Benign and malignant neoplasm of oral cavity is usually presented as swellings or ulcerations of affected tissue. The lesions are broadly categorized as potentially malignant disorders, benign and malignant neoplasm of epithelial and connective tissue origin for the convenience of learning. Neoplasm of oral cavity has a significantly lower incidence. Because of uncommon occurrence of oral neoplasm, retention of diagnostic skills is a challenging task. However, comprehensive understanding on clinical and pathologic details will help in correlating and presenting complaint and assisting in formulation of possible diagnosis. The key for successful therapeutic management depends on achieving right and timely diagnosis.
Key points
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Swelling of oral cavity may arise from surface epithelium or alternatively arise from pathology of underlying connective tissue structures.
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Most oral neoplasms are benign. Fibroma is the most common soft tissue tumor of oral cavity.
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Leukoplakia is the most common precancerous condition of oral cavity. Leukoplakia is strongly associated with smoking.
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Cancer of the head and neck is the fifth most common type of cancer in the world. Oral squamous cell carcinoma is the most common type of oral cancer.
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Benign/malignant lesion of jaw associated with child abuse is discussed.
Introduction
Benign, malignant, and reactive lesions of oral cavity present clinically as swelling/growth or an ulcerated swelling. Academically swelling is termed as tumors and growth of tumor is called as tumefaction, and hence many of the lesions described in this article are suffixed with “oma” (fibr oma ), which represents tumor. Oral tissues are vulnerable for benign or malignant growth due to factors such as trauma, infection (bacterial/viral/fungal), local irritation, smoking, alcohol misuse, or genetic damage. Tumors of oral cavity constitute to a small number of cases identified in a clinical practice and therefore challenges dentist in their office for diagnosis and/or management. Hence dentists are required to be more academically familiar, and continuously educating them on these conditions, especially on common type of oral conditions of this category, will enable dentists either to institute appropriate management or refer their patient to oral disease expert and oral surgeon at a right time. Although clinical and/or radiological details provide a clue in diagnosis, biopsy is required for arriving to a final definitive diagnosis, because some of the swellings may be associated with dysplastic features that may require an intensive surgical management.
This article discusses potentially malignant disorders and reactive lesions, benign, malignant conditions of oral cavity. In addition, oral lesions of abovesaid category that are associated with child abuse are also discussed. For the convenience of the reader, commonly encountered oral conditions on this category are listed in Table 1 . The oral conditions discussed will provide information on diagnosis, investigation, and outline on management.
| Potentially Malignant Disorders | Reactive Lesions | Epithelial Tumors | Connective Tissue Tumors | Oral Lesions Associated with Child Abuse |
|---|---|---|---|---|
| Leukoplakia Erythroplakia Oral submucous fibrosis Lichen planus |
Pyogenic granuloma Peripheral giant cell granuloma Perpheral ossifying fibroma Epulisfissuratum (inflammatory fibrous hyperplasia) Inflammatory papillary hyperplasia |
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Herpes simplex, Epstein–Barr Virus, cytomegalovirus, gonorrhea Molluscumcontagiosum Condyloma Accuminatum |
Diagnostic approach for swelling
The tumors can originate from epithelial or mesenchymal tissue and may be the result of inflammatory, neoplastic, developmental, or systemic diseases. The differential diagnosis on swelling from oral tissue must be formulated on parameters of surface appearance of swelling, location, consistency, and the presence or absence of pain. The first step in diagnostic approach for oral swelling is to check whether the swelling is arising from surface epithelium or, alternatively, arising from pathologic changes from the underlying soft tissue (ie, fibrous, fat tissue, blood vessels, lymphatic vessels, nerves, cartilage, or bone), resulting in secondary elevation of surface epithelium/tissue. The second step is to categorize them into benign, malignant, inflammatory, or reactive growth. The swellings that are movable, firm, and not indurated are in the benign category. The swellings that are fixed, indurated, ulcerated, or ulceroproliferative are likely to be malignant type. The swellings that are either tender or painful with or without sinus/fistulation are probably of an inflammatory origin. The swellings that occur secondary to injury are reactive lesions and may be associated with or without pain. Third step is to evaluate clinical parameters such as surface appearance of swelling, location, consistency, and the presence or absence of pain. The swelling observed on oral tissues may be a regular swelling or one of the following types: papillary, verrucous, dome-shaped, papule, polypoid, diffuse, or multifocal ( Table 2 ). Fourth step is evaluating status of lymph nodes. Lymph nodes that are palpable and hard and fixed to underlying structure are likely to be an association of malignant condition. Lymph nodes that are palpable and soft and movable favor benign growth association. Tenderness/pain associated with lymph node palpable is the characteristic of inflammation. The presence and absence of lymph node cannot differentiate benign from malignant conditions.
