Disorders of the Lips, Mouth, and Tongue

Disorders of the Lips, Mouth, and Tongue

When healthy, the lining of the mouth (oral mucosa) is reddish pink, and the gums, which fit snugly around the teeth, are paler pink. The roof of the mouth (palate) is divided into two parts. The front part has ridges and is hard (hard palate); the back part is relatively smooth and soft (soft palate). The inside and outside surfaces of the lips are distinctly divided by a wet-dry border (the vermilion border); the outside surface is skin-like, and the inside surface is moist mucosa. The tongue is normally not smooth: Tiny projections (papillae), which contain taste buds, appear on the surface.

The mouth may be affected by local conditions (conditions affecting only a specific area of the body)-such as some infections and injuries.

Also, systemic diseases (diseases affecting the body generally) - such as diabetes, AIDS, and leukemia - can cause changes in the mouth. Sometimes, the first signs of these diseases appear in the mouth and are recognised by a dentist.

Mouth Disorders
Problems that may develop in the mouth include various sores and growths, such as canker sores and cancerous growths. Also, the lining of the mouth or the palate may undergo certain changes in colour. Other problems include bad breath and salivary gland disorders.

Canker Sores
Canker sores are small, painful sores that appear inside the mouth.

The cause is unknown, but stress seems to play a role-for example, a college student may get canker sores during final exam week. A canker sore appears as a round white spot with a red border. The sore almost always forms on soft, loose tissue, particularly on the inside of the lip or cheek, on the tongue or soft palate, and some-times in the throat. Small canker sores (less than one-half inch in diameter) often appear in groups of two or three; generally, they disappear by themselves within 10 days and do not leave scars. Larger canker sores are less common; they may be irregularly shaped, can take many weeks to heal, and frequently leave scars.

The main symptom of a canker sore is pain - usually far more pain than would be expected from something so small. The pain, which lasts 4 to 10 days, worsens if the tongue rubs the sore or if the person eats hot or spicy foods. Severe canker sores can cause fever, swollen neck glands, and a generally run-down feeling. Many people who get canker sores get them repeatedly - perhaps one or more times a year.

Diagnosis and Treatment
A doctor or dentist identifies a canker sore by its appearance and the pain it causes. However, sores caused by herpes simplex virus may resemble canker sores.

Treatment consists of relieving the pain until the sores heal by themselves. An anesthetic such as viscous lidocaine can be swabbed on canker sores or used as a mouth rinse. This anesthetic relieves the pain for several minutes and can make eating less painful though it may also impair a person’s taste. A protective coating, carboxy-methylcellulose, also may be applied to relieve the pain. If a person has many canker sores, a doctor or dentist may prescribe a tetracycline mouthwash. Also, a person who has repeated outbreaks of severe canker sores may use this mouthwash as soon as a new sore appears. Another treatment option; cauterisation with silver nitrate, destroys the nerves under the canker sore. Occasionally, a doctor or dentist prescribes a corticosteroid ointment that’s applied directly to severe canker sores. A dexamethasone mouth rinse or prednisone tablets can be prescribed for severe episodes.

Oral Herpes Infection
Primary oral herpes infection (primary herpetic gingivostomatitis) is an initial infection by the herpes simplex virus that can cause rapidly developing, painful sores on the gums and other parts of the mouth. Secondary herpes (recurrent herpes labialis) is a focal reactivation of the virus that produces a cold sore.

Cause and Symptoms
Typically, an infant gets the herpes simplex virus from an adult who has a cold sore. The infant’s first such infection (primary herpes) causes general gum inflammation and extensive mouth soreness. The child may have a fever, swollen lymph nodes in the neck, and general discomfort; thus, the child may be cranky. Most cases are mild and go unrecognised. Parents often mistake the problem for teething or another illness. Within two or three days, very small blisters (vesicles) form in the child’s mouth. These may not be noticed because they rupture quickly, leaving the mouth raw and sore. The soreness may be anywhere in the mouth but always includes the gums. Though the child gets better in a week or so, the herpes simplex virus never leaves the body, and the infection commonly flares up later in life (secondary herpes). People who escape oral herpes in childhood but contract it as adults usually have more severe symptoms.

Unlike the original infection that causes widespread mouth soreness, the later flare-ups usually produce cold sores (fever blisters). These flare-ups are commonly triggered by sunburn on the lips, a cold, fever, food allergy, mouth injury, dental treatment, or anxiety. For a day or two before a blister appears, the person may feel tingling or discomfort (a prodrome) in the spot where the blister will erupt. This sensation is difficult to describe but is easily recognised by a person who has had herpes before. A raw, open sore may appear on the outer lip and then become crusty. Inside the mouth, a sore most commonly appears on the palate. Sores in the mouth start out as small blisters that quickly run together and form a painful, red sore.

