One doc oral med Flashcards
Give 5 signs and symptoms of TMD (5 marks)
Headaches, Ear pain, Muscle pain, Joint pain, Trismus, Clicking or popping noises, Crepitus
Give 5 aspects of causative advise for TMD (5 marks)
- Soft diet
- Stop parafunctional habits e.g. nail biting,
- Support mouth upon opening e.g. yawning,
- Relaxation e.g. physiotherapy,
- Don’t incise foods,
- Chew bilaterally,
- Cut food into small pieces,
- No wide opening,
- No chewing gum
Dawn is a final year university student and is a regular attender at your practice. She presents in the Easter holidays complaining of difficulty opening her mouth widely, facial pain and jaw clicking when chewing food. You suspect she has temporomandibular joint dysfunction syndrome.
What information could be elicited from your clinical examination in relation to your suspected diagnosis? (5)
Range of movement, TMJ clicking/crepitus, MoM hypertrophy, Tenderness on palpation
Intra-oral - intercisial opening distance (measure), Signs of bruxism, Wear facets, Scalloped tongue, Linea alba
What factors could predispose to temporomandibular dysfunction? (2)
- Female>Males,
- 18-30yrs,
- Stress,
- Habits - chewing gum
Having conducted your examination, you confirm the diagnosis of temporomandibular dysfunction. What would your first line of management be? (5)
- Counselling,
- Reassurance,
- Soft diet,
- Mastication on both sides,
- Avoid wide mouth opening,
- Stop habits: avoid chewing gum,
- Cut food in small pieces
- Splint therapy - Hard splints: michigan (bite raising appliance)
- Joint therapy - Acupuncture,
- Physiotherapy,
- Relaxation therapy
- Medication - Ibuprofen, Paracetamol, Muscle relaxants - tricyclic antidepressants
Are there any other conditions that might present with similar signs/symptoms and how might you exclude these? (2
- Myofascial pain syndrome: no clicky,
- Pericoronitis of L8: no clicky
You decide to construct a stabilisation splint. As your technician is unsure what this is, describe how you would like your splint made. (6)
- Cover all teeth,
- Hard acrylic,
- full occlusal coverage,
- Upper and lower alginates,
- face bow registration required,
- Requires to be ground in both in the lab and clinically to achieve maximum bilateral intercuspation,
- Wear facets,
- Sloping canine guide plane
A 48-year-old male patient presents for the first time in your practise. He is otherwise fit and healthy and takes no medications. He also wears a complete upper denture which is 9 years old.
What is noticeable about the patient’s palatal tissue? (2)
What diagnosis would you make? (1)
imagine pic..
Erythematous, Papillary hyperplasia
Denture induced stomatitis
What would be your first line of treatment for denture induced stomatitis? (2)
- Denture hygiene advice including cleaning,
- Tissue conditioner on the fitting surface of the denture
If this condition (denture induced stomatitis) persisted, what would be the next line of treatment you would pursue? (1)
Appropriate antifungal treatment (fluconazole)
You decide to make a new denture. What instructions would you give to the lab technician regarding the construction of the upper special tray for the new master impression? (1)
Please construct an upper special tray with a 2mm wax spacer, intra-oral handles, non-perforated, intra-oral finger rests in light cure PMMA
(3mm???)
This is a photograph of a slide prepared from a biopsy taken from a 58-year-old man with a (something, I’ve cut it off, any ideas?) palate
What is layer A formed from? (1)
layer A = keratin
Keratin is formed from the basal layer
What type of epithelium can you see in this picture? (1)
Keratinised stratified squamous epithelium
What is the brown pigment at B?
melanin
Describe the lesion clinically based on what you can identify in the slide. (2)
White area/patch with some areas of brown/grey colour.
Name two possible aetiological factors for the development of this lesion. (2)
White area/patch with some areas of brown/grey colour.
Smoking, Chronic inflammation, Drugs - hydroxychloroquine
Using the photograph, how would you assess if the lesion was potentially malignant (1)
melanin
Hyperchromatism and atypia
What features in the clinical appearance would make you highly suspicious that the lesion was potentially malignant? (1)
Exophytic growth, Raised rolled margins, Indurated
A patient presents for a regular check-up when you notice a lesion that is white and lacey in appearance in the left buccal mucosa.
What is your diagnosis? (2)
Lichenoid tissue reaction
What made you arrive at this diagnosis and how does this condition occur? (2)
lichenoid tissue reaction
As the lesion is adjacent to a large amalgam restoration, Type IV hypersensitivity reaction
Name TWO types of biopsy you could carry out to further investigate this lesion (2)
lichenoid tissue reaction
Incisional biopsy (punch), Fine needle aspiration
Name FOUR histological features of this condition (4)
lichenoid tissue reaction
- Keratinisation,
- “Hugging” band of lymphocytes,
- Basal cell liquefaction,
- Apoptosis,
- Sawtooth rete pegs
Candida Infection. You would be provided with one picture showing redness at the corner of the mouth. Diagnosis of this disease. (1)
Angular cheilitis
Name 2 microorganisms involved in this condition. (2)
angular cheilitis
Staphylococcus aureus, candida albicans
What microbiological sampling method should you ask for? (1)
angular cheilitis
swab
Name one immune deficiency disease and one gastrointestinal intestinal bleeding disease. And why are they more susceptible for this lesion. (2)
angular cheilitis lesion
- HIV: impaired immune function
- Coeliac: impaired nutrient absorption
Name one intra-oral disease that would be associated with this? (1)
angular cheilitis
Oral facial granulomatosis (OFG)
Why is miconazole prescribed to patient when microbiological sampling is not available? (1)
of angular cheilitis
Effective against both fungi and bacterial pathogens
What two instructions should be given to this patient who wears a denture. (2)
Denture hygiene: chlorhexidine or hypochlorite
Wear as little as possible
A patient attends with inflamed gingiva extending beyond the mucogingival margin. Give a diagnosis (1 mark)
Desquamative gingivitis
Give 1 descriptive term to describe it’s appearance (1 mark)
desquamative gingivitis
Erythematous, Ulcerated
Give 3 oral mucosal conditions associated with in this? (3 marks)
desquamative gingivitis
Pemphigus, Pemphigoid, Lichen planus
Give 2 local factors that may contribute to this (2 marks)
desquamative gingivitis
SLS, Plaque
What are 2 typical treatments you could use? (2 marks)
- Betamethasone mouthwash
- Tacrolimus ointment
Pemphigus Vulgaris.
