Oral Medicine Flashcards
OM and histology
1
Q
Fordyce Spots (4)
A
- Yellowish bumps
- Sebaceous spots
- Buccal mucosa and lips
- No associated pathology
2
Q
Linea Alba (2)
A
- Horizontal asymptomatic white lesion
- Along the occlusal plane
3
Q
Linea Alba Histology (3)
A
- Hyperkeratinosis
- Prominent or reduced granular layer
- Acanthosis
4
Q
Other names for geographic tongue (2)
A
Benign migratory glossitis
Erythema migrans
5
Q
Geographic Tongue (4)
A
- Loss of filiform papillae
- Areas of tongue atrophy and hyperkeratinisation
- Can affect other areas of oral mucosa
- Asymptomatic but sometimes sensitive to hot and spicy foods
6
Q
Fissured Tongue (4)
A
- Variation of normal
- Can occur later in life
- Commonly presents with geographic tongue
- Consider lightly brushing tongue
7
Q
Black Hairy Tongue (3)
A
- Hyperplasia of filiform papillae
- Build-up of commensal bacteria, food debris
- Pigment inducing fungi and bacteria
8
Q
Black Hairy Tongue Associations (4)
A
Smoking
Antibiotics
Chlorhexidine mouthwash
Poor OH
9
Q
Black Hairy Tongue Advice (5)
A
- Stop smoking
- Stay hydrated
- Lightly brush tongue
- Suck peach stone
- Eat fresh pineapple
10
Q
Desquamative Gingivitis (4)
A
- Full thickness erythema of the gingiva
- Descriptive - not diagnosis
- Bidirectional relationship with periodontal disease
- Not caused by plaque - exacerbated by it
11
Q
Bony Exostosis (4)
A
- Tori
- Can present on palate, mandible or buccal alveolus
- More prone to ulceration as mucosa thinner
- Rarely associated with pathology if not in normal regions
12
Q
Tori Questions/Suspicions (3)
A
Ask about GI symptoms
Increased suspicion if growing new ones or asymmetrical
Atypical site
13
Q
Haemangioma (3)
A
Collection of blood vessels whose walls have burst
Can grow to be large
Can be removed by a specialist
14
Q
Atrophic Glossitis (4)
A
Smooth tongue
Caused by iron or B12 deficiency
Will ulcer if not fixed
Ask GP for routine bloods
15
Q
Frictional keratosis (3)
A
Due to trauma
Keratinisation
If you can discern where a white patch has come from (trauma) you must get a biopsy
16
Q
Denture stomatitis (2)
A
Candida infection
Patient must remove denture at night and soak in solution
17
Q
Angular cheilitis (5)
A
- Can be due to denture hygiene
- Or Staphylococcus
- Or skin folds - face not dried
- Uncommonly low iron levels
- Treat reasons before medicating
18
Q
Which salivary replacement should never be used for patients with natural teeth
A
Glandosane as it is pH 5
19
Q
Lichen Planus vs Lichenoid Reactions
A
Lichen Planus is an autoimmune condition
Lichenoid reactions mimic lichen this but are reactions to drugs
20
Q
CRPS
A
Chronic Regional Pain
21
Q
What causes neuropathic pain?
A
Damage to the nervous system - nerve itself
22
Q
What will make neuropathic pain worse?
A
Surgery
23
Q
Dental pain without pathology
A
Atypical Odontalgia
24
Q
Pain which poorly fits in to standard chronic pain syndromes
A
Persistent Idiopathic Facial Pain
25
Epithelium of the oral mucosa
Stratified squamous
26
Types of oral mucosa (3)
Lining
Masticatory
Gustatory
27
Acanthosis
Hyperplasia of stratum spinosum
28
Elongated rete ridges
Hyperplasia of basal cells
29
Keratosis
keratinisation on a non keratinised site
30
Atrophy
Reduction in viable layers
31
Erosion
Partial thickness loss
32
Ulceration
Full thickness loss with fibrin on surface
33
Oedema types
Intracellular
Intercellular - spongiosis
34
Nutritional deficiencies for smooth tongue (2)
Iron
Vitamin B group vitamins
35
Nutritional deficiencies for geographic tongue (3)
Haematinics
B12
Folate
Ferritin
36
If fissures in fissured tongue are painful (3)
Could be another disease process
Candida
Lichen planus
37
Investigations for smooth tongue (2)
Haematinics
Fungal cultures
38
What is smooth tongue
Atophy
Sometimes called glossitis but not technically glossitis
39
When should swellings be referred? (6)
1. Symptomatic
2. Abnormal surrounding mucosa
3. Increasing in size
4. 'Rubbery'
5. Trauma from teeth
6. Unsightly
40
Leaf Fibroma (3)
1. Polyp which has be become flat due to denture
2. Removed and healed before new denture constructed
3. Friction will cause it to increase in size
