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Orofacial Disease: Update for the Dental Clinical Team: 6. Complaints Affecting Particularly the Lips Or Tongue

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Orofacial Disease: Update for the Dental Clinical Team: 6. Complaints Affecting Particularly the Lips Or Tongue ORAL MEDICINE ORAL MEDICINE Orofacial Disease: Update for the Dental Clinical Team: 6. Complaints Affecting Particularly the Lips or Tongue Crispian Scully and Stephen Porter Lip Pits Abstract: Certain lesions 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 lip 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 cheilitis. Surgical removal may be indicated B common complaints affecting the diseases. Black and brown hairy tongue for cosmetic purposes. lips. Blisters on the lips are usually appears to be caused by the accumulation caused by herpes labialis 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 palate are the most people, sebaceous glands (Fordyce reasons, but especially because of common congenital craniofacial spots) may be seen as creamy-yellow erythema migrans, lichen planus, glossitis abnormalities, and are discussed dots along the border between the and burning mouth syndrome. elsewhere. vermilion and the oral mucosa . The Geographic tongue (erythema migrans) is labial melanotic macule is an acquired an extremely common condition but of small, flat, brown to brown-black unknown aetiology. Fissured tongue is a Peutz-Jeghers Syndrome asymptomatic benign lesion. 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 stomatitis 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. Actinic cheilitis 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, pancreas, 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. 254 DENTAL UPDATE/JULY/AUGUST 1999 ORAL MEDICINE immunosuppression can reactivate the virus ● psychogenic causes; Inflammatory: ● ● Infections which is shed into the saliva, and there may drugs. ● Bites be clinical recrudescence, recurrently, to ● Crohn’s disease produce herpes labialis. Up to 15% of the ● Orofacial granulomatosis Angular Stomatitis ● population have recurrent HSV infections. Sarcoidosis Lesions typically appear at the Angular stomatitis is inflammation of the Traumatic: mucocutaneous junction, starting as skin and labial mucous membrane 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 ● Angioedema 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 corticosteroid 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 dentures, especially ● Nephrotic syndrome in diagnosis. Penciclovir (1%) or aciclovir where there is denture-induced stomatitis. Cysts (5%) cream, applied in the prodromal stage Candida is probably the major cause, but Hamartomas may help to abort or control lesions in staphylococci and other bacteria may be Neoplasms 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 ● angular cheilitis (stomatitis); an underlying immunological deficiency resemble other lesions such as early ● eczematous cheilitis; such as diabetes or HIV infection. 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; riboflavin, folate, iron and general protein by lipstick or excised for cosmetic reasons. ● actinic cheilitis. malnutrition, 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 ● burns; 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 sunlight, trauma, menstruation or ● erythema multiforme; patients, where the lesion is seen in persons 1999 JULY/AUGUST/DENTAL UPDATE 255 ORAL MEDICINE drugs such as warfarin, phenytoin and the It may be wise to seek specialist opinion sulphonylureas. Nystatin 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
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