Exam 2- Other White/Red Lesions Flashcards by MOLLY MINES

Name the lesion:
Immune system overreacting
Common (~2% of the population) benign condition of unknown cause primarily affecting the tongue (ex. Geographic tongue or benign migratory glossitis)

Erythema Migrans

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What category does Erythema Migrans fall under?

Immune-mediated

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Name the lesion: Yellowish/white border slightly red next to it, serpentine or scalloped border with central erythema and adjacent loss of filiform papillae
Lesions move around the mouth in days to weeks - faster than malignant lesions

Erythema Migrans

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T/F Erythema Migrans changes faster than a neoplasm grows.

True

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T/F Erythema Migrans can affect soft palate, buccal mucosa, and FOM.

True but very rare

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How do you tx Erythema Migrans?

NO tx

If sensitive to spicy foods have them avoid

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(T/F) 1/2 of fissured tongue pt have Erythema Migrans

False 1/3rd

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How do you distinguish an erythroplakia from Erythema Migrans?

erythroplakia - should have uniform redness

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Note: Saying white line vs white patch gives you an entirely different differential dx.

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What are the most common agents of chemical injury (3 things).

Aspirin burn
Hydrogen peroxide
Phenol

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Name the Lesion:

White surface change due to coagulation necrosis of epithelium, usually tissue sloughing/peeling

Chemical Injury

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Why do chemical injuries in the mouth turn white?

Coagulation necrosis

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T/F There are a variety of caustic agents for oral chemical injuries but most of them are from prescribed medications.

False

Many are OTC

Aspirin burn
Hydrogen peroxide
Phenol

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How quickly does chemical injury heal?

1-2 wk once offending agent is removed

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Name the pathology:

Etiology- Blunt trauma, increased BP (Valsalva, coughing)

If generalized, consider the clotting problem, viral infection (ex. Mono, measles)

Oral Mucosal Hemorrhage

Petechiae(e) - round, pinpoint area of hemorrhage <0.2 cm

Purpura - non elevated/slightly populated area of hemorrhage 0.3 - 1 cm

Ecchymosis (bruise) - non-elevated area of hemorrhage > 1 cm

Hematoma - solid swelling of blood in tissue (elevated)

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T/F Streptococcal Tonsillitis and Pharyngitis is most often a bacterial cause.

False - viral cause NOT bacterial

Viruses include - adenovirus, enterovirus, influenza, parainfluenza, EBV

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What would be the bacterial etiology of Streptococcal Tonsillitis and Pharyngitis?

Group A, B-hemolytic streptococci

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About 30% of acute strep cases in kids and 5-15% of acute strep cases in adult will be ______.

Bacterial

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Bacterial Streptococcal Tonsillitis and Pharyngitis can lead to _________ _______ with a rash (__________).

can lead to scarlet fever with a rash on the outside (Exanthem)

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How is Streptococcal Tonsillitis and Pharyngitis transmitted?

respiratory droplet or oral secretions

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Name the pathology:

Sudden onset of sore throat
Fever 101-104
Dysphagia
Tonsillar hyperplasia
Redness of oropharynx and tonsils
Yellowish tonsillar exudate
Palatal petechiae
Cervical LAD

Streptococcal Tonsillitis and Pharyngitis

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What is the presentation (s/s) Streptococcal Tonsillitis and Pharyngitis in children?

often have headache, malaise, anorexia, abdominal pain, vomiting

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What are the features the suggest viral etiology?
(7 things)

conjunctivitis
rhinorrhea (runny nose)
cough
hoarseness
diarrhea
viral exanthem (rash) in absence of fever

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How do you diagnose Streptococcal Tonsillitis and Pharyngitis?

If clinical features suggest bacterial origin, do rapid antigen detection test. If rapid test is negative, do throat culture.

If rapid test positive or throat culture suggest bacterial origin then give an antibiotic.

If viral no tx.

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What is the tx rationale for Streptococcal Tonsillitis and Pharyngitis?

to avoid complication of glomerulonephritis, RF, or tonsillar abscess Small percentage of pt they can develop antibodies that begin to attack kidney

T/F Streptococcal Tonsillitis and Pharyngitis is typically self-limited.

