Mouth Throat Flashcards
(152 cards)
1
Q
Why is oral health the key to overall health?
A
o Digestion (enzymes, mastication), healthy flora, non-specific immunity o Poor hygiene and flora can lead to GI, cardiovascular, respiratory, immune problems
2
Q
What info do you get in a mouth hx?
A
• o HPI: review LNOPQRST o Screenings: Date of last dental exam o Diet: sugar consumption, soda, etc o Dental and mouth hygiene habits o History of smoking, alcohol, drug use o Ever any x-rays of head/neck?
3
Q
How do you do PE for mouth and oral mucosa?
A
•
o Vitals: some conditions may have accompanying systemic signs/symptoms
o Have the patient remove dentures, if any.
o Inspection, palpation, palpate TMJ
4
Q
How do you do an oral inspection?
A
•
o Inspect lips and angle of mouth for color and moisture, lesions
o Use a tongue blade and penlight
o Teeth (number, condition, fillings, erosion of enamel)
o Gums (color, swelling, tenderness)
o Buccal mucosa (color, lesions)
o Roof of mouth (color, architecture of hard palate, lesions)
o Tongue (sides and undersurface also), note size, color, surface, moisture, lesions
o Pharynx: depress tongue while patient phonates (“Ahh”)
5
Q
• How do you do palpation in T/M PE?
A
o Wear gloves for oral palpation
o Cervical lymph nodes for enlargement, tenderness
o Tumors/masses; enlarged salivary ducts or glands
o Tongue masses or lesions
o Linea alba: white line in buccal mucosa at biting plane
6
Q
• How do you palpate TMJ in oral PE?
A
o Look for deviation of the jaw when opening/closing;
o Palpate over joint while opening/closing jaw for symmetry, crepitus
Have pt insert three fingers vertically for normal ROM
7
Q
o
What are some general finding in oral PE?
A
•
o Breath Odor: Halitosis - systemic or local disease (gingiva, smoking, diabetic ketoacidosis–sweet, liver failure—faintly sulfurous, renal failure—ammonia); alcohol on breath; Fetor oris - originates in the mouth, can be associated with appendicitis (add’l sx)
o Dryness of the mouth (xerostomia)- mouth breathing, dehydration, diuretics, salivary disease, sialoliths
o Gingiva: (Normally smooth, firm and contoured around the teeth); dark line: heavy metal poisoning? Painful swelling in gum: possible tooth abscess
o Teeth: Bruxism: clenching and grinding teeth wears down dental crowns, loosens teeth; Decay; Tooth loss
o Palate: Hard palate: petechiae (broken capillary blood vessels) (seen in Strep infx, suction); Soft palate: should elevate symmetrically when patient phonates “ahh” (CN IX, X); Uvula: check for inflammation, deviation
o Tongue and floor of the mouth: oral cancers under the tongue; tongue movements (CN XII, hypoglossal); enlarged tongue: dentures, inflammation, myxedema etc; papillae: enlarged or atrophied
8
Q
What are some labs done after oral PE (as indicated)?
A
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CBC, chem. screen; rapid strep; mono spot, throat culture, B12 levels, biopsy
9
Q
o
What imagins is done on the mouth (As indicated)?
A
•
X-rays of teeth; MRI or CT to evaluate masses
10
Q
o
• What referral (appropriate) may me done after oral PE?
A
o Dentist, ENT, Laryngologist, Neurologist
11
Q
• What are 5 conditions of the lips?
A
o Recurrent herpes labialis; carcinoma of the lips; mucocele; cheilitis; Angular cheilitis (aka perlèche, cheilosis, angular stomatitis)
12
Q
• What is recurrent herpes labialis?
A
o herpes simplex HSV; “cold sore” “fever blister”; HSV-1 moHt common, high incidence; contagious
o Prodrome (itching, burning, tingling) lasts approximately 12 to 36 hours, followed by eruption of clustered vesicles along the vermilion border. Subsequent rupture, ulceratation, and crusting
o Reactivation triggers: UV light, trauma, fatigue, stress, menstruation
o Concern re auto-innoculation to eye, skin
13
Q
What is carcinoma of the lips? Common type? Diagnosis?
A
•
o Etiologies: tobacco, alcohol, sunlight, poor oral hygiene or poorly fitting dentures.
o Often Squamous cell cancer (SCC): Lesion: painless, sharply demarcated, elevated, indurated border with ulcerated base may be verrucous or plaque like; Usually found on the mucocutaneous junction of the lips; Slow- growing, fails to heal, can bleed. High risk of metastasis
o Diagnosis: biopsy
14
Q
• What is mucocele? Etiology?
A
o Soft cyst, mucin-filled cavity with mucous glands lining the epithelium; Common on lips, under tongue (called a “Ranula” from latin rana—frog’s belly)
o Etiology: minor injury to ductal system of minor labial or sublingual salivary gland, by trauma
15
Q
• What are ssx of mucocele? Tx/prognosis?
A
o Signs & Sxs: Thick, mucus-type saliva produced by the damaged gland creates a clear or bluish bubble of various size (1-2cm), movable, cystic, may rupture. Bleeding may occur with further damage, lesion may then look red or purple
o History of enlargement, breaking, and shrinkage is fairly common. Can persist, rarely goes away on its own (dentist can surgically remove)
16
Q
• What is cheilitis?
A
o Erythema and scaling of the lips “chapped lips”
o Etiology: Use of retinoids (isotretinoin, acitretin), wind-burn, allergies, chronic lip licking (saliva causing irritant dermatitis)
o May become secondarily infected
17
Q
• What are ssx of angular cheilitis? Labs done?
A
o Deep cracks at labial commisure, if severe can split or bleed, form shallow ulcers. May become infected by Candida albicans; Staph aureus Often bilateral
o Lab: KOH prep to assess for Candida infx
18
Q
What is etiology of angular cheilitis?
A
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o Elderly: ill-fitting dentures, loss of teeth changing bite, sicca (dry mouth)
o Poor oral hygiene
o Nutritional deficiencies, esp. vitamin B (Riboflavin B2, Cyanocobalamin B12) and iron deficiency anemia (due to poor diet, malabsorption).
o Irritant or allergic reaction to oral hygiene or denture material
19
Q
• What other syndrome is angular cheilitis associated with?
