Mouth Lumps and Marks
Differential Diagnosis
Common Diagnoses
- 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 Infection
- Mucocoele (solitary Cystic Nodule Inside Lip)
Occasional Diagnoses
- Lichen Planus
- Trauma: Bitten Cheek
- Ranula
- 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 (See ‘Mouth Ulcers’ Section)
Rare Diagnoses
- Malignancy: SCC or Melanoma
- Pachyderma Oralis (from Irritants)
- Heavy Metal Poisoning (Lead, Bismuth, 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–Jeghers Spots: Brown Spots on the Lips
- Telangiectasia: May be a Sign of Osler–Weber–Rendu Syndrome
- Stevens–Johnson Syndrome
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Abscess | Ulcer | Fordyce Spots | Candida | Mucocoele | |
|---|---|---|---|---|---|
| Lesion Tender | Yes | Yes | No | Possible | No |
| Flat Lesion | No | Yes | No | Yes | No |
| Multiple Lesions | No | Possible | Yes | Yes | No |
| White Lesions | No | Yes | Possible | Yes | No |
| Lesion Scrapes Off | No | No | No | Yes | No |
Possible Investigations
Likely:None.
Possible:FBC, ESR, CRP, ferritin, B12 and folate, fasting glucose or HbA1c, swab of lesion, HIV test.
Small Print:Biopsy (performed at hospital).
- FBC, ESR, CRP and HIV are useful if immune deficiency (e.g. 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 are sometimes associated with oral aphthous ulceration – worth checking these in cases of recurrent or chronic ulceration (and see other possible investigations in ‘Mouth ulcers’ section).
- Fasting glucose or HbA1c to investigate possible diabetes if candidal infection otherwise unexplained.
- Mouth swab to confirm candidal infection, though a diagnostic trial of treatment is often the practical first step.
- Biopsy: Of suspicious lesions – this is inevitably performed in secondary care.
Top Tips
- Recurrent oral aphthous ulceration is a feature of a few systemic diseases (e.g. coeliac disease, Crohn’s disease, Behçet’s disease and AIDS) so be prepared to re-evaluate the history and widen the net of information gathering in repeat presentations.
- 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 and surrounding infection but are only a temporary measure and may delay definitive treatment in those trying to avoid seeing a dentist, and increase the risk of complications. Encourage patients to see a dentist in the first place – offering a referral letter can be helpful and may help to overcome any possible barrier to urgent access to a dentist at the dental reception desk.
- Always examine lumps by palpation from inside as well as outside the mouth. Wash latex gloves before the examination. Glove powder tastes foul!
Red Flags
- Always refer the 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.