Inflammation by Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India
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Transcript of Inflammation by Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India
InflammationDr. Amit T. Suryawanshi
Oral and Maxillofacial Surgeon Pune, India
Contact details :Email ID - [email protected] No - 9405622455
Contents
• Introduction. • Definition.• Historical background.• Cardinal signs of inflammation.• Types of inflammation.• Pathophysiology of inflammation.• Inflammatory cells & mediators.• Clinical perspectives. • Conclusion. • References.
Introduction
• Survival of all living organisms requires that they should eliminate foreign invaders , such as infectious pathogens & damaged tissues .
These functions are mediated by complex host immune response called as an Inflammation.
Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process.
Hence without inflammation, wounds and infections would never heal.
Inflammation
• Definition –
The word inflammation is derived from
Latin word inflammare, which means “to set
on fire.”
Inflammation
Inflammation is defined as “a protective response intended to eliminate the original cause of cell injury , necrotic tissues and tissues resulting from original insult . ”
Terms ending with suffix “ itis” denote inflammation .
Historical Background
1. Word inflammation – Latin word inflammare ( meaning – to set on fire ) 2. Celsus – A roman physician and medical writer (30
BC to 45 AD ) gave 4 cardinal signs of inflammation saying
“ Rubor et tumor cum calore et dolore.” (meaning - Redness and swelling come with heat
and pain )
3. Virchow added 5th Cardinal sign of inflammation in 1871
i.e. functio laesa (loss of function)
4. Cohnheim gave First description of diapedesis in 1873.
5. Lewis described Inflammation as the ‘‘triple response’’ to injury in 1927
Cardinal Signs Physiological rationale
1. Rubor ( Redness) Increased Blood flow
2. Tumor (Swelling ) Exudation of fluid
3. Calor (Heat) Increased Blood flow , Exudation of fluid, Release of inflammatory mediators
4. Dolor ( Pain ) Stretching of pain receptors and nerves by inflammatory exudates , chemical mediators
5. Functio laesa (Loss of function)
Pain,Disruption of tissue structure,Fibroplasia and metaplasia
Cardinal signs of inflammation & Its Physiological rationale
1. Acute inflammation – It is the rapid response to the injury or microbes or
other foreign substances that is designed to deliver leukocytes & plasma proteins to the site of injury .
Causes –2. Infections – Bacterial , viral , fungal or parasitic3. Trauma –Blunt or Penetrating 4. Tissue necrosis- 5. Foreign bodies – sutures 6. Immune reactions
Types of inflammation
• Outcomes of acute inflammation-1. Resolution2. Progression to chronic inflammion.3. Scarring or fibrosis
2. Chronic inflammation – It is inflammation of prolonged duration in which
active inflammation, tissue injury & healing proceed simultaneously .
Causes –1. Persistent infection 2. Immune mediated inflammatory diseases3. Prolonged exposure to potentially toxic agents
• Outcomes of Chronic inflammation-
1. Resolution2. Scarring or fibrosis
Pathophysiology of inflammation
Inflammed (Vasodilation in capillary bed)
NormalArteriole Venule
Capillary bed
Leukocyte Transmigration , Chemotaxis & Phagocytosis
Resolution of Inflammation
Pathophysiology of inflammation
Inflammatory cells
1. Blood leukocytes – Neutrophils , Macrophages, Lymphocytes.2. Plasma cells 3. Connective tissue cells – Fibroblasts, Mast cells.4. Cells of vascular walls .
Inflammatory mediators • Definition – Chemical substances that trigger certain
processes in an inflammatory reaction.
Cell derived Plasma derived
Histamine Kinin system mediators
Serotonin C- reactive protein
Neutrophilic proteases Complement system mediators
Interleukins( IL-1 . TNF- α )
Chemokines
Arachidonic acid (PG, LT)
PAF
• Plasma proteins & extracellular matrix also play an important role in process of inflammation.
Differences between Acute & Chronic Inflammation
Acute inflammation Chronic inflammation
Definition It is the rapid response to the injury or microbes or other foreign substances that is designed to deliver leukocytes & plasma proteins to the site of injury .
It is inflammation of prolonged duration in which active inflammation, tissue injury & healing proceed simultaneously .
