Oral lesions

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Synonyms and keywords: Oral cavity lesions, Oral cavity ulcers, Oral cavity infections, Mouth ulcers, Mouth lesions.

Overview

In many cases, mouth sores are attributed to herpes simplex virus and idiopathic aphthous stomatitis. Oral lesions can be indicative of a more serious underlying condition. A full review of the systems and a full skin exam are necessary to obtain an accurate diagnosis.

Pathophysiology

Oncology Medications

Diseases

Drugs

Xerostomia

Increase in pathogenic bacteria in a pathogenic biofilm

↓ pH

↑ bacterial growth

Oral lesions

Differential diagnosis of oral cavity lesions

Surface oral lesions
Oral lesions			Appearance	Associated conditions	Location	Microscopic	Image
White Lesions		Leukoedema	White or whitish grey edematous lesion Diffuse or patchy	Variant of normal oral mucosa	Buccal and labial oral mucosa	Intracellular edema or vacuolization of Malpighian cells
		Fordyce granules	White or yellow discrete papules Symmetrically distributed	Variant of normal oral mucosa	Buccal mucosa Vermillion border of the lips	Similar to normal sebaceous glands of skin Lacks hair follicles and almost always lack ductal communication with surface.
		Benign migratory glossitis	Red patches with white distinct border Map like appearance	Psoriasis Diabetes Reiter's syndrome Medications such as Oral contraceptive pills and lithium carbonate	Dorsal/Lateral surface of the tongue	Acanthosis with neutrophils throughout epithelium and surface Microabscesses, plus inflammatory infiltrate in lamina propria Resembles psoriasis
		Hairy tongue	Elongated filiform lingual papillae Carpet like appearance	Xerostomia Medications such as anti-psychotics HIV Amyotropic lateral sclerosis	Dorsum of the tongue	Marked elongation and hyperparakeratosis of the filiform papillae
		Hairy leukoplakia	White patches Corrugated in appearance Hairy, hair-like growths Permanent	EBV virus infection Immunosupression	Buccal mucosa Lateral surface of the tongue Floor of the mouth Palate	Hyperkeratotic oral mucosa due to piling of keratotic squamous epithelium Cowdry type A intranuclear inclusions Balloon cells with margination of chromatin
		White sponge nevus	White patches of tissue (nevi) Singular or multiple Thickened, velvety, sponge-like appearance	Hereditary	Buccal mucosa	Parakeratosis, acanthosis Extensive vacuolization Dyskeratotic cells exhibit dense peri and paranuclear eosinophilic condensations Abundant Odland bodies
		Lichen Planus	Reticular or papular lace like white lesions Multiple, Painful	Autoimmune disorders	Posterior buccal mucosa Gingival margin	Hyperkeratosis and acanthosis Granular cell layer, saw toothing of rete pegs, bandlike chronic inflammatory infiltrate Civatte bodies Artifactual cleft formation No atypia
		Frictional hyperkeratosis	White shaggy plaques Could be easily peeled without any pain leaving normal mucosa	Bite trauma Grinding of the teeth	Buccal mucosa Limited to line of dental occlusion	Hyperkeratinization and acanthosis Smooth, corrugated, or ragged, epthelial surface with multiple keratin projections
		Leukoplakia	White or grayish in patches that can't be wiped away Irregular or flat-textured Thickened or hardened in areas Along with raised, red lesions (speckled leukoplakia or erythroplakia), which are more likely to show precancerous changes	Smoking	Soft palate Floor of mouth Ventral surface of tongue and the retromolar area	Varies histologically from acanthosis, hyperkeratosis, dysplasia or carcinoma in situ Carcinoma in situ is associated with lymphocytes and macrophages
		Erythroplakia	Fiery red patch Smooth, velvety, granular or nodular lesions	Highest risk of malignant transformation	Soft palate Floor of mouth Ventral surface of tongue and the retromolar area	Thin atrophic epithelium with prominent subepithelial vascularity and inflammation Almost all erythroplakic lesions contain dysplastic cells
Oral lesions			Appearance	Associated conditions	Location	Microscopic	Image
Pigmented lesions	Ephelis		Flat red or light brown spots 3–10 mm in diameter Poorly defined and may merge into large patches	Sun exposed skin	Predominant in outer lips	Mild hyperpigmentation of basal keratinocytes, normal architecture
	Oral melanocytic macule		Focal pigmented brown lesions similar to ephelides Flat and mostly smaller than 1 cm Characterised by a focal increase in melanin production	Laugier Hunziker syndrome	Gingiva, Lower lip buccal mucosa palate	No atypia Melanin pigmentation tends to be present in significant amounts in the basal-cell layer
	Oral melanoacanthoma		Rapidly enlarging, asymptomatic, pigmented macule.	Strong female predilection	Buccal mucosa	Proliferation of benign dendritic melanocytes scattered throughout the epithelium, acanthosis and spongiosis
	Smoker's melanosis		Irregular macular hyperpigmentation of the oral mucosa. Brown patches	Smoking Tobacco chewing	Mandibular anterior gingivain cigarette smokers Buccal mucosa in pipe smokers. Hard palate in those who engage in reverse smoking	Increased melanin pigmentation is noted in the basal cell layer of the epithelium Melanin incontinence may also be noted in the underlying lamina propria
