6- AH Pharynx PD Lec 2022.pptx

Ahmad Halimi PA-C MSPAS [email protected] 1          Lips Gingiva Buccal mucosa Tongue Surface, sides and under surface Teeth Hard and soft palate Salivary glands Uvula Tonsils 2  Oral cavity extends from inner surface teeth to the oral pharynx  It forms the hard and soft...

Ahmad Halimi PA-C MSPAS [email protected] 1          Lips Gingiva Buccal mucosa Tongue Surface, sides and under surface Teeth Hard and soft palate Salivary glands Uvula Tonsils 2  Oral cavity extends from inner surface teeth to the oral pharynx  It forms the hard and soft palates  The soft palate terminates as the uvula  The tongue forms the floor of the mouth http://academic.kellogg.edu/herbrandsonc/bio201_mckinley/f 26-3a_oral_cavity_ante_c.jpg 3  Lips are muscular folds that surround entrance to mouth  Gingiva margins are scalloped with interdental papillae  Gingiva firmly attach to teeth, maxilla and/or mandible  Normal color: coral pink  Diffusely brown in darker- skinned people 4  Mucous membreane continuous with the gingiva and lines the cheeks  Stensen’s duct (parotid duct) opens into buccal mucosa near upper 2nd molar 5  Adjacent to the gingiva= alveolar mucosa which merges with labial mucosa of lip  Shallow gingivla sulcus between gums and each tooth is probed and measured by dentists  Periodontal disease leads to resorption of gingiva www.diabetesmonitor.c6  Composed of several tissues  Enamel, dentin, pulp and cementum  Enamel is the most highly calcified tissue in the body  Bulk of the tooth is dentin  Pulp lies under dentin – it containes branches of CNV 7  Deciduous teeth = primary dentition (20)  Secondary dentition = permanent teeth (32) 8  Lies at floor of mouth  Attaches to the hyoid bone  Main organ of taste  Aids in speech and mastication  Supplied by CNXII (hypoglossal)  Dorsum of tongue  Median sulcus  Foramen cecum  Papillae(circumvullate) and lingual tonsils posteriorly  Filiform papillae anterior  Taste buds 9  Taste buds  Sweet, salty, sour, bitter  Located on sides of circumvillate and fingiform papillae  Anterior 2/3  Sweet  CN VII (facial)  Posterior 1/3  Sour and bitter  CN IX (glossopharyngeal) www.doctorspiller.com/oral%20anatomy. htm  Lateral  salty 1  Always inspect for masses, lesions, leukoplakia, erythroplakia  Ranula (mucous retention cyst)  Unilateral, www.doctorspiller.com/oral%20anatomy. htm painless, bluish  Oral cancers often originate here  Inspect Wharton’s duct  Opening submandibular www.nyu.edu/dental/nexus/issues/spring200 7/90 1  Hard palate is a concave bone structure  Raised folds (rugae) are seen anteriorly  Soft palate is muscular and flexible  Lies posterior to the hard palate  Posteriorly ends in the uvula  Uvula aids in closing 1  Observe for  Cleft  1:1000 births  Candida www.ida.org.in/.../cleft%20lip%20palate.jpg  Petechiae  Seen in endocarditis, leukemia, mono  Torus palatinus  Bony protrusion on the palate- http://www.oralcancerfoundation.o r g/dental/dentalcomplications.htm www.wrongdiagnosis.com/phil /i mages/3185.jpg www.wrongdiagnosis.com/.../3185.html 1  Not part of the oral cavity proper  Three major glands  PAROTID   Largest, lies anterior to ear It’s duct (Stensen’s) enters oral cavity opposite to upper 2nd molar screening.iarc.fr/picoral/I3000002.jpg  SUBMANDIBULAR   2nd largest, located below and in front of mandible Wharton’s duct terminates in a papillae on either side of frenulum  SUBLINGUAL img.medscape.com/.../1048885-1080850-1701.jpg 1 Sublingual Gland  SUBLINGUAL Smallest, located beneath tongue  Drains through numerous small ducts all of which open into the floor of the mouth and are collectively termed the Duct of Rivinus; the largest is the major duct of the sublingual salivary gland called Bartholin duct   An edentulous 63-year-old woman presented with a 2-week history of discomfort in the right submental region.  Her symptoms were exacerbated by the anticipation of eating, and she reported having a 2-year history of episodic swelling in the area.  On external examination, the area was painful on palpation, but the overlying skin was normal and there was no lymphadenopathy.  Intraoral examination revealed the presence of a hardened nodule, 1.5 cm in length, in the oral floor. 