1) Oral manifestation of gastrointestinal diseases

— Pernicious anaemia (Ulcers, glossitis, angular stomatitis, erythema)

— Any malabsorption (Ulcers, glossitis, angular stomatitis)
— Chronic regurgitation (Tooth erosions, halitosis)
— Crohn’s disease (Mucosal tags, gingival hyperplasia, ulcers, glossitis, angular stomatitis)
— Coeliac disease (Ulcers, glossitis, angular stomatitis, dental hypoplasia)
— Chronic pancreatitis (Sialosis)
— Cystic fibrosis (Salivary gland swelling)
— Garnder’s syndrome (Osteomas)
a) IBS
— Ulcerative colitis: Pyostomatitis vegetans, major and minor aphthous ulcer,
hairy leukoplakia.
— Crohn’s disease: Linear and deep ulcer of vestibule, swellings of lips and face,
angular chelitis
b) Malabsorption
— Pernicious Anemia: Burning mouth, inflamed tongue, glossitis and glossodyria
— Folic acid deficiency anemia: Angular chelitis, aphthous ulcer
c) Eating disorders
Bulimia + Anorexia: Erosions of lingual surfaces of maxillary anterior teeth. Increased risk of
caries and periodontal diseases. Parotid gland swelling, teeth sensitive to thermal changes.
d) GERD — Erosion, mucosal erythema, mucosal atrophy, xerostomia, dysgensia.
e) Genetic disorders
— Gardner: Impacted teeth, supernumerary teeth, osteonsodontomas
f) Metastatic diseases of the jaw
g) Peptic ulcer disease
h) Jaundice

2) Oral manifestations of kidney diseases

— Chronic renal failure: Xerostomia, halitosis/taste disturbance, leukoplakia, dental
hypoplasia, bleeding tendency
— Post renal transplant: Infections (herpetic, candidal), bleeding tendency,
gingival hyperplasia, kaposis sarcoma, hairy leukoplakia
— Renal rickets (Vitamin D resistant): Delayed tooth eruption dental hypoplasia,
enlarged pulp.
— Nephrotic syndrome: Dental hypoplasia

Uremic Stomatitis
when blood urea reaches a level beyond 300 mg/100 ml
Two forms:
a) ulcerative stomatitis
- painful superficial ulcers covered by a pseudomembrane
b) non-ulcerative stomatitis
- painful diffuse edematous erythema with a thick greyish pseudomembrane

- Xerostomia
-uriniferous breath odor
-unpleasant taste
-hemorrhagic tendency and oral bleeding
-candidosis and other opportunistic infections

3) Oral manifestation of respiratory disease

Wegner granulomatosis — Ulcerations and gingival enlargement, strawberry gingivitis
Sarcoidosis — May include multiple, nodular, painless ulcerations of the gingiva, buccal
mucosa, labial mucosa and palate. Palatal gland swelling, Xerostomia, facial nerve palsy,
uveitis
a)
Sarcoidosis
- Painless ulcerations, gingivitis, localized swelling or nodules

b) Heerfordt-Waldenström syndrome
- sarcoidosis
- Xerostomia
-parotid gland swelling
-uveitis
-facial nerve palsy
-teeth loosening
-radiating pain
-nasal obstruction
-mandible tumefaction or maxillary bone loss

c) Lung cancer
- Jaw metastases (mandible), submucosal mass or hyperplastic reactive lesion
(soft tissue metastases)

d) Pulmonary tuberculosis
- Irregular ulcerations (secondary oral tuberculosis, hematogenous spread)

e) Cystic fibrosis
- Xerostomia
-tooth discoloration
-hypoplastic defects
-elevated calcium content, pH and buffering capacity of saliva

f) Wegener granulomatosis
- ―Strawberry gingivitis‖ (petechiae)
-ulcerations (oral mucosa, palate)
-tooth mobility and loss

g) Asthma
- Dental cavities and erosions
-periodontal disease
-candidiasis
-colonization with P. gingivalis (lowers prevalence of asthma)

h) Chronic obstructive pulmonary disease

- Periodontitis
 -thrush
-worsening dental status
-loss of alveolar bone
-colonization of airways from denture plaque biofilm

i) Inhaled medication
- effects on the quantity and quality of saliva
-decreased oral pH (β2 -agonists)
-candidiasis
-dysphonia
-tongue hypertrophy (ICS)
-xerostomia

j) Obstructive sleep apnea syndrome

- Inflammation (pharynx, uvula, soft palate, oral cavity)
- increased oral exhaled NO

4) Oral manifestation of neuromuscular diseases

a) Cerebrovascular disease
- excessive bleeding (due to anticoagulant therapy)
- Xerostomia

b) Amyotrophic lateral sclerosis (ALS)

-lower muscle function
-hyperactive gag reflex

c) Multiple sclerosis
-trigeminal neuralgia

d) Parkinson
-hypersialorrhea
-Xerostomia, due to anti-Parkinson drugs
-root caries and recurrent decay

e) Huntington’s disease
-Dysphagia and choreic movement of the face and tongue

f) Cerebral palsy
-enamel defects
-sialorrhea
g) Bell’s palsy
-masseter weakness
-chorda tympani nerve leads to loss of taste perception on the anterior two-thirds of the tongue
-reduced salivary secretion

h) Myasthenia gravis
-The facial muscles are commonly involved giving the patient an immobile and expressionless
appearance
-Tongue edema

i) Muscular dystrophy
-severe atrophy of the sternomastoid muscles with a resultant difficulty in the ability to turn the
head
-difficulty in chewing or in pursing the lips
-anterior open bite
-macroglossia
 -temporomandibular joint dysfunction

j) Epilepsy
-gingival overgrowth due to anticonvulsants

5) Gingival overgrowth
Gingival enlargement can be grouped into 4
categories: a) Inflammatory gingival enlargement
May be localized or generalized and is an inflammatory response that occurs when
plaque accumulates the teeth
b) Medication induced gingival enlargement
In contrast to inflammatory gingival disease, the gum tissues are firm, non-tender, pale
pink and does not bleed easily.
Stop medication (if patient can’t) surgical removal of the excess gingiva (gingectomy) may
be preformed but the condition will likely recur again
c) Hereditary gingival fibrzomatosis
Usually develops during childhood, slow growing generalized or occasionally enlargement of
the gingiva.
Surgical removal
d) Systemic causes of gingival enlargement
Pregnancy, hormonal imbalances, leukemia. Systemic conditions usually resolves when the
underlying condition is treated.

6) Loss of tongue cover

a) Atrophic glossitis
- smooth glossy tongue, caused by complete atrophy of the lingual papillae
- The dorsal tongue surface may be affected totally, or in patches
- burning sensation
-pain and/or erythema
-caused by: iron-deficiency anemia
pernicious anemia
B vitamin complex deficiencies
unrecognized and untreated celiac disease
xerostomia
Candidiasis may be a concurrent finding
b) Median rhomboid glossitis
- persistent erythematous, rhomboidal depapillated lesion in the central area of the dorsum of the
tongue, just in front of the circumvallate papillae
- is a type of oral candidiasis
c) Geographic tongue
- affects the dorsal surface of the tongue
- characterized by patches of depapillation and erythema bordered by a whitish peripheral zone
- burning sensation may be present
d) Geometric glossitis
- chronic lesion associated with herpes simplex virus (HSV) type I
- deep fissure in the midline of the tongue, which gives off multiple branches
- very painful
-erosions present in the depths of the fissures
- described as occurring in immunocompromised persons
e) Strawberry tongue
- hyperplastic (enlarged) fungiform papillae, giving the appearance of a strawberry
-can be red or white coating through which the papillae are protruding
-white strawberry occurs in scarlet fever and becomes red strawberry after 4-5 days
-also seen in Kawasaki syndrome and toxic shock syndrome
7) Oral manifestations of cardiovascular diseases
Hypertension (there are no recognized manifestations of hypertension but anti-hyperative
drugs can cause side effects) such as: Xerostomia, gingival overgrowth, salivary gland
swelling or pain, lichenoid drug reactions, erythema multiforme, taste sense alteration,
paresthesia.
Angina pectoris: Drugs used in t/t of angina may cause oral adverse effects like: Lichenoid
reaction, gingival swelling, ulcers (due to Ca channel blockers)
Rheumatic fever: (Strep throat): pain on swallowing, red and edematous soft palate and
oropharynx, areas of tonsillar ulceration and exudation
Rhemumatic heart disease: Increased oral temperature, pharyngitis, most prominent during
acute phase, distended neck veins and a bluish color of the skin.
Heart failure: Distentions of the external jugular veins, bleeding tendencies, bleeding can be
spontaneous or extravasational.
Cardiac arrhythmia’s: Agranulocytosis, oral ulceration, xerostomia, gingival hyperplasia.

