Pathology and Oral Medicine
Pathology and oral medicine tests pattern recognition plus the discipline to biopsy when a lesion does not behave. Expect mucosal ulceration, white and red patches, vesiculobullous disease, odontogenic cysts and tumors, salivary disease, and oral manifestations of systemic disease.
Core rules
- Any ulcer persisting beyond two weeks, indurated, fixed, or associated with lymphadenopathy needs biopsy or referral for suspected oral squamous cell carcinoma.
- Leukoplakia is a clinical diagnosis; erythroplakia is red, velvety, and has a higher malignant transformation risk. Both require biopsy after causes such as friction and candidiasis are addressed.
- Traumatic ulcers have a clear cause and heal after removal; syphilitic chancre and carcinoma can mimic them.
- Biopsy technique: incisional for large suspicious lesions, including representative epithelium and connective tissue; excisional for small benign lesions. Avoid necrotic center.
- Odontogenic keratocyst has a parakeratinized lining and high recurrence; ameloblastoma is locally aggressive; radicular cyst is inflammatory and associated with a nonvital tooth.
Worked example
A 58-year-old smoker has a 1.5 cm indurated ulcer on the lateral tongue for six weeks, with a firm submandibular node. Do not prescribe a mouthrinse or attribute it to a sharp tooth. Refer urgently for incisional biopsy and imaging; the working diagnosis is OSCC until histology proves otherwise.
Traps
- Reassuring a patient because the lesion is painless.
- Biopsying only the surface slough.
- Missing candidiasis as a reversible cause of a white patch.
- Confusing a radicular cyst with an odontogenic tumor on a single radiograph.