More diseaess-Kerr, Dry mouth Flashcards

Question

What is this clinical presentation?

Answer 1

Actinic cheilitis (Solar cheilosis) Typical presentation of angular cheilitis with erythema, crusting and mild fissuring of the angles of the mouth bilaterally.

Answer 2

Actinic cheilitis (Solar cheilosis) Early presetation: Smooth, blotchy, pale, dry areas Diffuse, irregular white plaque around line of the lip Crusted, Scaly ****

Answer 3

Actinic cheilitis has **2 times** of risk for developing SCC of the lip. SCC on the lips is 11 times as likely to metastasize compared to SCC found on other parts of the body

Answer 4

due to chronic ultraviolet light exposure.

Answer 5

* avoid sun exposure * Laser ablation is preferred for severe actinic cheilitis * surgical excision is recommended for severe actinic cheilitis with evidence of high-grade dysplasia * Lip Shaving” (Vermilionectomy) * can also use cryotherapy, electrodesiccation It requires long term follow up and **prognosis is good if caught early**

Answer 6

**_SCC_** arising from **Actinic Cheilitis**

Answer 7

**Oral Melanoma** a highly malignant neoplasia, arising from melanocytes, the cells that produce the brownish pigment melanin.

Answer 8

**Oral Melanoma** an ulcerated, blue-black, slightly elevated lesion in the edentulous, posterior right maxilla. The lesion extends across the residual alveolar ridge onto the palate and onto the facial aspect of the ridge.

Answer 9

**Oral Melanoma** patient with extensive, black-pigmented and irregularly bordered macule in the maxillary labial mucosa and midline facial gingiva, (teeth 8 and 9). (The patient's fingers are depicted.)

Answer 10

**Oral Melanoma** Large, blue-black, irregularly bordered lesion on the upper lip of a male Japanese patient. The diagnosis is oral melanoma.

Answer 11

Amalgam tattoo This image depicts two diffusely bordered, dark gray macules in the left posterior buccal mucosa adjacent to molar teeth that have been restored. .

Answer 12

Oral melanoacanthoma. the buccal mucosa of a middle-aged, black woman with a brown-black, irregularly bordered macule that arose suddenly. The patient was unaware of its presence.

Answer 13

**Oral melanotic macule** an irregularly shaped, tan-brown macule on the left hard palate in an edentulous patient.

Answer 14

Unknown. Ultraviolet radiation is an important causative factor for skin melanoma **Acute sun damage** can cause it more than chronic exposure

Answer 15

Fair skin A history of sunburn Excessive ultraviolet (UV) light exposure. Living closer to the equator or at a higher elevation Having many moles or unusual moles A family history of melanoma Weakened immune system.

Answer 16

* Surgical excision * Radiotherapy * Chemotherapy

Answer 17

Oral Melanoma

Answer 18

Oral Melanoma

Answer 19

Oral Melanoma

Answer 20

Traumatic ulcer caused by sharp or puncturing food stuff

Answer 21

Traumatic ulcer a chronic ulcer on the left posterior lateral border of the tongue caused by lingually tilted mandibular 3rd molar. Note central ulceration with peripheral keratosis

Answer 22

Traumatic ulcer Post-anaesthesia traumatic ulcer on lower lip.

Answer 23

Traumatic ulcer Most often on tongue, lips, buccal mucosa Any sites that may be injured by dentition

Answer 24

Traumatic Granuloma

Answer 25

Traumatic Granuloma (traumatic ulcertaive granuloma)

Answer 26

**Traumatic Granuloma** | ( Traumatic Ulcerative Granuloma)

Answer 27

**Etiology** * typically caused by trauma. In more than half the cases, the patient does not recall traumatizing the area although this may have occurred during sleep. * Chronic mucosal trauma from adjacent teeth * Some adjacent source of irritation

Answer 28

**Remove cause of irritation** Topical anesthetic or film for pain relief If there is no obvious cause then ► **biopsy**

Answer 29

Squamous cell carcinoma on the buccal mucosa)

Answer 30

**Erythroplakia and Squamous Cell Carcinoma** Erythroplakia is a general term for red, flat, or eroded velvety lesions that develop in the mouth. In this image, an exophytic squamous cell carcinoma on the tongue is surrounded by a margin of erythroplakia

Answer 31

Leukoplakia and Squamous Cell Carcinoma Leukoplakia is a general term for white hyperkeratotic plaques that develop in the mouth. About 80% are benign. However, in this image, squamous cell carcinoma is present in one of the leukoplakic lesions on the ventral surface of the tongue (arrow).

