Acute pharyngitis

1. Acute Pharyngitis
Acute Diphtheritic Pharyngitis
Oral Manifestations of Systemic Diseases

2. Acute Pharyngitis
•Definition: This is a commonest variety of sore
throat & usually associated with cold. It is
common and important prodormal
manifestetion of Measles, Typoid, Influenza,
etc.
•Aetiology:
Viruses: Rhino-, Adenovirus, Influenza A & B viruses,
Enterovirus, etc.
Bacterial: Haemolytic, Streptococcus, Haemophilus
influenzae, Pneumococcus, etc.

3. Clinical Features:
1.Mild (Simple):
sore throat, malase, fever, head ache, ear
ache, cervical lymphnodes, congested mucosa,
oedema & sometimes ulcers.
2. Severe (Septic):
t – 102 – 105°f, rigor, pulse, oedema palate &
uvula, mucopurulent, exudate, otatis media,
laryngitis.

4. Complications:
•Pneumonia
•Laryngitis
•Laryngotracheatis
•Bronchitis
•Septicaemia
•Pleurisy
•Pericarditis
•Nephritis
•Meningitis

5. Treatment:
-Symptomatic with bed rest, analgesics, plenty
of fluid, etc.
-If a significant bacterial complications has
occurred, antibiotics are indicated.
-In case of complications, treatment should be
directed accordingly.

6. Acute Diphtheritic Pharyngitis:
-A severe infection due to the gram +ve
bacillus (corynebacterium diphtheriac).
-Children are particularly affected, between 2-
5 years.
-Mode of transmission – droplet.
-Incubetion period: 2-7 days.

7. Clinical features:
-Onset is insidious.
-Sore throat.
- t: 99 – 101°f.
-Malase.
-Headache.
-False membrane on the tonsils, pillars, soft
palate, posterior ph. Wall.
-Colour of membrane, usually gray may be white
or dark brown.

8. Continued … ……
-Firmly attached to the mucosa.
-Leaves the bleeding surface when it is
removed, after which quickly reforms.
-It may spread to lkarynx, causing complete
obstruction, may need tracheostomy.
-Blood mixed nasal discharge.
- Cervical lymphnodes, tender.

9. Complications:
-Toxaemia
-Myocarditis
-Arrythmias
Cerculetory fealure
Death
-Neurological complications
-After 3-6 weeks
-Paralysis soft palate, diaphragm,
external occular muscles.

10. Differential Diagnosis:
-Acute Tonsillitis
-Infectious mononeuclosis
-I.P. – 5-7 weeks
-Hepato -, splenomegaly.
-Rubelliform rashes
-Accute Manifestation of leukaemia
-Agranulocytosis.

11. Treatment:
1.Antitoxin (20,000 – 120,000 units)
2.Benzyl Penicilin (600 – 1200 mg) 6 hourly
3.Rest
4.Tracheostomy – if needed.

12. •Oral cavity- window to the body
•Lesions of oral mucosa, tongue, gingiva,
dentition, periodontium, salivary gland,
facial skeleton, & extraoral skin
•Appropriate diagnosis & treatment
Oral Manifestations of Systemic Diseases:

13. Classification
1.Systemic Infectious diseases
2.Connective tissue disorders
3.Granulomatous diseases
4.Gastrointestinal diseases
5.Respiratory diseases
6.Haematological diseases
7.Endocrine diseases
8.Neurologic diseases
9.Nutritional deficiency
10.Immunodeficiency diseases
11.Drug reactions/radiotherapy
12.Dermatological diseases
13.Metabolic disorders
14.Neoplastic diseases

14. Infective diseases
1.Viral infection
2.Bacterial infection
3.Fungal infection
4.Protozoal infection

15. Viral infections
1.Herpes Simplex Stomatitis
2.Herpes Zoster
3.Herpangina
4.Hand Foot Mouth Disease
5.Cytomegalovirus Infection
6.Measles
7.Infectious Mononucleosis
8.Mumps
9.HIV

16. Viral infections
1.Herpes Simplex Stomatitis
2.Herpes Zoster
3.Herpangina
4.Hand Foot Mouth Disease
5.Cytomegalovirus Infection
6.Measles
7.Infectious Mononucleosis
8.Mumps
9.HIV

17. Herpes Simplex Stomatitis
•HSV-1: Primary herpetic Gingivostomatitis
Recurrent herpes labialis
•HSV-2:
•Primary herpetic Gingivostomatitis:
-most frequent cause of acute stomatitis in
children
-varies in severity, many infections -subclinical
-misdiagnosed as “teething”
-malaise, anorexia, irritability, fever, anterior
cervical lymphadenopathy, diffuse, purple,
boggy gingivitis
-multiple vesicles scarred ulcers(1-3mm)
-occasionally in adults

