Oral Med Flashcards
(204 cards)
1
Q
Causes of oral ulceration
A
trauma
immunological
infections
carcinoma
gastrointestinal
2
Q
recurrent aphthous stomatitis types
A
minor
major
herpetiform
Behcet’s syndrome
3
Q
medications which may induce oral ulceration
A
cytotoxic drugs - e.g. methotrexate
NSAID’s
nicorandil
4
Q
minor aphthous ulcers - features
A
commonest type of recurrent ulcertaion
round or oval with a red halo and yellow base
1-20 per crop
less than 10mm diameter
last up to 2 weeks
only affect non-keratinised mucosa
heals without scarring
usually a good response to topical steroids
5
Q
major aphthous ulcers - features
A
can last for months
can affect any part of the oral mucosa
may scar when healing
poor response to topical steroids
- intralesional steroids more effective
usually larger than 10mm
6
Q
herptiform apthae features
A
rarest form of aphthous ulcers
<5mm
multiple small ulcers on. non-keratinised or non-keratinised
heals within 2 weeks
heal without scarring
can coalesce into larger areas of ulceration
7
Q
Behcets disease diagnosis
A
- 3 episodes of mouth ulcers in a year
- at least 2 of the following: genital sore, eye inflammation, skin ulcers, pathergy
8
Q
RAS predisposing factors
A
genetics
viral and bacterial infections
systemic disease
stress
hormonal fluctuations
mechanical injuries/trauma
microelement deficiency
9
Q
aphthous ulcers - investigations
A
blood tests
- haematinic deficiecnies - iron, b12, folic acid
- coeliac disease - TTG
allergy tests
- contact or immediate hypersensitivity
10
Q
potential problems of recurrent aphthous stomatitis
A
infections
dehydrations and malnutrition
problems
11
Q
when to refer to oral medicine for RAS
A
no good result from treatment
children under 12
12
Q
What is a fibro-epithelial polyp?
A
a localised hyperplastic lesion
13
Q
fibro-epithelial polyp aetiology
A
overproduction of granulation and fibrous tissue in response to damage or trauma
14
Q
fibro-epithelial polyp - clinical features
A
commonly presents in buccal mucosa
often in areas of trauma
may be pedunculated or sessile
firm or soft
pink appearance
painless
can be ulcerated and easily traumatised
may have associated frictional keratosis
usually an isolated lesion
15
Q
fibro-epithelial polyps - histology
A
fibrous tissue in the core
thick interlacing collagen fibres
adjacent normal tissue
covered with squamous epithelium
may have hyperkeratosis
little inflammatory infiltrate
16
Q
fibro-epithelial polyp - management
A
photos
identify cause and correct if appropriate
consider excisional biopsy
17
Q
fibro-epithelial polyp - benefits and risks of excisional biopsy
A
benefits
- can confirm diagnosis - useful if uncertain or patient has ssc risk factors
- can remove lesion
risks
- surgical risks
- altered sensation
- recurrence or incomplete excision
18
Q
denture associated lesions - management
A
consider excision
denture hygiene
candida management
consider making new denture
19
Q
epulis - meaning
A
a reactive hyperplastic lesion on the gingivae
20
Q
fibrous epulis - what is it?
A
a fibro-epithelial polyp presenting on the gingiva
21
Q
fibrous epulis features
A
same colour as gingiva
may be ulcerated
histologically similar to polyps
- more likely to have varying amounts of inflammatory infiltrates
22
Q
Giant cell epulis features
A
also known as peripheral giant cell granuloma
red/purple appearance
sessile or pedunculated
often inderdentally
more common in children
23
Q
Giant cell epulis histology
A
vascular stroma
fibrous tissue
multinucleate osteoclast giant cells
24
Q
Giant cell epulis - management
A
excisional biopsy
OPT and/or CBCT
bone profile
parathyroid hormone assay
25
vasular epulis/pyogenic granuloma features
increase in size due to hormonal changes
if pregnant in pregnancy = pregnancy epulis
soft bright red appearance
may resolve during birth
if removed following birth, inflammation may decrease and resemble a fibrous epulis
may recur if removed during pregnancy
26
vascular epulis histology features
vascular appearance
variable amounts of inflammatory infiltrate
27
vascular epulis management options
in GDP - refer to oral surgery for further advice
keep under observation
- excise following birth
excisional biopsy
28
drugs linked to generalised gingival overgrowth
- calcium channel blockers
- ciclosporin
- phenytoin
29
non drug induced causes of generalised gingival overgrowth
chronic hyperplastic gingivitis
- mouth breathing, pregnancy
hereditary gingival fibromatosis
- enlarged, little inflammation, expansion of the tuberosities
- may require repeated gingivectomies to facilitate oral hygiene
granulomatous disease
- OFG
- Oral crohns etc
haematological malignancy
- gingival swelling/periodontal disease rapidly progressing in the presence of good OH?
