Oral Medicine

Question 1

Which of the following would be the most appropriate initial course of action in an 80 year-old man presenting with an ulcerated lesion in the anterior denture-bearing region?
a. Constuct new dentures
b. Ease dentures
c. Excisional biopsy
d. Incisional biopsy
e. urgent referral to maxillofacial unit

Answer 1

B. Ease of dentures
It is most commonly denture trauma. It will need to be eased and then reviewed in 2 weeks. If it has not improved, then referral is appropriate.

Question 2

Which area of the mouth is most commonly affected by burning mouth syndrome?
a. Hard palate
b. Lips
c. Retromolar region
d. Soft palate
e. Tongue

Answer 2

E. Tongue
Burning mouth is most frequently reported in the tongue (80% of patients).

Question 3

What demographic are most likely to develop burning mouth syndrome?
a. Post-menopausal women
b. Men > 50 years old
c. Pregnant women
d. Caucasian women under 60 years old
e. People of working class

Answer 3

A. Post-menopausal women
It seems to affect people of all races and socioeconomic backgrounds

Question 4

Which of the following is most commonly associated with an oral diagnosis of Crohn disease?
a. Clusters of ulceration
b. Dysaesthesia of the tongue
c. Mucosal blistering
d. Mucosal tags
e. Swollen lips

Answer 4

D. Mucosal tags
Although ulceration and swollen lips can also be present in patients with Crohn disease, the tissue diagnosis from mucosal tags will be what is diagnostic

Question 5

Which of the following medications is most likely to be associated with a dry mouth?
a. Aspirin
b. Atenolol
c. Bendroflumethazide
d. Captopril
e. Nicorandil

Answer 5

C. Bendroflumethazide
Bendroflumethazide is a thiazide diuretic, which is mainly used to treat hypertension. Diuretics (such as Bendroflumethazide) make you loose circulating volume and occasionally a patient can loose too much and become dehydrated.

Question 6

A patient presents with angular cheilitis, and you decide to perform some haematological investigations. Which of the following tests is not relevant to angular cheilitis?
a. Full blood count
b. Fasting venous glucose
c. Vitamin B12
d. Liver function tests
e. Ferritin

Answer 6

D. Liver function tests
Some studies have shown that 50% of patients with angular cheilitis have haematological abnormalities. Anaemia and diabetes are the most common of these and liver function tests are irrelevant.

Question 7

Which of the two following haematological abnormalities are most commonly associated with angular cheilitis?
a. Diabetes
b. Leukemia
c. Myeloma
d. Haemophilia
e. Anaemia

Answer 7

A and E: Diabetes and Anaemia

Question 8

Which of the following drugs is inappropriate for the treatment of angular cheilitis?
a. Aciclovir
b. Nystatin
c. Miconazole
d. Fluconazole
e. Amphotericin

Answer 8

A. Aciclovir
Aciclovir is an anti-viral agent and is mainly used for the human herpes virus. The rest are anti-fungals:
Nystatin, amphotericin and miconazole are used topically. Amphotericin can be used systemically (although isnt often used as it has many side effects). Fluconazole can be used systemically.

Question 9

Target lesions are associated with which of the following conditions?
a. Steven-Johnson syndrome
b. Major aphthous stomatitis
c. Pemphigus
d. Pemphigoid
e. Syphilis

Answer 9

A. Steven-Johnson Syndrome
Steven-Johnson Syndrome produces target lesions on the skin which look like “bull’s eyes”. This reaction is frequently caused by drug reactions, especially to sulphonamides. Patients can be systemically unwell, and more often than not require admission.

Question 10

What is the male to female ratio of the prevalence of recurrent aphthous stomatitis/ulceration?
a. 3:1
b. 2:1
c. 1:1
d. 1:2
e. 1:3

Answer 10

C. 1:1
Recurrent aphthous ulceration occurs equally in males and females

Question 11

What is the best treatment for mumps?
a. Aciclovir
b. Prednisolone
c. Augmentin
d. Clarithromycin
e. Nothing

Answer 11

E. Nothing
Mumps is a self-resolving condition that requires no treatment. It usually settles down after two weeks, but patients need to be aware that complications of mumps include orchitis or oophoritis which can lead to infertility.