What is this method? (2)
Direct immunofluorescence
What would the pathologist report with the result of the test?(3)
Diagnosis. (2)
direct immunoflorescence
Pemphigus vulgaris
Reasons behind this condition? (2)
pemphigus vulgaris
Autoimmune: type 2 hypersensitivity
Name one condition that would represent the lesion in the same way clinically, but would be different histopathologically? (1)
pemphigus vulgaris
pemphigoid
answer says “drug induced pemphigus”
Oral Squamous Cell Carcinoma.
This patient has a squamous cell carcinoma at the lateral border of the tongue. It is 5cm in width. There are bilateral ipsilateral lymph nodes palpated but <2cm. The presurgical examination shows that the cancer is not spread to any other structures.
List only two factors for oral squamous cell carcinoma. (2)
Alcohol, Smoking, HPV
Stage tumour with the TNM system. (1)
T3 N2 M0
T3 N2 M0
How would you grade the dysplasia histopathologically? (3)
Hyperplasia, Dysplasia (mild, moderate, severe), Carcinoma in situ
What interventions (medical or surgical) other than surgery could the patient have? (3)
OSCC
Radiotherapy, Chemotherapy, Immunotherapy
After removal of the lesion, how would you restore the function of the tongue? (1)
soft tissue grafting
Organism for denture stomatitis - picture (1)
Candida albicans
3 local factors for this (3)
denture stomatits
Poor OH, Wearing denture at night, Trauma, Smoking, Xerostomia, Inhaler
4 management options (4)
denture stomatitis
Chlorhexidine x2 daily (0.2%), Denture Hygiene, Tissue conditioner, Antifungals (fluconazole), Smoking cessation, Rinse after inhaler use
What will be seen on occlusal surfaces of teeth + what could you do in short term (2)
denture stomatitis???
Erosion due to inhaler - rinse mouth out and F varnish
Recurrent Aphthous Stomatitis:
Diagnose which type
Major, Minor, Herpetiform
State difference between major/minor
Recurrent Aphthous Stomatitis:
Minor: 1-20 ulcers, <10mm, heals in 1-2weeks, heals without scar, generally on non-keratinised mucosa
Major: Usually singular, 1-5, >10mm, heals with scar, heals within 6-12 weeks, can be found on all types of mucosa
Causes of recurrent aphthous stomatitis
Haematinic deficiency (iron, B12, folate), Trauma, SLS toothpaste, Allergy: Dietary problems & others, Anxiety & stress, Systemic disease, Menorrhoea, Chronic GI blood loss, Dietary malabsorption (Pernicious anaemia, Coeliac, Crohns), Ulcerative colitis
treatment for recurrent apthous stomatitis
- Chlorhexidine: x2 daily (0.2%) 10ml,
- Dietary avoidance (chocolate, cinnamon aldehyde, benzoates),
- Toothpaste change (SLS-free),
- Blood tests + correct deficiency (e.g. iron),
- Betamethasone mouthwash (0.5mg x2-4 times daily)
Potential problems of recurrent apthous stomatits
Infection, Dehydration
A patient enters your surgery and you suspect after your initial examination that they may have trigeminal neuralgia.
Describe the nature of the pain from trigeminal neuralgia (2 marks)
severe paroxysmal pain, worst ever, electric shock like lasting a few seconds, usually unilateral
The 2 most frequent causes of trigeminal neuralgia are? Name an investigation you could do into these. (3 marks)
- focal demyelination of the peripheral nerve
- trigeminal nerve compression from aberrant artery
MRI
If the patient had Trigeminal Neuralgia due to MS or a brain tumour what symptoms might they experience? 1 for MS, 2 for brain tumour. (3 Marks)
MS: intention tremor/loss of proprioception
Brain Tumour: Diplopia, memory loss
How could you manage this patients pain from trigeminal neuralgia? Give 1 surgical and 1 medical (2 marks)
- Carbamazepine 100mg 2x daily,
- Microvascublar decompression, Balloon compression, Gamma knife
What investigation/tests would you take before giving the medical management and why? (3 marks)
Blood tests - FBC
LFT (liver function test)
U&E - Sodium reduced, liver function reduced
Give 3 side-effects of this medical intervention (3 marks)
carbamazepine
GI disturbances, drowsiness, headache, visual disturbance, facial dyskinesias, folate deficiency, hypertension
Intra-oral manifestations of herpes?
Herpes labialis, Primary herpetic gingivostomatitis, Oral ulceration
Three causes of vesicles?
Erythema multiforme, Pemphigoid, Pemphigus
2 groups that cause oral ulceration?
of viruses
Herpes simplex, Coxsackie virus, EBV, Varicella Zoster virus
Coxsackie oral lesions?
Herpangina, Hand foot and mouth
Disorders caused by EBV?
Hairy leukoplakia, Glandular fever (infectious mononucleosis), Burkitt’s lymphoma
How herpes labialis forms?
