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Objective To attempt to establish criteria to differentiate between chronic ulcerative stomatitis (CUS) and oral lichen planus (OLP) with hematoxylin and eosin (H&E) staining alone. Study Design Ten confirmed cases of CUS were reviewed from the Stomatology Clinic at the Texas A&M University Baylor College of Dentistry. Results The original diagnosis on H&E evaluation was OLP, chronic mucositis, or mucositis with lichenoid features, but subsequent direct immunofluorescence (DIF) revealed a positive speckled intranuclear deposition of immunoglobulin G (IgG) in the basal and parabasal layers of the epithelium, confirming a diagnosis of CUS. Conclusions No consistent histopathologic features were present that would allow recognition of CUS from H&E analysis alone. DIF remains the gold standard for diagnosis.

Aim: The purpose of this study was to compare gender differences in the prevalence of oral lesions in HIV-infected Brazilian adults. Methodology: A retrospective study was conducted of medical records from HIV/AIDS patients from 1993 to 2004. Oral lesions were only included in this study if definitively diagnosed through microscopic analysis, therapeutic test or according to EC-Clearinghouse criteria. Results: A total of 750 men and 237 women were included in the study. Statistically significant differences were observed only for oral hairy leukoplakia, Kaposi sarcoma and lymphadenopathy (P < 0.01). However, a model of logistic regression showed that only oral hairy leukoplakia presented a significant association with gender and males had a significantly likelihood (four times higher than females) of presenting with this oral manifestation [OR 4.3 (95% CI: 1.39–13.36)]. Conclusion: These data shows that oral manifestations are less prevalent in females than in males, particularly oral hairy leukoplakia.

Emergency physicians should be comfortable treating most dental and related infections. In this article, we outline recommended techniques to perform a dental examination, explore common pathologies, recommend pain and antibiotic management strategies and review common pitfalls. How to avoid overprescribing opioid analgesics is discussed in depth, along with recent studies to support this strategy.

Purpose Hypesthesia or anesthesia of the lower lip (Vincent's symptom) is a common sign in patients with osteomyelitis of the mandible, especially in severe cases. Patients and Methods We observed an involvement of the inferior alveolar nerve in patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ). Surprisingly, we found Vincent's symptom also in patients with limited and early stages of BRONJ. Results These patients were successfully treated by surgical removal of the necrotic bone combined with preoperative and postoperative administration of antibiotics. We report on the occurrence and management of an involvement of the inferior alveolar nerve in patients with BRONJ and discuss possible causes. Conclusion We conclude that impairment of inferior alveolar nerve function can be an important early symptom or even the presenting symptom of BRONJ that is also easily detectable by bisphosphonate-prescribing physicians. Concerning the management of BRONJ, we conclude that surgical removal of necrotic bone combined with antibiotics is an adequate treatment in patients with osteonecrosis of the jaw.

Uremic stomatitis represents a relatively uncommon intraoral complication seen, mostly, in cases of end-stage renal disease or undiagnosed/untreated chronic renal failure. Its incidence has decreased due to the advent of renal dialysis. Clinically uremic stomatitis is characterized by the presence of painful plaques and crusts that are usually distributed on the buccal mucosa, dorsal or ventral surface of the tongue, gingiva, lips, and floor of the mouth. Treatment consists of improvement of urea blood concentration and the underlying renal failure, supported by increased oral hygiene with antiseptic mouthwashes and antimicrobial/antifungal agents if necessary. Although uremic stomatitis occurs in patients with end-stage renal disease, we report a case of a patient who exhibited an ulcerative form of uremic stomatitis related to the sudden relapse of uremia, although not in an advanced stage of her renal disease. A description of the clinical and microscopic appearance is given along with our hypothesis for the pathogenesis of the disease.

W e describe a woman from Korea with pyodermatitis-pyostomatitis vegetans associated with ulcerative colitis. On immunofluorescence examination, she demonstrated in vivo bound and circulating IgG antibasement membrane zone antibodies. The immunoelectron microscopy and immunoblot analysis showed that the antibodies reacted with the bullous pemphigoid antigen 230. We consider that the circulating autoantibodies to the bullous pemphigoid antigen 230 in this patient were an epiphenomenon, resulting from epidermal damage induced by inflammation of pyodermatitis-pyostomatitis vegetans.

