Cheilitis Granulomatosa (Miescher-Melkersson-Rosenthal Syndrome)

Granulomatous cheilitis is a chronic swelling of the lip due to granulomatous inflammation. Miescher cheilitis is the term used when the granulomatous changes are confined to the lip. Miescher cheilitis is generally regarded as a monosymptomatic form of the Melkersson-Rosenthal syndrome, although the possibility remains that these may be 2 separate diseases. Melkersson-Rosenthal syndrome is the term used when cheilitis occurs with facial palsy and plicated tongue.

Melkersson-Rosenthal syndrome is occasionally a manifestation of Crohn disease or orofacial granulomatosis.

Causes

The cause is unknown. A genetic predisposition may exist in Melkersson-Rosenthal syndrome; siblings have been affected, and a plicated tongue may be present in otherwise unaffected relatives. Crohn disease, sarcoidosis, and orofacial granulomatosis may present in a similar clinical fashion, and with identical histologic findings. Dietary or other antigens are the most common identified cause of orofacial granulomatosis. Contact antigens are sometimes implicated.

Medical Care

Simple compression for several hours daily may produce significant improvement. Intralesional corticosteroids may be helpful in some patients. Success with other treatments has been reported anecdotally. None of the agents listed below has been systematically evaluated.

• Nonsteroidal anti-inflammatory agents
• Antibiotic treatment of dental abscess (resulted in remission in anecdotal cases)
• Mast cell stabilizers
• Clofazimine
• Tetracycline (used for anti-inflammatory activity)
• Methotrexate
• Tacrolimus
• Infliximab

Surgical Care

• Surgery and radiation have been used.
• Surgery alone is relatively unsuccessful.
• Reduction cheiloplasty with intralesional triamcinolone and systemic tetracycline offer the best results. Give corticosteroid injections periodically after surgery to avoid an exaggerated recurrence.

Gingivitis

Gingivitis is an inflammation of the gums surrounding the teeth. Gingivitis is one of many periodontal diseases that affect the health of the periodontium (those tissues that surround the teeth and include the gums, soft tissues, and bone).

Periodontal diseases are often classified according to their severity. They range from mild gingivitis, to more severe periodontitis, and finally acute necrotizing ulcerative gingivitis, which can be life threatening.

• Bacteria can cause inflammation of the gums. Although bacteria are normally found in our bodies and provide protective effects most of the time, bacteria can be harmful. The mouth is a great place for bacteria to live. The warm, moist environment and constant food supply are everything bacteria need to thrive. If not for a healthy immune system, bacteria in the mouth would rapidly reproduce out of control, overwhelming the body's defense system.
• An infection begins when the body's immune system is overwhelmed. Gingivitis is an infection that occurs when bacteria invade soft tissues, bone, and other places that bacteria should not be. At the moment of infection, bacteria no longer help us, they begin to harm us. Infections, like other diseases, range from mild to severe or life threatening.

Gingivitis Causes

Gingivitis is considered to be a bacterial infection of the gums. The exact reason why gingivitis develops has not been proven, but several theories exist.

• For gingivitis to develop, plaque must accumulate in the areas between the teeth. This plaque contains large numbers of bacteria thought to be responsible for gingivitis. But it is not simply plaque that causes gingivitis. Almost everyone has plaque on their teeth, but only a few develop gingivitis.
• It is usually necessary for the person to have an underlying illness or take a particular medication that renders their immune system susceptible to gingivitis. For example, people with leukemia and Wegner disease have changes in the blood vessels of their gums that allow gingivitis to develop. Other people with diabetes, Addison disease, HIV, and other immune system diseases lack the ability to fight bacteria invading the gums.
• Sometimes hormonal changes in the body during pregnancy, puberty, and steroid therapy leave the gums vulnerable to bacterial infection.
• A number of medications used for seizures, high blood pressure, and organ transplants can suppress the immune system and change the structure of the gums enough to permit bacterial infection.

Gingivitis Symptoms

• Swelling, redness, pain, and bleeding of the gums are signs of gingivitis.
  
  
• The breath begins to take on a foul odor.
  
  
• The gums begin to lose their normal structure and color. The gums, which were once strong and pink, begin to recede and take on a beefy red, inflamed color.
  
  
• Inflammation—a complex system by which bacteria-fighting cells of the body are recruited to an area of bacterial infection—plays a major role in gingivitis. It is this inflammation of the gums that accounts for most of the symptoms of gingivitis.
  
  
  • When bacteria first begin to invade the gums, proteins present in the saliva and soft tissues called antibodies coat the bacteria and weaken it, making it an easy target for the body's immune system. The cells that encounter the bacteria first attempt to kill it and, in the mean time, release chemicals into the bloodstream to call other cells to their aid.
    
    
  • One particular cell called a macrophage is responsible for ingesting the bacteria and dissolving it with chemicals. This system works nicely, but it is not terribly efficient. While the invading bacteria are destroyed, chemicals used by the immune system cells to kill them are spilled into the surrounding tissues. This not only kills the bacteria but damages the nearby connective tissues and cells of the gums as well.
    
    
  • The body sees this inflammation as a small price to pay for stopping the bacteria. This process will continue until the source of the infection is removed.

Gingivitis Treatment

Self-Care at Home

The best home care for gingivitis is prevention.

• Regular dental visits to remove plaque build-up are necessary to combat gingivitis.

• Once a dentist removes plaque, regular brushing and flossing will minimize plaque formation. Even with good dental hygiene, plaque will begin to accumulate again.

Medical Treatment

Removing the source of the infection is primarily how simple gingivitis is treated.

• By brushing teeth regularly with a toothbrush and fluoride toothpaste approved by dentists, plaque build-up can be kept to a minimum.

• Flossing is another means of removing plaque in between teeth and other areas hard to reach.

• Regular check-ups with a dentist are also important. A dentist is able to remove plaque that is too dense to be removed by a toothbrush or dental floss.

• Severe gingivitis may require antibiotics and consultation with a physician. Antibiotics are medications used to help the body's immune system fight bacterial infection and have been shown to reduce plaque. By reducing plaque, bacteria can be kept to a level manageable by the human immune system. Taking antibiotics is not without risks and should only be done after consultation with a dentist or doctor.

Prevention

Good mouth and teeth care, regular dental follow-up, and treatment of underlying illnesses are also necessary for preventing gingivitis.

