The art and science of oral examination

Performing an accurate oral examination is an integral part of a complete dermatological evaluation. As dermatologists, we are frequently asked to assess and treat numerous oral pathologies, which include, but are not limited to, normal variants, infections, ulcers, granulomas, lymphomas, as well as primary and metastatic tumors of the mouth and lips. The oral mucosa can be the window through which one can see and make numerous systemic diagnoses. Some clinicians are apprehensive about performing this evaluation, or feel that this examination is outside of their realm of expertise. These concerns may reflect limited exposure and education during training. Therefore, this article aimed to educate the readers on how to complete an oral examination, demonstrate normal variants, and highlight potential pitfalls and limitations of performing oral biopsies.     

Unifocal Langerhans cell histiocytosis of the oral mucosa

A 24‐year‐old man was admitted for a painful gingival ulcer. Histology and immunohistochemistry of a lesional biopsy revealed the diagnosis of Langerhans cell histiocytosis (LCH). To rule out multifocal disease, a complete staging was performed. There was no evidence of bony lesions or any other organ involvement. The diagnosis of LCH restricted to the oral mucosa was established. The complete oral lesion was ablated by CO₂ laser and subsequently treated topically with triamcinolone acetonide. The patient is still in remission after one year of follow‐up. LCH confined to the oral mucosa is rare. It presents usually as an inflammatory or ulcerative lesion, easily leading to misinterpretation and delayed diagnosis. Patients with limited unifocal mucocutaneous disease, as in the present case, usually have an excellent prognosis. However, the oral lesion may represent an early sign of LCH, predating and progressing to an aggressive life‐threatening multiorgan disease.     

Melanin‐associated pigmented lesions of the oral mucosa: presentation,differential diagnosis,and treatment

Intraoral pigmentation is quite common and has numerous etiologies, ranging from exogenous to physiological to neoplastic. Many pigmented lesions of the oral cavity are associated with melanin pigment. The differential diagnosis of mucosal pigmented lesions includes hematomas, varices, and petechiae which may appear to be pigmented. Unlike cutaneous melanomas, oral melanomas are diagnosed late and have a poor prognosis regardless of depth of invasion. As such, the clinical presentation and treatment of intraoral melanoma will be discussed. Developing a differential diagnosis is imperative for a clinician faced with these lesions in order to appropriately treat the patient. This article will focus on the most common oral melanocytic lesions, along with mimics.     

The clinicopathological characteristics of oral lichen planus and its relationship with dental materials

The objective of this work was to carry out a clinicopathological study to ascertain whether clinical and histopathologic differences existed between oral lichen planus OLP patients with and without metal restorations. The predominant clinical form in both groups was reticular white, with no statistically significant differences between the forms associated or not with metal. The histological variables showed no statistically significant differences between the groups.     

Burning mouth syndrome: clinical presentation, diagnosis and treatment

Burning mouth syndrome is an oral dysaesthesia presenting as a burning sensation of the tongue and less frequently other oral and peri-oral sites. There may be other coincident symptoms and signs, but the defining feature is the absence of any obvious organic cause. Because of this the condition frequently remains unrecognized for extended periods with a variable progression of symptoms. The current paper describes the complex presentation of burning mouth syndrome with the major aim of increasing recognition.     

COVID‐19 from the perspective of dentists: A case report and brief review of more than 170 cases

A novel coronavirus which has appeared from China, has been circulating hastily around the world. We summarized the publications including oral manifestation of coronavirus disease 2019 (COVID‐19) cases based on PubMed and Google Scholar data bases, and also present a case that highlights oral lesions 2 days prior to the first COVID‐19 general symptoms. Two authors independently reviewed the papers, 17 studies of more than 170 confirmed cases between ages of 9 and 90 were included. The most common oral manifestation was dry mouth followed by dysgeusia and pseudomembranous fungal structure. Change in tongue sensation and ulceration, muscle pain during mastication, swelling in oral cavity, and herpetic lesions were other common symptoms. Associated symptoms, latency time, treatment, and prognosis have also been meticulously reviewed. We hope that careful clinical intraoral examination on all COVID‐19 positive patients and equally on any patients who need dental care will pave the way for further studies.     