8) Oral manifestations of psychosomatic diseases

a) Myofascial pain dysfunction syndrome (MPDS)
b) Atypical facial pain
c) Atypical odontogenic pain
d) Phantom pain
e) Burning mouth syndrome
f) Idiopathic xerostomia
g) Idiopathic Dysgeusia
h) Glossodynia
i) Glossopyrosis
j) Dental and periodontal diseases caused by bruxism
k) Biting of oral mucosa (self mutilation)
l) Oral lichen planus
m) Recurrent aphthous stomatitis
n) Psoriasis
o) Mucous membrane pemphigoid (MMP)
p) Erythema multiforme (EM)
q) Recurrent herpes labialis
r) Necrotising ulcerative gingivostomatitis
s) Chronic periodontal diseases (CPD)
t) Cancerophobia
u) Bruxism
-all these are caused due to stress, anxiety, drug abuse etc.
9) While lesions of oral mucosa
Lesions of the oral mucosa which are white results from a: thickened layer of keratin,
epithelial hyperplasia, intracellular epithelial edema, reduced vascularity
White lesions — Leukoplakia Hairy
leukoplakia Lichen
planus Linea alba
Nicotinic
stomatitis Uremic
stomatitis

Cinnamon contact stomatitis

Chemical burn
Candidiasis
Chronic biting
Geographic tongue
Hairy tongue
Furred tongue
Leukodema
Papilloma
Squamous cell carcinoma
Skin and mucosal grafts
Epithelial peeling
White sponge nevus
Verricous
carcinoma

10) Red lesions of oral mucosa

Red lesions are large heterogenous group of disorders of the oral mucosa, traumatic lesions,
infections, developmental anomalies, allergic reactions, immunologically mediated diseases,
premalignant lesions, and systemic diseases are included in this group. The red color of the
lesions may be due to thin epithelium, inflammation, dilatation of blood vessels or increased
numbers of blood vessels and extravasation of blood into the oral soft tissues.
Traumatic
erythema Thermal
burn Radiation
mucositis Fellatio
Geographic tongue
Median rhomboid glossitis
Denture stomatitis
Erythematous candidiasis
Squamous cell carcinoma
Erythroplakia
Plasma-cell gingivitis
Granulomatous gingivitis
Desquamative gingivitis
Contact allergen stomatitis
Gonococcal stomatitis
Hemangioma
Lupus erythematous
 Anemia
Thrombocytopenic purpura
Infectious mononucleosis
Reiter disease
Peripheral ameloblastoma
Sturge-Weber angiomatosis

11) Efflorescence of oral mucosa (macula, enanthema)

Enanthem or exanthema is a rash (small spots) on the mucosa membranes, it is characteristic
of patients with smallpox, measles, chicken pox and roseola infantum, it can also indicate
hypersensitivity. Hand, foot and mouth disease is a clinical syndrome characterized by an
oral ananthem and a macular, maculopapular or vesicular rash of the hands and feet.

12) Inflammatory hyperplasia of oral mucosa

Chronic irritants — calculus, sharp-edge cavities, overhanging restorations, chronic biting of
lips and cheeks
Prolonged chronic insults cause the body to produce abnormal healing tissues
called granulation tissues.
Ex — Pyogenic granuloma, hormonal tumor, traumatic hemangioma, fibroma,
epulis fissuratum, epulis granulomatous, papillary hyperplasia and peripheral
fibroma with calcification.
Symptoms or signs: (1) very red; (2) fairly soft and (3) polypoid or modular masses.
Microscopically, the lesion reveals granulomatous tissue covered with an intact layer of
stratified squamous non-keratinized epithelium. If the covering of the lesion is traumatixed,
a white necrotic area usually forms in the area of the injury and the lesion is now considered
as a pyogenic granuloma.
Treatment: Excisional biopsy combining with the elimination of the irritant is the
treatment of choice for lesions

13) Principles of therapy in oral medicine

Oral medicine is a specialty of dentistry that deals with:
-diagnosis and management of diseases and conditions that affect the oral and
maxillofacial region
-oral health care of compromised patients

oral medicine deals with 4 major areas:

- diseases of oral mucosa
-diseases or disorders of the orofacial region
-salivary glands
-orofacial pain
diagnosis can be done with clinical examination, and pathohistological examination

14) Medicaments used for treatment of oral diseases

Depending on the disease there’s different medicaments we can prescribe to the patient.
a) Medications to control pain and anxiety
Local anesthesia, general anesthesia, nitrous oxide or IV sedation is commonly used in dental
procedures to help control pain and anxiety.
b) Anti-inflammatory medications
Corticosteroids are anti-inflammatory medications that are used to relieve the discomfort and
redness of mouth and gum problems.
c) Anesthetics
Are used in the mouth to relieve pain or irritation caused by many conditions, including
toothache, sores in or around the mouth. They come in spray, dental paste, gel, ointments and
solutions. (Anbesol, Chloraseptic, Oracle and Xylocaine)
d) Medications to control plaque and
gingivitis Chlorhexidine
e) Antiseptics
f) Medications used to prevent tooth
decay Flouride
g) Dry mouth medications
To stimulate saliva production
Tetracyclines, antifungals.

15) Developmental anomalies of the tongue

a) Microglossia
Small tongue, difficulties in eating and
swallowing b) Macroglossia
Enlarged tongue, down syndrome, beckwith-weidemann syndrome, over development of the
musculature.
Clinical features: Noisy breathing, difficulties chewing/swallowing, drooling, slurred speech,
widened interdental space, open bite, dry/cracked tongue, ulceration
Treatment: Surgical reduction or trimming may be required when macroglossia disturbs the
oropharyngeal function.
c) Ankyloglossia
Can be either complete or partial ankyloglossia. Partial — occurs as a result of shortlingual
frenum or due to a frenum which attached too near to the tip of the tongue. Complete —
occurs as a result of fusion between the tongue and the floor of the mouth.
Treatment: Partial is self corrective, and complete can be surgically treated by frenulectomy
d) Cleft tongue
e) Fissured tongue
f) Median rhomboid glossitis
Treatment: Antifungal agents
(nystatin)
g) Benign migratory glossitis
h) Hairy tongue
i) Lingual varies
j) Lingual thyroid nodule
16) Viral stomatitis and division
There are four common viral infections which cause inflammation of the mouth:
a) Herpes simplex type I
Herpes group of viruses includes: Herpes simplex type I, Herpes varicella-zoostervirus
(VZV), Epstein-Barr virus (EBV), Cytomegalovirus (CMV), Human herpesvirus type -
6,-7,-8
b) Enterovirus — Hand, foot and mouth disease or herpangina
c) Herpes zooster or Varicella infection
d) Measles

