Family medicine
Oral / Dental Lesions
Oral and dental lesions are pathological changes in the tissues of the oral cavity, including the teeth, gingiva, tongue, palate, and mucosa, arising from infectious, inflammatory, traumatic, autoimmune, or neoplastic processes.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Recurrent aphthous stomatitis | Small (< 1 cm), round, painful shallow ulcers on non-keratinised mucosa; recurrent; heals in 7–14 days without scarring | 「個損口細細個、圓圓、好痛，通常自己好？以前試過？」(Small, round, painful, self-healing? Had it before?) |
| Traumatic ulcer | History of biting, sharp tooth, denture; single ulcer at trauma site | 「有冇咬親自己？有冇尖牙𠝹到？」(Did you bite yourself? Sharp tooth rubbing?) | |
| Dental caries / periodontal disease | Toothache, swollen gums, bleeding on brushing, visible caries | 「牙痛唔痛？刷牙有冇流血？」(Tooth pain? Bleeding when brushing?) | |
| Oral candidiasis (thrush) | White plaques that CAN be scraped off revealing red base; immunosuppression, dentures, inhaled steroids | 「口入面有冇白色嘅嘢可以刮走？有冇用噴霧吸入劑？」(White stuff you can scrape off? Using inhaled steroids?) | |
| Serious Not To Miss | Oral squamous cell carcinoma | Non-healing ulcer > 3 wks, indurated/rolled edges, painless, on lateral tongue/floor of mouth; neck nodes; smoking/alcohol | 「呢個損口超過三個禮拜都未好？邊緣硬唔硬？頸有冇粒嘢？」(Ulcer > 3 weeks? Hard edges? Neck lump?) [1][2] |
| Leukoplakia / Erythroplakia | White/red patch that cannot be scraped off; floor of mouth leukoplakia = highest malignant risk; speckled leukoplakia = highest transformation rate [1][2] | 「口入面有冇白色或者紅色嘅一撻，刮唔甩？」(White/red patch that won't scrape off?) | |
| Leukaemia (AML – monocytic) | Gum hypertrophy, bleeding, petechiae, fatigue, pallor [3][6] | 「牙肉有冇腫大？有冇容易瘀？成日覺得攰？」(Gum swelling? Easy bruising? Fatigue?) | |
| Pemphigus vulgaris | Painful oral erosions (often first site), flaccid blisters, Nikolsky sign +ve [7] | 「口入面損口好痛？有冇起水泡？皮膚捽下會唔會甩皮？」(Painful mouth erosions? Blisters? Skin peeling when rubbed?) | |
| Pitfalls | Herpes simplex (HSV-1) | Primary: gingivostomatitis with fever, vesicles on hard palate/gingiva; Reactivation: "cold sores" on lips [8] | 「嘴唇有冇起一粒粒水泡？有冇發燒？」(Lip vesicles? Fever?) |
| Lichen planus | Wickham's striae (white lace-like pattern) on buccal mucosa, bilateral; may be erosive | 「面頰入面兩邊有冇白色嘅網狀紋？」(White lace pattern on both cheeks?) | |
| Behçet's disease | Recurrent oral + genital ulcers + eye inflammation (uveitis); pathergy test | 「私密部位有冇損口？眼有冇紅痛？」(Genital ulcers? Red painful eyes?) | |
| Syphilitic chancre | Painless, indurated solitary ulcer; sexual history; RPR/VDRL | 「最近有冇新嘅性伴侶？個損口係唔係唔痛？」(New sexual partner? Painless ulcer?) | |
| Masquerades | Iron / B12 / folate deficiency | Glossitis (smooth, beefy-red tongue), angular stomatitis [3][9] | 「條脷有冇光滑咗？嘴角有冇裂？」(Tongue smoother? Cracked corners of mouth?) |
| Diabetes mellitus | Recurrent oral candidiasis, poor wound healing, periodontal disease | 「你有冇糖尿病？傷口係咪好耐都好唔到？」(Diabetes? Slow wound healing?) | |
| Drugs | Gum hypertrophy: phenytoin, cyclosporine; Oral ulcers: methotrexate, NSAIDs, nicorandil [3] | 「你有冇食抗癲癇藥或者免疫抑制藥？」(Taking anticonvulsants or immunosuppressants?) | |
| Depression / stress | Bruxism → mucosal trauma; neglected dental hygiene | 「最近壓力大唔大？瞓覺有冇咬牙？」(Stressed? Grinding teeth at night?) | |
| Trying to Tell Me Something? | Fear of oral cancer | Family member had cancer; saw something online; main RFC ≠ main symptom | 「你最擔心呢個係咩嚟㗎？有冇屋企人試過有口腔癌？」(What worries you most? Family history of oral cancer?) |
