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Erythematous bleeding gums are a common worldwide problem, which is almost always a localised inflammation associated with poor dental hygiene.7 Systemic problems usually as part of a bleeding diathesis need to be considered.
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The causes are summarised in the diagnostic strategy model (see TABLE 72.2).
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Acute necrotising ulcerative gingivitis (Vincent infection or trench mouth) caused by anaerobic organisms is rarely seen but is more common in undernourished or ill young adults under stress.
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Caused by plaque (bacterial biofilm) with calculus (tartar secondary to poor oral hygiene).
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++
++
Dental care—remove plaque and clean
Cease smoking
Mouthwash: chlorhexidine 0.2 or 0.12% aqueous solution 10 ml for 1 minute 8–12 hourly for 10 days or until pain abates (beware of superficial discolouration of teeth with prolonged use)
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Acute ulcerative gingivitis
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This is a very painful form of gingivitis. Treatment is as for gingivitis but add antibiotics, e.g. metronidozole 400 mg (o) 12 hourly or tinidazole 2 g (o) single dose and drain pus from abscess.4
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This is inflammation of the periodontal space. It is a sequel to gingivitis and shows periodontal ligament breakdown with recession or periodontal pocketing and alveolar bone loss. There is possible loosening of teeth and periodontal abscess formation (see FIG. 72.4). An underlying medical condition must be suspected.
++
++
Risk factors are smoking and diabetes.
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Treatment is meticulous dental treatment and mouthwashes. Antibiotics are rarely required.4
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Prevention of gingival disease
++
Use a fluoride, abrasive type of toothpaste.
Brush with a medium-to-soft, nylon-tufted, small-headed toothbrush.
Direct at gingival margin with a small horizontal motion.
Keep interdental spaces clean with dental flossing in a vertical direction or tooth picking.
Regular dental review—eliminate plaque.
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The dermatoses include lichen planus, pemphigus vulgaris (uncommon), mucous membrane pemphigoid (uncommon) and lupus erythematosus. The clinical appearance of these conditions in the mouth is quite different to the skin condition because of the environment, especially due to the presence of saliva.
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Histopathological examination (after appropriate biopsy) with immunofluorescence is recommended, especially because of the similarity of the lesions of lupus erythematosus and lichen planus, which are both considered to be potentially premalignant in the mouth.8
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affects 2% of the population, usually over 45 years
can vary from asymptomatic to severely painful
usually white lace-like patterns on mucosa, cheeks and tongue
may form superficial erosions
++
++
oral lesions may be first sign of SLE
usually on lateral aspects of the hard palate
can resemble lichen planus
++
Consider specialist referral.
++
Oral hygiene and pain control:
chlorhexidine mouthwash
or
tetracycline/nystatin mouthwash
or
topical analgesics (e.g. lignocaine preparation)
Corticosteroids:
topical (e.g. Kenalog in Orabase; betamethasone dipropionate 0.05%)
intralesional (e.g. triamcinolone 10 mg/mL, especially for lichen planus)
systemic—may be necessary in severe cases
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Pain in the tongue is a reasonably common symptom in general practice. The cause is usually obvious upon examination, but there are some obscure causes. As for many other oral mucosal problems, shared care with a dental or oral medical specialist is important. The causes of a sore or painful tongue are similar to that of the sore throat or mouth. Xerostomia is common in the elderly.
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Investigations may include an FBE, serum vitamin B12, folate and ferritin levels, a swab or a biopsy of a suspicious lesion.
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A diagnostic strategy with lists of causes is presented in TABLE 72.3.
++
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Look for evidence of trauma, especially from a sharp tooth.
A miserable child with a painful mouth and tongue is likely to have acute primary herpetic gingivostomatitis or hand, foot and mouth disease.
When taking the history, take note of self-medications, especially sucking aspirin, a history of skin lesions (e.g. lichen planus) and consider underlying diabetes or immunosuppression.
A long history of soreness with spicy or other foods indicates benign migratory glossitis (geographic tongue) or median rhomboid glossitis (see FIG. 72.5).