| Appearance of Swelling | Description |
|---|---|
| Papillary | The swellings that appear as fingerlike surface projections. |
| Verrucous | The swellings that have multiple fingerlike appearance but characterized by more irregular surface. |
| Dome-shaped | These are oval-shaped swellings with rolled margin and a central pit that may or may not be plugged with keratinaceous material. |
| Papules | These are small swellings that are <0.5 cms and are usually multiple in number. |
| Polypoid | These are similar to papules but exceed 1 cm in growth size and tend to be multifocal. |
| Nodular | These are raised solid lesions that are >5 mm in diameter. |
| Macule | Focal area of color change, which is neither elevated nor depressed to adjacent mucosa. |
| Diffuse | Swellings that are characterized by their multifocal appearance. |
The fifth step is to formulate differential diagnosis based on clinical details and plan for investigation for arriving at a final diagnosis through microscopic examination, that is, biopsy ( Fig. 1 ).
Potentially Malignant Disorders
Potentially malignant disorders convey that “not all lesions and conditions described under this term may transform to cancer, rather there is a family of morphologic alterations among which some may have an increased potential for malignant transformation.” Potentially malignant disorders serve as a clinical marker for future malignancy in oral mucosa. The risk factors for oral cancer and precancer are broadly categorized as established, strongly suggestive, possible, and speculative factors ( Table 3 ).
| Established | Strongly Suggested | Possible | Speculative |
|---|---|---|---|
| Smoking Chewing tobacco Snuff dipping Alcohol misuse Betel quid syphilis |
Sunlight (lip) Radiation |
Viruses Immune deficiency Dentition? Ethnicity? |
Mouthwashes Mate drinking Periodontal disease Familial |
Oral lichen planus
Lichen planus affects both skin and oral mucosa due to multiple factors ( Box 1 ), with prevalence of 0.5% to 1%. Lichen planus is characterized by symmetric appearance of bilateral white/white-grey striations or plaque. The lesion is predominantly observed on buccal mucosa, tongue, and gingival. The lesion tends to show erythematous, erosion- or blister-like appearance.
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Tobacco smoking and chewing
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Stress
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Dental materials
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Drugs
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Infectious components
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Autoimmunity
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Food allergies
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Immunologic alterations
Clinical features
The lesion is characterized by bilateral symmetric radiating white or greyish white striae, small angular, flat-topped papules only 0.5 mm to 2 cm with slight female predilection. The striae have lacelike appearance, which is termed as “Wickham striae.” The clinical types of lichen planus are reticular ( Fig. 2 ), atrophic, papular, bullous, plaque, erosive, or ulcerative. Erosive type has potential for malignant transformation to oral squamous cell carcinoma (OSCC).
Diagnosis
Clinical appearance is diagnostic; however, microscopic examination is necessary for securing final diagnosis.
Management
Corticosteroids and topical retinoid are helpful in relieving symptoms. Associated causative factors require elimination.
Erythroplakia
Erythroplakia is an uncommon potentially malignant disorder characterized by red patch that cannot be clinically or pathologically diagnosed as any other condition with a prevalence of 0.001% to 0.83%, whereas most of the erythroplakia diagnosed is 1.2 per 100,000 population in the United States. The causative factors for erythroplakia are tobacco, alcohol, candidial infection, hematinic deficiency, and chronic trauma.
Clinical features
Erythroplakia is characterized by well-defined erythematous patch or plaque with soft and velvety texture. Intermixed red and white patch is termed as erythroleukoplakia. Erythroplakia is predominantly observed in geriatric population (65–75 years) with no gender predilection. Frequently reported locations are floor of the mouth, tongue, and soft palate. Microscopic examination is usually indicated to rule out OSCC.
Management
Cessation of habit is the most important strategy in the patient management. Surgical excision is used due to association of dysplastic features in the tissue. The recurrence rate is lesser than 5% and postoperative follow-up is required.
Leukoplakia
Leukoplakia is a white patch or plaque that cannot be characterized clinically or pathologically as any other diseases. Tobacco smoking is the most common cause, with prevalence of leukoplakia ranging from 1.5% to 4.3%.
