|Year : 2018 | Volume
| Issue : 2 | Page : 73-79
Clinicoepidemiological analysis of patients with oral mucosal lesions attending dermatology clinics
Mohammed Abu El-Hamd, Soha Aboeldahab
Dermatology, Venereology and Andrology Department, Faculty of Medicine, Sohag University, Sohag, Egypt
|Date of Submission||22-Dec-2017|
|Date of Acceptance||25-Feb-2018|
|Date of Web Publication||17-Aug-2018|
Mohammed Abu El-Hamd
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, Sohag, 82524
Source of Support: None, Conflict of Interest: None
Background/Objectives The prevalence of oral mucosal lesions (OMLs) has a wide variety in different regions of the world. This study aimed to assess the prevalence, clinical presentations, and associated risk factors of OMLs among patients treated at Outpatient Clinics of the Dermatology, Venereology, and Andrology Department, Faculty of Medicine, Sohag University, Egypt.
Patients and methods This observational study included all patients with OMLs among patients treated at the Outpatient Clinics of the Dermatology, Venereology, and Andrology Department, Faculty of Medicine, Sohag University, Egypt, from January 2016 to June 2016. Patients underwent complete history taking, and general and local oral cavity examination. The OMLs were examined and diagnosed according to the WHO 1995 criteria.
Results Of the patients, 125 (2.6%) were diagnosed with different clinical types of OMLs (66 men and 59 women; mean age 28.59±14.8 years). Of these, 43 (34.4%) patients had a positive history of smoking. The most common types of OMLs were recurrent aphthous stomatitis (n=28, 22.4%), oral candidiasis (n=15, 12%), Behcet’s disease (n=12, 9.6%), recurrent herpes labialis (n=12, 9.6%), and oral lichen planus (n=7, 5.6%).
Conclusion The prevalence and distribution of OMLs were elucidated at Sohag University Hospital, Upper Egypt and the importance of smoking in the pathogenesis of OMLs was evidenced.
Keywords: aphthous stomatitis, Behcet’s disease, oral mucosal lesions
|How to cite this article:|
El-Hamd MA, Aboeldahab S. Clinicoepidemiological analysis of patients with oral mucosal lesions attending dermatology clinics. Egypt J Dermatol Venerol 2018;38:73-9
|How to cite this URL:|
El-Hamd MA, Aboeldahab S. Clinicoepidemiological analysis of patients with oral mucosal lesions attending dermatology clinics. Egypt J Dermatol Venerol [serial online] 2018 [cited 2018 Sep 19];38:73-9. Available from: http://www.ejdv.eg.net/text.asp?2018/38/2/73/231232
| Introduction|| |
The prevalence of oral mucosal lesions (OMLs) has a wide variety in various regions of the world. The prevalence of OMLs has been previously cited as 9.7% in Malaysia , 15% in Saudi Arabian , 41.2% in India , and 61.6% in Slovenia .
Feng et al.  reported that in a cross-sectional study in Shanghai, China, the most common types of OMLs were fissured tongue, recurrent aphthous ulcer, traumatic ulcer, and angular cheilitis. The most common significant risk factors for OMLs were the elderly age, smoking, and alcohol intake.
There are no previous studies assessing the prevalence, clinical presentations, and the associated risk factors of OMLs in Egypt. So, the aim of this study was to examine the prevalence, clinical presentations, and the associated risk factors of OMLs among patients treated at the Outpatient Clinics of the Dermatology, Venereology, and Andrology Department, Faculty of Medicine, Sohag University, Egypt.
| Patients and methods|| |
This clinical prospective observational study included all patients with OMLs among patients treated at the Outpatient Clinics of Dermatology, Venereology, and Andrology Department, Faculty of Medicine, Sohag University, Egypt, from January 2016 to June 2016. Approval from the Scientific Research Committee of Sohag Faculty of Medicine was taken. Informed consent was signed by all patients. This study was carried out according to the World Medical Association Declaration of Helsinki.
Patients with one of the following conditions were excluded: (a) Patients who could not open their mouths adequately for intraoral examination; (b) patients who had a recent history of maxillofacial trauma or surgery; and (c) patient who refused to participate in this study.
