Oral Medicine Flashcards
what does ICOP stand for
international classification of orofacial pain
what are the 2 main systems used in orofacial pain classification
- international classification of headache disorders 2018
- international classification of orofacial pain 2020
what 5 categories are within orofacial pain attributed to disorders of dentoalveolar and anatomically related structures
- tooth related pain
- pain from periodontium
- pain from oromucosa
- pain from salivary glands
- pain from bone
what type of pain do groups 2 and 3 of ICOP include
TMJ pain/ disorders
which nerves are of significance in orofacial pain attributed to lesion or disease of the cranial nerves
- trigeminal
- glossopharyngeal
what two categories are within pain attributed to lesion or disease of the trigeminal nerve in ICOP
- trigeminal neuralgia
- painful trigeminal neuropathies
what two categories are within pain attributed to lesion or disease of the glossopharygeal nerve
- glossopharyngeal neuralgia
- painful glossopharygeal neuropathies
what is the most widely accepted classification of orofacial pain
ICHD3
what 4 categories are within orofacial pains resembling presentations of primary headaches
- migraine
- tension headache (TTH)
- trigeminal autonomic cephalalgias (TACs)
- other primary headache disorders
what 3 categories come under idiopathic orofacial pain
- burning mouth syndrome
- persistent idiopathic facial pain
- persistent idiopathic dentoalveolar pain
what is an innocuous stimulus
something that wouldnt normally give rise to pain
what is trigeminal neuralgia
recurrent unilateral pains, abrupt in onset and termination
does trigeminal neuralgia always have a cause?
no, may develop on its own or as a result of another diagnosed condition
what may come along with the short sharp pains of trigeminal neuralgia
continuous moderate pain in the distribution of the affected nerve(s)
how long will trigeminal neuralgia pain last
a few seconds - 2 mins
what does the pain of trigeminal neuralgia feel like
severe, sharp
what is the pain of trigeminal neuralgia caused by
innocuous stimulus
give an example of innocuous stimulus
yawning
what is the final part of diagnosing trigeminal neuralgia
not better accounted for by any of the other ICHD-3 diagnosis’
what is the incidence of trigeminal neuralgia
4-13:100,000
what age does trigeminal neuraligia often affect
50-60
what age group is trigeminal neuralgia very uncommon in
less than 40
what would be suspicious of if a ot under 40 has trigeminal neuralgia
underlying disease process
what gender does trigeminal neuralgia affect more
female
what are the risk factors for trigeminal neuralgia
stroke
hypertension
is trigeminal neuralgia usually bilteral or unilateral
unilateral
which side of the face does trigeminal neuralgia affect more commonly
right
what would you suspect if a pt has bilateral trigeminal neuralgia
underlying disease process
what % of trigeminal neuralgia affects the opthalmic division
<5%
what % of trigeminal neuralgia is related to dental Tx or disease
22%
what might dental Tx or disease cause trigeminal neuralgia
sensitisation of the nerve
what % of pts consult a dentist first for trigeminal neuralgia
27%
what % of pts have pain free periods in trigeminal neuralgia
73%
what % of pts have a provoking factor in trigeminal neuralgia
96%
what is often a relieving factor for pts with trigeminal neuralgia
warmth and rest
what is the refractory period in trigeminal neuralgia
time after the pain where the trigger will no longer illicit a response
why is lachrymation an associated factor of trigeminal neuralgia
as pain so severe
what other conditions may be associated with trigeminal neuralgia
depression and anxiety
if the pain of trigeminal neuralgia is so bad, what may you be concerned about for your pt
suicide risk
what are the 3 classifications of trigeminal neuralgia
- classical trigeminal neuralgia
- secondary trigeminal neuralgia
- idiopathic trigeminal neuralgia
what is classical trigeminal neuralgia
develops without apparant cause other than neurovascular compression
what does compression of the nerve in trigeminal neuralgia cause that results in pain
demyelination of the nerve
where will morphological changes occur in classical trigeminal neuralgia
trigeminal nerve root
where is the trigeminal nerve root
posterior cranial fossa
how can you demonstrate the compression of nerves in classical trigeminal neuralgia
MRI
surgery
what usually cause the compression in classical trigeminal neuralgia
