Oral Medicine Flashcards
1
Q
What is herpangina?
A
A sudden viral illness in children. It causes small blisters on the hard palate. It is often seen in babies and children under 10.
2
Q
What virus causes herpangina?
A
Coxsackie A
3
Q
What is the salivary flow rate that if under would indicate a problem?
A
<1.5ml in 15 mins
4
Q
Karposis sarcoma is associated with which virus?
A
HHV-8
5
Q
What blood test should be done to monitor carbamazepine?
A
Liver count
6
Q
What is the first drug of choice for trigeminal neuralgia?
A
Carbemazepine
7
Q
Squamous cell papillomas are commonly caused by which virus?
A
HPV
8
Q
Syphilis is caused by which of the following bacterium?
A
T. Pallidum
9
Q
What condition causes several well-marginated ulcers, fiery red gingivae and conjunctivitis. No skin conditions.
A
Mucous membrane pemphigoid
10
Q
What is Kopliks spots?
A
A prodromal sign of measles
11
Q
What form of candidiasis has a chance of developing into a malignancy?
A
Chronic hyperplastic candidiasis
12
Q
Name medications that can cause gingival overgrowth
A
- Cyclosporin
- Phenytoin
- Nifedipine
- Sodium Valproate
13
Q
Which virus causes hand, foot and mouth diseae?
A
Coxsackie
14
Q
What is the site of action for amoxicillin?
A
Disrupts bacteria cell wall so bacteria cannot replicate.
15
Q
What is the site of action in metronidazole in bacteria?
A
Inhibiting nucleic acid synthesis.
16
Q
What is the approximate INR for a healthy person not on any medications?
A
1
17
Q
Which bacteria is most commonly microorganism associated with infective endocarditis?
A
Staphylococci
18
Q
What is aplasia in salivary gland development anomaly?
A
Failure to develop normally- aplasia of salivary glands is very rare. It may occur as an isolated event or as part of hereditary syndrome e.g down syndrome.
19
Q
What is atresia in salivary gland developmental anomaly?
A
Failure to become tubular in ducts - very uncommon. Submandibular duct is most commonly affected when it does occur.
20
Q
What is a salivary mucoceale and name the 2 types.
A
- A mucocoele is a cystic cavity filled with mucous.
2 types:
1. Extravasation mucocoele (also called mucous extravasation cyst)
2. Retention mucocoele (also called mucous retention cyst).
21
Q
What is the clinical features of a Extravasation mucocoele?
A
- Presents as a bluish or transparent swelling
- Most commonly affects minor glands especially in the lower lip
- Occurs over a wide age range but most frequently seen in children and young adults
- Asymptomatic
- May discharge to only re-form
- Typically history of trauma associated with the lesion
- Due to ruptured duct with leakage of saliva into surrounding connective tissue
- Leaked saliva elicits an inflammatory reaction
22
Q
What is the histology of an extravasation mucocoele?
A
- Lesion appears as a cystic cavity filled with mucin in connective tissue
- Mucin is surrounded by inflamed granulation tissue, typically with lots of macrophages
- Not classed as a true cyst as no epithelial lining
23
Q
What is the treatment for an extravasation mucocoele?
A
Removal of all of the mucocoele (excision) together with associated ruptured duct and gland where possible to prevent recurrence.
24
Q
What is the clinical features of a retention mucocoele?
A
- Similary appearance as a extravasation mucocoele but less common
- Rare on the lower lip
- Can affect major and minor salivary glands
- Represents cystic dilatation of a duct typically due to obstruction
25
What is the histology of a retention mucocoele?
Mucin retained with a dilated duct
Cyst lining is epithelial lining of the duct
As saliva is retained within the duct and doesnt escape, there is much less inflammation
26
What is the treatment for a retention mucocoele?
Excision
27
What is a ranula and what are clinical features of this?
A ranula is a fluid collection or cyst that forms in the floor of the mouth. "Frogs-belly like"
- Presents as soft bluish swelling in floor of the mouth
- Unilateral
- 2-3cm in size
- Its an uncommon form of mucous extrvasation cyst arising from sublingual gland
- A "plunging ranula" arises when the mucin passes through and develops below the mylohyoid as swelling in the neck
28
What is the treatment of a ranula?
Drainage of the cystic cavity and removal of sublingual gland.
29
What is sialadenitis and what are the most common causes?
Inflammation of the salivary glands and most common causes are bacterial or viral infections.
30
What are the clinical features of acute bacterial sialadenitis?
