Oral Medicine Flashcards
What do we use to treat primary herpetic gingivostomatitis
Self limiting usually but if immunocompromised or severe pain can prescribe ACICLOVIR 200MG 1 TABLET 5X DAY FOR 5 DAYS
25 TABLETS
What is herpes labialis and what can we do for this?
cold sore
can provide aciclovit 5% cream 2g, to be put on sore every 4 hours 5x day for 5 days and can be used for up to 10 days
What is varicella zoster?
Shingles
Tx: 800mg acilovir 1 tablet to be taken 5x day for 7 days
What are anti-fungals used for?
fungal infections including thrush (acute pseudomembranous candidiasis), chronic atrophic candidiasis (denture stomatitis)
What is the prescription for miconazole?
Miconazole gel 20mg/g, 80g tube, apply pea sized amount to lesion/upper denture after food 4x day
What is the prescription for fluconazole?
50mg fluconazole capsule
1 capsule a day for 7 days
What is the prescription for nystatin?
Nystatin oral rinse 100,000 units/ml 30ml, use 1ml after food 4x day for 7 days, retain for 5 minutes then swallow
What is angular chelitis normally caused by in:
- denture ts
- dentate pts
- denture pts = fungal infection
- dentate pts = bacteria
What is the tx for angular chelitis?
in fungal cases - MICONAZOLE CREAM 2%, 20G TUBE, APPLY TO ANGLES OF MOUTH 2X DAY FOR 10 DAYS AFTER LESIONS HAVE HEALD (this can be used for both fungal and bacterial)
in bacterial cases - sodium fusidate 2% - 15g, apple 4x day to lesions
Why is the mucosa pink/red?
Due to underlying BVs/CTs that are diluted by overlying epithelium
What are the different reasons for white lesions?
Hereditary - oral sponge navus
smokers keratosis
frictional keratosis
lichen planus
candida leukoplakia
carcinoma
What is leukoplakia?
Dx of exclusion = it is where there is no histopathological connotation and not associated with malignancy - no known cause
What are fordyces spots?
ectopic sebaceous glands - benign - nothing to worry about, normal structure
What is frictional keratosis?
This is where there is an obvious source of trauma, repeated trauma from sharp tooth, denture etc leads to deposition of keratin - 2 week review!!
What is smokers keratosis?
This is where the chemicals in cigs irritate the mucosa resulting in deposition of keratin - there is also over production of melanin by melanocytes as a rxn to trauma
What is idiopathic keratosis?
Inc keratin deposition with no known cause
Why may pt have white chemical burn in oral mucosa?
use of aspirin/alendronic acid in buccal sulcus, dissolved rather than swallowing (pt thinks this will help pain but it will not
What is acute pseudomembranous candidosis
thrush
caused by Candida albicans
fungal infection
common in - corticosteroid inhaler users, diabetics, immunocompromised, broad spectrum abx users
advice:
-rinse after inhaler
-spacer
-diabetic control
What is chronic atrophic candidiasis?
Denture stomatitis - red chance over denture covering area
What are some red flags for white lesions?
rolled borders
bleeding
raised
thickened
inflammatory margin - white lesion with red margin
unknown cause, lateral border of tongue, floor of mouth
What % of white lesions become cancerous?
1% - very low risk but we will keep pt under review and if any changes pt will be referred
Patient has white patch on FOM, discuss this with the pt and the need for a biopsy. Discuss RF
OSCE Q!
Explain that from clinical exam we have noticed you have a white lesion on the floor of your mouth - this is just under your tongue, have you noticed this before?
There are many causes for a white lesion and these include trauma, being hereditary, due to smoking. The majority of these lesions are harmless and usually cause no problems so I dont want you to worry however there are a small number of these lesions that canoe more serious and potentially cancerous
Due to the lesion being on the floor of mouth I would like to refer this to oral medicine as this area is a higher risk. I am aware this can be scary but I would rather it was seen by a specialist. This is also due to the fact you have additional risk factors including smoking and drinking.
What I will do is make an urgent referral to OM so they can see you quickly to examine the lesion - it is likely they will take a biopsy so this can be sent to the lab to investigate and know the exact cause as unfortunately we cant determine this without a biopsy. It is important to try not to worry and the aim of this test is to rule out anything sinister.
Explanation of appt - at the appt they will do an initial examination then they may carry out. abiospy - this is where they numb you up similar to getting a filling done, they will then take a small sample and afterwards place a few stitches to close this area up.