	Melanoma		Varies from dark brown to blue-black Mucosa-colored and white lesions are occasionally noted Erythema is observed when the lesions are inflamed.	Idiopathic	80% cases involve palate and maxillary gingiva Buccal mucosa, mandibular gingiva, and tongue lesions	Acral lentiginous Malignant cells often nest or cluster in groups in an organoid fashion
	Addison's disease		Mucosal hyperpigmentation	Autoimmune polyendocrine syndrome Autoimmune hypoparathyroidism resulting in hypocalcemia Vitiligo Premature ovarian failure Pernicious anemia Myasthenia gravis Chronic candidiasis Sjögren syndrome Chronic active hepatitis Diabetes mellitus type 1 Hypothyroidism Hashimoto thyroiditis Graves hyperthyroidism Adrenoleukodystrophy	Gingival Vermillion border of the lips Buccal mucosa, palateand tongue	Hyperparakeratinized areas showing acanthosis, spongiosis, exocytosis, vacuolar degeneration, Substantial deposition of melanin in all epithelial layers Melanocytic hyperplasia Dendritic melanocytes in all epithelial layers.
	Peutz jeghers syndrome		Flat, painless brown pigmented patches	Inherited, autosomal dominant	Perioral Freckling of the skin around lips and vermillion zone of the lips. Intraorally Buccal mucosa Tongue Labial mucosa	Mild acanthosis with elongation of the rete pegs with increased pigmentation in the melanocytes and adjacent keratinocytes
	Neurofibromatosis		Nodular neurofibroma Macroglossia Enlargement of filiform papillae	Cafe au lait macules Freckling in the axillary or inguinalregions (Crowe´s sign) Optic glioma Lisch nodules (irishamartomas) Sphenoid dysplasia A first-degree relative	Tongue Lips Palate Buccal mucosa Gingiva Floor of the mouth or the pharynx	Proliferation of all elements of peripheral nerves Schwann cells with wire like collagen fibrils, fibroblasts and collagen Perineurial cells in plexiform types, mitotic figures are rare
	Polyostotic fibrous dysplasia		Orofacial deformity Dental disorders Bone pains Compromised oral health	McCune-Albright syndrome	Predominantly involves musculo-skeletal defects of oral cavity Gingiva	Curvilinear trabeculae of metaplastic woven bone in hypocellular, fibroblastic stroma
	Amalgam tattoo		Blue-black macules	Dental Implant surgery	Gingival margin or proximal buccal mucosanear amalgam dental fillings	Pigmented fragments of metal within connective tissue A scattered arrangement of black or dark brown granules Large particles may be surrounded by chronically inflamed fibrous tissue
Oral lesions			Appearance	Associated conditions	Location	Microscopic	Image
Vesicular/Erythematous Ulcerative lesions	Infections	Herpes simplex virusinfections	Herpetic gingivostomatitis Painful ulcers covered by a yellowish pseudomembrane Ulcers that may coalesce to form bigger lesions Self limiting after 7 days	HSV 1 Infection	Gums Palate Tongue Lips	Keratinized and non-keratinized mucosa. Intra and intercellular edema (acantholysis) Intranuclear inclusions Multinucleate polykaryons (giant cells)
		Herpes zoster	Clustered small ulcers with characteristic unilateral pattern		Hard palate. Buccal mucosa Tongue Gingiva	Keratinocytes are multinucleated, acantholytic with distinct nuclear inclusions, found initially in follicular epithelium Late epidermal necrosis or full-thickness acantholysis Dermal nerve twigs may exhibit a perineural infiltrate of lymphocytes and neutrophils, sometimes associated with intraneural involvement Schwann cell hypertrophy and frank neural necrosis are occasionally encountered
		Hand foot mouth disease	Irregularly shaped shallow ulcers with yellow-grey base and hyperemic margin.	Coxsackievirus	Margings of tongue Inside of cheeks Anterior fauces On the mandible above the posterior molar teeth Soft palate	Vesicular lesions will demonstrate loose strands of fibrin, lymphocytes and neutrophils in the vesicular fluid. The presence of acantholysis in the epidermis and perivascular infiltration of leukocytes is seen in hand foot and mouth disease. The absence of intracelluar inclusion bodies differentiates it from the herpes simplex infection.
		Infectious mononucliosis	Tonsillar exudates Appear white, gray-green, or even necrotic Palatal petechiae with streaky hemorrhages and blotchy red macules	Epstein-Barr virus infection Kissing's Disease	Pharynx Tonsils	Reactive lymphoid hyperplasia Extensive immunoblastic proliferation in sheets and nodules, marked atypia resembling Reed-Sternberg cells
		Erosive lichen planus	Ulcerative stomatitis		Buccal mucosa Sides of the tongue Gingiva Lips
		Pseudomembranous candidiasis	Known as thrush. Usually asymptomatic. Confluent white wipeable plaques resembling curdled milk Superficially the plaques can be wiped off and the underlying mucosa often exhibits an erythematous appearance.	Chronic medications Immuno-suppressive conditions	Oral mucosa, Tongue Buccal mucosa Hard palate	Wet mount examination with 10% KOH or saline demonstrates hyphae, pseudohyphae, and blastospores.
		Histoplasmosis	Disease affect the lungs and cause acute or chronic respiratory problems in the immunocompromised population. Ulcerating erosive or nodular lesions in the oral mucous membrane. The oral lesions may also appear granulomatous and may be painful The ulcers may often resemble carcinoma or tuberculosis because of the raised and rolled borders, usually covered by a yellow or greyish membrane.	Ohio and Mississippi river valleys	Oral mucosa Tongue Palate Lips	Characterized by a budding yeast connected with a narrow base and is mostly identified within the macrophages and monocytes.
