Sunday, October 30, 2011

A Note on Muscles of the Face and Scalp.....With A Video

A Video on Muscles of the Face and Scalp
video

Muscles of the Facial Expression
Muscles of Facial Expression are unique in that they migrate to their destinations about the scalp, neck, and mostly about the face from second pharyngeal arch mesenchyme and thus receive their motor innervation via the facial nerve (CN VII), the nerve of the second arch. Although most of these muscles originate on bone, most do not insert on bone; rather, they insert into the dermis of the skin and freely intermingle with muscles in their vicinity. Upon contraction, this arrangement and groupings of muscles about the orifices of the face convey movements about these orifices that we interpret as emotions.
The muscles of the face (and scalp) are derived from the second pharyngeal arch (hyoid arch) mesenchyme that migrates to its final destination.
Muscles of the Face and Scalp
Considering the origin of these muscles, it is not surprising that they receive motor innervation from branches of the facial nerve (CN VII).
Rather than inserting into bone, these muscles insert into the dermis of the skin, thus their orchestrated contractions convey various shapes to the face that we interpret as emotions. It is important to understand that fascicles of these muscles intermingle with each other, and they tend to act in groups to control the orifices around which they are grouped, such as the orbit, nose, and mouth. It is according to this grouping that they are described.

Muscles of the Face and Scalp
Muscle
Location Origin
Scalp
Frontalis Forehead Procerus, corrugator, orbicularis oculi
Occipitalis Back of the head Mastoid process and superior nuchal line
Temporoparietalis Temple Temporal fascia
Ear
Auricularis anterior Anterior to ear Temporal fascia
Auricularis superior Above ear Temporal fascia
Auricularis posterior Behind ear Mastoid process
Nose
Procerus


Nasalis


Depressor septi


Eye
Orbicularis oculi Around the orbit Nasal process of frontal bone, frontal process of maxilla, medial palpebral ligament, and lacrimal bone
Corrugator Deep to the orbicularis oculi Medial aspect of superciliary arch
Mouth
Levator labii superioris Upper lip Zygoma and maxilla just above infraorbital foramen
Levator labii superioris alaque nasi Upper lip and side of nose Maxilla, frontal process
Levator anguli oris Corner of mouth Canine fossa of maxilla
Zygomaticus major Cheek and corner of mouth Temporal process of zygoma
Zygomaticus minor Cheek and corner of mouth Maxillary process of zygoma
Risorius Cheek Masseteric fascia
Depressor labii inferioris Lower lip Oblique line of mandible
Depressor anguli oris Corner of mouth Oblique line of mandible
Mentalis Chin Incisive fossa of mandible
Orbicularis oris Circumscribes the mouth Muscles in the vicinity, maxilla, nasal septum, mandible
Buccinator Cheek Pterygomandibular raphe, alveola arches of mandible and maxilla
Neck
Platysma Neck and chin Pectoral and deltoid fascia


Muscles of the Ear and Nose
The three external muscles of the ear are the auricularis anterior, superior, and posterior. Similarly, the three muscles of the nose are the procerus, nasalis, and depressor septi. These two groups of muscles are fairly inconsequential.

Muscles Surrounding the Orbit
Orbicularis Oculi
The orbicularis oculi muscle is composed of two parts, the palpebral portion and the orbital portion. The former originates from the medial palpebral ligament (attached to the medial aspect of the orbit) and inserts into the lateral palpebral raphe (attached to the lateral aspect of the orbit). The orbital portion of the muscle describes an oval around the orbit.
The orbicularis oculi is innervated by the temporal and zygomatic branches of the facial nerve and acts to close the eyelid completely. Forceful closure is mediated by the orbital portion, whereas the palpebral portion is responsible for light closure, as in blinking.

Corrugator
The corrugator (supercilii) muscle is located deep to the superomedial aspect of the orbicularis oculi, at the medial aspect of the eyebrow. It originates at the medial extent of the superciliary arch and inserts into the skin of the eyebrow.
It is innervated by the temporal and zygomatic branches of the facial nerve; the combined actions of the paired muscles approximate the eyebrows, producing frowns.