What to expect after biopsy? after having the biopsy you may feel like you have an ulcer when the area is healing - there may be pain bleeding bruising swelling and there is a risk of infection but OM will discuss this with you
RF - as we have previously discussed the risk factors for oral cancer include smoking and alcohol - it is very important you consider reducing/quitting in order to reduce this risk - have you every considered quitting smoking/drinking - I think this would be very beneficial fo your health
Any Qs?
OSCE STATION!!
Pt is diabetic and takes warfarin - O/E you notice the palate is red and inflamed and pt wears upper denture - sore to wear, tests have be done and confirm diagnosis of chronic erythematous candidiasis - explain the findings, recognise multifactorial cause and then provide OHI
Explain - from clinical exam and history you have a red mark on the roof of your mouth in the shape of the denture - from history and then tests conducted you have something known as chronic erythematous candidosis - this is a fungal infection that can happen in pts who wear dentures and also is common in those with diabetes. it results in your mouth being sore and painful with a red area of irritation where your denture normally is.
Wearing a denture and also being diabetic increases your chances of having this infection. In terms of your diabetes how well controlled is this?
Denture qs - how are you getting on with denture? cleaning routine? do you take it out at night?
PT ON WARFARIN - RELEVANT FOR PX
MANAGEMENT - in terms of managing this condition there are several ways we can manage this - firstly we want to make sure you leave the denture out at night to allow your tissues to breathe, it is also important to clean your denture several times a day (morning and night) - if acrylic can use sodium hypohclorite, soft brush and soap, leave in water over night, clean/rinse after mealtimes
OH - brushing palate nightly
Ask pt if this all makes sense and if any qs? also important to ensure diabetes is well controlled
If prescription needed we can give nystatin oral rinse –> 100/000 units/ml, 30ml, 1ml 4x day after food, retain for 5 mins then swallow
CHX 0.2% 300ml, 10ml 2x day for 1 minute then spit
if persistent the can consider new denture or if fit poor
If remaking denture for pt who has chronic erythematous candiasis what can we do?
We can reline denture with Coe-soft to provide relief and allow condition to heal so we can then take primary imps when pt no longer inflamed/in pain
What are some red lesions?
Denture related red lesion (chronic eryethamtous candidiasis)
Geographical tongue
Erythleukoplakia
Vascular Hameratoma
Pigmented lesions
external causes - CHX, tea, coffee, red wine, bacterial overgrowth
racial
reactive mealnosis - smoking (triggers melanocytes to produce melanin resulting in small areas of melanosis
melanoma - cancer
drugs - tetracycline - can stimulate melanin production by melancoytes
Addisons disease
localised - am tattoo
Red flag for red lesions?
FOM, lateral border of tongue, soft palate
rolled margins
ulcerated
bleeding
inc in size
pain
2 WEEK CANCER PATHWAYS
What is lichen planus?
Lichen planus is a chronic oral disease - it is an inflammatory condition that can affect the lining of the mouth and skin. the cause is not fully known and it affects around 1% of the population
How does lichen planus look?
white patches on inside of cheeks, tongue, gums, roof of mouth
What are some causes of lichen planus?
idiopathic
drugs
systemic disease
inflammatory rxn
herpes zoster
stress can make it worse
What are the main types of LP?
Reticular
Atrophic
Ulcerative
What is reticular LP?
lace like, web pattern on mucosa, underlying mucosa normal
What is atrophic LP?
this is where there is mucosal atrophy, there is a yellow fibrous covering at the base (if it is so atrophic that there is no epithelium it is known as ulcerative)
What is ulcerative LP?
Loss of epithelium, painful lesions, fibrous tissue covering CT
Symptoms of LP?S
Often can be none
burning sensation
sensitivity to hot/spicy foods
pain if ulcerative type of LP
Where else can be affected with LP apart from orally?
Skin
Genitals
Scalp
Nails
Where is most common site for LP orally?
Buccal mucosa - days to biopsy
gingival - very red look, may look like gum disease but no gum disease, excellent OH
tongue - can be due to amalgam trigger - check tongue at rest
lips
palate
How do we describe LP if:
- known cause
- no known cayse
LTR to … (amalgam, antihypertensive medication)
Idiopathic LP
What is a Lichenoid drug reaction?
This is where there is a widespread lesion throughout oral mucosa - it is often bilateral and mirrored and has a poor response to topical steroids as is caused by the drug!!
What is an amalgam related LTR?
This is where the amalgam filling is responsible for the LP, lesion is closely associated with amalgam - remove AM and replace with comp to see if LTR improves - on NHS pt will pay Am fee for comp due to LTR
What is the management of Lichen planus?
