OSCE DOC - Oral medicine Flashcards
Denture Induced Stomatitis (6 mins)
Patient diabetic and taking warfarin. Give findings and explain treatment.
A patient has a sore denture and sore palate, test done previously to confirm condition and you have received the results. Denture induced stomatitis affecting the hard palate, providing with picture showing this as well as results of a swab. Medical history includes diabetes type 2 and on warfarin for atrial fibrillation.
Explain findings to patient, recognise the multifactorial condition and provide oral hygiene advice. You can ask relevant questions to the actor, but you don’t need to take another medical history.
What questions should you ask the patient to understand a little more about their history?
Introduce self and designation (2 marks)
Brief history
* Acknowledges diabetic history and ask about control (2 marks) (if taking insulin in type 2, means they were unable to maintain control with behavioural changes, body weight reduction and oral hypoglycaemics such as metformin), ask about diabetic symptoms- tired, thirsty, going to toilet
* Ask about AF and warfarin- INR below 4
* Ask if denture worn at night (1 mark)
* Ask about denture hygiene (1 mark)
Denture Induced Stomatitis (6 mins)
Patient diabetic and taking warfarin. Give findings and explain treatment.
A patient has a sore denture and sore palate, test done previously to confirm condition and you have received the results. Denture induced stomatitis affecting the hard palate, providing with picture showing this as well as results of a swab. Medical history includes diabetes type 2 and on warfarin for atrial fibrillation.
Explain findings to patient, recognise the multifactorial condition and provide oral hygiene advice. You can ask relevant questions to the actor, but you don’t need to take another medical history.
What are some signs and symptoms that this patient may be experiencing?
- Red and sore palate
- Erythematous and oedema of denture bearing area
- Burning sensation
- Inflamed mucosa under upper denture
- Discomfort
- Bad taste and halitosis
Denture Induced Stomatitis (6 mins)
Patient diabetic and taking warfarin. Give findings and explain treatment.
A patient has a sore denture and sore palate, test done previously to confirm condition and you have received the results. Denture induced stomatitis affecting the hard palate, providing with picture showing this as well as results of a swab. Medical history includes diabetes type 2 and on warfarin for atrial fibrillation.
Explain findings to patient, recognise the multifactorial condition and provide oral hygiene advice. You can ask relevant questions to the actor, but you don’t need to take another medical history.
What is newtons classifcation of stomatitis?
Denture Induced Stomatitis (6 mins)
Patient diabetic and taking warfarin. Give findings and explain treatment.
A patient has a sore denture and sore palate, test done previously to confirm condition and you have received the results. Denture induced stomatitis affecting the hard palate, providing with picture showing this as well as results of a swab. Medical history includes diabetes type 2 and on warfarin for atrial fibrillation.
Explain findings to patient, recognise the multifactorial condition and provide oral hygiene advice. You can ask relevant questions to the actor, but you don’t need to take another medical history.
Explain to the patient in simple terms what the condition is and your clinical findings.
Denture induced stomatitis- explain clearly with no jargon (2 marks)
* Red inflamed area on areas of the mouth covered by the denture, commonly the roof of your mouth. Due to a yeast / fungus called candida. Typically pain free.
Patient has denture induced stomatitis which is a fungal infection causing inflammation of the tissues that are in contact with the denture and it can occur due to a variety of reason and is more susceptible in patients who are immunocompromised.
Denture Induced Stomatitis (6 mins)
Patient diabetic and taking warfarin. Give findings and explain treatment.
A patient has a sore denture and sore palate, test done previously to confirm condition and you have received the results. Denture induced stomatitis affecting the hard palate, providing with picture showing this as well as results of a swab. Medical history includes diabetes type 2 and on warfarin for atrial fibrillation.
Explain findings to patient, recognise the multifactorial condition and provide oral hygiene advice. You can ask relevant questions to the actor, but you don’t need to take another medical history.
Explain to the patient how you are going to manage their problem and how you are going to treat the disease?
