10/4/2018

WELCOME COPYRIGHTS EVERYONE This presentation, all handouts and content within, including design and concepts are the intellectual property of Neli M. Gontier.

©2018 Neli M. Gontier

TODAY’S Telling TOPICS • A Discussion of the Oral Cavity • Conditions Related to Nutritional Deficiencies : • Conditions Related to Bacterial Biofilms • Conditions Related to Fungal Overgrowth Stories • Conditions Related to Viral Infections • Conditions of Ideopathic Origin from the • Priority Areas for Oral Health Programs Oral Cavity

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LEARNING OUTCOMES 1. Demonstrate an understanding of the different Oral Health causes for oral conditions; The WHO defines oral health as… Worldwide 2. Recognize the signs of systemic health issues within the oral cavity; 3. Interpret those signs to assess possible health “…a state of being free from mouth and needs; facial pain, oral and throat cancer, oral 4. Discuss health and oral needs with their infection and sores, periodontal (gum) patients; disease, , tooth loss and 5. Develop a plan of treatment and/or referral for other diseases and disorders.” their patients; 6. Find applications for the WHO priority areas.

“…the mouth is the center of vital tissues and functions that are critical to total health and well-being across the life span… What do the statistics the mouth as a mirror of health and disease, as a sentinel or early warning system, as an accessible model for the in Canada tell us? study of other tissues and organs, and as a potential source of pathology affecting other systems and organs…”

Oral Health in America: A Report of the Surgeon General 2000

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• Every DDS = Average >1600 ppl • Canada ranks high for access to oral • Lower in ON & BC STATS health care (compared worldwide) STATS • Ratio declining in urban centers, • It ranks low on… increasing in rural areas • DMFT (decayed, missing, filled) • Access presents challenges in • Prevalence of chronic perio some provinces • 10% of pop. >15 years • NL/NB = 1 for every 2500 • Number of seniors with no teeth • SK/NU = 1 for every 2500 • 3 / 4 ppl visit a dental clinic once/yr • AB/MB = 1 for every 1700/1800 • 86% visit at least twice annually

Statistics tend to focus on… AND… there’s so much more Let’s Take to know about oral health! a Closer Look!

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Vitamins - Overview

• Catalysts for metabolic reactions • Energy • Growth • Cell maintenance • Two categories: Conditions Related to • Water-soluble Nutritional Deficiencies • Fat-soluble

Vitamins - Requirements Levels of Stress

• Varies from type to type • Rapid growth • Affected by… • Pregnancy / Lactation • Tobacco use • Physical exertion • Alcohol use • Recovery from… • Caffeine intake • Illness or fever • Medications • Accident • Levels of stress* • Injury • Life stressors

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What Happens When We are Stressed Some Results of Stress

• Physiological changes  Fight or Flight • Immune suppression  Chronic Inflammatory Resp. • Body sends signals to release… • Musculoskeletal tension  Aches, Pain, Migraines • Adrenaline • Cardiovascular effects  Damage to blood vessels • Cortisol • Endocrine releases  stress hormones, blood sugar • Noradrenaline (norepinephrine) from liver (increased risk of diabetes) • Acute Stress vs. Chronic Stress • Gastrointestinal effects  acid reflux, IBS • Continuous activation  wear and tear on body • Reproductive effects  decreased fertility, ED • Sleep disorders  hyper-arousal, depression, obesity

Angular Cheilosis - Symptoms Angular Cheilosis - Causes

• Redness, swelling at corners of the mouth • Vitamin-B2 (Riboflavin) or B6 (Pyridoxine) deficiency • Broken, bleeding skin • Iron deficiency (anemia) • Crusting • • Itchy • Braces • • Painful Ill-fitting dentures • Immuno-deficiency or disorder • Lasts days to even years • Diabetes • Seen in elderly, alcoholics or highly stressed • Fungal infections

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Angular Cheilosis - Tx If you are observing • Proper nutrition (dairy, meat, poultry, fish) • Supplementation angular cheilosis, then…