| Psychosocial stress | Work/relationship stress → aphthous exacerbation | 「最近生活有冇大轉變或者壓力？」(Any major life changes or stress?) |
Oral / Dental Lesions — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce yourself, set agenda | 「你好，我係陳醫生，今日由我幫你睇症。你可唔可以話我知今日有咩唔舒服？」(Hello, I'm Dr Chan, I'll be seeing you today. Can you tell me what brought you in?) | Rapport, interpersonal marks; open question |
| 0:30–1:30 | HPI: symptom analysis of oral/dental lesion — onset, site, size, colour, pain, change over time, aggravating/relieving factors, associated symptoms | 「個嘢喺口入面邊度？幾時開始？有冇痛？有冇大咗或者變咗樣？」(Where in the mouth? When did it start? Painful? Has it grown or changed?) | Demonstrates systematic history; captures CC & HPI accurately |
| 1:30–2:30 | Red flags & targeted systems review — weight loss, difficulty swallowing/speaking, neck lumps, bleeding, fever, skin/genital lesions, new medications | 「有冇消瘦？食嘢有冇困難？頸有冇腫咗？有冇流血？」(Weight loss? Difficulty eating? Neck swelling? Bleeding?) | Must-not-miss serious pathology; marks for completeness |
| 2:30–3:30 | PMH / Drug Hx / Allergy / FH / Social Hx — smoking, alcohol, betel nut, dentures, sexual history if relevant, occupation | 「你有冇食煙飲酒？有冇食檳榔？有冇長期食藥？對咩藥敏感？」(Smoking/alcohol? Betel nut? Chronic meds? Allergies?) | Risk factors for oral malignancy; drug causes of oral lesions |
| 3:30–4:30 | ICE — uncover hidden agenda | 「你自己覺得呢個嘢係咩嚟㗎？」「你最擔心啲咩？」「你嚟睇醫生最想我幫你做啲咩？」(What do you think it is? What worries you most? What were you hoping I could do today?) | Directly tested on Case Report Form; reveals hidden concerns (e.g. fear of cancer) |
| 4:30–5:15 | Signpost & summarise — state what you found, your impression, brief plan | 「我總結返，你口入面有個嘢…我覺得最有可能係…我建議…你覺得OK嗎？」(Let me summarise... most likely it is... I suggest... does that sound OK?) | Shows clinical reasoning; empathy; shared decision-making |
| 5:15–6:00 | Safety net & close | 「如果個嘢兩個禮拜都未好，或者突然大咗、流血、痛到唔得，你一定要返嚟睇。有冇其他嘢想問？」(If it doesn't improve in 2 weeks, or if it grows/bleeds/gets very painful, come back. Any other questions?) | Safety net scores marks; warm close |
Hidden agenda tip: A patient presenting with a "mouth ulcer" may really be terrified of oral cancer (family member had it, saw something online). Always ask 「你最擔心啲咩？」 early — this is often the RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think of… |
|---|---|---|---|---|
| Site | Where exactly in the mouth? | 「喺口入面邊度？舌頭、牙肉、面頰入面、定係嘴唇？」 | Lateral tongue, floor of mouth lesions have highest malignant risk [1] | Oral SCC if lateral tongue/floor of mouth |
| Onset & duration | How long has it been there? | 「出咗幾耐？幾時開始留意到？」 | > 3 weeks non-healing = red flag | Malignancy, chronic infection |
| Appearance | What colour is it? White, red, or ulcerated? | 「佢係咩色？白色、紅色、定係損咗皮？」 | Leukoplakia (white, cannot be scraped off) = premalignant; Erythroplakia (red plaque) = highest malignant transformation risk; Speckled leukoplakia = highest rate of malignant transformation [1][2] | Oral SCC / dysplasia |
| Pain | Is it painful? | 「痛唔痛？食嘢會唔會更加痛？」 | Painless lesion more worrying for malignancy; painful → aphthous, herpes, abscess | Aphthous ulcer, HSV, dental abscess |
| Change | Has it changed in size, shape or colour? | 「有冇大咗、變咗樣、或者變咗色？」 | Growing/changing = red flag for malignancy | Oral SCC |
| Number | Single or multiple lesions? | 「得一個定幾個？」 | Multiple → aphthous, HSV, hand-foot-mouth, pemphigus; single → malignancy, traumatic | See DDx |
