Oral Med Flashcards
1
Q
What are the 2 main systems for classifying orofacial pain?
A
- International classification of Headache Disorders Edition 3
- International Classification of Orofacial Pain 1st Edition 2020
2
Q
What are the 6 groups/categories of orofacial pain?
A
- Orofacial pain attributed to disorders of dentoalveolar and anatomically related structures
- Myofascial orofacial pain
- Temporomandibular joint (TMJ) pain
- Orofacial pain attributed to lesion or disease of the cranial nerves
- Orofacial pains resembling presentations of primary headaches
- Idiopathic orofacial pain
3
Q
What are the 2 subtypes of “orofacial pain attributed to lesion or disease of the cranial nerves”.
A
- Pain attributed to lesion or disease of the trigeminal nerve
- Pain attributed to lesion or disease of the glossopharyngeal nerve
4
Q
Name 2 conditions of “pain attributed to lesion or disease of the trigeminal nerve”.
A
- Trigeminal neuralgia
- Painful trigeminal neuropathies
5
Q
Name 2 coniditons of “pain attributed to lesion or disease of the glossopharyngeal nerve”.
A
- Glossopharyngral neuralgia
- Painful glossopharyngeal neuropathies
6
Q
Name 4 conditions of “orofacial pains resembling presentation of primary headaches”.
A
- Migraine
- Tension type headache (TTH)
- Trigeminal autonomic cephalalgias (TACs)
- Other primary headache disorders
7
Q
Name 3 conditions of “idiopathic orofacial pain”.
A
- Burning mouth syndrome (BMS)
- Persistent idiopathic facial pain (PIFP)
- Persistent idiopathic dentoalveolar pain
8
Q
Give a definition of trigeminal neuralgia
A
- Limited to the distribution of one or more divisions of the trigeminal nerve
- Normally unilateral
- Pain comes on very suddenly and ends just as suddenly
- Pain doesnt last very long but when it is there it is severe
- Pain like an electric shock
- Has recurrent bursts of this pain
- Pain usually triggered by an innocuous stimuli (a stimuli that wouldnt normally cause pain eg touching face)
9
Q
State the diagnostic criteria for trigeminal neuralgia.
A
A: Recurrent paroxsyms of unilateral facial pain in the distribution(s) of one or more divisions of the trigeminal nerve, with no radiation beyond, and fulfilling criteria B and C.
B: Pain has all of the following characteristics:
- Lasting from a fraction of a second to 2 minutes
- Severe intensity
- Electric shock like, shooting, stabbing, or sharp in quality
C: Precipitated by innocuous stimuli within the affected trigeminal distribution
D: Not better accounted for by another ICHD-3 diagnosis
10
Q
What is the incidence of trigeminal neuralgia?
A
- 4-13 per 100,000
- Age: 50-60 years (unusual under 40 to have this)
- Females > Males
11
Q
What are risk factors for trigeminal neuralgia?
A
- Hypertension
- Stroke
12
Q
What % of trigeminal neuralgia is related to dental treatment?
A
22%
13
Q
What % of patients have pain free periods which lasts either days, weeks, months or years?
A
73%
14
Q
Should trigeminal neuralgia raise concerns of an underlying disease causing this?
A
Yes
15
Q
The maxilla and mandibular division is the most commonly affected branches of trigeminal neuralgia, what % affects the opthalmic branch?
A
5%
16
Q
In what % of cases will the patient be able to identify a trigger zone for trigeminal neuralgia?
A
50%
17
Q
What % of cases have no relieving factors although warmth and rest may be helpful?
A
65%
18
Q
What is a refractory period?
A
After the pain has been triggered, there is a period of time where the pain wont recur even if a trigger is re-applied
19
Q
Trigeminal neuralgia pain is so severe is makes patients cry and if left untreated can lead to depression and anxiety. True or false?
A
True.
20
Q
What 3 categories is trigeminal neuralgia split into?
A
- Classical trigeminal neuralgia
- Secondary trigeminal neuralgia
- Idiopathic trigeminal neuralgia
21
Q
Give a description of classical trigeminal neuralgia.
A
Trigeminal neuralgia developing without apparent cause other than neurovascular compression.
22
Q
What is the diagnostic criteria for classical trigeminal neuralgia?
