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.

Recurrent Aphthous Ulcer

• Appearance:• Minor aphthous ulcer: <0.6 cm shallow

ulceration with gray pseudomembrane and erythematous halo on non-keratinized mucosa.

• Major aphthous ulcer: >0.5 cm ulcer, more painful, lasting several weeks to months; will scar.

Recurrent Aphthous Ulcer

• Differential Diagnosis:• Herpes simplex virus.• Chemical/traumatic ulcer• Vesiculoulcerative diseases• Squamous cell carcinoma

• Treatment:• Topical analgesics• Topical steroids

Inflammatory Conditions (Denture Related of the Oral

Mucosa)

• Inflammatory papillary hyperplasia

• Epulis fissurata (inflammatory fibrous dysplasia)

• Candidiasis

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.

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.

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.

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.

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.

Oral Candidiasis

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.

Etiology

Mixed infection of Candida albicans, staphylococci and streptococci.

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.

PAS Stained Candida Albicans Hyphae Embedded in The Oral Mucosa

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.

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.

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.

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.

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.

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.

Angular Cheilitis

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

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.

Chronic Mucocutaneous Candidiasis

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.

Management of Candidiasis

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 trouchesSig. Let 1 trouch dissolve in mouth 5 times daily.

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.

Candidiasis

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

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).

DIAGNOSIS AND MANAGEMENT

OF XEROSTOMIA IN THE ELDERLY PATIENT:

Salivary Gland Dysfunction and Xerostomia (Dry Mouth)

XEROSTOMIA

• Xerostomia (dry mouth) is defined as a subjective complaint of dry mouth that may result from a decrease in the production of saliva.

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 patient’s perception of quality of life.

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.

• 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.

•Lack of saliva will make the mouth more prone to disease and infection.

•Lead to a burning feeling.

Oral Dryness in the Elderly

0102030405060708090

Normal Radiotx Sjogren Drugs

Subjective sensation of oral dryness in the elderly

% P

op

ula

tio

n

Flow Rate of Saliva

0.00.10.20.30.40.5

20-39 yr 40-59 yr > 60 yr

Age

ml /

min

unstimulated

stimulated

Antimicrobial Factors in Human Whole Saliva

Non-immunoglobulin Factors OriginLysozyme Salivary 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 cellsMyeloperoxidase Crevicular fluid (PMNs) Cl- Salivary glands, crevicular fluidAgglutinins, aggregating proteins Salivary glandsHistidine-rich polypeptides Salivary glandsProline-rich proteins Salivary glands

Immunoglobulin FactorsSecretory IgA Salivary glandsIgA, IgG, IgM Crevicular fluid