| Recurrence | Has it happened before? | 「以前有冇試過？成日復發？」 | Recurrent = aphthous, HSV labialis; new persistent lesion = red flag | Recurrent aphthous stomatitis, HSV reactivation |
| Red flag: dysphagia | Difficulty swallowing? | 「吞嘢有冇困難？」 | Suggests pharyngeal/extensive disease | Oral/pharyngeal carcinoma |
| Red flag: neck lump | Any lumps in the neck? | 「頸有冇腫塊？」 | Cervical lymphadenopathy → metastatic oral CA | Metastatic SCC |
| Red flag: weight loss | Unintentional weight loss? | 「有冇無啦啦瘦咗？」 | Constitutional symptom → malignancy | Oral/systemic malignancy |
| Bleeding | Does it bleed? | 「有冇流血？」 | Bleeding from gums → gingivitis, leukaemia; ulcer bleeding → malignancy | Gum hypertrophy + bleeding → leukaemia (usually monocytic) [3] |
| Smoking / alcohol | Do you smoke or drink? | 「你有冇食煙、飲酒？食幾多、幾耐？」 | Major risk factors for oral SCC; Leukoplakia causes '5S': Sore teeth, Smoking, Spirits, Sepsis, Syphilis [3][4] | Oral malignancy, leukoplakia |
| Betel nut | Do you chew betel nut? | 「你有冇食檳榔？」 | Strong risk factor for oral submucous fibrosis / SCC | Oral SCC, submucous fibrosis |
| Dentures/trauma | Do you wear dentures? Any sharp teeth? | 「有冇戴假牙？有冇尖嘅牙成日𠝹到？」 | Chronic dental trauma → traumatic ulcer, buccal mucosa SCC risk [1] | Traumatic ulcer, buccal SCC |
| Medications | Any new medications? | 「最近有冇食新嘅藥？例如薄血丸、抗癲癇藥？」 | Phenytoin, phenobarbital, cyclosporine → gum hypertrophy [3]; methotrexate, steroids → oral ulcers | Drug-induced gingival hyperplasia / ulcers |
| Sexual Hx | Any oral sexual contact? Genital lesions? | 「有冇口交嘅性行為？私密部位有冇損口？」 | HSV, syphilis (chancre), HPV-related lesions | Primary syphilis, HSV, HPV |
| Systemic disease | Any known conditions — IBD, SLE, Behçet's? | 「你有冇其他長期病？例如腸炎、免疫系統嘅病？」 | Oral ulcers in Crohn's disease, coeliac disease, Behçet's, SLE [3][5] | Systemic autoimmune / inflammatory disease |
| Immune status | HIV status? Chemotherapy? | 「你有冇HIV或者做緊化療？」 | Immunocompromised → oral candidiasis, HSV, Kaposi sarcoma, hairy leukoplakia | Opportunistic infections |
| Nutrition | Any dietary restrictions? Vegetarian? | 「你食嘢有冇偏食？有冇戒口？」 | Glossitis = nutritional deficiency (Fe, B9, B12); Angular stomatitis = B6, B9, B12, iron deficiency [3] | Iron deficiency, B12/folate deficiency |
| Functional impact | Can you eat and drink normally? Affecting work/sleep? | 「食嘢飲嘢有冇受影響？影唔影響你返工瞓覺？」 | Assesses severity; scores biopsychosocial marks | Functional impairment for CRF |
| ICE | What do you think / worry / expect? | 見上方 Game Plan | Directly tested on CRF Q3 | Hidden agenda |
Case Report Form Answer Builder
Template: "Oral ulcer/lesion for [duration]"
High-yield HPI points to capture:
- Site (tongue, buccal mucosa, gums, palate, lip)
- Duration (< 3 wk vs > 3 wk — critical cutoff)
- Appearance: white/red/ulcerated; single vs multiple
- Pain: present or absent
- Change in size/shape
- Associated features: fever, dysphagia, weight loss, neck lump, bleeding
- Relevant risk factors: smoking, alcohol, dentures, medications, immunosuppression
- Recurrence pattern
| Likely RFC Scenario | How to Phrase |
|---|---|
| Worried lesion could be cancer | "To find out if the oral lesion is cancerous" |
| Pain affecting eating/sleeping | "For pain relief / to improve oral intake" |
| Non-healing ulcer after self-treatment | "To seek treatment for a non-healing oral ulcer" |
| Cosmetic concern (lip lesion) | "For treatment of unsightly lip lesion" |
Tip: RFC is often NOT the lesion itself but the fear behind it. Write the patient's actual motivation.
