Dental pathology

1. THE NORMAL PERIODONTIUM
 Consists of investing and supporting tissues of the
tooth
 Gingiva
 Periodontal ligament
 Alveolar Bone
 Cementum
 It is divided into two parts:
 The gingiva whose main function is protection of the
underlying tissues
 The attachment apparatus, composed of the periodontal
ligament , cementum and alveolar bone

4. Normal Periodontium

18. Types of gingivitis
Depending on course and duration
 Acute gingivitis: is of sudden onset and short
duration and can be painful
 Subacute: is less severe than acute
 Recurrent : reappears after treatment
 Chronic gingivitis: slow in onset, long
duration, usually painless and the most
common

19. Depending on distribution
 Localized or generalized : a group of teeth or
entire mouth
 Marginal : limited to the marginal gingiva
 Papillary : limited to the interdental papilla
 Diffuse : when the inflammation spreads to
the attached gingiva

23. OTHER GINGIVALINFECTIONS
Acute lesions of sudden onset, limited duration and well-defined
clinical features.
 Traumatic lesions, both physical and chemical
 Viral infections
 Bacterial infections
 Fungal infections
 Gingival abscess
 Aphthous ulcers
 Erythema multiforme
 Drug allergy

24. Traumatic lesions
Physical injury
 Mechanical or thermal
 Chemical damage
Asprin burn
Silver nitrate
Hydrogen peroxide
Careless use of caustics by dentist e.g. chlorophenol, tetra
acetic acid
–Asprin burn

25. Traumatic injuries
 The diagnosis is easy since the patient is
usually aware of the accident and suffers from
immediate and severe pain.
 A localized area of inflammation and
ulceration may form.

26.  Healing of traumatic lesions is fairly quick and begins
with epithelium covering the ulcer. Does not need
active treatment
 Healing can be complicated by secondary infection.
This may be accompanied by lymph gland
enlargement and malaise, then an antibiotic may be
needed.

27. Viral infections
 Acute herpetic gingivostomatitis
 Herpangina
 Hand foot and mouth disease
 Measles
 Herpes varicella/zoster virus infections
 Glandular fever
 HIV infection and AIDS

28. Acute herpetic gingivostomatitis
 Primary infection by the herpes simplex
virus type 1.
 Usually occurs in children (1-10) but may
affect older children or even adults
 Infection in neonates can produce
encephalitis or meningitis
 In children or adults it produces a febrile
illness or subclinical infection
 Incubation period is 5 days

29. CONT.
 Symptoms appear abruptly with fever and
temperatures as high as 39.4 C
 Lymph gland enlargement, malaise and the mouth and
throat may be painful
 Irritability in children, refusal to eat and increase
salivation
 Small vesicles form on the gingivae, tongue, buccal
mucosa and lips
 Vesicles burst and form round or irregular ulcers with
grey membrane and surrounded by a red mucosa
 There is acute gingivitis with redness swelling and
bleeding

30. Herpetic gingivostomatitis
 Symptoms subside in
10-21 days
 About 30% of patients
develop recurrent
infections later in life.
 The recurrence is
usually herpes labialis
and it is a reactivation
of the latent virus in
the trigeminal ganglion

31. Herpes labialis

32. Treatment
 Symptomatic and supportive
 In infants, milk of magnesia
 Benzocaine lozenges are useful in the older child
 Aspirin or paracetamol
 Phenergan a sedative in the child
 In severe cases acyclovir tabs 200mg four times daily or
suspension 5ml four times daily
 Acyclovir cream can be used as a preventive measure

33. Hand, foot and mouth disease
 Acute febrile illness
 Coxsackie virus A type 16
 Sporadic outbreak affecting mainly children
 Maculopapular and vesicular lesions appear on
the skin and oral mucosa
 Skin lesions affect the hands, arms and feet
 The oral vesicles break into ulcers
 Uneventful recovery in 10-14 days

35. Measles
 Severe febrile illness affecting mainly children
 Presents with fever, malaise, cough, conjunctivitis,
photophobia and lacrimation
 Blotchy macular rash
 Oral lesions present as Koplik’s spots which are
bluish-white specks surrounded by a bright red
margin on the buccal mucosa mainly
 Oral lesions precede skin lesions by a few days.
 Recovery in 2-3 weeks in healthy, fit well fed
children
 Can be serious in poor and malnourished
previously unexposed children
 Vaccination is available against measles

37. Herpes varicella/zoster virus infections
 Varicella or chickenpox is an acute febrile illness mainly
in children
 Widespread maculopapular or vesicular eruptions on the
skin
 Small vesicles also form on the oral mucosa, tongue and
gingival
 Recovery in 2-3 weeks

38.  Herpes zoster or shingles is caused by
reactivation of latent varicella virus and
common in older adults.
 Affects sensory nerves and produces severe
neuralgia
 Vesicular eruptions on the skin or mucosa
innervated by the affected sensory nerve