41
Pyogenic granuloma (4)
1. Granulation tissue - mixed inflammatory infiltrate on fibromyalgia vascular background
2. Not a granuloma, not pyogenic
3. Response to trauma
4. Also called vascular epulis on the gingiva
42
Investigations for Addisons disease (2)
BP
Electrolyte check
43
What do herpetic lesions tend to follow
Innervation of mucosa
44
What condition produces target like lesions on the skin
Erythema multiforme
45
Why are teeth red in porphyria
Haem products are incorporated into dental hard tissues
46
1-3 on Challacombe scale
Mirror sticks to buccal mucosa
Sticks to tongue
Saliva frothy
47
1-3 on Challacombe scale treatment
Sips of water and sugar free gum
48
Sjogrens Syndrome Complications (3)
1. Effects of oral dryness
2. Sialosis
3. Lymphoma risk
49
Effects of oral dryness (5)
1. Caries
2. Candida
3. Denture retention
4. Speech
5. Swallowing
50
Types of pemphigoid (3)
Bullous
Mucous membrane
Cicatritial pemphigoid
51
What does bullous pemphigoid affect
Skin
52
What does mucous membrane pemphigoid affect
All mucous membranes
53
What does cicatricial pemphigoid affect
Mucosa with scarring
54
Functions of saliva (4)
1. Acid buffering
2. Mucosal lubrication
3. Taste facilitation
4. Antibacterial
55
4-6 Challacombe scale
No saliva pooling on FoM
Tongue shows shortened papillae
Altered gingival architecture (smooth)
56
7-10 Challacombe scale
Mucosa glossy
Tongue lobulated/fissured
Cervical caries (>2 teeth)
Debris on palate or stuck to teeth
57
Antibodies found in pemphigoid (2)
C3
IgG
58
Antibodies found in pemphigus vulgaris (2)
C3
IgG
59
Antiviral therapy for shingles
800mg ACV
5x a day for 7 days
60
Pemphigoid histological appearance (immunofluorescence)
Linear staining along basement membrane
61
Pemphigus histological appearance (immunofluorescence)
Basket weave pattern
62
What ages can use a steroid mouthwash
>12
63
Lichen Planus histology (5)
1. Chronic inflammatory cell infiltrate
2. Saw tooth rete ridges
3. Basal cell damage
4. Patch acanthosis
5. Parakeratosis
64
Causes of giant cell lesions (2)
Unphagocytosable material
1. Local chronic irritation
2. Infective agents (TB)
65
Causes of oral white lesions (6)
1. Hereditary
2. Smoking
3. Frictional
4. Lichen planus
5. Candidal leukoplakia
6. Carcinoma
66
Causes of true increase in salivary flow (4)
1. Drugs
2. Dementia
3. CJD
4. Stroke
67
Clinical appearance of pemphigoid intraorally (2)
Thick walled blisters
Clear or blood filled blisters
68
Clinical features of HSV 1 and 2 (6)
1. Gingivostomatitis
2. Herpes labialis
3. Keratoconjunctivitis
4. Herpetic whitlow
5. Bell's palsy
6. Genital herpes
69
Common sites for mucoceles
Vibrating line
Lower lip
70
Common viruses implicated in lichen planus (2)
Hep C
Herpes
71
Most common oral lichen planus site
Buccal mucosa
72
Risk factors for oral cancer (4)
1. Smoking
2. Drinking
3. Low SES
4. Betel quid
73
Consequences of Sjogrens Syndrome (4)
1. Loss of salivary gland/lacrimal tissue
2. Enlargement of major salivary glands (symmetrical)
3. Increased risk of lymphoma
4. Oral and ocular effects - dry mouth and dry eyes
74
Hyposalivation cut off (resting)
< 0.1ml / min
75
Dysplasia definition
Disorder maturation in a tissue
76
Hamartoma
Benign mass of disorganised tissue native to a particular anatomical location
77
Describe an apthous ulcer
Yellow/grey base with erythematous margin
78
Characteristics of Crohn's Specific Apthous Ulceration (3)
Linear at depth of sulcus
Full of crohn's associated granulomas
Persist for months
79
Angina bullosa haemorrhagica (5)
1. Blood blisters on mucosa
2. Appear within minutes of eating
3. Last an hour then burst
4. Leave behind a small ulcer with no scarring
5. Heal within days
80
Field cancerisation concept
High cancer risk in the 5cm radius of the original primary
81
Diagnostic aids to oral cancer screening (2)
1. Toluidene blue
2. VELscope
82
Dysplasia vs atypia
Dysplasia disordered maturation in a tissue
Atypia disordered change in cells
83
Pemphigus vs pemphigoid
Pemphigus bullae are intra rather than inter epithelial
Pemphigus desmosomes joining epithelial cells affected rather than the hemidesmosomes connecting the epithelium to the connective tissue