True (3-4 days)

What is the definition of oral candidiasis?

Chronic infection with Candida albicans Dimorphic (yeast [round] and hyphal forms [long])

T/F Candida is a common oral organism normal to find in the mouth. The difference is if it causes an oral change, overgrowth is the problem.

True

_______% carriers state with subclinical infection for candidiasis.

~30-50%

What is the most common oral fungal infection?

Oral Candidiasis

Whos is likely to develop Oral Candidiasis?

Young/elderly Immunosuppressed Following broad-spectrum antibiotics Steroid therapy Cigarette smoking Denture wearers Xerostomia.

T/F One or more clinical patterns may exist of candidiasis.

True

Name the pathology: Removable cheesy, white plaques on buccal mucosa, palate and tongue Scraping reveals a normal or Erythematous (non-bleeding) surface Burning sensation or bad taste in the mouth Often acute onset with antibiotic exposure; slower onset with immunosuppression

Pseudomembranous candidiasis AKA Thrush

People with Pseudomembranous candidiasis (Thrush) often get it in an acute manner.

True

T/F When removing the white plaque in Oral Candidiasis there will be bleeding.

False!! Scraping reveals a normal or Erythematous/red (non-bleeding) surface

What 4 things fall under the Erythematous candidiasis (red, occasional white component) category?

1. Acute atrophic (antibiotic sore mouth) 2. Central papillary atrophy (“median rhomboid glossitis”) 3. Chronic Multifocal Candidiasis 4. Angular cheilitis

Name the pathology: reddish change is usually indication of candida Comes on after antibiotic use Scalded sensation to the tongue Diffuse loss of filiform papillae

Acute atrophic (antibiotic sore mouth) Erythematous candidiasis

Name the type of oral candidiasis: Well-demarcated red zone, atrophic, posterior dorsal tongue, midline, flat, smooth, often symmetric, anterior portion unaffected Often asymptomatic

Central papillary atrophy (“median rhomboid glossitis”) Erythematous candidiasis

Is Central papillary atrophy (“median rhomboid glossitis”) Erythematous candidiasis painful or non painful?

Non-painful pt is usually asymptomatic

Name the type of oral candidiasis: Central papillary atrophy + additional site (kissing lesion on palate or angular cheilitis) can have some what of a white component

Chronic Multifocal Candidiasis Erythematous candidiasis

Name the type of oral candidiasis: Erythema, fissuring and scaling of the angles of the mouth Waxes and wanes Can occur alone or with other form of erythematous candidiasis Reduced VDO predisposes to this presentation edentulous pt will often experience because of pooling of saliva in the corners of mouth

Angular cheilitis Erythematous candidiasis

Important to note that angular cheilitis will most likely have Staph areus and candida present in lesions. Why is this?

Because Staph aureus is found on the skin and in this area we are wrapping around to the skin (commissures)

Angular cheilitis __% candida alone __% Candida + Staph aureus __% Staph aureus alone

20% candida alone 60% Candida + Staph aureus 20% Staph aureus alone

When we say cheilocandidiasis what are we referring to?

More extensive perioral involvement (surrounding lips)

What is another name for denture stomatitis?

Chronic Atrophic Candidiasis

Name the candida pathology: Erythema of palatal denture-bearing area- typically asymptomatic. May be related to continuous denture wear.

Denture Stomatitis “Chronic Atrophic Candidiasis”

T/F Denture Stomatitis “Chronic Atrophic Candidiasis” is mostly a tissue response rather than true infection of mucosa as the denture is often contaminated with candida organisms, but invasion of mucosa is seldom seen.

True

How would you tx Denture Stomatitis “Chronic Atrophic Candidiasis”?

Tx the denture AND the mouth (mostly a response to what's in the denture so be sure to TX the denture)

What is a differential for Denture Stomatitis “Chronic Atrophic Candidiasis”?

Improper denture fit Allergy to denture base Inadequate cure of acrylic - need to get rid of the monomer which is usually not an issue now and days

Steroid Inhaler can predispose to _______ or _______________ candidiasis of the hard and soft palate .

Steroid Inhaler can predispose to erythematous or pseudomembranous candidiasis of the hard and soft palate .

