Clinicopathological analysis of common oral lesions

Background: Oral health is important to the quality of life of all individuals. Oral lesions can cause discomfort or pain that interferes with mastication, swallowing, and speech. Oral disease is a health problem that is not only a matter of oral hygiene and local condition, but can also be a precursor to other dangerous and potentially life threatening illnesses. The present study was designed to analyze the main clinicopathological aspects of most common oral lesions in patients who visit the Oral Diagnosis Clinic of the College of Dentistry, University of Sulaimani, Kurdistan region, Iraq. Patients and methods: This prospective study was performed on 3144 patients from July 2009-July 2010. In this study a total of 3144 patients were examined. Of these 1507 (47.93%) were males and 1637 (52.06%) females. The patients' age ranged between 10 to 79 years. An interview was conducted to collect information using a structured questionnaire which was completed by each patient. The lesions that could not be diagnosed by clinical examinations alone were analyzed histopathologically. Results: Among 3144 patients, only 799 patients (25.41%) had oral lesions. Females constituted 49.81% (n=398) and males 50.18 (n=401). The age range of the patients was between 10-79 years with a mean age of 33.75 years. Anatomic changes and developmental anomalies were considered as linea alba (16.68%), Fordyce's granules (12.37%), torus mandibularis (0.66%), torus palatinus (0.55%). Common oral lesions after those considered being anatomic changes and developmental anomalies were fissure tongue (18.23%), cheek biting (12.15%), hairy tongue (6.51%), and recurrent aphthous stomatitis (5.85%) , ankyloglossia (3.75%) , lingual varicosities (2.87%) , frictional (traumatic) keratosis (2.87%) , denture stomatitis (2.54%), recurrent herpes simplex virus infection (2.43%), traumatic ulcer (2.43%), geographic tongue (1.98%), fibroepithelial hyperplasia (1.32%), denture induced fibrous hyperplasia (1.21%) , angular cheilitis (0.99%) , oral lichen planus (0.88%) , median rhomboid glossitis (0.88%) , peripheral giant cell granuloma (0.22%) , and gingival hyperplasia (0.33%) . Conclusion: Routine examinations of oral cavities are valuable in identifying several oral lesions and this will help to establish early diagnosis and treatment and better prognosis particularly early precancerous and other oral lesions.


INTRODUCTION
Oral health is important to the quality of life of all individuals.Oral lesions can cause discomfort or pain that interferes with mastication, swallowing, and speech.Oral lesions can produce symptoms such as halitosis, xerostomia, or oral dysesthesia, which interfere with daily social activities (1) .Oral disease is a health problem that is not only a matter of oral hygiene and local condition, but can also be a precursor to other dangerous and potentially life threatening illnesses (2) .Diagnosis of wide variety of lesions that occur in the oral cavity is an essential part of dental practice.An important element in establishing a diagnosis is knowledge of the lesions' relative frequency, or prevalence at one point in time (3) .Among the broad spectrum of causes leading to changes in the oral mucosa are infections from bacteria, fungi, viruses, parasites, and other agents; physical and thermal influences, changes in the immune system, systemic diseases, neoplasia, trauma and other factors, some of which are issues of aging (4,5) .Traditionally, the mucosal membrane of the oral cavity has been looked upon as mirroring the general health (6) .
(1)Assistant professor.Department of Oral Medicine, College of Dentistry, University of Sulaimani.
(2)Assistant lecturer Department of Oral Medicine, College of Dentistry, University of Sulaimani.
The tongue lesions fissured, geographic and hairy tongue, oral lesions Fordyce granules, and leukoedema are classically considered to be developmental oral lesions rather than having virtual disease characteristics (6) .These lesions may be present at birth or become evident later in life.They may be discovered during routine dental examinations and vary depending on age, gender and/or race (7) .
Recurrent aphthous stomatitis is an ulcerative condition that affects the oral mucosa without evidence of an underlying medical disorder, or may be associated with other systemic diseases (8) .In particular, long-term habits such as using tobacco can cause precancerous or cancerous lesions (9) .Dental factors (poor oral hygiene, sharp teeth, and improperly fitting dentures) have been thought to play a role in the occurrence of oral mucosal lesions (4,10) .Denture wearers, besides suffering the characteristic lesions from the dentures, they present traumatic ulcerations with more frequency than nonusers, candidosis pathology occupying second place in frequency (11) .The present study was designed to analyze the main clinicopathological aspects of most common oral lesions in patients who visit the Oral Diagnosis Clinic of the College of Dentistry, University of Sulaimani.

