7 - Oral medicine Flashcards
What are some of the causes of oro-facial soft issue infections?
VIRAL
- primary herpes
- herpangina
- hand foot and mouth
BACTERIAL
- staph
- strep
FUNGAL
- Candida
Describe primary herpetic gingivostomatitis.
- acute infectious disease
- caused by the Herpes Simplex virus 1
- transmission by droplet formation with 7 day incubation
- herpes labialis is a common secondary infection
What are the signs and symptoms of primary heretic gingivostomatits?
- fluid filled vesicles, which rupture to painful rugged ulcers on the gingiva, tongue, lips, buccal and palatal mucosa (patients can be reluctant to eat or drink)
- severe oedematous marginal gingivitis
- fever
- headache
- malaise
- cervical lymphadenopathy
How do you treat primary herpetic gingivostomatitis?
- bed rest
- soft diet/keep hydrated
- paracetamol
- antimicrobial gel/mouthwash
- acyclovir (medically compromised children)
What is the most common complication of primary herpetic gingivostomatitis?
Dehydration
What causes the recurrence of herpes virus?
- 50-75% recurrence as herpes labialis
- triggered by stress, UV, being run down
What causes herpangina?
Coxsackie A virus
What causes hand foot and mouth?
Coxsackie A virus
How does herpangina present?
- vesicles in the tonsilar/pharyngeal region which rupture to painful ulcers
- lasts 7-10 days
How does hand foot and mouth present?
- ulceration of gingiva, cheeks, tongue and palate
- maculopapular rash on hands and feet
- lasts 7-10 days
How do you manage herpangina?
- bed rest
- soft diet/keep hydrated
- paracetamol
- antimicrobial gel/mouthwash
- acyclovir (medically compromised children)
How do you manage hand foot and mouth?
- bed rest
- soft diet/keep hydrated
- paracetamol
- antimicrobial gel/mouthwash
- acyclovir (medically compromised children)
Define oral ulceration.
Localised defect in the surface oral mucosa where the covering epithelium is destroyed leaving an inflamed area of connective tissue
What history is required for an ulcer?
- onset
- frequency
- number (present at on time)
- site
- size
- duration
- exacerbating dietary factors
- lesions in other areas
- associated medical problems
- treatment so far (beneficial or not?)
What are common causes of oral ulceration?
- unknown
- infection
- immune mediated disorder
- vesiculobullous disorder
- immunodeficiency disorder
- neoplastic/haemotological
- trauma
- vitamin deficiency
- recurrent apthous stomatitis
Give an example of an infection that causes ulceration.
VIRAL
- coxsackie
- herpes simplex
- HIV
BACTERIAL
- TB
- syphilis
Give an example of an immune mediated disorder that causes ulceration.
- Crohns
- SLE
- coeliac
Give an example of a vesiculobullous disorder that causes ulceration.
- bullous or mucous membrane pemphigoid
- linear IgA disease
Give an example of a neoplastic or haemotogocial disorder that causes ulceration.
- anaemia
- leukaemia
- cyclic neutropenia
Give an example of a deficiency that causes ulceration.
- iron
- B12
- folate
Define RAU.
- recurrent apthous ulceration
- most common cause of ulceration in children
- typically round or ovoid in shape with yellow/grey base
What are the 3 patterns of RAU?
- minor (<10mm, non keratinised mucosa, 10-14 days healing)
- major (>10mm, non keratinised, multiple weeks to heal)
- herpetiform (1-2mm, hundreds ay one time, no fever)
Describe the aetiology of RAU.
- unclear
- hereditary predisposition in 45% of cases
- iron deficiency 20%
- GI eg coeliac
- stress
- menstruation
What investigations are used in RAU?
- diet diary
- FBC
- haematinics
- coeliac screen
How do you manage RAU?
- diet analysis for exacerbating foods (deficiencies, traumatic eg avoid sharp/spicy, allergies)
- low ferritin = 3 months iron supplements
- low folate/B12 or positive anti-transglutaminase (coeliac) = refer to paediatrician
- pharmacological
How is RAU treated pharmacologically?
- prevention of superinfection (corsodyl 0.2%)
- protecting healing ulcers (gengigel or gelclair mouthwash, both hyaluronate)
- symptomatic relief (difflam 0.15% benzydamine hydrochloride, LA spray)
Describe OFG.
- orofacial granulomatosis
- uncommon chronic inflammatory disorder
- idiopathic or associated with systemic Crohn’s disease or sarcoidosis
- average age 11 years old
- more common in males
What are the clinical features of OFG?
- lip swelling
- full thickness gingival swelling
- swelling of non-labial facial tissues
- peri-oral erythema
- cobblestone appearance of buccal mucosa
- linear oral ulceration
- mucosal tags
- lip/tongue fissuring
- angular cheilitis
Describe the aetiology of OFG.
