Dental Update - Oral medicine: 7. red and pigmented lesions

Article

Specialist referral may be indicated if the Practitioner feels:

The diagnosis is unclear;

A serious diagnosis is possible;

Systemic disease may be present;

Unclear as to investigations indicated;

Complex investigations unavailable in primary care are indicated;

Unclear as to treatment indicated;

Treatment is complex;

Treatment requires agents not readily available;

Unclear as to the prognosis;

The patient wishes this.

This article covers first red lesions and then hyperpigmentation.

Red oral lesions

Red oral lesions are commonplace and usually associated with inflammation in, for example, mucosal infections. However, red lesions can also be sinister by signifying severe dysplasia in erythroplasia, or malignant neoplasms (Table 1).

Table 1. Most common causes of red lesions.

LOCALIZED Inflammatory lesions Geographic tongueCandidosisLichen planusDrug reactionsReactive lesionsPyogenic granulomasPeripheral giant cell granulomasAtrophic lesionsGeographic tongueLichen planusLupus erythematosusErythroplasiaVitamin B₁₂ deficiencyPurpuraTraumaThrombocytopeniaVascularTelangiectases (hereditary haemorrhagic telangiectasia or scleroderma)Angiomas (vascular hamartomas)NeoplasmsSquamous carcinomaKaposi's sarcomaGiant cell tumourWegener's granulomatosisGENERALIZEDCandidosisAvitaminosis B complex (rarely)Irradiation or chemotherapy-induced mucositisPolycythaemia

Inflammatory lesions

Most red lesions are inflammatory, usually:

Geographic tongue (erythema migrans) (Figure 1);

Viral infections (eg herpes simplex stomatitis);

Fungal infections;

Candidosis;

– Denture-related stomatitis; discussed below, is usually a form of mild chronic erythematous candidosis consisting of inflammation beneath a denture, orthodontic or other appliance (Figure 2);

– Median rhomboid glossitis; a persistent red, rhomboidal depapillated area in the midline dorsum of the tongue (Figure 3);

– Acute oral candidosis; may cause widespread erythema and soreness, sometimes with thrush, often a complication of corticosteroid or antibiotic therapy. Red lesions of candidosis may also be seen in HIV disease, typically in the palate (Figure 4);

Bacterial infections;

Cancer treatment-related mucositis; common after irradiation of tumours of the head and neck, or chemotherapy, eg for leukaemia;

Immunological reactions; such as lichen planus, plasma cell gingivostomatitis, granulomatous disorders (sarcoidosis, Crohn's disease, orofacial granulomatosis), amyloidosis, and graft versus host disease.

Figure 2. Candida-associated denture stomatitis.

Geographic tongue (erythema migrans)

Geographic tongue (erythema migrans) is a very common condition and cause of sore tongue, affecting at least 1–2% of patients. There is a genetic background, and often a family history. Many patients with a fissured tongue (scrotal tongue) also have geographic tongue. Erythema migrans is associated with psoriasis in 4% and the histological appearances of both conditions are similar.

Some patients have atopic allergies, such as hay fever, and a few relate the oral lesions to various foods, eg cheese. A few have diabetes mellitus.

Clinical features

Geographic tongue typically involves the dorsum of the tongue, sometimes the ventrum and, on occasions, it may affect other oral mucosal sites. It is often asymptomatic, but a small minority of patients complain of soreness and these patients are virtually invariably middle-aged. If sore, this may be noted especially with acidic foods (eg tomatoes or citrus fruits) or cheese.

There are irregular, pink or red depapillated map-like areas, which change in shape, increase in size, and spread or move to other areas, sometimes within hours (Figure 5).

The red areas are surrounded by distinct yellowish slightly raised margins (Figure 6). There is increased thickness of the intervening filiform papillae.

Diagnosis

The diagnosis of geographic tongue is clinical mainly from the history of a migrating pattern and the characteristic clinical appearance. Blood examination may rarely be necessary to exclude diabetes, or anaemia, if there is confusion with a depapillated tongue of glossitis.

Keypoints: geographic tongue

The cause is unknown but it may be inherited;

It resembles, and is associated rarely with, psoriasis;

It has no long-term consequences;

There is no cure and treatment is therefore aimed at controlling symptoms and reassuring the patient.

Management

Reassurance remains the best that can be given. Zinc sulphate 200 mg three times daily for 3 months or a topical rinse with 7% salicylic acid in 70% alcohol are advocated by some and may occasionally help.

