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Diseases of the Mouth

      Keywords

      Key points

      • The most common infection and disease of the mouth is caries. Caries is a chronic, transmissible disease caused by bacteria using sugar to create an acidic environment that erodes the teeth.
      • Candidiasis is an infection of the oral mucosa by the Candida species. The most prominent candida infection in humans is Candida albicans.
      • Approximately 50% of children will have some form of gingivitis; for adults, it is as much as 90% when all types and causes are included. Gingivitis is very prevalent during pregnancy due to hormonal changes.
      • Benign bony protuberances arise from the cortical plate and consist of lamellar bone. They are more common in the hard palate of the mouth but can also occur in the floor of the mouth. They are likely congenital but do not develop until adulthood.
      • Clinicians should pay close attention to a history of nonhealing ulcer or mass in the mouth or on the lip, or any area that bleeds easily or has unexplained pain. Other concerning symptoms for oral cancer may include dysphagia/odynophagia, chronic sore throat or hoarseness, or unexplained ear pain.

      Introduction

      The mouth is the gateway to the body.
      • Bouquot J.E.
      Bond’s book of oral disease.
      Disease in the mouth can cause systemic diseases (eg, bacterial endocarditis), and systemic disease can also lead to complications in the mouth (eg, Behcet disease). Patients often present first to their primary care provider with oral symptoms. Medical clinicians often defer diseases of the mouth to dental professionals, oral surgeons, and otolaryngologists; however, medical professionals should be comfortable with the diagnosis and initial management of many common diseases of the oral cavity. This article discusses 3 major categories of disease within the mouth (excluding the tongue and salivary glands):
      • 1.
        Mouth infections (caries and complications, candidiasis)
      • 2.
        Inflammatory conditions (gingivitis, periodontitis, and stomatitis)
      • 3.
        Common benign and malignant lesions (bony tori, mucocele, lichen planus, leukoplakia, cancer).

      Infections of the mouth

      Caries

      Description

      The most common infection and disease of the mouth is caries. Caries is a chronic, transmissible disease caused by bacteria using sugar to create an acidic environment that erodes the teeth. Over time this process leads to holes (cavities) in the tooth’s structure. The predominant bacterium involved is Streptococcus mutans, although the disease may have more to do with a disruption of a complex biofilm on the teeth than the overpopulation of one species. Fluoride and saliva are protective factors.
      • Selwitz R.H.
      • Ismail A.I.
      • Pitts N.B.
      Dental caries.

      Risk factors

      Risks for caries are multifactorial, including physical and socioeconomic factors. See Box 1.
      Risk factors for caries in adults
      • Previous caries
      • High oral bacterial counts (mainly S mutans)
      • Inadequate oral hygiene (brushing with fluoridated toothpaste and flossing)
      • Inadequate exposure to fluoride
      • Frequent consumption of sugary foods, snacks, and drinks
      • Low socioeconomic status
      • Physical or mental disabilities (making it difficult to brush/floss)
      • Existing appliances (trapping food)
      • Decreased salivary flow (due to medications or disease states)
      • Exposed roots (in elderly due to lack of enamel on roots)

      Prevalence

      Nearly 24% of adults aged 20 to 64 have untreated dental caries and 84% have had a dental restoration.
      • Dye B.A.
      • Li X.
      • Beltrán-Aguilar E.D.
      Selected oral health indicators in the United States, 2005–2008.
      The western developed countries tend to have more caries compared with lesser developed countries and this is thought to be second to the predominance of concentrated refined sweets in many countries.

      Clinical implications

      Untreated caries can lead to local and systemic infections. A cavity invades the pulp and root of the tooth, which includes the nerves and blood supply. This local infection can spread through surrounding gingival tissue, form an abscess, penetrate other layers of anatomy such as the cheek or airway, and ultimately infect the meninges or bloodstream. At a minimum, untreated cavities can cause pain and at worst has caused death through meningitis.

      Diagnostic options and dilemmas

      Routine screening examinations by medical and dental professionals can help identify caries early. Most professional organizations recommend an examination every 6 months. Mouth radiographs done periodically (common recommendation is every 2 years) can also help diagnose disease in the early stages.

