Chapter 032. Oral Manifestations of Disease (Part 7)

Ulcers Ulceration is the most common oral mucosal lesion. Although there are many causes, the host and pattern of lesions, including the presence of systemic features, narrow the differential diagnosis (Table 32-1). Most acute ulcers are painful and self-limited. Recurrent aphthous ulcers and herpes simplex infection constitute the majority. Persistent and deep aphthous ulcers can be idiopathic or seen with HIV/AIDS. Aphthous lesions are often the presenting symptom in Behçets syndrome (Chap. 320). Similar-appearing, though less painful, lesions may occur with Reiters syndrome, and aphthous ulcers are occasionally present during phases of discoid or systemic lupus erythematosus (Chap. 316)....
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Chapter 032. Oral Manifestations of Disease (Part 7) Chapter 032. Oral Manifestations of Disease (Part 7) Ulcers Ulceration is the most common oral mucosal lesion. Although there aremany causes, the host and pattern of lesions, including the presence of systemicfeatures, narrow the differential diagnosis (Table 32-1). Most acute ulcers arepainful and self-limited. Recurrent aphthous ulcers and herpes simplex infectionconstitute the majority. Persistent and deep aphthous ulcers can be idiopathic orseen with HIV/AIDS. Aphthous lesions are often the presenting symptom inBehçets syndrome (Chap. 320). Similar-appearing, though less painful, lesionsmay occur with Reiters syndrome, and aphthous ulcers are occasionally presentduring phases of discoid or systemic lupus erythematosus (Chap. 316). Aphthous-like ulcers are seen in Crohns disease (Chap. 289), but unlike the commonaphthous variety, they may exhibit granulomatous inflammation histologically.Recurrent aphthae in some patients with celiac disease have been reported to remitwith elimination of gluten. Of major concern are chronic, relatively painless ulcers and mixedred/white patches (erythroplakia and leukoplakia) of more than 2 weeks duration.Squamous cell carcinoma and premalignant dysplasia should be considered earlyand a diagnostic biopsy obtained. The importance is underscored because early-stage malignancy is vastly more treatable than late-stage disease. High-risk sitesinclude the lower lip, floor of the mouth, ventral and lateral tongue, and softpalate–tonsillar pillar complex. Significant risk factors for oral cancer in Westerncountries include sun exposure (lower lip) and tobacco and alcohol use. In Indiaand some other Asian countries, smokeless tobacco mixed with betel nut, slakedlime, and spices is a common cause of oral cancer. Less common etiologiesinclude syphilis and Plummer-Vinson syndrome (iron deficiency). Rarer causes of chronic oral ulcer such as tuberculosis, fungal infection,Wegeners granulomatosis, and midline granuloma may look identical tocarcinoma. Making the correct diagnosis depends on recognizing other clinicalfeatures and biopsy of the lesion. The syphilitic chancre is typically painless andtherefore easily missed. Regional lymphadenopathy is invariably present.Confirmation is achieved using appropriate bacterial and serologic tests. Disorders of mucosal fragility often produce painful oral ulcers that fail toheal within 2 weeks. Mucous membrane pemphigoid and pemphigus vulgaris arethe major acquired disorders. While clinical features are often distinctive,immunohistochemical examination should be performed for diagnosis and todistinguish these entities from lichen planus and drug reactions. Hematologic and Nutritional Disease Internists are more likely to encounter patients with acquired, rather thancongenital, bleeding disorders. Bleeding after minor trauma should stop after 15min and within an hour of tooth extraction if local pressure is applied. Moreprolonged bleeding, if not due to continued injury or rupture of a large vessel,should lead to investigation for a clotting abnormality. In addition to bleeding,petechiae and ecchymoses are prone to occur at the line of vibration between thesoft and hard palates in patients with platelet dysfunction or thrombocytopenia. All forms of leukemia, but particularly acute myelomonocytic leukemia,can produce gingival bleeding, ulcers, and gingival enlargement. Oral ulcers are afeature of agranulocytosis, and ulcers and mucositis are often severe complicationsof chemotherapy and radiation therapy for hematologic and other malignancies.Plummer-Vinson syndrome (iron deficiency, angular stomatitis, glossitis, anddysphagia) raises the risk of oral squamous cell cancer and esophageal cancer atthe postcricoidal tissue web. Atrophic papillae and a red, burning tongue mayoccur with pernicious anemia. B group vitamin deficiencies produce many of thesesame symptoms as well as oral ulceration and cheilosis. Cheilosis may also beseen in iron deficiency. Swollen, bleeding gums, ulcers, and loosening of the teethare a consequence of scurvy. Nondental Causes of Oral Pain Most but not all oral pain emanates from inflamed or injured tooth pulp orperiodontal tissues. Nonodontogenic causes may be overlooked. In most instancestoothache is predictable and proportional to the stimulus applied, and anidentifiable condition (e.g., caries, abscess) is found. Local anesthesia eliminatespain originating from dental or periodontal structures, but not referred pains. Themost common nondental origin is myofascial pain referred from muscles ofmastication, which become tender and ache with increased use. Many s ...