Primary infection, Latency, Reactivation (Upper = maxillary, Lower = mandibular), Secondary infection: causing a herpes labialis lesion
Picture of candidosis – Diagnose (1)
acute pseudomembranous candidosis
2 med conditions associated with it (2)
acute pseudomembranous candiasis
HIV, Poorly controlled diabetes
Swab + rinse – advantages and disadvantages of each(4)
Swab - Adv: site specific Dis: uncomfortable,
Rinse - Adv: quantifiable amount Dis: more difficult to standardise
What to ask pathologist for when sending sample (1)
acute pseudomembranous candidosis
Culture and sensitivity
2 drug interactions and the effects
Warfarin and statins
need another plus effects
Picture of apthous ulcers - Diagnose (1)
Minor apthous
2 investigations (2)
minor apthous
Haematinics, FBC
Given values from FBC + told normal values – had to diagnose which type of anaemia (1)
microcytic
2 reasons what causes microcytic (2)
Iron deficiency, Thalassaemia
3 topical treatments available for apthous ulcers - not brand name (3)
Benzydamine, Fluticasone, Beclomethasone, Doxycycline
Mid age female complaining of burning mouth with diffuse erythema (1)
Oral dysaesthesia
Male mid age, dull throbbing pain in maxillary region, made worse by bending over (1)
Sinusitis
Unilateral episodic pain lasting up to 20 mins, nose dripping + worse when shaking head (1)
Chronic Paroxysmal Hemicrania
Elderly + sharp shooting pain in right cheek when biting + lacrimation (1)
Trigeminal neuralgia
Temporal pain + weakness of shoulder muscles (1)
Temporal arteritis (accompanied by shoulder girdle weakness)
Denture induced stomatitis
Causes?
Immunosuppressed, Poor dental hygiene, Dentures worn over night, Trauma from ill fitting dentures, Xerostomia. Systemic steroids & broad spectrum antibiotics
Hygiene instruction?
for denture induced stomatitis
- Chlorhexidine mouthwash,
- Soak denture x2 daily (15mins) and rinse mouth x2, + Alkaline hypochlorite/Sodium hypochlorite (10 mins CoCr, 20 mins PMMA),
- Leave dentures out as often as possible,
- Brush denture after every meal with soft brush (esp on fitting surface),
- Take out at night time and leave in water overnight,
- Brush palate daily
Treatment If denture hygiene doesn’t work:
for denture stomatits
Antifungals (Miconazole, Nystatin),
Tissue conditioner,
New dentures: when resolved denture induced stomatitis
How to restore excessive FWS with worn dentures?
Occlusal pivots, Restore occlusal surface with auto-polymerising acrylic resin
Pigmented tongue
Local causes?
Smoking,
Medication - hydroxychloroquine,
Chromogenic bacteria causing black hairy tongue,
Melanoma,
Melanotic macule
Pigmented tongue
Systemic causes?
Racial, Lead poisoning, Addison’s, Kaposis sarcoma, Haemochromatosis
Lichen planus
Histological images
Keratosis, Atrophy or Hyperplasia, Lymphocyte hugging band, Lymphocyte epitheliotropism, Basal cell liquefaction, Apoptosis, Acanthosis, Saw tooth rete pegs
Comment on appearance of lichen planus
PPBREAD (Papular, plaque, bullous, reticular, atrophic, desquamative gingivitis)
(not the asked for answer??)
Features of disease (lichen planus)
- 30-50yo
- 1% malignant potential
- Recurrence common
Causes of lichen planus
Stress, Autoimmune, Idiopathic, Amalgam, SLS, Medications (NSAIDS, Anti-hypertensive, Anti-malarials, Anti-diabetics, Sulphonamides, Penicillamine)
Special investigations for lichen planus
Biopsy in: smoker, symptomatic, high risk area, Direct Immunofluorescence (DIF)
Treatment for lichen planus
- Asymptomatic: Observe, CHX, remove cause,
- Symptomatic: Remove cause, corticosteroids, antiseptic mouthwash
Pemphigus
Histological images
- Tzank cells
- Supra-basal split: attacks the desmosomes
Pemphigus
Comment on appearance
- Superficial blisters: clear fluid filled (on skin and mucosa)
- Rarely intact blisters/non-specific erosions
Pemphigus
Features of the disease
S - superficial, S - serious, S - steroids, potentially
Fatal: Protein and electrolyte imbalance
Causes of pemphigus
Autoimmune: type II hypersensitivity reaction
Treatment for pemphigus
- Azathioprine and steroids
- Special investigation for pemphigus
- direct immunofluorescence.
Order the salivary gland tumours by incidence
Pleomorphic adenoma (75%), Warthin’s tumour (15%), Adenoid Cystic Carcinoma (5%) (NB most common MINOR salv gland tumour), Mucoepidermoid Carcinoma (3%), Acinic Cell carcinoma (<1%)
What are the histological features of a pleomorphic adenoma?
Complete/incomplete capsule, duct-like structures, chondroid and myxomatous tissue, epithelium.
What histological feature is related to recurrence?
pleomorphic andenoma
Non/poorly encapsulated
What are the histological signs of Warthin’s tumour?
Cystic, distinct epithelium, lymphoid tissue
Histology of adenoid cystic carcinoma?
No capsule, tubular/swiss cheese like, solid.
What features of a parotid swelling would make you suspicious of malignancy?
