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bds4 exam study > Oral Medicine in Primary Care [oral med SCR overview] > Flashcards

Oral Medicine in Primary Care [oral med SCR overview] Flashcards

1
Q

Patients complaining of oral ulceration should be asked a number of questions prior to physical examination, what are they?

A
  • is the ulceration painful?
  • how many ulcers do you have?
  • how long have you suffered?
  • which sites in mouth are affected?
  • has this type of ulceration happened before?
  • have you recently started any drug therapy?
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2
Q

What types of ulceration are more commonly seen in children/adolescents?

A
  • traumatic ulceration
  • aphthous stomatitis
  • acute viral infection
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3
Q

A patient gives you a history of previous episodes of ulceration, what further questions must you ask these patients?

A
  • which site in mouth?
  • how long take to heal?
  • how many ulcers do you get at one time?
  • ulcers elsewhere on body?
  • any factors that predispose you to ulcers?
  • any allergies?
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4
Q

What are some potential causes of traumatic ulceration?

A
  • toothbrush
  • cheek biting
  • rough area of tooth/restoration
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5
Q

How would you treat a patient that presents with traumatic ulceration?

A
  • removal of any persistent traumatic factor
  • antiseptic MW chlorhexidine 0.2%
  • review in 3 weeks
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6
Q

A patient with suspected traumatic ulceration has been treated (removed stimulus & prescribed chlorhexidine) yet the ulcer persists longer than 3 weeks, what do you do?

A

Biopsy for histopathological investigation

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7
Q

What is stomatitis artefacta?

A

self-induced ulceration [self-harm]

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8
Q

How might an ‘aspirin-burn’ type traumatic ulcer present?

A

sloughing erosion at site where aspirin was placed/held [dissolution of aspirin is acidic causing burns]

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9
Q

What are the subtypes of Recurrent Aphthous Stomatitis (recurrent oral ulceration)?

A
  • minor
  • major
  • herpetiform
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10
Q

What is the most common type of recurrent aphthous stomatitis?

A

minor RAS

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11
Q

How does minor recurrent aphthous stomatitis present clinically?

A
  • small ovoid / circular lesions (5-9mm diameter)
  • non-keratinised sites
  • anterior part of oral cavity
  • tend to have 1-5 ulcers at a time
  • tends not to scar
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12
Q

How long does minor RAS take to heal roughly?

A

10-14 days

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13
Q

How does major RAS tend to present clinically?

A
  • larger lesions (<1cm diameter)
  • keratinised sites
  • posterior mouth
  • leaves residual scarring
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14
Q

How long does major RAS tend to last?

A

several weeks

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15
Q

What are some proposed aetiological factors of RAS?

A
  • haematinics deficiency
  • psychological [stress]
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16
Q

How does herpetiform RAS present clinically?

A
  • multiple small round ulcers (between 10-50)
  • can be so numerous they coalesce to form large irregular ulceration
  • 10-14 days healing time
  • no scarring
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17
Q

You suspect a patient has RAS due to anaemia, what blood tests should you do and how are these patients managed?

A
  • FBC, ferritin levels, haemoglobin levels
  • replacement haematinic therapy tends to resolve ulceration
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18
Q

Hypersensitivity can be implicated in RAS, give some examples that may trigger this?

A
  • chocolate
  • tomatoes
  • benzoic acid
  • sodium lauryl sulphate
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19
Q

If you suspect that RAS is as a result of hypersensitivity reaction, what investigation may be useful?

A

Patch testing to detect potential allergens

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20
Q

How should suspected RAS be managed in primary dental care at the initial visit?

A
  • full history of complaint
  • prescribe chlorhexidine 0.2% or benzydamine 0.15%, 3 times daily
  • dietary advice
  • avoid toothpaste with SLS
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21
Q

When should a patient with suspected RAS be reviewed after initial examination, what should be involved?

