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Allergies & immunologic diseases
- 1. Allergies & Immunologic Diseases Arsalan Wahid Malik ِحَّالر ِمنْحَّالر ِهللا ِمْسِبِميم 1
- 2. Allergies & Immunologic Diseases Recurrent Aphthous Stomatitis 2
- 3. Aphthous Stomatitis • Painful recurrent mucosal ulcers • Incidence: very common (5-66%) • Pathogenesis: - immunologic basis (cytotoxic T-cells) - reduced mucosal barrier - increased antigenic exposure - hereditary predisposition • Associated local and systemic factors 3
- 5. Aphthous Stomatitis • Allergy – food, cosmetics • Genetic – HLA-B12, B51, Cw7 • Hormonal – menstrual cycle • Infectious - streptococci, herpes virus • Nutritional – iron, B12, folic acid • Local trauma – non-keratinized mucosa • Psychosomatic/stress 5
- 6. Aphthous Stomatitis Associated Systemic Diseases: • Neutropenia • Anemia • Celiac disease – gluten sensitivty • Crohn’s disease • AIDS 6
- 7. Aphthous Ulcers: • Non-keratinized mucosa • Prodrome- burning, tingling, itching • Ulceration • Yellow fibrinopurulent exudate • Peripheral erythematous halo • Pain – out of proportion to size of lesion 7
- 9. Aphthous Ulcers Clinical Types: • Minor • Major • Herpetiform 9
- 11. Minor Aphthous Ulcers • Most common – 80% • Age: childhood – adolescence • Gender: female > male • Size: 0.3-1.0 cm • Number: 1-5 lesions • Duration: 7-14 days • Site: buccal and labial mucosa • Heal without scarring • Recurrences: variable (weeks – years) 11
- 13. Major Aphthous Ulcers • Rare –10% • Age: adolescence • Size: 1-3 cm • Number: 1-10 lesions • Duration: 2-6 weeks • Site: labial mucosa, soft palate, tonsil fauces • Heal with scarring – deep seated • Recurrence: frequent – persistent 13
- 15. Herpetiform Aphthous Ulcers: • Rare – 10% • Age: adulthood • Gender: female • Size: 0.1-0.3 cm (clusters) • Number: multiple - up to 100 • Duration: 7-10 days • Site: any mucosal surface • Heal without scarring • Recurrence: frequent, closely spaced 15
- 16. Aphthous Ulcers Histology: • Non-specific • Ulceration • Fibrinopurulent exudate • Granulation tissue • Acute and chronic inflammation • Leukocytoclastic vasculitis (vascular damage caused by nuclear debris from infiltrating neutrophils) 16
- 18. Aphthous Ulcers Management: • Mild aphthosis may require no therapy or some anesthetics • Main stay of therapy is corticosteroids • 0.01% dexamethasone elixir (Epodex N) in rinse and expectorate method • 0.05% betamethasone (betacin) gel • 0.05% flucinonide (TOP-Gel MCA) gel 18
- 19. Aphthous Ulcers Management: • Intralesion injection of triamcinolone acetonide (kenacort) – 40 mg. 1 ml ampule one OD • 0.05% clobetasol proprionate gel • 0.05% halobetasol propionate gel • Triamcinolone tablets dissolved over the lesion 19
- 20. Aphthous Ulcers Management: • In hard to reach areas like tonsillar pillars, beclomethasone spray is used • Alternative therapies – Acyclovir ( Aclova 200mg) TID – Chlorhexidine ( Enziclore rinse) – Colchicine – Cyclosporine (Consuprin) 25/100 mg – Dapsone – Thalidomide 20
- 21. Aphthous Stomatitis Associated Systemic Disorders • Behcet’s syndrome • Celiac disease • Neutropenia • Nutritional deficiency • Immunodeficiency • Crohn’s disease • Ulcerative colitis • Magic syndrome (Mouth and genital ulcers with inflamed cartilage syndrome) • PFAPA syndrome (periodic fevers with aphthous stomatitis, pharyngitis, and adenitis) • Reiter’s disease • Sweet’s syndrome • Ulcus vulvae acutum 21
- 22. Allergy & Immunologic Diseases Behcet’s Syndrome 22
- 23. Behcet’s Syndrome • Ocular inflammation-orogenital ulcerations • Etiology: immunologic basis • Environmental triggers – infection, toxins • Genetic: HLA – Bw51 • Age: 3rd decade • Gender: male : female (5:1) 23
- 24. Behcet’s Syndrome • Multisystem disorder • Mucous membranes • Cutaneous involvement • Ocular involvement • Joints - arthritic • Central nervous system - neurologic • Vasculitis - systemic - cardiovascular, gastrointestinal, lungs, renal 24