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

• is not cancer… Glossitis: • However, can be result of cancer • Squamous Cell Carcinoma • Inflammation of the • Oral sore, anywhere in oral • Painful cavity, that doesn’t heal • Smooth • May bleed • Flattened fungiform papillae • Growth/thickening of tissues • Purplish-red colour • May involve tongue pain • Beefy Tongue • Difficulty/painful chewing • Difficulty/painful swallowing • Sore throat

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Squamous Cell Carcinoma - Causes Pellagra – Oral Symptoms

• Exact cause(s) unknown • Filliform papillae atrophy • Mutations in cell DNA form a tumor • Swollen and painful tongue • Risk factors include: • Appearance red like raw meat • Tobacco use of any kind • Thick grayish coating on dorsal surface • Heavy alcohol consumption • Swollen, ulcerated gingiva • Excessive sun exposure • Increased salivation • HPV • May develop into NUG or necrotic • Weakened immune system

Pellagra - Symptoms Pellagra - Causes

• 3-Ds of Pellagra: Vitamin-B3 (Niacin) and tryptophan deficiencies • Diet lacking in sufficient protein intake 1. Dementia  confusion, irritability, depression/anxiety • May result from… 2. Diarrhea  nausea, vomiting • Eating disorders 3. Dermatitis  , face, feet, hands, neck, chest • Gastroenteritis or chronic GI disorders • Congenital metabolic disorders • Chronic alcoholism • Medications (e.g. anticonvulsants, immunosuppess.)

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Pellagra – Treatment Therapies Glossopyrosis - Symptoms

• Supplementation with vitamin-B3 • a.k.a. ‘’ • I.V. • Accompanied by Glossodynia – pain in the tongue • Oral • Affects menopausal women 7x more than men • Increased protein intake (esp. turkey) • Swollen, pale, painful tongue • Diagnosing and addressing other causes • Dysgeusia • Moisturize dry skin patches/rashes • Disappearance of fungiform & filliform papillae • Protect skin patches with sunscreen • Later on becomes redder, smooth and shiny • Itchy, tingly or numb

Glossopyrosis - Causes Glossopyrosis is often misdiagnosed as… Sjögrens Syndrome:

• Vitamin-B12 (Cobalamin), folic acid, iron deficiencies • Autoimmune disease associated with • Lack of intrinsic factor • Rheumatoid arthritis • Lupus • Secreted by stomach – helps B12 absorption • Type 2 diabetes • Mostly females over 40 years • Oral thrush • Dry eyes • Hormonal imbalance (menopause) • Dry mouth • Hypothyroidism • Increased risk for • Caries, oral thrush, vision problems • Alcoholism, Anorexia, Anemia (haemolytic)

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Glossopyrosis - Tx Scurvy - Symptoms

• Antiseptic oral rinses (EO) • Stomatitis • Proper nutrition (balanced diet) • Extremely red, swollen gingiva that spontaneously

• Supplementation of vitamin-B12 bleeds  necrosis • Some gut bacteria & fungi can synthesize it • Gingival hyperplasia and rapid periodontal destruction • Supplementation of folic acid and iron • Pain in the , upon opening of mouth • Topical antifungals • Slow wound healing • Analgesics for tongue pain • Ecchymosis • Treat any underlying cause(s) • Anemia & depression

Scurvy - Causes Role of Vitamin-C

• Vitamin-C deficiency • Metabolism of… • Strengthens tissues • Can occur in just 20 days • Bile • Promotes vascular integrity • • Usually due to… Thyroxine • Aids… • Epinephrine • Poverty  poor diet • Iron absorption • Steroid hormones • Folate & B utilization • Chronic alcoholism  malnutrition/malabsorption 12 • Formation of… • Supports immune system • Old age  poor absorption of nutrients/poor diet • Osteoblasts • Antioxidant • Vitamin-C is needed for many physiological processes • Fibroblasts • Odontoblasts

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Scurvy – Treatment Therapies Osteomalacia - Symptoms

• Vitamin-C supplementation, especially in winter • Decreased bone mineralization • Increased consumption of fresh fruits & vegetables • Deformities of the spine, pelvis & thorax • Treatment of comorbidities • Orally  loss of lamina dura • Physical symptoms include: • Pain & muscle weakness • Uneven gait • Kyphosis • Mostly women of childbearing age (calcium depletion)