      Management

      Prevention is the key. The patient should be advised to brush teeth twice daily with fluoridated toothpaste and floss daily.
      • Marinho V.C.
      Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Oral Health Group.
      An oscillating toothbrush is more effective than a regular toothbrush for preventing oral disease in adults.
      • Robinson P.G.
      • Deacon S.A.
      • Deery C.
      • et al.
      Manual versus powered toothbrushing for oral health.
      Routine screening is suggested as above. Children and adolescents should also be considered for fluoride varnish treatments, supplemental fluoride if primary water supply is not fluoridated, and sealants of secondary molars. Early caries can be treated with restoration; deeper cavities will require root canal or extractions.
      • Bouquot J.E.
      Bond’s book of oral disease.
      Secondary infections require antibiotics, incision and drainage, and definitive treatment of the tooth with restoration or extraction.
      • Douglass A.B.
      • Douglass J.M.
      Common dental emergencies.
      A delay in treatment can lead to spread of infection as outlined above. Initial antibiotics include penicillin (loading dose of 1000 mg, followed by 500 mg 3–4 times daily for 7–10 days) but broader antibiotics (such as clindamycin; loading dose of 600 mg, followed by 300 mg orally 3 times daily for 7–10 days) should be used if infection is spreading.
      • Matijevic S.
      • Lazi Z.
      • Kuljic-Kapulica N.
      • et al.
      Empirical antimicrobial therapy of acute dentoalveolar abscess.
      Secondary infections (cellulitis, meningitis) require hospitalization with intravenous antibiotics, computed tomographic imaging,
      • Hurley M.C.
      • Heran M.K.
      Imaging studies for head and neck infections.
      and consultation. Pain should be managed with acetaminophen and ibuprofen; depending on the degree of infection and pain, a short course of opioids may be necessary.
      • Cliff K.
      An evidence-based update of the use of analgesics in dentistry.

      Candidiasis

      Description

      Candidiasis is an infection of the oral mucosa by candida species. The most prominent candida infection in humans is Candida albicans (Fig. 1).
      Figure thumbnail gr1
      Fig. 1Oral candidiasis.
      (From López-Martínez R. Candidosis, a new challenge. Clin Dermatol 2010;28(2):178–84; with permission.)

      Risk factors

      Candida species are normal inhabitants of the gastrointestinal tract. Those that are immunocompromised are more susceptible to oral candidal infections, including elderly, infants, HIV-positive individuals, patients with cancer, and diabetes or those with glucose intolerance.
      • Akpan A.
      • Morgan R.
      Oral candidiasis.
      Certain medications cause individuals to be more prone, including antibacterial therapy (especially broad-spectrum antibiotics, which disrupt normal protective flora), inhaled steroids,
      • Yang I.A.
      • Clarke M.S.
      • Sim E.H.
      • et al.
      Inhaled corticosteroids for stable chronic obstructive pulmonary disease.
      and chemotherapy. Dentures also can get infected with Candida and the surrounding area may only be erythematous and not white.

      Prevalence

      Candidiasis is not common in the general public; annual estimates are 50 in 100,000. However, in high-risk populations the numbers are more prevalent: 5% to 7% of babies less than 1 month old; 9% to 31% of AIDS patients; nearly 20% of patients with cancer.

      Oral candidiasis statistics. Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases, Division of Foodborne, Waterborne, and Environmental Diseases. Available at: www.cdc.gov/fungal/candidiasis/thrush/statistics.html. Accessed February 20, 2013.

      Clinical implications

      The diagnosis for candidiasis is usually made through a history of risk factors and symptoms (including painless white patches in the mouth). Physical examination of white patches confirms the diagnosis. The white layer can be partially wiped off and there can be an erythematous mucosa underlying. Complications include a descending spread of the infection along the gastrointestinal tract causing esophageal and gastric candidiasis. Candida of the mouth can also present solely as angular cheilitis at the corners of the mouth, resulting in cracks in the skin. Candidiasis of dentures may present as only erythema of the mucosa.

      Diagnostic options and dilemmas

      Diagnosis can be aided with a slide preparation looking for hyphae. If pH is checked, it should be less than 4.5. If there is any doubt of a diagnosis, a culture can be obtained. A culture can also be helpful for recalcitrant infection to confirm species and sensitivities. Differential diagnosis includes leukoplakia, lichen planus, geographic tongue, and milk or other white foods.

