Oral medicine Flashcards
4.1 a) A 50-year-old patient presents with a brown lesion on the palatal mucosa. What characteristics would make you think it was a malignant melanoma?
i) Position – most common on the palate
ii) Colour – usually dark brown or black (although is it possible for some to be non-pigmented or red)
iii) Age – commonest between 40-60 years of age
iv) Often asymptomatic
v) The lesions are often firm and rubbery to touch. They are macular or nodular and may ulcerate.
vi) They may cause an enlarged node(s), may bleed or become sore – although these are often late presentation.
4.1 b) How would you manage this patient?
i) If suspicion of malignant melanoma, and urgent incisional biopsy is indicated to gain a tissue diagnosis, so the patient must be referred urgently to a suitable clinician
4.1 c) What is the prognosis for such lesion?
i) Poor prognosis; median survival is about 2 years.
4.1 d) What else could the lesion be if it is a single brown lesion in the palate?
i) Endogenous focal pigmentation
(1) Oral naevi
(2) Melanotic macule
(3) Malignant melanoma
(4) Oral melanoacanthoma
ii) Exogenous focal pigmentation
(1) Tattoo on oral mucosa
(2) Foreign bodies e.g. amalgam fragments embedded in tissue (amalgam tattoo)
(3) Heavy metals e.g. mercury.
(4) Smoking – smoker’s melanosis
(5) Drugs – minocycline, oral contraceptive pill, arsenic, heroin drug use.
4.1 e) If the patient had presented with multiple small brown lesions in the mucosa, what could have been the cause?
i) Oral melanocytic macules (ephelis)
ii) Racial pigmentation
iii) Addison’s disease
iv) ACTH producing tumours
v) Physiological pigmentation
vi) Peutz-Jeghers syndrome
vii) Post inflammatory melanin incontinence.
4.2 a) A 50-year-old woman presents to your surgery complaining of a dry mouth. What are the common causes of dry mouth?
i) Developmental – aplasia/atresia
ii) Salivary gland disease – Sjogren’s syndrome (primary/secondary), sarcoidosis, HIV infection, iatrogenic, drug-induced, radiotherapy, graft versus host.
iii) Psychogenic – oral dysaesthesia/burning mouth syndrome, anxiety and depression
iv) Dehydration – systemic febrile illness, diarrhoea, diabetes mellitus and insipidus, renal failure.
v) Alcohol
vi) Mouth breathing
vii) Iatrogenic drugs – anticholinergic, sympathomimetic or diuretic activity.
(PISSDD)
- Psychogenic – anxiety, exam stress
- Irradiation to head and neck
- Salivary gland disease (PISSSC)
o Primary biliary cirrhosis
o Infection – Hep C, HIV, EBV
o Salivary aplasia
o Sarcoidosis
o Systemic disease – diabetes, COPD, chronic renal disease
o Sjogrens disease
o Cystic fibrosis
- Systemic diseases
- Drugs – antihistamines, anti-hypertensives, anti-parkinsons
- Dehydration
4.2 b) How would you determine the cause of dry mouth?
i) Take the usual history from patient including c/o, HPC, MH, DH, SH.
ii) Ask specific questions:
(1) When do they feel their mouth is dry?
(2) What have they done to help the situation? E.g. frequent sips of water
(3) Difficulty eating/talking?
(4) Sore/burning mouth?
(5) Altered taste?
iii) Systemic questions:
(1) General health and well-being
(2) Any relevant medical conditions e.g. the above mentioned autoimmune diseases/diabetes/cancer.
iv) E/O:
(1) Look for swelling/enlargement of salivary glands, in particular parotid glands.