18. •Diagnosis:
-clinically
-scrapping or smears from the lesion
-immunofluorescent staining
-exfoliative cytology- typical
multinucleated giant cells
•Treatment:
-symptomatic
-acyclovir (systemic)-severe cases

19. •Recurrent Intraoral Herpes Simplex Infection:
-may affect healthy individual
-persistent lesions in immunocompromised
-chronic ulcer, raised, white border
-esp. at sites of trauma
-acyclovir

20. Herpes zoster (Shingles)
•Reactivation of Varicella –Zoster virus
•Predisposing factor: Immunocompromised
status
•One dermatome affected (trigeminal nerve)
•Unilateral
•Ulcers in the distribution of dermatome
•Mandibular nerve: ulceration of one side of
tongue, floor of the mouth, lower labial &
buccal mucosa
•Maxillary nerve: one side of palate, the
upper gingiva, buccal sulcus
•Lesions persists for 2-3 wks
Lesions on lips and chin

21. •Herpes Zoster Oticus (Ramsay Hunt
Syndrome)
•Ophthalmic Herpes Zoster
•Post Herpetic Neuralgia
•Diagnosis: clinically
•Treatment:
-Analgesics
-Antivirals(within 72 hrs of onset of
the lesions):acyclovir, famciclovir,
valacyclovir, & gabapentin

22. Herpangina
•Common in children
•Coxsackie virus group A,
Enteroviruses(30 & 71)
•Self limiting vesicular eruptions in
the oropharynx eg. soft palate,
uvula, tonsillar pillars, posterior
pharyngeal wall
•Similar to herpes simplex except the
lesions more commonly in
oropharynx rather than oral cavity
•Diagnosis: Clinically
•Treatment: Supportive

23. Hand, Foot and Mouth Disease
•Enterovirus 71,Coxsackie viruses, some
untypeable enteroviruses
•Young children
•Vesicular eruption in the oral cavity &
oropharynx dysphagia, dehydration
•Vesicles on the hands & feet
•Pyrexia, malaise, vomiting
•Short lived(5-8 days)
•Diagnosis: clinically
•Treatment: supportive

24. Infectious Mononucleosis
•Acute, self limiting, systemic viral
infection
•Epstein-Barr Virus
•Typical presentation: acute sore throat
& tender cervical lymphadenopathy
•Glandular disease
•Kissing disease
•Children & young adults
•Prodromal symptoms:
4-5 days, anorexia, malaise, fatigue,
headache

25. •Clinical features:-
Oral manifestations - early and common- palatal
petechiae, uvular edema, tonsillar exudate, gingivitis,
& rarely ulcers
-Generalized lymphadenopathy, hepatosplenomegaly,
maculopapular skin rash
•Laboratory tests:
Heterophile antibody(Paul Bunnel test, Monospot test)
•Treatment:
-Mild to moderate cases: Symptomatic
-Severe disease: Famciclovir
•Anti-EBV compounds: Maribavir
•Ampicillin based antibiotics should be avoided

26. Cytomegalovirus Infection
•Relatively rare
•Cytomegalovirus (CMV)
•HIV infection and immunocompromised
•Clinical features: asymptomatic
Oral lesions -nonspecific painful ulcerations-
gingiva & tongue
-Enlargement of parotid & submandibular
glands, dry mouth, fever, malaise, myalgia,
headache
•Laboratory tests:
HPE/Immunochemistry
•Treatment:
-Resolve spontaneously
-Ganciclovir (Persistent case)

27. Measles (Rubeola)
•Paramyxovirus
•Highly contagious
•Coryza, conjunctivitis & generalised
cutaneous erythematous rashes
•Oral cavity lesions: Pharyngotonsillitis
Koplik’s spot: small, spotty, exanthematous
lesions on buccal mucosa
•Vaccination program

28. Mumps
•Common viral illness
•Incubation period: 2-3 weeks
•Fever, malaise, myalgia, headache, &
painful parotid gland swelling
•Self limiting
•Complications: SNHL
•Diagnosis: Clinical
•Treatment: Supportive

29. Bacterial Infections
1.Tuberculosis
2.Syphilis
3.Leprosy

30. Tuberculosis
•Chronic, granulomatous, infectious
disease
•Mycobacterium tuberculosis
•Clinical features: Oral lesions – rare
secondary to pulmonary tuberculosis
•Pharynx- not common
Primary infection (Tonsils, Adenoids)
Secondary to coughing heavily of infected
sputum
•Ulcer: multiple, painful, irregular,
undermined border, granulating floor,
usually covered by a gray-yellowish
exudate, inflamed & indurated
surrounding tissue

