Oral Medicine 2 PDF - University of Jordan Dentistry 019

University of Jordan Dentistry 019 Oral Medicine- 2 WE ARE JUST FEW STEPS AWAY! Written by: Hatamleh Corrected by: Sereen Al-sawaeer Doctor: Dina Taimeh Sheet# 2 1|Page ...

University of Jordan Dentistry 019 Oral Medicine- 2 WE ARE JUST FEW STEPS AWAY! Written by: Hatamleh Corrected by: Sereen Al-sawaeer Doctor: Dina Taimeh Sheet# 2 1|Page   Slides  Doctor ‫ﺑﺳﻡ ﷲ ﺍﻟﺭﺣﻣﻥ ﺍﻟﺭﺣﻳﻡ‬ Oral mucosal ulcers Oral mucosal ulcers are actually a very common complaint among patients, it might be a reflection of a local cause or even a systemic cause and although we might sometimes need to do some histopathological examination and some laboratory tests. However, usually a careful clinical examination and a thorough history taking can usually provide us with insights into the nature of the ulcer. The complete loss of epithelium, exposing the underlying connective tissue.  usually the ulcer is when there is a complete loss of epithelium leaving exposed underlying connective tissue if there is a partial loss of the epithelium then that lesion would be called an erosion. The most common lesions affecting the oral mucosa. A sign of a wide spectrum of conditions involving the oral cavity. Many aetiologic factors – local or systemic. Diagnostic challenge – overlap in histological and clinical features. clinical features there are some clinical features which might be very helpful in reaching a diagnosis for the oral ulceration: Number of lesions Is it a solitary ulcer or does the patient have more than one ulcer. Solitary ulcer possibly a reflection of a traumatic lesion maybe. Multiple ulcers we might start thinking of possible recurrent of stomatitis or herpetic infection. Location The location of the ulcer is also very telling, for example if the patient has an ulcer on non-keratinized mucosa could it possibly be an aphthous ulcer or if it is for example next to a sharp tooth again, we might start thinking of traumatic lesions. Duration: > 2-3 weeks? If the ulcer has been there for several weeks, we might start thinking of possibly more Sinister reasons for ulceration. 2|Page  Presence of a blister preceding the ulcer Is there a blister that has preceded the ulcer we might start thinking of possibly immune mediated conditions or viral infections. Presence of other mucosal or skin changes. If there are other manifestations, for example mucosal or skin changes such as white striation which might be a reflection of lichen planus, also skin lesions for example in patients with pemphigus vulgaris or Bechet disease. So, all these clinical features might be very helpful in diagnosing the cause of the oral ulceration. Local causes Trauma We said earlier that ulceration might be a reflection of a local cause or a systemic cause. So, one of the common local causes of ulceration is trauma. Thermal – maxillary / palatal gingivae.  usually, the maxillary and palatal gingiva are very common sites of thermal trauma. Chemical: bleaching agents, cocaine, aspirin. Mechanical: parafunctional habit, poor dentures/ prosthesis, sharp teeth/fillings. Non-incidental: abuse or self-inflicted.  Usually, these ulcers are reactive oral ulcerations, and they are diagnosed on the basis of clinical presentation and history.  Once the source of the trauma has been identified and resolved, the ulcer usually also spontaneously resolves as the causative factor has been removed. Aphthae Recurrent Aphthous Stomatitis Minor, major, herpetiform. Patients are otherwise well.  by definition of recurrent aphthous stomatitis usually the patients are healthy and well 3|Page  Similar ulcers can be seen in systemic disease – Aphthous like ulcers Behcet syndrome, periodic fever syndromes, Crohn’s disease, ulcerative colitis.... etc. Recurrent Aphthous Stomatitis  At least 10% of the population  Typically starts in childhood or adolescence  Slight female predisposition  Patients are otherwise well o We already mentioned that the patients are usually fit and healthy, however there might be some risk factors or triggers associated with this condition Potential local triggers Potential systemic factors Trauma - appliances Genetic predisposition Psychological illness – stress (exams) Hematinic deficiency Smoking cessation Allergies - food, SLS Endocrine factors  Hematinic deficiencies may be relevant in some cases and hematinic include iron, folic acid and b12.  Allergies to some foods (for example cinnamon or benzoate), SLS is a detergent found in toothpaste so it's (sodium lauryl sulfate).  