Question 12

What is the male to female ratio of burning mouth syndrome?
a. 7:1
b. 3:1
c. 1:1
d. 1:3
e. 1:7

Answer 12

E. 1:7
Females are far more likely to develop burning mouth syndrome than males

Question 13

What is the mean age of presentation of burning mouth syndrome?
a. 18 years
b. 25 years
c. 40 years
d. 60 years
e. 80 years

Answer 13

D. 60 years
Burning mouth syndrome has a mean age of presentation of 60 years and is rarely seen in people younger than 45.

Question 14

Which of the following is not a common cause of burning mouth syndrome?
a. Vitamin B complex deficiency
b. Haematological disorders
c. Undiagnosed type II diabetes
d. Anaemia
e. Xerostomia

Answer 14

D. Anaemia
There are many other causes of burning mouth including: Vitamin B complex deficiency; haematological disorders; undiagnosed type II diabetes; xerostomia; parafunctional habits; poorly constructed dentures; cancerphobia; anxiety; depression; climacteric; and allergies.
It is important to investigate these patients haematologically and psychologically.

Question 15

A child of 14 months presents with blood-crusted lips, pyrexia (fever) and widespread ulceration. What is the most likely diagnosis?
a. Teething
b. Traumatic injury
c. Primary herpetic gingivostomatitis
d. Hand, foot and mouth
e. Human papilloma virus

Answer 15

C. Primary herpetic gingivostomatitis
A traumatic injury would be possible, but it is unlikely as the child has pyrexia. Teething would not cause blood crusted lips. HPV does not cause this.

Question 16

Which of the following are appropriate treatment(s) for primary herpetic gingivostomatitis?
a. Aciclovir
b. Fluconazole
c. Paracetamol
d. Antiseptic mouthwash
e. Clarithromycin

Answer 16

A+C+D
The appropriate treatment for primary herpetic gingivostomatitis is aciclovir, antiseptic mouthwash and paracetamol (for the fever). The child should also be discouraged from touching the lesion and their fluid intake should be increased.

Question 17

Which of the following does not cause reactivation of the herpes simplex infection?
a. Stress
b. Sunlight
c. Immunosuppression
d. Local trauma
e. Dental caries

Answer 17

E. Dental caries
Common triggers for the herpes simplex virus are: stress; local trauma; exposure to sunlight or cold; menstruation; systemic upset and immunosuppression.

Question 18

A 12 year old child who has had chickenpox previously presents with vesicles in and around his left ear, hearing loss and some facial nerve weakness. What is the diagnosis?
a. Herpes simplex 1 reactivation
b. Herpes simplex 2 reactivation
c. Ramsay-Hunt syndrome
d. Coxsackie viral infection
e. Infectious mononucleosis

Answer 18

C. Ramsay-Hunt syndrome
Ramsay-Hunt originates in the geniculate ganglion of the seventh cranial nerve and is associated with the varicella zoster infection.
Treatment is usually steroids and antivirals, to reduce the chance of permanent hearing loss.

Question 19

What is the usual prescription of aciclovir given to patients with acute herpes simplex infection?
a. 200mg twice daily for 5-10 days
b. 200mg three daily for 5-10 days
c. 200mg four daily for 5-10 days
d. 200mg five daily for 5-10 days
e. 200mg six daily for 5-10 days

Answer 19

D.
Aciclovir is one of the unusual medicines that is required to be taken five times daily

Question 20

A 70 year old patient presents with systemic upset, a unilateral headache around the temporal region, and severe cramp-like pain when the patient begins to chew. They have never had symptoms like this before. What is your diagnosis?
a. Paroxysmal facial hemicrania
b. Giant cell arteritis
c. Periodic migrainous neuralgia
d. Salivary calculi
e. Trigeminal neuralgia

Answer 20

B. Giant cell arteritis
This is a classic presentation of giant cell arteritis, which can be a medical emergency. It requires the prompt administration of prednisolone to prevent the onset of blindness.