blood vessel
where is the area of most vulnerability for classical trigeminal neuralgia
root entry zone
why is the root entry zone the area of most vulnerability for classical trigeminal neuralgia
where the peripheral and central myelins of schwann cells and astrocytes meet
describe the symptoms of classical trigeminal neuralgia
classical trigeminal neuralgia with persistent background facial pain
what is secondary trigeminal neuralgis caused by
underlying disease
what will a clinical exam of a pt with secondary trigeminal neuralgia show
significant sensory changes
what distinguishes secondary from classical trigeminal neuralgia
a diagnosis of underlying disease known to cause neuralgia
name 2 diseases known to cause secondary trigeminal neuralgia
MS
space occupying lesion eg tumour
what age group do secondary trigeminal neuralgia belong to
<30
is secondary trigeminal neuralgia bilateral or unilateral
bilateral
what imaging should be taken for trigeminal neuralgia
MRI
what is idiopathic trigeminal neuralgia
trigeminal neuralgia with no tests showing significant abnormalities
how is idiopathic trigeminal neuralgia often diagnosed
neither classical or secondary trigeminal neuralgia has been confirmed by any tests
what must an exam for trigeminal neuralgia include
cranial nerve exam –> CNV
what areas are imaged in an MRI for trigeminal neuralgia
head and internal auditory meatus
what is the diagnosis of facial pain reliant on
pain history
who should the GDP liaise with for trigeminal neuralgia
GP
oral med
when should there be urgent referral to a specialist oral med
- sensory/ motor deficits
- deafness/ ear problems
- optic neuritis
- history of malignancy
- bilateral TN pain
- systemic symptoms - fever, weight loss
- presentation in pts <30
what is the first line pharmacological Tx for trigeminal neuralgia
carbamazepine
can GDPs prescribe carbamazepine
yes
what can pts contraindicated/ not tolerant of carbamazepine take for trigeminal neuralgia
oxycarbazepine
what is the brand name for carbamazepine
tegretol
what type of drug is carbamazepine
anticonvulsant
what is carbamazepine liscensed for
bipolar and epilepsy
how does carbamazepine work
binds to voltage dependant Na channels inhibiting action potential
where is carbamazepine metabolised
liver
what enzymes metabolise carbamazepine
CYP3A4
why is the enzyme that metabolises carbamazepine important?
interactions with drugs that are metabolised by the same systems
what causes reduction of efficacy sometimes seen after the first few weeks of carbamazepine Tx
induces its own metabolism
what % of carbamazepine is excreted in the urine
70
what ethnicity of pts should carbamazepine not be prescribed to
han chinese/ thai origin
why can carbamazepine not be prescribed to han chinese/ thai pts
increased likelihood of steven johnsons syndrome
what testing is required to rule out steven johnsons syndrome
testing for HLAB*1502 allele
what does prescription of carbamazepine to steven johnson syndrome pts result in
extensive mucosal and skin ulceration and blistering
what can carbamazepine cause in pregnant pts
congenital malformations
what are 3 interacting drugs with carbamazepine
- st johns wort
- alcohol
- grapefruit
what advice must pts taking carbamazepine be given
how to recognise disorders of liver, skin and bone marrow
what is required if the pt on carbamazepine develops rash, fever, mouth ulcers, bruising or bleeding
immediate medical attention
what oral relevant side affect is there of carbamazepine
dry mouth
why are baseline blood tests taken for carbamazepine
potential effects on bone marrow, liver and renal function
what is the dose prescribed for carbamazepine
100mg x2 day for 1-3 days
what is the therapeutic range per day for carbamazepine
800-1200mg
what should be done once a trigeminal neuralgia pt taking carbamazepine is pain free for 4 weeks
trial dose reduction of carbamazepine
how often should monitoring blood tests be taken for pts on carbamazepine
weekly for first 4 weeks
then 1-3 monthly
what happens if a blood test for a pt on carbamazepine show abnormality
stop or dose reduction of carbamazepine
where can oxcarbazepine be prescribed
secondary care - not GDP
name 4 second line pharmacological Tx for trigeminal neuralgia
- lamotrigine
- baclofen
- gabapentin
- pregabalin
what additional management to pharmacological Tx can be given to pts with trigeminal neuralgia
- lidocaine nasal spray
- lidocaine ointment
- lidocaine as infil to trigger point
