Oral Medicine in Primary Care [oral med SCR overview] Flashcards
(157 cards)
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?
2
Q
What types of ulceration are more commonly seen in children/adolescents?
A
- traumatic ulceration
- aphthous stomatitis
- acute viral infection
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?
4
Q
What are some potential causes of traumatic ulceration?
A
- toothbrush
- cheek biting
- rough area of tooth/restoration
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
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
7
Q
What is stomatitis artefacta?
A
self-induced ulceration [self-harm]
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]
9
Q
What are the subtypes of Recurrent Aphthous Stomatitis (recurrent oral ulceration)?
A
- minor
- major
- herpetiform
10
Q
What is the most common type of recurrent aphthous stomatitis?
A
minor RAS
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
12
Q
How long does minor RAS take to heal roughly?
A
10-14 days
13
Q
How does major RAS tend to present clinically?
A
- larger lesions (<1cm diameter)
- keratinised sites
- posterior mouth
- leaves residual scarring
14
Q
How long does major RAS tend to last?
A
several weeks
15
Q
What are some proposed aetiological factors of RAS?
A
- haematinics deficiency
- psychological [stress]
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
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
18
Q
Hypersensitivity can be implicated in RAS, give some examples that may trigger this?
A
- chocolate
- tomatoes
- benzoic acid
- sodium lauryl sulphate
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
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
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
22
Q
What precipitating factors enable proliferation of the bacteria that causes necrotising gingivitis?
A
- smoking/tobacco
- stress
- immune deficiency (eg HIV)
23
Q
What bacteria causes Syphilis?
A
Treponema pallidum
24
Q
What is associated with the use of the potassium channel activator Nicorandil?
A
oral ulceration
25
What virus can cause oral ulceration, particularly in children? What is the characteristic sign?
coxsackie group A virus
- involvement of posterior part of mouth
26
How is coxsackie virus induced ulceration treated?
Symptomatic management
- antiseptic mouthwash (chlorhexidine 0.2%)
27
How long does a solitary ulcer have to last before it should be considered as potential mouth cancer?
3 weeks (with no improvement)
28
What is meant by the term erythroplakia?
red patch that cannot be characterised as any known disease
29
What erythematous conditions are commonly seen in primary care?
- chronic erythematous candidosis
- geographic tongue
30
What patients cannot be prescribed miconazole?
pts taking warfarin
31
How should angular chelitis be managed in primary care?
- provide topical antimicrobial to erythematous tissuess
- improve denture hygiene
- reduce sugar intake
- rinse after inhaler use
32
How should chronic erythematous candidosis (induced by denture wearing) be managed?
application of miconazole oromucosal gel to the fitting surface of appliance 4x a day
33
What is this patient suffering from?
angular chelitis
34
What condition is this patient suffering from?
orofacial granulomatosis (with associated angular chelitis)
35
What condition is this patient suffering from?
erythematous candidosis
36
What patient groups are predisposed to pseudomembranous candidosis & erythematous candidosis?
- pt taking inhaled corticosteroids
- cytotoxics or broad-spectrum antibiotics
- nutritional deficiencies
- pt with serious systemic disease eg leukaemia or HIV infection
37
What condition is this patient suffering from?
acute erythematous candidosis on the soft palate
38
Why can inhaled steroids predispose a pt to developing acute erythematous candidosis ?
steroids suppress host defence system locally & promotes candidal colonisation
39
What condition is this patient suffering from?
acute erythematous candidosis on dorsum of tongue
40
What condition is this patient suffering from?
geographical tongue
41
What condition is this patient suffering from?
geographical tongue with fissured tongue
42
What condition is this patient suffering from?
white sponge naevus
43
what causes white sponge naevus?
autosomal dominant inherited disorder
44
does white sponge naevus require treatment?
benign condition so no
45
What condition is this patient suffering from?
Fordyce's Spots (ectopic sebaceous glands)
46
What condition is this patient suffering from?
Linea Alba (frictional keratosis from cheek biting)
47
What condition is this patient suffering from?
aspirin burn
48
What condition is this patient suffering from?
pseudomembranous candidosis
49
How does chronic hyperplastic candidosis characteristically present?
bilaterally in the commissure region as homogenous/speckled white lesions
50
What is the most important local factor for development of chronic hyperplastic candidosis?
smoking!
51
How is chronic hyperplastic candidosis diagnosed?
Biopsy with histopathological examination which shows:
- candida hyphae in the epithelium
52
How should chronic hyperplastic candidosis be treated?
