Oral Med Flashcards
What is pain
-Unpleasant sensory and emotional experience
-Associated with actual or potential tissue damage
What is chronic pain
-Pain that has outlived its usefulness
-More than 3 months
What are the risk factors for TMJ
-Stress
-Bruxism
-Multiple pain conditions
-Sleep problems
-Exogenous hormone usage
-Females
-Facial trauma
What are signs of degenerative change in TMJ
-Clicking
-Crepitus
-Limitation of movement
-Sudden inability to close
What is involved in ‘self-care’ for TMJ
-Warmth to joints
-Muscle relaxants
-Jaw exercise
-Jaw massage
-Analgesics
-Attention to grinding
What are pharmacological treatments in managing TMJ
-Anti-anxiolytics
-Anti-depressants
-Corticosteroids
-Analgesics
-Muscle relaxants
What are the risk factors for persistent idiopathic facial pain
-Stress
-Dental intervention
-Prolonged dental treatment
-Severe dental infection
What is burning mouth syndrome
-Idiopathic burning or discomfort in the mouth
-Clinically normal oral mucosa
-Absence of medical or dental problems
What are local factors that can cause burning mouth symptoms
-Mucosal infection
-Soft tissue infection
-Parafunction
-Ill fitting dentures
-Hypersensitivity reaction
What are systemic factors that can cause burning mouth symptoms?
-Medical conditions
-Hormone deficiency
-Vitamin deficiency
-Medication
What are the associated symptoms of burning mouth syndrome
-Altered taste
-Sense of oral dryness
-Tongue thrusting
-Burning sensation
What are the causes of burning mouth
-Menopause
-Stress
What is the management of burning mouth
-Treat the mood
-Symptomatic management of reduced saliva
-Reassure the patient
-CBT
-Exclude local causes
What is glossopharyngeal neuralgia and its aetiology
-Sharp, shooting pain in the ear, the angle of the jaw and the base of the tongue
-Primary: decompression of nerve
-Secondary: vascular anomaly or tumour
What is the trigeminal neuralgia, its aetiology and predisposing factors
-Unilateral sharp shooting pain
-Caused by aberrant cerebellar artery causing decompression at the root of entry zone
-Can be caused by a tumour
-Hypertension and MS are risk factors
What is the treatment for trigeminal neuralgia
-Carbamazepine
-If not treated the remission periods will become less frequent
What is giant cell arteritis
-Sudden onset of headaches in the elderly
-Associated with thickened temporal artery
What are the symptoms of giant cell arteritis
-Headaches
-Visual disturbances
-Jaw and tongue claudication
-Chronic fatigue
What is the management of giant cell arteritis
-Corticosteroids
-Vitamin D and calcium
What are cluster headaches
-Severe headaches affecting the frontal, temporal and orbital region in the night
-Causes lacrimation and nasal congestion
-Affects middle aged
-More than 2 occurrences every week for more than 1 year
What is the management of cluster headaches
-Avoid triggers such as alcohol
-O2
-Nasal decongestants
-Subcutaneous injections of sumatriptan
-Prophylaxis with lithium or corticosteroids
What is the definition of a vesicle and a bulla
-Vesicle is a small fluid-filled blister less than 5mm in diameter
-Bulla is a large fluid-filled blister more than 5mm in diameter
What is the etiological classification of blisters and give an example of each
-Infective: HSV, herpangina, hand foot and mouth
-Immunological: MMP, PV
-Idiopathic: Erythema multiforme, drugs
-Collagen defect: Epidermalysis bullosa
What are the investigations for blistering conditions
-Incisional biopsy with a H&E stain to see the level of the blister within the epithelium
-Direct immunofluorescence
-Indirect immunofluorescence using patient’s serum
What is pemphigus vulgaris
-Intra-epithelial blistering disorder
-IgG auto-antibodies target the attachment proteins of desmosomes
-Causes dissolution of cell-to-cell adhesion
What are some risk factors for pemphigus vulgaris
