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    Oral Immunologic Diseases Recurrent Aphthous Stomatitis (Canker Sores R.A.S.)

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    tgopal27
    This document discusses various oral immunologic diseases including recurrent aphthous stomatitis, Behcet's syndrome, sarcoidosis, Wegener's granulomatosis, stomatitis medicamentosa, stomatitis venenata, perioral dermatitis, and angioedema. It provides details on clinical presentation, pathogenesis, diagnosis, and treatment of each condition. Key signs and symptoms, laboratory tests, histopathological findings, and medications used are outlined. The document is an educational reference for oral pathology residents and dental professionals.

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    Oral Immunologic Diseases Recurrent Aphthous Stomatitis (Canker Sores R.A.S.)

    Uploaded by

    tgopal27
    27 views12 pages
    This document discusses various oral immunologic diseases including recurrent aphthous stomatitis, Behcet's syndrome, sarcoidosis, Wegener's granulomatosis, stomatitis medicamentosa, stomatitis venenata, perioral dermatitis, and angioedema. It provides details on clinical presentation, pathogenesis, diagnosis, and treatment of each condition. Key signs and symptoms, laboratory tests, histopathological findings, and medications used are outlined. The document is an educational reference for oral pathology residents and dental professionals.

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    This document discusses various oral immunologic diseases including recurrent aphthous stomatitis, Behcet's syndrome, sarcoidosis, Wegener's granulomatosis, stomatitis medicamentosa, stomatitis venenata, perioral dermatitis, and angioedema. It provides details on clinical presentation, pathogenesis, diagnosis, and treatment of each condition. Key signs and symptoms, laboratory tests, histopathological findings, and medications used are outlined. The document is an educational reference for oral pathology residents and dental professionals.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    27 views12 pages

    Oral Immunologic Diseases Recurrent Aphthous Stomatitis (Canker Sores R.A.S.)

    Uploaded by

    tgopal27
    This document discusses various oral immunologic diseases including recurrent aphthous stomatitis, Behcet's syndrome, sarcoidosis, Wegener's granulomatosis, stomatitis medicamentosa, stomatitis venenata, perioral dermatitis, and angioedema. It provides details on clinical presentation, pathogenesis, diagnosis, and treatment of each condition. Key signs and symptoms, laboratory tests, histopathological findings, and medications used are outlined. The document is an educational reference for oral pathology residents and dental professionals.

    Copyright:

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    of 12

    Oral Immunologic Diseases

    Dr. Ioannis G. Koutlas Division of Oral Pathology


    All pictures are intellectual property of the Division of Oral and Maxillofacial Pathology or its Faculty. Duplication or any unauthorized use is prohibited.

    Recurrent Aphthous Stomatitis (Canker Sores; R.A.S.)


    Aphtha=Ulcer Cause unclear; recur in episodes Minor, major, herpetiform 20% of general population More often in females Clinical appearance and location are important

    Recurrent Aphthous Stomatitis


    Trauma can be precipitating factor Other factors include: food allergies, genetic predisposition, stress, nutritional deficiencies, hormonal influence, infectious agents, food (high acid content) Systemic disease: Inflammatory bowel disease (Crohn's disease & ulcerative colitis), Behcet's syndrome, leukopenia, allergy to gluten (gluten intolerance-sprue = celiac disease), cyclic neutropenia, immunocompromised status, MAGIC syndrome, PFAPA syndrome, Reiters disease, Sweet syndrome, ulcus vulvae acutum

    Systemic Diseases
    MAGIC syndrome: Mouth and genital ulcers & inflamed cartilage PFAPA: Periodic fever, aphthae, pharyngitits and adenitis Sweets syndrome: Acute febrile neutrophilic dermatosis
    Fever Neutrophilic leukocytosis Erythematous skin plaques or nodules Classic RAS Conjunction with malignant conditions, e.g. leukemia

