SOME DENTAL PROBLEMS AND THE SURGEON

RUSSELL HOPKINS M.R.C.S., F.D.S.R.C.S. Consultant In Oral , University Hospital of Wales, Cardiff THIS PAPER iS written as a presentation of part of a pictorial survey designed for the F.R.C.S. course. Of necessity it cannot deal with any subject in depth and excludes neoplasia and diseases of salivary tissue. Its intention is to familiarize the surgeon with the signs and symptoms of some diseases and problems of dental origin so that he can refer the patient for a dental opinion when necessary and have some under- standing of the management of these problems in the event of such advice being unavailable. Pain and of dental origin No surgeon should omit a clinical and radiological dental examina- tion in the investigation of atypical facial, oral, or cranial pain. Unerupted, impacted, or carious teeth have been justifiably implicated many times, but often after other extensive investigations had failed to demonstrate a cause. The dental investigation should be among the first, not the last, to be completed. Dental sepsis may cause pyrexia of unknown origin and refractory iron deficiency anaemia. Some patients claim that their dyspepsia cleared spontaneously after their dental clearance and new dentures. Patients still undergo major elective surgery with highly infective mouths, a known association of postoperative chest and surely an unnecessary danger. The acute dental . An acute produces pain, ag- gravated by changes in temperature, which may be referred throughout the distribution of the trigeminal nerve. Acute apical infection produces a severe, localized, throbbing pain and the causative tooth may be mobile and acutely tender to percussion. As the penetrates the cortical bone and periosteum into the soft tissue the acute pain eases, only to return as the pressure within the soft issue increases. It is at this stage that external swelling may become obvious. Depending on their anatomical position and taking the line of least resistance, most dental perforate labially or buccally within the origins of the oral musculature. Intraoral surgical drainage of the localized abscess, usually combined with the extraction of the offending tooth, suffices in the majority of cases. Postgraduate Lecture (Ann. Roy. Coll. S'Urg. Eno]. 1973, vol. s3) 95 RUSSELL HOPKINS Maxillary abscess. Particularly in children, an abscess arising from an incisor tooth may cause a grossly oedematous upper , while those arising from canine, premolar, or molar teeth may cause extensive oedema of the infraorbital and periorbital tissues by obstructing the anterior facial vein (Fig. 1); the communication of this vein via the

