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Oral Manifestations of Local and General Diseases
ORAL MANIFESTATIONS OF LOCAL AND GENERAL DISEASES By K
urt
H. T
h o m a ,*
H E horizon of dentistry has broad ened greatly in past decades. From a profession chiefly concerned with the care o f the teeth, which were cleaned, treated, filled, extracted and replaced, we have developed to the status o f a spe cialty of medicine. Today, we are first o f all concerned in a more extensive field, the health of the entire oral cavity, including the salivary glands. Secondly, we have come to real ize that there are no autonomic regions in the body. A n y experienced clinician knows that infections do not respect the limits of the field in which they orig inate, and that oral cancer m ay metas tasize to organs remote from the primary lesion. T h e modern investigator has taught us that systemic conditions such as nutri tional states, endocrine disturbances and metabolic disorders have important ef fects on the development of the teeth, and tend to improve or m odify the in herent growth pattern of the jaws and faces. In practice, we are utilizing recent knowledge gleaned from the work of re searchers to advise our patients regard ing conditions which form the back ground o f orthodontic problems and m ay be expected to inhibit dental caries and periodontal disease. Finally, we see in the mouth an in creasing degree of pathologic change
T
•Professor of oral surgery and Charles A. Brackett professor of oral pathology, Harvard University. Read before the Section on Oral Surgery and M edical Relations at the Seventy-Seventh Annual Midwinter Meeting of the Chicago Dental Society, February 18 , 19 4 1 . Jour. A .D .A ., V o l. 29, F eb ru ary 1942
D .M .D ., Boston, Mass. which is a sign o f somatic disease, or lesions produced by local infection through the activity of bacteria that have awaited the opportunity to become pathogenic when the soil became recep tive. Investigation o f these predisposing conditions leads into the domain of in ternal medicine. Thus, even diseases that appear to be entirely o f local origin often require general medication for effective treat ment, to improve the general health of the patient, to correct predisposing causes or to effect a cure through the hema togenous channels ; as, for example, with such chemicals as the sulfonamide drugs. In the oral cavity, these act not only by their presence in the tissue fluids, but also through the action o f the saliva in which they are contained and which constantly bathes the lesion. General medication by these drugs serves another important function : it prevents bacteremia and the spreading o f infection through the cir culation when operations such as tooth extraction are performed in infected areas. Thus the finger o f progress in dental practice, as well as in clinical and laboratory investigation, points definitely in the direction of medicine. O ral manifestations o f local and gen eral diseases is a timely and important subject, covering a field that is neglected by m any general practitioners, and often only because o f the more evident or more disturbing problems presented by the patient’s teeth. As there is not time to thoroughly discuss oral manifestations of local and general disease, I shall limit m yself to a cursory presentation o f cases 222
T h o m a — O r a l M a n if e s t a t io n s o f D is e a se s
seen in practice or in hospital clinics, hoping to further the recognition and correct diagnosis of both surgical and non-surgical lesions in the mouth. I doubt whether the accepted practice of classifying oral lesions as local or general manifestations is a fortunate one. D ivi sion into surgical and non-surgical lesions has greater advantages because it indi cates at once that some are treated by the oral surgeon, while others are in the
Fig. 2.— Mucous cyst of lower lip. field o f oral medicine, and should be treated by the dental internist. SU RG ICAL LESIO N S OF T H E M O U TH
W hile the surgical operation is dis tinctly a local method, by which lesions are excised by scalpel or endothermy knife, its effects and complications m ay be profound and far-reaching. Nor is
223
surgery always successful without cor rection of somatic conditions, and sup portive treatment is, very often, of para mount importance. I need only to m en tion the recurrence of pregnancy tumors if excised before parturition, and the problems presented b y operations on pa tients suffering from diabetes, avitam in oses and blood diseases. Following are some of the important surgical diseases of the mouth :
Fig. 4 .— Alveolar fissuratum.
hyperplasia
or
epulis
Malformations.— These clefts of the lip, face and palate often present serious problems to the surgeon, while abnormal ities of the tongue such as tongue-tie and hypertrophy o f the labial frenum are easily corrected. (Fig. 1.) Abscesses.— These m ay be due to in jury or odontogenic infection.
224
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
Cysts.— These lesions occur on the lip and tongue as so-called retention cysts; on the floor of the mouth as ranula, and on the palate as cysts of the papilla palatina. T h e former are due to the occlusion of the outlets of mucous gland s; the latter to the accum ulation o f secre tions in the nasopalatine duct. (Fig. 2.) Hypertrophy of the Oral M ucosa.— These cases are generally due to mechan ical irritation of long standing, present ing the picture of chronic inflammation. W e m ay distinguish several clinical form s: 1. Epulis granulomatosa, which grows
tissue forms, often bifid and containing a fissure into which the denture m ay ex tend. This very typical lesion is known as epulis fissuratum. Pregnancy Tumors.— These are an other manifestation of hyperplasia which appears in connection with stomatitis gravidarum. (Fig. 5.) T h ey are spher ical bodies of deep red or of blue, often attached by a broad pedicle to the gin gival papilla. T h ey are generally mul tiple. T h ey bleed easily when injured
Fig. 6 .— Peripheral giant-cell tumor (giant cell epulis).