Firm, attached to underlying structures, fast growth
Describe Desquamative gingivitis (2 Marks)
Clinically descriptive, Erythematous shedding and ulceration which involves the full width of the gingiva
Name two other conditions that you would see Desquamative gingivitis in? (2 Marks)
Pemphigus, Pemphigoid, Lichen planus
Describe how you would manage Desquamative gingivitis (4 Marks)
- Change of toothpaste (SLS–free),
- Improve oral hygiene (Plaque aggravates the lesions),
- Topical steroids - rinse or meter dose inhaler (MDI; or Steroid cream in (gum shield),
- Topical tacrolimus (immune modulator, rinse or cream),
- Systemic immunosuppression if required (rarely needed)
Mrs Patel is a 45 year old patient who is new to your practice. She is fit and well but complains of some soreness in her right cheek which she has had for a number of years. Your examination reveals a reddened area of buccal mucosa with a white lacy edge immediately adjacent to tooth 47. This tooth is almost entirely restored with a perfectly sound amalgam and is the abutment for rest seats and clasps on a chrome/cobalt partial denture which Mrs Patel has happily worn for the past 5 years and has a bleeding 6mm mesio-buccal pocket with associated grade I mobility. A periapical radiograph of tooth 47 reveals some mesial bone loss but no periapical pathology. All the other teeth are sound or minimally-restored with composite and the partial denture is well fitting.
What are your provisional diagnoses? (4 marks)
Traumatic lesions, Lichenoid reaction: amalgam, Chronic periodontal disease, Lichen planus, Oral cancer: squamous cell carcinoma
What additional investigations could be undertaken and how would you arrange these? (6 marks)
Traumatic lesions, Lichenoid reaction: amalgam, Chronic periodontal disease, Lichen planus, Oral cancer: squamous cell carcinoma
Incisional biopsy for histological examination, Blood tests (FBC, haematinics, auto-antibodies, random blood glucose) Referral to GMP, Clinical photography = dental hospital, Chronic perio disease: PGI, 6PPC, Patch testing: refer to dermatologist (for chrome)
What are Mrs Patel’s options for management of these problems? (10 marks)
Traumatic lesions, Lichenoid reaction: amalgam, Chronic periodontal disease, Lichen planus, Oral cancer: squamous cell carcinoma
- Traumatic lesions: smooth or take off the clasp
- Lichenoid reaction: amalgam replacement with composite
- Chronic periodontal disease: HPT
- Lichen planus: correct deficiency, medication, SLS free toothpaste
- Oral cancer: squamous cell carcinoma (remove the suspected possible causes and see if it resolves in 3 weeks. 3 weeks review, if not resolved. Refer.
Arthur is a 68 year old retired mechanic who presents at your practice after an absence of 2 years. He is partially dentate in the upper and lower arch and wears upper and lower acrylic prostheses. These prostheses were well fitting when provided by you 2 years ago. He now complains that the upper prosthesis no longer fits well and is uncomfortable. On examination the upper prosthesis does not seat fully in the edentulous regions. In addition, there are numerous early to moderately deep primary carious cavities. Periodontal examination reveals no periodontal pockets greater than 3-4 mm and minimal bleeding on probing. Radiographic examination confirms no obvious peri-radicular radiolucencies. To the contrary, there are large radio-opacities in relation to the roots of several teeth. There is minimal periodontal bone loss. In relation to his medical history he says he is taking medication for Paget’s disease.
Describe the anatomical changes, pathology and incidence behind the reason why the denture no longer fits? (4 marks)
Paget’s is a disease causing increased bone turnover. Bone swelling occurs as a result and thus the dentures don’t fit anymore. (increased osteoclastic and osteoblastic activity.) >55yrs, M>F
Why could Arthur have developed dental caries? (2 marks)
Polypharmacy and xerostomia in aging population, Diet and lifestyle factors - increased sugar intake, Non-fitting denture acting as plaque trap, Reduced manual dexterity for OH
Account for the most likely cause of the radio-opacities on the radiograph. (1 mark)
Paget’s caused hypercementosis
How are you going to manage his clinical care? Describe the treatment you would provide and treatment you would seek to avoid? (6 marks)
DHE & OHI (Diet, Fluoride), HPT (Scale, RSD), Caries management (excavation, RCT?), New dentures - may need to be replaced more frequently due to jaw enlargement, Regular monitoring - reassessment, Refer to specialist if complications arise
You decide Arthur needs to have extraction of a lower molar which does not have a radio-opacity associated with its root and you are aware he is taking bisphosphonates. What precautions would you take when you extract the tooth? (7 marks)
Chlorhexidine x2 daily 1 week pre-operatively, immediately before the extractions, post-operative chlorhexidine, Maintain OH, Achieve Primary intention closure, Use an atraumatic extraction technique, Refer to a specialist if complications develop, Avoid raising flaps
Name a life-threatening Vesicullo-bullous disease (1 mark)
Pemphigus
Name 2 methods of testing for this disease and describe the histology of a positive result (4 marks)
pemphigus
Direct Immunofluorescence: chicken wire appearance, H&E staining microscopy: tzank cells, supra-basal split, acantholysis
Describe how your management of this disease (4 mark)
- Topical/systemic steroid - beclometasone inhaler/prednisolone
- Immunomodulating drug: azathioprine, Analgesics
Primary herpetic gingivo-stomatitis - give symptoms/signs to identify it
Generalised Ulceration, Blood crusted lips, Pyrexia, Treatment, Fluid and electrolyte balancing, Self limiting - 10-14 days, Rest
Picture: generalised white plaque that scrape off easily and leave an erythematous base Diagnosis
Hairy leukoplakia
Two medical conditions that we might see this in
hairy leukoplakia
HIV, EBV
Advantages and disadvantages of mouth swab and oral rinse
Advantages: non-invasive, Disadvantages: often not diagnostic
get better answer
What to ask pathologist for when sending sample (1)
serology
Fluconazole interacts with many drugs…. Name 2 drugs and the effect the interaction would have
Warfarin (increased bleeding) and statins (hepatotoxicity)
3 causes for generalised pigmentation around the mouth
Racial, Medication, Addisons, Smoking
3 causes of localised pigmentation (brownish grey) in the mouth
Vascular malformations (Haemangiomas, Sturge-Weber), Macule/naevus, Pigmentary incontinence, Amalgam tattoo
Name two types of haemangioma
Capillary, Cavernous
What is the histological difference between them
(Capillary and cavernous haemangioma)
- Capillary: groups of smaller vessels, most of which are capillaries
- Cavernous: larger, dilated vascular spaces
Trigeminal neuralgia
2 clinical investigations you would do
MRI, Blood: FBC, haematinics, blood glucose
Trigeminal neuralgia: 2 neurological disorders that may give rise to this type of pain
MS, Brain tumour
First line drug management for trigeminal neuralgia
carbamazepine
What blood tests would you have to do before giving the above drug (Carbamazepine)
Must check: FBC, LFT, U&E’s for reduced Na (causes forgetfulness)
2 indications for surgery for trigeminal neuralgia
- Medical intervention ineffective
- Medical intervention contraindicated
Name one type of surgery
for trigeminal neuralgia
Microvascular decompression, Balloon compression, Gamma knife
Trigeminal neuralgia. – What conditions may this be a side effect of?
