Oral medicine/ oral pathology Flashcards
Give diff dx for scrapable white lesion according to surgical sieve
Inflammatory/infective
- fungal - pseudomembranous candidiasis
- bacterial - secondary syphillis
- viral -
Trauma
- thermal burn
- habitual cheek biting
Autoimmune
- RAU (minor and major)
Drugs
- aspirin burn
Give diff dx of UNSCRAPABLE white lesions acc to surgical sieve
Infective/inflammatory
- fungal - chronic hyperplastic candidiasis
Trauma
- hyperkeratosis +/- dysplasia
- frictional keratosis
- cheek biting (morsicatio buccarum)
- linea alba
Autoimmune/immune mediated
- lichen planus (reticular type - whickams striae)
Metabolic
- uremic stomatitis in renal failure
Idiopathic
- leukodema
- white sponge nevus
Neoplasia
- leukoplakia
- proloferative verrucous ca
- verrucous carcinoma
Give diff diagnosis of a mixed red white lesion
Infective/inflammatory
- fungal: candidiasis (erythematous/ pseudomembranous)
- bacterial:
- secondary syphillis (snailtrack)
- scarlet fever (white-red strawberry tongue)
- viral: primary herpes
Trauma
- thermal burns
Autoimmune
- lichen planus (reticular/erosive/atrophic type)
- lupus erythematous
Idiopathic
- eryhtema migrans
Neoplasia
- eryhtroleukoplakia
- scc
- actinic cheilosis
Diff dx of red lesions or red patches
Infective/ inflammatory
- erythematous candidiasis
- pharyngitis
- scarlet fever (strawberry tongue)
Trauma
- erosions
- radiation mucositis
Autoimmune
- erosive/atrophic Lichen
- lupus erythematous
Metabolic
- glossitis (d/t anemia)
Idiopathic
- erythema migrans
Neoplasia
- erythroplakia
-
Differential diagnosis of ulceartive lesions
Infective/inflammatory
- fungal - histoplasmosis, blastomycosis
- bacterial - impetigo, syphilis (primary and secondary), Noma,
- viral - herpes, chickenpox, shingles, herpangina, HFM dz
Trauma
- traumatic biting
- burns
Autoimmune/ immune mediated
- RAS
- pemphigus
- pemphigoid
- erythema multiforme
- Steven Johnson syndrome (TEN)
- Behcets syndrome
- Chrons disease
Metabolic
- Anemia
- Mronj/orn
Neoplasia
- SCC
Diff dx of vesiculobullous lesions
Infective
- herpes simplex (primary and secondary)
- herpes zoster
- coxsackie (herpnagina and HFM dz)
Autoimmune/immune-mediated
- pemphigus
- pemphigoid (BMMP)
- bullous type of Lichen planus
- erythema multiforme
- graft vs host dz
Hereditary
- epidermolysis bullosa
What are clinical presentations of syphillis
Primary syphilis
- presents on oral or genital
- chancre (painful ulcers)
- occasionally with erythematous swelling (vascular proliferation) may mimic pyogenic granuloma
Secondary syphilis
- disseminated throughout the body
- systemic symptoms such as malaise fever lymphadenopathy
- maculopapular cutaneous rash on skin everywhere
- oral lesion - multiple mucous patch with whitish/yellowish ulcerated center and reddish periphery - fuse patches forming snailtrack pattern
- split papules
- condyloma lata
Tertiary syphilis
- granulomatous inflammation - gumma
- interstitial glossitis
- syphilitic glossitis (precancerous)
Congenital syphilis
- triad of hutchison teeth, ocular keratitis, eight nerve deafness
- others include frontal bossing,high arched palate, mulberry molars, saddle nose
How to diagnose syphilis
Serological testing: VDRL, TPHA, FTA-ABS
Smear lesion : dark ground microscopic illumination of Treponema pallidum
Presentation of herpes simplex
HHV 1 - HSV1
HHV 2 - HSV 2 (sexually transmitted)
Primary herpes (primary herpes gingivostomatitis)
- vesiculobullous lesions which ruptures forming ulcers
- erythematous punched out lesion on gingival margin
Seondary (recurrent) herpes
- herpes labialis (canker sores - macules - vesicles - pustules - scabbed lesions)
