recurrent aphthous ulcer etiology: local altered immune response. systemic etiologies include...
TRANSCRIPT
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Recurrent Aphthous Ulcer
• Etiology:• Local altered immune response.• Systemic etiologies include nutritional
deficiencies (iron, B6, B12), diabetes mellitus, inflammatory bowel disease, immunosuppression.
• Biopsy will rule out other vesiculoulcerative disease.
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Recurrent Aphthous Ulcer
• Appearance:• Minor aphthous ulcer: <0.6 cm shallow
ulceration with gray pseudomembrane and erythematous halo on non-keratinized mucosa.
• Major aphthous ulcer: >0.5 cm ulcer, more painful, lasting several weeks to months; will scar.
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Recurrent Aphthous Ulcer
• Differential Diagnosis:• Herpes simplex virus.• Chemical/traumatic ulcer• Vesiculoulcerative diseases• Squamous cell carcinoma
• Treatment:• Topical analgesics• Topical steroids
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Inflammatory Conditions (Denture Related of the Oral
Mucosa)
• Inflammatory papillary hyperplasia
• Epulis fissurata (inflammatory fibrous dysplasia)
• Candidiasis
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Inflammatory Papillary Hyperplasia
• Etiology:• Poorly fitting denture• Occurs in more than 50%
of Denture Wearers
• Appearance:• Multiple small polypoid or
papillary lesions.• Typically on hard palate,
that produces a cobblestone appearance.
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Inflammatory Papillary Hyperplasia
• Etiology:• Poorly fitting denture• Occurs in more than 50%
of Denture Wearers
• Appearance:• Multiple small polypoid or
papillary lesions.• Typically on hard palate,
that produces a cobblestone appearance.
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Inflammatory Papillary Hyperplasia (Papillomatosis)
• Treatment:• Discontinue using denture• Surgical removal of hyperplastic tissue.• Occasionally tissue conditioner may
reduce the problem, while reconstruction of new denture may be necessary.
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Epulis Fissurata (Inflammatory Fibrous Dysplasia, Denture Granuloma)
• Etiology:– Over-extended denture flanges.– Resorption of alveolar bone that makes the
denture borders over-extended.
• Appearance:– Hyperplastic granulation tissue surrounds the
denture flange.– Pain, bleeding, and ulceration can develop.
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Epulis Fissurata (Inflammatory Fibrous Dysplasia, Denture Granuloma)
• Differential Diagnosis:• Verrucous carcinoma• Squamous cell carcinoma• Traumatic fibroma
• Treatment:• Small lesions may resolve if flanges of denture
are reduced.• Surgical excision is necessary prior to
rebasing/relining of denture.
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Oral Candidiasis
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Candidiasis
• Four fungal organisms: Candida albicans, Candida stellatoidea, Candida tropicalis, and Candida pseudotropicalis.
• Candida albicans is most common.• Morphologically, presents in 3 forms: yeast
cell, hypha and mycelium (last form is pathogenic phase).
• Carriers of oral candida do not show the mycelial phase.
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Etiology
Mixed infection of Candida albicans, staphylococci and streptococci.
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Classification of Oral Candidiasis
• Acute pseudomembranous candidiasis (moniliasis, thrush).
• Acute atrophic candidiasis (antibiotic sore tongue).• Chronic atrophic candidiasis (denture stomatitis).• Chronic hyperplastic candidiasis (candidal
leukoplakia, median rhomboid glossitis).• Angular cheilitis• Chronic mucocutaneous candidiasis.
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PAS Stained Candida Albicans Hyphae Embedded in The Oral Mucosa
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Acute Pseudomembranous Candidiasis (Thrush)
• Etiology:• Oral candidiasis
• Appearance:• White slightly elevated plaques that can be
wiped away leaving an erythmatous base.• Direct smear can be fixed and stained
using PAS reagent to reveal the candida hyphea microscopically.
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Acute Atrophic Candidiasis (Antibiotic Sore Tongue)
• Etiology:• Oral candidiasis secondary to antibiotics
or steroids.
• Appearance:• Similar to thrush without overlying
pseudomembrane: erythematous and painful mucosa.
• Differential Diagnosis:• Erosive lichen planus.• Chemical erosion.
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Chronic Atrophic Candidiasis (Denture Sore Mouth)
• Etiology:• Most common form of oral candidiasis;
candidal infection of denture as well.• Treatment should be directed towards
mucosa and denture.
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Chronic Atrophic Candidiasis (Denture Sore Mouth)
• Appearance:• Mucosa beneath denture is erythematous
with a well-demarcated border.• Swabs from the mucosal surface may
provide a prolific growth, but biopsy shows few candida hyphae in spite of high serum and saliva antibodies to candida.
• Differential Diagnosis:• Inflammatory papillary hyperplasia.
