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1. SEMINAR ON CANCRUM ORIS
AND APTHOUS STOMATITIS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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2. NOMA OR CANCRUM ORIS:
It is also called as gangrenous
stomatitis.
Rapidly spreading gangrene.
Occur in debilitated or nutritionally
deficient person.
Mainly seen in children but also occur in
adults.
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3. PREDISPOSING FACTORS:
A) undernourished person.
B)Debilitated person having infections
like Diphtheria,dysentery,measles,
pneumonia,scarlet fever,syphilis,
tuberculosis and blood dyscrasias
including anemia.
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4. Noma is considered as a secondary
complication rather then a primary
disease.
Causative organism-a)vincent‘s
organism
b)secondary
infection by streptococci,staphylococci
and diphtheria bacilli.
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5. Selye reported the production of a
noma like condition in rats as a result of
simultaneous administration of
cortisone and clipping of the mandibular
incisor forcing the animals to chew with
their gingiva and thus to cause
excessive mechanical injury to mucosa.
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6. Condition usually began around the gingiva
and progressed to destruction of the floor of
the mouth and lower lip.
Susceptibility to tissue injury which was
produced by cortisone and this can be
eliminated by pituitary growth hormone.
Selye suggested that Noma may not
necessarily be due to a specific pathogenic
agent but may be due to a pathogenic
situation.
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7. Clinical features: Start
with the small ulcer in
the gingival mucosa
which rapidly spreads
and involves the
surroundings tissue of
the jaws, lips ,and
cheeks by gangrenous
necrosis.
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8. Initial site is an area of stagnation
around a fixed bridge and crown the
overlying skin becomes inflamed,
edematous and finally necrotic with the
result that a line of demarcation
develops between healthy and dead
tissue,and large masses of the tissue
slough
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9. out leaving the jaw exposed.
The commencement of gangrene is
denoted by the appearance of
blackening of the skin.
Necrosis of the buccal fat pad and
subcutaneous fat pad is reported.
Foul odor has arised from gangrenous
tissue.
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10. Palate and tongue can also be involved
by this process.
High temperature during the Course of
the disease.
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11. Mortality rate:75%
Treatment:Immediate treatment of
malnutrition.
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12. APTHOUS STOMATITIS
Characterized by painful,recurring solitary or
multiple ulceration of the oral mucosa.
Incidence-20 %to 60%.
Prevalence:higher in professional person and
socioeconomic group.
Etiology-1)bacterial infection-L form
streptococus isolated from lesion.
Herpes simplex virus can not be isolated.
Images3.jpg
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14. Cohen:a) not an
autoimmune
disease.
b)local
immune response
against an
antigenically altered
oral mucosa.
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15. results of diffusion of bacterial toxins, food
and other substance acting as allergen.
Donatsky-elevated gamma globulin level
against sterptococus.
Recurrent apthous stomatitis-altered immune
response which is directed against non
pathogenic oral flora and host oral tissue.
4)chemical mediator
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16. 5)focal release of neuropeptide.
6)viral infection.
7)deficiency of folic acid and iron-
Wray reported –after examining 330 patients
47-total deficient person
23 deficient in iron,7 deficient in folic acid,6 in
vitamin B12 deficiency,11 had combined
deficiency.
8)patient with malabsorption condition.
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18. Precipitating factors:Trauma-
Graycowaski-local trauma is an factor in
75% of the cases.
Self-inflicted bite
Oral surgical procedure
Tooth brushing
Dental procedure,needle injection and
needle trauma.
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19. Endocrine condition-relationship between
occurrence of the menstrual period and
development of apthous ulcer.
Related with the level of progesterone
Woman have remission of disease during
pregnancy.
Onset of disease associated with menopause
and menarche.
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20. Psychic factors-association with acute
psychological problem and stress.
Allergic factor-association with asthma
hey fever,food or drug allergy.
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21. Clinical features:4 forms-1)minor
2)major
3)herpetiform
4)ulcer associated
with Bechets syndrome.
Main difference between 3 groups-clinically
and degree of severity.
Tingling and burning of oral mucosa before
starting the treatment.
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22. Minor apthous ulcer-
most commonly
occurred form.
Age-10 to 30 years.
Occurrence early in life.
Disease persist with
recurring attacks.
20% of population
affected.