- Parotid most often affected
- Decreased salivary flow is major predisposing factor
- Patients present with pain, swelling, tenderness, exudation of pus.
- Associated bacteria frequent Staphylococcus aureus, streptococci and anaerobes
31
What is the treatment for acute bacterial sialadenitis?
Appropriate antibiotics after culture/sensitivity testing.
32
What is the clinical feature of chronic bacterial sialadenitis?
-Usually secondary to duct obstruction
- Obstruction most frequently caused by stones/salivary calculi/mucous plugs (parotid)
- Submandibular gland most often affected
- Typically unilateral
- May be asymptomatic or may be intermittent painful swelling which is usually mealtime.
33
In what major salivary gland is most commonly affected by saliva stones?
Submandibular gland
34
What is saliva stones caused by?
Mineralisation of phosphates from supersaturated saliva being deposited around a central nidus of cell debris
- Calculi may form within ducts in the gland or in the main excretory duct.
35
What do saliva stones/calculi usually present as clinically?
- No symptoms until stone causes obstruction
- Typically unilateral pain/swelling, often at mealtimes.
- Calculi do not cause dry mouth however factors which increase saliva saturation e.g dry mouth can cause stones to form.
36
What is the treatment of saliva stones/calculi?
- Treatment varies depending on size and location of stones
- May be possible to remove or breakdown some stones. Alternatively it may be necessary to remove the gland, especially if it has become very damaged by longstanding infection.
37
What can be seen histologically in bacterial sialadenitis?
- The salivary acini become atrophic and are replaced by fibrous scar tissue.
- The salivary ducts within the gland become dilated and there is often hyperplasia of the duct epithelium
- A chronic inflammatory infiltrate with predominantly plasma cells and lymphocytes is seen within the gland
38
What can chronic bacterial sialadenitis result in from chronic inflammation?
Progressive chronic inflammation can result in almost complete replacement of salivary parenchyma by fibrous tissue. This can result in a firm mass within the gland which may be mistaken for a neoplasm.
39
What is the treatment for chronic bacterial sialadenitis?
- The gland may recover from sialadenitis if the associated obstruction can be removed.
- If more extensive sialdenitis, the obstruction and gland requires to be excised.
40
What is mumps?
Mumps is viral sialadenitis. It is an acute and contagious infection caused by paramoxyvirus. Spreads via saliva. Mumps causes painful swelling of parotids and other exocrine glands.
Patients also present with headache, fever, malaise.
41
What is HIV-associated salivary gland disease.
- May be the first clinical sign of HIV infection
- Causes swelling of the major saliva glands (most frequently parotid) and may be bilateral.
- Gland swelling is occasionally painful and soft to palpate.
- Multiple cysts are seen on imaging of the glands.
- Histopathology of glands shows multiple large cysts and dense lymphoid tissue. The features are suggestive but NOT definitely diagnostic.
42
What is necrotising sialometaplasia?
It is a rare, benign, self-limiting, reactive inflammatory disorder of the minor salivary gland mimicking a malignancy.
- More common in males than females
- More frequently seen in older patients and smokers
- It mainly affects minor salivary glands, especially those in hard palate
- Presents as a large, deep ulcer
- May be painful
- Slow to heal, often takes several weeks
43
What is the aetiology of nectrotising sialometaplasia?
Uncertain but it is likely to arise due to ischaemia or infarction secondary to trauma.
44
As necrotising sialometaplasia is suspicious for oral cancer a biopsy is often taken. What would the histopathology show in this case?
- Necrosis of salivary acini
- Inflammation and hyperplasia/metaplasia of salivary ducts.
- Changes in duct epithelium can again be mistaken for cancer.
45
What treatment is required for necrotising sialometaplasia?
None required, slows heals itself. Biopsy is usually curative.
46
What is Sjogrens syndrome?
An autoimmune disease of unknown cause characterised by lymphcytic infiltration and acinar destruction of lacrimal and salivary glands.
47
What are the 2 forms of Sjogrens syndrome and what are the clinical features of each form?
1. Primary Sjogrens syndrome - patients have dry eyes and mouth with no associated connective tissue.
2. Secondary Sjogrens - Patients have dry eyes and/or, a dry mouth and a connective tissue disease e.g rheumatoid arthritis.
48
In general what are the clinical features of Sjogrens syndrome?
- Onset of Sjogrens syndrome is in middle age
- Females are much more commonly affected than males
- Systemic symptoms include fatigue, joint pain, peripheral neuropathy
- Complications of dry mouth - caries, periodontal disease, difficulty with swallowing, speech, taste, predisposition to infection
- There may be a swelling of salivary glands esp parotid
- Eye problems due to dry eyes.
