Wednesday, 29 June 2011

Oral Manifestations of a Systemic Disease

A 16-year-old boy with fever (38.9°C) and sore throat for the last 8 days was unresponsive to antibiotics. He was febrile and anemic and had generalized lymphadenopathy and hepatomegaly. Oral examination revealed painful, bilateral extraoral herpetiform lesions adjacent to the vermilion border of the lower lip (Fig. 1). These lesions appeared as clusters of encrusted vesicles. Intraoral ulcerations, suggestive of herpes simplex infection were present on the marginal and interdental gingiva on the buccal and palatal aspects of all teeth as well as on the lateral borders of the tongue (Figs. 2 and 3). These deep, “punched-out” ulcerations were covered with curdy, milky-white patches suggestive of oral candidiasis. The colour of the gingiva varied from pale to purplish red; loss of normal contour and stippling of gingiva and purple bruising were observed on the posterolateral aspect of the palate (Fig. 2). Candidiasis was also noticed on the posterior third of the tongue (Fig. 3). The pericoronal gingivae on the erupting mandibular left and right second molars were inflamed and covered with oral thrush (Fig. 4). There were generalized stains and calculus.
Figure 1: Bilateral extraoral herpetiform lesions with vesicles and encrustation.
Figure 2: Palatal bruising; markedly swollen, friable and erythematous gingiva; soft, raised, curdy, milky-white plaques interdentally suggestive of candidiasis.
Figure 3: Ulceration, candidiasis and bruising (ecchymosis due to hemorrhage) on the tongue.
Figure 4: Herpetic ulcers; enlarged, edematous, reddened pericoronal flaps superimposed with candidiasis, which is evident on the tongue and interdental areas.

What is the condition?

Differential Diagnosis

The differential diagnosis included immunodeficiency, hematologic malignancies, viral infection, immunosuppressive therapy, genetic causes and systemic conditions, including aplastic anemia, systemic lupus erythematosus and cyclic neutropenia.
States of Immunodeficiency
Defects in the functioning of the immune system are characterized by increased susceptibility to frequent, severe and recurrent infections of the respiratory tract, skin and mucous membrane. These are classified by type of cell affected, i.e., defects of B-lymphocytes, T-lymphocytes, phagocytic cells or a complement cascade. Infections with major gram-positive organisms occur frequently in B-cell immunodeficiencies, whereas severe viral and fungal infections occur in T-cell immunodeficiencies.
Acquired immunodeficiencies are the result of extrinsic causes, such as malnutrition, aging and medications, e.g., cancer chemotherapy, steroids and immunosuppressive drugs used by organ transplant recipients and in auto-immune disease. Chronic infections, such as AIDS caused by HIV, also impair the functioning of the immune system. HIV destroys CD4 helper/inducer T cells and affects both humoral and cell-mediated immunity making the patient highly susceptible to opportunistic infections. Manifestations of overall progression of the disease are more common in children because of their immature immune system. A prolonged history of fever, chronic recurrent diarrhea, oral hairy leukoplakia and Kaposi’s sarcoma may be some of the differentiating factors. CD4+ T-lymphocyte values should be obtained if a child has a positive virologic test for HIV.
Hematologic Malignancies
This group of immunocompromised states may result from an underlying hematologic malignancy or the use of chemotherapeutic drugs. Myeloid leukemias are characterized by infiltration of blood, bone marrow and other tissues by neoplastic cells of granulocytic series; in lymphoblastic leukemias, the bone marrow is replaced with small, immature lymphoblasts. The diagnosis is established by bone marrow aspiration and cytology, immunophenotyping, immunohistochemistry, molecular analysis and cytogenetic analysis. Lymphomas are usually diagnosed after microscopic examination of lymph node biopsies, immunohistochemistry and the absence of peripheral blood involvement.
Viral Infection
Infectious mononucleosis, caused by Epstein-Barr virus, is characterized by fever, lymphadenopathy, hepatosplenomegaly and abnormal blood lymphocytes. It can be differentiated from acute leukemia by the distinctive morphology of reactive lymphocytes and lymphoblasts and elevated viral titers. Moreover, in viral disease, lymph nodes, liver and spleen are often soft and ill-defined, whereas in acute leukemia, they are firm and discrete.
Immunosuppressive Therapy
Immunosuppressive drugs include glucocorticoids and cancer chemotherapeutic agents; these produce deficiencies in the host defense system and make a child more prone to infections by opportunistic organisms.
Genetic Causes
Wiskott-Aldrich syndrome (WAS) is an inherited disorder of the immune system that affects only males and is characterized by recurring severe opportunistic infections, eczema and thrombocytopenia. The diagnosis is confirmed by demonstrating a decrease or absence of the WAS protein in blood cells or the presence of a mutation in the gene that codes the WAS protein. Moreover, WAS platelets are significantly smaller than normal platelets.
Systemic Conditions
Aplastic anemia is a rare blood dyscrasia, in which peripheral blood pancytopenia results from reduced or absent blood-cell production in the bone marrow, and normal hematopoietic tissue in the bone marrow is replaced by fatty marrow. Sepsis and hemorrhage are the main causes of death in these patients as a result of neutropenia and thrombocytopenia, respectively. The lymphadenopathy, hepatosplenomegaly and skeletal changes associated with leukemia are not seen. Bone marrow aspiration or biopsy confirms the diagnosis.
Systemic lupus erythematosus is a multi-organ system autoimmune disease characterized by widespread vasculitis and the presence of various auto-antibodies. Fever, joint symptoms, mild anemia and oral ulcers are usually present in active disease. Children with lupus frequently have lymphadenopathy and hepatosplenomegaly. Non-erosive, symmetric and polyarticular arthritis, typical erythematous “butterfly” rash over the malar area and discoid rash with a history of photosensitivity over the face and chest are pathognomonic. Prominent laboratory findings include lymphopenia, thrombocytopenia, low serum complement levels, a high-titered positive antinuclear antibody test and abnormal urinary sediment.
Cyclic neutropenia, an autoimmune disease, is characterized by cyclic fluctuations in neutrophil count. The cycle averages 21 days (14–36 days) with severe neutropenia (neutrophil count < 0.2 × 109/L) lasting 3–10 days. During the period of neutropenia, bone marrow aspirate shows signs of maturation arrest at the myelocytic stage. Cyclic neutropenia is associated with fever, recurrent oral ulcerations, pharyngitis, cervical lymphadenopathy and skin lesions. Intraoral features include severe recurrent gingivitis, loss of periodontal attachment, deep periodontal pocket formation and marked alveolar bone loss, often causing loss of teeth.

