Summary of Notes Flashcards
what is non-steroid topical therapy for
inconvenient lesions
what is steroid topical therapy for
disabling immunologically driven lesions
name some non-steroid topical therapies
chlorhexidine
benzydamine
bonjela
name some steroid topical therapies
hydrocortisone mucoadhesive pellet
betamethasone
beclomethasone MDI
what is the betamethasone prescription
dissolve 1mg in 10mls of water
rinse for 2 mins twice daily
what is beclomethasone prescription
50mcg inhaler
position over area
2 puffs 2-4x daily
what blood tests do patients need before starting systemic steroids
BBV screen
ferritin, folate, vitamin B12
FBC
electrolytes
liver function
pregnancy
what is keratosis
keratin production
what is acanthosis
thickening due to hyperplasia of stratum spinosum
what is elongated rete ridges
hyperplasia of basal cells
what is geographic tongue and what does it look like
alteration to maturation and replacement of normal epithelial surface
areas are semicircular white and red patches which can become sensitive
what is black hairy tongue and treatment
elongation of surface papilla becoming food stained
can be from bacterial colonisation/smoking
tongue scraper/nectarine stone
what is fissured tongue and implications
asymptomatic variation of normal
food trapping so inflammation and candida
what is glossitis and what treatment
smooth tongue with red appearance (atrophy)
investigate haematinics and fungal cultures
when are swellings referred
symptomatic
abnormal overlying and surrounding mucosa
increasing in size
rubbery
unsightly
why are lesions white
thickening of keratin meaning you cant see blood
less blood in tissues
what are fordyce spots
ectopic sebaceous glands
what is hereditary keratosis
white sponge naevus starting posteriorly and spreading anteriorly
fluid accumulation between cells
when do you refer a white lesion
raised/thickened
it is without cause
if on lateral tongue/soft palate/FoM
what are red lesions caused by
reduced flow causing inflammation
reduced thickness of epithelium
what are the features of mucosal melanoma
variable irregular outline with raised surface and would itch/bleed
what do you ask for ulcer history
where
blister or ulcer
if recurrent
size/shape
how long
same place
ulcer free period
what is recurrent herpetic lesions and where are they
ulceration is limited to one nerve group/branch
hard palate and recurs in the same place
patient aware of prodromal period with vesiculation
what is minor RAS
<10mm
lasts 2 weeks
non-keratinised mucosa
heal without scarring
responds to topicals
what is major RAS
> 10mm
lasts months
any part of mucosa
can scar
intralesional steroids better
what is herpetiform RAS
many small ulcers on non-keratinised mucosa
lasts 2 weeks
coalesce
not herpes
what is Behcets
oral-genital ulceration
need 3+ episodes of mouth ulcers a year and 2 of genital sores/eye inflammation/skin ulcers/pathergy
how do you treat Behcets
treat RAS
systemic immunomodulation (colchicine/azathioprine/mycophenolate)
what is the predisposition to RAS
genetics
systemic disease
stress
trauma
hormone fluctuations
viral and bacterial
what is aphthous ulcers like on a cellular level
damage to basal cells at basement membrane so cannot produce epithelial replacement cells
what are the investigations for aphthous ulcers
haematinics
coeliac disease
allergy testing
how do you manage RAS
correcting deficiencies
refer if coeliac
avoid SLS toothpaste
non-steroid topicals for inconvenient lesions
steroid topicals for disabling lesions
what are the patterns of lichen planus
reticular
atrophic
erosive
how do you manage RAS in children
3 month iron supplements
refer if no working treatment and children under 12
what is lichen planus like histologically
lymphocytic band hugging membrane
saw tooth rete ridges
basal cell damage
patchy acanthosis
parakeratosis
what is the immunology of lichen planus
langerhans cells present antigen to immune cells and lymphocytes activate to remove irritation
what drugs cause lichen planus
DMARDS - gold, quinine, B blockers, ACE inhibitors
what is lichen planus like on the gingiva
desquamative gingivitis
what do lichenoid drug reactions look like
bilateral
mirrored
respond poorly to treatment
when is amalgam replaced for amalgam reactions
if symptomatic or potentially malignant
management for mild lichenoid lesions
OTC chlorhexidine
benzydamine
avoid SLS
management for persisting lichenoid lesins
topical steroids - beclomethasone/betamethasone
what is the specialist management for lichenoid lesions
higher strength topicals
tacrolimus
clobetasol
hydroxychloroquine
azathioprine
mycophenolate
