</img>DENT 4215 13th February 2025 Dr Lalima Tiwari DENT 4215 13th February 2025 Dr Lalima Tiwari # Lecture Outline * **A brief review of oral anatomy** * **Develop a systematic approach to examining the soft tissues of the oral cavity** * **Learn descriptive terminology for describing oral lesions** * **Identify the characteristic features of lesions that suggest serious pathology** * **Be able to recognise some common oral lesions** <table> <tr> <th>The University of Western Australia</th> </tr> </table> #### Learning Objectives and Content - A brief review of oral anatomy - Develop a systematic approach to examining the soft tissues of the oral cavity - Learn descriptive terminology for describing oral lesions - Identify the characteristic features of lesions that suggest serious pathology - Be able to recognise some common oral lesions The official logo of The University of Western Australia, featuring a shield crest with the motto 'Seek Wisdom' alongside the institution's name. THE UNIVERSITY OF WESTERN AUSTRALIA # Brief review of oral anatomy Brief review of oral anatomy The University of Western Australia logo featuring a shield with a swan and books, accompanied by the university name in blue text. **Brief review of oral anatomy** Temporomandibular joint (lateral pole) Temporomandibular joint (lateral pole) # Brief review of oral anatomy The University of Western Australia logo featuring a shield with a black swan and open books, alongside the university's name in blue text. Brief review of oral anatomy **Parotid glands** **Submandibular glands** **Sublingual glands** #### Major Salivary Glands - Parotid glands - Submandibular glands - Sublingual glands # Brief review of oral anatomy The University of Western Australia logo featuring a shield with a swan and the university name in blue text. # Brief review of oral anatomy THE UNIVERSITY OF WESTERN AUSTRALIA The University of Western Australia institutional logo featuring the university name and emblem. # Brief review of oral anatomy The University of Western Australia institutional logo featuring the university crest and text. # Brief review of oral anatomy The University of Western Australia institutional logo featuring the university crest (swan) and text. Brief review of oral anatomy **Gingiva** **Right buccal mucosa** **Stenson's duct** opening The University of WESTERN AUSTRALIA #### Gingiva and Buccal Mucosa - Gingiva - Right buccal mucosa - Stenson's duct opening **Brief review of oral anatomy** University logo for The University of Western Australia, featuring a shield with a black swan and the text 'SEEK WISDOM'. # Brief review of oral anatomy * Ventral surface of tongue * Floor of mouth * Wharton's duct opening * Lingual frenum #### Sublingual Anatomy - Ventral surface of tongue - Floor of mouth - Wharton's duct opening - Lingual frenum # Brief review of oral anatomy THE UNIVERSITY OF WESTERN AUSTRALIA Brief review of oral anatomy - Uvula - Tonsillar pillars - Base of tongue #### Oropharyngeal Structures - Uvula - Tonsillar pillars - Base of tongue # Brief review of oral anatomy University of Western Australia institutional logo featuring a shield with a swan and books, accompanied by the text 'THE UNIVERSITY OF WESTERN AUSTRALIA'. THE UNIVERSITY OF WESTERN AUSTRALIA **A systematic approach to examining the** **soft tissues of the oral cavity** A systematic approach to examining the soft tissues of the oral cavity. The University of Western Australia logo featuring a shield with a swan and books, accompanied by the institution's name in blue text. img>The University of Western Australia logo</img> **Before every clinical examination should be a thorough clinical history!**  Before every clinical examination should be a thorough clinical history! Clinical photo showing a healthcare professional (nurse/doctor) with a stethoscope discussing clinical history with a patient at a desk with a laptop. The image illustrates the concept that 'Before every clinical examination should be a thorough clinical history!' # **A systematic approach to examining the soft tissues of the oral cavity** * **Use the same system every time to ensure you don't miss out any anatomical structures** * **Start with extra oral examination followed by intra oral exam** * **Palpation of the oral tissues is key** * **Equipment:** Intra oral mirrors (2), gauze, ruler, adequate light source (ideally LED white headlight affixed to loupes to keep both hands free) * **Try stand in front of the patient for the soft tissue exam?** #### Examination Principles - Use the same system every time to ensure you don't miss out any anatomical structures. - Start with extra oral examination followed by intra oral exam. - Palpation of the oral tissues is key. - Try to stand in front of the patient for the soft tissue exam. #### Required Equipment - Intra oral mirrors (2) - Gauze - Ruler - Adequate light source (ideally LED white headlight affixed to loupes to keep both hands free) **Extra oral examination** General Inspection: - Facial Symmetry - Profile Type - Cutaneous skin on face and scalp - TMJ and masticatory muscles - Lymph nodes - Salivary glands - Lips #### General Inspection Components - Facial Symmetry - Profile Type - Cutaneous skin on face and scalp - TMJ and masticatory muscles - Lymph nodes - Salivary glands - Lips The University of Western Australia institutional logo featuring a shield with a swan and open books. **Extra oral Examination** Bimanual palpation of TMJ and muscles of mastication– note any clicks, crepitus, restricted mouth opening, pain on palpation    #### TMJ and Musculature Bimanual palpation of TMJ and muscles of mastication—note any clicks, crepitus, restricted mouth opening, or pain on palpation. Clinical photo showing a profile view of a patient's face with a gloved hand palpating the jawline near the ear. This demonstrates the bimanual palpation of the TMJ and muscles of mastication mentioned in the OCR text. Clinical photo showing a frontal view of a patient's face with a gloved hand palpating the temple area. This illustrates the examination technique for the extra oral examination. Clinical photo showing a side view of a patient's face with a gloved hand palpating the cheek area (masseter muscle). This complements the other images to show different angles for examining the muscles of mastication. Extra oral Examination **b** **c** THE UNIVERSITY OF WESTERN AUSTRALIA • Level I nodes: submandibular and submental triangles • > 1 cm size suspicious of lymphadenopathy  #### Lymph Node Assessment: Level I - Level I nodes: submandibular and submental triangles - Nodes > 1 cm in size are suspicious of lymphadenopathy Two clinical photos labeled 'b' and 'c' showing extraoral examination of a patient's neck. Photo b displays the lateral view of the submandibular region with gloved fingers palpating the area near the jawline. Photo c shows the anterior view of the chin and submental triangle with gloved fingers palpating beneath the mandible. These images demonstrate the anatomical regions for Level I lymph node assessment as referenced in the OCR text. Extra oral Examination Level II, III, IV lymph nodes detected within the anterior triangle and posterior triangle of the neck **Use the sternocleidomastoid muscle as landmark!**     #### Lymph Node Assessment: Levels II, III, and IV - Level II, III, and IV lymph nodes are detected within the anterior triangle and posterior triangle of the neck. - Use the sternocleidomastoid muscle as a landmark! Anatomical diagram labeled 'a' showing the anterior triangle of the neck highlighted in yellow. It includes labels for 'anterior triangle' and 'sternocleidomastoid muscle', illustrating the anatomical landmarks used in extra oral examination. Anatomical diagram labeled 'a' showing the posterior triangle of the neck highlighted in green. The sternocleidomastoid muscle is visible as a boundary landmark, corresponding to the text instruction to use it for identifying lymph node levels. Clinical photograph labeled 'b' showing a gloved hand palpating the anterior triangle of the neck, demonstrating the physical examination technique for detecting lymph nodes in this region. Clinical photograph labeled 'b' showing a gloved hand palpating the posterior triangle of the neck, demonstrating the physical examination technique for detecting lymph nodes in this region. Extra oral Examination Lips **Sharply demarcated** **Homogenous in colour and texture** **Bimanual palpation for surface changes** **Note any colour irregularities or surface changes**  #### Lip Examination - Normal lips are sharply demarcated and homogenous in colour and texture. - Perform bimanual palpation for surface changes. - Note any colour irregularities or surface changes. Clinical photo of lips labeled 'A', demonstrating a healthy state with sharply demarcated vermilion border and homogenous color/texture as described in the OCR context.   