OM Sheet #5 By Zakaria Al-najjar

by **Sura** 31/10/2012, 10:48 pm

http://www.4shared.com/file/svnue-U4/oral_medicine_sheet_5.html

by **Shadi Jarrar** 15/11/2012, 6:46 pm

بسم الله الرحمن الرحيم

Necrotising ulcerative gingivitis: vincent’s disease

-It is a disease that affects the gingiva .

-When it affects only the gingiva we call it necrotizing ulcerative gingivitis.

and when it reaches the periodontium we call it necrotizing ulcerative periodontitis.

-the etiology:

It is an anaerobic bacteria that affects the marginal gingiva such as fusobacterium, spirochetes and prevotella intermedia.

-precipitating factors:

People which are mostly affected:

1. Heavy smokers

2. Poor oral hygiene

3. Upper respiratory tract infections

4. Immunocompromised (diabetes, leukemia, anemias and HIV)

5. Preexisting periodontitis.

6. Some drugs

-NUG presented clinically:

1. Pain

2. Halitosis

3. Necrosis and ulcerations along free gingival margin.

4. Loss of the interdental papillae (punched out papillae) or (crater-like ulcers)

5. Pseudomembrane

6. Redness of the gingiva

7. Bleeding upon minimal trauma.

-Diagnosis:

Smear and gram stain

-Treatment:

1. Improve the oral hygiene

2. Stop smoking

3. Drugs: metronidazole (250mg 1*3 for 5 days or one week)

Or penicillin v which is a narrow spectrum antibiotic

4. Chlorhexidine mouth washes, Very important.

5. If there is pain we can give him analgesics

6. Vitamin c

7. We remove all supra and sub gingival deposits and we do gingivoplasty ( we remove any irregularities ). This is after the resolution with metronidazole and Chlorhexidine after 48 hours .

*nutritional deficiencies also cause NUG.

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Tuberculosis :

-Tubercle bacillus is a chronic infectious granulomatous disease.

-it is transmitted by droplets that contain bacteria from infected person.

-TB divided to 2 types according to the oral manifestation:

1. Primary TB: is very rare, affects younger people, presented as single stellate painless ulcer with lymph node enlargement mostly on the tongue.

2. Secondary TB: secondary to lung TB

-The most important symptoms of TB:

1. Malaise 2.weight loss 3.fever 4.sweating 5. Cough

-So when the patient coughs most of the bacteria sticks to tongue then the mycobacterium seeds its cell in the tissues so it gives painful ulcer on dorsal lingual mucosa.

*so this is a lung TB (secondary TB) stellate single persistent chronic painful ulcer ( she talks about a pic in the slides )

- How to manage this patient- it is a contagious disease-

We take a smear and biopsy then culture it.

Ya3ny we take a sample of sputum we spread it on a slide and we stain it then we look for the mycobacterium if it is found

-The treatment is long term antibiotics for 6-9 months .(we don’t treat him we refer him to respiratory specialist )

* The primary TB affects young patients while the secondary affects the middle aged and elderly.

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Syphilis :

-It is a sexually transmitted disease

The etiology: treponema palladium spirochetes.

*if the mother is infected she transmits the disease to the fetus after 4 months of gestation -not before-

- There is three phases of syphilis

*They call it the great pretender disease because it gives wide range of symptoms that resembles other diseases symptoms.

- Primary syphilis: presented after exposure to the virus, the incubation period lasts up to 1 month.

-Then onset of a lesion occurs, which is hard, painless, punched-out lesion .that is more common at the lip then the tongue .The lesion called chancre.

*This chancre lasts for one week only, and then from 2-6 weeks the secondary stage begins.

*The primary and secondary phases of syphilis are highly contagious.

*if we only look to the lesion we can say it is syphilis or herpes labialis or squamous cell carcinoma -the differential diagnosis-

-the secondary phase:

-From 2-6 weeks

-Presented with rash and other symptoms but for oral medicine we are concerned about something called mucous patches in the oral mucosa.

-So fever, weight loss, malaise and skin rash are the symptoms.

*mucous patches are raised shallow patches on the lateral border of the tongue and the tip and the ventral surface of the tongue .they give after they are fused together what we call snail track patches (ulcers ).they call it like that because of their silvery appearance .

-Sometimes the oral lesion heals but the disease persist and progresses from primary to secondary to tertiary phase and if the patient doesn’t treated this could be fatal .it affects the heart and the brain .

-The lesion in the tertiary phase is less contagious and the lesions are granulomous called gummas and the second lesion on the tongue called syphilitic leukoplakia or syphilitic glossitis.

-The gumma affects more the hard palate and the tongue (lump with punched-out ulcer in the centre )

-This lesion if not treated may perforate the hard palate.

-Eventually this lesion (syphilitic glossitis) might lead to endarteritis obliterans which leads to ischemia then the tissues would be more susceptible to environmental carcinogens.

*So the syphilitic glossitis considered a potentially malignant lesion .

-The transition from secondary to tertiary phase might happen directly and sometimes -when the disease not discovered or not treated- it might be hidden in the body up to 15 years.

