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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