Lip Diseases
Content
Lips diseases and its management
Classification of Lip Disorders
Developmental
y y y y y y y y y y y y y
Congenital lip pits Commissural lip pits Double lip Cleft lip and cleft palate Glandular cheilitis Granulomatous cheilitis Angular cheilitis Contact cheilitis Eczematous cheilitis Actinic cheilitis Exfoliative cheilitis Plasma cell cheilitis Cheilitis due to drugs
Cheilitis
Carcinoma of lip Miscellaneous
y Chapping of lips y Actinic elastosis y Lip ulcers due to caliber persistent artery
Development of Lip
In the sixth week of intrauterine life, two medial nasal processes merge in midline. This will form intermaxillary segment which will give rise to center of upper lip. In adult, center of upper lip forms philtrum. Philtrum is bound laterally by two vertical ridges under the nostril. Lateral part of upper lip fissure presents in maxillary process. This may lead to cleft formation if it is not covered by epithelium and fused. Upper lip is thus formed from one-third medial nasal process and two-third maxillary process.
Anatomy
y Mucocutaneous junction²lips are fleshy folds lined by skin externally and mucous membrane
internally. The upper and lower lips close along the red margin which represents the mucocutaneous junction. y Surface ²the lips are covered with skin on the external surface and mucous membrane on the inner surface, which has profuse salivary glands. y Extent² the lip extends from the lower end of the nose to the upper end of the chin.
y Nasolabial groove² the upper lip borders onto the nose and is separated from the cheek by a
variably deep groove called as nasolabial groove.
y Lower lip²the lower lip is separated from the chin proper by a more or less sharp and deep
groove that is convex superiorly called as labiomental groove.
y Oral cornmissure²it is the angle where the upper and lower lip meets. y Philtruni ² the upper lip includes the philtrum, a midline depression, which can be followed to
the nose.
y Content²each lip mainly consists of bundles of striated muscle, orbicularis oris, superficial
fascia and submucosa. The skin of the lip contains sweat glands, hair and sebaceous gland. The dermal papillae are numerous, with rich capillary supply, which produce reddish pink color of the lips. y Vermilion zone²it is the transitional zone between the skin and the mucous membrane. The vermilion zone contains no hair or sweat glands and contains a few sebaceous glands. In some people, sebaceous glands may be seen as creamy yellow dots. Fordyce's spots along the border between vermilion border and the oral mucosa can also occur. y Blood supply of lips²submental artery to the lower lip and inferior and superior labial arteries to the upper lip.
y y y
Venous drainage²anterior facial vein and its branches corresponding to the facial artery provides the venous drainage of lips. Lymphatic drainage²from central part of lower lip, lymphatics drain to the submental node and rest of the lip to submandibular nodes. Nerve supply²mental nerve and superior labial nerve.
Develo pm enta l Diso rd ers o f Lip
Congenital Lip Pits
It is also called as 'paramedian lip pit or congenital fistula'.
Etiopathogenesis
y y y
Hereditary²it is inherited as an autosomal dominant trait. Notching of lip²there is notching of lips at an early stage of development with fixation of tissues at the base of the notch. Incomplete union ²it may occur due to failure of complete union of embryonic sulci of the lip, resulting in persistent lateral sulci on the embryonic mandibular arch.
Clinical Features
y
Sex predilection²it is more commonly seen in females. y Site²it is common on vermilion border of either side of midline. It is most commonly seen
y y y y
on lower lip. Lip pits or fistula is unilateral or bilateral depression. Size ²it may be upto 3-4 mm in diameter and may extend as deep as 2 cm. Appearance²lips,some times appear swollen, accentuating the appearance of the pit. Palpation²on palpation, sparse mucus secretion may be visible from the base of the lippit which occurs due to involvement of underlying minor salivary glands. Syndromes associated²congenital lip pits may occur in association with Van der Woude's syndrome (cleft lip, cleft palate and congenital lip pits). Another syndrome is associated with it is popliteal pterygium syndrome which also includes Popliteal webbing (pterygia), cleft lip / cleft palate, genital abnormalities and congenital bands connecting the upper and lower jaws (syngnathia).
Diagnosis
Clinical diagnosis²unilateral or bilateral depression on vermilion border of lip will diagnose these conditions.
Management
y Surgical excision²it is done for cosmetic purpose.
Commissural Pits
Commissural lip pits are mucosal invagination occurring at the vermilion border of lip.
Pathogenesis
They occur due to failure of normal fusion of embryonal maxillary and mandibular processes. It is transmitted as autosomal dominant transmission.
Clinical Features
y y y Sex distribution²it is more common amongst males and black people are affected more than white people. Site²if it is unilateral, it occurs on the right side of the lip. Appearance ² commissural pit appears as aunilateral or bilateral pit at the corner of the mouth on the vermilion surface. y Size²size ranges from a shallow dimple to a tract measuring 4 mm in length and tissue slightly raisedabove the opening. y Palpation²in squeezing of the lip pit, small amount of saliva can come out. Congenital lip pit²it may be associated with facial or palatal cleft.
Differential Diagnosis
y
Management
y Surgical excision²it is indicated only in severe condition, where salivary secretion excessive and
secondary infection can occur.
Double Lip
It is an anomaly characterized by a fold of excess tissue on the inner mucosal surface of the lip. It may be congenital or acquired because of trauma to the lip.
Pathogenesis
It occurs in 2nd or 3rd week of gestation due to persistent of the sulcus between the pars glabrosa and pars villosa of the lip. Clinical Features y Site²it usually occurs on inner aspect of upper lip. y Cupid bow appearance²when upper lip is tensed, double lip resembles 'cupid bow'. y Syndromes associated²it is associated with Ascher's syndrome which consists of double lip, blepharochalasis (it is drooping of the tissue between eyebrow and edge of the upper eyelid so that it hangs loosely over the margin of the lid) and non-toxic thyroid enlargement.
Diagnosis
y Clinical diagnosis²cupid bow appearance is typical.
Management
y Surgical excision.
Cleft Lip and Cleft Palate
It occurs along many planes as a result of fault or defect in the development.
Definition
Cleft Lip²it is a birth defect that results in a unilateral or bilateral opening in the upper lip between the mouth and the nose. It is also called as harelip. It is wedge shaped defect resulting from failure of two parts of the lip to fuse into a single structure. Cleft palate²cleft palate is a birth defect characterized by an opening in the roof of the mouth caused by a lack of t:ssue development.
Development of Cleft
In.general, patients with clefts have a deficiency of tissue and not merely a displacement of normal tissue. y Unilateral cleft lip²Acleft lip occurs when an epithelial bridge fails, due to lack of mesodermal delivery and its proliferation from the maxillary and nasal processes. It results from failure of maxillary process on one side to meet and fuse with medial nasal process. This will lead into the division of lip into medial and lateral part. It again occurs due to absence or deficiency of mesodermal masses or their failure to penetrate the ectodermal grooves lead to breakdown of the ectoderm, causing cleft formation. In unilateral cleft lip, the floor of the nose communicates freely with the oral cavity, maxilla on the cleft side is hypoplastic, columella is displaced to the normal side and the nasal ala on the cleft side is laterally, posteriorly and inferiorly displaced. y Bilateral cleft lip²in this, medial mass interposed between two maxillary processes grows down from lateral areas form above the maxillary process. In bilateral cleft lip, the central portion of
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the alveolar arch is rotated anteriorly and superiorly. Median cleft lip ²it results from partial and complete failure of the medial nasal process to merge. The cleft of lip occurs earlier and inhibits tongue migration, which maw then prevent horizontal alignment and fusion of the palatal shelves. Median cleft of mandibular lip ²it occurs due to failure of mesenchymal masses of mandibular process to merge together at 5 weeks of intrauterine life. Cleft of primery palate ± clefts of primary palate occur anterior to the incisive foramen. Clefts of secondary palate are due to lack of fusion of the palatal shelves and always occurs posterior to the incisive foramen. Cleft palate occurs due to disturbances in normal fusion of palatal shelves. This may occur due to failure to unite due to lack of force, interference by the tongue or a disparity in the size of parts involved. It results from failure of the lateral palatine process to meet and fuse with median palatine process. Inpalatal clefts, the muscles of soft palate are hypoplastic and insert in the posterior margin of the remaining hard palate rather than the midline raphe. Cleft of secondary palate²The secondary palate closes one week later in females, which may explain why isolated clefts of the secondary palate are more common in females. These are clefts posterior to the incisive foramen. They result of partial or complete failure lateral palatine process to meet, fuse and merge with each other. Cleft of primary and secondary palate²they result of failure of growth or lack of fusion of three palatine processes with nasal septum and each other.
