Oral Medicine Flashcards
What is Behçet’s disease?
“A rare disorder that causes blood vessel inflammation throughout your body.”
How is Behçet’s disease diagnosed from clinical intra-oral exam?
At least 3 episodes of aphthous ulceration in past 12 months, Plus at least two of:
- recurrent genital ulceration
- eye involvement
- skin lesions
- positive pathergy test
What is pathergy?
“ an exaggerated skin injury occurring after minor trauma such as a bump or bruise where ulceration or skin lesions may present and be resistant to healing.”
What are the two key features of Behçet’s disease?
- Pathergy
- Erythema nodosum
What is the management of recurrent aphthous stomatitis?
- SLS free toothpaste
- topical analgesic
- topical steroid
- diet modification- consider benzoate and cinnamon avoidance
- consider oral disease severity score
What types of topical therapy can dental practitioners working under the NHS prescribe to patients to help with aphthous ulceration?
- Analgesic mouthwashes
- Anti-microbial mouthwashes
- Topical steroids
Give three examples of analgesic medications/treatments that can be prescribed to treat aphthous ulcers on NHS?
- Benzydamine mouthwash or oromucosal spray
- Lidocaine ointment
- Lidocaine spray
Give two examples of antimicrobial mouthwashes that can be prescribed to treat aphthous ulcers on NHS?
- Chlorohexidine glauconate mouthwash
- Dispersible doxycycline tablet as mouthwash
Give three examples of topical steroids that can be prescribed to treat aphthous ulcers on NHS?
- Betamethasone soluble tablets (as mouthwash)
- Clenil modulie inhalation
- Hydrocortisone oromucosal tablets
What extremely important to establish before prescribing Betamethasone mouthwash to a patient suffering with recurrent aphthous stomatitis?
That the patient can spit it out and not swallow it. (If too much swallowed this can cause adrenal suppression)
What types of topical therapy can secondary care professionals prescribe to patients to help with aphthous ulceration?
- Topical steroids (varying potencies)
- Triple mouthwash (Betamethasone, doxycycline and nystatin suspension)
- Systemic medication (e.g. short course of prednisolone)
Where are common sites other than the mouth for lichen planus to occur?
- skin
- scalp
- oesophagus
- nails
- genitals
What are the 6 steps to initial management of lichen planus in primary care?
- Explanation of diagnosis
- Ask about other site involvement and refer if necessary
- Counsel re smoking cessation and alcohol moderation
- Advise of risk of oral cancer
- Baseline photographs
- Consider use of symptom severity measure (ODSS)
Does classical reticular lichen planus need referral?
No, this can be managed and monitored in dental practice every 6 months.
After diagnosis of lichen planus, what is the management?
- diet modification
- SLS free toothpaste
- topical analgesic
- topical steroid
- regular reviews, 6 monthly, potentially malignant mucosal disorder
Lichen planus has the same topical therapy treatment as recurrent aphthous ulceration, apart from one type of topical antimicrobial, which is this?
Doxycycline tablet mouthwash
What is the management of oral lichenoid reactions?
- liaise with GMP re medication
- consider placement of culpable restorative material (e.g. amalgam) with an alternative
- review 3 months (potential for malignant change higher than oral lichen planus)
Define, a blister >1cm in diameter that contains clear, serous, or haemorrhagic fluid.
Bulla
Define, a small blister <1cm in diameter that contains clear, serous, or haemorrhagic fluid.
Vesicle
What does rupture of a bulla/vesicle result in?
Development of an erosion/ulcer.
What two broad groups can vesiculobullous conditions be classified into depending on the level at which separation occurs?
- Intra-epithelial/epidermal (within epithelium/epidermis)
- Sub-epithelial/epidermal (below the basement membrane)
What are many of the vesiculobullous conditions a result of?
Production of antibodies against components of the epithelium or basement membrane zone
What two subgroups can intra-epithelial vesiculobullous conditions be further divided into?
- Acantholytic
- Non-acantholytic
Define, the separation of keratinocytes within the epidermis due to the loss of adhesion between keratinocytes (failure of the integrity of the intracellular/intraepidermal cell junctions).