- largely unknown
- allergens including cinnamon compounds, benzoates
- higher IgE mediated atopy rates than general population
What investigations can be completed to diagnose OFG?
- clinical
- lip biopsy (not essential)
- observe growth (Crohn’s)
- FBC and haematinics
- patch tests
- diet diary
- faecal calportectin (Crohn’s)
- endoscopy
- serum angiotensin converting enzyme (sarcoidosis)
How do you manage OFG?
- OH support
- symptomatic relief
- dietary exclusion
- manage nutritional deficiency
- topical steroids
- short courses of oral steroids
- intralesion corticosteroids
- surgical intervention (unresponsive to other tx)
What is geographic tongue?
- idiopathic and non-contagious, benign
- seen at young age
- shiny red areas on tongue with loss of filiform papillae surrounded by white margins
- causes intense discomfort (spicy food or tomato/citrus)
How do you manage geographic tongue?
- reassure parents that this is benign
- bland diet during flare ups
- haematinics for deficiencies
What are causes of solid swellings in the mouth?
- fibre-epithelial polyps
- epulides
- congenital epulis
- HPV-associated mucosal swellings
- neurofibromas
Describe a fibre-epithelial polyp.
- common
- firm pink lump (pedunctulated or sessile)
- usually in cheeks, also found in lips or tongue
- does not change size
- caused by minor trauma
- excision is curative
What are epulides?
- common solid swelling of mucosa
- benign hyperplastic lesion
- 3 main types (fibrous epulis, pyogenic granuloma, peripheral giant cell granuloma)
Describe fibrous epulis.
- pedunculated or sessile mass
- firm consistency
- similar colour to surrounding gingiva
- made up of inflammatory cell infiltrate and fibrous tissue
Describe pyogenic granulomas.
- also known as pregnancy epulis (regress after birth)
- often ulcerated
- haemorrhage spontaneously with mild trauma
- vascular proliferation support by fibrous stroma
- recur after removal
Describe peripheral giant cell granulomas.
- pedunculated or sessile swelling
- typically dark red and ulcerated
- arise inter proximally with an hourglass shape
- radiograph can reveal superficial erosion of superficial bone
- multinucleate giant cells in a vascular stroma
- may recur after excision
What congenital epulis?
- rare lesion
- occurs in neonates, F > M
- most commonly anterior maxilla
- granular cells covered with epithelium
- benign
- excision is curative
What are the types of HIV associated swellings?
- verruca vulgaris
- squamous cell papilloma
Describe verruca vulgaris.
- single or multiple lesion
- associated with skin warts
- caused by HPV 2 and 4
- found on keratinised epithelium (gingiva and palate)
- resolve spontaneously but can be excised)
Describe squamous cell papilloma.
- small pedunculated (cauliflower like) growths
- benign
- caused by HPV 6 and 11
- vary in colour from pink to white
- usually solitary
- excised
What are causes of fluid filled swellings in the oral cavity?
- mucoceles
- ranula
- Bohn’s nodules
- Epstein pearls
- haemangiomas
- vesiculobullous lesions
What are mucoceles?
- 2 types (mucous extravasation cyst and mucous retention cyst)
- bluish, soft, transparent cystic swelling
- affect minor or major salivary gland
- most common in lower lip minor glands
- can be excised
What is a ranula?
- mucocele in FOM
- arise in minor glands or ducts
- ultrasound or MRI required to exclude plunging ranula (through FOM)
- occasionally are lymphangioma (tumour)
What are Bohn’s nodules?
- gingival cysts
- remnant of dental lamina
- filled with keratin
- occurs on alveolar ridge
- found in neonates
- self resolve in a few months
What are Epstein pearls?
- small cystic lesions
- found in midline of palate
- trapped epithelium in midline
- 80% of neonates
- disappear in first few weeks
What is TMJDS?
- temperomandibular joint dysfunction syndrome
- characterised by pain, masticatory muscle spasm, truisms
What history is required for TMJDS?
- presenting symptoms
- when did it begin
- is it worse at a specific time of day (morning = clenching at night)
- exacerbating factors
- habits
- stress
How do you examine for TMJDS?
- palate MOM at rest and with teeth clenched
- palate TMJ at rest and when open/close (listen for click or crepitus, assess any deviation of jaw and extent of opening)
- asses any NCSTL
- signs of clenching in mucosa (scalloped tongue, buccal mucosa ridges)
How do you manage TMJDS?
- explain condition
- reduce exacerbating factors (eg. manage stress, avoid habits)
- bite splint
- soft diet
- symptomatic relief (ibuprofen, hot/cold compress)