A
- Reccurent paroxysms of unilateral facial pain fulfilling criteria for trigeminal neuralgia
- Demonstration on MRI or during surgery of neurovascular compression (not simply contact), with morphological changes in the trigeminal nerve root in the posterior cranial fossa.
23
Q
What is the root entry zone?
A
The point where the peripheral and central myelins of Schwann cells and astrocytes meet
24
Q
It is hypothesised that the morphological changes of the trigeminal nerve causes abnormal firing of the nerve: true or false?
A
true
25
What is classical trigeminal neuralgia with concomitant continuous pain?
Classical trigeminal neuralgia with persistent background facial pain.
- Will have recurrent paroxysms of unilateral facial pain fulfilling criteria for classical trigeminal neuralgia but will have concomitant continuous or near-continuous pain between attacks in the affected trigeminal distribution.
26
What is secondary trigeminal neuralgia?
Trigeminal neuralgia caused by an underlying disease. Clinical examination shows sensory changes in a significant proportion of these patients.
27
What is the diagnostic criteria for secondary trigeminal neuralgia?
- Recurrent paroxysms of unilateral facial pain fulfilling the criteria for trigeminal neuralgia, either purely paroxysms or associated with concomitant continuous or near-continuous pain.
- An underlying disease has been demonstrated that is known to be able to cause, and explaining the neuralgia.
28
What are 3 underlying diseases that are associated with secondary trigeminal neuralgia?
- Trigeminal neuralgia associated to multiple schlerosis (demyelination)
- Trigeminal neuralgia associated to space occupying lesion such as a cyst or tumour causing morphological changes.
- Trigeminal neuralgia attributed to another cause
29
What are some clinical features associated with secondary trigeminal neuralgia and what kind of imaging would you take?
- Tend to be patients <30 years
- Tend to have trigeminal sensory deficits
- Tend to have a bilateral trigeminal neuralgia
MRI scan ideally for this however if not available trigeminal reflexes may be tested.
30
What is idiopathic trigeminal neuralgia?
Trigeminal neuralgia with neither electrophysiological tests nor MRI showing significant abnormalities.
31
What is the diagnostic criteria for idiopathic trigeminal neuralgia?
- Recurrent paroxysms of unilateral facial pain fulfilling criteria for trigeminal neuralgia, either purely paroxysmal or associated with concomitant or continuous/near-continuous pain
- Neither classical trigeminal neuralgia nor secondary trigeminal neuralgia has been confirmed by adequate investigation including electrophysiological tests and MRI.
32
On examining a patient with suspected trigeminal neuralgia - a good history and examiantion is required for diagnosing. What are some "red flags" if noted in an exam that would require an urgent referral to a specialist?
- Sensory or motor deficits
- Deafness or other ear problems
- optic neuritis
- history of malignancy
- bilateral TN pain
- systemic symptoms eg fever, weight loss
- presentation in patients aged <30 years.
33
What is the first line of medical management for trigeminal neuralgia?
Carbamazepine - can be described for TN by GDPs working in the NHS or in private practice
Oxcarbazepine if carbamazepine is contr-indicated, not tolerated by the pt, or not providing adequate pain relief.
34
What is the pharmacology of carbazepine?
Brand name: Tegretol
Anti-convulsant: used for epilepsy and bipolar disorder
Binds to voltage dependent sodium channels therefore inhibit action potential membrane
Metabolised in the liver by enzymes in cytochrome group
Predominantly excreted in urine around 75% with remainder in faeces.
35
What 2 guidelines would you refer to when prescribing carbamazepine?
- BNF
-SDCEP
36
What are some considerations and cautions with carbamazepine?
- Do not prescribe for Han Chinese or Thai origin - testing required, increased liklihood of Stevens-Johnson syndrome
- Pregnancy- congenital malfunctions
- Hepatic and renal impairment - caution and monitoring
- Cross sensitivity with anticonvulsants
- Interactions: numerous includes herbal medicines e.g John Warts, alcohol and grapefruits
37
Patients or their carers must be given advice about how to recognize what disorders when taking carbamazepine?
- Liver
- Skin
- Bone marrow
Immediate medical attention is required if rash, fever, mouth ulcers, bruising or bleeding develop.
38
What instructions/advice would you give to a patient when prescribing carbamazepine?
