Essential human disease for dentists Flashcards

Question

What are the different drug classes of antihypertensives?

Answer 1

1) ACE inhibitors 2) Angiotensin II receptor blockers (ARBs) 3) Adrenergic inhibitors/Alpha blockers 4) Beta blockers 5) Calcium channel blockers 6) Diuretics

Answer 2

ACE inhibitor: - "pril" - Lisinopril, Enalapril, Ramipril - Inhibit ACE - Decrease SVR, SV

Answer 3

ARBs: - "sartan" - Losartan, Valsartan, Candesartan - Block Angiotensin II receptors - Decrease SVR, SV

Answer 4

Adrenergic inhibitors/alpha blockers: - "osin" - Doxazosin, Terazosin, Prazosin - Block alpha receptors - Decrease SVR

Answer 5

Beta blockers: - "lol" - Atenolol, Bisoprolol, Propranolol - Block beta receptors - Decrease HR, SV

Answer 6

Calcium channel blockers: - "dipine" + others - Amlodipine, Nifedipine, Diltiazem, Verapamil, - Block calcium channels - Decrease SVR

Answer 7

Diuretics: - "ide" - Furosemide (loop diuretic), Spironolactone (potassium sparing diuretic), Hydrochlorothiazide (Thiazide diuretic) - Facilitates diuresis, decrease fluid volume - Decrease SV

Answer 8

Yes. Reliable and complete analgesia is desirable to avoid distress to pts, which will induce increased sympathetic output and further increased blood pressure. The careful use of adrenaline containing LA causes minimal increases in BP so long as it is not given intravascularly or in excessive doses.

Answer 9

1) Stressful situations may cause an additional rise in BP which could precipitate systemic problems (e.g. stroke or myocardial infarction) 2) Post-operative bleeding is more likely to complicate surgical procedures in hypertensive pts. 3) There may be interactions between pt's hypertensive meds and drugs you with to prescribe 4) Many hypertensive have oral side-effects - xerostomia (diuretics) - gingival hyperplasia (nifedipine) - salivary gland swelling (clonidine) - lichenoid drug reactions (angiotensin-converting enzyme inhibitors) - altered taste (diuretic, ACE, ARBs, B-blockers?)

Answer 10

1. xerostomia (diuretics) 2. gingival hyperplasia (nifedipine) 3) salivary gland swelling (clonidine) 4) lichenoid drug reactions (angiotensin-converting enzyme inhibitors) 5) altered taste (diuretics, ACE, ARBs, B-blockers?)

Answer 11

- Hypertension is common, affecting between 5 and 10% of the population. - Do not carry out routine treatment on pts whose BP is greater than 160/110 - May be detected first in dental practice - Increased post-operative bleeding - Patients may also be taking aspirin as part of their management and thus suffer increased post-operative oozing. - Many antihypertensive medications have oral side effects - Check for drug interactions between antihypertensive meds and drugs prescribed as part of dental treatment - Hypertensive pts are at increased risk of cardiovascular disease (angina and myocardial infarct)

Answer 12

Ischaemic heart disease is the most common cause of death, accounting for 35% of total mortality, in the western world. 3% of adults suffer with angina, and 1% have had a myocardial infarction in the last 12 months.

Answer 13

Coronary atheroma is the most common cause of IHD.

Answer 14

Fixed: age, male, family. Modifiable (hard): hyperlipidaemia, smoking, hypertension, diabetes Modifiable (soft): obesity, lack of exercise, high intake of alcohol, personality, oral contraceptive.

Answer 15

Formation of an atheromatous plaque within the coronary arteries which produces a fixed constriction to blood flow. The plaque consists of a necrotic core containing cholesterol surrounded by increased smooth muscle and fibrous tissue. Endothelial lining is disrupted, thrombus formation occurs due to platelet adhesion and vessel lumen becomes narrowed.

Answer 16

Acute thrombus which completely occludes the vessel causes an MI.

Answer 17

Symptoms: severe, crushing, central chest pain that radiates down the left arm. Usually provoked by physical exertion and resolves with rest.

Answer 18

Can have severe, crushing, central chest pain that radiates down the left arm. IHD does not always cause chest pain; the pt may become breathless, feel nauseous, sweat or complain of pain in the right arm, neck or even jaw. If symptoms persist for longer than 15 mins and do not respond to rest of anti-anginal meds, then consider a possible MI

Answer 19

Conservative: modifying risk factors (e.g. cease smoking, lose weight, take sensible exercise) Medical: decrease myocardial oxygen demand (e.g. by using nitrates). Surgical: dilate affected vessels (angioplasty) and insert stents, or bypass the affected areas with vascular grafts (coronary artery bypass graft).

Answer 20

1. Dental tx may provoke an angina attack or an MI. 2. As a dentist, need to establish the severity of the pt's symptoms, provoking factors and whether their angina is stable or unstable. Stable angina is predictable; occurs under reproducible conditions, response to rest and medication. Unstable angina is unpredictable: may get progressively worse and occur at rest. 3. It is good practice to request pt takes GTN (glyceryl trinitrate) before you commence tx. 4. Avoid prolonged procedure 5. Minimise stress.

Answer 21

2% lidocaine with adrenaline 1:80 000.

Answer 22

No until their condition has been brought under control. Pts should be referred to doctor for management.

Answer 23

Pt who suffer with decubitus angina, which is brought on by lying flat, must not be treated supine.

Answer 24

1. Stop what you're doing 2. Reassure pt 3. Summon help 4. Place pt in comfortable position 5. Give GTN sublingually If no response then consider possibility of unstable angina or MI: 6. call an ambulance 7. place oxygen high flow 8. repeat GTN sublingual 9. Give aspirin 300mg chewed

Answer 25

> It is very common within the population, with 20% of males under 60 years affected. > It may present with toothache or pain in the jaw > Dental treatment may provoke symptoms or acute complications. > Determine whether symptoms are stable or unstable; stable pts can be treated in dental practice - preventative dentistry - plan short treatments - keep stress to minimum - give GTN pre-treatment - adequate local analgesia > Unstable pts should be referred to their doctor before any dental treatment. > In emergency stop tx, give GTN and consider the possibility of an MI. > There is no requirement for antibiotics cover for coronary artery bypass grafts of coronary artery stents. (if in doubt, liaise with cardiologist)

Answer 26

An acute inflammatory disease which primarily affects the joint and the heart. It is an autoimmune disorder that is usually preceded by a streptococcal sore throat. The heart valves can be damaged and become vulnerable to endocarditis.

Answer 27

Rheumatic fever affects 3% of pts following a group A B-haemolytic streptococcal sore throat. It is most common in childhood between 5 and 15 yers of age and is rare in adults. Poor socioeconomic groups are at increased risk.

Answer 28

Not fully understood but there are four absolute requirement for RF to occur: - A B-haemolytic streptococcal infection, a susceptible host, pharyngeal site and persistence of infection. - RF occurs 2 to 3 weeks after a streptococcal sore throat. - Connective tissues of heart, including valves, are susceptible to damage from autoimmune response.

Answer 29

"RF licks the joints and bites the heart" Most pts have a fever and a flitting polyarthritis. If heart is involved there may be a murmur, pericarditic pain or acute heart failure. Heart is the only tissue to suffer permanent damage and may lead to endocarditis or HF in the future.

Answer 30

Bed rest, analgesia, and eradication of the streptococcal infection.

Answer 31

1) Pts with a history of rheumatic fever have an increased risk of developing bacterial endocarditis following invasive dental treatment. 2) Antibiotic prophylaxis is required prior to invasive dental tx (check current guidelines!!!) Invasive dental tx includes > Tooth extraction > Tooth reimplantation > Implant placement > Subgingival scaling and probing > Endodontic treatment beyond the apex > Placement of matrix or orthodontic bands > Intraligamentary local anaesthetic

Answer 32

Condition caused by infection of the endocardium and heart valves, which is some cases is fatal. Commonly due to blood-borne bacterial infection but may be fungal in the immunocompromised. 50% of cases are due to Streptococcal viridans and, as a result, dental treatment is often implicated as the causal event.

Answer 33

Primarily affects older patients with degenerative valvular heart disease. Used to be common in pt who suffered valve damage due to rheumatic fever. Now there is an increased incidence in IV drug users.

Answer 34

Damaged or prosthetic heart valves are usually involved, as are areas affected by abnormal flow jets from heart defects (e.g. ventral septal defect). Normal valves on right side of heart can be affected in IV drug users. Mitral valve most often affected, with the formation of adherent vegetations along the damaged valve cusps. These consist of clumps of organisms, fibrin and platelets.

Answer 35

Local valvular damage causes incompetence or stenosis of valve, producing a new heart murmur that may change as the damage progresses. Distant effects occur as parts of the vegetation break away and pass in the blood stream to lodge at distant sites (e.g. kidney and brain) where they cause further local infection (septic emboli). Immune complexes are deposited at various sites in the body and causes rashes, nail splinter haemorrhages and rarely, Olser's nodes in the skin of the fingers. Finger clubbing also occur later in the process. Systemic effects include 'flu-like' illness and weight loss.

Answer 36

Primarily from the history, the results of multiple blood cultures and visualising the cardiac vegetations using ultrasound.

Answer 37

CHECK GUIDELINES FOR ABX PROPHYLAXIS.

Answer 38

> 10% of cases are thought to follow dental treatment. > 50% of cases are due to streptococcus viridans, an oral commensal. > Antibiotic prophylaxis should be given prior to invasive dental tx as per guidelines. > At risk pts include those with: - previous rheumatic fever - congenital heart disease - significant heart murmur - heart valve replacement - degenerative valvular disease - past episode of endocarditis

Answer 39

Increased prevalence in the elderly Affects 1% of people age 50 years increasing to 5% by age 75. 2/3rd of pts with HF will die within 5 years of diagnosis.

Answer 40

HF is due to a problem with either contraction (systole) or relaxation (diastole) of the heart muscles. There are three common causes: > hypertension > valvular heart disease > ischaemic heart disease

Answer 41

Left or right or both ventricles may be affected, depending on the cause. Failure of the left ventricle decreases the ability to pump blood to the body (poor tissue and organ perfusion) and causes fluid to build up in the lungs (pulmonary congestion). Failure of the right ventricle leads to build up of fluid in the periphery of the body (dependent oedema). Left ventricular failure often leads to right ventricular failure and then it is called congestive cardiac failure.

Answer 42

Depends on which side of the heart is affected! > shortness of breath which is worst on laying flat (orthopnoea) > quick weight gain due to fluid retention > swelling in ankles, legs and abdomen (dependent oedema) > fatigue and weakness other symptoms, such as nausea, palpitations, chest pain, waking suddenly at night unable to breath and changes in sleep pattern.

Answer 43

Confirm with a chest x-ray which reveals any cardiac enlargement or fluid build up in the lungs. An echocardiogram may be carried out to measure the pumping efficiency of the heart (ejection fraction)

Answer 44

lifestyle changes, medical treatments and, rarely, surgery: Lifestyle: weight loss, exercise, cessation of smoking, low-salt diet. Medical: - Diuretics reduce fluid overload - Inotropic drugs to increase cardiac contractility - ACE inhibitors to decrease cardiac workload Surgery: - valvular surgery - heart transplant (rare)

Answer 45

1) Most pts can be treated safely in dental practice under local anaesthetic 2) It is very common within the population, with 5% of over-75s affected. 3) Dental tx may provoke symptoms and pts may become breathless if laid flat in the dental chair. 4) Determine whether their symptoms are stable or unstable. Stable pts can be treated in dental practice: - preventative dentistry - plan short treatments - keep stress to a minimum. Unstable pts should be referred to their doctor before any dental treatment. 5) Use sedation with caution

Answer 46

Structural, functional or positional defects of the heart that are present at birth in approximately 1% of population. They may manifest at any time after birth or may never be detected at all. Must liaise with cardiologist before dental tx.

Answer 47

1% of live births are affected. 8 common lesions: 1) Ventricular septal defect 2) Patent ductus arteriosus 3. Atrial septal defect 4. Pulmonary valve stenosis 5. Aortic valve stenosis 6. Coarctation of the aorta 7. Tetralogy of Fallot 8. Transposition of the great vessels Familial tendency, males and females effected equally, and more than one defect may be present in an individual

Answer 48

No specific causes are found and it is likely that the aetiology is multifactorial.

Answer 49

Most heart defects either obstruct blood flow in the heart or great vessels or cause blood to flow through the heart in an abnormal way. Obstructive defects, Septal defects, Cyanotic defects, Shunts.

Answer 50

- Cyanosis if blood is not properly oxygenated. - HF due to abnormal pressures or volumes within the heart - Heart murmur if there is turbulent flow - Growth failure - Chest infections

Answer 51

Dental tx should not be undertaken without consultation with the patient's medical practitioner. May require antibiotic prophylaxis as they have an increased risk of developing endocarditis. (CHECK GUIDANCE) Pts with heart failure may not tolerate supine position in a dental chair and become breathless

Answer 52

> These defects are common within the population, affecting 1% > Many will require antibiotic prophylaxis before high-risk dental procedures (see endocarditis guidelines) > Liaise with the patient's doctor before embarking on treatment. > Preventive dental treatment should be a priority in order to avoid excessive antibiotic prescription and reduce dental sepsis.

Answer 53

DVT is due to the formation of a blood clot in the deep veins of the lower limbs. These clots may release fragments (emboli) which travel to the lungs, causing a pulmonary emboli.

Answer 54

DVT is very common but often asymptomatic problem. It can occur at any age, but is more common in those over 60.

Answer 55

This is due to one of three factors, known as Virchow's triad 1. Stasis of normal blood flow due to: > prolonged bed rest > general anaesthesia > long-distance economy travel > pregnancy 2. Damage to blood vessel wall due to: > trauma > inflammation 3. Composition change of the blood due to: > lupus erythematosus > antithrombin III > malignancy > oral contraceptive

Answer 56

Once formed, the blood clot enlarges and obstructs the local venous blood flow and may release fragments in to the systemic circulation.

Answer 57

Usually only one lower limb is affected and the symptoms include: > swelling > tenderness and pain > erythema of the overlying skin

Answer 58

1. Identification of high-risk pts and procedures 2. Prophylactic anticoagulation 3. Careful positioning and padding of patients on the operating table 4. Use of compression stocking and boots 5. Adequate fluid replacement 6. Early postoperative mobilisation

Answer 59

Most pts are anti-coagulated using warfarin to facilitate the resorption, prevention of extension and reformation of the DVT

Answer 60

> DVT may lead to pulmonary embolism > Pts are often anti-coagulated, with warfarin, and require special care before invasive procedures are carried out - BLEEDING RISK CHECK GUIDELINES.

Answer 61

- Are you generally fit and well? - Do you have any chest problems? - Do you suffer with shortness of breath? - What are your current medications?

Answer 62

Coughing up blood from the respiratory tract. May be caused by chest infection, inhaled foreign body, pulmonary oedema or lung cancer.

Answer 63

The sensation of shortness of breath. The speed of onset and duration may indicate the cause. Rapid onset: asthma, pulmonary embolus or inhaled foreign body. Gradual onset: obstructive airway disease or malignancy.

Answer 64

If dyspnoea (sensation of shortness of breath) is increased by lying flat. This may indicate a cardiac cause.

Answer 65

>12 breaths per minute - may indicate respiratory or cardiac problems.

Answer 66

A harsh, rasping sound on inspiration and is indicative of upper airway obstruction such as laryngeal oedema due to allergy swelling or a foreign body in the larynx.

Answer 67

Blue discoloration of the skin and mucous membranes. Only in extremities indicates poor perfusion (cold) or cardiac output. Detected centrally reflects hypoventilation, parenchymal lung disease, heart failure.

Answer 68

Unilateral dropping of upper eye lid, constriction of the pupil and lack of facial sweating. May be due to infiltrative spread of lung tumour to the cervical sympathetic chain.

Answer 69

An increasingly common, reversible, obstructive airway condition affection 5% of UK population. There are three characteristic features: 1) Hyper-responsive airways 2) Inflammation 3) Excess mucous production. Care must be taken not to provoke an acute attack or further suppress respiration during dental tx by inappropriate prescribing, excessive stress or the indiscriminate use of sedation.

Answer 70

Extrinsic: pollen, salivary proteins, pet fur Intrinsic: atopy with raised IGE levels, asthma gene (chromosome 11), bronchial hyper-reactivity Lifestyle/environmental: exercise (>cold air), stress, smoking, drugs (NSAIDs, B-blockers), pollution, viral infection (upper respiratory tract infections)

Answer 71

There is a triad of oedema, broncho-constriction and mucous plugging, affecting the bronchioles. This is reversible and causes a variable degree of obstruction. It is caused by mast cell degranulation and release of vasoactive amine (e.g. histamine and prostaglandin)

Answer 72

Depend of the severity of disease. Polyphonic expiratory wheeze to inability to breath, with cyanosis and coma. In children may be nocturnal cough which keeps the child awake. When severe asthma, pt may not be able to complete sentences and become increasing panicked and anxious. Life-threatening features: cyanosis, absent breathing sounds, confusion, exhaustion.

Answer 73

Stepwise tx of asthma of increasing severity. Step 1. Occasional B2 agonist (e.g. salbutamol) Step 2. Add B2 agonist + inhaled steroid. Step 3. Add long-acting B2 agonist. Step 4. Add a combination of theophylline leukotriene agonist. High-does inhaled steroid. Step 5. Add oral steroids and nebulisers. Prevention: avoid house dust, pet fur, and cold air and smoking cessation. Tx measured by assessment of symptoms and measurement of peak expiratory flow rate using peak flow meter.

Answer 74

> Most asthmatics can be treated safely under LA > Non-steroidal anti-inflammatory drugs may precipitate or worsen an asthma attack in sensitive patients. > Inhaled steroids may cause changes in the oral mucosa, e.g. candida infection in the palate. Advise patients to rinse with warm water after using their steroid inhaler. > Postpone treatment during exacerbations of the condition. > Use sedation with care. > Advise patient to use their inhaler at the beginning of each treatment session. > Patients who are taking steroids no longer need steroid cover for dental treatment under LA.

Answer 75

COPD is caused by a group of lung diseases that lead to damage of lung tissue with persistent and progressive limitation of air flow. Chronic bronchitis and emphysema are the two most common cause of COPD and often coexist. Smoking is implicated in 95% of cases.

Answer 76

4 major agents are involved: 1. Smoking (95%) 2. Atmospheric pollution 3. Respiratory infection 4. a1-antitrypsin deficiency (pulmonary protective protease).

Answer 77

In chronic bronchitis there is damage to the respiratory epithelium with ulceration, excess mucus production and variable airway narrowing.

Answer 78

Air-space dilation and loss of elastic tissue within the alveolar walls - leading to gas trapping, over inflation and limitation of expiratory airflow

Answer 79

Many pts are not aware of problem until significant damage has occurred. Chronic cough, production of excess sputum, shortness of breath and an expiratory wheeze. (In contrast to asthma, bronchodilators do not offer the same degree of relief). Potential complications include: - respiratory failure - right heart failure - pneumothorax

Answer 80

- Cessation of smoking - Drug therapy - targeted Abx, bronchodilators, inhaled and oral steroids. - Non-invasive ventilation - Breathing exercises and chest physiotherapy.