Mainly in professional
school students.
Familial association.www.indiandentalacademy.com
23. Ulcer will not preceded by vesicles and
it appear on the tongue, buccal
mucosa, floor of the mouth.
Rarely present on hard palate and
attached gingiva.
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24. One or two attacks in a year,one or two
attacks in a month ,never free from
lesion.
Appear as a single,painful
ulcer,diameter is less then .5 mm that is
covered by yellow fibrinous membrane
and surrounded by erythemeatous halo.
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25. Generalized edema of the oral cavity.
Parasthesia
Low grade fever
Localized lymphoadenopathy
Vesicle like lesion containing mucus.
Difficulties in eating.
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26. Common site of occurrence:buccal and
labial mucosa
Buccal and lingual sulci
Soft palate,gingiva labial mucosa.
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27. Lateral and ventral
surface of the
tongue is also
affected.
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28. Heal in 7 to 1o days without scar
formation.
Oral manifestation include mucosal
fissure,small multiple hyperplastic
nodule on the buccle mucosa produce
cobbel stone appearance.
Biopsy finding suggest nonceasenting
granuloma.
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30. Major apthous ulcer:most sever expression of
apthous stomatitis.
1 to 10 in number present in lips,cheeks
tongue, soft palate.
Painful and larger lesion and persist for
longer time
Heal with scar formation.
6 weeks to heal as soon as one disappear
another will appear
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31. Difficulties in eating,pain and
discomfort.
Show similar lesion in vagina,penis
larynx.
No particular age group,females
affected more then males.
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32. Herpetiform ulcer-present as a crop of
ulcers.
100 in numbers.
Palatal and gingival mucosa are
involved.
Pain is present and healing will occur in
1 or 2 weeks.
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33. Here the ulcer will be preceded by vesicle
and exhibit no virus infected cell.
Brooke and sapp-numerous small lesion
found in oral mucosa.
Small pinhead sized erosion that gradually
enlarge and coalesce
Painful lesion present for one to three years.
Immediate relief from tetracycline
mouthwash.
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34. Laboratory test-no herpes simplex virus
is cultured.
Absence of multinucleated giant cell.
No antibodies against herpes virus.
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37. Histopathology:minor apthous ulcer-
fibrinopurulent membrane covering the
ulcerated area.
Superficial colonies of microorganism present
in this membrane.
Inflammatory cell infiltration in connective
tissue.
Granulation tissue at the base of the lesion.
Epithelial proliferation at margins.
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38. Lesion begin at the excretory duct of
minor salivary gland.
Wood-anitschkow cell.
Mononuclear cell in submucosa and in
perivascular tissue in preulcerative
stage.
In ulcerative stage-CD4and CD8
lymphocyte.
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40. Treatment:mouth rinse-sodium bicarbonate in
warm water.
Drug-prednisone-20 to 40 mg daily for a week
Topical corticosteroid.
Intralesional injection of triamicolone.
Antibiotics-tetracycline suspension.
Tetracycline mouthwash-250 mg per 5 ml
used 4 times daily for 5 to 7 days .
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42. 250 mg of capsule in 30 ml of warm
water.(4 times in a day for 4 day)
Other
drugs:azathioprine,cyclophosphamide.
Thailodomide,pentixyfilline
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44. BEHCETS SYNDROME:Uncertain
etiology.
Pleuropnumonia like organism.
Autoimmune etiology.
Lehner-immunologic similarities
between this syndrome and recurrent
apthous stomatitis.
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45. Clinical features:between 10 to 45 year
of age.
Oral and genital ulceration,ocular
lesion,skin lesion.
Oral lesion-first occurrence
Painful and similar in appearance to
recurrent apthous stomatitis.
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46. Size ranging from several millimeter to
centimeter or more in diameter.
Ulcer have an erythematous border and
covered by gray or yellow exudates.
Genital ulcer are small and located on
scortum,root of the penis.
Ocular lesions-photophobia and
irritation
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47. Simple conjunctivitis to finally uveitis
and finally popyon
Skin lesions –small papules on the
trunk and limbs and around the
genitalia.
Involvement of CNS and cardiac and
pulmonary involvement is seen.
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51. Treatment and prognosis-supportive
treatment.
Remission after a period of months to
years.
Serious complication can lead to death.
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