MUKHAPAAKA- SARVASARA.

Dr. Pranav Bhagwat.

This is that

Ayurvedic View

Definition

- सु�श्रु�त नि�. १६

हे�त�

- वा ग्भट उ. २१

- चरक सु�. २४

- भ�लसु�निहेत चिच. ६

- भ�लसु�निहेत चिच. ६

रूप

- वा ग्भट उ. २१

Mukhpaaklaxan Vataj

Sushrut Sphotyukta and arun varniya vranotpatti.

vagbhat Ulcers are mild red in colour.Lips are coppery.Tongue is intolerant to cold, heavy and cracked.Patient opens his mouth with difficulty. (trismus)

Laxan Pittaj

sushrut Rakta or pittvarniya vranotpatti in mukha. daha.

vagbhat . dahatiktvakrata (bitter taste in mouth)ulcears appaears as those produced by application of kshara.

Laxan kaphaj

Sushrut Kandu, mand vedana tvak varniya vranotpatti.

Vagbhat Madhurasyata,Kanduyukta picchila vranotpatti

Raktaj Laxan

Sushrut Rakt or pitvarniya vranotpatti in mukha. daha

vagbhat There is dahaTiktvaktrata. ulcears appaears as those produced by application of kshar

Laxan Sannipatik

Vagbhat In sannipatik mukhpaak tridosha laxanas are observed.

- भ वाप्रक श मु�खर!ग चिच.

Mukhpaak samanya chikitsa

Siravedh and shirovirechanKaval dharan of madhu, gomutra, dugdha, ghrita.Kaval dharan of darvi svarasGandush of patoladi qwath.Khadiradi gutikaPatyha vati

Chikitsa for vataja mukhpaak

Pratisarana with panchalavan churna.

Nasya with vaathar dravya siddha oil

Snaihik dhumpaan with drugs lke arjun, erand, khadir, guggul and jatamansi.

Churna of pippali, saindhav and ela should be applied at the site of vrana

Chikitsa for pittaj and raktaj mukhpaak

Firsly shodhan has to be done by vaman and virechan by madhur and shit dravya.

Gandush done with sugarcane juice or sugar water.

Madhur dravya siddha dugdha used for gandush, kaval dharan and nasya.

Chewing the leaves of madayantika and spitting it out.

Chikitsa for kaphaj mukhpaak Pratisaran with kutaki, kshar and lavan

Gandush done with gomutra added with ash of palash, mushkaka and amlaki.

Leaves of phanijjaka, nirgundi and surasa(tulasi) are chewed and spitted out

Chikitsa for sannipatik mukhpaak

Tratment should be done according to predominance of doshas.Gorochan, kasis, saurastrika, rasanjan and mocharas boiled together added with honey and kept in an iron vesel. After it dries it is powdered mixed with honey and applied on ulcers

- भ वाप्रक श मु�खर!ग चिच.

ULCERS OF ORAL CAVITY INFECTIONS

VIRAL-HERPANGINA, HERPES SIMPLEX BACTERIAL-Vincent’s infection, TB, syphilis Fungal: Candidiasis

Immune disorders: Aphthous ulcer, Behcet’s syndrome Trauma

ill-fitting denture, phenol, aspirin burns, Hot food Neoplasms Skin disorders: Erythema multiforme, lichen planus,

BMMP, bullous pemphigoid, lupus erythematosus

Blood disorders: Leukaemia, agranulocytosis, pancytopenia

Drug allergy: Mouth washes, tooth paste, etc.Reactions to systemic drugs

Vitamin deficiencies Miscellaneous: Radiation mucositis,

cancer chemotherapy, diabetes mellitus, uraemia

INFECTIONS

HERPANGINA SYN: Vesicular stomatitis , Acute

lymphonodular pharyngitis Cause: Enteroviruses-Coxsackie A, EV

71 Characteristic vesicular rash on tonsillar

pillars, soft palate, uvula, tonsils, posterior pharyngeal wall

Discrete 1- to 2-mm vesicles and ulcers Enlarge over 2-3 days to 3-4 mm and

are surrounded by erythematous rings up to 10 mm

1-15 lesions are present, usually around 5

Usually resolve without complications Rarely, meningitis

Herpetic gingivostomatitis

Syn: orolabial herpes Cause: HSV Primary

Children Clusters of multiple vesicles ->

ulcers Fever, malaise and headache , sore

throat and lymphadenopathy. Secondary

Adults, mild Vermilion border of the lip > hard

palate and gingiva Reactivation of dormant virus in

trigeminal ganglion Acyclovir, 200 mg, five times a day

for 5 days to reduce viral load

Moniliasis (candidiasis)

caused by Candida albicans Thrush

white grey patches on the oral mucosa and tongue.