Endocrine factors may also be relevant for example during certain phases of the menstrual cycle and the contraceptive pill.  Possibly more common in higher socioeconomic groups RAS comes in three types/forms and the size of the ulcers, the time to heal and the location of the ulcers are the determining factors between these types. Minor RAS Most common type (75-85%) Small round ulcers, 2-4mm in diameter, few ulcers at a time (1-6). Yellowish base, surrounded by erythematous halo. Non-Keratinized mucosa. Healing in 7-10 days. No scarring. 4|Page Major RAS Uncommon (10-15%) Large size >1cm, few at a time (1-6). Any area of oral mucosa including keratinized areas Slow healing – up to 40 days VERY PAINFUL Scarring is possible Herpetiform ulcers Uncommon (5-10%) 10 at a time  ulcers are usually pinpoint small in size May coalesce to leave large ragged ulcers. Keratinized and non-keratinized mucosa Healing in 10-14 days May scar Diagnosis Mainly clinical – history and clinical features  So, a good history and examination are usually sufficient to diagnose RAS. History: exclude cutaneous, GI, genital or ocular features. Biopsy not usually indicated Investigations to exclude systemic disorders: - Blood tests: ESR, CRP, FBC, hemoglobin, red cell folate, ferritin, B12 and WBC  Inflammatory conditions: ESR & CRP which are raised in inflammatory conditions.  Anemia: FBC (CBC), hemoglobin level, red cell folate and B12.  Immune deficiencies: WBC count. 5|Page Aphthous like ulceration We mentioned earlier that aphthous like ulceration or RAS like ulcers might be a manifestation of a systemic disease, so they might be associated with: Immune deficiencies: HIV, cyclic neutropenia Behcet syndrome GI diseases Periodic fever syndromes.  refer to a group of diseases that cause periodic or episodic fever that do not have an infectious origin or an infectious cause. Drug-induced ulceration Other causes for oral ulceration in the oral cavity include medications, so these may give rise to more irregular and extensive ulceration in the oral cavity. Cytotoxic drugs used during chemotherapy such as methotrexate NSAIDS Nicorandil an agent to treat or to manage angina also one of the medications known to cause oral ulceration. Many others Systemic Disease oral ulcerations may also be a reflection of an underlying systemic disease 1. Blood Disorders  Anemia  Hematinic deficiencies  Leukemia (+ cytotoxic therapy). o associated features include: gingival bleeding and enlargement, lymphadenopathy. o In leukemia the oral ulceration may be due to neutropenia or due to anemia. o Other features of leukemia may be present like gingival hyperplasia of the marginal, attached and interdental gingiva and other causes of ulceration in leukemia may be due to side effects of chemotherapy or the cytotoxic therapy. Neutropenia, e.g. cyclic neutropenia 6|Page  o Cyclic neutropenia which is a cyclic reduction in the circulating levels of neutrophils around every 21 days, usually the affected patients may develop oral ulceration, fever, cutaneous abscesses and lymphadenopathy. 2. Infections  Viral In most instances, these give rise to short-term local illness. However, some might cause significant orofacial disease 1- Herpes Simplex I, II (primary herpetic stomatitis – herpes labialis) Viruses may also be a cause of oral ulceration, commonly caused by herpes simplex virus infection whether in its primary form called primary herpetic gingivostomatitis or its secondary form known typically as herpes labialis. Primary herpetic stomatitis the ulceration can arise on any oral mucosal surface. The gingiva becomes swollen, erythematous, and ulcerated, with ulceration affecting the free and/or attached gingiva. the ulcers are usually superficial and small. However, they may coalesce to give larger irregular ulcers within the oral cavity. Secondary HSV-1 infection or herpes labialis typically affects the Vermilion border of the lip but can also arise on the perioral or perinasal skin, and as we know it has a characteristic clinical pattern starting with paresthesia followed by erythema, vesiculation and superficial ulceration usually it heals spontaneously within one week. 2- Coxsackievirus: hand, foot, mouth disease The most commonly affected sites are the buccal mucosa, labial mucosa, and tongue but any site of the oral mucosa can be affected. Such vesicles are usually 2–7 mm in diameter and gradually disappear a er a period of about 1 week. causes oral ulceration it also presents with fever reduced appetite, sore throat and malaise usually also the palms of the hands and the soles of the feet are affected by small vesicles or small blisters. 