DOI: 10.5958/2319-5886.2015.00130.

International Journal of Medical Research

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 3 Coden: IJMRHS
Copyright @2015
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th
Received: 16 Mar 2015
Revised: 20 Apr 2015
Review article

ISSN: 2319-5886
Accepted: 7th May 2015

BILATERALLY OCCURRING MUCOSAL ALTERATIONS OF THE ORAL CAVITY-A REVIEW

Ceena Denny1, *Junaid Ahmed2, Ravikiran Ongole3, Nandita Shenoy4, Almas Binnal5
1,4

Associate Professor, 2Professor and HOD, 3Professor, 4,5Reader, Department of Oral Medicine and Radiology,
Manipal College of Dental Sciences, Manipal University, Mangalore - 575001, India
*Corresponding author email: [email protected]
ABSTRACT
Introduction: Lesions of the oral cavity could be unilateral / bilateral and could be the initial manifestation of
certain underlying pathology. Oral diagnosticians may be the ones who diagnose them in their initial stages.
Unilateral lesions have been well documented whereas bilateral soft tissue lesions have been rarely documented in
the literature. Hence we classified commonly occurring bilateral oro mucosal soft tissue lesions. Aim: To classify
bilaterally occurring oro-mucosal soft tissue lesions bilateral occurrence of lesions could be a normal variant or
indicative of pathology. Some of the lesions may or may not be symptomatic and some can even have a malignant
potential. It is imperative to know the different types of bilaterally occurring lesions as diagnosing such lesions of
the oral mucosa by the clinician is important through an adequate knowledge and thorough examination, followed
by investigation for the proper management and better prognosis for the patients.
Keywords: Bilaterally occurring, Intraoral lesions, Mucosal lesions
INTRODUCTION
A majority of oral lesions occurring in the oral
cavity are unilateral in nature. The anatomical
structures in the oral cavity appear bilaterally and
this feature usually provides the clinician a vital clue
to differentiate between a normal anatomy and a
clinical
pathology.
Bilaterally
occurring
maxillofacial pathologies though not very commonly
encountered in our daily practice, are important
since they may prove to be reliable indicators of
certain kind of lesions and hence aid in early
diagnosis thereby helping to reduce the morbidity
and mortality rates.
Bilaterally occurring oral lesions can occur both
intraorally and extraorally. The extraoral lesions that
can occur bilaterally include those affecting the
salivary glands, most commonly sjogrens syndrome,
mumps & sialadenosis. Muscular hypertrophy is
another commonly occurring extraoral bilateral
swelling in the orofacial region. The present review

paper will discuss exclusively about the intraoral

bilaterally occurring soft tissue lesions.
Intraoral bilaterally occurring mucosal alterations
can be broadly classified as:
Normal anatomic variants: Lingual tonsils,
Leukedema, Retrocuspid papillae, Palatal rugae
Lingual varices, Parotid papilla, Linea alba buccalis,
Racial pigmentation.
Developmental disturbances: Affecting the LipCongenital lip pits, Commissural lip pits, Cleft lip
Pigmented lesions: Physiologic pigmentation,Peutz
jeghers syndrome, Addisons disease, Heavy metal
pigmentation, Kaposis sarcoma, Drug induced
pigmentation, Post inflammatory pigmentation,
Smokers melanosis
White lesions of the oral cavity: White sponge
nevus, Benign hereditary intraepithelial dyskeratosis,
Traumatic keratosis, Lichen planus, Angular chelitis,
Oral hairy leukoplakia

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680

Normal variants:
Lingual Tonsil: Referred to as the fourth tonsil in
the waldeyers ring of lymphoid tissue. Situated at
the root of the tongue behind the circumvallate
papilla in front of the epiglottis.[1]The lingual tonsils
form nodular bulges in the root of the tongue, and
their general structure is similar to that of the
palatine tonsil. Crypts are deep, may be branched,
and are lined by a wet stratied squamous
epithelium that invaginates from the surface.
Leukedema: Sandstead and Lowe in 1953 was the
first to describe leukedema.[2]It is a common
mucosal alteration than a pathologic change
characterized by a grayish-white lesion of the buccal
mucosa in humans. Although it can involve the
labial mucosa and the soft palate, it most commonly
affects the buccal mucosa bilaterally.[3] It can occur
in any age group, but more commonly seen in the
adults.[4] Although present in population of different
countries and ethnic groups, it is more profound
among the black Americans.[5]Stretching of the
buccal mucosa makes the lesion disappear and this
characteristic of leukedema differentiates it from
other white lesions.[6]
Retrocuspid papillae: First reported by Hirschfeld
in 1947, retrocuspid papilla is a circumscribed round
or dome-shaped sessile nodule found on the lingual
surface of the mandibular cuspids near the
mucogingival junction measuring about 2-4mm. It is
soft, homogenous and pink in colour.[7](Fig 1)

