Coleman-2002 - Different Diagnosis of Oral Lesions - Rev

decision flow charts for the assessment of typical disease features may be inconsistent with the patients
Differential Diagnosis of Oral oral soft tissue lesions is based on several

traditional differential diagnostic
approaches that have been widely accept-
version of the disease. Therefore, one or two listed features
may be inconsistent with the patients presentation but the
diagnosis may still be correct. On the other hand, basing the
Soft Tissue Lesions ed (26).

The following comments are impor-
tant to keep in mind while using the deci-
diagnosis on only one or two features from among five or six
listed findings risks diagnostic error. In other words, the
greater the number of consistent findings, the stronger the
By Gary C. Coleman, D.D.S., M.S., Department of Diagnostic Sciences, Baylor College of Dentistry, sion charts that comprise the majority of diagnostic confidence, but perfect consistency with the listed
Texas A&M University Health Science Center, Dallas, Texas this article: features should not be expected in all cases.
3. The names of malignant neoplasms are shown in all upper
1. The decisions made early in the evalu- case letters and with broader arrows and borders of the boxes
ation of a lesion must be made care- surrounding the feature lists in the decision charts. This is
fully. Otherwise, taking the wrong intended to alert the clinician to the possibility of these seri-
T
choice early in the decision process ous diseases.
he diagnosis of soft tissue lesions of the oral will direct the assessment into the
cavity is a daily challenge for all dentists in wrong group of diseases. Therefore,
FIGURE 1: INITIAL
clinical practice. Many lesions are common the features that are the basis for
early decisions are relatively simple CATEGORIZATION OF ORAL LESIONS
and relatively characteristic in presentation, leaving The initial stage of the differential diagnosis for soft tissue
and dependable. However, they must
the dentist with little doubt about the diagnosis. In be interpreted with care. lesions of the oral cavity is the categorization of the abnormality in
other instances, however, unusual findings may 2. At the end of the decision sequence question by its primary manifestation. The four category options
leave the clinician with some diagnostic uncertainty. are the specific diseases preceded by a are as follows:
list of several clinical features that are
This is particularly unsettling if the possibility of white mucosal lesions;
typical of the classic presentation of dark (including red and pigmented) mucosal lesions;
potentially serious conditions, such as squamous each disease for comparison with the loss of mucosal integrity (vesicles, bullae bullae and ulcers); and
cell carcinoma, cannot be excluded. The most effec- typical findings of similar conditions. soft tissue enlargements.
tive approach to the evaluation of any diagnostic unfortunately, patients seldom pres-
ent the classic version of the disease, The appropriate category selection is usually apparent from
challenge is differential diagnosis. This is defined as the appearance of most oral lesions. However, a mixture of features
which implies that one or more of the
the process of comparing the patients status with
the known signs, symptoms, and other features of
Figure 1.
the diseases that are possible causes of the patients Categorization
condition or lesion. As simple as this definition of suspected
sounds, using the approach to consistently reach a nondental
abnormalities
correct diagnosis requires knowledge of both com- of the oral
mon and rare oral diseases as well as experience in cavity by
the systematic application of this extensive body of primary
manifestation.
information.
The capacity of contemporary personal computers to manage

extensive text and numerous images offers an alternative to tradi-
tional textbooks as a source of information useful to the dentist
confronted by such diagnostic problems. Also, computer programs
can arrange links in such a manner that the most relevant infor-
mation and images can be sorted from less helpful topics in a
given situation. This issue of the Texas Dental Journal includes a
CD-ROM (compact disc, read only memory) which consists of a
computer program developed to aid in the differential diagnosis of
oral soft tissue lesions. The program contains diagnostic informa-
tion about many oral lesions and several visual examples of each
condition. All of this material is arranged so that it is available as
needed during the evaluation of a specific type of oral lesion. Not
every reported oral condition has been included. Many rare dis-
eases have been excluded to make the program workable in eval-
uating the vast majority of lesions that the dentist is likely to con-
front. This article provides a conceptual framework to aid the user
in understanding the differential diagnostic strategy (1) that is the
basis of the computer program. The following series of algorithmic
Texas Dental Journal June 2002 / 484 Texas Dental Journal June 2002 / 485
decision flow charts for the assessment of typical disease features may be inconsistent with the patients
Differential Diagnosis of Oral oral soft tissue lesions is based on several
traditional differential diagnostic
approaches that have been widely accept-
version of the disease. Therefore, one or two listed features
may be inconsistent with the patients presentation but the
diagnosis may still be correct. On the other hand, basing the
Soft Tissue Lesions ed (26).

