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3rd year - module 6 > Oral medicine > Flashcards

Oral medicine Flashcards

1
Q

What are the two main systems for classifying orofacial pain?

A

1) International classification of Headache disorders edition 3 2018 (ICHD3)
2) International classification of orofacial pain, 1st edition 2020 (ICOP)

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2
Q

What are the six classifications of orofacial pain in the ICOP classification?

A

1) Orofacial pain attributed to disorders for dentoalveolar and anatomically related structures
2) Myofascial orofacial pain
3) Temporomandibular joint pain
4) Orofacial pain attributed to lesion or disease of cranial nerves
5) Orofacial pains resembling presentations of primary headaches
6) Idiopathic orofacial pain

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3
Q

What are temporomandibular disorders?

A

a group of conditions affecting the temporomandibular joint and/or the muscles of mastication

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4
Q

Where is the site of temporomandibular disorder pain?

A

jaw, ear, in front of ear, temple

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5
Q

What is temporomandibular disorder pain affected by?

A

jaw movement, function, parafunction

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6
Q

What kind of noises are heard when someone has a temporomandibular disorder?

A

clicking, snapping, popping, crepitus (grinding/crunching)
upon jaw movement
within past 30 days

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7
Q

What movements are indicative of a temporomandibular disorder?

A
  • restricted opening
  • interference in ability to eat
  • locking - intermittent/persistent, closed, open, able to release with manoeuvre
  • deviation
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8
Q

What habits are linked to temporomandibular disorders?

A

clenching, grinding, chewing or biting habits, musical instruments, singing

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9
Q

What co-morbidities can be linked to temporomandibular disorders?

A
  • fibromyalgia
  • chronic pain
  • psychological factors
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10
Q

How do you examine the lateral pole in a TMJ examination?

A

3 repetitions of opening, closing, lateral, protrusive movements, palpation
- does palpation elicit familiar pain
- any noises
- any noises audible to pt

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11
Q

What muscles are palpated in a TMJ examination?

A

Masseter
Temporalis

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12
Q

How do you assess the temporalis muscle?

A

palpate when pt clenches teeth, above ear and forwards above eye

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13
Q

How do you assess the masseter muscle?

A

bimanual palpation

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14
Q

A restricted mouth opening is considered to be what? (measurement)

A

40mm including incisal overlap

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15
Q

What are the two main types of pain related temporomandibular disorders?

A

1) Myalgia
2) Arthralgia

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16
Q

What are the three sub-types of Myalgia (pain related TMD)?

A

1) local myalgia
2) Myofascial pain
3) Myofascial pain with referral

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17
Q

What is arthralgia?

A

Pain in a joint

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18
Q

What are the six types of intra-articular temporomandibular disorders?

A
  • disc displacement with reduction
  • disc displacement with reduction with intermittent locking
  • disc displacement without reduction with limited opening
  • disc displacement without reduction without limited opening
  • degenerative joint disease
  • subluxation
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19
Q

What is myalgia?

A

pain of muscle origin, affected by jaw movement, function or parafunction and replication of this pain on provocation testing of the masticatory muscles

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20
Q

What is the history present in patients with myalgia?

A
  • pain in jaw, in front of ear or in the ear
  • modified with jaw movement, function or parafunction
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21
Q

How is myalgia examined?

A
  • confirmation of pain location(s) in the temporalis or masseter muscle and
  • familiar pain in masseter or temporalis with at least one of the following tests:
    1) palpation of temporalis or masseter
    2) maximum unassisted or assisted opening movements
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22
Q

What is arthralgia (dental)?

A

Pain of joint origin affected by jaw movement, function or parafunction and replicated by provocation testing of the TMJ

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23
Q

What history is present in a patient with arthralgia?

A
  • pain in the jaw, temple, ear or in front of the ear in the past month and
  • pain modified with jaw movement, function and parafunction
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24
Q

What is found on examination in a patient with arthralgia?

A
  • confirmation of pain location in area of TMJ(s) and
  • familiar pain on palpation of lateral palpation OR
  • on maximum unassisted or assisted opening, right or left lateral or protrusive movements
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25
Q

What is a disc displacement with reduction?

