Oral Med Flashcards
If a patient comes to you with a large ulcer, rolled edges and gradually increasing in size, what bacterial infection would you check for in their history?
Tuberculosis
What is the primary lesion in syphilis called and describe it?
It is called the chancre. it is painless, occurs at the site of infection. there is usually marked lymphadenopathy. ulcers last 1-2 months
What is the second lesion of syphilis called?
It is the snail track ulcer - the oral lesions have sloughy mucous patches. can clear up in 12 weeks, can last up to a year
What is a gumma?
this is the tertiary lesion of syphilis. it is necrotic granulous material on palate or tongue. can perforate the palate. this is the only non-infectious lesion of syphilis.
What causes primary hepetic gingivostomatitis?
HSV1/HSV2
What are the symptoms of primary herpetic gingivostomatitis? how would you treat it?
Child presents with multiple vesicles which break quickly and form shallow ulcers. there is mucositis.
lymphadenopathy and pyrexia.
Assure parent this is self limiting, child on soft diet, well hydrated - milk is good.
CHX to prevent secondary infection
paracetamol at the approved dose for weight to take down the pyrexia
aciclovir if very bad infection or if the child is immunocompromised
What diseases can varicella zoster cause?
Chicken pox and shingles
What are risk factors for shingles?
Elderly, immunocompromised, alcoholics
What is the clinical presentation of shingles?
it causes vesicles to errupt on the dermatome of the nerve it has infected. it heals in 2-4 weeks, scars, pipgments.
does not cross the midline, urgent referral to opthalmology if involves the eye
What are two diseases caused by the coxsackie virus?
herpangina
hand foot and mouth
What is the presentation of herpangina?
widespread ulcers on the mucosa, no gingivitis (difference to herpetic gingivostomatitis)
self limiting, 10-14 days
What disease is preceded by koplicks spots?
measles
What are the different types of oral candidosis?
pseudomembranous candidosis erythematous candidosis denture stomatitis angular cheilitis median rhomboid glossitis chronic hyperplastic candidosis chronic mucocutaneous candidosis
A patient presents with erythematous mucosa and white plaques which can easily be scraped off.
What Dx tests would you do and how would you treat it?
can do a swab of the area, or a mouth rinse with PBS for 1 mins. check for candida
treat with fluconazole, miconazole gels, nystatin gel
if glabrata or tropicalis - resistant to fluconazole so use CHX
careful of warfarin and statin interaction
what are the risk factors for angular cheilitis?
reduced OVD denture wearer immunocompromised diabetes haematinic deficiency
What are risk factors for median rhomboid glossitis?
inhaled steroids and smokers
How would you treat chronic hyperplastic candidosis?
Biopsy. incisional
systemic antifungals (floconazole and itraconzaole)
treat risk factor.
monitor as increased chance of malignant change
What are the classes of recurrent aphthous stomatitis?
Minor, Major, Herpetiform
What are the differences between the types of RAS?
minor - small ulcers, 1-6 at a time, non keratinised mucosa, heal 1-2 weeks, no scar
major - large ulcers, >10mm, last 1-2 months, keratinised mucosa, heal with scarring
herpetiform - very small ulcers, up to 100, FOM, lateral tongue, both keratinised and non keratinised mucosa. frequent recurrences
What types of bullous diseases should you be aware of?
pemphigus, pemphigoid, epidermolysis bullosa, angina bullosa haemorrhagica
What is angino bullosa haemorrhagica?
localised oral blood blister, soft palate and cheeks. exclude any other condition and reassure pt
Describe mucous membrane pemphigoid
mucous membrane bullae which rupture and heal with scarring. can affect eyes and lead to loss of vision.
test is direct or indirect immunofluoescence - IgG and C3 can be found at the basement membrane.
topical steroids, or methotrexate
what are the risk factors for erythema multiforme?
carbamazepine
penicillins
NSAIDs
infections (HSV, pneumonia)
How does erythema multiforme present?
immunologicaly mediated hypersensitivity reaction - skin and mucous membranes
get target lesions - concentrinc rings of erythema. pyrexia
self limiting around 1 month.
oral lesions form crusts and painful erosions.
What are different causes for sub-epithelial vesiculo-bullous lesions?
Angina bullosa haemorrhagica mucous membrane pemphigoid bullous pemphigoid lichen planus epidermolysis bullos erythema multiforme
What are different causes for oral white patches?
White spongy naevus frictional keratosis smokers keratosis stomatitis nicotina syphilitic leukoplakia chronic hyplerplastic candidosis pseudomembranous candidosis lichen planus lupus erythematosus leukoplakia (descriptive - hairy, pan oral) oral carcinoma skin grafts renal failure
What is a soft, diffuse, lesion with uneven thickness of the superficial layer. has no defined boundary and can affect anywhere in the mouth?
white spongy naevus
How would you diagnose frictional keratosis?
history, intraoral examination to look for any areas to cause trauma
Patient presents with white/grey base on the palate. there are numerous red papules present. what is the diagnosis?
this is stomatitis nicotina/nicotinic stomatitis. red patches are salivary glands. can be dysplastic or neoplastic. reversible if pt stops smoking
What are some localised causes of pigmentation of the oral mucosa?
foreign body - amalgam tattoo, tattoo, grit from trauma
local response to chronic trauma
ephelis (freckle)
pigmented naevi
peutz jeghers syndrome - perioral naevi
kaposis sarcoma - from HHV8 and related to end stage AIDS
malignant melanoma - dark, irregular outline, rapid growth
melanotic lesion
What are some generalised causes of pigmentation of the oral mucosa?
racial pigmentation - symmetrical and bilateral food - e.g. tobacco drugs CHX heavy metal salt deposits - deposited along gingival margin endocrine - addisons, nelson syndrome, haemochromatosis black hairy tongue
What lesions would you look our for as being pre-malignant?
leukoplakia speckled leukoplakie erythroplakia erosive lichen planus submucous fibrosis
What is sumbumous fibrosis and how would you diagnose it?
chronic and progressive scarring of oral connective tissue - hyperplasia and fibroblasts
caused by betel nut chewing.
pale mucosa, constraining fibrous bands, fibrosis of the submucosa. results in lips and cheeks becoming immobile and trismus
histopath shows epithelial atrophy and cellular atypia.
