Red and Blue Lesions
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ANGULAR CHEILITIS
Angular cheilitis (perlèche or angular cheilosis) is a superficial inflammatory condition of the labial commissures. It is more commonly seen in elderly patients who lose skin turgor, or in patients with a loss in vertical dimension (overclosure). A deficiency in riboflavin (vitamin B2) may also lead to angular cheilitis. Secondary infection with Candida albicans is common. The common clinical presentation includes:
- Red, swollen patches in the corners of a patient’s mouth where the lips meet.
- Can lead to bleeding, blistering or cracked, crusty appearance.
- Symptoms are often mild or non-existent.
Diagnosis is usually based on the lesion history and clinical presentation alone. Histological analysis of a smear may include:
- Positive indication of hyphae or fungal growth from a potassium hydroxide preparation, periodic acid–Schiff (PAS) stain, or culture on proper medium (Sabouraud’s, corn meal, potato agar etc.).
Your differential diagnosis should include:
- Herpes labialis.
- Erosive lichen planus.
Treatment options include:
- Identification and elimination of predisposing factor(s).
- Keeping the wound dry and clean.
- Antifungal cream (Nystatin, Ketoconazole, Clotrimazole, Miconazole).
- Antibacterial cream if necessary (Mupirocin, Fusidic Acid).
ECCHYMOSIS
Ecchymosis is the medical term for a larger-than-pinpoint bruise caused by soft tissue hemorrhage. Though trauma is the most common cause, ecchymosis can be caused by many conditions that affect bleeding including severe infection, malignancy, blood dyscrasia, thrombocytopenia, and hemophilia. Any vascular wall defects or coagulopathy will lead to excessive bruising. The common clinical presentation includes:
- Nonvesicular, macular surface.
- Does not blanch when pressure is applied.
- Can appear red, reddish-blue, or brown depending on extent and maturity.
Diagnosis is usually based on the lesion history and clinical presentation alone. A blood count and coagulation profile is often required to get to the root cause of the problem. Your differential diagnosis should include:
- Hemophilia.
- Kaposi’s sarcoma.
- Hemangioma.
- Thrombocytopenia.
- von Willebrand’s disease.
- Leukemia.
- Trauma.
Treatment involves addressing the etiology.
ERYTHROPLAKIA
Erythroplakia describes a chronic red mucosal macule that cannot be attributed to any other traumatic, vascular, or inflammatory cause. Erythroplakia is a clinical term and has no specific histopathologic definition. Erythroplakia is analogous to the term leukoplakia (white patches). Tobacco chewing, areca nut and alcohol drinking are strong risk factors for erythroplakia. Most patients fall between 45 and 55 years and the condition has a male preponderance. The most important biological element of oral erythroplakia involves its malignant potential. Almost all cases are premalignant or malignant when discovered. The common clinical presentation includes:
- Well-defined red macules that often have a velvety appearance.
- May be smooth or nodular.
- Most common on the floor of mouth, retromolar area, and lateral surface of the tongue.
- Usually asymptomatic.
- Clinical variations include homogeneous erythroplakia and erythroleukoplakia (speckled leukoplakia).
Diagnosis is based on the lesion history, clinical presentation and microscopic findings, which may include:
- Severe epithelial dysplasia.
- Carcinoma-in-situ.
- Invasive squamous cell carcinoma.
Your differential diagnosis should include:
- Atrophic candidiasis.
- Kaposi’s sarcoma.
- Ecchymosis.
- Contact stomatitis.
- Squamous cell carcinoma.
- Erythema migrans (Geographic tongue).
Treatment most often involves complete surgical excision. The prognosis is fair to good depending on the extent of dysplasia.
HEMANGIOMAS
Hemangiomas are developmental hamartomas (benign tumor-like growths made up of an abnormal mixture of cells). They are caused by the proliferation of endothelial cells that lead to vascular malformations. Congenital hemangiomas are the most common, presenting as bright red birthmarks that appear at birth or in the first weeks of life. The common clinical presentation includes:
- Varying color, from bright red to blue
- Varying size (can be large).
- Appear around time of birth, grow rapidly, and usually involute over several years.
- Most commonly affected areas include the scalp, lips, tongue, and buccal mucosa.
- Usually asymptomatic, but can cause distress for the parents.
Diagnosis is based on the lesion history and clinical presentation only. The blood-filled lesions will blanch under pressure then “refill”. Aspiration and imaging studies can confirm the diagnosis. You differential diagnosis should include:
- Vascular injuries leading to purpura.
- Telangiectasia.
- Kaposi’s sarcoma.
- Other vascular neoplasms.
Treatment options include:
- Simple monitoring for congenital hemangiomas.
- Surgery (scalpel, cryosurgery, laser).
- Sclerotherapy.