31. •Dorsum of the tongue - most commonly
affected- lip, buccal mucosa, & palate
•TB Esophagitis:
-swallowed sputum or direct spread from
adjacent lymph nodes
-stricture, fistula, mucosal irregularities
• Granulomatous Cheilitis- rare
•Laboratory tests: Sputum culture, HPE, CXR
•Treatment: ATT

32. Syphilis
•Treponema pallidum
-Acquired
-Congenital
1.Primary Syphilis
2.Secondary Syphilis
3.Tertiary Syphilis

33. Primary Syphilis
•Lips, tongue, buccal mucosa, & tonsils
•Site of inoculation- 3 weeks after the
infection, Papule, breaks down to form an
ulcer (chancre)
•Oral chancre: painless ulcer with a
smooth surface, raised borders, &
indurated margin
•Non tender cervical lymphadenopathy
•Spontaneous healing

34. Secondary Syphilis
•Most infectious
•Secondary stage – after 6–8 weeks &
lasts for 2-10 weeks
•Clinical features:
Malaise, low-grade fever, headache,
lacrimation, sore throat, weight loss,
myalgia,arthralgia, & generalized
lymphadenopathy
Mucous patches

35. •Hyperemia and inflammation of
pharynx & soft palate
•Snail Track ulcer :-
-Oral cavity & oropharnyx
-Ulcerated lesion covered with
grayish white membrane
which when scraped has pink base
with no bleeding

36. Syphilitic Pharyngitis
•May be congenital or acquired by
sexual intercourse
•Secondary stage most likely
• HIV positive patients

37. Tertiary Syphilis
•Tertiary syphilis - after a period of 4–7 years
•Typically painless
•No lymphadenopathy unless secondary infection
•Gumma:
-Characteristic lesion
-Hard palate, Nasal septum, Tonsil, PPW, or
Larynx
• VDRL may be negative

38. Congenital Syphilis
Early:
first 3 months of life, manifest as
snuffles nasal discharge purulent
Late:
Manifest at puberty
Gummatous lesion
• Oral lesions: high-arched palate, short
mandible, Hutchinson’s teeth, and
Moon’s or mulberry molars

39. Diagnosis:
1.Immunoflurorescence or dark field microscopy
2. Biopsy
3.Serology
Non-treponemal antibody tests:
-VDRL, RPR
-For screening and treatment follow up
Treponema specific antibody tests:
-FTA-ABS test, TPHA
-For confirmation
-Usually remains positive for life
Treatment: Penicillin( DOC)
Ceftriaxone, Erythromycin, or Doxycycline

40. Leprosy
•Mycobacterium Leprae
•Optimum temperature growth-less than body
temp preference for skin, mucosa &
superficial nerve
•Transmission- nasal discharge
•Both Humoral & cellular immune response
•Clinically- Chronic granulomatous disease
skin, peripheral nerve & nasal mucosa

41. •Nasopharynx to oropharynx: Granulomatous
lesion, ulcers, healing with fibrosis
•Larynx:
-Lesion like TB & Syphilis
-Supraglottic- mainly epiglottis, aryepiglottic
folds
-Epiglottis : hollow rod, mucosa studded with
tiny nodules- laryngeal stenosis & airway
obstruction
Diagnosis:
Punch biopsy, nasal scrapings (skin lesions &
ear lobules)
Treatment: Dapsone, Rifampicin &/or
Clofazimine

42. Protozoal infection
1.Toxoplasmosis
2.Leshmaniasis

43. Toxoplasmosis
•Toxoplasm gondii
•Zoonosis
•Self limiting
•Immunocompetent: asymptomatic
•Immunocompromised:
sore throat, malaise, fever, cervical
lymphadenopathy
Multiple organs involvement
(lungs, liver, skin, spleen, myocardium, eyes,
skeletal muscles, brain

44. •Transplacental infection:
about 45 %
subclinical infection- intrauterine death
•Diagnosis: serological
•Treatment:
-usually unnecessary
-combination of pyrimethamine & sulphadiazine

45. Leshmaniasis
involving Lips

46. Fungal infection
1.Candidiasis
2.Histoplasmosis
3.Cryptococcosis
4.Aspergillosis
5.Mucormycosis
6.Paracoccidomycosis
7.Blastomycosis