Oral lichen planus

Oral lichen planus is a chronic autoimmune inflammatory condition affecting the lining of your mouth, usually resulting in characteristic lacy white patches. Oral lichen planus occurs most often on the inside of your cheeks but also can affect your gums, tongue, lips and other parts of your mouth. Oral lichen planus sometimes involves your throat or esophagus.

While oral lichen planus usually begins during midlife, it can occur at any age. An initial episode of oral lichen planus may last for weeks or months. But unfortunately, oral lichen planus is usually a chronic condition and can last for many years. Although there's no cure, oral lichen planus can be managed with medications and home remedies.

Symptoms

Oral lichen planus signs and symptoms may include one or more of the following:

• Small, pale raised areas or bumps that form a lacy network on your tongue or inside your cheeks
• Shiny, red, slightly raised patches on your tongue or cheeks
• Red, open sores in your mouth
• Mouth pain
• Burning in your mouth
• Dry mouth
• A sense that your mouth feels rough
• Sore gums
• Sensitivity to hot or spicy foods
• A metallic taste or a blunted taste sensation
• Burning, swelling, bleeding and irritation with tooth brushing

Oral lichen planus usually causes only a limited lacy network of pale, slightly raised areas or shiny, red, raised patches on the sides of your tongue or inside your cheeks. Less commonly, it may turn in to a painful erosive lesion, or ulcer. Sometimes oral lichen planus causes no signs or symptoms other than the raised areas or patches. You may have periods when your oral lichen planus flares up, alternating with periods when you're symptom-free.

When you have oral lichen planus, you may also have the skin form, called lichen planus. You may notice lesions on other parts of your body, including your skin, scalp, nails and genitals.

When to see a doctor
See your doctor or dentist if you:

• Notice sores inside your mouth that don't heal
• Have lumps or white, red or dark patches in your mouth
• Have mouth pain
• Have a loss of feeling inside your mouth
• Have repeated bleeding in your mouth
• Notice any change in the way your mouth looks and feels
• Have lesions or sores on your skin, scalp, nails or genitals

Risk factors

While it's not known what causes oral lichen planus, factors that may increase your risk of the condition include:

• Sex. Women are more likely than are men to have oral lichen planus.
• Medications. Certain medications, such as some of those used to treat arthritis, heart disease, high blood pressure and malaria, may trigger oral lichen planus.
• Allergies. Oral lichen planus can result from an allergic reaction to food, food additives, fragrances, dyes, dental metals or other substances.
• Medical conditions. Certain medical conditions, including other immune disorders, are associated with oral lichen planus. These may include lichen planus of the skin, liver disease, graft-versus-host disease, primary sclerosing cholangitis, lupus erythematosus, primary biliary cirrhosis, Sjogren's syndrome, ulcerative colitis, alopecia areata, and myasthenia gravis.
• Dental issues. Sharp edges on your teeth, dental restorations, ill-fitting dental prostheses, some periodontal surgical procedures, and oral habits such as lip and cheek chewing may raise the risk of oral lichen planus.
• Betel quid. Chewing betel quid — a plant and nut combination common in Southeast Asia — may increase your risk.
• Psychological issues. Stress, depression and anxiety often accompany oral lichen planus and may worsen existing cases.

Complications

Besides pain and taste changes that may accompany oral lichen planus, the condition also may cause or be associated with such complications as:

• Squamous cell carcinoma. This is a form of skin or mucous membrane cancer. There's considerable controversy about whether oral lichen planus can increase the risk of this cancer since evidence has been mixed. The risk appears to be heightened with ulcerative forms of oral lichen planus and with tobacco use.
• Oral thrush (Candida albicans). Oral lichen planus and its treatment may increase the risk of this fungus infection. In some cases, it can become resistant to antifungal medications, resulting in a so-called superinfection that's difficult to control.

Tests and diagnosis

Frequently, your dentist is the first to notice oral lichen planus symptoms during a routine examination. The condition often can be diagnosed just by examining the affected areas of your mouth. In some cases, though, you may need to see a doctor or dentist who specializes in dermatology or oral medicine for a definitive diagnosis and treatment.

To make a diagnosis, your doctor may:

• Ask about your symptoms
• Discuss your medical history
• Examine your mouth and other areas of your body
• Order tests, such as blood and allergy tests, to rule out other conditions, such as yeast infections and canker sores
• Take a biopsy of your lesions, especially if they're erosive or ulcerated

Prevention

There's no sure way to prevent oral lichen planus. Getting underlying medical conditions under control may help oral lichen planus from worsening, though. Also, avoiding alcohol and tobacco can help reduce your risk of oral cancer, which has been linked to oral lichen planus.

Pericoronitis

Pericoronitis is a dental disorder in which the gum tissue around the molar teeth becomes swollen and infected. This disorder usually occurs as a result of wisdom teeth, the third and final set of molars that most people get in their late teens or early twenties.

What Causes Pericoronitis?

Pericoronitis can develop when wisdom teeth only partially erupt (break through the gum). This allows an opening for bacteria to enter around the tooth and cause an infection. In cases of pericoronitis, food or plaque (a bacterial film that remains on teeth after eating) may get caught underneath a flap of gum around the tooth. If it remains there, it can irritate the gum and lead to pericoronitis. If the pericoronitis is severe, the swelling and infection may extend beyond the jaw to the cheeks and neck.

What Are the Symptoms of Pericoronitis?

• Pain
• Infection
• Swelling in the gum tissue (caused by an accumulation of fluid)
• A "bad taste" in the mouth (caused by pus leaking from the gums)
• Swelling of the lymph nodes in the neck
• Difficulty opening the mouth

How Is Pericoronitis Diagnosed?

Your dentist will examine your wisdom teeth and how they are coming in, and see if any are partially erupted. He or she may take an X-ray periodically to determine the alignment of the wisdom teeth. Your dentist will also take note of any symptoms such as swelling or infection, and will check for the presence of a gum flap around a wisdom tooth.

How Is Pericoronitis Treated?

If the pericoronitis is limited to the tooth (for example, if the pain and swelling has not spread), treat it by rinsing your mouth with warm salt water. You should also make sure that the gum flap has no food trapped under it.

