4th Year #2

Question 1

Advantages of the coronal seal? vital and nonvital?

Answer 1

Vital:➢Provides increased pulpal protection➢Prevents caries at and beneath restoration marginNon-vital:➢Provides additional line of defence to endodontic seal➢Prevents caries at and beneath restoration margin

Question 2

Describe amalgam as a core material? Adv and Dis?

Answer 2

Advantages - Not especially technique sensitive - Strong in bulk section - Sealed by corrosion products - Can be bonded into place withcements and resinsDisadvantages- Best left to set for 24 hours before tooth preparation- Weak in thin section- Potential electrolytic action betweencore and metal crown- Not intrinsically adhesive- Poor aesthetics under ceramicrestorations

Question 3

Indications for amalgam as a core material?

Answer 3

 Excellent core build-up material for posterior teeth Excellent interim restoration for posterior teeth Adhesives and preparation features can often substitute for pinretention

Question 4

Describe composite as a core material? Adv and Dis?

Answer 4

Advantages - Strong- Can be used in a thinner section thanamalgam- Fast setting (either light or chemicallycured)- Does not always need a matrixduring placementDisadvantages- Highly technique sensitive- Relies on multi-stage dentinebonding requiring effective isolation- Dentine bond can be ruptured bypolymerisation contraction- Can be difficult to distinguishbetween tooth and core duringpreparation

Question 5

Indications of composite for core build up?

Answer 5

Excellent build-up material for posterior and anterior teeth if isolationassuredAesthetic interim restoration, but takes far longer to place than amalgam

Question 6

Should we remove the exisiting restoration?

Answer 6

Removal of existingrestorations allows properassessment of:➢The tooth’s structural integrity➢Pulpal exposure➢Underlying caries

Question 7

Describe the Nayyar core?

Answer 7

“Postless” preparationRetention from coronal and radicular toothtissueUses pulp chamber as retention and resistance form

Question 8

Advantages of the Nayyar core?

Answer 8

 Can be placed immediately after endo –reducing risk of coronal leakage Utilises coronal tooth structure to increaseretention Reduces stresses created by post placement Usually easily retrievable

Question 9

How to diagnose post-treatment disease?

Answer 9

may not be straight forward as you may be dealing with partially treated pulp canals, missed canals or procedural mishaps. These should be included in the diagnostic description.

Question 10

Name the 3 advantages of fixed options?

Answer 10

PsychologicalBiologicalFunctional

Question 11

What are the the psychological advantages of fixed options?

Answer 11

If own tooth used, reduces the impact of “loss”Looks and feels the same as before- no adaptation to new “body image”No need to remove – is part of the patient, no embarrassment

Question 12

What are the the biological advantages of fixed options?

Answer 12

No additional soft tissue coverageNo increase in plaque retentionMaintains interdental space effectively - worn constantly unable to remove

Question 13

What are the the functional advantages of fixed options?

Answer 13

Speech is unaffectedCannot be easily lostLess susceptible to breakageMinimal need for patient adaptation

Question 14

Explain the process to prepare a recently extracted tooth for fixed immediate replacement?

Answer 14

Extraction + cleaningTooth decoronatedRC sealed with GICOrtho wires attachedTooth carefully positioned and attached to adj teeth using composite resinOcclusion was carefully checked and adjusted

Question 15

Explain the process to prepare an acrylic tooth for fixed immediate replacement?

Answer 15

Model made prior to extractionLab cuts tooth from modelTrims acrylic denture tooth to fit space and occlusal schemeAdds orthodontic wire for bonding to adjacent teethAcrylic denture tooth to fit space and occlusal schemeOrthodontic wire for bonding to adjacent teeth

Question 16

Explain the process to prepare asemi-permanent solution for fixed immediate replacement?

Answer 16

Prepare palatal surfaces of both the pontic and abutment teethMake working casts of upper and lower archesCut tooth to be replaced from the modelReposition the “extracted” toothConstruct metal framework for retentive elementsExtraction of the affected toothPartially decoronate toothWiden canal access and irrigate with sodium hypochlorite solutionComplete trimming of the tooth to the correct gingival length and contour.Seal the opening to the pulp chamber with glass ionomer cement.Position tooth on metal retainer and bond with bonding agent.Position the bridge retainer accurately against the abutment tooth and check fit and asestetics.Carefully isolate the abutment tooth. Wash and dry the retainer.Bond the bridge into position using appropriate bonding agent.

Question 17

What are the risks and benefits of orthodontic treatment?

Answer 17

Benefit:- improved function- improved aestehticsRisks:- reduced dental health- failre to achieve aims

Question 18

Name the 7 suggested health benefits of orthodontic treatment?

Answer 18

Reducing caries susceptibility - however caries progression is multifactoralReduces Gingivitis and Periodontal disease - other factors can be importantReducing trauma risk (Correcting Increased overjet) - >6mm overjet 3 x riskMasticatory Function - overjet/AOB eating difficultiesSpeech - malocclusion little impactTooth impactionPsychological well being (Aesthetic impact) - impact on self-esteemand quality of life

Question 19

Name the 4 risks of orthodontic treatment?

Answer 19

• Dental caries (Decalcification) : - ↑poor oral hygiene, cariogenic diet * Root Resorption (Root shortening)* Ginigivitis / loss of attachment ↑ patients with unstable periodontal disease* Soft tissue trauma (Ulcers

Question 20

What is the purpose of the index of orthodontic treatment need?

Answer 20

developed to help determine likely impact of malocclusion on dental health and psychological well being.

Question 21

Name 3 types of treatment startegies for orthodontic treatment?

Answer 21

Orthodontic treatment onlyOrthodontic / Surgical TreatmentOrthodontic / Restorative Treatment

Question 22

What are the 6 indications for orthodontic treatment?

Answer 22

• Motivated Patient * Stable dental health * Caries free minimum of 12 months* Healthy periodontium* Low plaque scores (adequate Oral hygiene)* Benefits of orthodontic treatment outweigh risks (IOTN)

Question 23

Name the 4 contraindicators for orthodontic treatment?

Answer 23

• Poor Dental Health (active caries/periodontal health issues)* Oral Hygiene Issues * Poor Co-operation / Tolerance issues* Low treatment need (Risks vs Benefits-IOTN)

Question 24

Name the 3 types of orthodontic appliances?

Answer 24

• Removable* Functional * Fixed

Question 25

What is the definition of a removable appliance?

Answer 25

An orthodontic appliance that can be removed by the patient

Question 26

Name the 3 main components of an orthodontic appliance?

Answer 26

• Active Components* Retentive Components* Anchorage (Newtons 3rd Law of motion)* Baseplate/ Bite planes

Question 27

Name a form of retentive components?

Answer 27

Adams clasps

Question 28

Name a form of active component?

Answer 28

Palatal finger spring

Question 29

What is the definition of anchorage?

Answer 29

• Newtons ‘third law of motion’* For every force applied there is an equal and opposite reactionary force* Anchorage relates to control of these reactionary forces

Question 30

Name the 3 planes of space for anchorage?

Answer 30

• A-P * Transverse* Vertical

Question 31

What are the advantages and disadvantages of removable appliances?

Answer 31

Advantages* Can be removed for cleaning (after meals)* Cheap (cf fixed appliances)* Less chair-side time * Palatal Coverage / Good AnchorageDisadvantages* Appliance is removable!* Limited tooth movements possible (tipping)* Lower appliance poorly-tolerated

Question 32

What are 12 clinical tips for the use of a removable appliance?

Answer 32

• Fit appliance passively initially * Demo fit and removal carefully* Stress F/T wear except cleaning* Warn re: speech* No extractions until compliance confirmed* Review every 4 weeks* First return appointment* Assess progress- is patient wearing it (not in a box or their pocket !) * Appliance fit* Wear signs – on mucosa* Speech returned to normal* Gentle activation of active components

Question 33

Name the 8 indications for the use of a removable orthodontic appliance?

Answer 33

1. Alignment of mesially-inclined canines2. Crossbite correction3. Overjet reduction4. Overbite reduction5. Eliminate occlusal interferences6. Adjunct to fixed appliances7. Space maintenance8. Retention

Question 34

Name the 2 contraindications for removable orthodontic appliances?

Answer 34

Multiple tooth movements* Complex tooth movements required1. Intrusion/extrusion2. Bodily movement3. De-rotation

Question 35

What is the definition of a functional orthodontic appliance?

Answer 35

‘Removable or fixed orthodontic appliances which use forces generated by the stretching of muscles, fascia and/or periodontium to alter skeletal and dental relationships

Question 36

What are the benefits of using a functional orthodontic appliance?

Answer 36

• Growing Patients* Correct Malocclusions of Skeletal Origin* May modify growth ? ?* Commonly used in Class 2 patients with mandibular retrognathia.* Hoping to enhance mandibular growth/restrain maxillary growth * Treatment approach often referred to as ‘Growth Modification’

Question 37

What situation is best for a functional orthodontic appliance?

Answer 37

• Class 2 malocclusions-* Class 3 malocclusions (Less common)

Question 38

Describe an ideal functional orthodontic appliance patient?

Answer 38

• Growing patient* Class 2 div 1 malocclusion (or Class 2 Div 2 )* Mandibular Retrognathia* Average or reduced vertical proportions* Increased OJ/OB* (Well aligned arches) also crowded cases as first stage treatment

Question 39

Explain how to construct a functional appliance?

Answer 39

• U + L Alginate impressions* Working bite* Teeth out of occlusion* Postured forward (the facial musculature is stretched and forces are generated)

Question 40

Explain how to take a working bite for a functional appliance?

Answer 40

• Patient postures to Class 1 or edge to edge* Record the postured occlusion with wax or silicone registration paste

Question 41

Name 3 types of mode of action for rothodontic appliances?

Answer 41

• Dentoalveolar (Dental Effects)- Tipping movements - Eruption guidance* Skeletal (Orthopaedic or Growth Effects)- Restriction of maxillary growth- Increased rate of mandibular growth- Remodelling changes in the TMJ* Modification of soft tissue activity

Question 42

What is the definition of dental tipping?

Answer 42

• Typical Class 2 div 1- Upper incisor retroclination- Lower incisor proclination

Question 43

What is the definition of eruption guidance?

Answer 43

• Achieved with bite planes/capping- Anterior - PosteriorProduce - Differential eruption - Inhibits eruption of upper posteriors- Encourages mesial eruption of lower posteriors (Class 2 correction)

Question 44

What is the defintion of skeletal mode of action?

Answer 44

• Enhanced Mandibular Growth ?* Elongation is brought about by deposition at the condyle and the posterior border of the ramus.

Question 45

What is the definition of modifying soft tissues?

Answer 45

• Lip competency * Changing the linguo-facial muscle balance - Shields - Screens* Teeth erupt into a position of balance

Question 46

WHich modes of action do functional appliances use?

Answer 46

• Eruption guidance - Bite planes* Mandibular repositioning - Working bites* Altering soft tissue balance - Shields and modifying lip activity

Question 47

Name the 3 classifications for functional appliances?

Answer 47

• Tooth borne (‘Twin block’)- Mostly dental tipping- Good retention- generally well tolerated* Soft tissue borne- Less retention - Difficult to achieve 24 hr wear* Fixed functionals

Question 48

Name 3 examples of tooth borne functional appliances?

Answer 48

• Twin Block* Frankel* Bionator* Herbst

Question 49

Describe a twin block functional appliance? - retention?

Answer 49

• Tooth borne via Clasps* Most commonly used* Well tolerated* F/T wear possible* In 2 parts, one upper, one lower* Bite blocks posture the mandible forward

Question 50

Describe a frankel functional appliance? - dentition type? soft tissue? probelms?

