Oral Med Flashcards
(225 cards)
1
Q
Define xerostomia and hyposalivation
A
Xerostomia: dry mouth as result from
- absent/red. salivary flow
- change in saliva composition
- unknown reason
Hyposalivation: objective red. salivary secretion due to red. salivary gland function
2
Q
Functions of saliva
A
Lubrication: swallowing, speech Defence, antimicrobial properties Taste Digestion: amylase (starch), lipase (fat) Lavage, buffering
3
Q
Complications dry mouth
A
Dental: caries, depapillated tongue Oral soft tissue disease GIT dryness Dysphagia Dysphonia, hoarseness Psychological Nutritional, taste alteration
4
Q
Aetiology of dry mouth
A
Dehydration/red. fluid intake Habits: mouth breathing Medications Salivary Gland Disease Systemic Disease Change in oral perception due to - nerve damage - Alzheimer’s - stroke Psychological Age Idiopathic
5
Q
Salivary gland diseases possibly leading to dry mouth
A
Infection: viral (mumps), bacterial Obstruction - meal time syndrome - mucocele, ranula Damage: 2ry to cancer Tx Tumours Degernatiive: autoimmune destruction (Sjögren’s)
6
Q
Systemic diseases possibly leading to dry mouth
A
Sjögren’s DM Liver disease Amyloidosis Sarcoidosis Thyroid disease HIV-related 🙀
7
Q
Discuss sialadenosis
A
Sialosis Unspecific gland enlargement Non-painful Aetiology unknown - factors — eating disorder — medication — alcohol abuse — nutritional deficiency — DM — pregnancy
8
Q
Discuss sialadentitis and sialolithiasis
A
Sialadentitis
- enlargement 1/+ glands due to infection/inflammation/obstruction
- parotid, submandibular
- conditions: mumps, Sjögren’s, sarcoidosis
Sialolithiasis
- stones/calculi in glands causing pain + swelling
- submandibular
9
Q
Classification of salivary gland tumours
A
Benign
- nonepithelial
- epithelial
Malignant
- nonepithelial
- epithelial
10
Q
Types of benign epithelial salivary gland tumours
A
Pleomorphic adenoma Warthin tumour Monomorphic adenoma Oncocytoma Intraductal papilloma Sebaceous neoplasms
11
Q
Discuss pleomorphic adenoma and warthin tumour
A
Pleomorphic Adenoma
- most common tumour
- tail of parotid; minor glands H palate + U lip
- variable, diverse histological patterns of epithelium and connective tissue
- incomplete capsule: complete removal difficult = recurrence high
— radiotherapy common Tx following removal to kill cells
- slow growing + asymptomatic
Warthin tumour
- smooth, soft, parotid mass
- multicystic, well encapsulated
- recurrence low (5%); malignancy rare
12
Q
Types of benign non-epithelial salivary glands tumours
A
Haemangioma Neural sheath tumour Angioma Lymphangioma (cystic hygroma) Lipoma
13
Q
Discuss haemangioma
A
Benign non-epithelial salivary gland tumour
Vascular tumour
Usually parotid, sometimes submandibular
Solid mass cells + multiple anastomosing capillaries replace acinar structure
Rapid growth b/w 1-6/12, slowly red. until 12y
Dark red, lobulated, unilateral, compressible, asymptomatic mass
14
Q
Types of malignant epithelial salivary gland tumours
A
Mucoepidermoid carcinoma Adenoid cystic carcinoma Carcinoma ex-pleomorphic adenoma Clear/basal cell carcinoma Squamous cell carcinoma Epithelial-myoepithlial carcinoma Salivary duct carcinoma Lymphoepithelial carcinoma Sialoblastoma
15
Q
Discuss mucoepidermoid carcinoma
A
Malignant epithelial salivary duct tumour
Most common malignancy of parotid 8%
Mucous + epidermal cells
Grading: ratio epidermal cells inc. - low: non aggressive, good prognosis - int. - high: aggressive, high change metastasis regional lymph nodes — may resemble SSC
16
Q
Discuss adenoid cystic carcinoma
A
Malignant epithelial salivary gland tumour
2nd most common malignancy tumour
Most common malignancy submandibular
Slow growing, painless mass Locally invasive Metastasis - regional lymph nodes uncommon - distant (lungs) common
17
Q
Discuss carcinoma ex-pleomorphic adenoma
A
Malignant epithelial salivary gland tumour
Arises from incomplete removal of pleomorphic adenoma
2-4% all salivary gland malignancies
Sudden rapid growth otherwise stable/slow mass
Aggressive natural Hx + poor prognosis
Metastasis: regional + distant common
18
Q
Types of tumour-like lesions of salivary glands
A
Necrotising sialometaplasia
Lymphoepithelial Hyperplasia/benign lymphoepithelial lesions
Cystic lymphoid hyperplasia (AIDS)
Salivary gland cysts
19
Q
Discuss necrotising sialometaplasia + lymphoepithelial hyperplasia
A
Tumour-like lesions of salivary glands
Necrotising sialometaplasia
- benign, self-healing lesion minor glands
- mistaken for malignancy
— single, unilateral painless/slightly painful lesion H palate
- aetiology: unknown
— response to ischaemic necrosis of salivary tissue
Lymphoepithelial hyperplasia
- discreet mass/diffuse enlargement of part/whole parotid
- occasionally bilateral
- slow-growing, may be painful
20
Q
Most common 2ry cause of xerostomia
A
Sjögren’s syndrome
21
Q
What is Sjögren’s? Aetiology
A
Multisystem autoimmune disease
Aetiology: unknown
- virus triggering immune reaction
- genetic susceptibility
- gender predisposition: hormones (90% F >50y)
22
Q
What is Sjögren’s syndrome characterised by?
