OSCE Book - Oral Medicine

Question 1

You are a dentist in a GDP. You are seeing Mr Williams a 68 year old NP who has attended for a check up. Mr Williams suffers from hypertension which is controlled by atenolol 25mg. Examination has revealed a homogenous white patch on the buccal mucosa on THe LHS of his mouth. You are not sure as to the cause of the lesion and wish to refer the patient for specialist management. Please explain to Mr Williams why you are concerned about the lesion you have noticed and why you wish to refer him to a specialist.

Answer 1

1. Introduce yourself to the patient
2. Explain to the patient that there are many causes of white patches in the mouth. Some completely benign but some represent changes within the mucosa that are pre-malignant. The only way to be sure is to review the tissue under the microscope.
3. White patches that have an even white appearnace and are present on the cheek have a low risk of malignance
4. High risk Lesions are ones that are speckled, nodular and verrucous in appearance and tend to be on FOM, ventrolateral surface of teh tongue and soft palate
5. Some white patches can be caused by infections like candida infections, EBV (assocaited with HIV) and syphillis.
6. Explain to patient that there are no signs or symptoms to predict which white patches will progress to form SCC so it is sensible to biopsy lesions so they can be examined under the microscope.
7. In view of this you would like to refer the patient to a specialist for biopsy to determine course of treatment. Explain that a biopsy is when you numb the area and remove of a small amount of tissue before sitching it the area back up. It can be sore and swollen after but usually well controlled with pain killers.
8. Results of biopsy will determine the treatment. Low risk are monitored on reg basis. High risk lesions are surgically removed and patient then reg monitored
9. Ask if the patient has any questions

Question 2

What are some infections which can cause white patches to form in the mouth?

Answer 2

Candida infections
Epstein-Barr virus (associated with HIV)
Syphilis

Question 3

You are a dentist in GDP. You are seeing a NP who is a smoker and has smokers keratosis. Please give the patient advice on stopping smoking.

Answer 3

Smoking cessation 5As

• Ask- Smoker status, how many per day, how long for, what product; quitting history - how many attempts, what did they use to help, what went wrong; interested in quitting again?
• Advise- use clinical findings to support benefits of quitting i.e. reduce perio disease, prevents bad breath, improves healing
  also advice of the greater health benefits to body i.e. reduce risk of CVD, cancer, stroke, look younger etc. Past failures improve chances
• Assess- readiness to stop smoking
  Why is it important for them to stop smoking? (motivation)
  How confident would you be to start your quitting journey today?
• Assist- negotiate a stop date, review previous attempts to quit - what caused it to fail?
  inform patient about NRT and its role in managing withdrawal symptoms and increasing success - gums, patches, lozenges.
  suggest reduction in cigarettes per day +/- the use of a vape - vapes primary use is to reduce cigarettes
• Arrange follow up- referral to specialist services i.e pharmacy setting, community clinics, provide telephone services. NHS stop smoking services
  support at future dental appointments

Question 4

What is this? and what causes it?

Answer 4

Smokers keratosis
Also known as Smoker’s palate is a benign and often asymptomatic lesion of the oral cavity that occurs primarily in smokers due to the heat generated by smoking, resulting in hyperplasia, keratinization, and inflammation of the palate.

Question 5

A patient attends your surgery complaining of recurrent oral ulcers. Examination reveals minor aphthous ulcers. Please explain and give this patient advice on aphthous ulcers.

Answer 5

There are a number of causes of recurrent aphthous ulcers, however we often do not have a specific singular aetiological agent for the apthous ulceration.
Host Factors
Factors involving the host could include:
* Genetic
* Nutritional
* Systemic disease
* Endocrine
* Immunity
Nutritional Deficiencies
20% of all patients with aphthous ulcers will have deficiencies of either iron, folate or vitamin B12. Replacement therapy will cause remission or improvement however most are latent.

Triggers can be stress, hypersensitivity to foodstuffs eg benzoates (crisps and chocolate), smoking and injury to mucosa

Tx is to initally remove possible causes and then treat the symptoms.
For symptomatic relief CHX or benzydamine
There is also medication that can be used to treat the disease to modulate the immune response. This may either be topical with a Betamethasone mouthwash or a Beclometasone inhaler. It may also be systemic with systemic steroids (prednisolone) or Azathioprine

Answer any questions that the patient might have.

Question 6

What is benzydamine (also known as difflam)?

Answer 6

Benzydamine is a non-steroidal anti-inflammatory drug (NSAID).

