What is Oral Mucosal Lesions, Immunologic Diseases?
Diseases related to the immune system often affect the soft, moist tissue inside the mouth (known as ‘oral mucosa’), and this is often the first visible sign of the disease. Lesions or patches appearing inside the mouth can be linked to immune system problems or conditions thought to be triggered by the immune system. These lesions can cause discomfort and significantly affect a person’s quality of life. They may also be linked to other illnesses, particularly in those people who already have a high risk of disease.
The signs of these lesions, which can include recurring mouth ulcers, lichen-like patches, and other conditions such as lupus, blistering diseases, red skin rashes, and a condition causing the tongue to appear map-like, can often be hard to pinpoint. Their appearance can change, making them subtle and hard to recognize. A careful look at a patient’s medical history, tissue exams, and expert consultation from different medical specialties are usually needed for a precise diagnosis.
It’s important to note that for patients showing no other symptoms, a thorough clinical examination can give an early diagnosis and start treatment. While some patients may find the treatments to provide unpredictable results, others may be happy with simple, non-invasive therapies.
What Causes Oral Mucosal Lesions, Immunologic Diseases?
Recurrent Aphthous Stomatitis, or repeat mouth ulcers, are one of the most common mouth conditions that causes sores or ulcers in your mouth. There are three types: minor, major, and herpetiform (which can look like clusters of fever blisters). Doctors categorize these ulcers based on factors like how many there are, how long they last, where they appear, how often they come back, and how severe they are. We don’t know exactly what causes these ulcers, but it could be a combination of your genes and things like bacteria, viruses, certain food and medication, stress, lack of certain nutrients, or other diseases.
Oral Lichen Planus is a disease where your immune system attacks your own body tissues. This can affect the lining of your skin, eyes, vagina, and mouth. Sometimes, other diseases, local irritants or allergies, or drug reactions can look like Oral Lichen Planus. The inflammation that happens in your mouth can be due to the actual oral lichen planus disease, or it could be an allergic reaction to things like certain dental materials, toothpaste ingredients, food additives, and some medications like nonsteroidals (pain medication), blood pressure medication, malaria medication, and HIV medication.
Systemic Lupus Erythematosus (SLE) is an ongoing disease where your immune system attacks your own body’s tissues. This leads to inflammation and damage in different parts of your body.
Vesiculobullous Diseases are a group of conditions where the immune system disrupts the oral cavity, causing blisters to form. These include diseases like Mucous Membrane Pemphigoid and Pemphigus Vulgaris which both lead to the formation of small sacs filled with fluid (vesicles and bullae) in the mouth and other areas. In Mucous Membrane Pemphigoid, the immune system attacks parts of your skin or mucus membranes, causing a painful blistering rash. Pemphigus Vulgaris is another autoimmune blistering disorder where your skin and mucous membranes develop raw sores (erosions) as the immune system attacks the body skin and mucus membranes.
Erythema Multiforme is an abnormal immune system response where your skin and mouth develop ulcers and “target-like” spots. It’s most often linked to infections such as herpes simplex virus, Mycoplasma pneumoniae, and Epstein-Barr virus, but it can also be related to medications, food, vaccines, radiation therapy, and cancer.
Benign Migratory Glossitis, also called geographic tongue or erythema migrans, is an ongoing condition of inflammation. It typically affects the top part of your tongue. The exact cause is unknown but it’s believed to be an immune response.
Risk Factors and Frequency for Oral Mucosal Lesions, Immunologic Diseases
Recurrent aphthous stomatitis is the most common reason for recurring sores in the mouth. It occurs in 1 out of every 5 people, especially among teenagers and young adults. As a person grows older, this issue becomes less common and it’s rare for people over 40 to start experiencing it.
Oral lichen planus, an issue affecting the skin and mucous membrane inside the mouth, is fairly common. It affects roughly 0.22% to 5% of people globally. This condition is more common in women than men and usually starts showing up in people between their 40s and 80s.