A
Inflammation of exocrine glands w/ lymphocytic infiltration of lacrimal + salivary glands leading to xerostomia + xerophthalmia (sicca complex)
23
Q
Compare 1ry and 2ry Sjögren’s
A
1ry (Sicca): dry eyes + mouth
2ry: connective tissue disease (rheumatoid arthritis) + dry eyes and mouth
24
Q
General symptoms + signs of Sjögren’s
A
Dry mouth/eyes/skin/mucous membranes
Fatigue/fibromyalgia
Rheumatoid arthritis/connective tissue disease
Raynaud’s phenomenon
25
What is Raynaud’s phenomenon?
Condition in which spasm of capillaries causes extremities to change colour (white -> blue) and become painful
Usually response to cold
26
Oral signs + symptoms of Sjögren’s
No saliva pooling
Dry, atrophic mucosa
Sticky/glassy mucosa
Cracked lips
Oral burning sensation
Oral soreness
Sialadenitis: swelling, pain, fever
Oral candidiasis
Inc. DMF
Cervical + incisal decay pattern
Denture wearing difficulty
Dysohonia, dysphasia, dysgeusia
Halitosis
27
Discuss potential systemic complications/involvement of Sjögren’s
Haematological
- autoimmune haemolytic anaemia
- idiopathic thrombocytopenia purpura
- non-hodgkin’s lymphoma
Respiratory: interstitial fibrosis
Renal: renal tubular acidosis
Nervous: cranial/peripheral neuropathy
28
Classification criteria for Sjögren’s
1: ocular symptoms (subjective)
2: oral symptoms (subjective)
3: ocular signs (objective)
4: histopathology (objective)
5: salivary gland involvement (objective)
6: serum auto-Ab (objective)
29
What auto-Ab are involved in Sjögren’s?
Auto-Ab to Ro/SSA and La/SSB auto-Ag
| Act against auto-Ag in lacrimal and salivary glands
30
Classification criteria for 1ry and 2ry Sjögren’s
1ry
- symptomatic: any 4/6 +ve incl. histopathology and/or serum
- asymptomatic: any 3/4 objective measurements +ve
2ry
- systemic disease +
- 1/2 subjective measurement +
- 2/3 from ocular signs, histopathology, salivary gland involvement
31
Serious complications of Sjögren’s
Lymphoma
- 40x greater risk
- 10% SS pt develop non-Hodgkin’s lymphoma
Heart Block newborns
- maternal Ab cross placenta
Eye damage + Vision loss
- corneal ulcers due to unTx dry eyes + infection
32
Ix useful for Dx Sjögren’s
Salivary Assays (sialometry)
- whole unstim. salivary flow
- parotid/submandibular stim. flow
Bloods: specific auto-Ab (not all pt)
X-ray: sialograph
US
L lip minor gland biopsy (gold standard)
33
Tx/management of Sjögren’s/dry mouth
No cure
Regular appt; OHI, F- m/w
Tx/prevent candidiasis
Diet
- inc. H2O intake; esp. eating, speaking
- red. sugar
- avoid: caffeine, alcohol, fizzy drinks, tobacco
Stim. saliva: sugar free gum/sweets
Artificial saliva products: personal preference
Humidifier: esp. at night
34
Non/pharmacological management methods for Sjögren’s
Pharmacological
- parasympathetic nervous system agonist: pilocarpine
- only v severe cases
- many adverse effects: GIT, CVS, respiratory, GU (inc. urination)
Non-Pharmacological
- acupuncture
- electrostimulation: IO neural stim, (US approved)
35
Differentiate b/w ulcer and erosion
Erosion: partial loss skin/mucous membrane
Ulcer: total loss of epithelium
36
Define atrophy and plaque
Atrophy: loss of thickness
Plaque: raised uniformed thickening skin/mucous membrane w/ defined edge
37
Classification of oral ulcerative diseases by aetiology
```
Local
- trauma: chemical, electrical, thermal, radiation
- recurrent aphthous stomatitis
Systemic
Infective
- bacterial: TB, ANUG, syphilis
- viral: VZV, HSV, CAV, HIV, EBV
- fungal: histoplasmosis, aspergillosis, candidiasis
```
38
Cutaneous systemic diseases causing oral ulcers
```
Erosive lichen planus
Pemphigoid
Pemphigus
Erythema multiforme
Dermatitis herpetiformis
Epidermolysis bullosa
Linear IgA disease
Chronic ulcerative stomatitis
```
39
Blood diseases potentially causing oral ulcers
Anaemia
Leukaemia
Neutropenia
Myelodylastic syndrome
40
GI and CT diseases causing oral ulcers
GI
- coeliac
- Crohn’s
- ulcerative colitis
CT
- SLE/DLE
- Wegner’s granulomatosis
41
Drugs/Tx and malignancies potentially causing oral ulcers
Drugs/Tx
- cytotoxic drugs
- radiotherapy
- nicorandil (cardiac)
Malignancy
- SSC
- lymphoma
42
Classification of oral ulcers by recurrence
```
Recurrent
- aphthae
- erythema multiforme
Persistent: 2ry to systemic disease
Single episode
- trauma
- infective
- drug
Single persistent: neoplastic
```
43
Types of recurrent oral ulcers
```
Recurrent aphthous stomatitis
- major
- minor
- herpetiform
Smoking related aphthous stomatitis
Associated w/ Behçet’s disease
```
44
Compare minor, major, herpetiform RAS
Age: 10-19; <10; 20-19
No.: 1-5; 1-10; 5-20
Size: <10mm; >10mm; 0.5-3mm
Shape: oval; irregular/oval; round, may coalesce
Colour: grey base, erythematous border; grey base, +/- indurated edge; yellow base, erythematous base
Site: non-keratinised (B mucosa); any (fauces); non-keratinised (V tongue, FoM)
Duration: 1-2/52; 2-12/52; 1-2/52
Scarring: N; Y; N
45
