Diseases of the Soft Tissues of the Oral Cavity

By  Henry B. Clark, Jr., B.S., M.D., D.D.S.

            The tremendous scope of this subject could warrant the writing of several volumes on the material that should be included. An attempt will therefore be made to keep the remarks down to the minimum and to stress points that must be known in arriving at a diagnosis of each of the several diseases, with special attention, in appropriate instances, to features of differential diagnosis. Little, if anything will be said on treatment.

The diseases to be discussed are roughly of two types, those which occur as a manifestation of some systemic disturbance, and those which are purely local in nature. In the former group the mouth lesions may be a minor feature of the graver bodily ill, but at the same time of considerable importance as a diagnostic symptom. The latter may be local from the start and remain so, or in other cases begin in the mouth, only to later involve distant parts.

The classification presented is arbitrary and certainly open to criticism, but until the final chapter has been written on the etiology of such conditions as Agranulocytosis and Leukemia, it will be impossible to know under which head to list them. At length, an attempt has been made to discuss the lesions of the oral soft tissues under the forms; Inflammatory, Metabolic, Neoplastic, and the inevitable Miscellaneous.

Diseases of the Soft Tissues

  1. INFLAMMATORY

Gingivitis and Pyorrhea

Vincent’s Angina.

Agranulocytosis.

Syphilis.

Tuberculosis.

Actinomycosis.

Thrush.

The Acute Exanthemata.

Other Form of Stomatitis.

  1. METABOLIC.

The Anemia.

Sprue and Scurvy.

Poisons.

Leukemia.

  1. NEOPLASTIC

Epulis.

Leukoplakia.

Malignant Growths.

  1. MISCELLANEOUS.

Black Tongue.

Geographic Tongue.

Fordyce’s Disease.

Pemphigus.

INFLAMMATORY

Gingivitis and Pyhorrhea

We shall omit the usual remarks on etiology, mode of development, etc., and consider these conditions rather in the light of differential diagnosis. The diagnosis of “pyorrhea” is often made by the patient himself, but it then devolves upon the dentist to ascertain whether this is, in truth, just pyorrhea, or instead a manifestation of some systemic ailment. These points will be taken up in the appropriate subgroups below. Regarding gingivitis, somewhat the same applies, but in this case it in frequently necessary for the dentist to recognize and diagnose the disease, and if he does not keep constantly in mind the picture of normal versus abnormal gingival appearance, he too may entirely overlook it.

Vincent’s Angina

Also known sometimes as necrotic gingivitis, this is one of the states from which the above must be differentiated. The typical picture of inflamed, bleeding gums, covered with a dirty gray pseudo-membrane, ulcers on the tonsils, and so forth, is well known. Hirschfeld, however, warns us that there are no less than 16 other diseases with which Vincent’s can be confused. He discusses a destructive and a hypertrophic type, listing the diseases which can be confused with each. Perhaps one of the most diagnostic features is destruction of the septal gingivae or interdental papillae. This may be the only deciding feature in a case of a deep pocket where food is habitually impacted –in pyorrhea there will remain a thing septum of bone. Microscopic smears should not be relied on too heavily, but used only as supportive evidence. Figi believes a complete blood count should be done in every case, to rule out Leukemia and the other blood dyserasias.

Agranulocytosis

This interesting malady is sufficiently recent in point of study that we shall take time to dwell on it somewhat at length. The synonyms of Agranulocytic Angina and Malignant Neutropenia give suggestions as to its nature. Schaefer submits the clinical triad of:

  1. High fever,
  2. Prostration, and
  3. Lesions on the mucous membranes, but as is always the case with “triads”, they are not specifically descriptive of the one disease in question, and do not include all cases of it. To these three symptoms certain things must be added. The fever is steady, not hectic. The lesions are especially on the tonsils, but may be anywhere on the oral mucous membrane. They may even be on the mucosa of the anovulvar region or throughout the gastro-intestinal tract.

The process begins with reddening and local swelling, then a whitish exudation, sometimes pseudo-membranous, then ulceration and deep spreading neurosis. Pain is intense, and swallowing difficult. The breath is fetid. Occasionally the ulcers hemorrhage, but suppuration is absent. There is little or no lymphadenitis –“The course of the local invading army through territory where only old people and children remain.”

The diagnosis is clinched with the making of a white cell count and differential. The normal of around 8000 may drop as low as 300 or 400, with not a single granulocyte. The length of life of the PMN is around four days. Schaeffer has on this basis predicted relapses in patients who have suffered from the disease previously. Risdon’s theory is that normally in our bodies the nucleus of the polymorphs breaks down at the end of its fourth day of existence, this acting as a hormone, stimulating the bone marrow to produce white granular cells, and if that does not occur, infection in the form of necrosis of the mouth, intestines, etc. is likely to occur. It is stated that the white granular cells act as a barrier to infection, and if they are absent, necrosis of the mucous membrane is likely to result. He has had best results in therapy using Pentnucleotide, intramuscularly.

