Lesion, Bump, or Ulcer in the Mouth
One of the most common reasons for a patient to see an ENT doctor is in regards to a bump or an ulcer in the mouth... the main underlying concern being "Is it cancer?"
Although this webpage is not meant to be exhaustive in describing every single mass or lesion of the mouth under the sun, it does describe 90% of the time what most people have. Of course, this information is not meant to replace a physician visit and exam and you should see your doctor to ensure diagnostic accuracy and to receive proper treatment
One can classify nearly all oral masses or lesions under 4 distinct categories: Ulcers, Painless Bumps, Papilloma, Patches (ie leukoplakia), Cancer, and Other Variations. We'll go through each category separately.
There are two main flavors of ulcers... all benign and nothing to do with cancer.
The most common are aphthous ulcers which are relatively flat but extremely painful ulcers. There may or may not be a red rim around the white center. Most occur after trauma whether biting the area, hitting the area with a toothbrush, or getting it abraded from dental braces or dentures.
The second flavor of ulcer is due to the herpes virus. Generally these seemingly occur out of the blue without any specific trauma and initially starts out with many tiny pinpoint ulcers lined by red that may or may not join to create one big ulcer. These are even more painful than apthous ulcers... to the point that drooling occurs given the inability to even swallow spit due to the pain.
Treatment for both is basically the same. One can try over-the-counter orajel or saltwater rinses, but prescription medications help resolve these lesions more quickly. The main goto medication that makes the biggest difference is steroids, typically in liquid form that is rinsed and spit out but could also be applied as a gel (ie, fluocinolone 0.05% gel). Steroid solutions can also be soaked into a cotton ball and placed over the ulcer for longer duration of contact. Oftentimes the steroid is made in combination with lidocaine, nystatin, and/or diphenhydramine; such concoctions are often called "Miracle Mouthwash" or "Magic Mouthwash" or some other quirky name. For herpetic ulcers, steroids may be given to be swallowed as well.
Laser or treatment with silver nitrate can also be performed which helps more immediately with pain and speeds healing.
If aphthous ulcers and/or herpetic ulcers occur with frequent regularity (every month or two), there are some predisposing conditions to check out. Such conditions include vitamin/mineral deficiency (zinc, magnesium, iron, vitamin B12, folate, etc), immunodeficiency (low IgG, HIV, leukemia), hepatitis, Crohn's disease, allergic reaction, etc. Biopsy may also need to be considered... the trick being the ulcer needs to be present at time of biopsy before it disappears. Otherwise, one should try to minimize oral trauma as much as possible including avoiding abrasive toothpaste (ie, Rembrandt, Pronamel, Biotene) as well as avoid toothpaste containing sodium lauryl sulfate and fluoride (ie Tom's toothpaste, Closys). The toothbrush itself should be flexible with soft bristles.
In the next category of "painless bumps," we can further divide these into 3 different types... all benign without any cancer potential. As the category title states, there is no pain associated with these bumps.
The most common bump seen in the ENT clinic is the mucocele (show to the right). These are most commonly found on the lower lip just underneath the mucosal lining are analogous to a skin blister. They are soft, fluctuate in size, and may range in color from pink to purple. Mucoceles can develop spontaneously but can also develop after biting the area. Treatment is pretty straightforward. It needs to be completely removed surgically. Less invasive methods can be tried with needle aspiration or making a large hole for it to drain out. Unfortunately, the vast majority of the time, it comes right back. Complete surgical removal offers the best chance of "cure."
The next common painless bump seen is a fibroma of some kind shown to the left. These bumps almost always occur after biting the area. They are semi-firm or rubbery to touch with smooth countours are range in color from whitish-grey to pink. The fibroma actually involves the lining of the mouth (it's not under the mucus lining like a mucocele). Treatment is to completely surgically excise it and is curative.