| Component | Example Wording |
|---|---|
| Idea | "Patient thinks it may be a mouth ulcer from stress / worries it could be cancer" |
| Concern | "Worried that it is oral cancer because his father had tongue cancer" |
| Expectation | "Wants reassurance and referral for biopsy / wants medication to make it heal faster" |
For a typical FM station scenario:
- Recurrent aphthous stomatitis — if small, painful, round ulcer, < 2 wk, recurrent, non-keratinised mucosa, no red flags
- Minimum evidence: recurrent episode, < 1 cm round shallow ulcer on buccal/labial mucosa, painful, no induration, no neck nodes, heals spontaneously
If the stem has a > 3-week non-healing ulcer + risk factors → consider oral SCC or leukoplakia/erythroplakia as most likely.
| DDx | One Key Discriminator |
|---|---|
| Traumatic ulcer | History of mechanical trauma (denture, sharp tooth); single ulcer at trauma site; heals when cause removed |
| Oral candidiasis | White plaques that can be scraped off; risk factors (inhaled steroids, immunosuppression, dentures) |
| Oral SCC / premalignant lesion | Non-healing > 3 wk, indurated edges, painless, lateral tongue/floor of mouth, smoking/alcohol, neck node |
| Domain | Example |
|---|---|
| Biological | Recurrent oral ulceration causing pain and difficulty eating → nutritional impact |
| Psychological | Anxiety about possible oral cancer (cancer phobia); impact on mood and sleep |
| Social | Difficulty speaking/eating affecting work performance (e.g. teacher, salesperson); social embarrassment |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Recurrent aphthous ulcer | Small (< 1 cm), round/oval, shallow ulcer with yellow-grey pseudomembrane base and erythematous halo on non-keratinised mucosa (buccal, labial, floor of mouth) | Inspect oral cavity with spatula and torch; note size, shape, base, edge | Classic appearance; no induration (vs malignancy), no vesicles (vs HSV) |
| Oral SCC | Non-healing ulcer with indurated (hard, raised/rolled/everted) edges on lateral tongue or floor of mouth ± ipsilateral cervical lymphadenopathy [1][2] | Palpate the lesion with gloved finger for induration; palpate cervical lymph nodes | Induration = tissue invasion; hardness distinguishes malignancy from benign ulcer |
| Oral candidiasis | White plaques on erythematous base that can be scraped off with spatula | Gently scrape white patch with tongue depressor | Distinguishes candida from leukoplakia (leukoplakia cannot be scraped off) |
| HSV gingivostomatitis | Multiple grouped vesicles on erythematous base on hard palate / gingiva / lips; may see cervical lymphadenopathy [8] | Inspect for vesicles; note distribution on keratinised mucosa | Vesicular morphology + keratinised site distribution is pathognomonic |
| Leukoplakia | White patch/plaque on oral mucosa that CANNOT be scraped off [1][3] | Attempt to scrape with spatula — it remains | Defines leukoplakia; premalignant until proven otherwise |
| Pemphigus vulgaris | Nikolsky sign positive — gentle lateral pressure on perilesional skin causes shearing of epidermis [7] | Apply lateral pressure with finger on skin adjacent to erosion | Demonstrates intraepidermal acantholysis, characteristic of pemphigus |
| Iron/B12 deficiency | Glossitis — smooth, beefy-red tongue with loss of papillae ± angular stomatitis [3][9] | Inspect tongue dorsum; inspect mouth corners | Tongue papillae atrophy from rapid cell turnover sensitivity to nutritional deficiency |
| Drug-induced gum hypertrophy | Generalised gingival hyperplasia, firm, non-tender | Inspect gums; ask about phenytoin/cyclosporine use | Phenytoin, cyclosporine are classic causes [3] |
Top Traps That Lose Marks
- Forgetting to ask duration — the 3-week rule is the single most important discriminator. Any oral ulcer > 3 weeks = urgent referral to exclude malignancy.
- Not asking about smoking, alcohol, betel nut — these are the top risk factors for oral SCC and examiners expect them.
- Confusing leukoplakia with candidiasis — leukoplakia CANNOT be scraped off; candida CAN. This is a classic exam trap.
