أمراض اللثة PDF

‫أﻣﺮاض اﻟﻠﺜﺔ واﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ‬  ‫اﻟﻤﻈﮭﺮ اﻟﻄﺒﯿﻌﻲ ﻟﻠﺜﺔ‬ ‫§ اﻟﻠﺜﺔ ھﻲ ﺟﺰء ﻣﻦ اﻟﻐﺸﺎء اﻟﻤﺨﺎﻃﻲ اﻟﻔﻤﻮي ‪oral‬‬ ‫‪ mucous membrane‬واﻟﺬي ﯾﻐﻄﻲ اﻟﻨﺘﻮءات‬ ‫اﻟﺴﻨﺨﯿﺔ ‪ alveolar processes‬واﻷﺟﺰاء اﻟﻌﻨﻘﯿﺔ‬ ‫‪ cervical portions‬ﻟﻸﺳﻨﺎن ‪ ,‬وھﻲ ﺗﻘﺴﻢ إﻟﻰ ‪:‬‬ ‫§ اﻟﻠﺜﺔ اﻟﺤﺮة ‪ free gingiva :‬ا...

‫أﻣﺮاض اﻟﻠﺜﺔ واﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ‬  ‫اﻟﻤﻈﮭﺮ اﻟﻄﺒﯿﻌﻲ ﻟﻠﺜﺔ‬ ‫§ اﻟﻠﺜﺔ ھﻲ ﺟﺰء ﻣﻦ اﻟﻐﺸﺎء اﻟﻤﺨﺎﻃﻲ اﻟﻔﻤﻮي ‪oral‬‬ ‫‪ mucous membrane‬واﻟﺬي ﯾﻐﻄﻲ اﻟﻨﺘﻮءات‬ ‫اﻟﺴﻨﺨﯿﺔ ‪ alveolar processes‬واﻷﺟﺰاء اﻟﻌﻨﻘﯿﺔ‬ ‫‪ cervical portions‬ﻟﻸﺳﻨﺎن ‪ ,‬وھﻲ ﺗﻘﺴﻢ إﻟﻰ ‪:‬‬ ‫§ اﻟﻠﺜﺔ اﻟﺤﺮة ‪ free gingiva :‬اﻟﻨﺴﯿﺞ اﻟﻤﻤﺘﺪ ﺗﺎﺟﯿﺎ إﻟﻰ‬ ‫أﺳﻔﻞ اﻟﻤﯿﺰاب اﻟﻠﺜﻮي ‪.‬‬ ‫§ اﻟﻠﺜﺔ اﻟﻤﻠﺘﺼﻘﺔ ‪ attached gingiva :‬ﺗﻤﺘﺪ ذروﯾﺎ ﻣﻦ‬ ‫ﻣﯿﺰاب اﻟﻠﺜﺔ اﻟﺤﺮة إﻟﻰ اﻟﻤﻠﺘﻘﻰ اﻟﻤﺨﺎﻃﻲ اﻟﻠﺜﻮي‬ Diagram showing anatomic landmarks of the gingiva Normal gingiva (children)  Normal gingiva Children gingiva Adult gingiva ‫ﺗﺒﺪو اﻟﻠﺜﺔ ﺑﺸﻜﻞ ﻃﺒﯿﻌﻲ ﺑﻠﻮن زھﺮي ﻓﺎﺗﺢ ‪ ,‬ﻋﻠﻰ‬ ‫§‬ ‫اﻟﺮﻏﻢ ﻣﻦ أن اﻟﻠﻮن ﻗﺪ ﯾﻜﻮن ﻣﺮﺗﺒﻄﺎ ﺑﻌﺪد ﻣﻦ‬ ‫اﻟﻌﻮاﻣﻞ ‪:‬‬ ‫اﻟﺸﺨﺺ ‪person‬‬ ‫§‬ ‫ﺛﺨﺎﻧﺔ اﻟﻨﺴﯿﺞ ‪thickness of the tissue‬‬ ‫§‬ ‫درﺟﺔ اﻟﺘﻘﺮن ‪degree of keratinization‬‬ ‫§‬  ‫ﻣﻈﮭﺮ اﻟﻠﺜﺔ اﻟﻄﺒﯿﻌﻲ ﻋﻨﺪ اﻷﻃﻔﺎل‬ ‫‪Children gingiva‬‬ ‫اﻟﻠﻮن ‪:‬أﻛﺜﺮ اﺣﻤﺮارا ﻧﺘﯿﺠﺔ ﻟﺰﯾﺎدة‬ ‫§‬ ‫اﻟﺘﻮﻋﯿﺔ واﻟﻈﮭﺎرة اﻷﻗﻞ ﺛﺨﺎﻧﺔ ‪.‬‬ ‫اﻟﻤﻈﮭﺮ ‪:‬ﺳﻄﺢ اﻟﻠﺜﺔ أﻗﻞ ﺗﻨﻘﯿﻄﺎ وأﻧﻌﻢ ﻣﻦ‬ ‫§‬ ‫ذﻟﻚ اﻟﻤﻈﮭﺮ اﻟﻤﺸﺎھﺪ ﻟﺪى اﻟﺒﺎﻟﻐﯿﻦ‪.‬‬ ‫ﻟﺪى اﻟﺒﺎﻟﻐﯿﻦ اﻷﺻﺤﺎء ﯾﻜﻮن ﻟﻠﺜﺔ‬ ‫§‬ ‫اﻟﺤﻔﺎﻓﯿﺔ ﺣﺎﻓﺔ ﺣﺎدة ﺗﺸﺒﮫ اﻟﺴﻜﯿﻦ ‪.‬‬ ‫أﺛﻨﺎء ﻓﺘﺮة ﺑﺰوغ اﻟﺴﻦ ﻟﺪى اﻟﻄﻔﻞ ‪,‬ﺗﻜﻮن‬ ‫§‬ ‫اﻟﻠﺜﺔ أﺛﺨﻦ وﺗﻤﺘﻠﻚ ﺣﻮاﻓﺎ ﻣﺪورة ﻧﺘﯿﺠﺔ‬ ‫ﻟﻠﺘﻀﯿﻖ اﻟﻌﻨﻘﻲ ﻟﻸﺳﻨﺎن اﻟﻤﺆﻗﺘﺔ‬  ‫ﻣﻈﮭﺮ اﻟﻠﺜﺔ اﻟﻄﺒﯿﻌﻲ ﻋﻨﺪ اﻷﻃﻔﺎل‬ ‫ﻋﻤﻖ اﻟﺴﺒﺮ ‪ probing depth‬ﺣﻮل اﻷﺳﻨﺎن اﻟﻤﺆﻗﺘﺔ‬ ‫§‬ ‫ﺣﻮاﻟﻲ ‪ 2‬ﻣﻠﻢ ‪.‬‬ ‫ﻣﻮاﻗﻊ اﻟﺴﺒﺮ اﻟﻠﺴﺎﻧﯿﺔ واﻟﺪھﻠﯿﺰﯾﺔ أﻗﻞ ﻋﻤﻘﺎ ﻣﻦ اﻟﻤﻮاﻗﻊ‬ ‫§‬ ‫اﻟﻤﻼﺻﻘﺔ ‪.‬‬ ‫اﻟﺮﺑﺎط ﺣﻮل اﻟﺴﻨﻲ ‪ :‬أﻋﺮض ﻋﻨﺪ اﻷﻃﻔﺎل‬ ‫§‬ ‫ﻋﺮض اﻟﻠﺜﺔ اﻟﻤﻠﺘﺼﻘﺔ ‪:‬أﺿﯿﻖ ﻓﻲ اﻟﻔﻚ اﻟﺴﻔﻠﻲ ﻣﻨﮫ ﻓﻲ اﻟﻔﻚ‬ ‫§‬ ‫اﻟﻌﻠﻮي ‪ ,‬ﺣﯿﺚ ﯾﺰداد ﻛﻼ اﻟﻌﺮﺿﯿﻦ ﻣﻊ اﻻﻧﺘﻘﺎل ﻣﻦ اﻹﺳﻨﺎن‬ ‫اﻟﻤﺆﻗﺖ إﻟﻰ اﻹﺳﻨﺎن اﻟﺪاﺋﻢ ‪.‬‬ ‫اﻟﻌﻈﻢ اﻟﺴﻨﺨﻲ اﻟﻤﺤﯿﻂ ﺑﺎﻷﺳﻨﺎن اﻟﻤﺆﻗﺘﺔ ﺗﺒﺪي ﻋﻈﻤﺎ ﺣﺎﺟﺰﯾﺎ‬ ‫§‬ ‫أﻗﻞ ‪ ,‬ﻛﻤﺎ أﻧﮭﺎ أﻗﻞ ﺗﻜﻠﺴﺎ ﻣﻊ ﻓﺮاﻏﺎت ﻧﻘﯿﻮﯾﺔ أﻛﺒﺮ‪.‬‬ ‫اﻟﺘﮭﺎب اﻟﻠﺜﺔ ﻋﻨﺪ اﻷﻃﻔﺎل‪GINGIVITIS‬‬  ‫§ ھﻮ اﻟﺘﮭﺎب ﯾﺘﻀﻤﻦ ﻓﻘﻂ اﻟﻨﺴﺞ اﻟﻠﺜﻮﯾﺔ اﻟﻤﺠﺎورة ﻟﻠﺴﻦ ‪,‬ﯾﺘﻢ‬ ‫ﺗﻤﯿﯿﺰه ﻣﺠﮭﺮﯾﺎ ﺑﻮﺟﻮد اﻟﻨﺘﺤﺔ اﻻﻟﺘﮭﺎﺑﯿﺔ واﻟﻮذﻣﺔ إﺿﺎﻓﺔ‬ ‫ﻟﺒﻌﺾ اﻟﺘﺨﺮب ﻓﻲ اﻷﻟﯿﺎف اﻟﻠﺜﻮﯾﺔ اﻟﻜﻮﻻﺟﯿﻨﯿﺔ ‪ ,‬وﺗﻘﺮح‬ ‫وﺗﻜﺎﺛﺮ اﻟﻈﮭﺎرة اﻟﻤﻘﺎﺑﻠﺔ ﻟﻠﺴﻦ و اﻟﺬي ﯾﺮﺑﻂ اﻟﻠﺜﺔ إﻟﻰ اﻟﺴﻦ‪.‬‬ ‫§ اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺸﺪﯾﺪ ﻏﯿﺮ ﺷﺎﺋﻊ ﻧﺴﺒﯿﺎ ﻟﺪى اﻷﻃﻔﺎل‬ ‫§ اﻟﻌﻮاﻣﻞ اﻟﻤﺴﺒﺒﺔ اﻟﺮﺋﯿﺴﺔ اﻟﻤﺘﺮاﻓﻘﺔ ﻣﻊ اﻟﺘﮭﺎب اﻟﺜﺔ‬ ‫وأﻣﺮاض اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ اﻷﻛﺜﺮ ﻧﻮﻋﯿﺔ ھﻲ ﻃﺒﻘﺔ اﻟﺒﻠﯿﻚ‬ ‫اﻟﺠﺮﺛﻮﻣﯿﺔ اﻟﻤﺘﻜﻠﺴﺔ وﻏﯿﺮ اﻟﻤﺘﻜﻠﺴﺔ ‪.‬‬ ‫اﻟﺘﮭﺎب اﻟﻠﺜﺔ )‪(Gingivitis‬‬ ‫اﻟﺘﮭﺎب اﻟﻠﺜﺔ) ‪(Gingivitis‬‬  ‫ﺗﺮﻛﯿﺐ ﻃﺒﻘﺔ اﻟﺒﻠﯿﻚ اﻟﺠﺮﺛﻮﻣﯿﺔ‬ ‫§ ﺗﻌﺘﺒﺮ ﻃﺒﻘﺔ اﻟﺒﻠﯿﻚ اﻟﺠﺮﺛﻮﻣﯿﺔ واﻟﺘﻲ ﺗﺘﺄﻟﻒ ﻣﻦ ﺗﺮﺳﺒﺎت‬ ‫ﺟﺮﺛﻮﻣﯿﺔ ﻃﺮﯾﺔ ﺗﻠﺘﺼﻖ ﺑﺜﺒﺎت إﻟﻰ اﻟﺴﻦ ‪,‬ﻧﻈﺎم ﺟﺮﺛﻮﻣﻲ‬ ‫ﻣﻌﻘﺪ ﻣﺘﺮاﺑﻂ اﺳﺘﻘﻼﺑﯿﺎ ‪,‬ﻣﻨﻈﻢ ﺑﺸﻜﻞ ﻋﺎﻟﻲ ﯾﺘﺄﻟﻒ ﻣﻦ ﻛﺘﻞ‬ ‫ﺳﻤﯿﻜﺔ ﻣﻦ اﻟﻌﻀﻮﯾﺎت اﻟﺪﻗﯿﻘﺔ اﻟﻤﻄﻤﻮرة ﺿﻤﻦ اﻟﻘﺎﻟﺐ‬ ‫اﻟﺠﺮﺛﻮﻣﻲ ‪.‬‬ ‫§ وﻟﺪى ﺗﻮاﻓﺮھﺎ ﺑﺘﺮاﻛﯿﺰ ﻛﺎﻓﯿﺔ ﯾﻤﻜﻦ ﻟﮭﺬه اﻟﻄﺒﻘﺔ أن ﺗﺨﺮب‬ ‫ﻋﻼﻗﺔ اﻟﻤﻀﯿﻒ –اﻟﻄﻔﯿﻠﻲ ﻣﺴﺒﺒﺔ ﻧﺨﻮر ﺳﻨﯿﺔ وأﻣﺮاض‬ ‫اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ‪.‬‬  ‫اﻟﻘﻠﺢ )‪( calculus‬‬ ‫§ ﯾﻌﺘﺒﺮ اﻟﻘﻠﺢ ﺳﻮاء أﻛﺎن ﻓﻮق ﻟﺜﻮي أو ﺗﺤﺖ ﻟﺜﻮي‬ ‫ﻋﺎﻣﻞ ھﺎم ﻓﻲ ﺗﻄﻮر اﻷﻣﺮاض اﻟﻠﺜﻮﯾﺔ واﻟﻨﺴﺞ‬ ‫اﻟﺪاﻋﻤﺔ ‪.‬‬ ‫§ ﻓﻔﻲ دراﺳﺔ ﻋﻠﻰ ﺣﻮاﻟﻲ ‪1700‬ﻃﻔﻞ ﻣﻤﻦ ﺗﺮواﺣﺖ‬ ‫أﻋﻤﺎرھﻢ ﺑﯿﻦ ‪ 9 -14‬ﺳﻨﺔ وﺟﺪ أن ‪%56- 85‬‬ ‫ﻣﻦ اﻷﻃﻔﺎل ‪ -‬ﻣﻦ ﻛﻼ اﻟﺠﻨﺴﯿﻦ واﻟﺬﯾﻦ ﯾﻨﺘﻤﻮن‬ ‫ﻟﻤﺠﻤﻮﻋﺎت ﻋﻤﺮﯾﺔ ﻣﺨﺘﻠﻔﺔ أو ﻣﺠﻤﻮﻋﺎت ﻋﺮﻗﯿﺔ‬ ‫وإﺛﻨﯿﺔ ﻣﺨﺘﻠﻔﺔ – ﻟﺪﯾﮭﻢ ﻗﻠﺢ ﻓﻮق ﻟﺜﻮي ‪.‬‬ ‫اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺒﺰوﻏﻲ ‪Eruption gingivitis‬‬ ‫§ ﻧﻤﻂ ﻣﺆﻗﺖ ﻣﻦ اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي ‪,‬ﯾﺸﺎھﺪ ﻏﺎﻟﺒﺎ ﻟﺪى اﻷﻃﻔﺎل‬ ‫ﻣﺘﺮاﻓﻘﺎ ﻣﻊ ﺑﺰوغ ﺻﻌﺐ ‪ ,‬وﯾﺘﺮاﺟﻊ ﺑﻌﺪ ﻇﮭﻮر اﻟﺴﻦ ﻓﻲ‬ ‫اﻟﺤﻔﺮة اﻟﻔﻤﻮﯾﺔ ‪.‬‬ ‫§ أﻇﮭﺮت دراﺳﺔ ‪ Weddel‬و ‪Klein‬اﻟﺘﻲ أﺟﺮﯾﺖ ﻋﻠﻰ‬ ‫‪ 233‬ﻃﻔﻞ أن اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺒﺰوﻏﻲ وﺟﺪ ﻟﺪى ‪ 13%‬ﻣﻦ‬ ‫اﻷﻃﻔﺎل اﻟﺬﯾﻦ ﺗﺮاوﺣﺖ أﻋﻤﺎرھﻢ ﺑﯿﻦ ‪ 6-17‬ﺷﮭﺮ ‪34%,‬‬ ‫ﻣﻦ اﻷﻃﻔﺎل ﺑﻌﻤﺮ ‪18-23‬ﺷﮭﺮ‪ 39%,‬ﻣﻦ اﻷﻃﻔﺎل ﺑﻌﻤﺮ‬ ‫‪ 24-36‬ﺷﮭﺮ‪.‬‬ Eruption gingivitis Eruption gingivitis  ‫أﺳﺒﺎب اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺒﺰوﻏﻲ‬ ‫§ ﺗﺤﺪث اﻟﺰﯾﺎدة ﻓﻲ اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي ﺑﯿﻦ ‪ 6-7‬ﺳﻨﻮات ﺑﺸﻜﻞ‬ ‫واﺿﺢ ﻷن اﻟﺤﺎﻓﺔ اﻟﻠﺜﻮﯾﺔ ﻻ ﺗﺘﻠﻖ أي ﺣﻤﺎﯾﺔ ﻣﻦ اﻟﺤﻮاف اﻟﺘﺎﺟﯿﺔ‬ ‫ﻟﻠﺴﻦ أﺛﻨﺎء اﻟﻤﺮﺣﻠﺔ اﻟﻤﺒﻜﺮة ﻣﻦ اﻟﺒﺰوغ اﻟﻔﻌﺎل ‪ ,‬ﻛﻤﺎ أن‬ ‫اﻻﺣﺘﻜﺎك اﻟﻤﺴﺘﻤﺮ ﻟﻠﻄﻌﺎم ﻋﻠﻰ اﻟﻠﺜﺔ ﯾﺴﺒﺐ ﻋﻤﻠﯿﺔ اﻻﻟﺘﮭﺎب ‪.‬‬ ‫§ ﺗﺘﺠﻤﻊ اﻟﺒﻘﺎﯾﺎ اﻟﻄﻌﺎﻣﯿﺔ واﻟﻠﻮﯾﺤﺔ اﻟﺠﺮﺛﻮﻣﯿﺔ ﺣﻮل وﺗﺤﺖ اﻟﻨﺴﺞ‬ ‫اﻟﺤﺮة ‪ ,‬ﻣﻐﻄﯿﺔ ﺑﺸﻜﻞ ﺟﺰﺋﻲ ﺗﺎج اﻟﺴﻦ اﻟﺒﺎزغ وﺗﺴﺒﺐ ﺗﻄﻮر‬ ‫اﻟﻌﻤﻠﯿﺔ اﻻﻟﺘﮭﺎﺑﯿﺔ )اﻟﻤﺘﺮﻓﻘﺔ ﻣﻊ ﺑﺰوغ اﻷرﺣﺎء اﻟﺪاﺋﻤﺔ اﻷوﻟﻰ‬ ‫واﻟﺜﺎﻧﯿﺔ (‪.‬‬ ‫§ ﯾﻤﻜﻦ ﻟﻠﺤﺎﻟﺔ أن ﺗﻜﻮن ﻣﺆﻟﻤﺔ وﻗﺪ ﺗﺘﻄﻮر إﻟﻰ ﺗﻮاج أو ﺧﺮاج‬ ‫ﺣﻮل ﺗﺎﺟﻲ ‪.‬‬  ‫ﺗﺪﺑﯿﺮ اﻻﻟﺘﮭﺎب اﻟﺒﺰوﻏﻲ‬ ‫§ اﻻﻟﺘﮭﺎب اﻟﺨﻔﯿﻒ ‪:‬ﻻﯾﺤﺘﺎج ﻷي ﻣﻌﺎﻟﺠﺔ ﺳﻮى‬ ‫ﺗﺤﺴﯿﻦ اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ ‪.‬‬ ‫§ اﻟﺘﻮاج اﻟﻤﺆﻟﻢ ‪ :‬إرواء اﻟﻤﻨﻄﻘﺔ ﺑﺎﻟﻤﻮاد‬ ‫اﻟﻤﻠﻄﻔﺔ واﻟﻤﻀﺎدة ﻟﻠﺘﺨﺮﯾﺶ‪.