lesions of lip

LESIONS OF LIPS

1. LESIONS OF LIPS Created by VINAYAK PATHAK

2. INTRODUCTION:- Lips are soft, movable. It serve as the opening for food intake and in the articulation of sound and speech. The upper and lower lips are referred to as the "Labium superius oris " and "Labium inferius oris ", respectively. The junction where the lips meet the surrounding skin of the mouth area is the  vermilion border ,

3. 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 . 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.

4. Anatomy lips are fleshy folds lined by skin externally and mucous membrane internally, which has profuse salivary glands. The upper and lower lips close along the red margin which represents the mucocutaneous junction .

5. Classification of Lips Disorders C O L O R E D L E S I O N S #WHITE LESIONS Candidiasis Squamous cell papilloma Verruca vulgaris Condyloma Lichen planus Lichenoid drug eruption Actinic keratosis Squamous cell carcinoma Snuff dipper's lesion Cigarette smoker's lip Focal epithelial hyperplasia # RED LESIONS Hemangioma Sturge-Weber syndrome Thrombocytopenic purpura Rendu -Osler-Weber disease (hereditary hemorrhagic telangiectasia) Kaposi's sarcoma Contact allergy # BROWN LESIONS Nevus Labial melanotic macule Melanoma von Recklinghausen 's disease Albright's syndrome Peutz-Jeghers syndrome Addison's disease Hemochromatosis Kaposi's sarcoma # YELLOW LESIONS Lipoma Fordyce's disease

6. #ULCERATIVE LESIONS TRAUMATIC ULCER APHTHA HERPES SIMPLEX VIRUS ERYTHEMA MULTIFORME KERATOACANTHOMA SYPHLIS #ELEVATED LESIONS FlBROMA ( FlBROUS HYPERPLASIA) MUCOCELE ANGIOEDEMA LIPOMA SALIVARY GLAND TUMOR MINOR SALIVARY GLAND CALCULUS HEMANGIOMA NASOLABIAL CYST CONTACT ALLERGY CHELITIS GLANDULARIS CHELITIS GRANULOMATOSA MELKERSSON-ROSENTHAL SYNDROME SQUAMOUS CELL PAPILLOMA #DEVELOPMENTAL ABNORMALITIES CLEFT LIP DOUBLE LIP LOWER LIP SINUS COMMISSURAL PIT

7. Developmental Disorders of Lip Congenital Lip Pits It is also called as ‘paramedian lip pit or congenital fistula’. Etiopathogenesis • Hereditary • Notching of lip • Incomplete union Clinical Features • Sex predilection— more commonly seen in females. • Site—it is common on vermilion border of either side of midline. It is most commonly seen on lower lip. • Size—it may be upto 3-4 mm in diameter and may extend as deep as 2 cm. • Appearance—lips, some times appear swollen, accentuating • Palpation—on palpation, sparse mucus secretion may be visible from the base of the lip-pit which occurs due to involvement of underlying minor salivary glands.

8. Syndromes associated — vander Woude’s syndrome (cleft lip, cleft palate and congenital lip pits). Diagnosis Clinical diagnosis—unilateral or bilateral depression on vermilion border of lip will diagnose these conditions. Management • Surgical excision—it is done for cosmetic purpose.

9. 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.

10. Clinical Features • Sex distribution —it is more common amongst males and black people are affected more than white people. • Site— if it is unilateral, it occurs on the right side of the lip. • Appearance— commissural pit appears as a unilateral or bilateral pit at the corner of the mouth on the vermilion surface. • Size —size ranges from a shallow dimple to a tract measuring 4 mm in length and tissue slightly raised above the opening. • Palpation— in squeezing of the lip pit, small amount of saliva can come out. Differential Diagnosis • Congenital lip pit —it may be associated with facial or palatal cleft. Management • Surgical excision —it is indicated only in severe condition, where salivary secretion excessive and secondary infection can occur.

11. 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 • Site —it usually occurs on inner aspect of upper lip. • Cupid bow appearance— when upper lip is tensed, double lip resembles ‘cupid bow’ . Diagnosis • Clinical diagnosis —cupid bow appearance is typical. Management • Surgical excision

12. Cleft Lip It occurs along many planes as a result of fault or defect in the development. Definition Cleft lip— it 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. Etiology • Hereditary • Genetic • Nutritional disturbances • Developmental • Defective vascular supply • Mechanical disturbances • Infection

13. Clinical Features • Sex— it is more common in males as compared to females. • Site— it is more frequently seen on the left side than on the right side. • Teeth— teeth may be missing, deformed, displaced or divided, thus producing supernumerary teeth. • There is nasal distortion as lip and nasal tissue pulls towards the attached side. • Hare lip —this 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. Diagnosis • Clinical diagnosis —cleft can be seen clinically on lip and palate. • Radiological diagnosis —cleft palate involving alveolus is seen clearly on radiography.