84
Primary Sjogrens
No connective tissue disease
85
Secondary Sjogrens (4)
Connective tissue disease
SLE
RA
Scleroderma
86
Discoid lupus
No auto antibodies
87
Systemic lupus
Antibody involvement
88
Do major apthae respond well to topical steroids
No
89
Do major apthae scar
They may scar when healing
90
Do minor apthae scar
No
91
Drug classes that may induce gingival growth (3)
1. Anti-hypertensives (calcium channel blockers)
2. Anti-epileptics (phenytoin)
3. Immunosuppressants (ciclosporin)
92
Drugs used for systemic immunomodulation in Behcets disease (3)
1. Colchicine
2. Azathioprine
3. Biologics
93
Epstein Barr virus symptoms (6)
1. Fatigue
2. Fever
3. Sore throat
4. Head and body aches
5. Lymphadenitis (cervical and axillary)
6. Rash
94
Example of large vessel vasculitis disease
Giant cell arteritis
95
Example of medium vessel vasculitic disease (2)
Polyarteritis nodosa
Kawasaki disease
96
Example of small vessel vasculitis disease
Granulomatosis with polyangiitis
97
Examples of generalised brown or black lesions (4)
1. Racial/familial
2. Smoking
3. Drugs
4. Addisons disease
98
Examples of intrinsic mucosal pigmentation (4)
1. Melanotic macule
2. Melanocytic naevus
3. Melanoma
4. Effect of systemic dx
99
Examples of localised brown/black lesions (4)
1. Amalgam
2. Melanotic macule
3. Melanotic naevus
4. Malignant melanoma
100
From which type of mucosa do most oropharyngeal cancers in the UK arise
Clinically normal mucosa
101
Examples of drugs which can induce oral ulceration (4)
1. Potassium channel blockers
2. Bisphosphonates
3. NSAIDs
4. DMARDs
102
Steroid based topical treatments for mucosal lesions (3)
1. Hydrocortisone mucoadhesive pellet
2. Betamethasone mouthwash
3. Beclomethasone metered dose inhaler
103
Systemic iatrogenic causes of oral ulceration (3)
1. Chemotherapy
2. Radiotherapy
3. Graft versus host disease
104
Food triggers to avoid for patients with RAS/OFG (3)
1. SLS
2. Chocolate
3. E210-219 (benzoate and sorbate, cinnamon)
105
Scale for emotional symptoms of pain
HAD psychological score
106
Scale for physical symptoms of pain
McGill pain score
107
High risk oral sites for mouth cancer (7)
1. FoM
2. Lateral borders of tongue
3. Retromolar regions
4. Palate
5. Gingivae
6. Buccal mucosa
7. Tonsils
108
Histologically what is pemphigoid (3)
1. Sub-epithelial antibody attack
2. Epithelium and connective tissue split at junction
3. Hemidesmosomes attaching at the basement membrane lose their attachment
109
How are immunogenic blistering diseases investigated
Direct immunofluoresence
110
How are recurrent herpetic lesions treated
Aciclovir
111
How can salivary flow be measured on clinic
Resting flow rate
Spit into a tube continuously for 15 mins
112
Mucosa on fibroepithelial polyp
Same as surrounding mucosa
113
How common are fordyce spots
60-75% of adults
114
How common is geographic tongue
3%
115
Antineoplastic drug impact on salivation
They can accumulate in glands and kill off acinar cells over time
116
How do blisters form in vesiculobullous disease (2)
Auto-antibody attack on skin components which hold skin layers together
A split forms and fills with inflammatory exudate
117
Behcets disease diagnosis (~5)
1. Three episodes of mouth ulcers in a year
At least two of the following
2. Genital sores
3. Eye inflammation
4. Skin ulcers
5. Pathergy
118
Difference between herpetiform apthae and primary herpetic gingivostomatitis (2)
HSV affects keratinised mucosa
Patient may have systemic symptoms with HSV
119
Erythroleukoplakia management
Urgent referral
120
Lichenoid drug reaction management (2)
Risk benefit analysis
Assess severity
121
How can you prove pigmentation is due to amalgam
Biopsy
122
Enterovirus treatment (2)
Relieve symptoms
Prevent dehydration
123
How does aciclovir work
Inhibits viral DNA
124
Amyloidosis impact on major salivary glands
Deposition of protein in glands
125
Graft versus host impact on salivation
Immune damage to glands
126
Haemachromatosis impact on glands
Excess storage of iron within gland
127
HIV impact on salivary glands
Lymphoproliferative changes in glands
128
How does shingles present
