Year 3 Flashcards
What are the organic causes of xerostomia?
- Sjögren’s syndrome
- Irradiation
- Transient mumps (viral infection that leads to swelling of parotid glands)
- HIV infection
- HCV infection
- Sarcoidosis (small granulomas developing in organs of the body)
- Amyloidosis (disease caused by deposition of abnormal protein ‘Amyloid’ in tissues and organs through out the body)
- Iron deposition;
a. Haemotochromosis (slow build up of iron levels in the body)
b. Thalassaemia (abnormal formation of Haemoglobin leading to impaired RBC function)
What are the drugs associated with xerostomia?
- Diuretic overdose
- Drugs with antimuscarinic effect
- Tricyclics and some other anti depressants
- Antihistamines
- Antiemetics (used for nausea and vomiting)
- Antipsychotics (particularly phenothiazines)
- Some older antihypertensives (ganglion blocker and clonidine)
- Drugs with sympathomimetic actions
- Cold cures with ephedrine
- Decongestant
- Bronchodilators
- Appetite suppressant (particularly amphetamines)
What are functional causes of xerostomia?
- Dehydration
- Fluid deprivation or loss
- Haemorrhage
- Persistent diarrhoea/vomiting
- Phycogenic
a. Anxiety states
b. Depression - Drugs
Define signs and symptoms
Symptoms; subjective evidence of the disease (what the patient complains of)
Signs; an objective physical finding (what the clinician finds upon examining the patient)
What are symptoms of xerostomia?
- Dry mouth
- Difficulty swallowing
- Difficulty eating
- Difficulty speaking
- Difficulty wearing dentures
- Mucosal stick to each other and the teeth
- Bad taste in the mouth
- Halitosis
- Sore mouth
- Deteriorating dentition
- Swelling of the salivary gland
What are the signs of xerostomia?
- Salivary gland enlargement
- Mucosa sticks to dental mirror
- Consistency of saliva is stringy, frothy and thick
- Little or no pooling of saliva in floor of mouth
- Lobulated tongue
- Shiny mucosa
- Food debris
- Plaque accumulation
- Depapillated tongue (tongue becomes smooth)
Additional findings; - Evidence of candidiasis (angular cheilitis, erythematous mucosa, thrush, denture stomatitis)
- Smooth surface caries
- Traumatic ulceration (patient accidentally biting their cheeks)
- Poor denture retention
- Bacterial sialadenitis (infection and inflammation of salivary glands)
What are developmental causes of xerostomia?
- Aplasia (problems with glands); most likely to occur brought developmental defects and malformation of 1st and 2nd brachial arches. Eg; parotid gland aplasia in Treacher Collins syndrome
- Atresia (problems with ducts); congenital absence or narrowing of a duct which causes distension in the gland and atrophy (wasting away of the gland)
What is sialometry?
Sialometry is the objective evidence of reduced unstimulated salivary flow rate.
- Whole saliva
- 15 mins (ideal)
- 5 mins (clinical reality)
- Normal; 0.3 - 0.4ml/min
- Significant reduced rate; <0.1ml/min
- Stimulated sialometry is done with sugar free gum or saliva stimulating tablet (x10 of unstimulated); 1-2ml/min
What is sialography?
Sialography is an imaging technique used to demonstrate the ductal system of the parotid/submandibular
- It involves the introduction of a radiopaque contrast medium into the orifice of one of the major salivary glands via a catheter
- Radiographs (usually lateral obliques) are taken before and after the catheter is inserted
- These determine the flow of fluid and examine the drainage of the fluid
What is Schirmer test?
It is the objective evidence of the normal functioning of lacrimal glands (whether it produces enough tears to keep the eyes moist)
- The test uses paper strips (with rose Bengal die) inserted under the lower eyelid for 5 mins to measure tear production
- The amount of moisture on the paper is then measured
- Normal; more than 15mm
- Mild; 14-9mm
- Moderate; 8-4mm
- Severe; less than 4mm
What is scintigraphy?
Scintigraphy is an objective evidence of salivary gland function
- Technetium pertechnetate is intravenously injected and taken up by the salivary glands
- Scanning of the salivary gland is carried out every 30s
- Salivary gland function is then assessed with computer-assisted quantitative programmes
- This test is beneficial for comparing diseased gland with remaining healthy gland or to detect generalised loss of glandular function (especially useful for diagnosis of Sjögren’s syndrome)
What are complications of xerostomia?