Rate leukoplakia, erosive lichen planus, erythroplakia and speckled leukoplakia in order from highest risk of malignancy to lowest
erythroplakia
speckled leukoplakia
leukoplakia
erosive lichen planus
What are the most common sites for oral cancer?
floor of mouth
lateral border of tongue
retromolar area
What are the aetiological factors of oral cancer?
sunlight, alcohol, tobacco, alcohol and tobacco combined, chewing tobacco/paan, HPV, immuno suppression, socioeconomic deprivation
What is the clinical appearance of an oral SCC?
often painless ulcer > 3 weeks
- firm with raised edges, indurated, inflamed granular base. fixed to surrounding tissue. pain is late feature
might be swelling
might be leukoplakia, speckled leukoplakia, erythroplakia
What is glossodynia and what are the common causes?
painful tongue.
caused by haematinic deficiencies, candidosis, lichen planus, psychogenic
What would you ask about if a patient presented you with diffuse swelling of lips, cheek/face?
ask about GIT issues - could be oral crohns, could be orofacial granulomatosis. check also for sarcoidosis
What are the differences between angular cheilitis and actinic cheilitis?
angular is affecting the commisures of the lips. staph and candida infection
actinic is sun damage to lower lip. excessive keratin production and increased mitototic activity in basal cell layer. PREMALIGNANT
What are causes for xerostomia?
anxiety drugs systemic disease sjogrens dehydration mouth breathing radiation to head and neck surgical removal of salivary gland aplasia of salivary gland sialadenitis sialolithiasis sarcoidosis
What is sialadenitis, what causes it and how can it be treated?
this is infection of the salivary glands, caused by staph aureus infection, ascending bacteria from lack of salivary flow.
purulent discharge. almost always unilateral,
increase fluid intake, remove any calculi present
do not do sialography
What is mumps?
viral sialodenitis. different from bacterial as no purulent discharge. commonly bilateral parotid
What are causes of sialosis?
benign swelling of salivary glands
unknown aetiology, but linked with endocrine abnormalities, nutritional deficiencies, alcohol abuse and hormones.
What are the diagnostic features of sialosis?
hysto path shows acinar cell hypertrophy, sialography is normal.
What are diagnostic features of secondary sjogrens syndrome?
xerostomia, keratoconjunctivitis, CT disorder e.g. rheumatoid arthritis
What are the diagnostic features of primary sjogrens syndrome?
xerostomia - no CT component
What is meal time syndrome and how it is managed?
obstruction of salivary duct which causes pain and swelling of the salivary gland around smelling or eating food. most common is sub mand because of quality of saliva (mucous), duct is long, has a bend at hilum and goes up.
investigate with palpation, radiography, sialography, ulstrasound.
Tx by massaging,HSMT, arrange review
What does internal derangement of the TMJ mean?
the articular disc moves forward when the join rotates and translates. mechanical fault in the joint interfering with smooth working
how would you diagnose internal derangement of the TMJ?
joint clicks (disc moving over condyle), joint locks (disc deplaced and not reducing), pain (muscle spasm or alteration in synovial fluid)
What branch of CNV is most commonly affected by TGN? give 5 features of it
CNV3 - mandibular branch > max > opthalamic
shooting pain, intense, trigger point, short acting,
paroxysmal
how would you diagnose and treat TGN?
Hx, pt description, carbamazepin, phyenytoin, gabapentin,
re-assess regularly on pain scale
What is dry socket and what are risk factors for it?
Dry socket is alveolar osteitis, delayed healing of the socket resulting in exposed bone and pain
smoking, single tooth XLa, traumatic extraction, alcohol, mandible Xn, posterior tooth Xn
How would you treat a patient with dry socket?
- reassure
- provide warm LA to area
- flush with warm saline
- pack the socket with alvogyl
- review in a week
What is a common sign/symptom of a undisplaced unilateral fractured manidbular condyle?
how would you treat?
pain on movements of the mandible, but no occlusal alteration
get advice, monitor, analgesia
what is a common sign/symptom of orbital blow out fracture?
limited eye movements - especially up as the muscles are caught in the fracture
What would someone with a ZOM fracture present with?
swelling over affected area
ecchymosis
sub conjunctival haemorrhage
pain
if displaced - hollowing out over zygomatic arch
possible paraesthesia of area supplied by infraorbital nerve
What are the signs and symptoms of a patient presenting with TMJ dislocation and how would you treat?
deranged occlusion, class III occlusion, hollowing out of TMJ on that side, pain
sit patient down
stand infront of them, explain you are going to try to relocate TMJ
put gloves on, wrap gauze around thumbs
place thumbs in buccal sulcus on buccal shelf
puch down and back
advise dont open mouth wide, stifle yawns, soft diet, analgesia
if cant relocate, refer to maxfacs
What is the most appropriate medication for the following conditons?
