Transcript 2 Traumatic lesions

Traumatic lesions.
Clinic, diagnostics, treatment.
Oral ulcers
How to diagnose?
What is an ulcer?
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A mouth or oral ulcer is an open sore in the
mouth, or rarely a break in the mucous
membrane or the epithelium on the lips or
surrounding the mouth.
Epidemiology and frequency
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Mouth ulcer is a very common oral lesion.
Epidemiological studies show an average
prevalence between 15% and 30%. Mouth ulcers
tend to be more common in women and those under
45.
The frequency of mouth ulcers varies from fewer
than 4 episodes per year (85% of all cases) to more
than one episode per month (10% of all cases)
including people suffering from continuous recurrent
aphthous stomatitis
What cause ulcers?
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Trauma (physical injuries)
Chemical injuries
Smoking
Infection
- viral
- bacterial
- fungal
- protozoans
Immunodeficiency
Autoimmunity
Allergy
Dietary
Tools for diagnosis:
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History
Examination
Further investigation
Additional diagnostic methods – biopsy
Further investigation – questions you
should ask:
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How long have you had that ulcer?
How many ulcers do you have?
Is it painful?
Can you relate them to any trauma, hot food
or another factors?
Is it the first time or you had them before?
Where are they located in the mouth?
Do they start as ulcer or as vesicle/bulla?
Do you get them anywhere else on the body?
Step by step guide to performing an oral
cavity examination
Things you need to look for:
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Site
Number
Size
Shape
Base
Edge
Differential diagnostic, based on history
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How long have you had the ulcer?
Long time – chronic
1.
Chronic trauma (single, can identify the cause,
and should improve after removal)
2.
Malignancy (single, painless)
3.
TB (single ulcer in the tongue/palate,
associated symptoms – chronic cough)
4.
Mucous membrane pemphigoid (multiple ulcers
affect mainly gingiva, blood filled blisters)
5.
Primary or tetriary syphilis
Recent – acute
1.
Acute trauma (single, can identify the
cause, and should improve after removal)
2.
Viral infection (multiple, associated
symptoms – fever)
3.
Immune mediated disease (Erythema
multiforme, RAS)
How many ulcers do you have?
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1.
2.
3.
4.
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1.
2.
Single
Traumatic
Primary or tetriary syphilis
TB
Malignancy
Multiple
Viral infection
Immune mediated disease
Is it painful?
Yes
Acute causes (trauma, viral, immune mediate)
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No
Chronic causes (trauma, TB)
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Can you relate them to trauma or hot
food?
Yes
1.
Confirm traumatic ulcer
2.
Remove the cause
3.
Review after 1 week
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No
Look for other causes
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Do you get them anywhere else on the
body?
No
Think or oral conditions
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Yes – where?
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Skin – mucocutanous disease (lichen
planus, pemphigus)
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Traumatic lesions
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Mechanical trauma (acute or chronic)
Chemical injury (acid, alcali)
Physical injury (thermal injury, electrical
injury)
Mechanical trauma
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1.
2.
Can be:
Acute
Chronic
And caused by:
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6.
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A sharp edge of a
tooth
Accidental biting
Sharp, abrasive,or
excessively salty food
Poorly fitting dentures
Dental braces
Trauma from a tooth
brush
Patients bad habits
Dental braces
Acute trauma
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Single,
can identify the cause
should improve after
removal
Traumatic ulcers:
Clinical features
of traumatic ulcers:
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•They are clinically diverse, but usually appear as a single,
painful ulcer with a smooth red or whitish-yellow surface and a
thin erythematous halo.
•They are usually soft on palpation, and heal without scarring
within 6–10 days, spontaneously or after removal of the cause.
•However, chronic traumatic ulcers may clinically mimic a
carcinoma.
•The tongue, lip, and buccal mucosa are the sites of predilection.
•The diagnosis is based on the history and clinical features.
•However, if an ulcer persists over 10–12 days a biopsy must be
taken to rule out cancer.
Treatment
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Removing factors, caused trauma
Good hygiene of oral cavity
Antiseptic for 7-10 days
Analgetics if it is necessary
Topical steroids may be used for a short
time.
Biopsy
Leukoplakia
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Etiology:
-​trauma from habitual biting,
dental appliances
-​tobacco use
-​​alcohol consumption
-oral sepsis
-​local irritation
-syphilis​
-vitamin deficiency
-​endocrine disturbances​​
-dental galvanism
-actinic radiation (in the case of
lip involvement).
