|Year : 2020 | Volume
| Issue : 1 | Page : 20-25
A study on the pattern of oral cavity involvement in various dermatoses at tertiary care center
Pragya Ashok Nair, Namrata Bhavsar, Dhruv Patel, Jinal Tandel
Department of Dermatology and Venereology, Pramukhswami Medical College, Karamsad, Gujarat, India
|Date of Submission||03-Jan-2020|
|Date of Acceptance||27-Jan-2020|
|Date of Web Publication||16-May-2020|
Dr. Pragya Ashok Nair
Department of Dermatology and Venereology, Pramukhswami Medical College, Karamsad - 388 325, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Oral mucosa is in direct continuity with the skin externally and with the mucosa of oropharynx and nasopharynx internally. Dermatological diseases may involve the mucosa which can be an early predictor of any underlying disease. Materials and Methods: The present study was a cross-sectional observational study, conducted between May and October 2018 after institutional ethical clearance. Patients presenting with dermatoses involving oral cavity alone or with other sites belonging to all age groups and either sexes were included. Cutaneous, oral cavity, and systemic examination was done along with other relevant investigations which were required, and detailed examination was noted in a prestructured pro forma. Results: Out of 52 cases of oral cavity lesions, 55.76% were female and 40.38% were in 19–40 years of age group. Complaints of pain and burning sensation in the oral cavity were present in 48.07% of cases. Majority of patients (55.76%) had lesions over lips and buccal mucosa. Lichen planus was the most common clinical diagnosis seen in 40.38% of cases followed by herpes labialis in 17.30% of cases. Other mucosal sites involved were genital mucosa in 11.53%, followed by conjunctiva in 1.92% of patients. Hypertension was seen in 11.53% of cases. Discussion: Various dermatological disorders of diverse etiologies involve oral cavity. Any symptom or sign in the oral cavity should not be neglected because that can be an early predictor of any underlying disease. Routine intraoral examination should be incorporated in all dermatosis as the oral manifestations can represent preliminary signs or can coexist with the diseases. Conclusions: Thus, prompt diagnosis and management can minimize disease progression and improve the quality of life of an individual. Limitation: Small sample size was the limitation of our study.
Keywords: Dermatosis, herpes simplex, lichen planus, mucosa, oral cavity
|How to cite this article:|
Nair PA, Bhavsar N, Patel D, Tandel J. A study on the pattern of oral cavity involvement in various dermatoses at tertiary care center. Indian J Oral Health Res 2020;6:20-5
|How to cite this URL:|
Nair PA, Bhavsar N, Patel D, Tandel J. A study on the pattern of oral cavity involvement in various dermatoses at tertiary care center. Indian J Oral Health Res [serial online] 2020 [cited 2021 Nov 29];6:20-5. Available from: https://www.ijohr.org/text.asp?2020/6/1/20/284433
| Introduction|| |
Oral mucosa is one of the first barriers to the outside world which encounters various antigens, microorganisms and physical agents, and it in direct continuity with the skin externally and with the mucosa of oropharynx and nasopharynx internally. Dermatologic diseases are represented not only by numerous primary diseases that affect the skin but also by the common cutaneous manifestations of more profound systemic diseases, that may involve the mucosa of the body. Oral mucosal lesions (OMLs) may present to a dermatologist as well as a dental or ENT surgeons. Improving the knowledge about it in both the settings will strengthen and enhance interdisciplinary and multisectoral approach thus will lead to better management of patients with any oral pathology. The study was done with a primary objective to study the pattern of oral cavity involvement in various dermatoses and with a secondary objective to study association of oral manifestations with systemic disorders, involvement of other body sites and mucosal areas.
| Materials and Methods|| |
The present study was a cross sectional observational study, conducted between the month of May and October 2018 at Department of Dermatology, Venereology and Leprosy. Institutional ethical clearance was obtained before the study. Patients attending skin outpatient department with either dermatoses involving oral cavity alone or with other sites belonging to all age groups and either sexes were consecutively selected and included in the study. Informed written consent was taken in vernacular language from all patients. Patient's full history and detailed examination was noted in a prestructured pro forma. The parameters included in pro forma were age, sex, socioeconomical (SE) status, duration of lesion, past history, family history, habits and oral hygiene status. Cutaneous including oral cavity and systemic examination was carried out according to prestructured pro forma and findings were recorded. Relevant routine investigations like Hb, liver function tests, renal function tests, random blood sugar were done as and when required. KOH mount and biopsy were carried out to confirm the diagnosis if required. Patients were given appropriate treatment based on the diagnosis. Descriptive statistics and Chi-square method was used for statistical analysis.
| Results|| |
A total of 52 cases of oral cavity lesions were enrolled in this study. Of these, 29 (55.76%) were female and 23 (44.23%) were male. The most common age group affected was between 19 and 40 years with 21 (40.38%) cases, followed by 41–60 years with 12 (23.07%) cases. Maximum 41 (55.76%) patients belonged to middle SE strata [Table 1].
