Mouth Throat Flashcards
Why is oral health the key to overall health?
o Digestion (enzymes, mastication), healthy flora, non-specific immunity o Poor hygiene and flora can lead to GI, cardiovascular, respiratory, immune problems
What info do you get in a mouth hx?
• o HPI: review LNOPQRST o Screenings: Date of last dental exam o Diet: sugar consumption, soda, etc o Dental and mouth hygiene habits o History of smoking, alcohol, drug use o Ever any x-rays of head/neck?
How do you do PE for mouth and oral mucosa?
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o Vitals: some conditions may have accompanying systemic signs/symptoms
o Have the patient remove dentures, if any.
o Inspection, palpation, palpate TMJ
How do you do an oral inspection?
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o Inspect lips and angle of mouth for color and moisture, lesions
o Use a tongue blade and penlight
o Teeth (number, condition, fillings, erosion of enamel)
o Gums (color, swelling, tenderness)
o Buccal mucosa (color, lesions)
o Roof of mouth (color, architecture of hard palate, lesions)
o Tongue (sides and undersurface also), note size, color, surface, moisture, lesions
o Pharynx: depress tongue while patient phonates (“Ahh”)
• How do you do palpation in T/M PE?
o Wear gloves for oral palpation
o Cervical lymph nodes for enlargement, tenderness
o Tumors/masses; enlarged salivary ducts or glands
o Tongue masses or lesions
o Linea alba: white line in buccal mucosa at biting plane
• How do you palpate TMJ in oral PE?
o Look for deviation of the jaw when opening/closing;
o Palpate over joint while opening/closing jaw for symmetry, crepitus
Have pt insert three fingers vertically for normal ROM
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What are some general finding in oral PE?
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o 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)
o Dryness of the mouth (xerostomia)- mouth breathing, dehydration, diuretics, salivary disease, sialoliths
o Gingiva: (Normally smooth, firm and contoured around the teeth); dark line: heavy metal poisoning? Painful swelling in gum: possible tooth abscess
o Teeth: Bruxism: clenching and grinding teeth wears down dental crowns, loosens teeth; Decay; Tooth loss
o Palate: Hard palate: petechiae (broken capillary blood vessels) (seen in Strep infx, suction); Soft palate: should elevate symmetrically when patient phonates “ahh” (CN IX, X); Uvula: check for inflammation, deviation
o Tongue and floor of the mouth: oral cancers under the tongue; tongue movements (CN XII, hypoglossal); enlarged tongue: dentures, inflammation, myxedema etc; papillae: enlarged or atrophied
What are some labs done after oral PE (as indicated)?
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CBC, chem. screen; rapid strep; mono spot, throat culture, B12 levels, biopsy
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What imagins is done on the mouth (As indicated)?
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X-rays of teeth; MRI or CT to evaluate masses
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• What referral (appropriate) may me done after oral PE?
o Dentist, ENT, Laryngologist, Neurologist
• What are 5 conditions of the lips?
o Recurrent herpes labialis; carcinoma of the lips; mucocele; cheilitis; Angular cheilitis (aka perlèche, cheilosis, angular stomatitis)
• What is recurrent herpes labialis?
o herpes simplex HSV; “cold sore” “fever blister”; HSV-1 moHt common, high incidence; contagious
o Prodrome (itching, burning, tingling) lasts approximately 12 to 36 hours, followed by eruption of clustered vesicles along the vermilion border. Subsequent rupture, ulceratation, and crusting
o Reactivation triggers: UV light, trauma, fatigue, stress, menstruation
o Concern re auto-innoculation to eye, skin
What is carcinoma of the lips? Common type? Diagnosis?
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o Etiologies: tobacco, alcohol, sunlight, poor oral hygiene or poorly fitting dentures.
o Often Squamous cell cancer (SCC): Lesion: painless, sharply demarcated, elevated, indurated border with ulcerated base may be verrucous or plaque like; Usually found on the mucocutaneous junction of the lips; Slow- growing, fails to heal, can bleed. High risk of metastasis
o Diagnosis: biopsy
• What is mucocele? Etiology?
o 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)
o Etiology: minor injury to ductal system of minor labial or sublingual salivary gland, by trauma
• What are ssx of mucocele? Tx/prognosis?
o 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
o History of enlargement, breaking, and shrinkage is fairly common. Can persist, rarely goes away on its own (dentist can surgically remove)
• What is cheilitis?
o Erythema and scaling of the lips “chapped lips”
o Etiology: Use of retinoids (isotretinoin, acitretin), wind-burn, allergies, chronic lip licking (saliva causing irritant dermatitis)
o May become secondarily infected
• What are ssx of angular cheilitis? Labs done?
o Deep cracks at labial commisure, if severe can split or bleed, form shallow ulcers. May become infected by Candida albicans; Staph aureus Often bilateral
o Lab: KOH prep to assess for Candida infx
What is etiology of angular cheilitis?