what is GVHD and what is histology
transplant marrow sees host marrow as foreign and rejects the host
lymphocytic band along basement membrane and change in keratinisation
NO SAW TOOTH RETE RIDGES
what is lupus erythematous histologically
lymphocytic infiltrate deeper into connective tissue away from basement membrane
name 2 lichen like lesions
GVHD
lupus erythematous
how do you treat lichen like lesions
symptomatically like LP and liaise with physician
risks for oral cancer
smoking
drinking
socioeconomic
poor oral health
sexual activity
how to reduce oral cancer risk
stopping smoking and drinking
increase intake of fresh fruit and veg
what does low grade dysplasia show
tumour comes from normal epithelium
architectural changes in lower third
slight atypia
increased keratin production
well defined tumour islands with basal cell layer
invasion pattern with large rete ridges into connective tissue
what does high grade dysplasia show
little resemblance to epithelium
architectural change in upper third
lots of atypia
non-cohesive invasion
prominent mitotic figures
what is carcinoma in situ
cytologically malignant but not invading
abnormal architecture with severe atypia
what are the prognostic factors histologically for oral cancer
pattern of invasion
depth of invasion
perineural invasion
invasion of vessels
what does multi stage promotion mean for oral cancer
there was a tendency for cell division already but environmental changes promote it
what is field characterisation
higher risk of cancer with 5cm radius of primary lesion
screening tools for HPV16
screening
toluidene blue
velscope
photodynamic diagnosis
clinical judgement
what is vesiculobullous diseases
antibody mediated immune diseases
what is needed for DIF and what do you see
need biopsy, see antibody bound to tissue
what is needed for IIF and what do you see
blood plasma, see circulating antibodies
what does erythema multiforme look like
skin target lesions and oral ulceration
crusty lips and bleeding
what is the cellular level of erythema multiforme
large complex made of antigen and antibody unable to pass through capillaries so it gets stuck and activates complement causing perivascular inflammatory response
what is treatment for erythema multiforme
betamethasone, difflam, gelclair as barrier
40-60mg prednisolone for severe
400mg acyclovir for recurrent
what is the histology of erythema multiforme
inter and intracellular oedema overlying epithelium
acantholysis
elongation of rete pegs
vasodilation
connective tissue oedema
what is angina bullosa haemorrhagica clinical findings
blood blisters in mouth come on fast but burst after 1hr
DIF and IIF are negative
treatment for ABH
none
explain eating and steroid inhalers are triggers
what is pemphigoid
subepithelial antibody attack causing separation of epithelium from connective tissue and thick blister formation
what is the cellular level of pemphigoid
attack on hemidesmosomes of which BP180 and BP230 more commonly targeted
what does DIF of pemphigoid show
linear deposition of immunoglobulins along basement membrane
what does IIF show for pemphigoid
C3 and IgG
what is the treatment of pemphigoid
topical steroids (betamethasone rinse)
azathioprine, mycophenolate - immunosuppressive
rituximab - biologic
what is pemphigus
intraepithelial blistering disease attacking the desmosomes (desmoglein 1 and 3)
what does pemphigus appear as clinically
oral ulcerative lesions
desquamative gingivitis
open skin lesions
Nikolsky sign positive
what do you see histologically for pemphigus
acantholysis in lower spinous layers
suprabasal split and Tzank cells
what does DIF show for pemphigus
intralesional intercellular deposition of IgG and C3 along epidermal cell surfaces in areas of acantholysis
what does IIF for pemphigus show
circulating antibodies targeting epidermal cell surfaces
what is the treatment for pemphigus
betamethasone and difflam
prednisolone, azathioprine, mycophenolate
rituximab
what can dry mouth be caused by
salivary gland disease
drugs
medical conditions
radiotherapy
anxiety and somatisation disorders
what drugs cause dry mouth
ANTIMUSCARINIC CHOLINERGIC DRUGS
tricyclics
antipsychotics
antihistamine
atropine
diuretics
cytotoxics
what medical problems cause dry mouth
diabetes
renal disease
burns
vesiculobullous diseases
what are the direct salivary gland problems
aplasia
sarcoidosis
HIV
gland infiltration
cystic fibrosis
what is sarcoidosis
enlargement of glands due to granuloma change
gland changes with HIV
lymphoproliferative gland changes - increased size but decreased function
what is amyloidosis
deposition of protein
scale used to assess mucosal dryness
