Man Ali

8/4/2019 Man Ali

http://slidepdf.com/reader/full/man-ali 1/93

8/4/2019 Man Ali


IMMUNOLOGICALDISEASES OF THE

ORAL CAVITYBY MISS MANALI NAGAONKAR

3RD

BDS

2

8/4/2019 Man Ali


RECURRENT APTHOUS STOMATITIS

• RECURRENT APTHOUS MAJOR

• RECURRENT APTHOUS MINOR

•

RECURRENT APTHOUS HERPITIFORM

3

8/4/2019 Man Ali


ETIOLOGY

• BACTERIAL INFECTION

• IMMUNOLOGICAL ABNORMALITIES

• IRON VIT B 12 DEFICIENCY ….FOLIC ACID

DEFICIENCY• ENDOCRINE

• TRAUMA

•PRECIPITATING FACTORS

• PSYCHIC FACTORS

• ALLERGIC FACTORS

4

8/4/2019 Man Ali


RECURRENT APTHOUS MINOR

(CANKER SORES)• MORE IN WOMEN

• BTWEEN 10 TO 30 YRS OF AGE SINGLE OR MULTIPLESOLITARY ,COVERED BY GREY MEMBRANE,NECROTICCENTRE ,ERYTHEMATOUS HALO

•

VERY PAINFUL,DIFFICULTY IN SPEECH AND EATING• 2 TO 3 MM IN DIAMETER MANIFESTATIONS …..BURNING

SENSATION ,PARASTHESIA ,MALAISE,EDEMA ,VESICLE LIKELESIONS CONTAINING MUCUS

• SITES …..BUCCAL AND LABIAL MUCOSA ,BUCCAL AND

LINGUAL SULCI ,SOFT PALATE ,PHARYNX• PERSISTS FOR 7 TO 14 DAYS

• NO EVIDENCE OF SCARRING

5

8/4/2019 Man Ali


6

8/4/2019 Man Ali


7

8/4/2019 Man Ali


8

8/4/2019 Man Ali


RECURRENT APTHOUS MAJOR

• LARGE,PAINFUL,1 TO 10 N NO ,MORE SEEN IN HIV

• SITE- LIPS ,CHEEK ,TONGUE,SOFT PALATE

• DYSPHAGIA AND PAIN

• 1 CM IN DIAMETER ,PERSISTS FOR UPTO 6 WEEKS

,LEAVE A SCRA UPON HEALING

• FEMALES MORE AFFECTED

• SEVERE FORM…..PENIS,VAGINA,RECTUM,LARYNX

,RHEUMATOID ARTHRITIS ,CONJUCTIVITIS

9

8/4/2019 Man Ali


10

8/4/2019 Man Ali


11

8/4/2019 Man Ali


12

8/4/2019 Man Ali


RECURRENT APTHOUS HERPITIFORM

• CROPS OF MULTIPLE,SMALL ,SHALLOW ULCERS ,UPTO 100IN NO

• SITE ….IN THE ORAL CAVITY

• LESIONS ON THE INTRA ORAL MUCOSAL SURFACE

• AS SMALL PIN HEAD EROSIONS THAT ENLARGE• MORE PAINFUL

• PRESENT CONTINOUSLY FOR ONE TO THREE YRS

• TEMPORARY RELIEF WITH 2% TETRACYCLINE MOUTHWASH

•

NON KERATINISED MOVABLE AREAS ARE MOSTLY• AFFECTED

• SIMILAR TO HSV INFECTION

13

8/4/2019 Man Ali


HISTOLOGIC FEATURES

• MINOR APTHOUS SHOWS FIBRINOPURULENT

MEMBRANE

• INTENSE INFLAMMATION,LYMPHOCYTES ON

….PMNS ,LYMPHOCYTES ,EPITHELIAL

PROLIFERATION ,GRANULATION TISSUE

• TISSUE INVOLVEMENT GENERALLY

SUPERFICIAL

14

8/4/2019 Man Ali


15

NON-SPECIFIC MICRSCOPIC PICTURE

• Early – central zone of ulceration covered byfibrinoprulent memberane

• Connective tissue – increased vascularity andmixed inflammatory cellular infiltrate

• Marginal epthelium – spongiosis and

numerous mononuclear cells• Presence of band of lymphocytes intermixed

with histocyte in superficial connective tissue.