Over the distribution of a dermatome
129
Mumps diagnosis
Oral swab for DNA detection
130
How long should an exclusion diet last (2)
3 months
Then start reintroducing foods one by one
131
How common is it for patients with oral lichen planus to get skin lesions
50% of the time
132
Gingival biopsies
Job for a specialist
133
Persistent oral lichen planus management (3)
1. Topical steroids
2. Beclomethasone inhaler
3. Betamethasone rinse
134
Mild intermittent lichen planus treatment (4)
1. Topical OTC remedies
2. Chlorhexidine mw
3. Benzdamine mw
4. Avoid SLS containing toothpaste
135
Traumatic keratosis management (3)
1. Encourage smoking cessation
2. Get a photograph
3. Reverse traumatic element
136
How should you treat apthous ulcers with topical steroids
Pt. needs to be trained to notice ulcer in the prodrome period as epithelial damage happened before ulcer appears
137
Denture hyperplasia which does not resolve when denture is removed
Biopsy the area
138
What diagnosis should be considered when you see lichen planus or lichenoid lesions
Lupus
139
Imaging to investigate dry mouth (2)
1. Sialography
2. Salivary ultrasound
140
Who are apthous ulcers more common in (4)
1. Children and teenagers
2. Adults with occult GI/GU pathology
3. Anaemics
4. Malnourished pts
141
Initial management of OFG
Consider Crohn's
Dietary history and discuss exclusion diet
142
Sialosis investigations - not dental (5)
1. Bloods - FBC, U&E, bilirubin
2. BBV screen
3. Autoantibody screen
4. Glucose
5. MRI of major glands
143
Obstruction of salivary glands investigations (4)
1. Low dose plain radiography
2. Lower true occlusal
3. Sialography when infection free
4. Ultrasound assessment of duct
144
Is erythroplakia malignant
High malignant transformation
Urgen referral
145
Is leukoplakia malignant
No but has malignant potential
146
Main histological feature of OFG
Multinucleated giant cells
147
Topical treatment for OFG (3)
Miconazole for angular chelitis
Tacrolimus ointment for swollen areas
Intralesional steroid weekly for 3 weeks
148
Medicines commonly associated with oral lichen planus (5)
1. ACE inhibitors
2. Beta blockers
3. Diuretics
4. NSAIDs
5. DMARDs
149
Issue with burst blisters in pemphigoid (2)
1. Exposed connective tissue and leaking inflammatory exudate
2. Leads to dehydration and infection
150
Oral cancer risk in those who smoke and drink
5x
151
What causes pigmentation in Addisons disease
Raised ACTH
152
Prolonged steroid use risks (5)
1. Adrenal suppression
2. Osteoporosis risk
3. Peptic ulcer risk
4. Cushingoid fatures
5. Mania/depression risk
153
Sialosis in sjogrens
Usually permanent
154
Side effect of betamethasone mw
Small candida risk
155
Stage III and above oral cancer cure and survival rate
Cure < 50%
Survive < 30%
156
Symblepharon
A sign of cicatricial pemphigoid
157
Diseases that can look like lichen planus (2)
1. Lupus
2. GvH
158
Systemic medications for management of neuropathic pain (4)
Pregablin
Gapapentin
Amitriptyline
Duloxetine
159
Investigations for dry mouth (5)
1. Salivary flow test
2. Blood tests
3. Imaging
4. Dry eyes screen
5. Tissue examination
160
Sialosis associations (4)
1. Alcohol abuse
2. Cirrhosis
3. Diabetes mellitus
4. Drugs
161
Pemphigus symptoms timeline
Mucosa often affected up to 3 years before skin lesions
162
Topical medications for neuropathic pain (4)
1. Capsaicin
2. EMLA
3. Benzdamine
4. Ketamine
163
Tori and Bisphosphonates
Pts more likely to have avascular necrosis of tori than other parts of mandible
164
Tx for oral lesions seen in erythema multiform (5)
1. High dose systemic steroid
2. Systemic acyclovir secondary to this
3. Stay hydrated
4. Encourage analgesia
5. Allergy test
165
Anti-microbials (3)
1. Anti viral
2. Anti fungal
3. Antibiotics
166
Antifungal examples (3)
1. Miconazole
2. Fluconazole
3. Nystatin
167
Bethamethasone
Topical steroid mouthwash - unlicenced
168
Beclomethasone
Topical steroid metered dose inhaler (MDI) - unlicensed
169
Dry mouth treatments (5)
1. Salivix pastilles
2. Saliva orthana
3. Biotene oral balance
4. Artificial saliva DPF
5. Glandosane
170
Tricyclic antidepressant examples (2)
1. Amitriptilene