The following comments are impor-
tant to keep in mind while using the deci-
diagnosis on only one or two features from among five or six
listed findings risks diagnostic error. In other words, the
greater the number of consistent findings, the stronger the
By Gary C. Coleman, D.D.S., M.S., Department of Diagnostic Sciences, Baylor College of Dentistry, sion charts that comprise the majority of diagnostic confidence, but perfect consistency with the listed
Dallas, Texas; Catherine M. Flaitz, D.D.S., M.S., Department of Stomatology, University of Texas Dental this article: features should not be expected in all cases.
3. The names of malignant neoplasms are shown in all upper
Branch, Houston, Texas; and Steven D. Vincent, D.D.S., M.S., Department of Oral Pathology, Radiology,
1. The decisions made early in the evalu- case letters and with broader arrows and borders of the boxes
and Medicine, University of Iowa College of Dentistry, Iowa City, Iowa ation of a lesion must be made care- surrounding the feature lists in the decision charts. This is
fully. Otherwise, taking the wrong intended to alert the clinician to the possibility of these seri-
T
choice early in the decision process ous diseases.
he diagnosis of soft tissue lesions of the oral will direct the assessment into the
cavity is a daily challenge for all dentists in wrong group of diseases. Therefore,
FIGURE 1: INITIAL
clinical practice. Many lesions are common the features that are the basis for
early decisions are relatively simple CATEGORIZATION OF ORAL LESIONS
and relatively characteristic in presentation, leaving The initial stage of the differential diagnosis for soft tissue
and dependable. However, they must
the dentist with little doubt about the diagnosis. In be interpreted with care. lesions of the oral cavity is the categorization of the abnormality in
other instances, however, unusual findings may 2. At the end of the decision sequence question by its primary manifestation. The four category options
leave the clinician with some diagnostic uncertainty. are the specific diseases preceded by a are as follows:
list of several clinical features that are
This is particularly unsettling if the possibility of white mucosal lesions;
typical of the classic presentation of dark (including red and pigmented) mucosal lesions;
potentially serious conditions, such as squamous each disease for comparison with the loss of mucosal integrity (vesicles, bullae bullae and ulcers); and
cell carcinoma, cannot be excluded. The most effec- typical findings of similar conditions. soft tissue enlargements.
tive approach to the evaluation of any diagnostic unfortunately, patients seldom pres-
ent the classic version of the disease, The appropriate category selection is usually apparent from
challenge is differential diagnosis. This is defined as the appearance of most oral lesions. However, a mixture of features
which implies that one or more of the
the process of comparing the patients status with
the known signs, symptoms, and other features of
Figure 1.
the diseases that are possible causes of the patients Categorization
condition or lesion. As simple as this definition of suspected
sounds, using the approach to consistently reach a nondental
abnormalities
correct diagnosis requires knowledge of both com- of the oral
mon and rare oral diseases as well as experience in cavity by
the systematic application of this extensive body of primary
manifestation.
information.
The capacity of contemporary personal computers to manage

extensive text and numerous images offers an alternative to tradi-
tional textbooks as a source of information useful to the dentist
confronted by such diagnostic problems. Also, computer programs
can arrange links in such a manner that the most relevant infor-
mation and images can be sorted from less helpful topics in a
given situation. This issue of the Texas Dental Journal includes a
CD-ROM (compact disc, read only memory) which consists of a
computer program developed to aid in the differential diagnosis of
oral soft tissue lesions. The program contains diagnostic informa-
tion about many oral lesions and several visual examples of each
condition. All of this material is arranged so that it is available as
needed during the evaluation of a specific type of oral lesion. Not
every reported oral condition has been included. Many rare dis-
eases have been excluded to make the program workable in eval-
uating the vast majority of lesions that the dentist is likely to con-
front. This article provides a conceptual framework to aid the user
in understanding the differential diagnostic strategy (1) that is the
basis of the computer program. The following series of algorithmic
DIFFERENTIAL DIAGNOSIS OF ORAL
SOFT TISSUE LESIONS
can lead to uncertainty at this critical first tics of the lesion such as surface texture,
stage of the differential diagnosis. For sim- size, location, and marginal delineation,
plicity this scheme is arranged as indicat- as well as patient characteristics such as
ed in Figure 1 so that the categories toward age and gender, are then used to narrow
the right progressively take priority if more the range of diagnostic possibilities within
than one feature is present. For example, the major lesion category.
an enlargement with a white surface is In some patients healthy tissues may
considered in the enlargement category appear unusually prominent and may
rather than in the white lesion group. suggest the possibility of disease. Lingual
Similarly, a mixed red and white surface varices, leukoedema, and Fordyce gran-
lesion is evaluated in the dark lesion ules are common examples. The combina-
group. Also, central jaw lesions with tion of several secondary features such as
superficial clinical features such as bilateral symmetry, absence of symptoms,
enlargement are beyond the scope of this and lack of change over time (Figure 1) is
scheme because radiographic findings are helpful in determining that the suspected
central to their differential diagnosis. abnormality is actually a variation of
The goal is to eliminate as many caus- healthy tissues.
es from diagnostic consideration as possi-
ble, which simplifies the consideration of
more likely causes of the observed abnor- FIGURE 2: WHITE MUCOSAL
mality. Focusing the evaluation of the LESIONS
lesion within a major lesion group allows Several secondary clinical features of
the clinician to consider the diagnostic white mucosal lesions are essential to
possibilities that characteristically pro- their further evaluation. The surface tex-
duce the patients problem. Excluded from ture of white lesions may appear smooth
consideration are all of the diseases that or rough which suggests the nature of the
typically do not cause the primary mani- lesion. Some white lesions rub off with lat-
festation observed. Secondary characteris- eral pressure using a cotton gauze and are
Figure 2.
Initial differ-
ential diagno-
sis of white
mucosal
lesions.
Texas Dental Journal June 2002 / 486