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Chronic Hyperplastic Candidiasis(Candida Leukoplakia)
• Etiology• Oral Candidiasis lesions should be
considered as potentially premalignant. Treatment should be directed toward mucosa and Leukoplakia.
• Appearance• Confluent leukoplakic plaques
characterized by Candida invasion of oral epithelium with marked atypia.
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Angular Cheilitis
• Etiology:• Diminished occlusal vertical dimension• Vitamin B or iron deficiencies• Superimposed candidiasis• Affects approximately 6% of General Population
• Appearance:• Wrinkled and sagging skin at the lip commisures.• Desiccation and mucosal cracking.
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Angular Cheilitis
• Differential Diagnosis:• Dry chapped lips.• Basal cell carcinoma.• Squamous cell carcinoma.
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Angular Cheilitis
• Rx: Nystatin-triamcinolone acetonide ointment.
Disp: 15 gm tube.
Sig: Apply to affected area after each meal and qhs. Concomitant intraoral antifungal treatment may be indicated.
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Chronic Mucocutaneous Candidiasis
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Diagnostic Criteria
• C.F.U. in Candidiasis can vary from 1,000/ml to 20,000/ml.
• As an adjunct to saliva samples, smears stained with PAS.
• Thus clinical manifestations, salivary culture and stained smears are needed to confirm a diagnosis of Candidiasis.
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Management of Candidiasis
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Candidiasis• Rx: Nystatin oral suspension 100,000
units/ml.Disp: 60 ml.Sig: Swish and swallow 5 ml qid for 5 min.
• Rx: Nystatin ointment.Disp: 15 gm tube.Sig: Apply thin coat to affected areas after each meal and qhs.
• Rx: Clotrimazole trouches 10 mg.Disp: 70 trouchesSig. Let 1 trouch dissolve in mouth 5 times daily.
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Candidiasis
• Rx for Dentures: Improve oral hygiene of appliance.
• Keep denture out of mouth for extended periods and while sleeping.
• Soak for 30 min in solutions containing benzoic acid, 0.12% chlorhexidine, or 1% sodium hypochlorite and thoroughly rinse.
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Candidiasis
• Apply a few drops of Nystatin oral suspension or a thin film of Nystatin ointment to inner surface of denture after each meal.
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Rx for Refractory Candidiasis
• Fluconazole 100 mg (20 tabs; 2 tabs stat, then 1 tab daily).
• Itraconazole 100 mg (20 tabs; 1 tab bid).
• 2-4 weeks of Ketoconazole 200 mg (20 tabs, 1 tab daily).
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DIAGNOSIS AND MANAGEMENT
OF XEROSTOMIA IN THE ELDERLY PATIENT:
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Salivary Gland Dysfunction and Xerostomia (Dry Mouth)
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XEROSTOMIA
• Xerostomia (dry mouth) is defined as a subjective complaint of dry mouth that may result from a decrease in the production of saliva.
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XEROSTOMIA
• It affects 17-29% of samples populations based on self-reports or measurements of salivary flow rates.
• More prevalent in women.
• Can cause significant morbidity and a reduction in a patient’s perception of quality of life.
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SALIVA• It keeps the teeth healthy by
providing a lubricant, calcium and a buffer.
• It also helps to maintain the health of the gums, oral tissues (mucosa) and throat.
• It also plays a role in the control of bacteria in the mouth.
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• It helps to cleanse the mouth of food and debris.
• It provides minerals such as calcium, fluoride, and phosphorus.
• It helps in swallowing and digesting food.
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•Lack of saliva will make the mouth more prone to disease and infection.
•Lead to a burning feeling.
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Oral Dryness in the Elderly
0102030405060708090
Normal Radiotx Sjogren Drugs
Subjective sensation of oral dryness in the elderly
% P
op
ula
tio
n
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Flow Rate of Saliva
0.00.10.20.30.40.5
20-39 yr 40-59 yr > 60 yr
Age
ml /
min
unstimulated
stimulated
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Antimicrobial Factors in Human Whole Saliva
Non-immunoglobulin Factors OriginLysozyme Salivary glands, crevicular fluid (PMNs)Lactoferrin Salivary glands, crevicular fluid (PMNs)Salivary peroxidase Salivary glands SCN- Salivary glands, crevicular fluid H2O2 Salivary glands, crevicular fluid (PMNs),
bacterial and yeast cellsMyeloperoxidase Crevicular fluid (PMNs) Cl- Salivary glands, crevicular fluidAgglutinins, aggregating proteins Salivary glandsHistidine-rich polypeptides Salivary glandsProline-rich proteins Salivary glands
Immunoglobulin FactorsSecretory IgA Salivary glandsIgA, IgG, IgM Crevicular fluid