Kelainan rongga mulut dan Esofagus

1

Learning Object K-8 Kelainan rongga mulut (Disorders of the

mouth) Herpes stomatitis. Oral thrush, Acute necrotizing ulcerative gingivitis. Kelainan pada Oesophagus : Odinofagia. Disfagia K-9 : Kelainan pada Oesophagus : Gangguan pasase oesophagus. Striktura oesophagus Varises oesophagus Gangguan motilitas oesophagus /reflux oesophagitis. Corosive lesions of oesophagus 2

Kelainan rongga mulut: Rongga mulut & mukosanya adl.target dari

berbagai penyebab infeksi, bahan kimia,dan bahan fisikal, dipengaruhi berbagai penyebab peradangan pada mulut atau bgn dari penyakit sistemik.

Beberapa hal yang perlu diketahui antara lain

Herpes stomatitis. Oral thrush, acute necrotizing ulcerative gingivitis Dll.

3

HERPES STOMATITIS : Lokasi : pipi, tongue, gingiva or palatum. Gambaran Klinis : Erupsi vesicular unilateral & ulserasi linear

sesuaidistribusi of n. Trigeminus atau cabangnya.

Perjalanan penyakit : sembuh tanpa parut bila

tidak ada infeksi; bisa dijumpai post herpeticneuralgia.

Oral acyclovir, famcyclovir, or valacyclovir memperpendek masa penyembuhan and post

herpetic neuralgia.4

5

Investigation

6

Tests are not usually necessary in immunocompetent people, as history and examination will usually confirm the diagnosis.

Viral culture from swabs of lesions has been considered the gold standard but is limited by the short time period of viral shedding and the relatively low number of viral particles present in samples.

Treatment

Topical antiviral agents: Aciclovir 5% can be used from the age of 3 months. Penciclovir 1% cream should be used from the age of 12.

Treatment needs to be initiated at the onset of symptoms before vesicles appear.

Topical antivirals need to be applied frequently for a minimum of 4-5 days.

7

Aciclovir is active against herpes viruses but does not eradicate them. It can be used as systemic and topical treatment of herpes simplex infections of the mucous membranes and is used orally for severe herpetic stomatitis. Valaciclovir is an ester of aciclovir. It is licensed for herpes simplex infections of the skin and mucous membranes.

8

Referral

Seek advice for managing immunocompromised individuals, including people with HIV.

Seek specialist advice if neonatal herpes is suspected (rare; may present with skin, eye and/or mouth symptoms).

9

Oral thrush Lesi putih pada mukosa mulut.Tanda Klinis : – Tipe Pseudomembraneous (thrush) : daerah dengan

penebalan lunak berwarna putih krim dalam bentuk barisan),permukaan berdarah bila dogosok.

– Tipe Erythematous : datar, merah, terkadang area yang sakitdalam kelompok yang sama

– Candidal leukoplakia : Penebalan putih tidak dapat diangkat,penebalan epitel disebabkan candida.

– Angular cheilitis: fissures yang sakit pada sudut mulut. Perjalanan penyakit : Respon baik dgn terapi antifungal koreksi faktor predisposisi. Perjalanan sama dengan pseudomembraneous type. Respon dengan pemberian terapi jangka lama antifungal. Respon dengan terapi topical antifungal.

10

Penyebab : Pertumbuhan Candida dalam keadaan normal

dikontrol oleh adanya bakteri normal. Pertumbuhan berlebih dan tidak terkontrol pada

mulut disebabkan oleh faktor yang menurun kan resistensi natural, misalnya sakit, stress, pemakaian lama corticosteroids atau obat yang menekan immune system, dan kelainan immune misalnya (HIV/AIDS).

Disebabkan keadaan yang mengganggu keseimbangan normal microorganisms dalam mulut :

kebanyakan akibat pemakaian lama antibiotik , & uncontrolled DM & dengan perubahan hormonal akibat pregnancy atau penggunaan pil KB. 13

Symptoms Biasanya pada lidah, atau bgn

dalam pipi. – Warna keputihan – Nyeri - Mulut Kering.

14

Pemeriksaan dan Tests candida. Terlihat adanya area/lesi pada mulut,

lidah, atau pipi.

Lesi mudah disikat dan terlihat area kemerahan, nyeri dan bisa berdarah.