- systemic fluconazole 50mg/14 days
- smoking cessation advice
- more frequent check up exams due to known incidence of malignant change associated
53
what condition is this patient suffering from?
chronic hyperplastic candidosis
54
what condition is this patient suffering from?
reticular lichen planus
55
How is lichen planus managed in primary care? What are the options?
- 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
56
What suggests that a lesion is a lichenoid reaction and not lichen planus?
Asymmetry & palate involvement = suggest lichenoid reaction
57
What typically causes a lichenoid reaction?
- contact with restorative material
- adverse event associated with systemic drug therapy
58
What dental material is linked to causing lichenoid reactions when in contact with mucosa?
amalgam
59
what condition is this patient suffering from?
lichenoid reaction to amalgam
60
What drugs are most frequently implicated in a lichenoid reaction?
- NSAIDs
- ACE inhibitors
- beta blockers
- oral hypoglycaemic agents
- antimalarials
61
What are the 2 forms of Lupus Erythematosus?
- systemic (SLE)
- discoid (DLE)
62
How might lupus erythematosus present in the oral cavity?
oral white patches which resemble lichen planus
63
What site in the oral cavity is the most frequent site for development of squamous cell carcinoma?
lateral border of tongue
64
what condition is this patient suffering from?
squamous cell carcinoma on lateral tongue margin
65
what condition is this patient suffering from?
squamous cell carcinoma of buccal sulcus
66
what condition is this patient suffering from?
squamous cell carcinoma in left soft palate
67
What is the most striking feature of submucous fibrosis?
marked fibrous bands in the cheeks & soft palate that can be palpated like harp strings
68
What virus is responsible for primary herpetic gingivostomatitis?
HSV-1
69
What type of disease is primary herpetic gingivostomatitis?
blistering disease
70
what condition is this patient suffering from?
primary herpetic gingivostomatitis
71
what condition is this patient suffering from?
primary herpetic gingivostomatitis
72
How is primary herpetic gingivostomatitis treated in primary care?
Symptomatic relief as the condition will resolve within 10 days
- nutritious diet
- plenty fluids
- bed rest
- use of analgesics
- antimicrobial mouthwashes
73
If local measures do not work in the treatment of primary herpetic gingivostomatitis, what should be prescribed?
Aciclovir 200mg
- 1 tablet 5x a day
- for 5 days
74
What can trigger reactivation of latent HSV-1?
- emotional stress
- sunlight
- cold exposure
- systemic illness
- menstruation
75
what condition is this patient suffering from?
1. herpes labialis (blister)
2. herpes labialis (crust)
76
How is herpes labialis treated in primary care?
5% Aciclovir cream (2g)
- apply to lesions every 4 hours for 5 days
77
What virus causes chickenpox?
primary infection with vericella zoster virus
78
what condition is this patient suffering from?
Herpes zoster (shingles) presenting as unilateral ulceration of the palate
79
How should patients with shingles be treated in primary care?
Aciclovir 800mg
- 1 tablet 5x daily
80
What virus causes herpangina?
coxsackie virus (type A)
81
How does herpangina present in the oral cavity?
multiple vesicles on the soft palate & faucial region
82
How does erythema multiforme present clinically?
- blistering of the lips which become blood crusted
- extensive oral ulceration
- target lesions
83
How is mild acute erythema multiforme treated?
- antiseptic mouthwashe [chlorhexidine 2%]
- bed rest
- soft diet
84
How is severe erythema multiforme treated?
systemic course of prednisolone of 20-30mg once daily until symptoms improve
85
what condition is this patient suffering from?
angina bullosa haemorrhagica
86
How does angina bullosa haemorrhagica present clinically?
blood-filled solitary blister that develops within seconds (usually on soft palate)
- blister usually bursts spontaneously leaving an ulcerated area
87
What are the two types of pemphigoid?
- bullous pemphigoid
- mucous membrane pemphigoid
88
what are the oral features of mucous membrane pemphigoid?
Caused by subepithelial blistering:
- irregular areas of ulceration
- desquamative gingivitis
- blood filled bulla
89
What does histopathological examination of mucous membrane pemphigoid show?
subepithelial split/bulla & neutrophils
90
What does direct immunofluorescence of pemphigoid show?
Linear deposition of IgG and complement (C3) at the basement membrane
91
How is mucous membrane pemphigoid treated in primary care?
Topical corticosteroids
- Betamethasone
- Clobetasol
- Fluticasone
92
What is the most common type of pemphigus?
pemphigus vulgaris
93
How does pemphigus present clinically?