Name the category of candida: Non-removable white plaques Buccal mucosa, tongue common sites If superimposed on pre-neoplastic lesion, often speckled appearance

Chronic Hyperplastic candidiasis

A pt comes in with a lesion that looks like either Chronic Hyperplastic candidiasis or Leukoplakia. How would you tx this lesion?

First give antifungal and then bring pt back is lesion is still there then assume leukoplakia

What are the 2 most common sites to find Chronic Hyperplastic candidiasis (non-removable white plaque)?

Buccal mucosa and tongue

How to diagnose Oral Candidiasis?

1. Culture (More sensitive) 2-3 days to grow colonies 2-3 mm creamy white - yeast form 2. Cytology *KOH preparation Quick (Several minute) and inexpensive Not as sensitive as culture or stained slide Not permanent Can’t assess maturation of epithelial cells *Periodic acid schiff (PAS) stained slide next day results 3.Biopsy NOT necessary in most cases

What is more sensitive when diagnosing oral candidiasis culture or cytology?

culture

T/F If you suspect candida you should take a biopsy.

False think about cost, discomfort. you should just treat them with an antifungal

T/F When treating oral candida first treat it as an infection (anti-fungal) before treating it as an immune condition (steroid) .

True

What are the 5 drugs he said dentist use to tx oral candidiasis?

Nystatin (polene agent) Clotrimazole (imidazole agent) Miconazole (imidazole agent) Fluconazole/Diflucan (Triazole) Iodoquinol 1% cream + hydrocortisone (other)

Candidiasis Drugs: Polene agents: A. Nystatin B. Amphotericin B Imidazole agent A. Clotrimazole B. Miconazole C. Ketoconazole Triazole A. Fluconazole (Diflucan) B. Itraconazole C. Voriconazole D. Posaconazole Echinocandins Other A. Iodoquinol 1% cream + hydrocortisone

What drug matches below? 100 mg tabs Disp: 7 tabs Sig: Take 1 tab po each day for 1 wk Note: Interaction with oral hypoglycemic, coumadin, phenytoin, others Absolute contraindication with warfarin

Fluconazole (Diflucan)

Fluconazole (Diflucan) ____ mg tabs Disp: _____ tabs Sig: Take ________________________________ Note: Interaction with oral hypoglycemic, coumadin, phenytoin, others Absolute contraindication with __________

100 mg tabs Disp: 7 tabs Sig: Take 1 tab po each day for 1 wk Note: Interaction with oral hypoglycemic, coumadin, phenytoin, others Absolute contraindication with warfarin

T/F You can swallow nystatin to get a systemic effect.

True!

Name the drug to treat candidiasis Oral suspension (1:100,000 U/ml) Disp 350 ml Sig: swish with 2 tsp (1o ml) for 3 mine then spit (or swallow) 5x/day for a week Note: can also soak partial dentures overnight in solution to tx dentures (very diluted bleach solution to kill candida - don’t do for partials with metal because it will corrode instead prescribe nystatin for them to soak their denture)

Nystatin

Nystatin - _______ agent Oral suspension (_____________ U/ml) Disp ______ ml if needing to soak denture can give about 500 ml Sig: swish with ______ (10 ml) for 3 min then spit (or swallow) ________x/day for a week Note: can also soak partial dentures overnight in solution to tx dentures (very diluted bleach solution to kill candida - don’t do for partials with metal because it will corrode instead prescribe nystatin for them to soak their denture)

Nystatin - polene agent Oral suspension (1:100,000 U/ml) Disp 350 ml Sig: swish with 2 tsp (1o ml) for 3 mine then spit (or swallow) 5x/day for a week Note: can also soak partial dentures overnight in solution to tx dentures (very diluted bleach solution to kill candida - don’t do for partials with metal because it will corrode instead prescribe nystatin for them to soak their denture)

What drug can you soak partial dentures overnight in solution to tx dentures?

