Spring 2007
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Scientific Article Lumps,
Bumps and Common Oral Lesions
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Dentistry
is not simply about drilling and filling teeth, but every patient must
be examined in a comprehensive manner. This includes a thorough evaluation.
It’s imperative for the dentist to have knowledge regarding not
only the oral cavity but a general knowledge of systemic pathologies.
Various neoplasias, autoimmune diseases, endocrine malfunctions and bacterial,
viral, fungal infections all have oral manifestations. The majority of
individuals visit the dentist far more often than their physician, and
as a result, we are at a greater advantage of finding and starting early
treatment for some serious life threatening pathologies. Therefore, the
dentist must be aware of the various etiologies, oral and dermatological
manifestations, as well as treatment options. This will enable the oral
health care provider to neither under diagnose nor over diagnose the present
condition. Both of these actions have consequences. This article will
discuss only a few of the lumps, bumps and common oral lesions that may
be encountered in daily practice. The purpose of this article is to gear
the dental practitioners and students to examine the patient as a whole
and to bring the importance of oral and systemic pathology into modern
dentistry. My philosophy is “If the pieces of the puzzle don’t
seem to add up correctly, then there’s a piece that’s being
neglected.”
I’ll start with the most benign classifications and progress to the more feared malignancies. Firstly, I’d like to consider some common physical and chemical induced lesions that may be encountered. These findings may be mistaken for something more serious than they truly are. This is why obtaining a comprehensive examination is crucial. Common physically induced lesions include linea alba, morsicatio buccarum, exfoliative chelitis and angular chelitis. The etiology of lineaalba is most likely frictional irritation or pressure. Linea alba is a white line, usually bilateral and most prominently found at the level of the occlusal plane of the adjacent teeth, restricted to dentulous areas. Linea alba is not a leukoplakia because it can easily be identified clinically [figure 1].
Morsicatio buccarum is a fancy term for “cheek biting”. It’s most commonly bilateral and found in women before the age of thirty-five. Its clinical appearance is irregular and shredded, usually on the buccal mucosa or on the lateral borders of the tongue which makes this harmless factitious lesion resemble speckled erythroplakia, a combination of red and white lesion with erosive areas highly associated with cancer [figure 2].
Knowing the patient’s habits and looking for the bilateral appearance will rule out all serious pathologies. There are many etiologies associated with exfoliative cheilitis including overexposure to sun, wind and cold weather, mouth breathing, bacterial and fungal infections or it may in fact be associated with an autoimmune or vitamin deficiency. Exfoliative cheilitis may also be factitious as a result of chronic lip sucking. A similar condition termed angular cheilitis, is in fact the most common presentation of bacterial and fungal infections of the lips. Angular cheilitis is most often found in denture patients due to overclosure and mechanical irritation. It’s important to know the underlying cause in order to proceed with treatment. Treatment may involve simply applying chapstick with UV protection or may involve a micolog treatment involving antibacterial, antifungal as well as corticosteroids. In all of these cases, no biopsy is required and can all be identified and treated clinically. Some chemically induced lesions one may encounter in practice are aspirin burns, amalgam tattoos and lead poisoning. Once again, these lesions need to be differentiated from other more serious conditions. One manifestation of systemic metal intoxications such as with mercury, gold, bismuth, arsenic and lead is a state of hypersalivation. Lead as well as possibly bismuth produces a dark pigmentation along the free gingival margin referred to as a “lead line”. Heavy metal intoxications may also produce neurological effects including numbness, tingling and uncontrolled motor movements as well as altered taste and mucositis. Many of these manifestations are representative of other diseases as well. Therefore, a thorough examination is required. Lead poisoning is found in children that lick lead paints on old homes or lead batteries or in industrial workers. Gold is a type of treatment for arthritis. Mercury may be obtained from fish, in particular shark. Various chelating agents are used to treat systemic metal intoxications. Another area of focus in pathology is the common benign epithelial and soft tissue lumps and bumps. The most common epithelial proliferation is the papilloma. HPV viral subtypes 6 and 11 have been identified in up to 50% of oral papillomas. Three percent of all oral biopsies submitted are oral papillomas. Papillomas clinically present as a pedunculated, painless, nodular exophytic mass most predominantly on the tongue but also found on the soft palate and lips. Papillomas don’t progress to squamous cell carcinomas and are distinct entities. [figure 3].
