DISEASES OF ORAL CAVITY



DISEASES OF ORAL CAVITY

Dr. Nusrum Iqbal

Department of Medicine

Lahore Medical & Dental College

Lahore

Disorders affecting the teeth

Teething

Discoloration of teeth

Odontogenic infections

Facial space infections

Necrotizing fasciitis

Teething

Teething is traditionally blamed for a variety of signs and symptoms in infancy

Causes

Restlessness

Finger sucking

Gum rubbing

Drooling

Discoloration of teeth

Odontogenic infection

They arise mainly as a consequence of caries leading to pulpitis then pariepical infection

Facial space infection

They are usually polymicrobial, predominantly anaerobes

They are dangerous ( swelling ( obstruct air ways/ erode carotid vessels/ toxicity

Admit to hospital

Start high dose antibiotics

Necrotizing fasciitis

Uncommon

Potentially lethal infection of the subcutaneous tissue and deep facia with necrosis of the overlying skin due to thrombosis of blood vessels

Mortality 30%

Variety of micro-organisms like β haemolitic streptococci, anaerobes

Predisposing conditions are diabetes mellitus and immunodeficiency

Pain is disproportionate to the clinical appearance

Initially there is no fever but with in 24-48 hours there is a rapid rise in the temperature

Penicillin or a cephalosporin plus metronidazole are indicated

Disorders affecting the oral mucosa

Oral ulcers

Recurrent aphthae

White and red lesions

Desquamative gingivitis

Oral hyperpigmentation

Oral Ulcers

Very common

Most are traumatic or recurrent aphthae

Serious causes must always be excluded

A clinical history is of a great value

Causes

Local causes

Trauma

Chemical irritation

Burns

Irradiation

Recurrent aphtae

Neoplasms

Squamous cell carcinoma

Others

Systemic Causes

Mucocutaneous diseases

Lichen planus

Chronic ulcerative stomatitis

Pemphigus

Pemphigoid

Localized oral purpura

Erythema multiforme

Epidermolysis bullosa

Dermatitis herpetiformis

Linear IgA disease

Behcet’s and Sweet’s syndromes

Systemic Causes

Connective tissue and other diseases

Lupus erythematosus

Reiter’s dyndrome

Vasculitides

Giant cell arteritis

Wegener’s ganulomatosis

Periarteritis nodosa

Systemic Causes

Blood diseases

Leucopenias including HIV disease

Leukaemias and myelodysplastic syndrome

Deficiency states or anaemia

Hypereosinophilic syndrome

Systemic Causes

Gastrointestinal disease

Coeliac disease

Crohn’s disease

Ulcerative colitis

Systemic Causes

Infections

Viral mainly

Herpes viruses

Coxsackie viruses

ECHO viruses

Bacterial acute necrotizing gingivitis

Syphilis

Tuberculosis

Epithelioid angiomatosis

Systemic Causes

Infections

Fungal

Cryptococcosis

Histoplasmosis

Paracoccidioidomycosis

Blastomycosis

Zygomycosis

Aspergillosis

Protozoal

Leishmaniasis

Recurrent aphthae

They are recurring mouth ulcers that typically start in childhood

Very common and affect upto 25% of the population at sometime

Students have a higher incidence

A disease is usually self limiting

A few patients associate the ulcers with the stress, particular foods or trauma

Deficiency of iron, folate or vit. B12 however are found in 10-20% of patients

Treatment

Mouth wash of oral chlorxidine gluconate is useful

Topical steroids may be useful

Lignocaine gel or viscous solution may relieve pain

Features of recurrent aphthae

Onset usually in childhood or adolescence

Typically round or ovoid ulcers

Recurrences at intervals

Usually self-limiting. Ulcerative typically ceases before middle age

Causes of dry mouth

Latrogenic

Drugs (antimuscarinics; sympathominetics)

Cancer therapy (irradiation of salivary glands, radioactive iodine, cytotoxic drugs)

Graft-versus-host disease

Salivary gland disease

Aplasia

Sjogren’s syndrome

Sarcoidosis

HIV disease

Infiltrates (amyloidosis; haemochromatosis)

