Geographic tongue

Other names:

Erythema Migrans, Benign Migratory Glossitis, Erythema Areata Migrans, Stomatitis Areata Migrans

Wandering Rash, Glossitis Areata Exfoliativa , Lingua Geographica, Transitory Benign Plaques Of The Tongue , Dorsal surface of the tongue

It is categorized as a chronic inflammatory condition of the tongue characterized by small patches disappear and reappear in a short period of time (hours or days), change in shape or size. the lesions appear as annular, circinate, or serpiginous along with slightly depressed atrophic centers (devoid of filiform papillae) and raised grayish white borders. Co-existence of fissures may also be present. Burning sensation occurs when tongue comes in contact with tomato, cheese, mouth rinses etc. Whitish/yellow discoloration of the tongue is frequently due to a yeast infection

Main etiological factors responsible are : environmental sensitivity-asthma, allergies, stress, smoking , harmonal changes-pre-mensturation, pregnancy, vitamin deficiency

Histopathology:

Irregular areas of dekeratinized and desquamated filiform papillae (red in color) are surrounded by elevated whitish or yellow margins due to acantholysis and hyperkeratosis. Neutrophils migrate into the epithelial layer, creating what are termed Munoros abscesses.

It is linked with psoriasis on the basis of presence of these abscesses. However, both the entities are different.

Treatment:  

Remove known etiology

Smear for detection of candida; apply candid solution

Steroid application-Triamcinolone Acetonide Dental Paste USP,0.1%

Vit B supplements

Zincum Gluconium 2x, 13.3 mg-Cold-Eeze -Relieves in 2 days (homeopathic)

Chewing mint leaves/ candies

Nanotechnology: Need of the hour

       Nanotechnology is the science and technology of diagnosing, treating and preventing disease and traumatic injury; of relieving pain; and of preserving and improving human health, through the use of nanoscale-structured materials, biotechnology and genetic engineering, and eventually complex molecular machine systems and nanorobots.

         Prospective of a nanotech world:

   Ø It helps in the detection of tumor location, size, shape at a molecular level

   Ø Delivery of anticancer drugs to specific site

   Ø Target specific imaging

   Ø Overcome both non cellular and cellular-based drug resistance, to increase selectivity of drugs.

   Ø Remove microvascular obstruction

   Ø Perform non invasive tissue transplants

   Ø  Molecular repairs

   Ø Exchange new whole chromosomes

     (Further reference: Annals & Essences of dentistry.Vol IV Issue 1 Jan-Mar 2012)

        Goodbye to dental drills: Nanoneedles and Nanotweezers

   Ø Restoration of tooth structure with fluoride,calcium,phosphate releasing nanocomposites.

   Ø Dental enamel formation using nanorods, nanospheres, and recombinant amelogenins.

   Ø Delivery of Local anesthesia

   Ø  Dentition renaturalization

   Ø  Permanent hypersensitivity cure

   Ø  Complete orthodontic realignments during a single office visit

   Ø  Continuous oral health maintenance using mechanical dentif-robots incorporated in mouthwash & toothpaste. 

Herpes Zoster

Herpes Zoster: Figure shows  severe vesicular ulcerations over the left side of face, hard palate and lips.The patient is HIV positive.

Herpes Zoster

Introduction

• Herpes zoster is categorized as a viral infection caused by varicella zoster virus. It is commonly known by the names shingles, zona or zoster. 
• Clinically, it can be grouped under 3 phases namely prodrome, acute and chronic. During initial viral replication active ganglionitis develops with resultant neuronal necrosis and severe neuralgia.
•  It is characterized by the occurrence of a painful skin rash(maculopapular lesions) in a stripe or belt-like dermatomal pattern which is limited to one side of the body and does not cross the midline. These rashes convert into vesicles with erythematous base. The vesicles finally turn into scabs and heal in 2-3 weeks.
• Ophthalmic division of trigeminal nerve is most commonly involved.

Pathophysiology

 This particular virus is responsible for the acute onset of chicken pox, usually occurs in children and young adults. Herpes zoster is a continuation of this infection as the virus is not eliminated from the body but becomes latent in the cranial nerves, dorsal roots, nerve cell bodies or autonomic ganglion.The virus may travel from one ganglion to another thereby infecting other dermatomes. 

Herpes zoster mainly occurs in older individuals (50 yrs of age) with imuunocompromise status due to age, psychological stress, cancer therapies,underlying malignancy, mechanical trauma, hereditary or exposure to immunotoxins etc. recurrence is rare; in HIV patients the recurrence rate is quite high.