Pemeriksaan mikroscopi jaringan lesi, dapat memastikan infeksi Candida, tapi biasanya diagnosis dibuat dengan simple physical examination

15

Self - Care

Follow good oral hygiene practices. Brush the teeth at least twice a day and floss at least once a day.

Avoid mouthwashes or sprays which can destroy the normal balance of microorganisms in the mouth.

Visit dentist regularly. Especially for people with diabetes or wear dentures.

Limit the amount of sugar and yeast-containing foods intake. (Bread, beer, and wine encourage candida growth).

Quit smoking.

16

Treatment For thrush in infants, treatment is often NOT needed. It

usually gets better on its own within 2 weeks. Use a soft toothbrush and rinse your mouth with a diluted

3% hydrogen peroxide solution several times a day. An antifungal suspension (nystatin) can be use for severe

case of thrush. These products are usually used for 5 - 10 days.

Stronger oral medications such as fluconazole or itraconazole may be use if the infection has spread throughout the body or in a weakened immune system auch as HIV/AIDS.

17

Prognosis:

Menggangu proses makan,karena rasa tidak enak/sakit.

Biasanya respon dgn pengobatan, tapi bisa kambuh kembali.

Dapat meluas ke palatum, lidah, pipi,atau tenggorok.

Penyebaran ketempat lain bisa terjadi walau tidak umum

18

KOMPLIKASI : Gangguan nutrisi. Esophagitis Candida Penyebaran candida ke saluran cerna, paru,

kulit,dan area lainnya.

PENCEGAHAN : Penderita yang sering kambuh, atau risiko

tinggiuntuk terjadi oral thrush, bisa diberi profilaksis.(preventive) antifungal medications.

19

ACUTE NECROTIZING ULCERATIVE GINGIVITIS (Trench mouth, Vincent’s infection):lokasi biasanya : Gingiva.Gambaran klinis : sakit, perdarahan

gingiva ditandai dengan necrosis and ulserasi gingival papillae dan pinggirnya

Disertai lymphadenopathy dan bau mulut.

Terapi : debridement dan larutan peroxide, akan mengatasi keluhan dlm

24 jam antibiotik pada yg akut Bisa terjadi relaps.

20

21

Management

Includes local debridment ( ultrasonic scaling), subgingival curettage and use of mild oxygenating solutions.

Antibiotic thereby includes penicillins or erythromycin and metronidazole.

NSAIDs may be used for pain relief.

22

Kelainan pada Esofagus

Odinofagia. Disfagia Gangguan pasase oesophagus. Striktura oesophagus Varises oesophagus Gangguan motilitas oesophagus

/reflux oesophagitis. Corosive lesions of oesophagus

23

24

Kelainan Esofagus Dysphagia:( Disfagia)

– Kesulitan menelan.

Odynophagia:– Painful swallowing, is characteristic of nonreflux esophagitis (particularly monilial), herpes, and pill-induced esophagitis.

– may occur with peptic ulcer of the esophagus (Barrett's ulcer),carcinoma with periesophageal involvement, caustic damage of the esophagus, and esophageal perforation

25

Kelainan esofagus Phagophobia : rasa takut menelan, dan menolak

untuk menelan. Bisa terjadi pada hysteria, rabies, tetanus, dan

paralysis faring. Aphagia : obstruksi esofagus yg

komplit,biasanya akibat sangkutnya bolus dan merupakan suatu darurat medik.

Globus pharyngeus/globus sensation(globus hystericus) :

perasaan adanya gumpalan yang mondok di kerongkongan,tapi tidak ada kesulitan menelan. Dijumpai kontinu tapi tdk berhubungan dgn menelan. Bisa hilang sementara waktu menelan.

Penyebab umum globus sensation : ( GERD,anxiety disorder, Early hypopharyngeal

cancer, goiter.26

Heartburn, or pyrosis

ditandai rasa terbakar retrosternal, rasa tidakenak, bisa menjalar keatas/kebawah dada, sptgelombang.

- Bila berat, bisa menjalar kesebelah dada,leher, dan sudut rahang.

- Heartburn adl. Keluhan khas dari refluxesophagitis dan bisa berhubungan denganregurgitation rasa adanya cairan hangat naikketenggorok. Akan bertambah berat bila adatekanan, atau berbaring dan makin beratsesudah makan.