SOFT TISSUE LESIONS
often painful, which indicates that the Whether the distribution of white mucosal appearance is a
white appearance is caused by a superfi- single focal lesion, a diffuse region of abnormal white appearance,
cial material. The combination of these or multiple separate lesions is contributory to the differential diag-
and several additional features yields nosis within the epithelial thickening subgroup. Also, habitual use
three distinct lesion subgroups for white of substances such as alcohol and tobacco is often related to the
lesions as shown in Figure 2. development of certain white lesions and should be clarified by
history. Of particular importance is the appreciation of the diag-
nostic features that suggest the possibility that a white lesion is
FIGURE 3: idiopathic leukoplakia, which implies a higher probability of an
THE EPITHELIAL THICKENING eventual microscopic diagnosis of epithelial dysplasia or early
SUBGROUP squamous cell carcinoma.
The epithelial thickening subgroup of
white lesions is characterized by a rough
surface texture because the white appear- FIGURE 4: THE SURFACE MATERIAL AND
ance is caused by excessive keratin accu- SUBMUCOSAL CHANGE SUBGROUPS
mulation, which will not rub off. Also, The surface material subgroup of white lesions is character-
these lesions typically are asymptomatic. ized by rubbing off of the material causing the appearance with
This subgroup includes the largest num- lateral pressure of a gauze sponge. In addition, this may be some-
ber of diagnostic possibilities and thus what painful because the underlying epithelium is often thinned
the most likely diagnostic possibilities as or ulcerated. The diagnostic possibilities include pseudomembra-
compared to the other two white lesion nous candidiasis, chemical burn, and other ulcers such as aph-
subgroups. thae. The specific diagnostic findings for each condition usually
Tobacco
Figure 3. Differential diagnosis of white lesions of epithelial thickening.

DIFFERENTIAL DIAGNOSIS OF ORAL DIFFERENTIAL DIAGNOSIS OF ORAL
SOFT TISSUE LESIONS SOFT TISSUE LESIONS
Figure 5. Differential diagno-
sis of isolated red lesions of
the oral cavity.
rub
isolated red lesions is the identification of

those nonblanching lesions consistent
with idiopathic erythroplakia because
these lesions have a significant probabili-
ty of representing epithelial dysplasia or
Figure 4. Differential diagnosis of mucosal white lesions characterized by surface material or submucosal changes.
early squamous cell carcinoma.
allow a definitive clinical diagnosis within this group. Again, the ily distinguished subgroups within the FIGURE 6: THE MULTIPLE
listed secondary clinical findings typically allow a definitive diag- dark lesion category: AND DIFFUSE RED LESION
nosis within this small group of abnormalities. SUBGROUP
isolated red lesions; The diffuse red lesions represent
multiple or diffuse red lesions; inflammation of the affected region and
DARK MUCOSAL LESIONS isolated pigmented lesions; and definitive diagnosis relies on the area
Dark lesions of the oral mucosa are the result of increased vis- multiple or diffuse pigmented lesions. affected and associated findings as listed.
ibility of blood in connective tissue, accumulation of blood pig- For those conditions that produce multi-
ments, excessive melanin concentration, or dark foreign materials. ple sites of redness, blanching is a reliable
The nature of the materials causing the dark appearance is sug- FIGURE 5: THE ISOLATED finding for limiting the differential diagno-
gested by whether the color of the dark lesion is red, brown, or RED LESION SUBGROUP sis. The most significant conditions in the
black. Determining if the dark appearance is isolated or multifocal Isolated red lesions should be palpat- multiple red lesion subgroup, relative to
and documenting the location(s) affected are essential to the dif- ed to determine if they blanch. This indi- impact on patient care, are bleeding disor-
ferential diagnosis. All dark lesions of the oral mucosa should cates whether the visible blood causing ders and Kaposis sarcoma.
prompt an examination to determine if any similar lesions are the dark appearance is contained within
present on the skin as an indication of whether the process is vessels (blanching) or has escaped into the
localized to the oral cavity or is a more generalized condition. The tissue (nonblanching). The most signifi-
combination of color and distribution yields the following four eas- cant diagnostic issue in the evaluation of Figure 6. Differential diagnosis of multiple
and diffuse red lesions of the oral cavity.
Figure 5. Differential diagno-
sis of isolated red lesions of
the oral cavity.
rub
isolated red lesions is the identification of

those nonblanching lesions consistent
with idiopathic erythroplakia because
these lesions have a significant probabili-
ty of representing epithelial dysplasia or
Figure 4. Differential diagnosis of mucosal white lesions characterized by surface material or submucosal changes.
early squamous cell carcinoma.
allow a definitive clinical diagnosis within this group. Again, the ily distinguished subgroups within the FIGURE 6: THE MULTIPLE
listed secondary clinical findings typically allow a definitive diag- dark lesion category: AND DIFFUSE RED LESION
nosis within this small group of abnormalities. SUBGROUP
isolated red lesions; The diffuse red lesions represent
multiple or diffuse red lesions; inflammation of the affected region and
DARK MUCOSAL LESIONS isolated pigmented lesions; and definitive diagnosis relies on the area
Dark lesions of the oral mucosa are the result of increased vis- multiple or diffuse pigmented lesions. affected and associated findings as listed.
ibility of blood in connective tissue, accumulation of blood pig- For those conditions that produce multi-
ments, excessive melanin concentration, or dark foreign materials. ple sites of redness, blanching is a reliable
The nature of the materials causing the dark appearance is sug- FIGURE 5: THE ISOLATED finding for limiting the differential diagno-
gested by whether the color of the dark lesion is red, brown, or RED LESION SUBGROUP sis. The most significant conditions in the
black. Determining if the dark appearance is isolated or multifocal Isolated red lesions should be palpat- multiple red lesion subgroup, relative to
and documenting the location(s) affected are essential to the dif- ed to determine if they blanch. This indi- impact on patient care, are bleeding disor-
ferential diagnosis. All dark lesions of the oral mucosa should cates whether the visible blood causing ders and Kaposis sarcoma.
prompt an examination to determine if any similar lesions are the dark appearance is contained within
present on the skin as an indication of whether the process is vessels (blanching) or has escaped into the
localized to the oral cavity or is a more generalized condition. The tissue (nonblanching). The most signifi-
combination of color and distribution yields the following four eas- cant diagnostic issue in the evaluation of Figure 6. Differential diagnosis of multiple
and diffuse red lesions of the oral cavity.
SOFT TISSUE LESIONS
Figure 7.
Differential
diagnosis of
pigmented
lesions.
FIGURE 7: THE sibility of an underlying systemic Certain conditions that cause

