Cancrum /certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Cancrum /certified fixed orthodontic courses by Indian dental academy

  2. 2. NOMA OR CANCRUM ORIS:  It is also called as gangrenous stomatitis.  Rapidly spreading gangrene.  Occur in debilitated or nutritionally deficient person.  Mainly seen in children but also occur in adults.
  3. 3. PREDISPOSING FACTORS:  A) undernourished person.  B)Debilitated person having infections like Diphtheria,dysentery,measles, pneumonia,scarlet fever,syphilis, tuberculosis and blood dyscrasias including anemia.
  4. 4.  Noma is considered as a secondary complication rather then a primary disease.  Causative organism-a)vincent‘s organism  b)secondary infection by streptococci,staphylococci and diphtheria bacilli.
  5. 5.  Selye reported the production of a noma like condition in rats as a result of simultaneous administration of cortisone and clipping of the mandibular incisor forcing the animals to chew with their gingiva and thus to cause excessive mechanical injury to mucosa.
  6. 6.  Condition usually began around the gingiva and progressed to destruction of the floor of the mouth and lower lip.  Susceptibility to tissue injury which was produced by cortisone and this can be eliminated by pituitary growth hormone.  Selye suggested that Noma may not necessarily be due to a specific pathogenic agent but may be due to a pathogenic situation.
  7. 7.  Clinical features: Start with the small ulcer in the gingival mucosa which rapidly spreads and involves the surroundings tissue of the jaws, lips ,and cheeks by gangrenous necrosis.
  8. 8.  Initial site is an area of stagnation around a fixed bridge and crown the overlying skin becomes inflamed, edematous and finally necrotic with the result that a line of demarcation develops between healthy and dead tissue,and large masses of the tissue slough
  9. 9. out leaving the jaw exposed.  The commencement of gangrene is denoted by the appearance of blackening of the skin.  Necrosis of the buccal fat pad and subcutaneous fat pad is reported.  Foul odor has arised from gangrenous tissue.
  10. 10.  Palate and tongue can also be involved by this process.  High temperature during the Course of the disease.
  11. 11.  Mortality rate:75%  Treatment:Immediate treatment of malnutrition.
  12. 12. APTHOUS STOMATITIS  Characterized by painful,recurring solitary or multiple ulceration of the oral mucosa.  Incidence-20 %to 60%.  Prevalence:higher in professional person and socioeconomic group.  Etiology-1)bacterial infection-L form streptococus isolated from lesion.  Herpes simplex virus can not be isolated. Images3.jpg
  13. 13.  2)Immunologicabnormal ities: Lehner:a)autoimmune response b)detected IgM and IgG antibody in epithelial cell of the spinous layer of the oral cavity.  Addy and dolby:normal level of complement and antinuclear factor.
  14. 14.  Cohen:a) not an autoimmune disease. b)local immune response against an antigenically altered oral mucosa.
  15. 15.  results of diffusion of bacterial toxins, food and other substance acting as allergen.  Donatsky-elevated gamma globulin level against sterptococus.  Recurrent apthous stomatitis-altered immune response which is directed against non pathogenic oral flora and host oral tissue.  4)chemical mediator
  16. 16.  5)focal release of neuropeptide.  6)viral infection.  7)deficiency of folic acid and iron-  Wray reported –after examining 330 patients  47-total deficient person  23 deficient in iron,7 deficient in folic acid,6 in vitamin B12 deficiency,11 had combined deficiency.  8)patient with malabsorption condition.
  17. 17. 12)seen in HIVpatients
  18. 18.  Precipitating factors:Trauma- Graycowaski-local trauma is an factor in 75% of the cases.  Self-inflicted bite  Oral surgical procedure  Tooth brushing  Dental procedure,needle injection and needle trauma.
  19. 19.  Endocrine condition-relationship between occurrence of the menstrual period and development of apthous ulcer.  Related with the level of progesterone  Woman have remission of disease during pregnancy.  Onset of disease associated with menopause and menarche.
  20. 20.  Psychic factors-association with acute psychological problem and stress.  Allergic factor-association with asthma hey fever,food or drug allergy.
  21. 21.  Clinical features:4 forms-1)minor 2)major 3)herpetiform 4)ulcer associated with Bechets syndrome.  Main difference between 3 groups-clinically and degree of severity.  Tingling and burning of oral mucosa before starting the treatment.
  22. 22.  Minor apthous ulcer- most commonly occurred form.  Age-10 to 30 years.  Occurrence early in life.  Disease persist with recurring attacks.  20% of population affected.  Mainly in professional school students.  Familial
  23. 23.  Ulcer will not preceded by vesicles and it appear on the tongue, buccal mucosa, floor of the mouth.  Rarely present on hard palate and attached gingiva.
