GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on making sense of common but often tricky symptoms
Mouth lumps and marks can be unfamiliar – partly because it is rarely a GP's area of expertise, and partly because many mouth problems are seen by a dentist first. But a working knowledge of the area is useful.
• Apical tooth abscess (gumboil)
• Aphthous ulceration
• Fordyce spots (tiny white or yellow spots, on mucosa opposite molars and vermilion border of lips – they are sebaceous glands)
• Oral candida
• Mucocoele – solitary cystic nodule inside lip.
• Lichen planus
• Trauma – bitten cheek
• Torus – benign maxillary or mandibular outgrowth of bone (very common but usually asymptomatic so not commonly seen)
• Premalignant coloured areas: erythroplakia (red), leukoplakia (white), speckled leukoplakia (red and white), or verrucous leukoplakia
• Geographical and hairy tongue
• Tonsillar concretions
• Other forms of oral ulceration.
• Malignancy – SCC or melanoma
• Pachyderma oralis (from irritants)
• Heavy-metal poisoning due to lead, bismuth or iron – a dark line below the gingival margin
• Cancrum oris
• Sublingual dermoid cyst
• Sublingual gland tumour
• Pigmentation due to oral contraceptive pill – black or brown areas anywhere in the mouth
• Addison's disease – bluish hue opposite molars
• Peutz-Jegher spots – brown spots on the lips
• Telangiectasia – may be a sign of Osler-Weber-Rendu syndrome
• Stevens-Johnson syndrome
• FBC, ESR, CRP and HIV are useful if immune deficiency (such as as a background to candida infection) is suspected; FBC and ESR or CRP may be helpful in suspected malignancy too.
• Ferritin, B12 and folate deficiency is sometimes associated with oral aphthous ulceration – worth checking if ulcers are recurrent or chronic.
• Fasting glucose to investigate possible diabetes if candida is otherwise unexplained.
• Mouth swab to confirm candida, though a treatment trial is often the practical first step.
• Biopsy of suspicious lesions – this will be performed in secondary care.
• Always refer a patient with permanent red or white buccal mucosal patches. Biopsy is indicated.
• If an ulcer fails to heal within a few weeks, especially if it is painless, refer for a specialist opinion as a suspected malignancy.
• Do not fail to examine regional lymph nodes.
Enlarged nodes would be a significant finding, especially if they are non-tender and persistent.
• Recurrent oral aphthous ulceration is a feature of a few systemic diseases – such as coeliac disease, Behcet's disease and AIDS.
• It is tempting to give antibiotics for a dental abscess, but the old surgical maxim ‘if there's pus about, let it out' still holds true. Antibiotics may help reduce pain but could also delay definitive treatment in those trying to avoid the dentist. Offering a referral letter to the dentist may help get urgent access to a dentist.
• Always examine lumps by palpation from inside as well as outside the mouth. Wash latex gloves before the examination. Glove powder tastes foul!Mouth examination Mouth examination Quick sorter mouth lumps