Intro to OM Flashcards
BISOM
The British & Irish Society of Oral Medicine
Mucosal disease
- white patches
- red patches
- brown patches
- ulcers
- blisters
- lumps and bumps
Salivary gland disease
- hyposalivation
- hypersalivation
- swellings
- lumps and bumps
Facial/ Unexplained oral pain
- trigeminal neuralgia
- neuropathic pain
- other non- dental pain
How to work out causes of ulcers?
- history
- system inquiry
- examination
Oral Ulcers causes
- traumatic
- drug induced (iatrogenic)
- metabolic/ nutritional
- neoplastic
- infective
- inflammatory
- immunological/ inflammatory
Mucosa Colour
- keratinisation
- vasculature
- inflammation
- melanin
- candida
- exogenous factors
- epithelial thickness
White patches
- abnormal/ increased keratin
- increased epithelial thickness
- candida
- keratotic tissue cannot be wiped away
Candida
Risk Factors for Oral Candida Infection
- immunocompromised - medication, medical condition
- dentures: OH
- smoking
- inhaler use
- thrush/ yeast/ fungal infection
Management for Oral Candidiasis
Anti-fungal therapy
- Fluconazole
- Miconazole
- Nystatin
Local Measures
- rinse after inhalers
- use a spacer
- denture hygiene
- smoking cessation
Chronic problem, hence will return if local factors not treated
Traumatic keratosis
- increased keratin at site of trauma
- encourage smoking cessation
- get a photograph
- if high risk, refer to secondary care
Oral Lichen Planus/ Oral Lichenoid reaction Classification
- reticular
- atrophic
- papular
- erosive
- plaque like
- bullous
OLP
- CD8+ T cell mediated destruction of basal keratinocytes
- chronic inflammatory condition
- may be autoimmune disease but with no auto- antigen detected
- may be asymptomatic/ present as burning and stinging sensation
- malignant potential 1% over 10 years
Causes of OLP/ OLR
- ask about systemic symptoms/ recent cancer therapy
LUPUS and Graft vs Host disease
Drugs causing OLR
- Antihypersentives
- Antimalarias
- NSAIDs (non-steroidal anti-inflammatory drugs)
- Allopurinol
- Lithium
DM causing OLR
- amalgam
- gold
- nickel
- composite resin
OLP/ OLR Management
Symptomatic relief
- simple mw (HSMW)
- local anesthetic topical (Benzydamine/ Lidocaine)
- avoid spicy food and drinks (trigger factors)
- Steroid mw (Betamethasone mw, Beclomethasone inhaler, hydrocortisone oromucosal tablets)
- replace restorations
- referral for biopsy, increased cancer risk, stop cause of OLR
2 viruses commonly associated with Hairy Leukoplakia?
- non- removable white patch
- most common on lateral borders of tongue
- acanthotic and para-keratinised tissue, finger-like projections of keratin
- EBV (Epstein Barr Virus- Human Herpes virus 4)
- immunocompromised
- 20-25% of patients with HIV as tx improved
- can be seen in non-HIV immunocompromised
Leukoplakia
- diagnosis of exclusion
- no obvious cause for white patch
- malignant potential
- dysplastic - abnormal cellular changes -> malignancy
- require biopsy for histological examination
Red patches
- atrophy (thinner tissues)
- inflammation
Red patch with no clear cause has a high likelyhood of being dysplastic/ malignant
Classification of OLP (RAPEPB)
- reticular
- atrophic
- papular
- erosive
- plaque- like
- bullous
Erythematous Candidiasis
Desquamative gingivitis
Granulomatosis with Polyangiitis (GPA)
- blood vessels become inflammed
- known as “Wegner’s granulomatosis”
- systemic vasculitis
- fever & weight loss
- 92% have ear, nose, throat manisfestations
- potentially fatal
- manage with immunosuppresants
Erythroplakia
- velvety, firey, red patch
- DOE
- most will have dysplasia/ malignancy
- very high malignancy transformation
- URGENT REFERRAL
Orofacial Granulomatosis/ Oral Crohn’s (OFG)
- non- necrotising granuloma formation
- consider Gi investigation
Management of OFG
- topical steroids
- avoidance certain diets
- intralesional steroid
Biologics for Crohn’s
- Infliximab
- Adalimumab (anti-TNF)
- Ustekinumab (human monoclonal antibody, Anti IL21/23)
- Vedolizumab (Anti-a4b7)
Erythroleukoplakia
- speckled white and red patches
Management of Erythroleukoplakia
HIGH RISK
- refer to secondary care urgently
- aetiology same as leukoplakia/ erythroplakia
Things to assess
- location
- colour
- homo/ heterogeneity
- induration (hard/ soft)
- raised/ flat
- texture
- is it wipeable
- symmetry
Take a photo of it
General Approach
- through MH and SH
- through exam
- identify cause
- reverse reversible (rubbing dentures/ teeth/ poor OH)
- photography
- if no clear cause/ pt has risk factors, refer
- red patches with no known cause (high suspicion)
What is an ulcer?
