Oral Disease

Question 1

What are fordyce granules?

Answer 1

Ectopic sebaceous glands not a/w hair follicles (as opposed to meibomian, Montgomery, Tyson)

Question 2

Clinical appearance of Fordyce granules?

Answer 2

Multiple pinoint (1-2 mm) yellow-white papules on vermilion lips (upper > lower) and oral mucosa (mc buccal)

Question 3

What is geographic tongue?

Answer 3

Well-delineated erythematous areas of atrophy missing filiform papillae (appear bald) partially surrounded by white serpiginous or scalloped

borders

Question 4

What is the histology of geographic tongue?

Answer 4

Essentially psoriasis (regular acanthosis, neuts in horn, parakeratosis)

Question 5

What things are a/w geographic tongue?

Answer 5

Usually incidental and normal (2-3% of people)

• can be associated with atopy and psoriasis (pustular variant most commonly)

Question 6

What is fissured tongue?

Answer 6

Multiple deep furrows on the dorsal tongue especially in midline

Question 7

What things are associated with fissured tongue?

Answer 7

Down syndrome, Cowden, Melkerson-Rosenthal

• Often normal finding

Question 8

What is Melkerson-Rosenthal syndrome?

Answer 8

• Young adults
• Triad of fissured tongue, orofacial granulomatosis (lip edema from granulomas), and permanent facial nerve paralysis
• A/w sarcoidosis and Crohn’s

Question 9

What is black hairy tongue?

Answer 9

Keratin retention –> hypertrophic papillae from decreased sloughing

• Hairlike projections confluent elongated papillae
• Yellowish to brown-black staining from food, tobacco, or chromogenic bacteria
• Chromogenic bacteria mc seen post-abx therapy

Question 10

What things are associated with black hairy tongue?

Answer 10

Poor hygiene, smoking, hot drinks

Question 11

What is the treatment of black hairy tongue?

Answer 11

Treat by scraping or brushing the tongue +/- dilute H2O2

Question 12

What is median rhomboid glossitis?

Answer 12

Well-demarcated central erythematous atrophic area on dorsum of tongue in front of circumvallate papillae (largest papillae at the back)

Question 13

What can median rhomboid glossitis be associated with?

Answer 13

Found in ~1% of adults and often a/w overgrowth of candida

• Can be a sign of HIV or DM2 if extensive

Question 14

Treatment for median rhomboid glossitis?

Answer 14

Treatment is clotrimazole or oral fluconazole

(treat the cause - candida)

Question 15

What is atrophic glossitis?

Answer 15

Atrophy of papillae

• Smooth appearance, can be tender, burning sensation
• Can looks beefy and red

Question 16

What deficiencies are associated with atrophic glossitis?

Answer 16

B1 thiamine, B2 riboflavin, B3 niacin, B6 pyridoxine, B12 cobalamin, folate, iron

can also be seen in candidiasis and Sjogren’s syndrome

Question 17

What conditions are associated with desquamative gingivitis?

Answer 17

Seen in mucous membrane pemphigoid, LP, drug reaction, GVHD, autoimmune bullous disorders, EM, fixed drug, chronic ulcerative stomatitis, contact derm, foreign body

Question 18

What medications are associated with gingival hyperplasia?

Answer 18

Phenytoin, phenobarbital, lamotrigine, valproate, vigabatrin, ethosuximide, topiramate, primidone (antiseizure meds)

Calcium channel blockers: nifedipeine, amlodipine, diltiazem, felodipine, verapamil

Cyclosporin

Question 19

What is the timing of drug-related gingival hyperplasia?

Answer 19

Seen within the first year of medication use, worse if oral hygiene is poor

Question 20

What is a dental sinus?

Answer 20

Abnormal draining channel from a longstanding abscess a/w dead (devascularized) tooth (intraoral vs cutaneous)

• Intraoral: soft, non-tender, erythematous papule on alveolar process close to the affected tooth
• Cutaneous: erythematous papule, often with umbilicated or ulcerated center; found on chin or submandibular region (mandibular teeth > maxillary teeth)

Question 21

What is necrotizing ulcerative gingivits?

Answer 21

Also known as trench mouth

Painful, hemorrhagic, necrotic gingivae w/ classic punched out interdental papillae

It is a mixed bacterial infection in susceptible people (immunosuppression, malnutrition, stress, smoking, poor oral hygiene

Question 22

Treatment for necrotizing ulcerative gingivits?

Answer 22

Debridement followed by broad-spectrum abx

• low dose doxycycline for anti-inflammatory effects also recommended

Question 23

What are the 3 classifications of recurrent aphthous stomatitis?

Answer 23

Minor: mc, <5 mm

Major: >1 cm, deeper, longer-lasting

Herpetiform: multiple small grouped ulcers ( but unlike HSV favors non-keratinized mucosa)

Question 24

What can be associated with recurrent apthous stomatitis

Answer 24

Vitamin deficiencies, stress, hormones, and systemic dz (SLE, Behcets, IBD)

Question 25

Treatment for recurrent aphthous stomatitis?