- Caries
- Candidosis
- Halitosis
- Sialadenitis
Which gland contributes to unstimulated and stimulated salivary flow rate (respectively)?
Unstimulated salivary flow rate 1. 65% from submandibular gland 2. 15-20% from parotid gland 3. 7-8% from sublingual and minor glands Stimulated salivary flow rate 1. 45-50% from parotid
How does salivary flow fluctuate during the day?
Sleep 1. 40ml over 7 hours Awake 1. 300ml over 16 hours (unstimulated) 2. 200ml over 54 minutes (stimulated)
State type of saliva secretion with each gland and the duct associated with it when applicable
- Parotid; serous saliva (Stenson’s duct)
- Submandibular; serous and mucous saliva (Wharton’s duct)
- Sublingual; mucous saliva (Bartholin’s duct)
- Minor; mucous
What radiographs are appropriate to study the salivary gland?
This is usually used to detect calculi (but not all calculi are radio opaque)
- Parotid; panoramic/oblique lateral + anterior-posterior view radiograph
- Submandibular; panoramic + lower occlusal view (true and oblique)
What are indications and contraindications of sialography?
Indications;
1. To show structural abnormalities of the duct system
2. Atrophy of salivary acini (in case of Sjögren’s a characteristic ‘snowstorm’ appearance is seen)
Contraindications;
1. Presence of acute infection
2. Patient in severe pain
3. Calculus is known to be close to the duct (contract medium may further displace the calculus)
4. Suspected ‘mass’ lesions
What are the 3 phases demonstrated by sialography?
- Preoperatively
- The filling phase
- The emptying phase
What is sialadenitis?
Sialadenitis is the term used to describe inflammation of salivary gland (most commonly the result of viral or bacterial* infection)
*bacterial sialadenitis is usually a secondary consequence of either localised/systemic cause of reduced salivary flow
What are the types of symptomatic relief options for xerostomia?
Intrinsic (increases gland activity) 1. Sugar free gum 2. Pilocarpine Extrinsic 1. Saliva substitutes a) Mucin based b) Carboxymethylcellulose based
What is the most common candidal species involved in oral candidosis?
Candida albicans
Define Sjögren’s syndrome?
Sjögren’s syndrome is an autoimmune disease of the exocrine glands that particularly involve the salivary and lacrimal glands
- Primary; dry eyes (xerophthalmia) and dry mouth not associated with a connective tissue disease
- Secondary; dry eyes and dry mouth associated with a connective tissue disease (most commonly rheumatoid arthritis)
What are predisposing factors for oral candidosis?
- Physiological: old age, infancy, pregnancy
- Local tissue trauma: mucosal irritation, dental appliance, poor oral hygiene
- Antibiotic therapy: broad spectrum
- Corticosteroid therapy: topical, systemic or inhaler
- Malnutrition: haematinic deficiencies
- Immune defects: AIDS
- Endocrine disorders: diabetes mellitus, hypothyroidism, Addison’s disease (primary adrenal insufficiency)
- Malignancies: leukaemia
- Salivary gland hypofunction: irradiation, Sjögren’s syndrome, xerogenic drugs
Briefly describe how a swab is carried out
A swab (moistened with sterile saline if necessary) is wiped along the surface of the lesion and placed in a suitable transport medium. The sample should be sent promptly to the microbiology laboratory for culture and sensitivity
What is the classification of oral candidosis?
- Group 1 (primary oral candidosis)
Acute: pseudomembranous, erythematous
Chronic: pseudomembranous, erythematous, hyperplastic
Candida-associated-lesion: denture stomatitis, angular cheilitis, median rhomboid glossitis - Group 2 (secondary oral candidosis)
Oral manifestation of systemic mucocutaneous candidosis
What are the appropriate laboratory diagnosis of oral candidosis
- Swab test
- Smear test
- Biopsy (especially for chronic hyperplastic candidosis)
- Oral rinse
- Haematological tests (full blood count, serum ferritin/vitamin B12/ folate and blood glucose level)
What are some of the common therapy for treatment of oral candidosis?