Header section containing the title 'Intra oral examination' in bold blue text on the left and a logo for 'THE UNIVERSITY OF WESTERN AUSTRALIA' on the right. A composite figure demonstrating an intra-oral examination of the lower lip. It consists of three clinical photos labeled B, C, and D, linked by black arrows indicating a procedural sequence. Image B shows the lower lip being pulled down to reveal the mucosa; image C shows the teeth being retracted to view the upper gingiva; image D shows the upper lip being lifted to reveal the palate.   Clinical intraoral photograph labeled 'E' showing the upper and lower front teeth and gums. The caption identifies this as a view of the Maxillary and mandibular buccal gingiva. Clinical intraoral photograph labeled 'F' showing a gloved finger retracting the cheek to expose the inner lining of the mouth (buccal mucosa). This image demonstrates the physical examination step for visualizing the bilateral buccal mucosa. • Dorsal tongue → bilateral lateral tongue • Remember posterior lateral tongue, and lingual tonsils!  #### Tongue Examination - Examine the dorsal tongue, moving to bilateral lateral tongue. - Remember to check the posterior lateral tongue and lingual tonsils! Three clinical photos labeled G, H, I showing intraoral tongue examination: dorsal tongue view (G), bilateral lateral tongue view (H), and posterior lateral tongue/lingual tonsils view (I).    Clinical photo labeled 'J' showing a close-up view of the ventral surface of the tongue and the floor of the mouth. The image displays the midline raphe on the tongue and the underlying mucosa. Clinical photo labeled 'K' displaying an intra-oral view of the mandibular arch with the tongue retracted to expose the floor of the mouth. A vertical fold (frenulum) is visible in the center. Clinical photo labeled 'P' demonstrating the procedure for drying the floor of the mouth. It shows a gloved hand using gauze or a cotton swab inside the patient's cheek to dry the sublingual area, likely to evaluate saliva excretion from Wharton's duct as per the text instructions. Intra oral examination - Hard palate - Palatal gingiva - Palpate for submucosal swellings - Use tongue blade or mouth mirror to depress tongue to evaluate oropharynx - Evaluate from front of patient – not behind! - Say “Ahh” to evaluate elevation of soft palate - Evaluation of base of tongue  #### Palate and Oropharynx Assessment - Examine the hard palate and palatal gingiva. - Palpate for submucosal swellings. - Use a tongue blade or mouth mirror to depress the tongue to evaluate the oropharynx. - Evaluate from the front of the patient, not from behind. - Ask the patient to say "Ahh" to evaluate the elevation of the soft palate. - Perform an evaluation of the base of the tongue. Three-panel clinical procedure diagram illustrating intra oral examination steps. Panel L (top-left) shows a gloved finger depressing the tongue to expose the hard palate and palatal gingiva for palpation of submucosal swellings. Panel M (top-right) demonstrates using a tongue blade or mouth mirror to depress the tongue from the front of the patient to evaluate the oropharynx; includes instruction to say 'Ahh' to assess soft palate elevation. Panel N (bottom-left) displays use of a mouth mirror to visualize the base of the tongue. Arrows connect panels sequentially: L → M → N, indicating progression through the examination. Each panel is labeled with corresponding anatomical focus points derived from OCR context.  A composite clinical figure showing multiple intraoral examination views labeled A through P. The images include close-ups of lips (A), tongue surface (G), buccal mucosa (L, M), hard palate (C), gingiva (D), anterior teeth (E), maxillary molars (F), lingual frenum (J), floor of mouth (K), soft palate/uvula (M, N), lateral pharynx (O), and lower lip (P). These are educational visual regions demonstrating anatomical landmarks for oral health assessment. Finish with clinical photograph!  Finish with a clinical photograph! A photograph showing a person holding a DSLR camera with a large telephoto lens up to their eye, framed against a dark blue background. The image serves as a visual example of the instruction 'Finish with clinical photograph!' found below it. The University of Western Australia **Learn descriptive terminology for describing oral lesions** Learn descriptive terminology for describing oral lesions. The University of Western Australia logo featuring a shield with a swan and books. <img>Slide asking how to describe an intra oral lesion with a photographer  How to describe an intra oral lesion. Clinical photo showing a person holding a digital camera with a large lens pointed toward the viewer. In the context of describing an intra oral lesion, this image visually represents the act of photographing or documenting a lesion for diagnostic or educational purposes. # Reference **Patel, J., Tyers, C. & Sandhu, P. ** ### *Identify the text* ## Dental Slide  #### Reference Patel, J., Tyers, C. & Sandhu, P. Identify the text: Dental Slide A structured table titled 'Refer with “CLOTHS”' that serves as a mnemonic for describing oral lesions. The table has two columns: the first lists categories (Colour, Location, Outline, Texture, History, Size) and the second provides descriptive terms or parameters for each category. For example, under Colour it lists Red; White; Speckled; Pigmented, and under Size it specifies Length; Width; Depth (mm). This visual structure organizes key diagnostic features into a clear, referenceable format. | Term | Definition | | --- | --- | | Abscess | Localized collection of purulent exudate | | Atrophy | Loss of tissue resulting in thinning of the epithelium and usually associated with erythema | | Bulla | Fluid filled elevated lesion >5 mm in diameter | | Ecchymosis | Red/purple macular area of submucosal hemorrhage/extravasated blood | | Endophytic | A lesion that is growing inwards into the underlying tissue | | Erosion | Partial loss of the surface epithelium not extending through the full thickness | | Erythema | Redness of the mucosa usually caused by inflammation, atrophy of capillary dilatation | | Exophytic | A lesion that grows outwards from the surface epithelium | | Fissure | Linear slit or groove in the skin or mucosa | | Fistula | Abnormal tract connecting two body cavities | | Fixed | A lesion that is firmly attached to the overlying or underlying structures | | Hematoma | A localized swelling filled with blood | | Indurated | Hardening of soft tissue usually due to chronic inflammation or malignancy | | Macule | Circumscribed discolored flat lesion not raised above level of surrounding mucosa | | Mobile | A lesion that is freely movable and not attached to the overlying or underlying structures | | Nodule | Circumscribed elevated solid lesion >5 mm in diameter | | Papillary | A lesion that has numerous surface projections | | Papule | Circumscribed elevated solid lesion <5 mm in diameter | | Pedunculated | Exophytic lesion attached to the underlying tissue by a stalk | | Petechiae | Pin-point red or purple spots caused by submucosal hemorrhage | | Plaque | Slightly elevated area of mucosa with a flat surface | | Pustule | Circumscribed raised lesion containing pus | | Reticular | Resembling a net | | Sessile | Exophytic lesion attached to the underlying tissue by a broad base | | Ulcer | Break in continuity of the oral mucosa due to loss of full