39. Herpes zoster

42. BACTERIAL INFECTIONS
 Acute necrotizing ulcerative gingivitis
(NUG)
 Tuberculosis
 syphilis

43. Necrotizing Ulcerative
Gingivitis

45. Syphilis
Secondary syphilis occurs 6 weeks after primary
infection and produces skin rash and oral eruption. The
ulcers are either mucous patches or snail track

47. Acute Gingival Abscess

48. GINGIVALABSCESS
 Abscess formation may follow damage by toothpick
or fish bone if the foreign object is not removed.
 Gingival abscess associated with physical damage
 can also arise from wall of a gingival pocket
where drainage has been impeded
 localized shiny, painful, red swelling and
associated teeth TTP
 may drain spontaneously or require the removal
of foreign object
 hot salt water mouthwashes and antibiotics if
systemic involvement

49. Aphthous ulcers
 Most common type of recurrent ulcerative condition
 Possible defect of cell-mediated immune response
 painful lesions which appear without any reason, last for
several days to heal and, after sometime recur
 Cause unknown but may be auto-immunity to a
component of the oral mucosa.
 Related factors may be stress and hormonal changes
 In some patients related to the menstrual cycle
 Relationship between ulceration, iron-deficiency anaemia,
folic acid deficiency and Vitamin B12

50. Three types
 minor aphthous ulcers,
 major aphthous ulcers
 herpetiform ulcers

51. MINOR APHTHOUS ULCERS
Clinical features
 Well circumscribed white-yellow round lesion with red margin
 Usually less than 5 mm in size
 Affects non-keratinized oral mucosa
 Moderate to severe pain
 Heals without scarring within 7 to 10 days
 Affected patients report a history of aphthous ulcers usually for “as
long as they can remember”

52. Management
 Inquire about type of toothpaste used SLS (sodium
lauryl sulphate)-containing toothpastes may
aggravate condition)
 Discontinue any SLS-containing toothpaste for
1month.
 Discontinue use of any mouthwash
 Rx topical steroid (e.g., fluocinonide, clobetasol) to
be applied tid as soon as prodromal Symptoms occur
(may reduce duration of ulcer by half)
 Always instruct patient to come back if ulcer not
healed after 3 weeks

53. MAJORAPHTHOUS ULCERS
Clinical features
 Larger, more severe, less common than minor
 Ulcers 10 to 30 mm in diameter
 Extremely painful, heals with scarring within weeks or even
months
 Affected patients report a history of aphthous ulcers usually
for “as long as they can remember”
 Major “aphthous-like”ulcers occur among immunosuppressed
patients (HIV+; transplant recipients) with no prior history of
aphthous ulcers

54. MANAGEMENT
Topical steroids:
 Fluocinonide ointment 0.05% mixed 1/1
with orabase B(apply tid)
 Clobetasol ointment 0.05% mixed 1/1 with orabase
B(apply tid)
 Tablets of hydrocortisone
 Treatment topical anaesthetics
 Antibacterial rinses to clear secondary bacterial
infection,
 Tetracycline caps (250mg): dissolve in 1 Tbsp water,
then rinse for 1 minute + expectorate qid

55. Copyright © 2003, Elsevier Science (USA). All rights reserved.

56. 56

58. Periodontitis
Defined as:-
“an inflammatory disease of the supporting
tissues of the teeth caused by specific micro-
organisms resulting in progressive
destruction of the periodontal ligament and
alveolar bone with pocket formation,
recession, or both”

59. Periodontitis
 Chronic periodontitis
 Aggressive periodontitis
 Periodontitis as a manifestation of systemic
diseases

61. Chronic Periodontitis
 Prevalent in adults but can occur in children
 Amount of destruction consistent with local
factors
 Associated with variable microbial pattern
 Subgingival calculus frequently found
 Slow to moderate rate of progression with
possible periods of rapid progression
 Possibly modified by: systemic factors such as
diabetes and HIV; local factors: enviromental
factors such as smoking and emotional stress

62.  Localized or generalized
 Slight – 1-2mm of clinical attachment loss
 Moderate – 3-4mm CAL
 Severe - ≥ 5mm CAL

63. Chronic periodontitis

64. Aggressive periodontitis
 Otherwise clinically healthy patient
 Rapid attachment loss and bone
destruction
 A/o microbial deposits inconsistent with
disease severity
 Familial aggregation of diseased individuals

65. Localized form
 Circumpubertal onset of disease
 Localized to first molars or incisors with
proximal attachment loss on at least two
permanent teeth one of which is a first molar

66. Generalized form
 Usually affecting persons under 30 years of
age (maybe older)
 Generalized proximal attachment loss
affecting at least three teeth other than first
molars and incisors
 Pronounced episodic nature of periodontal
destruction
 Poor serum antibody response to infecting
agents

67. Periodontitis as a manifestation of
systemic diseases
Haematological disorders
1. Acquired neutropenia
2. Leukaemias
3. Other Genetic disorders
a. Familial and cyclic neutropenia
b. Down syndrome
c. Leukocyte adhesion deficiency syndrome
d. Papillon-Lefevre syndrome
e. Chediak-Higashi syndrome
f. Histiocytosis syndromes
g. Glycogen storage disease
h. Infantile genetic agranulocytosis
i. Cohen syndrome
j. Ehlers-Danlos syndrome (types IV andVIIIAD)
k. Hypophosphatasia. etc

68. Necrotizing periodontal
diseases
 Necrotizing ulcerative gingivitis
 Necrotizing ulcerative periodontitis
Tissue necrosis is the primary clinical feature.