8/4/2019 Man Ali


DIFFERENTIAL DIAGNOSIS

16

• No defINitive lab. Diagnosis, depends on theclinical presentation

• Lesions can be mistaken for recurrent

aphthous stomatitis include herpecticstomatitis, herpangina, erythema multiforme,

erosive lichen planus, pemphigus and

pemphigoid.

8/4/2019 Man Ali


TREATMENT AND PROGNOSIS

17

Immune enhancement

• Levimisole

• Vaccine

Immunosupression, inflammatory suppression

• Prednisone• Triamcicinolo acetonide

• Betamithasone-17-benzoate

• Antihistamine

Antibiotics• Suspension ,topical

• Chloramphenicol.

• Broad-spectrum antibiotics.

8/4/2019 Man Ali


18

Diet supplementation.

• Vitamin B12,folic acid .

• Iron.

• Zinc sulfate.

Symptomatic treatment .

• Xylocaine/lidocaine.

• Silver nitrate .

• Benadryl ,topical.

• Camphor – phenol .

8/4/2019 Man Ali


BEHCTES SYNDROME

19

• Disease of uncertain etiology .

• May resemble infectious diseases.

• National institute of health in 1977- humoral

antibodies and cell mediated immune responsesmay act either jointly or independently upon oralepithelium .

• Recurrent aphthous ulcer and Behcet ‘s syndromecan not be distinguished by antibodies and cellmediated immune responses .

• HLA MARKERS DIFFERENTIATE

8/4/2019 Man Ali


CLINICAL FEATURES

20

• More common in young adults (25 to 40 yrs).

• 5 to 10 times more common in males .

• Characterized by oral , genital ulcerations and ocular , skin lesions .

• First manifestation – appearance of oral and genital lesions witherythematous border .

• Genital ulcers are small located on scrotum, root of the penis ,orlabia majora .

• Ocular lesions – photophobia ,irritation , simple conjunctivitisuveitis

• Skin lesionssmall puspules or macules , erythema nodosum and

erythema multiform.• DISTINGUISHING FACTORS – CLASSIC TRIAD OF THE DISEASE

PRESENT

8/4/2019 Man Ali


8/4/2019 Man Ali


22

8/4/2019 Man Ali


A common case of HLA B 27 UVEITIS

23

8/4/2019 Man Ali


Histologic features :

• Nonspecific remarkably similar to recurrentaphthous ulcer .

• Endothelial proliferation .

• Vasculitis .Laboratory findings .

• Hypergyamaglobulinemia .

•

Mucocytrosis• Eosinophilia .

• Elevated ESR .

8/4/2019 Man Ali


TREATMENT AND PROGNOSIS

SYMPTOMATIC OR SUPPORTIVE MEASURES

25

8/4/2019 Man Ali


REITERS SYNDROME

• TYPICAL TETRAD ….NON ONOCCAL URETHRITIS,ARTHRITISCONJUNCTIVITIS,MUCOCUTANEOUSLESIONS

•

MALE TO FEMALE RATIO ….9 : 1• URETHRITIS IS THE FIRST SIGN

• ARTHRITIS …BILATERAL POLYARTICULAR

• SKIN LESIONS – RED OR YELLOW KERATOTICMACULES OR PAPULES WHICH DESQUAMATE

• HLA B 27 IS THE FACTOR PRESENT ,SEEN IN HIV

26

8/4/2019 Man Ali


SITES ….

27

8/4/2019 Man Ali


28

8/4/2019 Man Ali


ORAL MANIFESTATIONS

29

• Painless ,red,slightly elevated areas

,sometimes granular or even vesicular with

white circinate border on buccal mucosa ,lips

and gingiva .(pindborg etal)

• Palatal lesions – small bright red purpuric spot

which darken and coalesce .

• Geographic tongue appearance

• Circinate balanitis

8/4/2019 Man Ali


GEOGRAPHIC TONGUE

30

8/4/2019 Man Ali


Histologic features.

• No diagnostic findings .

• Parakeratosis ,acanthosis and

polymorphonuclear leukocyte infiltration of

epithelium .

