CHAPTER 86

Common Oral Lesions

Charlotte W. Lewis, MD, MPH, FAAP

Primary care physicians commonly evaluate lesions in the oral cavity. Knowledge of common congenital, developmental, infectious, traumatic, and neoplastic conditions that affect the mouth and its structures can help physicians recognize and manage these lesions appropriately. Although many oral lesions are benign or represent normal variants, others may require specific medical or surgical treatment. Some oral lesions offer clues to underlying syndromic diagnosis, indicate more serious infectious or systemic disease, or occur as side effects of certain medications.

Epidemiology

Oral pathology is common and covers a broad range of lesions. Benign oral lesions, such as gingival cysts, occur in approximately 75% of newborns. Approximately 20% of the population has at least a small torus palatinus, a benign bony overgrowth of the palate that usually begins in childhood. Ankyloglossia, commonly referred to as tongue-tie, affects approximately 5% of newborns. Fissured tongue affects approximately 2% of the population. Fissured tongue may be associated with benign migratory glossitis (ie, geographic tongue), which occurs in approximately 1% to 2% of children. Tobacco-associated keratosis occurs at the site of habitual placement of snuff or chewing tobacco and is estimated to affect more than 300,000 children in the United States. Leukoplakia, a premalignant condition associated with smokeless tobacco, occurs in approximately one-half of users. Although the resulting oral cancer is often diagnosed in the sixth or seventh decade of life, the habit of oral tobacco use typically starts in childhood—typically between 9 and 16 years of age. Among US high school students surveyed in 2017, 5.5% report current use of a smokeless tobacco product; use is higher in boys than girls and in whites as well as American Indians/Alaska Natives relative to other racial/ethnic groups.

Aphthous ulcers, commonly known as canker sores, are among the most common oral lesions in developed countries, with typical onset early in childhood. Approximately 20% to 25% of the US population experiences recurrent aphthous stomatitis (RAS). Oral lesions resulting from infections are also common. Approximately 35% of newborns and young infants develop oral candidiasis, commonly known as thrush. Oral herpes lesions are also common and are caused by human herpesvirus, usually type 1. By young adulthood, more than 50% of US individuals are seropositive for human herpesvirus 1. Approximately 20% to 40% of the population has experienced oral herpes at least 1 time.

Chronic (“ordinary”) gingivitis usually has its onset in the peripubertal age group, and it ultimately affects as many as 90% of adults. Smoking is a major risk factor for gingivitis and its sequelae– periodontal disease. In 2017, 20% of high school students reported current use of a tobacco product.

Clinical Presentation

Oral lesions may come to the attention of the physician in any number of ways. Some may be obvious at birth, such as a congenital epulis (also called congenital granular cell tumor), which typically presents as a mass arising from the maxillary alveolar ridge and protruding from the oral cavity in a neonate, potentially interfering with breathing or eating. Oral lesions may be an incidental finding on physical examination. For example, in examining a newborn, the pediatrician may notice small (approximately 2–3 mm in size) yellow-white papules along the palatal midline and can reassure the family that these are Epstein pearls, common lesions of no clinical significance. Most oral vascular malformations are present at birth, become more noticeable over time, and rarely regress. One of 3 vessel types usually predominates in such malformations: arterial, venous, or lymphatic. Microcystic lymphatic malformations often affect the tongue and surrounding soft tissue, can be friable, may interfere with eating and speaking, and can result in overgrowth of adjacent bones. When these lesions become infected, they rapidly enlarge and may compromise the airway.

The physician or parent/guardian may be the first to notice thrush. The incidence of oral candidiasis peaks around the fourth week after birth; thrush is uncommon in infants older than 6 to 9 months. Thrush can occur, however, at any age in predisposed patients (ie, immunosuppressed or deficient) and can affect the esophagus as well as the oropharynx. Candida albicans in combination with contact irritation has been implicated in angular cheilitis, which appears as crusty or scaling erythematous fissures at the cor-ners of the mouth. Other benign oral lesions, such as benign migratory glossitis, are brought to the attention of the physician because parents or guardians are concerned that they represent pathology; however, reassurance is appropriate.