		Blastomycosis	Ulcerative mucosal lesions Sessile projections, granulomatous or verrucous lesions. Small ulcers are characteristic oral manifestation and may present as a primary lesion or secondary to disseminated disease. Oral lesions may resemble actinomycosis without the suppurative element	Mississippi, Missouri and Ohio River valleys and the Great lakes region.	Ginguve Mostly Pulmonary Nodules	Classic appearance on modified Wright's stain Multinucleated yeast cell Single broad-based bud Round to oval in shape with 12 um diameter
		Coccidiodomycosis	Asymptomatic Pulmonary or extrapulmonary disease Oral lesions are uncommon Described as ulcerated granulomatous nodules Ulcers appear nonspecific and usually heal by hyalinization and scar	Dust exposure in endemic areas, due to occupational activities agricultural or construction workers Military personnel training in endemic areas Construction work, and model airplane competitions Natural disasters such as earthquakes and windstorms	Tongue	It is a dimorphic fungus and on microscopy, the following can be seen Spherule with endospores Rarely as hyphae in lung biopsy
	Autoimmune diseases	Pemphigus vulgaris	Superficial ulcers to small vesicles or blisters. In the oral cavity, the bubbles rapidly break, leaving a painful erosion producing burning sensation. The size of the ulcers is extremely variable. Nikolsky's sign	Inflammatory bowel disease Rheumatoid arthritis	Buccal mucosa Soft palate Lower lip Tongue Less frequently, at the gingiva	Intraepithelial blister with acantholysis and chronic inflammation
		Mucous membrane pemphigoid (Cicatricial pemphigoid)	Desquamative gingivitis The lesions show as simple erythema or true ulcerations affecting both the fixed gingiva and the adherent gingiva. The symptoms associated with these conditions go from burning sensation and bleeding to mastication impairment Pemphigoid blisters are less brittle than those seen in pemphigus Remain intact in the oral cavity for up to 48 hours	Hypothyroidism	Gingiva Buccal mucosa Palate	Subepidermal vesicle contains edema fluid, fibrin and variable inflammatory cells Perivascular lymphohistiocytic infiltrate, plasma cells and neutrophils Fewer eosinophils than generalized bullous pemphigoid Conjunctival squamous metaplasia with foci of hyperkeratosis and parakeratosis, accompanied by goblet cell depletion; conjunctival vesicles or bulla are rare
		Aphthous ulcer	Shallow, round to oval ulcer with white or yellow pseudomembrane surrounded by halo In chronic ulcer grey membrane may replace the yellow pseudomembrane	SLE IBD	Appear on the non-keratinizing epithelial surfaces in the mouth. Except the attached gingiva, the hard palate and the dorsum of the tongue	Non-keratinized oral mucosa along the labial or buccal surfaces, soft palate, floor of the mouth, ventral or lateral surface of the tongue and oropharynx
		Erythema multiforme	Prodromal skin target lesions, bullae and ulcerations with irregular borders and inflammatory halos, bloody encrustations on the lips	Infections e.g. EBV, CMV herpes, and mycoplasma etc Drugs e.g. sulfonamides, anticonvulsants etc	Lips Buccal mucosa Tongue	Subepidermal bullae with basement membrane in bullae roof due to dermal edema Severe dermal inflammatory infiltrate (includes lymphocytes, histiocytes) Eosinophils may be present, but neutrophils are sparse or absent Overlying epidermis often demonstrates liquefactive necrosis and degeneration, dyskeratotic keratinocytes May also have dermoepidermal bullae with basal lamina at floor of bullae Variable epidermal spongiosis and eosinophils No leukocytoclasis, no microabscesses, no festooning of dermal papillae
		Sjogren's Syndrome	Affects salivary and lacrimal glands Dryness in the mouth (xerostomia) Deficiency of tears causes xerophthalmia Lack of saliva predisposes patients to develop tooth cavities. Accumulation of plaque Edema and inflammations of the gingiva are frequent clinical signs. Moreover, a salivary flow decrease can develop opportunistic infections.	Crohn's disease	Gingiva Parotid gland Tooth	Extensive lymphoid infiltrate with germinal centers, often interstitial fibrosis and acinar atrophy
		Bullous pemphigoid	Discrete vesicle formation with Multiple ulcers Desquamative gingivitis as the most common presentation	Psoriasis Parkinson's disease Dementia Certain drugs e.g. spironolactone, loop diuretics and neuroleptics Malignancies e.g. breast cancer	Gingiva	Unilocular, subepidermal, nonacantholytic blisters with festooning (suspended in a loop between two points) of dermal papillae, infiltrate including eosinophils located in blister cavity and in the dermis Early erythematous lesion shows upper papillary dermal edema, perivascular lymphohistiocytic infiltrate, accompanied by conspicuous eosinophils
	Idiopathic conditions	Allergic contact stomatitis	Erythema, vesicle formation, erosion, ulcer formation and shaggy hyperkeratosis		Tongue Gums Hard palate Buccal mucosa	Oral mucosa may appear acanthotic, hyperkeratotic with elongated rete ridges Lamina propria infiltrated by lymphocytes, plasma cells, histiocytes and eosinophils Hallmark of ICD is perturbation of the skin barrier and epidermal regenerative hyperproliferation Hallmark of ACD is spongiosis
		Irritant contact stomatitis

