HEENT Week 2 Flashcards
General Findings: Breath Odor
- Halitosis - systemic or local disease (gingiva, smoking, diabetic ketoacidosis–sweet, liver failure—faintly sulfurous, renal failure—ammonia); alcohol on breath
- Fetor oris - originates in the mouth, can be associated with appendicitis (add’l sx)
What is a common cause of dryness of the mouth (xerostomia)?
anti-cholinergic medicines is a common cause
• mouth breathing, dehydration, diuretics, salivary disease, sialoliths
What are some common symptoms of Gingiva? What is the normal appearance?
• darkening/dark line: heavy metal poisoning?
• Painful swelling in gum: possible tooth abscess
(Normally smooth, firm and contoured around the teeth)
What are a couple general findings in the teeth?
- Bruxism (erosion): clenching and grinding teeth wears down dental crowns, loosens teeth
- Decay, Tooth loss
General findings of the palate (hard palate, soft palate and uvula)?
- Hard palate: Lesions, petechiae (broken capillary blood vessels) (seen in Strep infx, suction)
- Soft palate: should elevate symmetrically when patient phonates “ahh” (CN IX, X – glossopharyngeal and vagus)
- Uvula: check for inflammation, ulnar deviation (while palate rises assymetrically)
General findings of the tongue and floor of the mouth:
oral cancers under the tongue
tongue movements (CN XII nerve, hypoglossal)
enlarged tongue: dentures, inflammation, myxedema etc.
papillae: enlarged or atrophied
Recurrent Herpes Labialis (herpes simplex HSV)
- what is the most common cause?
- what is different about the 1st and recurring oubreaks?
- triggers?
- concerns?
“cold sore” “fever blister”
• HSV-1 most common, high incidence; very contagious
o 1st outbreak is usually most intense
• Recurrence often has a Prodrome (itching, burning, tingling) lasts approximately 12 to 36 hours, followed by eruption of clustered vesicles (raised bumps, fluid filled) along the vermilion border. Subsequent rupture, ulceratation, and crusting
• Reactivation triggers: UV light, trauma, fatigue, stress, menstruation
• Concern re auto-innoculation to eye, skin (other parts of body)
Carcinoma of the lips:
- etiologies
- most common type
Etiologies: tobacco, alcohol, sunlight, poor oral hygiene or poorly fitting dentures.
Often: Squamous cell cancer (SCC)
Squamous cell cancer (SCC): lips
- lesion
- location
- risk
- Dx
- Lesion: painless, sharply demarcated (borders), elevated, indurated border with ulcerated base may be verrucous (cauliflower) or plaque (raised, but flat) like, hard at border
- Location: Usually found on the mucocutaneous junction of the lips;
- Slow- growing, fails to heal, can bleed. High risk of metastasis → these specific characteristics need biopsy
- Diagnosis: biopsy
Mucocele
- description
- location
- etiology
- Signs & Sx
• Soft cyst, mucin-filled cavity with mucous glands lining the epithelium
• Common on lips, under tongue (called a “Ranula” from latin rana—frog’s belly)
Etiology: minor injury to ductal system of minor labial or sublingual salivary gland, by trauma
Signs & Sxs:
• Thick, mucus-type saliva produced by the damaged gland creates a clear or bluish bubble of various size (1-2cm), movable, cystic, may rupture. Bleeding may occur with further damage, lesion may then look red or purple
• History of enlargement, breaking, and shrinkage is fairly common. Can persist, rarely goes away on its own (dentist can surgically remove)
• Usually benign, but can affect Pt speech/chewing
Cheilitis
- description
- etiology
- Erythema and scaling of the lips “chapped lips”
- Etiology: Use of retinoids (isotretinoin, acitretin), wind-burn, allergies, chronic lip licking (saliva causing irritant dermatitis)
- May become secondarily infected
E. Angular cheilitis (aka Perlèche, Cheilosis, Angular Stomatitis)
- Signs & Sx
- Etiology
- Lab
Signs & Sxs:
• Local! Deep cracks at labial commisure, if severe can split or bleed, form shallow ulcers. May become infected by Candida albicans; Staph aureus Often bilateral
Etiology:
• Elderly: ill-fitting dentures, loss of teeth changing bite, sicca (dry mouth)
• Poor oral hygiene
• Nutritional deficiencies, esp. vitamin B (Riboflavin B2, Cyanocobalamin B12) and iron deficiency anemia (due to poor diet, malabsorption).
• Irritant or allergic reaction to oral hygiene or denture material
Lab: KOH prep to assess for Candida infx
• Dx: usually from observation, but KOH lab can confirm
Mouth
Lesions may occur anywhere on mouth structures; includes ulcerations, cysts, firm nodules (raised, bigger than papule), hemorrhagic lesions, papules (raised, firm), vesicles (fluid), bullae (bigger fluid), and erythematous lesions (solid/fluid filled, size, raised/flat).
• Vary in symptoms from asymptomatic to very painful.
• Typical etiologies: trauma, infection, systemic disease, drug use, or radiation therapy.
• Multiple causes/conditions. Need complete history, FHx, allergy history. PE: check whole body for lesions that may explain the oral ones. Direct smears, stains and cultures sometimes helpful.
*A solitary lesion that lasts >2 weeks should be biopsied for malignancy.
Oral Lichen planus:
- Non-erosive lesion: usu painless, vary from lace-like white patches/papules/streaks (Wickham striae) on buccal mucosa to erosions on gingival margin. If painful can interfere with eating. Not contagious.
- Etiology: unknown. Possible drug reaction, Hep C, worse with stress
- An erosive form can erupt into violet papules with white lines or spots, usually on the genitalia, lower back, ankles, and anterior lower legs; pruritus;
- If chronic, can increase risk for oral cancer.