      Management

      Prevention includes modifying risk factors (avoid antibiotics, use narrow spectrum antibiotics, consider probiotics when using antibiotics, rinse after inhaled steroid use). For treatment, Nystatin suspension, 100,000 U/mL given 4 to 6 times daily, is a common, effective treatment. It also comes as a pastille.
      • Pappas P.G.
      • Kauffman C.A.
      • Andes D.
      • et al.
      Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America.
      Clotrimazole (Mycelex), 10 mg troche, sucked on 20 minutes 5 times a day for 7 to 14 days is an alternative. For angular cheilitis, Nystatin ointment can be prescribed: 100,000 U/g to corners of mouth 2 to 3 times daily for 3 weeks. If dentures are involved, proper cleaning is important
      • Kanli A.
      • Demirel F.
      • Sezgin Y.
      Oral candidosis, denture cleanliness and hygiene habits in an elderly population.
      ; one technique is to clean with diluted (1:20) bleach. For infants with thrush, be sure to boil all pacifiers and bottle nipples. Infants should be treated with nystatin suspension 0.5 mL in each cheek 4 times daily until better, which is usually 7 to 10 days. Mother’s breasts should be treated as needed in breastfed babies with topical antifungals such as nystatin to the nipples of the breasts for the same duration. Oral agents (fluconazole or equivalent) can be used as second-line treatment or in cases of esophageal candidiasis.

      Inflammatory conditions of the mouth

      Gingivitis

      Description

      Gingivitis is a reversible form of inflammation of the gingival (Fig. 2). It is a mild form of periodontal disease. Classifications include plaque-induced, non-plaque-induced, and then gingivitis secondary to medications and systemic diseases.
      • Armitage G.C.
      Development of a classification system for periodontal diseases and conditions.
      Figure thumbnail gr2
      Fig. 2Gingivitis.
      (From Preshaw PM, Bissett SM. Periodontitis: oral complication of diabetes. Endocrinol Metab Clin North Am 2013;42:849–67; with permission.)

      Risk factors

      Risk factors for gingivitis are multifactorial. See Box 2.
      Risk factors for gingivitis
      • Poor dental hygiene/plaque formation
      • Eruption of primary or secondary teeth
      • Dental appliances (dentures, braces)
      • Malocclusion or dental crowding
      • Faulty dental restoration
      • Pregnancy
      • Uncontrolled diabetes mellitus
      • Smoking
      • Mouth breathing
      • Medications (gingival overgrowth): phenytoin, calcium channel blockers, cyclosporine
      • Viral illness
      • HIV-positive, AIDS
      • Stress; lack of sleep
      • Hospitalization
      • Malnutrition
      • Vitamin C deficiency (scurvy); coenzyme Q10 deficiency
      • Possible genetic link (up to 30% of population)
      • Hereditary gingival fibromatosis (rare)

      Prevalence

      Approximately 50% of children will have some form of gingivitis; for adults it is as much as 90% when all types and causes are included. Gingivitis is very prevalent during pregnancy due to hormonal changes. Other changes in hormonal activity can also increase prevalence of gingivitis in women, including menarche, menstruation, and use of contraceptives.
      • Mariotti A.
      Dental plaque-induced gingival diseases.

      Clinical implications

      Gingivitis is often acute but can be intermittent and relapsing; some patients do get chronic gingivitis. Prognosis is generally favorable because it does respond well to appropriate treatment. Some experts think that if left untreated, gingivitis may progress to periodontitis over months to years, which can lead to other issues (see Periodontitis below). There is a condition called acute necrotizing ulcerative gingivitis that includes a necrotic slough of the gingival and is caused by a compromised immune system and malnutrition seen mostly in undeveloped countries.

      Diagnostic options and dilemmas

      Patients report painful gums that bleed easily especially with brushing, flossing, and eating. A thorough history should explore risk factors. Physical examination reveals swollen and erythematous gums that are tender to palpation. Plaque and calculus may be present. Differential includes periodontitis, pericoronitis (a flap of gum tissue growing over a tooth), and other oral ulcerative diseases and infections.

      Management

      Care should include removing any offending agents (medications, tobacco products) and modify diet if malnutrition is a concern. Dental referrals may be necessary for cleaning and plaque removal or dental appliance refitting. General measures can include warm saline rinses, better oral hygiene, and analgesics if necessary. Chlorhexidine rinses, mouth rinses with essential oils, and fluoridated hydrogen peroxide-based mouth rinses have all been shown to reduce gingivitis significantly.
      • Stoeken J.E.
      • Paraskevas S.
      • van der Weijden G.A.
      The long-term effect of a mouthrinse containing essential oils on dental plaque and gingivitis: a systematic review.
      • Gunsolley J.C.
      Clinical efficacy of antimicrobial mouthrinses.
      Antibiotics are only necessary for acute necrotizing ulcerative gingivitis and include penicillin, metronidazole, and/or erythromycin. Prevention includes good oral hygiene, including daily high-quality flossing
      • Sambunjak D.
      • Nickerson J.W.
      • Poklepovic T.
      • et al.
      Flossing for the management of periodontal diseases and dental caries in adults.
      and use of an electric toothbrush twice daily,
      • Marinho V.C.
      Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Oral Health Group.
      healthy well-rounded diet, and regular dental checkups.