(2) Angular cheilitis
(3) Dry cracked lips
v) I/O:
(1) Lobulated/fissured tongue
(2) Candida
(3) Stringy saliva or parchment dry mouth
(4) New carious lesions
vi) Investigations:
(1) Salivary flow rate / sialometry
(2) Schirmer test (Sjogren’s)
(3) Urinalysis/blood glucose (diabetes)
(4) Antinuclear antibodies (ANA), SSA (Anti-Ro), SSB (Anti-La) to exclude Sjogren’s and sarcoidosis
(5) Rheumatoid factor (Sjogren’s)
(6) Erythrocyte sedimentation rate (Sjogren or sarcoid but non-specific marker)
(7) Serum immunoglobulin levels (connective tissue disease but non-specific)
(8) Labial gland biopsy
(9) Imaging (sialography/ultrasound/MRI) if lump
4.2 c) What are the dental concerns in such a patient?
i) Development of new carious lesions. Try to discourage these patients from using sugar-containing chewing gum or acidic sweets to help encourage saliva production.
ii) Consider fluoride mouthwash.
iii) Candidal infection may be present and require treatment.
iv) Might have difficulty retaining dentures.
v) Increased plaque
vi) Altered taste
4.3 a) List four possible aetiological factors for recurrent aphthae.
i) Genetic predisposition
ii) Immunological abnormalities
iii) Haematological deficiencies – Ferritin, Folate B12 deficiencies
iv) Stress
v) Hormonal changes
vi) Gastrointestinal disorders
vii) Infections
GDHIV
1. GI disease (IBD (UC or Chron’s), coeliac disease)
2. Drugs e.g. NSAIDS
3. Haematological disease (anaemia + haem deficiencies (iron, B12, folate)
4. Immune deficiency (AIDS)
5. Vasculitis (Bechet’s and SLE)
4.3 b) What types of recurrent aphthae are there? How do you differentiate between the types? (e.g. size, location, number)
i) Minor aphthae – singly or in crops (2-6) and they affect non-keratinised and mobile mucosa. They are usually less an 4mm diameter, <1cm. Last up to 10 days. Heal with no scarring.
ii) Major aphthae – Single or in crops (1-10), which may be greater than 1cm in diameter. Keratinised and non-keratinised mucosa. Masticatory mucosa and dorsum of tongue are often affected. May last 1 months or longer. Heal commonly with scaring.
iii) Herpetiform aphthae – small pin-point ulcers with 1-3mm diameter. Usually occur in crops of ulcers (10-100s), although they may coalesce to form larger ulcers. They occur in non-keratinised and keratinised mucosa. Heal in 7 to 10 days. Heal with no scarring.
4.3 c) How may recurrent aphthae be treated?
i) Treat underlying systemic disease
ii) Benzydamine (Difflam) mouthwash
iii) Corticosteroids (Betnesol mouthwash)
iv) Tetracycline mouthwashes
v) Chlorhexidine mouthwash
vi) Avoid SLS containing toothpaste
vii) Benzoate, cinnamon additive avoidance diet.
(1) Simple mouthwash
(a) Warm saltwater
(b) Sodium chloride
(2) Antimicrobial mouthwash
(a) Chlorhexidine 0.2%
(b) Hydrogen peroxide 6% mouthwash
(c) Doxycycline dispersible tablets
(3) Local analgesics
(a) Benzydamine, 0.15% MW
(b) Benzydamine oral mucosal spray, 0.15%
(c) Lidocaine ointment 5%
(d) Lidocaine spray 10%
(4) Topical corticosteroids
(a) Clenil Modulite (beclometasone dipropionate) 50micrograms/metered inhalation
(b) Betnesol (betamethasone) soluble tablets 500 micrograms.
(c) Hydrocortisone oromucosal tablets
4.4 a) What is angular cheilitis (stomatitis)?
i) Inflammation of the skin and the labial mucous membrane at the commissures of the lips.
4.4 b) How does angular cheilitis differ from actinic cheilitis?
i) Actinic cheilitis is a premalignant condition in which keratosis of the lip is caused by ultraviolet radiation from sunlight.
4.4 c) List three predisposing factors for angular cheilitis.
i) Wearing dentures and having denture-related stomatitis
ii) Nutritional deficiencies e.g. iron deficiency
iii) Immunocompromised
iv) Decreased vertical dimension resulting in infolding of the tissues at the corner of the mouth allowing skin to become macerated.
4.4 d) Which organisms commonly cause angular cheilitis?
i) Candida albicans, staphylococcus aureus, MRSA.
