Oral mucosa alterations

Any alteration of the mouth requires a thorough examination of the entire oral cavity: oral mucosa, gums, palate and tongue. Not only do we resort to inspection, but also palpation and pathological study are usually essential tools for diagnostic confirmation. Within alterations of the oral mucosa we will differentiate several sections:

Variations of the normal structure

• Fordyce disease: Characterized by the appearance of Fordyce spots (small isolated yellowish lesions or in groups, especially on the mucosa of the lip). Histologically, they are ectopic sebaceous glands, that is, of normal morphology but abnormal location.
• Fissured tongue: increased number of canals or folds on the back of the tongue. It is usually asymptomatic although it can suffer alterations secondary to traumatic processes (such as brushing) or infectious.
• Rhomboid media glossitis: Erythematous plaque on the central portion of the dorsum of the tongue. It is an epidermal hyperplasia whose colonization by candida is very frequent.
• Lingual varicose veins: they are dilated blue-purplish vessels located, above all, on the lateral and ventral faces of the tongue. They have no clinical significance.
• bull: exostosis or bony protrusion in the midline of the hard palate. It does not require treatment.

Among the periodontal diseases are:

• Periodontitis: periodontal inflammation that is the most common cause of tooth loss
• Gingival hyperplasia: abnormal development of the gums. It can be found in physiological states such as pregnancy, but the most common cause is secondary to medications (phenytoin, nifedipine, cyclosporine, or combinations of these). Some cases may require surgery.

Viral infections

• Acute herpetic gingivostomatitis: caused by the herpes simplex virus. It is more common in children. Only 50% give symptoms. It can present with an edematous oral mucosa with ulcers that coalesce, difficult to see the vesicles. They usually heal in 1-2 weeks without scarring. They may be accompanied by fever, laterocervical lymphadenopathy, and general impairment.
• Recurrent cold sores: present in 30% of the population. Etiology: Type I virus is the recurrent formation of vesicles in the outer third of the lip or perioral region. They usually last between 3-7 days. They heal without scarring. The application of the conventional antiretroviral does not reduce the duration of the process.
• Mouth-hand-foot disease: caused by Coxsackie type A. They are vesicular lesions in the oropharynx, skin of the hands and feet and the gluteal region. Heals without scarring in two weeks.
• Herpes zoster: caused by the varicella-zoster virus. They are vesicles that ulcerate following a unilateral target and causing neuralgia.

bacterial infections

The most commons are:

• Acute necrotizing ulcerative gingivitis.
• Syphilis.
• Gonorrhea.
• Tuberculosis.
• Actinomycosis.

Fungal diseases:

• Candidiasis: Candida albicans is present in 40% of healthy individuals. It can present with different clinical forms: thrush, chronic candidiasis, angular cheilitis, candidiasis glossitis. The infectious process is due to a decrease in the resistance capacity of the individual rather than to the pathogen itself. It is a frequent pathology in immunosuppressed patients.
• Histoplasmocytosis: caused by Histoplasma capsulatum. Frequent in individuals affected by systemic diseases. An ulcerated nodule is seen on the oral mucosa, very painful. It must be biopsied to confirm the diagnosis.

Dermatological diseases

• Pemphigus vulgaris: autoimmune blistering disease that affects the skin and mucous membranes. Of unknown cause.
• Lichen planus: pruritic, inflammatory and chronic papular rash that affects the skin and mucosa. Unknown cause but influenced by stress, viral infections and psychological overload.

Lichen planus lesions heal spontaneously or with treatment and often leave residual hyperpigmentation. Mucosal lichen planus is very common as a grouped or isolated grayish-white reticular rash.

• Erythema multiforme: of unknown cause. It presents with edema and erythema of the oral mucosa that progresses to a blister. It usually resolves in 4-6 weeks.
• Contact stomatitis: due to irritative or allergic contact reaction.

It can be due to physical agents such as heat or chemicals such as aspirin, peroxide, chlorhexidine mouthwash, and tobacco. It usually affects the hard palate. The allergic cause is usually associated with toothpastes, antiseptics and orthodontic products.

• Lblack glove hairsa: benign hyperplasia of filiform papillae of the anterior two thirds of the tongue. Macroscopically there is a pigmented and hairy area.