Systemic Lupus Erythematosus (SLE) is a disease that affects more women than men (about 8 times more likely to occur in women). It typically manifests in people in their 40s to 50s. Depending upon where someone lives and their ethnicity, there can be 12 to 50 cases per 100,000 people. With regards to how often it impacts the mucous lining in the mouth, estimates suggest that it can be present in 9% to 45% of traditional SLE patients and 3% to 20% in patients with the skin-focused form of the disease.
Vesiculobullous diseases, which include conditions like pemphigus vulgaris and mucous membrane pemphigoid, are rare. Pemphigus vulgaris affects about 0.1 to 0.5 out of 100,000 people a year. Mucous membrane pemphigoid affects about 2 out of every 1,000,000 people a year. These conditions are more common in people between their 50s to 70s, with mucous membrane pemphigoid being more common in women and pemphigus vulgaris affecting both genders equally.
Erythema multiforme, a type of hypersensitivity reaction that can cause skin rashes and hives, is fairly rare, with less than 1% of the population affected. It usually impacts people in their 30s to 40s and has a slightly higher occurrence in males.
Benign migratory glossitis, a harmless but discomforting condition that affects the tongue’s appearance and texture, is somewhat common, with a prevalence rate of 1% to 2.5% worldwide. It commonly appears in people in their 30s and 40s, with a slightly higher occurrence in women than men.
Signs and Symptoms of Oral Mucosal Lesions, Immunologic Diseases
Recurrent aphthous stomatitis, also known as canker sores, is a condition that causes painful ulcers in the mouth. These ulcers often have a characteristic look: a central area of breakdown, covered with a yellow-white substance, surrounded by a red ring. The severity of this condition can vary:
- Minor form: few recurrent sores, about 3 to 10 mm in size, healing in 7 to 14 days without leaving a scar.
- Major form: moderate recurrence rates, larger sores (1 to 3 cm in diameter), healing in 2 to 6 weeks and potentially leaving a scar.
- Herpetiform form: most frequent recurrences, numerous small sores (up to 100), healing in 7 to 10 days.
These mouth ulcers are sometimes linked to underlying systemic issues like a weakened immune system, inflammatory bowel disease, and Celiac disease. They could also suggest congenital disorders like Beçhet’s disease, mouth and genital ulcers with inflamed cartilage syndrome, and reactive arthritis.
Oral lichen planus is another condition that may affect your mouth. It presents as white, lace-like patches on the inside of your cheeks (reticular type), or mouth sores resembling those seen in erosive lichen planus. The latter may also affect your gums, leading to desquamative gingivitis, and may have components affecting the skin.
Systemic Lupus Erythematosus (SLE) often first shows signs in the mouth and may be confused with oral lichen planus. Oral ulcers are the most common oral finding, but other symptoms like altered salivary flow, oral pigmentation, cheilitis (cracks at the corners of the mouth), and a burning sensation in the mouth can also occur.
Vesiculobullous diseases present as fluid-filled skin lesions and ulcers that affect the mouth and other mucosal surfaces. Although you might only see painful ulcers and erosions due to the fragile nature of the vesicles and bullae in pemphigus vulgaris, they are generally robust in mucous membrane pemphigoid and are usually found intact.
Erythema multiforme typically results in ulcers in the mouth and lips, with bleeding crusts typically forming on the bottom lip. This pattern can mirror other conditions like SLE, but the skin manifestation- flat reddish or purplish spots with bright pink bumps in the center- usually helps in determining the correct diagnosis.
Benign migration glossitis causes painless, well-defined patches on the tongue. These patches can frequently change in location and size, sometimes disappear completely. However, patients might report a burning sensation when eating acidic or spicy foods when the patches are present. A separate condition called burning mouth syndrome may appear concurrently with benign migration glossitis, which can complicate both diagnosis and treatment.
Testing for Oral Mucosal Lesions, Immunologic Diseases
When a doctor examines oral mucosal lesions, which are abnormal areas of tissue in the mouth, there are several steps they follow. Firstly, they begin with a careful physical check-up, talk to the patient about their experiences, and may take a tissue sample (biopsy) if necessary. The doctor will physically feel (bimanual exam) and examine the lesion using bright light to understand its size, shape, color, texture, and location more accurately. They will ask when the lesion appeared, how it changed over time, and whether the person feels any pain associated with it.