47. Systemic Mycoses
•Chronic fungal infections
•Histoplasmosis (Histoplasma capsulatum)
•Blastomycosis (Blastomyces dermatitidis)
•Cryptococcosis (Cryptococcus neoformans)
•Paracoccidioidomycosis(Paracoccidioides
brasiliensis)
•Aspergillosis (Aspergillus species)
•Mucormycosis (Mucor, Rhizopus)

48. •Predisposing conditions:
-Immunocompromised status
eg. HIV infection
•Clinical features:
– Oral lesions – rare
– chronic, irregular ulcer
•Candidiasis rarely produces ulcers
•Deep mycosis: chronic lumps & ulcers

49. •Rhinocerebral Mucormycosis:
-typically commences in the nasal
cavity or paranasal sinuses
invade the palate
(black necrotic ulceration)
•Laboratory tests: Smear and
histopathological examination
•Treatment: Amphotericin B,
Itraconazole, Ketoconazole, &
Fluconazole

50. Collagen-Vascular & Granulomatous Disorders
1.Sjogren’s Syndrome
2.Systemic Lupus Erythematous (SLE)
3.Scleroderma
4.Dermatomyositis-Polymyositis
5.Sarcoidosis
6.Wegner’s Granulomatosis
7.Behcet’s Syndrome
8.Reiter’s Syndrome
9.Sweet Syndrome
10.Cogan’s Syndrome
11.Amyloidosis
12.Kawasaki Disease
13.Rheumatoid Arthritis (RA)
14.Polyarteritis Nodusa (PAN)
15.Sturge- Weber Syndrome
16.Ehlers-Danlos Syndrome
17.Cowden’s Disease

51. Sjogren’s Syndrome
•Autoimmune
•Female
•Primary Sjogren’s Syndrome:
•Secondary Sjogren’s Syndrome: associated
with RA, SLE, Scleroderma, Polymyositis,
Polyarteritis Nodusa
•Presents with xerostomia & parotid
enlargement
•Oral findings:
-Due to decreased salivadysphagia,
disturbances in taste & speech, burning
pain of mouth & tongue, increased dental
caries, increased predisposition to
infection (candidiasis)

52. •Mucosal changes: dry, red & wrinkled mucosa
•Fissured tongue, atrophy of tongue papillae
and redness of tongue, cracked & ulcerated
lips
Diagnosis:
-Minor salivary gland biopsy (mucosa of lower
lip)
-Periductal lymphocytic infiltrate
-Serum: Autoantibodies (ANA, antilacrimal &
antithyroid antibodies, RA factor)
Treatment :
-Steroid & immunossuppresive drugs
-Artificial saliva
-Constant dental evaluation

53. Systemic Lupus Erythematosus(SLE)
•Approx. one quarter of SLEoral
lesions
•Oral lesions: superficial ulcers with
surrounding erythema
•Lips & all oral mucosal surfaces
•Periodontal diseases, xerostomia

54. Scleroderma
•Deposition of collagen in the tissues or
around nerves & vessels
•Difficulty in opening mouth(due to
fibrosis of masticatory muscles),
immobility of tongue, dysphagia,
xerostomia
•Telangiectasia: lips, oral mucosa
•Association with Sjogren’s Syndrome &
CREST Syndrome(Calcinosis, Raynaud’s
phenomena, Esophageal hypomotility,
& Sclerodactly)

55. Kawasaki disease
•Mucocutaneous lymph node syndrome
•Vasculitis- medium & large arteries
•Children <5 yrs of age
•High grade fever
•Cardiovascular complications
•Oral findings: swelling of papillae on the
surface of tongue(strawberry tongue),
erythema of the buccal mucosa & lips
Lips are cracked, cherry red, swollen &
hemorrhagic

56. Laboratory tests: polymorphonuclear leukocytosis,
thrombocytosis, raised ESR & CRP
Diagnosis: 4 out of 6 clinical features with evidence of coronary
dilatation
1.Fever persisting>5 days
2.Bilateral conjunctival congestion
3.Erythema of lips, buccal mucosa & tongue
4.Acute non-purulent cervical lymphadenopathy
5.Polymorphous exanthema
6.Erythema of palms & soles (edemadesquamation)
Treatment: Aspirin, IVIg
Steroid avoided- risk of worsening coronary artery dilatation

57. Wegener’s Granulomatosis
•Rare chronic granulomatous disease
•Immunological
•Clinical features: necrotizing
granulomatous lesions of the respiratory
tract, generalized focal necrotizing
vasculitis, and necrotizing glomerulitis
•Oral lesions: solitary or multiple irregular
ulcers, surrounded by an inflammatory
zone
•Tongue, palate, buccal mucosa & gingiva
•Laboratory tests: HPE, c-ANCA
•Treatment: Steroids, Azathioprine, &
Cyclophosphamide