Systemic diseases, many clinical entities are associated with pathology of the oral mucosa, among them the most relevant would be:

• Behçet's disease (Oral and genital ulcers with ocular and neurological involvement).
• Reiter's disease.
• Systemic lupus erythematosus.
• Crohn's disease.
• Histiocytosis X.

Benign tumors

• Epulis: fibrous tumor of frequent location in the interdental papilla. It is usually reactive to the inflammatory process. It is the most common benign tumor of the oral mucosa.
• Pyogenic granuloma: pedunculated nodule with a soft consistency and reddish color, approximately 0.5-1 centimeter in diameter. Bleeds easily It is usually the answer to a minor trauma. It is more frequent during pregnancy and its most frequent location is the gum.
• Mucous retention cyst: very common cystic tumor in the mucous portion of the lower lips or ventral aspect of the tongue. Its size is usually less than one centimeter. It is usually secondary to minor trauma to the mucous glands. Clinically, a small tumor with a cystic consistency and bluish color is seen. When it affects the sublingual mucosa, its size is usually larger and it receives the proper name of ranula.
• Hemangioma: very frequent vascular tumor in the oral mucosa. Can be unique or multiple. It has different sizes and can be located in different regions of the oral mucosa. It takes on a bluish-red color. The larger ones are usually associated with macroglossia. They can be part of vascular syndromes.
• Lymphangioma: frequent tumor of the oral cavity due to proliferation of lymph nodes. Clinically appearance of one or more polylobulated masses and white-blue in color. Its most frequent location is the tongue causing, in this case, macroglossia. Treatment is surgical but difficult due to poor hemostasis.
• Granule cell tumor: tumor made up of granular cells, mainly affecting the tongue. It is usually approximately 0.5-3 centimeters in diameter. Its consistency is hard, nodular in appearance and slow growing. Differential diagnosis must be made with squamous cell carcinoma.
• Neurofibroma: mainly affects the tongue. A quarter of the patients that present it are affected by neurofibromatosis.

Premalignant and malignant lesions

• Actinic cheilitis: its chronic form is the consequence of excessive and prolonged exposure to sunlight. It predominantly affects the lower lip. Clinically, a scaly, silvery-white lesion on the labial mucosa with atrophic areas is seen. Bleeds easily Differential diagnosis must be made with squamous cell carcinoma.
• Nicotinic stomatitis: the oral mucosa of smokers shows typical inflammatory changes located on the palate. Later they will give whitish nodular lesions.
• Leukoplakia or leukoplakia: means "white spot". They are lesions that cannot be easily removed with scratching. Lichen planus should be ruled out in the presence of a whitish lesion. It has a well-defined whitish plaque appearance, with irregular edges and a rough or velvety surface. Its diagnosis is practically clinical but requires a confirmatory biopsy.
• Erythroplasia: well circumscribed erythematous plaques with a velvety surface. Located anywhere on the mucosa.
• Warty carcinoma of the oral cavity: is a variant of squamous carcinoma. It is slow growing and warty in appearance but locally invasive. It affects the oral mucosa and gums. Diagnosis must be made with biopsy. It does not usually metastasize at a distance and rarely does it in lymph nodes.
• Squamous cell carcinoma: usually affects individuals between the ages of 50 and 70. Its main risk factors are alcohol and tobacco. In addition, there is an inverse relationship between the consumption of fruits and vegetables and the incidence of oral cancer. The prognosis is highly variable depending on the time of diagnosis. Small lesions tend to have a better prognosis. The most common location is on the lower lip and takes the form of a hard ulcerated nodule with an inflammatory component. Inside the oral cavity, the tongue is the most frequent location, presenting the appearance of an indurated and painful nodule, often ulcerated, which is located in the anterior third of the tongue, especially on its lateral edges.

Patients with cancer of the oral mucosa have a high risk of recurrence or the appearance of secondary neoplasia and therefore require close follow-up. They should also avoid risk factors, especially alcohol and tobacco. In people over 50 years of age and habitual users of alcohol and tobacco, an annual oral exam is recommended.

• Malignant melanoma: rare entity. It is very aggressive and has a poor prognosis. Only 25% of patients survive to 5 years. The most common location is the gum and palate.