A

Review after 4 weeks
- if symptomatic improvement, maintain initial management
- prescribe doxycycline 100mg tablet dissolved in water & rinsed in mouth for 2 mins, 3x daily
- prescribe beclometasone, 2 puffs directly onto ulcers twice daily
- betamethasone tablets dissolved in 10ml water 4x daily

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22
Q

What precipitating factors enable proliferation of the bacteria that causes necrotising gingivitis?

A
  • smoking/tobacco
  • stress
  • immune deficiency (eg HIV)
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23
Q

What bacteria causes Syphilis?

A

Treponema pallidum

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24
Q

What is associated with the use of the potassium channel activator Nicorandil?

A

oral ulceration

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25
Q

What virus can cause oral ulceration, particularly in children? What is the characteristic sign?

A

coxsackie group A virus
- involvement of posterior part of mouth

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26
Q

How is coxsackie virus induced ulceration treated?

A

Symptomatic management
- antiseptic mouthwash (chlorhexidine 0.2%)

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27
Q

How long does a solitary ulcer have to last before it should be considered as potential mouth cancer?

A

3 weeks (with no improvement)

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28
Q

What is meant by the term erythroplakia?

A

red patch that cannot be characterised as any known disease

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29
Q

What erythematous conditions are commonly seen in primary care?

A
  • chronic erythematous candidosis
  • geographic tongue
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30
Q

What patients cannot be prescribed miconazole?

A

pts taking warfarin

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31
Q

How should angular chelitis be managed in primary care?

A
  • provide topical antimicrobial to erythematous tissuess
  • improve denture hygiene
  • reduce sugar intake
  • rinse after inhaler use
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32
Q

How should chronic erythematous candidosis (induced by denture wearing) be managed?

A

application of miconazole oromucosal gel to the fitting surface of appliance 4x a day

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33
Q

What is this patient suffering from?

A

angular chelitis

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34
Q

What condition is this patient suffering from?

A

orofacial granulomatosis (with associated angular chelitis)

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35
Q

What condition is this patient suffering from?

A

erythematous candidosis

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36
Q

What patient groups are predisposed to pseudomembranous candidosis & erythematous candidosis?

A
  • pt taking inhaled corticosteroids
  • cytotoxics or broad-spectrum antibiotics
  • nutritional deficiencies
  • pt with serious systemic disease eg leukaemia or HIV infection
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37
Q

What condition is this patient suffering from?

A

acute erythematous candidosis on the soft palate

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38
Q

Why can inhaled steroids predispose a pt to developing acute erythematous candidosis ?

A

steroids suppress host defence system locally & promotes candidal colonisation

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39
Q

What condition is this patient suffering from?

A

acute erythematous candidosis on dorsum of tongue

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40
Q

What condition is this patient suffering from?

A

geographical tongue

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41
Q

What condition is this patient suffering from?

A

geographical tongue with fissured tongue

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42
Q

What condition is this patient suffering from?

A

white sponge naevus

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43
Q

what causes white sponge naevus?

A

autosomal dominant inherited disorder

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44
Q

does white sponge naevus require treatment?

A

benign condition so no

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45
Q

What condition is this patient suffering from?

A

Fordyce’s Spots (ectopic sebaceous glands)

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46
Q

What condition is this patient suffering from?

A

Linea Alba (frictional keratosis from cheek biting)

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47
Q

What condition is this patient suffering from?

A

aspirin burn

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48
Q

What condition is this patient suffering from?

A

pseudomembranous candidosis

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49
Q

How does chronic hyperplastic candidosis characteristically present?

A

bilaterally in the commissure region as homogenous/speckled white lesions

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50
Q

What is the most important local factor for development of chronic hyperplastic candidosis?

A

smoking!

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51
Q

How is chronic hyperplastic candidosis diagnosed?

A

Biopsy with histopathological examination which shows:
- candida hyphae in the epithelium

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52
Q

How should chronic hyperplastic candidosis be treated?

A
  • systemic fluconazole 50mg/14 days
  • smoking cessation advice
  • more frequent check up exams due to known incidence of malignant change associated
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53
Q

what condition is this patient suffering from?