Answer 81

These pts rely on low oxygen tension to drive their respiration, so should not be given high-flow oxygen over long periods of time. (in emergency use 100% oxygen at a high flow rate?)

Answer 82

- Most pts with COPD can be treated safely under LA. - Keep tx sessions short. - Pts may find it difficult to cope with rubber dam due to increased airway obstruction. - Inhaled steroids may cause changes in the oral mucosa, i.e. Candida infection in the hard palate. Advise pts to rinse with warm water after using their steroid inhaler to prevent this occurring. - Postpone tx during exacerbations of the condition. - DO NOT SEDATE THESE PTS OR USE RELATIVE ANALGESIA. - Advise pt to use their inhaler at the beginning of each tx session.

Answer 83

The most common malignancy in the western world and third most common cause of death in the UK. Pts may present with head and neck symptoms.

Answer 84

Lung cancer is the main cause of lung cancer, accounting for up to 90% of cases. The risk increases with the intensity, quantity and duration of smoking.

Answer 85

Small-cell lung cancer (SCLC) - commonly occurs centrally in the lungs, has a rapid growth rate and metastases early. Non-small-cell lung cancer (NSCLC) - tends to have a slower rate of growth and tenancy to metastasise later.

Answer 86

Local: persistent cough, prolonged chest infection, chest pain increased by breathing and coughing, haemoptysis (coughing up blood), progressive shortness of breath, hoarse voice, horner's syndrome. Systemic: finger clubbing, weight loss, malaise, anaemia. Metastatic spread to bone, brain and liver causing: bone pain, neurological deficits, jaundice.

Answer 87

Depends on tumour histotype, location, degree of spread and fitness of the pt. In most pts, only palliative tx can be offered, including radio- and chemotherapy, supportive therapy and analgesia.

Answer 88

- Advice on how to stop smoking, and support, should be given to all smokers. - Lung cancer can present with: > cervical lymphadenopathy > distended neck veins > horner's syndrome - meiosis, ptosis and anhydrosis.

Answer 89

Increased risk of inhalation of foreign bodies during dental tx due to: - the close proximity between the operative field and the airway - small instruments used in dentistry - supine position of the patient - sedation-induced reduction in reflex airway protection

Answer 90

Typically objects pass down the most direct route from the pharynx into the right main bronchus and the right lower lobe of the lung. If the object is not retrieved rapidly, there is a risk of lung abscess or pneumonia. Impacted objects may irritate the respiratory tract and obstruct the airflow, causing cough, stridor and wheeze.

Answer 91

Majority of foreign bodies will be swallowed and pass into the alimentary tract, carrying a small risk of perforation as they pass through. If inhaled, large objects are likely to impact above the vocal cords, whereas smaller objects are more likely to pass into the lung. The patient may cough and choke but this is not always the case and inhalation may occur asymptomatically. Presentation may be delayed, with signs and symptoms of chronic lung infection.

Answer 92

Need high degree of clinical suspicion. If cannot locate missing object it is mandatory to refer pt for a chest x-ray in an attempt to exclude inhalation.

Answer 93

1. Look for it, around pt or in oral cavity. 2. If not found, consider inhalation. Ask pt to cough and turn their head to the side to aid location of the object. Use suction and good lighting to examine the oropharynx and carefully retrieve any objects with forceps. 3. If emergency, call ambo and give high flow oxygen. Consider sharp blow to back or heimlich manoeuvre. 4. Most objects retrieved using a bronchoscope.

Answer 94

> Up to 27% of inhalation incidence occur during dental tx. > The risk of inhalation is increased when consciousness if impaired e.g. sedation > Inhalation may occur asymptomatically. > You are obliged to ascertain the location of objects 'lost' during dental tx. > If you cannot locate a missing object a chest x-ray should be carried out to attempt to exclude inhalation. > If there are signs of airway obstruction the emergency services should be called and high-flow oxygen administered. - DO NOT ATTEMPT A SURGICAL AIRWAY UNLESS APPROPRIATELY TRAINED - Pts who have ingested sharp objects e.g. endodontic files, should be referred to hospital for assessment.

Answer 95

Use of rubber dam Restraining cords on instruments Avoiding over sedation

Answer 96

This occurs due to the blockage of a portion of the arterial system in the lungs. It is most commonly due to a blood clot shed from a DVT.

Answer 97

Most commonly due to emboli released from blood clots formed in the lower limbs as a result of deep vein thrombosis.

Answer 98

The embolus impacts and obstructs a portion of the pulmonary arterial circulation, resulting in collapse of the alveoli in the area and decreasing the efficiency of gas exchange.

Answer 99

Depends on size and position of the area obstructed: - sudden onset of chest pain - acute shortness of breath - haemoptysis (coughing up blood) - collapse - sudden death

Answer 100

Dissolved using thrombolytic drugs and then further thrombosis is prevented by anti-coagulation, mostly with warfarin/(DOACs?).

Answer 101

- Patients are often anticoagulated with warfarin, and required special care before invasive dental procedures are carried out (cf. haemotology)

Answer 102

Sarcoidosis is a common chronic granulomatous condition of unknown origin that may cause cervical lymph node enlargement and parotid gland swelling. Affects more females than males, increased incidence in Afro-Caribbean origin. Most commonly diagnosed between 20-40. Lungs and lymph nodes are commonlly affected, but any tissue or organ may be involved. Most pts are asymptomatic. Those who develop symptoms usually recover spontaneously; some may follow a relapsing, remitting course. Only 40% of those pts with symptoms require treatment with immune suppression.

Answer 103

Some 4% of pts with sarcoidosis develop parotid gland enlargement and a dry mouth. Cervical lymph node enlargement occurs in 15%. Sinus involvement may lead to repeated sinusitis. Patients may treat with immune suppressant drugs, increasing their risk of infection.

Answer 104

Dental anxiety may cause breathlessness. In most cases careful explanation and reassurance is all that is required to prevent any complications. In cases of severe anxiety, it may be better to carry out the tx using supplemental therapy to aid relaxation, eg. hypotherapy, acupuncture, IV/oral sedation or relative analgesia.

Answer 105

Extreme over-breathing - may occur in pts who are anxious or phobic. pH of plasma is increased as CO2 is blown off. This causes the Ca2+ in the plasma to be reduced and as a result muscle and nerve transmission are affected causing the pt to experience tingling of their extremities of muscle spasm. Treat by making pt re-breathe from a paper bag to raise their CO2 level. Further tx may require supplemental relaxation therapy.

Answer 106

Inadequate analgesia may cause the pt to become short of breath. This is best remedied by supplemental anaesthetic or, on occasion, it may be necessary to delay tx and give the pt a course of antibiotics to settle any acute infection.

Answer 107

Asthma may be provoked by anxiety, stress or the inappropriate prescription of NSAIDs to sensitive pts. It is characterised by difficulty in breathing out with an expiratory wheeze.

Answer 108

Pts with COPD tend to be chronically short of breath but the situation may be made worse by the use of a rubber dam, for example, which may further restrict air flow. If the pt has developed heart failure, they may become acutely breathless in the supine position.

Answer 109

Swelling of the tongue and laryngeal tissues may occur during anaphylaxis, causing acute airway obstruction. In addition to this, bronchospasm causes an asthma-like state with reduced airway patency and an expiratory wheeze.

Answer 110

Pt will often cough at time of inhalation - depending on where object impacts - may become acutely short of breath.

Answer 111

When affecting the left ventricle, HF causes fluid to accumulate in the lungs, leaving the pt short of breath. This is often made worse by lying the pt backwards during tx.

Answer 112

Angina may manifest as acute shortness of breath without the classical signs of central chest pain. Pts often have a history of cardiovascular problems e.g. MI

Answer 113

Often causes central crushing chest pain leading to acute shortness of breath. In addition to this the pt may develop sudden left heart failure and pulmonary oedema, making the situation worse.

Answer 114

Often causes acute shortness of breath with chest pain that is increased by the act of breath. There may be a recent history of CVT or prolonged immobility.

Answer 115

This is due to the escape of air into the pleural space, causing the affected lung to collapse. May occur spontaneously or, more commonly, is due to trauma or lung pathology. Those with history of chronic lung disease, e.g. emphysema, are at higher risk.

Answer 116

This cause progressive shortness of breath but there may be an acute exacerbation if there is an associated pneumothorax or haemorrhage from the tumour leading to acute obstruction of the airway of haemothorax.

Answer 117

> If not due to anxiety, sudden onset of shortness of breath is a serious sign. > In all cases stop tx and assess the pt. > Administration of high-flow oxygen 15L/min will do no harm. > If there is no immediate resolution the emergency services should be called.

Answer 118

1. Inflammatory: peptic ulcer disease, coeliac, Crohn's and Ulcerative colitis 2. Neoplastic: carcinoma of the oesophagus, stomach and colon 3. Functional: achalasia, diverticulosis and irritable bowel syndrome.

Answer 119

Dysphagia (difficulty swallowing) Pain - may result from acid reflux of spasm Cough or vomit - if food or liquids do not pass normally to the stomach they may reflux back to the pharynx, overflow into the lungs or present as a cough.

Answer 120

Loss of ganglia from intramural plexus leads to a failure of relaxation of the gastro-oesophageal sphincter. This produces a functional obstruction to oesophageal emptying with dysphagia for solids and liquids. Failure of peristalsis leads to progressive dilatation of the oesophagus.

Answer 121

History of smoking increases risk fivefold. Heavy consumption of alcohol raises it 20-fold.

Answer 122

Majority are squamous cell carcinomas while in the lower third they may be adenocarcinomas. Can spread to adjacent structures, including lymph nodes.

Answer 123

Usually present with dysphagia of gradual onset, which is initially to solids and later fluids. May also have pain on swallowing or effects of local spread e.g. recurrent laryngeal nerve palsy.

Answer 124

History, barium swallow test, endoscopy, biopsy. CT to stage disease and plan tx.

Answer 125

Patients may present with dysphagia which may be due to malignancy. Medicines may need to be prescribed in elixir form.

Answer 126

Acid refluxing into the oesophagus may cause pain, ulceration and spasm. Peptic ulcers can affect the oesophagus, stomach or duodenum.

Answer 127

Commonly due to mucosal inflammation caused by acid and pepsin, with Helicobacter pylori infection and stress. In the oesophagus ulceration is usually related to acid reflux while in the stomach it occurs due to decreased mucosal resistance, induced by smoking and/or NSAIDS. Duodenal ulceration is related to increased gastric acid production, which the duodenal secretions are unable to neutralise. In all cases, stress may play an important role.

Answer 128

Ulcers in the oesophagus usually affect the lower part, pyloric antrum is common in stomach and first part of duodenum. The natural history of the ulcers may lead to healing with scarring which may cause strictures. Complications of acute bleeds or perforation.

Answer 129

Classical presenting features are pain, which is relieved by eating. If a stricture develops this may be replaced by vomiting while and active bleed is a cause of haematemesis (vomiting of blood).

Answer 130

Modify risk factors and medical therapy with antacids, H2 blockers, e.g. ranitidine and proton pump inhibitors, e.g. omeprazole.

Answer 131

Prescription of NSAIDs must be avoided.

Answer 132

Sensitivity to gluten (wheat, barley, rye, oats) and has an HLA associated with B8.

Answer 133

The disease classically presents with a change in bowel habit (COBH). There is an increased frequency and bulky, offensive frothy greasy stool which flush with difficulty. There is often associated abdominal colic, weakness and weight loss. If the onset is in childhood this results in short stature and a 'failure to thrive'.

Answer 134

Presence of antibodies to gliadin and endomysium. Augmented by an endoscopic biopsy.

Answer 135

Malabsorption of B12, folate and iron causing: - oral ulceration - glossitis - angular cheilitis - anaemia Bleeding tendency due to malabsorption of vitamin K. Enamel defects may occur in the permanent dentition if the onset is in childhood.

Answer 136

A chronic granulomatous disease that may affect any part of the GI tract from the mouth to the anus. The terminal ileum is most commonly involved.

Answer 137

Unknown, usually starts in teens or early twenties with a second peak in old age

Answer 138

Intermittent abdominal pain, diarrhoea, abdominal distention (90%), anaemia and weight loss (50%), clubbing (50%), fresh blood or melaena (40%), fever (30%), fistulae and perinasal sepsis (20%), uveitis, arthritis, skin rashes (erythema nodosum).

Answer 139

Based on the appearance seen on barium enema, endoscopic examination, colonoscopy/ileoscopy and biopsy. The differential diagnosis included other granulomatous conditions such as tuberculosis and sarcoidosis. Can have labial swelling in Crohn's disease.

Answer 140

Correction of any nutritional deficiencies and the use of immunosuppressives such as prednisolone (acutely), azathioprine (long-term disease modifying) as well as other immunomodulating medications such as sulphasalazine and mesalazine. Surgical interventions may be necessary.

Answer 141

Oral manifestations are likely to occur at some stage in most patients and include: - Ulceration - Cobblestone mucosa - Facial and labial swelling - Mucosal tags - Pyostomatitis vegetans Malabsorption (particularly B12) may lead to oral complications. Immunosuppression increases the infection risk.

Answer 142

A chronic inflammatory bowel disease that affects the colon with backwash involvement of the terminal ileum.

Answer 143

Unknown, but usually present in the age group of 20-40 years. There is probably a genetic basis with a close link to ankylosing spondylitis and HLA-B27.

Answer 144

At presentation 30% are localized to the rectum while 20% are widespread. The presenting symptoms include painless, bloody diarrhoea with mucus which may be associated with fevers and periods of near normality (remissions). Superficial ulceration in the colon.

Answer 145

Diagnosis is from the history and by endoscopic examination (colonoscopy) which revels superficial ulceration and contact bleeding. The differential diagnosis includes carcinoma of the colon, food poisoning and pseudomembranous colitis.

Answer 146

Medical management includes a high-protein, high-fibre diet and immunomodulation with corticosteroids (acutely), azathioprine (long term), sulphasalazine and mesalazine. Surgical intervention may be required, particularly in the case of toxic megacolon.

Answer 147

Oral ulceration may occur. Immunosuppression increases the infection risk

Answer 148

Third commonest cancer in the UK

Answer 149

These include neoplastic polyps, long-standing ulcerative colitis (and possible crohn's), a positive family history, familial polyposis coli and previous cancer.

Answer 150

Often detected during investigation of unexplained anaemia. In 60% there is a mass on rectal examination. Presentation depends on site of the tumour in the colon: - left: bleeding PR, COBH, and tenesmus - right: anaemia, weight loss and abdominal pain - both: obstructive, perforation, haemorrhage or fistula.

Answer 151

Colonoscopy and biopsy. CT scan to determine seize and liver ultrasound to detect metastasis.

Answer 152

Primary surgery with adjuvant chemotherapy.

Answer 153

Oral manifestations of anaemia may occur.

Answer 154

A diverticulum is a herniation of the bowel mucosa through the bowel wall, which occurs at a weak point where it is pierced by blood vessels. Inflammation of a diverticulum results in diverticulitis which most commonly presents with abdominal pain. Treatment is with a high-fibre diet and may involve surgery if recurrent.

Answer 155

IBS is the commonest diagnosis made at gastrointestinal clinical and is characterised by intermittent diarrhoea, abdominal pain and bloating relieved by bowel action. Psychological factors account for most cases while some may relate to specific food intolerances. Women are more commonly affected than men.

Answer 156

Reassurance and explanation. A high-fibre diet and avoidance of dietary triggers may help.

Answer 157

May be associated with psychogenic oral symptoms such as chronic (atypical) facial pain, burning mouth syndrome and temporomandibular joint dysfunction.

Answer 158

This is vomiting of blood, most commonly from the upper gastrointestinal tract. This myst be distinguished from haemoptysis (coughing up blood). Vomited blood is usually partially digested and dark, resembling coffee grounds, and it may be mixed with food. If severe this can be life threatening, e.g. bleeding oesophageal varices. Causes: > congenital (haemophilia, ehlers-danlos syndrome, peutz-jeghers syndrome) > infective (helicobacter pylori-induced ulceration) > Inflammatory (peptic ulceration, gastritis, oesophagitis) > Trauma (surgery, swallowed blood from epistaxis) > Venous engorgement (oesophageal varices) > Neoplasia (oesophageal SCC, Gastric CA) > Drug induced (warfarin, NSAID induced gastric erosion)

Answer 159

Sense of smell

Answer 160

Visual acuity using Snellen chart Visual field

Answer 161

Assess eye movements. Lateral and vertical movements.

Answer 162

Facial sensation in the territories of the trigeminal nerve (frontal V1, maxillary V2, and mandibular V3) tested and mapped using a pin or cotton wool. Masseter and temporalis muscles can be palpated while pt clenches their teeth to assess the motor division of trigeminal

Answer 163

Facial movements - raise eyebrow, smile

Answer 164

VII lower motor neurones affect movement of both forehead and mouth whereas an upper motor neurone lesion affects just the mouth.

Answer 165

Hearing tested by whispering a number in one ear while masking the other.

Answer 166

speech, swallow and palatal movements. IX = glossopharyngeal X = vagus Lesion in either may result in dysarthria. Palatal movement to test vagus nerve

Answer 167

Shoulder shrug Accessory (XI) nerve supples sternocleidomastoids and part of the trapezius.

Answer 168

Tongue should be observed at rest for wasting or fasciculations. Stick tongue out, and watch if it deviates.

Answer 169

Hypoglossal (XII) lower motor neurone lesions cause the tongue to be wasted and to deviate to the side of the lesion. In bilateral upper motor neurone lesions the tongue becomes spastic and its movements slow and limited. Alternating tongue movements will be slow and irregular with a cerebellar lesion.

Answer 170

May be a feature of motor neurone disease, myasthenia gravis or a tumour in the medulla. Here the tongue is wasted. Can cause slurred speech, difficulty swallowing, choking and a hoarse voice.

Answer 171

UMN bulbar palsy is due to bilateral lesions (stroke, multiple sclerosis, motor neurone disease). Here the tongue is not wasted but movements are slow and stiff.

Answer 172

Bell's palsy is the most common cause of facial nerve paralysis. Pathogenesis is not fully understood but the condition is probably caused by latent Herpes viruses (Herpes Simplex Virus type 1 and Herpes zoster virus), which are reactivated from cranial nerve ganglia. Inflammation of the nerve results in nerve damage and a lower motor neurone (LMN) weakness that involves the whole musculature of one side of the face.

Answer 173

By contrast, upper motor neurone (UMN) weakness spares the forehead muscles and is usually due to a stroke or tumour of the cerebral hemisphere.

Answer 174

- Belly palsy caused by reactivation of HSV-1 or HZV from the cranial nerve ganglia causing inflammation of the nerve, causing nerve damage and LMN weakness. - Tumours of the eighth nerve or skull - Parotid tumour, inflammation, injury - Sarcoidosis (often bilateral weakness) - Middle ear or mastoid infections - Pontine lesions (demyelination of infarction) - The Ramsay Hunt syndrome due to herpes zoster infection of the geniculate ganglion produces severe facial palsy with a painful vesicular eruption on the palate and external auditory meatus; acyclovir should be given. - Melkersson's syndrome: association of recurrent facial nerve palsy, inflammatory swelling of the face and a geographical tongue. - Traumatic injury (parotid surgery and skull base fractures).