Although merely a painful annoyance for most people, flare-ups of oral herpes simplex can be life-threatening in people with immune systems compromised by diseases (such as AIDS), chemotherapy, radiation therapy, or bone marrow transplants. In such people, large, persistent sores in the mouth can interfere with eating, and the spread of the virus to the brain can be fatal.

The aim of treatment for primary herpes is to relieve the pain, so that the person can sleep, eat, and drink normally. The pain may keep a child from eating and drinking altogether, which, combined with a fever, can quickly lead to dehydration. Thus, a child should drink as much liquid as possible. An adult or older child can use a prescribed anesthetic mouthwash such as lidocaine to reduce pain. A mouth rinse containing baking soda may also be soothing.

Treatment for secondary herpes works best when started before the sore erupts - as soon as the person has the sensation that an attack is starting (prodrome). Taking Vitamin C during the prodrome may make a cold sore clear up faster.

Protecting the lips from direct sunlight by wearing a brimmed hat or a lip balm containing sun-screen can reduce the chances of an outbreak of cold sores. Also, a person should avoid activities and foods that are known to cause flare-ups. Anyone who suffers frequent, severe flare-ups may benefit from taking lysine (available at health food stores) for long periods of time.

Acyclovir ointment may reduce the severity of an attack and clear up the sore more quickly. Lip balms like petroleum jelly may keep the lips from cracking and reduce the risk of spreading the virus to neighboring areas. Adults with severe sores should be given antibiotics to prevent bacterial infections, but antibiotics do not affect the virus. For severe cases and for people with immune system deficiencies, acyclovir capsules may be precribed. Corticosteroids aren’t used for herpes simplex because they may allow the infection to spread.

Other Mouth Sores and Growths
Any sore that lasts for two or more weeks should be examined by a dentist or a doctor, especially if it is not painful. Painful sores inside the lip or cheek usually have less serious causes; they can be canker sores or can result from biting the lip or cheek accidentally.

Sores inside the mouth are often white, sometimes with red borders. A mouth sore may form when a person keeps an aspirin between the cheek and gum in a misguided effort to relieve a toothache. Sores in the mouth can be a sign of Behcet’s syndrome, which may also cause sores on the eyes and genitals.

A white, painless sore (chancre) that develops in the mouth or on the lips one to 13 weeks after a person has performed oral sex may be the first stage of syphilis. The sore usually goes away after several weeks. One to four months afterwards, a later sign of untreated syphilis - a white patch (mucous patch) - can also form on the lip or, more commonly, inside the mouth. Both the chancre and the mucous patch are so contagious that even kissing may spread the disease at these stages.

The floor of the mouth is a common area for cancer, particularly in middle-aged and elderly people who drink alcohol and smoke. Various types of cysts may also develop on the floor of the mouth. Often, these cysts are surgically re-moved because they annoy the person.

Large, fluid-filled blisters can form anywhere in the mouth. Commonly, they result from injury, but they may be related to diseases such as pemphigus. Some viral diseases, such as measles, can also cause temporary abnormalities inside the cheeks, especially in children.

Infections that spread from decayed lower teeth to the floor of the mouth can be serious. A very severe infection called Ludwig’s angina can cause severe swelling in the floor of the mouth, even forcing the tongue upward, blocking the airway. When this occurs, emergency measures are needed to keep the person breathing.

When a person bites the inside of the cheek, frequently, or repeatedly injures the inside of the mouth in some other way, an irritation fibroma may grow. This small, firm, painless bump can be removed surgically.

Warts can infect the mouth if a person sucks a wart growing on a finger. A different type of wart (condyloma acuminatum) may also be transmitted through oral sex. A doctor may treat a wart using several methods.

Necrotizing sialometaplasia is a sudden breakdown of the surface of the palate, creating a gaping sore in one or two days. Though the damage is often extensive and can be frightening, necrotizing sialometaplasia is painless. This disorder often follows injury to the area (during a dental procedure, for example) and clears up within two months.

A slow-growing projection of bone (torus) may form in the middle of the palate. This hard growth is both common and harmless. It appears during puberty and persists throughout life. Even a large growth can be left alone unless the mucosa over it gets scraped during eating or the person needs a denture that will cover the area.

Tumors on the palate, both cancerous and non-cancerous, occur most often in those between ages 40 and 60. In the early stages, there are few symptoms, though sometimes a person may notice a swelling in the palate or find that an upper denture has become unstable. Pain develops much later.

In late-stage syphilis, a hole (gumma) may appear in the palate.

Color Changes
If a person has anaemia, the lining of the mouth may be pale instead of the normal healthy reddish pink. If the anemia is treated, the normal color will return.

Newly -discoloured areas in the mouth should be examined by a doctor or dentist because they may be a sign of an adrenal gland disease or cancer (melanoma). White areas can appear anywhere in the mouth and often are simply food debris that can be wiped away. But if the area is raw and painful and it bleeds after wiping, the problem may be a yeast infection (thrush).