Soft tissue oral lesions
Reactive lesions		Appearance	Associated conditions	Location	Microscopic	Image
Inflammatory papillary hyperplasia		Benign lesion characterized by hyperemic mucosa One or more bulbous or nodular growth measuring less than 2 mm	Torus palatinus Candida albicans infections Use of upper dentures smoking poor oral condition	Hard palate	Papillary projections Stratified squamous epithelium Edematous connective tissue Chronic inflammatory infiltrate
Fibrous hyperplasia		Presents as a yellowish–white or mucosal colored, sessile, smooth-surfaced, asymptomatic, soft nodule. The surface may be hyperkeratotic or ulcerated, owing to repeated trauma.	Diphenylhydantoin ingestion Cyclosporine A Nifedipine	The most common intraoral site is along the occlusal line of the buccal mucosa It also affects the lower lip, tongue, hard palate and edentulous alveolar ridge	Unencapsulated, solid, nodular mass of dense and sometimes hyalinized fibrous connective tissue. The surface epithelium is usually atrophic, Show signs of continued trauma, such as, excess keratin, intracellular edema of the superficial layers or traumatic ulceration
Mucocele		Mucus cyst is a distinct, fluctuant, painless swelling of the mucosa. <1 cm in diameter Superficial lesions take on a bluish to translucent hue Deep lesions have normal mucosal coloration Bleeding into the swelling may impart a bright red and vascular appearance.	Rupture of salivary gland duct by blockade of salivary gland duct.	Lower lip Tongue Floor of mouth (ranula) Buccal mucosa	Inflammatory cells and mucin lift epithelium of sinus and periosteum away from underlying bone Epithelium may undergo squamous metaplasia Extravasation of mucin into lamina propria with muciphages
Necrotizing sialometaplasia		Non-ulcerated swelling that transforms into crater like ulcer 1-5cms	Inflammation of salivary gland Dental injuries	Hard palate >> Soft palate	Acinar necrosis in early lesions Squamous metaplasia of salivary glands
Periodontal abscess		The oral mucosa covering an abscess appears erythematous and painful to touch. The surface may be shiny due to stretching of the mucosa over the abscess. Before pus has formed, the lesion will not be fluctuant, and there will be no purulent discharge.	Originates in the dental pulp Associated with living tooth	Dental line Gingiva	Neutrophils are found surrounding a central area of soft tissue debris and destroyed leukocytes. At later stage, a pyogenic membrane is organized macrophages and neutrophils
Periapical abscess		Usually attached to tooth root Firm or have deflated capsule Lumen can contain thin serous or straw colored fluid, opaque yellow-white debris, muddy brown fluid from old hemorrhage or frank purulent debris	Originates in the dental pulp Associated with dead tooth	Dental line Gingiva	Lined by stratified squamous epithelium of variable thickness, often with scattered ciliated cells Exception is when epithelium is derived from maxillary sinus and thus lined with respiratory epithelium (pseudostratified ciliated columnar epithelium), may have acute inflammatory cell infiltrate
Tumors		Appearance	Associated conditions	Locations	Microscopic	Image
Epithelial tumors	Squamous cell carcinoma	Initially it may present as a painless, rough white or red lesion with induration In advanced stages it presents as a painful ulcerated lesion with elevated margins and increased nodularity and feels hard on palpation It may also appear as a fixed exophytic lesion with irregular margins, delayed healing after dental extraction or as a cervical lymph node enlargement	Tobacco use Alcohol HPV infection	Lip SCC arise almost exclusively on the lower lip Buccal mucosa Upper and lower gingiva Hard palate Anterior two-thirds of the tongue, including dorsal, ventral and lateral surfaces, and the floor of mouth	Squamous cell carcinoma may be well, moderately or poorly differentiated. SCC variants: Basaloid: Bimorphic i.e. both basaloid and squamous cell component. Solid basaloid appearing dysplastic island with biphasic pattern showing comedo type necrosis and pseudoglandular pattern. Abrupt foci of squamous differentiation with or without keratin pearls. Verrucous Intense keratinization, compressive pattern and minimal atypia. Papillary Spindle cell Adenosquamous Acantholytic Cunniculatum