Osteomalacia - Causes Osteomalacia – Treatment Therapies

• Vitamin-D deficiency or depletion • Vitamin-D supplementation, especially in winter • Causes poor absorption of calcium and depletion • Calcium supplementation, if needed • Magnesium supplementation to assist with Ca+ absorption • Sufficient sun exposure* (UVB) • High impact activities

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Hyperparathyroidism: If you think it’s • Excessive secretion of parathyroid hormone due to tumor osteomalacia, it may be… • 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 Conditions Related • K2 – formed by E.coli, dairy and meats • K3 – synthetic form (menadione), 2-3x potency to Bacterial Biofilms • Avoid taking with Vitamin-E*

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Postnasal Drip - Symptoms Postnasal Drip – Forms/Causes

• Needing to constantly swallow or clear throat • Acute • Coughing when lying down and worse at night • Seasonal allergies • Nausea from excess mucus being swallowed • Viral upper respiratory infections (cold/flu) • Sore and/or scratchy throat • Dry air • Mild to moderate congestion • Medications (BP meds, birth control pill) • Bad breath (Halitosis) • Chronic • Associated with bacterial biofilms • Associated with sinus infections

Post Nasal Drip – Treatment Therapies If you are observing • Antiseptic mouth rinse • Oral rinse postnasal drip, then… • Throat gargle • Essential Oil (EO) • Chlorhexidine*

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Chronic Rhinosinusitis (CRS): CRS - Symptoms

• Affects 13% of the population • Nasal congestion • Takes 12 wks acute  chronic • Headache • Facial pain and/or fullness • Predisposing factors include: • Yellow or green discharge from nose • Impaired sinus drainage • Dizziness or vertigo • Upper respiratory infections • Pain in the upper molars • Allergic responses • Halitosis • Malaise

CRS - Causes CRS Assessment Cheat Sheet Signs/Symptoms Maxillary Frontal Sphenoid Ethmoid

Between or PAIN & PRESSURE Cheek Above Eyes Behind Eyes Behind Eyes Maxillary Top of Head, RADIATING/ Alveolar Ridge/ Inner Corners Mastoid Upper Part of REFERRING TO Upper of Orbit Process, Nasal Bones • Impaired sinus drainage Posteriors Occipital Area Bend Down/ Bend Forward, • Upper respiratory infections Physical Physical WORSENS WHEN Forward Physical Activity Activity • Secondary bacterial infections Lie Down Activity Headache in Tightness in MAY PRESENT AS Vertigo Headache Forehead Back of Neck

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• Serious risks with CRS if left CRS – Treatment Therapies untreated • Infection of the eye socket • Nasal irrigation (Neti pot) • Middle ear infections • Antibiotic treatment • Dental/periodontal infections • Ultrasound therapy • Meningitis • Surgical interventions • Intracranial Abscesses • Functional Endoscopic Sinus Surgery • Osteomyelitis (bone infection) • Balloon Sinuplasty • Pott’s Puffy Tumour • Antiseptic mouth rinse* • Frontal bone • Adolescents

Cobblestone Throat - Symptoms Cobblestone Throat - Causes

• Red and bumpy (enlarged lymphatic tissue) • Postnasal Drip • Inflamed and irritated back of throat • Seasonal allergies • Tonsils and adenoid tissue involvement • Respiratory infections • Constant dry cough • Laryngopharyngeal Reflux (LPR) • Feeling as if something is caught in the throat • Type of acid reflux • Sore throat • Acid works its way up to the throat • Nausea • Cold, dry air (air conditioning) • Halitosis

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Cobblestone Throat - Tx • Cobblestone throat is not cancer • But, be alert to any… • Treat the source of the problem… • Ear pain • Supplementation to improve • Hoarseness of the voice immune functioning • Difficulties swallowing • Antiseptic oral rinse (EO) to • Lumps on the neck relieve symptoms from allergy • Unexplained weigh loss or upper respiratory infection • Suppression of acid reflux with antacids/meds

