Oral Manif.of Sys.dis

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10 Desember 1955

S.A. TY SKRI V IR GENEE SKUND E 1159

oorsaak van leukemie te beskou. Geweldige X-straal

masjinerie word deesdae by mediese sentrums aangele,

radioaktiewe is oto pe word steeds meer by diagnose,

behandeling en basiese navorsing gebruik; metodes

soos angiografie

en

kateterpassasie in die hart stel

steeds m ee r dokters

en hul assistente aan bestraling

bloot.

Di t

is dus moontlik dat leukemie n belangrike

mediese beroepsrisiko kan word. n Kritiese herbepaling

van die doeltreffendheid van die voorsorgsmaatreels wat

as straalbeskerming getref word, is nodig. Ons merk

met genoee dat die International Commission on Radio

logical Protection

b ai e a an dag

aan

hierdie probleem

bestee het.

8

,9 Die kommissie het n aantal voorstelle aan

die hand gedoen en die ,bevolking in gevaar kan gerus

daarmee vertroud raak.

Furth, J. en Kabajian,

H.

1934): Amer. J. Roentgenol.,

32,227.

2 Furth, J. 1946): Phy si ol . Rev ., 2 6, 47.

3

Kaplan,

H. S 954): Cancer Res., 14,535.

4. March,

H.

C. 1950): Amer. J.

Med.

Sci., 220, 282.

5

mrich,

H. 1946): New. Engl.

J.

Med., 234, 45.

6

M ol on ey , W. C. 1 95 5) :

Ibid.

253,88.

7

Court

Brown, W. M.

en

Abbot, J.

D.

1955): Lancet, 1,1283.

8 Red ak si e 1955): Bri t. M ed .

J.,

2, 370.

Idem

1955):

Ibid..

2, 606.

ORAL MANIFESTATIONS

radiation as potentially leukaemogenic. Mighty X-ray

plants are being in taIled at medical centres; ra di o

active is otopes ar e being used with g reat er freedom in

diagnosi, treatment and basic resea rc h; procedures

such a angiography and cardiac catheterization are

exposing more a nd m ore doc tors and their a sistants to

radiation.

is p o ible, therefore,

that

leukaemia may

become a m aj or occupatio nal hazard

of

the medical

profes ion. A critical re-evaluation

of

the protective

measures employed against radiation

is neces ary

and we

note with sati faction that the International Commission

on Radiological Protection has devoted considerable

attention to this problem.

The Commission has made

a number

of

proposals with which the population at

risk would be well advised

to

familiarize itself.

1. Fur th , J. and Kabajian, O. H. 1934): A me r. J. Roe nt ge no l. ,

32,227.

2. F ur th , J . 1946): Phys iol. R ev ., 26,47.

3. Kaplan,

H.

S. 1954):

Cancer

Res., 14, 535.

4. March, H. C. 1950): A me r. J . Med. S ci., 220, 282.

5. Ul rich, H. 1946): New. Eng l. J. M ed ., 234, 45.

6 . Moloney, W . C. 1955):

Ibid.

253, 88.

7.

Court Brown, W M. and Abbot, J. D. 1955): Lancet,1, 1283.

8. E di to ri al 1 95 5) : Bri t.

Med. J .,

2, 370.

9. Idem 1955): Ibid. 2, 606.

OF

SYSTEMIC DISEASES*

H. GOLDIN D.D.S.

MICH.),

L.D.S. R.e.S.,

ENG.

Maxillo-Facial n Oral Surgeon Pretoria

t

is with pleasure

that

I offer you this short talk on a

subject which so obviously calls for co-operation

between

our

two professions.

The

dental surge on is

interested in oral manifestations

of

systemic disease,

and the medical practitioner

is

well aware of systemic

manifestations

of

oral disease. We, in our blundering

way

try to drum

into

our dental students that we

should be the experts in the diagnosis of

mouth

lesions.

In the short time allotted we shall attempt to enumerate

the c om mone r c ondi ti ons found in

the m ou th , where

an early diagnosis may be

of

help, and i n so me cases

may even be life-saving.

Blood Dyscrasias

Leukaemia.

Let

me

first of all deal with

the

blood

dyscrasias. Nearly all blood diseases manifest some

local sign in the mouth and this is true especially with

the a cute leukaemias. H ere t he gingival bleeding may

be the first symptom. L at er we

may

see ulceration and

necrosis.

is

not

pleasant to remove a

tooth

in the

presence of leukaemia, and only afterwards find the

mouth going gangrenous just b ef or e the p at ie nt dies.