A
o May also be part of a group of symptoms in Plummer-Vinson syndrome (upper esophageal web, iron deficiency anemia, glossitis, and cheilosis)
20
Q
• What are the 4 classifications of conditions of the mouth?
A
o Mmucosal lesions
o Stomatitis
o Oral edema
o Other oral findings
21
Q
• What types of lesions are seen in the mouth?
A
o may occur anywhere on mouth structures; includes ulcerations, cysts, firm nodules, hemorrhagic lesions, papules, vesicles, bullae, and erythematous lesions.
Vary in symptoms from asymptomatic to very painful.
22
Q
o
• What are typical etiologies of mouth lesions?
A
o trauma, infection, systemic disease, drug use, or radiation therapy.
o Multiple causes/conditions.
23
Q
• How do you handle mouth lesions in the office?
A
o Need complete history, FHx, allergy history.
o PE: check whole body for lesions that may explain the oral ones.
o Direct smears, stains and cultures sometimes helpful.
o A solitary lesion that lasts >2 weeks should be biopsied for malignancy
24
Q
• What are the different types mucosal lesions of the mouth?
A
o Oral lichen planus o Leukoplakia o Erythroplakia o Oral squamous cell carcinoma (SCC) o Melanoma Fordyce’s spots
25
• What is oral lichen planus? Etiology?
o Non-erosive lesion: usu painless, vary from lace-like white patches/ papules/ streaks (Wickham striae) on buccal mucosa to erosions on gingival margin. If painful can interfere with eating. Not contagious.
o Etiology: unknown. Possible drug reaction, Hep C, worse with stress
26
• What can happen with oral lichen planus?
o An erosive form can erupt into violet papules with white lines or spots, usually on the genitalia, lower back, ankles, and anterior lower legs; pruritus;
o If chronic, can increase risk for oral cancer.
27
• What is leukoplakis? 2 Types?
o White patches or plaque on the oral mucosa that cannot be rubbed off.
o Precancerous hyperplasia of the squamous epithelium (thought to be early step in transformation of clonally independent cells) Up to 20% of lesions will progress to CA in 10yr
o Also seen in inflammatory conditions not associated with malignancy; ~ 90% of lesions in those > 40 yrs, M > F
28
• What is etiology of leukoplakia (presumptive factors)
o trauma from habitual biting, dentures tobacco use (oral tobacco, esp)
o oral sepsis; local irritation; alcoholism; syphilis; vitamin deficiency; endocrine disturbances; dental galvanism; AIDS
29
• what are ssx of oral leukoplakia?
o Located on tongue, mandibular alveolar ridge and buccal mucosa in ~50%; Also--palate, maxillary alveolar ridge, floor of mouth, retromolar regions
o Forms vary: nonpalpable, faintly translucent white areas to thick, fissured, papillomatous, indurated lesions.
o Surface is often shriveled in appearance and may feel rough on palpation.
o Can look like “flaking white paint”, may have red specks
o Color variants: white, gray, yellowish-white, brownish-gray (patients with heavy tobacco use.)
30
• What is found on PE of oral leukoplakia? Diagnosis?
o PE: lesion cannot be wiped away with gauze; Check for cervical LA, may indicate malignant changes
o Diagnosis: Biopsy to obtain a definitive diagnosis, multiple samples if large lesions
31
• What is ddx for oral leukoplakia?
o Candidiasis and aspirin burn (can be wiped away with a gauze)
o “Other” White Oral Lesions That Cannot Be Wiped Off with Gauze: traumatic or frictional keratosis; lichen planus; leukoedema; Systemic lupus erythematous SLE; galvanic keratosis; white sponge nevus; verrucous carcinoma; squamous cell carcinoma SCC
32
What is erythroplakia? Etiology? Dx? Risk factors?
•
o Red macule or plaque with well-demarcated edges with soft texture; Often on floor of mouth, tongue, palate
o Unknown etiology, but considered a type of epithelial dysplasia, thus pre-cancerous
o Cancer found in 40% of cases. Biopsy!
o Risk factors: smoking, alcohol
33
• What is epidemiology of oral SCC? Risk factors? Location?
o ~ 30,000 in US each year; 90% are smokers, alcohol is also a risk factor.
o Subset of SCC associated with HPV-16 infection
o Most on floor of mouth or on the lateral and ventral surfaces of tongue. Also lip, palate
34
• What are ssx of SCC?
o May appear as area of erythroplakia or leukoplakia;
o Exophytic or ulcerated: Both variants are indurated with a rolled border.
o Early lesion may be asymptomatic; Ulcerated lesions are often painful
o May be difficulty in speaking if lesion is large
o Metastatic mass (non-tender) in the neck may be the first symptom.
35
• What should you biopsy that may be SCC?
o any persistent papules, plaques, erosions or ulcers!
36
What is oral melanoma?
•
o Pigmented lesions with concerning signs: asymmetry, irregular borders, variable coloration, increasing diameter; lesion will not blanch
o Often diagnosed at later stages
37
• What is ddx for oral melanoma?
o Melanosis--symmetric lesions in individuals with dark skin
| o Oral melanotic macules—symmetric, stable, sharply delimited dark macules on lips or oral mucosa
38
• What are Fordyce’s spots?Epidemiology? Ddx?
o Benign neoplasms from sebaceous glands (sebaceous choristomas)
o Most common 20 -30 years; M = F
o DDX: Candida albicans - candida lesions wipe off, but Fordyce's granules do not
39
• What are ssx of fordyce’s spots?
o Asymptomatic, multiple, white to yellow, 1-2 mm papules, often occurring confluent cluster
o Most common on the vermillion/buccal mucosal border. Also on the inner surface of the lips, the retromolar region, tongue, gingiva, frenulum linguae or palate
40
• What is stomatitis?
o Inflammation of oral tissue from local or systemic conditions
41
• What is etiology of stomatitis?
o infection: strep, candida, Corynebacterium, syphilis, TB, measles, HIV, coxsackie virus, HSV, Varicella-zoster virus, fungus (Histoplasmosis, Mucor, Cryptococcus, Coccidiomycosis)
o deficiencies: vitamins B and C, iron
o leukemia
o mechanical trauma: poorly fitting dentures, improper nipples on bottles
o alcohol, tobacco, hot/spicy foods and drinks
o mouth breathing, cheek biting, irregular teeth, poor orthodontia
o chemicals eg, mercury poisoning (with marked salivation)
o allergy - intense shiny erythema with swelling, itching, dryness, burning
o drug hypersensitivity reaction
42
• what are the different types of stomatitis?