A

chronic hyperplastic candidosis

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54
Q

what condition is this patient suffering from?

A

reticular lichen planus

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55
Q

How is lichen planus managed in primary care? What are the options?

A
  • Beclomethasone spray 50micrograms puff 2x daily
  • Betamethasone 0.5mg tablet dissolved in 10ml of water, MW 2 mins 3x a day
  • Prednisolone 0.5mg tablet dissolved in 10ml of water, MW 2 mins 3x daily
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56
Q

What suggests that a lesion is a lichenoid reaction and not lichen planus?

A

Asymmetry & palate involvement = suggest lichenoid reaction

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57
Q

What typically causes a lichenoid reaction?

A
  • contact with restorative material
  • adverse event associated with systemic drug therapy
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58
Q

What dental material is linked to causing lichenoid reactions when in contact with mucosa?

A

amalgam

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59
Q

what condition is this patient suffering from?

A

lichenoid reaction to amalgam

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60
Q

What drugs are most frequently implicated in a lichenoid reaction?

A
  • NSAIDs
  • ACE inhibitors
  • beta blockers
  • oral hypoglycaemic agents
  • antimalarials
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61
Q

What are the 2 forms of Lupus Erythematosus?

A
  • systemic (SLE)
  • discoid (DLE)
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62
Q

How might lupus erythematosus present in the oral cavity?

A

oral white patches which resemble lichen planus

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63
Q

What site in the oral cavity is the most frequent site for development of squamous cell carcinoma?

A

lateral border of tongue

64
Q

what condition is this patient suffering from?

A

squamous cell carcinoma on lateral tongue margin

65
Q

what condition is this patient suffering from?

A

squamous cell carcinoma of buccal sulcus

66
Q

what condition is this patient suffering from?

A

squamous cell carcinoma in left soft palate

67
Q

What is the most striking feature of submucous fibrosis?

A

marked fibrous bands in the cheeks & soft palate that can be palpated like harp strings

68
Q

What virus is responsible for primary herpetic gingivostomatitis?

A

HSV-1

69
Q

What type of disease is primary herpetic gingivostomatitis?

A

blistering disease

70
Q

what condition is this patient suffering from?

A

primary herpetic gingivostomatitis

71
Q

what condition is this patient suffering from?

A

primary herpetic gingivostomatitis

72
Q

How is primary herpetic gingivostomatitis treated in primary care?

A

Symptomatic relief as the condition will resolve within 10 days
- nutritious diet
- plenty fluids
- bed rest
- use of analgesics
- antimicrobial mouthwashes

73
Q

If local measures do not work in the treatment of primary herpetic gingivostomatitis, what should be prescribed?

A

Aciclovir 200mg
- 1 tablet 5x a day
- for 5 days

74
Q

What can trigger reactivation of latent HSV-1?

A
  • emotional stress
  • sunlight
  • cold exposure
  • systemic illness
  • menstruation
75
Q

what condition is this patient suffering from?

A
  1. herpes labialis (blister)
  2. herpes labialis (crust)
76
Q

How is herpes labialis treated in primary care?

A

5% Aciclovir cream (2g)
- apply to lesions every 4 hours for 5 days

77
Q

What virus causes chickenpox?

A

primary infection with vericella zoster virus

78
Q

what condition is this patient suffering from?

A

Herpes zoster (shingles) presenting as unilateral ulceration of the palate

79
Q

How should patients with shingles be treated in primary care?

A

Aciclovir 800mg
- 1 tablet 5x daily

80
Q

What virus causes herpangina?

A

coxsackie virus (type A)

81
Q

How does herpangina present in the oral cavity?

A

multiple vesicles on the soft palate & faucial region

82
Q

How does erythema multiforme present clinically?

A
  • blistering of the lips which become blood crusted
  • extensive oral ulceration
  • target lesions
83
Q

How is mild acute erythema multiforme treated?