Etiology
y Hereditary²it is one of most important factors to be considered in the etiology. y Genetic²the main possible mode of transmission is by a single mutant gene; producing a large
y y y y y y
effect or by number of genes (polygenic inheritance), each producing small effects which together create this condition. Nutritional disturbances²riboflavin deficient diet can produce cleft palate and cleft lip. Developmental²physiological, emotional and traumatic stress during developmental stages. Defective vascular supply²defective vascular supply to the area may lead to ischemia which in turn may lead to cleft formation. Mechanical disturbances²here, the size of tongue may prevent union of the parts. Infection²infection and lack of inherent developmental force. Miscellaneous²steroid therapy during pregnancy, alcohol, toxins in the circulation.
Classification
First Classification y Unilateral incomplete. y Unilateral complete. y Bilateral incomplete. y Bilateral complete. Second by veau¶s y Cleft lip y Class I²A unilateral notching of vermilion border and it is not extending into the lip. y Class II² a unilateral notching of vermilion with cleft extending into lip but not including the floor of the nose. y Class III²a unilateral cleft of vermilion extending into the floor of the nose. y Class IV²any bilateral cleft of the lip, whether this is complete or incomplete.
y
Cleft palate Class I²involving only soft palate. Class II²involving soft and hard palate but not alveolus. Class Ill²involving soft and hard palate and alveolus of one side. Class IV²involving both the soft and hard palate and alveolus on both sides of the premaxilla. Third by Kernahan and Stark y Unilateral incomplete cleft of the primary palate. y Complete cleft of primary palate ending at the incisive foramen. y Bilateral complete cleft of the primary palate. y Incomplete isolated cleft of the secondary palate. y Complete cleft of the secondary palate²soft and hard palate. y Unilateral complete cleft of the primary and secondary palate. y Bilateral complete cleft of the primary and secondary palate. y Incomplete cleft of the primary palate and incomplete cleft of the secondary palate.
y o y
General y Sex²it is more common in males as compared to females. But incidence of isolated cleft palate is seen more in females. y Site²it is more frequently seen on the left side than on the right side. Left side is involved in 70% of the cases. Cleft of mandibular lip or jaws are rare. y Appearance ²a typical patient with cleft palate, cleft lip and ridge exhibits a large defect with a direct opening in the nasal cavity. y Teeth² disturbances in the dental structures are seen in this region so that teeth may be missing, deformed, displaced or divided, thus producing supernumerary teeth. Cleft lip
There is nasal distortion as lip and nasal tissue pulls towards the attached side.
y
Clinical Features
Hare lip²this term is used to apply for only median cleft lip. Hare lip is derived from the rabbit who normally have cleft in the middle of their lip.
y y y
Unilateral cleft lip- a unilateral cleft involves only one side of the lip. Bilateral cleft lip ± cleft lip is present on the both sides of the midline.
Incomplete cleft- it extends for varying distances forward to the nostril, but not upto the nostril. The upper part of lip has fused normally. y Complete cleft lip²it extends into nostril and palate is commonly involved. It is often associated with flattening and widening of the nostril of the affected side. y Symptoms²patient may be presented with difficulty in sucking. Pat ient also noticed defect ive speech particularly with the labial letters B, F, M, P and V. y Effect on tongue²there is soft tissue mass between the ends of the bone, uniting the tongue to the lip, so that tongue is bound down. Cleft palate y Site- may be cleft of the hard and soft palate or in some cases, cleft of soft palate alone. Entire premaxillary portion of bone may be missing and in such instances, the cleft appears to be entirely a midline defect. y Extent²cleft of palate may also vary in severit y, involving uvula or soft palate or extending all the way through the palate (Fig. 23-8) and indirectly to the alveolar ridge on one or both
y y y y
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sides. Symptoms- eating and drinking are difficult due to regurgitation of food and liquid through the nose. Speech problem is serious and teends to increase due to mental trauma. Defect in smelling ± it is due to contamination of the nasal mucous membrane with the oral organism through the cleft palate. Teeth ± the alveolar cleft interefers with the dental lamina. This will result in small upper lateral incisors, absent or even duplicate. Cross bite due to medial collapse of premaxilla. Associated anomalies²isolated cleft palate is associated with other developmental abnormalities like congenital heart disease, polydactyly and syndactyly, hydrocephalus, micro-cephalus, clubfoot, supernumerary ear, Spina bifida, hypertelorism and mental deficiency. Airway problems may arise in children with cleft palates, especially those with concomitant structural functional anomalies. Syndrome associated²most common syndrome is Pierre-Robin syndrome is the combination of micrognathia, cleft palate and glossoptosis. Patients may develop airway distress from their tongue becoming lodged in the palatal defect. Other syndromes which can be present are Goldenhar syndrome, median cleft face syndrome, oral facial digital syndrome, Pert¶s syndrome, Nagar syndrome, otopalatodigital syndrome , Down's syndrome, and Marfan's syndrome.
y It will determine presence and absence of unerupted teeth. The most common missing teeth
Radiographic Features
are maxillary lateral incisors. There is also presence of supernumerary teeth. Teeth are malformed and poorly positioned. y There is also malposition of the teeth in the region of cleft or in the whole maxilla. y It will reveal the extent of osseous deformity. There may be complete separation of the premaxilla and maxilla.
Diagnosis
y y
Clinical diagnosis- cleft ca be seen clinically on lip and palate. Radiological diagnosis- cleft palate involving alveolus is seen clearly on radiography.
Management
The complete rehabilitation of the condition requires a multi-disciplinary approach. y Cheiloplasty²it is surgical closure of the lip. A general 'rule of tens' is used in determining optimal timing of lip closure, i.e. 10 weeks of age, 10 pounds of body weight and 10 gm of Hb. At the time of lip closure, when an infant is under general anesthesia, an impression is made for the new obturator. y Obturator²between 3rd and 9th months of age, an obturator is used to provide cross-arch stability, support and to prevent collapse of maxillary arch. y Palatoplasty²it is performed to close an opening in the palate. Surgeons may close the palate in one surgery, when the child is about one year of age or the palate may be closed in two stages, the soft palate is closed first followed by the hard palate. y Bone grafting²sometimes, closure of palatal cleft may be done by bone grafting. y Orthodontic therapy ²orthodontic therapy is done to correct malocclusion. y Cleft rhinoplasty²to improve nasal function and correct the distortion. y Speech therapy²speech therapy is given to improve pronounciation of the words. y Psychotherapy²psychological management is necessary. y Feeding plate²to overcome initial feeding problems, feeding plate is used which acts as an obturator to prevent nasal reflux.
Cheilitis
It is inflammation of lip. Various types of cheilitis are described below.
Glandular Cheilitis or OrofacialGranulomatosos
It is also called as cheilitis glandularis. It is an uncommon condition in which lower lip becomes enlarged, firm and finally everted.
Etiology
y Sun exposure²glandular cheilitis can occur due to chronic exposure to sun.
y Hereditary²familial occurrence, suggesting a hereditary pattern is also present in glandular
cheilitis.
y Salivary gland inflammation²inflammation of enlarged heterotopic salivary glands can also be
causative factors.
y Others ²dust, tobacco use and emotional disturbances also been reported in this patients.
Types (Historical)
y Simple ²multiple, painless, pinhead sized lesions with central depression and dilated canals
are present.
y Superficial suppurative type (Baelz's disease)²it is characterized by painless swelling,
induration, crusting superficial ulceration of lip.
y Deep suppurative type (cheilitis glandularis apostematosa, myxadenitis labialis)²deep seated
infection with abscess and fistula tract that eventually forms a scar.
Clinical Features
y y y y
Age²it is more common in adults but sometimes, it can also occur in children. Site²lower lip is involved more often than the upper lip. Symptoms²enlargement of labial salivary glands occurs which can be nodular. Signs²orifices of secretory ducts are inflamed and dilated appearing as small red macules over the mucosa. y Palpation²viscid mucous secretion may seep from these openings of everted hypertrophic lips after pressure given on the lip. y Volkmann's cheilitis²it is more severe suppurative form of glandular cheilitis. The lip is considerably and permanently enlarged and is subjected to episodes of pain, tenderness and increased enlargement. The surface is covered by crust and scales beneath which the salivary duct orifice may be discovered.
y Malignant transformation²it is apparently pre-malignant and epidermoid carcinoma can be
associated with it in 18 to 35% of cases.