Fig. 5 .— Large pregnancy tumor in woman three weeks before parturition.
from extraction wounds and is due to irritation from a spicule of bone or tooth, or which forms a pedunculated area of hyperplasia o f the gingiva, often filling the space between decayed adjoining teeth. (Fig. 3.) 2. Palatal hyperplasia, caused by the suction chamber of a denture. 3. Alveolar hyperplasia, the common form resulting from the presence o f illfitting dentures. (Fig. 4.) From a socalled chronic traumatic ulcer, a fold of
Fig. 7 .— Fibroma of cheek.
and recur if excised before parturition. T h ey are made up o f fibrous tissue with marked angiomatous proliferation (fibroangioma). Peripheral Giant-Cell Tumors.— These tumors are seen in hyperparathyroidism, in which we find also the more common type o f central lesion. (Fig. 6.) It m ay be, however, a solitary tumor occurring in an otherwise normal patient. It gen
T h o m a — O r a l M a n if e s t a t io n s o f D is e a s e s
erally forms on the gingiva, and for this reason it is also known as giant-cell epulis. It is bluish and, in most instances, is sessile, but m ay be pedunculated. It shows a tendency to recur if not com pletely removed. The tissue consists of a synctium of immature connective tissue cells among which are scattered numer ous multinucleated foreign body giant cells. Fibromas.— This typical benign tumor
Fig. 8.— Fibrosarcom a of odontogenic origin.
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speak of fibromatosis or elephantiasis of the gingiva. Fibrosarcomas.— This malignant tumor is not infrequently encountered. (Fig. 8.) It is seen in young patients and is apt to recur after excision. It m ay de velop at the angle of the jaw , but also may be seen as an intra-oral lesion which grows rapidly and, when injured by the teeth, tends to ulcerate.
Fig. 10.— Sm all hem angiom a of lip.
Fig. 9.— L ipo m a of tongue.
is of frequent occurrence in the mouth. (Fig. 7.) It forms principally in the fissural area of the mucosa of the cheek, on the tongue and the lip, and sometimes on the gingiva as a soft or hard pedun culated, well-defined growth covered by a pale, smooth epithelium. O n the alveolar mucosa, however, it is frequently sessile and m ay cover a large area. When the entire gingiva is thickened, we may
Fig. 11 ••— H em angiom a of tongue of con gen ital origin.
Lipomas.— Lipom a forms especially in areas where adipose tissue is found. It m ay be pedunculated or m ay develop in the areolar gingiva or in the tongue. (Fig- 9 -) Hemangiomas.— Hemangioma is often
226
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o f congenital origin, and from insignifi cant early lesions. (Fig. 10.) Large tumors m ay develop. (Figs. n . ) T he fact that the blood can be temporarily forced out, only to rush back after pres sure ceases, is a diagnostic sign. It occurs on the tongue, lip and cheek, and some times at the gingival margin. Endotheliomas and Lymphocytomas. — These neoplasms are quite rare in the mouth. T h ey m ay occur on the palate. The reticulum cell sarcoma, a form of the malignant lymphocytoma, is made up of large round lymphoid cells with hyperchromatic nuclei and m ultinucle ated cells lying in atypical reticular tis sue. Early involvement o f the regional lymph glands is a clinical feature. Lymphosarcoma generally forms mul-
plakia. As cancer m ay start as a papil lomatous lesion, it is good practice to remove papillomas prom ptly by wide excision, and follow with postoperative irradiation if, on microscopic examina tion, m alignancy is found. Carcinomas.— Dentists who see pa tients at short intervals should be able to detect carcinoma early. (Figs. 15, 16.) Since it is impossible to distinguish be tween benign and m alignant growths when small, a biopsy should be performed promptly in all such cases. It must be remembered that the cure o f cancer de pends on early recognition, and that delay, even of a week, m ay mean the difference between life and death. Gan-
Fig. 12.— Lym phosarcom a of palate.
tiple lesions in the mouth. (Fig. 12.) These tumors resist resection and, after irradiation as well as surgical interfer ence, new tumors arise, and no form of treatment promises permanent benefit. M ixed Tumors.— These occur on the hard or soft palate, generally on one side. T h ey are sessile and grow very slowly, but recurrence after operation is quite common because o f lack of encap sulation. (Fig. 13.) Papilloma.— These are soft outgrowths from the surface of the mucosa or m ay form hard cornified warts by progressive keratosis. (Fig. 14.) T h e latter occur especially in areas affected by leuko
Fig. 13 .— Mixed tumor of palate.
cers arise from the tongue, lips, palate and alveolar mucosa. W hen slow grow ing and bulky, they are radioresistant; when of rapid growth and m ade up of poorly differentiated cells, they almost melt aw ay when treated by the roentgen m ethod; but because they are also dissem inated rapidly, they are liable to recur, and metastasis is often present when the lesion is small. M ost oral cancers are of the epidermoid variety, but occasionally a basal-cell carcinoma or adenocarci noma is seen. T h e latter are found prin cipally on the palate. Carcinom a grows
T h o m a — O r a l M a n if e s t a t io n s o f D is e a s e s
without regard to tissue. T h e jaws m ay be invaded and destroyed. n o n -s u r g ic a l le s io n s o f t h e m o u th
T h e oral mucosa often furnishes im portant diagnostic information. The membrane of the cheek, the lips, the gingiva and especially the tongue m ay present symptomatic changes, the correct
227
the metabolic disturbance remains un treated. W e m ay classify oral lesions as oral diseases essentially local in charac ter ; general inflammatory diseases; oral disease in blood dyscrasia; those of metabolic origin, and diseases of the salivary glands. O n ly those of general interest will be considered here. le s io n s e s s e n t ia lly l o c a l
T h e oral cavity is protected by strati fied squamous epithelium, the cells of which have a phagocytic action and are
Fig. 16.— A den ocarcin om a of palate.