Diagnosis of Patient

The patient’s history and clinical examination suggested a hematologic malignancy, and this diagnosis was further corroborated by results of a peripheral blood smear. The hemogram revealed hemoglobin level of 87 g/L, platelet count of 48 × 109/L, elevated total leukocytic count (210.5 × 109/L) and an increase in the number of myeloblasts (98% of the total leukocyte count) with a concomitant decrease in the lymphocyte count (2% of the leukocyte count). The peripheral blood smear revealed severe neutropenia (absolute neutrophil count [ANC], 0 × 109/L). Bone marrow biopsy and immunophenotyping confirmed the diagnosis of minimally differentiated acute myeloid leukemia.
Early bone marrow transplantation is the treatment of choice for acute myeloid leukemias. The patient has been undergoing chemotherapy at a nearby hematology centre and is currently in the consolidation phase. He is awaiting bone marrow transplant.
Leukemia is accompanied by febrile neutropenia, which is defined as the presence of fever (≥ 38.3°C) and a low neutrophil count. Neutropenia is classified as mild (ANC 1.0–1.5 × 109/L), moderate (ANC 0.5–1.0 × 109/L) or severe (ANC < 0.5 × 109/L). Severe neutropenia increases susceptibility to bacterial or fungal infections and impairs resolution of these infections. Leukemia also brings about defects in cell-mediated immunity that may increase the possibility of infection by an inherently present latent virus, such as herpes simplex virus (HSV), which manifests on the oral and circumoral mucosal surfaces. Confirmation of both herpetic gingivostomatitis and candidiasis by appropriate laboratory means is mandatory, even when prior empirical treatment is being contemplated.
Systemic antifungal therapy is indicated for patients who are at high risk of candidemia or are relatively resistant to topical antifungal agents. Nystatin in the form of a mouthwash or suspension or clotrimazole troche can be recommended for the treatment of oral candidiasis. If oral candidiasis is accompanied by an immunocompromised state, fluconazole or caspofungin is effective. The prophylactic use of the antiviral drug acyclovir is known to reduce the incidence of oral infections caused by HSV in patients with acute myeloid leukemia. Patients afflicted with hematologic malignancies are at a high risk of developing life-threatening septicemia due to odontogenic bacteria. Dental extractions and any other oral surgical procedures should be performed at least 3 weeks before the start of cancer chemotherapy. An ANC greater than 1.0 × 109/L and a platelet count of at least 60 × 109/L are acceptable for performing oral surgery.
This case demonstrates the importance for dental practitioners of recognizing mucocutaneous manifestations of systemic diseases. The oral cavity is an important portal of entry for microorganisms, which, in immunosuppressed patients, can lead to a systemic involvement accompanied by life-threatening complications. If such lesions are undetected and untreated, they often lead to a fulminant infection causing death. Dental prophylaxis and treatment of caries and gingivitis are necessary to eliminate the oral source of infection.