-Diet rich in leeks, garlics, onions
-Sulphydryl containing drugs (captopril)
-Non-thiol containing drugs (diclofenac, rifampicin)
What is the clinical presentation of pemphigus vulgaris
-Affects the buccal mucosa, gingiva, palate
-Positive nikolsky’s sign
-Desquamative gingivitis
-Mucosal and skin lesions
-If oesophageal involvement then dysphagia
-Slow healing erosions
Describe the histological findings associated with pemphigus vulgaris
-Direct IF shows fishnet appearance
-Histology shows acantholysis which is the epithelium splitting into single cells
-Intraepithelial clefting is where the blisters form between the splitting epithelial cells
What is the treatment for pemphigus vulgaris
-Topical corticosteroids
-Systemic corticosteroids
-Steroid-sparing agents (immunosuppressants) such as azathioprine
-IV immunoglobulins
-IV monoclonal antibodies
What is mucous membrane pemphigoid
-Sub-epithelial blistering disorder
-Chronic or unknown aetiology
-Circulating or bound antibodies targeting the basement membrane zone
What is the clinical presentation of mucous membrane pemphigoid
-Positive nikolsy’s sign
-Desquamative gingivitis
-No skin lesions
-Irregular painful erosions
-Occular pemphigoid
Explain the occular changes associated with mucous membrane pemphigoid
-Conjunctival scarring
-Irritation of the eyes, excessive tearing
-Entropion (inturning of the lower eyelid)
What is the treatment for mucous membrane pemphigoid
-Topical corticosteroids
-Systemic corticosteroids
-Azathioprine
-Anti-inflammatory antibiotics (doxycycline)
-Dapsone
What is bullous pemphigoid and what is the management
-Blistering condition of the skin only
-Treated with corticosteroids and dapsone
What is dermatitis herpetiformis
-Papulovesicular rash
-Associated with gluten sensitive enteropathy
-Clinical presentations as blisters on the elbows, buttocks and knees
-Transient oral ulceration
What is the treatment for dermatitis herpetiformis
-Dapsone
-Gluten free diet
What is erythema multiforme
-Chronic hypersensitive reaction
-Causes lip erosions which are painful and slow to heal
-Target/iris lesions of the skin
What are the causes of erythema multiforme
-Drugs
-Infections (HSV)
-Idiopathic
-Malignancy, SLE
What is angina bullosa hemorrhagica
-Single blood blisters on the junction of the hard and soft palate
-Usually rupture after one day and heal over one week
-Reoccurence may occur
What are the causes of angina bullosa hemorrhagica
-Use of inhaled steroids
-Diabetes (can cause vascular fragility)
-Hard/dry foods, dry mouth
What is the management of angina bullosa hemorrhagica
-FBC
-Difflam
-Chlorhexidine mouth wash
-Incision if causing respiratory depression
What is the definition of Xerostomia and hyposalivation
-Xerostomia is the feeling of dry mouth
-Hyposalivation is the objective reduction in salivary gland secretion due to reduced salivary gland function
What are the functions of saliva
-Antimicrobial properties
-Lavage and buffering
-Taste perception
-Digestion
-Lubrication for speech and swallowing
What are the complications of xerostomia
-Dryness of the GI tract
-Voice hoarseness
-Increased risk of soft tissue disease
-Dental problems
-Difficulty speaking and swallowing
What questions need to be asked in the diagnosis of xerostomia
-Have you had persistently swollen salivary glands for more than 3 months
-Do you feel dryness for more than 3 months
-Do you wake up at night needed to drink fluids
-Do you struggle to swallow dry foods without fluids
What is the aetiology of dry mouth
-Dehydration
-Age
-Idiopathic
-Medications
-Habits (mouth breathing)
-Systemic conditions
-Salivary gland disease
What are the classifications of salivary gland disease
-Infective (bacterial or viral siladenitis)
-Damage to salivary glands secondary to cancer therapy
-Tumour of salivary gland
-Obstruction (calculi)
-Degenerative disease (sjogrens)
