Oral Medicine Flashcards
what is mucous membrane pemphigoid
blistering lesions affecting different mucous membranes
why can MMP be considered to be dangerous
associated with oesophageal and laryngeal strictures and stenosis
how does MMP occur
body’s immune system mistakenly attacks its own mucous membranes
antibodies are produced that attack the proteins within the membrane
what do the antibodies associated with MMP attack in the mucous membranes
the proteins involved in anchoring the basement membrane to epithelial cells
what is the immunological mechanism of MMP
IgG and IgA bind to BP180 protein which forms an immune complex
activation of complement system
inflammatory cascade activation
influx of immune cells causes blisters to form
name four oral manifestations of MMP
bullae formation
ulcerations
erythema
stricture formation (cases of scarring)
name the four most common sites for MMP lesions to be seen on
buccal mucosa
gingiva
palate
tongue
name three extra-oral presentations of MMP
ocular involvement
skin lesions
nasal, genital or pharyngeal
what is nikolskys sign
dislodgement of intact superficial epidermis by a shearing force - inducing a bulla
how do you elicit Nikolskys sign
apply lateral pressure with thumbs/ fingers of peri-lesional skin
name two histological features of MMP
sub epithelial split with inflammatory cell infiltrate
hemi-desmosome involvement at basement membrane
what is direct immunofluorescence in MMP
gold standard for diagnosing MMP
detects linear IgG along basement membrane
what is indirect immunofluorescence in MMP
serological testing
IIF - detects for circulating IgG autoantibodies
ELISA - tests for BP180
how does pemphigus vulgaris develop
Anti-DSG1 and anti-DSG3 autoantibodies attack proteins on surface of keratinocytes
loss of cell-cell adhesion (acanthosis)
how does pemphigus vulgaris present intra-orally
oral erosion
where are biopsies taken for PV investigation
from the edge of an early lesion for H&E staining
what are Tzank cells
large round keratinocytes with hypertrophic nucleus and abundant basophilic cytoplasm
what is required for diagnosis of PV
direct immunofluorescence by testing for presence of autoantibodies in non-affected oral mucosa
why are samples taken peri-lesional when trying to diagnose MMP or PV
samples taken from affected sites are more likely to produce false negative result
due to destruction of immunoreactants during the disease process
what would develop if there are anti-dsg1 autoantibodies only
develop only skin blisters
what would develop if there are anti-dsg3 autoantibodies only
erosions/ ulcerations on mucosal membranes
what would develop if both anti-dsg1 and anti-dsg3 autoantibodies are present
both skin and mucosal lesions
what is Dapsone
used for mild MMP or PV
inhibits bacterial synthesis of dihydrofolic acid and synthesis of cytokines and chemokines
what dose of Dapsone should be prescribed
25-50 mg per day originally
increase monthly by 25-50mg until clinical remission achieved
or maximum of 200mg/ day reached
name three adverse effects of Dapsone
nausea
difficulty breathing
loss of appetite
what is Prednisolone
glucocorticoid steroid that has anti-inflammatory and immunosuppressive effects
how does Prednisolone work
binds to glucocorticoid receptor which mediates change in gene expression
inhibits neutrophil apoptosis
promotes anti-inflammatory genes (interleukin)
what dose of Prednisolone is prescribed
1-1.5mg/kg/day
name three side effects of Prednisolone
weight gain due to alteration in glucose tolerance
hypertension
bone resorption
what is Azathioprine
adjuvant immunosuppressive medicine
name four aspects of management of MMP and PV in primary dental setting
analgesic mouthwash
topical corticosteroids
SLS free toothpaste
antiseptic mouthwash
name four aspects of management of MMP and PV in secondary dental setting
systemic therapy with corticosteroids
biologic medication
adjuvant topical corticosteroids
what are biologic drugs
recombinant proteins that intervene in immunological processes
give two two examples of biologic agents
etanercept
rituximab
how does rituximab work
binds to B cells and inhibits production of anti-desmosomal igG antibodies
what is erythema multiforme
cutaneous and mucosa type III and IV hypersensitivity reactions h
what drug is used to stimulate saliva in Sjogren’s syndrome
pilocarpine
what is a neuralgia
intense stabbing pain that is usually brief
pain extends along the course of the affected nerve
what are the three potential causes of trigeminal neuralgia
1) idiopathic
2) vascular compression of trigeminal nerve