Fig. 14.— Papillom a of tongue.
F ig. 17.— Stom atitis nicotin a w ith leuko plakia and cyst form ation on the palate.
Fig. 15 .— Epidermoid carcinoma of lip.
interpretation of which m ay lead to the discovery o f serious somatic diseases. These, in turn, form a background for lesions in the mouth which will stub bornly resist local treatment as long as
constantly cast off and renewed. Thus injuries are promptly repaired. Chronic injuries, however, m ay cause permanent changes. This is typical of the effect of smoking or chewing tobacco; stomatitis nicotina or leukoplakia m ay result. Stomatitis Nicotina (Fig. 17).— This entity causes a periodically exfoliating leukoplakia with typical papular nodules
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due to the formation o f small cysts in the glandular system of the mucosa from occlusion of the outlet of their ducts. Leukoplakia.— This is another condi tion that is frequently caused by the use o f tobacco. (Fig. 18.) However, it was pointed out by U llm an (1936) that hypercholesteremia is an important pre disposing factor in some cases. Vitam in A deficiency and endocrine disturbances are other vital factors that must be con sidered.
ficiencies, especially deficiency o f ascor bic acid and nicotinic acid, are important. A correct diagnosis o f these underlying factors should be made in order to decide on medication.
Fig. 18.— Leu kop lakia of cheek.
Fig. 20.— A llergic stom atitis (shell fish) w ith can ker sore. T h e entire m ucosa was fiery red.
GEN ERAL IN FLA M M A T O R Y DISEASES
General inflammatory diseases m ay be caused by a large variety of conditions. T h e inflammation intensifies the redness o f the mucosa owing to capillary dila-
Fig. 19.— ^Streptococcic stom atitis.
Local Infections.— These produce a simple, membranous or ulcerating sto matitis when due to pyogenic bacteria. (Fig. 19.) As in the case of Vincent’s infection, predisposing conditions m ay play a predominant part. A ll oral organ isms are more pathogenic when the vital ity of the tissue is impaired. Debility, fatigue, blood dyscrasia and vitamin de
Fig. 2 1.— D ilan tin hypertrophy.
tion. T h e mucosa blanches on pressure. I f pressure is long continued, exudation m ay occur, with the formation of vesicles, and later crusting or infection of the desquamated area. Allergic Manifestations.— These m ay be due to contact allergy, such as is seen in denture sore mouth, or to protein
T h o m a — O r a l M a n if e s t a t io n s o f D is e a s e s
allergy, which m ay result in urticaria, erythema, angioneurotic edema, eryth ema m ultiforme and aphthosis. The ingestion o f drugs m ay have allergic re actions in patients who have a so-called idiosyncrasy. (Fig. 20.) Stomatitis Medicamentosa.— This may cause eruptions on the skin as well as in the mouth. Phenolphthalein, the barbit-
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ingestion of other metals m ay cause oral symptoms, the use of lead, mercury or bismuth causing typical conditions. Lichen Planus.— This disease affecting the skin and mucous membranes perhaps should be included here. (Fig. 22.) It causes nodular patches on the tongue and annular lesions which form a fine or
Fig. 22.— L ich en planus of cheek.
F ig. 24.— Sm ooth tongue itis) in pernicious anemia.
(H u n ter’s gloss
F ig. 23.— Pem phigus.
urates, iodine and iodoform are some of the frequent offenders. A special form of stomatitis medicamentosa is produced by the use of dilantin sodium, discovered by M erritt and Putnam (1939) and used to control epilepsy. In those who are susceptible, the gingivae become greatly hypertrophied. Gingivectom y affords only a temporary cure. (Fig. 21.) The
Fig. 25.— G in g iva l m yelogenous leukem ia.
h ypertrophy
due
to
wide meshed lacelike pattern on the m u cosa of the cheek and lips. Pemphigus.— This is another skin dis ease of which there are several varieties that m ay affect the oral cavity. There are cases on record in which the first signs of the disease occurred in the mouth, where bullae from 1 to 10 cm.
23°
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
in diameter formed in cycles. When these collapse, a foul yellow membrane covers the denuded area. (Fig. 23.) O RAL LE SIO N S IN BLO O D DYSCRASIAS
T h e recognition of blood dyscrasias is important because persons affected are poor surgical risks. T h ey are predisposed to local disease. V ery frequently, pa tients will present oral conditions which
F ig. 26.— Ecchym osis of skin and gingivitis in acute lym p h atic leukem ia.
smooth or m ay show desquamated areas due to atrophy o f the papillae. Pernicious Anem ia.— In this condition, the mucosa appears pale or yellowish and the tongue at first is red, but later be comes smooth from atrophy, which at tacks first the sides and later the dorsum of the tongue. T h e sign is known as
Fig. 28.— Sm ooth tongue and cheilitis in hypochrom ic anem ia com plicated by ribo flavin deficiency.
Fig. 27.— U lc e r of p alate in agranulocytosis.
m ay be recognized as symptomatic and give warning that a careful diagnosis should be made. Hypochromic Anem ia.— In this condi tion, the mucosa is pale and often there are petechiae present, indicating capil lary hemorrhage. T h e bleeding time m ay be prolonged, even though the clotting time is normal. T he tongue m ay be
Fig. 29.— G in givitis dysm enorrhea.
