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Introduction

There are several skin conditions that may affect the mouth and sometimes other mucosal sites that can be difficult to diagnose and treat as they fall between specialist areas. There are many more conditions that have a predilection for the mouth and often patients will seek help from their dentists initially.

In the Skin Health & Allergy centre we have clinicians with dual training in dermatology and oral medicine who are able to provide advice, investigate and treat many of these conditions. Where appropriate we also refer to our colleagues in ENT, digestive health, ophthalmology or women’s health providing a multidisciplinary approach to care.

Oral ulcers

There are multiple causes for this presentation ranging from the common aphthous type ulcers to rare blistering disorders such as pemphigus and pemphigoid. Patients may need blood tests, mouth swabs and sometimes an oral biopsy. Treatment will depend upon the diagnosis but will often include pain relief and anti-inflammatory mouthwashes or topical pastes. Systemic medication is needed for the more severe conditions or the blistering diseases. Rarely patients will present with a single ulcer that is suggestive of a more serious underlying cause and referral to maxillofacial surgery may be needed.

Lichen planus and oral white patches

Oral lichen planus is a common inflammatory condition affecting 1-2% of the population. It has many different presentations such as white lacy lines in the cheeks, red sore patches, ulcerated areas or thick white patches. It can be painless or for some patients very painful. A biopsy is often needed for diagnosis. There is a 1% annual risk of mouth cancer and so follow up is needed for all patients either by their dentist or an oral specialist. The condition may affect other sites such as the skin, scalp, nails and genitalia can persist for many years. A holistic approach to care is taken and all aspects of the condition are managed.

White patches may be due to simple friction from teeth or dental appliances but have other causes including a higher risk of oral cancer and biopsies may be needed in such conditions.

Sore tongue

This is a common symptom and may have several causes such as erythema migrans (geographic tongue), candida, lichen planus, any ulcerating condition or an abnormal sensitivity due to oral dysaesthesia (see below). Careful examination, swabs, blood tests and occasionally a biopsy may be needed to establish the diagnosis.

Geographic tongue is a harmless condition that fluctuates in activity and appears as red areas with a whitened margin. It moves around the surface of the tongue in some patients. It is variably uncomfortable and is managed with simple analgesia such as Difflam mouthwash.

Candida is a common infection in the mouth that may be evident on the surface of the tongue as a pink or red area sometimes also affecting the adjacent palate. It is diagnosed with a mouth swab and treated with antifungal medication. If the mouth is very dry the infection will be persistent and therefore expert help is needed to manage both conditions.

Sore lips

There are three main presentations of sore lips.

Eczema (exfoliative cheilitis): Dry flaking lips that peel and weep may be a sign of lip eczema. The diagnosis is clinical based upon history and examination. Mouth swabs are needed but oral biopsy is not required. Patch testing may be recommended to exclude contact allergies which may be relevant. Psychological aspects of the condition also need to be explored and managed alongside. It is a very upsetting condition for many patients as it may affect self confidence. Approaches to treatment are mainly local and topical but the outlook is very good.

Sun damage (actinic cheilitis) or lip lichen planus: These are both chronic painful conditions. Biopsies may be necessary for diagnosis and to guide treatment. Both are very treatable and early treatment is highly recommended.

Orofacial granulomatosis: Sore swollen lips might indicate a condition called orofacial granulomatosis. This is a diagnosis made when other causes such as Crohns disease or sarcoidosis have been excluded with additional tests. The earlier the diagnosis is made, the better the outlook.  Treatment may include dietary modification, anti-inflammatory ointments, corticosteroid injections or oral medication.

Pigmented lesions

There are many causes for oral pigmentation but the most common are also harmless and include:

Physiological: Here patients present with darkening of the lips, gums or other parts of the mouth. It is symmetrical and very common. No investigations or treatment are needed. It does persist and sometimes increases with time.

Freckles (lentigines): These are often seen on the lips and may be increased by sun exposure. If small and evenly pigmented they can be safely left alone.

Post inflammatory pigmentation: Any ulcer or area of friction or inflammation can leave a brownish ‘stain’ in the affected area as it heals. This usually fades with time and is entirely harmless

It is important to have any pigmented lesions examined to exclude the rare and more concerning lesions that require biopsy.

Altered taste or sensation (oral dysaesthesia or burning mouth syndrome)

This condition has different presentations which include burning of the lips tongue or other areas, tingling, numbness, or an altered taste. It is more common in females and more common over the age of 50. It can be associated with other pain syndromes and may have been triggered by stress in some patients. It is typically worse as the day progresses and is present most days. There are number of other health related conditions that need to be excluded with investigations. Treatment is then reassurance and sometimes medication.