Friday, 24 June 2011

Mono News LifeStyle News Wire

Surrey’s First Dental Hygiene Clinic Tackles Oral Health in B.C.
June 23, 2011 6:21 PM

June 23rd, 2011-Surrey, British Columbia—Surrey Dental Hygiene Clinic is proud to announce its official opening as the first independent dental hygiene clinic in Surrey, British Columbia. The official opening of the clinic will be held on Saturday, June 25th, 2011 from 10:30am to 4:30pm at 12989-109 Avenue, Surrey, BC V3T2N3. Festivities will include demonstrations in the latest in oral hygiene care as well as the traditional ribbon cutting ceremony, raffles, and a chance to win free teeth whitening and cleaning. These opening events are open to the general public and all are encouraged to drop in and participate in the celebrations.
“I am so excited to be opening Surrey's first independent dental hygiene clinic," stated Ronnie Singh. “This is a dream come true for me and I truly look forward to providing access to the best oral care to members of my community at very affordable rates. There are many residents in this area of B.C that do not have access to regular dental hygiene care, so I am thrilled to be able to help to satisfy this unmet clinical need within my own community."
The Surrey Dental Hygiene Clinic will provide patients with oral exams, digital x-rays, scaling & root planing, tooth polishing, fluoride treatments, Periowave™ Photodisinfection treatments for the treatment of gum disease as well as traditional teeth whitening services. The clinic is focused on broadening the scope of available dental services in the community by making treatments more affordable, attracting the large population who are currently not receiving regular dental hygiene care. Patients requiring more comprehensive care from a dentist will benefit from Surrey Dental Hygiene Clinic’s referral programs.
For more information regarding the Surrey Dental Hygiene Clinic and the Official Opening Ceremony on June 25th, please contact Ronnie Singh
About the Surrey Dental Hygiene Clinic and Ronnie Singh
Ronnie Singh is the Owner & Founder of Surrey Dental Hygiene Clinic. She is a Registered Dental Hygienist and a Certified Dental Assistant with over 23 years of experience in the dental industry. She began her tenure as a Certified Dental Assistant in 1987 and moved on to be a Treatment Coordinator, Dental Administrator, Dental Office Manager, Clinical & Administrative Instructor and Dental Hygienist. She has extensive knowledge in dealing with insurance companies and managing dental insurance coverage for her clients. Please visit for more information.

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Surrey Dental Hygiene Clinic

Sunday, 12 June 2011

Monday, 6 June 2011

Surrey Dental Hygiene Clinic: How do I know if I have gum disease?

Surrey Dental Hygiene Clinic: How do I know if I have gum disease?: "Symptoms of gum disease include: Bad breath that won't go away Red or swollen gums Tender or bleeding gums Painful chewing Loose teeth ..."

How do I know if I have gum disease?

Symptoms of gum disease include:

  • Bad breath that won't go away
  • Red or swollen gums
  • Tender or bleeding gums
  • Painful chewing
  • Loose teeth
  • Sensitive teeth
  • Receding gums or longer appearing teeth
Image of Tooth AnatomyAny of these symptoms may be a sign of a serious problem, which should be checked by a dentist or dental hygienist . 
At your dental visit the dentist or hygienist should:
  • Ask about your medical history to identify underlying conditions or risk factors (such as smoking) that may contribute to gum disease. 
  • Examine your gums and note any signs of inflammation.
  • Use a tiny ruler called a 'probe' to check for and measure any pockets.  In a healthy mouth, the depth of these pockets is usually between 1 and 3 millimeters.  This test for pocket depth is usually painless.
  • The dentist or hygienist may also
    • Take an x-ray to see whether there is any bone loss.
    • Refer you to a periodontist.  Periodontists are experts in the diagnosis and treatment of gum disease and may provide you with treatment options that are not offered by your dentist.