Majority of the lesions were gradually progressive in 35 (67.30%) cases, followed by rapidly progressive in 17 (32.69%) cases. In this study, 17 (32.69%) patients presented within 10 days of onset of lesion, followed by 16 (30.76%) cases with presentation of more than 6 months of duration [Table 2]. Complaints of pain and burning sensation in the oral cavity were present in 25 (48.07%) cases, whereas difficulty in eating was present in 20 (38.46%) patients. Habit of smoking was present in 9 (17.30%) cases, followed by tobacco chewing in 7 (13.46%) cases [Table 2].
In terms of oral hygiene, 43 (82.69%) cases had fair oral hygiene, whereas 9 (17.31%) cases had poor oral hygiene.
Maximum 29 (55.76%) patients had lesions over the lips and buccal mucosa, followed by tongue in 10 (19.23%) cases. Other mucosal sites involved were genital mucosa in 6 (11.53%) cases, followed by conjunctiva in 1 (1.92%) patient [Table 3].
Lichen planus was the most common clinical diagnosis seen in 21 (40.38%) cases, followed by herpes labialis in 9 (17.30%) cases [Table 4]. Single case of perioral dermatitis, warts, fixed-drug reaction, pellagra, and cheilitis were seen.
Six (11.53%) of them were known cases of hypertension, followed by 5 (9.61%) patients who were diabetic and 3 (5.76%) patients were of thyroid disorder and pulmonary TB each.
Among other body part involvement, upper and lower limbs were affected in 12 (23.07%) cases each, followed by face in 11 (21.15%) cases [Table 5].
| Discussion|| |
Mucocutaneous lesions commonly manifest as vesicular and/or ulcerative lesions. Various etiological factors contribute to the development of these lesions and encompass autoimmune, infectious, neoplastic, hematologic, reactive, nutritional, and idiopathic causes.
Numerous oral pathologies challenge the dermatologist. The oral cavity is vulnerable to a limitless number of environmental insults because of its exposure to the external world. Oral cavity involvement in dermatological disorders deserves special attention, as they may be the presenting clinical feature or the only sign of these disorders, sometimes life-threatening, affecting the quality of life in terms of pain, discomfort, social, and functional limitations. Many systemic conditions appear initially in the oral cavity; thus, prompt diagnosis can help in minimizing disease progression and organ destruction by timely management. Although there are many studies reported on individual lesions, there are very few studies that have dealt with a group of mucocutaneous lesions together. Moreover, there is no universally accepted classification of these mucocutaneous lesions.
|Figure 1: Reticular pattern of lichen planus with hyperpigmentation over right buccal mucosa|
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In our study with 52 cases, maximum 40.38% of cases were in 19–40 years of age group and females were affected in 55.76% of cases. Most of the cases (55.76%) were from middle SE status. Babu et al. in their study found that the prevalence of OMLs in patients with dermatological disease was 1.82%, with female predilection (54.3%) and mean age range of patients was 1–92 years, with the median age of 38 years. One possible explanation for female predilection was that they may be genetically more susceptible to develop the disease. Oral diseases could also be attributed to poor hygiene, low economic status, and health consciousness. Association has been reported between oral mucosal disorders and aging. Various causes leading to changes in the oral mucosa due to aging are infections, nutritional factors, metabolic changes, medication, prosthetic use, and habits of alcohol or tobacco.
Patients having dermatoses affecting oral mucosa present with different types of oral symptoms such as oral pain, burning sensation, bleeding, swelling, change of color, ulcers, erosions, crusting fissuring, or difficulty in eating. In our study, the most common complaint with which patients presented was difficulty in eating in 38.46%, followed by burning in 28.84% and pain in 19.23%. Less than 10 days of duration since presentation was seen in 32.69% of cases, whereas more than 6 months of duration was observed in 30.76% of cases.
A recent study has reported that the state of Manipur ranks 5th in consumption of tobacco among all the states of India according to the Global Adult Tobacco Survey. Predominance of malignant lesions, particularly squamous cell carcinoma, was the most common as 54% of the total population (66.6% men and 41.8% women) are using tobacco products in general, whereas 44% of the population is into smokeless or chewing tobacco products such as Gutka, Khaini, and Zarda, which are responsible for the high incidence of oral cancer cases in this tiny hilly state. In our study, no specific habits were elicited in 69.23% of cases, whereas 13.46% had history of tobacco chewing followed by 9.6% with cigarette smoking. Because the reported prevalence of addiction among general population is different from that of hilly region, we could not come across any case of oral malignancy presenting to us.