Tonsilloliths- Symptoms If you are observing • Inflamed throat • Irritable cough tonsilloliths, then… • Dysphagia • Otalgia • Tonsillitis • Chronic Halitosis • Can form unilaterally or bilaterally • Calcified pieces fall out into the mouth

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Tonsilloliths: Tonsilloliths - Causes

• Biofilm in the tonsilar crypts • Postnasal Drip • Calcify (calculus) • Chronic Rhinosinusitis (CRS) • Causes halitosis in 75% of cases • Bacterial biofilms • Deep tonsillar crypts • Occurs in approximately 10% of pop. • Mostly adults • Suffering from chronic tonsillitis

Tonsilloliths – Treatment Therapies - Symptoms

• Treat the source of the problem • a.k.a. lingua villosa nigra • Antiseptic oral rinses, gargling • Elongated filiform papillae of • Essential Oil (EO) the dorsum of tongue • Chlorhexidine • Brown/black discolouration • Referral to an ENT • Hairy appearance • Curettage + excision + irrigation • Benign condition

• Cryptolysis using a CO2 laser • Tonsillectomy

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Black Hairy Tongue – Causes BHT – Treatment Therapies

• Chromogenic bacteria • Treat the source of the problem • • Antiseptic mouth rinse (EO) • Poor oral hygiene • Brushing of the tongue • Heavy smoking • Improve OH • Radiation treatment • Some medications • Tetracycline • Antacids

Secondary Syphilis - Symptoms Syphilis - Causes

• -like sores in the mouth (and on genitals) • Bacteria Treponema.pallidum • Raised and desquamated patches on the tongue • Transmission through direct (sexual) contact • Accompanied by: • Enters through minor cuts, abrasions • Muscle aches • Mainly contagious during primary/secondary stages • Sore throat • Can be transmitted through kissing (active oral lesion) • Swollen lymph nodes • Mother can transmit to child: • S&S may last a few weeks then disappear/reappear • During pregnancy • During childbirth

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Syphilis – Treatment Therapies

• Early syphilis can be cured with single injection of antibiotics (penicillin) • Prevention: Conditions Related • Abstinence • Protected sex to Fungal Overgrowth • Screening

Oral Thrush - Symptoms Oral Thrush - Causes

• Thick, white coating on dorsum of tongue • Overgrowth of oral fungus (yeast) • Burning sensation of the tongue • Typically, Candida.albicans • Coating can be scraped off • Increased risks of thrush when… • Appears red underneath the white plaques • Diabetic • Altered taste • Elderly or very young (infants) • Pain in the mouth • Denture wearer • Taking antibiotics • Difficulty eating or drinking • Iron deficient or B-vitamin deficient • Immunocompromised

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Oral Thrush – Treatment Therapies If you are observing • Use of anti-fungal agents (oral medications) • Diligent oral hygiene practices oral thrush, then… • Antiseptic mouth rinse (EO) • Stabilized Stannous Fluoride • Control of diabetes • Supplementation • Iron supplements • B-complex

Median Rhomboid Glossitis - Symptoms Median Rhomboid Glossitis - Causes

• Affects males more often • Chronic infection • Oval or rhomboid-shaped midline depression • Most frequently seen in… • Red and smooth • Smokers and tobacco users • Flat or depressed de-papillated surface • Diabetics • Dorsum of tongue • Denture wearers • Usually asymptomatic (pain-free) • Discomfort for full-upper denture wearers

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Median Rhomboid Glossitis – Tx

• Antifungal (oral) medication Conditions Related • Antiseptic mouth rinse (EO) • Brushing of the tongue to Viral Infections • Improve OH

*If it doesn’t resolve… biopsy!

