Bun San Chong BDS, MSc., PhD, LDS RCS (Eng), FDS RCS (Eng), MFGDP (UK), MRD

• Specialist in Endodontics,
• London, UK

Consequently hiv transmission statistics male to male prograf 5 mg without prescription, patients with tumors of the ascending colon often present with symptoms such as fatigue hiv infection rates by country 2011 cheap prograf 5 mg online, palpitations hiv infection rate syria order prograf 1 mg with visa, and even angina pectoris and are found to have a hypochromic antiviral treatment for herpes cheap prograf 1 mg line, microcytic anemia indicative of iron deficiency. Because the cancer may bleed intermittently, a random fecal occult blood test may be negative. As a result, the unexplained presence of iron-deficiency anemia in any adult (with the possible exception of a premenopausal, multiparous woman) mandates a thorough endoscopic and/or radiographic visualization of the entire large bowel. Because stool becomes more formed as it passes into the transverse and descending colon, tumors arising there tend to impede the passage of stool, resulting in the development of abdominal cramping, occasional obstruction, and even perforation. Radiographs of the abdomen often reveal characteristic annular, constricting lesions ("apple-core" or "napkin-ring"). Cancers arising in the rectosigmoid are often associated with hematochezia, tenesmus, and narrowing of the caliber of stool; anemia is an infrequent finding. Although these symptoms may lead patients and their physicians to suspect the presence of hemorrhoids, the development of rectal bleeding and/or altered bowel habits demands a prompt digital rectal examination and proctosigmoidoscopy. Staging, Prognostic Factors, and Patterns of Spread the prognosis for individuals having colorectal cancer is related to the depth of tumor penetration into the bowel wall and the presence of both regional lymph node involvement and distant metastases. This radiographic appearance is referred to as an "apple-core" lesion and is always highly suggestive of malignancy. Unless gross evidence of metastatic disease is present, disease stage cannot be determined accurately before surgical resection and pathologic analysis of the operative specimens. It is not clear whether the detection of nodal metastases by special immunohistochemical molecular techniques has the same prognostic implications as disease detected by routine light microscopy. Most recurrences after a surgical resection of a largebowel cancer occur within the first 4 years, making 5-year survival a fairly reliable indicator of cure. The likelihood for 5-year survival in patients with colorectal cancer is stage-related. That likelihood has improved during the past several decades when similar surgical stages have been compared. The most plausible explanation for this improvement is more thorough intraoperative and pathologic staging. In particular, more exacting attention to pathologic detail has revealed that the prognosis following the resection of a colorectal cancer is not related merely to the presence or absence of regional lymph node involvement. Prognosis may be more precisely gauged by the number of involved lymph nodes (one to three lymph nodes versus four or more lymph nodes). A minimum of 12 sampled lymph nodes is thought necessary to define tumor stage accurately. Other predictors of a poor prognosis after a total surgical resection include tumor penetration through the bowel wall into pericolic fat, poorly differentiated histology, perforation and/or tumor adherence to adjacent organs (increasing the risk for an anatomically adjacent recurrence), and venous invasion by tumor (Table 35-6). In contrast to most other cancers, the prognosis in colorectal cancer is not influenced by the size of the primary lesion when adjusted for nodal involvement and histologic differentiation. Cancers of the large bowel generally spread to regional lymph nodes or to the liver via the portal venous circulation. The liver represents the most frequent visceral site of metastasis; it is the initial site of distant spread in one-third of recurring colorectal cancers and is involved in more than two-thirds of such patients at the time of death. In general, colorectal cancer rarely spreads to the lungs, supraclavicular lymph nodes, bone, or brain without prior spread to the liver. A major exception to this rule occurs in patients having primary tumors in the distal rectum, from which tumor cells may spread through the paravertebral venous plexus, escaping the portal venous system and thereby reaching the lungs or supraclavicular lymph nodes without hepatic involvement. When possible, a colonoscopy of the entire large bowel should be performed to identify synchronous neoplasms and/or polyps. The detection of metastases should not preclude surgery in patients with tumor-related symptoms such as gastrointestinal bleeding or obstruction, but it often prompts the use of a less radical operative procedure. At the time of laparotomy, the entire peritoneal cavity should be examined, with thorough inspection of the liver, pelvis, and hemidiaphragm and careful palpation of the full length of the large bowel. Following recovery from a complete resection, patients