Question 21

What would be the best blood test to aid your diagnosis of Giant Cell Arteritis?
a. Full blood count
b. Liver function tests
c. Erythrocyte sedimentation rate (ESR)
d. Vitamin B12
e. International normalised ratio (INR)

Answer 21

C. ESR
Erythrocyte Sedimentation Rate (ESR) is a marker of inflammation, and this will be markedly raised in patients with giant cell arteritis.

Question 22

A 15 year old patient presents with pyrexia (fever), sore throat and bilateral parotitis. However, on palpation of the parotids, the saliva is clear, and there is no xerostomia. What is the most likely diagnosis?
a. Measles
b. Mumps
c. Bacterial parotitis
d. Sjogren’s disease
e. Cytomegalovirus

Answer 22

B. Mumps
Sjogren’s disease is possible, however, there is no reduced saliva flow in this patient. Bacterial parotitis would produce pus-filled saliva (so it would not be clear). It would also be unusual to have bilateral bilateral bacterial parotitis.

Question 23

Which of the following viruses is associated with Kaposi’s sarcoma?
a. Human herpes virus 1
b. Human herpes virus 2
c. Varicella zoster virus
d. Cytomegalovirus
e. Human herpes virus 8

Answer 23

E. Human herpes virus 8
Kaposi’s sarcoma is an acquired immune deficiency syndrome (AIDS) - related illness associated with human herpes 8. It has three forms: classic, endemic and epidemic.

Question 24

A patient present with a unilateral, electric shock-like pain along the course of the mandible. He says it happens when he shaves, and it is the worst pain he has ever had. What is your likely diagnosis?
a. Temporomandibular joint dysfunction
b. Trigeminal neuralgia
c. Dental abscess
d. Parotitis
e. Paroxysmal facial hemicrania

Answer 24

B. Trigeminal neuralgia
This is a classic presentation of trigeminal neuralgia.

Question 25

What would be the best medication for trigeminal neuralgia?
a. Dothiepin
b. Fluoxetine
c. Carbamazepine
d. Prednisolone
e. Amitriptyline

Answer 25

C. Carbamazepine
Carbamazepine is the treatment of choice for trigeminal neuralgia. Patients are usually started on 100mg three times a day and then require an increased dose after a month or two.
Prednisolone is a steroid, used for many conditions but not neuralgia. The other drugs are more effective in patients with atypical facial pain.

Question 26

Which of the following blood tests are important when monitoring patients taking carbamazepine?
a. Vitamin B12
b. Ferritin
c. Erythrocyte sedimentation rate
d. Liver function tests
e. Serum folate

Answer 26

D. Liver function tests
Carbamazepine is metabolised in the liver and can lead to altered liver function and can cause drug-induced inflammation of the liver (hepatitis). It can also cause aplastic anaemia in a few patients, so a full blood count is also useful.

Question 27

What does a ferritin blood test check?
a. Blood insulin
b. Calcium levels
c. Blood oxygen
d. Iron levels
e. Clotting rate

Answer 27

D. Iron
Ferritin is a blood protein that contains iron. This test can be used to find out how much iron the body stores. If a ferritin test shows that the blood ferritin level is low, it means the body’s iron stores are low

Question 28

An 18 year old girl presents with a grossly enlarged lower lip, angular cheilitis, full-width gingivitis, mucosal tags and cobblestone mucosae. What is the most likely diagnosis?
a. Allergic reaction leading to anaphylaxis
b. Lichenoid reaction
c. Erythema multiforme
d. Orofacial granulomatosis (OFG)
e. Lichen planus

Answer 28

D. Orofacial Granulomatosis
An incisional biopsy down to muscle will show that this patient has non-caseating granulomas and lymphoedema, which are indicative of OFG.
It is associated with benzoates, and patients with OFG frequently have a large intake of these substances. Patients with OFG also show a tendency to have atopic conditions such as eczema and asthma.

