How can I learn about red and white lesions of the oral cavity?

Learning About Red and White Oral Cavity Lesions: A Clinical Approach

Recognition of Concerning Features

Any oral ulcer or red/white patch persisting beyond 2-3 weeks requires immediate biopsy and specialist referral to exclude squamous cell carcinoma. 1, 2

The most critical symptoms that should trigger urgent evaluation include:

• Chronic sore tongue or non-healing ulcers 1
• Persistent red or white patches in the mouth 1
• Painful or difficult swallowing 1
• Neck masses or lymphadenopathy 1, 2

Clinical Classification Framework

White Lesions

White oral lesions have multiple etiologies ranging from benign to malignant 3. The key diagnostic categories include:

• Leukoplakia: White patches that cannot be scraped off and have malignant transformation potential 4, 5
• Oral candidosis: White patches that can typically be wiped away, revealing erythematous base 6, 5
• Oral lichen planus: Reticular white striae, often bilateral, may have erosive component 6, 5
• HPV-related lesions: Squamous papilloma (94% of HPV oral lesions) and verruca vulgaris appear as flesh-colored to white papillary growths 7

Red Lesions

Red patches (erythroplakia) carry higher malignant transformation risk than white lesions 4, 5. Consider:

• Erythroplakia: Velvety red patches with highest malignant potential among oral lesions 4, 5
• Geographic tongue: Benign inflammatory condition with migratory red patches 6
• Inflammatory conditions: Including burning mouth syndrome and infectious causes like candidiasis 8
• Verrucous carcinoma: May present as red patches, typically with warty or cauliflower-like appearance 8

Mixed Red-White Lesions

Erythroleukoplakia (mixed lesions) represents an intermediate risk category requiring careful evaluation 4, 5.

Mandatory Diagnostic Work-Up

Complete clinical evaluation must include history of symptoms, complete physical examination with neck palpation, flexible head and neck fibreoptic endoscopy, performance status, nutritional status, dental examination, and psychosocial evaluation. 1

Laboratory Assessment

Before proceeding with biopsy, obtain:

• Complete blood count 1, 8
• Coagulation parameters 1, 8
• Liver enzymes and serum creatinine 1
• Albumin and thyroid-stimulating hormone 1
• Fasting blood glucose, HIV antibody, and syphilis serology 8

Biopsy Requirements

Pathological confirmation is mandatory for any lesion that cannot be definitively diagnosed after clinical examination, especially those persisting over 2 weeks or not responding to 1-2 weeks of treatment. 1, 8

• Examination and biopsy can be performed transorally under local anesthesia 1
• For pharyngolaryngeal lesions, endoscopic biopsy under general anesthesia is often preferred 1

Imaging Studies

Contrast-enhanced CT scan and/or MRI are mandatory to assess the primary tumor and regional lymph nodes. 1, 2

• CT and MRI have complementary roles and similar diagnostic value for neck evaluation 1
• Chest imaging is essential for high-risk tumors (presence of neck adenopathies) or heavy smokers 1
• PET-CT provides higher sensitivity than chest CT alone for detecting distant disease 1

Critical Pitfalls to Avoid

Do not treat empirically with topical corticosteroids without establishing a diagnosis when an ulcer has persisted >3 weeks. 2

Additional common errors include:

• Assuming benign aphthous ulcers (which heal within 7-14 days) when lesions persist longer 2
• Overlooking lymphadenopathy significance, which substantially increases malignancy concern 2
• Missing high-risk HPV types in condyloma acuminatum, which may harbor HPV 16 and 18 7
• Delayed biopsy of lesions with red flag features (progressive growth, ulceration, bleeding, induration, pain) 7

Risk Factor Assessment

Document the following risk factors that increase malignancy likelihood:

• Tobacco use (smoking and smokeless tobacco) 1, 2
• Alcohol consumption 1, 2
• HPV exposure history 1, 2
• Poor oral hygiene and ill-fitting dentures 1
• Betel nut chewing 1

Observation vs. Immediate Action Algorithm

Appropriate for Brief Observation (2-3 weeks):

• Lesions <5mm, soft consistency, normal coloration, stable appearance 7
• No red flag features present 7
• Patient maintains good oral hygiene and avoids local trauma 7

Requires Immediate Specialist Referral:

• Any lesion persisting >2-3 weeks 2, 8
• Presence of lymphadenopathy 2
• Red flag features: progressive growth, ulceration, bleeding, induration, pain, or functional impairment 7
• Oral tongue lesions (50-60% risk of occult neck metastasis) 2

Patient Management During Evaluation

While awaiting specialist assessment:

• Avoid hot, spicy, sharp, or hard foods that cause additional trauma 2
• Maintain good oral hygiene with gentle brushing and warm saline rinses 2
• Benzydamine hydrochloride oral rinse may provide symptomatic pain relief 2

Pathology Classification

Lesions should be classified according to the 4th edition WHO classification 1. For oropharyngeal lesions, HPV evaluation using p16 immunohistochemistry should be performed on all newly diagnosed squamous cell carcinomas 1.