ALLERGIC MANIFESTATION IN ORAL CAVITY. CHRONIC RECURRENT RECIDIVATED APHTHOUS STOMATITIS.

PRESENTED BY : AHMAD BDEIR

GROUP(3516)

PRESENTED TO : DR. DAINICI ALEX

Allergies

(from the Greek words: Allos - other, Ergon - action) this qualitative change of the body to exposure to substances of antigenic nature, which leads to a whole range of different disorders that develop in the body in the humoral and cellular immune responses (inflammation, spasm of the bronchial muscles, necrosis , shock, etc.).

Etiology
The cause of allergies can be the action with a variety of antigenic

substances (allergens) that cause an immune response in the body of the humoral and cell type.
By origin allergens are divided into: exogenous

endogenous.
Exogenous allergens include infectious (bacteria, fungi, viruses,

chlamydia, protozoa) and noninfectious (herbal, medicinal, including amalgam, denture materials, food, household and industrial). Endogenous allergens are divided into natural, primary (brain, lens, gonads, thyroid gland) or acquired, which is divided into noninfectious (cold, radiation, burns) and infectious (tissue microorganism, tissue - toxin).

sensibilization

Changes that occur in the body in response to the

first hit of the allergen, called sensibilization. Allergic reactions are immediate, delayed and mixed type. For immediate type reactions include anaphylaxis, angioedema Kvinke, urticaria. They develop in a matter of minutes of exposure in the body specific antigens.

Anaphylactic shock
is the highest degree of allergic reaction of

immediate type. Develops suddenly, within a few minutes, and then immediately after the introduction of antigen. The patient exhibits anxiety, fear, fever, chest tightness. Worried about breathing difficulties, frequent first, then - convulsive, nausea, vomiting, sweating, flushing of the skin, headache, throbbing in the head, loss of balance, falls, convulsions, spontaneous urination, defecation, drop in blood pressure - can be fatal.

Anaphylactic shock

Anaphylaxis Diagnosed

Anaphylaxis is diagnosed based on its symptoms.

People with a history of allergic reactions may be at greater risk for developing a severe reaction in the future. Skin testing may help confirm the substances that cause severe allergic reactions. However, this type of test may not be recommended if you have reason to suspect that you will have an anaphylactic reaction to the substance.

Treatment for Anaphylaxis

There is only one rapidly effective treatment for

anaphylaxis -- epinephrine by injection. Epinephrine is adrenaline and it rapidly reverses anaphylactic symptoms. It is typically given through an automatic injection device. The most common and most effective injection site is the thigh. If you are near someone who is going into anaphylactic shock, call for professional medical help immediately. CPR and other lifesaving measures may be required. In addition to epinephrine, treatment for shock includes intravenous fluids and medicines that support the actions of the heart and circulatory system. After a person in shock is stabilized, antihistamines and steriods may be given to further reduce symptoms.

Angioedema Quink
- localized accumulation of a large amount of fluid in

the connective tissue (the lips, eyelids, external genitalia, larynges, tongue). Edema appears quickly in tissue edema tense, but palpation pit is formed. Persists for several hours to 2 days. Disappears completely, leaving no change. Swelling of the larynx occurs constrictive asphyxia. Gives a recurrence. If the patient determines the allergen - can prevent swelling.

Angioedema Quink

treatment of Angioedema Quink

Mild symptoms may not need treatment. Moderate to severe

symptoms may need to be treated. Breathing difficulty is an emergency condition. People with angioedema should: Avoid any known allergen or trigger that causes their symptoms Avoid any medicines, herbs, or supplements that are not prescribed by a health care provider Cool compresses or soaks can provide pain relief. Medications used to treat angioedema include: Antihistamines Anti-inflammatory medicines (corticosteroids) Epinephrine shots (people with a history of severe symptoms can carry these with them) Inhaler medicines that help open up the airways Ranitidine (Zantac)

Delayed reaction
1) Contact stomatitis (on prostheses, medical

dressings, applications); 2) Toxic-allergic medication defeat local and general character. Delayed reaction occur in infectious allergy, syphilis, fungal and parasitic diseases, viral infections. Can be caused by chemicals, pharmaceuticals, cosmetics, materials of dental prosthesis, dentures, plastic, metal, amalgam and food.