Necrotizing oral lesions have been described in immunosuppressed patients, usually in association with gingival and periodontal pathoses. The etiology of these lesions has not been completely elucidated. We present 3 patients with a type of necrotizing stomatitis in which clinical patterns appear distinct from the periodontal forms of the disease. The lesions yielded bacterial cultures positive for Pseudomonas aeruginosa and reverted to no growth in 2 patients after proper antibiotic therapy. We propose that P aeruginosa may be responsible for selected necrotizing oral lesions with a clinical presentation lacking typical necrotizing periodontal disease and that this condition may represent the intraoral counterpart of ecthyma gangrenosum. In such cases, bacterial culture of the lesion becomes imperative because the disease does not respond to typical periodontal and antimicrobial therapy.

According to recent reports from the World Health Organization (WHO), noma (or cancrum oris), a hideous, ancient disease primarily affecting children living in poverty in parts of sub-Saharan Africa, is increasing. Noma often starts as an ulcer on the oral mucosa or as acute necrotizing gingivitis and commonly starts after a bout of measles or other disease. It quickly develops into a massive necrosis, moving from the inside outward, often involving major portions of the face. Early treatment with antibiotics, rehydration, correction of electrolytic imbalances, and administering nutritional supplements will halt the disease. The high mortality rate, however, indicates that many children are not given care or brought for care in time. Surviving victims often display severe facial deformities that demand extensive reconstructive surgery. Current research has elucidated parts of the pathogenesis of noma. The WHO started the International Action Network Against Noma in 1992, with its official launch on the World Health Day in 1994; a five-point action plan was presented and current work follows that plan.

Primary invasive mold infection of the oral cavity is a rare but serious complication in immunocompromised hosts. We report a case of fatal Trichoderma longibrachiatum stomatitis in a 66-year-old female patient with malignant lymphoma. The infection rapidly disseminated from the oral mucosa to the lungs during neutropenia. Despite intensive antifungal therapy with amphotericin B and itraconazole, there was a fatal progression of the condition. While Trichoderma species have been recognized to be pathogenic in profoundly immunosuppressed hosts, this is the first report of the primary oral focus causing a fatal infection.

The purpose of this study was to compare the prevalence of oral manifestations in human immunodeficiency virus (HIV)-infected patients on monotherapy, dual therapy, or triple therapy with the prevalence of those not on antiretroviral therapy (ART).A cross-sectional study of the oral manifestations of HIV was carried out on 284 HIV-infected patients, 89 of whom were undergoing ART (12 on monotherapy, 41 on dual therapy, and 36 on triple therapy) and 195 who were not undergoing ART. Oral manifestations were recorded by using established presumptive clinical criteria. Chi-square statistical tests and separate bivariate analyses were conducted by using the Spearman rank correlation to describe the relationship between the prevalence of oral lesions and ART.The detection of oral manifestations was significantly decreased in subjects on dual therapy and subjects on triple therapy in comparison with patients on monotherapy (P.05) and those on no ART regimen (P =.014). Oral manifestations were also significantly increased, with CD4 counts200 cells/mm(3) and a viral load3000 copies/mL (P.001).Compared with the non-ART group, subjects on combination ART had significantly fewer HIV-related oral manifestations-probably as a result of an expression of their reconstituted immune system.

