Gastroenterology - Diseases of the mouth and salivary glands

Question 1

Describe how herpes simplex virus affects the mouth?

Answer 1

HSV-1 infection often involves the mouth. Most often, it causes clusters of small vesicles on the lips (herpes labialis), but it may also cause widespread gingivostomatitis. Blisters tend to rupture and transform into ulcers, which form a crust and heal spontaneously.
Treatment is usually with oral acyclovir, valacyclovir etc

Question 2

Why does herpes labialis reccur?

Answer 2

Following the initial HSV-1 infection, the virus migrates along the facial nerves into the trigeminal ganglion, where it may remain in a dormant form indefinitely. Various other infections and even stressful conditions may activate the virus in the trigeminal ganglion. Activated viruses migrate along the nerves into the labial mucosa or skin, and thus herpetic vesicles reappear. Most often, reactivation of HSV-1 occurs after the common cold, which is why the herpetic vesicles are often called cold sores or fever blisters.

Question 3

Define herpangina?

Answer 3

Herpangina is an acute vesicoulcerative mucosal infection caused by Coxsackie A virus. It tends to occur in epidemics and affects small children. It begins in the form of vesiculopapular red lesions on the tonsils, soft palate, and uvula. These lesions are painful and ulcerate but heal spontaneously over a period of 2 to 5 days.

Cocksakie virus also causes hand foot and mouth disease in children.

Question 4

What are the oral features of diphtheria?

Answer 4

Diphtheria is caused by Corynebacterium diphtheriae. The toxin from this bacteria produces a “shaggy” grey pseudomembrane in the posterior pharynx and upper airways. Treatment is with erythromycin.

Question 5

What are the clinical features of peritonsilar abscess?

Answer 5

This collection of pus is usually caused by streptococcus pyogenes. The uvula deviates to the contralateral side, there is “hot potato voice” and foul smelling breath. It is usually a complication of tonsilitis. Treatment involves surgical drainage and antibiotics.

Question 6

What is Ludwig angina?

Answer 6

Cellulitis involving the submaxillary and sublingual space. Follows fascial planes and may spread into pharynx, carotid sheath, superior mediastinum.
Causes: dental extraction (most common), trauma to floor of mouth Treatment: surgical drainage; clindamycin + metronidazole. Involves anaerobic species.

Question 7

Define strep throat.

Answer 7

Exudative pharyngitis and tonsillitis caused by Streptococcus pyogenes are colloquially called strep throat. Infection with group A b-hemolytic S. pyogenes accounts for less than one third of all conditions suspected clinically to be strep throat. The most common causes of exudative pharyngitis are viruses, which account for more than 50% of all such infections.

Question 8

Describe the features of strep throat.

Answer 8

Infection with S. pyogenes is accompanied by fever, swelling of the neck, and pain on swallowing. The pharynx appears beefy red and moist, and a fibrinous grayish-yellow exudate appears on the tonsils. The cervical and submaxillary lymph nodes may become enlarged and painful. Definitive diagnosis depends on demonstrating streptococci in throat swab cultures. Antibodies to streptolysin O appear in the blood of 80% of reconvalescents after 2 weeks or later. It is important to follow the rise of the titer of these antibodies because they may be high from a previous infection.

Question 9

What causes Scarlett fever?

Answer 9

S.pyogenes.
It is characterised by tonsilitis, pharyngitis and glossitis.
The erythrogenic toxin produces rash on skin and tongue (strawberry tongue). There is an increased risk of glomerulonephritis. Nephritogenic strains pose no threat for rheumatic fever. Treat with penicillin.

Question 10

What is thrush?

Answer 10

Thrush is the common name for oral infection caused by Candida albicans. It presents in the form of white pseudo-membranes covering the mucosal surface of the tongue, buccal mucosa, or anywhere else in the oropharynx. These mucosal plaques can be easily scraped away, revealing an inflamed oral mucosa.

Question 11

Who develops oral candidiasis?

Answer 11

C. albicans is a common fungal saprophyte, found in approximately 40% of all healthy adults. Overgrowth of fungi is encountered in people suffering from diabetes, debilitating diseases, and immunodeficiency states and in cancer patients treated with cytotoxic drugs. Oral candidiasis is also encountered in some bottle-fed infants and older children treated with broad-spectrum antibiotics.

Question 12

List the oral manifestations of HIV

Answer 12

Gingivitis (in the form of gingival erythema or necrotizing ulcerative periodontitis; a common early sign of AIDS)
Candidiasis
Persistent aphthous stomatitis
Hairy leukoplakia (Epstein–Barr virus [EBV] related glossitis, typically located on the lateral sides of the tongue but sometimes occurring in the form of white plaques. May occur anywhere in the mouth.)
Kaposi sarcoma (Herpes virus 8–related vascular tumor. Red patches appear most often on
the hard palate.)

Question 13

Which skin or systemic conditions may present with oral manifestations?