```
o Oral candidiasis?
o Pseudomembranous stomatitis
o Recurrent aphthous tomatitis
o Herpetic gingivostomatitis
o Oral erythema multiforme
o Chancre
o Other causes
```
43
• What is oral candidiasis? Risk factors?
o “Thrush” “moniliasis”; Common oral fungal (yeast) infection by Candida albicans, C glabrata, C tropicalis
o Risk factors: denture-wearers, diabetics, use of antibiotics, exposure to chemotherapy or radiation, HIV/AIDS, use of inhaled glucocorticoids (eg asthmatics); common in infants
44
• What are ssx of oral candidiasis? Dx?
o SSX: Lesion: slightly raised soft white plaques (look like milk curds) that are easily wiped away, causing bleeding; May have burning sensation; Mouth appears dry (xerostomia
o Dx confirmed with KOH prep
o **Recurrent, persistent, extensive disease warrants immune status evaluation
45
• What is pseudomembranous stomatitis? Etiology? Sx?
o Inflammatory reaction that produces a membrane-like exudate
o Caused by chemical irritants or bacterial infections
o Fever, malaise, and LA may result or it may be localized to the mouth
46
• What is recurrent aphthous stomatitis?
o aphthae=”canker sores”
o Acute, painful, recurring, solitary or multiple necrotizing ulcerations of the oral mucosa.
o Possibly T-cell mediated localized destruction of oral mucosa
47
• What is etiology of recurrent aphthous stomatitis?
o Provocations- exact cause is unknown
o Trauma is the most common trigger: Physical: toothbrush abrasions, laceration by sharp foods/objects, biting, dental braces; Chemical irritants or thermal injury (coffee, tea), Foaming agent in toothpaste (Sodium lauryl sulfate)
o Food allergies, citric acid, artificial sugars, gluten
o Deficiencies in vitamin B12, iron, and folic acid
o Stress, illness, fatigue
o Immunodeficiency (eg HIV)
o Neutropenia-- history of taking antimetabolites (eg methotrexate)
o Hormonal changes, menstruation
o Associated with celiac disease and inflammatory bowel disease (eg Crohn’s dz)
48
What are ssx of recurrent aphthous stomatitis?
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o Painful lesions, occasionally have prodromal burning or tingling
o Ulcers are shallow, round to oval with a grayish base, with a red border
o Occur on non-keratinized, moveable mucosa: buccal and labial mucosa, buccal and lingual, sulci, ventral tongue, soft palate and floor of mouth.
o Some individuals have 2-4 outbreaks a year, while others can have continuous eruptions
49
• What are the 3 forms of aphthous ulcers? Difference?
o same disease spectrum, different by size, duration, location
o minor form, major form, herpetiform ulcers
50
• what are minor form aphthous ulcers?
o Most common/least severe form
o Develop in childhood and adolescence, and then sporadically throughout life
o Usually solitary, shallow, oval yellow-gray ulcer with raised yellowish border surrounded by an erythematous halo, <1 cm diameter
o Lasts 7 to 10 days; heals without scars
51
• What is the major form of aphthoush ulcers?
o multifocal, ragged edges, may be up to 2 cm in diameter, may last up to 6 weeks and may be immediately followed by a recurrent ulcer
o Heals with scarring and cause severe pain and discomfort
o Typically develop after puberty with frequent recurrences.
o Occur on moveable non-keratinizing oral surfaces, but the ulcer borders may extend onto keratinized surfaces
52
• What are herpetiform ulcers (aphthous)?
o most severe form; Occurs more frequently in females, and onset is often in adulthood.
o Small, numerous, pinpoint lesions (1–3 mm) that form clusters, coalesce into ulcers
o Typically heals in less than a month without scarring
53
• What is ddx of recurrent apthous ulcers?
o Secondary herpetic ulceration - history of vesicles preceding the ulcers, a location on periosteum-bound mucosa (gingival, hard palate) and crops of lesions.
o Trauma, pemphigus vulgaris and cicatricial pemphigoid.
o Systemic disorders: Crohn's disease, neutropenia and sprue.
54
• What is herpetic gingivostomatitis? Triggers?
o HSV-1 infection “cold sore”; Painful eruptions of the unmovable oral mucosa and vermilion border; Primary infection of HSV-1, common in children
o Triggers: trauma, emotional stress
55
• What are ssx of herpetic gingivostomatitis?
o Often a prodrome of pain, burning, tingling; also fever, malaise, LA, painful eating
o Eruption of multiple interoral vesicular lesions and erosions, erythematous base, crusting
o Self limited in 1-2 wks in most cases
o Kids: fever, LA, drooling, decreased oral intake due to pain (watch for dehydration)
o Recurrence is common
56
• What labs are done for herpeticgingivostomatitits? Ddx?
o Lab: Tzank smear, direct immunofluorescence smear, or viral culture
o DDX: aphthous stomatitis, erythema multiforme, drug eruptions, pemphigus
57
• What is oral erythema multiforme? Ddx?
o Hypersensitivity reaction to HSV, other organisms (eg Mycoplasma pneumoniae), drugs, or idiopathic with skin lesions and mucosal involvement
o DDX: aphthous stomatitis, allergic stomatitis, pemphigus, herpes
58
• What are the ssx of oral erythema multiforme?
o Painful stomatitis, sudden onset of diffuse hemorrhagic vesicles and bullae with erythematous base, on lips/mucosa
o Bullae rupture leaving raw, painful, friable surfaces, then form crusts
o May be Prodrome: sinusitis, rhinitis; may see a high fever for 4-5 days, and severe systemic symptoms
o Other areas of body – maculopapular erythematous lesions (target lesions) form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia
59
• What is chancre?
o Lesion: painless ulceration formed during the primary stage of syphilis, ~21 days after the initial exposure to Treponema pallidum, these ulcers usually form on or around the lips, tongue, also anus, penis, and vagina.