Clinically, they manifest themselves in the form of:

catarrhal stomatitis;

catarrh - gemorogical stomatitis;

vesico-erosive stomatitis; necrotizing stomatitis;

exudative erythema multiforme;

chronic recurrent aphthous stomatitis; prosthetic stomatitis;

syndrome Stevens-Jones;
Lyell syndrome.

Diagnosis of allergic lesions is based on the following criteria:

Allergic history;

Clinical features (giperergiya);

Allergological specific skin-allergy tests

(scarification, histamine, bacterial allergens, reaction leykotsitoliza); Hemogram (eosinophilia, leukocytosis and lifopeniya). Immunological reactions (Shelley, Coombs et al.)

Erythema exudative multiforme

Erythema exudative multiforme (EPE) -

developing acute disease characterized by polymorphous rash on the skin and mucous membranes, the cyclic flow and a tendency to recur in the autumn and spring. Manifest in different morphological elements: Spot; Papule; Small bubble Blisters; Bubbles (blister); Erosion; Crust.

Clinically identified two main forms of the exudative polymorphic erythema (EPE):
infectious-allergic;

toxic-allergic.

THE ETIOLOGY OF THE EPE

Infectious-allergic form An allergic reaction to bacterial allergens

(staphylococcal, streptococcal, E. coli). In 72% of patients had an allergy to staphylococcal and streptococcal allergen. Assumed a viral etiology. In the medical history of the patients have associated diseases - chronic lesions in the nasopharynx.
Toxic-allergic form Medications causing toxic - allergic form of EPE:

sulfonamides, antibiotics (tetracycline), aminopyrine, barbiturates, anesthetics, salicylic acid.

The clinical picture of infectious-allergic form of EPE.

Beginning - acute;

After hypothermia;
The body temperature rises to 38-39C; Headache;

Indisposition;
Pain in the throat; Pain in the muscles;

Pain in the articulation

After 1 - 2 days
The rash on the skin;

The rash on the mucous membrane of the mouth;

Rash on the red border of the lips; On the genitals (rarely);

The rash may be only in the mouth (5%), in other

cases the affected mucosa and skin.

After 2 - 5 days
Common effects has passed, but the temperature and malaise hold

another 2 - 3 weeks. The skin appear polymorphic rash on the back of the hands and feet, skin forearms and shins; Less commonly on the face, neck and torso; The spots are round, red, bluish-red, clearly defined, the size of a cherry stone or a penny; Central part of the spots swollen, raised, and they quickly turn into bubbles; Can appear papules, round, swollen, red or pale stagnant pink. On the surface may appear blisters with serous or hemorrhagic content; Central part of papules sinks and becomes cyanotic, blue-violet. On the periphery of papules grow and form a bright red halo; Covers of blisters dry up and in the center form crusts; The hands and forearms such formations are called "cockades";

The clinical picture of toxic-allergic form of EPE

Caused by increased sensitivity to drugs, it is not

peculiar to the seasonality of relapse. By the nature of precipitation is almost similar to the infectiousallergic form, and the mucous membrane is affected in almost all patients. On the mucous membrane in this form appear bubbles outwardly unchanged background. Erosions heal very slowly. Etiological factors and the immune system of the body will determine the length and severity of recurrence and gravity of the lesion.