Any non-healing or chronic ulcer requires urgent referral.
Macroglossia (large tongue): consider acromegaly, myxoedema, amyloidosis, lymphangioma.
Strawberry tongue: consider scarlet fever, Kawasaki disease.
Glossodynia (painful tongue): characteristically presents as a burning pain on the tip of the tongue.9 It can be a real ‘heartsink’ presentation. Consider depressive illness as an underlying cause.
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Erythema migrans (geographic tongue)
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Also known as benign migratory glossitis, this benign condition shows changing patterns of desquamatous areas and erythema on the dorsum and edges of the tongue. With the smooth red patches and raised whitish grey edges, the pattern resembles a relief map with mountain ridges. The border changes shape within weeks. It is irregular and slightly reddened.
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It is considered to be a hypersensitivity reaction but the offending allergen has not been identified. Stress, tobacco, alcohol, marijuana and spicy foods can aggravate the condition in some individuals.
++
The condition is self-limiting and there is no specific therapy.
Explanation and reassurance is important.
No treatment is recommended if asymptomatic.
If tender, benzocaine compound (Cepacaine) gargle 10 mL tds.
If persistent and troublesome, low-dose inhaled glucocorticoid (e.g. beclomethasone 50 mcg tds—don’t rinse after use).
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Black or hairy tongue
++
This is due to overgrowth of papillae or reduced wear of papillae, e.g. debility and lack of fibrous foods.
++
Appearance: dark, elongated filiform papillae giving brownish appearance to dorsum (posterior) of tongue.
Symptoms: bad tastes and malodorous oral cavity.
++
Unknown
Poor oral hygiene/debility
Iatrogenic (e.g. antibiotics, major tranquillisers, corticosteroids)
++
Brush or scrape tongue to remove stained papillae. Use a topical keratolytic agent such as salicylate, with pineapple being the most practical (95% cases are helped).
++
++
Note: The salicylate in pineapple can aggravate irritable bowel syndrome.
++
Consider sodium bicarbonate mouthwash.
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Oral dysaesthesia (‘burning mouth’ syndrome)
++
The classic chronic burning sensation of the oral cavity appears to have a neuropathic and/or psychological basis.1 Symptoms include:
++
altered sensitivity—burning pain or ‘raw’ sensation, mainly of the tongue and mucosa of lips
altered taste—sweet, salty, bitter or metallic
altered saliva (subjective)—quality and quantity
altered tooth sensation (e.g. ‘phantom tooth pain’)
dry mouth (xerostomia)
++
Consider the underlying cause:
++
medications
haematinic deficiency—iron, folate, vitamin B12
autoimmune disorder (e.g. Sjögren syndrome)
endocrine disorder (e.g. diabetes)
psychological disorder
++
++
Consider clonazepam 0.5–1 mg bd.
++
Cancer of the lip and oral cavity accounts for 2–3% of all newly diagnosed cancers in Australia.10
++
SCC is the most common malignancy of the oral cavity, accounting for 90% of cases. It has a 5-year survival rate of 65% without lymph node involvement and 50% with local node metastases.11 Cancer of the lip is usually treated successfully by excisional biopsy but intraoral cancer has significant morbidity and mortality.10
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Other malignancies include mucoepidermoid carcinoma, lymphoma, Kaposi sarcoma and malignant melanoma, which is usually found on the palate.
++
Predisposing or associated factors for SCC include tobacco and marijuana abuse, alcohol abuse, excessive sunlight and immune suppressive disorders such as HIV, lymphoma and various medications.
++
SCC is usually found as a chronic indurated ulcer on the ventral and lateral surfaces of the tongue followed by the floor of the mouth and buccal mucosa. It may present as a white patch or, more commonly, as a speckled white and red nodular patch or a red velvety patch.
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The red patches of erythroplakia (in particular) and the white patches of leucoplakia may be premalignant or early invasive cancer and necessitate further investigation, particularly incisional biopsy.
++
Treatment for oral cancer is surgery ± radiotherapy and chemotherapy.