60
• What are ssx of chancre? PE? Labs?
o SSX Painless single ulcerated lesion, indurated border, no central necrotic tissue; Tender cervical LA; typically last 2 wks to 3 mos without treatment
o PE: be sure to look for genital lesions as well
o Lab: PCR serology
61
• What are 5 other causes of inflammation and irritation of the mouth?
o many denture-related; frictional hyperkeratosis; epulis fissure; denture sore spot; denture sore mouth; irritation fibroma
62
• what is frictional hyperkeratosis?
o caused by chronic friction against an oral mucosal surface, resulting in a hyperkeratotic white lesion (a protective response to low-grade, long-term trauma).
o Leads to white line called linea alba if caused by biting
o If cause is uncertain, the lesion should be considered idiopathic leukoplakia and be biopsied
63
• What is epulis fissure? Ssx?
o Denture hyperplasia
o Ssx: Painless folds of fibrous connective tissue, firm or spongy to palpation with the impression of denture edge (tissue reaction—maxillary mucosa—to chronically ill-fitting dentures)
o Usually not highly inflamed, but may be erythematous or even ulcerated in the base where the edge of the denture flange fits
64
• What is denture sore spot?
o small, painful ulcers, characterized by an overlying, grayish necrotic membrane and surrounded by an inflammatory halo. Usually heals quickly once denture removed
65
• what is denture sore mouth?
o denture stomatitis- very common; Mucosa beneath the denture becomes extremely red (sharply demarcated and localized) and swollen, with either a smooth or granular appearance.
o Severe burning sensation is common.
o May be caused by allergy to acrylic or by fungal infection
66
• What is irritation fibroma? Epidemiology? Ddx?
o Most common benign oral soft tissue neoplasm
o most often 20 - 49 years; M = F
o DDX: based mainly on the location. Tongue - neurofibroma, neurilemmoma or granular cell tumor. Lower lip or buccal mucosa - lipoma, mucocele or salivary gland tumor.
67
• What are ssx of irritation fibroma?
o in buccal mucosa, lateral border of the tongue and the lower lip (area of trauma)
o Lesion: painless, sessile )fixed in one place) or occasionally pedunculated swelling that can be firm and resilient or soft and spongy in consistency; typically ≤ 1cm
o Color is slightly lighter than the surrounding mucosa from relative lack of vascular channels
o May become irritated or ulcerated
68
• What are 2 types of oral edema?
o Angioedema (Quincke’s edema) and Hereditary angioedema (hereditary angioneurotic edema)
69
What is oral angioedema? Onset? If allergic?
•
o Acute edema (swelling) of the skin, mucosa (mouth, throat, tongue) and submucosal tissues
o Rapid onset (over the period of minutes to several hours).
o Urticaria (itchy raised bumps) may develop if the angioedema is related to allergy.
o Hand swelling common
70
• What is etiology of oral angioedema?
```
o Allergic (most common,) not IgE mediated; Common allergens include: medications; foods (such as berries, shellfish, fish, nuts, eggs, milk, wheat); pollen; animal dander; insect bites; exposure to water, sunlight, cold or heat; emotional stress
o Infection or illness: autoimmune disorders, leukemia
```
71
• What are ssx of oral angioedema?
o Painless, non-pruritic (if non-allergic), nonpitting, and well-circumscribed areas of edema from increased vascular permeability.
o May progress to complete airway obstruction and death caused by laryngeal edema.
o May be chronic when lasting more than 3 weeks
72
• What is hereditary angioedema? Cause?
o Rare, autosomal-dominant inheritance, presenting as edema in the face, airway passages, hands and feet
o 85% are deficiencies of C1 esterase inhibitor, see family history
73
• What are ssx of hereditary angioedema? Triggers?
o Edema is unifocal, indurated (hardened), painful rather than pruritic
o Usually no associated itch or urticaria (non-allergic)
o May have recurrent episodes ("attacks") of abdominal pain, usually accompanied by intense vomiting, weakness, watery diarrhea, and flat, non-itchy splotchy/swirly rash.
o Precipitated by stress, infection, trauma, viral illness, though no cause may be apparent
74
• What are 5 “other” oral findings?
o Palatal or mandibular torus; hemangioma; varicosities; papilloma; lipoma
75
• What is palatal or mandibular torus? Cause? Incidence?
o Non-neoplastic, slowly growing nodular protuberance of bone. Of little clinical significance, except with interference with denture construction and placement.
o Likely hereditary
o Incidence F > M (2:1). Peak incidence occurs shortly before age 30
76
• What is hemangioma? Incidence?
o Proliferation of blood vessels, often congenital.
| o F>M : 2:1
77
• What are ssx of hemangioma? Ddx?
o SSx: Lesions are flat or raised, with a deep red or bluish-red color; Most common sites: lips, tongue, buccal mucosa and palate. Because of location, frequently traumatized and can undergo ulceration and secondary infection.
o DDX: Arteriovenous fistula: more likely if history of trauma to the area of the lesion
78
• What are oral varicosities? Location? Ssx?
o Dilated, tortuous veins in the oral cavity are attributed to increased hydrostatic pressure and poor support by surrounding tissues
o Commonly located on ventral aspect of the tongue, but may also be found on upper and lower lips, buccal mucosa and buccal commissure
o Blue, blanch when compressed
79
• What are ssx of oral papilloma? Location?
o Asymptomatic, well-circumscribed, usually pedunculated benign growths with numerous, small finger-like projections (papillary or verrucal)
o Generally < 1 cm in diameter, most often solitary
o Locations: any intraoral mucosal site and vermillion border of the lips, most common on soft palate or hard palate, uvula, tongue
80
• What is etiology of oral papilloma? Ddx?