In some cases, a tissue biopsy might be necessary for a definite diagnosis, especially if there is suspicion of severe abnormal tissue changes (epithelial dysplasia) or cancer such as squamous cell carcinoma. The way a biopsy process happens is that the tissue is either traditionally fixed in a chemical solution called formalin for standard lab tests or placed in another type of solution (like Michel’s, Zeus, or DIF) to study the tissue under a particular kind of microscope (direct immunofluorescence).
The biopsy is usually taken from unbroken tissue near the lesion because damaged or ulcerated tissue often doesn’t give enough clear information for diagnosis. Healthcare professionals, like oral and maxillofacial surgeons, ear, nose, and throat (ENT) doctors, dermatologists, or dentists typically perform the biopsy. The collected sample is then preferably sent for further examination (histopathologic analysis) to a specialist, who might have additional training in areas related to mouth, face, head, and neck or skin diseases.
Treatment Options for Oral Mucosal Lesions, Immunologic Diseases
If you have mild recurrent aphthous stomatitis, which can be described as recurring sores in the mouth, you might be able to manage the symptoms on your own or with over-the-counter numbing gels and pain relief medication. However, if at-home remedies aren’t working, your doctor may recommend a special type of medicine called corticosteroids, or treatment in the office using caustic, or tissue-destroying, chemicals. If you have major recurrent aphthous stomatitis, which tends to be more severe and persistent, you may need targeted corticosteroid therapy because chemical caustics are generally not suitable. If these treatments are not effective, your doctor may suggest an oral corticosteroid which can reach all areas of your body to reduce inflammation.
Reticular lichen planus is a type of skin disease that often doesn’t cause any discomfort and therefore doesn’t require treatment. If it’s caused by something you’re exposed to, like certain dental materials or toothpaste additives, it often clears up on its own once you avoid the irritant. If the cause isn’t clear, your doctor might give you a list of common irritants to try avoiding. In some cases, corticosteroids may be needed for the skin to completely heal.
Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect various parts of the body, including the mouth. Treatment usually involves lifestyle changes and medications tailored to the symptoms you experience. You may be advised to avoid sunlight to prevent flare-ups. Depending on the severity of the disease, your rheumatologist may also suggest pain relievers and other specific medications. Treating oral lesions, or mouth sores, often happens as a result of overall disease management.
Vesiculobullous diseases are a group of conditions that cause blisters or bubble-like lesions. Treating these diseases mainly involves controlling the disease’s overall activity in the body. Mild cases may be treated with topical steroids or other specific treatments whereas moderate to severe cases may need oral or IV medication, with the goal of relieving symptoms and reducing therapy to a safe and manageable level.
Erythema multiforme refers to a skin reaction caused by infections or medications. Treatment mainly includes removing the cause (like stopping offending medicine or treating an infection) and treating the sites of the reaction. For oral lesions, topical steroids might be applied, and in severe cases, oral steroids might be administered.
Benign migratory glossitis, also known as geographic tongue, is harmless and doesn’t usually require treatment. However, if you’re having symptoms, your doctor might suggest antihistamines or corticosteroids. Also, discomfort from certain foods might indicate a related disorder called burning mouth syndrome, which might need further evaluation.
For all the conditions discussed above, usually, simple management with topical or limited-use medication can be managed by a general doctor or dentist. However, if your condition remains undiagnosed, doesn’t respond to treatment, or is complex, referral to a rheumatologist or an experienced provider may be necessary, and a team approach could be needed for care. Remember, all these diseases can be hard to treat and may frustrate patient expectations. However, simple and effective management and patient education can often result in good outcomes.
What else can Oral Mucosal Lesions, Immunologic Diseases be?