KAPOSI'S SARCOMA
Kaposi’s Sarcoma (KS) gained public attention as an AIDS-defining malignancy during the 80’s and 90’s. It can present in individuals without HIV infection (classic idiopathic KS), in sub-Saharan Africa patients (endemic KS) and in transplant recipients (iatrogenic KS). The etiologic agent of all forms of Kaposi’s Sarcoma is KS herpesvirus (KSHV or HHV-8). The common clinical presentation includes:
- Classic form – slow but pernicious growth over many years. Oral lesions are rare.
- Endemic form – rapid growth. Oral lesions are rare.
- AIDS-associated KS – affects oral keratinized mucosa and mucoperiosteal tissue.
- Blue-ish macules, may become nodular.
- Strong predilection for the hard palate, followed by gingiva, buccal mucosa, and tongue.
- Less commonly seen since the advent of better management of AIDS.
- Usually asymptomatic.
Diagnosis is based on the lesion history, clinical presentation and microscopic findings, which may include:
- Vascular proliferation in the dermis.
- Spindle cell proliferation.
- Formation of slit-like spaces that are not lined by endothelium.
- Extravascular red blood cells.
Your differential diagnosis should include:
- Hematoma or ecchymosis.
- Hemangioma.
- Malignant melanoma.
- Pyogenic granuloma.
- Amalgam tattoo.
Treatment options include:
- Radiation therapy.
- Intralesional therapy (interferon-α, vincristine, vinblastine, sclerosing agents).
- Chemotherapy (interferon-α, vincristine, vinblastine, bleomycin, daunorubicin).
The prognosis varies on the host’s immune status but is generally poor in patients who present with the AIDS-associated form.
PLASMA CELL GINGIVITIS
Plasma Cell Gingivitis is a rare benign condition characterized by well demarcated erythematous and edematous gingivitis. It is usually caused by a hypersensitivity to an agent such as cinnamon, additive flavors, toothpaste, mouthwash or plaque antigens. The common clinical presentation includes:
- Erythema and edema with a velvety gingival surface.
- Surface epithelium becomes non-keratinized.
- Limited to the attached gingiva and often extends to the mucogingival junction.
Diagnosis is based on the lesion history, clinical presentation and microscopic findings, which may include:
- Dense infiltrate of normal plasma cells into the subepithelial gingival tissue.
- Plasma cells are separated into aggregates by strands of collagen.
Your differential diagnosis should include:
- Lupus erythematosus.
- Wegener’s granulomatosis.
- Chronic candidiasis.
- Lichen planus or lichenoid reaction.
- Mucous membrane pemphigoid.
Treatment usually involves the removal of the etiological agent only.
PYOGENIC GRANULOMA
Pyogenic Granuloma (granuloma pyogenicum) refers to a benign vascular tumor that is not pyogenic or granulomatous. It is caused by a hyperplastic reaction of capillaries and fibroblasts to chronic trauma/irritation. The exact mechanism is unknown, but pyogenic granulomas are linked to pregnancy, trauma, and immunosuppression, as well as certain medications such as retinoids, antiretroviral drugs, and oral contraceptives. The common clinical presentation includes:
- Lesions are most frequently located on oral gingiva.
- Can be found on the lips, tongue, buccal mucosa, palate and skin.
- Red, lobular to smooth appearance.
- May be sessile to pedunculated when found on the gingiva.
- May have an erosive surface and tendency to bleed.
- Covered by a yellow fibrinous exudate when ulcerated.
- Usually asymptomatic.
Diagnosis is based on the lesion history, clinical presentation and microscopic findings, which may include:
- Hyperplastic granulation tissue (aggregates of capillary-sized vessels).
- Scattered fibroblasts and a variegated inflammatory infiltrate.
Your differential diagnosis should include:
- Peripheral giant cell granuloma.
- Peripheral ossifying fibroma.
- Kaposi’s sarcoma.
- Vascular malformation (hemangioma).
Treatment options include:
- Surgical excision (extended to the periosteum or periodontal ligament).
- Laser ablation.
- Electrosurgery.
Lessons may occasionally return.
VARICES
Varices are dilated veins that can develop due to the loss of connective tissue tone of the vascular wall. Though they can be caused by congenital defects, oral lesions are strongly age related and often seen on the ventral surface of the tongue. Varices can also occur after soft tissue trauma. The common clinical presentation includes:
- Irregular, blue/purple lesions with a lobulated surface that may become thrombosed.
- Common on the lower lip and sublingual regions.
- Blanches with compression (diascopy).
- Asymptomatic.
Diagnosis is based on the lesion history and clinical presentation only. If a biopsy is indicated, microscopic findings may include:
- The appearance of a large thin-walled vein.
- Resemble cavernous hemangiomas.
- Lined by a flat mature endothelium.
- Lacks a muscular coat.
Your differential diagnosis should include:
- Mucocele.
- Vascular neoplasm.
- Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome).
- Lymphangioma.
- Kaposi’s sarcoma.
- Melanoma.
- Hemangioma.
No treatment is required and the prognosis is excellent.