‬‬ ‫§ اﻟﺘﻮاج اﻟﻤﺘﺮاﻓﻖ ﻣﻊ اﻻﻧﺘﺒﺎج واﻟﺘﮭﺎب اﻟﻌﻘﺪ‬ ‫اﻟﻠﻤﻔﺎوﯾﺔ ﯾﺠﺐ ﻣﻌﺎﻟﺠﺘﮫ ﺑﺎﻟﺼﺎدات اﻟﺤﯿﻮﯾﺔ ‪.‬‬ ‫اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي اﻟﻤﺘﺮاﻓﻖ ﻣﻊ إھﻤﺎل اﻟﺼﺤﺔ‬ ‫اﻟﻔﻤﻮﯾﺔ‬ ‫§ إن درﺟﺔ اﻟﻨﻈﺎﻓﺔ اﻟﺴﻨﯿﺔ وﺣﺎﻟﺔ اﻟﻨﺴﺞ اﻟﻠﺜﻮﯾﺔ‬ ‫ﻟﺪى اﻷﻃﻔﺎل ﻣﺘﺮاﺑﻄﺎن ﺑﺸﻜﻞ ﻛﺎﻣﻞ ‪.‬‬ ‫§ ﯾﻈﮭﺮ اﻟﺘﺤﺴﻦ اﻟﻨﻮﻋﻲ ﻓﻲ اﻟﻤﻘﺎﯾﯿﺲ اﻟﺨﺎﺻﺔ‬ ‫ﺑﺎﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي ﻷﻃﻔﺎل اﻟﻤﺪارس ﺑﻌﺪ اﻟﺒﺪء‬ ‫ﺑﺒﺮﻧﺎﻣﺞ إزاﻟﺔ اﻟﻠﻮﯾﺤﺔ اﻟﺠﺮﺛﻮﻣﯿﺔ اﻟﯿﻮﻣﻲ ‪.‬‬ ‫§ ﺗﺮﺗﺒﻂ اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ اﻟﻜﺎﻓﯿﺔ وﻧﻈﺎﻓﺔ اﻷﺳﻨﺎن‬ ‫ﺑﺘﻮاﺗﺮ اﻟﺘﻔﺮﯾﺶ وﻋﻤﻘﮫ ‪.‬‬  ‫اﻟﺘﺼﻨﯿﻒ واﻟﺘﺪﺑﯿﺮ‬ ‫§ اﻟﺘﺼﻨﯿﻒ ‪ :‬ﻣﺒﻜﺮ )‪, early(slight‬ﻣﺘﻮﺳﻂ‬ ‫‪, moderate‬ﻣﺘﻘﺪم ‪advanced‬‬ ‫§ اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﻤﺒﻜﺮ ردود ﺑﺴﺮﻋﺔ وﯾﻤﻜﻦ ﺗﺪﺑﯿﺮه‬ ‫ﺑﻤﻌﺎﻟﺠﺔ ﻓﻤﻮﯾﺔ وﻗﺎﺋﯿﺔ ﺟﯿﺪة وﺗﻌﻠﯿﻤﺎت اﻟﺘﻔﺮﯾﺶ‬ ‫اﻟﺠﯿﺪ واﺳﺘﺨﺪام اﻟﺨﯿﻮط ﻟﻠﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ اﻟﺴﻦ‬ ‫ﺧﺎﻟﯿﺎ ﻣﻦ اﻟﻠﻮﯾﺤﺔ اﻟﺠﺮﺛﻮﻣﯿﺔ ‪.‬‬ ‫§ اﻟﺘﮭﺎب اﻟﻠﺜﺔ ﻋﺎدة ﻣﺎ ﯾﻜﻮن أﻗﻞ ﺷﺪة ﻟﺪى اﻷﻃﻔﺎل‬ ‫ﻣﻨﮫ ﻟﺪى اﻟﺒﺎﻟﻐﯿﻦ ﺣﺘﻰ ﻋﻨﺪ ﻣﺴﺘﻮﯾﺎت ﻣﻤﺎﺛﻠﺔ ﻣﻦ‬ ‫اﻟﻠﻮﯾﺤﺔ ‪.‬‬ Moderate gingivitis Obvious erythema and edema. No stippling apparent; hemorrhage following probing of the sulcus.  Moderate gingivitis Moderate gingivitis in anterior segments Erythema and enlargement of the gingiva. Symptoms are more pronounced in mandible than in maxilla Radiographi -cally there is no evidence of destruction of the interdental bony septa. Papilla Bleeding Index (PBI).The pronounced gingivitis that is particularly obvious in the mandibular anterior area is corroborated by the PBI. Bleeding scores of 3 and 4 are recorded after "sweeping" the sulcus with a periodontal probe in the papillary regions Adnanced gingivitis Fiery redness, edematous and hyperplastic swelling; complete absence of any stippling; interdental ulceration, copious bleeding on probing, and spontaneous hemorrhage Moderate gingivitis Advanced gingivitis  Advanced gingivitis Advanced gingivitis The clinical symptoms of severe gingivitis such as erythema, edema and hyperplastic enlargement are observed. The anterior region is more severely affected (slight crowding, mouth breathing?). Probing reveals no attachment loss. The base of the pseudopockets is not apical to the cementoenamel junction.  Advanced gingivitis Radiographic- ally one observes no evidence of bone loss at the interdental septa, despite the severe inflammation  Advanced gingivitis Papilla Bleeding Index (PBI) Copious bleeding (PBI grade 4) occurs after sweeping the pseudopockets with a blunt periodontal probe. The inflammation is somewhat milder in the premolar and molar regions.  ‫اﻷﻣﺮاض اﻟﻠﺜﻮﯾﺔ اﻟﺤﺎدة‬ ACUTE GINGIVAL DISEASE  ‫اﻻﻧﺘﺎن ﺑﻔﯿﺮوس اﻟﺤﻸ اﻟﺒﺴﯿﻂ‬ HERPS SIMPLEX VIRUS INFECTION  ‫اﻻﻧﺘﺎن اﻷوﻟﻲ‬ ‫§ اﻻﻧﺘﺎن اﻷوﻟﻲ ‪:‬ﯾﺤﺪث ﻟﺪى اﻷﻃﻔﺎل دون ال ‪ 6‬ﺳﻨﻮات ﻣﻦ‬ ‫اﻟﻌﻤﺮ واﻟﺬﯾﻦ ﻟﻢ ﯾﻜﻦ ﻟﺪﯾﮭﻢ ﺗﻤﺎس ﻣﺴﺒﻖ ﻣﻊ ﻓﯿﺮوس اﻟﺤﻸ‬ ‫اﻟﺒﺴﯿﻂ ﻣﻦ اﻟﻨﻤﻂ اﻷول‬ ‫)‪Type 1 herpes simplex virus(HSV-1‬‬ ‫واﻟﺬﯾﻦ ﻻ ﯾﻤﺘﻠﻜﻮن أﺟﺴﺎم ﺿﺪﯾﺔ ﻣﻌﺪﻟﺔ ‪.‬‬ ‫§ ﯾﻌﺘﻘﺪ أن ‪ %99‬ﻣﻦ ﻛﻞ اﻻﻧﺘﺎﻧﺎت اﻷوﻟﯿﺔ ھﻲ ذات ﻧﻤﻂ ﺗﺤﺖ‬ ‫ﺳﺮﯾﺮي ‪. subclinical type‬‬ ‫§ ﻗﺪ ﯾﺤﺪث اﻻﻧﺘﺎن ﻟﺪى اﻟﺒﺎﻟﻐﯿﻦ اﻟﻤﺆھﺒﯿﻦ اﻟﺬﯾﻦ ﻟﻢ ﯾﺘﻌﺮﺿﻮا‬ ‫ﻟﻼﻧﺘﺎن اﻷوﻟﻲ ‪.‬‬ Herpetic stomatitis(primary) Primary Herpetic Gingivostomatitis  ‫اﻟﺘﻈﺎھﺮات اﻟﺴﺮﯾﺮﯾﺔ‬ ‫§ ﻗﺪ ﯾﺘﻢ ﺗﻤﯿﯿﺰ اﻻﻧﺘﺎن اﻷوﻟﻲ ﻟﺪى ﺑﻌﺾ أﻃﻔﺎل ﻣﺎ ﻗﺒﻞ‬ ‫اﻟﻤﺪرﺳﺔ ﺑﻘﺮﺣﺔ واﺣﺪة ﻓﻘﻂ أو اﺛﻨﺘﯿﻦ ﻋﻠﻰ اﻷﻏﺸﯿﺔ‬ ‫اﻟﻤﺨﺎﻃﯿﺔ اﻟﻔﻤﻮﯾﺔ ‪ ,‬واﻟﺘﻲ ﻗﺪ ﺗﻠﻘﻰ اھﺘﻤﺎﻣﺎ ﺿﺌﯿﻼ ﻣﻦ‬ ‫ﻗﺒﻞ اﻟﻄﻔﻞ أو ﻗﺪ ﻻ ﺗﻼﺣﻆ ﻣﻦ ﻗﺒﻞ اﻷھﻞ ‪.‬‬ ‫§ ﻗﺪ ﯾﺘﻈﺎھﺮ اﻻﻧﺘﺎن اﻷوﻟﻲ ﻟﺪى اﻷﻃﻔﺎل اﻵﺧﺮﯾﻦ‬ ‫ﺑﺄﻋﺮاض ﺣﺎدة وھﻮ ﻣﺎ ﯾﻄﻠﻖ ﻋﻠﯿﮫ ‪ :‬اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي‬ ‫اﻟﺤﻠﺌﻲ اﻟﺤﺎد‬ ‫‪Acute herpetic gingivostomatitis‬‬  ‫أﻋﺮاض وﻋﻼﻣﺎت اﻟﺸﻜﻞ اﻟﺤﺎد‬ ‫§ ﺗﺘﻄﻮر أﻋﺮاض اﻟﻤﺮض ﻓﺠﺄة وﺗﺘﻀﻤﻦ ﺑﺎﻹﺿﺎﻓﺔ ﻟﻠﻨﺴﺞ‬ ‫اﻟﻠﺜﻮﯾﺔ اﻟﺤﻤﺮاء اﻟﻨﺎزﻓﺔ ‪ ,‬ﺗﻮﻋﻚ ‪ ,‬إﺛﺎرة ‪ ,‬ﺻﺪاع وأﻟﻢ‬ ‫ﻣﺘﺮاﻓﻖ ﻣﻊ ﺗﻨﺎول اﻟﻄﻌﺎم واﻟﺴﻮاﺋﻞ ذات اﻟﻤﺤﺘﻮى‬ ‫اﻟﺤﺎﻣﻀﻲ ‪.‬‬ ‫§ اﻟﺨﺼﺎﺋﺺ اﻟﻤﻤﯿﺰة ‪:‬وﺟﻮد اﻟﺤﻮﯾﺼﻼت اﻟﺼﻔﺮاء أو‬ ‫اﻟﺒﯿﻀﺎء اﻟﻤﻤﻠﻮءة ﺑﺎﻟﺴﻮاﺋﻞ ‪,‬واﻟﺘﻲ ﺗﺘﻤﺰق ﺧﻼل ﺑﻀﻌﺔ‬ ‫أﯾﺎم ﻣﺸﻜﻠﺔ ﻗﺮﺣﺎت ﻣﺆﻟﻤﺔ ﯾﺘﺮاوح ﻗﻄﺮھﺎ ﺑﯿﻦ ‪ 3-1‬ﻣﻠﻢ‪,‬‬ ‫وﻣﻐﻄﺎة ﺑﻐﺸﺎء رﻣﺎدي ﻣﺒﯿﺾ وﻣﺤﺎﻃﺔ ﺑﻤﻨﻄﻘﺔ ﻣﻦ‬ ‫اﻻﻟﺘﮭﺎب ‪.‬‬  Acute Herpetic Gingivostomatitis Acute Herpetic Gingivostomatitis- vesicles  ‫§ ﺗﺸﺎھﺪ اﻟﻘﺮﺣﺎت ﻋﻠﻰ أﯾﺔ ﻣﻨﻄﻘﺔ ﻣﻦ اﻟﻐﺸﺎء اﻟﻤﺨﺎﻃﻲ ﺑﻤﺎ‬ ‫ﻓﻲ ذﻟﻚ ‪:‬اﻟﻤﺨﺎﻃﯿﺔ اﻟﺪھﻠﯿﺰﯾﺔ ‪ ,‬اﻟﻠﺴﺎن ‪ ,‬اﻟﺸﻔﺘﯿﻦ ‪ ,‬وﻣﻨﻄﻘﺔ‬ ‫اﻟﻠﻮزات ‪.‬‬ ‫§ ﯾﻤﻜﻦ ﻣﻼﺣﻈﺔ اﻵﻓﺎت اﻟﺘﻘﺮﺣﯿﺔ اﻟﻜﺒﯿﺮة ﻏﺎﻟﺒﺎ ﻋﻠﻰ اﻟﺤﻨﻚ أو‬ ‫اﻟﻨﺴﺞ اﻟﻠﺜﻮﯾﺔ أو ﻓﻲ ﻣﻨﻄﻘﺔ اﻟﻄﯿﺔ اﻟﻤﺨﺎﻃﯿﺔ اﻟﺪھﻠﯿﺰﯾﺔ ‪.‬‬ ‫§ ﻣﻌﺎﯾﯿﺮ اﻟﺘﺸﺨﯿﺺ ‪- :‬ارﺗﻔﺎع اﻷﺟﺴﺎم اﻟﻀﺪﯾﺔ ﻓﻲ اﻟﻤﺼﻞ‬ ‫ﺗﺠﺎه ‪ HSV-1‬إﻟﻰ أرﺑﻌﺔ أﺿﻌﺎف ‪.‬‬ ‫‪-‬زرع اﻵﻓﺔ ‪ :‬إﯾﺠﺎﺑﻲ ﺗﺠﺎه‪HSV-1‬‬  ‫اﻟﺘﺪﺑﯿﺮ‬ ‫ﯾﺘﻄﻠﺐ اﻟﺘﺪﺑﯿﺮ ﻧﻈﺎﻣﺎ ﻋﻼﺟﯿﺎ ﯾﻤﺘﺪ ل ‪ 14-10‬ﯾﻮم ‪.‬‬ ‫§‬ ‫أدوﯾﺔ ﻧﻮﻋﯿﺔ ﻣﻀﺎدة ﻟﻠﻔﯿﺮوﺳﺎت‪.‬‬ ‫§‬ ‫ﺗﻠﻄﯿﻒ اﻷﻋﺮاض اﻟﺤﺎدة ﺣﯿﺚ ﺗﺘﻢ اﻟﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ ﺗﻨﺎول اﻟﺴﻮاﺋﻞ‬ ‫§‬ ‫واﻷﻏﺬﯾﺔ ‪.