1. Dry mouth. Anything that reduces saliva will cause an increase in caries. So know about Sjogrens syndrome and any drugs that reduce saliva particularly antidepressants and anticholinergic drugs.
2. White and pink areas in the mouth can signify malignant or premalignant change so know the causes of leuko and erythroplakia. Remember erythroplakia is more likely to signify malignancy.
3. Candidiasis can present in various ways in the mouth. Make sure you know all of them.
4. Ulceration in the mouth may well cause a person to visit their dentist. Know the causes of mouth ulcers eg Apthous ulcers,Trauma, Malignancy, Lichen planus, herpes simplex, rarely herpes zoster, very rarely Pemphigus and Bullous Pemphigoid, Fixed drug eruptions,
5. Lichen planus has various presentations in the mouth and occassionally can be due to amalgam (Mercury} allergy. Know all about this condition and it's management.
6. Know what other general medical disorders will contribute to oral disease eg Diabetes, Cardiac failure, Asthma
7. Know the drugs commonly causing various oral problems eg hypertrophy, bleeding, pigmentation etc
8. Know some causes of lip and intra oral pigmentation because patients will notice this and ask you about it.
9. There are a few classic intraoral tumours. eg Torus, Fibroma, Pyogenic granuloma
10. Classic oral viral diseases such as Herpes simplex, zoster, Hand foot and mouth, Herpangina
11. Oral manifestatations of Immune system disorders especially AIDS
12. Miscellaneous- Gorlin Golitz syndrome, Cowden's syndrome, Darier's disease
Lets look at each of these topics in turn. When the images and text are all up I will add a video where I will describe each of the conditions and their management in more detail.
1. Dry Mouth
There are many causes of a dry mouth ranging from ageing, through diseases which attack the salivary glands such a Sjogrens , to drugs which act on the parasympathetic nervous system inervating these glands and to damage from local radiotherapy for other disorders, plus a few other medical diseases. These are listed in the second slide below.The video below looks at the dry mouth but concentrates on Sjogren's syndrome. Click the arrow to start it and then click on the wheel icon to change the resolution to HD and then click on the bottom right square to make it full screen. It is recorded in high definition if your internet is fast enough to show this.
Good dental care —See them frequently for cleaning, early caries repair and fluoride application after cleaning.
Try toothpastes and special chewing gum giving extra calcium. Use Chlorhexidine mouth washes and soak dentures in it overnight to reduce bacterial and candida infections. Use xylitol and sorbitol sweeteners as they are not fermented by mouth bacteria and hence are less cariogenic.
Fluoride puts a protective mineralised veneer on teeth demineralised areas. Use it in its many forms in Sjogren patients and with other causes of dry mouth
Dentures and implants —Dry mouth and dentures dont go well together. Implants may also give problems, Read up about it before deciding to use them.
.Brightening products — Watch the acidity of these products in Sjogrens patients. Use fluoride gels as well if you decide to use whitening agents.
2. White and pink areas in the mouth
These represent areas of thickening of the cornifying layer of the mucosal epithelium in the mouth. Some are simply benign hyperplasia but others are associated with cellular changes which signify either frank malignancy or the potential to change to such. This cellular atypia is known as dysplasia. You need to biopsy to see what type of thickening you are dealing with. If dysplasia is shown then the area should be removed either by lasering , curetting or surgical excision. Sometimes radiotherapy can be used.
Erythroplakia ie red and white areas is more likely to be malignant. You should take at least two punch biopsies of any significantly involved area in the mouth.
Candida can be superimposed on some of these red white lesions. Dont assume that a positive swab for candida explains what you are seeing!
Erythroplakia may be due to the papilloma virus but many of these are of the oncogenic type and can induce squamous cell carcinomas. Features should show up in the biopsy.
White areas in the mouth can be Candida but rub off, Buccal bite line, White sponge nevus, Leukedema, Leukoplakia, Morsicatio biccarum (cheek biting), Trauma induced white oral lesions eg chemicals, Cigarette keratoses, Nicotine stomatitis, Verrucous carcinoma and some SCCs
Vascular Red Lesions include Varicosities, Haemangiomas, Hereditary haemorrhagic Telangiectasia, Sturge Weber and Kaposi sarcoma
Inflammatory Red lesions include Lichen Planus, Lupus Erythematosus, EM like drug reactions, rarely Pemphigus vulgaris and good old Candida!
