Escolar Documentos
Profissional Documentos
Cultura Documentos
Supervisor:
Riani Setiadhi, drg, Sp.PM
Universitas Padjadjaran
Faculty of Dentistry
Bandung
2016
Title
Name :
NPM :
160112142502
CONTENT
CHAPTER 1 INTRODUCTION..1
CHAPTER 2 LITERATURE REVIEW..2
2.1 ORAL CANDIDIASIS.2
2.2 PETECIA AND GINGIVAL BLEEDING....4
2.3 ANGULAR CHEILITIS..5
2.4 MEMBRANE JAUNDICE..7
2.5 ATROPHIC GLOSSITIS....8
CHAPTER 3 DISCUSSIONS.10
CHAPTER 4 CONCLUSION.....22
REFERENCE LIST.....23
CHAPTER 1
INTRODUCTION
The oral cavity is an important anatomical location that carries out many
different physiologic processes, such as digestion, respiration, and speech
(Wadhawan, 2014). Furthermore, the oral cavity is also an important indicator of
the health of an individual. Oral lesions may manifest early, concomitant with a
systemic disease, disappearing with general health improvement, or later
persisting in spite of disease remission, and usually presenting developmental
abnormalities (Olczak-kowalczyk, 2014).
Manifestations of liver diseases include symptoms of malnutrition, ascites,
edema, esophageal varices and coagulation disorder. Medications such as
glucocorticoid or other immunosuppressant administered for autoimmune liver
disease maybe influence the oral health of the individual; it may disturb dental
development and may contribute to dental caries, periodontal disease and oral
mucosa lesions. Lesion type and severity depend on the age of the child when the
systemic disorders started, type and duration, as well as their impact (Olczakkowalczyk, 2014).
CHAPTER 2
LITERATURE REVIEW
There are many liver diseases that require professional care; the most
commonly known liver diseases are the hepatitis, liver cirrhosis, and liver fibrosis.
Results of a present studies indicate that a higher incidence of oral lesions is seen
with patient with cirrhosis of the liver, up-to-date publications suggest children
with liver failure are more prone to oral mucosa lesions than generally health
children, which might result from hypoproteinaemia, coagulopathy, malnutrition,
cholestasis or immunodeficiency. The most commonly seen oral manifestation in
liver disease patients is oral candidiasis, angular cheilitis, yellow or yellow-brown
hyperpigmentation, petechial, and atropic tongue (Bayless T & Deihl A, 2005).
Figure 2.1 Pseudomembranous oral candidiasis with plaques on the buccal and
sever thrush on tongue (Akpan & Morgan, 2002)
Figure 2.2 Petechia located on the vestibulum in the oral cavity (Finkelstein M,
2013)
patients with liver disease may also experience a folate and iron deficiency due to
the liver disease, in which folate cannot be metabolizes completely by the liver
and iron cannot be stored completely in the liver as ferratin. Hence, this
nutritional deficiency is also a factor of angular cheilitis in patients with liver
disease (Halsted et al, 2002).
Figure 2.4 Jaundice at the junction between hard and soft palate (Gomez I, et al,
2007)
are not dramatic as the bald tongue and often go unnoticed. Affected patients are
predisposed to developing angular cheilitis. (Daley & Armstrong, 2007)
Figure 2.5 Picture of atrophic glossitis also commonly known as the smooth
tongue (Daley T and Armstrong J, 2007)
CHAPTER 3
DISCUSSION
Liver diseases can be classified into acute or chronic, and based on the
extent and origin of the damage, chronic liver disease ranges from steatosis or
fatty liver to hepatocellular carcinoma, and includes hepatitis, fibrosis and
cirrhosis. Liver diseases can also be further classified as infectious such as
hepatitis A, B, C, D, E and G viruses, infectious mononucleosis, or secondary
syphilis and tuberculosis, or non-infectious such as substance abuse such as
alcohol and drugs (Pamplona et al, 2011).
Liver disease are very common, and the main underlying causes are viral
infection, alcohol abuse and lipids and carbohydrates metabolic disorders. The
liver has a broad range of functions in maintaining homeostasis and health such as
synthesize most essential serum proteins, produce bile and its transporters,
intervene in the regulation of nutrients, and metabolize and conjugate lipophilic
compounds to facilitate their excretion in bile or urine. Liver dysfunction alters
the metabolism of carbohydrates, lipids, proteins, drugs, bilirubin and hormones.
