Common oral lesion found Jerry Bouquot

JA O A
A R T I C L E S
The fir s t detailed study o f common oral connective tissue and mucosal lesions in US adults is
reported. M ore than 10% o f the 23,616 w hite Am ericans who p a rticip a ted in a mass screening
exam ination had at least one oral lesion. The 30 most common lesions, which represented more
than 93 % o f all reported lesions, are ranked according to gender-specific prevalence rates.
Leukoplakia was the most common mucosal lesion. O ral carcinom a ranked 24th overall. Data
fro m this study are compared with data fro m other studies dealing w ith the prevalence o f oral
lesions.
Common oral lesions found during a mass
screening examination
J e r r y E. B o u q u o t, D D S , M SD
erm s such as com m on, uncom ­
m on, ra re , a n d n o t uncom m on
long have been u sed by th e d ental
profession to describe o ral lesions, and yet
th e s e te r m s a r e d i f f i c u l t to d e f in e .
E pidem iologic descriptions o f oral cancer
are available,1' 4 b u t virtually all d escrip­
tions o f b en ig n oral lesions have com e
fro m th e clinical co llectio n s o f d e n ta l
schools, hospitals, an d oral pathology bi­
opsy services. A lth o u g h often useful in
o th e r respects, n o n e o f these collections o f
cases is rep resen tativ e o f o ral lesions in the
p o p u lation at large. H ow ever, concepts o f
epidem iologic term s such as incidence and
p r e v a le n c e u s u a lly a r is e fro m th e s e
clinicopathologic, n o n re p re se n ta tiv e in ­
vestigations. T h e results are that th e th ree
m ost widely d istrib u te d o ral pathology
textbooks o f th e past 2 decades have v irtu ­
ally no m ean in g fu l referen ces to the fre ­
quency o f oral disease in th e US p o p u la­
tion an d generatio n s o f dental students
have been ta u g h t how to identify a n d treat
th e “m ost co m m o n ” oral lesions w hen, in
fact, it is n o t know n w hat lesions are m ost
com m on.5' 7
Large-scale, popu latio n -b ased studies
T
50 ■ JAD A, V ol. 112, January 1986
A ge (sp an o f years)
F ig 1 ■ T h e sam p le p o p u la tio n fo r th is stu d y w as b ia se d d e lib e ra te ly to w a rd o ld e r a d u lts , as
th e y w e re m o re lik e ly to h a v e o ra l c an c e r. T h e a g e d is trib u tio n o f th e 23,616 a d u lts in the
sam p le p o p u la tio n is sh o w n . T h e m e d ia n a g e fo r th e sam p le w as 55.9 y e ars, w ith a sta n d a rd
d e v ia tio n o f 13.7 years.
ARTICLES
o f r o u tin e o r a l c o n n e c tiv e tis su e o r
m ucosal lesions w ere n o t published until
1971, a n d th e first o f those was lim ited in
scope. K n ap p 8 described the lesions found
m ost freq u en tly d u rin g the exam inations
o f 181,388 A rm y inductees. A lmost all o f
th e in d u ctees w ere m ales betw een 18 and
26 years old, an age bracket n o t know n fo r
th e p resen ce o f oral connective tissue or
m ucosal lesions. A n o th e r study, by Ross
an d G ross,9 was a difficult-to -u n d erstan d ,
ab breviated description o f oral soft tissue
o r m ucosal lesions th a t w ere fo u n d in
11,884 ad u lts aged 35 years o r older who
w ere e x a m in e d in a fre e , m u ltip h asic
h ea lth -sc re en in g clinic in a low -incom e
are a o f B rooklyn, NY. H ow ever, the d ata
from this study w ere re p o rte d using in­
a d e q u ate epidem iologic term s, which led
to in accu rate re p o rtin g o f th e d a ta .6,10
T h e p r e s e n t in v e s tig a tio n p r e s e n ts
po p u latio n -b ased info rm atio n on the eas­
ily d em o n strab le o r rem arkable oral con­
nective tissue an d m ucosal lesions; th a t is,
those lesions th a t w ould be likely to be
noticed in th e typical practice o f a dentist.
T h is investigation sum m arizes th e exam i­
nations p e rfo rm e d by dentists o f m ore
th an 32,000 adults, m ost o f w hom w ere
aged 35 years o r o ld e r an d w ere atten d in g
voluntarily o ral cancer screening clinics.
Table 1 ■ The 3,783 oral mucosal and connective tissue lesions found
in 23,616 adults are categorized according to each lesion’s clinical
appearance, and gender-specific prevalence rates per 1,000 people
are reported for each category.
Clinical appearance
Surface changes
White (keratotic)
Red discoloration*
White (nonkeratotic)f
Ulcers o r vesicles
Brown o r black discoloration
Soft tissue masses
T umors
Cystic swellings
Miscellaneous
Total
Methods
T h e d a ta w ere collected fro m 17 mass oral
sc re e n in g s in v a rio u s c o m m u n itie s in M in­
n e so ta b e tw e e n 1957 a n d 1972. F ro m th e
32,391 p atients ex am ined d u rin g those years,
23,616 d etailed exam ination cards w ere avail­
able fro m the U niversity o f M innesota School o f
D entistry to use in this study. T h e data have not
b een used, un til now, except fo r a few publica­
tions o f lim ited scope o r professional circula­
tio n .11' 13 T h e discrepancy in the availability o f
d a ta is e x p la in ed by th e fact th a t the first six
Females
Total
49.3
26.2
18.4
7.8
2.2
15.8
26.8
5.4
7.7
1.6
27.8
26.6
10.0
7.8
1.8
56.5
2.7
56.7
3.6
55.7
3.3
25.5
26.8
26.3
188.6
144.4
159.3
♦ E x clu d in g h e m a n g io m a s, w hich a re classified as tu m o rs.
fF o rd y c e ’s g ran u le s, w hite c o ated to n g u e , candidiasis, a m o n g o th ers.
m ass screenings used sim ple p a tie n t in fo rm a ­
tion cards th a t w ere considered in ad e q u ate fo r
inclusion in this investigation. All clinically visi­
ble oral abnorm alities, except caries, gingivitis,
a n d p e rio d o n titis, w ere re q u e ste d to be re ­
p o rte d fo r all sub seq u en t screenings, a n d lec­
tu r e s fr o m o r a l p a th o lo g is ts o r o ra l a n d
he most common clinical appearance of oral lesions found in
the sample population was that of a single, exophytic mass,
which accounted for 37.4% of all reported lesions.