Concerns for ankyloglossia may arise when a newborn has difficulty breastfeeding, particularly when the mother has persistent pain or trauma to her nipple with breastfeeding. Clinically significant ankyloglossia interferes with an effective latch and with normal tongue movement needed to efficiently transfer milk from the breast. Anterior ankyloglossia refers to a sublingual attachment to the underside of the tongue that is close to the tongue tip. In posterior ankyloglossia, the sublingual attachment is farther back on the tongue underside, but it still restricts motion of the tongue. The maxillary labial frenulum can appear quite prominent in infants and young children; however, it usually becomes much less obvious by the time the permanent central incisors erupt.

Physicians may be the first to note swollen, friable, erythematous gingiva along with plaque buildup on and between the teeth representing the initial presentation of chronic gingivitis. Chronic gingivitis is the first and only reversible stage of periodontal disease. Onset is typically in peripubertal children. Although young children experience gingivostomatitis from other causes, they do not usually harbor Actinobacillus actinomycetemcomitans or Porphyromonas gingivalis and thus do not commonly experience chronic gingivitis or periodontal disease.

Thickening of the mucosa, usually in the labial vestibule, offers clues to smokeless tobacco use. The severity of tobacco-related oral lesions demonstrates a dose-response relationship with the amount, frequency, and duration of smokeless tobacco exposure. Tobacco-associated keratosis is a predictable lesion that manifests as an area of thickening at the site of habitual placement of snuff or chewing tobacco. Chronic exposure to smokeless tobacco can result in the development of opaque-white to yellow-brown lesions with a wrin-kled appearance, known as leukoplakia and which is considered to be a premalignant condition.

Recurrent oral mucosal trauma, such as habitual biting of the inside of the lip or recurrent irritation from orthodontics, can induce oral lesions anywhere in the mouth but most often does so on the buccal or labial mucosa. One such lesion is a mucocele, which is a saliva-filled cyst that is usually less than 1 centimeter in diameter, round, painless, and opaque white or slightly blue in color. Pyogenic granuloma is another lesion that can occur at a site of recurrent mucosal or skin irritation. These lesions are blood red or reddish-brown, and they bleed easily. Although they can be protuberant and look scary to parents/guardians, both mucoceles and pyogenic granulomas are benign.

Other oral lesions may present in conjunction with other symptoms. Acute onset of “strawberry tongue,” indicating glossitis, often occurs with scarlet fever or Kawasaki disease. The initial herpes simplex virus oral infection–primary herpetic gingivostomatitis– which typically affects infants and young children, is characterized by multiple oral vesicular or ulcerative lesions, fever, malaise, cervical lymphadenopathy, and decreased oral intake. Reactivation of prior human herpesvirus 1 infection often affects the vermillion border of the lip, which is known as herpes labialis. Oral lesions may also indicate underlying serious systemic illness, such as Crohn disease, systemic lupus erythematosus, or acute myelogenous leukemia.

Some life-threatening, rapidly progressive infections begin in the mouth. Ludwig angina (see Chapter 89) is a painful, rapidly progressive, infectious process of the submandibular space, often presenting as induration and swelling of the floor of the mouth, neck swelling, a superiorly and posteriorly displaced tongue, difficulty swallowing, and subsequent airway obstruction. Ludwig angina is a potential complication of a dental infection; in children, however, Ludwig angina can occur without a clear etiology, or it can complicate oral trauma or gingivostomatitis. Vincent infection or acute necrotizing ulcerative gingivitis is painful, edematous, bleeding gums with ulcers, necrosis, and pseudomembrane formation in affected areas. When this spreads to the pharynx and tonsils, the condition is referred to as Vincent angina (also called trench mouth). Like Ludwig angina, Vincent angina can progress to life-threatening airway obstruction.

Some genetic syndromes are first detected because of oral lesions. For example, lip pits or mounds in conjunction with cleft lip and/ or cleft palate are virtually pathognomonic of Van der Woude syndrome, an autosomal-dominant cause of orofacial clefting. Hyperpigmented lesions (brown or dark blue, similar to freckles) on the lips or buccal mucosa may provide a clue in the diagnosis of Peutz-Jeghers syndrome, an autosomal-dominant condition of multiple intestinal hamartomas. Patients with Peutz-Jeghers syndrome may experience recurrent abdominal pain, intestinal obstruction, or bleeding, and have a 15-fold increased risk of intestinal cancer.