- intraoral herpes - ulcers
Gicw diff dx of lesions that appears as vesciles or bullous, ruptures becoming ulcers, and then scabbed
Infection
- recurrent herpes simplex (herpes labialis/ cold sores)
- secondary varicella zoster (shingles)
Autoimmune/ immune mediated
- pemphigus
- pemphigoid (bmmp/bullous)
- erythema multiforme
- Steven johnsons syndrome (TEN)
Diff dx of Positive Nikolsky sign
Pemphigus BMMP (cicatricial pemphigoid) Oral lichen planus (bullous type) Epidermolysis bullosa SLE Graft vs host disease Toxic epidermal necrolysis
What is epidermolysis bullosa
Dermatological disorder that inherited
Epidermolysis bullosa presentation
4 diff categories (simplex, junctional, dystrophic, Kindler syndrome)
Dystrophic most common in oral mucosa
- vesiculobullous lesions
- in trauma regions (knuckles, knees)
- bullae rupture - erosion/ulceration
- heals with scarring
What is pemphigus vulgaris
Systemic vesiculobullous disease
Intraepithelial clefting
Forms blisters but Erupts early
Forms erosions or ulcers
Positive Nikolsky’s sign
DIF - IgG, IgM, complement
Tx by systemic corticosteroid (usually long term)
And immunosuppressive agents (azathioprine)
Risks for long term steroids
- DM
- adrenal suppression
- weight gain
- osteoporosis
- peptic ulcers
- Cushing syndrome
Difference between bmmp and bullous pemphigoid?
Both produces chornic bullous lesions
Difference:
- BMMP is a progressive disease
- Bullous has periods of remission and relapse
What is Behcets syndrome
Immune mediated ulcerative disease that presents with a classic triad of oral, ocular and genital ulceration
Dx: Recurrent oral ulcers +/- ocular lesions, genital lesions, +ve pathergy test
Unknown cause - strong assoc with HLA leading to T-cell mediated immune reaction
No diagnostic test
May have positive finding on “pathergy test” where when saline is injected subcut, produces a sterile pustule after few days
Tx by topical corticosteroids, intralesional corticosteroids, systemic potent antiinflammatory such as methotraxate, colchicine, azathioprine, pentoxyfilline
Complications
Relapse and Remission
CNS complication
vascular complications
Reiters syndrome?
Immune mediated inflammation classically presenting with a triad of arthritis, uveitis, urethritis (inflammation of the joint, eyes and genital)
Triggered by STD (chlamydia/gonorrhea) or GI infection(salmonella)
Heerfordt syndrome?
Presentation of sarcoidosis non pulmonary involvement with classic features that includes:
- Parotid enlargement
- Facial paralysis
- Uveitis
- Fever
Lofgren syndrome?
Sarcoidosis presentation that involves
- Bilateral hilar lymphadenopathy
- Eryhtema nodosum
- Arthralgia
Melkerson-Rosenthal syndrome?
Recurrent facial paralysis, fissured tongue, swelling of face and lips
Presentation of orofacial granulomatosis
- nonspecific granulomatous inflammation that is not assoc with foreign body, infection and allergy
What is a HPV associated lesions?
Oral squamous papilloma Focal epithelial hyperplasia Fungiform sinonasal papilloma Conjunctival papilloma Verruca vulgaris (wart) Inverted papilloma OSCC
Tx for benign papilloma lesions
- surgical excision including the base of the lesion (to prevent recurrence)
- cryotherapy
- co2 laser
- electrocoagulation
Skin lesions
- topical salicylic acid
- intralesional IFN-alpha, bleomycin, 5-FU
- topical cryotherapy
HPV vaccination
OSCC - wide excision and recons +/- neck dissection +/- adjuvant radio/chemo therapy
What is the difference between Hodgkin and non hodgkins lymphoma?
Reed-Sternbeg cells in Hodgkin lymphoma
NHL does not have Reed-Sternberg cells
What is GVHD.