	Oral epithelial dysplasia	Lesion may appear as a homogeneous white or red patch, mixed white/red speckled area or as an ulcer	HPV-16, HPV-33	Common sites: Tongue Floor of the mouth Buccal mucosa Lips Other less common sites are gingiva, retromolar area and palate	Histopathologically it may be classified as Mild: Hyperkeratosis Basilar hyperplasia Increased hyperchromaticity Lower third of epithelial thickness involved Moderate: Parakeratosis Disorganization of the strata with basilar hyperplasia Nuclear enlargement and hyperchromaticity Drop shaped rete ridges involving one half of epithelial thickness Severe: Loss of cellular organization and polarity Basilar hyperplasia nuclear enlargement and hyperchromaticity Drop shaped rete ridges involving two-third of epithelial thickness
	Proliferative verrucous leukoplakia	Initially it may present as a white hyperkeratotic plaque that ultimately proliferates and becomes multifocal with confluent exophytic mass	HPV EBV Candida	Buccal mucosa Tongue Gingiva Alveolar ridge	Microscopic findings depends on the stage of the dsease as it progresses from leukoplakia to verrucous hyperplasia then to verrucous carcinoma and then papillary squamous cell carcinoma. The histopathological findings associated with PVL are as under: Hyperkeratotic epithelium showing basilar hyperplasia and hyperchromatic cells extending upto lower third of epithelium Stroma consisting of collagen fibres with plum to spindle shaped fibroblasts with patchy distribution of lymphocytes and plasma cells
Papillomas	Condyloma acuminatum	Painless, rounded, dome-shaped exophytic nodules 15 mm in diameter Have a broad base and a nodular or mulberry-like surface that is slightly red, pink or of normal mucosal color. Lesions may be multiple and are usually clustered	HPV, most commonly types 6,11,16 and 18	Labial mucosa Tongue Palate	Several sessile, cauliflower-like swellings forming a cluster
	Verrucous vulgaris	Soft, pedunculated lesions formed by a cluster of finger-like fronds or a sessile, dome-shaped lesion with a nodular, papillary or verrucous surface	HPV subtype 2,4,6,7,10,40.	Any oral site may be affected mostly: Hard and soft palate Labial mucosa Tongue Gingiva	Exophytic and comprise folds of hyperplastic stratified epithelium Cluster of finger-like projections
	Multifocal epithelial hyperplasia	Multiple asymptomatic lesions Soft rounded or flat plaque-like sessile swelling. Usually pink or white in color 2-10 mm in diameter	HPV 13 and 32	All areas of the oral cavity Labia Buccal mucosa Tongue	Rounded sessile swelling formed by a sharply demarcated zone of epithelial acanthosis Koilocytes similar to those of squamous papilloma are usually present “Mitosoid bodies”, which are nuclei with coarse clumped heterochromatin resembling a mitotic figure
Salivary type tumors	Mucoepidermoid carcinoma	Asymptomatic Bluish, domed swellings that resemble mucoceles or haemangiomas High-grade tumors result in ulceration, loosening of teeth, paraesthesia or anaesthesia		Palate (most common site) Buccal mucosa Lips: upper>lower Floor of oral cavity Retromolar pad	Low power microscopy shows low-grade tumor with both cystic and solid areas and an inflamed, fibrous stroma
	Pleomorphic adenoma	Painless, slow growing, submucosal masses, but when traumatized may bleed or ulcerate		Palate Lips and Buccal mucosa	Histopathological findings shows cellular, and hyaline or plasmacytoid cell
Soft tissue and Neural tumors	Granular cell tumor	Lesion presents as a smooth, sessile mucosal swelling 1-2 cm in diameter with a firm texture. The overlying epithelium is of normal color or may be slightly pale		Tongue is the most common single site Buccal mucosa Floor of oral cavity Palate Salivary gland	Plump eosinophilic cells with central small dark nuclei and abundant granular cytoplasm
	Rhabdomyoma	It usually presents as a non tender smooth, solitary or rarely multifocal nodule. Or as a confined intramuscular mass in the tongue		Floor of the mouth Base of the tongue Buccal mucosa Pharynx Larynx	Histopathologically, adult type rhabdomyoma is composed of large, polygonal vacuolated cells with eosinophilic cytoplasm. Vacuolization varies among cells and gives it a spider web appearance While fetal type rhabdomyoma has striated muscle fibres in different stage of maturation mixed with undifferentiated mesenchymal cells arranged randomly in a edematous stroma
