Oral Medicine Flashcards
Name the 4 categories of medcinies used in Oral Medicine (OM)?
Anti-microbial - virals, fungals and biotics
Topical Steroids - inhaled and mouthwash
Dry mouth medication - benzdamine wash
Others - carbamazepine
Name the 5 classification of medicines?
General Sales
Pharmacy Medicines
Prescription only Medicines
Controlled Drugs
Medical Devices
What is the definition of a licensed medication?
A medicine that has been proven in evidence to the MHRA to have efficacy and
safety at defined doses in a child and/or adult population when treating specified
medical conditions
Clinical trial data provided
Post licence surveilence via MHRA
What is the defintiion of an unlicensed medication?
Medicines that have not had evidence of efficacy submitted for the condition under
treatment
Will be ‘licenced medicines’ – but for another condition
Use is at the discretion of the treating physician
Patient must be informed that medicine is being used ‘off-licence’
Patient must be given PIL specific to the condition under treatment
Name antimicrobials used for OM? and what they treat?
virals - primary herpetic gingivostomatosis, recurrent herpetic lesions and shingles
- aciclovir
fungals - Acute pseudomembranous candidiasis and acute erythematous candidiasis
- miconazle
- fluconazole
- nystain
Name topical steroids used for OM? and what they treat?
Betamethasone mouthwash
Beclomethasone Metered Dose Inhaler
Both used for
- Treating aphthous ulcers
- Treating Lichen planus
What is the definition of a medical devices?
‘Medical device’ means any instrument, apparatus, implement, machine, appliance, implant, reagent for in vitro use,
software, material or other similar or related article, intended by the manufacturer to be used, alone or in combination, for
human beings, for one or more of the specific medical purpose
- diagnosis, prevention, monitoring, treatment or alleviation of disease,
• diagnosis, monitoring, treatment, alleviation of or compensation for an injury,
• investigation, replacement, modification, or support of the anatomy or of a physiological process,
• supporting or sustaining life,
• control of conception,
• disinfection of medical devices
• providing information by means of in vitro examination of specimens derived from the human body
Medical devices include dry mouth treatments - name 5 types of treatments?
Salivix pastilles
Saliva orthana
Biotene Oral Balance
Artificial Saliva DPF
Glandosane
Name 6 other medicines used in OM?
Tricyclic Antidepressants
Gabapentin/Pregabalin
Azathioprine
Mycophenolate
Hydroxycholoroquine
Colchicine
What needs to be considered before any drug is prescribed or drug is reccomended?
Clinical indication
Licenced or unlicensed for this use
Dose and route of administration
Important warnings for the patient
Drug interactions and cautions
Treatment duration and monitoring
What to include on a presciption?
Patient’s name, Address, Age (under 18)
Patient identifier – DoB, CHI Number
Number of Days treatment
Drug to be prescribed
Drug formulation and Dosage
Instructions on quantity to be dispensed
Instructions to be given to the patient
Signed – identifier of Prescriber
What are the rules and regulation on prescrption validity?
Six months from date issued
More than one item on a script
More than one repeated dispensing occasion
Tips for writing a prescription?
Key Patient information MUST be legible
AVOID abbreviations – write full instructions in INK
Only legal requirement is for dentist to SIGN prescription – this confirms all the
other information is correct and has been checked.
Essentially the SAME information for Private
– GDC number usually added
What are the advantages of written instruction for the patient?
Stressed patient may not remember instructions
Language issues may prevent proper understanding
Multilingual options, large print options
Contact number for Patient Issues with the medicine
Legal protection if post-treatment course questioned
What advice should you give to your patient after prescribing the drug?
Take drugs at correct time and finish the course
Unexpected reactions: STOP! and contact prescriber
Known side-effects should be discussed e.g. Metronidazole and alcohol
Keep medicines safe: especially from children
Types of drugs for mucosal disease?
Non-steroid topical therapy
- inconvientient lesions with discomfort
Steroid topical therapy
- disabling immunologically driven lesions
Non-steroid topical therapy for mucosal diease? - Name 4?
Chlorhexidene mouthwash
- dilute 50% with water if needed
Benzdamine mouthwash or spray
- green things help! Useful topical anaesthetic/pain relief
OTC remedies such as Igloo, Listerine, Bonjela
Anything else the patient finds helpful!
- check that it is not harmful though – bleach, aspirin!
Steroid topical therapy for mucosal diease? - Name 3?
Hydrocortisone mucoadhesive pellet
Betamethasone mouthwash
Beclomethasone Metered Dose Inhaler (MDI/Puffer) -
- CFC-free preparations, e.g. ‘Clenil Modulite’
How does it work - hydrocortisone mucoadhesive tablet?
allow tablet to dissolve over the ulcer
How to use betamethasone mouthwash?