Dosing regime:
- 100mg twice daily for 1-3 days
- review
- if necessary increase dose by 100mg every 2 days, introducing lunchtime and afternoon dose if necessary
- therapeutic range from 800-1200 mg per day
- once pain free for 4 weeks trial dose reduction
39
How often should patients get blood checks if prescribing carbamazepine?
- Not set regime however should have a baseline blood test prior to prescribing or as soon after- should get blood tests weekly for the first 4 weeks or until theyre on a stable dose
- Every 1-3 months after this
40
Name 4 second line drugs used to treat trigeminal neuralgia that can be used alone or in combination with carbamazepine or oxcarbamazepine.
- Lamotrigine
- Baclofen
- Gabapentin
- Pregabalin
41
What additional management can GDPs prescribe to help relieve symptoms of trigeminal neuralgia (one can be used as a diagnostic tool).
- Lidocaine 10mg per dose nasal spray for maxillary pain
- Lidocaine 5% ointment to be applied to trigger points as required.
- Lidocaine 2% 1:80,000 adrenaline can be used as infiltration/block to trigger point (diagnostic)
42
Why might other support such as psychological support be required for patients with trigeminal neuralgia?
- Severe pain
- May be difficult to control
- Side effects of medication
- Negative impacts on activities of daily living
- Negative impact on quality of life
- Depression
- Anxiety
- Suicidal ideation
43
Name examples of other support you can refer patients to for trigeminal neuralgia.
- Psychological support
- Role of nurse specialists (neurology department)
- National support groups: Trigeminal Neuralgia Association UK
44
State some indications where surgical management of trigeminal neuralgia would be beneficial for a patient.
- Medical management is ineffective
- Medication not tolerated
- Medication contra-indicated
- Short/no pain free periods
- complications
- adverse impact upon quality of life
45
What are the 2 different procedures of surgical mangement for trigeminal neuralgia?
1. Palliative destructive at the level of the grasserion ganglion. (ablation)
2. Posterior cranial fossa surgery (non-ablation)
46
What is palliative destruction at the level of the grasserian ganglion and name methods used for this.
- Involves controlled damage to the trigeminal ganglion of the peripheral branch of the trigeminal nerve with the aim of relieving pain.
Methods:
- radiofrequency thermocoagulation
- gycerol rhizolysis
- balloon compression
-steriotactic radiosurgery - gamma knife
47
What are methods of posterior cranial fossa surgery?
- microvascular decompression
- partial sensory rhizotomy
- internal neurolysis
48
What would be the typical surgical management of classical trigeminal neuralgia?
Microvascular decompression as long as not contraindicated
49
What would be the typical surgical management of idiopathic trigeminal neuralgia?
- neuroablative procedure
50
What roles are expected of the GDP when presented with a patient of suspected trigeminal neuralgia.
- Diagnose the majority of cases of TN
- To exclude a dental cause or contributing factor in patients symptoms
- Initiate medical management in conjunction with GMP
- Refer
51
Give a description of glossopharyngeal neuralgia.
A disorder characterised by unlateral brief stabbing pain, abrupt in onset and termination, in the distributions of not only the glossopharyngeal nerve but also of the auricular and pharyngeal branches of the vagus nerve. Pain is experienced in the ear, base of tongue, tonsillar fossa and/or beneath the angle of the jaw. It is commonly provoked by swallowing, talking or coughing and may remit relapse in the fashion of trigeminal neuralgia.
52
What is the diagnostic criteria of glossopharyngeal neuralgia?
A: Recurring paroxysmal attacks of unilateral pain in the distribution of the glossopharyngeal nerve, and fulfilling criteria B
B: Pain has all of the following characteristics:
- Lasting from a few seconds to 2 minutes
- Severe intensity
- Electric shock like, shooting, stabbing, or sharp in quality
- precipitated by yawning, swallowing, coughing or talking
C: Not better accounted for by another ICHD-3 diagnosis.
53
Name the 3 subtypes of glossopharyngeal neuralgia.
- Classical
- Secondary
- Idiopathic
54
What type of imaging would you do for investigation glossopharyngeal neuralgia?
- MRI extending down onto neck
55
What would be the first line of systemic management for glossopharyngeal neuralgia?
As for trigeminal neuralgia e.g carbamazepine
56
What are 3 categories/conditions of painful trigeminal neuropathies.
- Painful trigeminal neuropathy associated with herpes zoster virus
- Trigeminal post-herpetic neuralgia (post-herpetic neuralgia).