• Microabscess formation .

• Connective tissue – lymphocyte and plasma

cell infiltrate .

8/4/2019 Man Ali


Sarcoidosis (boeck’s sarcoid ,besnier-

boeck-schaumann disease)• Multi system granulomatious disease of unknown origin

characterized by the formation of uniform discrete compactnoncaseating epitheloid granulomas ,black>white .

• Etiology – infective and non infective .

•

Most favored infective (mycobacterium and propionibacterium).

• Associated with tuberculosis .(Gupta D et al)

• Most common in lungs ,skin , lymph nodes ,salivaryglands,spleen and bones.

DEPRESSION OF DELAYED TYPE HYPERSENSITIVITY,IMPAIREDCELL MEDIATED IMMUNITY ,INCREASE OR ABNORMALSERUM IMMUNOGLOBULINS ,LYMPHOPROLIFERATION

8/4/2019 Man Ali


Clinical features .

SITES …LUNGS,SKIN,LYMPH NODES,SALIVARY

GLANDS ,SPLEEN AND BONE

• Commonly seen in young and middle age.

• Mild malasise and cough – chief features .• Cutaneous lesions – 25 to 35 %.

• Multiple red patches that occur in group growslowly and do not tend to ulcerate .

• Hepatomegaly and splenomegaly .

• ERYTHEMA NODOSUM

8/4/2019 Man Ali


34

8/4/2019 Man Ali


MULTIPLE RED PATCHES

35

8/4/2019 Man Ali


Oral manifestation .

• Sarcoid granulomas – labial glands – 58%.

• Lesions on lip – small papular nodules or

plaques resemble fever blisters .

• Palate and buccul mucosa- bleblike ,

containing clear yellowish fluid OR SOLID

NODULES

8/4/2019 Man Ali


37

8/4/2019 Man Ali


Histologic features .

• No acid fast organisms can be demonstrated .

• Nest of epithelioid cells with multinucleated

giant

• cells-chief feature .

• Also contains T and B cells, various

immunoglobulins .

• Caseation and necrosisn do not occour .

8/4/2019 Man Ali


39

8/4/2019 Man Ali


Uveoparotid fever .

• Form of sarcoidosis .• Firm painless usually bilateral .Enlargement of parotid gland

• Inflammation of uveal tracts of the eye , cranial nerve involvement,submandibular sublingual and lacrimal gland involvement .

• Often presence of chronic low grade fever .

• Symptoms :• Lassitude

• Malaise

• Vague GI disturbances , nausea , vomiting .

• Xerostomia

• Patchy erythema on skin.

8/4/2019 Man Ali


• Enlargement of cervical lymph nodes .

• Lesions – uveoparotitis,conjunctivitis,uveitis , keratitis ,CORNEAL HERPES

• Signs and symptoms disappears in time

while parotid swelling and visualdisturbance may persist

• SEVENTH NERVE PARALYSIS .

8/4/2019 Man Ali


MIDLINE LETHAL GRANULOMA

• IDIOPATHIC PROGRESSIVE DESTRUCTION OF THENOSE ,PARANASAL SINUS ,PALATE ,FACE ANDPHARYNX

• DYSFUNCTION OF IMMUNE MECHANISM

…..GRANULOMA FORMATION • AFFECTED PERSON LACKS RESISTANT TO THE

PROGRESS OF THE DISEASE

• ASSOCIATD WITH NEOPLASTIC ANDINFLAMMATORY DISEASE

• MOST UNUSUAL CONDITION

42

8/4/2019 Man Ali


CLINICAL FEATURES

• ULCERATION OF PALATE AND NASAL SEPTUM ,STUFFINESS IN

THE NOSE

• PALATAL AND NASAL AND MALAR BONES INVOLVES

• PURULENT DISCHARGE ,PERFORATING SINUS TRACTS

,SLOUGHING OF THE SOFT TISSUES LEAVING A DIRECT

OPENING INTO THE NASOPHARYNX AND ORAL CAVITY

• VASCULAR ALLERGY ,ARTHUS PHENOMENON,PERIARTERITIS

NODOSA ,

• PATIENT ULTIMATELY DIES OF EXHAUSTION OR OF

HAEMORRHAGE IF A LARGE BLOOD VESSE BECOMES ERODED

43

8/4/2019 Man Ali


44

8/4/2019 Man Ali


45

8/4/2019 Man Ali


Histologic features:

• Extensive necrosis with infiltration of some inflammatory cells

• the formation of occasional new capillaries .

