oral med Flashcards
syphilis
sexually shared infection caused by t.pallidum
can be congenital / acquired
acquired is primary / secondary / tertiary
primary syphilis
painless round / ovoid lesion
lips common site
painless rubbery cervical lymphadenopathy may be a feature
highly contagious
resolves 2-3mths
secondary syphilis
1-4mths following healing of primary encounter
generalised macular skin rash
superficial ulcers
resolves 2-6wks although may enter latent phase
diagnosis of syphilis
serological tests i.e. TPHA / FTA
clinical features of candida (6)
- pseudomembranous (acute / chronic) - white / yellow plaques removed to reveal erythematous base which can bleed
- erythematous (acute / chronic) - commonly on dorsal surface of tongue, palate & buccal mucosa
- hyperplastic (chronic) - chronic discrete adherent white plaque like lesions, commonly at commissures
- denture induced stomatitis* - chronic erythema & oedema of mucosa in contact with fitting surface of denture
- angular cheilitis* - soreness, erythema, fissuring at angles of the lips
- median rhomboid glossitis* - papillary atrophy centrally placed anterior to circumvallate papillae
* candida associated lesions
local factors predisposing to candida
trauma / denture wearing / poor denture hygiene / xerostomia
systemic factors predisposing to candida
radiotherapy / AB therapy / diabetes / nutritional deficiency / immunosuppression / smoking
investigating candida
swab & smear from palate & denture for everything except chronic hyperplastic
only 2 to biopsy is chronic hyperplastic & median rhomboid glossitis
screen for deficiencies & diabetes
FBC, ferritin, folate, b12 & glucose
tx of candida
- fluconazole capsules 50mg 1 x 7 days
- miconazole gel 20mg/g pea size x 4 daily continue to use for 7 days after lesions healed
- nystatin oral suspension 100,000 units/ml rinse after food x 4 daily & use for 48hrs after lesions healed
contraindications of azole antifungals
warfarin
statins
PHG cause
HSV 1
sometimes HSV 2
transmission via direct contact with infected skin / saliva
PHG clinical features
pyrexia, malaise, painful mouth & throat, cervical lymphadenopathy
widespread IO vesicles which rapidly rupture to form small irregular superficial ulcers with erythematous halos
gingiva if infected appear inflamed & bleed readily
SELF LIMITING & resolve in 10-14 days
investigations for PHG
hx & clinical features
PCR / detecting virus in smear / viral culture
tx of PHG
mild - symptomatic i.e. analgesia & fluids, can also give
- CHX 0.2% 10ml rinse for 1 min x 2 daily until resolved
- H2O2 6% 15ml diluted for 2 mins x 3 daily until resolved
mod / severe / immunocompromised pts - aciclovir 200mg x5 for 5 days
recurrent herpetic infection
in form of herpes labialis (cold sores)
lies dormant in trigeminal ganglion
reactivated via:
- fever
- trauma
- sunlight exposure
- menstruation
- immunosuppression
tx = topical aciclovir 1% / 5% every 2hrs during prodromal stage
varicella zoster virus causes
varicella - chicken pox in children
zoster - shingles in adults
tx via aciclovir (higher dose) 800mg x 5 daily for 5 days
what is aciclovir
systemic anti viral inhibits DNA polymerase by acting as defective guanine molecule
coxsackie virus causes
herpangina
HFM disease
tx of both = control symptoms via soft diet, fluids, analgesia
HPV - squamous cell papilloma
common benign tumour found on soft palate but also may affect dorsum / lateral surfaces of tongue
3rd-5th decade
pedunculated or sessile cauliflower like swelling
causes of ulceration
traumatic
idiopathic
infection - viral / fungal / bacterial
systemic disease association
dermatological diseases
neoplastic
drug induced i.e. nicorandil (K channel activator)
3 types of recurrent aphthous stomatitis
- minor <10mm, last <14 days, scarring uncommon
- major >10mm, last >30 days, scarring common
- herpetiform F>M, 1-2mm, larger if ulcers coalesce, >30 days, scarring possible if ulcers coalesce
investigation & diagnosis of RAS
FBC, haematinics (folate, ferritin, B12), coeliac screen (TTG tissue transglutaminase antibodies), allergy
RAS tx
no specific
antiseptic MW - CHX 0.2% / benzydamine MW 0.15% rinse using 15ml every 1.5hrs as required (or use 0.15% spray)
topical corticosteroids - beclomethasone MDI 50mcg 1-2 puffs directly onto ulcers x2 daily // betamethasone MW 500mcg 1 tablet dissolved in 10ml water x 4 daily // hydrocortisone oromucosal tablets 2.5mg 1 tab dissolved next to lesion x 4 daily for 5 days