Management advice
1. Palate brushing 2x daily to treat condition (1 mark)
2. Can rinse mouth with CHX 0.2% 10ml 2x daily for 1 minute
3. Advice on cleaning denture (2 marks- 1 for brushing and 1 for soaking)
- Brushing after meals with a soft toothbrush and non-abrasive denture cream (or detergent)
- Use denture cleanser once daily according to manufacturer’s instructions- soaking in CHX mouthwash or sodium hypochlorite for 15 mins 2x daily (NaOCl only for acrylic dentures)
- Thoroughly rinse denture after soaking in solution
4. Leaving denture out at night and as often as possible during treatment period (1 mark)- **soak in plain water overnight **
5. Check denture fit- if themselves contributing to problem: adjust or remake (1 mark) (tissue conditioner on fitting surface of denture to allow tissues to heal when dentures are worn during treatment)
6. Limiting smoking if possible
7. Limit sugar in diet
8. Confirm that patient understands instructions. Get them to ask if they have any questions
9. Give away information leaflet if there is one available
This infection can be more common in patients with diabetes so emphasise need to control diabetes
Denture Induced Stomatitis (6 mins)
Patient diabetic and taking warfarin. Give findings and explain treatment.
A patient has a sore denture and sore palate, test done previously to confirm condition and you have received the results. Denture induced stomatitis affecting the hard palate, providing with picture showing this as well as results of a swab. Medical history includes diabetes type 2 and on warfarin for atrial fibrillation.
Explain findings to patient, recognise the multifactorial condition and provide oral hygiene advice. You can ask relevant questions to the actor, but you don’t need to take another medical history.
Examiner ask ‘what antimicrobial agent would you prescribe to treat this condition and why?’
- None or CHX moutwash
Assess 7 days later, and then do further treatment if needed
Nystatin (1 of 2 marks) (send 30ml; label 1ml after food 4x daily for 7 days; remove dentures before use, rinse suspension in mouth and hold near lesion for 5 mins before swallowing; continue use for 48 hours after lesions have healed)
Azole antifungal (deducted 2 marks due to warfarin interaction)
Primary Herpetic Gingivostomatitis (6 mins)
A patient brings her child to the clinic, not feeling well and is distressed. You are provided with an image.
Take a history, provide a diagnosis to the mother, provide ways to treat the condition and answer any questions the mother may have.
Take a history of this childs condition. What important questions need to be asked?
Introduce self and designation (2 marks)
Take history
* Number of days symptoms? (1 mark)
* Does the child have a fever? (1 mark)
* Child less active than normal? (1 mark) Has analgesia been used? (1 mark)
* Did it work? (1 mark)
* - PHG signs- lymphadenopathy, malaise, fever / pyrexia, erythematous gingivae, ulceration, loss of appetite, refuse to eat / brush
* - PHS symptoms- sore mouth and throat, fever, enlarged lymph nodes
Primary Herpetic Gingivostomatitis (6 mins)
A patient brings her child to the clinic, not feeling well and is distressed. You are provided with an image.
Take a history, provide a diagnosis to the mother, provide ways to treat the condition and answer any questions the mother may have.
What are the signs and symptoms of PHG?
- PHG signs- lymphadenopathy, malaise, fever / pyrexia, erythematous gingivae, ulceration, loss of appetite, refuse to eat / brush
- PHS symptoms- sore mouth and throat, fever, enlarged lymph nodes
Primary Herpetic Gingivostomatitis (6 mins)
A patient brings her child to the clinic, not feeling well and is distressed. You are provided with an image.
Take a history, provide a diagnosis to the mother, provide ways to treat the condition and answer any questions the mother may have.
Explain the diagnosis to the mother, explaining what the condition is, and reassure them of the severity.
Primary herpetic gingivostomatitis- explanation in lay persons terms (2 marks)
Contagious primary infection caused by herpes simplex virus (1 mark)
Self-limiting and will disappear in 7-10 days (1 mark)
High carriage rate in population, common (1 mark)
- Most often occurs in young children and is usually the first exposure a child has to herpes virus (which is also responsible for cold sores and fever blisters)
Most initial infections are subclinical but can present as this florid infection (3 marks)
- Explain in lay persons terms- usually no symptoms
- Often will present with blisters on the tongue, cheeks, gums, lips and roof of mouth. After the blisters pop, ulcers will form
- Other symptoms to watch out for are high fever, difficulty swallowing, drooling and swelling
- Also, because the sores make it difficult to eat and drink, dehydration can occur.
Child may or may not develop cold sores in future (1 mark)
Primary Herpetic Gingivostomatitis (6 mins)
A patient brings her child to the clinic, not feeling well and is distressed. You are provided with an image.
Take a history, provide a diagnosis to the mother, provide ways to treat the condition and answer any questions the mother may have.
What would be the management and treatment of this patient and explain this to the mother.
- Supportive
- Push fluid intake (1 mark) Due to risk of dehydration.