17) Avitaminosis
A vitamin deficiency can cause a disease or syndrome known as an avitaminosis or
hypovitamintosis. This usually refers to a long-term deficiency of a vitamin.
Vitamins — organic substances necessary for life, essential for normal functioning of body.
Can be divided into 2 groups: 1) Water-soluble: Vitamin C, all B vitamins
2) Fat-soluble: Vitamin A, D, E and K
Vitamin C deficiency (ascorbic acid): Blood vessels are dependent on Vitamin C to maintain
their collagen, bleeding gums and small hemorrhages under the skin can be signs of
developing vitamin C deficiency. Wounds fail to heal and teeth become loosened because
collagen cannot be formed. Scurvy
Vitamin B promotes growth, improves mental attitude, keeps nervous system, muscles and
heart functioning normally, relieves dental postoperative pain, aids in treatment of herpes
zoster
B2 (Riboflavin) Helps eliminate sore mouth, lips and tongue, benefits vision, skin, nails, hair
Cracks on the side of the mouth are one of the signs of riboflavin deficiency, other symptoms
include, sore throat with redness and swelling of the mouth and throat mucosa, glossitis.
B3 (Niacin) Helps eliminate canker sores and bad breath
Vitamin A promotes growth, strong bones, healthy skin, hair, teeth and gums.
Vitamin D deficiency: Severe tooth decay, rickets, osteomalacia, osteoporosis
Vitamin K deficiency: Nosebleeds, bleeding gums, blood in the urine or stool

18) Epidemiology of herpes zoster and varicella

Herpes zoster (Shingles) occurs as a result of reactivation of the VZV in adult patients, VZV
remains latent in the dorsal root ganglia including trigeminal ganglion, reactivation by
immunosuppression. Zoster is not a transmissible condition but non-immune persons may
attract varicella after close contact with patients with zoster.
Mainly seen in elderly and immunocompromised persons.
Chickenpox varicella is primarily a disease of children with most cases occurring during the
winter and spring most likely due to school contact. It is one of the classic diseases of
childhood, with the highest prevalence in the 4-10 year old age group. Varicella is highly
communicable with an infection rate of 90% in close contacts.

19) Herpetic stomatitis

Herpetic stomatitis is a viral infection affecting the mouth, which results in inflammation and
formation of ulcers. Herpes simplex virus or HSV-1 is the cause behind herpetic stomatitis.
Typically a childhood infection, seen between the ages of 2 and 4 years
old. Incubation period of 4-7 days.
Intraepithelial vesicles — which may be widespread
The oral vesicles break down to leave oral erosion that are initially pin-point, but which fuse
to produce irregular painful erosions. Prominent gingival edema, erythema and the tongue is
often coated. The patient will have a history of generalized prodromal symptoms that precede
oral lesions by 1-2 days, these symptoms include: fever, headache, nausea and vomiting and
cervical lymoth node enlargement.
Recurrent herpetic infections: HSV-1 remains latent in the trigeminal ganglion, these factors
can reactivate the virus: Fever, sunlight, trauma, immunosuppression and can produce herpes
labials and intraoral herpes.
Symptomatic treatment: Soft food and adequate fluid intake are important, antipyretics/
analgesics — paracetamol relieve pain and fever, local antiseptics — 0,2 % aqueous
chlorhexidine mouthwash. Antivirals

20) Hypertrophic changes of tongue cover

-white and black hairy tongue

-after antibiotic therapy
-after steroid therapy
-H2O2 mouth wash
-immunosuppressive drugs
-smoking
-high fever
-constipation
-hyperacidity

21) Decreased salivation/xerostomia

Xerostomia is dry mouth caused by reduced or absent flow of saliva. This condition can
result in discomfort, interfere with speech and swallowing, make wearing dentures difficult,
cause halitosis and impair oral hygiene by causing a decrease in oral pH and an increase in
bacterial growth. Long-standing xerostomia can result in severe tooth decay and oral
candidiasis.
Etiology: Drugs, radiation to the head and neck (for cancer treatment) systemic disorders are
less commonly the cause but xerostomia is common in Sjögrens syndrome and may occur in
HIV/AIDS, uncontrolled diabetes and certain other disorders.
Pathophysiology: Stimulation of the oral mucosa signals the salivatory nuclei in the medulla
triggering an efferent response. The efferent nerve impulses release acetylcholine at salivary
gland nerve terminals activating muscarinic receptors (M3) which increase saliva production
and flow.
Diagnosis: A tongue blade can be held against the buccal mucosa for 10 sec. If the tongue
blade falls off immediately when released, salivary flow is considered normal. Palpate the
submandibular, sublingual and parotid glands. Normal production is 0.3 to 0.4mL/min.
Significant xerostomia is 0.1mL/min.
Treatment: Cholinergic drugs, saliva substitutes, cause treated and causative drugs stopped
when possible, regular oral hygiene and dental care to prevent tooth decay.
22) Functional disorder of hypophysis/ hypo and hyperfunction
Growth hormone (GH) stimulates growth in childhood and is important for maintaining a
healthy body composition and well-being in adults. In adults its important for maintaining
muscle mass and bone mass.
Hyperfunction: Acromegaly — Is a syndrome that results when the anterior pituitary gland
produces excess growth hormone after epiphyseal plate closure at puberty. If GH is produced
in excess prior to epiphyseal plate closure, the result is gigantism.
Features that result from high level of GH include: Soft tissue swelling visibly resulting in
enlargement of the hands, feet, nose, lips and ears and a general thickening of the skin. Soft
tissue swelling of the vocal cords, pronounced brow protrusion, jaw protrusion, with
attendant macroglossia (enlargement of the tongue) and teeth spacing, anterior open bite and
malocclusion.
Diagnosis: MRI
Treatment: Surgical removal, drug therapy and radiation therapy of the pituitary.
Hypofunction: Delayed puberty, microdontia, retarded tooth eruption (eruption cysts), tooth
formation and growth of the alveolar regions of the jaws are abnormal and may be
disproportionately smaller than adjacent anatomic structures, leading to crowding and
malocclusion, poor oral hygiene (because of crowding) and may be prone for gingivitis and
periodontal disease.
— Pituitary dwarfism.

23) Increased saliva/ptyalism

Is excessive production of saliva. Hypersalivation can contribute to drooling if there is an
inability to keep the mouth closed or in difficulty in swallowing the excess saliva (dysphagia)
Etiology: Rabies, Pellagra (niacin or Vitamin B3 deficiency), GERD, pregnancy,
pancreatitis, liver disease, serotonin syndrome, mouth ulcers, oral infections, some
medications and toxins (such as mercury, copper, arsenic).
Treatment: Avoiding the underlying cause, mouth wash or brushing may have drying
effect. Anticholinergics could be considered for symptom management.

24) Specific diseases of salivary glands

— Functional disorders
— Obstructive disorders
— Non-neoplastic disorders
— Neoplastic disorders
Sialolithiasis (salivary gland stones): Tiny, calcium rich stones sometimes form inside the
salivary glands. The exact cause of these stones are unknown. Some stones may be related to:
Dehydration which thickens the saliva, decreased food intake, medications that decrease
saliva production, including certain antihistamines, blood pressure drugs and psychiatric
medications.

Some stones sit inside of the gland without causing any symptoms, in other cases a stone
blocks the gland’s duct, either partially or completely. When this happens the gland is
typically painful and swollen and saliva flow is partially or completely blocked. This can
be followed by an infection called sialadenitis.
Symptoms: Painful lump usually in the floor of mouth
Sialadenitis (infection of a salivary gland) painful that usually is caused by bacteria. More
common in elderly adults with salivary gland stones, but can also occur in infants during the
first few weeks of life.
Symptoms: Tender painful lump in the cheek or under the chin, foul-tasting discharge of
pus from the duct into the mouth
Viral infections: Mumps
Cysts — Symptoms: Painless
lump Benign tumors
Malignant tumors — Symptoms: Lump
Sjögrens syndrome — Symptoms: swelling of salivary glands, dry eyes and dry
mouth Sialadenosis: Nonspecific salivary gland enlargement, often affects the parotid
gland, idiopathic
Diagnosis: Blood tests, X-rays, CT, MRI, biopsy, fine needle aspiration (to determine
whether a tumor is cancerous)