- Bells palsy
- atypical facial pain
- acute pericoronitis
- post surgical pain
- angular cheilitis
- AB cover to prevent IE
- prevent post surgical bleeding
- TGN
- prednisolone, 0.5mg/kg BID/5 days
- amitriptyline, 10mg. PD
- metronidazole, 200mg, TID, 5 days
- paracetamole 500mg - 1000mg QDS, ibuprofen 200-400mg QDS
- fluconazole/miconazole gel
- amoxicillin, 3g taken 2 hours before procedure
- tranexamic acid mouthwash
- carbamazepine 100-200mg BID
What are 5 local haemostatic measures?
surgical packing, fibrin foam, pressure, suturing, tranexamic mouthwash, bone wax
What are some complications of a fractured mandible?
deranged occlusion anaesthesia of IAN paraesthesia of IAN anaesthesia or parasthesia of lingual nerve non union/mal union of the mandible infection
What signs and symptoms would make you suspect an OAC has been formed?
Diagnose by:
– Size of tooth
– Radiographic position of roots in relation to antrum
– Bone at trifurcation of roots
– Bubbling of blood
– Nose holding test (careful as can create an OAF)
– Direct vision
– Good light and suction - echo
– Blunt probe (take care not to create an OAF)
How would you treat an OAC?
if C not F, then suture closed if possible, buccal advancement flap if not to encourage healing.
metronidazole antibiotics
advise patient no straws, no wind instruments, no blowing nose for a couple of weeks
steam inhalation and nasal degoncestants
Where is the most likely spread of infection from a maxillary lateral incisor?
palatal area
buccal
Where is the most likely spread of infection from a mandibular third molar?
sub lingual sub mandibular sub masseteric retro pharyngeal lateral pharyngeal
Where is the most likely spread of infection from a maxillary canine?
infra orbital
What are boundaries of the submandibular space?
lateral: mandible below mylohyoid line
medial: mylohyoid muscle
inferior: deep cervical fascia and platysma and skin
What are the principles of managing a patient with a dental infection?
identify cause of the infection
establish drainage of the infection
provide appropriate antibiotic coverage
assess holistically predisposing factors for infection
supportive information (soft diet, fluid etc)
What are causes of Oral lichenoid reaction?
drugs (ACEIs, carbamazepine, NSAIDs, amalgam, CoCr, gold)
composites,
graft vs host disease
How would you diagnose oral lichen planus rather than lichenoid reaction?
OLP - bilateral, well defined sites (buccal mucosa/tongue)
mixed sub ep infiltrate in LP, increased vascularity)
OLR - unilateral, undefined sites + defined (gingiva, lips, palate). only lymphohystocytic infiltrate, deep LP and superficial mucosa, no change in vascularity
What are the management options for OLP and OLR
If lichenoid reaction - remove the causative factors such as the amalgam.
topical corticosteroids
oral hygiene instruction
Difflam mouthwash
monitor for changes - 3 months for 1st year, 6 months for 2 years
repeat biopsies if there are any changes
Radiograhpic differences between Pagets, albrights and cherubism?
pagets - osteitis deformans, dysregulated bone remodelling giving cotton wool appearance
maccune - albright - poly ostoticfibrous dysplasia showing ground glass appearance
cherubism - expansion of the mandible and a ‘soap bubble’ appearance
What are extraoral symptoms of ectodermal dysplasia?
fine and sparse hair
What are histopathological features of sjogrens?
extensive lymphoid infiltrate with germinal centres
interstitial fibrosis
acinar atophy
What can cause postural hypotention?
fall in cardiac output venous pooling in legs fall in stroke volume poor venous return anxiety states
What are signs and symptoms of TMJ problems?
Pain, locking of jaw, clicking of jaw, limited opening
How do you treat TMJ problems?
conservative advice: soft diet NSAIDs and paracetamol heat dont open mouth fully bite raising appliance - soft or hard acrylic mindfullness and reducing stress consciously unclench when you find yourself clenching
What are different white lesions which can be scraped off?
pseudomembranous candidosis moriscatio buccarum thermal burns sloughing traumatic lesion allergy to toothpaste/MW chemical burn secondary syphillis diptheria
What are different white lesions which cannot be scraped off?
leukoplakia leukoedema linea alba tobacco pouch keratosis lichen planus actinic cheilosis morsicatio white coated tongue nicotine stomatitis hairy leukoplakia hyperplastic candidiasos lupus erythematosus oral submucosal fibrosis white spongy naevus
Why do oral lesions appear white?
Acanthosis (thickening of the epithelium)
Hyperkeratosis (production of keratin)
Pseudomembranous (accumulation of organisms and debris on surface)
What is leukoplakia?
White plaque or patch which cannot be rubbed off - descriptive not diagnostic
requires diagnostic procedure to determine biologic behaviour
How does white sponge nevus present?
diffused thickening, corrugated white lesions. Bilateral mainly on buccal.
incisional biopsy and microscopic examination
painless, persistent, early childhood onset
no Tx
What is frictional keratosis?
benign hyperkeratosis from Chronic irritation
circumscribed, adherent plaque at site of irritation
painless, persistent
remove source of friction
Talk through pseudomembranous candidiasis (aetiology, description, diagnosis and Tx)
Aetiology: infection of mucosa by candidal albicans
description: multiple white plaques, non adherent. erythematous base. acute onset. bad taste
diagnosis: cytologic smear. perform periodic acid shiff (PAS) test to detect fugal organisms
Tx: topical antifungals (clotrimazole, nystatin, miconazole, ketoconazole)
persistent recurrence can indicate immunocompromised pt
What is the clinical significance of chronic hyperplastic candidiasis?
lesions might show evidence of epithelial dysplasia - suggests they are premalignant
What is the typical visual appearance of reticular lichen planus?
adherent, white, interlacing striations called wickhams striae. mostly buccal mucosa. usually painless
What is the typical visual appearance of plaque-like lichen planus?
adherent, circumscribed, confluent white plaques.