should be observed carefully for 5 years by semiannual physical examinations and yearly blood chemistry measurements. If a complete colonoscopy was not performed preoperatively, it should be carried out within the first several postoperative months. Subsequent endoscopic or radiographic surveillance of the large bowel, probably at triennial intervals, is indicated because patients who have been cured of one colorectal cancer have a 3­5% probability of developing an additional bowel cancer during their lifetime and a >15% risk for the development of adenomatous polyps. Anastomotic ("suture-line") recurrences are infrequent in colorectal cancer patients provided the surgical resection margins are adequate and free of tumor. This alarmingly high rate of local disease recurrence is believed to be due to the fact that the contained anatomic space within the pelvis limits the extent of the resection and because the rich lymphatic network of the pelvic side wall immediately adjacent to the rectum facilitates the early spread of malignant cells into surgically inaccessible tissue. The use of sharp rather than blunt dissection of rectal cancers (total mesorectal excision) appears to reduce the likelihood of local disease recurrence to ~10%. Radiation therapy, either pre- or postoperatively, reduces the likelihood of pelvic recurrences but does not appear to prolong survival. Preoperative radiotherapy is indicated for patients with large, potentially unresectable rectal cancers; such lesions may shrink enough to permit subsequent surgical removal. The probability of tumor response appears to be somewhat greater for patients with liver metastases when chemotherapy is infused directly into the hepatic artery, but intraarterial treatment is costly and toxic and does not appear to prolong survival appreciably. Oxaliplatin frequently causes a dose-dependent sensory neuropathy that usually resolves following the cessation of therapy. Monoclonal antibodies are also effective in patients with advanced colorectal cancer. Both cetuximab and panitumumab, when given alone, have been shown to benefit a small proportion of previously treated patients, and cetuximab appears to have therapeutic synergy with such chemotherapeutic agents as irinotecan, even in patients previously resistant to this drug; this suggests that cetuximab can reverse cellular resistance to cytotoxic chemotherapy. The use of both cetuximab and panitumumab can lead to an acne-like rash with the development and severity of the rash correlated with the likelihood of antitumor efficacy. The use of bevacizumab can lead to hypertension, proteinuria, and an increased likelihood of thromboembolic events. Patients with solitary hepatic metastases without clinical or radiographic evidence of additional tumor involvement should be considered for partial liver resection because such procedures are associated with 5-year survival rates of 25­30% when performed on selected individuals by experienced surgeons. Life-extending adjuvant therapy is used in only about half of patients >65 years of age. This age bias is completely inappropriate because the benefits and tolerance of adjuvant therapy in patients age 65+ appear similar to those seen in younger individuals. Abdominal symptoms are usually vague and poorly defined, and conventional radiographic studies of the upper and lower intestinal tract often appear normal. A careful small-bowel barium study is the diagnostic procedure of choice; the diagnostic accuracy may be improved by infusing barium through a nasogastric tube placed into the duodenum (enteroclysis). The symptomatology of benign tumors is not distinctive, with pain, obstruction, and hemorrhage the most frequent symptoms. These tumors are usually discovered during the fifth and sixth decades of life, more often in the distal rather than the proximal small intestine. Islet cell adenomas are 486 occasionally located outside the pancreas; the associated syndromes are discussed in Chap. These appear as small nodules in the duodenal mucosa that secrete a highly viscous alkaline mucus. Most often, this is an incidental radiographic finding not associated with any specific clinical disorder. Polypoid Adenomas About 25% of benign small-bowel tumors are polypoid adenomas (Table 35-5). They may present as single polypoid lesions or, less commonly, as papillary villous adenomas. As in the colon, the sessile or papillary form of the tumor is sometimes associated with a coexisting carcinoma. Multiple polypoid tumors may occur throughout the small bowel (and occasionally the stomach and colorectum) in the Peutz-Jeghers syndrome. The polyps are usually hamartomas (juvenile polyps) having a low potential for malignant degeneration. Mucocutaneous melanin deposits as well as tumors of the ovary, breast, pancreas, and endometrium are also associated with this autosomal dominant condition. Leiomyomas these neoplasms arise from smooth-muscle components of the intestine and are usually intramural, affecting the overlying mucosa. Ulceration of the mucosa may cause gastrointestinal hemorrhage of varying severity. Lipomas these tumors occur with greatest frequency in the distal ileum and at the ileocecal valve.

