Recurrent Aphthous Ulcer

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Recurrent Aphthous Ulcer

• Etiology
• Local altered immune response.
• Systemic etiologies include nutritional
  deficiencies (iron, B6, B12), diabetes mellitus,
  inflammatory bowel disease, immunosuppression.
• Biopsy will rule out other vesiculoulcerative
  disease.

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Recurrent Aphthous Ulcer

• Appearance
• Minor aphthous ulcer lt0.6 cm shallow ulceration
  with gray pseudomembrane and erythematous halo on
  non-keratinized mucosa.
• Major aphthous ulcer gt0.5 cm ulcer, more
  painful, lasting several weeks to months will
  scar.

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Recurrent Aphthous Ulcer

• Differential Diagnosis
• Herpes simplex virus.
• Chemical/traumatic ulcer
• Vesiculoulcerative diseases
• Squamous cell carcinoma
• Treatment
• Topical analgesics
• Topical steroids

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Inflammatory Conditions (Denture Related of the
Oral Mucosa)

• Inflammatory papillary hyperplasia
• Epulis fissurata (inflammatory fibrous dysplasia)
• Candidiasis

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Inflammatory Papillary Hyperplasia

• Etiology
• Poorly fitting denture
• Occurs in more than 50 of Denture Wearers
• Appearance
• Multiple small polypoid or papillary lesions.
• Typically on hard palate, that produces a
  cobblestone appearance.

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Inflammatory Papillary Hyperplasia

• Etiology
• Poorly fitting denture
• Occurs in more than 50 of Denture Wearers
• Appearance
• Multiple small polypoid or papillary lesions.
• Typically on hard palate, that produces a
  cobblestone appearance.

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Inflammatory Papillary Hyperplasia
(Papillomatosis)

• Treatment
• Discontinue using denture
• Surgical removal of hyperplastic tissue.
• Occasionally tissue conditioner may reduce the
  problem, while reconstruction of new denture may
  be necessary.

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Epulis Fissurata (Inflammatory Fibrous Dysplasia,
Denture Granuloma)

• Etiology
• Over-extended denture flanges.
• Resorption of alveolar bone that makes the
  denture borders over-extended.
• Appearance
• Hyperplastic granulation tissue surrounds the
  denture flange.
• Pain, bleeding, and ulceration can develop.

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Epulis Fissurata (Inflammatory Fibrous Dysplasia,
Denture Granuloma)

• Differential Diagnosis
• Verrucous carcinoma
• Squamous cell carcinoma
• Traumatic fibroma
• Treatment
• Small lesions may resolve if flanges of denture
  are reduced.
• Surgical excision is necessary prior to
  rebasing/relining of denture.

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Oral Candidiasis
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Candidiasis

• Four fungal organisms Candida albicans, Candida
  stellatoidea, Candida tropicalis, and Candida
  pseudotropicalis.
• Candida albicans is most common.
• Morphologically, presents in 3 forms yeast cell,
  hypha and mycelium (last form is pathogenic
  phase).
• Carriers of oral candida do not show the mycelial
  phase.

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Etiology

• Mixed infection of Candida albicans,
  staphylococci and streptococci.

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Classification of Oral Candidiasis

• Acute pseudomembranous candidiasis (moniliasis,
  thrush).
• Acute atrophic candidiasis (antibiotic sore
  tongue).
• Chronic atrophic candidiasis (denture
  stomatitis).
• Chronic hyperplastic candidiasis (candidal
  leukoplakia, median rhomboid glossitis).
• Angular cheilitis
• Chronic mucocutaneous candidiasis.

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PAS Stained Candida Albicans Hyphae Embedded in
The Oral Mucosa
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Acute Pseudomembranous Candidiasis (Thrush)

• Etiology
• Oral candidiasis
• Appearance
• White slightly elevated plaques that can be wiped
  away leaving an erythmatous base.
• Direct smear can be fixed and stained using PAS
  reagent to reveal the candida hyphea
  microscopically.

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Acute Atrophic Candidiasis (Antibiotic Sore
Tongue)

• Etiology
• Oral candidiasis secondary to antibiotics or
  steroids.
• Appearance
• Similar to thrush without overlying
  pseudomembrane erythematous and painful mucosa.
• Differential Diagnosis
• Erosive lichen planus.
• Chemical erosion.

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Chronic Atrophic Candidiasis (Denture Sore Mouth)

• Etiology
• Most common form of oral candidiasis candidal
  infection of denture as well.
• Treatment should be directed towards mucosa and
  denture.

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Chronic Atrophic Candidiasis (Denture Sore Mouth)

• Appearance
• Mucosa beneath denture is erythematous with a
  well-demarcated border.
• Swabs from the mucosal surface may provide a
  prolific growth, but biopsy shows few candida
  hyphae in spite of high serum and saliva
  antibodies to candida.
• Differential Diagnosis
• Inflammatory papillary hyperplasia.

