THERAPEUTIC DENTISTRY, 5TH YEAR STUDENTS (lecture #1) Oral mucosa – anatomy, functions. Pathologycal elements. Oral mucosa diseases and manifestations of systemic diseases. Classification of diseases of oral mucous membrane. Patients examination. Case history.

Oral medicine What is oral medicine? Broadly speaking, it is the field of medicine that encompasses the diagnosis and management of diseases the oral cavity. Many conditions produce oral signs and symptoms, and yet the oral cavity is an unfamiliar zone for many clinicians.

Physicians generally receive little formal training in dental and oral medicine, and tend to view the oral cavity as a place reserved for their ‘’dental’’ colleagues. Likewise, dentists are experts in the diagnosis and management of diseases related to the teeth: however, the proportion of dental education dedicated to the “non-dental” part of the oral cavity often falls short. For these reasons, it is not at all uncommon for a patient to visit five or ten doctors before receiving a correct diagnosis and treatment plan. That’s why that part of dentistry is so necessary to learn.

On current course we will take a view on such groups of diseases:

Classification of diseases of oral mucous membrane (By Borovsky E Classification of diseases of oral mucous membrane (By Borovsky E., Mashkyleison A. (Moscow Medical Dental University) I. Traumatic lesions 1. Mechanical 2. Physical 3. Chemical

II. Infectious lesions 1. Virus diseases 2. Bacterial diseases 3. Candidosis 4. Venereal diseases 5. Vinsent’s stomatitis

III. Allergic lesions IV. Medicament intoxications

V. Changes of oral mucous membrane in case of some systemic diseases. 1. Hyper – and hypovitaminosis 2. Endocrine diseases 3. Alimentary tract diseases 4. Cardio-vascular diseases 5. Blood diseases 6. Nervous system diseases 7. Other

VI. Changes of oral mucous in dermatosis with an autoimmune component VII. Tongue anomalies VIII. Cheilitis VIII. Precancer diseases

Bacterial infections of the mouth For example: Syphylis - a sexually transmitted or congenital infection caused by the bacterium Treponema pallidum.

Gonorrhea - a sexually transmitted infection caused by bacteria called Neisseria gonorrhea. This is a result of orogenital contact with an infected partner and presents as a nonspecific stomatitis or pharyngitis with frequent persisting superficial ulcers.

Viral infections of the mouth Such as : Herpes simplex virus (HSV) - responsible for common vesicular eruptions of the skin and mucosa. Although oral infection with HSV-1 and HSV-2 is described below, most oral-facial herpetic lesions are due to HSV-1. Antibodies indicating past infection are virtually ubiquitous in adults.

Acute and chronic candidiasis: Acute pseudomembranous candidiasis (thrush) is most common in infancy, old age and the immunosuppressed or debilitated (e.g., those on radiotherapy, cytotoxics, or steroids, or with diabetes, cancer, HIV, or hematological malignancy), or those on broad-spectrum antibiotics. Clinically it appears as creamy, lightly adherent plaques on an erythematous oral mucosa, usually on the cheek, palate, or oropharynx.

Chronic candidiasis: Chronic hyperplastic candidiasis (candidal leukoplakia) More commonly seen in smokers. Typically presents as a white patch on the oral commissural buccal mucosa bilaterally. Although there is an ↑ risk of malignant change, the initial approach after ensuring the diagnosis (microbiologically and histopathologically) is to eradicate the candidal infection.

Recurrent aphthous stomatitis (ulcers)

Premalignant lesions Leukoplakia is described as white patch or plaque that cannot be characterized clinically or pathologically as any other disease and is not associated with any physical or chemical agent except the use of tobacco (WHO).

Abnormalities of the lips and tongue

Tongue

Lips

Oral manifestations of HIV infection and AIDS

Allergic diseases:

Oral manifestations of different organs diseases:

Chronic trauma

First step to successful treatment is examination First step to successful treatment is examination. Lets remind ourselves oral cavity anatomy:

Anatomy of lips.

Tongue.

Floor of the mouth.

And oral mucosa anatomy:

Primary and secondary lesions elements of the oral mucous membrane The development of any mucous membrane disease characterized by appearance on the surface of original elements of lesion. Observed on the skin and mucous membrane rash consisting of individual elements according to their symptoms can be grouped into several groups: 1) change the color of oral mucosa; 2) change the surface of oral mucosa 3) limited fluid accumulation; 4) layers on the surface; 5) defects of oral mucosa.