- Connective tissue disease in patients with secondary Sjogrens syndrome.
49
What do patients with primary Sjogrens syndrome have a increased risk of developing?
Increased risk of developing lymphoma in affected glands.
50
A combination of diagnostic tests are used in the diagnosis of Sjogrens Syndrome. Describe how a biopsy may be taken and would you would expect to find in Sjogrens.
1. Labial gland biopsy- taken from the lower lip. The biopsy aims to get around 5-8 minor salivary glands.
2. The biopsy is examined, in particular noting focal periductal collections of 50 or more lymphocytes
51
What is the management of Sjogrens syndrome?
- Multidisciplinary
- Systemic symptoms e.g joint pain, fatigue normally assessed and managed by Rheumatology.
- Opthamology for eye symptoms.
- Dry mouth: as for other causes of dry mouth e.g stimulation and replacement.
- Some saliva replacement products specifically licensed for Sjogrens.
- The systemic acetyl choline esterase inhibitor pilocarpine may be prescribed by specialists to stimulate saliva production in patients with Sjogrens.
- Caries prevention
52
What is sialadenosis?
- A non-inflammatory, non-neoplastic, bilateral, symmetrical swelling of the parotid glands
- Painless
- Associated with malnutrition, anorexia, bulimia, alcoholism, diabetes mellitus, certain drugs and hormonal disturbances.
- Results in hypertrophy of serous acini
- Not entirely understood but changes likely due to salivary gland innervation problem secondary to peripheral autonomic neuropathy.
53
What % of tumours in the mouth are in the minor salivary glands?
15-20%.
54
What % of major salivary gland tumours occur in the parotid?
90%
55
Name the most common malignant major salivary gland tumour
Mucoepidermoid carcinoma.
56
Name the most common benign major salivary gland tumour.
Pleomorphic adenoma.
56
Histologically what would you expect to see for a mucoepidermoid carcinoma?
The tumour is uncapsulated and has an infiltrative pattern of growth. It consists variable proportions of 3 types of tumour cell:
1. Mucous-secreting cells
2. Epidermoid
3. Intermediate
Tumours with high mucous cell numbers tend to be cystic whereas mainly epidermoid lesions tend to be more solid and often more aggressive.
57
What are the clinical features of pleomorphic adenoma?
- Accounts for approximately 60% of all parotid tumours
- Slightly more common in females than in males
- Occur at any age, peak incidence in 5th and 6th decades
- Benign, painless, slow growing, "rubbery" lump
- Usually solitary although recurrences may be multifocal
- Most are associated with gene PLAG1 or HMGA2 arrangements
58
What is the histology for pleomorphic adenoma?
Well-circumscribed tumour
Incomplete fibrous capsule (tumour nodules can be extended through capsule)
May be cystic
Variety of histological appearances with a complex intermingling of epithelial and myoepithelial components. Tumour epithelial cells differentiate into connective tissue type and can form connective tissue e.g cartilage and bone.
59
What is the treatment for pleomorphic adenoma?
Complete excision. If incompletely excised pleomorphic adenoma has a high recurrence rate.
Malignant transformation can occur in pleomorphic adenoma, usually in long standing lesions. Transformed tumours, called carinoma ex pleomorphic, are typically with high grade malignancies and poor prognosis.
60
Name causes of a dry mouth
- Medication related
- Dehydration
- Anxiety
- Mouth breathing
- Diabetes
- Radiotherapy
- Systemic disease e.g Sjogrens syndrome
- Diurnal variation
- Salivary gland aplasia
61
What scale is used when assessing oral dryness
Challacombe scale
62
What does score 1-3 mean in the Challacombe scale.
Mild dryness. Routine check up monitoring.
63
What does score 4-6 mean in the Challacombe scale?
Moderate dryness. Further investigations if not clear.
64
What does score 7-10 mean in the Challaombe scale?
Severe dryness. Cause needs to be determined, exclude Sjogrens syndrome. Refer.
65
What are some clinical signs of a dry mouth?
- Mirror sticking to mucosa
- Lobulated tongue
- Saliva frothy
- No saliva pooling FOM
- Glossy appearance of oral mucosa esp palate
- Cervical caries
- Altered ginigval architecture
- Debris on palate or sticking to teeth
66
What are some additional findings that you may see in the mouth that are caused by a dry mouth?