Answer 175

It is due to herpes zoster infection of the geniculate ganglion of the facial nerve and produces a severe facial palsy with a painful vesicular eruption on the palate and external auditory meatus; aciclovir should be given.

Answer 176

Association of recurrent facial nerve palsy, inflammatory swelling of the face and a geographical tongue.

Answer 177

> Ear pain may precede the attack then facial weakness develops over 1 to 5 days and is often complete. > The face feels stiff and the patient has difficulty closing the eyelids, and difficulty with eating and smiling. > Altered taste can also occur due to involvement of the chorda tympani nerve. > Hyperacusis (distortion of sound in the ipsilateral ear) indicates involvement of the nerve supplying the stapedius muscle. > A branch also innervates the lacrimal glands and decreased production of tears on the affected side may result. After recovery of a proximal lesion there may be synkinesia (a blink causing ipsilateral movement of the lips) or crocodile tears (lacrimation accompanies salivation during eating) due to aberrant innervation.

Answer 178

Eighty percent fully recover in 1-2 months, but a small number, particularly diabetics and the elderly, have permanent facial weakness. **The risks of this may be reduced by a short course of high-dose prednisolone and aciclovir if started within the first few days of symptom onset. ** To prevent drying and other corneal injury, lubricating eye droops may be necessary and the eyelids should be taped closed during sleep.

Answer 179

A parotid tumour may present as facial palsy Occasionally dental treatment may cause facial nerve palsy. Accidental injection into the parotid gland during a misdirected mandibular block may anaesthetize the facial nerve. The condition will only last for the duration of the anaesthetic, but the eye must be protected with an eye patch.

Answer 180

The facial nerve is predominantly motor and the nucleus is in the pons. It leaves the brainstem to pass through the cerebello-pontine angle into the internal auditory canal (with the VIII cranial nerve). It lies close to the inner and middle ear in the temporal bone. It leaves the skull via the stylomastoid foramen to supply the muscles of facial expression and platysma.

Answer 181

Trigeminal neuralgia is a sudden, severe, brief stabbing, recurrent pain in the distribution of one of the division of the trigeminal nerve.

Answer 182

Usually occurs in the elderly; in younger people it can be secondary to multiple sclerosis.

Answer 183

This remains unknown but it is thought to be related to compression of the trigeminal nerve by blood vessels.

Answer 184

Dental: exposed dentine, fracture tooth, periodontitis, osteomyelitis Trigeminal neuropathy (e.g. compression of trigeminal roots from tumour or aberrant vessels) Glossopharngeal neuralgia Postherpetic neuralgia Cluster headaches Cranial arteritis Temporomandibular joint disorders Atypical facial pain

Answer 185

- Spasms of pain occur in the face, usually radiating from the corner of the mouth or from the gingivae toward the cheek and ear. - It is often triggered by touch, chewing, shaving or even cold wind. - The pain is severe and occurs hundred of times a day. - Facial sensation and the other cranial nerves are normal.

Answer 186

Carbamazepine is usually effective in controlling the pain, although dosages associated with drowsiness are often needed. Alternatives include phenytoin, lamotrigine, valproate and gabapentine. If the condition fails to respond to medical treatment, various surgical interventions are available, including cryotherapy, microvascular decompression, percutaneous balloon compression, radiofrequency thermocoagulation, and glycerol infection.

Answer 187

> Trigeminal neuralgia may occur after dental treatment. > Many patients attribute their pain to dental causes and will initially seek dental treatment > The pain can be confused with dental pain. A marcaine block can be very successful at producing immediate and even long-term relief of this painful condition. > Dental care may be difficult not only due to the pain experienced by the patient but also because of depression related to chronic pain and diminished salivation due to the use of tricyclic antidepressants. > Trigeminal neuralgia is rare in young people.

Answer 188

A stroke is a sudden neurological disturbance due to blockage or rupture of a brain blood vessel.

Answer 189

1. Ischaemia stroke (85% of all strokes) due to blockage of a cerebral artery by an embolus or by thrombus. If the neurological deficit last for less than 24 hours, it is called a transient ischaemia attack (TIA). 2. Haemorrhagic stroke due to intracerebral bleed 3. Subarachnoid haemorrhage due to rupture of a blood vessel (often an aneurysm or arteriovenous malformation) into the cerebrospinal fluid within the subarachnoid space.

Answer 190

Most ischaemic stroke is due to emboli arising from an internal carotid artery stenosed (narrowed) by atheroma. Occasionally emboli come from the heart affected by mitral valve disease, right to left shunts, bacterial endocarditis, or a mural thrombosis following myocardial infarction or atrial fibrillation.

Answer 191

- Age > 60 years - Diabetes mellitus - Cardiac disease - Smoking - Peripheral vascular disease - Oral contraceptive pill and pregnancy - Crack and cocaine - Hypertension - Polycythaemia - Hyperlipidaemia

Answer 192

Diagnosis is by CT or MRI. Carotid stenosis is imaged by Doppler ultrasound.

Answer 193

Involves reduction of risk factors and rehabilitation. Aspirin 150mg daily should be given and surgical endarterectomy considered for symptomatic carotid artery stenosis >70%.

Answer 194

This is much less common than ischaemic stroke and is immediately visible on CT scan. It usually occurs in hypertensives or those with coagulation disorders.

Answer 195

This presents with a severe headache 'like being hit on the back of the head with a cricket bat'. It may be provoked by exertion, sexual inter-coarse, or while straining. About 1/3 become unconscious and have a high risk of death or disability.

Answer 196

> Patient will often be taking anti-platelet medication or be anticoagulated. > Oral hygiene may be compromised due to weakness of the facial area or paralysis of extremities. > Swallowing may be compromised; adjust head position and ensure thorough, constant evacuation during dental procedures. > Communication may be difficult as speech and/or understanding may be affected. > Mobility may be affected.

Answer 197

Epilepsy is a central nervous system disorder in which seizures recur, usually spontaneously.

Answer 198

This involves differentiating between attacks that start all over the brain (generalised) and those that start in a focal area. A focal seizure can remain localised or may spread to involve the whole brain (secondary generalised).

Answer 199

This is not fully understood but patients with primary generalised epilepsy are more likely to have a family history of the disorder. Focal epileptic attacks arise from brain abnormalities such as tumours, infections, infarctions, after head injury, or from hippocampal sclerosis associated with frequent childhood febrile convulsions. Isolated non-recurrent seizures are commonly caused by metabolic disturbances (hypoglycaemia, hyponatraemia, uraemia, and liver failure), hypotension, alcohol and drugs.

Answer 200

Convulsions can be tonic (generalised stiffness) or clonic (repetitive shaking of the limbs); most seizures are tonic then clonic. Other features that point strongly to a diagnosis of epilepsy are: 1. Postictal (after fitting) confusion lasting 5-20 mins 2. Incontinence of urine 3. Biting the tongue or cheek 4. Inability to remember the onset 5. Stereotyped auras (hallucinations)

Answer 201

Generalised seizures - tonic-clonic (grand mal) - absence (petit mal) - common in children - myoclonic: shock-like jerks of the limbs. Focal seizures - simple - consciousness not impaired - complex - consciousness impaired

Answer 202

Anti-epileptic drugs (AEDs) are indicated for recurrent seizures. The choice of drug depends on the type of epilepsy and the side-effect profile of the drug. > cosmetic side-effects include weight gain, acne, hair loss and gingival hypertrophy. = e.g. phenytoin induced gingival hypertrophy > There are many drug interactions, e.g. phenytoin and carbamazepine are enzyme inducers. > Most AEDs cause delayed healing and increased risk of microbial infections. > Excessive bleeding can occur with carbamazepine and sodium valproate. Most seizures will terminate on their own, but prolonged seizures (>5-10 mins) should be terminated using intravenous or rectal diazepam. In practice use buccal midazolam 10mg in 1ml of liquid.

Answer 203

> Patients who have seizures need referral to specialist services and must stop driving. > Stress may precipitate seizures > Drug interactions are common with antiepileptic medications; always check in the BNF. > Most anti-epileptic drugs cause delayed healing and increased risk of infection, and some cause excessive bleeding. Oral manifestations from the use of AEDs include: - gingival hypertrophy (phenytoin) - xerostomia (carbamazepine) > In the event of seizure: - protect the airway - protect the patient from the surrounding environment but do not restrain. > Most seizures will stop on their own. Once the seizure has stopped the patient is likely to be drowsy so do not continue their dental treatment but briefly examine for dental trauma. They will need an escort home.

Answer 204

Dementia is characterised by gradual deterioration of intellect, memory and cognitive function in the absence of a disturbance of consciousness.

Answer 205

- Most common cause is Alzheimer's disease. Alzheimer's is associated with the formation of neurofibrillary tangles and amyloid plaques in the brain. - Degenerative disease (e.g. Alzheimer's disease) - Genetic (e.g. Huntington's chorea) - Vascular (e.g. multi-infarct dementia) - Metabolic (e.g. Wilson's disease) - Toxic (e.g. alcoholic dementia) - Deficiency. (e.g. Wernicke-Korsakoff syndrome in thiamine deficiency) - Mass lesion (e.g. cerebral tumour) - Infection (e.g. CJD, AIDS) - Inflammation (e.g. SLE) - Trauma - Hydrocephalus

Answer 206

These depend on the area of the cortex affected but may result in impairment of: - Intellect: e.g. impaired reasoning and calculation - Language e.g. difficulty reading, writing and disordered speech - Social function e.g. loss of personality, inability to work, withdrawn - Visuospatial function - Memory and concentration e.g. inattentive, difficulty retaining new information. Dementia is NOT associated with impaired consciousness

Answer 207

Depends on the cause of dementia but in all causes social support for patients and their families is essential.

Answer 208

> Dental treatment is challenging in patients with dementia as they often cannot understand the environment around them or what is being done to them. > Consent issues. May have fluctuating capacity or need medical power of attorney to help?

Answer 209

Parkinson's disease is an idiopathic disorder characterised by: - tremor (pill-rolling) - rigidity (cog-wheel) - akinesia (slow movements) - postural abnormalities

Answer 210

Pathology demonstrates degeneration of the nigrostriatal pathway with loss of dopaminergic input into the striatum. The substantia nigra loses pigment and Lewy bodies can be found.

Answer 211

This involves replacement therapy for the dopamine deficiency. The most effective treatment is 1-dopa which is converted in the brain by dopa-decarboxylase to dopamine.

Answer 212

- Rest tremor, initially just one limb - Progressive micrographia (small writing) - Loss of facial expression - Slowness in initiating movements - Delayed swallowing - Monotonous weak voice - Loss of arm-swing while walking - Hunched posture and loss of postural adjustment mechanisms (may fall) - Depression and dementia

Answer 213

> Do not interupt medication as pts are sensitive to even the smallest changes in drug regimen. > Avoid prescribing dopamine antagonists (e.g. metoclopramide) as these can make parkinsonian symptoms dramatically worse. > In advanced PD, pts may have difficulty in swallowing and are risk of aspiration > Oral hygiene is often impaired with the consequent increases in dental decay.

Answer 214

Multiple sclerosis (MS) causes attacks of neurological disturbance resulting from immune-mediated demyelination of the central nervous system.

Answer 215

The cause of MS is unknown but it is generally believed to be immune-mediated, involving both environmental and genetic factors.

Answer 216

A huge variety of neurological disturbance can occur but the commonest manifestations are as follows: > Optic neuritis resulting in loss of vision > Spinal cord lesions (myelitis) causing limb weakness or numbness/tingling. Sphincter control can also be affected. > Brainstem lesions resulting in vertigo and/or unsteadiness (ataxia). Eye movement abnormalities (nystagmus, gaze palsies and internuclear ophthalmoplegia) are also common.

Answer 217

Diagnosis of MS uses the McDonald criteria which rely on the objective evidence of dissemination of demyelinating plaques in both time and space.

Answer 218

Acute disabling relapses are treated with intravenous or oral steroids. This speeds up recovery but probably doesn't improve the eventual extent of the recovery. Muscle spasms can be treated with baclofen, diazepam or botulinum toxin infections. Anticholinergics are useful for urinary symptoms but may eventually self-catheterise. Physiotherapy and occupational therapy are important aspects of maintaining function in patients with MS. Disease-modifying drugs in MS: - Interferon-B: reduces the relapse rate by 1/3 but is not certain whether it prevents disability. - Azathioprine and mitoxantrone: reduces disability but have toxic side-effects.

Answer 219

> Infections and stress can make MS symptoms worse and should be avoided. > The most frequent oro-facial symptoms include trigeminal neuralgia, trigeminal sensory neuropathy (paraesthesia) and facial palsy. > Avoid NSAIDs if the pt is taking corticosteroids sue to the risk of peptic ulceration. > Patients may be taking long-term interferon-B; oral manifestations include: cheilitis, gingivitis, stomatitis, xerostomia, and candidiasis. > Polypharmacy is extremely common in these pts; check for drug interactions. > Patients may be taking corticosteroids or other immunosuppressants which increases their risk of infection.

Answer 220

Glasgow Coma Scale (GCS). the lower the score the higher the risk of intracranial complications. GCS is used to assess pts with head injury. It is scored out of 15; patients with a score of 8/15 or less require intubation and breathing may be compromised. - Best eye-opening response (/4) - Best verbal response (/5) - Best motor response (/6) Total /15

Answer 221

> Dental injuries common occur with head trauma > Custom-made mouthguards can reduce the rate of concussion as well as dental and mandibular injuries during sport. > NICE guidelines for dental practitioners (criteria for referral to A&E after a head injury) - GCS <15 at any time - any LOC - any focal neurological deficit - any suspicion of a skull fracture or penetrating head injury - amnesia - persistent headche - vomiting - seizure - previous cranial neurosurgery - a high-energy head injury - history of bleeding or clotting disorder - current anticoagulation - drug or alcohol intoxication - age > 65 years - suspicion of non-accidental injury - irritability or altered behaviour All of the above are associated with increased risk of intracranial complications.

Answer 222

> Raised intracranial pressure - dull frontal headache > Cranial arteritis - scalp is tender and is headache arising from arterial inflammation > Migraine - migraine with aura (classical) and migraine without aura (common). Both have unilateral, throbbing and usually severe. Associated with nausea and vomiting, photophobia and phonophobia. Usually lasts several hours. > Cluster headache - specific headache disorder consisting of severe pain over one eye. Lasts between 20 and 60 minutes and tend to re-occur at the same time each day for up to 6 weeks. > Tension-type headache - non-specific headache consists of a band of pain around the head. > Chronic daily headache - major cause is daily drug misuse from minor analgesics and opiates.

Answer 223

> Headaches are common and are a cause for facial pain > It is important to recognise and treat cranial arteritis, as arterial inflammation can lead to blindness.

Answer 224

The thyroid gland lies in the anterior midline of the neck below the thyroid cartilage. It is butterfly shaped, with two lobes and a central isthmus. Its main function is to regulate metabolic rate by production of thyroxine (T4), and triiodothyronin (T3). By production of calcitonin it has a role in calcium homeostasis. Over- and under-activity of the thyroid gland is the commonest of all endocrine problems. T3 and T4 feed back on the pituitary and perhaps hypothalamus to reduce thyroid releasing hormone (TRH) and thyroid stimulating hormone (TSH).

Answer 225

The under-activity of the thyroid gland may arise from disease of the thyroid or secondary to pituitary disease (reduced TSH drive).

Answer 226

- Congenital - Defects of hormone synthesis (e.g. iodine deficiency, drugs such as lithium or amiodarone) - Autoimmune (atrophic or Hashimoto's) - Infective - Iatrogenic (post-surgery or irradiation) - Infiltrative (tumour) Secondary causes? - Hypopituitarism.

Answer 227

- Mental slowness - Dry thin hair - Deep voice - Goitre - Cold intolerance - Anaemia - Pulmonary effusions - Bradycardia - Weight gain - Dry hair - Constipation - Menorrhagia - Myxoedema (accumulation of mucopolysaccharide in subcutaneous tissue)

Answer 228

Diagnosis is made from thyroid function tests: free T4 level is low, a high TSH confirms primary hypothyroidism

Answer 229

Treatment is with life-long replacement therapy (thyroxine).

Answer 230

> Children with hypothyroidism may have delayed dental development and an increased risk of decay and periodontal disease. > Adults with hypothyroidism may have an enlarged tongue, delayed tooth eruption, variable periodontal health, delayed wound healing and changed taste sensitivity. > Dental treatment should be avoided in patients with severe untreated hypothyroidism as a myxoedema coma can be precipitated by the use of CNS depressants (e.g. narcotics, sedation), surgical procedures and infections. > Patients with hypothyroidism may be sensitive to sedatives and opioid analgesics. However, they may also have a lower pain threshold.

Answer 231

This is common, affecting 2-5% of all females with a sex ratio of 5:1. Nearly all cases care caused by intrinsic thyroid disease.

Answer 232

Graves' disease Solitary toxic nodule/adenoma Toxic multinodular goitre Rarer causes include: acute thyroiditis (viral/autoimmune/post-irradiation) and drugs (e.g. amiodarone)

Answer 233

Diagnosis is made from thyroid function tests: serum TSH is suppressed with a raised T3 or T4.

Answer 234

1. Antithyroid drugs (e.g. carbimazole) inhibit thyroid hormone synthesis and are often given with beta blockers as many of the manifestations of hyperthyroidism are mediated via the sympathetic nervous system. 2. Radioactive iodine accumulates in the thyroid and destroys the gland by local radiation. 3. Surgery (subtotal thyroidectomy) should be performed only in those pts who have previously been rendered euthyroid. Surgery is particularly indicated for large goitres.

Answer 235

- exophthalmos (Grave's disease) - Goitre - Heat intolerance - Palpitations - Irregular pulse (atrial fibrillation) - Heart failure - Tremor - Weight loss - Proximal myopathy

Answer 236

> Hyperthyroidism may accelerate periodontal disease. > Premature tooth eruption occurs and oral and facial bones may be weakened. > Dental treatment should be avoided in patients with severe untreated hyperthyroidism, as a thyrotoxic crisis can be precipitated by stress, surgical procedures and infections. This is a medical emergency and carries a mortality of 10%. > Patients with hyperthyroidism may be sensitive to adrenaline (epinephrine) (contained in local anaesthetics). > Antithyroid drugs may predispose patients to infections and poor wound healing.

Answer 237

Disease of the thyroid often causes lumps or nodules to develop in the gland. Fortunately 95% of these are benign and only 10% are active 'hot', producing thyroid hormone. Approximately 8% of females and 4% of males will develop thyroid nodules. Once visible a thyroid swelling is called a goitre.

