Atlas Penyakit Mukosa Mulut

3 0 0 Atlas F e n y a k i t M u k o s a M u l u tEtnasPersenyawaan emas yang disuntikan secara intravena memberikan efek supresifpada reumatoid artritis, tetapi senyawa itu mempunyai toksisitas yang potensial.Seperd pada kasus logam berat lainnya, ekskresi emas sangat lambat. Emas disim-pan di dalam jaringan untuk waktu yang lama dan dapat dideteksi bekasnya di dalamurin selama 10 bulan sesudah disuntikkan. Reaksi toksik terdiri dari sakit kepala,demam, gatal, erupsi kulit, stomadtis dan albuminuria. Yang bersifat parah adalahkomplikasi seperti trombositopenia, anemia aplastik, dan agranulositosis.Stomatitis yang disebabkan emas dapat ddihat di bagian manapun pada mukosaoral, meskipun permukaan bawah lidah dan dasar mulut tampaknya paling seringterkena. Pada 18 penderita, yang dirawat dengan tiosulfat sodium emas, perubahanmukosa yang paling sering adalah ulserasi non-spesifik, erupsi seperti liken, atrofipapil filiformis pada lidah dan eritem difus^^. Lesi yang tipik tampak pada wanitaberusia 65 tahun yang diperlihatkan di sini, yang telah mendapat suntikan tiosulfatsodium emas (Sanocrysin) selama beberapa minggu. Mula-mula timbul eksantemayang terasa gatal pada siku; kemudian timbul ulserasi bilateral pada palatum.Penderita yang mendapat suntikan emas dapat mengalami stomadtis kontak ter-hadap restorasi emas di mulut^^^.Turunan hidantoinKira-kira tahun 1939, perubahan gingiva yang hiperplastik, ddaporkan pada peng-obatan epilepsi dengan obat 5,5 difenilhidantoin (phenytoin). Penggunaan namadagang untuk hiperplasia harus didnggalkan. Insidens yang dilaporkan mengenaitimbulnya hiperplasia gusi pada penderita yang mendapat pengobatan denganobat-obat turunan hidantoin, beragam dari 3 hingga 62%. Insidens hiperplasia lebihrendah sebelum pubertas; tidak ada predileksi terhadap jenis kelamin tertentu^^'.Tanda-tanda awal hiperplasia dmbul pada papd interdental, yang membesar danagak lebih merah daripada gusi sekitamya. Papil interdental yang membesar seringmenampakkan permukaan yang berbintik seperti pada gambar seorang laki-lakiberusia 27 tahun yang telah m i n u m 200 m g phenytoin (Difhydan)setiap hari selama6 tahun. Kemudian mahkota klinik pada gigi dapat tertutup seluruhnya oleh massapadat jaringan kenyal yang kuat yang tidak berdarah secara spontan atau denganmudah jika diperiksa. Pseudopoket yang tampak nyata dapat terbentuk olehhiperplasia yang pejal (massive) ini. Hiperplasia tak selalu dikaitkan dengan gejalaklinik. Hiperplasia yang disebabkan oleh phenytoin pada penderita yang tak bergigijarang terjadi. Telah dilaporkan satu kasus hiperplasia masif pada mukosa yangmenutupi gigi yang belum erupsi pada seorang anak laki-laki berusia 2 tahun. A n a kitu mendapat pengobatan hidantoin sejak lahir\"\"^^.

Cedera dan K e r a c u n a n 3 0 1 KERACUNAN OBAT

3 0 2 Atlas F e n y a k i t M u k o s a M u l u tTurunan hidantoinAnak laki-laki berusia 15 tahun yang terlihat di sini telah menerima 300 m gphenytoin (Difhydan) tiap hari selama 2 tahun. Hiperplasia yang tampak di sinisangat besar dan melibatkan \"attatched gingiva\". Papil interdental d iantara gigiinsisivus sentral bawah terbelah dua oleh lekukan yang halus. Gambar ini yangkadang-kadang terlihat pada hiperplasia gingiva phenytoin, disebabkan oleh tepirete epitel yang tumbuh ke bawah dan membelah jaringan kolagen yang hiperplastikmenjadi dua bagian. Seringkali gambaran klinik mengalami perubahan oleh per-darahan yang mengakibatkan gusi tampak merah membara, dan mungkin timbulr a b a s b e m a n a h (purulent discharge) d a r i p o k e t . T a m p a k s u a t u k o r e l a s i p o s i t i fantara keparahan pertumbuhan yang berlebihan dan peradangan gusi, kedalamanpemeriksaan, penumpukan kalkulus, skor plak, dan pengukuran tepi bebas gusi kebatas mukogingival. Pada penelitian yang sama tampak tak ada hubungan antarakeparahan lesi d a n usia penderita, penggunaan obat setiap harinya, tingkatphenytoin pada saliva atau plasma atau konsentrasi saliva pada metabolit phenytoinyang utama^^*. Mekanisme di belakang hiperplasia gingiva masih belum diketahui.Suatu penemuan bam adalah meningkatnya matriks non-kolagen dan menurunnyamatriks kolagen'^'.P a raformaldehydeLuka akibat zat kimia yang bersifat kronik dapat disebabkan oleh pemakaian obattertentu yang berkepanjangan oleh penderita atau pemakaian kaustik yang salaholeh dokter gigi, sehingga menyebabkan nekrosis kontak. Termasuk dalam kelom-pok pertama adalah pengaruh yang merugikan pada obat kumur biasa yang men-gandung sodium perborat pekat. Z a tini yang dikenal dapat mengakibatkanperubahan pada mukosa oral oleh karena penggunaan yang salah adalah yodium,fenol, dan nitrat perak. D i beberapa negara digunakan atau pernah digunakan paraformaldehyde, untuk mumifikasi pulpa, sering ditambahkan amidrikain kloridasebagai anestedkum. Paraform yang disiapkan dengan polimerisasi formialdehidoleh panas, melepas uap formaldehid pada suhu biasa. Itu mempakan kaustik, dandapat menyebabkan akibat sampingan yang tak diinginkan jika ddak ditanganidengan baik. Gambar memperlihatkan papil interdental vestibular yang nekrotik diantara geraham pertama dan kedua. Penderita seorang laki-laki bemsia 2 4 tahun,menderita pulpitis kronik pada geraham pertama. Dokter gigi mempergunakanparaformaldehyde untuk mematikan pulpa, tetapi kurang hati-hati ketika menutuplubang dengan zinc oxide- eugenol. Sebelum semen mengeras, sejumlah paraformtertekan ke luar hingga memasuki sela interdental, menyebabkan nekrosis papilinterdental dan tulang septum.

