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WELCOMEEVERYONE

COPYRIGHTS

This presentation, all handouts and content within,including design and conceptsare the intellectual property of

Neli M. Gontier.

©2018 Neli M. Gontier

TellingTongues:

Storiesfrom the

Oral Cavity

TODAY’STOPICS

• A Discussion of the Oral Cavity• Conditions Related to Nutritional Deficiencies• Conditions Related to Bacterial Biofilms• Conditions Related to Fungal Overgrowth• Conditions Related to Viral Infections• Conditions of Ideopathic Origin• Priority Areas for Oral Health Programs

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LEARNING OUTCOMES 1. Demonstrate an understanding of the different

causes for oral conditions;2. Recognize the signs of systemic health issues

within the oral cavity;3. Interpret those signs to assess possible health

needs;4. Discuss health and oral needs with their

patients; 5. Develop a plan of treatment and/or referral for

their patients;6. Find applications for the WHO priority areas.

Oral Health WorldwideThe WHO defines oral health as…

“…a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum)

disease, tooth decay, tooth loss and other diseases and disorders.”

“…the mouth is the center of vital tissues and functions thatare critical to total health and well-being across the life span…

the mouth as a mirror of health and disease, as a sentinelor early warning system, as an accessible model for the

study of other tissues and organs, and as a potential sourceof pathology affecting other systems and organs…”

Oral Health in America:A Report of the Surgeon General

2000

What do the statisticsin Canada tell us?

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STATS• Every DDS = Average >1600 ppl• Lower in ON & BC• Ratio declining in urban centers,

increasing in rural areas• Access presents challenges in

some provinces• NL/NB = 1 for every 2500• SK/NU = 1 for every 2500• AB/MB = 1 for every 1700/1800

STATS• Canada ranks high for access to oral health care (compared worldwide)

• It ranks low on…• DMFT (decayed, missing, filled)• Prevalence of chronic perio

• 10% of pop. >15 years• Number of seniors with no teeth

• 3 / 4 ppl visit a dental clinic once/yr• 86% visit at least twice annually

Statistics tend to focus on…AND… there’s so much more to know about oral health!

Let’s Takea

CloserLook!

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Conditions Related toNutritional Deficiencies

Vitamins - Overview

• Catalysts for metabolic reactions• Energy• Growth• Cell maintenance

• Two categories:• Water-soluble• Fat-soluble

Vitamins - Requirements

• Varies from type to type• Affected by…

• Tobacco use• Alcohol use• Caffeine intake• Medications• Levels of stress*

Levels of Stress

• Rapid growth• Pregnancy / Lactation• Physical exertion• Recovery from…

• Illness or fever• Accident• Injury

• Life stressors

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What Happens When We are Stressed

• Physiological changes Fight or Flight• Body sends signals to release…

• Adrenaline• Cortisol• Noradrenaline (norepinephrine)

• Acute Stress vs. Chronic Stress• Continuous activation wear and tear on body

Some Results of Stress

• Immune suppression Chronic Inflammatory Resp.• Musculoskeletal tension Aches, Pain, Migraines• Cardiovascular effects Damage to blood vessels• Endocrine releases stress hormones, blood sugar

from liver (increased risk of diabetes)• Gastrointestinal effects acid reflux, IBS• Reproductive effects decreased fertility, ED• Sleep disorders hyper-arousal, depression, obesity

Angular Cheilosis - Symptoms

• Redness, swelling at corners of the mouth• Broken, bleeding skin• Crusting• Itchy• Painful• Lasts days to even years• Seen in elderly, alcoholics or highly stressed

Angular Cheilosis - Causes

• Vitamin-B2 (Riboflavin) or B6 (Pyridoxine) deficiency• Iron deficiency (anemia)• Drooling

• Braces• Ill-fitting dentures

• Immuno-deficiency or disorder• Diabetes• Fungal infections

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Angular Cheilosis - Tx

• Proper nutrition (dairy, meat, poultry, fish)• Supplementation

• B2, Iron, C• Improve immune functioning• Control of diabetes• Lesions usually resolve when source of irritation is

removed or nutrition supports immune functioning

If you are observingangular cheilosis, then…

Glossitis:

• Inflammation of the tongue• Painful• Smooth

• Flattened fungiform papillae• Purplish-red colour

• Beefy Tongue

• Glossitis is not cancer…• However, can be result of cancer• Squamous Cell Carcinoma