thickness of oral epithelium resulting in exposure of underlying connective tissue which is usually coated by a white or yellow membrane | | Verrucous | An exophytic lesion with rough wartlike projections | | Vesicle | Fluid filled elevated lesion <5 mm in diameter |  - **Abscess**: Localized collection of purulent exudate - **Atrophy**: Loss of tissue resulting in thinning of the epithelium and usually associated with erythema - **Bulla**: Fluid filled elevated lesion >5 mm in diameter - **Ecchymosis**: Red/purple macular area of submucosal hemorrhage/extravasated blood - **Endophytic**: A lesion that is growing inwards into the underlying tissue - **Erosion**: Partial loss of the surface epithelium not extending through the full thickness - **Erythema**: Redness of the mucosa usually caused by inflammation, atrophy of capillary dilatation - **Exophytic**: A lesion that grows outwards from the surface epithelium - **Fissure**: Linear slit or groove in the skin or mucosa - **Fistula**: Abnormal tract connecting two body cavities - **Fixed**: A lesion that is firmly attached to the overlying or underlying structures - **Hematoma**: A localized swelling filled with blood - **Indurated**: Hardening of soft tissue usually due to chronic inflammation or malignancy - **Macule**: Circumscribed discolored flat lesion not raised above level of surrounding mucosa - **Mobile**: A lesion that is freely movable and not attached to the overlying or underlying structures - **Nodule**: Circumscribed elevated solid lesion >5 mm in diameter - **Papillary**: A lesion that has numerous surface projections - **Papule**: Circumscribed elevated solid lesion <5 mm in diameter - **Pedunculated**: Exophytic lesion attached to the underlying tissue by a stalk - **Petechiae**: Pin-point red or purple spots caused by submucosal hemorrhage - **Plaque**: Slightly elevated area of mucosa with a flat surface - **Pustule**: Circumscribed raised lesion containing pus - **Reticular**: Resembling a net - **Sessile**: Exophytic lesion attached to the underlying tissue by a broad base - **Ulcer**: Break in continuity of the oral mucosa due to loss of full thickness of oral epithelium resulting in exposure of underlying connective tissue which is usually coated by a white or yellow membrane - **Verrucous**: An exophytic lesion with rough wartlike projections - **Vesicle**: Fluid filled elevated lesion <5 mm in diameter Table 6: Descriptive terminology for oral lesions. A comprehensive two-column table listing medical terms (Term) alongside their specific clinical definitions (Definition). Key entries include Abscess, Atrophy, Bulla, Erosion, Exophytic, Fissure, Fistula, Fixed, Hematoma, Indurated, Macule, Mobile, Nodule, Papillary, Papule, Pedunculated, Petechiae, Plaque, Pustule, Reticular, Sessile, Ulcer, Verrucous, and Vesicle. - Atrophy: Loss of tissue resulting in thinning of the epithelium and usually associated with erythema - Image from: Bhattacharya, Preeti Tomar & Misra, Satya. (2017). Effects of Iron Deficiency on the Oropharyngeal Region: Signs, Symptoms, and Biological Changes. 10.1007/978-3-319-40007-5_4-1.  #### Atrophy Loss of tissue resulting in thinning of the epithelium and usually associated with erythema. Clinical photo of an oral lesion demonstrating atrophy: loss of tissue resulting in thinning of the epithelium and usually associated with erythema. The image shows a tongue with visible signs of atrophic changes. # Learn descriptive terminology for describing oral lesions **Bulla:** Fluid filled elevated lesion > 5 mm in diameter **(Blood filled Bulla) =** **Haemorrhagic bulla** Images from: Ugo, Ordioni & Hadj Saïd, Mehdi & Thiery, G. & Campana, Fabrice & Catherine, jean-hugues & Lan, Romain. (2018). Angina bullosa haemorrhagica: a systematic review and proposal for diagnostic criteria. International Journal of Oral and Maxillofacial Surgery. 48. 10.1016/j.ijom.2018.06.015.   #### Bulla - **Bulla**: Fluid filled elevated lesion > 5 mm in diameter - **Haemorrhagic bulla**: Blood filled Bulla Clinical photo showing an intraoral view of a large, dark purple blood-filled bulla (haemorrhagic bulla) on the soft palate. Clinical photo showing a smaller haemorrhagic bulla on the uvula/soft palate region of the oropharynx. # Learn descriptive terminology for describing oral lesions | Condition | Description | |----------|-------------| | Ecchymosis | Red/Purple macular area of submucosal haemorrhage/extravasated blood | | Petechiae | Pin-point red or purple spots caused by submucosal haemorrhage | | Purpura | Red/Purple macular area > 2 mm | Image from: Petechiae from “General and Oral Pathology for The Dental Hygienist.”Courtesy of Dr. Harvey Kessler https://www.rdhmag.com/career-profession/personal-wellness/article/16405016/petechiae-ecchymoses-or-purpura  #### Hemorrhagic Lesions - **Ecchymosis**: Red/Purple macular area of submucosal haemorrhage/extravasated blood - **Petechiae**: Pin-point red or purple spots caused by submucosal haemorrhage - **Purpura**: Red/Purple macular area > 2 mm Clinical photo of oral mucosa showing three distinct hemorrhagic lesions with superimposed labels and arrows: 'Purpura' points to a large red/purple macular area >2mm; 'Ecchymoses' indicates another diffuse submucosal hemorrhage; 'Petechiae' highlights multiple pin-point red spots. This visual demonstrates the size-based differentiation between these conditions as defined in the OCR text. # Learn descriptive terminology for describing oral lesions **THE UNIVERSITY OF WESTERN AUSTRALIA** **Erosion:** Partial loss of the surface epithelium not extending through the full thickness Image from: Okoh, Mercy & Omoregie, Osawe & Otakhoigbogie, Uwaila. (2015). PEMPHIGUS VULGARIS: A case report and literature review. AJOMPM. 1. 35-39.  #### Erosion Partial loss of the surface epithelium not extending through the full thickness. Clinical photo showing an oral lesion consistent with erosion: partial loss of the surface epithelium not extending through the full thickness. The image displays red, raw areas on the inner cheek and palate mucosa, surrounded by intact tissue, illustrating the superficial nature of the lesion as defined in the accompanying text. Learn descriptive terminology for describing oral lesions Erythema: Redness of the mucosa usually caused by inflammation, atrophy of capillary dilatation **THE UNIVERSITY OF WESTERN AUSTRALIA** Image from: https://www.oralcancerhub.org.au/lesion-guide/non-malignant-mucosal-disease/desquamative-gingivitis  #### Erythema Redness of the mucosa usually caused by inflammation, atrophy of capillary dilatation. Clinical photo of an oral lesion demonstrating erythema: redness of the mucosa above the upper anterior teeth. The gingiva shows diffuse redness and inflammation consistent with capillary dilatation as defined in the OCR context. <b>**Learn descriptive terminology for describing oral lesions**</b> **Exophytic:** A **bold** lesion that **bold** grows outwards from the surface epithelium Image from: Ripen, Z.M., Zainuddin, N.I. (2023). Painless Nodule on the Cheek: Fibroepithelial Polyp. In: Tilakaratne, W.M., Kallarakkal, T.G. (eds) Clinicopathological Correlation of Oral Diseases. Springer, Cham. https://doi.org/10.1007/978-3-031-24408-7_18  #### Exophytic A lesion that grows outwards from the surface epithelium. Clinical photo of an oral cavity showing the inner cheek (buccal mucosa). A black arrow points to a small, raised, smooth, pinkish-white nodule on the surface epithelium. The image demonstrates an 'exophytic' lesion growing outwards from the tissue. Teeth are visible in the lower foreground. **# Learn descriptive terminology for describing oral lesions** **Fissure**: Linear slit or groove in the skin or mucosa **1** The University of Western Australia Image from: Malik, Mohammed et al. Burning red tongue with grooves, JAAD Case Reports, Volume 5, Issue 10, 923 - 924  #### Fissure Linear slit or groove in the skin or mucosa. Clinical photo of a human mouth showing the tongue extended. The image demonstrates a 'fissured tongue' with multiple linear slits or grooves running across the dorsal surface of the tongue, illustrating the descriptive terminology for oral lesions. Learn descriptive terminology for describing oral lesions Papillary: A lesion that has numerous surface projections Image from: Betz, S.J. HPV-Related Papillary Lesions of the Oral Mucosa: A Review. *Head and Neck Pathol* 13, 80–90 (2019). https://doi.org/10.1007/s12105-019-01003-7  #### Papillary A lesion that has numerous surface projections. Clinical photo of the oral cavity showing a papillary lesion on the hard palate. The image illustrates numerous surface projections as described in the text, demonstrating the characteristic appearance of an HPV-related papillary lesion. <div> THE UNIVERSITY OF WESTERN AUSTRALIA Learn descriptive terminology for describing oral lesions Reticular striae: Resembling a net/ lace-like pattern </div> González-Moles MÁ, Keim-del Pino C, Ramos-García P. Hallmarks of Cancer Expression in Oral Lichen Planus: A Scoping Review of Systematic Reviews and Meta-Analyses. International Journal of Molecular Sciences. 