Unlicenced product
• Supply patient with a tailored information leaflet
Use Betnesol tabs 0.5mg
- 1mg 2 tablets
- 10mls water 2 teaspoons water
- 2 mins rinsing
- Twice daily
Refrain from eating/drinking for 30 min after use
DO NOT SWALLOW
Do not rinse after use
What must be included on betamethasone mouthwash PIL?
Licenced for other medical conditions
Explain dose range and frequency of use
Explain hazards of exceeding the standard dose
Add any known side effects – small oral candida risk
Add special instructions
How to use beclomethasone medical device?
Unlicenced product
- Supply patient with a tailored information leaflet
Dental Prescribing 50mcg/puff device
- Position device correctly – exit vent directly over ulcer area
- 2 puffs
- 2-4 times daily
- Don’t rinse after use
Must be a pressurised device
What must be included on beclomethasone medical device PIL?
This is an accepted and proven effective treatment for the oral condition
Licensed for other medical conditions – asthma and COPD
Instruct to discard the manufacturer’s PiL
Explain dose range and frequency of use
Explain technique used for oral lesions – different from use for lung conditions
Add any known side effects – small oral candida risk
Add special instructions
Systemic drugs used in OM, only for specialists?
Disease modulator
- colchine
Steroid
- prednisilone (ulcers) 30mg for 5 days
Immune suppressants:
- hydroxychloroquine - lichen planus
- azathioprine
- mycophenolate
Immunotherapy:
- adalimumab
- enterecept
Systemic use of steroid risk - side effects?
If prolonged course – or repeated short courses over many months
• 3 months continuous
• Gaps of 2 weeks or less between ‘pulses’ of prednisolone.
Adrenal suppression – steroid dependency – don’t stop suddenly – taper dose
Cushingoid features
Osteoporosis risk – bone prophylaxis – Calcium supps and bisphosphonates
- DEXA bone density scan may be needed from time to time
Peptic ulcer risk – Proton Pump Inhibitor prophylaxis
Mood/Sleep alteration and mania/depression risk – can be very quick onset
What preparation do patients need for systemic immunomodulatory treatmets?
Must ensure that immunosuppression will not harm the patient
Pre-existing medical condition not yet detected
Screening for:
Blood borne virus screen
- Hep B, Hep C, HIV
• FBC
• Electrolytes
• Liver Function tests
• Thiopurine Methyltransferase (TPMT)
- Only for Azathioprine use
• Zoster antibody screen
• EBV
• Chest X-Ray
- Evidence of previous/active TB
• Cervical Smear up to date
• Pregnancy test
What must be included when planning immunomodulatory treatment?
Needs full consent from patient
- Alternative treatments tried or discussed
Patient information given and patient reviewed to discuss this
- Short term risk – acute drug reaction
- Long term risk – cancer risk increased – Azathioprine and skin cancer especially
- Effective Contraception to be used and any pregnancy planned with clinical care team
Treatment outcome understood by patient and clinician
- Complete remission, acceptable level of symptoms
- Trial treatment – perhaps 6 months then reassess benefit/need for treatment
What are the differential diagnoses of oral white lesions? 5 examples?
Hereditary
Smoking/frictional
Lichen planus
- lupus erythematosus
- gvhd
Candidal leukoplakia
Carcinoma
What does a typical white spot lesion look like?
Thickening of the mucosa or keratin
- Less visibility of blood
Less blood in the tissues
- vasoconstrictor
What is the definition of Leukoplakia?
A white patch which cannot be scraped off or attributed to any other cause
No histopathological connotation
- it is a clinical description
Diagnosis of exclusion
1 - 5% become malignant
Name 4 types of leukoplakia?
Fordyce’s spots
Smoker’s Keratosis
Frictional Keratosis
Hereditary Keratosis
What is the link between smoking and leukoplakia?
Smokers are six times more likely to have “leukoplakia”
Low malignant potential of the lesion
- But higher oral cancer risk overall!
Name 3 types of infective leukoplakia?
Candidosis
- pseudomembranous acute (thrush)
- denture associated (chronic)
Herpes Simplex
When should you refer a white spot lesion?
Most are benign
If RED and WHITE concentrate on the RED part
If the lesion is becoming more raised and thickened
If the lesion is ‘without cause’
- lateral tongue
- anterior floor of mouth
- soft palate area
Why are red spot lesions red?
Blood flow increases
- inflammation
- dysplasia
Reduced thickness of the epithelium
What is the definition of Erythroplakia?
Atrophic or non-keratotic end of the spectrum
A red patch which cannot be attributed to any other cause
More of a concern for malignancy than leukoplakia
Why does a red/blue lesion look like it does? explain why?
Fluid in the connective tissue
- Dark – slow moving blood – varicosities
- veins or cavernous haemangioma
Light Blue – clear fluid
- saliva (mucocele), Lymph (Lymphangioma)
Name 2 types of vascular hamartomas?
Haemangioma
- capillary
- cavernous
What is thw defintion of a lymphangioma?
