Oral Diseases and Oral Manifestations of Gastrointestinal and Liver Diseases

Cheilitis

Cheilitis, inflammation of the lips, may include the vermilion, the mucosa, and the perioral skin, including the oral commissures. Treatment involves targeting or discontinuing the underlying cause of the inflammation.

Angular cheilitis (angular cheilosis, angular stomatitis) presents as painful edema and fissures due to inflammation and irritation at the oral commissures. Vitamin B ₂ (riboflavin) or iron deficiency may cause cheilitis. Infections may cause irritation to the lips. Oral habits like lip licking and lip biting may also predispose patients to angular cheilitis.

Exfoliative cheilitis (chronic chapped lips) is a chronic inflammation of the vermilion. Patients complain of dryness or itching in the setting of a wide variety of disorders (e.g., atopic dermatitis, psoriasis, chronic irritation, and allergies). Topical glucocorticoids or calcineurin inhibitors may be effective for symptomatic treatment.

Contact cheilitis, precipitated by an irritant or allergic reaction, presents with lip and perioral edema, erythema, and scale. Fragrances, lanolin, dodecyl gallate, and benzoyl peroxide in personal hygiene products and cosmetics, foods, personal habits, and topical medications (e.g., gentamicin) have been indicated as etiologies of allergic contact cheilitis. The most common allergens include fragrance mix and balsam of Peru.

Granulomatous cheilitis is a rare condition that presents with recurrent lip swelling associated with chronic enlargement and firmness of the lips. Lip biopsy shows noncaseating granulomas. Granulomatous cheilitis is associated with Crohn disease and tuberculosis, and as a component of Melkersson-Rosenthal syndrome (a rare condition characterized by fissured tongue and granulomatous cheilitis, with or without facial palsy and migraine).

Lip Neoplasms

Actinic cheilitis (actinic keratosis of the lip, solar cheilosis) is a premalignant lip epithelial dysplasia linked to chronic solar or ultraviolet radiation. Fair-skinned individuals, especially those with occupational exposure, older-age individuals, and those with a history of solid organ transplant (with subsequent immunosuppression) have a higher risk of developing actinic cheilitis. While the presentation is variable, loss of the vermilion border, with diffuse erythema, patchy whiteness, dryness, and vermilion scaling are the most typical symptoms. Lip biopsies from multiple sites should be taken, as location and degree of lip dysplasia cannot be predicted by clinical presentation alone. While there are currently no FDA-approved treatments for this disorder, treatment of the entire lip is indicated, as actinic cheilitis may progress to squamous cell carcinoma (SCC).

SCC is the most common oral neoplasm and most commonly affects the lower lip. Fair-skinned Caucasians, men, and HPV 16 or 18 infection may predispose patients to this malignant transformation of lip epithelial cells. Because SCC is a high-risk source of metastases, the diagnosis should include staging at initial evaluation. Treatment includes surgical excision and radiation therapy.

Xerostomia

Xerostomia (dry mouth) is a common complaint that results from destruction or atrophy of the salivary glands. Autoimmune disease (Sjögren syndrome, SLE, primary biliary cholangitis), radiation therapy, diabetes mellitus, infection, granulomatous diseases such as sarcoidosis and tuberculosis, chronic graft-versus-host disease, end-stage renal disease, hemochromatosis, amyloidosis, and Parkinson, as well as a variety of medications—anticholinergics, H ₁ antihistamines, tricyclic antidepressants, selective serotonin reuptakes inhibitors (SSRIs), hypnotics, sedatives, antihypertensives, antipsychotics, antiparkinson agents, and diuretics—can cause dry mouth. Xerostomia can predispose to oral candidiasis. It is not surprising that as patients age, the increasing number of medications and associated predisposing conditions may further contribute to the development of xerostomia.

Beyond physical exam, sialometric tests measuring salivary flow rate or stimulated salivary production, and salivary gland scintigraphy may be helpful in the diagnosis and therapeutic management of xerostomia. Sucking on sugarless mints and chewing gum helps stimulate increased salivary flow, which in turn assists in debris removal without increasing the risk of developing caries. Patients with xerostomia should avoid sweets and acidic foods or beverages to limit caries induction. Patients should be encouraged to sip water and suck ice chips frequently. Preparations containing 1% sodium carboxymethylcellulose may be used to moisten the oral cavity. Salivary stimulants such as cevimeline (Evoxac), 30 mg 3 times daily, or pilocarpine (Salagen), 5 mg 3 to 4 times daily, are effective sialogogues. Preventative pilocarpine use during radiation therapy may lessen the grade of radiation-induced xerostomia. Acupuncture, intraoral electrostimulation, and hyperbaric oxygen or amifostine for radiation therapy patients are emerging further management tools.

Sjögren Syndrome

Sjögren syndrome is a chronic autoimmune disease classified by the triad of xerostomia, keratoconjunctivitis sicca (dry eyes), and arthritis, but other systemic effects (extraglandular) are recognized (see Chapter 37 ). Over 4 million Americans are affected, with women outnumbering men by 9:1. Sjögren is characterized as primary when no other disorders are present or secondary when other systemic diseases are present. Oral manifestations of Sjögren syndrome are due to destruction of the salivary glands by a lymphocytic infiltrate that results in diminished or absent saliva, resulting in difficulty chewing, odynophagia, diminished taste and smell, mucosal erythema, increased incidence of dental caries, oral candidiasis, and salivary gland calculi. Marginal zone lymphoma, a non-Hodgkin lymphoma, is the most serious complication of Sjögren syndrome. Diagnosis is usually made based on clinical presentation, though laboratory demonstration of associated anti-SSA, anti-SSB antibodies, and/or rheumatoid factor, the Schirmer test for oral and ocular dryness, or sialometry may be useful. Salivary gland scintigraphy is used to objectively assess the severity and extent of salivary gland involvement and may be helpful in the diagnosis and therapeutic management of Sjögren. Treatment strategies for general xerostomia are also helpful in the management of Sjögren-induced xerostomia.

Glossitis, Glossodynia, and Oral Dysesthesia

Glossitis , inflammation and irritation of the tongue, occurs in a heterogeneous group of disorders ( Box 24.1 ). Patients may complain of lingual pain (glossodynia) or a burning sensation (glossopyrosis). Loss of filiform papillae results in a spectrum of changes, from patchy erythema with or without erosive changes to a completely smooth, atrophic, erythematous surface ( Fig. 24.1 ). Median rhomboid glossitis manifests as an asymptomatic, well-defined erythematous patch in the mid-posterior dorsum of the tongue. Candida infection, predominantly with Candida albicans , may present with a loss of the filiform papillae in such a pattern