o Etiology: Some oral papillomas are associated with the same human papillomavirus (HPV) subtype that causes cutaneous warts,
o DDX: Verruciform xanthomas: distinct predilection for the gingiva and alveolar ridge; Warty dyskeratoma: tends to occur as multiple lesions; Condylomata acuminate: usually larger and multifocal, with a broader base
81
• What is oral lipoma?
o Painless, benign, slow-growing mass of adipose tissue (on cheek, tongue)
o Yellow, non-tender, rubbery or soft, mobile (if on cheek)
o May affect speech if large
o May be hereditary component (familial multiple lipomatosis); may develop in area of trauma
82
• What are 4 conditions of the salivary glands?
o Sialadenitis: Painless benign swelling seen in many systemic diseases (eg hepatic cirrhosis, sarcoidosis, neoplasms, infections (mumps); Usually pain with mumps, malignancy and infection; others may be painless
o Sialolisthesis: Salivary duct stones, most common in the submandibular glands, Pain and swelling associated with eating
o Sjögren’s syndrome: Systemic inflammation (autoimmune) associated with dry eyes, mouth and mucus membranes
o Xerostomia: Many causes: drugs (diuretics, anticholinergics), Sjogren’s, salivary gland disorders, dehydration, mouth breathing. Contributes to tooth decay
83
• What are 6 conditions of the teeth and gums
o Gingivitis; Vincent’s angina, periodontitis, caries, toothache and infection, tooth loss (edentulism)
84
• What is gingivitis? Etiology?
o Inflammation of the gums with redness, swelling, changes in contours, pocket formation; May see watery exudate and bleeding; Common in puberty and during pregnancy
o Etiology: poor oral hygiene (most common), malocclusion, dental calculi, food impaction, faulty dental restorations, mouth breathing
o Note: drugs phenytoin (Dilantin) and nifedipine can cause gingival hypertrophy
85
• What are ssx of gingivitis? Prevention?
o Signs & Sxs: Swollen, bright-red or purple gums, may be shiny; Receding gum line “long in the tooth”; Usually painless, except when pressure is applied; Bleed easily, even with gentle brushing
o May be first sign of systemic dz: DM, poor nutrition, leucopenia, endocrine d/o
o Prevention: regular oral hygiene (daily brushing and flossing); sesame oil pulling, oral probiotics, CoQ10
86
• What is Vincent’s angina? Aka?
o Acute infection of the gingiva
o Trench Mouth; Acute Necrotizing Ulcerative Gingivitis ANUG
o acute membranous gingivitis, fusospirillary gingivitis, fusospirillosis, fusospirochetal gingivitis, necrotizing gingivitis, phagedenic gingivitis, ulcerative gingivitis, Vincent stomatitis, Vincent gingivitis, and Vincent infection.
87
• What is etiology of Vincent’s angina? Ssx?
o Etiology: Fusiform bacteria and spirochetes, neglectful oral hygiene; severe stress, malnutrition; More common with alcohol and tobacco use, HIV
o Signs & Sxs: Progressive painful infection with ulceration, swelling and sloughing off of dead tissue; Ulcerated lesions of the interdental papillae; can affect all gum tissue, bad odor, “punched out” looking lesions with a gray membrane; bleed easily
88
• What is periodontitis? Etiology? Risk factors?
o Infection of the periodontium causing inflammation of the periodontal ligament, gingival, cementum and alveolar bone
o Etiology: progressive gingivitis (plaque below gingival margins) leads to deep pockets that harbor anaerobic organisms, leading to bone loss
o Risks: poor hygiene (most common), Diabetes type II, leukemia, Crohn’s disease
89
• What are ssx of periodontitis?
o pain can be absent unless acute infection; Pain with chewing, food impaction in pockets; Tooth may be tender to percussion (tap with tongue blade); Visible plaque; Red, swollen gums with exudate, gums bleed easily
90
• what are caries? Etiology?
o Tooth decay, enamel erosion
o Etiology: Bacteria in plaque (eg Mutans streptococci) release acids that erode enamel
o Methamphetamine users have rapid tooth decay from xerostomia, bruxism, poor hygiene and nutrition = “meth mouth”
91
• What are ssx of caries? Prevention?
o SSx: early, no symptoms. As cavity invades dentin: pain with hot, cold, sweet food or beverages
o Prevention: regular brushing and flossing, cleanings, fluoride???
92
• What are some causes of toothache?
o Caries; Periodontitis; Eruption of wisdom tooth; Teething; Sinusitis
93
• What are some serious concomitant symptoms of toothache/infection?
o Headache, fever, swelling or tenderness in floor of mouth, cranial nerve abnormalities.
94
• What are 3 causes of toothache/infection?
o Apical abscess; Ludwig’s angina; Cavernous sinus thrombosis
95
• What is an apical abscess?
o development of infection deep into root; More severe pain; May visualize swelling of mucosa over involved tooth; URGENT DENTAL REFERRAL
96
• what is Ludwig’s angina? Ssx?
o Cellulitis of mouth floor, from dental infection (80%), lingual frenulum piercing. Staph or Strep infection spreads from sublingual to submaxillary space.
o SSX: Swelling, malaise, fever, dysphagia, possibly stridor. EMERGENCY
97
• What is cavernous sinus thrombosis? Ssx?
o Staph or strep infection in the cavernous sinus leads to development of blood clot. Affects the eye (swelling, etc)
o SSX: headache, vision changes, exophthalmos, paralysis of cranial nerves. EMERGENCY
98
• When is tooth loss seen?
o Kids: normal loss of deciduous teeth
| o Adults: mouth trauma, tooth injury, tooth decay, gum disease, Meth use
99
• What are some general signs and symptoms of conditions of the tongue?
o Difficulty moving the tongue; deviation of tongue; taste abnormalitites; color changes; hairy tongue (lingua villosa nigra); pain in the tongue; tongue tremor; furrows; dry tongue; smooth appearance (atrophic glossitis); enlarged tongue
100
• What may cause difficulty moving the tongue? Sx?