Fig. 1. Demonstrating the right-sided infraorbital and periorbital oedema caused by an acute alveolar abscess arising from the canine tooth. When the acute oedema had subsided a cord-like structure, almost certainly the thrombosed anterior facial vein, was found extending into the orbit. angular and ophthalmic veins with the cavernous sinus renders these ab- scesses potentially dangerous. The involvement of the infratemporal space by an abscess perfora- ting the bone above the origin of the buccinator is also hazardous because of the communication of the pterygoid venous plexus with the cavernous sinus. A patient with an infratemporal abscess will 96 SOME DENTAL PROBLEMS AND THE SURGEON complain of acute and pain radiating over the medial aspect of the mandibular ramus and pharynx, sometimes accompanied by dysphagia. Trismus permitting, visual examination will demonstrate swelling of the medial aspect of the mandibular ramus, while ex- ternal swelling and tenderness over the anterior aspect of the temporal fossa may be obvious. Intraoral drainage is achieved through a vertical incision permitting access to the medial aspect of the mandibular ramus; extraoral drainage is achieved through an incision placed in the junction between the frontal and temporal processes of the zygo- matic bone. An early maxillary abscess presenting palatally may not show evi- dence of hyperaemia or fluctuation because of the thickness and adherence of the palatal mucosa. Rarely abscesses from posterior molar teeth involve the soft and should be drained as for a quinsy- that is, with or without a topical anaesthetic and with the head tilted forward and downward. Mandibular abscess. Dental infection may spread directly to in- volve the several anatomical spaces described below or by lymphatics to the regional lymph nodes. Though the commonest cause of sub- mandibular or submental lymphadenitis is dental, the whole area of the lymphatic drainage should be suspect, so that unnecessary may be avoided. In children it is not uncommon to find that a cause of non-dental origin-for example, a pustule-has cleared before the acute submandibular abscess develops. Large submandibular and submental masses, clinically similar to a malignant , are seen occasionally, irreducible by normal- length courses of . Histological examination demonstrates non-specific inflammatory changes. In many cases no certain source of this infection is found. Sublingual abscess. The sublingual space lies above the mylohyoid muscle and is bounded medially by the geniohyoid and genioglossus muscles and laterally by the . Infection usually arises in an anterior incisor tooth, but a submandibular should be con- sidered. A sublingual abscess is drained intraorally, the incision being placed in the lingual sulcus to avoid the lingual nerve and submandi- bular duct. Submental abscess. Suppuration of the submental lymph nodes lying between the mylohyoid and platysma muscles causes an obvious external inflammatory swelling; a large abscess will eventually raise the floor of mouth and . An extraoral transverse incision should be used for drainage. 97 RUSSELL HOPKINS Submandibular abscess. The submandibular space is bounded bv the mylohyoid and platysma muscles and laterally by the mandible and contains the submandibular salivary gland, associated lymph nodes, and the facial artery. As the abscess enlarges, the definition of the lower border of the mandible is lost, this being an indication for extraoral drainage. The horizontal incision should be placed parallel to a skin crease well below the lower border of the mandible to avoid the man- dibular branch of the facial nerve. The full extent of the abscess should be explored with the finger or Hilton's forceps to break down any loculi. This approach also allows access to the parapharyngeal space (vide infra). The bilateral involvement of the sublingual and submandibular spaces (Ludwig's angina) is now rarely seen in the United Kingdom. Submasseteric and parapharyngeal abscess. Infection from a pos- terior molar tooth may penetrate the buccinator or superior constrictor muscle to lie deep to the masseter muscle on the lateral aspect of the mandible or to pass medially into the parapharyngeal space. The sub- masseteric abscess causes external swelling, tenderness of the muscle, and severe trismus and is drained either intraorally or in combination with an external incision.

