Group 7

Medical School, Tarumanagara University

Group 7
Tutor : dr. Arlends Chris, Msi
Group members : Kurnia Frastika Pangaribuan 405120090
Bernadetha Vania Eveliani 405130003
Vonny Verania Khuangga 405130005
Citra Dewi 405130023
Vitro Septrian 405130029
Gilda Jahja 405130035
Reyna Lauwsen 405130045
Rizky Lumalessil 405130071
Lisa Alverina 405130096
Stefan Cahyadi 405130107
Rachel Natalia 405130192
Ahmad Fathul Adzmi 405130213
 Review

complaints Bad breath, dry mouth, Smoking and

cracked lips consuming alcohol

Dental caries

Swelling below the right

jaw

Dysphagia White patches, ulcer on tongue

Lymphadenopathy Submandibular
abcess
Congenital Hereditary Candidiasis Leukoplakia
Learning Objectives

1. Anatomy, histology, biochemistry and physiology of the upper

digestive system.
2. Dysphagia.
3. Diagnostic procedures of caries dentis, gingivitis, mouth ulcers,
leukoplakia, halitosis, dry mouth, cleft lip, aphthous,
lymphadenopathy.
Learning Objective 1
Anatomy: Mouth and Oral Cavity
Anatomy: Teeth and Tongue
Anatomy: Salivary Glands

Glandula submandibularis, glandula parotidea, glandula sublingualis

Nodi lymphoidei submandibulares
Histology: Lip

http://classconnection.s3.amazonaws.com/340/flashcards/550340/jpg/lip1306729121652.jpg
Histology: Tongue
Filiform papillae Circumvallate papillae

http://www.vetmed.vt.edu

Fungiform papillae

http://www.lab.anhb.uwa.edu.au

http://www.vetmed.vt.edu
Histology: Teeth

http://www.histology.leeds.ac.uk/oral/mouth.php
Histology: Esophagus

http://legacy.owensboro.kctcs.edu/gcaplan/anat2/histology/esophagus3.jpg
Biochemistry: Enzymes
 Enzymes: breaking down food substances into forms
that can be absorbed and assimilated by the body.

 Normally secreted :
 In the mouth (as part of the saliva)
 By the stomach
 Released into the small intestines from the liver and pancreas
Biochemistry: Mouth  Saliva
 Secreted from the parotid,
submandibular and sublingual
glands
 Stimulated by mechanical
chewing, taste, and even sight,
smell, and thought of food
 The average daily  > 1000 ml
 pH of saliva is about 6,8
 Electrolytes in saliva  Na & Cl  Mucin (glycoprotein)
< K & HCO3
 The main constituents :
 Water (99.5%)
 Some inorganic substance
(e.g. Na, K, Cl, HCO3, traces
of iodide and thiocynate)
 Few organic substances
(urea, glucosa, lactic acid)
along with some enzyms
like lysozyme and ptyalin
Biochemistry: Esophagus
 Secretes only mucus
 Acts as a lubricant
 Protects the upper esophageal part from being excoriated by
food particles and the lower esophageal part from being
digested by the gastric juice flowing back from the stomach
Physiology: The Upper Digestive System
 Digestive Processes:
 Motility
 Secretion
 Digestion
 Absorption

Digestive Motility Secretion Digestion Absorption

organ
Mouth and Chewing Saliva: Carbohydrate No foodstuffs; a
salivary • Amylase digestion begins few medications
glands •Mucus (e.g. Nitoglycerin)
•Lysozyme
Pharynx and Swallowing Mucus None None
esophagus
Physiology: Functions of Saliva
 Begins digestion of dietary starches (amylase)
 Facilitates swallowing: moistening food particle & lubrication
(mucus)
 Antibacterial action by lysozyme, binding glycoprotein,
lactoferin, rinsing away material that may be a food source for
bacteria
 As a solvent for molecules that stimulates the taste buds
 Aids speech by facilitating movements of the lips & tongue
 Keep the mouth and teeth clean
 Rich in bicarbonate buffer: neutralize acids in food and acids
produced by bacteria in the mouth  prevent dental caries

Sherwood L. Human physiology: from cells to systems. 8th ed. Belmont:Brooks/Cole cencage Learning; 2013
Physiology of Swallowing

