Diseases of the mucous membranes are usually more
difficult to diagnose than skin diseases. This is partly due to
modification of the primary lesion either by the continuous mouth
moisture or by different ingredients in the mouth or those reaching
the mouth from outside, either through food or mouthwashes or
Mucous patches of the mouth should not be mixed
with milk patches in babies due to accumulation of milk on the inner
sides of the buccal mucosa.
Vesicles or bullae leave a grayish erosion after
ulceration, while papular lesions which may be significant on the
skin surface become difficult to differentiate in the mucous
membranes of the mouth.
Usually mouth lesions are whitish, macerated and
soft. Different physiological or pathological factors may affect the
buccal and tongue mucosa.
Some of the diseases of mucous membrane, which
accompany skin diseases were already discussed in the previous chapters.
Skin diseases associated with mucous membrane
Viral diseases such as Koplik‘s
spots of measles and herpes simplex.
DISEASES OF THE LIPS
Cheilitis is caused by different factors, which
may be allergic or inflammatory.
The lower lip is the
most common affected.
The lesion may be localized in the lip or may
extend to the adjacent mucocutaneous or even to the skin of the
Fig. 372 Cheilitis &Glossitis
Etiology of Cheilitis
Candidiasis is the commonest infections that
affect babies and young children. The infection may be severe
interfering with feeding and may be extensive affecting the whole
mucous membranes of the gastro-intestinal tract.
Bacterial and viral infections are also common.
Fig. 372. Chronic Cheilitis
Fig. 373. Chronic Actinic Cheilitis
Fig. 374. Cheilitis (Contact dermatitis)
Local hypersensitivity to antibiotics lozenges.
Mouth washes mainly fluorinated toothpaste.
Contact dermatitis from certain food stuffs such
as lemon, orange, tomato juices and certain food additives.
In older age groups cosmetics as lip sticks.
Photosensitivity causes chronic cheilitis. The
lips become scaly, fissured and swollen and may lead to leucoplakia
that is precancerous.
Fig. 375. Allergic Cheilitis
the openings of the
mucous ducts become patulous, where mucous drippling mainly during
sleeping which on drying causes inflammation of the lip. The mucous
glands are enlarged. The condition may be precancerous.
Fig. 377. Actinic chilitis & Leukplakia
Angular cheilitis. Fissuring of the
which become painful and bleed. Dental caries may be considered as
an important predisposing factor.
Cheilitis associated with other diseases and
Leucoplakia affects mainly the lower lips.
Vitamin deficiency mainly riboflavin.
Fig.378b. Chronic ulcerative cheilitis
|Drug reaction: Phenolphthalein causes slate blue
hyper pigmentation of the lips. Other drugs such as sulfa may cause
fixed drug reaction.
Fig. 379. Cheilitis( Drug
Fig. 380. Hairy tongue
GLOSSITIS AND STOMATITIS
The different factors, which may lead to
glossitis and stomatitis include the following:
Lack of proper hygiene of the mouth
Vitamin deficiency mainly vitamin C and B
The ulcers are punched out, covered by dirty
white pseudomembrane covering the mucous membranes of the tongue,
lips, buccal mucosa, tonsils, and the pharynx and may involve the
whole respiratory tract mucosa.
Children and young age groups are commonly
infected with herpes virus leading to herpetic lesions of the mouth,
tongue and lips. Painful ulcerations are common which may interfere
with feeding and increased salivation.
Gangrenous stomatitis occurs in children with
poor nutrition, lowered resistance and improper dental hygiene. The
lesions manifest with mucosal ulcerations of the mouth and
genitalia, which rapidly becomes gangrenous. The condition may
extend to the adjacent tissues and may be extensive involving the
bones and may be fatal.
Proper hygiene of the mouth and correction of the
Mild mouth wash antiseptics.
Tetracycline suspension orally. This should be
kept for few minutes in the mouth to have a local effect.
Care should be taking when treating babies or
young children with Tetracyclines. Another oral antibiotic
suspension such as Zithromax can be substituted for young age
RECCURENT APHTHUS STOMATITIS
The lesions are recurrent, tender, small shallow
erosions surrounded by an erythematous zone affecting the buccal
mucosa. These may interfere with feeding and speech. It is believed
that streptococcus infection may be the causative of recurrent
Fig. 381b. Aphthous stomatitis
The lesions may appear also on the genitalia and
has to be differentiated from other diseases of these areas such as
viral, fungal and Behcet‘s disease.