Lymphangioma
- most are cavernous
Tongue
- cystic hygroma
Name 3 types of connective tissue diseases?
Large vessel Disease
- giant cell (temporal) arteritis
Medium Vessel Disease
- polyarteritis nodosa
- kawasaki disease
Small vessel Disease
- granulomatosis with Polyangiitis
What are the 3 types of mucosal pigmentations?
Exogenous stain
Intrinsic Pigmentation
Intrinsic foreign body
Name the 4 examples of exogenous stains for mucosal pigmentation?
Tea
coffee
chlorhexidine
Bacterial overgrowth
Name the 4 examples of intrinsic pigmentation for mucosal pigmentation?
Reactive Melanosis/melanotic macule
Melanocytic naevus
Melanoma
Effect of systemic disease - paraneoplastic phenomenon
Name the 1 examples of intrinsic foriegn body for mucosal pigmentation?
Metals
Name the differential diagnoses for brown/black lesions - localised and generalsied?
Localised:
- Amalgam
- Melanotic Macule
- Melanotic naevus
-Malignant Melanoma
- Peutz-Jehger’s syndrome
- Pigmentary incontinence
- Kaposi’s sarcoma
Generalised:
- Racial/familial
- Smoking
- Drugs
- Addison’s disease (Raised ACTH conditions)
Name 2 types of melanin pigmentation?
Racial pigmentation
Melanotic macule
What questions to think about when deciding whether to refer for mucosal pigmentations?
Is it easily explained?
- Racial
- Smoking
- Medicines
Is it increasing in size, colour or quantity?
Any NEW systemic problem?
Do I have an EXISTING radiograph showing it to be amalgam?
What is the ateiolog of mucosal inflammation?
trauma - physical or chemical
infection - viral, bacterial or fungal
immunological
can be remalignant or melignant
How to decide whether something is a melanoma? questions?
Variable pigmentation
Irregular outline
Raised surface
Symptomatic
- Itch
- bleed
What is the purpose of a biopsy?
identifies or excludes malignancy
identifies dysplasia
identifies other disease, e.g. lichen planus
When must you biopsy?
if unexplained
When should a patient be referred to oral medicine?
Patients with abnormal and/or unexplained changes to the oral mucosa
- Practitioner threshold will vary with experience
If there is concern about dysplasia risk
- Appearance of lesion
- Risk site
- Risk behavior
- Family history
When should you NOT refer a patient to Oral Medicine?
Asymptomatic VARIATIONS of NORMAL mucosa
Benign conditions the practitioner has diagnosed that:
- Are asymptomatic
- Do not have potentially malignant risk
- For which there is no treatment
If unsure – consider clinical photography to
- Monitor area until next check up
- Send to specialist for an opinion
When should a mucsoal lesion be refered to oral medicine for an opinion?
ANYTHING the dentist thinks is might be cancer or dysplasia
- 2 week Cancer referral pathway for actual malignancies
- NICE and SIGN Head & Neck cancers guidelines
Any SYMPTOMATIC lesion that hasnot responded to standard treatment
- Hospital referral criteria
- SDCEP guidance
Any BENIGN lesion that the patient can’t be persuaded is not cancer…..
What is the oral mucosa made up of?
stratified squamous epithelium
lamina propria
gross types
- lining, masticatory, gustatory
microscopic
- non-keratinised
- keratinised
- orthokeratosis or parakeratosis
Different parts of the mouth which are keratinised and non-keratinised?
Keratinised - palate
Non-keratinised - cheek
What are the compartments of the oral mucosa?
STratum
Corneum
Granulosum
Spinosum
Basal
Lamina Properia
Cornified, Maturation, Progenitor
Name the 3 reactive chnages of the oral epithelium?
Keratosis
- nonkeratinised site
(parakeratosis)
Acanthosis
- hyperplasia of
stratum spinosum
Elongated rete ridges
- hyperplasia of basal cells
Name the 5 mucosal reactions of the oral mucosa?
Atrophy - reduction in viable layers
Erosion - partial thickness loss
Ulceration - fibrin on surface
Oedema - intracellular
- intercellular (spongiosis)
Blister - vesicle or bulla
How do age and nutritiona ffect the oral mucosa?
Age - progressive mucosal atrophy
Nutritional deficiency
- iron or B group vitamins
- atrophy
- predisposes to infection
Name 3 types of benign tongue conditions? Dorsal surface
Geographic tongue
- 1-2% of population - less in children
- desquamation - varied pattern and timing
Black hairy tongue
- hyperplasia of papillae
- bacterial pigment
Fissured tongue (scrotal tongue)
What are the symptoms of geographic tongue?
Sensitive with acidic/spicy foods
Intermittent
Much worse in young children
What is the aetiology of geographic tongue?
None!
Something else is causing the trouble
- Haematinic deficiency (B12, Folate, Ferritin)
- Parafunctional trauma
- Dysaesthesia
How to manage a black hairy tongue?
Sucking on a peach stone
What is the definition of a fissued tongue?