3. Candidiasis of the Mouth
It never ceases to amaze me how varied the clinical presentations of Candida are in the mouth. You get it as white semi adherent patches on a red base (Pseudomembranous candidiasis). You see it in the posterior third of the tongue as a red glazed area without the filiform papillae in Median rhomboid glossitis. If the patient has a dental plate then candida will present as a red area underneath it. This is known as Chronic Atrophic Candidiasis or (Denture Sore Mouth). Angular cheilitis is another manifestation helped by the persistent wetness of the redundant lateral folds. A generalised red mouth occurs after antibiotic use and is known as Acute Atrophic Candidiasis (Antibiotic Red Mouth) Chronic Hyperplastic Candidiasis has a grey pebbly surface on the dorsum of the tongue with red atrophic areas showing through. It is seen in diabetics and HIV sufferers.
If steroid ointments are used on the lips candida can grow on the vermillion surface and sometimes as pustules on the lip skin margin.
A patient with the genetic chronic mucocutaneous candidiasis can show all of these presentations at once!
Watch patients who use Steroid inhalers for asthma. They can get oral candidiasis.
4. Mouth Ulceration
If I see one big mouth ulcer that has been present for a month or more then it is a malignancy until a good biopsy proves otherwise.
Otherwise consider Trauma, Apthous ulcers, PseudoApthous ulcers from B 12 Iron or Folate deficiencies, a solitary big Sutton's ulcer (Giant Apthous)
If multiple apthous like ulcers consider Behcet"s syndrome (check the skin, eyes and genitals)
If a granulomatous histology consider TB or Histoplasmosis.
Remember the viral infective causes including herpes simplex and Zoster, the small ellipsoid Hand Foot and Mouth virus and ulcers induced by chemotherapy which may be direct toxicity from the drugs or superimposed viral infection. Graft versus Host disease may also cause mouth ulcers either lichenoid or due to secondary infection.
Then there is good old Lichen Planus and Pemphigus induced ulceration but there should be other clinical features of these conditions to point to the correct diagnosis.
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| Solitary Apthous ulcer |
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| Small herpetiform apthous ulcers |
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| Large Sutton's ulcer variant of Apthous ulceration |
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| A large ulcerated area like this is malignant until proven otherwise |
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| Primary herpes simplex stomatitis |
5. Lichen Planus
Let me start by saying that if a patient only has lichen planus in the mouth then consider it is a drug reaction.
In the mouth Lichen Planus will present as reticular, erosive, erythematous (atrophic) or plaque like areas. The classic is the Reticular or net like pattern on the buccal mucosae. More than 1 type can be found in the same patient.
The most common site of involvement is the posterior buccal mucosa Other common sites are the gingiva, labial mucosa, tongue, and vermillion of the lower lip . Infrequently, lesions develop on the palate, floor of the mouth, or upper lip.
Atrophic Lichen planus looks red.and is not ulcerated.Wickhams Striae may be seen around the outside of the atrophic red area. When this variant involves the gingivae it is called desquamative gingivitis.
Erosive Lichen Planus occurs after a blister bursts and the surface sloughs off. The centre has a yellowish pseudomembrane. It can resolve with scarring . It can cause hyperpigmentation in dark skinned individuals.
The Plaque type is white with a rough surface and often asymptomatic and seen on the buccal surface or tongue. Remember that an SCC malignancy can develope in areas of chronic LP!
Lichenoid mucositis occurs in oral mucosae adjacent to old amalgam fillings. Biopsies will be reported as lichen planus.Take them out and replace them with porcelin or composites.
Desquamative gingivitis with widespread erosions on the gingiva can occur with several inflammatory oral diseases including lichen planus .