Mucosal Lesions
Oral Lichen Planus
Leukoplakia
Leukoplakia
- age and gender
- etiology
- Signs & Sx
- PE
- Dx
White patches or plaque on the oral mucosa that cannot be rubbed off.
a. Precancerous hyperplasia of the squamous epithelium (thought to be early step in transformation of clonally independent cells) Up to 20% of lesions will progress to CA in 10yr
b. Also seen in inflammatory conditions not associated with malignancy
~ 90% of lesions in those > 40 yrs, M > F
Etiology: presumptive factors include:
• trauma from habitual biting, dentures, tobacco use (oral tobacco, esp)
• oral sepsis
• local irritation
• alcoholism
• syphilis
• vitamin deficiency
• endocrine disturbances
• dental galvanism
• AIDS
Signs & Sxs:
• Located on tongue, mandibular alveolar ridge and buccal mucosa in ~50%.
Also–palate, maxillary alveolar ridge, floor of mouth, retromolar regions
• Forms vary: nonpalpable (patch), faintly translucent white areas to thick, fissured, papillomatous (has a base and is out on a stock), indurated lesions.
• Surface is often shriveled in appearance and may feel rough on palpation.
o Can look like “flaking white paint”, may have red specks
• Color variants: white, gray, yellowish-white, brownish-gray (patients with heavy tobacco use.)
PE: lesion cannot be wiped away with gauze
• Check for cervical LA (lymph adenopathy), may indicate malignant changes
Diagnosis: Biopsy to obtain a definitive diagnosis, multiple samples if large lesions
DDX for Leukoplakia and
“Other” White Oral Lesions That Cannot Be Wiped Off with Gauze
DDX: Candidiasis and aspirin burn (can be wiped away with a gauze → potential pin point bleeding)
“Other” White Oral Lesions That Cannot Be Wiped Off with Gauze • traumatic or frictional keratosis • lichen planus • leukoedema • Systemic lupus erythematous SLE • galvanic keratosis • white sponge nevus • verrucous carcinoma • squamous cell carcinoma SCC
Erythroplakia
- description
- etiology
- why biopsy?
- risk factors
- Red macule (flat, colored lesion) or plaque (slightly raised) with well-demarcated edges with soft texture; Often on floor of mouth, tongue, palate
- Unknown etiology, but considered a type of epithelial dysplasia, thus pre-cancerous
- Cancer found in 40% of cases. Biopsy!
- Risk factors: smoking, alcohol
Oral Squamous Cell Carcinoma (SCC)
- most common location
- S&S
- DDX
- ~ 30,000 in US each year; 90% are smokers, alcohol is also a risk factor (we don’t know if
- Subset of SCC associated with HPV-16 infection
- Most on floor of mouth or on the lateral and ventral surfaces of tongue. Also lip, palate.
Signs & Sxs:
• May appear as area of erythroplakia (red) or leukoplakia (white);
• Exophytic (outward growth) or ulcerated (sunken in/erosion). Both variants are indurated with a rolled border.
• Early lesion may be asymptomatic, Ulcerated lesions are often painful
• May be difficulty in speaking/chewing if lesion is large
• Metastatic mass (non-tender) in the neck may be the first symptom. Firm, fixed mass.
***Biopsy any persistent papules, plaques, erosions or ulcers!
DDx – lipoma (fat-filled cyst),
Melanoma:
- what are the concerning factors
- DDx
Pigmented lesions with concerning signs:
• Asymmetry
• irregular borders
• variable coloration
• increasing diameter; lesion will not blanch
• (evolving)
*Often diagnosed at later stages
DDx: *Becomes more definitive upon biopsy (she doesn’t emphasize these DDxs on quizzes)
• Melanosis–symmetric lesions in individuals with dark skin
• Oral melanotic macules—symmetric, stable, sharply delimited dark macules on lips or oral mucosa
Fordyce’s Spots
- age and gender
- signs & sx
- DDx
Benign neoplasms from sebaceous glands (sebaceous choristomas)
•Most common 20 -30 years; M = F
Signs & Sxs:
•Asymptomatic, multiple, white to yellow, 1-2 mm papules, often occurring confluent cluster (central aggregation and thins out)
•Most common on the vermillion/buccal mucosal border. Also on the inner surface of the lips, the retromolar region, tongue, gingiva, frenulum linguae or palate
DDX: Candida albicans - candida lesions wipe off, but Fordyce’s granules do not wipe off
Description and etiology of STOMATITIS.