- Analgesia to control fever / pain (2 marks) (paracetamol / ibuprofen) (SDCEP- benzydamine spray can provide additional relief)
- Bed rest, take it easy (1 mark)
- Clean teeth with damp cotton roll or cotton cloth to rub around gums (1 mark)
- Can use dilute CHX to swab gums (1 mark) (SDCEP- the use of antimicrobial mouthwashes controls plaque accumulation if toothbrushing is painful and also helps to control secondary infection in general)
- As child has had problems for 3 days and is otherwise fit and healthy, antiviral medication (aciclovir) is not recommended (2 marks)
Primary Herpetic Gingivostomatitis (6 mins)
A patient brings her child to the clinic, not feeling well and is distressed. You are provided with an image.
Take a history, provide a diagnosis to the mother, provide ways to treat the condition and answer any questions the mother may have.
In what instances would you prescribe anti-viral medications for this condition and what would that prescription be?
- If necessary, i.e. severe or immunocompromised
- NB, if under 2 years, half dose (100mg)
- Patient’s name, DOB, address, CHI, age in numbers if under 12
- Aciclovir 200mg tablets- 5 day regime, send- 25 tablets, label- take 1 tablet 5 times daily
Refer immunocompromised patients to hospital.
Recurrent Aphthous Stomatitis (6 mins)
27-year-old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size (history provided, etc.).
Using this information and the available lab results (patient has low iron and folate) discuss the lab findings, the diagnosis and management options for this condition with the patient.
You do not need to gain any more information from the patient. Minor apthous ulcers
Explain to the patient their diagnosis.
- You have microcytic aneamia as a result of low iron and folate.
- This means that you have less RBC’s in your body
- RBC’s carry oxygen around your body to different tissues
- As a result of less oxygen you may feel tired, breathless or paler
- In addition to this you can also present with small ulcers in the mouth which last about 2 weeks and heal with no scaring.
- Recurrent aphthous stomatitis can also result from a nutritional deficiency, particularly lack of iron, vitamin B3 (as in pellagra), vitamin C (as in scurvy), folic acid, or vitamin B12.
Other causes can be mouth injury, stress, and some foods may trigger an attack.
Recurrent Aphthous Stomatitis (6 mins)
27-year-old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size (history provided, etc.).
Using this information and the available lab results (patient has low iron and folate) discuss the lab findings, the diagnosis and management options for this condition with the patient.
You do not need to gain any more information from the patient. Minor apthous ulcers
What can cause low iron and folate levels (microcytic aneamia)?
- Lack of iron in the patients diet is most common
- However can be more sinister with GI bleed, Crohns disease, Coeliac disease, UC
- Stomach ulcer or taking NSAIDs
Recurrent Aphthous Stomatitis (6 mins)
27-year-old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size (history provided, etc.).
Using this information and the available lab results (patient has low iron and folate) discuss the lab findings, the diagnosis and management options for this condition with the patient.
You do not need to gain any more information from the patient. Minor apthous ulcers
How would you manage this patient?
Management:
1. ‘Iron deficiency can easily be managed with iron supplements and an increase of iron in the diet’
1. ‘This would also resolve the minor ulceration in your mouth which tends to go away in 1-2 weeks without scarring’
1. ‘Your GP should be able to prescribe you iron supplements in tablets to be taken twice daily and might choose to investigate you further to determine if there is an underlying condition’
1. ‘My advice in the meantime is to try and increase the iron in your diet, avoid spicy foods like curries and if your mouth is very sore (can’t eat, etc.), I can prescribe a numbing mouthwash to allow you to be more comfortable
1. - Benzydamine mouthwash 0.15%- send 300ml, label- rinse or gargle using 15ml every 1.5 hours as required (can be diluted 1:1 with water if stinging, spit out after rinsing, not more than 7 days) or CHX (but probably too sore)
1. - Betamethasone mouthwash, beclomethasone inhaler, systemic immune modulation (systemic steroids, azathioprine)
Recurrent Aphthous Stomatitis (6 mins)
27-year-old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size (history provided, etc.).
Using this information and the available lab results (patient has low iron and folate) discuss the lab findings, the diagnosis and management options for this condition with the patient.
You do not need to gain any more information from the patient. Minor apthous ulcers
If this patient cause was not anaemia and was unknown how would you manage them?
