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LAS COMISURAS LABIALES COMO ASIENTO DE PROCESOS PATOLÓGICOS/ Medicina Oral 2000: 5: 165-8 the CORNEES of the MOUTH AS a SITE for PATHOLOGY Ciente, Etc

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LAS COMISURAS LABIALES COMO ASIENTO DE PROCESOS PATOLÓGICOS/ Medicina Oral 2000: 5: 165-8 the CORNEES of the MOUTH AS a SITE for PATHOLOGY Ciente, Etc mOlCINA Y PATOLOGÍA / MEDICINE AND Pfi El tejido conectivo contiene glándulas sudoríparas, glán• Las comisuras labiales dulas sebáceas y las bases de los folículos pilosos, que atra• viesan el epitelio. Este es continuo alrededor de las bases de los folículos, y el responsable de la producción de la querati- como asiento na de que está formado el pelo. Las glándulas sebáceas drenan en los folículos pilosos o, en ocasiones, directamente en la su• de procesos patológicos perficie de la piel. La zona bermellón carece de anejos de la piel. Sin embargo, pueden encontrarse a veces glándulas se• báceas, especialmente en las comisuras. Puesto que la zona MJTORESIAVTHORS bermellón también carece de glándulas mucosas, requiere un Eduardo Chímenos Küstner (J), José López López (2), frecuente humedecimiento con saliva por parte de la lengua Rafael Caballero Herrera (3). para prevenir su desecación. El epitelio de la zona bermellón (1) Profesor titular. Unidad de Medicina Bucal. Facultad de es queratinizado, fino y transparente. Las papilas de tejido co• Odontología, Universidad de Barcelona. España. nectivo son relativamente largas y delgadas, y contienen ovi• (2) Profesor asociado. Unidad de Medicina Bucal. Facultad de llos vasculares. La proximidad de estos vasos a la superficie, Odontología, Universidad de Barcelona. combinada con la transparencia del epitelio, da a la misma su (3) Catedrático. Unidad de Medicina Bucal. Facultad de Odontología, Universidad de Barcelona. coloración roja y, con ella, su nombre. Este color rojo es una característica humana. Chímenos E, López J, Caballero R. Las comisuras labiales como asiento de La zona de unión entre la zona bermellón y la mucosa bu• procesos patológicos. Medicina Oral 2000; 5: 165-8. © Medicina Oral. B-96689336. cal recibe a veces el nombre de zona intermedia o zona de ISSN 1137-2834 Klein, y es paraqueratinizada. En los lactantes, esta zona es más gruesa y constituye la llamada almohadilla de succión. RESUMEN La mucosa del labio es una mucosa limitante que está recu• Las comisuras de los labios son los dos repliegues cutáneo- bierta por un epitelio no queratinizado, relativamente espeso. mucosos situados a cada lado de la abertura bucal. Están re• La lámina propia también es ancha, pero las papilas son cor• cubiertos de piel por la parte extraoral y de mucosa por la in- tas e irregulares. Presenta una submucosa que contiene mu• traroral, sin que apenas exista bermellón entre ellas. Este pa• chas glándulas salivales menores, que vierten su secreción a so abrupto de zona mucosa húmeda a zona cutánea seca fa• la cavidad bucal. Bandas de tejido conectivo unen la mucosa vorece que ciertas situaciones, como la pérdida de dimen• labial con los músculos subyacentes (1). sión vertical de los dientes, las arrugas y los hábitos de la- La mucosa que recubre las mejillas (mucosa yugal) es, como meteo conviertan las regiones comisurales o angulares en la mucosa labial, una mucosa de revestimiento. El epitelio no áreas intertriginosas, asiento de patología diversa, sobre to• está queratinizado y la lámina propia es densa, con papilas cor• do infecciosa. Dado que esta patología se cronifica con fre• tas e irregulares. Presenta una submucosa con muchas glándu• cuencia, predisponiendo al desarrollo de lesiones que pue• las salivales menores. En ocasiones, a lo largo de una línea que den evolucionar desfavorablemente, nos parece interesante coincide con el plano oclusal, el epitelio se vuelve queratiniza• prestarle una atención especial, sobre todo en aras de su pre• do, formando una línea blanca (línea alba). En ocasiones pre• vención. senta glándulas sebáceas que parecen hacerse más evidentes en Palabras clave: Comisura labial, queilitis angular, queili- los varones después de la pubertad y en las mujeres después de tis retrocomisural, cáncer bucal. la menopausia, adoptando el aspecto de pequeños cúmulos ama• rillos. Estas formaciones se denominan granulos de Fordyce. El INTRODUCCIÓN papel, si tienen alguno, de las glándulas sebáceas en esta locali• Los labios son dos estructuras musculares (superior e in• zación es desconocido, aunque es importante diferenciarías de ferior) recubiertas de piel en su superficie extema y de mu• ciertas alteraciones patológicas (1). cosa bucal en la interna. Entre estos dos tejidos se encuentra Si bien, como hemos visto, en los labios se diferencian las la zona del bermellón (también conocida como zona roja o zonas descritas, éstas no ocupan la misma superficie en toda transicional del labio). Los músculos de los labios son estria• su extensión. Así, en sus extremos más extemos los labios su• dos y forman parte de los músculos de la expresión facial. La perior e inferior se unen formando unos pliegues denomina• piel y la superficie externa del labio muestran todas las ca• dos ángulos o comisuras labiales. Estas se caracterizan por racterísticas del resto de la piel. Un epitelio queratinizado se constituir una región anatómica especial donde, a diferencia sitúa sobre un lecho de tejido conectivo: la dermis. El límite del resto de la superficie labial, el bermellón es prácticamente entre ambos en esta área no presenta un plegamiento marca• inexistente. Por esta razón, la mucosa bucal a ese nivel, don• do. de también coincide la línea alba yugal, se continúa hacia el exterior directamente con la piel, sin zona transicional. Esta I Recibido: 4/6/99. Aceptado: 11/3/2000. | particularidad hace más susceptible dicha zona al desarrollo i Received: 4/6/99. Accepted: 11 /3/2000. I de ciertas lesiones. MEDICIIOM. 