- Painful post-traumatic trigeminal neuropathy
57
What does allodynia mean?
Pain in response to a stimulus which would not normally give rise to pain (touch).
58
What is hyperalgesia?
Increased response to a stimulus which would not normally cause pain e.g cold
59
What is hypoalgesia?
Reduction in response to a stimulus which would normally cause pain
60
What is hyperesthesia?
Increased cutaneous/mucosal sensitivity to a stimulus e.g touch/temperature changes
61
What is dysesthesia?
An unpleasant abnormal sensation affecting the skin or mucosa e.g burning/tingling/crawling/stinging/pain.
62
Give a description for painful trigeminal neuropathies.
- Facial pain in the distribution of one or more branches of the trigeminal nerve caused by another disorder and indicative of neural damage
- The primary pain is usually continuous or nearly continuous, and commonly describe as burning or squeezing like pins and needles.
- Superimposed brief pain paroxysms may occur, but these are not the predominant pain type. This combination distinguishes painful trigeminal neuropathies to the subtypes of trigeminal neuralgia
- There are clinically detectable sensory deficits within the trigeminal distribution, and mechanical allodynia and cold hyperalgesia are common.
63
Would the painful area (allodynia) be much larger in cases of painful trigeminal neuropathies or trigmenial neuralgia?
Larger painful area in painful trigeminal neuropathies.
64
Give a description of painful trigeminal neuropathies attributed to the herpes zoster virus.
Unilateral facial pain of less than 3 months duration in the distribution(s) of one or more branches of the trigeminal nerve, cause by and associated with other symptoms and/or clinical signs of acute herpes zoster
65
Give a description of of trigeminal post-herpetic neuralgia (painful trigeminal neuropathy)
Unilateral facial pain of at least 3 months duration in the distribution(s) of one or more branches of the trigeminal nerve with variable sensory changes, caused by herpes zoster.
66
What prevention measures can be taken to prevent painful trigeminal neuropathies assocated with the herpes zoster virus?
- Prevention of developing shingles (herpes):
Immunisations against herpes zoster 70-79 years.
- Prevention of trigeminal post-herpetic neuralgia: Antivirals up to 72 following appearance of lesions of shingles
67
What are some conservative management options for trigeminal post-herpetic neuralgia.
- Explanation and reassurance
- Relaxation
- Excercises
- Distraction
-Mindfulness
68
What are 2 topicals that a specialist/GMP can prescribe for trigeminal post-herpetic neuralgia?
- Lidocaine patches
- Capsaicin cream/patches
69
Name 3 systemic drugs that a specialist/GMP can be prescribed for trigeminal post-herpetic neuralgia?
1. Duloxetine (SSNRI)
2. Amitriptyline
3. Amantadine
70
Give a description for painful post traumatic trigeminal neuropathy.
Unilateral or bilateral facial or oral pain following and caused by trauma to the trigeminal nerve(s) with other symptoms and/or clinical signs or trigeminal nerve dysfunction.
71
What is the diagnostic criteria for post traumatic trigeminal neuropathy.
A: History of an identifiable traumatic event to the trigeminal nerve(s), with clinically evident positive (allodynia, hyperalgesia) and/or negative (hypoalgesia, hypoesthesia) sign of trigeminal dysfunction.
B: Evidence of causation demonstrated by both of the following:
- Pain in localised to the distribution(s) of the trigeminal nerve affected by traumatic event
- Pain has developed < 6 months after traumatic event.
72
Give a description for idiopathic orofacial pain.
Unilateral or bilateral intraoral or facial pain in the distributions of one or more branches of the trigeminal nerve for which the aetiology is uknown. The pain is usually persistent, of moderate intensity, poorly localised and described as dull, pressing or burning character.
73
What are the 3 subtypes of idiopathic orofacial pain.
- Persistent idiopathic facial pain
- Persistent idiopathic dentoalveolar pain
- Burning mouth syndrome.
74
What is the role of the GDP in dealing with chronic orofacial pain.
- Take a good pain history
- Exclude dental causes
- Check cranial nerves, urgent referral if any abnormalities
- Reassure, some suggest management techniques
- Refer
75
Give a description for "persistent idiopathic facial pain"
Persistent facial and/or oral pain, with varying presentations but recurring daily for more than 2 hours per day over more than 3 months in the absence of clinical neurological deficit.