T h is investigation is th e first detailed one
o f its type in this country an d should aid
d entists in th e ir u n d e rsta n d in g o f w hat
constitutes a com m on oral lesion.
Males
m axillofacial su rgeons to p articip atin g dentists
em p h asized this re q u est p rio r to each screen­
ing. O ral a n d m axillofacial su rgeons o r oral
p athologists (or both) w ere available at each
screen in g to confirm th e clinical diagnoses o f
difficult lesions a n d to reco m m en d o r p e rfo rm
biopsies. T h e ex am in ers p e rfo rm e d 349 biop­
sies o f lesions fo u n d in this g ro u p o f exam inees,
w hich re p re s e n te d 1.5% o f th e g r o u p a n d
11.6% o f all o f the lesions re p o rte d .
T h e com m unities sam pled ra n g e d in p o p u la ­
tion from 2,606 to 311,328 people, a n d the
n u m b e r o f p eople screened re p re se n te d 12.6%
o f th e p eo p le w ho w ere o ld er th a n 30 years in
those com m unities. H ow ever, m ore th an 86%
o f the p eo p le re p re se n te d in this investigation
re sid ed in co m m unities o f less th a n 27,000
p e o p le , a n d , in such com m unities, 61.6% o f the
p eo p le aged 30 years o r o ld e r w ere exam ined.
T h e larg e p e rc e n ta g e o f p a rtic ip a n ts is e x ­
p la in e d m ost likely by th e e x te n siv e use o f
new spapers, ra d io a n n o u n ce m e n ts, a n d com ­
m u n ity f o r u m s to p u b lic iz e e a c h o f th e
sc ree n in g s. T h e scree n in g s w ere sp o n so red
jo in tly by th e A m erican C a n ce r Society, th e
M innesota State D ental Association, th e U n i­
versity o f M innesota School o f D entistry, a n d
th e M innesota D e p artm en t o f H ealth.
T h is sam ple population was biased d e lib e r­
ately tow ard o ld er adults, and th e age d istrib u ­
tio n (Fig 1) shows how successful th e o rg an izers
w ere in a ttrac tin g th o se p eople m o re likely to
have oral cancer. T h e total sam ple m ean age o f
55.9 years was alm ost two tim es th a t o f the col­
lective com m unities’ average age o f 28.8 years.
T h e sam ple also was biased w ith re g a rd to race
a n d g e n d e r. O f th e total sam ple, 99.5% w ere
w hite a n d 35.9% w ere m ale, as c o m p a red w ith
th e collective co m m unities’ 30 years o r o ld er
p o p u latio n o f 47% m ales. T h is latter bias, how ­
ever, was c o u n teracted by th e use o f g en d erspecific prevalence rates in this investigation. A
m o re d etailed analysis o f the sc ree n e d p o p u la ­
tio n was published e arlie r.11
T h e exam ination c ard s o f p a tie n ts w ere re ­
viewed a n d c o m p u te r coded by a single inves­
tig ato r to elim inate in te rp e rso n a l d iffere n ce s in
th e term inology a n d in te rp re ta tio n o f previous
e x am in ers’ descriptions. All lesions re p o rte d in
un u su a l o r am biguous term inology w ere clas­
sified as m iscellaneous lesions. T h is practice ac­
co u n ts fo r a d isp ro p o rtio n ately high n u m b e r o f
m iscellaneous lesions re p o rte d in the d a ta but
allows fo r m ore security a bout th e specific clini­
cal diagnoses re p o rte d by exam iners.
Results
T h e d e n tis ts r e p o r te d fin d in g 3 ,7 8 3 o ra l
m ucosal a n d connective tissue lesions d u rin g
Bouquot : COM MON ORAL LESIONS ■ 51
ARTICLES
th e e x a m in a tio n o f th e sa m p le p o p u la tio n
(8,477 m ales; 15,139 fem ales). An additio n al
1,204 lesions w ere fo u n d on th e face, neck, o r
o ro p h a ry n x but a re not discussed in this paper.
T h e 3,783 oral a n d connective tissue lesions
w ere fo u n d in 2,824 p e o p le , o r 10.3% o f the
sam ple p o p u latio n . T h u s, a pproxim ately 25%
o f p eo p le with oral lesions h a d m ore th an one
lesion. A total o f 64 d iffe re n t diagnoses w ere
m ad e , som e as unspecific as “lesion.” T ab le 1
categorizes th e lesions into general g ro u p s ac­
c o rd in g to th e ir clinical ap p ea ran c e a n d in ­
c lu d e s g e n d e r-sp e c ific p re v alen c e ra te s fo r
each. A gain, the d a ta in T a b le 1 relate only to
th o se lesions th a t w ere obvious o r rem arkable.
T h u s, th e prevalence rates should be viewed
only as m inim al rates.