4.4 e) What medicaments could be used to treat this?
i) Miconazole gel and fusidic acid cream.
1) Miconazole cream 2%.
2) Sodium Fusidate Ointment 2%
3) For unresponsive cases: Miconazole (2%) and Hydrocortisone (1%) cream or ointment.
4.5 a) Acute pseudomembranous candidiasis or thrush is a presentation of candidal infection in the mouth. List four other ways in which candidal infections may present to a dentist.
i) Acute erythematous candidiasis – “antibiotic sore mouth”
ii) Chronic erythematous candidiasis – “denture stomatitis”
iii) Chronic hyperplastic candidiasis – “Candida leukoplakia”
iv) Median rhomboid glossitis
v) Angular stomatitis
4.5 b) What does acute pseudomembranous candidiasis look like in the mouth?
i) Whitish-yellow plaques or flecks cover the mucosa, but they can be wiped off, leaving erythematous mucosa underneath.
4.5 c) Smears are often taken from acute pseudomembranous candidiasis. How are these smears treated and what do they show?
i) Smears are gram-stained and show a tangled mass of gram-positive fungal hyphae as well as leucocytes and epithelium.
ii) Periodic acid-Schiff (PAS) staining
4.5 d) Name two azole-type drugs and two other drugs, which are not azoles, that are used to treat candidal infections.
i) Azoles – miconazole, fluconazole, ketoconazole, itraconazole
ii) Others – nystatin, amphotericin B, sodium fusidate ointment
4.6 Name the common types of white patches and what may cause them.
i) Frictional keratosis – friction
ii) Leukoedema – a variation of normal anatomy
iii) Candida infection – candida albicans infection
iv) Cheek biting – trauma from cheek biting
v) Fordyce spots – developmental (sebaceous glands in the mucosa)
vi) Lichen planus – unknown (lichen planus from graft vs host disease is uncommon)
vii) Lichenoid reactions – gold/antimalarials/dental amalgam
viii) Skin grafts – previous free flap to transfer tissue to cover an intraoral defect.
i) Variations of normal anatomy:
(1) Sebaceous glands
(2) Leukoedema
ii) Hereditary:
(1) White sponge naevus
iii) Infections:
(1) Bacteria – syphilis
(2) Viral – oral hairy leukoplakia
(3) Fungal – candidiasis
iv) Inflammatory causes:
(1) Oral submucous fibrosis
(2) Erythema migrans (geographic tongue)
v) Idiopathic:
(1) leukoplakia
vi) Systemic/immunological:
(1) Oral lichen planus
(2) Oral lichenoid lesions
(3) DLE/SLE
(4) Graft vs host disease
vii) Reactive:
(1) Frictional keratosis
(2) Occlusal keratosis
(3) Tobacco associated lesions
(4) Chemical burn
(5) Thermal burn
(6) Actinic cheilitis
b) What would you call a white patch than cannot be characterised clinically or pathologically as any other disease and which is not associated with any physical or chemical causative agent except the use of tobacco?
i) Leukoplakia
4.6 c) What are the clinical features of the different types of leukoplakia white patch?
i) Homogenous – consistent texture, not raised.
ii) Heterogenous – surface irregularities (increased malignancy risk)
iii) Erythroleukoplakia – white patch with red regions of erosion. (highest malignancy risk)
iv) Nodular leukoplakia?
v) Speckled leukoplakia?
4.6 d) A biopsy is usually done for these lesions. What type(s) of biopsy would be appropriate?
i) Incisional biopsy and oral brush biopsies are appropriate.
4.6 e) How are these lesions treated?
i) Removal of the causative agent (smoking)
ii) Surgical removal (traditional surgical techniques or with a laser)
iii) Photodynamic therapy
iv) Retinoids
v) Specialist referral
vi) Regular review and biopsy as appropriate.
