Oral medicine Flashcards
Give 5 signs and symptoms of TMD
* Headache. * Ear pain. * Muscle pain. * Joint pain. * Trismus. * Clicking or popping noises. * Crepitus.
Give 5 aspects of causative advice for TMD
* Soft diet. * Stop parafunctional habits ie nail biting. * Support mouth upon opening (yawning). * Relaxation. * Chew on both sides. * Cut food into smaller pieces. * Don’t incise food. * Avoid chewing gum. * Avoid over opening.
What information could be elicited from an examination in cases of suspected TMD?
* Range of movement. * Clicking/crepitus. * MoM hypertrophy. * Tenderness on palpation. * Reduced intercisal opening distance. * Signs of bruxism. * Scalloped tongue. * Linea alba
What factors could predispose someone to having TMD?
* Females more than males. * Age 18-30 years. * Stress. * Habits such as nail biting, chewing gum.
What would first line management of TMD be?
* Counselling, reassurance, soft diet, advice on chewing both sides, cut food, stop chewing gum.
* Splint therapy; soft splint, hot water bottle, hard splint, bite raising appliance
* Joint therapy; accupuncture, physio, relaxation.
* Drugs; Ibuprofen, paracetamol, muscle relaxants - tricyclic antidepressants.
What other conditions may present similarly to TMD and how would you exclude them?
* Pericoronitis (no clicking)
* Myofascial pain syndrome (no clicking)
You decide to construct a stabilisation splint. Your technician doesn’t know what this is. How would you write your lab sheet?
Please pour upper and lower alginates in 50/50 dental stone/plaster. Please provide contrast vacuum form splint in soft acrylic for lower arch, covering all occlusal surfaces while avoiding gingival margin.
What is your first line treatment for denture induced stomatitis?
* Tissue conditioner on the fitting surface of the denture
* Oral and denture hygiene instructions.
If denture induced stomatitis persisted after OH advice, what would be the next line of treatment?
Appropriate antifungal (fluconazole; 7 x 50mg capsules. Cannot be taken with warfarin or statins)
What are fordyce granules?
Sebaceous glands in the oral mucosa found in 80% of individuals. Cannot be rubbed off with gauze. NTR
What are the key features of geographic tongue?
* A common condition, affects 2% of the population at any one time.
* Usually the dorsum of the tongue
* Asymptomatic, irregular smooth map like areas with white raised margins.
* Thin epithelium, loss of filiform papillae.
* Reassure patient
* If symptomatic, treat with antifungal agents combined with topical steroids.
What are the key features of a cleft lip?
* Caused by failure of the normal orofacial development 6-12 weeks embryonic life.
* Most cases are idopathic but a number of drugs during pregnancy have been linked including phenytoin, cabazepine, steroids, diazepam. Smoking and folic acid deficiency
* Can be unilateral, bilateral, and incomplete or complete
* Cleft lip with palate can present problems with feeding, speech and hearing
What are Epsteins pearls?
* Small developmental lesions of the new born.
* Small, firm white-yellow keratin filled cyst
* Bohn’s nodule occurs on alveolar ridge, maxilla more common than mandible
What is ankyloglossia?
Also known as a tongue tie. A congenital oral anomaly that may restrict the mobility of the tongue.
Caused by an unusually short, thick lingual frenulum.
Prevalence reported to be 0.1-10.7%
Can affect feeding, speech, chewing and OH
Name 3 bacterial infections that can present in the oral mucosa
* Scarlet fever
* Syphilis
* Gonorrhoea
* Tuberculosis
Describe a cleft lip
* Approx 1 in 1000 live births
* Unilateral in 80% of cases
* Lack of fusion between medial nasal process and maxillary process
Describe a cleft palate
* Approx 1 in 2000 live births
* Lack of fusion between palatal shelves
What are lip pitts?
* Invaginations at commisssures or near midline
* Van der Woude syndrome = cleft and pitts
What is Leukoedema?
* White or whitish grey edematous (fluid filled) lesion of buccal mucosa
* Dissipates when cheek is stretched
What are fordyce granules?
* Ectopic sebaceous glands
* Benign
* No treatment
What is lingual thyroid?
*Thyroid tissue mass at midline base of tongue
* Located along embryonic path of thyroid descent
What is geographic tongue?
