Oral Medicine Flashcards
what can acyclovir be used for
primary herpetic gingivostomatitis
recurrent herpetic lesions
shingles
what can antifungals be used for
acute pseudomembranous candidiasis
acute erythematous candidiasis
what is on a prescription
patient details
CHI
number of days
drug prescribed
formulation and dose
quantity
directions to patient
signed and dated
how long is a prescription valid for
6 months from issue date
what advice is given to patients when giving them a prescription
take drugs at correct time and finish the course
unexpected reactions to stop and contact prescriber
known side effects discussed
keep away from children
when is topical steroid therapy used
disabling immunologically driven lesions
what medicines can be used for non-steroid topical treatment of oral mucosal lesions
chlorhexidine mouthwash
benzydamine mouthwash or spray
igloo/bonjela
what are the topical steroids used in dentistry
hydrocortisone mucoadhesive pellet
betamethasone mouthwash
beclomethasone MDI
what are the instructions for using betamethasone tablets
1 tablet dissolved in 10ml water as a mouthwash 4x daily
what are the instructions for beclomethasone MDI
1-2 puffs directed onto ulcers twice daily
what are the risks of long term systemic steroid medication
adrenal suppression
cushingoid features
osteoporosis
peptic ulcer
mood/sleep alteration
what are the risks of immunotherapy medication
infection risk
cancer risk
adverse drug reactions
if a patient is going to start immunomodulatory treatment what do they need before this
BBV screen
FBC
electrolytes
liver function
zoster antibody screen
EBV
chest x-ray
cervical smear
pregnancy test
how would you explain geographic tongue to a patient
variation of normal
small areas of change in tongue with semicircular white and red areas
doesnt need any treatment but can make it uncomfortable to eat spicy foods
can be associated with deficiencies
when do you refer a swelling
symptomatic
abnormal overlying and surrounding mucosa
increasing in size
rubbery consistency
trauma from teeth
unsightly
what are the generic causes of oral white lesions
hereditary
smoking/frictional
lichen planus
candida leukoplakia
carcinoma
localised causes of brown/black lesions
amalgam
melanotic macule
melanotic naevus
malignant melanoma
peutz-jegers syndrome
pigmentary incontinence
kaposi’s syndrom
generalised causes of brown/black lesions
racial/familial
smoking/drugs
addisons disease (raised ACTH)
what are the characteristic features of a mucosal melanoma
variable outline
irregular outline
raised surface
itchy/bleeds
what can cause a single episode of oral ulceration
trauma
first recurrent episode
primary viral infections
OSCC
what are the causes of recurrent oral ulceration
aphthous
lichen planus
vesiculobullous lesions
recurrent viral lesion
trauma
systemic disease
what are the questions to ask in oral ulceration history
where
size and shape
blister or ulcer
how long for
recurrent at the same site or different sites
painful
ulcer free period
what do you look for when examining an ulcer
margins
base
surrounding tissue
systemic illness
features of recurrent herpetic lesions
ulceration limited to one nerve group/branch
hard palate usually
recurs in same place
aware of prodrome period
pain = zoster
no pain = simplex
4 types of RAS
minor
major
herpetiform
behcets
features of minor RAU
<10mm
up to 2 weeks
non-keratinised mucosa
no scarring
features of major RAU
last for months
>10mm
any part of mucosa
may scar
features of herpetiform RAU
multiple small ulcers on non-keratinised mucosa only
heal within 2 weeks
coalesce into larger areas of ulceration
criteria for diagnosis of behcets
3 episodes of mouth ulcers in a year
2 of: genital sores, eye inflammation, skin ulcers, pathergy
predisposing factors for RAS
genetic predisposition
systemic diseases
stress
mechanical injuries
hormonal level fluctuations
microelement deficiencies
viral and bacterial infections
how to explain the immunology of an ulcer to a patient
usually your cells will shed and be replaced with new ones but with ulcers there is damage to the cells that make up the mucosa meaning that new cells cannot be made to replace the old ones which shed which causes the ulceration and exposes the tissue underneath the gum
what kind of ulcer is it likely to be if it is recurrent and self-healing exclusively affecting the non-keratinised mucosa
aphthae
tests for ulcers
ferritin, folate, vit B12
coeliac
allergy testing
