Assessment of oral mucosal disease

Oral mucosal lesions are common. They can be due to physiological changes, local disease, an oral manifestation of a skin condition, an adverse drug reaction or systemic disease (eg gastrointestinal disease). Successful management of an oral mucosal disease requires an accurate diagnosis.

Assessing an oral mucosal lesion involves taking a full patient history (including a medication history), performing a thorough extraoral and intraoral examination and using diagnostic investigations where appropriate. Have a high index of suspicion for oral cancer—see risk factors for oral cancer. If any 'red flag' features are present, the diagnosis is not clear, or the patient has not responded to initial treatment, early referral to an appropriate specialist is required1.

Note: Failure to respond to initial treatment, an unclear diagnosis or the presence of any suspicious features could indicate malignancy and warrant early referral.
Figure 1. ‘Red flag’ features of oral mucosal disease
  • oral ulcers that have lasted for more than 2 weeks
  • orals ulcers that recur
  • nontraumatic oral ulcers in children
  • pigmented lesions on the oral mucosa
  • red, white or mixed red and white lesions on the oral mucosa of unknown origin or with features of potentially malignant disease, such as:
    • induration
    • ulceration with rolled margins
    • fixation to underlying tissues
    • lesions in high-risk sites (eg lateral tongue, floor of mouth)
  • facial or oral paraesthesia
  • persistent oral mucosal discomfort with no obvious cause
  • lumps or swellings, including lymphadenopathy
  • swelling, pain or blockage of a salivary gland, suggestive of salivary gland disease (eg see Potential causes of salivary gland swelling for common causes of salivary gland swellings)
  • suspected allergy or adverse reaction to dental materials (eg oral lichenoid lesion)
  • dry mouth that is not adequately relieved with artificial salivary products and nonpharmacological methods
  • dry mouth caused by systemic disease
  • suspected oral manifestations of systemic disease (eg syphilis, Behçet syndrome, HIV, inflammatory bowel disease, lichen planus, pemphigoid)
  • lesions occurring in immunocompromised patients (eg patients with neutropenia or HIV infection)

Some oral mucosal diseases are associated with significant morbidity and mortality, particularly oral potentially malignant disorders and oral cancer. Oral potentially malignant disorders include:

Oral potentially malignant disorders can become malignant at the site of the lesion, but also predict an increased risk of cancer at other sites in the mouth, even in clinically normal appearing oral mucosa.

The following conditions can be managed in general practice, provided there are no 'red flag' features present that would warrant referral:

There are physiological causes of oral mucosal discolourations (eg Fordyce spots [ectopic sebaceous glands], leukoedema), which do not require active management.

1 An oral medicine specialist is the most appropriate specialist to diagnose and manage oral mucosal disease, but may not be accessible; an oral surgeon, dermatologist or otorhinolaryngologist are other options.Return