Learning Center: ORAL MUCOSAL LESIONS

Differential diagnosis of oral mucosal lesions

1.      Metabolic/Systemic/Endocrine

a.       Lichen planus – More likely in setting of relapsing polychondritis.  Lichen planus often manifests as lace-like leukoplakia.  Biopsy may be needed.

b.      Pemphigoid or pemphigus

c.       Autoimmune - Sjögren's syndrome, Crohn’s disease

d.      Diabetes

e. Sarcoidosis

f.        Decreased levels of vitamins B1, B2, B12, folate, iron, zinc

g.       Abnormal thyroid function

h.       Parkinson disease

i. Bechet’s (Behçet's) disease

2.      Infectious- consider the cleansing effect of an oral diet when NPO, immunocompromise

a.       Fungal (usually Candida species) “Thrush”

b.      Viral - including parvovirus, mumps, herpes, Coxsakie virus (hand, foot and mouth disease)

c.      Bacterial – Consider oral hygiene. Pyogenic granuloma may be the soft tissue manifestation of odontogenic infection.

3.      Neoplastic- squamous cell carcinoma, adenocarcinoma, odontogenic tumors extending to surface, lymphoma, mucosal melanoma, fibroma

4.      Trauma

a.       Mechanical

i.      Sharp or protruding teeth in contact with lesion

ii.      Torus mandibularis/torus palatini- prominence associated trauma

iii.      Tongue thrusting

iv.      Sucking

b.      Thermal - including food, drink, and smoke

c.       Neuropathy, e.g., chemotherapy-associated neuropathy with unconscious trauma

5.      Contact/Chemical

a.       Toothpaste, mouthwash, etc.  Anything new corresponding to onset?

b.      Spicy foods

c.       Tobacco, nicotine salts, betelnut

d.      Allergy to Food or dental amalgam/restoration

6.      Xerostomia and altered salivary quality

a.       Radiation with fields involving salivary glands

b.      Chemotherapy

c.       Other drugs- especially SSRIs, angiotensin converting enzyme inhibitors, anticholinergics, antihistamines, diuretics

d.      Sjögren's syndrome

7.      Other

a.       Radiation mucositis – during or after radiation fields involving the oral cavity

b.      Atrophic tongue

c.       Geographic tongue

8. Burning Mouth Syndrome is a chronic condition of a burning sensation of the oral mucosa for which no cause can be found.

Workup and initial recommendations

History, physical exam, occasional empiric topical therapy, laboratory evaluation, and sometimes biopsy.

Phlebotomy for fasting blood glucose, vitamin D (D2 and D3 ), vitamin B6 , zinc, vitamin B1 , and TSH.  

Advise no face contact with pets for now.  

Bland diet, ginger management of touch/mechanical use of mouth, and possibly a “magic mouthwash.”

Magic mouthwash

Various magic mouthwash formulations or recipes are available, sometimes used empirically, but with ingredients chosen to cover likely etiologic candidates (e.g., antifungal if thrush is considered).

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