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DISEASES OF ORAL CAVITY

DISEASES OF ORAL CAVITY. SYSTEMIC DISEASES. HIV (AIDS) Leukaemia Crohn’s disease Diabetes mellitus Down syndrome Sarcoidosis Chediak Higashi syndrome. Normal defense Mechanisms of oral mucosa : Competitive suppression ; by organisms of low virulence Secretory Ig A

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DISEASES OF ORAL CAVITY

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  1. DISEASES OF ORAL CAVITY

  2. SYSTEMIC DISEASES • HIV (AIDS) • Leukaemia • Crohn’s disease • Diabetes mellitus • Down syndrome • Sarcoidosis • Chediak Higashi syndrome

  3. Normal defense Mechanisms of oral mucosa : • Competitive suppression ; by organisms of low virulence • Secretory Ig A • Other immunoglobulins ; sub mucosal collection of lymphocytes and plasma cells. 4. Antibacterial effect of saliva 5. Irrigation/Cleansing effect of food and drinks

  4. Herpes simplex viral infection • Type : HSV -1, HSV -2 (genital herpes) • Age : Children 2 -4 years of age • Presentation: - Usually asymptomatic - Gingivostomatitis ; abrupt onset of vesicles/ ulcers - Fever, anorexia, lymphadenopathy

  5. Gross : • Vesicles ; few mm – large bullae • Filled with clear fluid • Ruptures to form shallow ulcer Histology : • Intracellular and intercellular edema • Intranuclear inclusions • Multinucleated giant cells

  6. Course of the disease : - Spontaneous resolution in 3-4 weeks time. - Remain dormant in the ganglion ; trigeminal Reactivation: • Trauma • Allergies • Exposure of UV light • URTI • Pregnancy - Menstruation - Extremes of temperature

  7. COMMON SITES OF RECURRENT LESION : • Lips • Nasal Orifices • Buccal mucosa • Gingiva • Hard palate

  8. Actinic cheilitis Premalignant condition due to chronic UVR exposure Affects lower lip, initially edematous & erythematous, later atrophic, white, scaly plaque, may obliterate vermillion border Ulceration or induration - biopsy to rule out malignant transformation Disorders of the Lips

  9. Angular cheilitis (perleche) Inflammatory reaction- erythema and maceration at the angles of mouth, fissuring and crusting may be present Predisposing factors- advanced age, ill-fitting dentures, thumb-sucking in children, oral Candidiasis, bacterial infections Disorders of the Lips…

  10. Disorders of the Lips… • Cheilitis glandularis • Inflammatory painless enlargement of lower lip, usually in elderly men • Triggered by actinic damage, bacterial infection, tobacco exposure, chronic irritation • Cheilitis glandularis apostematosa • Painful enlargement, eversion of lip with erosions and recurrent bacterial infections or malignanttransformation

  11. Exfoliative cheilitis (factitious cheilitis) Chronic superficial inflammation of vermilion borders of the lips Characterized by persistent scaling Attributed to repeated lip sucking, chewing or other manipulation of lips Disorders of the Lips…

  12. Granulomatous inflammation, acute onset of asymmetric swelling of the upper lip or lower lip Erythema, scaling, fissuring and erosions may develop Prolonged and recurrent course with eventual fixed swelling May be associated with constitutional symptoms, regional lymph node enlargement Granulomatous cheilitis (cheilitis granulomatosa)

  13. Granulomatous cheilitis • Melkersson-rosenthal syndrome- triad of lingua plicata ( fissured or furrowed tongue), facial paralysis and granulomatous cheilitis • Other cranial nerves (olfactory, auditory, glossopharyngeal, hypoglossal) may be involved • Biopsy- oedema, perivascular lymphocytic infiltrate, focal granulomas resembling sarcoidosis or Crohn’s disease