condition. Whether the pigmented ulcers can be distinguished by
PIGMENTED LESION
lesions are congenital or developed whether the onset of lesions is
SUBGROUP later in life is helpful in the evalu- acute or chronic. Lesion distribu-
Isolated pigmented lesions are ation of the underlying cause. tion as isolated or multifocal is
either flat or raised. The flat pig- another contributory diagnostic
mented lesions are usually incon- feature in this group. The patient
sequential, while a raised pigment- LOSS OF MUCOSAL affected by oral ulcers should
ed lesion may represent early INTEGRITY always be questioned concerning
intraoral melanoma. The condi- This group of lesions includes additional ulcers on the skin or
tions that produce multiple or dif- ulcers and lesions that typically other mucosal surfaces, because
fuse pigmented lesions are signifi- precede ulceration in the oral cav- several oral ulcerative conditions
cant because most imply the pos- ity such as vesicles and bullae. also affect the skin, genital

mucosa, or conjunctiva. Because FIGURE 8: THE INITIAL onset with limited clinical course, problem. Also, some conditions pre- or bacterial infection, which will disease, erythema multiforme, is
ulcers are painful, the patient can and those diseases that produce sented under red diffuse lesions, be revealed by the identification of included in this group because of
DIFFERENTIAL
usually provide a dependable gradual onset with a chronic, pro- such as atrophic candidiasis and the cause. Isolated ulcers that are the similar clinical presentation to
description of the severity of pain, DIAGNOSIS OF LOSS OF tracted course. In addition, a vari- nutritional deficiencies, can also nonpainful may be a chancre of the systemic viral infections that
duration of the lesions, precipitat- MUCOSAL INTEGRITY ety of severe systemic conditions, produce oral ulcers, particularly in primary syphilis, which may be produce oral ulcers.
ing factors, and other helpful clin- The initial evaluation of ulcer- such as highly elevated fever and combination with abrasive injury. revealed by the history.
ical information in their differen- ative oral conditions is based on uremia, may cause oral ulcers. Acute onset of multiple oral
tial diagnosis. history of the onset and clinical Typically, the compromised ulcers in association with fever and FIGURE 10: RECURRING
course. The two major subgroups health of the patient is usually a FIGURE 9: ACUTE ORAL other systemic manifestations is ORAL ULCERS
are ulcerative conditions of acute clear indication of the source of the ULCERS characteristic of several systemic The diseases of the recurring
Most acute ulcers confronted viral infections. The diagnostic fea- oral ulcer subgroup are character-
by the dentist are isolated and are tures of these conditions are com- ized by episodes of acute ulcer for-
Figure 8. caused by either traumatic injury pared in Figure 9. One nonviral mation that heal and subsequent-
Initial differ-
ential diag-
nosis of loss Figure 9.
of mucosal Differential
integrity. diagnosis of acute
oral ulcers.
mucosa, or conjunctiva. Because FIGURE 8: THE INITIAL onset with limited clinical course, problem. Also, some conditions pre- or bacterial infection, which will disease, erythema multiforme, is
ulcers are painful, the patient can and those diseases that produce sented under red diffuse lesions, be revealed by the identification of included in this group because of
DIFFERENTIAL
usually provide a dependable gradual onset with a chronic, pro- such as atrophic candidiasis and the cause. Isolated ulcers that are the similar clinical presentation to
description of the severity of pain, DIAGNOSIS OF LOSS OF tracted course. In addition, a vari- nutritional deficiencies, can also nonpainful may be a chancre of the systemic viral infections that
duration of the lesions, precipitat- MUCOSAL INTEGRITY ety of severe systemic conditions, produce oral ulcers, particularly in primary syphilis, which may be produce oral ulcers.
ing factors, and other helpful clin- The initial evaluation of ulcer- such as highly elevated fever and combination with abrasive injury. revealed by the history.
ical information in their differen- ative oral conditions is based on uremia, may cause oral ulcers. Acute onset of multiple oral
tial diagnosis. history of the onset and clinical Typically, the compromised ulcers in association with fever and FIGURE 10: RECURRING
course. The two major subgroups health of the patient is usually a FIGURE 9: ACUTE ORAL other systemic manifestations is ORAL ULCERS
are ulcerative conditions of acute clear indication of the source of the ULCERS characteristic of several systemic The diseases of the recurring
Most acute ulcers confronted viral infections. The diagnostic fea- oral ulcer subgroup are character-
by the dentist are isolated and are tures of these conditions are com- ized by episodes of acute ulcer for-
Figure 8. caused by either traumatic injury pared in Figure 9. One nonviral mation that heal and subsequent-
Initial differ-
ential diag-
nosis of loss Figure 9.
of mucosal Differential
integrity. diagnosis of acute
oral ulcers.
Figure 10. Figure 11. Differential
Differential diagnosis of ulcers
diagnosis of caused by autoim-
recurring mune diseases.
oral ulcers.
10 days
12 weeks duration
Major Aphthous Stomatitis,

