Oral Medicine Flashcards
3 main causes of orofacial soft tissue infections
- viral
- bacterial
- fungal
viral causes of orofacial soft tissue infections
primary herpes
herpangina
hand foot & mouth
MMR
epstein barr virus
varicella zoster
bacterial causes of orofacial soft tissue infections
staphylococcal
streptococcal
syphilis
TB
fungal causes of orofacial soft tissue disease
candida
describe primary herpetic gingivostomatitis
acute infectious disease caused by herpes simplex I
primary infection common in children
recurrence of this is herpes labialis which is cold sores
transmission by droplet formation with 7 day incubation
children under 1 very at risk
lasts 14 days & heals with no scarring
signs & symptoms of primary herpetic gingivostomatitis
- fluid filled vesicles that rupture to ulcers on gingivae, tongue, lips, buccal & palatal mucosa
- severe oedematous marginal gingivae
- fever, headache, nausea, malaise
- cervical lymphadenopathy
treatment of primary herpetic gingivostomatitis
rest, soft diet, paracetamol, antimicrobial gel or mouthwash, topical aciclovir for immunocompromised children
most common complication = dehydration
causes of PHG
sunlight stress or other causes of ill health
recurrent disease in 50-75% via herpes labialis
remains dormant in epithelial cells
describe herpangina
vesicles in the tonsillar / pharyngeal region
lasts 7-10 days
describe hand foot & mouth
ulceration on gingiva/tongue/cheeks/palate
maculopapular rash on hands and feet
lasts 7-10 days
describe oral ulceration
a localised defect in the surface oral mucosa where the covering epithelium is destroyed leaving an inflamed area of exposed connective tissue
10 key things to ask about
onset
frequency
treatment so far (i.e. helpful or unhelpful)
exacerbating factors
number
lesions in other areas
associated medical problems
duration
site
size
OFTEN LADSS
causes of oral ulceration (8)
infection - viral e.g. HFM, coxsackie virus, herpes simplex // bacterial e.g. TB, syphilis
immune mediated disorders - crohns, behcets, coeliac
vesiculobullous - pemphigoid, pemphigus vulgaris
inherited or acquired immunodeficiency disorders
neoplastic / haematological - anaemia, leukaemia, cyclic neutropenia
trauma
vit deficiencies - iron, B12, folate
recurrent apthous stomatitis
what is the most common cause of ulceration in children
recurrent apthous ulceration
describe recurrent apthous ulceration
round or ovoid in shape with a grey or yellow base and have a varying degree of perilesional erythema
describe the patterns of recurrent apthous ulceration
minor <10mm
major >10mm
herpetiform 1-2mm - can present with multiple ulcers but unlike herpetiform gingivostomatitis viral infection it is not accompanied by a fever or recurrent
investigations to undertake for oral ulceration
diet diary
FBC
haematinics i.e. folate/B12/ferritin
coeliac screen - anti-transglutaminase antibodies
management for oral ulceration
diet diary may suggest exacerbating food groups
low ferritin = 3mths of iron supplements
low folate/B12 / positive anti-transglutaminase antibodies = referral to paediatrician for further investigation
allergic factors - dietary exclusion / SLS free toothpaste
pharmacological management in GDP of oral ulceration
- prevention of superinfection - corsodyl 0.2% mouthwash
- protecting healing ulcers - gengigel topical gel (hyalonurate) // gelclair mouthwash (hyalonurate)
- symptomatic relief - difflam (0.15% benzydamine hydrochloride) // local anaesthetic spray
orofacial granulomatosis in children
uncommon chronic inflammatory disorder
idiopathic / associated with systemic granulomatous conditions e.g. crohn’s or sarcoidosis
av age = 11yrs
males > females
characteristic pathology = no caseating giant cell granulomas which then result in lymphatic obstruction
clinical features of OFG
same as oral Crohn’s
lip swelling - most common
full thickness gingival swelling
swelling of non labial facial tissues
peri-oral erythema
cobblestone appearance of buccal mucosa
linear oral ulceration
mucosal tags
lip/tongue fissuring
angular chelitis
investigations for OFG
measure growth - paediatric growth charts
FBC
haematinics
patch testing - ID triggers
diet diary - ID triggers
faecal calprotectin
endoscopy risky in childhood
serum angiotensin converting enzyme (raised in sarcoidosis)
OFG management
can be difficult
OH support
symptomatic relief as per oral ulceration
dietary exclusion
manage nutritional deficiencies
topical steroids
topical tacrolimus
short courses of oral steroids if unresponsive to topical
intralesional corticosteroids
surgical intervention - if unresponsive long standing disfigurement