3- Varicella Zoster Virus (chickenpox – shingles) Chicken pox: Macular-papular cutaneous rash that rapidly evolves into vesicles and later on pustules, accompanied by fever and malaise. The oral manifestations are short lasting small white-opaque vesicles that rupture and ulcerate, usually on the palate and buccal mucosa. 7|Page causes oral ulceration it also causes fever malaise and headaches oral lesions are actually quite common with varicella zoster infection or chicken pox however because the clinical picture is dominated by the skin lesions/rash the oral ulcers/manifestations may go unnoticed by the patient and the clinician. 4- HIV ❑ Infectious mononucleosis: The clinical features of infectious mononucleosis comprise pharyngitis, pyrexia, cervical lymphadenopathy, and possibly nausea and abdominal pain due to hepatitis and hepatosplenomegaly. These can be accompanied by a pink maculopapular rash that may be more profound if patients are prescribed ampicillin-type antibiotics. (wasn’t mentioned by the doctor)  Bacterial as well oral ulcers may also be caused by bacterial infections such as: Acute necrotizing ulcerative gingivitis (ANUG) this infection is usually caused by fusiform and spirochete bacteria and findings include pain which is of rapid onset, bleeding and most specifically ulceration and necrosis of the interdental papillae. other bacteria which might cause oral ulcers include syphilis and tuberculosis. Syphilis, which is an infection caused by Terponema pallidum, usually starts as a primary infection and if left untreated it passes to a secondary infection, latent and finally a tertiary infection. Primary syphilis is usually characterized by the presence of a chancer which is usually occurring at the site of inoculation so that is the lips and/or the tongue and it presents as a large and painless ulcer with an indurated margin even if no treatment was given usually chancer heal within 8 weeks. Secondary syphilis is characterized by a range of signs and symptoms such as skin rash, weight loss, headache and sore throat oral lesions are present in around 30% of individuals and are in the form of mucus patches which are highly infectious and can present as slightly elevated plaques which may be ulcerated, it may also present as multiple lesions that may coalesce together to give rise to what is known as snail tract ulcers. Extra: The characteristic rash of secondary syphilis may appear as rough, red, or reddish brown spots both on the palms of the hands and the bottoms of the feet. 8|Page Tertiary syphilis is characterized by the formation of a gumma which is a nodular and ulcerative lesion which usually occurs on the tongue or the palate and if bone is involved it leads to significant destruction manifesting as palatal perforation or an oronasal fistula. 3. GI diseases  GI diseases might also cause oral ulceration and RAS like lesions systemic features in association with GI diseases include constipation, abdominal pain, diarrhea and bloating. Other oral features might also be seen apart from ulceration such as cobblestoning, mucosal tags and swelling of the lips particularly in association with Crohn's disease.  Coeliac disease  Ulcerative colitis 4. Mucocutaneous disorders Another big group of conditions which affect the skin and mucosal surfaces might be responsible for oral ulcerations these mucocutaneous disorders include conditions such as oral lichen planus and include autoimmune bullous diseases such as pemphigus vulgaris and mucous membrane pemphigoid the most common among all of these mucocutaneous disorders is oral lichen planus. Lichen planus is an immunologically mediated mucocutaneous disorder which affects around 1-2% of the adult population it is more common in females. The most commonly involved oral sites are the buccal mucosa, lateral surfaces of the tongue, and gingivae, respectively, typically presents orally as bilateral involvement of the buccal mucosa it might also affect the gingiva and features as what we know as desquamative gingivitis 6 clinical patterns are described: reticular, plaque-like, erythematous, erosive/ulcerative, papular, and bullous, the most commonly seen pattern is the reticular pattern 9|Page  There is a small reported risk of malignant change in association with oral lichen planus around