Behcets Syndrome, or
Reiters Syndrome
ly recur. Multiple vesicle formation episode unless the patient is surfaces in contrast to the kera- the oral cavity is a prolonged FIGURE 12: tive ulcers are not limited to the
prior to the ulceration is the pat- immunocompromised. It is recur- tinized sites of herpetic ulcers. course of ulcers that may improve superficial surface but appear to
ORAL ULCERS
tern shown by the most common rent only in the sense that it is in severity or change in location, affect the subjacent connective
viral condition in this subgroup, preceded by an episode of varicel- but complete resolution is unusu- CHARACTERIZED BY tissue. This is indicated by ulcers
secondary herpes simplex infec- la (chicken pox). Aphthous stom- FIGURE 11: ORAL ULCERS al. The four principal diseases of TISSUE DESTRUCTION that cause cavitation relative to
tion. Herpes zoster is included in atitis is the most common condi- this subgroup share more similar- The diseases of the destruc- typical tissue contours and firm-
this subgroup because of the sim- tion of this group and is distin- CAUSED BY AUTOIMMUNE ities than distinguishing charac- tive oral ulcer subgroup produce ness to palpation of the deep tis-
ilarity to secondary herpes sim- guished from secondary herpes CONDITIONS teristics, which typically means chronic, progressive lesions. In sues. Such lesions can be caused
plex lesions, although herpes simplex outbreaks by the location The clinical pattern for that biopsy results are necessary contrast to the other subgroups of in rare instances by immune defi-
zoster typically produces a single of the lesions on nonkeratinized autoimmune diseases that affect to reach a definitive diagnosis. oral ulcers, however, the destruc- ciency diseases such as AIDS and
Figure 10. Figure 11. Differential
Differential diagnosis of ulcers
diagnosis of caused by autoim-
recurring mune diseases.
oral ulcers.
10 days
12 weeks duration
Major Aphthous Stomatitis,

Behcets Syndrome, or
Reiters Syndrome
ly recur. Multiple vesicle formation episode unless the patient is surfaces in contrast to the kera- the oral cavity is a prolonged FIGURE 12: tive ulcers are not limited to the
prior to the ulceration is the pat- immunocompromised. It is recur- tinized sites of herpetic ulcers. course of ulcers that may improve superficial surface but appear to
ORAL ULCERS
tern shown by the most common rent only in the sense that it is in severity or change in location, affect the subjacent connective
viral condition in this subgroup, preceded by an episode of varicel- but complete resolution is unusu- CHARACTERIZED BY tissue. This is indicated by ulcers
secondary herpes simplex infec- la (chicken pox). Aphthous stom- FIGURE 11: ORAL ULCERS al. The four principal diseases of TISSUE DESTRUCTION that cause cavitation relative to
tion. Herpes zoster is included in atitis is the most common condi- this subgroup share more similar- The diseases of the destruc- typical tissue contours and firm-
this subgroup because of the sim- tion of this group and is distin- CAUSED BY AUTOIMMUNE ities than distinguishing charac- tive oral ulcer subgroup produce ness to palpation of the deep tis-
ilarity to secondary herpes sim- guished from secondary herpes CONDITIONS teristics, which typically means chronic, progressive lesions. In sues. Such lesions can be caused
plex lesions, although herpes simplex outbreaks by the location The clinical pattern for that biopsy results are necessary contrast to the other subgroups of in rare instances by immune defi-
zoster typically produces a single of the lesions on nonkeratinized autoimmune diseases that affect to reach a definitive diagnosis. oral ulcers, however, the destruc- ciency diseases such as AIDS and
Figure 12.
Differential diag-
nosis of oral
ulcers character-
ized by tissue
destruction.
Figure 13. Initial differential diagnosis of intraoral soft tissue enlargements.
FIGURE 14: PAPILLARY