o Most often caused by nerve damage, nerve root disorder, cancer; May also be caused by ankyloglossia (short frenulum)
o May result in speech difficulties or difficulty moving food during chewing and swallowing
101
• What can cause deviation of the tongue?
o Hypoglossal paralysis CN XII (deviates to the paralyzed side)
102
• What can cause taste abnormalities? Terms?
o Damage to the taste buds, side effects of medications (albuterol, chemo), infection, Bell’s palsy, B3 or Zn deficiency, MS, damage to Facial N or Glossopharyngeal N
o Ageusia=loss of taste; dysgeusia=abnormal taste
103
• What can cause color changes of tongue?
o May occur with glossitis - papillae are lost, causing the tongue to appear smooth
o Geographic tongue: benign migratory glossitis; Localized area of loss of filiform papillae, erythematous patches with circumferential white or yellow polycyclic borders
o Consider: candidiasis, psoriasis, Reiter’s, lichen planus, leukoplakia, SLE, HSV, drug rxn
104
What can cause different types of color changes of tongue?
•
o White or yellow - local irritation; smoking and alcohol use
o Red (ranging from pink to magenta): folic acid and vitamin B-12 deficiency; pellagra; pernicious anemia; Plummer-Vinson syndrome; celiac disease; “strawberry tongue” of scarlet fever
o Dark- normal pigmentation of dark-skinned individual; Hyperpigmentation from: Drugs (tetracycline, linezolid, bismuth subsalicylate, PPIs, antidepressants); Addison’s disease
105
• What is hairy tongue? Possible causes?
o black or brown; Distal dorsal third looks hairy (black or green) due to hyperplasia of filiform papillae; Benign condition, painless, pt may experience “gagging” sensation
o AIDS; drugs (antibiotics, prednisone, estrogen); drinking coffee, alcohol; dyes in drugs and food; tobacco use; poor oral hygiene; Overuse of mouthwashes containing oxidizing or astringent agents; Candida or Aspergillis infection after antibiotic
106
• What are possible causes of pain in the tongue?
o injury, such as biting the tongue, can cause painful sores; heavy smoking; diabetic neuropathy, oral cancer, mouth ulcers, leukoplakia; after menopause, some women have a sudden feeling that their tongue has been burned (called “burning tongue syndrome” or idiopathic glossopyrosis); anemia; oral herpes (ulcers); neuralgia; dentures that irritate the tongue; referred pain from teeth and gums; referred pain from the heart; burning pain (DM, depression, anxiety, glossitis, heavy metal poisoning, early pellagra)
107
• what can cause tongue tremor?
o hyperthyroidism (fine tremor) ; nervousness (coarse tremor); alcoholism; paresis; Neurological disease (lower motor neuron dz, brain stem lesion, hypoglossal neuropathy, damage from organophosphates (insecticides))
108
what is furrows of the tongue? Cause?
•
o deep transverse (aka scrotal tongue) is congenital; long dry furrows
o Deep in mid-line, can become irritated with entrapped food debris
o Consider: dehydration; syphilis
109
• What might you consider if pt has dry tongue?
o without furrows consider Sjogren’s syndrome, with furrows think dehydration
110
• what atrophic glossitis, smooth appearance tongue? Causes?
o atrophy of the filiform papillae; Small smooth, glossy, tongue; may be red and painful; Intermittent burning, paresthesias of taste, sensitivity when eating acidic or salty foods
o Causes: low HCl; deficiencies: B12, folic acid, iron, protein; post gastrectomy; cirrhosis; Sjogren’s syndrome ; Celiac disease; Oral Candidiasis
111
• What can cause an enlarged tongue?
o Acromegaly; amyloidosis; reaction to food/ Rx; angioedema; cancer of the tongue; Down syndrome; hypothyroidism; infection; leukemia; lymphangioma; neurofibromatosis; pellagra; pernicious anemia; strep infection
112
• What is glossitis? Ssx?
o Acute or chronic inflammation that can be primary or secondary
o tongue swelling; smooth appearance to the tongue (if atrophic); tongue color changes (usually dark "beefy" red); pale: pernicious anemia; fiery red: deficiency of B vitamins; sore and tender tongue; difficulty with chewing, swallowing, or speaking
113
• what is etiology of glossitis?
o bacterial or viral infections (including oral herpes simplex)
o poor hydration and low saliva
o mechanical irritation or injury from burns, rough edges of teeth or dental appliances.
o exposure to irritants: tobacco, alcohol, hot foods, or spices
o allergic reaction to toothpaste, mouthwash, breath fresheners, dyes in candy, plastic in dentures or retainers, or certain blood-pressure medications (ACE inhibitors).
o Deficiencies: B12, other B vits, iron
o oral lichen planus; erythema multiforme; aphthous ulcer; pemphigus vulgaris; syphilis
114
• what is the anatomy of the pharynx?
o Pharynx: base of the skull to cricoid cartilage in three parts: nasopharynx: nasal cavity and Eustachian tube communication; oropharynx: from soft palate to larynx and anterior communication with oral cavity; hypopharynx: surrounds larynx and leads to the esophagus
o Contains: palatine tonsils, lymph aggregates, adenoids, lingual tonsils
115
• What are 9 types of inflammation of the pharynx?
o Acute pharyngitis; tonsillitis; peritonsilar abscess (quinsy PTA); parapharyngeal abscess; retropharyngeal abscess; recurrent/chronic infections of the pharynx; chronic irritation of the pharynx; velopharyngeal insufficiency; malignancies in the pharynx
116
• What are 4 common etiologies of acute pharyngitis?
o Inflammatory: viral infections (~90% of cases); bacterial infections (strep, staph, H. flu, STD); aphthous ulcers; herpes; fungus (oral thrush – babies)
o Traumatic: foreign bodies; irritant fluids; overheated food and drink; mouth breathing, low humidity; industrial fumes; gastric reflux
o Neoplasm
o Glossopharyngeal neuralgia, elongated styloid process
117
• What are 5 types of viral pharyngitis?
o Adenovirus: most common; throat often does not appear red, although may be very painful; first a runny nose (thin discharge), stuffiness, nose and throat discomfort; within 24-48 hours sore throat develops, lymph node enlargement is modest
o Infectious mononucleosis (EBV or CMV): exudative tonsillitis with marked redness and swelling of the throat; “kissing tonsils”; significant lymph gland swelling; Other symptoms include splenomegaly, persistent fatigue, weight loss; possibly hepatitis; Lab: CBC shows lymphocytosis and atypical lymphocytes, monospot
o Herpes simplex virus can cause multiple mouth ulcers
o Measles (paramyxovirus of genus Morbilliviris)
o Common cold (rhinovirus up to 80%); mild form, nasal sx, cough; 7 day course typical
118
What are 3 types of bacterial pharyngitis?