27

Causes of dysphagia

Diseases of the mouth and tongue e.g. Tonsillitis Neuromuscular disorders e.g. bulbar palsy,

myasthenia gravis Motility disorders e.g. achalasia, scleroderma,

diffuse esoph. Spasm Intrinsic lesions e.g. ,strictures

(benign/malignant),esoph. web/ring

Extrinsic pressure e.g. goiter, pharyngeal pouch,aortic aneurysm, enlarged left atrium

28

Dysphagia : adl kesukaran dalam menelan.Biasanya os mengeluh makanan tersangkut antaramulut, faring atau esofagus. salah arah dari makanan menyebabkan

nasal regurgitation, laryngeal dan aspirasi paru waktu menelan, merupakan tanda khas dari oropharyngeal dysphagia.

Lesi peradangan yang sakit yg menyebabkan odynophagia bisa juga menyebabkan penolakan untuk menelan.

Ada pasien yang dapat merasakan turunnya makanan ke esophagus. Sensitifitas seperti ini tidak berhubungan dgn suatu food sticking atau obstruksi.

29

Patofisiologi Disfagia

Tergantung pada lokasi anatomi—dibagi atasdisfagia oral,faringeal dan esofagial.

Transport bolus tergantung pada : ukuran bolus &lumen, kontraksi peristaltik, relaksasi normal dariUES dan LES selama menelan.

Disfagia ok bolus yg besar atau lumen sempit Disfagia mekanis (mechanical dysphagia)

Akibat lemahnya kontraksi peristaltik menyebabkan kontraksi non peristaltik dan gangguan relaksasi sfinkter disbt: motor dysphagia.

30

Disfagia orofaringeal :

Fase oral disfagia, adl berhubungan dgn pembentukan bolus yg jelek,makanan keluar mulut atau tinggal di mulut atau os merasa sulit memulai refleks menelan.

Kontrol bolus yg jelek-makanan ke dalam faring dan aspirasi ke laring dan/atau rongga hidung.

Fase faring disfagia : ok statis makanan dlm faring akibat prepulsi faring yg jelek dan obstruksi pada UES.

31

Dysfagia Orofaringeal

Stasis faring - nasal regurgitation & aspirasi laring selama dan setelah menelan.

Adanya regurgitasi nasal dan aspirasi laring selama menelan, adalah suatu“hallmarks” dari disfagiaorofaring.

32

Penyebab disfagia orofaringeal

Gangguan otot lurik-neurologik, miopati.

Lesi inflamasi mulut, faring dan laring.

tumor laring dan faring. Abses retrofaringeal Divertikulum Zenker (kantung

faringeal) Goiter

33

Oropharyngeal Mechanical DysphagiaI. Wall defects : A. Congenital: 1. Cleft lip, cleft palate 2. Laryngeal

clefts B. Post surgicalII. Intrinsic narrowing : A. Inflammatory 1. Viral (herpes simplex, varicella-zoster,

cytomegalovirus) 2. Bacterial (peritonsillar abscess) 3. Fungal (Candida) 4. Mucocutaneous bullous diseases 5. Caustic, chemical, thermal injury . B. Strictures 1. Congenital microganthia 2. Caustic

ingestion 3. Post-radiation C. Tumors 1. Benign 2. MalignantIII. Extrinsic compression A. Retropharyngeal abscess,

mass B. Zenker's diverticulum C. Thyroid disorders D. Vertebral

osteophytes 34

Oropharyngeal Motor DysphagiaI. Diseases of cerebral cortex and brainstemA. With altered consciousness or dementia 1. Dementias including Alzheimer's disease 2. Altered consciousness, metabolic encephalopathy, encephalitis, meningitis, cerebrovascular accident, brain injuryB. With normal cognitive functions 1. Brain injury 2. Cerebral palsy 3. Rabies, tetanus, neurosyphilis 4. Cerebrovascular disease 5. Parkinson's disease and other extrapyramidal

lesions 6. Multiple sclerosis (bulbar and pseudobulbar palsy) 7. Amyotrophic lateral sclerosis (motor neuron

disease) 8. Poliomyelitis and post-poliomyelitis syndrome

35

Orofaringeal motor dysfagiaII. Diseases of cranial nerves (V, VII, IX, X, XII)