Discuss Behçet’s disease
Chronic autoimmune disease
- affects small blood vessels
Triad: oral ulcers, genital lesions, recurrent eye inflammation
- oral ulcers indistinguishable from RAS
Clinical
- ulcers: oral, genital (50%), skin
- skin: spots, sores, lesions, ulcers, red patches, lumps
- eye: uveitis (50%), retinal vasculitis
— floaters, haziness, loss of vision
— pain, inflammation
- joint inflammation: pain, swelling
46
Management of oral ulcers
```
Eliminate local aggravating factors
Control infection
Control pain
Promote healing
Prevent recurrence
Assess response
```
47
General + local predisposing factors for candidiasis
General
- broad spectrum AB
- corticosteroids
- cytotoxics
- poorly controlled DM
- xerostomia
- nutritional deficiency
- immunosuppression
Local
- trauma: ill fitting denture
- smoking
- red. saliva flow
- carb rich diet
48
Discuss impact of drug therapy in candidal infections
Broad spectrum ABs, immunomodulators, xerogenic agents
ABs: alter commensal microflora
- Candida controlled by competition for dietary substrates + epithelial cell adhesion
Xerogenic: red. salivary flushing + antifungal components
49
Discuss impact of DM on candidal infections
Related to glycemic control
- poorly controlled = higher Candida carriage
```
Contributory
- red. salivary flow
- lower pH
- inc. salivary glucose
= inc. growth + colonisation
```
50
Discuss immunodeficiency + haematological factors related to candidal infections
Immunodeficiency
- candidiasis may be 1st presentation
- cell-mediated + humoral immunity in prevention + elimination of fungal infections
- candidiasis: >60% HIV, >80% AIDS
Haematological
- blood group H Ag acts as R for C. Albicans
- H Ag inc. blood type O
51
Discuss impact of diet on candidal infections
Protein energy malnutrition
Fe, folate, VitA/B12/C deficiency
Red. host defence + mucosal integrity
= hyphal invasion + infection
CHO rich: inc. candidal adhesion to epithelial
52
2 acute candidal infections
Pseudomembranous candidiasis
| Erythematous candidiasis
53
Discuss pseudomembranous candidiasis
Detachable confluent creamy-white/yellowish patches on mucosa
- tongue rare; depapillated if occurs
Wiped off: erythematous, occasionally bleeding base
Plaques: desquamated epithelial cells, necrotic material, fibrin, fungal hyphae
Usually asymptomatic
Found in immunocompromised
- HIV: oesophageal candidiasis; dysphagia, odynophagia, chest pain
Freq. associated angular cheilitis
54
Management of pseudomembranous candidiasis
Improve OH
Tx systemic: immunosuppression, DM, anaemia, hypothyroidism
Live active yoghurt
Topical
- CHX m/w
- nystatin suspension
- miconazole gel; interactions, systemic absorption
55
Discuss erythematous candidiasis
Characterised by erythematous patches +/- pain
Common: D tongue + palate, occasionally B mucosa
Associated: chronic broad spectrum AB + corticosteroids, HIV
56
Discuss chronic hyperplastic candidiasis
Pre-malignant condition
- Candida prod. nitrosamines -> malignant transformation
- unTx: 5-10% dysplasia, may develop OSCCh
Chronic hyperkeratosis in which Candida identified
Common: middle age M smoker
Asymptomatic
57
Clinical findings of chronic hyperplastic candidiasis
B mucosa towards commissures w/ bilateral distribution
White to erythematous raised lesions
- don’t rub off
Nodular/speckled (inc. risk malignancy) or homogenous plaque-like
Possible angular cheilitis
58
Management of chronic hyperplastic candidiasis
Biopsy: risk malignant transformation 15%
FBC: Fe, folate, B12, glucose, TFT
Remove predisposing: smoking
Topicals not effective
2-4/52 oral fluconazole
59
Discuss chronic erythematous candidiasis
Denture stomatitis
Chronic erythema of mucosa beneath fit surface acrylic denture
- excludes saliva from mucosa + allow candidal overgrowth
- 65% denture wearers
Associated: poor denture/OH + ill fitting denture
Usually asymptomatic; except angular cheilitis
60
Clinical findings + management of chronic erythematous candidiasis
Clinical
- marked erythema of P mucosa w/ sharply defined margin
- relief area present -> underlying spongy, granular change
- mistaken for acrylic hypersensitivity
Management
- OH
- eliminate trauma: tissue conditioner
- miconazole gel applies to fit surface
- no resolution = systemic or not compliant
61
Discuss angular cheilitis + aetiological factors
Symmetrical erythematous tissue @ angles of mouth/commissures
Elderly denture pt w/ denture stomatitis
Red. OVD + maceration of skin by saliva
C. Albicans, Staph. aureus, B-haemolytic Strep
Aetiology
- red. haematinics: B12/folate/Fe
- malabsorption: OFG, Crohn’s
- immunosuppression
- DM
- xerostomia
- ABs
62
Management of angular cheilitis
```
Remove predisposing
Correct OVD
Improve denture/OH
Address fissuring
Tx IO Candida
Miconazole gel on corners of mouth
Chronic: trimovate cream (AB, antifungal, steroid)
```
63