Symptoms - painless, fuzzy
white patches on the side of
the tongue or cheeks.
Clinic
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-​located on the tongue, mandibular alveolar ridge and buccal
mucosa in ~50%.
-​palate, maxillary alveolar ridge, lower lip, floor of the mouth and
the retromolar regions are somewhat less frequently involved.
-​may vary from nonpalpable, faintly translucent white areas to
thick, fissured, papillomatous, indurated lesions.
-​surface is often wrinkled or shriveled in appearance and may
feel rough on palpation.
-​color may be white, gray, yellowish-white, or even brownish-gray
in patients with heavy tobacco use.
Physical:
-​lesion cannot be wiped away with a gauze
Differential diagnosis:
1.
Candidiasis and aspirin burn - can be wiped
away with a gauze
2.
Erythroplakia (a red plaque that does not
rub off), is a dysplastic lesion (or worse) in
90 percent of cases.
Treatment
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Treat dental causes such as rough teeth,
irregular denture surface, or fillings as soon
as possible.
Stopping tobacco or/and alcohol.
Removal of leukoplakic patches with
using a scalpel, a laser or an extremely cold
probe that freezes and destroys cancer cells
(cryoprobe).
Chemical injures:
Chemicals such
as aspirin or alcohol
that are held or that
come in contact with
the oral mucosa may
cause tissues to
become necrotic and
slough off creating an
ulcerated surface.
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Treatment:
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Wash a mouth with lot of water
Analgetics (for 3-5 days )
Antiseptics ( for 7 – 10 days)
Keratolytics (after 5-7 days)
Keratoplastics (after 7-10 days)
Physical injures:
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Electric Burns to the Mouth
-are most commonly
caused when a child bites
into a cord, touches the
male ends of a "live" but
improperly connected cord,
or sucks on the female end
of an extension cord that is
plugged into the wall. The
vast majority of the patients
is younger than three years.
Treatment:
Conservative
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Antiseptics
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Antibiotics
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Analgetic
2. Surgical (after the healing was completed
and after the degree of functional and/or
aesthetic deformity was established (usually
6 months post-injury)).
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Stomatitis
Description
Stomatitis is an inflammation of the lining of any of the soft-tissue
structures of the mouth. Stomatitis is usually a painful condition,
associated with redness, swelling, and occasional bleeding from
the affected area. Bad breath (halitosis) may also accompany the
condition. Stomatitis affects all age groups, from the infant to the
elderly.
 Definition
Inflammation of the mucous lining of any of the structures in the
mouth, which may involve the cheeks, gums, tongue, lips, and
roof or floor of the mouth. The word "stomatitis" literally means
inflammation of the mouth. The inflammation can be caused by
conditions in the mouth itself, such as poor oral hygiene, poorly
fitted dentures, or from mouth burns from hot food or drinks, or
by conditions that affect the entire body, such as medications,
allergic reactions, or infections.
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Herpetic stomatitis
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Herpetic stomatitis is a
viral infection of the
mouth that causes
ulcers and
inflammation. These
mouth ulcers are not
the same as canker
sores, which are
caused by a different
virus.
Symptoms:
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Blisters in the mouth, often on the
tongue, cheeks, palate, gums, and a
border between the lip (red colored)
and the normal skin next to it
Decrease in food intake, even if the
patient is hungry
Difficulty swallowing (dysphagia)
Drooling
Fever (often as high as 104
°Fahrenheit) may occur 1 - 2 days
before blisters and ulcers appear
Irritability
Pain in mouth
Swollen gums
Ulcers in the mouth, often on the
tongue or cheeks -- these form after
the blisters pop
Causes
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Herpetic stomatitis is a contagious viral illness
caused by Herpes virus hominis (also herpes
simplex virus, HSV). It is seen mainly in young
children. This condition is probably a child's first
exposure to the herpes virus.
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An adult member of the family may have a cold sore
at the time the child develops herpetic stomatitis.
More likely, no source for the infection will be
discovered.
Differential diagnostics:
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Streptococcal pharyngitis –does not involve the lips
or perioral tissues and vesicles do not precede the
ulcers
Erythema multiforme – ulcers are larger, usually
without a vesicular stage and are less likely to affect
the gingiva.
Aphthous stomatitis – the multiply lesions, palatal
and gingival location are indicative to herpesvirus
infection. Additionally, aphthae usually localized
only on nonceratinized mucoza, such as the floor of
the mouth, alveolar mucosa and buccal mucosae.