30
squamous cell papilloma features
benign growth - wart
any aspect of oral mucosa
pedunculated OR sesile
cauliflower appearance
often keratinised surface
result from viral infection
- typically HPV
not associated with malignant transformation
single or multiple lesions
may present in immunocompromised patients
31
squamous cell papilloma histology
finger like processes of hyperplastic squamous epithelium
thin cores of vascular connective tissue
32
squamous cell papilloma - management
excisional biopsy
observation
- if no red flag sign, symptoms or oral cancer risk factors
33
black hairy tongue pathophysiology
hyperplasia of filiform papillae
build up of commensal bacteria, food debris
pigment inducing fungi and bacteria
34
black hairy tongue cause
specific cause unknown
linked to
- smoking
- antibiotics
- chlorhexidine mouthwash
- poor oral hygiene
35
black hairy tongue management
reassure
stop smoking
stay hydrated
lightly brush tongue
gentle exfoliation of tongue surfaces
- peach stones
eat fresh pineapeale
36
White patches - potential causes (CLINK)
congenital
lichen planus
infections
neoplastic/potentially neoplastic
keratosis
37
Give examples of neoplastic and potentially malignant white patches
squamous cell carcinoma
leukoplakia
sub mucous fibrosis
actinic chelitis
38
Squamous cell carcinoma red flags
> 3 week duration
> 50 years old
smoking
high alcohol consumption
history of oral cancer
non-homogenous
non-healing ulceration
tooth mobility
non-healing extraction sockets
difficulty speaking or/and swallowing
weight loss
fatigue
appetite loss
cervical lymphadenopathy
numbness/altered sensation
39
squamous cell carcinoma management
urgent suspected cancer referral to oral and maxillofacial surgery
be honest with patient and explain concern
explain that they will need to get a biopsy/sample promptly
40
Leukoplakia - define
a white patch or plaque that cannot be characterised clinically or pathologically
- can't be rubbed away
41
proliferative verrucous leukoplakia features
up to 85% undergo malignant transformation
warty surface with white/yellow appearance
common sites palate and gingiva
will enlarge over time
often very extensive and impractical to remove
42
oral submucous fibrosis features
related to paan use
pale in colour
firm to palpate
fibrous bands develop
typically affects buccal mucosa and soft palate
mouth opening over time diminishes
43
oral sub mucous fibrosis malignant transformation rate
5%
44
erythroplakia features
atrophic lesion
localised
well defined borders
can have speckled appearance - erythroleukoplakia
strong association with tobacco use
50% malignant transformation rate
45
melanotic macule features
single brown lesion
- comprised of a collection of melanin containing cells
flat
non raised
typically <1cm diameter
no rapid change
painless
common on vermillion border
46
melanoma features
rare
may arise from a pigmented naeuvus
palate or maxillary gingiva most common
refer if suspected melanoma
47
melanoma - warning signs (ABCDE)
asymmetry
border irregularity
colour irregularity
diameter >6mm
evolving
- shape, size, colour, elevation
48
Kaposi's sarcoma features
vascular neoplasm/tumour
human herpes virus 8 associated
disorganised epithelial cell growth
mainly presents in immunocompromised
Reddish-blue or brown foci
can present on skin, oral mucosa or GI tract
49
Kaposi's sarcoma management
surgery
radiotherapy
chemotherapy
immunotherapy
managing underlying immunodeficiency
50
oral candidosis local risk factors
xerostomia
poor oral hygiene
dentures
smoking
mouth piercings
irradiation to the mouth or salivary glands
inhaled/topical corticosteroids e.g. asthmatics
51
systemic risk factors for oral candidosis
extremes of age
- neonates, elderly
malnutrition
diabetes
HIV/AIDS
Haematinic deficiency
broad-spectrum antibiotics
chemotherapy
haematological malignancy
52
How to manage oral candida infections
investigate and manage predisposing factors
- smoking