mostly dorsum of tongue
What is hairy leukoplakia, and how do you diagnose and treat it?
hyperplasia of oral ep and hyperkeratosis. caused by EBV
co infection with c. albincans can occur.
adherent white plaques on lateral border of tongue. corrugated/shaggy appearance. bilateral
DNA probe on sample to Dx EBV
can give high dose aciclovir
- pts with hairy leukoplakia with HIV are liekly to progress to AIDS within 2 years
What is the clinical significance of smoking-related leukoplakia?
if on FoM has highest incidence of malignant transformation
cannot determine clinically if is malignant - need Bx
What does smokers pouch keratosis look like?
circumscribed, adherent, white plaques, varying thickness. present where tobacco is placed. can be associated with gingival recession adjacent to it.
persistent lesions can develop into verrucous carcinoma
What is the clinical significance of oral submucous fibrosis?
can develop into SCC
What is actinic cheilitis (actinic cheilosis) and what is the clinical significance?
Chronic exposure to UV
irregular, diffuse adherent white thickening of the involved ep. lower lip vermillion
10% turn into SCC
What is denture stomatitis?
description, diagnosis, treatment
infection of mucosa by C. albincans. from denture
if diffuse - broad spectrum ABs or immunosuppression
take cytologic smear, PAS stain.
generalised erythematous mucosa of denture bearing area
treat with miconazole or nystatin gel on denture and mucosa.
good denture hygiene
accompanied with papillary hyperplasia.
What does angular cheilitis look like and how do you treat it?
exaggerated commisures. erythematous fissuring. generally ill fitting denture wearer
loss of OVD, staph infection, haematinic deficiencies, chronic irritation (licking)
what is the clinical significance of erythroplakia?
highly likely to exhibit dysplastic change, premalignancy or malignancy
can be carcinoma in situ
multifocal lesions are common
How would you diagnose erythema migrans?
history - lesions move. possible burning sensation
clinically - circumscribed erythematous patches. elevated hyperkeratotic borders. dorsum and ventral surfaces of tongue.
What are causes of fissured tongue and how would you treat it?
common in Down syndrome, possible xerostomia. cause is unknown.
Part of Melkerson-rosenthal syndrome (fissured tongue, cheilitis granulomatosa, unilateral facial nerve palsy(
how would you diagnose a traumatic ulcer?
superficial ulcer surrounded by erythematous mucosal margin
yellow surface pseudomembrane
painful, Hx of trauma, traumatic ulcerated granulomas can persist for longer
remove suspected aetiology - does it heal?
How does wegener’s granulomatosis present?
deep granulomatous ulcers of the palate, focal erythematous gingival swelling with pebbly surface.
may cause destruction of alveolar bone and tooth mobility
What is necrotising sialometaplasia?
ischemic necrosis following loss of blood supply to minor salivary gland. deep ulcer, hard palate, off midline.
can be from LA injection
painful. Biopsy
What systemic diseases can predispose pt to ulcers?
blood dyscrasias (cyclic neutropenia, agranulocytosis)
Crohns disease
cancer chemo
where is the most common site for minor salivary gland neoplasms?
palate.
half of these are malignant
mets often to lungs and bone
How do you diagnose MMP and PV?
incisional Bx
half tissue placed in formalin for histopath
half placed in Michels solution for direct immunofluoresence
in what condition do you see haemorrhagic crusting along the vermillion border?
erythema multiforme
What are local and systemic causes of pigmented lesions?
Local: amalgam tattoo melanotic macule black hairy tongue smokers melanosis melanocytic nevus malignant melanoma
Systemic: racial pigmentation peutz-jeghers syndrom addisons disease kaposis sarcoma
how can you determine smokers melanosis from racial pigmentation?
smokers melanosis is diffuse and irregular and located on the anterior labial mucosa
racial pigmentation is symmetrical and restricted to the attached mucosa
What is the aetiological factor of kaposis sarcoma?
HIV and HHV-8
How does a malignant melanoma present?
larger than 5mm irregular margins irregular pigmentation ulceration of overlying mucosa can be macular or elevated most commonly on gingiva and palate
What is a pyogenic granuloma?
reactive hyperplasia from irritation
vascularised granulation tissue.
can occur on any mucosal site
solitary, circumscribed, red nodule. sessile or pedunculated
red, firm. painless. persistent. poor OH.
Tx with excision and OHI
if pregnant female - pregnancy epulis
What are different causes for localised gingival enlargement?
pyogenic granuloma Peripheral giant cell granuloma eruption cysts/eruption haematoma gingival cysts abscess
What must you rule out with a peripheral giant cell granuloma?
Brown tumours of hyperparathyroidism
metastatic carcinoma
What is a peripheral ossifying fibroma?
reactive hyperplasia, similar to pyogenic granuloma and peripheral giant cell granuloma
solitary, circumscribed, sessile or pedunculated.
exclusivel to attached gingiva
need to remove down to periosteum
What is actinomycosis?
soft tissue infection caused by actinomycoses isrealii
initial site of infection is usually perio pocket
cutaneous swelling, fistula formation
sulfur granules in pus. swelling at inferior border of mandible/gingiva.
Rx show periapical radiolucency with non-vital tooth
What is a lipoma?
benign neoplasm of fat. can be reaction to local trauma.
solitary circumscribed nodule, sessile.
superficial lesions are yellow, deep are pink
What is a neuroma?
nerve bundle proliferation in response to trauma. solitary, circumscribed, pink, sessile. occurs on mucosa overlying mental foramen
What is a neruofibroma?
benign neoplasm of neurofibroblasts
List the aetiological agents for DIGO
phenytoin
cyclosporin
calcium channel blockers
exacerbating factors include poor OH, plaque/calculus
What do you need to be aware of in a patient receiving treatment for cancer?
mucositis
radiation caries on smooth surfaces
salivary changes
prevention is key
How do you diagnose a Staphne’s bone cavity?
it is always below the IAN canal
What could be a differential for a palatal swelling/enlargement?
kaposis sarcoma (nodular) abscess palatal tori peripheral ossifying fibroma denture hyperplasia pleomorphic adenoma of parotid
What are clinical signs and symptoms of a fractured jaw?