2. Nortriptilene
171
How do tricyclic antidepressants work
Work centrally in CNA to reduce pain transmission
172
Immunosuppressant examples (2)
1. Azathioprine
2. Mycophenolate
173
Immune modifying drug examples (2)
1. Hydroxycoloquine
2. Colchicine
174
Lichen planus and fungus
Often lichen planus presents with a fungal infection on top of the cell changes to treatment started with an anti fungal
175
Info for prescriptions (7)
1. Pt sticker
2. Number of days tx
3. Drug to be prescribed
4. Formulation and dosage
5. Quantity to be dispensed
6. Instructions to pt
7. Signature
176
How long is a prescription valid
6 months
177
Drug prescribing for mucosal diseases (2)
Non steroid topical therapy for uncomfortable lesions
Steroid topical therapy for disabling immunologically driven lesions
178
How to use bethamethasone mouthwash (6)
1. Betnesol 0.5mg tablets
2. Dissolve 2 tablets in 10mls (2tsp) water
3. 2 mins rinsing
4. Twice daily
5. Don't rinse/eat afterwards for 30 mins
6. Don't swallow
179
PIL
Patient instruction leaflet
180
How to use beclomethasone (5)
1. 50mcg/puff
2. Position vent over ulcer area
3. 2 puffs
4. 2-4 times daily
5. Do not rinse after use
181
Why should steroids not be stopped suddenly (2)
1. Should taper dose
2. Steroid dependancy
182
Immunosuppression preparation (9)
1. BBV screen
2. FBC
3. Electrolytes
4. Liver function
5. Zoster antibody screen
6. EBV
7. Chest x-ray
8. Cervical smear
9. Pregnancy test
183
What should be tested for before azathioprine
Thiopurine methyltransferase (TPMT)
184
Long term risk of azathioprine
Skin cancer risk
185
Why are red lesions red? (3)
1. Inflammation
2. Dysplasia
3. Reduced thickness of epithelium
186
Types of haemangioma (2)
Capillary
Cavernous
187
Types of lymphangioma (2)
Most are cavernous
Cystic hygroma
188
When to refer mucosal pigmentation (3)
1. Not easily explained
2. Increasing in size/quantity
3. NEW systemic problem
189
Melanoma Signs (5)
1. Variable pigmentation
2. Irregular outline
3. Raised surface
4. Itchy
5. Bleeds
190
Types of lichen planus (3)
Reticular
Atrophic/Erosive
Ulcerative
191
Things that contribute to the colour of the mucosa (7)
1. Epithelial thickness
2. Vasculature
3. Inflammation
4. Keratinisation
5. Candida
6. Melanin
7. Exogenous factors
192
Risk factors for candida infection (4)
1. Immunocompromised
2. Dentures
3. Smoking
4. Inhaler use
193
Anti-fungal drugs (3)
1. Fluconazole
2. Miconazole
3. Nyastatin
194
Local measures to prevent candida (4)
1. Rinse after inhalers
2. Use a spacer
3. Denture hygiene
4. Smoking cessation
195
Things to assess when you examine a patch (8)
1. Location
2. Colour
3. Homo/heterogeneity
4. Induration (hard or soft)
5. Raised or flat
6. Texture
7. Wipeable?
8. Symmetry
196
General approach to white patches (5)
1. Thorough history
2. Identify a cause
3. Reverse reversible
4. Photos
5. No clear cause or pt has additional risk factors - refer
197
What type of hypersensitivity is erythema multiforme
Type 3
198
Immune systemic diseases with local effects (6)
1. Erythema multiforme
2. Pemphigus
3. Pemphigoid
4. Lupus
5. Sjogrens
6. Systemic sclerosis
199
OM diseases with cell mediated immunity (2)
1. Lichen planus
2. OFG
200
OM diseases with antibody mediated immunity (2)
1. Pemphigus
2. Pemphigoid
201
Vesicle size
1-2mm
202
Epitopes
Part of protein antigen
203
Target of many antigens in vesicullobullous diseases
Desmoglein
204
Which type of immunofluorescence is preferable
Direct
205
Direct immunofluorescence (2)
1. Antibody mediated tissue disease
2. Antibody bound to tissue
206
Indirect immunofluorescence (3)
1. Circulating antibody not yet bound to tissue
2. Detected from plasma sample
3. Not always useful for diagnosis
207
Vesicullobullous conditions (5)
1. Erythema multiforme
2. Pemphigus
3. Pemphigoid
4. Angina bullosa haemorrhagica
5. Bullous lichen planus
208
Target lesions
Erythema Multiforme
209
Steven Johnsons syndrome
Most extreme form of erythema multiforme with multi system involvement
210
Aetiology of erythema multiforme (2)
1. Antigen which has usually been encountered before
2. Large antigen/antibody complex which gets stuck in tissues