As can be seen from I'able 1, the m ost com ­
m on clinical a p p ea ran c e o f o ral lesions in this
p o p u latio n was th a t o f a single, exophytic mass,
w hich acco u n ted fo r 37.4% o f all re p o rte d le­
sio n s (Fig 2). O f th e se m asses, 5.5% w ere
cystic— usually m ucoceles. A p roblem arose re l­
ative to th e re p o rtin g o f h em angiom as in this
study. M ost e x am in ers w ho re p o rte d th a t diag­
nosis did so w ithout d escribing th e masses. As a
result, n o way now exists to d e te rm in e which
h e m a n g io m a s w e re f l a t a n d w h ic h w e re
exophytic. T h e prevalence o f exophytic lesions
listed in T ab le 1 u n d o u b ted ly is h ig h er th a n the
tru e prevalence because it includes all h e m a n ­
giom as (Fig 3). It also is possible th a t a few
pyogenic g ra n u lo m as w ere included u n d e r this
d ia g n o s is b e c a u s e o n ly o n e p y o g e n ic
g ra n u lo m a was re p o rte d d u rin g the ex am in a­
tion perio d .
O f th e m ucosal su rface lesions, m ost w ere
w hite, k eratotic entities, accounting fo r 37.6%
o f such lesions. T h e large n u m b e r o f lesions in
th e m iscellaneous category has been ex p lain ed
earlier, b u t it can be stated f u r th e r th a t 34.5% o f
th e lesions in the m iscellaneous category w ere
o f the n ondiagnostic lesion types, and the o th e r
65.5% w ere iden tified in 32 d iffere n t diagnoses
th a t w ere difficult to categorize (for exam ple,
a n g u la r c h e ilitis, sc a r tissu e , a n d fissu re d
to n g u e, an exam ple o f w hich is show n in Fig 4).
Because o f the d e a rth o f epidem iologic data
re la tin g to n o n m alig n an t oral lesions, it seem ed
a p p ro p ria te to p ro v id e a re fe re n c e list th a t
ra n k e d th e 30 m ost com m on o ral soft tissue a n d
m ucosal lesions fo u n d in o ld e r A m ericans.
T ab le 2 p re sen ts such a ra n k in g according to
prevalence rates fo r m ales a n d females. T h is
table re p re se n ts 93.1% o f all lesions re p o rte d .
L eukoplakia is d e fin e d , fo r this p a p er, as a
w hite, k eratotic patch th at c an n o t be scraped o ff
o r given a d iffe re n t nam e, such as nicotine
p alatin u s o r lichen p lanus (Fig 5). T h e a p p e a r­
ance o f m o re th a n 26% o f th e leukoplakias
fo u n d in this population re q u ire d that biopsies
o f th e p atches be do n e. O f these leukoplakias,
13.8% w ere epithelial dysplasias a n d 12.2%
w ere early invasive squam ous cell carcinom as
(g rad e I). T o ri a n d exostoses a re not soft tissue
lesions b u t a re inclu d ed in T ab le 2. A p p ro x i­
m ately h a lf o f th e in flam m atory ulcers w ere
labeled trau m atic ulcers (often d e n tu re related)
b u t 39.9% w ere said to be ap h th o u s ulcers a n d
52 ■ JA D A , V ol. 112, January 1986
F i g 2 ■ A p p r o x i m a t e l y 3 .7 % o f t h e
e x a m in e e s h a d soft tis su e m a sse s in th e ir
m o u th s . I r rita tio n fib ro m a s (show n) a re u s u ­
a lly o n th e b u c ca l m u c o sa a n d w e re th e m o st
fre q u e n tly d ia g n o se d so ft tis su e le sio n .
F ig 3 ■ T h e m o st fre q u e n tly n o tic e d o ra l
d is c o l o r a tio n , h e m a n g io m a (s h o w n ), w as
f o u n d o n th e la b ia l m u c o sa in a p p ro x im a te ly
tw o -th ird s o f th e sam p le p o p u la tio n e x a m ­
in e d a n d w as th e m o st co m m o n lip le sio n in
fe m a le s.
F ig 5 ■ L e u k o p la k ia (show n) w as th e m ost
co m m o n le sio n d ia g n o se d d u r in g th e m ass
s c re e n in g e x a m in a tio n , a n d th e b u c c a l m u ­
c o sa w as th e in tra o ra l site m o st fre q u e n tly
in v o lv e d .
Fig 4 ■ T h e s ec o n d m o st c o m m o n to n g u e
le sio n re p o rte d w as fis s u re d to n g u e (show n);
it w as th e 11th m o st c o m m o n o ra l lesion.
13.0% o f the total w ere c hronic e n o u g h to re ­
qu ire th a t biopsies be p e rfo rm e d (Fig 6). Re­
sults o f two o f th e 16 biopsies disclosed th a t the
ulcers w ere squam ous cell carcinom as, a n d the
o th e r carc in o m a s w ere called leu k o p lak ias.
M any o f the “inflam m ations” o r “irrita tio n s”
w ere d e n tu re re la te d a n d in clu d e d such diag­
noses as d e n tu re sore m o u th , d e n tu re sore spot,
o r buccal irritatio n at the occlusal plane. O f the
tori, 69% w ere located o n th e palate. A p p ro x i­
m ately 24% o f the papillom as w ere fo u n d on
th e labial m ucosa. B ecause biopsies w ere d o n e
on only a th ird o f the papillom as (Fig 7), it is
likely th a t som e o f th e labial lesions in th e re ­
m ain in g tw o-thirds w ere v e rru c a vulgaris. All
cases o f lichen p lanus w ere re p o rte d as n onerosive a n d nonbullous, a n d only o n e case had
evidence o f skin lesions alo n g with the oral le­
sions. Biopsies w ere d o n e o n only a q u a rte r o f
th e e p id e rm o id cysts fo u n d in the sam ple p o p u ­
lation; thus, sim ilar clinical findings such as
d e rm o id a n d lym phoepithelial cysts should be
included in this classification, especially because
a th ird o f these cysts w ere fo u n d on th e poste­
rio r lateral p a rt o f the tongue.