Keypoints for patients: geographic tongue

This is a common condition;

The cause is unknown;

It may be inherited;

There may be an allergic component;

It is not thought to be infectious;

It is associated, rarely, with psoriasis;

It has no long-term consequences.

Patient information and websites:

http://www.eaom.eu/files/geographic_tongue.pdf

http://www.mayoclinic.com/health/geographic-tongue/DS00819

Denture-related stomatitis (denture-induced stomatitis; denture sore mouth; chronic erythematous candidosis)

Denture-related stomatitis consists of mild inflammation of the mucosa beneath a denture – usually a complete upper denture. This is a common condition, mainly of the middle-aged or elderly; more prevalent in women than men.

Aetiopathogenesis

Dental appliances (mainly dentures), especially when worn throughout the night, or a dry mouth, favour development of this infection. It is not caused by allergy to the dental material (if it were, it would affect mucosae other than just that beneath the appliance).

However, it is still not clear why only some denture-wearers develop denture-related stomatitis, since most patients appear otherwise healthy.

Dentures can produce a number of ecological changes; the oral flora may be altered and plaque collects between the mucosal surface of the denture and the palate.

The accumulation of microbial plaque (bacteria and/or yeasts) on, and attached to, the fitting surface of the denture and the underlying mucosa produces an inflammatory reaction. When Candida is involved, the more common terms ‘candida-associated denture stomatitis’, ‘denture-induced candidosis’ or ‘chronic erythematous candidosis’ are used.

In addition, the saliva that is present between the maxillary denture and the mucosa may have a lower pH than usual. Denture-related stomatitis is not exclusively associated with infection, and occasionally mechanical irritation is at play.

Clinical features

The characteristic presenting features of denture-related stomatitis are chronic erythema and oedema of the mucosa that contacts the fitting surface of the denture (Figure 2). Uncommon complications include:

Angular stomatitis (soreness and erythema at the commissures (Figure 7);

Papillary hyperplasia in the vault of the palate.

Figure 7. Angular stomatitis (cheilitis).

Classification

Denture-related stomatitis has been classified into three clinical types (Newton's classification), increasing in severity:

A localized simple inflammation or a pinpoint hyperaemia;

An erythematous or generalized simple type presenting as more diffuse erythema involving a part of, or the entire, denture-covered mucosa;

A granular type (inflammatory papillary hyperplasia) commonly involving the central part of the hard palate and the alveolar ridge.

Diagnosis

Denture-related stomatitis and angular stomatitis are clinical diagnoses, although may be confirmed by microbiological investigations. In addition, haematological and biochemical investigations may be appropriate to identify any underlying predisposing factors, such as hyposalivation, nutritional deficiencies, anaemia and diabetes mellitus in patients unresponsive to conventional management.

Keypoints for dentists: denture-related stomatitis

Denture-related stomatitis is caused mainly by a yeast (Candida), but bacteria may also be involved;

It may be precipitated by prolonged wearing of a dental appliance, especially at night;

It predisposes to angular cheilitis;

It is best controlled by:

Leaving out the appliance, allowing the mouth to heal;

Disinfecting the appliance (as per additional instructions);

Using antifungal creams or gels (eg miconazole; Daktarin), oral suspension (eg nystatin; Nystan) or capsules (fluconazole; Diflucan) regularly for up to 4 weeks;

The appliance may require adjustment or changing;

Blood tests, microbiological studies or biopsy may be required if the lesion is unresponsive.

Management

The denture plaque and fitting surface is infested with micro-organisms, most commonly Candida albicans and, therefore, to prevent recurrence, dentures should be left out of the mouth at night, and stored in an appropriate antiseptic which has activity against yeasts (Table 2).

Table 2. Management of denture-related stomatitis.

Denture hygiene measuresAntifungal therapy (eg topical or systemic)If unresponsive to above, investigate for underlying predisposing factors

Cleansers containing alkaline hypochlorites, disinfectants, or yeast lytic enzymes are most effective against Candida. Denture soak solution containing benzoic acid is taken up into the acrylic resin and can completely eradicate C albicans from the denture surface. Chlorhexidine gluconate can also eliminate C albicans on the denture surface and a mouthwash can reduce the palatal inflammation. A protease-containing denture soak (Alcalase protease) is also an effective way of removing denture plaque, especially when combined with brushing.

