Oral Manifestations in Hematologic Diseases
Though oral manifestations in hematologic disorders typically appear after disease progression, bleeding from or texture or color changes of the oral mucosa can be the presenting symptom.
The prominent oral signs of thrombocytopenic purpura include widespread capillary oozing from the gingival margin of all the teeth. From adherent clots a fetid odor may emanate. Spontaneous hemorrhages of greater severity may arise, especially in areas of inflammation. Petechial spots also appear as purplish red patches on the lips and other mucosa. Erosion and ulcerations are seen only in debilitated, advanced cases.
In the acute phases of agranulocytosis, ulcerative lesions of the mouth and pharynx, accompanied by dysphagia, are frequently seen and may be the initial presentation of the disease. The disease may be acute or chronic (cyclic and recurrent); it may be primary or a sequel of a systemic infection, hormonal dysfunction, or idiosyncratic drug reaction. Because the myeloid cells are arrested in maturation, the mucous membranes are subject to rapid invasion of bacteria. With sudden onset the oral mucosa is involved by necrotic ulcers, which show little or no surrounding erythema. All types of gingivitis and stomatitis with gangrenous areas have been observed in the pharynx, tonsils, and hard palate. Malodourous breath and excessive salivation can be seen in severe presentations.
The frequency of oral lesions in chronic leukemia is appreciable and varies considerably in severity. Beginning insidiously, pallor of the mucous membrane may be followed by soft hypertrophy and ulceration of the gingivae, with spontaneous bleeding, and fusospirochetal infection in necrotic papillae, producing a foul odor. A blackish, pseudomembranous exudate may cover the tongue, gingivae, and fauces. Enlargement of the gingiva begins usually in the lower interior region. Teeth may loosen, and pulpal liquefaction or abscessed pulps with odontalgia may appear. In the lymphatic form the lymphoid structures of the floor of the mouth and tongue, together with the submandibular lymph nodes, may become enlarged. In general, the acute leukemias produce symptoms more severe than the chronic variants.
In polycythemia vera (erythremia, or Vaquez disease), the skin and oral tissues show a vivid purplish red discoloration. Superficial vessels are distended, and the gingivae are swollen and bleed frequently. Petechiae are often noted.
In pernicious anemia, the oral mucosa accepts a pale or greenish yellow color, except for the tongue, which is bright red. The latter is in a state of chronic inflammation, characterized by irregular, fiery-red patches resembling a burn, near the tip and the lateral margins (Hunter or Moeller glossitis). A sensation of burning, itching, or stinging is always present, and patients complain of paroxysmal pain or tenderness to food intake or to cold and hot fluids. These symptoms appear in the early stages of pernicious anemia, sometimes prior to or during periods of hematologic remission. The later stages of the oral manifestations, including the gradual loss of the papillae and progressive atrophy of the tongue, are rarely encountered. Tongue manifestations of the disease must be distinguished from other forms of glossodynia and glossopyrosis, from allergic lesions, from the lingual anifestations in syphilis, and from geographic tongue.