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o Elderly: ill-fitting dentures, loss of teeth changing bite, sicca (dry mouth)
o Poor oral hygiene
o Nutritional deficiencies, esp. vitamin B (Riboflavin B2, Cyanocobalamin B12) and iron deficiency anemia (due to poor diet, malabsorption).
o Irritant or allergic reaction to oral hygiene or denture material
• What other syndrome is angular cheilitis associated with?
o May also be part of a group of symptoms in Plummer-Vinson syndrome (upper esophageal web, iron deficiency anemia, glossitis, and cheilosis)
• What are the 4 classifications of conditions of the mouth?
o Mmucosal lesions
o Stomatitis
o Oral edema
o Other oral findings
• What types of lesions are seen in the mouth?
o may occur anywhere on mouth structures; includes ulcerations, cysts, firm nodules, hemorrhagic lesions, papules, vesicles, bullae, and erythematous lesions.
Vary in symptoms from asymptomatic to very painful.
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• What are typical etiologies of mouth lesions?
o trauma, infection, systemic disease, drug use, or radiation therapy.
o Multiple causes/conditions.
• How do you handle mouth lesions in the office?
o Need complete history, FHx, allergy history.
o PE: check whole body for lesions that may explain the oral ones.
o Direct smears, stains and cultures sometimes helpful.
o A solitary lesion that lasts >2 weeks should be biopsied for malignancy
• What are the different types mucosal lesions of the mouth?
o Oral lichen planus o Leukoplakia o Erythroplakia o Oral squamous cell carcinoma (SCC) o Melanoma Fordyce’s spots
• What is oral lichen planus? Etiology?
o 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.
o Etiology: unknown. Possible drug reaction, Hep C, worse with stress
• What can happen with oral lichen planus?
o 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;
o If chronic, can increase risk for oral cancer.
• What is leukoplakis? 2 Types?
o White patches or plaque on the oral mucosa that cannot be rubbed off.
o 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
o Also seen in inflammatory conditions not associated with malignancy; ~ 90% of lesions in those > 40 yrs, M > F
• What is etiology of leukoplakia (presumptive factors)
o trauma from habitual biting, dentures tobacco use (oral tobacco, esp)
o oral sepsis; local irritation; alcoholism; syphilis; vitamin deficiency; endocrine disturbances; dental galvanism; AIDS
• what are ssx of oral leukoplakia?
o Located on tongue, mandibular alveolar ridge and buccal mucosa in ~50%; Also–palate, maxillary alveolar ridge, floor of mouth, retromolar regions
o Forms vary: nonpalpable, faintly translucent white areas to thick, fissured, papillomatous, indurated lesions.
o Surface is often shriveled in appearance and may feel rough on palpation.
o Can look like “flaking white paint”, may have red specks
o Color variants: white, gray, yellowish-white, brownish-gray (patients with heavy tobacco use.)
• What is found on PE of oral leukoplakia? Diagnosis?
o PE: lesion cannot be wiped away with gauze; Check for cervical LA, may indicate malignant changes
o Diagnosis: Biopsy to obtain a definitive diagnosis, multiple samples if large lesions
• What is ddx for oral leukoplakia?
o Candidiasis and aspirin burn (can be wiped away with a gauze)
o “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
What is erythroplakia? Etiology? Dx? Risk factors?
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o Red macule or plaque with well-demarcated edges with soft texture; Often on floor of mouth, tongue, palate
o Unknown etiology, but considered a type of epithelial dysplasia, thus pre-cancerous
o Cancer found in 40% of cases. Biopsy!
o Risk factors: smoking, alcohol
• What is epidemiology of oral SCC? Risk factors? Location?
o ~ 30,000 in US each year; 90% are smokers, alcohol is also a risk factor.
o Subset of SCC associated with HPV-16 infection
o Most on floor of mouth or on the lateral and ventral surfaces of tongue. Also lip, palate
• What are ssx of SCC?
o May appear as area of erythroplakia or leukoplakia;
o Exophytic or ulcerated: Both variants are indurated with a rolled border.
o Early lesion may be asymptomatic; Ulcerated lesions are often painful
o May be difficulty in speaking if lesion is large
o Metastatic mass (non-tender) in the neck may be the first symptom.
• What should you biopsy that may be SCC?
o any persistent papules, plaques, erosions or ulcers!
What is oral melanoma?
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o Pigmented lesions with concerning signs: asymmetry, irregular borders, variable coloration, increasing diameter; lesion will not blanch
o Often diagnosed at later stages
• What is ddx for oral melanoma?
o Melanosis–symmetric lesions in individuals with dark skin
o Oral melanotic macules—symmetric, stable, sharply delimited dark macules on lips or oral mucosa
• What are Fordyce’s spots?Epidemiology? Ddx?
o Benign neoplasms from sebaceous glands (sebaceous choristomas)
o Most common 20 -30 years; M = F
o DDX: Candida albicans - candida lesions wipe off, but Fordyce’s granules do not
• What are ssx of fordyce’s spots?
o Asymptomatic, multiple, white to yellow, 1-2 mm papules, often occurring confluent cluster
o 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
• What is stomatitis?
