Oral Medicine Flashcards
how to diagnose oral candidiasis
pt hx
clinical findings
what to note from pt exam when considering oral candidiasis
- appearance i.e. colour / site / distribution / symptoms / duration
- medical hx taking note of immunosuppression / diabetes / radiotherapy / chemotherapy
- medications i.e. antibiotics / steroid inhalers
- ask about denture hygiene if applicable i.e. night time wear / cleaning / denture fit i.e. is there trauma / food trap
acute pseudomembranous candidiasis i.e. oral thrush
appearance & tx
a - white patches (milk curds) that can be wiped off to reveal bleeding bases; cheeks, palate, oropharynx
t - identify & address underlying cause - diabetes / HIV / antibiotic use / smoker, improve OH, CHX MW, antifungals - miconazole (2.5ml QDS continue at least 7 days after lesion healed), nystatin rinse (100,000 units QDS 7 days continue 48hrs after lesions healed), fluconazole is most effective
chronic hyperplastic candidiasis i.e. candidal leukoplakia
appearance & tx
a - white patch on commissures, buccal mucosa, dorsum of tongue
t - associated with heavy smokers, iron, B12, folate deficiency; biopsy, check vitamin levels, stop smoking advice, 2-4wks oral fluconazole (chance of malignancy)
acute erythematous / atrophic candidiasis (antibiotic sore mouth)
appearance & tx
a - red shiny atrophic mucosa
c - chronic use of antibiotics / steroid inhalers, immunosuppression (HIV), xerostomia
t - spacer device, rinse after inhaler, tx as oral thrush
chronic erythematous stomatitis (denture stomatitis) appearance & tx
a - diffuse redness in denture bearing area, asymptomatic
t - remove dentures at night, clean & brush with warm soapy water, soak in NaOCl / CHX, miconazole gel 5-10ml to affected area or inside of denture QDS until 48hrs after lesions have resolved, refer to GMP if suspect systemic cause (vitamin levels / medications i.e. steroids / endocrine)
angular cheilitis appearance & tx
a - red cracked corners of mouth
c - trauma / immunosuppression / malabsorption (crohn’s / coeliac) / iron or B12 deficiency / broad spectrum antibiotics / candida infection / incorrect OVD dentures
t - correct cause i.e. FBC for vitamins, dentures, topical miconazole to continue for 10 days after lesions resolve
what to ask in exam when pt has ulceration
- MH
- onset - is it due to trauma i.e. # tooth / ill fitting dentures or is it spontaneous
- recurrence - 1st episode or multiple ?
- duration i.e. >3wks
- site - keratinised v non keratinised, is it a high risk area such as lateral border of tongue, FoM, soft palate & oropharynx
- size
- shape
- number
- outcome - healing with or without scarring
management advice for pt to do at home for ulcer to speed up healing & reduce pain
soft diet
avoid spicy / citrus food
cool drinks through a straw and try to avoid hot drinks
use soft toothbrush with SLS free toothpaste
warm salty water rinses
ice cubes over sores
OTC numbing gels e.g. oragel, iglu, anbesol
antiseptic MW i.e. CHX or peroxide based, benzydamine MW or spray
process when reviewing ulcer 3wks later
if still present after 3wks refer to hospital for assessment & tx
if present after 3wks and you suspect oral cancer then refer a urgent 2wk referral for biopsy investigation
medications with oral ulceration listed as common side effect
NSAIDs
beta blockers
methotrexate
penicillin
nicorandil
allopurinol
sulphonamides
sulfasalazine
gold
anti convulsants i.e. phenytoin, carbamazepine, phenobarbital
systemic conditions with oral ulceration listed as a manifestation
herpetic gingivostomatitis HSV-1
lichen planus
vesiculobullous disease i.e. MMP
HFM disease (coxsackie virus)
haematological malignancy (leukaemia)
squamous cell carcinoma
erythema multiforme
haematinic deficiency i.e. vit b12 / iron / folate
inflammatory bowel disease i.e. crohn’s / ulcerative colitis
causes of dry mouth
- meds i.e. anticholinergic
- dehydration
- drinking & smoking
- mouth breathing
- anxiety