Fig. 2. A tomogram showing the soft palate engorged with pus in a patient who developed a parapharyngeal abscess one month after the removal of 4 wisdom teeth. Complete trismus prevented any visual examination and a tracheostomy under local analgesia was required before incision and drainage. (Reproduced by kind permission of the Honorary Editor, British Journal of Oral Surgery.) 98 SOME DENTAL PROBLEMS AND THE SURGEON The parapharyngeal abscess which may also follow mandibular block injections or peritonsillar infection lies in the prismatic space bounded laterally by the medial aspect of the ramus of the mandible and the medial pterygoid, medially by the superior constrictor muscle, and posteriorly by the parotid gland, muscles arising from the styloid pro- cess, and the prevertebral muscles. The roof is formed by the base of skull with the cranial foramina and the apex by the carotid sheath. Infection may spread through the cranial foramina or down the carotid sheath, and may produce an immediate hazard to life if pus passes medial to the superior constrictor muscle and upwards into the soft palate. Intense trismus may prevent clinical examination of the mouth and oropharynx; tomography should then be used (Fig. 2). Depending on its extent, the abscess is drained either intra- or extra- orally. The involved soft palate should be drained separately'. Antibiotics and surgery. Antibiotics may abort the early alveolar abscess or acute lymphadenitis. Alternative antibiotics should be pre- scribed if there is no satisfactory response within 3 or 4 days. The continuation of treatment for longer than 7-10 days is to be deprecated unless there are extenuating circumstances. At that time, and in the absence of fluctuation, antibiotics should be stopped and events awaited. The phlegmon may reactivate and require drainage; it may however continue to subside. A 'sterilized' abscess will take several weeks to resolve and may exacerbate whereas, provided that the source of infection has been eradicated, an adequately drained abscess will rapidly subside. Facial sinuses. A not unusual history of this lesion is one of mul- tiple excisions with the clinical diagnoses varying from infected sebaceous to basal cell lesions. The commonest origin of a facial sinus is dental. Its investigation is incomplete without full mouth radiography of even apparently healthy mouths. Some sinuses become fistulae as physiological resorption of the alveolus uncovers their source. Sinuses of short duration heal after removal of the source of infection, the slight puckering of the scar being acceptable. Well-developed sinuses are unsightly and invaginated, with the track epithelialized and usually palpable in the labial or buccal sulcus. They require excision in continuity. The elliptical incision of the skin is angled to permit the placing of the scar parallel to the skin creases. In contrast to the dental sinus is not normally surrounded by areas of indurated tissue. The dry socket-acute osteitis. Normally occurring 2 or 3 days after an extraction, this produces an intense throbbing pain, which ra- diates to the ear from the lower molar regions. After irrigation, the socket is packed with a mixture of eugenol and zinc oxide or a proprietary product, normally combined with the use of 99 RUSSELL HOPKINS systemic analgesics. Antibiotics are not normally indicated. Should the symptoms persist for longer than a week, the exposed necrotic bone should be removed surgically under local analgesia so that the socket fills with a blood clot. Antibiotic cover may then be needed. . The acute form, rarely seen in the United Kingdom, presumably as a result of antibiotic treatment and improved dental care, usually occurs either secondarily to acute sepsis or following the re- moval of infected dental tissue. has been reported in some refractory cases of osteomyelitis of the jaw and should be excluded2. Pain and swelling are acute, the constitutional disturbance is severe, and, in the mandible, anaesthesia of the lip is a significant diagnostic finding. Osteomyelitis of the maxilla is much rarer and causes much oedema of the cheek and periorbital tissues; it occurs in the very young, where the por;tal of entry may be minor trauma of the palatal mucosa. Radiological investigation of the early case of osteomyelitis may avail little, as bony changes do not appear for up to 2 or 3 weeks. Treatment is with antibiotics, which should be continued for several weeks, analgesics, and bed rest. If conservative treatment fails or a recurrence heralds the presence of sequestra, the lateral aspect of the mandible should be decorticated intraorally and the wound packed to allow drainage and granulation to occur. Additional extraoral drainage may be required. Simple sequestrectomy suffices in the maxilla. Several varieties of chronic osteomyelitis are reported: (a) Osteomyelitis with proliferative periostitis (Garre's). In the jaws it presents in the first and second decades as a painless rounded bony swelling of the -lower border and lateral cortex of the mandible. Radio- logy usually demonstrates gross periapical infection of a carious tooth and several layers of subperiosteal bone. Treatment consists in dental extraction; the abnormal bone tissue is usually resorbed within a few months (Fig. 3a). (b) Chronic focal sclerosing osteomyelitis is in almost all cases asso- ciated with low-grade dental infection and appears on the radiograph as an area of increased radio-opacity. In the edentulous mandible it should not be confused with sclerotic secondary deposits (Fig. 3b). Chronic inflammatory disease. Actinomyces israeli is found in nor- mal healthy mouths. With the introduction of antibiotics the classic gross cervicofacial lesion of actinomycosis is rarely seen in the United King- dom. Nowadays a typical history, following an extraction or a fracture of the jaw, is one of recurrent bouts of swelling, possible discharge, and minimal discomfort previously controlled by repeated short courses of antibiatics. 100 SOME DENTAL PROBLEMS AND THE SURGEON The lesion, produced by direct rather than lymphatic spread, occurs in the cheek or submental or submandibular region. Relatively painless, it is typically indurated, 1-2 cm in diameter, and sometimes with one or two discharging sinuses. If a bacteriological examination of pus or