PATIENTS AND METHODS
Evaluation basis: This prospective study was performed on 3144 patients, of these 1507 (47.93%) were males and 1637 (52.06%) were females.The patients' ages were between 10 to 79 years.All patients included in this study were referred to the Department of Oral Medicine, College of Dentistry, University of Sulaimani from July 2009-July 2010.The bases for attending to the clinic were to seek dental treatment.Patients: An interview was conducted to collect information using a structured questionnaire which was completed by each patient and the examiner.Both dental and general medical histories of the patients were obtained.Methods: The patients were examined clinically by two trained examiners using artificial light, mouth mirror, gauze.At the time of clinical examination, we established a preliminary diagnosis.Some of the mucosal changes where diagnosed solely by clinical examination (e.g.linea alba, fissured tongue, etc.).Some times a cotton swab was used to remove evident debris; a swab was always used to test whether a white lesion could be wiped off.In some cases where the observed lesion could be of traumatic origin, this was eliminated and the patients were requested to return for evaluation 15 days later for a new exploration.During the clinical examination, the following elements including features of the lesion, anatomical location, extension, etiological factors or related factors, dental status were analyzed.The diagnosis was made based on history, clinical features, and investigations according to the WHO (1997) criteria (12) .When clinical features were not diagnostic and where no clinical improvement was observed, a biopsy was undertaken.

RESULTS
Among 3144 patients examined, 905 oral lesions were diagnosed and their distribution was as follows: Distribution of tongue disease according to age and sex in 905 oral lesions: Tongue lesions were considered as fissure tongue (18.23%), black hairy tongue (6.51%), ankyloglossia (3.75%), geographic tongue (1.98%) and scalloped tongue (0.33%) as shown in table (1).(-100) * Some patients had more than one lesion, so the number of lesions was more than the number of the patients Distribution of anatomic changes and developmental anomalies according to age and sex in 905 oral lesions: Anatomic changes and developmental anomalies were considered as linea alba (16.68) followed by Fordyce's granules (12.37%), torus mandibularis (0.66%), and torus palatinus (0.55%) as shown in table (2).Distribution of ulcerative, vesicular and bullous lesions according to age and sex in 905 oral lesions: The most common ulcerative lesion was RAS (5.85%) followed by recurrent herpes simplex virus infection and traumatic ulcer (2.43%) as shown in table (3).Distribution of white lesions according to age and sex in 905 oral lesions: The most common white lesion was cheek biting (12.15%) followed by frictional keratosis (2.875%), oral lichen planus (0.88%) as shown in table (4).

Distribution of candidiasis according to age and sex in 905 oral lesions:
The number of patients with denture stomatitis was 23, 18 patients were females whom constituted 78.26% and 5 patients were males whom constituted 21.73%.The number of patients with angular cheilitis was 9, 4 patients were females whom constituted 44.44% and 5 patients were males whom constituted 55.55% as shown in table (5).

Distribution of benign lesions according to age and sex in 905 oral lesions:
The most common benign lesion was fibroepithelial hyperplasia (1.32%) followed by denture induced fibrous hyperplasia (1.21%) as shown in table (6).