treatment of recurrent aphthae
correct deficiencies
refer for investigations if coeliac positive
avoid dietary triggers
what topical treatment is recommended for ulcers as per SDCEP
non-steroid for infrequent ulcers
steroid based for disabling and frequent ulcers
causes of lichen planus
genetics
stress
injury
localised skin disease like herpes zoster
systemic viral infection
contact allergy
drugs
how to explain lichen planus to a patient
immune reaction to irritation which it is trying to remove which can be either something localised that we can change (filling/drugs) or can be an illness
what investigation is usually done for lichen planus
incisional biopsy
medications which commonly cause lichen planus
ACE inhibitors
B blockers
diuretics
NSAIDs
DMARDs
appearance of a lichenoid drug reaction to medication
widespread lesions
bilateral and mirrored
poorly respond to standard steroid treatment
what is the management of lichenoid drug reactions
weigh up benefit of drug to risk of removing it and liaise with GP
treat discomfort
tests for lichen planus
biopsy
haematinics
FBC
autoantibody if lupus suspected
treatment used for mild intermittent lesions of lichen planus
chlorhexidine
benzydamine
avoid SLS containing toothpaste
treatment used for persisting symptomatic lesions of lichen planus
topical steroids (beclo/beta)
clobetasol/tacrolimus creams
high risk sites for mouth cancer
floor of mouth
lateral border of tongue
retromolar regions
soft and hard palate
tonsillar areas
risk level for smokers who dont drink
2X
increased with quantity, duration and frequency
duration more important than frequency
risk level for drinkers
2X risk
frequency more important than duration (more drinks each day)
risk level for someone who smokes and drinks
5X risk
increases with frequency and duration of smoking and alcohol consumption
chance of white lesions becoming oral cancer in 10 years and in 20 years
1.4% in 10
4% in 20
what is TNM staging for cancer
T - size
N - nodal spread
M - metastatic spread
name some vesiculobullous conditions
erythema multiforme
pemphigus
pemphigoid
angina bullosa haemorrhagica
bullous lichen planus
presentation of erythema multiforme
skin target lesions
ulcers in mouth
crusty lips
what to tell patients about angina bullosa haemorrhagica
blood blisters in mouth
initiated by minor trauma (eating and steroid inhalers)
heals with no scars within days
can use CHX mouthwash after burst
can recur
it is benign!
what is mucous membrane pemphigoid
subepithelial antibody attack causing separation of epithelium at basement membrane from connective tissue (thick blister formation)
antibodies involved in pemphigoid
C3 and IGG
what is pemphigus vulgaris
intraepithelial attack on the desmosomes making it more of an erosive ulcerative appearance than pemphigoid
causes of dry mouth
salivary gland disease
drugs
medical conditions
dehydration
radiotherapy and cancer treatment
anxiety and somatisation disorders
what types of drugs cause a dry mouth
ANTI-MUSCARINIC CHOLINERGIC DRUGS
- tricyclics
- antipsychotics
- antihistamine
- atropine
- diuretics
- cytotoxics
what medical problems induce dehydration
diabetes
renal disease
stroke
addisons disease
vesiculobullous diseases
what direct problems to the salivary gland would reduce salivary flow
aplasia (ectodermal dysplasia)
sarcoidosis
HIV disease
gland infiltration
cystic fibrosis
tests for investigating salivary disease
FBC
U&Es
liver function tests
C-reactive protein
glucosa
anti-ro
anti-la
antinuclear antibody
complement C3 and C4
USS (flow test)
labial gland biopsy
imaging (US)
oral consequences of sjogren’s syndrome
caries, denture retention, infections, functional issues
salivary enlargement
lymphoma risk
oral symptoms of sjogrens
daily feeling of a dry mouth > 3 months
recurrent swelling of glands as an adult
frequently dtink liquid to aid swallowing dry foods
management of sjogrens syndrome
diet advice
OHI
5000ppm toothpaste
salivary stimulant - pilocarpine
salivary substitutes
how is Crohn’s screened for
growth monitoring
monitor altered bowel habits
faecal calprotectin
what to exclude in the diet of an OFG patient
benzoates, sorbate, cinnamon, chocolate
management of OFG
3 month exclusion diet
topical treatment to angular cheilitis
topical treatment to lip swelling (injections)
how to explain OFG to a patient
the lymphatic drainage of your face has been blocked with cells due to an immune reaction to something
this can take weeks/months to go down or not go down at all