The final flavor of painless bump is a pyogenic granuloma (shown to the right). These bumps are fleshy in apearance with a smooth but irregular countoured surface. It almost can be described as a pink snail or worm popping up. The color is almost always some shade of red, but can also be the same color as the surronding mucosal lining.
Pyogenic granuloma, as with fibroma, usually occurs after some type of trauma to the area and is treated the same way with surgical excision. However, topical steroid application or even steroid injection to the area can be helpful and be tried prior to surgery.
A papilloma bump can be considered a "painless bump," but has been given its own special separate category due to one significant difference from the others... it DOES have a small but significant cancer potential. However, please note that a papilloma is NOT cancer just like actinic keratosis of the skin (sun-damaged skin) is not considered cancer. However, just like actinic keratosis of the skin can be considered "pre-cancer", papilloma should be considered in a similar way.
Papilloma is caused by the human papilloma virus, otherwise known as HPV. This is the same virus that is known to cause cervical cancer and the reason why women undergo pap smears. Fortunately, not all HPV strains have a high risk for causing cancer. At this time, there are over 150 different strains of HPV. Only 15 high-risk HPV types have been identified, including major culprits HPV types 16 and 18, which together cause about 70 percent of cervical cancers and is increasingly suspected of causing oral cancer as well. In fact, this virus has now surpassed smoking as the leading cause of oral cancer in people under 50 years of age. This elevated trend is felt to be due to oral sex becoming a more accepted mainstream practice.
In any case, papilloma of the mouth is a painless bump that can occur anywhere in the mouth. It can be found on the uvula, tonsil, palate, cheek, lip, etc. It has an irregular pitted surface like a strawberry or rasberry. It is typically pink to red in color though white can also occur. Treatment is surgical excision and is "curative." Curative is in quotes because although the mass is gone, it can recur in the same place or elsewhere given the virus itself is not "cured" and can trigger the papilloma growth again. The papilloma should be typed for HPV to determine if a high-risk HPV type is present. If so, the oral cavity should be examined regularly for recurrence and any suspicous lesions biopsied to minimize risk of oral cancer development. Our office also offers the Oral HPV Spit Test to check for any microscopic evidence for HPV infection in the mouth or throat that may lead to recurent papilloma formation.
Recent studies suggest that the quadrivalent HPV vaccine can eradicate this problem in patients who suffer from recurrent oral papillomas, regardless of the HPV type.
Leukoplakia are thick white patches that appear anywhere in the mouth, though most commonly involve mucosa of the cheek, lips, or under the tongue. They are typically benign, but in about 5% of cases, may actually represent pre-cancerous change.
Such lesions can often resolve with quitting smoking, chewing tobacco, and/or alcohol along with prescription mouthwashes containing steroids and other anti-inflammatory ingredients. If dentures are present, they may need to be readjusted if rubbing in the area where leukoplakia is present. However, if the leukoplakia does not resolve with these interventions, a biopsy is recommended to evaluate for possible pre-cancerous changes (dysplasia) or at worst, actual cancerous presence.
Oral Lichen Planus
Whereas leukoplakia are thick white patches that appear anywhere in the mouth, lichen planus appears more lace-like though some forms can approach appearing like a patch or even an ulcer. About 5% of the population is affected with most being women over 50 years.
The cause of lichen planus is controversial with arguments made for it being caused by some type of immune dysregulation, autoimmune disorder, or an unusual allergic reaction, the specific antigen being as of yet unknown. Regardless, the only way to diagnose lichen planus is by biopsy. It is also controversial whether lichen planus can turn into cancer at some point; repeat biopsies may be required if any unusual change in appearance happens. Treatment is mainly symptomatic utilizing steroids, but cure is typically not achievable. Rather, the goal of treatment is management of symptoms.
Given the difficulty with managing lichen planus, I typically refer such patients once diagnosed to Dr. Grant Anhalt at Johns Hopkins who is an expert in this condition. Although he is a dermatologist by training, he does treat oral mucosal lichen planus.