- Polyene anti fungal agents
Pros
a) Available in various forms (lozenges/creams/suspensions)
b) Relatively free from side effects
c) Resistance is uncommon
Cons
a) Distinctive taste
b) Poor patient compliance
Examples
a) Nystatin
b) Amphotericin B - Azoles
Pros
a) Available as systemic treatment (valuable for systemic disease)
b) Miconazole is both anti fungal and anti bacterial
Cons
a) Resistance is common (problem with immunocompromised patient)
b) Unfavourable pharmacokinetic interaction with a number of drugs including warfarin, statins, ciclosporine (immunosuppressant) - Chlorhexidane could also be prescribed as it is antibacterial and anticandidal (but it should not be used together with nyastatin due to pharmacokinetic interaction)
What are key features of acute/chronic pseudomembranous candidosis?
- Also known as thrush
- Common in HIV and indicate low immunity (immunocompromised patients are usually associated with chronic candidosis)
- Creamy soft patches that are readily wiped off leaving a raw bleeding base
- Smear shows gram positive hyphae
- Histology shows hyphae invading superficial epithelium with proliferative and inflammatory response
- Has various predisposing factors
What are key features of acute erythematous candidosis?
- Also known as acute atrophic candidosis
- Resembles thrush without the overlying pseudomembrane
- Only variant of candida with pain association
- Epithelium is thin and atrophic with candidal hyphae embedded superficially in the epithelium
- This form of candidosis is common with AIDS patient (immunocompromised) as well as patients undergoing prolonged antibiotic/steroid therapy
What are features of chronic hyperplastic candidosis?
- Also known as candidal leukoplakia
- The lesion appear as raised irregular white plaques which may be “speckled” or nodular in appearance
- The plaque unlike thrush cannot be scraped off
- Hyphae grows into full thickness of the epithelium
- It is considered a premalignant lesion and it is more likely to occur in patients who smoke
- Most commonly on the commissures of the mouth
What are key features of denture stomatitis?
- Also known as chronic erythematous candidosis
- Candidal infection due to trauma to tissues (caused by dental appliance)
- Marked redness of palatal mucosa (directly related to area covered by appliance)*
- Rarely associated with pain
- Gram stained smears show candidal hyphae
* Newton’s classification of Candida-associated denture stomatitis
What are key features of angular cheilitis?
- Multi factorial condition with a number of local and systemic predisposing factors
- In most cases, deep folds at the angle of the mouth become traumatised as a result of continual wetting by saliva
- It could also be a result of underlying systemic condition
- Angular cheilitis of bacterial origin (and not candida) is treated with fusidic acid cream
What are key features of median rhomboid glossitis?
- Abnormality in the midline of the dorsum of the tongue immediately in front of the circumvallate
- Appears as an area of depapillation (may be red/white/yellow)
- Lesions often associated with candida
- Patient should undergo blood test to exclude haematinic deficiency or diabetes
How many types of herpes simplex virus are there and which part of the body are affected by each virus respective?
- HSV type 1: oral mucosa, pharynx and skin
2. HSV type 2: predominant genitalia
What are key features of chronic mucocutaneous candidosis?
- Candidosis of the oral cavity, skin and other structures (fingernails)
- Skin lesion may include widespread and disfiguring lesion of the face and scalp
- Can be familial CMC or diffuse CMC
- Due to mutation in one/two specific genes causing malfunctioning T cell
- Oral lesion initially resemble thrush > resemble chronic hyperplastic candidosis
How does herpes simplex virus (type 1) manifest itself?
- Primary infection: primary herpetic gingivostomatitis
2. Recurrent infection: herpes labialis
What are the typical features of herpes labialis?
- Caused by the reactivation of herpes simplex virus
- Commonly known as cold sore
- Recurrence may be provoked by various factors including menstruation, strong sunshine, common cold etc
- Occurs in 3 stage:
Stage 1; tingling/burning/itching sensation
Stage 2; appearance of vesicles surrounded by a mildly erythematous area
Stage 3; fluid-filled vesicles burst and form a scab - Whole process takes about 10 days
- Aciclovir and penciclovir are best treatment options
What are the typical features of primary herpetic gingivostomatitis?
- Transmitted by close contact
- Vesicles followed by ulcers affecting any part of the oral mucosa
- Two most favourite sites for vesicles are hard palate and dorsum of tongue
- Gingivitis is sometimes associated (usually in children)
- Lymphadenopathy (swelling of lymph nodes) and fever of variable severity
- Smears from vesicles show ballooning degeneration of viral-damaged cells
- Rising titre of antibodies to HSV confirms the diagnosis
- Aciclovir is the treatment of choice
How does the varicella zoster virus manifests itself?
