Benign Oral Mucosal Lesions

Question 1

What is geographic tongue?

Answer 1

Surface of the tongue has been replaced in whole areas on a single occasion.
Halting of the epithelial replication so that the continuing loss of cells from the surface of the tongue without replacement causes thinning of the epithelial layer- these will appear red.
Some areas appear red and some appear white.

Question 2

What are the signs and symptoms of geographic tongue?

Answer 2

Small areas of change in the tongue, semi-circular red and white areas.
Sensitivity to spicy foods.
Intermittent
Worse in children
Some patients don’t have any symptoms.

Question 3

What follow up investigations would you request for someone with geographic tongue?

Answer 3

Full blood count- haematinics (Iron, folate and B12).
Investigate if there is a parafunctional habit- soft splint may be useful.
Dysaesthesia.

Question 4

What is black hairy tongue?

Answer 4

Tongue appears to be discoloured and fuzzy- caused by bacterial colonisation or elongated filiform papillae that is being stained by food and drinks.

Question 5

What treatment would be required for geographic tongue?

Answer 5

No treatment.
Advise the patient to avoid spicy foods and request further investigations.
Advise them to see their GP.

Question 6

What is likely to cause black hairy tongue?

Answer 6

Tea, coffee, chlorhexidine mouthrinse- staining the elongated papillae of the tongue.

Question 7

What advice can you give the patient regarding black hairy tongue?

Answer 7

Improve diet- peaches and peach stones sucked.
Brush your tongue, tongue scraper.

Question 8

What is a fissured tongue?

Answer 8

Fissures within the tongue can become deeper and cause food and debris to be trapped within them.

Usually asymptomatic but can be uncomfortable if food gets stuck.

Question 9

What advise would you give the patient regarding their fissured tongue?

Answer 9

Make sure to brush the tongue with a soft brush to clean out the fissures and reduce the risk of infection.

Question 10

What is glossitis?

Answer 10

Inflammation of the tongue.
Tongue appears to have no papillae, very smooth.

Question 11

What investigations may be required if a patient presents with glossitis?

Answer 11

Haematinics
Fungal cultures- lichen plants

Question 12

What is a fibrous epulis?

Answer 12

Soft tissue swelling on the gingivae only.
Caused by chronic inflammation/chronic trauma to the gingivae- usually sub gingival calculus.

Question 13

What are the signs and symptoms of a fibrous epulis?

Answer 13

Appears on the gingivae as a localised enlargement.
Firm consistency.
Similar colour to surrounding gingivae.
Inflammatory cell infiltrate and fibrous tissue.
May be areas of ulceration or erosion.
Poor OH, calculus present.

Question 14

What is a vascular epulis?

Answer 14

Soft, deep red/purple swelling on the gingivae, caused by vascular proliferation and infiltration of granulation tissue.
Haemorrhage spontaneously with mild trauma.

Question 15

What is a pyogenic granuloma?

Answer 15

Same as a vascular epulis but is found anywhere in the road cavity, except the gingivae.

Often ulcerated- does not have an epithelial surface over the top.

Arises from failure of normal healing.

Question 16

What is a pregnancy epulis?

Answer 16

Soft, red/purple swelling found on the gingivae of pregnant individuals.
Usually caused by localised trauma by calculus, exacerbated by pregnancy hormones.

Question 17

What is a giant cell epulis?

Answer 17

Inflammatory lesion on the gingivae, usually anteriorly or interproximally, caused by infiltration of macrophages in a vascular stroma with granulation tissue.

Question 18

Why are giant cells recruited in a giant cell epulis?

Answer 18

Material that is trying to be removed by the macrophages may be too difficult to remove.
Macrophages recruited.

Question 19

What stimuli may be present in a giant cell epulis?

Answer 19

Local chronic irritation.
Infective agents- TB bacillus.
Hormal stimulation of cells- osteoclasts.

Question 20

What is the clinical presentation of a giant cell epulis?

Answer 20

Red and ulcerated area on the gingivae.
Broad base.

Question 21

What further investigations may be required for a giant cell epulis/peripheral giant cell granuloma?

Answer 21

Biopsy.
FBC.
Investigate vit D, malabsorption, renal disease.

