except mononucleosis.
Primary herpes Vesicles & ulcers may be present anywhere in the oral cavity, pharynx, lips or perioral skin; gingiva is edematous & erythematous; lymphadenopathy is common; malaise, fever & diarrhea in some cases.
Recurrent herpes Occurs on sun-exposed surfaces of lips; intraorally occurs on keratinized mucosa (dorsum of tongue, hard palate, attached gingiva); usually recurs in same location; heals in a predictable period of time for each patient.
Varicella (chickenpox) Crops of pruritic papules, vesicles, ulcers on trunk spreading to arms, legs & face; mild malaise, fever & lymphadenopathy; occasional oral ulcers.
Herpes zoster (shingles) Prodromal pain followed by vesicles & ulcers in the distribution of a sensory nerve; unilateral lesions; postherpetic neuralgia may occur.
Herpangina (Coxsackievirus A) Vesicles & ulcers in posterior oral cavity & pharynx; may have mild systemic manifestations.
Hand, foot and mouth disease
(Coxsackievirus A)
Vesicles & ulcers of oral & pharyngeal mucosa; vesicles & macules on hands and feet; mild systemic manifestations.
Rubeola (measles) Fever, conjunctivitis, photophobia, cough, nasal discharge; oral vesicles (Koplik spots); erythematous maculopapular skin rash on face spreading to trunk & extremities.
Epstein-Barr virus Infectious mononucleosis Generalized lymphadenopathy; splenomegaly; hepatomegaly; palatal petechiae; erythematous oral & pharyngeal mucosa; occasionally mucosal ulcers; no vesicular stage.
IDIOPATHIC
Each disease must be considered as a separate entity.
Aphthous ulcers Abrupt onset of recurrent ulcers on nonkeratinized mucosal surfaces; individual ulcers heal in a predictable period of time which is variable for each patient; may be menstrually related; familial history common; “herpetiform” aphthae refer to multiple crops of small aphthous ulcers; “major” aphthae are deeper, longer lasting and more frequent ulcers which often heal with scarring.
Erosive lichen planus Erythematous mucosal lesions usually with areas of ulceration; often bilateral distribution; white epithelial striae at edge of erythematous areas; atrophy of filiform papillae may be seen; chronic course.
Medication-induced mucositis A variety of drugs cause mucosal lesions that do not appear to be allergic in nature; mucosal lesions consists of ulcers and erosions occurring on both keratinized & nonkeratinized mucosal surfaces.
Contact stomatitis Burning, pain, ulcers, erosions, erythema sometimes covered with shaggy hyperkeratosis. Most commonly secondary to cinnamon flavoring.
Erythema multiforme Sudden onset of diffuse mucosal ulcers involving buccal & labial mucosa; sometimes recurrent with variable periods of remission; skin lesions present “iris” or “target” appearance on palmar & plantar surfaces; lymphadenopathy is rare.
Erythroplasia (erythroplakia): epithelial dysplasia, carcinoma in situ, superficially-invasive squamous cell carcinoma Asymptomatic, persistent, erythematous, velvety, focal to diffuse mucosal areas; more common in heavy consumers of alcohol.
Table 4. Soft Tissue Enlargements
Reactive Tumors
Regress, resolve Persistent and progressive
Often symptomatic Often asymptomatic
Growth rate: hours, days, weeks Growth rate: weeks, months, years
Fluctuate in size Persistent & progressive
Sometimes associated with tender, soft lymph nodes Lymph nodes not enlarged unless associated with metastatic cancer; then they are firm & non-tender
Sometimes associated with systemic manifestations Systemic manifestations occur late in the course of cancer
Benign Tumors Malignant Neoplasms
Slow growth: months, years Rapid growth: weeks, months
Overlying mucosa is usually normal unless traumatized Overlying mucosa more likely to be ulcerated
Often not fixed to surrounding structures Fixed to surrounding structures
May move teeth May loosen teeth
Asymptomatic More likely to be painful
Well circumscribed Poorly circumscribed
Table 5. Benign Epithelial Tumors
BENIGN EPITHELIAL TUMORS
Firm; non-tender; fixed to the surface; rough or cauliflower surface; pale.
Papilloma Pedunculated; exophytic
Verruca vulgaris Broad-based; exophytic
Condyloma acuminatum Broad-based; exophytic; multiple lesions; frequently genital lesions
Table 6. Benign Mesenchymal Tumors
BENIGN MESENCHYMAL TUMORS
Overlying mucosa is normal unless traumatized; usually well-circumscribed, asymptomatic, slowly growing
Irritation fibroma Firm or compressible
Epulis fissuratum (inflammatory fibrous hyperplasia) Located adjacent to flange of removable denture; firm or compressible
Peripheral ossifying fibroma Occursonly on gingiva; firm; sometimes ulcerated; sometimes vascular; may move teeth
Leiomyoma Firm; sometimes vascular.
Rhabdomyoma Firm; located in areas of skeletal muscle
Peripheral giant cell granuloma Occurs only on gingiva or attached alveolar mucosa; vascular
Hemangioma Congenital; compressible; vascular; circumscribed or diffuse
Lymphangioma Congenital; compressible; usually diffuse; not vascular
Pyogenic granuloma Vascular; compressible; frequently has rapid growth, ulcerated, bleeds easily
Lipoma Encapsulated; compressible; sometimes yellow
Neuroma (traumatic or amputation neuroma) Firm; usually tender to palpation; size of lesion is dependent upon size of involved nerve
Neurofibroma Firm or compressible; non-tender; circumscribed or diffuse; may occur with neurofibromatosis
Schwannoma (neurilemoma) Encapsulated; firm; non-tender;
Granular cell tumor Firm; sometimes overlying surface is rough
Congenital epulis Firm; congenital; occurs only on attached alveolar mucosa
Table 7. Benign Salivary Gland Tumors
BENIGN SALIVARY GLAND TUMORS
Well-circumscribed; slowly growing; asymptomatic; overlying mucosa is normal unless traumatized; occur only where salivary glands are present (everywhere in the oral mucosa except midline and anterior hard palate, gingiva and attached alveolar mucosa).
Pleomorphic adenoma (Mixed tumor) Encapsulated; firm or compressible
Monomorphic adenoma Encapsulated; firm or compressible
Oncocytoma Encapsulated; firm; occurs in older adults
Papillary cystadenoma lymphomatosum
(Warthin tumor)
Encapsulated; firm or compressible; occurs in parotid gland
Adenoid cystic carcinoma* Firm
Acinic cell carcinoma* Firm
Mucoepidermoid carcinoma, low-grade* Compressible or fluctuant
Polymorphous low-grade adenocarcinoma* Firm
* These are malignant neoplasms, but they sometimes have the clinical & historical features of benign neoplasms.
Table 8. Soft Tissue Cysts
SOFT TISSUE CYSTS
Compressible; well-circumscribed; asymptomatic; slowly growing; overlying mucosa is normal.
Gingival cyst Located on attached gingiva anterior to 1st molars
Lymphoepithelial cyst Usually has yellow color; occurs in floor of mouth, ventral & lateral surfaces of tongue, soft palate & tonsillar area; also occurs in anterior cervical lymph node chain (branchial cleft or cervical lymphoepithelial cyst)
Epidermoid or dermoid cyst “Doughy” to palpation; usually occurs in floor of mouth; occurs commonly in skin
Thyroglossal tract cyst Occurs in midline of neck; may be attached to hyoid bone & moves when patient swallows
Nasolabial cyst Located in maxillary labial fold & ala of nose area
* These are cysts, but they have the clinical & historical features of benign neoplasms.