58. Sarcoidosis
•Systemic granulomatous disease
•Any organ
•Noncaseating granuloma:
-characteristic lesion
•Oral manifestations: multiple, nodular,
painless ulceration of the gingiva, buccal
mucosa, tongue, lips, & palate
•Salivary gland swelling
•Diagnosis: Biopsy
•Treatment: Systemic steroids

59. Behcet’s Syndrome
•Chronic, multisystemic inflammatory
disorder
•Triad of symptoms: Aphthous ulcers,
Genital ulcers & Ocular lesions (uveitis,
conjunctivits, keratitis)
•Etiology – unclear
•Immunogenetic basis
•Clinical features - common in males
•Onset -20–30 years age

60. Rheumatoid Arthritis
•Progressive destruction of articular & periarticular
structure eg. TMJ
•TMJ pathology: clicking, locking, crepitus,
tenderness in the preauricular area, pain during
mandibular movement
•Oral cavity involvement-not common
•Association with secondary Sjogren’s Syndrome
•Immunosuppressive drugsacute stomatitis,
candidiasis, recurrent HSV infection

61. Reiter’s Syndrome
•Triggered by infectious agent in genetically
susceptible
•Young male (20-30 yrs)
•Characterized by conjunctivitis, asymmetric
lower extremity arthritis, non-gonococcal
urethritis, circinate balanitis, keratoderma
blennorrhagia
•Mnemonic : “can’t see, can’t pee, can’t
climb a tree”
•Oral lesions: papules & ulcerations on the
buccal mucosa, gingiva, palate, & lips
•Lesions on the tongue mimic geographical
tongue
•Diagnosis: HPE
•Treatment: Systemic steroid, NSAID

62. Hematological Diseases
1.Iron Deficiency Anaemia
2.Sickle Cell Anaemia
3.Langerhans Cell Histiocytosis
4.Osler-Weber-Rendu disease (HHT)
5.Plummer-Vinson Syndrome
6.Leukaemia
7.Agranulocytosis
8.Myelodysplastic Syndrome
9.Cyclic Neutropenia
10.Idiopathic Thrombocytopenic Purpura
11.Multiple Myeloma

63. Iron Deficiency Anaemia
•Oral manifestations:
Atrophic glossitis, mucosal pallor,
angular stomatitis, flattening of
tongue papillae, geographic
glossitis

64. Leukaemia
•Etiology- genetic & environmental factors
(viruses, chemicals, radiation)
•Clinical features: Leukaemia– acute & chronic,
myeloid or lymphocytic
•All forms - Oral manifestations
•Oral lesions:
-Ulcerations, spontaneous gingival
hemorrhage, petechiae, ecchymosis,
tooth loosening, & gingival hypertrophy
•Laboratory tests:
Peripheral blood smear, bone-marrow
examination
•Treatment: Chemotherapy, bone-marrow
transplantation, supportive therapy

65. Osler-Weber-Rendu Disease
(Hereditary Hemorrhagic Telangiectasia)
•Autosomal dominant
•Telangiectasia of dorsum of tongue,
oral cavity, buccal mucosa, lips, palate
& nasal mucosa
•Apparent at puberty
•Lung, liver, & GI tract arterio-venous
malformations
•Treatment: regular iron therapy,
laser therapy

66. Plummer Vinson Syndrome
(Patterson-Brown-Kelly Syndrome)
•Oral manifestations: Dysphagia, iron def.
anaemia, atrophic glossitis, angular
stomatitis, & koilonychia
•Female, in fourth decade
•Barium swallow: web in post-cricoid region
•Pre-malignant Post-cricoid carcinoma
•Treatment:
-Esophageal dilatation
(if symptoms from web)
-Follow up-developing carcinoma

67. Idiopathic Thrombocytopenic Purpura (ITP)
•Oral lesions may be the first
manifestation of this condition
•Petechiae, ecchymoses,
& haematoma anywhere on the oral
mucosa
•Spontaneous bleeding from the
gingiva
•Treatment:
-Systemic steroids, Splenectomy

68. Agranulocytosis
•Etiology: Drug or infection
•Clinical features:
Oral lesions -multiple necrotic ulcers covered
with dirty pseudomembrane
•Buccal mucosa, tongue, palate, & tonsillar
area
•Severe necrotizing gingivitis
•Laboratory tests: White blood count & bone-
marrow aspiration
•Treatment: Antibiotics, white blood cell
transfusions, granulocyte colony-stimulating
factor (G-CSF) or granulocyte-macrophage
colony-stimulating factor (GM-CSF)