Clinical features
Leukoplakia is characterized by flat to slighted elevated, nonscrapable white or gray patches that are usually seen among midaged adult men with smoking habit. Leukoplakia can be seen at vermillion border of the lip, buccal mucosa, floor of the mouth, gingiva, or tongue. Causes of leukoplakia include tobacco smoking or chewing; betel quid; alcohol; trauma; infections such as syphilis and Candida albicans; chemicals such as Sanguinaria; ultraviolet radiation; iron-deficiency anemia; immune deficiency state; human papillomavirus (HPV) 16 and 18; and deficiency of vitamin A, B12, and C. Various clinical forms of leukoplakia are thin, thick, homogenous, granular, nodular, verrucous, verruciform, speckled, or proliferative verrucous leukoplakia. Intermixed white-red patches are called as erythroleukoplakia. Speckled leukoplakia has a higher potential of malignant transformation to OSCC.
Diagnosis
Differential diagnosis of leukoplakia include aspirin burn, candidiasis, frictional keratosis, leukoedema, linea alba, lupus erythematosus, cheek bite, syphilis, smoker’s palate, and white sponge nevus. History and clinical details are adequate for ruling out differential diagnosis. Microscopic examination should be done to confirm diagnosis of leukoplakia and evaluate the association of dysplasia. Biopsy is also important to rule out squamous cell carcinoma.
Management
Cessation of habit is the most important strategy in the patient management. Surgical excision is used due to association of dysplastic features in the tissue. An approach for management of leukoplakia depend on elimination of cause and biopsy report ( Fig. 3 ).
Reactive Lesions
Reactive lesions are growths resulting from trauma or irritation and characterized by slow-growing, painless, pedunculated or sessile mass with or without bleeding tendency. The surface of the growth may vary from smooth to ulcerated tissue. Lymph node may be palpable and tender due to inflammatory origin.
Pyogenic granuloma
Pyogenic granuloma is a tumorlike growth exuberant resulting from tissue response to local irritation or trauma.
Clinical features
Pyogenic granuloma is characterized by painless, smooth, lobulated, pedunculated mass with bleeding tendency. However, cases have been reported with sessile growth or without bleeding tendency. Lesion appears red to pink with varying size ( Fig. 4 ). The lesion occurs due to trauma, calculus, plaque, overhanging restoration, implantitis, pregnancy or hormonal change. Rapid growth of tissue alarms with malignant appearance. Lesion is predominantly seen as gingival swelling more commonly from labial side.
Diagnosis and management
Microscopic examination is usually done to rule out malignancy. The treatment options include surgical excision, curettage, cryotherapy, chemical and electric cauterization, lasers, and intralesional corticosteroids.
Peripheral ossifying fibroma
Peripheral ossifying fibroma is one of the common reactive growths of soft tissues, and mineralized component of the lesion possibly originates from periosteum or periodontal ligament. This lesion is considered to be a resultant of reparative response to intrabony hemorrhage and inflammation.
Clinical features
Peripheral ossifying fibroma is characterized by nodular, red/pink, pedunculated/sessile mass occurring at papilla of the gingiva with surface ulceration. The lesion mimics pyogenic granuloma and is predominantly seen among teenagers and women. Most of the cases were reported in incisor and canine region of maxillae.
Diagnosis
Radiographic examination of the tissue shows minimal cortical plate expansion with or without severe root resorption. Microscopic examination is usually indicated to rule out pyogenic granuloma and peripheral giant cell granuloma.
Management
Conservative surgical excision with curettage to prevent recurrence. Approximately 8% to 10% of cases show recurrence.
Peripheral giant cell granuloma
Peripheral giant cell granuloma is another reactive lesion that is categorized as tumorlike growth. Trauma is the most common cause for occurrence and seen predominantly in root canal–treated tooth. Radiographic changes are helpful in recognition.
Clinical features
Peripheral giant cell granuloma is a red or blue, nodular gingival or alveolar sessile/pedunculated mass that measures less than 2 cm. There is no specific age predilection and is frequently reported on women. Mandibular anterior is the most common region of occurrence.
Diagnosis and management
Radiologically the lesion shows cupping resorption of alveolar bone. The cupping effect is reflection of base of the lesion. Microscopic examination is required to rule out peripheral ossifying fibroma and pyogenic granuloma. Conservative surgical excision with thorough oral prophylaxis, scaling, and root planning are used for removal of source irritation that is, supra/sub-gingival calculus. Approximately 10% to 18% of cases showed recurrence.
Inflammatory papillary hyperplasia
This is a hyperplastic connective tissue growth that is seen among edentulous patients with ill-fitting partial or complete dentures. Ill-fitting denture, sharp edges, trauma, and poor denture hygiene are the most common causes.
Clinical features
Papillary hyperplasia is characterized by asymptomatic papillary/fingerlike growth of tissue beneath denture ( Fig. 5 ) predominantly seen in hard palate surface and remains asymptomatic until secondary infection. The secondary infection can cause redness, soreness, pain, or burning sensation.