Muscles Surrounding the Mouth
Orbicularis Oris
The orbicularis oris completely encircles the mouth. Its fibers are positioned at various depths and angles in the two lips. Fascicles of this muscle, some of which are derived from those of neighboring muscles—especially the buccinator—freely intermingle with fascicles of other muscles acting on the lips, permitting extensive movability. Many of the fibers of the buccinator cross over each other at the angle of the mouth so the upper fibers proceed to the lower lip and the lower fibers to the upper lip. Hence, the origin of the orbicularis oris is complex and is usually considered to be from the fibers of the surrounding muscles as well as from the alveolar portion of the maxilla, the septum of the nose, and the area lateral to the incisive fossa of the mandible. Insertion is into the skin and into itself, forming an ellipse around the mouth.
Buccal branches of the facial nerve innervate this complex muscle, which closes the lips and, during stronger contraction, purses them, as in osculation and whistling.

Risorius
The risorius is a small, horizontally placed muscle that originates in the masseteric fascia and inserts in the skin of the corner of the mouth. This is the smiling muscle; it is responsible for drawing the corners of the mouth laterally. The risorius is innervated by buccal and mandibular branches of the facial nerve.

Depressors of the Lip
The depressor labii inferioris is quadrangular in shape. It originates on the medial extent of the oblique line of the mandible and inserts into the skin of the lower lip. It acts to depress the lower lip.
The depressor anguli oris (triangularis) originates on the oblique line of the mandible and inserts into the skin of the corner of the mouth and depresses it, expressing sadness.
The mentalis is a small muscle of the chin. Its origin is in the incisive fossa of the mandible, and it inserts into the skin of the chin to wrinkle it and also to protrude the lower lip, as in drinking.
The platysma was previously detailed in Chapter 7. All of the muscles of this group, except the platysma, are innervated by the buccal and mandibular branches of the facial nerve.

Elevators of the Lip
Five muscles elevate the lip and corner of the mouth. The levator labii superioris alaque nasi is the most medial of these muscles, originating from the frontal process of the maxilla passing inferiorly along the  side of the nose. It then splits into a medial and a lateral portion to insert into the wing of the nose and into the upper lip. This muscle functions in dilating the nostril and raising the upper lip.
The levator labii superioris originates from the maxilla and zygoma just inferior to the orbit. Its fibers pass across the infraorbital foramen to insert into the upper lip, lateral to and intermingling with the fibers of the levator labii superioris alaque nasi. The levator labii superioris elevates and protrudes the upper lip.
The levator anguli oris lies deep to the levator labii superioris. It originates below the infraorbital foramen, from the canine fossa of the maxilla, to insert into the corner of the mouth. This muscle elevates the angle of the mouth and assists in the formation of the nasolabial furrow.
The zygomaticus minor, a slender muscle arising from the maxillary process of the zygomatic bone, inserts just lateral to the insertion of the levator labii superioris muscle. This muscle elevates the upper lip. It also assists in the formation of the nasolabial furrow.
The zygomaticus major is the lateral-most muscle of this group. It originates on the temporal process of the zygomatic bone and inserts into the corner of the mouth. This muscle elevates the corner of the mouth and pulls it laterally.
All of the five muscles acting to elevate the lips are innervated by the buccal branches of the facial nerve.

Muscle of the Cheek
The buccinator, a quadrangule-shaped muscle occupying the space between the mandible and the maxilla, is the primary muscular component of the cheek. It lies deep to the muscles of facial expression and is separated from them by the buccopharyngeal facia and the buccal fat pad. The parotid duct pierces the substance of this muscle to enter the oral vestibule.
The buccinator originates on the maxilla and mandible, specifically on the buccal surfaces of the alveolar processes in the vicinity of the three molars, and from the pterygomandibular raphe, a collagenous tendinous inscription attached to the pterygoid hamulus and the mylohyoid line of the mandible. This raphe is interposed between the buccinator and superior pharyngeal constrictor muscles.
The buccinator inserts into the fleshy corner of the lip in such a fashion that the upper fascicles and the lower fascicles decussate at the corner of the mouth and insert into the lower and upper lips, respectively, becoming fibers of the orbicularis oris. The highest and lowest fascicles, however, continue without decussation into the upper and lower lips, respectively.
The buccinator muscle acts to press the mucosa of the cheek against the teeth, thus aiding in mastication and deglutition. In addition, it assists in distending the oral vestibule and forcefully expelling air, as in blowing dust particles off a surface. The buccal branch of the facial nerve innervates this muscle.