Discuss medium rhomboid glossitis + chronic mucocutaneous candidiasis
Median rhomboid
- chronic candidal infection w/ atrophy filiform papillae
- asymptomatic diamond shaped smooth area ant. circumvallate papillae
- associated smoking + corticosteroids
- may have kissing lesion on palate
Chronic mucocutaneous
- chronic candidal infections involving skin, nails, mucous membranes
- associated w/ rare congenital conditions
- aetiology: impaired cellular immunity
64
Discuss polyenes
Antifungal: fungicidal through interacting w/ ergosterol in membrane
Nystatin
- inhibit ergosterol synthesis
- no but absorption
- adverse: irritation, sensitisation, nausea
Amphotericin
- binds fungal membrane ergosterol; disrupt membrane
- no gut absorption
- IV: severe systemic infections
- adverse: mild GI disturbance
65
Discuss azoles
Antifungals; fungostatic (have to remove predisposing too)
Inhibit lanosterol demethylase = prevent ergosterol synthesis
Resistance rising
Types
- imidazoles
- triazoles
66
Discuss imidazoles
Antifungals
Miconazole
- topical gel; mucosa, denture (inc. compliance)
- AB activity
- gut absorption: interaction w/ warfarin, statins
Ketoconazoles
- rarely used
- hepatotoxic
- nonspecific: inhibit testosterone + cortisol synthesis
67
Discuss triazoles
Antifungals
Fluconazole
- better toxicity profile cf ketoconazole
- expensive
- contraindications: pregnant, breast feeding
- interactions: benzodiazepines, Ca channel blockers, warfarin, cyclosporin
Itraconazole
Vorticonazole
68
Define vesicle + bulla
Vesicle: small, fluid filled blister <5mm
Bulla: large, fluid filled blister >5mm
69
Clinical features of primary herpetic gingivostomatitis
HSV1
Prodromal: fever, malaise
```
Clinical
- multiple herpetic oral ulcers
— 2-3mm vesicles erupt keratinised tissues
— rupture -> widespread painful ulcers; heal 7-10d
- diffuse gingivitis
- cervical lymphadenitis
- fever, malaise
- severe
— lip erosions
— lymphadenopathy
— pharyngotonsilitis
```
70
Dx + management 1ry herpetic gingivostomatitis
Dx: clinical, possible viral culture
Management
- supportive
- antiviral if severe
- CHX m/w; prevent 2ry bacterial infection
- fluid intake
- analgesic, antipyretic
- prevent spread/limit contact
71
Discuss recurrent herpes labialis
Cold sores
40% pt experience recurrence
Prodrome: tingling/burning
Reactivation
- HSV1 dormant in DRG
- breakdown in local/systemic immunosurveillance
- trigger: UV, immunosuppression, trauma, post-op, infection, menstruation
Clinical
- vesicular eruption -> breakdown crusting lesion
- vesicles enlarge, coalesce, weep, rupture (2-3d), crust, heal (10d)
72
Prevention of recurrent herpes labialis
Suncream; red. freq.
Topical acyclovir/penciclovir
Severe/freq.: systemic prophylactic acyclovir
73
Discuss herpetic whitlow
HSV recurrence involving skin
Acquired from pt saliva
Highly infective
Intensely painful
Management
- analgesic
- elevation, splinting
- systemic antiviral
74
Discuss erythema multiforme
Mucocutaneous blistering condition
Mucosal erosions + lip blistering w/ skin lesions
T3 hypersensitivity
Aetiology
- drugs: NSAID, anti-epileptic, barbiturates, antifungals
- infection: HSV, Hep, HIV
- systemic: SLE, pregnancy, malignancy
- idiopathic 50%
75
Clinical features of erythema multiforme
Sites: extremities, mucous membranes
```
Oral
- bullae on erythematous base
— breakdown rapidly -> irregular ulcers, bleed, crust
- lips freq.; swollen, bloody, crusted
- gingiva rare
```
Skin
- erythematous macules + papules
- target/iris: central pale area surrounding by oedema + bands of erythema
76
Discuss chickenpox
VZV/HHV3
```
Condition of children (90%)
Itchy maculopapular rash
- back, chest, face, limbs
- maculopapular -> vesicular -> pustular
Initial site URT; droplet infection
```
Oral: erythematous ulcers of palate/fauces/uvula
77
Discuss shingles
Recurrence of VZV
Affect single dermatome, unilateral
Predilection for CN5/7
- oral/skin lesions if V2/3 affected
Occasionally underlying immunosuppression
- likely VZV lays in DRG or cranial nerve ganglion from childhood
- progressive + disseminated
Prodrome: pain, parathesia
Vesicles on erythematous base, scab, heal w/o scar
78
Discuss post-herpetic neuralgia and Ramsay-Hunt syndrome
Complications of VZV
Post-herpetic neuralgia
- severe shooting pain
- constant burning
Ramsay-Hunt
- VZV affect geniculate ganglion CN7
- ipsilateral LMNL; total paralysis
- vesicular rash EAM
- loss of taste ant. 2/3 tongue
79
Management of VZV
>50y: antiviral (inc. risk PHN)
Commence within 72h rash
- dec.: duration, pain severity + duration
- red. neural damage; red. risk PHN
CNV1 assessment
Analgesics
80
Conditions caused by EBV
HHV4
```
Infectious mononucleosis
Oral hairy leukoplakia
Non-Hodgkin’s lymphoma
Burkitt’s lymphoma
Nasopharyngeal carcinoma
```
81
Discuss infectious mononucleosis
EBV
Kissing disease of teenager; salivary spread
Clinical
- fever, malaise, weight loss