However we are forced to remove teeth in s om e cases

of the c hr on ic leukaemias. Here, of course, we work

in close c o-o pe rati on with the att end in g d oc to r, who

might suggest e xtr acti ng while t he re is a t empo ra ry

improvement under X-ray treatment.

A

paper

delivered at a

joint

meeting of the

Northern

Transvaal

Branch

of

the Medical Association

and

the Northern Transvaal

Branch of the Dental . \ssociation.

3

Agranulocytosis. Often the dental surgeon is the

first to rec ogni ze this disease. The picture is sudden

onset

of

severe ulceration i n the

mouth,

rapidly pro

gressing t o necrosis. T hi s is a n ugly sight, which o nc e

seen is never forgotten. Agra nulocyt osis in the mouth

l ooks like a streptococca l infection gone mad. is a

raw , inflamed m outh w it h tissues in various stages of

ulceration.

Erythema Multiforme. The

mouth manife tations

of

this disease can l ook very m uc h like t he above,

and

are

very often confusing becau se long af te r t he skin e rup

t ion has subsi de d, t he mouth may flare up. Of course

the

healed ski n scars of e rythema m ul ti form e hel p i n

the clinical diagnosis. In the m ou th t he picture is

one

of inflamed, raw, ulcerating surfaces over the wh ole

oral cavity.

Hodgkin s Disease. This often starts with glands in

the

neck

and

the

p atien t suspects a local co ndi ti on in

the mouth. By the time

the

lymphatic tissue of the

mouth

is affected the disease is usually far a dva nced.

Then

you see a most unusual picture of heaped-up lymph

tissues

all

over the palate and mouth. This may ulcerate

from

econdary infection.

In chronic lymphatic leukaemia, when you

have

hyperplasia

of

lymphatic ti ue, the first signs may be

cervical a denit is a nd the patient reports su pecting

infected teeth.

Pernicious Anaemia. Apart from

the

pale, yellowish

appearance

of

lips and oral muco a, a marked feature

is H unte r

glossitis-an

atrophy

of

the filiform papillae



1160

S

M E D I C L

J O U R N L

10 December 19

of

the ton gu e, which leaves a s mo oth b ur ning tongue,

due to t he desquamation

of the

epithelial covering

of

the nerve endings. The causes

of

atrophy of the papillae

of the

ton gu e are near ly always systemic. They may b e

nutritional deficiencies; the condition is found in

pellagra, sprue,

the

secondary anaemias, hyperchlor

hydria and acWorhydria, and in alcoholics probably

due to deficiency).

Haemophilia. As dental surgeons we are very inter

ested, for we deal a l ot with b lo od. The haem at ol ogi st s

distinguish different

factors the

labile factor, Christmas

fa ct or etc. Ma ny patients

are on

Dicumerol, Heparin,

and

o th er a nt ic oa gul ant d ru gs ; they m ay

be

bleeding

from the gums

i

they

are

not

being

controlled but

even under control they will bleed after extraction.

History-taking will avoid accidents.

Purpura.

In

this condi tion we see bleeding from

gums and swollen gums

and

also ecchymosis u nd er

mucous membranes.

Bleeding gums with gingival hypertrophy

These conditions are often seen in children.

Among

other factors, mouth breathing is a common

cause. Incidentally, after

the

E.N.T. specialist h as

done

his part, the patient should be taught to breathe

normally by giving him a mouth shield.

Vitamin-Deficiency Diseases

Vitamin C 0 need to enlarge on scurvy. We see

spongy, hypertrophied gums, sore bleeding gums,

loose teeth. There is also a subclinical s curvy, wh ich

is not

always recognized.

Vitamin B.

With

deficiency

of

this vitamin, especially

r iboflavin, occu r ang ular ch eilos is and ton gu e lesions.

Perleche is often seen in elderly people, wearing den

tures. They have atrophy

of

the alveolar ridges

and

their mou th s b ecome over-closed. Their dentur es sink,

and

t he chin tries

to

meet

the

nose. They get cracked

lips, saliva d ro ols out and, with vitamin-B deficiency,

infection with

Monilia Candida albicans

occurs. This

perleche can be cleared

up

by opening their bites by

relining dentures, massive vitamin-B therapy,

and

the anti-fungoid antibiotic mycostaton. These yeast

infections,

of

cou rs e, are the cau se

of

t hru sh . The a nt i

biotics upset the balance

of

nature; the fungoid growths

thrive

and

vitamin-B is interfered with.