Pathophysiology

Neonatal and Other Developmental Lesions

Gingival cysts in the neonate include Epstein pearls, Bohn nodules, and dental lamina cysts; these are caused by entrapment of tissues during embryologic development. Congenital epulis of the newborn is a rare, gingival tumor of unclear etiology that occurs more commonly in the maxilla than the mandible, with female predilection (8:1), and may occur as a single tumor or multiple tumors. The etiology of fissured tongue and geographic tongue are unknown. Fissured tongue tends to cluster in families, suggesting a genetic etiology, and can also occur in Down syndrome. Benign migratory glossitis results from the loss of the tiny fingerlike projections, called papillae, on the surface of the tongue, giving the tongue a map-like appearance. The inciting factors responsible for oral vascular malformations are not well understood. Ankyloglossia is thought to result from a localized failure of apoptosis.

Traumatic

Some of the most common oral lesions noted on physical examination result from minor accidental self-bites to the lip or buccal mucosa. Most of these lesions resolve quickly, but recurrent trauma may result in pyogenic granuloma or fibroma formation. A mucocele results from traumatic rupture of a minor salivary gland with subsequent cyst formation.

Infectious

Although an infectious etiology to aphthous ulcers has been proposed, their true etiology remains unclear. Oral herpes lesions usually are the result of infection with human herpesvirus 1. Herpangina results from coxsackievirus A infection. Candida albicans causes oral candidiasis. Thrush occurs when normal host immunity is immature (as in neonates) or suppressed (eg, during steroid treatment) or when normal flora is disrupted (eg, while on antibiotics). Newborns may be colonized with C albicans during birth. Other sources of transmission to neonates include colonized maternal skin in contact during breastfeeding, pacifiers, and bottle nipples.

Chronic gingivitis occurs after buildup of bacterial plaque on the teeth, adjacent gingiva, and pockets between teeth and gums. Bacteria within plaque release toxins that cause an inflammatory response; the most commonly involved species are gram-negative anaerobic bacteria, including A actinomycetemcomitans and P gingivalis.

Both Ludwig angina and Vincent infection/angina result from polymicrobial infection, including anaerobes.

Other

Drug-induced gingival hyperplasia can occur in patients taking corticosteroids, phenytoin (most common cause in children), cyclosporine A, or nifedipine. It results from fibrous tissue overgrowth but, much like ordinary gingivitis, is exacerbated by poor oral hygiene and presence of plaque.

Differential Diagnosis

Age at onset, location and characteristics of the lesion, and accompanying signs and symptoms often help narrow the differential diagnosis. The appearance of 1- to 3-mm cysts in the mouth of a neonate is indicative of Epstein pearls, which are the most common and usually are present along the palatal midline; dental lamina cysts, which usually are located bilaterally along the crest of the dental ridge about where the first molars typically erupt; or Bohn nodules, which are found on the buccal and lingual aspects of the ridge, away from the midline. A protuberant mass from the anterior maxillary ridge of a newborn should prompt suspicion for a congenital epulis; however, examination by a pathologist after resection is important to confirm the diagnosis. A mucocele is a painless, clear or bluish, fluid-filled cyst that results from damage to the salivary duct, resulting in extravasation of mucus from the gland into the surrounding soft tissue.

White plaques involving the buccal, lingual, and palatal mucosa are suggestive of oral candidiasis. Thrush can sometimes be confused with milk remaining in the child’s mouth after feeding. Scraping the lesion to determine if the white substance is readily removed (as milk is) helps differentiate this from oral candidiasis, in which the white plaques do not easily scrape off; additionally, after scraping, the base of the thrush lesion may be erythematous or may bleed. Some infants and young children have a white coating to the tongue as a normal variant. The lack of white patches on other mucosal surfaces should call into question the diagnosis of thrush. In fissured tongue, grooves that vary in depth are noted along the dorsal and lateral aspects of the tongue.

