ORAL' MANIFESTATIONS IN SYSTEMIC DISEASES ...

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ORAL MANIFESTATIONS IN SYSTEMIC DISEASES There are atrophic lesions of mucosal surfaces including the buccal and pharyngeal mucosa. Dysphagia is a feature. The tongue is smooth and sore, due to atrophy of the filiform papillae, and sometimes it is wrinkled. The mouth may show angular lesions as occurs in riboflavin deficiency. There is paleness, weakness and sometimes koilonychia. Ahlbom (1935) cotlsiders that this syndrome is responsible for a high proportion of the buccal and pharyngeal cancer that occurs in women. Darby (1946) emphasizes the importance of the iron deficiency and reports six representative cases in which the oral condition remained after vitamin B complex therapy but was alleviated with the administration of iron. Pernicious Anaemia This type of macrocytic anaemia has now been shown to be due to a deficiency of an anti-anaemia substance. The latter is normally provided through the interaction of the intrinsic factor of Castle which is in the gastric secretion, with the extrinsic factor which is thought to be a thermostable component of the vitamin B complex as yet unidentified. Achlorhydria is a most constant finding. Diagnosis is made from the blood picture. The red cell count is low, even falling below 1 million per c.mm., and there is anisocytosis, poikilocytosis and nucleated red cells. The colour index is high. There is a leukopenia. A characteristic early feature that occurs in about two-thirds of the cases is recurrent soreness of the tongue. During an exacerbation the tongue becomes very painful and red. The whole of the dorsum is usually affected though it may be limited to certain areas. Sometimes there is ulceration. In many cases, if untreated, there is eventually atrophy of the filiform papillae and desquamation of epithelium so that the tongue appears smooth-the typical Hunter's glossitis. It is nearly always clean. The lips and oral mucosa, including that of the palate, occasionally have a pale yellowish appearance. The skin sometimes has a pale yellowish tint. There are neurological and gastro-intestinal symptoms. With intramuscular injections of liver extract or vitamin B12 the oral and general symptoms are alleviated. Sprue In this disease, a macrocytic hyperchromic anaemia and multiple vitamin deficiencies may occur during its course. The cause is unknown and it is noteworthy that though it is endemic in certain tropical regions the natives are not usually affected, an exception to this being in Puerto Rico. In recent years non-tropical sprue or idiopathic steatorrhoea has been observed in more temperate climates. The outstanding pathological feature is that the mucosa of the 239 18-2
H. H. STONES alimentary tract from the oral cavity to anus tends to undergo atrophic changes, and the liver and pancreas may also atrophy. Hence steatorrhoea is a feature of the disease. The bone marrow may show aplastic or hyperplastic changes. In view of the mucosal changes a multiple vitamin deficiency is to be expected and Cayer, Ruffin and Perlzweig (1945) have shown that there are low values for certain components of the vitamin B complex, particularly thiamin and riboflavin, though the nicotinic acid level is not much affected, and for vitamins A and C. The oral lesions usually occur after the typical general symptoms. The most noteworthy change is in the tongue which may show atrophy of the papillae and desquamation of epithelium so that it becomes smooth, red and sensitive. Only a part of the tongue may be affected either one or both sides, or the tip or dorsum, thereby giving it a patchy appearance. Occasionally the affected areas and also the buccal mucosa are covered with patches of a yellowish grey membranous ulceration. Somewhat rarely the tongue has a fissured appearance. Lesions sometimes occur at the angles of the mouth. The general symptoms vary, typical features being persistent diarrhoea with frothy light coloured stools and weakness. Purpura Haemorrhages from mucous membranes and into the skin and joints can be classified into symptomatic or non-thrombocytopenic purpura and thrombocytopenic purpura. Symptomatic or non-thrombocytopenic purpura.-In one type the probable pathology is toxic damage to cells of the capillary walls allowing the extravasation of red blood corpuscles. It is observed in various infections, toxic disturbances, vitamin C and P deficiency, and in hereditary familial purpura simplex. Another type is due to a deficiency of the normal clotting elements of the blood such as prothrombin, fibrinogen, vitamin K, or to qualitative changes in the blood platelets. Thrombocytopenic purpura.-In this condition there is a marked reduction in the number of platelets in the blood from the normal 400,000 or 500,000 per cmm. to 60,000 per cmm. or even less. The bleeding time is prolonged to several times the normal level of four minutes, though the clotting time is unaffected. There is defective clot retraction and a positive tourniquet test. Acute and chronic recurrent forms are observed. The oral manifestations of purpura are of varying severity. The symptomatic type may only show petechiae and blebs containing blood in the gingivae or other parts of the mucosa. In the severe and haemorrhagic types the gingivae are swollen and purplish, and pressure from dentures may even induce bleeding. There is bleeding from other mucous membranes, and petechiae and ecchymoses occur on the skin. The patient has the features arising from loss of blood. 240
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