- Missing systemic causes — always screen for iron/B12 deficiency (glossitis, angular stomatitis), leukaemia (gum hypertrophy + petechiae), and drugs (phenytoin).
- Ignoring ICE — the patient often has cancer phobia. If you don't elicit it, you lose Q3 marks AND miss the RFC.
- Not examining the neck — cervical lymphadenopathy is the key physical sign for metastatic oral SCC. Always mention it.
- Forgetting sexual history — syphilitic chancre and HSV are pitfalls. A painless solitary oral ulcer in a young patient needs sexual history.
Must-not-miss red flags for urgent referral:
- Non-healing oral ulcer > 3 weeks
- Indurated, fixed ulcer
- Unexplained red/white patch (erythroplakia/leukoplakia)
- Cervical lymphadenopathy
- Trismus, tongue deviation, paraesthesia
- Unexplained tooth mobility
Safety-net closing line: 「如果個嘢超過兩至三個禮拜都未好，或者大咗、硬咗、流血、頸有粒嘢，你一定要盡快返嚟，我會轉介你做進一步檢查。」 (If it doesn't heal in 2–3 weeks, or gets bigger/harder/bleeds/neck lump appears, come back urgently — I'll arrange further investigation.)
High Yield Summary
What to ASK:
- Site, duration (< or > 3 wk), appearance (white/red/ulcer), pain, single vs multiple, recurrence, change
- Red flags: weight loss, dysphagia, neck lump, trismus, paraesthesia
- Risk factors: smoking, alcohol, betel nut, dentures, medications (phenytoin), immunosuppression, sexual history
- Systemic: nutritional deficiency symptoms (glossitis, angular stomatitis), autoimmune disease
- ICE — especially cancer phobia
What to WRITE:
- CC: "Oral ulcer / white patch on [site] for [duration]"
- RFC: Usually fear of cancer or pain affecting function
- Most likely Dx: Recurrent aphthous stomatitis (if typical) or Oral SCC (if > 3 wk + risk factors)
- DDx: Traumatic ulcer, oral candidiasis, oral SCC/leukoplakia (choose 3 relevant to stem)
- Biopsychosocial: pain/eating difficulty | cancer anxiety | work/social impact
- Physical sign: Appearance of ulcer (shallow + halo = aphthous vs indurated edges = SCC); cervical LN exam
What NOT to MISS:
- 3-week rule for oral ulcer referral
- Leukoplakia cannot be scraped off (premalignant); erythroplakia has highest malignant transformation; speckled leukoplakia has highest rate of malignant transformation [1][2]
- Gum hypertrophy differential: gingivitis, drugs (phenytoin, cyclosporine), scurvy, leukaemia (monocytic), pregnancy [3]
- Glossitis + angular stomatitis = think nutritional deficiency (Fe, B12, folate) [3]
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: MBBS Final MB (Surgery) (Felix PY Lai).pdf — Cancer of tongue, pathogenesis of oral premalignant lesions (pp. 244, 256) [2] Lecture slides: GC 219. Infections and tumours in pharynx and oral cavity.pdf [3] Senior notes: Ryan Ho Fundamentals.pdf (p. 62) and Ryan Ho GI.pdf (p. 10) — Oral cavity lesions: leukoplakia, glossitis, gum hypertrophy, aphthous ulcers, angular stomatitis [4] Senior notes: Ryan Ho Fundamentals.pdf (p. 62) — Leukoplakia causes '5S' [5] Senior notes: Block A - Chronic diarrhoea_ irritable bowel syndrome and inflammatory bowel disease.pdf — Extraintestinal manifestations of IBD [6] Senior notes: Block A - High white cell count_ acute and chronic leukaemia.pdf (p. 3) — Gingival overgrowth in acute monoblastic leukaemia [7] Senior notes: Block A - Dermatology PBL 2.pdf — Pemphigus vulgaris with oral mucosal involvement [8] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p. 18) — HSV-1 gingivostomatitis and herpes labialis [9] Senior notes: Block A - Pallor_ diagnosis of anaemia.pdf (p. 18) — Glossitis and angular stomatitis in pernicious anaemia
Oligomenorrhoea
Oligomenorrhoea is infrequent menstruation characterized by menstrual cycles occurring at intervals greater than 35 days but less than 6 months.
Oral / Dental Pain
Oral or dental pain is nociceptive or inflammatory pain arising from structures of the teeth, gingiva, oral mucosa, or jaw, most commonly caused by dental caries, pulpitis, periodontal disease, or abscess.