What are some systemic diseases associated with dry mouth
-Diabetes
-HIV
-Liver disease
-Sjogrens syndrome
-Sarcoidosis
What is important to do when examining salivary glands
-Muscle weakness
-Parasthesia
-Facial nerve weakness
-Compressible mass
-Lymphadenopathy
What is sialosis
-Bilateral, non-specific inflammation of salivary glands (usually parotid)
-Aetiology is unknown
-Associated with alcoholism, nutritional deficiencies, pregnancy, diabetes
What is sialolithiasis
-Presence of stones or calculi in the submandibular gland
-Causes mealtime syndrome
What is sialadenitis
-Enlargement of the parotid or submandibular gland due to infection, inflammation or obstruction
-Can be caused by mumps, sarcoidosis, sjogrens
What is pleomorphic adenoma
-Benign epithelial salivary gland condition
-Affects parotid gland
-Diverse histological patterns
-Incomplete capsule can make excision difficult
What is warthin’s tumour
-Benign epithelial salivary gland condition
-Smooth, soft parotid mass
-Low rate of reoccurence
What is a haemangioma
-Benign non-epithelial vascular tumour
-Common in children
-Dark red, lobulated mass
-Common in parotid gland
-Fast growth from 0-6 months, slow growth till 12 years
What is necrotising sialometaplasia
-Benign, self-healing condition affecting minor salivary gland
-Single unilateral lesion on the hard palate
What is mucoepidermoid carcinoma
-Malignant salivary gland tumour affecting parotid gland
-Made of mucous and epidermoid cells
-Low grade is easy to treat
-High grade has regional metastases to the lymph nodes
What is adenoid cystic carcinoma
-Malignant salivary gland tumour affecting submandibular gland
-Regional metastases less common, but can have distant metastases to the lungs
What is carcinoma ex-pleomorphic adenoma
-Regional and distant metastases are common
-Sudden growth, aggressive
What is sjogre’s syndrome
-Autoimmune condition
-Primary: dry eyes and dry mouth
-Secondary: dry eyes, dry mouth, connective tissue disorder such as rheumatoid arthritis
What are the special investigations for sjogren’s syndrome
-Blood test to look for anti-Ro, anti-La antibodies
-Imaging (sialography, US)
-Saliva flow rate test
What is the management for salivary gland disease
-Regular dental visits, good OH, fluoride
-Diet advice
-Sip water frequently
-Use sugar free gum
-Artificial saliva
-Treat candida
-Pilocarpine in severe cases
Complications of sjogrens
-Lymphoma
-Heart block
-Eye damage
What are the effects of changes in iron, folate and B12 on the oral environment
-Atrophy of the epithelium
-Depapilation of the tongue
-Changes to the filoform papilla which results in candida infection and soreness
-Glossitis (iron deficiency: smooth, B12 deficiency: raw beefy red)
-ROU
-Angular chelitis
-Burning mouth syndrome
-Patterson Kelly syndrome (kolinchyia, iron deficiency anaemia, post-cricoid webs, glossitis)
-Candida
What are the oral features of alcoholism
-Sialosis
-Dental erosion
-Oral squamous cell carcinoma
-Liver cirrhosis
What are the oral features of bulimia nervosa
-Maintain a consistent weight unlike anorexia
-Russel’s signs on the hands
-Erosion
-Sialosis
-Ulcers on the palate
-Angular chelitis
What are the predisposing factors for ANUG
-Stress
-Immunocompromised
-Poor OH
-Smoking
-Malnutrition
What is the clinical presentation of ANUG
-Punched out ulceration of the gingiva
-Halitosis (rotting hay smell)
-Pain
-Periodontal pockets
-Sloughing of the gingiva
What is the treatment for ANUG
-Analgesics
-Antibiotics if systemic involvement
-Chlorhexidine mouthwash
-Periodontal assessment
-Good OH
-Smoking cessation
What are the effects of vitamin C deficiency
-Proliferation of the blood vessels around the gingiva and the hair follicles
-Causes cork screw hairs
-Causes exfoliation of teeth
-Scurvy
What are the effects of zinc deficiency
-Benign migratory glossitis
-Lethargy
