ORAL MEDICINE ORAL MEDICINE

Orofacial : Update for the Dental Clinical Team: 6. Complaints Affecting Particularly the or Tongue

Crispian Scully and Stephen Porter

Lip Pits Abstract: Certain are exclusively or typically found in specific sites; these are discussed in this and the next two articles in this series. Dimples are common at the commissures but pits are uncommon and are distinct Dent Update 1999; 26: 254-259 pits sited more centrally on either side of the philtrum, ranging from 1 to 4 mm in Clinical Relevance: The lips vary very much between ethnic groups and it is diameter and depth, present from infancy, important to know the normal appearance as well as signs of pathological disease. often showing a familial tendency and sometimes associated with sinuses or pits on the ears. Rarely they become infected and present as recurrent or refractory listers and spots are the most many illnesses, particularly febrile . Surgical removal may be indicated B common complaints affecting the . Black and brown hairy tongue for cosmetic purposes. lips. Blisters on the lips are usually appears to be caused by the accumulation caused by but this must of epithelial squames and the proliferation be differentiated from carcinoma and of chromogenic micro-organisms. The Cleft Lip other less common causes. In some tongue may be sore for a variety of Cleft lip and/or are the most people, sebaceous glands (Fordyce reasons, but especially because of common congenital craniofacial spots) may be seen as creamy-yellow migrans, , abnormalities, and are discussed dots along the border between the and burning syndrome. elsewhere. vermilion and the . The (erythema migrans) is labial melanotic macule is an acquired an extremely common condition but of small, flat, brown to brown-black unknown aetiology. is a Peutz-Jeghers Syndrome asymptomatic benign . Clinically common developmental abnormality; its Peutz-Jeghers syndrome is a rare autosomal it may resemble other lesions such as significance is not known but it may be dominant trait characterized by discrete, early melanoma but it is unchanging in complicated by geographic tongue. brown to bluish black macules around the character. Angular is a clinical Lichen planus and burning mouth (Dent mouth, nose and eyes, and polyps in the syndrome, in which may be implicated Update 1999; 26: 31-39) were discussed small intestine which may undergo infective agents, mechanical factors, in another article of this series. intussusception or malignant change. immune deficiency or nutritional The first article presented several Patients with this syndrome are also at deficiencies. is general observations on diagnosis and increased risk of developing cancer in the premalignant keratosis of the lip caused treatment which should be borne in mind gastrointestinal tract, , breast and by exposure to the sun. in relation to the lesions described here. reproductive organs. The main complaints of the tongue involve furring or soreness. The tongue is rarely furred in healthy individuals but CONGENITAL LESIONS OF Multiple Mucosal Neuroma may be coated with off-white debris in THE LIPS Syndrome These include: The rare familial syndrome of multiple endocrine neoplasia type 2b (type-3) is ● Fordyce's spots (discussed in Dent characterized by medullary carcinoma of Crispian Scully, PhD, MD, MDS, FDS RCPS, FFD RCSI, the thyroid and phaeochromocytoma in FDS RCS, FDS RCSE, FRCPath, FMed Sci, Professor, Update 1999; 26: 123-129); ● and Stephen Porter, PhD, MD, FDS RCSE, FDS RCS, lip pits; association with multiple mucosal Professor, Eastman Dental Institute for ● cleft lip; neuromas .These cause the lips to be thick, Oral Health Care Sciences, University of ● Peutz-Jeghers syndrome; and slightly everted and have a bumpy London. ● multiple mucosal neuroma syndrome. surface.