Answer 238

Most are asymptomatic and detected by the patient, dentist or doctor during a routine examination. Rarely there may be pain, difficulty swallowing, the feeling of a 'lump in the throat', stridor (difficulty inhaling), symptoms of hyperthyroidism or hoarseness of the voice. Thyroid swellings move on swallowing.

Answer 239

Adenoma Cyst Carcinoma Multinodular goitre Hashimoto's thyroiditis Effect of previous operation or radioiodine therapy Parathyroid cyst or adenoma Thyroglossal cyst Aneurysm

Answer 240

Asymptomatic benign nodules may just require observation. Toxic nodules can be removed surgically or treated with radioiodine.

Answer 241

> Thyroid swelling may be picked up during routine examination of the neck > Swelling at the base of the tongue may be due to accessory thyroid tissue left at the foramen caecum.

Answer 242

There are normally four parathyroid glands, one located at each pole of the thyroid. They are central to calcium regulation.

Answer 243

This condition is usually caused as a result of post-thyroid surgery or as idiopathic/autoimmune cases.

Answer 244

Clinical features are related to the hypocalcaemia which causes neuromuscular instability: - Chvostek sign: circumoral twitching secondary to gentle tapping of the facial nerve. - Trousseau's sign: carpal spasm when blood pressure cuff >20mmHg higher than systolic blood pressure - Seizures - Laryngospasm and bronchospasm - Circumoral paraesthesia

Answer 245

> Hypoparathyroidism may be part of the polyglandular syndrome type 1 which is also associated with Addison's disease; oral candidiasis is often a difficult problem to treat

Answer 246

Has an incidence of 1 per 1000 and is more common in females and in the fifth decade. 80% of cases are due to a parathyroid adenoma; the majority of the rest arise from parathyroid hyperplasia. Hyperparathyroidism is usually asymptomatic but a few patients have the classic 'bones, stones, groans and abdominal moans' symptoms related to hypercalcaemia.

Answer 247

- Primary hyperparathyroidism - Carcinoma - Abnormal vitamin D metabolism - Immobilisation - Other endocrine disorders - Drugs: e.g. thiazide diuretics - Renal disease

Answer 248

- Bones: salt-and-pepper skull, bone cysts, subperiosteal resorption of the distal phalanges - Stones: renal stones - Groans: malaise, weakness and depression - Abdominal moans: peptic ulceration

Answer 249

> May present with Brown tumours of the mandible or maxilla > Loss of lamina dura around the teeth is pathognomonic > Hyperparathyroidism may be associated with other autoimmune diseases.

Answer 250

Pituitary tumours are the commonest cause of pituitary disease. As with most endocrine disease, problems may arise due to excess hormone secretion, by local effects of the tumour, or by inadequate hormone production by the remaining normal pituitary (hypopituitarism).

Answer 251

This is uncommon and is almost always due to a pituitary tumour secreting growth hormone. It can be diagnosed by the failure of GH to suppress to <2mlU/L in the glucose tolerance test. Clinical features include hand and foot enlargement, coarse facial features, overbite of the lower jaw, splaying of the teeth, macroglossia, interdental separation, hypertension and diabetes.

Answer 252

Deficiency of hypothalamic releasing hormones or of pituitary trophic hormones can either be elective of multiple. Clinical features depend on the extent of deficiency. Rather than prolactin deficiency, hyperprolactinaemia occurs due to the loss of the normal inhibitory control by dopamine. Steroid and thyroid hormones are essential for life and must be given as oral replacement drugs. Other hormones are replaced for symptomatic control.

Answer 253

> Growth in facial features in acromegaly may affect dentures, bridges and orthodontic work, as well as restorations. > Extractions may be difficult due to ankylosis. Patients also not as medically robust as they appear. > Dental management may be complicated by multiple endocrine problems, hypertension, cardiac complications and arthritis.

Answer 254

The adrenal gland produces steroid hormones (from the cortex) and secretes catecholamines (from the medulla). Three classes of steroid hormones are produced: > glucocorticoids (wide ranging effects on metabolism, fluid balance and the immune response) > mineralocorticoids (affect sodium and potassium balance) > androgens

Answer 255

Primary hypoadrenalism due to destruction of the adrenal cortex is rare. It usually occurs in females and is most often caused by autoimmune diseases (80%).

Answer 256

- Buccal pigmentation - Postural hypotension (dizziness on standing up) - Anorexia and malaise - Dehydration - Loss of body hair - Weight loss - Pigmented palmar creases - Pigmentation, especially of new scars.

Answer 257

Diagnosis is made by measuring plasma cortisol and/or an ACTH stimulation test can be performed.

Answer 258

Treatment is with long-term glucocorticoid and mineralocorticoid replacement.

Answer 259

- Frontal blading (men) - Depression/psychosis - Moon face - Buffalo hump - Acne - Plethora - Thin skin - Bruising - Hypertension - Weight gain/fluid retention - Diabetes - Striae - Osteoporosis - Proximal myopathy (muscle weakness)

Answer 260

This condition arises from a sustained overproduction of glucocorticoid (cortisol). It occurs most often following therapeutic administration of exogenous steroids (e.g. prednisolone).

Answer 261

Diagnosis is made by confirming hypercortisolism (loss of diurnal variation in cortisol or dexamethasone suppression test) and then localising the cause.

Answer 262

> Patients taking oral steroids are prone to infection so antibiotics should be considered for surgical procedures. > Steroid cover for dental procedures - look up guidelines > In addison's disease pigmentation of the oral mucous membranes is a common finding.

Answer 263

- Frontal blading (men) - Depression/psychosis - Moon face - Buffalo hump - Lemon on stick appearance - Weight gain/fluid retention - Hypertension - Thin skin - Bruising - Diabetes - Striae - Osteoporosis - Proximal myopathy (muscle weakness)

Answer 264

- It has been recommended in the past that a steroid booster (steroid cover) should be given prior to dental treatment in all patients taking long-term oral steroid medication to prevent a steroid crisis and collapse. Look up guidelines!

Answer 265

> Patients taking oral steroids are prone to infection so antibiotics should be considered for surgical procedures. > Steroid cover - look up guidelines > In Addison's disease pigmentation of the oral mucous membranes is a common finding.

Answer 266

Diabetes mellitus is a syndrome characterised by high blood glucose levels (hyperglycaemia) and deranged metabolism resulting from defects in insulin secretion and/or insulin action. Diabetes mellitus is a common problem and affects 1.8 million people in the UK.

Answer 267

Type 1 diabetes (5-10%) - Autoimmune destruction of the pancreatic Beta cells - Commonly occurs in childhood and adolescence - Patients are prone to other autoimmune disease Type 2 diabetes (90-95%) - Impaired insulin function - Risk increases with age, obesity and lack of exercise - Strong genetic predisposition Other causes of diabetes - Gestational = onset during pregnancy - Endocrinopathies = increased cortisol, glucagon, GH - Drugs = steroids, thiazides - Pancreatic diseases - Genetic defects of Beta cell function or insulin action

Answer 268

- Random glucose >= 11.1 mmol with symptoms of diabetes - Fasting glucose >= 7.0 mmol - Oral glucose tolerance test 11.1 mmol at the 2-hour interval

Answer 269

- Insulin is synthesised in pancreatic Beta cells and is secreted in response to raised blood sugar. It promotes glucose uptake into cells and its storage in the liver as glucagon. Insulin also promotes uptake of fatty acids and amino acids and their conversion into triglycerides and protein stores. - When there is a lack of insulin, cells are unable to use blood glucose as an energy source so triglycerides are broken down into fatty acids. These are used as an alternative source of fuel leading to the production of ketones.

Answer 270

The main features of diabetes are a direct consequence of hyperglycaemia. The excess glucose in the blood is excreted via the kidneys (glycosuria) which causes an osmotic diuresis (polyuria) leading to dehydration and thirst (polydipsia) and subsequent weight loss.

Answer 271

- Hypoglycaemia - Autonomic symptoms (sweating, palpitations, shaking) - Neurological symptoms (confusion, seizures, coma) - Diabetic ketoacidosis (seen mainly in type 1 DM) - Hyperosmolar non-ketotic coma (seen mainly in type 2 DM)

Answer 272

These are mainly due to vascular problems related to accelerated atheroma formation. - Macrovascular (large vessel): > 2x risk of stroke > 3.5x risks of MI > 50x risk of foot amputation - Microvascular (small vessel): > retina with loss of vision > kidney leading to renal failure > nerves causing glove and stocking numbness and autonomic nervous system problems. Other: - Increased infection risk due to dysfunctional polymorphs, high glucose and poor blood supply. - Susceptibility to periodontal disease, especially if poorly controlled diabetes. - Salivary gland dysfunction leading to dry mouth - Burning mouth syndrome - Increased prevalence of lichen planus - More active dental caries - Traumatic oral ulcers - Oral candidiasis is often present.

Answer 273

Diet control Exercise Frequent self-monitoring of blood glucose levels Insulin and/or oral hypoglycaemic medications Diagnosis and aggressive treatment of complications

Answer 274

Treatment is multidisciplinary. Objective is to maintain blood glucose levels as close to normal as possible in order to delay the onset or progression of complications. Type 1 diabetes: treated by injections of insulin; formulations of different durations are available. Type 2 diabetes: usually treated with oral hypoglycaemic drugs including sulphonylureas (stimulate insulin secretion and increase insulin sensitivity) and biguanides (increase insulin sensitivity only). Sulphonylureas: chlorpropamide, glyburide, glimepiride, glipizide, tolazamide, and tolbutamide Biguanides: Metformin, Phenformin The glycated haemoglobin assay (HbA1c) reflects mean glycaemia levels over the preceding 2-3 months and is used to assess glycaemic control.

Answer 275

> Diabetes is a disease that affects the whole body, particularly the cardiovascular system. Oral manifestations include: - rapidly progressing periodontal disease - gingivitis - xerostomia - oral candidiasis - poor wound healing - burning mouth and/or tongue - increased infection risk - lichen planus > For invasive procedures, prophylactic antibiotics are often given as postoperative infections are common in diabetes - check guidelines. > Dental procedures involving LA should avoid disruption to normal eating patterns as hypoglycaemia can rapidly develop in diabetics if they miss a meal but have taken their usual hypoglycaemic medication. For this reason, they are usually scheduled first AM appointments or operations. > Avoid sedation as it may mask the symptoms of hypoglycaemia

Answer 276

Common systemic disease that predominantly affects the joints, resulting in a severely disabling and symmetrical polyarthritis. Female:Male 3:1. In a quarter of pts the temporomandibular joint (TMJ) is affected but this is often asymptomatic. The cervical spine involvement occurs in 40% of pts.

Answer 277

RA is a chronic inflammatory disease with a genetic predisposition. The cause of which remains unknown.

Answer 278

These can be divided into two groups: 1. Intra-articular (within the synovial joints) where there is inflammation of the synovium, destruction of the joint cartilage, soft tissues and adjacent bone. This leads to impaired movement, deformity, pain and swelling. The hands and wrists are most commonly affected. The atlanto-axial joint of the cervical spine is often affected, which may make the neck vulnerable to damage during dental treatment. 2. Extra-articular (systemic features) which includes rheumatoid nodules, secondary Sjogren's syndrome, vasculitis, pulmonary fibrosis, pericarditis and carpal tunnel syndrome.

Answer 279

Made by the presence of at least 4 out of 7 of the criteria of the American Rheumatology Society: a. morning stiffness b. arthritis in >3 joint areas c. arthritis of the hands. d. symmetric arthritis e. presence of rheumatoid nodules f. positive rheumatoid factor g. radiographic changes in the hand.

Answer 280

Multidisciplinary team approach involving eduction, support, medial and surgical tx. 2 groups of drugs: 1. Anti-inflammatory drugs which give symptomatic relief, i.e. aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), and COX-2 inhibitors. 2. Disease-modifying anti-rheumatic drugs (DMARDs), which modify the fundamental pathological process, i.e. steroids, tumour necrosis factor inhibitors and immune suppressants.

Answer 281

Physical: a. arthritis related > is the neck stable for treatment? > is the TMJ symptomatically involved? b. haematological > the associated anaemia may lead to glossitis, burning mouth syndrome, and angular cheilitis > altered liver function may affect drug metabolism c. drugs > NSAIDs are often prescribed at high doses > Immune suppressants may increase the risk of infection > Aphthous ulceration may occur Social: a. mobility > access to treatment may be restricted > domiciliary visits may be required > disabled facilities may be required > the pt may not be able to hold a conventional toothbrush Psychological: > pain, lack of mobility, dry eyes and mouth associated with Sjogrens syndrome may lead to depression.

Answer 282

A form of arthritis in which the sacroiliac joints and spine become ossified. It usually manifests in the early twenties and rarely after the age of 35. Its origin is multifactorial. there is often back pain and progressive restriction of movement. In about 20% of cases complete rigidity of the spine and pelvis occurs, affecting the patient's ability to walk and move.

Answer 283

> Spinal deformity may make access for treatment difficult. > Patients may be prescribed NSAIDs for symptomatic relief.

Answer 284

These conditions represent the opposite ends o the spectrum of the same disease, involving granulomatous inflammation. - Polymyalgia rheumatic (PMR) commonly affects the musculature of the pelvic and shoulder girdles, causing stiffness and pain. - In giant cell arteritis there is granulomatous inflammation within the arteries of the head and neck, leading to headache and scalp tenderness, most commonly in the temporal region. - Both conditions are more common in the over-60 age group and there are often systemic features of tiredness, weight loss and fever. In both conditions the erythrocyte sedimentation rate (ESR) is often raised.

Answer 285

- Headache/stroke - Tenderness over temporal area - Temporal artery: visible, tender, pulseless - Blindness if untreated - Jaw claudication

Answer 286

> If untreated giant cell arteritis can lead to irreversible blindness - refer to GP if giant cell arteritis suspected > Jaw claudication may indicate the presence of giant cell arteritis --> Jaw claudication refers to pain or discomfort in the jaw that typically occurs while chewing. It is a classic symptom of giant cell arteritis (GCA). > Patients with PMR have an increased risk of giant cell arteritis

Answer 287

- Osteoporosis is a common condition affecting one in three women and one in 12 men over the age of 50. - There is a decrease in mineral density of normally mineralised bone. - The whole skeleton is affected with significant weakening of the structure leading to fractures of the hip and wrist. - Fractures of the vertebral bodies lead to collapse of the spine and deformity. - Osteoporosis is classified as primary if no predisposing or causative disease can be found or secondary if there is an identifiable cause, e.g. steroid therapy or renal disease. Post-menopausal women are at the greatest risk and some protection can be offered by hormone replacement therapy.

Answer 288

> There is no significant dental implications of primary osteoporosis > Dental implants may take longer to integrate in osteoporotic bone

Answer 289

This is the most common form of arthritis and is due to degenerative destruction of the joint cartilage and under-lying bone. Unlike rheumatoid arthritis it is limited to the joints and does not affect other tissues. The large weight-bearing joints hips and knees are most commonly affected but the hands, feet and spine may also be involved. Pain after repetitive use is the main symptom with decreased range of movement is severe cases. In primary osteoarthritis there is no detectable cause and this is usually age-related. In secondary osteoarthritis a cause can be found, e.g. trauma, surgery or obesity. The main aim of treatment is to reduce pain and restore function. This often required regular analgesia and joint replacement.

Answer 290

> Patients may be taking regular NSAIDs so avoid overdose. > Antibiotic prophylaxis for invasive dental procedures in those with prosthetic joint replacement is controversial.

Answer 291

Paget's disease is chronic disease of bone in which there is disorganised breakdown and reformation of bone leading to deformity and altered function. The cause is unknown but may be related to to a slow virus infection. About 3% of the population are affected, males and females are at equal risk and it is rarely diagnosed under the age of 40. There are random phases of bone resorption and deposition leading to disorganised bone structure. The affected bones become weakened and susceptible to fracture. Bony foraminae become narrowed, putting pressure on the underlying nerves. Skull x-ray showing classical features of Paget's disease with 'cotton wool' appearance of the bone.

Answer 292

Deformity Bone pain Headaches Hearing loss

Answer 293

Tx includes calcium supplementation, drugs to reduce the rate of bone turnover, i.e. bisphosphonates, and occasionally surgery.

Answer 294

If the jaw bones are affected there may be: > mobility of the teeth > occlusal derangement > difficult tooth extraction > hypercementosis > osteomyelitis > increased incidence of facial pain

Answer 295

It is involved with almost all of the biochemical pathways that permit growth, fight disease, supply nutrients, provide energy and carry out detoxification. - Protein metabolism: synthesis of all proteins apart form gamma-globulins. - Carbohydrate metabolism: glucose homeostasis - Lipid metabolism: metabolism of lipoproteins - Bile acid metabolism: conjugation of bilirubin and production of bile - Drug and hormone metabolism: catabolism and breakdown of a large number of drugs, hormones and vitamins - Immunological: Kupffer's cells act as a sieve for bacteria and other antigens carries to it via the portal system.

Answer 296

Alcohol consumption is the most common cause of liver disease in the UK. Other less common causes are viral infections, autoimmunity, prescription drugs and genetic disease. The liver is also affected by disease of the biliary tree, particularly gallstones.

Answer 297

- Jaundice: this is a yellow pigmentation of the skin, sclerae and oral mucosa due to deposition of bilirubin in tissues. It is detectable when the bilirubin is above 30-60 mmol/L. - Spider naevi: these small arterial dilations may be detected in the skin of the face and neck. - Palmar erythema: redness of the palms of the hand. - Dupuytren's contracture: fixed flexion of the little and sometimes ring finger due to thickening of the palmar fascia - Finger clubbing: loss of the normal angle at the ged of the nails - Multiple bruises: these occur on areas exposed to trauma due to the underlying clotting defect - Delayed healing: this is may be due to the decreased synthesis of protein and immunoglobulins. - Confusion: this may occur in severe cases due to unmetabolised toxins reaching the CNS.

Answer 298

Inflammation of the liver which may be acute of chronic, causing enlargmeent, tenderness and deranged function. Viral infection with hepatitis A, B, C, D or E is the most common cause of inflammation of the liver and can present a significant cross-infection risk as well as liver damage. Other viruses, including CMV, EBV, Varicella, Rubella, Toxoplasma and Coxsackie virus and HIV can also cause hepatitis (cf. infectious disease section). Alcoholic hepatitis can occur even with moderate intake in susceptible individuals. In rare circumstances acute hepatitis can lead to hepatic failure and death, for example paracetamol overdose.

Answer 299

This results from necrosis of liver cells followed by fibrosis and nodule formation. This causes disruption of blood flow through the liver an loss of function. The diagnosis is a histological one and requires a biopsy although the severity of cirrhosis can be determined clinically. If the cirrhosis is asymptomatic the long-term prognosis is usually good, provided the causative factor is under control. Alcohol-induced cirrhosis has a worse prognosis. Patients must abstain from alcohol whatever the cause of their cirrhosis. In long-standing cases there is a small risk of developing hepatocellular carcinoma.

Answer 300

Most of the drugs administered during dental treatment are metabolised by the liver and may affect liver enzyme function. In decompensated disease treatment should be post-poned until the failure has been dealt with as there is a high risk of accelerating the rate of failure.

