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1 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Chapter 3 Immunity.

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1 1 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Chapter 3 Immunity

2 2 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.  Outline  The Acquired Immune Response  Antigens  Cellular Involvement in the Immune Response  Major Divisions of the Immune Response  Memory and Immunity  Types of Immunity  Immunopathology  Oral Diseases with Immunologic Pathogenesis  Autoimmune Diseases that Affect the Oral Cavity

3 3 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. The Acquired Immune Response  (pg. 82)  Defends the body against injury  Has the capacity to remember and respond more quickly the second time a foreign material enters the body  Works with the inflammatory response and a working repair process  Involves white blood cells, especially lymphocytes and their products

4 4 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Antigens  (pg. 82)  Foreign substances  Mainly proteins, often microorganisms and their toxins  Human cells that have been transformed  May be tumor cells, or cells infected with viruses

5 5 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Antigens (cont.)  Human tissue  Organ transplants, tissue grafts, incompatible blood types during a transfusion  Autoimmune diseases  Tissue from the person’s own body becomes an antigen

6 6 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Cellular Involvement in the Immune Response  B lymphocytes  T lymphocytes  Macrophages  Cytokines

7 7 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Cellular Involvement in the Immune Response (cont.)  (pg. 83)  Cells that are able to recognize and respond to antigen  Derived from precursor cells in bone marrow (stem cells)  20% to 25% of the WBC (white blood cell) population  Two main types  B lymphocytes (B cells)  T lymphocytes (T cells)  Also there are natural killer cells (NK cells)  Can destroy cells recognized as foreign without recognizing specific antigens

8 8 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Cellular Involvement in the Immune Response (cont.)

9 9 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. B Lymphocytes  (pgs )  Mature and reside in lymphoid tissue  Lymph nodes, tonsils, and other body tissue  B lymphocytes travel to the site of injury when stimulated by antigen  Two main types Plasma cells Plasma cells  Produce specific antibodies B memory cell B memory cell  Retains the memory of previously encountered antigen and will clone itself in the presence of antigen

10 10 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. B Lymphocytes (cont.)

11 11 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Plasma Cells  Produce antibodies that are categorized into 5 classes of immunoglobulins, which are carried in blood serum  All have the same basic “Y” structure, but have an area with variable (V) structure at the tips of the Y  The stem of the Y is constant (C) for all 5 types, and links the antibody to other components of the immune response  Immune complex  Antigen combined with antibody

12 12 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. T Lymphocytes  (pgs. 83, 85)  Travel to the thymus and mature  The thymus is large in an infant, shrinks as the child matures  Several different types of T lymphocytes  Memory cells  T-helper cells Increase functioning of B lymphocytes Increase functioning of B lymphocytes  T-suppressor cells Turn off functioning of B lymphocytes Turn off functioning of B lymphocytes  T-cytotoxic cells Attack virally infected cells or tumor cells Attack virally infected cells or tumor cells

13 13 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. T Lymphocytes (cont.)

14 14 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Macrophages  (pg. 84)  Active in phagocytosis of foreign material  Produce cytokines called monokines  Help both B and T lymphocytes  After phagocytosis, they process and present antigen to lymphocytes  This stimulates lymphocytes to travel from lymphoid tissue to the injury site  Amplify the immune response but do not remember the antigen like lymphocytes

15 15 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Cytokines (Cont.)

16 16 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Cytokines (Cont.)  (pgs ) (Table 3-2)  Proteins made by cells that are able to affect the behavior of other cells  Different cytokines have different functions.

17 17 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Major Divisions of the Immune Response  (pgs )  Humoral response  B lymphocytes are the primary cells.  Involves production of antibodies  Cell-mediated response  T lymphocytes are the primary cells. Lymphocytes may work alone or be assisted by macrophages. Lymphocytes may work alone or be assisted by macrophages.  The cell-mediated portion regulates both major responses.

18 18 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Major Divisions of the Immune Response (cont.)

19 19 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Memory and Immunity  (pg. 86)  The immune system has memory; the inflammatory system does not.  Some lymphocytes retain memory of an antigen after an initial encounter.  This means the immune response will be faster and stronger the next time an antigen enters the body.  The retained memory is called immunity.