Recurrence of lesions may be predisposed by:
Lower body resistance.
Emotional and psychic trauma.
Trauma: self-biting, hard, harsh toothbrushes and
other tools used for cleaning of the mouth and teeth.
Allergy to certain types of foods and additives
such as tartrazine.
Infections such as herpes virus infections may
predispose to recurrence.
It is usually not easy to differentiate such
condition from other diseases affecting the buccal mucosa:
Herpes simplex infections
Mucous patches of syphilis
Vitamin deficiency mainly scurvy and pellagra.
Treatment of the predisposing factors.
General hygiene of the mouth and teeth.
Avoid strong mouth antiseptics
Avoid mouthwashes containing allergenic
Avoid contact with certain foods such as citrus,
spicy and harsh foodstuffs.
Different local applications were used with
Tetracycline suspension especially if kept in the
mouth few minuets before swallowing, may give good results in some
Xylocaine viscous 2 % (Lidocaine) may be used
especially in painful conditions few minuets before feeding for
infants and children.
Local topical steroid (Kenalog orabase) or
prednisone lozenges may be used if viral or bacterial infections are
Lesions of the inner sides of lips can be touched
gently by swab moistened with salicylic acid 3% and lactic acid 4 %
prepared in flexible collodion .
RECURRENT HERPES SIMPLEX OF THE MOUTH
Recurrent herpetic lesions of the mouth are a
real problem especially in young age. Herpes simplex virus causes
The lesions appear as small grouped vesicles
surrounded by an erythematous zone which later rupture, leaving
shallow ulcerations with a red base.
Fig. 382. Herpes Labialis
Typical clinical picture, which includes painful,
grouped vesicles or ulcerations on an erythematous base.
Tzank test: scrapings from the base of the ulcers
stained with Wright‘s stain show the
multinucleated giant cells.
Immunoflorecent tests are diagnostic.
This is a viral disease caused by Coxsackie virus
affecting mainly children especially in summer time.
Modes of Infection
It is believed that certain species of flies can
transmit the disease.
Direct infection from infected individuals.
Fever, which may be high, headache, sore throat,
anorexia and dysphagia.
Skin lesions may appear in different forms
Mucous membranes manifestations:
Minute papules, vesicles and ulcers surrounded by
an erythematous areola appear on the mucous membrane, which are
characteristically apparent on the pharynx, tonsils and throat .The
lesions appear usually in small groups, which may coalesce and
The ulcers are shallow, grayish yellow and
(Aphtosis, occulo-oral genital syndrome)
Behcet‘s syndrome is
Skin lesions may be:
Papulo -pustules, subungual abscess and pyoderma.
Cerebellar syndrome resembling multiple
Mucous membrane manifestations
Mucous membrane lesions are single or multiple
with dirty grayish base surrounded by red halo. Mucous membrane of
the buccal mucosa, palate, lips and tongue may be involved.
Ulcerations may leave scarring
The ulcers are tender and cause severe pain that
may interfere with eating, speech and gives a foul smell of the
Ulceration of the scrotum, penis and urethra.
Ulceration of labia, vagina and cervix.
Ulceration of the anal area, crural areas and
perineum. The ulcers are extremely painful.
Healing of ulcers may lead to scarring and
Severe peri-orbital pain and photophobia.
Conjunctivitis, hypopyon, iritis, iridocyclitis.
Blindness may be the end stage due to optic nerve
This syndrome occurs chiefly in young males and
may affect children.
This syndrome is characterized by triad
Eye: Conjunctivitis, iritis, and keratitis.
Urethritis: Non-bacterial, painful and bloody
urination and pyuria. Cystitis, prostatitis and seminal vesiculitis
Arthritis: Swollen and tender joints.