Table. Differential diagnosis

Diagnostic feature Life history EPE Chronic diseases of upper respiratory tract, gastrointestinal tract Muscle pain, articulation pain, headache, body temperature to 38 and rarely above 1-2 days before the rash Diffuse and spotted erythema, erosion, extensive irregular shapes, spots, pimples, blisters, erosions, crusts True Acute herpetic stomatitis Not complicated Medicamentous stomatitis Often previously experienced an allergic reaction to medication Severe symptoms of cold or other diseases about which treatment is prescribed

Prodromal stage

1 to 3-4 days - fever, from subfebril to 3940C, intoxication

The main elements of rash

Polymorphism

Vesicles on the lips, face, round and confluent erosions in the mucosa of the mouth, blisters, erosions, crusts False

Serous (catarrhal) inflammation, erosion, irregular shapes, less bubbles, a spot (total erythema), erosion, bubbles Mono-and polymorphic eruption

Table. Differential diagnosis

Diagnostic feature Favourite localization a) on the skin EPE Hands, forearms, legs, bluish - purple papules with a bubble in the center Lips, anterior oral mucosa, transitional folds Acute herpetic stomatitis About - oral region vizikuly, erosion, then crusts. Medicamentous stomatitis A variety of rashes on the face, trunk (recover in short time), at least - single and multiple bubbles Dorsum of tongue, palate, the sublingual area, sometimes other departments After the abolition of the allergen - new lesions usually do not occur

Favourite localization b) in the mouth cavity

Any areas, acute gingivitis.

Duration of the rash

5-7 days, sometimes up to 11-13 days.

In mild form - 1-2 days with moderate and severe - 2-4 days, with severe up to 5 days or more

Treatment
Examination of each patient to identify the sites of infection, which are in the

maxillofacial region;

Rehabilitation of the oral cavity; Removal of foci of infection.

Anti-inflammatory therapy: Aspirin 0.5 - 4 times a day. The drug inhibits the biosynthesis of inflammatory

mediators (histamine, serotonin, bradykinin, prostaglandins).

Desensitization therapy: suprostin - 0,025; dimidrol - 0.05; pipolfen -

0.025, (1 table. 3 times a day); tavegil - 0.001 (1 tab. 2 times a day); fenkarol 0.025, (2 Table. 3 times a day), Promethazine, gistaglobulin 1,2,3 mL per course (4 - 10 injections). These drugs inhibit or eliminate the action of histamine, reducing capillary permeability, edema, hyperemia, itching. course), and has anti-inflammatory antitoxic, desensitizing effect (stimulates the synthesis of thiol enzymes).

Detoxification therapy: 30% sodium thiosulfate (10 ml / in 10-12 per

Treatment

Vitamin: vitamin B, C, nicotinic acid (1 ml 1% solution of acid nicotinic(1 ml 1% solution natrium nicotinat intramuscular over day number 10) 1 ml of 5% solution of ascorbic acid number 10 in a day. Vitamin C is involved in the regulation of redox processes, carbohydrate metabolism, blood coagulation, tissue regeneration, the formation of steroid hormones, the synthesis of collagen, normalize capillary permeability. Antibiotic therapy (in severe cases) - is aimed at removing the secondary microflora - has antibacterial effect on gram + and gram - microflora. Disrupt the synthesis of bacterial cell envelope protein: ampicillin 250-50 mg 4 times a day / m 4 - 6 days. Ampioks 0.2 - 0.4 to 4 times a day; Oxacillin sodium, lincomycin 0.25 mg 4 times a day, oletetrin - 250 th.units 4 times a day 4 to 6 days. Corticosteroids (in severe cases): Prednisolone (triamsinolon, dexamethasone) 20-30 mg per day. Since epithelization dose prednisolone was reduced to 0. 005 g 1 in 7 days. Hydrocortisone. The drug has anti-inflammatory and anti-allergic desensitizing effect. Off work, depending on the severity of the process.

Diet (not irritating, anti alergical) - removal of products with allergic effects.

CHRONIC RECURRENT APHTHOUS STOMATITIS

Chronic recurrent aphthous stomatitis (CRAS) - a

chronic inflammatory disease of the oral mucosa, characterized by the appearance of the ulcer (thrush), occurring with periodic remissions and frequent exacerbations. 5% of all diseases of the oral mucosa. Be ill people of both sexes from 3 to 60 years and older.