3) multiple sclerosis, connective tissue disease, space occupying lesion
how does trigeminal neuralgia present
unilateral maxillary or mandibular division pain
stabbing pain
lasts 5-10 seconds
name three triggers of trigeminal neuralgia
wind/ cold
touch
chewing
what features of presentation would make you more concerned than usual for trigeminal neuralgia patient
less than 40
sensory deficit in facial region
other cranial nerve lesions
what are the three first line drugs for treatment of trigeminal neuralgia
carbamazepine
oxacarbazepine
lamotrigine
what are three examples of second line drug therapy for trigeminal neuralgia
gabapentin
pregabalin
phenytoin
how should trigeminal neuralgia be managed
use of carbamazepine
often difficult to control pain first thing in morning - avoid triggers at this time
pain diary
responsive to local anaesthesia
name side effects of carbamazepine
thrombocytopenia
neutropenia
pancytopenia
skin reactions
when would surgery be considered for trigeminal neuralgia treatment
when approaching maximum tolerable medical management even if pain controlled
younger patients with significant drug use
what are four surgical options for trigeminal neuralgia
microvascular decompression (MVD)
destructive central procedures
sterotactic radiosurgery
destructive peripheral neurectomies
name complications after trigeminal neuralgia surgery
sensory loss
motor deficits
what are trigeminal autonomic cephalagias
unilateral head pain predominantly over CN V1
what are prominent features of trigeminal autonomic cephalagias that occur on the same side as the headache
conjunctival injection
nasal congestion
eyelid oedema
ear fullness
miosis and ptosis (Horner’s syndrome)
what is ptosis
drooping or falling of the upper eyelid
what is miosis
a constricted pupil
what are cluster headaches
pain occurring mainly orbital and temporal regions
attacks unilateral
can last 15 mins to 3 hours
rapid cessation of pain
how do cluster headaches present
sharp burning or piercing pain on one side of face at same time of day
can happen multiple times a day
usually occurs in periods of 1-3 months with at least 1 month of remission in between
how is circadian periodicity related to cluster headaches
attacks occur at same time each day
bouts occur at same time each year
what is a chronic cluster headache
bouts lasting more than 1 year without remission
remission lasts less than 1 month
what is the difference between paroxysmal hemicrania and cluster headaches
pain lasts shorter in paroxysmal hemicrania
paroxysmal hemicrania not affected by circadian rhythm
what are examples of abortive medications for cluster headaches
subcutaneous sumatriptan
oral prednisolone
name preventative medications for cluster headaches
verapamil
lithium
CGRP monoclonal antibodies
what is the treatment options for paroxysmal hemicrania
no abortive treatment
prophylaxis is with indomethacin or COX-II inhibitors
what is oral dysaesthesia
abnormal sensory perception in absence of abnormal stimulus
name sensations a patient with oral dysesthesias might experience
burning or nipping feeling
dysgeusia
dry mouth
name predisposing factors for oral dysaesthesia
haematinic deficiencies
fungal/ viral infections
anxiety and stress
what is dysgeusia
bad taste/ smell/ halitosis
what must be ruled out when investigating dysaesthesias
infection
tumours
how is dysaesthesia managed
explain condition to patient
assess anxiety
drug therapy - anxiolytic vs neuropathic
what are examples of anxiolytic medication used for dysaesthesia
nortiptyline
vortioxetine
name two examples of neuropathic medication used to treat oral dysaesthesia
gabapentin/ pregabalin
clonazepam topical mouthwash
how are patients classified with TMD
if it is disease or disfunction
name four causes of TMD
occlusion
grinding
clenching stress
stress
what signs should be looked for in TMD
clicking joint
locking with reduction
limited mouth opening
tenderness of MOM
parafunction signs
what investigations are used for TMD pain
ultrasound
CBCT
MRI
arthroscopy
name five management strategies for TMD
CBT
bite splint and soft diet
tricyclic antidepressants
physiotherapy
acupuncture/ botox
name five possible non-dental causes of facial pain
oral malignancy
mucosal lesions
BMS
salivary gland pathology
what aspect of social history is thought to make TMD pain worse
smoking
what assessments can be used for facial pain
quality of life scores
HAD questionnaire
what is CRPS
chronic regional pain syndrome
delocalised pain
spreads around anatomical boundaries
bilateral
why may you experience shingle vesicles in the ear
CN VII supplies sensory part of the ear