Risk factors including age hiv infection cure buy 0.5 mg prograf, gender antiviral side effects generic prograf 0.5mg fast delivery, daily contacts and various genetic polymorphisms should be targeted by any surveillance programme hiv infection on skin order prograf 5 mg without a prescription. This may be explained by the higher proportion of young people antiviral imdb order 5 mg prograf fast delivery, a higher annual risk of infection 119 and shorter life expectancies in comparison with industrialized countries (Solari et al. Predominance of diabetus disease and cardiovascular diseases in Kuwait is related to under-nutrition according to age and gender (Dye et al. Tuberculosis exposure is affected by internal and external environmental risk factors. Kuwait infrastructure has changed substantially and awareness of socio-demographic changes may speed-up diagnosis of tuberculosis. The author follows direct administrative supervision in the project field to improve quality of work and has no authority to interfere with the entry to Kuwait of any immigrant having positive result(s) and/or latent tuberculosis infection diagnoses. The researcher provided research staff with basic background information about the study and project step follow-ups. Each potential participant in the project screening was adequately informed of the aims, methods and sources of funding of the screening, any possible conflicts, the institutional affiliations of the researcher and the study benefits and potential risks. On request, immigrant has all human rights to be informed about his/her research extra- (non)compulsory test results of both interferon gamma release assays and/or tuberculin skin test but not chest X-ray (the ordinary test) results. The findings of the review formed the basis and context for the development of the methodological design and the screening of the new immigrants to Kuwait as follows. Project implementations were preceded by a preliminary clarification of all research steps and the four tuberculosis diagnostic test procedures. The prevalence of latent tuberculosis infected individuals in the six billion populations infected with Mycobacterium tuberculosis worldwide is five to ten percent (two billion) individuals and these cases are always at risk of re- 127 activation to the active tuberculosis disease form and further distributing tuberculosis infection. The size was increased to one hundred and eighty immigrants with the availability of screening diagnostic tests (n = 180). All eligible participants were approached to enroll in the study after accepting the informant consent and after being briefed on their interviewee rights. There was an absolute language barrier with difficulty in contact even with the help of a third party (e. He/she was newly diagnosed as having acute infectious disease within the last six months before entry to Kuwait. He/she had a history of previous positive tuberculin skin test result less than 6 months prior to entry and enrollment, and 6. He/she missed follow-up for a tuberculin skin test reading result after five days. An expert and highly-qualified data collector speaking four languages was trained for data extraction to obtain tuberculosis-related answers (Step 2). Finally, in (Step 4) immigrants were referred to radiography for taking ordinary compulsory chest X-ray. The total time for management of each case was between 45 and 60 minutes and three to four participants were interviewed per day within four working days during the four months of the study. Step 1 this began with random selection of any registered immigrant and invitation to participate after he/she provided informed consent and preliminary agreement for participation (written or verbal; Appendix 10 and Appendix 11) after being given an explanation of all field examination testing, and adoption pledge primarily signed by the researcher (Appendix 12 and Appendix 13). Step 3 In the nursing room the following examinations and test procedures were performed: 1. Body weight (in Kilogram) and height (in centimetre) were measured and recorded on the tuberculin skin sheet (Appendix 7) 2. The left forearm was chosen by convention to avoid errors in allocating the test site during reading. A small flexible caliper (15 cm length ruler calibrated in millimetre) was used to measure any firm and well circumscribed induration or soft well-defined margin swellings. Evaluating the number of spots obtained provides a measurement of the abundance of M. The test was considered to have failed if the negative control spot count was more than ten spots (> 10 spots) or if there were less than twenty spots (< 20 spots) in the positive control and both panels A and B was nonreactive according to the criteria above. The research investigator was responsible