 infants and children systemic malignancy and

diabetes or taking broad spectrum antibiotics, cytotoxic drugs, steroids or radiation.

Thrush can be treated by topical application of nystatin or clotrimazole.

Hand, foot and mouth disease Cause: Coxsackievirus A16

and enterovirus 71 (EV71) spread via the fecal-oral and

perhaps respiratory routes primarily in children vesicular palmoplantar

eruption and erosive stomatitis.

Cloudy vesicles with a red halo are highly characteristic of this disease.  

IMMUNE DISORDERS

Aphthous ulcers

Recurrent and superficial Aetiology: Unknown. Autoimmune,

Nutritional (Folate, B12, Iron), Viral, Bacterial, Food allergies, Hormonal, Stress

usually involving movable mucosa, i.e. inner surfaces of lips, buccal mucosa, tongue, floor of mouth and soft palate, sparing mucosa of the hard palate and gingivae.

Minor form more common, ulcers are 2–10 mm in size and

multiple with a central necrotic area and a red

They heal in about 2 weeks without leaving a scar.

Major form, ulcer is very big, 2–4 cm in size, and heals with a scar but is soon followed by another ulcer.

Behcet’s syndrome (Oculo-oro-genital syndrome) Behçet's disease is a complex multisystem disease

characterized by oral and genital ulcers and other systemic features.

Diagnosis is based on the International Criteria for Behçet's Disease including: oral aphthae, genital aphthae, ocular lesions, cutaneous lesions, and a positive pathergy test.

Cutaneous lesions should display a neutrophilic vascular reaction on histopathologic examination.

Seen worldwide, with the highest prevalence reported in Turkey and Japan

prevalence and often the severity is increased in the Middle East and the Mediterranean

predominantly affect males

Cause and Pathogenesis Heredity, immunologic factors, infectious

agents, inflammatory mediators, and clotting factors likely contribute.

Oral aphthae, or Canker sores are often the initial feature of Behçet's disease and constitute a requisite diagnostic feature

usually occur in crops of more than 3 to 10s

painful and shallow, and they heal without scarring over 1 to 3 weeks

Genital ulcers typically occur on the scrotum and penis in males and on the vulva or vaginal mucosa in females.

These aphthae are similar in appearance to oral lesions, but they have a greater tendency to scar and may recur less frequently.[

Cutaneous- erythema nodosum–like lesions, pyoderma gangrenosum–like lesions, Sweet's syndrome–like lesions, cutaneous small vessel vasculitis, and

pustular vasculitic lesions including lesions induced by trauma—the so-called pathergy lesion.

Pathergy signifies the development of erythematous pustules or papules 24 to 48 hours following puncture of the skin with a 20- to 21-gauge sterile needle.

Specimens from all these lesions demonstrate a neutrophilic vascular reaction on histopathologic analysis.

Ophthalmic (83% to 95% of men and 67% to 73% of women)  anterior and posterior uveitis, retinal vasculitis, and hypopyon, with

secondary glaucoma, cataract formation, decreased visual

acuity, and synechiae formation

Arthritis of Behçet's disease is typically a nonerosive, inflammatory, symmetric, or asymmetric oligoarthritis

Central nervous system (CNS) involvement is most commonly characterized by brain stem or corticospinal tract syndromes

(neuro-Behçet's syndrome), venous sinus thrombosis, increased intracranial pressure isolated headache.

Cardiac complications include myocardial infarction, pericarditis, arterial and venous thromboses, and aneurysm formation. 