14. Management The complete rehabilitation of the condition requires a multi-disciplinary approach. Cheiloplasty • Obturator • Palatoplasty • Bone grafting • Orthodontic therapy • Cleft rhinoplasty • Speech therapy • Psychotherapy • Feeding plate

15. Cheilitis It is inflammation of lip. Various types of cheilitis are Described Glandular Cheilitis It is also called as cheilitis glandularis . It is an uncommon condition in which lower lip becomes enlarged, firm and finally everted. Etiology • Sun exposure • Hereditary • Salivary gland inflammation • Others— dust, tobacco use and emotional disturbances • multiple, painless, pinhead sized lesions with central depression and dilated canals are present. • Superficial suppurative type ( Baelz’s disease)—it is characterized by painless swelling, induration, crusting and superficial ulceration of lip.

16. Deep suppurative type (cheilitis glandularis apostematosa myxadenitis labialis)— Deep seated infection with abscess and fistula tract that eventually forms a scar. Clinical Features • Age —it is more common in adults but sometimes, it can also occur in children. • Site— lower lip is involved more often than the upper lip. • Symptoms— enlargement of labial salivary glands occurs which can be nodular. • Signs— orifices of secretory ducts are inflamed and dilated appearing as small red macules over the mucosa.

17. Volkmann’s cheilitis — It 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.

18. Malignant transformation— it is apparently pre-malignant and epidermoid carcinoma can be associated with it in 18 to 35% of cases. Diagnosis • Clinical diagnosis —everted hypertrophic lip with secretion after pressure on lip. Management • Vermilionectomy or lip shave ded . • Surgical excision

19. Granulomatous Cheilitis or Orofacial Granulomatosis It is also called as ‘ Miescher’s syndrome ’ or ‘ cheilitis granulomatosa ’. Etiology Local causes • Chronic oral/dental infection • Embedded foreign material • Allergy to cosmetics, foods, oral hygiene products and dental restorative materials. Systemic causes • Chronic granulomatous disease • Crohn’s disease • Sarcoidosis • Tuberculosis

20. Clinical Features • Age and sex —it is seen in adults as well as in children and there is female predilection. Symptoms • There is diffuse swelling of the lips, especially the lower lip • In some cases, an attack is accompanied by fever and mild constitutional symptoms including headache and even visual disturbances. • Enlarged lip can create cosmetic problems, difficulty during eating, drinking or speaking. • Syndrome— it is associated with Melkersson Rosenthal syndrome which consists of fissured tongue and facial paralysis. Diagnosis • Clinical diagnosis —soft swelling of lip with fever,headache and vesicle can be seen.

21. Differential Diagnosis • Cheilitis glandularis • Angioedema • Sarcoidosis • Crohn’s disease • Lymphangioma Management • Corticosteroid injection —repeated 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. • Cheiloplasty —surgical stripping of lip can be done.

22. Angular Cheilitis It is also called as ‘ Perleche ’, ‘ Angular cheilosis’ ‘ Cheilocandidiasis ’. Causes • Microorganisms — candida albicans, staphylococci and streptococci. • Mechanical factors —overclosure of jaws. Nutritional deficiency— riboflavin, folate and iron deficiency • Other factors —hypersalivation, Down’s syndrome Clinical features • Age —it occurs in young children as well as in adults. • Symptoms— it is characterized by feeling of dryness and a burning sensation at the corners of the mouth. • Appearance— it is usually a roughly triangular area of erythema and edema at one or more, commonly both the angles of mouth.

23. Diagnosis • Clinical diagnosis —triangular area or erythema with wrinkled macerated mucosa at angle of mouth. Management • Removal of the cause • Nutritional supplement— vitamin B and iron supplements • Fusidic acid ointment— it is used in staphylococcal infection. • Miconazole— miconazole may be preferred, if angular cheilitis is due to candidiasis (cream applied locally together with an oral gel). • Gentian violet application— in some cases, it is useful.

24. 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 • Lipsticks • Lip salves and other medicaments • Mouth washes and dentifrices • Dental preparations • Foods —oranges, mangoes and artichokes are among the food plants which occasionally cause allergic cheilitis and dermatitis of the skin around the lips.

25. Clinical Features • Site —lipstick cheilitis is usually confined to the vermilion borders but more often extends beyond that. • Signs and symptoms— there may be persistent irritation and scaling or a more acute reaction with edema and vesiculation Management Topical steroids will give symptomatic relief-- 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 more 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 • Chronic sun exposure —it is the main cause, so it usually occurs in hot, dry regions, in outdoor workers and in fair skinned people .

26. Clinical Features • Site —the lower lip is more commonly affected than the upper lip. • Age and sex distribution— it is more commonly seen in adult’s patient. It is less common in females. • Signs— in 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 edges.