69. Gastrointestinal Diseases
1.Inflammatory Bowel Disease
(Crohn’s disease & Ulcerative colitis)
2.Gastro-esophageal Reflux
3.Peutz-Jegher’s Syndrome
4.Celiac disease
5.Chronic liver disease
6.Malabsorption Diseases

70. Crohn’s Disease
•Diffuse nodular swelling in lips
(painless), angular cheilitis,
cobblestone appearance of buccal
mucosa or mucosal tag, Aphthous
ulcer
•May precede intestinal symptoms or
may be the only manifestations in
some cases
•Systemic steroids

71. Ulcerative Colitis
•Destructive oral ulceration due to
immune mediated vasculitis
•Polystomatitis Vegetans:
microabscess on lips, palate, ventral
tongue
•May manifests as aphthous ulcers
•Exacerbation & remission

72. Gastroesophageal Reflux Disease
•Mucosal & gingival erosion
caused by acid
•Erosion of tooth enamel

73. Endocrine Diseases
1.Diabetes Mellitus
2.Thyroid Disorders
3.Cushing’s Disease
4.Addison’s Disease

74. Diabetes Mellitus
•Oral manifestations- variable &
nonspecific
•Fungal & bacterial infection
•Gingivitis, periodontitis, xerostomia,
glossodynia, taste change
• Rx: Control of DM
Antiobiotic/Antifungal
•Oral hygiene

75. Thyroid Diseases
•Hypothyroidism: Macroglossia
•Congenital Hypothyroidism: Macroglossia,
pronounced lips, & delayed tooth eruption with
malocclusion
•Hyperthyroidism:
Facial & skin manifestations: upper eyelid
retraction, exophthalmous, hyperpigmentation,
& skin erythema
Oral manifestations: early loss of primary teeth
with subsequent rapid eruption of permanent
teeth(young children)
lymphoid tissue hyperplasia- tonsillar &
oropharynx (Grave’s disease)

76. Cushing’s Syndrome
•Long term, high dose corticosteroid
administration
•Moon or round face, buffalo humps,
central obesity, osteoporosis, DM, HTN
•Oral symptoms:
-Increased susceptibility to oral
infections (candidiasis)
-Muscle weakness difficulty with
speaking, & swallowing
Dx: Dexamethasone suppression test
Rx: Depends on the cause

77. Addison’s Disease
•Primary adrenal insufficiency
•Destruction of adrenal cortex eg.
autoimmune, metastasis, infection,
haemorrhage
•Oral manifestations: diffuse or patchy
pigmentation of the skin & mucous
membranes (due to increased ACTH-cross
reacts with melanin receptors)
•Buccal mucosa, palate, lips, & gingiva
•Diagnosis: ACTH test
•Treatment: Replace steroid
(glucocorticoid/mineralocorticoid)

78. Renal Disease
(Uraemic Stomatitis)
•Painful plaques and crust on buccal mucosa,
dorsum of tongue, & floor of mouth covered
with gray pseudomembrane exudate, &
painful ulcers
•Bleeding diathesis: inhibited platelet
aggregation eg. petechiae, ecchymoses
•Irritation & chemical injury of mucosa-
ammonium compounds
•Xerostomia, unpleasant taste, burning mouth,
uriniferous breath odour
•A/W with acute rise in blood urea nitrogen
•Heal spontaneously after resolution of
uraemic state eg. after hemodialysis

79. Dermatologic Conditions
1.Lichen Planus
2.Pemphigus Vulgaris
3.Mucous Membrane Pemphigoid
4.Erythema Multiforme
5.Stevens-Jhonson Syndrome
6.Toxic Epidermal Necrolysis

80. Lichen Planus
•Chronic, mucocutaneous, autoimmune
disorder
•Precipitating factors: genetic
predisposition, stress, drug, food
•Oral manifestations: White papules
-coalesce, forming a network of lines
(Wickham’s striae)
•Buccal mucosa, gingiva, & tongue, lips
& palate

81. •Skin lesions: Pruritic papules-flexor surface
of extremities
•Malignant transformation
•Diagnosis:
-Clinically
-Histopathological examination
•Treatment:
-No treatment- asymptomatic lesions
-Topical steroids & Systemic steroids

82. Pemphigus Vulgaris
•Autoimmune disease
•Antibodies against desmoglein3 (antigen)
•Disassociation of the epithelium at suprabasal
layer with acantholysis
•Bullous lesionsrupturespainful bleeding
ulcers
•Oral, ocular mucosa, & skin
•Palate, gingiva, tongue
•Diagnosis:
-Nikolsky’s sign:(+)
new lesions develops after pressure applied to
asymptomatic oral mucosa
-HPE
-Direct immunofluorescence