White areas in the mouth may also be thickened layers of keratin; these areas are called leukoplakia. A tough protein, keratin normally protects the outermost layer of the skin but also is found in small quantities in the lining of the mouth. Sometimes keratin can build up in the mouth, particularly in people who smoke or use snuff or smokeless tobacco.

Reddened areas in the mouth (erythroplakia) may result when the lining of the mouth thins and blood vessels show through more than usual. White or red areas may be noncancerous (benign), precancerous, or cancerous (malignant). Such areas need to be checked by a dentist or doctor without delay.

A person with a fine, lacy network of white lines (lichen planus) inside the cheeks or on the side of the tongue may also have an itchy skin rash. Lichen planus can cause painful sores, but most of the time the condition causes no discomfort.

Spots that resemble tiny grains of white sand surrounded by a red ring (Koplik’s spots), appearing on the inner cheeks opposite the back teeth, may be the first sign of measles.

Color changes in the palate can come from irritation or infection. The palate of a longtime pipe-smoker has a white, pebbly, hard appearance with many red spots (smoker’s palate). If other sores last for more than two weeks, the person should see a doctor or dentist.

After a person has performed vigorous oral sex on a male partner, small pinhead-sized red spots from broken blood vessels (petechiae) may appear on the palate. These spots disappear within a few days. Such spots can also be a sign of a blood disorder or infectious mononucleosis.

Red, overgrown areas on the palate most often result from poorly fitting dentures or dentures left in the mouth too long. Generally, all removable dental appliances, except for orthodontic retainers, should be taken out at bedtime, cleaned, and placed in a cup of water. In a person with AIDS, purplish patches caused by Kaposi’s sarcoma may appear on the palate. To relieve discomfort and improve the palate’s appearance, a doctor can treat these patches.

Bad Breath
Bad breath (halitosis) can be real or imagined. When real, it’s most often caused by a combination of food lodged between the teeth and poor oral hygiene that results in gum disease and infection. Proper brushing and flossing can eliminate the problem.

Odors from foods that contain volatile oils, such as onions and garlic, pass from the blood-stream into the lungs and are breathed out. Oral hygiene can not remove these odors.

Certain diseases also produce bad breath. Liver failure gives the breath a mousy odour; kidney failure makes the breath smell like urine; and severe, uncontrolled diabetes makes the breath smell like nail polish remover (acetone). A lung abscess causes very severe halitosis.

Salivary Gland Problems
The largest pair of salivary glands lies just behind the angle of the jaw, in front of the ears. Two smaller pairs are deep in the floor of the mouth. Tiny salivary glands are distributed throughout the mouth.

When the flow of saliva is insufficient, the mouth feels dry. Because saliva offers some natural protection against tooth decay, less saliva can lead to more cavities. A dry mouth can result from drinking too little liquid, breathing through the mouth, or taking certain medications or from diseases that affect the salivary glands such as Sjogren’s syndrome. The mouth also dries out somewhat as a person ages. A duct draining a salivary gland can be blocked by an accumulation of calcium called a stone. Such blockage makes saliva back up, causing the gland to swell.

It also may become infected with bacteria. If swelling worsens just before mealtime or particularly when a person is eating a pickle, it surely results from a blocked duct. Here’s why: Anticipating the sour pickle’s taste stimulates saliva flow, but if the duct is blocked, the saliva has no place to go. Sometimes, a dentist can push the stone out by pressing on both sides of the duct. If that fails, a fine-wire-like instrument can be used to pull the stone out. As a last resort, the stone can be removed surgically.

An injury to the lower lip - for instance, from biting -may harm a tiny salivary gland and block the flow of saliva. As a result, the gland may swell and form a small, soft lump (mucocele) that appears bluish. Over a few weeks, the lump usually disappears by itself, but it can easily be removed by dental surgery if it becomes bothersome or frequently recurs.

Mumps, certain bacterial infections, and other diseases can cause the major salivary glands to swell. Swelling also can result from cancerous or noncancerous tumors in the salivary glands; this swelling is usually firmer than that caused by infection. If the tumor is cancerous, the gland may feel stone-hard.

Inflammation and infection of the salivary glands, often caused by a stone blocking the salivary duct, develop more frequently than tumors. Nevertheless, any salivary gland swelling warrants medical attention. To determine the cause of swelling, a dentist or doctor may obtain a sample (biopsy) of salivary gland tissue.

Changes in The Lips
The lips may undergo changes in size, colour, and surface. Some of these changes are harmless - for instance, as people age, their lips may grow thinner. Other changes may indicate medical problems.

Lip Size
An allergic reaction can make the lips swell. The reaction may be caused by sensitivity to certain foods, medications, cosmetics, or airborne irritants. But at least half the time, the cause remains a mystery.

