• ‘Free’ sebaceous glands (i.e. not associated with hair follicles) evident in as many as 75% of adults.

• Multiple 1- to 2-mm yellowish papules on the vermilion lips (upper > lower) and oral mucosa (especially buccal).

• Incidental finding on the dorsum of the tongue in ~2–3% of the population; may occasionally be associated with psoriasis, especially pustular variants.

• Well-demarcated areas of erythema and atrophy of the filiform papillae, surrounded by a whitish, hyperkeratotic serpiginous border (Fig. 59.1); lesions tend to migrate over time, may affect other oral sites, and are occasionally associated with a burning sensation.

• Asymptomatic finding that is occasionally associated with conditions such as granulomatous cheilitis (see below) and Down syndrome.

• Multiple grooves or furrows are present on the dorsal tongue, especially centrally (Fig. 59.2).

• Reflects accumulation of keratin on the dorsum of the tongue; contributing factors may include poor oral hygiene, smoking, and a soft diet.

• Confluence of hairlike projections, which represent elongated papillae, with yellowish to brown-black discoloration (Fig. 59.3); may have exogenous staining from food, tobacco, or chromogenic bacteria (especially following antibiotic therapy); some patients report an unpleasant odor or taste.

• DDx: pigmented papillae of the tongue (in individuals with darkly pigmented skin).

• Rx: scraping or brushing the tongue.

• Normal variant that is more often evident in smokers and individuals with darkly pigmented skin.

• Grayish-white, opalescent, sometimes ‘moth-eaten’ appearance of the buccal > labial mucosa; typically becomes less evident upon stretching.

• Found in ~1% of adults, often associated with local overgrowth of Candida.

• Well-demarcated diamond- or oval-shaped area of erythema and atrophy on the dorsum of the tongue (Fig. 59.4).

• Rx: clotrimazole troches or oral fluconazole (for dosage, see Table 64.5).

• Clinical finding that can occur in several immune-mediated vesicular and erosive disorders (Fig. 59.5); favors women over 40 years of age.

• Diffuse gingival erythema with varying degrees of sloughing and erosion; frequently painful.

• Because desquamative gingivitis is often a manifestation of mucous membrane (cicatricial) pemphigoid and other autoimmune bullous disorders, evaluation should include routine histology plus direct and indirect immunofluorescence studies (see Chapter 23).

• Rx: treatment of underlying condition plus meticulous oral hygiene.

• Systemic medications and other causes of gingival enlargement are listed in Table 59.2.

• Drug-related gingival enlargement typically develops during the first year of administration and is first evident in the interdental papillae.

• Occurs in the setting of a chronic periapical abscess in a carious tooth.

• Intraoral (‘parulis’): soft, nontender, erythematous papule on the alveolar process in the region of the affected tooth.

• Cutaneous: erythematous papule, often with an umbilicated or ulcerated center; found on the chin or submandibular region (mandibular teeth) > the cheek or upper lip (maxillary teeth) (Fig. 59.6).

• Results from reactive connective tissue hyperplasia in response to local trauma.

• Smooth pink papulonodule; most often located on the labial mucosa, especially of the lateral lower lip, or along the ‘bite line’ of the buccal mucosa.

• Rx: if bothersome, excision with histologic evaluation to exclude a neoplastic condition.

• Characteristic mucosal changes related to habitual chewing or biting.

• Shaggy white mucosa, usually bilaterally in the buccal region along the ‘bite line’ (Fig. 59.7).

• Translucent to bluish papule due to disruption of a minor salivary gland duct, most often located on the lower mucosal lip (Fig. 59.8; see Chapter 90).

• Results from cytotoxic effects on the oral epithelium, especially in the setting of neutropenia; typically develops 4–7 days after administration of chemotherapy and ≥2 weeks after beginning radiation therapy.

• Multiple erosions and/or ulcerations favor the gingivae, lateral tongue, and buccal mucosa; self-limited.

• DDx: herpetic or candidal infections (may be concomitant).

• Rx: topical anesthetics, analgesics, maintenance of oral hygiene; palifermin (recombinant human keratinocyte growth factor) can reduce severity but produces whitish discoloration of the dorsum of the tongue due to hyperkeratosis.

• Common condition characterized by recurrent oral ulcers, with a peak prevalence during the second and third decades of life; outbreaks may be triggered by trauma, psychological stress, or hormonal fluctuations.

• Minor aphthae (most frequent form): painful, round to ovoid, shallow ulcers that are usually <5 mm in diameter; feature a yellowish-white to gray pseudomembranous base, well-defined border, and prominent erythematous rim (Fig. 59.10); favor the buccal or labial mucosa and typically heal in 1–2 weeks without scarring.

• Major aphthae: larger (>1 cm), deeper ulcers that persist for up to 6 weeks; occasionally affect keratinized mucosa (e.g. dorsum of tongue, hard palate, attached gingiva) as well as nonkeratinized mucosa, may heal with scarring, and are more common in HIV-infected individuals.

• Herpetiform aphthae: simultaneous development of numerous small lesions that tend to coalesce; tends to favor nonkeratinized mucosa, unlike recurrent oral HSV, which favors keratinized mucosa.

• Complex aphthosis: frequent outbreaks of multiple (≥3) oral aphthae, or recurrent genital as well as oral aphthae, in the absence of Behçet’s disease (see Chapter 21).