-Growth retardation
-Poor wound healing
-Alopecia
What is the treatment of benign migratory glossitis
-Difflam (benzydamine rinse)
-Treat associated candida infection
-Corticosteroids
-Exclude other sources of tongue soreness
What is coeliac disease
-Inflammatory condition affecting the small intestine
-Induced by gluten
What are the oral manifestatiosn of coeliac disease
-Enamel hypoplasia
-ROU
-Angular chelitis
-ROU
-Exacerbation of lichen planus
-Glossitis (burning mouth)
What oral lesions are characteristic of crohn’s disease
-Mucosal tags
-Cobblestone mucosa
-Lip fissuring
-Deep linear ulceration
What is orofacial granulomatosis and its management
-Labial swelling which is recurrent
-Associated with a granulomatous infection
-Can be associated with angular chelitis, mucosal tags, mucosal ulceration
-Avoid cinnamon, use corticosteroids
Whats is peutz-jehghers
-Genetic condition resulting in perioral and vermillion freckles
-Risk of intestinal polyps
What is lichen planus
-Immune-mediated
-Basal cell degeneration
-Caused by cytotoxic T-cells
-Skin and oral lesions
What are the predisposing factors for lichen planus
-Diabetes
-Liver disease
-Stress
-Spicy/acidic foods
What are the types of lichen planus
-Reticular
-Erosive
-Ulcerative
-Plaque-like
-Bullous
-Papular
Where does lichen planus affect
-Skin and oral lesions
-Areas of high friction (kobener’s phenomenon)
-Buccal mucosa, gingiva, tongue (rarely hard palate)
-Hair, nails, genitals
What are the key histopathological features for lichen planus
-Basal cell degeneration/liquefaction
-Hyperkeratosis
-Saw tooth rete ridges
-Lymphocyte-dominant sub-epithelial band
Management of lichen planus
-Reassure patient and warn them of malignant transformation
-Eliminate traumatic factors of restorations
-Eliminate chemical irritation from spicy or acidic foods
-Good OH to reduce plaque
-Eliminate SLS products
-Alcohol and smoking cessation
Pharmacological management of lichen planus
-Topical and systemic corticosteroids
-Calcineurin inhibitors (tacrolimus/pimecrolimus)
What is lichenoid reaction and management
-Similar to lichen planus
-Response to drugs or dental materials
-Take a good drug history
-Removal of the drug or material under rubber dam will resolve the symptoms
Describe the histology of lichenoid reaction
-Similar to lichen planus
-Increased eosinophils
-Considerable basal cell liquefaction
What is the clinical presentation of DLE
-Scaly, well-demarcated, atrophic skin lesions
-Found in areas exposed to sunlight
-Oral lesions similar to lichen planus
-SLE found on palate unlike lichen planus
What are the special investigations for DLE
-Biopsy
-Serum
What are the histological features of DLE
-Parakeratosis or orthokeratosis
-Basal cell degeneration
-Chronic inflammatory cell infiltration of sub-epithelial layer
-Irregular pattern of acanthosis
What is the management of DLE
-Oral lesions management is same as lichen planus
-Chloroquine or SPF for skin lesions
What are the risk factors for GVHD
-Elderly donor or recipient
-Poorly matched grafts
What are the features seen with GVHD
-Oral dryness
-Burning sensation
-Reduced oral opening if sclerotic form of GVHD
What is the management of GVHD
-Topical analgesics
-Corticosteroids
-Tacrolimus
-Increased risk of OSCC developing so monitor regularly
What is the management of GVHD
-Topical analgesics
-Corticosteroids
-Tacrolimus
-Increased risk of OSCC developing so monitor regularly
What is the difference between an erosion and an ulcer
-An erosion is a partial loss of skin or mucous membrane
-An ulcer is a total loss of epithelium
What is the relevant history we would take for an ulcer
-Age
-Smoking and alcohol
-Check for other malignancy
What are the features we would consider in a ulcer history
-Size, site, shape
-Age of onset
-Duration and frequency of attack
-Ulcer-free periods
-Prodrome
-Coalesce?