Clinical features

• Symptoms of herpes zoster include headache, fever, and malaise. These are potentiated by paresthesia –pricking pain, tingling, numbness; burning pain, itching and oversensitivity of the tissues. 
• These skin rashes over a period of time convert into opaque vesicles (1-4 mm) and blisters filled with serous exudates. This exudate is replaced by blood and the vesicles are crusted giving the skin a darkened hue. Finally the crust falls off and the skin heals. This phenomenon takes place within a period of 7-10 days. Scarring remains after the disease subsides.
• Maxilla is frequently involved associated with devitalisation of teeth. Significant bone necrosis with loss of teeth is also present in some cases. 
• Tongue, lips and hard palate are other common sites.
• Pulpal necrosis and internal root resorption.These lesions are often misdiagnosed and endodontic treatment and extractions may be carried out by the dental surgeon .
• Facial paralysis may be observed.
• In the pregnancy period, this infection (chicken pox) may lead to complications in the foetus and newborn.

Complications

Post herpetic neuralgia- When the pain persists in the lesional area after the healing of mucocutaneous lesions that lasts more than 3 months after the initiation of acute rash, it is termed as post herpetic neuralgia. It is a burning, throbbing, stabbing kind of pain which is flared by light, contact with clothes or any other trigger factors. This may take 2 months to 1 year time to resolve completely. Prognosis is bad in such cases. High risk in old age due to decline in cell mediated immunity.

Zoster sine herpete/Zoster sine eruptione – Such patient has all the symptoms of herpes zoster except the characteristic rash.

Herpes zoster opthalmicus - It involves eyes and occurs in approximately 10–25% of cases. It is caused by the virus invading and reactivating the ophthalmic division of trigeminal nerve. It may lead to conjunctivitis, keratitis and optic nerve nerve palsies.

Herpes zoster oticus/ Ramsay Hunt Syndrome II - Involves the ear. Nerves like facial and vestibulocochlear are affected resulting in hearing defects and vertigo/rotational dizziness.

Diagnosis:

Polymerase chain reaction and Dot blot technique-detection of VZV DNA in lymph of blisters.

Specific IgM antibody test of blood/fluorescein conjugated monoclonal antibodies.

Electron microscope examination – For virus particles.

Tsanck smear helps to diagnose acute infection with a herpes virus, but does not distinguish between HSV and VZV.

Differential diagnosis:

Herpes Simplex virus

Treatment:

Aimed to shorten the course of disease, prevent post herpetic neuralgia and dissemination.

Preventive vaccine: Zostavax

              Analgesics

§        Mild to moderate NSAIDs

§        Severe pain-opioid analgesics like morphine

§        Topical calamine lotion

§        Capsaicin cream (Zostrix)

§        Topical lidocaine nerve blocks

§        Gabapentine with antivirals- post herpetic neuralgia

    Antiviral drugs

§        Acyclovir

§        Famciclovir

§        Valacyclovir

These drugs are most beneficial if taken within 72 hours of development of the    first vesicle. People who are at a high risk for repeated attacks of infection, five daily oral doses of acyclovir are usually effective.

Steroid therapy

Controversial results have been mentioned in various studies due to their high risk of inducing post herpetic neuralgia. But, in immunocompromised elderly patients corticosteroids along with antiviral drugs have proved to be useful in healing and crusting of lesions.

Percutaneous nerve stimulation

Biofeedback

               

Normal Radiographic Anatomy

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Normal Radiographic Anatomy

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ALLAGILLE SYNDROME

Alagille syndrome (AS) is an autosomal dominant disorder showing genetic predominance of one parent mainly seen in infants having severe cholestatic jaundice and heart murmurs. Therefore, such patients are diagnosed incidentally while screening a liver dysfunction or cardiac patient. It is associated with various abnormalities in liver, skeleton, impaired growth, eyes, kidneys and heart. Such patients exhibit a peculiar and characteristic facial appearance.

It is also known as arteriohepatic dysplasia.

Pathophysiology: Localized mutation of the JAG1 gene (20p12) occurs with variable expression.

The various features seen in the head and neck region in Alagille Syndrome are broadened forehead, pointed chin, elongated nose with bulbous tip. Mental retardation along with poor growth is also reported. These features become more pronounced as the age progresses.

Dentition shows hypoplastic lesions with heavy discoloration of teeth. Due to poor oral hygiene and the ill effects of medications prescribed to the patient to counter the effects of graft rejection (liver and heart). The gingival condition is bad showing signs of inflammation and edema. So, a dental consultation is must for a patient planned or undergoing treatment of this syndrome.

The various medications given to improve the bile flow and reduce itching are Ursodiol, Hydroxyzine, Cholesysteramine and Phenobarbitol. High doses of multivitamins like A, D, E, K prove to a successful measure to treat Alagille syndrome. Oral prophylaxis is mandatory. Corrective surgeries are also done in these cases.

Radiographic buzz: Dilaceration

Bull’s eye appearance: Unique variation of dilacerations, seen when the roots of mainly posterior teeth hides itself behind the crown giving it a floating appearance .It occurs as a result of 90 degree deviation of the roots.