Saturday, October 29, 2011

A Note on Active Components of removable orthodontic appliances


Active components

The active components comprise of springs, bows,screws and elastics. Springs and bows are made of hard drawn stainless steel wire.  In situations where teeth to be moved are also included in retention and anchorage screws are used. Elastics are used intra orally in cases where traction of individual teeth required and extra orally when head gear is used for reinforcement of anchorage or for distal movement of teeth.

Spring design

Palatally approaching springs are made of 0.5mm stainless steel wire as wires lesser in thickness than this would get distorted when the child handle the appliance.
Palatal cantilever spring also should be as  long as possible to obtain maximum flexibility. However, dimensions of the oral cavity limits the maximum length that can be achieved. A coil of 0.3mm internal diameter could be incorporated to increase the effective length of the wire used for construction of the spring. It is better if the coil is wound in such a way it unwinds as the tooth moves. Because the elastic properties of the spring is superior if Bauschinger effect is used during activation.  A palatal spring may be unstable in the vertical direction so that it can get deflected vertically towards the palate causing difficulty in insertion of the appliance or causing trauma to the palate. The stability of the spring could be improved by incorporating a guard wire on the palatal surface of the spring and boxing the spring with acrylic on its oral side.

Buccaly approaching spring
If a canine is buccally placed it is difficult to approach the correct point of contact with a palatally approaching spring. In such cases, it is important to make a buccally approaching spring.  If a buccaly approaching spring is made of 0.5mm wire it will not be stable in the labial sulcus. Stability could be improved by if 0.5mm wire could be sheathed with stainless steel tubing which has 0.5mm internal diameter. The tubing is then incorporated into the base plate. This improves the stability of the spring. Such supported springs are used for canine retraction (supported buccal canine retractor) and for over jet reduction (Robert’s retractor). 

Buccaly approaching springs and bows can be made of 0.7mm wire they have adequate stability but they are extremely rigid. (Self supported buccal canine retractors and labial bows made of 0.7mm wire) so even a 1mm activation may apply a heavy force on the teeth.

Single cantilever spring ( finger spring)
Single cantilever spring ( finger spring)
Is made of 0.5mm wire. A coil of 3mm internal diameter is incorporated into the spring close to its point of emergence from the base plate. This increases the effective length of the wire improving its flexibility. 

When palatal cantilever spring is constructed it is necessary to determine the correct path of movement and then the required point of contact should be marked on the model. A line is drawn on the model at right angle to the path of tooth movement and through the mid crown width of the tooth. This will indicate the correct position of the coil. Arm of the spring should be either straight or cranked to make sure the tangent drawn at the point of contact is perpendicular to the desired path of movement of the tooth. The free end of the wire should be finished after the base pate has been processed. A palatal spring is boxed to protect it from damage so that it lies in the recess between the base plate and the mucosa.  If the spring catches between teeth during removal it may get distorted in such situations if the spring is used for movement of the tooth along the arch distortion can b prevented 
By incorporating a guard wire palatal to it so that a channel is made between the base plate and the guard wire.

