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Patients often present at primary care with what they think are common ulcers. In the rare cases where the lesion turns out to be malignant, early intervention through diagnosis and timely referral can lead to an improved prognosis.
The oral cavity consists of hard and soft tissues, with at least 28 teeth in adults (excluding the third molars, also known as ‘wisdom teeth’).
A thorough oral examination allows a holistic approach to the patient’s chief complaint and is the key to making an early diagnosis of an underlying systemic condition.
Thorough oral examination should include palpation
of the lymph nodes, muscles of mastication and temporomandibular joint (TMJ) prior to the start of
the examination of the intraoral structures, such as
the dentition and soft tissue structures including the
tongue, floor of mouth, and buccal and labial mucosae.
The following cases studies illustrate the management
of oral lesions in primary care and the importance of
early recognition of potentially malignant oral lesions.
The patient was an 18-year-old Chinese female with
the chief complaint of painful tongue with tightness
in the cheeks with some surface roughness. She
reported not being able to eat well. The oral
symptoms had started about three months ago.
She is healthy with no known drug allergies and no
reported use of tobacco or alcohol. She does not
take any medications regularly.
On examination, her oral hygiene was fair with
minimal plaque and she was caries-free.
She presented with white reticular striations on the
bilateral lateral surfaces of the tongue (Figures
1 and 2) with erosive mucosal changes, covered
with yellowish fibrinous exudate and erythematous
margins.Figure 1 Right lateral
border of tongue.
Central area of
by yellow fibrinous
membrane with surrounding white
Figure 2 Left lateral
focal area of erosive
Both sides of the buccal mucosa presented with
patches of white reticular striations with no ulcerations
or mass effect (Figure 3). These lesions are
Figure 3 Left (A) and right (B) buccal mucosae with white
The clinical differential diagnosis included oral lichen
planus (OLP), oral involvement of an underlying
systemic autoimmune condition such as systemic
lupus erythematosus or discoid lupus. An incisional
biopsy was performed to confirm the definitive
Microscopic findings were consistent with lichenoid
mucositis, recommending clinicopathologic correlation
for the diagnosis of OLP.
Blood serology tests to check for autoimmune
conditions including rheumatoid factor (RF), anti-nuclear
antibody (ANA) and double-stranded DNA
(dsDNA) were done with no significant findings.
The patient was diagnosed with OLP based on the
clinical and histopathologic findings.
What is oral lichen planus
Oral lichen planus (OLP) is a chronic mucocutaneous
inflammatory condition that tends to affect the oral
mucosa, although the skin and other mucosal surfaces
such as the oesophageal and vaginal mucosae can
OLP has several clinical presentations including the
reticular, plaque-like, erosive/atrophic, ulcerative
and bullous forms. An individual patient can have a
combination of these types.
Reticular OLP. The most common and
characteristic of OLP. This form of OLP is usually
asymptomatic, commonly found on bilateral
buccal mucosa as lacy, white lines referred to as Wickham’s striae. One of the common complaints
from patients with reticular OLP is roughness of
the cheeks with some tightness.
Plaque-like OLP. A less common form of OLP, it
commonly occurs on the dorsum of the tongue
and can be accompanied by depapillation of the
surrounding dorsal surfaces of the tongue. Some
patients complain of dysgeusia or reduced taste
Erosive/atrophic OLP. The mucosa commonly presents with redness due to thinning of the
surface epithelium and can affect any mucosal
surface, including the tongue, gingiva and buccal
mucosa. In most instances, individuals with erosive
lichen planus are uncomfortable when eating and
drinking, particularly with foods and drinks that are
at extremes of temperature, acidic, coarse or spicy.
Ulcerative OLP. In severe cases, ulceration can
develop. Individuals affected by ulcerations may
experience pain even when not eating or drinking,
with complaints of reduced quality of life.
Bullous OLP. It is the rarest form of OLP. It is
characterised by the formation of vesicles or
bullae, which usually develop in the presence
of the other forms of OLP. These bullae tend to
rupture easily forming shallow ulcerations in
the background of striations and erythematous
Managing and treating oral lichen planus
The main treatment goal is elimination of oral
symptoms to improve quality of life.