      Periodontitis

      Description

      Periodontitis is a deep inflammation of the gingiva, including the ligaments and supporting structure of the teeth. It is caused by persistent exposure of the mouth to bacteria and plaque, leading to chronic inflammation. (Therefore, like many conditions of the mouth, it is not simply inflammatory but inflammatory and infectious.) Over time this leads to periodontal ligament destruction, loss of supporting alveolar bone, and loosening of teeth. Two major types are chronic and aggressive.

      Risk factors

      Poor oral hygiene (lack of brushing and flossing) and lack of dental cleanings lead to chronic plaque accumulation. Other contributing factors include tobacco exposure, HIV, pregnancy, and diabetes.
      • Taylor G.W.
      Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective.

      Prevalence

      Periodontitis is common. An estimated 20% of adults are affected by periodontitis.
      • Eke P.I.
      • Dye B.A.
      • Wei L.
      • et al.
      Prevalence of periodontitis in adults in the United States: 2009 and 2010. CDC Periodontal Disease Surveillance workgroup.

      Clinical implications

      Periodontitis is the leading cause of tooth loss in adults. Edentulism has been associated with an overall increase in morbidity and mortality.
      • Brown D.W.
      Complete edentulism prior to the age of 65 years is associated with all-cause mortality.
      Local infection may also occur resulting in abscess formation. Multiple studies have shown an association between periodontitis and cardiovascular disease, preterm labor, and worsening diabetes among other disease states (although interventions may not improve outcomes making prevention a key goal).
      • Friedewald V.E.
      • Kornman K.S.
      • Beck J.D.
      • et al.
      The American Journal of Cardiology and J Periodontol editors' consensus: periodontitis and atherosclerotic cardiovascular disease.
      • Southerland J.H.
      • Taylor G.W.
      • Moss K.
      • et al.
      Commonality in chronic inflammatory diseases: periodontitis, diabetes, and coronary artery disease.
      • Xiong X.
      • Buekens P.
      • Fraser W.D.
      • et al.
      Periodontal disease and adverse pregnancy outcomes: a systematic review.
      The inflammation within the mouth leads to a systemic cascade of interleukins and prostaglandins that have wide ranging effects.
      • Kumar J.
      • Samelson R.
      Oral health care during pregnancy and early childhood practice guidelines.
      Interventions to treat periodontitis are not always helpful for the systemic condition (ie, cardiovascular disease, preterm labor) in many studies, raising the question of whether prevention of periodontitis would have a more profound effect.

      Diagnostic options and dilemmas

      Clinical examination and history reveal painful gums that bleed easily. Advanced disease includes loose teeth. Radiographs show bone loss. Dental assessments to categorize disease will include probing depth of gingiva, attachment loss, and bone loss.

      Management

      Periodontitis is treated by dental professionals with deep root scaling and planing of bacteria and calculus to address the inflammation deep into the root. Topical antibiotics (metronidazole, minocycline, and doxycycline) and systemic antibiotics (doxycycline 100 mg daily, metronidazole 500 mg twice daily) are also used.
      • Eberhard J.
      • Jepsen S.
      • Jervøe-Storm P.M.
      • et al.
      Full-mouth disinfection for the treatment of adult chronic periodontitis.
      • Krayer J.W.
      • Leite R.S.
      • Kirkwood K.L.
      Non-surgical chemotherapeutic treatment strategies for the management of periodontal diseases.
      Chlorhexidine rinses may also be prescribed. Oral hygiene is an essential aspect of management and can be supported by medical professionals. Oral hygiene should include brushing twice daily with fluoridated toothpaste, ideally using an electric oscillating toothbrush, flossing daily, avoiding sugary snacks and drinks, avoiding tobacco products, and regular dental visits and cleanings.

      Stomatitis

      Description

      Stomatitis is an inflammation of the mucous lining of the mouth, which can include the tongue, gingiva, lips, buccal surface, and floor of the mouth. It is usually erythematous and can be ulcerated and usually painful.

      Risk factors

      Stomatitis can have many causes and therefore there can be many risks, including poor oral hygiene, malnutrition, dietary deficiencies (ie, iron, folic acid, vitamin B6 and B12), chronic systemic disease (ie, inflammatory bowel disease, Behcet disease), immune deficiencies (ie, leukemia, AIDS), poor fitting dentures, smoking, and cancer therapies.
      • McBride D.R.
      Management of aphthous ulcers.