20 20 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Types of Immunity  Passive Immunity  Active Immunity

21 21 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Passive Immunity  (pg. 86)  Using antibodies created by another person to prevent infectious disease  Natural When antibodies from the mother pass through the placenta to the developing fetus When antibodies from the mother pass through the placenta to the developing fetus  Acquired When antibodies are acquired through an injection When antibodies are acquired through an injection Short lived but fast acting Short lived but fast acting

22 22 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Active Immunity  (pg. 86)  Antibodies created by the person themselves  Natural Protection conferred following survival from an infectious disease Protection conferred following survival from an infectious disease  Acquired Injection or ingestion of either altered pathogenic microorganisms or products of those microorganisms – immunization with a vaccine Injection or ingestion of either altered pathogenic microorganisms or products of those microorganisms – immunization with a vaccine

23 23 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Immunopathology  (pg. 86)  The study of immune reactions involved in disease  The immune system can malfunction and cause tissue damage. Hypersensitivity Hypersensitivity Autoimmune diseases Autoimmune diseases

24 24 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hypersensitivity (Cont.)  (pgs ) (Table 3-3)  An allergic reaction  An exaggerated response  Tissue destruction occurs as a result of the immune response.  Four main types

25 25 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hypersensitivity (Cont.)

26 26 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Type I Hypersensitivity  (pg. 87)  Immediate (anaphylactic type)  The reaction occurs within minutes after exposure to an antigen.  Plasma cells produce IgE. IgE causes mast cells to release histamine, causing increased dilation and permeability of blood vessels and constricting smooth muscle in bronchioles of the lungs. IgE causes mast cells to release histamine, causing increased dilation and permeability of blood vessels and constricting smooth muscle in bronchioles of the lungs.  The reaction may range from hay fever to asthma and life-threatening anaphylaxis.

27 27 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Type II Hypersensitivity  (pg. 87)  Cytotoxic type  Antibody combines with an antigen bound to the surface of tissue cells, usually a circulating RBC (red blood cell).  Activated complement components, IgG and IgM antibodies in blood, participate in this type of hypersensitivity reaction.  This destroys the tissue that has the antigens on the surface of its cells (e.g., Rh incompatibility).

28 28 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Type III Hypersensitivity  (pg. 87)  Immune complex type (serum sickness)  Immune complexes are formed between microorganisms and antibody in circulating blood. These complexes leave the blood and are deposited in body tissues, where they cause an acute inflammatory response. These complexes leave the blood and are deposited in body tissues, where they cause an acute inflammatory response.  Tissue destruction occurs following phagocytosis by neutrophils.

29 29 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Type IV Hypersensitivity  (pg. 87)  Cell-mediated type (delayed)  T lymphocytes that previously have been introduced to an antigen cause damage to tissue cells or recruit other cells.  Responsible for the rejection of tissue grafts and transplanted organs

30 30 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hypersensitivity to Drugs  (pgs )  Drugs can act as antigens.  Topical administration may cause a greater number of reactions than oral or parenteral routes.  But the parenteral route may cause a more widespread and severe reaction.

31 31 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Autoimmune Diseases  (pg. 88)  Immunologic tolerance  The body learns to determine self from nonself.  Autoimmune disorder  The recognition mechanism breaks down; some body cells are not tolerated and are treated as foreign antigens.

32 32 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Immunodeficiency  (pg. 88)  An immunopathologic condition  A deficiency in number, function, or interrelationships of the involved WBC’s and their products  May be congenital or acquired  Infections and tumors may occur as a result of the deficiency.

