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- ArrythmiasCerculetory 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 hourly3. Rest4. Tracheostomy – if needed.

• Oral cavity- window to the body

• Lesions of oral mucosa, tongue, gingiva, dentition, periodontium, salivary gland, facial skeleton, & extraoral skin

• Appropriate diagnosis & treatment

Oral Manifestations of Systemic Diseases:

Classification

1.Systemic Infectious diseases 2.Connective tissue disorders3.Granulomatous diseases4.Gastrointestinal diseases5.Respiratory diseases6.Haematological diseases7.Endocrine diseases8.Neurologic diseases9.Nutritional deficiency10.Immunodeficiency diseases11.Drug reactions/radiotherapy12.Dermatological diseases13.Metabolic disorders14.Neoplastic diseases

Infective diseases

1.Viral infection

2.Bacterial infection

3.Fungal infection

4.Protozoal infection

Viral infections

1.Herpes Simplex Stomatitis2.Herpes Zoster3.Herpangina 4.Hand Foot Mouth Disease5.Cytomegalovirus Infection6.Measles7.Infectious Mononucleosis8.Mumps9.HIV

Viral infections

1.Herpes Simplex Stomatitis2.Herpes Zoster3.Herpangina 4.Hand Foot Mouth Disease5.Cytomegalovirus Infection6.Measles7.Infectious Mononucleosis8.Mumps9.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. Tuberculosis2. Syphilis3. 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 purulentLate: 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 microscopy2. Biopsy3.Serology Non-treponemal antibody tests: -VDRL, RPR -For screening and treatment follow upTreponema specific antibody tests: -FTA-ABS test, TPHA-For confirmation-Usually remains positive for lifeTreatment: 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. Candidiasis2. Histoplasmosis3. Cryptococcosis4. Aspergillosis5. Mucormycosis6. 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 Disorders1. Sjogren’s Syndrome2. Systemic Lupus Erythematous (SLE)3. Scleroderma4. Dermatomyositis-Polymyositis5. Sarcoidosis6. Wegner’s Granulomatosis7. Behcet’s Syndrome8. Reiter’s Syndrome9. Sweet Syndrome10. Cogan’s Syndrome11. Amyloidosis 12. Kawasaki Disease13. Rheumatoid Arthritis (RA)14. Polyarteritis Nodusa (PAN)15. Sturge- Weber Syndrome16. Ehlers-Danlos Syndrome17. 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 salivadysphagia,

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 SLEoral 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 days2.Bilateral conjunctival congestion3.Erythema of lips, buccal mucosa & tongue4.Acute non-purulent cervical lymphadenopathy5.Polymorphous exanthema6.Erythema of palms & soles (edemadesquamation)

Treatment: Aspirin, IVIgSteroid 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 drugsacute 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 Anaemia3. Langerhans Cell Histiocytosis4. Osler-Weber-Rendu disease (HHT)5. Plummer-Vinson Syndrome6. Leukaemia 7. Agranulocytosis 8. Myelodysplastic Syndrome9. Cyclic Neutropenia 10. Idiopathic Thrombocytopenic Purpura11. 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 Reflux3.Peutz-Jegher’s Syndrome4.Celiac disease5.Chronic liver disease6.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 Mellitus2. Thyroid Disorders3. Cushing’s Disease4. 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 Planus2. Pemphigus Vulgaris3. Mucous Membrane Pemphigoid4. Erythema Multiforme5. Stevens-Jhonson Syndrome6. 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 lesionsrupturespainful 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 areablisterrupturesirregular 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, & erythemablisters 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 Disease2. Alzheimer’s Disease3. Bell’s Palsy4. Mobius syndrome5. Melkersson-Rosenthal Syndrome6. Guillain-Barre Syndrome7. Bulbar palsy8. Multiple Sclerosis9. Myasthenia Gravis10. Myotonic Muscular Dystrophy11. 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 expressiondistortion 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 intake2. Impaired digestion & absorption3. 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 papulesnodular, 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