•
| o Group A streptococcus (GAS, most common); non-group streptococcus; diphtheria
119
• What are ssx of GAS pharyngitis?
o generalized symptoms; typically enlarged and tender lymph glands, with bright red inflamed and swollen throat, often unilateral, progresses more rapidly than viral infections; May have a high temperature, headache, myalgia, arthralgia
120
• what is the cinical probablility of GAS pharyngitis using Modified Centor Criteria?
o One point each: 1. Absence of cough 2. Tender anterior cervical adenopathy 3. Tonsillar exudate 4. History of fever
o Some sources additionally use age: 44 subtract one point
o Scoring: < 10% (no need for antibiotic therapy); 2-3 points: risk of strep 15% if score is 2, 32% if score is 3 (abx if throat culture is positive); >3 points: risk of strep is 53% (treat empirically with antibiotics)
o Negative predictive value if all PE findings absent is 80%. Positive predictive value if all PE finding present is only 40-60%. The Centor Criteria is more useful to rule Strep pharyngitis OUT (if no findings are present)
121
• What are 2 types of complications of GAS pharyingitis?
o potential, but rare
o Non-suppurative: rheumatic fever, toxic shock, glomerulonephritis, PANDAS (pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (presents with episodes of OCD)). All very rare but serious
o Suppurative: tonsillopharyngeal cellulitis, peritonsillar and retropharyngeal abscess, sinusitis, meningitis, brain abscess, otitis media, strep bacteremia. All are infrequent but compelling reasons for antibiotic therapy
122
How is diagnosis made for GAS pharyngitis?
•
o Throat culture (24-48 hrs)
o and/or Rapid Streptococcal Antigen Test RSAT or “rapid strep”; With proper technique: sensitivity 70-90%, specificity 90+ %; Positive test is useful to diagnose GAS; Negative test does not rule out GAS nor identify non-group A Strep
123
• what is non-group streptococcus pharyngitis?
o group C or group G: not associated with rheumatic fever
124
• what is diphtheria caused pharyngitis? Ssx? Dx?
o Potentially life threatening URI caused by Corynebacterium diphtheriae toxin still endemic to Africa, SE Asia, S Amer, Middle East, some of Eastern Europe; Check history of travel
o SSx: in 30% of cases--characteristic dirty gray, tough fibrous membrane in tonsillar area, may cause dyspnea or stridor. Membrane will bleed with scraping; mild sore throat, dysphagia, low grade fever, nausea, vomiting
o complications: myocarditis or nervous system toxicity
o Dx: by gram stain and culture. Reportable to health dept. if diagnosed.
125
• What is the prevalence, fever, nodes, pain, erythema like for viral, bacteria, fungal pharyngitis?
o Prevalence: common; less common; least common
o Fever: Low, <102°; 101-104°; none
o Nodes: Little change; Common LA; Occasional LA
o Pain: Mild-moderate; mod-severe; mod
o Erythema: 1+ red around tonsils, cobblestoning; 3-4+, beefy red; White or red patches
126
• What is tonsillitis? 3 main types?
o Acute inflammation of the palatine tonsils
o Acute - either bacterial or viral in origin
o Subacute – (between 3 wks-3 mos) often caused by the bacterium Actinomyces
o Chronic - can last for long periods, almost always bacterial (tonsils fibrotic)
127
What is etiology of bacterial vs viral tonsillitis?
•
o Bacterial - may be caused by Group A strep GAS
o Viral - may be caused by numerous viruses (Epstein-Barr, Adenovirus)
128
• What are ssx of tonsillitis? Ddx?
o SSX: sudden onset, high fever, malaise, vomiting common; enlarged hyperemic tonsils with purulent exudate; may see membrane on tonsils; fetid breath
o DDX: diphtheria
129
• What are 3 complications with tonsillitis?
o peritonsillar abscess (quinsy)
o tonsilloliths: whitish-yellow deposits produced by bacteria feeding on mucus which accumulates in crypts. These "tonsil stones" emit pungent odor from volatile sulphur compounds
o hypertrophy of the tonsils - can result in snoring, mouth breathing, and obstructive sleep apnea
130
• what is a peritonsillar abscess? Etiology?
o Quinsy, PTA, Serious!
o abscess between tonsil and pharyngeal constrictor ms, typically several days after the onset of tonsillitis, a type of cellulitis (common: strep, staph or H. flu)
o et: usually a complication of an untreated or partially treated acute tonsillitis as the infection spreads to the peritonsillar area; affects children and adults, rare in small children
131
• what are ssx of PTA?
o Early: worsening unilateral sore throat and pain during swallowing (dysphagia)
o persistent pain in the peritonsillar area, fever, malaise, headache and change in voice (hot potato voice) may appear
o neck pain with tender, swollen lymph nodes, referred ear pain and breath odor.
o redness and edema in the tonsillar area of the affected side and the uvula may be displaced towards the unaffected side
o Fever can be >103°F
o May be limited ability to open the mouth (trismus)
132
• What is a parapharyngeal abscess?
o Serious! suppuration of the parapharyngeal lymph nodes. abscess is lateral to the superior constrictor muscle and close to the carotid sheath; markedly swollen anterior triangle in the neck
o throat itself may appear normal; can occur at any age
133
• what is a retropharyngeal abscess?
o Medical emergency! infection in one of the deep spaces of the neck; immediate life-threatening emergency, with potential for airway compromise and other catastrophic complications
o usually occurs in small children or infants (adults too) as complication of suppurative retropharyngeal lymph nodes. Infection spread from the nose, ears, sinuses or tonsils
134
• what are ssx of retropharyngeal abscess?
o sore throat, dysphagia, pain on swallowing (odynophagia), jaw stiffness (trismus), or neck stiffness (torticollis)
o muffled voice, the sensation of a lump in the throat
o constitutional complaints: fever, chills, malaise, decreased appetite, and irritability
o difficulty breathing is an ominous complaint that signifies impending airway obstruction.