systemic corticosteroids - prednisolone
other = azathioprine, dapsone etc
behcets syndrome
comprises triad of RAS, genital ulceration & posterior uveitis
diagnosis essentially clinical
tx - via immunosuppressive agents e.g. corticosteroids / azathioprine / topical tacrolimus
oral ulceration managed as for RAS
intraepithelial vesiculobullous disease
pemphigus vulgaris
viral infections (HSV / HZV / CXS)
subepithelial vesiculobullous disease
angina bullosa haemorrhagica
mucous membrane pemphigoid
lichen planus
erythema multiforme
direct immunofluorescence in vesiculobullous diseases
pemphigus = intercellular IgG & C3, basket weave pattern
mucous membrane pemphigoid & bullous pemphigoid = linear IgG & C3 at basement membrane zone
angina bullosa haemorrhagica
older people
rapid formation of blood filled blister
usually soft palate
ruptures to leave superficial ulcer which is self limiting
unknown aetiology
tx - reassure & antiseptic MW for symptomatic relief
pemphigus vulgaris
autoimmune skin disease
clinical - widespread bullous lesions, oral lesions in almost all pts, positive nikolsky sign, INTACT IO BULLAE ARE RARE, tend to rupture shortly after they form, pain, scarring uncommon
failure to tx may be fatal
pemphigus vulgaris investigation & diagnosis
routine histopathological exam of perilesional tissue
with direct / indirect immunofluorescence
IgG & C3 bind to component of desmosomes (predominantly desmoglein 3)
circulating antibody titre reflects severity of disease & can be used as marker of disease acitivty
pemphigus vulgaris tx
immunosuppressive therapy & corticosteroids +/- azathioprine
mucous membrane pemphigoid
chronic subepithelial bullous disorder principally affecting the elderly
lesions on oral / genital mucosa
heals with scarring
clinical - bullae thick walled, intact for days before rupturing to leave superficial areas of ulceration, may also present as desquamative gingivitis
mucous membrane pemphigoid investigation & diagnosis
histopathological examination shows subepithelial bulla formation
immunofluorescence shows IgG & C3 at basement membrane
erythema multiforme
self limiting vesiculobullous disease affecting skin +/- mucous membranes
usually young adult males
precipitating factors = HSV / thiazide diuretics / carbamazepine
clinical - skin lesions, erythematous maculopapular rash, target lesions, haemorrhagic crusting of lips with extensive bullous lesions which rapidly rupture to form widespread painful erosions, ocular involvement may lead to conjunctival scarring & blindness
usually subside within 2wks but can recur
erythema multiforme investigation, diagnosis & tx
clinical picture but can confirm with biospy
tx = identify & eliminate precipitating factor if possible e.g. aciclovir if HSV, prevent dehydration, systemic corticosteroids +/- azathioprine
white sponge naevus
benign keratin defect
autosomal dominant
genetic
biopsy will confirm
reassure
no tx
other white patches
chemical burn - resolves following removal of irritant
smoker’s keratosis - typically palate, tongue. commissures
frictional keratosis - in response to chronic low grade trauma e.g. cheek biting - will resolve when irritation removed
leukoplakia
white patch that cannot be wiped off or characterised clinically or pathologically as any other disease essentially a diagnosis of exclusion
erythroplakia
bright red patch that cannot be attributed to any other cause
factors associated with increased rate of malignant transformation (3)
site of lesion - FoM, ventral surface of tongue, lingual alveolar mucosa
presence of epithelial dysplasia
clinical nature - nodular / speckled leukoplakia
chronic hyperplastic candidiasis
aka candidal leukoplakia
persistent white / speckled red/white lesion
predisposing factors:
- tobacco usage
- nutritional deficiency
- poor denture hygiene
- corticosteroid inhaler use
mx - biopsy of all red / white lesions, eliminate predisposing factors, antifungal therapy
oral submucous fibrosis
increased risk with chewing betel quid / areca nut
epithelial dysplasia common finding histological evidence of carcinoma in 5-6%
progressive fibrosis
aetiological factors of mouth cancer
tobacco
alcohol *
diet
UV
chronic candida i.e. chronic hyperplastic candidosis (premalignant condition)
HPV
immunosuppression
syphilis *
* causes mucosal atrophy which in turn thins epithelium making it more susceptible to carcinogens