1  The oral mucosa was normal in texture, with mild erythema (Panel A).  Performance of a milking maneuver along the length of Wharton's duct resulted in interrupted salivary flow and local mucosal blanching.  A dental occlusal radiograph (Panel B) confirmed that the nodule was a radioopaque sialolith.  Large sialoliths may lead to ductal obstruction, salivary stasis, and infection. 1 Sialolith of the Submandibular Salivary Gland Lemos-Júnior CA, Camargo A. N Engl J Med 2011;364:551-551.  Enlargement from infection or tumor  “kissing   picturesofstrepthroat.com tonsils” Crypts may develop with chronic infections May see exudate /membrane with www.healthofchildren.com/images/gech_0001_0000  Strep  Infectious Mononucleosis emedicine.medscape.com/article1/8782051-overview      ½ children ages 5-17 have 1-8 cavities Average adult has 10-17 teeth decayed, missing or filled Adults: gingivitis & periodontal disease 50-80% respectively > 50% ADULTS over age 65 ARE EDENTULOUS Counseling on oral hygiene  Use fluoride-containing toothpaste  Brushing and flossing  Annual dental exams/cleanings  Diet, tobacco, alcohol  Denture care 2  20% PC office visits  Often sore throat, difficulty swallowing, swollen glands  Oral cancer represents 3% all cancers  30,000 new cases annually  8000 deaths/year (killing 1 person/hour)  Death rate > cervical, Hodgkin’s, Brain liver, ovarian cancer and malignant melanoma  20X risk of second cancer after 1st occurrence  2:1 male/female  2:1 African-American-to-White death ratio  Risk factors  Tobacco product use, chewing betel nuts 2  Pain, dysphagia, swollen glands  Ulceration  Bleeding  Mass  Halcitosis  Snoring  Xerostomia(dry mouth) 2  Appraising oral hygiene  Recognize caries and periodontal disease  Recognize oral lesions, regional lymphadenopathy, salivary glands & bony structures  Recognize systemic problems associated with oral disease  Assess jaw motion and dental appliances  Know when dental treatment should be postponed due to medical problem 2  Inspection  Palpation  Equipment  includes: Pen light, gloves (latex free), tongue depressor 2  Lips  Note color, moisture, lumps, lesions, ulcers, cracking, scaliness, swelling Buccal mucosa  Note color, ulcers, lesions, nodules Gingiva    Color, lesions, bleeding, hyperplasia, recession, inflammation  Roof of mouth  Color, continuity  Tongue and floor of mouth  Note color and texture, ulcers, nodules  Pharynx: soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx  Note color, symmetry, presence of exudate, swelling, ulceration, or tonsillar enlargement2  Lips  Observe color and moisture  Note lumps, lesions, ulcers, cracking, scaliness or swelling 72.233.24.94/.../uploads/2008/12/f21.jpg 2  Inspect for Color Ulcers Lesions White patches Nodules This patient has an aphthous ulcer on the  Gingiva (gums)  Color: normally pink  Redness with gingivitis  Black line with lead poisoning  Lesions, Bleeding, Hyperplasia, Recession,  Teeth Inflammation  Color  Number  Shape and position/alignment  Caries, loose teeth  Dentures www.enexus.com www.humanillnesses.com/.../Gum - Disease.html 2  Inspect  Color, masses, lesions  Architecture/ Cleft continuity  Torus palatinus  g www.tattoo-doodoo.com/.../roof-of-mouth-star.jp www.hakeem-sy.com/main/files/images/torus.jpg 3  Tongue  Inspect for asymmetry  Tests CNXII (hypoglossal)  Note color and texture  Observe for fasciculations, wasting  Palpate for masses  Grasp tongue with gloved hand, feel for induration  Floor of mouth  Note, masses, lesions, Wharton’s duct, swelling, ranula deviates to affected side 3   Second most common cancer of the mouth second only to cancer of the lip Usually squamous cell  Induration increases the chance of malignancy  Most often on the side of the tongue followed by base NEJM 328: 186, 1993 3  Ask the patient to say “ah” or yawn  Watch rise and fall of soft palate  CN IX, CN X (glossopharyngeal & vagus)  Listen  uvula drawn to NORMAL side for hoarseness CN X  Insert tongue blade and observe gag reflex  CN IX and X i.ytimg.com/vi/dPIkJ9XfgvU/2.jpg 3  Note color and symmetry  Look for  Exudate  Swelling  Ulceration  Enlargement  Crypts hardinmd.lib.uiowa.edu/.../handfootmouth1.html 3 3 3 3   Softening then fissuring of skin at edges of mouth Nutritional deficiency or overclosure of mouth .. Secondary Candida  Excessive exposure sun  Usually lower lip  Pallor, scaly, thickened and slightly everted lip 3  Diffuse, nonpitting tense swelling  Develops rapidly Abates slowly   Usually allergic (Ace-I) however does NOT itch!   