Answer 50

• Soft tissue borne appliance (‘Monobloc’)* Good in mixed dentition - Tooth loss does not affect retention* Good when soft tissues significantly contribute to the malocclusion- Expressive lower lip, lip trap* Problems : bulky, P/T wear only and breakages+

Question 51

How to maximise the success of a functional appliance?

Answer 51

• Keen patient and family support* Mild / moderate skeletal problem* Patient actively growing * Coordinate treatment with pubertal growth spurt- Boys age 12-14- Girls age 11-13

Question 52

Do functional appliances grow mandibles?

Answer 52

• Controversial* Early studies (Animal) suggested significant skeletal effects * Recent RCTs suggest mainly dental effects 90% and 10 % skeletal* Large individual variation in response* Difficult to predict

Question 53

Explain why to use a functional appliance to correct an increased overjet?

Answer 53

• Reduce risk of trauma * Improve profile* Help to allow lips to become competent* Improve smile aesthetics* Makes subsequent fixed orthodontics easier or can even be the only treatment required

Question 54

What is the definition of a fixed appliance?

Answer 54

• ‘Orthodontic appliance that is ‘fixed’/attached to teeth’. * Many different systems /lots of manufacturers

Question 55

Describe the differences in force betweeen fixed and removable appliances?

Answer 55

Bodily movement: - 1 area of tension- Heavier forces 100-150 gmsTipping: - different areas of tension (2)- Lighter forces 25-30 gms

Question 56

Name the 7 indications for the use of fixed appliances?

Answer 56

• Multiple tooth movements* Space closure with bodily movement * Intrusion/extrusion of teeth * Rotation correction * OB control with incisor intrusion* Mild to moderate skeletal discrepancies (camouflage treatment)* Severe Skeletal Discrepancies (+ Surgery)

Question 57

Name the advantages and disadvantages of using a fixed appliance?

Answer 57

Advantages:* Treating complex cases* High standards of finishing* Wear co-operation is not as essential as with removable appliances but still OH and diet care !* Less bulkier than removable appliances* Do not affect speechDisadvantages* Diet restriction and meticulous OH * Can cause iatrogenic effects (decalcification)* Cause Orthodontic root resorption (shortening)* Require special skill and training* Require close monitoring

Question 58

Describe the differences between Fixed and Removable?

Answer 58

Fixed:- Bodily Movement- Multiple tooth movements- Rotations corrected- OH more difficult- Less Co-op ??Removable:- Tipping movements only- Simple tooth movements- Rotations not corrected- OH easier (Removable)- More Co-op (Wear compliance)

Question 59

Name the components of fixed appliances?

Answer 59

BracketsArchwireElastic ligature

Question 60

What is the defintion of a bracket?

Answer 60

‘Handles on the teeth’ – control tooth position in combination with archwire.* 0.022’’ (inch) slot width size commonest * 0.018’’ (inch) more common in past* Slot design specific for each tooth (prescription)

Question 61

Describe the material of a bracket?

Answer 61

• Base of bracket* Curved to fit each tooth* Mesh base / retains composite resin* Pre –coated (APC) with composite .* Non pre-coated

Question 62

Name the 7 bracket types?

Answer 62

• Metal – standard SWA brackets ↑ * Metal – Self ligating* Metal- ‘tip-edge’* Aesthetic Systems* Ceramic* Lingual * (Aligners)

Question 63

What are the benefits of self ligating brackets?

Answer 63

• Claims by manufacturers* Quicker treatment * Allows expansion/favours non-extraction tx* Controversial as no evidence to support * Studies / RCTs* No difference Tx time* ? Longer appt intervals

Question 64

Describe a self ligating bracket type?

Answer 64

• Self Ligating* eg‘Damon’, Speed, Innovation, Smartclip* Active or Passive clip or gate* Less friction cf normal ligation

Question 65

What is the definition of tip edge brckets?

Answer 65

• Different tx philosophy* 2 stage tooth movement* Easy tipping – bracket ‘cut away’ design * Tip crowns and then upright roots* Lighter on anchorage

Question 66

What is the defintion of a lingual bracket type?

Answer 66

• Lingual* ‘Incognito’ 3M system* Expensive* Cast Gold* Customised for each tooth* Bonded – indirectly with preformed trays* Different instruments* Archform shape -‘mushroom’

Question 67

Explain the process to bond brackets to the teeth?

Answer 67

• Isolate* Pumice/Prophylaxis* Acid Etch (Phosphoric acid)* Irrigate/Dry* Apply Bonding agent* Place bracket with composite resin on bracket base* Remove excess composite* Light Cure

Question 68

What is the definition of an orthodontic band?

Answer 68

• Now – used on molars * Different sizes* Cemented with G.I.C* Separators / 1 week before placement* Can pre-select on model* Cemented with glass ionomer cement or light cured compomer* Glass ionomer / fluoride release

Question 69

What is the definition of an archwire?

Answer 69

• Interaction archwire/bracket slot → tooth movement* Archwire Variations* Shape * Size* Alloy type

Question 70

Describe the different types of archwire shapres?

Answer 70

• Round eg .014 Niti* Square eg .020 x .020 NiTi* Rectangular eg .019 x .025 NiTi

Question 71

Name the 3 alloy types of archwire?

Answer 71

• Nickel Titanium* Stainless Steel* B-Titanium (TMA)

Question 72

What is the definiion of NiTi archwire alloy?

Answer 72

• Thermally active / non thermally active* Super-elastic* increased Flexible* Shape memory * Initial alignment stages of treatment

Question 73

What is the defintiion of stainless steel archwire?

Answer 73

• increased Stiffness* increased Rigidity* decreased Flexibility* - if multistrated it increases* Working archwires* Levelling* Space closure* Finishing (add bends)

Question 74

What is the definition of Beta - Titanium archwire?

Answer 74

• Beta – Titanium (TMA)* Half way between NiTi and SS* Some flexibilty but more rigid than NiTi* Useful finishing stages of treatment eg adding torque or bends to archwire

Question 75

What is the definition of a elastic modules ligature?

Answer 75

• Used to retain archwire* Varied colours

Question 76

What is the definition of a elastic chain ligature?

Answer 76

• ‘Linked’ elastic modules* Used to space close

Question 77

What is the definition of a transpalatal arch?

Answer 77

• Across upper arch between molars* Soldered or removable attached to molar bands* Increases posterior anchorage* Maintains molar widths

Question 78

What is the definition of a Nance appliance?

Answer 78

• Similar to TPA* Anchors upper molar position* Acrylic button for additional anchorage from palate

Question 79

What is the definition of a coil spring?

Answer 79

• Orthodontic Coil Springs * Open/closed* Used space closure and openig

Question 80

What is the definition of a Zing String (Power thread)

Answer 80

• Elastic thread or tubing* Used to apply traction forces to teeth during fixed appliance treatment

Question 81

What is the definition of an expanders-RME?

Answer 81

• Rapid maxillary expander (RME)* Commonly cemented with bands on 1st permanent molars and 1st premolars* Midline screw* Activated to expand upper arch (1/2 mm per day hence ‘rapid’)

Question 82

What is the defintion of an expanders-Quad helix?

Answer 82

• Fixed expansion appliance* Bands on 1st permanent molars* Has 4 circle loops (helices) to give flexibility and good range of action

Question 83

What is the definition of temporary anchorage device?

Answer 83

• ‘TADS’* Titanium screws* Inserted intra-radicular alveolar bone* Topical/LA* Common sites- between upper 5 and 6.

Question 84

Describe the 4 general categories of elastics?

Answer 84

• Class I – Intra-arch* Class II – Inter –arch :To correct Class II malocclusion* Class III – Inter –arch :To correct Class III malocclusion* Vertical – To correct open bitesOthers* Anterior cross elastics - correct dental centreline discrepancies* Posterior cross elastics

Question 85

Summary of the management of patients with mandibular third molars?

Answer 85

Asymptomstic high risk - caries, perio, resorption and cysts/tumoursSymptomatic high risk - acute pericorontis, unrestorable caries, perio disease, resorption, fracture, abscess or surrounding pathology Asymptomatic low risk - bisphosphonates, antiangiogenics and chemo, radiotherapy H/N, immunosuppression, mandibular fracture and cancerSymptomatic low risk - TMJ disorder, parotid disease, skin lesion, migraines, referred pain or oropharyngeal cancer

Question 86

Name the 7 ways in which the root can be affected by the nerve?

Answer 86

Darkening of rootDeflection of rootNarrowing of rootDark and bifid rootInterruption of white line of canal Diversion of canalNarrowing of canal

Question 87

What to do for a horizontally impacted tooth?

Answer 87

Decoronation

Question 88

What to do for a vertically impacted tooth..

Answer 88

Root separation

Question 89

Complication with sectioning teeth?

Answer 89

Failure to split roots Drill to far through the bone - lingual nerve damage or causing an OAC

Question 90

Name other techniques for tooth sectioning.

Answer 90

Hemisection- surgical separation of a multi rooted tooth and extraction of one or more rootsRoot resection- sectioning and removal of a diseased rootPremolarisation- sectioning of lower molar crown between roots to leave 2 single teeth to allow maintainer of oral hygiene Coronectomy- removal of crown but leaving the roots in situ

Question 91

Contraindications to coronectomy?

Answer 91

Too close to IAN canalActive infectionPreexisitng numbnessPreexisiting mobilityHorizontally impacted tooth along IANMedical conditions

Question 92

Name 7 indications for removal of 8s according the the NICE guidelines?

Answer 92

Unrestorable cariesNon-treatable pupal and/or periapical pathologyCellulitis, abscess and osteomyelitisFracture of toothResorption of tooth or adjacent teethDisease of the following such as cyst/tumourTooth impeding surgery or reconstructive jaw surgery

Question 93

When should you leave 8s in place?

Answer 93

Symptom freeNo evidence of diseaseRemoving the tooth may cause more harm

Question 94

Name 5 non-NICE guidelines for removal?

Answer 94

To exclude atypical facial painTo prevent late lower incisor crowding or relapse of orthoPrior to travel Financial - >25Known later complications

Question 95

When does pericoronitis become a valid indication for wisdom tooth removal?

Answer 95

Severe first case of pericoronitis Second or subsequent episodes should be considered

Question 96

NICE consultation 2017-2019 findings?

Answer 96

Removal of non-pathological 8s is not indicated, however down the line the 8s will become a problem and be extracted

Question 97

What is the overall risk of nerve damage of lower wisdom tooth extractions?

Answer 97

Up to 5%

Question 98

Neurapraxia definition?

Answer 98

Contusion of the nerve in which the continuity of the nerve is maintained - blunt trauma, traction or local ischaemia

Question 99

Axonotomesis defintion?

Answer 99

Discontinuity of the axons but the shealth is intact - severe blunt trauma, nerve crushing and extreme traction

Question 100

Neurotmesis defintion?

Answer 100

Complete loss of nerve continuity - mandibular fracture

Question 101

Anaesthesia definition?

Answer 101

Lack of sensation

Question 102

Paraesthesia definition?

Answer 102

Spontaneous and subjective altered sensation that a patient does not find painful

Question 103

Dysaesthesia definition?

Answer 103

Spontaneous and subjective altered sensation that a patient does find painful

Question 104

Hypoaesthesia definition?

Answer 104

Decreased sensitivity of a nerve to stimulation

Question 105

Hypoalgesia definition.

Answer 105

Decreased sensitivity to noxious stimulation

Question 106

Hyperaesthesia definition?

Answer 106

Increased sensitivity if annerve to stimulation

Question 107

Hyperalgesia definition?

Answer 107

Increased sensitivity to noxious stimulation

Question 108

Allodynia definition?

Answer 108

Pain caused by a stimulus that does not normally cause pain

Question 109

What are Winter’s classification of impacted wisdom teeth?

Answer 109

VerticalMesioangularHorizontalDistoangular

Question 110

When is 4/0 Coated vicryl used?

Answer 110

delicate or maceratedmucosa. Easy to pull toohard and break the suturewhen suturing.