  14. Disorders of Tongue • Glossodynia (burning mouth syndrome)- spontaneous burning, discomfort, pain, irritation, or rawness of the tongue, has no identifiable etiology most of the time • Etiology- • Idiopathic, Infection, Allergic/contact hypersensitivity, Mechanical trauma • Xerostomia, Geographic tongue/ Fissured tongue • Vesiculobullous disease, temporomandibular dysfunction • Referred pain from teeth or tonsils • Drugs- Antibiotics, psychiatric medications, chemotherapy

  15. Neurologic Peripheral nerve damage Diabetic neuropathy Trigeminal neuralgia Acoustic neuroma Psychiatric Depression Anxiety Cancerophobia Somatoform disorder Systemic disorders Anemia (iron deficiency, pernicious) Nutritional deficiency Gastroesophageal reflux disease Sjogren syndrome Hypothyroidism Acquired immunodeficiency syndrome Etiology of Glossodynia

  16. GLOSSITIS: Definition: Inflammation of the tongue Causes: - Vitamin B12 deficiency (Pernicious anemia) - Deficiency of riboflavin, niacin, pyridoxine - Sprue-----Vitamin B deficiency - Iron deficiency anaemia -----Vitamin B deficiency - Plummer Vinson syndrome; Combination of iron deficiency anemia, Glossitis and Esophageal dysphagia

  17. OTHER CAUSES: • Carious tooth • Ill - fitting dentures • Syphilis • Inhalation burns • Ingestion of corrosive chemicals

  18. Disorders of Tongue… • Glossitis- presents as pain, irritation or burning, hypogeusia, or dysgeusia • Atrophic glossitis • Due to filiform de-papillation • Mild patchy erythema to a completely smooth, atrophic, beefy-red surface • Etiology - pernicious anemia, protein and other nutritional deficiencies, chemical irritants, drug reactions, amyloidosis, sarcoidosis, vesiculobullous diseases, oral candidiasis and systemic infections • Moeller or Hunter glossitis of pernicious anemia affects the lateral aspects and tip of the tongue respectively

  19. Presentation : Large beefy tongue • Mechanism: Atrophy of papillae ----- Thinning of mucosa ---- Exposure of underlying blood vessels.

  20. Median rhomboid glossitis - atrophic disorder of the tongue secondary to chronic candidiasis Disorders of Tongue…

  21. Geographic tongue- benign inflammatory condition, due to Loss of filiform papillae Erythematous plaques with an annular or serpiginous well demarcated white border Etiology- Psoriasis, Reiter syndrome, atopic dermatitis, diabetes mellitus, anemia, hormonal disturbances, Down syndrome, lithium therapy Disorders of Tongue…

  22. Fissured tongue (furrowed tongue, scrotal tongue, grooved tongue) normal variant seen in 5-11% individuals Numerous small irregular fissures oriented laterally on the dorsal tongue Also seen in - Melkersson-Rosenthal syndrome, Psoriasis, Down syndrome, Acromegaly, Sjogren syndrome Disorders of Tongue…

  23. Herpetic geometric glossitis - rare cause of fissuring of tongue, presents with acute onset of pain and deep longitudinal grooves with smaller lateral fissures Disorders of Tongue…

  24. Hairy tongue (white or black hairy tongue) - hypertrophy of filiform papillae resembling hair-like projections Associated with - heavy tobacco use, mouth breathing, antibiotic therapy, poor oral hygiene, general debilitation, radiation therapy, chronic use of bismuth containing antacids, lack of dietary roughage White, yellow green, brown, or black color is due to chromogenic bacteria or staining from exog source Disorders of Tongue…

  25. Oral hairy leukoplakia- caused by Epstein-Barrvirus, presents as asymptomatic, corrugated, white plaques with accentuation of vertical folds along the lateral borders .Predominantly seen in HIV infection, organ transplant recipients and patients on chemotherapy Disorders of Tongue…