Fig 1: Retrocuspid papilla

Palatal rugae: Palatal rugae are bilateral, irregular,
asymmetric ridges of the mucous membrane
extending laterally from the incisive papilla and the
anterior part of the median palatal raphe. Winslow
was the first to describe them in 1732. Its size
increases due to normal growth, but remains in the

Ahmed et al.,

same position throughout the patients life and it is

unique in each person.[8]
Lingual varices: Varicosities are benign lesions of
blood which are commonly seen in the head and
neck region. In the oral cavity it is commonly seen
on the ventral surface of the tongue, other sites
involved are the lips and the cheeks.[9, 10]Varicosities
are more prominent in the elderly & are usually seen
occurring bilaterally on either sides of the midline on
the ventral surface of the tongue. Varicosity in the
oral cavity presents as purplish blue spots, nodules
or ridges and are usually asymptomatic.[11](Fig 2)

Fig 2: Lingual varices on the ventral surface of the

tongue

Parotid papilla: The parotid papilla is a small

elevation of tissue that marks the opening of the
parotid duct on the inner surface of the cheek usually
opposite the maxillary second molar.[12]It can
occasionally appear as an exaggerated growth giving
it an appearance of a pathological condition.
Linea alba buccalis: Its a Normal variation which
appears as a white line extending from the corners of
the mouth to the posterior region at the level of
occlusal plane bilaterally, usually associated with
frictional keratosis /trauma from the facial surface of
teeth.[13]
Racial pigmentation: Physiologic pigmentation,
which is common in African, Asian and
Mediterranean populations, occurs due to an
increase in the melanocyte activity rather than an
increase in their number. It varies from light to dark
brown. In the oral cavity, the attached gingiva is
most commonly affected and is seen bilaterally in a
ribbon like fashion. [14] The other sites affected are
the buccal mucosa, hard palate, lips and tongue.
Developmental disturbances:
Soft tissue disturbances affecting the lip
Congenital lip pits and commissural lip pits:
Developmental defects that usually occur on the
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paramedian portion of the vermilion border of lower

lip and commissural lip pits are those seen at the
commissural areas.
It shows an autosomal
inheritance pattern. Presence of congenital lip pits,
with or without cleft lip and/or palate is termed as
Van Der Woude syndrome.[15]Other syndromes
associated with congenital lip pits are popliteal
pterygium syndrome, oral-facial-digital syndrome
and Marres and Cremers syndrome.[16] (Fig 3)

Fig 3: Commissural lip pits

Cleft lip: A cleft lip and palate is an abnormal gap
in the upper lip and the roof of the mouth. As the lip
and palate develop separately, it is possible for the
development of an infant to be born with only a cleft
lip, only a cleft palate, or a combination of both.
Cleft can be either unilateral / bilateral/can be either
only lip /palate or can be a combination.[17]
Pigmentation: Pigmentation other than due to race
can occur due to increased melanin deposition in
association with certain systemic diseases like Peutz
- Jeghers syndrome (mucocutaneous pigmentation
spots of mouth hand and feet and intestinal
polyps),[18]Addisons Disease ( homogenous or
blotchy pigmentation of skin, oral cavity,
conjunctiva and genitalia) [19,20] and can have both
oral and extraoral manifestations.
Heavy metal pigmentation: Increased levels of
heavy metals in the blood can cause discoloration in
the oral cavity. It appears as a blue black line along
the gingival margin extending bilaterally.[ 21]
Post inflammatory pigmentation: Pigmentation of
the oral mucosa which is usually seen associated
with healed chronic oro-mucosal lesions like lichen
planus, lichenoid reaction, pemphigus etc. appears as
brown to black discoloration in the oral cavity and is
usually seen as brownish black diffuse pigmentation
present bilaterally.[22] (Fig 4)