 

 

 

Syphilis

SYPHILIS must always be kept –not in the back, but-in the front of the dentist’s mind. The reasons are several; he must protect himself from unknowingly acquiring it, he must scrupulously avoid transmitting it from one patient to the other, and lastly, his diagnosis will make it possible for treatment to be begun as early as possible.

CHANCRE in or about the oral cavity constitute a small but significant percentage of the whole. And feels that any lesion which is indurated, with a necrotic base, should be carefully examined for the S. Padilla. The lymph nodes are involved early, which immediately rules our carcinoma.

MUCOULS PATCHES occur on the oral mucous membrane at some time during the course of many cases. They may be nearly invisible, requiring good natural light to demonstrate them, but they teem with spirochetes. They are to be distinguished from aphthae, herpes, erythema multiforme, or other vesicular eruptions.

Any destructive, perforating lesion of the palate, nasal septum, or external nose, is gumma until proved otherwise. The progress is usually painless and without hemorrhage, which are points of difference with cancer.

Tuberculosis

Tuberculosis of the oral mucosa is nearly always secondary to far advanced pulmonary or laryngeal phthisis. It usually appears as superficial linear ulcers of the lips or tongue, being attended with definite pain. Bleeding is common, and the ulcers are often multiple. Carefully taken scrapings will often reveal the acid fast bacillus.

Figi reports a type of lesion which is painless, solitary, and insidious, usually on the lip, tongue, or check. Biopsy reveals the four cardinal histological features of TB. X-Ray of the chest in such cases usually discloses old mild healed lesions.

Actinomycosis

In his excellent review of the subject, havens tells us that the disease is caused by the Actinomyces Hominis, is characterized by chronicity and a tendency to form areas of induration which slowly break down and form tracts of granulation tissue and superficial abscesses. He defends his view onthe etiological agent saying that A. Bovis produce lesions of bone, while A. Hominis rarely, if ever, does. Figi goes further to say that it rarely involves the mandible or the mucous membrane of the mouth.

Finding of the characteristic sulfur granules in the pus establishes the diagnosis, and is virtually the only positive way of accomplishing it. Microscopic sections of the tissue may contain the granules but frequently do not, and there are no other typical changes in the tissues which differentiate this disease from other types of chronic inflammation. If the pockets have been open and lead to the mouth secondary infection may have entered, which will usually destroy the diagnostic evidence.

In a differential diagnosis, cancer, tuberculosis and an acute phlegmon must be rled out.

In 60% of all cases involving the head and neck the condition is fatal (Havens.) 15 to 20% of these follow the extraction of teeth. When death ensues, it is due to extension to the cranium and thorax, the spread usually occurring by direct extension, as it seldom passes by blood stream or lymphatics.

Thrush

This condition is characterized by the presence of whitish or grayish exudate-like patches covering a varying amount of the oral mucosa. As these patches are wiped with gauze, an excoriated often oozing surface is exposed which is extremely tender. There is commonly so much discomfort associated with the disease that nourishment is interfered with to a marked extent. Most cases will present a rather clear diagnosis, but culture of smears will show the yeast forms and mycelium.

The whitish threadlike areas of chronic thrush often resemble Leukoplakia. The process may cover the entire interior of the mouth, and even extend farther down the alimentary canal.

The Acute Exanthemata

MEASLES may show a mildly inflamed throat, but it present no points for differential diagnosis. The Koplik Spots, however, which occur two or three days before the rash breaks, are diagnostic if found. They appear as whitish or light pink spots on a bluish background, on the inner side of the cheek.

The strawberry tongue and fiery throat of Scarlet Fever need little more than a mention here. The so-called punctate erythema of the skin rash can be detected int he manifestations on the oral mucosa with close examination.

In Mumps, besides the swelling of the parotid, the papilla of Stenson’s Duct may be elevated and reddened, exuding a thin, milky fluid.

The pseudomembrane of Diphtheria is distinctive, but in all doubtful cases nose and throat cultures should be taken. The sore throats of Influenza, Septic Sore Throat, etc. are usually without interesting characteristics.

