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D R M A R K H O R N I N G
L T , D C , U S N R
The Rainbow of Common Lesions
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Overview
What to take away
There are many common oral lesions
Some require treatment, many do not
Basics of differential diagnosis
You need to know some of the likely possiblilities
Normal from Not Normal
Organization by Color
Pink
White
Red and White
Blue/Black/Brown
Yellow
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D E V E L O P I N G A D I F F E R E N T I A L D I A G N O S I S
How I would start diagnosis
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Chief Complaint
Outside of routine dental exam, there will be a CC
Pain & Symptoms?
Onset and duration?
Often underestimated
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Look at Dental Chart
To see if there is a history of similar problem in past
Possible odontogenic causes from
endodontics
operative dentistry
oral surgery
etc.
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Medical History Form
Tobacco Use
Medicines
Allergies
Surgeries/Hospitalizations
Medical Conditions
Family History
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Exam
Extra Oral Head and Neck
Symmetry Swelling TMJ Lymphadenopathy
Intra Oral Lesion
Location Color Size Shape Raised (exophytic)/Depressed (endophytic)/Flat (Macule) Texture: Soft, fluctuant, hard, indurated, fluid filled, lobes
Look at surrounding teeth
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Oral/Oropharyngeal Cancer- The facts
• Oral and orophayngeal cancer accounts for 30% of Head and Neck Cancer in US
• Oral and oropharyngral cancer is the 8th most common cancer in the US
• 39,500 new cases of Oral Cancer per year in US (90% OSCC)
• 7,500 people will die of oral and oropharyngeal cancer this year in the US
• 500,000 new cases of Oral Cancer per year Globally
• Approximately 50% of patients diagnosed with N+ OSCC will ultimately die of their disease
Ries LAG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2005. Bethesda, MD; National Cancer Institute; 2007.
Holmes JD, Martin RA, Gutta R. Characteristics of head and neck cancer patients referred to an oral and maxillofacial surgeon in the United States for Management. JOMS 2010; 68:
555-561
Greenlee RT, Murray T, Bolden S, et al. Cancer Statistics, 2000. CA: A Cancer Journal for Clinicians 2000;50:7-33
Swango PA. Cancers of the oral cavity and phaynx in the United States: an epidemiological overview. Journal of
Public Health Dentistry 1996;56:309-318
Surveillance, Epidemiology and End Results (SEER) Program, NCI Surveillance Research Program
November 2006 submission of SEER Series 9 (1996-2003)
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F R O M M O S T T O L E A S T C O M M O N
PINK
Color of Lesions
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Exostoses and Tori-Color: Pink -Size: Variable-Shape: Round-Texture: Hard (it’s bone)
Pink Lesions
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Exostoses and Tori
Pain: None, unless ulcerated
Duration: Years
Characteristics: Hard
Extraneous normal bone growth (up to 25% of people)
Location:
Palate
Inner mandible
Buccal bone adjacent to teeth
Treatment: None
Med-evac: No
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Fibroma-Color: Pink-Size: Variable-Shape: Round and Raised-Texture: Soft
Pink Lesions
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Fibroma
Pain: None
Duration: Years
Characteristics:
Most common “tumor” of the mouth
Reactive hyperplasia of fibrous tissue
Normally from trauma (cheek or tongue)
Treatment: Excision and biopsy
Med-evac: No
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F R O M M O S T T O L E A S T C O M M O N
WHITE
Color of Lesions
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Morsicatio & Linea Alba-Color: White-Size: cm’s-Shape: Line and irregular/Flat-Texture: Soft & Rough
White Lesions
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Morsicatio & Linea Alba
Pain: Unlikely
Duration: Variable
Characteristics:
Located at occlusal plane, rough appearance
Pt may be aware of cheek chewing habit
Treatment: None , or remove irritant
Med-evac: No
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Tobacco Pouch Keratosis-Color: White-Size: cm’s-Shape: Pouchlike irregular /Flat-Texture: Soft & Rough
White Lesions
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Tobacco Pouch Keratosis
Pain: Unlikely
Duration: While smokeless tobacco continues
Characteristics:
Abrasion located at habitual site
Rough white
4 x cancer risk
Treatment: Remove irritant, biopsy if does not resolve in 2 weeks
Med-evac: No
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Leukoedema-Color: White-Size: cm’s-Shape: Regular/Raised-Texture:Soft
White Lesions
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Leukoedema
Pain: None
Duration: Inherited
Characteristics:
Located at buccal mucosa
When cheeks stretched, lesion fades
Treatment: None
Med-evac: No
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Leukoplakia-Color: White-Size: cm’s-Shape: irregular /Flat-Texture:S oft
White Lesions
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Leukoplakia
Pain: None
Duration: Variable
Characteristics: White patch that does not rub off and has no other diagnosis
Considered precancerous
Miscellaneous causes, carcinogens, trauma, microorganisms
Treatment: After initial detection follow-up in two weeks, if still present Biopsy
Med-evac: No 4-15% malignant transformation, usually takes years to
develop. However, refer when available
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Lichen Planus-Color: White-Size: cm’s-Shape: Irregular, lacelike, FlatTexture: Soft
White Lesions
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Lichen Planus
Pain: None, possible itching
Duration: Variable
Characteristics: Characteristic striations or lace-like crisscrossing white lines
Immune mediated
Generally asymptomatic
Treatment: Generally none
Conditions can be caused by medicinal reaction
If severe and erosive, (mixed white/erythema) topical corticosteroids
Med-evac: No, evaluation when available if continually symptomatic
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Papilloma-Color: White-Size: mm’s-Shape: Round, Raised/pedunculated-Texture: Soft
White Lesions