Several other conditions can cause the lips to swell. One inherited condition, angioedema, causes recurrent bouts of swelling. Noninherited conditions - such as erythema multiforme, sun-burn, or trauma - may also cause the lips to swell. Certain types of severe lip enlargement may be reduced with steroid injections. For other types, excess lip tissue may be removed surgically to improve appearance.

With age, the lips may grow thinner. They can be enlarged for cosmetic reasons using collagen injections or injections of fat taken from another part of the body. But lip surgery carries some risk that the smooth border around the outer edges of the lips may become distorted.

Lip Colour and Surface
The sun’s rays or cold, dry weather can make the lips peel. So can an allergic reaction to lipstick, toothpaste, food, or beverages. After the cause of the problem is eliminated, the lips usually return to normal. Sometimes, a doctor may prescribe a corticosteroid ointment to stop the peeling.

Sun damage in particular may make the lips hard and dry, especially the lower lip. Red speckles or a white, filmy look signals damage that increases the chance of subsequent cancer. This type of severe sun damage can be reduced by covering the lips with a lip balm containing sun-screen or by shielding the face from the sun’s harmful rays with a brimmed hat.

Freckles and irregularly shaped brownish areas (melanotic macules) are common around the lips and may last for many years. These marks should not cause concern, but small, scattered, brownish-black spots may be a sign of an inherited intestinal disease in which polyps form in the stomach and intestines (Peutz-Jeghers syndrome).

Kawasaki syndrome can cause dryness and cracking of the lips and reddening of the lining of the mouth.

With inflammation of the lips (cheilitis), the corners of the mouth may become painful, irritated, red, cracked, and scaly. Fungus (thrush) may grow in the corners of the mouth, keeping them sore. Cheilitis may result from a lack of the B vitamin riboflavin in the diet, but this deficiency is rare in the United States.

Vertical skinfolds and irritated skin may develop in the corners of the mouth if complete dentures don’t separate the jaws adequately. Treatment consists of adjusting or replacing the dentures.

A raised area or a sore with hard edges on the lip may be a form of skin cancer.

Changes in The Tongue
Injury is the most common cause of tongue discomfort. The tongue has many nerve endings for pain and touch and is far more sensitive to pain than most other parts of the body. The tongue is frequently bitten accidentally but heals quickly. A sharp, broken filling or tooth can do considerable damage to this delicate tissue.

An overgrowth of the normal projections on the tongue can give it a hairy appearance. These "hairs" may become discolored if a person smokes or chews tobacco, eats certain foods, or has coloured bacteria growing on the tongue. The tongue may also appear hairy after fevers, after antibiotic treatment, or when peroxide mouth-wash is used too often. The top of the tongue may look black if a person takes bismuth preparations for an upset stomach. Brushing the tongue with a toothbrush can get rid of such discoloration.

A mesh of white lines or white curdlike material on the sides of the tongue that can be wiped away and leaves a bleeding surface may indicate thrush.

Redness of the tongue may be a sign of pernicious anemia or a vitamin deficiency. Iron deficiency anemia may also make the tongue look pale and smooth (because of a loss of its normal projections). The first sign of scarlet fever may be a change from the tongue’s normal colour to a strawberry, and then raspberry, colour. Whitish patches, similar to those sometimes found inside the cheeks, may accompany fever, dehydration, the second stage of syphilis, thrush, lichen planus, leukoplakia, or mouth breathing. A smooth red tongue and painful mouth may indicate pellagra, a type of malnutrition caused by a deficiency of niacin in the diet. In geographic tongue, some areas of the tongue are white, and others are red and smooth. The areas of discoloration seem to move around over a period of years or a lifetime. The condition is usually painless, and no treatment is needed.

Although small bumps on both sides of the tongue are usually harmless, a bump on only one side may be cancerous. Unexplained red or white areas, sores, or lumps on the tongue - especially if painless - may be signs of cancer and should be examined by a doctor. Most mouth cancers grow on the sides of the tongue or on the floor of the mouth. Cancer almost never grows on the top of the tongue.

Sores on the tongue can be caused by herpes simplexvirus, tuberculosis, bacterial infection, or early-stage syphilis. Sores can also be caused by allergies or by immune system diseases.

Glossitis is inflammation (redness, pain, swelling) of the tongue. Glossodynia is a burning or painful sensation of the tongue. Usually, it has no characteristic appearance or obvious cause; however, pressure exerted on the teeth by the tongue, an allergic reaction, or irritants such as alcohol, spices, or tobacco may cause this sensation.

Changing brands of toothpaste, mouthwash, or chewing gum may provide relief. Glossodynia is sometimes a sign of emotional upset or mental illness. Low doses of antianxiety medications can help. Regardless of cause, the condition often goes away with time.

Writer is former faculty member of University of Georgia.

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