what dose of lidocaine nasal spray can be given to TN pts
10mg
when would lidocaine nasal spray be given to TN pts
for maxillary pain
where would lidocaine ointment be applied for TN pts
trigger point
what can a lidocaine infiltration to the trigger point of TN pts also be used as, as well as pain relief
diagnostic tool
what national support groups may be useful for TN pts
- trigeminal neuralgia association UK
what can be recommended to the pt if medication doesnt work to manage trigeminal neuralgia
surgery
when is surgery particularly relevant to trigeminal neuralgia
- medical management ineffective
- medication not tolerated
- medication contra-indicated
name 3 indications for surgery to managed trigeminal neuralgia
- short/no pain free period
- complications
- adverse affect on quality of life
what is done in surgical management of trigeminal neuralgia
palliative destruction at level of the grasserion ganglion
how is destruction of the grasserion ganglion done in surgery for trigeminal neuralgia
- radiofrequency thermocoagulation
- glycerol rhizolysis
- balloon compression
- steriotactic radiosurgery - gamma knife
what surgery is usually used in classical trigeminal neuralgia
microvascular decompression
what 3 surgeries can be used in trigeminal neuralgia
- microvascualr decompression
- partial sensory rhizotomy
- internal neurolysis
what surgery is done for trigeminal neuralgia if there is no neurovascular compression
neuroabalative procedure
what is the role of the GDP in trigeminal neuralgia
- diagnosis
- exclusion of dental pathology
- initiate medical treatment with GMP
- referral
what category does glossopharyngeal neuralgia come under
painful lesions fo the cranial nerves
what other distribution of nerve can glossopharyngeal neuralgia be felt?
vagus
where is pain often experienced in glossopharyngeal neuralgia
- ear
- base of the tongue
- tonsillar fossa
- beneath angle of mandible
what is glossopharyngeal neuralgia commonly provoked by
swallowing, talking and coughing
what divisions are there of glossopharyngeal neuralgia
- classical
- secondary
- idiopathic
what investigation would be done for glossopharyngeal neuralgia
MRI
what systemic management is there for glossopharyngeal neuralgia
carbamazepine
what other category of conditions is grouped in with glossopharyngeal neuralgia and trigeminal neuralgia under painful lesions of the cranial nerves
painful trigeminal neuropathies
name the 3 categories of painful trigeminal neuropathies
- painful trigeminal neuropathy attributed to the herpes zoster virus
- trigeminal post-herpetic neuralgia
- painful post-traumatic trigeminal neuropathy
what is allodynia
pain in response to a stimulus which would not normally cause pain
what is hyperalgesia
increased response to a stimulus which would normally cause pain
what is hypoalgesia
reduction in response to a stimulus which would normally cause pain
what is hyperesthesia
increased cutaneous/mucosal sensitivity to a stimulus
what is dysesthesia
unpleasant/ abnormal sensation affecting the skin or mucosa
what is pain in painful trigeminal neuropathies indicative of
neural damage
how does the primary pain in painful trigeminal neuropathies feel
continuous burning/squeezing
what may occur along with the primary pain in painful trigeminal neuropathies
brief pain that isnt the predominant pain type
how do the allodynic areas in painful trigeminal neuropathies differ from the trigger zones in trigeminal neuralgia
allodynic areas are much larger
what is painful trigeminal neuropathies attributed to the herpes zoster virus
unilateral facial pain of less than 3 months to one or more branches of the trigeminal nerve and associated symptoms of herpes zoster virus
what is acute herpes zoster
shingles
what is post herpetic painful trigeminal neuropathy
unilateral pain for more than 3 months caused by the herpes zoster virus
how can pts avoid shingles
vaccines
who can get the herpes zoster vaccine
70-79 year olds
how is post-herpetic trigmeinal neuralgia avoided
antivirals up to 72 hrs following the appearance of shingles
what antivirals are given for shingles to avoid post-herpetic TN
aciclovire
what is the immediate management for post herpetic TN
paracetamol and codeine
what self management techniques are given to pts with painful trigeminal neuropathies
- relaxation
- distraction
- exercise
- mindfulness
what topical agents can be given for painful trigeminal neuropathies
- lidocaine patches
- capsaicin cream