Fissured tongue is a benign condition characterized by deep grooves (fissures) in the dorsum of the tongue.
Although these grooves may look unsettling, the condition is usually painless.
Some individuals may complain of an associated burning sensation
The cause is unknown, but it may be partly a genetic trait. Aging and environmental factors may also contribute to the appearance
Is there another disease process there?
- Candida
- Lichen planus
What is the defintion of glossitis? And possible investigations?
What is Glossitis?
- Glossitis can mean soreness of the tongue, or more usually inflammation with depapillation of the dorsal surface of the tongue (loss of the lingual papillae), leaving a smooth and erythematous (reddened) surface
What investigations are needed?
- Haematinics
- Fungal cultures
What is the definition of black hairy tongue?
is a condition of the tongue in which the small bumps on the tongue elongate with black or brown discoloration, giving a black and hairy appearance.
What is the aetiology of black hairy tongue?
smoking,
xerostomia (dry mouth),
soft diet,
poor oral hygiene
certain medications
What is the aetiology of glossitis?
Often caused by nutritional deficiencies
- Fe
- B
- Infection
- others
When should you refer a swelling to Oral Medicine?
Symptomatic (pain is a feature of salivary gland malignancy!)
Abnormal overlying and surrounding mucosa
Increasing in size
‘rubbery’ consistency
Trauma from teeth
Unsightly
What is the definition of a pyogenic granuloma?
granulation tissue – mixed inflammatory infiltrate on fibro-vascular background
any mucosal site response to trauma
Not a granuloma, not pyogenic
other names
- gingiva – aka vascular epulis
most frequent site
- gingiva, during pregnancy
pregnancy epulis
Name the 5 causes of mucosal ulcerative reactions?
Trauma
Immunological
Infections
GI
Carcinoma
Name the differential diagnoses for immunological and GI mucosal ulcerative reactions?
Immunological:
- aphthous ulcers
- lichen planus
- Lupus
- vesiculo-bullous
- Erythema multiforme
GI:
- Crohn’s
- UC
What are the differential diagnoses for single episode oral ulceration?
Trauma
1st episode of Recurrent Oral Ulceration
Primary Viral infections
Oral Squamous Cell Carcinoma
What are the differential diagnoses for Recurrent Oral Ulceration?
Aphthous ulceration
- minor, major, herpetiform
Lichen Planus
Vesiculobullous lesions
- pemphigoid, pemphigus
- angina bullosa haemorrhagica
- erythema multiforme
Recurrent viral lesion – HSV, VZV
Trauma
Systemic disease – Crohn’s Disease ulceration
Describe the difference between Crohn’s ulcers and aphthous ulcers?
Aphthous-type ulcers:
- haematinic deficiency associated
- behave like aphthous ulcers
Crohn’s specific ulcers:
- linear at the depth of the sulcus
- full of Crohn’s associated granulomas
- persist for months – intralesional steroids help
Explain what to include for an Oral Ulceration History?
Where?
Size & Shape?
Blister or ulcer?
How long for?
- more than 2 weeks?
Recurrent?
- same site? different Sites?
Painful?
Explain how to describe/examine an ulcer?
Margins?
- flat? raised? rolled?
Base?
- soft? firm? hard?
Surrounding tissue
- inflamed? normal?
Systemic Illness?
What is the definition of traumatic ulceration?
Common
Usually single episode
- can be recurrent if cause not removed
Normal or abnormal epithelium
Healing
- remove cause
- heal in about 2 weeks
Describe a recurrent herpetic lesion? - location and treatment
Ulceration limited to one nerve group/branch
Often Hard palate
- lesion recurs in the same place
- patient often aware of prodrome and vesiculation which bursts
- PAIN suggests Herpes ZOSTER rather than
simplex
Treat with systemic ACICLOVIR
- prophylactic if a severe problem
Describe recurrent aphthous stomatitis (RAS)? severity? diagnosis?
Severity:
- minor
- major
- herpetiform
- Behçet’s syndrome
Diagnosis by :
- history
- examination
What is the general rule for recurrent self-healing ulcers?
Those affecting exclusively the non-keratinized mucosa are inevitably aphthae.
The overall summary of Oral Ulceration?
Not all ulcers are aphthous!
Is the lesion on keratinized or non-keratinized mucosa
Are there systemic symptoms?
- consider infection – herpes group, coxsackie group
Always look for a traumatic cause
- primary – sharp edge on a tooth/appliance
- secondary – parafunction rubbing mucosa against the teeth
What is the definition of an Aphthous Ulcer?
- Immunologically generated RECURRING oral ulcers
- Follow a set pattern depending upon the ulcer type
- Genetically driven with environmental modification
- Multifactorial environmental triggers and variable expression
- Ulcer experience may change as ‘risk factors’ change over life
Describe the characteristics of a minor aphthous ulcers?
