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Oral Diseases


  • In addition to common benign lesions such as bite fibromas and mucoceles, oral findings can represent clues to the diagnosis of skin disorders (e.g. lichen planus, early pemphigus vulgaris) or cutaneous signs of systemic disease ( Table 59.1 ). Table 59.2 provides an overview of topical care for oral inflammatory conditions.

    Table 59.1
    Systemic diseases with oral manifestations.
    Disorder Oral findings
    Primary systemic amyloidosis (see Ch. 39 )

    • Macroglossia, often with scalloped edges (due to dental impressions) or hemorrhagic papulonodules (see Fig. 39.3 ); xerostomia

    Nutritional deficiencies (see Ch. 43 )

    • Atrophic glossitis (see text), stomatitis

    • Scurvy : gingival enlargement, hemorrhage and erosions (see Fig. 43.7 B)

    Inflammatory bowel disease

    • Crohn disease : oral cobblestoning and ulcers (aphthous or linear; see Fig. 59.16 ), angular cheilitis, orofacial granulomatosis (see text)

    • Pyostomatitis vegetans (ulcerative colitis > Crohn): oral pustules and erosions in a “snail track-like” arrangement

    Behçet disease (see Ch. 21 )

    • Aphthae (see text)

    Sarcoidosis (see Ch. 78 )

    • Orofacial granulomatosis (see text), xerostomia, salivary gland enlargement

    Sjögren syndrome (see Ch. 37 )

    • Xerostomia

    Granulomatosis with polyangiitis (see Ch. 19 )

    • Gingival hemorrhage with a friable micropapular surface (“strawberry gums”; see Fig. 59.17 )

    Leukemia

    • Hemorrhage due to thrombocytopenia, infections (viral, fungal, bacterial), gingival enlargement due to leukemic infiltration (especially in [myelo]monocytic forms)

    Genodermatoses

    • Tuberous sclerosis complex : oral fibromas, dental enamel pits

    • Cowden syndrome : oral papillomas favoring lips and tongue (see Fig. 45.3 C and 52.1 B)

    • Multiple endocrine neoplasia type 2B : mucosal neuromas – papulonodules favoring lips and anterior tongue (see Fig. 52.2 B)

    • Darier disease : whitish papules and rugose plaques favoring palate and gingivae (see Fig. 48.8 )

    • Lipoid proteinosis : diffuse infiltration or cobblestoned papules favoring lips and tongue/frenulum, xerostomia (see Fig. 40.4 B)

    • Chronic mucocutaneous candidiasis (see Fig. 49.3 A)

    • Classic hyper-IgE syndrome : retention of primary teeth, candidiasis

    • Ectodermal dysplasias : hypodontia, cone-shaped teeth

    • Basal cell nevus syndrome : odontogenic keratocysts of mandible > maxilla

    • Gardner syndrome : osteomas of maxilla and mandible

    • Peutz–Jeghers syndrome: brown macules on lips and oral mucosa (see Fig. 45.3 B)

    Table 59.2
    Topical care for oral inflammatory conditions.
    Oral hygiene

    • Soft toothbrush

    • Water pick, soft-tipped gum pick, or waxed tape-type dental floss to remove plaque

    • Non-alcohol-based mouthwash

    • Avoid trauma, e.g. sharp/rough dental restorations/appliances or biting cheeks

    Topical anesthetics for erosions/ulcers

    • 2% viscous lidocaine (to surface of ulcers or as swish & spit)

    • “Magic mouthwash” with equal parts of: (1) 2% viscous lidocaine; (2) diphenhydramine 12.5 mg/5 ml; (3) magnesium and aluminum hydroxide plus sucralfate (Maalox®); consider adding dexamethasone elixir and/or nystatin suspension

    • Dyclonine lozenges (e.g. Sucrets®)

    • Benzocaine gel or lozenges

    Topical anti-inflammatory medications

    • Corticosteroids, e.g. clobetasol 0.05% gel/ointment, fluocinonide 0.05% gel/ointment, triamcinolone 0.1% paste BID

    • Dexamethasone elixir 0.5 mg/5 ml, swish and spit 5 ml BID–TID (leaving in mouth for 5 minutes) ∗