	Lymphangioma	Circumscribed painless swelling Soft and fluctuant on palpation Irregular nodularity of the dorsum of the tongue	Developmental malformation Genetic abnormalities Turner's syndrome	Tongue	Thin-walled, dilated lymphatic vessels of different size, which are lined by a flattened endothelium
	Hemangioma	Flat, and erythematous red patches.	POEMS syndrome Castleman disease PHACES syndrome	Buccal mucosa Gums Lips	Increased number of vessels (normal / abnormal) Readily recognizable vascular structures with red blood cells or transudate Lined by single layer of non atypical endothelial cells
	Kaposi sarcoma	Purplish, reddish blue or dark brown macules Plaques and nodules that may ulcerate	HIV and HHV-8	Hard palate is most frequently affected, followed by the gums	Spindle cells with minimal nuclear atypia
	Myofibroblastic sarcoma	Painless swelling or an enlarged mass		Tongue	Infiltrative tumor with a diffuse growth pattern on a myxoid background Spindle shaped tumor cells arranged in intertwined fascicles of varying length Tumor cell have scant amount of eosinophilic cytoplasm with a oval shaped nuclei
Hematolymphoid tumors	Plasmablastic lymphoma	It may appear as thickened ulcerative lesion that may invade the adjacent bone	HIV EBV HHV-8	Intraoally: Gingival mucosa Palatal mucosa	Diffuse sheet of large immunoblastic, plasmablastic cells with abundant eosinophilic cytoplasm having peripheral nuclei and vesicular chromatin
	Langerhan cell histiocytosis	Swelling Pain Gingivitis Loose teeth and Ulceration	Associated with: Eosinophilic granulomas Multifocal multisystem disease	Jaw bone Intraoral soft tissues Gingiva Palate Floor of mouth Buccal mucosa Tonsil	Biopsy shows ovoid langerhans cells with deeply grooved nuclei, thin nuclear membrane and abundant eosinophilic cytoplasm
	Extramedullary myeloid sarcoma	Isolated tumor-forming intraoral mass	History of acute myeloid leukemia, predominantly in the monocyticor myelomonocytic subtypes	Palate Gingiva	Diffuse infiltration of the connective tissue by poorly differentiated hematopoietic cells the cells are large, round to oval with basophilic cytoplasm and dense nuclei
Tumors of uncertain histiogenesis	Congenital granular cell epulis	Solitary Pedunculated fibroma like lesion	Congenital Spontaneously regresses over first 8 months of life	Gum pads Attached to the alveolar ridge near the midline	Sheets of polygonal cells Abundant granular, eosinophilic cytoplasm Single basophilic nucleus Scant fibrous stroma
	Ectomesenchymal chondromyxoid tumor	Asymptomatic Slow growing solitary nodule		Tongue, mainly on its anterior side	Tumor cells in myxoid, chondroid or hyalinized background Round, cup-shaped, fusiform, or polygonal cells with uniform small nuclei and moderate amounts of faintly basophilic cytoplasm Some tumors may show nuclear pleomorphism, hyperchromatism, and multinucleation
Cysts	Oral Lymphoepithelial cyst (Branchial cleft cyst)	Painless White to yellow Soft to firm submucosal nodule Less than 1 cm	HIV	Floor of the mouth Laterla margin of the tongue	Cystic cavity lined with: Stratified squamous and/or pseudostratified columnar epithelial cells containing desquamative epithelial and inflammatory cells
	Oral Epidermoid cyst	A slow growing nonfluctuating mass Soft and painless		Commonly Midline or sublingual region of the floor of the mouth Rarely buccal mucosa	Histopathologically: The cavity is lined with stratified squamous epithelium and lumen containing lamellar keratin
	Lingual thyroglossal tract cyst	Painless or minimally painful Well defined, smooth and cystic mass	Airway obstruction in infants	Base of the tongue	Cystic mass lined with non-keratinized stratified squamous epithelium with underlying stroma consisting of mucus glands, muscle fibres and inflammatory infiltrate
	Nasolabial cyst ( Klestadt cyst)	Non-tender distension of the nasolabial fold due to swelling and elevation of the lateral nasal ala It may extend inferiorily into labial sulcus or laterally widening the nasal vestibule. Elevation of the bridge of the nose		Nasal alar and sublabial region Anterior maxillary region	Pseudostratified columnar epithelium with intermittent occurrence of goblet like mucin producing cells and also cuboidal epithelial lining Stroma consisiting of non-specific chronic inflammatory infiltrate and cholesterol cleft formation