4.7 a) Sjogren’s syndrome is a well-known cause of a dry mouth. Name four other causes of dry mouth.
i) Psychogenic – anxiety, exam stress
ii) Irradiation to head and neck
iii) Salivary gland disease
(1) Primary biliary cirrhosis
(2) Infection – Hep C, HIV, EBV
(3) Salivary aplasia
(4) Sarcoidosis
(5) Systemic disease – diabetes, COPD, chronic renal disease
(6) Sjogrens disease
(7) Cystic fibrosis
iv) Systemic diseases
v) Drugs – antihistamines, anti-hypertensives, anti-Parkinson’s
vi) Dehydration – systemic febrile illness, diarrhoea, diabetes, renal failure.
4.7 b) What is the difference between primary and secondary Sjogren syndrome?
i) Primary Sjogren syndrome comprises of dry mouth and dry eyes.
ii) In secondary Sjogren syndrome there is a dry mouth and dry eyes in association with a connective tissue disease e.g. rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis.
4.7 c) What type of biopsy is often carried out to diagnose Sjogren syndrome and why?
i) Labial salivary gland biopsy. This is because the minor salivary glands are usually involved at a microscopic level even though they may not be enlarged.
4.7 d) What microscopic features would the biopsy show if the patient had Sjogren syndrome?
i) Focal collections of lymphoid cells are seen adjacent to blood vessels, and the greater the number of foci the worse the disease. There is also acinar atrophy.
4.7 e) What other investigations could be carried out to diagnose Sjogren syndrome?
i) Blood tests – antinuclear antibodies (ANA, SSA (anti-Ro), SSB (anti-LA); rheumatoid factors, erythrocyte sedimentation rate (ESR)
ii) Parotid salivary flow rate / Sialometry
iii) Schirmer test
iv) Sialography
4.8 a) The following diseases/conditions may have signs and symptoms that are seen in and around the mouth. Match the disease/condition with the oral signs and symptoms.
(1) Acute leukaemia,
(2) AIDS
(3) Rheumatoid arthritis
(4) HIV carrier
(5) Melkersson-Rosenthal syndrome
(6) Peutz-Jeghers syndrome
(7) Gorlin-Goltz syndrome
(8) Crohn’s disease
(9) Measles
(10) Marfan’s syndrome
(11) Syphilis
(12) Cleidocranial dysplasia
(13) Lichen planus
i) Acute leukaemia = gingival hypertrophy and bleeding
ii) AIDS = Kaposi sarcoma
iii) Rheumatoid arthritis = recently developed anterior open bite
iv) HIV carrier = hairy leukoplakia
v) Melkersson-Rosenthal syndrome = fissured tongue
vi) Peutz-Jeghers syndrome = perioral pigmentation
vii) Gorlin-Goltz syndrome = multiple odontogenic keratocystic tumours
viii) Crohn’s disease = cobblestoned buccal mucosa
ix) Measles = Koplik spots
x) Marfan’s syndrome = high-arched palate
xi) Syphilis = moon molars
xii) Cleidocranial dysplasia = supernumerary teeth
xiii) Lichen planus = Wickham striae
4.9 a) What do you understand by the term ‘erythroplakia’?
i) Erythroplakia = any lesion of the oral mucosa that presents as a red velvety plaque, which cannot be characterised clinically or pathologically as any other condition.
4.9 b) What is often seen histologically?
i) Often show dysplasia or even carcinoma in situ or frank carcinoma histologically.
(1) Dysplasia: Atypical mitosis, loss of cellular polarity, altered nuclear/cytoplasmic ratio, loss of decrease in intercellular adherence, drop-shaped rete ridges.
4.9 c) Put the following lesions in order of malignant potential with the most malignant first.
White sponge naevus, erythroplakia, leukoplakia, speckled leukoplakia
i) Erythroplasia > speckled leukoplakia > leukoplakia > white sponge naevus.
4.9 d) In the following conditions coloured lesions may appear in the mouth. What colour are they and are they localised or generalised?
(1) Kaposi sarcoma
(2) Haemangioma
(3) Amalgam tattoo
(4) Addison disease
(5) Irradiation mucositis
i) Kaposi sarcoma = reddish purplish (localised)
ii) Haemangioma = red/purple (localised to area of haemangioma)
iii) Amalgam tattoo = blue/black (localised)
iv) Addison disease = brown patches (localised to certain areas e.g. occlusal line)
v) Irradiation mucositis = red (generalised in region of irradiation).