Inflammation of oral tissue from local or systemic conditions
Etiology:
•infection: strep, candida, Corynebacterium, syphilis, TB, measles, HIV, coxsackie virus, HSV, Varicella-zoster virus, fungus (Histoplasmosis, Mucor, Cryptococcus, Coccidiomycosis)
•deficiencies: vitamins B and C, iron
•leukemia
•mechanical trauma: poorly fitting dentures, improper nipples on bottles
•alcohol, tobacco, hot/spicy foods and drinks
•mouth breathing, cheek biting, irregular teeth, poor orthodontia
•chemicals eg, mercury poisoning (with marked salivation)
•allergy - intense shiny erythema with swelling, itching, dryness, burning
•drug hypersensitivity reaction
Oral Candidiasis (“Thrush” “moniliasis”)
- Description
- Risk Factors
- SSx
- Dx
Common oral fungal (yeast) infection by Candida albicans, C glabrata, C tropicalis
Risk factors: (common in individuals with other diagnoses) denture-wearers, diabetics, use of antibiotics, exposure to chemotherapy or radiation, HIV/AIDS, use of inhaled glucocorticoids (eg asthmatics); individual who has had a transplant and taking immunosuppressive drugs; common in infants
SSX: Lesion: slightly raised soft white plaques (look like milk curds) that are easily wiped away, causing bleeding
o May have burning sensation
o Mouth appears dry (xerostomia)
Dx confirmed with KOH prep
**Recurrent, persistent, extensive disease warrants immune status evaluation → not necessarily dangerous by itself, but may indicate a larger, deeper and undiscovered issue
Types of Stomatitis
Oral Candidiasis
Pseudomembranous stomatitis
Recurrent Aphthous Stomatitis: (aphthae=”canker sores”)
Herpetic Gingivostomatitis: HSV-1 infection “cold sore”
Oral Erythema Multiforme
Chancre
Pseudomembranous stomatitis
- etiliogy
- Sx
Inflammatory reaction that produces a membrane-like exudate
•Caused by chemical irritants or bacterial infections
•Fever, malaise, and LA may result or it may be localized to the mouth
Recurrent Aphthous Stomatitis: (aphthae=”canker sores”)
- etiology
- S & Sx
- DDx
Acute, painful, recurring, solitary or multiple necrotizing ulcerations of the oral mucosa. Possibly T-cell mediated localized destruction of oral mucosa
Etiology: Provocations (exact cause is unknown)
o Trauma is the most common trigger:
• Physical: toothbrush abrasions, laceration by sharp foods/objects, biting, dental braces
• Chemical irritants or thermal injury: (coffee, tea)
• Sodium lauryl sulfate: foaming agent in toothpaste
o Food allergies, citric acid, artificial sugars, gluten
o Deficiencies in vitamin B12, iron, and folic acid
o Stress, illness, fatigue
o Immunodeficiency (eg HIV)
o Neutropenia– history of taking antimetabolites (eg methotrexate) – fewer than normal WBCs
o Hormonal changes, menstruation
o Associated with celiac disease and inflammatory bowel disease (eg Crohn’s dz)
Signs & Sxs:
o Painful lesions, occasionally have prodromal burning or tingling
o Ulcers= shallow, round to oval with a grayish base, with a red border
o Occur on non-keratinized, moveable mucosa: buccal and labial mucosa, buccal and lingual sulci, ventral tongue, soft palate and floor of mouth.
o Some individuals have 2-4 outbreaks a year, while others can have continuous eruptions
** Different from herpes: no vesicles, no crusting, not a viral infxn
DDX:
o Secondary herpetic ulceration - history of vesicles preceding the ulcers, a location on periosteum-bound mucosa (gingival, hard palate) and crops of lesions.
o Trauma, pemphigus vulgaris and cicatricial pemphigoid.
o Systemic disorders: Crohn’s disease, neutropenia and (tropical) sprue.
Three forms of aphthous ulcers (same disease spectrum, different by size, duration, location)
*Not going to be emphasized
- Minor form – Most common/least severe form
Develop in childhood and adolescence, and then sporadically throughout life; Usually solitary, shallow, oval yellow-gray ulcer with raised yellowish border surrounded by an erythematous halo, <1 cm diameter; Lasts 7 to 10 days; heals without scars - Major form - multifocal, ragged edges, may be up to 2 cm in diameter, may last up to 6 weeks and may be immediately followed by a recurrent ulcer; Heals with scarring and cause severe pain and discomfort; Typically develop after puberty with frequent recurrences. Occur on moveable non-keratinizing oral surfaces, but the ulcer borders may extend onto keratinized surfaces
- Herpetiform ulcers - most severe form
Occurs more frequently in females, and onset is often in adulthood. Small, numerous, pinpoint lesions (1–3 mm) that form clusters, coalesce into ulcers. Typically heals in less than a month without scarring.
Herpetic Gingivostomatitis:
- Triggers
- S & Sx
- Lab
- DDx
HSV-1 infection “cold sore”; Painful eruptions of the unmovable oral mucosa and vermilion border; Primary infection of HSV-1, common in children
Triggers: trauma, emotional stress
Signs & Sxs:
o Often a prodrome of pain, burning, tingling; also fever, malaise, LA, painful eating
o Eruption of multiple interoral vesicular lesions and erosions, erythematous base, crusting
o Self limited in 1-2 wks in most cases
o Kids: fever, LA, drooling, decreased oral intake due to pain (watch for dehydration)
o Recurrence is common
Lab: Tzank smear, direct immunofluorescence smear, or viral culture
DDX: aphthous stomatitis, erythema multiforme, drug eruptions, pemphigus
Oral Erythema Multiforme:
- SSx
- DDx
Hypersensitivity reaction to HSV, other organisms (eg Mycoplasma pneumoniae), drugs or idiopathic with skin lesions and mucosal involvement
SSx: Painful stomatitis, sudden onset of diffuse hemorrhagic vesicles and bullae with erythematous base, on lips/mucosa
o Bullae rupture leaving raw, painful, friable (easily bleeds) surfaces, then form crusts
o May be Prodrome: sinusitis, rhinitis
o May see a high fever for 4-5 days, and severe systemic symptoms
o Other areas of body – maculopapular erythematous lesions (target lesions) form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia → shape of bulls eye
DDx: aphthous stomatitis, allergic stomatitis, pemphigus, herpes
Chancre
- SSX
- PE
- Lab
Lesion: painless ulceration formed during the primary stage of syphilis, ~21 days after the initial exposure to Treponema pallidum, these ulcers usually form on or around the lips, tongue, also anus, penis, and vagina. *Common to have lesions elsewhere when it forms in the mouth
SSX:
o Painless single ulcerated lesion, (firm) indurated border, no central necrotic tissue
o Tender cervical LA
o Chancres typically last 2 wks to 3 mos without treatment (but infxn can persist to tertiary/quaternary syphilis that damages the nervous system)
PE: be sure to look for genital lesions as well
Lab: PCR serology
Other causes of inflammation and irritation in the mouth
- Frictional hyperkeratosis
- Epulis Fissura (Denture hyperplasia)
- Denture sore spot
- Denture sore mouth (denture stomatitis)
- Irritation Fibroma
Frictional hyperkeratosis
caused by chronic friction against an oral mucosal surface, resulting in a hyperkeratotic white lesion (a protective response to low-grade, long-term trauma).
