OM Sheet #2 By Fatmeh Qooqazeh

by **Sura** 8/10/2012, 1:39 am

http://www.4shared.com/file/JpwGfBLp/OM_sheet_2_by_fatemah_qooqazeh.html

by **Shadi Jarrar** 15/11/2012, 6:40 pm

By the name of allah

Oral medicine

2^nd lec .

Dr.samar Burgan

Today we will talk about :

- Acute necrotic stomatitis or mucositis

- Fixed drug eruption

- Recurrent aphthous stomatitis

- Behcet’s disease

- Lupus erythematosus

- Erythema multiforme

Acute necrotic stomatitis or mucositis

It is result from absence of granulocytes in peripheral blood particularly neutrophills .

This occur specially in immune suppression patient , like cancer patient who take chemotherapy ,radiation , or patient with bone marrow disease .

This occur during the period of chemotherapy and few days after, then healing occurs .

Patient presented with shallow, painful ulcers with red erythmetus patches around it , then its turn to acute necrotic ulcer .

The ulcers are as a result of immune suppression , there is no inflammatory rxn around ulcers .

If the ulcers don’t disappear, the patient may have malnutrition, or viral or fungal infection, so we have to find out why the ulcers don’t disappear.

Radiation treatment can destroy the salivary glands resulting in oral dryness “ xerostomia “ and mucositis.

So we should protect all the soft tissues in oral cavity before the radiotherapy.

Diagnosis

- Can be made from CBC , to find any absence of granulocytes .

- History .

They found that chemotherapy patient have deficiency in serum zinc level , so always we do serum zinc level test for these patients .

Treatment

- Supportive , until the cell regenerate themselves .

- Avoid spicy food , acidic drink , very hot and very cold food , smoking ,and sharp foods like (potato chips ) .

- Give them oral hygiene measures , soft –tooth brush , use bland tooth paste (without any chemicals ) or natural toothpaste like herbal toothpaste .

- Mixture of Corticosteroid oral rinse , with nystatin suspension ,acyclovir suspension (alcohol- free ) , and lidocaine oral solution , rinse and gargle for 2 min. and spit out immediately , repeat ½ hr before each meal and at bed time .

- Solution of salt and baking soda ( sodium bicarbonate ) can also be used as oral rinse every 2 hrs .

- Biotine oral rinse and tooth paste ,and biotene oral balance gel are used often to moisten the mouth while sores are healing and this also helps control oral bacteria . biotene (SLS free )

- NSAIDs are often required to ease pain .

- Provide zinc supplementation for loss of taste .

Fixed drug eruption :

Is uncommon occurrence which characteristically recurs in the same site or sites each time a particular drug is taken so its allergy to some drugs , usually the offending agent is just one drug .

So the aetiology is allergic reaction to a medicine .

In dentistry commonly from NSAIDs , and there is many other drugs like , fluconazole , tetracycline , doxycycline , antihistamine, sulpha drugs

How dose it present ??

It is appear as skin patches without pruritus but with burning sensation .

They are sometimes solitary patches at first , but with repeated attacks new lesions may appear , and existing ones may increase in size .

Lesions may occur around the mouth or the eyes, in oral cavity it’s appearing as ulceration or erosive, atrophic lesion with burning sensation.

These patches heal without any scaring.

Diagnosis:

It’s not easy to diagnose this problem, from the history of drugs as the lesion usually develops within 30 min to 8 hrs of taking a certain drug .

Treatment :

- Identification the offending agents , then ask the patient to withdraw the drug or change it .

- We can give antihistamine if the lesions are pruritus or painful to relief the symptoms .

Recurrent aphthous stomatitis ( RAS )

This is the second most common oral condition after traumatic ulcers , of unknown etiology , but there is precipitating factors include stress ,truma,allergy, endocrine alteration , and about 30-40 % of patients with RAS report a family history ,so it is possible to have genetic predisposition for this problem .

RAS ,higher prevalence has been found in upper socioeconomic groups , its may related to the type of food they have !!

Types of RAS :

80% minor RAS .