83. •Treatment:
Systemic steroids &
immunosuppressive agents
(eg. mycophenolate mofetil)
Paraneoplastic Pemphigus:
•Occurs in association with
underlying neoplasms eg.
Lymphoproliferative disease or
thymoma
•Often partial response to systemic
steroids

84. Mucous Membrane Pemphigoid
•Antigen: Human alpha-6 integrin
•Oral manifestations- recurrent vesicles or
bullae (persists longer than pemphigus)
that rupture, leaving large, superficial
painful ulcers
•Gingival involvement - desquamative
gingivitis characterised by erythematous,
sore gingivae
•Diagnosis: Biopsy
•Treatment: topical steroid/systemic
immunosuppressive drugs

85. Erythema Multiforme
•Skin and mucous membranes
•Immunologically mediated
•Triggered by: infective agents (eg. HSV), drugs
(sulphonamides, barbiturates), food additives
or chemical, immunization
( BCG,HBV)
•Oral lesions: begins as erythematous
areablisterrupturesirregular painful
ulcers
•Lips, buccal mucosa, tongue, soft palate, &
floor of mouth
•Skin manifestations: erythematous, flat,
round macules, papules, or plaques, usually in a
symmetrical pattern- target or iris like lesions
•HPE & Immunostaining
•Treatment: supportive, systemic steroids

86. Stevens–Johnson Syndrome
•Severe form of erythema multiforme, involving oral
mucous membrane, eyes, & genital area
•Etiology: Drugs (salicylates, sulfonamides, penicillin,
barbiturates,carbamazepine, phenytoin etc.)
•oral lesions - vesicle formation, followed by painful
erosions - grayish-white or hemorrhagic
pseudomembranes - extend to the pharynx, larynx, and
esophagus
•Ulceration of skin & mucosal surfaces(eg. mouth,
urethra, conjunctiva, & lungs)
•Typical target lesions on palms & soles with blistering in
the centre
•Diagnosis: Clinical presentation
•Treatment:
-self limiting
-Supportive, & Systemic steroids

87. Toxic Epidermal Necrolysis
•Severe skin & mucous membrane disease
•Etiology: Drugs
•Clinical features: low-grade fever, malaise,
arthralgia, conjunctival burning sensation,
skin tenderness, & erythemablisters
appear-skin - lifted up - whole body surface
appears scalded
•Nikolsky’s sign –positive
•Oral manifestations: diffuse erythema,
vesicles and painful erosions - lips &
periorally, buccal mucosa, tongue, & palate
•Diagnosis: Clinically
•Treatment: Systemic steroids, antibiotics,
fluids, and electrolytes

88. Neurologic Diseases
1.Parkinson’s Disease
2.Alzheimer’s Disease
3.Bell’s Palsy
4.Mobius syndrome
5.Melkersson-Rosenthal Syndrome
6.Guillain-Barre Syndrome
7.Bulbar palsy
8.Multiple Sclerosis
9.Myasthenia Gravis
10.Myotonic Muscular Dystrophy
11.Tuberous Sclerosis

89. Parkinson’s Disease
•Extrapyramidal symptoms
•Loss of facial expression
•Difficulty with mastication, slow
speech, & tremors of head, lips, &
tongue
•Esophageal dysmotility & dysphagia
•Impaired lip seal drooling fungal
infection of lip commissure (angular
cheilitis)

90. Alzheimer’s Disease
•Dementia
•Inability to perform self care (oral hygiene)- self
neglect & loss of cognitive and motor skills
•Poor oral hygiene- increased prevalence of dental
plaque, dental caries, & gingival bleeding

91. Multiple Sclerosis
•Demyelination of central nervous
system
•Remitting & exacerbating course
•Loss of muscle coordination, weakness
of the tongue, & loss of upper
extremity severely impairs
orodental hygiene
•Trigeminal neuralgia- also common
characterized by excruciating, unilateral
pain of the lips, gingiva, or chin
triggered by contact with certain areas
of the face, lips, or tongue

92. Bell’s Palsy
•Idiopathic unilateral lower motor neuron
palsy (7
th
cranial nerve)
•Lack of control of the muscles of facial
expressiondistortion of facial
appearance
•Loss of functional ability of cheek & lips
(affected side)poor oro-dental hygiene

93. Melkersson-Rosenthal Syndrome
•Characterized by -unilateral facial palsy, recurrent facial
swelling, & lingua plicata (fissured tongue)

94. Nutritional Deficiency
•Vitamins & trace elements
1.Inadequate intake
2.Impaired digestion & absorption
3.Increased losses

