NEET MDS Lessons
Oral Medicine
Actinomycosis is a rare but serious bacterial infection that typically affects the face, neck, and thoracic and abdominal areas. It is caused by Actinomyces israelii, which are anaerobic, filamentous bacteria that are part of the normal oral and gastrointestinal flora. The infection usually occurs when these bacteria invade tissues through breaks in the mucosal barrier, often following dental procedures, oral infections, or surgery. It is not contagious and does not spread from person to person.
Actinomycosis is a relatively rare, chronic bacterial infection caused by
Actinomyces, a genus of Gram-positive, anaerobic, or microaerophilic bacteria
that are part of the normal oral flora. The most common species involved in oral
infections are Actinomyces israelii, Actinomyces naeslundii, and Actinomyces
viscosus.
Features of Actinomycosis in Oral Medicine:
1. Presentation: Oral actinomycosis typically presents as a slowly progressive,
indurated, and painless mass with a firm consistency. The lesion may appear as a
nodule, a swelling, or a diffuse infiltration of the tissue.
2. Sulfur granules: A characteristic feature of actinomycosis is the presence of
sulfur granules, which are microscopic collections of bacteria surrounded by a
dense, eosinophilic material.
3. Microscopic appearance: Under the microscope, the bacteria form filamentous
structures called "radiating clubs" or "ray fungi" due to their branching
pattern.
4. Predisposing factors: The infection often occurs in individuals with poor
oral hygiene, dental caries, periodontal disease, or following oral surgery or
trauma, which can disrupt the mucosal barrier and allow the bacteria to invade
deeper tissues.
5. Clinical forms: There are three main forms of oral actinomycosis:
cervicofacial, which affects the neck and face; actinomycetoma, which is a
chronic, localized infection of the jaw or other bone; and systemic
actinomycosis, which is less common but can disseminate to the lungs, liver, and
other organs.
The disease manifests in different forms based on the site of infection:
1. Cervicofacial actinomycosis: This is the most common form,
accounting for 60% of cases, and often enters through the mouth or throat. It
may appear as a slowly growing, painful mass in the neck or face, with possible
drainage of pus through the skin.
2. Thoracic actinomycosis: This type occurs when the bacteria
spread to the lungs, often following aspiration from the oral cavity. It can
mimic pneumonia at first but may progress to form abscesses and damage
surrounding structures such as ribs and vertebrae.
3. Abdominal actinomycosis: This form typically begins in the
gastrointestinal tract, often the appendix or cecum. It can spread to the liver
and other abdominal organs, causing pain, swelling, and the formation of
abscesses.
4. Pelvic actinomycosis: Associated with the use of
intrauterine contraceptive devices (IUCDs), this infection occurs in the female
reproductive system and may cause pelvic inflammatory disease-like symptoms or
infertility.
The diagnosis of actinomycosis is often challenging due to its
nonspecific symptoms and the difficulty in culturing the bacteria, which require
anaerobic conditions. Microscopically, the characteristic 'sulfur granules' can
be identified in pus or biopsy samples, which consist of clumps of bacteria
surrounded by neutrophils and a fibrin network. These granules can be visualized
with specific stains such as Gomori methenamine silver (GMS).
Treatment for actinomycosis involves the administration of high
doses of antibiotics for an extended period, typically penicillins (such as
penicillin G or amoxicillin) or, if penicillin-allergic, alternatives like
clindamycin, erythromycin, or tetracyclines. The duration of treatment can range
from several months to over a year, depending on the severity and location of
the infection.
Surgical intervention may be necessary in some cases to drain abscesses, remove
infected tissue, or correct an underlying condition that facilitated the
infection. For example, in pelvic actinomycosis, removal of the IUCD is often a
critical step in treatment.
Prevention includes maintaining good oral hygiene and regular dental care, as
well as careful monitoring and management of any breaks in mucosal barriers.
Actinomycosis, while not common, requires early and aggressive treatment to
prevent complications and ensure the best possible outcome for patients. It is
important for medical professionals to consider actinomycosis in the
differential diagnosis of chronic suppurative infections, especially in
immunocompromised individuals or those with a history of recent surgery or
trauma to the affected areas.