A
  • antiseptic mouthwashe [chlorhexidine 2%]
  • bed rest
  • soft diet
84
Q

How is severe erythema multiforme treated?

A

systemic course of prednisolone of 20-30mg once daily until symptoms improve

85
Q

what condition is this patient suffering from?

A

angina bullosa haemorrhagica

86
Q

How does angina bullosa haemorrhagica present clinically?

A

blood-filled solitary blister that develops within seconds (usually on soft palate)
- blister usually bursts spontaneously leaving an ulcerated area

87
Q

What are the two types of pemphigoid?

A
  • bullous pemphigoid
  • mucous membrane pemphigoid
88
Q

what are the oral features of mucous membrane pemphigoid?

A

Caused by subepithelial blistering:
- irregular areas of ulceration
- desquamative gingivitis
- blood filled bulla

89
Q

What does histopathological examination of mucous membrane pemphigoid show?

A

subepithelial split/bulla & neutrophils

90
Q

What does direct immunofluorescence of pemphigoid show?

A

Linear deposition of IgG and complement (C3) at the basement membrane

91
Q

How is mucous membrane pemphigoid treated in primary care?

A

Topical corticosteroids
- Betamethasone
- Clobetasol
- Fluticasone

92
Q

What is the most common type of pemphigus?

A

pemphigus vulgaris

93
Q

How does pemphigus present clinically?

A
  • non-specific oral mucosal ulceration/erosions
  • flaccid skin blisters that rapidly evolve into oozing erosions
94
Q

How does pemphigus present on histopathological examination?

A

Intra-epithelial split
- suprabasilar acantholysis (loss of cell-cell adhesion between epidermal cells)
- tzanck cells

95
Q

What does direct immunofluorescence of pemphigus vulgaris show?

A
  • Inter-cellular deposition of IgG in the epithelium
  • Basket-weave appearance
96
Q

How is pemphigus treated?

A
  • high dose prednisolone (50-60mg daily)
  • azathioprine (50-100mg daily)
97
Q

what condition is this patient suffering from?

A

squamous cell papilloma

98
Q

what condition is this patient suffering from?

A

fibroepithelial polyp

99
Q

Where is it most common to see a fibroepithelial polyp?

A

labial mucosa, tongue & buccal mucosa at occlusal line

100
Q

How is fibroepithelial polyp treated?

A

surgical removal

101
Q

what condition is this patient suffering from?

A

pyogenic granuloma

102
Q

What is sialosis?

A

persistent swelling of the salivary tissues (non-neoplastic, non-inflammatory)

103
Q

what condition is this patient suffering from?

A

amalgam tattoo

104
Q

How can you confirm diagnosis of amalgam tattoo?

A

Intra-oral radiograph shows radiopaque material in soft tissues consistent with clinical area affected

105
Q

How can you differentiate between haemangioma & amalgam tattoo clinically?

A

Haemangioma blanches under pressure, amalgam tattoo does not

106
Q

What condition is this patient suffering from? What treatment options are available?

A

HAEMANGIOMA
- surgical removal
- cryosurgery
- arterial embolisation
- injection of sclerosing agents

107
Q

what condition is this patient suffering from?

A

Melanotic macule
- focal area of pigmentation
- look for changes in these lesions frequently
- otherwise does not require treatment

108
Q

what condition is this patient suffering from?

A

malignant melanoma
- irregular borders that may be raised
- variable pigmentation

109
Q

What causes “hairy tongue”?

A

elongation of the filiform papillae & subsequent discolouration from external factors

110
Q

what condition is this patient suffering from?

A

black hairy tongue

111
Q

what condition is this patient suffering from?

A

Smoker’s Melanosis
- tobacco smoke stimulates melanin production by melanocytes

112
Q

What are patients at risk of developing if they frequently chew Betel/areca nut?

A
  • submucous fibrosis
  • oral cancer
113
Q

what condition is this patient suffering from?

A

Black extrinsic staining due to CHEWING BETEL (areca nut)

114
Q

How do drug-induced pigmentations tend to be coloured inn the oral cavity?