• TREATMENT:

•

Usually fatal diseases .• Corticosteriod therapy .

• Coupled with antibiotics for secondary infection .

• Some authorities believe that the disease is best treated with

high dose of radaition therapy.

8/4/2019 Man Ali


WEGENER’S GRANULOMATOSIS

• CLINICAL FEATURES

• INFANTS TO ELDERLY ,MAJORITY IN 4 TH OR 5 TH DECADE OF

THE LIFE

• MALE PREDOMINANCE

• RHINITIS,OTITIS,SINUSITIS

• COUGH,HEMOPTYSIS,FEVER,JOINT PAINS,HAEMORRHAGIC OR

VESICULAR SKIN LESIONS

•

GRANULOMATOUS LESIONS OF THE LUNG• GLOMERULONEHRITIS …..UREMIA…..TERMINAL RENAL

FAILURE

47

8/4/2019 Man Ali


Oral manifestations

• Involvement of gingiva strawberrygingivitisulcerations

• Starts from interdental papilla-spreads toperiodontal structures and lead to bone loss ,

tooth mobility .• Hyperplastic gingivitis(Israelson et al)

• Ulceration of palate due to extension of diseasefrom nose.

• Spontaneous exfoliation of teeth and failure of healing after removal of tooth.

8/4/2019 Man Ali


STRAWBERRY GINGIVITIS

49

8/4/2019 Man Ali


HISTOLOGIC FEATURES

• MIXED INFLAMMATION AROUND THE BLOOD

VESSELS

• VASCULITIS

• ORAL BIOPSY ….PSEUDOEPITHELIOMATOUS

HYPERPLASIA AND SUBEPITHELIAL ABSCESS

• GINGIVAL LESIONS …SCATTERED GIANT CELLS

50

8/4/2019 Man Ali


Laboratory findings

• Anemia

• Leukocytosis

• Elevated E.S.R.

• Hyperglobinemia

• Hematuria

•

Some patients- circulating immune complex.

8/4/2019 Man Ali


TREATMENT

• PREDNISONE

• CYCLOPHOSPHAMIDE

52

8/4/2019 Man Ali


Chronic granulomatous disease

• Uncommon herediatary CONDITION caused due x

linked mode of tranmission.

• Majority patients are males

• Characterised by severe reccurent infection as aresult of defect of intracellular leukocyte enzyme

formation

• Failure to destroy catalase positive organism.

A VARIANT TRANSMITTED AS AN AUTOSOMAL

RECESSIVE CHARACTERISTIC

8/4/2019 Man Ali


CLINICAL FEATURES

CLINICAL FEATURES

INFECTION FROM INFANCY …..LUNG

,LIVER,SPEEN,BONE,ECZEMATOUS LESIONS ON

THE FACE ,LEADING TO NECROSIS AND

GRANULOMA FORMATION

ABSCESS ,SEPTICAEMIA

,PNEUMONIA,PERICARDITIS ,MENINGITIS,OSTEOMYLELITIS

54

8/4/2019 Man Ali


Oral manifestation

• Diffused stomatitis with or without solitary or

multiple ulcerations.

• benign migratory glossitis

• Enamel hyperplasia in very rare cases

8/4/2019 Man Ali


Histologic features

• Small granulomas with mononuclear

histocytes

• Multiple inulated giant cells

• Central necrosis with polymorphonuclear

leukocyte may also be present.

8/4/2019 Man Ali


Diagnosis and treatment

• Diagnosis:- neutrophil function test

• Treatment :- vigorous treatment of infection

Angioedema (angioneurotic edema

8/4/2019 Man Ali


Angioedema (angioneurotic edema,

Quincke’s edema)

• Diffused erythematous swelling of skin mucosa and submucosal connective tissue.,

• Results in death due to GI or respiratory tractinvolvement.