Sherwood L. Human physiology: from cells to systems. 8th

ed. Belmont:Brooks/Cole cencage Learning; 2013
Learning Objective 2
 Dysphagia
Definition People with dysphagia have difficulty swallowing and may even
experience pain while swallowing (odynophagia), may be completely
unable to swallow or may have trouble safely swallowing liquids, foods,
or saliva
Risk - Problem with the neural control or the structures
Factors - Weak tongue or cheek muscles
- A stroke or other nervous system disorder
- After cancer surgery
Etiology - Any condition that weakens or damages the muscles and nerves used
for swallowing
- Stroke or head injury
- People born with abnormalities of the swallowing mechanism
- Cancer of the head, neck, or esophagus
- An infection or irritation
- Disorders of the esophagus
Dysphagia: Symptoms
Oral Phase Pharyngeal Phase Esophageal Phase
- Drooling - Foamy phlegm, nasal - Sticking
- Oral regurgitation - Pain
retention - Coughing while eating / - Regurgitation
- Difficulty in drinking - Hiccups
chewing or - Coughing before / after - More difficulty
inadequately swallow with solids
chewed food - Wet / hoarse / breathy
- Stranded voice, weak cough,
phlegm inappropriate breathing
- Food sticking - Swallowing in-
coordination
- Aspiration, food sticking
http://www.nidcd.nih.gov/health/voice/pages/dysph.aspx
 Dysphagia
Diagnosis - Transnasal esophagoscopy
- Cervical auscultation
- Blood tests  including TSH, vit B12, CK
- Imaging studies  videofluoroscopy, CT scan, MRI, chest radiography
- Endoscopic examination
- Esophageal pH monitoring
- Pulmonary function tests
Treatments - Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST)
- Videofluoroscopic swallow study (VFSS)
- Muscle exercises to strengthen weak facial muscles or to improve
coordination
- Exercise and facilitates technique
• Indirect (eg, exercises to strengthen swallowing muscles)
• Direct (eg, exercises to be performed while swallowing)
- Surgical intervention
Complications - Aspiration pneumonia
- Loss weight
- The development of a pocket outside the esophagus
http://www.nidcd.nih.gov/health/voice/pages/dysph.aspx
 Achalasia
Definition A primary esophageal motility disorder characterized by the
absence of esophageal peristalsis and impaired relaxation of the
lower esophageal sphincter (LES) in response to swallowing
Sign and - Dysphagia (most common)
Symptoms - Regurgitation
- Chest pain
- Heartburn
- Weight loss
Diagnosis - Barium swallow
- Esophageal manometry
- Prolonged esophageal pH monitoring
- Esophagogastroduodenoscopy
Treatments - CCB and nitrates
- Endoscopic intrasphincteric injection of botulinum toxin
- Laparoscopic Heller myotomy
- Peroral endoscopic myotomy (POEM)
- Surgery fails  endoscopic dilatation first
http://reference.medscape.com/article/169974-overview
http://gi.org/guideline/diagnosis-and-management-of-achalasia/
 Angina Ludwig
Definition A bilateral infection of the submandibular space that consists of
two compartments in the floor of the mouth, the sublingual space
and the submylohyoid / submaxillary space
Etiology - Odontogenic infections
- Mandible fracture, neck trauma, tongue piercing, sialdenitis,
neoplasm, and other parapharyngeal infections
- Polymicrobial infection
- Patients with immunocompromising conditions
Symptoms - Dental pain
- Neck pain and swelling
- Dysphonia
- Dysphagia
- Dysarthria
- Respiratory distress with dyspnea, tachypnea, or stridor

http://www.medscape.com/viewarticle/551650_4
https://www.nlm.nih.gov/medlineplus/ency/article/001047.htm
 Leukoplakia
Definition Whitish patch or plaque that is associated with the use of tobacco
Etiology Idiopatic
Risk Factors - Tobacco use
- Alcohol consumption
- Chronic irritation
- Candidiasis
- Vitamin deficiency
- Endocrine disturbances
Treatments - Vitamin A and retinoids
- Systemic beta carotene
- Lycopene (a carotenoid)
- Ketorolac as mouthwash
- Local bleomycin
- Mixture of tea used both topically and systemically with a reduced benefit
- Surgical treatment