- underlying systemic disease or deficiency
- steroid inhaler
- denture hygiene
oral hygiene
topical antifungals
- systemic antifungals
53
miconazole oral gel preparation and how to use
20 mg/g
80g tube
apply pea sized amount after food 4 times daily
54
nystatin oral suspension preparation and instructions
30ml 100,000 units/ml
1ml after food 4 times daily for 7 days
advise patient t to continue use for 48 hours after lesions have healed
55
Fluconazole dose and frequency
50mg
1x a day for 7 days
56
Miconazole oral gel contraindications (same as fluconazole capsules)
warfarin
- increases anti-coagulant effect
statins
- risk of rhabdomylosis and myopathy with some statins
57
Acute pseudomembranous candidosis features
'thrush'
- white flecks resemble breast of thrush bird
commonly seen in neonates
in adults - "disease of the diseased"
58
acute pseudomembranous candidosis appearance
white slough on mucosa surface
- easily wiped off
underlying erythematous base
59
acute pseudomembranous candidosis (oral thrush) management
predisposing factors need to be investigated and dealt with
oral hygiene
topical
- miconazole oral gel
- nystatin oral mouthwash
systemic if topical ineffective or infection is extensive or severe
- fluconazole capsules
60
chronic hyperplastic candidosis clinical signs (candidal leukoplakia(
usually occur on buccal mucosa
- at labial commissure/corner of the mouth
often bilaterally
white or speckled red/white appearance
can occur on tongue - less common
61
chronic hyperplastic candidosis diagnosis
incisional biopsy with PAS stain
- is there dysplasia?
62
Why would you give fluconazole before a biopsy for a patient with chronic hyperplastic candidosis?
to allow pathologist to see potential dysplasia more clearly
fungal-related inflammation can give false positives for dysplasia
63
chronic hyperplastic candidosis management
predisposing factors - treat
systemic antifungal
stop smoking
careful clinical follow up in oral med clinic or GDP
- management of dysplasia as required
64
denture-related stomatitis features
candida infection of mucosa beneath a dental appliance
common in patients in care facilities
- elderly, dry mouth, high sucrose diet, poor OH
common upper complete denture
- micro-environment
65
denture related stomatitis clinical signs and symptoms
pain or discomfort
bad breath
dryness
burning sensation in mouth
redness
66
acute erythematous candidosis clinical features
aka atrophic candidosis
most commonly presents with associated 'burning'
palate most commonly affected
67
acute erythematous candidosis predisposing factors
recent broad spectrum antibiotics
corticosteroids
diabetes
HIV
nutritional factors
68
acute erythematous candisosis diagnosis and management
diagnosis
- clinical
- oral rinse or swab
management
- medical referral
- topical antifungal
- systemic antifungal
69
angular chelitis signs and symptoms
soreness
erythema
fissuring
crusting
bleeding
at corners of mouth
70
angular chelitis management
predisposing factors
- may require new dentures
- underlying disease or deficiency?
denture hygiene
OHI
topical antifingal - miconazole cream - effective against fungus and some bacteria
topical antibacterial - sodium fusidate ointment
- when clearly bacterial in nature e.g. non-denture wearer
71
which species are linked to angular chelitis?
candida
staphylococcus
streptococcus
72
primary herpetic gingivostomatitis symptoms
fever
malaise
red, fiery oedamatous gingiva
vesicles - ulcers
73
How to diagnose primary herpetic gingivostomatitis
clinical history
viral swab for PCR if uncertain
74
HSV-1 tends to lay dormant in...
the trigeminal ganglion
75
primary herpetic gingivostomatitis management
largely supportive
- fluids
- soft diet
- chlorhexidine to prevent secondary infection of oral lesions
- difflam mouthwash
- paracetamol
76
When would urgent specialist care with systemic antivirals be indicated for primary herpetic gingivostomatitis patients?