2022; 23(21):13099. https://doi.org/10.3390/ijms232113099  #### Reticular Striae Resembling a net/lace-like pattern. Clinical photograph showing two views of oral mucosa exhibiting reticular striae. The left panel displays a close-up of the buccal mucosa with a classic white, lace-like network pattern on an erythematous background. The right panel shows another area of the oral cavity (possibly buccal or labial mucosa) with similar white striations and some areas of erythema. This visual demonstrates the 'net/lace-like' appearance characteristic of reticular striae in Oral Lichen Planus as described in the accompanying text. --- **Learn descriptive terminology for describing oral lesions** **Plaque:** Slightly elevated area of mucosa with a flat surface **Homogenous:** Same colour, consistency, texture throughout the entire lesion **Non-homogenous:** not the same colour, consistency, texture throughout the entire lesion  Image from: Van der Waal, I. Oral Leukoplakia: Present Views on Diagnosis, Management, Communication with Patients, and Research. Curr Oral Health Rep 6, 9–13 (2019). https://doi.org/10.1007/s40496-019-0204-8  #### Plaque and Homogeneity - **Plaque**: Slightly elevated area of mucosa with a flat surface - **Homogenous**: Same colour, consistency, texture throughout the entire lesion - **Non-homogenous**: Not the same colour, consistency, texture throughout the entire lesion Clinical photograph of the oral cavity showing teeth and mucosal surface with a patchy white lesion consistent with plaque, possibly non-homogenous in appearance. The image demonstrates the visual characteristics of 'plaque' as defined by the adjacent text: a slightly elevated area of mucosa with a flat surface that is not the same colour, consistency, or texture throughout (non-homogenous). The source citation is located below the image. **Learn descriptive terminology for describing oral lesions** Papule: Circumscribed elevated solid lesion <5 mm in diameter Image from: Nico, M.M., Fernandes, J.D., & Lourenço, S.V. (2011). Oral lichen planus  #### Papule Circumscribed elevated solid lesion < 5 mm in diameter. Clinical photo showing a close-up view of an oral mucosal surface. The tissue appears reddish with distinct white, raised bumps scattered across the area. This image demonstrates a 'Papule,' which is defined in the OCR context as a circumscribed elevated solid lesion <5 mm in diameter. <ul> <li>Images from: Rawlings N, Willis A. Oral Ulceration - Clinical Feature. JIDA. Published online April 13, 2023. doi:10.58541/001c.74191</li> <li>Fourie, J, & Boy, SC. (2016). Oral mucosal ulceration - a clinician's guide to diagnosis and treatment. <i>South African Dental Journal</i>, 71(10), 500-508.</li> <!-- Ref: University Brand --> <li>The University of Western Australia</li> </ul> # **Learn descriptive terminology for describing oral lesions** **Ulcer**: Break in continuity of the oral mucosa due to loss of full thickness of oral epithelium resulting in exposure of underlying connective tissue which is usually coated by a white or yellow membrane Figure 1: Ulceration of the ventro-lateral border of the tongue situated in the unkeratinised mucosa, with breach of the entire thickness of the epithelium to expose the underlying connective tissue. **Indurated**: hardening of soft tissue usually due to chronic inflammation or malignancy    #### Ulcer and Induration - **Ulcer**: Break in continuity of the oral mucosa due to loss of full thickness of oral epithelium resulting in exposure of underlying connective tissue which is usually coated by a white or yellow membrane. - **Indurated**: Hardening of soft tissue usually due to chronic inflammation or malignancy. Clinical photo of oral mucosa showing ulceration with a break in continuity and exposure of underlying connective tissue. Figure 1: Clinical photo of ulceration on the ventro-lateral border of the tongue, showing breach of entire epithelial thickness. Caption text included below image. Clinical photo showing induration (hardening) of soft tissue in the mouth, likely due to chronic inflammation or malignancy as described in adjacent text. # The University of Western Australia ## Learn descriptive terminology for describing oral lesions ### So, you note an intra oral lesion, how do you describe it?  So, you note an intra oral lesion, how do you describe it? Clinical intraoral photograph showing the floor of the mouth (sublingual region) with a white, patchy lesion on the mucosa. A gloved hand is retracting the tongue to visualize the area. **Identify the characteristic features of lesions that suggest serious pathology** Identify the characteristic features of lesions that suggest serious pathology **Identify the characteristic features of** **lesions that suggest serious pathology** **The University of Western Australia** **Rather, when is a referral of a lesion considered** **urgent?** **WHO, WHAT, WHEN, WHERE, WHY/HOW?** #### Determining Referral Urgency Rather, when is a referral of a lesion considered urgent? Consider the following framework: - WHO - WHAT - WHEN - WHERE - WHY/HOW The official logo of The University of Western Australia, featuring a shield with a swan and the university name in blue text. **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** Is there a chance of malignancy?  Is there a chance of malignancy? Clinical photo montage showing six different oral lesions: a white and yellow lesion on the tongue with a gloved hand; a red lesion on the palate; a white patch on the tongue; a small raised lesion in the cheek; a red lesion on the lower lip; and a large ulcerative lesion on the gum. The images are arranged in two rows of three, providing visual examples of potential malignancy in the oral cavity. The University of Western Australia Squamous cell carcinoma <p> The University of Western Australia </p> <p> Squamous cell carcinoma </p>   Squamous cell carcinoma Clinical photograph showing the oral cavity with a focus on the tongue. A distinct, irregular, whitish-pink exophytic mass lesion is visible on the dorsal surface of the tongue, consistent with squamous cell carcinoma as indicated by the caption below. Captioned label box containing text 'Squamous cell carcinoma' identifying the visualized pathology in the clinical photo above. **Identify the characteristic features of lesions that suggest serious pathology** <div style="text-align: right; margin-right: 20px;"> <img /> </div> **Who?