If your tooth, jaw and cheek are swollen and painful, see your dentist right away. He or she can treat the infection with antibiotics (usually penicillin, unless you are allergic). You can also take pain relievers such as aspirin, acetaminophen, or ibuprofen. The dentist may also prescribe a pain medication.

If the pain and inflammation are severe, or if the pericoronitis recurs, oral surgery to have the gum flap or wisdom tooth removed may be necessary. Your dentist can make the appropriate referral to the oral and maxillofacial surgeon. A low-level laser can be used to reduce pain and inflammation associated with pericoronitis.

Trigeminal neuralgia

Imagine having a jab of lightning-like pain shoot through your face when you brush your teeth or put on makeup. Sound excruciating? If you have trigeminal neuralgia, attacks of such pain may occur frequently.

You may initially experience short, mild attacks, but trigeminal neuralgia can progress, causing longer, more frequent bouts of searing pain. These attacks can be spontaneous or provoked by even mild stimulation of your face. Trigeminal neuralgia affects women more often than men, and it's more likely to occur in people who are older than 50.

Because of the variety of treatment options available, having trigeminal neuralgia doesn't necessarily mean you're doomed to a life of pain. Doctors usually can effectively manage trigeminal neuralgia with medications, injections or surgery.

Symptoms

You may have one or more of these symptom patterns with trigeminal neuralgia:

• Occasional twinges of mild pain
• Episodes of severe, shooting or jabbing pain that may feel like an electric shock
• Spontaneous attacks of pain or attacks triggered by things like touching the face, chewing, speaking, and brushing teeth
• Bouts of pain lasting from a few seconds to several seconds
• Episodes of several attacks lasting days, weeks, months or longer — some people have periods when they experience no pain
• Pain in areas supplied by the trigeminal nerve (nerve branches), including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead
• Pain affecting one side of your face at a time
• Pain focused in one spot or spread in a wider pattern
• Attacks becoming more frequent and intense over time

Causes

The trigeminal nerve carries sensation from your face to your brain. In trigeminal neuralgia, also called tic douloureux, the nerve's function is disrupted. Usually, the problem is contact between a normal artery or vein and the trigeminal nerve, at the base of your brain. This contact puts pressure on the nerve and causes it to malfunction.

Trigeminal neuralgia can occur as a result of aging, or it can be related to multiple sclerosis or a similar disorder that damages the myelin sheath protecting certain nerves. Less commonly, trigeminal neuralgia can be caused by a tumor compressing the trigeminal nerve. In other cases, a cause cannot be found.

A variety of triggers may set off the pain of trigeminal neuralgia, including:

• Shaving
• Stroking your face
• Eating
• Drinking
• Brushing your teeth
• Talking
• Putting on makeup
• Encountering a breeze
• Smiling

Tests and diagnosis

Your doctor will review your medical history and ask you to describe your pain — how severe it is, what part of your face it affects, how long it lasts and what seems to trigger it. You'll also undergo a neurological examination, during which your doctor examines and touches parts of your face to try to determine exactly where the pain is occurring and — if you appear to have trigeminal neuralgia — which branches of the trigeminal nerve may be affected.

You may need to have a magnetic resonance imaging (MRI) scan of your head, which can show if multiple sclerosis is causing trigeminal neuralgia.

Facial pain can be caused by many different disorders, so an accurate diagnosis is important. Your doctor may order additional tests to rule out other conditions.

Treatments and drugs

Medications are usually the first treatment for trigeminal neuralgia, and many people are successfully treated with medication and require no surgical treatment. However, over time, some people with the disorder eventually stop responding to medications, or they experience unpleasant side effects. For those people, injections or surgery provide other treatment options.

Medications
Medications to lessen or block the pain signals sent to your brain are the most common initial treatment for trigeminal neuralgia.

• Anticonvulsants. Carbamazepine (Tegretol, Carbatrol), phenytoin (Dilantin, Phenytek) and oxcarbazepine (Trileptal) are the most common anticonvulsant medications used to treat trigeminal neuralgia. Other anticonvulsants include lamotrigine (Lamictal) or gabapentin (Neurontin). If the anticonvulsant you're using begins to lose effectiveness, your doctor may increase the dose or switch to another type. Side effects of anticonvulsants may include dizziness, confusion, drowsiness, double vision and nausea. Anticonvulsants have been linked to an increased risk of suicidal thoughts and behavior, so be sure to monitor your mood closely if you're taking an anticonvulsant for the first time. Also, carbamazepine can trigger a serious drug reaction in some people, mainly those of Asian descent, so genetic testing may be recommended before you start carbamazepine.
• Antispasticity agents. Muscle-relaxing agents such as baclofen may be used alone or in combination with carbamazepine or phenytoin. Side effects may include confusion, nausea and drowsiness.

Alcohol injection
Alcohol injections provide temporary pain relief by numbing the affected areas of your face. Your doctor will inject alcohol into the part of your face corresponding to the trigeminal nerve branch causing pain. The pain relief isn't permanent, so you may need repeated injections or a different procedure in the future.

Surgery
The goal of surgery for trigeminal neuralgia is either to stop the blood vessel from compressing the trigeminal nerve, or to damage the trigeminal nerve to keep it from malfunctioning. Damaging the nerve often causes temporary or permanent facial numbness, and with any of the surgical procedures, the pain can return months or years later. Surgical options include:

• Microvascular decompression (MVD). Instead of damaging the trigeminal nerve, MVD involves relocating or removing blood vessels that are in contact with the trigeminal root, and separating the nerve root and blood vessels.

  During MVD, your doctor makes an incision behind the ear on the side of your pain. Then, through a small hole in your skull, part of your brain is lifted to expose the trigeminal nerve. Any artery in contact with the nerve root is directed away from the nerve, and the surgeon places a pad between the nerve and the artery. If a vein is compressing the nerve, the surgeon typically will remove it. If no artery or vein appears to be compressing the nerve, your surgeon may sever the nerve instead.

  MVD can successfully eliminate or reduce pain most of the time, but pain can recur in some people. While MVD has a high success rate, it also carries risks. There are small chances of decreased hearing, facial weakness, facial numbness, double vision, and even a stroke or death. Since MVD doesn't damage the trigeminal nerve, most people who have this procedure have no facial numbness afterwards.

