Oral Medicine

Question 1

3 main causes of orofacial soft tissue infections

Answer 1

1. viral
2. bacterial
3. fungal

Question 2

viral causes of orofacial soft tissue infections

Answer 2

primary herpes
herpangina
hand foot & mouth
MMR
epstein barr virus
varicella zoster

Question 3

bacterial causes of orofacial soft tissue infections

Answer 3

staphylococcal
streptococcal
syphilis
TB

Question 4

fungal causes of orofacial soft tissue disease

Answer 4

candida

Question 5

describe primary herpetic gingivostomatitis

Answer 5

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

Question 6

signs & symptoms of primary herpetic gingivostomatitis

Answer 6

• fluid filled vesicles that rupture to ulcers on gingivae, tongue, lips, buccal & palatal mucosa
• severe oedematous marginal gingivae
• fever, headache, nausea, malaise
• cervical lymphadenopathy

Question 7

treatment of primary herpetic gingivostomatitis

Answer 7

rest, soft diet, paracetamol, antimicrobial gel or mouthwash, topical aciclovir for immunocompromised children
most common complication = dehydration

Question 8

causes of PHG

Answer 8

sunlight stress or other causes of ill health
recurrent disease in 50-75% via herpes labialis
remains dormant in epithelial cells

Question 9

describe herpangina

Answer 9

vesicles in the tonsillar / pharyngeal region
lasts 7-10 days

Question 10

describe hand foot & mouth

Answer 10

ulceration on gingiva/tongue/cheeks/palate
maculopapular rash on hands and feet
lasts 7-10 days

Question 11

describe oral ulceration

Answer 11

a localised defect in the surface oral mucosa where the covering epithelium is destroyed leaving an inflamed area of exposed connective tissue

Question 12

10 key things to ask about

Answer 12

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

Question 13

causes of oral ulceration (8)

Answer 13

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

Question 14

what is the most common cause of ulceration in children

Answer 14

recurrent apthous ulceration

Question 15

describe recurrent apthous ulceration

Answer 15

round or ovoid in shape with a grey or yellow base and have a varying degree of perilesional erythema

Question 16

describe the patterns of recurrent apthous ulceration

Answer 16

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

Question 17

investigations to undertake for oral ulceration

Answer 17

diet diary
FBC
haematinics i.e. folate/B12/ferritin
coeliac screen - anti-transglutaminase antibodies

Question 18

management for oral ulceration

Answer 18

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

Question 19

pharmacological management in GDP of oral ulceration

Answer 19

1. prevention of superinfection - corsodyl 0.2% mouthwash
2. protecting healing ulcers - gengigel topical gel (hyalonurate) // gelclair mouthwash (hyalonurate)
3. symptomatic relief - difflam (0.15% benzydamine hydrochloride) // local anaesthetic spray

Question 20

orofacial granulomatosis in children

Answer 20

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

Question 21

clinical features of OFG

Answer 21

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

Question 22

investigations for OFG

Answer 22

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)

Question 23

OFG management

Answer 23

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

Question 24

describe geographic tongue in children

Answer 24

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

Question 25

management of geographic tongue in children

Answer 25

rule our haematinic deficiencies bland diet during flare ups likely to become less troublesome with age

Question 26

5 examples of solid swellings

Answer 26

1. fibroepithelial polyp 2. epulides 3. congenital epulis 4. HPV associated mucosal swellings 5. neurofibromas

Question 27

describe fibroepithelial polyps

Answer 27

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

Question 28

describe epulides & what are the 3 main types

Answer 28

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

Question 29

fibrous epulis

Answer 29

pedunculated / sessile mass firm consistency similar colour to surrounding gingivae inflammatory cell infiltrate & fibrous tissue

Question 30

pyogenic granuloma / pregnancy epulis

Answer 30

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

Question 31

peripheral giant cell granuloma

Answer 31

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

Question 32

congenital epulis

Answer 32

rare lesion occurs in neonates most commonly affects anterior mucosa F>M granular cells covered with epithelium benign simple excision curative

Question 33

2 types of HPV associated swellings

Answer 33

1. verruca vulgaris 2. squamous cell papilloma

Question 34

verruca vulgaris

Answer 34

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

Question 35

squamous cell papilloma

Answer 35

small pedunculated cauliflower like growths benign HPV 6 & 11 vary in colour from pink to white usually solitary treatment = surgical excision

Question 36

4 main fluid swellings

Answer 36

1. mucoceles 2. ranula 3. Bohn's nodules 4. epstein pearls

Question 37

2 variants of mucoceles

Answer 37

1. mucous extravasation cyst - normal secretions rupture into adjacent tissue 2. mucous retention cyst - secretions retained in an expanded duct

Question 38

describe mucoceles

Answer 38

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

Question 39

describe ranula

Answer 39

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

Question 40

Bohn's nodules

Answer 40

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

Question 41

epstein pearls

Answer 41

small cystic lesions found along mid palatal line thought to be trapped epithelium in palatal raphe in 80% neonates disappear in 1st few weeks

Question 42

most common condition affecting temporomandiublar joint region

Answer 42

temporomandibular joint dysfunction syndrome (TMJDS)

Question 43

characterisation of TMJDS

Answer 43

pain masticatory muscle spasm limited jaw opening

Question 44

TMJDS extraoral exam

Answer 44

- 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)

Question 45

TMJDS intraoral exam

Answer 45

- assessment of any dental wear facets - signs of clenching / grinding; scalloped lateral tongue surface and buccal mucosa ridges

Question 46

management of TMJDS

Answer 46

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