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.