33 33 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Diseases with Immunologic Pathogenesis  Aphthous ulcers  Urticaria and angioedema  Contact mucositis and dermatitis  Fixed drug eruptions  Erythema multiforme  Lichen planus  Reactive arthritis (Reiter syndrome)  Langerhans cell disease

34 34 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Aphthous Ulcers  (pgs )  Painful oral ulcers with an unclear cause  Occur in about 20% of the population  Trauma is the most common precipitating factor. May be caused by emotional stress or certain food May be caused by emotional stress or certain food  May be associated with certain systemic diseases  Thought to have an immunologic pathogenesis  Occur in three forms: minor, major, and herpetiform

35 35 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Minor Aphthous Ulcers  (pg. 89)  Discrete, round or oval ulcers  Occur on movable mucosa Up to 1 cm in diameter with a erythematous halo surrounding a yellowish-white fibrin surface Up to 1 cm in diameter with a erythematous halo surrounding a yellowish-white fibrin surface  May have single or multiple lesions  May have a prodrome of 1 to 2 days

36 36 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Minor Aphthous Ulcers (cont.)

37 37 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Major Aphthous Ulcers  (pgs )  Larger (>1 cm), deeper, and longer lasting than minor aphthous ulcers  Very painful  Occur in the posterior of the mouth more often than minor aphthous ulcers  May require several weeks to heal  May require a biopsy

38 38 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Major Aphthous Ulcers (cont.)

39 39 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Herpetiform Aphthous Ulcers  (pgs )  Tiny (1 to 2 mm)  Resemble herpes simplex ulcers  Painful, generally occur in groups

40 40 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis of Minor Aphthous Ulcers (Cont.)

41 41 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis of Minor Aphthous Ulcers (Cont.)  (pgs ) (Table 3-4)  Clinical appearance  Location  Herpetic lesions appear on mucosa fixed to bone, aphthous lesions appear on movable tissue  Clinical history  Aphthous ulcers do not produce systemic signs or symptoms as do herpetic lesions

42 42 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Treatment of Minor Aphthous Ulcers  (pg. 91)  Treatment  There are several OTC medications such as Orabase and Zilactin.  Topical or systemic steroids may help.  Topical anesthetic may help.

43 43 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Urticaria (Hives)  (pg. 91)  Appears as multiple areas of well- demarcated swelling of skin  May have itching (pruritis)  Lesions caused by localized areas of vascular permeability in superficial connective tissue

44 44 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Angioedema  (pg. 91)  Lesions caused by diffuse swelling due to increased permeability of deeper blood vessels  The skin covering the swelling appears normal  Usually do not have itching

45 45 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Urticaria and Angioedema  (pgs )  Often idiopathic cause  May be due to infection, trauma, emotional stress, and certain systemic diseases  May be due to ingested allergens

46 46 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Contact Mucositis and Dermatitis  (pg. 92)  Lesions resulting from contact of an allergen with skin or mucosa  Involves CMI (cell-mediated immunity)  The mucosa initially becomes erythematous and edematous. Often there is burning and pruritus Often there is burning and pruritus  Later, the area becomes white and scaly.  Treatment  Topical and/or systemic corticosteroids

47 47 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Contact Mucositis and Dermatitis (cont.)

48 48 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Fixed Drug Eruptions  (pgs )  Lesions that appear in the same site each time a drug is introduced  Generally appear suddenly after a latent period and subside when the drug is discontinued  May be single or multiple slightly raised, reddish patches or clusters of macules on the skin, or sometimes the mucous membranes  May have pain or pruritis

49 49 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Fixed Drug Eruptions (cont.)  A type of allergic reaction (Type III)  Immune complexes are deposited along the endothelial walls of blood vessels.  Inflammation causes vasculitis with damage to the vessel wall.  This creates erythema and edema in superficial layers of skin or mucosa.  Treatment  The drug causing the reaction should be identified and discontinued.

50 50 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Erythema Multiforme  (pgs )  Cause is not clear; may be a hypersensitivity reaction  Most commonly occurs in young adults, affects men more commonly than women  Target lesion  Characteristic skin lesion with concentric erythematous rings alternating with normal skin color

51 51 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Erythema Multiforme (cont.)

52 52 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Erythema Multiforme (cont.)  (pgs )  Skin lesions can range from macules to papules to bullae.  Oral lesions are usually ulcers  Frequently form on lateral borders of the tongue  Crusted and bleeding lips are frequently seen.  Gingival involvement is rare.  May be chronic or may have recurrent acute episodes

53 53 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Erythema Multiforme (cont.)