Answer 301

1. Paracetamol - limit dose to 2 grams in decompensated disease 2. NSAIDS - avoid in decompensated disease 3. Amoxicillin - no change 4. Metronidazole - reduce dose to 1/3 and frequency to once daily in decompensated disease 5. Clindamycin - reduce dose 6. Tetracycline - avoid 7. Miconazole - avoid 8. Lignocaine - avoid in decompensated disease 9. Halothene - avoid 10. Midazolam - avoid as may cause coma.

Answer 302

> Post-operative haemorrhage due to deficiency of clotting factors > Altered drug metabolism (check Appendix II of the BNF) > Cross-infection risk in patients infected with hepatitis B, C and HIV > Delayed healing due to protein and immunoglobulin deficiency > Avoid intravenous sedation due to risk of coma > Liver transplant pts require antibiotic cover for invasive dental procedures > Liaise with the physician concerned before treatment.

Answer 303

The kidneys receive approx 25% of the cardiac output per minute normally producing 1-2 litres of urine per day. Most drugs along with other waste products are excreted by the kidneys and they have an important role in homeostasis and hormone synthesis. - Elimination of waste materials - Maintenance of blood pressure - Maintenance of the compensation of the body fluid: > regulation of electrolyte balance > regulation of acid-base balance > regulation of calcium balance - Endocrine: > erythropoietin secretion > renin-angiotensin system > vitamin D metabolism

Answer 304

Diabetes is the main cause of end-stage renal failure (ESRF) accounting for 40% of cases. The kidneys may also be damaged by hypertension, ascending infection and immunological mechanisms. Important aspects of dent: renal failure, dialysis, transplantation

Answer 305

This is said to occur when the kidneys fail to maintain excretory function as a result of reduced glomerular filtration rate. This may be acute of chronic.

Answer 306

This is associated with a decline in renal function over a few hours or days. Aetiology: may be pre-renal (poor perfusion), renal or post-renal (obstruction). Clinical features: vary depending on the level of uraemia and range from none, through oliguria (polyuria) to weakness, fatigue, lassitude to pruritis, breathlessness and eventually confusion, fits and even coma. Treatment is based on identification and tx of the underlying cause, careful maintenance of fluid balance and dialysis where the level of toxic wastes needs to be reduced.

Answer 307

This represents end-stage renal disease. Aetiology: diabetes (40%), hypertension (25%) and glomerulonephritis (12%). Clinical features: patients may be asymptomatic but may suffer from anaemia, nausea, pruritis, hypertension, disturbed urine production, vomiting, oedema, dyspnoea, neuropathy, confusion, fits and coma. Oral manifestations: > ulceration > candidiasis > parotitis > fetor (ammonia-containing breath) > lytic lesions in the jaw bone Tx: dialysis is often required with a view to transplantation Dialysis: allows removal of waste products from the blood when the kidneys have failed. Toxins diffuse across a semi-permeable membrane towards a low concentration present in the dialysis fluid. 2 common techniques are haemodialysis and peritoneal dialysis. Transplantation: tx choice for end-stage renal failure

Answer 308

1. Paracetamol - short course only 2. NSAIDS - avoid if possible 3. Amoxicillin - reduce dose 4. metronidazole - no change 5. Clindamycin - no changes if short course 6. Tetracycline - avoid 7. Miconazole - reduce dose 8. Lignocaine - no change 9. Halothane - no change 10. Midazolam - avoid if possible, use lower dose.

Answer 309

Haemodialysis - require a blood flow of 200mL per minute via a surgically created arterio-venous (AV) fistula in the forearm. The process takes 4-5 hours three times per week during which the pt is heparinised to minimise the risk of clotting. Peritoneal dialysis - may be either continuous ambulatory (via a permanent catheter) or intermittent (pt remains in bed) which is usually used in ARF. The most common complication of both techniques is peritonitis.

Answer 310

> Preventative dentistry, the key to management. > Minimise the drugs used and alter doses as required. > Treat under local anaesthetic. > Treat infections aggressively as patients are often immunosuppressed by the disease or treatment. > High risk of hypertension and its complications. > Screen for bleeding tendencies in CRF before invasive dental procedures. > Lytic lesions may occur in the jaw bones due to secondary hyperparathyroidism. > Dialysis patients: - Treat on non-dialysis days to avoid bleeding tendency from heparin administration. - Antibiotic cover for AV fistulas - Increased risk of hepatitis B, C and HIV carriage. > Transplant pt: see more details elsewhere. (Ch17)

Answer 311

Anaemia is a reduction in the oxygen-carrying capacity of blood. It is defined by a low value for haemoglobin.

Answer 312

Epidemiology: women btw 15-44 years. Children under 5 years, pregnant women, low social class. Classification based on red-cell corpuscle volume (MCV): - microcytic (small) MCV <80 fl - normocytic MCV 80-96fl - macrocytic (large) MCV >96fl

Answer 313

Anaemia may be caused by a number of disease states of secondary to drug therapy. Any of the following mechanisms may result in anaemia: 1. Reduced red-cell production a) defect in haemoglobin function b) decreased production (e.g. deficiency state or bone marrow aplasia) 2. Increased red-cell destruction (haemolysis) 3. Loss of red cells from the circulation (bleeding) 4. Dilutional effect from increased plasma volume (e.g. pregnancy)

Answer 314

After acute blood loss: collapse, breathlessness, tachycardia, poor volume pulse, reduced blood pressure, and marked peripheral vasoconstriction. Mild anaemia: asymptomatic or associated with lethargy and pallor, particularly of the mucous membranes. Severe anaemia: - Cardiorespiratory effects: exertional dyspnoea, tachycardia palpitations, angina, cardiac failure. - Neuromuscular effects: headaches, vertigo, light-headedness, faintness, tinnitus and increased sensitivity to cold. - Gastrointestinal effects: loss of appetite, nausea and bowel disturbance - Genitourinary effects: menstrual irregularities, urinary frequency, and loss of libido.

Answer 315

> There is marked reduction in the oxygen-carrying capacity of the blood in severe anaemia (Hb <7.0g/dl) resulting in poor wound healing and widespread organ dysfunction; caution with sedation and drug prescribing. > Oral manifestations of iron deficiency anaemia: - angular stomatitis - aphthous ulcers - atrophic glossitis - oesophageal web - burning mouth

Answer 316

- Increased blood loss (e.g. menorrhagia, gastrointestinal, malignancy) - Increased iron requirement (e.g. pregnancy) - Inadequate intake (e.g. vegetarian) - Impaired absorption (e.g. coeliac disease) tx - remove cause and replace with iron supplements (e.g. oral ferrous sulphate 200mg tds)

Answer 317

Iron deficiency - most common (iron decr, ferritin decr, red cell count decr) Thalassaemia (iron norm, ferritin norm, Hb A2 HbF incr, red cell count incr) Sideroblastic anaemia Lead poisoning

Answer 318

Angular stomatitis Atrophic glossitis Aphthous ulcers Burning mouth Oesophageal web - (causes dysphagia)

Answer 319

Genetically inherited disorder of haemoglobin. Production of either alpha or Beta chains of haemoglobin may be reduced, resulting in alpha and beta thalassaemia respectively.

Answer 320

> Bony abnormalities may occur > Regular blood transfusions can lead to iron overload, resulting in cardiac failure. > Patients are prone to recurrent infections > Patients may have severe anaemia

Answer 321

Most commonly due to deficiency of vitamin B12 or folate. > Both result in megaloblastic haemopoiesis on bone marrow examination. Normoblastic haemopoiesis is seen with other causes of macrocytic anaemia, such as alcoholic liver disease and hypothyroidism. > Vit B12 deficiency > Folate deficiency > Liver disease (esp alcohol-relateD) > Hypothyroidism > Marrow infiltration > Drug treatment (e.g. azathioprine) > Pregnancy

Answer 322

Vit B12 is involved in DNA synthesis, so that a deficiency results in abnormal cell growth and maturation. Causes: - inadequate intake (e.g. vegans) - impaired absorption (e.g. pernicious anaemia, Crohn's disease). Complications: - neurological symptoms (subacute combined degeneration of the or, peripheral neuropathy) - oral manifestations (glossitis and angular stomatitis) and anaemia

Answer 323

> Burning tongue due to glossitis > The tongue may appear smooth and red due to depapillation ('beefy tongue') > Angular stomatitis > Atrophic glossitis > Burning mouth

Answer 324

Folate is required for normal synthesis of red blood cells. A deficiency results in a macrocytic anaemia similar to that occurring with vitamin B12 deficiency. Causes: - Increased folate requirement (e.g. pregnancy) - Inadequate intake (especially old age) - Impaired absorption - Drugs (e.g. methotrexate)

Answer 325

> Increased incidence of oral candidiasis.

Answer 326

Anaemia of chronic disease associated with: - chronic infections (e.g. tuberculosis) - chronic diseases (e.g. rheumatoid arthritis, renal failure) - cancer (e.g. carcinoma, lymphoma) Cause is not fully understood but is probably related to production of inflammatory mediators. There is no specific tx for this form of anaemia.

Answer 327

Sickle cell anaemia is an autosomal recessive, chronic haemolytic disorder associated with intermittent acute crises. Particularly common in West AFricans and Afro-Caribbeans. When exposed to low oxygen tensions of acidaemia, HbS polymerises, resulting in distortion and sickling of red cells leading to premature death and blockage of the microcirculation (deformed red blood cells get stuck in small vessels causing tissue ischaemia and death). Clinical features: - progressive anaemia - exogenous erythropoiesis, with frontal bossing - repeated splenic infarction, resulting in hyposplenism and an increased rate of infection.

Answer 328

> It is safe to treat patients with sickle cell disease in dental practice under local anaesthetic. > Sickle-positive patients are at risk of acute crises if they become: - dehydrated - hypoxic - hypothermic > Sedation in dental practice should be avoided. > General anaesthesia poses the greatest risk to sickle-positive patients and should be carried out only when absolutely necessary and by a specialist anaesthetist. > Sickle cell crises rarely occur in those with sickle cell trait.

Answer 329

1. Vasoconstriction to limit blood flow 2. Activation and aggregation of platelets by thrombin and fibrinogen to form a platelet plug. 3. Activation of the coagulation cascades resulting in a fibrin clot. 4. Fibrin degradation by plasmin resulting in clot dissolution.

Answer 330

von Willebrand factors (vWF) The adhesion of platelets to collagen exposed after vascular injury is mediated by vWF.

Answer 331

It mediates the adhesion of platelets to collagen exposed after vascular injury. It also stabilises factor VIII in the intrinsic coagulation cascade.

Answer 332

> May present with gingival bleeding or prolonged bleeding after tooth extraction > May have associated factor VIII deficiency

Answer 333

Haemophilia is an X-linked recessive bleeding disorder in which certain clotting factors are missing. The disease usually affects only males, but some female carriers can also have low factor levels. - Haemophilia A = defective factor VIII - Haemophilia B (Christmas disease) = defective factor IX. Both disorders cause bleeding into joints and soft tissues that can be spontaneous.

Answer 334

> Dental tx in haemophiliacs should be carried out only in liaison with specialist haematology services. > General guidelines are: - infiltration of LA requires no cover with coagulation factor concentrate - scaling and polishing of teeth usually requires no cover with coagulation factor concentrate - haemophilia centres will have a protocol to cover both extractions and following administration of an inferior dental nerve block, and will usually recommend and overnight stay. > Some treatments will involve replacing the missing clotting factors, usually by giving genetically engineered recombinant factors +/- desmopressin (stimulates release of factor VIII) > Potential hazards from dental work include delayed bleeding in retropharyngeal space after inferior dental nerve block and bleeds into the tongue after cuts from dental instruments. > Many of the adult patients are known to be HIV- and/or hepatitis C-positive, infected from contaminated blood products in the 19-70s and early 1980s, and thus precautions should be taken to prevent cross-infection.

Answer 335

Reduced platelet numbers It can arise as a result of reduced platelet production (e.g. bone marrow infiltration or aplasia), increased platelet destruction (e.g. ITP, DIC, sepsis) or sequestration (e.g. hypersplenism). Bleeding generally does not occur until the platelet count has fallen below 10-20 x10^9/L.

Answer 336

1. NSAIDs (aspirin) - inhibit cyclo-oxygenase resulting in reduced platelet aggregation. 2. Clopidogrel - inhibit platelet ADP 3. Glycoprotein IIb/IIIa inhibitors - inhibit the platelet receptor for fibrinogen thus blocking platelet aggregation 4. B-lactam antibiotics - bind and/or modify platelet membrane resulting in abnormal aggregation 5. Nitrates and B-blockers - inhibit platelet aggregation 6. Heparin, sulfonamides, quinidine - cause thrombocytopenia

Answer 337

- Spontaneous cutaneous purpura (bleeding) - Mucous membrane bleeding and nosebleeds - Menorrhagia and postpartum haemorrhage - Retinal or subconjunctival haemorrhage - GI or intracranial bleeding

Answer 338

Acute self-limiting ITP is the usual form in children and often arises post-virally. Chronic ITP is an autoimmune disease of adults associated with antibodies against platelet glycoprotein complexes.

Answer 339

Warfarin inhibits vitamin-K dependent reactions of the coagulation cascade. This leads to a decrease in thrombin, factors II, VII, IX, X and proteins C and S. Indications for warfarin: - prophylaxis of embolisation in rheumatic heart disease and AF - prophylasic and tx of venous thrombosis and PE - prosthetic heart valves - stroke prophylaxis in pts with transient ischaemic attacks

Answer 340

International Normalised Radio (INR) Prothrombin time (PT) INR = patient's PT:control PT It is usually between 2.0 and 4.5 when anticoagulant effect is required.

Answer 341

rash liver disorders and jaundice alopecia skin necrosis bruising and an increased bleeding. tendency gastrointestinal upset pancreatitis

Answer 342

> Pre-treatment evaluation: - Check need for endocarditis prophylaxis - Schedule an appt within 24 hrs of INR measurement - Avoid block injection - Beware of pts with fluctuating INR readings > Pts with an INR <4.0 can have most dental tx (multiple XLA should be carried out in stages) with additional haemostatic measures: - Atraumatic surgery - Packing of the socket with haemostatic gauze e.g. surgicel - Careful suturing of all sockets - Additional pressure application - Careful check for haemostasis. > NSAID analgesia should be avoided due to the risk of peptic ulceration and the additional anti-platelet effect.

Answer 343

Blood formation - occurs in the bone marrow of the axial skeleton (vertebrae, ribs, sternum and pelvis). All blood cells are derived from a common (pluripotent) stem cell. Stem cells not only renew themselves, but give rise to a series of progenitor cells, one of each lineage.

Answer 344

- Acute leukaemias are malignant tumours of haemopoietic precursor cells. There are two types based on origin: 1. Acute myeloid leukaemia (AML) 2. Acute lymphoblastic leukaemia (ALL)

Answer 345

AML: more common with increasing age ALL: commonest malignancy in childhood and is rare in adults. Prognosis is good for childhood ALL (cure rate >70%). Prognosis for AML varies depending on age (worst if >60 years) and type of AML.

Answer 346

Red cells Platelets Granulocytes, Monocytes/macrophages, Basophils/mast cells

Answer 347

B lymphocytes T lymphocytes

Answer 348

Rapid presentation is common and patients are seriously ill. Bone marrow suppression > Anaemia (lack of RBC) > Purpura and bleeding (lack of platelets) > Infection (lack of WBC) Organomegaly > Lymph nodes > Spleen > Liver Systemic symptoms > Malaise > Sweats > Weight loss/anorexia

Answer 349

Full blood count, blood film and bone marrow examination

Answer 350

- Intensive chemotherapy to eradicate the leukaemic cells and supportive measures (e.g. blood and platelet transfusions, prophylactic antibiotics). - Bone marrow transplantation may be appropriate.

Answer 351

1. Chronic myeloid leukaemia (CML) 2. Chronic lymphocytic leukaemia (CLL)

Answer 352

Chronic myeloid leukaemia (CML) is a rare disease that is most common in middle age. Chronic lymphocytic leukaemia is the commonest adult leukaemia and is predominantly a disease of the elderly, and of males. Most pts with early stage, asymptomatic CLL die of unrelated causes. Prognosis of CML is variable but overall median survival is 5.5 years.

Answer 353

Chronic leukaemias are asymptomatic and are discovered incidentally on the full blood count preformed for unrelated reasons: - massive organomegaly: particularly hepatosplenomegaly in CML and lymphadenopathy in CLL - anaemia due to bone marrow suppression - systemic symptoms: malaise, sweats, weight loss - recurrent infections due to immunodeficiency are common in CLL and. there is a high incidence of haematological autoimmune disease (e.g. 5-10% develop autoimmune haemolytic anaemia)

Answer 354

- Supportive for CLL (e.g. immunoglobulin for recurrent infections) with chemotherapy being reserved for symptomatic or progressive disease.

Answer 355

> Patients may present first to the dentist: > 1. ALL is the commonest childhood malignancy and may present with gingival bleeding, oral ulceration, sore mouth and increased susceptibility to infections (e.g. oral candidiasis). > 2. CLL is the commonest leukaemia in adults and may present with cervical lymphadenopathy or Herpes zoster infections. > Prophylactic antibiotics are recommended for invasive procedures and infections should be treated promptly and aggressively. > Patients who have undergone transplantation may have additional complications. > Extensive chemotherapy regimens often leave pts with reduced reserves in many systems. > Gingival infiltration can occur with some subtypes of AML (M4, M5).

Answer 356

Lymphomas are tumours of lymph nodes (Hodgkin's disease) or tumours of lymphoreticular tissue derived from malignant B or T cells (non-Hodgkin's lymphoma).

Answer 357

Non-Hodgkin's lymphoma (NHL) is an increasingly common cause for cancer mortality in young adults. Hodgkin's disease is uncommon in children; median age of onset is 28 years with a smaller second peak in the elderly.

Answer 358

unknown for NHL Epstein-Barr virus (DBV) may play a role in Hodgkin's disease.

Answer 359

These reflect whether the tumour is low-grade (indolent course, presents with widespread lymphadenopathy) or high-grade (short history of localised rapidly enlarging lymphadenopathy). Hodgkin's disease typically presents as painless cervical and supraclavicular lymphadenopathy. Systemic features (weight loss, night sweats, fever or pruritus) can occur with both types of lymphoma. - Jaw (involved in Burkitt's high-grade NHL) - spleen (involved in 30% with Hodgkin's disease) - Bone marrow (involved in NHL) - Oropharynx - CNS - GI tract - Skin (involved in T cell lymphomas)

Answer 360

Histological and is usually made form a lymph node biopsy. Imaging is used to document extent of disease for staging. FBC = normochromic normocytic anaemia ESR = raised LDH = raised, indicates poor prognosis in NHL LFTs = abnormality indicates liver involvement Ca2+ = raised with bone involvement

Answer 361

Depends on extent of involvement. Radiotherapy is used for localised disease, chemotherapy for generalised disease.