Hunter’s glossitis, and there often is a burning sensation associated with it. (Fig. 24.) _ Leukem ia.— Both myelogenous and lym phatic leukemia frequently cause marked hypertrophy o f the gingiva due to invasion o f the tissue by leukopoietic
T h o m a — O r a l M a n if e s t a t io n s o f D is e a se s
cells. (Fig. 25.) There is, however, a disposition to local infection and ulcera tion. (Fig. 26.) Evidence o f ecchymosis o f the skin, as well as in the mouth, is a sign that should be taken as a warning. Agranulocytosis.— This condition is characterized by fever and an almost complete absence of granular leukocytes. It also predisposes the patient to infec tion and the formation o f ulcers in the mouth. A great number o f deaths have been reported, following tooth extraction. (Fig. 27.) O RAL LE SIO N S D U E TO M ET A B O LIC D ISTU RBAN CES
T h e diseases causing the most serious oral disturbances are the vitam in defi-
Fig. 30.— D iab etic gingivitis.
ciencies, endocrine imbalance, uremia and diabetes. Vitamin Deficiency.— This m ay have various manifestations in the oral mu cosa. It is important to keep in mind that several deficiencies usually exist at the same time, because, in food, the fatsoluble and water-soluble vitamins are closely associated. Scorbutic Stomatitis.— This condition occurs in ascorbic acid deficiency. G in gival inflammation and hypertrophy are present. T h e gingivae are blue and there is evidence of ecchymosis. There is a predisposition to hemorrhage and infec tion.
23 1
Vitamin B Deficiency.— This m ay in clude a deficiency o f thiamine, nicotinic acid and riboflavin. Glossalgia and minor neuralgia of the face are often cured by the administration of thiamine. T h e beefy tongue and ulcerations due to the presence o f V incent’s organisms gen erally yield to nicotinic acid therapy, while cheilitis fissuratum, so commonly a sign o f this deficiency, heals when ribo flavin is given to the patient. (Fig. 28.) Stomatitis Dysmenorrheica.— Various conditions occur periodically in the mouths o f those suffering from abnormal or difficult menstruation. These m ay be due to vaginal absorption or to endocrine dysfunction. W e m ay find inflammation o f the gingiva, spontaneous bleeding and
Fig. 3 1.— Sialogram show ing in jected duct and peripheral injection of parotid gland. F illin g in center indicates tum or form ation.
often habitual aphthosis. (Fig. 29.) Stomatitis Gravidarum.— This is due to the excess of hormones produced dur ing pregnancy. It has been experiment ally produced by Ziskin (1938) by injection of folluetin, and extract of pregnancy urine. T h e gingivae are hypertrophied and inflamed, and preg nancy tumors m ay form, as already stated. Uremic Stomatitis.— This often causes xerostomia. T h e tongue has a brown coating. T h e gingivae are edematous and bleed easily, and the breath has a urinous odor.
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T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
Diabetic Stomatitis.— In uncontrolled diabetes, gingivitis is present in various degrees o f severity, and the deposit of gingival calculus is an outstanding fea ture. There is lowered resistance o f the tissue to infection. (Fig. 30.) DISE ASE S O F T H E S A L IV A R Y GLANDS
T h e secretions o f the salivary glands are o f great importance to the health of the teeth and the oral mucosa. Although we have known for a long time that the constituents of the saliva follow those o f the blood, and that certain products and m any chemicals ingested are excreted by the salivary glands, we have only recently given attention to the beneficial or the deleterious effects in the mouth o f nor m al or abnormal salivary secretion. Infection of the Salivary Glands.— In fection causes characteristic swellings of the salivary glands, and is caused either by involvement o f the gland itself or by the presence of stones in or by strictures of the ducts. Sialograms are generally used to make a diagnosis. T umons of the Salivary Glands.— Various tjjjaoig. m ay form. Th&se again are recognized in the sialogram if lipiodol or iodochloral is injected-. T u mors are recognized by buckling o f the duct, filling defects, bone erosion and localized effusion. (Fig. 31.)
