Oral pathology

Question 1

What is herpes simplex virus (HSV)?

Answer 1

Herpes simplex virus is an enveloped double stranded DNA virus that belongs to alpha herpes virus

Question 2

What are the 2 types of HSV?

Answer 2

HSV-1
HSV-2 (Rarely oral, usually causes genital herpes)

Question 3

When do most people acquire HSV?

Answer 3

Childhood

Question 4

What percentage of UK adults have been infected with HSV?

Answer 4

70%

Question 5

How is HSV transmitted?

Answer 5

Via infected oral secretions during close contact

Question 6

How may primary infection with HSV-1 present?

Answer 6

• Asymptomatic
• May cause primary gingivostomatitis

Question 7

What is primary gingivostomatitis?

Answer 7

Disease of preschool children, represents the worst end of spectrum of disease seen during primary HSV1 infection

A severe inflammatory reaction with vesicle formation leading to painful ulcers (gingivostomatosis)

Question 8

How does primary gingivostomatitis present?

Answer 8

Systemic upset (Fever, local lymphadenopathy)
Vesicles and ulcers on lips, buccal mucosa and hard palate

Question 9

What is shown?

Answer 9

Primary gingivostomatitis (Severe inflammatory reaction to primary HSV-1 infection)

Question 10

How long does primary gingivostomatitis usually take to recover?

Answer 10

3 weeks

Question 11

What is an infective hallmark of all herpes viruses?

Answer 11

The hallmark of all herpes viruses is the ability of viruses to establish latent infections that persist for the life of the individual

Question 12

What are some factors that can cause reactivation of HSV-1 from the trigeminal ganglia?

Answer 12

Stress
Trauma
Febrile illnesses
UV radiation

Question 13

What is the common name for latent HSV-1 reactivation?

Answer 13

Cold sore (Herpes labialis)

Question 14

Describe the pattern of latency and activation in HSV-1

Answer 14

• Not all reactivations are symptomatic, and only 1/2 of infected people get clinical recurrences
• Multiple cycles of latency and activation possible but natural history is for decreasing frequency

Question 15

How does latent HSV infection present?

Answer 15

Oral herpetic lesions

Question 16

What is herpetic whitlow?

Answer 16

HSV infection of the finger

Question 17

How does herpetic whitlow occur?

Answer 17

Innoculation of the virus through a break in the skin barrier

Question 18

Who is most at risk of herpetic whitlow?

Answer 18

• Dentists
• Anaesthetists
• Children at the time of primary oral infection through finger biting

Question 19

What is shown?

Answer 19

Herpetic whitlow

Question 20

What is a possibly fatal form of HSV-1 infection?

Answer 20

Herpes simplex encephalitis

Question 21

How does herpes simplex encephalitis present?

Answer 21

Rapid onset of:
- Fever
- Headache
- Seizures
- Focal neurological signs
- Impaired consciousness

Question 22

How is HSV-1 infection investigated?

Answer 22

Swab of lesion in virus transport medium - detection of HSV DNA by PCR

Question 23

How is HSV-1 infection managed?

Answer 23

Antiviral medications e.g. acyclovir help to reduce the severity and frequency of symptoms, but cannot cure the infection

Question 24

What is herpangitis?

Answer 24

Benign clinical syndrome characterised by fever and painful papulo-vesiculo-ulcerative oral enanthem

Question 25

What causes herpangina?

Answer 25

Coxsackie viruses (enterovirus)

Question 26

Who is most at risk of herpangina?

Answer 26

Children

Question 27

How does herpangina present?

Answer 27

- High fever - Throat - hyperemia and yellow/greish-white papulovesicular lesions

Question 28

What is shown?

Answer 28

Herpangina

Question 29

How is herpangina investigated?

Answer 29

Clinical diagnosis or by PCR test of swab in viral transport medium

Question 30

How is herpangina managed?

Answer 30

Supportive - viral, self-limiting

Question 31

What is hand, foot and mouth disease?

Answer 31

Clinical syndrome characterised by an oral enanthem and a macular, maculopapuar, or vesicular rash of the hands and feet, usually spreading around a family

Question 32

What causes hand, foot and mouth disease?

Answer 32

Coxsackie viruses

Question 33

How does hand, foot and mouth disease present?

Answer 33

Oral enanthem and a macular, maculopapuar, or vesicular rash of the hands and feet

Question 34

What is shown?