describe geographic tongue in children
idiopathic and non contagious
benign change to mucosa with loss of filiform papillae
shiny red areas surrounded by white margins and appears to migrate over time
can be very uncomfortable
thinner oral mucosa in children
management of geographic tongue in children
rule our haematinic deficiencies
bland diet during flare ups
likely to become less troublesome with age
5 examples of solid swellings
- fibroepithelial polyp
- epulides
- congenital epulis
- HPV associated mucosal swellings
- neurofibromas
describe fibroepithelial polyps
common
firm pink lump (pedunculated / sessile)
mainly in cheeks along occlusal line; lips or tongue
once established remains constant size
initiated by minor trauma
surgical excision is curative
benign nature means difficult to justify GA
describe epulides & what are the 3 main types
common solid swelling of oral mucosa; benign hyperplastic lesions. 3 main types:
1. fibrous epulis
2. pyogenic granuloma
3. peripheral giant cell granuloma
mainly anterior to molar teeth in maxilla - management is surgical but tendency to recur
fibrous epulis
pedunculated / sessile mass
firm consistency
similar colour to surrounding gingivae
inflammatory cell infiltrate & fibrous tissue
pyogenic granuloma / pregnancy epulis
soft deep red/purple swelling
often ulcerated
haemorrhage spontaneously or with mild trauma
vascular proliferation supported by a delicate fibrous stroma
reaction to chronic trauma e.g. calculus
tend to recur after removal
peripheral giant cell granuloma
pedunculated / sessile swelling
typically dark red & ulcerated
usually arises interproximally & has an hour glass shape
radiographs may reveal superficial erosion to interdental bone
multinucleate giant cells in a vascular stroma
may recur after surgical excision
congenital epulis
rare lesion
occurs in neonates
most commonly affects anterior mucosa
F>M
granular cells covered with epithelium
benign
simple excision curative
2 types of HPV associated swellings
- verruca vulgaris
- squamous cell papilloma
verruca vulgaris
solitary / multiple intra oral lesions
may be associated with skin warts
caused by HPV 2 & 4
commonly on keratinised tissue i.e. gingivae / palate
can be removed surgically
squamous cell papilloma
small pedunculated cauliflower like growths
benign
HPV 6 & 11
vary in colour from pink to white
usually solitary
treatment = surgical excision
4 main fluid swellings
- mucoceles
- ranula
- Bohn’s nodules
- epstein pearls
2 variants of mucoceles
- mucous extravasation cyst - normal secretions rupture into adjacent tissue
- mucous retention cyst - secretions retained in an expanded duct
describe mucoceles
bluish soft transparent cystic swelling
can affect minor / major salivary glands
most = minor glands of lower lip
peak incidence = 2nd decade
most will rupture spontaneously
surgery only if lesion fixed in size as will likely damage adjacent glands leading to recurrence
surgical excision involves removal of cyst and adjacent damaged minor salivary gland
describe ranula
mucocele in floor of mouth
can arise from minor salivary glands / ducts of sublingual or submandibular glands
ultrasound/MRI needed to exclude plunging ranula (extend through FOM into submental/submandibular space)
occasionally found to be lymphangioma - benign tumour of lymphatics
Bohn’s nodules
gingival cysts
remnants of dental lamina
filled with keratin
occur on alveolar ridge
found in neonates (1st 28 days)
usually disappear in early months of life
epstein pearls
small cystic lesions
found along mid palatal line
thought to be trapped epithelium in palatal raphe
in 80% neonates
disappear in 1st few weeks
most common condition affecting temporomandiublar joint region
temporomandibular joint dysfunction syndrome (TMJDS)
characterisation of TMJDS
pain
masticatory muscle spasm
limited jaw opening
TMJDS extraoral exam
- palpation of MoM both at rest & clenching to assess tenderness and/or hypertrophy
- palpation of TMJ at rest and when opening / closing to assess tenderness & click/crepitus
- assessment of opening ; check for deviation of jaw and assess extent of opening (normal = 40-50mm)
TMJDS intraoral exam
- assessment of any dental wear facets
- signs of clenching / grinding; scalloped lateral tongue surface and buccal mucosa ridges
management of TMJDS
reduce exacerbating factors - manage stress, avoid habits i.e. clenching, grinding, nail biting, a bite raise/guard if nocturnal habit
allow overworked muscles to rest - avoid wide opening, soft diet with little chewing
symptomatic relief - use ibuprofen (anti-inflammatory)
teeth should not be in contact at rest