Accordingly, liver disease is characterized by a series of aspects that must be
taken into account in the context of medical and dental professions (Pamplona et
al, 2011).
Liver diseases have extrahepatic manifestations that can be seen in the oral
cavity, which include symptoms such as oral petechia and gingival bleeding, oral
candidiasis, atrophic glossitis, yellow or yellow-brown hyperpigmentation of the
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oral mucosa, coated tongue, and angular cheilitis. Theses symptoms should be
made known to all dental professions as the dental management for patients with
liver diseases would be different from those that do not have liver diseases
(Pamplona et al, 2011).
Hepatitis of viral origin comprises a heterogeneous group of diseases
caused by at least 6 different types of viruses: A, B, C, D, E and G. Hepatitis A is
caused by the hepatitis A virus (HAV), and is transmitted via the enteral route as a
result of the ingestion of contaminated water or food. The disease is normally
mild and self-limiting, and typically presents symptoms such as fever, fatigue,
abdominal discomfort, diarrhea, nausea and/or jaundice. Hepatitis B is transmitted
through sexual contact, intravenous drug use and blood transfusions. An important
consideration among dental professionals as dental professionals are three to four
times great at risk of percutaneous transmission through punctures or cuts with
instruments infected from HBV-positive patients, or absorption through the
mucosal surfaces (eyes, oral cavity). Transmission through saliva can occur as a
result of absorption from mucosal surfaces. Hepatitis C infection is the main cause
of chronic liver disease and of liver-related morbidity and mortality worldwide;
the hepatitis C virus is normally transmitted via the parenteral route from infected
blood. The source of contagion includes blood transfusion, percutaneous exposure
through contaminated instruments, and occupational exposure to blood (Pamplona
et al, 2011).
Alcoholic liver disease is one the 10 most common cause of death in the
industrialized world, in which the clinical spectrum of alcoholic liver disease
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ranges from simple liver steatosis with alcoholic hepatitis to more sever
steatohepatitis or cirrhosis. The condition ranges from asymptomatic forms to
liver failure and life-threatening situations, and is usually accompanied by
febricula, jaundice, leukocytosis and liver enzyme elevations (Pamplona et al,
2011).
Non-alcoholic fatty liver is defined as the accumulation of fat in the liver,
representing over 5% of the weight of the organ. The observed liver damage
ranges greatly from simple steatosis to steatohepatitis, advanced fibrosis and
cirrhosis. This disorder is mainly associated with obesity, diabetes, hyperlipidemia
and insulin resistance and excessive triglyceride accumulation within the liver
cells (Pamplona et al, 2011).
Liver cirrhosis has very well defined morphological characteristics that
lead to destruction of the liver parenchyma. The disease is accompanied by a
series of extrahepatic manifestations in other body organs and system. Liver
cirrhosis is irreversible, and is characterized by the formation of fibrous scarring
in the liver; with the formation of regeneration nodules that increase resistance to
blood flow through organ (Pamplona et al, 2011).
The oral cavity can reflect liver dysfunction in the form of mucosal
membrane jaundice, bleeding disorder, petechia, increased vulnerability to
bruising, gingival bleeding (even in response to minimum trauma), cheilitis,
smooth and atrophic tongue, and oral candidiasis. The oral manifestation of liver
dysfunctions patients can be due to the drugs taken by the patient or due to the
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metabolize in the liver and excreted out of the body in the form of stool. If liver
dysfunction is present, the bilirubin is not properly excreted from the body, thus
resulting in an excessive bilirubin in the blood, which would then accumulate in
the tissue. Hence, causing a yellowish appearance on the skin, oral mucosa, and
sclera. The oral lesions are more commonly seen in the soft palate and the lingual
frenulum. Dentists should pay attention to the color of the oral mucosa as it can
determine the underlying systemic disease the patient is currently experiencing
(Daley & Armstrong, 2007).