c o n c l u s io n
I should like to emphasize what I hope the presentation of these cases has brought to ligh t; namely, that the etiol ogy of oral lesions is frequently compli cated. N o single factor explains any process o f life, and the cause of most diseases is m ade up o f a number of fac tors. O ne or the other seems to be more important and takes on the character of the exciting cause, but this m ay be due only to the fact that it is the most ob vious factor or the one that is tempo rarily best understood. Thus, it is all the more important to follow Osier’s advice to treat the patient and not the disease. This is timely advice for the man trained in a specialty which is looked on as an autonomic profession; a truth which, when understood, will break down the artificial wall between dentistry and medicine. b ib l io g r a p h y
H. H., and P u t n a m , T. J .: Sodium Diphenyl Hydantionate in Treatment of Convulsive Disorders. I.A .M .A ., 111 : i o 6 8 , September 1 7 , 1938 . U l l m a n n , K .: Ueber Leukoplakia electro galvánica und hypercholesterinica. Dermat. Wchnschr., 1 0 2 : 425 , April 4 , 19 3 6 . Z i s k i n , D. E .: Effects of Certain Hormones on Gingival and Oral Mucous Membranes. J.A.D.A., 2 5 :422 , March 1938 . 53 Bay State Road. M
e r r it t ,
urt
H. T
h o m a ,*
H E horizon of dentistry has broad ened greatly in past decades. From a profession chiefly concerned with the care o f the teeth, which were cleaned, treated, filled, extracted and replaced, we have developed to the status o f a spe cialty of medicine. Today, we are first o f all concerned in a more extensive field, the health of the entire oral cavity, including the salivary glands. Secondly, we have come to real ize that there are no autonomic regions in the body. A n y experienced clinician knows that infections do not respect the limits of the field in which they orig inate, and that oral cancer m ay metas tasize to organs remote from the primary lesion. T h e modern investigator has taught us that systemic conditions such as nutri tional states, endocrine disturbances and metabolic disorders have important ef fects on the development of the teeth, and tend to improve or m odify the in herent growth pattern of the jaws and faces. In practice, we are utilizing recent knowledge gleaned from the work of re searchers to advise our patients regard ing conditions which form the back ground o f orthodontic problems and m ay be expected to inhibit dental caries and periodontal disease. Finally, we see in the mouth an in creasing degree of pathologic change
T
•Professor of oral surgery and Charles A. Brackett professor of oral pathology, Harvard University. Read before the Section on Oral Surgery and M edical Relations at the Seventy-Seventh Annual Midwinter Meeting of the Chicago Dental Society, February 18 , 19 4 1 . Jour. A .D .A ., V o l. 29, F eb ru ary 1942
D .M .D ., Boston, Mass. which is a sign o f somatic disease, or lesions produced by local infection through the activity of bacteria that have awaited the opportunity to become pathogenic when the soil became recep tive. Investigation o f these predisposing conditions leads into the domain of in ternal medicine. Thus, even diseases that appear to be entirely o f local origin often require general medication for effective treat ment, to improve the general health of the patient, to correct predisposing causes or to effect a cure through the hema togenous channels ; as, for example, with such chemicals as the sulfonamide drugs. In the oral cavity, these act not only by their presence in the tissue fluids, but also through the action o f the saliva in which they are contained and which constantly bathes the lesion. General medication by these drugs serves another important function : it prevents bacteremia and the spreading o f infection through the cir culation when operations such as tooth extraction are performed in infected areas. Thus the finger o f progress in dental practice, as well as in clinical and laboratory investigation, points definitely in the direction of medicine. O ral manifestations o f local and gen eral diseases is a timely and important subject, covering a field that is neglected by m any general practitioners, and often only because o f the more evident or more disturbing problems presented by the patient’s teeth. As there is not time to thoroughly discuss oral manifestations of local and general disease, I shall limit m yself to a cursory presentation o f cases 222
T h o m a — O r a l M a n if e s t a t io n s o f D is e a se s
seen in practice or in hospital clinics, hoping to further the recognition and correct diagnosis of both surgical and non-surgical lesions in the mouth. I doubt whether the accepted practice of classifying oral lesions as local or general manifestations is a fortunate one. D ivi sion into surgical and non-surgical lesions has greater advantages because it indi cates at once that some are treated by the oral surgeon, while others are in the
Fig. 2.— Mucous cyst of lower lip. field o f oral medicine, and should be treated by the dental internist. SU RG ICAL LESIO N S OF T H E M O U TH
W hile the surgical operation is dis tinctly a local method, by which lesions are excised by scalpel or endothermy knife, its effects and complications m ay be profound and far-reaching. Nor is
223
surgery always successful without cor rection of somatic conditions, and sup portive treatment is, very often, of para mount importance. I need only to m en tion the recurrence of pregnancy tumors if excised before parturition, and the problems presented b y operations on pa tients suffering from diabetes, avitam in oses and blood diseases. Following are some of the important surgical diseases of the mouth :
Fig. 4 .— Alveolar fissuratum.
hyperplasia
or
epulis
Malformations.— These clefts of the lip, face and palate often present serious problems to the surgeon, while abnormal ities of the tongue such as tongue-tie and hypertrophy o f the labial frenum are easily corrected. (Fig. 1.) Abscesses.— These m ay be due to in jury or odontogenic infection.
224
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
Cysts.— These lesions occur on the lip and tongue as so-called retention cysts; on the floor of the mouth as ranula, and on the palate as cysts of the papilla palatina. T h e former are due to the occlusion of the outlets of mucous gland s; the latter to the accum ulation o f secre tions in the nasopalatine duct. (Fig. 2.) Hypertrophy of the Oral M ucosa.— These cases are generally due to mechan ical irritation of long standing, present ing the picture of chronic inflammation. W e m ay distinguish several clinical form s: 1. Epulis granulomatosa, which grows
tissue forms, often bifid and containing a fissure into which the denture m ay ex tend. This very typical lesion is known as epulis fissuratum. Pregnancy Tumors.— These are an other manifestation of hyperplasia which appears in connection with stomatitis gravidarum. (Fig. 5.) T h ey are spher ical bodies of deep red or of blue, often attached by a broad pedicle to the gin gival papilla. T h ey are generally mul tiple. T h ey bleed easily when injured
Fig. 6 .— Peripheral giant-cell tumor (giant cell epulis).
