Diseases of the Mouth and Salivary Gland Flashcards
Aphthous Ulcers
AKA Canker sore
? associated with human herpes virus 6
STRESS is a major predisposing factor!
Aphthous Ulcers Common location
Typically found on buccal and labial mucosa
Spares gingival and palatal mucosa
Common & easy to identify
Aphthous Ulcers S/S
Single or multiple
Often recurring
Painful
Small, round ulcerations with yellow-gray
centers surrounded by red halos
Aphthous Ulcers Tx
Minor (<1cm)—generally heal, 10 -14 days
Major (>1cm)—can be disabling due to pain
- If large or not improving, consider biopsy
Symptom care
Salt water or medicated rinses (swish and spit)
Cimetidine (Tagamet) has been helpful in patients with recurrent ulcers
!! Topical steroids (triamcinolone, in adhesive base (Orobase))
Aphthous Ulcers
Large or persistent areas may be caused by
erythema multiforme, drug allergies, HSV, bullous or pemphigus diseases, Behcet disease or inflammatory bowel disease
Necrotizing Ulcerative Gingivitis
AKA “Trench Mouth” and Vincent Angina”
Necrotizing Ulcerative Gingivitis - cause
infection of the gums with spirochetes & fusiform bacteria
sudden onset
Necrotizing Ulcerative Gingivitis - common in
young adults in times of stress
underlying systemic disease
Necrotizing Ulcerative Gingivitis - S/S
Gums - tender and inflamed
Affected gingiva between teeth ulcerates and may be covered with a gray exudate which can be removed with gentle pressure
F/tender, bleeding gums, halitosis and cervical lymphadenopathy
bad smelling breath
Necrotizing Ulcerative Gingivitis - Tx
Warm half-strength peroxide rinses or other antibacterial rinses
Oral antibiotics- Penicillin and Metronidazole
Debridement ?
Herpes Stomatitis - type and cause
HSV Type 1
Prodrome: burning/tinging
Then, small vesicles form that rupture and form scabs
Problematic in the HIV population- more frequent and potentially severe
stress can bring this on
Herpes stomatitis - lesion location
attached gingiva and mucocutaneous junction of lip, tongue, buccal mucosa and soft palate
Herpes stomatitis -
Primary infxn symptoms
malaise, fever, headache and cervical lymphadenopathy
Herpes stomatitis -
Recurrences
usually occur on the LIPS
Herpes stomatitis - Tx
Adults : common, mild and short-lived; typically requires no intervention - symptomatic care
oral acyclovir, valacyclovir (or topical)
(Usually only effective if started within 24-48 hours of onset of symptoms)
Primary syphilis
Chancre
Single, indurated painless ulcer on the mucosa
Resolves spontaneously, 4 - 6 weeks
bx can help with dx
Secondary Syphilis
a well-defined white plaque on the labial or palatal mucosa =
(CONDYLOMA LATA)
Oral Candidiasis cause
overgrowth of candida species
MC in either systemic or local immunosuppression!
(steriods, chemo/rad, abx use, HIV, DM, dentures)
Oral Candidiasis - common in
the elderly and very young
individual who use powder inhalers (Recommend rinsing, swishing and spitting after use)
Oral candidiasis - tongue blade use
DOES scrape off and reveals eryth. base
Oral candidiasis - S/S
Throat or mouth pain
Erythema of the oral cavity, Creamy, white patches/plaques
May have associated burning, may be worse with certain foods/drink
Oral candidiasis - Dx
Clinical
wet prep/bx if needed
Consider HIV testing
HIV + pts, oral exam every visit & dental visits every 6 mos.
Oral candidiasis - Tx
Antifungal therapy
Topical: Clotrimazole troches or Nystatin solution (1st line usually)
Oral: Fluconazole, Ketoconazole (not common)
Oral candidiasis can spread
down esophagus and throat/pharynx
same tx - swish and swallow
Mucoceles
Cystic lesions found in the mouth, usually lower lip (oral mucousa!)
Common, benign
develop following trauma (self-biting) or obstruction of a minor salivary gland
Mucoceles - S/S
Variable in size, contains gelatinous fluid
Nodule, with a thick roof
Chronic lesions = firm, inflamed, poorly circumscribed nodules; bluish, translucent; fluctuant
Mucoceles - Dx
clinical,
biopsy if needed
Mucoceles - Tx
Avoid any further trauma = resolution
Excision if not improving, bothersome or progressing
Ranula
found under tongue!