    • Corticosteroid inhaler BID

    • Tacrolimus 0.1% ointment BID

    • Tacrolimus 1 mg capsule dissolved in 0.5–1 L of water, swish and spit 5 ml BID (leaving in mouth for ≥2 minutes) ∗

    Prevention of secondary infection ∗∗

    • Clotrimazole 10 mg troches 4 times/day

    • Nystatin suspension (400,000–6000,000 units), swish and swallow 4 times/day

    • Chlorhexidine 0.12% oral rinse, swish and spit BID

    • Dilute hydrogen peroxide (one part 3% solution, 2 parts water), swish and spit BID

    ∗ Especially for patients with more widespread involvement.

    ∗∗ Consider for patients with extensive oral erosion/ulceration, especially if using topical or systemic immunosuppressive agents.

  • Oral manifestations of infectious diseases (e.g. candidiasis, viral enanthems, findings associated with HIV infection) are covered in the chapters focused on these conditions.

Common Oral Mucosal Findings

Fordyce Granules

  • “Free” sebaceous glands (i.e. not associated with hair follicles) evident in as many as 75% of adults ( Fig. 59.1 ).

    Fig. 59.1, Fordyce granules.

  • Multiple 1- to 2-mm yellowish papules on the vermilion lips (upper > lower) and oral mucosa (especially buccal).

Geographic Tongue (Migratory Glossitis)

  • Incidental finding on the dorsum of the tongue in ∼2–3% of the population; may occasionally be associated with psoriasis, especially pustular variants.

  • Well-demarcated areas of erythema and atrophy of the filiform papillae, surrounded by a whitish, hyperkeratotic serpiginous border ( Fig. 59.2 ); lesions tend to migrate over time, may affect other oral sites, and are occasionally associated with a burning sensation.

    Fig. 59.2, Geographic tongue.

Scrotal (Fissured) Tongue

  • Asymptomatic finding that is occasionally associated with conditions such as granulomatous cheilitis (see below) and Down syndrome.

  • Multiple grooves or furrows are present on the dorsal tongue, especially centrally ( Fig. 59.3 ).

    Fig. 59.3, Fissured tongue.

Hairy Tongue (Black Hairy Tongue)

  • Reflects accumulation of keratin on the dorsum of the tongue; contributing factors may include poor oral hygiene, smoking, and a soft diet.

  • Confluence of hairlike projections, which represent elongated papillae, with yellowish to brown-black discoloration ( Fig. 59.4 ); may have exogenous staining from food, tobacco, or chromogenic bacteria (especially following antibiotic therapy); some patients report an unpleasant odor or taste.

    Fig. 59.4, Hairy tongue.

  • DDx: pigmented papillae of the tongue (in individuals with darkly pigmented skin).

  • Rx: scraping or brushing the tongue.

Leukoedema

  • Normal variant that is more often evident in smokers and individuals with darkly pigmented skin.

  • Grayish-white, opalescent, sometimes “moth-eaten” appearance of the buccal > labial mucosa ( Fig. 59.5 ); typically becomes less evident upon stretching.

    Fig. 59.5, Leukoedema.

Median Rhomboid Glossitis (Central Papillary Atrophy)

  • Found in ∼1% of adults, usually associated with local candidiasis.

  • Well-demarcated diamond- or oval-shaped area of erythema and atrophy on the dorsum of the tongue ( Fig. 59.6 ).

    Fig. 59.6, Median rhomboid glossitis.

  • Rx: clotrimazole troches or oral fluconazole (for dosage, see Table 64.5 ).

Periodontal and Dental Conditions with Dermatologic Relevance

Desquamative Gingivitis

  • Clinical finding that can occur in several immune-mediated vesicular and erosive disorders ( Fig. 59.7 ); favors women over 40 years of age.

    Fig. 59.7, Differential diagnosis of desquamative gingivitis.

  • Diffuse gingival erythema with varying degrees of sloughing and erosion; frequently painful.

  • Because desquamative gingivitis is often a manifestation of mucous membrane (cicatricial) pemphigoid and other autoimmune bullous disorders, evaluation should include routine histology plus direct and indirect immunofluorescence studies (see Ch. 23 ).

  • Rx: treatment of underlying condition plus meticulous oral hygiene.

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