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Acute pharyngitis

This document summarizes various oral manifestations of systemic diseases. It describes acute pharyngitis caused by viruses like rhinovirus or bacteria like streptococcus. It then discusses diphtheritic pharyngitis caused by Corynebacterium diphtheriae. Finally, it provides a detailed overview of oral manifestations of various infectious diseases including herpes, tuberculosis, syphilis, and fungal infections; connective tissue disorders like Sjogren's syndrome and lupus; and other conditions such as oral cancer. The document serves as a comprehensive reference for oral signs of systemic illness.

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Acute Pharyngitis Acute Diphtheritic Pharyngitis Oral Manifestations of Systemic Diseases
Acute Pharyngitis • Definition: This is a commonest variety of sore throat & usually associated with cold. It is common and important prodormal manifestetion of Measles, Typoid, Influenza, etc. • Aetiology: Viruses: Rhino-, Adenovirus, Influenza A & B viruses, Enterovirus, etc. Bacterial: Haemolytic, Streptococcus, Haemophilus influenzae, Pneumococcus, etc.
Clinical Features: 1. Mild (Simple): sore throat, malase, fever, head ache, ear ache, cervical lymphnodes, congested mucosa, oedema & sometimes ulcers. 2. Severe (Septic): t – 102 – 105°f, rigor, pulse, oedema palate & uvula, mucopurulent, exudate, otatis media, laryngitis.
Complications: • Pneumonia • Laryngitis • Laryngotracheatis • Bronchitis • Septicaemia • Pleurisy • Pericarditis • Nephritis • Meningitis
Treatment: - Symptomatic with bed rest, analgesics, plenty of fluid, etc. - If a significant bacterial complications has occurred, antibiotics are indicated. - In case of complications, treatment should be directed accordingly.
Acute Diphtheritic Pharyngitis: - A severe infection due to the gram +ve bacillus (corynebacterium diphtheriac). - Children are particularly affected, between 2- 5 years. - Mode of transmission – droplet. - Incubetion period: 2-7 days.
Clinical features: - Onset is insidious. - Sore throat. - t: 99 – 101°f. - Malase. - Headache. - False membrane on the tonsils, pillars, soft palate, posterior ph. Wall. - Colour of membrane, usually gray may be white or dark brown.
Continued … …… - Firmly attached to the mucosa. - Leaves the bleeding surface when it is removed, after which quickly reforms. - It may spread to lkarynx, causing complete obstruction, may need tracheostomy. - Blood mixed nasal discharge. - Cervical lymphnodes, tender.
Complications: - Toxaemia - Myocarditis - Arrythmias Cerculetory fealure Death - Neurological complications - After 3-6 weeks - Paralysis soft palate, diaphragm, external occular muscles.
Differential Diagnosis: - Acute Tonsillitis - Infectious mononeuclosis - I.P. – 5-7 weeks - Hepato -, splenomegaly. - Rubelliform rashes - Accute Manifestation of leukaemia - Agranulocytosis.
Treatment: 1. Antitoxin (20,000 – 120,000 units) 2. Benzyl Penicilin (600 – 1200 mg) 6 hourly 3. Rest 4. Tracheostomy – if needed.
Oral Manifestations of Systemic Diseases: • Oral cavity- window to the body • Lesions of oral mucosa, tongue, gingiva, dentition, periodontium, salivary gland, facial skeleton, & extraoral skin • Appropriate diagnosis & treatment
Classification 1.Systemic Infectious diseases 2.Connective tissue disorders 3.Granulomatous diseases 4.Gastrointestinal diseases 5.Respiratory diseases 6.Haematological diseases 7.Endocrine diseases 8.Neurologic diseases 9.Nutritional deficiency 10.Immunodeficiency diseases 11.Drug reactions/radiotherapy 12.Dermatological diseases 13.Metabolic disorders 14.Neoplastic diseases
Infective diseases 1.Viral infection 2.Bacterial infection 3.Fungal infection 4.Protozoal infection
Viral infections 1.Herpes Simplex Stomatitis 2.Herpes Zoster 3.Herpangina 4.Hand Foot Mouth Disease 5.Cytomegalovirus Infection 6.Measles 7.Infectious Mononucleosis 8.Mumps 9.HIV
Viral infections 1.Herpes Simplex Stomatitis 2.Herpes Zoster 3.Herpangina 4.Hand Foot Mouth Disease 5.Cytomegalovirus Infection 6.Measles 7.Infectious Mononucleosis 8.Mumps 9.HIV
Herpes Simplex Stomatitis • HSV-1: Primary herpetic Gingivostomatitis Recurrent herpes labialis • HSV-2: • Primary herpetic Gingivostomatitis: -most frequent cause of acute stomatitis in children -varies in severity, many infections -subclinical -misdiagnosed as “teething” -malaise, anorexia, irritability, fever, anterior cervical lymphadenopathy, diffuse, purple, boggy gingivitis -multiple vesicles scarred ulcers(1-3mm) -occasionally in adults
• Diagnosis: -clinically -scrapping or smears from the lesion -immunofluorescent staining -exfoliative cytology- typical multinucleated giant cells • Treatment: -symptomatic -acyclovir (systemic)-severe cases
• Recurrent Intraoral Herpes Simplex Infection: -may affect healthy individual -persistent lesions in immunocompromised -chronic ulcer, raised, white border -esp. at sites of trauma -acyclovir
Herpes zoster (Shingles) • Reactivation of Varicella –Zoster virus • Predisposing factor: Immunocompromised status • One dermatome affected (trigeminal nerve) • Unilateral • Ulcers in the distribution of dermatome • Mandibular nerve: ulceration of one side of tongue, floor of the mouth, lower labial & buccal mucosa • Maxillary nerve: one side of palate, the upper gingiva, buccal sulcus • Lesions persists for 2-3 wks Lesions on lips and chin
• Herpes Zoster Oticus (Ramsay Hunt Syndrome) • Ophthalmic Herpes Zoster • Post Herpetic Neuralgia • Diagnosis: clinically • Treatment: -Analgesics -Antivirals(within 72 hrs of onset of the lesions):acyclovir, famciclovir, valacyclovir, & gabapentin
Herpangina • Common in children • Coxsackie virus group A, Enteroviruses(30 & 71) • Self limiting vesicular eruptions in the oropharynx eg. soft palate, uvula, tonsillar pillars, posterior pharyngeal wall • Similar to herpes simplex except the lesions more commonly in oropharynx rather than oral cavity • Diagnosis: Clinically • Treatment: Supportive
Hand, Foot and Mouth Disease • Enterovirus 71,Coxsackie viruses, some untypeable enteroviruses • Young children • Vesicular eruption in the oral cavity & oropharynx dysphagia, dehydration • Vesicles on the hands & feet • Pyrexia, malaise, vomiting • Short lived(5-8 days) • Diagnosis: clinically • Treatment: supportive
Infectious Mononucleosis • Acute, self limiting, systemic viral infection • Epstein-Barr Virus • Typical presentation: acute sore throat & tender cervical lymphadenopathy • Glandular disease • Kissing disease • Children & young adults • Prodromal symptoms: 4-5 days, anorexia, malaise, fatigue, headache
• Clinical features:- Oral manifestations - early and common- palatal petechiae, uvular edema, tonsillar exudate, gingivitis, & rarely ulcers -Generalized lymphadenopathy, hepatosplenomegaly, maculopapular skin rash • Laboratory tests: Heterophile antibody(Paul Bunnel test, Monospot test) • Treatment: -Mild to moderate cases: Symptomatic -Severe disease: Famciclovir • Anti-EBV compounds: Maribavir • Ampicillin based antibiotics should be avoided
Cytomegalovirus Infection • Relatively rare • Cytomegalovirus (CMV) • HIV infection and immunocompromised • Clinical features: asymptomatic Oral lesions -nonspecific painful ulcerations-gingiva & tongue -Enlargement of parotid & submandibular glands, dry mouth, fever, malaise, myalgia, headache • Laboratory tests: HPE/Immunochemistry • Treatment: -Resolve spontaneously -Ganciclovir (Persistent case)
Measles (Rubeola) • Paramyxovirus • Highly contagious • Coryza, conjunctivitis & generalised cutaneous erythematous rashes • Oral cavity lesions: Pharyngotonsillitis Koplik’s spot: small, spotty, exanthematous lesions on buccal mucosa • Vaccination program
Mumps • Common viral illness • Incubation period: 2-3 weeks • Fever, malaise, myalgia, headache, & painful parotid gland swelling • Self limiting • Complications: SNHL • Diagnosis: Clinical • Treatment: Supportive