in pregnant women and neonates
77
Factors which can cause reactivation of HSV
sunlight
- UV radiation
unwell
- fever
tissue injury
stress
immunosuppression
hormones
- menstrual cycle
78
recurrent herpes simplex virus management
avoidance of triggers
antivirals in prodrome period
- acyclovir 5% cream every 4 hours (herpes labialis) - can be applied for up to 10 days
- acyclovir 200mg tablets 5x per day for 5 days (intra-oral herpes)
immunocompromised - specialist referral
79
varicella signs and symptoms
mainly children
- complication risk in adults
highly contagious
- via respiratory droplets or lesion
fever
malaise
truncal rash
- itch, papules, vesicles, scabs
oral ulcers
80
zoster - signs and symptoms
rash in one dermatome - scabs
pain before, during and after lesions
vesicles and ulcers intra-orally
81
diseases linked to Epstein bar virus
oral hairy leukoplakia
burkitt's lymphoma
nasopharyngeal cancer
82
oral AIDS defining illnesses
oral candidosis
acute necrotising ulcerative gingivitis
kaposi sarcoma
oral hairy laukoplakia
non-hodgkin's lymphoma
aphthous-like ulcers
83
Coxsackie viruses are linked to which diseases?
hand, foot and mouth
herpangina
84
Herpangina clinical signs
numerous vesicles
- soft palate
- uvula
- fauces
85
Coxsackie virus management
supportive
fluids
paracetamol
soft diet
benzydamine
chlorhexidine to aid oral hygiene
86
oral cancer risk factors
smoking
poor oral hygiene
alcohol
HPV
chewing tobacco
low fruit/veg consumption
socio economic background
87
what is oral epithelial dysplasia?
abnormal growth
can only be diagnosed on histology
carried a higher risk of becoming cancer than 'normal' tissue
88
basal hyperplasia histological features
increased basal cell numbers
architecture
- regular stratification
- basal compartment is larger
no cellular atypia
89
mild dysplasia histological features
90
moderate dysplasia histological features
91
severe dysplasia histological features
92
What is lichen Planus?
a common chronic immune mediated mucocutaneous disease
93
Lichen Planus can commonly effect...
oral mucosa
skin
- including nails and scalp
ano-genital mucosa
94
how do oral lichenoid lesions and oral lichen planus differ?
oral lichen planus: no specific identifiable aetiological factor
oral lichenoid lesions: an identifiable aetiological factor OR a manifestation of a systemic disease
95
risk factors for OLP and OLL
stress
dental materials
SLS
medical conditions
medication
nutritional deficiency
chronic trauma
hypertension
96
conditions which are associated with an increased OLP or OLL risk
graft versus host disease
diabetes
lupus
auto-immune diseases
97
types of lesions seen in OLP/OLL
reticular
atrophic
papular
erosive
plaque like
bullous
98
OLP and OLL symptomatic relief (first line)
0.15% Benzydamine (Difflam) mouthwash or spray
- mouthwash for generalised
- spray for localised lesions
rinse or gargle every 1 1/2 hours as required
- usually for no more than 7 days
99
OLP and OLL symptomatic relief - if benzydamine doesn't work
betamethasone 500 mcg soluble tablets
- fully dissolve tablet in 10ml water
- rinse for 5 minutes
- spit after rinsing
- do not swallow
- repeat up to 4x daily
Beclometatsone 50mcg inhaler
- 1-2 puffs twice daily to affected area
100
Advice for patients with OLP/OLL
SLS free toothpaste
avoid trigger foods
- make patient aware food isn't causing it or making the disease work
101
what is required in a referral for OLP/OLL?