MS or brain tumour.
Trigeminal neuralgia: What special investigations may help your diagnosis?
MRI, OPT to rule out dental pain.
What investigations should you do if you are going to use Carbamazepine?
FBC, Liver function test, urea and electrolytes before, during and after.
What are the side effects of carbamazepine?
liver dysfunction, allergy, ataxia, nausea, sedation, nightmares
What are 2 ways TN can occur?
1 → demyelination causing CNV ischaemia.
2→ aberrant arteriole in the cerebello-pontine region lying on the nerve
How else can TN be managed?
Balloon compression → necrosis of nerve, microvascular decompression to separate blood vessel and nerve, cryosurgery, Gamme Knife, long acting bupivacaine.
What are the indications for these types of procedure?
surgery for TN
Symptoms persist despite medical intervention, pts with adverse effects of medication.
What muscles are examined in a patient with temporomandibular disorder?
Masseter, temporalis, (lateral pterygoid, medial pterygoid)
What are the common causes? (TMD)
Stress, parafunction, occlusal discrepancies, trauma.
What nerve supplies the TM?
TMJ?
auriculotemporal nerve.
What are the signs and symptoms of TMD
Pain, stiffness, limited opening, click, crepitus, deviation on opening, locking, headache.
Detail conservative management advice for TMD
limit mouth opening, soft diet, avoid habits e.g. nail biting, cut up food, stifle yawns, wear BRA, analgesics, warm compress, de-stress, limit posturing, stop gum chewing
What are the mechanisms of a bite splint?
how can it help TMD
Minimise parafunctional habits. Minimise load on TMJ. Provide stable occlusion. Eliminate occlusal interferences.
What is arthrocentesis?
Washing of the upper superior joint space of the TMJ. Carried out under LA. Solution injected in which breaks fibrous adhesion and washes away inflammatory exudate.
Give 2 other possible surgical options for TMD
other than arthrocentesis
arthroscopy, arthroplasty, condylectomy, total joint replacement, high condylar shave
What are the histological features of lichen planus?
- Keratinisation
- Lymphocytes/macrophages
- Atrophy/hyperplasia
- Apoptosis
- Basal Cell liquefaction leading to colloid bodies
- Blue band of chronic inflammatory cells
- Saw tooth rete ridges (not always).
What are the types of lichen planus?
PPBREAD – papular, plaque, bullous, reticular, erosive, atrophic, desquamative gingivitis.
What is the aetiology of lichen planus
Idiopathic OR LTR → drugs (NSAIDS, beta-blockers, hypoglycaemics, diuretics, anti-malarials), Hep C, amalgam, gold or SLS.
When do you biopsy with lichen planus
All symptomatic, All smokers, and high risk site
How is lichen planus managed?
Asymptomatic and reticular → monitor and reduce risk factor.
Others →remove cause if known, topical steroids, systemic steroids, immunomodulators. Can use difflam MW and CHX MW.
Patient has suspected trigeminal neuralgia.
What tests would you conduct before arriving at this diagnosis? (2 marks)
- Performing inferior alveolar block (to rule out TMD/muscle pain)
- MRI
- FBC
What drug therapy would you provide? (1 mark)
TN
carbamazepine
What tests would you carry out every 3 months? (1 mark)
TN
Checking for any improvement, giving patient pain scale to monitor
TN: Blood tests?
FBC
LFT
TN:
When would you decide to go for surgical management? (2 marks)
- No improvement of condition with carbamazepine and had been tried for substantial period
- Medication causing side effects
- If the patient requested it
Give an example of surgical management (1 mark)
TN
balloon compression
What are the I/O manifestations of herpes?
Vesicles that burst to form blisters, 1-3mm.
Name 2 other types of human herpes virus
Epstein-Barr Virus (HHV4), Varicella Zoster (HHV3), HHV8 ass.w/ Kaposi’s sarcoma, Cytomegalovirus
Which cranial nerve does herpes become associated with?
trigeminal
Name the common triggers for reactivation of herpes.
stress, being unwell, sunlight, immunosuppression.
What is anaemia?
A reduction in the oxygen carrying capacity of the blood due to a deficiency of haemoglobin or red blood cells.
What are the general signs and symptoms of anaemia?
Fatigue, malaise, pallor, weakness, dizziness.
What are the oral signs of anaemia?
Recurrent oral ulceration, candida, glossitis/smooth(- iron), beefy (-VitB12/folate), oral disaesthesia, mucosal pallor.
Name the type of anaemia from MCV
- Microcytic <80fL → Iron deficiency, Thalassemia
- Normocytic 80-95fL → pregnancy, bleeding, sickle cell anaemia
- Macrocytic >96fL → VitB12 and Folate.
What are the causes of xerostomia?