• Oral sore, anywhere in oral cavity, that doesn’t heal

• May bleed• Growth/thickening of tissues• May involve tongue pain• Difficulty/painful chewing• Difficulty/painful swallowing• Sore throat

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Squamous Cell Carcinoma - Causes

• Exact cause(s) unknown• Mutations in cell DNA form a tumor• Risk factors include:

• Tobacco use of any kind• Heavy alcohol consumption• Excessive sun exposure• HPV• Weakened immune system

Pellagra – Oral Symptoms

• Filliform papillae atrophy• Swollen and painful tongue• Appearance red like raw meat• Thick grayish coating on dorsal surface• Swollen, ulcerated gingiva• Increased salivation• May develop into NUG or necrotic stomatitis

Pellagra - Symptoms

3-Ds of Pellagra:

1. Dementia confusion, irritability, depression/anxiety2. Diarrhea nausea, vomiting3. Dermatitis lips, face, feet, hands, neck, chest

Pellagra - Causes

• Vitamin-B3 (Niacin) and tryptophan deficiencies• Diet lacking in sufficient protein intake• May result from…

• Eating disorders• Gastroenteritis or chronic GI disorders• Congenital metabolic disorders• Chronic alcoholism• Medications (e.g. anticonvulsants, immunosuppess.)

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Pellagra – Treatment Therapies

• Supplementation with vitamin-B3• I.V.• Oral

• Increased protein intake (esp. turkey)• Diagnosing and addressing other causes• Moisturize dry skin patches/rashes• Protect skin patches with sunscreen

Glossopyrosis - Symptoms

• a.k.a. ‘Burning Mouth Syndrome’• Accompanied by Glossodynia – pain in the tongue• Affects menopausal women 7x more than men• Swollen, pale, painful tongue• Dysgeusia• Disappearance of fungiform & filliform papillae• Later on becomes redder, smooth and shiny• Itchy, tingly or numb

Glossopyrosis - Causes

• Vitamin-B12 (Cobalamin), folic acid, iron deficiencies• Lack of intrinsic factor

• Secreted by stomach – helps B12 absorption• Type 2 diabetes• Oral thrush• Hormonal imbalance (menopause)• Hypothyroidism• Alcoholism, Anorexia, Anemia (haemolytic)

Glossopyrosis is often misdiagnosed as…

Sjögrens Syndrome:• Autoimmune disease associated with

• Rheumatoid arthritis• Lupus

• Mostly females over 40 years• Dry eyes• Dry mouth• Increased risk for

• Caries, oral thrush, vision problems

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Glossopyrosis - Tx

• Antiseptic oral rinses (EO)• Proper nutrition (balanced diet)• Supplementation of vitamin-B12

• Some gut bacteria & fungi can synthesize it• Supplementation of folic acid and iron• Topical antifungals• Analgesics for tongue pain• Treat any underlying cause(s)

Scurvy - Symptoms

• Stomatitis• Extremely red, swollen gingiva that spontaneously

bleeds necrosis• Gingival hyperplasia and rapid periodontal destruction• Pain in the mandible, upon opening of mouth• Slow wound healing• Ecchymosis• Anemia & depression

Scurvy - Causes

• Vitamin-C deficiency• Can occur in just 20 days• Usually due to…

• Poverty poor diet• Chronic alcoholism malnutrition/malabsorption• Old age poor absorption of nutrients/poor diet

• Vitamin-C is needed for many physiological processes

Role of Vitamin-C• Metabolism of…

• Bile• Thyroxine• Epinephrine• Steroid hormones

• Formation of…• Osteoblasts• Fibroblasts• Odontoblasts

• Strengthens tissues• Promotes vascular integrity• Aids…

• Iron absorption• Folate & B12 utilization

• Supports immune system• Antioxidant

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Scurvy – Treatment Therapies

• Vitamin-C supplementation, especially in winter• Increased consumption of fresh fruits & vegetables• Treatment of comorbidities

Osteomalacia - Symptoms

• Decreased bone mineralization• Deformities of the spine, pelvis & thorax• Orally loss of lamina dura• Physical symptoms include:

• Pain & muscle weakness• Uneven gait• Kyphosis

• Mostly women of childbearing age (calcium depletion)

Osteomalacia - Causes

• Vitamin-D deficiency or depletion• Causes poor absorption of calcium and depletion