for provincial coordination, fieldwork organization and quality control through coordination of the implementation process, and manipulated and reviewed daily all collected data to ensure legible, complete and consistent recording (Chiang et al. Handling of blood samples and assay components, their use, storage and disposal were also in accordance with defined procedures in appropriate national 144 biohazard safety guidelines or regulations. Care was also taken when working with chemicals considered as potentially hazardous. All recorded questionnaire data were double entered on daily basis by two data entry specialist and revised finally by the researcher checking for discrepancies between the two entries to ensure accuracy. Data were expressed and entered as number for the quantitative variable and as interval number for qualitative variables. Kappa value = (A-E)/ (N-E) A = all positives and negatives common to both techniques E = (positives)/N + (negatives/N) N = the total number of immigrant participants tested by the four techniques A Kappa value can lay between 0 and 1, where 0. A negative Kappa value indicates that the two tests agreement is less than expected by chance (Altman, 1991). Also defined as a range of values has a specified probability of including the true value of the risk factor variable, if the research studies are repeated. This corresponds to hypothesis testing with p-values, with a conventional cut-off for p of less than 0. The p-value is the probability of obtaining an actually observed test results which often rejects the null hypothesis when the pvalue is less than 0. The range of data set is simply a possible limit of spread and is defined as the difference between the highest and lowest values. The researcher and involved project staff companion carried out a pilot study to clarify the field steps using only the project questionnaire and tuberculin skin test followed by ordinary chest X-ray reading (Step 1-4; described in Figure 3. Major limitation in administration and data collection for future facilitations were identified. The search includes only studies published in English and relevant to tuberculosis diagnostic testing. Another limitation is the small sample size which might constrain generalization of the results to a larger population and wider community. This is a research study that can be used to design both qualitative and quantitative mass screening programme, supported with evidence-based statistical findings able to confirm the research hypotheses in strengthening the health system and medical care services. Tuberculosis must be considered as an inter-related risk factors-disease that needs to be addressed through combinations of social, economic, environmental interventions. Similarly, multi-factorial explanation model of the 158 resurgence of tuberculosis, including the interaction between biomedical, political, cultural, and economic factors which point to the analytical challenges achieved by combination of variable disease transmissions with global addressing of environmental conditions such as exposure risk and the socio-cultural surroundings (Dean and Fenton, 2010). Written informed consent was obtained from all participants, which was preceded by adoption pledge signed by the investigator. Analyses of risk factor variables and diagnostic test variants (uni- or multivariate) results were analyzed under 95% confidence intervals 160 using C. The minimum age of participants was 20 years and the oldest immigrant in the study was aged 56 years. Egyptians represented the majority of immigrants coming from non-endemic countries: 14. The majority of participants had graduated from secondary school and higher levels of education 73. For example Filipino participants commonly had diploma and university qualifications 81. Sixty percent (108/180) of immigrant homes in their mother country contained one to ten persons, 32. Duration time taken to reach the health care services in mother country within less than one hour was answered by 86. The minimum duration of accessibility was 2 minutes and the maximum time to reach health services was 150 minutes (Figure 4. Also 95% of immigrants reported having proper sewage systems in their living places and houses. The purpose of in-put migration according to the proposed occupation in Kuwait was subdivided into the following jobs: First came to work in house-related jobs (working as housemaid, driver, cooker and guardian/gardener) were 47. The distribution of environmental contacts inside- and outside households of the immigrants in their mother countries according to latent tuberculosis infection categories is shown in Table 4. Participants with a current history of taking regular pharmaceutical therapy (mainly skin anti-allergic steroids) were 11.