ENLARGEMENTS OF SURFACE
EPITHELIUM
Enlargements of this subgroup are all
caused by a subtype of the human papil-
loma virus and are all similar to the most
granulomatous infections caused are solitary, but careful examina- lesions includes the greatest common example, the squamous papillo-
by fungi other than candidal tion should determine if addition- number of diagnostic possibilities ma. These lesions are firm and nontender
species. The most ominous cause al enlargements are present. relative to the other three lesion to palpation, pale in color and exhibit a
of cavitating ulcers, however, is Alteration of the surface mucosa groups. However, the most com- rough, papillary surface texture. An iso-
malignant neoplastic disease and should be noted because this may mon oral enlargements are rela- lated oral lesion with these features is a
the most common oral example is indicate the composition or possi- tively characteristic. The combi- squamous papilloma, while a similar iso-
squamous cell carcinoma. ble cause of the enlargement. The nation of surface texture, sensi- lated enlargement on the lip (dry surface)
precise location of the enlarge- tivity to pressure, presence of an is verruca vulgaris or wart. Multiple
ment should be determined apparent cause and clinical papillomatous lesions of the mucosa are
SOFT TISSUE because this can suggest the ori- course are the most helpful fea- typical of condyloma acuminatum or
ENLARGEMENTS gin of the lesion. tures in the initial categorization venereal warts.
The palpation characteristics of soft tissue enlargements of the
of soft tissue enlargements pro- oral cavity. Additional findings
vide an indication of the composi- FIGURE 13: THE INITIAL that may aid this decision are list-
tion of the abnormality, as well as ed in Figure 13.
DIFFERENTIAL
eliciting whether or not the
enlargement is inflammatory as DIAGNOSIS OF ORAL
indicated by tenderness to pres- ENLARGEMENTS Figure 14. Differential diagnosis of oral pap-
sure. Most intraoral enlargements The oral enlargement group of illary enlargements of surface epithelium.
Figure 12.
Differential diag-
nosis of oral
ulcers character-
ized by tissue
destruction.
Figure 13. Initial differential diagnosis of intraoral soft tissue enlargements.
FIGURE 14: PAPILLARY