Acantholysis
Name 4 acantholytic intraepithelial vesiculobullous conditions.
- Pemphigus vulgaris
- Pemphigus foliaceous
- Paraneoplastic Pemphigus
- Drug induced Pemphigus
Name 3 non-acantholytic intraepithelial vesiculobullous conditions (viral infections).
- Herpes simplex
- Herpes zoster
- Coxsackie infections
What intra-epithelial vesiculobullous condition is suggested from these clinical findings?
Flaccid (floppy) bullae/vesicles which rupture easily to leave areas of erosion and ulceration. A positive Nikolskys sign is an indicator.
Pemphigus vulgaris
Define a positive Nikolsky’s sign.
Where top layer of skin/mucosa can be removed with lateral rubbing leaving a moist base
In investigation of Pemphigus vulgaris, what two autoantibodies likely to be detected?
Desmoglein 3
Desmoglein 1
What is the gold standard investigation for detecting autoantibodies when investigating Pemphigus vulgaris?
Direct immunofluorescence (DIF)
What quantitative investigations provide a means of monitoring response to therapy and may be used for diagnostic purposes if:
- Patient does not wish to undergo biopsy
- biopsy is contra-indicated
- biopsy is non-diagnostic
IDIF and ELISA
What is the correct management of Pemphigus vulgaris?
- Recognition of signs and symptoms
- Prompt referral to secondary care
What local management can be implicated for Pemphigus vulgaris?
- Topical analgesic mouthwash (e.g. Gelclair)
- Topical steroids
What is the most commonly administered drug for systemic management of Pemphigus vulgaris?
Rituximab
The condition Pemphigus vulgaris is so rare, so why is it important to us as dentists?
- can be exacerbated by dental treatments or x-rays
- it is a life-threatening disease which we can hopefully detect early before complications arise
What Subepithelial vesiculobullous condition is suggested by these clinical features?
- Turgid (tense) bullae/vesicles which rupture to leave areas of erosion and ulceration. May be present as Desquamative gingivitis, confined to the gingiva.
- may have conjunctival involvement
Mucous membrane pemphigoid
Why is conjunctival involvement of mucous membrane pemphigoid particularly significant?
May result in scarring and loss of sight
What are the two investigations required for mucous membrane pemphigoid?
- Biopsy
- DIF
What is the local management of mucous membrane pemphigoid?
- topical analgesic mouthwash
- topical steroids
- good OHI
What systemic management is used for mild mucous membrane pemphigoid?
Doxycycline
What systemic management is used for severe mucous membrane pemphigoid?
- dapsone/prednisolone/ DMARD’s (e.g. Rituximab)
What is the main trigger for erythema multiforme (in 70% if cases)?
HSV
How can erythema multiforme be prevented in a patient with HSV?
Long term prophylactic herpes medication (aciclovir)
Name two orofacial pains attributed to lesion or disease of the trigeminal nerve.
- Trigeminal neuralgia
- Painful trigeminal neuropathies
Name two orofacial pains attributed to lesion or disease of the Glossopharyngeal nerve.
- Glossopharyngeal neuralgia
- Painful Glossopharyngeal neuropathies
Define, recurrent unilateral orofacial pain characterised by sharp shooting (electric shock like) pain that lasts seconds to minutes.
Trigeminal neuralgia
Define, orofacial pain characterised by lower intensity pain that is prolonged or continuous burning sensation.
Painful trigeminal neuropathy
Define, orofacial pain characterised by episodes of severe stabbing pain in the throat, tongue, tonsils and ears, can last several seconds to a few minutes.
Glossopharyngeal neuralgia
Define three orofacial pains that resemble presentations of Primary headaches.
Migraine
Tension type headache
Trigeminal autonomic cephalalgias
Define, a headache that can cause severe throbbing pain or pulsing sensation, usually on one side of the head.
Migraine
Define, the most common primary headache disorder with mild to moderate pain on both sides of the head.