15 % major RAS

5 % herpetiform RAS

RAS its quiet common ,its affect more than 10% of population , from 20 – 25 % of population affected with RAS “ canker sore “ .

Minor RAS :

Its usually affect non – keratinized mucosa , buccal mucosa , labial mucosa , floor of the mouth and ventral surface of the tongue .

Ulcers are smaller than 8-10 mm and tend to heal within 10-14 days without scarring , 2-3 up to 10 in number of aphthae .

The ulcer is rounded or oval , with necrotic center cover with pseudo membranous surrounded by erythematic well defined borders .

Usually the onset is during the childhood , and its painful specially if its infected ,patient come with lymphnode enlargement and fever .

Those ulcers heal without scarring .

Major RAS :

Large in size , more than 1 cm ,usually needs more time to heal around 1 month ,and when it heal leave scarring .

Major aphthae , also referred to as periadenitis mucosa necrotica recurrens or Sutton’s disease .

Usually its affect the mucosa overlying minor salivary glands “ labial mucosa , lower labial mucosa , soft palate and throat “

Its much more painful than minor because its deeper and larger .

Affects people after puberty that help to differentiate it from minor RAS whin start in childhood .

Herpetiform RAS :

Uncommon type 5-10 % , affect more women in middle age 40-70 yrs , small very painful ulcers seen in everywhere on the oral mucosa , 10-100 in number ,they tend to fuse and produce larger ulcer , then it heal within 2 weeks without scarring .

All type of RAS , usually come as episodes 2-4 times each year ( simple aphthosis ) , some may have almost continuous disease activity with new lesions developing as older lesions heal ( complex aphthosis ) .

Diagnosis :

- Family history and clinical criteria .

- Full medical history to rule out other ulcerative disorders and condition such as : Crohn disease , Behcet’s disease ,HIV infection and neutropenia .

- CBC ,serum ferritin , serum red cell folate level , serum vit B12level .

- Antibody of celiac disease

IgA anti – gliadin antibody ( AGA)

IgA anti – endomysial antibody (EMA)

IgA anti – transglutaminase antibody (ATA)

These test to rule out celiac disease from diagnosis .

Treatment:

1^st line of treatment is corticosteroids topical , or systemic .

If the ulcer is mild , we give antiseptic and anesthetic mouth rinse , with topical steroid gel .

If the ulcer is sever we give more potent topical steroid like dexamethazone elixate .

If ulcer is resistant we give short term course of systemic steroids over 10 days , then by topical ( 40 mg 20 x 20 for 5 days ) then we minimize the dose by 5 mg every day till reach 5 mg , then minimize it by 1 mg for every day .

- Topical tetracycline plus nicotinamide or doxycycline alone administered as oral rinse , can provide relief for ulcers especially herpetiform type .

- Using SLS free tooth paste help in reduce the amount , size and recurrence of oral ulcers in up to 80 % of patients .

SLS : it is material found in all detergent , that give the foam .

In Jordan SLS free tooth paste called bioten dry mouth .

- Vit B12 pills ( 1000 mg) in Jordan we have 500 mg so I give 2 tablets along 1-2 months ,been found to be sffective in treating RAS , regardless of whether there is vitamin deficiency present .

- Zinc supplementation if there is zinc deficiency .

Behcet’s Disease :

It is a form of vasculitis mainly of small vessels ,that can lead to ulceration and other lesions .

Aetiology :

Unknown cause , with some suggests of genetic background and environmental factors .

It affects male 10 x time more than female (10:1) of 20-40 yrs of age .

Overreaction of immune system that make exaggerated inflammation “ in blood vessels “ .

In 50% of bahcet’s patients , the ulcers are founded in soft palate , so one of the deferential diagnosis for ulcers in soft palate is behcet’s disease .

Diagnosis :

There is no specific pathological test for bahcet’s disease , there is specific pattern and criteria for daiagnosis .

- Bahcet’s disease to be diagnosed , aperson must have oral aphthous ulcers of any shape , size or numbers at least 3 times in one year , along with 2 or more out of the next 4 hallmark symptoms :

· Genital ulcers

· Skin lesions

· Eye inflammation ( uveitis, iritis, retinal vasculitis ..)

