Soft tissue lesions and conditions of the mouth, and methods of their investigation
At the end of this chapter you should have an understanding of:
- 1. Soft tissue lesions and conditions of the mouth.
- 2. Biopsies.
Fibroepithelial polyp (FEP)
These are common, benign, slow-growing fibrous lumps (Figure 6.1) which are usually painless. Fibroepithelial polyps are usually caused by trauma or from a source of irritation to the soft tissues such as a sharp tooth or cheek biting. They are often seen in adults, commonly presenting on the tongue, buccal mucosa and lips. They have the appearance of a shiny, smooth, round lump. Fibroepithelial polyps may attach to the mucosa by either a stalk or at the base of the lump itself. Fibroepithelial polyps may also present on the palate as a flattened lesion known as leaf fribroma. These palatal lesions usually occur under an ill-fitting denture.
These present as small, benign, cauliflower-like lesions which are usually white or pink in colour. Papillomas (Figure 6.2) are most commonly found on the tongue, lips, buccal mucosa or on the palate, particularly where the hard and soft palate join. Papillomas are caused by a type of human papilloma virus (HPV); however, this type of papilloma appears to be benign as opposed to other types of papillomas in the body which may become malignant.
Mucocele (mucus cyst/mucus extravasation cyst)
Mucoceles (Figure 6.3) are painless, translucent, smooth, soft swellings. They may vary in size, and can be up to 1–2 cm in diameter. They commonly occur on the inside of the lower lip, but may also occur on the ventrum of the tongue, floor of mouth and occasionally the palate. Mucoceles may appear slightly bluish/white in colour. These lesions are usually attributed to trauma of a minor salivary gland, for example accidentally biting the lip. When recording the history of the lesion during the assessment appointment, the patient may explain that the swelling ruptures from time to time then recurs. Many patients wish to have these lesions removed as the position of the mucocele, particularly on the lower lip, may be troublesome to the patient particularly when eating; further trauma may also occur through accidental biting of the lesion. However, if the mucocele is small and not troublesome they may be left and kept under observation. If they are removed, as with all soft tissue lesions the sample should be sent to pathology for a histology report to confirm diagnosis.
Haemangiomas are vascular lesions consisting of malformed blood vessels. These lesions appear as flat red, purple or bluish areas usually occurring on the lip, buccal mucosa, palate or tongue. As haemangiomas are vascular they are soft and compressible, and blanch upon pressure. They are frequently left due to the complication of haemorrhage associated with their removal.
Lichen planus (Figure 6.4) is usually symptomless; however, some patients suffer from painful flare-ups which can be troublesome, affecting the patient’s ability to eat and drink, and can be distressing at times. It is a common condition that, orally, can affect areas of the buccal mucosa, tongue, floor of mouth and gingiva. It is distinguishable by its white lace-like patterns and/or red, angry, erosive areas. Confirmation of suspected lichen planus is usually carried out by performing a biopsy. Although there is no ‘cure’ for any confirmed diagnosis, it is important that more serious conditions are ruled out through histopathology investigation. Lichen planus is a persistent condition and although there is no definitive treatment, the condition is usually symptom free. During any flare-ups, a steroid mouthwash may shorten the duration of any painful, troublesome episodes. Patients who suffer with lichen planus are kept under review and, if the presentation of the lesion changes, a further biopsy may be performed.
Geographic tongue is a common, benign, inflammatory condition. It commonly affects the dorsum area of the tongue. It may be asymptomatic but for some patients it can cause soreness, particularly when eating acidic or spicy food as this can make the condition worse. Geographic tongue is a non-contagious condition. Areas of depapillation develop, leaving areas of erythema (red). These smooth, red patches are irregular in shape, size and may give the appearance of a map-like pattern on the tongue. These areas can spread, move or change within days or weeks and may even spontaneously resolve only for a new area to appear in a new location on the tongue. The cause of geographic tongue is unknown, but there has been suggestion that it may be linked to a genetic predisposition as it is a condition that tends to run in families. There is no specific treatment. Many people with geographic tongue find that avoiding certain foods helps to control the condition. For any soreness or discomfort, over–the-counter analgesics or a non-steroidal anti-inflammatory may be used. An anaesthetic mouthwash may prove helpful and, on occasions, corticosteroids and zinc supplements.
Also known as oral thrush, oral candidiasis is a fungal infection of the mouth. It may appear as a white patch which can be removed by gentle rubbing to reveal an area of redness. Its development may be associated with factors including poor oral hygiene, medications such as steroidal inhalers, antibiotic therapy and also diabetes and xerostomia. Patients may be unaware of its presence within the mouth as it can be symptomless. Some however may experience discomfort, a burning sensation or an unpleasant taste (dysgeusia). Treatment may include the use of anti-fungal medication and mitigation of the primary factors causing the condition.
These are common, self-limiting, shallow, circular lesions with a white/yellow area surrounded by a red border which may be slightly raised. Ulcers may present individually or as a cluster of several lesions. Individual ulcers are usually caused by trauma to the oral tissues. Many are painful and tender which may cause transient difficulties with oral hygiene, eating, drinking, speaking and swallowing. As there is no curative treatment for ulcers, management of the condition involves ameliorating any pain or discomfort while allowing the lesion to heal.
Ulcers (also known as aphthae, aphthous or aphthosis) may be attributed to trauma, anxiety, stress, systemic disease and possible deficiencies in some vitamins. Ulcers may also be linked to hormonal changes and a genetic predisposition. Recurrent episodes of ulceration may indicate a need for further investigation, and haematological analysis by routine blood screening can exclude any underlying deficiencies, particularly in iron, folic and B12 levels.
- • Less than 10 mm in diameter.
- • Self-limiting/-healing within 7–10 days.
- • Heals without scarring.
- • A diameter greater than 10 mm.
- • Longer lasting.
- • Painful, deep lesions that when healed leave scarring.
Although ulcers are usually self-limiting, should an underlying cause of the ulceration be suspected referral to a specialist for further investigation may be necessary. Any unexplained ulceration of the oral mucosa, tongue or gingiva persisting for more than 3 weeks should be urgently referred to the maxillofacial consultant.
Burning mouth syndrome
Burning mouth syndrome is also sometimes referred to as glossodynia. Burning mouth syndrome (BMS) is characterised by a burning pain in the mouth which has no obvious cause. The pain can be localised, affecting areas of the tongue, lip, palate or gingiva or widespread, involving large areas of the mouth. There are many known factors which may be attributed to BMS, but it can be difficult to determine the definitive cause. These underlying factors may include:
- • Low levels of iron, folic acid and vitamin B12.
- • Oral candidiasis.
- • Xerostomia.
- • Gastric reflux.
- • Neuropathy.
- • Hormonal changes.
- • Allergic reaction.
- • Stress, anxiety and depression.
Blood tests and a microbiology swab may disclose an underlying cause which, when treated, will resolve the symptoms of BMS. However, BMS may unfortunately be a long-term condition. Medication may be offered to help patients cope with the chronic pain.