A

intracapsular biomechanical disorder involving the condyle-disc complex. In closed mouth position, disc is in an anterior position relative to condylar head and the disc reduces on mouth opening.
Clicking, popping, snapping may occur with disc reduction

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26
Q

What history is present in a patient with disc displacement with reduction?

A

history of ‘noise’ in past 30 days in movement/function OR
patient report of any noise during examination

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27
Q

What is found on examination in patients with disc displacement with reduction?

A
  • clicking, popping, snapping during opening AND closing on palpation during at least 1 of 3 repetitions of opening and closing OR
  • noises on opening OR closing movements on palpation during at least 1 of 3 repetitions AND
  • noises during at least 1 of 3 repetitions of left and right lateral or protrusive movements
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28
Q

What is a disc displacement without reduction with limited opening?

A

the disc does not reduce with opening. Persistent limited mandibular movement which does not reduce when patient/clinician performs manoeuvre.
Closed lock

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29
Q

What is the history present in a patient with disc displacement without reduction with limited opening?

A
  • jaw locked so that mouth will not fully open
  • limitation in jaw opening significant to limit movement and interfere with eating
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30
Q

What is found upon examination in a patient with a disc displacement without reduction with limited opening?

A

maximum assisted opening (passive stretch) movement <40mm including vertical incisal overlap

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31
Q

What is degenerative joint disease?

A

a degenerative disorder involving the joint characterised by deterioration of articular tissue with concomitant osseous changes in the condyle and/or articular eminence

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32
Q

What history is present in a patient with degenerative joint disease?

A

history of noise in past 30 days on jaw movement or in function OR
pt reports of noise during examination

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33
Q

What is found upon examination of a patient with degenerative joint disease?

A

crepitus with palpation during at least one of the following; opening, closing, right or left lateral or protrusive movements

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34
Q

What is subluxation?

A

a hypermobility disorder involving the disc condyle complex and the articular eminence
open lock
open mouth disc condyle complex is anterior to articular eminence and is unable to return to a normal closed position without manipulative manoeuvre

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35
Q

What is the difference between subluxation and luxation?

A

if patient can manoeuvre joint back into position = subluxation
if assistance of clinician required = luxation

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36
Q

What history is present in a patient with subluxation?

A
  • in last 30 days jaw locking or catching in a wide open position, even for a moment AND
  • inability to close the mouth from a wide open position without a manipulative manoeuvre
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37
Q

What is found upon examination in a patient with subluxation?

A

no examination findings but if disorder present at time of clinical examination then;
inability to return to a normal closed mouth position from wide open lock without manipulative manoeuvre

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38
Q

How are temporomandibular disorders managed?

A

initial management in primary care:
- reversible and conservative
- explanation
- advice focusing on self-management
- analgesia

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39
Q

What conservative management techniques are advised by GDPs for patients with TMDs?

A
  • rest and relaxation
  • avoid wide mouth opening
  • jaw exercises
  • modify diet
  • regular application of gentle heat (chronic conditions)
  • regular application of cold pack (acute onset pain &/or restricted mouth opening)
  • NSAIDs
  • paracetamol
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40
Q

What can be prescribed to patients suffering from muscle spasm or disc displacement without reduction with limited opening?

A

diazepam 5 day course so long as not contraindicated

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41
Q

When should a TMD patient be referred?

A
  • history of trauma/fracture
  • history of inflammatory arthritis
  • persistent or worsening symptoms lasting for more than 3 months despite primary care treatment
  • persistent inability to manage a normal diet
  • severe pain and dysfunction from internal derangement that does not respond to conservative measures
  • an uncertain diagnosis
  • other chronic pain related co-morbidities
  • marked restricted mouth opening
  • recurrent dislocation
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42
Q

What is pain attributed to lesion or disease of the trigeminal nerve called?

A
  • trigeminal neuralgia
  • painful trigeminal neuropathies
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43
Q

What is pain attributed to lesion or disease of the glossopharyngeal nerve called?

A
  • glossopharyngeal neuralgia
  • painful glossopharyngeal neuropathies
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44
Q

What is trigeminal neuralgia?

A

disorder characterised by recurrent unilateral brief electric shock-like pains, abrupt in onset and termination, limited to distribution of one or more divisions of the trigeminal nerve and triggered by innocuous stimuli

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45
Q

How can trigeminal neuralgia develop?