Answer 362

> NHL is common in young adults, and may present with oropharyngeal involvement of Waldeyer's ring, causing a sore throat or noisy breathing. > Lesions may be found in the salivary glands > Burkitt's lymphoma is found in pts from EBV-endemic areas and commonly involves the jaw. > Patients who have undergone transplantation may have additional complications.

Answer 363

Multiple myeloma is characterised by malignant proliferation of a single clone of bone marrow plasma cells and is the most common type of paraproteinaemia. Peak incidence in 7th decade. More common in males and Afro-Caribbeans.

Answer 364

Can result from: - Tumour replacement of bone marrow causing bone marrow suppression: anaemia, leucopenia and thrombocytopenia - Protein of paraprotein causing an increased viscosity of the blood and amyloid. - lytic lesions in the bone causing bone pain, pathological fractures and hypercalcaemia. - renal impairment due to dehydration and hypercalcaemia - infections of the oral cavity (fungal and bacterial) and respiratory tract; the latter are a major cause of death.

Answer 365

- Supportive measures (e.g. analgesia, rehydration and tx of infection) and median survival is 3-4 years. - Chemotherapy and plasma exchange may be required for symptomatic hyperviscosity.

Answer 366

> Multiple myeloma is a cause of lytic lesions in the jaw and skull. > Pts may present with anaemia or bleeding problems. > Pts are prone to oral candidiasis. > Cautions with NSAIDs if renal impairment exists. > Patient's who have undergone transplantation may have additional complications.

Answer 367

A circumscribed flat change in the colour of skin which is less than 1cm in diameter

Answer 368

Circumscribed palpable elevation of the skin <1cm in diameter

Answer 369

Circumscribed palpable elevation of the skin >1cm in diameter

Answer 370

Flat lesion >1cm diameter

Answer 371

A slightly raised lesion >1cm diameter

Answer 372

A raised lesion <0.5cm containing clear fluid

Answer 373

A vesicle >0.5cm

Answer 374

Dilation of capillaries

Answer 375

1. Atrophic dermatitis 2. Seborrheic dermatitis 3. Lichen simplex 4. Contact allergic dermatitis 5. Contact irritant dermatitis

Answer 376

This is a chronic, itchy disorder with a strong genetic predisposition. Often associated with asthma or rhinitis. Onset in infancy in 60% patients with 80% clear between the ages of 2 and 5 years.

Answer 377

- Erythema, weeping, papules, vesiculation. - Chronic eczema is associated with dryness, scaling, lichenification,, hyperpigmentation. May be secondary infection with staphyococcus aureus or with herpes simplex virus.

Answer 378

- avoidance of known allergen - regular 'wet wrapping' of limbs in children - topical steroids and/or tacrolimus ointment - antibiotics - sedating antihistamines

Answer 379

- Type IV hypersensitivity reaction. - Contact exposure to allergen in previously sensitised individual. - Occupational risk/hobbies e.g. dentists, nurses, hairdressers, gardening.

Answer 380

> Patient may be on corticosteroids > Eczema may affect the lips (cheilitis) > Dentists and allied professionals are at high risk of developing allergic contact dermatitis and should always protect themselves from high-risk dental materials.

Answer 381

Common chronic benign hyperproliferation condition of the skin that affects 2% of population. There is family history in approx one-third. Characterised by symmetrical well-defined erythematous plaques with a thick silvery scale. Treatment: topical preparations, emollients, corticosteroids, systemic therapies including methotrexate, cyclosporin, retinoids, infliximab.

Answer 382

> Joint involvement may impair OH > Rarely oral changes may be seen, e.g. erythema migrans-like appearance > Patients may be immunosuppressed.

Answer 383

A relatively common pruritic autoimmune disorder of unknown aetiology. Onset usually 30-60 years, with similar incidence in males and females. Always consider lichenoid drug eruption,, e.g. gold, beta-blockers, thiazides. Clinical variants: - hypertrophic, atrophic, linear - acute generalised, annular, palmar or plantar, bullous - oral (several patterns), actinic (check lips) - genital (often associated with oral).

Answer 384

- hyperkeratosis, 'saw-tooth' rete ridges, degeneration of the basal layer, and band-like lymphocytic infiltrate in papillary dermis.

Answer 385

topical: corticosteroids, emollients systemic: prednisolone, azathioprine, cyclosporin.

Answer 386

> Oral lesions often present and are painful if atrophic or erosive. > Consider other mucosal site involvement e.g. oesophagus and eyes > The pt may be taking corticosteroids and may be at increased risk of infection.

Answer 387

These are autoantibody-mediated group of disorders characterised by the appearance of blisters or erosions of skin and/or mucosal sites, e.g. the mouth, eyes, nasopharynx, genitalia, oesophagus or larynx. Blistering occurs at different levels of skin/mucous membrane. Subepidermal blister: > Bullous pemphigoid > Mucous membrane pemphigoid > Linear IgA disease > Epidermolysis bullosa acquisita Intercellular blister: > Pemphigus vulgaris

Answer 388

- Diagnosis is confirmed by characteristic histology and direct immunofluorescence (IF). - The subepidermal group demonstrate linear fluorescent staining (IgG, IgA, C3) at the dermoepidermal junction. - Intraepidermal IgG is consistent with pemphigus group.

Answer 389

Usually combines topical corticosteroid preparations with immunosuppressive agents, e.g. dapsone or prednisolone combined with a steroid-sparing agent such as azathioprine or mycophenolate mofetil.

Answer 390

These are autoantibody-mediated group of disorders characterised by the appearance of blisters or erosions of skin and/or mucosal sites, e.g. the mouth, eyes, nasopharynx, genitalia, oesophagus or larynx. Blistering occurs at different levels of skin/mucous membrane. Subepidermal blister: > Bullous pemphigoid > Mucous membrane pemphigoid > Linear IgA disease > Epidermolysis bullosa acquisita Intercellular blister: > Pemphigus vulgaris - Pt will likely be on topical corticosteroid preparations with immunosuppressive agents, e.g. dapsone or prednisolone combined with a steroid-sparing agent such as azathioprine or mycophenolate mofetil.

Answer 391

- Commonest malignant neoplasm of skin arising from the basal layer of keratinocytes. - It is commonly seen on sun exposed sites, e.g. the face, particularly around the eyes, nose, scalp and trunk. - Tumour enlarges slowly and is locally destructive but rarely metastasises. - Common is an erythematous nodular lesion with a pearly opalescent edge and superficial dilated capillaries. - Tx depends on type, site, size and general health of pt. Most definitive therapeutic interventions are surgical excision occasionally followed by radiotherapy.

Answer 392

These tumour also arise from keratinocytes but have potential for metastatic spread either via lymphatics or more rarely haematogenous dissemination. They characteristically arise de novo in sun-exposed sites, e.g. lower lip, however, they may arise from pre-existing lesions such as actinic keratoses of Bowen's disease. Immunocompromised pts are at higher risk, e.g. transplant recipients. The tumour may be nodular or ulcerative and is often painful. Tx: Excision or radiotherapy

Answer 393

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are both types of nonmelanoma skin cancer, but they differ in several ways, including: > Location = BCC usually appears on the face, especially the nose, cheeks, forehead, and eyelids. SCC often appears on the face, ears, neck, hands, or arms, but can also develop around the genitals. > Appearance = BCC is usually pink and translucent. SCC can appear as a scaly red patch, a tough and thickened patch of skin, a wart, or a raised growth with a depression. > Growth rate = SCC is generally faster growing than BCC. > Spread = BCC rarely spreads to other parts of the body, but SCC can spread to the lymph nodes and even to internal organs. > Causes = Both BCC and SCC are typically caused by long-term exposure to UV rays from the sun or tanning beds. SCC can also be caused by certain types of leukemia and certain targeted therapies. > Treatment = BCC is usually treated with surgical removal. SCC can be treated with surgical removal, immunotherapy, or radiation therapy. > Survival rate = Both BCC and SCC have very high survival rates if diagnosed and treated promptly. However, advanced SCC may have a 5-year survival rate below 40%. BCC and SCC make up 95% of nonmelanoma skin cancers, with BCC outnumbering SCC by a ratio of about 3 to 1.

Answer 394

Tumour is derived from melanocytes in the basal layer of the epidermis and may arise either de novo or from a pre-existing pigmented lesion, e.g. an intradermal naevus. It often metastasises early therefore early detection and excision is critical. Risk factors: excess sun exposure, particularly in early childhood, white skin, RFMH of melanoma and multiple naevi. Frequent sites include leg in females, the back in males and face in older pts of either sex. Prognosis based on depth of invasion within the dermis.

Answer 395

A change in shape, size, colour of mole. A new naevus which is enlarging Itching or bleeding from a mole A naevus greater than 5mm in size.

Answer 396

> Skin tumours e.g. basal cell carcinoma, squamous cell carcinoma and melanoma commonly present on the face. > Basal cell carcinoma: - Commonest malignant neoplasm of skin arising from the basal layer of keratinocytes. - It is commonly seen on sun exposed sites, e.g. the face, particularly around the eyes, nose, scalp and trunk. - Tumour enlarges slowly and is locally destructive but rarely metastasises. - Common is an erythematous nodular lesion with a pearly opalescent edge and superficial dilated capillaries. > Squamous cell carcinoma: -These tumour also arise from keratinocytes but have potential for metastatic spread either via lymphatics or more rarely haematogenous dissemination. - They characteristically arise de novo in sun-exposed sites, e.g. lower lip, however, they may arise from pre-existing lesions such as actinic keratoses of Bowen's disease. Immunocompromised pts are at higher risk, e.g. transplant recipients. - The tumour may be nodular or ulcerative and is often painful. - Tx: Excision or radiotherapy > Melanoma: - Tumour is derived from melanocytes in the basal layer of the epidermis and may arise either de novo or from a pre-existing pigmented lesion, e.g. an intradermal naevus. - It often metastasises early therefore early detection and excision is critical. - Risk factors: excess sun exposure, particularly in early childhood, white skin, RFMH of melanoma and multiple naevi. - Frequent sites include leg in females, the back in males and face in older pts of either sex.

Answer 397

Hypothyroidism > dry, coarse hair > pruritus Graves disease: - pretibial myxoedema, pruritus, hyperhidrosis, periorbital soft-tissue swelling Addison's disease: > Hyperpigmentation of skin and mucous disease Cushing's syndrome: - Buffalo hump, truncal obesity, striae, acne vulgaris, hirsutism Diabetes: > granuloma annulare - localised or generalised, necrobiosis lipoidica, recurrent of persistent fungal and bacterial infections of skin, pruritis, vascular disease - large and small vessel ischaemia, lipoatrophy. Acromegaly: > Soft tissue hypertrophy, greasy skin Crohn's and ulcerative colitis: - pyoderma gangrenosum (also associated with RA, and haematological disorders, e.g. paraproteinaemia, myeloma). Perianal ulceration, skin tags, fistulae. Oral - aphthae and 'cobblestone' appearance of mucosa. Systemic lupus erythematosus: > malar rash on face, vasculitic lesions, Raynaud's phenomenon, alopecia, scarring skin/scalp lesions in discoid lupus Scleroderma - skin thickening and contractures.

Answer 398

Increase in body temperature which helps to prevent multiplication of many pathogens. Adverse effect; delirium and febrile conditions.

Answer 399

Inflammation results from the release of inflammatory mediators and increases vascular permeability, allowing cells of the immune system to reach areas of infection. It is characterised by erythema, oedema, pain and heat in affected area.

Answer 400

Mycobacterium tuberculosis. Spread by inhalation of infected sputum. TB most commonly occurs in the lungs but may involve many other systems or organs (non-pulmonary), including CNS, spine, remal and GI tracts.

Answer 401

- cough >2 weeks - pain in chest - haemoptysis - weakness and fatigue - weight loss - fever and night sweats.

Answer 402

Diagnosis: clinical exam, chest x-ray, tuberculin testing, microbiology and histological exam of specimens. Tx: prolonged use (>6 months) of multiple antibiotics to avoid resistance.

Answer 403

> All dental staff should be vaccinated > Painful ragged ulcers can occur in the mouth, usually secondary to pulmonary TB. > Cervical lymphadenopathy may occur. > Pts with open pulmonary TB post a high cross-infection risk: delay tx if possible.

Answer 404

Caused by bacterium: Treponema pallidum Spread by direct contact.

Answer 405

Disease occurs in stages: - primary syphilis - painless, indurated ulcer, at the site of infection (chancre). - secondary syphilis - fever, rash, and snail-track ulcers in mouth or genital regions due to systemic spread of the bacterium. - latent period - may last up to 2 years, during which slow tissue damage occurs. - tertiary syphilis - gumma formation which affects skin, mucosa and bone. Degeneration of the spinal cord may lead to dementia, pains and ataxia - 'general paralysis of the insane'.

Answer 406

> Oral ulceration - during primary and secondary stages. > Oral gumma - tertiary syphilis > Involvement of neck lymph nodes. > Congenital abnormalities of teeth, Hutchinson incisors, Moon molars. > Papules at commissures. > Cardiovascular defects.

Answer 407

Methicillin-resistant Staphylococcus aureus (MRSA) is resistance to certain antibiotics, including methicillin, oxacillin, penicillin and amoxicillin. Severe staphylococcal infections, including those mediated by MRSA, occur most frequently among in-patients who have weakened immune systems.

Answer 408

o If dental staff are found to be colonised with MRSA this must be eradicated before any further patient contact occurs. o Universal cross-infection measures are adequate.

Answer 409

RNA hepatovirus. It is highly infection common disease. Its incidence is increased by poor sanitation, so many children in the developing world are infected either clinically or subclinically and have immunity. Spread is via orofaecal route.

Answer 410

o Nil, except to distinguish it from other types of hepatitis – see below.

Answer 411

A double-stranded DNA virus. Is uncommon in UK. Spread mainly by parental, sexually or perinatally.

Answer 412

Chronic liver disease, death from which occurs in 15-25% of chronically infected people.

Answer 413

> Immunisation of all healthcare workers. > Cross-infection control > Abnormal drug metabolism in liver > Abnormal clotting factors

Answer 414

Spread = mainly parental, sexually and perinatally. Symptoms = - malaise, anorexia, jaundice, enlarged + tender liver, nausea, muscle pains, arthritis. Diagnosis = serology tests for antigens and antibodies

Answer 415

> Cross-infection control > Abnormal drug metabolism in liver > Abnormal clotting factors.

Answer 416

Epidemiology: primary infection is often seen in childhood and adolescence. Spread: direct contact Symptoms: pyrexia, malaise, lymphadenopathy, oral vesicles which beak down to form ulcers, painful, lasts 10 days. Diagnosis: usually clinical. Management: hydration, soft diet, analgesia, topical and systemic acyclovir 200mg 5 times a day for 5 days.

Answer 417

- Herpes simplex encephalitis. - Virus becomes latent in the trigeminal ganglion or basal ganglia of the brain. - It may be reactivated to cause a secondary infection.

Answer 418

> Herpetic whitlow - finger infection with herpes virus by direct contact with lesions. > Acute herpetic gingivostomatitis - oral vesicles break down to form ulcers that are painful and last 10 days. Erythematous gingiva. Painful to brush teeth. > Need to ensure child has fluid intake as can dehydrate quickly. > Oral lesions - virus may become latent in the trigeminal ganglion or basal ganglia of the brain. May be reactivated to cause a secondary infection.

Answer 419

Reactivation of latent virus following primary herpes infection of following subclinical primary infection. - reactivating factors: trauma, chemical, sunlight, hormones, stress, immunosuppression and concurrent infection. - symptoms: during the prodromal 24-hours, prickling sensation on the lip is followed by vesicle formation; then the lesion crusts over. There may be severe pain and lymphadenopathy. - diagnosis: clinical - management: acyclovir topical paste, applied five times daily for 5 days. This needs to be applied int he prodromal phase to be effective.

Answer 420

o > Lesions of the lips. o > Acyclovir cream started in prodromal phase when prickling sensation on lip, before vesicle formation, attempts to shorten duration of cold sore.

Answer 421

Varicella Zoster Virus (VZV) Epidemiology: common childhood infection Spread: direct contact with patients with chickenpox or shingles (herpes zoster). Symptoms: fever, malaise, lymphadenopathy, itchy vesicular rash which starts on the trunk or head and spreads across body. Mucosal lesions also occur. Diagnosis: usually clinical Management: supportive, with analgesics and antihistamines for rash. In adults and severe childhood cases acyclovir 800mg five times a day for 5 days can be used, but to be most effective it must be started at the first sign of the rash. Complications: reactivation of dormant virus in nerve tissue to give herpes zoster or shingles.

Answer 422

> Oral lesions - ulcers.

Answer 423

Reactivation of VZV in a dermatomal distribution which can include regions of the trigeminal nerve. Symptoms: severe pain, vesicles and ulceration. Diagnosis: usually clinical. Management: acyclovir 800mg 5x/day for 7 days, but needs to be given within 72 hours of onset to be effective. Complications: if the ophthalmic nerve of the trigeminal nerve is involved there is risk of corneal involvement and permanent scarring. Post-herpetic neuralgia occurs in up to 50% of elderly patients following resolution of the infectious process. Its incidence is reduced by use of acyclovir during the infective period. Once established, neuralgia is difficult to treat; gabapentin and tricyclic antidepressants are effective in some cases.

Answer 424

- Complications: if the ophthalmic nerve of the trigeminal nerve is involved there is risk of corneal involvement and permanent scarring. - Post-herpetic neuralgia occurs in up to 50% of elderly patients following resolution of the infectious process. Its incidence is reduced by use of acyclovir during the infective period. - Once established, neuralgia is difficult to treat; gabapentin and tricyclic antidepressants are effective in some cases.

Answer 425

> Oral lesions - distribution depends of branch of nerve affects (unilateral) > Clinical presentation: herpes zoster infection of the maxillary division of right trigeminal nerve - affects half of the palate. > Pain - if V2 or V3 branches of trigeminal nerve involved may be misdiagnosed as toothache. > Post-herpetic neuralgia leads to chronic facial pain - control with gabapentin/tricyclic antidepressants.

Answer 426

Epstein-barr virus infects B lymphocytes and causes antibody production, although not necessarily against EBV. Epidemiology: occurs worldwide and most people become infected at sometime during their lives. Primary infection: infectious mononucleosis/glandular fever ('kissing disease') Symptoms: fever, malaise, lymphadenopathy, intra-oral petechial rash at the junction of the hard and soft palate, white exudate over tonsils, pharyngeal swelling. - The duration of fever varies, for a few weeks to several months. Diagnosis: clinical, PCR Management: symptomatic.

Answer 427

- Hairy leukoplakia, seen on the lateral borders of the tongue. - Burkitt's lymphoma seen in African children - Nasopharyngeal carcinoma in Far East. - EBV may play a role in Hodgkin's disease.

Answer 428

> Primary infection is infectious mononucleosis/glandular fever. - Cervical lymphadenopathy - Creamy exudate over pharynx and tonsils - Pharyngeal swelling - Intra-oral petechial rash at the junction of the hard and soft palate. > Other condition caused by EBV: - Hairy leukoplakia, seen on the lateral borders of the tongue. - Burkitt's lymphoma seen in African children - Nasopharyngeal carcinoma in Far East. - EBV may play a role in Hodgkin's disease.