Fig. 5 .— Large pregnancy tumor in woman three weeks before parturition.
from extraction wounds and is due to irritation from a spicule of bone or tooth, or which forms a pedunculated area of hyperplasia o f the gingiva, often filling the space between decayed adjoining teeth. (Fig. 3.) 2. Palatal hyperplasia, caused by the suction chamber of a denture. 3. Alveolar hyperplasia, the common form resulting from the presence o f illfitting dentures. (Fig. 4.) From a socalled chronic traumatic ulcer, a fold of
Fig. 7 .— Fibroma of cheek.
and recur if excised before parturition. T h ey are made up o f fibrous tissue with marked angiomatous proliferation (fibroangioma). Peripheral Giant-Cell Tumors.— These tumors are seen in hyperparathyroidism, in which we find also the more common type o f central lesion. (Fig. 6.) It m ay be, however, a solitary tumor occurring in an otherwise normal patient. It gen
T h o m a — O r a l M a n if e s t a t io n s o f D is e a s e s
erally forms on the gingiva, and for this reason it is also known as giant-cell epulis. It is bluish and, in most instances, is sessile, but m ay be pedunculated. It shows a tendency to recur if not com pletely removed. The tissue consists of a synctium of immature connective tissue cells among which are scattered numer ous multinucleated foreign body giant cells. Fibromas.— This typical benign tumor
Fig. 8.— Fibrosarcom a of odontogenic origin.
225
speak of fibromatosis or elephantiasis of the gingiva. Fibrosarcomas.— This malignant tumor is not infrequently encountered. (Fig. 8.) It is seen in young patients and is apt to recur after excision. It m ay de velop at the angle of the jaw , but also may be seen as an intra-oral lesion which grows rapidly and, when injured by the teeth, tends to ulcerate.
Fig. 10.— Sm all hem angiom a of lip.
Fig. 9.— L ipo m a of tongue.
is of frequent occurrence in the mouth. (Fig. 7.) It forms principally in the fissural area of the mucosa of the cheek, on the tongue and the lip, and sometimes on the gingiva as a soft or hard pedun culated, well-defined growth covered by a pale, smooth epithelium. O n the alveolar mucosa, however, it is frequently sessile and m ay cover a large area. When the entire gingiva is thickened, we may
Fig. 11 ••— H em angiom a of tongue of con gen ital origin.
Lipomas.— Lipom a forms especially in areas where adipose tissue is found. It m ay be pedunculated or m ay develop in the areolar gingiva or in the tongue. (Fig- 9 -) Hemangiomas.— Hemangioma is often
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o f congenital origin, and from insignifi cant early lesions. (Fig. 10.) Large tumors m ay develop. (Figs. n . ) T he fact that the blood can be temporarily forced out, only to rush back after pres sure ceases, is a diagnostic sign. It occurs on the tongue, lip and cheek, and some times at the gingival margin. Endotheliomas and Lymphocytomas. — These neoplasms are quite rare in the mouth. T h ey m ay occur on the palate. The reticulum cell sarcoma, a form of the malignant lymphocytoma, is made up of large round lymphoid cells with hyperchromatic nuclei and m ultinucle ated cells lying in atypical reticular tis sue. Early involvement o f the regional lymph glands is a clinical feature. Lymphosarcoma generally forms mul-
plakia. As cancer m ay start as a papil lomatous lesion, it is good practice to remove papillomas prom ptly by wide excision, and follow with postoperative irradiation if, on microscopic examina tion, m alignancy is found. Carcinomas.— Dentists who see pa tients at short intervals should be able to detect carcinoma early. (Figs. 15, 16.) Since it is impossible to distinguish be tween benign and m alignant growths when small, a biopsy should be performed promptly in all such cases. It must be remembered that the cure o f cancer de pends on early recognition, and that delay, even of a week, m ay mean the difference between life and death. Gan-
Fig. 12.— Lym phosarcom a of palate.
tiple lesions in the mouth. (Fig. 12.) These tumors resist resection and, after irradiation as well as surgical interfer ence, new tumors arise, and no form of treatment promises permanent benefit. M ixed Tumors.— These occur on the hard or soft palate, generally on one side. T h ey are sessile and grow very slowly, but recurrence after operation is quite common because o f lack of encap sulation. (Fig. 13.) Papilloma.— These are soft outgrowths from the surface of the mucosa or m ay form hard cornified warts by progressive keratosis. (Fig. 14.) T h e latter occur especially in areas affected by leuko
Fig. 13 .— Mixed tumor of palate.
cers arise from the tongue, lips, palate and alveolar mucosa. W hen slow grow ing and bulky, they are radioresistant; when of rapid growth and m ade up of poorly differentiated cells, they almost melt aw ay when treated by the roentgen m ethod; but because they are also dissem inated rapidly, they are liable to recur, and metastasis is often present when the lesion is small. M ost oral cancers are of the epidermoid variety, but occasionally a basal-cell carcinoma or adenocarci noma is seen. T h e latter are found prin cipally on the palate. Carcinom a grows
T h o m a — O r a l M a n if e s t a t io n s o f D is e a s e s
without regard to tissue. T h e jaws m ay be invaded and destroyed. n o n -s u r g ic a l le s io n s o f t h e m o u th
T h e oral mucosa often furnishes im portant diagnostic information. The membrane of the cheek, the lips, the gingiva and especially the tongue m ay present symptomatic changes, the correct
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the metabolic disturbance remains un treated. W e m ay classify oral lesions as oral diseases essentially local in charac ter ; general inflammatory diseases; oral disease in blood dyscrasia; those of metabolic origin, and diseases of the salivary glands. O n ly those of general interest will be considered here. le s io n s e s s e n t ia lly l o c a l
T h e oral cavity is protected by strati fied squamous epithelium, the cells of which have a phagocytic action and are
Fig. 16.— A den ocarcin om a of palate.