54 54 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Erythema Multiforme (cont.)  (pgs )  Stevens-Johnson syndrome  The most severe form More extensive and painful oral lesions More extensive and painful oral lesions Genital mucosa and mucosa of eyes may be involved. Genital mucosa and mucosa of eyes may be involved. Lips generally are encrusted and bloody. Lips generally are encrusted and bloody.

55 55 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Erythema Multiforme (cont.)  (pg. 93)  Diagnosis  Based on clinical features and by exclusion of other diseases  Treatment and prognosis  Topical or systemic corticosteroids  Eye lesions may lead to blindness.

56 56 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Lichen Planus  (pgs )  A benign, chronic disease affecting skin and oral mucosa  Unknown cause  Lesions have characteristic Wickham striae  Most commonly on buccal mucosa  Lesions may be on the tongue, lips, floor of mouth, and gingiva.  Present in about 1% of the U.S. population  Most common in middle age  Slightly more common in women

57 57 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Lichen Planus (cont.)

58 58 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Types of Lichen Planus  (pgs )  Reticular lichen planus  Most common form  Erosive and bullous lichen planus  Epithelium separates from connective tissue  Desquamative gingivitis can be caused by lichen planus.  Skin lesions  2 to 4 mm papules most commonly in lumber region, flexor surfaces of the wrist, anterior ankle

59 59 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Types of Lichen Planus (cont.)

60 60 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis of Lichen Planus  (pgs )  Based on clinical appearance and possibly biopsy  Epithelial atypia and dysplasia may occur in lesions that clinically appear to be lichen planus.  These lesions may be premalignant.

61 61 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Treatment and Prognosis of Lichen Planus  (pg. 96)  A chronic disease  Treated when symptomatic  Regular oral examination and biopsy of suspicious lesions are necessary as these patients may be at increased risk of development of squamous cell carcinoma.

62 62 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Reactive Arthritis (Reiter Syndrome)  (pgs )  Classic syndrome includes arthritis, urethritis, and conjunctivitis, but all components may not be present.  An antigenic marker called HLA-B27 is present in most patients, meaning there may be a genetic influence.  Probably an abnormal immune response to a microbial antigen  Skin and mucous membrane lesions may be observed.  May see aphthous ulcers, erythematous lesions, and geographic tonguelike lesions

63 63 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Reactive Arthritis (Reiter Syndrome) (cont.)

64 64 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Reactive Arthritis  Diagnosis  Clinical signs and symptoms  HLA-B27 antigenic marker  Treatment and prognosis  Disease lasts for weeks to months.  Recurrent attacks are common.

65 65 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Langerhans Cell Disease (Histiocytosis X)  (pgs )  Includes three entities  Letterer-Siwe disease  Hand-Schuller-Christian disease  Solitary eosinophilic granuloma  All have Langerhans cells and eosinophils.

66 66 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Langerhans Cell Disease (Histiocytosis X) (cont.)

67 67 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Langerhans Cell Disease  A type of macrophage  An immunocompetent cell of the mononuclear phagocyte series and participates in CMI  Treatment  Eosinophilic granuloma is treated by conservative surgical excision.  Low-dose radiation may be used

68 68 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Autoimmune Diseases that Affect the Oral Cavity  Sjögren Syndrome  Systemic Lupus Erythematosus  Pemphigus Vulgaris  Mucous Membrane Pemphigoid  Bullous Pemphigoid  Behçet Syndrome

69 69 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Autoimmune Diseases that Affect the Oral Cavity (cont.)  (pgs ) (Table 3-5)  Several autoimmune diseases affect the oral cavity.  The immune system treats the person’s own cells and tissues as antigens.

70 70 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Autoimmune Diseases that Affect the Oral Cavity (cont.)

71 71 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Sjögren Syndrome  (pgs )  Affects the salivary and lacrimal glands  Results in a decrease in saliva and tears causing a dry mouth (xerostomia) and dry eyes (xerophthalmia)  The combination may be called sicca syndrome.