* Also called benign migratory glossititis and erythema migrans
* White ringed lesions surrounding central red islands that migrate over time
* Occasionally hurt and burn
* No treatment - can adjust diet if symptomatic
What is fissured tongue?
* Folds and furrows of dorsum of tongue.
* Melkersson-Rosenthal syndrom = fissured tongue and granulomatous chelitis (red, inflammed lips), and facial paralysis.
* Remember with; Mels Bells, Rosy Red
What is angioma?
Tumours composed of blood or lymph vessels
What is a hemangioma?
* Congenital focal proliferation of capillaries
* Most undergo involution, but some persistent lesions are excised
What are lymphangioma?
* Congenital proliferation of lymph vessels. Oral lymphangiomas are very rare, purple spots on the tongue. Called cystic hygroma when it occurs in the neck.
* Sturge-weber syndrome = angiomas of the arachnoid and pia mater and skin along the distribution of the trigeminal nerve
What are exostoses/tori?
Excessive cortical bone growth
What is a dermoid cyst?
* If it appears above the mylohyoid it will be a mass in the midline of the FoM
* If it appears below the mylohyoid it will be a mass in the upper neck
* Contains adnexal structures like hair and sebaceous glands.
* Doughy consistency
What is an oral lymphoepithelial cyst?
* Epithelial cyst within lympoid tissue of oral mucosa.
* Palatine and lingual tonsils are common locations
What is Stafne Bone defect?
* A radiolucency in posterior mandible below IAC
* Due to lingual concavity
* May appear as cyst but is not a pathology
What is a nasopalatine duct cyst?
* Heart shaped radiolucency in nasopalatine canal
* Casued by cystification of canal remnants
* Treatment; exision
What is a traumatic bone cyst?
* Also called a simple bone cyst and idiopathic bone cavity.
* Large radiolucency scalloped around roots
* No epithelial lining (dead space) in middle of teenagers mandible.
* Usually associated with traumatic injury
* Treatment; aspirate to diagnose and monitor
What is linea alba?
* White line in buccal mucosa
* Type of focal hyperkeratosis due to chronic friction on mucosa
What is a traumatic ulcer?
Very common ulcer caused by trauma (biting, sharp food etc)
Erosion = incomplete break
Ulcer = complete break through epithelium
What is a chemical burn?
A burn caused by aspirin, hydrogen peroxide, silver nitrate, phenol
What is nicotine stomatitis?
Red dots are inflammed salivary duct openings.
Only premalignant if related to reverse smoking.
More common in chronic heavy smokers
What is an amalgam tattoo?
Traumatic implantation of amalgam particles into the mucosa.
Tiny radiopaque particles in xray
What is smoking associated melanosis?
Chemicals in tobacco stimulate melanocytes.
Brown, diffuse, irregular macules.
Typically seen in anterior gingiva.
Reversible is smoking discontinued
What is melanotic macule?
Benign hyperpigmentation in mucous membrane.
Basically, a freckle of the mucosa.
Peutz-Jeghers Syndrome = freckles and intestinal polyps (think of someone spotty in their PJs with an upset stomach)
What is hairy tongue?
Elongated filiform papillae
What is dentifrice associated sloughing?
Toothpaste related.
Related to surfactant ingredient sodium lauryl sulfhate.
Recommend SLS free toothpaste
What are the different categories of submucosal heamorrhage?
All of these are extravascular lesions that do not blanch.
In contrast, vascular lesions like haemangiomas do blanch.
Petechiae = 1mm haemorrhages (valsalva maneuver, violent cough, fallatio)
Purpura = slightly larger than petechiae
Ecchymosis 1cm or bigger bruise
Hematoma = mass of blood within tissue caused by trauma such as an LA needle
Treatment = eliminate cause if possible
A patient presents for a regular check up and you notice a white and lacey appearing lesion in the buccal mucosa. What is your diagnosis?
Leukoplakia until confirmed histopath diagnosis
lichenoid tissue reaction
There is an amalgam restoration in the lower molar. What made you arrive at the diagnosis of lichenoid tissue reaction and how does it occur?
Reaction adjacent to restoration, type iv hypersensitivity reaction
Name 2 biopsies you could carry out to investigate this lesion
Punch biopsy and incisional biopsy
Name four histological features of lichenoid tissue reaction?