Cedera dan K e r a c u n a n 3 0 3 KERACUNAN OBAT

3 0 4 Atlas Penyakit M u k o s a M u l u tKlorheksidin (Chlorhexidine)Klorheksidin adalah zat and bakteri dengan aktivitasterhadap bakteriGram-positifdan Gram-negatif juga rugi. Toksisitas klorheksidinrendah. Klorheksidin dalamkonsentrasi 0,2 dan 0 , 1 % efisien untuk mencegah pembentukan plak dan gingividspada manusia^'**. Efek samping seperti mengubah w a m a gigi dan lidah danmengganggu rasa yang lebih jarang telah diamad ddak begitu jarang terjadi. Y a n glebih jarang terjadi adalah pengelupasan epitel oral yang terdapat pada 10 orang diantara 148 orang yang berkumur dengan 0 , 2 - 0 , 1 % klorheksidin setiap hari selama17 m i n g g u ' ^ . Pada 7 contoh, lesi itu kecd dan hanya berlangsung dalam jangkaw a k t u yang pendek. N a m u n pada 3 penderita laiimya lesi yang timbul lebih pa: ahseperti tampak pada seoraftg laki- laki bemsia 18 tahun yang gambamya diperlihat-kan di samping. Penderita telah berkumur dengan 0,2% klorheksidin glukonat.Kemudian menderita perasaan terbakar pada mukosa oral dan rasa sakit sehubungandengan eritem pada gusi dan lekuk pipi (buccal groove). Pada beberapa daerahterjadi pengelupasan epitel. Pada waktu di kerok tampak erupsi kecd , lesimenghilang ketika konsentrasi dikurangi menjadi 0,1%.Asam asetilsalisilat ( L u k a bakar akibat aspirin = aspirin b u r n )Luka bakar akibat zat kimia yang sering teriihat dalam mulut disebabkan olehpemakaian tablet yang berisi asam asetdsalisilat dalam sulkus vestibular dekatdengan gigi yang terasa sakit. Karena nama dagang aslinya untuk asam asetil-salisdat adalah aspirin, lesi yang diakibatkannya sering disebut luka bakar aspirin.Luka itu tampak tak lama sesudah tablet diletakkan pada tempatnya. Penderitamengalami rasa terbakar pada mukosa dan daerah yang terkena menjadi pucat ataupudh. Jika mukosa terkena obat dalam waktu yang singkat, timbuUah lesi berwamapudh dan berkerut, sedangkan kalau lebih lama terkena, lesi itu akan membengkak,berwama pudh dan kasar. Gambar berasal dari seorang laki-laki berumur 31 tahunyang berusaha meringankan rasa sakitnya di premolar pertama atas kanan denganmenempatkan tablet asam asedlsalisilat pada sulkus vestibular. Lesi tersebut sangatluas, termasuk kelompok lesi yang membengkak dan kasar. Luka bakar akibataspirin pada mulut adalah akibat pengelupasan mukosa karena koagulasi proteindalam sel epitel superfisial^*^. Disebabkan oleh p H 3,5 asam asetdsalisilat. L u k abakar akibat zat kimia dimulutmungkin juga disebabkan oleh penanganan berbagaimedikasi secara ceroboh, seperti \" V a m i s h \" lubang gigi atau asam hidrofluorik.Buah segar atau jus segar yang berlebihan dapat menyebabakan luka bakar akibatzat kimia pada mukosa mastikasi dalam kaitannya dengan tindakan higiene oralyang salah

Cedera dan K e r a c u n a n 3 0 5 KERACUNAN OBAT

3 0 6 Atlas Penyakit M u k o s a M u l u tT i m a h h i t a m ( L e a d • plumbum)Keracunan timah hitam masih merupakan salah satu bahaya industri yang palingpenting. Pigmentasi gingiva yang disebabkan oleh timah hitam juga telah dijumpaip a d a b e b e r a p a p e n d e r i t a d e n g a n r i w a y a t p i k a {'pica') k a d a n g - k a d a n g p a d a r e t a r d a s imental. Intoksikasi ditandai dengan rasa tidak enak pada otot-otot secara keselu-ruhan, sakit kepala, menurunnya berat badan, konstipasi, kolik timah hitam, anemia,w a m a kulit kelabu, dan perubahan w a m a gusi. Garis dmah hitam pada gingiva{\"halo saturninus\", \"Burtons line\") d a p a t m e r u p a k a n t a n d a y a n g m e n g a r a h k eintoksikasi timah hitam. Garis tersebut berwama hitam kebiru-biruan, lebarbeberapa milimeter dan mengikud tepi bebas gusi. Itu disebabkan oleh depositsulfida timah hitam yang tak dapat larut dalam sel endotel kapiler dan histiosit. Garistimah hitam tidak tampak pada orang yang tak bergigi , dan pada penderita yangwarna kulitnya gelap mungkin sukar dibedakan dengan pigmentasi gingivafisiologik^'^. Diagnosis banding terhadap kalkulus dapat dibuat dengan menempat-kan secarik kertas kecil pada poket gingiva, seperti tampak pada gambar, garis timahhitam akan tampak jelas terpisah dari gigi.Sisipan memperlihatkan jaringangingivayang hdang, menampakkan endapan dmah hitam di dalam poket. Penderita adalahseorang laki-laki berusia 47 tahun yang telah bekerja selama 6 bulan sebagaipenggerinda logam.A i r raksa (Merkuri)Keracunan air raksa disebabkan oleh penggunaan obat yang mengandung air raksa,terutama dalam bentuk diuretik atau sebagai akibat bahaya industri. Gejalakeracunan air raksa secara sistemik termasuk malaise, neusea, anoreksia, diareb e r d a r a h , d a n o l i g u r i a . K e r a c u a n a n i t u m e n y e b a b k a n h e n t i j a n t u n g {cardiac arrest),kolids hemoragik, kerusakan ginjal, dan perubahan-perubahan oral. Manifestasioral terdiri dari saliva yang berlebihan, rasa logam, perubahan warna selaput lendirdan stomadds. Perubahan warna jarang kelihatan. Gusi menjadi bengkak, berwarnamerah dan nekrotik; pada stadium lanjut gigi goyang dan tulang alveoler kelihatandan nekrotik.Lesi mukosa oral terdiri dari membran kuning kelabu, sering berben-tuk sirsiner. Daerah yang terkena m u n g k i n sangat luas dan nekrotik\"*\"*^. Penderitayang diperlihatkan d i sini adalah seorang laki-laki berusia 4 8 tahun yang telahbekerja dan kontak langsung dengan air raksa di suatu pabrik. Sesudah 1 minggudia menderita malaise, sakit tenggorokan dan gusi berdarah. D i samping mengenait e p i b e b a s g u s i d a n b a g i a n g u s i y a n g m e l e k a t {attached gingiva) p a d a n y a j u g at e r d a p a t l e s i y a n g s e r u p a p a d a m u k o s a p i p i d a n t e p i l i d a h . U r i n b e r i s i 1 1 . 0 0 0 y/Lair raksa . Yang normal adalah 10 y/L.