211
Where is erythema multiforme most likely to present
Lips and anterior part of mouth
212
Erythema Multiforme Tx (4)
1. Systemic steroids
2. Systemic aciclovir
3. Stay hydrated
4. Encourage analgesia
213
What is the most common reason for hospitalisation in erythema multiforme
Dehydration - pt unable to eat or drink
214
Reccurent erythema multiforme tx (3)
1. Consider prophylactic aciclovir daily
2. Allergy test
3. Consider infective agent - mycoplasma
215
ABH
Angina Bullosa Haemorrhagica
216
ABH Aetiology (3)
1. Most common oral blistering condition
2. Relatively painless
3. Common at vibrating line & occlusal line
217
ABH Blisters (3)
1. Rapid onset - (few minutes)
2. Last days then burst
3. Heal with no scarring
218
ABH Tx (3)
1. Pt education
2. Reassurance
3. No tx available
219
In pemphigoid, where does the epithelium split
Sub basement membrane
220
Pemphigoid/Pemphigoid biopsies (2)
1. Peri-lesional biopsy essential
2. Epithelium almost always splits away from the sample
221
RAS - Types (3)
1. Minor
2. Major
3. Herpetiform
222
Ulcer free period for minor apthous ulcers
Good guide to morbidity - longer ulcer free, less morbidity
223
Minor apthous ulcers (3)
1. <10mm diameter
2. <2 weeks
3. Only affect NON-KERATINISED mucosa
224
Do minor apthous ulcers respond well to topical steroids
Usually
225
Major apthous ulcers (4)
1. Months
2. Any part of mucosa
3. May scar when healing
4. Usually larger than 10mm
226
Herpetiform Apthae (4)
1. Non keratinised mucosa
2. 2 weeks
3. Can coalesce into larger areas of ulceration
4. Early stages looks like primary herpetic gingivostomatitis
227
Herpetiform apthae and herpes viruses (2)
1. Herpetiform apthae nothing to do with herpes viruses
2. HSV keratinised involvement, herpetiform apthae only non-keratinised mucosa
228
What is Behcet's disease
Primarily vasculitis - inflammation of blood vessels
229
RAS Tx (4)
1. Colchicine - first tx
2. Azathioprine/Mycophenolate
3. Biologics (infliximab)
4. Managed with help of rheumatology
230
Treating apthous ulcers (4)
1. Damage before ulcer appears
2. Prodrome period
3. Tx on top of ulcer will do nothing, damage is underneath
4. Daily topical steroid mouth rinse may be of benefit
231
Apthous Ulcers Investigations (3)
1. Haematinics
2. Coeliac
3. Allergies
232
Coeliac disease tests (2)
1. TTG
2. If TTG+, test anti-gliadin and anti-endomysial antibodies
233
Apthous Ulcers Tx (3)
1. Correct blood deficiencies
2. Refer for investigations if coeliac +
3. Avoid dietary triggers
234
Apthous ulcers in children (4)
1. Typically during growth spurts
2. Feet grow first - new shoes?
3. Usually respond to 3/12 iron supplements
4. If from birth - genetic
235
Genetic apthous ulcers in children (4)
1. Consider allergy testing as well as bloods
2. Symptomatic tx during ulcer periods
3. Issues with betnesol <12 - license
4. Betnesol - child must be able to rinse and spit
236
What should be done for RAS/apthous ulcers before referral (3)
1. Simple investigations
2. If iron deficient - 3/12 iron supplements
3. Topical tx outlined in SDCEP
237
Gingival lichen planus
OH very important in settling lesion especially interdental
238
Gingival biopsies
Difficult - take care when deciding to do this or not
239
Tongue biopsies
Easy but painful when healing
240
Difference between lichen planus and lichenoid lesions histologically
Very little difference
241
Gingival veneer for lichen planus (2)
1. Vacuum formed splint
2. Topical steroid placed inside
242
Intermittent lichen planus
No need for medication during good times
243
GVHD
Graft vs Host Disease
244
Things that look like lichen planus intra-orally (2)
GVHD
Lupus
245
What looks similar to lichen planus histologically (2)
Lichenoid reactions
GVHD
246
Lichen planus and lymphocytes
Lymphocytic band along basement membrane
247
Lupus with systemic autoantibodies
Termed systemic lupus erythematosis
248
Lupus (4)
1. Palate
2. Can be only oral
3. Can be systemic
4. If only oral - treat symptomatically as lichen planus
249
Intra-oral examination for salivation problems (3)
1. Minor salivary glands
2. Duct orifices
3. Fluid expression - quality and quantity
250