Question 111

When is 3/0 vicryl rapide used?

Answer 111

across sockets andapplying pressure to achievehaemostasis

Question 112

Name 2 types of peri-raduclar surgery?

Answer 112

Root end resection (apicectomy)Retrograde root filling (RRF)

Question 113

What is the flap design for peri-radicular surgery?

Answer 113

3 sided full thickness BMPF- Risk of gingival recession in thevisible anterior region especiallynoticeable with crowned teeth

Question 114

What flap design can be used for peri-raducular surgery to minimise the risk of gingival recession?

Answer 114

Luebke –Oschenbein sub-marginal flap:- Minimises risk of gingival recession- Difficult to suture as the horizontal incision is inattached gingivae- Requires at least 4mm of attached gingivaeSemi-lunar flap:- poor healing (flap margin not on solid bone)- minimised gingival recession

Question 115

How to promote healing for flap design?

Answer 115

by preserving blood supply – wide base

Question 116

When suturing over the bone, what must you do?

Answer 116

Place the mesial relieving incisionaway from the area of bone removal/lossto provide support for the incision margin when closed

Question 117

Describe the process to remove a mesio-angulary impacted partially eruped LL8?

Answer 117

1. Mucoperiosteal flap marginsincised – 3 sided BMPF2. Flap retracted from buccal side3. Collar of bone guttered frombuccal side of LL84. Sectioning of toothThe groove has been drilled only half way through thetooth bucco-lingually to protect the lingual nerve5. Elevator used to separate the 2 roots6. Distal root delivered with forceps7. Mesial root elevated into the space created by removal of the distal root – disimpacted – thendelivered8. Socket debrided and washed withcopious sterile saline9. Wound closure with sutures

Question 118

Describe the palatal flap for buried canines?

Answer 118

1. Sacrifice the incisive bundle – no clinicalsignificance to the resulting area of anaesthesia2. Extensive crevicular incision extending from UR6 to UL4 on the palatal aspect as no relieving incisions possible3. Buried canine located and exposedby drilling overlying bone

Question 119

Name 2 types of flap design is for oro-antral communiction?

Answer 119

Buccal Advancement Flap:- based on a 3 sided BMPF with the periosteal layerscored to permit extension of the flap to the palatal side- pull flap across defect and suturePalatal Rotational Flap:- based arounnd the greater palantine vascular bundle

Question 120

What is the main side effect of a buccal advancement flap?

Answer 120

Results in loss of buccal sulcus depth makingsubsequent denture fit difficult without further sulcus deepening surgery.

Question 121

Name the 4 categories of medcinies used in Oral Medicine (OM)?

Answer 121

Anti-microbial - virals, fungals and bioticsTopical Steroids - inhaled and mouthwashDry mouth medication - benzdamine washOthers - carbamazepine

Question 122

Name antimicrobials used for OM? and what they treat?

Answer 122

virals - primary herpetic gingivostomatosis, recurrent herpetic lesions and shingles- aciclovirfungals - Acute pseudomembranous candidiasis and acute erythematous candidiasis- miconazle- fluconazole- nystain

Question 123

Name topical steroids used for OM? and what they treat?

Answer 123

Betamethasone mouthwashBeclomethasone Metered Dose InhalerBoth used for - Treating aphthous ulcers- Treating Lichen planus

Question 124

What to include on a presciption?

Answer 124

Patient’s name, Address, Age (under 18)Patient identifier – DoB, CHI NumberNumber of Days treatmentDrug to be prescribedDrug formulation and DosageInstructions on quantity to be dispensedInstructions to be given to the patientSigned – identifier of Prescriber

Question 125

Types of drugs for mucosal disease?

Answer 125

Non-steroid topical therapy - inconvientient lesions with discomfortSteroid topical therapy- disabling immunologically driven lesions

Question 126

Non-steroid topical therapy for mucosal diease? - Name 4?

Answer 126

Chlorhexidene mouthwash- dilute 50% with water if neededBenzdamine mouthwash or spray - green things help! Useful topical anaesthetic/pain reliefOTC remedies such as Igloo, Listerine, BonjelaAnything else the patient finds helpful!- check that it is not harmful though – bleach, aspirin!

Question 127

Steroid topical therapy for mucosal diease? - Name 3?

Answer 127

Hydrocortisone mucoadhesive pelletBetamethasone mouthwashBeclomethasone Metered Dose Inhaler (MDI/Puffer) - - CFC-free preparations, e.g. ‘Clenil Modulite’

Question 128

How does it work - hydrocortisone mucoadhesive tablet?

Answer 128

allow tablet to dissolve over the ulcer

Question 129

How to use betamethasone mouthwash?

Answer 129

Unlicenced product• Supply patient with a tailored information leafletUse Betnesol tabs 0.5mg - 1mg 2 tablets - 10mls water 2 teaspoons water - 2 mins rinsing - Twice dailyRefrain from eating/drinking for 30 min after useDO NOT SWALLOWDo not rinse after use

Question 130

What must be included on betamethasone mouthwash PIL?

Answer 130

Licenced for other medical conditionsExplain dose range and frequency of useExplain hazards of exceeding the standard doseAdd any known side effects – small oral candida riskAdd special instructions

Question 131

How to use beclomethasone medical device?

Answer 131

Unlicenced product - Supply patient with a tailored information leafletDental Prescribing 50mcg/puff device - Position device correctly – exit vent directly over ulcer area - 2 puffs - 2-4 times daily - Don’t rinse after useMust be a pressurised device

Question 132

What must be included on beclomethasone medical device PIL?

Answer 132

This is an accepted and proven effective treatment for the oral conditionLicensed for other medical conditions – asthma and COPDInstruct to discard the manufacturer’s PiLExplain dose range and frequency of useExplain technique used for oral lesions – different from use for lung conditionsAdd any known side effects – small oral candida riskAdd special instructions

Question 133

Systemic drugs used in OM, only for specialists?

Answer 133

Disease modulator- colchineSteroid- prednisilone (ulcers) 30mg for 5 daysImmune suppressants:- hydroxychloroquine - lichen planus- azathioprine- mycophenolateImmunotherapy:- adalimumab- enterecept

Question 134

Systemic use of steroid risk - side effects?

Answer 134

If prolonged course – or repeated short courses over many months• 3 months continuous • Gaps of 2 weeks or less between ‘pulses’ of prednisolone.Adrenal suppression – steroid dependency – don’t stop suddenly – taper doseCushingoid featuresOsteoporosis risk – bone prophylaxis – Calcium supps and bisphosphonates- DEXA bone density scan may be needed from time to timePeptic ulcer risk – Proton Pump Inhibitor prophylaxisMood/Sleep alteration and mania/depression risk – can be very quick onset

Question 135

What are the differential diagnoses of oral white lesions? 5 examples?

Answer 135

HereditarySmoking/frictionalLichen planus- lupus erythematosus- gvhdCandidal leukoplakiaCarcinoma

Question 136

What does a typical white spot lesion look like?

Answer 136

Thickening of the mucosa or keratin- Less visibility of bloodLess blood in the tissues- vasoconstrictor

Question 137

What is the definition of Leukoplakia?

Answer 137

A white patch which cannot be scraped off or attributed to any other causeNo histopathological connotation- it is a clinical descriptionDiagnosis of exclusion1 - 5% become malignant

Question 138

Name 4 types of leukoplakia?

Answer 138

Fordyce’s spotsSmoker’s KeratosisFrictional KeratosisHereditary Keratosis

Question 139

What is the link between smoking and leukoplakia?

Answer 139

Smokers are six times more likely to have “leukoplakia”Low malignant potential of the lesion- But higher oral cancer risk overall!

Question 140

Name 3 types of infective leukoplakia?

Answer 140

Candidosis- pseudomembranous acute (thrush)- denture associated (chronic)Herpes Simplex

Question 141

When should you refer a white spot lesion?

Answer 141

Most are benignIf RED and WHITE concentrate on the RED partIf the lesion is becoming more raised and thickenedIf the lesion is ‘without cause’- lateral tongue- anterior floor of mouth- soft palate area

Question 142

Why are red spot lesions red?

Answer 142

Blood flow increases- inflammation- dysplasiaReduced thickness of the epithelium

Question 143

What is the definition of Erythroplakia?

Answer 143

Atrophic or non-keratotic end of the spectrumA red patch which cannot be attributed to any other causeMore of a concern for malignancy than leukoplakia

Question 144

What are the 3 types of mucosal pigmentations?

Answer 144

Exogenous stainIntrinsic PigmentationIntrinsic foreign body

Question 145

Name the 4 examples of exogenous stains for mucosal pigmentation?

Answer 145

TeacoffeechlorhexidineBacterial overgrowth

Question 146

Name the 4 examples of intrinsic pigmentation for mucosal pigmentation?

Answer 146

Reactive Melanosis/melanotic maculeMelanocytic naevusMelanomaEffect of systemic disease - paraneoplastic phenomenon

Question 147

Name the 1 examples of intrinsic foriegn body for mucosal pigmentation?

Answer 147

Metals

Question 148

Name the differential diagnoses for brown/black lesions - localised and generalsied?

Answer 148

Localised:- Amalgam- Melanotic Macule- Melanotic naevus -Malignant Melanoma- Peutz-Jehger’s syndrome- Pigmentary incontinence- Kaposi’s sarcomaGeneralised:- Racial/familial- Smoking- Drugs- Addison’s disease (Raised ACTH conditions)

Question 149

Name 2 types of melanin pigmentation?

Answer 149

Racial pigmentationMelanotic macule

Question 150

How to decide whether something is a melanoma? questions?

Answer 150

Variable pigmentationIrregular outlineRaised surfaceSymptomatic- Itch- bleed

Question 151

When should a patient be referred to oral medicine?

Answer 151

Patients with abnormal and/or unexplained changes to the oral mucosa- Practitioner threshold will vary with experience If there is concern about dysplasia risk- Appearance of lesion- Risk site- Risk behavior- Family history

Question 152

When should you NOT refer a patient to Oral Medicine?

Answer 152

Asymptomatic VARIATIONS of NORMAL mucosaBenign conditions the practitioner has diagnosed that:- Are asymptomatic- Do not have potentially malignant risk- For which there is no treatmentIf unsure – consider clinical photography to- Monitor area until next check up- Send to specialist for an opinion

Question 153

When should a mucsoal lesion be refered to oral medicine for an opinion?

Answer 153

ANYTHING the dentist thinks is might be cancer or dysplasia- 2 week Cancer referral pathway for actual malignancies- NICE and SIGN Head & Neck cancers guidelinesAny SYMPTOMATIC lesion that hasÂnot responded to standard treatment- Hospital referral criteria- SDCEP guidanceAny BENIGN lesion that the patient can’t be persuaded is not cancer…..

Question 154

Name the 3 reactive chnages of the oral epithelium?

Answer 154

Keratosis - nonkeratinised site (parakeratosis) Acanthosis - hyperplasia of stratum spinosum Elongated rete ridges - hyperplasia of basal cells

Question 155

Name the 5 mucosal reactions of the oral mucosa?

Answer 155

Atrophy - reduction in viable layersErosion - partial thickness lossUlceration - fibrin on surfaceOedema - intracellular - intercellular (spongiosis)Blister - vesicle or bulla

Question 156

What are the symptoms of geographic tongue?

Answer 156

Sensitive with acidic/spicy foodsIntermittentMuch worse in young children

Question 157

What is the aetiology of geographic tongue?

Answer 157

None!Something else is causing the trouble- Haematinic deficiency (B12, Folate, Ferritin)- Parafunctional trauma - Dysaesthesia

Question 158

What is the definition of a fissued tongue?