Cedera dan K e r a c u n a n 3 0 7EFEK TOKSIK TIMAH HITAM

3 0 8 Atlas Penyakit M u k o s a M u l u tMukositis akibat radiasiPenggunaan roentgenterapi dan kurieterapi dalam perawatan penyakit ganas oraldapat mempunyai akibat yang merusakkan struktur oral yang normal di sekitamya.Yang paling terkenal adalah osteoradionekrosis yang masih merupakan komplikasiyang agak sering terjadi. Akibatnya lain yang tidak menyenangkan adalahmukosids akibat radiasi pada mukosa oral. Perubahan yang pertama timbul men-jelang akhir minggu pertama terapi yang terdiri dari mukosa pipi yang menjadimerah. Menjelang pertengahan minggu kedua, timbul bercak-bercak pudh padamukosa bibir, pipi dan lidah\"**^. Dengan dilanjutkannya perawatan tersebut,mukosids akan menjadi lebih parah, lidah menjadi tempat timbulnya glositis danmungkin terjadi ulserasi. Jika kelenjar liur berada dalam lapangan radiasi, penderitam u n g k i n akan kehdangan rasa dan kadang-kadang m u l u t terasa pahit dan kering.Tingkat tanda dan gejala ini berhubungan dengan dosis radiasi dan akan terjadipenyembuhan secara bertahap bila radiasi telah dihendkan'^. Penderita yang tam-pak di sini adalah seorang wanita berusia 46 tahun yang mendapat radium moulddan radiasi cobalt pada karsinoma di dasar mulut. Bibir, permukaan bawah lidahdan dasar mulut merupakan tempat mukosids yang luas ditandai oleh ulserasi yangtertutup fibrin dan eritem yang nyata.Edema angioneurotikGambar memperlihatkan pembengkakan lidah, terutama pada bagian kanan, padaseorang laki-laki berusia 43 tahun. Selama dua tahun penderita tersebut menderitaserangan urdkaria, rekurens kadang- kadang sedap hari, pada kulit dan mengalamipembengkakan bibir dan lidah. Pemeriksaan laboratorium tennasuk beberapa tes\"patch\", d d a k m e n u n j u k k a n s e s u a t u y a n g a b n o r m a l . B e r d a s a r k a n p e m e r i k s a a nradiografik gigi, diketahui terdapat tiga gigi yang terkena osteids periapikal. Setelahfokus inidibuang juga tidak menyembuhkan urtikariamaupun edema. Karena tidakada latar belakang keturunan, keadaan itu di diagnosis sebagai edema angioneurotiknon-heriditer. Ada dua dpe edema angioneurodk, dpe non-heriditer dan tipe heri-diter. Kedua dpe itu mempunyai gejala yang sama pada kulit, tetapi tipe heriditersering mempunyai manifestasi viseral. Tipe non-heriditer agak mudah di diagnosis,karena lesinya sangat jelas. Tidak adanya rasa sakit, panas dan w a m a merahmembedakan keadaan tersebut terhadap proses infeksi akut''^. Lesi pada edemaangioneurotik biasanya tunggal, tetapi kadang-kadang terdapat juga lesi multipel.Pada beberapa kasus, edema tersebut berkembang secara bertahap dalam beberapajam, sedangkan pada kasus lain terjadi pembengkakan yang timbul secara sangattiba-tiba.