Disease	Presentation	Risk Factors	Diagnosis	Affected Organ Systems	Important features	Picture
Diseases predominantly affecting the oral cavity
Oral Candidiasis	Dysphagia or odynophagia White patches on the mouth and tongue	Newborn babies Denture users Poorly controlled diabetes As a side effect of medication, most commonly having taken antibiotics. Inhaled corticosteroids for the treatment of lung conditions (e.g, asthma or COPD) may also result in oral candidiasis which may be reduced by regularly rinsing the mouth with water after taking the medication. People with poor nutrition, specifically vitamin A, iron and folate deficiencies. People with an immune deficiency (e.g. as a result of AIDS/HIV or chemotherapy treatment). Women undergoing hormonal changes, like pregnancy or those on birth control pills. Organ transplantation patients	Clinical diagnosis Confirmatory tests rarely needed	Localized candidiasis Oral and esophageal candidasis Candida vulvovaginitis Chronic mucocutaneous candidiasis Invasive candidasis Candidaemia Candida endocarditis Candida osteoarticular disease	Oral candidiaisis is a benign self limiting disease unless accompanied by immunosuppression.	Tongue infected with oral candidiasis - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=11717223.jpg
Herpes simplex oral lesions	Fever Sore throat Painful ulcers	Stress Recent URTI Female sex	Physical examination Viral culture Tzanck smear	Orofacial Infection Anogenital Infection Ocular Infection Herpes Encephalitis Neonatal Herpes Herpetic Whitlow Herpes Gladiatorum	The symptoms of primary HSV infection generally resolve within two weeks	Oral herpes simplex infection - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=19051042.jpg
Aphthous ulcers	Painful, red spot or bump that develops into an open ulcer	Being a female Between the ages of 10-40 Family history of aphthous ulcers	Physical examination Diagnosis of exclusion	Oral cavity	Self-limiting , Pain decreases in 7 to 10 days, with complete healing in 1 to 3 weeks	By Ebarruda - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=7903358
Squamous cell carcinoma	Non healing ulcer, nodule, indurated plaque or mass May involve skin, lips, inside the mouth, throat or esophagus	Chronic sun or UV exposure Fair skin Elderly age (>45 yrs) Male sex Smoking	Physical exam Biopsy	Oral Cavity Floor of mouth Lateral tongue Throat Esophagus	Malignant Can spread to TMJ Some times associated with leukoplakia
Leukoplakia	White leathery spots on the mucous membranes of the tongue and inside of the mouth Lateral borders of tongue	Atypical Tobacco use Chronic irritation Immunodeficiency Bloodroot (sanguinaria)	Physical exam Diagnosis of exclusion Biopsy	Vulvar lesions occur independent of oral lesions	Associated with HIV Persistant white spots Benign but can progress to carcinoma after almost 10 years Oral proliferative verrucous leukoplakia is an aggressive sub type with multiple lesions and higher conversion to warts or carcinoma
Melanoma	A lesion with ABCD Asymmetry Border irregularity Color variation Diameter changes Bleeding from the lesion	UV radiations Genetic predisposition Old age Male gender Family or personal history of melanoma Multiple benign or atypical nevi	ABCD characteristics Bleeding or ulceration may show malignancy Serum LDH may be elevated in case of malignancy Biopsy	Can metastasize All UV radiation or sun exposed areas can be effected independently 1-2 to hundreds of granules	Neural crest cell derivative Development begins with disruption of nevus growth control Progression involves MAPK/ERK pathway N-RAS or BRAF oncogene also involved
Fordyce spots	Rice-like granules or spots Small, painless, raised, pale, red or white 1 to 3 mm in diameter	Greasy skin types Some rheumatic disorders Hereditary nonpolyposis colorectal cancer Lower gingiva (gums) Vestibular mucosa	Physical exam Small keratin-filled pseudocysts May be seen on incidental mucosal biopsy Biopsy not done for them primarily	Oral cavity Vermilion border of the lips Oral mucosa of the upper lip Buccal mucosa in the commissural region often bilaterally Genitals	Benign neoplasms with sebaceous features Visible sebaceous glands No surrounding mucosal change Several adjacent glands may coalesce into a larger cauliflower-like cluster
Burning mouth syndrome	Burning or tingling on the lips, tongue, or entire mouth	Nutritional deficiencies Chronic anxiety or depression Diabetes type 2 Menopause Oral thrush or dry mouth, or damaged nerves transmitting taste Female gender Menopause	Presentation Physical exam	Oral cavity	Pain typically is low in the morning and builds up over the day Low dosages of benzodiazepines, tricyclic antidepressants or anticonvulsants may be effective
