Oral Medicine Dr. Qianming Ian CHEN
ORAL MEDICINE Oral medicine is the specialty of dentistry that is concerned with the oral health care of medically compromised patients and with the diagnosis and nonsurgical management of medically related disorders or conditions affecting the oral and maxillofacial region. Oral medicine specialists are concerned with the nonsurgical medical aspects of dentistry. These specialists are involved in the primary diagnosis and treatment of oral diseases that do not respond to conventional dental or maxillofacial surgical procedures.
ORAL MEDICINE The Third World Workshop on Oral Medicine (Chicago, 1998) was charged with updating and summarizing the state of the field in four major areas: (1) Diseases of the oral mucosa (2) Infectious diseases of the orofacial region (3) Orofacial pain (4) Salivary gland and chemosensory disorders
DESCRIPTIVE TERMINOLOGY OF ORAL LESIONS
ORAL PAPULE small, solid, elevated lesion < 1 cm with about equal diameter and depth. Small Hill
ORAL NODULES Papules that grow become nodules. Solid tissue mass. > than 1 cm size. Inflammatory type. Neoplastic type. Nodules that grow become tumors. Small Mountain
ORAL MACULE Flat, well-circumscribed, non palpable, non-elevated lesion. Usually < 1 cm. Different color from surrounding skin. Present as black, purple, blue, brown, red, yellow and white lesions. Color Change
ORAL PLAQUE Solid raised lesions Usually > 1 cm Large papules
VESICLE & BULLA Elevated listerlike lesions containing clear fluid < than 1 cm: Vesicle > 1 cm: bulla Serum or Lymph Thin epi cover INTRA-EPIDERMAL or SUB-EPIDERMAL
PUSTULE A fluid filled sack that contains cloudy and or purulent material. Infection related. Painful Usually elevated.
ULCERS, EROSIONS, FISSURES o o o A defect in the epithelium: Ulcers Moist red lesions: Erosions A. Follows blister. B. Follows pustule. C. Epidermis lost: Linelike cut: Fissures
ORAL DISEASES PRESENT IN LIMITED WAYS A. Blister Vesicle Bulla B. Erosion Ulcer C. Papule Nodule Tumor
Infectious Diseases
Infections Viral Fungal Bacterial
Viral Infections Herpes Simplex Primary Herpetic Gingivostomatitis Secondary Herpetic Infections Herpes Zoster (Varicella) Herpangina Hand, Foot, and Mouth Disease
Herpes Simplex ETIOLOGY: HSV-1 and or HSV-2. AGE: HSV-1 2-4 ; HSV-2 sexual maturity
Herpes Simplex Herpes simplex 1 (HSV-1) Most primary infections are silent. The incubation period: 5 7 days or 2 to 12 Usually associated with oro-facial lesions. However, in immunocompromised individuals the virus may disseminate.
Herpes Simplex Primary Herpetic Gingivostomatitis Prodromal symptoms: flulike A cluster of Vesicles Multiple shallow ulcers Both the keratinized and gland-bearing intra-oral surfaces Ulcerative gingivitis Systemic symptoms of fever, lymphadenopathy, myalgia.
Herpes Simplex Secondary Herpetic Infections The common coldsore or fever blister Precipitated by fever, menstruation, ultraviolet light, emontional strees A cluster of Vesicles Prodromal symptoms: tingling or burning lip lesions
Fungal Infections Candidiasis Systemic Mycoses Aspergillosis Histoplasmosis Cryptococcosis Mucormycosis Coccidioidomycosis Paracoccidioidomycosis Blastomycosis
Candidiasis Infection of the skin or mucous membrane with any species of Candida, but chiefly Candida albicans; Usually localized in the skin, nails, mouth, vagina, vulva, bronchi, or lungs, but may invade the bloodstream; Occurs commonly as a secondary infection associated with immune system compromise. Newborn infants may have contracted the organism during passage through the birth canal.
Candidiasis Caused by yeast-like fungus Common inhabitant in oral cavity Also known as moniliasis or thrush
Candidiasis Classification of Basic Types of Oral Candidiasis Acute Pseudomembraneous ("thrush") Atrophic ("erythematous") Chronic Hyperplastic ("candidal leukoplakia")
Candidiasis Acute Pseudomembraneous Candidiasis (Thrush) A clinical form of C. albicans infection that consists of creamy, loose patches of desquamative epithelium containing numerous matted mycelia over an erythematous mucosa that is easily removed; Common in patients with more severe predisposing factors.
Candidiasis Atrophic (Erythematous) Candidiasis A clinical form of C. albicans infection in which the mucosa is thinned, smooth, and bright red with symptoms of burning and increased sensitivity; commonly found on the palate under a denture but also on the tongue and other mucosal surfaces.