M any o th e r diagnoses o f lesions fo u n d in the
sam ple g ro u p w ere m ade. T h e follow ing lesions
have prevalence rates o f .04/1,000 to .4/1,000
sam ple p o p u latio n a n d a re listed in decreasing
o rd e r o f th e frequency w ith w hich they were
fo u n d : leu k o ed em a, glossitis, ra n u la , candi­
diasis, bifid uvula, gingival fibrous hyperplasia,
c o m m issu ra l lip p its, sia lo lith , x a n th o m a ,
pyogenic g ra n u lo m a, sialadenitis, pigm ented
nevus (m ole), a n d m acroglossia.
I f m icroscopically p ro v e d squam ous cell car­
cinom as w ere tre a te d as se p a ra te lesions in
T a b le 2, they w ould ra n k as th e 14th m ost
com m on lesion fo r m ales (2.4/1,000 males), the
4 3 rd m ost com m on lesion fo r fem ales (.04/
1,000 fem ales), a n d th e 24th m ost com m on le­
sion fo r b oth g en d ers (1.1/1,000 sam ple popula­
tion) (Fig 8). Slightly m o re th an 30% o f lesions
described clinically as p ro b ab le o r possible car­
cinom as w ere co n firm ed m icroscopically to be
carcinom as.
T h e location o f an oral lesion o ften is critical
in d e te rm in in g its d ifferen tial diagnosis. A final
ra n k in g o f lesions by site is provided in T able 3.
Discussion
T h e prevalence o f a disease is defin ed as
th e frequency th at a disease occurs or re-
ARTICLES
Table 2 ■ The most frequently reported mucosal lesions, which represent 93.1% of all
lesions reported, are ranked by prevalence rates for males (n = 8,477), females (n = 15,139)
and for both genders combined (N = 23,616). Prevalence rates per 1,000 people are
enclosed in parentheses.*
Rank
Leukoplakia
(45.2)
2
Palatal or
m andibular tori
Fordyce’s
granules
Inflam m ation
or irritation
Irritation
fibroma
Hem angiom a
(22.8)
3
4
5
6
7
8
9
10
11
12
Inflam m atory
ulcer
Papilloma
Tobacco or
sn u ff pouch
Fissured
tongue
Varicosities
(17.7)
(15.8)
(13.0)
(8.4)
(5.4)
(5.3)
(4.3)
(3.5)
(3.5)
16
17
Geographic
tongue
Epulis
fissuratum
Herpes
labialis
Enlarged
lingual tonsil
Scar tissue
H em atom a
(2.4)
(2.0)
18
Mucocele
(1.9)
19
Angular
cheilitis
Papillary
hyperplasia
Lichen
planus
Black
hairy tongue
Buccal
exostoses
Median rhom boid
glossitis
Chronic
cheek bites
Epiderm oid
cyst
Nicotine
palatinus
Amalgam
tattoo
Smooth,
red tongue
O ral melanotic
macule
(1.8)
13
14
15
20
21
22
23
24
25
26
27
28
29
30
Total
Males and females
Females
Males
1
(3.4)
(3.4)
(2.4)
(2.4)
(1.7)
(1.2)
(1.2)
(0.9)
(0.8)
(0.7)
(0.7)
(0.6)
(0.6)
(0.6)
(0.6)
174.2/1,000
Palatal or
m andibular tori
Leukoplakia
Inflam m ation
o r irritation
Irritation
fibroma
Fordyce’s
granules
Inflam m atory
ulcer
Epulis
fissuratum
Papilloma
H em angiom a
Papillary
hyperplasia
Varicosities
Fissured
tongue
Geographic
tongue
Herpes
labialis
Mucocele
Scar tissue
Angular
cheilitis
Chronic
cheek bites
H em atom a
Enlarged
lingual tonsil
Lichen
planus
Amalgam
tattoo
Oral melanotic
macule
Buccal
exostoses
Median rhom boid
glossitis
Smooth,
red tongue
Epidermoid
cyst
Lipoma
Nonlingual
oral tonsils
Black
hairy tongue
(30.0)
Leukoplakia
(29:1)
(20.0)
Palatal or
m andibular tori
Inflam m ation
o r irritation
Irritation
fibroma
Fordyce’s
granules
Hem angiom a
(27.6)
(18.0)
(11.4)
(5.2)
TCTj"“
(4.4)
(4-2)
(4.1)
(3.8)
(3.4)
(3.1)
(3.0)
(2.6)
(2.6)
(1.9)
(1.9)
(1-4)
(1.4)
(1.2)
(1.1)
(1.0)
(1.0)
(0.9)
(0.5)
(0.5)
(0.4)
(0.4)
(0.3)
(0.3)
135.1/1,000
Inflam m atory
ulcer
Papilloma
Epulis
fissuratum
Varicosities
Fissured
tongue
Geographic
tongue
Papillary
hyperplasia
Herpes
labialis
Mucocele
Scar tissue
A ngular
cheilitis
Enlarged
lingual tonsil
Hem atom a
Tobacco or
sn u ff pouch
Chronic
cheek bites
Lichen
planus
Buccal
exostoses
Amalgam
tattoo
O ral melanotic
macule
Median rhom boid
glossitis
Black
hairy tongue
Smooth
red tongue
Epiderm oid
cyst
Lipoma
(17.3)
(11.9)
(9.4)
(5.5)
(5.2)
(4.6)
(4.1)
(3.4)
(3.2)
(3.1)
(3.1)
(2.5)
(2.4)
(2.1)
(1.9)
(1.6)
(1.6)
(1.4)
(1.2)
(1.1)
(0.9)
(0.9)
(0.9)
(Ô.6)
(0.6)
(0.5)
(0.5)
(0.3)
147.6/1,000
* I f m icroscopically p ro v ed c arcin o m a was in clu d e d , it w o u ld ra n k 14th fo r m ales a n d 2 4 th f o r b o th g en d ers; sev ere ep ith e lia l dy sp lasia w o u ld r a n k 18th fo r m ales
(2.1/1,000 m ales), 2 9 th fo r fem ales (.4 /1 ,0 0 0 fem ales), a n d 2 4 th fo r b o th g e n d e rs (1.1/1,000 p eo p le).