- lassitude
- generalised tender lymphadenopathy
- pharyngitis
- faucial oedema
- cream tonsillar exudate
- oral petechia: H/S P junction
- gingival bleeding, ulcers
82
Dx + management of infectious mononucleosis
Dx: Paul Bunnell+; monospot+
Management
- symptomatic
- maintain fluid
- antiseptic m/w
- analgesic
83
Discuss oral hairy leukoplakia
Risk
- immunocompromised
- potent oral/inhaled corticosteroids
- transplant pt
Clinical
- demarcated corrugated white lesion
- lat. border tongue
Management: control immunosuppression
84
Discuss measles
Paramyxovirus
Acute, contagious infection
Clinical
- fever, rhinitis, cough, conjunctivitis
- maculopapular rash
- Koplik’s spot; 1-2d pre-rash
— B/L mucosa, soft P
— irregular patchy erythema w/ tiny central white specks
85
Importance of Koplik’s spot
Pathognomonic of measles
86
Discuss mumps
Paramyxovirus
Painful swelling major salivary glands
— usually asymmetrical
Respiratory spread
Clinical
- headache, nausea, fatigue
- dry mouth, trismus
- joint pain
- pyrexia
- mild abdominal pain
87
General features of hand, foot + mouth disease
CAV16 mainly
1ry childhood, highly infectious
Prodrome: mild systemic upset
Triad: macular + vesicular eruptions hands, feet + oropharyngeal mucosa
88
Oral + dermatological clinical findings + management of hand, foot + mouth disease
Oral
- multiple shallow painless ulcers/vesicles
- pharynx, S palate, B mucosa, tongue
- rarely req. dental opinion
- no lymphadenopathy, gingiva spared
Skin
- erythematous macules + vesicles hands + feet
- may be deep + blister
- transient: 1-3d
Management
- supportive
- antiseptic m/w
- self resolving
89
Discuss herpangia
CAV2/4/5/6/8
Childhood
```
Clinical: mild
- sudden onset pyrexia + pharyngitis
- oral: 2d
— multiple papules, vesicles, ulcers on S palate + fauces
— salivary glands: swelling, pain
```
Management
- no active Tx
- self resolving: 10d
90
Clinical features of HPV
Human papillomavirus
HPV2/4: most commonly cause mucosal warts
Butcher’s warts: hands, fingers (HPV7)
Verruca vulgaris (HPV2/4)
- white warty lesions w/ granular surface (cauliflower appearance)
- auto-inoculation from fingers: L mucosa, palate, lingual frenum
Condyloma acuminatum (HPV6/11/60)
- soft pink papillary lesion
- venereal contact: labial + lingual mucosa
- multiple lesions
91
Management of HPV
Tx all sites simultaneously
May resolve spontaneously
Surgical excision
Cryotherapy
Laser Tx
Medical Tx: inc. immune system
92
Discuss Kaposi’s sarcoma
Cancer of endothelium (blood vessels)
Associated HHV8
Site: skin, eye, mouth, nose, mucosa
Clinical
- reddy-blue/purple macules/nodules
- may ulcerated
Pathognomonic of AIDS
Tx: ART
93
Discuss affect of haematinic deficiencies on oral mucosa
Clinically mild B12/folate/Fe deficiency -> generalised epithelial atrophy + depapillation D tongue
Altered epithelial metabolism -> abnormal structure + keratinisation
Filiform papillae sensitive -> soreness, red. taste, ulcer, candidiasis
94
Oral conditions associated w/ haematinic deficiencies
```
Glossitis
- smooth, depapillated (Fe)
- raw, beefy (B12, folate)
Angular cheilitis, candidiasis
Recurrent Oral Ulceration
- B12/Fe/Folate in 20%
- typically normal Hb +/- altered MCV
Burning mouth
Plummer-Vinson syndrome
```
95
Discuss Plummer-Vinson syndrome
F
Characterised by
- Fe anaemia
- post-cricoid web
- glossitis
Inc. incidence oropharyngeal carcinoma
96
Effects of malnutrition on mucosa
Protein Energy Malnutrition
- impairment of non/specific immunity
- ascorbate deficiency
- inc. blood + saliva free corticosteroids
Retinol/Zn
- diminished cell mediated immunity
- early breakdown oral mucosa integrity
Ascorbic Acid
- impaired phagocytosis
- altered Ab response to viral Ag
97
Oral signs of alcoholism
Sialosis (nonspecific gland enlargement)
Erosion (2ry reflux)
Liver cirrhosis signs: easy bruising, prolonged bleeding
Malnutrition
98
Discuss bulimia nervosa
Obsessive control of weight
- repeated bouts of over eating then purging
Typically young F, 20s
Clinical
- weight: normal range
- hypokalaemia: repeated vomiting
- sialosis
- erosion
- Russel’s sign: calluses D hand
- ulcers S palate
- angular cheilitis
99
Risk factors + clinical signs acute necrotising ulcerative gingivitis
Risk
- poor plaque control
- malnutrition
- smoking
- stress
- immunocompromised
Clinical
- punched out ulcers tip of interdental papilla; readily bleed
- necrotic slough covering interdental papilla
- lymphadenopathy
100
Aetiology + predisposing factors of necrotising stomatitis
Noma
Aetiology: bacterial
- porphyromonas gingivalis
- fusobacterium nucleatum
- prevotella intermedia
Predisposing
- poverty, proximity to livestock
- poor OH
- measles
- malaria
- PEM + vit(A,B)/Zn deficiency
- disease: AIDS, VZV, CMV
101
Clinical features of noma
Necrotising stomatitis
Putrid odour
Rapid devastating necrotising destruction of soft/hard tissues