Answer 429

HIV infects CD4 lymphocytes, causing severe deficiency of T helper cells resulting in immunodeficiency, which in the absence of tx, leads to death by opportunistic infection. Epidemiology: worldwide HIV Spread: exchange of virus-infected body fluids. Heterosexual intercourse, vertical transmission to infants, homosexual intercourse, sharing intravenous drug-using equipment. Clinical features: following infection there are a number of stages in the progression of HIV: - primary HIV infection 6-8 weeks. - seroconversion - clinical latent period with or without persistent generalised lymphadenopathy 15 to 18 months. - early symptomatic HIV infection - AIDS (CD4 cell count below 200/mm3) - Advanced HIV infection --> CD4 count <50/mm3) Monitor disease progression by CD4 count + viral load. Management: - prevention of transmission by eduction - prevention of opportunistic infections - early detection and treatment of neoplasms. - combined antiretroviral therapy.

Answer 430

In needlestick injury the chance of seroconversion is about 4:1000. This can be reduced by 80% if post-exposure prophylaxis (PEP) is given within the first hour; the benefit decreases with time.

Answer 431

> Consider PEP (post-exposure prophylaxis) for needlestick injuries from high-risk patients. 1. HIV +ve 2. High-risk behaviour. > Universal cross-infection control measures. > Patient more prone to infections. > Oral manifestations: - Candida - Hairy leukoplakia of tongue - Kaposi sarcoma - Aggressive periodontal disease - Oral papilloma - Squamous cell papilloma - Parotitis - Cervical lymphadenopathy - Lymphoma

Answer 432

Spread: droplet infection Incubation period: 2-3 weeks Symptoms: sore throat, conjunctivitis, fever, macular rash appears on day 3 which coalesces to form a 'blush' which fades in about 5 days, cervical lymphadenopathy and arthralgia. Diagnosis: clinical Management: immunisation of children as part of MMR. Tx of infection is supportive - bed rest and analgesics. Children must be kept from school for 5 days following onset of rash. Complications: If infection occurs within 4 months of pregnancy, high risk of congenital defects. Thrombocytopenic purpura and encephalitis.

Answer 433

- Enlarged posterior cervical lymph nodes - Pharyngitis - Facial rash

Answer 434

Caused by paramyxovirus. Epidemiology: Common childhood infection Spread: droplet, childhood infection. Incubation period: 10-14 days. Symptoms: URTI, irritability, fever and febrile convulsions, conjunctivitis, Koplik spots (rash in buccal mucosa), maculopapular skin rash appears after 3-4 days behind ears and spreads to face and trunk; by time the rash reaches the legs the fever has started to resolve. Diagnosis: clinical but is an uncommon condition so lab tests may be used. Management: Prevention by immunisation of children aged 12-15 months by live attenuated vaccine (usually as part of MMR). Treatment of the infection is supportive with bed rest, analgesics and fluids.

Answer 435

> Koplik spots (rash in buccal mucosa) > Pharyngitis > Facial rash

Answer 436

- Mumps is caused by paramyxovirus - Epidemiology: common childhood infection - Spread: droplet spread, usually children affected - Incubation period: 2-3 weeks - Symptoms: affects exocrine glands, commonly resulting in tender bilateral parotid swelling. Orchitis (more common in adult men), pancreatitis, mastoiditis, and oophoritis can occur. Diagnosis: Usually clinical Management: prevention by immunisation aged 12-15 months with a live attenuated vaccine (usually part of MMR). Treatment is supportive, analgesics, bed rest and fluids.

Answer 437

Enlarged and tender parotid glands.

Answer 438

A normal commensal of skin and mucosa. Infection is usually opportunistic following a predisposing local or systemic cause, e.g. denture wearers, dry mouth, antibiotic, steroid or cytotoxic therapy, immunosuppression, iron and folate deficiency and diabetes.

Answer 439

Depends on the area of skin affected, there is often reddened mucosa or skin with creamy exudates. Diagnosis: smear from lesion will show yeasts. Management: treat predisposing cause and administer topical or systemic antifungals.

Answer 440

o Oral cavity commonly infected o Often a sign of underlying disease o Causes angular cheilitis at commissure of lips o Local or systemic causes: denture wearers, dry mouth, antibiotics, steroid or cytotoxic therapy, immunosuppression, iron and folate deficiency and diabetes.

Answer 441

> An evolving sinusitis can present as an ill-defined toothache in the maxilla. Need to distinguish between sinusitis and dental decay to avoid unnecessary dental treatment. > Acute sinusitis usually follows a viral infection. > Chronic sinusitis may have a dental cause e.g. unobserved oro-antral fistula or retained dental root. > Cancer of the paranasal sinuses is rare, hidden within the recesses of the face, and is usually advanced when diagnosed. It can be heralded by vague, unrelated and progressive pain.

Answer 442

o > Patients with TMJ dysfunction sometimes present to the ENT surgeon will complaints of fullness in the ear. o > Cancers of the mouth and throat produce referred pain to the ear. A complaint of a sore throat or dysphagia with unilateral earache is a cancer until proven otherwise. It is indicative of a cancer (squamous cell carcinoma) involving the oropharynx or larynx and is due to referred pain from the glossopharyngeal nerve.

Answer 443

- The commonest cause of mild airway obstruction is enlarged tonsils. - Large pitted tonsils can collect debris and may be responsible for halitosis. - Severe obstructions can occur in children secondary to micrognathia or TMJ ankylosis. This is because the mandible does not develop sufficiently to draw the tongue forward and as a result the drawing tongue obstructs the airway.

Answer 444

- Obesity - Alcohol (relaxant) - Posture - Micronasia.

Answer 445

o Malignant disease in the oropharynx (tonsil and base of tongue) is frequently hidden so diagnosis can be delayed. The pharynx is covered by a layer of lymphoid tissue (Waldeyer’s ring) and squamous cell carcinoma tends to burrow beneath this layer and remain hidden from view. The sites at risk are tonsil and base of tongue. This is a common source of litigation. o Unilateral earache, progressive, unremitting pain are symptoms indicative of cancer. Palpate the tongue or tonsil for the presence of a hard mass. o Tumours can be diagnosed from symptoms of unremitting progressive pain usually radiating to the ear (unilateral) and possible evidence of asymmetrical enlargement of the tonsils or tongue base. Palpation is the most valuable diagnostic tool as it can reveal a hard tissue mass. o Tumours of the larynx tend to be identified early because they interfere with the tone of voice. o A persistent hoarse voice in a middle-aged smoker requires investigations.

Answer 446

Diseases which occur when lymphocytes react against self antigens i.e. antigens on the individual's own tissues.

Answer 447

When the immune system is unable to make an adequate immune response to control pathogens.

Answer 448

When there is an exaggerated response of the immune system to an antigen.

Answer 449

A steroid card - as tx often involves immunosuppression with corticosteroids.

Answer 450

Short-term complications: > Mood disturbance > Insomnia Long-term complications: > Weight gain > Cushing's syndrome (moon face, striae, acne) > Cataracts > Hypertension > Osteoporosis and avascular necrosis > Muscle wasting > Diabetes > Peptic ulceration > Delayed wound healing > Increased susceptibility o infections Seizures Thinning skin Excessive weight gain Rapid heartbeat mOod changes Infections Disturbed vision Slow wound healing Marked adrenal suppression occurs when doses >30mg/day are taken for more than 2-3 weeks. It is therefore vital that pts do NOT ABRUPTLY STOP TX otherwise they will develoop symptoms of acute adrenal insufficiency that may be life-threatening. In addition pts may be unable to initiate a sufficient adrenocortical response with illness or surgery and may require additional steroid cover.

Answer 451

A multisystem disease with a widespectrum of clinical manifestations. Predominantly young women, particularly afro-caribbean descent. Pathogenesis: anti-DNA antibodies are characteristic of SLE but other antibodies directed against the cell nucleus and immune complexes are found. Drug-induced lupus may occur in slow acetylators on taking hydralazine, procainamide, penicillamine and some anticonvulsants and antibiotics.

Answer 452

Eyes: Sjogren's syndrome Mucosal ulcers Muscles: Myalgia NS: psychosis, epilepsy, stroke Skin: malar 'butterfly' rash, discoid lupus Heart: pericarditis, myocarditis Kidneys: lupus nephritis Blood: haemolytic anaemia Raygnaud's phenomenon Joints: arthralgia and systemic arthritis.

Answer 453

o Oral lesions  More than 40% of people with SLE have oral lesions, which can include ulcers, leukoplakic plaques, and lichenoid lesions. These lesions can be difficult to diagnose because their morphology varies depending on the type of disease. o ? perio, missing teeth, TMJ disorders, xerostomia for Sjogren’s or drugs. o May be on corticosteroids or immunosuppressants.

Answer 454

It is a multisystem disorder than may present with oral ulceration. Pathogenesis is not entirely clear but is associated with vasculitis, autoantiboides to the oral mucous membrane and immune complexes. Tx includes analgesia and NSAIDs but immunosuppression is required for severe disease.

Answer 455

Recurrent orogenital ulceration and uveitis.

Answer 456

o Severe mouth ulcers o Immunosuppression tx

Answer 457

Systemic sclerosis is associated with inflammation, fibrosis and vascular damage to the skin and internal organs. Rare disease that usually affects women ages 30-50 years. Pathogenesis: characterised by fibrosis (scleroderma) thickening of the skin with tethering to subcutaneous tissues. Autoantibodies are present. Tx: supportive as no drug has been show to halt progression of disease.

Answer 458

Raynaud's phenomenon and skin involvement (scleroderma, telangiectasia, capillary nailbed changes) are commonly found. The GI tract, heart, lungs and kidneys may also be involved.

Answer 459

> e.g. Systemic lupus erythematosus, Behcet's disease and systemic sclerosis. > Autoimmune disease may present first in the mouth (e.g. oral ulcers in Behcet's disease). > Patients may be taking corticosteroids and thus prone to delayed healing and increased susceptibility to infection. Furthermore, additional steroid cover may be required for surgical procedures under GA.

Answer 460

Failure of the immune system to produce and adequate immune response to control pathogens. - often results in increased susceptibility to infections. Immunodeficiencies are classified as primary (congenital) or secondary (acquired, e.g. HIV). They can arise from deficiencies in lymphoid cells, phagocytes and complement. Patients with immunodeficiency are prone to opportunistic infections from pathogens that normally do not cause problems in immunocompetent individuals. Deficiencies of other cells of the immune response (e.g. B cells, complement) are associated with staphylococcal and streptococcal infections.

Answer 461

> Fungal infections e.g. Candida albicans infecting the mucous membranes, hair, skin and nails. > Parasitic infections e.g. Pneumocytis carinii producing pneumonia or Toxoplasma gondii producing CNS cysts > Viral infections e.g. Herpes zoster and Herpes simplex causing severe localised ulceration; CMV may affect many organs , including lungs (pneumonia) and brain (encephalitis) > Bacterial infections e.g. mycobacterial infection of internal organs (lung, CNS)

Answer 462

When there is an exaggerated immune response to an antigen. This results in local tissue injury and/or systemic symptoms, including shock or death. There are 4 main types of sensitivity

Answer 463

This occurs when an allergen interacts with a specific IgE antibody that is present on mast cells. Degranulation of the mast cell release histamine and other vasoactive mediators that activate an inflammatory response. Type 1 hypersensitivity reactions usually occur within minutes of exposure to the antigen and may cause mild symptoms or anaphylactic shock. Examples include allergic rhinitis (hayfever), allergic asthma and food allergy.

Answer 464

Cell-bound antigens interacts with specific IgG or IgM antibodies to form in situ complexes that activate complement, leading to cell lysis and death. These reactions take many hours to develop and occur in transfusion reactions and some autoimmune diseases (e.g. myasthenia gravis)

Answer 465

In type III hypersensitivity, soluble immune complexes form in the circulation and are deposited in various tissues where they activate complement. Systemic lupus erythematosus is an example of type III hypersensitivity.

Answer 466

This is initiated by interaction of T cells with antigen when it is complexed with MHC molecules. T-cell-mediated immunity arises over several days and occurs with granulomatous disease (e.g. tuberculosis) contact dermatitis, hashimoto's thyroiditis and organ allograft rejection.

Answer 467

> Latex allergy is a common and potentially life-threatening problem and should be screened for in all patients. > The risk of latex allergy is related to exposure: dentists should wear powder-free, latex-free gloves to minimise exposure. > Patients with latex allergy must avoid all contact with latex.

Answer 468

1. Anxiety disorder 2. Mood disorders 3. Somatoform disorders 4. Schizophrenia and other psychotic disorders 5. Substance-related disorders 6. Eating disorders

Answer 469

Physical: - Tachycardia and chest tightness - Dizziness and hyperventilation - Diarrhoea - Dry mouth and bruxism - Myofacial pain as a result of jaw clenching, posturing or nail biting - Swallowing difficulty - 'globus hystericus' Psychological - aggression - lack of concentration and poor memory - reduced pain threshold - exaggerated reaction to stimuli - sleep loss

Answer 470

These are irrational fear of an object or situation leading to avoidance behaviour.

Answer 471

Brief episodes of intense anxiety or panic. Panic attacks may be precipitated by dental treatment and lead to hyperventilation and loss of control.

Answer 472

State of persistent anxiety not due to a specific situation or object.

Answer 473

Be sympathetic, empathy, reassurance and give pt control ('put hand up if you need me to stop'). Very anxious and phobic patients may benefit from sedation or relaxation techniques to facilitate dentistry. More severe cases require tx under care of a psychiatrist. Therapies include cognitive behavioural therapy, counselling and medical therapy (B-blockers, antidepressants, minor tranquilisers).

Answer 474

> An aggressive or unfriendly patient may just be anxious. > A sympathetic and empathetic approach to anxious patients is essential. > Remember that sweating and tachycardia may be due to hypoglycaemia in a diabetic patient, for example, and not anxiety. > An up-to-date drug history is an imperative. Check all interactions in the BNF before treatment. > Dry mouth may be explained by anxiety or the drugs used for therapy.

Answer 475

1. Depressive 2. Biopolar - in depression there is sustained depression of mood that is accompanied by various features such as sleeplessness, loss of appetite and suicidal thoughts. Depression can can secondary to pathological process - e.g. endocrine abnormality or side-effect of certain drugs. - in biopolar, there are alternating episodes of depression and euphoria.

Answer 476

Biological: - Appetite disturbance (loss) - Weight disturbance (weight loss) - Early morning waking - Decreased energy - Loss of concentration - Reduced sex drive Psychological - Persistently depressed mood - Anhedonia (loss of pleasure) - Feeling of guilt, worthlessness and self blame. - Recurrent thoughts of death (suicidal ideation).

Answer 477

'Atypical syndromes' such as IBS (irritable bowel syndrome), BMS (burning mouth syndrome), ME (myalgic encephalomyelitis - 'chronic fatigue syndrome'), TMJ PDS (TMJ pain dysfunction syndrome) and fibromyalgia.

Answer 478

Cognitive behaviour therapy, psychotherapy, exercise and various types of counselling are as effective as antidepressant drugs that are often prescribed.

Answer 479

> Mood disorders affect 10% of population. > The dental profession is a high-risk group of suicide and mood disorders. > Check interactions and side-effects of prescribed drugs (many antidepressants cause dry mouth) > Adequate informed consent can be difficult to obtain. > Understanding and empathy is helpful when dealing with these patients. > There is an increased incidence of TMJ pain dysfunction syndrome and atypical facial pain in this group.

Answer 480

Somatoform disorders are characterised by the presence of physical symptoms that cannot be adequately explained by a medical condition or substance taken. Patients express their inner conflicts and distress as physical symptoms.

Answer 481

Pts present with a variety of physical symptoms, including pain, paraesthesia, burning mouth, and temporomandibular joint (TMJ) dysfunction. The symptoms have often been present for years, cross normal anatomical boundaries and have not responded to previous physical tx. There is frequently a history of multiple consultations and negative investigation results. In dysmorphic disorder the patient may feel that their teeth are deformed and demand unrealistic tx for apparently normal dentition. Atypical facial pain is a common manifestation in dental practice. It is characterised by a persistent dull pain that has changed little over time. it is more common in the upper jaw and crosses anatomical boundaries. Older women are most commonly affects, who may in extreme cases have all their teeth, in the affected quadrant, extracted with no relief.

Answer 482

Atypical facial pain is a common manifestation in dental practice. It is characterised by a persistent dull pain that has changed little over time. it is more common in the upper jaw and crosses anatomical boundaries. Older women are most commonly affects, who may in extreme cases have all their teeth, in the affected quadrant, extracted with no relief.

Answer 483

Early identify. Avoid multiple investigations and physical tx. Referral to specialist clinics. Need pts to make the link btw emotional and physical symptoms. Atypical facial pain responds well to tricyclic antidepressant medication.

Answer 484

> Somatoform disorders affect up to 13% of population. > Attempt to rule out physical cause without excessive investigation. > Common dental presentation are: - atypical facial pain - temporomandibular joint dysfunction - burning mouth syndrome - paraesthesia > Understanding and empathy is helpful when dealing with these pts.

Answer 485

Schizophrenia is a psychosis and is characterised by hallucinations (auditory, somatic and sometimes visual), delusions and disorders of thought. Aetiology: various theories include genetic predispotiion, biochemical imbalance in the brain (dopamine), brain damage (perhaps by viruses and drugs such as marijuana) and structural brain abnormalities.

Answer 486

1) Hallucinations, 2) Delusions 3) Thought disorders 1) Hallucinations - a false sensory perception in the absence of external stimulus. It may be: - auditory, visual, tactile, gustatory. 2) Delusion - unshakable belief in something untrue which may be: persecutory (people out to get you), grandiose (believe you have special powers), reference (thinking that special messages are being transmitted to you) 3) Thought disorder: - thought insertion: 'someone putting thoughts in to my head' - thought broadcasting - thought withdrawal - feeling passivity. Pts are often adamant in their belief. Lack of insight. Pts may also hold paranoid beliefs and be socially withdrawn and difficult to communicate with.

Answer 487

> Most schizophrenics can be treated safely in general dental practice. > Drug treatment may lead to dry mouth and uncontrolled facial movements making treatment difficult, affecting speech and swallowing and denture wear problematic. > There is often severe dental neglect with increased caries and periodontal disease > Adequate informed consent may be difficult or impossible to obtain in some circumstances.

Answer 488

Physical: - Liver disease: cirrhosis, hepatitis - GI disease: ulcers and varices, pancreatitis - CNS: encephalopathy - Cardiac disease: cardiomyopathy - Vitamin deficiencies - Weight gain - Repeated traumatic injury Social: - Deterioration of relationships - problems with work and finance - Increased criminal activity - Decrease social standing. Psychological: - Mood disorders - Anxiety disorders - Deliberate self-harm - Sexual problems - Morbid jealousy - Alcoholic psychosis.

Answer 489

Life-threatening delirium tremens, characterised by fits, hallucinations, tachycardia and hypotension.