Diagnosis
y Clinical diagnosis²everted hypertrophic lip with secretion after pressure on lip.
Management
y Vermilionectomy or lip shave²due to high incidence of associated malignancy, a
vermilionectomy or surgical stripping of lips has been recommended. It will give satisfactory cosmetic results. y Surgical excision²if the lips are grossly enlarged, excision of an elongated ellipse of tissue may be required.
Granulomatous Cheilitis or Orofacial Granulomatosis
It is also called as 'Miescher's syndrome' or 'cheilitis grantilomatosa' .This condition is described in 1945 by Miescher. It is a condition of unknown etiology that is not related to chelitis glandularis except by the similarity in the clinical appearance of the two diseases.
Etiology
Local causes y Chronic oral / dental infection y Embedded foreign material y Allergy to cosmetics, foods, oral hygiene products and dental restorative materials. Systemic causes y Chronic granulomatous disease y Crohn's disease y Sarcoidosis y Tuberculosis
Clinical Features
y Age and sex²it is seen in adults as well as in children and there is female predilection. y Symptoms
y There is diffuse swelling of the lips, especially the lower lip . y In some cases, an attack is accompanied by fever and mild constitutional symptoms including
headache and even visual disturbances.
y Enlarged lip can create cosmetic problems, difficulty during eating, drinking or speaking. y Signs²in some cases, scaling, fissuring and vesicles or pustules have been reported. y Palpation²the swelling is usually soft and exhibits no pitting on pressure. Swelling
eventually becomes firmer and acquires the consistency of that of hard rubber.
y
Lymph nodes²the regional lymph nodes are enlarged in some cases, but not always.
y Skin²the skin and adjacent mucosa may be of normal color or erythematous. y Syndrome²it is associated with Melkersson Rosenthal syndrome which consists of fissured
tongue and facial paralysis.
Diagnosis
y Clinical diagnosis²soft swelling of lip with fever, headache and vesicle can be seen.
Differential Diagnosis
y Cheilitisglandularis²in this condition there is involvement of labial salivary gland. y Angioedema ² it is recurrent condition and swelling subsides after giving antihistaminic. y Sarcoidosis²symptoms of fatigue and lethargy are present. y Crohn's disease²gastrointestinal symptoms are present in this case. y Lymphangioma²it is congenital lesion.
Management
y Corticosteroid injection²repeated injection of triamcinolone into the lips every few weeks
may be effective. Before giving steroids, topical anesthetics gels was applied over the lesion and then 0.1% of triamcinolone acetonide injection is given. This injection should be given weekly for 7 to 10 weeks.
y Cheiloplasty²surgical stripping of lip can be done.
Angular Cheilitis
It is also called as 'Perleche', 'Angular cheilosis"Cheilocanclidiasis'.
Causes
y Microorganisms²particularly candida albicans, but also staphylococci and streptococci. y Mechanical factors²overclosure of jaws such as in edentulous patients or in patients with
artificial denture which lack proper vertical dimensions. In it, folds are produced at the corners of the mouth in which saliva tends to collect and the skin becomes macerated, fissured and secondarily infected. Prognathism may give rise to similar state of affair in young. The recurrent trauma from dental flossing may occasionally be also implicated. y Nutritional deficiency²it can also occur due to riboflavin, folate and iron deficiency with a superimposed fungal or bacterial infection. General protein deficiency can also cause cheilitis. y Diseases of skin- atopic dermatitis involving the face is often ,associated with angular cheilitis. The incidence also appears to be increased in seborrhoeic dermatitis. y Other factors²hypersalivation, Down's syndrome, large tongue and constant dribbling being the contributory factors. A rare cause is the presence of a sinus of developmental origin at the angles of the mouth.
Clinical Features
y Age²it occurs in young children as well as in adults. y Symptoms- it is characterized by feeling of dryness and a burning sensation at the corners of
the mouth.
y Appearance²it is usually a roughly triangular area of erythema and edema at one or more,
commonly both the angles of mouth.
y Signs²epithelium at the commissures appears wrinkled and somewhat macerated .In time,
wrinkling becomes more pronounced to form one or more deep fissures or cracks which appear ulcerated but do not tend to bleed, although a superficial exudative crust may form.
y Rhagades²linear furrow or fissures radiating from the angle of mouth (rhagades) are seen in
more severe forms, especially in denture wearers.
y Prognosis ²if the lesion is not treated, they often show a tendency for spontaneous remission.
Diagnosis
mouth.
y Clinical diagnosis²triangular area or erythema with wrinkled macerated mucosa at angle of
Management
y Removal of the cause²underlying primary cause should be identified and treated. y Nutritional supplement ²a course of vitamin B and iron supplements are useful in these cases. y Fusidic acid ointment²it is used in staphylococcal infection. The lesions should be swabbed
first and then fusidic acid ointment or cream should be applied at least four times a day.
y Miconazole²miconazole may be preferred, if angular cheilitis is due to candidiasis (cream
applied locally together with an oral gel).
y Gentian violet application²in some cases, it is useful.
Eczematous Cheilitis
The lips are involved secondary to atopic eczema but possibility of contact dermatitis must also be considered. The management of atopic eczema of the lips is with emollient and topical steroids.
Contact Cheilitis
Definition
Contact cheilitis is an inflammatory reaction of the lips provoked by the irritants or sensitizing action of chemical agents in direct contact with them.
Causes
Lipsticks²they are composed of mineral oils and waxes which form the stick; castor oil as a solvent for the dyes, lanolin as an emollient preservative, perfumes and color. The color includes azo dyes and eosin, which is a bromofluorescein derivative. Sunscreen applied in the form of lipstick can also cause contact cheilitis. y Lipsalves and other medicaments²lipsalves containing lanolin are frequently applied for dryness or chapping. Phenyl salicylates and antibiotics have also been incriminated as a cause of cheilitis. y Mouthwashes and dentifrices²essential oils such as peppermint, cinnamon, clove, spearmint and bactericidal agents can cause cheilitis. Propolis, derived from resin and collected by bees, is a well known sensitizer which has been used in toothpastes. y Dental preparations²mercury and eugenol may cause cheilitis in the absence of stomatitis. Allergy to epimine containing materials used for crowns and bridges can cause cheilitis. y Foods²oranges, mangoes and artichokes are among the food plants which occasionally cause allergic cheilitis and dermatitis of the skin around the lips. y Miscellaneous objects²metal hair clips, metal pencils, cobalt paint on blue pencil can also y
cause cheilitis. Clinical Features
y Site²lipstick cheilitis is usually confined to the vermilion borders but more often extends
beyond that.
y Signs and symptoms²there may be persistent irritation and scaling or a more acute reaction
with edema and vesiculation.
Diagnosis
If acute eczematous changes are obviously present, the diagnosis of contact cheilitis presents no difficulty. If an allergic reaction is suspected, patch test can be carried out.
Management
Topical steroids will give symptomatic relief but the offending substance must be traced and avoided. Most commonly used topical steroids use is 1% triamcinolone acetonide.
Actinic Cheilitis
It is also called as Actinic cheilosis. Some other terms which use are Farmer's lips or Sailor's lip as these people are mom exposing to sunlight.
Definition
It is a pre-malignant squamous cell lesion resulting from long-term exposure to solar radiation and may be found at the vermilion border of lip as well as other sun exposed surfaces.
Etiology
y Chronic sun exposure²it is the main cause, so it usual::occurs in hot, dry regions, in outdoor
workers and fair skinned people.
Clinical Features
y Site²the lower lip is more commonly affected than the upper lip as it receives more solar
radiation than the upper lip.
y Age and sex distribution²it is more commonly seen in adult's patient. It is less common in
females due to sunscreen effect of lipstick and less common in blacks due to protective effect of melanin. y Signs²in the early stages, there may be redness and edema but later on, the lips become dry and scaly. If scales are removed at this stage, tiny bleeding points are revealed. With the passage of time. these scales become thick and horny with distinct edge. Patient can remove scales but it again reforms within few days. Epithelium becomes palpably thickened with small grayish white plaques. Vertical fissuring and crusting occurs, particularly in the cold weather. y Margin²there is blurring of the margin betwee vermilion zone and cutanous portion of lip.
y Superficial erosion²at times, vesicle may appear which rupture to form superficial erosions.