Acute
- oedema
- cheek perforation
- 2ry infection -> rapid death
Chronic
- fibrous scar
- oral strictures
- trismus
- dental malposition (tooth movement)
- salivary incontinence
102
Discuss VitC deficiency
Essential collagen synthesis cofactor
Clinical
Initial: enlargement + keratosis follicles -> cork screw hairs
Later
- blood vessel proliferation around follicles + interdental papilla
- gingival hyperplasia w/ haemorrhage
- tooth mobility + exfoliation
- cutaneous bleeding + purpura
103
Causes of Zn deficiency
Moderate
- malabsorption
- deficient diet
- chronic renal disease
- sickle cell disease
Severe
- acrodermatitis enteropathica
- post-penicillamine Tx
104
Clinical signs of Zn deficiency
General
- diarrhoea, lost appetite
- lethargy, depression
- pustular bullous dermatitis
- alopecia
- retarded growth
- hypogonadism
- poor wound healing
Oral
- delayed wound healing
- hypogeusia
- angular cheilitis
- candidal superinfection
- perioral psoriasiform
- erythema migrans
105
What is coeliac disease?
Genetically determined chronic inflammatory small intestine disease due to gluten sensitivity
106
Clinical findings of coeliac disease
General
- malabsorption w/ chronic diarrhoea
- weight loss
- abdominal distension
- fatigue
- childhood anaemia
- LP exacerbation
Oral
- recurrent oral ulceration
- dental hypoplasia
- glossitis, burning mouth
- angular cheilitis
107
Occult manifestations of coeliac disease
```
Metabolic bone disease
Fe/folate deficiency
Infertility
Autoimmune disease: Sjögren’s, DM
Malignancy: SCC, NHL
```
108
Disease dental hypoplasia seen in coeliac disease
```
96%, children 83% adults
Enamel defects; symmetrically + chronologically distributed
Mild enamel defects
- rough surface
- horizontal grooves
- shallow pits
```
109
What is Crohn’s disease? Aetiology
Chronic aggressive inflammatory bowel disease
Discontinuous (‘skip lesions’) pattern of transmural inflammation
Affect whole GIT w/ large ulcerations + occasional granulomata
Aetiology: unknown
- genetic: NOD2
- environmental: enteric microflora, nutrition
- host immune response
110
Oral features of Crohn’s
```
Gingival swelling + mucosal tags
Cobblestone mucosa; ulcerated fissures
Lip swelling: diffuse, soft, non-tender
Angular cheilitis
Persistent irregular ulcers, ROU
```
111
What is orofacial granulomatosis?
Predominantly labial swelling associated w/ granulomatous inflammation
Continuum
- overt Crohn’s chronic granulomatous cheilitis Melkerson-Rosenthal syndrome
112
Clinical features of orofacial granulomatosis
Non-tender recurrent lip/lower face swelling
- eventually becomes persistent
Lymphadenopathy
```
Angular cheilitis
Ulceration
Vertical labial fissures
Mucosal tags
Tongue fissuring
```
113
Management of orofacial granulomatosis
```
Spontaneous remission unusual
Diet: exclude benzoate, cinnamon
Corticosteroids
Topical tracolimus
Thalidomide
Adalimumab
```
114
Discuss Peutz-Jeghers syndrome
Rare, autosomal dominant
Multiple small perioral + vermillion freckles
Pigmented spots: IO, extremities, nasal + rectal mucosa
- no risk of melanoma
Hamartomatous intestinal polyps: abdominal pain + rectal bleeding
- risk internal malignancy: gut, breast, genital
115
Discuss black hairy tongue
Localised oral pigmentation
Aetiology
- elongation of filiform papillae
- + extrinsic staining
- + overgrowth pigment prod. bacteria/fungi
Associated
- smoking
- antiseptic m/w
- ABs
May alternate w/ white hairy tongue
Management
- reassure + info
- OH
- smoking cessation
- tongue brushing: avoid over brushing
- oxidising m/w
116
Discuss amalgam tattoo
Aetiology
- XLA amalgam filled tooth
- removal amalgam filling
Site
- mandibular gingiva
- alveolar mucosa
Slate grey, black/blue macules
No elevation
No size change; margins may blur
Histology
- lamina propria: fine granular black/brown pigment encases elastic fibres + basement membrane fo superficial capillaries
- within cytoplasm of histiocytes
117
Discuss graphite tattoo
2nd most common exogenous cause localised oral pigmentation
Ant. palate children
Biopsy: mandatory to rule out malignancy
- abundance granulation tissue
- destruction of labial cortical bone 1s
- residues of solid black granules
Histology
- mild chronic inflammatory cell infiltrate
- multinucleate giant cells
- solid granules consistent w/ pencil graphite
118
Management of amalgam/graphite tattoo
```
X-ray: amalgam in tissue
Reassure: not health hazard
Observation
Excision: clinical doubt
Q-switched ruby laser: shatters particles
```
119
Discuss metallic salt deposition
Metallic sulphide deposition along gingival margin
- bismuth, Pd, mercuric salts
Salts in crevicular fluid precipitate as sulphides by H2S from bacteria
Pd/Burton’s lines: linear grey/black lines along gingival margin
120
Discuss oral melanotic macule
```
F>M
Benign, localised areas of pigmentation
Focal inc. melanin prod.