May be small and well circumscribed or “plunging”
similar to mucocele
Ranula - tx
can be excised but need to go down to base to avoid recurrence
resolve on their own if small usually
Glossitis
Inflammatory disorder of the tongue
loss of filiform papillae
rarely painful
Glossitis - Appearance
smooth, glossy appearance with red or pink background
Glossitis - causes
Nutritional deficiencies (B12, Niacin, Riboflavin, Iron, Vit E)
Drug reactions
Dehydration
Malnutrition- protein/calorie deficit
Certain irritating foods and liquids
Autoimmune disorders- Sjogren’s, Celiac
Glossitis - Tx
underlying cause / improve nutritional diet
Glossodynia
AKA “Burning Mouth Syndrome” or burning tongue
Burning and pain of the tongue +/- glossitis
MC in post-menopausal women
Glossodynia - associated with
Diabetes Mellitus
Drugs (diuretics)
Tobacco
Xerostomia (dry mouth)
Candidiasis
Glossodynia - Tx
underlying causes, change long-term meds, smoking cessation
Meds (if needed): clonazepam
Behavioral therapy may be helpful
If occurring on only one side of tongue, neurologic lesions need to be ruled out
Fissured tongue
Deep grooves located on the midline or evenly distributed on the tongue surface
Can be a normal tongue variant seen in adults
Fissured tongue - Tx
generally asymp.
although if irritation from entrapped debris occurs, brushing the tongue may be helpful
Fissured tongue - associated w/
malnutrition, Down Syndrome, Vitamin B deficiency
predisposing factor for halitosis
Black tongue
Hyperpigmentation of the tongue and oral mucosa
commonly seen in dark-skinned individuals
Black Tongue - less common causes
drugs (tetracyclines, bismuth subsalicylate)
proton pump inhibitors Addison disease
pellagra (niacin deficiency)
Black Hairy Tongue
harmless, temporary cond. - tongue discoloration
Buildup of dead cells on the papillae
papillae easily trap bacteria, yeast, tobacco, food or other substances
Black Hairy Tongue - tx
Resolves by eliminating cause & by practicing good oral hygiene
Angular Chelitis
Acute or chronic inflammation of the labial mucosa at the lateral commissures
Angular Chelitis - Causes
Excessive moisture from saliva - (secondary infxn = candidiasis or S. aureus)
More common in older age, denture wearers, poor oral hygiene
Nutritional deficiencies, in younger patients- lip licking, thumb sucking, drooling
Angular Chelitis - S/S
Erythema, maceration, scaling, fissuring
painful, usually bilateral
ulceration, crusting, cracking
Angular Chelitis - Dx
clinical
culture?
KOH prep?
Angular Chelitis - Tx
improve denture fit/hygiene,
optical oral hygiene,
barrier creams/ointment,
topicals
Geographic tongue
AKA benign migratory glossitis
Recurrent inflammatory disorder - unknown etiology - affects the dorsum of the tongue
areas of atrophy
lesions change location, pattern, size, and migrate
Geographic tongue - s/s
usually asymp.
sometimes sensitive or painful w/ certain foods/ drinks
may be associated w/ atopy, psoriasis, or reactive arthritis
Geographic tongue - Dx
clinical
bx for DDX
Geographic tongue - Tx
none necessary
Hairy Leukoplakia
NOT premalignant
common early finding of HIV
also seen in organ transplant pts
Hairy Leukoplakia - cause
EBV
Hairy Leukoplakia - appearance and location
Slightly raised leukoplakic areas with a “hairy” surface
commonly lateral border of tongue
Hairy Leukoplakia - Tx
nonspecific
improves w/ antiretroviral meds to treat HIV
Gingival hyperplasia
develop as a result of inflammation in response to long-standing gingivitis
in children OR due to certain medications
Gingival hyperplasia - medication causes
phenytoin, cyclosporine, calcium channel blockers
Gingival hyperplasia - tx
if isolated - consider bx
Gingivitis
MC form of periodontal gum dz
(precursor to periodontitis)
Gingivitis - S/s
Inflammatory (red/ swelling)
bleeding may occur w/ brushing/flossing
Gingivitis - Tx
Good, regular, oral hygiene
Regular dental check-ups and removal of tartar/plaque
Periodontitis
Gingival inflammation accompanied by loss of supportive connective tissue
chronic form MC in adults - lead to destructino of periodontium and tooth loss
Dental Caries - cause
microbs that make acids on tooth surface from di/monosaccharides
demineralization of enamel
tooth decay
Dental Caries - S/S
initially asymp.
