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Stomatitis


Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Treatment (2)
Differentials
Etiology

Frequently children <5 yrs old by HSV-1 infection.

Pathophysiology

Oral inflammation and Ulcers that may be mild and localized or severe and widespread.

Risk Factors

Recurrent aphthous stomatitis (RAS), Viral infection, trauma, tobacco, Xerostomia (dry mouth)

Symptoms

Initial burning sensation, sore throat, excess salivation, bad breath, inability to eat, pain in mouth, fever

Clinical Findings

Fever (up to 104* F), pharyngeal edema, and erythema, w/ vesicular or ulcerative lesion on oral & pharyngeal mucosa, dehydration

Treatment

1)Lesions heal without treatment in 7-10 days.
2)Tylenol or Ibuprofen is appropriate. 3) Topical treatment lidocaine, Soft diet w/out acidic or salty foods

Differentials

aphthous stomatitis, erythema multiforme, syphilitic chancre, carcinoma, and Coxsackieviruscaused lesions
Aphthous Ulcers

Etiology
Symptoms
Clinical Findings
Treatment
Etiology

idiopathic recurrent ulcers, found in all areas of oral mucosa except hard palate, gingiva, and vermilion. Aka canker sore, ulcerative stomatitis

Symptoms

Painful 7-10 days, healed in 1-3 weeks.

Clinical Findings

Minor: flat & <1 cm in diameter Major: raised borders >1cm, last weeks or months herpetiform: clusters of very small ulcers. Yello-gray fibrinoid centers w/red halos

Treatment

Topical corticosteroids (triamcinolone acetonide). Lidocaine topicals, chlorhexidine topical mouthwash
Lichen Planus

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

Skin disease occurs most commonly in pts 30-60 yrs of age
•Cell mediated immunity plays a role
•drugs
•hepatitis C

Pathophysiology

Recurrent, pruritic , inflammatory eruption resulting from keratinocyte apoptosis.

Risk Factors

women>men

Symptoms

•Pain and sensitivity to certain foods
•Chronic exacerbations and remissions
• Itching

Clinical Findings

•Reticulated, lacy, bluish-white, linear lesions (Wickham's stiae) are hallmark
•oral ulcers
•milky white papules
• erythematous flat papules on wrist, forearms, genitalia

Dx/Labs

histopathology

Treatment

• Topical glucocorticoids
• Intralesional triamcinolone 3mg/ml for oral mucosal lesions
•cyclosporine 5mg/kg per day

Differentials

Oral leukoplakia
Behcet's Syndrome

Etiology (3)
Pathophysiology
Risk Factors (2)
Symptoms
Clinical Findings
Dx/Labs (3)
Treatment (3)
Etiology

• Unknown, rare
• common in young people 20-30 yrs of age
• genetic predisposition

Pathophysiology

Multi-organ vasculitic inflammation with one major feature, recurrent oral aphthous ulcers.

Risk Factors

• Highest in Japan, South East Asia, the Middle East, and Southern Europe
• males > females

Symptoms

recurrent oral aphthous ulcers, genital ulcers, fatigue, superficial thrombophlebitis, skin pustules, iridocyclitis, posterior uveitis. Eye problems as well.

Clinical Findings

"punched out" Ulcers of 3 to 10mm with rolled overhanging borders and necrotic base

Dx/Labs

• Dermatopathology
• (+)Pathergy test -> formation of pustule within 48 hrs
• HLA typing. Association with HLAB5 and HLA-B51

Treatment

• Potent topical glucocorticoids
• Intralesional triamcinolone, 3 to 10mg/ml injected at ulcer base
• Thalidomide, 50-100 mg by mouth in the evening
Erythema Multiforme

Etiology (3)
Pathophysiology (2)
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment (3)
Differentials
Etiology

• acute blistering eruption that occurs in all age groups, though young adults most commonly
• most common cause of minor is Herpes Simplex • most common cause of major (AKA Stevens-Johnson syndrome) is drugs (allopurinol, phenytoin, NSAIDS and sulfa drugs)

Pathophysiology

• Minor is localized popular eruption of the skin – most often seen in lower labial mucosa
• Major is widespread vesicularbullous lesions and erosions of the mucous membranes (“bulls eye” lesions seen on skin with central bulla)