Torus palatinus	Bony growth on midline of the hard palate Nodular mass covered with normal mucosa	Genetic predisposition Autosomal dominant	Physical exam Types Flat tori Spindle tori Nodular tori Lobular tori	Hard palate	More common in Asian and Inuit populations Twice more common in females Repeated trauma can cause bleeding Surgery may be required in symptomatic
Diseases involving oral cavity and other organ systems
Behcet's disease	Painful mouth sores Acne like skin lesions Headache, fever, poor balance, disorientation Abdominal pain, diarrhea or bleeding Uveitis Joint swelling and joint pain Genital sores wit pain and scaring Aneurysms	Over active immune system	Physical examination	Mouth Genitals GIT Eye Joints Skin Vascular system Brain	Outbreaks of exaggerated inflammation Affects smaller blood vessels
Crohn's disease	Chronic, episodic diarrhea or constipation Abdominal pain Vomiting Weight loss or weight gain	Smoking Whites and European Jews Hormonal contraception Diets high in microparticles, sweet, fatty or refined foods Industrialized country	Typical history and symptoms Skip lesions on biopsy Anti-Saccharomyces cerevisiae antibodies (ASCA) Anti-neutrophil cytoplasmic antibodies (ANCA)	Eyes Joints Skin	May lead to Obstructions Abscesses Free perforation Hemorrhage
Agranulocytosis	Fever or chills Frequent infections Unusual redness, pain, or swelling around a wound Mouth ulcers Abdominal pain Burning sensation when urinating Sore throat	Medications Cytotoxic chemotherapy Hematologic malignancies Autoimmune disorders	Neutropenia <100 cells per micro litre Eosinopenia Basopenia	Oral cavity Skin GIT Urinary system Conjunctiva	Immunocompromization Types Drug-induced Malignant Autoimmune
Syphilis	Chancre Regional lymphadenopathy	Multiple sexual partners Illicit drug use Unprotected sex Men who have sex with men Residence in highly prevalent areas HIV infection Presence of other STIs Previous history of STIs Intravenous drug use	Darkfield microscopy Non treponemal tests like VDRL and RPR test) Treponemal testsFTA-ABS tests, (TP-PA) assay, enzyme immunoassays, and chemiluminescence immunoassays)	Oral cavity Penis Cervix Labia Anal canal Rectum CNS CVS	Primary syphilis Chancre Secondary syphilis Condylomata lata Latent syphilis Asymptomatic Tertiary syphilis Gummas Neurosyphilis
Coxsackie virus	Fever Sores in the mouth Rash with blisters Aches	Pregnancy immunodeficiency	History and Physical exam Throat swabs Swabs from the lesion Tzanck test	Oral cavity Skin	Symptomatic treatment
Chicken pox	Conjunctival symptoms Catarrhal symptoms Characteristic spots on the trunk appearing in two or three waves Itching	Pregnancy Premature infants born to susceptible mothers All infants born at less than 28 weeks gestation or who weigh =1000 grams Immunocompromised	History and physical exam PCR to detect VZV in skin lesions (vesicles, scabs, maculopapular lesions)	Oral cavity Skin	Sodium bicarbonate in baths or antihistamines for itching Paracetamol (acetaminophen) for fever Prednisolone is contraindicated
Measles	Fever Rash Cough Coryza (runny nose) Conjunctivitis (pink eye) Malaise Koplick spots in mouth	Unvaccinated individuals Crowded and/or unsanitary conditions Traveling to less developed and developing countries Immunocompromized Winter and spring seasons Born after 1956 and never fully vaccinated Health care workers	History and examination PCR for Measles-specific IgM antibody PCR for Measles RNA	Oral cavity Skin Respiratory tract Eyes Throat	Caused by Morbillivirus Primary site of infection is the respiratory epithelium of the nasopharynx Transmitted in respiratory secretions, via aerosol droplets containing virus particles

Causes

Causes in Alphabetical Order

• Agranulocytosis
• Aphthous stomatitis
• Allergic contact dermatitis
• Behcet's disease
• Bollus disease
• Chemotherapy drugs
• Erythema multiforme
• Herpes stomatitis
• Histoplasmosis
• Primary syphilis
• Self limited viral disease
• Squamous cell carcinoma

Diagnosis

History and Symptoms

• Past medical/medicinal history
• If the lesions occur in the same locations every time, culpit is HSV
• Consider the patients sexual history
• Evaluate open and mucosal lesions
• Lichen planus - lacy white plaques

Laboratory Findings

• Culture for HSV-1
• RPR
• CBC
• Punch biopsy

Treatment

Medical Therapy

Acute Pharmacotherapies

• Orabase and topical steroids can increase speed of healing
• Aphthous stomatitis - intralesional triamcinalone injections
• HSV (recurrent) - acyclovir
• Bollous disease - corticosteroids

References

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