ENLARGEMENTS OF SURFACE
EPITHELIUM
Enlargements of this subgroup are all
caused by a subtype of the human papil-
loma virus and are all similar to the most
granulomatous infections caused are solitary, but careful examina- lesions includes the greatest common example, the squamous papillo-
by fungi other than candidal tion should determine if addition- number of diagnostic possibilities ma. These lesions are firm and nontender
species. The most ominous cause al enlargements are present. relative to the other three lesion to palpation, pale in color and exhibit a
of cavitating ulcers, however, is Alteration of the surface mucosa groups. However, the most com- rough, papillary surface texture. An iso-
malignant neoplastic disease and should be noted because this may mon oral enlargements are rela- lated oral lesion with these features is a
the most common oral example is indicate the composition or possi- tively characteristic. The combi- squamous papilloma, while a similar iso-
squamous cell carcinoma. ble cause of the enlargement. The nation of surface texture, sensi- lated enlargement on the lip (dry surface)
precise location of the enlarge- tivity to pressure, presence of an is verruca vulgaris or wart. Multiple
ment should be determined apparent cause and clinical papillomatous lesions of the mucosa are
SOFT TISSUE because this can suggest the ori- course are the most helpful fea- typical of condyloma acuminatum or
ENLARGEMENTS gin of the lesion. tures in the initial categorization venereal warts.
The palpation characteristics of soft tissue enlargements of the
of soft tissue enlargements pro- oral cavity. Additional findings
vide an indication of the composi- FIGURE 13: THE INITIAL that may aid this decision are list-
tion of the abnormality, as well as ed in Figure 13.
DIFFERENTIAL
eliciting whether or not the
enlargement is inflammatory as DIAGNOSIS OF ORAL
indicated by tenderness to pres- ENLARGEMENTS Figure 14. Differential diagnosis of oral pap-
sure. Most intraoral enlargements The oral enlargement group of illary enlargements of surface epithelium.
Figure 15. Figure 16.
Differential diagnosis Differential
of acute diagnosis of
inflammatory soft tissue
soft tissue reactive
enlargements. hyperplasias
of the oral
cavity.
Surface vascularity
FIGURE 15: ACUTE (mucocele) or ranula is the most plasias related to denture irrita-
likely diagnostic possibility. tion are characteristic and seldom
INFLAMMATORY
Angioedema is a non-infectious a diagnostic challenge. Similarly,
ENLARGEMENTS reaction to a variety of stimuli and generalized gingival hyperplasia
Tenderness to palpation, ery- its diagnosis is suggested by the will be evident and prompts the
thema and an acute course sug- location and recurring pattern. clinician to identify the causative
gest that an enlargement should factor. An isolated gingival
be evaluated in this subgroup of enlargement will be a pyogenic
diseases. The infectious examples FIGURE 16: REACTIVE granuloma, peripheral fibroma, or
such as pericoronitis and cellulitis peripheral giant cell granuloma. FIGURE 17: BENIGN abnormal tissue will only be iden- ly indicated by the location. Some
HYPERPLASIAS OF SOFT tified by palpation of deep struc- limitation of the solid lesions can
are very common and will not The distinction among these three SUBMUCOSAL CYSTS
present a diagnostic challenge in TISSUES possibilities can usually be made
tures. Nearly all of these entities be based on whether the tumor is
AND NEOPLASMS are uncommon. The initial distinc- firm or slightly compressible, how-
most situations once the probable The enlargements of the reac- on the basis of color and surface This large subgroup of tion is based on palpation as ever, definitive diagnosis in most
cause of the infection is identified. tive hyperplasia subgroup typical- appearance. The most common enlargements is characterized by either cystic (fluid-filled) com- cases relies on biopsy results.
The combination of fluctuation in ly are moderate to slow in their lesion in this group, the traumatic nodular or dome-shaped contours pressibility or firmness of a solid Tumors of minor salivary gland
size, location and history of injury growth, are located in typical sites fibroma, Is pale, firm and located with normal appearance of the tissue mass. The diagnosis of origin can develop anywhere in
is a strong indication that a and are associated with chronic in an area subjected to pinching superficial surface and slow pro- which type of cyst a compressible the oral cavity except the gingiva
mucous retention phenomenon irritation of some type. The hyper- injury. gression. In some instances the enlargement represents is typical- and anterior hard palate. It is
Figure 15. Figure 16.
Differential diagnosis Differential
of acute diagnosis of
inflammatory soft tissue
soft tissue reactive
enlargements. hyperplasias
of the oral
cavity.
Surface vascularity
FIGURE 15: ACUTE (mucocele) or ranula is the most plasias related to denture irrita-
likely diagnostic possibility. tion are characteristic and seldom
INFLAMMATORY
Angioedema is a non-infectious a diagnostic challenge. Similarly,
ENLARGEMENTS reaction to a variety of stimuli and generalized gingival hyperplasia
Tenderness to palpation, ery- its diagnosis is suggested by the will be evident and prompts the
thema and an acute course sug- location and recurring pattern. clinician to identify the causative
gest that an enlargement should factor. An isolated gingival
be evaluated in this subgroup of enlargement will be a pyogenic
diseases. The infectious examples FIGURE 16: REACTIVE granuloma, peripheral fibroma, or
such as pericoronitis and cellulitis peripheral giant cell granuloma. FIGURE 17: BENIGN abnormal tissue will only be iden- ly indicated by the location. Some
HYPERPLASIAS OF SOFT tified by palpation of deep struc- limitation of the solid lesions can
are very common and will not The distinction among these three SUBMUCOSAL CYSTS
present a diagnostic challenge in TISSUES possibilities can usually be made
tures. Nearly all of these entities be based on whether the tumor is
AND NEOPLASMS are uncommon. The initial distinc- firm or slightly compressible, how-
most situations once the probable The enlargements of the reac- on the basis of color and surface This large subgroup of tion is based on palpation as ever, definitive diagnosis in most
cause of the infection is identified. tive hyperplasia subgroup typical- appearance. The most common enlargements is characterized by either cystic (fluid-filled) com- cases relies on biopsy results.
The combination of fluctuation in ly are moderate to slow in their lesion in this group, the traumatic nodular or dome-shaped contours pressibility or firmness of a solid Tumors of minor salivary gland
size, location and history of injury growth, are located in typical sites fibroma, Is pale, firm and located with normal appearance of the tissue mass. The diagnosis of origin can develop anywhere in
is a strong indication that a and are associated with chronic in an area subjected to pinching superficial surface and slow pro- which type of cyst a compressible the oral cavity except the gingiva
mucous retention phenomenon irritation of some type. The hyper- injury. gression. In some instances the enlargement represents is typical- and anterior hard palate. It is
Figure 17. Figure 18. Differential diagnosis of
Differential malignant neoplasms of the oral and
diagnosis of paraoral regions.
benign sub-
mucosal
cysts and
neoplasms.
integrity, and soft tissue enlarge-
ments. Various secondary clinical
features are particularly helpful
and dependable in the differential
diagnosis of each lesion category.
The differential diagnostic strategy
illustrated in this article allows
