Disorders of oral, vaginal mucous membranes overlooked by physicians

September 1, 2010

Dermatologists should be able to diagnose and treat disorders of the oral and vaginal mucous membranes with the same authority they bring to skin problems, experts say.

Key Points

National report - Dermatologists should be able to diagnose and treat disorders of the oral and vaginal mucous membranes with the same authority they bring to skin problems, experts say.

"The sort of things dermatologists do on skin without thinking about it, we should be doing within the mouth," she says.

Dr. Torgerson begins by having patients open their mouths and relax their tongues so she can examine the back and roof of the mouth. "Then I use a tongue depressor and look at the inside of the cheeks," followed by all sides of the tongue, she says.

"Next, I concentrate on dentition and gingiva," still using the tongue depressor, particularly to help her view the sides of the gums. "And when I examine the front of the mouth, I have patients help me by grabbing their lips and doing the eversion for me," Dr. Torgerson says.

Additionally, she says dermatologists must not forget to examine the patient's mouth when closed. "The first things to consider are the vermilion border, cutaneous lip and symmetry of the jaw. You can palpate the temporomandibular joint; examine the neck, consider symmetry and palpate for lymph nodes," she says.

Pigments matter

Dermatologists also must remember that just as skin contains pigment variations, so do mucous membranes. "One of the most common areas affected are the attached gingiva. The color can be a little different; the texture should be normal, and these gingiva should be asymptomatic," Dr. Torgerson says.

Leukoedema tends to occur more frequently in darker-skinned patients, Dr. Torgerson says. "It looks like a milky-white shiny covering on the buccal mucosa. The more you stretch the skin, the less obvious it will be." It also looks symmetric side-to-side, she says.

The bite line is a hyperkeratotic change that occurs where the teeth come together. It's usually bilateral and asymptomatic. "The nuisance comes in when you ask, 'Is this lichen planus or a bite line?' Over time, you'll get a feel for it," Dr. Torgerson says. Patients who worry about bite lines, leukoedema or gingival pigmentation generally require reassurance, she says.

Dr. Torgerson says that some patients have asked her to perform cosmetic treatments on oral Fordyce spots. "But I leave them alone," she says. "I don't want scarring as a result."

Prominent circumvallate papillae located on the back of the tongue can vary in size, Dr. Torgerson says. "I have heard otolaryngologists say that they use it as a 'soft' sign of reflux, but I don't believe it's very predictable in that regard," she says.

Amalgam tattoos inside the mouth appear as grayish to blackish markings in linear or macular form, usually near a dental restoration. "If there's any question about whether an amalgam tattoo is melanocytic, take a biopsy," Dr. Torgerson says.

Mucoceles result from dilation of the salivary gland or extravasation of saliva. "The most common location is the lower lip. If you stretch the lip, and it's superficial, you'll see a bluish hue in the area. Mucoceles may wax and wane in size. Usually people come to us because they've become a nuisance" that's easily excised, she says.

For a furred tongue, which consists of hypertrophic filiform papillae, Dr. Torgerson recommends daily brushing with a toothbrush or tongue scraper. Other interventions include increasing dietary fiber intake, and stopping smoking and mouth breathing, she says. A high degree of hypertrophy and the presence of bacteria can produce a "black" furred tongue, which is more likely to cause a ticklish sensation and may require brushing with hydrogen peroxide, Dr. Torgerson says.

"The absolute opposite is a smooth tongue, which is caused by atrophy of the filiform papillae," usually in older patients. Potential causes include nutritional deficiencies, "But if there's nothing that can be addressed, and it's not a reversible process, a bland, soft diet usually works best for the patient," she says.