• Leads to white line called linea alba if caused by biting
• If cause is uncertain, the lesion should be considered idiopathic leukoplakia and be biopsied
Epulis Fissura (Denture hyperplasia) - SSx
Signs & Sxs:
• Painless folds of fibrous connective tissue, firm or spongy to palpation with the impression of denture edge (tissue reaction—maxillary mucosa—to chronically ill-fitting dentures)
• Usually not highly inflamed, but may be erythematous or even ulcerated in the base where the edge of the denture flange fits
**Ask Px with dentures to remove to ensure a good exam
Denture sore spot
small, painful ulcers, characterized by an overlying, grayish necrotic membrane and surrounded by an inflammatory halo. Usually heals quickly once denture removed
Denture sore mouth (denture stomatitis)
very common
• Mucosa beneath the denture becomes extremely red (sharply demarcated and localized) and swollen, with either a smooth or granular appearance.
• Severe burning sensation is common.
• May be caused by allergy to acrylic or by fungal infection
Irritation Fibroma
- SSx
- DDx
Most common benign oral soft tissue neoplasm; most often 20 - 49 years; M = F
Signs & Sxs:
o in buccal mucosa, lateral border of the tongue and the lower lip (area of trauma)
o Lesion: painless, sessile or occasionally pedunculated swelling that can be firm and resilient or soft and spongy in consistency; typically ≤ 1cm
o Color is slightly lighter than the surrounding mucosa from relative lack of vascular channels
o May become irritated or ulcerated
DDX: based mainly on the location
o Tongue - neurofibroma, neurilemmoma or granular cell tumor
o Lower lip or buccal mucosa - lipoma, mucocele or salivary gland tumor.
Oral Edema
- Angioedema
2. Hereditary angioedema
Angioedema: (Quincke’s edema)
- Etiology
- SSx
Acute edema (swelling) of the skin, mucosa (mouth, throat, tongue) and submucosal tissues,
• Rapid onset (over the period of minutes to several hours).
• Urticaria (itchy raised bumps) may develop if the angioedema is related to allergy.
• Hand swelling common
Etiology: contact with Ag that stimulates immune response
a. Allergic (most common,) not IgE mediated. Common allergens include:
- medications
- foods (such as berries, shellfish, fish, nuts, eggs, milk, wheat)
- pollen
- animal dander
- insect bites
- exposure to water, sunlight, cold or heat
- emotional stress
b. Infection or illness: autoimmune disorders, leukemia
Signs & Sxs:
o Painless, non-pruritic (if non-allergic), nonpitting, and well-circumscribed areas of edema from increased vascular permeability.
o May progress to complete airway obstruction and death caused by laryngeal edema.
o May be chronic when lasting more than 3 weeks
**Could very well be an emergency situation
Hereditary angioedema (hereditary angioneurotic edema) *not to be emphasized
Rare, autosomal-dominant inheritance, presenting as edema in the face, airway passages, hands and feet; 85% are deficiencies of C1 esterase inhibitor, see family history
Signs & Sxs:
• Edema is unifocal, indurated, painful rather than pruritic
• Usually no associated itch or urticaria (non-allergic)
• Precipitated by stress, infection, trauma, viral illness, though no cause may be apparent
• Patients can also have recurrent episodes (“attacks”) of abdominal pain, usually accompanied by intense vomiting, weakness, watery diarrhea, and flat, non-itchy splotchy/swirly rash.
Other Oral Findings
- Palatal or Mandibular Torus
- Hemangioma
- Varicosities
- Papilloma
- Lipoma
Palatal or Mandibular Torus
age/gender
Non-neoplastic (not cancerous), slowly growing nodular protuberance of bone. Of little clinical significance, except with interference with denture construction and placement. Likely hereditary.
• Incidence F > M (2:1). Peak incidence occurs shortly before age 30.
Hemangioma
Proliferation of blood vessels, often congenital. F>M : 2:1
Signs & Sxs:
- Lesions are flat or raised, with a deep red or bluish-red color
- Most common sites: lips, tongue, buccal mucosa and palate. Because of location, frequently traumatized and can undergo ulceration and secondary infection.
DDX: Arteriovenous fistula: more likely if history of trauma to the area of the lesion
Varicosities
- common location
- SSx
Dilated, tortuous veins in the oral cavity are attributed to increased hydrostatic pressure and poor support by surrounding tissues
Commonly located on ventral aspect of the tongue, but may also be found on upper and lower lips, buccal mucosa and buccal commissure
Signs & Sxs: Blue, blanch when compressed
Papilloma
- Etiology
- SSx
- Locations
- DDX
Etiology: Some oral papillomas are associated with the same human papillomavirus (HPV) subtype that causes cutaneous warts,
Signs & Sxs:
- Asymptomatic, well-circumscribed, usually pedunculated benign growths with numerous, small finger-like projections (papillary or verrucal)
- Generally < 1 cm in diameter, most often solitary (small)
Locations: any intraoral mucosal site and vermillion border of the lips, most common on soft palate or hard palate, uvula, tongue
DDX:
- Verruciform xanthomas - distinct predilection for the gingiva and alveolar ridge
- Warty dyskeratoma– tends to occur as multiple lesions
- Condylomata acuminata– usually larger and multifocal, with a broader base
Lipoma
Painless, benign, slow-growing mass of adipose tissue (on cheek, tongue)
- Yellow, non-tender, rubbery or soft, mobile (if on cheek)
- May affect speech if large
- May be hereditary component (familial multiple lipomatosis); may develop in area of trauma
- May be elsewhere on the body.