Oral candidiasis and angular cheilitis are also oral manifestation of patient
with liver dysfunction. Oral candidiasis are caused by the opportunistic growth of
the oral fungal known as candidia albican, resulting in symptoms such as white
patches or plaque on the oral mucosa or tongue, erythematous gingival mucosa,
and sometimes burning sensation can also be felt by the patient. The cause of oral
candidiasis in patients with liver dysfunction are normally drug induced, which
immunosuppressive drugs such as prednisone and azathioprine are taken by the
patient to decrease inflammation of the liver in autoimmune hepatitis. Thus, the
immunosuppressive drug taken by the patient would be a factor in the
manifestation of oral candidiasis as the immune system of the host is suppressed.
On the other hand, angular cheilitis can also be due to a fungal infection, causing
the vermillion border to crack and slight edematous and erythematous can be seen
on the vermillion border as well (Hassan et al, 2014).
Last but not least, atrophic glossitis can also be seen in patients with liver
dysfunction. Atrophic glossitis is also known as smooth tongue because of the
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atrophy of the filliform papillae. Nutritional deficiency of iron, folic acid, vitamin
B12, riboflavin, and niacin are common causes of atrophic glossitis (Reamy et al,
2010). Anemia is a condition normally seen in patient with liver dysfunction, this
can be due to the thrombocytopenia conditions due the hemorrhage from the
esophageal or gastric varices; the involvement of alcohol in which it has a
negative impact on the bone marrow, leading to the development of secondary
malnutrition of which the anemia may be caused by folic acid deficiency; the
treatment of chronic hepatitis C with a combination of interferon and ribavirin can
cause ribavirin-induced hemolysis. Hence, the anemic condition induced by the
liver dysfunction would manifest as atrophic glossitis in the oral cavity causing
the tongue to appear smooth and sometimes causes a painful sensation on the
tongue (Gonzales-C R, et al, 2009).
Atrophic glossitis is also known as smooth tongue because of the smooth,
glossy, appearance with a red or pink background. The smooth appearance quality
is caused by the atrophy of the filiform papillae. Atrophic glossitis is primarily a
manifestation of underlying conditions such as amyloidosis, drug reactions,
systemic infections, nutritional deficiencies and pernicious anemia, and warrants a
thorough diagnostic evaluation. Nutritional deficiencies of iron, folic acid, vitamin
B12, riboflavin, and niacin are common causes. Other etiologies include systemic
infections, localized infection, amyloidosis, celiac disease, protein-calories
malnutrition, and xerostomia triggered by some medications and Sjoren
syndrome. Atrophic glossitis caused by nutritional deficiency often causes a
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extending to the adjacent skin are associated with habitual lip sucking and chronic
Candida infection (Greenberg MS and Glick M, 2003).
The treatment of angular cheilitis of fungal infection etiology is the topical
imidazole derivative such as 1% clotrimazole ointment, 2% ketoconazole gel, or
nystatin ointment are efficacious in treating angular cheilitis (Greenberg MS and
Glick M, 2003). Angular cheilitis can also result from a polymicrobial infection,
consisting of Candida and S. aureus or enteric bacteria, local application of
fusidic acid 2% ointment (Jenkinson HF and Douglas LJ, 2002). Miconazole
nitrate 2% gel can be applied to the affected area as well, because it is an
antifungal with some activity against gram-positive bacteria including
streptococci and staphylococci and is the treatment of choice for angular cheilitis
(Cross LD and Short L, 2009).
Dental plaque is the primary etiology for chronic gingivitis, which
typically develops within 10 to 21 days in the absence of plaque control.
Approximately 50% of the population over the age of 30 has some form of
gingivitis. Although mechanical plaque control can be an effective strategy for
preventing the progression of periodontal diseases, most individuals do not
adequately brush their teeth, and only 11% to 51% of the population admits to
using dental floss or some types of inter-dental cleaning device on a daily basis.
The daily use of an effective antiseptic mouthwash is generally considered a
simple strategy most patients can easily incorporate into their home care routine.
Thus, using an antiseptic mouthwash to supplement mechanical plaque removal
can produce an antimicrobial effect thorough the mouth (Osso & Kanani, 2013).
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Besides plaque control, antiseptic mouthwashes are also indicated for oral
conditions such as oral sores, halitosis, xerostomia, and periodontal diseases
(Parashar A, 2015).