  26. Disorders of Tongue… • Macroglossia- congenital or acquired process, tongue is disproportionately large relative to the patient’s jaw size • Difficulty with mastication and speech and accidental tongue biting are common • Differential- Down syndrome, hypothyroidism, Beckwith-Wiedemann syndrome, neurofibromatosis, infection by mycobacteria, filamentous bacteria or fungus, amyloidosis

  27. Disorders of Salivary Glands • Xerostomia (dry mouth) - decreased saliva production • Women are twice as affected as men • Signs and symptoms - diminished or altered taste and smell, halitosis, heavy plaque accumulation, difficulty in wearing dentures, recurrent yeast infections, burning sensation, difficulty swallowing, dry or cracked lips, salivary calculi and increased thirst

  28. Causes of xerostomia • Medications - Antidepressants, antihistamines, diuretics • Medical conditions - Parkinson disease, diabetes, anemia, cystic fibrosis, rheumatoid arthritis • Granulomatous inflammation - tuberculosis, sarcoid, Sjögren syndrome, HIV, amyloid • Dehydration - Fever, excessive sweating, vomiting, diarrhea, blood loss, burns, smoking, consumption of tea, coffee • Radiation therapy of head and neck • Surgical removal of the salivary glands • Old Age

  29. Mucocele (mucous retention cysts)- benign, painless, dome- shaped fluctuant papules, due to trauma or obstruction of minor salivary gland ducts Multiple mucoceles - graft vs host disease, lichen planus, cicatricial pemphigoid Disorders of Salivary Glands

  30. Ranula - large, bluish, translucent fluctuant mass in the floor of the mouth due to obstruction of the submandibular and or sublingual duct Diffuse parotid gland enlargement - acute mononucleosis, HIV infection Disorders of Salivary Glands

  31. Disorders of Gingiva & Periodontium • Gingivitis - erythema, edema, and blunting of the interdental papillae, without bone loss • Predisposing factors - poor oral hygiene, tobacco use, diabetes • Periodontitis -chronic infection of connective tissue, periodontal ligament and alveolar bone • Long-term periodontitis is associated with increased risk of diabetes, heart disease, stroke and preterm birth • birth control pills, diabetes, steroids, Down syndrome, Langerhans cell histiocytosis, HIV predispose to periodontitis • Juvenile periodontitis is associated with genetic defects in leukocyte chemotaxis • Papillon-Lefevre syndrome - severe and destructive periodontal disease, teeth exfoliation

  32. Disorders of Gingiva & Periodontium • Erosive gingivostomatitis (desquamative gingivitis)- inflammation and erythema of the gingiva, nonspecific reaction pattern, may be due to viral infection, autoimmune, inflammatory and blistering disorders • Lichen planus - painful or asymptomatic lacy white patches, plaques or papules, often with erosions and ulcerations • Lichenoid mucositis - NSAIDS, antihypertensive medications, contact allergy, graft-versus-host disease

  33. GINGIVITIS • Gingiva: Soft tissue mucosal lining in between the teeth comprising of stratified squamous epithelium. • Its inflammation is called gingivitis- Pathogenesis : lack of oral hygiene----dental plaque beneath the gumline----mineralisation---- calculus (Tartar)----Release of acidic end product----Inflammation.

  34. Prevalence :Higher in Adolescence Treatment : Aimed at prevention of the disease and reducing the accumulation of plaque/ calculus formation : 1. Brushing 2. Flossing 3. Regular dental visits 4. Maintenance of good oral hygiene

  35. PERIODONTITIS : • Inflammation of the supporting structures of the teeth (Periodontal ligament, alveolar bone) - Severe persistent infection----loss of tooth.