We

see monilia

infections thrush of

the mouth and

tongue from

babyhood

t o old age . The medical people see enteritis,

pruritus, etc. from monilia infections. The fungus also

grows under unclean dentures, leading

to

denture sore

mouths.

Vitamin

V itamin K is necess ary f or p ro th ro mb in

formation. When we know that liver dysfunction is

present

and

we wish to extract, we refer

the

patient

to

his

doctor

if we wish to avoid excessive haemorrhage.

By the

way, h yp er tens ion is a f requent cause

of

socket

haemorrhage.

Syphilis.

We have

had

syphilis

ad nauseum, but

familiarity must not breed con temp t. Thirty-five

per

cent

of

finger syphilis occurs in dentists.

Our

patients

p resent with n umer ou s and v ar ied lesions in the mou th ,

and

many are

atypical but

we teach

that

all m ou th

lesions a re suspect, for syphilis simulates a lmost

diseases.

The

highly contagious chancre on the

does not always resemble the penile chancre. t som

times appears as a mere small soft abrasion inside t

lip or on

the

lip, completely aty pical; it may loo k li

a cigarette bu rn

or

any other sore on the lip. Th

primary syphilis

of

the mouth is easily overlooke

Sockets

can

become infected by syphilis.

The secondary stages seen in

the

mouth resemb

almos t anything. W e may see fu ng atin g g ro wths tee

ing with Treponema pallida.

In the

t hi rd s tag e gu

m atous i nfi ltration l eads t o p erf or at ion

of

the ha

palate and collapse

of the

nose; 40

of

all g umma

are

found in the mouth. We see syphilitic osteomyeli

of

the man dible going on to f ractur e

of

the jaw, a

also all so rt s

of

h ar d lumps and fibrous healing sca

With syphilis there

is

an arteritis,

and

thus we get d

sockets, etc., thr ou gh lack of blood supply. We als

of

course, see all the s tigmata

of

congenital syphilis.

Herpes Simplex. This virus disease occurs on t

lips and in the mouth and may resemble the lesions

syphilis.

Aphthous Stomatitis,

known also as the aphtho

ulcer or dyspeptic ulcer, is considered by many to

herpes simplex. Unli ke Vincent s stomatitis t hi s co

dition does not respond to treatment. The aphtho

ulcer

is

consi dered b y ma ny to b e

due

to a virus whi

is normally present i n mucous membranes. A nyt hi

that lowers the local resistance may precipitate

attack an injection, scratches f ro m food

or

toot

brush,

any

of

these m ay be an exci ting cause.

In Scarlet Fever, a Streptococcus haemolyticus infe

tion, the

t hroat and

or al lesions develop

at

a ve

early stage; t he c oated tongue cleans up

and

after

few days we see the strawberry tongue. -

With Measles the Koplik spots appear 3

or

4 da

before the skin is affected.

Cancrum Oris Gangrenous Stomatitis may follo

any d ebilitating disease. These d ay s they r ecov er wi

treatment,

but

leave some very badly deformed mouth

Parotitis is seen following operations on debilitate

elderly people.

is associated w ith lack

of

secretio

an d poor oral hygiene.

Chemicals and Drugs.

P oiso ning with fluorin

bismuth, l ea d a nd me rc ury all leave their

mark

in th

mouth. We see s tomatitis due

to

medicaments. Fo

instance, the anti-epileptic drugs may cause a ver

severe hypertrophic gingivitis; very good oral hygien

might prevent this. We also see phenophthalein poison

ing and iodine poisoning.

Sprue.

In

this debilitating disease atrophic change

occur all

the

way from t he oral cavity to the anus.

Lichen Planus. is said that 60

of

p atients have

form

of oral

lichen p lanu s. We certainly see it o ften n

t he m out h only, with no skin manifestations. A diffe

€ ntial

diagnosis can be made histologically from leuco

plakia. Anti -ca ncer campai gns b ri ng these lesions t

the atten tion

of

the patients

and

they come

for

con

sultation, or sometimes through heavy smoking o

spicy foods the c ondit ion becomes painful. As a rul

it is painless.

Pemphigus.

This

is

very painful

and

may

appear

i

the mout h as painful bullae or ulcers years b ef or e th





1162 S.A. MEDICAL

JOURNAL

10 December 1955

metastasize to the jaw. I t is very disconcerting, to say

the least, when one has removed a jaw tumour, to find

it was only a secondary growth. Metastatic carcinomas,

lymphosarcomas, osteosarcomas, syphilis, can all give

rise to oral symptoms, and are a frequent cause of

obscure pain. Many giant-cell tumours are secondary

to

some irritation

of

the parathyroid gland, which is

causing an upset

of

the calcium-phosphorus balance.