Diagnosis:

-primary phase we do scrapping to the chancre smear we look using a special instrument called dark-field microscope.

-in secondary and tertiary we take a blood sample and do serology test (fluorescent treponemal antibody absorption test (FTA-ABS) and treponema palladium particle agglutination assay (TPPA))

-if the results are positive then we have to refer the patient to venereologist.

Treatment:

-IM injection of penicillin G (1 injection or 3 injections according to the stage and severity)

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Actinomycoses:

-it is a rare, chronic disease.

-it affects more the face and neck.

-the causative bacteria is actinomyces israellii.

-this bacteria is found naturally in the nose and throat.

-in people aged between 30-60 years when they have deep periodontal pocket or fractured bone or post extraction socket this bacteria enters deep in these areas (deep pockets , extraction socket ,fractured bone especially in the mandible).

*this anaerobic bacteria needs favorable environment to grow (this is why it is rare )

-so this bacteria enters the tissues (60% in soft tissues) and gives abscess and multiple draining sinuses.

*the abscesses after a while becomes red lump, and breaks through the skin and opens as a multiple draining sinuses (these sinuses heals by scarring).

Diagnosis:

- smear of the fluid and culture of the tissues.

-positive kveim test confirms the diagnosis.

Treatment:

- Initially penicillin G injection then oral penicillin.

*it needs heavy doses of penicillin because it is difficult to enter the tissues and sinuses.

- So we need long course of oral penicillin from 6-12 months.

*if the patient allergic to penicillin we give him doxycycline.

- We must open the abscess and drain the pus.

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Acute pseudo membranous candidiasis :

-Known as thrush or moniliasis.

- It is acute fungal infection

- Candida albicans is the most common cause

- I have to check the no. of colonies to know if there is an infection or not; because 40-50% of population have Candida in the normal flora.

Precipitating factors:

a. Local factors: 1.continous use of mouth washes

2. Heavy smoking 3.poor oral hygiene 4.xerostomia

B. systemic factors: drugs and diseases that cause immunosuppresion (diabetes, leukemia, HIV, chemotherapy, immunosuppressant, cancer, irradiation.)

It presents clinically:

- It can affect any mucosa in the oral cavity

- It is a soft, creamy white patches that can be wiped off the mucosa; and the surrounding mucosa is not inflamed.

*oral thrush always combined with angular chelitis.

Diagnosis:

1. Smear and gram stain and see under the microscope to see hyphae.

2. Culture swab (saboured’s medium) and see no. of colonies.

Treatment:

· We have to know the etiology

· We have to give the patient topical antifungal such as micostatin (1*4 or 1*3) for 2-3 weeks.

· If the patient is immunocompromised we give him systemic anti fungal such as fluconazole (50 mg per day) (1 tablet for 2 weeks or 2*1 for 1 week)

· Miconazole gel for angular chelitis.

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Erythematous candidiasis:

- Two types:

1. Acute (acute atrophic candidiasis) (anbiotic sore tongue)

2. Chronic (chronic atrophic candidiasis) (denture stomatitis)

Etiology: Candida albicans

-the acute patches I can see it on the dorsal lingual mucosa, palate and buccal mucosa (depapillation of tongue)

- The acute called Erythematous and there is burning sensation

- The chronic limited to the fitting surface of upper denture.

*the median rhomboid glossitis it is raised rhomboidal atrophic erythematous lesion on dorsum of the tongue (in the past they thought that it is congenital in origin) now they consider it a type of erythematous candidiasis .

Treatment:

- Topical antifungal Miconazole oral gel.

- In the case of chronic candidiasis if the denture made of acrylic I will soak it in mannitol (sodium hypochlorite) .and if the denture is metallic I will soak it in cetavlon (10% cetrimide).

- In refractory cases we give azole-resistant fluconazole .

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Acquired immune deficiency syndrome:

- AIDS was first recognized in 1981 in young men

- 75% of new infections are transmitted heterosexually

- after infection the HIV establishes itself in the lymphocytes where it undergoes incubation period from 6 months to 2 years up to 18 years .

- The preAIDS period: the patient suffers from chills, sweats, loss of weight, diarrhea, generalized lymph nodes enlargement.

- The AIDS period: there is oral manifestation which is the first clinical manifestation.

*oral manifestations:

1. Florid candidiasis

2. Kaposi sarcoma

3. Recurent herpetic infections

4. RAS

5. burkitt-type lymphoma

6. Squamous cell carcinoma

7. Malignant melanoma

8. Hairy leukoplakia

9. NUG

*the most important systemic manifestation is: PCP (pneumocyctic pneumonia), GIT infections, and renal damage.

Diagnosis:

1. Candida smear

2. Bronchoscopy and take sample .

3. Biopsy if there is hairy leukoplakia

Treatment:

1. HAART (highly active antiretroviral therapy)

That reduces mortality and morbidity

2. Treat the opportunistic infections.

BEST WISHES,

ZAKARIA AL-NAJJAR

ORAL MEDICINE
SHEET NO.5

OM Sheet #5 By Zakaria Al-najjar

OM Sheet #5 By Zakaria Al-najjar

Re: OM Sheet #5 By Zakaria Al-najjar