Answer 32

**HPV + SCC** Area affected: ( Oropharynx cancers largely involved tonsils, . Posterior 3rd of the Tongue) Younger pts, 3:1 Males to females ratio, high socio-eco status Incidence is decreasing less aggressive → higher survival rates ( Better than HPV negative SCC) **HPV - SCC** The chief risk factors for oral squamous cell carcinoma are Smoking (especially \> 2 packs/day) Alcohol use Risk increases dramatically when alcohol use exceeds 6 oz of distilled liquor, 15 oz of wine, or 36 oz of beer/day. The combination of heavy smoking and alcohol abuse is estimated to raise the risk 100-fold in women and 38-fold in men. ( this affects these ares : the tongue, floor of mouth, buccal mucosa, or gingiva) mostly men, low socio-economic factors Incidence is decreasing Very aggressive → lower survival rates

Answer 33

Early stage: Radiation and/or Surgical removal Late stage : combination of surgery, radiation therapy, or chemotherapy

Answer 34

**Graphite tattoo** Most common location on the palate and gingiva Gray, black, or blue-ish macule

Answer 35

**Graphite tattoo** Gray, black, or blue-ish macule

Answer 36

If patient is concerned for cosmetic reasons ► then removal of lesion with autogenous graft

Answer 37

result from pencil lead that is traumatically implanted, usually during the elementary school years

Answer 38

Traumatic ulcer of the tongue.

Answer 39

**Hemangioma of Infancy** a relatively common benign proliferation of blood vessels that primarily develops during childhood. display a rapid growth phase with endothelial cell proliferation, followed by gradual involution.

Answer 40

Hemangioma of Infancy

Answer 41

○ Because most hemangiomas of infancy undergo involution, management often consists of “watchful neglect.”

Answer 42

Necrotizing Sialadenometaplasia an uncommon, usually self-limiting, benign inflammatory disorder of the salivary glands. *Here it is on the palate*

Answer 43

**Necrotizing Sialadenometaplasia** *we see two ulcers on the palate* *Mostly ● Palatal salivary glands ○ Possible for parotid ● 75% of case on posterior palate ● Hard\>Soft palate ● 2/3rd are unilateral*

Answer 44

*The cause is uncertain, although the hypothesis of ischemic necrosis after vascular infarction seems acceptable.*

Answer 45

No Treatment Needed but we need to biopsy to rule out other diseases

Answer 46

**Frictional Keratosis.** There is a rough, hyperkeratotic change to the posterior mandibular alveolar ridge (“alveolar ridge keratosis”), because this area is now edentulous and becomes traumatized from mastication. **Such frictional keratoses should resolve when the source of irritation is eliminated and should not be mistaken for true leukoplakia.**

Answer 47

**Frictional Keratosis** **the white surrounding a a traumatic ulcer** Symptomatic traumatic ulceration of the left mid-ventral tongue associated with a sharp left lower molar. The ulcer has flat edges and is surrounded by an area of frictional keratosis.

Answer 48

Leukoplakia Linea alba Chronic cheek chewing (bite injury) Candidiasis Oral Lichen planus Squamous cell carcinoma

Answer 49

Frictional keratosis on the tongue

Answer 50

* Trauma from Sharp cusp & ortho appliance * Chronic mechanical irritation (chronic biting) * Masticatory function * Normal hyperplastic response * Dentures/missing teeth

Answer 51

* Remove the cauative factor that caused the trauma * observe large lesion regularly excellent prognosis

Answer 52

**dry‐mouth** patient a classic example **• Classic fissuring • depapillation of the tongue papilla • some white changes on the tongue.**

Answer 53

**dry‐mouth** from radiation Note the Ropy, frothiness on the palate. - The tissues are red and irritated due to candida infection as well.

Answer 54

**dry Mouth** Cervical caries related to radiation. The patient is a smoker and coffee drinker --\> explains the staining

Answer 55

dry Mouth Incisal caries in a radiation patient: **Incisal caries is a sure sign of severe dry mouth/ significant salivary gland hypofunction**

Answer 56

**Xerostomia-related Caries** **Or** **Dry Mouth** . Extensive cervical caries of mandibular dentition secondary to radiation-related xerostomia.

Answer 57

**Xerostomia** The subjective experience of a dry mouth (ie a symptom) **Salivary Hypofunction** The objective measurement of a reduction in salivary flow (a sign)

Answer 58

**Stimulated Saliva Production** **▪ 200+ ml/day ▪ Flow rate: mean 1-2 ml/min, maximum 7 ml/min** o “Normal” range is very wide

Answer 59

**300 ml/day ▪ Flow rate: mean 0.3 ml/min**

Answer 60

* **Dehydration** * **Medical conditions** * **Body posture** * **Lighting conditions** * **Circadian/circannual rhythm (lowest during)** * **Medications** Age is an independent factor for whole saliva andsubmandibular/sublingual gland secretion (but notparotid).

Answer 61

* **Mechanical stimuli** * **Vomiting** * **Gustatory/olfactory stimuli (acid/smell)** * **Gland size** Age is an independent factor for whole saliva (but not for parotid and minor gland secretions)

Answer 62

Central inhibition as a result of connections between the primary salivary centers and the higher centers of the brain.