Submucous Fibrosis

Definition: Submucous fibrosis represents a multifactorial

disorder; with the considered chief etiologic factor being the

consistent and habitual use of areca (betel) nut, either in the form of chewing or simply placing a quid of material (paan masala) in the buccal or labial sulcus several time per day, or in a packaged powdered form with other components (guthka), over many years.

premalignant condition with transformation rates as high as 7.6%

Etiology and pathogenesis:   failure of collagen remodeling altered epithelial-mesenchymal interactions -

>formation of collagenous bands and aggregates within the submucosa and lamina propria.

diminished level of functional collagenase levels 

Clinical Features Changes of submucous fibrosis are

most marked over soft palate, faucial pillars and buccal mucosa

Initial mucosal alterations: erythema with or without vesiculation.

Later: slow diminishment of erythema and a progressive decrease in the degree of oral opening and tongue mobility

Pallor of the normally pink mucosa becomes evident as the underlying chronic inflammation recedes and fibrosis and hyalinization progress. 

Scar bands may become evident deep within the buccal soft tissues, further limiting jaw opening and function.

Development of squamous cell carcinoma is characterized by a gradual thickening of the epithelial surface with hyperplastic to verrucous surface qualities becoming evident.

Histology:  juxtaposition of atrophic

epithelium surfacing a subjacent fibrosis.

Early connective tissue alterations are characterized by delicate and loosely arranged collagen fibers with progressive degrees of hyalinization

In the late stages: complete hyalinization

of the supportive connective tissue.

Variable degrees of chronic inflammation occur in the form of lymphocytes and plasma cells.

Variable levels of dysplasia have been noted.

Management of oral submucous fibrosis is problematic, particularly in advanced cases and when the use of areca-containing products remains in place.

Medical: Avoid irritant factors Topical injection of steroids-Dexamethasone Treat existent anaemia or vitamin deficiencies Encourage jaw opening exercises.

Surgical Surgical release procedures of scar bands have been

only modestly successful.

More recently collagenase and pentoxifylline administration in separate studies has been proposed

Other conditions.

Migratory Glossitis The grooves running laterally

across the tongue are one obvious diagnosis (fissured tongue). The white areas suggest another diagnosis. Note that some of white areas form partial rings, a characteristic of geographic tongue. Usually the tongue looks red in the center of the rings; however, in this case the entire tongue looks red obscuring these features except at the tip where the typical appearance is preserved. The two vesicles on the near lateral surface are probably related to geographic tongue

Nicotine Stomatitis The white color of this patient's

hard palate and the white elevations with red centers are characteristic of nicotine stomatitis. The red dots are the orifices of minor salivary gland ducts the epithelium of which does not keratinize. This patient should be informed that the smoking habit has caused these changes and that a malignancy may develop here or elsewhere.

Suppurative Apical Periodontitis The raised, red gingival

lesion is probably associated with the carious mandibular first molar tooth. There probably is a periapical lesion at the molar apex that is draining onto the surface. If so, the lesion is located at the drainage site. While the lesion could be called a "pyogenic granuloma," it is commonly called a "parulis."

Median Rhomboid Glossitis The rough reddish area in

the midline of the tongue is median rhomboid glossitis--few other diseases occur in this location. For years, it has been assumed that median rhomboid glossitis is cause by faulty tongue development; however, more recently, Candida infestation has been posed as its etiology.

Lichen Planus The white intersecting lines

affecting this patient's buccal mucosa is characteristic of lichen planus. This condition may occur on the skin, on the oral mucosa, or on both skin and mucosa. It is usually bilateral and may sometimes cause ulceration (erosion) of the mucous membrane. The red posterior area may be the beginning of such "erosive lichen planus."

Lichen planus

Oral lichen planus (OLP) can occur without cutaneous disease.

Onset before middle age is rare; the mean age of onset is in the sixth decade.

Women outnumber men by more than 2:1.

Mucous membrane involvement is observed in more than 50% of patients with cutaneous lichen planus

The most common location of OLP is the buccal mucosa (80% to 90%) followed by the tongue (30% to 50%)

Lavy white lesions on buccal mucosa

Angular stomatitis

Ulcerative stomatitis