- Angular chelitis
- Erythematous mucosa
- Thrush
- Denture stomatitis
- Traumatic ulceration
- Poor denture retention
- Bacterial sialadenitis
67
How long should you do an unstimulated saliva flow rate and what is considered normal and significantly reduced?
15mins
Normal >0.2ml/min
Significantly reduced rate <0.1ml/min
68
What would the management be in a patient that score 1-3 on the Challacombe scale.
May not need treatment, sugar free chewing gum, attention to hydration
69
What would the management be in a patient that scores 4-6 on the Challacombe.
Sugar free gum or sialogogues. Consider saliva substitutes and topical fluoride.
70
What would the management be in a patient that scores 7-10 on the Challacombe.
Saliva substitutes and topical fluoride.
71
What can you advise a patient to take to stimulate saliva flow.
- Sugar free chewing gum/sweets
- Artificial saliva pastilles
- Saliva- stimulating tablets
72
What systemic treatment can be prescribed to treat dry mouth?
Pilocarpine
73
What saliva replacement options you can prescribe to a patient?
Sprays:
- Neutral pH, electrolyte composition, fluoride
- Glandosane
- Saliveze
Gels:
- Contain antimicrobials e.g lactoferrin, lactoperoxidase
-Biotene oral balance saliva replacement gels.
74
What are the 2 concentrations of sodium fluoride toothpaste you can give to a patient of high caries risk (severe dry mouth)
0.619% 2800ppm
1.1% 5000ppm
75
What is the name for when strands of gelatinous milky white material removable by wiping, secondary to mucosal irritation and mouthwashes.
Epitheliolysis.
76
How would you manage epitheliolysis
SLS free toothpaste and cease mouthwash.
77
What white lesion is described as a "white plaque that cannot be removed by rubbing/scraping, may have a shaggy surface, appear macerated or be associated with ridging, clinical appearance should match cause".
Frictional keratosis
78
What local analgesics can you prescribe for pain from geographic tongue?
- Benzydamine oromucosal spray 0.15%
- Benzydamine mouthwash 0.15%
- Lidocaine ointment 5%
- Lidocaine spray 10%
79
What genetic mutation causes white sponge nevus.
Keratin 4 and 13.
80
What type of hypersensivity is a lichenoid reaction?
Type IV
81
Name 4 drugs that can induce oral ulceration.
1. Nicorandil
2. Methotrexate
3. Bisphosphonates
4. NSAID's
82
What is RAS and what are the 3 types?
Recurrent apthous stomatitis.
Major
Minor
Hepetiform
83
What other systemic disease have been linked to RAS?
- Coeliac disease
- Chronic Inflammatory bowel disease (Crohns disease)
- Haematinic deficiencies such as anaemia.
84
Define acantholysis.
"The separation of keratinocytes within the epidermis due to the loss of adhesion between keratinocytes"
85
Name some acantholytic intra-epithelial vesiculobullous lesions
- pemphigus vulgaris
- pemphigus follaceous
- drug induced pemphigus
86
Name some non-acantholytic intra-epithelial vesiculobullous lesions.
- viral infections e.g herpes simplex, herpes zoster, coxsackie.
87
What autoantibodies are associated with pemphigus vulgaris?
Desmoglein 1 and 3. These autoantibodies are usually IgG class.
88
How are vesiculobullous lesions diagnosed?
Direct immumofluoresense
89
What is Nikolskis sign?
Present in pemphigus vulgaris - this is demonstrated when lateral pressure is applied on the border of an intact blister, which results in the dislodgement of the normal epidermis and extension of the blister.
90
Name examples of sub-epithelial vesiculobullous diseases.
1. Erythema multiforme
2. Pemphigoid e.g mucous membrane pemphigoid, bullous pemphigoid
3. Dermatitis herpetiformis
4. Epidermolysis bullosa acquisita
5. Angina bullosa haemorhagica
6. Bullous lichen planus
91
What are clinical features of mucous membrane pemphigoid?
Tense bullae/vesicles which rupture to leave areas of erosion and ulceration. All areas of oral mucosa may be affected. May be confined to the gingivae and present as desquamative gingivitis.
92
What other site involvement may be present in mucous membrane pemphigoid?
Conjunctivits is of particular involvement as results in scarring which may lead to loss of sight. All patients should be assessed by an opthamologist.
Other sites: nasal, genital, larynx, oesophagus and skin.
93
What are the 2 major antigens associated with mucous membrane pemphigoid?
BP 180
Laminin-332
94
What is the aetiology of geographic tongue?