NSAIDs work by reducing the hormones that cause swelling (inflammation) and pain in your body.

Because benzydamine comes as a mouthwash, mouth spray or lozenge, it will only help with pain in the mouth. It will not work on pain in any other part of the body. Benzydamine helps with the symptoms of mouth ulcers, sore throats or when babies are teething.

Question 7

Which antimicrobrial would you prescribe in the following clinical situation?
- Acute periapical or periodontal abscess

Answer 7

Only if systemic symptoms, otherwise should be managed by local measures.

First choice - Pen V (40tablets) 250mg tablets x2, 4x daily for 5 days.
Second choice - Amoxicillin (15 tablets) 500mg, 3x daily for 5 days.

Question 8

Which antimicrobrial would you prescribe in the following clinical situation?
* ANUG (P)

Answer 8

First choice - Metronidazole (9 tablets) 400mg. 1 Tablet 3x daily for 3 days
Second choice - Amoxicillin (9 capsules) 500mg. 1 capsule 3x daily for 3 days

Question 9

Which antimicrobrial would you prescribe in the following clinical situation?
* Angular cheilitis

Answer 9

Miconazole cream 2% 20g tube apply to angles of the mouth 2x daily
N.B advise patient to use for 10days after lesions have healed
DO not give to warfarin or statin patients

Question 10

Which antimicrobrial would you prescribe in the following clinical situation?
* Denture stomatitis

Answer 10

Fungal infection can treat with local measures first before prescribing. Soak denture in CHX mouthwash 15mins 2x daily, leave dentures out the mouth at night, clean and brush palate daily

1. Fluconazole 50mg (7)capsules 7 days 1x daily
2. Miconazole oromucosal gel 20mg/g. 7 day regime. 80g tube. Apply to pea sized amount to fitting surface of upper denure after food 4x daily. Continue 7 days after lesions have healed.

Question 11

Which antimicrobrial would you prescribe in the following clinical situation?
* Recurrent herpes labials

Answer 11

• Aciclovir cream 5%. Send 2g and apply to lesion 5 times daily every 4hrs for 5 days
• 5%, 5x daily for 5 days

Question 12

Which antimicrobrial would you prescribe in the following clinical situation?
* Primary herpetic gingivostomatitis

Answer 12

• Usually symptomatic treatment but if necessary systemic aciclovir 100-200mg 5x a day for 5 days
• Local measures first are make sure hydrated, alter diet and CHX MW and analgesics

Question 13

A patient complains of dry mouth
i) What are the possible causes of dry mouth?
ii) What dental complications do patients with dry mouths suffer from?

Answer 13

A
- Polypharmacy
- Drug therapies (eg anticholinergics, antihistamines, tricyclic antidepressants, anti-reflux agents)
- Radiation damage to salivary glands
- Immune related diseases (SJogren syndrome)
- Dehydration
- Diabetes
- Renal failure
- Anxiety
- Smoking
B
- Difficulty swallowing and talking
- Altered taste
- Uncomfortable mouth
- Cant retain denture aswell
- Increases risk of caries
- Increases risk of candida infections and angular chelitits
- Acute suppurative sialadenitis is inflammation of the salivary glands caused by bacterial infection. It most commonly involves the parotid glands

Question 14

You are seeing a patient with a dry mouth in the oral medicine clinic. You suspect they have Sjogrens syndrome. You wish to carry out some special tests to confirm your diagnosis. Explain to the patient which special tests you want to get done and what they involve.

Also explain to the patient what could happen in the future to the salivary glands and how this may present.

Answer 14

Introduce yourself to the patient
Explain the tests you want to carry out
Salivary flow rate - This measures the rate of saliva production over a certain length of time. You get the patient to spit into a tube. A rest and when stimiulated (after chewing)
Eye tests - Lacrimal gland flow rate by schirmer’s - explain that tear production is often decreased when salivary flow rate is decreased. It involves placing a piece of filter paper under the eye for 5mins and seeing how far the tear drops travel. Less than 5mm indicates reduced tear production.
Labial gland biopsy - This is gold standard, you take a small sample under LA of the minor salivary gland in the lip and sent to histopathology. The area is then sutured and heals in a week.
Blood tests - Present of anti-Ro and anti-La auto antibodies

Ask patient if they have any questions?

Question 15

You are seeing a patient with a dry mouth in the oral medicine clinic. You suspect they have Sjogrens syndrome.

Also explain to the patient what could happen in the future to the salivary glands and how this may present.

