Книга_4440_Библиотеки_им_академика_М_И_Перельмана

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230

6 History andExamination ofLip andOral Cavity

• Downward corner of mouth—Oral commissures positioned inferior to the midline labial ssure.

• Mouth narrow—Distance between the commissures more than 2 SD below the mean.

• Upward corner of the mouth—Oral commissures positioned superior to the midline labial ssure.

• Mouth wide—Distance between the oral commissures more than 2 SD above the mean.

• Dry lips

• Cracking corner (actinic cheilitis)

• Tingling, pain, numbness of lip and skin around the mouth.

• Burning or tingling sensation—Vitamin B12 deciency, depression, anxiety, menopause.

6.1.2 Symptoms/History/Chief Complaints ofOral Cavity Disease

(a) Halitosis (bad breath)—It is used to dene

an unpleasant or offensive odour emanating from breath regardless of whether the odour originates from an oral or non-oral source. The chemistry of halitosis is complex.

• Types of halitosis—There are various types of bad breath experienced by the patient.

– Rotten egg smell—Anaerobic bacte-

rial organisms usually play a prominent role in breaking down amino acids into volatile, foul smelling, sulphur- containing compounds and also because gut microbiota breaks down sulphur and releases that eggysmelling gas.

– Fruity or sweet smell—Ketoacidosis, a

complication of diabetes, often presents in the breath having a sweet, fruity odour. Ketones produced due to the breakdown of fat, which often resembles acetone, produce a fruity odour.

– Mouldy or fungus smell—Sinus infec-

tions often cause thick, yellowish-

green mucus to drip from the nose to the back of the throat, which smells like mould or fungus.

– Faecal smell—Intestinal obstruction

causes such smell.

– Fishy smell-A damaged kidney no lon-

ger can lter the waste and toxins. These toxins and waste start to accumulate throughout the body results in a shy breath smell.

• Duration – Short duration—Food, smoker, tobacco

chewing, poor dental hygiene, dry mouth, peritonsillar abscess, dental abscess, dental carries.

– Long (chronic)—Poor dental hygiene,

sinusitis, GERD, tonsillar debris, CA oral cavity.

• Mode of onset – Sudden—Dental abscess, medication,

acute sinusitis.

– Gradual—Dry mouth, tooth decay, oral

cancer, tooth decay.

• Associated symptoms—Nasal discharge,

sputum production, H/O diabetes mellitus, kidney disease, regurgitation, constipation. Recurrent tonsillar infection, dry mouth, H/o radiotherapy, H/O lever failure, psychiatric illness.

Halitophobia—A psychiatric condition consisting of a highly exaggerated concern about halitosis and falls on the spectrum of social anxiety disorders.

(b) Pain in the oral cavity—Oral pain, although

nonspecic, can be an indicator of localized or systemic dysfunction. It can be a result of infectious diseases affecting the tongue (glossitis), lips (cheilitis) or any other region of oral mucosa (stomatitis). Dental disorders can be an alternative source of oral pain. Similarly, it may be secondary to a salivary gland, pharyngeal, neurological or psychological disorder.

• Duration of pain

6.1 Symptoms/Chief Complaint/History ofLip andOral Cavity Disorders

231

– Acute—Trauma, ulcer, stomatitis, gin-

givitis, glossitis, cheilitis, aphthous ulceration, infection, dental origin, periodontitis

– Chronic—Dry mouth, canker sores,

BMS, aphthous ulcer

• Site of pain – Tongue—Glossitis, trauma, candidia-

sis, BMS (anterior part) – Lips—Cheilitis, trauma, boil, BMS – Mucosa of oral cavity—Stomatitis,

candidiasis – Gum—Gingivitis, infected gum – Teeth—Tooth decay, tooth abscess,

tooth fracture, damaged lling, loose

crown, non-erupted tooth, wisdom

tooth – Palate—Ulcer, dental abscess, BMS

(anterior part)