Cedera dan K e r a c u n a n 3 0 9EFEK-EFEK LAIN AKIBAT PENYEBAB EKSTERNAL

3 1 0 Atlas Penyakit M u k o s a M u l u tT a t o amalgam ( A m a l g a m tattoo)Pigmentasi mukosa oral yang disebabkan oleh amalgam (campuran perak, timahdan air raksa) yang disebut tato amalgam, adalah lesi yang terkenal. Dalam sampelsecara acak pada penduduk Swedia ditemukan tato amalgam di dalam mulutsebanyak 8% . Dalam kebanyakan kasus gingiva dan alveolar merupakan tempatyang mengalami perubahan wama*\"*. Secara klinik, tatu amalgam tampak sebagaidaerah berpigmen yang nyata berwama kebiru-biruan, kehitam-hitaman atau ke-labu. Secara khas tampak noda berpigmen yang ddak menonjol. Gambar memper-lihatkan contoh khas tato amalgam yang terletak pada gingiva seorang laki-lakiberusia 25 tahun. A m a l g a m dapat mencapai mukosa dengan berbagai cara. Tatoamalgam dapat terjadi sebagai akibat retaknya tumpatan amalgam perak pada w a k mpencabutan gigi dan masuknya pecahan-pecahan amalgam ke dalam luka pen-cabutan gigi; ketika luka sembuh amalgam akan terletak dekat permukaan mukosa.Sebab tato amalgam yang lain adalah ketika partikel kecd amalgam terjatuh kedalam jaringan periodontal pada waktu dilakukan prosedur penumpatan padalubang aproksimal. A m a l g a m dapat pula tergeser letaknya pada waktu prosedurperawatan endodontik di mana apeks ditutup dengan amalgam .Aspek histologiktato amalgam akan diuraikan di bawah ini.T a t o logam (Metal tattoo)Sebagian pengalaman dokter gigi adalah bahwa bur atau disk selama prosedurperawatan gigi dapat tergelincir dan melukai mukosa oral. Pada sebagian besarkasus semacam itupenyembuhan berlangsung cepat dan tak terjadi apa-apa. N a m u nkadang-kadang bekas permanen dapat terdnggal dalam bentuk suatu daerah ber-pigmen. Inidisebabkan oleh adanya partikel logam. Gambar di sebelah menunjuk-kan perubahan w a m a pada mukosa pipi kiri seorang laki-laki berusia 56 tahun yangmendapat kecelakaan beberapa tahun sebelum pemeriksaan ini. Dokter gigipenderita itu mempergunakan disk karborundum yang tergelincir dan menembusmukosa pipi. Pardkel ebonit terdnggal di tempat itu dan menyebabkan bindk yangmengalami pigmentasi. Dalam bintik yang mengalami pigmentasi yang disebabkanoleh amalgam, partikel logam dapat berbentuk pecahan-pecahan yang berkaitandengan reaksi benda asing dan dalam bentuk budr yang halus di sepanjang jaringani k a t y a n g m e n y e b a b k a n n o d a p e r a k in vivo p a d a s e r a t y a n g b e r s i f a t p r e k o l a g e n .Tato logam dapat pula terlihat pada kasus di mana saluran akar gigi susu telah diisidengan bahan yang berisi perak. Bila akar dan tulang mengalami resorpsi logamdapat terlihat melalui mukosa\"*^. Diagnosis banding yang paling pendng untuksemua daerah yang mengalami pigmentasi adalah melanoma, yang sebaliknya darideposit logam yang merupakan lesi yang datar, melanoma merupakan lesi yangmenonjol.

C f d e r a dan K e r a c u n a n 3 1 1KOMPLIKASI PERAWATAN MEDIK

3 1 2 Atlas Penyakit Mukosa M u l u t\"Stomatitis\" akibat g u l u n g a n kapas (Cotton r o l l \"stomatitis\")Pengalaman kebanyakan dokter gigi, gulungan kapas yang ditempatkan pada suklusvestibular kadang-kadang menimbulkan luka pada mukosa. D a l a m sebagian besarkasus, lesi ditemukan pada gusi di maksila. Bila gulungan kapas pada kasus seperditu diambil, lapisan luar gulungan kapas itu melekat pada mukosa di bawahnya dandalam waktu satu atau dua hari akan timbul lesi yang tertutup fibrin. Lesi itusuperfisial dan cepat sembuh secara spontan, dapat terasa cukup menyakitkan.Gambar berasal dari seorang wanita berusia 24 tahun yang terkena \"stomatitis\"gulungan kapas sesudah gulungan itu diletakkan di dalam suklus. Etiologi\"stomathis\" gulungan kapas tidak dapat dipahami dengan sempurna. Pengambdangulungan itu secara kasar ditambah dengan mengeringnya mukosa karena kapas itudapat merupakan faktor penunjang; di daerah yang paling sering terkena, terdapatsangat sedikit saliva karena penderita menyandarkan kepalanya ke belakang padakursi perawatan gigi. Juga pernah disarankan bahwa gulungan kapas mungkin berisibahan yang mengiritasi atau lesi itu disebabkan oleh reaksi alergi, tetapi kemung-kinan ini sangat kecd'*^. Juga iskemia lokal yang disebabkan oleh obat anestetikharus diperhitungkan sebagai faktor etiologi.V a k s i n i a pada mukosa m u l u tJika seorang anak divaksinasi terhadap penyakit cacar (smallpox) dan, dengan jari,memindahkan vaksin ke bagian lain tubuh, dapat terjadi suatu inokulasi sekundersetempat. Untuk dapat menerima kasus i m sebagian vaksinia, lesi pada tempatinokulasi sekunder harus konsisten dengan poliferasi dan nekrosis yang menandaivaksinia primer'*^'. Mukosa oral dapat menjadi tempat inokulasi sekunder padaseorang anak perempuan berusia 8 tahun yang menderita retardasi mental yanggambamya diperlihatkan di samping. A n a k itu divaksinasi terhadap cacar di bahu.Sepuluh hari kemudian suatu lesi keputih-putihan yang mempunyai pusat di tengah(centrally umbilicated) timbul pada komisura kiri dan pada lidah karena anak itumeletakkan jarinya pada tempat vaksinasi dan membawa vaksin ke dalam mulut-nya. Terdapat enam lesi pada dorsum lidah. Lesi vaksinia pada mukosa mulutmempunyai kecenderungan untuk menjadi satu dan menimbulkan plak dengangaris luar yang menjalar dan tepi yang menonjol^**. Lesi oral dibagi menjadi tigakategori: pustular, papular dan difterik''^^.Lidah merupakan bagian yang palingsering terlibat dalam rongga mulut dengan bibir (komisura), gusi, mukosa pipi,tonsil dan uvula ddak begitu sering terkena. (Dengan izin Dr. B . RUSSELL, Copen-hagen, Denmark).