General manifestations: Fever, weakness and
Skin manifestations: Multiple small,
yellowish vesicles and ulcers on the palms and soles. Lesions of the
palms and soles become thickly hyperkeratotic and crusted resembling
Mucous membrane manifestations: Mucous
membrane lesions are superficial ulceration of the genitalia and
mucous membranes of pharynx and hard palate.
Cardiac manifestations: are rare
manifestations of the disease. Endocarditis, myocarditis,
pericarditis and aortic insufficiency are uncommon manifestations.
DRYNESS OF THE MOUTH
Dryness of the mouth may be due to different
local or systemic factors.
anticholinergic or sympathomimetic activity is the most common cause
of dryness of the mouth. Atropine, belladonna, panthene,
dimenhydrinate (Drammamine), antidepressants, Phenothiazines and
Race is the
most important cause of oral pigmentation.
disease is the association of circumoral and sometimes intra oral
melanosis with small intestinal polyposis.
cause a grayish-brown oral hyperpigmentation.
Gold salts may
cause purplish gingival discoloration.
may cause oral white patches.
antimalarial drugs such as chloroquine, quinacrine and
hydroxychloroquine drugs may cause hyperpigmentation of the mucous
Mepacrine: causes yellow discoloration of the
buccal mucous membranes.
Amodiaquine or quinidine causes blue-black
ACTH therapy: may cause brown pigmentation.
Busulphan, causes blue line of gums
Fig. 383. Oral Hyperpigmentation
Chloropromazine: may cause purple or yellowish
brown pigmentation of the skin and mucous membranes.
Minocycline: may produce blue-gray gingival
This syndrome is characterized by pigmentation
and intestinal polyposis.
The pigmented macules may be present at birth and
usually appear in infancy and early childhood, but may develop later
in life. The oral mucous membrane is almost constantly involved. The
oral pigmentation is usually permanent, but the macules on the lips
and skin may fade after puberty. Rarely, the nails may be pigmented,
diffusely or in longitudinal bands.
Mucous membrane manifestations
Round, oval or irregular patches of brown or
almost black pigmentation 1-5 mm in diameter are irregularly
distributed over the buccal mucosa, the gums, the hard palate and
the lips, especially the lower. Mucosal and facial pigmentation
without evidence of intestinal polyposis may be found in relatives.
Intestinal polyposis may cause repeated bouts of abdominal colic,
vomiting, intussusceptions, malignancy and rectal bleeding.
The pigmented macules on the face are smaller,
dark often under 1 mm and are concentrated around the nose
Larger macules may be present on the hands, feet,
palms and soles.
Abdominal pain is usually caused by intestinal
Rectal bleeding is common and haematemesis may
occur with gastric or duodenal polyps.
WHITE PATCHES OF THE BUCCAL MUCOSA
Different factors may cause white patches of the
Infections: of the buccal mucosa such as
herpetic lesions may cause white patches surrounded by an
Thrush: produces oral white patches.
Mucous patches of syphilis: Grayish white
painful patches, slightly elevated and surrounded by an erythematous
area. The buccal lesions occur most frequently on the inner lower
lips, tongue and other parts of the mouth. The mucous patches are
highly contagious and serological tests of syphilis are positive.
Benign mucosal pemphigoid
Hairy leucoplakia: is a white lesion that
appears on the tongue and whitish flaky pseudomembrane on an
Culture will reveal the causative organism.
Leucoplakia: lichenoides lesions are
associated with various drugs, liver disease or graft-versus-host
White sponge nevus: white, thickened spongy
patches appear on the inner sides of lips, cheeks and sides of the
Carcinoma may present as a white lesion.
Dyskeratosis congenita causes white patches
REDNESS OF THE BUCCAL MUCOSA
marginal gingivitis is the usual cause of gingival redness.
sides of the tongue are erythematous and soggy which may become
The mucous membrane of the tongue and buccal cavity is red.
conditions of the buccal mucosa due to mouth washes, chewing gums,
toothpaste and others.
neoplasms such as carcinoma.
may be a manifestation of hereditary hemorrhagic telangiectasia or
systemic sclerosis or may follow radiotherapy.
sarcoma may present as a red, purple, brown or bluish macule or
Iron, folate or
vitamin B12 defficiency may produce the red tongue.
tongue may also present with red patches.
