ĐĎॹá>ţ˙ €‚ţ˙˙˙~˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁ5@ đż0]bjbjĎ2Ď2 +^­X­Xˇ+˙˙˙˙˙˙ˆ2222222Fngngngng‚gŒFivňhhhhhhhhÄuĆuĆuĆuĆuĆuĆu$[wR­ypęu92jhhjjęu22hh#vŻoŻoŻojf2h2hÄuŻojÄuŻoŻoĹop•22¨uhh ŕçq•cĽÁng}n˜uÄu9v0iv uz“nz¨uFF2222z2¨uhZth@Żo´h4čh/hhhęuęuFF$3j43Ľo FFj4DISEASES OF ORAL CAVITY Dr. Nusrum Iqbal Department of Medicine Lahore Medical & Dental College Lahore Disorders affecting the teeth Teething Discoloration of teeth Odontogenic infections Facial space infections Necrotizing fasciitis Teething Teething is traditionally blamed for a variety of signs and symptoms in infancy Causes Restlessness Finger sucking Gum rubbing Drooling Discoloration of teeth Odontogenic infection They arise mainly as a consequence of caries leading to pulpitis then pariepical infection Facial space infection They are usually polymicrobial, predominantly anaerobes They are dangerous ( swelling ( obstruct air ways/ erode carotid vessels/ toxicity Admit to hospital Start high dose antibiotics Necrotizing fasciitis Uncommon Potentially lethal infection of the subcutaneous tissue and deep facia with necrosis of the overlying skin due to thrombosis of blood vessels Mortality 30% Variety of micro-organisms like ˛ haemolitic streptococci, anaerobes Predisposing conditions are diabetes mellitus and immunodeficiency Pain is disproportionate to the clinical appearance Initially there is no fever but with in 24-48 hours there is a rapid rise in the temperature Penicillin or a cephalosporin plus metronidazole are indicated Disorders affecting the oral mucosa Oral ulcers Recurrent aphthae White and red lesions Desquamative gingivitis Oral hyperpigmentation Oral Ulcers Very common Most are traumatic or recurrent aphthae Serious causes must always be excluded A clinical history is of a great value Causes Local causes Trauma Chemical irritation Burns Irradiation Recurrent aphtae Neoplasms Squamous cell carcinoma Others Systemic Causes Mucocutaneous diseases Lichen planus Chronic ulcerative stomatitis Pemphigus Pemphigoid Localized oral purpura Erythema multiforme Epidermolysis bullosa Dermatitis herpetiformis Linear IgA disease Behcet’s and Sweet’s syndromes Systemic Causes Connective tissue and other diseases Lupus erythematosus Reiter’s dyndrome Vasculitides Giant cell arteritis Wegener’s ganulomatosis Periarteritis nodosa Systemic Causes Blood diseases Leucopenias including HIV disease Leukaemias and myelodysplastic syndrome Deficiency states or anaemia Hypereosinophilic syndrome Systemic Causes Gastrointestinal disease Coeliac disease Crohn’s disease Ulcerative colitis Systemic Causes Infections Viral mainly Herpes viruses Coxsackie viruses ECHO viruses Bacterial acute necrotizing gingivitis Syphilis Tuberculosis Epithelioid angiomatosis Systemic Causes Infections Fungal Cryptococcosis Histoplasmosis Paracoccidioidomycosis Blastomycosis Zygomycosis Aspergillosis Protozoal Leishmaniasis Recurrent aphthae They are recurring mouth ulcers that typically start in childhood Very common and affect upto 25% of the population at sometime Students have a higher incidence A disease is usually self limiting A few patients associate the ulcers with the stress, particular foods or trauma Deficiency of iron, folate or vit. B12 however are found in 10-20% of patients Treatment Mouth wash of oral chlorxidine gluconate is useful Topical steroids may be useful Lignocaine gel or viscous solution may relieve pain Features of recurrent aphthae