Remove the

irritation-perhaps

an adenoma

of

the

parathyroid-and the giant-cell tumour of the jaw may

disappear.

Maxillary sinusitis causes pain in the face and dental

symptoms.

Odontalgia

may

result from flying

at

altitudes above

5,000 feet.

We see cases

of

Hand Schiiller Christian disease.

In the past one operated for this condi tion,

but

it

responds to

X-ray

therapy,

and

jaw opera tions can be

avoided.

is one of the diseases in which diagnosis

is so important. We have cases where teeth have loos

ened up in children for apparently no reason. One has

extracted them, only to find one was dealing with

an

osteosarcoma for example. All loose teeth are

no t due

to pyorrhoea

or

absesses. One sees a number of cases

of

carcinoma of the antrum causing dental symptoms;

an upper molar may become loose and painful-after

extraction a fungating growth may appear in the socket

and the dentist may be blamed by an ignorant family

for having caused the carcinoma. Osteogenic sarcomas

cause teeth to become loose, and when a lovely child

dies a

few

months after

an

extraction, it is only human

for the family to look for a scapegoat. Always be

suspicious of an inflammatory mass

round

a tooth or

a tooth socket.

Derangement

the Temporo-Mandibular Joint. This

may give rise

to

all sorts

of

pain in

the

face and

oral

cavity. We dentists call it our joint, because it affects

us so

much-naturally

it affects the patient too. One

has no t ime here to go into this vast subject. A 700-page

book has been written

by

a dental surgeon

on

this

joint

and

its disturbances, and there is indeed a vast

amount

of

literature on the subject.

The pains caused by derangement of the T.M. joint

may be from myositis or fibrositis due to strains in

muscles

and

ligaments with changes in the joint . Rheu

matoid arthritis affects the T.M. joint as well as osteo

arthritis. We must remember that osteo-arthritis

is

not due

to

a focus

of

infection.

Cleidiocranial Dysostosis. Dentists are interested in

this disease, in which

we

get incomplete ossification

of the fontanelle, lack of scapula and non-eruption

of teeth with many supernumerary teeth as well.

osteitis deformans Paget s disease the first

changes are often those seen in the maxilla, whereas in

acromegaly it

is

the mandible that first grows so large,

and in leontiasis ossia you see the typical lion face.

Radio-therapy. These days dentists see some

un-

fortunate results of radio-therapy, such as radio-necrosis

going

on

to an intractable radio-osteomyelitis.

Lastly, a few words about mouth odours. These are

not all due to mouth conditions. Nose and sinus con

ditions may be the cause or lung absesses or many

other conditions. Onion and garlic are absorbed in

the intestines

and

the odour is due to elimination

through the lungs.

In closing may I leave this thought with you? Our

two professions

are

so closely allied biologically, that

in the interest of the patient we have to work in the

closest co-operation. This may account for the perfect

harmony and understanding

that

exists between the

two professions,

who

after all are working with but the

same

object-to

benefit the patient.

A

TOXOPLASMIN

SKIN-TESTING SURVEY AMONGST A

GROUP OF

SOUTH AFRICAN

BANTU

J SCHNEIDER M.B., B.CH., D.T.M.

H

and D.

GODDARD M.B., B.CH.

Medical Registrars University

the Witwatersrand and Coronation Hospital Johannesburg

and

J. HEI

TZ

PH.D.

Department

Parasitology South African Institute

r

Medical Research Johannesburg

The toxoplasmin skin-test has been described as a

useful aid in the diagnosis of third-stage toxoplasmosis,

and

in making population surveys (Frenkel and Fried

lander ). According to these workers the term third

stage of toxoplasmosis includes both chronic and past

cases showing clinical or laboratory evidence of infec

tion. They maintain

that

toxoplasmin skin-tests are

positive during the third stage of the disease, but that

in

first-stage (acute) toxoplasmosis skin reactions are

negative, and are usually negative in the second stage

(subacute form) of the disease as well. From the fore

going it is obvious that toxoplasmin intradermal tests

may be used to ascer tain the prevalence of third-stage

toxoplasmosis amongs t the general population. The

test is based on dermal hypersensitivity to toxoplasma

antigen and in this respect resembles the tuberculin

(Mantoux) test.

o references have appeared

in

the South African

medical literature regarding the prevalence of third

stage toxoplasmosis amongst the general population of

Oral Manif.of Sys.dis

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