Watch for candida superinfection in cases of oral lichen planus
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This is histology of skin lichen planusDifferential DiagnosesConsider other white patches such as Leukoedema, Leukoplakia, Candida, Squamous cell carcinoma, Lichenoid drug reaction, Lichenoid reaction to amalgum mercury, Graft versus host disease in transplant patients and erosions from other autoimmune blistering diseases such as pemphigus. mucosal pemphigoid, Bullous p[emphigoid, lupus erythematosus and EBA.Lichenoid Drug Eruptions
ACE Inhibitors for hypertension
Beta Blockers for heart rhythm problems
Hydroxychloroquine for malaria or Lupus
Thiazide diuretics for oedema
TreatmentNon Drug - good oral hygiene No irritation from abnormal teeth or appliances Avoid local mouth trauma stop smoking avoid acid and salty foods Drugs Topical steroids Kenalog in orabase Topical tacrolimus Intrlesional steroid injection Kenacort Topical and Oral Cyclosporin Oral Steroids Retinoids Imuran |
6. General Medical Conditions causing Oral problems
Under this heading I usually think of Erythema multiforme after drugs or herpes virus infections, lichenoid drug reactions and apthous ulcers especially those secondary to iron, B12 or folate deficiency.
Then there are oral side effects of drugs used to treat medical conditions such as antiepileptic gum hypertrophy and mouth ulcers from cytotoxic drugs. Any disease reducing saliva eg Sjogrens will cause both caries and periodontal problems as will saliva reducing drugs in many other disorders.
Many viral exanthems have oral features but they are usually short lived eg Koplic spots in measles and elliptical vesicles in Hand Foot and Mouth disease.
Venereal disiseases can also have oral presentations such as chancre in syphilis.
However by general medical diseases we should consider Diabetes, Cardiac failure, Chronic lung disease and Asthma etc. What oral problems do they cause? A main contributer here are the drugs they are taking.
Anaemia by reducing oxygen carriage impairs healing. Vitamin B deficiency causes angular cheilitis and iron deficiency causes a sore glazed painful tongue (glossodynia) and apthous ulcers.
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| Graft versus host disease occurs particularly after an allogenic bone marrow transplant for say leukaemia where cytotoxic T cells attack the graft and host skin, mouth, liver and salivary glands. |
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| Syphilitic ulcer on the tongue |
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| Syphilitic ulcer lip Image courtesy of Dr Ted Rosen |
7. Drug causes of Oral Problems
We have dealt with some of these drugs already in other sections but there are a few classic drugs you should be aware of. I will list them at the end of this section. There are also a few classic oral drug induced diseases such as Erythema multiforme (Stevens Johnson variant), Fixed drug reaction and Lichen planus like responses.
Tetracyclines - stained teeth
Fluoride supplements - stained teeth
Hydroxychloroquine - pigmentation
Minomycin - pigmentation
Methamphetamines - severe caries
Bisphosphonates - osteonecrosis after dental extractions
Cytotoxic drugs - erosions, candida
ACE inhibitors - Lichen planus
NSAIDS - Fixed drug Lip
Dry Mouth from Antidepressants, Antihistamines, Cardiac drugs, Anticholinergics for bladder incontinence,
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| Erythema multiforme with erythema and ulcers in the mouth and lip surfaces |
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| These are often on the lip in Fixed drug reactions |
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| Composite view of the lesions on the lips and skin in Erythema multiforme Note Target lesions |
8. Lip and Intra oral Pigmentation
Dark or black pigmentation in the mouth raises the prospect of melanoma. However there are many other causes. You can get benign pigmented nevi in the mouth! Nonetheless if new they should all be biopsied.
Dentists are going to see a lot of amalgam tatoos. They are usually buccal opposite the back amalgam filled molars.Remember India ink and graphite from pencil injuries can also cause intra oral tatoo like lesions.
Racial factors often explain intra oral pigmentation, sometimes called melanoplakia but I dislike the term as it suggests it is raised. Look at the extensive oral physiologic pigmentation in the first image below! Also consider Addison's disease. Heavy Metal poisoning from Mercury, Lead and Silver.
Lip freckles are seen in Peutz Jeger syndrome and the Laugier Hunziger syndrome.
Solitary pigmented lip macules are seen after blistering sunburns and are known as Labial melanotic macules. They have no malignant potential.
Remember some drugs can cause oral pigmentation particularly hydroxychloroquine in lupus erythematosus and malaria and long term high dose Minomycin used for Rosacea.