• Type of pain – Intermittent—Dental hypersensitivity

(cavitary lesion, gingival recession, erosion) pulpitis

– Continuous—Irreversible pulpitis, api-

cal periodontitis

• Side of pain – Unilateral—Acute apical periodon-

titis

– Bilateral—TM joint dysfunction uni-

lateral dental causes

• Character of pain – Dull aching—Alveolar osteitis or

alveolitis, chronic apical periodontitis, TM joint disorder

– Sharp, achy or throbbing pain—

Nociceptive pain, acute apical periodontitis, trigeminal neuralgia

– Shooting, stabbing or burning—

Neuropathic pain

– Burning and/or tingling (neuropathic

pain)—Lichen planus, geographical tongue, burning mouth syndrome

• Severity of pain – Mild—Gingivitis, aphthous ulceration – Moderate—Dental carries, gingivitis,

glossitis

– Severe—Dental abscess, carcinoma

(stage IV), trigeminal neuralgia

• Aggravating and relieving factors

Aggravating factor

Biting No

Hot, cold and sweet

Relieving factors Diagnosis

Cracked cusp, loose

movement No eating Exposed dentine, lost

lling, fractured tooth

lling, carries

Differential Diagnosis of Toothache (Table6.3)

• Site—Table 6.4 shows the swelling of the oral cavity with differential diagnosis.

• Duration

– Short—Abscess, haematoma, glossitis – Long—Benign tumour, retention cyst,

papilloma, broma, epulis

• Size—Small, medium or large

• Mode of onset—Sudden or gradual

• Associated symptoms—Pain, bleeding, foul smelling, loose teeth

(d) Growth (Table6.5)

• Site—Labial mucosa, buccal mucosa, anterior 2/3 of tongue, hard palate, lower alveolar ridge, upper alveolar ridge, oor of mouth, retromolar trigone

• Type of growth

– Exophytic (proliferative) (Table6.6) – Endophytic (ulcerative)—This type of

growth grows inside.

• Duration—Short duration points towards infective aetiology and long duration towards the tumour

• Size—Small, medium or large size of tumour noted for staging

• Mode of onset—Sudden onset growth points towards infective, trauma aetiology and insidious onset tumour

• Associated symptoms—Pain, bleeding, foul smelling, loose teeth, neck swelling, trismus

• H/O gutkha, tobacco chewing, smoking, chute (reverse smoking), alcohol consumption, sharp jagged tooth, chewing paan.

(e) Ulcer—Type of ulcer—Ulcerations of the

oral cavity can be classied based on (1) duration of ulcer, (2) number of ulcers and (3) etiological factors

• Presentation of oral ulcer – Single or multiple ulcers in the oral

cavity

232

Table 6.3 Shows differential diagnosis of toothache

Type of toothache and associated symptoms Diagnosis Tingling and burning sensation, sensitivity on one side Cavity of tooth Intense, vague, throbbing, pounding, burning pain, swelling pain,

nausea, fever, pain in the jaw Pain caused by exposure to stimuli like cold and sweet ceases

within 1–2s Painful chewing, gum bleed on touch brushing, bad breath Periodontitis Pain with movement of the jaw Trauma Pain is associated with swelling Unerupted tooth Sharp, short, shooting pain Cracked cusp, loose lling fracture tooth,

Dull throbbing, persistent pain localized and tooth tender on percussion

Dull throbbing, persistent pain with local inammation Impacted food, pericoronitis Dull throbbing, persistent pain Acute necrotizing ulcerative gingivitis, Dull throbbing, persistent pain which may be diffused Dry socket, TM joint dysfunction

Table 6.4 Differential diagnosis of swelling of the oral cavity

Site Clinical presentation Diagnosis Soft palate, hard palate, uvula,

tongue and lips Anywhere in oral cavity Mucosa covered, pedunculated

All sites Bluish in colour Haemangioma Anterior 2/3 of tongue Lymphangioma Hard palate, mandible Solitary nodule or lobulated mass Torus Anterior tongue or cheek Soft smooth, reddish to purple,