25) Functional disorders of gonads

Syphilis
primary syphilis
-may involve the lip, tongue or palate
- small, firm, pink macule changes to a papule which ulcerates to form a painless round ulcer with
a raised margin and indurated base, heal spontaneously in 3–8 weeks
- enlarged, painless regional lymph nodes
secondary syphilis
- after 6–8 weeks
- highly infectious painless ulcers
- lymphadenopathy
tertiary syphilis
- localized granuloma, affecting particularly palate or tongue, later they break down to form deep
chronic punched-out ulcers that are not infectious
- More common is leukoplakia on the dorsum of the tongue, having a high potential for malignant
change
- Congenital syphilis may present with dental anomalies such as Hutchinson teeth
Gonorrhea
- Oropharyngeal asymptomatic carriage of gonococci
- Mucosal erythema, sometimes with edema and ulceration may occur

26) Anatomical and morphological characteristics of normal

tongue and function
Muscular organ
Dorsum is divided into the:
— Anterior two thirds
— Posterior one third
The two parts are separated by a shallow- V shaped furrow called the terminal
sulcus, anterior two thirds are covered with thick keratinized epithelium.
There’s three types of papilla:
1) Filiform — Small and conical, they cover the whole surface and give the dorm its
rough appearance.
2) Fungiform — Less numerous and are visible as small red dots
3) Circumvallate — Are larger than the others, there are 10-12 and in front of the
sulcus terminal is.
4) Foliate — Are localized in front of the terminal sulcus but on the marginal border
Function: Mastification, swallowing, and is the primary organ of taste in the
gustatory system. The tongue also serves of cleaning the teeth, speech.

27) Types of allergic reactions/ early and late

Type I — Immediate hypersensitivity involving IgE (Anaphylactic shock, angioedema) Type

II — Hypersensitivity caused by IgE and IgM antibodies directed towards cell surface
antigens (Drug induced reactions, hemolitical anemia, agranulocytosis, thrombocytosis)
Type III — Immune complex reaction involving IgG, IgA, IgM (Serum disease)
Type IV — Delayed hypersensitivity with T-lymphocytes (Contact dermatitis,
tuberculin reaction)
The early phase of the allergic reaction typically occurs within minutes or seconds, itching,
smooth muscle cells cause contraction, goblet cells cause mucous production and endothelial
cells cause vasodilation and edema.
The late phase of the allergic reaction occurs within 8-12 hours and is caused by the induced
synthesis and release of mediators including leukotrienes, chemokine and cytokines from the
activated mast cells. It is associated with a second phase of smooth muscle contraction,
edema.

28) Anatomical, morphological and physiological characteristics of

unchanged oral mucosa
The oral mucosa is the mucous membrane lining the inside of the mouth and consists of
stratified squamous epithelium termed oral epithelium and an underlying connective tissue
termed lamina propria.
The oral mucosa is protective, provides a barrier to microorganisms, toxins and various
antigens, has a role in immunological defence, both humoral and cell-mediated, minor glands
within the oral mucosa provide lubrication and buffering as well as secretion of some
antibodies. The mucosa is richly innervated providing input for touch, proprioception, pain
and taste. Reflexes such as gagging, retching and salivating are initiated by receptors in the
oral mucosa.
There’s 3 types of mucosa identified according to their primary function:
1) Masticatory mucosa (60%)
2) Lining mucosa (25%)
3) Specialized mucosa (15%)
In cheeks, lips and parts of hard palate a layer of loose fatty glandular tissue containing
vessels and nerves supplying the mucosa separates the oral mucosa from underlying bone or
muscle: submucosa
In gingiva and parts of hard palate, oral mucosa directly attached to underlying bone. This
provides a firm inelastic attachment: Mucoperiosteum
There’s 4 layers:
— Stratum basale (basal layer)
— Stratum spinosum (prickle layer)
— Stratum granulosum (granular layer)
— Stratum corneum (keratinized layer)

29) Damage to oral tissues by medicaments, nicotine, alcohol and drugs

Medicaments side effects: Xerostomia, oral candidiasis, gingival overgrowth, Inflammation
of the lining inside of the mouth (Mucositis), ulcers, taste changes, tooth decay, tooth
discoloration,.
Nicotine side effects: Staining of teeth, reduction of the ability to smell and taste, halitosis,
smoker’s palate, smoker’s melanosis, coated tongue, oral trush, gum disease, oral precancer
and cancer.
Alcohol side effects: Periodontal disease, cancerous cells can develop, cavities
Drugs side effects: Tooth loos and gum disease, dry mouth, tooth decay and erosion, tooth
grinding and jaw clenching, mucosal dysplasia. Depending on what drug are used but also
ulcers, edema, necrosis, septum perforation (cocaine), perforation of the palate.

30) Black hairy tongue, geographic tongue

— Hairy tongue: is a relatively common disorder that is due to marked accumulation of
keratin on the filiform papillae of the tongue resulting in a hairlike pattern.
Etiology: Unknown, predisposing factors are poor oral hygiene, oxidizing mouthwashes,
antibiotics, excessive smoking, emotional stress and bacterial and candida infections.
Clinical features: Color may range from white, to brown or black
Treatment: Elimination of predisposing factors, brushing of tongue, local use of keratolytic
agent.
— Geographic tongue: is a relatively common benign condition, primarily affecting the
tongue and rarely other oral mucosa sites
Etiology: Idiopathic
Clinical features: Multiple, well-demarcated, erythematous, depapillated patches, typically
surrounded by a slightly elevated whitish border and usually restricted to the border of the
tongue.
The lesions persists for a short time in one area, then disappear slightly and reappear in
another area. Usually asymptomatic and often coexists with fissured tongue. Treatment:
Reassurance of the patient

31) Pemphigus chronicus vulgaris

Is a severe chronic bullous autoimmune mucocutaneous disease. Etiology: Autoimmunity
Clinical features: Pemphigus vulgaris is the most common resulting in 90-95% of the cases,
more than 70% of pempighus vulgaris begins with oral involvement. Oral lesions: bullae,
which rapidly rupture, leaving painful erosions with a tendency to extend peripherally. The
buccal mucosa, labial mucosa palate, tongue and floor of the mouth and gingiva are often
involved.
Treatment: Systemic steroids

32) Agranulocytosis
Is a hematological disorder characterized by a severe reduction of the granulocyte series,
particularly neutrophils.
Etiology: Drugs or infections are commonly the cause although some cases are idiopathic
Clinical features: Has a sudden onset and is characterized by chills, fever, malaise and sore
throat.
Bacterial infections often develops, oral lesions are common early signs, and consists of
multiple necrotic ulcers covered by a grayish- white or dark and dirty pseudomembrane
without a red halo.
Buccal mucosa, tongue, palate and tonsillar area are the most common sites of involvement.
Laboratory tests: White blood count and bone-marrow aspiration
Treatment: Antibiotics, white blood-cells transfusion
33) Aphthous stomatitis
or Recurrent aphthous ulcers, are among the most common oral mucosal lesions with a
prevalence of 10-30% in the general population.
Etiology: Unclear, predisposing factors include trauma, allergy, genetic predisposition,
endocrine disturbances, emotional stress and AIDS.
Clinical features: Three clinical variations have been recognized: minor, major and
herpetiform ulcers. Minor aphthae are the most common form and they present clinically a
small, painful round ulcers 3-6mm in diameter covered by a whitish-yellow membrane and
surrounded by a thin red halo. The lesions may be single or multiple and they heal without
scarring in 7-12 days.
The major form is characterized by deep painful ulcers 1-2cm in diameter that persists for 3-6
weeks and may cause scarring.
Herpetiform is characterized by small, painful, shallow ulcers 1-2mm in diameter with a
tendency to coalesce into larger irregular ulcers.
Treatment: Topical steroids, in severe cases intralesional steriod injection or systemic steroids
in low doses for 4-8 days.

34) Oral manifestations of HIV

Fungal lesions: Candidiasis, histoplasmosis, cryptococcus neoformans Viral
lesions: Herpes simplex, herpes zoster, human papilloma virus lesions,
cytomegalovirus, hairy leukoplakia and epstein-Barr virus
Bacterial lesions: Periodontal disease, mycobacterium avium-intracellulare
Neoplastic lesions: Karposi’s sarcoma, lymphoma
Other: Oral ulceration, idiopathic thrombocytopenia purport, salivary gland disease and
xerostomia.