Diagnosis of oral squamous cell carcinoma and its precursor lesions

Improvement of survival rate and quality of life after treatment of oral squamous cell carcinoma as well as cost reduction requires reliable early diagnosis of the tumor and its precursor lesions. Four different screening methods are primarily employed: toluidine blue staining (visually detected lesions: sensitivity 70–100%, specificity 25–67%), photodynamic diagnosis (sensitivity 94–99%, specificity 60–89%), autofluorescence (no data published so far) and modern oral cytology (sensitivity 80%,specificity 95–100%).Additional analytic procedures such automated image analysis, DNA image cytometry and immunocytochemistry can be used to enhance the low sensitivity of conventional oral cytology.While these methods have achieved sensitivity and specificity approaching 100%, the studies involved clearly‐defined entities such as large oral squamous cell carcinomas and aphthae. The modern and methodenhanced oral cytology is a simple, value‐based and inexpensive tool for early diagnosis of oral squamous cell carcinoma and its precursor lesions. Surgical biopsy and histopathological examination remains the gold standard for definitive diagnosis.     

Oral manifestations of inflammatory bowel disease: a review based on the observation of six cases

Inflammatory bowel disease (IBD) comprises two chronic, tissue‐destructive, clinical entities: Crohn's disease (CD) and ulcerative colitis (UC), both immunologically based. Bowel symptoms are predominant, but extra‐intestinal complications may occur, including involvement of the oral cavity. Oral involvement during IBD includes several types of lesions: the most common are aphthae; uncommon lesions include, among others, pyostomatitis vegetans and granulomatous lesions of CD. Starting with a presentation of six patients with oral manifestations, which were crucial for the final diagnosis of IBD, a review on the subject is presented. Oral involvement in IBD may be previous or simultaneous to the gastrointestinal symptoms. However, in the majority of cases, bowel disease precedes the onset of oral lesions by months or years. In many patients, the intestinal symptoms may be minimal and can go undetected; thus, most authors believe that the bowel must be thoroughly examined in all patients with suspected IBD even in the absence of specific symptoms. Usually, the clinical course of oral lesions is parallel to the activity of IBD; therefore, oral manifestations are a good cutaneous marker of IBD.     

Aphthous ulcers

Aphthous ulcers are one of the most common oral diseases worldwide. Their clinical presentation is characterized by multiple, recurrent, small, round, or ovoid ulcers with circumscribed margins and erythematous haloes present in different sizes. Oral lesions similar to aphthous ulcers may be present in several systemic diseases. This article will summarize the differential diagnosis of aphthous ulceration, with emphasis on a practical guide for the management of recurrent aphthous ulceration, including topical and systemic therapy.     

Oral manifestations of adverse drug reactions: guidelines

Background Adverse drug reactions are noxious and unintended responses to a medicinal product. Many drugs have the potential to induce adverse reactions in the mouth. The extent of such reactions is unknown; however, because a lot of them are asymptomatic, many are believed to go unnoticed. Adverse oral drug reactions are responsible for oral lesions and manifestations that can mime local or systemic disease. Their pathogenesis, especially of the mucosal reactions, is largely unknown and appears to involve complex interactions between the drug in question, other medications, the patient's underlying disease, genetics and lifestyle factors. Aim In this study, we have listed the principal signs and symptoms of oral and perioral adverse drug reactions and the responsible drugs. Diagnosis for adverse drug reaction is not easy given also the limited utility of laboratory tests. The association between a drug and an adverse drug reaction is mostly based on the disappearance of the reactions following discontinuance of the offending drug. Sometimes, it is useful to perform rechallenge tests reintroducing the drug to establish cause and effect. Conclusions Knowledge of adverse drug‐induced oral effects helps health professionals to better diagnose oral disease, administer drugs and improve patient compliance during drug therapy and may foster a more rational use of drugs.     

仅表现口腔粘膜糜烂的副肿瘤性天疱疮临床及免疫学研究

目的：报告1例仅表现为口腔粘膜糜烂的副肿瘤性天疱疮患者的临床及免疫学特征。方法：对患者进行系统及皮肤科、口腔科临床学、医学影像学、组织病理学和免疫学检查。结果：通过上述检查，结果符合副肿瘤天疱疮，并发现患者合并胸部caslleman’s病，患者存在抗210kDa(Envoplakin)及190kDa(Periplakin)的抗体。结论：临床上遇有仅表现口腔粘膜顽固性糜烂溃疡的患者，要考虑到PNP的可能。PNP患者潜在肿瘤的发现与切除是目前治疗PNP最有效的方法。     

Serum and urine nickel in nickel-sensitized women: effects of oral challenge with the metal