      Prevalence

      There are no specific estimates of these conditions but the following is a general guideline: very common: herpetic stomatitis (Fig. 3), hand-foot-mouth disease, and recurrent aphthous stomatitis; common: herpangina, nicotinic stomatitis, and denture-related stomatitis. The remaining causes are uncommon or rare.
      Figure thumbnail gr3
      Fig. 3Herpes simplex stomatitis.
      (From Fatahzadeh M, Schwartz R. Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management. J Am Acad Dermatol 2007;57(5):737–63; with permission.)

      Clinical implications

      Most of the common and less serious forms of stomatitis resolve over days to weeks.
      • Ship J.A.
      Recurrent aphthous stomatitis. An update.
      Resolution is expedited when offending agents are removed (eg, nicotine for nicotinic stomatitis or refitting poorly fitted dentures for denture-related stomatitis).

      Complications

      Complications include intraoral scarring and possible restriction of oral mobility if stomatitis is severe or chronic. Infectious causes can have systemic effects (eg, gangrenous stomatitis leading to facial disfigurement and even death; herpetic stomatitis can be associated with ocular or central nervous system involvement). Systemic disease can also have other systemic effects (eg, Behçet disease may result in vision loss, colitis, vasculitis, large-artery aneurysms, or encephalitis).

      Diagnostic options and dilemmas

      Patients usually present with complaints of a burning sensation or localized pain (minimal to severe pain), intolerance to temperature changes, and irritation with certain foods. Constitutional symptoms may include low-grade fever, malaise, and headache. Nutrition deficiencies, exposures to medications, foods, or oral products, recent cancer or cancer treatments, nicotine exposure, and systemic symptoms, such as fever, other lesions, or rashes, should be inquired about.
      The physical examination should include comprehensive oral examination of all mucosal surfaces. Erythema and edema are the usual oral manifestations. Ulceration can occur in some cases. If Candida is involved, a white patch can also be present. Usually no tests are needed. If the diagnosis is in question, the following tests may be helpful: herpes simplex virus culture; serologic testing for syphilis; complete blood count, and cultures to determine secondary infection. A biopsy may be needed for persistent or recurrent lesions. Immunofluorescence is useful in the differential diagnostic between recurrent aphthous stomatitis and bullous skin diseases.

      Management

      Treatment of stomatitis depends on the cause. If cause is allergic, removal of the agent is critical. For infectious causes, antibiotic or antifungal medications are best. Steroidal anti-inflammatory drugs can help for systemic conditions with stomatitis manifestation. If the cause of stomatitis is due to medical treatment or cancer therapy, therapies may need to be altered.
      There are many approaches to providing relief topically in the mouth. See Box 3.
      Local agents for symptom relief of mouth ulcerations
      • Acetaminophen or ibuprofen as primary agents for analgesia
      • 2% viscous lidocaine (swish and spit)
      • Liquid diphenhydramine (swish and spit) for allergic stomatitis
      • Silver nitrate, 1 application until lesion is white
        • Alidaee M.R.
        • Taheri A.
        • Mansoori P.
        • et al.
        Silver nitrate cautery in aphthous stomatitis: a randomized controlled trial.
      • Topical steroid (Kenalog) in Orabase 3‐4 times daily
      • Dexamethasone ointment 3 times daily
        • Liu C.
        • Zhou Z.
        • Liu G.
        • et al.
        Efficacy and safety of dexamethasone ointment on recurrent aphthous ulceration.
      • Miracle mouth rinses: various combinations of the following in equal parts (swish and spit) multiple times daily:
        • Maalox or Mylanta, diphenhydramine, lidocaine
        • Maalox or Mylanta, diphenhydramine, Carafate
        • Nystatin, diphenhydramine, hydrocortisone
      Steroids, colchicine, and cytotoxic drugs can be used for Behçet disease. Antibiotics are necessary for gangrenous stomatitis (penicillin and metronidazole are reasonable first-line agents; often started intravenously). For candidiasis, Nystatin oral suspension (swish and swallow) should be tried. Acyclovir 200 to 800 mg 5 times a day for 7 to 14 days for herpetic stomatitis.
      For prevention or reducing severity of mucositis with cancer treatments, these agents have some evidence of benefit: allopurinol, aloe vera, amifostine, cryotherapy, glutamine (intravenous), honey, keratinocyte growth factor, laser, and polymixin/tobramycin/amphotericin antibiotic pastille/paste.
      • Worthington H.V.
      • Clarkson J.E.
      • Bryan G.
      • et al.
      Interventions for preventing oral mucositis for patients with cancer receiving treatment.