- pain, swelling, loss of function
- occlusal derangement
- numbness of lower lip
- loose/mobile teeth
- bleeding
- AOB
- facial asymmetry
- deviation of mand to opposite side
What are the ways to classify a mand fracture?
- involvement of surrounding tissue
- number of fractures
- side of fracture
- site of fracture
- direction of fracture
- specific different types of fractures
- displacement of fracture
What factors influence displacement of a mand fracture
direction and angulation opposing occlusion mangitude of force mechanism of injury soft tissue intact - integrity of periosteum muscle forces other associated fractures
How do you diagnose a fractured mandible?
two rads at 90 degrees to each other (OPT+PA)
How do you treat a mand fracture?
control pain and infection
ORIF if displaced, no treatment if not
What are different pathological reasons for jaw fracture?
generalised bone diseases (Pagets) OI osteoporosis fibrous dysplasia hyperparathyroidism localised bone disease (osteomyelitis, ORNJ, cysts, odontomes, tumours)
What are complications of mandibular fracture?
loss of teeth delay in union infection malunion non union late onset trismus persisting mental anaesthetia
What are complications of condylar fracture?
trismus osteoarthritis subluxation late trismus deviation ankylosis open bite neurologial - VII nerve paresis vascular - aneurysms
How do you treat a fractured mandible in an edentulous patient?
modified dentures
gunnings splints
What are primary fascial spaces?
spaces directly adjacent to origin of odontogenic infections. first site of spread
vestibular, canine, buccal, submental, sublingual, sub mandibular
What would you look for in a canine space infection?
infection of buccal space, or zygomaticotemporal space
then temporal space
obliteration of nasolabial fold
can spread to cavernous sinus
What teeth are most likely to cause a submental space infection?
anterior mand teeth
infection is deep to mentalis
What is the most likely cause for submandibular space infection?
lower molars
can spread to sub masseteric space and lateral pharyngeal space and on to mediastinum
What is ludwigs agnina?
bilateral submand, sub ling and sub mental involvement.
high mortality - needs early aggressive intervention
What are secondary fascial spaces?
become involved following spread from primary spaces
pterygomandibular masseteric superficial and deep temporal infratemporal lateral pharyngeal retropharyngeal
What is the hallmark of a masticator space infection?
trismus
What are causes for parapharyngeal space swellings?
odontogenic infections
infections of pharynx, tonsils, adenoids, mastoids, susurrativce lymphadenitites
What are different routes of spreading dental infection?
connective tissue
blood stream
lymphatic vessels
What is cellulitis?
spreading infection, chatacterised by rubor, calor, oedema, loss of function
What influences the spread of odontogenic infection?
thickness of bone around site of infection
position of muscle attachments
virulence of organism
immune system function
What are the indications that a patient has a severe infection?
fever dehydration rapid progression of swelling pain and trismus quality/location of swelling elevation of tongue problems with speech or swallowing
What are the criteria for systemic inflammatory response syndrome?
>2 of the following temp <36 or >38 HR >90bpm RR>20 per min WBC <4000 or >12000/ml
What antibiotics would you use for odontogenic infections and why?
penicillins - broad spectrum
metronidazole - for obligate anaerobes
erythromycin - second choice if mild
clindamycin - if anaerobes resistant to other
What are risks of odontogenic infections?
airway compromise orbital cellulitis cavernous sinus thrombosis brain abscesses mediastinitis
What is the difference between an OAC and an OAF?
• Acute – technically an oro-antral
communication
• Chronic – An oro-antal fistula (OAF)/
epithelial lined tract
list some different sampling techniques and when they would be used
aspiration - blood sample
aspiration - abscess (avoids contamination)
FNA - cells from solid lesion/cytology
excisional Bx - clearly benign lesions and small
incisional Bx - large lesions, uncertain diagnosis
punch Bx - removes core, minimal damage, 4 or 6mm
How do you select tissue for biopsy?
large enough area, representative, multiple Bx might be needed, is perilesional tissue needed?
refer if suspicious/upper lip
What is a fibrous epulis and how do you treat?
Swelling arising from the gingivae • Hyperplastic response to irritation • Overhanging restoration • Subgingival calculus • Smooth surface, rounded swelling • Pink and pedunculated • Excisional biopsy • Coe pack dressing • Removal of source of irritation
What is an FEP and how do you treat?
caused by frictional irritation
sessile or pedunculated, pink, smooth surface
surgically excise (place suture through and cut around)
How does a giant cell granuloma present?
(giant cell epulis)
distinct structure of epithelial shaped macrophages,
multi nucleated giant cells in vascular stroma, lymphocytes and fibroblasts
in ant regions of mouth, deep red/purple
sessile
Rx to check for central origin (radiolucency)
surgically excise and curettage of wound. Coe Pack
how does a squamous cell papilloma present?
palate, buccal mucosa, lips
benign, pedunculated neoplasm, white cauliflower surface
What is burning mouth syndrome?
an oral dysasthesia with no identifiable cause.