Osteomalacia – Treatment Therapies

• Vitamin-D supplementation, especially in winter• Calcium supplementation, if needed• Magnesium supplementation to assist with Ca+

absorption• Sufficient sun exposure* (UVB)• High impact activities

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If you think it’sosteomalacia, it may be…

Hyperparathyroidism:

• Excessive secretion of parathyroid hormone due to tumor

• Normally regulated by calcium levels in blood

• Oral symptoms include:• Loss of bone density• Soft tissue calcifications• Pulp stones• Loosening of teeth• Dental abnormalities• Mandibular tori

Deficiencies of Vit-D/Calcium – Tx

• Supplementation, especially in winter• Magnesium to support absorption• Vitamin-K* - binds Ca+/minerals in bone formation

• K1 – green plant sources• K2 – formed by E.coli, dairy and meats• K3 – synthetic form (menadione), 2-3x potency• Avoid taking with Vitamin-E*

Conditions Relatedto Bacterial Biofilms

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Postnasal Drip - Symptoms

• Needing to constantly swallow or clear throat• Coughing when lying down and worse at night• Nausea from excess mucus being swallowed• Sore and/or scratchy throat• Mild to moderate congestion• Bad breath (Halitosis)

Postnasal Drip – Forms/Causes

• Acute• Seasonal allergies• Viral upper respiratory infections (cold/flu)• Dry air• Medications (BP meds, birth control pill)

• Chronic• Associated with bacterial biofilms• Associated with sinus infections

Post Nasal Drip – Treatment Therapies

• Antiseptic mouth rinse• Oral rinse• Throat gargle

• Essential Oil (EO)• Chlorhexidine*

If you are observingpostnasal drip, then…

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Chronic Rhinosinusitis (CRS):

• Affects 13% of the population• Takes 12 wks acute chronic

• Predisposing factors include:• Impaired sinus drainage• Upper respiratory infections• Allergic responses

CRS - Symptoms

• Nasal congestion• Headache• Facial pain and/or fullness• Yellow or green discharge from nose• Dizziness or vertigo• Pain in the upper molars• Halitosis• Malaise

CRS - Causes

• Impaired sinus drainage• Upper respiratory infections• Secondary bacterial infections

CRS Assessment Cheat SheetSigns/Symptoms Maxillary Frontal Sphenoid Ethmoid

PAIN & PRESSURE Cheek Above Eyes Behind EyesBetween or Behind Eyes

RADIATING/ REFERRING TO

Maxillary Alveolar Ridge/

Upper Posteriors

Inner Corners of Orbit

Top of Head,Mastoid Process,

Occipital Area

Upper Part of Nasal Bones

WORSENS WHENBend Down/

ForwardLie Down

Bend Forward,Physical Activity

Physical Activity

PhysicalActivity

MAY PRESENT AS Vertigo Headache in Forehead

Tightness in Back of Neck

Headache

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CRS – Treatment Therapies

• Nasal irrigation (Neti pot)• Antibiotic treatment• Ultrasound therapy• Surgical interventions

• Functional Endoscopic Sinus Surgery• Balloon Sinuplasty

• Antiseptic mouth rinse*

• Serious risks with CRS if left untreated• Infection of the eye socket• Middle ear infections• Dental/periodontal infections• Meningitis• Intracranial Abscesses• Osteomyelitis (bone infection)

• Pott’s Puffy Tumour• Frontal bone• Adolescents

Cobblestone Throat - Symptoms

• Red and bumpy (enlarged lymphatic tissue)• Inflamed and irritated back of throat• Tonsils and adenoid tissue involvement• Constant dry cough• Feeling as if something is caught in the throat• Sore throat• Nausea• Halitosis

Cobblestone Throat - Causes

• Postnasal Drip• Seasonal allergies• Respiratory infections• Laryngopharyngeal Reflux (LPR)

• Type of acid reflux• Acid works its way up to the throat

• Cold, dry air (air conditioning)

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Cobblestone Throat - Tx

• Treat the source of the problem…• Supplementation to improve

immune functioning• Antiseptic oral rinse (EO) to

relieve symptoms from allergy or upper respiratory infection

• Suppression of acid reflux with antacids/meds

• Cobblestone throat is not cancer• But, be alert to any…

• Ear pain• Hoarseness of the voice• Difficulties swallowing• Lumps on the neck• Unexplained weigh loss

Tonsilloliths- Symptoms

• Inflamed throat• Irritable cough• Dysphagia• Otalgia• Tonsillitis• Chronic Halitosis• Can form unilaterally or bilaterally• Calcified pieces fall out into the mouth