Answer 34

Hand, foot and mouth disease

Question 35

How is hand, foot and mouth disease investigated?

Answer 35

Clinical diagnosis or by PCR test of swab in viral transport medium

Question 36

How is hand, foot and mouth disease managed?

Answer 36

Supportive

Question 37

What is an aphthous ulcer?

Answer 37

An aphthous ulcer is typically a recurrent round or oval sore or ulcer inside the mouth on an area where the skin is not tightly bound to the underlying bone They are usually surrounded by an inflammatory halo

Question 38

What are some common locations in the mouth for aphthous ulcer formation?

Answer 38

Inside of the lips and cheeks or underneath the tongue

Question 39

What causes aphthous ulceration?

Answer 39

Most likely due to immune dysfunction triggered by an external factor e.g. emotional stress, certain foods (salty foods)

Question 40

What is another name for aphthous ulcer?

Answer 40

Canker sore

Question 41

How long do aphthous ulcers usually last?

Answer 41

Self limiting - each ulcer lasts less than 3 weeks

Question 42

What is oral candidiasis?

Answer 42

Fungal mouth infection that causes white spots or patches in the mouth

Question 43

What causes oral candidiasis?

Answer 43

Candida albicans

Question 44

What are some risk factors for oral candidiasis?

Answer 44

Post antibiotics Immunosuppressed Smokers Inhaled steroids

Question 45

How does oral candidiasis present?

Answer 45

White patches on red, raw mucous membranes in the throat/mouth

Question 46

What is shown?

Answer 46

Oral candidiasis

Question 47

How is oral candidiasis managed?

Answer 47

Nystatin or fluconazole

Question 48

What are some causes of oral ulceration?

Answer 48

Primary syphilis Mucosal leishmaniasis Behcet's disease Coeliac disease IBD Reactive arthritis (Reiter's disease) Drug reactions Skin disease

Question 49

How does primary syphilis spread?

Answer 49

Direct sexual contact with the infectious lesions of another person

Question 50

What bacteria causes primary syphilis?

Answer 50

Treponema pallidum

Question 51

What are some common sites of entry for syphilis?

Answer 51

Genitals Mouth Pharynx

Question 52

What is shown?

Answer 52

Mucosal leishmaniasis

Question 53

Where are leishmania species most commonly found?

Answer 53

Africa Americas

Question 54

What is Behcet's disease?

Answer 54

Inflammatory, multisystemic disorder

Question 55

What are some features of Behcet's disease?

Answer 55

Oral ulceration Genital ulceration Uveitis Visceral organ involvement (E.g. GI, resp, cardio, MSK)

Question 56

Where is Behcet's disease most commonly found?

Answer 56

Middle East and Asia

Question 57

How does coeliac's disease or IBD present in the mouth?

Answer 57

Recurrent aphthous ulcers

Question 58

How can reactive arthritis present in the mouth?

Answer 58

Painless oral ulcers

Question 59

What are some drugs that can cause mouth ulcers?

Answer 59

NSAIDs ß-blockers Sulfonamides

Question 60

What are some skin diseases that present with oral ulceration?

Answer 60

Lichen planus Pemphigus Pemphigoid

Question 61

What is squamous cell papilloma?

Answer 61

Generally benign papilloma that arises from the stratified squamous epithelium

Question 62

Describe the aetiology of squamous cell papilloma of the mouth

Answer 62

- Two peaks of incidence - <5 years and between 20-40 years - Related to HPV exposure - types 6 and 11 - Children - aggressive disease - Adults - often solitary

Question 63

How does squamous cell papilloma of the mouth present?

Answer 63

- Painless lesion most commonly found in the mucosa of the hard and soft palate - Commonly involves soft palate, tongue, lips, tonsils but can occur anywhere there is stratified squamous epithelium (e.g. skin, oesophagus, cervix)

Question 64

What is shown?

Answer 64

Squamous cell papilloma of the mouth

Question 65

What will macroscopic biopsy show in squamous cell papilloma?

Answer 65

Exophytic, sessile or pedunculated mass

Question 66

What will microscopic biopsy show in squamous cell papilloma?

Answer 66

Finger-like projection, fibrovascular core covered by stratified squamous epithelium

Question 67

How is squamous cell papilloma managed?

Answer 67

- Most cases require no treatment - When treatment required, options include cryotherapy, topical salicylic acid and surgical excision