Oral lesions

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2] Aditya Ganti M.B.B.S. [3]

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


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.


Oncology Medications
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[1][2]
  • White or whitish grey edematous lesion
  • Diffuse or patchy
Fordyce granules[3][4][5][6]
  • White or yellow discrete papules
  • Symmetrically distributed
Benign migratory glossitis[7][8][9]
  • Red patches with white distinct border
  • Map like appearance
  • Dorsal/Lateral surface of the tongue
Geographic tongue 01.JPG
Hairy tongue[10][11][12][13]
Black tounge.jpg
Hairy leukoplakia[14][15]

White patches

  • Corrugated in appearance
  • Hairy, hair-like growths
  • Permanent
Oral-Hairy leukoplakia.jpeg
White sponge nevus[16][17]
  • White patches of tissue (nevi)
  • Singular or multiple
  • Thickened, velvety, sponge-like appearance
  • Parakeratosis, acanthosis
  • Extensive vacuolization
  • Dyskeratotic cells exhibit dense peri and paranuclear eosinophilic condensations
  • Abundant Odland bodies
Lichen Planus[18][19]
  • Reticular or papular lace like white lesions
  • Multiple, Painful
Lichen Planus Fig7.tiff.jpg
Frictional hyperkeratosis[20][21]
  • White shaggy plaques
  • Could be easily peeled without any pain leaving normal mucosa
Frictional hyperkeratosis.jpg
  • 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
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
  • Predominant in outer lips
  • 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
  • Strong female predilection
Smoker milanosis.jpg
  • Varies from dark brown to blue-black
  • Mucosa-colored and white lesions are occasionally noted
  • Erythema is observed when the lesions are inflamed.
Addisons hyperpigmentation.jpg



Peutz jegher syndrome new photo for diagnosis.jpg
Oral neurofibromatosis.jpg
  • Orofacial deformity
  • Dental disorders
  • Bone pains
  • Compromised oral health
  • Predominantly involves musculo-skeletal defects of oral cavity
  • Gingiva
  • 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 Melanthocoma.png
Oral lesions Appearance Associated conditions Location Microscopic Image

Ulcerative lesions

Infections Herpes simplex virusinfections[40][41][42]

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
  • Keratinized and non-keratinized mucosa.
  • Intra and intercellular edema (acantholysis)
  • Intranuclear inclusions
  • Multinucleate polykaryons (giant cells)
Herpes labialis.jpg
Herpes zoster[43][44][45]
  • Clustered small ulcers with characteristic unilateral pattern
  • 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[46][47][48]
  • Irregularly shaped shallow ulcers with yellow-grey base and hyperemic margin.
  • Coxsackievirus
  • 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.
Hand foot mouth disease 07a.jpg
Infectious mononucliosis[49][50]
  • Epstein-Barr virus infection
  • Kissing's Disease
  • Reactive lymphoid hyperplasia
  • Extensive immunoblastic proliferation in sheets and nodules, marked atypia resembling Reed-Sternberg cells
1200px-Mono tonsils.JPG
Erosive lichen planus[51][52][53]
Pseudomembranous candidiasis[54][55][56]
  • 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
  • Wet mount examination with 10% KOH or saline demonstrates hyphae, pseudohyphae, and blastospores.
Human tongue infected with oral candidiasis--By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=11717223.jpg
  • Ohio and Mississippi river valleys
  • Mississippi, Missouri and Ohio River valleys and the Great lakes region.
  • Ginguve
  • Mostly Pulmonary Nodules

Classic appearance on modified Wright's stain

Blastomycosis cropped.JPG
  • 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

Coccidioidomycosis 01.jpg
Autoimmune diseases Pemphigus vulgaris[69][70][71]
  • Intraepithelial blister with acantholysis and chronic inflammation
Pemphigus vulgaris.jpeg
Mucous membrane pemphigoid (Cicatricial pemphigoid)[72][73][74]
  • 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[75][76][77]
  • Shallow, round to oval ulcer with white or yellow pseudomembrane surrounded by halo
  • In chronic ulcer grey membrane may replace the yellow pseudomembrane
  • Appear on the non-keratinizing epithelial surfaces in the mouth.
  • Except the attached gingiva, the hard palate and the dorsum of the tongue
Canker sore.jpg
Erythema multiforme[78][79]
EM oral.png
Sjogren's Syndrome

Affects salivary and lacrimal glands

Bullous pemphigoid
  • Psoriasis
  • Parkinson's disease
  • Dementia
  • Certain drugs e.g. spironolactone, loop diuretics and neuroleptics
  • Malignancies e.g. breast cancer
  • 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
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
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.
  • 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.
Necrotizing sialometaplasia
  • Non-ulcerated swelling that transforms into crater like ulcer
  • 1-5cms
Necrotizing sialometaplasia 001.jpg
Periodontal abscess
  • Originates in the dental pulp
  • Associated with living tooth
  • 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
Abces parulique.jpg
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
  • 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:


  • 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.



