fremitus occurs in either of the alveolar bones when an individual sustains
trauma from occlusion. It is a result of teeth exhibiting at least slight
mobility rubbing against the adjacent walls of their sockets, the volume of
which has been expanded ever so slightly by inflammatory responses, bone
resorption or both. As a test to determine the severity of periodontal disease,
a patient is told to close his or her mouth into maximum intercuspation and is
asked to grind his or her teeth ever so slightly. Fingers placed in the labial
vestibule against the alveolar bone can detect fremitus.
CREST is a
form of Systemic Sclerosis (scleroderma) which is characterized by Calcinosis
(calcium deposits), usually in the fingers; Raynaud's;loss of muscle control of
the Esophagus, which can cause difficulty swallowing; Sclerodactyly, a tapering
deformity of the bones of the fingers; and Telangiectasia, small red spots on
the skin of the fingers, face, or inside of the mouth. (Also see: What is
Scleroderma?, Types of Scleroderma and Systemic Symptoms)
only two of the five CREST symptoms for a diagnosis of CREST (either "pure" or
"plus") to be made. For example, a patient with Calcinosis and
Raynaud's would have CREST (which for precision may also be written as CRest,
but it is CREST nonetheless.)
forms of scleroderma can cause small white calcium lumps to form under the skin
on fingers or other areas of the body.
called calcinosis. The lumps may break through the
skin and leak a chalky white liquid.
commonly occur on the hands, or near joints such as elbows or knees, although
they may appear anywhere.
a vascular disorder commonly found in sclerodema. It is an extreme spasm of
blood vessels in response to cold or stress. The fingers and/or toes become
white and/or blue, and may become red on re-warming.
skin on the fingers become tight, stretched, wax-like, and hardened it is
called sclerodactyly. Sclerodactyly is commonly associated with atrophy of the
underlying soft tissues.
Telangiectasia are dilated superficial blood vessels
Most fungal infections in the oral cavity are due to Candida species,
most commonly Candida albicans.
Where candidosis is related to dentures, denture hygiene instruction should be stressed. Non-metal dentures should be soaked regularly overnight in sodium hypochlorite 1% (Milton’s solution) and metal-containing dentures similarly in chlorhexidine 0.2% solution.
Nystatin and amphotericin (polyenes)
These agents attach to the fungal cell membrane and disrupt fluid and electrolyte permeability. They are not absorbed from the GI tract and hence act locally .
Dosage regimens for nystatin and amphotericin
Pastilles 100 000 units
Oral suspension 100 000 units/ml
Ointment/cream 100 000 units/g
Oral suspension 100 mg/ml
Miconazole (an imidazole)
Similar action to the polyenes. Effective against some Gram-positive
bacteria such as Staph. aureus. More effective than polyenes in angular cheilitis due to possible mixed fungal/bacterial infection.
Available as oral gel, cream and in combination with hydrocortisone.
Oral gel (25 mg/ml) 5–10 ml held over area affected (after food) or applied to fitting surface of upper denture for the treatment of denture stomatitis (chronic erythematous candidosis).
Cream (2%) Apply to angles of lips 2–3 times daily. Cream or ointment (2%) with hydrocortisone (1%) Apply to angles of lips 2–3 times daily. May be useful for clearing long-standing angular cheilitis but should not be used for longer than 10 days.
Fluconazole (a triazole)
This systemically acting agent inhibits fungal enzymes concerned
with ergosterol synthesis. It appears to have low systemic toxicity.
Form Capsules (50 mg) and oral suspension (50 mg/5 ml). Dose 50 mg daily for 7–14 days. Higher doses will be required in immune compromised patients.
Cautions Avoid in renal disease, pregnancy and lactation, children.
Side effects Nausea, diarrhea and allergic manifestations are the most serious effects.
Main interactions are with antihistamines, oral hypoglycaemic agents and warfarin.
Itraconazole is another potent triazole antifungal agent.
Angular cheilitis is a combined staphylococcal, streptococcal, and candidal infection, involving the tissues at the angle of the mouth, often with an underlying precipitating factor, e.g. iron deficiency and B12 deficiency anaemia. Therefore, haematological deficiency should be investigated with a FBC red cell folate, B12, and glucose.
Anecdote suggests aninadequate OVD can also predispose, but correction of this alone will not resolve the condition. Often associated with chronic atrophic candidosis. Clinically, see red, cracked, macerated skin at angles of the mouth, often with a gold crust.
Infecting organisms can be identified on culture ofswabs of the area, although it is usual to make a clinical diagnosis.
Rx:miconazole cream, which is active against all three infecting organisms. Rx needs to be prolonged, up to 10 days after resolution of clinical lesion, and carried out in conjunction with elimination of any underlying factors.
Unless the classic golden yellow crusts associated with S. aureus are present, treatment should be commenced withantifungal drugs, e.g. a combined miconazole/hydrocortisone cream (miconazole has some antibacterial properties).
When clinical features indicateS. aureus infection, fusidic acid cream is appropriate. If intra-oral candidiasis is present, this must be treated concurrently or recurrence of the angular stomatitis will occur. Iron deficiency is a significant aetiological factor in angular cheilitis.