A

without apparent cause or be a result if another diagnosed disorder. Additionally, there may be concomitant continuous pain of moderate intensity within distribution(s) of affected nerve division(s)

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46
Q

What is the diagnostic criteria for trigeminal neuralgia?

A

A) recurrent paroxysms of unilateral facial pain in 1 or more divisions of trigeminal nerve, no radiation beyond and fulfilling criteria B and C
B) pain has all following characteristics
- lasting from fraction of a second to 2 mins
- severe intensity
- electric-shock like, shooting, stabbing or sharp
C) precipitated by innocuous stimuli within trigeminal distribution
D) not better accounted for by another ICHD-3 diagnosis

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47
Q

What age range does trigeminal neuralgia occur in?

A

50-60

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48
Q

What sex does trigeminal neuralgia more commonly occur in?

A

females > males

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49
Q

What is the aetiology associated with the three sub-types of trigeminal neuralgia?

A

1) neurovascular compression - classical TN
2) underlying disease - secondary TN
3) no apparent cause - idiopathic TN

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50
Q

What is used to investigate trigeminal neuralgia?

A

high resolution magnetic resonance imaging (MRI)

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51
Q

The diagnosis of facial pain is almost exclusively reliant on what?

A

Pain history

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52
Q

What are the ‘red flags’ that may necessitate a more urgent referral to specialist services regarding trigeminal neuralgia?

A
  • 28 sensory or motor deficits
  • deafness or other ear problems
  • optic neuritis
  • history of malignancy
  • bilateral TN pain
  • systemic symptoms (e.g. fever, weightloss)
  • presentation in patients under 30
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53
Q

What are the three sections of orofacial pains resembling presentations of primary headaches?

A

orofacial migraine (migraine)
tension type orofacial pain (tension headache)
trigeminal autonomic orofacial pain (trigeminal autonomic cephalalgias)

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54
Q

What are the two types of migraine?

A

migraine without aura
migraine with aura

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55
Q

What is a migraine without aura?

A

recurrent headache disorder manifesting in attacks lasting 4-72hrs. Typical characteristics of the headache are unilateral location, pulsating quality, moderate to severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia

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56
Q

What are the diagnostic criteria for migraine without aura?

A

A) at least 5 attacks fulfilling criteria B-D
B) headache attacks lasting 4-72hrs
C) headache has at least two of the following 4 characteristics
- unilateral location
- pulsating quality
- mod to severe pain intensity
- aggravation by or causing avoidance of routine physical activity
D) during headache at least one of following:
- nausea and/or vomiting
- photophobia and phonophobia
E) not better accounted for by another ICHD-3 diagnosis

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57
Q

What is migraine with aura?

A

recurrent attacks, lasting minutes, of unilateral fully-reversible visual, sensory or other CNS symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms

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58
Q

What are the diagnostic criteria for migraine with aura?

A

A) at least two attacks fulfilling criteria B and C
B) one or more of the following fully reversible aura symptoms:
- visual, sensory, speech and/or language, motor, brainstem, retinal
C) at least 3 of the following 6 characteristics:
1) at least one aura symptom spreads gradually over >_5mins
2) 2 or more aura symptoms occur in succession
3) each individual aura symptom lasts 5-60mins
4) at least one aura symptom is unilateral
5) at least one aura symptom is positive
6) the aura is accompanied or followed within 60mins by headache

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59
Q

What is idiopathic orofacial pain?

A

unilateral or bilateral intraoral or facial pain in the distribution(s) of one or more branches of the trigeminal nerve(s) for which the aetiology is unknown. The pain is usually persistent, of moderate intensity, poorly localised and described as dull, pressing or of burning character

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60
Q

What are the three sub-types of idiopathic orofacial pain?

A

1) persistent idiopathic facial pain
2) persistent idiopathic dentoalveolar pain
3) burning mouth syndrome

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61
Q

What are the basic features common to patients with idiopathic orofacial pain?

A
  • daily pain
  • > 2hrs duration per day
  • for >3 months
  • no apparent abnormality to account for symptoms
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62
Q

Are conventional analgesics e.g. paracetamol, NSAIDs, opioids effective at treating idiopathic orofacial pain?