- Less than 10mm diameter
- Last up to 2 weeks
- ONLY affect NON-Keratinised mucosa
- Heal without scarring
- Usually a good response to topical steroids
This is the commonest type of recurrent oral ulceration
- One is a nuisance, many more at once can be disabling
The ULCER FREE PERIOD is a good guide to morbitity
– longer ulcer free + less morbidity
Describe the characteristics of a major aphthous ulcers?
- Can last for months
- Can affect ANY part of the oral mucosa
- keratinised OR non keratinised or both - MAY scar when healing
- Poorly responsive to topical steroids
- intralesional steroids often more useful
Usually LARGER than 10mm
- may get smaller ulcers too – diagnose from the worst ulcer
Describe the characteristics of a herpetiform aphthae ulcer?
- Rarest form of Aphthous ulcers
- Multiple small ulcers on non-keratinized mucosa
- Heal within 2 weeks
Can coalesce into larger areas of ulceration
NOTHING to do with herpes viruses
- in the early stages looks like primary herpetic gingivostomatitis
- in HSV get KERATINISED epithelium involved – not in herpetiform aphthae
What cause Oral and Genital Ulceration?
Behçet’s Disease (mainly)
Vesiculobullous diseases
Lichen Planus
How to diagnose Behcet’s disease?
Many who don’t meet the criteria
Diagnosis
- three episodes of mouth ulcers in a year
- at least two of the following: genital sores, eye inflammation, skin ulcers, pathergy
What is the definition of Behcet’s Disease? and where can it effect?
PRIMARILY a Vasculitis – inflammation of blood vessels
- Oral & genital ulceration
- Eye disease
- snterior or posterior uveitis – can lead to loss of vision in 20% - Bowel ulceration – iliocaecal area – pain and cramping
- Heart and lungs
- Brain
- Joints
How to manage a patient with Behcet’s Disease?
Treat local oral disease or RAS
Systemic immunomodulation where multisystem involvement:
- Colchicine used ‘off label’ often a first treatment
- Azathioprine/Mycophenolate
- Biologics – infliximab and others
Managed with help of Rheumatology
- also National specialist treatment centres
Name the 7 predisposing factors for Recurrent Aphthous Stomatitis (RAS)?
Viral and bacterial infections
Genetic predisposition
Systemic diseases
Stress
Mechanical injuries
Hormonal level fluctuations
Microelement deficiences
What to remember for Aphthous ulcers?
Damage happen before the ulcer appears
- treatment is most effective in ulcer rpodrome period
What tests to carry out when investigating aphthous ulcers?
Blood test:
- haematinic deficiencies Iron B12 or folic acid
- coeliac disease
- TTG (tissue transgutaminase)
- if TTg +ve anti-glidain and anti-endomysial abs
Allergy tests - contact or immediate hypersensitivty
- food additives E210-E219
- benzoate
- sorbate
- cinnamon
- chocolate
Explain the treatment of a recurrent Aphthae?
Management:
Correct blood deficiencies
- ferritin (iron), folic Acid, vit B12
Refer for investigation if Coeliac positive
- endoscopy and jejunal biopsy
Avoid dietary triggers
- SLS containing toothpaste – (Sensodyne Pronamel and Kingfisher are SLS free)
Dietary triggers
- identified from testing
- empirical dietary avoidance – use FOOD MAESTRO app to help with identifying foods
Explain the treatment of a recurrent Aphthae?
Management:
Correct blood deficiencies
- ferritin (iron), folic Acid, vit B12
Refer for investigation if Coeliac positive
- endoscopy and jejunal biopsy
Avoid dietary triggers
- SLS containing toothpaste – (Sensodyne Pronamel and Kingfisher are SLS free)
Dietary triggers
- identified from testing
- empirical dietary avoidance – use FOOD MAESTRO app to help with identifying foods
What drugs can be prescribed for aphthous ulcers?
In dental practice follow SDCEP ’Drugs in Dentistry’ Guidance
Non-Steroid Topical Therapy
- for inconvenient lesions
Steroid Topical Therapy
- for disabling lesions
Why do chuildren get aphthous ulcers?
Periods of rapid growth – very few before this
- 8-11 years and 13-16 years
- feet usually grow first so look for ‘new shoe sign’
Treatment
- usually respond to 3/12 iron supplements – always check the diet for peculiarities
NOT related to growth (present since birth) then largely a genetic component:
- consider allergy testing as well as bloods
Treatment:
- issues with Betnesol under age 12 - licence
- issues with Betnesol if child unable to spit mouthrinse out reliably
When should you refer an Aphthous ulcer case?
After simple investigations
After topical trreatment
If no good result has been achieved
If patient under 12 YO
What is the defintion of oral thrush?
Caused by candida
Can be associated with dentures causing denture stomatitis
What species of candida causes oral thrush?
Candida albicans
Name the 10 host factors that predispose you to developing oral thrush?