72 72 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Sjögren Syndrome (cont.)  (pg. 99)  May be associated with other autoimmune disorders  Primary Sjögren syndrome – when it occurs alone  Secondary Sjögren syndrome - when it occurs with other autoimmune disorders  Patient may complain of oral discomfort due to dry mouth.  May see loss of filiform and fungiform papillae on the dorsum of the tongue

73 73 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Sjögren Syndrome (cont.)  (pg. 99)  Affects both major and minor salivary glands  Parotid gland enlargement occurs in about 50% of patients.  Biopsy reveals a characteristic appearance.  Major salivary glands Replacement with lymphocytes and the presence of islands of epithelium called epimyoepithelial islands Replacement with lymphocytes and the presence of islands of epithelium called epimyoepithelial islands  Minor salivary glands Aggregates of lymphocytes surrounding the salivary gland ducts Aggregates of lymphocytes surrounding the salivary gland ducts

74 74 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Sjögren Syndrome (cont.)

75 75 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Sjögren Syndrome (cont.)  Patient may complain of burning and itching of eyes and photophobia.  Severe eye involvement may lead to ulceration and opacification of the eyes.  Raynaud phenomenon  20% of these patients will have this disorder affecting fingers and toes Initial pallor and subsequent cyanosis of skin due to cold or stress Initial pallor and subsequent cyanosis of skin due to cold or stress Hyperemia when blood vessels are warmed Hyperemia when blood vessels are warmed

76 76 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Sjögren Syndrome (cont.)  90% of these patients have a positive response to rheumatoid factor, an antibody to IgG present in serum  It is an antibody to an antibody.  Other autoantibodies, anti-Sjögren syndrome A, and anti-Sjögren syndrome B are also present.

77 77 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Management of Sjögren Syndrome  (pg. 100)  Diagnosis is made when two of three components are present.  Xerostomia Measurement of salivary flow and biopsy can help Measurement of salivary flow and biopsy can help  Keratoconjunctivitis sicca Confirmed with eye examination Confirmed with eye examination  Rheumatoid arthritis  For most patients, the course of the disease is chronic and benign but these patients are at risk for the development of other more serious diseases.

78 78 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Management of Sjögren Syndrome (cont.)

79 79 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Treatment of Sjögren Syndrome  (pg. 100)  Symptomatic  Nonsteroidal antiinflammatory agents for arthritis May need corticosteroids and immunosuppressive drugs for severe cases May need corticosteroids and immunosuppressive drugs for severe cases  Saliva substitutes for xerostomia Humidifier, sugarless gum, or lozenges Humidifier, sugarless gum, or lozenges Pilocarpine Pilocarpine  Glasses and/or artificial tears to protect eyes

80 80 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Systemic Lupus Erythematosus (SLE)  (pgs )  An acute and chronic inflammatory autoimmune disease  No known cause  Affects women 8 times more frequently than men, predominantly during childbearing years  Three times more frequent in black women than in white women

81 81 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Systemic Lupus Erythematosus (SLE) (cont.)  A syndrome with a wide range of disease activity  Usually chronic and progressive Periods of remission and exacerbation Periods of remission and exacerbation  Autoantibodies to DNA are present in serum  May have a genetic component

82 82 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features of Systemic Lupus Erythematosus (SLE)  (pgs )  Skin lesions occur in 85% of individuals  “Butterfly” rash on bridge of nose  May be erythematous lesions on fingertips  Arthritis and arthralgia are common.  Oral lesions accompany skin lesions in about 25% of patients with discoid LE.  Erythematous plaques or erosions May have white striae; resemble lichen planus but are less symmetric May have white striae; resemble lichen planus but are less symmetric

83 83 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features of Systemic Lupus Erythematosus (SLE) (cont.)

84 84 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis of Systemic Lupus Erythematosus (SLE)  (pgs )  Usually based on multiorgan involvement and presence of antinuclear antibodies in serum  Inflammatory infiltrate is around blood vessels in connective tissue.

85 85 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Treatment and Prognosis of Systemic Lupus Erythematosus (SLE)  Aspirin and antiinflammatory drugs for mild signs and symptoms  Hydroxychloroquine and corticosteroids along with immunosuppressive agents may be used.  The text recommends consultation with the patient’s physician before initiating dental treatment.