Other Forms of Stomatitis

The oral diagnostician usually faces the various skin diseases with considerable horror, feeling that he knows all too little about them, yet believing that his skill should be such that he able to make diagnoses on the appearance of oral lesions alone. Some consolation should be taken from the words of French who discusses the problem as follows:

“Certain conditions make for greater difficulty in diagnosis of oral conditions than those of the skin. The mucosa is more transparent, and color contrasts of individual lesions are not so distinct. Maceration of the lesion occurs because of moisture, or characteristics may be obscured by secondary infection. Vesicles and bullae become quickly eroded. Papules are covered by a gray membrane or become eroded, forming ulcers. Trauma from food and drink often modifies the appearance of the lesion. Often an accurate diagnosis of the oral lesions can be made only by observing associated and more typical manifestations on the skin.”

On the lips eczema, psoriasis, seborrhea, lupuserythematosis, lesions due to physical agents and drugs, and cheilitis are to be found occasionally. The latter is peculiar to the lips, usually follows trauman, and presents a mucopurulent secretion exuding from the mucous glands.

The oral lesions of Lichen Planus are usually found on the buccal mucous membrane along the line of closure of the teeth. It characteristically shows a meshwork of fine white lines or gray, pinhead-sized papules arranged in rings or crescents. It is to be differentiated from lues and leukoplakia.

Pellagra’s “watermelon tongue” somewhat resembles an acute Vincent’s Infection, if the skin lesions of the former are not considered.

Erythema Multiforme presents crusted lesions of the lips and vesicles in the mouth, which bear little resemblance to the skin lesions.

A Blatomycosis abscess of the tongue is a medical curiosity.

 

 

METABOLIC

The Anemias

Pernicious Anemia is very often accompanied by a characteristic glossitis which results in atrophy of the mucous membrane, giving an “ironed out” appearance to the surface. Secondary anemias may show a sore tongue.

SPRUE is characterized by a sore and excoriated tongue, excessive intestinal fermentation, and light colored, frothy stools. Since it is rare in temperate zones, it is of academic interest only here.

SCURVY is one of the deficiency diseases, being due to an improper supply in the diet of Vitamin C. It is attended with distinctive changes in the bones and lesions of the blood vessels; these give rise to bone tenderness and hemorrhages in various parts of the body. For the purpose of this paper it is of interest that the gums become red, swollen, and bleed easily. In far advanced cases the teeth become loose due to necrosis of the alveolar process, the breath being extremely foul (Cecil). The pain in extremities doe to subperiosteal hemorrhages, the dietary history, and other evidences of hemorrhages without decrease of coagulating elements in the blood should all serve to distinguish if from similar disorders.

Poisons

Included here are the effects of bismuth, lead, mercury, arsenic, phosphorus, and a few others. Three of these are usually now seen in luetics under treatment, who have had an excess of the respective drug given them. The other two are usually occupational in origin. It is said that lead gives a blue line on the gum, bismuth a black line, etc., but in our experience these findings are more easily encountered in textbooks than patients. The effect is usually one of swollen, bleeding gums, and a metallic taste.

Leukemia

The oral findings here are not specific, the interest lying in the possibility that the dentist may unearth a case of Leukemia when he encounters an atypical case of hypertrophic gingivitis which does not respond to the usual periodontia procedures. In Leukemia of either the acute or chronic type –lymphatic or myclogenous –there may be bleeding from the gums, or the first sign of the disease may be an intractable hemorrhage form the socket of a recently extracted tooth. Late in the chronic forms, or at the onset of the acute forms acute stomatitis frequently develops and progresses to severe ulceration. The bleeding is due to the marked reduction in the number of blood platelets.

NEOPLASTIC

Epulis

This group includes the greatest number of the new growths of the mouth. Defined as “any tumor on the gum” it may include giant cell tumor, fib, roma, carcinoma, sarcoma, papilloma, pyogenic granuloma, etc. The general pathologists still fail to accept the classification of the oral pathologist, and continue to regard epulis as a definite histological entity, accounting for much of the confusion in the literature on this subject. Obviously the diagnosis of epulis depends upon a careful visual examination of the entire mouth. Microscopic examination will be needed to determine the complete diagnosis, but since this is not always feasible, it is recommended that the tumor be preserved in formalin after excision for subsequent examination if there is latter any change at the site of the growth.

Leukoplakia

Figi give us three principal types: squamous, papillary, and syphilitic, but Hollander does not attempt such a grouping. It would seem that this former classification is open to criticism, as is any such where no common feature is used to divide the cases. Hence, in this case Figi has used morphology to identify the first two groups, and a specific organism for the third. In any event, the factor of syphilis is an important one, some observers believing that 90% of patients with leukoplakia have syphilis, and very few hold that there is no correlation between them.

The primary interest, aside from the connection with lues, is the possibility of the lesions becoming malignant. Figi feels that his squamous type is innocent until it begins to become thick and leathery, when its complete and thorough removal is indicated. He regards the papillary forms malignant, and the syphilitic type, usually found on the tongue, or within the angles of the mouth, very prone to ulcerate and undergo carcinomatous degeneration.