pain
temp. sensitivity
Dental Caries - Tx
filings
Dental Caries - prevention
regular dental care (fluoride toothpaste)
dietary changes
Dental Abscess
Infxn, pocket of pus, around tooth - untreated cavity, an injury or from prior dental work
Dental Abscess - periapical
tip of root
Dental Abscess - periodeontal
in the gums at the side of the tooth root
Dental Abscess - s/s
toothache
temp. sensitivity
swelling face/cheek
swollen/tender lymph nodes
Dental Abscess - Dx
X-rays, CT for extent of infxn (can lead to airway compromise if untxed)
Dental Abscess - Tx
oral abx
abx rinses
I&D, root canal, dental extraction
page Dentistry not ENT
Ludwig’s Angina
Suppurative odontogenic infection which extends to the facial spaces
BILATERAL submandibular spaces!!
Ludwig’s Angina - s/s
Usually secondary to infected 2nd or 3rd mandibular molar
Aggressive, rapidly spreading cellulitis
WITHOUT lymphadenopathy
WITH potential for airway obstruction
Ludwig’s Angina - Dx
clinical
CT imaging of choice
palpate floor of mouth!! which should be elevated
Ludwig’s Angina - Tx
1st- MANAGE AIRWAY
IV abx
if abscess - drain
Leukoplakia
white lesion, patch or plaque of the oral mucosa
CANNOT be removed by rubbing the mucosal surface
benign, 6% dysplastic or early SCC
Leukoplakia - causes and location
to chronic irritation (dentures, smokeless tobacco, lichen planus)
lateral mouth, inside lip, lateral tongue
Leukoplakia - Dx
Bx to rule out cancer
(esp. if enlarging, indurated or ulcerative and extending deeper than submucosa)
Leukoplakia - DDx
thrush, lichen planus
Leukoplakia - Tx
nothing specific
Erythroplakia
Red, mucosal plaques
definite erythematous component (unlike leukoplakia - similar tho)
Erythroplakia - common in and locations
older men
lateral tongue, floor of mouth, soft palate, alveolar ridge
Erythroplakia - Dx
Bx - 90% malignant (look for erythroplakia in leukoplakia!)
Erythroplakia - Tx
nothing specific
Oral lichen planus
Chronic inflammatory autoimmune disease
Oral lichen planus - appearance
Lacy/Reticular leukoplakia , may be erosive
can vary significantly
May mimic other diseases (candidiasis, hyperkeratosis, SCC)
Oral lichen planus - DX
bx required to prove dx and rule out other dz
Oral lichen planus - TX
manage pain and discomfort
topical CS
Oral and Oropharyngeal Cancer
Any cancer arising within the oral or oropharyngeal cavity
Oral cancers: 90%
90% Squamous Cell Carcinoma
Oropharyngeal: significant association with
HPV
Oral and Oropharyngeal Cancer
Major risk factors
Increased age (esp >45)
Tobacco use (chewing and smoking)
Alcohol use
Oral and Oropharyngeal Cancer - who needs bx
Any area of erythroplakia
Any enlarging area of leukoplakia
Any lesion that has submucosal depth on palpation
Ulcerative lesions
Oral and Oropharyngeal Cancer - locations
Lateral tongue
Floor of the mouth
Gingiva
Buccal area
Palate
Tonsillar fossa
+ palpation of the neck for enlarged lymph nodes
Oral cancer
Early lesions appear as…
More advanced lesions -
as leukoplakia or erythroplakia
- larger, with invasion into the tongue (may be palpable or ulceration)
Oral cancer - s/s and location
early - painless and subtle physical changes
majority - ant 2/3 of tongue and floor of mouth
Oral cancer - tx
early detection key!