Cystic fibrosis

Others

Dehydration

Diabetes mellitus

Diabetes insipidus

Renal failure

Haemorrhage

Other causes of fluid loss or deprivation

Oral Hyperpigmentation

Congenital

Racial (even in some Caucasians)

Naevi

Syndromes

Preutz-Jeghers syndrome

Carry complex

Laugier-Hunziker syndrome

Oral Hyperpigmentation

Acquired

Endocrine or metabolic

Addison’s disease

ACTH therapy

ACTH-producing tumours (lung cancer)

Haemochromatosis

Nelson’s syndrome

Neoplastic

Melanoma

Kaposi’s sarcoma

Metals

Amalgams tattoo

Bismuth, mercury, lead, silver

Oral Hyperpigmentation

Acquired

Drugs

Smoking

Antimalarials

Cytotoxics (busulphan particularly)

Oral contraceptives

Phenothiazines

Minocycline

Zidovudine

Clofazimine

Others

HIV infection and AIDS

Dry Mouth

Drugs

Irradiation

Sjogren’s syndrome and

HIV infection

Sialorrhoea (hypersalivation)

It should distinguished from drooling

It can be induced by

Lesions in the mouth

Foreign body

Rabies

Anticholinesterases/ Clozapine

Psychogenic

Salivary gland swellings

Inflammatory

Mumps

Bacterial ascending sialadenitis

Obstructive sialadenitis

Sjogren’s syndrome

Sarcoidosis

HIV infection

Angiolymphoid hyperplasia

Kimura’s disease

Neoplastic

Pleomorphic adenoma and others

Endocrine and metabolic

Alcoholic cirrhosis

Diabetes mellitus

Acromegaly

Malnutrition or bulimia

Cystic fibrosis

Chronic renal failure

Amyloidosis

Haemochromatosis

Drugs (rarely)

Isoprenaline

Phenylbutazone

Iodides

Chlorhexidine

Halitosis

Oral infections (especially periodontal)

Dry mouth

Foods, or smoking

Drugs

Solvent abuse

Alcohol

Chloral hydrate

DMSO (dimethyl sulphoxide)

Systemic disease

Respiratory tract tumours and infections (nose, sinuses, pharynx, larynx, bronchi, lungs)

Cirrhosis and liver failure

Renal failure

Diabetic ketosis

Gastrointestinal disease

Psychogenic disorders

Esophageal disease

Psychogenic

Globus hystericus

Organic

Mouth

Xerostomia

Inflammatory or neoplastic lesions

Pharynx

Inflammatory or neoplastic lesions

Foreign bodies

Sideropenic dysphagia

Pouch

Oesophagus

Benign stricture

Carcinoma

Esophageal disease

Scleroderma

External pressure from mediastinal lymph nodes

Neutrological and neuromuscular causes

Achalasia

Syringobulbia

Cerebrovascular accidents

Cerebrovascular disease (pseudobulbar palsy)

Motor neurone disease

Guillain-Barre syndrome

Poiomyelitis

Diphtheria

Cerebellar disease

Myopathies

Myasthenia gravis

Muscular dystrophies

dermatomyositis

Gastroesophageal reflux disease

It is described as the retrosternal burning caused by gastric content reflux into the esophagus.

Development of GERD

Multifactorial

Structural abnormalities of the antireflux barrier

Dysfunction of the lower esophageal sphincter (most common) mainly the transient LES relaxations(TLESRs)

Medications like Ca channel blockers, TCAs, nitrates and anticholinergics

Content of meals ( Gastric distension cause more TLESRs)

Foods high in fats (direct relaxations of the LES)

Acidic drinks ( cola, orange juice, tea, and beer)

Classical Symptoms

Heart burn

Acid regurgitation

Less Classic symptoms

Water brash ( hypersalivvation associated with episode of the reflux)

Dysphagia

Globus sensation

Extra esophageal symptoms

Chronic cough ( asthma, bronchitis and aspiration)

Hoarseness

Dental erosions

Atypical symptoms

Noncardiac chest pain

Importance of GERD

Associated with impairment in quality of life

Risk factor for Barrett esophagus (a premalignant condition)

Diagnosis of GERD

There is no single “ gold standard” study to assess all the manifestations of GERD

Clinical history

Acid suppression test

24 hour ambulatory esophageal pH monitoring

Barium upper GI tract radiography

Endoscopy

Gastroesophageal scintigraphy

Bernstein test( an intraesophageal acid infusion test)

Who Needs a Diagnostic Test?

