口 腔 診 斷 及 口 腔 病 理 學 導 論口 腔 診 斷 及 口 腔 病 理 學 導 論 頭頸部 口 腔 診 斷

Real-time polymerase chain reaction (RT-PCR)- 聚合酶連鎖反應

口 腔 診 斷 A 40 y/o female suffered from 37 toothache for 3 months No other abnormal mucosal lesion was noted Diagnosed her symptoms to be periodontitis Prosthetic crown of tooth 37 was removed to perform endodontic tx Dentist A

口 腔 診 斷 Severe pain of tooth 37 persisted Severe pain of tooth 37 persisted Dentist B The post extraction The post extraction wound remained unhealed wound remained unhealed Refered her to visit KMU Refered her to visit KMU dental dept for further tx dental dept for further tx Tooth 37 was extracted Tooth 37 was extracted

口 腔 病理 Biopsy— 活體切片檢查 病 理 診 斷病 理 診 斷

口 腔 病理 Extraction Extraction of tooth 37 of tooth 37 Dentist C 切片檢查 病 理 診 斷病 理 診 斷 口腔癌

口 腔 診 斷 及 口 腔 病 理 學 導 論口 腔 診 斷 及 口 腔 病 理 學 導 論 口 腔 病理 病 理 診 斷病 理 診 斷 口 腔 診 斷 臨 床 診 斷臨 床 診 斷 一 體 的 兩 面一 體 的 兩 面

Subtopics Relationships between chronic oral infectious diseases & systemic diseases Systemic diseases manifested in oral cavity Systemic Diseases & Oral Cavity Oral cavity Systemic diseases bacteria

Systemic Diseases & Oral Cavity 1. Oral bacteria causing bacterial endocarditis Bacterial endocarditis bacteremia Blood smear of sepsis

Systemic Diseases & Oral Cavity 2. Relationships of periodontobacteria and cardiovascular diseases (CVD) 牙 周 感 染 與 心 臟 血 管 疾 病 的 關 係 牙 周 感 染 與 心 臟 血 管 疾 病 的 關 係

Systemic Diseases & Oral Cavity 3. Pathogens for bacterial pneumonia in oral cavity (Epidemiological view) LCL: lower confidence limit UCL: upper confidence limit OHI: Oral Hygiene Index PercentileOHI value Estimate of odd ratio LCL UCL

Systemic Diseases & Oral Cavity Silent aspiration Colonization 3. Pathogens for bacterial pneumonia in oral cavity (Pathway)

Systemic Diseases & Oral Cavity 3. Pathogens for bacterial pneumonia in oral cavity (Cytokine) Trachea Bronchus IL: interleukin TNF: tissue necrosis factor Cytokine ( 細胞素 )

Systemic Diseases & Oral Cavity Nephritis Arthritis 4. Oral chronic infectious diseases cause secondary diseases

Systemic Diseases & Oral Cavity Metastatic infection from oral cavity Endocarditis Brain abscess Sinusitis Ludwig’s angina Orbital cellulitis Osteomyelitis Skin ulcer Pustulosis palmaris et plantaris 4. Oral chronic infectious diseases cause secondary diseases

Systemic Diseases & Oral Cavity Metabolic injury by oral bacterial toxin Coronary heart disease Abnormal pregnancy outcome Persistent pyrexia Idiopathic trigeminal neuralgia Atypical facial pain Acute myocardial infarction 4. Oral chronic infectious diseases cause secondary diseases

Systemic Diseases & Oral Cavity 4. Oral chronic infectious diseases cause secondary diseases Metastatic inflamma- tion by oral bacteria Bechet’s disease Crohn’s disease Inflammatory bowel disease Uveitis

Systemic Diseases & Oral Cavity 4. Oral chronic infectious diseases cause secondary diseases - Bechet’s disease Criteria: recurrent oral ulceration + ≥ 2 others findings Criteria for diagnosis for Bechet’s disease FindingsDefinitions Recurrent oral ulceration Eye lesions Skin lesions Positive pathergy test Recurrent genital ulceration