Bacterial Infections 1. Tuberculosis 2. Syphilis 3. Leprosy
Tuberculosis • Chronic, granulomatous, infectious disease • Mycobacterium tuberculosis • Clinical features: Oral lesions – rare secondary to pulmonary tuberculosis • Pharynx- not common Primary infection (Tonsils, Adenoids) Secondary to coughing heavily of infected sputum • Ulcer: multiple, painful, irregular, undermined border, granulating floor, usually covered by a gray-yellowish exudate, inflamed & indurated surrounding tissue
• Dorsum of the tongue - most commonly affected- lip, buccal mucosa, & palate • TB Esophagitis: -swallowed sputum or direct spread from adjacent lymph nodes -stricture, fistula, mucosal irregularities • Granulomatous Cheilitis- rare • Laboratory tests: Sputum culture, HPE, CXR • Treatment: ATT
Syphilis • Treponema pallidum -Acquired -Congenital 1. Primary Syphilis 2. Secondary Syphilis 3. Tertiary Syphilis
Primary Syphilis • Lips, tongue, buccal mucosa, & tonsils • Site of inoculation- 3 weeks after the infection, Papule, breaks down to form an ulcer (chancre) • Oral chancre: painless ulcer with a smooth surface, raised borders, & indurated margin • Non tender cervical lymphadenopathy • Spontaneous healing
Secondary Syphilis • Most infectious • Secondary stage – after 6–8 weeks & lasts for 2-10 weeks • Clinical features: Malaise, low-grade fever, headache, lacrimation, sore throat, weight loss, myalgia,arthralgia, & generalized lymphadenopathy Mucous patches
• Hyperemia and inflammation of pharynx & soft palate • Snail Track ulcer :- -Oral cavity & oropharnyx -Ulcerated lesion covered with grayish white membrane which when scraped has pink base with no bleeding
Syphilitic Pharyngitis • May be congenital or acquired by sexual intercourse • Secondary stage most likely • HIV positive patients
Tertiary Syphilis • Tertiary syphilis - after a period of 4–7 years • Typically painless • No lymphadenopathy unless secondary infection • Gumma: -Characteristic lesion -Hard palate, Nasal septum, Tonsil, PPW, or Larynx • VDRL may be negative
Congenital Syphilis Early: first 3 months of life, manifest as snuffles nasal discharge purulent Late: Manifest at puberty Gummatous lesion • Oral lesions: high-arched palate, short mandible, Hutchinson’s teeth, and Moon’s or mulberry molars
Diagnosis: 1.Immunoflurorescence or dark field microscopy 2. Biopsy 3.Serology Non-treponemal antibody tests: -VDRL, RPR -For screening and treatment follow up Treponema specific antibody tests: -FTA-ABS test, TPHA -For confirmation -Usually remains positive for life Treatment: Penicillin( DOC) Ceftriaxone, Erythromycin, or Doxycycline
Leprosy • Mycobacterium Leprae • Optimum temperature growth-less than body temp preference for skin, mucosa & superficial nerve • Transmission- nasal discharge • Both Humoral & cellular immune response • Clinically- Chronic granulomatous disease skin, peripheral nerve & nasal mucosa
• Nasopharynx to oropharynx: Granulomatous lesion, ulcers, healing with fibrosis • Larynx: -Lesion like TB & Syphilis -Supraglottic- mainly epiglottis, aryepiglottic folds -Epiglottis : hollow rod, mucosa studded with tiny nodules- laryngeal stenosis & airway obstruction Diagnosis: Punch biopsy, nasal scrapings (skin lesions & ear lobules) Treatment: Dapsone, Rifampicin &/or Clofazimine
Protozoal infection 1. Toxoplasmosis 2. Leshmaniasis
Toxoplasmosis • Toxoplasm gondii • Zoonosis • Self limiting • Immunocompetent: asymptomatic • Immunocompromised: sore throat, malaise, fever, cervical lymphadenopathy Multiple organs involvement (lungs, liver, skin, spleen, myocardium, eyes, skeletal muscles, brain
• Transplacental infection: about 45 % subclinical infection- intrauterine death • Diagnosis: serological • Treatment: -usually unnecessary -combination of pyrimethamine & sulphadiazine
Leshmaniasis involving Lips
Fungal infection 1. Candidiasis 2. Histoplasmosis 3. Cryptococcosis 4. Aspergillosis 5. Mucormycosis 6. Paracoccidomycosis 7. Blastomycosis
Systemic Mycoses • Chronic fungal infections • Histoplasmosis (Histoplasma capsulatum) • Blastomycosis (Blastomyces dermatitidis) • Cryptococcosis (Cryptococcus neoformans) • Paracoccidioidomycosis(Paracoccidioides brasiliensis) • Aspergillosis (Aspergillus species) • Mucormycosis (Mucor, Rhizopus)
• Predisposing conditions: -Immunocompromised status eg. HIV infection • Clinical features: – Oral lesions – rare – chronic, irregular ulcer • Candidiasis rarely produces ulcers • Deep mycosis: chronic lumps & ulcers
• Rhinocerebral Mucormycosis: -typically commences in the nasal cavity or paranasal sinuses invade the palate (black necrotic ulceration) • Laboratory tests: Smear and histopathological examination • Treatment: Amphotericin B, Itraconazole, Ketoconazole, & Fluconazole
Collagen-Vascular & Granulomatous Disorders 1. Sjogren’s Syndrome 2. Systemic Lupus Erythematous (SLE) 3. Scleroderma 4. Dermatomyositis-Polymyositis 5. Sarcoidosis 6. Wegner’s Granulomatosis 7. Behcet’s Syndrome 8. Reiter’s Syndrome 9. Sweet Syndrome 10. Cogan’s Syndrome 11. Amyloidosis 12. Kawasaki Disease 13. Rheumatoid Arthritis (RA) 14. Polyarteritis Nodusa (PAN) 15. Sturge- Weber Syndrome 16. Ehlers-Danlos Syndrome 17. Cowden’s Disease
Sjogren’s Syndrome • Autoimmune • Female • Primary Sjogren’s Syndrome: • Secondary Sjogren’s Syndrome: associated with RA, SLE, Scleroderma, Polymyositis, Polyarteritis Nodusa • Presents with xerostomia & parotid enlargement • Oral findings: -Due to decreased salivadysphagia, disturbances in taste & speech, burning pain of mouth & tongue, increased dental caries, increased predisposition to infection (candidiasis)
• Mucosal changes: dry, red & wrinkled mucosa • Fissured tongue, atrophy of tongue papillae and redness of tongue, cracked & ulcerated lips Diagnosis: -Minor salivary gland biopsy (mucosa of lower lip) -Periductal lymphocytic infiltrate -Serum: Autoantibodies (ANA, antilacrimal & antithyroid antibodies, RA factor) Treatment : -Steroid & immunossuppresive drugs -Artificial saliva -Constant dental evaluation
Systemic Lupus Erythematosus(SLE) • Approx. one quarter of SLEoral lesions • Oral lesions: superficial ulcers with surrounding erythema • Lips & all oral mucosal surfaces • Periodontal diseases, xerostomia
Scleroderma • Deposition of collagen in the tissues or around nerves & vessels • Difficulty in opening mouth(due to fibrosis of masticatory muscles), immobility of tongue, dysphagia, xerostomia • Telangiectasia: lips, oral mucosa • Association with Sjogren’s Syndrome & CREST Syndrome(Calcinosis, Raynaud’s phenomena, Esophageal hypomotility, & Sclerodactly)
Kawasaki disease • Mucocutaneous lymph node syndrome • Vasculitis- medium & large arteries • Children <5 yrs of age • High grade fever • Cardiovascular complications • Oral findings: swelling of papillae on the surface of tongue(strawberry tongue), erythema of the buccal mucosa & lips Lips are cracked, cherry red, swollen & hemorrhagic
Laboratory tests: polymorphonuclear leukocytosis, thrombocytosis, raised ESR & CRP Diagnosis: 4 out of 6 clinical features with evidence of coronary dilatation 1.Fever persisting>5 days 2.Bilateral conjunctival congestion 3.Erythema of lips, buccal mucosa & tongue 4.Acute non-purulent cervical lymphadenopathy 5.Polymorphous exanthema 6.Erythema of palms & soles (edemadesquamation) Treatment: Aspirin, IVIg Steroid avoided- risk of worsening coronary artery dilatation
Wegener’s Granulomatosis • Rare chronic granulomatous disease • Immunological • Clinical features: necrotizing granulomatous lesions of the respiratory tract, generalized focal necrotizing vasculitis, and necrotizing glomerulitis • Oral lesions: solitary or multiple irregular ulcers, surrounded by an inflammatory zone • Tongue, palate, buccal mucosa & gingiva • Laboratory tests: HPE, c-ANCA • Treatment: Steroids, Azathioprine, & Cyclophosphamide