<4mm = less likely metatasize
<2cm = local resection
Larger lesions = combo resection, neck dissection, and external beam radiation
Oral cancer - prognosis
dependent on stage at dx
stage 1 about 90%, higher stages about 60%
Oropharyngeal Cancer arising in the …
soft palate, tonsils, base of tongue, pharyngeal wall and vallecular
Oropharyngeal Cancer - MC
SCC and presents later than oral cavity CA
Oropharyngeal Cancer - risk factors
similar to oral CA
Oropharyngeal Cancer - signficant assoc. w/
HPV infxn (70%) - respond well to RADIATION
Oropharyngeal Cancer - S/s
unilateral throat masses (1 large tonsil = abnormal)
painful swallowing
weight loss
ipsilateral cervical lymphadenopathy
persist. sore throat, diffi. swallowing, voice changes, cough, lump in throat/neck
Oropharyngeal Cancer - dx
bx
eval for metastases
Oropharyngeal Cancer - Tx
surgical resection tumors + external beam rad +/- chemo
Sialadenitis
Acute infection of the salivary gland
MC parotid or submandibular
Retrograde bacterial contamination from the oral cavity
Sialadenitis - process
Ductal obstruction -> mucous plug -> salivary stasis -> secondary infection
Sialadenitis - MC bacterial cause
S. aureus
Sialadenitis - other causes
strep species, H. influ
Sialadenitis - s/s
Acute swelling of the gland
Bad taste
Fever
Dry mouth
Increased pain and swelling with meals due to duct obstruction
Tenderness and erythema of the duct opening
Sialadenitis - Tx
IV/oral abx
Hydration
warm compresses
Sialagogues (lemon drops, sour candy or Pilocarpine)
Gland massage
imaging and refer if no improvement
I&D?
Sialadenitis - complications
Abscess
Stricture
Stone
Tumor
Suppurative sialadenitis
Parotitis
Acute infection of the parotid gland
Parotitis - s/s and dx
neck swelling - parotid tail rides low
look inside mouth and press - purulence draining from parotid duct
rule out mumps in kids w/ parotid/facial swelling
Parotitis - tx
typically non-surgical
Acute Suppurative Sialadenitis
Typically one major salivary gland is affected
Usually the parotid
Acute Suppurative Sialadenitis - s/s
Pain and swelling of the affected gland
Induration
Tenderness
Massage of the gland may express pus from intraoral orifice
Acute Suppurative Sialadenitis - Tx
warm compresses
sialogagues
oral hygiene
oral abx (augmentin)
Sialolithiasis
Formation of a stone in the salivary ductal system
Most common: Wharton duct- submandibular gland
Sialolithiasis - s/s
Large, radiopaque
Less common- Stensen duct- parotid gland
Smaller, radiolucent
post-prandial pain and local swelling
may have recent history of sialadenitis
Sialolithiasis - dx
NCCT if stone not palpable (imaging of choice)
Sialolithiasis - Tx
Hydration
Warm compresses
Sialogogues
Analgesics
Refer to ENT for removal or if severe symptoms and not responding
Chronic Salivary Disorders
Inflammatory or infiltrative
Unilateral or bilateral parotid gland enlargement
Lymphoephithelial/granulomatous diseases:
- Sjogren’s
- Sarcoidosis
Chronic Salivary Disorders
Metabolic disorders
Alcoholism
DM
Vitamin def.
Chronic Salivary Disorders
Certain drugs
Thioureas, iodine, cholinergics
Any medication that stimulates salivary flow and causes more viscous saliva
Salivary Gland Tumors
MC site : parotid gland (80%)
benign 80% - MC tumor = pleomorphic adenoma (but potential to become malign.)
tumors of submandibular 40-50% malig
Salivary Gland Tumors
MC malignant tumors
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Salivary Gland Tumors S/S
slow growing
painless masses
facial n. involve strongly corresponds to malign
Salivary Gland Tumors - Dx
fine needle aspiration (FNA) vs. excision
FNA is old or too unhealthy for surgery
Salivary Gland Tumors - Tx
refer ENT
Salivary Gland Tumors - prog
5 yr survival rate about 72%
varies on stage and type
Xerostomia
AKA “dry mouth”
Salivary glands do not make enough saliva to lubricate the mouth
Xerostomia - causes
Med SE: Antihistamines, antidepressants, antipsychotics, parkinson’s disease medications, diuretics, neuroleptics, anti-cholinergic medications
untreated depression
Radiation of head or neck
Xerostomia - tx
Sialogogues
Freq. sips water
Ice chips,
Saliva substitutes- sprays (biotene)
Change/adj meds
oral pilocarpine
cavity prevention - overnight fluoride trays
Xerostomia - complications
dental caries
parotid gland enlargement
fissuring lips
oral candidiasis
halitosis
ulcers/inflamm of tongue
Torus Palatinus
Bony overgrowth (exostosis) -midline of the hard palate
very common - develops during childhood and enlarges over time slowly
Torus Palatinus - appearance
a bony, hard, nodular, lobular, or spindle-shaped mass covered with normal mucosa
Torus Palatinus - s/s and dx
gen. asymp.
rapid change/growing, not on midline, or atypical appearance = refer for imaging/bx
Torus Palatinus - tx
surgical removal (symptomatic or protruding fit of dental devices)
Torus mandibularis (mandibular exostoses)
lingual,
More common than torus palatinus