‬‬ ‫ﺗﻄﺒﯿﻖ اﻟﻤﺨﺪرات اﻟﻤﻮﺿﻌﯿﺔ اﻟﻤﺴﻜﻨﺔ ﻣﺜﻞ ‪dyclonine‬‬ ‫§‬ ‫)‪ (diclon) hydrochloride (0.5%‬ﻗﺒﻞ وﻗﺖ اﻟﻮﺟﺒﺔ ﺳﯿﺮﯾﺢ‬ ‫ﺑﺸﻜﻞ ﻣﺆﻗﺖ اﻷﻟﻢ وﯾﺴﻤﺢ ﻟﻠﻄﻔﻞ ﺑﺘﻨﺎول اﻷﻃﻌﻤﺔ اﻟﻄﺮﯾﺔ‪.‬‬ ‫ﯾﻤﻜﻦ وﺻﻒ ﻣﺨﺪر ﻣﻮﺿﻌﻲ آﺧﺮ ﻣﺜﻞ اﻟﻠﯿﺪوﻛﺎﺋﯿﻦ ‪(xylocaine‬‬ ‫§‬ ‫) ‪ , viscous‬ﺣﯿﺚ ﯾﻤﻜﻦ ﻟﻠﻄﻔﻞ أن ﯾﺤﺘﺠﺰ ﻓﻲ ﻓﻤﮫ ﻣﻘﺪار ﻣﻠﻌﻘﺔ‬ ‫ﻃﻌﺎم ﻣﻦ اﻟﻤﺨﺪر ﻓﻲ اﻟﻔﻢ ﻟﻤﺪة ‪ 3-2‬دﻗﺎﺋﻖ ﻟﯿﻄﺮح ﻓﯿﻤﺎ ﺑﻌﺪ‪.‬‬ ‫ﺗﻨﺎول اﻟﻔﯿﺘﺎﻣﯿﻨﺎت اﻟﺪاﻋﻤﺔ أﺛﻨﺎء ﺳﯿﺮ اﻟﻤﻌﺎﻟﺠﺔ ‪.‬‬ ‫§‬  ‫اﻷدوﯾﺔ اﻟﻤﻀﺎدة ﻟﻠﻔﯿﺮوﺳﺎت‬ ‫إن اﻟﺪﻋﺎﻣﺔ اﻷﺳﺎﺳﯿﺔ ﻣﻦ اﻟﻤﻌﺎﻟﺠﺔ اﻟﻤﺤﺪدة ھﻲ ﺟﺮﻋﺎت ﻣﻨﺘﻈﻤﺔ ﻣﻦ‬ ‫§‬ ‫اﻷدوﯾﺔ اﻟﻤﻀﺎدة اﻟﻔﯿﺮوﺳﯿﺔ اﻟﺠﮭﺎزﯾﺔ اﻟﻨﻮﻋﯿﺔ ﻣﺘﺮاﻓﻘﺔ ﻣﻊ ﻣﺴﻜﻨﺎت‬ ‫ﺟﮭﺎزﯾﺔ )‪ (acetaminophen‬أو اﯾﺒﻮﺑﺮوﻓﯿﻦ أﺛﻨﺎء ﺳﯿﺮ اﻟﻤﻌﺎﻟﺠﺔ‬ ‫اﻷدوﯾﺔ اﻟﻤﻀﺎدة ﻟﻠﻔﯿﺮوﺳﺎت اﻟﻤﺘﻮاﻓﺮة ﺣﺎﻟﯿﺎ ‪acyclovir:‬‬ ‫§‬ ‫‪. Famciclovir ,valacyclovir‬‬ ‫ﺗﺜﺒﻂ ھﺬه اﻷدوﯾﺔ اﻻﺳﺘﻨﺴﺎخ اﻟﺤﻤﻮي ﻓﻲ اﻟﺨﻼﯾﺎ اﻟﻤﺆوﻓﺔ ﺑﺎﻟﻔﯿﺮوس ‪.‬‬ ‫§‬ ‫ﯾﻌﻄﻰ )‪ acyclovir(zovirax‬ﺑﺸﻜﻞ ﻛﺒﺴﻮﻻت أو ﻣﻌﻠﻖ‬ ‫§‬ ‫‪ suspension‬ﻟﺪى اﻷﻃﻔﺎل ﻋﻠﻰ ﺧﻤﺲ ﺟﺮﻋﺎت ‪,‬ﺑﻤﺎ ﯾﻌﺎدل‬ ‫‪1000‬ﻣﻠﻎ ﻟﻤﺪة ‪ 10‬أﯾﺎم ‪.‬‬ ‫اﻟﻤﺮاھﻘﯿﻦ ‪:‬ﻛﻮرس اﻟﻤﻌﺎﻟﺠﺔ أﯾﻀﺎ ‪ 10‬أﯾﺎم ﻟﻜﻦ اﻟﺠﺮﻋﺎت اﻟﯿﻮﻣﯿﺔ أﻗﻞ‬ ‫§‬ ‫ﺗﻮاﺗﺮا وﻣﯿﻠﻠﯿﻐﺮاﻣﺎت أﻗﻞ ﯾﻮﻣﯿﺎ ﻣﻦ ‪.acyclovir‬‬ ‫اﻟﺤﻸ اﻟﺸﻔﻮي اﻟﻨﺎﻛﺲ‪Recurrent herpes labialis :‬‬ ‫§ ﺑﻌﺪ اﻟﮭﺠﻤﺔ اﻷوﻟﯿﺔ اﻟﺒﺪﺋﯿﺔ ﺧﻼل اﻟﻄﻔﻮﻟﺔ ‪,‬ﯾﺼﺒﺢ‬ ‫ﻓﯿﺮوس اﻟﺤﻸ اﻟﺒﺴﯿﻂ ﻏﯿﺮ ﻓﻌﺎل وﯾﺒﻘﻰ ﻓﻲ ﻋﻘﺪة اﻟﻌﺼﺐ‬ ‫اﻟﺤﺴﯿﺔ‪.‬‬ ‫§ ﻏﺎﻟﺒﺎ ﻣﺎ ﯾﻈﮭﺮ اﻟﻔﯿﺮوس ﻻﺣﻘﺎ ﻛﻤﺎ ﻓﻲ ﺣﺎﻟﺔ اﻟﺮﺷﺢ أو‬ ‫اﻟﺤﻤﻰ ﻋﻠﻰ اﻟﺴﻄﺢ اﻟﺨﺎرﺟﻲ ﻣﻦ اﻟﺸﻔﺎه ‪ ,‬وھﺬا ﻣﺎ ﯾﺸﺎر‬ ‫إﻟﯿﮫ ﻋﻠﻰ أﻧﮫ اﻟﺤﻸ اﻟﺸﻔﻮي اﻟﻨﺎﻛﺲ )‪. (RHL‬‬ ‫§ ﯾﺤﺼﻞ ﺣﻮاﻟﻲ ‪%5‬ﻣﻦ اﻟﻨﻜﺲ داﺧﻞ اﻟﻔﻢ ‪ ,‬وﻣﻊ ﻋﻮدة‬ ‫اﻟﮭﺠﻤﺎت ﺗﺘﻄﻮر اﻟﻘﺮﺣﺎت ﺑﺎﻟﻀﺮورة ﻓﻲ اﻟﻤﻨﺎﻃﻖ ﻧﻔﺴﮭﺎ‬ Recurrent herpes labialis (RHL) Herpes labialis 5% of recurrences are intraoral  ‫أﺳﺒﺎب اﻟﺤﻸ اﻟﺸﻔﻮي اﻟﻨﺎﻛﺲ‬ ‫§ ﺗﺮﺗﺒﻂ ﻋﻮدة اﻟﻤﺮض ﻏﺎﻟﺒﺎ ﺑﺤﺎﻟﺔ اﻟﺸﺪة‬ ‫اﻟﻌﺎﻃﻔﯿﺔ واﻧﺨﻔﺎض ﻣﻘﺎوﻣﺔ اﻟﻨﺴﺞ‬ ‫اﻟﻨﺎﺗﺠﺔ ﻋﻦ أﺷﻜﺎل ﻣﺘﻨﻮﻋﺔ ﻣﻦ اﻟﺮض ‪,‬‬ ‫اﻟﺘﻌﺮض اﻟﺸﺪﯾﺪ ﻷﺷﻌﺔ اﻟﺸﻤﺲ ‪,‬‬ ‫اﻟﻤﻌﺎﻟﺠﺔ اﻟﺴﻨﯿﺔ )اﻟﺘﺨﺮﯾﺶ ﻣﻦ ﻣﺎدة‬ ‫اﻟﺤﺎﺟﺰ اﻟﻤﻄﺎﻃﻲ ‪ ,‬أو ﺣﺘﻰ اﻹﺟﺮاءات‬ ‫اﻟﯿﻮﻣﯿﺔ اﻟﺮوﺗﯿﻨﯿﺔ(‬  ‫اﻟﻤﻌﺎﻟﺠﺔ‬ ‫وھﻲ ﺗﺘﻀﻤﻦ اﻟﻤﻀﺎدات اﻟﻔﯿﺮوﺳﯿﺔ اﻟﺠﮭﺎزﯾﺔ اﻟﻨﻮﻋﯿﺔ اﻟﻤﻨﺎﻗﺸﺔ‬ ‫§‬ ‫ﻣﺴﺒﻘﺎ ﻓﻲ اﻻﻧﺘﺎن اﻷوﻟﻲ ‪,‬واﻟﺘﻲ ﯾﺘﻮﺟﺐ ﺗﻨﺎوﻟﮭﺎ ﻣﺒﺎﺷﺮة ﺑﻌﺪ‬ ‫ﻇﮭﻮر اﻷﻋﺮاض اﻟﺴﺎﺑﻘﺔ ‪prodromal symptomes‬‬ ‫ﻟﻠﻨﻜﺲ‪.‬‬ ‫اﻟﺠﺮﻋﺔ اﻟﯿﻮﻣﯿﺔ ھﻲ ﻧﻔﺲ ﺗﻠﻚ اﻟﻤﻌﻄﺎة ﻓﻲ اﻻﻧﺘﺎن اﻷوﻟﻲ ﻟﻜﻦ‬ ‫§‬ ‫ﻣﺪة اﻟﻤﻌﺎﻟﺠﺔ ھﻲ ﻋﺎدة ‪ 5‬أﯾﺎم ﺑﺪﻻ ﻣﻦ ‪ 10‬أﯾﺎم ‪.‬‬ ‫ﯾﻤﻜﻦ ﺗﻄﺒﯿﻖ ﻣﻀﺎدات اﻟﻔﯿﺮوﺳﺎت اﻟﻤﻮﺿﻌﯿﺔ )‪(penciclovir‬‬ ‫§‬ ‫ﻋﻠﻰ ﺷﻜﻞ ﻛﺮﯾﻢ ﻋﻠﻰ اﻵﻓﺎت ﺣﻮل اﻟﻔﻤﻮﯾﺔ ‪,‬ﻟﻜﻦ ﻻ ﯾﺠﺐ ﺗﻄﺒﯿﻘﮫ‬ ‫ﻋﻠﻰ اﻵﻓﺎت داﺧﻞ اﻟﻔﻤﻮﯾﺔ ‪.‬‬ ‫ﻛﻤﺎ ﻻ ﯾﺘﻮﺟﺐ إﻋﻄﺎء ﻛﺮﯾﻢ ‪ penciclovir‬وﻣﻀﺎدات‬ ‫§‬ ‫اﻟﻔﯿﺮوﺳﺎت اﻟﺠﮭﺎزﯾﺔ ﺑﺸﻜﻞ ﻣﺘﺰاﻣﻦ ‪.‬‬  ‫ﺗﻌﺮض ﻃﺒﯿﺐ اﻷﺳﻨﺎن‬ ‫§ ﻟﻘﺪ ذﻛﺮ أﻧﮫ ﻏﺎﻟﺒﺎ ﻣﺎ ﯾﺘﻌﺮض ﻃﺒﯿﺐ اﻷﺳﻨﺎن‬ ‫ل ‪ HSV-1‬ﺣﯿﺚ ﯾﻘﻊ ﺟﺰءا ﻛﺒﯿﺮا ﻣﻨﮭﻢ ﺗﺤﺖ‬ ‫ﺧﻄﺮ اﻻﻧﺘﺎن اﻷوﻟﻲ ﺑﺎﻟﺤﻸ‪.‬‬ ‫§ ﻟﺪى اﻷﺧﺬ ﺑﻌﯿﻦ اﻻﻋﺘﺒﺎر اﻟﻌﺠﺰ اﻟﻤﮭﻨﻲ‬ ‫اﻟﻤﺮاﻓﻖ ﻻﻧﺘﺎن ‪ HSV-1‬ﻓﻲ اﻷﺻﺒﻊ أو‬ ‫اﻟﻌﯿﻦ ‪ ,‬ﯾﺘﻮﺟﺐ اﺳﺘﺨﺪام ﺣﻮاﺟﺰ وﻗﺎﺋﯿﺔ ﻓﻌﺎﻟﺔ‬ ‫ﻣﻦ أﺟﻞ ﺳﻼﻣﺔ أﻋﻀﺎء اﻟﻤﮭﻦ اﻟﻄﺒﯿﺔ‪.‬‬  ‫ﻗﺮﺣﺔ اﻟﻘﻼع اﻟﻨﺎﻛﺲ‬ RECURRENT APHTHOUS ULCER (CANKER SORE)  ‫اﻟﺘﻌﺮﯾﻒ & اﻟﺘﻈﺎھﺮات اﻟﺴﺮﯾﺮﯾﺔ‬ ‫§ وﯾﺸﺎر إﻟﯿﮫ أﯾﻀﺎ ﻋﻠﻰ أﻧﮫ اﻟﺘﮭﺎب ﻓﻢ ﻗﻼﻋﻲ ﻧﺎﻛﺲ‬ ‫)‪ recurrent aphthous stomatitis (RAS‬ھﻮ‬ ‫ﺗﻘﺮح ﻣﺆﻟﻢ ﻋﻠﻰ اﻟﻐﺸﺎء اﻟﻤﺨﺎﻃﻲ ﻏﯿﺮ اﻟﻤﻠﺘﺼﻖ ﯾﺸﺎھﺪ ﻟﺪى‬ ‫أﻃﻔﺎل اﻟﻤﺪرﺳﺔ واﻟﺒﺎﻟﻐﯿﻦ ‪,‬ﺣﯿﺚ ﺗﺒﻠﻎ ذروة ﺣﺪوﺛﮫ ﺑﯿﻦ‬ ‫‪ 19-10‬ﺳﻨﺔ ‪.‬‬ ‫§ ﺗﻤﯿﺰ ﺑﺘﻘﺮﺣﺎت ﻧﺎﻛﺴﺔ ﻋﻠﻰ اﻷﻏﺸﯿﺔ اﻟﻤﺨﺎﻃﯿﺔ اﻟﺮﻃﺒﺔ ﻟﻠﻔﻢ ‪,‬‬ ‫ﺣﯿﺚ ﺗﺘﺸﻜﻞ ﻛﻞ ﻣﻦ اﻵﻓﺎت اﻟﻤﻨﻔﺼﻠﺔ و اﻟﻤﻨﺪﻣﺠﺔ ﺑﺴﺮﻋﺔ‬ ‫ﻓﻲ ﻣﻮاﻗﻊ ﻣﻌﯿﻨﺔ ‪.‬‬ ‫§ ﻟﮭﺎ ﻗﺎﻋﺪة ﺗﺸﺒﮫ ﻓﻮھﺔ اﻟﺒﺮﻛﺎن‪ ,‬ﻣﺪورة إﻟﻰ ﺑﯿﻀﻮﯾﺔ ‪,‬‬ ‫وﺣﻮاف ﻣﺤﻤﺮة ﻣﺮﺗﻔﻌﺔ ﻣﺘﺮاﻓﻘﺔ ﻣﻊ اﻷﻟﻢ ‪.‬‬ Minor aphthous Major aphthous ulcer on lower lip RECURRENT APHTHOUS ULCER  ‫اﻟﺘﺼﻨﯿﻒ‬ ‫§ ﺗﺒﺪوﻛﮭﺠﻤﺎت ﻣﻦ اﻵﻓﺎت اﻟﺜﺎﻧﻮﯾﺔ ‪ minor‬أو‬ ‫ﻓﺮدﯾﺔ ‪, single‬رﺋﯿﺴﯿﺔ ‪ major‬أو ﻣﺘﻌﺪدة‬ ‫‪ multiple‬أو اﻟﺸﻜﻞ اﻟﺤﻠﺌﻲ ‪herpetiform‬‬ ‫§ ﺗﺪوم اﻵﻓﺎت ﻟﻤﺪة ‪ 12-4‬ﯾﻮم ‪,‬وﺗﺸﻔﻰ ﺗﻠﻘﺎﺋﯿﺎ ‪,‬‬ ‫وﻧﺎدرا ﻣﺎ ﺗﺘﺮك ﻧﺪﺑﺎت )اﻵﻓﺎت اﻟﻜﺒﯿﺮة(‪.‬‬ ‫§ ﻏﺎﻟﺒﺎ ﻣﺎ ﯾﺘﻀﻤﻦ وﺻﻒ ‪ RAU‬ﻣﺼﻄﻠﺢ‬ ‫‪) canker sores‬اﻟﻘﺮﺣﺔ اﻷﻛﺎﻟﺔ (‬ ‫ﻗﺪ ﺗﺘﺮاﻓﻖ ﻗﺮﺣﺔ اﻟﻘﻼع اﻟﻨﺎﻛﺲ ﻣﻊ أﻣﺮاض ﺟﮭﺎزﯾﺔ أﺧﺮى ‪:‬‬ ‫§‬ ‫اﻟﺤﻤﻰ اﻟﺪورﯾﺔ‬ ‫§‬ ‫اﻟﺘﮭﺎب اﻟﻔﻢ اﻟﻘﻼﻋﻲ‬ ‫§‬ ‫اﻟﺘﮭﺎب اﻟﺒﻠﻌﻮم‬ ‫§‬ ‫اﻟﺘﮭﺎب اﻟﻐﺪة‬ ‫§‬ ‫داء ‪Bechet‬‬ ‫§‬ ‫ﻣﺮض ‪Crohn‬‬ ‫§‬ ‫اﻟﺘﮭﺎب اﻟﻜﻮﻟﻮن اﻟﺘﻘﺮﺣﻲ‬ ‫§‬ ‫ﻗﻠﺔ اﻟﻌﺪﻻت‬ ‫§‬ ‫ﻣﺘﻼزﻣﺎت ﻧﻘﺺ اﻟﻤﻨﺎﻋﺔ‬ ‫§‬ ‫ﻣﺘﻼزﻣﺔ ‪Reiter‬‬ ‫§‬  ‫أﺳﺒﺎب ﻗﺮﺣﺔ اﻟﻘﻼع اﻟﻨﺎﻛﺲ‬ ‫§ ﻏﯿﺮ ﻣﻌﺮوف ﺑﺸﻜﻞ دﻗﯿﻖ ‪,‬ﻟﻜﻦ ﺗﻢ اﻋﺘﺒﺎر ﺑﻌﺾ اﻟﺤﺎﻻت‬ ‫اﻟﻤﻮﺿﻌﯿﺔ ‪,‬اﻟﺠﮭﺎزﯾﺔ ‪,‬وﻋﻮاﻣﻞ وراﺛﯿﺔ ﻣﻨﺎﻋﯿﺔ وﻋﻮاﻣﻞ‬ ‫ﺟﺮﺛﻮﻣﯿﺔ إﻧﺘﺎﻧﯿﺔ ﻋﻠﻰ أﻧﮭﺎ أﺳﺒﺎب ﻣﺤﺘﻤﻠﺔ ‪:‬‬ ‫§ ﻓﺮط ﺣﺴﺎﺳﯿﺔ ﻣﺘﺄﺧﺮة ﺗﺠﺎه اﻟﺸﻜﻞ )‪ (L form‬ﻣﻦ اﻟﻌﻘﺪﯾﺎت‬ ‫اﻟﺪﻣﻮﯾﺔ واﻟﺘﻲ ﺗﻤﺜﻞ إﺣﺪى ﻣﻜﻮﻧﺎت اﻟﺠﺮاﺛﯿﻢ اﻟﻔﻤﻮﯾﺔ‬ ‫اﻟﻄﺒﯿﻌﯿﺔ‪.‬‬ ‫§ ﻣﻦ اﻟﻤﺤﺘﻤﻞ أن ﺗﺤﺼﻞ اﻵﻓﺎت ﻧﺘﯿﺠﺔ رد اﻟﻔﻌﻞ اﻟﻤﻨﺎﻋﻲ‬ ‫اﻟﺬاﺗﻲ ﻟﻠﻈﮭﺎرة اﻟﻔﻤﻮﯾﺔ ‪.‬‬  ‫أﺳﺒﺎب ﻗﺮﺣﺔ اﻟﻘﻼع اﻟﻨﺎﻛﺲ‬ ‫اﻟﻌﻮاﻣﻞ اﻟﻤﻮﺿﻌﯿﺔ ‪ :‬اﻟﺮض ‪,‬اﻟﺤﺴﺎﺳﯿﺔ ﺗﺠﺎه ﻣﻜﻮﻧﺎت ﻣﻌﺠﻮن‬ ‫§‬ ‫اﻷﺳﻨﺎن ‪ ,‬وﻋﺴﺮ وﻇﯿﻔﺔ اﻟﻐﺪة اﻟﻠﻌﺎﺑﯿﺔ ‪.‬‬ ‫اﻟﺮض اﻟﺜﺎﻧﻮي ھﻮ ﻋﺎﻣﻞ ﻣﺆھﺐ ﺷﺎﺋﻊ وﯾﻔﺴﺮ ﺣﻮاﻟﻲ ‪ %75‬ﻣﻦ‬ ‫§‬ ‫اﻟﺤﻮادث )اﻷذﯾﺎت اﻟﻨﺎﺗﺠﺔ ﻋﻦ ﻋﺾ اﻟﺨﺪ واﻟﺘﺨﺮﯾﺶ اﻟﻮﺟﮭﻲ‬ ‫اﻟﺜﺎﻧﻮي (‪.‬‬ ‫اﻟﻌﻮز اﻟﻐﺬاﺋﻲ ووﺟﺪ ﻟﺪى ‪%20‬ﻣﻦ اﻷﺷﺨﺎص اﻟﻤﺼﺎﺑﯿﻦ‬ ‫§‬ ‫ﺑﻘﺮﺣﺎت ﻗﻼﻋﯿﺔ )ﻋﻮز اﻟﺤﺪﯾﺪ ‪ ,‬ﻋﻮز ﻓﯿﺘﺎﻣﯿﻦ ‪, B12‬وﺣﻤﺾ‬ ‫اﻟﻔﻮﻟﯿﻚ ‪.‬‬ ‫اﻟﺤﺪوث اﻟﻌﺎﻟﻲ ﻟﻼﺿﻄﺮاﺑﺎت اﻟﻤﻌﺪﯾﺔ اﻟﻤﻌﻮﯾﺔ واﻟﺸﺪة اﻟﻨﻔﺴﯿﺔ ‪.‬‬ ‫§‬ ‫أﺳﺒﺎب ﻣﺤﺘﻤﻠﺔ أﺧﺮى ‪ :‬ﻓﯿﺮوس اﻟﺤﻸ اﻟﺒﺴﯿﻂ ‪ ,‬ﻓﯿﺮوس‬ ‫§‬ ‫اﻟﺤﻸاﻟﺒﺸﺮي ﻧﻤﻂ ‪ , 6‬اﻟﺤﻤﻰ اﻟﻤﻀﺨﻤﺔ ﻟﻠﺨﻼﯾﺎ ‪ ,‬ﻓﯿﺮس اﺑﺸﺘﺎﯾﻦ‬ ‫ﺑﺎر ‪.