<~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~] -w -

Fig. 3. (a) A radiograph of a 13-year-old patient demonstrating prolifera- tive periostitis arising as a result of chronic infection around a lower 6-year molar. (b) Chronic focal sclerosing osteomyelitis arising beneath a root-filled non-vital first lower molar tooth. discharge is possible, a Gram stain may confirm the diagnosis; the re- sults of culture are frequently disappointing. In the absence of pus the diagnosis is made on clinical or histological grounds.I Treatment with penicillin should continue for at least 6 weeks. Clindamycin, which is concentrated in salivas, and lincomycin, which has a relatively higher concentration in bone, are suitable alternatives. 101 RUSSELL HOPKINS An endosseous focus of infection should be surgically removed if possible. Tuberculosis of the oral cavity is rare and is secondary to pulmonary disease, often presenting as painful undermined ulcers on the tongue4. Gummata of the palate and tongue are seen occasionally, and syphilitic of the tongue with potential malignant change is well recognized. A is seen occasionally on the and tongue and the 'snail track' and mucous patch lesions of secondary syphilis occur on the . Syphilis should be excluded when osteomye- litis of the jaw is being treated2. Crohn's disease;, sarcoidosis6, and Hodgkin's disease7 havc been re- ported in the oral cavity. Gingival and mucosal are used in the diagnosis of amyloid disease. The abnormal normal Clusters of creamy-yellow ectopic sebaceous glands are found in the mouth, particularly along the cheeks and lips. Close examination will reveal a central duct full of excreted material. Terined Fordyce's spots, they are of no clinical significance. Enlarged, apparently painful, talteral circumvallate papillae are oc- casionally suspected of being a new growth, particulary by the middle- aged anxious patient, as are enlarged fibrous maxillary tuberosities. The latter, the bony midline palatal , and the bilateral tori mandibularis occurring on the lingual aspect in the premolar area are of significance only to the prosthetist. The tongue The elderly patient complaining of glossodynia is likely ito be de- pressed, though treatment of an iron deficiency anaemia may give beneficial results. The smooth resulting from this type of an- aemia is well known, but not so the generalized ulceration of the tongue and oral mucous membrane. Candidal infection, , and avitaminosis are other causes of tongue lesions. The misnamed median rhomboid glossitis, in reality the remains of the tuberculum impar, presents as a firm, raised, furrowed, non-ulcerated area free of filiform papillae in the midline at the junction between the posterior third and anterior twou-thirds of the tongue. Of little Isignifi- cance, i-t is sometimes mistaken for a neoplasm8. The migratory lingua geographica is of no clinical significance. but the hypertrophied filiform papillae of 'black' hairy tongue precipitated by antibiotics or heavy i's aesthetically unpleasanit and may cause a foetor oris. If required, the papillae are amenable to curettage; the antibiotic-precipitated variety may additionally require repeated ap- plications of antiseptic, such as dequalinium, to prevent recurrence. 102 SOME DENTAL PROBLEMS AND THE SURGEON Apart from in the newborn, section of a tongute tie is inadequate. In the young it should be excised despite the presence of normal speech, for any limitation of movement will impair the cleansing mechanism of the tongue and increase the incidence of caries. The fibrous frenum and the underlying band of muscle, together with its insertion, should be removed through a narrow elliptical incision. The adjacent mucous membrane is undermined and, after haemostasis, interrupted sutures are inserted through mucous membrane and underlying tongue muscle. This may be facilitated by bilateral transverse relieving incisions of the mucous membrane. Complicated Z-plasty techniques are unnecessary. The tongue's shape facilitates the excision of a lesion and the closure of the wound, provided that the mucosa is undermined. The muscle layers should be approximated by deep, tension-free, catgut sutures. Surface sutures should also be inserted deeply and be tension-free. Small infected lacerations are better left to granulate. which they do with little obvious scar formation. Cysts Cysts of dental origin. A dental results from the stimulus provided by chronic inflammation on the epithelial remnants found in the periodontal membrane (the cell rests of Malassez). If the non-vital causative tooth has been extracted, the remaining cyst is termed 're- sidual'. The cyst is lined by dental epithelium and its sac is thickened as a result of chronic inflammation. The cyst contents are rich in cholesterol. A arises as a result of degeneration of the reduced enamel epithelium overlying an unerupted tooth, the of which lies within the uninfected mature cyst cavity. A primordial or arises spontaneously from the remnants of the dental lamina. The uninfected cyst wall is thin and fri- able, a factor in the unusually high recurrence rates of some series. Sometimes the epithelium demonstrates excessive mitotic activity, and it is likely that some carcinomata reported as developing within a dental cyst have arisen in this type9. The keratin content of the cyst is visually similar to sebaceous material. In the multiple basal cell naevi syndrome multiple odontogenic keratocysts of the jaws are found associated with naevi and vertebral and other skeletal anomalies10. Expansile dental cysts present with symptoms secondary to swelling or occasionally as an acute infection, which must first be controlled with antibiotics and, where possible, drainage. If the periphery of a dental cyst is accessible through an intraoral approach, it may be readily enucleated. If possible the subperiosteal flap is planned so that the final suture line is supported by bone and not blood clot. All epithelial margins of the gingival crevice and the 103 RUSSELL HOPKINS flap must be excised before suturing, and it is essential that inversion of the sutured margins does not occur. In the absence of a dental opinion a tooth is extracted if its apices lie within the cyst cavity.