E. SALIVARY GLANDS
- Sialadenitis:
Painless benign swelling seen in many systemic diseases (eg hepatic cirrhosis, sarcoidosis,
neoplasms, infections (mumps)
Usually pain with mumps, malignancy and infection; others may be painless
*If swollen due to infection → pain- Sialolisthesis:
Salivary duct stones, most common in the submandibular glands
Pain and swelling associated with eating
- Sialolisthesis:
3. Sjögren’s syndrome:
Systemic inflammation (autoimmune) associated with dry eyes, mouth and mucus membranes
- Xerostomia: Dry Mouth
Many causes, often iatrogenic: drugs (diuretics, anticholinergics), Sjogren’s, salivary gland disorders , dehydration, mouth breathing. Contributes to tooth decay
Sialadenitis
Painless benign swelling seen in many systemic diseases (eg hepatic cirrhosis, sarcoidosis, neoplasms, infections (mumps)
- Usually pain with mumps, malignancy and infection; others may be painless
- If swollen due to infection → pain
Sialolisthesis:
Salivary duct stones, most common in the submandibular glands
Pain and swelling associated with eating
Sjögren’s syndrome:
Systemic inflammation (autoimmune) associated with dry eyes, mouth and mucus membranes
Xerostomia: Dry Mouth
Many causes, often iatrogenic: drugs (diuretics, anticholinergics), Sjogren’s, salivary gland disorders , dehydration, mouth breathing. Contributes to tooth decay
Gingivitis
- etiology
- SSx
- Prevention
Inflammation of the gums with redness, swelling, changes in contours, pocket formation behind the gums → places for bacteria to harbor; puffiness
- May see watery exudate and bleeding
- Common in puberty and during pregnancy
Etiology: poor oral hygiene (most common), malocclusion, dental calculi, food impaction, faulty dental restorations, mouth breathing
- Note: drugs phenytoin (Dilantin) and nifedipine can cause gingival hypertrophy
Signs & Sxs:
• Swollen, bright-red or purple gums, may be shiny
• Receding gum line “long in the tooth”
• Usually painless, except when pressure is applied
• Bleed easily, even with gentle brushing
• May be first sign of systemic dz: DM, poor nutrition, leucopenia, endocrine d/o
Prevention: regular oral hygiene - daily brushing and flossing. sesame oil pulling, oral probiotics, CoQ10
Vincent’s angina: (Trench Mouth; Acute Necrotizing Ulcerative Gingivitis ANUG)
- Etiology
- SSx
- Acute infection of the gingiva
- Other terms used: acute membranous gingivitis, fusospirillary gingivitis, fusospirillosis, fusospirochetal gingivitis, necrotizing gingivitis, phagedenic gingivitis, ulcerative gingivitis, Vincent stomatitis, Vincent gingivitis, and Vincent infection.
Etiology:
• Fusiform bacteria and spirochetes, neglectful oral hygiene; severe stress, malnutrition
• More common with alcohol and tobacco use, HIV
Signs & Sxs:
• Progressive painful infection with ulceration, swelling and sloughing off of dead tissue
• Ulcerated lesions of the interdental papillae; can affect all gum tissue, bad odor, “punched out” looking lesions with a gray membrane; bleed easily
Periodontitis
- Etiology
- Risks
- SSx
Infection of the periodontium causing inflammation of the periodontal ligament, gingival, cementum and alveolar bone
Etiology: progressive gingivitis (plaque below gingival margins) leads to deep pockets that harbor anaerobic organisms, leading to bone loss
Risks: poor hygiene (most common) Diabetes type II, leukemia, Crohn’s disease
SSx: pain can be absent unless acute infection
• Pain with chewing, Food impaction in pockets
• Tooth may be tender to percussion (tap with tongue blade)
• Visible plaque. Red, swollen gums with exudate, gums bleed easily
Caries
- Etiology
- SSx
- Prevention
Tooth decay, enamel erosion
Etiology:
• Bacteria in plaque (eg Mutans streptococci) release acids that erode enamel
• Methamphetamine users have rapid tooth decay from xerostomia, bruxism, poor hygiene and nutrition. “meth mouth”
SSx: early, no symptoms. As cavity invades dentin: pain with hot, cold, sweet food or beverages
Prevention: regular brushing and flossing, cleanings, fluoride??? *Folic Acid, CoQ10 swishing or oil pulling
Toothache and infection
Some causes of toothache: • Caries • Periodontitis • Eruption of wisdom tooth • Teething • Sinusitis *Serious concomitant symptoms: Headache, fever, swelling or tenderness in floor of mouth, cranial nerve abnormalities.
Apical Abscess
- a cause of toothache and infxn
development of infection deep into root
More severe pain; May visualize swelling of mucosa over involved tooth
***URGENT DENTAL REFERRAL and Rx for antibiotics
Ludwig’s Angina
- a cause of toothache and infxn
Cellulitis of mouth floor, from dental infection (80%), lingual frenulum piercing. Staph or Strep infection spreads from sublingual to submaxillary space.
SSX: Swelling, malaise, fever, dysphagia (difficulty swallowing), possibly stridor (whistling while breathing in → narrowed airway).
*EMERGENCY → concern is deepening into brain
Cavernous sinus thrombosis
- a cause of toothache and infxn
Staph or strep infection in the cavernous sinus leads to development of blood clot. → goes to brain
SSX: headache, vision changes, exophthalmos (eyes bulge forward), paralysis of cranial nerves.
*EMERGENCY → hospitalization
Tooth loss (edentulism)
Kids: normal loss of deciduous teeth
Adults: mouth trauma, tooth injury, tooth decay, gum disease, Meth use
General Signs and Symptoms:
- Difficulty Moving The Tongue
- Deviation Of Tongue:
- Taste Abnormalities
- Color Changes
- Hairy Tongue
- Pain In The Tongue
- Tongue Tremor
- Furrows
- Dry Tongue
- Smooth appearance (atrophic glossitis): atrophy of the filiform papillae
- Enlarged Tongue
Difficulty Moving The Tongue
- Most often caused by nerve damage (hypoglossal cranial nerve), nerve root disorder, cancer
- May also be caused by ankyloglossia (short frenulum)
- May result in speech difficulties or difficulty moving food during chewing and swallowing
- With tongue deviation, the tongue “points to the side with the problem” when asked to stick their tongue out.