Treatment of Actinomycosis in Oral Medicine:
The treatment of actinomycosis involves a combination of surgical and medical
interventions:
1. Antibiotics: The cornerstone of treatment is the administration of
antibiotics that are effective against anaerobic bacteria, such as penicillins
(penicillin G or amoxicillin), particularly penicillin V, for several months to
ensure eradication of the infection. In penicillin-allergic patients,
alternatives like clindamycin, erythromycin, or tetracyclines may be used.
2. Surgical drainage: If the infection has caused abscesses, surgical drainage
may be necessary to release the pus and reduce swelling.
3. Incision and curettage: For localized infections, surgical removal of the
affected tissue and curettage of the bone may be performed to remove the
necrotic material and allow for healing.
4. Debridement: Removing the devitalized tissue can help in reducing the
bacterial load and facilitate the antibiotic treatment.
5. Maintaining oral hygiene: Good oral hygiene practices are crucial to prevent
recurrence of the infection. This includes regular brushing, flossing, and
professional dental cleanings.
6. Treatment of underlying conditions: Addressing any predisposing factors such
as dental caries or periodontal disease is essential to prevent reinfection.
7. Monitoring and follow-up: Patients should be monitored for signs of
recurrence, and any persistent symptoms should be evaluated with imaging and
biopsy if necessary.
The prognosis of oral actinomycosis is generally good with appropriate
treatment. However, the infection can be challenging to diagnose due to its
rarity and the similarity of its clinical presentation to other oral diseases. A
high index of suspicion, combined with a thorough medical and dental history,
clinical examination, and microbiological and histopathological confirmation, is
essential for accurate diagnosis and effective management.
Oral medicine is the specialty of dentistry concerned with the oral health care of patients with chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.
Oral medicine acts a focus for specialist interdisciplinary care of patients with symptoms arising from the mouth that do not relate directly to teeth.
These symptoms are often chronic and may have a significant psychological, as well as physical impact on the patient’s quality of life. In some instances, symptoms and signs reflect local problems restricted to the mouth. However, symptoms and signs can represent oral manifestations of more widespread disease.
Oral medicine practice depends on good diagnostic ability, in depth knowledge in identifying and removing the underlying cause from local, systemic ,genetic and environmental factors.
Oral physicians should adapt the demographic changes andmedical advancements with academic and research orientation for expansion of oral medicine and radiology andshoulder the responsibility of being part of patient's overall health care team.
Emergency conditions in Dental Clinics
Faint - due to Pain or anxiety.
Signs and symptoms
• May be preceded by nausea and closing in of visual fields
• Pallor and sweating
• Heart rate below 60 beats/min (bradycardia) during attack.
T/t
• Give oxygen
• Expect prompt recovery.
• Need to encourage oxygenated blood flow to brain as rapidly as possible
• May need to block vagal activity with atropine and allow heart rate to increase.
If the patient is slow to recover, consider other diagnosis or give 0.3-1 mg atropine i.v.
Hyperventilation- due to Anxiety
Signs and symptoms
• Light-headed
• Tingling in the extremities
• Muscle spasm may lead to characteristic finger position (carpopedal spasm).
Treatment
• Reassure
• Ask patient to re-breathe from cupped hands or reservoir bag of inhalational sedation or general anaesthetic apparatus.
• Reduce anxiety
• Over-breathing has blown off carbon dioxide, resulting in brain blood vessel vasoconstriction. Return carbon dioxide levels in blood to normal.
Postural hypotension- More likely to occur if the patient is taking betablockers,which reduce the capacity to compensate for normal cardiovascular postural changes.
Signs and symptoms
• Light-headed
• Dizzy
• Loss of consciousness on returning to upright or standing position from supine position.
Treatment
Lay the patient flat and give oxygen
Sit the patient up very slowly.
Encourage oxygenated blood flow to brain.
Diabetic emergencies: hypoglycaemia- Patient may have taken medication as normal but not eaten before dental visit.