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can reactivate the virus ● psychogenic causes; Inflammatory: ● ● which is shed into the , and there may drugs. ● Bites be clinical recrudescence, recurrently, to ● Crohn’s disease produce herpes labialis. Up to 15% of the ● Angular Stomatitis ● population have recurrent HSV infections. Sarcoidosis Lesions typically appear at the Angular stomatitis is of the Traumatic: mucocutaneous junction, starting as skin and labial at the ● Traumatic or postoperative: macules that rapidly become papular, commissures of the lips. A fairly common oedema haematoma vesicular, and then pustular. The lesions lesion, it is seen mainly in elderly people. surgical emphysema scab and heal within 7 to 10 days, usually Immunologically mediated: without scarring. Widespread recalcitrant Aetiology ● lesions may appear in immunocompromised Angular stomatitis is a clinical syndrome, Endocrine and metabolic: patients. in which several factors may be implicated, ● Obesity Diagnosis is largely clinical though viral alone or in combination. ● Systemic therapy culture, immunodetection or electron Infective Agents. Oral candidosis causing ● Cushing’s syndrome ● Myxoedema microscopy are used very occasionally. angular stomatitis is particularly common ● Acromegaly Assay of serum antibodies is of little help in people wearing , especially ● Nephrotic syndrome in diagnosis. Penciclovir (1%) or where there is denture-induced stomatitis. Cysts (5%) cream, applied in the prodromal stage is probably the major cause, but Hamartomas may help to abort or control lesions in staphylococci and other may be healthy patients; systemic aciclovir or other isolated from the lesions . Permanent cure antivirals may be needed for can be achieved only by eliminating the Table 1. Acquired lip swelling. immunocompromised patients. Candida beneath the upper denture. Mechanical factors. In a patient with dentures of inadequate vertical dimension, ACQUIRED LIP LESIONS Cheilitis (Inflammation of the and as a normal consequence of the ageing The causes of labial or orofacial swelling Lips) process, the upper lip overhangs the lower are summarized in Table 1. Cheilitis may arise as a primary disorder of at the angles of the mouth, producing an the lips. Alternatively, inflammation extends oblique curved fold and keeping a small from nearby skin or, less often, from oral area of skin constantly macerated and liable Labial Melanotic Macule mucosal lesions. There are several forms to develop angular stomatitis. (Solitary Labial Lentigo) of cheilitis: Immune deficiency. Angular stomatitis The labial melanotic macule is an acquired associated with candidosis resistant to small, flat, brown to brown-black ● chapping of the lips; therapy may be an early manifestation of asymptomatic benign lesion. Clinically, it may ● (stomatitis); an underlying immunological deficiency resemble other lesions such as early ● eczematous cheilitis; such as or HIV . melanoma but it is unchanging in character. ● contact cheilitis; Nutritional deficiency. Nutritional Most are solitary and seen near the midline, ● drug-induced cheilitis; deficiencies, in particular deficiencies of on the lower lip vermilion. They can be hidden ● infective cheilitis; , , and general protein by lipstick or excised for cosmetic reasons. ● actinic cheilitis. , are occasionally incriminated in angular stomatitis. Riboflavin deficiency There are also a number of rarer forms. produces smooth, shiny red lips associated Blisters with angular stomatitis, and this combination Blisters on the lips may be caused by herpes has been called cheilosis . Crohn’s disease labialis usually, but other less common Chapping of the Lips or orofacial granulomatosis may be found causes include: Chapping is a reaction to adverse in some patients. environmental conditions, usually ● ; exposure to freezing cold or to hot, dry Clinical Features ● mucoceles; winds. The lips become sore, cracked and Angular stomatitis is typically bilateral ● impetigo; scaly. Application of petroleum jelly helps, (Figure 1), a roughly triangular area of ● allergic cheilitis. as does avoidance of the causative erythema and oedema and persistent. Linear conditions. furrows or fissures radiating from the Herpes Labialis Desquamation and crusting of the lips commissures (rhagades) are seen in the more Herpes was discussed fully in the fourth may also be caused by: severe forms, especially in denture wearers. article of this series (Dent Update 1999; 26: 73-80), and therefore a synopsis only ● dehydration; Diagnosis and Management is given here. ● exposure to hot dry winds; Diagnosis is usually obvious clinically. HSV, once acquired, remains latent in the ● fever; Underlying systemic disease must be trigeminal ganglion. Factors such as fever, ● cheilitis; sought and treated, especially in young , trauma, menstruation or ● ; patients, where the lesion is seen in persons

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drugs such as warfarin, phenytoin and the It may be wise to seek specialist opinion sulphonylureas. or amphotericin where there is the possibility of malignant (as cream or ointment) should therefore change. Treatment, required to relieve be tried first in patients taking these drugs. symptoms and to prevent development of Fluconazole is also effective but there carcinoma, is with: are a number of contraindications and potential drug interactions, including with ● topical 5% three times warfarin. Any staphylococcal infection daily for 10 days, or trichloracetic acid or should be treated with ointment tretinoin; or cream at least four times daily. ● vermilionectomy (lip shave); Figure 1. Angular cheilitis (bilateral It may sometimes help to construct new ● . angular stomatitis). dentures which restore facial contour and normal commissural anatomy. In very rare Following treatment, the best protection intractable cases, surgery, or occasionally against recurrence is the regular use of a injections, may be necessary to liquid or gel waterproof lip salve achieve this. containing para-aminobenzoic acid.

