Tutorial 2 Flashcards
what is the diagnosis
“net-like, lacy, buccal mucosa, white striae”
reticular lichen planus
what questions re-lichen planus would you ask pt
when, how long, has it changed, symptoms
genital, scalp, skin symptoms
impact on life
how long amalgam
what medical conditions are associated with oral lichen planus
diabetes
lupus
hyperthyroidism
autoimmune
hepatitis c
GVHD
hypertension
viral infections
what other tissues are affected by oral lichen planus
skin
scalp
nails
genitals
eye
pharynx
oesophagus
describe the pathophysiology of oral lichen planus
CD8+ T CELL MEDIATED DESTRUCTION OF BASAL KERATINOCYTES
upon cd8+ T cells recognising antigen of basal keratinocytes, release of granzyme and perforin which disrupts cell membrane, leading to death
describe what you would see in histology of OLP
death of basal keratinocytes
band-like lymphocytic infiltrate
acanthosis
hyperparakeratosis
saw tooth rite pegs
epithelial atrophy
how would you describe OLP to pt
immune system attacking itself
mouth therefore forms a protective layer
chronic inflammation
management of reticular OLP primary care
education and reassurance
clinical photos
advise SLS free TP, OHI, PMPR
benzydamine 0.15% MW or spray
betamethasone 500mcg in 10ml water, rinse 5mins and spit 4x day
beclamethasone 50mcg inhaler, 1-2 puffs 2x day
avoid triggers
change amalgam
what is the risk of malignant change in OLP
1% risk over 10 years
when would you refer OLP pt to secondary care
symptomatic
non-reticular
unilateral/non-symmetrical distribution
unclear diagnosis
other risks for malignant change
biopsy indicated
OLP presents on buccal mucosa with large yellow ulceration and erythematous border
pt reports constant pain which worsens when eating
what is diagnosis subtype
erosive aka ulcerative
what systemic options can be used to tx OLP if topical therapies are unsuccessful
prednisolone
hydrochloroquine
methotrexate
prednisolone side effects
nausea, anxiety, hypertension
increased risk of infection
skin reactions
peptic ulcer
osteoporosis
lesion presents on the right lateral border of the tongue
raised, multilocular, sessile, exophytic
what will you do
refer urgent max fax cancer referral
reticular, white striations on the buccal mucosa, starburst appearance
next to large amalgam restoration on the 47
what is the diagnosis and the primary etiological factor
oral lichenoid lesion due to amalgam
contact type 4 hypersensitivity reaction
how would you manage oral lichenoid reaction in primary care
removal of amalgam and replace with composite
reassure
benzydamine if symptomatic
benefits vs risks of changing amalgam rest in lichenoid reaction
benefits =
may improve lesion, resolve pain, decreased malignant potential
risks =
no guarantee improvement, damage to teeth [rct, crown], cost, loss of amalgam
pt has oral lichenoid reaction
how could you gain more information to confirm amalgam is the cause
patch testing via dermatology
pt presents with ulcer on left side of tongue
“yellow centre, white diffuse borders, concave, white halo”
there is a sharp rest - what is the provisional diagnosis?
pt then comes back 3 weeks later and no improvement
what do you do now?
traumatic ulceration - smooth sharp
refer max fax as non-healing ulcer, >3 weeks, removed trauma
not firm or rolled margins
suspect TUGSE as non healing ulcer with granulation tissue
pt presents with
“round/ovoid ulcerations, grey base, erythematous halo”
they say it lasts 10 days, few weeks without and comes back again
they are 5-7mm
what is your diagnosis
recurrent aphthous stomatitis
pt presents with RAS
what investigations would you consider
FBC, haematinics [vitb12, folate, ferritin], coeliac
ESR
ANA
viral screens
pt with RAS now reports genital ulceration
pt mother is from turkey
what is provisional diagnosis, what HLA subtype would this be
behcet’s disease
HLA = B51
pt presents with painful gums, full-thickness desquamative gingivitis, fluid filled lump on soft palate
give differential diagnoses
what other sites may be affected
MMP
PV
anogenital, skin, scalp, nasal
pt presenting with desquamative gingivitis
you suspect blistering disease
what topical therapies could you provide
betamethasone MW
clobetasol via custom made tray
can a pt with potential blistering disease be exclusively managed by GDP?
who would be further involved
no
MDT - oral med, ophthalmology, gynaecology, dermatology
what special investigations would be done to confirm blistering disease diagnoses
biopsy - H+E staining, DIF
blood sample - indirect IF
differentiate H+E findings in MMP vs PV
MMP has sub epithelial splitting
PV has intraepithelial splitting
differentiate DIF findings MMP vs PV
MMP - linear deposits of IgG at basement membrane
PV - “chicken-wire” epithelial, IgG andC3 deposition
triamcinolone for MMP side effects
intralesional injection
insomnia, anxiety, vomiting, blurred vision, dizzy
rutiximab MMP side effects
infusion reactions
infections
hepatitis B reactivation
fatigue
weakness
headaches
dizzy
what is the term given to features of pemphigus caused by malignancy
paraneoplastic pemphigus
what is elisa
enzyme linked immosorbent assay
used to detect and measure antibodies, antigens, proteins and hormones
antigen/antibody, target substance, enzyme added, measure enzyme activity
what antibodies would you be positive for in pemphigus vulgaris
anti-dsg3
what antibodies would you be present for in mucous membrane pemphigoid
anti-BP180
which indirect immunofluorence substrate can be helpful in diagnosis of pemphigus driven by malignancy
monkey oesophagus