Bouquot : COMMON O RAL LESIONS ■ 53
ARTICLES
F ig 6 ■ A p p ro x im a te ly 25% o f th e 3,783 le ­
s io n s re p o rte d w ere m u ltip le , a s is tru e o f th is
tra u m a tic u lc e r o v e rly in g a to ru s p a la tin u s.
P a la ta l to ri w e re th e m o st co m m o n o ra l le ­
sio n s in fe m a le s a n d th e m o st co m m o n le ­
s io n s o f th e h a rd p a la te.
F ig 7 ■ S q u am o u s p a p illo m a (show n) w as
th e m o st co m m o n n e o p la sm r e p o rte d a n d w as
th e m o st c o m m o n so ft tis su e m ass o n th e
to n g u e .
V ? v*
F ig 8 ■ I f m ic ro sc o p ic a lly p ro v e d s q u am o u s
c ell c a rc in o m a (show n) h a d b e e n in c lu d e d in
th e ra n k in g o f c lin ic a l le sio n s, it w o u ld h a v e
b e e n th e 14th m o st co m m o n le sio n in m a le s
a n d th e 2 4 th m o s t c o m m o n le sio n f o r b o th
g e n d e rs c o m b in e d .
curs in a p o p u latio n at a p articu lar tim e.14
Prevalence d iffers fro m incidence, w hich
is d efin e d as th e n u m b e r o f new cases o f a
d is e a s e th a t a r e d ia g n o s e d d u r i n g a
specified p e rio d .14 A review o f th e dental
literatu re discloses th a t these term s often
a re used im properly. T h is is tru e even
th o u g h , in 1941, M cC arthy15 attem p ted to
pro v id e th e prevalence rates fo r com m on
oral m ucosal disease. It w ould be useful to
be able to provide th e profession with the
an n u a l incidence o f a disease. H ow ever,
even studies o f large p opulations, such as
th e p r e s e n t o n e , can p ro v id e n o th in g
m o re th an prevalence data. For th e p u r ­
poses o f this study it can be assum ed that
th e 23,616 persons included in this inves­
tigation w ere exam ined at a single, mass
screening, as no statistically significant d if­
feren ces existed betw een th e populations
o f th e 17 sep arate M innesota screening
clinics.11 T his d ata base is m o re than 4.5
tim es la rg e r than the m inim um d a ta base
fo r prevalence studies reco m m en d ed by
54 ■ JA D A , V ol. 112, January 1986
F ig 9 ■ I t is lik e ly th a t o n ly th e m o re sev ere
c ase s o f so m e e x tre m e ly co m m o n le sio n s,
s u c h as lin g u a l v a ric o sitie s (show n), w ere re ­
p o rte d d u r in g th e m ass s c r e e n in g e x a m in a ­
tio n .
th e W orld H ealth O rg a n iz atio n .16
T h e age bias o f this sam ple (Fig 1) is an
advantage in th a t it allows fo r access to
inform ation ab o u t th e g ro u p m ost likely to
have oral soft tissue disease. T h e d isadvan­
ad ju stin g th e m ost com m on lesion, leuko­
plakia, to th e US p o p u latio n fo r 1970, the
p o p u latio n figures m ost relev an t to the
tim e d u rin g which these d a ta w ere col­
lected. W hen all ages are in clu d ed in the
p o p u latio n base, th e cru d e p revalence rate
o f 29.1/1,000 people p ro v id ed in T ab le 2
decreases to 16.1/1,000 people.
T h e use o f m ultiple ex am in ers, few o f
w hom w ere specialists in oral disease d iag ­
n o sis is a n o t h e r d is a d v a n ta g e o f th e
m e th o d o f d a ta collection u sed in this
study; it tends to cause u n d e rre p o rtin g o f
b o rd erlin e lesions a n d lesions th a t a re con­
sid e re d v ariatio n s o f n o rm a l an ato m y ,
such as F ordyce’s g ran u les, tori, an d var­
icosities (Fig 9). T h e m eth o d o f d ata collec­
tion used also m eans th a t som e o f the
diagnoses m ust rem ain questionable. T his
p ro b lem , how ever, was c o u n te re d with
som e success by th e use o f o n e perso n to
review all the p atien t in fo rm atio n cards
a n d by the liberal use o f the m iscellaneous
category, as explained earlier. T o date,
th e re is no m ore practical way o f exam in­
ing 32,000 persons w ithout th e use o f such
help. T h e use o f such ex am in ers, how ever,
has an advantage. Prevalence rates d e te r­
m ined are sim ilar to those th a t a re found
typically in the practice o f dentistry.