Objective. The purpose of this retrospective study was to delineate the histopathologic, immunohistochemical, and virologic characteristics of 18 cases of necrotizing ulcerative stomatitis. Study design. Eighteen examples or oral ulcerations in human immunodeficiency virus–seropositive individuals were identified that displayed unique histopathologic features. Immunohistochemic staining for CD1a, CD3, CD23, CD68, HLA-DR, p24, cytomegalovirus, HSV-1, and HSV-2 was performed, along with in situ hybridization for Epstein-Barr virus RNA and special staining for bacteria and fungi. Results. The lesions demonstrated ulceration, extensive necrosis, leukocytoclasia, histiocytic vasculitis with luminal fibrin clots, and a prominent infiltrate of large atypical cells with amphophilic cytoplasm, vesicular nuclei, and prominent nucleoli, interspersed with crescentic histiocytes, a histologic picture resembling extranodal Kikuchi’s disease. Immunohistochemical findings suggested that the large atypical cells were histiocytes. Fifty-six percent (10/18) of the cases were immunoreactive for human immunodeficiency virus p24 within focal histiocytes, whereas Epstein-Barr virus RNA was identified in 1 (6%) of 17 cases. Conclusions. Necrotizing ulcerative stomatitis is an inflammatory disease characterized by specific, reproducible microscopic features. We postulate that the histopathologic resemblance of necrotizing ulcerative stomatitis to extranodal Kikuchi’s disease reflects a similar immune response to differing pathogens. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:323-32)

Objective We examined the diagnostic utility of the presence of oral lesions, individually and in combination, in identifying severe immunosuppression, defined as CD4 cell count under 200. Study design Data were collected on 82 HIV-seropositive homosexual men and 82 HIV-seropositive injection drug users who volunteered to participate in a longitudinal study of HIV infection. CD4 cell counts were measured within 24 hours of oral examination. Methods Sensitivity, specificity, positive predictive value, negative predictive value, and the odds ratio were computed to assess the association between oral lesions and CD4 less than 200. In addition to the individual lesions, we studied the diagnostic properties of sets of three to six lesions. For each set of lesions, a patient was classified as positive for the set if he or she had one or more lesions in that set. Results In homosexual men and injection drug users, individual lesions had low sensitivity, high specificity, and moderate positive and negative predictive values. Odds ratios reflected weak correlation to immunosuppression. When lesion sets were considered in homosexual men, sensitivity rose dramatically with only modest decreases in specificity. The positive and negative predictive values remained almost the same. Similar results for lesion sets were obtained in injection drug users, with greater reduction in specificity but stable positive and negative predictive values. Odds ratios indicated that for homosexual men, the more lesions included in the set, the stronger the correlation with immunosuppression. For injection drug users, strong correlations were observed for all lesion sets. Conclusions Analysis of sensitivities and odds ratios in homosexual men suggest that it may be valid to note the occurrence of a greater number of oral lesions than is currently done in staging patients with HIV infection. Among injection drug users, monitoring a larger number of lesions neither improves nor reduces the correlation to severe immunosuppression.

The oral manifestations of infectious diseases is a major topic since the prevalence rate has increased, and usually poses diagnostic and therapeutic dilemmas to the oral clinician. The clinical features of the most common and important oral infectious diseases are discussed.

Background. Oral lesions are common findings in HIV-related disease, but little is known about their significance in predicting immune suppression among a representative group of HIV-infected persons. Methods. Oral examinations were performed on 454 patients who came to an outpatient dental clinic for dental care. CD4+ cell counts were obtained within 2 months of the examination. Results. In persons with a specific lesion and a CD4+ cell count below 200 cells/mm 3 the corresponding mean CD4+ cell counts and predictive values were 149.5 cells/mm 3 and 69.9% for candidiasis, 143.3 cells/mm 3 and 70.1% for oral hairy leukoplakia, 126.0 cells/mm 3 and 69.4% for xerostomia, 51.8 cells/mm 3 and 95.1% for necrotizing ulcerative periodontitis, 98.7 cells/mm 3 and 87.0% for long-standing herpes simplex virus infections, 66.6 cells/mm 3 and 93.6% for Kaposi's sarcoma, and 33.7 cells/mm 3 and 100% for major aphthous ulcers. The mean CD4+cell count declined with increased numbers of different concurrent lesions. Conclusion. The presence of specific oral manifestations and the number of different concurrent intraoral lesions among HIV-infected persons are associated with severe immune suppression and AIDS. Oral examinations are an essential component for early recognition of disease progression and comprehensive evaluation of HIV-infected patients.