Cacogeusia (an unpleasant taste in the mouth) and
halitosis are caused by different factors mainly:
Oral or nasal
disorders such as suppurative respiratory infections, hepatic or
renal failure, diabetic ketosis or gastrointestinal disease.
LOSS OF SENSE OF TASTE
Drugs such as
disease such as cerebral metastases, and lesions affecting the
chorda tympani may be responsible for loss of the sense of taste.
commonly produces an apparent loss of the sense of taste.
Abraham-Inpijn L. Oral and otal
manifestations as the primary symptoms in Wegener‘s
granulomatosis. J Head Neck Pathol 1983; 2: 20-2.
Basu MK, Asquith P. Oral manifestations of
inflammatory bowel disease. Clin Gastroenterol 1980; 9 (2): 307.
Browning S, Hislop S, Scully C et al. The
association between burning mouth syndrome and psychosocial
disorders. Oral Surg 1987; 64: 171-4.
Budzt-Jorgensen E. Oral mucosal lesions
associated with the wearing of removable dentures. J Oral Pathol
1981; 10: 65-80.
Berger RS, Mandel EB, Hayes TJ et al.
Minocycline staining of the oral cavity. J Am Acad Dermatol 1989;
Cotaldo E. Solar cheilitis. J Dermatol Surg
Oncol 1981; 7: 289-95.
Dorey JL, Blasberg B, MacEntee MI et al.
Oral mucosal disorders in denture wearers. J Pros Dent 1985; 53:
Hartman KS. Histiocytosis X. A review of 114
cases with oral involvement. Oral Surg 1980; 49: 38-54.
Hietanen J. Clinical and cytological
features of oral pemphigus. Acta Odontol Scand 1982; 40: 403-14.
Laskaris GC, Sklavounou A, Stratigos J.
Bullous pemphigoid, cicatricial pemphigoid and pemphigus vulgaris:
a comparative clinical survey of 287 cases. Oral Surg 1982; 54:
Lamey PJ, Lewis MAO, Rees TD et al.
Sensitivity reaction to the cinnamaldehyde component of
toothpaste. Br Dent J 1990; 168: 115-18.
James J, Ferguson MM, Forsythia A et al.
Oral lichenoid reactions related to mercury sensitivity. Br J Oral
Maxillofac Surg 1987; 25: 474-80.
Kerr DA, McClarchey KD, Regezi JA. Allergic
gingivostomatitis (due to gum chewing). J Periodontol 1971; 42;
Lamey PJ, Carmichael F, Scully C. Oral
pigmentation, Addison‘s disease and
results of screening. Br Dent J 1985; 158: 297-305.
Marks R, Radden BG. Geographic tongue: a
clinicopathological review. Aust J Dermatol 1981; 22: 75-9.
Manton S, Scully C. Mucous membrane
pemphigoid. Oral Surg 1988; 66: 37-40.
Nisengard RJ, Nieders M. Desquamative
lesions of the gingiva. J Periodontol 1981; 52: 500-10.
Picascia DD, Robinson JK. et al. Actinic
cheilitis, a review of the aetiology, differential diagnosis and
treatment. J Am Acad Dermatol 1987; 17: 255-64.
Schoenfeld RJ, Schoenfeld FI. Angular
cheilitis. Cutis 1977; 19: 213-16.
Scully C. Chronic atrophic candidosis
(leading article). Lancet 1986; ii: 437-8.
Scully C. Orofacial manifestations in
chronic granulomatous disease of childhood. Oral Surg 1981; 51:
Scully C, Porter SR. The mouth and skin.
In: Verbov JL, ed. New Clinical Applications in Dermatology:
Relationships in Dermatology Vol 8. Lancaster: MTP Press, 1988:
Touyz LZG, Peters E. Candidal infection of
the tongue with non-specific inflammation of the palate. Oral Surg
1987; 63: 304-8.
Theaker JM, Porter SR, Fleming KA. Oral
epithelial dysplasia in vitamin B12 deficiency. Oral Surg 1989;
Walker DM, Stafford DG, Huggett R et al.
The treatment of denture-induced stomatitis. Br Dent J 1981; 151:
Winer LH. Black hairy tongue. Arch Derm 1958; 77: 97-103.