Question 29

Which substance(s) is OFG closely associated with?
a. Cinnamon
b. Gluten
c. Benzoates
d. Lactose
e. Nickel Allergy

Answer 29

A and C

Question 30

Which gastrointestinal condition is commonly associated with orofacial granulomatosis?
a. Ulcerative colitis
b. Crohn’s disease
c. Coeliac disease
d. Irritable bowel disease
e. Hirschsprung’s disease

Answer 30

B. Crohns disease
Crohn’s disease has the same histological features as OFG and is present in 12% of patients with OFG.

Question 31

In patients who truly have an allergic reaction to local anaesthetic, which one of the following is the most likely cause?
a. Lidocaine
b. Adrenaline
c. Octapressin
d. Methylparaben
e. Sodium chloride

Answer 31

D. Methylparaben
Methyparaben is the preservative in local anaesthetics and is the most common cause of allergic reactions in patients. Occasionally sodium bisulphite is used as a preservative and this too can cause an allergic reaction. It would be highly unlikely that the patient is allergic to adrenaline as the body produces it.

Question 32

Which of the following does not predispose a patient to candidosis?
a. Currently taking a broad spectrum antibiotic
b. Taking prednisolone daily
c. Agranulocytosis
d. Stress
e. Folic acid deficiency

Answer 32

D. Stress
All the other are predisposing factors to candidosis

Question 33

What condition is Wickham’s striae associated with?
a. Pseudomembranous candidosis
b. Chronic hyperplastic candidosis
c. Lichenoid reactions
d. Lichen planus
e. White sponge naevus

Answer 33

D. Lichen Planus
Lichen planus is a systemic as well as oral disease. It is actually more commonly found extra-orally. Wickham’s striae are irregular, itchy, white streaks on the flexor surfaces of the forearms, elbows and ankles.

Question 34

Which of the following antibodies is NOT associated with Sjogren’s syndrome?
a. Anti-Ro
b. Anti-La
c. Rheumatoid factor
d. Anti-nuclear antibodies
e. Anti-smith antibodies

Answer 34

E. Anti-Smith Antibodies
Anti-smith antibodies are associated with systemic lupus erythematosus.

Question 35

Sjogren’s syndrome is associated with other autoimmune diseases (CREST). Which one of the following is not involved in CREST syndrome?
a. Calcinosis
b. Raynaud’s phenomenon
c. Rheumatic fever
d. Oesophageal dysmotility
e. Telangiectasia

Answer 35

C. Rheumatic Fever
Patients with Sjogren’s syndrome frequently have other autoimmune disorders.

Question 36

Which of the following is not a common presentation of Sjogren’s syndrome?
a. Xerostomia
b. Dysphasia
c. Arthritis
d. Xerophthalmia (dry eyes)
e. Trismus

Answer 36

E. Trismus
Xerostomia is the most common presentation, but they may have other systemic diseases which are linked to this. It is important to ask them if they have cold fingers, difficulty swallowing and arthritis, and to look for telangiectasia (dilation of capillaries).

Question 37

A 75 year old lady with a history of gastric cancer who has been clear of the disease for 25 years presents to you with a red, raw, beefy tongue, oral ulceration, tachycardia, numbness in the extremities and an unusual gait.
What is the most likely diagnosis?
a. Iron-deficiency anaemia
b. Vitamin B12 deficiency
c. Recurrence of gastric cancer
d. Brain tumour
e. Alzheimer’s disease

Answer 37

B. Vitamin B12 Deficiency
Having had gastric cancer previously, it is likely that the patient has a reduced amount of intrinsic factor, and therefore reduced absorption of Vitamin B12. As she has been clear of cancer for 25 years it is unlikely that she has had a recurrence or a brain tumour. Vitamin B12 deficiency leads to the classic red, raw beefy tongue, oral ulceration and peripheral neuropathy.