Uniformly flat black/brown macule
Distinct borders, <5mm
```
Site
- any mucosal surface; OC rare
- lip lesion; reaction to sun damage
Management
- benign
- remove: Dx, avoid long term follow up
- lip: monitored if no suspicious feature
121
Discuss oral melanoma
Rare: 1-2% all melanomas
Site
- palate common
- any site
- lips, gingiva
Clinical
- darkish brown/black; 30% amelanotic
- irregular poorly defined borders
- irregular colour distribution
- thickening
122
Prognosis of oral melanoma
Poor: 5-20% 5yr survival
```
Late Dx
Early metastasis; rich blood + lymphatics
- lungs
- liver
- lymph node
Aggressive histology
Difficult local clearance
```
123
Discuss ecchymosis
Brushing
Red/blue
Hx: trauma
Spontaneous: underlying platelet/coagulation disorder
124
Discuss varices
Abnormal venous dilation
Site: lip, sublingual
```
Clinical
- painless
- blue, lobulated
- blanch
- thickened + hard
— thrombosis w/ calcified phleboliths
```
Management
- observation
- excision
- sclerotherapy, laser ablation
125
Aetiology of Peutz-Jegher’s syndrome
Mutated LKB1 gene on chromosome 19
| Codes serine-threonine kinase
126
Management Peutz-Jegher’s syndrome
No Tx req.
- no melanoma transformation
Counselling + monitoring
Risk internal malignancy: gut, breast, genital
127
Discuss racial pigmentation
POC; 5% Caucasian
Mostly gingiva (1s), any mucosa poss
Generalised
A/symmetrical
128
Discuss betel nut pigmentation
Areca nut pigmentation mucosa + teeth
Yellow/orange/brown
Risks
- TSL
- staining
- lichenoid reaction
- submucous fibrosis
- epithelial dysplasia
- OSCC
129
Discuss paan use
Combination: betel nut, leaf, slaked lime, spices, tobacco
All carcinogenic
Severe attrition
130
Management of betel nut/paan user
Info
Cessation advice
NRT
Biopsy if req.
131
Discuss post-inflammatory hyperpigmentation
```
Post-mucosal irritation + inflammation
- inc. pigmentation during healing phase
Usually generalised
Common: chronic LP B mucosa
Histology: melanin drop out
```
132
Discuss mediation related hyperpigmentation
Many medications + mechanisms
Mechanisms
- IO inflammatory reaction
- stim. melanin: arsenic combine w/ thiols groups
- react w/ melanin: phenothiazines + minocycline
S:
- palate
- B mucosa
- gingiva
Management: drug cessation
133
Examples of drugs causing hyperpigmentation
Blue-Grey
- chloroquine
- minocycline
- fluoxetine
- amiodarone
Brown
- bleomycin
- busulphan
- cyclophosphamide
- minocycline
- doxycycline
- aziodthymidine
- propranolol
134
Discuss Addison’s disease
```
1ry adrenal insufficiency
- autoimmune
- infection: HIV, TB, sarcoidosis
Adrenal cortical atrophy + insufficiency
- dec. cortisol + aldosterone
```
Hyperpigmentation: 2ry melanocyte stim. by inc. ACTH
Streaks/patches of blue/black pigmentation (water spaniel)
Management: steroid replacement therapy
135
Clinical features of Addison’s disease
```
Cutaneous bronzing sun exposed sites
- hyperpigmentation scars + flexures
Genital pigmentation
Vitiligo
Hypotension
Hypoglycaemia
Salt craving
Weight loss, lethargy
Nausea, vomiting
```
136
Discuss Cushing’s disease
```
Aetiology: inc. ACTH secretion from ant. pituitary gland
Clinical
- cataract
- hypertension
- hirsuitism
- hyperglycaemia
- skin thinning
- ulcers
- hyperpigmentation
```
137
What is Nelson’s syndrome?
Condition following removal both adrenal glands due to Cushing’s syndrome
Macro-adenomas develop which prod. ACTH
138
Discuss McCune-Albright syndrome and hyperthyroidism
Albright
- genetic disorder; mutation of GNAS gene
- affect: bone, skin, endocrine system
- clinical
— fibrous dysplasia
— cafe au lait macules
— hyper-functioning endocrine; Cushing’s, hyperthyroidism
Hyperthyroidism
- tachycardia
- heat intolerance
- palmar sweating
- weight loss, inc. hunger
- diarrhoea
139
Discuss lichen planus; epidemiology, aetiology, symptoms
Epidemiology
- 1-4% popn.
- 0.5-2% oral
- oral chronic: 4-25y
- skin: 18/12
Aetiology
- immunologically mediated
- cytotoxic T cell
- basal keratinocytes targeted; Ag unknown
- related: stress, spice, DM, liver disease
Symptoms
- asymptomatic
- pain/discomfort w/ spice/citrus
- aesthetics concerns
140
Discuss oral LP
Reticular: white lines, asymptomatic
Erythematous/Atrophic: superficial redding due to mucosal thinning
Erosive/Ulcerative: painful, chronic
Symmetrical: skin + oral
S: B mucosa, tongue, gingiva
- palate rare
141
What is Koebner phenomenon?