Tension type headache (TTH)
Define, a primary headache characterised by trigeminal neuralgia with prominent autonomic features such as lacrimation (eye watering), rhinorrhoea (redness) and miosis (drooping of eyelids).
Trigeminal autonomic cephalalgias (TACS)
What sex and age range is most commonly affected by TN?
Females, 50-60 years old
What are the three types of trigeminal neuralgia?
- Classical (neurovascular compression with morphological changes in trigeminal nerve root)
- Secondary (caused by underlying disease)
- Idiopathic (diagnostic tests show no significant abnormalities)
What radiographic image is most suitable for investigation of Orofacial pains attributed to the trigeminal region?
MRI
What are the two most likely underlying diseases that could cause secondary trigeminal neuralgia?
- Attributed to multiple sclerosis
- Attributed to space occupying lesion (e.g. cyst or tumour)
If a patient presents with bilateral TN, what does this suggest about type of TN?
Most likely secondary TN
What are the 7 “red flags” in terms of oro-facial pain, that necessitate a more urgent referral to specialist services?
- Sensory or motor deficits
- Deafness or other ear problems
- Optic neuritis
- History of malignancy
- Bilateral TN pain
- Systemic symptoms (e.g. fever/weight loss)
- Presentation in patients under 30
What is the first line tx for trigeminal neuralgia that can be prescribed by GDP’s working under the NHS?
Carbamazepine
What is the alternative medication to carbamazepine appropriate for tx of trigeminal neuralgia where carbamazepine is contraindicated, not tolerated or doesn’t bring adequate pain relief?
Oxcarbazepine
Oxcarbazepine can be prescribed by GDP’s on the NHS. True or false?
False, should be prescribed by a specialist
What is the action of carbamazapine?
Binds to voltage dependent sodium channels thus inhibiting action potential generation
What two conditions other than TN, is carbamazepine licensed for use?
Epilepsy and bi-polar disorder
What are two very important considerations for safe prescribing of carbamazepine to patients?
- Do not prescribe for patients of Han Chinese or Thai origin as increases likelihood of Steven’s-Johnson syndrome
- Interactions with numerous substances- of special note: St John’s Wort, alcohol and grapefruit
What additional management to carbamazepine can NHS GDP’s prescribe for TN?
- lidocaine nasal spray, ointment or infiltration/block at trigger point
What are the two types of surgery for management of trigeminal neuralgia?
- Palliative destructive at the level of the grasserion ganglion
- Posterior cranial fossa surgery
What type of posterior cranial fossa surgery is the most frequently carried out surgery in the management of TN?
Microvascular decompression
What is the role of the GDP in management of trigeminal neuralgia?
- Diagnosis
- Exclusion of dentoalveolar pathology
- Initiate medical management in conjunction with GMP
- Refer
What other cranial nerve does Glossopharyngeal neuralgia involve, other than the Glossopharyngeal nerve (IX)?
Vagus nerve (X)
What is the investigation and systemic management of Glossopharyngeal neuralgia?
Investigations = high resolution MRI of head and neck
Systemic management = carbamazepine
What are the three types of painful trigeminal neuropathies?
- Painful trigeminal neuropathy attributed to the herpes zoster virus
- Trigeminal post-herpetic neuralgia
- Painful post-traumatic trigeminal neuropathy
Define the painful trigeminal neuropathy terminology:
“pain in response to stimulus which would not normally cause pain e.g. light touch”
Allodynia
Define the painful trigeminal neuropathy terminology:
“Increased response to a stimulus which would normally cause pain”
Hyperalgesia
Define the painful trigeminal neuropathy terminology:
“ reduction in response to a stimulus which would normally cause pain”
Hypoalgesia
Define the painful trigeminal neuropathy terminology:
“ increased cutaneous/mucosal sensitivity to a stimulus e.g. touch, temperature changes”
Hyperesthesia
Define the painful trigeminal neuropathy terminology:
“An unpleasant abnormal sensation affecting the skin or mucosa e.g. burning, tingling, crawling, stinging, pain”
Dysesthesia
How can you differentiate between painful trigeminal neuropathy attributed to the herpes zoster virus and Trigeminal post-herpetic neuralgia?
painful trigeminal neuropathy attributed to the herpes zoster virus is a facial pain of less than 3 months duration.