‬‬  ‫اﻟﺘﺪﺑﯿﺮ‬ ‫§ ﯾﺮﻛﺰ ﻋﻠﻰ ﺗﻌﺰﯾﺰ ﺷﻔﺎء اﻟﻘﺮﺣﺔ وﺗﻘﻠﯿﻞ ﻣﺪﺗﮭﺎ ‪,‬وإﻧﻘﺎص أﻟﻢ‬ ‫اﻟﻤﺮﯾﺾ ‪,‬اﻟﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ ﺗﻐﺬﯾﺔ اﻟﻤﺮﯾﺾ ‪,‬وﻣﻨﻊ أو اﻹﻗﻼل‬ ‫ﻣﻦ ﺗﻮاﺗﺮ ﻧﻜﺲ اﻟﻤﺮض ‪.‬‬ ‫§ اﺳﺘﺨﺪﻣﺖ ﻋﻮاﻣﻞ ﻣﻀﺎدة ﻟﻼﻟﺘﮭﺎب وأدوﯾﺔ ﻣﺴﻜﻨﺔ و‪/‬أو‬ ‫ﻣﻌﺪﻻت اﻟﻤﻨﺎﻋﺔ اﻟﺠﮭﺎزﯾﺔ وﻋﻮاﻣﻞ ﻣﺜﺒﻄﺎت اﻟﻤﻨﺎﻋﺔ )ﻋﻮاﻣﻞ‬ ‫ﻣﻮﺿﻌﯿﺔ ‪ :‬ﻛﺮﯾﻤﺎت وﻣﺮاھﻢ (‪.‬‬ ‫§ ﻛﻮرﺗﯿﻜﻮﺳﺘﯿﺮوﺋﯿﺪات اﻟﻤﻮﺿﻌﯿﺔ) ‪%0.025‬‬ ‫‪Triamcinolne‬أو ‪ 0.5%clobetasol‬ﻣﻊ ﻻﺻﻖ‬ ‫ﻣﺨﺎﻃﻲ ﻣﺜﻞ‪(orabase‬‬  ‫اﻟﺘﺪﺑﯿﺮ‬ ‫§ اﻟﻤﻀﺎﻣﺾ اﻟﻤﻮﺿﻌﯿﺔ ﺗﺴﺎﻋﺪ ﻓﻲ اﻟﺮاﺣﺔ ﻣﻦ‬ ‫ﻗﺮﺣﺔ اﻟﻘﻼع اﻟﻨﺎﻛﺲ ‪:‬‬ ‫§ اﻟﺘﻄﺒﯿﻖ اﻟﻤﻮﺿﻌﻲ ﻟﻠﺘﺘﺮاﺳﻜﻠﯿﻦ ﻋﻠﻰ اﻟﻘﺮﺣﺎت‬ ‫ﻏﺎﻟﺒﺎ ﻣﺎ ﯾﺴﺎﻋﺪ ﻓﻲ اﻹﻗﻼل ﻣﻦ اﻷﻟﻢ وﺗﻘﺼﯿﺮ زﻣﻦ‬ ‫اﻟﻘﺮﺣﺔ ‪,‬إﺿﺎﻓﺔ ﻟﻠﻤﻀﺎﻣﺾ اﻟﺤﺎوﯾﺔ ﻋﻠﻰ ﻣﻌﻠﻖ‬ ‫إﺣﺪى اﻟﺘﺘﺮاﺳﯿﻜﻠﯿﻨﺎت ﻟﻜﻦ ﺑﺪون ﺑﻠﻌﮭﺎ ‪.‬‬ ‫§ ﻛﻤﺎ ﺗﺰﯾﻞ ﻣﻀﺎﻣﺾ اﻟﻜﻠﻮرھﯿﻜﺰﯾﺪﯾﻦ ﻣﻦ أﻋﺮاض‬ ‫اﻟﻘﺮﺣﺔ‬ (VINCENT ‫اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺘﻘﺮﺣﻲ اﻟﺤﺎد(اﻧﺘﺎن‬ ACUTE NECROTIZING ULCERATIVE GINGIVITIS  ‫§ ﯾﺤﺪث ﻓﻲ ﺑﻌﺾ اﻷﺣﯿﺎن ﻟﺪى أﻃﻔﺎل ﺑﻌﻤﺮ ‪12-6‬‬ ‫ﺳﻨﺔ ‪.‬‬ ‫§ ﯾﺤﺪث اﻟﺸﻔﺎء ﺧﻼل ‪ 36‬ﺳﺎﻋﺔ ﻣﻦ اﻟﺒﺪء ﺑﺎﻟﻤﻌﺎﻟﺠﺔ‬ ‫ﺑﺎﻟﺒﻨﺴﻠﯿﻦ وﺗﻄﺒﯿﻖ‪. hydrogen peroxide‬‬ ‫§ اﻟﺘﺸﺨﯿﺺ ‪:‬اﺷﺘﻤﺎل اﻟﺤﻠﯿﻤﺔ ﺑﯿﻦ اﻟﺴﻨﯿﺔ اﻟﻤﻼﺻﻘﺔ‬ ‫‪ interproximal papilla‬ووﺟﻮد ﺗﻤﻮﺗﺎت‬ ‫اﻷﻏﺸﯿﺔ اﻟﻜﺎذﺑﺔ ﻣﻐﻄﯿﺔ اﻟﻨﺴﯿﺞ اﻟﺤﻔﺎﻓﻲ‬ ‫‪pseudomembranous necrotic‬‬  ACUTE NECROTIZING ULCERATIVE GINGIVITIS I nitial stage I nitial acute ulcerative destruction of several papilla tips (arrows). Other papillae exhibit signs of mild inflammation, but no destruction.  ACUTE NECROTIZING ULCERATIVE GINGIVITIS Radiographi cally one observes no evidence of resorption Of interdental septal bone.  Destruction of papilla tips in the maxilla (ANUG) Necrosis of the papilla between central and lateral incisors is apparent. Note simultaneous erythema and swelling, especially at the base of the papilla. Between the lateral incisor and the canine one observes the earliest signs of necrosis. Erythema of the papilla is noted between the two central incisors, but no clinically visible destruction  Destruction of papilla tips in the mandible Each papilla exhibits signs of incipient ulceration, and each is already covered by a pseudomembrane consisting of fibrin, dead tissue cells, leukocytes and bacteria. A 26-year-old male experienced an aggressive acute exacerbation for the second time. In addition to the pronounced gingivitis, attachment loss has occurred in the maxillary anterior and molar regions: Acute ANUG Generalized ulcerative Localized ulcerative periodontitis periodontitis  ACUTE NECROTIZING ULCERATIVE GINGIVITIS (VINCENT INFECTION)  ‫اﻟﻌﻮاﻣﻞ اﻟﻤﺴﺒﺒﺔ‬ ‫ﺗﺘﻀﻤﻦ اﻟﻌﻀﻮﯾﺎت اﻟﺪﻗﯿﻘﺔ اﻟﻤﺴﺆوﻟﺔ ﻋﻦ اﻟﻤﺮض‬ ‫§‬ ‫ﺑﻮرﻟﯿﺎت ﻓﻨﺴﺎن ‪Borrelia Vincentii‬‬ ‫§‬ ‫اﻟﻌﺼﯿﺎت اﻟﻤﻐﺰﻟﯿﺔ ‪ fusiform bacilli‬واﻟﺘﻲ‬ ‫§‬ ‫ﯾﺸﺎر إﻟﯿﮭﺎ ﻋﻠﻰ أﻧﮭﺎ ﻋﻀﻮﯾﺎت دﻗﯿﻘﺔ ﻣﻠﺘﻮﯾﺔ ‪.‬‬ ‫اﻟﺘﻈﺎھﺮات اﻟﺴﺮﯾﺮﯾﺔ‪ :‬اﻟﻨﺴﺞ اﻟﻠﺜﻮﯾﺔ ﻧﺎزﻓﺔ ﻣﻠﺘﮭﺒﺔ‬ ‫§‬ ‫ﻣﺆﻟﻤﺔ ‪ ,‬ﺷﮭﯿﺔ ﺿﻌﯿﻔﺔ ‪,‬ﺣﻤﻰ ﻋﺎﻟﯿﺔ) ‪, (40‬ﺗﻮﻋﻚ‬ ‫ﻋﺎم وراﺋﺤﺔ ﻛﺮﯾﮭﺔ ‪.‬‬  ‫اﻟﺘﺪﺑﯿﺮ‬ ‫§ ﯾﺴﺘﺠﯿﺐ ﺑﺸﻜﻞ دراﻣﺎﺗﯿﻜﻲ ﺧﻼل ‪ 48-24‬ﺳﺎﻋﺔ ﻣﻦ‬ ‫اﻟﺘﺠﺮﯾﻒ ﺗﺤﺖ اﻟﻠﺜﻮي ‪subgingival curettage‬‬ ‫واﺳﺘﺨﺪام اﻟﻤﺤﺎﻟﯿﻞ اﻟﻤﺆﻛﺴﺠﺔ اﻟﺨﻔﯿﻔﺔ ‪.‬‬ ‫§ اﻟﺤﺎﻟﺔ اﻟﺤﺎدة ‪:‬اﻟﻤﻌﺎﻟﺠﺔ ﺑﺎﻟﻤﻀﺎدات اﻟﺤﯿﻮﯾﺔ ﻣﺴﺘﻄﺒﺔ ﻟﺪى‬ ‫ﻣﺸﺎھﺪة اﻟﻤﺮﯾﺾ ﻷول ﻣﺮة ‪.‬‬ ‫§ ﺗﺤﺴﯿﻦ اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ ‪,‬واﺳﺘﺨﺪام اﻟﻤﻀﺎﻣﺾ اﻟﻤﺆﻛﺴﺪة‬ ‫اﻟﺨﻔﯿﻔﺔ ﺑﻌﺪ ﻛﻞ وﺟﺒﺔ ‪,‬و اﻟﻤﻀﻤﻀﺔ ﻣﺮﺗﯿﻦ ﯾﻮﻣﯿﺎ ب‬ ‫‪ Chlorhexidine‬ﺳﯿﺆدي ﻟﻠﺘﻐﻠﺐ ﻋﻠﻰ اﻻﻧﺘﺎن ‪.‬‬  ‫ﺗﻤﯿﯿﺰ اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺘﻘﺮﺣﻲ اﻟﺘﻤﻮﺗﻲ اﻟﺤﺎد ﻋﻦ اﻟﺘﮭﺎب اﻟﻠﺜﺔ‬ ‫اﻟﺤﻠﺌﻲ اﻟﺤﺎد‬ ‫اﻟﻘﺮﺣﺎت ﻣﻊ اﻟﮭﺎﻻت اﻟﺤﻤﺮاء ﻋﻠﻰ اﻟﺸﻔﺎه واﻟﺨﺪود ھﻲ‬ ‫§‬ ‫ﺧﺼﺎﺋﺺ ﻣﻤﯿﺰة ﻻﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺤﻠﺌﻲ اﻟﺤﺎد ‪.‬‬ ‫إﺟﺮاءات اﻟﻮﻗﺎﯾﺔ اﻟﻌﻼﺟﯿﺔ واﻟﺘﻨﻀﯿﺮ ﺳﺘﺆدي ﻻﺳﺘﺠﺎﺑﺔ ﻣﺮﻏﻮﺑﺔ‬ ‫§‬ ‫ﻓﻲ ﺣﺎﻻت ‪ ANUG‬ﻟﻜﻦ ﻟﯿﺲ ﻓﻲ ﺣﺎﻟﺔ اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺤﻠﺌﻲ‬ ‫اﻟﺤﺎد ‪.‬‬ ‫اﻟﻤﺤﺎوﻻت اﻟﻌﻼﺟﯿﺔ ﺑﺎﻟﻤﻀﺎدات اﻟﺤﯿﻮﯾﺔ ﺳﺘﻨﻘﺺ ﻣﻦ اﻷﻋﺮاض‬ ‫§‬ ‫اﻟﺤﺎدة ﻓﻲ ‪ ANUG‬وﻟﻜﻦ ﻟﯿﺲ ﻓﻲ اﻻﻧﺘﺎن اﻟﻔﯿﺮوﺳﻲ ‪.‬‬ ‫اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺤﻠﺌﻲ اﻟﺤﺎد ﻏﺎﻟﺒﺎ ﻣﺎ ﯾﺸﺎھﺪ ﻟﺪى أﻃﻔﺎل ﻣﺎ ﻗﺒﻞ‬ ‫§‬ ‫اﻟﻤﺪرﺳﺔ وﻓﻲ اﻷﻓﻮاه اﻟﺘﻲ ﯾﻮﺟﺪ ﻓﯿﮭﺎ ﻣﺨﺮﺷﺎت وﺻﺤﺔ ﻓﻤﻮﯾﺔ‬ ‫ﺿﻌﯿﻔﺔ ‪ ,‬أﻣﺎ ‪ ANUG‬ﻓﻨﺎدرا ﻣﺎ ﯾﺤﺪث ﻟﺪى أﻃﻔﺎل ﻣﺎ ﻗﺒﻞ‬ ‫اﻟﻤﺪرﺳﺔ وﯾﺘﻄﻮر ﻋﺒﺮ ﻓﺘﺮة أﻃﻮل ‪.‬‬  (‫داء اﻟﻤﺒﯿﻀﺎت اﻟﺤﺎد (اﻟﺴﻼق‬ ACUTE CANDIDIASIS (THRUSH, CANDIDOSIS, MONILIASIS) ‫‪Candida (Monilia) albicans‬‬ ‫§ ھﻮ ﻣﻜﻮﻧﺎت ﺷﺎﺋﻌﺔ ﻓﻲ اﻟﺤﻔﺮة اﻟﻔﻤﻮﯾﺔ ﻟﻜﻦ ﻗﺪ‬ ‫ﺗﺘﻜﺎﺛﺮ ﺑﺴﺮﻋﺔ ﻣﺴﺒﺒﺔ ﺣﺎﻟﺔ ﻣﺮﺿﯿﺔ ﻋﻨﺪﻣﺎ‬ ‫ﺗﻨﺨﻔﺾ ﻣﻘﺎوﻣﺔ اﻟﻨﺴﺞ‪.‬‬ ‫§ ﺗﺒﺪو آﻓﺎت اﻟﻤﺮض اﻟﻔﻤﻮي ﻋﻠﻰ اﻧﮭﺎ ﺑﻘﻊ ﺑﯿﻀﺎء‬ ‫ﻣﺮﺗﻔﻌﺔ ﻣﻜﺴﻮة ﺑﺎﻟﻔﺮو ‪,‬وﯾﻤﻜﻦ إزاﻟﺘﮭﺎ ﺑﺴﮭﻮﻟﺔ‬ ‫ﻟﺘﺆدي ﻟﻨﺰف اﻟﺴﻄﺢ اﻟﺬي ﺗﺤﺘﮫ ‪.‬‬ ‫§ ﯾﺼﺎب اﻟﻤﻮاﻟﯿﺪ اﻟﺠﺪد ﺑﺎﻟﺴﻼق أﺛﻨﺎء اﻟﻤﺮور ﻋﺒﺮ‬ ‫اﻟﻤﮭﺒﻞ ﺣﯿﺚ ﺗﻨﺸﺄ ﺳﺮﯾﺮﯾﺎ ﺧﻼل اﻷﺳﺒﻮﻋﯿﻦ‬ ‫اﻷوﻟﯿﻦ ﻣﻦ اﻟﺤﯿﺎة ‪.‬‬ Pseudomembranous candidiasis on the palate Acute pseudomembranous candidosis  ‫اﻟﺘﺪﺑﯿﺮ‬ ‫§ اﻟﻤﻀﺎدات اﻟﺤﯿﻮﯾﺔ اﻟﻤﻀﺎدة ﻟﻠﻔﻄﻮر ‪ antifungal‬ﻣﺘﻮاﻓﺮة‬ ‫ﻟﻤﻌﺎﻟﺠﺔ اﻟﺴﻼق ‪:‬‬ ‫§ ﻣﻦ أﺟﻞ اﻟﻤﻮاﻟﯿﺪ واﻷﻃﻔﺎل اﻟﺼﻐﺎر ﺟﺪا ‪:‬ﻣﻌﻠﻖ ﻣﻦ ‪1‬ﻣﻞ‬ ‫)‪ 100,000‬وﺣﺪة (ﻣﻦ اﻟﻨﯿﺴﺘﺎﺗﯿﻦ )‪(mycostatin‬‬ ‫ﺣﯿﺚ ﺗﺴﺘﺨﺪم ﻛﻨﻘﺎط ﻓﻲ اﻟﻔﻢ أرﺑﻊ ﻣﺮات ﯾﻮﻣﯿﺎ )اﻟﺪواء ﻏﯿﺮ‬ ‫ﺳﺎم وﻏﯿﺮ ﻣﺨﺮش(‪.