76
What is the diagnostic criteria for persistent idiopathic facial pain.
A: Facial and/or oral pain fulfilling criteria B and C
B: Recurring daily for >2 hours per day for >3 months
C: Pain has both of the following charactersitics:
- Poorly localised and not following the distribution of peripheral nerves
- Dull, aching or nagging quality
D: Clinical neurological examination is normal
E: A dental cause has been excluded by appropriate investigations
77
Name some clinical features associated with persistent idiopathic facial pain
- F>M
- 14-19% bilateral
- Constant daily pain (57-90%)
- Characteristics: deep poorly localised, nagging, burning, gripping, throbbing, pressure
- 17-35% pain free months
- Provoking factor: stress, cold weather, chewing, head movements, life events
- Relieving factors: warmth, pressure, medication
- Associated factors: dental treatment, psychiatric conditions, altered sensations.
78
When would special imaging be carried out with persistent idiopathic facial pain and what type of imaging would you do?
-MRI/CT/CBCT
- if pain has neuropathic components e.g short lived pain like TN
- If sensory deficit detected on checking trigeminal nerve
- If abnormality detected when checking cranial nerves
- If doubt with respect to diagnosis
- If patient continues to have significant concerns with respect to underlying cause such that they are unable to accept diagnosis.
79
How would you manage persistent idiopathic facial pain
- Cognitive behavioural therapy
-Self management techniques
- topical treatments (lidocaine patches/ointments)
- medication: amitripyline/duloxetine.
80
Describe persistent idiopathic dentoalveolar pain
Persistent unilateral intraoral dentoalveolar pain, rarely occuring in multiple sites, with varying features but recurring daily for more than 2 hours per day for more than 3 months in the absence of any preceding causative event.
81
What is the diagnostic criteria for persistent idiopathic dentoalveolar pain?
A: Intraoral dentoalveolar pain fulfilling criteria B and C
B: Recurring daily for >2hours for >3 months
C: Pain has both of the following characteristics:
- Localised to a dentoalveolar site
- Deep,dull, press-like quality
D: Clinical and radiographic examinations are normal and local causes have been excluded.
82
What are some clinical features of persistent idiopathic dentoalveolar pain.
Characteristics: severe throbbing, aching
Provoking factor: hot and cold, dental treatment, pressure on tooth
Relieving factors: warmth, pressure, medication
Associated factors: bruxism, emotional problems, anxiety, depression, hypersensitivity to hot and cold
83
What is the role of the GDP in persistent idiopathic dentoalveolar pain?
- Exclude dental causes
- Avoid unnecessary pulp extripations and extractions
- check cranial nerves
- reassure, suggest some self management techniques
- refer
84
How would persistent idiopathic dentoalveolar pain be managed?
- explanation and reassurance
- self management techniques
- topical - lidocaine ointment
- amitripyline/duloxetine
85
What is burning mouth syndrome?
An intraoral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day for more than 3 months without evident causative lesions on clinical examination and investigation.
86
What is the diagnostic criteria for burning mouth syndrome?
- recurring daily for > 2 hours per day and > 3 months
- pain has both of the following characteristics: burning quality, felt superficially in the mucosa
- Oral mucosa is of normal appearance and local or systemic factors have been excluded
87
What is the incidence of burning mouth syndrome?
1-15% general population
18-33% post menopausal women
F>M 3:1
88
Whats the most common sites affected in burning mouth syndrome?
- tongue (most common)
- palate
- lips
89
What local causes should you be excluding before a diagnosis of burning mouth syndrome?
- parafunctional habits
- dry mouth
- GORD: particularly if posterior part is affected
- candidiosis
90
What systemic causes should you be excluding before a diagnosis of burning mouth syndrome?
- anaemia
- haematinic deficiency
- diabetes (undiagnosed or poorly controlled)
- thyroid dysfunction
- medications e.g ACE inhibitors
91
How would burning mouth syndrome be managed?
- explanation and reassurance
- self-management techniques
- topical treatments: benxydamine mouthwash or oromucosal spray
- secondary care topical treatments: capsaicin mouthwash, clonazepam (oral rinse/tablet sucked then spat out)
- amitrityline/duloxetine
92
What is the GDPs role in burning mouth syndrome?
