Midterm Flashcards
- Leukoplakia
- An intraoral white plaque that does not rub off and can not be identified as any well known entity.
- If it can be rubbed off, it is not Leukoplakia
- If it is easily recognizable as a well known entity, it is not Leukoplakia.
What are the five white lesions that CAN be scraped off?
- Materia Alba
- White coated tongue
- Burn (thermal, chemical, cotton roll, etc.)
- Pseudomembranous candidiasis
- Toothpaste or mouthwash overdose
Does white coated tongue cause pain, and how do you treat it?
- Asymptomatic
* Treatment is tongue scraping or brushing
How do you treat leukoplakia?
When in doubt, cut it out.
What could leukoplakia look like on the histology slide?
- Hyperkeratosis
- Dysplasia
- Carcinoma-in-situ
- Invasive squamous cell carcinoma
Where are the three most common locations of leukoplakia?
- Floor of mouth
- Tongue
- Lip
What is the best guide to potential progression of oral lesions?
Degree of dysplasia
What is the percentage transformation rate of severe dysplasia?
16%
• Mean transformation time 4.3 years
• Histologic grade significantly affected rate
• Excision significantly decreased rate
- Tori
- Torus Palatinus: 20-35%, 2F:1M, C=B
* Torus Mandibularis: 7-10%, M>F, C=B, 90% bilateral
- Inflammation or Irritation
Traumatic Ulcer
Pericoronitis
Periodontal Abscess (Parulis)
A.N.U.G.
- Fibroma
- MOST COMMON BENIGN NEOPLASM OF THE ORAL CAVITY
- Buccal mucosa > labial mucosa > tongue > gingiva
- Surgical excision
- Fordyce Granules
- Ectopic sebaceous glands
- 80% of the population
- yellowish white papules
- buccal mucosa > lips
- no treatment
- Hemangioma
- Benign proliferation of blood vessels
- 10 - 12% of children
- Clinically blanches under pressure
- Inflammatory Ulcer (Recurrent Aphthous Ulcer)
- Affects 20-25% of the population
- Non-keratinized, non-bound down mucosa
- 1-2 lesions, .5-1 cm in diameter
How do you treat hemangiomas?
• Treatment – surgery, laser, embolization, Clinical Observation, Removal, Sclerotherapy
How do you treat recurrent aphthous ulcerations?
• Treatment – Topicial Steroids
What is the etiology of recurrent aphthous ulcers?
• ETIOLOGY: “Different things in different people”. Autoimmune THEORY, Hypersensitivity THEORY, Stress THEORY, etc THEORY.
What are the prescriptions for recurrent aphthous ulcers?
• PRESCRIPTIONS: Aphthasol, Betamethasone, Temovate, Decadron, Lidex, Kenalog, Medrol, Etc.
- Papilloma
• Benign proliferaJon of squamous epithelium (HPV ?)
• Tongue > Soft palate
• Solitary pedunculated
wart-like
How do you treat papillomas?
• Treatment - Surgical excision
What are the variations of papillomas?
- Verruca Vulgaris (wart),
- Condyloma Acuminatum (Venereal wart),
- Focal Epithelial Hyperplasia (Heck’s Disease),
- Sinonasal Papillomas
- Epulis Fissuratum
Focal inflammatory hyperplasia at the flange of an ill-fitting denture. Single or multiple folds of tissue in the vestibule.
How do you treat epulis fissuratum?
Surgical excision, reline or remaking the denture
- Varicosities
Pretty normal
- Fissured Tongue
- Numerous grooves or fissures on the dorsal tongue, 2-6 mm deep.
- Cause ??? Heredity?
- 2 - 5% of the population, increasing with age
- Mild burning or soreness sometimes
- Treatment - Brush the tongue
- Geographic Tongue
- “Erythema Areata Migrans”, “Benign Migratory Glossitis”
- 1 - 3% of the population, 2F>1M
- Dorsal tongue, rarely ventral
- Asymptomatic with rare cases of sensitivity to hot or spicy foods
- No treatment
- Papillary Hyperplasia
- Denture papillomatosis
- 20% of the patients who wear their dentures 24 hours a day
- Hard palate, pebbly surface
- Asymptomatic
How do you treat papillary hyperplasia?
• Treatment - surgical excision (scapel, electro-, cryo-, laser-surgery) then reline or remake of the denture
- Herpes Viral Infection
Recurrent Herpes Simplex
• Almost ALWAYS on keratinized, bound mucosa (palate, attached gingiva)
• Symptoms are less intense
• Lesions begin as 1-3 mm vesicles
– Rapidly collapse to form a cluster of erythematous macules that coalesce and slightly enlarged
– Damaged epithelium is lost – Central, yellowish area of ulceration – Heals in 7-10d
- Acute herpetic gingivostomatitis: Initial exposure between 6 months - 5 years of age
- Recurrent herpetic infections: herpes labialis, intraoral recurrent lesions, herpetic whitlow, herpetic keratoconjunctivitis
What are the antiviral medications for herpes?