A. Basilar meningitis (chron inflammatory, neoplastic) B. Nerve injury C. Neuropathy (Guillain-Barré syndrome, familial

dysautonomia, sarcoid, diabetic and other causes) III. Neuromuscular A. Myasthenia gravis B. Eaton-Lambert syndrome C. Botulinum toxin D. Aminoglycoside & other drugs IV. Muscle disorders A. Myositis (polymyositis, dermatomyositis sarcoidosis) B. Metabolic myopathy (mitochondrial myopathy,thyroid

myopathy) C. Primary myopathies (myotonic dystrophy, oculopharyngeal myopathy) 36

Esophageal dysphagia Penyakit intraesofagus : Striktur jinak – esofagitis refluks, esofagitis

korosif, trauma. Karsinoma Rings dan webs Gangguan motorik-akalasia, spasma difus,

sklerosissistemik.

Tekanan dari luar atau ekstrinsik : Kelenjar dan tumor mediastinum. Aneurisma Pembesaran atrium kiri Dysphagia: penekanan esofagus oleh anomali

arterisubklavia kanan atau pbl. Darah besar lain.

Hernia hiatus paraesofageal (terputar).37

Esophageal Dysphagia

Pd dewasa, lumen esofagus dapat distensi spdiameter 4 cm. Bila esofagus tdk dapat dilatasimelebihi diameter 2.5 cm -, dysphagia thdmakanan normal solid.

Dysphagia permanen terjadi bila esophagustdk dapat distensi melebihi 1.3 cm.(Criticalnarrowing of the lumen for onset of dysphagia)

38

Esofageal dysfagiaEsophageal Mechanical Dysphagia I. Wall defects A. Congenital B. Tracheoesophageal fistula II. Intrinsic narrowingA. Inflammatory esophagitis 1. Viral (herpes simplex, varicella- zoster, cytomegalovirus) 2. Bacterial 3. Fungal (Candida) 4. Mucocutaneous bullbous

diseases 5. Caustic, chemical, thermal injury 6. Eosinophilic esophagitisB. Webs and rings 1. Esophageal (congenital, inflammatory) 2. Lower esophageal mucosal ring (Schatzki's ring) 3. Eosinophilic esophagitis 4. Host-versus-graft diseaseC. Benign strictures 1. Peptic 2. Pill-induced 3. Inflammatory (Crohn's disease, Candida, mucocutaneous

lesions) 5. Ischemic,.Postoperative,. Post-radiation, CongenitalD. Tumors 1. Benign 2. Malignant 39

Esofageal Dysfagia III. Extrinsic compression A. Vascular compression ( left atrial enlargement, aortic aneurysm) B. Posterior mediastinal mass C. Postvagotomy hematoma and fibrosisEsophageal Motor DysphagiaI. Disorders of cervical esophagusII. Disorders of thoracic esophagusA. Diseases of smooth muscle or excitatory nerves1. Weak muscle contraction or LES tone a. Idiopathic b.Scleroderma and

related collagen vascular diseases c. Hollow visceral myopathy d. Myotonic dystrophy e. Metabolic neuromyopathy (amyloid, alcohol?, diabetes?) f. Drugs:anticholinergics, smooth muscle relaxants

2. Enhanced muscle contraction a. Hypertensive peristalsis (nutcracker esophagus) b. Hypertensive LES, hypercontracting LES

B. Disorders of inhibitory innervation 1. Diffuse esophageal spasm 2. Achalasia a. Primary b. Secondary 3. Contractile (muscular) lower esophageal ring

40

Tumor Esofagus

41

Investigation Barium swallow or esophagram. This involves

drinking a fluid containing a barium compound that coats the esophagus and tumor so that they show up on x-ray. If the stomach is also looked at, the test is called an upper gastro-intestinal series or upper G.I. series

Esophagoscopy This is performed by the surgeon or gastro-

enterologist (a specialist in stomach and bowel diseases)

Biopsy or removal of a small piece of the tumor is carried out if a tumor is seen. This gives a definite diagnosis - noting whether there is malignancy or not and if malignant, what type of malignancy (squamous cell carcinoma or adenocarcinoma)

42

CAT (computerized axial tomography) scan of the abdomen to determine whether or not the cancer has spread to the liver or lymph glands (nodes), which are common sites for spread of esophageal cancer

43

Achalasia

Esofagogram

46

TERIMA KASIH

47