detailed history
clinical findings
provisional diagnosis
a reason why it needs seen in specialist care
details of treatments tried
excellent clinical photos
referral; to oral medicine or local oral and maxillofacial surgery unit
102
Risks of biopsy in oral lichen planus
pain
bleeding
brusing
swelling
infection
altered sensation - temporary or permanent
sutures
103
Benefits of biopsy in oral lichen planus cases
confirms diagnosis
may identify dysplasia
can exclude vesiculobullous disorders
104
Histological features of OLP/OLL
keratosis
hyperplastic epithelium
lymphocytes in epithelium
basal cell destruction
band-like lymphocytic infiltrate
epithelial atrophy or erosion
105
vesicle - define
<5mm visible accumulation of fluid within or beneath epithelium
- e.g. a small blister
106
bullae - define
>5mm visible accumulation of fluid within or beneath epithelium
- e.g. a bigger blister
107
Give examples of vesiculobullous conditions
mucous membrane pemphigoid
pemphigus vulgaris
Erythema multiform
Stevens-Johnson syndorme/ toxic epidermal necrosis
108
mucous membrane pemphigoid - clinical features
oral vesicles/blisters
- ulcers
- robust blisters, sometimes blood filled
heals with scarring
desquamative gingivitis
ocular lesions
- scarring of conjunctiva
anogenital lesions
skin lesions
- scalp
nasal mucosa affected
109
mucous membrane pemphigoid diagnosis
clinical/histological/immunopathological
biopsy
- H & E staining from affected tissue
- direct immunofluorescence microscopy - from perilesional tissue
indirect immunofluorescence
- blood sample
110
MMP symptomatic relief
benzydamine mouthwash
oral hygiene instruction
111
MMP systemic treatment options
prednisolone
doxycycline
methotrexate
azathioprine
rituximab
112
pemphigus vulgaris clinical features
blisters, erosions and ulcers
- oral bullae - quickly rupture to leave erosions/ulcers (thin walled blisters that rupture easily)
- heal without scarring
- desquamative gingivitis
- ocular involvement
- aeorodigestive tract
- anogenital blistering
- skin affected
pain
potentially lethal
systemically unwell
- impaired oral intake
- sepsis- secondary infection
113
pemphigus vulgaris pathogenesis
antibodies (mainly IgG) directed against desmosomes
loss of cell-cell contact in epithelium
- intra-epithelial split forms
- flaccid blisters
114
pemphigus vulgaris - diagnosis (clinical/histological/immunopathological)
Nikolsky's sign
- rubbing the mucosa induces a bulla
biopsy
- H and e staining from affected tissue
- direct immunofluorescence microscopy from perilesional tissue
indirect immunofluorescence
- blood sample
- more sensitive in pemphigus vulgaris than mucous membrane pemphigoid
115
What is OFG/Orofacial Granulomatosis
Chronic inflammatory disease
relapsing and remitting lip swelling
can also involve
- perioral skin
- buccal mucosa
- gingiva
- floor of mouth
- tongue
116
OFG histopathology
typically non-caseating granulomas with or without multinucleate giant cells
granulomas deep in oral mucosa
- missed if specimen too shallow
lymphoedema
dilated lymphatics
pervisacular lymphatic infiltrate
indistinguishable from Crohn's
117
OFG clinical features
lip swelling
buccal cobblestoning
gingival enlargement
stag horning
mucosal tags
linear ulceration
skin changes
118
OFG and Crohn's similarities
histopathologically indistinguishable
relapsing and remitting course
clinical features similar
119
OFG investigations
FBC, haenatinitics - inflammatory markers
fecal calprotectin
oral biopsy - deep
endoscopy and biopsy if abdominal symptoms
serum ACE
patch testing
120
OFG treatment
benzoate and cinnamon exclusion diet
- beneficial in 54%-78%
- strict adherence for 3 months and introduce foods one at a time
liquid enteral nutrition 6 weeks
topical steroid for intraoral involvement
- betamethasone 500mcg tablets in water
- flixonase 400mcg nasules in water
- beclomethasone 50mcg inhaler
- clobetasol ointment 0.05%
topical 0.1% tacrolimus for skin involvement and lip swelling
intralesional triamcinolone 40mg/ml
121
What is trigeminal neuralgia?