95. •Vitamin A deficiency:
-Dyskeratotic changes of the skin & mucous
membranes
-Angular cheilitis
-Defects in the dentin & enamel of developing
teeth
•Vitamin B2 (Riboflavin) deficiency:
-Angular cheilitis
-Burning pain in the lips, mouth, & tongue
•Vitamin B3 (Niacin) deficiency (Pellagra):
-Dermatitis, dementia,& diarrhoea
-Oral manifestations: glossitis (red, swollen) &
stomatitis, burning tongue

96. •Vitamin B6 deficiency:
-Peripheral neuropathy
-Oral lesions-similar to pellagra
(i.e. glossitis & stomatitis)
•Vitamin C deficiency (Scurvy):
-Cofactor for collagen synthesis
-Weakened vessels are responsible for
petechiae, ecchymoses, delayed wound
healing
•Deficiency of Vitamin B12 & Folic acid:
-Megaloblastic anemia
-Oral findings: angular cheilitis, recurrent
aphthous ulcers, & glossitis

97. •Vitamin D deficiency & Calcium deficiency:
-Calcium metabolism
-Mandibular osteopenia/osteoporosis, enamel
hypoplasia

•Vitamin k deficiency:
-Haemorrhagic diathesis
-Oral haemorrhagic bullae
•Zinc deficiency:
-Taste changes
-Acrodermatitis Enteropathica: angular cheilitis, ulcers,
glossitis, crusting, scaling of the lips as well as ulcers,
erosions & fissures

98. Oral lesions associated with HIV
•Early recognition, diagnosis, & treatment of HIV
associated oral lesions - reduce morbidity
•Oral lesions-
-Early diagnostic indicator of HIV infection
-Stage of HIV infection
-Predictor of the progression of HIV disease

99. Oral lesions associated with HIV
•Fungal Infection: Bacterial Infection:
-Candidiasis -Linear Gingival Erythema
-Histoplasmosis -Necrotizing Ulcerative Periodontitis
-Cryptococcosis -Mycobacterium Avium Complex
•Viral Infection: Neoplastic:
-Herpes simplex -Kaposi’s Sarcoma
-Herpes zoster -Non-Hodgkin’s Lymphoma
-HPV Infection Others:
-CMV Infection -Recurrent Aphthous Ulcers
-Hairy Leukoplakia -Salivary Gland Disease

100. Human Papilloma Virus Infection
•Oral warts (papillomas), skin warts, &
genital warts – HPV(types 7,13,& 32)
Clinical Features:
•Arises from Stratified squamous
epithellium, painless, exophytic,
numerous finger like projections-
cauliflower like appearance
•Tongue, gingiva, & palate
•Biopsy- Histologic diagnosis
•Treatment: -Surgical removal
-Laser (CO2 laser)

101. Hairy Leukoplakia
•Epstein Barr virus
•Common, characteristic lesion-HIV infection
•White, asymptomatic, raised, corrugated,
unremovable patch on lateral marigns of
tongue
•The surface is irregular and may have
prominent folds or projections, sometimes
markedly resembling hairs
•Lateral margins may spread to dorsum of
tongue
•Diagnosis: Biopsy
•Treatment:
-Usually asymptomatic-Rx not required
-Antiviral(Aciclovir/valaciclovir)

102. Kaposi’s Sarcoma
•Most common malignancy in HIV (+Ve)
•Human Herpes Virus-8(KSHV)
•Derived from capillary endothelial cells
•Occur intraorally, either alone or in a/w skin
& disseminated lesions (lymph nodes, salivary
gland)
•Intraorally- hard palate, buccal mucosa, &
gingiva
-bluish, purple or red patches or
papulesnodular, ulcerate & bleed
•Diagnosis: Biopsy
•Treatment:
-Low dose radiation & chemotherapy
(eg.Vinblastine)
-Surgical excision (eg.CO2 laser)
-Immunotherapy (Interferon)

103. Non-Hodgkin’s Lymphoma
•Etiology: Unknown, genetic &
environmental factors (viruses, radiation)
•Clinical features:
–Both sexes - any age
–Lymph nodes involved
–Oral lesions - part of a disseminated
disease, or the only sign
•Oral Lymphoma: diffuse, painless swelling,
which may or may not be ulcerated -soft
palate, the posterior part of the tongue,
the gingiva, & the tonsillar area
•HPE & Immunohistochemical examn
•Treatment: Radiotherapy & chemotherapy

104. Salivary gland Disease
•Xerostomia– generalised
enlargement of parotid glands
•Lymphoepithelial cysts- parotid
gland