The mucosal infection is eradicated by brushing the palate with chlorhexidine mouthwash or gel, and using miconazole gel, nystatin oral suspension or fluconazole, administered concurrently with an oral antiseptic, such as chlorhexidine, which has antifungal activity.

Keypoints for patients: denture sore mouth (denture-related stomatitis)

Denture sore mouth is common, but rarely sore;

It is caused mainly by a yeast (Candida) that usually lives harmlessly in the mouth and elsewhere;

It is not transmitted to others;

It may be precipitated by prolonged wearing of a dental appliance, especially at night, which allows the yeast to grow;

It predisposes to sores at the corners of the mouth (angular cheilitis);

It has no serious long-term consequences;

Blood tests, microbiological studies or biopsy may be required.

It is best controlled by:

Leaving out the appliance, allowing the mouth to heal;

Cleaning the appliance (as below);

Disinfecting the appliance (as per additional instructions);

Using antifungal creams or gels regularly for up to 4 weeks;

The appliance may require adjustment or changing;

Keep the appliance as clean as natural teeth. Clean both surfaces (inside and outside) after meals and at night. Use washing-up liquid and a toothbrush and lukewarm water and hold it over a basin containing water, in case you drop it, which could cause it to break. Never use hot water, as it may alter the colour. A disclosing agent, for example Rayners Blue or Red food colouring (available at most supermarkets) can be applied with cotton buds, to help see whether you are cleaning the appliance thoroughly enough. If stains or calculus deposits are difficult to remove, try an overnight immersion (eg Dentural, Milton or Steradent), or an application of Denclen.

Dentures should be left out overnight, so that your mouth has a rest. It is not natural for your palate to be covered all the time and the chances of getting an infection are increased if the dentures are worn 24 hours a day. Ensure you leave the dentures out for at least some time and keep them in Dentural or Steradent, as they may distort if allowed to dry out.

Special precautions for dentures with metal parts; Denclen, Dentural and Milton may discolour metal, so use with care. Brush briefly to remove stains and deposits, rinse well with lukewarm water and do not soak overnight.

Before re-use, wash in water and brush the appliance to remove loosened deposits.

Website and patient information

http://emedicine.medscape.com/article/1075994-overview

Neoplastic lesions: red neoplasms include:

Peripheral giant cell tumours;

Angiosarcomas, such as Kaposi's sarcoma, a common neoplasm in HIV/AIDS, appears in the mouth as red or purplish areas or nodules, especially seen in the palate;

Squamous cell carcinomas;

Wegener's granulomatosis.

Vascular anomalies (angiomas and telangiectasia) include:

Dilated lingual veins (varices) may be conspicuous in elderly persons; this is part of the normal spectrum;

Haemangiomas (Figures 8–10) are usually small isolated developmental anomalies, or hamartomas;

Telangiectasias (Figure 11) – dilated capillaries – may be seen after irradiation and in disorders such as hereditary haemorrhagic telangiectasia and systemic sclerosis.

Figure 8. Vascular hamartoma (haemangioma on tongue).

Figure 9. Vascular hamartoma (haemangioma in palate).

Figure 10. Haemangioma in floor of mouth.

Figure 11. Telangiectasia, lips and tongue.

Angiomas are benign and usually congenital. In general, most do not require any active treatment, unless symptoms develop, in which case they can be treated by injection of sclerosing agents, cryosurgery, laser excision or surgical excision.

Vesiculobullous disorders, such as erythema multiforme, pemphigoid and pemphigus, may present as red lesions (Article 2), especially localized oral purpura, which presents with blood blisters (Figure 12). Specialist referral is usually indicated.

Figure 12. Angina bullosa haemorrhagica.

Reactive lesions

Reactive lesions that can be red are usually persistent soft lumps (Figures 13 and 14) which include:

Pyogenic granulomas; and

Peripheral giant cell granulomas.

Figure 13. Pyogenic granuloma, lower lip.

Specialist referral is usually indicated.

Atrophic lesions

The most important red lesion is erythroplasia, since it is often dysplastic (see below). Geographic tongue also causes red lesions (see above). Desquamative gingivitis is a frequent cause of red gingivae (Figure 15), which is almost invariably caused by lichen planus or pemphigoid, and iron or vitamin deficiency states may cause glossitis (Figure 16) or other red lesions.