3 types -
- progressively gets worse over day
- constant
- random (more likely to be allergens)
How would you treat a patient coming to your clinic with unilateral shooting pain?
take a full pain history
cranial nerve test
rule out odontogenic cause
MRI to rule out central cause
assess suicidal intent
carbamazepin 100mgBD, increase 100mg ever 3 days until symptom free
- CBZ can cause liver dysfunction so need bloods every 3 months
What are different endogenous and exogenous causes of pigmentation of the oral mucosa?
endo:
haemaglobin
haemosiderin
melanin
exo: amalgam graphite heavy metals chromogenic bateria
what are different treatment options for TGN?
carbamazepin - 100mg BID and increase 100mg every 3 days until symptom free
gabapentin
phenytoin
surgical cryotherapy, microvascular compression, gamma knife
What factors could predispose someone to TMJ?
stress parafunctions (bruxism and clenching) chewing gum weight lifting and clenching swimming and moving jaw
What presents with similar symptoms to TMJ and how would you exclude them from the diagnosis?
myofascial pain dysfunction syndrome (muscle spasms, trigger points and tiredness)
How would you construct a splint for a patient with TMJ?
pour impression in 100% stone lower hard acrylic splint cover all occlusal surfaces half covering crown 2mm thick hard acrylic
What is desquamative gingivitis?
it presents as fiery, friable, florid red gingiva. painful. buccal/labial attached gingiva.
clinical description of oral manifestation.
superficial ep atrophies and separates from rest.
immune response
caused by SLS, trauma, OLP
What causes burning mouth syndrome?
reduced vascularisation
neuropathy - sensory changes into nociceptors
nutritional deficiencies lead to atropy
What is a differential diagnosis for BMS?
oral dysastshesia, diabetes, stroke, xerostomia, menopause, stress, anxiety, cancerphobia, fungal infection, allergy
nutritional deficiencies
What are the different routes of spread of oral SCC??
invasive = nodes
depends on site and what is close
but largely lymphatic or haematogenous
What are the classifications of dysplasia and what do they mean?
mild = dysplastic changes relating to 1/3/ ep
moderate = dysplastic changes 2/3 of ep
severe = dysplastic changes of over 2/3 of ep
carcinoma in situ = full thickness dysplastic change, but no breach of basement membrane
signs = hyperchromatism pleomorphism change size/number mitotic bodies in ep
List the common salivary gland tumours in order
pleomorphic adenoma warthin tumour adenocystic carcinoma mucoepidermoid carcinoma asinic cell carcinoma
(larger glands through to smaller ones)
what are different histological findings of a pleomorphic adenoma?
benign mixed tumour
circumscribed
ep tissue intermingled with mucoid, myxoid or chondroid tissues
variable capsulation
ep and myoep form ducts/strands/sheets
can get squamous metaplasia
Why do pleomorphic adenomas recur?
the capsule is incomplete and friable. allows satellites
What are different treatment options for salivary gland calcuclus?
surgery lithotripsy basket removal sialoendoscopy laser ablation
What are the indications for antibiotic therapy?
prophylaxis in cases of IE
adjunct to surgical therapy
if inaccessible to surgery initially
systemic involvement
What is the presentation of pemphigus vulgaris?
mouth can be first presenation
friable bulla leaving ragged edge, persistent erosions.
desquamative gingivitis
positive nikloskys sign (unethical)
risk or death of hypobullaemic fluid loss
What are different causes of RAS?
genetic behcets nutritional deficiencies (haematinics - diet or absorption) systemic disease GI disease endocrine immunity stress
What are the functions of a bite raising appliance?
habit breaker
stabilises muscles
psychological
What radiographic information is required before XLA lower 8
diversion/deflection of canal darkening of root where canal crosses interuption of white lines deflection of root narrowing or canal juxta apical area
What are different types of damage to nerves during surgery?
neuropraxia (bruise)
anotmesis (sliced sheath)
neutrotmesis (sliced nerve)
why would a denture stop fitting in a patient with Pagets disease of the bone?
get enlargement of max - over activity of osteoclasts and osteoblasts
chaotic bone alteration of deposition and resorption
increased risk over 55s and male
get hypercementosis of roots
if you need to extract a tooth from a patient who is on BPs, what precautions do you have to take?
advise pt of risk of extraction, get written consent with this and information sheet advise to rince BID with CHX 1 week before XLA clean area before with CHX use atruamtic XLA technique avoid flaps primary closure where possible CHX BID for 2 mths monitor until healed
What tests are regularly carried out on a patient receiving treatment for TGN?
LFTs - ALT
FBCs
pain tests
What are two different types of haemangiomas?
what is the difference?
capillary
cavernous
cap = aggregated capillaries, endo lining, separated by CT
cav = mass of dilated cavernous vascular spaces, endo lining, separated by CT
Whats the differential diagnosis for denture induced hyperplasia?
leaf fibroma
fibroepithelial polyp
How would you remove denture induced hyperplasia?
LA, excise and biospy. suture. remake denture
put suture into lesion to lift it up
What are histopathological features of denture hyperplasia?
thickening of epithelium
What would make a patient more susceptible to post surgical bleeding?
- haemophilia a/b
- warfarin
- oral anticoagulants
- LMW heparins
- leukaemia
- thrombophilia
If a patient has high alkaline phosphatase, what is the likely diagnosis?