Sarcoidosis • Systemic granulomatous disease • Any organ • Noncaseating granuloma: -characteristic lesion • Oral manifestations: multiple, nodular, painless ulceration of the gingiva, buccal mucosa, tongue, lips, & palate • Salivary gland swelling • Diagnosis: Biopsy • Treatment: Systemic steroids
Behcet’s Syndrome • Chronic, multisystemic inflammatory disorder • Triad of symptoms: Aphthous ulcers, Genital ulcers & Ocular lesions (uveitis, conjunctivits, keratitis) • Etiology – unclear • Immunogenetic basis • Clinical features - common in males • Onset -20–30 years age
Rheumatoid Arthritis • Progressive destruction of articular & periarticular structure eg. TMJ • TMJ pathology: clicking, locking, crepitus, tenderness in the preauricular area, pain during mandibular movement • Oral cavity involvement-not common • Association with secondary Sjogren’s Syndrome • Immunosuppressive drugsacute stomatitis, candidiasis, recurrent HSV infection
Reiter’s Syndrome • Triggered by infectious agent in genetically susceptible • Young male (20-30 yrs) • Characterized by conjunctivitis, asymmetric lower extremity arthritis, non-gonococcal urethritis, circinate balanitis, keratoderma blennorrhagia • Mnemonic : “can’t see, can’t pee, can’t climb a tree” • Oral lesions: papules & ulcerations on the buccal mucosa, gingiva, palate, & lips • Lesions on the tongue mimic geographical tongue • Diagnosis: HPE • Treatment: Systemic steroid, NSAID
Hematological Diseases 1. Iron Deficiency Anaemia 2. Sickle Cell Anaemia 3. Langerhans Cell Histiocytosis 4. Osler-Weber-Rendu disease (HHT) 5. Plummer-Vinson Syndrome 6. Leukaemia 7. Agranulocytosis 8. Myelodysplastic Syndrome 9. Cyclic Neutropenia 10. Idiopathic Thrombocytopenic Purpura 11. Multiple Myeloma
Iron Deficiency Anaemia • Oral manifestations: Atrophic glossitis, mucosal pallor, angular stomatitis, flattening of tongue papillae, geographic glossitis
Leukaemia • Etiology- genetic & environmental factors (viruses, chemicals, radiation) • Clinical features: Leukaemia– acute & chronic, myeloid or lymphocytic • All forms - Oral manifestations • Oral lesions: -Ulcerations, spontaneous gingival hemorrhage, petechiae, ecchymosis, tooth loosening, & gingival hypertrophy • Laboratory tests: Peripheral blood smear, bone-marrow examination • Treatment: Chemotherapy, bone-marrow transplantation, supportive therapy
Osler-Weber-Rendu Disease (Hereditary Hemorrhagic Telangiectasia) • Autosomal dominant • Telangiectasia of dorsum of tongue, oral cavity, buccal mucosa, lips, palate & nasal mucosa • Apparent at puberty • Lung, liver, & GI tract arterio-venous malformations • Treatment: regular iron therapy, laser therapy
Plummer Vinson Syndrome (Patterson-Brown-Kelly Syndrome) • Oral manifestations: Dysphagia, iron def. anaemia, atrophic glossitis, angular stomatitis, & koilonychia • Female, in fourth decade • Barium swallow: web in post-cricoid region • Pre-malignant Post-cricoid carcinoma • Treatment: -Esophageal dilatation (if symptoms from web) -Follow up-developing carcinoma
Idiopathic Thrombocytopenic Purpura (ITP) • Oral lesions may be the first manifestation of this condition • Petechiae, ecchymoses, & haematoma anywhere on the oral mucosa • Spontaneous bleeding from the gingiva • Treatment: -Systemic steroids, Splenectomy
Agranulocytosis • Etiology: Drug or infection • Clinical features: Oral lesions -multiple necrotic ulcers covered with dirty pseudomembrane • Buccal mucosa, tongue, palate, & tonsillar area • Severe necrotizing gingivitis • Laboratory tests: White blood count & bone-marrow aspiration • Treatment: Antibiotics, white blood cell transfusions, granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF)
Gastrointestinal Diseases 1.Inflammatory Bowel Disease (Crohn’s disease & Ulcerative colitis) 2.Gastro-esophageal Reflux 3.Peutz-Jegher’s Syndrome 4.Celiac disease 5.Chronic liver disease 6.Malabsorption Diseases
Crohn’s Disease • Diffuse nodular swelling in lips (painless), angular cheilitis, cobblestone appearance of buccal mucosa or mucosal tag, Aphthous ulcer • May precede intestinal symptoms or may be the only manifestations in some cases • Systemic steroids
Ulcerative Colitis • Destructive oral ulceration due to immune mediated vasculitis • Polystomatitis Vegetans: microabscess on lips, palate, ventral tongue • May manifests as aphthous ulcers • Exacerbation & remission
Gastroesophageal Reflux Disease • Mucosal & gingival erosion caused by acid • Erosion of tooth enamel
Endocrine Diseases 1. Diabetes Mellitus 2. Thyroid Disorders 3. Cushing’s Disease 4. Addison’s Disease
Diabetes Mellitus • Oral manifestations- variable & nonspecific • Fungal & bacterial infection • Gingivitis, periodontitis, xerostomia, glossodynia, taste change • Rx: Control of DM Antiobiotic/Antifungal • Oral hygiene
Thyroid Diseases • Hypothyroidism: Macroglossia • Congenital Hypothyroidism: Macroglossia, pronounced lips, & delayed tooth eruption with malocclusion • Hyperthyroidism: Facial & skin manifestations: upper eyelid retraction, exophthalmous, hyperpigmentation, & skin erythema Oral manifestations: early loss of primary teeth with subsequent rapid eruption of permanent teeth(young children) lymphoid tissue hyperplasia- tonsillar & oropharynx (Grave’s disease)
Cushing’s Syndrome • Long term, high dose corticosteroid administration • Moon or round face, buffalo humps, central obesity, osteoporosis, DM, HTN • Oral symptoms: -Increased susceptibility to oral infections (candidiasis) -Muscle weakness difficulty with speaking, & swallowing Dx: Dexamethasone suppression test Rx: Depends on the cause
Addison’s Disease • Primary adrenal insufficiency • Destruction of adrenal cortex eg. autoimmune, metastasis, infection, haemorrhage • Oral manifestations: diffuse or patchy pigmentation of the skin & mucous membranes (due to increased ACTH-cross reacts with melanin receptors) • Buccal mucosa, palate, lips, & gingiva • Diagnosis: ACTH test • Treatment: Replace steroid (glucocorticoid/mineralocorticoid)
Renal Disease (Uraemic Stomatitis) • Painful plaques and crust on buccal mucosa, dorsum of tongue, & floor of mouth covered with gray pseudomembrane exudate, & painful ulcers • Bleeding diathesis: inhibited platelet aggregation eg. petechiae, ecchymoses • Irritation & chemical injury of mucosa-ammonium compounds • Xerostomia, unpleasant taste, burning mouth, uriniferous breath odour • A/W with acute rise in blood urea nitrogen • Heal spontaneously after resolution of uraemic state eg. after hemodialysis
Dermatologic Conditions 1. Lichen Planus 2. Pemphigus Vulgaris 3. Mucous Membrane Pemphigoid 4. Erythema Multiforme 5. Stevens-Jhonson Syndrome 6. Toxic Epidermal Necrolysis
Lichen Planus • Chronic, mucocutaneous, autoimmune disorder • Precipitating factors: genetic predisposition, stress, drug, food • Oral manifestations: White papules -coalesce, forming a network of lines (Wickham’s striae) • Buccal mucosa, gingiva, & tongue, lips & palate
• Skin lesions: Pruritic papules-flexor surface of extremities • Malignant transformation • Diagnosis: -Clinically -Histopathological examination • Treatment: -No treatment- asymptomatic lesions -Topical steroids & Systemic steroids
Pemphigus Vulgaris • Autoimmune disease • Antibodies against desmoglein3 (antigen) • Disassociation of the epithelium at suprabasal layer with acantholysis • Bullous lesionsrupturespainful bleeding ulcers • Oral, ocular mucosa, & skin • Palate, gingiva, tongue • Diagnosis: -Nikolsky’s sign:(+) new lesions develops after pressure applied to asymptomatic oral mucosa -HPE -Direct immunofluorescence
• Treatment: Systemic steroids & immunosuppressive agents (eg. mycophenolate mofetil) Paraneoplastic Pemphigus: • Occurs in association with underlying neoplasms eg. Lymphoproliferative disease or thymoma • Often partial response to systemic steroids