The most common soft tissue tumor of the oral cavity is the fibroma. Similar to papillomas, fibromas are asymptomatic unless secondarily irritated. They are sessile, nodular, pink, firm, and normally found on the buccal mucosa [figure 4].
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The pyogenic granuloma is also a common soft tissue tumor found in the oral cavity. The name is quite misleading and makes you think it’s in fact a granuloma with histiocytes. However, similar to the periapical granuloma, it’s a lesion that simply contains granulation tissue. It differs from the fibroma such that it’s always red, ulcerated and vascular histologically. The pyogenic granuloma is also sometimes referred to as the “pregnancy tumor”. However, pyogenic granulomas are not distinctly found in pregnant women and may in fact be found in both men and women. The pyogenic granuloma is most often found on the gingiva. The treatment for all these benign proliferations is surgical excision making sure you get the base of the lesion to prevent recurrence. The next series of lesions should bring more concern upon finding. These lesions include erythroplakia, proliferative verrucous leukoplakia (PVL) and submucous fibrosis. By definition, leukoplakia is a white patch that doesn’t scrape off. More importantly, it cannot be identified clinically as another lesion. Therefore, this classification excludes the linea alba which was discussed earlier as well as lesions such as leukoedema. Leukoedema is simply a developmental lesion found mainly in African American women. It normally occurs bilaterally in the buccal mucosa. Leukoedema is in fact a white lesion that doesn’t rub off but it fails to meet the second part of the definition for leukoplakia. Leukoedema disappears when stretched because its etiology is excess fluid accumulated in the spinous layer of the epithelium [figure 5].
By definition then, erythroplakia is a red patch that doesn’t scrape off and can’t be identified as another lesion clinically. Twenty five percent of all leukoplakic lesions are either dysplasia or cancer at time of biopsy. This statistic jumps to 50% if the leukoplakia is found in the non-keratinised areas of the ventral tongue and floor of the mouth. Erythroplakia are even more indicative of dysplastic or cancer changes at time of biopsy. Regardless of their location, 90% of these lesions show at least dysplastic changes. More than 80% of patients with oral leukoplakia and erythroplakia are smokers and mostly men. Therefore, it’s crucial to take a full exam as well as perform an oral cancer screening on each patient. Oral submucous fibrosis is a chronic, progressive scarring and high risk precancerous condition primarily seen in the Indian subcontinent. It has been linked to the chronic placement in the mouth of betel quid. The chief complaint of these patients is trismus (pain on opening) and stomatopyrosis (burning). The most commonly affected area is the soft palate as well as the retromolar pad and buccal mocosa. It’s crucial to perform biopsies on all suspicious lesions and to surgical excise or perform immediate subsequent treatments based on the progression of the lesion. Actinic keratosis is another premalignant condition and may be found on the facial skin as well as on the lower lip vermillion which is termed actinic cheilosis. Fair skinned males with a lot of UV exposure are at higher risk. The clinical appearance is a crusted, possibly ulcerated lesion with possibly no vermillion border present or “everting” of the lower lip. The treatment of choice is to perform a lip shave. Finally, the most common and malignant oral lesion is squamous cell carcinoma. Squamous cell carcinoma presents as the most common head and neck cancer and still only has a 50% survival rate [figure 6].
The etiology involves
both instrinsic and extrinsic factors. A painless ulcer in the oral cavity has a very small list of differential diagnoses. The most benign case would be chronic traumatic eosinophilic ulcerations that have become asymptomatic over time. Other possibilities include granulomatous lesions such as those found in TB, sarcoid, wegener’s granulomatosis and tertiary syphilis ulcers. The most feared diagnosis would be a neoplasia including squamous cell carcinoma. The most common intraoral carcinoma is found on the tongue, either posterior lateral borders or ventral surfaces. Other sites may include the soft palate, gingiva or buccal mucosa. Warning signs include irregular radiolucencies, moth eaten appearance, unusual widening of the periodontal ligament and disappearance of cortical bone on radiographs. The patient’s best interest should always come first. In order to do that, the oral health care provider needs to be educated on all aspects of oral pathology. Since the prognoses of oral malignancies are incredibly poor, prevention becomes key. By focusing just on the teeth, the oral health care provider can miss many important findings that may cost the patient’s life. About the
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