Uncertain- increased in patients who suffer from psoriasis
95
What are the signs/symptoms and clinical features of geographic tongue?
signs/symptoms:
- can be asymptomatic or symptomatic (symptoms only when eating such as spicey foods)
Clinical features:
- Well defined area of erythema, yellow/white/cream border, all surface of tongue.
96
How would you manage geographic tongue?
SLS free toothpaste
Modify diet
Cease mouthwash use
Local analgesia's
97
What is the aetiology of leukoedema??
? secondary to low grade mucosal irritation causing intracellular oedema.
98
What are the signs/symptoms and clinical features of leukoedema?
Signs/symptoms: usually asymptomatic.
Clinical features: buccal and labial mucosa filmy grey/white appearance, soft on palpation.
99
What is stomatitis nicotina?
The inflammation of the minor salivary glands present due to chronic smoking habit. Not a potential malignant disorder.
100
What is Behcets disease?
A rare disorder that causes blood vessels inflammation throughout your body. It can causes ulceration in the mouth, eye inflammation and skin rashes and lesions.
101
What would you expect to see in minor recurrent apthous stomatitis? (MiRAS)
Small (<1cm), multiple ulcers that have yellow floors and typically heal within 2 weeks. Affects non-keratinized sites within the mouth.
102
What would you expect to see in major recurrent apthous stomatitis? (MaRAS)
Ulcers typically 1-3cm in diameter, occuring either singly or 2-3 at a time and usually last for 4-6 weeks. Any oral site may be affected.
103
What would you expect to see in herpetiform recurrent apthous stomatitis?
The number of ulcers is often increased and often involves as many as 50 lesions
104
How should you manage RAS in all cases?
- Exclude haemitinic deficiencies e.g FBC (ferritin, vitamin B12, folate).
- Exclude systemic involvement e.g Crohns, Coeliac disease.
- Dont forget to ask re diet - may be secondary to poor iron intake
- Symptom management e.g local analgesics.
105
What is Sicca Syndrome?
Dry mouth and dry eyes without the diagnosis of Sjogrens syndrome.
106
What is the classification for orofacial pain?
International Classification for Orofacial Pain 2020 (ICOP)
107
What is the 6 groups of Orofacial pain in ICOP?
1. Orofacial pain attributed to disorders related to dentoalveolar and anatomically related structures
2. Myofascial orofacial pain
3. Temporomandibular joint pain
4. Orofacial pain attributed to lesion or disease of the cranial nerves
5. Orofacial pains resembling presentations of primary headaches
6. Idiopathic orofacial pain.
108
What further 2 groups can be "Orofacial pain attributed to lesion or disease of the cranial nerves" be divided into?
1. Pain attributed to lesion or disease of the trigeminal nerve
2. Pain attributed to lesion or disease of the glossopharyngeal nerve
109
What are 2 disorders of "Pain attributed to lesion or disease of the trigeminal nerve"?
1. Trigeminal neuralgia
2. Painful trigeminal neuropathies
110
What are 2 disorders of "Pain attributed to lesion or disease of the glossopharyngeal nerve"?
1. Glossopharyngeal neuralgia
2. Painful glossopharyngeal neuropathies
111
What 4 categories can "Orofacial pains resembling presentations of primary headaches" be divided into?
1. Migraines
2. Tension type headaches (TTH)
3. Trigeminal autonomic cephalalgias (TAG)
4. Other primary headache disorders
112
What 3 categories can "Idiopathic Orofacial Pain" be divided into?
1. Burning mouth syndrome
2. Persistent Idiopathic Facial Pain (PIFP)
3. Persistent idiopathic dentoalveolar pain
113
Give a description of the pain in trigeminal neuralgia.
- Recurrent unilateral brief electric shock like pains
- Abrupt in onset and termination
- Limited to one or more of the divisions of the trigeminal nerve and triggered by innocuous stimuli
- May develop without apparent cause or be a result of another diagnosed disorder.
- There may be concomitant continuous pain of moderate intensity.
114
Describe the diagnostic criteria (ICHD) required for diagnosis of trigeminal neuralgia
A: Recurrent paroxysms of unilateral facial pain in the distribution(s) of the trigeminal nerve with no radiation beyond.
B: Pain has all of the characteristics:
- electric shock like, shooting or stabbing in quality
- severe intensity
- lasting from a fraction of a second to 2 minutes
C: Precipitated by innocuous stimuli within the affected trigeminal distribution
D: Not better accounted for by another ICHD-3 diagnosis
115
What is usually the provoking factors in trigeminal neuralgia?