Answer 13

Important vesiculobullous and ulcerating diseases include the following:
1) Bullous pemphigoid (bullae with linear deposits of immunoglobulin G (IgG) along the basal
membrane between the epithelium and the connective tissue)
2) Pemphigus vulgaris (bullae with deposits of IgG along the cell membrane of epithelial cells)
3) Erythema multiforme (complex hypersensitivity reaction to infectious agents and drugs
presenting with bullae and ‘‘multiforme’’ lesions)
4)Stevens–Johnson syndrome (severe erythema multiforme, often lethal)
5) Lichen planus (T-cell-mediated hypersensitivity) - associated with Wickham striae on buccal mucosa (fine, white lacy lesions)
6) Behcets syndrome - small vessel vasculitis

Question 14

Who gets Behcets?

Answer 14

Behcets is a combination of environment and genetic factors - HLA-B27 and B51 associations. It may be precipitated by herpes simplex virus or parvovirus.

Clinically, it presents with recurrent attacks of apthous ulcers, genital ulcerations, uveitis, and erythema nodosum lasting 1 to 4 weeks.

Question 15

List the oral manifestations of deficiency states.

Answer 15

Vitamin B2 - angular cheilitis
Vitamin B12 - glossitis (“burning of the tongue”)
Vitamin C - bleeding from the gums
Iron - atrophic glossitis (Plummer-Vinson syndrome)

Question 16

What causes macroglossia?

Answer 16

Macroglossia is an enlarged tongue. Causes include:
Myxedema
Downs syndrome
Acromegaly
Amyloidosis 
MEN IIb

Question 17

List some causes of glossitis

Answer 17

Iron deficiency
Vitamin B12 deficiency
Folic acid deficiency
Vitamin C defiency
Niacin (Pellagra)
Scarlett fever 
Hairy leukoplakia (EBV associated)

Question 18

What is sialadenitis?

Answer 18

Sialadenitis is inflammation of the salivary glands. The parotid gland, the largest of all salivary glands, is most often affected. The inflammation can be acute or chronic. The salivary gland is typically enlarged and sensitive to palpation. Inflammation may affect the production of saliva and result in sialorrhea (excess of saliva) or xerostomia (dry mouth due to the cessation of salivation).

Question 19

What are the main causes of parotitis?

Answer 19

Inflammation can be caused by viruses, bacteria, or immunologic mechanisms:
1) Viral parotitis: The best-known cause of infectious parotitis in children is the mumps
virus. Other viruses that can cause parotitis are parainfluenza and influenza virus,
cytomegalovirus, EBV, and human immunodeficiency virus.
2) Suppurative parotitis: Ascending bacterial infection through the parotid duct occurs in
elderly people who have dry mouth from debilitating diseases, poor oral hygiene, drugs (anticholinergic drugs stop salivation), and following general anesthesia. The most common cause is Staphylococcus aureus.
3) Autoimmune parotitis: Salivary and lacrimal glands are involved in Sjo ̈gren syndrome. This autoimmune disease may occur in a primary form involving only the salivary and lacrimal glands or in a secondary form, in the course of another autoimmune disease such as systemic lupus erythematosus.

Question 20

What is Mikulicz syndrome?

Answer 20

The term Mikulicz syndrome is used in clinics to describe chronic painful swelling of salivary and lacrimal glands. It may be a manifestation of Sjo ̈gren syndrome or another autoimmune disease, sarcoidosis, or tuberculosis. Biopsy must be performed to determine the exact cause of chronic salivary and lacrimal gland swelling and to exclude an underlying lymphoma or tumor.

Question 21

What is the difference between leukoplakia and erythroplakia?

Answer 21

Leukoplakia means “white patch”.
Erythroplakia is a red patch.

These lesions initially show squamous hyperplasia of the epidermis which may progress to squamous dysplasia or squamous cell carcinoma. Leukoplakia has a 30% risk of progression, erythroplakia has a 60% risk of progression.

They are caused by chronic mechanical irritation, all forms of tobacco use, alcohol abuse, and HPV. Always biopsy these lesions because of the risk of progression to oral cancer.

Question 22

What is the most common benign tumour of the oral cavity?

Answer 22

Squamous papilloma.

May occur on the tongue, gingiva, palate or lips

Question 23

What are the risk factors for developing malignant oral cancer?

Answer 23

Most oral tumours are well differentiated SCCs. More common in men than women.

Risk factors:

1) HPV most common risk factor
2) Cigarettes
3) Alcohol abuse (synergistic with smoking)
4) Chronic irritation from dentures
5) Lichen planus

Most common location is the anterior two thirds of the tongue. Metastases is normally to tonsillar, cervical and submandibular lymph nodes.

Question 24

Which salivary gland is the most commonly affected by cancer?

Answer 24

Parotid gland is the most common site.
Major salivary gland tumours are more likely to be benign, minor salivary gland tumours are more likely to be malignant.

Pleomorphic adenoma (mixed tumour) is the most common benign tumour, is female dominant and presents as a painless, palpable mass at the angle of the jaw. Tumour projections through the capsule increase risk of recurrence. It can transform into a malignant tumour and involvement of the facial nerve is a sign of malignancy.