Answer 158

Fissured tongue is a benign condition characterized by deep grooves (fissures) in the dorsum of the tongue. Although these grooves may look unsettling, the condition is usually painless. Some individuals may complain of an associated burning sensationThe cause is unknown, but it may be partly a genetic trait. Aging and environmental factors may also contribute to the appearanceIs there another disease process there?- Candida- Lichen planus

Question 159

What is the defintion of glossitis? And possible investigations?

Answer 159

What is Glossitis?- Glossitis can mean soreness of the tongue, or more usually inflammation with depapillation of the dorsal surface of the tongue (loss of the lingual papillae), leaving a smooth and erythematous (reddened) surfaceWhat investigations are needed?- Haematinics- Fungal cultures

Question 160

What is the definition of black hairy tongue?

Answer 160

is a condition of the tongue in which the small bumps on the tongue elongate with black or brown discoloration, giving a black and hairy appearance.

Question 161

What is the aetiology of black hairy tongue?

Answer 161

smoking, xerostomia (dry mouth), soft diet, poor oral hygienecertain medications

Question 162

What is the aetiology of glossitis?

Answer 162

Often caused by nutritional deficiencies- Fe- B- Infection- others

Question 163

What is the definition of a pyogenic granuloma?

Answer 163

granulation tissue – mixed inflammatory infiltrate on fibro-vascular backgroundany mucosal site response to traumaNot a granuloma, not pyogenicother names- gingiva – aka vascular epulismost frequent site- gingiva, during pregnancypregnancy epulis

Question 164

What are the differential diagnoses for single episode oral ulceration?

Answer 164

Trauma1st episode of Recurrent Oral UlcerationPrimary Viral infectionsOral Squamous Cell Carcinoma

Question 165

What are the differential diagnoses for Recurrent Oral Ulceration?

Answer 165

Aphthous ulceration- minor, major, herpetiformLichen PlanusVesiculobullous lesions- pemphigoid, pemphigus- angina bullosa haemorrhagica- erythema multiformeRecurrent viral lesion – HSV, VZVTraumaSystemic disease – Crohn’s Disease ulceration

Question 166

Describe the difference between Crohn’s ulcers and aphthous ulcers?

Answer 166

Aphthous-type ulcers:- haematinic deficiency associated- behave like aphthous ulcersCrohn’s specific ulcers:- linear at the depth of the sulcus- full of Crohn’s associated granulomas- persist for months – intralesional steroids help

Question 167

Explain what to include for an Oral Ulceration History?

Answer 167

Where?Size & Shape?Blister or ulcer?How long for?- more than 2 weeks?Recurrent?- same site? different Sites?Painful?

Question 168

Explain how to examine an ulcer?

Answer 168

Margins?- flat? raised? rolled?Base?- soft? firm? hard? Surrounding tissue- inflamed? normal?Systemic Illness?

Question 169

What is the definition of traumatic ulceration?

Answer 169

CommonUsually single episode - can be recurrent if cause not removedNormal or abnormal epitheliumHealing - remove cause - heal in about 2 weeks

Question 170

Describe a recurrent herpetic lesion? - location and treatment

Answer 170

Ulceration limited to one nerve group/branchOften Hard palate- lesion recurs in the same place- patient often aware of prodrome and vesiculation which bursts- PAIN suggests Herpes ZOSTER rather than simplexTreat with systemic ACICLOVIR - prophylactic if a severe problem

Question 171

Describe recurrent aphthous stomatitis (RAS)? severity? diagnosis?

Answer 171

Severity:- minor- major- herpetiform- Behçet’s syndromeDiagnosis by :- history- examination

Question 172

The overall summary of Oral Ulceration?

Answer 172

Not all ulcers are aphthous!Is the lesion on keratinized or non-keratinized mucosaAre there systemic symptoms? - consider infection – herpes group, coxsackie groupAlways look for a traumatic cause - primary – sharp edge on a tooth/appliance - secondary – parafunction rubbing mucosa against the teeth

Question 173

What is the definition of an Aphthous Ulcer?

Answer 173

NAME?

Question 174

Describe the characteristics of a minor aphthous ulcers?

Answer 174

• Less than 10mm diameter- Last up to 2 weeks- ONLY affect NON-Keratinised mucosa- Heal without scarring- Usually a good response to topical steroidsThis is the commonest type of recurrent oral ulceration- One is a nuisance, many more at once can be disablingThe ULCER FREE PERIOD is a good guide to morbitity – longer ulcer free + less morbidity

Question 175

Describe the characteristics of a major aphthous ulcers?

Answer 175

• Can last for months- Can affect ANY part of the oral mucosa - keratinised OR non keratinised or both- MAY scar when healing- Poorly responsive to topical steroids - intralesional steroids often more usefulUsually LARGER than 10mm - may get smaller ulcers too – diagnose from the worst ulcer

Question 176

Describe the characteristics of a herpetiform aphthae ulcer?

Answer 176

• Rarest form of Aphthous ulcers- Multiple small ulcers on non-keratinized mucosa- Heal within 2 weeksCan coalesce into larger areas of ulcerationNOTHING to do with herpes viruses - in the early stages looks like primary herpetic gingivostomatitis - in HSV get KERATINISED epithelium involved – not in herpetiform aphthae

Question 177

What cause Oral and Genital Ulceration?

Answer 177

Behçet’s Disease (mainly)Vesiculobullous diseasesLichen Planus

Question 178

How to diagnose Behcet’s disease?

Answer 178

Many who don’t meet the criteriaDiagnosis - three episodes of mouth ulcers in a year - at least two of the following: genital sores, eye inflammation, skin ulcers, pathergy

Question 179

What is the definition of Behcet’s Disease? and where can it effect?

Answer 179

PRIMARILY a Vasculitis – inflammation of blood vessels- Oral & genital ulceration- Eye disease - snterior or posterior uveitis – can lead to loss of vision in 20%- Bowel ulceration – iliocaecal area – pain and cramping- Heart and lungs- Brain- Joints

Question 180

How to manage a patient with Behcet’s Disease?

Answer 180

Treat local oral disease or RASSystemic immunomodulation where multisystem involvement: - Colchicine used ‘off label’ often a first treatment - Azathioprine/Mycophenolate - Biologics – infliximab and othersManaged with help of Rheumatology - also National specialist treatment centres

Question 181

Name the 7 predisposing factors for Recurrent Aphthous Stomatitis (RAS)?

Answer 181

Viral and bacterial infectionsGenetic predispositionSystemic diseasesStressMechanical injuriesHormonal level fluctuationsMicroelement deficiences

Question 182

What tests to carry out when investigating aphthous ulcers?

Answer 182

Blood test:- haematinic deficiencies Iron B12 or folic acid- coeliac disease - TTG (tissue transgutaminase) - if TTg +ve anti-glidain and anti-endomysial absAllergy tests - contact or immediate hypersensitivty- food additives E210-E219- benzoate- sorbate- cinnamon- chocolate

Question 183

Explain the treatment of a recurrent Aphthae?

Answer 183

Management:Correct blood deficiencies - ferritin (iron), folic Acid, vit B12Refer for investigation if Coeliac positive - endoscopy and jejunal biopsyAvoid dietary triggers - SLS containing toothpaste – (Sensodyne Pronamel and Kingfisher are SLS free)Dietary triggers - identified from testing - empirical dietary avoidance – use FOOD MAESTRO app to help with identifying foods

Question 184

What drugs can be prescribed for aphthous ulcers?

Answer 184

In dental practice follow SDCEP ’Drugs in Dentistry’ GuidanceNon-Steroid Topical Therapy - for inconvenient lesionsSteroid Topical Therapy - for disabling lesions

Question 185

Why do chuildren get aphthous ulcers?

Answer 185

Periods of rapid growth – very few before this- 8-11 years and 13-16 years- feet usually grow first so look for ‘new shoe sign’Treatment- usually respond to 3/12 iron supplements – always check the diet for peculiaritiesNOT related to growth (present since birth) then largely a genetic component:- consider allergy testing as well as bloodsTreatment:- issues with Betnesol under age 12 - licence- issues with Betnesol if child unable to spit mouthrinse out reliably

Question 186

When should you refer an Aphthous ulcer case?

Answer 186

After simple investigationsAfter topical trreatmentIf no good result has been achievedIf patient under 12 YO

Question 187

What is the defintion of oral thrush?

Answer 187

Caused by candidaCan be associated with dentures causing denture stomatitis

Question 188

What species of candida causes oral thrush?

Answer 188

Candida albicans

Question 189

Name the topical and systemic treatment of oral thrush?

Answer 189

Topical:- nystatin - miconazoleSystemic:- fluconazole- targeted therapy

Question 190

Explain how to use nystatin suspension?

Answer 190

1ml QDSKeep in mouth for as long as possibleContinue for 48 hours after resolvedLow risk for inters

Question 191

Explain how tonuse miconazole oral gel?

Answer 191

2.5 ml QDS - gold in mouth after foodContinue for 7 days after resolvedUse gel to brush dentures

Question 192

What treatment is advised for angular cheilitis?

Answer 192

Miconazole- antifungal- bacteriostatic vs gram positive- topical- with mild steroid

Question 193

Name the drug interactions of Miconazole?

Answer 193

Inhjbits the metabolism of drugs metabolised by the CYP3A4 and CYP 2C9 enzyme systemsCYP3A4:- statins - Ca ch blocker- tacrolimus- carbamazepine- midazolam CYP2C9- warfarin- sulphonylureas - phenytoin

Question 194

Name the contraindications of miconazole?

Answer 194

Liver dysfunctionCoadministration with drugs that are metabolised by CYP3A4Substrates known to prolong QT interval - astemizole, cisapride, dofetilide, mizolastine, pimozide, quinidine, sertindole and terfenadineErgot alkaloidsHMG-CoA reductase inhibitors - simvastatinTriazolam and oral midazolam

Question 195

Explain how to take fluconazole?

Answer 195

50-200mg capsules50-5ml oral suspensionIV avaliable 50mg once a day for 7-14 days100mg if immunocompromised

Question 196

Name the 6 contraindications of fluconazole?

Answer 196

Mod inhib of P3A4 and 2C9Strong inhib of 2C19AlfentanilAmitriptylineBenzodiazepinesCitalopramClopidogrelWarfarin

Question 197

Which 5drug types cause dry mouth?

Answer 197

OpoidsAnticholinergics AntidepressantsDiureticsOxygen

Question 198

Explain how to manage dry mouth?

Answer 198

Treat underlying causeReview medicationGood oral hygieneDietary adviceRegular dental checksRegular sips of waterLubricate cracked lipsSaliva substitutesSaliva stimulants

Question 199

At what age does lichen planus usually affect?

Answer 199

30-50 years old

Question 200

What is the histopathological findings of lichenoid reaction?

Answer 200

Chronic inflammatory cell infiltrate Saw tooth rete ridgesBadal cell damagePatchy acanthosis Parakeratosis

Question 201

What is the histopathological findings of licehn planus?

Answer 201

OrthokerstosisWedge shaped hypergrabulosisDermal epidermal Junction obscured lymphocytesVacuoles at basal laterLuck band of lymphocytes under epidermisCivatte bodies - dead keratinocytes

Question 202

What are the 8 aetiologices of lichen planus

Answer 202

AutoimmuneViralGenetic predispositionPhysical and emotional stressTrauma - scraped or after surgery an isomorphic response (koebnerisation)Localised skin disease - herpes zoster - isotopic responseContact allergy - amalgamDrugs - gold, quinine, beta blockers and ACE inhibitors

Question 203

What are the symptoms of lichen planus?

Answer 203

Often noneMay relate to thinning of epithelium - sensitive to hot and spicy food- burning sensation in the mucosa

Question 204

What other body parts can LP affect?

Answer 204

SkinScalpGenitalsHairNails

Question 205

What are the 5 main sites for oral LP?

Answer 205

Biccal mucosaGingiva - desquamative gingivitisTongue- lateral or dorsumLipsPalate

Question 206

Describe buccal lichen planus?