Sustained tachypnea (respiratory rate hiv infection cdc generic prograf 1mg without a prescription, >30 breaths/min) is frequently a harbinger of impending respiratory collapse; mechanical ventilation is often initiated to ensure adequate oxygenation latest hiv infection rates generic prograf 5mg overnight delivery, divert blood from the muscles of respiration hiv viral infection cycle generic 1 mg prograf otc, prevent aspiration of oropharyngeal contents antiviral use in pregnancy generic 1 mg prograf with visa, and reduce the cardiac afterload. The results of recent studies favor the use of low tidal volumes (6 mL/kg of ideal body weight or as low as 4 mL/kg if the plateau pressure >30 cmH2O). Patients undergoing mechanical ventilation require careful sedation with daily interruptions; elevation of the head of the bed helps to prevent nosocomial pneumonia. Stress ulcer prophylaxis with a histamine H2-receptor antagonist may decrease the risk of gastrointestinal hemorrhage in ventilated patients. Bicarbonate is sometimes administered for severe metabolic acidosis (arterial pH <7. Patients who are hypercatabolic and have acute renal failure may benefit greatly from hemodialysis or hemofiltration. Recovery is also assisted by preventing skin breakdown, nosocomial infections, and stress ulcers. Frequent monitoring of blood glucose levels is indicated to avoid hypoglycemia during intensive insulin therapy. Numerous interventions have been tested for their ability to improve survival in patients with severe sepsis. Unfortunately, none of these agents has improved rates of survival among patients with severe sepsis or septic shock in more than one large, randomized, placebocontrolled clinical trial. This lack of reproducibility has had many contributing factors, including (1) heterogeneity in the patient populations studied and the inciting microbes and (2) the nature of the "standard" therapy also used. A dramatic example of this problem was seen in a trial of tissue factor pathway inhibitor. Whereas the drug appeared to improve survival rates after 722 patients had been studied (p =. This inconsistency, even within a carefully selected patient population, argues strongly that a sepsis intervention should show significant survival benefit in more than one placebo-controlled clinical trial before it is accepted as part of routine clinical practice. The drug seemed highly efficacious at the interim analysis in December 2000, but this trend reversed later in the trial. Demonstrating that therapeutic agents for sepsis have consistent, reproducible efficacy has been extremely difficult, even within well-defined patient populations. Some experts have advocated "bundling" of multiple therapeutic maneuvers into a unified, algorithmic approach to management that would become the standard of care for patients with severe sepsis. Bundling of therapies obscures the efficacy and toxicity of the individual interventions and allows little room for individualizing therapy. A careful retrospective analysis found that the apparent efficacy of all sepsis therapeutics studied to date has been greatest among the patients at greatest risk of dying before treatment; conversely, use of many of these drugs has been associated with increased mortality rates among patients who are less ill. The authors proposed that whereas neutralizing one of many different mediators may help patients who are very sick, disrupting the mediator balance may be harmful to those whose adaptive defense mechanisms are still working. Of the individual covariates, the severity of underlying disease most strongly influences the risk of dying. Casefatality rates are similar for culture-positive and culturenegative severe sepsis. In developed countries, most episodes of severe sepsis and septic shock are complications of nosocomial infections. These cases might be prevented by reducing the number of invasive procedures undertaken, limiting the use (and duration of use) of indwelling vascular and bladder catheters, reducing the incidence and duration of profound neutropenia (<500 neutrophils/L), and more aggressively treating localized nosocomial infections. Indiscriminate use of antimicrobial agents and glucocorticoids should be avoided, and optimal infection-control measures should be used. Several studies point to associations between allelic polymorphisms in specific genes and risk of severe sepsis; if these associations prove to be broadly applicable, such