Chewing, talking, touching, cold.
116
What are the 3 different types of trigeminal neuralgia?
1. Classical
2. Secondary
3. Idiopathic
117
Give a description of classical trigeminal neuralgia and the diagnostic criteria.
Description: Trigeminal neuralgia developing without apparent cause other than neurovascular compression
Diagnostic criteria:
A: - recurrent paroxysms of unilateral facial pain fulfilling criteria for trigeminal neuralgia
- Demonstration on MRI or during surgery of neurovascular compression, with morphological changes within the root
118
Why is the trigeminal root end zone a particular area of vulnerability for trigeminal neuralgia?
- Is the point where the central and peripheral myelins of Schwann cells and astrocytes meet
- Morphological changes results in abnormal firing of the nerve
119
What is classical trigeminal neuralgia with concomitant continuous pain?
Trigeminal neuralgia with persistent background facial pain
120
Give a description and a diagnostic criteria for secondary trigeminal neuralgia.
Description: Trigeminal neuralgia caused by an underlying disease. Clinical examination shows sensory changes in a significant proportion of these patients.
Diagnostic criteria:
A: Recurrent paroxysms of unilateral facial pain fulfilling criteria for trigeminal neuralgia, either purely paroxysmal or associated with continuous pain.
B: An underlying disease has been demonstrated that is known to be able to cause, and explaining the neuralgia.
C: Not better accounted for by another ICHD diagnosis
121
Name 3 groups that can be sub-categorised from secondary trigeminal neuralgia.
1. Trigeminal neuralgia attributed to multiple sclerosis (demyelination of sheaths)
2. Trigeminal neuralgia attributed to space occupying lesion (eg cyst, tumour)
3. Trigeminal neuralgia attributed to other causes
122
Give a description and diagnostic criteria for idiopathic trigeminal neuralgia.
Description: Trigeminal neuralgia with neither electrophysiological tests nor MRI showing significant abnormalities.
Diagnostic criteria:
A: Recurrent paroxysms of unilateral facial pain fulfilling criteria of trigeminal neuralgia, either purely paroxysmal or associated with continuous pain
B: Neither classical or secondary trigeminal neuralgia has been confirmed by adequate investigation including electrophysiological tests and MRI
C: Not better accounted for another ICHD disorder.
123
Idiopathic trigeminal neuralgia can either be purely paroxysmal or can be associated with concomitant continuous pain. True or false?
True.
124
What are some clinical features that are "red flags" that may prompt you to send an urgent referral to specialist services with regards to trigeminal neuralgia?
- Bilateral symptoms of trigeminal neuralgia
- sensory or motor deficits
- deafness or other ear problems
- history of malignancy
- optic neuritis
125
What is the first and second line medication for trigeminal neuralgia?
First line: Carbamazepine
Second line: Oxcarbazepine
126
Give a description of carbamazepine.
- Brand name is Tegretol
- Anti-convulsant used for epilepsy and bipolar disorder
- Binds to voltage dependent sodium channels which inhibits its action potential generation
- Metabolized in the liver by enzymes e.g CYP3A4
- Excreted predominantly in urine
127
Name contra-indications/cautious when prescribing carbamazepine.
1. Han Chinese or Thai origin
2. Pregnancy- congenital marformations
3. Herpatic and renal impairment - caution and monitoring
4. Cross sensitivity with other anti-convulsants
5. Interactions with herbal medicines such as St. Johns Wart, grapefruit and alcohol.
128
What should patients or their carers be given specific advice about when prescribing carbamazepine?
How to recognize disorders of skin, liver and bone marrow.
Immediate medical attention is required if rash, fever, mouth ulcers, bruising or bleeding develops.
129
Why are baseline blood tests important to be carried out and how often should these be done after prescribing carbamazepine?
- Baseline blood tests should be carried out as has adverse affects on liver, renal and bone marrow function.
- Prior to commencing carbamazepine or straight after the medication has started. Then weekly for the first 4 weeks. After this every 1 to 3 months.
130
What is the dosage regime for carbamazepine?
- 100mg twice daily for 1-3 days
- review
- if necessary increase by 100mg every 2 days, introducing lunchtime and afternoon doses if needed.
- therapeutic range 800 to 1200mg per day
- once pain free for 4 weeks reduce dose.
131
What additional support can you offer a patient with dealing with trigeminal neuralgia?
- Psychological support
- Role of nurse specialists
- National support groups
132
Give examples of surgical management for trigeminal neuralgia.
