Red Patch in Mouth

• Clinical Definition: A well-defined,  persistent red patch in the oral mucosa or on the lips, gums, or tongue resulting from the presence of mucosal dysplasia, inflammation, vascular dilatation, or exposure to vasculature.

• Symptoms: Non-healing lesion over 14 days, rapid growth rate, bleeding upon contact, induration (hardening/firming under tissue).

• Treatment Options: Surgical excision, CO2 laser debridement, topical immune modulator therapy, antifungal therapy based on biopsy results.

Oral red patches can be associated with a variety of visual, tactile and sensory alterations:

• Visual Appearance: The oral red patch is typically a bright red, smooth-velvety lesion which may display speckling of white lesions (speckled leukoplakia or erythroleukoplakia).

• Texture: The surface area of the lesion may feel somewhat raised compared to normal tissue; it may have some erosion depending on how long the lesion has been present.

• Sensation: Many patients experience glossodynia (burning mouth syndrome) when consuming hot spicy food items or acidic products. However, it is well documented that many high risk erythroplakic lesions are completely asymptomatic until later stages.

• Irritation: Some patients will experience discomfort during mastication, swallowing, or while brushing their teeth adjacent to where the lesion exists.

A medical evaluation should be initiated immediately by an oral medicine specialist or oral maxillofacial surgeon if you note any of the following symptoms/changes:

• Persistence: Any lesion that persists beyond 14 days without resolution.

• Texture: The base of the lesion becomes indurated upon palpation.

• Bleeding: If there is spontaneous bleeding without a history of direct traumatic injury to the site.

• Associated Symptoms: Difficulty swallowing (dysphagia), unexplained tooth mobility, continuous ear pain (referred otalgia), and swelling of cervical lymph nodes.

The causes for the formation of an oral red patch are caused by various chemical, biological, and mechanical factors such as:

• Carcinogenic Habitual Causes: Repeated chronic exposure to carcinogens found in chewed betel quid (paan), smokeless tobacco, gutka and alcohol consumption.

• Fungal Infection: Candidiasis that presents erythema with poor fit denture placement or after systemic antibiotics have been taken.

• Mechanical Injury Due to Repeated Friction: A continuous abrasion of mucosa due to friction created by a fractured tooth, a poorly fitting acrylic denture, or a poorly fitted dental restoration.

• Autoimmune & Inflammatory Disease: Autoimmune diseases, including conditions such as Erosive Lichen Planus and Pemphigus Vulgaris which present themselves as desquamation or erythematous mucosal surfaces.

• Use of Substances: The combination of using tobacco products and consuming betel nut (areca nut) preparation and drinking alcoholic beverages increases the risk of developing mucosal dysplasia.

• Dietary Deficiency: Poor dietary intake of nutrients (iron, B12, Folate) will compromise the integrity of the mucosal surface creating it vulnerable to atrophy.

• Thermal-Chemical Irritant Exposure Over Time: Consuming very high temperature liquids on a regular basis or repeatedly consuming highly spiced preparations.

• Age, Oral Hygiene Practices, and Immunological Status: An age greater than 40 years old, poor oral hygiene practices, or having an immunocompromised status.

A step-by-step home assessment to perform safely in a well-lit mirror:

• Wash Your Hands Thoroughly: Wash your hands with soap and water to keep from spreading a secondary infection.

• Visual Examination: Gently elevate your lips, extend your tongue, and visually inspect all mucous membrane areas (your cheeks, tongue, floor of the mouth, soft palate) under intense lighting.

• Light Touching/Feeling: Using your clean, gloved index finger lightly touch/feel the area you are assessing. Compare how it feels as opposed to the feeling of surrounding tissue. Is the area elevated? Does it feel like sandpaper? Is it harder than adjacent tissue?

• Document: Document the red spots. Don't attempt to remove skin or rub vigorously. Schedule an appointment for evaluation and/or treatment with a specialist if after two weeks the red spot has not resolved itself.

The diagnosis of erythroplakia involves an orderly clinical process:
 

• Visual/Palpation: Clinical inspection using visual examination and tactile palpation to assess the size, shape, location, surface texture, elevation, and degree of induration. 

• Stain with Toluidine Blue: Use a local application of toluidine blue dye to selectively stain abnormal/dysplastic cells that will assist in selecting a biopsy site.

• Histopathological Biopsy: The ultimate test for definitive diagnosis. A small piece of tissue (either incisional or punch biopsy) is removed and evaluated microscopically to assess the degree of cellular dysplasia/malignancy present.

• Advance Imaging Techniques: CT scans and MRI studies may be ordered when tissue invasion into deeper structures/bone is suspected.