  24. 24.  One or two attacks in a year,one or two attacks in a month ,never free from lesion.  Appear as a single,painful ulcer,diameter is less then .5 mm that is covered by yellow fibrinous membrane and surrounded by erythemeatous halo.
  25. 25.  Generalized edema of the oral cavity.  Parasthesia  Low grade fever  Localized lymphoadenopathy  Vesicle like lesion containing mucus.  Difficulties in eating.
  26. 26.  Common site of occurrence:buccal and labial mucosa  Buccal and lingual sulci  Soft palate,gingiva labial mucosa.
  27. 27.  Lateral and ventral surface of the tongue is also affected.
  28. 28.  Heal in 7 to 1o days without scar formation.  Oral manifestation include mucosal fissure,small multiple hyperplastic nodule on the buccle mucosa produce cobbel stone appearance.  Biopsy finding suggest nonceasenting granuloma.
  29. 29.
  30. 30.  Major apthous ulcer:most sever expression of apthous stomatitis.  1 to 10 in number present in lips,cheeks tongue, soft palate.  Painful and larger lesion and persist for longer time  Heal with scar formation.  6 weeks to heal as soon as one disappear another will appear
  31. 31.  Difficulties in eating,pain and discomfort.  Show similar lesion in vagina,penis larynx.  No particular age group,females affected more then males.
  32. 32.  Herpetiform ulcer-present as a crop of ulcers.  100 in numbers.  Palatal and gingival mucosa are involved.  Pain is present and healing will occur in 1 or 2 weeks.
  33. 33.  Here the ulcer will be preceded by vesicle and exhibit no virus infected cell.  Brooke and sapp-numerous small lesion found in oral mucosa.  Small pinhead sized erosion that gradually enlarge and coalesce  Painful lesion present for one to three years.  Immediate relief from tetracycline mouthwash.
  34. 34.  Laboratory test-no herpes simplex virus is cultured.  Absence of multinucleated giant cell.  No antibodies against herpes virus.
  35. 35.
  36. 36.
  37. 37.  Histopathology:minor apthous ulcer- fibrinopurulent membrane covering the ulcerated area.  Superficial colonies of microorganism present in this membrane.  Inflammatory cell infiltration in connective tissue.  Granulation tissue at the base of the lesion.  Epithelial proliferation at margins.
  38. 38.  Lesion begin at the excretory duct of minor salivary gland.  Wood-anitschkow cell.  Mononuclear cell in submucosa and in perivascular tissue in preulcerative stage.  In ulcerative stage-CD4and CD8 lymphocyte.
  39. 39.  Presence of macrophages and mast cells.  Differential diagnosis:1)herpes simplex infection.  Trauma.  Pemphigus vulgaris.  Mucous membrane pemphigoid.
  40. 40.  Treatment:mouth rinse-sodium bicarbonate in warm water.  Drug-prednisone-20 to 40 mg daily for a week  Topical corticosteroid.  Intralesional injection of triamicolone.  Antibiotics-tetracycline suspension.  Tetracycline mouthwash-250 mg per 5 ml used 4 times daily for 5 to 7 days .
  41. 41.  Steroid ointment-1.5 %cortisone acetate applied locally.  Hydrocortisone acetate antibiotics lozenges.  Chemical cautery.
  42. 42.  250 mg of capsule in 30 ml of warm water.(4 times in a day for 4 day)  Other drugs:azathioprine,cyclophosphamide. Thailodomide,pentixyfilline
  43. 43.
  44. 44.  BEHCETS SYNDROME:Uncertain etiology.  Pleuropnumonia like organism.  Autoimmune etiology.  Lehner-immunologic similarities between this syndrome and recurrent apthous stomatitis.
  45. 45.  Clinical features:between 10 to 45 year of age.  Oral and genital ulceration,ocular lesion,skin lesion.  Oral lesion-first occurrence  Painful and similar in appearance to recurrent apthous stomatitis.
  46. 46.  Size ranging from several millimeter to centimeter or more in diameter.  Ulcer have an erythematous border and covered by gray or yellow exudates.  Genital ulcer are small and located on scortum,root of the penis.  Ocular lesions-photophobia and irritation
  47. 47.  Simple conjunctivitis to finally uveitis and finally popyon  Skin lesions –small papules on the trunk and limbs and around the genitalia.  Involvement of CNS and cardiac and pulmonary involvement is seen.
  48. 48.
  49. 49.
  50. 50.  Histologic features-similar to recurrent apthous stomatitis.  Endothelial proliferation.  Vasculitis.  Laboratory findings: hypergammaglobulinemia leucocytosis eosinophilia elevated sedimentation rate.
  51. 51.  Treatment and prognosis-supportive treatment.  Remission after a period of months to years.  Serious complication can lead to death.
  52. 52. For more details please visit