• Glycerol injection. During this procedure, called percutaneous glycerol rhizotomy (PGR), your doctor inserts a needle through your face and into an opening in the base of your skull. The needle is guided into the trigeminal cistern, a small sac of spinal fluid that surrounds the trigeminal nerve ganglion — where the trigeminal nerve divides into three branches — and part of its root. Images are made to confirm that the needle is in the proper location, and then a small amount of sterile glycerol is injected. After three or four hours, the glycerol damages the trigeminal nerve and blocks pain signals. Initially, PGR relieves pain in most people. However, some people have a later recurrence of pain, and many experience facial numbness or tingling.
• Balloon compression. In percutaneous balloon compression of the trigeminal nerve (PBCTN), your doctor inserts a hollow needle through your face and into an opening in the base of your skull. Then, a thin, flexible tube (catheter) with a balloon on the end is threaded through the needle. The balloon is inflated with enough pressure to damage the nerve and block pain signals. PBCTN successfully controls pain in most people, at least for a while. Most people undergoing PBCTN experience some facial numbness, and more than half experience temporary or permanent weakness of the muscles used to chew.
• Electric current. Percutaneous stereotactic radiofrequency thermal rhizotomy (PSRTR) selectively destroys nerve fibers associated with pain. While you're sedated, your doctor places a hollow needle through your face and into an opening in your skull. Once the needle is positioned, an electrode is threaded through it to the nerve root. You're then awakened from sedation so that you can indicate when and where you feel tingling from the mild current pulsed through the tip of the electrode. When the neurosurgeon locates the part of the nerve involved in your pain, you are returned to sedation. Then the electrode is heated until it damages the nerve fibers, creating an area of injury (lesion). If your pain isn't eliminated, your doctor may create additional lesions. Almost everyone who undergoes PSRTR has some facial numbness after the procedure.
• Severing the nerve. A procedure called partial sensory rhizotomy (PSR) involves cutting part of the trigeminal nerve at the base of your brain. Through an incision behind your ear, your doctor makes a quarter-sized hole in your skull to access the nerve. Because it cuts the nerve at its source, your face will be numb permanently. In some cases, instead of cutting the nerve the surgeon will choose to traumatize the nerve by rubbing it.
• Radiation. Gamma-knife radiosurgery (GKR) involves delivering a focused, high dose of radiation to the root of the trigeminal nerve. The radiation damages the trigeminal nerve and reduces or eliminates the pain. Relief occurs gradually and can take several weeks to begin. GKR is successful in eliminating pain for the majority of people, but sometimes the pain may recur. The procedure is painless and typically is done without anesthesia. Because this procedure is relatively new, the long-term risks are not yet known.

Alternative medicine

Few clinical studies have been done on the effectiveness of alternative treatments for trigeminal neuralgia, so there's little evidence to support their use. However, some people have found improvement with these treatments. Always ask your doctor before trying an alternative treatment, since they may interact with your other medications. Complementary and alternative treatments for trigeminal neuralgia include:

• Acupuncture
• Biofeedback
• Vitamin therapy
• Nutritional therapy
• Electrical stimulation of nerves

Oroantral fistula

Abnormal communication between the maxillary sinus and oral cavity. It is most often a complication of tooth extraction, but may also occur after apicectomy; it may also develop spontaneously due to severe periodontal disease. The teeth most frequently involved are the upper second molar, followed by the first molar. Small fistulae may close spontaneously, but larger fistulae usually require surgical closure. Preoperative determination of the size of the fistula is often unreliable. The appearance of oroantral fistula on multiplanar CT imaging is disruption of the bony floor of the maxillary sinus, with soft tissue opacification of the maxillary sinus. Dental reformatted CT can be useful for evaluating patients suspected of having oroantral fistula. However, the bone between the roots of the teeth and the maxillary sinus may be very thin and is sometimes not visible on CT images. Moreover, the roots may appear to project into the maxillary sinus; this should not be misinterpreted as evidence of an oroantral fistula.

Dental Fistula

Fistula

A fistula is a tunnel conducting pus from one infection to the site of another. A mouth fistula is called a gum boil. More generally a fistula is due to destruction of intervening tissue between the two sites and is a major component of a periapical abscess. Inflamed pus forms an abscess causing a pressure increase in the surrounding tooth area. If the pus that accumulates at the end of the tooth have no alternate pathways for drainage over time spontaneous drainage may occur through bone next to the root end. The pathway through which the pus has burrowed is called a fistula.

Fistulas usually form near the roof of the mouth or on the gum and are difficult to detect. A fistula can also be known as a Parulis as this is the term given to the point at which the fistula reaches the surface of the mouth presented as a small pimple. This pimple usually ruptures to form an opening.

Treating a fistula requires antibiotics and extraction of the tooth that led to the fistula via root canal surgery. Also draining the abscess that led to the fistula is a treatment method although this is usually followed by root canal surgery.

Dry Sockets (Alveolar Osteitis)

Dry sockets, termed alveolar osteitis by dentists, are a fairly commonplace complication associated with having a tooth extracted. While the exact pathogenesis of dry sockets has not been thoroughly explained, their occurence is associated with a situation where the blood clot normally expected to occupy the extraction site and initiate its healing has instead been lost. The net result is that the healing of the socket becomes delayed.

The symptoms of a dry socket are pain, foul odor and foul taste emanating from the tooth extraction site. These symptoms characteristically do not appear until some days after the tooth has been removed. Clinical experience and dental research have identified a number of factors that seem to place dental patients at greater risk for experiencing dry sockets. If the dentist and dental patient keep these factors in mind when planning for and then proceeding with a tooth extraction they may help to minimize the risk for dry socket formation.

The use of analgesics (pain pills), either non-prescription or prescription, is typically not the most effective solution for controlling the pain and discomfort associated with dry sockets. In most cases the best treatment involves a dentist inserting a medicated dressing, daily if needed, into the dry socket. The idea is that this treatment dressing helps to control the level of pain the dental patient experiences until the (delayed) healing process is able to progress and resolve the symptoms of the dry socket.

What are dry sockets?

A dry socket, more formally referred to as alveolar osteitis by dentists, is a fairly common complication associated with tooth extractions. The formation of a dry socket involves a scenario where the blood clot which forms in the tooth socket's after the extraction isn't properly retained (either it disintegrates by way of fibrinolysis or becomes dislodged). Since this blood clot is an important factor in protecting the boney socket and initiating the healing process, the healing of the extraction site is interrupted and becomes delayed.