Answer 25

Topical CS +/- local anesthesia If necessary, colchicine or dapsone Thalidomide for major

Question 26

Which one, leukoplakia or erythroplakia, is more common associated with malignancy?

Answer 26

Erythroplakia show more severe epithelial dysplasia than leukoplakia and are more likely to be malignant

Question 27

What is leukoplakia and erythroplakia?

Answer 27

White vs red patch/plaque that cannot be characterized clinically or pathologically as any other disease; sharply demarcated borders - Leukoplakia mc on the mouth floor, lateral/ventral tongue, and soft palate

Question 28

What is the treatment for leukoplakia and erythroplakia?

Answer 28

Biopsy is needed If interpretation is "hyperkeratosis of unknown significance," the options depend on the age of the patient, medical status of the patient, and size of the lesion - Narrow removal (surgery, cryo, or laser) and lifetime follow-up with wider excision of recurrences - Follow-up of patient with re-biopsies as necessary and removal of lesion if there is noticeable progression in size or change in the nature of the lesion

Question 29

What is proliferative verrucous leukoplakia?

Answer 29

Heterogenous white plaques with a rough verrucous surface +/- nodular and red areas - often multifocal, present for 1-2 decades, and have had multiple biopsies - F:M 4:1, seventh+ decade - higher risk of maligngant transformation (70-100%) to SCC or verrucous carcinoma

Question 30

Treatment of proliferative verrucous leukoplakia?

Answer 30

**Biopsy q3-6 months on red and verrucous areas, multiple biopsies for extensive lesions** Should be managed by oral surgeons or oral specialists familiar with the condition Tx: refractory to laser; involve ENT for excision

Question 31

What is nicotine stomatitis?

Answer 31

- Caused by inflamed salivary ducts - Clinically presents as a gray-white palatal mucosa with numerous umbilicated papules - Tx: stop offending agent (pipe smokers) - will resolve in 1-2 weeks

Question 32

Etiologies of angular chelitis?

Answer 32

Irritant, but also frequently infected with candida or staph ## Footnote *DDx: lip-licking dermatitis (more diffuse), syphilitic split papules, HSV (usually unilateral)*

Question 33

What is cheilitis glandularis?

Answer 33

Inflammatory hyperplasia of lower labial salivary glands --\> pinpoint erythematous macules (site of salivary ducts), variable hypertrophy/eversion of the lower lip, and sticky mucoid film - Feels nodular d/t enlarged glands - seen in adult men with h/o chronic sun exposure and/or lip irritation - Increased SCC risk

Question 34

Treatment for cheilitis glandularis?

Answer 34

Cryosurgery, 5-FU, imiquimod, PDT, CO2 laser ablation, Mohs surgery

Question 35

What HPV's are associated with verrucous carcinoma (oral florid papillomatosis?

Answer 35

HPV-6/11

Question 36

Should oral florid papillomatosis be irradiated?

Answer 36

Avoid radiation b/c of risk of anaplastic transformation

Question 37

What are some key features of salivary gland tumors?

Answer 37

M/c location is the posterior hard palate - upper lip mucosa - buccal mucosa Most are BENIGN - p/w painless, rubbery, firm swelling Malignant types may become painful

Question 38

What is the presentation of chemotherapy and radiotherapy-induced mucositis?

Answer 38

Multiple erosions +/- ulcerations that favor gingivae, lateral tongue, and buccal mucosa

Question 39

What is the most common timeline for chemotherapy and radiotherapy-induced mucositis

Answer 39

4-7 days post-chemo administration and \>2 weeks after starting radiation

Question 40

What is the treatment for chemotherapy and radiotherapy-induced mucositis?

Answer 40

Self-limited -- topical anesthetics, maintain good oral hygiene

Question 41

What are some oral findings in leukemia?

Answer 41

- Associated intraoral findings include infections and gingival hemorrhage - Gingival enlargement occurs mc w/monocytic and myelomonocytic leukemias

Question 42

What are the most common cause of foreign body tattoos?

Answer 42

Foreign body tattoos are most common cause of acquired oral pigmentation and mostly due to implantation of dental amalgam

Question 43

What should you be thinking if you see a question w/ macroglossia and carpal tunnel syndrome?

Answer 43

Systemic Amyloidosis (especially B2microglobulin/renal associated)

Question 44

What oral findings can be seen w/ Crohn's disease?

Answer 44

- Oral cobblestoning and ulcers (aphthous or linear) - Angular cheilitis - Orofacial granulomatosis

Question 45

What is pyostomatitis vegetans?

Answer 45

Multiple pinpoint yellow pustules in a serpentine configuration with a red background Evolves into snail-track ulcers Labial, gingival, and buccal mucosa Deep edematous folds of buccal mocosa

Question 46

Pyostomatitis vegetans is most commonly associated with what disorders?

Answer 46

W/w IBD (UC \>\> Crohn’s), improves with IBD Tx