Oral Lesions and Differential Diagnosis

Overview

  • Aim of the session: Improve confidence in identifying oral lesions, particularly red and white patches.

  • Importance of differentiating between benign, potentially malignant, and malignant lesions.

  • Understanding when to reassure, treat, or refer patients.

Classification of Oral Lesions

  • Classification based on color can be messy, better to categorize:

    • Benign or Infectious Lesions

    • Potentially Malignant Lesions

    • Malignant Lesions

Common Oral Lesions

White Patches

  • Conditions presenting as white patches: e.g., SCC (Squamous Cell Carcinoma), oral lichen planus, leucoplakia, etc.

  • Some lesions may transition between red and white appearances.

  • Examples to cover: candida, leukoplakia, etc.

Red Patches

  • Conditions that can present as red patches: e.g., ulcers, erythroplakia (high risk of malignancy).

  • Importance of distinguishing between benign causes and those requiring urgent referrals.

Systematic Approach to Diagnosis

  • Utilize a systematic approach, such as the surgical sieve, can help in forming differential diagnoses.

  • Consider factors such as trauma, dental problems, metabolic diseases, etc.

Clinical Example Case Study

Example: Elderly Male with Tongue Ulcer

  • Patient profile: 45 years old, heavy smoker, presenting with a tongue ulcer for six weeks, indurated but pain-free.

  • Historical context: Need to consider risk factors for SCC, the importance of identifying non-painful ulcers that may indicate malignancy.

  • Distinguishing features of lesions like traumatic ulcers vs. major aphthous ulcers, syphilis, or SCC.

Distinguishing Features of Lesions

  • Traumatic Ulcers: Indurated, keratotic border, associated with trauma from sharp teeth.

  • Aphthous Ulcers: More inflamed margins; major aphthous ulceration is distinct in healing timelines.

  • Infectious Causes: Suited for diagnoses like syphilis or candida where patient history is key.

Oral Cancer Insights

  • High rates of oral cancer due to societal factors, socioeconomic deprivation impacting risk.

  • Urgent referrals necessary for suspicious lesions:

    • Lesions that bleed (spontaneous or contact bleeding) should raise immediate concern.

    • Early diagnosis is crucial, with a high survival rate (90%) if detected early.

Benign Oral Lesions

Leukoedema

  • Harmless lesion; appearance changes when buccal mucosa stretched.

  • Reassurance sufficient; no biopsy required.

Erythema Migrans (Geographic Tongue)

  • Benign condition where patches may migrate over time.

  • Asymptomatic cases can be managed without referral, but symptomatic cases might require further investigation or treatment.

Candida Infections

  • Candida: Common opportunistic infection appearing in immunocompromised patients.

  • Types:

    • Acute pseudomembranous: Easily wiped off, leaving an erythematous base.

    • Chronic erythematous: Often linked to denture wear.

  • Important to manage underlying risk factors to prevent recurrence.

Potentially Malignant Disorders

Leukoplakia

  • White patches with potential cancer risk, inability to wipe off indicates need for referral.

  • Assess for dysplasia via biopsy and follow up based on results.

Erythroplakia

  • Red lesions have a high rate of dysplasia; urgent referral required upon suspicion.

Lichen Planus

  • An immune-mediated inflammatory disease affecting various demographics.

  • Different presentations (reticular, erosive) observed. Referral necessary for symptomatic cases.

  • Importance of monitoring for malignancy and managing any dysplastic changes.

Final Notes and Recommendations

  • Encourage patients for self-examinations and reporting new or worsening symptoms.

  • Utilize proper referral pathways based on observed lesions and patient risk factors.

  • Always consider underlying health conditions and comprehensive oral hygiene practices.