What are the symptoms of a dry socket?
With most tooth extractions a dental patient will experience some level of discomfort at the extraction site (no matter how minor) on the day the tooth has been removed and then, with each day that passes, less and less pain as the healing process progresses. In those cases where a dry socket forms, the patient typically notices that their level of discomfort does progressively diminish for the first few days but then, between three and five days after the extraction, pain from the extraction site begins to intensify.

Dry socket signs and symptoms ...

The pain associated with a dry socket can be moderate to severe in intensity and often has a throbbing component. The pain can be just localized to the extraction site or it may radiate from the extraction site to the patient's ear or eye (on the same side of their face). Additionally, the dental patient may notice a foul odor or taste emanating from the tooth socket. Upon visual inspection (when possible) the tooth socket will appear to be empty (minimal or no blood clot or granulation tissue present) and when looking down into the socket exposed bone is visible. The term "dry socket" is derived from this empty socket appearance. The lymph nodes in the patient's jaw or neck may become enlarged.

How often do dry sockets occur?

The frequency of occurrence for dry sockets, when considering for all tooth extractions collectively, is roughly on the order of 1 to 3%. Extractions involving lower teeth, especially molars, are statistically more likely to result in dry socket formation. Dry sockets may occur in as many as 20% of the cases involving the extraction of mandibular (lower) impacted wisdom teeth.

What causes dry sockets?

• Dental patients who don't follow their dentist's postoperative instructions have a greater incidence of dry sockets.
• Dental patients who have experienced dry sockets with past tooth extractions are at greater risk for developing a dry socket with future tooth extractions.
• Traumatic tooth extractions are more likely to result in dry socket formation.
• Patients who smoke tend to have a greater incidence of dry socket formation.
• Women who take oral contraceptives are at greater risk for dry sockets.
• The presence of bacteria may play a role in dry socket formation.
• The age of the dental patient may be related to the risk for experiencing dry sockets.

How do dentists treat dry sockets?

The focus of the protocol that a dentist follows when providing treatment for a patient who has a dry socket is usually only supportive and palliative. A dry socket is a situation where the extraction site's healing has been delayed. With time the extraction site will still go ahead and heal on its own, it will just take longer than it would otherwise. Dry socket treatments do not speed up the healing of the wound, they simply help to mitigate the discomfort the patient experiences while the (now prolonged) healing process takes place.

It's typical that the discomfort associated with a dry socket is difficult to control with analgesics (pain pills) alone (either non-prescription or prescription). Usually the best treatment solution involves returning to your dentist's office so they can wash out the extraction site and then place a medicated dressing into the socket.

The dressing that is selected for placement into the tooth socket will vary from dentist to dentist depending upon their previous experiences with different products. Some of the more common ingredients incorporated into dry socket dressings are eugenol (an extract of clove oil) and benzocaine (an anesthetic). Usually the dressing is changed (depending on the patient's comfort requirements) every 24 to 48 hours for 3 to 6 days. A patient can experience dramatic relief, even within an hour, once a dry socket dressing has been placed.

Oral Candidiasis

Oral Candidiasis or Oral thrush is a condition in which the fungus Candida albicans accumulates on the lining of your mouth.

Oral thrush causes creamy white lesions, usually on your tongue or inner cheeks. The lesions can be painful and may bleed slightly when you scrape them or brush your teeth. Sometimes oral thrush may spread to the roof of your mouth, your gums, tonsils or the back of your throat.

Although oral thrush can affect anyone, it occurs most often in babies and toddlers, older adults, and in people with compromised immune systems. Oral thrush is a minor problem for healthy children and adults, but for those with weakened immune systems, symptoms of oral thrush may be more severe, widespread and difficult to control.

Symptoms

Oral thrush usually produces creamy white lesions on your tongue and inner cheeks and sometimes on the roof of your mouth, gums and tonsils. The lesions, which resemble cottage cheese, can be painful and may bleed slightly when rubbed or scraped. Although oral thrush symptoms often develop suddenly, they may persist for a long time.

In severe cases, the lesions may spread downward into your esophagus — the long, muscular tube stretching from the back of your mouth to your stomach (Candida esophagitis). If this occurs, you may experience difficulty swallowing or feel as if food is getting stuck in your throat.

Signs and symptoms in infants and breast-feeding mothers
Healthy newborns with oral thrush usually develop symptoms during the first few weeks of life. In addition to the distinctive white mouth lesions, infants may have trouble feeding or be fussy and irritable. They can also pass the infection to their mothers during breast-feeding. The infection may then pass back and forth between mother's breasts and baby's mouth. Women whose breasts are infected with candida may experience the following signs and symptoms:

• Unusually red or sensitive nipples
• Shiny or flaky skin on the areola
• Unusual pain during nursing or painful nipples between feedings
• Stabbing pains deep within the breast

Causes

Microorganisms such as viruses, bacteria and fungi are everywhere, including in and on your own body. In general, the relationship between you and the microorganisms in your body is mutually beneficial. You provide nutrition, protection and transportation for them, while they stimulate your immune system, synthesize essential vitamins, and help protect against harmful viruses and bacteria.

But your relationship to microorganisms in the world at large is more complex. Some microbes are highly beneficial, whereas others — such as those that cause malaria and meningitis — can be deadly. For that reason, your immune system works to repel harmful invading organisms while maintaining a balance between "good" and "bad" microbes that normally inhabit your body.

But sometimes these protective mechanisms fail. Oral thrush and other candida infections occur when your immune system is weakened by disease or drugs such as prednisone, or when antibiotics disturb the natural balance of microorganisms in your body.

These illnesses may make you more susceptible to oral thrush infection:

• Chronic mucocutaneous candidiasis. This group of rare disorders is marked by a chronic candida infection of your mouth and fingernails and of the skin on your scalp, trunk, hands and feet. Scaly, crusted lumps known as granulomas also may develop in your mouth or on your nails and skin.
• HIV/AIDS. The human immunodeficiency virus (HIV) — the virus that causes AIDS — damages or destroys the cells of your immune system, making you more susceptible to opportunistic infections your body would normally resist. One of the most common opportunistic infections is oral thrush. Thrush is rare in the early stage of AIDS. It usually only appears if levels of the virus-fighting cells known as CD4 fall below 300.
• Cancer. If you're dealing with cancer, your immune system is likely to be weakened both from the disease and from treatments such as chemotherapy and radiation, increasing your risk of candida infections such as oral thrush.
• Diabetes mellitus. If you don't know you have diabetes or the disease isn't well controlled, your saliva may contain large amounts of sugar, which encourages the growth of candida.
• Vaginal yeast infections. Many women experience at least one vaginal yeast infection (Candida vulvovaginitis) before menopause. Vaginal yeast infections are caused by the same fungus that causes oral thrush. Although a yeast infection isn't dangerous, if you're pregnant you can pass the fungus to your baby during delivery. As a result, your newborn may develop oral thrush within the first several weeks after birth.

