oral lesions

The mouth is made from a complex structure of dental tissues that work together to carry out essential functions. Some of these components include the lips, oral mucosa, tongue, teeth, and gums. Like any other part of our body, the oral tissues are prone to infection and disease spread. Such a wide range of oral lesions can affect the health and functions of the mouth.

Typically, the standard oral lesions include Leukoplakia, lichen planus, aphthous ulcers, herpetic, and traumatic lesions. Several causes can lead to the formation of oral lesions in the mouth. Some of them include localized trauma from sharp tooth edges or broken fillings, viral infections, an underlying systemic condition, allergy, dermatological disease, or excessive stress.

Oral lesions are quite challenging to diagnose and detect the cause of the lesion. It usually requires thorough clinical inspection, oral examination, and biopsy. Treatment often depends on the extent and severity of oral lesions. Today’s article will highlight some of the common oral lesions. Additionally, we will provide you an overview of the different causes, symptoms, diagnosis, and treatments of oral lesions.

What are oral lesions?

Oral lesions are typically described as a change in the structure, texture, and function of the oral mucosa. Oral lesions can occur as a break in the skin or mucosal layer, loss of surface tissue, and necrosis of the oral tissue. (1)

Such forms are clinically characterized as an ulcer, nodular growth, mucosal patch, or an infectious coat. Some of the developmental characteristics of oral lesions include –

  • Development in the form of a single or a cluster of multiple outgrowths in the mouth
  • The lesions may persist for more than two weeks
  • Lesions are susceptible to frequent inflammation and secondary infection
  • Advanced stages of oral lesions may lead to the formation of non-healing ulcers in the mouth

What causes oral lesions?

There is a wide range of causes that can lead to formation for different oral lesions. This range includes the following –

  • Bacterial, viral, or fungal infections may lead to the formation of herpetic sores and candidiasis.
  • Dermatological diseases are the leading cause for the development of leukoplakia and lichen planus.
  • Localized trauma to the mucosal layers can cause ulcer formations in the mouth. Trauma can occur from broken fillings, sharp teeth, acidic food, a physical blow to the face, stress, and cancer therapy. (2)
  • Underlying systemic conditions such as anemia, nutritional deficiency, and gastrointestinal problems
  • Recurrent episodes of aphthous ulcers

What are the clinical signs and symptoms of oral lesions?

Usually, the clinical signs and symptoms of oral lesions may be specific to the type of infection or disease. However, some of the common symptoms may include the following –

  • Pain and discomfort while speaking
  • Burning sensation in the mouth
  • Development of one to multiple shallow ulcers (3)
  • Self-healing ulcers that may occasionally reoccur at 1-3 months intervals
  • Some lesions may present as a patch or nodules growing on the mucosal lining of the mouth
  • Difficulty in chewing and swallowing
  • Red or white discoloration of the affected tissue
  • Bad breath

What are the common types of oral lesions?

Leukoplakia and Erythroplakia

The World Health Organization describes Leukoplakia as a non-scrapable, white plaque, or patch that cannot be characterized as any other disease both clinically and pathologically. (4). Erythroplakia holds the same definition as Leukoplakia except that it is a red patch. A combination of the two is rarely seen as a red and white patch on the mucosal surface and is referred to as Erythroleukoplakia. (5)

Excessive alcohol consumption and tobacco use are considered as the prime cause of Leukoplakia and erythroplakia. These lesions are usually not painful, which makes them one of the most commonly ignored oral lesions. Such lesions are diagnosed on routine dental examinations or during advanced stages.

Oral lichen planus

Lichen planus is one of the most common dermatological diseases that affect the mouth. The prevalence of skin and mucosal lesions is 50% each. Usually, oral lichen planus involves the tongue and buccal mucosa.

Oral lichen planus can occur in various shapes and forms. However, one of the most common forms of oral lichen planus includes the reticular type. It appears as an elevated, fine white line called Wickham’s striae, which forms a lace-like pattern on the tissue surface. (6)

Aphthous ulcer

Recurrent aphthous stomatitis is one of the most common forms of recurrent oral ulcers. Although the exact cause of this lesion is not clear, some of the contributing factors may include excessive stress, nutritional deficiency, and hormonal changes. Aphthous ulcers are typically divided into major and minor ulcerative lesions. Usually, these varieties differ in two aspects –

  • The minor ulcers occur in clusters of multiple lesions as compared to major ulcers that may develop individually or in a bunch of 5-7 ulcers.
  • Major ulcers may heal by scarring while the minor ulcers do not leave a scar.

They typically appear as flat papules on the movable mucosal layers, such as the lower lip, lateral border of the tongue, and soft palate. (7)

The ulcers are characterized by a red margin with a depressed center. Aphthous ulcers are self-healing and usually disappear within 7-10 days. However, they tend to reoccur at 1-3 months intervals. Often these ulcers are asymptomatic. However, occasional pain and discomfort may be present while eating or speaking.

Herpetic lesions

Herpetic lesions can occur in various forms, such as herpetic labialis, cold sores, blisters, and painful ulcers. The spread of the HSV-1 virus usually causes it. Some of the common oral sites that may be affected by herpetic lesions include the vermillion border of the lip, lateral border of the tongue, and gingival tissue. Patients with herpetic lesions often experience systemic symptoms like –

  • Fever and fatigue
  • Lymph node swelling
  • Headache
  • Nausea and vomiting
  • Loss of appetite

Typically, there are two definite types of oral herpetic lesions –

  • Primary herpetic gingivostomatitis – small vesicular eruptions in the mouth generally characterize this condition. The blisters soon rupture and turn into a painful oral ulcer covered by a yellowish-grey membrane. (8)
  • Herpes labialis – the reactivation of the HSV-1 virus causes this condition. The patient usually experiences repetitive episodes of painful ulcer formations that form a crust around the lips and corner of the mouth. Other symptoms may include tingling or burning sensation and itching around the lesion.