oral features of OFG
perioral erythema
angular cheilitis
stag horning of FoM
linear fissure ulcer in the buccal sulcus
proliferative full thickness erythematous gingivitis
what results from an unstimulated salivary flow test and a schirmer test be abnormal
USS - <1.5ml in 15mins
schirmer test - <5mm wetting of paper in 15 mins
what saliva substitutes are available
glandosane (acidic)
saliva orthana
lozenges
chewing gum
what are the true causes of hypersalivation
drugs
dementia
CJD
stroke
name a few drugs that would cause hypersalivation
clozapine
buprenorphine
clonazepam
how to treat problems with excess saliva
treat cause (anxiety)
drug tor educe salivation
gland botox
swallowing control
gland removal/duct repositioning
symptoms of mumps
gland inflammation
joint pain
nausea
dry mouth
tiredness
pyrexia
loss of appetite
how to explain a mucocele to a patient
blocked small salivary gland
small lump filled with saliva
usually bursts in days and will taste salty
related to minor injuries such as lip biting
signs of neuropathic pain
constant burning/aching pain with no apparent cause
fixed location
fixed intensity
history of injury in that area usually creates damage to the nerve
topical and systemic medication for neuropathic pain
EMLA, benzydamine
pregabalin
gabapentin
tricyclics
what facial pain conditions are important to be aware of
atypical odontalgia
oral dysaesthesia (burning mouth, touch dysaesthesia, dry mouth dysaesthesia)
trigeminal neuralgia
TMD
cluster headaches
what is oral dysaesthesia
abnormal sensory perception in absence of abnormal stimulus
predisposing factors to oral dysaesthesia
deficiencies
fungal and viral infections
anxiety and stress
gender (women)
what systemic issue is burning mouth syndrome most likely to be associated with
haematinic deficiency
how do you manage dysaesthesia
explain condition to patient
assess degree of anxiety
treatment to empower patient
anxiolytic medication (nortriptyline, mirtazapine)
physical signs in TMD
clicking joint
locking with reduction
limitation of opening mouth
tenderness of MoM
tenderness of neck muscles
management of TMD
information about the joint itself and the condition
physical therapy (soft diet, exercises, splint)
tricyclics
physiotherapy
acupuncture
clinical psychology
causes of trigeminal neuralgia
idiopathic
classical (vascular compression)
secondary (MS/tumour)
presentation of trigeminal neuralgia
unilateral maxillary or mandibular division pain
stabbing pain
5-10 seconds
continuous or sudden
remission and relapses
triggers for trigeminal neuralgia
cutaneous
wind/cold
touch
chewing
first line drugs for trigeminal neuralgia
carbamazepine 100mg
oxcarbazepine
lamotrigine
management of trigeminal neuralgia
carbamazepine
pain diary
side effects of carbamazepine
blood dyscrasias
electrolyte imbalances
neurological deficits
liver toxicity
skin reactions
surgical options for trigeminal neuralgia
microvascular decompression
stereotactic radiosurgery
radiofrequency thermocoagulation
balloon compression
destructive peripheral neurectomies
what are the characteristics of painful trigeminal neuropathy (post-herpetic neuralgia etc)
localised to trigeminal nerve distribution
burning/squeezing/pins and needles
primary pain continuous but superimposed by brief pain paroxysms
what nerve does trigeminal autonomic cephalalgias affect
ophthalmic division of trigeminal nerve (V1)
what prominent cranial parasympathetic autonomic features are present with trigeminal autonomic cephalalgias
conjunctival injection
nasal congestion
eyelid oedema
ear fullness
miosis and ptosis
features of a cluster headache
pain orbitally and temporally
unilateral only
rapid onset
lasts 15 mins - 3 hours
rapid cessation of pain
can come in bouts
features of paroxysmal hemicrania
pain orbitally and temporally
unilateral only
rapid onset
lasts 2-30 mins
rapid cessation of pain
what drug therapy can be used for cluster headaches
sumatriptan/zolmitriptan
oxygen
name 3 types of fibrous overgrowths
fibrous epulis
pyogenic granuloma
giant cell lesions
name some reactive hyperplastic lesions
fibroepithalial polyp
denture induced hyperplasia
leaf fibroma
papillary hyperplasia of palate
features of chronic hyperplastic candidosis
commissures
smokers
dysplasia may be present
treatment of chronic hyperplastic candidosis
systemic antifungal
biopsy
smoking cessation
observation
what is the grading categories of epithelial dysplasia
hyperplasia
mild
moderate
severe
carcinoma in situ