- Acyclovir 5% ointment (Zovirax), 15 gm tube, apply 5 times a day with fingercot at first symptom
- Acyclovir 200mg. capsules, dispense 50, 1 cap 5 x daily
- Famciclovir (Famvir) 125 mg tablets, bid for 5 days.
- Penciclovir 1% (Denavir) Cream, 2 gm tube, apply q2h.
- Prodromal stages is best time to start treatment (Use VIROXYN)
- Prophylaxis: Lysine 500 mg tab. QD
- Mucocele
- Rupture & spillage of saliva into the soft tissues
- Young adults, trauma related
- Lower lip - most common location
- Treatment - Surgical excision along with the feeder gland
- Scar Tissue
- Post trauma locations
- Post surgical locations
- Treatment - none
- Angular Cheilitis
• Causes: Reduced vertical dimension, salivary pooling, candidiasis
How do you treat angular cheilitis?
• Treatment: antifungals, increase the vertical dimension
- Lingual Tonsil
- Lymphoid hyperplasia on the posterior lateral borders of the tongue, bilateral
- Discrete 1 cm masses which enlarge and turn red with infection
- Treatment: none
- Hematoma
- Accumulation of blood within the tissues secondary to trauma
- Treatment: none
- Tobacco Pouch Keratosis
• Soft, fissured gray-white lesion of the mucosa located in the area of chronic snuff placement
• Histologic appearance varies based upon duration
• Treatment: Cessation of “dipping”
If use continues, results may progress from Dysplasia to Verrucous Carcinoma (cauliflower)
- Chronic Cheek Biting
- Morsicatio buccarum, labiorum, linguarum
- 2F:1M
- Irregular ragged white mucosa
- Treatment: none or bite guard
- Lichen Planus
Oral lichen planus must be differentiated from lichenoid drug reactions, and there are dozens of drugs that can cause it.
• Chronic mucocutaneous disease
• Middle aged, 3F:2M
• Skin lesions: purple, pruritic, polygonal papules
• Oral lesions: Reticular (Striae of Wickham), Erosive
What are the two forms of lichen planus?
Reticular and Erosive
How do you treat lichen planus?
• Treatment: Steroids
• Aphthasol 5%, 5 gm tube, apply to ulcer
• Betamethasone (Celestone) Syrup, dispense 8
oz., 1 tsp qid, gargle & expectorate.
• Temovate .05% ointment, 15 tube
• Decadron Elixir 0.5mg/5ml, Rinse & expectorate.
• Lidex 0.05% ointment or gel
• Medrol Dose pack
- Buccal Exostoses
- Bony protuberances on the buccal of the mandible and/or maxilla
- Treatment: Removal only with chronic repeated trauma or preprosthetic surgery
- Amalgam Tattoo
- Implantation of dental amalgam into oral soft or hard tissue
- Black, blue or grey in soft tissue tattoos
- May be radiopaque
- Treatment: none, however biopsy may be necessary to rule out melanoma
- Oral Melanotic Macule
• Focal Melanosis (“oral freckle”) • Solitary well-demarcated tan to dark brown macule, 1-7 mm • 2F:1M • Lower lip > buccal mucosa > gingiva • Treatment: none, however biopsy may be indicated to rule out melanoma
- Median Rhomboid Glossitis
- Central papillary atrophy of the tongue
* Asymptomatic erythematous zone in the midline posterior dorsal tongue
How do you treat median rhomboid glossitis?
• Treatment: antifungals and brushing of the tongue
- Black Hairy Tongue
Condition is usually asymptomatic, but occasional patients complain of:
Gagging sensation, Bad taste, Halitosis, Esthetics
- Smooth Red Tongue
- Causes: Pernicious anemia, Medications, Avitaminosis
- Symptoms: burning and pain
- Treatment: find the underlying cause and stop it
- Epidermoid Cyst
- Skin cysts associated with inflammation of a hair follicle • Oral cysts occur in the midline of the floor of the mouth • Slow growing, painless, rubbery mass
- Treatment: Surgical removal
- Lipoma
- Benign tumor of fat
- Skin lesions: trunk and proximal portions of the extremities
- Oral lesions: buccal mucosa > tongue > floor of the mouth > lips
- Yellowish soft nodular mass
- Treatment: Surgical excision
What are the characteristics of white lesions?