· Pathergy reaction test ( papule more than 2 mm in diameter , 1-2 days or more after needle-prick )

Treatment :

There is local (topical ) and systemic therapy .

Topical :

Tetracycline or doxycycline oral rinse is the best treatment for aphthous ulcer of bahcet’s disease

Ther is 2 uses for doxycycline as oral rinse :

- Herpetiform RAS

- Ulcers of bahcet’s disease .

In very early stage we can give corticosteroids, and the usage of hyalurinic acid oral solution can reduce pain and inflammation of oral ulcers .

Systemic therapy :

We treat with systemic corticosteroids ,colchicine.

In treatment you should know the main things .

Lupus erythematosus :

Chronic autoimmune connective tissue disease , that can affect any part of the body ,heart , joint, liver …

Occure 9 time more in female than male (9:1) .

Aetiology :

- It is an autoimmune disease in which the immune system attacks the body’s cells and tissues , resulting in inflammation and tissue damage .

- Possible triggers include hereditry , infection , drugs and sunlight.

- Hormonal changes may play a role which could explain why it is much more common in women .

We have 2 types of LE :

- Systemic lupus erythematosus (SLE) .

- Discoid lupus erythematosus (DLE ).

SLE , presented by butterfly – like redness ( malar butterfly ) may come with skin rash , fatigue, weight loss , hair loss and nephritis .

Intraoraly , painless oral ulcers , commonly occur on palate , buccal mucosa , and gingival .

When I found an ulcers in hard palate , I should exclude :

· Pemphigus vulagris .

· Lupus erythematosus .

· Behcet’s disease .

DLE , which is a chronic skin condition of sores with inflammation and scarring favouring the face , ears , scalp . skin lesion only no oral lesion >

Up to 10% of persons with DLE eventually develop the systemic form of lupus .

Diagnosis :

- Incisional biopsy from the edge of oral ulcer that shows perivascular inflammatory infiltrate .

- Blood tests include CBC , U & E , liver enzymes , renal function

- ANA and anti-double strand DNA (dsDNA ) antibody testing are recommended.

Treatment :

There is no cure for SLE and the treatment is directed toward decreasing inflammation and the level of autoimmune activity .

Avoid exposure to chemicals , sun .

Mild or remittent disease can sometimes be safely left untreated .

Erythema Multiforme

Is common , self – limited mucocutaneous disorder , with peak incidence at the age of 20-30 yrs .

.

We have 2 types :

- EM minor ( common type )

- EM major ( uncommon type )

EM minor :

It is of acute onset that is characterised by typical target skin lesions , its itchy affects mainly extremities .

Oral lesion include cracked , bleeding , crusted lips and diffuse widely spread superficial ulceration, mainly in the anterior oral cavity .

The attack occurs one or twice a year and the condition usually resolved after 6 or 7 episodes .

The frequency of recurrence usually decrease with time .

Minor is self-limiting .

EM major :

May be related to Stevens – Johnson syndrome (SJS ) ,and toxic epidermal necrolysis (TEN) .

The sever form usually begins as febrile erosive stomatitis , sever conjunctivitis

Major is life threatening .

Aetiology :

- It is unknown aetiology .

- EM minor usually follows an antecedent herpes simplex or mycoplasma infection .

- More than 50 % of EM major is attributed to medications .

Diagnosis :

- Appearance of the skin lesion.

- Biopsy and microscopic examination of the tissue.

Treatment :

Mild form :

- Topical steroid oral rinse and gel .

- Topical anaesthetics to ease the oral pain .

- Paracetamol .

- Antihistamine to control itching .

sever form :

- Its difficult to treat .

- Oral antibiotics .

- Systemic corticosteroids .

Best wishes J

Fatemah Qooqazeh

OM Sheet #2 By Fatmeh Qooqazeh

OM Sheet #2 By Fatmeh Qooqazeh

Re: OM Sheet #2 By Fatmeh Qooqazeh