Mucous Membrane Pemphigoid • Antigen: Human alpha-6 integrin • Oral manifestations- recurrent vesicles or bullae (persists longer than pemphigus) that rupture, leaving large, superficial painful ulcers • Gingival involvement - desquamative gingivitis characterised by erythematous, sore gingivae • Diagnosis: Biopsy • Treatment: topical steroid/systemic immunosuppressive drugs
Erythema Multiforme • Skin and mucous membranes • Immunologically mediated • Triggered by: infective agents (eg. HSV), drugs (sulphonamides, barbiturates), food additives or chemical, immunization ( BCG,HBV) • Oral lesions: begins as erythematous areablisterrupturesirregular painful ulcers • Lips, buccal mucosa, tongue, soft palate, & floor of mouth • Skin manifestations: erythematous, flat, round macules, papules, or plaques, usually in a symmetrical pattern- target or iris like lesions • HPE & Immunostaining • Treatment: supportive, systemic steroids
Stevens–Johnson Syndrome • Severe form of erythema multiforme, involving oral mucous membrane, eyes, & genital area • Etiology: Drugs (salicylates, sulfonamides, penicillin, barbiturates,carbamazepine, phenytoin etc.) • oral lesions - vesicle formation, followed by painful erosions - grayish-white or hemorrhagic pseudomembranes - extend to the pharynx, larynx, and esophagus • Ulceration of skin & mucosal surfaces(eg. mouth, urethra, conjunctiva, & lungs) • Typical target lesions on palms & soles with blistering in the centre • Diagnosis: Clinical presentation • Treatment: -self limiting -Supportive, & Systemic steroids
Toxic Epidermal Necrolysis • Severe skin & mucous membrane disease • Etiology: Drugs • Clinical features: low-grade fever, malaise, arthralgia, conjunctival burning sensation, skin tenderness, & erythemablisters appear-skin - lifted up - whole body surface appears scalded • Nikolsky’s sign –positive • Oral manifestations: diffuse erythema, vesicles and painful erosions - lips & periorally, buccal mucosa, tongue, & palate • Diagnosis: Clinically • Treatment: Systemic steroids, antibiotics, fluids, and electrolytes
Neurologic Diseases 1. Parkinson’s Disease 2. Alzheimer’s Disease 3. Bell’s Palsy 4. Mobius syndrome 5. Melkersson-Rosenthal Syndrome 6. Guillain-Barre Syndrome 7. Bulbar palsy 8. Multiple Sclerosis 9. Myasthenia Gravis 10. Myotonic Muscular Dystrophy 11. Tuberous Sclerosis
Parkinson’s Disease • Extrapyramidal symptoms • Loss of facial expression • Difficulty with mastication, slow speech, & tremors of head, lips, & tongue • Esophageal dysmotility & dysphagia • Impaired lip seal drooling fungal infection of lip commissure (angular cheilitis)
Alzheimer’s Disease • Dementia • Inability to perform self care (oral hygiene)- self neglect & loss of cognitive and motor skills • Poor oral hygiene- increased prevalence of dental plaque, dental caries, & gingival bleeding
Multiple Sclerosis • Demyelination of central nervous system • Remitting & exacerbating course • Loss of muscle coordination, weakness of the tongue, & loss of upper extremity severely impairs orodental hygiene • Trigeminal neuralgia- also common characterized by excruciating, unilateral pain of the lips, gingiva, or chin triggered by contact with certain areas of the face, lips, or tongue
Bell’s Palsy • Idiopathic unilateral lower motor neuron palsy (7th cranial nerve) • Lack of control of the muscles of facial expressiondistortion of facial appearance • Loss of functional ability of cheek & lips (affected side)poor oro-dental hygiene
Melkersson-Rosenthal Syndrome • Characterized by -unilateral facial palsy, recurrent facial swelling, & lingua plicata (fissured tongue)
Nutritional Deficiency • Vitamins & trace elements 1. Inadequate intake 2. Impaired digestion & absorption 3. Increased losses
• Vitamin A deficiency: -Dyskeratotic changes of the skin & mucous membranes -Angular cheilitis -Defects in the dentin & enamel of developing teeth • Vitamin B2 (Riboflavin) deficiency: -Angular cheilitis -Burning pain in the lips, mouth, & tongue • Vitamin B3 (Niacin) deficiency (Pellagra): -Dermatitis, dementia,& diarrhoea -Oral manifestations: glossitis (red, swollen) & stomatitis, burning tongue
• Vitamin B6 deficiency: -Peripheral neuropathy -Oral lesions-similar to pellagra (i.e. glossitis & stomatitis) • Vitamin C deficiency (Scurvy): -Cofactor for collagen synthesis -Weakened vessels are responsible for petechiae, ecchymoses, delayed wound healing • Deficiency of Vitamin B12 & Folic acid: -Megaloblastic anemia -Oral findings: angular cheilitis, recurrent aphthous ulcers, & glossitis
• Vitamin D deficiency & Calcium deficiency: -Calcium metabolism -Mandibular osteopenia/osteoporosis, enamel hypoplasia • Vitamin k deficiency: -Haemorrhagic diathesis -Oral haemorrhagic bullae • Zinc deficiency: -Taste changes -Acrodermatitis Enteropathica: angular cheilitis, ulcers, glossitis, crusting, scaling of the lips as well as ulcers, erosions & fissures
Oral lesions associated with HIV • Early recognition, diagnosis, & treatment of HIV associated oral lesions - reduce morbidity • Oral lesions- -Early diagnostic indicator of HIV infection -Stage of HIV infection -Predictor of the progression of HIV disease
Oral lesions associated with HIV • Fungal Infection: Bacterial Infection: -Candidiasis -Linear Gingival Erythema -Histoplasmosis -Necrotizing Ulcerative Periodontitis -Cryptococcosis -Mycobacterium Avium Complex • Viral Infection: Neoplastic: -Herpes simplex -Kaposi’s Sarcoma -Herpes zoster -Non-Hodgkin’s Lymphoma -HPV Infection Others: -CMV Infection -Recurrent Aphthous Ulcers -Hairy Leukoplakia -Salivary Gland Disease
Human Papilloma Virus Infection • Oral warts (papillomas), skin warts, & genital warts – HPV(types 7,13,& 32) Clinical Features: • Arises from Stratified squamous epithellium, painless, exophytic, numerous finger like projections-cauliflower like appearance • Tongue, gingiva, & palate • Biopsy- Histologic diagnosis • Treatment: -Surgical removal -Laser (CO2 laser)
Hairy Leukoplakia • Epstein Barr virus • Common, characteristic lesion-HIV infection • White, asymptomatic, raised, corrugated, unremovable patch on lateral marigns of tongue • The surface is irregular and may have prominent folds or projections, sometimes markedly resembling hairs • Lateral margins may spread to dorsum of tongue • Diagnosis: Biopsy • Treatment: -Usually asymptomatic-Rx not required -Antiviral(Aciclovir/valaciclovir)
Kaposi’s Sarcoma • Most common malignancy in HIV (+Ve) • Human Herpes Virus-8(KSHV) • Derived from capillary endothelial cells • Occur intraorally, either alone or in a/w skin & disseminated lesions (lymph nodes, salivary gland) • Intraorally- hard palate, buccal mucosa, & gingiva -bluish, purple or red patches or papulesnodular, ulcerate & bleed • Diagnosis: Biopsy • Treatment: -Low dose radiation & chemotherapy (eg.Vinblastine) -Surgical excision (eg.CO2 laser) -Immunotherapy (Interferon)
Non-Hodgkin’s Lymphoma • Etiology: Unknown, genetic & environmental factors (viruses, radiation) • Clinical features: – Both sexes - any age – Lymph nodes involved – Oral lesions - part of a disseminated disease, or the only sign • Oral Lymphoma: diffuse, painless swelling, which may or may not be ulcerated -soft palate, the posterior part of the tongue, the gingiva, & the tonsillar area • HPE & Immunohistochemical examn • Treatment: Radiotherapy & chemotherapy
Salivary gland Disease • Xerostomia– generalised enlargement of parotid glands • Lymphoepithelial cysts- parotid gland
Acute pharyngitis

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Acute pharyngitis

  • 1.
    Acute Pharyngitis AcuteDiphtheritic Pharyngitis Oral Manifestations of Systemic Diseases
  • 2.
    Acute Pharyngitis •Definition: This is a commonest variety of sore throat & usually associated with cold. It is common and important prodormal manifestetion of Measles, Typoid, Influenza, etc. • Aetiology: Viruses: Rhino-, Adenovirus, Influenza A & B viruses, Enterovirus, etc. Bacterial: Haemolytic, Streptococcus, Haemophilus influenzae, Pneumococcus, etc.
  • 3.