Onset usually in childhood or adolescence Typically round or ovoid ulcers Recurrences at intervals Usually self-limiting. Ulcerative typically ceases before middle age Causes of dry mouth Latrogenic Drugs (antimuscarinics; sympathominetics) Cancer therapy (irradiation of salivary glands, radioactive iodine, cytotoxic drugs) Graft-versus-host disease Salivary gland disease Aplasia Sjogren’s syndrome Sarcoidosis HIV disease Infiltrates (amyloidosis; haemochromatosis) Cystic fibrosis Others Dehydration Diabetes mellitus Diabetes insipidus Renal failure Haemorrhage Other causes of fluid loss or deprivation Oral Hyperpigmentation Congenital Racial (even in some Caucasians) Naevi Syndromes Preutz-Jeghers syndrome Carry complex Laugier-Hunziker syndrome Oral Hyperpigmentation Acquired Endocrine or metabolic Addison’s disease ACTH therapy ACTH-producing tumours (lung cancer) Haemochromatosis Nelson’s syndrome Neoplastic Melanoma Kaposi’s sarcoma Metals Amalgams tattoo Bismuth, mercury, lead, silver Oral Hyperpigmentation Acquired Drugs Smoking Antimalarials Cytotoxics (busulphan particularly) Oral contraceptives Phenothiazines Minocycline Zidovudine Clofazimine Others HIV infection and AIDS Dry Mouth Drugs Irradiation Sjogren’s syndrome and HIV infection Sialorrhoea (hypersalivation) It should distinguished from drooling It can be induced by Lesions in the mouth Foreign body Rabies Anticholinesterases/ Clozapine Psychogenic Salivary gland swellings Inflammatory Mumps Bacterial ascending sialadenitis Obstructive sialadenitis Sjogren’s syndrome Sarcoidosis HIV infection Angiolymphoid hyperplasia Kimura’s disease Neoplastic Pleomorphic adenoma and others Endocrine and metabolic Alcoholic cirrhosis Diabetes mellitus Acromegaly Malnutrition or bulimia Cystic fibrosis Chronic renal failure Amyloidosis Haemochromatosis Drugs (rarely) Isoprenaline Phenylbutazone Iodides Chlorhexidine Halitosis Oral infections (especially periodontal) Dry mouth Foods, or smoking Drugs Solvent abuse Alcohol Chloral hydrate DMSO (dimethyl sulphoxide) Systemic disease Respiratory tract tumours and infections (nose, sinuses, pharynx, larynx, bronchi, lungs) Cirrhosis and liver failure Renal failure Diabetic ketosis Gastrointestinal disease Psychogenic disorders Esophageal disease Psychogenic Globus hystericus Organic Mouth Xerostomia Inflammatory or neoplastic lesions Pharynx Inflammatory or neoplastic lesions Foreign bodies Sideropenic dysphagia Pouch Oesophagus Benign stricture Carcinoma Esophageal disease Scleroderma External pressure from mediastinal lymph nodes Neutrological and neuromuscular causes Achalasia Syringobulbia Cerebrovascular accidents Cerebrovascular disease (pseudobulbar palsy) Motor neurone disease Guillain-Barre syndrome Poiomyelitis Diphtheria Cerebellar disease Myopathies Myasthenia gravis Muscular dystrophies dermatomyositis Gastroesophageal reflux disease It is described as the retrosternal burning caused by gastric content reflux into the esophagus. Development of GERD Multifactorial Structural abnormalities of the antireflux barrier Dysfunction of the lower esophageal sphincter (most common) mainly the transient LES relaxations(TLESRs) Medications like Ca channel blockers, TCAs, nitrates and anticholinergics Content of meals ( Gastric distension cause more TLESRs) Foods high in fats (direct relaxations of the LES) Acidic drinks ( cola, orange juice, tea, and beer) Classical Symptoms Heart burn Acid regurgitation