Diagnosis and management
Clinical appearance of the lesion is diagnostic. The growth is usually removed surgically. Denture hygiene instructions must be followed to prevent recurrence.
Inflammatory fibrous hyperplasia
Inflammatory fibrous hyperplasia is a reactive growth resulting from poor denture hygiene practices and chronic injury/irritation from the denture. Concurrent occurrence of candidiasis may be observed.
Clinical features
The lesion is characterized by painless, pink to red, nodular, circumscribed polypoid mass with bleeding tendency. The lesion may be symptomatic, that is, pain when associated with irritation or erythematous changes. Female predilection is observed. Hard palate is the most common site and occasionally seen over mandibular alveolar ridge. Few cases of inflammatory fibrous hyperplasia have been reported with candidiasis and human immunodeficiency virus infection.
Diagnosis and management
Clinical appearance is diagnostic. Surgical removal of hyperplastic tissue and fabrication of new denture is advised. Individuals with candidiasis are managed with antifungal medications.
Tumors of Epithelial Tissue Origin
The tumors of this origin are characterized by the swelling that arises from surface epithelium. The recognition of tumors as epithelial versus mesenchymal tissue origin is not just academic importance but to understand relevance of clinical, histologic behavior, aggressiveness and prognosis. The relevance of above-mentioned areas greatly varies in malignant neoplasms. Hence the topics covered here are discussed under 2 headings: benign and malignant lesions.
Benign epithelial tumors of oral mucosa
Squamous papilloma
Squamous papilloma is a viral-induced benign proliferation of stratified squamous epithelium of oral tissue. The swelling is characterized by solitary occurrence of finger-like projection of surface epithelium. The occurrence of this lesion is presumably associated with low-risk type of HPV (types 6 and 11). The mode of transmission of HPV for inducing this lesion is not clear.
Clinical presentation
Squamous papilloma is characterized by painless, slow-growing, fingerlike projection of surface epithelium that are either sessile or pedunculated with normal-appearing color or whitish change. Soft palate is the most commonly encountered site involvement; however, it can occur on tongue, lips, or buccal mucosa. No specific gender predominance is observed. The dimension of the lesion is often varying with their size being less than 0.5 mm to 3 cm. Lymph nodes are not affected in this condition.
Diagnosis
Microscopic examination of biopsied tissue is helpful in achieving final diagnosis. The differential diagnosis of this condition can include verruca vulgaris when the lesion appears rougher and irregular surface tissue growth; condyloma accuminatum should be considered when the lesion is associated with whitish appearance and blunt surface projections.
Management
Surgical excision of lesion along with base of the surface tissue will provide good prognosis. Recurrence of lesion is uncommon.
Verruca vulgaris
Verruca vulgaris is characterized by white papillary growth of surface epithelium that is either sessile or pedunculated. The condition is predominantly observed in cutaneous surfaces, whereas in oral cavity it is observed in vermilion border of lip. Because of higher predilection on epidermis (skin) the condition is often noted as common/cutaneous wart. The lesion is often associated with low-risk type of HPV (HPV 2, 4, 6, and 40). The mode of transmission of HPV for inducing this lesion is autoinoculation of virus from affected skin or mucous membrane.
Clinical presentation
Verruca vulgaris is characterized by painless, white papillary growth of surface epithelium that is either sessile or pedunculated. Although it is uncommon in oral mucosal surfaces, the cases have been reported on labial mucosa and anterior tongue. The lesion appears in small size and grows rapidly to attain its maximum size. Multiple lesions can occur in oral cavity.
Diagnosis
Microscopic examination of biopsied tissue is necessary for arriving final diagnosis. Differential diagnosis of squamous papilloma may be considered when the lesion has less white color.
Management
Surgical excision of the lesion should include base of the lesion. Very few cases have reported with recurrence.
Focal melanosis
Benign pigmented lesion is characterized by well-circumscribed, painless, flat, brown mucosal discoloration with increase in pigmentation possibly due to increase in number of melanocytes at basal cell layer of epithelium. Focal melanosis is frequently observed on lips. The lesion is managed by surgical excision specially to rule out malignant melanoma.
Clinical presentation
Focal melanosis is a painless, slow-growing pigmented macule that is a predominantly brown change of oral mucosa on the affected region. However, cases with blue, brown, or black have been reported. Female predilection is observed and can be seen in any age group. Although lip is the most commonly encountered site, the lesion can be seen on gingiva, buccal mucosa, or palate ( Fig. 6 ).