Risk Factors

Males>females

Symptoms

• In major causes pain on eating, swallowing and urination

Clinical Findings

erythematous macules and edematous papules with vesicular centers that become dusky violet.
• Lesions found on hands and feet

Dx/Labs

• Skin biopsy

Treatment

•oral acyclovir prophlaxis
•diphenlydramine elixir mixed with kaopectate oral wash
• Erythema major is best treated in a burn unit

Differentials

Urticaria -> goes away within 24 hrs
Candiasis of the Mouth

Etiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs (2)
Treatment (3)
Etiology

aka Thrush, caused by yeasts of Candida albicans
• chewing tobacco
• precancerous if can't be scrapped off

Risk Factors

immunosuppressed individual, AIDS/HIV infection, Uncontrolled diabetes mellitus or anemia, Dentures

Symptoms

Pain, Thrush that often presents on side of tongue

Clinical Findings

White plaques on buccal mucosa, palate, oropharynx, or tongue. Scrapping lesion reveals erythematous, nonulcerated mucosa under plaques.

Dx/Labs

KOH preparation or Gram stain

Treatment

•Topical antifungal (nystatin or clotrimazole)
•Prophylactic use of fluconazole or itraconazole
•Dentures must be removed and properly cleaned
Herpes Stomatitis (gingivostomatitis)

Etiology (2)
Pathophysiology
Symptoms
Clinical Findings
Treatment
Etiology

• HSV-1
• frequent in children < 5 yrs old

Pathophysiology

Infection occurs via inoculation onto susceptible mucosal surface or break in the skin.

Symptoms

Abrupt onset, w/ sore throat, excess salivation, bad breath, inability to eat. Fever, irritability malaise initial presentation several days before the lesions appear.

Clinical Findings

Oral or perioral vesicles. Lip lesions -> ulcerate -> crust. Fever as high as 40 * C (104* F)

Treatment

Lesions heal w/o tx in 7-10 days, supportive tx w/ Tylenol or Ibuprofen. Topical tx w/combination diphenhydramine & Maalox. Children < 12 use oral Acyclovir
Oral Leukoplakia

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

Candida-but not eliminated w/ antifungal meds Contains large quantities of Epstein-Barr virus

Pathophysiology

White patch of mucosal tissue and oral mucosa and larynx, progresses to cancer of a period of 30 years in 30% of patients.

Risk Factors

Immunodeficient individuals

Symptoms

white patches on tongue, gums, roof of your mouth, Usually painless, but may be sensitive to touch, heat, spicy foods, or other irritation.

Clinical Findings

White plaque most frequently on lateral surfaces of tongue bilaterally, small to irregular "hairy" or "feathery" lesions with prominent fold or projections that cannot be scraped off

Dx/Labs

Biopsy HIV antibody test

Treatment

Referral: Consultations with dentists, dermatologists, or infectious disease specialist

Differentials

-Candidiasis of the mouth
-Lichen planus
Parotitis

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

Mumps virus (paramyxovirus) -acute systemic viral infection usually occurring in children 5-9 yrs old

Pathophysiology

Inflammation of parotid glands. Highly contagious.

Risk Factors

unvaccinated, international traveler

Symptoms

Fever
Malaise
Headache
anorexia
ear pain

Clinical Findings

Painful, swollen parotid glands (around angle of jaw)
Swollen salivary glands
Facial edema
Mild leukoplakia
lymphocytosis

Dx/Labs

Viral swab, Serum IgM if orig assay was negative.

Treatment

Treat symptoms, usually parotitis is self limiting unless complicated by orchitis, pancreatits, meningitis.

Differentials

parainfluenza, coxsackievirus, HIV, EBC, influenza A, Sjogrens syndrome,, parotid duct obstruction, sarcoidosis
Sialadenitis

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

Can be bacterial or from duct obstruction

Commonly affects submandibular or parotid gland.

*Usually unilateral

Pathophysiology

Can be bacterial infection of salivary glands.

Decrease in salivary flow predisposes an individual for infection.