Answer 206

CommonestCan be found anywhere - ant at commisure- mid- post around 3rd molarMainly an incidental findingEasy to biopsy

Question 207

Describe gingival lichen planus?

Answer 207

Found in isolationTermed desquamative gingivitis- similar to gingival pemphigoid and to plasma cell gingivitis - clear histologicalVery erythematous appearance to the gingivaPatchyReticular pattern more commonOral hygiene is essential to settle the lesion - plaque driven- especially interdentally Biopsy can be difficult - risk of damage to attachment area- adherent attached mucosa damaged lifting from bone

Question 208

Describe tongue lichen planus?

Answer 208

Dorsum usually idiopathic- loss of papillary becoming smoothLateral may be drug/amalgam trigger- amalgam most likely in isolated lesion- look at tongue rest position - contact amalgam?Easy biopsy but painful

Question 209

Describe lip lichen planus?

Answer 209

On the lipBiopsy hard?Looks soreErythema

Question 210

What is it called if the cause is known for oral lesion?

Answer 210

Lichenoid reaction to…

Question 211

Medications which can cause LP?

Answer 211

ACE inhibBeta blockersDiuretics - bendroflu and frusemideNSAIDs DMARDsRare - phenothiazines

Question 212

What are the discriminative characteristics of a lichenoid drug reaction?

Answer 212

Widespread lesionBilateral and mirrorsPoorly response to standard steroid treatment

Question 213

How to manage lichenoid drug reactions?

Answer 213

Benefit of the drug vs the risk of stopping the drugHow bad is the discomfort from the symptoms If significant symptoms - may need to find alternative medicationDiscuss with GP

Question 214

Explain the overall lichen planus management for the patient?

Answer 214

Remove any cause- medicines- dental restorationsBiospy- unless a good reason not toBlood test- haematinics- fbc- if lulus suspected autoantibody screen for ANA, Ro and dsDNA

Question 215

What treatment would be recommended for mild intermittent lichen planus lessons?

Answer 215

Topical OTC remedies- chlorhexidine - benzdamineAvoid SLS containing toothpaste

Question 216

What treatment would be recommended for a persisting synthetic lichen planus lesion?

Answer 216

Topical steroids- beclomethasone inhaler - betamethasone rinse Higher strength steroid- skin steroid cream - ClobetasolTopical tacrolimus mwHydroxycholorquineSystemtic immumodilators - azathioprine and mycophenolate

Question 217

What are the histological findings of lupus erythematosis?

Answer 217

Basal vacuolar damageAtrophic epitheliumMelanophageIntense lymphocytic infiltrate

Question 218

Describe lichen like lesions?

Answer 218

Underlying disease needs considerationGVHD common after stem cell transplantLupus lesion can be- only in mouth - discoid lupus no auto abs- mouth and elsewhere (systemic ANA/Ro/dsDNAIf oral symptoms only treat like lichen llanjs

Question 219

Name 5 vesiculobulloua conditions?

Answer 219

Erythema multiformPemphigusPemphigoidAngina Bullish HaemorrhagiaBullous lichen planus

Question 220

What is the defintion of Pemphigoid?

Answer 220

A subepithelial antibody attackThick walled blisters- persist to be seen- clear or blood filled

Question 221

Name 3 different forms and presentations of Pemphigoid?

Answer 221

Bullous pemphigoid - skinMucous membrane pemphigoid - all mucous membranes Cicatritial pemphigoid - mucosal with scarring

Question 222

Describe the histopathogy of pemphigoid?

Answer 222

Sub epithelial split - epithelial/CT tissue junctionHemi-desmosomes involved at basement membrane

Question 223

Describe how Pemphigoid is seen with immunofluorescence?

Answer 223

Linear staining along the basement membrane C3 and IgG detected in this area in ‘standard’ pemphigoid IgA occasionally found - linear staining with C3 is ‘Linear IgA disease’- granular IgA and C3 deposits is seen in ‘dermatitis herpetiformis’

Question 224

What is a symblepharon?

Answer 224

Pemphigoid that is present on the eye

Question 225

Non-oral locations of Pemphigoid?

Answer 225

Oral and skin lesions- bullous on skin- mucous mem usually mouth, eye or genitals (needs specialist)Scarring is a feature in some cases - cicatritial pemphigoid

Question 226

How to manage Pemphigoid?

Answer 226

SteroidsImmune modulating drugs- azathioprine- mycophenolate

Question 227

What is the defintion of Pemphigus?

Answer 227

Commonest form is vulgarisIntraepithelial bullaeClinically:- more common in females and over 50s- genetic with ashkenazi JewsSites:- skin- mucosaThey blister, then burst and then it spreads

Question 228

Describe Pemphigus histopathologically?

Answer 228

Supra-basal split with tzank cells

Question 229

Describe Pemphigus using immunofluorescence?

Answer 229

Very greenBasket weave pattern - around each epithelial cellC3 and IgG in Pemphigus vulgaris

Question 230

How to treat Pemphigus?

Answer 230

It affects the mucosa and skin Rarely see intact bullae- intra epithelial blistersCan be fatal without disease- complications of treatment are major cause of death

Question 231

Name the 2 types of immunogenic immune mediated disease?

Answer 231

Cell mediatedAntibody mediated

Question 232

Name 3 types of local immunological oral disease?

Answer 232

Aphthous ulcersLichen planusOrofaxial granulomatosis

Question 233

Name 6 systemic diseases with local oral effects?

Answer 233

Eythema multiformPemphigusPemphigoidLupusSystemic sclerosisSjogren’s syndrome

Question 234

Type 3 Hypersensitivity example?

Answer 234

Erythema multiform

Question 235

Name 3 examples of cell mediated immunity?

Answer 235

Aphtous ulcersLichen PlanusOrofaxial Granulomatosis

Question 236

Name 2 examples of antibody mediated immunity?

Answer 236

PemphigusPemphigoid

Question 237

How do cells of the epidermis adhere to eachother?

Answer 237

Via desmosomes and hemidesmosomes 2 proteins - desmoglein (VIP) and desmocollin

Question 238

Explain the mechanism of action for immunofluorescence?

Answer 238

A fluorescein molecule is attached to an engineered antibody, that when binds fluorescence and becomes active

Question 239

Explain the difference between direct and indirect immunofluorescence?

Answer 239

Direct:- antibody mediated tissue disease- antibody bound to tissues - targeted in DIFIndirect:- circulating antibody not yet bound to the tissue- detected by immunofluorescence from a plasma sample- not always useful for diagnosis - often good for monitoring disease activity

Question 240

What is the defintion of erythema multiforme?

Answer 240

Acute onset - more menSkin - show target lesionsMucosa - show ulcersFor young males it is recurrent within a short period

Question 241

What specific sites do erythema multiforme target?

Answer 241

Lips and anterior part of the mouthHeals in 2 weeksVery painful - unable to eat or drink

Question 242

What os erythema multiforme relation to Stevens Johnson syndrome?

Answer 242

Can be involved with Stevens-Johnson syndrome- sevre multisystem involvement- skin, conjunctivae, nose, pharynx, mouth and genitals

Question 243

What is the treatment for erythema multiforme?

Answer 243

Oral lesions:Urgent medical therapy:- systemic steroids of up to 60mg per day- systemic aciclovirEncourage fluid - possible I Encourage analgesia If recurrent:- prophylactic acyclovir daily- allergen test for triggersMycoplasma infective agent

Question 244

What is the defintion of angina bullous haemorrhagica?

Answer 244

Commonest oral blistering condition Blood blisters in mouth:- buccal mucosa and soft palate- rapid onset- 1 hr then burstPainlessIniated by minor trauma or eatingHeal with no scar within days

Question 245

Give a brief overview of how to treat and what tests for angina bullish haemorrhagica?

Answer 245

Non specific ulcerationDIF and IFF negativeNo defectsChlorhex MWMay recur

Question 246

How to manage angina bullish haemorrhagica?

Answer 246

No treatmentReassure patient that is benignExplain known triggers

Question 247

Why are mucosal lesions more frequent in children?

Answer 247

Clinical issues traditionally related to immunologicalimmaturity

Question 248

Name the 2 types of congenital oral mucosal lesions?

Answer 248

HereditaryDevelopmental defects

Question 249

Name the 6 types of acquired oral mucosal lesions?

Answer 249

TraumaticDrug-relatedChronic inflammatoryHyperplasticNeoplasticInfective

Question 250

What is the defintion of white sponge naevus?

Answer 250

HereditaryInherited as autosomal dominant condition . Defect in keratin gene 4 and 13.Uncommon

Question 251

Name the clinical features of white sponge naevus?

Answer 251

•White, soft, irregularly thickened, nodefined borders•Bilateral•Genital tissues can also be affected•Often misdiagnosed with candidosis

Question 252

Name the histopathology of white sponge naevus?

Answer 252

•Uniform acanthosis•Hyperparakeratosis• Intracellular oedema•No dysplasia, no inflammation

Question 253

How to manage white sponge naevus?

Answer 253

Reassurance

Question 254

Describe the clinical features of fordyce’s granules?

Answer 254

â–ªEctopic sebaceous glandsâ–ªAssociation with hormonal changes in puberty?â–ªBilateral, most commonly on buccal mucosa

Question 255

Describe the clinical feattures of folaite papillae?

Answer 255

â–ªPinkish soft nodulesâ–ªBilateral, ventral tongueâ–ªLymphoid tissue, sometimesinflamed/hyperplastic

Question 256

Describe the clinical features of geographic tongue?

Answer 256

â–ªDorsum of tongueâ–ªIrregular, smooth, red areas (depapillated)with sharply-defined edgeâ–ªRecurrent, migrates

Question 257

Describe the histology of geographic tongue?

Answer 257

â–ªThinning of epithelium at centre, mildhyperplasia at peripheryâ–ªEpithelium infiltrated by neutrophils

Question 258

Explain how to manage geographic tongue?

Answer 258

reassurance. If symptomatic exclude heamatological deficiencies.Median rhomboid glossitis generally not seen in children

Question 259

Describe the clinical fearues of frictional keratosis?

Answer 259

â–ªPale and translucent or white/dense withrough surface

Question 260

Describe the histology of frictional keratosis?

Answer 260

Epithelial hyperplasia, with thick granularcell layer and hyperorthokeratosisâ–ªScattered subepithelial lymphocytes

Question 261

Describe the clinical features of traumatic ulcer?

Answer 261

Mechanical, thermal or chemical traumaâ–ªInflammation levels and clinical features varyâ–ªYellowish floor of fibrin slough often present

Question 262

Describe the histology of traumatic ulcers?

Answer 262

Non-specific ulceration. See RASâ–ªDestruction of epitheliumâ–ªTissue infiltration by neutrophils

Question 263

Describe the clinical features of a mucocele?

Answer 263

â–ªMost commonly on lower labial mucosaâ–ªOverlying mucosa is intact and healthytypically circularâ–ªFirm or fluctuant and bluish

Question 264

Describe the histology of a mucocele?

Answer 264

â–ªDamage to duct of salivary glandâ–ªMucin and macrophages surrounded bycompressed connective tissuesâ–ªNo epithelial lining

Question 265

Name a drug-induced oral mucsoal lesion?

Answer 265

Chemo-induced stomatitisAspirin burns

Question 266

Describe the clinical features for recurrent aphthous stomatitis?

Answer 266

â–ªIdiopathic, but systemic factors known to modulate the severity of diseaseâ–ªOnset in childhood, but peak in adolescenceMinorMajorHerptiform

Question 267

Describe the histology of recurrent aphthous stomatitis?

Answer 267

â–ªInitial lymphocitic infiltration?â–ªDestruction of epitheliumâ–ªTissue infiltration by neutrophilsâ–ªDilated vessels

Question 268

What should be excluded when dealing with recurrent aphthous stomatitis?

