[MUSIC] Aphthous alteration is something that's experienced by the patient as being a rather acute oral disease. It is often a disease that will recur at some point as a single ulcer or multiple ulcerations. Some of these ulcers can be small, less than a half of a centimeter, or some can be very larger, greater than a centimeter. Recurrent Aphthous stomatitis Is a very common condition seen in children and adolescents. Turns out that a child has approximately 90% chance of developing this condition, if he or she has parents who have also had the condition. It's also associated with a higher socioeconomic status. Those that have gone to professional school also have noted to have a higher prevalence. If we see patients that present to us that are 25 years old and are complaining of more ulcers rather than less ulcers that they can remember, we will evaluate the patient for various nutritional deficiency. As nutritional deficiencies have been associated with Aphthous ulceration. Conditions like low iron, low folic acid, or low B12 have been associated with an increase in Aphthous ulceration. Aphthous ulcers have been also associated with various disorders including very common disorders like anemia or Celiac disease but they've also been associated with inflammatory disorders like Behcet's disease and bowel disorders like Crohn's disease or Ulcerative colitis. Apthous stomatitis or Apthous ulcers have also been associated with those patients with immunologic problems such as those with HIV infection or those with low white blood cells. Here we see a picture of the most common type of Apthous ulceration which we will usually see in the lower gingival tissue. Here's another very common sight, the lower lip, we refer to it as lower labial mucosa, in which we see a very shallow necrotic ulcer. The next condition I'd like to talk about is Candida albicans. Candida albicans often presents as acute lesions in the mouth. It turns out Candida is a yeast that's found in the human digestive and genitourinary tracts. It is also very common in the oropharyngeal region. There are some studies that show approximately 60% of the non-immunocompromised patients will harbor Candidal species in their mouth. Candida's an opportunistic unicellular yeast-like fungus. It's often related to xerostromia or dry mouth. Patients that have diabetes, patients that have been on broad spectrum antibiotic therapy and those patients that are immunosuppressed. Candida has four clinical presentations. The pseudomembranous presentation, which is the most common, and once again referred to as thrush. The atrophic presentation, a presentation that involves the corners of the mouth and referred to as angular chielitis. As well as hyperplastic candidiasis, a rather thickened candidal infection. When we treat patients with Candidal infection we use often topical agents. Topical antifungals that are either rinsed in the mouth or dissolved in the mouth in the performable losinger. In patients, however, that have a significant dry mouth, we will consider using a systemic anti-fungal medication; a pill that's taken. Some of these anti-fungal medications when used systemically, have significant drug interactions and therefore we need to check what medications the patient is presently taking. Here's an example of a pseudomembranous candidiasis that we see in the upper palate. This is often described as a white, cheese-like material that's easily rubbed off, which leaves a raw or bleeding surface. In this case we see sometimes what's referred to as a beefy, red tongue. This is a red, erythematous tongue that is associated with a Candidal infection, a yeast infection. More commonly we'll see it underneath the denture, and in this case it's very easy to see that this hard palate, which is the support structure for this denture, is arathematives or beefy red. Here's an example of where a yeast infection affected the hard and soft palate. As I mentioned earlier sometimes immunosuppression can cause a yeast infection. In this case, the patient was using an oral inhaler that was a corticosteroid. The corticosteroid has changed the local immunologic reactions that occur in the mouth, leading to a presentation as you see on the slide. Here's an example of a yeast infection that is affecting the angles of this gentlemen's mouth. These are a yeast infection that causes erythema and thickening in the corners of his mouth. Sometimes this is associated with over closure of the mouth. In this case, this gentleman was going without dentures and, therefore, his facial structure collapsed over itself leaving a fold of tissue which made him susceptible to getting a yeast infection in that fold. And, finally, here's an example of Hyperplastic Candidasis. Unlike the pseudomembranous candidiasis, you're unable to wipe this tissue clear. You're unable to wipe this yeast away from this tissue. This is often much more difficult to treat and is often treated both with systemic and sometimes topical preparations. Another condition that is often associated with Candile infection, although perhaps not directly caused by a yeast infection, is what we see here. And this is referred to as median rhomboid glossitis, in which a rhomboid erythematous area in the dorsum of the tongue is associated with some soreness. Occasionally, it can even be slightly nodular. The reason I include this is often the first method of treating this is with an antifungal preparation. The last condition I'd like to talk about is Lichen Planus. Lichen Planus is the most common oral mucosal condition that we see. It effects approximately 2% of the population. And when it does, it's often associated with multiple lesions, often occurring not only in the mouth but also on the skin. These lesions often will occur in patients that are between the ages of 30 and 60 years old. There is a female predilection for this disorder. And this disorder of Lichen Planus can also have various clinical presentations. Importantly, Lichen Planus appears to have a malignant transformation potential. It is the reason that our patients that have Lichen Planus, we will often request that they monitor for this condition lifelong. Here are some various presentations of Lichen Planus. This is the most common presentation in which we see white, lacy lines, sometimes referred to as Wickham's striae, in the patient's right buccal mucosa. Here is the same type of presentation in the roof of the mouth, or the hard pallet. Occasionally, the Lichen Planus can also have a significant arathemitus component, with a very mild white component. So, a significant red component, in absence of those white lacy lines. In this case it's associated with desquamative, or peeling gingivitis. Here we're looking at the roof of the mouth with a very, very similar presentation. And in this case, ulceration formation. You'll notice at the border of the ulcer, we do see some white lacy lines extending from the ulceral vereal. Here's a rather severe form of Lichen Planus that's referred to as erosive Lichen Planus. This Lichen Planus is on the lateral border of the tongue, but with more careful inspection, you can see white, lacy lines also on the dorsum or the top of the tongue.