Risk factors

Anyone can develop oral thrush, but the infection is especially common in infants and toddlers whose immune systems aren't fully developed. In addition, babies can pass the infection to their mothers during breast-feeding.

You're also more likely to develop oral thrush if you:

• Are an older adult
• Have a compromised immune system
• Use oral corticosteroids or antibiotics
• Use a corticosteroid inhaler for asthma

Tests and diagnosis

Oral thrush can usually be diagnosed simply by looking at the lesions, but sometimes a small sample is examined under a microscope to confirm the diagnosis.

In older children or adolescents who have no other risk factors, an underlying medical condition may be the cause of oral thrush. If your doctor suspects that to be the case, your doctor will perform a thorough physical exam as well as recommend certain blood tests to help find the source of the problem.

Thrush that extends into the esophagus can be serious. To help diagnose this condition, your doctor may ask you to have one or more of the following tests:

• Throat culture. In this procedure, the back of your throat is swabbed with sterile cotton and the tissue sample cultured on a special medium to help determine which bacteria or fungi, if any, are causing your symptoms.

• Endoscopic examination. In this procedure, your doctor examines your esophagus, stomach and the upper part of your small intestine (duodenum) using a lighted, flexible tube with a camera on the tip (endoscope). The test, called an esophagogastroduodenoscopy, takes between 30 and 60 minutes.

  You'll be given a sedative to make you more comfortable and a local anesthetic so that you don't cough or gag when the endoscope is inserted. There's a slight risk of perforation of your esophagus, stomach or duodenum and of an adverse reaction to medication you may be given.

• Barium swallow. In this test, you'll need to drink one or two barium "milkshakes" — glasses of thick, chalky liquid that may be flavored so they go down more easily. X-rays are then taken as the barium flows through your esophagus into your stomach.

Complications

Oral thrush is seldom a problem for healthy children and adults, although the infection may return even after it's been treated. For people with compromised immune systems, however, thrush can be more serious.

People with HIV may have especially severe symptoms in their mouth or esophagus, which can make eating painful and difficult. If the infection spreads to the intestines, it becomes difficult to receive adequate nutrition, just when it's needed most. In addition, thrush is more likely to spread to other parts of the body in people with cancer, HIV or other conditions that weaken the immune system. In that case, the areas most likely to be affected include the digestive tract, lungs and liver.

Treatments and drugs

The goal of any oral thrush treatment is to stop the rapid spread of the fungus, but the best approach may depend on your age and the cause of the infection.

Treating oral thrush in children
Toddlers with mild oral thrush who are otherwise healthy may need no treatment at all. If the infection develops after a course of antibiotics, your doctor may suggest adding unsweetened yogurt to your child's diet to help restore the natural balance of bacteria. Infants or older children with persistent thrush may need an antifungal medication.

Treating oral thrush in infants and nursing mothers
If you're breast-feeding an infant who has oral thrush, you and your baby will do best if you're both treated. Otherwise, you're likely to pass the infection back and forth. Your doctor may prescribe a mild antifungal medication for your baby and an antifungal cream for your breasts. If your baby uses a pacifier or feeds from a bottle, wash and rinse nipples and pacifiers in a mixture of equal parts of white vinegar and water every day until the thrush clears up.

Treating oral thrush in healthy adults
If you're a healthy adult with oral thrush, you may be able to control the infection by eating unsweetened yogurt or taking acidophilus capsules or liquid. Acidophilus is available in natural food stores and many drugstores. Some brands need to be refrigerated to maintain their potency. Yogurt and acidophilus don't destroy the fungus, but they can help restore the normal bacterial flora in your body. If this isn't effective, your doctor may prescribe an antifungal medication.

Treating oral thrush in adults with weakened immune systems
Most often, your doctor will recommend an antifungal medication, which may come in one of several forms, including lozenges, tablets or a liquid that you swish in your mouth and then swallow.

Candida albicans can become resistant to antifungal medications, especially in people with late-stage HIV infection. A drug known as amphotericin B may be used when other medications aren't effective.

Some antifungal medications may cause liver damage. For this reason, your doctor will likely perform blood tests to monitor your liver function, especially if you require prolonged treatment or have a history of liver disease.

Prevention

The following measures may help reduce your risk of developing candida infections:

• Rinse your mouth. If you have to use a corticosteroid inhaler, be sure to rinse your mouth or brush your teeth after taking your medication.
• Try using fresh-culture yogurt containing Lactobacillus acidophilus or bifidobacterium or take acidophilus capsules when you take antibiotics.
• Treat any vaginal yeast infections that develop during pregnancy as soon as possible.
• See your dentist regularly — at least every six to 12 months — especially if you have diabetes or wear dentures. Brush and floss your teeth as often as your dentist recommends. If you wear dentures, be sure to clean them thoroughly and often.
• Watch what you eat. Try limiting the amount of sugar and yeast-containing foods you eat, including bread, beer and wine. These may encourage the growth of candida.

Burning mouth syndrome

Burning mouth syndrome causes chronic burning pain in your mouth. The pain from burning mouth syndrome may affect your tongue, gums, lips, inside of your cheeks, roof of your mouth, or widespread areas of your whole mouth. The pain can be severe, as if you scalded your mouth.

Unfortunately, the cause of burning mouth syndrome often can't be determined. While that makes treatment more difficult, don't despair. By working closely with your health care team, you can usually get burning mouth syndrome under control.

Other names for burning mouth syndrome include scalded mouth syndrome, burning tongue syndrome, burning lips syndrome, glossodynia and stomatodynia.