Secondary infection may occur.
y Nodule formation²eventually warty nodules may form which tend to vary in size with
fluctuation in the degree of edema and inflammation.
y Signs of malignant transformation²the possibility of malignancy must always be considered
if following features are present; y Ulceration in actinic cheilitis. y A red and white blotchy appearance with an indistinct vermilion border. y Generalized atrophy or focal areas of whitish thickening. y Persistent flaking and crusting. y Indurations at the base of keratotic lesion.
Diagnosis
y Clinical diagnosis²redness, edema with history of chronic sun exposure will give clue to
diagnosis.
Management
y Topical fluorouracil²for mild cases, application of 5% fluorouracil three times daily for 10
days is suitable. It produces brisk erosion but lips heal within 3 weeks. Application of 5fluorouracil to the lip will produce erythema, vesiculation, erosion ulceration, necrosis and epithelialization. In some cases, podophyllin is also used. y CO2 snow²rapid freezing with CO: snow or liquid nitrogen on swab stick is used to remove superficial lesions. y y Vermilionectomy (lip shaves)²under local anesthesia, the vermilion border is excised b a scalpel and closure is then achieved by advancing the labial mucosa to the skin. Postoperative complications include paresthesia, lip pruritis and labial scar tension. y Laser ablation²carbon dioxide laser therapy has been used to vaporize the vermilion. Good results with no postoperative paresthesia or significant scarring have been reported. y Electrodesiccation²it refers to the deeply penetrating tissue dehydration produced by the insertion of electrodes into the tissue. y Prevention²following management, prevention of recurrence by regular use of sunscreen lip salves is advisable. Liquid or gel waterproof preparation containing para-aminobenzoic acid probably gives the best protection.
Exfoliative Cheilitis
It is also called as Factitious cheilitis. It is a chronic superficial inflammatory disorder of the vermilion border of lips characterized by persistent scaling and flaking.
Causes
y Chronic injury²these cases may occur due to repeated lip sucking, chewing or other
manipulation of the lips.
y Personality disorders²emotional disturbance, psychological difficulties and stress can also
lead to exfoliativecheilitis.
Clinical Features
y Age and sex distribution²age of occurrence is seen in younger group. Most cases occur in girls. y Site²the process starts in the middle of the lower lip and spreads to involve the whole of the
lower lip or both the lips.
y Symptoms²the patient complains of irritation or burning and can be observed frequently on biting
or sucking the lips. y Signs²it consists of scaling and crusting, more or less confined to the vermilion borders and persisting in varying severity for months or years. y Perioral skin²there is erythema of perioral skin.
Diagnosis
y Clinical diagnosis²Scaling, crusting with perioral skin erythema will aid to diagnosis.
Management
y Reassurance and psychotherapy²this is done to overcome personality disorders. After this, many
patients get relief. y Topical steroids²hydrocortisone cream is useful in resolving some chronic cases in some patients. y Combination ²hydrocortisone can be combined with iodoquinol (antibacterial and antimycotic) cream can be used in chronic cases of exfoliativecheilitis. y Others therapy ²it includes topical silver nitrate, salicylic acid, antibacterial and antifungal formulation.
Plasma Cell Cheilitis
It is an idiopathic benign inflammatory condition characterized by dense plasma cell infiltrate in the mucosa close to the body orifice.
Clinical Features
y Site²it can affect penis, vulva, lips, buccal mucosa, palate, gingiva, tongue, epiglottis and
larynx. y Sign²it presents as circumscribed patches of erythema ,usually on the lower lip in elderly persons.
Diagnosis
y Clinical²not possible. y Laboratory ²on histopathological examination plasma cell can be seen.
Management
It responds to topical application of powerful steroids intradermal injection of triamcinolone.
Drug-induced Cheilitis
Hemorrhagic crusting of the lips is a feature of steven johnson syndrome which is commonly caused by drugsl but, cheilitis can occur as an isolated feature of a drug reaction- either as a result of allergy or a pharmacological effect. The aromatic retinoids, etretinate and isotretinoin causes dryness and cracking of lips in most patients.
Carcinoma of Lip
Squarnous cell carcinoma is the commonest malignancy, affect the vermilion zone. It occurs in light skinned who have chronic exposure to sunlight.
Clinical Features
y Age and sex distribution²there is peak appearance in and 7th decade of life. It is more y y y y y
common in males compared to females. Site- is most common on the lower lips of fair skinned people and persons who work in outer climate. Onset²it usually begins on vermilion border of lip to one side of the rnidline and it may be covered crust due to absence of saliva. Actinic cheilitis²it is preceded by actinic cheilitis which is characterized by innocuous looking white plaque:-the lip. Symptoms²patient may complain of difficulty in speech difficulty in taking food and inability to close the mouth. There is also pain, bleeding and paresthesia. Signs y It often commences as a small area of thickening, induration and ulceration or irregularity of the surface. y In some cases, it commences as a small warty growth or fissure on the vermilion border of the lip. y Crater like lesion having a velvety red base and rolled indurated borders. y As the lesion enlarged, it takes papillary or an ulcerative form. y In untreated cases, there is total destruction of lip and invasion of cheek, the gums and the mandible.
Extent- papillary lesion grows slowly and infiltrared the deeper relatively late whereas ulcerative growth invade early. y Metastasis²it may metastasize and it is usually ipsilateral. Carcinoma of the upper lip metastasizes earlier and more frequently than carcinoma of the lower lip. It involves submaxillarv and submental nodes first and then deep cervical nodes. Spread by direct extension into surrounding structures and by metastasis which is through lymphatic channels. y
Diagnosis
y Clinical diagnosis²ulcerative growth with destruction of lip is present. y Laboratory diagnosis²it is mainly well differentiated malignancies.
Management
y Surgical²prognosis is good if the treatment is done before metastasis. y The best results are seen when being obtained when the entire lip mucosal field is removed for
early lesion.
Miscellaneous Disorders Chapping of the Lips
It is a reaction to adverse environmental conditions in which keratin of the vermilion zone loose its plasticity. y Causes²it is caused by exposure to freezing cold or to hot, dry wind, but acute sunburns can
cause very similar changes. y Clinical features²lip becomes sore, cracked and scaly. The affected subjects tend to lick the lips or to pick at the scales which make conditions worse. y Management²Management is by application of petroleum jelly and avoidance of the causative environmental conditions.
Actinic Elastosis
It is also called as 'Solar elastosis' or 'Senile elastosis'.
Causes
Sunlight exposure-it is caused by prolonged exposure to UV light. UV radiation can
produce collagen degeneration in the dermis and extent of this effect is dependent upon factors such as the thickness of stratum corneum, melanin pigment, clothing or chemical sunscreens.
Clinical Features
y Site-it is seen on the labial mucosa exposed to sun. y Age-it occurs in elderly population.
y Signs -white area of atrophic epithelium develops with underlying scarring of the lamina
propria. y Appearance-it includes leathery appearance, laxity with wrinkling and various pigmentary changes. y Clinical types- clinically, it is manifested in three forms:
y Cutis rhornboidalis - thickened skin with furrow giving an appearance of rhomboidal
network. y Dubreuilh'selastoma- diffuse plaque like lesions. y Nodular elastoidosis - nodular lesion.
Caliber Persistent Artery
A caliber persistent artery is defined as an artery with a diameter larger than normal near a mucosal or external surface. In this condition, main arterial branch extends upto the superficial tissue without reduction in the diameter is present.
Clinical Features
y Age and sex distribution-it is more commonly seen in adults as in adults there is loss of
tone in the connective tissue.
y Site- either lip can involve or some patients have bilateral lesion. y Appearance-the lesion present as linear, arcuate or papular elevation on the lip. y Ulcer formation-such artery in the lip may cause chronic ulceration which can be mistaken for
squamous carcinoma. The ulcer is attributed to continual pulsation from the large artery running parallel to the surface. y Signs-pulsation can be seen in the lesion. Pulsation present in lateral direction.
Management
y No treatment is necessary and some time, biopsy is to avoid the misdiagnosis of the
lesion.
