Theme 5 - Principles of oral medicine Flashcards
What is hairy tongue?
Clinical manifestation of elongation of filiform papillae on dorsum of tongue. Often a response to infections, fever, xerostomia, antibiotics, tobacco. Varied in distribution of papillae, length and colour.
What is the treatment for hairy tongue?
Eliminate cause, reassure, tongue brushes, keratinolytic drugs?
What is geographic tongue/glossitis migrans?
Depapillation of the filiform paillae on the dorsum of tongue, causing erythematous configurations varied in size, shape and number. Bordered by a slight increase in filiform papillae making a white margin. May periodically disappear
What has geographic tongue been associated with?
- Pustular psoriasis (most common)
- Allergy
- Hormonal disturbances
- Jeuvenile diabetes
- Reiter syndrome
- Downs syndrome
- Nutritional deficiency
- Psychological upset
- Fissured tongue
- Lichen planus
How is geographic tongue diagnosed?
Clinical appearance and history. Only biopsy if bizarre manifestation. Histologically - loss of filiform papillae, elongated rete ridges, neutrophil accumulation
What is median rhomboid glossitis?
Rhomboidal reddish smooth or nuclear surface in midline of dorsum of tongue - thought to be persistence of embryological midline (tuberculum impar) or associated with candidiasis. No tx.
What is fissured tongue? What syndromes is it often seen in?
Inherited or acquired condition grooves or fissures on dorsum of tongue - no tx
Downs syndrome
Melkersson-Rosenthal syndrome (also cheilitis granulomatosa and facial nerve paralysis)
What is crenated tongue? What patients is it frequent in?
Shallow impressions on the lateral margin of tongue due to teeth. Frequent in macroglossia, bruxism, chronic anxiety
What is hypertrophy of the foliate papillae?
Localised in posterior lateral borders of tongue, large protruding nodules that have become inflamed in response to local chronic irritation or infection as contain lymphatic tissue. No tx
What are fordyce granules? WHat are the clinical features?
Manifestations of heterotic sebaceous glands. Raised yellow spots, rarely coalescing. Occur mainly on mucosal surface of upper lip, commisures, buccal mucosa and retromolar regions
What is a white sponge naevus?
Inherited autosomal dominant mutation of keratin 13 and 14. Appears at birth, asymptomatic, bilateral white lesions with shaggy or spongy wrinkled surface. Usually involved buccal mucosa but sometimes tongue, fom, esophagus, pharynx, genitalia
What is the diagnosis and management of white sponge nevi?
Dx - clinical and biopsy
Tx- none, or topical tetracycline
What is leukoedema?
Bilateral diffuse, grey-white milky surface with symmetry in distribution and occurs on buccal mucosa. Variation of normal, more common in blacks due to increased thickness of epithelium.
How is leukoedema diagnosed?
Stretching of buccal mucosa, opaque patch will disappear
If a patient has crenated tongue due to macroglossia, what could be the causes of macroglossia?
- Myxedema
- Acromegaly
- Amyloidosis
If a patient presents with suspected fordyce granules, what is the differential diagnosis?
Lichen planus
What is a spot or maculae?
A flat lesion simply reflecting a change of the mucosal colour, smooth or finely granular.
What is a patch or plaque?
A thickened lesion with a slightly rough surface
What is the difference between an erosion and an ulceration?
Erosions involve epithelium only whereas ulcerations are deeper where whole epithelium breached and breakdown of connective tissue
What is a bullae or blister?
Lesion consisting of fluid retention within or under epithelium, larger than vesicles, usually single or not in great number, burst and give way to erosions
What are vesicles?
Small pockets of liquid within or under the epithelium, usually no larger than a few mm and numberous e.g. recurrent herpes stomatitis
What is pemphigous?
Intra-epithelial blistering from altered adhesion between keratinocytes
What is pemphigoid?
Sub-epithelial blistering from altered adhesion at the basement membrane zone
What are papillary verrucous lesions?
Raised lesions on the mucosa that can be localised or widespread, sessile or pedunculate, white or red. Defined by their thickness and surface features.
What are the differential diagnoses of a ST lump?
- Cyst
- Abscess
- Granuloma
- Hyperplasia
- Neoplasia
What are the types of hyperplastic lumps?
- Pyogenic granuloma
- Denture granuloma
- Epulides
- Fibroepithelial polyp
- Squamous cell papilloma
- Mucoceles
What is a fibroepithelial polyp? How is it managed?