Symptoms

Symptoms of burning mouth syndrome include:

• A burning sensation that may affect your tongue, lips, gums, palate, throat or whole mouth
• A tingling or numb sensation in your mouth or on the tip of your tongue
• Mouth pain that worsens as the day progresses
• A sensation of dry mouth
• Increased thirst
• Sore mouth
• Loss of taste
• Taste changes, such as a bitter or metallic taste

The pain from burning mouth syndrome typically has several different patterns. It may occur every day, with little pain when you wake but becoming worse as the day progresses. Or it may start as soon as you wake up and last all day. Or pain may come and go, and you may even have some entirely pain-free days.

Whatever pattern of mouth pain you have, burning mouth syndrome symptoms often last for years before proper diagnosis and treatment. In some cases, though, symptoms may suddenly go away on their own or become less frequent. Burning mouth syndrome usually doesn't cause any noticeable physical changes to your tongue or mouth.

Causes

When the cause of burning mouth syndrome isn't known, the condition is called primary or idiopathic burning mouth syndrome. Sometimes burning mouth syndrome is caused by an underlying medical condition, such as a nutritional deficiency. In these cases, it's called secondary burning mouth syndrome.

Some research suggests that primary burning mouth syndrome is related to problems with taste and sensory nerves of the peripheral or central nervous system. Secondary burning mouth syndrome is a symptom of one or more underlying medical problems. Underlying problems that may be linked to secondary burning mouth syndrome include:

• Dry mouth (xerostomia), which can be caused by various medications or health problems.
• Other oral conditions, such as oral yeast infection (thrush), oral lichen planus and geographic tongue.
• Psychological factors, such as anxiety, depression or excessive health worries.
• Nutritional deficiencies, such as lack of iron, zinc, folate (vitamin B-9), thiamin (vitamin B-1), riboflavin (vitamin B-2), pyridoxine (vitamin B-6) and cobalamin (vitamin B-12).
• Dentures. Dentures can place stress on some of the muscles and tissues of your mouth, causing mouth pain. The materials used in dentures also can irritate the tissues in your mouth.
• Nerve damage to nerves that control taste and pain in the tongue.
• Allergies or reactions to foods, food flavorings, other food additives, fragrances, dyes or other substances.
• Reflux of stomach acid (gastroesophageal reflux disease) that enters your mouth from your upper gastrointestinal tract.
• Certain medications, particularly high blood pressure medications called angiotensin-converting enzyme (ACE) inhibitors.
• Oral habits, such as tongue thrusting and teeth grinding (bruxism).
• Endocrine disorders, such as diabetes and underactive thyroid (hypothyroidism).
• Hormonal imbalances, such as those associated with menopause.
• Excessive mouth irritation, which may result from overbrushing of your tongue, overuse of mouthwashes or having too many acidic drinks.

Risk factors

Burning mouth syndrome is uncommon, affecting women more frequently than it does men. It generally starts when you're an older adult, in your 50s, 60s or even 70s.

Burning mouth syndrome usually begins spontaneously, with no known triggering factor. But some research studies suggest that certain factors may increase your risk of developing burning mouth syndrome. These risk factors may include:

• Being a so-called "supertaster," or someone with a high density of the small tongue bumps called papillae, which contain taste buds
• Upper respiratory tract infection
• Previous dental procedures
• Allergic reactions to food
• Medications
• Traumatic life events
• Stress

Complications

Complications that burning mouth syndrome may cause or be associated with are mainly related to pain and include:

• Difficulty sleeping
• Irritability
• Depression
• Anxiety
• Difficulty eating
• Decreased socializing

Tests and diagnosis

There's no one test that can determine if you have burning mouth syndrome or what may be causing your mouth pain. Instead, your doctor or dentist will try to rule out other problems before diagnosing burning mouth syndrome.

Your doctor or dentist will review your medical history and medications, examine your mouth and ask you to describe your symptoms, your oral habits and your oral care routine. In addition, your doctor will likely perform a general medical examination, looking for signs of any other conditions.

As part of the diagnostic process, you may have some of the following tests:

• Blood tests. Blood tests can check your complete blood count, glucose level, thyroid function, nutritional factors and immune functioning, all of which may provide clues about the source of your mouth pain.
• Oral cultures. Taking samples from your mouth can tell whether you have a fungal, bacterial or viral infection.
• Imaging. Your doctor may recommend an MRI, CT scan or other imaging tests to check for other health problems.
• Allergy tests. Your doctor may suggest allergy testing to see if you may be allergic to certain foods, additives or even substances in dentures.
• Salivary measurements. With burning mouth syndrome, you may feel like you have a dry mouth. Salivary tests can confirm whether you have a reduced salivary flow.
• Psychological questionnaires. You may be asked to fill out questionnaires that can help determine if you have symptoms of depression, anxiety or other mental health conditions.
• Gastric reflux tests. These can determine if you have gastroesophageal reflux disease (GERD).

In addition, if you take medications that may contribute to mouth pain, your doctor may suggest temporarily stopping those medications, if possible, to see if your pain goes away. Don't try this on your own, since it can be dangerous to stop some medications.

Treatments and drugs

There's no one sure way to treat burning mouth syndrome, and solid research on the most effective methods is lacking. Treatment depends on your particular signs and symptoms, as well as any underlying conditions that may be causing your mouth pain. That's why it's important to try to pinpoint what's causing your burning mouth pain. Once any underlying causes are treated, your burning mouth syndrome symptoms should get better.

If a cause can't be found, treatment can be challenging. There's no known cure for primary burning mouth syndrome. You may need to try several treatment methods before finding one or a combination that is helpful in reducing your mouth pain. Treatment options may include:

• A lozenge-type form of the anticonvulsant medication clonazepam (Klonopin)
• Alpha-lipoic acid, a strong antioxidant produced naturally by the body
• Oral thrush medications
• Certain antidepressants
• B vitamins
• Cognitive behavioral therapy
• Special oral rinses or mouth washes
• Saliva replacement products
• Capsaicin, a pain reliever that comes from chili peppers

Surgery isn't recommended for burning mouth syndrome.

Source:
http://www.mayoclinic.com/health/burning-mouth-syndrome/DS00462

Behcet Syndrome

Behcet's syndrome is classically characterized as a triad of symptoms that include recurring crops of mouth ulcers (aphthous ulcers), genital ulcers, and inflammation of a specialized area around the pupil of the eye (the uvea). The inflammation of the area of the eye that is around the pupil is called uveitis. Behcet's syndrome is also sometimes referred to as Behcet's disease.