• Elimination of Traumatic Factors: Smoothing rough edge of enamel, repair/restoration of broken restoration, adjustment of ill-fitting prosthesis.

• Pharmacologic Therapy with Topicals: Application of potent topical steroids (i.e. Triamcinolone acetonide; clobetasol) to reduce autoimmune destruction of mucosa.

• Excision of Localized Pathology: Excision of localized benign/dysplastic pathology using traditional cold-steel technique or advanced Diode-laser technology.

• Oncologic Therapy: Multidisciplinary management involving surgical excision, neck dissection, radiotherapy, and/or chemotherapy provided by an Oral Oncology Team.

The cost of diagnosis and treatment in Kerala will depend on the level of clinical complexity and whether you go to a private physician or clinic:

• Diagnostic Evaluation / Incisional Biopsy: Depending on the location, the diagnostic evaluation including biopsy may cost anywhere from Rs. 1,500 to Rs. 4,500 in a private clinic. However, most of the diagnostics available in private clinics are available free of cost or at a lower cost at the public dental college programs in Kerala.

• Removal/Laser Treatment of Minor Lesion: Removal of minor lesions by minor surgical excision or laser therapy may cost between Rs. 3,500 to Rs. 12,000 based on the size of the lesion being treated and the device being used.

• Complex Procedure/Hospital Based Intervention: These hospitalizations are associated with higher costs due to hospital stay. Hospital based treatments may be reimbursed under the patient's state sponsored health insurance plans or private health insurance policies

• General Dental Practitioners: For initial examination, screening, routine dental care or minor adjustments to an existing denture.

• Oral Medicine & Radiologists: To diagnose mouth lesions and perform vital staining, and for management of non-surgically treated inflammation.

• Oral & Maxillofacial Surgeons: To do all the necessary surgery to obtain biopsy material from a lesion or to remove large areas of dysplasia or carcinoma.

• Routine Non-Emergency Appointment (1-2 weeks): A person finds a new red area on their tongue with no other systemic signs (e.g. fever) and it is pain-free.

• Emergency/Urgent Appointments (48-72 hours): The red area has been present for more than 14 days, it continues to grow rapidly, it is speckled white and red (leukoplakia).

• Immediate Appointments (24 hour): Difficulty swallowing, sudden swelling, enlargement of lymph nodes in the neck, and bleeding persists.

1. Why does the red patch I have remain after I do multiple warm saltwater rinses?

The warm saltwater may help reduce the mild bacterial inflammation but will never be able to get rid of a true mucosal dysplasia, persistent fungal infection or long term structural tissue damage. Any red patch that lasts longer than two weeks should be formally evaluated clinically.

2. Does chewing betel nuts create a permanent red spot in your mouth?

Yes. The long-term use of areca nut, betel leaf and smokeless tobacco creates a chronic chemical/physical injury which can lead to precancerous conditions such as erythroplakia and/or oral submucous fibrosis.

3. Are all red spots in the mouth caused by cancer? 

No. Most red spots in the mouth occur due to non-cancerous reasons including localized fungal infections, mechanical injuries or autoimmune diseases. Erythroplakia has a higher risk of becoming cancerous than most other forms of oral lesions; therefore, a professional diagnosis is required.

• Oral Leukoplakia: A white lesion found on the mucosal surface usually alongside a red patch (erythroleukoplakia).

• Erythematous Candidiasis: Fungal infection resulting in a generalized redness commonly found on the palatine area or tongue.

• Oral Submucous Fibrosis (OSMF): Chronic condition associated with long-term use of areca nuts characterized by mucosal blanching, red patches and trismus.

• Habit Cessation Counseling: A structured program to abstain from smoking, drinking alcohol, and chewing betel nut product as a way to avoid having lesions recur.

• Denture Prosthetic Readjustment/Realignment: Relining or realigning dentures so they no longer rub against the mucosa causing irritation.

• Routine Preventative Fluoride Therapy and Prophylaxis: Clinical dental scaling and fluoride application on an outpatient basis to maintain a clean environment in the mouth which will help in eliminating harmful bacteria.

The early detection of erythroplakia is essential in helping to prevent development of oral squamous cell carcinoma. All patients at risk due to their geographic location or other factors, such as past or current habits of using betel nut, tobacco or excessive alcohol should be seen routinely for examination of their mucous membranes at least once every six months. Any red area that has not healed after two weeks needs to have a diagnostic biopsy performed; the waiting period should never be used as an empirical approach. In addition to maintaining proper oral health hygiene, limiting exposure to potential irritants and getting professional treatment promptly are significant factors to improve patient long-term success.