- exclude mucosal abnormality, local causes and systemic, if suspected, in collaboration with GMP
- avoid unecessary treatment
- check cranial nerves
- reassure, self management techniques, trial of benzydamine as mouthwash/ oral spray
- refer
93
Name dry mouth symptoms.
- dry mouth
- difficulty eating
- difficulty swallowing
- difficulty wearing dentures
- mucosal surfaces stick to each other and/or teeth
- bad taste in the mouth/altered taste
- halitosis
- sore mouth
- deteriorating dentition
- salivary gland swelling persistent/recurrent
94
What is xerostomia?
A sensation of oral dryness
95
What things in a patients medical history could contribute to a dry mouth?
- Uncontrolled diabetes
- Radiotherapy
- Polypharmacy
96
What would you be asking for a patients dental history with dry mouth?
- have they become to develop difficulty wearing dentures?
- Have they developed soreness in their mouth that they never had before
97
What would you be considering in a patients social history with dry mouth?
- Smoker? Smokers more susceptible to dry mouth
- Alcohol leading to dehydration
- Stressful occupation
98
What would you be looking for in a patients family history when considering dry mouth?
- Is there any family history of type 1 diabetes
- Rheumatoid arthiritis or lupus run in family? Can lead to Sjorgens Syndrome if so.
99
What scale can assess the severity of oral dryness?
The Challacombe Scale
100
Give the 10 clinical signs on the challacombe scale that would indicate a dry mouth.
1. Mirror sticks to buccal mucosa
2. Mirror sticks to tongue
3. Saliva frothy
4. No saliva pooling FOM
5. Tongue shows generalised shortened papillae
6. Altered gingival architecture (smooth)
7. Glossy appearance of oral mucosa especially palate
8. Tongue lobulated/fissured
9. Cervical caries on more than 2 teeth
10. Debris on palate or sticking to teeth
101
What does a score of 1-3 indicate on the Challacombe scale?
Mild dryness. Routine check up monitoring
102
What does a score of 4-6 indicate on the Challacombe scale?
Moderate dryness. Further investigations if cause not clear.
103
What does a sore of 7-10 indicate on the Challacombe scale?
Severe dryness. Cause needs to be determined exclude Sjorgens, refer.
104
What would the recommended management be for the Challacombe scale 1-3?
May not need treatment, sugar free chewing gum, attention to hydration.
105
What would the recommended management be for the Challacombe scale 4-6?
Sugar free gum or sialogogues. Consider saliva substitutes and topical fluoride.
106
What would the recommended management be for the Challacombe scale 7-10?
Saliva substitutes and topical fluoride.
107
What are some additional findings that can be present in the mouth as a result of dry mouth?
- Evidence of candidosis: angular chelitis, erythematous mucosa, thrush, denture stomatitis
- Traumatic ulceration
- Poor denture retention
- Bacterial sialadenitis
108
What additional investigation can you carry out to determine oral dryness?
Measure unstimulated salivary flow rate. Measure the whole saliva for 15 mins.
Can do stimulated salivary flow rate however this is undiagnostic but can have therapeutic significance.
109
What is the normal salivary flow rate and therefore what would be a significantly reduced rate of saliva?
Normal rate= >0.2ml/min
Significantly reduced rate = <0.1ml/min
110
What is the normal stimulated salivary rate?
>0.4ml/min
111
Name potential causes of dry mouth.
- age related
- stress
- mouth breathing
- diabetes
- side effect of medication
- head and neck radiation treatment
- chemotherapy
- sjorgens syndrome
- HIV infection
- Hepatitis C
- Sarcoidosis
- Graft versus host disease
- Renal failure
- Salivary gland aplasia
- Cystic fibrosis
112
What medications are known to have a side effects causing dry mouth?
- Urologicals: solefenacin, oxybutinin
- Nervous system: quetiapine, duloxetine, fluoxetine, amitriptyline.
113
For patients that have had chemotherapy when would you expect recovery of a dry mouth?
2-8 weeks
114
For patients that have had radiotherapy to the head and neck, when would you expect some recovery post treatment?
6-12 months
115
Which saliva gland is most susceptible to radiotherapy and why?
Parotid- contains more acinic cells which are more sensitive to radiotherapy.
116
Describe the pathology of Sjorgens Syndrome.