Anterior 1/3 of tongue, buccal mucosa

Lower lip Bluish, soft, cystic mass Mucocele Floor of mouth Cystic translucent Ranula Floor of mouth Whitish swelling through mucosa Dermoid cyst

Irregular surface, pedunculated, <1cm

tumour, soft to rm

bleed-to-touch mass This is mucosa- covered hard

swelling

6 History andExamination ofLip andOral Cavity

Tooth abscess

Pulpitis

exposed dentine, lost lling, carries Periapical infection, sinusitis

Papilloma

Fibroma

Pyogenic granuloma

Solitary brous tumour

Table 6.5 Shows differential diagnosis of growth of oral cavity

Symptoms/sign Diagnosis depending on site Growth, common in lower lips Carcinoma lip Growth or non-healing ulcer, trismus, white patches Carcinoma of buccal mucosa Growth or swelling, non-healing ulcer, neck swelling, ankyloglossia,

trismus, bleed on touch, dysphagia Growth or swelling or non-healing ulcer, loose teeth Carcinoma hard palate Growth or swelling or non-healing ulcer

Loose teeth, commoner than lower alveolus, neck swelling Growth or non-healing ulcer Carcinoma oor of mouth Trismus, growth Carcinoma of retromolar trigone Growth/ulcer with loose teeth Carcinoma of upper alveolus

Carcinoma or anterior 2/3 of tongue

Carcinoma lower alveolus

6.1 Symptoms/Chief Complaint/History ofLip andOral Cavity Disorders

Table 6.6 Differential diagnosis of exophytic growth in the oral cavity

Lesion with a smooth surface Lesion with a rough surface Reactive hyperplastic lesion—Pyogenic granuloma,

pregnancy tumour, irritating broma, peripheral ossifying broma, peripheral giant cell granuloma, epulis ssuratum, leaf-like broma, epulis granulomatous, pulp polyp

Salivary gland lesion—Mucocele, ranula, pleomorphic adenoma, mucoepidermoid carcinoma, adenoid cystic carcinoma

Mesenchymal lesion—Neurobroma, schwannoma, lipoma, lymphoma, haemangioma, lymphangioma

Reactive hyperplastic lesion—Giant cell broma, inammatory papillary hyperplasia

Haemangioma, lymphangioma

Squamous cell carcinoma, verruca vulgaris, condyloma acuminatum, verrucous carcinoma, squamous papilloma, multifocal epithelial hyperplasia (Heck’s disease)

233

– Small or large-sized ulcers in the oral

cavity – Pain in ulcer and oral cavity – Cotton-like feeling—Oral candidiasis – Blisters on mouth, tongue, hand and

buttock – White/black patches in the oral cavity – Spider web-like painful white patches

in the oral cavity—Lichen planus

• Duration of ulcer – Acute oral ulcer—Acute oral ulcer lasts

– Chronic oral ulcer—Ulcerative lesion

lasts for more than 2weeks, they may be painful or painless.

– Recurrent oral ulcer—It presents with a

history of comparable episodes with irregular healing and may last for more than 2weeks. These ulcers are caused by aphthous stomatitis, herpetic stomatitis, herpes-associated erythema multiforme, cyclical neutropenia and

Behcet’s disease (Table6.6). for no longer than 2weeks and is typically painful.

Name of lesion Gender Location Age Shape Number features Rec. aphthous

ulceration

Rec. herpetic stomatitis

Herpesassociated erythema multiforme

Cyclic neutropenia

Bachet’s disease

Women Non-

keratinized mucosa on all sites

Both Hard palate Any age Scalloped

Men Lips 20–40 Map like Multiple Bullae and ulceration

Both All subsites of

the oral cavity

M:F All subsites of

the oral cavity

>20years of age

Begins in childhood

25–50years Aphthous

Differential Diagnosis of Recurrent Oral Ulcer

Symmetrical Solitary

border

Aphthous like

or multiple

Multiple Recurrent herpes simplex

Multiple Episodic ulcer with

Multiple Concomitant genital

Burning, painful, brin covered with erythematous border

labialis, intraoral herpes

with irregular border and inammatory halo, bloody encrustation on lips

erythematous halo, concomitant fever, gingival recession

ulcer, ocular and skin lesions

234

6 History andExamination ofLip andOral Cavity

• Numbers of ulcers (Table6.7) – Single/solitary oral ulcer—The solitary

ulcer is the occurrence of a single ulcerative lesion.

