Oral Medicine, Oral Pathology and Oral Radiology
Diagnosing mucosal lesions
Biopsy any ulcer persisting beyond two weeks, any erythroplakia (the highest malignant transformation risk) and any non-homogeneous leukoplakia. Oral squamous cell carcinoma classically presents as an indurated ulcer with rolled margins, often on the lateral tongue or floor of the mouth; risk factors are tobacco, betel/areca nut (oral submucous fibrosis), alcohol and HPV. Red-and-white mixed lesions need urgent referral.
Immune and vesiculobullous disease
Recurrent aphthous stomatitis is the commonest ulcerative disease; treat with topical corticosteroid and analgesia. Oral lichen planus shows Wickham striae with erosive areas; manage symptomatically and monitor. Pemphigus vulgaris shows intraepithelial acantholysis with a positive Nikolsky sign, whereas mucous membrane pemphigoid is subepithelial with tense blisters; both need biopsy with direct immunofluorescence. Candidiasis (pseudomembranous, erythematous, angular cheilitis) responds to topical nystatin or miconazole, with systemic fluconazole if refractory.
Radiology
Follow ALARA. Paralleling technique with a film holder and long cone reduces distortion. Panoramic images give a low-dose overview but produce ghost images, and the focal trough can blur the anterior region. CBCT answers three-dimensional questions - impacted teeth, root fracture, implant planning - and is not a screening tool.
Worked example
A 55-year-old with a 1 cm indurated ulcer on the lateral tongue present for five weeks despite a soft diet needs urgent referral for incisional biopsy, not a course of antiseptic mouthwash.
Traps
- Calling every white patch leukoplakia - exclude frictional keratosis and candidiasis first.
- Assuming a normal radiograph excludes malignancy.
- Confusing pemphigus (intraepithelial) with pemphigoid (subepithelial) histologically.
- Forgetting that erythroplakia carries a higher transformation risk than homogeneous leukoplakia.