If you are observingtonsilloliths, then…

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Tonsilloliths:

• Biofilm in the tonsilar crypts• Calcify (calculus)• Causes halitosis in 75% of cases

• Occurs in approximately 10% of pop.• Mostly adults• Suffering from chronic tonsillitis

Tonsilloliths - Causes

• Postnasal Drip• Chronic Rhinosinusitis (CRS)• Bacterial biofilms• Deep tonsillar crypts

Tonsilloliths – Treatment Therapies

• Treat the source of the problem• Antiseptic oral rinses, gargling

• Essential Oil (EO)• Chlorhexidine

• Referral to an ENT• Curettage + excision + irrigation• Cryptolysis using a CO2 laser• Tonsillectomy

Black Hairy Tongue - Symptoms

• a.k.a. lingua villosa nigra• Elongated filiform papillae of

the dorsum of tongue• Brown/black discolouration• Hairy appearance• Benign condition

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Black Hairy Tongue – Causes

• Chromogenic bacteria• Xerostomia• Poor oral hygiene• Heavy smoking• Radiation treatment• Some medications

• Tetracycline• Antacids

BHT – Treatment Therapies

• Treat the source of the problem• Antiseptic mouth rinse (EO)• Brushing of the tongue• Improve OH

Secondary Syphilis - Symptoms

• Wart-like sores in the mouth (and on genitals)• Raised and desquamated patches on the tongue• Accompanied by:

• Muscle aches• Sore throat• Swollen lymph nodes

• S&S may last a few weeks then disappear/reappear

Syphilis - Causes

• Bacteria Treponema.pallidum• Transmission through direct (sexual) contact• Enters through minor cuts, abrasions• Mainly contagious during primary/secondary stages• Can be transmitted through kissing (active oral lesion)• Mother can transmit to child:

• During pregnancy• During childbirth

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Syphilis – Treatment Therapies

• Early syphilis can be cured with single injection of antibiotics (penicillin)

• Prevention:• Abstinence• Protected sex• Screening

Conditions Relatedto Fungal Overgrowth

Oral Thrush - Symptoms

• Thick, white coating on dorsum of tongue• Burning sensation of the tongue• Coating can be scraped off• Appears red underneath the white plaques• Altered taste• Pain in the mouth• Difficulty eating or drinking

Oral Thrush - Causes

• Overgrowth of oral fungus (yeast)• Typically, Candida.albicans• Increased risks of thrush when…

• Diabetic• Elderly or very young (infants)• Denture wearer• Taking antibiotics• Iron deficient or B-vitamin deficient• Immunocompromised

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Oral Thrush – Treatment Therapies

• Use of anti-fungal agents (oral medications)• Diligent oral hygiene practices

• Antiseptic mouth rinse (EO)• Stabilized Stannous Fluoride

• Control of diabetes• Supplementation

• Iron supplements• B-complex

If you are observingoral thrush, then…

Median Rhomboid Glossitis - Symptoms

• Affects males more often• Oval or rhomboid-shaped midline depression• Red and smooth• Flat or depressed de-papillated surface• Dorsum of tongue• Usually asymptomatic (pain-free)• Discomfort for full-upper denture wearers

Median Rhomboid Glossitis - Causes

• Chronic oral candidiasis infection• Most frequently seen in…

• Smokers and tobacco users• Diabetics• Denture wearers

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Median Rhomboid Glossitis – Tx

• Antifungal (oral) medication• Antiseptic mouth rinse (EO)• Brushing of the tongue• Improve OH

*If it doesn’t resolve… biopsy!

Conditions Relatedto Viral Infections

Gingivostomatitis - Symptoms

• Fever and overall malaise, fever, headache, halitosis…• Cervical lymphadenopathy, then…• Oral Symptoms:

• Multiple vesicles or tender sores• On oral mucosa, tongue and gingiva• Can be around the outside of the mouth• Ulcerations• Painful, reddened, swollen, bleeding gingiva

• Herpes Simplex Virus Type I• Cocksackie Virus (HFMD)• Streptococcus sp. (GABH)• Actinomyces sp.• Poor OH

Gingivostomatitis - Causes

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• Rest and hydration• Antipyretics and analgesics• Antiviral medications (systemic) to shorten duration• Avoidance of irritating foods or beverages• Continue with OH home-care – desensitizing agent

