The Mouth Flashcards
Leucoplakia
Leucoplakia is an oral mucosal white patch that will not rub off and is not attributable to any other known disease. On the underside of the tongue. It is a premalignant lesion, with a transformation rate which ranged from 0.6% to 18%. Oral hairy leucoplakia is a shaggy white patch on the side of the tongue seen in HIV, caused by EBV. When in doubt, refer all intraoral white lesions.
Aphthous ulcers
20% of us get these shallow, painful ulcers on the tongue or oral mucosa that heal without scarring.
Causes of severe ulcers: Crohn’s and coeliac disease; Behçet’s; trauma; erythema multiforme; lichen planus; pemphigus; pemphigoid; infections (herpes simplex, syphilis, Vincent’s angina).
Minor ulcers: avoid oral trauma (e.g. hard toothbrushes or foods such as toast) and acidic foods or drinks. Tetracycline or antimicrobial mouthwashes (e.g. chlorhexidine) with topical steroids (e.g. triamcinolone gel) and topical analgesia.
Severe ulcers: possible therapies include systemic corticosteroids (e.g. oral prednisolone 30-60mg/d PO for a week) or thalidomide (absolutely contraindicated in pregnancy).
Biopsy any ulcer not healing after 3 weeks to exclude malignancy; refer to an oral surgeon if uncertain.
Candidiasis (thrush)
Causes white patches or erythema of the buccal mucosa. Patches may be hard to remove and bleed if scraped.
Risk factors: extremes of age; DM; antibiotics; immunosuppression (long-term corticosteroids, including inhalers; cytotoxics; malignancy; HIV).
Treat with nystatin suspension 400000U (4mL swill and swallow/6h). Fluconazole for oropharyngeal thrush.
Cheilitis (angular stomatitis)
Fissuring of the mouth’s corners is caused by denture problems, candidiasis, or deficiency of iron or riboflavin (vitamin B2).
Gingivitis
Gum inflammation +/- hypertrophy occurs with poor oral hygiene, drugs (phenytoin, cyclosporin, nifedipine), pregnancy, vitamin C deficiency (scurvy), acute myeloid leukaemia, or Vincent’s angina.
Microstomia
The mouth is too small, e.g. from thickening and tightening of the perioral skin after burns or in epidermolysis bullosa (destructive skin and mucous membrane blisters +/- ankyloglossia) or systemic sclerosis.
Oral pigmentation
Perioral brown spots characterise Peutz-Jegher’s. Pigmentation anywhere in the mouth suggests Addison’s disease or drugs (e.g. antimalarials). Consider malignant melanoma.
Telangiectasia: systemic sclerosis, Osler-Weber-Rendu syndrome.
Fordyce glands: creamy yellow spots at the border of the oral mucosa and the lip vermillion. Sebaceous cysts, common and benign.
Aspergillus niger colonisation May cause a black tongue.
Teeth
A blue line at the gum-tooth margin suggests lead poisoning. Prenatal or childhood tetracycline exposure causes a yellow-brown discolouration.
Tongue
This may be furred or dry (xerostomia) in dehydration, drug therapy, after radiotherapy, in Crohn’s disease, Sjögren’s, and Mikulicz’s syndrome.
Also look for glossitis, macroglossia, tongue cancer.
Glossitis
A smooth, red, sore tongue, e.g. caused by iron, folate or B12 deficiency. If local loss of papillae leads to ulcer-like lesions that change in colour and size, use the term geographic tongue (harmless migratory glossitis).
Macroglossia
The tongue is too big. Causes: myxoedema, acromegaly, amyloid. A rankle is a bluish salivary retention cyst to one side of the frenulum, named after the bulging vocal pouch of frogs’ throats.
Tongue cancer
Appears as a raised ulcer with firm edges. Risk factors: smoking, alcohol. Spread: anterior 1/3 of tongue drains to submittal nodes; middle 1/3 to submandibular nodes; posterior 1/3 to deep cervical nodes. Treatment: radiotherapy or surgery. 5yr survival (early disease): 80%. When in doubt, refer.
White intraoral lesions: causes
Idiopathic keratosis Leucoplakia Lichen planus Poor dental hygiene Candidiasis Squamous papilloma Carcinoma Hairy oral leucoplakia Lupus erythematosus Smoking Aphthous stomatitis Secondary syphilis