‬‬ ‫§ ﻣﻌﻠﻖ ‪10) clotrimazole‬ﻣﻠﻎ ‪/‬ﻣﻞ ( ﺣﯿﺚ ﯾﻄﺒﻖ ‪2-1‬‬ ‫ﻣﻞ ﻣﻨﮫ ﻋﻠﻰ اﻟﻤﺴﺎﺣﺎت اﻟﻤﺘﺄﺛﺮة أرﺑﻊ ﻣﺮات ھﻮ ﻣﻀﺎد‬ ‫ﻓﻄﺮي ﻓﻌﺎل ‪.‬‬  ‫اﻟﺘﺪﺑﯿﺮ )اﻟﻤﻌﺎﻟﺠﺔ اﻟﺠﮭﺎزﯾﺔ(‬ ‫§ ﻣﻌﻠﻖ ‪ fluconazole‬اﻟﺠﮭﺎزي )‪ 10‬ﻣﻠﻎ ‪/‬ﻣﻞ ( آﻣﻦ‬ ‫اﻻﺳﺘﺨﺪام ﻟﺪى اﻟﻤﻮاﻟﯿﺪ وﺑﺠﺮﻋﺔ ﻛﺎﻣﻠﺔ ﺗﺼﻞ ل ‪ 6‬ﻣﻠﻎ ‪/‬ﻛﻎ‬ ‫أو أﻗﻞ ‪.‬‬ ‫§ ﻣﻦ أﺟﻞ اﻷﻃﻔﺎل اﻷﻛﺒﺮ ﺑﻤﺎ ﯾﻜﻔﻲ ﻟﯿﺘﻌﺎﻣﻠﻮا ﺑﺎﻷدوﯾﺔ اﻟﺼﻠﺒﺔ‬ ‫ﻟﯿﺴﻤﺤﻮا ﺑﺎﻧﺤﻼﻟﮭﺎ ﻓﻲ اﻟﻔﻢ ﺗﺴﺘﺨﺪم أﻗﺮاص‬ ‫‪ clotrimazole‬أو أﻗﺮاص اﻟﻨﯿﺴﺘﺎﺗﯿﻦ ‪.‬‬ ‫§ ﻣﻦ أﺟﻞ اﻷﻃﻔﺎل اﻷﻛﺒﺮ ﺑﺸﻜﻞ ﻛﺎف ﻟﯿﺒﺘﻠﻌﻮا ‪,‬ﻗﺪ ﯾﺘﻢ وﺻﻒ‬ ‫‪100) fluconazole‬ﻣﻠﻎ ﻣﻀﻐﻮﻃﺎت ( ﺿﻤﻦ ﻛﻮرس‬ ‫ﯾﻤﺘﺪ ل ‪ 14‬ﯾﻮم ﻣﻦ أﺟﻞ اﻟﻤﺮﺿﻰ اﻟﺬﯾﻦ ﻟﻢ ﯾﺴﺘﺠﺐ اﻻﻧﺘﺎن‬ ‫ﻟﺪﯾﮭﻢ ﺗﺠﺎه اﻟﻌﻮاﻣﻞ اﻟﻤﻀﺎدة ﻟﻠﻔﻄﻮر اﻟﻤﻮﺿﻌﯿﺔ ‪.‬‬  ‫اﻻﻧﺘﺎﻧﺎت اﻟﺠﺮﺛﻮﻣﯿﺔ اﻟﺤﺎدة‬ ACUTE BACTERIAL INFECTIONS  ‫اﻟﺘﮭﺎب ﻟﺜﻮي ﺣﺎد ﺑﺎﻟﻌﻘﺪﯾﺎت ‪acute‬‬ ‫§‬ ‫‪ streptococcal gingivitis‬ﻣﻊ ﻟﺜﺔ ﺣﻤﺮاء‬ ‫ﻣﺆﻟﻤﺔ وﻣﺘﺸﻘﻘﺔ واﻟﺘﻲ ﺗﻨﺰف ﺑﺴﮭﻮﻟﺔ ﻣﻊ ﺗﻀﺨﻢ‬ ‫اﻟﺤﻠﯿﻤﺎت وﺧﺮاﺟﺎت ﻟﺜﻮﯾﺔ ‪.‬‬ ‫اﻟﺰرع اﻟﺠﺮﺛﻮﻣﻲ ﯾﻈﮭﺮ ﺳﯿﻄﺮة اﻟﻌﻘﺪﯾﺎت اﻟﺤﺎﻟﺔ ﻟﻠﺪم ‪.‬‬ ‫§‬ ‫اﻟﻤﻌﺎﻟﺠﺔ ‪ :‬اﻟﻤﻀﺎدات اﻟﺤﯿﻮﯾﺔ اﻟﻮاﺳﻌﺔ اﻟﻄﯿﻒ إذا ﻣﺎ‬ ‫§‬ ‫اﻋﺘﻘﺪ أن اﻻﻧﺘﺎن ذو ﻣﻨﺸﺄ ﺟﺮﺛﻮﻣﻲ ‪.‬‬ ‫ﺗﺤﺴﯿﻦ اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ ﻣﻊ ﻣﻀﺎﻣﺾ ﻛﻠﻮرھﯿﻜﺰﯾﺪﯾﻦ‪.‬‬ ‫§‬ ‫اﻻﻧﺘﺎﻧﺎت اﻟﺠﺮﺛﻮﻣﯿﺔ اﻟﺤﺎدة‬ ‫اﻻﻧﺘﺎﻧﺎت اﻟﺠﺮﺛﻮﻣﯿﺔ اﻟﺤﺎدة‬ ‫اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﻤﺰﻣﻦ ﻏﯿﺮ اﻟﻨﻮﻋﻲ‬ CHRONIC NONSPECIFIC GINGIVITIS  ‫§ ﯾﺸﺎھﺪ ﺑﺸﻜﻞ ﺷﺎﺋﻊ أﺛﻨﺎء ﺳﻨﻮات اﻟﻤﺮاھﻘﺔ أو ﻣﺎ‬ ‫ﻗﺒﻠﮭﺎ ‪.‬‬ ‫§ ﻗﺪ ﯾﻜﻮن اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي اﻟﻤﺰﻣﻦ ﻣﻮﺿﻊ ﻓﻲ‬ ‫اﻟﻤﻨﻄﻘﺔ اﻷﻣﺎﻣﯿﺔ ‪ ,‬أو ﻗﺪ ﯾﻜﻮن ﻣﻌﻤﻤﺎ ‪.‬‬ ‫§ اﻟﺘﻈﺎھﺮات اﻟﺴﺮﯾﺮﯾﺔ ‪:‬آﻓﺔ ﻟﺜﻮﯾﺔ ﺣﻤﺮاء ﻧﺎرﯾﺔ ‪,‬وﻻ‬ ‫ﺗﺘﺮاﻓﻖ ﻣﻊ ﺣﻠﯿﻤﺎت ﻟﺜﻮﯾﺔ دھﻠﯿﺰﯾﺔ ﺑﯿﻦ ﺳﻨﯿﺔ‬ ‫ﻣﺘﻀﺨﻤﺔ أو ﺗﺘﺮاﻓﻖ ﺑﺸﻜﻞ ﻛﺒﯿﺮ ﺑﺎﻟﻤﺨﺮﺷﺎت‬ ‫اﻟﻤﻮﺿﻌﯿﺔ ‪.‬‬  ‫اﻷﺳﺒﺎب‬ ‫§ اﻻﺿﻄﺮاب اﻟﮭﺮﻣﻮﻧﻲ ‪:‬وھﺬا ﯾﺪل ﻋﻠﯿﮫ اﻧﺘﺸﺎر‬ ‫اﻟﻤﺮض ﻣﻦ ﻧﺎﺣﯿﺔ ﺗﻔﻀﯿﻠﮫ ﻟﺴﻦ اﻟﺒﻠﻮغ و ﻟﻺﻧﺎث ‪.‬‬ ‫§ اﻟﻤﻘﺎﻃﻊ اﻟﻨﺴﯿﺠﯿﺔ واﺳﺘﺨﺪام اﻟﻤﻠﻮﻧﺎت اﻟﺨﺎﺻﺔ‬ ‫ﯾﺜﺒﺖ وﺟﻮد اﻻﻧﺘﺎن اﻟﺠﺮﺛﻮﻣﻲ ‪.‬‬ ‫§ اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ ﻏﯿﺮ اﻟﻜﺎﻓﯿﺔ وﻃﺒﻘﺔ اﻟﺒﻠﯿﻚ‬ ‫اﻟﺠﺮﺛﻮﻣﯿﺔ ھﻲ ﻣﻦ دون ﺷﻚ اﻟﺴﺒﺐ اﻟﺮﺋﯿﺴﻲ ﻟﮭﺬا‬ ‫اﻟﻨﻮع اﻟﻤﺰﻣﻦ ﻣﻦ اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي ‪.‬‬  ‫اﻷﺳﺒﺎب‬ ‫اﻟﻜﻤﯿﺎت ﻏﯿﺮ اﻟﻜﺎﻓﯿﺔ ﻣﻦ اﻟﻔﻮاﻛﮫ واﻟﺨﻀﺮوات ﺿﻤﻦ اﻟﻮﺟﺒﺔ‬ ‫§‬ ‫ﺗﺆدي ﻟﻌﻮز ﻓﯿﺘﺎﻣﯿﻨﻲ ﺗﺤﺖ ﺳﺮﯾﺮي ‪,‬ﻗﺪ ﯾﻜﻮن ﻋﺎﻣﻞ ﻣﺆھﺐ‬ ‫ھﺎم‬ ‫ﺳﻮء اﻻﻃﺒﺎق ‪,‬وﺗﺮاﻛﺐ اﻷﺳﻨﺎن اﻟﺘﻲ ﺗﺠﻌﻞ اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ‬ ‫§‬ ‫وإزاﻟﺔ ﻃﺒﻘﺔ اﻟﺒﻠﯿﻚ ﺻﻌﺒﺔ ھﻲ أﯾﻀﺎ ﻋﻮاﻣﻞ ﻣﺆھﺒﺔ ھﺎﻣﺔ ‪.‬‬ ‫اﻵﻓﺎت اﻟﻨﺨﺮة ﻣﻊ اﻟﺤﻮاف اﻟﺤﺎدة اﻟﻤﺨﺮﺷﺔ ﺑﺎﻹﺿﺎﻓﺔ‬ ‫§‬ ‫ﻟﻠﺘﺮﻣﯿﻤﺎت اﻟﻤﻌﯿﺒﺔ ‪.‬‬ ‫اﻟﻤﺨﺮﺷﺎت اﻟﻤﻮﺿﻌﯿﺔ )اﻟﺘﻨﻔﺲ اﻟﻔﻤﻮي(‪.‬‬ ‫§‬ ‫اﻟﺘﮭﺎب ﻟﺜﻮي ﻧﺎﺟﻢ ﻋﻦ اﻟﺘﻨﻔﺲ اﻟﻔﻤﻮي‬  ‫اﻷﻣﺮاض اﻟﻠﺜﻮﯾﺔ اﻟﻤﻌﺪﻟﺔ ﺑﺎﻟﻌﻮاﻣﻞ اﻟﺠﮭﺎزﯾﺔ‬ GINGIVAL DISEASES MODIFIED BY SYSTEMIC FACTORS ‫اﻷﻣﺮاض اﻟﻠﺜﻮﯾﺔ اﻟﻤﺘﺮاﻓﻘﺔ ﻣﻊ اﻟﺠﮭﺎز اﻟﺼﻤﻲ‬ GINGIVAL DISEASES ASSOCIATED WITH THE ENDOCRINE SYSTEM ‫§ اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺒﻠﻮﻏﻲ ‪ puberty gingivitis‬ھﻮ ﻧﻤﻂ ﻣﻤﯿﺰ‬ ‫ﻣﻦ اﻟﺘﮭﺎب اﻟﻠﺜﺔ واﻟﺬي ﯾﺘﻄﻮر ﻏﺎﻟﺒﺎ ﻟﺪى اﻷﻃﻔﺎل ﻓﻲ ﻣﺮﺣﻠﺔ‬ ‫اﻟﺒﻠﻮغ وﻣﺎ ﻗﺒﻠﮫ ‪.‬‬ ‫§ ﯾﺤﺪث اﻟﺘﻀﺨﻢ اﻟﻠﺜﻮي ﻓﻲ اﻟﻠﺜﺔ اﻟﺤﻔﺎﻓﯿﺔ ‪,‬وﺑﻮﺟﻮد اﻟﻤﺨﺮﺷﺎت‬ ‫اﻟﻤﻮﺿﻌﯿﺔ ﯾﻤﻜﻦ ﺗﻤﯿﯿﺰه ﺑﻮﺳﺎﻃﺔ اﻟﺤﻠﯿﻤﺎت ﺑﯿﻦ اﻟﺴﻨﯿﺔ اﻟﺒﺼﻠﯿﺔ‬ ‫اﻟﺒﺎرزة ﻟﺪرﺟﺔ أﻛﺒﺮ ﻣﻦ اﻟﺘﻀﺨﻢ اﻟﻠﺜﻮي اﻟﻤﺘﺮاﻓﻖ ﻣﻊ اﻟﻌﻮاﻣﻞ‬ ‫اﻟﻤﻮﺿﻌﯿﺔ ‪.‬‬ ‫§ ﯾﻘﺘﺼﺮ اﻟﺘﻀﺨﻢ ﻓﻲ اﻟﻨﺴﺞ اﻟﻠﺜﻮﯾﺔ ﻓﻲ اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺒﻠﻮﻏﻲ ﻋﻠﻰ‬ ‫اﻟﻘﻄﺎع اﻷﻣﺎﻣﻲ وﻗﺪ ﯾﻜﻮن ﻣﻮﺟﻮدا ﻓﻲ ﻗﻮس واﺣﺪة ‪ ,‬ﻓﻲ ﺣﯿﻦ‬ ‫ﺗﺒﻘﻰ اﻟﻨﺴﺞ اﻟﻠﺜﻮﯾﺔ اﻟﻠﺴﺎﻧﯿﺔ ﺑﺸﻜﻞ ﻋﺎم ﻏﯿﺮ ﻣﺘﺄﺛﺮة ‪.‬‬ § Occurs from a lack of proper oral hygiene and accumulation of dental plaque and calculus -Peak incidence of involvement around age 11. (puberty gingivitis) -Females have a great susceptibility to gingivitis  Puberty gingivitis Puberty gingivitis 13-year-old female with severe hyperplastic gingivitis. Copious bleeding on probing. Plaque and mouth breathing were the main causes of the gingival inflammation. The pubertal hormonal surge may have been a cofactor. Morbidity of gingivitis in 10,000 persons. A peak is observed during puberty.  Puberty gingivitis, orthodontic treatment A 13-year-old male patient lost his maxillary central incisors due to an accident. Gingivitis, possibly puberty- related, was present before the accident. Orthodontic means were used to move the lateral incisors mesially. This may have caused some extrusion of interdental tissue. In the absence of adequate plaque control, a severe inflammatory hyperplasia occurred between the lateral incisors  ‫اﻟﺘﺪﺑﯿﺮ‬ ‫§ ﯾﺠﺐ أن ﺗﺘﻮﺟﮫ ﻣﻌﺎﻟﺠﺔ اﻟﺘﮭﺎب اﻟﻠﺜﺔ اﻟﺒﻠﻮﻏﻲ‬ ‫ﻟﺘﺤﺴﯿﻦ اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ ‪,‬إزاﻟﺔ اﻟﻤﺨﺮﺷﺎت‬ ‫اﻟﻤﻮﺿﻌﯿﺔ ‪,‬ﺗﺮﻣﯿﻢ اﻷﺳﻨﺎن اﻟﻨﺨﺮة ‪ ,‬ﻛﻤﺎ أن‬ ‫اﻟﺘﻐﯿﺮات ﻓﻲ اﻟﻐﺬاء ﺿﺮورﯾﺔ ﻟﺘﺄﻛﯿﺪ ﻛﻔﺎﯾﺔ اﻟﺤﺎﻟﺔ‬ ‫اﻟﻐﺬاﺋﯿﺔ ‪.‬‬ ‫§ ﻓﻲ اﻟﺤﺎﻻت اﻟﺸﺪﯾﺪة ﺗﻌﺘﺒﺮاﻹزاﻟﺔ اﻟﺠﺮاﺣﯿﺔ ﻟﻠﻨﺴﺞ‬ ‫اﻟﺤﻔﺎﻓﯿﺔ واﻟﻤﻼﺻﻘﺔ اﻟﻠﯿﻔﯿﺔ اﻟﺜﺨﯿﻨﺔ ﻣﻌﺎﻟﺠﺔ ﻓﻌﺎﻟﺔ‪.‬‬  ‫ﻓﺮط اﻟﻨﻤﻮ اﻟﻠﺜﻮي اﻟﻤﺤﺮض ﺑﺎﻟﻔﯿﻨﻮﺗﺌﯿﻦ‬ PHENYTOIN-INDUCED GINGIVAL OVERGROWTH  ‫§ ﯾﺴﺒﺐ اﻟﻔﯿﻨﻮﺗﺌﯿﻦ )دﯾﺎﻻﻧﺘﯿﻦ(‪ ,‬اﻟﻤﺴﺘﺨﺪم ﻛﻤﻀﺎد اﺧﺘﻼج رﺋﯿﺴﻲ‬ ‫ﻓﻲ ﻣﻌﺎﻟﺠﺔ اﻟﺼﺮع ‪ ,‬درﺟﺎت ﻣﺘﻔﺎوﺗﺔ ﻣﻦ ﻓﺮط اﻟﺘﻨﺴﺞ اﻟﻠﺜﻮي‬ ‫‪. gingival hyperplasia‬‬ ‫§ ﯾﺘﺮاوح ﺣﺪوث ﻓﺮط اﻟﻨﻤﻮ اﻟﻠﺜﻮي اﻟﻤﺤﺮض ﺑﺎﻟﻔﯿﻨﻮﺗﺌﯿﻦ ﻟﺪى‬ ‫اﻟﻤﺮﺿﻰ اﻟﺬﯾﻦ ﯾﺨﻀﻌﻮن ﻟﻤﻌﺎﻟﺠﺔ ﻃﻮﯾﻠﺔ اﻷﻣﺪ ﺑﺎﻟﻔﯿﻨﻮﺗﺌﯿﻦ ﺑﯿﻦ‬ ‫‪.