Etiology
The leading role in the pathogenesis of diseases of the

oral mucosa play an infectious-allergic factor. , A change in reactivity, its sensitization, reflected in increased sensitivity to Proteus, Staphylococcus, Streptococcus, Escherichia coli. Several authors prefer the pathogenesis of autoimmune disease processes. In 1956 and I.G. Lukomsky and I.O. Novik could suggest allergic nature of recurrent aphthae, as repeated relapses coincided with disorders of the endocrine system, menstruation and exacerbations of the gastrointestinal tract, which is clearly an indirect confirmation of the pathogenesis of allergic HRAS. As allergies can be food, toothpaste, dust, worms and their waste products.

Clinic picture
Mild form - aphthae single (1-2), painless covered with

fibrinous deposit. Anamnesis revealed signs of pathology of the digestive system, the tendency to constipation, flatulence. Scatological study of feces identify violations in the process of digestion, disorders of the stomach and pancreas. Moderately severe form - mucosa slightly swollen, pale, and in the anterior oral aphthae are, up to 3 pieces, sharply painful to the touch, covered with fibrinous deposit. Regional lymph nodes are enlarged, mobile, not soldered to the skin, palpation of them painful. Aphthae evolution occurs within 510 days, due to the resistance of the organism. Anamnesis revealed signs of pathology of the gastrointestinal tract constipation, pain in the navel area, bloating, lack of appetite. Scatological study of excrement allows a violation of the digestion of proteins, carbohydrates and fats.

Clinic picture
Severe form - characterized by multiple eruptions

aphthae on the oral mucosa, which are located in different parts of the mucosa. Exacerbation are frequent, often monthly or continuous course of illness. In the early days of the disease can raise the temperature to 37.2-38C, headache, fatigue, weakness, apathy. There is a sharp pain of the oral mucosa when eating, talking and at rest. When fibergastroscope and sigmoidoscopy can detect mucosal hyperemia, changing terrain folds, the presence of erosions and the aphthas under epithelialization and bleeding.

I.M. Rabinovich et al. [1998] suggest a clinical classification of chronic recurrent aphthous stomatitis: fibrinous form - is characterized by the appearance of the AFL and 3 5 aphthes and them epithelization from 7-10 days; necrotic form - flowing to the primary destruction of the epithelium and the appearance of necrotic deposits; glandular form - primarily affects the epithelium of the small salivary glandule, thereby reducing its functional activity; deform form - characterized by the formation disfiguring scars in place of aphthous elements that change the configuration of the mucosa.

Forms of chronic recurrent aphthous stomatitis

Typical form. Characterized by the appearance of the

mucous aphthas of Mikulic. Occurs most frequently. The general condition of the patient does not suffer. Number of aphthas in the mouth 1-3, a painless and located on the side of transition mucosa and the lateral surface of tongue. Mikulic aphthas healing during 10 days. Ulcer or scar form. Characterized by the appearance aphthas by Setton of the mucous membrane of oral cavity. Aphtha is bigger, deep, with jagged edges, painful on palpation. Healing aphtha by Setton accompanied by the formation of scar, epithelialization is complete by 20-25 days. In aphthosis by Setton suffers overall condition, headache, malaise, adinamy, apathy, the temperature rises to 38 C.

Forms of chronic recurrent aphthous stomatitis

Deforming form. Characterized by the occurrence of all forms of

chronically recurrent apotheosis stomatitis (CRAS) signs of scars, but there are deeper destructive changes of the connective tissue framework of the mucous membrane, the process involved a private mucosa and submucosa. In the field of ulcer healing have deep, dense scarring, deforming the mucosa of the soft palate, palatal arches, the side surface and the tip of the tongue, mouth angles, up to microstomie. Suffers from the general state - headache, adinamy, apathy, temperature 38-39 C. Aphthae scar slowly for 1.5-2 months.
Lihenoide form. Reminiscent of lichen planus. The mucous membrane -

limited areas of hyperemia, which frames subtle whitish roller hyperplastic epithelium at this stage resembles HRAS focal desquamation of the mucosa. Later mucous erosion appears one or more of the aphthes.

Forms of chronic recurrent aphthous stomatitis

Fibrinous form. Characterized by the appearance of focal

hyperemia, with effusion of fibrin. Can take back development, or leads to the aphthes.
Glandular form. Changes observed in the parenchyma of

small salivary glands or ducts walls, swelling of the mucous with followed ulceration. Salivary gland enlargement, gaping ducts.