-Smoking cessation/menstruation
What is the classification of ulceration
-Single persistent: neoplastic
-Single episode: trauma, infective, drugs
-Recurrent: RAS, erythema multiforme
-Recurrent: secondary to systemic disease
What are the characteristics of major RAS
->10mm diameter
-Oval
-Grey base, erythematous border
-All surfaces
-Heals after up to 3 months
-Scars on healing
-1-10 in a crop
-Occurs in first decade of life
What are the characteristics of minor RAS
-<10mm diameter
-Oval
-Grey base, indurated border
-Non-keratinised, esp. buccal mucosa
-Heals after 1-2 weeks
-No scars
-1-5 in a crop
-Occurs in second decade of life
What are the characteristics of herpetiform RAS
-0.5-3mm in diameter
-Round, coalesce
-Yellow base, erythematous border
-Non-keratinised, esp floor of mouth
-Heals after 1-2 weeks
-Up to 20 in a crop
-Occurs in third decade of life
What are the special investigations for ulcers
-Blood tests
-Biopsy
-Imaging
What is the treatment for ulcers
-Topical or systemic analgesics to relieve the pain
-Corticosteroids to promote healing
-CHX mouthwash to maintain health
What is behcet’s disease
-Triad of oral ulceration, uveitis, and genital involvement
What is Candida albicans sensitive to
-Temperature
-pH
-Availability of nutrients
-These can cause normal organisms to become pathogenic
What are the histological findings associated with candida
-Gram stained smear
-Associated with tangled hyphae
-Detached epithelial cells
-Leucocytes
What are the general factors affecting candida infection
-Broad spectrum antibiotics
-Nutritional deficiency
-Immunosuppression
-Diabetes
-Xerostomia
What are the local factors affecting candida infection
-Poorly fitting dentures
-Smoking
-Carbohydrate rich diet
How does drug therapy impact on candida infections
-Broad spectrum antibiotics will alter the microflora in the mouth
-Reduces competition for other substrates
-Xerogenic agents reduce salivary flushing capacity
-Saliva contains anti-fungal agents
How does diabetes increase risk of candida infection
-Reduced pH
-Increased blood glucose concentration which acts as a substrate for candida
How does immunodeficiency cause candida infection
-Cell mediate and humoral immunity is important in the prevention of fungal infections
What is the presentation of acute pseudomembranous candida
-Creamy white plaques that rub off to reveal an erythematous, bleeding base
What is the management of acute pseudomembranous candida
-Improve oral hygiene
-Investigate and treat systemic causes
-Nystatin suspension or miconazole
-Chlorhexidine mouthwash
What is the presentation and risk factors for chronic hyperplastic candida
-White lesions found bilaterally at the buccal mucosa close to the lip commisures
-Do not rub off
-Common in smokers, middle aged males
What is the management for chronic hyper plastic candida
-Biopsy is mandatory due to malignant transformation risk
-Remove predisposing factors such as smoking
-Check for iron, folate, B12 levels
-Oral fluconazole for 2-4 weeks
What is denture stomatitis
-Associated with upper acrylic dentures
-Poor fit of denture excludes saliva from the supporting mucosa
-Associated with inadequate denture hygiene
What is the newton’s classification
-Type 1: pinpoint erythema
-Type 2: diffuse erythema limited to fit surface of the denture
-Type 3: Nodular appearance of palatal mucosa
What is the management of denture stomatitis
-Improve denture and oral hygiene
-Eliminate trauma with soft tissue conditioners
-Apply miconazole gel
What is the management of angular chelitits
-Correct vertical dimension
-Improve denture hygiene
-Treat with trimovate cream to the corners of the lips
-Miconazole gel
What is median rhomboid glossitis
-Localised candida infection
-Causes atrophy of the filiform papilla anterior to the circumvallate papilla
-Usually a smooth diamond shape
-Associated with smoking and corticosteroid use
What are the possible sampling methods for candida infection and their advantages or disadvantages
-Saliva culture: not useful in xerostomia
-Swab: identifies the type of candida present, but does not quantify
-Smear: quantitative
-Biopsy: requires minor oral surgery
