4. DIAGNÓSTICO Y RESULTADOS
4.3 Análisis de Resultados
Amalgam or other foreign materials incorporated into a wound may cause a tattoo.
Incidence
Common
Age mainly affected
After adolescence
Sex mainly affected
M=F
Aetiology
Amalgam or dust can become incorporated in healing wounds after tooth extraction or apicectomy or beneath mucosa. Similar lesions can result if pencil lead (graphite) or other similar foreign bodies become embedded in the oral tissues. Occasionally adolescents may deliberately have tattoos made in their mouth.
Clinical features
Tattoos usually:
• Do not grow in size;
• Are usually seen close to the teeth if caused by amalgam (Figure 4.3);
• Are often in the buccal mandibular gingiva (Figure 4.4), the floor of the mouth,
or the scar of an apicectomy where there has been a retrograde root-filling if
caused by amalgam (Figure 4.5);
• May be in the palate if caused by graphite (Figure 4.6);
• May occasionally show opacities on radiography.
Figure 4.2
Amalgam tattoo in a typical site
Figure 4.3
Amalgam tattoo after apicectomy
Figure 4.4 Amalgam tattoo
Figure 4.5 Amalgam tattoo
Figure 4.6
G raphite tattoo from a childhood accident involving a pencil penetrating the palatal mucosa
Diagnosis
• The diagnosis is usually obvious from the location history and clinical appearance;
• Radiography may or may not help to confirm the diagnosis;
• Biopsy may be indicated in cases where the clinical diagnosis is equivocal, in order to exclude a naevus or melanoma, but otherwise these lesions are innocuous.
Management
• These lesions can be left alone if the diagnosis is certain;
• Those rare tattoos which need removal for cosmetic reasons can be excised or removed with a Q-switched ruby laser.
Amyloid
Aphthae (recurrent aphthous stomatitis, RAS; Tables 4.4 and 4.5)
Definition
RAS are recurrent mouth ulcers which typically start in childhood and have a
natural history to improve with age (Figure 4.7).
Figure 4.7
Recurrent aphthous stomatitis
Incidence
RAS affect up to 250% of the population.
Table 4.4 Characteristics of the different types of recurrent aphthous stomatitis
Age mainly affected
Sex mainly affected
M=F
Aetiology
There may be: • A family history;
• Associations with HLA-antigens B51 and Cw7;
• Changes in cell-mediated immune responses and cross-reactivity with
Streptococcus sanguis or heat shock protein.
There appears to be a genetically determined immunological reactivity to unidentified antigens, possibly microbial. Research has shown equivocal associations with various viruses (cytomegalovirus, varicellazoster virus, herpes simplex virus), and other microorganisms (streptococci, Helicobacter pylori). Immunological changes are detectable, but there is no reliable evidence of
autoimmune disease (Figures 4.8-4.12).
Most patients with RAS are well, but some prove to have associations with: • Stress;
• Trauma;
• Deficiency of a haematinic such as iron, folate or vitamin B12 (about 10-20%), or B1;
• Coeliac disease or Crohn's disease; • Menstruation;
• Food allergy: some react to nuts, chocolate, potato crisps, etc.
Aphthae are less common in smokers than in nonsmokers, and sometimes they appear when smokers give up the habit.
Figure 4.8 Recurrent aphthous stomatitis: an immunological reaction to various antigens eventually damages keratinocytes and epithelial basement membrane
Figure 4.9
Recurrent aphthous stomatitis: keratinocytes express HLA antigens at an early stage
Figure 4.10
Recurrent aphthous stomatitis: T lymphocytes move into early lesion
Figure 4.11
Recurrent aphthous stomatitis: cytokines from T lymphocytes attract natural killer cells
Figure 4.12 Recurrent aphthous stomatitis: multiple cytokines appear involved in pathogenesis of damage to keratinocytes
A small minority of patients prove to have systemic disease such as: • Behgçet's syndrome;
• Immunodeficiencies, including HIV disease, IgG2 deficiency and cyclic
neutropenia;
• A syndrome with periodic fever and pharyngitis, but with no neutropenia; • Cytophagic histiocytic panniculitis;
• Sweet's syndrome.
Clinical features
Recurrent aphthae typically:
• Start in childhood or adolescence;
• Are multiple (Figure 4.13);
• Are ovoid or round (Figure 4.14);
• Recur;
• Have a yellowish depressed floor (Figure 4.15);
• Have a pronounced red inflammatory halo (Figure 4.16).
Aphthae may present different clinical appearances and behaviours (Table 4.4).
Minor aphthae (Mikulicz's aphthae; MiRAS) are recurrent, often ovoid ulcers
with an inflammatory halo, and: • are small, 2-4 mm in diameter; • Last 7-10 days;
• Tend not to be seen on gingiva, palate or dorsum of tongue (Figures 4.17 and
4.18);
• Heal with no obvious scarring (Figure 4.19).