86 86 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Pemphigus Vulgaris  (pgs )  A severe, progressive autoimmune disease affecting skin and mucous membranes  Characterized by intraepithelial blister formation resulting from acantholysis, a breakdown of cellular adhesion between epithelial cells  Genetic and ethnic factors have been reported.  Often seen in Ashkenazic Jews

87 87 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Pemphigus Vulgaris (cont.)  (pg. 103)  Oral lesions  The first signs of disease occur in the oral cavity in more than 50% of cases. May be shallow ulcers, to fragile vesicles, to bullae May be shallow ulcers, to fragile vesicles, to bullae  Nikolsky sign Rubbing with a finger can produce a bullae. Rubbing with a finger can produce a bullae.

88 88 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Pemphigus Vulgaris (cont.)

89 89 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Pemphigus Vulgaris (cont.)  (pgs )  Skin lesions  Erythema, bullae, erosions, ulcers  Microscopic appearance  Acantholytic cells The loss of attachment between epithelial cells leads to cells that appear rounded. The loss of attachment between epithelial cells leads to cells that appear rounded.  Tzanck cells

90 90 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis of Pemphigus Vulgaris  Made by biopsy and microscopic examination  Direct immunofluorescence Identifies autoantibodies present in tissue Identifies autoantibodies present in tissue  Indirect immunofluorecence The patient’s serum is used to detect circulating autoantibodies. The patient’s serum is used to detect circulating autoantibodies.

91 91 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Treatment and Prognosis of Pemphigus Vulgaris  High doses of corticosteroids  May include immunosuppressive drugs  Mortality rate of 8% to 10% in 5 years is related to complications of corticosteroid treatment.

92 92 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Mucous Membrane Pemphigoid (Cicatricial Pemphigoid) (BMMP)  (pgs )  A chronic autoimmune disease  Affects oral mucosa, conjunctiva, genital mucosa, and skin  Not as severe as pemphigus vulgaris  Gingival lesions have been called desquamative gingivitis, but this may be seen with lichen planus and pemphigus as well.  Will see positive Nikolsky sign

93 93 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Mucous Membrane Pemphigoid (Cicatricial Pemphigoid) (BMMP) (cont.)

94 94 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis of Mucous Membrane Pemphigoid  (pg. 104)  Made by biopsy and histologic examination  No degeneration of epithelium occurs  An inflammatory infiltrate, usually with predominant plasma cells and eosinophils, is seen in connective tissue.

95 95 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Treatment and Prognosis of Mucous Membrane Pemphigoid  A chronic disease with a benign course  Topical corticosteroid for mild cases  Systemic corticosteroids may be required for more severe cases.  Eye lesions can lead to eye damage.

96 96 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Bullous Pemphigoid  (pg. 105)  Some investigators believe bullous and mucous membrane pemphigoid are variants of a single disease, but 80% of these patients are older than 60.  Oral lesions are less common than in cicatricial pemphigoid.  Treatment  Systemic corticosteroids and nonsteroidal antiinflammatory drugs

97 97 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Behçet Syndrome  (pg. 105)  A chronic, recurrent autoimmune disease  Primarily oral ulcers, genital ulcers, ocular inflammation  No sex predilection; mean onset is 30 years  Autoantibodies to human mucosa may be found.  Oral ulcers are similar in appearance to aphthous ulcers.

98 98 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Behçet Syndrome (cont.)

99 99 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis of Behçet Syndrome Diagnosis of Behçet Syndrome  Requires that two of three types of lesions (oral, genital, and ocular) be present.  A pustular lesion after needle puncture suggests Behçet syndrome.

100 100 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Treatment and Prognosis of Behçet Syndrome  (pg. 105)  Systemic and topical corticosteroids  Chlorambucil is used for ocular lesions.

101 101 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Discussion Questions  What is an autoimmune disorder?  What is the difference between an antigen and an antibody?  What are the differences between active and passive immunity?  What oral diseases have an immunologic pathogenesis?  What is an autoimmune disorder?  What are the oral symptoms of Sjögren syndrome?  What are differences between pemphigus and pemphigoid?


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