• Pathogenesis:-

1] allergic angioedema (due to mast cell degradation)

2] associated with use of ACE inhibitors

3]activation of complement pathway• Presence of high level of antigen antibody complex

• Grossly elevated peripheral blood eosinophillic count.

8/4/2019 Man Ali


Clinical features

• Soft,non tender,diffuse edematous,solitary ormultiple

• Lips ,chin,eyes,tongue,pharynx,larynx,hands,arms,legs,genitals

and buttocks• Enlargement usually resloves within 24 to 72 hrs

• Git symptons include pain ,vomitting,waterydiarrhoea

• Perioral or periorbital oedema

• Skin colour normal or slightly pink

59

8/4/2019 Man Ali


60

8/4/2019 Man Ali


TREATMENT

Antihisatmines

Laryngeal involvement ….intramuscular

epinephrine

Iv corticosteroids

C1 – inh deficiency respond to intubation and

tracheotomy

Androgens such as danazol ,stanazol for

hereditary and acquired form

61

8/4/2019 Man Ali


Drug allergy

• IGE MEDIATED REACTIONS …ANTIBODY BINDS

TO THE DRUG THAT IS ALREADY ATTACHED TO

THE CELL SURFACE

• IN NON IMMUNOLOGIC DRUG REACTIONS,DRUGS DIRECTLY AFFECT THE MAST CELLS

WHICH CAUSES RELEASE OF CHEMICAL

MEDIATORS

62

8/4/2019 Man Ali


Clinical features :

• Skin lesions , arthralgia ,fever,

lymphadenopathy and rarely agranulocytosis .

• Common drugs aspirin , barbiturates ,

chloromphenicol, tetracycline ,penicillin ,streptomycin and sulphonamides .

8/4/2019 Man Ali


treatment

• Antihistamines (cortisone)

• Adrenaline

• Corticosteroids

64

8/4/2019 Man Ali


Oral manifestation .

• Stomatitis medicamentosa .

• Ulceration, necrosis, hemorrhage , gingivalhyperplasia.

• Altered salivary function .

• Altered taste sensation.

• Allergic reactions erythema multiforme ,

• Negative patch taste .

•Localized erythema and edema .

• Gingiva – necrotizing gingivitis or vincent’s diseases .

• Hairy tongue .

8/4/2019 Man Ali


HAIRY TONGUE

66

8/4/2019 Man Ali


CONTD

• Intraoral fixed drug reactions

• Lichenoid drug reactions

• Elongation and staining of filiform papillae

,producing a heavy coating of the tongue

• Anaphylactic stomatitis

67

8/4/2019 Man Ali


Histologic features.

• Non specific patterns .

• Admixture of lymphocytes ,eosinophils and

neutrophils .

• Vacuolar changes of basal layer and individual

necrotic epithelial cells .

• Distinctive annular fluorescence

pattern.(string of pearl’s ).

• Basal cell cytoplasmic antibody .

8/4/2019 Man Ali


Treatment

• Antihistamines ( cortisone )

• Adrenaline

• Corticosteroids

• Anaphlactic stomatitis …antihistamines

69

8/4/2019 Man Ali


Contact stomatitis and dermatitis

• Causative agent chemical in nature

• Haptens

• Require conjugation with proteins to become

effective

• Process occurs with the aid of intra epithelial

langerhans cells

70

• DENTAL OR COSMETIC PREPARATIONS .

8/4/2019 Man Ali


1. Dentrifrices .

2. Mouth washes .

3. Denture powder .

4. Lipsticks , candy ,cough drops, chewing gum .

• DENTAL MATERIALS :

1. Rubber dam .

2. Vulcanite .

3. Alcrylic .

4. Metal alloy base .

•

DENTAL THERAUPATIC AGENTS :1. Alcohols

2. Antibiotics

3. Iodides ,phenols

4. Procaine .

8/4/2019 Man Ali


Clinical features

• Stomatitis venenata

• Itching and burning sensation

• Skin becomes rough and dry

• Appearance of erythema

• Vesicle formation

•

Vesicle rupture …it becomes more severe

72

8/4/2019 Man Ali


Oral manifestations .

• Mucosa – remarkably inflamed and edematous .

• Bright red gingiva in all quadrants .

• Buccal mucosa – puffy , dark red , revealing ,engorged and

ejected superficial capillaries on closure examination .