DIFFERENTIAL DIAGNOSIS
With chronic recurrent herpetic stomatitis. With erythema multiforme. Chronic traumatic erosions and ulcers. With secondary syphilis. With medicamentous stomatitis. With ulcero-necrotizing gingiva stomatitis Vincent. With aphthosis Bednar. With Behcet's syndrome

Treatment of CRAS

Remediation of chronic foci of infection. Dental health. Analgesia of oral mucosa: application of 2% solution of novocaine, 2% trimekaine, 2% lidocaine, 4% solution piromekaine, 2-5% piromekaine ointment, 2% lidocaine gel, 5% suspension anestezina in lycerol. Applications warm anesthetics with proteolytic enzymes. Can be used trypsin, chemotripsin, lysozyme dozoksiribonukleaza, ribonuclease, lysozyme oxidase. Lizoamidaza. Lizoamidaza has bacteriolising and immunostimulatory effect. Application for 10-15 minutes 1 time a day. Treatment of oral mucosa antiseptics (0.02% solution Frc, 0.02% solution ethacridine lactate, 0.06% chlorhexidine, 0.1% solution Dimexidum etc.). Mouth trays with Tantum Verde dosage 15 ml 3-4 times a day for 5-6 days. The drug has a strong analgesic effect. Mundizal gel in the form of application to the mucous membrane of the mouth for 20 minutes 3-4 times a day, treatment individual, an average of 5-10 days. The drug has analgesic, anti-inflammatory and epithelialization actions.

Treatment of CRAS
Blockade by elements of the defeat of the type of infiltration anesthesia to

accelerate epithelialization aphthous. (1% solution of novocaine, trimekaina 1%, 1% lidocaine 2 ml).
Anesthetic with hydrocortisone - 0.5 ml. Hydrocortisone has anti-

inflammatory, desensitizing and anti-allergic effect, inhibits the activity of hyaluronidase, reduces capillary permeability.
Honsurid 0.1 g with any anesthetic under aphthous. Accelerates the repair

processes in nonhealing ulcers. Number of blocks selected individually (1 - 10), are available daily or every other day. Amount of anesthetic to block - 2-4 ml.
Application of collagen films with various drugs, particularly with

corticosteroids, dimedrol, anesthetics, etc. The film is fixed to erosion and provides its anti-inflammatory and antiallergic effects for 40-45 min, then the film dissolves. Prolonged effect of the drug gives the maximum therapeutic effect.

General treatment of CRAS

A diet rich in vitamins. Never use a sharp, spicy, coarse food and alcoholic beverages. Desensitization (de-sensibilization) therapy. Tavegil, diazolin, pipolfen, dimedrol, suprastin, fenkarol 1 tablet 2 times a day for a month. Sodium thiosulfate 30% solution of 10 ml intravenously slowly through the day, the course of treatment of 10 injections. The drug has a powerful anti-inflammatory, desensitizing and antitoxic effect. Gistaglobulin or gistaglobin 2 ml 2 times a week intramuscularly, per course of treatment 6 - 10 injection. With the drug in the body to produce anti-histamine antibodies and increases the ability of serum to inactivate free histamine. Levamisole (Decaris) to 0.15 g 1 per day, per treatment 3 tablets in 3-5 days, repeat the treatment. All 3 courses of treatment, ie 9 tablets. The drug helps to restore Tlymphocytes and phagocytes. The drug regulates cellular immunity. Vitamin U of 0.05 g 3 times a day, treatment 30-40 days. Stimulates wound healing of the oral mucosa. In severe disease are appointed corticosteroids, prednisone 15-20 mg per day. Reduced dose of 5 mg per week after epithelialization of erosions and ulcers. Sedatives and tranquilizers are assigned as indicated. Delargin 1 mg 2 times a day, intramuscularly for 10 days. The drug has a strong analgesic effect optimized epitelization of erosions and ulcers.