Oral medicine:

Bacterial infections:
Scarlet fever

An infectious disease of 4-8 year olds

May be due to a delayed type hypersensitivity to streptococcal erythrogenic
toxin.
Symptoms
Sore throat
General malaise and fever
Red rash.
Signs:
Oral mucosa
reddened
Tongue
1. first, dorsum develops white coating through which white edematous
fungiform papillae project (strawberry tongue)
o 2. Second, white coating shed and dorsum becomes smooth and red with
enlarged fungiform papillae (raspberry tongue).

Treatment:
Systemic conditions only resolve with penicillin, otherwise oral manifestation
resolves within 14 days.
Tuberculosis

Re-emerging infectious disease affecting immune-compromised and elderly

patients.
1/3 of global population is affected by TB, but oral involvement is rare
Caused by mycobacterium tuberculosis.
It occurs due to open pulmonary infection or coexisting HIV
Signs:
Deep painful ulcer with raised borders, gradually increasing in size
Diagnosis:
PCR may facilitate definitive treatment.
Histopathology:
Necrotizing granuloma with langhans giant cells and epithelioid cells
Ziehl-Nielsen stain reveals mycobacterium
Treatment:
Refer to a chest physician for management as combination chemotherapy is

required.
Syphilis

Sexually transmitted disease caused by treponema pallidum

1ry lesion:

Chancre (firm painless ulcerated nodule) develops at the site of inoculation.

Genitalia and anus are the most common sites
but it can present on tongue and lips
Highly infectious.
Cervical lymphoadenopathy which resolves spontaneously in 1-2 months.

2ry lesions:
Develops 2-4 months after the primary with cutaneous rash
condylomata
Systemic features:
Malaise, fever, headache and weight loss.
Orally:
sensitive sloughy mucous patches known as snail track ulcers
(serpiginous ulceration)
Highly infectious and syphilis serology is positive at this stage
Ulcers clear up by 12 weeks, although there may be recurrence up to 1 year.

3ry lesion:
Develops several years later in 30% of the patients
Marked by gumma formation
necrotic granulomatous reaction usually affecting the palate
or tongue,
which enlarges and ulcerates and may lead to perforation of
the palate.
Non-infectious
Multisystem disorder (CNS involvement and vasculitis)
Congenital
syphilis

Due to treponema pallidum crossing placental barrier leading to appearance

of:
o Saddle nose
o Frontal bossing
o Sensorineural deafness
o Hutchinson incisors (peg shaped with notch)
o Mulberry molars (moon)

gonorrhea

15x more common than syphilis

Due to orogenital contact with an infected partner
Caused by Neisseria diplococcic and swabs may reveal gram ve intracellular
diplococci
Appears as:
o Non specific stomatitis or pharyngitis
o Frequent persistent superficial ulcers
o Purulent gingivitis
Treatment:
High dose penicillin and note that any sexually transmitted infection should
be referred to genitourinary medicine specialist.

Viral infection:
herpes
simplex

Most common viral infection affecting the mouth

Type 1 is more dominant than type 2 which is usually related to genital infection

Primary HSV:

o
o

Severity increase with age

Often subclinical and asymptomatic in 80%.
Appearance:
widespread stomatitis and unstable mucosa with vesicles that breakdown to form
shallow painful ulcers
enlarged tender cervical lymph nodes
halitosis
coated tongue
fever and general malaise for 10 14 days.
Diagnosis:
Clinical features and history
Microscopically:
Ballooning degeneration of epithelial cells
Intranuclear viral inclusions (Lipshutz bodies)
Treatment:
Since its self limiting disease:
Bed rest
Topical and systemic analgesia
Soft or liquid diet with extra fluid intake

 Prevention of secondary infection with chlorhexidine mouthwash.

Severely illed or immunocompromised patients should receive systemic
acyclovir.

Rare complication:
Herpetic encephalitis and meningitis

Recurrent HSV infections:

30% of the patients affecting mucocutaneous junction of the lips (herpes
labialis, cold sore)
Its a reactivation of the primary infection which is
believed to lie dormant in dorsal root, and autonomic or
cranial nerve ganglia (trigeminal or geniculate)
Usually recurs on area of distribution supplied by one branch of
trigeminal nerve.

o
o
o
o

Predisposing factors:
Trauma:
during removal of 8
immunosuppression
Exposure to sunlight
Stress and febrile illness

LESS COMMONLY

Signs and symptoms:

Prodromal phase:
o Burning and tingling over 24 hours
Followed by vesiculation and pain.
Treatment:
Lesions may respond to 1% penciclovir or acyclovir 5% cream if
used in Prodromal stage.
Systemic acyclovir in immunosuppressed or frequent
recurrences.