%95-0‬‬ ‫§ ذﻛﺮ ﺑﻌﺾ اﻟﻤﺆﻟﻔﯿﻦ ﻋﻼﻗﺔ إﯾﺠﺎﺑﯿﺔ ﺑﯿﻦ ﻣﺴﺘﻮى اﻟﻔﯿﻨﻮﺗﺌﯿﻦ ﻓﻲ‬ ‫اﻟﻤﺼﻞ واﻟﻠﻌﺎب وﺷﺪة ﻓﺮط اﻟﻨﻤﻮ اﻟﻠﺜﻮي اﻟﻤﺤﺮض ﺑﺎﻟﻔﯿﻨﻮﺗﺌﯿﻦ‬ ‫)‪ (PIGO‬ﻓﻲ ﺑﻌﺾ اﻟﺤﺎﻻت ‪,‬ﻓﻲ ﺣﯿﻦ ﯾﻨﻜﺮ ﺑﻌﻀﮭﻢ اﻵﺧﺮ وﺟﻮد‬ ‫أي ﺗﺮاﺑﻂ ﺑﯿﻨﮭﻤﺎ ‪,‬ﺣﯿﺚ ﻟﻢ ﯾﻼﺣﻆ أي ارﺗﺒﻂ ﻣﻦ أﺟﻞ ﻋﻤﺮ‬ ‫اﻟﻤﺮﯾﺾ ‪ ,‬ﺟﺮﻋﺔ اﻟﻔﯿﻨﻮﺗﺌﯿﻦ اﻟﯿﻮﻣﯿﺔ أو اﻟﻜﻠﯿﺔ ‪,‬ﻣﺪة اﻟﻤﻌﺎﻟﺠﺔ أو‬ ‫ﻣﺴﺘﻮى اﻟﻔﯿﻨﻮﺗﺌﯿﻦ ﻓﻲ اﻟﻤﺼﻞ ‪.‬‬  ‫اﻟﺘﻄﻮر واﻟﻤﻈﮭﺮ اﻟﺴﺮﯾﺮي‬ ‫§ ﯾﻤﻜﻦ ﻣﻨﻊ ‪ PIGO‬أو إﻗﻼﻟﮫ ﺑﻮﺳﺎﻃﺔ إﺟﺮاءات اﻟﺼﺤﺔ‬ ‫اﻟﻔﻤﻮﯾﺔ واﻟﻮﻗﺎﯾﺔ اﻟﺴﻨﯿﺔ‪.‬‬ ‫§ ﯾﺒﺪأ ‪ PIGO‬ﺑﺎﻟﻈﮭﻮر ﻣﺒﻜﺮا )‪ 3-2‬أﺳﺎﺑﯿﻊ ﺑﻌﺪ اﻟﺒﺪء‬ ‫ﺑﺎﻟﻤﻌﺎﻟﺠﺔ ( ﺣﯿﺚ ﯾﺒﻠﻎ ذروﺗﮫ ﺑﯿﻦ ‪ 24 -18‬ﺷﮭﺮ ‪.‬‬ ‫§ اﻟﻤﻈﮭﺮ اﻟﺴﺮﯾﺮي ‪ :‬ﺗﻀﺨﻢ ﻏﯿﺮ ﻣﺆﻟﻢ ﻓﻲ اﻟﻠﺜﺔ اﻟﻤﻠﺘﺼﻘﺔ ‪.‬‬ ‫ﻏﺎﻟﺒﺎ ﻣﺎﺗﻜﻮن اﻟﻘﻄﺎﻋﺎت اﻷﻣﺎﻣﯿﺔ واﻟﺪھﻠﯿﺰﯾﺔ أﻛﺜﺮ ﺗﺄﺛﺮا ﻣﻦ‬ ‫اﻟﻘﻄﺎﻋﺎت اﻟﻠﺴﺎﻧﯿﺔ واﻟﺨﻠﻔﯿﺔ ‪.‬ﺗﻜﻮن اﻟﻤﻨﺎﻃﻖ اﻟﻤﺘﺄﺛﺮة‬ ‫ﻣﻌﺰوﻟﺔ ﻓﻲ اﻟﺒﺪاﯾﺔ ﻟﻜﻨﮭﺎ ﺗﺼﺒﺢ ﻣﻌﻤﻤﺔ أﻛﺜﺮ ﻓﯿﻤﺎ ﺑﻌﺪ ‪.‬‬  ‫اﻟﺘﻄﻮر واﻟﻤﻈﮭﺮ اﻟﺴﺮﯾﺮي‬ ‫§ ﻣﺎ ﻟﻢ ﯾﻜﻦ ھﻨﺎك اﻧﺘﺎن أو اﻟﺘﮭﺎب ﺛﺎﻧﻮي ‪,‬ﺗﺒﺪو اﻟﻠﺜﺔ‬ ‫زھﺮﯾﺔ وﺛﺎﺑﺘﺔ وﻻ ﺗﻨﺰف ﺑﺴﮭﻮﻟﺔ ﻋﻨﺪ اﻟﺴﺒﺮ ‪.‬‬ ‫§ ﻟﻜﻦ ﻋﻨﺪﻣﺎ ﺗﻨﻤﻮ اﻟﻔﺼﯿﺼﺎت ‪,‬ﯾﺼﺒﺢ اﻟﺘﺸﻘﻖ‬ ‫واﺿﺤﺎ ﻓﻲ ﻣﻨﺘﺼﻒ اﻟﺴﻦ ‪.‬‬ ‫§ ﻓﻲ ﺑﻌﺾ اﻟﺤﺎﻻت ﯾﺼﺒﺢ اﻟﺴﻄﺢ اﻹﻃﺒﺎﻗﻲ ﻟﻠﺴﻦ‬ ‫ﺑﺄﻛﻤﻠﮫ ﻣﻐﻄﯿﺎ ‪,‬ﺣﯿﺚ ﯾﻨﺘﺞ ﻓﺮط اﻟﻨﻤﻮ ﻋﻦ ﺗﻨﺎﻗﺺ‬ ‫ﺗﺤﻠﻞ اﻟﻜﻮﻻﺟﯿﻦ وﺑﻠﻌﻤﺘﮫ وﻓﺮط ﺗﺼﻨﻊ اﻟﻜﻮﻻﺟﯿﻦ ‪.‬‬ § Associated with phenyoin -Also associated with: Ca channel blockers such as nifedipine and immunosuppressant cyclosporine. Gingival enlargement caused by phenytoin  ‫اﻟﻤﺸﺎﻛﻞ اﻟﻨﺎﺗﺠﺔ و اﻟﺘﺪﺑﯿﺮ‬ ‫§ اﻟﻤﺸﺎﻛﻞ اﻟﺘﺠﻤﯿﻠﯿﺔ ‪,‬ﺻﻌﻮﺑﺔ ﻓﻲ اﻟﻤﻀﻎ ‪ ,‬إﻋﺎﻗﺔ اﻟﻜﻼم ‪,‬‬ ‫ﺗﺄﺧﺮ اﻟﺒﺰوغ ‪,‬ﺑﺰوغ ﻣﻨﺤﺮف ‪,‬رض اﻟﻨﺴﺞ ‪ ,‬اﻟﺘﮭﺎب ﺛﺎﻧﻮي‬ ‫ﯾﺆدي ﻷﻣﺮاض اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ‪.‬‬ ‫§ اﻟﺘﺪﺑﯿﺮ ‪ :‬ﻟﺴﻮء اﻟﺤﻆ ﻻ ﺗﻮﺟﺪ ﻣﻌﺎﻟﺠﺔ ﺷﺎﻓﯿﺔ ‪,‬إذ ﻏﺎﻟﺒﺎ ﻣﺎ‬ ‫ﺗﻜﻮن اﻟﻤﻌﺎﻟﺠﺔ ﻋﺮﺿﯿﺔ ‪.‬‬ ‫§ اﺳﺘﺨﺪﻣﺖ ﻣﻀﺎدات اﻟﮭﯿﺴﺘﺎﻣﯿﻦ ‪,‬اﻟﺴﺘﯿﺮوﺋﯿﺪات اﻟﻘﺸﺮﯾﺔ ‪,‬‬ ‫إﺿﺎﻓﺎت ﺣﻤﺾ اﻻﺳﻜﻮرﺑﯿﻚ )ﻓﯿﺘﺎﻣﯿﻦ ‪ , ( C‬اﻟﻤﻀﺎدات‬ ‫اﻟﺤﯿﻮﯾﺔ اﻟﻤﻮﺿﻌﯿﺔ ‪,‬اﻟﻤﻀﺎﻣﺾ اﻟﻘﻠﻮﯾﺔ ﻣﻊ ﻧﺠﺎح ﻣﺤﺪود‬ ‫واﻋﺘﺒﺮت ﻏﯿﺮ ﻓﻌﺎﻟﺔ ‪.‬‬  ‫§ ﺗﻌﺘﻤﺪ اﻟﻤﻌﺎﻟﺠﺔ اﻟﺴﻨﯿﺔ اﻟﻤﻮﺻﻰ ﺑﮭﺎ ﺣﺪﯾﺜﺎ ﻋﻠﻰ‬ ‫اﻷﻋﺮاض واﻟﻌﻼﻣﺎت اﻟﺴﺮﯾﺮﯾﺔ اﻟﻔﻤﻮﯾﺔ واﻟﺘﻲ ﺗﺘﺮاوح‬ ‫ﻣﻦ ﺗﺤﺴﯿﻦ اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ واﻟﺘﻲ ﺗﺘﻀﻤﻦ ‪ :‬ﺟﮭﺎز‬ ‫اﻹرواء ‪ irrigating device‬ﻣﻊ اﺳﺘﺨﺪام‬ ‫اﻟﻤﻀﺎﻣﺾ اﻟﻤﻀﺎدة ﻟﻠﻮﯾﺤﺔ )ﻛﻠﻮرھﯿﻜﺰﯾﺪﯾﻦ‬ ‫‪ ,(%0,12‬اﻟﻮﻗﺎﯾﺔ واﻟﺘﻄﺒﯿﻖ اﻟﻤﻮﺿﻌﻲ ﻟﻔﻠﻮراﯾﺪ‬ ‫اﻟﺼﻮدﯾﻮم ‪ ,‬إﻟﻰ اﻟﺘﻘﻠﯿﺢ وﺗﺴﻮﯾﺔ اﻟﺠﺬر ﻗﺒﻞ اﻻﺳﺘﺌﺼﺎل‬ ‫اﻟﺠﺮاﺣﻲ ﻟﻠﻀﺨﺎﻣﺎت ‪.‬‬ Broxojet has a multi-stream head. Variously colored tips permit the use a single device for the entire family. Aromatics and disinfectant additives may be combined with the water spray (e.g., chlorhexidine, 0.05%). Tips for various types of irrigators. Sulcus (pocket) irrigator Traditional irrigators have been modified for rinsing of sulci and/or periodontal pockets (WaterPikplus PeriodontoPik). These provide a pulsating flow under limited, safe pressure, to avoid injury to or activation of a pocket. Chlorhexidine may be added in these instruments  ‫اﻟﺘﮭﺎب اﻟﻠﺜﺔ ﺑﻌﻮز ﺣﻤﺾ اﻷﺳﻜﻮرﺑﯿﻚ‬ ASCORBIC ACID DEFICIENCY GINGIVITIS  ‫ﯾﺘﺮاﻓﻖ اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي ھﺬا ﻣﻊ ﻋﻮز ﻓﯿﺘﺎﻣﯿﻦ ‪ , C‬وھﻮ ﯾﻘﺘﺼﺮ ﻋﺎدة‬ ‫§‬ ‫ﻋﻠﻰ اﻟﻨﺴﺞ اﻟﺤﻔﺎﻓﯿﺔ واﻟﺤﻠﯿﻤﺎت ‪,‬ﻣﺘﺮاﻓﻘﺎ ﻣﻊ أﻟﻢ ﺷﺪﯾﺪ وﻧﺰف ﻋﻔﻮي ‪.‬‬ ‫ھﺬا اﻟﻨﻮع ﻣﻦ اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي ﻧﺎدر ﻟﺪى اﻷﻃﻔﺎل ‪ ,‬ﻟﻜﻨﮫ ﻗﺪ ﯾﺤﺪث ﻟﺪى‬ ‫§‬ ‫اﻷﻃﻔﺎل اﻟﺬﯾﻦ ﯾﺘﺤﺴﺴﻮن ﻟﻌﺼﺎﺋﺮ اﻟﻔﻮاﻛﮫ ﻋﻨﺪﻣﺎ ﯾﺘﻢ إھﻤﺎل اﻟﻤﻌﺎﻟﺠﺔ‬ ‫اﻟﺘﻌﻮﯾﻀﯿﺔ ﻣﻦ ﻓﯿﺘﺎﻣﯿﻦ ‪. C‬‬ ‫ﻋﻨﺪﻣﺎ ﺗﺸﯿﺮ اﻟﺘﺤﺎﻟﯿﻞ اﻟﺪﻣﻮﯾﺔ ﻟﻌﻮز ﻓﯿﺘﺎﻣﯿﻦ ‪ , C‬وﺑﻌﺪ اﺳﺘﺒﻌﺎد اﻟﺤﺎﻻت‬ ‫§‬ ‫اﻟﺠﮭﺎزﯾﺔ اﻟﻤﻤﻜﻨﺔ اﻷﺧﺮى ‪,‬ﺳﯿﺴﺘﺠﯿﺐ اﻟﺘﮭﺎب اﻟﻠﺜﺔ ﺑﺸﻜﻞ دراﻣﺎﺗﯿﻜﻲ‬ ‫ﻟﻺﺿﺎﻓﺎت اﻟﯿﻮﻣﯿﺔ ﻣﻦ ‪ 500-250‬ﻣﻠﻎ ﻣﻦ ﺣﻤﺾ اﻷﺳﻜﻮرﺑﯿﻚ ‪.‬‬ ‫ﻗﺪ ﯾﺤﺘﺎج اﻷﻃﻔﺎل اﻷﻛﺒﺮ واﻟﺒﺎﻟﻐﻮن ‪ 1‬غ ﻣﻦ ﻓﯿﺘﺎﻣﯿﻦ ‪ C‬ﻟﻤﺪة أﺳﺒﻮﻋﯿﻦ‬ ‫§‬ ‫ﻟﺘﺴﺮﯾﻊ اﻟﺸﻔﺎء ‪.‬‬ ‫اﻟﻤﻌﺎﻟﺠﺔ اﻟﺴﻨﯿﺔ اﻟﻜﺎﻣﻠﺔ ‪,‬ﺗﺤﺴﯿﻦ اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ ‪,‬وإﺿﺎﻓﺎت ﻓﯿﺘﺎﻣﯿﻦ ‪C‬‬ ‫§‬ ‫واﻟﻔﯿﺘﺎﻣﯿﻨﺎت اﻷﺧﺮى اﻟﻤﻨﺤﻠﺔ ﺑﺎﻟﻤﺎء ﺳﯿﺤﺴﻦ ﺑﺸﻜﻞ ﻛﺒﯿﺮ ﻣﻦ اﻟﺤﺎﻟﺔ‬ ‫اﻟﻠﺜﻮﯾﺔ ‪.‬‬ ‫أﻣﺮاض اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ﻟﺪى اﻷﻃﻔﺎل‬ PERIODONTAL DISEASES IN CHILDREN  ‫ھﻮ ﻣﺮض اﻟﺘﮭﺎﺑﻲ ﻓﻲ اﻟﻠﺜﺔ واﻟﻨﺴﺞ اﻟﻌﻤﯿﻘﺔ وﯾﺘﻤﯿﺰ ب ‪:‬‬ ‫§‬ ‫ﺗﺸﻜﻞ اﻟﺠﯿﺐ‬ ‫§‬ ‫ﺗﺨﺮب اﻟﻌﻈﻢ اﻟﺴﻨﺨﻲ اﻟﺪاﻋﻢ‬ ‫§‬ ‫ﯾﻤﻜﻦ ﺗﺤﺪﯾﺪ اﻟﻀﯿﺎع اﻟﻌﻈﻤﻲ ﻟﺪى اﻷﻃﻔﺎل ﻋﻠﻰ اﻟﺼﻮر اﻟﺸﻌﺎﻋﯿﺔ‬ ‫§‬ ‫اﻟﻤﺠﻨﺤﺔ ﺑﻤﻘﺎرﻧﺔ ارﺗﻔﺎع اﻟﻌﻈﻢ اﻟﺴﻨﺨﻲ اﻟﺪاﻋﻢ ﻣﻊ اﻟﻤﻠﺘﻘﻰ‬ ‫اﻟﻤﯿﻨﺎﺋﻲ اﻟﻤﻼﻃﻲ ‪.‬‬ ‫اﻟﻤﺴﺎﻓﺎت اﻟﺘﻲ ﺗﺘﺮاوح ﺑﯿﻦ ‪ 3-2‬ﻣﻠﻢ ﯾﻤﻜﻦ اﻋﺘﺒﺎرھﺎ ﺿﯿﺎع‬ ‫§‬ ‫ﻋﻈﻤﻲ ﻣﺜﯿﺮ ﻟﻠﺸﻚ ‪,‬أﻣﺎ اﻟﻤﺴﺎﻓﺎت اﻷﻛﺒﺮ ﻣﻦ ‪3‬ﻣﻠﻢ ﻓﺘﺸﯿﺮ ﻟﻔﻘﺪان‬ ‫ﻋﻈﻤﻲ ﺻﺮﯾﺢ ‪.‬‬ ‫اﻟﻀﯿﺎع اﻟﻌﻈﻤﻲ ﻋﺎدة ﻣﺎ ﯾﻜﻮن ﺑﯿﻦ اﻷرﺣﺎء اﻷوﻟﻰ واﻟﺜﺎﻧﯿﺔ ‪.