35) Leukoplakia
The lesion is defined as a white patch or plaque, firmly attached to the oral mucosa that
cannot be classified as any other disease entity. It’s a precancerous lesion.
Etiology: Unknown, tobacco, alcohol, chronic local friction and candida are important
predisposing facts. HPV may also be involved
Clinical features: 3: Homogenous (common), speckled (less common) and verrucous (rare)
Speckled and verrucous leukoplakia have a greater risk for malignant transformation than the
homogenous form. The buccal mucosa, tongue, floor of the mouth, gingiva and lower lip are
the most commonly affected sites.
Laboratory test: Histopathological examination
Treatment: Elimination or discontinuation of predisposing factors, systemic retinoid
compounds. Surgical excision is the treatment of choice

36) Lupus ertyhematosus and scleroderma

Lupus erythematous is a chronic immunologically medicated disease
Etiology: Autoimmune
Clinical features: Oral lesions are well-defined central atrophic red area surrounded by a sharp
elevated border of irradiation whitish striae. Telangiectasia, petechiae, edema, erosions,
ulcerations and white hyperkeratoric plaques can be seen,
Laboratory tests: Histopathological examination
Treatment: Steroids, antimalarials
CREST syndrome, is a clinical variant of scleroderma characterized by a combination of
Calcinosis cutis, Reynaud phenomenon, Esophageal dysfunction, Sclerodactyly and
Telangiectasia.
Scleroderma is a multi-system disease, within the group of connective tissue diseases
Etiology: Unknown, characterized by abnormal synthesis of connective tissues.
Clinical features: Plaques that may be surrounded by a halo. Xerostomia

37) Dysfunction of parathyroid glands/hypo and hyperfunction

Parathyroid hormone plays an important role in the metabolism of calcium and phosphorus,
so, influence the mineralization of bone and teeth. Parathyroid disorder may lead to hyper pr
hyposecretion of hormone which results in various oral manifestations.
Hyperparathyroidism; The most common clinical manifestation of HPT is brown tumor, loss
of bone density, mobile teeth, drifting of teeth, jaw bone pain, sensitive teeth in mastication
and percussion, soft tissue calcifications and dental abnormalities such as development
defects, alterations in dental eruption.
Hypoparathyroidism: Most frequent dental abnormalities are enamel hypoplasia (enamel is
thin), delayed eruption and there may be multiple unerupted teeth.
Teeth appear dull white in color with hypo plastic pitting, microdontia, roots are often short
or malformed, teeth may show ankylosis, severe dental caries. There may be chronic
candidiasis of the oral mucosa, paresthesia of the tongue or lips and facial twitching can
occur
Diagnosis: Serum calcium, serum phosphate, alkaline phosphatase tests
Treatment for Hyperparathyroidism: Management of the brown tumor, jaw enlargement
Treatment for Hypoparathyroidism: Vitamin D or its analogs, calcium salts and drugs that
increase renal tubular resorption of calcium.

38) Oral manifestations with changes in white blood cells/leucosis

— Agranulocytosis; Necrotizing ulceration of oral mucosa, tonsils, hemorrhage occur, excess
salivation.
— Cyclic Neutropenia; Necrotic gingiva, necrotizing ulceration with severe bone loss, severe
gingivitis, reversible stomatitis
— Chediak-Higashi Syndrome: Severe gingivitis, ulceration, glossitis, periodontal
breakdown
— Leukocytosis
— Infectious Mononucleosis; (kissing disease) acute gingivitis and stomatitis, palatine
petechiae, petechial hemorrhages of soft palate near the junction
— Leukemia; Gingivitis, hemorrhage, petechiae, ulceration - in severe cases; teeth almost
hidden, bleed easily, necrosis, rapid loosening of teeth due to destruction of bone

39) Saliva, characteristics, composition and role

Composition of saliva; 4 major components; 1) Mucus that serves as a lubricant, 2) Amylase
that initiates the digestion of starch, 3) Lingual lipase that begins the digestion of fat, 4)
Electrolyte solution (Na+,Cl-, K+, HCO3- — moistens food, 5) Proteins and enzymes:
Histatins, cystatins, lysozyme, salivary peroxidase.
Electrolytes; Sodium, potassium, calcium, magnesium, chloride, bicarbonate, phosphate,
iodine.
Role/function of saliva: Antibacterial, buffering, digestion, mineralization, lubrication and
viscosity, anti fungal and antiviral
Characteristics of saliva: 3 major glands Parotid, submandibular and sublingual gland.
The composition of saliva varies depending on different physiological conditions, the minor
glands secrete spontaneously at a low rate during the night. In daytime and at rest movements
of the tongue and lips and mucosal dryness stimulate secretion. Eating is a strong stimulation
of saliva, a number of sensory receptors are activated in response to food intake; gustatory
receptors, mechanoreceptors, nociceptors and olfactory receptors. Age is another important
variable affecting the salivary proteome.

40) Anemia and polyglobulia

— Anemia is due to folate and vitamin B12 deficiency, or iron deficiency.
Clinical signs/symptoms: Glossitis, red color, atrophic papillae, recurrent aphthae, candidal
infection, angular stomatitis, and oral pain.
— Polycythaemia or polyglobulia; Polycythemia Vera, secondary polycythemia, relative
polycythemia, the oral mucosa may appear deep red to purple; the gingiva may be edematous
and bleed easily; there may be submucosal petechiae, ecchymosis, hematoma formation may
be present.

41) Damages of oral tissues by thermal and electrical stimuli and changes
with radiation
Thermal burns to the oral mucosa are fairly common, usually due to contact with very hot
foods, liquids or hot metal objects. Clinical features; Red painful edema that may undergo
desquamation, leaving erosions. The lesions heal spontaneously within a week.
Patients with oral electrical burns are usually treated at burn centers, it can involve the lip,
tongue, mucous membranes and the underlying bone. Electrical burns more commonly affect
the oral commissure. The lesions are usually painless, charred yellow with little bleeding.
Swelling then develops and by the 4th day following the burn the area becomes necrotic and
the epithelium sloughs off.
Changes with radiation; Oral radiation mucositis is a side effect of radiation treatment of head
and neck tumors. Clinical features: Classified as early and late. Early — May begin at the end
of the first week of radiotherapy and consist of erythema and edema of the oral mucosa, soon
after erosions or ulcers may develop, covered with a whitish-yellow excudate. Xerostomia,
loss of taste and burning and pain during mastication, swallowing and speech is common.

42) Differential diagnosis of ulcers

Superficial ulceration of the oral mucosa often present a diagnostic challenge to the physician
because of the similarity of one ulcer to another.
A diagnosis is made by the analysis of multiple factors, including the lesion’s location, size,
grouping, onset, patients age, involvement of other systems of the body, and course of the
disease.
— Varicella, herpangina, recurrent aphthous stomatitis, Behcet’s disease, Steven-Johnsons
syndrome, traumatic ulcer, recurrent herpetic stomatitis, pemphigus vulgaris and benign
mucosa membrane pemphigoid.

43) Degenerative diseases of salivary glands

Inflammatory and degenerative conditions of the salivary glands are rare but there are many
of them.
— Mumps: An infectious disease caused by a virus, one of the most common childhood
diseases, causes painful swelling of the parotid gland or parotitis and is often accompanied by
inflammation of other tissues. Vaccination is highly effective in preventing this disease.
— Stones or sialioliths; Can form in salivary glands and cause obstruction of ducts, also
resulting in pain and swelling. Most common in the submandibular gland.
— Sjögrens syndrome: Autoimmune, causes immune-mediated destruction of the cells that
produce tears in the lacrimal gland and saliva in the salivary glands. Patients with Sjögrens
syndrome have persistent dry eyes and dry mouth and are extremely uncomfortable and the
lack of tears and saliva can cause considerable damage to the eyes and teeth.