Whereas, Trigeminal post-herpetic neuralgia is a facial pain which persists and recurs for at least 3 months
What is the prevention of trigeminal post-herpetic neuralgia?
Antivirals (e.g. aciclovir) up to 72 hours following appearance of lesions of shingles
Evidence of causation is required to diagnose painful post-traumatic trigeminal neuropathy. What two factors should be assessed as evidence for causation?
- Pain is localised to the distribution of he trigeminal nerve affected by the traumatic event
- Pain has developed <6 months after traumatic event
Define this type of orofacial pain:
“unilateral or bilateral intra-oral or facial pain in the distribution of one or more branches of the trigeminal nerve for which the aetiology is unknown. The pain is usually persistent, of moderate intensity, poorly localised and described as dull, pressing or of burning character.”
Idiopathic orofacial pain
What are the three types of idiopathic orofacial pain?
- Persistent idiopathic facial pain
- Persistent idiopathic dentoalevolar pain
- Burning mouth syndrome
What are the 4 basic features common to members of idiopathic orofacial pain group?
- Daily pain
- > 2 hours duration per day
- For >3 months
- No apparent abnormality to account for symptoms
Conventional analgesics (e.g. paracetemol, NSAIDs, opioids) are usually ineffective against idiopathic facial pain. True or false?
True
What is the role of the GDP in the management of chronic orofacial pain?
- Good pain history
- Exclude dental causes
- Check cranial nerves, urgent referral if abnormalities
- Reassure, suggest some self-management technqiues
- Refer
What are the two therapy management strategies you can recommend to individuals with idiopathic orofacial pain,
- Cognitive behavioural therapy (CBT)
- Acceptance and commitment therapy (ACT)
What type of idiopathic orofacial pain is described?
“Persistent facial and/or oral pain, with varying presentations but recurring daily for more than 2 hours/day over more than 3 months, in the absence of clinical neurological deficit.”
Persistent idiopathic facial pain
What does ICHD-3 stand for and what is its use?
The international classification of headache disorders, comprehensive and evidence based system for diagnosing and classifying headache disorders.
What are the first line systemic treatments for management of idiopathic orofacial pain?
- Amitriptyline/nortryptyline
- Duloxetine
Why are Gabpentin and pregablin no longer first line tx for idiopathic orofacial pain according to NICE guidelines?
They are now controlled drugs as patients can develop dependency on these medications.
What type of idiopathic orofacial pain is described?
“Persistent unilateral intra oral dentoalveolar pain, rarely occurring in multiple sites, with variable features but recurring daily for more than 2 hours per day for more than 3 months, in the absence of any preceding causative event.”
Persistent idiopathic dentoalveolar pain
Define glossodynia.
Burning mouth syndrome where only tongue is affected
Define the type of idiopathic orofacial pain:
“ an intra-oral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day for more than 3 months, without evident causative lesions on clinical examination and investigation.”
Burning mouth syndrome
Why are post-menopausal women predisposed to burning mouth syndrome?
Evidence that in post-menopausal women there are changes in the peripheral nerves supplying the lining of the mouth and in particular the tongue, which may predispose these individuals to burning mouth syndrome.
What sites in the mouth are most commonly affected by burning mouth syndrome?
Tongue
Palate
Lips
What are the local causes that need to be excluded for diagnosis of burning mouth syndrome?
- parafunctional habits
- dry mouth
- GORD
- candidosis
What are the systemic causes that need to be excluded for diagnosis of burning mouth syndrome?
- anaemia
- haematinic deficiency
- diabetes
- thyroid dysfunction
- medication e.g. ACE inhibitors
What does NAD stand for?
No mucosal abnormality to account for symptoms
What topical treatment can you offer for management of burning mouth syndrome in primary care?
Benzydamine as mouthwash or oromucosal spray
What topical treatment can you offer for management of burning mouth syndrome in secondary care?
- capsaicin mouthwash
- clonazepam (do not swallow!)