what systemic agents can be given for painful trigeminal neuropathies
- duloxetine
- amltriptylene
- amantadine
who are topical and systemic agents for painful trigeminal neuropathies prescribed by
- specialist
- GMP
which is the only type of painful trigeminal neuropathies which can be bilateral
painful post traumatic TN
what is post traumatic T neuropathies
unilateral/ billateral facial pain following and caused by trauma to trigeminal nerve
how would you diagnose post traumatic TN
identifiable event with signs of nerve dysfunction
how long within the traumatic event does post traumatic TN have to develop to be classified as such
<6 months
what nerves does idiopathic orofacial pain affect
trigeminal
what does idiopathic mean
unknown cause
what is the intensity of idiopathic orofacial pain
moderate
how does idiopathic orofacial pain feel
dull, pressing or burning sensation
name 3 members of idiopathic orofacial pain
- persistent idiopathic facial pain
- persistent idiopathic dentoalveolar pain
- burning mouth syndrome
what are the basic features of idiopathic orofacial pain
- daily pain
- > 2hrs duration per day
- no apparent abnormality
what is significant about conventional analgesics in idiopathic orofacial pain
ineffective
what medical histories are often related to idiopathic orofacial pain
- chronic pain elsewhere in the body
- contact with pain services
- depression/anxiety
what is the role of the GDP inidiopathic orofacial pain
- pain history
- exclude dental cause
- check cranial nerves
- reassure and self management techniques
- refer
what therapy may be available for idiopathic orofacial pain
- cognitive behavioural therapy
- acceptance and commitment therapy
what are topical treatments for idiopathic orofacial pain dependant on
site and type of pain
name 4 systemic treatments for idiopathic orofacial pain
- amitriptylene
- duloxetine
- fluoxetine
- gabapentin/ pregabalin
what type of drug is amitriptylene
tricyclic
when might pts particularly benefit from gabapentin/ pregabalin
when the pain has a neuropathic component
how would you know the pain in idiopathic orofacial pain has a neuropathic component
sharp shooting pain
who, other than a specialist, can you refer the pt to for idiopathic orofacial pain
pain management services
what was persistent idiopathic orofacial pain previously known as
atypical facial pain
what characteristics does persistent idiopathic orofacial pain have
- > 2hrs per day for >3 months
- poorly localised not following the peripheral distribution of the nerve
- dull aching quality
who does persistent idiopathic orofacial pain affect more commonly
females
what % of persistent idiopathic orofacial pain is bilateral
14-19%
what % of pts have pain free months in persistent idiopathic orofacial pain
17-35%
name some relieving factors of persistent idiopathic orofacial pain
- warmth
- pressure
- medication
name some provoking factors of persistent idiopathic orofacial pain
- stress
- cold weather
- chewing
- head movements
- life events
name 3 associated factors of persistent idiopathic orofacial pain
- dental Tx
- psychiatric conditions
- altered sensations
what may persistent idiopathic orofacial pain be preceded by
- dental Tx
- minor injury
- operation
what investigations may be taken for persistent idiopathic orofacial pain
- MRI
- CBCT
- CT
when would special investigations be taken for persistent idiopathic orofacial pain
- pain has neuropathic component
what would you do if the pt has persistent idiopathic orofacial pain with sensory deficit on checking CNV
CBCT
CT
MRI
what is the only topical treatment that a GDP can prescribe
lidocaine ointment
what is the first line systemic treatment for persistent idiopathic orofacial pain
amitriptylene
what might some cases of persistent idiopathic orofacial pain match the description of
painful post-traumatic trigeminal neuropathy
what was peristent idiopathic dentoalveolar pain previously known as
atypical odontalgia
is peristent idiopathic dentoalveolar pain unilateral or bilateral
unilateral
how often does peristent idiopathic dentoalveolar pain occur
> 2hrs per day for >3months
what characteristics does peristent idiopathic dentoalveolar pain have
- localised to dentoalveolar site
- deep dull pressure
name some provoking factors of peristent idiopathic dentoalveolar pain
- hot and cold
- dental Tx
- pressure on tooth
name 3 relieving factors of peristent idiopathic dentoalveolar pain
- warmth
- pressure
- medication
name 6 associated factors of peristent idiopathic dentoalveolar pain