69. Necrotizing ulcerative
periodontitis

70. Abscesses of the
periodontium
A periodontal abscess is a localized purulent
infection of periodontal tissues and is
classified by its tissue of origin
 Gingival abscess
 Periodontal abscess
 Pericoronal abscess

71. Periodontal abscess

72. DrugAllergy
 Can be provoked by:-
 Penicillin
 Diazepam
 Local anaesthetic
 Codeine
 Tetracycline
 Barbiturates
 Others

73. Drug allergy and contact hypersensitivity
 Two types:-
 Those following systemic
administration of a drug or chemical
 Those following direct contact with
the oral mucosa

74.  Manifestation depends on the type of allergic
response provoked, ranging from simple drying
of the mouth to the most severe response,
anaphylactic shock, which is potentially fatal.
 Hypersensitivity to drugs may involve type 1, II,
III and IV mechanisms.

75. Symptoms
 Burning sensation of oral mucosa, swelling,
redness of the tongue, lips and gingivae
 Peeling epithelium leaving very sore ulcerated
areas
 Gingivae, bright red and sensitive.
 Poor oral hygiene due to the sensitivity in
brushing

76. Contact hypersensitivity
Reactions of the oral mucosa have been reported to:-
 Chewing gum
 Toothpaste
 Mouthwashes
 Sweets
 Cosmetics
 Topical anaesthetic
 Topical antibiotics
 Periodontal dressings
 Flavouring agents e.g. peppermint, menthol cinnamon and
eugenol

77. Management
 Implicated substance immediately withdrawn.
 Antihistamine
 Injection of hydrocortisone hemisuccinate
 In anaphylactic shock, intramuscular injection
of 0.5ml of 1:1000 adrenaline is necessary
 Frequent warm saline rinses.

79. DEFINITION
 PERICORONITIS (From the Greek
peri, “around”, Latin corona “crown”
and itis, “inflammation”) also known
as operculitis, is the inflammation of
soft tissues surrounding the crown of a
partially erupted tooth, including the
gingiva (gums) and the dental follicles.

80. ANATOMIC RELATIONSHIP
 The occlusal surface of an involved
tooth may be partly covered by a flap of
tissue, the operculum, which exists
during the eruption of the tooth and
may persist afterwards.
 Varying degrees of eruption,
malposition, or impaction may further
complicate the soft tissue architecture

82. CONT…
 An accumulation of bacteria and debris beneath the operculum
 Mechanical trauma (e.g. biting the operculum with the
opposing tooth).
 Often associated with partially erupted and impacted
mandibular third molars.
 Periodontal pain.
 Pulpitis from dental caries (tooth decay).
 Acute myofascial pain in the temporomandibular joint
disorder.

85. CLINICAL FEATURES
 The symptoms vary based on whether the condition is acute
or chronic.
ACUTE
 Sever pain near the back teeth
 Swelling of gum tissue due to fluid accumulation
 Pain when swallowing
 The discharge of pus

86. CHRONIC
 Bad breath
 A bad taste in the mouth
 A mild or dull ache lasting for one or two days
 Swelling of the lymph nodes in the neck
 Infection
 Fever
 Loss of appetite

87. COMPLICATIONS
 The involvement may become localized in the form of
a pericoronitis abscess.
 It may spread posteriorly into the oropharyngeal area
and medially to the base of the tongue, making
swallowing difficult.
 Involvement of sub maxillary, cervical, deep cervical
and retropharyngeal lymph nodes.

88. CONT…
 The partially erupted or impacted mandibular
third molar is the most common site of
pericoronitis.
 The space between the crown of the tooth
and overlying gingival flap is an ideal area for
the accumulation of food debris and bacterial
growth.
 An influx of the inflammatory fluid and
cellular exudates results in an increase in the
bulk of the flap.

89. CONT…
 Swelling of the cheek in the region of the angle of
the jaw and lymphadenitis.
 Mandibular movement is limited (Trismus).
 Toxic systemic complications – fever, leucocytosis
and malaise.
 Foul taste and an inability to close the jaws.
 Radiating pain to the ear, throat, and floor of the
mouth.

90. RISK FACTORS
 Occur in young adults in their mid 20s who are
experiencing poorly erupting wisdom teeth.
 Poor oral hygiene.
 Excess gum tissue.
 Fatigue and emotional stress

91. TREATMENTS
Depending on the severity of the condition, the
treatment option may vary.
 Gently flush the area with warm water or antiseptic
to remove debris and exudates
 Pain management and resolving the pericoronal
inflammation and/or infection
 Antibiotics can be prescribed in severe cases.
 Minor oral surgery to remove the overlapping
gingival tissue
 Wisdom tooth or teeth removal

92. Questions?
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