Thickened epithelial covering - Hyperkeratosis, acanthosis, dysplasia, carcinoma Decreased vascularity - Anemia Increased collagen - Submucous fibrosis
When we are describing lesions, what five characteristics should we describe?
- Size
- Morphology
- Location
- Texture
- Color
- A fibroma is a 2 mm sessile nodule on buccal mucosa, smooth surfaced, and pink in color
What are the characteristics of red lesions?
Thinner epithelium
Increased vascularity
A dissolution of the collagen content of the subepithelial tissue
What is another name for Wright’s lesion?
Localized spongiotic gingival hyperplasia
If you blanch a lesion and blood goes away, then it is not a hematoma. True or False?
True
What are the characteristics of blue lesions?
Venous blood collection as opposed to the red of arterial blood collection
Tyndall effect
Medications
What are the characteristics of black lesions?
Melanin: a pigment produced by cells called melanocytes, acts as a sunscreen and protects the skin from ultraviolet light
Heavy metals: amalgam, iron, bismuth
What are the characteristics of brown lesions?
Melanin
Hemosiderin: a yellowish brown granular pigment formed by the breakdown of hemoglobin, found in phagocytes
What are the characteristics of yellow lesions?
Adipose tissue
Sebaceous material (skin oil) as noted in fordyce granules
Pus as it is a collection of necrotic material, PMNs, and lymphocytes
What is the order of the most common colors found abnormally in the oral cavity?
Most to Least:
- White
- Red
- Black
- Blue and Yellow (Tie)
What do you do if you see a white lesion in the mouth?
First thing you do is try and rub it off, if it does come off, then it is probably one of those five things. If it doesn’t, than could be leukoplakia. Remove obvious frictional causes, and biopsy after two weeks
If you see inflamed red gums, what is the initial clinical diagnosis, and how can you treat it?
Desquamative gingivitis. The differentials are mucous membrane pemphigoid, pemphigus, allergies, and rarely SLE.
- Biopsy for confirmation, and then you can use topical steroids.
If you notice lichen planus on a patient, how can you differentiate it from psoriasis?
Ask them if they have itchy skin lesions on rest of body. If they do, that’s not psoriasis.
What is Dr. Trump’s “go to” therapy for lichen planus?
Topical steroid application. He likes Clobetasol Propionate Gel (Temovate) 0.05%. 15 or 30 gram tube.
Have them dry the infected area, gently massage a thin amount two to three times a day.
When do you use pastes vs creams vs gels vs all over mouth vs just one area?
Pastes and creams are more for skin, gel more for mouth. Paste is an option for the mouth but cream is not.
If all over the mouth, use a rinse instead of a gel, or if it is on the soft palate.
What are the prescriptions Dr. Trump likes to give for lichen planus and recurrent aphthous ulcers?
Fluocinonide (Lidex)
- 0.05% gel
- 15 or 30 gram tube
- Dry the affected area and gently apply a thin amount 2-4 times daily, depending on how bad it is.
- Has moderate potency (not yet proven with FDA)
Clobetasol Proprionate (Temovate)
- 0.05% gel
- 15 or 30 gram tube
- Dry the affected area and gently apply a thin amount 2-3 times daily
- Has high potency
Dexamethasone Elixir (Decadron) (Is a Rinse)
- 0.5mg/5ml
- 12-16 oz (about 500 ml or .5 liters)
- Rinse with 1 tsp. for 2 minutes 2-4 times daily and expectorate
- Has moderate potency
- Tell them that it is a solution and you want 0.5mg/5mL
- Give them enough to give them a few months of comfort, but then they will get back in to get more.
-For a rinse, he does 3 refills, for Temovate he only does 1
What are the eight white plaques that do not rub off in the mouth, and how do you treat them?
- Leukoplakia - Biopsy
- Linea Alba - Nothing
- Leukoedema - Nothing
- Chronic Cheek Chewing - Bite Guard
- Nicotine Stomatitis - Discontinue
- Tobacco Pouch Keratosis - Discontinue
- Lichen Planus - Steroids
- Oral Hairy Leukoplakia - Treat AIDS
What are some of the prescriptions for recurrent aphthous ulcers (red and white lesions)?
Aphthasol
Dexamethasone
Temovate (Clobetasol Proprionate)
Lidex
What can you use on TUGSE when topicals don’t work?
Intra-lesional injections. Kenalog 10 (10 mg/ml) Kenalog 40 (40 mg/ml) - 1 ml for every 1 cm of tissue - 10 mg per cm of lesional tissue - 1 ml of Kenalog 10 or 0.25 ml of Kenalog 40
What are the various forms of candidiasis?