Autoimmune chronic inflammatory condition polyclonal B cell proliferation. Acinar atrophy secondary to infiltration by lymphoctyes. Exocrine glands.
117
Where does Sjorgens syndrome primarily affect?
eyes and mouth
118
What would you see in secondary Sjorgens syndrome?
- dry mouth
- dry eyes
- connective tissue disorder such as rheumatoid arthritis, lupus erythamatosus
119
List different investigations can that be carried out for diagnosing Sjorgens syndrome.
- Unstimulated whole salivary flow rate
- Lacrimal flow rate
- Ocular staining score
- Serology for connective tissue diseases
- Minor labial gland biopsy
- Ultrasound of salivary glands
- Full blood count
- Inflammantory markers
- IgG
- Sialography
120
What initial questions should you be asking a patient before moving on to further diagnosing for sjorgens syndrome?
- Have you had a daily feeling of dry mouth for over 3 months?
- Do you frequently drink liquids in aid in swallowing dry food?
- Have you had daily, persistent, troublesome dry eyes for more than 3 months
- Do you have recurrent sensation of sand/gravel in your eyes?
- Do you use tear substitutes more than 3 times daily?
121
What 5 investigations are in the criteria for diagnosis sjorgens syndrome and how much do they score by?
- serology (positivie anti Ro/SSA) = 3 points
- Labial gland biopsy (1 point per foci/4mm)
- Abnormal ocular staining (1 point)
- Schirmers test result <5mm/5min (1 point)
- Unstimulated salivary flow rate <0.1ml/min (1point)
122
What the minimum score to meet the criteria for primary sjorgens syndrome?
4
123
List the conditions that are in the exclusion criteria for sjorgens syndrome.
- AIDS
- sarcoidosis
- amyloidosis
- graft versus host disease
- IgG4 related disease
- Hep C
- history of head and neck radiotherapy
124
Why is a diagnosis of Sjorgens Syndrome important?
- Can refer to rheumatology to manage any systemic involvement
- Increased risk of lymphoma in Sjorgens syndrome
- May lead to diagnosis of an associated connective tissue disease in secondary Sjorgens
125
What is the role of the GDP for dry mouth?
- History
- Examination- using Challacombes scale
- Is referral necessary
- Management
126
What can dentists prescribe/recommend for stimulation of saliva.
- Artificial saliva pastilles DPF (Salivix)
- SST (Saliva stimulating tablets)
- Sugar free chewing gum/sweets
- Salivix plus pastilles
- Xerostom pastilles
- Xylimelts
127
What can specialists prescribe for xerostomia following irradiation for head and neck cancer; dry mouth and dry eyes in sjorgens syndrome.
Pilocarpine (5mg and increase).
128
What side effects can pilocarpine cause?
GI disturbances
sweating
129
What is sicca syndrome?
combination of dry mouth and dry eyes
130
What can dentists prescribe for post radiotherapy or sicca syndrome for saliva replacement?
- artificial saliva oral spray DTF (xerotin)
- Artificial saliva protective spray DPF
- Artificial saliva substitute spray
- Glandosane aerosol spray
- Saliveze oral spray
- Artificial salvia gel
- BioXtra (mouthspray)
-BioXtra (moisturising gel)
131
What advice can you give to a patient to prevent caries as higher risk with xerostomia.
- Diet advice
-OHI
- Fluoride: Sodium fluoride mouthwash 0.05% alcohol free
Sodium fluoride toothpaste 0.619% or 1.1% (2800ppm or 5000pm)
132
What complication can occur from xerostomia where patients present with acute onset salivary gland swelling where it is tender to touch, overlying skin is erythematosus and an unpleasant discharge. The main bacteria causing this infection is staph aureus.
Bacterial sialadenitis.
133
Name another complication that occurs due to xerostomia which is not candidal or bacterial sialadenitis.
staphylococcal mucositis
134
What medications are strongly related to excess saliva production?
clozapine, olanazipine, venlafaxine, quetiapine, risperidone.
135
What is the classical presentation of sialadenosis and when does it occur?
Bilateral, symmetrical, diffuse parotid salivary gland enlargement.
Diabetes, liver disease, bulimia, malnutrition, pregnancy, idiopathic.
136
What is the treatment for sialadenosis?
None required.
137
What are drugs that can cause oral ulceration?
methotrexate
nicorandil
bisphosphonates
NSAID