Immunosuppression
Endocrine disorders
Nutritional deficiency
Antibiotics
Steroids
Female
Extremes of age
Hospitalisation
Smoking
High carb diet
Name the 5 intraoral factors that predispose you to oral thrush?
Poor oral hygiene
Salivary gland dysfunction
Oral mucosal damage
Dental prosthesis
Changes to commensal flora
Name the topical and systemic treatment of oral thrush?
Topical:
- nystatin
- miconazole
Systemic:
- fluconazole
- targeted therapy
Explain how to use nystatin suspension?
1ml QDS
Keep in mouth for as long as possible
Continue for 48 hours after resolved
Low risk for inters
Explain how tonuse miconazole oral gel?
2.5 ml QDS - gold in mouth after food
Continue for 7 days after resolved
Use gel to brush dentures
What treatment is advised for angular cheilitis?
Miconazole
- antifungal
- bacteriostatic vs gram positive
- topical
- with mild steroid
Name the drug interactions of Miconazole?
Inhjbits the metabolism of drugs metabolised by the CYP3A4 and CYP 2C9 enzyme systems
CYP3A4:
- statins
- Ca ch blocker
- tacrolimus
- carbamazepine
- midazolam
CYP2C9
- warfarin
- sulphonylureas
- phenytoin
Name the contraindications of miconazole?
Liver dysfunction
Coadministration with drugs that are metabolised by CYP3A4
Substrates known to prolong QT interval - astemizole, cisapride, dofetilide, mizolastine, pimozide, quinidine, sertindole and terfenadine
Ergot alkaloids
HMG-CoA reductase inhibitors - simvastatin
Triazolam and oral midazolam
Explain how to take fluconazole?
50-200mg capsules
50-5ml oral suspension
IV avaliable
50mg once a day for 7-14 days
100mg if immunocompromised
Name the 6 contraindications of fluconazole?
Mod inhib of P3A4 and 2C9
Strong inhib of 2C19
Alfentanil
Amitriptyline
Benzodiazepines
Citalopram
Clopidogrel
Warfarin
How importance is drug resistance to antifungal?
A growing problems
Most common in azoles
Explain a dentists role in antimicrobial stewardship?
Don’t start antibiotics without bacterial infection
Use local guidelines
Document everything such as indication, duration, dose and route
Review clinical diagnosis and the need for the pt to continue the dose 48 hours after symptoms go
Name 7 types of oral symptoms?
Dry mouth
Oral discomfort
Taste disturbance
Difficulty chewing
Difficulty swallowing
Difficuly speaking
Halitosis
Advice for toothbrushing?
At least twice a day
Small headed brush
Medium texture filament
Soft brush if very sore
Toothpaste between 1350-1550 ppm Fl
Water if toothpaste is unworkable
How can a nurse care for a patients teeth if they can’t?
Twice daily brushing
Gloves with toothpaste
Small circular motions
Start on outer surfaces then move to inner surfaces
Spit out toothpaste after brushing
Avoid rinsing
How can a nurse care for a patients denture?
Cleanse denture after meals
Cleaned and removed overnight
Ensure denture fits well
Adhesive if necessary
How can a nurse care for a patients soft tissue?
Glove and run finger over tissues
Renew gause on cleansing
Can use cleaning stock if gause not good
Record mouth condition
How can a nurse care for a patients lips?
Moisten with water
Apply saliva replacement
Or apply aqueous cream BP
What to implement for a dry or coated mouth patient?
At least 4 x a day
Review medicines
Gently remove coating, debris and plaque
Maintain hydration
Stimulate saliva
Which 5drug types cause dry mouth?
Opoids
Anticholinergics
Antidepressants
Diuretics
Oxygen
Explain how to manage dry mouth?
Treat underlying cause
Review medication
Good oral hygiene
Dietary advice
Regular dental checks
Regular sips of water
Lubricate cracked lips
Saliva substitutes
Saliva stimulants
What does saliva consist of?
6.8-7.4 pH
Water
Mucin-principal active component
Electrolytes
Enzymes
Proteins
Name saliva stimulants?
Sugar free chewing gum or sweets
Frozen fruit juices or lollies
Organic acids such as salivix pastilles
Describe artifical saliva?
Mucon or carboxymethylcellulose based
Short duration of action
Avoid acidic products - glandosane
Neutral pH
- AS saliva Orthana
- Biothene Oralbalance gel
- BioXtra gel
- Saliveze
Which saliva replacements can a dentist prescribed on the NHS?
Glandosane
Saliveze
Salivix pastilles
Salivox Plus pastilles
At what age does lichen planus usually affect?
30-50 years old
What percentage of skin and oral cases are there.
50% oral lesions
10-30% skin lesions
Name the main types of Lichen Planus and their
Cutaneous - skin
Reticular - commonest
Erosive - premalignant
Desqamative attached gingivae
Descriptors - Atrophic/Ulcerated/ Plaque
What is the histopathological findings of lichenoid reaction?