- Primary infection: chickenpox
2. Reactivation infection: herpes zoster
What are typical features of herpes zoster (of trigeminal area)?
- Typically affects the elderly
- Pain precedes the rash (2-3 days)
- Facial rash accompanies the stomatitis
- Lesions localised to one side, within any distribution of the divisions of the trigeminal nerve
- Malaise can be severe
- Can be life threatening in HIV patients
- Rising titre of VZV-specific IG-M antibody confirms diagnosis
- Best treatment option is systemic aciclovir (800mg x 5 times a day x 7 days)
- Sometimes followed by post herpetic neuralgia (particularly in elderly)
What are groups of Coxsackie virus?
- Group A (affects oropharyngeal region)
2. Group B
What are the two infections caused by Group A Coxsackie virus?
- Hand, foot and mouth disease
2. Herpangina
What are key features of hand, foot and mouth disease?
- Highly infectious and occurs as mini-epidemics
- School children are predominantly affected (occasionally spreading to parents and teachers)
- The oral lesions consists of small ulcers relatively few in number and distributed all over the oral mucosa
- Macular (round) rash with vesiculation on PALMAR surface of hand and PLANTAR surface of feet
- Symptoms resolve in a week
- No specific treatment is available or needed
What are the types of HPV infections associated with cervical and oral cancers?
- HPV 16
2. HPV 18
What are key features of herpangina?
- Mild infection predominantly in children that occurs in mini-epidemics
- Patient complains of malaise, sore throat with some degree of muscle weakness and pain
- Small vesicular lesion appear in the posterior part of the mouth (soft palate)
- Lesions fade after 3-5 days
- No treatment is available or needed
How does HPV virus manifests itself?
It causes warty lesions on the skin and mucous membrane
What are the key features of AIDS?
- Caused by retrovirus HIV 1
- Transmitted sexually, by intravenous drug abuse, blood and blood products
- Due to infection and consequent inactivation of CD-4 expressing cells (T helper cell) leading to functional disabling of the host’s immune system
- Deaths are mainly due to opportunistic infection
- Triple therapy is the most effective choice of treatment (protease inhibitor + nucleoside reverse transcriptase inhibitor + non nucleoside reverse transcriptase inhibitors)
What are the two types of warts and where are they commonly seen?
Common wart (verruca vulgaris)
1. Skin and oral mucosa (due to auto inoculation by chewing warts on hands)
2. White cauliflower like lesion (indistinguishable from squamous cell papilloma)
Venereal warts (condyloma acuminatum)
1. Also known as genital warts
2. May occur in the mouth as a result of orogenital sexual contact
3. They appear as soft, pink papillary lesion particularly on the soft palate and tongue
What are the common oral lesion associated with HIV infection?
- Fungal: Thrush and other forms of candidosis
- Viral: Herpes simplex, varicella zoster, hairy leukoplakia (EB virus)
- Bacterial: HIV-associated gingivitis and periodontitis
- Tumours: Kaposi’s sarcoma, lymphoma
What are the causes of pulpitis?
- Dental caries
- Traumatic exposure of the pulp
- Fracture of a crown or cusp
- Cracked tooth syndrome
- Thermal or chemical irritation
What are key features of reversible pulpitis?
- Transient and short duration of pain that resolves after stimulus is removed
- Occurs in response to hot, cold and sweet food
- Pain is described as short and sharp
- Progresses to irreversible pulpitis is left untreated
Define pulpitis
Inflammation of the dental pulp tissue due to bacteria
Why does pulpitis cause pain?
- Due to pressure on the irritated nerve endings by inflammatory infiltrate within rigid pulp chamber
- Due to release of pain-producing substances from damaged tissues
What are key feature of irreversible pulpitis?
- Dull, aching, pulsing/throbbing pain
- Occurs spontaneously often at night (affects sleep)
- Occurs in response to thermal stimuli
- Pain persists after removal of stimulus
- Not affected (or very limited effect) by analgesics
When does acute pulpitis progresses to chronic pulpitis?
- Acute pulpitis: reversible pulpitis > irreversible pulpitis
- Chronic pulpitis: pulpal death > periapical periodontitis
Why is pulpal pain poorly localised?