Actinic Cheilitis Eczematous Cheilitis Also known as of lip or The lips are often involved in atopic solar cheilosis, this is premalignant eczema, but the possibility of contact keratosis of the lip caused by exposure to (contact cheilitis) must also be Figure 2. Actinic cheilitis. B (UVB) irradiation. considered. The treatment of atopic eczema of the lips is with emollients and Aetiology topical ; potent steroids Cheilitis due to acute is common, such as fludrocortisone may be required . and clinically resembles ‘chapping’ of the lips. Particular care is needed to protect the vermilion of the lips with adequate Contact Cheilitis in people who are exposed to Contact cheilitis is an inflammatory reaction high levels of UVB, such as mountaineers, of the lips, provoked by irritant or wind-surfers, sailors and skiers. sensitizing actions of chemicals. It is seen Most actinic cheilitis is seen on the lower mainly in adult women. Figure 3. Furred tongue. lip of fair-skinned men in their fourth to eighth decades of life spending time Aetiology outdoors in hot, dry regions. Many substances have been implicated, but most cases are caused by contact without dentures, unilateral cases and Clinical Features with: patients in whom there are other lesions In the early stages there may be redness such as ulcers or glossitis. and oedema; later features include ● lipsticks or lip salves; In all cases in denture-wearers, Candida dryness and scaling, vertical fissuring and ● bactericidal agents; should be sought, not only in the lesions crusting, development of vesicles and ● tartar-control dentifrices, which but also from the denture fitting surface. superficial erosions (Figure 2). Later still contain pyrophosphate compounds; Treatment is sometimes difficult and the becomes palpably ● epimine-containing materials used for may need to be prolonged. The best thickened with small greyish-white temporary crowns and bridges; solution is often to keep the dentures out plaques. Eventually, warty nodules may ● other dental materials; of the mouth as much as possible. form and may undergo malignant change. ● items commonly sucked such as Dentures should be kept out of the mouth metal hair clips, pencils (cobalt paint or at night and stored in a candidacidal Diagnosis and Management metals), etc.; solution such as hypochlorite or The diagnosis is clinical but may ● nail varnish; . Denture-induced stomatitis be warranted in severe cheilitis and must ● essential oils, such as eugenol, and angular stomatitis should be treated always be considered when there are peppermint, cinnamon, cloves and with an anti-fungal agent. may suspect features such as: spearmint in food and other materials; be preferable (cream applied locally, ● wooden and nickel mouthpieces of together with the oral gel) as it has some ● ulceration; musical instruments. Gram-positive bacteriostatic action. ● red and white blotchy appearance However, there is a fairly high relapse rate with an indistinct ; Clinical Features unless treatment is prolonged, and ● generalized with focal areas There may be persistent irritation and miconazole is absorbed and may very of whitish thickening; scaling or a more acute reaction with oedema occasionally potentiate the action of ● persistent flaking and crusting. and vesiculation.