Candidiasis

Candidiasis is a typical fungal infection that is caused by Candida albicans. Some of the contributing factors for candidiasis include smoking, diabetes, dry mouth, HIV infection, prolonged chemotherapy, and excessive use of antibiotics. Typically, candidiasis can be divided into two types depending on the underlying cause.

  • Acute candidiasis, also known as oral thrush, is characterized by the formation of a white, creamy plaque-like layer that easily rubs off when wiped with a gauze. As the layer peels off of the tissue surface, it leaves a raw, red, ulcerative surface beneath it. Common sites of occurrence include the tongue, palate, buccal mucosa, and sometimes the throat. (9)
  • Chronic candidiasis, also known as denture sore mouth, is characterized as a red velvety patch or plaque-like lesion that usually forms on the hard palate. Typically, this lesion is caused by poor denture hygiene. Additionally, people who wear dentures even while sleeping may be susceptible to chronic candidiasis.
  • Angular cheilitis is another form of candidiasis which is characterized as red erythematic fissures formed as the corners of the mouth. Often in such cases, the patient may experience constant soreness, burning sensation, and reduced mouth opening. Angular cheilitis is typically caused by a combination of vitamin B, folic acid deficiency accompanied by candida albicans infection.

Traumatic lesions

Traumatic lesions may clinically resemble other white or ulcerative lesions of the mouth. However, the presence of an irritant near the affected area gives a clear sign that the lesion is caused by local trauma to the tissue. (10) Some of the common traumatic oral lesions may include the following –

  • Aspirin burns – It looks like a red/white plaque-like lesion, which is typically found on the buccal mucosa. It is caused due to sucking on an aspirin tablet.
  • Irritational keratosis – It is formed due to constant trauma caused by a sharp tooth, broken filling, or a dental appliance such as a denture or orthodontic wire.
  • Fibroma – fibroma is characterized as a smooth pink nodule that commonly occurs on the tongue, buccal mucosa, or the lower lip. A fibroma is usually firm in consistency and is caused by chronic irritation from biting on the soft tissue.
  • Mucocele – a mucocele is caused by the rupture of minor salivary gland ducts in the lower lip. It occurs as a bluish pink swelling that may decrease and increase in size over time.

How are oral lesions diagnosed?

Diagnosis of oral lesions is often challenging for the clinician. Thorough patient history is recorded to rule out any systemic conditions or medications that may cause the alterations of the oral tissues.

Extensive clinical inspection and examination are followed to identify the characteristic signs and symptoms that may determine the diagnosis of the lesion. Additionally, x-ray studies and in advanced cases, a biopsy may help to detect the cause and diagnose the type of oral lesion.

What is the treatment to cure oral lesions?

Treatment of oral lesions usually depends on the extent, severity, and type of lesion as diagnosed by the clinician. Some of the treatments available for different oral lesions are listed below –

  • Traumatic lesions are usually treated by removing the irritant from the affected site. It usually involves re-restoration of a broken filling, smoothening of a sharp tooth, and correction of the dental appliance. Other traumatic lesions like fibroma and mucocele are monitored and removed surgically.
  • Candidiasis – treatment of acute candidiasis includes a course of topical antifungals like clotrimazole and nystatin. Additionally, systemic antifungals may be used to improve immune function.

Topical antifungal creams or ointments usually treat chronic candidiasis and angular cheilitis. The patient must follow proper hygiene protocols that include regular denture cleaning. Moreover, the patients must remove the denture before sleeping in the night and store it in water. (11)

  • Leukoplakia and Erythroplakia – since these lesions are considered pre-cancerous, they must be monitored to check the progression of the lesion. Moreover, the patient is scheduled for habit counseling to quit the use of tobacco. A treatment of topical corticosteroids may be used to manage the progression of the lesion.
  • Lichen planus – treatment of lichen planus includes a robust course of topical corticosteroids like fluocinonide. Corticosteroid mouthwash may be used in symptomatic lesions.
  • Aphthous ulcers – the treatment of aphthous ulcers is usually supportive and focused on relieving pain and discomfort. Aphthous sores typically heal by themselves. However, palliative therapy like stress reduction, hormonal check, and nutritional supplementation may be followed to improve the condition. Medications like topical corticosteroids, analgesics, and antimicrobials may be given occasionally.
  • Herpetic lesions – treatment of herpetic lesions include systemic antiviral therapy using acyclovir. Additionally, antibiotics, fluid intake, and pain relievers may be advised to speed up the healing process. Corticosteroids have proven to be useful in treating herpetic lesions. However, they must be taken under the supervision of the professional.

Take away message

Oral lesions are defined as a wide range of abnormal tissue disruption or growth that may affect the health and functions of the mouth. There are several types of oral lesions. Some of the common ones include leukoplakia, oral lichen planus, viral and fungal infections, traumatic lesions, and aphthous ulcerations.

Each type of oral lesion has a characteristic appearance that may range from an ulcer, blister, patch, plaque to painful swellings, and surface alterations. Some of the common symptoms associated with oral lesions include pain and discomfort, difficulty in chewing and swallowing, red, inflamed tissue surface, and reduced mouth opening.

Treatment of oral lesions depends upon the type of condition, its cause, extent, and severity. Most of the time, a symptomatic approach is followed to relieve the pain and speed up the healing process. Routine dental check-ups are essential to keep a regular check on any changes that may occur in your mouth.