- bruxism
- emotional problems
- hypersensitivity to hot and cold
- anxiety
- depression
- hypotensive therapy
what is the incidence of peristent idiopathic dentoalveolar pain after dental Tx involving removal of a sensory nerve
1.6%
what topical Tx may be indicated for peristent idiopathic dentoalveolar pain
lidocaine ointment 5%/ spray 10%
what was burning mouth syndrome previously known as
oral dysaesthesia
what can the sensation of burning mouth syndrome be described as
dysaesthetic
what characteristics does burning mouth syndrome have
- burning quality of pain
- felt superficially in the oral mucosa
what has to be excluded before diagnosis of burning mouth syndrome
local o r systemic causes
what else may accompany burning mouth syndrome apart from the burning pain
taste disturbance
what is the incidence of burning mouth syndrome in the general population
1-15%
what is the incidence of burning mouth syndrome in post menopausal women
18-33%
who does burning mouth syndrome affect more by what ratio
women 3:1
what is there evidence of in post menopausal women that may contribute/ cause burning mouth syndrome
changes in peripheral nerves supplying the lining of the mouth and tongue
what sites does burning mouth syndrome affect
- lips
- palate
- tongue
which site is most commonly affected in burning mouth syndrome
tongue
is there any mucosal abnormality that accounts for the symptoms of burning mouth syndrome
no
what local factors must be excluded in order to diagnose burning mouth syndrome
- parafunctional habits
- dry mouth
- GORD
- candidioses
what symptoms of GORD may imitate burning mouth syndrome
burning of the posterior of the mouth
what systemic causes have to be excluded to diagnose burning mouth syndrome
- anaemia
- haematinic deficiency
- diabetes
- thyroid dysfunction
- medication
what medication may imitate burning mouth syndrome
ACE inhibitors
when might diabetes imitate burning mouth syndrome
undiagnosed/ poorly controlled
what investigations would be taken to exclude any systemic causes of the symptoms of burning mouth syndrome
- FBC
- haematinics
- RBG/HbA1c
- TSH
-Zn - sialometry
when would serum zinc tests be needed to diagnose burning mouth syndrome
if taste disturbance
how would candidal infection be ruled out in diagnosing burning mouth syndrome
swab/ oral rinse
what would be prescribed in primary care for the management of burning mouth syndrome
- benzydiamine as mouthwash or oromucosal spray
what would be prescribed in secondary care for the treatment of burning mouth syndrome
- capsaicin mouthwash
- clonazepam oral rinse
how would a pt with burning mouth syndrome make up capsaicin mouthwash
mix tobasco with water
what is Xerostomia?
sensation of a dry mouth
what is xerostomia dependant on
subjective - dependant on the pts experince
what is a symptom
subjective evidence of a disease
what is a sign
an objective physical finding
how long does the pt have to have had a dry mouth for to consider sjogrens
> 3 months
what medical factors may cause a dry mouth
- polypharmacy
- diabetes
- radio/chemotherapy
how would you know that dry mouth is medication related
lines up with when the pt started taking the medication
what in the dental history may indicate a dry mouth
- increase in caries
- difficulty wearing dentures
- soreness in mouth when previously symptom free
what type of caries is more common in dry mouth
- smooth surface/cervical
what 3 factors in the SH may be related to dry mouth
- smoking
- alcohol
- stress
why does alcohol cause dry mouth
dehydration
what family history may lead you to suspect a pt with dry mouth may have secondary sjogrens
- any connective tissue disorders
- rhematoid arthritis
- lupus
what would a challacombe score of 1-3 indicate
mild dryness
how would you treat scores 1-3 on challacombe
routine check ups and monitoring
at does a challacombe score of 4-6 indicate
moderate dryness
how would you treat scores 4-6 on challacombe
further investigation if cause not clear
is there any need to refer if the cause of moderate oral dryness is clear
no
what would a challacombe score of 7-10 indicate
severe dryness
how would you treat a challacombe score of 7-10
refer - even if you know the cause
why does the cause of a challacombe score of 7-10 need to be determined
to rule out sjogrens
when would a pt be given saliva substitutes
challacombe 7-10
when would a pt be given sialogogues
challacombe 4-6
what else might you find in a pt with dry mouth
- oral candidiasis
- traumatic ulceration