Cedera dan K e r a c u n a n 3 1 3KOMPLIKASI PERAWATAN MEDIK

3 1 4 Atlas Penyakit M u k o s a M u l u tReaksi graft-versus-hospesReaksi Graft-verras-hospes ( G V H R ) atau penyakit graft-ver^M^-hospes adalahgejala imunologi multisistem yang kompleks yang ditandai oleh pencangkokan(engraftment) sel imunokompeten dari satu individu kepada hospes yang ddakhanya imunodefisien tetapi juga memdiki isoantigen transplantasi yang merupakanbenda asing terhadap cangkokan (graft) dan oleh sebab itu mampu mensdmulasigraft tersebut*^. Insidens G V H R yang dilaporkan dalam transplantasi sumsumtulang dari berbagai pusat berkisar dari 20 hingga 50%. Bentuk akut G V H R ditandaidengan ruam kulit, hepatitis dan diare, dengan menifestasi kulit sebagai aspek yangpaling penting pada G V H R . Manifestasi oral dapat timbul 21 hingga 43 hari sesudahtransplantasi sebagai papula halus, likenoid dan atau reaksi deskuamatif*\"*. Bentukkronik dapat mengikutibentuk akut atau timbul 'de novo' kira-kira 100 hari sesudahtransplantasi. Gambaran yang konstan pada G H V R kronik adalah erupsi kulit yangseperti liken planus yang berkembang menjadi skleroderma. Manifestasi oral dapattimbul dalam bentuk keratosis likenoid dan ulserasi. Perubahan yang kedua meru-pakan gambaran yang jelas pada seorang laki-laki berusia 18 tahun pada gambar disamping. Ia menderita leukemia limfatik akut dan menjalani transplantasi sumsumtulang. Setelah 7 minggu timbul perubahan likenoid d ibeberapa tempat padamukosa oral. Kemudian dmbul ulserasi yang luas.Reaksi graft-versus-hospesPerubahan histoiogi yang menandai G V H R dibagi menjadi dua proses yang jelas1) respons limfoid dan 2 ) reaksi limfosit agresor (lesi epitelial destruktir ^'').Tempat yang menjadi sasaran lesi epitelial destruktif termasuk epitel kulit, selaputlendir skuamosa, hati dan usus kecil dan besar. Epitel oral akan menampakkannekrosis koagulasi fokal. Sel nekrotik mungkin jatuh kelamina propria sebagaib a d a n \"nummified\"^^^. P e r u b a h a n s e p e r t i i t u d a p a t d e n g a n m u d a h m e n e r a n g k a ngambaran drastis yang terlihat secara klinik seperti pada seorang wanita berusia 43tahun yang gambamya diperlihatkan di samping. Lima bulan sebelum gambar inidibuat, penderita telah mendapatkan transplantasi sumsum tulang karena anemiaaplastik. Manifestasi oral dapat merupakan tanda G H V R yang pertama.Penyelidikan belakangan ini^'^ telah menganalisis aliran kelenjar liur minor labialdan konsentrasi sodium pada penderita G V H R . Konsentrasi sodium saliva mening-kat dan peningkatan ini berkaitan dengan peradangan dan destruksi aksini dansaluran kelanjar minor. Jadi jika penerima transplantasi sumsum tulang diketahuimengalami peningkatan sodium saliva labial, maka kemungkinannya bahwa iamengalami perubahan patologik pada kelenjar liur labial adalah 9 1 % .

Cedera dan K e r a c u n a n 3 1 5KOMPLIKASI-KOMPLIKASI PERAWATAN MEDIK



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CODING O FCONTENT O FT H E ATLAS ACCORDING TO: INTERNATIONAL CLASSIFICATION O F DISEASES APPLICATION TO DENTISTRY AND STOMATOLOGY I C D - D A (1978)I. INFECTIVE AND PARASITIC DISEASES017.80 Tuberculosis 24017.80 Atypical tuberculosis 24030. VO Leprosy 26034.00 Streptococcal gingivostomatitis 26034.10 Scarlatina 28039.30 Actinomycosis 28052. X0 Chickenpox 30053. X0 Herpes zoster 30-32054.00 Herpes labiahs 32054.2X Herpetic gingivostomatitis 34055.V0 Measles 36074.00 Herpangina 36074.30 Vesicular stomatitis with exanthem 38075.XO Infectious mononucleosis 38078.10 Viral wart 40078.11 Condyloma acuminatum 40-42085.00 Leishmaniasis 42090.50 Circumoral furrow in congenital syphilis 44091.20 Primary syphihs 44091.30 Mucous patches in secondary syphilis 46095.x 1 Palatal perforation in tertiary syphilis 48095.X2 Atrophic glossitis in tertiary syphilis 48095.X2 Interstitial glossitis and carcinoma in tertiary syphilis 50098.80 Gonococcal stomatitis 50098.80 Gonococcal dermatitis syndrome 52099.30 Reiter's syndrome 52lOI.XO Acute necrotizing gingivitis 54101.XI Acute necrotizing stomatitis 54112.00 Acute pseudomembranous candidiasis 56112.01 Acute atrophic candidiasis 56112.03 Chronic atrophic candidiasis (angular cheilosis) 58112.02 Chronic hyperplastic candidiasis 58112.02 Chronic localized candidiasis on dorsum of tongue 60112.02 Chronic multifocal oral candidiasis 60112.03 Chronic atrophic candidiasis-denture stomatitis, type II . . . . 62112.03 Chronic atrophic candidiasis - denture stomatitis, type III . . . 62112.02 Papillary hyperplasia of palate 64112.05 Chronic mucocutaneous candidiasis 64112.08 Acquired mucocutaneous candidiasis 66112.04 Candida-endocrinopathy syndrome 66115.X0 Disseminated histoplasmosis 68116.10 South American blastomycosis 68 117.00 Rhinosporidiosis 70 122.90 Hydatid cyst 70 135.XO Sarcoidosis 72 136.10 Behcet's syndrome 72