https://www.nlm.nih.gov/medlineplus/ency/article/001046.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4268300/
 Oral Candidiasis
Definition A condition in which Candida albicans accumulates on the lining of your
mouth
Symptoms -Creamy white lesions on your tounge, inner cheeks, and sometimes on
the roof of your mouth, gums, and tonsils
- A cottage cheese-like appearance
- Redness or soreness
- Slight bleeding
- Cracking and redness at the corner of your mouth
- A cottony feeling in your mouth
- Loss of taste
Risk -Some health conditions  HIV/AIDS, cancer, DM, vaginal yeast
Factors infections
- Undergoing chemotherapy or radiation treatment for cancer
- Wearing dentures
-Taking antibiotics or oral or inhaled corticosteroids
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/definition/con-20022381
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/symptoms/con-20022381
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/risk-factors/con-20022381
 Mumps
Etiology Paramyxovirus
Sign and - Fever
Symptoms - Headache
- Muscle aches
- Tiredness
- Loss of appetite
- Swollen and tender salivary glands under the ears on one or both
Diagnosis - PCR
- Culture
- Serology
Complications - Orchitis
- Pancreatitis
- Unilateral deafness
- Death
MMR Vaccine - One dose for children 12 months and older
- Second dose for school-age children and adults

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/mumps.pdf
http://www.cdc.gov/mumps/about/signs-symptoms.html
 Glossitis
Definition Problem in which the tongue is swollen and changes color, often
making the surface of the tongue appear smooth
Etiology - Allergic reactions to oralcare products, foods, or medicine
- Dry mouth due to Sjogren syndrome
- Infection from bacteria, yeast or viruses
- Injury
- Skin conditions that affect the mouth
- Irritants
- Hormonal factors
Symptoms - Problems chewing, swallowing, or speaking
- Smooth surface of the tongue
- Sore, tender, or swollen tongue
- Pale or bright red color to the tongue
- Tongue swelling
- Blocked airway

https://www.nlm.nih.gov/medlineplus/ency/article/001053.htm
 Cleft Lip Cleft Palate
• The lip forms between the fourth  The roof of the mouth (palate) is
and seventh weeks of pregnancy formed between the sixth and
• A cleft lip happens if the tissue ninth weeks of pregnancy
that makes up the lip does not join  A cleft palate happens if the tissue
completely before birth that makes up the roof of the
• This results in an opening in the mouth does not join together
upper lip completely during pregnancy
• The opening in the lip can be a
small slit or it can be a large
opening that goes through the lip
into the nose
• Children with a cleft lip also can
have a cleft palate

http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html
Esophageal Atresia
 Esophageal atresia is a congenital defect
 The upper esophagus ends and does not connect
with the lower esophagus and stomach
 Tracheoesophageal fistula (TEF) is a condition in
which an abnormal channel (fistula) connect the
windpipe (trachea) to the tube that leads from the
mouth to the stomach (esophagus)

http://emedicine.medscape.com/article/935858-overview
https://www.nlm.nih.gov/medlineplus/ency/article/000961.htm
Squamous cell carcinoma
 90% of oral cancers are of the squamous cell type
 Early carcinoma may clinically appear as leukoplakia or
erythroplasia or as a mixture of both
 Risk factors are smoking and alcohol
 Treatment: surgical excision and possible irradiation.
Chemotherapy is adjunctive at this time.
 Prognosis: overall five year survival rate is abt 50%
 DD: all ulcerations present for more than 2-3weeks with
no apparent cause should be biopsied to rule out
carcinoma
Learning Objective 3
 Caries Dentis
Definition A common problem that occurs when acids in your mouth
dissolve the outer layers of your teeth
Risk Factors - Diet (food and drink high in carbohydrats)
- Poor oral hygiene
- Smoking and alcohol
- Dry mouth
Sign and - Toothache
Symptoms - Tooth sensitivity (tenderness or pain)
- Grey, brown or black spots
- Bad breath
- Unpleasant taste in mouth
Physical - Early sign: chalky white appearance of the enamel surface
Examinations - If the caries progresses: enamel surface becomes dark brown or
black
- Late sign: holes or cavites in the affected tooth
Diagnosis X-ray
http://www.nhs.uk/conditions/Dental-decay/Pages/Introduction.aspx
http://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html
http://www.nhs.uk/Conditions/Dental-decay/Pages/Causes.aspx
http://www.myvmc.com/diseases/dental-caries/
 Mouth Ulcers
Definition Small lesions that develop in your mouth or at the base of your gums
Risk Factors - Woman
- Family history of mouth ulcers
Types - Simple canker sores  may appear three or four times a year and
last up to a week; occur in people between 10 and 20 years of age
- Complex canker sores  occur more often in people who have
previously had them
Etiology - Minor injury to mouth
- Toothpastes and mouth rinses that contain sodium lauryl sulfate
- Food sensitivities to acidic foods
- Lack of essential vitamins like B-12, zinc, folate, and iron
- Allergic response to mouth bacteria
- Hormonal influxes during menstruation
- Emotional stress
- Bacterial, viral, or fungal infections