Question 22

What is the difference between a fibrous epulis, vascular epulis and giant cell epulis?

Answer 22

All originate on the gingivae.

Fibrous epulis- in response to localised trauma, lesion is same colour as underlying mucosa, firm consistency, usually poor OH.

Vascular epulis- red/purple lesion, haemorrhages easily with trauma, histologically will see blood vessels and granulation tissue. May be caused by localised trauma or systemic causes.

Giant cell epulis- red/purple, may be caused by systemic causes, histologically there will be lots of macrophages and granulation tissue.

Question 23

What is a fibroepithelial polyp?

Answer 23

Firm pink lump (same colour as underlying mucosa) (pedunculate or sessile), usually caused by accidental biting of the cheek/tongue or from a sharp tooth.
Usually in the cheeks/tongue/lip.
Remains a constant size once established.
No inflammation around the base of the lesion.

Histologically- thick fibrous tissue covered by thick epithelium.

Question 24

What is the treatment for fibroepithelial polyp?

Answer 24

Surgical excision.
Treat cause- i.e. sharp tooth.

Question 25

What is denture induced hyperplasia?

Answer 25

Hyperplasia of the fibrous tissue caused by an ill fitting denture.
Flabby ridge.

Question 26

What is the treatment for denture induced hyperplasia?

Answer 26

Construct new denture that fits better.
Remove the flabby ridge.
If you have taken all these steps and it is not better, take a biopsy.

Question 27

What is papillary hyperplasia of the palate?

Answer 27

Nodules present on the plate in someone with poor denture hygiene and an ill-fitting denture.
Candidal infection may be present.

Question 28

What is the treatment for papillary hyperplasia?

Answer 28

New denture construction.
OHI and denture care instructions.
If candida present- do the above things and if systemic treatment required
- Fluconazole 50mg- 1 capsule a day for 7 days.
- myconazole gel 20mg/g- apply 4 times a day after food.
- Nystatin- 100,000 units per ml. 1ml after food, 4 times a day for 7 days.

Question 29

What is a mucocele?

Answer 29

Cyst arising from connection with the minor salivary glands.

Appear clear/blue, soft to touch.
Usually in the lower lip.
Most will rupture spontaneously.
May require surgical excision if the lesion is fixed in size- removal of mucocele and underlying minor salivary gland.

Question 30

What is a ranula?

Answer 30

Mucocele in the FOM.
Can arise from minor salivary gland or sublingual and submandibular gland.

Ultrasound or MRI required to rule out plunging ranula

Question 31

What are tori?

Answer 31

Bony overgrowths associated with parafunctional habits.
Found in the palate or lower lingual regions.

Patients taking bisohisphonates at risk of this.

Question 32

What is a haemangioma?

Answer 32

Vascular lesion that is described as a hamartoma
- Normal tissue structure but their number is greatly increased or their location is abnormal.

Appears as a purple/red, well rounded lesion.
If you press on it, it will blanch.
Usually on the lips, tongue, buccal mucosa and palate.

Lesion will increase and reduce in size- this would suggest that it is vascular origin, rather than a malignancy.

Question 33

When should swellings be referred to oral medicine?

Answer 33

Symptomatic lesion.
Abnormal overlying and surrounding mucosa.
Increasing in size.
Rubbery consistency
Trauma from teeth
Unsightly

Question 34

What is the difference between a capillary haemangioma and a cavernous haemangioma?

Answer 34

Capillary- oxygenated blood, appears red.
Cavernous- dark/blue- slow moving blood through veins.

Question 35

What is a lymphangioma?

Answer 35

Build up of lymph fluid caused by blockage of lymphatic ducts.

Appears blue/translucent.
Usually cavernous- on the tongue.

Question 36

A giant cell lesion can be central or peripheral, how can you tell the difference?

Answer 36

Take a radiograph- if it is central, you will see it on a radiograph.
If there is no obvious area of trauma or OH is good- think systemic factors.

Question 37

What tests might you request if you think a giant cell lesion is of central origin?

Answer 37

Full blood count- check for parathyroid hormone.
Renal tests- test for renal failure.
Hypocalcaemia.

Radiograph will show lack of lamina dura around the entire root.

Radiograph of hand- loss of cortical bone- terminal phalanges.