3 4 2 Atlas Penyakit M u k o s a M u l u tII. NEOPLASMSI40.IX-*M8070/3Carcinoma of lip (vermilion border) 7414I.21-M8070/3 Carcinoma of border of tongue 7614I.3X-M8070/3 Carcinoma of inferior surface of tongue 76143.1X-M8812/3 Fibrosarcoma of gingiva 78I43.1X-M8070/3 Carcinoma of alveolar ridge 78144.0X-M8070/3 Carcinoma of floor of mouth 80140.6X-M8070/3 Carcinoma of labial commissure 80140.6X-M8070/3 Carcinoma of labial commissure and buccal mucosa 82I45.0X-M805I/3 Verrucous carcinoma of buccal mucosa 82145.2X-M8070/3 Carcinoma of palate 84I45.2X-M8070/3 Carcinoma of palate in reverse smoker 84I45.2X-M8200/3 Adenoid cystic carcinoma of palate 86162.9-M8010/3 Metastasis from lung carcinoma 86172.8-M8720/3 Malignant melanoma of buccal mucosa 88174.9- 148140/3 Metastasis from mammary carcinoma 88200.00-M9640/3 Histiocytic lymphoma 90200.10-M9610/3 Lymphocytic lymphoma 90200.20-M9750/3 Burkitt's lymphoma 92201.V0-M9650/3 Hodgkin's disease 92202.1X-M9700/3 Mycosis fungoides 94205.V0-M9860/3 Chronic leukemia 94205. V0-M9860/3 Acute leukemia 96-98206. V0-M9830/3 Monocytic leukemia 98207.00-M9841/3 Acute erythremic myelosis 100210.44-M8052/0 Papilloma of palate 100210.42-M8051/0 Verrucous hyperplasia of oral mucosa 102210.40-M8146/0 Monomorphic adenoma - adenolymphoma of buccal mucosa . . 1022I0.47-M8146/0 Monomorphic adenoma - sialoadenoma papilliferum of retromola.- area 104210.01-M8147/0 Monomorphic adenoma - basal cefl adenoma of upper hp . . . 104210.44-M8940/0 Pleomorphic adenoma of palate 106210.47-M8430/1 Mucoepidermoid tumor of retromolar area 106210.40-M8810/0 Fibroma of buccal mucosa 108214.X0-M8850/0 Lipoma of floor of mouth 108210.12-M9560/0 Neurilemoma of tongue 110210.43-M8890/0 Vascular leiomyoma of gingiva 110210.12-M9580/0 Granular cell myoblastoma of tongue 112210.43-M9310/0 Peripheral ameloblastoma of alveolar ridge 114210.44-M8790/0 Blue nevus of palate 114210.47-M8750/0 Intramucosal nevus of retromolar area 116210.44-M7840/0 Junctional nevus of palate 116210.40-M8742/2 Lentigo malignum of buccal mucosa 118210.40-M8720/0 Nevus of Ota 118210.44-M9150/0 Hemangiopericytoma of palate 120228.00-M9131/0 Capillary hemangioma of labial sulcus 120228.00-M9121/0 Cavernous hemangioma of tongue 122228.10-M9172/0 Lymphangioma of tongue 122228.10-M9173/0 Cystic, hygroma 124237.70-M9540/1 Neurofibromatosis 124237.70-M9550/0 Multiple mucosal neuroma syndrome 126• Refers to the numerical index of morphology of neoplasms { I C D O ) .

Kepustakaan 3 4 3III. ENDOCRINE, NUTRITIONAL, AND METABOLIC DISEASES243.X0 Athyroidism 126250.X0 Diabetes mellitus 128253.00 Acromegaly 128255.40 Hypoadrenocorticism 130260.X0 Protein malnutrition (kwashiorkor) 130265.20 Niacin deficiency 132267.XO Ascorbic acid deficiency 132272.80 Urbach-Wiehte disease 134273.30 Macroglobulinemia 134277.00 Mucoviscoidosis 136277.30 Amyloidosis 136-138278.30 Hypercarotinemia 138277.80 Eosinophilic granuloma of bone 140279.10 Acquired immunodeficiency syndrome - candidiasis 142279.10 Acquired immunodeficiency syndrome - Kaposi's sarcoma . . . 144IV. DISEASES O F T H E BLOOD AND BLOOD-FORMING ORGANS280.X0 Iron deficiency anemia 144280.X0 Sideropenic dysphagia 146281.00 Pernicious anemia 146-148287.10 Thrombasthenia 148287.40 Thrombocytopenia 150288.00 Malignant neutropenia 150288.01 Cyclic neutropenia 152288.09 Chronic idiopathic neutropenia 154288.10 Chronic granulomatous disease 140-142V. MENTAL DISORDERS300.9 Selfinflicted injury 154VI. DISEASES OF THE NERVOUS SYSTEM335.20 Amyotrophic lateral sclerosis 156352.5X Paralysis of hypoglossal nerve 156351.8X Melkersson-Rosenthal syndrome 158-160VII. DISEASES OF THE CIRCULATORY SYSTEM446.30 Malignant granuloma 160446.40 Wegener's granulomatosis 162448.00 Hereditary hemorrhagic telangiectasia . . . . . . . . . 162-164456.80 Subhngual varicosities 164VIII. DISEASES OF THE RESPIRATORY SYSTEM487.80 Influenza 166IX. DISEASES OF THE DIGESTIVE SYSTEM523.80 Idiopathic gingival fibromatosis 168523.82 Gingival cyst 170

3 4 4 Atlas Penyakit Mukosa Mulut523.83 Peripheral giant cell granuloma 170525.2X 172523.86 Atrophy of maxillary alveolar ridge 172523.88 166526.00 Denture irritation hyperplasia 174527.61 174527.61 Toothbrushing-induced gingival ulcerations 176527.85 Eruption cyst 176528.IX 178528.IX Mucocele of labial salivary glands 180528.20 180-182528.21 Mucocele (ranula) of sublingual gland 182528.22 184528.40 Necrotizing sialometaplasia 186528.41 186528.44 Cancrum oris 188528.58 188528.6X Gangrenous ulceration 190112.02-528.6X 190528.6X Recurrent aphthous ulcerations 192-194528.6X 196528.70 Herpetiform ulcerations 196528.71 198528.72 Periadenitis mucosa necrotica recurrens 198528.73 200528.74 Gingival cysts in newborns 202528.78 202528.78 Dermoid cyst of floor of mouth 204528.80 204528.80-140.6X Sublingual lymphoepithelial cyst 206528.90 208528.93 Exfoliative cheilitis 208528.93 210528.94 Leukoplakia of buccal mucosa 210528.95 212528.96 Candida-infected leukoplakia of labial commissure 212528.96 214528.98 Leukoplakia 214529.1X 216529.2X Nodular (speckled) leukoplakia of labial commissure 218529.32 218529.31 Erythroplakia of buccal mucosa 220529.31 220529.5X Leukoedema of buccal mucosa 222529.6 222529.80 Smoker's palate 224555.00 224 Focal epithelial hyperplasia Geographic stomatitis Denture stomatitis with multiple intramucosal fistulae Glassblower's white patch Oral submucous fibrosis Oral submucous fibrosis with carcinoma Linea alba Cheek-bitting Lip-biting Pyogenic granuloma Eosinophilic granuloma of oral mucosa Melanoplakia Smoker's melanosis ^ Verruciform xanthoma Geographic tongue Median rhomboid glossitis Hypertrophy of foliate papilla . . . .- Black hairy tongue Hairy tongue Phcated tongue Glossodynia Crenated tongue Crohn's disease .X. DISEASES OF THE GENITOURINARY SYSTEM585.XO Uremia 226XI. COMPLICATIONS OF PREGNANCY