** * Age * Gender * Medical status - Immunocompromised? - Previous history of cancer? - Loss of weight? * Habits and behaviours - Smoking status - Alcohol intake - Betel quid, areca nut - Alcohol-containing mouthwash use **The patient, and their associated risks**  #### Patient Profile and Associated Risks (Who?) - **Demographics** - Age - Gender - **Medical Status** - Immunocompromised status - Previous history of cancer - Unexplained loss of weight - **Habits and Behaviours** - Smoking status - Alcohol intake - Betel quid or areca nut use - Use of alcohol-containing mouthwash Clinical consultation photo showing a female patient sitting on a yellow sofa discussing her symptoms or history with a healthcare provider (back visible). The image visually represents the context for assessing patient risk factors such as age, gender, medical status, and habits. Identify the characteristic features of lesions that suggest serious pathology **[THE UNIVERSITY OF WESTERN AUSTRALIA]** **Figure 13.10 ‘Red flag’ features of oral mucosal disease** * oral ulcers that have lasted for more than 2 weeks * oral 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 **Figure 13.9** 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) From: Therapeutic Guidelines – Oral, Assessment of Oral Mucosal Disease #### Red Flag Features of Oral Mucosal Disease - Oral ulcers that have lasted for more than 2 weeks - Oral 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 (e.g., 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 - Suspected allergy or adverse reaction to dental materials (e.g., 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 (e.g., syphilis, Behçet syndrome, HIV, inflammatory bowel disease, lichen planus, pemphigoid) - Lesions occurring in immunocompromised patients (e.g., patients with neutropenia or HIV infection) University logo for The University of Western Australia featuring a shield with a swan and book.  Educational slide titled 'Identify the characteristic features of lesions that suggest serious pathology' from The University of Western Australia. Contains eight labeled clinical images: Ulcers (white lesion), Red/White lesions (erythematous patch), Pigmented lesions (dark mass), Lumps/Mass/Swelling (buccal swelling), Persistent pain or Neurological symptoms (lightning bolt icon), Trismus (mouth open showing restricted jaw movement), Dry mouth (dry tongue), and Oral manifestations of systemic diseases (gingival inflammation). Each image includes a descriptive caption below. # **When?** **When?** **DURATION** > **2 WEEKS** **EARLY REFERRAL TO AN ORAL MEDICINE SPECIALIST**    #### Duration (When?) - **Duration > 2 weeks**: Requires early referral to an oral medicine specialist. A stopwatch icon representing the 'DURATION' category in a medical referral guideline context. A checkmark icon representing the condition '> 2 WEEKS' for duration. An envelope icon representing the action 'EARLY REFERRAL TO AN ORAL MEDICINE SPECIALIST'.    Clinical photo labeled 'Tongue' showing two views of oral lesions on the tongue. The left image shows a lesion with white and red areas, while the right image displays another lesion with similar characteristics. Clinical photo labeled 'Floor of Mouth' showing two views of oral lesions in the floor of the mouth. The left image reveals a lesion near teeth with some discoloration, and the right image shows another lesion with visible surrounding tissue changes. Clinical photo labeled 'Soft Palate' showing two views of oral lesions on the soft palate. The left image displays a red lesion, and the right image shows another lesion with surrounding tissue changes. - Why? Or... How? - Reported trauma? - Remove traumatic agent - Review in 2 weeks - Lesion persistent? - Early Referral - Oral manifestation of systemic condition? - Unsure of trigger?  #### Etiology and Clinical Progression (Why? or How?) - **Reported Trauma** 1. Remove the suspected traumatic agent. 2. Review the patient in 2 weeks. 3. If the lesion is persistent, initiate an early referral. - **Systemic Factors** - Is it an oral manifestation of a systemic condition? - Are you unsure of the trigger? Flowchart diagram titled 'Why? Or... How?' illustrating a clinical decision pathway. The flow starts with 'Reported trauma?', proceeds to 'Remove traumatic agent', then 'Review in 2 weeks', followed by a decision point 'Lesion persistent?'. If the lesion is persistent or if there is an 'Oral manifestation of systemic condition?' or the provider is 'Unsure of trigger?', the path leads to 'Early Referral'. <br> **_The University of Western Australia_ logo (top right corner)_** **Use the 5 Ws to create your referral letter** **_**Who?_**_** **_**What?_**_** **_**When?_**_** **_**Where?_**_** **_**Why? Or, How?**_**_** **_Add the clinical photograph_** **_Call the specialist if urgent!!!_**   #### Referral Letter Components Use the 5 Ws to structure your referral letter: - **Who?** - **What?** - **When?** - **Where?** - **Why? Or, How?** **Additional Requirements:** - Add a clinical photograph. - Call the specialist directly if the case is urgent! Illustration of a medical professional holding a clipboard and pen, demonstrating the context for creating a referral letter. List of steps to create a referral letter using the 5 Ws (Who, What, When, Where, Why/How), plus instructions to add clinical photographs and call specialists if urgent. # **Be able to recognise some common oral lesions** - Geographic tongue - Benign alveolar ridge keratosis - Traumatic ulcers - Oral candidosis - Recurrent aphthous stomatitis - Fibroepithelial polyp - Actinic cheilitis - Oral lichen planus - Oral leukoplakia **[](https://www.westernaustralia.edu.au)** The following common oral lesions should be recognized during a soft tissue examination: - Geographic tongue - Benign alveolar ridge keratosis - Traumatic ulcers - Oral candidosis - Recurrent aphthous stomatitis - Fibroepithelial polyp - Actinic cheilitis - Oral lichen planus - Oral leukoplakia The University of Western Australia logo featuring a shield with an open book and a swan symbol above the text 'THE UNIVERSITY OF WESTERN AUSTRALIA'. # Be able to recognise some common oral lesions ## **Geographic Tongue, Benign migratory glossitis, Erythema migrans** * **Chronic, benign inflammatory condition of the tongue** * **Relapsing-recurring loss of filiform papillae** * **Affects 1-2% of population** * **Patients often seek professional advice due to unusual appearance of tongue or increased sensitivity to spicy or acidic foods** * **Exact aetiology unknown** * Linked to atopic patients; Eczema, Asthma, food sensitivities, Psoriasis * **Clinical features:** * Often asymptomatic, or some burning/sensitivity to acidic or spicy foods * Frequently presents on dorsal or ventral tongue * Begins as one ore more depapillated areas which enlarge to form slightly depressed, red patches with a white surrounding rim * Results in a map like pattern = “Geographic tongue” * Self limiting, heals within few days * **Diagnosis: Clinical diagnosis, biopsy usually unnecessary** * **Management:** * Asymptomatic: No treatment indicated, education, reassurance * Symptomatic: 2% viscous lidocaine, benzydamine hydrochloride (Difflam), mild topical corticosteroids  #### Overview - Chronic, benign inflammatory condition of the tongue - Relapsing-recurring loss of filiform papillae - Affects 1-2% of the population - Patients often seek professional advice due to unusual appearance of the tongue or increased sensitivity to spicy or acidic foods #### Aetiology - Exact aetiology unknown - Linked to atopic patients: Eczema, Asthma, food sensitivities, Psoriasis #### Clinical Features - Often asymptomatic, or some burning/sensitivity to acidic or spicy foods - Frequently presents on dorsal or ventral tongue - Begins as one or more depapillated areas which enlarge to form slightly depressed, red patches with a white surrounding rim - Results in a map-like pattern (Benign migratory glossitis / Erythema migrans) - Self-limiting, heals within a few days #### Diagnosis and Management - **Diagnosis:** Clinical diagnosis; biopsy is usually unnecessary - **Management:** - Asymptomatic: No treatment indicated, education, reassurance - Symptomatic: 2% viscous lidocaine, benzydamine hydrochloride (Difflam), mild topical corticosteroids Clinical photograph composite (Fig. 12) showing three views of oral lesions: (a) Benign migratory glossitis on the tongue dorsum with macular erythema and atrophy of filiform papillae, circinate white borders; (b) patchy depapillation of the tongue dorsum with faint white rim; (c) Migratory stomatitis on lower lip mucosa with white circular and linear lesions. **Be able to recognise some common oral lesions** Benign alveolar ridge keratosis * Benign, frictional/traumatic hyperkeratosis on keratinised alveolar ridge mucosa or palatal mucosa * Results from mechanical trauma, likely from food crushed against edentulous