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Diagnosis and Management be coated with off-white debris in many mouthwashes responsible. The diagnosis is clinical; erythema illnesses, especially febrile diseases (Figure The condition may be improved by multiforme may present similarly but 3). The coating appears more obvious in stopping , increasing the patients with the latter usually also have and in ill patients, especially standard of , brushing the oral or other erosions. If an allergic reaction those with poor oral hygiene or who are tongue with a toothbrush (in the is suspected, patch tests should be carried dehydrated. evenings; see above), using sodium out using appropriate concentrations of bicarbonate mouthwashes, chewing the substances concerned. Specialist Diagnosis and Management pineapple or sucking a peach stone. referral may be warranted. Exclude other conditions such as thrush Topical corticosteroids will give (rarely occurs on the dorsum of tongue), symptomatic relief but the offending chronic candidosis, hairy Fissured Tongue substance must be traced and avoided. (lateral borders of tongue) or other leukoplakias. Aetiology Treatment of the underlying condition This is a common developmental Other Lip Lesions often suffices but it can be useful to brush abnormality, of no known significance. A Other lesions of the lips include swellings the tongue to remove the coating. This is fissured (scrotal) tongue is found in many caused by: best done in the evenings, since brushing normal persons, and often in people with early in the morning often leads to Down’s syndrome or Melkersson- ● oedema (trauma or infection or insect retching. It is important also to maintain Rosenthal syndrome. bite); good oral hygiene. ● angioedema; Clinical Features ● Crohn’s disease; Multiple fissures are usually present on ● orofacial granulomatosis; Superficial Brown Staining the dorsum of the tongue, and may be ● sarcoidosis; Superficial brown discoloration of the complicated by geographic tongue ● mucoceles; tongue and teeth may be caused by (Figure 5). ● tumours; cigarette smoking, some drugs (such as ● abscesses; iron salts), some foods and beverages (such Diagnosis and Management as coffee and tea), betel and chlorhexidine. The diagnosis is usually clear-cut although and ulceration, caused by: Such discoloration is easily removed and it must be differentiated from the lobulated is of little consequence. tongue seen in Sjogren’s syndrome. ● trauma; Management is to reassure the patient. ● herpes labialis; ● burns; Black or Brown Hairy Tongue ● ; Geographic Tongue ● other infections; Aetiology This condition is also known as erythema ● tumours. Black or brown hairy tongue appears to be migrans or benign migratory glossitis. Red caused by the accumulation of epithelial patches that change in size and shape and squames and the proliferation of resemble a map (hence ‘geographic’) may LESIONS OF THE TONGUE chromogenic micro-organisms. be seen in persons of all ages but are Occasionally, a may be typically detected in adults. caused by antimicrobial therapy, especially Furred Tongue with broad-spectrum drugs such as Aetiology Furred tongue is a common problem, mainly tetracyclines or griseofulvin. The latter Geographic tongue is an extremely in adults. condition is related to overgrowth of common condition but of unknown Candida species and may respond to aetiology. It has a genetic background and Aetiology withdrawal of the drug. Smoking, drugs (e.g. a familial pattern is common. It is The coating appears to be of epithelial, food iron salts) and poor oral hygiene associated with psoriasis in 4% of patients. and microbial debris which collects (proliferation of chromogenic micro- because it is not mechanically removed. organisms, not ) may Clinical Features Indeed, the tongue is the main reservoir of predispose. There are irregular demarcated areas of some micro-organisms such as Candida desquamation mainly on the dorsum of albicans and some streptococci. Clinical Features the tongue and, rarely, the adjacent oral A brown or black hairy appearance of the mucosa (Figure 6). The red areas are often Clinical Features central dorsum of tongue, most severe surrounded by a yellow border. Red areas Coating of the tongue is quite commonly posteriorly (Figure 4). The filiform papillae change in shape, increase in size, and seen in healthy adults, particularly in are excessively long and stained. spread or move to other areas within edentulous patients, people eating a soft, hours. The condition may cause some non-abrasive diet, with poor oral hygiene, Diagnosis and Management soreness, especially when acidic foods or who are fasting. Diagnosis is clear-cut. It is important (e.g. tomatoes) are being eaten. The dorsum, particularly posteriorly, may to discontinue any drugs or Geographic tongue is often found in

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) may lead to particularly tetracycline; of folic acid and iron; ileal disease such as ● topical corticosteroids; ● Crohn’s disease may lead to B12 xerostomia; malabsorption. ● immune defects. It is uncommon except in people taking Clinical Features or steroids, or infected with HIV. The sore tongue may appear quite normal, or it may be red and depapillated. There Clinical Features may be: Diffuse erythema and soreness of tongue are the main findings but there may also be Figure 4. Black hairy tongue. ● linear or patchy red lesions (especially patches of thrush.