4.10 a) A 45-year-old patient presents with a lump in the palate. Give four possible diagnoses.
i) Torus palatinus
ii) Unerupted tooth
iii) Dental abscess
iv) Papilloma
v) Neoplasm – (benign/malignant) – salivary (pleomorphic adenoma/adenocarcinoma); squamous cell carcinoma; lymphoma)
4.10 b) List four factors in the history that may help with the diagnosis. (palatal lump)
i) Duration of the lump
ii) Associated features, e.g. tooth ache, periodontally involved teeth
iii) Any change in size/consistency
iv) Any exacerbating factors, e.g. loose denture, denture granuloma, trauma.
v) Any medical conditions which may be associated with the lump, e.g. neurofibromatosis, drugs, hormonal, other malignancies.
4.10 c) Give four clinical features than may help you decide on the diagnosis. (palatal lump)
i) Position of the lump (e.g. midline – developmental torus palatinus)
ii) Consistency (fluid – pus/blood/cystic fluid); soft, firm, hard – tumour; bony hard – tooth, torus palatinus).
iii) Colour (e.g. red – vascular lesion or Kaposi sarcoma)
iv) Discharge (pus/blood/cystic fluid)
v) Surface texture (uniform/nodular or ulcerated may indicate tumour; anemone-like – papilloma)
vi) Associated features (e.g. carious upper first molar).
4.10 d) What investigations may be used to aid the diagnosis. (palatal lump)
i) Imaging (plain radiography: panoramic radiograph, upper standard occlusal, long cone periapical)
ii) Computed tomography/come beam CT
iii) Biopsy (fine needle aspiration; incisional/punch biopsy; excisional)
iv) Blood test if suspicion of underlying blood dyscrasia
4.11 a) List eight features that one needs to determine in a patient presenting with pain.
i) Site
ii) Onset
iii) Character
iv) Radiation
v) Associated factors – effect on sleep, pyrexia, malaise, loss of appetite
vi) Time – duration of each episode, periodicity
vii) Exacerbating and relieving factors
viii) Severity
4.11 b) Which features would make you think a patient had atypical/idiopathic facial pain?
i) Pain unrelated to the anatomical divisions of nerve, often crossing the midline.
ii) No organic cause can be found.
iii) Investigations do not show anything abnormal
iv) Long-standing and continuous, often with no exacerbating or relieving factors
v) Conventional analgesics provide no relief
vi) Often described as unbearable.
4.11 c) What treatment is there for atypica/idiopathic facial pain?
i) Atypica/idiopathic facial pain is usually managed medically. The drugs of choice include tricyclic antidepressants, e.g. nortriptyline, amitriptyline, doxepin, trazodone, dosulepin, fluoxetine.
4.12 a) A 30-year-old man presents with weakness on the left side of his face. Name two possible intracranial and two possible extracranial causes.
i) Extracranial
(1) Bell’s palsy
(2) Malignant parotid neoplasm
(3) Post-parotidectomy
(4) Sarcoidosis (Heerfordt’s syndrome)
(5) Incorrect administration of local anaesthetic
(6) Melkersson-Rosenthal syndrome
ii) Intracranial
(1) Cerebrovascular accident (strokes)
(2) Intracranial tumour
(3) Multiple sclerosis
(4) HIV
(5) Lyme disease
(6) Ramsey-Hunt syndrome
(7) Trauma to base of skull
b) How will you teel whether a nerve lesion causing a facial weakness had an upper motor neurone cause or a lower motor neurone cause?
i) In a lower motor neurone lesion, the patient cannot wrinkle their forehead on the affected side, but in an upper motor neurone lesions they retain movement of their forehead. Hence to determine which one it is, you need to ask the patient to raise their eyebrows and wrinkle their forehead.
c) What is Ramsay-Hunt syndrome?