The pulps of individual teeth are not precisely represented on the sensory cortex. Thus it may be felt in any of teeth of the upper/lower jaw of the affected site*
*rarely the pain may be referred to a more distant site such as the ear
Compare and contrast periodontal and periapical abscess
Periapical Abscess
1. Manifestation of untreated apical periodontitis (due to bacteria and pulpal breakdown products leaving the canal and causing inflammation of the periodontal ligament)
2. Severe pain that disturbs sleep
3. Associated with intra oral and facial swelling
4. Tooth non vital and severely tender to percussion
Periodontal abscess
1. Manifestation of acute infection of the periodontal pocket
2. Gingival tenderness > throbbing pain
3. Tooth affected is vital and tender to percussion (not severe)
4. Overlying gingiva is red and swollen
What are key features of psychogenic (atypical) facial pain?
- Women of middle age or older are mainly affected
- Absence of organic signs and triggering factors
- Pain often poorly localised
- Description of pain may be bizarre
- Delusional symptoms often associated
- Lack of response to analgesics
- Unchanging pain persisting for many years
- Sometime with good response to anti depressive treatments
How is an abscess formed?
- Bacteria causes tissue necrosis
- Pus forms by the action of neutrophil proteolytic enzymes
- The process is localised by granulation tissue forming the abscess wall*
* surrounding tissues may become swollen by diffusion of inflammatory exudate into them (oedema)
How does fascial space infection differ from an abscess?
In fascial space infections (a form of cellulitis):
- Fasciae covering muscle bundles are normally in close apposition
- If these fascias are forced apart, avascular spaces are created
- If localisation of bacterial fails, inflammatory exudate open up fascial space, carrying bacteria with it into the tissue planes
- Unlike oedema the exudate in cellulitis form vehicle for spread of infection
What are the main types of deep fascial space infection?
- Sublingual
- Submandibular (separated by mylohyoid; submaxillary + sublingual)
- Parapharyngeal
What are the clinical features of fascial space infection/ cellutis?
- Diffuse swelling: tense and tender (board-like tenderness)
- Pain: limit opening of mouth and cause dysphagia (swallowing difficulty)
- Fever
- Malaise
- Overlying skin is taut and shiny
- Swollen regional lymph nodes
- Severe systemic upset associated
What are the key features of Ludwig’s Angina?
- Severe form of cellulitis usually arising from lower second or third molars
- Involves submandibular and sublingual spaces (bilaterally) > lateral pharyngeal and pterygoid spaces
- Painful swelling of upper part of neck and floor of mouth on both sides
- Tongue may be pushed up the soft palate or oedema of the glottis may occur
- Causes dysphagia and asphyxia
What are the key requirements for management of Ludwig’s Angina
- Immediate admission to hospital
- Procurement of a sample for culture and sensitivity testing
- Aggressive antibiotic treatment
- Securing airway with tracheostomy if necessary
- Drainage of swelling to reduce pressure
What are key features of atypical odontalgia?
- Pain is often localised to one tooth or a row of teeth
- Affected tooth/teeth are said to ache or exquisitely sensitive to heat, cold or pressure
- Treatment of dental disease has no effect and if extracted symptom moves to an adjacent tooth
- Psychiatric assessment is needed
What are the two sources of TMJ pain?
- Muscles, joint structures and other associated tissue as a result of abnormal physical activity within the joint
- Pathological changes in the joint itself (may be associated with systemic abnormality)
What are the four key aspects in investigating the stomatognathic system?
Pain:
1. Within the joint or from the muscles of mastication
2. Constant with acute exacerbation (usually associated with radiation of pain from joint)
3. May occur in the morning or during the evening
4. Muscular pain may cause headache
Joint sounds
1. Represents the movement of one component of the joint over the others
2. Can mean that the disc is slipping out of place or malfunctioning
3. Presence of a click on its own does not indicate a problem
Restriction of opening
1. Some report difficulty in wide opening
2. Others may have problems applying pressure or closing mouth
3. The inability to open mouth widely due to reflex muscular spasm of the masticatory muscles is known as trismus (temporary)
4. Patient often complains that their jaw ‘locks’. This is due to the disc being squashed and bunched up anteriorly preventing further opening
Swelling
1. Patients occasionally complain of swelling over the maxilla/parotid
2. Tenderness is also often associated
What is the normal amount of mandibular opening?
Inter-incisal opening of approximately 35-45mm
What are the muscles that should be palpated in association with TMJ dysfunction?
- Masseter
2. Temporalis
What are other terms used to describe temporomandibular pain dysfunction syndrome?
- Myofacial pain dysfunction
- Facial arthromyalgia
- Facial pain dysfunction
- Masticatory muscle disorder