Less Classic symptoms Water brash ( hypersalivvation associated with episode of the reflux) Dysphagia Globus sensation Extra esophageal symptoms Chronic cough ( asthma, bronchitis and aspiration) Hoarseness Dental erosions Atypical symptoms Noncardiac chest pain Importance of GERD Associated with impairment in quality of life Risk factor for Barrett esophagus (a premalignant condition) Diagnosis of GERD There is no single “ gold standard” study to assess all the manifestations of GERD Clinical history Acid suppression test 24 hour ambulatory esophageal pH monitoring Barium upper GI tract radiography Endoscopy Gastroesophageal scintigraphy Bernstein test( an intraesophageal acid infusion test) Who Needs a Diagnostic Test? Initial symptoms of unclear etiology Lack of substantial response to adequate acid suppression therapy History and symptoms suggestive of GERD complications Atypical or extraesophageal symptoms that are possibly related to GERD Typical symptoms but objective confirmation of the diagnosis before antireflux surgery is performed What Test is needed? Typical symptoms ( acid suppression test) Absence of any substantial improvement in the symptoms is an indication for EGD and 24 hour ambulatory esophageal monitoring Alarm symptoms like long duration of symptoms, dysphagia, hematemesis or malena, and weight loss ( EGD) New onset of symptoms of any functional gastrointestinal disorder, including GERD, in patients older than 65 also requires investigation Atypical noncardiac chest pain( acid suppression test) Extraesophageal symptoms ( 24 hour pH monitoring) Medical Management Treatment Rationale Managing the typical and atypical symptoms of GERD Preventing complications Maintaining relief of symptoms Treatment Options Lifestyle changes Self medications H2 receptor blocker Motility agents Proton pump inhibitors Anti reflux surgery Baclofen/ domperidone Motility Disorders of Esophagus Pharyngeal pouch Achalasia Diffuse esophageal spasm Nutcracker esophagus Systemic sterosis Benign esophageal stricture Pharyngeal pouch Incoordination of swallowing within the pharynx leads to herniation through the cricophryngeus muscle and formation of a pouch Most patients are elderly Regurgitation, halitosis and dysphagia can occur Barium swallow demonstrate the pouch and reveals incoordination of swallowing Surgical myotomy and resection of the pouch are indicated in symptomatic patients Achalasia It is characterized by a hypertonic lower esophageal sphincter which fails to relax in response to the espophageous swallowing wave and decrease peristalsis in the body of esophagus Cause is unknown Degeneration of ganglion cells with in the sphincter and the body of the esophagus occurs Chagase disease cause by trypanosoma cruzi is one cause of achalasia Clinical Features Middle life Dysphagia develops slowly and is initially intermittent. It is worse for solid and is eased by drinking liquids, standing and moving around after eating Heart burn doesn’t occur Severe chest pain Nocturnal pulmonary aspiration Predisposes to squamous carcinoma Investigations Chest radiograph Widening of the mediastinum Features of aspiration pneumonia Fluid level behind a cardiac shadow Barium swallow Tapered narrowing of the lower esophagus Dilated esophageal body, aperistalsis Endoscopy To rule out carcinoma Manomentry High pressure, nonrelaxing lower esophageal sphinter with poor contractility of the esophageal body Management