Most patients develop not more than six minor ulcers at any single episode.
Major aphthae (Sutton's ulcers; MaRAS) are recurrent, often ovoid ulcers
with an inflammatory halo, but are less common, much larger (Figure 4.20) and
more persistent than minor aphthae, and can affect the soft palate (Figures 4.21
and 4.22) and dorsum of tongue as well as other sites. Sometimes termed
periadenitis mucosa necrotica recurrens (PMNR), major aphthae: • Can be well over 1 cm in diameter;
• Are most common on the soft palate, fauces and lips;
• Can take several months to heal (Figure 4.23);
• May leave obvious scars on healing (Figures 4.24 and 4.25).
Figure 4.13
Recurrent aphthous stomatitis, these are often small multiple ulcers
Figure 4.14
Recurrent aphthous stomatitis: ulcers are round or ovoid with an inflammatory halo
Figure 4.15
Recurrent aphthous stomatitis: ulcers have a yellowish floor
Figure 4.16
Recurrent aphthous stomatitis: ulcers have a surrounding
Figure 4.17
Recurrent aphthous
stomatitis: minor aphthae in a typical site
Figure 4.18
Recurrent aphthous
stomatitis: minor aphthae affect mobile non-
keratinised mucosa
Figure 4.19
Recurrent aphthous stomatitis: healing minor aphthous ulcer
Herpetiform ulcers (HU) are so termed because the patients have a myriad of
small ulcers that clinically resemble those of herpetic stomatitis (Figure 4.26). It
is, however, a distinct entity, lacking the associated fever, gingivitis and lymph node involvement of primary herpetic stomatitis. HU are more common in females and:
• Start as multiple pinpoint aphthae;
• Enlarge and fuse to produce irregular ulcers (Figure 4.27);
••
Can be seen on any mucosa, but especially on the ventrum of the tongueDiagnosis
Aphthae are diagnosed from the history and clinical features. There is no diagnostic test of value but blood tests may be useful for excluding
Figure 4.20
Recurrent aphthous stomatitis: major aphthae are large and persistent
Figure 4.21
Recurrent aphthous
stomatitis: major aphthae may affect the palate and tongue
Figure 4.22
Recurrent aphthous
stomatitis: major aphthae are large, persistent and can affect any site
Figure 4.23 Recurrent aphthous stomatitis: persistent major aphthae Figure 4.24 Recurrent aphthous stomatitis: scarring after major aphthae
Figure 4.25
Recurrent aphthous stomatitis: severe scarring from major aphthae in this patient with Behgçet’s syndrome
Figure 4.26
Recurrent aphthous stomatitis: herpetiform ulcers are multiple and small initially
possible deficiencies or other conditions, and then a specialist opinion may be of help. Features that might suggest a systemic background, and indicate the need for specialist referral, include:
Any suggestion of systemic disease from extraoral features such as:
• Genital lesions; • Skin lesions; • Ocular lesions;
• Gastrointestinal complaints (e.g. pain, altered bowel habits, blood in faeces); • Loss of weight; • Weakness; • Chronic cough; • Fever; • Lymphadenopathy; • Hepatomegaly; • Splenomegaly;
An atypical history such as:
• Onset of ulcers in later adult life; • Exacerbation of ulceration;
Figure 4.27
Recurrent aphthous stomatitis: herpetiform ulcers fuse to produce ragged lesions
Figure 4.28
Recurrent aphthous stomatitis: herpetiform ulcers often affect the ventrum of the tongue
• Severe aphthae;
• Aphthae unresponsive to topical hydrocortisone or triamcinolone.
Presence of other oral lesions, especially:
• Candidiasis (including angular stomatitis); • Glossitis;
• Purpura or gingival bleeding; • Gingival swelling; • Necrotizing gingivitis; • Herpetic lesions; • Hairy leukoplakia; • Kaposi's sarcoma.
Management
The aims of treatment of RAS are to reduce pain, reduce ulcer duration and increase disease-free intervals. There is no absolute cure.
Any underlying predisposing factors should be treated and, where possible, allergens and irritant foods such as potato crisps should be avoided. Treat aphthae with:
• Benzydamine rinse or spray to ease the discomfort (Table 10.2);
• Chlorhexidine 0.2% aqueous mouthwash (Table 10.1);
• Topical corticosteroids such as hydrocortisone hemisuccinate 2.5 mg pellets or 0.1% triamcinolone acetonide in Orabase used four times daily or, rarely, more
potent topical corticosteroids (e.g. betamethasone or beclomethasone (Table
10.5));
• In adults, tetracycline rinses using 250 mg capsules in water four times daily for up to 4 weeks.
Other agents such as thalidomide are effective and may be needed, but these
should be given by a physician, since there may be serious adverse effects (Table
10.7). A range of other agents have appeared effective in small trials but hard
evidence of their efficacy is lacking (Table 4.5).