Pigmented spots on lips and buccal mucosa AD disorder  Gen’l GI hamartomatous polyposis and mucocutaneous pigments on lips and mucosae 3   Small red spots on lips Osler-WeberRendu Syndrome  Multiple telangiectasias thruout GIT  Can lead to bleeding    Cold sores, fever blisters HSV I and II PAINFUL Cluster of vesicles on erythematous base  Later ooze/crust  Lasts 7-14d 4  1º syphilitic lesion  Firm … ulcerates  Infectious!  Usually lower lip  Scaly plaque … ulcer and crust or nodular 4  Abnormally large  Can touch the uvula and obscure the posterior pharynx  White or grey exudate  With fever and cervical adenopathy  think GPA Strep/ Mono/ Adenovirus 4     Erythema Swelling Pain Viral mostly … or bacterial 4  Corynebacteriu m diphtheriae  Vaccine (DPTa)  Erythema, grey exudate forms pseudomembrane on uvula, pharynx and tongue  Candidiasis  Thick, white plaques adherent to underlying mucosa  2º ABX or steroids 4    HHV 8 Seen in AIDS Deep purple lesions  Midline bony growth of hard palate  Can also be seen lingual surface of mandible – torus mandibularis  Harmless, Benign 4   Normal sebaceous glands Yellowish spots on buccal mucosa or lips   Early sign of measles (rubeola) White specs  Like grains of salt on red background  Buccal mucosa near 1st and 2nd molars 4  Small red spots  Result when blood escapes from capillaries into the tissue  May be 2º biting, infection, trauma, thrombocytopen ia  Thickened white patch  Pre-cancerous  2º chewing tobacco, local irritant 4    Gingival margins reddened and swollen Interdental papillae are blunted, swollen and red Often, gums bleed when brushed  Acc’d by fever, malaise, enlarged lymph nodes  Ulcers in interdental papillae  Grey pseudomembranes form along gum margins Gums bleed, foul 4 breath    Swelling, +/inflammatio n Causes  Aka pregnancy tumor, epulis  Tumor-like mass originates in interdental papilla  Red, soft, bleeds easily  Seen in 1% pregnancies  Dilantin therapy  Puberty  Pregnancy  Leukemia 4  Condition of teeth   Chewing surfaces worn down Ersosion of the enamel from lingual surfaces  Yellow-brown dentin exposed Exposes yellowbrown dentin  Seen in bulemia   Also pictured is gum recession giving “long tooth” appearance  From recurrent regurgitation of stomach contents 5   Smaller More widely spaced  Notched on biting surfaces  Sign of congenital syphilis  Recurrent trauma  Holding things between teeth (nails/bobby pins)  Contour, size and spacing of teeth not affected 5  Benign  Scattered smooth red areas denuded of papillae  “map like” appearan ce  Yellow or brown/black elongated filiform papillae of dorsum of tongue  Benign  May follow ABX Tx 5   Seen with increasing age benign  Aka atrophic glossitis  Seen with deficiency riboflavin, niacin, folic acid, vitB12, Iron, pyridoxine, chemotherapy 5  Thick white coating  Candida  Raw red where exudate wiped off   1st described 1984 2º EBV virus  Whitish, raised Feathery or corrugated pattern  Sides of tongue  Cannot be scraped off  mostly seen in HIV/AIDS http://emedicine.medscape.c5o2   Painless 2º stage  Highly infectious  Grayish membrane  Painless  White patch  Suspicious for malignancy 5  Small, purlish or blue-black  Painful, round, oval ulcer  Round swellings  White or yellowgrey  Under tongue   Seen with age Surrounded by halo of reddened mucosa  benign  Single or multiple  Lasts 7-24 d 5  Rounded bony growths  Inner surfaces of mandible  Usu bilateral   Asymptomati c Harmless  Floor of mouth  Ulcerated  Erythematou s 5  The lips are pink and well hydrated without lesions or fissures.  Mucosa of oral cavity is pink without masses, leukoplakia or other lesions.  Dentition and dental hygiene are good.  The tongue is midline and does not deviate to either side.  The pharynx does not show any abnormalities.  The palate is intact without ulcers or masses. 5