44) Functional disorder of pancreas

Some diseases which involve other parts of the GI tract can manifest in the mouth alone or in
combination, including:
— GERD cause acid erosion of the teeth and halitosis
— Gardner’s syndrome can be associated with failure of tooth eruption, supernumerary teeth
and dentigerious cysts.
— Peutz-Jeghers syndrome can cause dark spots on the oral mucosa or on the lips or the skin
around the mouth
— Several GI diseases, especially those associated with malabsorption can cause recurrent
mouth ulcers, atrophic glossitis and angular cheilitis (egg Crohn’s disease is sometimes
termed orofacial granulomatosis when it involves the mouth alone)
— Sideroepenic dysphagia can cause glossitis, angular cheilitis.

45) Cheilitis – Definition and types

Cheilitis is inflammation of the lips, it may include the perioral skin, the vermilion border
and/or the labial mucosa. It can be either acute or chronic, and most cheilitis is caused by
exogenous factors such as dryness and acute sun exposure.
— Cheilitis glandularis
— Cheilitis granulomatosa
— Melkersson-Rosenthal
— Exfoliative chelitis
— Contact chelitis
— Actinic chelitis
— Angular chelitis
— Lip-licking chelitis
— Median lip fissure
— Angioneurotic edema
— Lymphedema due to radiation
— Systemic diseases
46) Tuberculosis in oral cavity
Is a chronic infectious disease that can affect any part of the body including the mouth. It
usually affects the lungs.
May be either primary or secondary in occurrence, primary lesions are uncommon seen in
younger patients, and present as single painless ulcer with regional lymph node enlargement.
The secondary lesions are common often associated with pulmonary disease usually present as
single indurated, irregular, painful ulcer covered by inflammatory exudates in patients of any
age group.
Oral TB may occur at any location on the oral mucosa but the tongue is most commonly
affected, other sites include the palate, lips, buccal mucosa, gingiva, palatine tonsil and floor
of the mouth.
Salivary glands, tonsils and uvula are also frequently involved.
Oral lesions may be present in a variety of forms such as ulcers, nodules, tuberculomas and
periodical granulomas.
Oral manifestations of TB can also be in the form of superficial ulcers, patches, indurated soft
tissue lesions or even lesions within the jaw that may be in the form of TB osteomyelitis or
simple bone radiolucency.
Primary lesion - lateral margin of the tongue which rest against rough, sharp or broken teeth
or at the site of other irritants. Tubercular ulcers of the tongue may involve the tip, lateral
margins, dorsum, the midline and base of the tongue. They are irregular, pale.

47) Functional disorder of adrenal glands/Hypo and hyper function

Function of adrenal glands include anti inflammatory and immunosuppressive properties.
Responsible for cortisol production (regulates the metabolism of carbohydrates, fat and
protein) also they produce aldosterone (regulates sodium and potassium critical in the
maintenance of blood pressure)
Hypofunction — Addison’s disease: Primary adrenal insufficiency, oral manifestations
include: diffuse or patchy pigmentation of the skin and mucous membranes (due to increased
ACTH cross reacts with melanin receptors)
Usually seen on the buccal mucosa, palate, lips and gingiva
Diagnosis: ACTH test
Treatment: Replace steroid (glucocorticoid/mineralocorticoid)
Hyperfunction — Endogenous Cushing’s syndrome results from some derangement of the
body’s own system of secreting cortisol.
(THE WORD CUSHINGOID IS A USEFUL WAY TO CONSIDER THE
COMPLICATIONS AND SYMPTOMS OF CUSHINGS SYNDROME:)
Cataracts, Ulcers, Skin, Hypertension, Infections, Necrosis, Glycosuria, Osteoporosis,
Immunosuppression and Diabetes.

48) Hemophilia, hemorrhagic purpura

Hemophilia: Hemophilia is an X-linked hereditary disorder.
A disorder of blood coagulation, results in severely prolonged clotting time, is due to a
deficiency in plasma proteins involved in coagulation. Types of Hemophilia, the two most
common types are type A and type B.
Type A is caused by a deficiency of plasma thromboplastinogen or factor VIII
Type B christmas disease, less common, the clotting defect is plasma thromboplastin or factor
IX
Oral manifestations of Hemophilia: Spontaneous gingival bleeding, petechiae, ecchymosis.
Hemorrhagic purpura: A reddish-blue or purplish discoloration of skin or mucosa from
spontaneous extravasation of blood. May be due to a defect or deficiency in blood platelets.
Blood may ooze from gingival margins. Purpura also called blood spots or skin hemorrhages
can be located on mucous membranes on the inside of the mouth. Purpura occurs when small
blood vessels burst causing blood to pool under the skin.

49) Diseases of salivary glands/Bacterial and viral infections

Bacterial — Parotitis; is inflammation of the parotid gland, it can be acute, chronic or chronic
with acute exacerbations.
Etiology of parotitis is assumed to be ascending infection from the oral cavity. Dehydration,
malnutrition, immunosuppression, dental infections, tracheostomy and medications that
suppress salivary flow.
Chronic bacterial parotitis may exist in the presence of calculi or stenosis of the ducts
secondary to injury and less likely as a sequel of acute bacterial infection.
Diagnosis: Sudden onset of indurated, warm, erythematous swelling, with intense local pain
and tenderness. Often associated with high fevers, chills. The infection is usually unilateral.
Pathogen: Straphylococcus, anaerobes and mixed infections
Viral — Acute viral infection: Mumps, a viral parotitis caused by the paramyxovirus (RNA
virus) is a common childhood inflammatory disease of the salivary glands with occasional
serious complications. Although infection of the parotid glands is the most common
manifestation many other organs can be involved.
Mumps is usually asymptomatic, the parotitis can include swollen and tender salivary glands
with the parotid gland most commonly affected. The patient may also complain of earaches
which lasts about 1 week and are usually bilateral.

50) Erythema multiforme

On skin and mucous membranes, immunologically mediated.
Triggered by infective agents (HSV), drugs, food additives or chemical, immunization
Oral lesions: Begins as erythematous area — blister then ruptures — irregular painful ulcers
Includes and can appear on lips, buccal mucosa, tongue, soft palate and floor of mouth Skin
manifestations; Erythematous, flat, round modules, papule or plaques usually in a
symmetrical pattern.
Treatment; Supportive, systemic steroids.
Stevens-Johnson syndrome is a severe form of erythema multiforme involving mucous
membrane, eyes and genital area.
Oral lesions: Vesicle formation, painful erosions, ulceration of skin and mucosal surfaces

51) The most common characteristic pathohistological changes of

the epithelium of the oral cavity

-Leukoplakia: thickened keratin layer of epithelium (hyperkeratosis) with or without thickened

spinouts layer (acanthosis)
-Erythroplakia: severe epithelial dysplasia, carcinoma in situ and invasive squamous cell
carcinoma in 90% of cases

-Smookeless Tobacco: hyperkeratinized and acanthotic squamous epithelium with or without

cellular vacuolization or edema of Glycogen-rich cells

-Submucous Fibrosis: Deposition of dens and hypervascular collagen in connective tissue with
variable numbers of chronic inflammatory cells

-Lichen Planus: diverse degrees of orthokeratosis and parakeratosis

-Inverted Schneiderian Papilloma: Obvious hyperplasia and hyperkeratosis in basal layer

-Actinic Keratosis: Atrophic stratified squamous epithelium with remarkable keratin

productions and varying degrees of dysplasia

52) Mechanical injuries of the oral mucosa

Mechanical traumatic ulceration — occurs through biting, sharp cusps, outstanding teeth or ill
fitting intramural appliances. Such ulcers don’t present a problem clinically but 3 criteria must
be followed: 1) Cause of trauma must be identified 2) The cause must fit the shape, size and
site of the ulcer 3) On removal of the cause the ulcer must show signs of healing within 10
days.