o Inflammation of oral tissue from local or systemic conditions
• What is etiology of stomatitis?
o infection: strep, candida, Corynebacterium, syphilis, TB, measles, HIV, coxsackie virus, HSV, Varicella-zoster virus, fungus (Histoplasmosis, Mucor, Cryptococcus, Coccidiomycosis)
o deficiencies: vitamins B and C, iron
o leukemia
o mechanical trauma: poorly fitting dentures, improper nipples on bottles
o alcohol, tobacco, hot/spicy foods and drinks
o mouth breathing, cheek biting, irregular teeth, poor orthodontia
o chemicals eg, mercury poisoning (with marked salivation)
o allergy - intense shiny erythema with swelling, itching, dryness, burning
o drug hypersensitivity reaction
• what are the different types of stomatitis?
o Oral candidiasis? o Pseudomembranous stomatitis o Recurrent aphthous tomatitis o Herpetic gingivostomatitis o Oral erythema multiforme o Chancre o Other causes
• What is oral candidiasis? Risk factors?
o “Thrush” “moniliasis”; Common oral fungal (yeast) infection by Candida albicans, C glabrata, C tropicalis
o Risk factors: denture-wearers, diabetics, use of antibiotics, exposure to chemotherapy or radiation, HIV/AIDS, use of inhaled glucocorticoids (eg asthmatics); common in infants
• What are ssx of oral candidiasis? Dx?
o SSX: Lesion: slightly raised soft white plaques (look like milk curds) that are easily wiped away, causing bleeding; May have burning sensation; Mouth appears dry (xerostomia
o Dx confirmed with KOH prep
o **Recurrent, persistent, extensive disease warrants immune status evaluation
• What is pseudomembranous stomatitis? Etiology? Sx?
o Inflammatory reaction that produces a membrane-like exudate
o Caused by chemical irritants or bacterial infections
o Fever, malaise, and LA may result or it may be localized to the mouth
• What is recurrent aphthous stomatitis?
o aphthae=”canker sores”
o Acute, painful, recurring, solitary or multiple necrotizing ulcerations of the oral mucosa.
o Possibly T-cell mediated localized destruction of oral mucosa
• What is etiology of recurrent aphthous stomatitis?
o 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), Foaming agent in toothpaste (Sodium lauryl sulfate)
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)
o Hormonal changes, menstruation
o Associated with celiac disease and inflammatory bowel disease (eg Crohn’s dz)
What are ssx of recurrent aphthous stomatitis?
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o Painful lesions, occasionally have prodromal burning or tingling
o Ulcers are 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
• What are the 3 forms of aphthous ulcers? Difference?
o same disease spectrum, different by size, duration, location
o minor form, major form, herpetiform ulcers
• what are minor form aphthous ulcers?
o Most common/least severe form
o Develop in childhood and adolescence, and then sporadically throughout life
o Usually solitary, shallow, oval yellow-gray ulcer with raised yellowish border surrounded by an erythematous halo, <1 cm diameter
o Lasts 7 to 10 days; heals without scars
• What is the major form of aphthoush ulcers?
o 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
o Heals with scarring and cause severe pain and discomfort
o Typically develop after puberty with frequent recurrences.
o Occur on moveable non-keratinizing oral surfaces, but the ulcer borders may extend onto keratinized surfaces
• What are herpetiform ulcers (aphthous)?
o most severe form; Occurs more frequently in females, and onset is often in adulthood.
o Small, numerous, pinpoint lesions (1–3 mm) that form clusters, coalesce into ulcers
o Typically heals in less than a month without scarring
• What is ddx of recurrent apthous ulcers?
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 sprue.
• What is herpetic gingivostomatitis? Triggers?
o HSV-1 infection “cold sore”; Painful eruptions of the unmovable oral mucosa and vermilion border; Primary infection of HSV-1, common in children
o Triggers: trauma, emotional stress
• What are ssx of herpetic gingivostomatitis?
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
• What labs are done for herpeticgingivostomatitits? Ddx?
o Lab: Tzank smear, direct immunofluorescence smear, or viral culture
o DDX: aphthous stomatitis, erythema multiforme, drug eruptions, pemphigus
• What is oral erythema multiforme? Ddx?
o Hypersensitivity reaction to HSV, other organisms (eg Mycoplasma pneumoniae), drugs, or idiopathic with skin lesions and mucosal involvement
o DDX: aphthous stomatitis, allergic stomatitis, pemphigus, herpes
• What are the ssx of oral erythema multiforme?
o Painful stomatitis, sudden onset of diffuse hemorrhagic vesicles and bullae with erythematous base, on lips/mucosa
o Bullae rupture leaving raw, painful, friable surfaces, then form crusts
o May be Prodrome: sinusitis, rhinitis; 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
• What is chancre?
o 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.
• What are ssx of chancre? PE? Labs?
o SSX Painless single ulcerated lesion, indurated border, no central necrotic tissue; Tender cervical LA; typically last 2 wks to 3 mos without treatment
o PE: be sure to look for genital lesions as well
o Lab: PCR serology