- Local: Mouth breathing, Candida, Alcohol, Smoking, Sialolith
- Salivary gland diseases: Sjogren’s, CF, HIV, Sarcoidosis, Amyloidosis, Haemochromatosis
- Drugs: Tricyclic Antidepressants, Antipsychotics, Antihistamines, Diuretics, Atropine, Cytotoxics
- Dehydrating conditions: Diabetes (1+2), Renal disease, Stroke, Addison’s, Persisting vomiting
- Radiotherapy and cancer treatments
- Anxiety and somatisation disorders
How can you assess this intraorally?
xerostomia
Mirror stick test to cheek and tongue, check saliva pooling, salivary flow rate test
What are the oral signs and symptoms?
xerostomia
Increased cervical caries, frothy saliva, loss of gingival architecture, glossy appearance of gingiva, tongue fissuring, increased perio, difficulty eating, speaking, swallowing, denture control, halitosis, candida.
How can it be managed?
xerostomia
- Treat cause: hydration, modify drugs, control diabetes, control somatoform disorder.
- Prevent diseases: caries, candida/angular cheilitis.
- Saliva substitute/stimulator: Saliva Orthana/Pilocarpine
Name 3 salivary substitutes
Glandosane, saliva orthana, Biotene
Name 3 sugar substitutes
xylitol, manitol, sorbitol
List 3 salivary proteins
IgA, PRP, mucins, histatin
List 3 salivary enzymes
lipase, lysozyme, amylase.
When are antibiotics indicated for dental treatment?
- Temporary treatment of acute infection where drainage or XLA is not possible.
- With spreading infection e.g. cellulitis.
- Adjunctive to surgical treatment e.g. aggressive periodontitis.
- Immunocompromised patients.
Give 5 ways antibiotics work?
- Cell wall destruction
- Protein synthesis inhibition
- DNA synthesis inhibition
- DNA replication inhibition
- Cell membrane inhibition
Give 3 disadvantages of antibiotics
Resistance, GI upset, Drug interactions, hypersensitivity
Name 3 antibiotics used in dental treatment and include regime example
Metronidazole (200mg 3x day 3-5 days)
Amoxicillin (500mg 3x day 5 days)
Erythromycin (250mg 4xday 5 days).
What are the mechanisms of antibiotic resistance?
Drug inactivation, altered target site, reduced accumulation, altered metabolism
What is desquamative gingivitis?
Descriptive term: Gingivae appear erythematous, ulcerated and desquamative (shedding).
Give three differential diagnoses
desquamative gingivitis
lichen planus, pemphigoid, pemphigus.
How is it managed?
desquamative gingivitis
Confirm diagnosis and manage diagnosis appropriately. May involve blood tests/direct immunofluorescence. Control local irritating factors e.g. plaque, poor restorations. Modify OH if pt cannot manage regular toothbrushing due to pain. Consider replacing removable with fixed pros.
How can you differentiate between upper and lower motor neuron disease?
‘Upper spares upper” – everything above eyebrows still functions in UMN
How does this difference occur?
How can you differentiate between upper and lower motor neuron disease?
The upper part of the facial motor nucleus receives innervation from both crossed and uncrossed fibres so the frontalis and orbicularis oculi muscles are spared.
Give 5 possible causes for LMN disease
lower motor neuron disease
Reactivated HSV causing Bell’s Palsy, MS, trauma, parotid tumour, misplaced LA
How is LMN managed?
80% resolve in weeks. Prednisolone to reduce swelling of facial nerve at stylomastoid foramen, eye protection
What is geographic tongue?
Intraoral psoriasis of dorsum of tongue. Affects 1-2%
How is it managed?
geographic tongue
reassure and monitor
What is coxsackie virus?
RNA virus
Name 3 diseases it causes (coxsackie virus)
Hand foot and mouth, herpangina, haemorrhagic conjunctivitis, aseptic meningitis
What is Epstein-Barr Virus?
Human herpes virus 4
Name 3 diseases it causes
EBV
Hairy leukoplakia, Burkitt’s lymphoma, infectious mononucleosis (glandular fever)
Your patient is an asthmatic and takes 2 inhalers. What kind of inhalers will these likely be?
- Beta-agonist (e.g. blue salbutamol)
- Corticosteroid (e.g. brown beclomethasone).
What is asthma?
Reversible airflow obstruction. 1. Smooth muscle contraction 2. Inflamed mucosa causing swelling, 3. Increased mucus secretion.
What are the signs and symptoms of asthma?
Wheeze, cough, rash, shortness of breath.
What are the dental effects of inhalers and what advice should be given?
- Increased candida infections due to steroid effects
- increased erosion due to acidic
- decrease in saliva exacerbating both
- Dry mouth
- Patients should be advised to rinse with water after using inhalers
- use inhalers correctly and use a spacer
- Regular preventative advice applies.
What other considerations should be given?
asthma
Possible allergy to colophony in fluoride varnish.
Medical emergencies for asthma attacks.
What percentage of people in Scotland are being treated for asthma?
Up to 7% (asthma.org.uk)
You have biopsied a potentially malignant lesion. List 11 histological signs of epithelial dysplasia
- Hyperchromatism
- Pleomorphism
- Basal cell hyperplasia
- Drop shaped rete ridges
- Altered basal cell polarity
- Increase/abnormal mitoses
- Increased area:vol of nucleus:cytoplasm
- Enlarged nuclei
- abnormal stratification
- Abnormal keratinisation
- Loss of intercellular adhesion.
How is dysplasia graded?
Basal Cell Hyperplasia, Mild dysplasia (low 1/3, mild atypia and architecture changes), Mod dysplasia (mid 1/3), severe dysplasia (upper 1/3), carcinoma-in-situ (full thickness).
You believe your patient to be suffering from oral dysaesthesia. What is another name for this?