Palliative destructive at the level of the grasserion ganglion:
- radiofrequency thermocoagulation
- glycerol rhizolysis
- balloon compression
- gamma knife
Posterior cranial fossa surgery
- Microvascular decompression
- partial sensory rhizotomy
- internal neurolysis
133
What are indications for surgical management of trigeminal neuralgia?
- Medications ineffective
- Medications not tolerated
- Medication contra-indicated
- Adverse impact on quality of life
134
What would be the surgical management of choice in classical trigeminal neuralgia
Microvascular decompression as there is compression of the trigeminal
135
What would the surgical management of choice be in idiopathic trigeminal neuralgia?
- Neuroablative procedure
136
Give a descrption for glossopharyngeal neuralgia.
"A disorder characterized by unilateral brief stabbing pain, abrupt in onset and termination, in this distributions not only of the glossopharyngeal nerve but also of the auricular and pharyngeal branches of the vagus nerve. Pain is experienced in the ear, base of tongue, tonsillar fossa, and/or beneath the angle of the jaw. It is commonly provoked by swallowing, talking or coughing and may remit and relapse in the fashion of trigeminal neuralgia."
137
What is the diagnostic criteria for glossopharyngeal neuralgia?
A: Recurrent paroxysmal attacks of unilateral pain in the distribution of the glossopharyngeal nerve and fulfilling criteria B
B: Pain has all of the following characteristics:
- lasting from a few seconds to 2 minutes
- severe intensity
- electric shock-like, shooting, stabbing or sharp in quality
-precipitated by swallowing, coughing, talking, or yawning.
C: Not better accounted for by another ICHD disorder.
138
What are the subcategories of glossopharyngeal neuralgia?
1. Classical
2. Secondary
3. Idiopathic
139
What are special investigations used for diagnosing glossopharyngeal neuralgia?
same as for TN - MRI imaging but lower to include base of tongue and neck
140
What systemic management of glossopharyngeal neuralgia?
Carbamazapine
141
What are the 3 sub-categories of painful trigeminal neuropathies?
1. Painful trigeminal neuropathy attributed to herpes zoster virus
2. Trigeminal post-herpetic neuralgia
3. Painful post-traumatic trigeminal neuropathy
142
Define allodynia.
Pain experienced in respose to a stimulus that would not normally cause pain e.g light touch
143
Define hyperalgesia.
Increased response to a stimulus which would normally cause pain e.g cold.
144
Define hypoalgesia.
Reduction in response to a stimulus which would normally cause pain.
145
Define hyperesthesia
Increased mucosal/sensitivity to a stimulus e.g temperature change.
146
What is dysesthesia?
An unpleasant abnormal sensation affecting the skin e.g burning, tingling, stinging.
147
Give a description for pain trigeminal neuropathies.
- The primary pain is usually continuous or near-continuous, and commonly described as burning and squeezing or likened to pins and needles
- There are clinically detectable sensory deficits within the trigeminal distribution, and mechanical alloydynia and cold hyperalgesia are common, fulfilling IASP criteria for neuropathic pain
148
Give a description of painful trigeminal neuropathies attributed to herpes zoster virus.
Unilateral facial pain of less than 3 months duration in the distribution(s) of one or more branches of the trigeminal nerve, caused by and associated with other symptoms and/or clinical signs of acute herpes zoster.
149
Give a description of trigeminal post-herpetic neuralgia.
Unilateral facial pain persisting and recurring for at least 3 months in the distribution(s) of one or more branches of the trigeminal nerve with variable sensory changes, caused by herpes zoster.
150
What can be done to prevent and manage painful trigeminal neuropathy related to herpes zoster virus?
- Vaccines available of herpes zoster virus (70-79 years)
- Antivirals up to 72 hours following appearance of shingles
- Management by paracetamol and codeine
151
Give a description and diagnostic criteria for painful post-traumatic trigeminal neuropathy
Description: Unilateral or bilateral facial or oral pain following and caused by trauma to the trigeminal nerve(s) with other symptoms and/or clinical signs of trigeminal dysfunction
Diagnostic criteria:
A: History of an identifiable traumatic event to the trigeminal nerve(s) with clinically evident positive (hyperalgesia/allodynia) and/or negative (hypoesthesia, hypoalgesia) signs of trigeminal nerve dysfunction
B: Evidence of causation demonstrated by both of the following:
- Pain is localized to the distribution(s) of the trigeminal nerve(s) affected by the traumatic event
- Pain has developed <6months after the traumatic event
*some potential in symptom overlap with persistent idiopathic facial pain*
152
Give a description for "idiopathic orofacial pain"
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 localized and described as dull, pressing or burning in character.