Ptns receiving allogenic bone marrow transplantation to treat bone marrow/blood diseases
- leukemia
- lymphoma
- multiple myeloma
- aplastic anemia
- thalassemia
- sickel cell anemia
- disseminated mets disease
HLA-match allogenic transplant
But still may develop immune reaction when the transplanted cells attack the native body
Presentation of GVHD
Acute -within firdt few weeks after transplant
- rash mild to severe that mimics TEN + diarrhea + nausea + vomitting + abd pain + liver dysfunction
Chronic - white striae on mucosa, ulcers, red plaques, xerostomia
Ix for immune-mediated diseases
Autobodies identification
- direct IF
- indirect IF
- IHC
- ELISA
What is the diff dx of GVHD
Any ulcerative diseases
- EM, SJS, TEN
- SLE
- Sjogrens syndrome
- pemphigus
Lichen planus?
Immune-mediated lesion of skin and mucosa
Types of lichen planus
Reticular lichen planus
Erosive LP
Does LP has tendency for malignancy?
LP is a premalignant condition
With 1% rate transformation for erosive LP
Mucosa lesions of LP presents with
Oral lesions - reticular, erosive, bullous
- Wickhams striae
- mixed red and white lesions
- erosive type: central ulceration with peripheral radiating white striae
- may have candidiasis superimposed (difficult to diagnose)
Skin lesions for Lichen planus?
Skin lesions - purple polygonal papules
Affecting flexor surfaces of extremities
Itch and can be painful on scratch
How to diagnose Lichen planus?
Diagnosis
- biopsy with DIF, saw-toothed rete ridges
- rule out Other differentials
Diff dx of lichen planus
Chronic long standing traumatic ulcer Chronic ulcerative stomatitis Eryhtroleukoplakia Lichenoid SLE GVHD Scc
Tx for lichen planus and lichenoid reactions
No tx for reticular type unless symptomatic - may b superimposed with candidiasis - antifungal topical
Erosive lp - stronger topical steroid (bethamethasone, flucinonide gels)
Heals within 2 weeks. But can flare up. So reaaplication of topical steroid
Systemic steroid responds very well but usually not necessary!
Psoriasis?
Immune mediated chronic skin disease Triggering agent (unknown) cause activation of T lymphocytes
Presentation of psoriasis
Mainly affects skin - appear as well demarcated eryhematous plaque with silvery scale
Rare - oral lesion with erythematous linear patches that flares when skin flares also
“Erythema migrans”
Undortunate complication - psoriatic arthritis
Tx for psoriasis
Topical agents: Vit D analogues Retinoids Steroids Tacrolimus
Lupus erythematous presentations
Systemic lupus erythematous (SLE)
Chronic cutaneous LE (CCLE)
Subacute cutaneous LE (SCLE)
SLE presentations
Kidney failure (40-50%) Endocarditis (50% on autopsy) Arthralgia/myalgia (95%) Malar rash (50%) Anemia (70%) Leukopenia (60%) Oral lesions (40%) - appear lichenoid - ulcers - eryhtema - hyperkeratosis
CCLE presentations
No systemic signs
Lesions affecting skin and oral (commonly in the face and neck)
- discoid lupus erythematous
- scaly erythematous patches
- heals with scar and hypo/hyperpigmentation
Oral lesions
- appear like erosive LP
- atrophic erythematous center surrounded by white radiating striae (just like erosive LP)
SCLE Presentation
In between SLE and CCLE
Treatment of LE
Avoid sun exposure (photosensitivity) NSAIDs with antimalarials (hydroxychloroquine) Topical steroids Immunosuppresants/immunomodulants - steroids - tacrolimus - low dose thalidomide
Investigations to diagnose LE
Biopsy - patchy deposits of PAS+ materials in BM (differentiates between LP)
DIF on lesions- deposition of IgM, IgG, c3
DIF on normal skin - lupus band test +ve in SLE (50% of cases)
Specific antibodies for SLE
- anti dsDNA ab
- antiSm ab
- ANA