Answer 268

Extraoral involvement should be excluded, e.g. GI (coeliac disease, Crohn’s), genital/ocular(Behcet’s).

Question 269

Describe the clinical features for erythema multiforme?

Answer 269

▪Mostly HSV-related, drug-induced▪Cutaneous erythema or “target” lesions▪Ulceration of outer lip with bleeding,crusting.▪Intraorally irregular fibrin- covered erosionand erythema▪Ddx with HSV-1 infection

Question 270

Describe the histology of erythema multiforme?

Answer 270

â–ªNecrosis of keratonocytesâ–ªEpithelial infiltration by inflammatory cellsâ–ªIntraepithelial or subepithelial vesiculation

Question 271

Describe the clinical features for orofacial granulomatosis?

Answer 271

▪Swelling of the lips▪Mucosal nodularity (cobblestoning)▪Mucosal tags▪Gingival hyperplasia▪Aphthous oral ulcers▪Children more likely to develop Crohn’s disease

Question 272

Describe the histology for orofacial granulomatosis?

Answer 272

Granulomas containingmultinucleated giant cellsâ–ªLymphoedema

Question 273

What are possible differential for orofacial granulomatosis?

Answer 273

DDx with sarcoidosis and tubercolosis. Primary TB of the oral cavity is rare,?morecommon in children than adults

Question 274

Describe the clinical features for oral lichen planus?

Answer 274

â–ªWhite striae and/or mucosal atrophy, and/orerosions, and/or plaquesâ–ªDesquamative gingivitis in isolation or incombination with aboveâ–ªBilateral lesions

Question 275

Describe the histology for oral lichen planus?

Answer 275

Basal membrane thickening Band-like lymphocitic infiltrate Colloid bodies,apoptotic basal cells

Question 276

Describe the clinical features for mucous membrane pemphigoid?

Answer 276

â–ªBullae, sometimes intact, can appear as bloodblisters. If ruptured raw ulcerâ–ªDesquamative gingivitisâ–ªConjuctival involvementâ–ªCutaneous involvement less prominent thanbullous pemphigoid

Question 277

Describe the histology for mucous membrane pemphigoid?

Answer 277

•Separation of full thickness of epithelium from CT•Linear deposition of IgG and C3/C4 along basalmembrane.•Auto-antibodies bind along basal membrane indirect immunofluorescence assay•CT infiltrated with inflammatory cells

Question 278

Describe the clinical features of pemphigus?

Answer 278

▪Fragile vesicles/bullae▪Ruptured vesicles▪Nikolsky’s sign positive▪Widespread cutaneous involvement

Question 279

Describe the histology for pemphigus?

Answer 279

•Acantholysis•Intraepithelial vesicles.•‘Chickenwire’ deposition of IgG and C3/C4within the epithelium.•Anti-desmoglein3 antibodies bindintercellular substance in directimmunofluorescence assay

Question 280

Deswcribe the clinical features for epydermolysis bullosa?

Answer 280

â–ªSubepithelial bullae leading to severe scarring after minimal trauma.â–ªType VII collagen defect.â–ªAutosomal recessive

Question 281

Describe the clinical features for a pyogenic granuloma?

Answer 281

â–ªSoft, red polypoidswellingâ–ªMost commonly gingivalbut not exclusively

Question 282

Describe the histology for a pyogenic granuloma?

Answer 282

•Granulation tissue•Dilated blood vessels inoedematous CT•Dense infiltration byneutrophilsNO GRANULOMAS, NOPYOGENIC BACTERIA

Question 283

Describe the clinical features of a giant cell epulis?

Answer 283

â–ªSoft, violaceus swellingâ–ªCentral gingival segmentsRelated to resorption of deciduous teeth?

Question 284

Describe the histology for giant cell epulis?

Answer 284

•Subepithelial clusters of giant cells in fibro-vascular tissue

Question 285

What to exclude when dealing with a giant cell epulis?

Answer 285

Need to exclude central GCG andunderlying hyperparathyroidism

Question 286

Describe the clinical features of vascular malformation?

Answer 286

Purple nodular lesionâ–ªBlanches upon pressure

Question 287

Describe the histology for a vascular malformation?

Answer 287

•Capillary: small vessels and vasoformative tissue•Cavernous: large blood filled sinusoids

Question 288

Name 2 pigmentary chnages ivolved with oral mucosal lesions?

Answer 288

Puetz-Jeghers syndromeAddison’s Disease

Question 289

Name the clinical features of Peutz-Jegher’s syndrome?

Answer 289

Clinical featuresâ–ªIntestinal polyposisâ–ªMucocutaneous pigmented lesionsappearing during childhood

Question 290

Describe the histology for Addison’s disease?

Answer 290

•Mild acanthosis•Melanin in basal layer

Question 291

Describe the clinical features for warts?

Answer 291

HPV 2, 4•White or pinkish, raised•Sessile or pedunculated•Often multiple•Mainly secondary to self inoculation

Question 292

Describe the histopathology of warts?

Answer 292

•Papillary processes of hyperplastic epithelium with acanthosis, hyperkeratosis,hyperplastic basal cell layer•Connective tissue core•Koilocytes often present

Question 293

Describe the clinical features for pseudomembranous candidosis?

Answer 293

•Acute•Thick white pseudomembranes of various sizes•Erythematous background•Often idespread

Question 294

Diseases that cause immunocompromisation and lead to oral mucosal lesions?

Answer 294

HIV/AIDS

Question 295

What infections are diagnostic for acute HIV infection?

Answer 295

PyrexiaSkin rashHaedacheDiarrhoea OropharyngitisOral mucosal erythema

Question 296

What infections are diagnostic fir ARC asymptomatic seropostive HIV?

Answer 296

LymphoadenopathyPersistent pyrexiaDiahorreaWeight losFatigue and malaise

Question 297

What infections are diagnostic for AIDS?

Answer 297

Kaposi’s sarcomaNH lymphomaThrombocytopeniaNeurologival diseases

Question 298

What drug is Pre-exposure prophylaxis of HIV?

Answer 298

Trivada - emtricitabine

Question 299

When will HIV/AIDS related oral lesions occur?

Answer 299

May occur during mild immunodeficiency and prior to severe opportunistic infectionsEvidence suggests that patient s with oral.lesikns may progress to AIDS more rapidly compared to patients without

Question 300

Why can oral lesions occur?

Answer 300

Immunodeficiency

Question 301

Name 5 oral mucosal lesions strongly associated with HIV?

Answer 301

Candidiasis: - erythematous, pseudo and angular cheilitisHairy leukoplakiaKaposi sarcomaNH lymphomaPerio disease: linear gingival erythema, necrotising gingivitis and periodontitis - more commonly seen due to immunosuppressant therapy

Question 302

Describe candidiasis in HIV patients?

Answer 302

Mild immunodeficiency If psuedomem, indicative of acture immunosuppression - widespread oropharyn and oesoph Can persist for monthErythamtousHyperplastic

Question 303

Describe linear gingival erythema in HIV patients?

Answer 303

Red band involving the free gingival margin - not plaque induced - hypermedia due to vasoactive cytokines

Question 304

Describe hairy leukoplakia in HIV?

Answer 304

Not pre malignant White patches that can’t be removed Lateral border of the tongueVertical white folds with hair like surfaceSmooth

Question 305

Describe the histopathology of hairy leukoplakia?

Answer 305

Acabthotic parakerarinsed epithelium Finger like keratin projections on the surfaceBand of ballon cells in prickle cell layerSecondary candidal infections Swollen cells are EBV+ (koliocytes), EBV demonstration essential for diagnosis

Question 306

Describe Kaposi sarcoma in HIV patients?

Answer 306

Most commonly associated with HIVHHV8Involves skin and mucosal surfacesRed purple patch - becomes nodular

Question 307

Describe the histopathology of Kaposi sarcoma?

Answer 307

Early lesions consit of proliferating endothelial cells, extravasated blood cells, haemosiderin and inflamm cellsLate lesions have a more predominant vascular component and atypical spindle cells

Question 308

Describe non-hodgkins lymphoma in HIV patients?

Answer 308

AIDA and severely immunocompromised patientsAssociated with EBV

Question 309

Name 4 less commonly oral mucosal lesions with HIV?

Answer 309

Bacterial infectionsSalivary glabd diseaseOral ulceration Viral infections

Question 310

Describe HSV and VZV infections in HIV?

Answer 310

More severe and higher recurrence

Question 311

Describe the HPV infection in HIV patients?

Answer 311

6,11 and 16Venereal warTransmitted via oro genital contact Multiple white/pink nodulesFuse forming sessile or pedunculated papillary lesions

Question 312

Describe the histopathology of HPV in HIV patients?

Answer 312

Induce hyperplastic changes rather than ballooning degenerationFibrovascular core covered by stratified squamous epithelium with- hyperpladtiv basal cell layer - acanthosis- parakeratosisKoilocytes

Question 313

Describe atypical ulceration in HIV patients?

Answer 313

Oropharyns most commonly affectedAssociated with CMV infection- can also be aphthous stomatitis

Question 314

Describe salivary gland disease in HIV patients?

Answer 314

Salivary gland enlargement - mainly parotidXerostomuaLymphocyte infiltration Lympho-epothelial cystsEnlargement of intraparotid nodes as part of P

Question 315

How is Oral cancer classified?

Answer 315

International Classification of Disease for Oncology- ICD-O

Question 316

What makes classification of cancer difficult?

Answer 316

Makes comparison difficult Makes epidemiology difficultMakes treatment planning difficult

Question 317

Name the 2 distinct disease patterns for oral cancer?

Answer 317

Oral Cavity Cancer (OCC) Oro-Pharyngeal Cancer (OPC)

Question 318

Describe the epidemiology of OCC?

Answer 318

2.5 per 100,000 pop (2012)Almost HALF (48.7%) in south central AsiaMale 2:1 Female Incidence not increasing worldwide- Decreasing in men, increasing in women- Linked to reduction in tobacco useScottish Cancer Registry- 10% increase 2001-2012

Question 319

Name the 6 common sites for mouth cancer?

Answer 319

Floor of the mouthLateral border of the tongueRetromolar regionsSoft and hard palateGingivaeBuccal mucosa

Question 320

Name the 3 higher sites for SSC in drinkers and smokers?

Answer 320

FoMLat. border of the tongueSoft palate

Question 321

Name the 8 sites of oral cancer?

Answer 321

LipsPalateTonsilsFoMOther throatTongueOropharynxGums

Question 322

Describe the epidemiology for OPC?

Answer 322

1.4 per 100,000 popMost in North America and south central AsiaMale 4.8:1 FemaleRates rapidly rising, especially in High Income areas (North America)- Linked to rising HPV epidemicScottish Cancer Registry- 85% increase 2001-2012 – highest increase for any cancer

Question 323

Name the 5 main risk factors and their associations to Oral Cancer? - how much does each RF multiply the risk of OC?

Answer 323

Smokers who don’t drink x2 risk- Increases with quantity, duration and frequency of tobacco use- Fewer cigarettes for longer duration worse than high number, short term- Smoking risks were generally greater for larynx cancerDrinkers (3-4 drinks/day) x2 risk- Never smoked population- Frequency more important than duration – more drinks each day key- alcohol drinking for oral cavity and pharyngeal cancersSmoke and Drink x5 risk- Increases with frequency and duration of smoking and alcohol consumption- No safe lower limitBetel quid (paan) x3 risk- mixture of substances including areca nut with or without tobacco wrapped in a betel leaf and placed in the mouth Socioeconomic Status x2 risk- Even without other risk factors- Low educational attainment

Question 324

Name the 3 risk factors that have not been confirmed as certain to increase the overall risk of Oral cancer?