polymorphisms can be used prospectively to identify high-risk patients and to target preventive or therapeutic measures to them. Studies indicate that 50­70% of patients who develop nosocomial severe sepsis or septic shock have experienced a less severe stage of the septic response (e. Research is needed to develop adjunctive agents that can damp the septic response before organ dysfunction or hypotension occurs. The lung injury may be direct, as occurs in toxic inhalation, or indirect, as occurs in sepsis (Table 30-1). These include older age, chronic alcohol abuse, metabolic acidosis, and severity of critical illness. The exudative phase is notable for early alveolar edema and neutrophil-rich leukocytic infiltration of the lungs with subsequent formation of hyaline membranes from diffuse alveolar damage. Within 7 days, a proliferative phase ensues with prominent interstitial inflammation and early fibrotic changes. However, some patients enter the fibrotic phase, with substantial fibrosis and bullae formation. In response to proinflammatory mediators, leukocytes (especially neutrophils) traffic into the pulmonary interstitium and alveoli. In addition, condensed plasma proteins aggregate in the air spaces with cellular debris and dysfunctional pulmonary surfactant to form hyaline membrane whorls. Alveolar edema predominantly involves dependent portions of the lung, leading to diminished aeration and atelectasis. Consequently, intrapulmonary shunting and hypoxemia develop, and the work of breathing increases, leading to dyspnea. The pathophysiologic alterations in alveolar spaces are exacerbated by microvascular occlusion, which leads to reductions in pulmonary arterial blood flow to ventilated portions of the lung, increasing the dead space, and pulmonary hypertension. Although usually present within 12­36 h after the initial insult, symptoms can be delayed by 5­7 days. In the acute phase of the syndrome (right-hand side), there is sloughing of both the bronchial and alveolar epithelial cells, with the formation of protein-rich hyaline membranes on the denuded basement membrane. Neutrophils are shown adhering to the injured capillary endothelium and marginating through the interstitium into the air space, which is filled with protein-rich edema fluid. The influx of protein-rich edema fluid into the alveolus has led to the inactivation of surfactant. Tachypnea and increased work of breathing frequently result in respiratory fatigue and ultimately in respiratory failure. Laboratory values are generally nonspecific and primarily indicative of underlying clinical disorders. The chest radiograph usually reveals alveolar and interstitial opacities involving at least three-quarters of the lung fields. Acinar 293 architecture is markedly disrupted, leading to emphysemalike changes with large bullae. Intimal fibroproliferation in the pulmonary microcirculation leads to progressive vascular occlusion and pulmonary hypertension. The physiologic consequences include an increased risk of pneumothorax, reductions in lung compliance, and increased pulmonary dead space. Most patients recover rapidly and are liberated from mechanical ventilation during this phase. Despite this improvement, many still experience dyspnea, tachypnea, and hypoxemia. Some patients develop progressive lung injury and early changes of pulmonary fibrosis during the proliferative phase. Histologically, the first signs of resolution are often evident in this phase with the initiation of lung repair, organization of alveolar exudates, and a shift from a neutrophil to a lymphocyte-predominant pulmonary infiltrate. These specialized epithelial cells synthesize new pulmonary surfactant and differentiate into type I pneumocytes. Thus, caring for these patients requires close attention to (1) the recognition and treatment of the underlying medical and surgical disorders (e. Ventilator-Induced Lung Injury Despite its life- saving potential, mechanical ventilation can aggravate lung injury. Experimental models have demonstrated that ventilator-induced lung injury appears to require two processes: repeated alveolar overdistention and recurrent alveolar collapse. Because of their differing compliance, attempts to fully inflate the consolidated lung may lead to overdistention and injury to the more "normal" areas of lung. Mortality was significantly lower in the low tidal volume patients (31%) compared with the conventional tidal volume patients (40%).