The reticular form of OLP often does not require
any treatment. Adequate information on OLP should
be made available to the patient. Most importantly,
patients must be informed of the importance of
periodic observation even if the oral lesions remain
Erosive/ulcerative lesions in most cases tend to be more symptomatic, especially when eating spicy
foods or drinking hot drinks, while in other cases, the
lesions may be asymptomatic. Management of these
erosive/ulcerative lesions involves the use of topical
immunosuppressive agents such as corticosteroids, tacrolimus or intralesional corticosteroid injections
for recalcitrant lesions. In severe cases, a short
course of systemic corticosteroids can be prescribed.
At times, patients may develop oral candidiasis
(pseudomembranous or erythematous types), a
type of fungal infection, even before the initiation of
topical corticosteroid therapy.
In cases with oral candidiasis (pseudomembranous
or erythematous types), topical antifungals and/or
systemic antifungals can be prescribed.
Chlorhexidine mouthwash can also be given as it
has some fungicidal properties.
In the author’s experience, nystatin suspension has
been ineffective in eradicating oral candidiasis due
to several reasons such as the need for multiple
dosing daily, containing high sugar content and
bad tastes which in turn lead to poor patient
compliance. A preferred topical antifungal agent
is miconazole 2% gel or ketoconazole 2% gel in
addition to chlorhexidine rinse.
In some cases, a course of systemic fluconazole can
In patients with persistent erosions/ulcerations
who are unresponsive to topical therapy, referral
to an oral medicine trained dentist may be
With an ageing population, there is also an
increasing number of patients with other medical
comorbidities that can affect the management
of these oral lesions, such as those with poorly-controlled
diabetes and hepatitis B infection.
The patient was a 42-year-old Chinese female
with a chief complaint of a non-healing ulcer on
the right lateral border of the tongue for a duration
of three months (Figure 4) . She reported slight
discomfort at the tongue ulcer.
Figure 4 Focal area of ulceration on the right
lateral border of tongue. The lesion remains
the same after use of topical steroids.
Her medical history was non-significant with no
known drug allergies. She did not recall possible
trauma to the lesional site. She was a non-smoker
and social drinker.
The patient was referred by her general practitioner
to the National Dental Centre Singapore.
On examination, there were no palpable cervical
lymph nodes, facial asymmetry or abnormal jaw
movement. Her oral hygiene is good with no
The clinical differential diagnosis included traumatic
ulcer and oral squamous cell carcinoma.
Topical corticorsteroid (Clobetasol proprionate
0.2% ointment) was prescribed for two weeks. At
her two-week review, there was no improvement
in the lesion and an incisional biopsy was
Microscopic examination revealed a superficially
invasive squamous cell carcinoma.
The patient was subsequently referred to the
Head and Neck Oncology team at the National
Cancer Centre Singapore for wide surgical excision
with ipsilateral neck dissection. Further histologic
examination revealed no involvement of the lymph
nodes and the surgical margins, both deep and
peripheral, were cleared of tumour.
Differential diagnoses for oral ulcers are not
exhaustive, thus one must be vigilant and timely
referral for management of these oral ulcers is
important. As shown in this case, a delay in diagnosis
may lead to spread of cancer cells, affecting
the prognosis and management of the condition.
In addition, continued follow-up of oral ulcers is
important to ensure that that there is complete
resolution of the ulceration. Otherwise, a biopsy
should be considered to rule out malignant changes.
Dr Chelsia Sim is a Consultant at the National Dental Centre Singapore (NDCS) who
graduated from the National University of Singapore (NUS) and obtained her Master’s
degree and advanced training in oral medicine at the University of California, San Francisco. Following that, she completed another residency in oral and maxillofacial pathology at the University of Iowa.
She currently runs the Oral Medicine Unit in the Department of Oral & Maxillofacial
Surgery at NDCS, and is actively engaged in the surgical biopsy service at Singapore
General Hospital. Dr Sim also teaches oral and maxillofacial pathology to the dental
undergraduates at NUS.
Her clinical interests include diagnosis and management of oral mucosal diseases
including autoimmune mucocutaneous diseases. She also treats patients with oral
precancerous lesions with carbon dioxide laser.GPs can call the SingHealth Duke-NUS Head & Neck Centre for appointments at the following hotlines:
Singapore General Hospital: 6326 6060Changi General Hospital: 6788 3003Sengkang General Hospital: 6930 6000KK Women’s and Children’s Hospital: 6692 2984National Cancer Centre Singapore: 6436 8288National Dental Centre Singapore: 6324 8798
HEAD AND NECK;Mouth