Kepustakaan 3 4 5646.80 Pregnancy gingivitis 226646.81 Pregnancy granuloma 228XII. DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE686.00 Pyoderma vegetans 228686.80 Acrodermatitis enteropatjiica 230692.8 Allergic contact stomatitis due to acrylic denture material. . . . 230692.8 Allergic contact stomatitis due to toothpaste aromatics . . . . 232692.8 Allergic contact stomatitis due to eugenol 232692.8 Contact stomatitis due to propolis 234692.8 Lesion related to amalgam restoration 234692.8 Allergic contact stomatitis due to gold inlay 236694.00 Dermatitis herpetiformis 236694.00 Pemphigus vulgaris 238694.41 Pemphigus vegetans 240694.60 Benign mucous membrane pemphigoid .240-242695.10 Erythema multiforme exudativum 242-244695.40 Discoid lupus erythematosus 244-246696.10 Psoriasis vulgaris 246696.10 Pustular psoriasis 248697.01 Reticular lichen planus 248697.04 Plaque tyype of lichen planus 250697.02 Atrophic lichen planus 250697.02 Erosive lichen planus 252697.03 Bullous lichen planus 252697.01-M8070/3 Malignant transformation in oral lichen planus 254697.01-M8080/2 Erythroplakia associated with lichen planus 256701.10 Keratoacanthoma 256701.20 Malignant acanthosis nigricans 258701.80 Actinic elastosis (cheilitis) 258XIII. DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE710.00 Systemic lupus erythematosus 260710.10 Progressive systemic sclerosis 260710.20 Sjogren's syndrome 262710.30 Dermatomyositis 262XIV. CONGENITAL ANOMALIES745.20 Tetralogy of Fallot 264749.00 Cleft uvula 266749.11 Cleft lip 266750.0X Ankyloglossia 268750.24 Congenital lip pits 268750.25 Fordyce's condition 270750.26 White sponge nevus 270757.10 Nevus unius lateris 272757.31 Dyskeratosis congenita 272757.32 Dyskeratosis folhcularis 274757.34 Dystrophic epidermolysis bullosa 274-276757.36 Pseudoxanthoma elasticum 276

757.39 Benign acanthosis nigricans 278757.50 Pachyonychia syndrome 278759.20 Lingual thyroid 280759.50 Tuberous sclerosis 280759.60 Encephalofacial angiomatosis 282759.63 Peutz-Jeghers' syndrome 284759.8 Hereditary mucoepithehal dysplasia 286759.8 Acrokeratosis verruciformis 284XVL SYMPTOMS, SIGNS AND ILL-DEFINED CONDITIONS782.4 Acquired icterus 286XVII. INJURY AND POISONING900.8 Submucosal ecchymoses after fellatio 288947 Electric bum 288960.0 Systemic penicillin adminstraation 290961.3 Quinoline and hydroxyquinoline derivatives 290963.1 Cytostatic drugs - methotrexate 292963.1 Immunosuppressive drugs - azathioprine: stomatitis 292963.1 Immunosuppressive drugs - azathioprine: carcinoma 294963.1 Immunosuppressive drugs - azathioprine: Kaposi's sarcoma . . . 294963.1 Immunosuppressive drugs - ciclosporin: gingival hyperplasia. . . 296963.8 Penicillamine 296965.1 Salicylates 298965.6 Antirheumatic drugs - indomethacin 298965.6 Qold 300966.1 Hydantoin derivatives 300-302976.7 Paraformaldehyde 302976.0 Chlorhexidine 304983.1 Acetylsalicylic acid (Aspirin burn) 304984 Lead 306985.0 Mercury 306990 Radiation mucositis 308995.1 Angioneurotic edema 308996.8 Graft-versus-host reaction 314998.40 Amalgam tattoo 310998.48 Metal tattoo 310998.90 Cotton roll \"stomatitis\" 312999.3 Vaccinia of oral mucosa 312