Classification of Lip Disorders
Developmental
y y y y y y y y y y y y y
Congenital lip pits Commissural lip pits Double lip Cleft lip and cleft palate Glandular cheilitis Granulomatous cheilitis Angular cheilitis Contact cheilitis Eczematous cheilitis Actinic cheilitis Exfoliative cheilitis Plasma cell cheilitis Cheilitis due to drugs
Cheilitis
Carcinoma of lip Miscellaneous
y Chapping of lips y Actinic elastosis y Lip ulcers due to caliber persistent artery
Development of Lip
In the sixth week of intrauterine life, two medial nasal processes merge in midline. This will form intermaxillary segment which will give rise to center of upper lip. In adult, center of upper lip forms philtrum. Philtrum is bound laterally by two vertical ridges under the nostril. Lateral part of upper lip fissure presents in maxillary process. This may lead to cleft formation if it is not covered by epithelium and fused. Upper lip is thus formed from one-third medial nasal process and two-third maxillary process.
Anatomy
y Mucocutaneous junction²lips are fleshy folds lined by skin externally and mucous membrane
internally. The upper and lower lips close along the red margin which represents the mucocutaneous junction. y Surface ²the lips are covered with skin on the external surface and mucous membrane on the inner surface, which has profuse salivary glands. y Extent² the lip extends from the lower end of the nose to the upper end of the chin.
y Nasolabial groove² the upper lip borders onto the nose and is separated from the cheek by a
variably deep groove called as nasolabial groove.
y Lower lip²the lower lip is separated from the chin proper by a more or less sharp and deep
groove that is convex superiorly called as labiomental groove.
y Oral cornmissure²it is the angle where the upper and lower lip meets. y Philtruni ² the upper lip includes the philtrum, a midline depression, which can be followed to
the nose.
y Content²each lip mainly consists of bundles of striated muscle, orbicularis oris, superficial
fascia and submucosa. The skin of the lip contains sweat glands, hair and sebaceous gland. The dermal papillae are numerous, with rich capillary supply, which produce reddish pink color of the lips. y Vermilion zone²it is the transitional zone between the skin and the mucous membrane. The vermilion zone contains no hair or sweat glands and contains a few sebaceous glands. In some people, sebaceous glands may be seen as creamy yellow dots. Fordyce's spots along the border between vermilion border and the oral mucosa can also occur. y Blood supply of lips²submental artery to the lower lip and inferior and superior labial arteries to the upper lip.
y y y
Venous drainage²anterior facial vein and its branches corresponding to the facial artery provides the venous drainage of lips. Lymphatic drainage²from central part of lower lip, lymphatics drain to the submental node and rest of the lip to submandibular nodes. Nerve supply²mental nerve and superior labial nerve.
Develo pm enta l Diso rd ers o f Lip
Congenital Lip Pits
It is also called as 'paramedian lip pit or congenital fistula'.
Etiopathogenesis
y y y
Hereditary²it is inherited as an autosomal dominant trait. Notching of lip²there is notching of lips at an early stage of development with fixation of tissues at the base of the notch. Incomplete union ²it may occur due to failure of complete union of embryonic sulci of the lip, resulting in persistent lateral sulci on the embryonic mandibular arch.
Clinical Features
y
Sex predilection²it is more commonly seen in females. y Site²it is common on vermilion border of either side of midline. It is most commonly seen
y y y y
on lower lip. Lip pits or fistula is unilateral or bilateral depression. Size ²it may be upto 3-4 mm in diameter and may extend as deep as 2 cm. Appearance²lips,some times appear swollen, accentuating the appearance of the pit. Palpation²on palpation, sparse mucus secretion may be visible from the base of the lippit which occurs due to involvement of underlying minor salivary glands. Syndromes associated²congenital lip pits may occur in association with Van der Woude's syndrome (cleft lip, cleft palate and congenital lip pits). Another syndrome is associated with it is popliteal pterygium syndrome which also includes Popliteal webbing (pterygia), cleft lip / cleft palate, genital abnormalities and congenital bands connecting the upper and lower jaws (syngnathia).
Diagnosis
Clinical diagnosis²unilateral or bilateral depression on vermilion border of lip will diagnose these conditions.
Management
y Surgical excision²it is done for cosmetic purpose.
Commissural Pits
Commissural lip pits are mucosal invagination occurring at the vermilion border of lip.
Pathogenesis
They occur due to failure of normal fusion of embryonal maxillary and mandibular processes. It is transmitted as autosomal dominant transmission.
Clinical Features
y y y Sex distribution²it is more common amongst males and black people are affected more than white people. Site²if it is unilateral, it occurs on the right side of the lip. Appearance ² commissural pit appears as aunilateral or bilateral pit at the corner of the mouth on the vermilion surface. y Size²size ranges from a shallow dimple to a tract measuring 4 mm in length and tissue slightly raisedabove the opening. y Palpation²in squeezing of the lip pit, small amount of saliva can come out. Congenital lip pit²it may be associated with facial or palatal cleft.
Differential Diagnosis
y
Management
y Surgical excision²it is indicated only in severe condition, where salivary secretion excessive and
secondary infection can occur.
Double Lip
It is an anomaly characterized by a fold of excess tissue on the inner mucosal surface of the lip. It may be congenital or acquired because of trauma to the lip.
Pathogenesis
It occurs in 2nd or 3rd week of gestation due to persistent of the sulcus between the pars glabrosa and pars villosa of the lip. Clinical Features y Site²it usually occurs on inner aspect of upper lip. y Cupid bow appearance²when upper lip is tensed, double lip resembles 'cupid bow'. y Syndromes associated²it is associated with Ascher's syndrome which consists of double lip, blepharochalasis (it is drooping of the tissue between eyebrow and edge of the upper eyelid so that it hangs loosely over the margin of the lid) and non-toxic thyroid enlargement.
Diagnosis
y Clinical diagnosis²cupid bow appearance is typical.
Management
y Surgical excision.
Cleft Lip and Cleft Palate
It occurs along many planes as a result of fault or defect in the development.
Definition
Cleft Lip²it is a birth defect that results in a unilateral or bilateral opening in the upper lip between the mouth and the nose. It is also called as harelip. It is wedge shaped defect resulting from failure of two parts of the lip to fuse into a single structure. Cleft palate²cleft palate is a birth defect characterized by an opening in the roof of the mouth caused by a lack of t:ssue development.
Development of Cleft
In.general, patients with clefts have a deficiency of tissue and not merely a displacement of normal tissue. y Unilateral cleft lip²Acleft lip occurs when an epithelial bridge fails, due to lack of mesodermal delivery and its proliferation from the maxillary and nasal processes. It results from failure of maxillary process on one side to meet and fuse with medial nasal process. This will lead into the division of lip into medial and lateral part. It again occurs due to absence or deficiency of mesodermal masses or their failure to penetrate the ectodermal grooves lead to breakdown of the ectoderm, causing cleft formation. In unilateral cleft lip, the floor of the nose communicates freely with the oral cavity, maxilla on the cleft side is hypoplastic, columella is displaced to the normal side and the nasal ala on the cleft side is laterally, posteriorly and inferiorly displaced. y Bilateral cleft lip²in this, medial mass interposed between two maxillary processes grows down from lateral areas form above the maxillary process. In bilateral cleft lip, the central portion of
y
y y
y
y
the alveolar arch is rotated anteriorly and superiorly. Median cleft lip ²it results from partial and complete failure of the medial nasal process to merge. The cleft of lip occurs earlier and inhibits tongue migration, which maw then prevent horizontal alignment and fusion of the palatal shelves. Median cleft of mandibular lip ²it occurs due to failure of mesenchymal masses of mandibular process to merge together at 5 weeks of intrauterine life. Cleft of primery palate ± clefts of primary palate occur anterior to the incisive foramen. Clefts of secondary palate are due to lack of fusion of the palatal shelves and always occurs posterior to the incisive foramen. Cleft palate occurs due to disturbances in normal fusion of palatal shelves. This may occur due to failure to unite due to lack of force, interference by the tongue or a disparity in the size of parts involved. It results from failure of the lateral palatine process to meet and fuse with median palatine process. Inpalatal clefts, the muscles of soft palate are hypoplastic and insert in the posterior margin of the remaining hard palate rather than the midline raphe. Cleft of secondary palate²The secondary palate closes one week later in females, which may explain why isolated clefts of the secondary palate are more common in females. These are clefts posterior to the incisive foramen. They result of partial or complete failure lateral palatine process to meet, fuse and merge with each other. Cleft of primary and secondary palate²they result of failure of growth or lack of fusion of three palatine processes with nasal septum and each other.