If not anaemia
- dietary modification (benzoates, sorbate, cinnamaldehyde),
- correct deficiency,
- correct systemic disease,
- remove trauma,
- remove allergens / SLS
Recurrent Aphthous Stomatitis (6 mins)
27-year-old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size (history provided, etc.).
Using this information and the available lab results (patient has low iron and folate) discuss the lab findings, the diagnosis and management options for this condition with the patient.
You do not need to gain any more information from the patient. Minor apthous ulcers
What diet advice would you give to this patient?
- Want to have foods high in iron and folate. Rice, meat, tofu, eggs, green vegtables like kale.
- Avoid benzoates
- Avoid chocolate, tomatoes, SLS products
White Patch FOM (6 mins)
Discuss need for biopsy and possibility of oral cancer.
Discuss patient risk factors
- Discuss the possible causes of a white patch
- Lichenoid reaction
- Lichen planus
- Smokers keratosis
- Hyperkeratosis due to truma
- SCC
- Hereditary- white sponge naevus, Fordyce spots
White Patch FOM (6 mins)
Discuss need for biopsy and possibility of oral cancer.
Discuss patient risk factors (as patient smokes and drinks alcohol)
Discuss the white patch on the floor of the mouth
- Introduce yourself to the patient
- 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.
- White patches that have an even white appearance and are present on the cheek have a low risk of malignance
- High risk Lesions are ones that are speckled, nodular and verrucous in appearance and tend to be on FOM, ventrolateral surface of the tongue and soft palate
- Some white patches can be caused by infections like candida infections, EBV (assocaited with HIV) and syphillis.
- 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.
- 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.
- 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
- Ask if the patient has any questions
White Patch FOM (6 mins)
Discuss need for biopsy and possibility of oral cancer.
Discuss patient risk factors (as patient smokes and drinks alcohol)
Discuss this patients risk factors with them.
Management of risk factors:
Smoking cessation advice. 5As
Reduce alcohol consumption- mention 14 units- consider the patch as a wake up call to quit
Synergistic effect of smoking plus alcohol
Primary Herpetic Gingivostomatitis (6 mins)
Teen- with systemic involvement. Aciclovir prescription.
Please write a prescription for a child under 2 years of age and one for a child over 2 years of age.
Aciclovir prescription:
200mg tablets or oral suspension (200mg/5ml or 100mg/5ml)
Send- 25 tablets
Label- 1 tablet 5 times daily (5x200mg for >2 y/o, 5x100mg for <2y/o)
For 5 days
100mg for under 2
Label the lymph nodes on this diagram.
Giving Biopsy Results- Epithelial Dysplasia- Alcohol (6 mins)
Biopsy results = dysplasia
Discuss diagnosis and give advice regarding alcohol intake.
Explain to the patient there diagnosis in empathetic manner.
- Establish what patient knows about the biopsy and possible implications.
- Break news of the diagnosis
- ‘Epithelial dysplasia which has a potential to be cancerous’
- Stress to the patient:
- ‘This is not cancerous yet but there is evidence of abnormal tissue change’
- Ensure they understand:
- ‘This diagnosis implies that there is a higher risk for a transformation to malignancy’
- Good news: ‘The good news is that the risk can be reduced by removing the factors that can cause cancer’
- Like by reducing thier alcohol consumption
- Staying below the recommended 14units per week and avoid binge drinking
What are the 3As and 1R for alcohol. What are some examples for each step.
3 As, 1R
Ask- how much do you drink / units? What kind? Eye-opener? Family concerns?
Advise- effects on general and dental health
- stress that alcohol increases the risk of oral cancer
- oral effects- fungal, caries, dry mouth, perio, poor wound healing, dental erosion, bruxism, increased bleeding so reduced clotting
- general effects- increased risk of stroke, cardiac disease, liver disease
Assess- whether patient is willing to reduce drinking, inform them that this is fundamental to prevent oral cancer
Refer- alcoholics anonymous
Guidelines- maximum 14 units per week with at least 2-3 drink free days
- ‘In your case you should consider cutting alcohol completely due to it being a risk factor for your dysplasia turning to cancer
OFG (6 mins)
History of patient given- swollen lips all his life. Chat through history, ask and ascertain local and systemic signs.
How does OFG cause swelling? and what type of reaction is OFG?
OFG causes inflammation which then blocks drainage of lymphatics and this causes swelling of the lips.
OFG is an autoummune conditon caused by a type 4 sensitivity reaction to things like:
- Benzoates
- Chocolate
- Sorabic acid
