Cancrum /certified fixed orthodontic courses by Indian dental academy

SEMINAR ON CANCRUM ORIS
AND APTHOUS STOMATITIS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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.

PREDISPOSING FACTORS:
 A) undernourished person.
 B)Debilitated person having infections
like Diphtheria,dysentery,measles,
pneumonia,scarlet fever,syphilis,
tuberculosis and blood dyscrasias
including anemia.

 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.

 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.

 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.

 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.

 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

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.

 Palate and tongue can also be involved
by this process.
 High temperature during the Course of
the disease.

 Mortality rate:75%
 Treatment:Immediate treatment of
malnutrition.

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.
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 2)Immunologicabnormal
ities:
Lehner:a)autoimmune
response
b)detected IgM
and IgG antibody in
epithelial cell of the
spinous layer of the oral
cavity.
 Addy and dolby:normal
level of complement
and antinuclear factor.

 Cohen:a) not an
autoimmune
disease.
b)local
immune response
against an
antigenically altered
oral mucosa.

 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

 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.

12)seen in HIVpatients

 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.

 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.

 Psychic factors-association with acute
psychological problem and stress.
 Allergic factor-association with asthma
hey fever,food or drug allergy.

 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.

 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

 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.

 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.

 Generalized edema of the oral cavity.
 Parasthesia
 Low grade fever
 Localized lymphoadenopathy
 Vesicle like lesion containing mucus.
 Difficulties in eating.

 Common site of occurrence:buccal and
labial mucosa
 Buccal and lingual sulci
 Soft palate,gingiva labial mucosa.

 Lateral and ventral
surface of the
tongue is also
affected.

 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.

 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

 Difficulties in eating,pain and
discomfort.
 Show similar lesion in vagina,penis
larynx.
 No particular age group,females
affected more then males.

 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.

 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.

 Laboratory test-no herpes simplex virus
is cultured.
 Absence of multinucleated giant cell.
 No antibodies against herpes virus.

 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.

 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.

 Presence of macrophages and mast
cells.
 Differential diagnosis:1)herpes simplex
infection.
 Trauma.
 Pemphigus vulgaris.
 Mucous membrane pemphigoid.

 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 .

 Steroid ointment-1.5 %cortisone
acetate applied locally.
 Hydrocortisone acetate antibiotics
lozenges.
 Chemical cautery.

 250 mg of capsule in 30 ml of warm
water.(4 times in a day for 4 day)
 Other
drugs:azathioprine,cyclophosphamide.
Thailodomide,pentixyfilline

 BEHCETS SYNDROME:Uncertain
etiology.
 Pleuropnumonia like organism.
 Autoimmune etiology.
 Lehner-immunologic similarities
between this syndrome and recurrent
apthous stomatitis.

 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.

 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

 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.

 Histologic features-similar to recurrent
apthous stomatitis.
 Endothelial proliferation.
 Vasculitis.
 Laboratory findings:
hypergammaglobulinemia
leucocytosis
eosinophilia
elevated sedimentation rate.

 Treatment and prognosis-supportive
treatment.
 Remission after a period of months to
years.
 Serious complication can lead to death.

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