Adjustment of palatal cantilever springs
It is necessary to check whether the spring contact the tooth correctly and lies closer to the gingival margin. The spring is then activated by 3mm.  The spring should not be adjusted at the point where it emerges from the base plate because it is appoint where there is stress concentration. If the wire is further work hardened it will break at this point. The correct site for adjustment is along the free arm of the spring as close to the coil as possible. After activation of the spring the point of contact should be checked and it is adjusted so that the tangent drawn at the point of contact is perpendicular to the intended direction of movement.  Once activate the appliance should be seated in the mouth and try to release the spring and see the amount of activation. In a case of a canine the spring should not go beyond the tip of the canine when it is in the passive status. The force generated with activation of the spring could be measured with a tension gauge as shown in the picture.
Single cantilever spring should be cranked when it is made on a tooth in the labial segment. This is to enable the spring to be embedded in the base plate without interfering with the other teeth.

Double cantilever spring ( Z spring)
Z spring
When a tooth which is in cross bite has to be moved by a considerable distance single cantilever is not satisfactory. In such cases it is necessary to modify the cantilever spring. Double cantilever or Z springs are made in such 0.5mm wire to suit the clinical situation. The arms of the springs should be as long as possible to reduce the stiffness of the spring. If the limbs are short the range of activation will be limited and also the child may find it difficult to insert the appliance.

The palatal surface has a slant therefore the spring should be made perpendicular to the palatal surface of the tooth to minimize the intrusive effect of the spring which is not satisfactory in cases with cross bites. The spring also will tend to slip incisally and become passive.   In cases where there is a doubt about the stability of the spring  a guard wire could be incorporated below the spring to prevent downward displacement of the spring. These guard wires could be made with a reservoir in cases with marked palatal displacement of the incisors.

Adjustment
Both limbs of the double cantilever spring should be adjusted during activation. First, adjustment is carried out to the palatal limb close to the coil of the fixed end of the spring. This will establish the correct degree of activation. Then the second adjustment is made at the other end of the limb to make the free limb perpendicular to the intended path of movement.

T spring
T spring
 In cases where buccal movement of a premolar or a canine is needed if a single cantilever or a double cantilever spring is used patient may find it difficult to insert the spring. A T spring which is made of 0.5mm wire may be satisfactory for this purpose. The mechanical principles of a T spring is similar to single cantilever spring but both free ends are embedded in acrylic making it less flexible compared to it. The force applied by the spring has both vertical and horizontal components. If the tooth surface of the tooth at the point of contact is early vertical as in first premolar the intrusive component is small. If T springs are made on incisors which has a sloping surface such as the cingulum plateau of the upper incisor the intrusive component will be much larger. This has two disadvantages. One is the intrusive force may cause intrusion of the upper incisor which is unfavorable in cross bite cases and the reaction to this vertical component of the force may tend to dislodge the appliance.  Therefore t springs are not used in anterior teeth.

T spring is activated by pulling it away from the base plate if the spring over activate it may not seat properly; therefore extra care should be taken to avoid over activation. When the tooth is moving outwards the spring may not be in contact with the tooth. The spring should be elongated by adding wire from the reservoir.

Buccal springs

Buccaly approaching springs can be used for mesio-distal movement palatal movement or when an attachment is bonded on teeth for extrusion of the teeth or for rotation. As the sulcus depth is limited special care should be taken when the impression is taken for working model. Impression should be muscle trimmed to avoid encroachment of the spring into the muscle attachments. Bucccaly approaching springs may get distorted when the patient is trying to remove the appliance therefore every precaution should be undertaken to improve the strength and the stability of the spring.

Buccal canine retractor

 Depending on the thickness of the wire used buccal springs the flexibility and stability changes.

Self supported buccal canine retractor
Self supported buccal canine retractor
This is made of 0.7mm wire. It has a good strength and stability but even a slight activation may apply a great an excessive force even with 1 mm activation.

Supported buccal canine retractors
Supported buccal canine retractor
This is made of 0.5mm wire. Therefore the flexibility of the spring is satisfactory. As it is made on a sloping surface of the tooth it may be unstable in vertical palne so that the point of contact will change applying jiggling forces on the tooth. The stability of the spring in the vertical palne can be improved by supporting the wire with a tubing of a 0.5mm internal diameter. It is more than twice as flexible as the self supported retractor. This is not flexible as palatal retractor as the free end of the wire which is not supported is not long enough but has excellent mechanical properties when compared with a self supported canine retractors.