Signs and symptoms
• Shaking and trembling
• Sweating
• Hunger
• Headache and confusion.
Treatment
• If the patient is conscious, give three sugar lumps or glucose and a little water or glucose oral gel; repeated if necessary in 10 minutes
• If the patient is unconscious, inject 1 mg (1 unit) glucagon by any route (subcutaneous, intramuscular or i.v.).
Return blood glucose level to normal by giving glucose or by converting the patient's own glycogen to glucose by giving glucagon.
Further management
• Transfer the patient to A&E
• Give up to 50 ml 20% glucose i.v. infusion followed by 0.9% saline flush as the glucose damages the vein
• Expect prompt recovery.
Grand mal epileptic seizure- Usually the patient is a known epileptic
• Epilepsy may not be well controlled
• Seizure may be initiated by anxiety or by flickering light tube.
Signs and symptoms
- Sudden loss of consciousness associated with tonic phase in which there is sustained muscular contraction affecting all muscles, including respiratory and mastication
- Breathing may cease and the patient becomes cyanosed
- The tongue may be bitten and incontinence occur After about 30 seconds, a clonic phase supervenes, with violent jerking movements of limbs and trunk.
Treatment• Ensure patient is not at risk of injury during the convulsions but do not attempt to restrain convulsive movements
• Make no attempt to put anything in mouth or between the teeth
• After movements have subsided, place the patient in the recovery position and check airway
• The patient may be confused after the fit: reassure and offer sympathy
• After full recovery, send the patient home unless the seizure was atypical or prolonged or injury occurred.
• Maintain oxygenated blood to brain
• Protect from physical harm
• Administer anticonvulsant.
Further management
Risk of brain damage is increased with length of attack; therefore, treatment should aim to terminate seizure as soon as possible.
If convulsive seizures continue for 15 minutes or longer or are repeated rapidly (status epilepticus):
• transfer to A&E
• remove dentures, insert Guedel or nasopharyngeal airway
• give oxygen
• give 10-20 mg i.v. diazepam (2.5 mg/30 s) as Diazemuls but beware of respiratory depression, or diazepam solution for rectal administration in hospital.
Emergency conditions in Dental Clinics
Hypoadrenalism - Usually the patient is known to have Addison's disease or to be taking steroids long term and has forgotten to take the tablets.
Signs and symptoms
• Pallor
• Confusion
• Rapid weak pulse.
Treatment:
Give oxygen
Give 200 mg hydrocortisone sodium succinate by slow i.v. injection.
Give steroid replacement
Determining and managing underlying cause once the crisis over.
If required:
• Transfer to Emergeny hostpital
• Fluids and further hydrocortisone, both i.v.
Acute asthma - Exposure to antigen but precipitated by many factors including anxiety.
Signs and symptoms
• Persistent shortness of breath poorly relieved by bronchodilators
• Restlessness and exhaustion
• Tachycardia greater than 110 beats/min and low peak expiratory flow
• Respirations may be so shallow in severe cases that wheezing is absent.
Treatment
Excluded respiratory obstruction
Sit the patient up
Give oxygen
Salbutamol (Ventolin) via a nebuliser (2.5-5 mg of 1 mg/ml nebuliser solution) or via a large-volume spacer (two puffs of a metered dose inhaler 10-20 times: one puff every 30 seconds up to 10 puffs for a child)
Reassure and allow home if recovered.
• Bronchodilatation.
If Major Problem recommend to hospital Emergeny
• Hydrocortisone sodium succinate i.v.: adults 200 mg; child 100 mg
• Add ipratropium 0.5 mg to nebulised salbutamol
• Aminophylline slow i.v. injection of 250 mg in 10 ml over at least 20 minutes: monitor or keep finger on pulse during injection.
Caution in epilepsy: rapid injection of aminophylline may cause arrhythmias and convulsions.
Caution in patients already receiving theophylline: arrhythmias or convulsions may occur.
Anaphylactic shock
Signs and symptoms
• Paraesthesia, flushing and swelling of face, especially eyelids and lips (Fig. 13)
• generalised urticaria, especially hands and feet
• wheezing and difficulty in breathing
• rapid weak pulse.