Systemic Diseases & Oral Cavity 4. Oral chronic infectious diseases cause secondary diseases *Pricking a sterile needle into forearm or lower lip *Positive when the puncture causes an aseptic erythematous nodule or pulstule (>2mm) at hrs *At reaction site, there is initially an accumulation of neutrophils, followed by mononuclear cells Skin testOral test Forearm Lower lip

Systemic Diseases & Oral Cavity 4. Oral chronic infectious diseases cause secondary diseases Definition of different grades of skin pathergy test Grade of test Clinical characteristic of the test at 48 h Negative (-) Suspect (+/-) Positive (+) Only erythema <2 mm Only erythema > 3 mm or papule 1-2 mm + erythema < 2 mm 1+ Papule 2-3 mm + erythema > 3 mm 2+ Papule > 3 mm + erythema > 3 mm 3+ Pustule 1-2 mm + erythema > 3 mm 4+ Pustule > 2 mm + erythema > 3 mm Erythema/Papule/Pustule--Diameter

Systemic Diseases & Oral Cavity HypopyonErythema nodosum A horizontal layer of inflammatory cells 4. Oral chronic infectious diseases cause secondary diseases Oral ulcerGenital ulcer

Systemic Diseases & Oral Cavity 4. Oral chronic infectious diseases cause secondary diseases – Crohn’s disease Labial swelling & fissuring Mucosal tag Ulceration Cobblesing stone mucosa

Systemic Diseases & Oral Cavity Dermatitis 5. Heat shock proteins producing by oral bacteria may induce dermal diseases

Systemic Diseases & Oral Cavity Prevotella intermedia Porphyromonas gingivalis Toxin: lipopolysaccharide Estrogen 6. Gingivitis pathogens cause pregnancy disorders

Systemic Diseases & Oral Cavity 6. Gingivitis pathogens cause pregnancy disorders

Systemic Diseases & Oral Cavity 牙周 病糖 尿 病糖 尿 病 7. Periodontitis and diabetic mellitus

Systemic Diseases & Oral Cavity Periodontal infection & systemic conditions - potential linkage & possible pathogenic mechanisms Periodontal infection Cardiovascular diseases Diabetes mellitus Adverse pregnancy outcomes Pulmonary infections

Systemic diseases manifested in oral cavity

Virus ( 病毒 ) Uncoating Replication Release Attachment HIV gp 120 gp 41 CCR5 Life cycle Attachment Penetration translocate endocytosis fusion

Host cell CCR5 gp 120 CD4 gp 120 Attachment H I V gp 41 H I V gp 41 Gp120 能與 CD4 受體結合， 但無法直接引導 HIV 進入 host cell CCR5 將 gp120 拉開後， gp41 引導 HIV 進入 host cell

Host cell Life - Cycle Possible ways of HIV therapy Drugs block binding (attachment & fusion) Drugs inhibit reverse transcriptase Drugs under study would inhibit integrase Some existing drugs inhibit protease CCR5 脂質套膜 套膜蛋白 gp 41 Attachment Nucleus Integration 蛋白質外殼 Budding CD4 H I V HIV RNA Cytoplasm H I V gp 41 Attachment Reverse- transcription Uncoating Reverse- transcriptase Integrase HIV mRNA Protease Infected other host cells Cytoplasm Caspid Fusion Other Host cell gp 120 Reverse transcriptase Integrase Protease

受體 CD4 CCR5 Macrophage T-cell CCR5 Early stage Late stage

Virus ( 病毒 ) CD4 T-cell count Viral load Acute phase Chronic phase AIDS

Oral Manifestations of AIDS Candidiasis (thrush) Candidiasis (atrophic) Kaposi sarcoma Necrotizing gingivitis

Hairy leukoplakia H&E EBV Oral Manifestations of AIDS

Twenty-year incidence of KS at the University of California San Francisco Oral KS cases/year N = 203 Oral Kaposi’s sarcoma: Biopsy accessions as an indication of declining incidence No. of cases Due to highly active antiretroviral therapy in 1995 Oral Manifestations of AIDS

Hairy leukoplakia Oral candidiasis Our Collected Case

Oral Manifestations of AIDS Our Collected Case – Burkitt’s lymphoma