Paget’s disease of the bone
If a patient has high serum calcium, what is the likely diagnosis?
hyperparathyroidism
if a 15 year old has bilateral buccal swelling, what is a likely diagnosis?
cherubism
mumps
What is a likely diagnosis if there is a radiolucency with a loss of the lamina dura?
fibrous dysplasia
browns tumour
If a patient presents with skin pigmentation and precocious puberty, what would be a likely diagnosis?
fibrous dysplasia
What are histological features of atrophic lichen planus?
hugging band of lymphocytes
civatte bodies
hyperkeratotic epidermis with irregular acanthosis
deposits of fibrin in basement membrane zone
What are the two classifications of vesiculobullous diseases?
sub epithelial (pemphigoid) intra epithelial (pemphigus)
What is the systemic cause of pemphigus and pemphigoid?
autoimmune attack by IgG to either desmosomes or hemidesmosomes
If Tzanck cells are present in the histological sample, what is the diagnosis?
pemphigus
What systemic drugs are used to treat pemphigus?
corticosteroids and azazthioprine
What are histological features of medial rhomboid glossitis?
pseudoepitheliomatous hyperplasia
elongated rete pegs
superficial candical hyphae infiltration
polymorphonuclear leukocytic inflammatory infiltrate
How do you treat xerostomia?
treat the cause - sip water, stop smoking, saliva replacement (saliva orthana), pilocarpine, suck ice cubes
What are some dental complications of xerostomia?
problems with denture retention taste dysphagia mucosal irritation caries salivary gland infections problems speaking
What can cause swelling of the salivary gland?
infection (bacterial or viral) mucocele/ranula neoplasm (pleomorphic adenoma/acinic cell carcinoma, mucoepidermoid carcinoma) blockage hyperplasia sialosis
What is sialosis?
uncommon, bilateral, painless autonomic neuropathy
benign and diffuse swelling. non inflammatory enlargement of minor salivary gland
What are causes of sialosis?
diabetes melitus alcoholism hormone changes malnutrition (bulimia and anorexia) Rx H&N drugs
What are some systemic factors predisposing to candidal infection?
diabetes radiotherapy steroids ABs nutritional deficiency immunosuppression smoking cariogenic diet extremes of life
What are causes for granulomatous conditions?
reaction to environment, genetics, infections, organisms, idiopathic
What is OFG?
Orofacial granulomatosis
clinically and histologically identical to Crohns disease, diagnosis of exclusion. no GIT symptoms
What can cause oral dysaesthesia?
nutritional deficiencies DM dentures - stability, low freeway space, hypersensitivity, stomatitis mucosal infections xerostomia psychological factors drugs (captopril) allergies
What can be used to treat RAS?
betametasone MW (0.5mg tabs) beclometasone inhaler (50ug) CHX 0.2% BID azathioprine doxycycline MW difflam mouthwash
What is the half-life of midazolam?
1-4 hours
What do you measure to assess a patient for IV sedation?
ASA classification (GDSH takes I and II) BP weight (BMI) MH HR level of co-operation O2 saturation
What are the ASA classifications?
I - medically fit and well
II - well controlled disease
III - severe disease that is limiting but not incapacitating
IV - incapacitating disease, constant threat to life
V - pt not expected to live
What is constantly monitored during IVS?
HR
O2 sats
level of consciousness
(BP at 5 min intervals)
what are physiological signs in someone with severe pain?
increased HR, BP, caridac output and sweating
reduced salivary flow
dilation of pupils
What is the maximum dose of paracetamol and how would you deal with patient over this dose?
4g/24 hours
over this - go to hospital even if they are feeling well
What might delay osseointegration?
overheating of bone during placement non-biocompatible material used inappropriate surface of implant premature loading overloading poor oral hygeine
give 2 surgical interventions to help inadequate bone levels
bone graft
bone augmentation
What are the main descriptive features of a pathology in the mouth?
site morphology colour size consistency
How do you diagnose different types of ulcers?
number outline margin depth size separate/coalescing regular/irregular borders raised superficial/deep
why are red lesions red, and what are common causes?
red from haemoglobin from blood flow in increased inflammation or thinner epithelium
trauma/infection/proliferation of BVs, petechia, pupura, ecchymosis, haematoma
Why are white lesions white, and what are different changes making them white?
changes in the epithelium or lamina propria ep changes: hyperkeratosis (keratin layer) acanthosis (stratum spinosum) necrosis fluid accumulation
LP changes:
increased collagen
change in collagen maturation
What is a peripheral giant cell tumour?
vascular lesion, with multinucleated giant cells and extravasated RBCs
exclusively attached to gingiva
response of gingivae to chronic trauma
associated with pyogenic granuloma and peripheral ossifying fibroma
If a patient presents with acute oral ulceration, what are some differential diagnoses and their obvious clinical appearance?
minor RAS (attached mucosa) Major RAS (unattached mucosa) PHG (all mucosa) allergies - cant be scraped off erythema multiforme (target) herpangina (soft palate and oropharynx) herpes zoster - doesnt cross midline traumatic (history) HF+M - hands and feet necrotising sialometaplasia (vibrating line) chancre - painless
patient presents with chronic oral ulceration, what are some differential diagnoses and their obvious clinical appearance?
erosive OLP - bilateral SCC - non healing MMP - ocular and genitals PV - other skin facticial ulcer - no induration traumatic granuloma - no healing TB noma - gangrenous necrosis after ANUG
What are some pericoronal unilocular radiolucencies and how can you differentiate them?
dentigerous cyst - around crown of tooth
eruption cyst - erupting tooth
odontogenic keratocyst
orthokeratinised odontogenic cyst - lined by keratin
ameloblastic fibroma - young people
asenomatoid odontogenic tumour - upper 3-3
calcifying odontogenic cyst (gorlin cyst)
What are some unilocular radiolucencies around the pericapical area and how can you differentiate them?
periapical granuloma - non vital tooth
periapical cyst - non vital tooth
periapical scar - endo treatment and destruction of cortical plate
What are some unilocular radiolucencies not around the pericapical or pericoronal area and how can you differentiate them?