Nystatin

__________ (Mycelex) ______ __ troches Disp: ____ Sig: Dissolve 1 troche in mouth ___x/day 1 week

Clotrimazole (Mycelex) 10 mg troches Disp: 50 Sig: Dissolve 1 troche in mouth 5x/day 1 week

Iodoquinol 1% cream + hydrocortisone Disp: ____ tube Sig: Apply to corners of mouth __x day (TID) for up to ___ weeks

Disp: 1 tube Sig: Apply to corners of mouth 3x day (TID) for up to 2 weeks hydrocortisone clears the red, iodoquinol tx candida

What candidiasis drug is used for angular cheilitis?

Iodoquinol 1% cream + hydrocortisone

T/F Pt can use nystatin oral suspension and lick sides of lips to tx angular cheilitis.

TRUE

A patient with angular cheilitis, erythematous patches, ulcers, or fissured/atrophied (especially tongue) in the mouth that doesn't respond to antifungal therapy should have bloodwork done to check for a __________ ___________.

Nutritional Deficiency often pt will feel fatigue / weakness

T/F Candida does not usually have ulcers.

True

What category does oral lichen planus fall under?

Immune mediated condition dont really know the etiology but not a true immune mediated response

What age group does oral lichen planus most commonly occur?

Adults

T/F Lichen planus only has oral lesions.

False can occur on skin - itchy purplish bumps

Name the lesion: May occur only in mouth or with skin lesions (itchy purplish bumps) Typically symmetrical Possible to have desquamative gingivitis (RED not puffy like perio disease) Architecture to the lesion (circles) Tend to have ulceration Tends to come and go (wax and wane) in severity

Oral lichen planus

T/F Oral lichen planus does not have ucleration.

False tends to have ulceration

Where are you most likely to find oral lichen planus?

Bilateral buccal mucosa, tongue, and gingiva

Oral lichen planus typically has architecture to the lesion like ______.

Circles

What are the two major forms of oral lichen planus?

1. Reticular 2. Erosive/ulcerative

What Oral Lichen Planus form is the most common?

Reticular

What feature is common with reticular lichen planus?

Interlacing white lines/striation (“wickham's striae”) or papules

In reticular oral lichen planus there can be dorsal tongue involvement. Describe this lesion.

patchy keratosis and atrophy

T/F Reticular oral lichen planus is painful.

False it NON PAINFUL

T/F Erosive lichen planus is painful

True

Describe erosive/ulcerative lichen planus.

Shallow ulcers peripheral erythema radiating white line (striated border)

Where is it common to have erosive oral lichen planus?

down in the mandibular vestibule

Erosive/ulcerative: When involving gingiva, may create a bright red, eroded appearance called “__________ _____________.”

desquamative gingivitis

T/F Reticular oral lichen planus can happen on the lip.

True

What will a biopsy of lichen planus show?

Lichenoid mucositis

Oral lichen planus will show Lichenoid mucositis under a microscope. List the histological features.

1. Thickened layer of parakeratin 2. Rete ridges are pointed/ saw tooth shaped or effaced (just gone) 3. Band like infiltration of lymphocytes forming along the epithelial CT interface causes vacuole formation 4. Lymphocytes start to destroy cells and you get fluid accumulation because the cell are being destroyed. This causes vacuole formation and hydropic (water degeneration) of the basal layer 5. Cells undergo apoptosis - chromatin pattern of nucleus shrink down and the cytoplasm gets really pink

What would direct immunofluorescence on oral lichen planus show?

shaggy band of fibrinogen deposited at the basement membrane zone where the destruction is happening between epithelial and CT layer NOTE NO ANTIBODY PRODUCTION

T/F Oral lichen planus has antibody production.

FALSE - no which makes it an important to help distinguish between other pathologies

How do you managment oral lichen planus?

1. Treat an associated candidiasis - Candida may be superimposed on lichen planus, altering the appearance and making it more symptomatic 2. Pt education - incurable but manageable,waxes and wanes, not contagious 3. Reticular LP usually requires no therapy 4. Erosive LP should be treated with one of the stronger topical corticosteroids 5. Meticulous oral hygiene help disease control (cleaning every 3-4 months)

How do you tx erosive lichen planus vs reticular?

Erosive LP should be treated with one of the stronger topical corticosteroids (ex. Fluocinonide gel, clobetasol gel); systemic steroid usually not needed but if you use it should be for a very short duration Reticular NO tx

What is the prognosis for oral lichen planus?

Good may last for many years though