- non-specific oral mucosal ulceration/erosions
- flaccid skin blisters that rapidly evolve into oozing erosions
94
How does pemphigus present on histopathological examination?
Intra-epithelial split
- suprabasilar acantholysis (loss of cell-cell adhesion between epidermal cells)
- tzanck cells
95
What does direct immunofluorescence of pemphigus vulgaris show?
- Inter-cellular deposition of IgG in the epithelium
- Basket-weave appearance
96
How is pemphigus treated?
- high dose prednisolone (50-60mg daily)
- azathioprine (50-100mg daily)
97
what condition is this patient suffering from?
squamous cell papilloma
98
what condition is this patient suffering from?
fibroepithelial polyp
99
Where is it most common to see a fibroepithelial polyp?
labial mucosa, tongue & buccal mucosa at occlusal line
100
How is fibroepithelial polyp treated?
surgical removal
101
what condition is this patient suffering from?
pyogenic granuloma
102
What is sialosis?
persistent swelling of the salivary tissues (non-neoplastic, non-inflammatory)
103
what condition is this patient suffering from?
amalgam tattoo
104
How can you confirm diagnosis of amalgam tattoo?
Intra-oral radiograph shows radiopaque material in soft tissues consistent with clinical area affected
105
How can you differentiate between haemangioma & amalgam tattoo clinically?
Haemangioma blanches under pressure, amalgam tattoo does not
106
What condition is this patient suffering from? What treatment options are available?
HAEMANGIOMA
- surgical removal
- cryosurgery
- arterial embolisation
- injection of sclerosing agents
107
what condition is this patient suffering from?
Melanotic macule
- focal area of pigmentation
- look for changes in these lesions frequently
- otherwise does not require treatment
108
what condition is this patient suffering from?
malignant melanoma
- irregular borders that may be raised
- variable pigmentation
109
What causes "hairy tongue"?
elongation of the filiform papillae & subsequent discolouration from external factors
110
what condition is this patient suffering from?
black hairy tongue
111
what condition is this patient suffering from?
Smoker's Melanosis
- tobacco smoke stimulates melanin production by melanocytes
112
What are patients at risk of developing if they frequently chew Betel/areca nut?
- submucous fibrosis
- oral cancer
113
what condition is this patient suffering from?
Black extrinsic staining due to CHEWING BETEL (areca nut)
114
How do drug-induced pigmentations tend to be coloured inn the oral cavity?
Blueish/blue-grey appearance
115
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?
Trigeminal neuralgia
116
A patient is suffering from trigeminal neuralgia. What drug can be prescribed as a first line treatment for this pt?
Carbamazepine 100mg 3x a day
- if no resolution, increase dose by 100mg increments daily until pain control achieved
117
What blood tests would you require when prescribing a pt carbamazepine?
- FBC
- U&Es
- LFTs (liver function tests)
118
What surgical procedure can help patients with Trigeminal Neuralgia?
(microvascular decompression) MVD
119
What aetiological factors are associated with the development of burning-mouth syndrome?
- vitamin B deficiency
- haematological disorders
- xerostomia
- maturity-onset diabetes
- parafunctional habits
- anxiety & depression
120
What haematological investigations should be carried out in pts with suspected burning mouth syndrome?
- FBC
- vit B12
- ferritin
- corrected whole blood folate
- HbA1c
121
What information can you guide oral medicine patients to in order for them to read up on their conditions?
British & Irish Society for Oral Medicine [they provide pt information leaflets on variety of oral med disorders]
122
What differential diagnoses could apply to a single or localised area pigmented lesion?
- amalgam tattoo
- haemangioma
- melanocytic nevus
- melanotic macule
- malignant melanoma
- Kaposi's sarcoma
123
What differential diagnoses could apply to multiple or widespread pigmented lesions?
- black hairy tongue
- drug induced pigmentation
- smoker associated pigmentation
- physiological pigmentation
- Addison's disease
- betel nut/paan chewing
124
What differential diagnoses could apply to a white lesion that is painful?
- aspirin/chemical burn
- lichen planus
- lichenoid reaction
- lupus erythematous
125
What differential diagnoses could apply to a white lesion that is painless?
- white sponge nevus
- frictional keratosis
- nicotinic stomatitis
- leukoplakia
- pseudomembranous candidiasis
- chronic hyperplastic candidiasis
- squamous cell carcinoma
- submucous fibrous
126
What differential diagnoses could apply to a red lesion that is painful and may ulcerate?