developing tooth bud radicular cyst nasopalatine duct cyst (spreads AP) periodontal cyst residual periapical cyst (after Xn) odontogenic keratocyst giant cell granuloma (ant mand) stafnes bone cavity (below IAN) cemento-osseous dysplasia - young. mand schwannoma - IAN
What are some mulitlocular radiolucencies?
odontogenic keratocyst ameloblastoma (post mand) giant cell granuloma - ant mand ameloblastic fibroma - young odontogenic myxoma - cobweb trabeculation calcifying epithelial codontogenic tumour - impacted tooth central haemangioma - honeycomb aneurysmal bone cyst - younger cherubism - multiple quads hyperparathyroisism - browns tumour
What are some radiolucencies with poorly defined borders?
periapical granuloma osteomyelitis MRONJ simple bone cyst (scallops between roots) metastatic tumour (pain) ORNJ multiple myeloma (older) osteosarcoma (younger)
What are some well demarcated radiopacities?
exostoses tori retained root condensing osteitis (apex of NV tooth) compound or complex odontome
What gives a ground glass appearance to bone?
fibrous dysplasia
hyperparathyroidism
What gives a sunburst appearance to bone?
osteosarcoma
intraosseous haemangioma
what gives a cotton wool appearance to bone?
pagets disease of the bone
cemento osseous dysplasia
gardner syndrome
What gives onion skin opacities?
proliferative petrosis
ewing sarcoma
langerhans cell histocytosis
What are the different classifications of dysplasia and what do they mean?
mild: alterations limited to basal layer and parabasal cells
moderate: involvement from basal layer to mid of spinous layer
severe: involvement from basal layer to above midpoint of ep
carcinoma in situ: dysplasia of entire thickness of epithelium, no invasion
what histopathological changes occur in dysplasia?
nuclear pleomorphism, hyperchromatism, scattered mitotic figures
What is chlorhexidine and what is its mode of action?
bisbiguanide
dicationic molecule which adheres to the pellicle and can also disrupt the bacterial membrane
antiseptic and antibiotic - bacteriostatic and bacteriocidal.
What is substantivity?
the ability of a substance to continue exerting effects after the contact time
what are some uses of chlorhexidine
post surgery MW full mouth disifnection irrigating under the operculum for pericoronitis (some health boards) irrigating dry socket immunocompromised patients before and after XLA for pts on BPs post trauma pt unable to physically clean
How do you diagnose the different types of perio?
plaque levels/sites/attachment loss
if attachment loss is consistent with level of plaque - chronic
if attachment loss is not consistent with level of plaque - aggressive
if >30% sites affected, generalised
if <30% sites affecfed - localised
1-2mm is mild
3-4mm is moderate
>5mm is severe
How do you treat desquamative ginigivitis?
betamethasone or beclamethosone
tacrolimus MW
What is an ameloblastoma?
what does it look like radiographically?
an aggressive odontgenic epithelium neoplasm - well defined
locally invasive. most commonly the posterior mandible and ramus. resorbs tissue
multilocular radiolucency. honeycomb/soap bubblee
What is an odontogenic keratocyst?
an odontogenic epithelium neoplasm. thin keratinised lining. well defined radiolucency. minimal expansion as AP growth
post mand and ramus.
generally single, multiples = gorlin-goltz
What is a dentigerous cyst?
where is it most commonly found?
what does it look like radiographically?
cyst around crown >5mm from enamel of unerupted tooth. 8s/max 3s
well defined, corticated radiolucency. border continuous with ACJ
What is a lateral periodontal cyst and what does it look like radiographically?
incidental finding mostly. cyst - lateral to vital tooth.
well defined and corticated. can obliterate lamina dura and can resorb teeth
What is a nasopalatine canal cyst and what does it look like radiographically?
non odontogenic cyst in the nasopalatine canal. incidental finding. between apices of max centrals if >1cm
well defined, unilocular radiolucency. corticated and heart shaped
lamina dura is always intact as not associated with the teeth
What is a periapical/radicular cyst?
cyst around apex or lateral canal of NON VITAL tooth (different to lateral perio cyst)
will resorb.
can cause rarefying osteitis (loss of bone)
well defined, may be corticated, unilocular radiolucency
how does a simple bone cyst appear?
radiolucency, posterior mandible. well defined but no cortical. scallops between roots
What is ankylosis and how does it appear radiographically?
fusion of a tooth root with surrounding bone. absence of PDL space
What is the difference between dens invaginus and dens in dente?
dens in dente is more severe - has >50% of canal space affected
both give a teardrop sign on the canal
What is hypercementosis and how does it appear?
increased cementum deposition around the apices of a root. root appears more bulbous
What is a talon cusp and how do you treat it?
hyperplasia of cingulum of anterior tooth
selective griding 1mm at a time and place a dressing on. obliterates pulp in cusp
What does a taurodont look like?
elongated body and pulp chamber, shorter than normal roots - the bifucation might be closer to apex. multi rooted teeth only, crown is normal
what is a fibrous scar?
healing with fibrous tissue instead of bone after XLa or surgery
radiolucent, well defined edge
What are the most common sites for mandibular fracture?
angle of mand
neck of ramus
anterior mand
compare infra and supra bony pockets
supra bony -
base of pocket is coronal to alveolar bone
horizontal bone loss
PDL and transeptal fibres arranged horizontally
infrabony pocket-
bast of pocket is apical to crest of alveolar bone
vertical pattern of destruction
PDL are angular, transeptal fibres are oblique
How would you manage desquamative gingivitis?
improve OHI
tacrolimus or betamatasone MW
Bx if symptomatic or smoker
identify cause and eliminate
Name 2 methods for testing for pemphigus vulgaris and what a positive result looks like
direct immunofluorescence - IgG against desmoglein in desmosomes - basket weave appearane
H+E stain - intraepithelial split with Tzanck cells