‬‬ ‫§‬  ‫اﻟﺘﮭﺎب اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ذو اﻻﺑﺘﺪاء اﻟﻤﺒﻜﺮ‬ ‫‪EARLY-ONSET PERIODONTITIS‬‬  ‫اﻟﺘﺼﻨﯿﻒ‬ ‫ذﻛﺮﻧﺎ أن ھﻨﺎك أﻧﻮاع ﻣﺘﻌﺪدة ﻣﻦ أﻣﺮاض اﻟﻨﺴﺞ‬ ‫اﻟﺪاﻋﻤﺔ ‪:‬‬ ‫§ اﻟﺘﮭﺎب اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ اﻟﻤﺰﻣﻦ )اﺑﺘﺪاء ﺑﻄﻲء(‪:‬‬ ‫§ اﻟﺸﻜﻞ اﻟﻤﻮﺿﻌﻲ‬ ‫§ اﻟﺸﻜﻞ اﻟﻤﻌﻤﻢ‬  ‫اﻟﺘﮭﺎب اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ذو اﻻﺑﺘﺪاء اﻟﻤﺒﻜﺮ‬ ‫اﻟﺘﮭﺎب اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ذو اﻻﺑﺘﺪاء اﻟﻤﺒﻜﺮ‪ ,‬وھﻮ ﻣﺼﻄﻠﺢ ﻧﻮﻋﻲ‬ ‫§‬ ‫ﻟﻮﺻﻒ ﻣﺠﻤﻮﻋﺔ ﻣﺘﻨﻮﻋﺔ ﻣﻦ أﻣﺮاض اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ اﻟﺤﺎدﺛﺔ ﻟﺪى‬ ‫اﻷﺷﺨﺎص اﻟﯿﺎﻓﻌﯿﻦ اﻷﺻﺤﺎء واﻟﺘﻲ ﯾﻤﻜﻦ ﺗﻘﺴﯿﻤﮭﺎ إﻟﻰ ‪:‬‬ ‫‪ -1‬ﺷﻜﻞ ﻣﻮﺿﻌﻲ ‪ :‬اﻟﺘﮭﺎب ﻧﺴﺞ داﻋﻤﺔ ﺷﺒﺎﺑﻲ ﻣﻮﺿﻌﻲ‬ ‫§‬ ‫)]‪(localized juvenile periodontitis [LJP‬‬ ‫‪ -2‬ﺷﻜﻞ ﻣﻌﻤﻢ ‪ :‬اﻟﺘﮭﺎب ﻧﺴﺞ داﻋﻤﺔ ﺷﺒﺎﺑﻲ ﻣﻌﻤﻢ ‪(generalized‬‬ ‫§‬ ‫)]‪juvenile periodontitis [GJP‬‬ ‫‪ -3‬اﻟﺸﻜﻞ ﻗﺒﻞ اﻟﺒﻠﻮﻏﻲ ‪, prepubertal‬وﯾﻌﺘﻘﺪ أن ﻟﮫ ﺷﻜﻠﯿﻦ ﻣﻌﻤﻢ‬ ‫§‬ ‫وﻣﻮﺿﻌﻲ ‪(localized and generalized prepubertal‬‬ ‫)‪periodontitis‬‬ ‫اﺣﺘﻤﺎل إﺻﺎﺑﺔ اﻟﺬﻛﻮر ب ‪ GJP‬أﻛﺒﺮ ﻣﻦ اﻹﻧﺎث)‪( 4.3 : 1‬‬ ‫§‬  ‫اﻟﺘﮭﺎب اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ﻗﺒﻞ اﻟﺒﻠﻮﻏﻲ‬ ‫§ ﯾﻤﻜﻦ أن ﯾﺤﺪث ﺑﺎﻟﺸﻜﻞ اﻟﻤﻮﺿﻊ ‪ ,‬ﻟﻜﻦ ﻋﺎدة ﻣﺎ ﯾﺸﺎھﺪ‬ ‫ﺑﺎﻟﺸﻜﻞ اﻟﻤﻌﻤﻢ‪.‬‬ ‫§ ﯾﻌﺒﺮ اﻟﺘﮭﺎب اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ﻗﺒﻞ اﻟﺒﻠﻮﻏﻲ) اﻟﻤﻮﺿﻌﻲ( ﻋﻦ‬ ‫ﻓﻘﺪان ﻣﻮﺿﻌﻲ ﻓﻲ اﻻرﺗﺒﺎط اﻟﺒﺸﺮي إﺿﺎﻓﺔ ﻟﻀﯿﺎع اﻟﻌﻈﻢ‬ ‫اﻟﺴﻨﺨﻲ ﻓﻘﻂ ﻓﻲ اﻹﺳﻨﺎن اﻟﻤﺆﻗﺖ ﻟﺪى اﻷﻃﻔﺎل اﻷﺻﺤﺎء ‪.‬‬ ‫§ ﯾﺒﺪو أﻧﮫ ﯾﻨﺸﺄ ﺣﻮاﻟﻲ اﻟﺴﻨﺔ اﻟﺮاﺑﻌﺔ ﻣﻦ اﻟﻌﻤﺮ أو ﻗﺒﻞ ‪ ,‬إذ‬ ‫ﻋﺎدة ﻣﺎ ﯾﺸﺎھﺪ ﺿﯿﺎع اﻟﻌﻈﻢ ﻋﻠﻰ اﻟﺼﻮر اﻟﺸﻌﺎﻋﯿﺔ ﺣﻮل‬ ‫اﻷرﺣﺎء اﻟﻤﺆﻗﺘﺔ و ‪ /‬أواﻟﻘﻮاﻃﻊ‬ Clinical picture - 2 1/2-year-old child The maxillary anterior tooth 51 and all mandibular front teeth and the canines were lost spontaneously. The gingivitis is unimpressive. Aphthous-like lesion in the lower left region. The radiograph clearly depicts the pronounced attachment loss on the anterior teeth, in the presence of complete roots. The pulp chambers appear to be above average in size. Panoramic radiograph Irregular and in some areas extreme attachment loss is revealed on all maxillary deciduous teeth. The mandibular deciduous molars appear to be only slightly involved at this time. Tooth 61, which was present in the clinical picture (was spontaneously exfoliated before the panoramic film was taken,some two weeks after the initial visit.  ‫اﻟﺘﻈﺎھﺮات اﻟﺴﺮﯾﺮﯾﺔ‬ ‫§ أﻋﻤﺎق اﻟﺴﺒﺮ ﻏﯿﺮ اﻟﻄﺒﯿﻌﯿﺔ ‪,‬ﻣﻊ اﻟﺘﮭﺎب ﻟﺜﻮي ﺛﺎﻧﻮي ‪,‬‬ ‫ﻓﻘﺪان ﻋﻈﻤﻲ ﺳﺮﯾﻊ ‪,‬وﻛﻤﯿﺎت دﻧﯿﺎ إﻟﻰ ﻣﺘﻔﺎوﺗﺔ ﻣﻦ‬ ‫اﻟﻠﻮﯾﺤﺔ ‪ ,‬ﺷﺬوذات ﻓﻲ دﻓﺎﻋﺎت اﻟﻤﻀﯿﻒ)ﻓﻔﻲ اﻟﺸﻜﻞ‬ ‫اﻟﻤﻮﺿﻊ ﯾﻼﺣﻆ ﺷﺬوذات ﻓﻲ اﻟﻌﺪﻻت أو وﺣﯿﺪات‬ ‫اﻟﻨﻮى‪ ,‬ﻟﻜﻦ ﻟﯿﺲ ﻛﻠﯿﮭﻤﺎ ﻛﻤﺎ ﻓﻲ اﻟﺸﻜﻞ اﻟﻤﻌﻤﻢ( ‪,‬ﻧﺨﻮر‬ ‫ﻣﻼﺻﻘﺔ واﺳﻌﺔ ﻣﺴﮭﻠﺔ ﺗﺜﺒﯿﺖ اﻟﺒﻠﯿﻚ وﺿﯿﺎع اﻟﻌﻈﻢ ‪,‬‬ ‫ووﺟﻮد ﺗﺎرﯾﺦ ﻋﺎﺋﻠﻲ ﻣﻦ اﻟﺘﮭﺎب اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ‪.‬‬ ‫§ ﯾﺤﺪث اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي ﻣﻊ ﺗﺸﻘﻘﺎت ﻟﺜﻮﯾﺔ وﺗﻘﺮﺣﺎت‬ ‫ﻣﻮﺿﻌﯿﺔ ﻓﻲ اﻟﺤﻮاف اﻟﻠﺜﻮﯾﺔ‪.‬‬  ‫اﻟﺘﺪﺑﯿﺮ‬ ‫ﺗﻌﺘﻤﺪ اﻟﻤﻌﺎﻟﺠﺔ ﻋﻠﻰ اﻟﺘﺸﺨﯿﺺ اﻟﻤﺒﻜﺮ ‪,‬اﻟﺘﺠﺮﯾﻒ اﻟﺴﻨﻲ ‪ ,‬ﺗﺴﻮﯾﺔ‬ ‫§‬ ‫اﻟﺠﺬر ‪,‬إﺟﺮاءات اﻟﻮﻗﺎﯾﺔ ‪ ,‬ﺗﻌﻠﯿﻤﺎت اﻟﺼﺤﺔ اﻟﻔﻤﻮﯾﺔ ‪ ,‬ﺗﺮﻣﯿﻢ اﻷﺳﻨﺎن‬ ‫اﻟﻨﺨﺮة ‪ ,‬إزاﻟﺔ اﻷﺳﻨﺎن اﻟﻤﺆﻗﺘﺔ اﻟﺘﻲ ﻓﻘﺪت اﻟﺪﻋﻢ اﻟﻌﻈﻤﻲ ‪ ,‬إﺿﺎﻓﺔ‬ ‫ﻟﺰﯾﺎدة ﺗﻮاﺗﺮ ﺟﻠﺴﺎت اﻟﻤﺘﺎﺑﻌﺔ ‪.‬‬ ‫ﯾﻌﺘﺒﺮ اﺳﺘﺨﺪام اﻟﻤﻀﺎﻣﺾ اﻟﻤﻀﺎدة ﻟﻠﺠﺮاﺛﯿﻢ )ﻛﻠﻮرھﯿﻜﺰﯾﺪﯾﻦ(‬ ‫§‬ ‫واﻟﻤﻌﺎﻟﺠﺔ ﺑﺎﻟﻤﻀﺎدات اﻟﺤﯿﻮﯾﺔ ﻓﻌﺎﻻ ﻓﻲ إزاﻟﺔ إﻣﺮاﺿﯿﺎت اﻟﻨﺴﺞ‬ ‫اﻟﺪاﻋﻤﺔ ‪.‬‬ ‫ﯾﻤﻜﻦ اﺳﺘﺨﺪام) ‪ Amoxicillin ( Augmentin‬ﻟﺪى اﻷﻃﻔﺎل‬ ‫§‬ ‫)‪250‬ﻣﻠﻎ ﺛﻼث ﻣﺮات ﻓﻲ اﻟﯿﻮم ﻟﻤﺪة ‪ 10‬أﯾﺎم (‬ ‫اﻟﺘﺘﺮاﺳﯿﻜﻠﯿﻦ )‪ 250‬ﻣﻠﻎ ﻣﺮﺗﯿﻦ ﻓﻲ اﻟﯿﻮم ﻟﻤﺪة ‪ 10‬أﯾﺎم (أو ﻣﺸﺘﻘﺎﺗﮫ‪,‬‬ ‫§‬ ‫ھﻮ ﻣﻀﺎد ﺣﯿﻮي ﻓﻌﺎل ﺿﺪ ‪ Aa‬واﻟﻌﻀﻮﯾﺎت اﻟﺪﻗﯿﻘﺔ اﻷﺧﺮى‬ ‫اﻟﻼھﻮاﺋﯿﺔ اﻟﺴﻠﺒﯿﺔ اﻟﻐﺮام‬ ‫اﻟﺘﮭﺎب اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ اﻟﺸﺒﺎﺑﻲ اﻟﻤﻮﺿﻊ)‪(LJP‬‬ ‫اﻟﻤﻈﺎھﺮ اﻟﻤﻤﯿﺰة ‪ :‬ﯾﺤﺪث )‪ (LJP‬ﻟﺪى اﻷﻃﻔﺎل اﻷﺻﺤﺎء‬ ‫§‬ ‫واﻟﺒﺎﻟﻐﯿﻦ )اﻟﻤﺮاھﻘﯿﻦ( ﺑﺪون دﻟﯿﻞ ﺳﺮﯾﺮي ﻋﻠﻰ اﻟﻤﺮض‬ ‫اﻟﺠﮭﺎزي ‪.‬‬ ‫ﯾﺘﻢ ﺗﻤﯿﯿﺰه ﺑﻔﻘﺪان ﻋﻈﻤﻲ ﺳﺮﯾﻊ وﺷﺪﯾﺪ ﻓﻲ اﻟﻌﻈﻢ اﻟﺴﻨﺨﻲ‬ ‫§‬ ‫ﺣﻮل أﻛﺜﺮﻣﻦ ﺳﻦ داﺋﻤﺔ ‪,‬وﻋﺎدة ﺣﻮل اﻷرﺣﺎء اﻷوﻟﻰ‬ ‫واﻟﻘﻮاﻃﻊ ‪.‬‬ ‫ﻓﻘﺪان اﻟﻌﻈﻢ ﺣﻮل اﻷﺳﻨﺎن اﻟﻤﺆﻗﺘﺔ ﯾﻤﻜﻦ أن ﯾﻜﻮن ﻣﻦ‬ ‫§‬ ‫اﻟﻤﻌﻄﯿﺎت اﻟﻤﺒﻜﺮة ﻟﮭﺬا اﻟﻤﺮض ‪.‬‬ ‫ﺗﺘﺮاوح ﻧﺴﺒﺔ ﺣﺪوث ‪ LJP‬ﺑﯿﻦ ‪ 0,1‬و ‪ %1,5‬ﻣﻊ ﻧﻤﻮذج‬ ‫§‬ ‫ﻣﺘﻨﺎﻇﺮ ﺟﺎﻧﺒﯿﺎ ﻣﻦ ﻓﻘﺪان اﻟﻌﻈﻢ ‪.‬‬ Upon cursory inspection the gingivae also appear healthy; however, numerous sites bleed after gentle probing. Clinical picture -15-yearold female Clinical picture -15-yearold female Caries-free dentition. Caries-free dentition Bitewing radiograph - 15-year-old with LJP Two years later, obvious bony defects are visible mesial to l6 and distal of 46 (red arrows). Virtually identical defects were also found on the contralateral side. Early finding: LJP! The significance of regular clinical and radiographic screening in youngsters is clear. Radiographic survey Routine periapical radiographs do not portray the osseous craters on the mandibular first molars as well as the bitewings.No bone loss is apparent on any teeth other than the first permanent molars.  ‫اﻟﻤﻈﺎھﺮ اﻟﺴﺮﯾﺮﯾﺔ‬ ‫§ ﺳﺮﯾﺮﯾﺎ ‪ :‬ﻣﺮﺿﻰ ‪ LJP‬ﻟﺪﯾﮭﻢ اﻟﺘﮭﺎب ﻗﻠﯿﻞ ﻓﻲ اﻟﻨﺴﺞ أو ﺑﺪون‬ ‫اﻟﺘﮭﺎب وﻛﻤﯿﺔ ﻗﻠﯿﻠﺔ ﺟﺪا ﻣﻦ اﻟﺒﻠﯿﻚ اﻟﺴﻨﻲ ﻓﻮق اﻟﻠﺜﻮي أو اﻟﻘﻠﺢ ‪.‬‬ ‫اﻟﺘﻘﺪم ﻓﻲ ﻓﻘﺪان اﻟﻌﻈﻢ أﺳﺮع ب ‪ 4-3‬ﻣﺮات ﻣﻘﺎرﻧﺔ ﻣﻊ اﻟﺘﮭﺎب‬ ‫اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ ﻟﺪى اﻟﺒﺎﻟﻐﯿﻦ ‪.