    Clinical Features: 1.Mild (Simple): sore throat, malase, fever, head ache, ear ache, cervical lymphnodes, congested mucosa, oedema & sometimes ulcers. 2. Severe (Septic): t – 102 – 105°f, rigor, pulse, oedema palate & uvula, mucopurulent, exudate, otatis media, laryngitis.
  • 4.
    Complications: • Pneumonia • Laryngitis • Laryngotracheatis • Bronchitis • Septicaemia • Pleurisy • Pericarditis • Nephritis • Meningitis
  • 5.
    Treatment: - Symptomaticwith bed rest, analgesics, plenty of fluid, etc. - If a significant bacterial complications has occurred, antibiotics are indicated. - In case of complications, treatment should be directed accordingly.
  • 6.
    Acute Diphtheritic Pharyngitis: - A severe infection due to the gram +ve bacillus (corynebacterium diphtheriac). - Children are particularly affected, between 2- 5 years. - Mode of transmission – droplet. - Incubetion period: 2-7 days.
  • 7.
    Clinical features: -Onset is insidious. - Sore throat. - t: 99 – 101°f. - Malase. - Headache. - False membrane on the tonsils, pillars, soft palate, posterior ph. Wall. - Colour of membrane, usually gray may be white or dark brown.
  • 8.
    Continued … …… - Firmly attached to the mucosa. - Leaves the bleeding surface when it is removed, after which quickly reforms. - It may spread to lkarynx, causing complete obstruction, may need tracheostomy. - Blood mixed nasal discharge. - Cervical lymphnodes, tender.
  • 9.
    Complications: - Toxaemia - Myocarditis - Arrythmias Cerculetory fealure Death - Neurological complications - After 3-6 weeks - Paralysis soft palate, diaphragm, external occular muscles.
  • 10.
    Differential Diagnosis: -Acute Tonsillitis - Infectious mononeuclosis - I.P. – 5-7 weeks - Hepato -, splenomegaly. - Rubelliform rashes - Accute Manifestation of leukaemia - Agranulocytosis.
  • 11.
    Treatment: 1. Antitoxin(20,000 – 120,000 units) 2. Benzyl Penicilin (600 – 1200 mg) 6 hourly 3. Rest 4. Tracheostomy – if needed.
  • 12.
    Oral Manifestations ofSystemic Diseases: • Oral cavity- window to the body • Lesions of oral mucosa, tongue, gingiva, dentition, periodontium, salivary gland, facial skeleton, & extraoral skin • Appropriate diagnosis & treatment
  • 13.
    Classification 1.Systemic Infectiousdiseases 2.Connective tissue disorders 3.Granulomatous diseases 4.Gastrointestinal diseases 5.Respiratory diseases 6.Haematological diseases 7.Endocrine diseases 8.Neurologic diseases 9.Nutritional deficiency 10.Immunodeficiency diseases 11.Drug reactions/radiotherapy 12.Dermatological diseases 13.Metabolic disorders 14.Neoplastic diseases
  • 14.
    Infective diseases 1.Viralinfection 2.Bacterial infection 3.Fungal infection 4.Protozoal infection
  • 15.
    Viral infections 1.HerpesSimplex Stomatitis 2.Herpes Zoster 3.Herpangina 4.Hand Foot Mouth Disease 5.Cytomegalovirus Infection 6.Measles 7.Infectious Mononucleosis 8.Mumps 9.HIV
  • 16.
    Viral infections 1.HerpesSimplex Stomatitis 2.Herpes Zoster 3.Herpangina 4.Hand Foot Mouth Disease 5.Cytomegalovirus Infection 6.Measles 7.Infectious Mononucleosis 8.Mumps 9.HIV
  • 17.
    Herpes Simplex Stomatitis • HSV-1: Primary herpetic Gingivostomatitis Recurrent herpes labialis • HSV-2: • Primary herpetic Gingivostomatitis: -most frequent cause of acute stomatitis in children -varies in severity, many infections -subclinical -misdiagnosed as “teething” -malaise, anorexia, irritability, fever, anterior cervical lymphadenopathy, diffuse, purple, boggy gingivitis -multiple vesicles scarred ulcers(1-3mm) -occasionally in adults
  • 18.
    • Diagnosis: -clinically -scrapping or smears from the lesion -immunofluorescent staining -exfoliative cytology- typical multinucleated giant cells • Treatment: -symptomatic -acyclovir (systemic)-severe cases
  • 19.
    • Recurrent IntraoralHerpes Simplex Infection: -may affect healthy individual -persistent lesions in immunocompromised -chronic ulcer, raised, white border -esp. at sites of trauma -acyclovir
  • 20.
    Herpes zoster (Shingles) • Reactivation of Varicella –Zoster virus • Predisposing factor: Immunocompromised status • One dermatome affected (trigeminal nerve) • Unilateral • Ulcers in the distribution of dermatome • Mandibular nerve: ulceration of one side of tongue, floor of the mouth, lower labial & buccal mucosa • Maxillary nerve: one side of palate, the upper gingiva, buccal sulcus • Lesions persists for 2-3 wks Lesions on lips and chin
  • 21.
    • Herpes ZosterOticus (Ramsay Hunt Syndrome) • Ophthalmic Herpes Zoster • Post Herpetic Neuralgia • Diagnosis: clinically • Treatment: -Analgesics -Antivirals(within 72 hrs of onset of the lesions):acyclovir, famciclovir, valacyclovir, & gabapentin
  • 22.
    Herpangina • Commonin children • Coxsackie virus group A, Enteroviruses(30 & 71) • Self limiting vesicular eruptions in the oropharynx eg. soft palate, uvula, tonsillar pillars, posterior pharyngeal wall • Similar to herpes simplex except the lesions more commonly in oropharynx rather than oral cavity • Diagnosis: Clinically • Treatment: Supportive
  • 23.
    Hand, Foot andMouth Disease • Enterovirus 71,Coxsackie viruses, some untypeable enteroviruses • Young children • Vesicular eruption in the oral cavity & oropharynx dysphagia, dehydration • Vesicles on the hands & feet • Pyrexia, malaise, vomiting • Short lived(5-8 days) • Diagnosis: clinically • Treatment: supportive
  • 24.
    Infectious Mononucleosis •Acute, self limiting, systemic viral infection • Epstein-Barr Virus • Typical presentation: acute sore throat & tender cervical lymphadenopathy • Glandular disease • Kissing disease • Children & young adults • Prodromal symptoms: 4-5 days, anorexia, malaise, fatigue, headache
  • 25.
    • Clinical features:- Oral manifestations - early and common- palatal petechiae, uvular edema, tonsillar exudate, gingivitis, & rarely ulcers -Generalized lymphadenopathy, hepatosplenomegaly, maculopapular skin rash • Laboratory tests: Heterophile antibody(Paul Bunnel test, Monospot test) • Treatment: -Mild to moderate cases: Symptomatic -Severe disease: Famciclovir • Anti-EBV compounds: Maribavir • Ampicillin based antibiotics should be avoided
  • 26.
    Cytomegalovirus Infection •Relatively rare • Cytomegalovirus (CMV) • HIV infection and immunocompromised • Clinical features: asymptomatic Oral lesions -nonspecific painful ulcerations-gingiva & tongue -Enlargement of parotid & submandibular glands, dry mouth, fever, malaise, myalgia, headache • Laboratory tests: HPE/Immunochemistry • Treatment: -Resolve spontaneously -Ganciclovir (Persistent case)
  • 27.
    Measles (Rubeola) •Paramyxovirus • Highly contagious • Coryza, conjunctivitis & generalised cutaneous erythematous rashes • Oral cavity lesions: Pharyngotonsillitis Koplik’s spot: small, spotty, exanthematous lesions on buccal mucosa • Vaccination program
  • 28.
    Mumps • Commonviral illness • Incubation period: 2-3 weeks • Fever, malaise, myalgia, headache, & painful parotid gland swelling • Self limiting • Complications: SNHL • Diagnosis: Clinical • Treatment: Supportive
  • 29.
    Bacterial Infections 1.Tuberculosis 2. Syphilis 3. Leprosy
  • 30.
    Tuberculosis • Chronic,granulomatous, infectious disease • Mycobacterium tuberculosis • Clinical features: Oral lesions – rare secondary to pulmonary tuberculosis • Pharynx- not common Primary infection (Tonsils, Adenoids) Secondary to coughing heavily of infected sputum • Ulcer: multiple, painful, irregular, undermined border, granulating floor, usually covered by a gray-yellowish exudate, inflamed & indurated surrounding tissue
  • 31.
    • Dorsum ofthe tongue - most commonly affected- lip, buccal mucosa, & palate • TB Esophagitis: -swallowed sputum or direct spread from adjacent lymph nodes -stricture, fistula, mucosal irregularities • Granulomatous Cheilitis- rare • Laboratory tests: Sputum culture, HPE, CXR • Treatment: ATT
  • 32.