Most common ST swelling. Develops after chronic irritation and is a round, dome shaped, sessile soft mass, asymptomatic. Usually pink but may have white keratotic surface.
Management = excision
What is a denture granuloma? How is it managed?
Common mucosal reaction to poorly fitting denture - multiple painless mucosal folds parallel to alveolar ridges. Can be ulcerations at base of folds.
Management = surgical removal of hyperplastic tissue and new better fitting dentures
Epulis applied to any swelling on the gingivae and are reactions to irritation. Describe the following epulis
a) Fibrous epulis/peripheral fibroma
b) Pyogenic granuloma
c) Peripheral giant cell granuloma
d) Ossifying fibroma
a) Same colour as surrounding gingivae
b) Deep red and soft, consisting of many dilated blood vessels in loose connective tissue with dense inflammatory infiltrate
c) Purple/blue. More aggressive, erodes underlying alveolar bone and causes root resorption (cupping resorption seen radiographically). Females>males, peak prevalence 50-60yrs, mandible>maxilla.
d) PDL cells give rise to cells capable of osteogenesis
What are the types of benign neoplastic lumps?
- Haemangioma
- Neurilemmoma
- Leiomyoma
- Lymphangioma
- Lipoma
- Neurofibroma
- Neuroma
- Granular cell tumour
- Salivary gland tumour
What is a haemangioma? How is it diagnosed?
Mostly vascular malformations, soft mass, smooth or lobulated, sessile or pedunculated and may vary in size. Usually deep red/purple. Most common on tongue, vermilion of lip or buccal mucosa.
Diagnosis - blanch on application of pressure from glass slide (diascopy). Not aspiration as bleeds/
Oral haemangiomas are present in some syndrome, what are they and what are they characterised by?
Sturge-webber syndrome
- Affects skin and NS
- Babies born with port wine stain birthmark on face
- Epilepsy, developmental and intellectual disability
Maffuccis syndrome
- Affects bone and skin
- Multiple enchondromas (benign tumours of cartiledge), bone deformities and haemangiomas
- Abnormal growths may become cancerous
What is a lymphangioma? What can it cause in the tongue or in the lips? What its the Tx?
Uncommon tumour that forms translucent, smooth or nodular soft mass on tongue, lips and buccal mucosa. Bleeding into lymphatic spaces can cause sudden purplish discolouration.
Tongue = macroglossia
Lips = macrocheilia
Tx = surgical excision, but complete removal difficult as non-encapsulating and infiltrating
What is a lipoma?
Common benign tumour. Found in buccal mucosa, tongue, lip, palate, FOM, retromolar area, gingivae (most likely to least). If surface epithelium thin then yellowish hue. Tx = excision
What is a neuroma?
Can be:
- Solitary circumscribed neuroma = single and not related to trauma and often in palate
- Traumatic neuroma = Single as a consequence of trauma, most common in lip, tongue and mental nerve area, can be painful
- Multiple as part of a syndrome ie multiple endocrine neoplasia type 2B = thyroid, adrenal gland, intestinal cancers
What is a neurofibroma?
Uncommon tumour arising from nerve sheath forming smooth painless lumps. Can be solitary or multiple as part of a syndrome (neurofibromatosis type 1 (NF1)/recklinghausens disease
What is a neurilemmoma/schwannoma?
Rare benign nerve sheath neoplasm composed of schwann cells. Sporadic in nature, associated with NF2 or schwannomatosis (syndromes)
What is a granular cell tumour?
Typically involve larynx and tongue, asymptomatic slow growing single nodule in submucosa. Schwannian tumour that contains lysosomes, so have granular eosinophilic quality to cytoplasm. Most are solitary but if multiple part of a syndrom e.g. noonan syndrome, NF1 and LEOPARD syndrome
What is a leiomyoma and rhabdomyoma?
Leiomyoma = benign tumour arising from smooth muscle commonly found in uterus and GIT, rare in mouth
Rhabdomyoma = striated muscle neoplasms, rare in mouth
Both cause painless submucosal swelling
What does skin/patch testing test for? What are its limitations?
Tests for type IV cell mediated delayed hypersensitivity e.g. to dental materials
Reproducibility and methodological problems
What is exfoliative cytology? What are its advantages and disadvantages?
Examination of cells scraped from the surface of a lesion or material from aspirates of a cyst.