Gingivostomatitis - Symptoms Gingivostomatitis - Causes

• Fever and overall malaise, fever, headache, halitosis… • Cervical lymphadenopathy, then… • Virus Type I • Oral Symptoms: • Cocksackie Virus (HFMD) • Multiple vesicles or tender sores • Streptococcus sp. (GABH) • On , tongue and gingiva • Actinomyces sp. • Can be around the outside of the mouth • Poor OH • Ulcerations • Painful, reddened, swollen, bleeding gingiva

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Gingivostomatitis - Tx

• 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 Ideopathic Conditions • Gentle cleaning of tongue • Mouth rinses (EO, xylocaine, salt-water)

Leukoplakia - Symptoms - Causes

• White or gray-like patches (tissue overgrowth) • Irritation from rough surfaces • Develop on tongue or inside of cheeks • Smoking/tobacco, alcohol use • Occurs in adults of any age – mostly elderly • Sun exposure to lips • Sensitive to touch, heat, spicy foods • HIV/AIDS • Can be fuzzy in appearance - “” • Oral Cancers (rare) • Usually seen in those with HIV/AIDS • Possible relationship with Vitamin-A deficiency • Can resemble thrush • Can affect skin, scalp, nails and genitals

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Leukoplakia – Treatment Therapies • Leukoplakia is not cancer • Can be precancerous • Remove source of irritation • So, be alert to any… • Chronic cases increase risks of oral cancers • Fuzziness to the surface • Surgical removal for lesions that do not resolve • Plaques that do not resolve • Hairy Leukoplakia requires anti-viral medications • Pain associated with a lesion • Supplementation with Vitamin-A (retinol) has shown • Redness around a lesion promise

Lichen Planus - Symptoms - Causes

• White, lacy streaks and patches on lining of mouth • Exact cause(s) unknown & tongue • Does NOT run in families • Immune system disorder • Is NOT transmissible • Typically, no pain or discomfort… BUT… • Can cause… • Burning sensations • Pain • Red • Sore patches

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Lichen Planus – Treatment Therapies Aphthous Ulcers - Symptoms

• Mild cases do not require treatment • Ulceration on any surface • More severe cases may be managed with… in oral cavity • Antiseptic mouth rinses (EO) • Round or oval • Steroid sprays • Remain for a 10-14 days • Steroid tablets dissolved in water and used as rinse • Painful • Sensitive to acidic foods or beverages

Aphthous Ulcers - Causes Aphthous Ulcers – Treatment Therapies

• Exact cause(s) unknown • Mild ones usually resolve on their own • Local trauma • Persistent ones may require… • Triggers include: • Topical anesthetics • Infections • Antiseptic mouth rinse (EO or CHX) • Hypersensitivities • Rx drugs - corticosteroids • Hormones • Dental laser ablation or surgical removal • Vitamin/mineral deficiencies • Chemical cauterization • Medications • Referral to oral pathologist or ENT • Stress*

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• Recurrent Aphthous Ulcers may - Symptoms be a marker for underlying systemic diseases… • Reddened patches on dorsum of tongue • Inflammatory Bowel Syndrome • White, elevated margins/borders • Nutritional deficiencies • Round, oval or irregularly-shaped • Celiac Disease • Patches change locations, shapes, sizes quickly • Behçet Syndrome (Vasculitis) • Can persist in one area for some time • Reiter’s Syndrome (Reactive • Filliform papillae disappear from area Arthritis) • Fungiform papillae remain • HIV/AIDS • Slight burning sensation • Can co-exist with Fissured Tongue

Geographic Tongue - Causes Geographic Tongue – Tx

• Exact cause(s) unknown • OTC analgesics (if painful) • Is NOT transmissible • Antiseptic mouth rinses (EO) • Possible link with • Anesthetic mouth rinse (if painful) • Possible link with Lichen Planus • Antihistamine mouth rinse • Risk factors include: • Coricosteroid rinse or ointment • Family history • Vitamin-B complex supplementation • Fissured Tongue • Biotin • Improve OH

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Fissured Tongue - Symptoms Fissured Tongue - Causes

• Shallow and deep fissures on dorsum and sides of • Exact cause(s) unknown tongue • Is NOT transmissible • Typically found on middle-third of tongue • Probable link with Geographic Tongue • Occurs in about 5% of people • More common with age • Affects men more than women • Often co-exists with Geographic Tongue

Fissured Tongue – Tx The WHO has also identified Priority Areas several priority areas for • Usually resolves on its own Oral Health • OTC analgesics (if sensitive) for consideration when Programs • Antiseptic mouth rinses (EO) initiating or improving • Vitamin-B complex supplementation • Biotin oral health programs. • Improve OH

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THANK YOU

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