– Multiple oral ulcer—Multiple explains the

incidence of numerous ulcerative lesions.

• Site of oral ulcer—Ulcer can develop over any

site of the oral cavity (Table6.8).

• Associated history – Diarrhoea, weight loss, stomach pain,

anaemia, joint pain, bloating, fatty stool, skin rashes—Coeliac disease

– Fever, sore throat, skin rashes—Hand, foot

and mouth disease

– Cotton-like feeling, loss of taste, pain while

Table 6.7 Differential diagnosis of solitary and multiple oral ulcers

Acute solitary ulcer Acute multiple ulcer Traumatic (sharp food, accidental biting, thermal,

chemical, necrotizing sialometaplasia)

Chronic solitary ulcer Chronic multiple ulcer Sustained traumatic ulcer, necrotizing sialometaplasia,

eosinophilic ulcer, ulcerative SCC, CMV-associated ulcer, tubercular, syphilitic, oral blastomycosis, oral mucormycosis

eating—Oral candidiasis – Ill-tting denture—Gingivostomatitis – Fatigue, weakness, pale skin, tongue swell-

ing, grey hair—Anaemia – History of stress, ill, weakened immune

system, excessive sun exposure—Cold

sores

• Past history—Ruled out the past H/O – Use of braces, poor-tting dentures and

other apparatus that may rub against the mouth and gums, in <30years, may cause gingivostomatitis.

– Any history is suggestive of systemic dis-

eases like coeliac disease, inammatory bowel disease, diabetes mellitus, Behcet’s

Primary herpetic gingivostomatitis, herpes zoster, herpangina, hand, foot and mouth disease, erythema multiforme, necrotizing ulcerative gingivitis, oral hypersensitivity reaction, plasma cell stomatitis, chemotherapy related

Pemphigus vulgaris, mucous membrane pemphigoid, bullous pemphigoid, lichen planus,

Table 6.8 Differential diagnosis of ulcer according to site

Site of oral ulcer Acute ulcer Chronic ulcer Labial mucosa (lip) Traumatic ulcer, necrotizing sialometaplasia,

primary herpetic gingivostomatitis, erythema multiforme

Buccal mucosa Traumatic ulcer, hand, foot and mouth disease Sustained traumatic ulcer,

Gum (gingiva) Herpes zoster (shingles), necrotizing ulcerative

gingivitis

Tongue Traumatic ulcer, herpes zoster (shingles), hand,

foot and mouth disease

Floor of mouth Aphthous ulcer Tubercular Hard palate Herpes zoster (shingles), hand, foot and mouth

disease

Soft palate Necrotizing sialometaplasia, herpangina, hand,

foot and mouth disease, candidiasis Retro molar trigone Necrotizing sialometaplasia Any sites Oral hypersensitivity reaction, aphthous ulcer,

chemotherapy related

Sustained traumatic ulcer, CMVassociated ulceration, syphilis

eosinophilic ulcer, pemphigus vulgaris, lichen planus

Tubercular, pemphigus vulgaris, bullous pemphigoid, lichen planus

Sustained traumatic ulcer, eosinophilic ulcer, tongue, syphilis, lichen planus

Syphilis, oral mucormycosis, pemphigus vulgaris

SCC, oral blastomycosis

6.1 Symptoms/Chief Complaint/History ofLip andOral Cavity Disorders

235

disease, weak immune system and HIV/ AIDs.

– A decient lling, stress or anxiety, hor-

monal changes during pregnancy, puberty and menopause, medications including beta-blockers and painkillers.