Answer 324

Family History- 1st degree relative with H&N cancer may be importantOral Health- Early data suggests poor oral health may be associated with an increased cancer risk – small effectSexual Activity- a slight increased risk for oropharyngeal cancer with: - six or more lifetime sexual partners- four or more lifetime oral sex partners- early age (<18 years) of sexual debut (INHANCE)

Question 325

What are the benefits of reducing smoking and alcohol intake?

Answer 325

Benefits seen between 1-4 yearsRisks reduced and reached a similar level to those who had never smoked after 20 years of quitting. In contrast, the risk effects associated with quitting heavy alcohol consumption take 20 years to begin to emerge.

Question 326

What are the benefits of improving SE status?

Answer 326

Socioeconomic status- SE status is on a par with smoking and alcohol in terms of magnitude (two-fold increased risk)- specifically low educational attainment and low income. - These risks were not fully explained by smoking and alcohol consumption (‘the cause of the cause’)- have a more direct effect associated with socioeconomic circumstances

Question 327

What are the benefits of reducing poor diet choices?

Answer 327

• There is limited new evidence in relation to dietary factors beyond confirming that a high intake of fresh fruits and vegetables were associated with reducing by half the oral cancer risk- Obesity was not associated with an increased oral cancer risk- young people (aged 30-years or less) oral cancer was more likely in those who self-reported a low body mass index (BMI)

Question 328

Name 4 potentially malignant lesions?

Answer 328

White lesions (leukoplakia)Red lesions (erythroplakia)Lichen planus- Candidal Leukoplakia- Chronic Hyperplastic CandidiasisOral Submucous Fibrosis

Question 329

Describe the epidemiology of white lesions in OC?

Answer 329

incidence 0.2 - 4%- wide variation in different populations- Reliability of data not clearmalignant change- varied reports, most under 4%- period prevalence2.5% in 10 years, 4% in 20 yearsMost oral carcinomas in UK arise in initially clinically normal mucosaMost cancer in high incidence areas (e.g. India) from potentially malignant lesionWorldwide leukoplakia is 50 to 100 times more likely to progress to cancer than clinically normal mucosa

Question 330

Name 3 types of descriptions of white lesions?

Answer 330

HomogenousErosiveNon-homogenous on atrophic background

Question 331

How does erythroplakia compare to leukoplakia?

Answer 331

much less frequent than leukoplakiamuch higher risk of cancergreater dysplasia risk- Up to 50% already be carcinomano good follow-up studies available

Question 332

What are the common characteristics of dysplasia and the new categorisation of severity?

Answer 332

Based on:- Cellular Atypia- Epithelial Architectural OrganisationNew categorisation- Low grade- high grade- carcinoma-in-situ

Question 333

Describe the histological low grade of oral mucosal dysplasia?

Answer 333

Easy to identify that the tumour originates from squamous epitheliumArchitectural change into lower third Cytological atypia or dysplasia may not be prominent Shows a considerable amount of keratin productionEvidence of stratificationWell formed basal cell layer surrounding the tumour islands Tumour islands are usually well defined and are often continuous with the surface epithelium Invasion pattern with intact large branching rete pegs ‘pushing’ into underlying CT(Where there is architectural change into middle third, depending on the level of cytological atypia will be classified into low grade or high grade)

Question 334

Describe the histological high grade of oral mucosal dysplasia?

Answer 334

Show little resemblance to a normal squamous epitheliumArchitectural change upper third Usually show considerable atypiaInvade in a non-cohesive pattern with fine cords, small islands and single cells infiltrating widely through the CTMitotic figures are prominent and many may be abnormal Degree of differentiation used to predict prognosis

Question 335

Describe the histological carcinoma in situ of oral mucosal dysplasia?

Answer 335

Theoretical conceptCytologically malignant but not invadingAbnormal architecture- Full thickness (or almost full)- Severe cytological atypiaMitotic abnormalities frequent

Question 336

Name the histoloigcal prognostic facors which give information on survivability?

Answer 336

Pattern of Invasion- Bulbous rete pegs infiltrating at same level is considered of a better prognosis than widely infiltrating small islands and single cells Depth of Invasion- Risk of metastases for a tumours greater than 4mm was 4x greater than for a tumour less than 4mmmPerineural Invasion- Is seen in up to 60% of OSCCs but is most significant when a tumour is seen within a large nerve at a site some distance from the main tumour massInvasion of Vessels- Widely thought to be associated with lymph node metastaes and a poor prognosis

Question 337

Describe the Field Cancerisation concept?

Answer 337

Multiple primaries possible over time- up to 15 to 20 in some patientsConcept of “field cancerisation”- high cancer risk in 5cm radius of original primary - that’s most of the mouth/pharynxSynchronous or metachronous lesions- Can occur at the same time as the primary or at later times

Question 338

Name the multiple variables for clinical cancer staging of OC?

Answer 338

site size (T)spread (N&M)

Question 339

Describe the different varying change of cancer prognosis/survivability?

Answer 339

1/3 patients present at stage I/II- Stage I - 80% cure rate - Stage II – 65% cure rate- Later than this 5 year survival <50%, cure <30%- If untreated, with metastases, survival is about 4 monthsSurgery, Radiotherapy and Chemo/Immunotherapy all used- Choice will depend on patient choice and health/prognosis- Tumour location, size and nutitional status all important For resectable tumours, primary surgery offers the best outcome- Post surgical radiotherapy or chemotherapy

Question 340

Describe the aetiology, behaviour and prognosis of Lip cancer?

Answer 340

Lower lip- non-healing ulcer or swellingAetiology- Sunlight UV-B- smokingBehaviour - slow growth - local invasion- rarely metastasise to nodesGood prognosis as early detection

Question 341

How is OC detected?

Answer 341

Difficult to do – a judgement from experience- Use the ’Oral Cancer Recognition Toolkit’ - Developed jointly by Cancer Research UK and the British Dental Association

Question 342

What are the advantages and disadvantages of OC screening?

Answer 342

Benefits vs HarmUndetected lesions vs False positiveCost of Screening vs Cost of diseaseCost of Screening vs Disability from disease

Question 343

Name the 5 OC screening tools?

Answer 343

HPV16 screeningToluidene blueVELscopePhotodynamic Diagnosis (PDD)Clinical judgement of experienced clinician

Question 344

Describe what and how toluidine blue is and used?

Answer 344

false positive in inflammatory lesions ? 50 % false negatives good for invasive disease, but usually clinically evident

Question 345

Describe what and how VELscope is and used?

Answer 345

Autofluorescence of tissues with blue light- Loss of fluorescence equates to ‘change’- Change may be cancer but can be other changesPublished work ‘thin’- May well work, but evidence not yet adequate

Question 346

Explain the duty of Primary care dentistry in OC screening/detection?

Answer 346

Part of General CPD requirement nowDentist has opportunity for PRIMARY PREVENTION in patients attending for regular oral careDentist must be familiar with and competent in:- Smoking cessation advice - Alcohol reduction advice- Healthy diet promotionThere is a GDC expectation that a dentist will do this as part of ‘good patient care’ rather than any particular remunerationDentist has to make decision about their referral threshold for potentially malignant lesionsMonitor with photographs and education Remove local factors where ulcer may be due to trauma, then review2 WEEK RULE for referral to clinic for the hospitalPatient must be initially seen within this time62 day referral to treatment time for cancer patients

Question 347

What is the definition of precancerous lesion?

Answer 347

An altered tissue in which cancer is more likely to form

Question 348

What is the defintiion of precancerous condition?

Answer 348

A generalised state associated with an increased cancer risk

Question 349

Name the 4 types that can’t be conisdered leukoplakia?

Answer 349

Tobacco related lesions Smokers keratosis Chronic hyperplastic candidosis Frictional keratosis

Question 350

What is the definition of leukoplakia?

Answer 350

It is a clinical diagnosisIt has NO histological connotationEpithelial dysplasia may or may not be presentNon-homogeneous types are more likely to be dysplastic

Question 351

Describe the epidemiology of leukoplakia?

Answer 351

• Incidence ? 0.2 – 10% but wide variation in different parts of the world. 6 x commoner in tobacco users. Male > Female world wide but only marginally so in the west. More common in the “elderly.” - Malignant change in 3 -28%- Period prevalence - how many in what time? 2.5% in 10 years, 4% in 20 years (West) ? % in Far east and Africa

Question 352

Name the clinical predictors of malignancy?

Answer 352

Clinical appearance - very variableNon-homogeneousVerrucous, speckled, Ulcerated, leuko-erythroplakia

Question 353

Describe the molecular progression of oral cancer?

Answer 353

The development of oral cancer involves the progressive accumulation of 6 -10 genetic alterations in an epithelial cell leading to uncontrolled proliferation and clonal expansion.A genetic progression model based on chromosomes frequently identified as showing Loss of Heterozygosity (LOH) in oral carcinogenesis suggests:- Normal mucosa experiences a LOH at 9p: leads to predysplastic lesion.- Predysplastic lesion experiences an additional LOH at 3p, 17p :leads to dysplasia.- Dysplastic lesion experiences further LOH at 11q,13q and 14q leads to carcinoma-in-situ.- C-I-S lesion experiences a further LOH at 6p,8,4q which leads to invasion

Question 354

What is the definition of hyperplasia?

Answer 354

Increased cell numbersArchitecture regular stratification altered compartment sizeNO cellular atypia

Question 355

What is the definition of hyperplasia of stratum spinosum (acanthosis)

Answer 355

Architecture -increased maturationcompartment

Question 356

What is the definition of basal cell hyperplasia?

Answer 356

increased basal cells

Question 357

What is the definition of low grade (mild hyperplasia)

Answer 357

Architecture -change in lower thirdMild -cytological atypia

Question 358

What is the definition of high grade (mod/severe dysplasia)

Answer 358

Architecture -change into middle/upper third Marked cytological atypiaPossibility of numerous abnormal mitoses

Question 359

What is the definition of oral candidosis?

Answer 359

Opportunistic fungal infection of the oral cavity.- Oral rarely in itself painful- Oesophageal may be in HIV

Question 360

How do people aquire candida?

Answer 360

Majority of normal population are healthy carriersMost common isolate is C. albicans

Question 361

Name 5 candidal virulence factors?

Answer 361

AdherenceSwitching mechanismsGerm tube formationExtracellular enzymesAcidic metabolites

Question 362

Name the local predisposing factors for candidal infections?

Answer 362

SmokingDenturesLocal corticosteroidsXerostomiaTopical antimicrobials

Question 363

Name the general predisposing factors for candidal infections?

Answer 363

Extremes of ageEndocrine disease- DiabetesImmunodeficiency- Steroid use, HIVNutritional deficiency- ironAntibiotics

Question 364

Name the classification of oral candidosis?

Answer 364

Acute Pseudomembranous- Sudden local/systemic immunosuppressionChronic Erythematous- Longstanding & persisting issue- e.g. below poor fitting dentures, HIV, median rhomboid glossitis and antibioticChronic Hyperplastic

Question 365

How to diagnose oral candidosis?

Answer 365

Laboratory tests- Differentiate from commensal- Only by QUANTIFIABLE assay- Culture and sensitivity to inform treatment- Multiple sites usually- Smear/microscopy occasionally

Question 366

How to diagnose candidosis via lab?

Answer 366

Swab (mucosa or denture )Whole saliva/Oral rinse- Growth onto selective agarOral rinse- Patient rinses with 10ml of PBS. Inoculate onto selective agar on spiral plater. - Has the advantage of being a “Quantitative technique”

Question 367

How to identify candidaosis in the lab?

Answer 367

Direct microscopyGerm Tube testPhysiological tests- Carbohydrate fermentation- Carbohydrate and nitrogen assimilationCommercial systems- API 20C systemsBiopsy- Essential for diagnosis of hyperplastic candidosis.- PAS stainDirect smear

Question 368

Name the 5 candida species?