Fig. 14.— Papillom a of tongue.
F ig. 17.— Stom atitis nicotin a w ith leuko plakia and cyst form ation on the palate.
Fig. 15 .— Epidermoid carcinoma of lip.
interpretation of which m ay lead to the discovery o f serious somatic diseases. These, in turn, form a background for lesions in the mouth which will stub bornly resist local treatment as long as
constantly cast off and renewed. Thus injuries are promptly repaired. Chronic injuries, however, m ay cause permanent changes. This is typical of the effect of smoking or chewing tobacco; stomatitis nicotina or leukoplakia m ay result. Stomatitis Nicotina (Fig. 17).— This entity causes a periodically exfoliating leukoplakia with typical papular nodules
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due to the formation o f small cysts in the glandular system of the mucosa from occlusion of the outlet of their ducts. Leukoplakia.— This is another condi tion that is frequently caused by the use o f tobacco. (Fig. 18.) However, it was pointed out by U llm an (1936) that hypercholesteremia is an important pre disposing factor in some cases. Vitam in A deficiency and endocrine disturbances are other vital factors that must be con sidered.
ficiencies, especially deficiency o f ascor bic acid and nicotinic acid, are important. A correct diagnosis o f these underlying factors should be made in order to decide on medication.
Fig. 18.— Leu kop lakia of cheek.
Fig. 20.— A llergic stom atitis (shell fish) w ith can ker sore. T h e entire m ucosa was fiery red.
GEN ERAL IN FLA M M A T O R Y DISEASES
General inflammatory diseases m ay be caused by a large variety of conditions. T h e inflammation intensifies the redness o f the mucosa owing to capillary dila-
Fig. 19.— ^Streptococcic stom atitis.
Local Infections.— These produce a simple, membranous or ulcerating sto matitis when due to pyogenic bacteria. (Fig. 19.) As in the case of Vincent’s infection, predisposing conditions m ay play a predominant part. A ll oral organ isms are more pathogenic when the vital ity of the tissue is impaired. Debility, fatigue, blood dyscrasia and vitamin de
Fig. 2 1.— D ilan tin hypertrophy.
tion. T h e mucosa blanches on pressure. I f pressure is long continued, exudation m ay occur, with the formation of vesicles, and later crusting or infection of the desquamated area. Allergic Manifestations.— These m ay be due to contact allergy, such as is seen in denture sore mouth, or to protein
T h o m a — O r a l M a n if e s t a t io n s o f D is e a s e s
allergy, which m ay result in urticaria, erythema, angioneurotic edema, eryth ema m ultiforme and aphthosis. The ingestion o f drugs m ay have allergic re actions in patients who have a so-called idiosyncrasy. (Fig. 20.) Stomatitis Medicamentosa.— This may cause eruptions on the skin as well as in the mouth. Phenolphthalein, the barbit-
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ingestion of other metals m ay cause oral symptoms, the use of lead, mercury or bismuth causing typical conditions. Lichen Planus.— This disease affecting the skin and mucous membranes perhaps should be included here. (Fig. 22.) It causes nodular patches on the tongue and annular lesions which form a fine or
Fig. 22.— L ich en planus of cheek.
F ig. 24.— Sm ooth tongue itis) in pernicious anemia.
(H u n ter’s gloss
F ig. 23.— Pem phigus.
urates, iodine and iodoform are some of the frequent offenders. A special form of stomatitis medicamentosa is produced by the use of dilantin sodium, discovered by M erritt and Putnam (1939) and used to control epilepsy. In those who are susceptible, the gingivae become greatly hypertrophied. Gingivectom y affords only a temporary cure. (Fig. 21.) The
Fig. 25.— G in g iva l m yelogenous leukem ia.
h ypertrophy
due
to
wide meshed lacelike pattern on the m u cosa of the cheek and lips. Pemphigus.— This is another skin dis ease of which there are several varieties that m ay affect the oral cavity. There are cases on record in which the first signs of the disease occurred in the mouth, where bullae from 1 to 10 cm.
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in diameter formed in cycles. When these collapse, a foul yellow membrane covers the denuded area. (Fig. 23.) O RAL LE SIO N S IN BLO O D DYSCRASIAS
T h e recognition of blood dyscrasias is important because persons affected are poor surgical risks. T h ey are predisposed to local disease. V ery frequently, pa tients will present oral conditions which
F ig. 26.— Ecchym osis of skin and gingivitis in acute lym p h atic leukem ia.
smooth or m ay show desquamated areas due to atrophy o f the papillae. Pernicious Anem ia.— In this condition, the mucosa appears pale or yellowish and the tongue at first is red, but later be comes smooth from atrophy, which at tacks first the sides and later the dorsum of the tongue. T h e sign is known as
Fig. 28.— Sm ooth tongue and cheilitis in hypochrom ic anem ia com plicated by ribo flavin deficiency.
Fig. 27.— U lc e r of p alate in agranulocytosis.
m ay be recognized as symptomatic and give warning that a careful diagnosis should be made. Hypochromic Anem ia.— In this condi tion, the mucosa is pale and often there are petechiae present, indicating capil lary hemorrhage. T h e bleeding time m ay be prolonged, even though the clotting time is normal. T he tongue m ay be
Fig. 29.— G in givitis dysm enorrhea.