      Common lesions of the mouth

      Bony Tori

      Description

      Bony tori is a benign bony protuberance that arises from the cortical plate and consists of lamellar bone (Fig. 4).
      • Bouquot J.E.
      Bond’s book of oral disease.
      They are more common in the hard palate of the mouth but can also occur in the floor of the mouth. They are likely congenital but do not develop until adulthood.
      Figure thumbnail gr4
      Fig. 4Bony tori.
      (From Swartz MH. Textbook of physical diagnosis: history and examination. Philadelphia: Saunders; p. 324–61.)

      Risk factors

      Risk factors include age and possibly family history.

      Prevalence

      In the United States, the prevalence is approximately 3%, seen slightly more often in women than in men
      • Liu C.
      • Zhou Z.
      • Liu G.
      • et al.
      Efficacy and safety of dexamethasone ointment on recurrent aphthous ulceration.
      (Palatal tori 25%–35%; mandibular tori 7%–10%).

      Clinical implications

      Bony tori do not usually cause any symptoms. On occasion, they can cause mechanical interference with eating or denture placement.

      Diagnostic options and dilemmas

      Tori are usually painless and go unnoticed. Medical personnel can sometimes confuse them for cancerous growths.

      Management

      No management is necessary unless the tori are interfering with oral function or denture fabrication. An oral surgery consult would be appropriate in these situations.

      Mucocele

      Description

      Mucoceles are benign fluid-filled sacs within the lining of the epithelium (Fig. 5). They contain mucous glands.
      Figure thumbnail gr5
      Fig. 5Mucocele.
      (From Wu CW, Kao YH, Chen CM, et al. Mucoceles of the oral cavity in pediatric patients. Kaohsiung J Med Sci 2011;27(7):276–9; with permission.)

      Risk factors

      Risk includes mild oral trauma, which leads to disruption of the salivary gland duct.

      Prevalence

      The prevalence of mucoceles is common and is usually seen in patients under the age of 20.

      Clinical implications

      The lesions are seldom symptomatic, but often are aggravating because a person will continue to retraumatize them when eating. Patients will present with pinkish/blue soft papules or nodules. Palpation reveals a gelatinous sac usually. Most frequently they occur on the lower lip (ie, result of biting of the lip). They vary in size.

      Diagnostic options and dilemmas

      Mucoceles are usually easy to diagnose. If there is a lack of gelatinous material, it may simply be gingivitis. Any lesion that does not heal in the mouth over 4 to 6 weeks should be followed up for further assessment and possible biopsy or excision for pathologic evaluation.

      Management

      Lesions will often rupture spontaneously, which should lead to complete resolution.
      • Chi A.C.
      • Lambert III, P.R.
      • Richardson M.S.
      • et al.
      Oral mucoceles: a clinicopathologic review of 1,824 cases, including unusual variants.
      If the lesions are symptomatic, they can be excised, which must include the entire cyst to prevent recurrence. Aspiration alone is not recommended because it will provide short-term relief but recurrence is common. Alternative treatments include cryosurgery or laser, which also has shown good results with low recurrence rates and the latter being well tolerated.
      • Huang I.Y.
      • Chen C.M.
      • Kao Y.H.
      • et al.
      Treatment of mucocele of the lower lip with carbon dioxide laser.

      Lichen Planus

      Description

      Lichen planus is a chronic inflammatory condition of unknown cause, likely an immune response (Fig. 6).
      Figure thumbnail gr6
      Fig. 6Lichen planus.
      (From Scully C, Carrozzo M. Oral mucosal disease: Lichen planus. Br J Oral Maxillofac Surg 2008;46:15–21; with permission.)

      Risk factors

      Ther are no risk factors, possibly age. There may be a genetic link. One proposed theory is that lichen planus is a response to an infection, medication, or trauma.
      • Roopashree M.R.
      • Gondhalekar R.V.
      • Shashikanth M.C.
      • et al.
      Pathogenesis of oral lichen planus–a review.

      Prevalence

      Lichen planus affects 1% to 2% of the population and can occur at any age but is more predominant over age 40; there is a female-to-male ratio of 1.4:1.
      • McCartan B.E.
      • Healy C.M.
      The reported prevalence of oral lichen planus: a review and critique.

      Clinical implications

      Clinical implications are benign; however, if not exhibiting classical features or not responding to therapy, they may require a biopsy to confirm diagnosis. Lichen planus occurs at other sites in the body including skin and genitals.

      Diagnostic options and dilemmas

      Lichen planus are asymptomatic. Usually they will appear like white lace-like striations in the buccal surface. Alternative presentation is an erythematous atropic-appearing lesion; these lesions can be more painful. There is a third type that is more erosive.
      • Eisen D.
      The clinical manifestations and treatment of oral lichen planus.