Answer 368

C. albicansC. glabrataC. tropicalisC. kruseiC. dubliniensis

Question 369

Describe the principles of management for candidal infection?

Answer 369

Correction of predisposing factors OH, diet, trauma, steroid inhaler hygieneIdentify underlying illnessesAntifungal agentCo-infection with other microorganisms?

Question 370

Name different categories of antifingal drugs?

Answer 370

Polyenes- Nystatin- AmphotericinImidazole- Miconazole- ClotrimazoleTriazoles- Fluconazole - Itraconazole

Question 371

Explain the treatment regimes for oral candidosis?

Answer 371

Topical Therapy (lengthy courses required) - Nystatin (pastille, suspension, cream and ointment)- Amphotericin (not available in the UK)- MiconazoleSystemic treatment (often preferred)- Fluconazole- Itraconazole

Question 372

What is the definition of miconazole?

Answer 372

• Imidazole antifungal- Not absorbed systemically- Available as a cream, ointment, patch or a gel - Don’t use gel for skin lesions (orange!) - Cream/ointment available with hydrocortisone - Available without prescriptionSlow release adhesive preparation availableACTIVE AGAINST STAPHYLOCOCCI as well as Candida

Question 373

Name the types of systemic antifungals and their treatment regimes?

Answer 373

Fluconazole - 50mg capsules taken once daily- 14 day courseItraconazole- 100mg capsule - 14 day course- 100mg twice in once daily for Pseudomembranous candidiasis

Question 374

Name 3 antifungals that have resistance?

Answer 374

C. glabrataC. kruseiiC. dubliniensis

Question 375

Name the disease that come from Human herpesvirus/

Answer 375

Herpes simplex virus (HSV) - Primary herpetic stomatitis - Herpes labialis (recurrence) Varicella-Zoster Virus (VZV) - Chickenpox - Zoster (recurrence) Epstein-Barr Virus - Infectious mononucleosis Cytomegalovirus (CMV) HHV8- Kaposi’s sarcoma

Question 376

Explain the virion replication cycle?

Answer 376

Virus attachment and entryUncoating of virionMigration of acid to nucleusTranscriptionGenome replicationTranslation of virus mRNAsVirion assemblyRelease of new virus particles

Question 377

Effect of viral infections on host cells?

Answer 377

Cell death (cytopathic effect)Latent infectionHyperplasia Transformation

Question 378

Explain the lifecycle of HSV, VZV associated leison?

Answer 378

Intranuclear oedema (glass-appearance of nuclei) at basal cell layer“Ballooning degeneration” : Keratinocytes swelling and loss of attachment. Cells can be multinucleated with eosinophilic intranuclear inclusions and eosinophilic cytoplasmProgressive cell swelling (cells are large and clear)Rupture of infected cells and release of viral particles to non-infected cells

Question 379

Explain how to diagnose human herpesvirus?

Answer 379

Laboratory investigations available:- Antigen-specific IgG or IgM serum titres- PCR- Immunofluorescence, immunocytochemistry on affected tissue- Virus isolation from lesion and cultivation

Question 380

Describe the apperance of primary herpetic stomatosis?

Answer 380

HSV-1- Incubation period: 5-7 days- Intraoral vesicles- Vesicles on lips and crusting due to exudate coagulation- Generalized gingival inflammationExtra-oral involvement:- peri-oral- fingers (herpetic whitlow)- eyesSymptoms- Pain- Dysphagia- Dehydration - May be associated with fever, lymphadenopathy, - Pharyngitis in adolescentsRecurrent infection:- Occur in the same location, unilateral and recur 2-3 times a year on average- Most commonly on lips, but can involve other perioral tissues- Erythematous areas papules vesicles ulcers- Intraoral mucosal involvement is less common. - Chronic ulcers in immunocompromised individuals

Question 381

Describe the apperance of chickenpox?

Answer 381

VZV- Prodromes: fever, fatigue, pharyngitis- Small ulcers (rarely intact vesicles) mainly on soft palate and fauces- Intraoral lesions may precede skin lesions Recurrent infeection (Zoster)- Prodromes: pain and parasthesia- Unilateral vesicular eruption following distribution of sensory nerves, e.g. divisions of the trigeminal nerve, geniculate ganglion of facial nerve (Ramsay Hunt syndrome).- Intraoral vesicles rupture quickly- Cutaneous lesions clear within 3 weeks. Pain may persist (post-herpetic neuralgia)

Question 382

Describe the managment for HSV-1 and VZV mild infections?

Answer 382

Symptomatic relief :- Hydration- Rest- Pain relief- Antimicrobial mouthwashes (chlorhexidine 0.2%, H2O2 6%)Mild infection of the lips in healthy individuals:- Aciclovir cream 5% every 4 h- Penciclovir cream 1% every 2 h

Question 383

Describe the managment for HSV-1 and VZV severe and immunocompromised infections?

Answer 383

Severe infections in non-immunocompromised patients:- 200 mg Aciclovir tabs or oral suspension, 5 times daily, 5 days- Prophylaxis: aciclovir 400mg twice daily (in liaison with specialist)Immunocompromised patients:- 400mg Aciclovir tabs or oral suspension, 5 times daily, 5 days- Both adults and childrenImmunocompromised with severe infection:- Refer to specialist/GP for treatmentShingles:- 800mg Aciclovir tabs or oral suspension, 5 times daily, 5 days, within 72 h onset of rash- Not in children- Refer to specialist/GP

Question 384

Describe the apperance of infectious mononucleosis?

Answer 384

EBV:- Long incubation period (4-6 weeks)- Prodromes: severe fatigue, malaise and anorexia (10-15 days)- Main symptoms: fever, pharyngitis and generalizedlymphoadenopathy (cervical nodes)Diagnostic features:- Paul-Brunell test +- Raised anti-EBV antibodies. - If above are negative consider CMV and toxoplasmosis.- Possible oral signs: tonsilar exudate, palatal petechiae

Question 385

Describe the apperance of CMV?

Answer 385

Mostly subclinicalIf symptomatic, clinically similar to infectious mononucleosisLarge, shallow ulcers (Cytomegalovirus-associated ulceration) in immunocompromised individuals. Histopathology: Non-specific ulceration but CMV+ inclusion bodies present at ulcer floor.

Question 386

Describe the apperance of hand-foot and mouth disease?

Answer 386

Coxsackie Virus (A):- Incubation period is 4-7 days. Highly infectious.- Small ulcers (rarely intact vesicles) causing little pain mainly on buccal, labial, lingual and palatal mucosae- Vesicles and ulcers on hands and feet (occasionally oral ulcers or skin rash in isolation)- No gingivitis, no lymphadenopathy, no systemic upset- Self-limiting (7 days)

Question 387

Describe the apperance of herpangina?

Answer 387

Coxsackie A and B strains:- Prodromes: muscular pain, nausea, malaise.- Small ulcers mainly on palate, uvula, tonsils- Associated with fever, dysphagia and oropharyngitis- Self-limiting (8-10 days)

Question 388

Describe the apperance of measles?

Answer 388

Koplik’s spots - Prodrome of measles (2-4 days before measles cutaneous rash).Appear mostly on buccal mucosa (opposite molars).White spots against an erythematous background.

Question 389

Describe the apperance of warts?

Answer 389

HPV 2,4:- White or pinkish, raised but mostly sessile- Similar to squamous cell papilloma, but more rounded and sessile- Often multiple- Mainly children affected, secondary to self inoculation

Question 390

Describe the apperance of squamous papilloma?

Answer 390

More common in individuals >20 of ageExophitic, peduncolatedDistinctive branched structure, finger-like processes, white or pinkishUp to 20 mm in diameter

Question 391

Describe the apperance of condyloma acuminatum?

Answer 391

HPV 6, 11, 16:Venereal wartHIV infection manifestationTransmitted via oro-genital contactMultiple white/pink nodules.Fuse forming sessile or pedunculated papillary lesion.

Question 392

Describe the management of oral mucosal HPV-related lesions?

Answer 392

Diagnosis- Clinical- Biopsy (excisional if possible)Treatment- Reassurance and monitoring- Cryotherapy- Surgical excision

Question 393

Describe the histopathology of oral mucosal HPV-related lesions?

Answer 393

HPVs induce hyperplastic changes rather than “ballooning degeneration”Fibro-vascular core covered by stratified squamous epithelium with - hyperplastic basal cell layer- acanthosis - hyperortho/parakeratosisKoilocytes

Question 394

Name the 2 categories for diagnosis of infections? And their options?

Answer 394

Clinical features- history- examLaboratory tests- microscopy- culture- mass spec- nucleic acid amp- immuno tests

Question 395

Describe what sampling and testing involves?

Answer 395

Culture and sensitivity:- swab - mouth and related sitesWhole salivaAspirateSmearBiopsyBlood

Question 396

How to decide if infection need treatment?

Answer 396

Active symptoms:- directly related to the infectious agentConsequences of infection:- local- systemic

Question 397

How to decide appropriate treatment for infection?

Answer 397

Culture and sensitivity test - always preferredBest guessExperienceSide effect profile Cost

Question 398

What is the defintion of staphylococcal infection

Answer 398

Uncommon as an acute problem- immunocompromised Very common as chronic mixed infection (related angular cheilitis)Topical treatment sufficient If systemic indicated- consider narrow spectrum

Question 399

What is the defintion of scarlet fever?

Answer 399

Exotoxin mediated mucocutaneous manifestations

Question 400

Name the 4 clinical features of scarlet fever?

Answer 400

Incubation period of 2-4 daysProdromes: nausea, malaise, vomiting, pharyngitis and lymphoadenopathyMacular erythemaOral mucosa erythematous and oedematousDorsum tongue covered by white thick coating with enlarged fungiform papillae

Question 401

What are the clinical features of tuberculosis?

Answer 401

Chronic, painless and irregular ulcer Covered by yellowish exudateSurrounding tissue indurated with inflammLocalisation- tongue, palate gingivae, and lipsAssoc subman and services lymphoadenopathy

Question 402

What isnthe histopathology of tuberculosis ?

Answer 402

Granukomas containing muktinuc giant cells- mycobacteria not always identifiable

Question 403

What are the oral manifestations of syphilis?

Answer 403

Primary - chancre Secondary - mucosal patches and blisters LatentTertiary - gumma, CV and CNS complications

Question 404

What is the defintion of gonorrhea?

Answer 404

Second most common STIOral lesions result of progenitor contactNon-specific oral presentation:- multiple ulcers- erythema- white pseudomembranes- painful pharyngitis- lymphoadeno

Question 405

What are the clinical features of actinomycosis?

Answer 405

Cerviofacial most common form Painful and slow growing hard swelling Absfesses and draining sinusesDischarge yellow purulent material

Question 406

What are the histopathologucal features of actinomycosis?

Answer 406

Colony of actinomyces in centreDense collection of inflamm cellsSurround by wall of fibrous tissue

Question 407

Court ordered mandate for release of dental records?

Answer 407

Must be sent to the lawyer

Question 408

What if a patient doesn’t attend their referral appointment?

Answer 408

If it is possibly harmful such as a biopsy - you should try and persuade them to goIf they still refuse to go to their referral and explain that they don’t want to be referred anymore - you still MUST refer them, protected under the data protection act. If they still don’t attend it is essential to try and persuade them to go

Question 409

What is the period of time for a complaint to be dealt informally?

Answer 409

5 days

Question 410

If a formal complaint has been made, when must the dentist acknowledge it?

Answer 410

Within 3 working days

Question 411

How many days must the complaint be responded to?

Answer 411

20 days

Question 412

Complaints procedure - how long to reply?

Answer 412

Acknowledge receiving complaint within 3 daysRespond informally in 5 days And respond formally in 20 days5 days response to decide formally or informally3 days after formal 20 days in total

Question 413

How can the patient take their complaint to the next step?

Answer 413

Complaint NHS Ombudsman, within 28 day reply