finals - allergies/ immuno diseases

Question 1

_ aka canker sores

common, _ relationship

unknown pathogenesis - immune-mediated process

most common in children and young adults

possible triggers = stress, local trauma, menstrual cycle, tomatos

Answer 1

recurrent aphthous ulcerations

familial relationship

minor, major, herpetiform variations

Question 2

_ aphthous ulcerations

most common form with the fewest recurrences, shortest duration of lesions

almost exclusively occur on _ site

Answer 2

minor aphthous ulcerations

nonkeratinized moveable mucosa

buccal/labial mucosa, ventral tongue, floor of mouth, soft palate

Question 3

1-5 painful ulcers: preceded by erythematous macule with prodromal symptoms

erythematous halo - central area of ulceration and red halo, round to oval ulcer 3-10mm

heal without scarrying 7-14 days

Answer 3

minor aphthous ulcerations

most common, fewest recurrences, shortest duration of lesion

Question 4

_ aphthous ulcerations

longer duration per episode, 1-3cm ; heal in 2-6 weeks often with scarring

1-10 lesions - labial mucosa, soft palate, tonsillar fauces

Answer 4

major aphthous ulcerations

Complaint will sometimes be sore throat, not so much the intraloral pain

Question 5

_ aphthous ulercations

greatest number of lesions and most frequent recurrences

individual lesions small 1-3mm

any oral mucosal surface

Answer 5

herpetiform aphthous ulcerations

Most unique and least common
- Most frequent ulcerations (continuous)
Small!

Moveable tissue non keratinized tissue location is most common
But these herpetiform aphthous ulcerations can occur anywhere

Question 6

herpetiform aphthous ulcerations superficial resemble primary HSV

heal in 7-10 days, but recurrences tend to be closely spaced

another way to distinguish?

Answer 6

Recurrent herpes - no because it is on attached gingiva and palate

Primary herpes - acute out break and then heals - systemic health declines and patient feels like sick

Herpetiform aphthous ulcerations - have had some previous and not as much as an urgency - coming and going weeding out

if really can’t dx - then do exfoliative cytology

Question 7

recurrent aphthous ulcerations

dx? tx?

Answer 7

dx - based on clinical presentation - histopathology non-specific - just to rule other things out

tx - topical high potency corticosteroids (Betamethasone dipropionate, Clobetasol propionate)

Only need to apply until the pain it gone (immune response over) - need a lot of applications because saliva will take it off - If no erythema - the corticosteriod won’t probably work bc immune response is over

Question 8

multisystem disorder (like Celiac disease) with oral aphthous-like ulcerations

abnormal immune process triggered by an environmental or infectious Ag in a genetically predisposed individual (pesticides)

Answer 8

Behcet’s syndrome

highest prevalence in Turkey, Japan, and Eastern Mediterranean countries

much less frequent in US

Question 9

Behcet’s Syndrome classic triad

Answer 9

oral ulcerations (similar to aphthous ulcers) - 75% of cases, occur in 99% cases - soft palate and oropharynx - back of oral cavity

genital ulcerations - 75% of cases

ocular disease - 70% of cases - posterior uveitis - conjunctivitis, corneal ulceration, arteritis,

also hace cutaneous lesions, arthritis, CNS, cardio, GI, muscular, Pulmonary, renal

Question 10

Behcet’s syndrome

dx- based on clinical presentation and positive _ test

Answer 10

pathergy test - 20 G needle and sterile saline - inject subq and see if there is a response

Question 11

Behcet’s Syndrome

tx

Answer 11

topical or systemic immunosupprussive and/or immunomodulatory therapy - early aggressive therapy for severe cases

Px - generally good; relapsing/remitting course

Question 12

unknown etiology; appears to represent an abnormal immune rxn

most often in adults
non-necrotizing granulomatous inflammation, presenting as persistent non-tender swelling

lips most common site, may involve any oral or perioral location - if have GI problem then it is probably Crohn’s

Answer 12

orofacial granulomatosis

Cheilitis granulomatosa - only lip involvement

melkersson-rosenthal syndrome - non-tender lip sweelingm Bell’s palsy, fissured tongue

Question 13

type of oral granulomatosis

non-tender lip swelling
Bell’s palsy
fissured tongue

Answer 13

Melkersson-Rosenthal syndrome

Question 14

superficial vascular ectasia(dilation) , vasculitis, edema, leaky

non-necrotizing granulomas (may be sparse)

no evidence of foreign material and special stains to rule out specific infection

Answer 14

orofacial granulomatosis

Question 15

orofacial granulomatosis

Pt’s require thorough medical eval

remove sources of inflammation, then _ works best

Px?

Answer 15

intralesional corticosteroids work best - multiple injections may be necessary

Px - good, primarily a cosmetic problem

Question 16

unknown etiology, necrotizing granulomatous process with vasculitis
uncommon but well recognized disease

Inflammation of vessels , usually response to inhaled Ag
Upper and lower airway - lungs, main thing is renal(kidney) involvment

Answer 16

Wegener’s Granulomatosis aka Granulomatosis with Polyangiitis

Question 17

generalized Wegener’s or Classic Wegener’s

what systems are affected

Answer 17

upper and lower resp tracts

renal-kidney

Question 18

limited Wegener’s which systems affected

Answer 18

upper and lower resp tracts

Without rapid renal - may overtime develop renal but currently no renal involvment

Question 19

Superficial Wegener’s

which systems affected

Answer 19

skin and mucosa

This is oral mucosa and skin - we will probably see this version

Question 20

Epistaxis - acute bleeding from nose, purulent discharge, pain, nasal obstruction

destruction of nasal septum

dry cough, hemoptysis, dyspnea, chest pain

proteinura, RBC casts

oral manifestations?