challacombe scale
investigations for salivary disease
FBC, U&E, liver function, C reactive protein, glucose, antibody, complement, functional assay, tissue assay, sialography, radiography
what is the unstimulated salivary flow test
spitting into tube for 15 mins
expected amount >1.5ml for normal function
treatable causes for dry mouth
dehydration
medication related
poor diabetes control
somatoform disorders
what is true hypersalivation caused by
drugs - buprenorphine, clozapine
dementia
CJD
stroke
how to manage hypersalivation
treat cause
give drugs
biofeedback training
surgery
causes of salivary gland enlargement
mumps, HIV
mucocele obstruction
sialosis and sjogrens
what is a mucocele
secretion retention in duct extravasated into tissues
what is subacute obstruction associated with
eating caused by sialolith, mucous plugging and duct damage from chronic infection
imaging for subacute obstruction
lower true occlusal
sialography if no infection
ultrasound
how to treat duct stricture
stretch with balloon catheters
how to treat duct dilatation
remove gland if reccurent
what is sialadenitis look like on histology
ducts and acini replaced with scar tissue
management of subacute obstruction
surgical sialolith removal
sialography
potential gland removal if swelling not going away
what is sialosis
enlargement with no identifiable cause
cause of sjogrens on cellular level
incomplete cell apoptosis leading to antigens being improperly exposed so there is dysregulation of inflammatory process
what does sjogrens cause
gradual loss of gland tissue through inflammatory destruction
enlarged glands
increased risk of lymphoma
oral and ocular effects
components of AECG
require 4 of the following:
dry eyes/mouth
autoantibody
imaging
radionucleotide assessment
histopathology >1 focus
components of ACR-EULAR
score more than 4
histopathology - weight 3
autoantibody - weight 3
dry eyes/mouth - weight 1
oral symptoms of sjogrens criteria
dry feeling >3 months
recurrent gland swelling
have to drink liquid to aid swallowing
ocular symptoms of sjogrens criteria
include dry eyes >3 months
feels like sand in eyes
tear substitutes used >3x/day
abnormal results of unstimulated salivary flow and schirmer test
<1.5ml/15mins
<5mm wetting/5 mins
tests for sjogrens
unstimulated saliva
schirmer test
anti-ro, anti-la
MRI
labial gland biopsy
management of sjogrens
OHI
5000ppm
diet
symptomatic treatment
pilocarpine
complications of sjogrens
caries
infections
speech
lymphoma with gland enlargement
signs of OFG in mouth
peripheral oedema
angular cheilitis
full thickness erythematous gingivitis
stag horning of FoM
linear fissure ulcer on labial sulcus
management of OFG
3 month exclusion diet
topical treatment for angular cheilitis and lip swelling
miconazole and tacrolimus ^
intralesional traimcinolone steroid
azithromycin, prednisolone pulse, azathioprine/mycophenolate (systemic)
what to assess for facial pain
PAIN scores
psychological scores
quality of life scores
what is chronic regional pain
autonomic nerve damage after an injury can cause a reflex arc of pain
- delocalised pain
- feeling of swelling and heat
- colour change in overlying skin
- autonomic changes
- disabling pain
example of neuropathic pain condition
post herpetic neuralgia
what medications can treat neuropathic pain such as post herpetic neuralgia
capsaicin
EMLA
benzydamine
pregabalin
gabapentin
tricyclics
what is oral dysaesthesia
abnormal sensory perception in absence of stimulus
symptoms of oral dysaesthesia
burning mouth
dysgeusia
paraesthesia
dry mouth
what is burning mouth syndrome linked to
haematinic deficiencies
how do you manage dysaesthesia
explaining condition to patient assess degree of anxiety and anxiolytics/neuropathics
symptoms of trigeminal neuralgia
unilateral maxillary/mandibular division pain lasting 5-10 seconds with remissions and relapses
triggers including wind/cold/touch
drug therapy for TN
carbamazepine 100mg MR
side effects of carbamazepine
blood problems
electrolyte imbalances
neurological defects
what is trigeminal autonomic cephalalgias
unilateral severe head pain occurring with congestion/eyelid oedema and ear fullness
cluster headache symptoms
unilateral orbital/temporal pain lasting 15 mins - 3 hours
1-3 attacks per day
can get bouts of these at the same time of year and attack at same time of day
treatment for cluster headache
sumatriptan 6mg and 100% O2 (attack)
lidocaine injection/prednisolone (bout)
verapamil (prevent)
symptoms of paroxysmal hemicrania
unilateral orbital/temporal pain lasting 2-30 mins
2-40 attacks per day with no rhythm
prophylaxis of paroxysmal hemicrania
indomethacin