    Minor Aphthae Recurrent Aphthous Stomatitis


    NO FORMATION OF VESICLES/BULLAE

    Substantial evidence of an immunologic pathogenesis Slightly elevated levels of antibodies to oral mucous membranes Cell-mediated immunity
    T-helper cells in the early stage T-cytotoxic in ulcerative stage T-helper in healing stage

    Most common Round oval ulcers up to 1 cm in diameter surfaced by yellow-white fibrin covering, surrounded by a halo of erythema Mucosa not covering bone, occasionally extending to the gingiva; anterior part of the mouth more often Early stage 1-2 days Burning sensation or soreness Heal in 7-21 days

    Major Aphthae
    Sutton's disease or periadenitis mucosa necrotica recurrens Larger than 1 cm Deeper and last longer Lips and posterior (faucial pillar, soft palate) May require biopsy
    DD: Squamous cell carcinoma, fungal infection

    Heal with scarring

    Aphthous Stomatitis Herpetiformis


    Demonstrate the greatest number; as many as 100 1-3 mm resembling herpes simplex virus ulcers Occur in groups and can coalesce Recurrences closely spaced Any oral site Female predominance

    Treatment
    No treatment Topical therapy for pain Systemic therapy for severe cases Topical steroids: betamethasone, fluocinonide, clobetasol propionate Many other therapies: colchicine, levamisole, dapsone, pentoxifylline,thalidomide, cytotoxic, MAO inhibitors, antibiotics, laser ablation Complex cases: Identification of the agent

    Behet's Syndrome
    Multisystem disease HLA-B51; bacteria, viruses, pesticides G.I. tract, cardiovascular system, C.N.S.(paralysis, dimentia), lungs, eyes (uveitis, conjunctivitis, cataracts, glaucoma), skin (erythema nodosum, pseudofolliculitis, acneiform nodules), and genitals (painful ulcers especially in men) Oral aphthae are a consistent feature Six or more; major aphthae high prevalence Pathergy testing

    Sarcoidosis
    Systemic chronic granulomatous disorder of unknown etiology (Mycobacterial infection ?) 10-15x in blacks, females, 20-40 years Dyspnea, chest pain, fatigue, arthralgia, weight loss Can arise insidiously; 20% of cases discovered after routine chest x-ray (hilar lymphadenopathy) Lungs: (Pulmonary hypertension & respiratory failure) Lymph nodes Skin: Lupus pernio, erythema nodosum Eyes: Keratoconjuctivitis sicca

    Sarcoidosis
    Lupus pernio: violaceous indurated lesions of the skin (nose, lips, face) Heerfordt's syndrome (Uveoparotid fever)
    Parotid enlargement Anterior uveitis of the eye Facial paralysis Fever

    Sarcoidosis
    Oral involvement (can be first manifestation)
    Isolated mass Multiple nodular growths Intraosseous lesions
    Ill-defined radiolucencies Localized periodontal disease Can be first manifestation

    Lfgren syndrome
    Erythema nodosum Bilateral hilar lymphadenopathy Arthralgia

    Minor salivary gland involvement, mucoceles

    Sarcoidosis
    Histopathology
    Chronic granulomatous inflammation Calcifications (Schaumann bodies) Asteroid bodies

    Laboratory tests
    Kweim test
    Historic, 50-80% accuracy, false positive

    Angiotensin Converting Enzyme


    Elevated

    Treatment
    No treatment Corticosteroids, other immunosuppressant medications

    Orofacial Granulomatosis
    Histologically: Non-specific granulomatous inflammation Includes Melkersson-Rosenthal syndrome and Miescher cheilitis Abnormal immune response

    Systemic Diseases That May Mimic Orofacial Granulomatosis


    Chronic granulomatous disease
    X-linked, neutrophil microbicidal activity defective Early life onset Candidiasis, eczematous cheilitis, ANUG Quantitative nitroblue tetrazolium test (-), neutrophilic leukocytosis, hypergammaglobulinemia