Elements of damage is conventionally divided into primary as the result on an unchanged oral mucosa, and secondary as the result from transformation or damage to existing items.

Main pathological elements (all that diseases consist of): The primary elements of rash include: 1) macula, 2) bundle (papules), 3) nodule, 4) vesicle, 5) bulla, 6) pustule, 6) cyst, 7) blister, 8) fissure.

Macules a circumscribed change in skin color without elevation or depression.

Macules

Papules A papule is a small, solid, elevated skin lesion less than 0.5cm in diameter. The top of a papule can be flat, pointed, or rounded. Papules are seen in many skin diseases, including acne, fungal infections, and lichen planus.

Papules

Nodule a palpable solid lesion of varying size, greater than 0.5 cm and less than 2 cm in diameter, which may be present in the epidermis, dermis or subcutis.

Nodules

Vesicle a circumscribed elevated lesion which contains free fluid. Vesicles are 0.5 cm or less in diameter.

Vesicle

Bulla Bullae are similar to blisters and vesicles, with the only difference being in size. When a blister becomes larger than 1 centimeter in diameter, it is a bulla.

Bulla

Vesicle and bulla

Nikolsky's Sign Nikolsky's Sign: a disadhesion of skin assessed by light pressure at the edge of a preexisting bulla.

Pustule A pustule is a small elevation of the skin containing cloudy or purulent material usually consisting of necrotic inflammatory cells. These can be either white or red.

Pustule Pustules are often associated with hair follicles, but they can exist independently of a follicle. Pustules are seen in acne, cutaneous yeast infections, pustular psoriasis, and folliculitis.

Cyst A cyst is an epithelial-lined cavity containing liquid, semi-solid, or solid material usually in the dermis.

Cyst

Fissure A fissure is a crack in the skin that is usually narrow but deep

Fissure

Fissure

Main pathological elements (all that diseases consist of): The secondary items considered: 1) erosion, 2) ulcer, 3) fracture, 4) scales, 5) crust, 6) scar, 7) lihenization.

Erosion a loss of epidermis above the basal layer leaving denuded surface.

Ulcer An ulcer is a discontinuity of the skin exhibiting complete loss of the epidermis and often portions of the dermis and even subcutaneous fat

Ulcer

Scales a heaping up of stratum corneum or keratin.

Crust dried serum, pus, or blood usually mixed with epithelial and sometimes bacterial debris.

Lichenification epidermal thickening characterized by visible and palpable thickening of the skin with accentuated skin markings

Lichenification

Scar fibrous tissue replacing normal skin in areas of healing.

Examination methods clinical (main) – using near patient bed or dental unit; paraclinical (additional) - instrumental, lab, x-ray. All examinations that hold usind additional services.

Main examination methods Subjectively (patient interview) - complaints, life history, anamnesis; Object examination – external and internal mouth review.

Head and facial appearance Look for specific deformities ,facial disharmony , syndromes, traumatic defects , and facial palsy . Skin Lesions of the face should be examined for color, scaling, bleeding, and crusting, palpated for texture and consistency and whether they are fixed to or arising from surrounding tissues.

Eyes Note obvious abnormalities such as exophthalmus and lid retraction (e.g., hyperthyroidism) and ptosis (drooping eyelid). Examine conjunctiva for chemosis (swelling), pallor, e.g., anemia or jaundice. Look at the iris and pupil.

Neck Inspect from in front and palpate from behind. Look for skin changes, scars, swellings, and arterial and venous pulsations. Palpate the neck systematically, starting at a fixed standard point, e.g., beneath the chin, working back to the angle of the mandible and then down the cervical chain, remembering the scalene and supraclavicular nodes.

Visible skin surfaces Note colour and general condition of the visible skin surfaces: some pathological changes there can be additional (or first) symptom of some diseases

Oropharynx and tonsils These can easily be seen by depressing the tongue with a tongue blade. The hypopharynx and larynx are seen by indirect laryngoscopy using a head light and mirror, and the postnasal space is similarly viewed.

Additional tests Special clinical tests (temperature diagnostics, index rating of oral hygiene, periodontal index); Functional tests methods (electric pulp test, fluorescent diagnostics, determination of periodontal capillaries); Lab test methods (clinical and biochemical parameters of blood, urine, saliva, oral and gingival liquids); Microbiological; Allergic; X-ray.

Intraoral radiography Orthopantomography Tomography Sialography Fluorescence diagnostic