Propolis has been used since ancient times in folk medicine for its alleged beneficial effects. It is a potent sensitizer and is well recognized as a cause of occupational allergic eczematous contact dermatitis in apiarists. Recently, there has been an increase in allergic eczematous contact dermatitis because of nonoccupational exposure to propolis in "natural products" and biocosmetics. This report describes a patient who had acute oral mucositis with ulceration as a result of using propolis-containing lozenges.

An objective evaluation of 55 patients with chronic vesiculoerosive oral diseases was made to compare the beneficial and adverse effects of prednisone treatment. Patients were divided into groups of high, intermediate, and low drug dosages, as well as short and long periods of administration. Prednisone benefited 49 patients in spite of the fact that 55% had some adverse side effects. The duration of prednisone administration appeared to have a larger impact on side effects than the daily amount given. The most common side effects were gastrointestinal disturbances, mood alterations, polyuria and insomnia. There were no significant changes in blood pressure, blood sugar level, weight, or white blood cell counts. This study confirmed that systemic prednisone is a useful and beneficial treatment modality for patients with chronic oral inflammatory diseases.

The present work is one in a series of studies carried out to verify the relationship between bacteria and gingival tissues in pericoronitis. Exudates from 6 cases of acute pericoronitis were examined by light and electron microscopy, including ultrathin sections and negative staining. While bacterial phagocytosis was prevalent in all the exudates studied, spirochetes, which were the predominant microorganisms, were not observed being phagocytized by PMNs or macrophages. The presence of spirochetes in pericoronitis as compared with acute necrotizing ulcerative gingivitis is discussed.

Simian acquired immunodeficiency syndrome (SAIDS) is a retrovirus-induced immunodeficiency disease that affects certain nonhuman primates and has many parallels to human AIDS. We examined 72 rhesus monkeys (Macaca mulatta) exposed to SAIDS retrovirus serotype-1 (SRV-1) and 81 healthy control monkeys at the California Primate Research Center to determine the prevalence of oral lesions. At the time of examination, 69 of the 72 monkeys exposed to SRV-1 had serologic and/or virologic evidence of SRV-1 infection. None of the 81 control monkeys had any evidence of infection with SRV-1. Acute necrotizing ulcerative gingivitis (ANUG), oral yeast infections, and noma occurred in 10% (p less than 0.01), 4%, and 1%, respectively, of the study group of 72 animals but were found in none of the control animals. Thus, ANUG occurs rather frequently in rhesus monkeys with evidence of SRV-1 infection. The reproducible immunodeficiency that follows inoculation of SRV-1 in rhesus monkeys promises to be a useful model for studying the pathogenesis of ANUG associated with immunodeficiency.

Adverse drug reactions involving the mouth are less common than those affecting the skin. The diagnosis of these reactions requires, in some instances, a high index of suspicion as they can mimic other disease states such as erythema multiforme or xerostomia. On the other hand, reactions such as gingival hyperplasia secondary to the phenytoins (Fig. 1) are quite characteristic. Characteristic reactions are given in Table 1. The pathogenic mechanisms are similar to those causing adverse drug reactions in the skin. These are discussed in detail elsewhere in this volume. Examples of adverse drug reactions by pathogenic mechanisms are given in Table 2. The clinical interview is the single most helpful aid to the diagnosis of the adverse drug reaction affecting the mouth. As with cutaneous drug eruptions, certain drugs are much more likely to cause reactions than others. For example, drugs causing xerostomia include antidepressants, tranquilizers, antihypertensives, and gastrointestinal antispasmodics. The phenytoins and the antirheumatic agents may be taken for weeks or months before the reaction develops. For most reactions, drugs recently administered should receive the highest suspicion. There is no laboratory examination to assist in establishing the diagnosis of an adverse drug reaction in the mouth. A biopsy of the mucosa can help classify the mechanism of damage, such as vasculitis, and exclude other conditions, such as pemphigus, but cannot establish a drug causation. Thus, the clinical history, coupled with a high index of suspicion, remains the single best tool for the diagnosis of an adverse drug reaction involving the mouth. In this chapter, the adverse drug reaction of the mouth will be discussed, as they present to the clinician, by signs or symptoms. Suggestions about therapy will be interspersed with the drug reaction and will be discussed in general at the end of the chapter.