Etiology
y Hereditary²it is one of most important factors to be considered in the etiology. y Genetic²the main possible mode of transmission is by a single mutant gene; producing a large
y y y y y y
effect or by number of genes (polygenic inheritance), each producing small effects which together create this condition. Nutritional disturbances²riboflavin deficient diet can produce cleft palate and cleft lip. Developmental²physiological, emotional and traumatic stress during developmental stages. Defective vascular supply²defective vascular supply to the area may lead to ischemia which in turn may lead to cleft formation. Mechanical disturbances²here, the size of tongue may prevent union of the parts. Infection²infection and lack of inherent developmental force. Miscellaneous²steroid therapy during pregnancy, alcohol, toxins in the circulation.
Classification
First Classification y Unilateral incomplete. y Unilateral complete. y Bilateral incomplete. y Bilateral complete. Second by veau¶s y Cleft lip y Class I²A unilateral notching of vermilion border and it is not extending into the lip. y Class II² a unilateral notching of vermilion with cleft extending into lip but not including the floor of the nose. y Class III²a unilateral cleft of vermilion extending into the floor of the nose. y Class IV²any bilateral cleft of the lip, whether this is complete or incomplete.
y
Cleft palate Class I²involving only soft palate. Class II²involving soft and hard palate but not alveolus. Class Ill²involving soft and hard palate and alveolus of one side. Class IV²involving both the soft and hard palate and alveolus on both sides of the premaxilla. Third by Kernahan and Stark y Unilateral incomplete cleft of the primary palate. y Complete cleft of primary palate ending at the incisive foramen. y Bilateral complete cleft of the primary palate. y Incomplete isolated cleft of the secondary palate. y Complete cleft of the secondary palate²soft and hard palate. y Unilateral complete cleft of the primary and secondary palate. y Bilateral complete cleft of the primary and secondary palate. y Incomplete cleft of the primary palate and incomplete cleft of the secondary palate.
y o y
General y Sex²it is more common in males as compared to females. But incidence of isolated cleft palate is seen more in females. y Site²it is more frequently seen on the left side than on the right side. Left side is involved in 70% of the cases. Cleft of mandibular lip or jaws are rare. y Appearance ²a typical patient with cleft palate, cleft lip and ridge exhibits a large defect with a direct opening in the nasal cavity. y Teeth² disturbances in the dental structures are seen in this region so that teeth may be missing, deformed, displaced or divided, thus producing supernumerary teeth. Cleft lip
There is nasal distortion as lip and nasal tissue pulls towards the attached side.
y
Clinical Features
Hare lip²this term is used to apply for only median cleft lip. Hare lip is derived from the rabbit who normally have cleft in the middle of their lip.
y y y
Unilateral cleft lip- a unilateral cleft involves only one side of the lip. Bilateral cleft lip ± cleft lip is present on the both sides of the midline.
Incomplete cleft- it extends for varying distances forward to the nostril, but not upto the nostril. The upper part of lip has fused normally. y Complete cleft lip²it extends into nostril and palate is commonly involved. It is often associated with flattening and widening of the nostril of the affected side. y Symptoms²patient may be presented with difficulty in sucking. Pat ient also noticed defect ive speech particularly with the labial letters B, F, M, P and V. y Effect on tongue²there is soft tissue mass between the ends of the bone, uniting the tongue to the lip, so that tongue is bound down. Cleft palate y Site- may be cleft of the hard and soft palate or in some cases, cleft of soft palate alone. Entire premaxillary portion of bone may be missing and in such instances, the cleft appears to be entirely a midline defect. y Extent²cleft of palate may also vary in severit y, involving uvula or soft palate or extending all the way through the palate (Fig. 23-8) and indirectly to the alveolar ridge on one or both
y y y y
y
sides. Symptoms- eating and drinking are difficult due to regurgitation of food and liquid through the nose. Speech problem is serious and teends to increase due to mental trauma. Defect in smelling ± it is due to contamination of the nasal mucous membrane with the oral organism through the cleft palate. Teeth ± the alveolar cleft interefers with the dental lamina. This will result in small upper lateral incisors, absent or even duplicate. Cross bite due to medial collapse of premaxilla. Associated anomalies²isolated cleft palate is associated with other developmental abnormalities like congenital heart disease, polydactyly and syndactyly, hydrocephalus, micro-cephalus, clubfoot, supernumerary ear, Spina bifida, hypertelorism and mental deficiency. Airway problems may arise in children with cleft palates, especially those with concomitant structural functional anomalies. Syndrome associated²most common syndrome is Pierre-Robin syndrome is the combination of micrognathia, cleft palate and glossoptosis. Patients may develop airway distress from their tongue becoming lodged in the palatal defect. Other syndromes which can be present are Goldenhar syndrome, median cleft face syndrome, oral facial digital syndrome, Pert¶s syndrome, Nagar syndrome, otopalatodigital syndrome , Down's syndrome, and Marfan's syndrome.
y It will determine presence and absence of unerupted teeth. The most common missing teeth
Radiographic Features
are maxillary lateral incisors. There is also presence of supernumerary teeth. Teeth are malformed and poorly positioned. y There is also malposition of the teeth in the region of cleft or in the whole maxilla. y It will reveal the extent of osseous deformity. There may be complete separation of the premaxilla and maxilla.
Diagnosis
y y
Clinical diagnosis- cleft ca be seen clinically on lip and palate. Radiological diagnosis- cleft palate involving alveolus is seen clearly on radiography.
Management
The complete rehabilitation of the condition requires a multi-disciplinary approach. y Cheiloplasty²it is surgical closure of the lip. A general 'rule of tens' is used in determining optimal timing of lip closure, i.e. 10 weeks of age, 10 pounds of body weight and 10 gm of Hb. At the time of lip closure, when an infant is under general anesthesia, an impression is made for the new obturator. y Obturator²between 3rd and 9th months of age, an obturator is used to provide cross-arch stability, support and to prevent collapse of maxillary arch. y Palatoplasty²it is performed to close an opening in the palate. Surgeons may close the palate in one surgery, when the child is about one year of age or the palate may be closed in two stages, the soft palate is closed first followed by the hard palate. y Bone grafting²sometimes, closure of palatal cleft may be done by bone grafting. y Orthodontic therapy ²orthodontic therapy is done to correct malocclusion. y Cleft rhinoplasty²to improve nasal function and correct the distortion. y Speech therapy²speech therapy is given to improve pronounciation of the words. y Psychotherapy²psychological management is necessary. y Feeding plate²to overcome initial feeding problems, feeding plate is used which acts as an obturator to prevent nasal reflux.
Cheilitis
It is inflammation of lip. Various types of cheilitis are described below.
Glandular Cheilitis or OrofacialGranulomatosos
It is also called as cheilitis glandularis. It is an uncommon condition in which lower lip becomes enlarged, firm and finally everted.
Etiology
y Sun exposure²glandular cheilitis can occur due to chronic exposure to sun.
y Hereditary²familial occurrence, suggesting a hereditary pattern is also present in glandular
cheilitis.
y Salivary gland inflammation²inflammation of enlarged heterotopic salivary glands can also be
causative factors.
y Others ²dust, tobacco use and emotional disturbances also been reported in this patients.
Types (Historical)
y Simple ²multiple, painless, pinhead sized lesions with central depression and dilated canals
are present.
y Superficial suppurative type (Baelz's disease)²it is characterized by painless swelling,
induration, crusting superficial ulceration of lip.
y Deep suppurative type (cheilitis glandularis apostematosa, myxadenitis labialis)²deep seated
infection with abscess and fistula tract that eventually forms a scar.
Clinical Features
y y y y
Age²it is more common in adults but sometimes, it can also occur in children. Site²lower lip is involved more often than the upper lip. Symptoms²enlargement of labial salivary glands occurs which can be nodular. Signs²orifices of secretory ducts are inflamed and dilated appearing as small red macules over the mucosa. y Palpation²viscid mucous secretion may seep from these openings of everted hypertrophic lips after pressure given on the lip. y Volkmann's cheilitis²it is more severe suppurative form of glandular cheilitis. The lip is considerably and permanently enlarged and is subjected to episodes of pain, tenderness and increased enlargement. The surface is covered by crust and scales beneath which the salivary duct orifice may be discovered.
y Malignant transformation²it is apparently pre-malignant and epidermoid carcinoma can be
associated with it in 18 to 35% of cases.