153
What are the 3 sub-categories of idiopathic orofacial pain.
1. Persistent idiopathic facial pain
2. Persistent idiopathic dentoalveolar pain
3. Burning mouth syndrome.
154
In general describe the pain that patients would feel in idiopathic orofacial pain.
Daily pain
>2 hours duration per day
had for >3months
no apparent abnormality to account for symptoms.
155
What systemic medications can be prescribed in secondary care for management of idiopathic orofacial pain?
- Amitriptyline
- Duloxetine
- Fluoxetine
156
What is important in management to idiopathic orofacial pain in addition to topical/systemic medications?
Ensuring you are considering pyschological aspect.
Self management techniques such as relaxation, distraction, mindfulness etc.
157
What is the diagnostic criteria for persistent idiopathic facial pain?
A: Facial and/or oral pain fulfilling criteria B and C
B: Recurring daily for >2 hours/day for >3 months
C: Pain has both of the following characteristics
- Poorly localized, and not following the distribution of a peripheral nerve
- dull, aching, or nagging quality
D: Clinical neurological examination is normal
E: A dental cause has been excluded by appropriate investigation
F: Not better account for by another iCHD diagnosis
158
What are the clinical features of persistent idiopathic facial pain?
- F>M
- 14-19% bilateral
- Constant daily pain
- Some pain free months
- Pain is deep poorly localized, nagging, burning or gripping
- Provoking factors are stress, cold, chewing, head movements
- Relieving factors are warmth, pressure, medication
- Associated factors are dental treatment, psychiatric conditions.
159
What is the role of the GDP for facial pain?
- Exclude dental cause
- check cranial nerves
- reassure, suggest some self management techniques
- refer
160
What investigations would be carried out (if any) in secondary care for persistent idiopathic facial pain?
MRI/CT/CBCT may be considered if:
- pain has neuropathic components such as TN symptoms
- If sensory deficit detected
- If abnormality detected on checking cranial nerves
- If in doubt reg diagnosis
161
What are some examples of topical treatments that can be prescribed in secondary care to patients with persistent idiopathic facial pain?
- lidocaine ointment
- lidocaine patches
- capsaicin cream
- levomenthol cream
162
What systemic management can be prescribed in secondary care to patients with persistent idiopathic facial pain?
- Amitriptyline
- Duloextine
163
What is the risk when prescribing pregabalin or gabapentin for pain control?
Patients have been known to developing dependency on these drugs therefore amitriptyline/duloxetine are the preferred choice.
164
Give a description for persistent idiopathic dentoalveolar pain.
Persistent unilateral intraoral dentoalveolar pain, rarely occuring in multiple sites, with variable features for more than 2 hours per day for more than 3 months, in the absence of any preceding causative event.
165
Describe the diagnostic criteria for persistent idiopathic dentoalveolar pain.
A: Intraoral dentoalveolar pain fulfilling criteria B and C
B: Recurring daily for >2 hours per day >3 months
C: Pain has both of the following characteristics
- Localized to a dentoalveolar site
- Deep, dull, pressure like quality
D: Clinical and radiographic examinations are normal and local causes have excluded
E: Not better accounted for by another ICOP or ICHD diagnosis
166
What are some provoking factors of persistent idiopathic dentoalveolar pain?
hot and cold, dental treatment, pressure on tooth
167
What are some relieving factors for persistent idiopathic dentoalveolar pain?
warmth, pressure, medication
168
What are associated factors with persistent idiopathic dentoalveolar pain?
bruxism, emotional problems, hypersensitivity to hot and cold, anxiety or depression, hypotensive therapy.
169
What is the diagnostic criteria for burning mouth syndrome?
A: Oral pain fulfilling criteria B and C
B: Recurring daily > 2 hours per day for > 3 months
C: Pain has both of the 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, ICHD diagnosis.
170
What are examples of systemic causes that have to be ruled out to get a diagnosis of burning mouth syndrome?
- anaemia
- haematinic deficiency
- diabetes - uncontrolled or poorly controlled
- thyroid dysfunction
- medication e.g ACE inhibitor
171
What can you prescribe in primary care for management of pain for burning mouth syndrome?
- benzydamine as mouthwash or oromucosal spray (Difflam)
172
What is prescribed in secondary care for management of pain in burning mouth syndrome?
- Capsaicin mouthwash
- Clonazepam
- Amityiptylline
- Duloxetine
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