I am especially indebted to my wife Vasiliki and my children Panagiotis and Katerina for their continuous love and support for all those years of my involvement in Oral Medicine, and during the preparation of this guide.
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Clinical cases
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1 Bleeding
Bleeding in the mouth may be a sign of various conditions related to the structure of blood vessels, the number or function of white blood cells and especially platelets, the deficiency or dysfunction of clotting factors or even interaction of various drugs. Some of these bleeding disorders appear at a very young age; some are also found among close relatives (inherited) while others are noticed later with a negative family history (acquired). The severity of the bleeding ranges from minor hemorrhages from gingivae and other parts of the oral mucosa with the formation of petechiae or ecchymosis (Figure 1.0), to extensive bleeding in other parts of the body, causing severe blood loss, even jeopardizing the patient's life.
The more important causes of oral bleeding are seen in Table 1.
Figure 1.0 Tongue hematoma in a woman with seizures.
Table 1 Conditions related to oral bleeding.
| Common and important conditions |
| Local conditionsGingivitis/periodontitisGranuloma pyogenic/giant cellJaw fractureTraumaTumors invading blood vesselsSystemic conditionsCongenitalHemophilia A or BVon Willebrand's diseaseOther factor deficienciesGlanzman thrombastheniaAcquiredrelated to coagulationLiver diseaseVit. K deficiency, warfarin drug useDisseminated intravascular coagulationrelated to thrombocytopeniaIdiopathicDrug‐inducedCollagen vascular diseaseSarcoidosisHemolytic anemiaLeukemiaMyelomaWaldestmomrelated to platelet dysregulationAlcoholismChronic renal failureDrugsLiver diseaserelated to vascular disordersAngina bullosa hemorrhagicaAngiomasEhrler‐Danlos syndromeHereditary hemorrhagic telangiectasiaInfections from Ebola, HIV, HSV; EBV, RubellaMarfan syndromePurpuraScurvyrelated to fibrinolysisAmyloidosisStreptokinase treatment |
Case 1.1
CO: A 62‐year‐old woman was referred by her family doctor for evaluation of several red spots on her lips, mouth, and the skin of her fingers.
HPC: The red spots had been present since childhood, but had become greater on the surface of her face over the last five years causing cosmetic problems and patient’s concern.
PMH: Her medical history revealed a chronic iron deficiency anemia which still remained despite the fact that the patient was in the post‐menopause phase and had been treated occasionally with iron tablets. No other serious medical problems were recorded except for a few episodes of nose and gut bleeding which had caused her to ask for medical advice. She was a non‐smoker and non‐drinker.
OE: The examination revealed numerous red vascular papules, variable in size, ranging from pin head‐like lesions to small red plaques at the vermilion border of her lips, and on the tongue and buccal mucosae (Figure 1.1a). A few asteroid‐like red lesions, were also seen on the skin of her fingers (Figure 1.1b) and inside her nose which were responsible for her episodes of epistaxis.
Q1 Which is the possible cause of her red spots?
1 Crest syndrome
2 Sjogren syndrome
3 Rendu‐Osler‐Weber syndrome
4 Rosacea
Ataxia‐telangiectasia
Answers:
1 No
2 No
3 Rendu‐Osler‐Weber syndrome or hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant condition that affects blood vessels throughout the body (telangiectasia; arteriovenous malformations) with a tendency for bleeding. This vascular dysplasia is commonly seen in oral, nasopharynx, lung, liver, spleen, gastrointestinal and urinary tracts, conjunctiva and the skin of arms and fingers.
4 No
5 No
Comments: Skin telangiectasias are also seen in patients with ataxia telangiectasia, Crest and Sjogren syndromes. In rosacea, main vascular lesions are the broken vessels that are located exclusively on the skin predominantly on the middle of the face, as in ataxia telangiectasia. In ataxia telangectasia, the vascular lesions are associated with poor coordination, and in Crest syndrome with calcinosis and sclerodactyly and Raynaud phenomenon. Sjogren's syndrome affects the mouth, eyes, nose and other organs causing dryness, swelling of the salivary glands and facial telangiectases.
Q2 Which are the main complications of this condition?
1 Anemia
2 Pulmonary hemorrhage
3 Ischemic stroke
4 Skin photosensitivity
5 Mental retardation
Answers:
1 Iron