Keratinisation, ‘hugging’ band of lymphocytes, basal cell liquefaction, apoptosis, sawtooth rete pegs
What is your diagnosis?
Angular cheilitis
Name two microorganisms involved in angular cheilitis
staphylococcus aureus, candida albicans
What microbiological sampling method should you ask for to diagnose angular cheilitis?
Swab
Name one immune deficient disease and one GI bleeding disease and why are they more susceptible to angular cheilitis?
HIV; impared immune function.
Coeliac; impared nutrient absorption
Name one intraoral disease that would be associated with angular cheilitis
Any one of the following;
* Denture induced stomatitis
* Orofacial granulomatosis
* Crohns
Why is miconazole prescribed to a patient with angular cheilitis when microbiological sampling is not available?
It is effective against both fungal and bacterial pathogens
A patient attends with inflammed gingiva extending beyond the mucogingival margin. Give a diagnosis
Desquamative gingivitis
Give one descriptive term for the appearance of desquamative gingivitis
Firey, erythmatous, ulcerated
Give 3 oral mucosal conditions associated with desquamative gingivitis
Pemphigus, pemphigoid, lichen planus
What are two typical treatments that could be used for desquamative gingivitis?
Betamethasone mouthwash. Tacrolimus ointment
Define what is a cyst?
An epithelial lined cavity containing fluid or semi fluid
What are the two broad types of odontogenic cysts?
Inflammatory and Developmental
What are the two types of inflammatory odontogenic cysts?
Radicular and residual
What are the four types of developmental odontogenic cysts?
Keratocyst, eruption cyst, dentigerous cyst, lateral periodontal cyst
List four diagnostic tools in cyst identification?
Any four of;
* Sensibility tests
* Radiographic features
* Aspiration
* Protein content
* Biopsy of the cyst lining
What is the aetiology of radicular cysts?
* Accounts for 60% of odontogenic cysts
* Associated with a non vital tooth
* Epithelial source; epithelial cell rests of malassez
* Sequential to pulp necrosis in areas of chronic inflammation
What is the radiographic appearance of a radicular cyst?
* Well demarcated
* Associated with the apex of a tooth
* Can be apical lateral or residule
* Residule cysts occur when there has been a cyst associated with a tooth which has been extracted, but the cyst remains
What is the relavant histology for radicular cysts?
* Uniform layer of squamous cell epithelium
* Epithelium desquamates into the lumen which contains necrotic debris and protein rich fluid
* Epithelium may have Rushton bodies
* Lumen or wall may contain cholesterol cleft, dystrophic calcifications, RBCs and haemosiderin pigmentation
What diagnostic notes are associated with a radicular cyst?
* Straw coloured aspirate
* Sensibility tests will show an unresponsive tooth.
What is the aetiology of a dentigerous cyst?
* Commonist type of developmental cyst
* Associated with an unerupted tooth
* Epithelial source; reduced enamel epithelium
* Accounts for 18-24% of jaw cysts
* Can lead to displacement and root resorption of other teeth
What are the radiographic features of a dentigerous cyst?
* Central, lateral and circumferential radiolucencys
*Unilocular radiolucent area associated with crown of an unerupted tooth.
* Large cyst - pseudo impression of multilocular bhowever this is because trabecular bone persistently tries to grow through.
* Well defined and often sclerotic border, but an infected cyst may show less defined borders.
* Usually 3-4mm in diameter, if below this diameter likely to be an enlarged dental follicle
What are the histological features of a dentigerous cyst?
* Connective tissue layer; loosly arranged fibrous wall. Island of inactive epithelial cell rests.
* Epithelial lining; 2-4 layers of cuboidal epithelium. Flat interface connecting the epithelium and connective tissue.
* Inlammation; collagen increase in connective tissue layers. Infiltrate of inflammatory cells. Epithelial hyperplasia. Development of retentions ridges. Squamous features
What is the aetiology of an eruption cyst?
* Epithelial source; reduced enamel epithelium. Soft tissue equivalent of a dentigerous cyst
* Produce a round, soft, blue cyst over the gingivae
* They occur when the dental follicle separates from the erupting tooths crown in the soft tissue
* Can relf resolve or require a small excision to drain the fluid and allow the tooth to erupt
* No radiograph is required
What are the histological features of an eruption cyst?