Ameloblastoma usually presents as a painless swelling of the jaw, but the chief complaint is rarely of ulceration. A case of ameloblastoma with a complaint of gingival ulcer in a 75-year-old Japanese male who was treated by an en bloc removal of the tumor with gingival ulcer is described and discussed. There is no evidence of recurrence, and the postoperative course was uneventful.

Including teeth and supporting structures and oral tissues in the physical examination provides an opportunity for physicians to play an important role in preventive dentistry. Recommendations should include plaque control, fluoride supplementation, reduced sugar intake and dietary counseling. Examination for precancerous and cancerous lesions as well as oral manifestations of systemic diseases is part of physician responsibility. Measurement of salivary flow rate and salivary composition furnishes useful indicators in a variety of salivary gland and systemic diseases that affect salivary gland function. Physicians treating dentists should be aware of problems that may arise from occupational hazards; these include hearing loss from high noise levels, mercury intoxication (amalgam fillings), and hepatitis B. Hepatitis B transmission by the dentist should also be of concern.

Aplastic anemia is a failure of all the cellular components of the bone marrow and, untreated, usually results in death from bleeding and/or infection within 4 months. Treatment by bone marrow transplantation offers the only means of survival. When a bone marrow graft fails, the patient is extremely susceptible to severe infection and/or hemorrhage. In this case, a bone marrow transplantation in a 34-year-old white man with aplastic anemia failed. Among the medical problems that subsequently developed were severe, prolonged and life-threatening oral bleeding and infection.

Thirteen patients with prolonged history of recurrent ulcerative stomatitis were studied for food sensitivity by intradermal testing procedures. The pattern of skin sensitivity reactions elicited did not establish allergy to food as etiologically responsible for recurrent ulcerative stomatitis, in terms of the group as a whole or for individual persons therein, with regard to the group of foods as a whole or any food in particular.

T UFTl has reported on a patient with recurrent ulcerative stomatitis in whom a marked sensitivity to citric acid was demonstrated as one, if not, the only, ct,iological factor in the recurrence of these lesions. Tuft suggests that allergy to this material might, be rcsponsiblc for lesions in ot,hcr pat,ients with this syndrome. Our study was dircct,ed at eraluat,ing the relationship of citric acid and several other mat,erials (which were described by Tuft as implicated also by virtue of their citric acid content or chemical relationship) in terms of a group of patients with documented recurrent ulcerative (aphthous) stomatitis. OLW criteria for selection of patients to be included in this group were as follows: Recurrent oral apht,hac, when observed at their inception (which is infrequent), are generally seen as vesicles. Usually, the lesions are recurring ulcers, commonly from 1 to 12 mm. in size but occasionally measuring 2 to 3 cm., appearing anywhere in the oral cavity. They are extremely sensitive and painful, and often t,hey are covered by necrotic membranes or exudates. The ulcers are most often round or oval, occasionally with irregular peripheries, and surrounded by an area of inflammation. Single or multiple lesions may recur periodically. The ulcers usually heal in from ten to fourteen days, but they arc soon followed by new lesions or crops of lesions. An important differential diagnostic criterion is the absence of dermatologic lesions relatable to the oral aphthae. The clinical picture of patients with recurrent ulcerative stomatitis does not include the genit,al or c-ye symptoms characteristic of Behset’s syndrome or the skin lesions of erythema multiforme exudativum or pemphigus.

Erythrocyte catalase levels were studied in subjects attending the Department of Periodontology in Edinburgh. The mean level in 41 cases of ulceromembranous gingivitis, 1.13 × 10−8 mol/g Hb, was significantly lower than in 206 controls, 1.64 × 10−8 mol/g Hb. Marked changes in erythrocyte catalase levels with time were noted, suggesting a seasonal variation, with a peak around January–March.

p e n i c i l l i n a n d k e p t r e f r i g e r a t e d r e t a i n t h e i r e f f e c t i v e n e s s a t l e a s t t w e n t y t h r e e w e e k s . 5 . O t h e r d r u g s u s e d i n t r e a t m e n t o f t h e r o o t c a n a l , i n c o m b i n a t i o n w i t h p e n i c i l l i n p a p e r p o i n t s , d o n o t i n a c t i v a t e t h e p e n i ­ c i l l i n . A s y n e r g i s t i c a c t i o n i s t h e r e s u l t . — 1 North Crawford Street.