Hollander states that carcinoma can develop only from lesions of long standing which crack or become ulcerated.

The sixth decade is the commonest age of occurrence, and most leukoplakia is seen in men. The lesions show many variations, but the usual form is a somewhat rough, grayish white, slightly raised area, which may be on the lips, check, alveolar gingivae, tongue, palate, or fauces.

Hollander gives us nine factors to be considered in determining the cause:

  1. Syphilis
  2. Tobacco
  3. Alcohol
  4. Decayed or Infected Teeth.
  5. Hot or Highly Spiced Food.
  6. Trauma.
  7. Badly Fitting Dental Appliances.
  8. Electricity.
  9. In some Cases No Cause Can be Found.

Malignant Growths

These are chiefly epitheliomas, but adenocarcinoma of mixed tumor type, hemangioendiothelioma, and sarcoma occur occasionally. The prognosis depends upon the duration of the tumor before it is found and treated, and upon the histological appearance. Sarcoma metastasizes so rapidly that most of these patients die within the year, even though the primary growth has been removed. Of the carcinomas the papillary type usually are less malignant, while the infiltrating type or those with a wide base are more treacherous. The connection of the remarks on epulis (above) are petinent here and if the procedure recommended were universally adopted by dentists, a definite step would have been made in the war on this dread disease.

MISCELLANEOUS

Black Tongue

Lingua Nigra appears primarily as a black, hairy area over the posterior portion of the dorsum of the tongue. Figi states that the etiology is unknown but Hirschfeld says it is definitely and always due to too vigorous anti-Vincent’s therapy, giving accurate descriptions of case reports to support his thesis. It is not a percancerous lesions but frequently seriously worries the patient. He will usually have taken strong cathartics and applied various strong drugs locally, further complicating the picture. Hirschfeld’s description of the process is that the filiform papillae have become hornified and hypertrophied as a result of continued use of sodium perborate and similar drugs.

 

 

 

Geographic Tongue

This condition requires no treatment but may cause considerable concern on the part of the patient. The slightly clevated, rounded, grayish rings, surrounding reddened areas, are apparently due to pressure areas of the tongue against other intraoral structures. The configurations change their shape from time to time.

Fordyce’s Disease

This “disease” is scarcely such, as it also requires no therapy. The condition shows numerous minute, yellowish, granular nodules within the mucous membrane of the lips and cheeks –normal condition, due to the presence of sebaceous glands in this area.

Pemphigus

Stovia says the bullous pseudomembranous ulcers always appears first in the mouth, preceding the skin lesions by about three weeks. Dermatologists distinguish several forms, but in any event, it is doubtful whether any true, bona fide case has recovered.

Ranula

Stovin’s description will suffice: “A cystic tumor, situated in the floor of the mouth. Its exact etiology is unknown, but it is generally considered to be caused by a congenital defect or an obstruction in one of the salivary ducts, usually the sublingual, though some authors believe it to be a cystic degeneration of one of the lobes of the affected gland. It appears as a tense, thin-walled swelling at the side of the floor of the mouth, pushing the tongue upward. The symptoms are chiefly mechanical.

BIBLIOGRAPHY

 

  1. Aison, E. L. “Blood Dyscrasias, the Oral Symptoms, Their Significance and Relation to the practice of Dental Surgery.” JADA, Vol. XXI, pp. 1612-24, 1934.
  2. Bartels, H. A. “The Streptococci: Recent Observations of Interest to the Dentist.” JADA, Vol. XX, p.1818. 1933.
  3. Baum, H. B. “Occupational Diseases of the Mouth.” Cosmos, Vol. LXXVI, p. 247. 1934.
  4. Boyko, G. V. “Differential Diagnosis of the Mouth Lesions in Local and Systemic Disease.” Cosmos, Vol. XLLV, p. 1161. 1933.
  5. Bunting, R. W. A Textbook of Oral Pathology. Lead and Febiger. 1929. (Section on Tumors, by Carl W. Waldron.)
  6. Burkahst, H. H. “Canker Sores.” Ortho and Dent. for Children, Vol. XIX, p. 1066. 1933.
  7. Dalitsch, W. W. “Vincent’s Stomatitis and Related Infections.” JADA, Vol. XXI, p. 1255, 1934.
  8. Crulce, C. G. “Oral Diseases in Children.” JADA Vol. XXII, p. 1226. 1935.
  9. Downing, J. G. “Fungus and Other Infections of the Mouth.” Appolonian, Vol. X, p. 5. 1935.

 

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