The same epithelial lining found in a dentigerous cyst
What is the aetiology of a keratocyst?
* Associated with a missing tooth
* Can be linked with inferior alveolar nerve paraesthesia.
* Linked with Gorlin-Goltz syndrome.
* Difficult to enucleate and high recurrence rate due to its thin friable lining
What are the radiological features of a keratocyst?
* Well defined radiolucency
* Can be unilocular or multilocular
* Typically found in the posterior of the mandible (thinking logically, the 3rd molars are commonly abscent, hence this is why keratocysts could be most commonly found here)
What are the histological features of a keratocyst?
* Thin friable wall meaning they are difficult to enucleate.
* 6-8 uniform layers of stratified squamous epithelium.
* Flat epithelial-connective tissue interface.
* Inconspicuous rete ridges
* Basal palisading evident in the basal layer
Describe the management of cysts
* Enulcleatuion involves the complete removal of the cyst.
* Incomplete removal can lead to recurrence.
* Marsupulization can be used if there is a high risk of IAN damage or mandibular fracture. This is where a surgical window is created allowing the contents to drain. This is sutured open and can be maintained with a packing material.
* The enucleation can then take place once the cyst has decreased in size
What are the categories of herpes simplex virus?
Primary - pan oral (in and around mouth). Self limiting (will go away on its own), typically occurs in childhood. Treatment involves treating painful symptoms. Latent in trigeminal ganglion.
Recurrent - appears on keratinized tissue. Herpes labialis (cold sore, fever, blisters), vermillion border. Recurrent intraoral herpes - attached gingiva, hard palate.
Reactivation is triggered by stress, sunlight or immunosupression
What are the different categories of varicella zoster virus?
Primary = chicken pox. Self limiting and generally occurs in childhood. Latent in trigeminal ganglion.
Recurrent = herpes zoster aka shingles.
Ramsay Hunt Syndrome - herpes zoster reactivation
What is the oral presentation of measles?
Kopliks spots (Buccal mucosa spot ulcers) that precede skin rash.
Primary is self limiting and tends to occur in childhood.
What is a Papilloma?
A wart.
CAused by several strains of HPV.
Benign epithelial pedunculated or sessile proliferation on the skin or mucosa
What is actinomycosis?
Caused by actinomyces israali (filamentous) NOT fungal!
Opportunistic infection, chronic and granulomataous.
Periapical - jaw infections.
Cervicofacial - head and neck infections
Sulfer granules in purulent exudate
What is Scarlet fever and what is its oral presentation?
Caused by group A strep
When strep throat becomes a systemic infection
Strawberry tongue = white coated tongue with red inflammed fungiform papillae
What is candidiasis?
Thrush.
Pseudomemranous - white plaque that rubs off
Atrophic - red
Median rhomboid glossitis - loss of lingual papilla
Angular chelitis - corner of mouth.
Treat with antifungal such as azole or statin
What would you likely notice on a pts palate who has been wearing the same F/- for 10+ years?
Erythematous palate
Papillary hyperplasia
A patient presents with an erythematous palate and paplillary hyperplasia. What diagnosis would you make?
Denture induced stomatitis
If you see brown pigment in a histology slide, what is it likely to be?
Melanin. Possibly from nicotine
Name two possible aetiological factors for the development of a white patch with some areas of brown spots on the palate?
Smoking (reverse smoking)
Chronic inflammation
Drugs - hydroxychloroquine
What features in the clinical appearance of a white patch would make you suspicious that it was potentially malignant?
Exopytic growth
Raised, rolled margins
Indurated
Name an intra oral disease associated with angular chelitis
Oral facial granulomatosis
What are some diagnostic featurs of pemphigus vulgaris?
History - soreness and blistering in the mouth, other mucosa and skin
Clinical features of pemphigus vulgaris
* Blisters, erosions and or desquamative gingivitis
* Bullaw appear on any part of the oral mucosa but break rapidly so rarely seen
* Pt usually presents with large, painful, irregular and persistant red lesions, by the time they become secondarily infected turn into erosions with yellowish fibrinous slough
What is the management of pemphigus vulgaris
Aim to promote healing, prevent infection, decrease formation and relieve pain
Take steps to reduce blistering by avoiding trauma from hard foods/contact sports
Corticosteroids