(a)

_-1...jI|I*I11-|~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~......

Fig. 4. (a) A radiograph demonstrating a dentigerous cyst enclosing a lower third molar in a 70-year-old patient. Much of the mandibular rmius, condylar neck, and coronoid process have been destroyed. (b) The same patient 13 months later with obvious bone regeneration The cyst had been marsupialized and the molar had been extracted under local analgesia. With antibiotic cover no foreign material need be inserted into the cyst cavity. If the wound breaks down postoperatively, the cavity should be packed (vide infra). 104 SOME DENTAL PROBLEMS AND THE SURGEON Marsupialization is advised when size and access make complete enu- cleation unlikely, or where other considerations, such as ill health, contraindicate a general anaesthetic. A liberal window is cut over the cyst and the contents are replaced by a 'squeeze-dried' half-inch (1.3-cm) gauze pack of Whitehead's varnish. When healing of the margins is complete this pack is usually replaced by a removable obturator fa- shioned from gutta percha or acrylic, the under-surface of which must be reduced at monthly intervals to allow bone regeneration (Fig. 4a and b). Accessible irregular areas of the cyst lining should be biopsied. Odontogenic keratocysts, frequently large and inaccessible when first seen, are ideally treated by marsupialization with the excision of the overlying epithelium and the microcysts which are frequently found in the area. A second operation to remove the residual lining should be completed when the cyst cavity is reduced and accessible". With this type of cyst an extraoral approach is contraindicated in view of the risk of seeding in the soft tissues'2. Once invaded by a dental cyst, the maxillary antrum allows its rapid expansion. They may be either enucleated or marsupialized into the oral cavity or antrum, the oral wound being closed by primary suture". The latter technique is frequently combined with an antrostomy. An oro- antral or oronasal will result if the cyst is marsupialized into both the mouth and antrum and/or an antrostomy is performed. Cysts of non-dental origin. Mucous cysts, possibly resulting from obstruction of a duct, typically present on the lower lip as painless, bluish, semitransparent swellings 1-2 cm in diameter with a history of recurrent spontaneous rupture. The mucosal surface may be hyper- keratotic if it has been traumatized by the teeth. The vertical elliptical incision should include at least two-thirds of the surface area of the cyst, the mucous membrane being stroked lightly with the blade. The cyst and surrounding mucous glands should be ex- cised down to the underlying muscle and the wound closed by mattress sutures. Attempts to dissect out the cyst alone will result in its rup- ture. Similar problems occur with the found in the floor of the mouth arising from the sublingual or other mucous glands of the area. The ranula requires marsupialization and frequently the excision of the offending mucous gland. Dermoid cysts present in the midline, either above or below the mylohyoid muscle. Although fluctuant, they are firm, cannot be trans- illuminated, and, unlike the ranula, appear yellowish. The intraoral incision is made in the sagittal plane, and extracapsular dissection may have to be carried downwards to the hyoid bone (Fig. 5). Squamous and respiratory epithelium may be found in the rare naso-labial cyst, which occurs in the area between the nose and the upper labial sulcus, in the globulo-maxillary cyst, which occurs between 105 RUSSELL HOPKINS the second incisor and canine tooth in the line of fusion between the frontonasal and maxillary processes, and in the incisive canal cyst, which lies on the palatal aspect of the premaxilla. There is now considerable doubt as to the existence of the median palatal or mandibular cysts previously described.