http://www.healthline.com/symptom/mouth-ulcers
http://www.webmd.com/oral-health/guide/canker-sores
Sign and - Painful sore or sores inside your mouth
Symptoms - Tingling or burning sensation before the sores appear
- Round, white or gray, with a red edge or border
- Fever
- Physical sluggishness
- Swollen lymph nodes
Treatments - Rinse of saltwater and baking soda
- Applying ice to canker sores
- Using mouth rinse that contains steroid to reduce pain and
swelling
- Using topical pastes
- Using oral steroids
Complications - Cellulitis of the mouth
- Dental infections (tooth abscesses)
- Oral cancer
- Spread of contagious disorders to other people

http://www.healthline.com/symptom/mouth-ulcers
http://www.webmd.com/oral-health/guide/canker-sores
https://www.nlm.nih.gov/medlineplus/ency/article/001448.htm
Halitosis
 Definition
 Bad breath, oral malodor
 The result of microbial metabolism

 Diagnostic procedures
 Organoleptic measurements: the use of one’s nose to smell and rank the
intensity of odors.
 Rosenberg scale
 0 - Odor cannot be detected
 1 - Questionable malodor, barely detectable
 2 - Slight malodor, exceeds the threshold of malodor recognition

 3 - Malodor is definitely detected

 4 - Strong malodor
 5 - Very strong malodor
Dry Mouth
 Definition
 The feeling that there
is not enough saliva
in the mouth.
 A subjective
complaint-symptom
of dry mouth.
Lymphadenopathy
 Definition
 Swelling of the lymph nodes.

 Diagnostic Procedures
 For chronic lymphadenopathy (>3 wk):
 CBC count, including a careful evaluation of the peripheral blood
smear
 Lactate dehydrogenase (LDH) and uric acid
 Chest radiography
 B henselae (catscratch) serology if exposed to a cat
 Tuberculosis skin test (TST) and interferon-gamma release assay (eg,
Quantiferon Gold)
Summary and suggestion
 According to the informations obtained from the problem text,
the patient may be having dysphagia caused by achalasia.
 His smoking and alcohol drinking habit may be the cause of
the white patches of the oral mucosa and ulcers on tongue.
 Lymphadenopathy may be the cause of the swelling of the
right jaw.
 His previous history of surgery when he was a newborn due to
inability of swallowing may be caused by congenital disorders:
esophageal atresia or cleft lip/cleft palate.

 To establish the diagnosis, we suggest the patient to do some

further examinations and stop his smoking and drinking habit.
Referensi
 Sobotta, Atlas der Anatomie des Menschen , 23. A. Elsevier GmbH. Munchen. 2010.
 Sherwood L. Human physiology: from cells to systems. 8th ed. Belmont:Brooks/Cole cencage Learning;
2013.
 http://www.nidcd.nih.gov/
 http://gi.org/
 http://www.medscape.com/
 https://www.nlm.nih.gov/
 http://www.ncbi.nlm.nih.gov/
 http://www.cdc.gov/
 http://www.nhs.uk/
 http://www.webmd.com/
 http://www.mayoclinic.org/
 http://www.healthline.com/
 http://www.nidcr.nih.gov/
 http://dentistry.umkc.edu/
 https://www.urmc.rochester.edu/