- poor denture retention
- bacterial sialadenitis
name 4 symptoms of oral candidiasis
- angular chelitis
- erythematous mucosa
- thrush
- denture stomatitis
how might objective evidence of a salivary flow rate be obtains
unstimulated saliva flow rate test
how long does unstimulated saliva flow rate test take
15 mins
what is the normal flow rate of saliva
> 0.2ml/min
what would be significantly reduced rate of saliva flow
<0.1ml/min
why cant the pt spit or talk during unstimulated salivary flow test
will stimulate saliva
is the stimulated salivary flow rate test of diagnostic significance
no
what will the stimulated salivary flow rate test provide
therapeutic help - will indicate whether the salivary glands will respond to stimulation
what should the treatment be if the stimulated salivary flow rate test is significantly decreased in its results
saliva replacements as the glands wont respond to stimulation
what gland should be used for stimulated salivary flow rate test
parotid
what is the normal stimulated salivary flow rate
0.4ml/min
what do viruses HIV and hep C do that cause dry mouth
cause changes similar to sjogrens that cause hypofunction
what condition causes changes in oral mucosa similar to that of oral granulmatosis and chrones
sarcoidosis
what symptoms to chrones cause in the mouth
- lip swelling
- salivary glands lymphadenopathy
what symptoms does oral granulmatosis cause in the mouth
- lip swelling
- salivary gland lymphadenopathy
what symptoms does sarcoidosis cause in the mouth
- lip swelling
- salivary gland lymphadenopathy
what oral condition does graft vs host disease mimic in the mouth h
lichen planus/ lichenoid reaction
what is salivary gland aplasia
gland fails to develop
how does cystic fibrosis cause dry mouth
causes damage to the salivary glands
does the removal of a major salivary gland lead to dry mouth
no
why does removal of a major salivary gland not lead to dry mouth
other glands compensate for it
why do people get age related dry mouth
- age related changes to the salivary glands
- polypharmacy
why would a good SH be relevant to dry mouth
may be very stressed/ smoker/ high alcohol intake
what does saliva production drop to during sleep
0.1ml/min
why is mouth breathing sleep really bad for dry mouth pts
saliva production is already reduced during sleep
what is the test of choice for diabetes pts to know their blood glucose concentration
glycosylated haemoglobin
how many medications have strong evidence of causing dyr mouth
56
what medications are known to often interact with saliva production
urologicals, nervous system drugs
radiotherapy pts can have some recovery of saliva function after having had Tx, what time frame can this occur within
6 to 12 months
12 months after having had radiotherapy, is the pts salivary function likely to improve
no
what type of gland is more susceptible to radiotherapy Tx
serous
how long after chemotherapy will salivary gland function recover
2-8 weeks
does dry mouth after chemotherapy persist
not usually - scute symptoms
what % of the population suffer from sjogrens syndrome
3-4%
what type of disease is sjogrens
autoimmune chronic inflammatory condition
what does the body produce against salivary gland cells in sjogrens syndrome
polyclonal B cells
what happen secondary to infiltration by lymphocytes in sjogrens ysndrome
acinar atrophy
what can sjogrens syndrome affect
all exocrine glands
what places will the pt usually complain of being symptomatic in sjogrens syndrome
- mouth
- eye s
what % of sjogrens syndrome pts are women
90
what is the average age on onset for sjogrens syndrome
50
what is secondary sjogrens accompanied by
connective tissue disorder
give four examples of connective tissue disorders accompanying sjogrens syndrome
- rheumatoid arthritis
- lupus erythematous
- systemic sclerosis
- primary biliary sclerosis
how many salivary glands are harvested in minor labial salivary gland biopsy
3-4
which tests for sjogrens can be done outwith the dentsit
- ocular staining score
- lacrimal flow rate
what is the lacrimal flow rate also known as
schirmir tets
what is the most basic salivary gland tests that can be done to tests for sjogrens syndrome
unstimulated whole salivary flow rate test
what must you warn the pt of in advance for minor salivary gland biopsy
paraesthesia of the area plus 15mm periphery
why is there risk of paraesthesia in minor salivary gland biopsy
lots of nerves in the area that can get damaged
what chance of paraethesia is there in minor salivary gland biopsy