- cancer tx
- MH i.e. diabetes, HIV, sjogren’s
home management advice for pt with dry mouth
drink water
suck ice cubes
suck sugar free sweets
reduce caffeine / alcohol / foods that cause irritation (spicy/citrus)
use SLS free toothpaste
what is SLS free toothpaste
sodium lauryl sulfate free toothpaste
this is the main foaming agent
e.g. sensodyne
good for those with sensitivities
management of dry mouth in practice
regular check ups to assess dryness, check for caries & fluoride application
warn pt of side effects of side mouth i.e. increased risk of decay, gum disease, poorly fitting dentures & fungal infections
can prescribe:
- 2800/5000 ppmF toothpaste, MW, sprays, gels
- check BNF for suitable sialalogues
- biotene oralbalance, xerotin, salivix are the common ones
- saliva orthana recommended post radiotherapy or in sjogrens
* be wary of glandosane as it is acidic & erosive in the dentate pt
medications that commonly cause dry mouth
beta blockers - propanolol, atenolol
anti convulsant - carbamazepine, gabapentin
analgesics - morphine, oxycodone
anti emetics - dexamethasone, sodium citrate, pepto bismol
parkinson’s drugs - levodopa
diuretics - furosemide
anti depressants - amitriptyline, citalopram, fluoxetine
antihistamines - loratadine, fexofenadine, chlorpheniramine
anti psychotics - clozapine, phenothiazine
anti manic drugs - lithium
pink IO swelling differential dx
fibroepithelial polyp
drug induced hyperplasia
crohn’s
orofacial granulomatous
warts & condylomata
focal epithelial hyperplasia
SCC
salivary gland tumour
red IO swelling differential dx
pyogenic granuloma
giant cell granuloma
denture induced hyperplasia
scurvy
SCC
white IO swelling differential dx
squamous papilloma
SCC
blue IO swelling differential dx
mucocele
ranula
yellow IO swelling differential dx
bone exostosis
sialolith
pigmented lesion in single or localised area differential dx
amalgam tattoo
haemangioma
melanocytic naevus (pigmented naevus)
melanotic macule (freckle)
kaposi’s sarcoma
pigmented lesion widespread or multiple differential dx
black hairy tongue
drug induced pigmentation
smoker’s associated pigmentation
physiologic pigmentation
hereditary haemorrhagic telangiectasia
sturge weber syndrome
addison’s
peutz jegher’s syndrome
thrombocytopenia
painful white patches differential dx
chemical burn (aspirin)
lichen planus
lichenoid reaction
lupus erythematous
painless white patches differential dx
white sponge naevus
dyskeratosis congenita
frictional keratosis
nicotinic stomatitis
leukoplakia
pseudomembranous candidiasis
chronic hyperplastic candidiasis
skin graft
hairy leukoplakia
SCC
submucous fibrosis
red patches that are painful & may ulcerate differential dx
erosive lichen planus
post radiotherapy mucositis
contact hypersensitivity reaction
red patches that are painful with no ulceration differential dx
iron deficient anaemia
pernicious anaemia
folate deficiency
angular cheilitis
acute erythematous candidiasis
geographic tongue
median rhomboid glossitis
red patches that are painless & may ulcerate differential dx
SCC
infectious mononucleosis
red patches that are painless with no ulceration differential dx
erythroplakia
chronic erythematous candidiasis
single or small no of discrete ulcers differential dx
traumatic ulceration
minor / major recurrent aphthous stomatitis
cyclic neutropenia
behcet’s disease
tuberculosis
syphilis
SCC
necrotising sialometaplasia
multiple discrete ulcers differential dx
ANUG
herpetiform recurrent aphthous stomatitis
behcet’s disease
multiple diffuse ulcerations differential dx
erosive lichen planus
lichenoid reaction
GVHD
radiotherapy induced mucositis
ORN
blistering conditions in young children differential dx
chicken pox
HFM disease
herpangina
PHG
recurrent HSI (labialis / oral ulceration)
mucocele
blistering conditions in older people differential dx
shingles
pemphigoid
pemphigus
erythema multiforme
linear IgA disease
dermatitis herpetiformis
angina bullosa haemorrhagica