A

usually ineffective

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63
Q

What are some related conditions to idiopathic orofacial pain?

A
  • chronic pain elsewhere in body
  • current/past contact with pain services
  • depression/anxiety
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64
Q

What is the role of the GDP regarding idiopathic orofacial pain?

A
  • good pain history
  • exclude dental causes
  • check cranial nerves, urgent referral if any abnormalities
  • reassure, suggest some self-management techniques
  • refer
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65
Q

Who can you refer an idiopathic orofacial pain patient to?

A

local pain management service

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66
Q

What is burning mouth syndrome?

A

an intraoral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day, for more than 3 months, without evident causative lesions on clinical examination and investigation

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67
Q

What are the diagnostic criteria for burning mouth syndrome?

A

A) oral pain fulfilling criteria B and C
B) recurring daily for >2hrs per day for >3mths
C) pain has both following characteristics:
- burning quality
- felt superficially in the oral mucosa
D) oral mucosa is of normal appearance and local or systemic causes have been excluded
E) not better accounted for by another ICOP or ICHD-3 diagnosis

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68
Q

What are the sites of burning mouth syndrome?

A
  • lips
  • palate
  • tongue
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69
Q

What is found upon examination in burning mouth syndrome?

A

no mucosal abnormality to account for symptoms

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70
Q

What local causes must be excluded for a burning mouth syndrome diagnosis?

A

1) parafunctional habits
2) dry mouth
3) GORD
4) candidosis

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71
Q

What systemic causes must be excluded for a burning mouth syndrome diagnosis?

A

1) anaemia
2) haematinic deficiency
3) diabetes - undiagnosed or poorly controlled
4) thyroid dysfunction
5) medication e.g. ACE inhibitors

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72
Q

What investigations are done to exclude local and systemic causes before a burning mouth syndrome diagnosis?

A
  • FBC
  • haematinics
  • RBG/HbA1c
  • TSH
  • Zn
  • sialometry
  • exclude candidal infection
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73
Q

What is the role of the GDP regarding the management of persistent idiopathic dentoalveolar pain?

A
  • exclude mucosal abnormality, local causes and systemic, if suspected, in collaboration with GMP
  • avoid unnecessary treatment
  • check cranial nerves
  • reassure, suggest some self-management techniques, trial of benzydamine as mouthwash/oromucosal spray
  • refer
74
Q

Name four common incidental findings in oral medicine?

A

1) geographic tongue (erythema migrans, benign migratory glossitis)
2) brown/black hairy tongue
3) amalgam tattoo
4) vascular malformations

75
Q

What is a torus mandibularis?

A

A torus mandibularis is a noncancerous, bony growth that forms on your lower jaw and sits under your tongue

76
Q

What is a torus palatinus?

A

a bony growth on the roof of your mouth. These growths are harmless, but can be uncomfortable and inconvenient

77
Q

What is a lingual varicosity?

A

Sublingual varices (SLV) are dilated tortuous veins that may be seen along the ventral surface of the tongue or floor of mouth, and tend to become more prominent with age

78
Q

What are fordyce spots?

A

enlarged, slightly raised sebaceous (oil) glands that appear in hairless areas of your skin. They commonly appear around the edges of your lips (vermillion border) and inside of your cheeks

79
Q

What is leukoedema?

A

asymptomatic, whitish or. whitish-gray edematous lesion of the oral mucosa

80
Q

What are the main 5 classes of oral ulceration?

A

1) traumatic
2) iatrogenic
3) idiopathic
4) infective
5) autoimmune

81
Q

What are the three sub-types of traumatic oral ulceration?

A

1) physical
2) chemical
3) thermal

82
Q

What comes under iatrogenic oral ulceration?

A

drug induced oral ulceration

83
Q

What is an example of idiopathic oral ulceration?

A

recurrent apthous ulceration

84
Q

What is an example of infective oral ulceration?

A

viral (e.g. herpes simplex)

85
Q

What is an example of autoimmune oral ulceration?

A
  • mucous membrane pemphigoid
  • pemphigus vulgaris
86
Q

What is the general appearance of oral ulcers?