- 25. Behcet’s Syndrome Oral Involvement: • Occurs in 99% of cases • In 25-75% is first manifestation of disease • Aphthous ulcerations (40% - major) • 6 or more lesions, frequent recurrences • Site: soft palate – oropharynx • Irregular ragged deep seated ulcers • Large zone of erythema 25
- 26. Behcet’s Syndrome • Ocular lesions - 70 – 85% of patients, male predilection - uveitis, conjunctivitis, corneal ulceration - pain, blindness, cataracts, glaucoma 26
- 27. Behcet’s Syndrome • Genital ulcerations - 75% of patients - deep seated scar, recur less frequently • Cutaneous lesions -pustules -pyoderma -erythema -cutaneous pathergy (skin hyper-reactivity) 27
- 28. Behcet’s Syndrome • Arthritis - self limiting - non-deforming - knees, wrists, elbows, ankles • Neurologic - occurs in 10-25% of cases - paralysis, dementia - poor prognosis • Systemic vasculitis - multiple organ systems 28
- 29. Behcet’s Syndrome Histology: • Leukocytoclastic vasculitis • Neutrophilic infiltration • Erythrocyte extravasation • Fibrinoid necrosis • Ulceration 29
- 30. Behcet’s Syndrome • Treatment: - topical or systemic steroids - systemic immunosuppressive drugs • Clinical course: - highly variable - remitting and relapsing - resolution over 5 to 7 years • Prognosis: - good, low mortality - neurologic and vascular complications 30
- 32. Sarcoidosis • Multi-system granulomatous disease • Etiology: immunodysregulation • Antigenic exposure: mycobacteria • Incidence: uncommon, southeastern U.S. • Race: Blacks (10:1) • Gender: female > male • Age: 20-40 years 32
- 33. Sarcoidosis • Pulmonary • Lymph nodes • Skin • Eyes • Salivary glands • Lacrimal glands • Bone • Central nervous system • Cardiovascular 33
- 34. Sarcoidosis • Acute or insidious onset • Dyspnea, cough, chest pain • Fever, fatigue, malaise, weight loss • Salivary enlargement – sicca syndrome • Hepatosplenomegaly • 20% are asymptomatic 34
- 35. Sarcoidosis Ocular Involvement: • 25% of cases • Uveitis • Glaucoma • Lacrimal enlargement • Keratoconjunctivitis sicca 35
- 36. Sarcoidosis Oral Involvement: • Uncommon • Mucosal lesions • Submucosal swelling or mass lesion • Bone destruction • Periodontitis • Salivary enlargement • Sicca syndrome - xerostomia 36
- 37. Heerfordt’s Syndrome • Parotid enlargement • Facial paralysis • Anterior uveitis • Fever 37
- 38. Sarcoidosis Histology: • Granulomatous inflammation • Epitheliod histiocytes • Lymphocytes • Multinucleated giant cells • Negative for organisms and foreign material 38
- 40. Sarcoidosis Diagnosis: • Clinical findings • Radiographic findings – chest x-ray, bone lesions • Clinical laboratory findings • Biopsy - lymph node - minor salivary gland - parotid - noncaseating granulomas 40
- 41. Sarcoidosis Clinical Laboratory Findings: • Elevated serum angiotensin converting enzyme (ACE) • Hypercalcemia • Elevated serum alkaline phosphatase • Elevated (ESR) • Eosinophilia • Leukopenia, thrombocytopenia, anemia 41
- 42. Sarcoidosis • Treatment: Corticosteroids • Prognosis: - variable clinical course - 60% resolve spontaneously - 20% resolve with steroids - 4-10% mortality - pulmonary, cardiac, CNS complications 42
- 43. Allergies & Immunologic Diseases Wegener’s Granulomatosis 43
- 44. Wegener’s Granulomatosis • Systemic necrotizing vasculitis • Granulomatous inflammation • Etiology: immunologically mediated • Incidence: rare • Genetic predisposition • Fatal clinical course if untreated 44
- 45. Wegener’s Granulomatosis • Upper respiratory tract – nose and sinuses • Lower respiratory tract – lungs • Renal – glomerulonephritis • Skin, eyes, ears • Variable clinical behavior • Disseminated • Localized - superficial 45
- 46. Wegener’s Granulomatosis Clinical Presentation: • Systemic symptoms - fever • Pulmonary -cough -hemoptysis - dyspnea - chest pain 46
- 47. Wegener’s Granulomatosis Oral Involvement: • 6% of cases • Strawberry gingivitis – early manifestation • Mucosal ulcerations • Bone destruction – tooth mobility • Palatal perforation • Salivary enlargement • Pain, poor wound healing 47