Burning mouth syndrome
Who is most likely affected?
burning moouth
F»>M – Mostly menopausal women, 50yo
What are your differential diagnoses?
burning mouth
Lichen planus, pulpitis/dental effect, ROU, Denture problems, xerostomia, diabetes.
What are the likely signs and symptoms?
burning mouth
Burning tongue, xerostomia, paraesthesia → Mucosa appears clinically normal.
What investigations might you carry out?
burning mouth
FBC, haematinics, glucose, salivary flow rate, parafunction assessment, denture assessment, psychiatric assessment
How is it managed?
burning mouth
Reassurance, correct any deficiencies/blood sugar, correct parafunction or denture fault, difflam mouthwash, Gabapentin (antineuropathic therapy)/antidepressant therapy, CBT
What is orofacial granulomatosis?
Type IV sensitivity reaction. Granulomatous inflammation resulting in lymphomatous swelling due to blockage of lymph channels.
What condition is it associated with?
OFG
Crohn’s 15%.
What is the aetiology?
OFG
Autoimmune, hypersensitivity to SLS, benzoates, cinnamon. Non-caseating giant cell granulomas.
What is the histological appearance?
OFG
Non-caseating giant cells, oedema, dilated lymph.
What are the signs and symptoms?
OFG
Lip swelling and crusting, angular cheilitis, buccal cobblestoning, ulceration of mandibular buccal sulcus, staghorning of sublingual folds, full thickness gingivitis.
How is it managed?
OFG
Dietary advice for allergens, antibiotics (erythromycin), tacrolimus on lips, oral steroids, NO surgery.
What does dentally fit mean?
Being free from any dental disease before the start of cancer treatment.
What is a multi-disciplinary team?
Team of individuals of various disciplines/specialties who work together to provide the best holistic care for the patient.
List 4 members of an MDT for someone being treated for oral cancer
Oncologist, special care dentist, restorative dentist, physiotherapist, nutritionist, speech and language therapist, radiologist, hygienist, OMFS etc etc
What risks is the patient at following radiotherapy, apart from mucositis?
Xerostomia, osteoradionecrosis, increased infection, poor wound healing
What are the grades of mucositis?
- Sore and erythematous
- Erythema and ulcer but can eat
- Ulcers and liquids only
- Cannot take anything orally
How is it managed?
mucositis
Prevention, CHX, good OH, ice chips, topical lidocaine, SLS free TP, tea tree oil, analgesics.
What is the histological difference between pemphigus and pemphigoid?
- Pemphigoid - Sub-basal split, autoantibodies attack hemidesmosomes
- Pemphigus - Supra-basal split, autoantibodies attack desmosomes, Tzank cells, acantholysis
How do they differ clinically?
pemphigus and pemphigoid
- Pemphigoid has thick, full epidermis blood blisters that may persist to be seen clinically.
- Pemphigus has clear, superficial fluid filled blisters that often burst.
How may these conditions be investigated?
pemphigus and pemphigoid
- Immunofluorescence: Direct – biopsied area autoantibodies
- Indirect – serum autoantibodies
How are they managed?
pemphigus and pemphigoid
- Topical: Betamethasone mouthwash (0.5mg x2-3/day)
- Beclometasone inhaler (50mg x2-3/day)
- Systemic: Systemic steroids
- Immunomodulator (azathioprine)
- Referral to ophthalmologist if worried about pemphigoid
What are the risk factors for oral cancer?
Multifactorial → Smoking, alcohol (combo x35), poor OH, diet, viral e.g. HPV 16&18, age, betel quid
What are the signs and symptoms of oral cancer?
Sites: lateral border of tongue, floor of mouth, soft palate. Signs: >3months unexplained white/red patch, ulcer, swelling, hoarseness, unexplained mobility, dysphagia. Ulcer w/ rolled border, indurated, bleeding, numbness, pain (late presentation), exophytic
How does cancer spread?
Locally, lymphatic, blood.
What is the metastatic cascade?
Intravasation → survive in circulation → arrest in organ/tissue → Extravasation →Survive extravasation → Initial proliferation → established growth
What is the TNM staging?
Tumour (Tx, Tis, T0-4), Nodes (Nx, N0-3), Metastases (M0-M1). Combine the scores to get an overall stage 1-4 increasing in severity.
What is necrotising sialometaplasia?
Vascular damage of palatine vessels causing blockage in flow to minor salivary gland
What is the aetiology?
necrotising sialometaplasia
Vascular damage of palatine vessels causing blockage in flow to minor salivary gland
What is the aetiology?
necrotising sialometaplasia
Small vessel infarct → smoking, trauma, LA
How does it appear histologically?
necrotising sialometaplasia
Surface slough necrotic tissue, hyperplasia, metaplasia of the ducts, necrosis of salivary acini
How is it managed?
necrotising sialometaplasia
Spontaneous healing
A patient presents with a swollen lower lip. Give three differential diagnoses other than a mucocele.
Trauma, OFG, SSC.
What is a mucocele?
Recurrent lip swelling due to a damaged minor salivary gland. Burst and recur.
How does it appear histologically?
Macrophage lined cavity with saliva and granulation tissue → foam cells.
How is it managed?
mucoele
Excision of mucocele and gland.
What is it called in the floor of the mouth?
a mucocele
Ranula.
Give 6 types of oral candida
- Pseudomembraneous
- Erythematous
- Hyperplastic
- Angular cheilitis
- Median rhomboid glossitis
- denture induced stomatitis
Where does median rhomboid glossitis occur?
Dorsum of the tongue anterior to the sulcus terminalis.
Give 3 histological features of it
oral candida
candida hyphae infiltration, PMNL infiltration, elongated rete ridges, hyperplastic rete ridges.
Give 3 methods of testing for candida
swab, oral rinse, biopsy.
What are the virulence factors of candida?
Adhesins, switching mechanism, germ tube formation, extracellular enzymes, acidic metabolites.