White pseudomembranous Erythematous - Central papillary atrophy of tongue (Median Rhomboid Glossitis - Angular Cheilitis - Denture Stomatitis
What are the four forms that antifungals come as?
- Rinse
- Troche
- Tablet
- Cream/ointment
What is the best treatment for angular cheilitis?
Mycolog II
- 0.1% Triamcinolone and Nystatin 100,000 units/gram ointment.
- in 15 gram tube,
- used sparingly to affected areas qid
(There is also just a nystatin ointment that is dispensed the same way)
How is nystatin oral suspension administered?
Nystatin (Mycostatin) oral suspension (100,000 units/ml)
- Dispense 180 ml
- Rinse with 1-2 tsp for 3-4 minutes qid and expectorate, unless affecting soft pharynx, then swallow
- Remember not to use the rinse with dry mouth or severe caries because this has sugar. Use Clotrimazole (Mycelex) troche in this case.
What is the name of the antifungal troche?
Clotrimazole (Mycelex) Troche 10 mg
- This is used when patients hate the rinse
- Dispense 50
- Dissolve one troche 5 times a day. Let it dissolve in mouth
Hematomas clinically blanch under pressure. True or False?
False, neither does petechiae. Hemangiomas will blanch under pressure though. And you treat them with surgery, laser, or observation.
Where is erythroplakia most commonly found?
Floor of mouth, tongue, and soft palate
- 90% are histologically severe dysplasia, Ca in situ, or squamous cell carcinoma
What is oral melanoacanthoma and how do you treat it?
Acquired pigmentation Reactive process due to trauma Seen almost always in blacks Most common in females in 20 to 30s Buccal mucosa Lesions increase rapidly in size Incisional biopsy to rule out melanoma
What are the typical red lesions?
- Erythematous candidiasis
- Angular cheilitis
- Lingual tonsil
- Hemangioma
- Hypersensitivity reaction
- Erythroplakia
What are the typical black lesions?
- Racial pigmentation
- Amalgam Tattoo
- Oral melanotic macule
- Intramucosal nevus
- Oral Melanoacanthoma
- Malignant Melanoma
What are the typical blue lesions?
- Blue nevus
- Varicosities
- Hemangioma
- Mucocele/Ranula
- Salivary duct cyst
- Mucoepidermoid carcinoma
What is a granular cell tumor?
Benign soft tissue neoplasm that shows a predilection for the oral cavity
Most common site is the tongue (up to 50%) – Dorsal surface
Asymptomatic, sessile nodule that is less than 2 cm
May be yellow or mucosal-colored
African American patients may experience multiple tumors
What are the typical yellow lesions?
- Fordyce granules
- Lymphoid hyperplasia (lingual tonsil)
- Gum boil (Parulis)
- Lipoma
- Granular Cell Tumor
What are the main medications that cause xerostomia?
Anti-depressants, beta blockers, sleeping aids
What does biotene and mouth kote help treat?
Xerostomia
What are tips for patients with xerostomia?
- Sip water throughout the day
- Suck on ice (do not chew)
- Discontinue alcohol, caffeine, soda
- Humidifier at night
- Lubricate lips (lanolin)
- Fluoride supplementation
What is the prescription for xerostomia?
PIlocarpine (Salagen)
- 5 mg tablets
- Dispense 90 tablets
- 5 mg three times a day for first month, and then titrating to maximum dose of 30 mg per day depending upon response and tolerance
- Approved for tx of dry mouth from radiation/chemotherapy. Sjogren’s Syndrome
- Medications with anticholinergic effects counteract
- Benadryl, some antidepressants - Biggest side effect is sweating
What can we use for dry lips?
- Chapstick
- Aquaphor
- Blistex complete
- Lanolin
What are the main prescriptions for herpetic infections?
Acyclovir (Zovirax)
- Caps and ointment
- 200 mg, dispense 50, 1 cap 5 times a day
- 5% ointment, dispense 15 gram tube, apply to affected area 5 times a day with fingercot
Famciclovir (Famvir)
- 125 mg tablets
- Dispense 10 tablets, take 1 tablet twice daily for five days
What can cause burning mouth?
- Lubrication
- Candidiasis treatment
- Nutritional treatment (B12, folate, iron, zinc)
- Diabetic control
- Eliminate triclosan/tarter control products
- Switch hypertensive medication if on ACE-inhibitor
- Clonazepan 0.5 mg tablet. Start with dissolving half a 0.5 mg tab twice daily and slowly increase to 1 mg twice a day
- Alpha Lipoic Acid
- Capsaicin
What is needed for a prescription of a controlled substance?