15 women with a positive patch test only to nickel (Ni) and without atopy and 10 control women were selected for the study. Blood and urine specimens were collected with a standard procedure either before (at 8 a.m.) or 4 and 24 h after the ingestion of 10 mg of Ni (as Ni sulfate). 7 of the Ni-sensitized patients showed a flare-up of eczema and/or urticaria during the test, while the other women were non-symptomatic. Serum and urine Ni of controls and Ni-sensitized women did not significantly differ. Serum and urine Ni levels determined before the oral Ni challenge were in the range of reference values recently reported by other authors (0.2–2.0 μg/l of serum or urine). Ni was greatly augmented in urine and serum 4 h after the challenge (25th–75th percentiles: 43–264 μg/l urine Ni and 15–52 μg/l serum Ni). 24 h after Ni ingestion, urine Ni was 41–153 μg/l and serum Ni 4–17 μg/l. Our study confirms a previous investigation showing similar levels of serum and urine Ni following ingestion of the metal in control and Ni-sensitized women without atopy.     

Oral lichenoid reactions associated with amalgam: improvement after amalgam removal

BACKGROUND: The pathogenetic relationship between oral lichenoid reactions (OLR) and dental amalgam fillings is still a matter of controversy. OBJECTIVES: To determine the diagnostic value of patch tests with amalgam and inorganic mercury (INM) and the effect of amalgam removal in OLR associated with amalgam fillings. METHODS: In 134 consecutive patients 467 OLR were classified according to clinical criteria. One hundred and fifty-nine biopsies from OLR lesions were histologically diagnosed according to the World Health Organization criteria for oral lichen planus (OLP) and compared with 47 OLP lesions from edentulous patients without amalgam exposure. One hundred and nineteen patients were patch tested with an amalgam series. In 105 patients (357 of 467 lesions) the amalgam fillings were removed regardless of the patch test results and OLR were re-examined within a follow-up period of about 3 years. Twenty-nine patients refused amalgam removal and were taken as a control group. RESULTS: Eleven patients with OLR (8.2%) had skin lesions of lichen planus (LP). Histologically, the lesions in the OLR group could not be distinguished from those seen in the OLP group. Thirty-three patients (27.7%) showed a positive patch test to INM or amalgam. Amalgam removal led to benefit in 102 of 105 patients (97.1%), of whom 31 (29.5%) were cured completely. Of 357 lesions, 213 (59.7%) cleared after removal of amalgam, whereas 65 (18.2%) did not improve. In the control group without amalgam removal (n = 29) only two patients (6.9%) showed an improvement (P < 0.05). Amalgam removal had the strongest impact on lesions of the tongue compared with lesions at other sites (P < 0.05), but had very little impact on intraoral lesions in patients with cutaneous LP compared with patients without cutaneous lesions (P < 0.05). Patients with a positive patch test reaction to amalgam showed complete healing more frequently than the amalgam-negative group (P < 0.05). After an initial cure following amalgam removal, 13 lesions (3.6%) in eight patients (7.6%) recurred after a mean of 14.6 months. CONCLUSIONS: Of all patients with OLR associated with dental amalgam fillings, 97.1% benefited from amalgam removal regardless of patch test results with amalgam or INM. We suggest that the removal of amalgam fillings can be recommended in all patients with symptomatic OLR associated with amalgam fillings if no cutaneous LP is present.     

Composite and heterogeneous keratohyalin in the human buccal mucosa

Summary The electron microscopic examination of three biopsies from a patient with multiple oral fibroepithelial hyperplasias revealed composite and heterogeneous keratohyalin granules in the marginal zone of the lesions. Neither composite nor heterogeneous reticular keratohyalin has as yet been described in the human buccal mucosa.     

Three cases of oral mucosal tuberculosis in patients on tumour-necrosis-factor-α blockers

We present three cases of oral mucosal lesions caused by Mycobacterium tuberculosis in patients treated with anti-tumour necrosis factor-α for psoriasis or rheumatoid arthritis. Diagnosis of oral mucosal tuberculosis was not easily established in any of the cases. A comparison between these cases and other previously described forms of oral mucosal tuberculosis is presented.     

Oral exposure to a nickel-containing dental alloy of persons with hypersensitive skin reactions to nickel

In 10 partially dentate subjects, all with long histories of skin reactions to nickel, prosthetic treatments were performed with fixed prosthetic appliances manufactured in a denial alloy containing 66% nickel. During lime periods varying from 12 to over 40 months, these subjects were controlled using a variety of dental and medical methods. Neither adverse general nor oral clinical nor histological reactions were noted during the observation.