OM- OFG and Systemic diseases

Question 1

Compare Orofacial granulomatosis to an angio-oedema?

Answer 1

Increased fluid in the oral and facial soft tissues.

Orofacial granulomatosis is due to a blockage of the lymphatic drainage causing accumulation of fluid in the soft tissues.
There is no increase in exudate from the capillaries into the tissues.
Histologically-we see giant cells that are obstructing the lymphatics.

Angio-oedema is due to increased vascular permeability allowing fluid to leak out of the capillaries into the soft tissues. The lymphatic drainage is working but is overwelmed. Histologically we see fluid in the connective tissue region.

Question 2

What causes Orofacial granulomatosis?

Answer 2

Granulomas present in the tissues. This can be due to:
* Sarcoidosis- unusual unless present in other sites e.g. lymph nodes or salivary glands.
* Tuberculosis- usually in mouth or face without pulmonary disease
* Chron’s disease-

Question 3

Why do we get granulomas?

Answer 3

In type 4 hypersensitivity reactions macrophages are activated to phagocytose the allergen.
If there is a problem removing the allergen, the macrophages fuse together to produce a giant cell granuloma.

Question 4

List symptoms of orofacial granulomatosis?

Answer 4

• Erythema of the peri-oral tissues (Disease extending well out from the mouth)
• Angular cheilitis
• Swollen lips
• Fissured lips
• Full thickness gingivitis (not plaque related)
• Enlarged submandibular duct (Stag horning)
• Cobblestoning.
  Angular cheiltitis
  Orofacial eryethma
  Cobblestoning
  Fissured tongue
  Fissured lips.

Question 5

If a child presents with OFG. How does this influence our treatment of the patient?

Answer 5

Chron’s screening.
Get parents to be aware of any changes in bowel habits/ abdominal pain.
Growth monitoring at each visit (nutritional problem= problem with bowel)

Refer for foecal calproctectin test (good marker for inflammatory bowel changes in patients >7 years old.

It can be related to dietary triggers so we could place the patient on an exclusion diet.

Question 6

What is an exclusion diet?

Answer 6

When you avoid the following foods containing:
* Benzoic acid (Found in tomatoes & tomato sauce.
* Sorbic acid.
* Cinnamon products
* Chocolate
* E210-219
100% Compliance for 3 months and then you can reintroduce any favourite excluded foods unless they cause symptoms.

Question 7

How do we treat Orofacial granulomatosis medically?

Answer 7

Topical treatment-
Angular cheilitis- topical miconazole gel 20 mg/g
Tacrolimus ointment- for areas of lip swelling and facial erythema to help disperse obstructed giant cells.

Intralesional steroid injection (Triamicinolone injected into the area of swelling)
Systemic treatment to help immune modulation:
Pulsed azithromycin
Prednisolone pulse
Aziathioprine/ mycophenolate .

Question 8

What is the difference between orofacial granulomatosis and oral chrons?

Answer 8

If the patient has chron’s disease then we call it Oral chron’s. If the patient does not have chron’s disease it is known as orofacial granulomatosis.

Question 9

How can systemic diseases manifest dentally?

Answer 9

It can affect the:
* tooth structure formation.
* Content of tooth. .

If it affects primary teeth (cause by something prenatally/ perinatally)
If it affects secondary teeth (caused by a perinatal/ childhood)

Question 10

Your patient has attended with this clinical presentation.
What has caused this?

Answer 10

ectodermal dysplasia

Question 11

Your patient has attended with this clinical presentation.
What has caused this?

Answer 11

Syphillis infection - changes to incisors- more triangular or peg like (Hutcheson’s incisors)

Question 12

Your patient has attended with this clinical presentation.
What has caused this?

Answer 12

Any illness-
So the damage to development occurs at the same time but this affects different teeth at different stages of development.

Question 13

Your patient has attended with this clinical presentation.
What has caused this?

Answer 13

This is pigmentation as a result of the buildup of bilirubin in the blood.

Question 14

Your patient has attended with this clinical presentation.
What has caused this?

Answer 14

This is pigmentation due to tetracycline use during dental development.

Question 15

Your patient has attended with this clinical presentation.
What has caused this?

Answer 15

This is due to porphyria.
(change in the haem levels in the blood)

Question 16

What systemic diseases can cause excess parathyroid hormone and discuss the impact of these levels on the mouth?

Answer 16

Renal failure. Hypocalcaemia. Parathyroid tumour.

Increased PTH increases the calcium broken down from bone. This causes a loss of cortical bone around the teeth (once the caue is treated the cortical bone will return)

Question 17

What systemic disease can cause raised ACTH levels and discuss the impact of these levels on the mouth.

Answer 17

Cushings and addisons disease,
Raised ACTH a reactive melanosis of the oral mucosa (pigmentation)

Question 18

What causes haematinic deficiencies and what effect can this have on the mouth ?

Answer 18

Malabsorption (GI diseases- coeliac/ Crohn’s)
Blood loss (Crohn’s/ ulcerative colitis/ Peptic ulcer disease/ bowel cancer/ liver disease)
Increased demand

Effect- oral ulceration and a painful tongue.

Question 19

Patient presents with this clinically,
Give differential diagnoses and how would we final a final diagnosis ?

Answer 19

White striae on an erythematous background.
Systemic lupus erythematous
Lichen planus
Would use immunology to distinguish between these.

Question 20

How does systemic sclerosis affect the connective tissues?

Answer 20

There is a loss of elasticity around the mouth (peri-oral fibrosis)

Question 21

Discuss this clinical presentation?

Answer 21

Wegner’s granulomatosis- A vascularitic change on the gingivae causing ischaemia and necrosis of the tissues that can spread to the airway.

Question 22

How can immune deficiencies affect the mouth?

Answer 22

Warts
Accquired infections e.g. candida
HIV (purple change of the mucosa known as Kaposki’s sarcoma)
Reactivation of herpes simplex.

Question 23

Give the oral effects of medical therapy?

Answer 23

Dry mouth
Oral ulceration e.g. Nicoradnil
Lichenoid reaction- ACE inhibitors/ beta blocker
Angiooedema
Osteonecrosis (bisphosphonates)