a disorder characterised by recurrent unilateral brief electric shock pains, abrupt in onset and termination
- limited to the distribution of one or more divisions of the trigeminal nerve
- triggered by innocuous (non-harmful) stimuli
- may develop without apparent cause or be a result of another diagnosed disorder
122
trigeminal neuralgia - consequences
suicide
- 78% of patients had considerable negative thoughts
depression and anxiety
8% have had irreversible and unnecessary dental treatment
47% have been prescribed 3 medications which have been ineffective
123
name the classifications of trigeminal neuralgia
classical
secondary
idiopathic
124
diseases which may cause trigeminal neuralgia
multiple sclerosis
space occupying lesion
other
- skull base deformity
- connective tissue disease
genetic causes of neuropathy
125
idiopathic trigeminal neuralgia features
unilateral or bilateral pain in the distribution of one or more trigeminal nerve branches
- indicative of neural damage but of unknown aetiology
- purely paroxysmal
- with concomitant continuous pain
126
Classical TN pathophysiology
neurovascular conflict of the superior cerebellar artery
compression leads to demyelination
resulting in ectopic firing
- can be observed in asymptomatic patients
127
idiopathic TN pathophysiology
no conflict but unregulated sodium ion inflow resulting in depolarisation
128
Trigeminal neuralgia - how might a patient describe the pain?
stabbing
electric shock
severe
memorable first episode
scary
10/10
129
common TN triggers
eating
washing face
brushing teeth
eating
speaking
smiling
cold wind
stress
temperature change
130
Trigeminal neuralgia - red flag features to ask about
sensory motor defects
deafness
loss of balance
optic neuritis
history of cranio-facial malignancy
bilateral TN
systemic symptoms
< 30 years of age
131
Prescribing Carbamazepine - considerations
check BNF for interactions
care in elderly
- increases risk of falls
care in those operating heavy machinery or driving or childcare
arrange blood monitoring with GP
- FBC/U+E/LFT
132
Carbamazepine risks
hyponatraemia
- low sodium in the blood
- increased with other medications such as bendroflumethiazide
falls
unsteadiness
confusion
rash/skin reaction
- more common in Han Chinese and Thai populations
side effects usually dose dependent
- low risks at 100mg 2x daily
133
why is an MRI taken for trigeminal neuralgia patients?
to exclude underlying disease
134
Oxacarbazepine - how does it effects differ from carbamazepine
tends to be better tolerated
greater risk of lowering sodium levels
135
trigeminal neuralgia second line medications
lamotrigine
baclofen
gabapentin
pregablin
136
burning mouth disorder - definition
a chronic orofacial pain with an intraoral burning or dysaesthetic sensation that recurs for more than 2 hours a day on 50% of the days over more than 3 months
- without evident causative lesions on clinical investigation and examination
137
Burning mouth syndrome is a diagnosis of exclusion. what conditions do you need to exclude?
oromucosal diseases
- e.g. oral lichen planus
hyposalivation
tongue parafunction
anaemia
vitamin b12 and b9 deficiency
diabetes mellitus
use of ACE inhibitors
138
burning mouth disorder - symptoms
pain of a burning quality affecting the mouth lining
often tongue is the focus
can affect multiple sites
may be associated xerostomia or dysgeusia
often bilateral presentation
often relieved with eating
often worsen as day progresses
139
burning mouth syndrome - common triggers
dental procedures
medical procedures
new medications
illness
stressful life events
140
burning mouth disorder - mechanisms
likely a combination of peripheral or central or peripheral/central neuropathy
and
reduced brain dopaminergic acridity which normally inhibits nociceptive signalling
141
role of the dentist in burning mouth syndrome cases
take a history that includes questions on potential triggers and how it impacts daily life
look for other diagnoses
show empathy
recognise pain is real and tell them this
let patient know they are not alone
provide BISOM leaflet on BMD a an unconfirmed diagnosis
142
Burning mouth disease - secondary care management
education and reassurance
alpha lipoic acid
- likely a placebo
distraction techniques
CBT
clonazepam topically 500mcg tablet crushed in water
nortriptyline
gabapentin
pregablin
duloxetine
143
persistant idiopathic facial pain - symptoms
poorly localised unilateral pain
- can present bilaterally
usually maxillary region affected
described as dull, nagging, aching, throbbing
can be sharp exacerbations
persistent and daily
aggravated by stress
144
persistent idiopathic dentoalveolar pain symptoms
well localised moderate intensity pain
any tooth or mucosa of extraction site
most commonly premolar or molar regions of maxilla
character - dull, pressure like
difficult to distinguish from odontogenic pain
145
Sjogrens - eye symptoms
persistent troublesome dry eyes for > 3 months
recurrent sensation of sand/gravel in eyes
tear substitutes used > 3 times a day
146
Sjogrens oral symptoms
daly feeling of a dry mouth for > 3 months
recurrent swelling of salivary glands as an adult
frequently drinking liquid to aid swallowing dry foods
147
What gland biopsy is taken to provide histopathological analysis for a sjogrens diagnosis?