black hairy tongue
benign
overgrowth of filiform papillae with lack of normal desquamation
overgrowth of bacteria / fungi cause discolouration
exacerbated by tobacco use
reassure, brush tongue, tongue scraper
geographic tongue
irregular partially depapillated areas on anterior 2/3s of tongue often with distinct white margins
regress & reappear on other parts of tongue
asymptomatic but may show sensitivity to hot spicy food
for pilocarpine to work
pts must have some residual functional salivary gland tissue
sialadenitis
local e.g. calculus or systemic e.g. diabetes / sjogrens causes of reduced salivary flow invoke ascending infection from oral flora i.e. s.aures / s.viridans
pain & swelling of affected gland, pyrexia, malaise, cervical lymphadenopathy
tx - ABs / drainage by use of sialogogues
burning mouth syndrome
chronic pain disorder (burning) in the absence of mucosal pathology
investigate - haematinics, diabetes control, psychological factors
persistent idiopathic facial pain
diagnosis of exclusion
pain - persistent & present daily
confined to outset of 1 side of face
not associated with other signs
high incidence of depression / anxiety
tx via SSRIs e.g. fluoxetine / tricyclic antidepressant i.e. amitriptyline
trigeminal neuralgia
classical ( compression of nerve)
secondary (to space occupying lesion i.e. tumour / MS )
idiopathic
severe paroxysmal pain, lasts secs, mandib > max branch of TN, older pts, electric shock like pain
investigate - MRI, cranial nerve testing, OPT to rule out dental cause
tx - carbamazepine, oxcarbazepine, gabapentin, phenytoin, valproate
malignant transformation of lichen planus
1% chance over 10 year period
aetiology of lichen planus
exogenous - dental materials / food allergens / drugs e.g. diuretics, beta blockers / infection i.e. bacterial plaque & candida / stress / tobacco / trauma
systemic - GVHD / nutritional deficiencies / diabetes mellitus / liver disease
histological features of lichen planus
acanthosis
liquefaction degeneration of basal cell layer
inflammatory cell infiltrate in deeper layers of epithelium
dense subepithelial band of chronic inflammatory cells with well defined lower border
tx of lichen planus
antiseptic MW - CHX 0.2% / benzydamine MW 0.15% rinse using 15ml every 1.5hrs as required (or use 0.15% spray)
topical corticosteroids - beclomethasone MDI 50mcg 1-2 puffs directly onto ulcers x2 daily // betamethasone MW 500mcg 1 tablet dissolved in 10ml water x 4 daily
systemic corticosteroids - prednisolone
azathioprine
topical tacrolimus
this is for tx of symptomatic lesions, asymptomatic don’t require active tx
systemic lupus erythematous
autoimmune disorder of unknown aetiology, potentially drug induced i.e. phenytoin F>M 9:1
photosensitive erythematous rash (butterfly), arthritis, anaemia = main symptoms
oral lesions in 1/3 of pts, similar to those of lichen planus with erythematous lesions & superficial erosions
difficult to tx & may only respond to high dose systemic corticosteroids
orofacial granulomatosis
if pt has crohn’s this is termed oral crohn’s
clinical - recurrent ulcers diffuse lip or cheek swelling cobblestone appearance of mucosa mucosal tags full width gingivitis granulomatous angular cheilitis vertical fissures of the lips
upper v lower motor neurone lesions
upper -> affects only lower part of face on opposite side e.g. cerebrovascular accident, MS
lower -> affects whole face on same side e.g. Bell’s palsy, trauma, parotid gland tumour, otitis media
bell’s palsy
acute onset over several hrs
recover spontaneously
protect cornea while palsy present
oral features of anaemia
recurrent oral ulceration
atrophic glossitis
angular cheilitis
oral dysaesthesia
oral features of leukaemia
bleeding, mucosal pallor, increased predisposition to infections e.g. candida / herpes, ulceration, gingival swelling
lesions strongly associated with HIV infection
candidiasis
hairy leukoplakia
kaposi’s sarcoma
non hodgkin’s lymphoma
periodontal disease (ANUG/P)
hairy leukoplakia
usually asymptomatic
bilateral vertically corrugated white patches on lateral margins of tongue
marker of underlying immunodeficiency
opportunistic infection of oral mucosa by EBV
marker of poor prognosis in HIV pts
non hodgkin’s lymphoma
uncommon but well recognised complication of HIV infection
rapidly enlarging, firm, rubbery swelling
fauces / palate / gingivae
tx via radio/chemotherapy