A n additional question may arise n o t as
to the validity o f the p rese n t d ata b ut as to
its p ertin en ce. A re th e d ata o u td a ted ? T h e
answ er is no. T h ese most com m on oral
m ucosal a n d connective tissue lesions have
n o t been show n to ch an g e readily in eith er
th e ir ap p earan ce o r th e ir freq u en cy with
the passage o f tim e. T h e prevalence o f
h e r p e s lab ialis m ay c h a n g e as b e tte r
trea tm e n ts becom e available. T h e p rev a­
lence o f epulis fissurata m ay ch an g e as
m o re peo p le m ain tain an d retain th e ir
d en titio n . T h e prevalence o f leukoplakia
may ch an g e as sm oking habits change. But
ore than 10%of a group of 23,616 adults had at least one oral
lesion that was unusual enough to be recorded by a dentist.
tage is th a t it does n ot allow fo r g e n e r­
alizations to be m ade ab o u t th e en tire US
p opulation, as the sam ple p o p u latio n in ­
cludes only o ld e r w hite A m ericans. T h e
d an g e r o f applying these prevalence data
to a d iffe ren t p o p u latio n is show n by age
these changes, in all likelihood, have not
o ccu rred yet. Also, no la rg e r o r m o re reli­
able d ata base exists from w hich to glean
this inform ation.
T h e p ro p o rtio n o f p eo p le wilh o ral le­
sions u nusual en o u g h fo r a d en tist to re-
ARTICLES
p o rt th em o n an exam ination card, m ore
th an 10% o f th e p rese n t pop u latio n , is
large, b u t it should be assum ed th a t this
p o p u latio n is biased tow ard oral lesions.
T h e p articipants w ere volunteers a tte n d ­
ing free o ral screening clinics. T h is bias,
how ever, w ould a p p e a r to be co u n tered ,
a n d p ro b a b ly n e g a te d , by th e u n d e r ­
rep o rtin g m e n tio n e d earlier and by the
fact th a t th e sam ple population was such a
large p ro p o rtio n o f all o ld e r p ersons in the
areas in w hich th e screenings w ere held.
Most o f th e pathologic conditions that
th e d en tal profession has considered to be
co m m o n a re , a c c o rd in g to th is study,
com m on. T able 2 lists the nam es o f several
lesions th a t seldom have been placed in a
com m on category. T h ey include nonlingual o ral tonsils (benign lym phoid ag g re­
gates), lipom as, ep id erm o id cysts, buccal
exostoses, o ral m elanotic m acules, chronic
cheek bites, an d an g u lar cheilitis. C on­
versely, certain lesions that long have been
considered com m on are n o t listed in T able
2; fo r e x a m p le , p y o g en ic g ra n u lo m a s
(perhaps a disease o f y o u n g er persons),
S h ira ,17 in his p a p e r on co m m o n oral
m ucosal a n d connective tissue lesions, in ­
cluded 16 o f th e p resen t investigation’s 30
com m on oral lesions. C arcinom a an d se­
vere epithelial dysplasia each w ould be in ­
cluded as o n e o f th e 30 com m on oral le­
sions if m icroscopic lesions w ere included
in the ran k in g , which justifies fre q u en t
a n d th o ro u g h o ral exam inations o f every
d en tal patient.
T ab le 2 also provides, fo r th e first tim e,
at least th e beg in n in g o f a d efinition o f
com m on o ral lesions. I f th e first 30 lesions
listed a re accepted as a p a rt o f th e d efin i­
tion, th en a lesion th at is com m on would
be fo u n d in approxim ately .3/1,000 to 30/
1,000 sam ple po p u latio n , o r .03% to 3% o f
th e total populatio n . T h e m ost com m on
lesion m ust be co n sid ered serious because
o f its p o tential fo r m alignancy.
It could follow th a t a lesion fo u n d in a
g ro u p o f individuals as larg e as th e p resen t
o n e, b u t a p p e a rin g in freq u en tly en o u g h
to be listed in th e first 30 lesions listed,
could be te rm ed u n co m m o n (prevalence
r a te s o f a b o u t 0 .0 3 -0 .3 /1 ,0 0 0 sa m p le
po p u latio n ). Any lesion n ot fo u n d in this
larg e g ro u p could, probably correctly, be
te rm e d ra re (prevalence rates less th an
.03/1,000 total p o p u latio n o r 3/100,000
p erso n s). T h is te rm in o lo g y is d eriv e d ,
h o w ev e r, fro m th e s tu d y o f an o ld e r
g ro u p . K n a p p ’s8 in fo rm a tio n , g lean ed
f r o m a s tu d y o f A rm y in d u c te e s , a
y o u n g er g ro u p , indicates th a t all b u t the
follow ing fo u r types o f oral connective tis­
sue an d m ucosal lesions a re u n co m m o n o r
ra re by th e fo reg o in g d efinition: papillary
hy p erp lasia, papillom as, fibrom as, an d in ­
flam m atory ulcers.
Several aspects o f the p rese n t investiga­
tion deal w ith gender-specific differences
an d sim ilarities o f oral disease frequency.
Table 3 ■ The most common oral connective tissue and mucosal lesions are ranked according to
location- and gender-specific prevalence rates.
