Oral pathology for the primary-care clinician

Benign migratory glossitis appears as irregular, maplike patches on the tongue (shown here).
Benign migratory glossitis appears as irregular, maplike patches on the tongue (shown here).

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At a glance

  • Tobacco users are almost four times as likely to have an oral lesion than those who have never used tobacco.
  • Recurrent aphthous stomatitis, or canker sores, can be painful and may interfere with food intake and speech.
  • More than half of all intraoral cancers in the United States are located on the tongue.
  • Candidiasis is present intraorally without clinical manifestation in 30%-50% of people.

Primary-care clinicians will see a variety of oral conditions during routine physical examinations. There are many superficial mucosal lesions, masses, and tumors that affect the oral cavity. The size, location, surface appearance, texture, duration, and associated pain should be noted. Further, forming a differential diagnosis of oral disease requires knowledge of the pathogenesis, characteristics, and proper treatment. When informing patients of the diagnosis, the clinician should be comfortable discussing the prognosis of the condition. In descending order of prevalence, common oral lesions include recurrent aphthous stomatitis (RAS), hyperkeratosis, candidiasis and angular cheilitis, oral nevi, leukoedema, benign migratory glossitis, squamous cell carcinoma (SCC), acute necrotizing ulcerative gingivitis, lichen planus, and herpes labialis. Tobacco users are almost four times as likely to have an oral lesion than those who have never used tobacco products. Treatment may range from use of topical ointment to referral to an oral and maxillofacial surgeon for biopsy.

This article provides a rundown of the diagnosis and treatment of some of the most common oral lesions you will come across in your practice.

Benign migratory glossitis

Benign migratory glossitis, also known as geographic tongue or erythema migrans, is usually an asymptomatic inflammatory disorder of unknown etiology that affects the epithelium of the tongue. Estimated prevalence is approximately 2% of the population.1 This condition is twice as common in females. Local loss of filiform papillae leads to ulcerlike lesions that rapidly change in color and size. Geographic tongue presents as multiple well-demarcated zones of erythema, concentrated at the tip and lateral borders, surrounded by a slightly elevated yellowish-white and serpentine border. The condition is characterized by exacerbations and remissions, and the lesions may have a migrating pattern.2 It has been suggested that benign migratory glossitis is an oral manifestation of psoriasis.3 Numerous case reports of successfully treating refractory benign migratory glossitis with systemic immunosuppressive therapy (e.g., cyclosporine) strengthen the proposed immunologic etiology of this condition. This condition is usually asymptomatic, but occasionally patients complain of pain when eating (especially with spicy foods). When seen in other parts of the oral cavity, benign migratory glossitis is called stomatitis areata migrans or ectopic geographic tongue.

No treatment is necessary unless the patient is symptomatic. The patient should be reassured that geographic tongue is a benign process. Several treatment modalities exist, including topical steroids, zinc supplements, and topical anesthetic rinses. None has been proven to be uniformly effective.4

Lichen planus

Oral lichen planus is an inflammatory condition that affects 1%-2% of U.S. adults. Etiology is unknown, but immune-mediated CD8+ cytotoxic T cell-induced apoptosis of epithelial cells is believed to be a causative factor. The condition is predominantly found in men older than age 40 years. The two known forms of lichen planus are reticular and erosive. The reticular form has bilateral, asymptomatic, white, lacy striations known as Wickham's striae. Papules may also be present on the posterior buccal mucosa. Erosive lichen planus results in erythematous, painful ulcers, often surrounded by white, lacy, radiating patterns of striae. Generalized erythema and gingival ulcerations may also occur.

Reticular lichen planus is readily identified, but the erosive form often requires biopsy for diagnosis.

Treatment is typically only necessary for the erosive form. Topical steroids or topical tacrolimus (Protopic) have been found to be very effective treatments. A small number of clinical cases of erosive lichen planus have demonstrated transformation to a dysplastic lesion or carcinoma.5 Therefore, patients should be followed every six months to identify any changes in the appearance of the lesion.

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