A breach in the mucosa
- localised defect, where a destruction of epithelium exposing underlying connective tissue
Causes of Oral Ulceration
- traumatic
- metabolic/ nutritional
- allergic/ hypersensitivity
- infective
- inflammatory
- immunological
- drug induced (iatrogenic)
- neoplastic
- idiopathic
Clues to the cause of ulcer?
- site
- onset
- duration
- number
- texture
- appearance
- size
- pain
- predisposing factors
- relieving factors
Traumatic ulcers
- white keratotic borders
- clear causative agent -> fractured cusp
- surrounding mucosa feels normal
- ulcer soft
- chemical burns, such as etch?
Aphthous ulcers
- most common ulcerative condition
- painful
- red border
- yellow/ white centre
- multiple triggers: stress, trauma, allergy, sensitivity
3 types
- Major: greater than 1cm, longer healing time
- Minor: less than 1cm, heals 2-3 weeks
- Herpetiform: multiple small ulcers that may coalesce
Types of Recurrent Aphthous Stomatitis
- Major: >1cm, longer healing time
- Minor: < 1cm, healing time 2-3 weeks
- Herpetiform: multiple small ulcers that may coalesce
Causes of RAS
- metabolic and nutritional
- children/ teenagers: associated with growth
- adults with occult GI/GU pathology
- malnourishment
- anemia
Blood test for Anaemia
- Full blood count
- Urea & electrolytes, FBC, Liver Function test
- FBC, Anti- nuclear Antibodies (ANA), Coeliac screen
- FBC, Vit. B12, Folate, Ferritin, CS
- FBC, Erythrocyte Sedimentation Rate, HIV screening
Inflammatory/ Immunological Ulcers
- Behcet’s- mouth, skin, genitals, eyes
- Necrotising sialometaplasia (picture)
- LP
- Vesiculobullous disease
CT disease
- Systemic Lupus Erythematous
- Rheumatoid Arthritis
- Scleroderma
Gastrointestinal pathology is associated with oral ulcers, what could you ask the patient to enquire into any GI symptoms?
Gut
- abdominal pain
- PR blood/ mucus
- altered bowel motion
- unintentional weight loss
CTD
- joint pain
- photosensitive rashes
- xeropthalmia/ xerostomia (oral dryness)
- fatigue
Infective ulcers
Primary Herpes Simplex Virus
- affect children between 2-5
- associated with fever
- headache, malaise, dysphagia, cervical lymphadenopathy
- short lasting vesicle on tongue, lips, buccal, palatal, gingival -> form ulceration
Varicella- Zoster virus
- primary VZV infection (chicken pox)
- virus remains in sensory ganglion
- reactivation of latent virus resulting in VCZ infection (shingles)
- reactivation due to immunicompromised/ acute infection
- liaise with GP to provide analgesia/ difflam if painful
Iatrogenic Ulcers
- chemotherapy
- radiotherapy
- GvHD
- Drug induced: K+ channel blockers, bisphosphonates, NSAIDs, DMARDs
Which of these features of an ulcer would make it higher risk for oral cancer?
- exophytic: grow outwards of mucosal surface
- rolled borders
- raised
- hard to touch
- non movable
- not always painful
- sensory disturbance
Oral Ulceration Local Management
- sus then refer urgently to OMFS
- reverse the reversible
- refer to GP for FBC/ coeliac/ Haematinics if aphthous appearance
- simple mw (HSMW)
- antiseptic MW (hydrogen peroxide/ CHX/ Doxycycline)
- Local anaesthetic (Benzydamine spray/ mw)
- Steroid mw (Betamethasone)
- Steroid inhaler (Beclomethasone)
- onward referral
Pain in OM