alveolar ridge * Oral mucosa responds with deposition of keratin and benign epithelial hyperplasia * Most common in 5th-6th decades of life * Clinical features: * Asymptomatic, poorly demarcated white plaque * Mandibular retromolar pad, edentulous maxillary or mandibular alveolar ridge mucosa * Surface often rough, slightly verrucous * Diagnosis: Biopsy may be performed to establish diagnosis, rule out dysplasia * Management: Benign lesion with no malignant potential, no treatment required. Should be differentiated from leukoplakia which has malignant potential. **Fig. 6 Benign alveolar ridge keratosis**: poorly demarcated **white** plaque of the **(a) right retromolar** pad and **(b) left retromolar** pad  #### Overview - Benign, frictional/traumatic hyperkeratosis on keratinised alveolar ridge mucosa or palatal mucosa - Results from mechanical trauma, likely from food crushed against edentulous alveolar ridge - Oral mucosa responds with deposition of keratin and benign epithelial hyperplasia - Most common in 5th-6th decades of life #### Clinical Features - Asymptomatic, poorly demarcated white plaque - Located on mandibular retromolar pad, edentulous maxillary or mandibular alveolar ridge mucosa - Surface often rough, slightly verrucous #### Diagnosis and Management - **Diagnosis:** Biopsy may be performed to establish diagnosis and rule out dysplasia - **Management:** Benign lesion with no malignant potential; no treatment required. Should be differentiated from leukoplakia which has malignant potential. Clinical photo showing oral lesions: (a) right retromolar pad and (b) left retromolar pad. Both images display poorly demarcated white plaques on the alveolar ridge mucosa, consistent with benign alveolar ridge keratosis. # Be able to recognise some common oral lesions ## Traumatic ulcers - Reactive oral ulcers: trauma affecting mucosal lining of mouth - Self-inflicted - Mechanical trauma – sharp margins of teeth, prosthesis, denture flange, self-biting, factitious injuries - Ulcer: complete loss of epithelium which exposes the underlying connective tissues - Clinical presentation: - Mechanical: areas or erythema surrounding a central removable, yellow fibrinopurulent membrane - Can develop a rolled white border of hyperkeratosis immediately adjacent the area of ulceration - Can affect any oral mucosal surface – tongue, lips, buccal mucosa - Diagnosis: - History - Clinical presentation - Identify trauma - Resolve spontaneously once causative factor has been identified and removed (10-14 days) - Management: - Identify trauma - Resolve spontaneously once causative factor has been identified and removed (10-14 days) - Chlorhexidine gel, mouthrinse - Lignocaine gel, Benzydamine hydrochloride mouthrinse (Difflam) - **Review after treatment, if lesion persists, further investigations are warranted including biopsy to rule out malignancy** --   #### Overview - Reactive oral ulcers caused by trauma affecting the mucosal lining of the mouth - Causes include: - Self-inflicted injuries - Mechanical trauma: sharp margins of teeth, prosthesis, denture flange, self-biting, factitious injuries - Definition: Complete loss of epithelium exposing underlying connective tissues #### Clinical Presentation - Mechanical: Areas of erythema surrounding a central removable, yellow fibrinopurulent membrane - Can develop a rolled white border of hyperkeratosis immediately adjacent to the area of ulceration - Can affect any oral mucosal surface: tongue, lips, buccal mucosa #### Diagnosis and Management - **Diagnosis:** - History and clinical presentation - Identify trauma source - Should resolve spontaneously once causative factor is identified and removed (10-14 days) - **Management:** - Identify and remove trauma source - Chlorhexidine gel or mouthrinse - Lignocaine gel, Benzydamine hydrochloride mouthrinse (Difflam) **Review after treatment: if the lesion persists, further investigations are warranted, including biopsy to rule out malignancy.** Clinical photograph (labeled 'a') showing the oral cavity with a traumatic ulcer on the tongue. The image displays a central removable, yellow fibrinopurulent membrane surrounded by erythema, consistent with mechanical trauma from sharp tooth margins as described in the text. Clinical photograph (labeled 'b') showing an Oral squamous cell carcinoma lesion on the tongue. This visual serves to contrast a benign traumatic ulcer with a malignant lesion that may present similarly if left untreated or misdiagnosed. **Be able to recognise some common oral lesions** ### Oral candidosis * Most common fungal infection in the mouth * Caused by *Candida albicans* * **Pseudomembranous candidosis**: * White, curdy papules and plaques can be scraped off mucosal surface leaving behind erythematous, bleeding mucosa * Occurs in: Recent antibiotic use, steroid therapy, immunocompromised patients * **Erythematous candidosis**: * Erythematous, raw-appearing lesions of oral mucosa * Occurs in: Denture use: well-delineated erythema limited to denture bearing areas, common on hard palate * Median rhomboid glossitis: atrophy of midline of dorsal tongue * Angular cheilitis: painful erythema and fissuring on corners of lips * **Diagnosis**: * Clinical diagnosis * Can confirm with cytology, scrape, swab * **Patient management**: * Topical and systemic antifungal medications: nystatin, miconazole, amphotericin * Management of prosthesis #### Overview - Most common fungal infection in the mouth - Caused by *Candida albicans* #### Clinical Variants 1. **Pseudomembranous candidosis**: - White, curdy papules and plaques that can be scraped off mucosal surface leaving behind erythematous, bleeding mucosa - Occurs in: Recent antibiotic use, steroid therapy, immunocompromised patients 2. **Erythematous candidosis**: - Erythematous, raw-appearing lesions of oral mucosa - Denture use: well-delineated erythema limited to denture-bearing areas, common on hard palate - Median rhomboid glossitis: atrophy of midline of dorsal tongue - Angular cheilitis: painful erythema and fissuring on corners of lips #### Diagnosis and Management - **Diagnosis**: - Clinical diagnosis - Can confirm with cytology, scrape, or swab - **Patient Management**: - Topical and systemic antifungal medications: nystatin, miconazole, amphotericin - Management of prosthesis The official logo of The University of Western Australia, featuring a shield with a swan and book elements alongside the university name in blue text.     Clinical photograph (a) showing Pseudomembranous candidosis. The image displays white plaques and papules accompanied by erythema involving the hard and soft palate. Clinical photograph (b) demonstrating Erythematosus candidosis. It shows erythema of the palatal mucosa beneath a denture. Clinical photograph (c) displaying Median rhomboid glossitis. Clinical photograph (d) illustrating Angular cheilitis in an edentulous patient after antibiotic therapy. The image shows erythematous, macerated areas at the commissures. # Be able to recognise some common oral lesions THE UNIVERSITY OF WESTERN AUSTRALIA ## Recurrent aphthous stomatitis * **Common oral mucosal disease affects 10 – 20% of general population** * **Recurring ulcers of oral mucosa, manifesting first in childhood or adolescence in patients with no other systemic diseases** * **Can present as minor, major, herpetiform and severe** * **Minor aphthous stomatitis:** * **Most common form** * **< 1 cm in diameter, single or multiple** * **Round, shallow, symmetric** * **Painful when present (first 3-4 days), usually last 7- 10 days** * **Heal without scarring** * **Major aphthous stomatitis:** * **> 1 cm diameter, deep, extremely painful lesions** * **Interfere with speech** * **Last for weeks or months** * **Heal with scar formation** * **Herpetiform aphthous stomatitis:** * **Rare variant with multiple small ulcers** * **Few millimetres with crop-like appearance, coalesce to form large lesion with irregular margin** * **Heal within 7 – 10 days** * **Severe aphthous stomatitis:** * **Variant in which patients are almost never ulcer free** * **Chronic pain, malnutrition, weight loss** * **Develop new ulcers when previous ones are healing**    #### Overview - Common oral mucosal disease affecting 10–20% of the general population - Recurring ulcers of oral mucosa, manifesting first in childhood or adolescence in patients with no other systemic diseases #### Clinical Variants - **Minor aphthous stomatitis:** - Most common form - < 1 cm in diameter, single or multiple - Round, shallow, symmetric - Painful for the first 3-4 days; usually lasts 7-10 days - Heals without scarring - **Major aphthous stomatitis:** - > 1 cm diameter, deep, extremely painful lesions - Interfere with speech - Last for weeks or months - Heal with scar formation - **Herpetiform aphthous stomatitis:** - Rare variant with multiple small ulcers - Few millimetres with crop-like appearance; coalesce to form large lesions with irregular margins - Heal within 7–10 days - **Severe aphthous stomatitis:** - Variant in which patients are almost never ulcer-free - Chronic pain, malnutrition, weight loss - New ulcers develop while previous ones are healing Clinical photo of minor recurrent aphthous stomatitis on the buccal mucosa. Shows a single, round, shallow ulcer with a yellowish-white center and red halo, consistent with the description of being < 1 cm in diameter. Clinical photo of major recurrent aphthous stomatitis on the soft palate. Shows a large (> 1 cm), deep, irregularly shaped ulcer with significant surrounding erythema, interfering with normal anatomy as described. Composite figure showing herpetiform recurrent aphthous stomatitis. Panel (a) shows multiple small ulcers coalescing on the soft palate; panel (b) shows similar lesions on the lower labial mucosa. Images demonstrate the 'crop-like appearance' mentioned in text. # **Be able to recognise some common oral lesions** **Recurrent aphthous stomatitis** * **Diagnosis:** * History * Laboratory tests may be helpful: rule out haematological deficiencies and systemic conditions * Biopsies to rule out vesiculobullous disorders * **Management** * Treatment may not be necessary as pain is tolerable and does not interfere with daily life * Reduce pain and frequency * 10% benzocaine, viscous lidocaine, benzydamine hydrochloride * Reassurance and patient education * Topical corticosteroids and other immunosuppressive agents can be used for more severe ulcers to shorten duration and size of ulcers #### Diagnosis - History - Laboratory tests may be helpful to rule out haematological deficiencies and systemic conditions - Biopsies to rule out vesiculobullous disorders #### Management - Treatment may not be necessary if pain is tolerable and does not interfere with daily life - Goals: Reduce pain and frequency - Medications: 10% benzocaine, viscous lidocaine, benzydamine hydrochloride - Reassurance and patient education - Topical corticosteroids and other immunosuppressive agents can be used for more severe ulcers to shorten duration and size University of Western Australia logo featuring a shield with a swan and open book symbol above the text 'THE UNIVERSITY OF WESTERN AUSTRALIA'. # Be able to recognise some common oral lesions The University of Western Australia *Seeke wisdom* **Fibroepithelial polyp** * Fibrous nodule * Induced by recurrent local irritants of oral cavity –bite trauma, denture irritation, food impaction, poor oral hygiene * **Pathophysiology**: Reactive proliferation rather than true neoplasm * **Clinical Features** * Smooth, round, exophytic nodule * Pedunculated or sessile with normal overlying epithelium * Can be ulcerated, or demonstrate thickened white surface (hyperkeratosis) * Asymptomatic generally * 1-2 cm in diameter * Labial mucosa, tongue, palate * **Diagnosis** * Definitive diagnosis made upon histopathological examination * Highly suspected based on clinical features * **Treatment** * Surgical excision with removal of local irritants  #### Overview - Fibrous nodule induced by recurrent local irritants of the oral cavity (bite trauma, denture irritation, food impaction, poor oral hygiene) - **Pathophysiology**: Reactive proliferation rather than a true neoplasm #### Clinical Features - Smooth, round, exophytic nodule - Pedunculated or sessile with normal overlying epithelium - Can be ulcerated or demonstrate a thickened white surface (hyperkeratosis) - Generally asymptomatic - 1-2 cm in diameter - Common sites: Labial mucosa, tongue, palate #### Diagnosis and Treatment - **Diagnosis**: - Highly suspected based on clinical features - Definitive diagnosis made upon histopathological examination - **Treatment**: - Surgical excision with removal of local irritants Clinical photo showing a fibroepithelial polyp on the inner labial mucosa. The lesion appears as a smooth, round, exophytic nodule, consistent with the description in the text. Black gloves are visible holding the lip to expose the lesion. # Be able to recognise some common oral lesions ## Oral leukoplakia * **WHO** defines OLK as "**a predominantly white plaque of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer**". * Six times more prevalent in smokers and use of alcohol * Risk of malignant transformation: 0.13% and 36.4% * **Homogenous** * Sharply demarcated * Uniform white plaque * Smooth, fissured, wrinkled surface * Consistent surface topography throughout * **Non-homogenous leukoplakia** * Verrucous * Nodular * Speckled (erythroleukoplakia) * Palpate for firmness or induration * **Clinical diagnosis** * Biopsy to exclude dysplasia or malignancy * Management: clinical surveillance vs excision    #### Definition - **WHO definition**: A predominantly white plaque of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer. - Six times more prevalent in smokers and those who use alcohol - Risk of malignant transformation: 0.13% to 36.4% #### Clinical Types - **Homogenous**: - Sharply demarcated - Uniform white plaque - Smooth, fissured, or wrinkled surface - Consistent surface topography throughout - **Non-homogenous**: - Verrucous - Nodular - Speckled (erythroleukoplakia) - Note: Palpate for firmness or induration #### Diagnosis and Management - **Diagnosis**: Clinical diagnosis; biopsy required to exclude dysplasia or malignancy - **Management**: Clinical surveillance versus surgical excision Clinical photo of the upper anterior maxillary gingiva showing a white plaque lesion. The image corresponds to the 'Oral leukoplakia' topic, illustrating the visual appearance of the condition defined in the text as a 'predominantly white plaque'. The lesion appears as a whitish patch on the gum tissue above the teeth. Clinical photo of posterior mandibular molars and gingiva showing a non-homogenous leukoplakia lesion. This demonstrates one of the subtypes listed in the text under 'Non-homogenous leukoplakia', appearing as an irregular white area on the buccal mucosa near the teeth. Clinical photo of the lateral border of the tongue showing a speckled white lesion with red areas (erythroleukoplakia). This image visually represents the 'Speckled (erythroleukoplakia)' subtype mentioned in the 'Non-homogenous leukoplakia' section of the text.  