Initial symptoms of unclear etiology

Lack of substantial response to adequate acid suppression therapy

History and symptoms suggestive of GERD complications

Atypical or extraesophageal symptoms that are possibly related to GERD

Typical symptoms but objective confirmation of the diagnosis before antireflux surgery is performed

What Test is needed?

Typical symptoms ( acid suppression test)

Absence of any substantial improvement in the symptoms is an indication for EGD and 24 hour ambulatory esophageal monitoring

Alarm symptoms like long duration of symptoms, dysphagia, hematemesis or malena, and weight loss ( EGD)

New onset of symptoms of any functional gastrointestinal disorder, including GERD, in patients older than 65 also requires investigation

Atypical noncardiac chest pain( acid suppression test)

Extraesophageal symptoms ( 24 hour pH monitoring)

Medical Management

Treatment Rationale

Managing the typical and atypical symptoms of GERD

Preventing complications

Maintaining relief of symptoms

Treatment Options

Lifestyle changes

Self medications

H2 receptor blocker

Motility agents

Proton pump inhibitors

Anti reflux surgery

Baclofen/ domperidone

Motility Disorders of Esophagus

Pharyngeal pouch

Achalasia

Diffuse esophageal spasm

Nutcracker esophagus

Systemic sterosis

Benign esophageal stricture

Pharyngeal pouch

Incoordination of swallowing within the pharynx leads to herniation through the cricophryngeus muscle and formation of a pouch

Most patients are elderly

Regurgitation, halitosis and dysphagia can occur

Barium swallow demonstrate the pouch and reveals incoordination of swallowing

Surgical myotomy and resection of the pouch are indicated in symptomatic patients

Achalasia

It is characterized by a hypertonic lower esophageal sphincter which fails to relax in response to the espophageous swallowing wave and decrease peristalsis in the body of esophagus

Cause is unknown

Degeneration of ganglion cells with in the sphincter and the body of the esophagus occurs

Chagase disease cause by trypanosoma cruzi is one cause of achalasia

Clinical Features

Middle life

Dysphagia develops slowly and is initially intermittent.

It is worse for solid and is eased by drinking liquids, standing and moving around after eating

Heart burn doesn’t occur

Severe chest pain

Nocturnal pulmonary aspiration

Predisposes to squamous carcinoma

Investigations

Chest radiograph

Widening of the mediastinum

Features of aspiration pneumonia

Fluid level behind a cardiac shadow

Barium swallow

Tapered narrowing of the lower esophagus

Dilated esophageal body, aperistalsis

Endoscopy

To rule out carcinoma

Manomentry

High pressure, nonrelaxing lower esophageal sphinter with poor contractility of the esophageal body

Management

Endoscopic

Forceful pneumatic dilatation

Injection of botulium toxin

Surgical myotomy (Heller’s operation)

Diffuse Esophagus spasm

Late middle age

Episodic chest pain which may mimic angina

Accompanied by transient dysphagea

Some cases occur in response to GERD

Oral or submingual nitrates or nifidipine may relieve attacks

Nutcracker esophagus

Is a condition in which extremely forceful peristaltic activity leads to episodic chest pain and dysphagia

Systemic Sclerosis

Muscle of the esophagus is replaced by fibre tissue

Esophageal peristalsis fails

Heart burn and dysphagia are common

Esophagitis is often severe

Benign fibre strictures can occur

Long term therapy with proton pump inhibitors drugs

Benign Esophageal Stricture

Consequence of GERD

Occurs most often in elderly patients

Rings occur at esophagogastric junction (schatzki ring) cause intermittent dysphagia

Post cricoid web is a rare complication of iron deficiency anemia (plummer-vinson syndrome)

Benign strictures are treated by endoscopic dilatation

Thank you…

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