    Crohns disease Sarcoidosis Tuberculosis

    Local Processes That Can Present As Orofacial Granulomatosis


    Chronic oral infection Foreign material Allergy

    Wegeners Granulomatosis
    Necrotizing granulomatous lesion Respiratory tract Necrotizing glomerulonephritis Systemic vasculitis of small arteries and veins Hypersensitivity response to inhaled antigen? Secondary reaction to an infection Three types
    Classic Limited Superficial

    Wegeners Granulomatosis
    URT: Nasal discharge, otitis media, sore throat, epistaxis, destruction of nasal septum LRT: Dry cough, dyspnea, hemoptysis, chest pain Kidneys: Glomerulonephritis, proteinuria, RBC casts Mouth
    Strawberry gingivitis (unique); early and only Nonspecific ulcerations; late

    Wegeners Granulomatosis Diagnosis


    Clinical findings Histopathologic findings Laboratory tests
    c-ANCA: Cytoplasmic antineutrophil cytoplasm Ab
    1:80 (NL: 1:40) 90-95% (+) for acute generalized 60% for localized A rising titer during treatment indicates relapse

    Wegeners Granulomatosis Treatment


    Lethal without treatment
    Mean survival: 5 months 80% dead at one year 90% dead by two years

    c-ANCA/anti proteinase 3 Abs


    97% specific; 90% sensitive

    Cyclophosphamide (2mg/kg/day) and prednisone (1 mg/kg/day) Beclomethasone nasal spray Trimethoprim-sulfamethoxazole


    Bacterial challenge for URT

    p-ANCA: Perinuclear Elevated ESR, WBC, normocytic normochromatic anemia

    Cyclosporine

    Stomatitis Medicamentosa
    Erythema multiforme Anaphylactic stomatitis Fixed drug eruption Lichenoid drug reaction Lupus erythematosus-like reaction Pemphigus-like eruption Non-specific vesiculoulcerative lesions

    Stomatitis Medicamentosa
    Detailed medical history Identify medications that have been associated with allergic responses OVER-THE-COUNTER MEDICATIONS Association may be acute and obvious or it may be delayed If more than one medication is suspected serial elimination may be indicated DO NOT WORK ALONE

    Stomatitis Venenata
    a.k.a. Contact stomatitis
    Acute and chronic

    Food and food additives, chewing gums, candies, mouthwashes, glove material (latex), anesthetics, dental impression material, denture adhesive preparations Rare because
    Contact is brief Saliva dilutes and removes antigens Rapid dispersal and absorption Allergen may be not recognized

    Stomatitis Venenata
    If skin is sensitized, mouth may or may not demonstrate reaction If mouth is sensitized, skin usually demonstrates reaction Female predominance Small vesicles, aphthae, itching, edema, hyperkeratotic lesions, erythema and epithelial desquamation Types

    Stomatitis Venenata
    Exfoliative cheilitis or perioral dermatitis Plasma cell gingivitis
    Cinnamon, other herbs

    Contact stomatitis due to cinnamon and mint


    Shaggy hyperkeratosis and erythema

    Contact stomatitis due to dental amalgam


    Lichenoid lesions opposite to restoration

    10

    Perioral Dermatitis
    Corticosteroids worsen the lesions Tartar control toothpastes, bubble gum moisturizers, night creams, cosmetic products; in adults ~90% women Irritant or skin occlusion and flora proliferation Zone of spared skin adjacent to vermilion Perinasal, periorbital lesions Circumoral dermatitis

    11

    Angioedema (Angioneurotic edema)


    Patients are not neurotic Mast cell degranulation ACE inhibitors (captopril, enalapril, lisinopril) drug reactions Activation of complement
    Hereditary
    Quantitative reduction in the inhibitor that prevents transformation of C1 to C1 esterase Dysfunctional inhibitor

    Acquired
    Lymphoproliferative disorders; formation of autoantibodies; minor trauma Lupus erythematosus Peripheral eosinophilia

    Angioedema (Angioneurotic edema)


    Antihistamines Intramuscular epinephrine Intravenous steroids ACE inhibitors should be avoided if implicated C1-INH deficiency
    Avoid vigorous exercise and trauma Danazol or stanozolol (adrogens) Corticosteroids

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