- erosive lichen planus
- post radiotherapy mucositis
- contact hypersensitivity reaction
127
What differential diagnoses could apply to a red lesion that is painful and has no ulceration?
- iron deficiency anaemia
- pernicious anaemia
- folate deficiency
- angular cheilitis
- acute erythematous candidiasis
- geographical tongue
128
What differential diagnoses could apply to a red lesion that is painless and may ulcerate?
- squamous cell carcinoma
129
What differential diagnoses could apply to a red lesion that is painless and no ulceration?
- erythroplakia
- chronic erythematous candidiasis
130
What oral med differential diagnoses could be applied to extra-oral swelling?
- trauma
- dental infection
- sialosis
- ranula
- Crohn's disease
- orofacial granulomatosis
- salivary gland tumour
- squamous cell carcino,a
- paget's disease
- fibrous dysplasia
- acromegaly
131
What oral med differential diagnoses could apply to a pink intra-oral swelling?
- fibroepithelial polyp
- drug induced hyperplasia
- crohn's disease
- orofacial granulomatosis
- warts & condylomata
- focal epithelial hyperplasia
- squamous cell carcinoma
- salivary gland tumour
132
What oral med differential diagnoses could apply to a red intra-oral swelling?
- pyogenic granuloma
- giant cell granuloma
- denture induced hyperplasia
- scurvy
- squamous cell carcinoma
133
What oral med differential diagnoses could apply to a white intra-oral swelling?
- squamous cell papilloma
- squamous cell carcinoma
134
What oral med differential diagnoses could apply to a blue intra-oral swelling?
- mucocele
- ranula
135
What oral med differential diagnoses could apply to a yellow intra-oral swelling?
- bone exostosis
- sialolith
136
What autoantibodies are involved in pemphigus vulgaris?
IgG
137
What are the target antigens in pemphigus vulgaris?
Desmoglein 1 and 3
138
What antigens are associated with mucous membrane pemphigoid?
BP180 and BP230
139
What are desmosomes?
specialised structures that help cells adhere to each other in tissues
140
How do autoantibodies in pemphigus act?
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
What are the 6 clinical subtypes of oral lichen planus?
- reticular
- plaque-like
- atrophic
- erosive
- papular
- bullous
142
What are characteristic features of temporomandibular joint dysfunction?
- trismus
- pain over condylar region
- tender MoM
143
What can cause TMD?
Parafunctional habits (clenching/grinding)
144
How is TMD treated?
- hard acrylic bite raising appliance
- stress management techniques
- masseter botox
145
What symptoms can xerostomia cause?
- oral discomfort
- burning
- difficulty in swallowing
- difficulty in talking
- altered taste
- poor denture retention
146
What are the clinical signs associated with xerostomia?
- failure of dental restorations
- caries at cervical margins
- lobulated tongue
- food debris between teeth
- oral candidosis
- frothy saliva
147
What are the five main causes of prolonged reduction of salivary production?
- drug induced
- diabetes
- autoimmune disease
- radiotherapy
- absence of salivary glands
148
What is seen in this photograph?
pseudomembranous candidosis
149
How does reticular lichen planus present clinically?
white striation/overlapping lines (wickham striae), papules or plaques
150
How does erosive oral lichen planus present clinically?
erythema (via inflammation or epithelial thinning) and ulceration with periphery of the lesions surrounded by keratotic striae
sometimes presents as desquamative gingivitis
151
How does plaque oral lichen planus present clinically?
white, homogenous, slightly elevated, smooth lesion (commonly affects dorsum of tongue)
152
How does lichen planus present on the skin?
purple to brown raised rash that can be very itchy
153
What are the histological features of oral lichen planus?
- acanthosis
- sawtooth rete pegs
- basal cell degeneration
- inflammatory cells (lymphocytes) in subepithelial layer
- Civatte bodies (degenerated epithelial cells)
154
How is oral lichen planus treated? primary vs secondary care
Primary:
- topical corticosteroids
Secondary:
- systemic corticosteroids
- topical immune modulating agents (tacrolimus/cyclosporine)
- systemic immune modulating agents (azathioprine/mycophenolate)
155
How is Sjögren's Syndrome diagnosed?
2016 ACR/EULAR Classification
- series of tests that get a score
- if sum of scores is >/= 4 they have Sjögrens
156
What are the tests involved in the 2016 ACR/EULAR Classification?
- salivary gland biopsy
- antibody positivity
- ocular staining score
- Schirmer's test
- sialometry
157
What antibodies are present in pt's with Sjögren's syndrome?
- anti-Ro/SSA
- anti-La/SSB