Adjustment 
An activation of 2mm one quarter of the canine width is sufficient. Care should be taken not to bend the wire as it emerges from the tubing. As this a site of stress concentration it may fracture. Buccal retractor should be activated in two planes. Distal activation is carried out at the coil by bending the anterior limb over the round beak. Of a pair of spring forming pliers. Palatal activation is done along the anterior limb below the coil. Patient should be instructed to seat the spring carefully on the mesial surface of the tooth  as it may catch on the cuspal incline of the canine and remain ineffective or cuuse intrusion of the tooth.

Reverse loop buccal retractor

This retractor is satisfactory in the lower arch as there is a shallow sulcus. Flexibility of the retractor depends on the height of the vertical loop. Therefore it should be kept as long as possible. The main problem of this spring is it is stiff in the horizontal plane where flexibility is needed and unstable in the vertical plane.

Activation
As the spring is made of 0.7mm wire it should not be activated more than 1mm. this can be activated in two ways. One is by cutting 1mm wire from the end of the spring and recontourig the free end around the tooth or the other by opening the loop by 1 mm.

Bows
In labial bows both ends of the bow are embedded in acrylic. They could be either passive or active. Passive labial bows are used to improve retention of the appliance or as a retainer after correction of over jet. Active labial bows are used for incisor retraction.

Active labial bows
The choice of the labial bow mainly depend on the amount of incisor retraction needed. In cases with severe over jet a flexible labial bows such as Robert’s retractor is preferred. In cases with slight over jet or where minor irregularities need correction, a less flexible labial bow is preferred.

Labial bow with U loops
U loop labial bow
This labial  bow is constructed with 0.7mm wire. Flexibility of the bow depend on the height of the loop. The depth of the sulcus limits the height of the loop. The bow is rigid in horizontal plane  as the wire is thick but flexible in the vertical plane making the stability ratio poor. Only advantage of this labial bow is in cases with palatal springs for canine retraction this labial bow could be incorporated in the same appliance and once the canines have been retracted the labial bow could be activated for over jet correction. As the forces generated by this labial bow is very high there is a risk of anchorage loss.

Activation of u loop labial bow. The bow is adjusted at ‘U’ loops. The activation should be very slight. Once activated labial bow should be displaced palatally only by 1mm.

Split labial bow
Split labial bow
Flexibility of U loop labial bow could be improved by splitting it in the middle. But the activation will be difficult. During activation extra care should be taken to prevent flattening of the labial segment. Labial bow should be activated at the U loops .

Labial bow with reverse loops.
This is also made of 0.7mm wire. The flexibility of this labial bow is much superior to U loop labial bow as the reverse loops incorporate more wire into the labial bow. But during construction extra care should be taken to keep the loops clear of the Adam’s clasps on first molars. If this bow is incorporate with canine retractors the labial bow will have added control on distally moving canines. As this bow also comparatively rigid it should be activated only by 1mm.

Activation
Activation of the labial bow with reverse loop is carried out in two stages. The vertical loop is first opened by compressing t at the loop as shown in the figure. This lowers the labial bow in the incisor region. A compensating bend should be made at the base of the loop to make the contact of the labial bow with the upper incisor correct.

Extended labial bow
Extended/Flexible labial bow
Extended labial bow also made of 0.7mm wire. But the flexibility is very much improved by incorporationg large loops when compared with U loop labial bow. In units where facilities are not available  for construction of Roberts Retractors this is a useful alternative. As the loops are comparatively large patients find it uncomfortable.

Activation the extended labial bow should be activated with special care as the loops can get distorted leading to trauma either tot the gum or lip.  Loop forming pliers with groves on one beak is used for the activation.  Adjustments are carried out on tow places. First the on the upper border of the loops marked A  to make the activation effective and then at the  point B B’  to make the level of the bow on incisor teeth. as this labial bow is also made of 0.7mm wire only 1 mm of activation is recommended.