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Papilloma
Pain: No
Duration: Appears over months and stays until removed
Characteristics:
Pedunculated, cauliflower appearance with surface projections
Similar to warts (verruca vulgaris) caused by HPV
Treatment: Excise
Med-evac: No, refer when available
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F R O M M O S T T O L E A S T C O M M O N
RED & WHITE
Color of Lesions
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Ulcerations (Traumatic & Apthous& Herpetic)-Color: White/Red -Size: mm’s -Shape: Circular, Flat -Texture: Soft / Ulcerated
Red and White Lesions
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Ulcerations (Traumatic & Apthous & Herpetic)
Pain: Yes Duration: 7-10 days Characteristics: Trauma induced is self-diagnosed Apthous (canker sores) may be stress, immune, or unknown
etiologies Cheek, inner lip, tongue (not gingiva or hard palate)
Herpetic (cold sores) – herpes simplex virus I or II, often stress/trauma causes recurrence Lips, but also gingiva or hard palate
Treatment: None required Traumatic/Apthous: symptomatic (mouthwash coating, cautery,
severe with corticosteroids [lidex, betamethasone, etc]) Recurrent Herpetic: may treat with antiviral (e.g. Acyclovir, etc)
Med-evac: No
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Geographic Tongue-Color: White/Red -Size: cm’s -Shape: Wavy, Flat -Texture: Soft
Red and White Lesions
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Geographic Tongue
Pain: None
Duration: Years
Characteristics:
Alternating patterns of atrophic papillae (red and white)
Unknown causes, immune/hormone mediated
Treatment: None
Med-evac: No
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Candidiasispseudomembranous - thrush
angular cheilitismedian rhomboid glossitis
Red and White Lesions
Color: White/Red
Size:cm’s
Shape: Wavy, Flat
Texture:Soft
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Candidiasis
Pain: Burning
Duration: Normally post antibiotic treatment
Immunocompromised
Angular cheilitis (moist or traumatized angles of mouth)
Characteristics: Most common fungal infection
White, “curdled-milk” plaques that scrape off
Red erythematous areas
Treatment: Antifungal (e.g. nystatin, clotrimazole troche, etc)
Med-evac: No
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Necrotizing Ulcerative Gingivitis “Trench mouth”
Red and White Lesions
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NUG
Pain: Yes
Duration: Days
Characteristics: Punched out and ulcerated interdental papilla & severe gingivitis
More common in military service due to stress-related corticosteroids – immunosuppression
Up to 7% in military recruits
Other factors: smoking, poor oral hygiene, inadequate sleep, malnutrition
Treatment: Remove bacterial challenge, peridex rinse, antibiotics in severe cases with lymphadenopathy/fever
Med-evac: No
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Squamous cell carcinoma
Red and White Lesions
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SCC
Pain: Generally non-painful
Duration: Patient aware of site for 4-24 months prior to seeking treatment
Characteristics: 94% of oral cancers
Most common sites: lateral tongue, floor of mouth, lower lip
Vary from exophytic to endophytic, irregular rolled borders, often ulcerated, indurated (hard)
Treatment: Biopsy wide excision, radiation, chemo
Med-evac: Evaluate with biopsy ASAP if lesion is not resolving
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F R O M M O S T T O L E A S T C O M M O N
BLUE AND BLACK
Color of Lesions
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Mucus retention “cyst”Ranula
Blue/Black Lesions
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Mucocele / Ranula
Pain: Yes, especially at meal time
Duration: Days to years
Characteristics: Trauma disruption of salivary duct
Soft fluid filled (saliva)
Ranula: floor of mouth, can cause raising of the tongue and measure in the centimeters
Treatment: Often self rupturing, but can recur
Med-evac: Recurrent mucoceles: treatment can be easily deferred
Ranula: sometimes airway a concern
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Amalgam tattoo
Blue/Black Lesions
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Amalgam Tattoo
Pain: None
Duration: Years
Characteristics:
Staining of gingiva from impregnated amalgam
Differential with radiograph
Treatment: None
Med-evac: No
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Melanoma
Blue/Black Lesions
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Melanoma
Pain: None
Duration: Months to years 45% 5-year survival rate for oral melanoma
Characteristics: suspect ABCD A: Asymmetry
B: Borders irregular
C: Color variation
D: Diameter greater than 6mm
Pigmented lesions in the mouth (not amalgam tattoos) biopsy
Treatment: Biopsy large margin excision
Med-evac: Refer
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F R O M M O S T T O L E A S T C O M M O N
YELLOW
Color of Lesions
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Fordyce Granules
Yellow Lesions
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Fordyce Granules
Pain: None
Duration: Years
Characteristics:
Multiple yellow/white accumulations of ectopic sebaceous glands
Lips, Buccal mucosa
Treatment: Reassure
Med-evac: No
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Superficial Abscess
Yellow Lesions
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Superficial Abscess
Pain: Yes, from severe to mild Duration: Days to weeks (if draining) Characteristics:
Fluctuant abcess from non-vital tooth Normally perforates the bone to the buccal Frequently cause is obvious
Fractured/carious tooth History of adjacent tooth with deep restoration Periodontal Disease etiology may be less obvious
Treatment: I&D and [pulpectomy or extraction of infected tooth] Antibiotics when definitive treatment unavailable
Pen VK 500mg QID, Clindamycin 300mg QID, others
Med-evac: Good when lesion is localized, treat ASAP Spreading space infections need much more speedy definitive care (drains, IV antibiotics,
etc)
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Yellow
Fordyce Granules
Superficial Abscess
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Refer Quickly-ish
Tooth Related
Abcess
Non Tooth Related
Ranula
Squamous Cell
Melanoma