- 49. Wegener’s Granulomatosis Renal Involvement: • Occurs late in disease course • Proteinuria • Hematuria • Red cell casts • Renal failure • Most common cause of death 49
- 50. Wegener’s Granulomatosis Diagnosis: • Clinical findings • Radiographic changes • Biopsy • Clincal laboratory findings - antineutrophil cytoplasm antibodies (cANCA) - serum creatinine, urinalysis 50
- 51. Wegener’s Granulomatosis Histology: • Vasculitis – small arteries and veins • Transmural inflammation • Necrotizing Granulomatous inflammation -histiocytes -multinucleated giant cells -neutrophils, lymphocytes, eosinophils 51
- 52. Wegener’s Granulomatosis • Treatment: - Cyclophosphamide (immunomodulator) - Steroids - Immunosuppressive drugs • Prognosis: - Early recognition and treatment are critical - Prolonged remissions are typical - Fatal if untreated – renal failure 52
- 53. Allergies & Immunologic Diseases Allergic Mucosal Reactions to Systemic Drug Administration (Stomatitis Medicamentosa) 53
- 55. Allergic Drug Reaction • Incidence: common • Numerous offending medications • Increased use of medications • Oral vesiculoulcerative lesions • Pain, mucosal erythema, ulcerations • Variable reaction patterns 55
- 56. Allergic Drug Reaction Clinical Patterns: • Lichenoid mucositis • Erythema multiforme • Lupus erythematosus-like reaction • Pemphigus-like reaction • Fixed drug eruption • Anaphylactic stomatitis 56
- 57. Allergic Drug Reaction • Diagnosis: - medical history - temporal relationship - serial elimination of drugs - biopsy • Treatment: - discontinue medication - topical steroids 57
- 58. Allergic Drug Reaction • Diagnosis: - medical history - temporal relationship (the timing of the relationship between a factor and an outcome. It is one of the criteria used to assign causality to a relationship) - serial elimination of drugs - biopsy • Treatment: - discontinue medication - topical steroids 58
- 59. Allergies & Immunologic Diseases Allergic Contact Stomatitis 59
- 60. Allergic Contact Stomatitis • Contact hypersensitivity reaction • Incidence: relatively rare • Numerous offending agents • Gender: female > male • Oral vesiculoulcerative lesions • Burning pain • Erythema, ulceration, keratosis • Cheilitis – perioral dermatitis 60
- 61. Allergic Contact Stomatitis Causative Agents: • Foods - chewing gum – cinnamon • Dentifrices – tartar control • Mouthwashes • Topical anesthetics • Dental materials 61
- 62. Allergic Contact Stomatitis • Diagnosis: - careful history - temporal relationship – elimination - biopsy – lichenoid and perivascular pattern - allergy testing • Treatment: - eliminate allergen - topical steroids, antihistamines 62
- 63. Allergies & Immunologic Diseases Contact Stomatitis From Artificial Cinnamon Flavoring 63
- 64. Contact Reaction to Cinnamon • Candy • Chewing gum • Toothpaste • Mouthwashes • Dental floss • Breath fresheners • Beverages • Confectioneries • Processed meats 64
- 65. Contact Reaction to Cinnnamon • Incidence: common • Artificial flavoring – high concentrations • Prolonged frequent contact with mucosa • Site: buccal mucosa, lateral tongue • Symptoms: pain, burning • Lesions: erythematous, erosive, hyperkeratotic 65
- 66. Contact Reaction to Cinnamon • Histology: - lichenoid and perivascular inflammation • Treatment: - recognize and discontinue exposure - resolution within one week - recurrence within 24 hours - biopsy 66
- 67. Allergies & Immunologic Diseases Contact Reaction to Dental Amalgam 67
- 68. Dental Amalgam • Mercury • Silver • Tin • Copper • Zinc • Palladium 68
- 69. Reaction to Dental Amalgam • Incidence: rare (1/1,000,000) • 1-2% of patients with mercury allergy • Hypersensitivity (rare direct toxicity) • Mercury is most frequent antigen • Site: buccal mucosa, lateral tongue, gingiva • Direct contact – does not migrate • Asymptomatic – periodic erosion 69
- 70. Reaction to Dental Amalgam • Lichenoid Inflammation • Treatment: - plaque control/oral hygiene - polishing/recontouring - replace restoration • Resolves with removal of restoration • Biopsy 70