    Syphilis • Treponemapallidum -Acquired -Congenital 1. Primary Syphilis 2. Secondary Syphilis 3. Tertiary Syphilis
  • 33.
    Primary Syphilis •Lips, tongue, buccal mucosa, & tonsils • Site of inoculation- 3 weeks after the infection, Papule, breaks down to form an ulcer (chancre) • Oral chancre: painless ulcer with a smooth surface, raised borders, & indurated margin • Non tender cervical lymphadenopathy • Spontaneous healing
  • 34.
    Secondary Syphilis •Most infectious • Secondary stage – after 6–8 weeks & lasts for 2-10 weeks • Clinical features: Malaise, low-grade fever, headache, lacrimation, sore throat, weight loss, myalgia,arthralgia, & generalized lymphadenopathy Mucous patches
  • 35.
    • Hyperemia andinflammation of pharynx & soft palate • Snail Track ulcer :- -Oral cavity & oropharnyx -Ulcerated lesion covered with grayish white membrane which when scraped has pink base with no bleeding
  • 36.
    Syphilitic Pharyngitis •May be congenital or acquired by sexual intercourse • Secondary stage most likely • HIV positive patients
  • 37.
    Tertiary Syphilis •Tertiary syphilis - after a period of 4–7 years • Typically painless • No lymphadenopathy unless secondary infection • Gumma: -Characteristic lesion -Hard palate, Nasal septum, Tonsil, PPW, or Larynx • VDRL may be negative
  • 38.
    Congenital Syphilis Early: first 3 months of life, manifest as snuffles nasal discharge purulent Late: Manifest at puberty Gummatous lesion • Oral lesions: high-arched palate, short mandible, Hutchinson’s teeth, and Moon’s or mulberry molars
  • 39.
    Diagnosis: 1.Immunoflurorescence ordark field microscopy 2. Biopsy 3.Serology Non-treponemal antibody tests: -VDRL, RPR -For screening and treatment follow up Treponema specific antibody tests: -FTA-ABS test, TPHA -For confirmation -Usually remains positive for life Treatment: Penicillin( DOC) Ceftriaxone, Erythromycin, or Doxycycline
  • 40.
    Leprosy • MycobacteriumLeprae • Optimum temperature growth-less than body temp preference for skin, mucosa & superficial nerve • Transmission- nasal discharge • Both Humoral & cellular immune response • Clinically- Chronic granulomatous disease skin, peripheral nerve & nasal mucosa
  • 41.
    • Nasopharynx tooropharynx: Granulomatous lesion, ulcers, healing with fibrosis • Larynx: -Lesion like TB & Syphilis -Supraglottic- mainly epiglottis, aryepiglottic folds -Epiglottis : hollow rod, mucosa studded with tiny nodules- laryngeal stenosis & airway obstruction Diagnosis: Punch biopsy, nasal scrapings (skin lesions & ear lobules) Treatment: Dapsone, Rifampicin &/or Clofazimine
  • 42.
    Protozoal infection 1.Toxoplasmosis 2. Leshmaniasis
  • 43.
    Toxoplasmosis • Toxoplasmgondii • Zoonosis • Self limiting • Immunocompetent: asymptomatic • Immunocompromised: sore throat, malaise, fever, cervical lymphadenopathy Multiple organs involvement (lungs, liver, skin, spleen, myocardium, eyes, skeletal muscles, brain
  • 44.
    • Transplacental infection: about 45 % subclinical infection- intrauterine death • Diagnosis: serological • Treatment: -usually unnecessary -combination of pyrimethamine & sulphadiazine
  • 45.
  • 46.
    Fungal infection 1.Candidiasis 2. Histoplasmosis 3. Cryptococcosis 4. Aspergillosis 5. Mucormycosis 6. Paracoccidomycosis 7. Blastomycosis
  • 47.
    Systemic Mycoses •Chronic fungal infections • Histoplasmosis (Histoplasma capsulatum) • Blastomycosis (Blastomyces dermatitidis) • Cryptococcosis (Cryptococcus neoformans) • Paracoccidioidomycosis(Paracoccidioides brasiliensis) • Aspergillosis (Aspergillus species) • Mucormycosis (Mucor, Rhizopus)
  • 48.
    • Predisposing conditions: -Immunocompromised status eg. HIV infection • Clinical features: – Oral lesions – rare – chronic, irregular ulcer • Candidiasis rarely produces ulcers • Deep mycosis: chronic lumps & ulcers
  • 49.
    • Rhinocerebral Mucormycosis: -typically commences in the nasal cavity or paranasal sinuses invade the palate (black necrotic ulceration) • Laboratory tests: Smear and histopathological examination • Treatment: Amphotericin B, Itraconazole, Ketoconazole, & Fluconazole
  • 50.
    Collagen-Vascular & GranulomatousDisorders 1. Sjogren’s Syndrome 2. Systemic Lupus Erythematous (SLE) 3. Scleroderma 4. Dermatomyositis-Polymyositis 5. Sarcoidosis 6. Wegner’s Granulomatosis 7. Behcet’s Syndrome 8. Reiter’s Syndrome 9. Sweet Syndrome 10. Cogan’s Syndrome 11. Amyloidosis 12. Kawasaki Disease 13. Rheumatoid Arthritis (RA) 14. Polyarteritis Nodusa (PAN) 15. Sturge- Weber Syndrome 16. Ehlers-Danlos Syndrome 17. Cowden’s Disease
  • 51.
    Sjogren’s Syndrome •Autoimmune • Female • Primary Sjogren’s Syndrome: • Secondary Sjogren’s Syndrome: associated with RA, SLE, Scleroderma, Polymyositis, Polyarteritis Nodusa • Presents with xerostomia & parotid enlargement • Oral findings: -Due to decreased salivadysphagia, disturbances in taste & speech, burning pain of mouth & tongue, increased dental caries, increased predisposition to infection (candidiasis)
  • 52.
    • Mucosal changes:dry, red & wrinkled mucosa • Fissured tongue, atrophy of tongue papillae and redness of tongue, cracked & ulcerated lips Diagnosis: -Minor salivary gland biopsy (mucosa of lower lip) -Periductal lymphocytic infiltrate -Serum: Autoantibodies (ANA, antilacrimal & antithyroid antibodies, RA factor) Treatment : -Steroid & immunossuppresive drugs -Artificial saliva -Constant dental evaluation
  • 53.
    Systemic Lupus Erythematosus(SLE) • Approx. one quarter of SLEoral lesions • Oral lesions: superficial ulcers with surrounding erythema • Lips & all oral mucosal surfaces • Periodontal diseases, xerostomia
  • 54.
    Scleroderma • Depositionof collagen in the tissues or around nerves & vessels • Difficulty in opening mouth(due to fibrosis of masticatory muscles), immobility of tongue, dysphagia, xerostomia • Telangiectasia: lips, oral mucosa • Association with Sjogren’s Syndrome & CREST Syndrome(Calcinosis, Raynaud’s phenomena, Esophageal hypomotility, & Sclerodactly)
  • 55.
    Kawasaki disease •Mucocutaneous lymph node syndrome • Vasculitis- medium & large arteries • Children <5 yrs of age • High grade fever • Cardiovascular complications • Oral findings: swelling of papillae on the surface of tongue(strawberry tongue), erythema of the buccal mucosa & lips Lips are cracked, cherry red, swollen & hemorrhagic
  • 56.
    Laboratory tests: polymorphonuclearleukocytosis, thrombocytosis, raised ESR & CRP Diagnosis: 4 out of 6 clinical features with evidence of coronary dilatation 1.Fever persisting>5 days 2.Bilateral conjunctival congestion 3.Erythema of lips, buccal mucosa & tongue 4.Acute non-purulent cervical lymphadenopathy 5.Polymorphous exanthema 6.Erythema of palms & soles (edemadesquamation) Treatment: Aspirin, IVIg Steroid avoided- risk of worsening coronary artery dilatation
  • 57.
    Wegener’s Granulomatosis •Rare chronic granulomatous disease • Immunological • Clinical features: necrotizing granulomatous lesions of the respiratory tract, generalized focal necrotizing vasculitis, and necrotizing glomerulitis • Oral lesions: solitary or multiple irregular ulcers, surrounded by an inflammatory zone • Tongue, palate, buccal mucosa & gingiva • Laboratory tests: HPE, c-ANCA • Treatment: Steroids, Azathioprine, & Cyclophosphamide
  • 58.