      Management

      Topical medium-to-high potency steroids can be helpful: dry area and apply 3–4 times daily.
      • Thongprasom K.
      • Carrozzo M.
      • Furness S.
      • et al.
      Interventions for treating oral lichen planus.
      Goals of management are to decrease pain if present and to prevent scarring. Good oral hygiene, avoiding irritating foods/drinks and tobacco, and removing any appliances that irritate the area may be helpful. Secondary treatments that have some proven benefit include intralesional corticosteroids, cyclosporine, and pimecrolimus and tacrolimus.

      Leukoplakia (and Erythroplakia)

      Description

      Leuokoplakia are premalignant lesions that present as white patches or mucosal thickening (Fig. 7). Erythroplakia are similar lesions that have a red or red and white appearance. The lesions are hyperplasia of the squamous epithelium and although they begin as a benign reactive, inflammatory process can also evolve to transformative dysplasia.
      Figure thumbnail gr7
      Fig. 7Leukoplakia and erythroplakia.
      (From Wu CW, Kao YH, Chen CM, et al. Mucoceles of the oral cavity in pediatric patients. Kaohsiung J Med Sci 2011;27(7):276–9; with permission.)

      Risk factors

      The risk factors are similar to oral squamous cell cancers (see Oral Cancer below). Biggest risk factors are carcinogens, especially smokeless tobacco products and repeat trauma. More evidence is emerging about the role of human papilloma virus (HPV) and leukoplakia.
      • Cianfriglia F.
      • Di Gregorio D.A.
      • Cianfriglia C.
      • et al.
      Incidence of human papillomavirus infection in oral leukoplakia. Indications for a viral aetiology.

      Prevalence

      Benign leukoplakia is common. Erythroplakia is less common. It is estimated that between 1% and 20% of benign lesions become malignant within 10 years.
      • Lee J.J.
      • Hong W.K.
      • Hittelman W.N.
      • et al.
      Predicting cancer development in oral leukoplakia: ten years of translational research.

      Clinical implications

      White and red lesions in the mouth can be simple trauma, gingivitis, or lichen planus. Areas of the mouth where trauma is common (eg, inside of cheek) have thicker linings and therefore lesions in this area are less likely to be dysplastic. However, traumatic or nontraumatic lesions that do not resolve within 4 weeks should be biopsied. (Note that oral hairy leukoplakia is a different form of mucosal thickening and is not a premalignant lesion. It usually involves the tongue in HIV-infected patients and is not covered in this article.)

      Diagnostic options and dilemmas

      Usually lesions are asymptomatic and noticed by patients incidentally. (This is the reason periodic examinations by dental and medical professionals can find such lesions before they become more serious.) Lesions will often begin as white or red patches and then progress to thicker plaques or even erosions. Ulcerated lesions are more likely to be cancerous. Clinicians may visualize lesions at any of these stages.

      Management

      All white or erythematous lesions that cannot be explained or persist should be biopsied.
      • van der Waal I.
      • Schepman K.P.
      • van der Meij E.H.
      A modified classification and staging system for oral leukoplakia.
      Depending on local expertise, dentists, oral surgeons, and otolaryngologists can perform this procedure. If moderate or severe dysplasia is identified, then surgical excision is the treatment of choice. Mild lesions can be treated with cryotherapy or laser ablation but do not allow for pathologic confirmation of complete removal. Prevention should include advising all patients to avoid tobacco products.

      Oral Cancer

      Description

      Malignancies arising from the lips, tongue, floor of the mouth, salivary glands, buccal mucosa, gums, hard and soft palate, oropharynx, nasopharynx, and hypopharynx or other ill-defined sites within the lip, oral cavity, or pharynx. Ninety percent are squamous cell carcinomas; the others include lymphomas and adenocarcinomas from minor salivary gland origin and sarcomas.

      Risk factors

      Seventy-five percent of head and neck cancers are linked to tobacco (smokeless or smoked, including cigars and pipes) and alcohol.
      • Blot W.J.
      • McLaughlin J.K.
      • Winn D.M.
      • et al.
      Smoking and drinking in relation to oral and pharyngeal cancer.
      Use of both alcohol and tobacco greatly increases risk as compared with those who use tobacco or alcohol alone (synergistic effect). HPV-positive oral cancers has increased by 225% recently and is now responsible for 2.8/100,000 individuals.
      • Chaturvedi A.K.
      • Engels R.A.
      • Pfeiffer R.M.
      • et al.
      Human papilloma virus and rising incidence of oropharangeal cancer incidence in the United States.
      Ultraviolet light exposures increase risk for cancers of the lips. Radiation exposure from treatment of other facial cancers increases risk of salivary gland cancers. Chronic mechanical irritation (eg, sharp tooth edge, poor-fitting denture) and poor oral hygiene may also contribute. Other possible risk factors include HIV and betal nut chewing (other parts of the world).