Question 38

Which of the following drugs does not cause a lichenoid reaction?
a. Beta-blockers
b. Gold
c. Allopurinol
d. Nifedipine
e. Anti-malarials

Answer 38

D. Nifedipine
Nifedipine causes gingival hyperplasia not a lichenoid reaction

Question 39

Which one of the following conditions/lesions is not caused by viruses?
a. Koplik’s spots
b. Herpetiform ulceration
c. Herpes labialis
d. Hand, foot and mouth disease
e. Herpangina

Answer 39

B. Herpetiform Ulceration
Herpetiform ulceration means that the ulcers look like herpes but are not caused by the herpes virus. Hand, foot and mouth disease and herpangina are caused by coxsackie virus. Koplik’s spots are associated with measles.

Question 40

Which of the following is not a type of lichen planus?
a. Plaque-like
b. Atrophic
c. Hyperplastic
d. Erosive
e. Reticular

Answer 40

C. Hyperplastic

Question 41

In which age group does lichen planus usually occur?
a. 0-18 years
b. 18-30 years
c. 30-50 years
d. 50-70 years
e. 70+ years

Answer 41

C. 30-50 years

Question 42

Approximately what percentage of people with lichen planus skin rash develop white streaks on the inside of their cheeks, gums or tongue?
a. 20%
b. 30%
c. 40%
d. 50%
e. 60%

Answer 42

D. 50%
These white streaks on the oral mucosa are usually painless and not itchy and may not be noticed unless looked for. Sometimes lichen planus of the mouth occurs without any skin rash.

Question 43

If temporal arteritis is left untreated, what is the most serious complication?
a. Blindness
b. Deafness
c. Anosmia
d. Paralysis of the muscles of mastication
e. Loss of taste

Answer 43

A. Blindness

Question 44

Which one of the following is not described in a classical history of trigeminal neuralgia?
a. 10/10 pain
b. Shooting or electric shock-like pain
c. There is a trigger factor
d. It is bilateral
e. Occurs in the region of the mandibular branch of the trigeminal nerve

Answer 44

D. It is bilateral
Trigeminal neuralgia is a neuropathic disorder of the trigeminal nerve that causes episodes of intense pain in the eyes, lips, nose, scalp, forehead and jaw. The pain is unilateral.

Question 45

What age does trigeminal neuralgia normally develop?
a. Before 30 years of age
b. Between 30-40 years of age
c. Between 40-50 years of age
d. After 50 years of age
e. During puberty

Answer 45

D. After 50 years of age
Trigeminal neuralgia usually develops after the age of 50 and it is more common in women. Although, there have been some cases of trigeminal neuralgia in patients as young as 3 years old.

Question 46

To which virus does the varicella zoster belong?
a. Coxsackie
b. Herpes
c. Hepadnavirus
d. Parvovirus
e. Respiratory syncytial virus (RSV)

Answer 46

B. Herpes
Varicella zoster infection leads to chickenpox (varicella), which may result in complications including encephalitis and pneumonia.

Question 47

What percentage of cases of the varicella zoster viruses reactivate later in life?
a. 0-10%
b. 10-20%
c. 20-30%
d. 30-40%
e. 40-50%

Answer 47

B. 10-20%
Varicella Zoster infection leads to chickenpox. Even when the clinical symptoms of chickenpox has resolved, the varicella zoster virus remains dormant in the nervous system. In about 10-20% of cases, varicella zoster reactivates later in life to cause a disease known as herpes zoster or shingles.

Question 48

A boy presents with bilateral parotitis. What is the most likely diagnosis?
a. Sjogren’s syndrome
b. CREST
c. Salivary calculi
d. Mumps
e. Hand, foot and mouth

Answer 48

D. Mumps
Painful swelling of the salivary glands (especially the parotid) is the most typical presentation. Painful testicular swelling and rash may also occur. The symptoms are not usually severe in children. In adolescent boys and men, complications such as infertility or subfertility are more common (although are still rare).