Rank
Site
Labia oris
Bucca
Gender*
T ongue
H ard
palate
Leukoplakia
Hem angioma
F
Hemangioma
M
M
Fordyce’s
granules
Fordyce’s
granules
Leukoplakia
H erpes
labialis
Leukoplakia
F
Leukoplakia
M
Varicosities
F
Varicosities
M
T orus
palatinus
Torus
palatinus
Inflam m ation or
irritation
Inflam m ation or
irritation
Epulis
fissuratum
Epulis
fissuratum
Mandibular
tori
Mandibular
tori
F
Soft
palate
M
F
Maxillary
ridge
M
F
M andibular
ridge
2
M
F
Floor
o f m outh
It
M
F
Irritation
fibroma
Inflam m ation
irritation
Inflam m ation
irritation
Fissured
tongue
Fissured
tongue
Inflam m ation
irritation
Inflam m ation
irritation
Papilloma
3
Irritation
fibroma
Irritation
fibroma
Irritation
fibroma
Leukoplakia
or
Hem angioma
or
Varicosities
or
or
Papilloma
Leukoplakia
Inflam m ation or
irritation
Leukoplakia
Inflam m ation or
irritation
Geographic
tongue
Geographic
tongue
Papillary
hyperplasia
Papillary
hyperplasia
Oral
tonsils
Oral
tonsils
Buccal
exostoses
Buccal
exostoses
Inflam m ation or
irritation
Leukoplakia
4
H erpes
labialis
Angular
cheilitis
Tobacco or
snuff pouch
Inflam m ation or
irritation
Inflam m atory
ulcer
Inflam m atory
ulcer
Papilloma
Leukoplakia
Irritation
fibroma
Irritation
fibroma
Irritation
fibroma
Scar
tissue
Inflam m ation or
irritation
Leukoplakia
Epulis
fissuratum
Epulis
fissuratum
5
Angular
cheilitis
Leukoplakia
Inflam m ation or
irritation
Inflam m atory
ulcer
Varicosities
Mucocele
or ranula
Irritation
fibroma
Irritation
fibroma
Nicotine
palatinus
Leukoplakia
Hem angiom a
Hem angiom a
Irritation
fibroma
Irritation
fibroma
Irritation
fibroma
Irritation
fibroma
*M = m ale, F = fem ale,
tF ir s t, o r m ost c o m m o n lesion in th is site.
Bouquot : COM M ON O RAL LESIONS m 55
ARTICLES
Table 4 ■ Compared are the prevalence rates per 1,000 adults of com­
mon oral lesions reported in US investigations.
Bouquot (this study), 1985
Ross and Gross,9 1971
Diagnosis___________________ (N = 23,616)_______________ (N = 11,884)
Leukoplakia
Inflam m ation or
irritation
Irritation
Fibroma
Hem angioma
Inflam m atory
ulcer
Papilloma
Epulis
fissuratum
Papillary
hyperplasia
Geographic
tongue
Mucocele
Scar tissue
Enlarged
lingual tonsil
Chronic
cheek bites
Lichen planus
Squamous cell
carcinoma^
Amalgam
tattoo
Median rhomboid
glossitis
28.5 (45.2)*
17.3
5.7 to 32.4
30.9
11.9 (13.0)
5.5 (8.4)
7.9
t
Knapp,8 1971
(N = 181,388 males)
.2
t
1.2
.1
5.2
4.3
(5.4)
(4.7)
11.1
4.1
.5
2.2
4.1
(3.4)
t
.4
3.1
(1.7)
27.3§
7.1
3.1
2.4
2.1
(3.4)
(1.9)
t
1.4
3.1
.5
.2
t
1.6
(2.4)
t
.3
1.2
1.1
(.7)
(1.2)
t
t
.2
.1
1.1
(2.4)
.1
.0
.9
(.6)
+
.1
.6
(.8)
t
.1
♦Prevalence rate s fo r m ales a re en clo sed in p a re n th e se s.
t N o e p id em io lo g ic d a ta w e re available fo r lesion.
tO n ly listed as “d e n tu r e h y p e rp la sia s.”
§ M icroscopically p ro v ed .
T ab le 2 shows a correlatio n betw een the
ran k in g s o f soft tissue lesions fo u n d in
m ales an d those fo u n d in fem ales. Even
th o u g h leukoplakia is, as expected, m uch
m o re p rev alen t in th e o ld e r males o f this
sa m p le p o p u la tio n th a n in th e o ld e r
fem ales, leukoplakia also is the second
m ost com m on oral lesion in o ld e r females.
T h e p revalence rates o f several lesions
w ere significantly d iffe re n t in males and
fem ales, a lth o u g h th e d ifferen ces w ere
n o t reflected necessarily in significant d if­
ferences in ranking. T h ese lesions are leu­
k o p la k ia , F o rd y c e ’s g ra n u le s , h e m a n ­
giom a, papillary h y perplasia o f the palate,
a n d oral m elanotic m acules. T able 3 also
shows th e significant d ifferences fo u n d in
th e frequencies o f com m on lesions that
occur in various oral sites.
W ith re g a rd to a com parison o f th e p re ­
sent d ata with those d ata d eterm in e d by
th e o th e r US epidem iologic investigations
o f com m on oral lesions, T able 4 shows a
reasonably close co rrelation o f prevalence
56 ■ JA D A , V ol. 112, January 1986
rates
those
o ld e r
those
fro m th e p rese n t p o p u latio n with
fro m a study by Ross an d G ross9 o f
p ersons in B rooklyn, NY, a t least for
lesions th a t a re well d efin ed clini­
a d im in u tio n o f prevalence rates fo r al­
m ost every oral m ucosal and connective
tissue lesion. His sum m ary concurs with
th e belief th a t soft tissue lesions are u n ­
I
he 30 most common lesions represented more than 93% of all
reported lesions andprovided a prevalence rate of 147.6/1,000
people examined.
c a lly ; th a t is, f ib r o m a s , p a p illo m a s ,
m ucoceles, an d scar tissue. L eukoplakia is
not d efin ed by this study an d its d ata could
be in te rp re te d as p ro v id in g a prevalence
rate fo r this disease o f betw een 5.7/1,000
an d 32.4/1,000 total p o p u latio n . K n ap p ’s8
sum m ary o f lesions in young males shows
com m on in young adults.