A

the majority of non-neoplastic oral ulcers are superficial and have a yellow/creamy yellow base
in some cases there may be erythema of the surrounding tissue

87
Q

What is leukoedema?

A

white or whitishgray edematous lesion of the buccal and labial oral mucosa
so common it is considered normal variation

88
Q

Following a diagnosis of a traumatic ulceration, when should the ulcer be reviewed?

A

eliminate source and review after no longer than 14 days

89
Q

What are four key causes of drug induced oral ulceration?

A

1) methotrexate
2) Nicorandil
3) bisphosphonates
4) NSAIDs

90
Q

What is methotrexate used to treat and what is its relevance in oral medicine?

A
  • antimetabolite and immune modulating drug
  • daily in chemotherapy regimen or once per week for conditions like rheumatoid arthritis, psoriasis
  • can cause oral ulceration
91
Q

What supplement should patients on methotrexate be given and why?

A
  • folate supplement
  • methotrexate reduces DNA synthesis and cell turnover by inhibiting dihydrofolate reductase which converts folate into an active form
92
Q

Why should inhalation sedation (nitrous oxide) be avoided in patients taking methotrexate?

A
  • increased anti-folate effect due to drug interactions
93
Q

In what scenario would a patient taking methotrexate require urgent referral?

A

suffering mucositis or widespread ulceration

94
Q

What is nicorandil and what is its relevance in oral medicine?

A
  • potassium channel blocker
  • second line prophylaxis for angina
  • can cause serious skin, mucosal and eye ulceration including GI ulcerations, perforations, haemorrhage etc
95
Q

What kind of ulceration can oral bisphosphonates cause and in what circumstance does ulceration most commonly occur?

A
  • superficial ulceration, may be extensive
  • most cases result of inadequate ingestion (tablet allowed to dissolve in mouth rather than swallowing immediately, direct toxic effect on oral mucosa)
96
Q

What is recurrent aphthous stomatitis?

A

recurrent ulcers confined to the mouth seen in the absence of systemic disease

97
Q

What is recurrent aphthous like stomatitis?

A

ulcers very similar to those seen in RAS that arise in association with systemic disease including GI disease

98
Q

At what age does recurrent aphthous stomatitis occur?

A

childhood to 40yrs

99
Q

What are the three forms of recurrent aphthous stomatitis?

A
  • minor
  • major
  • herpetiform
100
Q

What classifies as a minor recurrent aphthous stomatitis?

A

(80% of cases). This is less than 5 mm in diameter and heals within 1–2 weeks.

101
Q

What classifies as major recurrent aphthous stomatitis?

A

large (often more than 10 mm) and takes weeks or months to heal and leaves a scar

102
Q

What classifies as herpetiform recurrent aphthous stomatitis?

A

multiple pinpoint ulcers that heal within a month

103
Q

What is the pathogenesis behind recurrent aphthous stomatitis?

A

T lymphocyte mediated immune response

104
Q

What are the three phases of recurrent aphthous stomatitis?

A

1) pre-ulcerative
2) ulcerative
3) healing

105
Q

What is the aetiology behind recurrent aphthous stomatitis and recurrent aphthous like stomatitis?

A

unclear but; stress, menstrual cycle, hypersensitivity to foods, GI disease, anaemia/haematinic deficiency, drug history, smoking cessation, family history

106
Q

Why do anaemia/haematinic deficiency predispose to mucosal disease?

A
  • epithelial atrophy
  • compromised cell mediated immunity
  • cytotoxicity of leucocytes reduced
107
Q

What investigations are carried out to explore recurrent oral ulceration?

A
  • FBC - anaemia? WBC count?
  • haematinics - serum ferritin, serum vitamin B12, serum folate
  • immunology for coeliac disease - antibodies against tissue transglutaminase
108
Q

What could cause GI linked recurrent oral ulceration as a result secondary to disease elsewhere in the GI tract?

A
  • blood loss secondary to peptic ulceration
  • Malabsorption (B12)
109
Q

Blood loss from the upper GIT results in what?

A

dark brown/black, smelly, sticky stools (malena)

110
Q

You should offer serological testing for coeliac disease to people with what signs/symptoms?