Diagnosis
y Clinical diagnosis²everted hypertrophic lip with secretion after pressure on lip.
Management
y Vermilionectomy or lip shave²due to high incidence of associated malignancy, a
vermilionectomy or surgical stripping of lips has been recommended. It will give satisfactory cosmetic results. y Surgical excision²if the lips are grossly enlarged, excision of an elongated ellipse of tissue may be required.
Granulomatous Cheilitis or Orofacial Granulomatosis
It is also called as 'Miescher's syndrome' or 'cheilitis grantilomatosa' .This condition is described in 1945 by Miescher. It is a condition of unknown etiology that is not related to chelitis glandularis except by the similarity in the clinical appearance of the two diseases.
Etiology
Local causes y Chronic oral / dental infection y Embedded foreign material y Allergy to cosmetics, foods, oral hygiene products and dental restorative materials. Systemic causes y Chronic granulomatous disease y Crohn's disease y Sarcoidosis y Tuberculosis
Clinical Features
y Age and sex²it is seen in adults as well as in children and there is female predilection. y Symptoms
y There is diffuse swelling of the lips, especially the lower lip . y In some cases, an attack is accompanied by fever and mild constitutional symptoms including
headache and even visual disturbances.
y Enlarged lip can create cosmetic problems, difficulty during eating, drinking or speaking. y Signs²in some cases, scaling, fissuring and vesicles or pustules have been reported. y Palpation²the swelling is usually soft and exhibits no pitting on pressure. Swelling
eventually becomes firmer and acquires the consistency of that of hard rubber.
y
Lymph nodes²the regional lymph nodes are enlarged in some cases, but not always.
y Skin²the skin and adjacent mucosa may be of normal color or erythematous. y Syndrome²it is associated with Melkersson Rosenthal syndrome which consists of fissured
tongue and facial paralysis.
Diagnosis
y Clinical diagnosis²soft swelling of lip with fever, headache and vesicle can be seen.
Differential Diagnosis
y Cheilitisglandularis²in this condition there is involvement of labial salivary gland. y Angioedema ² it is recurrent condition and swelling subsides after giving antihistaminic. y Sarcoidosis²symptoms of fatigue and lethargy are present. y Crohn's disease²gastrointestinal symptoms are present in this case. y Lymphangioma²it is congenital lesion.
Management
y Corticosteroid injection²repeated injection of triamcinolone into the lips every few weeks
may be effective. Before giving steroids, topical anesthetics gels was applied over the lesion and then 0.1% of triamcinolone acetonide injection is given. This injection should be given weekly for 7 to 10 weeks.
y Cheiloplasty²surgical stripping of lip can be done.
Angular Cheilitis
It is also called as 'Perleche', 'Angular cheilosis"Cheilocanclidiasis'.
Causes
y Microorganisms²particularly candida albicans, but also staphylococci and streptococci. y Mechanical factors²overclosure of jaws such as in edentulous patients or in patients with
artificial denture which lack proper vertical dimensions. In it, folds are produced at the corners of the mouth in which saliva tends to collect and the skin becomes macerated, fissured and secondarily infected. Prognathism may give rise to similar state of affair in young. The recurrent trauma from dental flossing may occasionally be also implicated. y Nutritional deficiency²it can also occur due to riboflavin, folate and iron deficiency with a superimposed fungal or bacterial infection. General protein deficiency can also cause cheilitis. y Diseases of skin- atopic dermatitis involving the face is often ,associated with angular cheilitis. The incidence also appears to be increased in seborrhoeic dermatitis. y Other factors²hypersalivation, Down's syndrome, large tongue and constant dribbling being the contributory factors. A rare cause is the presence of a sinus of developmental origin at the angles of the mouth.
Clinical Features
y Age²it occurs in young children as well as in adults. y Symptoms- it is characterized by feeling of dryness and a burning sensation at the corners of
the mouth.
y Appearance²it is usually a roughly triangular area of erythema and edema at one or more,
commonly both the angles of mouth.
y Signs²epithelium at the commissures appears wrinkled and somewhat macerated .In time,
wrinkling becomes more pronounced to form one or more deep fissures or cracks which appear ulcerated but do not tend to bleed, although a superficial exudative crust may form.
y Rhagades²linear furrow or fissures radiating from the angle of mouth (rhagades) are seen in
more severe forms, especially in denture wearers.
y Prognosis ²if the lesion is not treated, they often show a tendency for spontaneous remission.
Diagnosis
mouth.
y Clinical diagnosis²triangular area or erythema with wrinkled macerated mucosa at angle of
Management
y Removal of the cause²underlying primary cause should be identified and treated. y Nutritional supplement ²a course of vitamin B and iron supplements are useful in these cases. y Fusidic acid ointment²it is used in staphylococcal infection. The lesions should be swabbed
first and then fusidic acid ointment or cream should be applied at least four times a day.
y Miconazole²miconazole may be preferred, if angular cheilitis is due to candidiasis (cream
applied locally together with an oral gel).
y Gentian violet application²in some cases, it is useful.
Eczematous Cheilitis
The lips are involved secondary to atopic eczema but possibility of contact dermatitis must also be considered. The management of atopic eczema of the lips is with emollient and topical steroids.
Contact Cheilitis
Definition
Contact cheilitis is an inflammatory reaction of the lips provoked by the irritants or sensitizing action of chemical agents in direct contact with them.
Causes
Lipsticks²they are composed of mineral oils and waxes which form the stick; castor oil as a solvent for the dyes, lanolin as an emollient preservative, perfumes and color. The color includes azo dyes and eosin, which is a bromofluorescein derivative. Sunscreen applied in the form of lipstick can also cause contact cheilitis. y Lipsalves and other medicaments²lipsalves containing lanolin are frequently applied for dryness or chapping. Phenyl salicylates and antibiotics have also been incriminated as a cause of cheilitis. y Mouthwashes and dentifrices²essential oils such as peppermint, cinnamon, clove, spearmint and bactericidal agents can cause cheilitis. Propolis, derived from resin and collected by bees, is a well known sensitizer which has been used in toothpastes. y Dental preparations²mercury and eugenol may cause cheilitis in the absence of stomatitis. Allergy to epimine containing materials used for crowns and bridges can cause cheilitis. y Foods²oranges, mangoes and artichokes are among the food plants which occasionally cause allergic cheilitis and dermatitis of the skin around the lips. y Miscellaneous objects²metal hair clips, metal pencils, cobalt paint on blue pencil can also y
cause cheilitis. Clinical Features
y Site²lipstick cheilitis is usually confined to the vermilion borders but more often extends
beyond that.
y Signs and symptoms²there may be persistent irritation and scaling or a more acute reaction
with edema and vesiculation.
Diagnosis
If acute eczematous changes are obviously present, the diagnosis of contact cheilitis presents no difficulty. If an allergic reaction is suspected, patch test can be carried out.
Management
Topical steroids will give symptomatic relief but the offending substance must be traced and avoided. Most commonly used topical steroids use is 1% triamcinolone acetonide.
Actinic Cheilitis
It is also called as Actinic cheilosis. Some other terms which use are Farmer's lips or Sailor's lip as these people are mom exposing to sunlight.
Definition
It is a pre-malignant squamous cell lesion resulting from long-term exposure to solar radiation and may be found at the vermilion border of lip as well as other sun exposed surfaces.
Etiology
y Chronic sun exposure²it is the main cause, so it usual::occurs in hot, dry regions, in outdoor
workers and fair skinned people.
Clinical Features
y Site²the lower lip is more commonly affected than the upper lip as it receives more solar
radiation than the upper lip.
y Age and sex distribution²it is more commonly seen in adult's patient. It is less common in
females due to sunscreen effect of lipstick and less common in blacks due to protective effect of melanin. y Signs²in the early stages, there may be redness and edema but later on, the lips become dry and scaly. If scales are removed at this stage, tiny bleeding points are revealed. With the passage of time. these scales become thick and horny with distinct edge. Patient can remove scales but it again reforms within few days. Epithelium becomes palpably thickened with small grayish white plaques. Vertical fissuring and crusting occurs, particularly in the cold weather. y Margin²there is blurring of the margin betwee vermilion zone and cutanous portion of lip.
y Superficial erosion²at times, vesicle may appear which rupture to form superficial erosions.