Roberts retractor
Roberts retractor
Roberts Retractor is a flexible labial bow made of 0.5 mm wire. The strength and stability of the bow is improved by inserting the wire into a tubing with 0.5mm internal diameter. Horizontal section of the bow is made into a smooth curve and extends from distal of lateral incisor on one side to the other. The vertical section of the bow and the coil  gives the  flexibility to the bow. Coil is made as the wire emerges from the tubing the tubing with the wire is inserted into the base plate distal to the retracted canines.  Coil should be of adequate size, at least 0.3 mm internal diameter.

Activation
This bow is very flexible and activation of 3mm is sufficient. Activation should be carried out with great care. If wire is bent at  the point where it emerges from the tube it is liable to fracture. This a point of stress concentration. The activation is carried out by bending the vertical limb inwards below the coil. As the incisors are moving back the bow drops down therefore the horizontal part should be lifted up to maintain the correct point of application  of force on incisors.

Labial bow with Apron Spring.
This is similer to the Roberts retractor with regard to the flexibility. Apron spring is made of either 0.4 mm wire or 0.35mm wire. It has a horizontal part which is smoothly curved to take the shape of the labial surface and vertical limbs which is wound onto the heavy base arch of 0.9mm wire.

Activation
Labial bow with apron spring is activated by bending the wire inwards along the vertical limbs. This is liable to fracture. But a new apron spring could be wound chairside.

Screws
Expansion screw
A screw can be incorporated in to the base plate to use a source of force generation. The screw transmits the force through the base plate which come into contact with it. The screw applies an intermittent force

Many types of screws are commercially available. The screw should have adequate travel  good stability and should be of minimal bulk which are desirable properties. Number of guide pins determines the stability of the screw. Screws with  double guide pins are more stable. But in cases with restricted space screws with single guide pins have an added advantage. Activation is carried by the patient once or twice weekly.   Screws sometimes may tend to turn back when there is resistance to tooth movement. Screws apply an intermittent heavy force. This is not a big problem as at any given time the screw activation in less than or equal to 0.2mm. therefore the movement of the tooth is still within the limits of the periodontium so that extensive hyalinization do not occur. Therefore spring loaded screws which dissipate the force slowly  over a long period of time so that a continuous force is applied on the teeth. but spring loaded screws are very bulky making a limitation for their use.

Activation
The direction in which the screw should be indicated on the base plate using a marker embedded in the base plate. The patient is given a key to open the screw. A quarter turn opening of the screw per week will move the tooth about a 1mm per month.

Friday, October 28, 2011

Oral manifestations of systemic diseases


GIT diseases
Crohn disease
diffuse labial, gingival or mucosal swelling
cobblestoning of buccal mucosa and gingiva
aphtous ulcers
mucosal tags
angular cheilitis
oral granulomas
Crohn disease
Ulcerative colitis
oral signs are present in periods of exacerbation of disease
aphtous ulceration or superficial hemorrhagic ulcers
angular stomatitis
pyostomatitis vegetans, pyostomatitis gangrenosum
pyostomatitis vegetans
Gastroesophageal reflux
reduction of the pH of the oral cavity below 5,5 – enamel damage
damage of the dentin – higher sensitivity (to temperature..), caries
enamel damage and
damage of the dentin
Chronic liver diseases
jaundice
petechiae or gingival bleeding (hemostasis disorder)

Hematologic diseases
Anemias
folate and vit. B12 deficiency or iron deficiency
glossitis
red colour
atrophic papilae
recurrent aphthae
candidal infection
angular stomatitis
oral pain

Leukemia
gingival hypertrophy
petechiae
mucosal ulcers
                  hemorrhage
            Treatment of leukemia
reactivation of herpes simplex virus – oral mucosistis
gingival hypertrophy in leukemia
Summary of oral manifestations of gastrointestinal and hematologic diseases
Labial swelling
Crohn's disease

Glossitis
   Crohn's disease
   Iron-deficiency anemia
   Pernicious anemia
   Ulcerative colitis