Fig. 5. A view taken durnag the dissection of a sublingual dermoid cyst. The patient had been unaware of its existence until it was noted by his dental surgeon. Oroantral flsttlae These result from the close proximity of the antral floor to the apices of the premolar and molar teeth and combinations of apical or antral infection, root curvature, and in some cases faulty extraction technique. The majority of flstulae heal spontaneously, but for a few patients the initial symptoms of unilateral epistaxis and escape of fluids into the nose or air into the mouth are soon replaced by those of acute or chronic sinusitis with oralI discharge. Antral polypi may be seen herniating into the mouth (Fig. 6a). Inevitably, the bony defect is much larger than that of the soft tissue and any attempt to close the fistula by removing the alveolus and cobb- ling the soft tissue together is likely to fail at the cost of much-needed alveolar bone. Closure is a simple matter provided that several pre- requisites are met: (a) The subperiosteal flap must be broadly based to ensure a good blood supply; it must be free of tension and its edges and those of the recipient site free of epithelium and infected tissue. (b) The suture line should be supported by bone without inversion. (c) The sut- 106 SOME DENTAL PROBLEMS AND THE SURGEON ures should approximate mucosal edges without constriction. (d) An infected antrum should be cleared of polypi and an antrostomy per- formed. An indwelling cannula permits saline lavage and aspiration postoperatively. Subperiosteal buccal flaps are most commonly used, and after re- flection their advancement is obtained by section of the periosteum at the base of the flap at right angles to the path of advancement. If still inadequate, digital examination will demonstrate fibrous septa within the tissues which are sectioned with blunt-ended scissors. This may precipitate the prolapse of part of the buccal pad of fat, but this is of nuisance value only (Fig. 6b).

(a) (b) Fig. 6. (a) Traumatized antral polyps herniating into the mouth through a large oroantral fistula. (b) The postoperative result. Some surgeons prefer to use rotational palatal flaps based on a greater palatine artery, the denuded bone granulating under a White- head's pack which is sutured in position. This flap should be used if the bony defect is mainly palatal. With either technique difficulty may be experienced where teeth are adjacent to the fistula; extractions may be required to give an adequate clearance. Gentle tissue technique, care of wound edges, and the rotational in- sertion of cutting needles at right angles to the mucosal edge are of paramount importance to oral surgeons, most of whom find catgut and nylon unsuitable in the mouth and prefer to use black silk for mu- cosal closure. 107 RUSSELL HOPKINS Oral hyperplasia Areas of pedunculated fibroepithelial hyperplasia are sometimes found on the mucosa adjacent to gaps in the dentition. They are soft, mobile, approximately 1-2 cm in diameter, covered by normal epithelium, and easily excised.