The prevalence of acute ulcerative gingivitis in Nigerian children aged 2–6 years was—Ibadan City 11.7%, Abebeyun 11.7%, Igun 1.7%, Akufo 26.9% and Uboma 12.6%. Two of the 63 individuals with acute ulcerative gingivitis had cancrum oris simultaneously. The age range of the children with acute ulcerative gingivitis was 2 years to 12 years. Seventeen of the 50 houses visited in Ibadan City with children aged 2–6 years had one or more children with acute ulcerative gingivitis. Of the 98 rural households with children aged 2–6 years, 20 had one or more children with acute ulcerative gingivitis. In Ibadan City 73 per cent of the children with acute ulcerative gingivitis lived in a house where another child had the infection.

Quantitative estimations of fusiforms were made on saliva from “normal” subjects and from cases of acute ulcerative gingivitis (A.U.G.). It was found that the mean viable count of fusiforms in saliva of patients with A.U.G. (1.79 × 106 per ml) was significantly higher (P < 0.001) than that found in saliva of “normal” subjects (2.72 × 105 per ml). Fusobacterium nucleatum was predominant in both cases, accounting for about 75 per cent of the total fusiforms. Strain B of Leptotrichia buccalis apparently showed a disproportionate increase in saliva from A.U.G. compared with “normal” conditions (from 1.8 to 7.1 per cent of the total fusiforms).

Fusospirochetal lesions, their relationships, and appropriate treatment have been described, and a classification has been presented.

Vincent’s infection as a disease entity has received the attention of research workers and clinicians, principally since its outbreak among the American troops during World War I. The literature has become a maze of statements and coun­ terstatements as to causative agents and as to methods of treatment. The bacteria Fusiformis dentium and Borrelia vincenti, acting in symbiosis, are, at the present time, regarded by many as the causative agents. Before such a role can be assigned to these organisms, fur­ ther investigations of the entire flora of the oral cavity must be undertaken. Many mouths that are entirely free from the clinical manifestations of Vin­ cent’s infection will yield a positive bac­ teriologie smear. Many similar mouths will be entirely free from the organisms often regarded as causative. The utiliza­ tion of bacteriologic smears in diagnosis is of little value in the absence of clinical symptoms of the disease. There is agreement in the literature to the effect that there are a number of predisposing factors in the disease, in­ cluding dietary deficiency, blood dyscrasia, debilitating disease and chronic irritation of a chemical or physical nature. The extent to which any of the predisposing factors influence the course of the disease has not been defined. Many authors have stated that a defi­ ciency in vitamin B2, vitamin D, nico­ tinic acid or ascorbic acid is conducive to Vincent’s infection. Employment of any or all of the vitamin compounds in treatment is of questionable value since it is doubtful whether dentists, without complicated laboratory procedures, are

The need for a simple and safe drug in tablet form for the treatment of Vincent's disease has been discussed, and the literature on the use of metronidazole for this purpose has been reviewed. Age distribution, main complaints, and some possible etiologic factors in fifty patients with Vincent's disease have been given. The treatment of these fifty patients with metronidazole has been described, and the results of this treatment have been assessed.

Fifteen cases of acute ulcerative necrotizing gingivitis have been treated by the oral administration of aurcomycin with excellent results. The advantages of this drug over penicillin have been discussed.

This case illustrates the development of multiple painful oral ulcers caused by methotrexate that was one of a combination of chemotherapeutic drugs administered for the treatment of small cell carcinoma of the lung. Although the oral mucositis is self-limiting and resolves when the drug dose is reduced or therapy is discontinued, severe pain and discomfort may cause physical debilitation. Moreover, the risk of secondary oral infections is high in patients undergoing such therapy, and if the appropriate treatment is not instituted, fatal systemic dissemination of the infection may occur.