Approach to Oral Mucosal Lesions
🔍 1. Core Concept
- Oral
lesions มี differential diagnosis กว้างมาก
(benign → premalignant
→ malignancy → infection → systemic disease)
- การวินิจฉัยต้องอาศัย:
- history
+ morphology + location
- อาจเป็น:
- isolated
lesion
- หรือ manifestation ของ systemic
disease
🧾 2. Initial Evaluation (สำคัญที่สุด)
2.1 History (structured approach)
ให้ถามเป็น checklist:
🔹 Lesion characteristics
- Location
(tongue only? diffuse?)
- Color → white / red / pigmented /
ulcer / vesicle
- Morphology
→ macule, papule,
plaque, ulcer
- Duration
- Change
over time
🔹 Symptoms
- Pain,
bleeding, discharge
- LN
enlargement
- systemic
symptoms (fever, weight loss, rash)
🔹 Risk factors
- Tobacco
/ alcohol / betel quid (สำคัญใน SEA)
- Drugs
(especially new meds)
- Immunosuppression
(HIV, chemo)
- Denture
/ trauma
2.2 Physical Examination
🔹 Intraoral exam
- Inspect
+ palpate:
- location,
size, color
- induration
(→ malignancy)
- examine
systematically:
- lips
→ buccal mucosa → gingiva → tongue → floor → palate
🔹 Extraoral exam
- facial
asymmetry / mass
- cervical
lymph nodes
⚠️ 3. Red Flag for Malignancy
(VERY IMPORTANT)
ใช้ mnemonic: RULE
- Red
/ red-white lesion
- Ulcer
- Lump
- Enduration
👉 lesion >3 weeks → ต้อง biopsy
🧩 4. Classification by
Morphology
🔳 A. White / Red lesions
Benign
- Frictional
keratosis
- Morsicatio
(cheek biting)
Infection
- Candidiasis
- wipe
off ได้ → pseudomembranous
- wipe
off ไม่ได้ → hyperplastic
Premalignant (OPMD)
- Leukoplakia
→ malignant
transformation ~10%
- Erythroplakia
→ high risk มาก
- Oral
lichen planus
Malignant
- SCC
(most common)
- ulcer
+ indurated margin
- tongue
(lateral) common site
⚫ B. Pigmented lesions
Benign
- Melanotic
macule
- Smoker’s
melanosis
- Drug-induced
pigmentation
- Amalgam
tattoo
Suspicious
- Melanoma
- asymmetry
- irregular
border
- color
variation
- rapid
growth
👉 suspicious → biopsy
🔴 C. Ulcerative / erosive
lesions
Common
- Aphthous
ulcer
- Recurrent
aphthous stomatitis
Infection
- HSV
(painful + prodrome)
- Coxsackie
(HFMD)
- Syphilis
(painless chancre)
Systemic disease
- Behçet
(oral + genital ulcers)
- SLE
- IBD
Drug-related
- SJS/TEN
- mTOR
inhibitor
🫧 D. Vesiculobullous /
autoimmune
- Pemphigus
vulgaris → flaccid
bullae → erosions
- Mucous
membrane pemphigoid →
desquamative gingivitis
- Erythema
multiforme
👅 5. Tongue lesions
(high-yield)
Normal variants
- Fissured
tongue
- Geographic
tongue
Important conditions
- Atrophic
glossitis →
nutritional deficiency (Fe, B12, folate)
- Black
hairy tongue →
antibiotics / poor hygiene / smoking
- Median
rhomboid glossitis →
Candida
🧠 6. Clinical Pattern
Recognition (practical shortcut)
|
Finding |
Likely Dx |
|
White wipeable plaque |
Candida |
|
White non-wipeable plaque |
Leukoplakia |
|
Painful recurrent ulcers |
Aphthous |
|
Ulcer + induration |
SCC |
|
Pigmented irregular lesion |
Melanoma |
|
Multiple ulcers + genital |
Behçet |
🧪 7. When to Investigate
Biopsy (key decision)
- lesion
>3 weeks
- suspicious
features (RULE)
- unclear
diagnosis
- pigmented
lesion suspicious melanoma
Lab (case-by-case)
- HIV
(recurrent candidiasis / hairy leukoplakia)
- CBC,
iron, B12 (atrophic glossitis)
- autoimmune
panel (SLE, pemphigus)
💊 8. Management
Principles
- Treat
underlying cause
- remove
irritants (trauma, dentures)
- antifungal
(Candida)
- topical
steroids (aphthous, lichen planus)
- urgent
referral + biopsy (suspected cancer)
🔑 Key Takeaways (สำหรับใช้จริง)
- Oral
lesion = pattern recognition + red flag detection
- ทุก lesion ที่ >3 สัปดาห์
→ biopsy
- RULE
mnemonic ใช้คัดกรอง cancer
- Candida
vs leukoplakia → wipe
test
- SEA
context → ต้องถาม betel quid
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