Answer 490

1. Have you felt the need to Cut down? 2. Have you ever been Annoyed if others criticise your drinking habits? 3. Ever felt Guilty about your drinking 4. Ever drink first thing in the morning - an Eye opener.

Answer 491

High gamma-GT and macrocytosis.

Answer 492

> There is a tendency towards harmful drinking within the dental profession. > Increased risk of oral cancer, particularly if smoking as well. > Organ damage: - Liver disease: drug metabolism, bleeding tendency - GIT: gastritis and oesophagitis - avoid NSAIDS - Cardiac: risk of arrhythmia with LA - CNS: poor comprehension of treatment > Poor compliance with treatment > Adequate informed consent may be impossible to obtain from someone who is under the influence of alcohol. > Avoid metronidazole as it may cause disulfiram reaction. > Repeated traumatic injuries to teeth are common. > Dangerously hypoglycaemic patients may appear to be drunk. > If you have concerns then seek advice from a physician before starting treatment.

Answer 493

Drug dependence (addiction) is the compulsive use of a substance despite negative consequences. It implies that if the person stops taking the drug they suffer physical and/or psychological withdrawal symptoms and signs. Commonly used drugs of dependence, part from alcohol and nicotine, include: - Stimulants: > Cocaine and derivatives > Amphetamines and derivatives - Hallucinogens: > Cannabis > Solvents > LSD - Narcotics: > opioids such as morphine, heroin, pethidine and codeine - Hypnotics: > barbituates > benzodiazepines

Answer 494

Restlessness, aggression, hallucinations and other signs associated with mental illness.

Answer 495

> Tobacco and cannabis use are risk factors for head and neck cancers. > Drug users may be manipulative and demand repeated prescriptions of opioid analgesics. > Intravenous drug users have an increased incidence of endocarditis. > There is an increased risk of cross-infection due to HIV and hepatitis B and C among intravenous drug users. > Drug tolerance is common and patients may react unexpectedly to intravenous sedation. > Refer to hospital if you have concerns.

Answer 496

Anorexia nervosa Bulimia nervosa

Answer 497

The voluntary starvation and exercise stress with a refusal to maintain a minimum body weight. Individuals often believe that they are overweight even though they are grossly underweight. Aetiology: largely unknown, but there is a complex interplay of genetic, hormonal, psychological and social factors. Four main diagnostic criteria: 1. Avoidance of normal weight 2. Disturbance of weight perception 3. Fear and loathing of obesity - will diet even when very underweight 4. Amenorrhea in women

Answer 498

- Relentless dieting and exercising - Low body mass (>15% below expected) - Laxative and diuretic abuse - Habitual vomiting, amenorrhea - Languno hair over body (very fine) - Low BP and postural drop in BP - Depression and suicide Tx must address underlying psychological factors involving CBT and social support. In severe cases pt may be admitted to hospital under Mental Health Act for nourishment and intensive therapy.

Answer 499

> Tooth erosion due to vomiting (especially palatal surfaces of upper incisors) > Salivary gland enlargement due to vomiting > The low body mass may require drug dose alterations > Dizziness when sitting up due to postural hypotension

Answer 500

This is characterised by binge eating, self-induced vomiting and generally normal body weight or weight loss, not as severe as in anorexia.

Answer 501

- Binge eating and vomiting with generally normal weight - Russell's sign of calluses on the back of hand due to pushing fingers down the throat to induce vomiting. - Laxative, diuretic, thyroxine and purgative abuse - Fear of becoming overweight, but generally happy with their present weight. Tx: CBT can help.

Answer 502

- Tooth erosion due to vomiting

Answer 503

Warfarin, NSAIDs, Heparin, DOACs

Answer 504

Immunosuppressants Steroids

Answer 505

Antibiotics Carbamazepine Phenytoin

Answer 506

Nifedipine, Cyclosporin, Phenytoin

Answer 507

Antibiotics Diuretics NSAIDS B-blockers Gold salts Penicillamine Anti-malarials Allopurinol

Answer 508

Nicorandil Cytotoxics

Answer 509

ACE inhibitors Inhalers Metronidazole

Answer 510

Anti-cholinergics Anti-depressants Anti-parkinsons Anti-hypertensives Anti-histamines Phenothiazines Tranquilizers

Answer 511

o Tooth loss – ¼ over 65 have lost all teeth. Some retain and need complex restorative tx. o Periodontal disease o Oral cancer – esp past history of smoking and excess alcohol consumption o Dry mouth – side effect meds. Other causes include salivary gland disease, e.g. secondary Sjogren’s. Jaw irradiation for tx of malignant disease. Dehydration.

Answer 512

o Diseases – commonly heart and circulatory disease, muscoskeletal and respiratory emphysema or bronchitis. o Reduced physical reserve – may not be able to cope with treatments o Healing and repair – reduced, increased healing time. o Polypharmacy – xerostomia, etc. o Disability/impaired functional status – impeded self care and ability to cope with demands of treatment. If memory impaired, impact consent and understanding/retention of tx options. o Social circumstances – investigate if have little social support and isolated o Psychological – decreased perceived need for tx. Only seek tx when desperate need. Increased level of anxiety towards tx leads to avoidance behaviour. Increased risk of mood disorder.

Answer 513

o Most elderly pts can be treated safely using local anaesthetic in dental practice. o To maximise safety:  Avoid sedation as there may be increased sensitivity to benzodiazepines and concurrent airway disease.  Be aware of the risks of polypharmacy. o Patients may have multiple medical conditions so close liaison with their general medical practitioner or physician is often required. o Be aware of accessibility issues, including:  Transport facilities, access to surgery, communication problems. o Be aware of valid consent

Answer 514

* Dental relevance of autism * o Autism is a developmental disability characterised by severely impaired social interaction and communication skills. o Repeated traumatic injury to teeth due to fall and seizures. o Self-induced mucosal injury and bruxism o Caries due to increased intake of sugar-containing foods and difficulty performing routine oral hygiene. o Variable degree of functional and intellectual impairment can affect communication, understanding and ability to perform tasks. Behaviour may be erratic with a tendency towards frustration and violent acts. o May be unpredictable body movements which can make tx difficult and even dangerous. Seizures are common and many pts are treated with anti-epileptic mediation.

Answer 515

Abnormal body movements and muscle coordination due to non-progressive lesions in the immature brain. 3 types based on type of movement abnormality: - spastic (60%) = hypertonic - ataxic = short jerky - dyskinetic = slow writhing

Answer 516

o Speech, chewing and swallowing difficulties. o Increased incidence of caries o Drooling o Malocclusion o Many pts have learning difficulties. There is an increased incidence of visual and hearing problems, seizures and speech disorders. o Depending on severity, tx can be carried out in general practice. Involuntary movement may make this impossible and necessitate treatment under GA in a specialist centre

Answer 517

Characterised by inattention, hyperactivity and impulsiveness. Affected children have inability to focus of maintain attention.

Answer 518

o Behavioural problems during treatment. o Characterised by inattention, hyperactivity and impulsiveness. Affected children have inability to focus of maintain attention.

Answer 519

Trisomy of chromosome 21.

Answer 520

- Flattened facial profile due to hypoplasia or mid-face - Prominent epicanthic fold - Vertical creases from inner canthus to nasal bridge, gives class mongoloid appearance - Relative macroglossia due to reduced size of mid-face and oral cavity - Neck is short and broad. - Flattened area over the occiput (brachycephaly).

Answer 521

- Cardiac abnormality (40%) - T-cell deficiency - Learning difficulties - Associated medical problems, e.g. epilepsy, hypothyroidism, diabetes - Decreased airway patency/obstructive sleep apnoea due to decreased muscle tone

Answer 522

o Cardiac abnormalities may need antibiotic cover o Malocclusion o Aphthous ulcers o Candida o Perio/ANUG due to immune defect o Relative macroglossia o Mouth breathing (dry mouth) o Delayed tooth eruption

Answer 523

- Physical - Emotional - Sexual - Neglect

Answer 524

o Delayed presentation o Inconsistent history o Unexplained history o Story changes with time, story changes with teller o Unusual pattern of injury – neck safe zone, non-body prominence o Repeated injury o Bruises of different colours – different time o Abnormal child and parent relationship o Information from a third party o Child on the protection register o Head and neck signs may indicate abuse:  Torn labial frenum  Contusions on face of in the palate  Jaw fracture  Oral STDs  Subconjunctival haemorrhage  Bite marks  Burn marks  Scalds

Answer 525

o It is part of care to safeguard and promote the welfare of children. o Up to 50% of abuse cases have head and neck signs of symptoms o Delayed presentation, story changing with time, story changes with teller, unusual pattern of injury, repeated injury. o Abuse can be physical, emotional, sexual, neglect o Children’s act 1989, Common law duty of confidence, Data protection act 1998 o Public interest in safeguarding a child’s welfare overrides confidentiality.

Answer 526

No! don't use in under 12s due to risk of Reye's syndrome

Answer 527

Not in under 12s! risk of tooth staining and enamel hypoplasia

Answer 528

Avoid in under 16s or emotionally immature due to unpredictable reaction

Answer 529

Most of the baby's organs are forming and is period crucial for baby's development. Only urgent procedures. Best to plan procedures during second trimester to minimise potential risk.

Answer 530

Dental chair uncomfortable for mother. In certain positions, enlarged uterus may obstruct low in the inferior vena cava.

Answer 531

Lidocaine and novocaine.

Answer 532

Citanest should be avoided as the vasoconstrictor, octapressin, may induce labour.

Answer 533

Penicillin, amoxicillin, clindamycin are acceptable.

Answer 534

Tetracycline - causes discolouration of child's deciduous and permanent dentition. Metronidazole - teratogenic potential and should be avoided in pregnant patients.

Answer 535

Paracetamol is preferred analgesic for pregnant women, and producing containing acetaminophen, such as Tylenol, are approved.

Answer 536

NSAIDs (aspirin or ibuprofen) which might induce allergy in the unborn fetus. Opioid/opiate medicatiations.

Answer 537

Risk of fetal hypoxia.

Answer 538

A study suggests an association between women's exposure to dental radiographs and low-weight births. Dentists should use both an abdominal apron and thyroid collar to minimise radiation exposure.

Answer 539

Pregnancy has an association with gingivitis. This is because: - High plasma oestrogen and progesterone increase gingival blood flow and cause an exaggerated inflammatory response to plaque. - Alteration in dental plaque - Negligence Pregnancy epulis (pyogenic granuloma) – rare, usually painless gingival lesion that develop in response to plaque. They usually subside shortly after child-birth but may still cause a significant cosmetic problem and require surgical removal.

Answer 540

A disorder that affects 5% of pregnancies and is a rapidly progressive condition that affects the mother and the unborn child. It is defined as: 1. A rise in blood pressure of more than 15mmHg diastolic or more than 30mmHg systolic from measurement in early pregnancy; or to more than 140/90mmHg in late pregnancy. 2. Proteinuria or more than 3g per 24 hours. 3. And/or oedema. Risk factors: first pregnancy in women under 17 or over 35, FMH of high blood presure, multiple birth pregnancy, poor diet during pregnancy, obesity, smokers, other health problems (blood vessel conditions, kidney disease, diabetes) High blood pressure that typically occurs after 24th week and can cause a decrease in blood and oxygen supply to mother and baby. > In mother can lead to kidney problems, breathing problems, seizures, strokes and even death. > Babies may have problems growing, getting enough oxygen and other complications. High blood pressure will resolve postpartum for most women.

Answer 541

Diabetes that develops during pregnancy. Less serious than other types of pregnancy and usually resolves after birth. Symptoms: thirst, frequent urination, weight loss, lethargy and weakness. Diagnosed through routine blood and urine tests which are carried out in all pregnancies. Untreated, can lead to pre-eclampsia and fetal abnormalities such as cleft palate. Risk factors: increasing age, obesity, family history of diabetes, previous large baby, previous perinatal loss. Tx: - regular blood glucose monitoring - a diet high in fibre and carbohydrates, and low in sugar and fat. - exercise - insulin infections in some cases.

Answer 542

Symptoms include weakness, fatigue, shortness of breath and headaches. Risk factors: - lack of iron, less often it is caused by folic acid deficiency. - women from low socio-economic groups, and teenagers. Pts with severe anaemia are more likely to deliver early and have small babies. Iron and folate supplements are given during pregnancy and for several months after delivery in order to help the body replace the lost blood cells and iron stores.

Answer 543

o Measles (rubella) – association with pre-term labour and birth defects. Rubella vaccine recommended for non-immune women who consider starting family.

Answer 544

o Varicella zoster virus – pregnant women exposed to chicken pox usually experience a benign, self-limiting infection. If women have antibodies to VZV, fetus not at risk of chickenpox even if mother develops shingles during pregnancy. Antibodies transferred to infant through placenta through pregnancy. In non-immune pregnancy women, chickenpox is associated with increased fetal and maternal morbidity and mortality.

Answer 545

* Dental relevance of Pregnancy * o Avoid unnecessary dental treatments, particularly in the first and third trimesters. o Avoid x-rays o Avoid aspirin and NSAIDs, sedatives and hypnotics as these may have deleterious effects on the fetus. o Local anaesthetics are safe to use in pregnancy but combinations containing vasopressin should be avoided. o Some antimicrobials (e.g. tetracycline and metronidazole) should be avoided during pregnancy. o GA and sedation should be avoided due to risk of fetal hypoxia. o Pregnancy has an association with gingivitis. This is because:  High plasma oestrogen and progesterone increase gingival blood flow and cause and exaggerated inflammatory response to plaque.  Alteration in dental plaque  Negligence o Pregnancy granuloma – rare, usually painless gingival lesion that develop in response to plaque. They usually subside shortly after child-birth but may still cause a significant cosmetic problem and require surgical removal. o Pre-eclampsia (high blood pressure, proteinuria and/or oedema) – risk to mother and baby. Resolve after birth for most. o Gestations diabetes (diabetes type III) – diabetes during pregnancy, usually resolves after birth. Symptoms: thirst, frequent urination, weight loss, lethargy and weakness. Untreated, can lead to problems for mother (e.g. pre-eclampsia) and fetal abnormalities such as cleft palate. o Anaemia. Severe anaemia – likely to deliver early and have small babies. Iron and folate supplements given during pregnancy and for several months after delivery. o Measles (rubella) – association with pre-term labour and birth defects. Rubella vaccine recommended for non-immune women who consider starting family. o Varicella zoster virus – pregnant women exposed to chicken pox usually experience a benign, self-limiting infection. If women have antibodies to VZV, fetus not at risk of chickenpox even if mother develops shingles during pregnancy. Antibodies transferred to infant through placenta through pregnancy. In non-immune pregnancy women, chickenpox is associated with increased fetal and maternal morbidity and mortality.

Answer 546

o > Preventive dentistry is important o > It is reasonable to give antibiotic cover for invasive dental procedures. o > There is an increased susceptibility to infection. o > High risk of hepatitis B/C and cross-infection. o > Increased incidence of hypertension and IHD. o > Oral effects of immune suppressant drugs:  Increased risk of opportunistic infection * Candidiasis * Herpes simplex virus  Ulceration  Increased incidence of malignancy  Gingival hyperplasia (ciclosporin)  Slow wound healing + infection o If the transplanted organ is failing there may be altered drug metabolism. o Steroids – steroid cover, steroid side effects. o Graft vs host disease. o Autograft = from one part of body to another o Allograft = between individuals of same species o Zenograft = between species

Answer 547

o Ciclosporin – gingival hyperplasia, diabetes, hypertension o Tacrolimus – nephrotoxicity, hair loss, hypertension o Azathioprine – leucopenia, hair loss o Mycophenolate – GI upset, leucopenia o Steroids – hypertension, osteoporosis, diabetes, cushingoid face o General – infections, malignancy

Answer 548

- Cancers in children tend to arise from discrete genetic defects whereas those in the elderly occur through gradual accumulation of non-specific damage over time.

Answer 549

- Tobacco and alcohol: mouth, throat, lung, oesophagus, pancreas and bladder cancer. - Radiation: haematological disorders and thyroid cancer. - Infective agents such as papilloma virus cervical and pharyngeal, posterior tongue and tonsillar cancer - Hepatitis B: liver cancer - UV radiation: squamous cell carcinoma, basal cell carcinoma, malignant melanoma.

Answer 550

Leukaemia, of which 80% are acute lymphoblastic type. ALL = acute lymphoblastic leukaemia H+N: Sarcomas or retinoblastoma.

Answer 551

Breast, prostate, lung and colorectal cancers.

Answer 552

Breast, prostate, lung, kidney and thyroid. Migrate through blood stream and tend to alight at areas of high vascularity such as the temporomandibular joint or where the inferior dental artery enters and exits the mandible.

Answer 553

o The majority of children with cancer receive chemotherapy as a part of their treatment. o Local treatment in the head and neck (surgery and radiotherapy) can lead to facial deformity, altered tooth morphology (short roots, wide pulp cavities, altered crown morphology), malocclusion. o Systemic chemotherapy may have long-term effects in the form of growth retardation, cardiac toxicity, lung fibrosis and diminished bone marrow function. o Also, there is a risk of the patient developing second primary cancers in childhood. o Unless the individual received a course of radiotherapy directed at the jaws (which is uncommon) the risk of bone infection is low. o Dental treatment does not pose a particular risk to the patient. o Most common childhood cancer is Acute Lymphoblastic Leukaemia (ALL). o Most common H+N childhood cancers: sarcomas or retinoblastomas.

Answer 554

o The dental implications of treatment of solid tumours outside the head and neck is minimal. o Dental implications of cancer therapy pertain mainly to cancer of the mouth and to a less extent the salivary gland. This is because the full force of treatment is focused on the jaws. Those patients who continue to smoke and drink have a higher risk of cancer. Growth retardation is not a problem in the adult population. Surgery can lead to trismus and poor access to the oral cavity. A liquid diet incrases the risk of dental caries. Similarly, radiation therapy reduces salivary secretions, alters the oral flora and even with excellent OH, pts are at significant risk of root caries. Dental extractions, particularly in the mandible, place the patient at risk of osteoradionecrosis. It is recommended that all extractions in the mandible post-radiotherapy should be undertaken by specialist. o Most common adult malignancies: Breast, prostate, lung and colorectal. o Tumours that tend to metastasise to the jaws: Breast, prostate, lung, kidney and thyroid.  Migrate through blood stream and tend to alight at areas of high vascularity such as the temporomandibular joint or where the inferior dental artery enters and exits the mandible.

Answer 555

o The vast majority of disabled people can be treated safely in dental practice. Disability is common. o Disabled patients and staff should be able to gain easy access to all the services in dental practice. Domiciliary treatment may be required. o There is an increased incidence of oral disease in disable patients. o May require assistance to brush teeth. o Severe neuromuscular, neurological or learning difficulties – incontinence of saliva, bruxism, incr tooth wear. o Seizure disorders – frequent traumatic injury to teeth and oral soft tissues o Down’s syndrome – perio. o Anti-Parkinson’s and antidepressants – dry mouth, leading to swallowing and speech difficulties and increased susceptibility to caries. o Disorders of muscle control and movement – denture wear and routine dental management is difficult.