Different immune-related diseases could affect the oral lining, often overlapping with other similar conditions. Here are some categories and their potential diagnoses:
Recurrent Aphthous Stomatitis could stem from:
- Herpes simpex virus (HSV)
- Vesiculo-bullous diseases li>
- Oral lichen planus
It could be Lichenoid Lesions and Related Conditions such as:
- Oral lichen planus
- Lichenoid mucositis
- Graft-vs-host disease
Vesiculobullous Lesions include:
- Pemphigus vulgaris
- Mucous membrane pemphigoid
- Oral lichen planus
It might be Systemic Lupus Erythematosus (SLE) with symptoms like:
- Lichenoid mucositis
- Oral lichen planus
- Cutaneous lupus
Erythema Multiforme could be a result of:
- Stevens-Johnson Syndrome
- Vesiculobullous diseases
- Fixed drug reaction
Benign Migratory Glossitis could be mistaken for:
- Oral candidiasis
- Oral lichen planus
- Systemic Lupus Erythematosus (SLE)
What to expect with Oral Mucosal Lesions, Immunologic Diseases
The outcome for patients with lesions in the mouth, which are often linked to immune system disorders, can vary, but these disorders often come and go over time. Treating these oral sores primarily involves addressing the symptoms during flare-ups and trying to prolong periods without symptoms by avoiding what caused the sores in the first place.
Treatments mentioned earlier can typically manage these diseases well. But over time, these diseases may come back and the treatments may need to be intensified. Also, if no clear cause of the disease can be found and the disorder becomes less passive over time, more aggressive treatments can lead to significant side effects and patients may find them hard to stick with. Some patients might even choose to stop their treatments or find them not satisfactory.
As with many other diseases linked to the immune system, the long-term outcome can vary greatly. The frequency and severity of flare-ups can greatly affect how satisfied a patient is with their overall treatment.
Possible Complications When Diagnosed with Oral Mucosal Lesions, Immunologic Diseases
Generally, lesions in the mouth caused by immune reactions heal on their own. However, they can sometimes lead to complications, most often associated with the underlying autoimmune disease, or side effects of medications to reduce inflammation. For instance, in conditions like pemphigus vulgaris or mucous membrane pemphigoid, widespread sores in the mouth and on the skin can lead to scarring. If these conditions are not treated, they can result in severe dehydration, which can be life-threatening.
More worrisomely, some disease types, specifically ulcerative oral lichen planus, have the potential to turn into malignant growths. While the risk is low, the presence of oral lichen planus has been linked with a higher chance of cancerous changes in the mouth. This claim has its share of controversy, as there isn’t enough conclusive evidence to prove a direct link. Some experts suggest that similar characteristics between a potentially malignant lesion and a transforming lichen planus could be the cause of this historical association. Also, since both lichen planus and squamous cell carcinoma are relatively common, the chances of both appearing at the same site may confuse the correlation. Additionally, conditions like epithelial dysplasia and proliferative verrucous leukoplakia can resemble lichenoid lesions, making them hard to distinguish. Advocates for the premalignant potential of lichen planus cite the heightened susceptibility of the chronically inflamed and weakened lining in the mouth to carcinogens, immune system dysregulation, and decreased immune surveillance.
Even though the initial check-up and treatment are usually managed by a general dentist or family doctor, they might need the support of various specialists for further treatment. Only addressing the visible symptoms without regular follow-up checks or assessing other possible related conditions may delay the diagnosis of a more significant systemic autoimmune condition. It’s crucial for primary care physicians, including dentists, to refer these cases to specialists like oral and maxillofacial surgeons, dermatologists, ophthalmologists, or otolaryngologists when necessary. Referral to a rheumatologist might be required if simple treatments do not help to control or stop the condition from recurring.
Preventing Oral Mucosal Lesions, Immunologic Diseases
Some patients may naturally be more prone to certain conditions due to their immune system’s response, implying that their genetics play a role. This means it might not be possible to fully prevent these conditions. However, if the disease is detected early and properly identified, along with determining any environmental causes, there’s a good chance that a patient’s symptoms can be well managed.
Patients should also be informed about potential triggers and environmental factors that can contribute to their condition. It’s also crucial to inform them about making certain lifestyle changes to avoid these triggers and factors. This will help minimize the chances of exacerbating their condition.