Secondary infection may occur.
y Nodule formation²eventually warty nodules may form which tend to vary in size with
fluctuation in the degree of edema and inflammation.
y Signs of malignant transformation²the possibility of malignancy must always be considered
if following features are present; y Ulceration in actinic cheilitis. y A red and white blotchy appearance with an indistinct vermilion border. y Generalized atrophy or focal areas of whitish thickening. y Persistent flaking and crusting. y Indurations at the base of keratotic lesion.
Diagnosis
y Clinical diagnosis²redness, edema with history of chronic sun exposure will give clue to
diagnosis.
Management
y Topical fluorouracil²for mild cases, application of 5% fluorouracil three times daily for 10
days is suitable. It produces brisk erosion but lips heal within 3 weeks. Application of 5fluorouracil to the lip will produce erythema, vesiculation, erosion ulceration, necrosis and epithelialization. In some cases, podophyllin is also used. y CO2 snow²rapid freezing with CO: snow or liquid nitrogen on swab stick is used to remove superficial lesions. y y Vermilionectomy (lip shaves)²under local anesthesia, the vermilion border is excised b a scalpel and closure is then achieved by advancing the labial mucosa to the skin. Postoperative complications include paresthesia, lip pruritis and labial scar tension. y Laser ablation²carbon dioxide laser therapy has been used to vaporize the vermilion. Good results with no postoperative paresthesia or significant scarring have been reported. y Electrodesiccation²it refers to the deeply penetrating tissue dehydration produced by the insertion of electrodes into the tissue. y Prevention²following management, prevention of recurrence by regular use of sunscreen lip salves is advisable. Liquid or gel waterproof preparation containing para-aminobenzoic acid probably gives the best protection.
Exfoliative Cheilitis
It is also called as Factitious cheilitis. It is a chronic superficial inflammatory disorder of the vermilion border of lips characterized by persistent scaling and flaking.
Causes
y Chronic injury²these cases may occur due to repeated lip sucking, chewing or other
manipulation of the lips.
y Personality disorders²emotional disturbance, psychological difficulties and stress can also
lead to exfoliativecheilitis.
Clinical Features
y Age and sex distribution²age of occurrence is seen in younger group. Most cases occur in girls. y Site²the process starts in the middle of the lower lip and spreads to involve the whole of the
lower lip or both the lips.
y Symptoms²the patient complains of irritation or burning and can be observed frequently on biting
or sucking the lips. y Signs²it consists of scaling and crusting, more or less confined to the vermilion borders and persisting in varying severity for months or years. y Perioral skin²there is erythema of perioral skin.
Diagnosis
y Clinical diagnosis²Scaling, crusting with perioral skin erythema will aid to diagnosis.
Management
y Reassurance and psychotherapy²this is done to overcome personality disorders. After this, many
patients get relief. y Topical steroids²hydrocortisone cream is useful in resolving some chronic cases in some patients. y Combination ²hydrocortisone can be combined with iodoquinol (antibacterial and antimycotic) cream can be used in chronic cases of exfoliativecheilitis. y Others therapy ²it includes topical silver nitrate, salicylic acid, antibacterial and antifungal formulation.
Plasma Cell Cheilitis
It is an idiopathic benign inflammatory condition characterized by dense plasma cell infiltrate in the mucosa close to the body orifice.
Clinical Features
y Site²it can affect penis, vulva, lips, buccal mucosa, palate, gingiva, tongue, epiglottis and
larynx. y Sign²it presents as circumscribed patches of erythema ,usually on the lower lip in elderly persons.
Diagnosis
y Clinical²not possible. y Laboratory ²on histopathological examination plasma cell can be seen.
Management
It responds to topical application of powerful steroids intradermal injection of triamcinolone.
Drug-induced Cheilitis
Hemorrhagic crusting of the lips is a feature of steven johnson syndrome which is commonly caused by drugsl but, cheilitis can occur as an isolated feature of a drug reaction- either as a result of allergy or a pharmacological effect. The aromatic retinoids, etretinate and isotretinoin causes dryness and cracking of lips in most patients.
Carcinoma of Lip
Squarnous cell carcinoma is the commonest malignancy, affect the vermilion zone. It occurs in light skinned who have chronic exposure to sunlight.
Clinical Features
y Age and sex distribution²there is peak appearance in and 7th decade of life. It is more y y y y y
common in males compared to females. Site- is most common on the lower lips of fair skinned people and persons who work in outer climate. Onset²it usually begins on vermilion border of lip to one side of the rnidline and it may be covered crust due to absence of saliva. Actinic cheilitis²it is preceded by actinic cheilitis which is characterized by innocuous looking white plaque:-the lip. Symptoms²patient may complain of difficulty in speech difficulty in taking food and inability to close the mouth. There is also pain, bleeding and paresthesia. Signs y It often commences as a small area of thickening, induration and ulceration or irregularity of the surface. y In some cases, it commences as a small warty growth or fissure on the vermilion border of the lip. y Crater like lesion having a velvety red base and rolled indurated borders. y As the lesion enlarged, it takes papillary or an ulcerative form. y In untreated cases, there is total destruction of lip and invasion of cheek, the gums and the mandible.
Extent- papillary lesion grows slowly and infiltrared the deeper relatively late whereas ulcerative growth invade early. y Metastasis²it may metastasize and it is usually ipsilateral. Carcinoma of the upper lip metastasizes earlier and more frequently than carcinoma of the lower lip. It involves submaxillarv and submental nodes first and then deep cervical nodes. Spread by direct extension into surrounding structures and by metastasis which is through lymphatic channels. y
Diagnosis
y Clinical diagnosis²ulcerative growth with destruction of lip is present. y Laboratory diagnosis²it is mainly well differentiated malignancies.
Management
y Surgical²prognosis is good if the treatment is done before metastasis. y The best results are seen when being obtained when the entire lip mucosal field is removed for
early lesion.
Miscellaneous Disorders Chapping of the Lips
It is a reaction to adverse environmental conditions in which keratin of the vermilion zone loose its plasticity. y Causes²it is caused by exposure to freezing cold or to hot, dry wind, but acute sunburns can
cause very similar changes. y Clinical features²lip becomes sore, cracked and scaly. The affected subjects tend to lick the lips or to pick at the scales which make conditions worse. y Management²Management is by application of petroleum jelly and avoidance of the causative environmental conditions.
Actinic Elastosis
It is also called as 'Solar elastosis' or 'Senile elastosis'.
Causes
Sunlight exposure-it is caused by prolonged exposure to UV light. UV radiation can
produce collagen degeneration in the dermis and extent of this effect is dependent upon factors such as the thickness of stratum corneum, melanin pigment, clothing or chemical sunscreens.
Clinical Features
y Site-it is seen on the labial mucosa exposed to sun. y Age-it occurs in elderly population.
y Signs -white area of atrophic epithelium develops with underlying scarring of the lamina
propria. y Appearance-it includes leathery appearance, laxity with wrinkling and various pigmentary changes. y Clinical types- clinically, it is manifested in three forms:
y Cutis rhornboidalis - thickened skin with furrow giving an appearance of rhomboidal
network. y Dubreuilh'selastoma- diffuse plaque like lesions. y Nodular elastoidosis - nodular lesion.
Caliber Persistent Artery
A caliber persistent artery is defined as an artery with a diameter larger than normal near a mucosal or external surface. In this condition, main arterial branch extends upto the superficial tissue without reduction in the diameter is present.
Clinical Features
y Age and sex distribution-it is more commonly seen in adults as in adults there is loss of
tone in the connective tissue.
y Site- either lip can involve or some patients have bilateral lesion. y Appearance-the lesion present as linear, arcuate or papular elevation on the lip. y Ulcer formation-such artery in the lip may cause chronic ulceration which can be mistaken for
squamous carcinoma. The ulcer is attributed to continual pulsation from the large artery running parallel to the surface. y Signs-pulsation can be seen in the lesion. Pulsation present in lateral direction.
Management
y No treatment is necessary and some time, biopsy is to avoid the misdiagnosis of the
lesion.