27. Diagnosis • Clinical diagnosis —redness, edema with history of chronic sun exposure will give clue to diagnosis. Management • Topical fluorouracil • CO 2 snow • Vermilionectomy (lip shaves) • Laser ablation • Electrodesiccation • Prevention

28. 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 • Chronic injury — due to repeated lip sucking, chewing or other manipulation of the lips. • Personality disorders— emotional disturbance, psychological difficulties and stress. Clinical Features • Age and sex distribution —age of occurrence is seen in younger group. Most cases occur in girls. • Site— the process starts in the middle of the lower lip and spreads to involve the whole of the lower lip or both the lips. • Symptoms— the patient complains of irritation or burning and can be observed frequently on biting or sucking the lips. • Signs— it consists of scaling and crusting, more or less confined to the vermilion borders and persisting in varying severity for months or years.

29. Diagnosis • Clinical diagnosis— Scaling, crusting with perioral skin erythema will aid to diagnosis . Management • Reassurance and psychotherapy • Topical steroids— hydrocortisone cream • Combination— hydrocortisone can be combined with iodoquinol (antibacterial and antimycotic) cream can be used in chronic cases of exfoliative cheilitis. • Others therapy— it includes topical silver nitrate, salicylic acid, antibacterial and antifungal formulation.

30. 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 • Site —it can affect penis, vulva, lips, buccal mucosa, palate, gingiva, tongue, epiglottis and larynx. • Sign— it presents as circumscribed patches of erythema , usually on the lower lip in elderly persons. Diagnosis • Clinical— not possible. • Laboratory— on histopathological examination plasma cell can be seen. Management It responds to topical application of powerful steroids or to intradermal injection of triamcinolone. Drug-induced Cheilitis 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 cause dryness and cracking of lips in most patients.

31. Carcinoma of Lip Squamous cell carcinoma is the commonest malignancy to affect the vermilion zone. It occurs in light skinned people who have chronic exposure to sunlight. Clinical Features • Age and sex distribution— 6 th and 7th decade of life. It is more common in males • Site— it is most common on the lower lips of fair skinned people • Onset— it usually begins on vermilion border of the lip to one side of the midline and it may be covered with crust due to absence of saliva. • Symptoms— patient may complain of difficulty in speech, difficulty in taking food and inability to close the mouth. There is also pain, bleeding and paresthesia. Signs -- It often commences as a small area of thickening, induration and ulceration or irregularity of the surface • In some cases, it commences as a small warty growth or fissure on the vermilion border of the lip. • As the lesion enlarged, it takes papillary or an ulcerative form. • In untreated cases, there is total destruction of lip and invasion of cheek, the gums and the mandible.

32. Diagnosis • Clinical diagnosis— ulcerative growth with destruction of lip is present. • Laboratory diagnosis— it is mainly well differentiated malignancies. Management • Surgical—prognosis is good if the treatment is done before metastasis. • The best results are seen when being obtained when the entire lip mucosal field is removed for early lesion.

33. Miscellaneous Disorders Chapping of the Lips It is a reaction to adverse environmental conditions in which keratin of the vermilion zone loose its plasticity. • Causes — it is caused by exposure to freezing cold or to hot, dry wind, but acute sunburns can cause very similar changes. • Clinical features —lip becomes sore, cracked and scaly. The affected subjects tend to lick the lips or to pick at the scales which make conditions worse. • Management — Management is by application of petroleum jelly and avoidance of the causative environmental conditions.

34. 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 • Site —it is seen on the labial mucosa exposed to sun. • Age— it occurs in elderly population. • Signs— white area of atrophic epithelium develops with underlying scarring of the lamina propria. • Appearance— it includes leathery appearance, laxity with wrinkling and various pigmentary changes. • Clinical types— clinically, it is manifested in three forms: • Cutis rhomboidalis — thickened skin with furrow giving an appearance of rhomboidal network. • Dubreuilh’s elastoma — diffuse plaque like lesions . • Nodular elastoidosis — nodular lesion.

35. 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 • Age and sex distribution —it is more commonly seen in adults. Site— either lip can involve or some patients have bilateral lesion. • Appearance— the lesion present as linear, arcuate or papular elevation on the lip. • Ulcer formation— such artery in the lip may cause chronic ulceration which can be mistaken for squamous cell carcinoma. The ulcer is attributed to continual pulsation from the large artery running parallel to the surface. • Signs— pulsation can be seen in the lesion. Pulsation is present in lateral direction. Management • No treatment is necessary and some time, biopsy is done to avoid the misdiagnosis of the lesion.

36. References :- Burket’s oral medicine 11 th edition Oral and maxillofacial medicine second edition – crispian scully Textbook of oral medicine by anil govindrao ghom Differential diagnosis of oral and maxillofacial lesion Norman k. wood & Paul w. goaz

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