‬‬ ‫§ ﻻ ﯾﻌﺘﻘﺪ أن ‪ LJP‬ﻣﺮض ﻣﻔﺮد ﺑﺸﻜﻞ ﻛﺎﻣﻞ ‪,‬إن اﻷﻧﻮاع‬ ‫اﻟﺠﺮﺛﻮﻣﯿﺔ اﻟﻤﺴﺒﺒﺔ اﻟﻤﺤﺘﻤﻠﺔ ھﻲ ‪ Aa‬ﺑﺎﻟﻤﺸﺎرﻛﺔ ﻣﻊ أﻧﻮاع‬ ‫ﻣﺸﺎﺑﮭﺔ ﻟﻠﻌﺼﯿﺎت ‪,‬وﻗﺪ ذﻛﺮت أﺷﻜﺎل ﻣﺨﺘﻠﻔﺔ ﻣﻦ اﻟﻌﯿﻮب ﻓﻲ‬ ‫اﻟﻌﺪﻻت ﻟﺪى اﻟﻤﺮﺿﻰ اﻟﻤﺼﺎﺑﯿﻦ ب ‪.LJP‬‬ ‫§ ﻣﻌﻈﻢ اﻟﻤﺮﺿﻰ اﻟﻤﺼﺎﺑﯿﻦ ‪ LJP‬ﻟﺪﯾﮭﻢ ﺷﺬوذات ﻓﻲ ﻋﺪﻻت اﻟﺪم‬ ‫اﻟﻤﺤﯿﻄﯿﺔ واﻻﻧﺠﺬاب اﻟﻜﯿﻤﺎﺋﻲ ‪,‬ﻛﻤﺎ ﯾﺸﻚ ﺑﻌﺾ اﻟﻤﺆﻟﻔﯿﻦ ﺑﻮﺟﻮد‬ ‫أﺳﺎس وراﺛﻲ ل‪LJP‬‬ Clinical picture Pigmented gingiva. Very mild gingivitis in anterior area and posterior segments. The type and severity of the disease process cannot be ascertained by a "quick look. Maxillary anterior area during flap procedure (right) 9 mm of attachment loss can be seen in those areas typical for LJP: teeth 21 and 22. Initial radiographic view Radiographic survey The radiographic picture of this advanced stage of disease reveals severe involvement of the maxillary anterior teeth and first permanent molars, which is typical for LJP. In this 21-year-old female, in whom LJP began during puberty, incipient osseous resorption has now also begun on other teeth  ‫اﻟﺘﮭﺎب اﻟﻨﺴﺞ اﻟﺪاﻋﻤﺔ اﻟﺸﺒﺎﺑﻲ اﻟﻤﻌﻤﻢ‬ ‫§ وﯾﺤﺪث ﻟﺪى اﻟﺒﺎﻟﻐﯿﻦ واﻟﻤﺮاھﻘﯿﻦ ﻣﺆﺛﺮا ﻋﻠﻰ ﻛﺎﻣﻞ اﻟﻨﺴﯿﺞ‬ ‫اﻟﺪاﻋﻢ ‪.‬‬ ‫§ اﻟﻤﻈﺎھﺮ اﻟﻤﻤﯿﺰة‪ :‬ﯾﺒﺪي اﻷﺷﺨﺎص اﻟﻤﺼﺎﺑﯿﻦ ب ‪GJP‬‬ ‫اﻟﺘﮭﺎب ﻧﺴﺞ داﻋﻤﺔ ﻣﻤﯿﺰ ﻣﻊ ﺗﺮاﻛﻤﺎت ﻛﺒﯿﺮة ﻣﻦ اﻟﻘﻠﺢ‬ ‫واﻟﻠﻮﯾﺤﺔ‬  ‫اﻟﻤﻌﺎﻟﺠﺔ‬ ‫§ ﺗﻌﺘﻤﺪ اﻟﻤﻌﺎﻟﺠﺔ اﻟﻨﺎﺟﺤﺔ ﻋﻠﻰ اﻟﺘﺸﺨﯿﺺ اﻟﻤﺒﻜﺮ ‪ ,‬اﺳﺘﺨﺪام‬ ‫اﻟﻤﻀﺎدات اﻟﺤﯿﻮﯾﺔ ﺗﺠﺎه اﻟﻌﻀﻮﯾﺎت اﻟﺪﻗﯿﻘﺔ اﻟﻤﺆﻧﺘﻨﺔ ‪,‬‬ ‫واﻹﻋﺪاد ﻟﺒﯿﺌﺔ ﺧﺎﻟﯿﺔ ﻣﻦ اﻻﻧﺘﺎن ‪.‬‬ ‫§ ﺗﺘﻀﻤﻦ ﻣﻌﺎﻟﺠﺔ ﻛﻼ اﻟﻨﻤﻄﯿﻦ اﻟﺠﺮاﺣﺔ واﺳﺘﺨﺪام‬ ‫اﻟﺘﯿﺘﺮاﺳﯿﻜﻠﯿﻦ )وأﺣﯿﺎﻧﺎ ﺑﺎﻟﻤﺸﺎرﻛﺔ ﻣﻊ اﻟﻤﯿﺘﺮوﻧﯿﺪازول( ‪,‬‬ ‫وﺣﯿﺚ أن ﻋﻀﻮﯾﺎت ال ‪ Aa‬ﺗﺨﺘﺮق ﻇﮭﺎرة اﻟﺠﯿﺐ اﻟﻠﺜﻮي ‪,‬‬ ‫ﻓﺈن إﻋﻄﺎء ‪ doxycycline‬ﻟﻤﺪة أﺳﺒﻮﻋﯿﻦ ﻗﺪ ﻇﮭﺮ أﻧﮫ‬ ‫ﯾﻨﻘﺺ ﻣﻦ ﺗﻌﺪاد ‪.Aa‬‬ ‫§ اﻻﺳﺘﺌﺼﺎل اﻟﺠﺮاﺣﻲ ﻟﻠﻨﺴﺞ اﻟﻤﻮؤﻓﺔ وﺗﺴﻮﯾﺔ ﺳﻄﻮح اﻟﺠﺬر‬ ‫ﻟﻜﻞ اﻷﺳﻨﺎن أﺛﻨﺎء اﻟﺠﺮاﺣﺔ ‪.‬‬ ‫§ ﻣﻌﺎﻟﺠﺔ ‪ LJP‬ﺗﺘﻀﻤﻦ اﻟﺘﻘﻠﯿﺢ وﺗﺴﻮﯾﺔ اﻟﺠﺬر ﻟﻜﻞ اﻷﺳﻨﺎن ‪,‬‬ ‫ﻣﻊ إرواء ﻣﺘﺰاﻣﻦ ﻟﻌﻤﻖ اﻟﺴﺒﺮ ﺑﻤﺤﺎﻟﯿﻞ ﻣﻠﺤﯿﺔ ﻏﯿﺮ ﻋﻀﻮﯾﺔ‬ ‫ﻣﺸﺒﻌﺔ ‪ ,‬و‪%1‬ﻣﻦ ‪, chloramine‬ﺑﺎﻹﺿﺎﻓﺔ‬ ‫ﻟﻠﺘﺘﺮاﺳﯿﻜﻠﯿﻦ اﻟﺠﮭﺎزي )‪1‬غ ﻛﻞ ﯾﻮم ( ﻟﻤﺪة ‪ 14‬ﯾﻮم ‪.‬‬ ‫§ اﻟﻌﻨﺎﯾﺔ اﻟﻤﻨﺰﻟﯿﺔ ﻟﻠﻤﺮﯾﺾ ‪ :‬ﺗﻄﺒﯿﻖ ﯾﻮﻣﻲ ﻟﻤﻌﺠﻮن ﻣﻦ‬ ‫ﺑﯿﻜﺮﺑﻮﻧﺎت اﻟﺼﻮدﯾﻮم و‪%3‬ھﯿﺪروﺟﯿﻦ ﺑﯿﺮوﻛﺴﯿﺪ ‪.‬‬ ‫§ ﻣﻌﺎﻟﺠﺔ ‪ GJP‬أﻗﻞ ﺗﻨﺒﺆا‪.‬‬  ‫ﻓﻘﺪان اﻷﺳﻨﺎن اﻟﻤﺒﻜﺮ ﻓﻲ اﻹﺳﻨﺎن اﻟﻤﺆﻗﺖ‬ PREMATURE BONE LOSS IN THE PRIMARY DENTITION  ‫§ ﻓﻘﺪان ﻋﻈﻤﻲ ﺳﻨﺨﻲ ﻣﺘﻘﺪم ﻣﺘﺮاﻓﻖ ﻣﻊ ﻣﺮض‬ ‫ﺟﮭﺎزي ﻟﺪى اﻷﻃﻔﺎل واﻟﻤﺮاھﻘﯿﻦ ﻛﻤﺎ ﻟﺪى اﻟﺒﺎﻟﻐﯿﻦ ‪.‬‬ ‫§ اﻟﺘﺨﺮب اﻟﻌﻈﻤﻲ ﻓﻲ اﻹﺳﻨﺎن اﻟﻤﺆﻗﺖ ﻓﻲ ﻏﯿﺎب‬ ‫اﻟﻌﻮاﻣﻞ اﻟﻤﻮﺿﻌﯿﺔ ﯾﻮﺣﻲ وﺑﺸﺪة ﻟﻤﺮض ﺟﮭﺎزي ‪.‬‬ ‫§ ﯾﻌﺘﻘﺪ أن اﻟﻌﯿﻮب ﻓﻲ وﻇﯿﻔﺔ اﻟﺨﻼﯾﺎ اﻟﻤﻨﺎﻋﯿﺔ‬ ‫واﻟﻌﺪﻻت ﺗﺰﯾﺪ ﻣﻦ ﺗﺄھﺐ اﻟﻤﺮﯾﺾ ﻻﻟﺘﮭﺎب اﻟﻨﺴﺞ‬ ‫اﻟﺪاﻋﻤﺔ اﻻﻧﺘﺎﻧﯿﺔ ‪.‬‬  ‫اﻷﻣﺮاض اﻟﻤﺆھﺒﺔ‬ ‫§ ﻧﻘﺺ اﻟﻔﻮﺳﻔﺎﺗﺎز‪,‬ﻣﺘﻼزﻣﺔ ﺑﺎﺑﻠﯿﻮن –ﻟﯿﻔﯿﻔﯿﺮ‪,‬‬ ‫ﻧﺪرة اﻟﻤﺤﺒﺒﺎت ‪ ,‬ﻧﻘﺺ اﻟﻌﺪﻻت اﻟﺪوري ‪,‬‬ ‫اﻟﺪم ‪ ,‬اﻟﺴﻜﺮي‪ ,‬ﻣﺘﻼزﻣﺔ داون ‪,‬ﻣﺘﻼزﻣﺔ‬ ‫‪, chediak- higashi‬ﻋﯿﻮب اﻟﺘﺼﺎق‬ ‫اﻟﻜﺮﯾﺎت اﻟﺒﯿﻀﺎء ‪ ,‬ورم ﺧﻼﯾﺎ ﻻﻧﻐﺮھﺎﻧﺲ‬ ‫)‪(histocytosis‬‬ Localized acute inflammation of the gingivae, which exhibit some edematous swelling as well as areas of shrinkage. Plaque and calculus are abundant. Almost all of the deeper pockets exhibit signs of activity (pus). Radiographic survey The radiographs confirm the clinical findings. Teeth 15,14,12; 21 and 32 must be extracted.  ‫ﻣﺘﻼزﻣﺔ ﺑﺎﺑﻠﯿﻮن –ﻟﯿﻔﯿﻔﯿﺮ‬ ‫اﻟﻤﺘﻼزﻣﺔ ﻧﺎدرة واﻟﺴﺒﺐ ﻏﯿﺮ ﻣﻌﺮوف ‪.‬‬ ‫§‬ ‫ﻧﻤﻂ اﻟﻮراﺛﺔ ‪ :‬ﻣﻘﮭﻮر ﻣﺤﻤﻮل ﻋﻠﻰ اﻟﺼﺒﻐﯿﺎت اﻟﺠﺴﺪﯾﺔ ‪.‬‬ ‫§‬ ‫ﺗﺒﺰغ اﻷﺳﻨﺎن اﻟﻤﺆﻗﺘﺔ ﺑﻮﻗﺘﮭﺎ اﻟﻄﺒﯿﻌﻲ ‪,‬وﺑﻌﻤﺮ اﻟﺴﻨﺘﯿﻦ ﯾﺤﻚ‬ ‫§‬ ‫اﻟﻄﻔﻞ اﻟﻨﺴﺞ اﻟﻠﺜﻮﯾﺔ وﯾﺘﺼﺮف ﻛﻤﺎ ﻟﻮأﻧﮭﺎ ﻣﺆﻟﻤﺔ ‪.‬‬ ‫ھﻨﺎك ﻣﯿﻞ ﻟﻠﻨﺰف اﻟﻠﺜﻮي ﻟﺪى ﺗﻔﺮﯾﺶ اﻷﺳﻨﺎن ‪.‬‬ ‫§‬ ‫ﻓﺮط ﺗﻘﺮن ﻓﻲ راﺣﺔ اﻟﯿﺪﯾﻦ وأﺧﻤﺺ اﻟﻘﺪﻣﯿﻦ ‪.‬‬ ‫§‬ ‫ﺗﺘﻘﻠﻘﻞ اﻷﺳﻨﺎن ﻓﻲ ﻋﻤﺮ ‪ 2,5‬ﺳﻨﺔ ‪,‬ﻛﻤﺎ ﺗﻈﮭﺮ اﻟﺼﻮر اﻟﺸﻌﺎﻋﯿﺔ‬ ‫§‬ ‫اﻣﺘﺼﺎص ﻋﻈﻢ أﻓﻘﻲ ﺷﺪﯾﺪ‪.‬وﺑﺴﺒﺐ اﻻﻟﺘﮭﺎب اﻟﻠﺜﻮي وﻋﺪم ارﺗﯿﺎح‬ ‫اﻟﻤﺮﯾﺾ ‪,‬ووﺟﻮد اﻟﺠﯿﻮب اﻟﻠﺜﻮﯾﺔ اﻟﻤﻮؤﻓﺔ ﺗﻔﻘﺪ اﻷﺳﻨﺎن اﻟﻤﺆﻗﺘﺔ‬ ‫ﺑﻌﻤﺮ ‪ 3‬ﺳﻨﻮات‬ Papillon-Lefevre Syndrome (PLS) with palmar and plantar hyperkeratoses The hyperkeratotic area exhibits cracks and fissures, which are actually wounds that have occurred due to normal function. These heal poorly and slowly. The patient suffers from these palmar lesions mostly in winter. Hyperkeratosis on sole and lateral border of foot.The sharp line of demarcation between hyperkeratotic areas and normal-appearing skin corresponds to the outline of the shoe worn by this patient. Minor trauma to the skin elicits this type of severe hyperkeratotic response. Dermatologists, too, can treat this disease only symptomatically ‫أﺳﻨﺎن ﻋﺎﺋﻤﺔ ﺑﺪون دﻋﻢ ﻋﻈﻤﻲ‬  ‫اﻟﺘﺸﺨﯿﺺ واﻟﻤﻌﺎﻟﺠﺔ‬ ‫اﻟﻔﺤﻮص اﻟﻨﺴﯿﺠﯿﺔ ﻟﻸﺳﻨﺎن ﺗﻈﮭﺮ ﻧﻤﻮذج اﻣﺘﺼﺎص ﻣﺒﻜﺮ ﻣﻊ‬ ‫§‬ ‫ﻧﺴﯿﺞ ﻟﺒﻲ ﻃﺒﯿﻌﻲ ﺑﺎﻟﻀﺮورة ‪,‬واﻟﻤﻼط ﻃﺒﯿﻌﻲ وﯾﻐﻄﻲ ﺑﻨﯿﺔ‬ ‫اﻟﺠﺬر‪.‬‬ ‫اﻟﺘﺸﺨﯿﺺ ‪:‬اﻟﺘﻐﯿﺮات اﻟﻔﻤﻮﯾﺔ ‪,‬آﻓﺎت اﻟﺠﻠﺪ ‪,‬اﻟﺠﺮاﺛﯿﻢ ‪,‬اﺧﺘﺒﺎر‬ ‫§‬ ‫‪ ELISA‬ﻟﺘﺤﺪﯾﺪ اﻷﺟﺴﺎم اﻟﻀﺪﯾﺔ ‪ IgG‬ﺗﺠﺎه ‪. Aa‬‬ ‫ﯾﺘﺄﺛﺮ اﻷﺳﻨﺎن اﻟﺪاﺋﻤﺔ ﻓﯿﻤﺎ ﺑﻌﺪ وﺑﻨﻔﺲ اﻟﻄﺮﯾﻘﺔ ‪.‬‬ ‫§‬ ‫اﻟﺘﺪﺑﯿﺮ ‪ :‬ﺗﺤﺪﯾﺪ اﻟﻌﻮاﻣﻞ اﻟﻤﻤﺮﺿﺔ اﻟﻨﻮﻋﯿﺔ ‪,‬اﻟﻤﻌﺎﻟﺠﺔ ﺑﺎﻟﻤﻀﺎدات‬ ‫§‬ ‫اﻟﺤﯿﻮﯾﺔ اﻟﻨﻮﻋﯿﺔ )ﻣﯿﺘﺮوﻧﯿﺪازول ‪ +‬ﺗﯿﺘﺮاﺳﯿﻜﻠﯿﻦ ‪+‬‬ ‫ﻛﻠﻮرھﯿﻜﺰﯾﺪﯾﻦ (ﺗﺠﺎه ھﺬه اﻟﺠﺮاﺛﯿﻢ وﻗﻠﻊ ﻛﺎﻣﻞ اﻷﺳﻨﺎن ﻣﺒﻜﺮا‬ ‫ﺑﺸﻜﻞ ﻛﺎف ﻟﻨﺆﻣﻦ ﺑﯿﺌﺔ ﺧﺎﻟﯿﺔ ﻣﻦ اﻻﻧﺘﺎن ﻗﺒﻞ ﺑﺰوغ اﻷﺳﻨﺎ ن‬ ‫اﻟﺪاﺋﻤﺔ ‪ ,‬وﻏﺎﻟﺒﺎ ﻣﺎﺗﻨﺘﮭﻲ اﻟﺤﺎﻟﺔ ﺑﺄﺟﮭﺰة ﻛﺎﻣﻠﺔ‪.‬‬ The End