Patients often present to GP practices with oral lesions as they may struggle to get a dental appointment. It is important to know which lesions need to be referred and which lesions are potentially serious and need an urgent 2WW referral.
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Ulcers
Ulcers indicate a break in the oral mucosa. Oral ulcers are very common and most patients will not need to seek medical attention for them.
History
- Size
- Site
- Number at one time
- Time for a single ulcer to resolve
- Time between outbreaks
- Prodromal symptoms
- Any obvious triggers? E.g. premenstrual, stress
- Any systemic problems
- Presence of scarring
- Medications e.g. nicorandil
Risk factors
- Smoker
- Heavy alcohol intake
- Paan/betel nut chewing
- History of oral cancer
Red flag features
- Irregular border
- Firm/indurated
- Lymphadenopathy
- Sensation changes/weakness
- Present for >3 weeks
- Painless
- Loose teeth
Suspicious ulcers
If any red flag features or strong risk factors are present, patients should be referred to OMFS under a 2WW. Oral cancers are often squamous cell carcinomas and are strongly associated with the risk factors discussed above.
Benign ulceration
Benign ulceration is usually related to trauma. Often this is due to a sharp tooth and requires smoothing by a dentist, as seen in the image below. It can also be due to burns or other trauma. These ulcers normally reduce and disappear with time, and often the patient will know the trigger.
Recurrent ulceration
Recurrent ulceration is common but can impact quality of life if it persists and they are very painful. It can be linked to iron deficiency anaemia, low B12, low folate, low zinc, and systemic conditions such as coeliac or Crohn’s disease. It is therefore important to do necessary blood tests and take a thorough history. Otherwise, recurrent ulceration can be from an unknown cause.
Management includes treating any underlying cause and symptomatic relief with Difflam or steroid mouthwashes. If simple measures do not help the patient can be referred to an oral medicine or OMFS department.
Patches
Patches in the mouth can be a variety of colours and can be due to multiple causes, including systemic problems. They can often be pre-malignant/malignant, so it is important to refer patients where the cause is unclear or when risk factors are present. Mixed red and white patches are most likely to be sinister, followed by red patches, then white patches.
White patches
A white patch that does not easily rub off indicates ‘thickening’ of the epithelium. When no cause can be found it is called leukoplakia. Biopsy is often needed for diagnosis and to rule of premalignancy. It can be due to oral lichen planus (web-like striae, often on the inside of the cheeks and can be related to skin lesions), candidal infection or frictional keratosis (due to chronic trauma).
Red patches
These patches indicate epithelial atrophy. When no cause can be found it is called erythroplakia. These are very suspicious for premalignancy/malignancy and so require a biopsy. Benign red patches can be due to candida or geographic tongue (condition that causes red patches that move on the tongue).
Pigmented lesions
Pigmented lesions are often normal or due to outside chemicals. Rarely they can be oral melanoma, which is much rarer than on the skin so may need biopsy. They can be due to smoking, ‘tattooing’ of the mucosa (from a dental amalgam filling), black hairy tongue (due to poor oral hygiene) or systemic problems (for example Addison’s disease).
Lumps and swellings
Red flag features
- Associated ulceration
- Fixed to deep tissues
- Irregular border
- Lymphadenopathy
- Nerve changes
- High-risk areas (lateral tongue, floor of mouth, lip, cheek)
- Rapidly growing
Risk factors
- Smoker
- Heavy alcohol intake
- Paan/betel nut chewing
- History of oral cancer
Malignant causes
All presentations of a ‘lump’ in the mouth need to be investigated for malignancy through a biopsy and further imaging unless there is an obvious cause. Squamous cell carcinoma related to risk factors is the most common. Treatment of oral cancer is usually surgical excision, neck dissection +/- chemo/radiotherapy.
Infection
Infections and abscesses in the mouth are common. Lumps due to infection normally have an obvious cause, rapid onset, fluctuant and are related to pain or feeling generally unwell. Please see the orofacial infections article for further information.
Fibroepithelial polyp
This is a benign fleshy mobile lump on the gum or mucosa. It is often caused by chronic irritation and diagnosis is normally clinical. Treatment and definitive diagnosis are through an excisional biopsy normally done by OMFS after a routine referral.
Mucocele
Mucoceles are a collection of saliva caused by trauma to a minor salivary gland. Therefore, they are usually seen on the inside of the lower lip. Again, this is a clinical diagnosis and treatment is excision with removal of the underlying gland to prevent recurrence.
Bony swellings
Bony swellings are normally physiological outgrowths called ‘tori’. They are usually present for many years. They are usually found as either a symmetrical smooth midline swelling of the hard palate, or bilateral symmetrical smooth swellings of the mandible, most often inside the jaw next to the tongue. Any changes in appearance can be suspicious and warrant an urgent referral.
Conclusion
While it is difficult to differentiate between all these lesions, the most important thing is to know when to refer patients urgently, which patients need a routine referral and which patients require medical input.
References
Payne, K.F., Goodson, A.M., Tahim, A.S., Ahmed, N. and Fan, K.F., 2015. On-call in Oral and Maxillofacial Surgery. Libri Publishing.
Isaac, R., Goodson, A.M., Payne, K.F., Tahim, A.S. and Brennan, P.A., 2022. Oral and Maxillofacial Surgery: An Illustrated Guide for Medical Students and Allied Healthcare Professionals. Libri Publishing.
Written by Dr Janhvi Shah BDS (Hons) MBBS MFDS (RCSEd) PgCert MedEd