Answer 15

It is possible to get salivary gland enlargement due to MALT (mucosal associated lymphoid tissue) lymphoma-B cell lymphoproliferation as a later change in Sjogrens syndrome. This would present as a firm enlargement of one or more glands.
Biopsy would be needed to confirm then referral to an oncologist.

Question 16

What is sialography and what can it be used for?

Answer 16

Sialography is a test in which you inject a radio-opaque dye into the patients salivary gland duct and then take a radiograph of the gland and assocaited duct.
This allows you to see any strictures, stones, filling defects and functional abnormalities of the gland.

Question 17

What is scintigraphy? and what would it be used for?

Answer 17

IV injection of radioactive isotope. Uptake of the radioactive isotope is then assessed using a gamma camera to visualise functional salivary gland tissue.

Question 18

A patient attends your surgery complaining of a white patch in their mouth. He is concerned about it.
A - What is the differential diagnosis of the lesion

Answer 18

1. Introduce yourself to the patient
2. Be sympathetic with his concerns
3. As dont have detailed history or examination there are lots of possible causes of white patches.
   Neoplastic and potential malignant disease
   - Leukoplakia
   - Carcinoma
   - Keratosis
   Inflammatory conditions
   - Infective diseases; candida, hairy leukoplakia (EBV), papilloma
   Non-infective conditions; Lichen planus, lupus erythematosus
   Congenital;
   - White sponge naevus
   - fordyce spots
   Other
   - Cheek biting (traumatic keratosis)
   - burns
   - graft

Question 19

A patient attends your surgery complaining of a white patch in their mouth. He is concerned about it.
B - What steps would you take to reach a diagnosis

Answer 19

• History and examination very important
  MH
• Drugs - antibiotics, immunosuppressants, steroids may predispose patient to candida infections
• Underlying diseases predisposing to candida infection
• Syphilis - rare causing white patch
  DH
• Restorations causing lichenoid reactions
• Check biting and trauma
• Chemical burns
  SH
• Smoking and alcohol increases risk group of SCC
  Examination
  E/O - angular chelitis or nodal involvement
  I/O - Charactrer of patch (does it wipe off or is it fixed (candida)). Is it uniform or straited LP, EBV
  Site of patch - where is it and is it bilateral or unilateral
• Is there any local causes from sharp teeth, dentures etc
• Blood tests
• Oral Swabs for candia
• Incisional biopsy

Answer any questions the patient might have.

Question 20

What is a likely diagnosis?

Answer 20

Raticular lichen planus or lichenoid tissue reaction

Question 21

Reticular Lichen planus

This condition can occur as one of a number of clinical subtypes. What are they?
Lichen planus

Answer 21

Clinical subtypes
* Erosive/desquamative
* Papular
* Atrophic
* Plaque like
* Bullous

Question 22

Reticular lichen planus

What are the predisposing factors?

Answer 22

• Drugs, eg antimalarials, antidiabetic drugs, NSAIDs, antihypertensives
• Dental restorations like gold and amalgam
• Graft verus host disease
• Hep C and chronic liver disease

Question 23

Reticular lichen planus

Where else can this condition occur and what are the lesions like?

Answer 23

Skin nails and genitalia may be effected
* Itchy, purple, raised patches are often seen on the wrists
* Skin of scalp effected can see hair loss
* Nails appear ridged
* Genitalia has white lesions similar to the mouth

Question 24

What is the difference between lichen planus and lichenoid tissue reaction?

Answer 24

They are effectively the same thing. However once the cause is known it becomes known as a lichenoid tissue reaction.

Lichen Planus is a cell mediated immune reaction of unknown cause.

Question 25

Please explain to the patient what Lichen planus is and how you would manage it.

Answer 25

1. Introduce yourself to the patient
2. Explain to the patient that this is a common conditon called lichen planus.
3. It effects some people on their skin, their mouth and sometimes both.
4. It can last many years
5. The cause of LP is unknown. However some people get mouth lesions called lichenoid reactions as a result of drugs (antimalarials, antidiabetic drugs, NSAIDs) or dental restorative materials, eg amalgam
6. It is not infectious

Management
Asymptomatic Lichen Planus
If the Lichen Planus is asymptomatic then very little is needed to be done to treat it. It should therefore be observed. Due to the link between lichen planus and oral hygiene, chlorhexidine can be given and this may help to improve the situation.
Symptomatic Lichen Planus
If the lichen planus is causing bother to the patient then it should be eased. First we would try removing the cause, so if due to oral hygiene improving this, or amalgam then replacing the amalgam. Avoid spicey and salty foods.
If drugs are likely implicated consult the pateints GP. Difflam (benzydamine hydrochloride MW) can be used to numb sore area. Topical or systemic steroids can also be given, or systemic immunomodulation such as azathioprine.