Chronic inflammatory cell infiltrate
Saw tooth rete ridges
Badal cell damage
Patchy acanthosis
Parakeratosis
What is the histopathological findings of licehn planus?
Orthokerstosis
Wedge shaped hypergrabulosis
Dermal epidermal Junction obscured lymphocytes
Vacuoles at basal later
Luck band of lymphocytes under epidermis
Civatte bodies - dead keratinocytes
What does the histopathological findings tell us?
Lymphocyte activation
Overreaction to normal trigger
Virus umplicated in immune upregulation but NOT as a cause of LP - hep C or herpes
Sometimes has external triggers - medicines or amalgam
What are the 8 aetiologices of lichen planus
Autoimmune
Viral
Genetic predisposition
Physical and emotional stress
Trauma - scraped or after surgery an isomorphic response (koebnerisation)
Localised skin disease - herpes zoster - isotopic response
Contact allergy - amalgam
Drugs - gold, quinine, beta blockers and ACE inhibitors
What are the symptoms of lichen planus?
Often none
May relate to thinning of epithelium
- sensitive to hot and spicy food
- burning sensation in the mucosa
What other body parts can LP affect?
Skin
Scalp
Genitals
Hair
Nails
What are the 5 main sites for oral LP?
Biccal mucosa
Gingiva - desquamative gingivitis
Tongue- lateral or dorsum
Lips
Palate
Describe buccal lichen planus?
Commonest
Can be found anywhere
- ant at commisure
- mid
- post around 3rd molar
Mainly an incidental finding
Easy to biopsy
Describe gingival lichen planus?
Found in isolation
Termed desquamative gingivitis
- similar to gingival pemphigoid and to plasma cell gingivitis - clear histological
Very erythematous appearance to the gingiva
Patchy
Reticular pattern more common
Oral hygiene is essential to settle the lesion - plaque driven
- especially interdentally
Biopsy can be difficult
- risk of damage to attachment area
- adherent attached mucosa damaged lifting from bone
Describe tongue lichen planus?
Dorsum usually idiopathic
- loss of papillary becoming smooth
Lateral may be drug/amalgam trigger
- amalgam most likely in isolated lesion
- look at tongue rest position - contact amalgam?
Easy biopsy but painful
Describe lip lichen planus?
On the lip
Biopsy hard?
Looks sore
Erythema
What is it called if the cause is known for oral lesion?
Lichenoid reaction to…
Medications which can cause LP?
ACE inhib
Beta blockers
Diuretics - bendroflu and frusemide
NSAIDs
DMARDs
Rare - phenothiazines
Name 3 types of DMARDs?
Penicillamine
Gold
Sulphasalazine
What are the discriminative characteristics of a lichenoid drug reaction?
Widespread lesion
Bilateral and mirrors
Poorly response to standard steroid treatment
How to manage lichenoid drug reactions?
Benefit of the drug vs the risk of stopping the drug
How bad is the discomfort from the symptoms
If significant symptoms - may need to find alternative medication
Discuss with GP
What is the defintion of amalgam contact sensitivity LP?
Is it the amalgam, Mercury or something else as the trigger
Patch test to the allergen
How to manage an amalgam related lichen planus lesion?
If asymptomatic do nothing
Any replacement will lose tooth tissue
Which materials to replace amalgam with?
Composite
Glass
Gold - low palladium alloy
Bonded crown
Srmamentarium for amalgam removal?
Dam
High vol suction
PPI
Avoid during preg
Explain the overall lichen planus management for the patient?
Remove any cause
- medicines
- dental restorations
Biospy
- unless a good reason not to
Blood test
- haematinics
- fbc
- if lulus suspected autoantibody screen for ANA, Ro and dsDNA
What treatment would be recommended for mild intermittent lichen planus lessons?
Topical OTC remedies
- chlorhexidine
- benzdamine
Avoid SLS containing toothpaste
What treatment would be recommended for a persisting synthetic lichen planus lesion?
Topical steroids
- beclomethasone inhaler
- betamethasone rinse
Higher strength steroid
- skin steroid cream - Clobetasol
Topical tacrolimus mw
Hydroxycholorquine
Systemtic immumodilators
- azathioprine and mycophenolate
Graft vs host disease
What are the histological findings of lupus erythematosis?
Basal vacuolar damage
Atrophic epithelium
Melanophage
Intense lymphocytic infiltrate
Describe lichen like lesions?
Underlying disease needs consideration
GVHD common after stem cell transplant
Lupus lesion can be
- only in mouth - discoid lupus no auto abs
- mouth and elsewhere (systemic ANA/Ro/dsDNA
If oral symptoms only treat like lichen llanjs
Name 5 vesiculobulloua conditions?
Erythema multiform
Pemphigus
Pemphigoid
Angina Bullish Haemorrhagia
Bullous lichen planus
What is the defintion of Pemphigoid?
A subepithelial antibody attack
Thick walled blisters
- persist to be seen
- clear or blood filled
Name 3 different forms and presentations of Pemphigoid?