Deviation Of Tongue:
Hypoglossal paralysis CN XII (deviates to the paralyzed side)
Taste Abnormalities
• Damage to the taste buds, side effects of medications (albuterol, chemo), infection,
o Bell’s palsy, B3 or Zn deficiency, MS, damage to Facial N or Glossopharyngeal N, smoking
• Ageusia=loss of taste; dysgeusia=abnormal taste
Color Changes
• May occur with glossitis - papillae are lost, causing the tongue to appear smooth
• Geographic tongue: benign migratory glossitis
o Localized area of loss of filiform papillae, erythematous patches with circumferential white or yellow polycyclic borders
• Consider: candidiasis, psoriasis, Reiter’s (reactive arthritis), lichen planus, leukoplakia, SLE, HSV, drug rxn
• White or yellow - local irritation; smoking and alcohol use
• Red (ranging from pink to magenta) tongue:
o folic acid and vitamin B-12 deficiency
o pellagra
o pernicious anemia
o Plummer-Vinson syndrome
o celiac disease
o “strawberry tongue” of scarlet fever
• Dark- normal pigmentation of dark-skinned individual
o Hyperpigmentation from:Drugs (tetracycline, linezolid, bismuth subsalicylate, PPIs antidepressants), Addison’s disease
Hairy Tongue (lingua villosa nigra) - Possible Causes
black or brown; Distal dorsal third looks hairy (black or green) due to hyperplasia of filiform papillae; Benign condition, painless, pt may experience “gagging” sensation
Possible causes:
o AIDS
o drugs (antibiotics, prednisone, estrogen)
o drinking coffee, alcohol
o dyes in drugs and food
o tobacco use
o poor oral hygiene
o Overuse of mouthwashes containing oxidizing or astringent agents.
o Candida or Aspergillis infection after antibiotic
Pain In The Tongue
Possible causes:
- injury, such as biting the tongue, can cause painful sores.
- heavy smoking.
- diabetic neuropathy, oral cancer, mouth ulcers, leukoplakia.
- after menopause, some women have a sudden feeling that their tongue has been burned; called “burning tongue syndrome” or idiopathic glossopyrosis.
- anemia
- oral herpes (ulcers)
- neuralgia
- dentures that irritate the tongue
- referred pain from teeth and gum
- referred pain from the heart
- burning pain - DM, depression, anxiety, glossitis, heavy metal poisoning, early pellagra
Tongue Tremor:
• hyperthyroidism (fine tremor) nervousness (coarse tremor)
• alcoholism
• paresis
• Neurological disease: lower motor neuron dz; brain stem lesion, hypoglossal neuropathy,
o damage from organophosphates (insecticides)
Furrows:
deep transverse (aka scrotal tongue) is congenital; long dry furrows
• Deep in mid-line, can become irritated with entrapped food debris
• Consider: dehydration; syphilis
Dry Tongue
without furrows consider Sjogren’s syndrome, with furrows think dehydration
Smooth appearance (atrophic glossitis): atrophy of the filiform papillae
• Small smooth, glossy, tongue; may be red and painful
• Intermittent burning, paresthesias of taste, sensitivity when eating acidic or salty foods
• Causes:
o low HCl
o deficiencies: B12, folic acid, iron, protein
o post gastrectomy
o cirrhosis
o Sjogren’s syndrome
o Celiac disease
o Oral Candidiasis
Enlarged Tongue
- causes
Causes o acromegaly o amyloidosis o allergic reaction to food/ Rx o angioedema o cancer of the tongue o Down syndrome o hypothyroidism o infection o leukemia o lymphangioma o neurofibromatosis o pellagra o pernicious anemia o strep infection
Glossitis:
Acute or chronic inflammation that can be primary or secondary
Etiology:
- bacterial or viral infections (including oral herpes simplex).
- poor hydration and low saliva
- mechanical irritation or injury from burns, rough edges of teeth or dental appliances.
- exposure to irritants: tobacco, alcohol, hot foods, or spices
- allergic reaction to toothpaste, mouthwash, breath fresheners, dyes in candy, plastic in
- dentures or retainers, or certain blood-pressure medications (ACE inhibitors).
- Deficiencies: B12, other B vits, iron
- oral lichen planus, erythema multiforme, aphthous ulcer, pemphigus vulgaris, syphilis
Signs & Sxs:
- tongue swelling; smooth appearance to the tongue (if atrophic)
- tongue color changes (usually dark “beefy” red)
o pale: pernicious anemia
o fiery red: deficiency of B vitamins
- sore and tender tongue
- difficulty with chewing, swallowing, or speaking
- Acute Pharyngitis:
Etiology:
a. Inflammatory
o viral infections (~90% of cases)
o bacterial infections (strep, staph, H. flu, STD)
o aphthous ulcers
o herpes
o fungus (oral thrush – babies)
b. Traumatic
o foreign bodies
o irritant fluids
o overheated food and drink
o mouth breathing, low humidity
o industrial fumes
o gastric reflux
c. Neoplasm
d. Glossopharyngeal neuralgia, elongated styloid processAdenovirus
most common type of acute pharyngitis
throat often does not appear red, although may be very painful; first a runny nose (thin discharge), stuffiness, nose and throat discomfort; within 24-48 hours sore throat develops, lymph node enlargement is modest
Infectious mononucleosis (EBV or CMV)
a type of acute pharyngitis
exudative tonsillitis with marked redness and swelling of the throat. “kissing tonsils”; significant lymph gland swelling
Other symptoms include splenomegaly, persistent fatigue, weight loss; possibly hepatitis.