Disseminated histoplasmosis 6 8 Erythroleukemia 100Disseminated lupus erythematosus 2 6 0 Erythroleukoplakia 190, 196Drug stomatitis 244, 2 9 0 - 3 0 2 Erythroplakia 80, 82, 190, 1 9 6 , 2 5 6Drugs, adverse effect of 290-302 Erythroplasie de Queyrat 196Dryness, oral mucosa 136, 146, 226 Eugenol, allergy to 232Dubreuilh's precancerous melanosis 118 Exanthem 38Duhring's disease 236 Exfoliatio areata linguae 2 1 6Dyskeratosis congenita 272 Exfoliative cheihtis 188Dyskeratosis follicularis 274Dysphagia 146, 228, 260, 280 Facial edema 158Dysphagia, sideropenic 146 Facial paralysis 158Dysplasia, epithelial 66, 102, 196, 206, 254, Factitial gingivitis 154 Fallot's tetralogy 2 6 4 256 Familial benign chronic neutropenia 154 Fasciculation, tongue 156Dyplasia, hereditary mucoepithehal 286 Fatal granulomatous disease of childhoodDystrophic epidermolysis bullosa 2 7 4 - 2 7 6 140-142Ebonite 250 Fellatio, effect on oral mucosa 2 8 8Ecchymoses, oral mucosa 96, 98, 100, 134, Fever blister 32 Fibrocystic disease 136 138, 148, 150, 274, 288 Fibroma 1 0 8 , 124Echinococcus granulosus 70 Fibromatosis, idiopathic gingival 168Ectodermosis pluriorificialis 2 4 2 - 2 4 4 Fibrosarcoma 78Edema 158 Fibrosis, oral submucous 2 0 4 - 2 0 6Edema, angioneurotic 3 0 8 Fiessinger-Rendu's syndrome 2 4 2 - 2 4 4Elastosis, actinic (semile) 74, 2 5 8 Fissured tongue 222, 248, 264Electric burn 2 8 8 Fistulae, multiple intramucosal 202Electrogalvanic lesion 2 3 4 Flabby ridges 172Elephantiasis gingivae 168 Florid oral papillomatosis 102Enamel hypoplasia 66, 126, 274 Focal epithelial hyperplasia 2 0 0Enanthema 148, 166, 246, 248 Foliate papiUae, hypertrophy 2 1 8Encephalofacial angiomatosis 282 Fohate papillitis 2 1 8Endocrine candidosis syndrome 6 6 Folic acid deficiency 60Enteritis, regional 158, 2 2 4 Follicular lymphoid hyperplasia 90Enterovirus 38 Fordyce's condition 2 7 0 Frenulum, lingual, abnormal 2 6 8Eosinophilic granuloma of bone 140 Fusobacterium 54Eosinophilic granuloma of oral mucosa 212Ephelides 116, 212 Galvanism 234Epidermolysis bullosa, acquisit 276 Gangrenous stomatitis 178Epidermolysis bullosa, dystrophic 274, 276 Gangrenous ulceration 180Epidermolysis bullosa, lethal 274, 276 Geographic stomatitis 202Epiloia 2 8 0 Geographic tongue 2 1 6 , 222, 246, 248Epithelial dysplasia 66, 102, 196, 206, 254, Giant cell granuloma, peripheral 170 Gigantism 128 256 Gingial ulcerations 166Epstein-Barr virus 38, 92 Gingiva, enlargement 96, 98, 100, 1 6 8 . 2 9 6 ,Epstein's pearls 186Epulis 42, 78, 86, 108, 110, 112, 170, 172, 300-302 Gingival bleeding 96, 98, 122, 128, 132, 134, 210, 228Epulis fissuratum 172 160, 164, 228Epundia 42 Gingival cyst 170Ercoquin 2 9 0 Gingival cysts in newborns 186Eruption cyst 174 Gingival fibromatosis 168Erythema migrans 202 Gingivitis, acute necrotizing 34, 5 4Erythema multiforme exudativum 46, 242-244Erythremic myelosis 1 0 0

Infectious mononucleosis 3 8 254Inflammatory papillary hyperplasia 62 Lichen planus, papular 248Influenza 166 Lichen planus, plaque type 248, 2 5 0Injuries, selfinflicted 154 Lichen planus, reticular 2 4 8 , 254Interstitial syphilitic glossitis 5 0 Lichen planus, ulcerative 252Intramucosal nevus 116 Lichen-like reactions 300, 314Iron deficiency 58, 66, 1 4 4 , 146, 182 Linea alba 208Irritation hyperplasia 172 Lingua dissecta 222 Lingua fissuratum 222Jadassohn-Lewandowski syndrome 2 7 8 Lingua geographica 2 1 6 , 222Jaundice, acquired 138 Lingua indentata 224Junctional nevus 116 Lingua lobata 4 6 - 4 8 , 134, 238Juvenile acanthosis nigricans 2 7 8 Lingual phlebectasias 164 Lingua plicata 158, 222Kaposi's sarcoma 142, 1 4 4 , 2 9 4 Lingua villosa nigra 2 2 0Keratoacanthoma 74, 2 5 6 Lingual thyroid 2 8 0Keratosis follicularis 274 Lingual varicosities 164Koplik's spots 36 Lip-biting 2 1 0Kwashiorkor 1 3 0 , 178 Lipoglycoproteinosis 134 Lipoma 108Lead, toxic effect of 306 Lip pits, congenital 2 6 8Leiomyoma 110 Lip sinuses, congenital 2 6 8Leishmania Branziliensis 42 Lip-sucking 2 1 0Leishmaniasis 42 Lupus erythematosus, acute systemic 2 6 0Lentigo 116 Lupus erythematosus, discoid 2 4 4 - 2 4 6 , 260,Lentigo maligna 118Leproma 26 290Leprosy 26 Lupus erythematosus, disseminated 2 6 0Lethal midline granuloma 160 Lymphadenopathy 32, 34, 38, 46, 52, 96,Leukemia, acute 9 6 - 9 8Leukemia, chronic 94, 96 140Leukemia, lymphoblastic 94 Lymphadenopathy-associated virus 144Leukemia, monocytic 9 8 Lymphangioma 1 2 2 - 1 2 4Leukemia, myelogenous 94 Lymphoepithelial cyst 188Leukoedema 198, 210, 258 Lymphocytic lymphoma 90Leukoedema exfoliativum mucosae oris 2 7 0 Lymphoma 262, 294Leukokeratosis nicotina palati 198 Lymphoma, Burkitt's 92Leukokeratosis, oral 278 Lymphoma, histiocytic 90Leukoplakia 46, 50, 58, 74, 76, 82, 112, Lymphoma, lymphocytic 9 0 Lymphogranulomatosis, benign 72 1 9 0 - 1 9 6 , 204, 206, 208, 210, 234, 246, 254, Lymphogranulomatosis, malignant 92 258, 270, 272 Lymphoproliferative disease 90Leukoplakia, candidal 5 8 , 80, 196 Lymphosarcoma 90, 92Leukoplakia, hairy 142Leukoplakia, homogeneous 58, 9 0 - 1 4 4 , 2 5 0 Macrocheilia 128, 136, 158Leukoplakia, malignant transformation 196 Macroglobulinemia 134Leukoplakia, nodular 66, 76, 80, 190, 1 9 6 , Macroglossia 124, 126, 128, 136, 138, 224 294 Malaria 178Leukoplakia, speckled 58, 1 9 0 , 196, 254Leukoplakia, verrucous 190 Malignant acanthosis nigricans 2 5 8Lichen planus 194, 242, 2 4 8 - 2 5 6 Malignant granuloma 160Lichen planus, atrophic 248, 2 5 0 , 256 Malignant melanoma 8 8Lichen planus, bullous 248 Mahgnant transformation of leukoplakiaLichen planus, erosive 46, 248, 250Lichen planus, malignant transformation 196 Malignant transformation of lichen plan\" 254 Measles 3 6 , 178