Cancrum1 /certified fixed orthodontic courses by Indian dental academy

CANCRUM ORIS
AND
APHTHOUS STOMATITIS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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.

PREDISPOSING FACTORS
1. Undernourished person.
2. Debilitated person having infections like :
• Diphtheria
• dysentery
• measles
• Pneumonia
• Scarlet fever
• Syphilis
• Tuberculosis
• Blood dyscrasias
including anemia.

• 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.

 Condition usually began around the
gingiva and progressed to destruction of
the floor of the mouth and lower lip.
 Selye suggested that Noma may not
necessarily be due to a specific
pathogenic agent but may be due to a
pathogenic situation.

CLINICAL FEATURES: Starts with a small
ulcer in the gingival mucosa which rapidly
spreads and involves the surroundings
tissue of the jaws, lips ,and cheeks by
gangrenous necrosis.www.indiandentalacademy.com

 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 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.

 Palate and tongue can also be involved by
this process.
 High temperature during the Course of the
disease.

 Mortality rate:75%
 Treatment:Immediate treatment of
malnutrition.

APHTHOUS 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.

 2)Immunologic abnormalities:
Lehner : a)autoimmune response
b)detected IgM and IgG antibody in
epithelial cells of the spinous layer of the oral
cavity.
 Addy and dolby :normal level of complement
and antinuclear factor.

 Cohen:
a) not an autoimmune
disease.
b) local immune
response against an
antigenically altered
oral mucosa.

 results of diffusion of bacterial toxins, food
and other substance acting as allergen.
 Donatsky-elevated gamma globulin level
against sterptococus.
 Recurrent aphthous stomatitis-altered
immune response which is directed against
non pathogenic oral flora and host oral tissue.
 chemical mediator

 focal release of neuropeptide.
 viral infection.
 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.
 seen in HIV patients
 Patient with malabsorption conditions.

 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.

 Endocrine condition-relationship between
occurrence of the menstrual period and
development of aphthous ulcer.
 Related with the level of progesterone
 Woman have remission of disease during
pregnancy.
 Onset of disease associated with menopause
and menarche.

 Psychic factors-association with acute
psychological problem and stress.
 Allergic factor-association with asthma hey
fever,food or drug allergy.

 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 disease.

 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 association.www.indiandentalacademy.com

 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.

 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 erythematous halo.

 Generalized edema of the oral cavity.
 Paresthesia
 Low grade fever
 Localized lymphadenopathy
 Vesicle like lesion containing mucus.
 Difficulties in eating.

 Common site of occurrence:buccal and
labial mucosa
 Buccal and lingual sulcus
 Soft palate,gingiva labial mucosa.

 Lateral and ventral
surface of the
tongue is also
affected.

 Heal in 7 to 1o days without scar
formation.
 Oral manifestation include mucosal
fissure,small multiple hyperplastic nodule
on the buccal mucosa produce cobble
stone appearance.
 Biopsy finding suggest noncaseating
granuloma.

 Major aphthous ulcer:most severe expression
of aphthous 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

 Difficulties in eating,pain and discomfort.
 Show similar lesion in vagina,penis larynx.
 No particular age group,females affected
more then males.

 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.

 Here the ulcers will be preceded by vesicles
and exhibit no virus infected cells.
 Brooke and Sapp -numerous small lesion
found in oral mucosa.
 Small pinhead sized erosions that gradually
enlarge and coalesce
 Painful lesions present for one to three years.
 Immediate relief from tetracycline
mouthwash.

 Laboratory test-no herpes simplex virus
is cultured.
 Absence of multinucleated giant cell.
 No antibodies against herpes virus.

HISTOPATHOLOGY
 minor apthous ulcer-fibrinopurulent
membrane covering the ulcerated area.
 Superficial colonies of microorganisms
present in this membrane.
 Inflammatory cell infiltration in connective
tissue.
 Granulation tissue at the base of the lesion.
 Epithelial proliferation at margins.

 Lesion begins at the excretory duct of
minor salivary gland.
 Wood-anitschkow cell.
 Mononuclear cell in submucosa and in
perivascular tissue in pre-ulcerative
stage.
 In ulcerative stage-CD4and CD8
lymphocytes are present.

 Presence of macrophages and mast
cells.
Differential diagnosis:
 herpes simplex infection.
 Trauma.
 Pemphigus vulgaris.
 Mucous membrane pemphigoid.

TREATMENT
1. mouth rinse-sodium bicarbonate in warm
water.
2. Drug-prednisone-20 to 40 mg daily for a
week
3. Topical corticosteroid.
4. Intralesional injection of triamicolone.
5. Antibiotics-tetracycline suspension.
6. Tetracycline mouthwash-250 mg per 5 ml
used 4 times daily for 5 to 7 days .

 Steroid ointment-1.5 %cortisone acetate
applied locally.
 Hydrocortisone acetate antibiotics
lozenges.
 Chemical cautery.

 250 mg of capsule in 30 ml of warm
water.(4 times in a day for 4 day)
 Other
drugs:azathioprine,cyclophosphamide.
Thailodomide,pentixyfilline

Treatment modalities for recurrent
aphthous stomatitis
 Immune enhancement-levamisole
Vaccine
Immunosuppression,inflammatory
suppression:prednisone
antihistamine

 Antibiotics:tetracycline suspension
broad spectrum antibiotics
 Antiseptics:silver nitrate
gentian violet
 Diet supplementation:vitamin B12
iron
zinc sulphate

 Symptomatic treatment:Xilocaine
silver nitrate

BEHCETS SYNDROME
 Uncertain etiology.
 Pleuropnumonia like organism.
 Autoimmune etiology.
 Lehner-immunologic similarities
between this syndrome and recurrent
apthous stomatitis.

CLINICAL FEATURES
 Occurs 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.

 Size ranging from several millimeter to
centimeter or more in diameter.
 Ulcer have an erythematous border and
covered by gray or yellow exudates.
 Genital ulcers are small and located on
scrotum,root of the penis.
 Ocular lesions-photophobia and
irritation

 Simple conjunctivitis to finally uveitis
 Skin lesions –small papules on the trunk
and limbs and around the genitalia.
 Involvement of CNS and cardiac and
pulmonary involvement is seen.

Histologic features
 similar to recurrent apthous stomatitis.
 Endothelial proliferation.
 Vasculitis.
 Laboratory findings:
hypergammaglobulinemia
leucocytosis
eosinophilia
elevated sedimentation rate.

TREATMENT AND PROGNOSIS
1. supportive treatment.
2. Remission after a period of months to
years.
3. Serious complication can lead to death.

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