Lab: CBC shows lymphocytosis and atypical lymphocytes, monospot
Other common causes:
c. Herpes simplex virus can cause multiple mouth ulcers d. Measles (paramyxovirus of genus Morbilliviris) e. Common cold (rhinovirus up to 80%); mild form, nasal sx, cough. 7 day course typical * Often a reason for overRx of antibiotics
Bacterial pharyngitis
a. Group A streptococcus
b. Non-group Streptococcus (group C or group G
c. Diphtheria
a. Group A streptococcus – (GAS)
- SSx
- Clinical Probability Point System
- Complications
- Dx
most common bacterial agent for bact. pharyngitis
generalized symptoms; typically enlarged and tender lymph glands, with bright red inflamed and swollen throat, often unilateral, progresses more rapidly than viral infections; May have (systemic) a high temperature, headache, myalgia, arthralgia
Clinical probability using Modified Centor Criteria for GAS pharyngitis. One point each:
1. Absence of cough
2. Tender anterior cervical adenopathy
3. Tonsillar exudate
4. History of fever: Age 44 subtract one point
Scoring:
< 10% (no need for antibiotic therapy)
2-3 points: risk of strep 15% if score is 2, 32% if score is 3 (ab if throat culture is positive)
>3 points: risk of strep is 53% (treat empirically with antibiotics)
Negative predictive value if all PE findings absent is 80%. Positive predictive value if all PE finding present is only 40-60%. The Centor Criteria is more useful to rule Strep pharyngitis OUT (if no findings are present)
Complications (potential, but rare)
1. Non-suppurative: rheumatic fever, toxic shock, glomerulonephritis, PANDAS (pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (presents with episodes of OCD)). All very rare but serious 2. Suppurative (developing, infective processes): tonsillopharyngeal cellulitis (bacterial infxn inside the skin), peritonsillar and retropharyngeal abscess, sinusitis, meningitis, brain abscess, otitis media, strep bacteremia. All are infrequent but compelling reasons for antibiotic therapy
Dx: Throat culture (24-48 hrs) And/or: Rapid Streptococcal Antigen Test RSAT or “rapid strep”
- With proper technique: sensitivity 70-90%, specificity 90+ %
+ Positive test is useful to diagnose GAS
- Negative test does not rule out GAS nor identify non-group A Strep
Non-group Streptococcus
(group C or group G)—not associated with rheumatic fever
Diphtheria
Potentially life threatening URI caused by Corynebacterium diphtheriae toxin still endemic to Africa, SE Asia, S Amer, Middle East, some of Eastern Europe.
SSx: in 30% of cases–characteristic dirty gray, tough fibrous membrane in tonsillar area (pseudomembrane), may cause dyspnea or stridor. Membrane will bleed with scraping.
• mild sore throat, dysphagia, low grade fever, nausea, vomiting
• complications: myocarditis or nervous system toxicity
Diagnosis by gram stain and culture. Reportable to health dept. if diagnosed.
3 main types of Tonsillitis
Acute inflammation of the palatine tonsils
3 main types:
a. Acute (within 3 weeks-ish) - either be bacterial or viral in origin
b. Subacute – (between 3 wks-3 mos) often caused by the bacterium Actinomyces
c. Chronic (generally, > 3 mos.)- can last for long periods, almost always bacterial (tonsils fibrotic)
Tonsilitis:
- Etiology
- SSx
- DDx
- Complications
Etiology:
a. Bacterial - may be caused by Group A strep GAS
b. Viral - may be caused by numerous viruses (Epstein-Barr, Adenovirus)
SSX: sudden onset, high fever, malaise, vomiting common
enlarged hyperemic tonsils with purulent exudate
may see membrane on tonsils
fetid breath
DDX: diphtheria, pharyngitis
Complications:
a. peritonsillar abscess (quinsy) See below
b. tonsilloliths: whitish-yellow deposits produced by bacteria feeding on mucus which accumulates in crypts. These “tonsil stones” emit pungent odor from volatile sulphur compounds
c. hypertrophy of the tonsils - can result in snoring, mouth breathing, and obstructive sleep apnea
Peritonsillar abscess: (quinsy) PTA
- Etiology
- SSx
Serious! abscess between tonsil and pharyngeal constrictor ms, typically several days after the onset of tonsillitis, a type of cellulitis (common: strep, staph or H. flu)
Etiology:
• usually a complication of an untreated or partially treated acute tonsillitis as the infection spreads to the peritonsillar area
• affects children and adults, rare in small children (infants)
Signs & Sxs:
• Early: worsening unilateral sore throat and pain during swallowing (dysphagia)
o persistent pain in the peritonsillar area, fever, malaise, headache and change in voice (hot potato voice) may appear
• neck pain with tender, swollen lymph nodes, referred ear pain and breath odor.
• redness and edema in the tonsillar area of the affected side and the uvula may be displaced towards the unaffected side
• Fever can be >103°F
• May be limited ability to open the mouth (trismus)
*Refer to hospital
Parapharyngeal abscess
Serious!
suppuration of the parapharyngeal lymph nodes. abscess is lateral to the superior constrictor muscle and close to the carotid sheath; markedly swollen anterior triangle in the neck (externally visualized!)
• throat itself may appear normal
• can occur at any age
Retropharyngeal abscess
medical emergency!
infection in one of the deep spaces of the neck; usually occurs in small children or infants (adults too) as complication of suppurative retropharyngeal lymph nodes. Infection spread from the nose, ears, sinuses or tonsils
***immediate life-threatening emergency, with potential for airway compromise (blocking airway) and other catastrophic complications
Signs & Sxs:
• sore throat, dysphagia, pain on swallowing (odynophagia), jaw stiffness (trismus), or neck stiffness (torticollis)
• muffled voice, the sensation of a lump in the throat
• constitutional complaints: fever, chills, malaise, decreased appetite, and irritability
• difficulty breathing is an ominous complaint that signifies impending airway obstruction.