– H/O ulceration, healing, predisposing fac-

tor, sun exposure – H/O anaemia—Fatigue, palpitation, fatigue – H/O folate deciency—Fatigue, weakness,

pale skin, tongue swelling, grey hair.

• Personal history—Ruled out personal H/O— Vegetarians and vegans, the habit of eating hard foods (e.g. potato chips), food preservatives (specically benzoic acid and benzoates), chocolate, tomatoes, citrus fruits and other foods high in acidity or spice, use of toothpaste containing the foaming agent such as sodium lauryl sulphate

• Menstrual history—Ruled out heavy menstrual ow, which can develop iron deciency anaemia in females.

Aetiology/Causes of Oral Ulceration

Oral ulcers may be caused by various aetiologies.

• Recurrent aphthous stomatitis (canker sores)—Recurrent aphthous stomatitis (RAS) presents as painful round or oval ulcers that recur at different sites in the mouth. It has been categorized into three subtypes (Table6.9)

• Traumatic ulcer—The ulcer in the oral cavity can be caused by different types of trauma (Table6.10)

• Oral ulcer due to infective diseases: There are various systemic and local diseases which can cause oral ulceration (Table6.11)

• Oral ulceration secondary to skin disease (Table6.12)

• Oral ulceration caused by vitamin or nutri- tional deciency (Table6.13)

• Oral ulcer due to other miscellaneous

causes

Table 6.9 Shows different subtypes of recurrent aphthous ulceration

Minor RAS Major RAS Herpetiform RAS Occurs in groups of around ve

small ulcers. It appears on the non-keratinized sites in the mouth, such as buccal mucosa, labial mucosa or the oor of the mouth and usually heals within 10–14days.

Table 6.10 Shows different traumatic oral ulcers

Type of injury Description Factitious/self-trauma Positive H/O biting the cheek, tongue or lips or rubbing a ngernail, pen or toothpick

inside the mouth. The lingual frenum is also vulnerable to ulceration by repeated friction during oral sexual activity.

Thermal injury Positive H/O using hot food or beverages, burns are usually on the palate or posterior

buccal mucosa.

Electric burn Commonly affects the oral commissure (corner of the mouth). The lesions are usually

initially painless, charred and yellow with little bleeding, then swelling develops.

Chemical burn Positive H/O caustic chemical, holding aspirin tablet, eugenol, chloramphenicol,

hydrogen peroxide, silver nitrate, phenol.

Radiation- induced stomatitis

H/O radiation present. Mucosal erosions and ulceration, xerostomia (dry mouth).

Occurs as one to three ulcers at any one time. Involve any oral sites and may take several weeks to heal.

Involves between 10 and 50 small ulcers at non-keratinized sites that heal within 10–14days.

236

Table 6.11 Shows infective oral ulcerations

Symptoms Diagnosis Acute painful infection of the gums presented with acute pain, bleeding and foul

breath.

It most often occurs in young children and is usually the rst exposure a child has to the herpes virus which is also responsible for cold sores and fever blisters. The blisters of primary herpetic gingivostomatitis rupture rapidly to produce bloodcrusted lips and widespread oral ulceration which is extremely painful, with multiple small ulcers affecting any site in the mouth.

It is a mild, contagious viral infection common in young children. It is characterized by sores in the mouth and a rash on the hands and feet. Hand-foot and mouth disease is most commonly caused by a coxsackievirus.

White-grey patch on oral mucosa and tongue, common in infants, immunocompromised

Table 6.12 Shows oral ulceration secondary to skin diseases

Symptoms Diagnosis Site—Floor of the mouth, palate and gums. Eyes, genitals and anus, trachea Erythema multiforme

It is a mucocutaneous disease characterized by vesicles and bullae (i.e. blisters). Both vesicles and bullae are uid-lled lesions, and they are distinguished by size (vesicles being <5–10mm and bullae being larger than 5–10mm).