Onset Rapid Insidious
Duration Short ( Few minutes to days )
Long (Days to years )
Acute inflammation Chronic inflammation
Specificity Non- specific Specific, where immune response is activated
Cells involved Neutrophils Lymphocytes , plasma cells , macrophages , fibroblasts
Vascular changes
Active vasodilation ,Increased vascular permeabilty
New vessels formation(Neoangiogenesis )
Fluid exudation & edema
Present Absent
Cardinal signs Present Absent
Acute inflammation
Chronic inflammation
Tissue necrosis Absent Ongoing
Systemic manifestations
High grade fever Low grade fever, weight loss , anemia
Clinical Perspectives
Inflammatory diseasesAcute inflammatory diseases-
Chronic inflammatory diseases -
1. Acute suppurative osteomyelitis
1. Chronic suppurative osteomyelitis
2. Chronic focal sclerosing osteomyelitis
3. Chronic diffuse sclerosing osteomyelitis.
4. Garre’s osteomyelitis
Acute inflammatory diseases-
Chronic inflammatory diseases -
Acute Pericoronitis Chronic Pericoronitis
Acute Sialadentitis Chronic Sialadentitis
Acute Maxillary sinusitis Chronic Maxillary sinusitis
Acute Stomatitis Chronic Stomatitis
Infectious arthritis _
_ Rheumatoid arthritis
Rheumatoid arthritis
• Etiology –
1. Unknown 2. The is evidence that it may be a hypersensitive reaction to bacterial toxins specifically of streptococci.
It is a debilitating systemic disease of unknown origin , characterized by progressive involvement of the TM joint ,(particularly bilateral involvement)
Clinical features –General – 1. Slight fever, Weight loss, Fatigue Extraoral – 1. Swelling over joint region , Stiffness , pain on movement . 2. Clicking is uncommon. 3. Over period of years there may be ankylosis but its not inevitable.
• Radiographic appearance -
Infectious Arthritis
• Incidence- very rare.
• Etiology –
Infection – Gonococci, Streptococci, staphylococci, pneumococci & tubercle bacillus .
• Etiopathogenesis – 1. Spread can be hematogenous , Lymphatic
or by direct extension of foci of infection . 2. Most commonly , it spreads directly from foci of infection. - Adjacent cellulitis - Osteomyelitis Which may follow - Dental infection. - Infection of parotid gland, ear.
• Clinical features – 1. Severe pain in joint , tender on palpation in joint region. 2. Trismus. 3. Results in ankylosis , most commonly fibrous ankylosis .
Osteomyelitis • Definition – It is defined as an inflammation of marrow
spaces of bone with tendency of involvement of cortical plates and periosteum.
• Etiology – 1. Dental infection
Predisposing factors –2. Fractures 3. Gunshot wounds 4. Radiation damage 5. Paget's disease6. osteopetrosis
• Systemic factors –1. Malnutrition 2. Acute leukemia3. Uncontrolled diabetes mellitus 4. Sickle cell anemia5. Chronic alcoholism
Types of osteomyelitis –
1. Acute suppurative osteomyelitis 2. Chronic suppurative osteomyelitis 3. Chronic focal sclerosing osteomyelitis4. Chronic diffuse sclerosing osteomyelitis.5. Garre’s osteomyelitis
Acute suppurative osteomyelitis
• Definition-• “Acute suppurative osteomyelitis of jaw is a
sequela of periapical infection that often results in a diffuse spread of infection throughout the medullary spaces, with subsequent necrosis of bone .”
• Etiology – Dental infection
• Clinical features –1. Severe pain , trismus , paresthesia of lip 2. Elevation of temprature 3. Regional lymphadenopathy 4. Pus may exude through gingival pocket 5. In maxilla , infection spread is local, while in
mandible its diffuse .
Radiographic appearance -
Chronic Suppurative Osteomyelitis
• Chronic suppurative osteomyelitis may develop in inadequately treated acute osteomyelitis or may arise from dental infection without preceding acute stage.
• Etiology – 1. Followed by acute osteomyelitis2. Dental infection
• Clinical features –1. Mild pain , trismus , paresthesia of lip 2. Elevation of temprature 3. Regional lymphadenopathy 4. In acute exacerbation ,the suppuration may
perforate the bone , mucosa and overlying skin to form a fistulous tract.
Cutaneous fistula Intraoral fistula with draining abscess
Radiographic appearance -
Chronic Focal Sclerosing Osteomyelitis
• It is an unusual reaction to the mild bacterial infection entering the bone through a carious tooth in persons who have a high degree of tissue resistance and reactivity .
• Here , tissue reacts to the infection by proliferation of cells rather than destruction.
• Etiology – Mild dental infection
• Clinical features –1. No signs and symptoms except for mild pain
due to infected pulp.
• Radiograph –
Chronic Diffuse Sclerosing Osteomyelitis
• It is analogous to the focal form of disease , representing proliferative reaction of the bone diffusely to the low- grade infection.
• Etiology – 1. Generalized periodontal disease.2. Multiple teeth infection (mild)
• Clinical features –
1. No clinical indications of its presence.2. Occasionally , there is acute exacerbation of
the chronic infection results in vague pain , unpleasant taste , mild suppuration &
formation of fistula over the mucosal surface.