All included patients underwent a detailed medical history including age, sex, smoking, alcohol use, other special habits (addicting drug intake), oral hygiene, dental restoration material (fillings etc.), dentures, clinical presentations and sites of OMLs, recurrence of OMLs, associated dermatological diseases, associated medical diseases, and medical treatments.
Patients underwent general examination and complete local oral examination under good illumination for lips, labial mucosa, and sulcus, commissures, buccal mucosa, gingiva and alveolar ridge, tongue, floor of the mouth, and the soft and the hard palate. The OMLs were examined and diagnosed according to the WHO 1995 criteria . The patients underwent complete dermatological examination.
Cytological smears were obtained from patients with recurrent herpes labialis, and lesions which required histopathological confirmation were referred to the oral surgery clinic for biopsy. Immunofluorescence diagnostic procedure was performed as per the requirement.
SPSS, version 16.0 (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis. The data were descriptive statistics.
| Results|| |
Of the patients, 125 (2.6%) were diagnosed with different clinical types of OMLs (66 men and 59 women; mean age 28.59±14.8 years) in relation to all examined patients (n=4800). Forty-three (34.4%) patients had a positive history of smoking ([Table 1]).
The most common types of OMLs were recurrent aphthous stomatitis (n=28, 22.4%), oral candidiasis (n=15, 12%), Behcet’s disease (n=12, 9.6%), recurrent herpes labialis (n=12, 9.6%), oral lichen planus (n=7, 5.6%), pemphigus vulgaris (n=6, 4.8%), angular cheilitis (n=6, 4.8%), retinoid cheilitis (n=6, 4.8%), angioedema (n=5, 4%), fordyce spots (n=4, 3.2%), mucocele (n=4, 3.2%), Stevens–Johnson syndrome (SJS) (n=4, 3.2%), dentures stomatitis (n=3, 2.4%), and smoker melanosis n=3 (2.4%) ([Table 1] and [Figure 1],[Figure 2],[Figure 3],[Figure 4]).
|Figure 2 32-years-old female patient with two ulcers at the buccal mucosa (Behcet’s disease).|
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|Figure 3 34-years-old female patient with white streaks at the buccal mucosa (oral lichen planus).|
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According to the age, patients with OMLs were classified into three groups: the first group (patients of <20 years old, included oral candidiasis, angular cheilitis, and retinoid cheilitis), the second group (patients between 20 and 40 years old, included aphthous ulcers, Behcet’s disease, recurrent herpes labialis, angioedema, Fordyce spots, mucocele, SJS, smoker melanosis, black hairy tongue, DLE cheilitis, fissured tongue, and Peutz–Jeghers syndrome), and the third group [patients of >40 years old, included pemphigus vulgaris, denture stomatitis, actinic cheilitis, and toxic epidermal necrolysis (TEN)].
The main affected sites of the mucosal oral cavity were buccal mucosa in 50.4% (n=63) patients, lips in 38.4% (n=48) patients, tongue in 17.6% (n=22) patients and mixed sites in 6.4% (n=8) patients.
Dermatological lesions were found in 44 (35.2%) patients. The main associated medical diseases were tonsillitis in 6.4% of the patients n=8, and diabetes mellitus in 4.8% (n=6) of the patients. The main medical treatments were systemic steroids in 9.6% (n=12) of the patients, NSAIDs in 7.2% (n=9) of the patients, antibiotics in 6.4% (n=8) of the patients, insulin in 4.8% of the patients (n=6), and systemic retinoid in 4.8% (n=6) of the patients ([Table 2]).
|Table 2 Dermatological manifestations, medical diseases, and treatments of patients with oral mucosal lesions|
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| Discussion|| |
In the present study, the prevalence of OMLs was 2.6% (n=125) in relation to all examined patients (n=4800). This finding concurs with that from the study of Ramirez-Amador et al. , who reported that the frequency of OMLs in the dermatology clinic was 2.8%. Compared with this study, the prevalence of OMLs was found to be higher in the study of Zain et al.  (9.7%) and Saraswathi et al.  (4.1%). Thus, the variation in the prevalence of OMLs may be influenced by sample size, geographic distribution, biologic and genetic profile of the patients, and study design.