• Zone of ulceration – lips .

• Chronic cases – mucosaerythematous , hyperkeratotic

• Scaling , fissuring , or cracking of vermillion lip border.

•

Contact stomatitis .

8/4/2019 Man Ali


Histologic features

• Intra and inter cellular edema of the

epithelium along with the vesicle formation

within the epithelium or at the basement

membrane• Increased eosinophils

• Lymphocytes and plasma cells

• Engorged and dilated blood vessels

• Connective tissue – edema

74

8/4/2019 Man Ali


Diagnosis and treatment .

• Diagnosis – patch test

• Treatment- removal of offending material

Contact stomatitis with cinnamon

8/4/2019 Man Ali


Contact stomatitis with cinnamon

flavouring

• Toothpaste –plasma cell gingivitis ,edema

,erythema

• Erythematous mucositis of the buccal mucosa

and tongue ,exfoliative chilitis ,circumoraldermatitis

• Lingual keratosis

• Buccal mucosa – oblong,hyper keratotic

lesions with an erythematous base

76

8/4/2019 Man Ali


Contact stomatitis .

• Cinnamon oils –flavoring agent .

• Used in ice-cream , soft drinks alcoholic

beverages processed meats ,gum , candy

,tooth paste and mouth washes .

8/4/2019 Man Ali


78

l f

8/4/2019 Man Ali


Histologic features .

• Acanthotic epithelium with elongated reteridges thinned suprapapillary palates .

• Hyperkeratosis and neutrophil exocytosis is

observed .• Connective tissue exhibits a diffuse chronic

inflammatory infiltrate predominantlyconsisting of lymphocytes .

• Characteristic perivascular infiltration of lymphocytes .

d

8/4/2019 Man Ali


Treatment and prognosis

• Reaction disappears within a week of

discontinuance of cinnamon products

• Reappears with use of cinnamon products

80

Contact stomatitis from chronic oral

8/4/2019 Man Ali


Contact stomatitis from chronic oral

mucosal contact with dental amalgam

• neurotoxicity ,kidney dysfunction, reduced

incompetence, alterations of oral and

intestinal flora , birth defects ,

• Contact lichenoid reactions to amalgam

81

8/4/2019 Man Ali


8/4/2019 Man Ali


83

B f l

8/4/2019 Man Ali


Because of gloves ….

84

Cli i l d hi t l i l f t

8/4/2019 Man Ali


Clinical and histological features .

• Commonly seen in posterior buccal mucosa,ventral borders of the tongue and gingival cuffsadjacent to subgingival amalgam restorations.

•

White or ertythematous with or without striae .• Histologically features similar to lichen planus like

hydropic degeneration of basal cell layer .

• Hyperkeratotic or atropic epithelium ,and dense

band- like chronic inflammatory infiltrateconsisting predominantly of lymphocytes areobserved

T t t d i

8/4/2019 Man Ali


Treatment and prognosis .

• Improving oral hygienic ,smoothening,polishing ,and recontouring of the restoration

before adopting aggressive measures .

• Amalgam replaced with a non-metallicrestoration .

P i l d titi

8/4/2019 Man Ali


Perioral dermatitis

• Skin disease of the circum oral area due totartar control,bubble gum ,night creams

,toothpaste, moisturizers

• Topical corticosteroids is inciting agents

87

Cli i l f t

8/4/2019 Man Ali


Clinical features

• Pruritis

• Female predominance

• Lesions as papules or papulopustules

• Surface surrounding the vermillion border of

the lip ,with zone of spared skin immediately

adjacent to the vermillion border .

88

8/4/2019 Man Ali


89

Hi t l i f t

8/4/2019 Man Ali


Histologic features

• Rosacea like pattern

• Chronic lymphohistiocytic dermatitis

• Mimicking sarcoidosis

90

T t t d i

8/4/2019 Man Ali


Treatment and prognosis .

• topical corticosteroid and prescribing topicalmetronidsazole

• With out topical tetracycline .

• Recurrences are uncommon.

Bibliography

8/4/2019 Man Ali


Bibliography

• Shafer’s textbook of oral pathology

92

8/4/2019 Man Ali


Man Ali

Documents

Transcript of Man Ali