Hunter’s glossitis, and there often is a burning sensation associated with it. (Fig. 24.) _ Leukem ia.— Both myelogenous and lym phatic leukemia frequently cause marked hypertrophy o f the gingiva due to invasion o f the tissue by leukopoietic
T h o m a — O r a l M a n if e s t a t io n s o f D is e a se s
cells. (Fig. 25.) There is, however, a disposition to local infection and ulcera tion. (Fig. 26.) Evidence o f ecchymosis o f the skin, as well as in the mouth, is a sign that should be taken as a warning. Agranulocytosis.— This condition is characterized by fever and an almost complete absence of granular leukocytes. It also predisposes the patient to infec tion and the formation o f ulcers in the mouth. A great number o f deaths have been reported, following tooth extraction. (Fig. 27.) O RAL LE SIO N S D U E TO M ET A B O LIC D ISTU RBAN CES
T h e diseases causing the most serious oral disturbances are the vitam in defi-
Fig. 30.— D iab etic gingivitis.
ciencies, endocrine imbalance, uremia and diabetes. Vitamin Deficiency.— This m ay have various manifestations in the oral mu cosa. It is important to keep in mind that several deficiencies usually exist at the same time, because, in food, the fatsoluble and water-soluble vitamins are closely associated. Scorbutic Stomatitis.— This condition occurs in ascorbic acid deficiency. G in gival inflammation and hypertrophy are present. T h e gingivae are blue and there is evidence of ecchymosis. There is a predisposition to hemorrhage and infec tion.
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Vitamin B Deficiency.— This m ay in clude a deficiency o f thiamine, nicotinic acid and riboflavin. Glossalgia and minor neuralgia of the face are often cured by the administration of thiamine. T h e beefy tongue and ulcerations due to the presence o f V incent’s organisms gen erally yield to nicotinic acid therapy, while cheilitis fissuratum, so commonly a sign o f this deficiency, heals when ribo flavin is given to the patient. (Fig. 28.) Stomatitis Dysmenorrheica.— Various conditions occur periodically in the mouths o f those suffering from abnormal or difficult menstruation. These m ay be due to vaginal absorption or to endocrine dysfunction. W e m ay find inflammation o f the gingiva, spontaneous bleeding and
Fig. 3 1.— Sialogram show ing in jected duct and peripheral injection of parotid gland. F illin g in center indicates tum or form ation.
often habitual aphthosis. (Fig. 29.) Stomatitis Gravidarum.— This is due to the excess of hormones produced dur ing pregnancy. It has been experiment ally produced by Ziskin (1938) by injection of folluetin, and extract of pregnancy urine. T h e gingivae are hypertrophied and inflamed, and preg nancy tumors m ay form, as already stated. Uremic Stomatitis.— This often causes xerostomia. T h e tongue has a brown coating. T h e gingivae are edematous and bleed easily, and the breath has a urinous odor.
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Diabetic Stomatitis.— In uncontrolled diabetes, gingivitis is present in various degrees o f severity, and the deposit of gingival calculus is an outstanding fea ture. There is lowered resistance o f the tissue to infection. (Fig. 30.) DISE ASE S O F T H E S A L IV A R Y GLANDS
T h e secretions o f the salivary glands are o f great importance to the health of the teeth and the oral mucosa. Although we have known for a long time that the constituents of the saliva follow those o f the blood, and that certain products and m any chemicals ingested are excreted by the salivary glands, we have only recently given attention to the beneficial or the deleterious effects in the mouth o f nor m al or abnormal salivary secretion. Infection of the Salivary Glands.— In fection causes characteristic swellings of the salivary glands, and is caused either by involvement o f the gland itself or by the presence of stones in or by strictures of the ducts. Sialograms are generally used to make a diagnosis. T umons of the Salivary Glands.— Various tjjjaoig. m ay form. Th&se again are recognized in the sialogram if lipiodol or iodochloral is injected-. T u mors are recognized by buckling o f the duct, filling defects, bone erosion and localized effusion. (Fig. 31.)
c o n c l u s io n
I should like to emphasize what I hope the presentation of these cases has brought to ligh t; namely, that the etiol ogy of oral lesions is frequently compli cated. N o single factor explains any process o f life, and the cause of most diseases is m ade up o f a number of fac tors. O ne or the other seems to be more important and takes on the character of the exciting cause, but this m ay be due only to the fact that it is the most ob vious factor or the one that is tempo rarily best understood. Thus, it is all the more important to follow Osier’s advice to treat the patient and not the disease. This is timely advice for the man trained in a specialty which is looked on as an autonomic profession; a truth which, when understood, will break down the artificial wall between dentistry and medicine. b ib l io g r a p h y
H. H., and P u t n a m , T. J .: Sodium Diphenyl Hydantionate in Treatment of Convulsive Disorders. I.A .M .A ., 111 : i o 6 8 , September 1 7 , 1938 . U l l m a n n , K .: Ueber Leukoplakia electro galvánica und hypercholesterinica. Dermat. Wchnschr., 1 0 2 : 425 , April 4 , 19 3 6 . Z i s k i n , D. E .: Effects of Certain Hormones on Gingival and Oral Mucous Membranes. J.A.D.A., 2 5 :422 , March 1938 . 53 Bay State Road. M
e r r it t ,