Causes of dry mouth (5)
1. Salivary gland disease
2. Drugs
3. Medical conditions and dehydration
4. Cancer treatments
5. Anxiety
251
Why are changes to gland stimulation more noticeable in older patients
Acinar tissue loss over the years makes changes more pronounced
252
Medical conditions impacting salivary glands (2)
Indirect effect - external to gland
Direct effect
253
Anti-muscarinic cholinergic drugs (6)
1. Tricyclic antidepressants
2. Antipsychotics
3. Antihistamine
4. Atropine
5. Diuretics
6. Cytotoxics
254
What types of drugs can cause dry mouth (3)
1. Anti muscarinic
2. Diuretics
3. Lithium
255
Chronic medical problems which can reduce salivation (5)
1. Diabetes
2. Renal disease
3. Stroke
4. Addisons
5. Vomiting
256
Acute medical problems which can reduce salivation (4)
1. Acute oral mucosal diseases
2. Burns
3. Vesicullobullous diseases
4. Haemorrhage
257
Direct salivary gland problems (5)
1. Aplasia
2. Sarcoidosis
3. HIV
4. Gland infiltration
5. Cystic fibrosis
258
Dry mouth in children
They may not complain of a dry mouth if they've never had normal salivation
259
Ectodermal dysplasia impact on salivation
Salivary aplasia
260
Sarcoidosis impact on salivation
Enlargement of submandibular and parotid gland
261
HIV impact on salivation (2)
Enlargement of glands
Any pt that presents with this should be offered HIV test
262
Haemochromatosis
High level of ferritin
263
Salivary disease investigations (4)
1. Blood tests
2. Functional assay
3. Tissue assay
4. Imaging
264
Minor salivary gland biopsy (2)
Preffered to major gland biopsy
Minor salivary glands reflect inflammatory issues in major glands
265
Dry mouth with no dry mouth (3)
Anxiety and somatisation disorders
Anxiety causes dryness
Information from mouth misunderstood by small changes at synapses
266
Hyposalivation (stimulated)
<0.5ml/min
267
Dry mouth with only symptomatic treatment (3)
1. Sjogrens
2. Cancer tx
3. Salivary gland disease
268
Symptomatic dry mouth tx (3)
1. INTENSE dental prevention
2. Salivary substitutes
3. Salivary stimulants
269
Dry mouth from somatoform disorders - diagnosis
Diagnosis of exclusion
270
Blood tests for dehydration (2)
U&Es
Glucose
271
Dry eyes test
Shirmer test
272
Salivary stimulants (2)
1. Pilocarpine (Salagen)
2. Side effects - sweating, tachycardia
273
Perceived increased in salivary flow (2)
1. Swallowing
2. Postural drooling
274
Drug causes of hypersalivation (4)
1. Anticholinesterases
2. Bromides
3. Clonazepam
4. Ketamine
275
Dealing with excess saliva (4)
1. Treat cause
2. Drugs to reduce salivation
3. Biofeedback training - swallowing
4. Surgery to salivary system
276
Changes in gland size (3)
1. Viral inflammation
2. Secretion retention
3. Gland hyperplasia
277
Mucocele
Recurrent mucous retention cyst
278
Duct Dilation (4)
Prevents normal emptying
Micro-organisms lead to persisting and recurrent sialadenitis
Sausage shape in ducts
Stagnant saliva - infection risk
279
Classification of Sjogrens (3)
1. Sicca (Partial)
2. Primary
3. Secondary
280
What is Sjogrens
Autoimmune disease which affects salivary glands and other parts of the body
281
Diagnosis of Sjogrens (3)
1. Complex - no single test
2. American-European Consensus Group (AECG)
3. ACR-EULAR joint criteria
282
Autoantibodies involved in Sjogrens (2)
1. Anti Ro
2. Anti La
283
How many criteria from the AECG need to have a positive finding for Sjogrens diagnosis
4
284
Abnormal unstimulated salivary flow
<1.5ml/min
285
AECG Criteria for Sjogrens (5)
1. Dry eyes/mouth
2. Autoantibody
3. Imaging findings
4. Radio nucleotide assessment
5. Histopathology
286
First tests for Sjogrens (5)
1. Least harmful first
2. UWS
3. Salivary USS
4. Anti-Ro antibody
5. Baseline MRI of major glands - for comparison for future lymphoma screen
287
Next test for Sjogrens
Labial gland biopsy
288
Sjogrens Management (4)
1. Enhanced prevention
2. Salivary stimulants
3. Consider immune modulating tx - hydroxychloroquine, methotrexate
4. Liaise with rheumatologist
289
Tooth substance pigmentation (2)
1. Billirubin
2. Tetracycline
290
Oral mucosal effects from systemic disease (5)
1. Giant cell granuloma
2. OFG
3. RAS
4. Dermatoses
5. Drug reactions
