Candidial Leukoplakia (Chronic Hyperplastic Candidiasis) – “White Lesion”

Etiology an infection of the oral mucosa caused by fungus; candida albicans or infected epithelial tissue, which becomes hyperplastic with a formation of excess surface keratin (callused).

Typical Visual Cues a circumscribed white plaque found at the site of fungal infection that will not rub off with gauze, most often found on the anterior buccal mucosa adjacent to the commissure (corner of the mouth); may occasionally be found at the lateral border of the tongue.

Useful Clinical Information more common in adults, considered a painless and persistent lesion.

Treatment Recommendations antifungal agents for treatment of oral candidiasis, such as Mycostatin Nystatin, Mycelex clotrimazole, or Fungizone amphotericin B. Systemic antifungal agents for chronic candidiasis include:  Nizoral Ketoconazole, Diflucan Fluconazole or Sporanox Itraconazole.

Clinical Significance oral lesions found in tobacco users should be viewed with increased suspicion.

Leukoplakia
Leukoplakia
Image courtesy of AIDS Image Library

Erythroplakia – “Red Lesion”

Etiology a significant risk factor to the oral mucosa is chronic exposure to carcinogenic components found in all types of tobacco.  The other common risk factor is chronic alcohol exposure.  Even worse is a combination of both.

Typical Visual Cues a circumscribed, or ill-defined, erythematous plaque that varies in size, thickness and surface configuration.  It has a velvety appearance and occurs most frequently on the floor of the oral cavity, ventral area of the tongue and the soft palate.

Useful Clinical Information a painless and persistent lesion, found more commonly in adult males and patients who report tobacco exposure.

Treatment Recommendations the patient should be counseled in a tobacco cessation program if biopsies reveal that the lesion is premalignant.  Then, a more extensive therapy is indicated and the patient should be re-evaluated at regular intervals for other oral mucosal changes.

Clinical Significance erythroplakia occurs less frequently than leukoplakia, but it is much more likely to exhibit microscopic evidence of premaligancy.

Erythroplakia
Erythroplakia
Image courtesy of NYU College of Dentistry

Squamous Cell Carcinoma

Etiology idiopathic (unknown). Risk factors include:  tobacco use, alcohol use, sun radiation, genetic predisposition, nutritional deficiency, immunosuppression, and infections, such as candidal leukoplakia and human papillomavirus.

Typical Visual Cues a deep-seated ulcerated mass, fungating ulcerated mass, ulcer margins commonly elevated, adjacent tissues commonly firm to palpation, and may have residual leukoplakia and/or erythroplakia.

Useful Clinical Information more common in adult males, continuous enlargement, local pain, referred pain often to the ear, and paresthesia often of the lower lip.

Treatment Recommendations patient should be counseled to stop tobacco use and given a referral to a local medical treatment facility for appropriate treatment (surgery, radiation therapy, chemotherapy), and a careful periodic re-evaluation.

Clinical Significance early diagnosis is essential for cure, presence of lymph node metastasis greatly worsens the prognosis, approximately 50% of patients have evidence of lymph node metastasis at time of diagnosis (that is why the extraoral examination is so critical at the time of each intraoral examination), and patients who have had one cancer are at greater risk of having a second oral cancer.

Squamous Cell Carcinoma
Squamous Cell Carcinoma
Image courtesy of Associated Content

Malignant Melanoma

Etiology a malignant neoplasm of melanin-producing cells. Chronic exposure to sun radiation and a fair complexion increases the risk for skin lesions.

Typical Visual Cues larger than 0.5 cm in diameter, irregular margins, irregular pigmentation, any change in pigmentation, ulceration of the overlying mucosa, macular (superficial spreading) or elevated (nodular), and most often occurs on gingiva and the palate.

Useful Clinical Information occurs most often in adult males, usually painless, rapidly enlarging.

Treatment Recommendations refer to a local medical treatment facility for the appropriate surgery and chemotherapy.

Clinical Significance malignant melanoma is an extremely aggressive form of cancer, early diagnosis is essential for cure, patients with oral mucosal lesions generally have a poor prognosis.

Melanoma
Melanoma
Image courtesy of DoctorSpiller.com
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