The ingestion ot metals such as mercury, lead, and bismuth in medicinal compounds and through industrial contact may result in oral manifestations owing to either intoxication or absorption without evidence of toxicity.
Bismuth Intoxication. Chronic bismuth intoxication is characterized by gastrointestinal disturbances, nausea, vomiting, and jaundice, as well as by an ulcerative gingivostomatitis, generally with pigmentation and accompanied by a metallic taste and burning sensation of the oral mucosa. Ihe tongue may be sore and inflamed. Urticaria, e.xanthematous eruptions of different types, bullous and purpuric lesions, and herpes zoster-like eruptions and pigmentation of the skin and mucous membranes are among the dermatologie lesions attributed to bismuth intoxication. Acute bismuth intoxication, which is less commonly seen, is accompanied by met hemoglobin format ion, cyanosis, and dyspnea.91 Hismuth pigmentation in the oral cavity usually appears
as u narrow, bluish-black discoloration of the gingival margin in areas of préexistent gingival inflammation (see ( hapter 17 and Fig. 17-11). Such pigmentation results from the precipitation of particles of bismuth sulfide associated with vascular changes in inflammation. It is not evidence of intoxication but simply indicates the presence of bismuth in the bloodstream. Bismuth pigmentation in the oral cavity also occurs in cases of intoxication. It assumes a linear form if the marginal gingiva is inflamed.
Lead Intoxication. Lead is slowly absorbed, and toxic symptoms are not particularly definitive when they do occur.100 There is pallor of the face and lips and gastrointestinal symptoms consisting of nausea, vomiting, loss of appetite, and abdominal colic. Peripheral neuritis, psychologic disorders, and encephalitis have been reported. Among the oral signs are salivation, coated tongue, a peculiar sweetish taste, gingival pigmentation, and ulceration. The pigmentation of the gingiva is linear (burtonian tine), steel gray, ami iissociated with local irritation. Oral signs may occur without toxic symptoms.
Mercury Intoxication. Mercury intoxication is characterized by headache, insomnia, cardiovascular symptoms, pronounced salivation (ptyalism), and a metallic taste.4 Gingival pigmentation iu Uncut form results from the deposition of mercuric sulfide. The chemical also acts as an irritant, which accentuates the préexistent inflammation and commonly leads to notable ulceration of the gingiva itinl adjacent mucosa and destruction of the underlying bone. Mercurial pigmentation of the gingiva also occurs in areas of local irritation in patients without symptoms of intoxication.
Other Chemicals. Other chemicals, such as phosphorus, arsenic, and chromium, may cause necrosis of the alveolar bone with loosening and exfoliation of the teeth." 1 " Inflammation and ulceration of the gingiva are usually associated with destruction of the underlying tissues. Benzene intoxication is accompanied by gingival bleeding and ulceration with destruction of the underlying bone.
Fig. 12-27 Characteristic clubbing of the lingers in the patient shown in Fig. 1 2-26, consistent with untreated congenital cyanotic heart disease.
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