A
  • faltering growth
  • persistent/unexplained abdominal/GI symptoms
  • prolonged fatigue
  • unexpected weightloss
  • severe or persistent mouth ulcers
  • unexplained iron, vit B12 or folate deficiency
  • Type I diabetes, at diagnosis
  • IBS
  • first degree relative of people with coeliac disease
111
Q

How is Crohn’s disease linked to recurrent oral ulceration?

A
  • direct involvement of oral mucosa
  • secondary to anaemia/haematinic deficiency as a result of malabsorption or blood loss
112
Q

How are ulcerative colitis and recurrent oral ulceration linked?

A
  • secondary to anaemia/iron deficiency as a result of blood loss
113
Q

What is Genodermatoses?

A

inherited (autosomal dominant) white lesions, may also be sporadic

114
Q

What is the epidemiology of genodermatoses?

A
  • rare
  • occur in birth/infancy/childhood/adolescence
  • F>M
115
Q

What are the signs and symptoms of genodermatoses?

A
  • asymptomatic
  • patient may feel roughness and/or notice white areas
116
Q

What are the clinical features of genodermatoses?

A
  • white/greyish white patches which merge with surrounding normal appearing mucosa.
  • Firmly adherent
  • no associated erythema or ulceration
  • Surface is folded, soft and spongy
  • any area of oral mucosa, variable extent
117
Q

What other sites can be involved in genodermatoses?

A
  • oesophageal
  • nasal
  • genital
  • ano-rectal mucosa
  • skin, nails, hair and teeth NOT affected
118
Q

How is a suspected genodermatoses investigated?

A
  • diagnosis usually based on clinical grounds +/- FH
  • biopsy if in doubt
  • genetic testing for mutation - keratin 4 and/or 13
119
Q

How is genodermatoses managed?

A
  • explanation for patient
  • NOT a potentially malignant disorder
120
Q

What is the aetiology of leukoedema?

A

?secondary to low grade mucosal irritation, causing intracellular oedema

121
Q

What are the signs and symptoms of leukoedema?

A

asymptomatic

122
Q

What are the clinical features of leukoedema?

A

buccal and labial mucosa filmy white/grey appearance, soft on palpation

123
Q

How is a diagnosis of leukoedema decided?

A

made on clinical grounds

124
Q

How is leukoedema managed?

A

explanation of condition
advice regarding potential source of irritation

125
Q

What is epitheliolysis?

A

oral mucosal peeling (unrecognised superficial desquamation of oral mucosa)

126
Q

What is the aetiology of epitheliolysis?

A

secondary to mucosal irritation by toothpaste, mouthwashes

127
Q

What is the epidemiology of epitheliolysis?

A

prevalence uncertain, wide age range

128
Q

What are the signs and symptoms of epitheliolysis?

A

asymptomatic

129
Q

What are the clinical features of epitheliolysis?

A

strands of gelatinous, milky white material removable y wiping, no significant abnormality of underlying tissue

130
Q

How is epitheliolysis managed?

A

explanation of condition, avoidance of sodium lauryl sulphate (SLS) containing products, cease mouthwash use

131
Q

What is traumatic keratosis?

A

keratosis secondary to physical (frictional), chemical or thermal irritation

132
Q

What are the signs and symptoms of traumatic keratosis?

A

asymptomatic, affected area may fell rough or ridged to the patients tongue

133
Q

What are the clinical features of traumatic keratosis?

A

white plaque not removed by rubbbing/scraping, may have a shaggy surface, appear macerated or be associated with ridging, clinical appearance should match cause

134
Q

How is traumatic keratosis managed?

A

explanation of condition, management/removal of cause. If lesion does not resolve - biopsy.

135
Q

What is stomatitis nicotina?

A

smoker’s palate, is a reaction seen on the roof of the mouth caused by extreme heat in the mouth, most commonly from smoking. 60% pipe smokers, 30% cigarette smokers

136
Q

Is stomatitis nicotina a potentially malignant disorder?

A

no

137
Q

What is the clinical presentation of stomatitis nicotina?

A

generalised white/greyish white appearance of the hard palate extending into the soft palate
- small red dots <_1mm represent the inflamed openings of minor salivary glands

138
Q

How is stomatitis nicotina managed?

A

smoking cessation

139
Q

What is oral lichen planus/lichenoid reactions?