Erythroplakia (erythroplasia)

Erythroplasia is a rare condition defined as ‘any lesion of the oral mucosa that presents as bright red velvety plaques which cannot be characterized clinically or pathologically as any other recognizable condition’.

Mainly seen in elderly males, it is far less common than leukoplakia, but far more likely to be dysplastic or undergo malignant transformation.

Clinical features

Erythroplakia is seen most commonly on the soft palate, floor of mouth or buccal mucosa. Some erythroplakias are associated with white patches, and are then termed speckled leukoplakia (Figure 17).

Figure 17. Erythroplasia in soft palate complex.

Diagnosis

Biopsy to assess the degree of epithelial dysplasia and exclude a diagnosis of carcinoma.

Prognosis

Erythroplasia has areas of dysplasia, carcinoma in situ, or invasive carcinoma in most cases. Carcinomas are seen 17 times more often in erythroplakia than in leukoplakia and these are therefore the most potentially malignant of all oral mucosal lesions.

Management

Erythroplastic lesions are usually (at least 85%) severely dysplastic or frankly malignant. Any causal factor, such as tobacco use, should be stopped, and lesions removed.

There is no hard evidence as to the ideal frequency of follow-up, but it has been suggested that patients with mucosal potentially malignant lesions be re-examined:

Within 1 month;

At 3 months;

At 6 months;

At 12 months and

Annually thereafter.

Purpura (bleeding into the skin and mucosa) is usually caused by:

Trauma, occasional small petechiae are seen at the occlusal line in perfectly healthy people;

Localized oral purpura or angina bullosa haemorrhagica is an idiopathic, fairly common cause of blood blisters, often in the soft palate, in older people (Figure 12). Sometimes the use of a corticosteroid inhaler precipitates this;

Thrombocytopenia can result in red or brown pinpoint lesions (petechiae) or diffuse bruising (ecchymoses) at sites of trauma, such as the palate;

Suction (eg fellatio may produce bruising in the soft palate).

Diagnosis

Diagnosis of red lesions is mainly clinical but lesions should also be sought elsewhere, especially on the skin or other mucosae.

It may be necessary to take a blood picture (including full blood count and platelet count), and assess haemostatic function or exclude haematinic deficiencies. Investigations needed may include other haematological tests and/or biopsy or imaging.

Management

Treatment is usually of the underlying cause, or surgery.

Hyperpigmentation

Oral mucosal discoloration may be superficial (extrinsic) or due to deep (intrinsic – in or beneath mucosa) causes and ranges from brown to black.

Causes of extrinsic discoloration include:

Habits such as tobacco or betel use;

Coloured foods or drinks (such as liquorice, beetroot, red wine, coffee and tea);

Drugs (such as chlorhexidine, iron salts, crack cocaine, minocycline, bismuth subsalicylate and lansoprazole).

Black hairy tongue (Figure 18) is one extrinsic type of discoloration seen especially in patients on a soft diet, smokers, and those with dry mouth or poor oral hygiene. The best that can usually be done is to avoid the cause where known, and to advise the patient to brush the tongue or use a tongue-scraper.

Causes of Intrinsic discoloration are summarized in Table 3.

Table 3. Main causes of intrinsic mucosal hyperpigmentation.

Localized

Amalgam or other tattoo

Naevus

Melanotic macule

Neoplasms (eg Malignant melanoma or Kaposi's sarcoma)

Pigmentary incontinence

Peutz-Jegher's syndrome

Generalized

Racial pigmentation

Localized irritation, eg tobacco or betel

Drugs, eg antimalarials

Pregnancy/oral contraceptive pill

Addison's disease (hypoadrenalism)

Localized areas of pigmentation may be caused mainly by:

Amalgam tattoo (embedded amalgam). Typically, this is a single blue-black macule in the mandibular gingivae, or at least close to the scar of an apicectomy (Figures 19 and 20), or where amalgam has accidentally been introduced into a wound, is painless, and does not change in size or colour. A lesion suspected to be an amalgam tattoo is best radiographed first to see if there is radio-opaque material present, though not all are radio-opaque. If the lesion is not radio-opaque, it is best biopsied to exclude naevi or melanoma. Similar lesions can be caused by other foreign bodies (eg graphite tattoo), local irritation or inflammation.