A co m parison o f th e p rese n t d ata with
th e d ata p ro v id ed by analyses rec o rd e d in
textbooks shows th e d ifferen ce betw een
th e u n d e rre p o rtin g o f an investigation
such as this one an d th e com plete re p o rt­
ing o f an investigation, w hich looks exclu­
ARTICLES
Qarcinoma and severe epithelial dysplasia each would be included as one of the 30 common oral
lesions if microscopic lesions were included in the ranking, which justifies frequent and thorough
oral examinations of every dental patient.
sively fo r a single, specific type o f lesion
an d reco rd s even th e sm allest o f such le­
sions fo u n d . H ow ever, th e textbooks5-7
provide epidem iologic d a ta fo r only th ree
o f the lesions listed in this p ap e r. A com ­
plete rec o rd in g o f specific lesion ex am in a­
tio n s is r e p o r t e d by H a l p e r i n a n d
o th e rs18,19 in a sum m ary o f th e exam ina­
tions o f 2,478 consecutive patients e n te r­
ing th e university’s school o f d entistry fo r
ro u tin e d en tal care. W hen all cases o f geo­
graphic to n gue, fo r exam ple, are included
in th eir d ata base, a large prevalence rate
o f 14/1,000 sam ple p o p u latio n is d e te r­
m ined. H ow ever, if cases considered mild
are excluded, the prevalence rate fo r cases
o f g e o g ra p h ic to n g u e in th e stu d y o f
H alp erin an d o th e rs18,19 decreases to a
level sim ilar to that fo u n d in the p resen t
investigation: 4.8/1,000 sam ple p o p u la ­
tion (H alperin a n d o th e rs18,19) com pares
v ery fav o rab ly w ith 3 .1 /1 ,0 0 0 sa m p le
p o p ulation (p resen t study). O th e r investi­
gations20,22'28 o f geog rap h ic to n g u e re p o rt
prevalence rates fro m 3/1,000 to 43/1,000
sam ple p o p ulation, with A xell’s21 g ro u p
show ing a prevalence ra te o f m o re than
7 1 /1 ,0 0 0 s a m p le p o p u l a t i o n . T h e s e
studies, along with those m entioned ea r­
lier, account fo r virtually all epidem iologic
investigations o f benign oral m ucosal le­
sions, with the exception o f studies o f leu­
koplakia an d gingivitis.
Summary
T h e p resen t investigation has provided
th e first d etailed re p o rt o f com m on con­
nective tissue an d m ucosal lesions o f th e
oral cavity in a US w hite population. Al­
th o u g h the d ata collection techniques are
flawed som ew hat, th e d ata are considered
rep resen tative an d , th e re fo re , significant.
M ore th a n 10% o f a g ro u p o f 23,616
adults (m ost o ld e r th a n 35 years) had at
least o n e o ral lesion th a t was u n u su a l
en o u g h to be re c o rd e d by a dentist. T h e
m ost com m on clinical ap p e aran c e o f a le­
sion was an exophytic mass, b u t th e m ost
com m on o ral connective tissue/m ucosal
lesion was leukoplakia. T h e 30 m ost com ­
m on lesions, w hich re p re se n te d m ore th an
93% o f all re p o rte d lesions, are ranked
10. G uggenheim er, J., and others. Benign neoplas­
according to th e gender-specific p rev a­
lence rates o f each lesion. T h ese 30 m ost tic and non-neoplastic lesions o f the oral cavity and
com m on lesions p ro v id ed a prevalence oropharynx. In Barnes, L., ed. Surgical pathology of
the head and neck. New York, Marcel Dekker, 1985.
ra te o f 147.6/1,000 people exam ined. O ral
11. Bouquot, J.E. An epidemiologic evaluation o f
cancer ran k e d 24th overall in prevalence. oral carcinoma, prem alignant epithelial dysplasia and
T h e re was little d ifferen ce betw een the nonspecific clinical keratoses in an adult Minnesota
ra n k e d lesio n s o f m ales a n d th o se o f population o f 23,616. Thesis, University o f Minnesota,
1974.
fem ales. A com parison was m ad e betw een
12. Gorlin, R.J. T h e Willmar, Winona and Marshall
d ata fro m this study an d th e d ata from programs: pilot studies in oral cancer detection 1957o th e r studies d ealin g with prevalence o f 1959. J O ral Surg 19:302-309, 1961.
13. Vickers, R.A.; Gorlin, R.J.; and Lovestedt, S.A.
com m on o ral lesions. T h e co m p ariso n
show ed th a t a co rrelatio n exists betw een Minnesota oral cancer detection 1957-1964—results.
NW Dent 1:339-342, 1964.
prevalence rates fo r w ell-defined lesions
14. MacMahon, B., and Pugh, T.F. Epidemiology,
a n d in d ic a te d th a t v ery m ild cases o f principles and methods. Boston, Little, Brown & Co,
com m on oral lesions probably are not re ­ 1970.
15. McCarthy, F.P. A clinical and pathologic study
p o rte d in mass screenings o f the type p re ­
o f oral disease. JAM A 116:16-21, 1941.
sented in this article.
-------------------J'ACMv---------------------T h e author thanks Drs. R. J. Gorlin and R. A. Vic­
kers o f the University of Minnesota, and Dr. S. A.
Lovestedt (now retired) o f the Mayo Clinic, Rochester,
MN, for their help in designing, administering, and
saving data from the Minnesota Oral Cancer Screen­
ing Clinics.
Dr. Bouquot was Ju n io r Faculty Fellow, American
Cancer Society, durin g p a rt o f the present investiga­
tion, and is chairm an and professor, departm ent of
pathology, School o f Dentistry, and professor, de­
partm ent o f pathology, School o f Medicine, West Vir­
ginia University, M organtown, WV 26506. Address
requests for reprints to the author at the West Virginia
University School o f Dentistry.
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