165 VOL. 5 / N.° 3 MAY.-JUL. 2000 Medicina Oi CHIMENOS E. y cois. prótesis no se van cambiando a medida que se desgastan sus TABLA MTABLE 1 superficies triturantes, las fuerzas masticatorias van alterando Grados de queilitis comisural cada vez más la dimensión vertical, de forma simétrica o asi• Degrees of commissural cheilitis métrica, y las relaciones oclusales y anatómicas de los tejidos blandos favorecen cada vez más los repliegues comisurales. Localizada, con lesión mínima en la piel. I: Se convierten entonces estos en áreas intertriginosas. Localizfíl, minimitm skin lesión. Las infecciones que con más frecuencia asientan en las co• Fisurada, con rágades más extensas y profundas misuras labiales son las bacterianas (por cocos), las micóti- II: que la anterior. Fissured. with more extensive and deep rluigodes than ahove. cas (por C. albicans) y las víricas (por H. simplex). Se deno• minan queilitis angulares o comisurales, y Ohman las clasifi• Fisuras intensas que se extienden de forma radial có en 4 grados, según su extensión (Tabla 1) (2). Las infec• desde el ángulo a la piel. III: Intense fissures with a radial distribiition from the angle ciones producidas por C. albicans suelen asociarse a deter• lo the skin. minados factores favorecedores de carácter local y sistémico (3), que fácilmente permiten el desarrollo de una extensión Eritematosa y se extiende al borde de los labios. IV: No hay fisuras. cutánea y mucosa del hongo (Fig. 1). Si la extensión mucosa Erythematous. e.xtending to the margin of the lips: no fissures. se cronifica, lo cual puede estar favorecido por el hábito ta- báquico sobre todo, y también por un mayor o menor grado de sequedad bucal (con frecuencia de origen farmacológico), puede desarrollarse una candidiasis retrocomisural. En esta PATOLOGIA COMISURAL localización se observan candidiasis hiperplásicas o hipertró• La pérdida de dientes, sobre todo de los primeros molares ficas crónicas que no se desprenden con el raspado y que tam• permanentes, modifica la denominada dimensión vertical, en bién se denominan leucoplasias candidiásicas (Fig. 2). La el sentido de disminuirla. La dimensión vertical contribuye a presencia de estas lesiones puede suponer un riesgo de ma- mantener el equilibrio entre las fuerzas masticatorias, las rela• lignización (4, 5). ciones oclusales dentarias y las relaciones anatómicas de los Dadas las especiales características histológicas del berme• tejidos blandos. Al perderse dientes y disminuir dicho pará• llón labial, esta zona anatómica, que posee una estructura sin• metro, la relación oclusal se «hunde», aproximándose más las gular, es más sensible al efecto de factores exógenos tales como arcadas superior e inferior. Ello se observa también en la re• las radiaciones solares, el viento, el frío y el calor, todo lo cual gión comisural y en los pliegues perilabiales, que se acentúan. predispone a un tipo de patología inflamatoria considerada co• El sellado labial en la región comisural pierde eficacia y se fa• mo precancerosa: la queilitis aclínica (6). Esta obedece sobre vorece el babeo. Esta situación es más evidente cuando se tra• todo a la acción de las radiaciones ultravioleta B (UVB), y se ve ta de pacientes portadores de prótesis móviles completas muy favorecida por otras circunstancias, como las queilitis exfoliati- antiguas, condición que comporta una pérdida precoz de la di• vas o Asuradas previas, el tipo de pigmentación cutánea del pa- mensión vertical asociada a una sustitución protésica. Si las / / Fig. 2: Candidiasis hiperplásica (leucoplasia candidiásica) retrocomisural Fig. 1: bilateral en un paciente fumador y bebedor importante, usuario de Queilitis angular asociada a Candida albicans en un paciente drogas intravenosas y VIH +. seropositivo al VIH. Bilateral relrocommissural hyperplastic candidosis (candiJosic Angular cheilitis associated with Candida albicans in an HlV-seropositive leukoplakia) in a heavy smoking and drinking. HIV +. intravenous ¡Hilicnt. substance abusing patient. 1 23 VO' LAS COMISURAS LABIALES COMO ASIENTO DE PROCESOS PATOLÓGICOS/ Medicina Oral 2000: 5: 165-8 THE CORNEES OF THE MOUTH AS A SITE FOR PATHOLOGY ciente, etc. La coincidencia de varios de los factores menciona• dos puede facilitar el desarrollo de un carcinoma espinocelular en la superficie labial. Aunque la localización más frecuente de este tipo de lesiones no suele ser las comisuras labiales, éstas no están exentas de riesgo, como se observa en la Figura 3 (7). DISCUSIÓN Según se desprende de lo dicho con anterioridad, las lesio• nes de los labios en general, y de las comisuras en particular, exigen una atención especial, dado el potencial de maligniza- ción que han demostrado tener.
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