labial gland
parotid can also be sampled
148
Sjogrens test diagnosis criteria (give scores)
Blood test for anti-ro antibodies (score 3)
gland biopsy: focus score of > or = 1 (score 3)
slit lamp examination: abnormal ocular staining score > or = 5 (score 1)
Filter paper: schemer;s test without anaesthetic < or = 5mm/5 min (score 1)
spit in cup: unstimulated salivary flow <0.1ml/min (score 1)
149
A classification of sjogrens disease requires a cumulative score of...
4 or more
150
Sjogrens histopathology: what can be seen in minor glands?
focal lymphocytic sialadenitis
acinar loss
fibrosis
151
Sjogrens histopathology: what can be seen in major salivary glands?
lymphocytic infiltrate
epithelial hyperplasia
152
Sjogren's disease head and neck complications
oral infection
caries risk
functional loss
- speech
- swallowing
problems with denture retention
salivary lymphoma
153
Sjogrens disease is a multisystem autoimmune disease. what other systems can it effect? give clinical features
CNS
- fatigue
- peripheral and CN neuropathies
skin
- rashes
vascular
- Raynaud's syndrom e
eyes
- corneal ulcers
respiratory
- cronic cough
GI
- dysphasia
- pancreatic insufficiency
haematological
- anaemia
musculoskeletal
- myalgia, arthralgia
GU
- vaginal dryness
154
How to assess the severity of a dry mouth
gland palpation
duct expression
challacombe scale
155
dry mouth management
treat underlying cause
preventative care
symptomatic relief
artificial saliva products
156
potential underlying causes of dry mouth
dehydration
caffeine
smoking
alcohol
medications
diabetes
somatoform disorder
157
dry mouth preventive care includes...
caries prevention
- diet
- fluoride
SLS free toothpaste for sore tongue
candida management
158
give examples of some saliva substitutes
sprays
- Glandosane (pH 5.75)
- saliva orthana
- Xerotin
lozenges
- saliva orthana
- Saliva stimulating tablets
saliva stimulants
- pilocarpine
oral care gels
- bioextra gel
- xerostom
159
what saliva substitute should not be used in dentate patients and why?
glandosane
- acidic
160
simple lifestyle measures to manage sjogrens
moist oily foods and sauces
humidify home environment
regular exercise
omega 3 supplements
glasses/goggles to reduce tear evaporation
warm eye compress 10 mins daily
161
What are the major salivary glands?
parotid
submandibular
sublingual
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obstructive sialadenitis symptoms
intermittent swelling of salivary glands
usually unilateral
may or may not have inflammation
usually painful
often associated with mealtimes
can be chronically obstructed
most common in the submandibular gland
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obstructive sialadenitis is also known as...
mealtime syndrome
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obstructive sialadenitis potential causes
sialoiths - duct calculi
stricture in the salivary duct
salivary duct oedema
- trauma
neoplasm
mucous plug
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obstructive sialadenitis history -questions to ask
pain history if needed
ask if associated with eating/food
coming and going or persistent
swallowing problems
bad taste or pus
generally unwell
- to exclude acute infection
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obstructive sialadenitis clinical examination
extra oral exam
bimanual palpation of floor of mouth
express saliva from ducts
- pus?
- obstruction?