  36. PATHOGENESIS • Poor oral hygiene • Shift in bacterial flora; 300 different org • Facultative gram positive organism – Healthy site • Anaerobic gram negative microaerophilic organisms – Diseased site. • Actinobacillus, Porphyromonas gingivalis, Provotella intermedia

  37. Acute necrotizing ulcerative gingivitis (trench mouth, vincent disease) Punched- out ulcers of the interdental papillae, gingival hemorrhage, severe pain, foul odor Fever and lymphadenopathy are common Disorders of Gingiva & Periodontium

  38. Precipitating factors- poor oral hygiene, nutritional deficiency, alcohol and tobacco use, Immunosuppression Etiologic agents- Treponema, Selenomonas, Bacteroides, Prevotella and Borrelia vincentii Disorders of Gingiva & Periodontium

  39. Aphthous ulceration • Acute, recurrent, painful ulcers on nonkeratinized mucosa • Most common cause of oral ulcerations • Effect up to 40-50 % of the population • Ulcers with a gray or yellow pseudomembrane and erythematous margin • Potential triggers - heredity, food and medication allergy, decreased mucosal barrier integrity, hematologic and immunologic disorders, emotional stress, and trauma

  40. Aphthous Ulcers….. • Superficial ulceration of oral mucosa • Age : First two decades • Presentation: Extremely painful recurrent lesion • Gross: single or multiple ,shallow ulcer surrounded by hyperaemia

  41. HISTOLOGY: • Predominant monuclear cells, scattered neutrophils CLINICAL COURSE : - Spontaneous resolution (7-10days) • Persists for weeks ETIOLOGY : Unknown TREATMENT : Symptomatic

  42. Aphthous ulceration

  43. Aphthous ulceration • Systemic Conditions Associated • Hematinic deficiency (up to 20%)- iron, folic acid or vitamin B12 deficiency • Gastrointestinal malabsorption (3%) - Celiac disease, dermatitis herpetiformis, gluten-sensitive enteropathy, Crohn disease, pernicious anemia • Systemic lupus erythematosus, reactive arthritis • HIV • Behcet disease • PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) • MAGIC(mouth and genital ulcers inflam cartil)

  44. Major criteria Oral Aphthae Genital Ulcers Ocular- Iridocyclitis, Retinal vasculitis,Optic atrophy CNS lesions- Meningoencephalitis, cerebral infarction, psychosis, cranial nerve palsies, cerebellar and spinal cord lesions Dermatological Pustules Erythema nodosum Minor criteria Proteinuria and haematuria Thrombophlebitis Aneurysms Arthralgias Behcet’s disease

  45. Non-aphthous erosions & ulcers • Pemphigus vulgaris, paraneoplastic pemphigus, bullous pemphigoid, cicatricial pemphigoid, EB acquisita • Epidermolysis bullosa simplex, junctional EB & dystrophic EB demonstrate the most severe • Discoid and SLE- oral discoid lupus is characterized by “sunburst” erythematous plaques surrounded by white radiating striations • Erythema multiforme and stevens-johnson syndrome/toxic epidermonecrolysis

  46. Non-aphthous erosions & ulcers… • Chronic ulcerative stomatitis - autoimmune mucosal erosive disorder • Resemble erosive LP • Direct immunofluorescence- IgG bound to nuclei of keratinocytes of basal and lower epithelial layers • Responsive to Hydroxychloroquine

  47. Iatrogenic mucositis • Complications of systemic chemotherapy and head and neck radiation, occurs due to direct tissue injury of the mucosal epithelium

  48. Localized Amalgam, tattoo Ephelis / Naevus Malignant melanoma Kaposi’s sarcoma Peutz–Jegher syndrome Laugier–Hunziker syndrome Melanotic macules Generalized Racial Localized irritation, e.g. smoking Drugs, e.g. phenothiazines, antimalarials, minocycline, contraceptives, mephenytoin Addison’s disease/ Nelson’s syndrome Ectopic adrenocorticotrophic hormone (e.g. bronchogenic carcinoma) Albright’s syndrome Haemochromatosis Neurofibromatosis, incontinentia pigmenti Malignant acanthosis nigricans Disorders of mucosal pigmentation

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