It may or may not present with skin symptoms of two types – Reticular—It appears as bilateral and symmetrical white, lacy patches on buccal

mucosa. It is usually asymptomatic

– Erosive—These lesions are red, swollen tissues or open sores, which principally

affect the buccal mucosae, labial mucosa, tongue and attached gingivae and may cause burning, pain or other discomfort. Symptoms can come on slowly or start all at once with dryness in the mouth or a metallic, burning taste. These sores can be painful and hurt the most when having spicy, salty, acidic (orange juice, tomato) or alcoholic.

Benign mucous membrane pemphigoid (BMMP) is a heterogeneous group of autoimmune chronic inammatory, subepithelial blistering disorders, predominantly involving the mucous membranes. It has a female predilection and commonly occurs after the fth decade of life. The oral mucosa is affected in more than 90% of cases.

6 History andExamination ofLip andOral Cavity

Acute necrotizing ulcerative gingivostomatitis (Vincent infection)

Herpetic gingivostomatitis (e.g. herpes simplex virus 1)

Hand, foot and mouth disease (e.g. Coxsackie virus)

Oral candidiasis

(febrile mucocutaneous syndrome), herpes iris, erythema multiforme type, dermatostomatitis

Vesiculobullous disease (mucous membrane pemphigoid/pemphigus)

Lichen planus

BMMP

– Haematological malignancy (e.g. leukae-

mia)—Typical oral manifestations of acute leukaemia include gingival swelling, oral ulceration, spontaneous gingival bleeding, petechiae, mucosal pallor, herpetic infections and candidiasis.

– Inammatory bowel disease (e.g. Crohn’s

disease, coeliac disease)—Main oral manifestations of Inammatory bowel diseases (IBD) are cobble stoning of the oral mucosa, labial swellings with vertical ssures, pyostomatitis vegetans, angular cheilitis, perioral erythema and glossitis.

– Hairy leukoplakia—Oral hairy leukoplakia

is a condition triggered by the Epstein-Barr virus (EBV). The lesion of hairy leukoplakia presents as a white patch, which almost exclusively occurs on the lateral surfaces of the tongue; the lesion may grow to involve the dorsal surface of the tongue. The rare sites of hairy leukoplakia are buccal mucosa, soft palate, pharynx or oesophagus. The texture is vertically corrugated (‘hairy’) or thickly furrowed and shaggy in appearance.

6.1 Symptoms/Chief Complaint/History ofLip andOral Cavity Disorders

Table 6.13 Shows the oral ulcer due to nutritional or vitamin deciency

Symptoms or clinical features Haematinic deciency Cracked lips, angular cheilosis Vitamin B1 thiamine deciency Inammation of the tongue, angular cheilosis, ulcerative

gingivitis Periodontal disease, anaemia, sore throat, burning

sensation in oral cavity Delayed tooth eruption, reduced tooth size, salivary

gland dysfunction Decrease epithelial tissue development, impaired tooth

formation, enamel hypoplasia Angular cheilosis, halitosis bone loss, haemorrhagic

gingivitis, detachment of periodontal bres, painful ulcers in the mouth

Salivary gland dysfunction very red, painful tongue with a burning sensation, dysphagia, angular cheilosis

Vitamin B2 (Riboavin), vitamin B3 (niacin)

Vitamin B6

Protein/calorie malnutrition

Vitamin A

Vitamin B12 deciency

Iron deciency

237

– Fissured tongue—This is a benign condition,

in which the dorsal surface of the tongue is marked by a deep, prominent groove in the midline. There may also be small furrows or ssures across the surface that cause a wrinkled appearance of the tongue.

– Geographical tongue—This is a benign,

harmless condition of the tongue in which the dorsal surface of the tongue has loss of papilla, presented as a smooth superior surface with red patches.

– Median rhomboid glossitis—This is a

benign condition of the dorsal surface of the tongue, presented as a smooth, red, at or raised, nodular area of the central or posterior part of the tongue with loss of papillae.

– Squamous cell carcinoma (mouth can-

cer)—This is a malignant condition of the tongue that presents as a non-healing ulcer/ growth on the lateral border of the tongue.