in deficiency); ● depapillation with erythema—termed Diagnosis and Management patients who have a fissured tongue. glossitis (in deficiencies of iron, folic acid Diagnosis is mainly clinical but it can or B ). Lingual depapillation sometimes be helpful to smear for candidal Diagnosis and Management begins at the tip and margins of the hyphae or to take an oral rinse to assess The diagnosis is clinical and no dorsum but later involves the whole the degree of candidal infection. investigations are usually needed unless dorsum; Treatment should first be directed to the there is the possibility of deficiency ● pallor (). predisposing cause. The patient should glossitis. Some specialists believe stop smoking, and be given . geographic tongue to be a form of psoriasis. There may also be oral ulceration and Very similar lesions may be seen in psoriasis angular stomatitis. and also in Reiter’s syndrome (transiently). Median Rhomboid Glossitis There also may be confusion with lichen Diagnosis and Management planus and . It is important to differentiate this condition Aetiology The condition is not serious and there is from erythema migrans, lichen planus and This was considered to be a developmental no effective treatment. Patients should, acute candidosis. lesion but current evidence suggests that however, be informed about the condition, Treatment is replacement therapy after it is in fact a candidal lesion. Usually the and reassured (Table 2). the underlying cause of the deficiency is patient is adult and almost invariably a established and rectified. smoker. A similar lesion may be seen in HIV- infected individuals. Foliate Papillitis The size and shape of the foliate papillae Glossitis due to Candidosis Clinical Features on the posterolateral margins of the tongue There is a depapillated rhomboidal, are variable. The papillae occasionally swell Aetiology usually asymptomatic, area in the centre if irritated mechanically or if there is an with Candida line of the dorsum of tongue anterior to the upper respiratory infection. Located at a species, particularly C. albicans, may result circumvallate papillae (Figure 7). The lesion site of high predilection for lingual cancer, from predisposing factors such as: may be flat or nodular, red, or red and white. they may give rise to anxiety about cancer. ● broad spectrum antimicrobials, Diagnosis and Management The diagnosis is usually made on clinical Glossitis in Deficiency States grounds alone. Biopsy is not usually Glossitis is a red, often sore, tongue. It is needed as the location is typical and uncommon. tumours are rare at this site. The patient should stop smoking. Aetiology Antifungals may be indicated but if the Deficiencies of iron, folic acid, or vitamin lesion fails to clear, laser excision is

B12 (rarely other ) are the cause. warranted. Iron deficiency is common and usually a consequence of heavy bleeding such as in menorrhagia, or from the gastrointestinal Tongue Swelling tract. The latter may be due to a peptic ulcer, Discrete lumps may be of various causes: inflammatory bowel disease, or a malignant . Folic acid deficiency is seen ● congenital—lingual thyroid, mainly where the diet is poor in leafy haemangioma, lymphangioma; ● vegetables. is inflammatory—infection, abscess; uncommon except in people suffering from ● traumatic—oedema, haematoma, pernicious anaemia, vegan vegetarians, foreign body; dietary faddists or malabsorption states. Figure 5. Fissured (scrotal) tongue. ● cysts; Diseases of the small intestine (such as ● neoplasms—fibrous lump, papilloma,