Can take biopsy to confirm diagnosis and monitor due to risk of malignant Transformation, as a population 1% or all lichen planus has a chance of malignant transformation.

Question 26

This 24 year old women is complaining of recurrent cold sores on her lip. On examination, she has herpes labialis

Please explain to her what the sores are and how to manage them.

Answer 26

1. Introduce yourslef to the patient
2. Explain that this is a common condition that effects about 15% of the population
3. The sores are caused by herpes simplex virus
4. You will have been infected by the virus in the past with or without symptoms. The virus then lays dormant in the patients nerves. Specifically the trigeminal nerve until it is triggered.
5. The virus can be triggered by sunlight, stress, trauma, immunosuppression, fever and menstration.
6. Reassure the patient and say the sores should come and go within 7-10days.
7. The lesions are contagious however so contact should be avoided
8. Treatment is anti-viral creams. Aciclovir 5% cream can be applied to sore 5x a day every 4-5hrs. This must be done as soon as symptoms develop, i.e tingling or prickling sensation on the lip.
9. Ask if the patient has any questions

Question 27

Pleae obtain consent from this fit and healthy patient for the surgical removal of fibroepithelial polyp from her tongue under LA.

Answer 27

1. Introduce yourself to the patient
2. Explain that you wish to gain consent to remove a lump on their tongue

In order to gain consent must over these points with the patient
1. The aim of the procedure is to remove this troublesome lump. If the lump is not remvoved then it may enlarge and continue to be truamatised
2. Once removed it should not come back unless the area is traumatised again
3. The procedure will be down under LA, which will mean you will require some injections to make the area go numb
4. Once the area is numb you will feel pressure but no pain. If they do feel pain then let the operator know and can top up the LA.
5. Once the lump is removed it will be sent to histopathology for examination under the microscope. Reasssure that this is normal practice for all lumps and bumps removed.
6. The wound will then be stitched up with dissolving stitches but may bleed for a short while
7. POI for caring for the wound will be given after the procedure
8. The wound should heal within a week but during that time the area will be a bit sore and swollen so can take pain medications as needed
9. Ask if the patient has any questions

Fill in the consent form and get the patient to then sign it.

N.B The main purpose of gaining consent is to explain the procedure to the patient and ensuring that they understand it and agree to have it carried out.

Question 28

Please carry out an excisional biopsy on this fibroepithelial polyp on this biopsy pad.

Props:
- Scalpel with No15 blade
- Toothed tissue forceps
- Needle holder
- 3-0 suture (black silk or vicryl)
- Suture scissors
- Biopsy pad

Answer 28

Question 29

You are reviewing a patient who has had an incisional biopsy for a white patch in their mouth. The histopathology report states that the lesion shows features of mild dysplasia.

Please explain to the patient what this means, the significance of the diagnosis and how this may be managed?

Answer 29

1. Introduce yourself to the patient
2. Explain to the patient that the biopsy showed evidence of mild displasia, which means abnormal growth within the tissue.
3. Explain that it is possible to get a whole spectrum of changes in the tissue. From normal at one end to carcinoma (cancer) at the other. Between these two ends of the spectrum there is differentiating grades of dysplasia (mild,moderate and severe) and carcinoma in situ. This biopsy showed mild dysplasia which means that there were some abnormalities within the tissue but it is not carcinoma
4. Explain that some lesions do progress to from carcinoma, however, some lesions regress. Reported rates of malignant change vary widely so it is not possible to give individual patients an exact rate.
5. Having an area of dysplasic change means the patient is of higher risk of getting dysplastic changes elsewhere in the mouth and then developing cancer
6. Explain the management includes
   - Reducing as many predisposing factors as possible. smoking, chewing tobacco, betel nut chewing, high alcohol intake.
   - Treating any assocaited candida infections if present
   - Treating any nutrional deficiencies
7. Explain that the patient may require long term monitoring at regualr intervals.
   - Photographs of the lesion
   - Repeated biopsys at later dates
   - Areas of mild dysplasia arnt often removed but if it does progress then surgical removal of the lesion may be indicated. (laser, cyrotherapy or surgucal removal_
8. Reassure the patient that they have not got orla cancer but they need to be aware of the small change it might develop.
9. Ask if they have any questions