Answer 63

* **May be a reduction in baseline sialometry which is still above “normal.”** * *If they get a decrease in the salivary flow, they still may be in the normal range, but for them the experience is that they have got dry mouth.* * **Saliva film thickness** * *Palatal mucous gland secretions?* * *Anterior dorsum of tongue?* * **Relative contributions by glands** * Mucins, proteins? * **Alterations in sensory perception?** * **Mental status/central inhibition?**

Answer 64

**● Dehydration ● Medications (Rx & OTC)** * *Direct damage to glands* * *Head and neck radiotherapy* * *As a result of radiation it’s irreversible damage to the glands* * *Chemotherapy (reversible)* * *Autoimmune diseases* * *Primary vs Secondary Sjögren’s Syndrome, GVHD* * *HIV disease* **● Decreased mastication (tooth loss, soft diet) ● Conditions affecting the CNS:** * Psychologic disorders (depression/anxiety?), Alzheimer’s, Parkinson’s, Cerebral palsy

Answer 65

**Abnormal unstimulated USFR= \<0.1–0.2ml/min** **Abnormal stiumated SFR = \<0.5ml/min**

Answer 66

* Salivary stimulation (OTC) to stimulate their glands * Salivary lubrication ( to improve it) * Humidification ( like a humidifier in the room at night) * Hydration/prevent dehydration (ie avoid alcohol, caffeine both will act as a * diuretic and lead to dehydration). * Monitor closely to rule out emerging disease ( to see whether they are developing Sjogren’s or something else 􀀀 we want to follow them over time)

Answer 67

* Look for possible causes (major cause will be medications & can dehydration or others) * Restore chewing function (Masticatory issues) * Reduce medication‐induced salivary hypofunction * Prescribe Salivary stimulation OTC, Rx medications, others * Prescribe Salivary lubrication * Humidification ‐use humidifiers * Hydration/prevent dehydration (ie avoid alcohol, caffeine) * Treat oral consequences (such as candidiasis treated with an antifungal or caries with management of caries).

Answer 68

* If dehydrated ► rehydrate or treat underlying condition * People with uncontrolled diabetes, once you control the diabetes‐ their flow comes back. * All we can do is offering Salivary substitutes (sprays, gels, rinses ) * For patients with high dose radiation treatment ► makes sure they get the INRT * Minimizing damage to salivary glands ( there are other strategies for that) * Prevention and treatment of oral complications

Answer 69

– Muscarinic agonists: – **Pilocarpine** 5‐7.5mg tid & qhs (can go as high as 10mg qid) – **Cevimeline** 30mg tid (can go as high as 60mg tid) _Contradicated for_ : **CV disease, hepatic, renal or respiratory diseases or narrow angle glaucoma** **Pilocarpine affects M1 & M3** _side effects_ (sweating, flushing, rhinitis, increased urination, weakness and some experience the shakes. ) **Cevimeline affects M3 only** fewer side effects

Answer 70

**SJÖGREN’S SYNDROME** Autoimmune exocrinopathy Marked bilateral parotid gland enlargement in a patient with primary Sjögren syndrome Dry mouth and eyes resulting from a chronic progressive loss of secretory function (Slowly but surely, the salivary glands and/or lacrimal glands (some cases are more lacrimal & less salivary or vice versa); slow & progressive Patients with Sjogren’s can have bilateral salivary gland enlargement (parotid) (Sometimes we may see a unilateral enlargement of the salivary glands due to retrograde infections.) **increased risk of lymphoma (MALT type)**

Answer 71

**SJÖGREN’S SYNDROME** _Dry Mouth_ very severe cervical disease & very dry lips

Answer 72

Depapillated & Fissured Tongue ## Footnote **SJÖGREN’S SYNDROME**

Answer 73

a patient with a **_bacterial sialadenitis_** who has **_SJÖGREN’S SYNDROME_** When we examine such patients and ”milk” the gland ► you actually see a purulent drainage from the gland itself.

Answer 74

These patients **LOW USFR, no response to stimulation (aka abnormal USFR/SFR)** * Rehydrate if dehydrated * Treat underlying conditions (i.e. DM) * Salivary substitutes (glycerin) * Minimize damage to glands from radiation * Prevention of complications & palliative treatment * Optimal hygiene * Restore caries * Smooth sharp edges in oral cavity * Fluoride therapy * Antifungals * Chlorhexidine rinses w/o alcohol * Sialendoscopy * Salitron - salivary pacemaker * ALTENS (acupuncture like transcutaneous electrical nerve stimulation)

Answer 75

**Sjögren Syndrome** * bilateral enlargement of the submandibular glands * angular cheilitis, dry and cracked lips and fissured and despapilated tongue * severe ocular lesions.

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