• Recurrent aphthae can occur in the setting of systemic disorders such as inflammatory bowel disease, SLE, and Behçet’s disease (see Table 59.1).

• DDx: in addition to associated systemic conditions, may include HSV infection, trauma, and the disorders listed in Fig. 59.5.

• Rx: superpotent topical CS gel, topical analgesics; if severe or frequent recurrences: vitamin B₁₂, colchicine, dapsone, thalidomide (the latter is especially helpful for major aphthae).

• The term orofacial granulomatosis refers to non-infectious, non-necrotizing granulomatous inflammation of the lips, face, and/or oral cavity; this term includes isolated granulomatous cheilitis as well as manifestations of Crohn’s disease and sarcoidosis (see Table 59.1); usually develops during the second or third decade of life.

• Granulomatous cheilitis presents as diffuse swelling of the lip(s) (lower > upper or both) that can initially be intermittent (raising the possibility of angioedema) but is eventually persistent (Fig. 59.11); patients may have oral cobblestoning, recurrent aphthae, and gingival enlargement, and the less frequent association with a scrotal tongue and/or facial nerve palsy is referred to as Melkersson–Rosenthal syndrome.

• Rx: intralesional CS, topical calcineurin inhibitors, dapsone, tetracyclines (given for several months), thalidomide or TNF inhibitors (for severe disease); patients should be evaluated for signs of Crohn’s disease and sarcoidosis.

• Irritant or allergic contact stomatitis can result from a variety of foods, food additives, and materials used in dentistry; in particular, cinnamon flavoring and dental amalgam (‘silver’ fillings) can lead to a lichenoid mucositis histologically.

• Shaggy white or erythematous areas, most often on the buccal mucosa or lateral tongue; lacy white streaks (resembling lichen planus) or erosions may be seen (Fig. 59.12).

• Rx: evaluation with patch testing and avoidance of offending agents, sometimes requiring replacement of amalgam with other materials.

• Presents as gray-white discoloration of the palate, often with umbilicated papules that represent inflamed salivary ducts (Fig. 59.13).

• Manifestation of several nutritional deficiencies (e.g. vitamin B₁₂ [pernicious anemia], folate, iron, niacin [pellagra], riboflavin; see Chapter 43) and candidiasis.

• Presents with a smooth, ‘beefy red’ tongue (Fig. 59.14); involvement may initially be patchy but is eventually diffuse and may be associated with a burning sensation or sore mouth.

• Leukoplakia refers to a white patch or plaque on the oral mucosa that cannot be clinicopathologically characterized as a specific disease process; typically occurs in middle-aged and older adults (men > women), especially those who use tobacco ± alcohol, and is regarded as a premalignant condition for SCC.

– Often a homogeneous white patch or plaque, but may be nonhomogeneous and ‘speckled’ (e.g. white flecks on a red base); usually has sharply demarcated borders (Fig. 59.17).

• Similarly, erythroplakia is defined as a red intraoral patch or slightly elevated, velvety plaque that cannot be diagnosed as a particular disease; biopsies usually show more severe epithelial dysplasia than leukoplakia.

• Often affects the buccal mucosa, lower inner lip, floor of the mouth, and lateral or ventral tongue.

• The degree of histologic epithelial dysplasia influences the risk of transformation to SCC; nonhomogeneous leukoplakia, erythroplakia, and lesions located on the floor of the mouth or lateral/ventral tongue also have higher malignant potential.

• DDx of leukoplakia: may include SCC, lichen planus, candidiasis, morsicatio buccarum (see above), and nicotine or contact stomatitis.

• After elimination of possible causative factors (e.g. tobacco use, candidiasis, irritation/trauma) for 2–6 weeks, persistent lesions should be biopsied.

• Rx: for leukoplakia with moderate to severe dysplasia or in high-risk sites and for erythroplakia – excision, cryosurgery, or laser ablation; all patients need longitudinal evaluation and should avoid carcinogenic habits.

• Proliferative verrucous leukoplakia, which tends to occur in women without traditional risk factors, is characterized by multifocal red and white patches that eventually develop a verrucous surface; difficult to treat and associated with high risk of transformation to SCC.

• Most common malignancy of the oral cavity, favoring middle-aged and older men; risk factors include tobacco and alcohol use, HPV infection (see Chapter 66), and betel nut chewing.

• May present as an ulcer, exophytic mass, or area of induration; most often on the lateral or ventral tongue and floor of the mouth (Fig. 59.18).

• DDx: leukoplakia, traumatic ulcer (Fig. 59.19), salivary gland tumor, amelanotic melanoma.

• Rx: combinations of surgery, radiation therapy (especially if HPV-associated), and chemotherapy.

• Verrucous carcinoma (oral florid papillomatosis) is a low-grade variant of SCC that presents as slowly growing, exophytic papillomatous masses that favor the buccal mucosa and gingiva; Rx: excision, traditionally avoiding radiation therapy due to a possible association with anaplastic transformation.

• Uncommon oral malignancy that favors middle-aged and older men; often diagnosed at a locally advanced stage.

• Pigmented (with findings similar to cutaneous melanoma; see Chapter 93) > amelanotic, with a predilection for the hard palate and maxillary gingivae.

• DDx: for pigmented lesions – foreign body tattoo (Fig. 59.20), blue nevus, oral melanotic macule, physiologic pigmentation.