Varicella
zoster

Human herpes virus type 3

It is a neurogenic DNA virus which causes chickenpox as
a 1ry infection (Varicella) and shingles as a reactivation
(zoster)

Chickenpox:
An itchy, vesicular, cutaneous, centripetal rash
affects children with peak age 5-9 years
Rarely affecting the oral mucosa.
Patients are contagious from 1 2 days before the rash, until all
lesions crusted.

Shingles:
Commoner in the immunocompromised, alcoholic and elderly.
It is confined to the distribution of a nerve, the virus staying
either in the dorsal root ganglion of a peripheral nerve or the
trigeminal ganglion.
Always presents as a unilateral lesion never crossing the
midline
Facial or oral lesions may arise in the area supplied by the
branches of trigeminal nerve.

herpangia

Human
papilloma
virus

Diagnosis:
Pre eruption pain
Followed by the development of painful vesicles on skin or oral
mucosa.
Vesicles rupture to give ulcers or crusting skin wounds in the
distribution.
These usually clear in 2 4 weeks, with scarring and
pigmentations
Often followed by severe post herpetic neuralgia in up to 15%
for years.

Treatment:
Symptomatic relief
Caused by coxsachie virus A
Confined to children
Appearance:
Wide spread of ulcers on oral mucosa
Fever and general upset
No gingivitis (D.D. herpetic stomatitis)
May be preceded by sore throat and conjunctivitis
Mistaken as teething.
Treatment:
Self limiting in 10 14 days
Ttt as herpetic stomatitis.
More than 40 types are sexually transmitted.
Those are classified into 2 types:
Low risk HPV (6 & 11): no cancer may occur but cause skin warts

(condylomata acuminatum) on or around genitals, anus, mouth or throat.

Has been associated with:
squamous cell papilloma
condylomata acuminatum (multiple white/pink nodules)
focal epithelial hyperplasia (multiple painless papules)
verruca vulgaris (white exophytic lumps)
high risk HPV (16 & 18):
Has been associated with:
oropharyngeal cancer (cancers of the middle part of the throat,
including the soft palate, the base of the tongue, and
the tonsils).
Cervical cancer
Anal cancer
Treatment and prevention:
1. The Food and Drug Administration (FDA) has approved
three vaccines to prevent HPV
infection: Gardasil, Gardasil 9, and Cervarix. These
vaccines provide strong protection against new HPV
infections, but they are not effective at treating
established HPV infections or disease caused by HPV.
2. condoms are unlikely to provide complete protection
against the infection.
3. Treatment only available for the cell changes
(precancerous and cancerous):
Refer to oral cancer section

Non soft tissue lumps of the mouth:

abscess
Brown tumour
Dermoid cyst
Congenital
epulis
Peripheral
giant cell
granuloma
Pregnancy
epulis
Pyogenic

granuloma
Fibroepithelial
polyp
Irritation
(denture)
hyperplasia
Mucoceles
Ranula
Granulomata
Haemangioma

Developmental lesions of blood vessels

Present at birth

Lymphoangio
ma
Vascular
malformation

They are developmental lesions of blood vessels which do not regress but grow
in patient.
Ttt: interventional radiology and surgery
Warts/squamou Main etiological factor is HPV
s papillomata
Found in those with STD or AIDS, but usually of no link.
Warts are rare in mouth but usually transmitted from skin warts
Papillomas are common in mouth; appears as multiply papillated pink or white
asymptomatic lumps
Ttt: excision biopsy (if on stalk- ligate or diathermy base as they contain a
prominent vessel
ORAL CANCER:
Cancer of the mouth accounts for about 2% of all malignant tumors.
Oral cancer is preventable in 75% of cases.
Site:
Floor of the mouth is the commonest single site (75%)
High risk sites include retromolar region and lateral tongue.
MF
In 6th and 7th decades mainly.
Etiology:
1. Cancer of the lip: exposure to sun light is the main etiology

MEDICINE RELEVVANT TO DENTISTRY:

MEDICAL THEORY:
ANEMIA:
Definition: decrease in the level of circulating hemoglobin to below normal
reference range for a patients age and sex, indicating an underlying problem.
Clinical features:
General fatigue
Heart failure
Angina on effort
Pallor (look at conjunctivae and palmar creases, but unreliable)
Brittle nails and / or spoon shaped nails (koilonychia)
Oral discomfort, ulceration, glossitis and angular cheilitis.
Types of anemia:
Microcytic anemia
MCV 80 f
1. Iron deficiency anemia
(Defective production of
RBCs).
2. Thalassemias
(defective hemoglobin
synthesis)
3. Lead poisoning
(inhibition of hemoglobin
synthesis)
Normocytic anemia
MCV 80 100 f
Hemolytic anemia
Macrocytic anemia

MCV more than 100 f