A

Blueish/blue-grey appearance

115
Q

A pt presents to you with an “electric shock pain” on one side of their face that is a 10/10 in severity, some triggers include smiling/eating/touching area. What condition do you think the pt has?

A

Trigeminal neuralgia

116
Q

A patient is suffering from trigeminal neuralgia. What drug can be prescribed as a first line treatment for this pt?

A

Carbamazepine 100mg 3x a day
- if no resolution, increase dose by 100mg increments daily until pain control achieved

117
Q

What blood tests would you require when prescribing a pt carbamazepine?

A
  • FBC
  • U&Es
  • LFTs (liver function tests)
118
Q

What surgical procedure can help patients with Trigeminal Neuralgia?

A

(microvascular decompression) MVD

119
Q

What aetiological factors are associated with the development of burning-mouth syndrome?

A
  • vitamin B deficiency
  • haematological disorders
  • xerostomia
  • maturity-onset diabetes
  • parafunctional habits
  • anxiety & depression
120
Q

What haematological investigations should be carried out in pts with suspected burning mouth syndrome?

A
  • FBC
  • vit B12
  • ferritin
  • corrected whole blood folate
  • HbA1c
121
Q

What information can you guide oral medicine patients to in order for them to read up on their conditions?

A

British & Irish Society for Oral Medicine [they provide pt information leaflets on variety of oral med disorders]

122
Q

What differential diagnoses could apply to a single or localised area pigmented lesion?

A
  • amalgam tattoo
  • haemangioma
  • melanocytic nevus
  • melanotic macule
  • malignant melanoma
  • Kaposi’s sarcoma
123
Q

What differential diagnoses could apply to multiple or widespread pigmented lesions?

A
  • black hairy tongue
  • drug induced pigmentation
  • smoker associated pigmentation
  • physiological pigmentation
  • Addison’s disease
  • betel nut/paan chewing
124
Q

What differential diagnoses could apply to a white lesion that is painful?

A
  • aspirin/chemical burn
  • lichen planus
  • lichenoid reaction
  • lupus erythematous
125
Q

What differential diagnoses could apply to a white lesion that is painless?

A
  • white sponge nevus
  • frictional keratosis
  • nicotinic stomatitis
  • leukoplakia
  • pseudomembranous candidiasis
  • chronic hyperplastic candidiasis
  • squamous cell carcinoma
  • submucous fibrous
126
Q

What differential diagnoses could apply to a red lesion that is painful and may ulcerate?

A
  • erosive lichen planus
  • post radiotherapy mucositis
  • contact hypersensitivity reaction
127
Q

What differential diagnoses could apply to a red lesion that is painful and has no ulceration?

A
  • iron deficiency anaemia
  • pernicious anaemia
  • folate deficiency
  • angular cheilitis
  • acute erythematous candidiasis
  • geographical tongue
128
Q

What differential diagnoses could apply to a red lesion that is painless and may ulcerate?

A
  • squamous cell carcinoma
129
Q

What differential diagnoses could apply to a red lesion that is painless and no ulceration?

A
  • erythroplakia
  • chronic erythematous candidiasis
130
Q

What oral med differential diagnoses could be applied to extra-oral swelling?

A
  • trauma
  • dental infection
  • sialosis
  • ranula
  • Crohn’s disease
  • orofacial granulomatosis
  • salivary gland tumour
  • squamous cell carcino,a
  • paget’s disease
  • fibrous dysplasia
  • acromegaly
131
Q

What oral med differential diagnoses could apply to a pink intra-oral swelling?

A
  • fibroepithelial polyp
  • drug induced hyperplasia
  • crohn’s disease
  • orofacial granulomatosis
  • warts & condylomata
  • focal epithelial hyperplasia
  • squamous cell carcinoma
  • salivary gland tumour
132
Q

What oral med differential diagnoses could apply to a red intra-oral swelling?