53) Pemphigoid and Dhuring

Two major types of pemphigoid:
1) Bullous pemphigoid
2) Mucous membrane pemphigoid
Through in contrast to pemphigus, lesions are larger and leave denuded area while they trust,
do heal and rarely fatal.
— Bullous pemphigoid: Pathogenesis: Interaction of auto-antibody with BP antigen on the
lamina lucid of the basement membrane, complement activation and attraction of neutrophils
and eosinophils.
Clinical features: Bullous lesions
— Mucous membrane pemphigoid: Skin involvement is less common, oral mucosa being the
most common site 90%, and 2nd being the conjuctiva.
Clinical features: Common sites; Limbs, abdomen, axilla, face and groin.
Urticaria or eczema may persist for several weeks to several months before vesico-bullous
lesion appear, these vesicles and bullae are thick-walled and tensed and may remain for some
days. Rupture doesn’t always occur. Oral, eye and skin lesions are present.
Oral manifestations: Desquamative gingivitis is the most common oral manifestation and
mey be the only site. Gingival lesions consists of generalized edema, inflammation and
desquamation with localized areas of discrete vesicle formation.
Dhuring

Duhring's disease, is a chronic blistering skin condition, characterised by blisters filled with a watery fluid.
The age of onset is usually about 15-40. Men and women are equally affected. Intensely itchy, chronic
papulovesicular eruptions, usually distributed symmetrically on extensor surfaces (buttocks, back of neck,
scalp, elbows, knees, back, hairline, groin, or face). The blisters vary in size from very small up to 1 cm
across. THERAPY: TETRACYCLINE
54) Pigmentations of the oral cavity
Blue, brown and black discoloration constitute the pigmented lesions of the oral mucosa.
— Endogenous pigments: Include melanin, bilirubin and hemosiderin. The most important is
melanin which is synthesized by melanocytes in the basal epithelial layer and then transferred
to keratinocytes. Generalized increased activity of melanocyes may occur in systemic disease,
(Addison’s disease) it may also be a component of other mucosal lesions (lichen plans,
response to smoking or with HIV)
Malignant melanoma, melanocytic nevi, basal cell carcinoma, squamous cell carcinoma.
— Exogenous pigments: Most common is the amalgam tattoo.
Diagnosis: Color of lesion, site, shape, margins, flat (macule) or raised (nodule), patient age,
habits, symptoms
— Peutz-Jeghers syndrome: Autosomal dominant, mucocutaneous pigmentation, black spots
(macule) on the perioral skin, lips, buccal mucosa and tongue
— Addison’s disease
— Hemachromatosis (chronic disease, excess iron, ferritin and hemosiderin) in tissues
— Heavy metal pigmentation
— Kaposi’s sarcoma
— Drug induced pigmentation
— Smoker’s Melanosis
— Hemangioma and vascular malformation
— Varix and thrombus
— Melanotic maccules
— Pigmented nevi

55. Functional disorder of thyroid gland

Hypothyroidism

Childhood hypothyroidism known as cretinisim is characterized by thick lips, large protruding

tongue (macroglossia), malocclusion and delayed eruption of teeth. Thickening of the lips and
macroglossia is due to increased accumulation of subcutaneous mucopolysaccharides i.e.,
glycosaminoglycans due to decrease in the degradation of these substances. The long-term
effects of severe hypothyroidism on craniofacial growth and dental development have also
included impaction of the mandibular second molars. This seems to be caused by a dissociation of
ramus growth and failure of normal resorption of the internal aspect of the ramus, resulting in
insufficient space for proper eruption of these teeth.

The common oral findings in hypothyroidism include the characteristic macroglossia, dysgeusia,
delayed eruption, poor periodontal health, altered tooth morphology and delayed wound
healing.[6] Before treating a patient who has a history of thyroid disease, the dentist should
obtain the correct diagnosis and etiology for the thyroid disorder, as well as past medical
complications and medical therapy.

Hyperthyroidism
The oral manifestations of thyrotoxicosis, includes increased susceptibility to caries, periodontal
disease, enlargement of extraglandular thyroid tissue (mainly in the lateral posterior tongue),
maxillary or mandibular osteoporosis, accelerated dental eruption[8] and burning mouth
syndrome.

Burning mouth syndrome, a condition that causes a burning pain in the mouth, and Sjogren's
syndrome, a condition that causes dry mouth, are more common in people with thyroid disease.

In Graves disease, on extra-oral examination the thyroid may be enlarged or noticeably palpable.
The enlarged gland may be more visually noticeable when the patient is in a supine position in the
dental chair. But in more severely enlarged thyroids, the bulge in the neck is noticeable even
when the patient is sitting upright or standing.

56) Stomatitis gangrenosa (Noma), stomatitis ulceronecroticans

Stomatitis gangrenosa NOMA: Is a rapidly progressive, polymicrobal often gangrenous
infection of the mouth or genitals.
Signs: Ulcers
Pathogen: Fusobacterium necrophorum and prevotella intermedia interacting with one or
more other bacterial organisms such as Borrelia vincentii, porphyromonas gingivalis,
straphylococcus aureus
Etiology: Malnutrition, dehydration, poor hygiene, measles, unsafe drinking water,
immunodeficiency disease including AIDS
Treatments: Antibiotics and improved nutrition, sometimes surgery is needed
Stomatitis ulcernecroticans: Caused by Fusobacterium gangrenous oral lesions. predisposing
factors are emotional stress, smoking, poor oral hygiene, local trauma and mainly HIV
infection.
Clinical signs: Painful necrosis of the interdental papillae and the gingival margins and the
formation of craters covered with a gray pseudomembrane. Rarely the lesions may extend
beyond the gingiva (necrotizing ulcerative stomatitis)

57) Stomatitis angularis

Also called Cheilitis angularis — is a common disorder of the corners of the mouth. Etiology:
Reduced vertical dimension, mechanical trauma, Candida albicans, straphylococci,
streptococci, iron-deficiency anemia, riboflavin deficiency.
Clinical signs: Erythema, maceration, fissuring, erosions and crusting at the commissures. A
burning sensation and a feeling of dryness may occur, remissions and exacerbations are
common.
Treatment: Correction of the occlusal vertical dimension, topical steroids and anti fungal
ointments.

58. Allergic stomatitis

There are basically two types of hypersensitivity reactions involved in allergic stomatitis:

---type I immediate hypersensitivity

---type IV delayed hypersensitivity

The allergic stomatitis may present with clinical appearances that mimic classic oral
vesiculobullous and ulcerative lesions. Differential diagnosis from specific mucosal diseases is
important in the treatment of oral allergy. Precise history taking and the elimination of the
causative agents will be necessary.

59) Benign tumors of the oral cavity

1) Odontogenic — Derived from tooth forming elements, the more primitive the dental tissue
found, the more aggressive the tumor and vice versa, only found in the jaws, locally aggressive
and rarely malignant
a) Epithelial tumors; Ameloblastoma, calcifying epithelial odontogenic tumor, adenomatoid
odontogenic tumor, squamous odontogenic tumor
b) Mesenchymal tumors: Odontogenic fibroma, cementoblastoma, odontogenic myxoma,
cementifying fibroma
c) Mixed tumors (epithelial and mesenchymal) Odontoma, ameloblastic fibroma,
ameloblastic fibro-odontome
2) Non odontogenic — Can be found in other regions of the body
a) Fibro-osseus tumors: Ossifying fibroma, juvenile ossifying fibroma
b) Langerhans cell disease: Chronic localized, chronic disseminated, acute disseminated
c) Giant cell lesions: Giant cell tumor, hyperparathyroidism, cherubim, aneurysmal bone cyst,
central giant cell granuloma
d) Neurogenic tumors: Schwannoma, neurofibroma
e) Osteoid stoma and osteoblastoma
f) Osteoma chrondroma
g) Desmoplastic fibroma