i) Herpes zoster infection of the geniculate ganglion which produces a facial palsy. There will also be vesicles in the region of the external auditory meatus and the palate due to the viral infection.
d) What treatment is indicated for Ramsay-Hunt syndrome?
i) Aciclovir. A short course of high dose steroids is also recommended by some although this is not universally accepted.
ii) Systemic antiviral agents reduce pain, and reduce the incidence of post-herpetic neuralgia and viral shedding – aciclovir is drug of choice.
iii) Start treatment ideally at diagnosis or within 72 hours of the onset of the rash; even after this point antiviral treatment can reduce the severity of post-herpetic neuralgia.
iv) Aciclovir tablets, 800mg. 1 tablet 5x/day 7/7.
4.13 a) Fill in the blanks in this paragraph on herpes zoster.
Herpes zoster is caused by the …A… (organism) which lies latent in …B… . It tends to affect …C… (age) of patients. The chief complaint is …D… . The lesions are in the form of …E… . The treatment is …F… at a dose of …G… mg five times a day for …H… . Medication for pain relief is also prescribed and …I… (another drug) may also help with the pain and speed healing. Postherpetic neuralgia is …J… and persisting for more than …K… months.
A) Varicella zoster virus
B) Dorsal root ganglia.
C) Middle age or older
D) Pain or tenderness in dermatomes
E) Rash, vesicles or ulcerations
F) Systemic aciclovir
G) 800
H) 7 days
I) Systemic corticosteroids
J) Pain developing during the acute phase of herpes zoster
K) 6 months
4.14 a) Give four causes of localised gingival swelling(s).
i) Periodontal abscess
ii) Fibrous epulis
iii) Denture-induced granuloma
iv) Pregnancy epulis
v) Papilloma
vi) Giant cell lesion/epulis
vii) Tumour
4.14 b) For the above four causes, which features and/or what additional investigations would aid in diagnosis.
(i. periodontal abscess, ii. fibrous epulis, iii) denture-induced granuloma, iv) pregnancy epulis, v) papilloma, vi) giant cell lesion/papilloma, vii) tumour.)
i) Periodontal abscess – associated with deep periodontal pocket and/or non-vital tooth.
ii) Fibrous epulis – firm, pink/red, may be associated with poor oral hygiene, an excisional biopsy.
iii) Denture-induced granuloma – excisional biopsy and treat the cause, i.e. poorly fitting denture.
iv) Pregnancy epulis – red lesion associated with pregnancy gingivitis, excised post-partum if still present.
v) Papilloma – white cauliflower-like lesion, excisional biopsy.
vi) Giant cell lesion/epulis – purple-red, radiograph, excisional biopsy and curettage, blood test to exclude giant cell granuloma and hyperparathyroidism.
vii) Tumour – urgent referral to surgeon for incisional biopsy, radiography to look for bony involvement and computed tomography (CT) and magnetic resonance imaging (MRI) to stage the disease.
4.15 a) What are the signs and symptoms of primary herpetic gingivostomatitis?
i) Patients have multiple vesicles in their mouth, which burst to leave painful ulcers. There is often gingivitis. Patients feel generally unwell with fever and malaise. There is cervical lymphadenopathy.
4.15 b) What is the causative agent? (primary herpetic gingivostomatitis)
i) Herpes simplex virus 1 (DNA virus)
4.15 c) How would you treat it? (primary herpetic gingivostomatitis)
i) Bed rest, soft diet, fluid, analgesia.
ii) Chlorhexidine or tetracycline mouthwash to prevent secondary infection of the ulcers.
iii) Aciclovir in severe cases or medically compromised patients.
4.15 d) Primary herpetic stomatitis may be followed by recurrent herpes labialis. How does this happen?
i) Virus remains dormant in the trigeminal ganglion and can be reactivated by factors such as sunlight, stress, exposure to cold, pregnancy, menstruation, immunosuppression, common cold or fever.