Bisguanides have a very broad antimicrobial spectrum effective with both
gram negative and gram positive bacteria. Chlorhexidine gluconate is a catonic
bisguanide and was presented to the market as a 0.2% mouthwash. The
mechanism of action of bisguanide is to bind strongly to bacterial cell membranes,
increasing the cell permeability, this initiating leakage and/or precipitating
intracellular components. Furthermore, it binds to salivary mucins, reducing
pellicle formation, thereby inhibiting subsequent colonization. It also hinders the
adsorption of bacteria onto the tooth surface (Asadoorian J, 2006).
The advantage of chlorhexidine gluconate over other catonic agents is that
it can bind strongly to many sites in the oral cavity and is released slowly over 7
to 12 hours after rinsing, thus providing considerable substantivity and a sustained
antimicrobial effect restricting bacterial proliferation. Chlorhexidine gluconate
binds strongly with anionic glycoproteins and phosphorproteins on the mucosa
and tooth pellicle, but it can also bind to cell surfaces of bacteria affecting the
cells ability to adhere. Unfortunately, chlorhexidine gluconate has several
clinically significant disadvantages including brown staining of the teeth, tongue,
and restorations, particularly on composites, requiring professional removal;
alterations of taste perception of up to four hours after rinsing; and potentially
increased supra-gingival calculus build-up. Hypersensitivity of mucosa and hairy
tongue are less common side effects (Asadoorian J, 2006).
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activity. The essential oils prevent bacteria from aggregating with gram positive
pioneer species, slows bacterial multiplication, and extract endotoxins from gram
negative pathogens, thus reducing bacterial load. The essential oils also reduces
plaque maturation time and decrease plaque mass and pathogenicity (Asadoorian
J, 2006).
Povidone-iodine is a water-soluble combination of molecular iodine and
the solubilizing agent polyvinyl-pyrrolidone. This iodophor has a bacterial effect
similar to that of pure iodine; is effective against most of the bacteria, including
putative periodontal pathogens, fungi, mycobacteria, viruses, and protozoa.
Previous studies have showed that povidone iodine, as a mouthwash exerts only
an immediate antibacterial effect and unlike chlorhexidine, is not retained at
antibacterial levels within the oral cavity after expectoration (Venkataraghavan K
et al, 2014).
Oxygenating agents such as hydrogen peroxide, sodium peroxyborate and
peroxycarbonate act by liberating nascent oxygen to loosen debris, remove stains
and kill anaerobic microorganisms. They have a broad spectrum of antimicrobial
properties. Oxygenating agents containing mouthwashes are recommended for
acute ulcerative conditions, to relieve soreness caused by dentures, orthodontic
appliances and stain removal (Parashar A, 2015).
The incorporation of ethanol into mouthwashes serves several purposes: it
is a solvent for other active ingredients, has antiseptic properties and acts as a
preservative. Ethanol is easy to produce and relatively cheap (Werner & Seymour,
2009). Additionally, ethanol has antimicrobial activity against various bacteria,
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CHAPTER 4
CONCLUSION
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REFERENCE LIST
Asadoorian J, (2006). CDHA Position Paper on Commercially Available Overthe-Counter Oral Rinsing Products. Canadian Journal of Dental Hygiene.
40(4).
Akpan A and Morgan R, (2007) Oral Candidiasis. Postgrad Med J. 78, pp. 455459
Bayless T and Deihl A, (2005) Advanced Therapy in Gastroenterology and Liver
Disease. Baltimore, America. Pmph inc.
Cross DL and Short L, (2009). Angular Cheilitis Occurring during Orthodontic
Treatment. A Case Series. Journal of Orthodontics, 35, pp. 229-233.
Daley T and Armstrong J, (2007). Oral manifestation of gastrointestinal diseases.
Can J Gastroentrerol. 21(4).
Devani A, (2007). Answer: Can you identify this condition. Can Fam
Physician.53(6)
Finkelstein M, (2013). A Guide to Clinical Differential Diagnosis of Oral
Mucosal Lesions. [online] Available at: http://www.dentalcare.com/enUS/dental-education/continuing-
education/ce110/ce110.aspx?
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