Candidiasis Chronic Hyperplastic Candidiasis A clinical form of C. albicans infection consisting of white plaques or papules against an erythematous background containing hyphae in the parakeratin layer of the thickened epithelium.
Common Oral Lesions Associated with HIV Infection
Common Oral Lesions in Patients with AIDS Candidiasis Intraoral Esophageal "Hairy" leukoplakia Diffuse herpes simplex gingivostomatitis Diffuse varicella-zoster lesions Kaposi sarcoma Non-Hodgkin lymphoma HIV gingivitis / periodontitis Acute nonspecific ulcers
HIV CANDIDIASIS Considered predictive of HIV infection and onset of AIDS High dose antifungal needed.
Kaposi s Sarcoma(KS) Oral KS has a variety of clinical presentations Initially oral KS may appear as a small patch Color may range from bluish-purple to a deep red or even black With time, the lesion may become exophytic and nodular and darken in color
Kaposi s Sarcoma(KS) KS may be seen anywhere in the oral cavity, including the gingiva Palate appears to be the most common location The larger lesions may be ulcerated and uncomfortable
Hairy Leukoplakia(HL) Clinical Description Oral HL is a lesion which is seen in the HIV-infected individual HL may be one of the first signs of HIV infection and a significant clinical marker un terms of predicting the development of AIDS HL appears as an irregular shaped white plaque which cannot be rubbed off.
Hairy Leukoplakia(HL) The plaque may appear smooth, corrugated or shaggy(hairy) Usually seen on the lateral borders of the tongue but may occasionally involve the dorsal or ventral tongue, or buccal and labial mucosa
Hairy Leukoplakia(HL) Clinical Description HL may vary in size, small localized lesions are just as prognostic for the development of AIDS as large profuse ones HL is typically asymptomatic and may occur unilaterally or bilaterally Candida is often found to exist concomitantly with HL
HIV COURSE: adapted from: Mandel (Ed.) (1997). Atlas of Infectious Disease, Paramount, Hong Kong.
Immune Related Mucocutaneous Diseases and Dermatological Disorders
Allergic Reactions varied and nonspecific in appearance may be asymptomatic or painful 2 types stomatitis medicamentosa contact stomatitis agents commonly implicated dental metals flavoring agents
Contact Stomatitis Patients who react sensitively shortly after contact with an allergen. Erythema and edema Sensitivity to various stimuli May take many forms including erythematous, ulcerative/erosive, and leukoplakic Confirmation by patch test
Stomatitis Medicamentosa An allergic reaction of the oral mucosa to the systemic administration of a medication. Oral Mucosal Allergic Reaction Patterns Erythema multiforme Anaphylactic stomatitis Intraoral fixed drug eruptions Lichenoid drug reactions Lupus erythematosus-like eruptions Pempigus-like drug reactions Nonspecific vesiculo-ulcerative lesions
Stomatitis Medicamentosa Anaphylactic stomatitis An allergic reaction of the oral mucosa to the systemic administration of a medication.
Immune-Mediated Diseases
Immune-Mediated Diseases PemphigusVulgaris Paraneoplastic Pemphigus Cicatricial Pemphigoid Linear IgA Disease Angina Bullosa Hemorrhagica Epidermolysis Bullosa Acquisita Bullous Pemphigoid Erythema Multiforme Stevens-Johnson Syndrome Toxic Epidermal Necrolysis
Immune-Mediated Diseases Erythema Migrans Lichen Planus Graft-Versus-Host Disease Psoriasis Lupus Erythematosus Systemic Sclerosis CREST Syndrome
Pemphigus Vulgaris Autoimmune disease; acantholysis condition, the lesions are intraepithelial, IgG in epithelium. Very serious, potentially fatal skin disease. FEMALES, peoples of the Mediterranean Region (Jewish, Italian peoples). Clinical: Blisters rare, usually broken as erosion. Positive Nikolsky. B-PENS TX: Biospy and Oral Medicine and Dermatology treat (Steroids).
Pemphigus Vulgaris
Cicatricial Pemphigoid (Benign Mucous Membrane Pemphigoid, Mucous Membrane Pemphigoid) It is also referred to as cicatricial pemphigoid, since scarring can result during the healing process. Positive Nikolsky, C3 and IgG target cell junctions. FEMALES more common, blisters seen. TX: Biopsy and steroids.
Cicatricial Pemphigoid
Erythemia Multiforme Skin and oral tissues. Skin lesions have a characteristic "bull's-eye" or target appearance on the hand. Oral clinical characteristics of this condition include crusting and ulceration of the lips ulceration and erythema to varying degrees on the mucosal tissues involved.
Erythemia Multiforme Bulls Eye Lesions
Erythemia Multiforme ERYTHEMIA MULTIFORME
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