291
Giant cell lesions - Types
Peripheral
Central
292
Giant cell lesions (4)
1. Check PTH
2. Renal failure
3. Hypocalcaemia
4. Parathyroid tumour
293
Crohns Screening (3)
Faecal Calprotecting assay - screening test for endoscopy
Unreliable in younger children
Good predictor of Crohn's disease activity
294
UWS
Unstimulated Whole Saliva
295
USS
Salivary Ultrasonography
296
MCTD
Mixed connective tissue disease
297
Reasons for haematinic deficiencies (4)
1. Poor dietary intake
2. Malabsorption
3. Blood loss
4. Increased demand - growth
298
Which has more malignancy potential - OLL or OLP
Oral lichenoid lesions
3% transformation rate
299
OLL
Oral lichenoid lesions
300
OLP
Oral Lichen Planus
301
Pathogenesis of lichen planus
CD8+ T cells trigger apoptosis of the basal cells of oral epithelium
302
OLP and OLL infiltrate
OLP - mixed infiltrate
OLL - Strict lymphohistocytic infiltrate
303
Where is infiltrate in OLP vs OLL
OLP - Limited to lamina propria
OLL - Deeper distribution
304
Primary care treatment of OLL (2)
1. Remove or replace cause
2. Suppress immune system with corticosteroids
305
Secondary care treatment of OLL/OLP (4)
1. Hydroxychloroquine
2. Azathioprine, mycophenolate
3. Topical tacrolimus
4. Systemic steroids
306
Special investigations for Sjogrens (5)
1. Salivary gland biopsy
2. Antibody positivity
3. Ocular staining score
4. Schirmer test
5. Sialometry
307
Labial gland biopsy score on ACR/EULAR for Sjogrens
3
308
Anti Ro antibody positivity score on ACR/EULAR
3
309
OSS
Ocular Staining Score
310
Histopathology of salivary glands in Sjogrens (3)
1. Lymphocyte infiltration
2. Proliferation of lining
3. Duct dilation
311
What antibodies are implicated in SLE
Antinuclear antibodies
ANA
312
Intra-oral manifestations of SLE (8)
1. Ulcers
2. Erosion
3. Hyposalivation
4. Pigmentation
5. Burning mouth
6. Fissured tongue
7. Cheilitis
8. Secondary Sjogrens
313
Types of mucosal lesions in SLE (2)
1. Discoid
2. Non-specific apthous ulcers
314
Extra-oral manifestations of SLE (5)
1. Anaemia
2. Arthritis
3. Butterfly rash
4. Increased stroke risk
5. Pericarditis
315
Lupus arthritis
Also known as Jaccouds arthropathy
316
Lupus nephritis
Inflammation of kidneys due to formation of immune complexes
317
How many of the ACR/EULAR criteria must a patient meet to be classed as having SLE
10+
318
SLE disease severity (3)
1. Mild
2. Moderate
3. Severe or organ threatening
319
Severe organ threatening SLE tx
Hydroxychloroquine with high dose IV glucocorticosteroids for flare ups
320
Treatment foal for SLE/SS (4)
Control of symptoms
Remission of disease
Better QoL
Prevent organ damage
321
When are methotrexate and azathioprine used for SLE
When a pt fails to respond to the max dose of glucocorticosteroids
322
Mechanism of action of NSAIDs
Inhibit COX enzymes thus reducing the synthesis of prostaglandins involved in inflammatory process
323
Why should Sjogrens patients be monitored
To look out for complications like lymphoma
324
What is OFG (2)
1. Blockage of lymphatic drainage due to immune reaction
2. Angio-oedema
325
Granulomatous conditions (4)
1. Crohns
2. OFG
3. Sarcoidosis - rare
4. TB - rare
326
How long does angio-oedema last in OFG
Quick onset
Slow to settle
Weeks/months
327
Systemic treatment for OFG (~2)
1. Pulsed azithromycin - 3 months
2. Systemic immune modulation - prednisolone for short term, azathioprine/mycophenolate for long term
328
Patterns of oral cancer (2)
1. Oral cavity cancer (OCC)
2. Oro-pharyngeal cancer (OPC)
329
Unconfirmed potential risks for oral cancer (3)
1. Family history
2. OH
3. Sexual activity
330
What can MMP result in if left untreated (2)
Eosophageal and laryngeal stenosis
Blindness
331
How to distinguish pemphigus and bulbous pemphigoid
Nikolkys Sign
332
Nikolskys Sign (2)
Apply lateral pressure on peri-lesional skin
Shearing force dislodges upper layers of epidermis from lower layers
333
ELISA testing
Indirect immunofluorescence
Requires serum collection
334
Pemphigus tx (3)
1. Dapsone
2. Prednisolone
3. Azathioprine/mycophenolate
335
Primary care for MMP and PV (3)
1. Maintaining OH
2. Diet advice
3. Anti-inflammatory and analgesics