(a)

(h)

Fig. 7. (a) Extensive hyperplasia in the lower labial sulcus resulting from an over-extended denture flange. (b) The postoperative view after supra- periosteal excision, sulcus deepening, and skin grafting. 108 SOME DENTAL PROBLEMS AND THE SURGEON Over-extended dentures cause acute ulceration and in time hyper- plasia in the sulci, which may be extensive and fissured. Sometimes mistaken for malignancy, they are initially treated by markedly reducing or discarding the denture. Small areas may be excised down to scar-free tissue under local anaesthesia. Many patients with extensive hyper- plasia have lost the necessary sulcus depth for denture retention and the excision of the lesion should be combined with a supraperiosteal sul- cus deepening. The raw surface is usually covered by a Thiersch graft taken from a non-hair-bearing area, held in position by a dental ap- pliance (Fig. 7). Nicotinic and denture sore mouth Seen most commonly in the heavy pipe or cigarette smoker, the lesion presents on the posterior aspect of the hard palate where it is un- protected by a denture. The mucosa becomes nodular owing to thickening and hyperkeratinization, each nodule having a central red spot, the inflamed orifice of an accessory palatal gland. This lesion is not to be confused with the incorrectly named denture 'sore mouth'. Here the denture-bearing area of the palatal mucosa is granular and red. This and the frequently accompanying angular cheilosis result from the combination of ill-fitting dentures and chronic moniliasis. Leukoplakia This lesion is seen commonly on the cheek, particularly around the commissures, floor of mouth, and tongue, and its appearance varies from a thin, milky-white plaque to a much thicker lesion with scattered areas of or frank ulceration. The latter lesion is frequently infected by monilia; called hyperplastic candidosis, it should be judged premalignant and biopsied. The association between syphilis and leuko- plakia of the dorsum of the tongue is well known, but pipe and cigar smoking and tobacco chewing are probably the major aetiological fac- tors in the United Kingdom'3. Treatment. There is no place for beam irradiation in the treatment of leukoplakia. Yttrium-90, caesium-137, and iridium have replaced ra- dium for topical application and are widely used in some centres. Frictional keratoses seen commonly in the denture-bearing areas will normally disappear after the denture has been relieved or the jagged tooth removed. The hyperplastic candidoses may be improved by topical and systemic treatment with amphotenicin B or nystatin, the latter hav- ing an unpleasant taste, resulting in little patient cooperation. Small localized lesions should be excised and allowed to granulate; closure of moderate-sized defects should be obtained with advancement or rotational flaps of undermined mucosa. Extensive lesions should be grafted with non-hair-bearing skin, preventing subsequent scarring: this 109 RUSSELL HOPKINS normally requires a preoperatively constructed dental appliance. Where the extent of the lesion or the general health of the patient contra- indicates radical surgery, excision of the more dangerous areas must suffice. The periphery of the lesion may be marked preoperatively, as the definition is poor once the operation has commenced. Cryosurgery may replace excisional surgery in the future treatment of this lesion, and the clinical use of bleomycin, an antimitotic antibiotic with a specific action on squamous lesions, has yet to be evaluated. Leukoplakia should be differentiated from oral lichen planus and the lesion produced by the 'cheek chewer', which may mimic it. Clinically, the hyperkeratotic lichen lesion is not a continuous plaque but rather a collection of radiating and intersecting lines with a surrounding hyper- aemic flare (Whickham's striae). These occur around the periphery of the ulcerative lesions. Irritative oral lichen planus is treated by topical steroid application. Oral lichen planus may occur in the absence of skin lesions. The chronic midline fissure and actinic keratosis The chronic fissure of the lower lip may be improved with topical steroid preparations and/or by the use of a holder in the case of heavy cigarette smokers. A wedge excision extending to the mucocutaneous junction will give better long-term results. Premalignant solar keratosis of the lower lip may be treated by the excision of the exposed vermilion down to muscle and extending to the mucocutaneous junction. Closure is obtained by undermining the mucosa of the lower lip to the alveolar crest, advancing it, and suturing it to the skin edge. This technique inverts the lower lip, lessening the sub- sequent risk of recurrence. Anterior tongue flaps may also be used14. The epulides (a) The congenital presents in the newborn most commonly in the maxilla, and has a histology similar to that of a granular cell myoblastoma. (b) Fibromata are found throughout the mouth and gingivae. Normally pedunculated, they may achieve quite large proportions. Unless trauma- tized, the pink surface has a non-ulcerated, irregular appearance. If the lesion develops underneath an upper denture, it is flattened and is known as a leaf . (c) The blue/red peripheral giant cell reparative granuloma is found principally in the deciduous-tooth-bearing area of the mouth. Histologi- cal examination demonstrates a non-encapsulated, vascular lesion with a fibrous tissue stroma containing a large number of multinucleate giant cells. The lesion must be differentiated from the central osteoclastoma. This epulis is of interest to general surgeons in view of its association with hyperparathyroidism, which may present in this manner in a sig- 110 SOME DENTAL PROBLEMS AND THE SURGEON nificant number of cases. In the event of negative biochemical investiga- tions, it is advisable that they be repeated at intervals for several yearst5. (d) The friable, haemorrhagic pregnancy epullis, normally associated with a pregnancy , is found associated with poor , particularly in the last trimester of pregnancy. It normally regresses after parturition. Surgery is required if repeated haemorrhage results or regression does not occur. (e) The . Arising as a result of chronic infection for example, a retained root or subgingival calculus-these are friable, haemorrhagic, and often surround a small discharging sinus. (f) The peripheral haemangioma. One of the rarer causes of persisting haemorrhage, this may be an extension of an underlying and much more hazardous central lesion, which shows the classical radiological honeycomb appearance. (g) Carcinoma. Surgical treatment. Epulides and a surrounding collar of normal tissue require excising down to bone, the cortex of which is either re- moved or thoroughly curetted. Involved teeth may be curetted, but should be extracted if much of their supporting bone has been destroyed or the lesion is recurrent. Denuded areas of bone should be covered by a suitable pack for approximately 2 weeks while granulation occurs. The eradication of the source of infection will usually clear a pyo- genic granuloma.