This study reported that the prevalence of OMLs with dermatological diseases was 33.6%, which was in agreement with Goncalves et al. , who observed that the frequency of OMLs with dermatological diseases was 35.7%.
In this study, OMLs were common in men (52.8%) than women (47.2%), which was in agreement with Avcu and Kanli . This may be related to higher prevalence of smoking among men.
The present study showed that 50.4% of OMLs were presented on the buccal mucosa. Most of these OMLs were related to mechanical friction or trauma which is common in this area, which was similar to Ali et al. , who reported that 49.1% of OMLs were presented on the buccal mucosa.
Several other sites were also involved in this study (lips 38.4%, tongue 17.6%, and mixed sites 6.4%); therefore a thorough, systematic approach to the intraoral examination is important. Also, patients may have more than one lesion, so the step-by-step clinical examination should not stop once a lesion is encountered.
This study showed that aphthous ulcers were the most common OMLs (22.4%). This finding was similar to Gándara et al.  who reported that the aphthous stomatitis lesions appear in 24% of the patients, but Ali et al.  reported that traumatic ulcers were the most common ulcerative lesions, followed by recurrent herpes and aphthous ulcers.
The frequency oral candidiasis in this study was 12%, mainly oral thrush. Most epidemiological studies of oral candidiasis have shown very varied results (0.01–37%). The differences in data collection methods, sampling sites, population subgroups, and analysis techniques were responsible for the relatively wide variety of prevalence of Candida carrier status .
In this study, 12 (9.6%) patients had a history of recurrent herpes labialis. The lesions were equal in men and women. Six (50%) patients were cigarette smokers and three (25%) of the patients had diabetes mellitus. According to Kovac-Kovacic and Skaleric , a history of herpes labialis was found in 16.0% of the patients. This difference in prevalence of disease may be related to geographic distribution.
In this study, 12 (9.6%) of the patients were diagnosed as Behcet’s disease, which was common in men with a history of cigarette smoking (n=8, 66.6%). The oral ulcers are seen more commonly on the buccal mucosa and on the mucosal surface of lips, which was similar to Mc Carty et al. . In our study, recurrent oral ulcers were associated with genital ulcers in 100% and acneiform eruptions in 50% of the patients, but without any history of systemic affection. We advised all the cases for ocular consultation.
In this study, seven (5.6%) patients showed oral lichen planus. The lesions were more common in men than in women. The most common clinical type of oral lichen planus was reticular type and buccal mucosa was the most affected site. These results were consistent with results of the study by Oliveira Alves et al.  who reported that the prevalence of oral lichen planus was 6%.
In this study, six (4.8%) of the patients had pemphigus vulgaris, four of them were women.
All the cases showed oral affection. Cytological smear, histopathological examination, and direct immunofluorescence were done and were positive in all the cases. These results were consistent with the results of the study by Arvind Babu et al.  who showed that seven patients out of 3500 were diagnosed with pemphigus vulgaris and five of them were women.
In this study, six (4.8%) patients had angular cheilitis which was common in men than in women. Feng et al.  reported that the prevalence of angular cheilitis was 0.86%.
In this study, six (4.8%) patients were diagnosed as drug-induced cheilitis. The lesions were equal in men and women. All the patients were acne vulgaris patients on isotretinoin.
In this study, five (4%) of the patients had nonhereditary angioedema and presented mainly in the lips. Angioedema was more common in women than in men. It was associated with a history of tonsillitis in 60% of the patients, cystitis in 40%, and headache in one case. Five (100%) of the patients used NSAIDs and four (80%) of the patients used antibiotics before the appearance of angioedema. Madsen et al.  reported that angioedema was found in 7.4% of the patients.
In the present study, oral mucocele was found in four (3.2%) of the patients and presented mainly in the lower lip. The prevalence was equal in male and female patients. Benevides dos Santos et al.  reported that oral mucocele was found in 2.2% of the patients, but Kovac-Kovacic and Skaleric  showed that oral mucocele was found in 0.9% of the patients.