Give 5 antifungal agents
miconazole, fluconazole, chlorhexidine, nystatin, itraconazole.
chlorhexidine??
What medication is contraindicated for azoles?
Warfarin and statins.
What are the signs of adrenal insufficiency?
Oral pigmentation, weakness, anorexia, loss of body hair, postural hypotension, lethargy.
What emergency can be associated with this?
adrenal insufficiency
Adrenal crisis.
What information should be on a prescription?
Pt name and address, age if under 12, date, number of days of treatment, generic drug name, SEND, LABEL, score out extra space, GDP name in capitals, signature, GDP stamp.
What are the common dosages for 2 antibiotics given for dental infections?
- Amoxcillin 500mg capsules. SEND:15 capsules. LABEL: 1 capsule 3 times daily.
- Metronidazole 200mg tablets. SEND: 15 tablets. LABEL: 1 tablet 3 times daily.
What is the rate of infection for HIV on exposure?
0.3%
Same for HepC and HepB
rate of infectioni on exposure
HepC 3%, HepB 30%
Name 6 oral lesions associated with HIV
- Candida – erythematous and pseudomembraneous, especially without risk factors.
- Candida associated lesions e.g. angular cheilitis and median rhomboid glossitis.
- Hairy leukoplakia
- Kaposi’s sarcoma
- Non-Hodgkin’s lymphoma
- Periodontal disease e.g. NUG/NUP
How is HIV diagnosed and treated?
Diagnosis with ELISA and treatment with HAART.
What is a fibrous epulis?
Localised fibrous enlargement of gingival tissues.
What is the aetiology?
fibrous epulis
low grade chronic irritation
How does it appear histologically?
fibrous epulis
Ulceration, granulation, metaplastic bone
How is it known on sites other than gingivae?
fibrous epulis
Localised fibrous enlargement of gingival tissues.
What is a pyogenic granuloma?
Granulation tissue response to trauma.
How does it appear histologically?
pyogenic granuloma
Granulation tissue, blood vessels.
What MCV is indicative of microcytic iron deficiency anaemia?
<80fL.
Name 3 GI diseases that may cause this
microcytic iron deficiency anaemia
Crohn’s, ulcerative colitis, coeliac disease
Give 4 intraoral signs of anaemia
recurrent aphthae, beefy tongue, mucosal pallor, poor wound healing, smooth tongue, mucosal atrophy, candida.
A generalised white plaque wipes off to reveal underlying erythematous tissue. What is your diagnosis?
Pseudomembraneous candidosis
Give 2 medical conditions this may be seen in
Pseudomembraneous candidosis
HIV, diabetes, any oral steroids, immunocompromised etc etc.
What are the advantages and disadvantages of a swab and an oral rinse?
SWAB→ simple and site specific but can be contaminated.
RINSE → records whole mouth and can separate healthy organisms but not site specific and some pts find it difficult.
Name 2 drugs that interact with Fluconazole
Warfarin and statins (e.g. simvastatin)
What information is provided on a lab sheet for a sample?
Pt name and details, GDP name and details, clinical description and prov.diagnosis, Tests →previous, required today e.g. culture, viral, ESR, specimen site and type, ABs → previous, current, today, resistance, Drug and MH, DH, signature, date, time of sample.
What is Sjogren’s syndrome?
Autoimmune disease causing WBC (B-cell proliferation) destruction of exocrine glands.
What other conditions can it be associated with?
Rheumatoid arthritis, SLE, Scleroderma
Name 6 investigations used to help diagnose it
Sjogrens
- Subjective dry eyes → >3 months, gravel/sand feel, using tear subs 3x daily.
- Objective dry eyes → Schirmer test <5mm in 5mins.
- Subjective dry mouth → >3 months need liquid to swallow or gland swelling.
- Objective dry mouth → unstimulated salivary flow <1.5ml in 15mins.
- Auto-antibody findings → anti-Ro and anti-La.
- Histopathology → biopsy of labial gland @ premolar region of inner lip w/>5 minor glands.
What are the minor histological findings? Minor
Sjogrens
Acinar loss, focal lymphocytic sialadenitis, fibrosis.
Major histological findings
sjogrens
Myoepithelial islands, Epithelial hyperplasia, Acinar loss, Lymphocytic infiltrate.
Name 4 oral complications
sjogrens
increased caries, increased perio, denture retention difficulty, increased infection eg. Candida, salivary lymphoma.
Give 3 other causes of xerostomia
dehydration, medications, head and neck radiotherapy, smoking.
What systemic drug may be used to manage Sjogrens?
Prilocarpine.
Name a hereditary white patch
White sponge naevus
How does it appear histologically?
White sponge naevus
Parakeratosis, oedema in prickle layer.
How does smoker’s keratosis appear histologically?
Keratosis, Melanin pigment
Give 6 causes of pigmentation
- Exogenous: amalgam, smoking, lead poisoning
- Endogenous: racial, melanotic macule, melanoma
Name two types of haemangioma
capillary, cavernous, Sturge-Weber syndrome
What are the histological differences between them?
capillary, cavernous, Sturge-Weber syndrome haemangioma
Vary with the type of haemangioma e.g. capillary has capillaries all the same size with no blood outside them, cavernous has large spaces and irregular sizes.
A patient presents with denture induced hyperplasia. Give 2 differential diagnoses?
SCC, leaf fibroma, pyogenic granuloma.
What factors have resulted in denture induced hyperplasia?
Ill fitting denture causing chronic trauma. Fibrous reaction of gingiva.
How would you manage this?
denture induced hyperplasia.
LA, excision of hyperplastic area. Denture requires short term tissue conditioner and then remade.
Name 2 histological features of denture induced hyperplasia
Pseudo-epithelial hyperplasia, often with candida.