+
quick and easy
LA not required
Special technique like immunostaining can be applied
Useful for detecting virally damaged cells, acantholytic cells (pemphigus) or candida hyphae
-
Unreliable for diagnosis of cancer
Frequent false positive and negative results
What is a biopsy?
The removal of a small piece of tissue from the body and diagnosing under a microscope
What are the indications for a biopsy?
- Lesions that have neoplastic or premalignant features or are enlarging
- Persistent lesions of uncertain aetiology
- Persistent lesions that are failing to respond to Tx
- Confirmation of the clinical diagnosis
What are the possible reasons for failures in histological diagnosis?
- Specimin poorly fixed or damaged during removal
- Histological features have several possible causes e.g. granulomas
- Histological features are difficult to interpret
- Inflammation may mask correct diagnosis
- Disease does not have diagnostic histological features e.g. apthous ulcers
- Specimin unrepresentative of the lesion or too small
What is an incisional biopsy?
Taking a small sample with representative healthy and diseased tissue
What is an excisional biopsy?
Removal of the complete lesion. Rarely done in oral cavity, mainly when a lesion is small (less than 1cm) and definitely benign
What should you do when taking an incisional biopsy?
- Take it from the most suspicious area and include healthy tissue
- Sufficiently deep to allow study of interface between epithelium and connective tissue
- 4-5mm large minimum
- Put sample on paper with epithelium facing up for better orientation
- Fix sample immediately in formalin
- Suture with fine needle and resorbable suture
What should you not do when taking an incisional biopsy?
- Inject LA directly into lesion
- Directly apply pressure as tissue may be damaged and artefacts may be introduced
- Cut a wedge-shaped incision since it will include only a small amaount of lamina propria and basal layer
- Squeeze or crush tissue with forceps
What is direct immunofluoresence?
Uses tissue. Microscopy aims to detect any in situ deposition of immunoglobulins and/or complement in the patients skin or mucous membrane.
What is indirect immunofluoresence?
Uses blood. Microscopy aims to detect any circulatory antibodies present in the patients sera that bind to skin/mucous components
What is the 1 stage technique for direct immunofluoresence?
1) Sample placed on OCT compound and frozen immediately or skin samples placed in saline soaked gauze/michels medium and snap frozen
2) Half of sample processed for DIF, half for normal histology
3) Frozen sample cut into thin section
4) Fluorescein- conjugated antibodies against human IgG, IgM, IgA, C3 and fibrinogen shows up apple green under UV light
If it is a presumed bullous disease
a) where must the sample be carried out
b) What must be avoided
a) Where there is epithelium present (no erosions or ulcers)
b) splitting of the epithelium and punch biopsies
How are DIF specimins interpreted?
- Number and type of immunoreactants
- The location of the deposition
- The immunomorphology of the deposition
What is seen on DIF if it is mucous memebrane pemphigoid?
Linear basement membrane zone (BMZ) deposition with IgG and C3
What is seen on DIF if it is oral lichen planus?
Shaggy fibrinogen deposition along the BMZ without any other immunoreactants
What is seen on DIF if it is pemphigus?
Intercellular space deposition with IgG - fishnet appearance
What is the 2 stage technique for indirect immunofluorescence?
1st = incubate pt diluted serum with normal substrate (human skin)
2nd = exposition of the substrate to fluoroscein conjugated antibodies
Allows for titration to determine the highest dilution yielding visible fluorescence
What is seen on IIF if it is pemphigus?
Fishnet appearance
What is the salt-split skin technique
a) Used to diagnose?
b) how is it produced?
a) Subepidermal blistering diseases - bullous pemphigoid
b) Incubation 48-72hrs with IM NaCL to split the human skin through the lamina lucida leaving certain BMZ components on top and other on the bottom of the splint - increases sensitivity of IIF
Give example of immunosuppressant drugs that are systemic for the following categories:
a) Glucocorticoids
b) Antiproliferative immunosuppressants
c) Alkylating drugs
a) Prednisolone
b) Azathioprine, Mycophenolate mofetil
c) Cyclophosphamide
How do glucocorticoids work?
What are the side effects of short term glucocorticoid treatment (less than 3 weeks)?
What are the side effects of long term glucocorticoid treatment (more than 4 weeks)?
What is the most common long term side effect of glucocorticoid use, when does it occur most rapidly and with what dose?
How is GC induced osteoporosis prevented with drugs?