In the great majority of the cases the lesion is located on the posterior part of the hard palate antiviral eye ointment prograf 1mg lowest price, but isolated cases have been described on the lower lip hiv infection map prograf 1mg on-line, buccal mucosa symptoms of hiv infection mayo clinic cheap 1 mg prograf mastercard, retromolar pad hiv infection from blood test prograf 5 mg cheap, parotid gland, and extraorally. The cause of the lesion is unknown, although the theory of ischemic necrosis after vascular infarction seems acceptable. The lesion has a sudden onset and clinically may present as a nodular swelling that later leads to a painful craterlike ulcer with irregular and ragged border. The differential diagnosis includes mucoepidermoid carcinoma, other malignant salivary gland tumors, squamous cell carcinoma, lethal midline granuloma, traumatic ulcer, and pleomorphic adenoma. Other Salivary Gland Disorders Sialolithiasis Sialoliths are calcareous deposits in the ducts or the parenchyma of salivary glands. The submandibular gland sialoliths are the most common (about 80%), followed by parotid gland, sublingual glands, and minor salivary glands. When sialoliths increase in size, they may produce partial or complete obstruction of the duct, leading to a sialadenitis. Clinically, it presents as a painful swelling of the gland, especially during a meal. When the sialolith is located at the peripheral part of the duct, inflammation occurs. If the calculus is large, it is palpable and occasionally can be seen at the duct orifice. Sialadenosis Sialadenosis is a rare noninflammatory, nonneoplastic enlargement of the parotid and rarely the submandibular glands. The exact etiology remains unknown but the disorder has been found in association with liver cirrhosis, diabetes mellitus, chronic alcoholism, malnutrition, and thyroid and ovarian insufficiencies. Clinically, it presents as a bilateral painless swelling of the parotids that usually recurs. It is usually present in association with systemic diseases, such as tuberculosis, sarcoidosis, lymphoma, and leukemia. Therefore the meaning of the syndrome is theoretical and the diagnosis of the underlying disease has to be established. Xerostomia Xerostomia is not a nosologic entity, but a symptom caused by a decreased or total absence of salivary secretions. Clinically, the oral mucosa is dry, red, cracked, and the epithelium becomes atrophic. Laboratory test to determine xerostomia are the salivary flow rate, sialography, histopathologic examination, scanning, and serologic tests. Pilocarpine and an etholetrithione have been used to stimulate salivary gland secretion. Tumor-like Lesions Pyogenic Granuloma Pyogenic granuloma is a common granulation tissue overgrowth in reaction to mild irritation. It has a higher incidence in females (ratio 2:1) and occurs at any age, although about 60% of the patients are between 11 and 40 years of age. Clinically, pyogenic granuloma appears as a painless exophytic, nodular mass that is pedunculated or sessile with a deep red color. The surface may be smooth or lobulated, often ulcerated, and it is covered by a white-yellowish membrane. The lesion is soft and has a tendency to hemorrhage spontaneously or after slight irritation. The gingiva is the most common site of involvement (about 70%), followed by the tongue, lips, buccal mucosa, palate, etc. Pregnancy Granuloma Pregnancy granuloma occurs during pregnancy and is clinically and histopathologically identical to pyogenic granuloma. Clinically, it appears as a single pedunculated mass with a smooth surface and red color. The differential diagnosis includes pyogenic granuloma and peripheral giant cell granuloma. During pregnancy, it can be removed under local anesthesia if it causes discomfort. Postextraction Granuloma Postextraction granuloma, or epulis granulomatosa, is a pyogenic granuloma that characteristically appears in the tooth socket after tooth