Bullous pemphigoid - skin
Mucous membrane pemphigoid - all mucous membranes
Cicatritial pemphigoid - mucosal with scarring
Describe the histopathogy of pemphigoid?
Sub epithelial split - epithelial/CT tissue junction
Hemi-desmosomes involved at basement membrane
Describe how Pemphigoid is seen with immunofluorescence?
Linear staining along the basement membrane
C3 and IgG detected in this area in ‘standard’ pemphigoid
IgA occasionally found
- linear staining with C3 is ‘Linear IgA disease’
- granular IgA and C3 deposits is seen in ‘dermatitis herpetiformis’
What is a symblepharon?
Pemphigoid that is present on the eye
Non-oral locations of Pemphigoid?
Oral and skin lesions
- bullous on skin
- mucous mem usually mouth, eye or genitals (needs specialist)
Scarring is a feature in some cases
- cicatritial pemphigoid
How to manage Pemphigoid?
Steroids
Immune modulating drugs
- azathioprine
- mycophenolate
What is the defintion of Pemphigus?
Commonest form is vulgaris
Intraepithelial bullae
Clinically:
- more common in females and over 50s
- genetic with ashkenazi Jews
Sites:
- skin
- mucosa
They blister, then burst and then it spreads
Describe Pemphigus histopathologically?
Supra-basal split with tzank cells
Describe Pemphigus using immunofluorescence?
Very green
Basket weave pattern - around each epithelial cell
C3 and IgG in Pemphigus vulgaris
How to treat Pemphigus?
It affects the mucosa and skin
Rarely see intact bullae
- intra epithelial blisters
Can be fatal without disease
- complications of treatment are major cause of death
Explain 2 different types of immune mediated disease?
Hypersensitivity
Immunogenic
How many types of hypersentivitiy?
5
Name the 2 types of immunogenic immune mediated disease?
Cell mediated
Antibody mediated
Name 3 types of local immunological oral disease?
Aphthous ulcers
Lichen planus
Orofaxial granulomatosis
Name 6 systemic diseases with local oral effects?
Eythema multiform
Pemphigus
Pemphigoid
Lupus
Systemic sclerosis
Sjogren’s syndrome
Type 3 Hypersensitivity example?
Erythema multiform
Name 3 examples of cell mediated immunity?
Aphtous ulcers
Lichen Planus
Orofaxial Granulomatosis
Name 2 examples of antibody mediated immunity?
Pemphigus
Pemphigoid
Immunological skin diseases?
Skin and oral.mucosa.share many antigens and epitopes
- blistering skin conditions can also affect the mouth
Explain the mechanism of immunological skin disease?
Auto-antibody attack on skin compartments causing loss of cell to cell adhesion
- causing splits in the skin
- fill with inflammatory exudate
- form vesicles or blisters
How do cells of the epidermis adhere to eachother?
Via desmosomes and hemidesmosomes
2 proteins - desmoglein (VIP) and desmocollin
Explain the mechanism of action for immunofluorescence?
A fluorescein molecule is attached to an engineered antibody, that when binds fluorescence and becomes active
Explain the difference between direct and indirect immunofluorescence?
Direct:
- antibody mediated tissue disease
- antibody bound to tissues - targeted in DIF
Indirect:
- circulating antibody not yet bound to the tissue
- detected by immunofluorescence from a plasma sample
- not always useful for diagnosis - often good for monitoring disease activity
What is the defintion of erythema multiforme?
Acute onset - more men
Skin - show target lesions
Mucosa - show ulcers
For young males it is recurrent within a short period
What is the aetiology of erythema multiforme?
Immune complex?
- drugs
- herpes simplex
- mycoplasma
What specific sites do erythema multiforme target?
Lips and anterior part of the mouth
Heals in 2 weeks
Very painful - unable to eat or drink
What os erythema multiforme relation to Stevens Johnson syndrome?
Can be involved with Stevens-Johnson syndrome
- sevre multisystem involvement
- skin, conjunctivae, nose, pharynx, mouth and genitals
What is the treatment for erythema multiforme?
Oral lesions:
Urgent medical therapy:
- systemic steroids of up to 60mg per day
- systemic aciclovir
Encourage fluid - possible I
Encourage analgesia
If recurrent:
- prophylactic acyclovir daily
- allergen test for triggers
Mycoplasma infective agent
What is the defintion of angina bullous haemorrhagica?
Commonest oral blistering condition
Blood blisters in mouth:
- buccal mucosa and soft palate
- rapid onset
- 1 hr then burst
Painless
Iniated by minor trauma or eating
Heal with no scar within days
Name 4 types of auto-immune disease related to sjogrens?
Describe the timeline of Sjorgens Syndrome
Describe the symptoms of Sarcoidosis?
Describe Challacombe Scale of Mucosal Dryness?
Flow rate normal vs abnrmal?