    Sarcoidosis • Systemicgranulomatous disease • Any organ • Noncaseating granuloma: -characteristic lesion • Oral manifestations: multiple, nodular, painless ulceration of the gingiva, buccal mucosa, tongue, lips, & palate • Salivary gland swelling • Diagnosis: Biopsy • Treatment: Systemic steroids
  • 59.
    Behcet’s Syndrome •Chronic, multisystemic inflammatory disorder • Triad of symptoms: Aphthous ulcers, Genital ulcers & Ocular lesions (uveitis, conjunctivits, keratitis) • Etiology – unclear • Immunogenetic basis • Clinical features - common in males • Onset -20–30 years age
  • 60.
    Rheumatoid Arthritis •Progressive destruction of articular & periarticular structure eg. TMJ • TMJ pathology: clicking, locking, crepitus, tenderness in the preauricular area, pain during mandibular movement • Oral cavity involvement-not common • Association with secondary Sjogren’s Syndrome • Immunosuppressive drugsacute stomatitis, candidiasis, recurrent HSV infection
  • 61.
    Reiter’s Syndrome •Triggered by infectious agent in genetically susceptible • Young male (20-30 yrs) • Characterized by conjunctivitis, asymmetric lower extremity arthritis, non-gonococcal urethritis, circinate balanitis, keratoderma blennorrhagia • Mnemonic : “can’t see, can’t pee, can’t climb a tree” • Oral lesions: papules & ulcerations on the buccal mucosa, gingiva, palate, & lips • Lesions on the tongue mimic geographical tongue • Diagnosis: HPE • Treatment: Systemic steroid, NSAID
  • 62.
    Hematological Diseases 1.Iron Deficiency Anaemia 2. Sickle Cell Anaemia 3. Langerhans Cell Histiocytosis 4. Osler-Weber-Rendu disease (HHT) 5. Plummer-Vinson Syndrome 6. Leukaemia 7. Agranulocytosis 8. Myelodysplastic Syndrome 9. Cyclic Neutropenia 10. Idiopathic Thrombocytopenic Purpura 11. Multiple Myeloma
  • 63.
    Iron Deficiency Anaemia • Oral manifestations: Atrophic glossitis, mucosal pallor, angular stomatitis, flattening of tongue papillae, geographic glossitis
  • 64.
    Leukaemia • Etiology-genetic & environmental factors (viruses, chemicals, radiation) • Clinical features: Leukaemia– acute & chronic, myeloid or lymphocytic • All forms - Oral manifestations • Oral lesions: -Ulcerations, spontaneous gingival hemorrhage, petechiae, ecchymosis, tooth loosening, & gingival hypertrophy • Laboratory tests: Peripheral blood smear, bone-marrow examination • Treatment: Chemotherapy, bone-marrow transplantation, supportive therapy
  • 65.
    Osler-Weber-Rendu Disease (HereditaryHemorrhagic Telangiectasia) • Autosomal dominant • Telangiectasia of dorsum of tongue, oral cavity, buccal mucosa, lips, palate & nasal mucosa • Apparent at puberty • Lung, liver, & GI tract arterio-venous malformations • Treatment: regular iron therapy, laser therapy
  • 66.
    Plummer Vinson Syndrome (Patterson-Brown-Kelly Syndrome) • Oral manifestations: Dysphagia, iron def. anaemia, atrophic glossitis, angular stomatitis, & koilonychia • Female, in fourth decade • Barium swallow: web in post-cricoid region • Pre-malignant Post-cricoid carcinoma • Treatment: -Esophageal dilatation (if symptoms from web) -Follow up-developing carcinoma
  • 67.
    Idiopathic Thrombocytopenic Purpura(ITP) • Oral lesions may be the first manifestation of this condition • Petechiae, ecchymoses, & haematoma anywhere on the oral mucosa • Spontaneous bleeding from the gingiva • Treatment: -Systemic steroids, Splenectomy
  • 68.
    Agranulocytosis • Etiology:Drug or infection • Clinical features: Oral lesions -multiple necrotic ulcers covered with dirty pseudomembrane • Buccal mucosa, tongue, palate, & tonsillar area • Severe necrotizing gingivitis • Laboratory tests: White blood count & bone-marrow aspiration • Treatment: Antibiotics, white blood cell transfusions, granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF)
  • 69.
    Gastrointestinal Diseases 1.InflammatoryBowel Disease (Crohn’s disease & Ulcerative colitis) 2.Gastro-esophageal Reflux 3.Peutz-Jegher’s Syndrome 4.Celiac disease 5.Chronic liver disease 6.Malabsorption Diseases
  • 70.
    Crohn’s Disease •Diffuse nodular swelling in lips (painless), angular cheilitis, cobblestone appearance of buccal mucosa or mucosal tag, Aphthous ulcer • May precede intestinal symptoms or may be the only manifestations in some cases • Systemic steroids
  • 71.
    Ulcerative Colitis •Destructive oral ulceration due to immune mediated vasculitis • Polystomatitis Vegetans: microabscess on lips, palate, ventral tongue • May manifests as aphthous ulcers • Exacerbation & remission
  • 72.
    Gastroesophageal Reflux Disease • Mucosal & gingival erosion caused by acid • Erosion of tooth enamel
  • 73.
    Endocrine Diseases 1.Diabetes Mellitus 2. Thyroid Disorders 3. Cushing’s Disease 4. Addison’s Disease
  • 74.
    Diabetes Mellitus •Oral manifestations- variable & nonspecific • Fungal & bacterial infection • Gingivitis, periodontitis, xerostomia, glossodynia, taste change • Rx: Control of DM Antiobiotic/Antifungal • Oral hygiene
  • 75.
    Thyroid Diseases •Hypothyroidism: Macroglossia • Congenital Hypothyroidism: Macroglossia, pronounced lips, & delayed tooth eruption with malocclusion • Hyperthyroidism: Facial & skin manifestations: upper eyelid retraction, exophthalmous, hyperpigmentation, & skin erythema Oral manifestations: early loss of primary teeth with subsequent rapid eruption of permanent teeth(young children) lymphoid tissue hyperplasia- tonsillar & oropharynx (Grave’s disease)
  • 76.
    Cushing’s Syndrome •Long term, high dose corticosteroid administration • Moon or round face, buffalo humps, central obesity, osteoporosis, DM, HTN • Oral symptoms: -Increased susceptibility to oral infections (candidiasis) -Muscle weakness difficulty with speaking, & swallowing Dx: Dexamethasone suppression test Rx: Depends on the cause
  • 77.
    Addison’s Disease •Primary adrenal insufficiency • Destruction of adrenal cortex eg. autoimmune, metastasis, infection, haemorrhage • Oral manifestations: diffuse or patchy pigmentation of the skin & mucous membranes (due to increased ACTH-cross reacts with melanin receptors) • Buccal mucosa, palate, lips, & gingiva • Diagnosis: ACTH test • Treatment: Replace steroid (glucocorticoid/mineralocorticoid)
  • 78.
    Renal Disease (UraemicStomatitis) • Painful plaques and crust on buccal mucosa, dorsum of tongue, & floor of mouth covered with gray pseudomembrane exudate, & painful ulcers • Bleeding diathesis: inhibited platelet aggregation eg. petechiae, ecchymoses • Irritation & chemical injury of mucosa-ammonium compounds • Xerostomia, unpleasant taste, burning mouth, uriniferous breath odour • A/W with acute rise in blood urea nitrogen • Heal spontaneously after resolution of uraemic state eg. after hemodialysis
  • 79.
    Dermatologic Conditions 1.Lichen Planus 2. Pemphigus Vulgaris 3. Mucous Membrane Pemphigoid 4. Erythema Multiforme 5. Stevens-Jhonson Syndrome 6. Toxic Epidermal Necrolysis
  • 80.
    Lichen Planus •Chronic, mucocutaneous, autoimmune disorder • Precipitating factors: genetic predisposition, stress, drug, food • Oral manifestations: White papules -coalesce, forming a network of lines (Wickham’s striae) • Buccal mucosa, gingiva, & tongue, lips & palate
  • 81.
    • Skin lesions:Pruritic papules-flexor surface of extremities • Malignant transformation • Diagnosis: -Clinically -Histopathological examination • Treatment: -No treatment- asymptomatic lesions -Topical steroids & Systemic steroids
  • 82.
    Pemphigus Vulgaris •Autoimmune disease • Antibodies against desmoglein3 (antigen) • Disassociation of the epithelium at suprabasal layer with acantholysis • Bullous lesionsrupturespainful bleeding ulcers • Oral, ocular mucosa, & skin • Palate, gingiva, tongue • Diagnosis: -Nikolsky’s sign:(+) new lesions develops after pressure applied to asymptomatic oral mucosa -HPE -Direct immunofluorescence
  • 83.