Answer 20

Wegener’s Granulomatosis

oral - large chronic ulcers, “strawberry gingivitis”, palatal ulcer with oral-antral fistula

Question 21

2 things that can cause saddle-nose deformity

Answer 21

syphilis and Wegener’s granulomatosis

Question 22

strawberry gingivitis is very specific for _

stays on hard tissue, starts at interdental papilla and spreads latterly

Answer 22

Wegener’s granulomatosis

aka Granulomatosis with Polyangiitis

Question 23

microscopic appearance

poorly formed granulomas, mixed inflammation

subepi hemorrhage

vasculitis - usually in gingiva - hard to pick up on biospy

Answer 23

Wegener’s aka Granulomatosis with Polyangiitis

Question 24

Wegener’s aka Granulomatosis with Polyangiitis

even if we think we know Dx, we usually stll do blood test bc _

Answer 24

auto-Ab’s directed against neutrophils have been ID’d in a high percentage of patients (ANCA)

PR3-ANCA (c-ANCA) most useful**

MPO-ANCA(p-ANCA) seen in other systemic vasculitides

Question 25

prior to _ 95% of Wegener’s aka Granulomatosis with Polyangiitis cases died within 5 years, now complete response(remission) is expected in 75% of patients; relapse rate of 30%

Answer 25

immunosuppressive therapy

Prednisone and cyclophophamide (steriod sparing) vs. methotrexate

limited and superficial forms may progress to classic WG

Question 26

vast numbers of meds are capable of producing oral mucosal alterations - sometimes acute, other times like 10 years to show up

what does the mucosal changes look like

Answer 26

ulceration and erosion with variable erythema and white striae

lichenoid appearnace - interlacing white keratioic lines

buccal, labial mucosa and ventrolateral tongue

Question 27

inflammatory alterations that recur at the same site after the administration of a medication

not always present, but recurrent at the same site/location

Answer 27

fixed drug eruption

Question 28

medication induced mucosal alterations which mimic appearance of lichen planus

Moves around a little more, not in exact same location
Lichen planus is usually bilaterally

Answer 28

lichenoid drug rxn (unilateral)

more of these rxns than fixed drug ruption

Question 29

how to Dx allergic rxn to systemic drug

tx - discontinue responsible med in conjunction with pt physician - replace with alternate drug

possible topical corticosteroids

Answer 29

biopsy non-specific

detailed med and clinical hx with complete list of Rx and OTC

if more than one med suspected, serial elimination, muscosal alterations resolve after discontinue med (recur on reintroduction)

within 1 month oral mucosa should return to normal

Question 30

list of agents reported to cause oral mucosal and perioral allergic contact rxns is diverse

foods, flavors, gum, candy, OHI products, cosmetics, gloves, rubber dam, metals, dentues, impression materials, etc.

Answer 30

allergic contact stomatitis

frequency of true allergic rxn appears to be rare

Question 31

mild/barely visible erythema to extensive erythema, edema, erosions, ulcerations, exfoliation

may be asymptomatic or burning, itching, stinging

Answer 31

allergic contact stomatitis

ID of temporal relationship btw contact with agent and oral changes

Need to confirm agent that pt was exposed to and oral change
Need to keep food dairy - chapstick or anything

Question 32

patch testing?

allergic contact stomatitis

Answer 32

Insert subepidermal needle with various agents
- Looking for response - usually red
Not perfect test for oral mucosa - because skin is different than oral mucosa

Question 33

allergic contact stomatitis

3 forms

Answer 33

dentrifice related sloughing - product of oral hygiene

oral mucosal cinnamon rxn

lichenoid amalgam rxn

Question 34

dentrifice-related sloughing (allergic contact stomatisis)
toothpaste can cause widespread desquatiom of the superficial epi (like chemical peel)

minimal/mild erythema

associated with _ and _

Answer 34

sodium lauryl sulfate ( foaming agent) and sodium pyrophosphate (plaque reduction)

Question 35

dentrific- related sloughing

allergic contact stomatisis
tx?

Answer 35

none - harmless process

switch to Fl toothpaste

Question 36

erythema with overlying shaggy hyperkeratosis

pain and burning

Answer 36

oral mucosal cinnamon rxn

toothpaste - diffuse gingiva

gum/candy- localized

resolution within one week following discontinuation of the cinnamon

Question 37

associated with old amalgam restorations undergoing corrosion and release of metallic ions

limited to mucosal surfaces directly in contact with the restoration (buccal mucosa, ventral and lateral tongue)

mimic linchen planus but are localized

white or erythematous +/- peripheral striae

Answer 37

lichenoid amalgam rxn allergic contact stomatisis

smooth, polish and recontour old amalgam

replace with composite or porcelain crown

Question 38

Angioedema - diffuse edematous swelling of soft tissue

_ mediated hypersensitivity rxn most common

contact rxn - foods, cosmetics, drugs, etc

physical stimuli - heat, cold, excersise, sun exposure

_ - cause excess bradykinin

_ deficificeny - inherited or acquired

Answer 38

IgE most common

angiotensin-converting enzyme (ACE) inhibitors - excess bradykinin

C1 esterase inhibitor (C1-INH) deficiency

Question 39

relatively rapid onset of soft tissue swelling

non-painful; pruritus and erythema may be seen

solitary or multiple sites

commonly affects head/neck region (face, lips, tongue, FOM, pharynx, larynx)

resolution in 24-72 hours - rapid onset and rapid resolution

Answer 39

angioedema

IgE hypersens rxn most common

Dx - clinical presentation with known trigger, evaluation for adequate fxnal C1-INH

Question 40

treatment for angioedema

Answer 40

oral anti-histamine, IM epinephrine, IV corticosteroids

ACE inhibitor- related and C1-INH deficiency non-responsive to standard tx

prevention