      Prevalence

      Occurrence is 12/100,000/y for oral cancers and when head and neck cancers are taken collectively there are 53,000 new cases annually and 11,500 deaths per year,
      • Siegel R.
      • Naishadham D.
      • Jemal A.
      Cancer statistics, 2013.
      representing 3% of all cancers in the United States, which is the sixth leading cause of cancer-related mortality. There is 30% to 50% higher incidence in African-Americans than in Caucasians; male > female (2:1); predominant age: >40 years. Oral cancer is the eighth most common cancer worldwide.

      Clinical implications

      Five-year survival rates have changed very little in the past decade; however, quality of life is much improved.
      • Genden E.M.
      • Ferlito A.
      • Silver C.L.
      • et al.
      Contemroary management of cancer of the oral cavity.
      Unfortunately lesions are often detected late. If detected at an early stage, survival from oral cancer is better than 90% at 5 years, whereas late-stage disease survival is only 30%. HPV-related oral cancers have lower recurrence rates than non-HPV-related cancers after excision.

      Complications

      Complications from disease and treatments include functional and/or cosmetic disabilities proportional to the degree of surgery, location, and stage of tumor. Radiation therapy or chemotherapy can cause stomatitis with or without candidiasis, tissue hypoxia, tongue mucositis, and fibrosis. Xerostomia (dry mouth) is also a common side effect of treatments, which can lead to caries or dysphagia. Radiation may also cause new neoplasms.

      Diagnostic options and dilemmas

      Clinicians should pay close attention to a history of a nonhealing ulcer or mass in the mouth or on the lip, or any area that bleeds easily or has unexplained pain. Other concerning symptoms may include dysphagia/odynophagia, chronic sore throat or hoarseness, or unexplained ear pain. A thorough oral examination that includes visualization and palpation should be done (and also for those at high risk at regular intervals). Oral cancers can present in many forms. Most concerning are friable granular raised lesions or ulcers that can be confused with infection. Margins may be indurated and hard and extending beyond the borders of the ulcer. A firm neck mass may also suggest metastatic disease. White or red lesions that do not resolve should be biopsied, which is the gold standard for definitive diagnosis. Brush biopsy may be used for smaller oral lesions although, because some studies show brush biopsy to have low sensitivity/specificity, a negative result should be followed with transoral biopsy.
      • Siegel R.
      • Naishadham D.
      • Jemal A.
      Cancer statistics, 2013.
      Further imaging is needed for staging. Differential includes stomatitis, infection, benign ulcers, leukoplakia, and lichen planus.

      Management

      Treatment varies depending on the location. Surgery and radiotherapy for early disease are comparable. Primary radiotherapy (and/or chemotherapy for palliation) is suggested for unresectable tumors and patients not amenable to surgery.
      A dental consult should be obtained before any treatment to prevent serious complications later and to treat or eliminate questionable tooth and gum disease. The severity of mucositis during treatment can be lessened with aloe vera, amifostine, cryotherapy, granulocyte colony stimulating factor, intravenous glutamine, honey, keratinocyte growth factor, laser, polymyxin/tobramycin/amphotericin, antibiotic pastille/paste, and sucralfate.
      • Worthington H.V.
      • Clarkson J.E.
      • Bryan G.
      • et al.
      Interventions for preventing oral mucositis for patients with cancer receiving treatment.
      Avoidance of risk factors for secondary prevention and periodic surveillance examinations are important.
      • Brocklehurst P.
      • Kujan O.
      • Glenny A.M.
      • et al.
      Screening programmes for the early detection and prevention of oral cancer.

      Summary

      There are a host of diseases that manifest in the mouth primarily or secondarily. Medical clinicians should become familiar with presentations for common and serious conditions as outlined above. Clinicians can often make initial diagnosis and management decisions and then refer as necessary. Often a team approach is needed for more complex or chronic conditions. Primary care providers can play an important role in prevention and early diagnosis by advising patients to perform proper hygiene and avoid tobacco and excess alcohol, have regular dental checkups, minimize prescribing medications with oral effects, promote a healthy diet, examine the oral cavity periodically, and make timely referrals.

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