Regarding the distribution of mucosal lesions in the oral cavity, different sites in oral cavity show predilection for different types of lesions. Different interactions between genetic and environmental factors in the oral mucosa lead to the formation of different lesions. The site of the lesion is also an important etiological factor. Cheek/buccal mucosa (32.2%) was the most commonly affected site, followed by vestibular region (25.6%), tongue (19.3%), labial mucosa (10.1%), and palate (7.8%), whereas gingiva (3.1%) and the floor of the mouth (1.0%) were the least involved in a study by Kamble et al. They found that tobacco-related and premalignant and malignant disorders were the most prevalent occurring on buccal mucosa.
Ali et al. in their study reported 49.1% of lesions on buccal mucosa, whereas Mansour Ghanaei et al. and Patil et al. reported tongue and hard palate as the most common sites of occurrence of OMLs, respectively. Lips and bilateral buccal mucosa were affected in 55.76% of cases each in our study, followed by tongue in 19.23% and palate in 15.38% of cases.
In our study, with total 52 patients, 40.38% had lichen planus, 17.30% had herpes labialis, 6.9% had aphthae [Figure 7], and 5.76% had candidiasis and mucocele [Figure 8] each, whereas in a study of 60 adults by Ramírez-Amador et al., the most frequent oral conditions observed were pemphigus vulgaris (18.3%), lichen planus (8.3%), candidiasis (8.3%), recurrent aphthous ulcers (6.7%), herpetic lesions (6.7%), xerostomia (6.7%), and traumatic lesions (6.7%).
Lichen planus was first described by Wilson in 1869 and is thought to affect 0.5%–1% of the world's population. The condition can present as white lesions characterized by linear striations. About half of the patients with skin lesions have oral lesions, whereas about 25% present with oral lesions alone. It is seen clinically as reticular, papular, plaque-like, erosive, atrophic, or bullous types. Intraorally, the buccal mucosa, tongue, and the gingiva are commonly involved, although other sites may be rarely affected.
Our study showed oral lichen planus in 21 (40.38%) cases, of which 12 (57.1%) presented with erosions followed by 5 (23.8%) cases with pigmentation. Erosive lesions were observed in 66.67% of patients and reticular pattern in 33.33% of patients in the study of 12 (12.77%) cases of Lichen planus (LP).
Most of the dermatological diseases are confined to the stratified squamous epithelium and thus may involve skin, oral, and other mucosae, such as the nasal, ocular, and genital mucosa. Some patients present with oral lesions only, whereas in others, there may be involvement of skin and other mucous membranes. Genital mucosa was affected in 11.53% followed by conjunctiva in 1.92% of patients in our study. Other body part involvement was seen in 23.07% of cases each of upper and lower limbs, followed by face in 21.15% of cases.
Hypertension was seen in 11.53% of cases followed by 9.61% of patients who were diabetic and 5.76% of patients were of thyroid disorder and pulmonary TB each. There is an association between hypertension and gingival/periodontal pathology. There are reported group of people showing increased incidence of dental caries, which may be correlated with the hypo salivation in patients who were on anti-hypertensive therapy. Facial nerve paralysis was associated with the malignant hypertension. Gingival enlargement is seen in patients taking anti-hypertensive medication especially calcium channel blockers. The most common drugs causing this side effect are the angiotensin-converting enzyme inhibitor drugs especially the captopril.
Knowledge and understanding of diabetes and periodontal health is low among diabetic patients, and most are unaware of the oral health complications and of the need for proper preventive care. Patients may have a higher prevalence of mucosal disorders possibly associated with chronic immunosuppression, delayed healing, and/or salivary hypofunction. These alterations include: Oral fungal infections such as oral candidiasis, fissured tongue, irritation fibroma, traumatic ulcers and lichen planus. Periodontal disease, burning mouth syndrome, dental caries, periapical lesions, xerostomia and taste disturbance were more prevalent among diabetic patients.
Small sample size was the limitation in our study. We intend to continue this study over a period of time to see the correlation of oral cavity lesions with other systemic diseases and also to evaluate the quality of life in such patients.
| Conclusions|| |
Dermatoses constitute an area of great scientific and odontological interest, considering that oral lesions can precede many dermatosis for long periods of time, being, sometimes, the only signs of the disease. Thus, dermatologist and dental surgeon should know about the importance of an interdisciplinary approach for diagnosis and management diseases, thus to improve the quality of life of patients.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]