Stomatolog y

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3.3 Prevention of Parodontopathies

Prevention of parodontopathies begins already at nursing age, when a care of the proper development of jaws is needed. At older children, a dentist should focus on orthodontic irregularities, anatomic deviations of a mucosa (high attachment of the frenulum, shallow vestibule) and timely diagnostics of the oral mucous membrane inflammations during puberty. It is very important that all disorders listed above are cured and eliminated. Oral hygiene belongs to substantial preventive measures.

Tools and devices for maintaining a proper oral hygiene.

1. Toothbrush, manual or electric. The working part of a toothbrush should be short, fitted with bundles of plastic fibers, rounded at their ends. The optimal strength and softness of fibers should be determined by a dentist according to the state of periodontium. A toothbrush should be replaced at least every three months, otherwise its effectiveness decreases.

2. Toothpaste, completes oral hygiene and makes it more pleasant. The use of a toothpaste shortens time needed for teeth cleaning, but it is not necessary for perfect cleaning. Composition of toothpastes varies. At present, toothpastes with slightly acidic reaction and not too abrasive properties are preferred. Dental powders are not suitable. They may damage teeth enamel due to their high abrasivity. The use of mouthwashing solutions is not too advisable, either. Their use leads away from proper oral hygiene and they damage the mucosa after prolonged use.

Methods of teeth cleaning and their practicing under a supervision of an attending dentist or nurse represent a substantial part of the home dental care. Current stomatologic literature prefers the cleaning technique that is called roll or sweep method. This method is based on a rubbing movement of a toothbrush from gums towards the teeth crowns. A toothbrush is laid on a gingiva under 45 degrees angle and it is moved towards teeth while rotating and rubbing movements are applied. Teeth should be cleaned at least two times daily (in the morning and at the evening), with duration of minimum of two minutes.

3. Dental floss is used for cleaning of interdental spaces and a sulcus. A floss, stretched at a plastic holder, removes well all that remains after brushing with a toothbrush. This way of cleaning is suitable especially for densely spaced teeth. Gum massages should be practiced by a patient and a dentist, who also selects an appropriate method. Massages can be done with a toothbrush, rubber or plastic stimulators, or cotton-tipped swabs (Q-Tips) wetted in an astringent solution. Massages may as well be done with the use of irrigators (Irigostoma brand name) that utilize a permanent or interrupted stream of water (or medicinal solution) under pressure. The aim of massages is to increase the gums blood supply and its metabolism rate, support keratosis of the epithelium, to remove plaque and a sulcus's content, decrease an edema and to prevent formation of connective tissues.

4. Diseases of Oral Mucosa

Diseases of oral cavity mucous membranes are among the most difficult chapters in stomatology namely because individual morphae (especially blisters) change rapidly due to mastication and wet environment and their typical form lasts very shortly. A physician has to rely on an anamnesis, evaluation of the course of a disease and auxiliary examinations that help to complete a picture of a disease.

4.1 Etiology of Mucous Diseases

Etiology of mucous diseases is a multi-factorial one. Many effects take part for these diseases to occur: mechanical (traumatizing), thermal, chemical, electro-galvanic effects, radiation, etc. Besides these external effects, internal factors, such as nutritional deficiencies, disorders of iron, lipids, saccharides, vitamins, proteins or minerals metabolism, play a role. It is rare that mucous diseases would be restricted to oral mucosa only, usually they are in a close relationship with general changes of an organism, especially with skin diseases. The variability of changes inside a mouth is determined both by various arrangement of mucosa at different parts of oral cavity, and by saliva composition. Both specific and non-specific immune mechanisms (phagocytic cells and immunoglobulin antibodies) play a role at these processes. The immune system has an important role at oral mucosa diseases and to a large extent determines its resistance against pathologic noxas.

All morphae that are known in dermatology may be found on a sick oral mucosa; except incrustations and scales (squama) that occur at the lips vermilion only. An aphta is typical for oral mucosa only. It begins with a small blister that erodes rapidly and gets covered with fibrin. It is surrounded by a regular inflammatory rim (halo).

4.2 The Selected Disorders of Oral Mucosa

Cheilitis (inflammation of lips) should always be in hands of a specialist - dentist, since it may be transformed into a phlegmon that puts a patient into a serious risk. Thrombophlebitis v. angularis may spread into brain sinuses and cause a suppurative lepto-meningitis.

