A routine part of an oral examination should be inspection not only of the teeth and gums but also of the soft tissues in and around the mouth. Changes in these tissues are known as Oral mucosal disorders. These disorders are common. The vast majority of these disorders are innocuous and can be easily diagnosed based upon their appearance alone. However, some lesions are not as easy to identify and may require a biopsy (removal of a piece of the lesion to examine under a microscope). A very small percentage of these disorders may be precancerous or even cancer. Premalignant lesions and early cancers are usually asymptomatic (i.e. the patient has no pain and they don’t even know they have a lesion), so regular dental review is important to pick up these subtle changes.
Sore / Dry Mouth –is common in middle aged or elderly patients, they may complain of burning pain with or without dryness. These symptoms may be linked to hematological (blood) conditions or, occasionally, conditions such as Sjögren’s syndrome where investigations are normal.
Recurrent aphthous stomatitis (RAS) is a common condition, affecting the mouth that typically starts in childhood or adolescence as recurrent small ulcers. It is the commonest oral mucosal disorder, affecting 10-15% of people. Approximately 40% of patients with RAS have a family member affected with the condition. RAS is not contagious (it can’t be passed from one person to another).
Most RAS cases are minor aphthous ulceration which are characterised by small, shallow ulcers which heal in 10-14 days without scarring. Major aphthous ulcers are larger, deeper and heal in 2-4 weeks with scarring. If mouth ulcers have not resolved within 4 weeks an oral & maxillofacial surgeon opinion should be obtained.
Toothpaste containing sodium lauryl sulfate, trauma, stress, cessation of smoking, menstrual cycle association, and food allergies may predispose to developing RAS Aphthous like ulcers may appear in iron deficiency, folate deficiency, vitamin B-12 deficiency, Coeliac disease, Crohn disease, Behçet syndrome, HIV and cancer.
The treatment of RAS is aimed at controlling the symptoms. Steroids may be used to reduce the frequency and severity of ulceration. Analgesic and antibiotic mouthwashes may reduce the pain and discomfort. Avoidance of predisposing factors is also beneficial.
Vesiculobullous Disorders are a series of blistering disorders that affect the mouth. These blisters may contain blood or clear fluid, and may leave a scar when they burst. The main ones are pemphigoid and the potentially fatal auto-immune disease pemphigus. A biopsy is usually required to differentiate the different types. Blood filled blisters can also occur, usually on the palate, in the harmless condition of angina bullosa haemorrhagica.
Burning mouth syndrome is a relatively common condition that is characterised by abnormal sensation of the lining of the mouth. Burning mouth syndrome is more common in post-menopausal women. Blood tests and mouth swabs are taken, and if those tests are normal, and if the mucosa (lining) of the mouth appears normal, then a diagnosis of burning mouth syndrome is made. Burning mouth is not related to anything serious, ad it is not contagious. Burning mouth syndrome is a frustrating situation for both patients and doctors as we don’t know what causes it and we don’t have a treatment for it.
White and Red Patches are common in the mouth. The important distinction is between those which are harmless and those which are, or are potentially, cancerous.
Candidiasis (oral thrush) can occur in an acute form or a chronic form usually associated with the wearing of dentures. Debilitating illness, immuno-suppression and radiotherapy are predisposing factors. Treatment is with anti-fungal therapy or occasionally laser surgery for cases of hypertrophic candidiasis. Candidiasis is a benign condition.
Lichen planus is an inflammatory condition that can affect the lining of the mouth as well as the skin. . Some patients have the condition on the skin, hair, nails or genitals. It is common and affects up to 2% of the population. The cause of lichen planus is unknown. Although there is no known cure treatment can be given to make the symptoms better. In the mouth lichen planus is usually found on the inside of the cheeks and on the side of the tongue. Usually lichen planus has a lace-like pattern of streaky white patches that occasionally can be thickened. Sometimes lichen planus may be associated with red patches or sores. Lichen planus is not cancer, is not inherited, is not contagious and is not related to your diet. However some foods you eat may make the patches of lichen planus sore. Lichenoid drug reactions are common so it is important to check the medications you are taking.
In its mildest form it may be asymptomatic and will be picked up on a routine dental examination. More severe cases may cause ulceration, soreness and discomfort in the mouth. The appearance of lichen planus is usually typical and can be diagnosed by an experienced doctor by taking a history and looking inside your mouth. However it usually best to confirm the diagnosis a biopsy. If lichen planus is not causing any problems it does not require treatment. Topical steroids are the mainstay of treatment in symptomatic cases and good oral hygiene helps reduce symptoms.
You may find it helpful to keep a diary and look for trigger events if you have a flare-up of symptoms. These flare-ups may be related to particular foods, stress or local trauma. it may be beneficial to change to a milder form of toothpaste. If mouth ulcers are present with lichen planus and they have not resolved within 4 weeks an oral & maxillofacial surgeon opinion should be obtained.
Precancerous and cancerous lesions can present as red and/or white patches.
Leukoplakia is a clinical term that is used to describe certain white patches in the mouth. Not all white patches are called leukoplakia – just the ones that cannot be rubbed off and cannot be diagnosed as any other condition or disease. Leukoplakia is important because, over time (typically months to years), a percentage of these white patches may transform to oral cancer. There is a higher risk of transformation at some sites such as the floor of the mouth.
Many times a direct cause cannot be identified, but a large percentage of patients with leukoplakia have smoked or are ex smokers.
Diagnosis of leukoplakia is made by taking a medical history, and conducting a thorough examination. A biopsy is often required. Management includes the elimination of risk factors, in particular smoking especially when combined with consumption of alcohol, and biopsy. Treatment depends on several things and is different for every individual and ranges from no treatment to observation to further surgery.
Erythroplakia (red patches) and erythroleukoplakia (a mixture of red and white patches) should always be considered malignant until proven otherwise and it is essential that all these suspicious lesions are referred to the appropriate oral & maxillofacial clinic without investigation or biopsy in primary care.
More information can be found at http://www.aaoms.org/oral_cancer.php