If suspected/known cause –> remove cause
if unclear –> biopsy –> send to lab for histopathological investigation
consider blood testing for haematinic deficiencies (ferritin, folate, bit b12)
Management of mild/intermittent lesions?
Often no tx needed - pt can use simple OTC remedies such as CHX 0.2%, 300ml, 10ml 2x day for 1 min then spit
benzydamine mouthwash
avoid SLS toothpaste as this can be a trigger for LP
If above not successful then we can use:
- beclomethasone inhaler (0.5mg puff, 2x 2-3 times a day)
-betematason MW (1mg/10ml - 2x day)
What can we tell pt about LP activity?
LP has intermittent periods of activity - there may be ties where you are asymptomatic and require no management or other times where you have a flare up of symtoms and may require to use OTC remedies or prescription from us
What can OM prescribe for LP?
Higher strength topical steroids
Tacrolimus
Systemic immunomodulators - aziothiorpine
What is the chance LP becomes cancerous?
1% chance - very low and rare however we will monitor the lesion and if any changes then we can refer onto OM for specialist opinion - condition is a spectrum - ranges from asymptomatic white patches, to painful erosive/ulceraruve areas that tend to have higher risk of malignancy
OSCE STATION
Pt has been dx with lichen planus - explain what this is, the causes and tx
Lichen planus is a chronic oral condition that is inflammatory - it is a very common condition seen in oral medicine that affects your mouth and can also affect your skin - it results in white patches like the ones you have in your mouth
The cause of the condition is not fully understood however it can be a result of a reaction to a drug, to silver fillings or it can also be idiopathic which means there is no known cause
In terms of management - the management of the condition depends on how much this condition affects you - lichen planus is a condition that can go through periods where you are asymptomatic and require no treatment however at other times can be painful or uncomfortable and require tx
Tx includes:
- OTC CHX - 0.2% 300ml, 10ml 2x day
-Benzdyamine MW 0.15% - NSAID mouthwash
- Avoid SLS toothpaste as this can trigger condition
If these are not effective we can prescribe topical steroids in the form of either a mouthwash or inhaler (beclometasone inhaler (0.5mg - 2 puffs 2-3x day or betametasone MW - 1mg/10ml 2x day for 1 minute)
if still not effective then we can refer you to OM who can prescribe stronger topical steroids
It is important to be aware that there is a very small chance that these lesions can become cancerous - around 1% in 10 years so the risk is very low however it is important we regularly review this lesion and if any change the we will refer you and a biopsy may be taken. The condition is a spectrum condition that goes from asymptomatic white lesions to symptomatic ulcerative lesions that tend to have a high risk of malignancy
Do you have any qs?
What are the 4 types of candida?
Acute pseudomembranous candidiasis - thrush
Chronic atrophic candidiasis - denture stomatitis
Chronic hyperplastic candidais - malignancy risk, normally in oral commissures
Acute erythematous candidiasis - HIV, broad spectrum abx
What is tx for candida infections?
Fluconazole capsules -50mg 1 capsule each day for 7 days
miconazole gel 20mg/g, 80g tube, pea sized, 4x day after food, 7 days after healed
Nystatin oral rinse - 100,000units/ml, 1ml 4x day after food, 5 mins and then swallow
OSCE STATION
Pt has chronic hyperplastic candidosis - discuss cause and management
Explain - on examination and from biopsy result you have something known as chronic hyperplastic candidiasis - this is a fungal infection which is caused by a fungus known as Candida albicans. It results in white lesions commonly seen on the corners of the lips (angles the mouth)
This is a types of lesion we want to keep under review as it has the potential to progress to cancer - this is very rare and there is a low risk however still imprint we monitor and refer to OM who may want to biopsy the lesion to rule out anything sinster and keep you under rvirew - important not to worry about this as the risk is low
Risk factors that contribute to this conditon include smoking, alcohol, steroid inhaler, deficiencies (haematicnic def), dry mouth, diabetes, abx use, dentures
Management of condition:
- if pt uses inhaler - inhaler use advice
- if denture - denture advice
-smoking cessation advice
-refer to OM for biopsy
-monitor
-if poor OH, CHX
prescription of anti-fungal
MICONAZOLE GEL - 20MG/G, 80G TUBE, APPLY PEA SIZED AMOUNT TO LESION 4X DAY
Red flag sites for OC?
FOM
Soft palate
tongue - lateral border
retromolar regions