Erosion of enamel and dentin
Anorexia nervosa/bulimia
        Gastroesophageal reflux
Ulcerations and erosions
   Crohn's disease
   Iron-deficiency anemia
   Pernicious anemia
   Pyostomatitis vegetans
   Ulcerative colitis

Gingivitis
Anorexia nervosa/bullimia
Crohn's disease
Scurvy

Hemorrhage
Pyostomatitis vegetans
Scurvy
        Ulcerative colitis
Angular cheilitis
Iron-deficiency anemia

Aphthous ulcers
Crohn's disease
Pernicious anemia
Ulcerative colitis

Intraoral burning
   Iron-deficiency anemia
   Pernicious anemia

Candidiasis
   Crohn's disease (steriod therapy)
   Iron-deficiency anemia
   Pyostomatitis vegetans (steriod therapy)
   Ulcerative colitis (steroid therapy


Connective-tissue diseases
Sjรถgren syndrome
autoimmune disease
men : women - 1 : 9
50 years and older
     Main signs
sicca syndrome
keratoconjuctivitis sicca
xerostomia
     Oral signs
decrease in saliva
xerostomia
dry, red, wrinkled mucosa
difficulty in swalloving and eating
disturbance in taste and speech
increased dental caries
infections
atrophy of the papilae
candidiasis

Kawasaki disease
vasculitis of medium and large arteries
    Oral signs
swelling of papilae on the surface of the tongue (strawbery tongue)
intense erythema of the mucosal surfaces
cracked, cherry red, swolen and hemorrhagic lips

Scleroderma
diffuse sclerosis of the skin, GIT, heart muscle, lungs, kidney
    Oral signs
pursed lips – dificult to open the mouth
esophageal sclerosis ® gastroesophageal reflux – damage of enamel
pale, rigid mucosa
teleangiectasias
decreased mobility of tongue
salivary hypofunction

Lupus erythematosus
autoimmune disease
        Oral signs
ulcerations
similar tooral lesions of lichen planus – painful
petechiae
damage of salivary glands - xerostomia

Pulmonary diseases
Cystic fibrosis
    Oral signs
disorder of salivary glands
swelling lips
gingivitis
dryness

Sarcoidosis
    Oral signs
multiple, nodular, painles ulcerations of the gingiva, bucal mucosa, labial mucosa and palate
tumorlike swelling  of salivary glans
swelling of the tongue
xerostomia
                      facial nerve palsy
Cutaneous diseases
Psoriasis
    Oral signs
fissured tongue
small white papules
red and white plagues
bright red patches

Acantosis nigricans
hyperpigmentation, papillomatosis
    Oral signs
gingival hyperplasia
gingiva, tongue, lips – papilomas

Endocrine diseases
Diabetes mellitus
    Oral signs
xerostomia caused decreased salivation and increased glucosa level in saliva
gingivitis
oral infections
candidiasis
higher incidence of caries
bilateral enlargement of parotid glands
altered taste
burning mouth syndrome

Hypoparathyroidism
    Oral signs
candidiasis
upper lip twitching

Hyperparathyroidism
    Oral signs
loss of the lamina dura surrounding the roots of the teeth
decrease of trabecular density
osseous lesions „brown tumor“

Cushing´s syndrome
    Oral signs
fatty tissue deposition – „moon face“
osteoporosis ® pathological fractures of the mandible, maxilla or alveolar bone
delayed healing of fractures and also sof tissue injuries
moon face
Addison´s disease
Oral signs
„bronzing“ hyperpigmentation of the skin
oral mucosal melanosis – buccal mucosa, tongue
hyperpigmentation
Renal diseases
Uremic stomatitis
rare
in undiagnosed and untreated chronic renal failure
irritation and chemical injury of mucosa by ammonia or ammonium compounds
              Signs
painful plagues and crusts – bucal mucosa, the floor or dosrum of the tongue, floor of the mouth
Type I
generalized or localized erythema
exudate
pain, burning, xerostomia, halitosis, gingival bleeding, candidiosis
Type II
ulceration
secondary infection
anemia
painful plagues and crusts – bucal mucosa, the floor or dosrum of the tongue, floor of the mouth

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