A
  • pyogenic granuloma
  • giant cell granuloma
  • denture induced hyperplasia
  • scurvy
  • squamous cell carcinoma
133
Q

What oral med differential diagnoses could apply to a white intra-oral swelling?

A
  • squamous cell papilloma
  • squamous cell carcinoma
134
Q

What oral med differential diagnoses could apply to a blue intra-oral swelling?

A
  • mucocele
  • ranula
135
Q

What oral med differential diagnoses could apply to a yellow intra-oral swelling?

A
  • bone exostosis
  • sialolith
136
Q

What autoantibodies are involved in pemphigus vulgaris?

A

IgG

137
Q

What are the target antigens in pemphigus vulgaris?

A

Desmoglein 1 and 3

138
Q

What antigens are associated with mucous membrane pemphigoid?

A

BP180 and BP230

139
Q

What are desmosomes?

A

specialised structures that help cells adhere to each other in tissues

140
Q

How do autoantibodies in pemphigus act?

A

IgG autoantibodies target desmogleins, which are proteins present in desmosomes leading to detachment of skin cells from one another causing blistering
- specifically desmoglein 1 & 3

141
Q

What are the 6 clinical subtypes of oral lichen planus?

A
  • reticular
  • plaque-like
  • atrophic
  • erosive
  • papular
  • bullous
142
Q

What are characteristic features of temporomandibular joint dysfunction?

A
  • trismus
  • pain over condylar region
  • tender MoM
143
Q

What can cause TMD?

A

Parafunctional habits (clenching/grinding)

144
Q

How is TMD treated?

A
  • hard acrylic bite raising appliance
  • stress management techniques
  • masseter botox
145
Q

What symptoms can xerostomia cause?

A
  • oral discomfort
  • burning
  • difficulty in swallowing
  • difficulty in talking
  • altered taste
  • poor denture retention
146
Q

What are the clinical signs associated with xerostomia?

A
  • failure of dental restorations
  • caries at cervical margins
  • lobulated tongue
  • food debris between teeth
  • oral candidosis
  • frothy saliva
147
Q

What are the five main causes of prolonged reduction of salivary production?

A
  • drug induced
  • diabetes
  • autoimmune disease
  • radiotherapy
  • absence of salivary glands
148
Q

What is seen in this photograph?

A

pseudomembranous candidosis

149
Q

How does reticular lichen planus present clinically?

A

white striation/overlapping lines (wickham striae), papules or plaques

150
Q

How does erosive oral lichen planus present clinically?

A

erythema (via inflammation or epithelial thinning) and ulceration with periphery of the lesions surrounded by keratotic striae

sometimes presents as desquamative gingivitis

151
Q

How does plaque oral lichen planus present clinically?

A

white, homogenous, slightly elevated, smooth lesion (commonly affects dorsum of tongue)

152
Q

How does lichen planus present on the skin?

A

purple to brown raised rash that can be very itchy

153
Q

What are the histological features of oral lichen planus?

A
  • acanthosis
  • sawtooth rete pegs
  • basal cell degeneration
  • inflammatory cells (lymphocytes) in subepithelial layer
  • Civatte bodies (degenerated epithelial cells)
154
Q

How is oral lichen planus treated? primary vs secondary care

A

Primary:
- topical corticosteroids

Secondary:
- systemic corticosteroids
- topical immune modulating agents (tacrolimus/cyclosporine)
- systemic immune modulating agents (azathioprine/mycophenolate)

155
Q

How is Sjögren’s Syndrome diagnosed?

A

2016 ACR/EULAR Classification
- series of tests that get a score
- if sum of scores is >/= 4 they have Sjögrens

156
Q

What are the tests involved in the 2016 ACR/EULAR Classification?

A
  • salivary gland biopsy
  • antibody positivity
  • ocular staining score
  • Schirmer’s test
  • sialometry
157
Q

What antibodies are present in pt’s with Sjögren’s syndrome?

A
  • anti-Ro/SSA
  • anti-La/SSB

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