    • Treatment: Systemicsteroids & immunosuppressive agents (eg. mycophenolate mofetil) Paraneoplastic Pemphigus: • Occurs in association with underlying neoplasms eg. Lymphoproliferative disease or thymoma • Often partial response to systemic steroids
  • 84.
    Mucous Membrane Pemphigoid • Antigen: Human alpha-6 integrin • Oral manifestations- recurrent vesicles or bullae (persists longer than pemphigus) that rupture, leaving large, superficial painful ulcers • Gingival involvement - desquamative gingivitis characterised by erythematous, sore gingivae • Diagnosis: Biopsy • Treatment: topical steroid/systemic immunosuppressive drugs
  • 85.
    Erythema Multiforme •Skin and mucous membranes • Immunologically mediated • Triggered by: infective agents (eg. HSV), drugs (sulphonamides, barbiturates), food additives or chemical, immunization ( BCG,HBV) • Oral lesions: begins as erythematous areablisterrupturesirregular painful ulcers • Lips, buccal mucosa, tongue, soft palate, & floor of mouth • Skin manifestations: erythematous, flat, round macules, papules, or plaques, usually in a symmetrical pattern- target or iris like lesions • HPE & Immunostaining • Treatment: supportive, systemic steroids
  • 86.
    Stevens–Johnson Syndrome •Severe form of erythema multiforme, involving oral mucous membrane, eyes, & genital area • Etiology: Drugs (salicylates, sulfonamides, penicillin, barbiturates,carbamazepine, phenytoin etc.) • oral lesions - vesicle formation, followed by painful erosions - grayish-white or hemorrhagic pseudomembranes - extend to the pharynx, larynx, and esophagus • Ulceration of skin & mucosal surfaces(eg. mouth, urethra, conjunctiva, & lungs) • Typical target lesions on palms & soles with blistering in the centre • Diagnosis: Clinical presentation • Treatment: -self limiting -Supportive, & Systemic steroids
  • 87.
    Toxic Epidermal Necrolysis • Severe skin & mucous membrane disease • Etiology: Drugs • Clinical features: low-grade fever, malaise, arthralgia, conjunctival burning sensation, skin tenderness, & erythemablisters appear-skin - lifted up - whole body surface appears scalded • Nikolsky’s sign –positive • Oral manifestations: diffuse erythema, vesicles and painful erosions - lips & periorally, buccal mucosa, tongue, & palate • Diagnosis: Clinically • Treatment: Systemic steroids, antibiotics, fluids, and electrolytes
  • 88.
    Neurologic Diseases 1.Parkinson’s Disease 2. Alzheimer’s Disease 3. Bell’s Palsy 4. Mobius syndrome 5. Melkersson-Rosenthal Syndrome 6. Guillain-Barre Syndrome 7. Bulbar palsy 8. Multiple Sclerosis 9. Myasthenia Gravis 10. Myotonic Muscular Dystrophy 11. Tuberous Sclerosis
  • 89.
    Parkinson’s Disease •Extrapyramidal symptoms • Loss of facial expression • Difficulty with mastication, slow speech, & tremors of head, lips, & tongue • Esophageal dysmotility & dysphagia • Impaired lip seal drooling fungal infection of lip commissure (angular cheilitis)
  • 90.
    Alzheimer’s Disease •Dementia • Inability to perform self care (oral hygiene)- self neglect & loss of cognitive and motor skills • Poor oral hygiene- increased prevalence of dental plaque, dental caries, & gingival bleeding
  • 91.
    Multiple Sclerosis •Demyelination of central nervous system • Remitting & exacerbating course • Loss of muscle coordination, weakness of the tongue, & loss of upper extremity severely impairs orodental hygiene • Trigeminal neuralgia- also common characterized by excruciating, unilateral pain of the lips, gingiva, or chin triggered by contact with certain areas of the face, lips, or tongue
  • 92.
    Bell’s Palsy •Idiopathic unilateral lower motor neuron palsy (7th cranial nerve) • Lack of control of the muscles of facial expressiondistortion of facial appearance • Loss of functional ability of cheek & lips (affected side)poor oro-dental hygiene
  • 93.
    Melkersson-Rosenthal Syndrome •Characterized by -unilateral facial palsy, recurrent facial swelling, & lingua plicata (fissured tongue)
  • 94.
    Nutritional Deficiency •Vitamins & trace elements 1. Inadequate intake 2. Impaired digestion & absorption 3. Increased losses
  • 95.
    • Vitamin Adeficiency: -Dyskeratotic changes of the skin & mucous membranes -Angular cheilitis -Defects in the dentin & enamel of developing teeth • Vitamin B2 (Riboflavin) deficiency: -Angular cheilitis -Burning pain in the lips, mouth, & tongue • Vitamin B3 (Niacin) deficiency (Pellagra): -Dermatitis, dementia,& diarrhoea -Oral manifestations: glossitis (red, swollen) & stomatitis, burning tongue
  • 96.
    • Vitamin B6deficiency: -Peripheral neuropathy -Oral lesions-similar to pellagra (i.e. glossitis & stomatitis) • Vitamin C deficiency (Scurvy): -Cofactor for collagen synthesis -Weakened vessels are responsible for petechiae, ecchymoses, delayed wound healing • Deficiency of Vitamin B12 & Folic acid: -Megaloblastic anemia -Oral findings: angular cheilitis, recurrent aphthous ulcers, & glossitis
  • 97.
    • Vitamin Ddeficiency & Calcium deficiency: -Calcium metabolism -Mandibular osteopenia/osteoporosis, enamel hypoplasia • Vitamin k deficiency: -Haemorrhagic diathesis -Oral haemorrhagic bullae • Zinc deficiency: -Taste changes -Acrodermatitis Enteropathica: angular cheilitis, ulcers, glossitis, crusting, scaling of the lips as well as ulcers, erosions & fissures
  • 98.
    Oral lesions associatedwith HIV • Early recognition, diagnosis, & treatment of HIV associated oral lesions - reduce morbidity • Oral lesions- -Early diagnostic indicator of HIV infection -Stage of HIV infection -Predictor of the progression of HIV disease
  • 99.
    Oral lesions associatedwith HIV • Fungal Infection: Bacterial Infection: -Candidiasis -Linear Gingival Erythema -Histoplasmosis -Necrotizing Ulcerative Periodontitis -Cryptococcosis -Mycobacterium Avium Complex • Viral Infection: Neoplastic: -Herpes simplex -Kaposi’s Sarcoma -Herpes zoster -Non-Hodgkin’s Lymphoma -HPV Infection Others: -CMV Infection -Recurrent Aphthous Ulcers -Hairy Leukoplakia -Salivary Gland Disease
  • 100.
    Human Papilloma VirusInfection • Oral warts (papillomas), skin warts, & genital warts – HPV(types 7,13,& 32) Clinical Features: • Arises from Stratified squamous epithellium, painless, exophytic, numerous finger like projections-cauliflower like appearance • Tongue, gingiva, & palate • Biopsy- Histologic diagnosis • Treatment: -Surgical removal -Laser (CO2 laser)
  • 101.
    Hairy Leukoplakia •Epstein Barr virus • Common, characteristic lesion-HIV infection • White, asymptomatic, raised, corrugated, unremovable patch on lateral marigns of tongue • The surface is irregular and may have prominent folds or projections, sometimes markedly resembling hairs • Lateral margins may spread to dorsum of tongue • Diagnosis: Biopsy • Treatment: -Usually asymptomatic-Rx not required -Antiviral(Aciclovir/valaciclovir)
  • 102.
    Kaposi’s Sarcoma •Most common malignancy in HIV (+Ve) • Human Herpes Virus-8(KSHV) • Derived from capillary endothelial cells • Occur intraorally, either alone or in a/w skin & disseminated lesions (lymph nodes, salivary gland) • Intraorally- hard palate, buccal mucosa, & gingiva -bluish, purple or red patches or papulesnodular, ulcerate & bleed • Diagnosis: Biopsy • Treatment: -Low dose radiation & chemotherapy (eg.Vinblastine) -Surgical excision (eg.CO2 laser) -Immunotherapy (Interferon)
  • 103.
    Non-Hodgkin’s Lymphoma •Etiology: Unknown, genetic & environmental factors (viruses, radiation) • Clinical features: – Both sexes - any age – Lymph nodes involved – Oral lesions - part of a disseminated disease, or the only sign • Oral Lymphoma: diffuse, painless swelling, which may or may not be ulcerated -soft palate, the posterior part of the tongue, the gingiva, & the tonsillar area • HPE & Immunohistochemical examn • Treatment: Radiotherapy & chemotherapy
  • 104.
    Salivary gland Disease • Xerostomia– generalised enlargement of parotid glands • Lymphoepithelial cysts- parotid gland