- Mustbedatedandsignedondayofissue
- Patient’sfullnameandaddress
- Practitioner’sfullnameandaddressandDEA#
- Drugname
- Strength
- Dosageform
- Quantityprescribed
- Directionsforuse
- Numberofrefills(ifany)
- Writteninink,indeliblepencil,ortypewritten
- Manually signed
Schedule II controlled substances
• Requirewrittenprescription
• Nofederaltimelimittofill
• Nospecificfederallimitstoquantities(somestatesand insurance carriers limit to 30-days)
• Refillsprohibited
• Multipleprescriptions(90days)permitted(conditions
exist)
• Facsimile(fax)prescriptionsokforpreparationonly (original must be presented for dispensing)
• Emergencyphoneprescriptiononlyforquantitytocover emergency period provided original prescription received within seven days
What are some examples of schedule II narcotics?
hydrocodone products like Vicodin & Norco oxycodone (OxyContin®, Percocet®), and fentanyl (Sublimaze®, Duragesic®).
Prescriptions for schedule lll, lV and V may be oral, written, or faxed, and refills are ok and can be done by call-in. True or False?
True
What is in the superscription of a classical prescription?
Superscription—patient’s name,address, date and Rx (recipe)
What is in the inscription of a classical prescription?
name of drug, dose form, and quan0ty
What is in the subscription of a classical prescription?
directions to pharmacist
What is in the transcription of a classical prescription?
directions to patient
What does a modern prescription look like?
Heading—name and address and phone # prescriber
–name and address of the patient
–date of prescription
Body—Rx symbol
–name, form (tablet) and dosage size or concentration of drug
–amount or quantity –directions to patient
–“Disp: 20 tabs”
–“Sig: 1 tab q4h prn pain”
Twice a day
bid
with
c
capsule
cap
before meals
ac
dispense
disp
gram
gm
grain
gr
drop
gtt
hour
h
at bedtime
hs
number
no
no refill, do not repeat
non rep
after
p
after meals
pc
by mouth
p.o.
as needed
prn
every
q
every day
qd
4 times a day
qid
without
s
write (label)
sig
immediately
stat
tablet
tab
3 times a day
tid
When is prednisone used and what is the prescription?
For autoimmune or vesicular bolus, pemphigoid, pemphigus, lichen planus after gel proved not to work. This is systemic.
Prednisone 10 mg tab
Disp: 40
Sig: 2 tabs bid x 7d, then 1 tab bid x 4d, then 1 tab daily til gone
What two things are used for sores in mouth, sore throat, or anything to just soothe the mouth?
Xylocaine Viscous 2%
Disp: 100ml
sig: Rinse with 1 tsp as needed and spit out
Magic Mouthwash
-Equal parts maalox, benadryl, and xylocaine viscous 2%. This will help soothe and numb the mouth.
What is the brand name of nystatin oral suspension?
Mycostatin
What is the brand name of Clotrimazone troche 10mg?
Mycelex
What is the brand name of Nystatin/triaincinolone acetonide ointment?
Mycolog II
What is the brand name for acyclovir caps 200mg?
Zovirax
What is the brand name for Fluocinonide gel?
Lidex
What is the brand name for Dexamethasone Elixir 0.5mg/5ml?
Decadron
What is the brand name for Clobetasol proprionate 0.05% gel?
Temovate
Prescription Form - How to treat lichen planus?
• Treatment: Steroids
• Aphthasol 5%, 5 gm tube, apply to ulcer
• Betamethasone (Celestone) Syrup, dispense 8
oz., 1 tsp qid, gargle & expectorate.
• Temovate .05% ointment, 15 or 30 gm tube
• Decadron Elixir 0.5mg/5ml, Rinse & expectorate.
• Lidex 0.05% ointment or gel
• Medrol Dose pack
- You can use Aphthasol 5%, 5 gm tube, apply to ulcer
- (High Potency Topical Corticosteroid) - Fluocinonide 0.05% (Lidex). Dispense 15 gm tube. Apply sparingly to affected areas qid.
- Dexamethasone Elixir 0.05mg/5ml (Decadron) - Dispense two 100 ml bottles. Rinse with 1 tsp for 3-4 min after meals and at bedtime and spit out
- (Highest Potency) - Clobetasol Propionate 0.05% Gel (Temovate). Suspense 15 g tube. Have them dry the infected area, gently massage a thin amount two to three times a day.
- And if gel is not working, use Prednisone (systemic) 10 mg tablets. Dispense 40 tablets. Sig: 2 tabs bid for 7 days, then 1 tab bid for 4 days, then 1 tab daily til gone.