The cause of Behcet's syndrome is not known. The disease is more frequent and severe in patients from the Eastern Mediterranean and Asia than those of European descent. Both inherited (genetic) and environmental factors, such as microbe infections, are suspected to be factors that contribute to the development of Behcet's syndrome. Behcet's syndrome is not felt to be contagious.

What are symptoms of Behcet's syndrome?

The symptoms of Behcet's syndrome depend on the area of the body affected. Behcet's syndrome can involve inflammation of many areas of the body. These areas include the arteries that supply blood to the body's tissues. Behcet's syndrome can also affect the veins that take the blood back to the lungs to replenish the oxygen content. Other areas of body that can be affected by the inflammation of Behcet's syndrome include the back of the eyes (retina), brain, joints, skin, and bowels.

The mouth and genital ulcers are generally painful and recur in crops (many shallow ulcers at the same time). They range in size from a few millimeters to 20 millimeters in diameter. The mouth ulcers occur on the gums, tongue, and inner lining of the mouth. The genital ulcers occur on the scrotum and penis of males and vulva of women and can leave scars.

Inflammation of the eye, which can involve the front of the eye (uvea) causing uveitis, or the back of the eye (retina) causing retinitis, can lead to blindness. Symptoms of eye inflammation include pain, blurred vision, tearing, redness, and pain when looking at bright lights. It is very important for patients to have this sensitive area monitored by an eye specialist (ophthalmologist).

If the arteries become inflamed (arteritis) in patients with Behcet's syndrome, it can lead to death of the tissues whose oxygen supply depends on these vessels. This could cause a stroke if affecting the brain, belly pain if affecting the bowel, etc. When veins become inflamed (phlebitis), the inflammation can involve large veins that develop blood clots which can loosen to cause pulmonary embolism.

Symptoms of inflammation of the brain or tissue that covers the brain (meninges) include headaches, neck stiffness, and is often associated with fever. Inflammation of the brain (encephalitis) and/or the meninges (meningitis) can cause damage to nervous tissue and lead to weakness or impaired function of portions of the body. This can result in confusion and coma. Typically these features occur later in the disease course, years after the diagnosis.

Joint inflammation (arthritis) can lead to swelling, stiffness, warmth, pain, and tenderness of joints in patients with Behcet's syndrome. This occurs in about half of patients with Behcet's syndrome at sometime during their lives. Knees, wrists, ankles, and elbows are the most common joints affected.

The skin of patients with Behcet's syndrome can develop areas of inflammation which spontaneously appear as raised, tender, reddish nodules (erythema nodosum), typically on the front of the legs. Some patients with Behcet's syndrome develop a peculiar red or blistery skin reaction in places where they have been pierced by blood-drawing needles (see pathergy test in diagnosis section below). Recent research has found that acne occurs more frequently in patients with Behcet's syndrome that also have arthritis as a manifestation.

Ulcerations can occur at any location in the stomach, large or small bowel in patients with Behcet's disease.

How is Behcet's syndrome diagnosed?

Behcet's syndrome is diagnosed based on the finding of recurrent mouth ulcerations combined with any two of the following: eye inflammation, genital ulcerations, or skin abnormalities mentioned above. A special skin test called a pathergy test can also suggest Behcet's syndrome. (The other criteria above are still required for ultimate diagnosis.) This test consists of pricking the skin of the forearm with a sterile needle. The test is called positive and suggests Behcet's syndrome when the puncture causes a sterile red nodule or pustule that is greater than two millimeters in diameter at 24 to 48 hours.

Tests such as skin biopsy, lumbar puncture, MRI scan of the brain, and bowel tests are considered based upon symptoms that are present.

What is the treatment of Behcet's syndrome?

The treatment of Behcet's syndrome depends on the severity and the location of its manifestations in an individual patient.

Steroid (cortisone) gels, pastes (such as Kenolog in Orabase) and creams can be helpful for the mouth and genital ulcers. Colchicine can also minimize recurrent ulcerations. Mouth and genital ulcers healed and were reported at a national meeting of the American College of Rheumatology as less frequent in nine or 12 patients who were treated with Trental (pentoxifylline). Trental also seemed to maintain the healed ulcers for up to the 29 months of the study. The effectiveness of Trental, the researchers said, seemed to be enhanced by the combination with colchicine in some patients.

Joint inflammation can require nonsteroidal anti-inflammatory drugs (such as ibuprofen and others) or oral steroids. Colchicine and oral and injectable cortisone are used for inflammation involving the joints, eyes, skin, and brain. Sulfasalazine (Azulfidine) has been effective in some patients for arthritis.

Bowel disease is treated with oral steroids and sulfasalazine.

Diligent treatment of eye inflammation is essential. Patients with eye symptoms or a history of eye inflammation should be monitored by an ophthalmologist. Recent research has reported successful management of resistant eye inflammation with new biologic medications that block a protein that plays a major role in initiating inflammation, called TNF. These TNF-blocking medications, including infliximab (Remicade) and etanercept (Enbrel), can also be helpful for severe mouth ulcerations.

Severe disease of the arteries, eyes, and brain can be difficult to treat and require powerful medications that suppress the immune system called immunosuppressive agents. Immunosuppressive agents used for severe Behcet's syndrome include chlorambucil (Leukeran), azathioprine (Imuran), and cyclophosphamide (Cytoxan). Cyclosporine has been used for resistant disease.

Recent studies suggest that thalidomide may be of benefit for certain patients with Behcet's syndrome in treating and preventing ulcerations of the mouth and genitals. Side effects of thalidomide include promoting abnormal development of fetal growth, nerve injury (neuropathy), and hypersedation.

Recent research further suggests that patients who have had heart-valve replacement because of severe damage as a result of inflammation can benefit by immune suppression with azathioprine and prednisone after operation.

Trials are currently underway evaluating interferon alpha for the treatment of eye disease in patients with Behcet's syndrome.

Behcet's Syndrome At A Glance

• Behcet's syndrome is associated with inflammation of various areas of the body.
• Symptoms of Behcet's syndrome depend on the body areas affected.
• Recurrent mouth ulcers are characteristic of Behcet's syndrome.
• Treatment of Behcet's syndrome depends on the severity and the location of its manifestations.

Source:
http://www.medicinenet.com/behcets_syndrome/article.htm