Treatment:
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Good oral hygiene
Acyclovir family of antiviral medications – non
later than 48 hours!
Analgetic ( or oral topical anesthetic )
Diet (no hot or pepper food)
Antiseptics
Aphthous Ulcers
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Of all the type of
nontraumatic ulcaration
that affect oral mucosa
that is the most
common.
Aphthous ulcers are also
known as canker sores.
They are painful,
temporary sores that may
occur anywhere in the
mouth. Usually, they
show up in several
places:
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On the inside of the lips
Inside the cheeks
On the tongue
At the base of the gums
Canker sores on tongue:
Etiology:
Immune system disorders
Other conditions cause similar sores:
Blood and immune system diseases,
including HIV
Vitamin and mineral deficiencies
Allergies
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Trauma
Crohn's disease
Lupus
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Clinical features:
Three forms of aphthous ulcers have been recognized:
minor, major and herpetiform.
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Major Ulcerations (> 0,5cm)—10% of lesions
extremely painful (odynophagia)... typically heal with scar formation
Appearance- deeply cratered ulcers
Duration- > 1 month for healing.
Location- posterior oral cavity.
Number – 1- 10
NOTE- THINK OF HIV DISEASE PROGRESSION OR IMMUNOSUPPRESION
Minor Ulceration (1-5 mm)—85% of lesions
painful… heal without scar formation
Duration- 7-10 days
Location- anterior oral cavity
Number – 1-5
Herpetiform Ulceration (1-3mm lesions that form clusters)—5% of lesions.
Sxs- as above (but more severe)
Number – 10-100
Locational – any intraoral site
Minor ulcers:
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Are the most commonly
encountered form
Single, painful oval
ulcer less than 0,6 mm,
covered by a yellow
fibrinous membrane
Last 7 to 10 days
Periods of freedom
from disease – 2-3
weeks to year
Major ulcers:
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Lesions are larger: more
than 10 mm
More painful
Persist longer that minor
aphthae
One ulcer disappears,
another one starts
Healing generally occurs in
6 weeks and longer
Chronic stress, common
disease can cause
Herpetiform ulcers
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Recurrent crops of
small ulcers
Healing generally
occurs in 1 to 2 weeks
Not preceded by
vesicle and exhibit no
virus-infected cells
Treatment:
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Oral hygiene
Avoiding spicy food
Oral rising with sodium bicarbonate
Analgesics
Antiseptics
Anti – inflammatory agents
Antimicrobial and corticosteroids
Noma
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also known as cancrum oris or gangrenous
stomatitis, is a gangrenous disease leading
to tissue destruction of the face, especially the
mouth and cheek.
Noma (derived from the Greek "nomein" meaning
"to devour") is a devastating gangrenous disease
which attacks children, quickly destroying their
mouth, nose, and face, and which can prove fatal
after just a few weeks. Noma, also known as
cancrum oris, seems to start on the gum and
extends outwards to the cheeks and lips.
NOMA FACTS
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NOMA FACTS
Mainly attacks children 2-14
years old.
Africa accounts for the
majority of the cases.
The World Health
Organization estimates that
100,000 children contract
noma every year.
Without treatment, the
mortality rate is 70-90%.
Most victims starve to death
because their jaw muscles are
literally eaten away and they
cannot chew; others die as the
infection spreads.
key players in the process :
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Fusobacterium necrophorum
Prevotella intermedia
Borrelia vincentii
Porphyromonas gingivalis
Tannerella forsynthesis
Treponema denticola
Staphylococcus aureus
The reported predisposing factors include:
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The reported predisposing factors include:
Malnutrition or dehydration
Poor oral hygiene
Poor sanitation
Unsafe drinking water
Proximity to unkempt livestock
Recent illness
Malignancy
An immunodeficiency disorder, including AIDS
Symptoms:
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The early features of noma include soreness of the mouth,
a swollen tender cheek,
a foul-smelling purulent oral discharge,
fetid odor in the mouth of the affected child,
swelling of the regional lymph nodes,
anorexia,
grayish-black discoloration of the skin in the affected area.
The long-term effects of Noma depend largely on the anatomic
sites of the lesion, the extent and severity of tissue destruction
and the stage of development of the dentition and facial skeleton
prior to onset of the disease.
Treatment:
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The progression of the disease can be halted
with the use of antibiotics and improved
nutrition;
however, its physical effects are permanent
and may require reconstructive plastic
surgery to repair.
Reconstruction is usually very challenging
and it should be delayed until full recovery
(usually about one year following initial
intervention)