This study found that four (3.2%) of the patients were diagnosed with Fordyce granules. The prevalence was equal in male and female patients. These results were consistent with the results of the study by Al-Mobeeriek and AlDosari  who showed that Fordyce granules was presented in 3.8% of the patients. However, Ali et al.  reported that Fordyce granules were the most common type of oral lesion (20.4%) and more frequently seen among men. This might be due to the high number of androgen receptors in the oral sebaceous glands of men. Androgens bind to these receptors, resulting in an increase in the size and metabolic rate of the sebaceous gland.
This difference in the prevalence of disease may be related to a small number of the included patients in this study.
This study found that four (3.2%) patients were presented with SJS. Oral, ocular, and cutaneous lesions were observed in these patients. The oral manifestations were ulcerative and erosive lesions over the lips and on the buccal mucosa. This result was similar to Arvind Babu et al.  who found that SJS was seen in 4% of the patients.
In the present study, three (2.4%) patients were diagnosed with smoker melanosis; hyperpigmentation was detected over the palate, gingiva, and the buccal mucosa. It was diffuse and of irregular patches, and dark brown to brownish black in color. All the cases were men who were cigarette smokers. Many studies have shown that the prevalence of smoker melanosis was 1.14%  and 2.3% . The melanin production in the oral mucosa of smokers serves as a protective response against some of the harmful substances in tobacco smoke.
In this study, three (2.4%) of the patients were diagnosed with dentures stomatitis. The lesions were more common in women than in men (mean age of 54.00+3.46 years). Kovac-Kovacic and Skaleric  detected denture stomatitis in 4.3% of the patients. Cueto et al.  reported that in all the patients who were diagnosed with denture-induced stomatitis, it was mainly associated with poor denture hygiene, night use of dentures, and lack of fit dentures.
In this study, only two (1.6%) female patients were diagnosed with discoid lupus erythematosus. Ulcerative oral lesions were observed over the lips. Butterfly-shaped malar rash and discoid rash with no other systemic manifestations were seen. Discoid lupus erythematosus was observed in 1.5% (1/65) according to Arvind Babu et al. , which was similar to our study.
In this study, two (1.6%) patients were diagnosed with fissured tongue (one man andenone woman), which was similar to Sedano et al. , who found that the prevalence of fissured tongue increased with age and the lesion in men and women displayed equal prevalence.
This study found that black hairy tongue was seen in two (1.6%) of the patients. Both cases were men and cigarette smokers. This result was similar to that found by Avcu and Kanli  who showed that a peak age of prevalence of 35–44 years has been reported and men demonstrated a higher prevalence than women.
This study found that actinic cheilitis was seen in two (1.6%) patients and presented mainly in the lower lip. Both cases were male cigarette smokers. Both patients had a history of chronic sun exposure. Histopathological examination was done to prove the diagnosis. Tortorici et al.  observed actinic cheilitis in 0.8% of the patients.
In this study, one (0.8%) male patient was diagnosed with Peutz–Jeghers syndrome. This patient had mucocutaneous pigmentation (buccal mucosa, perioral, and lips), and had GIT symptoms; so we advised him for gastroenterology consultation.
In this study, one (0.8%) female patient was diagnosed with TEN. The age of the patient was 54 years old. This patient was on antiepileptic treatment (carbamazepine) for long duration. This patient presented with multiple erosive and ulcerative areas all over the body with oral mucosal and lip erosions and crusts. Arvind Babu et al.  observed TEN in 3/3500 dermatological patients.
The current study has several limitations. The sample size was small because this study has been performed on outpatients in the dermatology clinics; however, many similar studies in the literature originated from oral medicine/ dentistry clinics. This may be the cause of a lower number of patients included over 6 months in the current study as compared with other studies. May be further studies from both dermatology and oral medicine clinics in Egypt would change the prevalence of different presentations. In addition, multicenter studies are required to give more realistic results of the prevalence, clinical presentations, and associated risk factors of patients with OMLs.
This study included that aphthous ulcers and oral candidiasis were the most common types of OMLs. OMLs were frequently associated with smoking. Efforts to increase patient awareness of the oral effects of smoking and to eliminate the habit are needed to improve oral and general health.
The authors acknowledge the faculty and postgraduates in the department for their invaluable help in conducting this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]