ACKNOWLEDGEMENTS I wish to thank my colleagues Dr. Peter Thompson, F.F.A.R.C.S., and Mr. H. 0. Jones, F.R.C.S., for their encouragement, helpful advice, and criticism, Mrs. Diana Twamley for her ever-cheerful secretarial help, and Mr. B. A. Jones of the Department of Dental Photography.

REFERENCES 1. HOPKINS, R. (1973) British Journal ofOral Surgery, 10, 300. 2. HESLOP, I. H. (1968) British Journal ofOral Surgery, 6, 59. 3. QUALE, A. A., a nd WHITMARSH, V.B (1972) British Journal ofOral Surgery, 10, 24. 4. MITCHELL, R. G., BROWNE, R. M., and MARSLAND, E. A. (1966) British Journal ofOral SurgerIv, 4, 1. 5. DUDENEY T. P. (1969) Proceedings ofthe Royal Society ofMedicine, 62, 1237. 6. DAWSON-WATTS, K. (1968) British Journal ofOral Surgery, 6, 108. 7. FOREMAN, G. H., and WESSON C. M. (1970) British Journal ofOral Surgery, 7, 143. 8. COOKE, B. E. D. (1962) British Dental Journal, 112, 389. 9. HARDMAN, F. G. (1963) British Journal of Oral Surgery, 1, 124. 10. RAYNE, J. (1971) British Journal ofOral Surgery, 9, 65. 11. FICKLING, B. W. (1965) Proceedings ofthe Royal Society ofMedicine, 58, 847. 12. EMERSON, T. H., and WHITELOCK, R. I. H. (1972) British Journal ofOral Surgery, 9, 181. 13. BINNrE, W. H., CAWSON, R. A., and HILL, G. B. (1972) in England and Wales, VI, 17. H.M.S.O., London. 14. WILSON, J. S. P., and KEMBLE, J. V. H. (1972) British Journal ofOral Surgery, 9, 186. 15. FACCINI, J. M., HARRIS, M., and WATSON, L. To be published.

111