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Chronic Hyperplastic Candidiasis(Candida
Leukoplakia)

• Etiology
• Oral Candidiasis lesions should be considered as
  potentially premalignant. Treatment should be
  directed toward mucosa and Leukoplakia.
• Appearance
• Confluent leukoplakic plaques characterized by
  Candida invasion of oral epithelium with marked
  atypia.

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Angular Cheilitis

• Etiology
• Diminished occlusal vertical dimension
• Vitamin B or iron deficiencies
• Superimposed candidiasis
• Affects approximately 6 of General Population
• Appearance
• Wrinkled and sagging skin at the lip commisures.
• Desiccation and mucosal cracking.

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Angular Cheilitis

• Differential Diagnosis
• Dry chapped lips.
• Basal cell carcinoma.
• Squamous cell carcinoma.

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Angular Cheilitis

• Rx Nystatin-triamcinolone acetonide ointment.
• Disp 15 gm tube.
• Sig Apply to affected area after each meal and
  qhs. Concomitant intraoral antifungal treatment
  may be indicated.

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Chronic Mucocutaneous Candidiasis
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Diagnostic Criteria

• C.F.U. in Candidiasis can vary from 1,000/ml to
  20,000/ml.
• As an adjunct to saliva samples, smears stained
  with PAS.
• Thus clinical manifestations, salivary culture
  and stained smears are needed to confirm a
  diagnosis of Candidiasis.

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Management of Candidiasis
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Candidiasis

• Rx Nystatin oral suspension 100,000 units/ml.
• Disp 60 ml.
• Sig Swish and swallow 5 ml qid for 5 min.
• Rx Nystatin ointment.
• Disp 15 gm tube.
• Sig Apply thin coat to affected areas after
  each meal and qhs.
• Rx Clotrimazole trouches 10 mg.
• Disp 70 trouches
• Sig. Let 1 trouch dissolve in mouth 5 times
  daily.

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Candidiasis

• Rx for Dentures Improve oral hygiene of
  appliance.
• Keep denture out of mouth for extended periods
  and while sleeping.
• Soak for 30 min in solutions containing benzoic
  acid, 0.12 chlorhexidine, or 1 sodium
  hypochlorite and thoroughly rinse.

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Candidiasis

• Apply a few drops of Nystatin oral suspension or
  a thin film of Nystatin ointment to inner surface
  of denture after each meal.

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Rx for Refractory Candidiasis

• Fluconazole 100 mg (20 tabs 2 tabs stat, then 1
  tab daily).
• Itraconazole 100 mg (20 tabs 1 tab bid).
• 2-4 weeks of Ketoconazole 200 mg (20 tabs, 1 tab
  daily).

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DIAGNOSIS AND MANAGEMENT OF XEROSTOMIA IN THE
ELDERLY PATIENT
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Salivary Gland Dysfunction and Xerostomia (Dry
Mouth)
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• XEROSTOMIA
• Xerostomia (dry mouth) is defined as a subjective
  complaint of dry mouth that may result from a
  decrease in the production of saliva.

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• XEROSTOMIA
• It affects 17-29 of samples populations based on
  self-reports or measurements of salivary flow
  rates.
• More prevalent in women.
• Can cause significant morbidity and a reduction
  in a patients perception of quality of life.

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SALIVA

• It keeps the teeth healthy by providing a
  lubricant, calcium and a buffer.
• It also helps to maintain the health of the gums,
  oral tissues (mucosa) and throat.
• It also plays a role in the control of bacteria
  in the mouth.

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• It helps to cleanse the mouth of food and debris.
  
• It provides minerals such as calcium, fluoride,
  and phosphorus.
• It helps in swallowing and digesting food.

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• Lack of saliva will make the mouth more prone to
  disease and infection.
• Lead to a burning feeling.

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Antimicrobial Factors in Human Whole Saliva
Non-immunoglobulin Factors Origin Lysozyme Sal
ivary glands, crevicular fluid (PMNs) Lactoferrin
Salivary glands, crevicular fluid
(PMNs) Salivary peroxidase Salivary glands
SCN- Salivary glands, crevicular fluid
H2O2 Salivary glands, crevicular fluid
(PMNs), bacterial and yeast
cells Myeloperoxidase Crevicular fluid (PMNs)
Cl- Salivary glands, crevicular
fluid Agglutinins, aggregating proteins Salivary
glands Histidine-rich polypeptides Salivary
glands Proline-rich proteins Salivary
glands Immunoglobulin Factors Secretory
IgA Salivary glands IgA, IgG,
IgM Crevicular fluid