Endoscopic Forceful pneumatic dilatation Injection of botulium toxin Surgical myotomy (Heller’s operation) Diffuse Esophagus spasm Late middle age Episodic chest pain which may mimic angina Accompanied by transient dysphagea Some cases occur in response to GERD Oral or submingual nitrates or nifidipine may relieve attacks Nutcracker esophagus Is a condition in which extremely forceful peristaltic activity leads to episodic chest pain and dysphagia Systemic Sclerosis Muscle of the esophagus is replaced by fibre tissue Esophageal peristalsis fails Heart burn and dysphagia are common Esophagitis is often severe Benign fibre strictures can occur Long term therapy with proton pump inhibitors drugs Benign Esophageal Stricture Consequence of GERD gh†íöG N  Ž $ o p z { Ý ó  9]ĂĎQXÍÝÁŃk{ hx%Źž-˛łŃy4KÇŢŔ×…Čćw5@_wDNŻÂ™Ź!(!‰!!1#D#b#x#Ů#ó#A$S$i$öďčöďöďöďöďöďŢďŢďöďÓďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďhŸchŸcmHsH jŕđhŸchŸc hŸc5\ hŸchŸchŸchŸc5\S)@`gh†§žÖěíöF G N [ j w  ˜ Ž úúúúúúúňňňňňúúňúňęęęęúúňúúú & FgdŸc & FgdŸcgdŸc]ţ $ \ Ż Á Ý ó ü Š ˜ J Ň : ô 9]i{‘ŠŔÁÂĂĎŰúúňňňňúęęęęęęęęúňňňňňúúúúňň & FgdŸc & FgdŸcgdŸc*QXel€†’Ł­ĹÍÝô *5L`v˘ÁŃ÷÷ň÷ęęęę÷÷ęęňâÚÚÚÚÚÚÚÚÚÚň & FgdŸc & FgdŸc & FgdŸcgdŸc & FgdŸcŃö )>Vk{ŠŹÔń 5EUhxƒ‘ ˛ż÷ďďďďďďę÷ďďďďęâÚÚÚę÷ďŇŇŇ & FgdŸc & FgdŸc & FgdŸcgdŸc & FgdŸc & FgdŸcżćďü%07FUlz†”žŹž?a„Ô#-`÷÷÷÷ňę÷ââââââ÷âňâââââââÚÚ & FgdŸc & FgdŸc & FgdŸcgdŸc & FgdŸcłŃű4y˜Â1HPco{§ˇžĘÜďţ 4÷ňęęęęňâÚÚÚâÚÚÚÚÚÚÚâÚÚÚÚÚ & F gdŸc & F gdŸc & FgdŸcgdŸc & FgdŸc4KVw}‡Ÿ­ÇŢçţBSepyŠ‘ĄŔ×úňęęęâââúâÚŇŇŇŇŇÚŇŇÚŇŇú & F gdŸc & FgdŸc & FgdŸc & FgdŸc & FgdŸcgdŸc×áçďý!5DP[gn…•ĄšÇČć #8EL÷ďççççççççďçâÚÚÚÚââÚÚŇŇŇ & FgdŸc & FgdŸcgdŸc & F gdŸc & FgdŸc & FgdŸcLkwŁÄÝđü $5@_w‹¨ŔĐćň.÷÷ňęââââââââęâęââââââââęââ & F gdŸc & F gdŸcgdŸc & FgdŸc.6DNw“™§ŻżÚëEao€™ŻÂÎŕčîů÷÷ňęęęęââââęââââââňÚŇÚÚŇ & FgdŸc & FgdŸc & F gdŸc & F gdŸcgdŸc & F gdŸců$GVms~™Ź¸ç  & @ m ƒ › ¨ ł Ć Ń ă ř ÷ď÷÷÷÷ď÷÷ęâââÚÚÚÚÚÚÚÚÚÚÚÚ & F gdŸc & F gdŸcgdŸc & FgdŸc & FgdŸcř !(!‰!!Ź!ß!H"’"Ë"ţ"1#D#O#b#x#ž#Č#Ů#ó#&$1$A$S$÷ňęňâââââââňÚÚňŇŇŇňŇŇŇň & FgdŸc & FgdŸc & FgdŸc & FgdŸcgdŸc & F gdŸcS$i$|$Ş$ç$ů$L%]%s%Ÿ%Á%Ë%é% &=&b&¤&Ú&!'…'š'Ä'A(Š(2)i)÷ňęęňââââââââňâââââňÚÚÚÚÚ & FgdŸc & FgdŸc & FgdŸcgdŸc & FgdŸci$|$ç$ů$ &=&…'š'›)Ă)/*A*É*é*`+q+Ű,ĺ,L.^.p//ä0ď0]1u172L2¸2Ë2˛3Ď3ă3\]]]öďöďöďöďöďöďöďöďöďöďöďöďöďöďöďöďíďŕÜhŸchŸchŸc56\]U hŸchŸchŸchŸc5\$i)›)Ž)Ă)ö)*/*A*S*d*x*ˆ*Ÿ*ł*É*é*ú*++2+D+`+q+đ+ ,÷ňęâââňÚÚÚÚÚÚÚňÚÚÚÚÚÚňŇŇ & FgdŸc & FgdŸc & FgdŸc & FgdŸcgdŸc & FgdŸc ,;,‰,Ű,ĺ,œ-­-.L.^.j.¤.////N/p///Ź/Î/ň/0+0Q0\0r0÷÷÷ň÷÷÷÷ň÷÷÷÷÷÷÷ňęâââęââęâ & FgdŸc & FgdŸcgdŸc & FgdŸcr0~0â0ă0ä0ď0ú0151[1\1]1u1…1°1Ô1ů172L2¸2Ë2˙23@3÷ďęęęâÚÚâęęęŇŇŇŇŇęâęĘĘĘ & FgdŸc & FgdŸc & FgdŸc & FgdŸcgdŸc & FgdŸc & FgdŸc@3\3~3˛3Ď3ă3&\{\×\]]]]]÷÷÷ň÷÷÷÷÷ňňňđgdŸc & FgdŸc Occurs most often in elderly patients Rings occur at esophagogastric junction (schatzki ring) cause intermittent dysphagia Post cricoid web is a rare complication of iron deficiency anemia (plummer-vinson syndrome) Benign strictures are treated by endoscopic dilatation Thank you… )0P:pŸc°Đ/ °ŕ=!°"°# $ %°œ@@ń˙@ NormalCJ_HaJmH sH tH DA@ň˙ĄD Default Paragraph FontRi@ó˙łR  Table Normalö4Ö l4Öaö (k@ô˙Á(No Listˇ+^˙˙˙˙)@`gh†§žÖěíöFGN[jw˜Ž     $\ŻÁÝóüŠ˜Ý!U˛ń!3Iaxyz{‡“ťâ $8>J[e}…•ŹşŘâí.GZy‰ŽÂÔáö#3BdŒŠÄÔíý 0 ; I X j w ž § ´ Í Ý č ď ţ $ 2 > L V d v ¸ ÷  < Œ Ű ĺ  7 k ‰ ł Ó ě 1 E P z Ď é '3_ov‚”§śÂě/5?We–ŸśČŐú (1BIYx™Ÿ§ľŮíü&=GMYq€žĹŰđý#/HU[|•¨´ÂÜíř/CU`xˆžŞťĘ×ćîü/9KQ_gw’Łý'8Qgz†˜ ŚąÔÜ˙%+6GQdpŸĆĐŢř%;S`k~‰›°ŔŕAUd—Jƒśéü0v€‘ŤŢéů !4bŸą+WyƒĄŘő\’Ů=R|ůaę! 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