135
• What happens with recurrent/chronic infections of the pharynx?
o chronically inflamed tonsils often because of incomplete resolution of previous infections.
o scarring, fibrosis occurs
o treatment varies according to age as tonsils are more important
136
• what is etiology of chronic irritation of the pharynx?
o chronic sinusitis; allergies; dental problems; chronically infected tonsils; chronic bronchitis; mouth breathing; septal deviation; vocal abuse; tobacco, alcohol use; hot or spicy foods; low humidity; industrial fumes
o may be a complication of nephritis, cirrhosis, cardiac disease, AIDS, gastric reflux, hiatal hernia, overweight and pregnancy
137
• what are ssx of chronic irritation of the pharynx?
o thickened pharyngeal mucosa “cobblestoning”, hypertrophic lymph tissue
o check for chronic infection of the nose and gums, for mouth breathing
o barium swallow may be needed to rule out malignancy
138
• what is velopharyngeal insufficiency?
o incomplete closure of the sphincter between the oro- and nasopharynx, resulting in impaired deglutition and speech
o nasal speech and weakness of the voice
o requires surgery if there is significant regurgitation of food
139
• what are some malignancies in the pharynx? Ddx?
o Usually SCC; sometimes a mass in the neck is a first sign
o pain accompanied by an abnormal sensation of sticking in throat
o early stages, the tumor appears as a red smooth mass, sometimes with surface keratinization
o DDX: erythroplakia
140
• What are 6 conditions of the larynx?
o Hoarseness; laryngitis; epiglottitis; vocal cord polyp or nodule; vocal cord contact ulcers; laryngeal (vocal cord) squamous cell carcinoma (SCC)
141
• What is hoarses of the larynx? Causes?
o structural changes in the vocal cords that impair their ability to vibrate
o if recent onset: URI, polyps of the vocal cords; rule out sinus and respiratory disease
o if chronic: in children usually due to vocal abuse, or allergies; in adults: alcohol and tobacco are common causes
o local causes: inflammation, polyps, hypothyroidism, fibrous nodes, leukoplakia, papilloma, CA
o neurological causes: nerve impairment in the cords, myasthenia gravis, Parkinson’s, recurrent nerve paralysis
o general causes: weak expiratory airflow due to tracheal compression, or general weakness
o systemic causes: aortic aneurysm, TB, syphilis, hypothyroidism
o emotional causes (lump in throat sensation with HP Ignatia)
142
• what is laryngitis? Etiology?
o hoarse voice or the complete loss of the voice because of irritation to the vocal cords
o Etiology: Infection (bacterial, viral, or fungal); inflammation due to overuse of the vocal cords; excessive coughing
143
• What are ssx of laryngitis?
o voice change, hoarseness and aphonia, tickling sensation in the throat, need to clear throat; symptoms vary; may be severe with pain and dysphagia, dyspnea; can accompany other URI, allergies; acute or chronic, depending on duration
144
• what is epiglottitis? Etiology?
o Medical emergency!
o bacterial infection of the epiglottis, most often caused by Haemophilus influenzae type B; also Streptococcus pneumoniae or Streptococcus pyogenes.
145
• What are ssx of epiglottitis?
o fever, difficulty swallowing, drooling, and stridor; appears acutely ill, anxious, very quiet; shallow breathing with the head held forward, must sit up in bed.
o early symptoms are insidious but rapidly progressive, and swelling of the throat may lead to cyanosis and asphyxiation.
o typically affects children 2-5 years (not as common –HiB vaccine?)
146
• How is diagnosis made for epiglottitis? Ddx?
o DO NOT try to visualize throat! REFER
o lateral C-spine X-ray: “thumbprint sign” suggests the diagnosis of epiglottitis.
o confirmed by direct inspection using laryngoscopy, although this may provoke airway spasm.
o DDX: croup, peritonsillar abscess, and retropharyngeal abscess.
147
• What is a vocal cord polyp or nodule? Etiology? Ssx? Dx?
o benign, often bilateral lesion
o Etiology: vocal abuse (singers), allergies, inhalation of irritants
o Ssx: hoarseness and a breathy voice quality; visualize with indirect laryngoscopy
o Dx by visualization and biopsy
148
• What are vocal cord contact ulcers? Cause? Ssx?
o unilateral or bilateral ulcers on the mucus membrane over the arytenoid cartilage
o cause: gastric reflux most common
o SSX: mild pain on speaking and swallowing, hoarseness; prolonged ulceration leads to granulomas formation
149
• What is laryngeal (vocal cord) SCC? Causes? Ssx?
o most common type of cancer in the head and neck (90% of all head and neck cancers)
o alcohol and tobacco predispose; more common in males
o SSX: hoarseness, pain on swallowing or chewing
150
• What hx Q’s should you as if pt presents with lumps in the neck?
patient’s age, general state of health, presence of pain and associated symptoms
151
o
| • what may be the cause of lumps in the neck?
o Adults: most are due to inflammatory or neoplastic conditions of the cervical lymph nodes
o Kids: usually due to recurrent tonsillitis
o Tuberculosis, brachial cysts.
152
• What are 4 types of lumps in the neck?
o Cervical LA, suspected with acute inflammation of the tonsils, pharynx. Tender, rubbery
o Neoplasm of the lymphatic chain: NT cervical LA, hard, immobile, large also from metastases from other areas; confirm with biopsy
o Salivary gland swelling: may be inflammatory (mumps, bacteria) or the result of a stone in duct
o Medial neck swellings: from thyroid condition or spread of infection from other areas