60) Fetor ex ore

Halitosis, bad breath — It is estimated to be the third most frequent reason for seeking dental-
aid following tooth decay and periodontal diseases.
Pathophysiology: Formed by bacterial putrefaction of food debris, cells, saliva and blood.
Proteolysis of proteins, peptides, amino acids, free thiol groups and volatile sulphides. Results
from any form of sepsis and despite good hygiene, good dentition the posterior dorm of
tongue is often a source.
Etiology: Oral and throat causes, nasal/nasopharyngeal problems, systemic disease,
physiologic considerations, drugs, food and psychologic disorders.
Oral and throat causes include — Periodontal disease, dental caries, denture, dry mouth, post-
nasal drip, black hairy tongue, peritonsilar abscess.
Among many others.
Diagnosis: Oral examination, history, smelling, sampling

61) Mycotic diseases of the oral cavity/candidiasis and actinomycosis

Candidiasis — Is the most common oral fungal infection.
Etiology; Usually caused by candida albicans, predisposing factors are local (poor oral
hygiene, xerostomia, mucosal damage, dentures, antibiotic mouthwashes) and systemic
(antibiotics, steroids, immunosuppressive drugs, radiation, HIV infection, hematological
malignancies, neutropenia, iron-deficiency anemia, endocrine disorders).
Clinical signs: Oral candidiasis is classified as primary consisting of lesions on the oral and
perioral area, and secondary, consisting of oral lesions of mucocutaneous disease.
Primary candidiasis includes 5 clinical varieties: Pseudomembranous, erythematous, nodular,
papillary hyperplasia of the palate, and candida-associated lesions (angular cheilitis, median
rhomboid glossitis, denture stomatitis) The main forms of candidiasis that produce white
lesions are the following:
— Pseudomembranous candidiasis (most common, creamy white, slightly elevated,
removable spots or plaques. May be localized or generalized and appear more frequently on
the buccal mucosa, soft palate, tongue and lips. Xerostomia a burning sensation and an
unpleasant taste are the most common symptoms)
— Nodular candidiasis (chronic, appears clinically as white, firm and raised plaque that
usually does not detach)
— Mucocutaneous candidiasis (white and usually multiple plaques, which cannot be
removed)
Treatment: Antifungals (nystatin)
Actinomycosis — Is a chronic granulomatous infectious disease.
Etiology: Actinomyces israelii
Clinical signs: Oral lesions appear in the cervicofacial form of the disease and present as an
inflammatory, hard swelling that grows slowly. Multiple abscesses and draining sinuses
intramurally and on the skin are common. The tongue, buccal mucosa, gingiva, tonsils and
lips are the most common sites involved.
Lab tests: Bacteriological and histopathological examination
Treatment: Penicillin or erythromycin or tetracycline, surgery

62) Manifestation of skin diseases in the oral cavity

Oral signs may precede cutaneous symptoms and enable early diagnosis of skin disorders.
Lichen planus — affects 1-2% of the population with a slight female predominance. Etiology
is unclear, but histopathologically it is characterised by an autoimmune T-cell mediated
destruction of basal keratinocytes. Presents as: hyperkeratotic striae affecting buccal mucosa,
tongue, attached gingiva and lips in a symmetrical distribution, usually asymptomatic but with
mild oral discomfort or a burning sensation may be reported.
Reticular, papular, plaque like, erosive and bullous
Lupus erythematous — Chronic autoimmune disorder
Pemphigus vulgaris — Rare autoimmune vesiculobullous disorder, painful, shallow, irregular
erosions with friable adjacent mucosa often associated with desquamative gingivitis. Buccal
mucosa, ventral aspect of the tongue and floor of the mouth are the initial sites.
Mucous membrane pemphigoid — Desquamative gingivitis, painful irregular areas of
ulceration and blood filled vesicles or bullae.
Erythema multiforme — Etiology: HSV, drugs, painful erosions with irregular margins,
affecting the labial mucosa. There’s minor and major, major - lesions with widespread
erosions and hemorrhagic crusts.
Dermatitis herpetiformis — Pruritic blisters on the skin or oral mucosa that subsequently
rupture to leave painful erosions.

63) Manifestation of syphilis in the oral cavity

1) Primary syphilis: Affects the lips, tongue, buccal mucosa and tonsils. 3 weeks after the
infection, clinically we can see a papule that breaks down to form an ulcer. Painless ulcer
with a smooth surface, raised borders and indurated margin.
2) Secondary syphilis: Most infectious, incubation after 6-8 weeks and lasts for 2-10 weeks -
clinical features: Malaise, low-grade fever, headache, lacrimation, sore throat, weight loss,
myalgia, and generalized lymphadenopathy. The ulcer is covered with grayish white
membrane which when scraped has a pink base with no bleeding.
3) Teriary syphilis: After a period of 4-7 years, is typically painless, there is no
lympohadenopathy unless secondary infection.
Congenital syphilis — Early; First 3 months of life, manifest as snuffles: nasal discharge
purulent. Late: Manifest at puberty. Oral lesions: High-arched palate, short mandible,
Hutchinson’s teeth and moon or mulberry molars.
Diagnosis: Immuniflurorescence, biopsy, serology
Treatment: Penicillin

64) Glossodynia and pyrosis

Burning mouth syndrome is a burning sensation in the mouth with no underlying dental or
medical cause. No signs of disease are found in the mouth. People with burning mouth
syndrome may also have a dry mouth sensation where no cause can be found such as reduced
salivary flow, tingling in the mouth or an altered taste or smell.
May be primary or secondary.
Type 1 — Symptoms not present upon waking and then increase throughout the day
Type II — Symptoms upon waking and through the day
Type III — No regular pattern of symptoms
Symptoms: BMS has no signs, if clinical signs are visible then another explanation for the
burning sensation may be present. Erythema and edema of papillae on the tip of the tongue ay
be a sign that the tongue is being habitually pressed against the teeth. The number and size of
filiform papillae may be reduced, if the tongue is very red and smooth then there is likely a
local or systemic cause.
Can cause BMS: Hypthyroidsm, neuropathy, geographic tongue, candidiasis, fissured tongue,
lichen planus, HSV, deficiency of iron folic acid or various B vitamins, HIV
Treatment: Underlying issue first, or then with antidepressants, anticonvulsants.
Pyrosis - Psoriasis — Uncommon inside of the mouth, it is more likely to develop in those
with the more severe form of psoriasis especially pustular psoriasis. It is a chronic
inflammatory skin disorder, there’s scaly plaques.
There are several types of oral lesions: Irregular red patches with raised yellow or white
borders similar to geographic tongue, redness of the oral mucosa, ulcers, peeling gums called
desquamative gingivitis, pustules.
Treatment or management: Corticosteroids, antiseptic mouthwashes.

65) Lichen planus - forms and clinical picture

Oral lesions: May be tender and painful, are located on the sides of the tongue, inside of the
cheek or gums. Look like blue-white spots and form lines in a lacy network, sometimes they
can form painful ulcers. 2/3 are asymptomatic, usually present bilaterally and most common
site is the posterior buccal mucosa, other locations may include tongue, gingiva, alveolar
mucosa, palate, lip.
Patients report a roughness of the lining of the mouth, sensitivity of the oral mucosa to hot or
spicy foods, painful oral mucosa, red or white patches on the oral mucosa or oral ulcerations.
Types of oral lichen planus: Reticular form, papular type, plaque-like, bullies, erythematous or
atrophic, ulcerative.

66) Toxic stomatitis and defense factors in the oral cavity

Toxic stomatitis can be caused by a metal prosthesis. Toxic reaction to metal prostheses is shown
by characteristic syndromes: burning of language, hypersalivation, glossodynia, disturbance of the
nervous status, defeat of bodies of a digestive tract.
The saliva at persons with prostheses from a lame and cobalt alloy, increases.
If in an oral cavity there are prostheses from stainless steel and gold and there is a corrosion, then in
saliva the content of gold, copper and silver increases.
Poisoning with lead is characterized by bleeding, an ulceration of gums, hypersalivation, increase
and morbidity of lymph nodes at a palpation. The mechanism of action is explained by the fact that
lead promotes a spasm of blood vessels, development of anemia