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obstructive sialadenitis investigations in primary care
lower occlusal x ray or OPT to identify calcification
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obstructive sialadenitis investigations in secondary care
- ultra sound scan
- sialography
- MRI or CT may be indicated in some cases
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obstructive sialadenitis conservative measures
massage gland and duct
heat application
sucking on citrus fruits or sugarfree sweets
stay hydrated
excellent oral hygiene
simple analgesia
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sialadenitis - define
inflammation of the salivary glands
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acute viral sialadenitis clinical features
painful parotid swelling
usually bilateral
- can sometimes be a single gland
no hyposalivation
10% have submandibular gland involvement
- very rare to only involve sm gland
malaise, fever and feeling generally unwell
- likely precedes parotid swelling
swelling lasts approximately 7 days
trismus
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mumps management
no specific antivirals
supportive management
- hydration
- analgesia
- pyrexia management
- isolation for 6-10 days may be advisable
- contact public health
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salivary gland swelling - other extra oral features which would indicate referral; to OM or GP
shortness of breath
cough
chest pain
macroglossia
peripheral neuropathy
bruising
peripheral oedema
GI symtoms
fatigue
weight loss
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Mucocele - define
a cystic lesion of the minor salivary glands
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mucoceles commonly present in...
lower labial mucosa
floor of mouth
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mucocele appearance
fluctuant
blue swelling
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give the 2 types of mucocele
mucous extravasation (90%)
mucous retention (10%)
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mucous extravasation aetiology and features
caused by trauma to minor salivary duct
not lined by epithelium
- therefore not a true cyst
termed ranula if on floor of mouth
most commonly present in lower lip/labial mucosa
most common under age of 30
- peak incidence 2nd decade
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mucous retention cyst aetiology and features
saliva being retained in duct/gland
- more common over age of 50
- never seen in lower lip
- cystic dilation of the duct
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excision of mucocele - risks
high recurrence rate
potential damage to neighbouring structures
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most common salivary gland neoplasm
Pleomorphic adenoma (PSA)
182
sublingual gland neoplasms are..
uncommon and usually malignant
183
parotid gland neoplasms are...
usually pleomorphic adenomas
184
submandibular gland neoplasms are..
usually pleomorphic adenomas
1/3 are malignant
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Pleomorphic adenoma features
most common salivary gland tumour
arises from duct epithelium
slow growing
usually benign
3% recur within 5 years of excision
malignant change uncommon
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Warthin's tumour features
second most common salivary gland tumour
associated with smoking
benign
asymptomatic
slow growing
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What is the most common malignancy of the parotid and minor salivary glands?
mucoepidermid carcinoma
- often found in the palate
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Where are adenoid cystic carcinomas usually found?
submandibular gland
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minor salivary gland neoplasms are..
50% malignant
50% pleomorphic adenomas
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neoplasms management if benign
surgical excision
(facial nerve injury risk)
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neoplasms - red flags
red flags
- facial palsy
- sensory loss
- pain
- difficulty swallowing
- trismus
- rapid growth
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Which HPV strains are linked to oral cancer?
HPV 16 and 18
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What is a haemangioma?
a common, benign growth made of a collection of small blood vessels that form a lump under the skin
- very common in children
- F>M
- may removes
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What is a vascular malformation?
a congenital lesion formed due to abnormal blood vessel development
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haemangioma and vascular malformations - management options
no tx if asymptomatic and no aesthetic concern
ultrasound
cryotherapy
cauterisation
MRI +/- angiogram for large lesions
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which strain of candida is resistant to fluconazole?
candida glabrata
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pros and cons of oral swabs
advantage
- simple and site specific
disadvantages
- can be easily contaminated
- uncomfortable
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pros and cons of oral rinse
advantages
- records whole mouth and can separate healthy organisms
disadvantages
- not site specific
- some patients find the rinse process difficult to do
199
What investigations can be undertaken for a patient with burning mouth disorder?
FBC
salivary flow rate
denture assessment
psychiatric assessment
intra/oral exam for parafunctional habits
200
What would be seen in direct immunofluorescence in Mucous membrane pemphigoid?
linear deposition of IgG along the basement membrane
201
What would be seen in H+E staining in pemphigus?
intra-epithelial acantholysis
202
What would be seen in direct immunofluorescence in pemphigus?
intracellular deposition of IgG and C3
- chickenwire appearance
203
What would be seen in indirect immunofluorescence in pemphigus?
titre of autoantibody correlates with disease severity
204
what is paraneoplastic pemphigus?
a rare variation of pemphigus vulgaris
associated with underlying malignancy
- usually haematological
severe mucosal and skin involvement
typically systemically unwell
high mortality