(f) Discolouration of mucosa—Oral mucosa is

normally pink in colour, highly keratinized, rm and stippled. The masticatory mucosa is pale and covers the hard palate, dorsal surface of the tongue and gingiva, while the non-masticatory mucosa is thin, less keratinized and more pinkish, covering the remaining intraoral structures.

• White—Leukoplakia, hairy leukoplakia, oral candidiasis

• Blue—Haemangioma, cyanosis, lead poisoning (bluish discolouration of gingiva)

• Redish—Erythroplakia, trauma

• Black—Melanoplakia, hydroxychloroquine drug side effect, black hairy tongue

• Brown—Peutz-Jegher syndrome, Laugier- Hunziker syndrome

• Light brown—Addison’s disease

• Tan to dark brown—Melanotic macule

• Dark brown to black—Melanocanthoma, melanoma, smoker’s melanosis

(g) Reduced mouth opening

• Mode of onset

– Sudden—Trauma, peritonsillar abscess – Gradual—TM joint arthritis, OSMF,

tetanus

• Duration

– Acute—Trauma, peritonsillar abscess,

tetanus

– Chronic—TM joint dysfunction,

OSMF, ankylosis of TM joint

• Progression

– Progressive—Tetanus, peritonsillar

abscess, OSMF

– Non-progressive—Bony ankylosis of

TM joint

• Associated history of pain and trauma— Throat pain, odynophagia, pain in TM joint, pain on chewing.

238

6 History andExamination ofLip andOral Cavity

Clinical Features of OSMF (Table6.14)

(h) Restricted mouth opening—It is caused by

either trismus or ankylosis.

• Types of restricted mouth opening – Trismus—Trismus, derived from the

Greek ‘trismus’, refers to restriction of the range of motion of the jaws. It is commonly referred to as ‘lockjaw’; trismus typically stems from a sustained, tetanic spasm of the muscles of mastication.

– Ankylosis—Ankylosis is a stiffness of

a joint due to abnormal adhesion and rigidity of the bones of the joint. It is true (intra-articular ankylosis) and false (extra-articular ankylosis).

• Duration—It can be divided into acute

and chronic depending on duration (Table6.15).

Table 6.14 Shows stagewise clinical features of OSMF

Stage of OSMF Intraoral Extraoral Early stage/stage 1 Symptoms—Burning sensation, stomatitis,

excessive salivation Signs—Blister formation, blanching oral mucosa, thin palpable brous band

Moderate stage/stage 2 Symptoms—Burning sensation, stomatitis,

gradual decrease in mouth opening, xerostomia, loss of taste, difculty in blowing cheek, whistling, defective gustatory sensation, vesicle formation Signs—Petechiae, rigid oral mucosa, blanching of oral mucosa, thick brous band, shrunken uvula, with altered shape

Advance stage/ Stage 3

Symptoms—Burning sensation, stomatitis, xerostomia, restricted mouth opening, unable to blow off cheek and whistle Signs—Thick palpable band, white marble-like appearance of the cheek, depapillation of the tongue, blanching of oral mucosa, sunken uvula with altered shape, loss of suppleness of mucosa, restricted tongue movement

• Mode of onset – Sudden—Fracture zygomatic arch,

fractured mandible, peritonsillar abscess

– Gradual—TM joint ankylosis

• Progression – Progressive—TM joint ankylosis – Non-progressive—Fracture zygomatic

arch, fracture mandible

• Associated symptoms—Pain, inability to

chew, deviation of jaw to one side

• Causes of trismus—The trismus is caused

by either local or systemic disorders (Table6.16).

(i) Difculty/Pain in Chewing—The difculty

in chewing often results from changes to the mouth, jaw or tongue cancer. It may be acute or chronic.