Table categorizing oral white lesions into four groups: Developmental (Fordyce's granules, White sponge nevus), Reactive (Frictional keratosis, Chemical injury, Morsciato mucosae oris, Leukoedema, Smokeless tobacco keratosis, Nicotinic stomatitis), Infections (Candidosis, Oral hairy leukoplakia), and Immune-Mediated Autoimmune conditions (Geographic tongue, Oral lichen planus and lichenoid reactions). # Be able to recognise some common oral lesions Oral lichen planus * Chronic, immune-mediated, inflammatory disorder with characteristic relapses and remissions * Display reticular lesions * Accompanied or not by atrophic, erosive, ulcerative and/or plaque type areas * Diagnosis: clinical and histopathology * Management: Topical or systemics corticosteroids, immunosuppressive treatment * Regular monitoring advised to monitor disease activity, symptomology and prevent malignant transformation * 0.44% - 1.4% * Higher in smokers, excessive alcohol intake, non-reticular types | Clinical criteria | Presence of bilateral, more or less symmetrical white lesions affecting buccal mucosa, and/or tongue, and/or lip, and/or gingiva | | :--- | :--- | | | Presence of white papular lesions and lace-like network of slightly raised white lines (reticular, annular, or linear pattern) with or without erosions and ulcerations | | | Sometimes presents as desquamative gingivitis | | Histopathological criteria | Presence of a well-defined band-like predominantly lymphocytic infiltrate that is confined to the superficial part of the connective tissue | | | Liquefactive degeneration of the basal cell layer | | | Epithelial thinning and sometimes ulceration caused by failure of epithelial regeneration as a result of basal cell destruction seen in atrophic subtype. Mixed inflammatory infiltrate may be found | Endorsed Diagnostic criteria of oral lichen planus based on Oral potentially malignant disorders: A consensus report from an international seminar on nomenclature and classification, convened by the WHO Collaborating Centre for Oral Cancer  #### Overview - Chronic, immune-mediated, inflammatory disorder with characteristic relapses and remissions - Malignant transformation risk: 0.44% - 1.4% (higher in smokers, excessive alcohol intake, and non-reticular types) - Management: Topical or systemic corticosteroids, immunosuppressive treatment - Regular monitoring advised for disease activity, symptomology, and prevention of malignant transformation #### Diagnostic Criteria **Clinical Criteria** - Presence of bilateral, more or less symmetrical white lesions affecting buccal mucosa, tongue, lip, and/or gingiva - Presence of white papular lesions and lace-like network of slightly raised white lines (reticular, annular, or linear pattern) with or without erosions and ulcerations - Sometimes presents as desquamative gingivitis **Histopathological Criteria** - Presence of a well-defined band-like predominantly lymphocytic infiltrate confined to the superficial part of the connective tissue - Liquefactive degeneration of the basal cell layer - Epithelial thinning and sometimes ulceration caused by failure of epithelial regeneration (atrophic subtype); mixed inflammatory infiltrate may be found A structured table detailing the clinical and histopathological criteria for oral lichen planus. The table is divided into two main sections: 'Clinical criteria' and 'Histopathological criteria'. Under 'Clinical criteria', it lists bilateral symmetrical white lesions affecting buccal mucosa/tongue/lip/gingiva, reticular/annular/linear patterns of white papules with or without erosions, and desquamative gingivitis. Under 'Histopathological criteria', it describes a band-like lymphocytic infiltrate in the superficial connective tissue, liquefactive degeneration of the basal cell layer, and epithelial thinning/ulceration due to basal cell destruction. A footer notes these are endorsed diagnostic criteria based on WHO Collaborating Centre for Oral Cancer consensus.     Clinical photo showing white striated lesions on the buccal mucosa adjacent to a molar tooth. Clinical photo showing a whitish plaque-like lesion on the buccal mucosa near the tongue. Clinical photo showing generalized erythema (redness) and inflammation of the gingiva surrounding teeth. Clinical photo showing dark purple or blue discoloration of the dorsal surface of the tongue. **Be able to recognise some common oral lesions** • 68 year old female, non-smoker, biopsy proven oral lichen planus • Lost to follow up since 2019 • Presented December 2021 complaining of six month history of tongue pain   #### Case Study - 68-year-old female, non-smoker - Biopsy-proven oral lichen planus - Lost to follow-up since 2019 - Presented December 2021 complaining of a six-month history of tongue pain Clinical photo showing an open mouth with a close-up view of the tongue. The image displays a white, lacy, reticular pattern on the dorsal surface of the tongue, characteristic of oral lichen planus. There are also visible areas of erythema and a small ulceration or lesion near the midline. Text box containing clinical case details relevant to the photo above. It describes a '68 year old female, non-smoker, biopsy proven oral lichen planus' who was 'Lost to follow up since 2019' and 'Presented December 2021 complaining of six month history of tongue pain'.  Clinical photograph showing actinic cheilitis on the lower lip with blurred vermilion border, white and red-white plaques, and signs of chronic sun exposure. # Take home messages **The University of Western Australia** * Important to understand normal anatomy * Develop a systematic soft tissue examination method in order to avoid missing important anatomical sites * Always palpate the lymph nodes * Always take a clinical photograph of any lesions that you note * Remember **CLOTHS** when describing lesions * Remember the **5Ws (Who, What, When, Why, How/Why)** when you see an oral lesion? * If oral lesion present for **> 2 weeks**, or unable to identify a trigger consider an **early referral to an oral medicine specialist** * Use the **5Ws** to create your referral letter – include the clinical photograph * Oral leukoplakia, Actinic cheilitis and Oral lichen planus are common oral conditions which carry risk of malignant transformation and **require specialist care** #### Key Takeaways for Clinical Practice - Understand normal anatomy thoroughly to distinguish it from pathological changes. - Develop and follow a systematic soft tissue examination method to ensure no anatomical sites are overlooked. - Perform palpation of the lymph nodes as a standard part of every examination. - Document any identified lesions with clinical photographs. - Utilize the **CLOTHS** acronym when providing descriptive details of lesions. - Apply the **5Ws (Who, What, When, Where, Why/How)** framework when evaluating an oral lesion. #### Referral and Specialist Care - If an oral lesion persists for more than two weeks or if a specific trigger cannot be identified, consider an early referral to an oral medicine specialist. - Use the **5Ws** framework to structure referral letters and ensure clinical photographs are included. - Recognize that conditions such as oral leukoplakia, actinic cheilitis, and oral lichen planus carry a risk of malignant transformation and require specialist management. **The University of Western Australia** **Any questions?** lalima.tiwari@uwa.edu.au Any questions? lalima.tiwari@uwa.edu.au [^1]: Original PDF page 1: [[L3 Soft tissue examination 2025_quiz version.pdf#page=1|L3 Soft tissue examination 2025 quiz version, p.1]] [^2]: Original PDF page 2: [[L3 Soft tissue examination 2025_quiz version.pdf#page=2|L3 Soft tissue examination 2025 quiz version, p.2]] [^3]: Original PDF page 3: [[L3 Soft tissue examination 2025_quiz version.pdf#page=3|L3 Soft tissue examination 2025 quiz version, p.3]] [^4]: Original PDF page 4: [[L3 Soft tissue examination 2025_quiz version.pdf#page=4|L3 Soft tissue examination 2025 quiz version, p.4]] [^5]: Original PDF page 5: [[L3 Soft tissue examination 2025_quiz version.pdf#page=5|L3 Soft tissue examination 2025 quiz version, p.5]] [^6]: Original PDF page 6: [[L3 Soft tissue examination 2025_quiz version.pdf#page=6|L3 Soft tissue examination 2025 quiz version, p.6]] [^7]: Original PDF page 7: [[L3 Soft tissue examination 2025_quiz version.pdf#page=7|L3 Soft tissue examination 2025 quiz version, p.7]] [^8]: Original PDF page 8: [[L3 Soft tissue examination 2025_quiz version.pdf#page=8|L3 Soft tissue examination 2025 quiz version, p.8]] [^9]: Original PDF page 9: [[L3 Soft tissue examination 2025_quiz version.pdf#page=9|L3 Soft tissue examination 2025 quiz version, p.9]] [^10]: Original PDF page 10: [[L3 Soft tissue examination 2025_quiz version.pdf#page=10|L3 Soft tissue examination 2025 quiz version, p.10]] [^11]: Original PDF page 11: [[L3 Soft tissue examination 2025_quiz version.pdf#page=11|L3 Soft tissue examination 2025 quiz version, p.11]] [^12]: Original PDF page 12: [[L3 Soft tissue examination 2025_quiz version.pdf#page=12|L3 Soft tissue examination 2025 quiz version, p.12]] [^13]: Original PDF page 13: [[L3 Soft tissue examination 2025_quiz version.pdf#page=13|L3 Soft tissue examination 2025 quiz version, p.13]] [^14]: Original PDF page 14: [[L3 Soft tissue examination 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