In scarlet fever, the tongue initially has a white coating overlying the red swollen papillae of the tongue—the “white strawberry tongue,” which desquamates at approximately day 4 or 5 of illness, leaving the “red strawberry tongue.” In Kawasaki disease, initial presentation usually includes a bright red strawberry tongue and red, dry, cracked lips. Other clinical features and select laboratory testing help differentiate Kawasaki disease from scarlet fever. Both Kawasaki disease and scarlet fever require specific treatment to avoid long-term complications. For scarlet fever, treatment is with penicillin to avoid rheumatic fever, and for Kawasaki disease, treatment is with intravenous immunoglobulin to prevent coronary artery aneurysms.

Common oral ulcers include aphthous ulcers, herpes gingivostomatitis, and herpangina. Oral herpes may be characterized by multiple vesicular lesions, which, after rupture, appear as ulcers involving the lips, skin around the mouth, tongue, and mucosal membranes, typically in the anterior portion of the mouth. The initial infection may occur between 1 and 3 years of age. Aphthous ulcers also involve the anterior mouth, typically along the wet vermillion; however, they usually first appear at a somewhat older age (ie, in the preschool years or later) and with fewer lesions than oral herpes. Factors that may predispose to the development of RAS include familial tendency, trauma, hormonal factors, food or drug hypersensitivity, immunodeficiency, celiac disease, inflammatory bowel disease, and emotional stress. Herpangina may present similarly to herpes, but it more typically involves the posterior pharynx and the palate. Similar lesions on the hands or foot, as in hand-foot-and-mouth disease, may lend support to coxsackievirus A as the etiology.

Trauma to the salivary duct may result in a mucocele. In contrast, a pyogenic granuloma is an erythematous, nonpainful, smooth or lobulated mass that often bleeds easily when touched, whereas a fibroma is a moderately firm, smooth-surfaced, pink, sessile or pedunculated nodule, usually noted on the buccal mucosa in the occlusal plane. When located on the gingiva, a pyogenic granuloma can be confused with a periapical abscess, which is an erythematous, pus-filled cyst that occurs when infection spreads from the root of an infected tooth to surrounding tissues (also called a gum boil or a parulis). If the abscess ruptures, it often leaves a periapical fistula.

Erythematous and friable gums often indicate the presence of chronic gingivitis. Typically, plaque is seen on and between the teeth. In contrast with plaque-associated chronic gingivitis, which is usually painless or only mildly uncomfortable, acute necrotizing ulcerative gingivitis (Vincent infection) is quite painful, acute in onset, and associated with ulcers, necrosis, and pseudomembrane formation in affected areas. Swollen and inflamed gingiva can be presenting signs of leukemia in an ill-appearing child with an abnormal complete blood count.

Evaluation

History

The history is very important in evaluating oral lesions and determining the need for further treatment or referral. Key factors to include in the history are age at onset, duration, inciting factors, other medical problems, medications, tobacco use, family history, ill contacts, and associated or systemic symptoms and signs, such as fever (Box 86.1).

Physical Examination

Physical examination of the oral structures should start with the lip (dry and wet vermillion) and surrounding skin (the “white lip”). The examination should then turn to the mucosa, gingiva, teeth, and palate; all aspects of the tongue (ie, superior, inferior, both sides); sublingual structures; frena; and posterior pharynx. The physician should note the number, size, location, and characteristics of the lesions, because this information can be helpful in narrowing the differential diagnosis. The presence and duration of fever should be ascertained. The rest of the body should be examined with specific attention to the presence of other lesions, rashes, lymphadenitis, or arthritis.

Anterior ankyloglossia may be obvious because of a notched or heart-shaped tip of tongue. In more severe cases, the tight and short sublingual frenum makes it difficult to pass a finger under the tongue. Difficulty lifting the tongue to the middle of the mouth and/ or difficulty extruding the tongue past the gingiva are other characteristics suggestive of anterior or posterior ankyloglossia.

Laboratory Tests

In otherwise healthy children who present with oral ulcerative lesions, supportive care is typically implemented without pursuing a definitive etiology. If a specific diagnosis is required, human herpesvirus and coxsackievirus can be identified and differentiated with polymerase chain reaction testing. Likewise, oral candidiasis in an otherwise healthy infant usually is managed without diagnostic tests. However, a potassium hydroxide 10% microscopic slide preparation of scrapings from the lesion should demonstrate the characteristic spherical budding yeasts and pseudohyphae. An excisional biopsy or resection may be necessary to determine histology and diagnosis of other oral lesions.

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