Not signicant

Signs—Prominent masseter muscle and antegonial notch, nasal twang, sunken cheek, loss of nasolabial fold

Signs—Sunken cheek, prominent molar bone, ellipsoidal mouth opening, thinning of mouth opening, atrophy of facial musculature, loss of nasolabial fold, inter-incisional mouth opening <5mm, hypertrophied stiff masseter muscle

Table 6.15 Shows causes of restricted mouth opening

Acute <3months Chronic >3months Trauma—Fracture zygomatic arch, fracture mandible,

tripod fracture, sub-condylar fracture, oral surgery, sub-condylar fracture, dental infection, haematoma Infection—Acute tetanus, peritonsillar abscess, dental infection, dislocation

Malunion of maxillafacial trauma, TM joint ankylosis, OSMF, coronoid hyperplasia, brosis of temporalis muscle TMJ dysfunction syndrome

6.1 Symptoms/Chief Complaint/History ofLip andOral Cavity Disorders

Table 6.16 Shows causes of trismus

Types/site of lesion Differential diagnosis/causes Intra-articular Meniscal disease, synovitis, ankylosis, arthritis Extra-articular Congenital Infection Odontogenic or masticatory space Periapical, periodontal, pericoronal

Non-odontogenic infection Peritonsillar abscess, meningitis, brain abscess,

parotid infection/abscess

Iatrogenic Radiation or chemotherapy Radiation-induced brosis, osteoradionecrosis

Dental treatment and oral surgery Extraction Drug induced Antiemetics, antipsychotic, antihistamine,

succinylcholine Tumours and others Myositis ossicans, submucous brosis, parotid tumours, TM joint tumours Traumatic Zygomatic fracture, mandibular dislocation, foreign body injury TMJ Myofascial muscle spasm, prolonged mouth opening Miscellaneous Malignant hyperpyrexia, psychogenic, lupus erythematosus, tetany, systemic sclerosis

Table 6.17 Shows D/D of painful chewing

Acute Chronic Mucositis, infection of teeth and gum, maxillofacial

trauma, dental abscess, gingivitis, pulpitis, peritonsillar abscess Acute parotitis, tongue paralysis, ankyloglossia, oral ulcer

Xerostomia due to post-radiation, post-chemotherapy, anti-depressant drugs Gum ds, tooth decay and tooth loss TM joint disorder, TM joint ankylosis OSMF, unerupted tooth, tongue paralysis

239

• Duration—It can be classied as either acute or chronic (Table6.17).

• Mode of onset

– Sudden—Trauma, mucositis, dental

abscess, acute parotitis, oral ulcer.

– Gradual/insidious—Xerostomia, post-

chemotherapy, TM joint ankylosis, tongue paralysis, unerupted teeth.

• Associated symptoms—Earache, trauma, dental pain, maxillofacial trauma.

(j) Reduced salivation/xerostomia (dry

mouth)

• Presentation—It can be presented with halitosis, cracking and ssuring of oral mucosa, dysgeusia, oral thrush, glossodynia, sticky or stringy saliva.

• Duration of symptoms

– Acute—Dehydration, exercise, anti-

histaminic drug.

– Chronic—Radiation, chemotherapy,

medication, systemic disease.

• Mode of onset of symptoms

– Sudden—Dehydration, exercise

– Gradual—Radiation, medication,

tobacco chewing, ageing, DM, hypertension

• Associated symptom or history—H/O radiation, medication (anti-hypertensive, diuretics, anti-anxiety, anti-depressant, anti-histaminic), tobacco chewing, dehydration, ageing, exercising or playing in the heat, systemic diseases (DM, parkinsonism, rheumatoid arthritis, SLE, scleroderma, sarcoidosis, amyloidosis, cystic brosis, Sjogren syndrome, depression, snoring, etc.)

(k) Sialorrhea (drooling of saliva)—Sialorrhea

arises from either excess saliva production (hypersecretion) or impaired swallowing of saliva. Hypersecretion can be seen with teething, parasympathomimetic or sympatholytic drugs, rabies and irritants such as capsaicin. Impaired swallowing may be due to infectious (severe pharyngitis, tonsillitis, epiglottitis, peritonsillar abscess, parapharyngeal/retropharyngeal abscess, subman-

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