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may be detected histologically even in the absence of clinically apparent lesions. Congo red or thioflavine T staining of biopsy material is usually required in order to confirm the diagnosis although, in advanced amyloidosis, the deposits may be noted on conventional haematoxylin and eosin staining. Other investigations may include urinalysis (Bence-Jones proteinuria), a blood picture, serum and urine electrophoresis, Figure 6. Geographic tongue. erythrocyte sedimentation rate and marrow biopsy; and skeletal survey for myeloma. Thus specialist referral is indicated. carcinoma, granular cell tumour (granular Management is of the underlying disease cell myoblastoma), Kaposi’s sarcoma. (where present), is difficult, and requires specialist care. Chemotherapy with Midline lumps in the posterior tongue melphalan, corticosteroids or rarely prove to be due to a lingual thyroid. fluoxymesterone are usually used. Surgical Figure 7. Median rhomboid glossitis. The neck should be examined and a scan reduction of the tongue is inadvisable performed to ensure the presence of a normal because the tissue is friable, often bleeds thyroid before such a lump is excised. excessively and the swelling quickly recurs. ● Reinish EI, Raviv M, Srolovitz H et al. Tongue, Generalized lingual swelling may be due primary amyloidosis and multiple myeloma. Oral to: Further Reading Surg Oral Med Oral Pathol 1994; 77: 121-125. ● Brook IM, King DJ, Miller ID. Chronic ● Rodu B, Martinez MG. Peutz-Jeghers ● Down’s syndrome; granulomatous cheilitis and its relationship to syndrome and cancer. Oral Surg Oral Med Oral ● Crohn’s disease. Oral Surg Oral Med Oral Pathol Pathol 1984; 58: 584-588. angioma; ● ● 1983; 56: 405-407. Scully C. Handbook of Oral Diseases. London: inflammatory oedema; ● Buchner A, Hansen LS. Pigmented nevi of the Martin Dunitz, 1999. ● angioedema; oral mucosa. Oral Surg Oral Med Oral Pathol ● Scully C, Bagan JV, Eisen D, Porter SR, Rogers ● gigantism; 1980; 49: 55-62. RS. of the Lips. Oxford: Isis Medical, ● ● acromegaly; Burton J, Scully, C. The lips. In: Champion RH, 1999. ● Burton J, Burns DA, Breathnach SM, eds, ● Scully C, Cawson RA. Medical Problems in amyloidosis; Textbook of Dermatology, 6th ed. Oxford: , 4th ed. Oxford: Butterworth-Heinemann, ● other rare causes. Blackwells, 1998; pp.3125-3148. 1998. ● Chandler K, Chaudhry Z, Kumar N, Barrett ● Scully C, Flint S, Porter S. Oral Diseases. AW, Porter SR. Melanocanthoma: a rare cause of London: Martin Dunitz, 1996. Amyloidosis oral hyperpigmentation. Oral Surg Oral Med Oral ● Scully C, Welbury R. Colour Atlas of Oral Pathol Oral Radiol Endod 1997; 84: 492-494. Disease in Children and Adolescents . London: Amyloidosis is a rare condition ● Eveson JW, Scully C. Colour Atlas of Oral Mosby-Wolfe, 1994. characterized by deposition in tissues of Pathology. London: Mosby-Wolfe, 1995. ● Scully C. The pathology of orofacial disease. an eosinophilic hyaline material, amyloid, ● Jones JH, Mason DK. Oral Manifestations of In: Barnes IE, Walls AWG, eds. Gerodontology. which has a fibrillar structure on electron Systemic Disease, 2nd ed. London: Baillière Oxford: Wright, 1994; pp.29-41. Tindall, 1980. ● Scully C, Porter SR. Oral mucosal disease: a microscopy. ● Kaugars GE, Heise AP, Riley WT et al. Oral decade of new entities, aetiologies and melanotic macules. A review of 353 cases. Oral associations. Int Dent J 1994; 44: 33-43. Aetiology Surg Oral Med Oral Pathol 1993; 76: 59-61. ● Scully C. Diagnosis and diagnostic Amyloid deposits are not all the same. In ● Millard HD, Mason DK, eds. Perspectives on procedures: general and soft tissue diagnosis. In: 1993 World Workshop on Oral Medicine . Ann Pathways in Practice. London: Faculty of General primary (including myeloma-associated) Arbor: University of Michigan Press, 1995. Dental Practice, Royal College of Surgeons of amyloid they consist of immunoglobulin ● Reade PC, Sim R. Exfoliative cheilitis—a England, 1993; pp.25-33. light chains. In secondary and other forms ? Int J Oral Maxillofac Surg 1986; ● Scully C. Prevention of oral mucosal disease. of amyloid, AA proteins are found. 15: 313-317. In: Murray JJ, ed. Prevention of Oral and Dental Secondary amyloidosis is now seen mainly Disease, 3rd ed. Oxford: Oxford University Press, in rheumatoid arthritis and , 1995; pp.160-172. ● This is a common condition ● Scully C. The oral cavity. In: Champion RH, and rarely affects the mouth. ● Burton J, Ebling FJG, eds. Textbook of The cause is unknown Dermatology, 5th ed. Oxford: Blackwells, 1991; Clinical Features ● It may be inherited from parents pp.2689-2769. ● Scully C. The oral cavity. In: Champion RH, Oral amyloidosis is almost exclusively seen ● It is not thought to be infectious Burton J, Burns DA, Breathnach SM, eds, in primary amyloidosis. Manifestations ● It is rarely associated with psoriasis Textbook of Dermatology , 6th ed. Oxford: include , in up to 50% of Blackwells, 1998; pp.3047-3124. ● It has no long-term consequences patients, and oral petechiae or blood-filled ● van der Wal N, van der Kwast WA, van der bullae. ● There is no reliably effective Waal I. Median rhomboid glossitis: a follow-up of treatment 16 patients. J Oral Med 1986; 41: 117-120. ● Diagnosis and Management Winchester L, Scully C, Prime SS et al. Cheilitis Table 2. Patient information sheet for glandularis: a case affecting the upper lip. Oral Biopsy is required; oral amyloid deposits geographic tongue. Surg Oral Med Oral Pathol 1986; 62: 654-657.

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