extraction. The cause is usually the presence of a foreign body, such as bone sequestrum, amalgam remnants, with subsequent reactive inflammatory tissue formation. Fistula Granuloma Fistula granuloma is a pyogenic granuloma that is characteristically found at the opening of the duct of a dental or periodontal fistula. Clinically, it appears as a well-circumscribed pedunculated or sessile tumor of dark red color that is hemorrhagic and often ulcerated. It usually appears on the gingiva, but it can also be found at an edentulous area. Peripheral Giant Cell Granuloma Peripheral giant cell granuloma is a tumor with characteristic clinical and histopathologic features, which is exclusively found on the gingival region of both jaws. It is not a true neoplasm, but a tissue reaction to local irritation occurring during mixed dentition. Before the 16th year of age, it is more common in males, although after the 16th year of age, it is twice as common in females. Congenital Epulis of the Newborn Congenital epulis of the newborn is a rare non-neoplastic reactive or degenerative lesion probably arising from mesenchymal cells. It appears in newborn infants, exclusively on the alveolar ridges of the maxilla and mandible. The lesion develops commonly on the maxilla and occurs about ten ti mes more frequently in female than male babies. Clinically, it is present at birth, and it appears as an asymptomatic solitary pedunculated tumor of red or normal color, which ranges from a few millimeters to a few centimeters in diameter. The differential diagnosis includes the melanotic neuroectodermal tumor of infancy, pyogenic granuloma, and fibroma. Patsakas A, Demetriou N, Angelopoulos A: Melanin pigmentation and inflammation in human gingiva. Fraser F, Warburton D: No association of emotional stress or vitamin supplement during pregnancy to cleft lip or palate in man. Kolas S, Halperin V, Jefferis K, et al: the occurrence of torus palatinus and torus mandibularis in 2,478 dental patients. Natsume, N, Suzuki T, Kawai T: the prevalence of cleft lip and palate in the Japanese: Their birth prevalence in 40. Sewerin I: the sebaceous glands in the vermilion border of the lip and in the oral mucosa of man. A clinical, histological and microradiographic study with special reference to oral manifestations. Banoczy J, Sugar L, Frithiof L: White sponge nevus: Leukoedema exfoliativum mucosae oris. Abnormalities of the enamel, dentine, cementum and the dental pulp: Histological examination of 13 teeth from 6 patients. Bazopoulou E, Laskaris G, Katsabas A, Papanicolaou S: Familial benign acanthosis nigricans with predominant, early oral manifestations. Bergman R, Friedman-Birnbaum R: Papillon-Lefevre syndrome: A study of the long-term clinical course, recurrent pyogenic infections and the effects of etretinate treatment. Tagami Y, Akutsu Y, Suzuki M, Takahashi M: Familial benign chronic pemphigus generalized by pseudomonas infection. Gorlin R, Cohen M, Levin S: Syndromes of the Head and Neck: Oxford University Press, New York-Oxford, 1990. Haneke E: the Papillon-Lefevre syndrome: Keratosis pulmoplantaris with periodontopathy. Heinze R: Pemphigus chronicus benignus familiaris (Gougerot-Hailey-Hiley) mit Schleimhautbeteiligung bei einer Diabetikerin. Ida M, Nakamura T, Utsunomiya J: Osteomatous changes and tooth abnormalities found in the jaws of patients with adenomatosis coli. Laskaris G, Drikos G, Rigopoulos A: Oral-facial-digital syndrome: Report of a case. Laskaris G, Vareltzidis A, Avgerinou G: Focal palmoplantar and oral mucosa hyperkeratosis syndrome. Selected Bibliography Thormann J, Kobayasi T: Pachyonychia congenita JadassohnLewandowsky: A disorder of keratinization. Mechanical Injuries Bergendal T, Isaccson G: Effect of nystatin in the treatment of denture stomatitis. Bergendal T, Isacsson G: A combined clinical, mycological and histological study of denture stomatitis.

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