systematic elimination of many
diseases from the list of diagnosis
options while focusing the clini-
cians consideration on likely diag-
nostic possibilities.
The accompanying CD-ROM
contains a computer program to
aid in the differential diagnosis of
soft tissue lesions of the oral cavi-
ty. The presentation of the oral
conditions is organized based on
Dental Lamina Cyst
the algorithmic decision scheme
Eruption Cyst
Gingival Cyst for the differential diagnosis of oral
Canalicular Adenoma lesions that is represented by the
Basal Cell Adenoma figures in this article. The presen-
Pleomorphic Adenoma tation of each condition in the pro-
Others gram includes several visual
examples as well as short discus-
sions of the pathology, diagnostic
features, differential diagnosis,
and management of the condition.
ACKNOWLEDGEMENTS
This project has been gener-
ously supported by the Texas
important to note that some ness. More than 90 percent of CONCLUSION Cancer Council, the Dental References correlations, ed 3. Philadel-
malignant salivary tumors such intraoral malignancies will be Differential diagnosis provides phia: Saunders, 1999.
as the adenoid cystic carcinoma squamous cell carcinoma. This is Oncology Education Program, and 5. Wood NK, Goaz PW. Differen-
the diagnostic approach needed to the Texas Dental Foundation. We 1. Coleman GC, Nelson JF.
often present very benign features particularly likely if the patient compare the diagnostic findings tial diagnosis of oral lesions,
are particularly grateful to Mr. Principles of oral diagnosis. St
early in the course of the lesion. uses tobacco and alcohol and is exhibited by the patient with those ed 5. St Louis: Mosby Year
Scot Frederick of Media Resources Louis: Mosby Year Book, 1993.
more than 40 years of age. A vari- of several diseases capable of pro- Book, 1997.
at Baylor College of Dentistry. He 2. Bhaskar SN. Synopsis of oral
ety of uncommon oral malignan- ducing the clinical findings shown 6. Flaitz CM. Differential diagno-
invested hundreds of hours in the pathology, ed 7. St Louis: CV
FIGURE 18: SOFT cies must also be considered as by the patient. Classification of sis of oral mucosal lesions in
design and arrangement of mate- Mosby, 1986.
TISSUE MALIGNANCIES remote possibilities when the gen- soft tissue lesions is based on the rials in the computer program. 3. Neville BW, Damm DD, Allen,
children and adolescents. Adv
Malignant tumors of the oral eral features of malignant disease tissue affected and the primary Dermatol 2000; 16:39-78.
CM, Bouquot JE. Oral & max-
cavity are suggested by relatively are present. manifestation of the abnormality. illofacial pathology. Philadel- Corresponding author: Dr. Gary
rapid progression, alteration of Lesion categories are white phia: Saunders, 1995. Coleman, Department of Diagnostic
the surface mucosa, induration to mucosal lesions, dark mucosal 4. Regezi JA, Sciubba JJ. Oral Sciences, Baylor College of Dentistry, P.O.
palpation, and little or no tender- discolorations, loss of mucosal pathology: clinical-pathologic Box 660677, Dallas, TX 75266-0677.
Figure 17. Figure 18. Differential diagnosis of
Differential malignant neoplasms of the oral and
diagnosis of paraoral regions.
benign sub-
mucosal
cysts and
neoplasms.
integrity, and soft tissue enlarge-
ments. Various secondary clinical
features are particularly helpful
and dependable in the differential
diagnosis of each lesion category.
The differential diagnostic strategy
illustrated in this article allows
systematic elimination of many
diseases from the list of diagnosis
options while focusing the clini-
cians consideration on likely diag-
nostic possibilities.
The accompanying CD-ROM
contains a computer program to
aid in the differential diagnosis of
soft tissue lesions of the oral cavi-
ty. The presentation of the oral
conditions is organized based on
Dental Lamina Cyst
the algorithmic decision scheme
Eruption Cyst
Gingival Cyst for the differential diagnosis of oral
Canalicular Adenoma lesions that is represented by the
Basal Cell Adenoma figures in this article. The presen-
Pleomorphic Adenoma tation of each condition in the pro-
Others gram includes several visual
examples as well as short discus-
sions of the pathology, diagnostic
features, differential diagnosis,
and management of the condition.
ACKNOWLEDGEMENTS
This project has been gener-
ously supported by the Texas
important to note that some ness. More than 90 percent of CONCLUSION Cancer Council, the Dental References correlations, ed 3. Philadel-
malignant salivary tumors such intraoral malignancies will be Differential diagnosis provides phia: Saunders, 1999.
as the adenoid cystic carcinoma squamous cell carcinoma. This is Oncology Education Program, and 5. Wood NK, Goaz PW. Differen-
the diagnostic approach needed to the Texas Dental Foundation. We 1. Coleman GC, Nelson JF.
often present very benign features particularly likely if the patient compare the diagnostic findings tial diagnosis of oral lesions,
are particularly grateful to Mr. Principles of oral diagnosis. St
early in the course of the lesion. uses tobacco and alcohol and is exhibited by the patient with those ed 5. St Louis: Mosby Year
Scot Frederick of Media Resources Louis: Mosby Year Book, 1993.
more than 40 years of age. A vari- of several diseases capable of pro- Book, 1997.
at Baylor College of Dentistry. He 2. Bhaskar SN. Synopsis of oral
ety of uncommon oral malignan- ducing the clinical findings shown 6. Flaitz CM. Differential diagno-
invested hundreds of hours in the pathology, ed 7. St Louis: CV
FIGURE 18: SOFT cies must also be considered as by the patient. Classification of sis of oral mucosal lesions in
design and arrangement of mate- Mosby, 1986.
TISSUE MALIGNANCIES remote possibilities when the gen- soft tissue lesions is based on the rials in the computer program. 3. Neville BW, Damm DD, Allen,
children and adolescents. Adv
Malignant tumors of the oral eral features of malignant disease tissue affected and the primary Dermatol 2000; 16:39-78.
CM, Bouquot JE. Oral & max-
cavity are suggested by relatively are present. manifestation of the abnormality. illofacial pathology. Philadel- Corresponding author: Dr. Gary
rapid progression, alteration of Lesion categories are white phia: Saunders, 1995. Coleman, Department of Diagnostic
the surface mucosa, induration to mucosal lesions, dark mucosal 4. Regezi JA, Sciubba JJ. Oral Sciences, Baylor College of Dentistry, P.O.
palpation, and little or no tender- discolorations, loss of mucosal pathology: clinical-pathologic Box 660677, Dallas, TX 75266-0677.

Coleman-2002 - Different Diagnosis of Oral Lesions - Rev

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decision flow charts for the assessment of typical disease features may be inconsistent with the patients

Differential Diagnosis of Oral oral soft tissue lesions is based on several

Soft Tissue Lesions ed (26).

The capacity of contemporary personal computers to manage

Soft Tissue Lesions ed (26).

The capacity of contemporary personal computers to manage

Texas Dental Journal June 2002 / 486

Figure 3. Differential diagnosis of white lesions of epithelial thickening.

Texas Dental Journal June 2002 / 488

isolated red lesions is the identification of

isolated red lesions is the identification of

FIGURE 7: THE sibility of an underlying systemic Certain conditions that cause

Texas Dental Journal June 2002 / 492

Major Aphthous Stomatitis,

Major Aphthous Stomatitis,

Figure 13. Initial differential diagnosis of intraoral soft tissue enlargements.

FIGURE 14: PAPILLARY

Figure 13. Initial differential diagnosis of intraoral soft tissue enlargements.

FIGURE 14: PAPILLARY

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