• Radiograph-
Garre’s Osteomyelitis
• It is also called as chronic ,non-suppurative osteomyelitis with proliferative periostitis .
• This is distinctive osteomyelitis in which there is focal gross thickening of the periosteum with peripheral reactive bone formation resulting from mild irritation or infection.
• Etiology – Dental infection
• Clinical features-1. Toothache or pain in the jaw 2. Bony hard swelling on the outer surface of
the jaw.
• Radiographic appearance-
Pericoronitis
• Definition –• “Pericoronitis is an inflammation of the gingiva
that covers the chewing surface of the molars which have not fully erupted in the oral cavity. Most commonly , it occurs with third molar which is impacted or erupting .”
Clinical features –
1. Pain 2. Swelling and erythema over the gingiva
covering the tooth .3. Trismus 4. Halitosis 5. Bad taste6. Submandibular lymphadenopathy.
Sialadenitis• It is an inflammatory disease of the major
salivary glands characterized by swelling of the glands believed to be the result of infection.
• Etiology –1. Bacterial or viral infection 2. Mostly occurs in debilitated patients suffering
from dehydration , suppression of salivary secretion or sialolithiasis or after a surgery
Clinical features –
• Oral or facial pain, especially while eating• Erythema over the side of the face or upper neck
(Parotitis)• Swelling (particularly in preauricular region, below
the jaw, or on the floor of the mouth)• Trismus • Fever• Xerostomia • Bad taste • Pus may drain into the mouth.
Parotitis
Sialadenitis of Submandibular gland
Extraoral
Maxillary Sinusitis • Inflammation of mucosa of Maxillary sinus is
Maxillary sinusitis . • Etiology –1. Infection2. Trauma 3. Allergy 4. Infected odontogenic cyst 5. Oroantral communication or fistula 6. Displaced tooth or root
Signs -
Extraoral- 1. Tenderness over cheek . Intraoral- 1. Percussion of maxillary molars show tenderness. 2. Existence of oroantral fistula with or without polypoid mass extruding from socket . 3. Fetor oris on blowing the nose.
Symptoms
1. Nasal blocking following rhinitis 2. Postnasal discharge with constant irritation
requiring clearing of throat.3. Heavy feeling of head.4. Constant throbbing pain in upper part of
cheek or entire side of face which is exacerbated by bending down.
5. Chills , fever ,difficulty in breathing .
Stomatitis • Stomatitis is an inflammation of the mucous lining of any
of the structures in the oral cavity.
Etiology –
• Poor oral hygiene• Dietary protein deficiency• Infections • Iron deficiency anemia • Ill fitting dentures • Mouth burns from hot food or drinks • Medications• Allergic reactions• Radiation therapy
Clinical features
• Pain• Mouth ulcers• Burning sensation• Paresthesia• Bad taste• Excessive salivation
Denture stomatitis
Clinical features
Oral ulcers
Necrotizing fasciitis• “It is defined as a rapidly progressing infection
located in the deep fascia with secondary necrosis of subcutaneous tissue , usually sparing the muscles and accompanied by
high fever ”
Etiology –• Infection- Streptococcus pyogenes
Predisposing factors –• Diabetes mellitus , malignancy , drug addiction
Clinical features-
• High fever .• Erythmatous cellulitis with ill-defined margins • Severe pain but affected area is anesthetized.• Progression of disease is rapid with change in
skin colour from red blue to green in 36 hours • By 4th to 5th day , it leads to cutanous
gangrene.• Skin bullae may devlope• There is no lymphadenopathy.
Acute Necrotizing Ulcerative Gingivits • It is an endogenous oral infection that is characterized
by necrosis of gingiva.
• Etiology –• Infection – Fusiform bacilli , spirochetes
• Predisposing factors –
1. Local factors-• Poor oral hygiene • Preexisting gingivitis• Smoking • Emotional stress
• Systemic factors –• Nutritional deficiency – Vit.- B2 , C
• Debilitating diseases – I. Leukemia II. Aids III. Syphilis
Clinical features –
1. Onset is sudden with Pain , profuse salivation, & metallic taste.
2. Spontaneous gingival bleeding.3. Loss of sense of taste.4. Fetid odor 5. Typical “ Punched out ” crater like ulceration
mostly on interdental papilla ,gingiva becomes brown in colour.
Conclusion
• It is necessary for the oral surgeons to have knowledge about inflammation to diagnose inflammatory diseases and inflammatory lesions and to treat them in Surgical or conservative approach .
References
Books-• Robbin’s Basic Pathology 8th edition • Shafer‘s Textbook Of Oral Pathology 6th edition• Atlas of Pathology
Articles-• Tufts OpenCourseWare © 2008 Tufts University• BJSM article
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