A

ongoing (chronic) inflammatory condition that affects mucous membranes inside your mouth. may appear as white, lacy patches; red, swollen tissues; or open sores. may cause burning, pain or other discomfort

140
Q

What is the aetiology of oral lichen planus?

A

unknown in approz 75% of cases
approx 25% cases reaction to medication/dental material

141
Q

What are the signs of oral lichen planus?

A
  • any site, tongue, cheeks, gingivae most common
  • usually bilateral
  • palatal mucosa rarely affected
142
Q

What are the clinical criteria for a diagnosis of oral lichen planus?

A

multifocal symmetric distribution
- white and red lesions exhibiting one or more of the following criteria:
1) reticular/papular
2) atrophic (erythematous)
3) erosive (ulcerative)
4) plaque
5) bullous
6) lesions not exclusively localised to sites of smokeless tobacco placement
7) not localised exclusively adjacent to and in contact with dental restorations
8) lesion onset doesn’t correlate to start of medication
9) lesion onset doesn’t correlate to use of cinnamon-containing products

143
Q

What does bullous mean?

A

characterised by blisters or bullae

144
Q

What symptoms can be associated with oral lichen planus?

A
  • asymptomatic
  • affected area may feel rough
  • soreness only on eating e.g. spicy, salty, acidic, rough, hot and toothbrushing
  • soreness at all times exacerbated by above factors
  • symptoms tend to wax and wane in severity
  • stress may be exacerbating factor
145
Q

What other sites can be involved in oral lichen planus/lichenoid reactions?

A
  • skin
  • scalp
  • nails
  • genital - may be particularly problematic in females (vulvovaginal gingival lichen planus)
  • less common: oesophagus, larynx, anus, bladder, eyelids, lacrimal glands
146
Q

What investigations can be done for oral lichen planus/lichenoid reactions?

A
  • diagnosis can be based on clinical grounds if classical presentation
  • biopsy
  • swab if suspect super-added candida
  • blood tests if associated disease suspected
147
Q

What is the initial non-pharmacological management in primary care for oral lichen planus/lichenoid reactions?

A
  • explanation of diagnosis
  • ask re. other site involvement
  • advise potentially malignant
  • counsel re. smoking cessation and alcohol moderation
  • baseline photographs
  • consider referral if concerns re; possible malignancy, diagnosis or ability to manage in primary care
148
Q

What are the management options for oral lichen planus/lichenoid reactions?

A
  • asymptomatic - no treatment required
  • symptomatic - match treatment to symptoms severity
149
Q

What medications commonly cause lichenoid reactions?

A
  • antihypertensives - ACE inhibitors (beta blockers, propanolol, atenolol), calcium channel blockers (amlodipine), thiazide diuretics, loop diuretics (furosemide)
  • oral hypoglycaemics - tolbutamide, chlorpropamide (sulphonylureas)
  • non-steroidal anti-inflammatory drugs - ibuprofen, naproxen, phenylbutazone
150
Q

What is hairy leukoplakia?

A

leukoplakia caused by the Epstein-Barr virus (human herpes virus 4)

151
Q

What are the clinical features of hairy leukoplakia?

A
  • firmly adherent, corrugated surface
  • lateral border of tongue
  • often super-added candida
152
Q

What is hairy leukoplakia associated with?

A

strongly associated with HIV but can arise in any immunosuppressed/immunocompromised individual and in patients using topical corticosteroids

153
Q

How is hairy leukoplakia investigated?

A

biopsy, HIV testing should be offered

154
Q

What makes the appearance of hairy leukoplakia worse?

A

chlorhexidine mouthwash worsens staining

155
Q

What are the four main types of candidosis?

A
  • acute pseudomembranous (thrush)
  • chronic hyperplastic
  • acute erythematous
  • chronic erythematous
156
Q

What is acute pseudomembranous candidosis?

A

Thrush
- white patches removed by scraping leaving an erythematous/bleeding base

157
Q

What are the underlying local and/or systemic predisposing factors of acute pseudomembranous candidosis?

A
  • dry mouth
  • steroid inhaler use
  • anaemia
  • nutritional deficiency
  • diabetes
  • immunosuppressed/immunocompromised
  • extremes of age
158
Q

What investigations can be done for candidosis?