Opposed to leukoplakia which are white patches, erythroplakia are red patches that can appear anywhere in the mouth. Just as with leukoplakia, erythroplakia most commonly appears on the mucosa of the cheeks, lips, and under the tongue.
Unlike leukoplakia, however, erythroplakia has a high risk (~75%) for being pre-cancerous or cancerous.
Such lesions must be biopsied.
Fortunately, these lesions are quite rare compared to leukoplakia which is far more common.
In this most concerning category of an oral bump, it is the dreaded cancer which is what most people are worried about. Unfortunately, cancer does not have a characteristic appearance. It can be smooth (lymphoma of the tonsil), ulcerated, fungating, raised, irregular, etc. There is no"typical" appearance or color. However, there are some rules of thumb where the concern for cancer increases, especially if the bump/lesion has more than a few of the following characteristics:
- It hurts
- Ulcer AND raised or depressed appearance (unlike aphthous ulcer which is flat)
- Consistently getting larger over time
- Lip or tongue paralysis
- Hard to open the mouth completely (trismus)
- The bump/lesion is very hard/firm to touch
- Bad smell present
- You smoke/drink
- You practice oral sex
- One tonsil is larger than the other
If there's a concern, see your local ENT doctor!
There's a couple things that may occur if cancer concern is present, not in any particular order:
- A small biopsy
- CT scan
- Laryngoscopy to determine extent
- Sedated examination of the throat with more biopsies (aka Pan-Endoscopy)
- Chest X-ray
- Blood test (if HPV+)
What exactly occurs depends on the location, size, and presence of neck masses. Treatment depends on what type of cancer it is. But Squamous Cell Carcinoma (SCC) is by far the most common cancer of the oral cavity by a long-shot. Lymphoma is perhaps the next most common followed by the rest which are rare: acinic cell caricinoma, adenocarcinoma, mucoepidermoid carcinoma, verrucous cell carcinoma, etc.
If cancer is present, there are some characteristics that make it more serious or not.
Early stage (good) cancer is charaterized as size being 2cm or smaller, no neck masses, and well differentiated in appearance under the microscope.
Late stage cancer (bad) cancer is characterized as being 4cm or larger, presence of neck masses, and undifferentiated in appearance under the microscope.
Obvious middle stage is something in between these two.
More Oral Lesions
Of course, not every bump or lesion in the mouth is technically abnormal, but rather considered a variation of normal which may cause more visual concern than anything else. Of course, they may also cause annoying symptoms which may lead a patient to get treatment.
Tongue Stone - A small concretion of gritty particles that smell and taste terrible produced by the tonsil itself within pits.
Upper Lip Tie - A small flap tethers the upper lip to the gum preventing the upper lip from flaring out.
Linea Alba - A linear ridge-like white line that appears on the inside cheek mucosa due to friction between the teeth and the soft layer of the cheeks.
Geographic Tongue - Has been compared similarly to psoriasis, except affecting the tongue.
(Image from Wikipedia)
Torus Mandibularis - Analagous to a bunion on the foot, but on the jaw.
|Torus Palatinus - Analogous to a bunion on the foot, but on the roof of mouth.|
Black Hairy Tongue - For more information, click here.
(Image from Wikipedia)
|Circumvallate Papillae - Normal large taste buds in the very back of the tongue.|
|Large Adenoids - When adenodis which originate in the very back of the nose are low-lying AND becomes large, they can start to pooch down into the mouth where they can be seen appearing behind the palate.|
|Nasal Polyp - Nasal polyps actually originate in the nasal cavity and one would only be able to see it in the mouth as shown in the picture above if they get truly enormous in size... to the point that a patient would most likely also be complaining of complete nasal obstruction as well. Compared to adenoids, the surface of the mass is smooth and somewhat translucent. Treatment is typically sinus surgery though medications can be tried first.|
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