Anguli infectiosi (stomatitis angularis, painful lip angles) do not possess an immediate danger for a patient, although they usually signal a general illness. This disease is a concomitant sign of hypochromic anemia, ariboflavinosis, iron deficiency, diabetes, and also Sjögren’s and Plummer Vinson’s syndromes. It also affects people with lowered occlusion (lacking teeth or with a wrongly made denture), often in combination with candidiasis.

Glossitis (inflammation of the tongue) has a colorful etiology. At children, this disease may originate as a result of the tongue traumatization by a persistent coughing (e.g. in case of pertussis - whooping cough - a small ulcer at the tongue frenulum - Rig’s disease). Glossitis of an allergic origin (drugs induced) that are associated with formation of vesicles, ulceration an edema, are common. Glossitis often appears during a general sickness, but certain kind of inflammation of the tongue is rarely a pathognomonic sign of a particular disease. The tongue’s filiform papillae react in the most sensitive way (usually by atrophic changes) to alterations in an organism. Glossitis atrophica appears frequently during malignant anemia, Faber’s anemia, pellagra, ariboflavinosis and sprue. It is also a part of xerostomy accompanying Sjögren’s syndrome, severe diabetes, liver malfunctions and chronic colitis.

Lingua villosa nigra (black hairy tongue) is characterized by hypertrophy and coloration of the filiform papillae. It appears as a result of a long term treatment with antibiotics or oxidants.

Lingua geographica (map-like tongue) is characteristic by bounded smooth areas on the dorsum of the tongue. These areas are divided from those with a physiologic surface by a noticeable white edge. The surface picture changes during the course of the disease. At children, this phenomenon may be inherited and does not require any treatment, in adults it may appear in connection with gastrointestinal tract diseases.
Inflammation of the whole oral mucosa is called stomatitis. If various metals are present at oral cavity, stomatitis electrogalvanica may rise at sensitive individuals. This disorder is accompanied by salivation defects, metal-like bad taste, dynic or neuralgia-forming problems. Erythemas, surface erosions or sclerotization defects appear on the mucosa. Alterations of the oral mucosa may as well originate during general infectious diseases - Koplik’s spots during measles, or raspberry colored tongue during the scarlet fever. In other cases, changes inside a mouth are primary and the major symptom of a disease - gingivostomatitis herpetica or ulcerosa.
Bullous (blistery) diseases.

The most serious disease of this group is pemphigus vulgaris. The primary morpha is a vesicle or bulla without an inflammatory rim. Besides large blisters, just disruptions of the epithelium and a livid, dim mucosa are sometimes observed. Crusts appear on the vermilion, the tongue is covered with an uncleanly flaccid fur. Diagnosis is supported by Nikolsky sign - tearing off the mucosa’s epithelial cover by pressure applied by fingers. Histological picture shows an intraepithelial blister and acantholysis. The diagnosis is confirmed by a positive result of immunofluorescence. Corticosteroids and even sometimes cytostatics are used for therapy.

Benign pemphigus and bullous pemphigoid are diseases similar to vulgar pemphigus. However, during histological examination, a subepithelial blister can be found. These diseases can be differentiated by immunofluorescence assays as well.

Lichen ruber planus belongs among diseases with an unclear etiology, accompanied by defect of keratinization. It affects the oral mucosa with no skin manifestations in 50% of cases. The basic morpha is a whitish, matte and flat papula. Morphae often aggregate and form porcelain-white, net-like or garland-like structures. Sometimes, morphae fuse together and their typical form can be found only at edges. Therapy is usually accomplished with “Kenalog” in “Orabase”, anti-malaric drugs, hypodermic injections of procaine containing “Kenalog” in cases of localized foci.

Mucous manifestations of drugs intolerance have colorful and variable clinical picture. The predominant part of the clinical picture in case of purely allergic reactions is an acute mucosa inflammation. Erythema, catarrhal inflammation, blistering, pseudo-membranous changes, even erosions and ulcers can be found. The tongue shows a wet, whitish and intensified fur. If toxic effects prevail, these signs are rather localized, with erosions and ulcers. Unaffected mucosa remains pale. Hyperkeratoses or lichenous morphae appear at a chronic intoxication. The tongue has less fur and a smooth surface. Hyperkeratoses occur on its smooth surface. Similar manifestations can be observed at epileptics after treatment with barbiturates or patients suffering with rheumatism after treatment with gold.