Spindle cell




Squamous cell carcinoma.jpg
Oral epithelial dysplasia[80]
  • 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: Histopathologically it may be classified as



  • Parakeratosis
  • Disorganization of the strata with basilar hyperplasia
  • Nuclear enlargement and hyperchromaticity
  • Drop shaped rete ridges involving one half of epithelial thickness


  • Loss of cellular organization and polarity
  • Basilar hyperplasia
  • nuclear enlargement and hyperchromaticity
  • Drop shaped rete ridges involving two-third of epithelial thickness
Leukoplakia 003.jpg
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

The histopathological findings associated with PVL are as under:

Proliferative verrucous leukoplakia.jpg
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 Several sessile, cauliflower-like swellings forming a cluster
Condyloma acuminatum.jpg
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


Any oral site may be affected mostly:

Verrucous vulgaris.jpg
Multifocal epithelial hyperplasia
  • Soft rounded or flat plaque-like sessile swelling.
  • Usually pink or white in color
  • 2-10 mm in diameter

13 and 32

  • Rounded sessile swelling formed by a sharply demarcated zone of epithelial acanthosis
  • Koilocytes similar to those of squamous papilloma are usually present
Hecks disease.jpg
Salivary type tumors Mucoepidermoid carcinoma 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

Histopathological findings shows cellular, and hyaline or plasmacytoid cell
Pleomorphic adenoma (Benign mixed tumor) oral 001.jpg
Soft tissue and Neural tumors Granular cell tumor
  • The overlying epithelium is of normal color or may be slightly pale
Plump eosinophilic cells with central small dark nuclei and abundant granular cytoplasm
Granular cell tumor oral 001.jpg
  • 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
Fetal intermediate cellular type rhabdomyoma.jpg
  • Circumscribed painless swelling
  • Soft and fluctuant on palpation
  • Irregular nodularity of the dorsum of the tongue
Thin-walled, dilated lymphatic vessels of different size, which are lined by a flattened endothelium
Lymphangioma oral 001.jpg
Buccal hemangioma 001.jpg
Kaposi sarcoma[85][86] HIV and HHV-8 Spindle cells with minimal nuclear atypia
Kaposi's sarcoma oral 001.jpg
Myofibroblastic sarcoma[87][88][89]
  • Painless swelling or an enlarged mass
Hematolymphoid tumors Plasmablastic lymphoma[90][91][92] It may appear as thickened ulcerative lesion that may invade the adjacent bone Intraoally:
Langerhan cell histiocytosis[93][94][95]

Associated with:

Biopsy shows ovoid langerhans cells

with deeply grooved nuclei, thin nuclear membrane and abundant eosinophilic cytoplasm

Langerhans cell histiocytosis - high mag.jpg
Extramedullary myeloid sarcoma[96][97][98] Isolated tumor-forming intraoral mass History of acute myeloid leukemia,

predominantly in the monocyticor myelomonocytic subtypes

Tumors of uncertain histiogenesis Congenital granular cell epulis[99][100]
  • Congenital
  • Spontaneously regresses over first 8 months of life
Ectomesenchymal chondromyxoid tumor[101][102]
  • Tongue, mainly on its anterior side
Cysts Oral Lymphoepithelial cyst (Branchial cleft cyst)[103][104]
  • Painless
  • White to yellow
  • Soft to firm submucosal nodule
  • Less than 1 cm
  • Floor of the mouth
  • Laterla margin of the tongue
Cystic cavity lined with:
Oral Epidermoid cyst[105][106][107]
  • A slow growing nonfluctuating mass
  • Soft and painless


Lingual thyroglossal tract cyst[108][109]
  • 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
Thyroglossal duct cyst.jpg
Nasolabial cyst ( Klestadt cyst)[110][111][112]

Disease Presentation Risk Factors Diagnosis Affected Organ Systems Important features Picture
Diseases predominantly affecting the oral cavity
Oral Candidiasis
  • Denture users
  • 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.
  • Clinical diagnosis
  • Confirmatory tests rarely needed
Localized candidiasis

Invasive candidasis

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
  • Stress
  • Recent URTI
  • Female sex
  • 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
  • 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 Squamous cell carcinoma
  • Vulvar lesions occur independent of oral lesions
Melanoma Oral melanoma
Fordyce spots Fordyce spots
Burning mouth syndrome
Torus palatinus Torus palatinus
Diseases involving oral cavity and other organ systems
Behcet's disease Behcet's disease
Crohn's disease
Syphilis oral syphilis
Coxsackie virus
  • Symptomatic treatment
Hand-foot-and-mouth disease
Chicken pox Chickenpox
  • 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
Koplick spots (Measles)
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Causes in Alphabetical Order[1][2]


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


Medical Therapy

Acute Pharmacotherapies


  1. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN140510368X

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