DISCUSSION
Among 3144 patients, only 799 patients (25.41%) had oral lesions.Females constituted 49.81% (n=398) and males 50.18 (n=401).The age range of the patients was between 10-79 years with a mean age of 33.75 years.Tongue lesions were considered as fissure tongue (18.23%), black hairy tongue (6.51%), ankyloglossia (3.75%), geographic tongue (1.98%) and scalloped tongue (0.33%).The most common tongue lesion was fissured tongue, the number of patients with fissured tongue was 76 patients (46.06%) were females and 89 patients (53.93%) were males.This compatible with other studies done by Mathew et al. (13) in southern India, and Mojarrad and Vaziri (14) in which fissured tongue was more common among males.The commonly affected age group (40.60%) was between 20-29 years, this is compatible with Neville et al. (15) in which fissured tongue may be seen in children or adults, but the prevalence and severity appear to increase with age and disagrees with the study done by Mathew et al. (13) in southern India in which 41-60 years of age were the most common affected age group.The number of with geographic tongue was 18, 11 patients (61.11%) were females and 7 patients (38.88%) were males.The most commonly affected age group was 20-29 years, this is compatible with the study done by Jainkittivong and Langlais in which geographic tongue was more common among females and the highest incidence (39.4%) occurred in the 20-29 age groups (16) .Anatomic changes and developmental anomalies were considered as linea alba (16.68) followed by Fordyce's granules (12.37%), torus mandibularis (0.66%), and torus palatinus (0.55%).we did not compare our results with other studies because there was no studies about the clinicopathological aspect of these lesions, as these lesions are almost always analyzed in a prevalence study either alone or with other lesions.
The most common white lesion was cheek (12.15%) followed by frictional keratosis (2.875%) and oral lichen planus (0.88%).The number of patients with cheek biting was 110, 66 patients (60%) were females and 44 patients (40%) were males.The most commonly affected age group (64.54%) was between the ages of 20-29 years; this is compatible with other studies done by Neville et al. (15) and Cebeci et al. (9) in which cheek biting was more common among females.The number of patients with frictional (traumatic) keratosis was 26, 12 patients (46.15%) were females and 14 patients (53.84%) were males.The most commonly affected age group (50%) was between the ages of 20-29 years, this is compatible with other studies done by Mathew et al. (13) and Cebeci et al. (9) in which frictional (traumatic) keratosis was more common among males and the most commonly affected age group was between 21-40 years.The number of patients with oral lichen planus was 8, 5 patients (62.5%) were females and 3 patients (37.5%) were males.The most commonly affected age group (37.5%) was between the ages of 20-29 years with mean age of 41.62, this is compatible with other studies that were done by Pakfetrat et al. (17) in which lichen planus was more common among females.This study is compatible with other studies done by Pakfetrat et al. (17) in which OLP was more prevalent in third to fourth decades of life and disagrees with the finding of Oliveira Alves et al. (18) in which a predominance of OLP was observed in the fifth, sixth and seventh decades of life.The majority of the oral lichen planus (50%) were seen in the buccal mucosa, followed by tongue (28.56%), anterior gingiva (7.14%), retromolar pad area (7.14%) and alveolar ridge (7.14%) in a descending order.This is in agreement with other studies done by Pakfetrat et al. (17) and Oliveira Alves et al. (18), in which buccal mucosa was the site most affected, followed by the tongue and gingiva.
The most common ulcerative lesion was RAS (5.85%) followed by recurrent herpes simplex virus infection and traumatic ulcer (2.43%).The number of patients with recurrent aphthous stomatitis was 53, 29 patients (54.71%) were females and 24 patients (45.28%) were males.The most commonly affected age group (62.26%) was between the ages of 20-29 years, this is compatible with other studies in which recurrent aphthous ulcers were more common among females Gaphor and Hussien, (19) .The majority of the minor recurrent aphthous ulcerations (33.87%) were seen in the lower lip, followed by the mucobuccal fold area (20.96), buccal mucosa (17.74%), lateral tongue (8.06%), upper lip (8.06%), tip of tongue (6.45%), and ventral tongue (4.83%) in a descending order.This is in agreement with Gaphor and Hussien, which stated that minor aphthous ulcers were found in nonkeratinized mobile mucosa of the oral cavity (19).
The number of patients with denture stomatitis was 23, 18 patients (78.26%) were females and 5 patients (21.73%) were males, this is compatible with other studies done by Baena-Monroy et al. in which they confirm that stomatitis mainly affects women (20) .The most commonly affected age groups (26.08%, 26.08%) were between 40-49, and 50-59 years, they were also a little bit younger than the patients of other studies Vitkov and Lugstein (21) and Baena-Monroy et al. (20) in