Recurrent/Chronic Infections of the Pharynx
chronically inflamed tonsils often because of incomplete resolution of previous infections.
• scarring, fibrosis occurs
• treatment varies according to age as tonsils are more important <age 12 (immune fx)
• cobblestoning
Chronic irritation of the pharynx
Etiology: o chronic sinusitis o allergies o dental problems o chronically infected tonsils o chronic bronchitis o mouth breathing o septal deviation o vocal abuse o tobacco, alcohol use o hot or spicy foods o low humidity o industrial fumes o may be a complication of nephritis, cirrhosis, cardiac disease, AIDS, gastric reflux, o hiatal hernia, overweight and pregnancy
Signs & Sxs:
- thickened pharyngeal mucosa “cobblestoning”, hypertrophic lymph tissue
- check for chronic infection of the nose and gums, for mouth breathing
- barium swallow may be needed to rule out malignancy
Velopharyngeal insufficiency
incomplete closure of the sphincter between the oro- and nasopharynx, resulting in impaired deglutition and speech
• nasal speech and weakness of the voice
• requires surgery if there is significant regurgitation of food
Malignancies in the pharynx (usually SCC)
- SSX
- DDx
sometimes a mass in the neck is a first sign
- pain accompanied by an abnormal sensation of sticking in throat
- early stages, the tumor appears as a red smooth mass, sometimes with surface keratinization
DDX: erythroplakia
General Findings in the Larynx
Hoarseness
Laryngitis
Epiglottitis
Hoarseness
- Causes: recent onset, chronic, local, neurological, general, systemic, emotional
structural changes in the vocal cords that impair their ability to vibrate
Causes:
• if recent onset: URI, polyps of the vocal cords; rule out sinus and respiratory disease
• if chronic: in children usually due to vocal abuse, or allergies; in adults: alcohol and tobacco are common causes
• local causes: inflammation, polyps, hypothyroidism, fibrous nodes, leukoplakia, papilloma, CA
• neurological causes: nerve impairment in the cords, myasthenia gravis, Parkinson’s, recurrent
o nerve paralysis
• general causes: weak expiratory airflow due to tracheal compression, or general weakness
• systemic causes: aortic aneurysm, TB, syphilis, hypothyroidism
• emotional causes (lump in throat sensation with Homeopathy: Ignatia)
Laryngitis:
- etiology
- SSx
hoarse voice or the complete loss of the voice because of irritation to the vocal cords
Etiology:
• Infection (bacterial, viral, or fungal)
• inflammation due to overuse of the vocal cords
• excessive coughing
Signs & Sxs:
• voice change, hoarseness and aphonia, tickling sensation in the throat, need to clear throat
• symptoms vary; may be severe with pain and dysphagia, dyspnea
• can accompany other URI, allergies
o acute or chronic, depending on duration
Epiglottitis
- Etiology
- SSX
- Diagnosis
- DDx
medical emergency!
Etiology:
bacterial infection of the epiglottis, most often caused by Haemophilus influenzae type B; also Streptococcus pneumoniae or Streptococcus pyogenes.
Signs & Sxs:
• fever, difficulty swallowing, drooling (signifies significant issue with swallowing), and stridor.
• appears acutely ill, anxious, very quiet shallow breathing with the head held forward, must sit up in bed.
• early symptoms are insidious but rapidly progressive, and swelling of the throat may lead to cyanosis and asphyxiation.
• typically affects children 2-5 years (not as common –HiB vaccine?)
Diagnosis:
- DO NOT try to visualize throat! REFER
- lateral C-spine X-ray: “thumbprint sign” suggests the diagnosis of epiglottitis.
- confirmed by direct inspection using laryngoscopy, although this may provoke airway spasm.
DDX: croup, peritonsillar abscess, and retropharyngeal abscess. Anything that has difficulty swallowing and strider
Vocal cord polyp or nodule
- Etiology
- SSx
- Dx
benign, often bilateral lesion
Etiology: vocal abuse (singers), allergies, inhalation of irritants
Signs & Sxs:
- hoarseness and a breathy voice quality
- visualize with indirect laryngoscopy
Dx by visualization and biopsy
Vocal cord contact ulcers
- Etiology
- SSx
unilateral or bilateral ulcers on the mucus membrane over the the arytenoids cartilage
cause: gastric reflux most common
SSX: mild pain on speaking and swallowing, hoarseness prolonged ulceration leads to granulomas formation
Laryngeal (vocal cord) Squamous cell cancer: SCC
- predisposition
- SSx
most common type of cancer in the head and neck (90% of all head and neck cancers)
- alcohol and tobacco predispose; more common in males
- SSX: hoarseness, pain on swallowing or chewing
Lumps in the neck
- Hx
- Etiology
- Types
Hx: patient’s age, general state of health, presence of pain and associated symptoms
Etiology:
- Adults: most are due to inflammatory or neoplastic conditions of the cervical lymph nodes
- Kids: usually due to recurrent tonsillitis
- Tuberculosis, brachial cysts.
Types:
- Cervical LA
- Neoplasm of the lymphatic chain
- Salivary gland swelling
- Medial neck swellings
Cervical LA
suspected with acute inflammation of the tonsils, pharynx. Tender, rubbery
Neoplasm of the lymphatic chain
NT cervical LA, hard, immobile, large; also from metastases from other areas; confirm with biopsy
Salivary gland swelling
may be inflammatory (mumps, bacteria) or the result of a stone in duct
Medial neck swellings
from thyroid condition or spread of infection from other areas