Fig 4: Post inflammatory pigmentation on the left

buccal mucosa
Smokers melanosis: It was Hedin in 1977 who
termed the brownish pigmentation present in the oral
cavity associated with use of tobacco. It can occur
anywhere in the oral cavity but more commonly it
affects the attached gingiva in the mandibular
anterior region and the interdental papilla.[23]
Kaposis sarcoma: Is a malignant, multifocal
systemic disease that originates in the vascular
endothelium.[24]It is the most common malignancy
seen associated with HIV. Orally it manifests as
single or multiple painless, brownish red to
violaceous macule or papule. The most commonly
affected sites are the hard palate and gingiva. [25](Fig
5)

Fig 5: Kaposis sarcoma affecting the palate

White lesions of the oral cavity:
White sponge nevus: An autosomal dominant
disorder which affects the skin and the oral mucosa.
In the oral mucosa it appears as bilateral,
asymptomatic white, diffuse corrugated plaques. It
usually affects the buccal mucosa, ventral surface of
the tongue, labial mucosa, alveolar ridge and floor of
mouth in the descending order.[26]
Hereditary benign intraepithelial dyskeratosis
(HBID): Rare autosomal dominant disorder
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characterized by elevated epithelial plaques located

on the ocular and oral mucous membranes.It has a
seasonal variation with increase in the severity
during the spring and summer.[27] Oral lesions are
usually asymptomatic and appear as multiple white
plaques, bilaterally.[28]
Traumatic keratosis/ frictional keratosis: A
chronic white lesion/patch which is benign and selflimiting seen usually on the buccal mucosa as a
result of constant rubbing of two surfaces. Usually it
is seen bilaterally along the line of occlusion or
because of constant rubbing of the wisdom teeth in
buccal mucosa against the cheek. It disappears once
the causative agent is removed.[29]
Lichen planus: Is a chronic immune mediated
disease which has a mucocutaneous involvement
with varied presentations. In the oral cavity, its
usually seen bilaterally and presents as either
reticular, plaque, bullous, erosive, atrophic and/or
pigmented forms. More commonly it affects the
middle aged women. Lichen planus can involve any
site but more common sites are buccal mucosa,
gingiva, dorsum of the tongue, labial mucosa, and
lower vermilion lip in descending order.[30] (Fig 6)

nonscrapable, bilateral lesion on the lateral /ventral

surface of the tongue and it could be an early
indicator of undiagnosed HIV. (Fig 8)

Fig 7: Angular Chelitis

Fig 8: Hairy leukoplakia on the lateral border of

the tongue
DISCUSSION

Fig 6: Oral lichen planus on the buccal mucosa

Angular Chelitis: Also known as perleche which is
derived from French meaning to lick ones lip. Seen
in older people and manifests as inflammation of the
lips at the two corners of the lips, which starts as
erythema followed by ulceration and then
crustations. Patient complains of soreness, pain and
burning sensation. Predisposing factors leading to
angular
chelitis
include
malnourishment,
immunocompromised conditions, decreased vertical
dimension of mouth, superimposed candidal
infection, xerostomia etc.[31] (Fig 7)
Oral hairy leukoplakia: Caused by Epstein BarrVirus and is most commonly seen in patients
infected with HIV. It manifests as hairy white

Among the various lesions occurring in the oral

cavity few lesions could be normal variants, while
others could be with or without malignant potential
and most of them are not diagnosed at an early
stage.32 Some of these lesions occurring in the oral
cavity could heal spontaneously while other lesions
may need treatment to prevent any further
complications. Biopsy maybe considered for those
lesions that persist to rule out any dysplastic
changes.33 Hence, diagnosing such lesions in the
very early stage could in turn be beneficial for the
patient. We have attempted here to provide a concise
classification of the soft tissue lesions that most
commonly occur bilaterally in the oral cavity. We
also believe this should be useful for the dental
practitioners for easy identification of such unique
lesions.
CONCLUSION
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Int J Med Res Health Sci. 2015;4(3):680-685

The occurrence of a lesion can be a vital indicator to

the kind of disease group it belongs. To formulate
appropriate treatment strategies for the management
of oral disorders, it is imperative that one should be
trained to recognize and differentiate normal
morphological conditions that occur bilaterally from
Oro-mucosal pathologies.Furthermore, the early
clinical diagnosis of such bilaterally occurring
maxillofacial pathologies can result in better, faster
intervention and management of such unique
conditions.
The aim of this paper here is to create awareness and
provide a ready reckoner about these specific
conditions which can provide a useful guide for a
more efficient diagnosis by the clinician.
ACKNOWLEDGEMENT
I acknowledge all the staff of my department for
their valuable contribution
Conflict of Interest: Nil
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