During a mixed allergo - toxic mucous reaction, mucous manifestations combine after the initial allergic reaction followed by the toxic and mucous component of the reaction. Tiny hemorrhages, above which the mucosa decomposes thus forming erosions, are among the first clinical signs of this disease. Upon a long-term intoxication, potentially malignant leukoplakias may emerge.

A stomatitis of viral etiology appears usually after an influenza. These diseases are accompanied by redness of mucosa at the soft palate. Some viral diseases, such as variola, varicella, vaccinia, herpes simplex, zoster or herpetic gingivostomatitis, cause appearance of blisters. Red Koplik’s spots appear at molars area during measles; a catarrhal inflammation of mucosa occurs during rubeola. Exulcerations and tiny hemorrhages can be found in a mouth during infectious mononucleosis.

Viral hepatitis is commonly accompanied with difficulties during opening a mouth and redness at the Stenon’s duct. Poliomyelitis acuta anterior shows a similar picture on the tongue as scarlet fever, a triangular pale area around the mouth, whitish spots on the boundary of the soft and hard palates and a triangular exanthema on the hard palate. Dermatophytic mucous inflammations, candidiases, are caused by infection of Candida (Monilia) albicans. Small white spots or coatings that can be originally easily wiped off, appear on the mucosa. They grow deeper later on and form tuberous aggregates. The danger of candidosis lays in a possibility of spreading the disease into other organs. Generalization of this disease represents a life threatening situation for a patient. Therapy is mostly local - rubbing of lesions with 2% solution of gentian violet and borax with glycerin. At the same time, high doses of vitamins B and C are administered. At serious cases, anti-mycotic drugs have to be administered generally. It is important to note that moniliasis can be induced by a long-term administration of antibiotics. Some oral mucosa inflammations originate on the basis of immune system disorders. One of them, stomatitis aphtosa recidivans, is currently proposed to be renamed to aphtosis minor. A small blister with an inflammatory rim that breaks soon and gets covered with fibrin, occurs on the mucosa. Before it outbursts, patients report an aura in the form of burning and tension of a particular place at the mucosa. A strong painfulness comes after an erosion appears. Patients usually have several aphtae inside their mouth at all times and undergo just short periods of rest. Aphtae never affect the hard palate mucosa, attached gingiva or lips vermilion.

Therapy: local rubbing with 5-10% solution of silver nitrate and gentian violet. Mouth washes with chamomile and salvia, sometimes with Framykoin, trypsin may be used locally. Good results have been achieved with Škach’s combination of three compounds: pyridoxine, folic acid and vitamin B12. Epithelization can be quickened by Solcoseryl.

Periadenititis mucosa necrotisans reccurens (aphtosis maior) is a serious disease characteristic by deep mucous defects around small salivary glands ducts that are painful, persistent and heal with scars. The therapy is identical with that of aphtae minores, it is much more difficult, however. In some cases, hypos with Kenalog are successful.

Erythema exsudativum multiforme Hebrae is a disease that affects mainly youngsters. Its basis is an immunodeficiency. Up to 50% cases of oral mucosa efflorescence are without dermatologic manifestations. Exanthema, papulae and small blisters appear on the mucosa. The iris form is typical for the skin, it may be found occasionally at the palate. Notable hemorrhagic crusts appear on the lips vermilion. The disease is accompanied by catarrhal gingivitis. The tongue is covered with an intense white fur, erosions or exulcerations may sometimes be found on its edges. The disease appears mainly during spring or fall. It is considered to be benign but it may have a fatal end in some cases. Therapy is tedious - epithelization preparations can be used locally, general anti-inflammatory treatment, corticoids, eventually immunologic treatment.

Aphtous stomatitis in combination with iritis and ulceration of genitalia may be parts of the Bechcet’s syndrome. It is a serious disease that may result in blindness due to purulent iritis. Similarly as in case of multiform erythema, the therapy is based on the use of corticoids and antibiotics. Currently, immunosupressants are used.

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