• Gentle teeth brushing• Gentle cleaning of tongue• Mouth rinses (EO, xylocaine, salt-water)

Gingivostomatitis - Tx

Ideopathic Conditions

Leukoplakia - Symptoms

• White or gray-like patches (tissue overgrowth)• Develop on tongue or inside of cheeks• Occurs in adults of any age – mostly elderly• Sensitive to touch, heat, spicy foods• Can be fuzzy in appearance - “Hairy Leukoplakia”

• Usually seen in those with HIV/AIDS• Can resemble thrush

• Can affect skin, scalp, nails and genitals

Leukoplakia - Causes

• Irritation from rough surfaces• Smoking/tobacco, alcohol use• Sun exposure to lips• HIV/AIDS• Oral Cancers (rare)• Possible relationship with Vitamin-A deficiency

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Leukoplakia – Treatment Therapies

• Remove source of irritation• Chronic cases increase risks of oral cancers

• Surgical removal for lesions that do not resolve• Hairy Leukoplakia requires anti-viral medications• Supplementation with Vitamin-A (retinol) has shown

promise

• Leukoplakia is not cancer• Can be precancerous• So, be alert to any…

• Fuzziness to the surface• Plaques that do not resolve• Pain associated with a lesion• Redness around a lesion

Lichen Planus - Symptoms• White, lacy streaks and patches on lining of mouth

& tongue• Immune system disorder• Typically, no pain or discomfort… BUT…• Can cause…

• Burning sensations• Pain• Red gums• Sore patches

Lichen Planus - Causes

• Exact cause(s) unknown• Does NOT run in families• Is NOT transmissible

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Lichen Planus – Treatment Therapies

• Mild cases do not require treatment• More severe cases may be managed with…

• Antiseptic mouth rinses (EO)• Steroid sprays• Steroid tablets dissolved in water and used as rinse

Aphthous Ulcers - Symptoms

• Ulceration on any surface in oral cavity

• Round or oval• Remain for a 10-14 days• Painful• Sensitive to acidic foods or

beverages

Aphthous Ulcers - Causes• Exact cause(s) unknown• Local trauma• Triggers include:

• Infections• Hypersensitivities• Hormones• Vitamin/mineral deficiencies• Medications• Stress*

Aphthous Ulcers – Treatment Therapies

• Mild ones usually resolve on their own• Persistent ones may require…

• Topical anesthetics• Antiseptic mouth rinse (EO or CHX)• Rx drugs - corticosteroids• Dental laser ablation or surgical removal• Chemical cauterization• Referral to oral pathologist or ENT

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• Recurrent Aphthous Ulcers may be a marker for underlying systemic diseases…• Inflammatory Bowel Syndrome• Nutritional deficiencies• Celiac Disease• Behçet Syndrome (Vasculitis)• Reiter’s Syndrome (Reactive

Arthritis)• HIV/AIDS

Geographic Tongue - Symptoms• Reddened patches on dorsum of tongue• White, elevated margins/borders• Round, oval or irregularly-shaped• Patches change locations, shapes, sizes quickly• Can persist in one area for some time• Filliform papillae disappear from area• Fungiform papillae remain• Slight burning sensation• Can co-exist with Fissured Tongue

Geographic Tongue - Causes

• Exact cause(s) unknown• Is NOT transmissible • Possible link with Psoriasis• Possible link with Lichen Planus• Risk factors include:

• Family history• Fissured Tongue

Geographic Tongue – Tx

• OTC analgesics (if painful)• Antiseptic mouth rinses (EO)• Anesthetic mouth rinse (if painful)• Antihistamine mouth rinse• Coricosteroid rinse or ointment• Vitamin-B complex supplementation

• Biotin• Improve OH

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Fissured Tongue - Symptoms

• Shallow and deep fissures on dorsum and sides of tongue

• Typically found on middle-third of tongue• Occurs in about 5% of people• More common with age• Affects men more than women• Often co-exists with Geographic Tongue

Fissured Tongue - Causes

• Exact cause(s) unknown• Is NOT transmissible • Probable link with Geographic Tongue

Fissured Tongue – Tx

• Usually resolves on its own• OTC analgesics (if sensitive)• Antiseptic mouth rinses (EO)• Vitamin-B complex supplementation

• Biotin• Improve OH

Priority Areas for

Oral HealthPrograms

The WHO has also identifiedseveral priority areas

for consideration wheninitiating or improvingoral health programs.

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THANKYOU