A
  • oral rinse - colony forming units (CFU) per ml of rinse
  • saliva sample - CFU per ml of saliva
  • imprint culture - CFU per mm2 mucosa
  • swab - light or profuse growth
  • sensitivity testing to antifungals can be carried out
  • investigation of underlying cause - FBC, serum B12, folate, ferritin, HbA1c, TSH
159
Q

What fungi is usually associated with candidosis?

A

candida albicans

160
Q

What is chronic hyperplastic candidosis?

A

variant of oral candidiasis that classically presents as a white patch on the commissures of the oral mucosa and it is mostly caused by Candida albicans

161
Q

What does chronic hyperplastic candidosis present as and where?

A
  • firmly adherent white plaques, may be inter-mingled erythema and nodular
  • commissure/anterior region of buccal mucosa most commonly affected, often bilateral, may also affect tongue
162
Q

What is a significant aetiological factor associated with chronic hyperplastic candidosis?

A

cigarette smoking

163
Q

What is a diagnosis of chronic hyperplastic candidosis based on?

A

biopsy, swab may be non-diagnostic - candida infiltrates deeply into the epithelium

164
Q

Is chronic hyperplastic candidosis classed as a potentially malignant disorder?

A

Not anymore no

165
Q

What is the aetiology of geographic tongue?

A

unknown, increased incidence in patients who suffer from psoriasis

166
Q

What are the signs and symptoms of geographic tongue?

A

asymptomatic, symptoms only eating or symptomatic

167
Q

What are the clinical features of geographic tongue?

A
  • well defined areas of erythema
  • yellow/white/cream border
  • all surfaces of tongue
168
Q

What are the two types of candidosis that present with red patches?

A
  • acute erythematous candidosis
  • chronic erythematous candidosis
169
Q

What is acute erythematous candidosis and what did it used to be termed?

A

areas of erythema, tongue often affected
- previously referred to as antibiotic sore tongue - suppression of local commensal bacteria allowing candidal overgrowth
- dry mouth also a risk factor

170
Q

What are three examples of candida associated lesions presenting as red patches?

A
  • angular cheilitis (angular stomatitis)
  • denture stomatitis
  • median rhomboid glossitis
171
Q

What is denture stomatitis and how does it present?

A
  • palatal mucosa most commonly affected
  • often asymptomatic or pt reports soreness/burning
  • any appliance with mucosal coverage
  • erythema may be patchy or generalised
  • papillary hyperplasia of affected mucosa, if longstanding condition and/or taking medication that predisposes to hyperplasia (nifedipine, ciclosporin, phenytoin)
172
Q

What three medications can predispose patients to hyperplasia?

A
  • phenytoin
  • ciclosporin
  • nifedipine
173
Q

What Newton Type of denture stomatitis is it if the erythema is patchy?

A

Newton type I

174
Q

What Newton Type of denture stomatitis is it if the erythema is generalised?

A

Newton Type II

175
Q

What Newton Type of denture stomatitis is it if there is papillary hyperplasia of the affected mucosa?

A

Newton Type III

176
Q

What is angular cheilitis?

A

erythema, cracking, crusting and bleeding of the skin at the angles of the mouth

177
Q

What should you check for when you find angular cheilitis?

A
  • accompanying signs of intra-oral candidiasis, often associated with denture stomatitis
  • may be underlying anaemia/haematinic deficiency
178
Q

What microbe is angular cheilitis caused by?

A

candida alone or staph aureus alone or a combination of the two
beta-haemolytic streptococci are also occasionally isolated

179
Q

What is median rhomboid glossitis?

A

roughly rhomboidal shaped area of depapillation and erythema in the middle of the dorsum of the tongue

180
Q

What can median rhomboid glossitis present with and where can corresponding erythema be found?

A
  • may be associated hyperplasia resulting in a lobular appearance
  • corresponding area of erythema affecting palatal mucosa
181
Q

What investigations can be done when dealing with red patches caused by candidosis?

A
  • oral rinse - colony forming units (CFU) per ml of rinse
  • saliva sample - CFU per ml of saliva
  • imprint culture - CFU per mm2 mucosa
  • swab - light or profuse growth

3rd year - module 6 (14 decks)

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