These may develop over 15 to 30 minutes following the oral administration of a drug or rapidly over a few minutes following i.v. drug administration.
Treatment
Lay patient flat and raise feet
Give oxygen
Give 0.5 ml epinephrine (adrenaline) 1 mg/ml (1 in
1000) intramuscular
— 0.25 ml for 6-12 years
— 0.12 ml for 6 months to 6 years
repeated every 10 min until improvement.
Requires prompt energetic treatment of
• laryngeal oedema
• bronchospasm
• hypotension.
• Chlorphenamine (chlorpheniramine) 10 mg in 1 ml intramuscular or slow i.v. injection
• Hydrocortisone sodium succinate 200 mg by slow i.v. injection: valuable as action persists after that of adrenaline has worn off
• Fluids i.v. (colloids) infused rapidly if shock not responding quickly to adrenaline.
Stroke - Stroke results from either cerebral haemorrhage or cerebral ischaemia.
Signs and symptoms
• Confusion followed by signs and symptoms of focal brain damage
• Hemiplegia or quadriplegia
• Sensory loss
• Dysphasia
• Locked-in syndrome (aware, but unable to respond).
Treatment
Maintain and transfer for further investigation.
Benzodiazepine overdose - Overdose can result from a large or a fast dose of benzodiazepine or can occur in a sensitive patient.
Signs and symptoms
• Deeply sedated
• Severe respiratory depression.
Treatment
Flumazenil (Annexate) 200 mg over 15 seconds as 100 mg/ml i.v. followed by 100 mg every 1 minute up to maximum of 1 mg Maintain airway with head tilt/chin lift
Give oxygen.
Treatment
The action of the benzodiazepine is reversed with the specific antagonist.
Angina and myocardial infarction
Signs and symptoms
• Sudden onset of severe crushing pain across front of chest, which may radiate towards the shoulder and down the left arm or into the neck and jaw; pain from angina usually radiates down left arm
Skin pale and clammy
Shallow respirations
Nausea
Weak pulse and hypotension
If the pain not relieved by glyceryl trinitrate (GTN) then cause is myocardial infarction rather than angina.
First-line treatment of angina and myocardial infarction
Allow patient to rest in position that feels most comfortable:
• in presence of breathlessness this is likely to be the sitting position, whereas syncopal patients will want to lie flat
• often an intermediate position will be most appropriate.
Angina -
Angina results from reduced coronary artery lumen diameter because of atheromatous plaques
Myocardial infarction is usually the result of thrombosis in a coronary artery.
Angina is relieved by rest and nitrates:
• Glyceryl trinitrate spray 400 mg metered dose (sprayed on oral mucosa or under tongue and mouth then closed)
• Give oxygen
• Allow home if attack is mild and the patient recovers rapidly.
Myocardial infarction
If a myocardial infarction is suspected:
• give oxygen
• aspirin tablet 300 mg chewed.
• Pain control
• Vasodilatation of blood vessels to reduce load on heart.
Further management for severe angina or myocardial infarction
• Transfer to Emergency
• Diamorphine 5 mg (2.5 mg in older people) by slow i.v. injection (1 mg/min)
• Early thrombolytic therapy reduces mortality.
Cardiac arrest
• Most cardiac arrests result from arrhythmias associated with acute myocardial infarction or chronic ischaemic heart disease
• The heart arrests in one of three rhythms
— VF (ventricular fibrillation) or pulseless VT (ventricular tachycardia)
— asystole
— PEA (pulseless electrical activity) or EMD (electromechanical dissociation).
Signs and symptoms
• Unconscious
• No breathing
• Absent carotid pulse.
Treatment
• Circulation failure for 4 minutes, or less if the patient is already hypoxaemic, will lead to irreversible brain damage
• Institute early basic life support as holding procedure until early advanced life support is available.
• Transfer to Emergency
• Advanced life support.
Advanced life support for cardiac arrest
Advanced airway management techniques and specific treatment of the underlying cause of cardiac arrest constitute advanced life support (ALS).