1%
what classification criteria is used for the diagnosis of primary sjogrens syndrome
american college of rheumatology ACR/ european league against rheumatism 2016
what score on the classification score does a pt have to have to be diagnosed with sjogrens
4
who manages systemic involvement of sjogrens syndrome
rheumatologist
what do pts have an increased risk of in primary sjogrens
lymphoma
why is diagnosis of sjogrens important
- increased risk of lymphoma
- may lead to diagnosis of connective tissue disorder
what must a GDP decide on diagnosis dry mouth
if referral is needed
what is sicca syndrome
dry mouth and eyes without an accompanying diagnoses of sjogrens
why is stimulation of saliva preferable to replacement
replacements dont recreate the composition of saliva
what tool can help in the management of dry mouth pts
challacombe scale
what are some replacement saliva products sepcific to
radiotherapy or sicca syndrome pts
what is most expensive, replacement saliva or stimulants
replacement
what can GDPs prescribe to stimulate saliva flow
- saliva pastilles
- saliva stimulating tablets
what is in saliva pastilles
mixture of citric and malic acid
who are saliva stimulating tablets prescribed to
only pts with impaired salivary gland function
what is an alternative option to prescribing salivary stimulating products
stimulate their own saliva flow using sugar free gum/sweets
what can be prescribed as systemic therapy for dry mouth
pilocarpine
where would pilocarpine be prescribed for a pt with dry mouth
secondary care
when would pilocarpine be prescribed for a dry mouth p t
- H&N cancer pt
- sjogrens pt
what type of inhibitor is pilocarpine
acetylcholine esterase
what dose of pilocarpine is prescribed for pts with dry mouth
5mg
who should glandosane oral spray be avoided in
dentate pts
why should glandosane oral spray be avoided in dentate pts
acidic pH
what might you need to tell a pt when prescribing saliva arthana
mucin derived from pig stomach
can saliva replacements be purchased over the counter
yes
why are gels good for pts with dry mouth at night
they stay around in the mouth longer that the sprays
other than replacements/stimulants, what else might you want to prescribe to a pt with dry mouth
fluoride mouthwash/ toothpaste
what infection might a pt with dry mouth get
bacterial sialadenitis
what microbe causes bacterial sialadenitis
staph aureus
what would you prescribe for bacterial sialadenitis
flucloxacilin
what is the name for excessive saliva production
sialorrhea
why might sialorrhea be seen in parkinsons pts
disphagia issues
what is sialadenosis
salivary gland swelling
what is the presentation of sialadenosis
- acute bilateral swelling of parotid glands
what is the Tx for lichen planus if the pt is asymptomatic
nothing
what should the Tx for lichen planus be matched to in a symptomatic pt
symptom severity
how often should a lichen planus pt be reviewed
6 monthly
what should a lichen planus pt be advised of
potentially malignant disorder
what is the incidence of malignant change in lichen planus
1%
what might be given as topical therapy for lichen planus by GDP
- benzydamine mouthwash/ spray
- lidocaine ointment 5%
- lidocaine spray 10%
what topical antimicrobial may be given to lichen planus pt by GDP
chlorhexidine mouthwash
what topical steroids can be given to a lichen planus pt by GDP
- betamethasone tablets 500mg
- clenil modulate 50mg inhalation
- hydrocortisone oromucosal tablets
what is in triple mouthwash prescribed in secondary care for lichen planus
- betamethasone 500mg
- doxycyclin 100mg
- nystatin
what systemic medication may be given for lichen planus in secondary care
- short course of prednisolone
- DMARDs
what is the management for apthous stomatitis
- diet modification
- SLS free toothpaste
- topical analgesic
- topical steroid
what diet modifications may be suggested for apthous stomatitis pts
- cinnamon avoidance
- benzoate avoidance
what antimicrobials can be prescribed for apthous stomatitis by GDP
- chlorhexidine mouthwash
- doxycycline tablet as mouthwash
what topical steroids can be prescribed for apthous stomatitis by GDP
- betamethasone 500mg
- clenil mouthwash 50 micrograms
- hydrocortisone oromucosal tablets
what management is done in secondary care for apthous stomatitis
- topical steroids
- triple mouthwash
- systemic medication
what systemic medication is given in secondary care for apthous stomatitis
- short course of predisolone
- colohione
- DMARDs