Risk Factors

Dehydration Associated w/ chronic illness
Sjogren syndrome

Symptoms

•Acute swelling
•↑ pain & swelling during meals
•Foul taste in mouth
•Dry mouth
•Fever
•Facial pain
•↓ ability to open mouth
•Swelling of face

Clinical Findings

•Swelling & pain of salivary glands
•Tenderness and erythema of duct opening
•Exudate can be massaged from duct
•May have ductal plug

Dx/Labs

Culture any exudate
ultrasound or CT scan to rule out tumor


Treatment

oral penicillinase-resistant antibiotic, such as cloxacillin or dicloxacillin, 500 mg, every 6 hours (if bacterial)
Hydration
Warm compress
Sialagogues (lemon drops)
Massage gland

Differentials

Mumps, sarcoidosis, tuberculosis, parotid and submandibular tumor, dental abscess
Sialalithiasis

Etiology
Pathophysiology
Risk Factors
Symptoms
Dx/Labs
Treatment
Differentials
Etiology

Uncertain

Pathophysiology

Intermittent salivary stasis results in an alteration of the mucoid elements of saliva forming an organic gel. This gel becomes the framework for the deposition of salts, which leads to the development of calculi.

Risk Factors

Salivary stasis and ductal inflammation and injury, history of multiple cases of acute suppurative sialadenitis

Symptoms

recurrent episodes of postprandial salivary colic with pain and swelling.

Dx/Labs

Imaging of the salivary glands for sialolithiasis may be accomplished with plain radiographs, conventional and digital sialography, US, CT, and MRI

Treatment

1st line: use of sialogogues, local heat, hydration, and massaging of the involved gland. If salivary gland infection is suspected, prompt antibiotic coverage should be started
2nd line: surgery
Dental Abscess


Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Symptoms

Pain, edema, erythema, drainage, halitosis,

Clinical Findings

Facial pain, gingival swelling, erythema, fistula, granuloma, lymphadenopathy, fever

Treatment

DDS referral: Tooth extraction, pulpectomy or endodontics or treat underlying causes of abcesses.
Fractured Tooth

Symptoms
Clinical Findings
Treatment
Symptoms

Pain, nerve pain

Clinical Findings

Broken or cracked tooth. Fracture line down side of tooth., may extend to pulp

Treatment

Repair or extraction. Abx if infection is likely. PCN, preventative-no ice chewing, hard candy, popcorn kernels. Wear face mask for contact sports. Refer: DDS
Dental Caries

Symptoms
Clinical Findings
Treatment
Symptoms

Pain, sensitivity to cold hot sweets, fever & malaise if infection is persistent

Clinical Findings

Darkened spots on teeth, holes,

Treatment

Good oral hygiene, DDS routine checkups, prevention
Gingivitis

Etiology
Pathophysiology
Risk Factors
Symptoms
Treatment
Etiology

especially in young children

Pathophysiology

Inflam. of the marginal and the interdental papillary portion of the periodontium/ can progress to periodontal disease w/o tx

Symptoms

Gum bleeding/irritaton in oral soft tissues

Treatment

Good oral hygiene, routine cleanings 2 x yr. Waterpick use, brushing bid. Good diet & ↓ sweets PCN 250mg tid refer: Hygienist, DDS for xray to assess bone loss,
Oral cancers

Risk Factors
Symptoms
Dx/Labs
Treatment
Risk Factors

Smoking, chewing tobacco

Symptoms

white or red patches in mouth, mouth sore that won’t heal, bleeding in mouth, loose teeth, problems or pain with swallowing, lump in the neck, earache

Clinical Findings

palpable lesion of the lip, tongue, or other mouth area -> becomes ulcer & bleeds

Treatment

Referral: treatment professionals from the realms of radiation, surgery, chemotherapy, nutrition, dental professionals, and even psychology
Xerostomia (in older adults)

Etiology
Consequences
Etiology

Not age related. Medical conditions and medications are to blame. Medications such as sedatives, antipsychotics, antidepressants, antihistamines, diuretics and anticholinergics. Also, Sjogren's syndrome.

Consequences

  • A dry, sore mouth
  • Halitosis
  • It can restrict dietary choices (and therefore compromise nutrition)
  • Alter sense of taste
  • Chronic esophagitis
  • GERD
  • Dental caries
  • Denture tolerance
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