Tobacco also causes a brown intra oral pigmentation in really heavy smokers. This is called Smoker's melanosis.
See the reference for the above image.
See the reference for the above image
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Melanoma of the oral cavity Note the irregular spreading edge |
9. Classic intra oral tumours
Here I always think of traumatic or Irritation fibromas , mucoceles and tori plus implantation lip cysts from trauma but there are also oral tumours particularly hard tongue swellings and salivary gland tumours ( pleomorphic adenomas), Kaposi's sarcoma in AIDS cases and rarely lymphomas particularly Hodgkins disease with peritonsilar tumours and neurofibromas. Vascular and lymphatic malformations may present as oral swellings from an early age..
There are also several other intra oral nodules that have specific dental origins such as the retrocuspid papilla, and the oral lymphoepithelial cyst. The Periphertal Odontogenic fibroma arises from the cells of the periodontal ligament and thus differs in location from the irritation fibroma which it resembles.
Lipomas, Traumatic neuromas and neurofibromas also occur in the mouth. Multiple small neurofibromas on the lips or floor of the mouth should have you thinking of the Multiple endocrine neoplasia syndrome which as the name suggests has neoplasia of several endocrine organs.
Osteomas are known as periosteal when they arise from the outer surface of the bone and endosteal osteomas arise within the medullary bone. More than one osteoma should have you thinking of Gardner's syndrome with associated intestinal polyps which unlike Peutz Jager have a high tendency to become malignant.
PS In the video I initially correctly attribute a Marfanoid look to the Multiple endorine neoplasia syndrome then I make a mistake and change my mind and relate it to Gardner's syndrome. Wrong!
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Kaposi's sarcoma a herpes 8 virus induced vascular tumour presenting as a purplish discoloration on the gums. |
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Ulcerated Squamous cell carcinoma tongue |
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Lymphomas presenting as peritonsillar tumours |
10. Classic oral viral diseases
Papilloma virus infections are numerically the commonest intra oral virus infection but Herpes simplex, zoster, herpangina and hand foot and mouth disease are the other big four with EBV ( infectious mononucleosis) up there as well.
Cytomegalovirus invades salivary tissue causing salivary gland swellings and xerostomia. It can also cause apthous ulcer like lesions but really only in AIDS cases
View the source of the above image.
View the source of the image above
This is oral hairy leukoplakia due to Epstein Bar virus in HIV patients.
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Primary infection with herpes simplex giving severe stomatitis |
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These may be condyloma accuminatum ie venereal warts often Types 6 and 11 |
View the source of the above image.
11. Oral Signs of Immune System disorders
This can be wide ranging eg Autoimmune diseases such as Sjogren's, with the dry mouth, Lupus erythematosus with oral blisters and ulcers, Pemphigus with blisters and ulcers, EBA etc.
Many diseases have some immune considerations eg Graft versus Host disease in bone marrow transplants. Diabetes will lead to a reduction in efficiency of your immune system. Severe periodontal disease from any cause will "stress" the immune system and lead to more severe periodontal disease.
Primary immune deficiency diseases are rare but those with defects in neutrophil phagocytic function all give rise to severe periodontal disease and bacterial mouth infections. T cell deficiency diseases tend to cause viral mouth infections.
The main acquired immune deficiency disease is HIV infection and AIDS. Here you see chronic oral herpes infections, oral hairy leukoplakia due to EB vius and Kaposi's sarcoma from Herpes 8 infection plus chronic oral candidiasis.
Patients with Chronic Mucocutaneous candidiasis have a specific immune defect in dealing with candida albicans and will get severe oral and vaginal or genital candidiasis plus severe nail dystrophy but their immune system is perfectly ok otherwise!
Patients with Chronic Mucocutaneous candidiasis have a specific immune defect in dealing with candida albicans and will get severe oral and vaginal or genital candidiasis plus severe nail dystrophy but their immune system is perfectly ok otherwise!
12. Miscellaneous
Oral Papules - Cowdens syndrome, Darier's disease
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Cowdens syndrome with flat wart like papules on the lip. See this case in the reference below |
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Oral papules on the palate in Darier's disease See this case in Globalskinatlas |
Big Tongue - Hypothyroidism, Primary Amyloidosis and myeloma
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