4.15 e) Describe the lesions of herpes labialis and how you would manage them.
i) Lesions appear at the mucocutaneous junction of the lips. The patient often has a prodromal itching/prickling sensation prior to the appearance of the lesion, which starts off as a papule and then forms vesicles that burst leaving a scab. They usually heal without scarring after 7-10 days.
ii) The lesions will heal without treatment but if given early, i.e. in the prodromal phase, antiviral cream such as penciclovir or aciclovir may prevent lesions from occurring or at least speed the healing.
4.16 a) Select from the list the most appropriate diagnostic test for the various conditions/diseases. Each option may be used only once.
(1) Full blood count
(2) History and clinical examination
(3) Lower standard occlusal radiograph
(4) Autoantibody blood tests
(5) Immunohistochemistry
(6) Serum angiotensin converting enzyme
(7) Erythrocyte sedimentation rate
(8) Paul Bunnell test
(9) Culture and sensitivity
(10) Smear
(i) Sjogren syndrome
(ii) Dental abscess causing submandibular space infection
(iii) Benign mucous membrane pemphigoid
(iv) Burning mouth
(v) Glandular fever
(vi) Giant cell arteritis
(vii) Acute pseudomembranous candidiasis
(viii) Sarcoidosis
(ix) Trigeminal neuralgia
(x) Submandibular duct salivary calculus
i) Sjogren syndrome = Autoantibody blood tests
ii) Dental abscess causing submandibular space infection = culture and sensitivity
iii) Benign mucous membrane pemphigoid = Immunochemistry
iv) Burning mouth = full blood count
v) Glandular fever = Paul Bunnell test
vi) Giant cell arteritis = Erythrocyte sedimentation rate
vii) Acute pseudomembranous candidiasis = smear
viii) Sarcoidosis = serum angiotensin-converting enzyme
ix) Trigeminal neuralgia = history and clinical examination
x) Submandibular duct salivary calculus = lower standard occlusal radiograph
4.17 a) The picture shows the buccal mucosa of a 45-year-old woman. What is the name of this common condition?
i) Oral lichen planus/lichenoid reaction
4.17 b) This condition may have other presentations in the mouth. Name four.
i) Reticular
ii) Annular
iii) Atrophic
iv) Desquamative gingivitis
v) Erosive
vi) Plaque-like
vii) Papular
4.17 c) Where else may the patient get lesions in the mouth? (OLP)
i) Dorsum of tongue and gingivae
4.17 d) In which extraoral sites may such lesions occur and what are they like? (OLP)
i) Flexor surfaces of wrists (purplish, papular, itchy)
ii) Genitals (similar to oral lesions)
iii) Nails (ridges)
iv) Head (alopecia)
4.17 e) This condition may be caused by certain drugs. Name three such drugs.
i) B-blockers
ii) Oral hypoglycaemics
iii) NSAIDS
iv) Gold
v) Penicillamine
vi) Some tricyclic antidepressants
vii) Antimalarials
viii) Thiazide diuretics
ix) Alopurinol
4.18 a) Fill in the blanks using words from the list below. Each word can only be used once.
…A… disease is due to sensitivity to …B… . Patients may suffer from malabsorption of …C…, …D…, and …E…, and may have the following oral signs: …F…, …G…, and …H…. .
…I… disease is a chronic …J…, that may affect any part of the gastrointestinal tract, but most commonly affects the …K… . Oral signs may be seen such as mucosal tags, …L…, …M… and …N… .
1) Crohn’s/irritable bowel syndrome, coeliac disease/granulomatous disease/ulcerative colitis.
2) Gluten/vitamin b12/folate/iron/vitamin C/vitamin D
3) Cobblestone mucosa/lip swelling/oral ulceration/lichen planus/angular cheilitis/glossitis/gingival swellings
4) Ileum/jejunum/stomach
i) A) Coeliac
ii) B) Gluten
iii) C) Vitamin B12
iv) D) Folate
v) E) Iron
vi) F) Oral ulceration
vii) G) Angular cheilitis
viii) H) Glossitis
ix) I) Crohn’s
x) J) Granulomatous disease
xi) K) Ileum
xii) L) Cobblestone mucosa
xiii) M) Lip swelling
xiv) N) Oral ulceration