Melanotic macules are usually flat, single brown collections of melanin-containing cells, seen particularly on the vermilion border of the lip (Figure 21) and on the palate. If there is any doubt over the diagnosis they are best removed to exclude melanoma.

Naevi are blue-black, often papular, lesions formed from increased melanin-containing cells (naevus cells) seen particularly on the palate. They are best removed to exclude melanoma.

Pigmentary incontinence may be seen in some inflammatory lesions, such as lichen planus, especially in smokers.

Malignant melanoma is rare, seen usually in the palate (Figure 22) or maxillary gingivae. Features suggestive of malignancy include a rapid increase in size, change in colour, ulceration, pain, the occurrence of satellite pigmented spots or regional lymph node enlargement. Incisional biopsy to confirm the diagnosis followed by radical excision is indicated.

Kaposi's sarcoma is usually a purple lesion seen mainly in the palate (Figure 23) or gingivae of HIV-infected and other immunocompromised people.

Figure 21. Melantonic macule, lower labial mucosa.

Keypoints: single hyperpigmented lesions

If the lesion could be an amalgam tattoo, consider taking a radiograph;

If the lesion is radio-opaque, it is probably an amalgam tattoo and should be left alone;

If the lesion is not radio-opaque, or if it was not initially considered likely to be an amalgam tattoo, biopsy it.

Generalized pigmentation, often mainly affecting the gingivae (Figure 24) is common in people of colour, and is racial and due to melanin. Seen mainly in black and ethnic minority groups, it can also be noted in some fairly light-skinned people. Such pigmentation may be first noted by the patient in adult life and then incorrectly assumed to be acquired.

In all other patients with widespread intrinsic pigmentation, systemic causes should be excluded. These may include:

Drugs

– Tobacco, which can also cause intrinsic hyperpigmentation – smoker's melanosis (Figure 25);

– Antimalarials, oral contraceptive pill, anticonvulsants, minocycline, phenothiazines, gold, busulphan and other drugs;

– Heavy metals (such as mercury, lead and bismuth) not used therapeutically now, rarely cause pigmentation through industrial exposure;

Pregnancy;

Hypoadrenalism (Addison's disease). Hyperpigmentation in this is generalized but most obvious in normally pigmented areas (eg the nipples, genitalia), skin flexures, and sites of trauma. The mouth may show patchy hyperpigmentation. Patients also typically have weakness, weight loss, and hypotension.

Diagnosis

The nature of oral hyperpigmentation can sometimes only be established after further investigation.

In patients with localized hyperpigmentation, in order to exclude melanoma, radiographs may be helpful (they can sometimes show a foreign body) and biopsy may be indicated, particularly where there is a solitary raised lesion, a rapid increase in size, change in colour, ulceration, pain, evidence of satellite pigmented spots or regional lymph node enlargement. If early detection of oral melanomas is to be achieved, all pigmented oral cavity lesions should be viewed with suspicion. The consensus of opinion is that a lesion with clinical features, as above, seriously suggestive of malignant melanoma, are best biopsied at the time of definitive operation.

In patients with generalized or multiple hyperpigmentation, Specialist referral is indicated.

Management

Management is of the underlying condition.

Patients to refer:

Erythroplasia/erythroplakia – in view of high risk of malignant transformation;

Squamous carcinoma;

Melanoma;

Kaposi's sarcoma;

Wegener granulomatosis in view of associated systemic disease.

Amalgam, trams and Northern Ireland

The adult orthodontic–restorative interface. Part 2: treatment strategies for the management of developmental conditions

Oral medicine: 7. red and pigmented lesions

Authors

David H Felix

Jane Luker

Crispian Scully

Article

Red oral lesions

Inflammatory lesions

Geographic tongue (erythema migrans)

Clinical features

Diagnosis

Keypoints: geographic tongue

Management

Keypoints for patients: geographic tongue

Denture-related stomatitis (denture-induced stomatitis; denture sore mouth; chronic erythematous candidosis)

Aetiopathogenesis

Clinical features

Classification

Diagnosis

Keypoints for dentists: denture-related stomatitis

Management

Keypoints for patients: denture sore mouth (denture-related stomatitis)

Reactive lesions

Atrophic lesions

Erythroplakia (erythroplasia)

Clinical features

Diagnosis

Prognosis

Management

Diagnosis

Management

Hyperpigmentation

Keypoints: single hyperpigmented lesions

Diagnosis

Management

Patients to refer: