A guide to common oral lesions

[drsnehamaheshwari]

Angular cheilosis

DESCRIPTION: This lesion appears as fissuring and maceration at the labial commissures. The term cheilitis and cheilosis have both been used to describe the same disease.

ETIOLOGY: It is doubtful that this condition is caused by vitamin deficiency in the United States. Studies have shown that the two most common organisms responsible for this condition are Candida albicans and Staphylococcus aureus. This condition is commonly seen in older patients having loss of vertical dimension, in younger patients with orthodontic appliances, and those with a lip licking habit.

TREATMENT: In those patients who have obvious overclosure, restoration of vertical dimension is of benefit. Application of antifungal ointment to eliminate Candida organisms is indicated.

PROGNOSIS: Good

DIFFERENTIAL DIAGNOSIS: The disease is so characteristic that it cannot be confused with any other lesion. 

        

[drsnehamaheshwari]

Peripheral giant cell granuloma

DESCRIPTION: The peripheral giant cell granuloma appears as a nodular soft tissue mass arising from gingival or alveolar mucosa. The color may be red but is often a blue-grey. Most are approximately a centimeter in size, although they may be larger. The peak age is around 40 years but they occur in all ages with a female prevalence. There is almost equal distribution between maxillary and mandibular gingival. The term “peripheral” is included in the name to separate this lesion from a histologically similar lesion which occurs inside the jaws. Jaw lesions are referred to as the “central” giant cell granuloma. The peripheral granuloma may cause pressure resorption of underlying alveolar bone and less commonly resorption of the adjacent tooth. They are not painful. Histologically this lesion consists of fibroblasts and multinucleated giant cells.

ETIOLOGY: Unknown

TREATMENT: Conservative excision. The recurrence rate is approximately 10%.

PROGNOSIS: Good.

DIFFERENTIAL DIAGNOSIS: Pyogenic granuloma and peripheral ossifying fibroma. 

        

[drsnehamaheshwari]

Drug-induced gingival hyperplasia (Dilantin hyperplasia)                                             

DESCRIPTION: Drug-induced gingival enlargement was first described almost 50 years ago with the use of the anticonvulsant Dilantin (phenytoin). Other drugs especially calcium channel blockers such as Procardia (nifedipine) and cyclosporine have also been implicated. Dilantin causes gingival enlargement in almost 50% of those that regularly take it, while only about 25% of patient talking cyclosporine and calcium channel blockers have enlargement. Poor oral hygiene and especially dental plaque accentuate the enlargement. Superimposed gingivitis also causes boggy and red tissues that mask the true nature of the enlargement.

ETIOLOGY: Drug induced. As stated above, the condition may become aggravated by superimposed gingivitis and periodontitis. There is evidence that associated drugs may impair the secretion of collagenase by gingival fibroblasts permitting the accumulation of excessive gingival collagen.

TREATMENT: The inflammatory component may be reduced by good dental hygiene. The fibrous overgrowth requires surgical removal. Discontinuance of associated drugs may result in gradual regression of the overgrowth within one year.

PROGNOSIS: Good

DIFFERENTIAL DIAGNOSIS: Hereditary gingival fibromatosis, hyperplastic gingivitis from dental neglect, and leukemic infiltrates of the gingiva. 

        

[drsnehamaheshwari]

Traumatic ulcer         

DESCRIPTION: An ulcer by definition is a localized area on the skin or mucosa in which the surface epithelium has been destroyed. The shape and size of traumatic ulcers are so variable as to defy a simple description. They are usually painful and of short duration.

ETIOLOGY: Common causes of traumatic ulcers include: denture irritation, biting injuries, burns and friction irritation from sharp or fractured teeth.

TREATMENT: The treatment is to remove the cause if it is known. Relief of pain can be achieved with topical agents such as Orabase-B® with Benzocaine, Zilactin® or Soothe-N-Seal.

PROGNOSIS: The ulcer should heal if the cause is removed. An ulcer which does not heal within two to three weeks should be biopsied to rule out malignancy.

DIFFERENTIAL DIAGNOSIS: Traumatic ulcers must be differentiated from squamous carcinoma, bacterial, fungal and viral diseases, and other oral mucosal diseases. 

        

[drsnehamaheshwari]

Geographic tongue        

(benign migratory glossitis, erythema migrans)

DESCRIPTION: The lesions of this disease on the tongue are so characteristic that recognition should be instantaneous. The dorsal tongue displays map-like areas that are smooth and red with a whitish-yellow perimeter. The disease may involve any oral mucosal surface in which case the name erythema migrans is more appropriate. Atrophy of the filliform papillae is usually a finding on the dorsal tongue.

All ages are affected. We have seen it in a child six months old. The number of lesions varies from one to many. Old lesions heal and new ones form, waxing and waning in rhythm with most due to unknown forces. Some complain of a burning sensation.

ETIOLOGY: Unknown although a hypersensitivity reaction to unknown antigens has been suspected.

TREATMENT: None is usually required. In those with symptoms, topical steroid ointment or gel may be beneficial. Secondary fungal colonization should also be suspected in symptomatic lesions.

PROGNOSIS: This is a chronic disease lasting months to years with periods of remission and exacerbation.

DIFFERENTIAL DIAGNOSIS: Typical lesions are diagnostic. Variable clinical presentation may suggest lichen planus or candidiasis. 

        

[drsnehamaheshwari]

Condensing osteitis

DESCRIPTION: Condensing osteitis is a reaction to infection. It differs from other periapical inflammatory diseases in that there is a bone production rather than bone destruction. The result is a radiopaque lesion. This sclerotic reaction is apparently brought about by good patient resistance coupled with a low degree of virulence of the offending bacteria. It is more commonly seen in the young and seems to show special predilection for the periapical region of lower molars. The associated tooth is carious or contains a large restoration. We are reluctant to state the reaction of the tooth to pulp testing because of lack of sufficient personal experience and paucity of published information. Theoretically, the results should be abnormal. Current level of knowledge suggests that the pulp is irreversibly inflamed. Uncommonly, condensing osteitis occurs as a reaction to periodontal infection rather than dental infection.

ETIOLOGY: Infection of periapical tissues by organisms of low virulence.

TREATMENT: Vitality of the overlying tooth should be investigated. If the pulp is inflamed or necrotic, endodontics or extraction are the options.

PROGNOSIS: In those cases in which the offending tooth is extracted, the area of condensing osteitis may remain in the jaws indefinitely, and is termed osteosclerosis or bone scar.

DIFFERENTIAL DIAGNOSIS: Idiopathic osteosclerosis and cementoblastoma. An abnormal result with pulp testing strongly suggests condensing osteitis and tends to rule out osteosclerosis and cementoblastoma. 

        

[drsnehamaheshwari]

Peripheral ossifying fibroma

DESCRIPTION: This lesion appears as a mass arising from the gingiva adjacent to teeth  or between teeth. It favors teenagers and young adults. Those arising between teeth may separate the teeth and produce pressure resorption of the interdental bone. It’s not unusual to see a “saddle” lesion straddling the ridge with a labial and lingual lobe. Color is normal or slightly red. Histologically the bulk of this lesion is moderately cellular fibrous connective tissue frequently containing foci of bone, cementum, or dystrophic calcification. When inflammation is present, plasma cells frequently predominate.

ETIOLOGY: Unknown                         

Treatment: Excision. The recurrence rate is about 15%. Extraction of the adjacent teeth is seldom necessary.

Prognosis: Good

Differential Diagnosis: Peripheral fibroma bears a great resemblance to pyogenic granuloma and peripheral giant cell granuloma. Histologic examination is necessary to distinguish between them.

        

[drsnehamaheshwari]

Necrotizing ulcerative gingivitis        

(Vincent’s infection, trench mouth)

DESCRIPTION: This is a specific type of infection of oral mucosa whose lesions are found chiefly on marginal gingiva. Necrosis of the interdental papillae that spreads to involve adjacent facial and lingual surfaces is virtually diagnostic. The ulcerated gingiva is covered by creamy exudates. Patients have pain and halitosis and in severe cases, fever and cervical lymphadenitis. Spread of lesions into the throat has been referred to as Vincent’s angina. The disease occurs in all age groups but is uncommon in children.

ETIOLOGY: Treponema, Selenomonas, and Prevotella species have been identified in the lesions. They are suspected of being the chief etiologic agents although reinoculation of these organisms into tissues of volunteers has not reproduced the disease. Reduction of patient resistance is thought to play an etiologic role.

TREATMENT: Treatment consists of debridment and cleaning the teeth plus a broad spectrum antibiotic in those with fever and cervical lymphadenitis. Topical anesthetics may provide palliation.

PROGNOSIS: Good                                                                 

DIFFERENTIAL DIAGNOSIS: Agranulocytosis 

        

[drsnehamaheshwari]

Periapical dental granuloma

DESCRIPTION: The dental granuloma is a foci of chronic inflammation around the apex of a tooth root and is a sequela of pulpitis. Radiographically it appears as a periapical radiolucency. The border is usually distinct but this cannot be relied upon. The overlying tooth is ordinarily insensitive to electric pulp testing. While sensitivity to percussion may be present, many patients are asymptomatic. An acute infectious episode will result in pain, and often results in a formation of an abscess with a draining sinus tract and/or parulis formation. Osteomyelitis and cellulitis are an ever present danger.

ETIOLOGY: Like the periapical cyst, the dental granuloma is a direct sequela of inflammation of a pulp that has extended into the surrounding periapical tissue. Pulpitis is usually caused by infection secondary to caries but may be caused by trauma.

TREATMENT: Treatment consists of endodontic therapy or extraction.

PROGNOSIS: Good

DIFFERENTIAL DIAGNOSIS: If the tooth is nonvital, the differential diagnosis includes radicular cyst and periapical abscess. 

        

[drsnehamaheshwari]

Periapical cyst (radicular cyst)

DESCRIPTION: This is a cyst at the apex of a tooth with a necrotic pulp and is a sequelae of pulpitis. Periapical cysts bear a radiographic resemblance to dental granulomas. About the only substantive difference is the presence of an epithelium lined central cavity in the cyst. The associated tooth is usually asymptomatic. Acute infectious episodes may cause pain. The lesion appears as a sharply circumscribed radiolucent lesion around the apex of the associated tooth. It is often stated to have a thin sclerotic rim at the border but this feature is absent as often as it is present.

ETIOLOGY: This cyst is a direct sequela of inflammation of the pulp that has extended into the adjacent periapical tissues.

TREATMENT: Treatment consists of endodontic therapy or extraction of the associated tooth with curettage of the cyst.

PROGNOSIS: Good

DIFFERENTIAL DIAGNOSIS: Dental granuloma. Lesions such as keratocyst, ossifying fibroma, giant cell granulomas, and the lytic stage of osseous dysplasia may occur at the apex of a tooth and masquerade as a periapical cyst. Several odontogenic tumors may also present in a similar fashion.

COMMENT: A periapical infection with suppuration is correctly called a periapical abscess. An abscess may arise de novo or in a preexisting granuloma or cyst. Drainage of pus provides considerable relief of pain and hastens healing. 

        

[drsnehamaheshwari]

Condensing osteitis

DESCRIPTION: Condensing osteitis is a reaction to infection. It differs from other periapical inflammatory diseases in that there is a bone production rather than bone destruction. The result is a radiopaque lesion. This sclerotic reaction is apparently brought about by good patient resistance coupled with a low degree of virulence of the offending bacteria. It is more commonly seen in the young and seems to show special predilection for the periapical region of lower molars. The associated tooth is carious or contains a large restoration. We are reluctant to state the reaction of the tooth to pulp testing because of lack of sufficient personal experience and paucity of published information. Theoretically, the results should be abnormal. Current level of knowledge suggests that the pulp is irreversibly inflamed. Uncommonly, condensing osteitis occurs as a reaction to periodontal infection rather than dental infection.

ETIOLOGY: Infection of periapical tissues by organisms of low virulence.

TREATMENT: Vitality of the overlying tooth should be investigated. If the pulp is inflamed or necrotic, endodontics or extraction are the options.

PROGNOSIS: In those cases in which the offending tooth is extracted, the area of condensing osteitis may remain in the jaws indefinitely, and is termed osteosclerosis or bone scar.

DIFFERENTIAL DIAGNOSIS: Idiopathic osteosclerosis and cementoblastoma. An abnormal result with pulp testing strongly suggests condensing osteitis and tends to rule out osteosclerosis and cementoblastoma. 

        

[drsnehamaheshwari]

Amalgam tattoo

DESCRIPTION: An amalgam tattoo is a localized area of blue-gray pigmentation. The amalgam is relatively inert and usually causes no tissue damage. The discoloration is permanent.

ETIOLOGY: The accidental and usually unavoidable implantation of dental amalgam in oral soft issues produces this lesion.

TREATMENT: None required.               

PROGNOSIS: Good

DIFFERENTIAL DIAGNOSIS: Differential diagnosis is ordinarily not a problem. Amalgam tattoo should easily be distinguished from nevi which are usually brown. Amalgam tattoos are usually blue-grey. The rare blue nevus may resemble amalgam tattoo. It should be remembered that melanoma occurs in the mouth. Any tattoo that changes in a short period of time should be biopsied. 

        

[drsnehamaheshwari]

Hairy tongue (coated tongue)

DESCRIPTION: This is an ignoble name for a lesion. The dorsal surface of the tongue appears hairy and is discolored. The hairy texture is imparted by excessive kerantinization of the filiform papillae. The keratin may take on the color of extrinsic stains and display a variety of colors.

ETIOLOGY: It occurs more frequently among heavy smokers, those taking wide-spectrum antibiotics, those with xerostomia, and those with poor oral hygiene. The exact cause is unknown.

TREATMENT: Treatment consists of brushing the tongue with a soft bristle toothbrush or the use of a commercial tongue scraper. If there is an obvious cause, it should be eliminated. Oral lubricants may assist those with xerostomia.

PROGNOSIS: Good                                                                 

DIFFERENTIAL DIAGNOSIS: Candidiasis. 

        

[drsnehamaheshwari]

Nasopalatine duct cyst

DESCRIPTION: This developmental cyst forms from remnants of the nasopalatine duct, in the incisive canal in the midline of the anterior maxilla. The cyst may overlap the roots of the maxillary central incisor teeth. It is usually asymptomatic and discovered on routine dental films where it appears as an oval or heart-shaped radiolucent lesion. Rarely this cyst will expand overlying mucosa. It does not interfere with tooth vitality and seldom causes root resorption. It maybe found in edentulous patients. This cyst is differentiated from other cysts by the histologic presence of respiratory epithelium and the presence of nerves and muscular arteries in the wall.

ETIOLOGY: This is a developmental cyst presumably arising from epithelial remnants of the nasopalatine duct.

TREATMENT: Surgical enucleation.

PROGNOSIS: Good                                                                                                                   

DIFFERENTIAL DIAGNOSIS: Radicular cyst, keratocyst, and central bone tumors. 

        

[drsnehamaheshwari]

Snuff lesion (smokeless tobacco lesion)

DESCRIPTION: The lesion develops on the mucosa where smokeless tobacco is held. The usual appearance is white, wrinkled or corrugated mucosa. Gingival recession is a common manifestation with cervical erosion of teeth a less frequent finding. Symptoms are uncommon.

ETIOLOGY: Prolonged use of smokeless tobacco produces such as chewing tobacco or snuff.

TREATMENT: Biopsy should be done to rule out dysplasia, otherwise no treatment is necessary.

PROGNOSIS: Verrucous and squamous carcinomas arise in smokeless tobacco lesions more than chance alone can explain. One article noted almost a 50-fold increased risk of cancers of the gingival and buccal mucosa in females who were chronic users. The duration necessary to induce dysplastic or malignant change is unknown but appears to be at least 20 years.

DIFFERENTIAL DIAGNOSIS: The clinical appearance of the lesion plus a history of using smokeless tobacco establishes the diagnosis. 

        

[Author]

Posts