Feature of LP
| Lesion in areas of inc. friction; flexures, O line
142
Discuss extra-oral forms of LP
```
Cutaneous
- flexure surfaces wrists + shins
- symmetrical, bilateral
- koebner phenomenon
- wickham’s striae: surface network fine white lines
- purple pruritic polygonal papules + plaques
— red -> violaceous
— flat topped
— few mm
```
Nails: 10%
- longitudinal pitting + grooving
- reversible
- possible onycholysis
Lichen planopilaris: scarring alopecia
143
Discuss vulvovaginal-gingival syndrome
```
Severe variant of LP
Often unrecognised
Usually ulcerative + symptomatic
- desquamation of vulval, gingival + gingival mucosa
Progressive vulval disease -> scarring
Malignant transformations reported
```
144
Histological features of LP
```
Subepithelial band of inflammatory cells
- lymphocytes
Basal cell liquefaction/degeneration
+/- hyperkeratosis
Saw tooth rete ridges in epidermis
```
145
Management of LP
No cure
- red. inflammation + pain
- prevent complications
Asymptomatic: reassure, GDP review
```
Symptomatic
- remove provoking
- red. irritation: spice, acid
- OH
— desquamative gingiva may prevent OH
— alternative OH; alcohol free corsodyl
```
146
Medications for LP management
Corticosteroids: 1st line
- topical/systemic
- risk suppression HPA
```
Topical Calcineurin inhibitors
- protein in synthesis IL2
— viral for T-cell activation
- cyclosporine
- tacrolimus
- pimecrolimus
```
147
What is lichenoid reaction?
Condition clinically + histologically similar to LP w/ identifiable aetiology
No pathognomonic histology
Uni/bilateral
May be ulcerative
Dx: withdraw drug
148
Clinical features of lichenoid reaction
Clinical
- soreness similar to LP esp. erosive
- indistinguishable from LP
- asymmetric; if due to local cause
- more likely erosive + palate/tongue
Oral Contact Hypersensitivity Reaction
- sensitised to DM component
- Au, bisGMA, Am, Hg, Ni
- S: mucosa in direct contact
- patch test+
149
Histology of lichenoid reaction
Similar to LP
```
Infiltrate may be deeper + less defined
Poss more plasma cells + eosinophils
Perivascular infiltrate possible
Colloid bodies + basal cell Ab in epithelium
Consider bale basal cell liquefaction
```
150
Management of lichenoid reaction
Drug Hx + T relationship important
Patch test if local
Withdraw drug
As LP until resolution
151
Discuss discoid lupus erythematous
Chronic indolent disorder
Cutaneous + oral
Aetiology
- autoimmune
- may be precipitated by drug/environment/viral/hormonal
- auto-Ab + cell mediated immunity against cellular components
152
Cutaneous + oral features of DLE
```
Cutaneous
- sun exposed sites
- 1/+ oval plaques on face/scalp/hands
- well demarcated red, atrophic scaly plaques
— w/ keratin plugs in dilated follicles
- generalised telangiectasia
- scarring -> alopecia + pigmentation
```
Oral
- less well demarcated erythematous ares surrounded by fine white striae
- may ulcerate; active or in those progress to SLE
- bilateral on L/B/alveolar mucosa, vermillion border
- palate: SLE
153
DLE histology
Ortho/parakeratosis
Liquefaction of basal layer
Hyalinisation of subepithelial connective tissue
Chronic inflammatory infiltrate in subepithelial tissue
Irregular acanthosis
Civatte/colloid bodies
Keratotic plugging
154
Management of DLE
Oral: LP
Cutaneous
- chloroquine + potent topical steroids
- sunblock useful but not sufficient
- others: cytotoxics, dapsone, thalidomide, retinoids
155
Discuss graft v host disease
Common, serious complication follow allogeneic bone marrow transplantation
- within 6-24/12 post-BMT
Graft lymphocytes against recipient host cells
Risk
- poorly matched graft
- old donor/recipient
156
What is graft v leukaemia affect?
Ability of donor immune cells to eliminate/keep underlying disease in long term remission
157
Clinical features GvHD
```
May be asymptomatic
Burning oral discomfort
- lesions: reticular/ulcerative/erosive
Salivary gland involvement -> oral dryness
- superficial palatal + labial mucocele
Red. opening following sclerotic GvHD
```
158
Management of GvHD
Topical analgesic: lidocaine, benzydamine
Corticosteroids: betamethasone m/w, fluocinonide/clobetasol gels
Tacrolimus ointment
Regular monitoring as OSCC inc. risk
159
What is pemphigus vulgaris?
Chronic organ specific autoimmune blistering disease
Aetiology: T2 hypersensitivity
- circulating + bound IgG auto-Ab against desmosome adhesins
— dissolution of cell-cell adhesion
- diet: garlic, onion, leaks, mustard
- medication: thiol containing drugs; penicillamine, captopril
160
Clinical features of pemphigus vulgaris
Nikolsky sign: blisters rapidly breakdown -> erosions
Desquamative gingivitis (60%)
Fragile blisters; slow healing
Dysphagia, odynophagia
Oral
- bullae fragile + short lived
- large shallow non-healing ulcers
- S: P, B mucosa, gingiva
Cutaneous
- large, non-healing erosions + ulcers
- 3-4/12 post-oral lesions
- frank blisters rare
161
Ix and histological features of pemphigus vulgaris
Ix
- biopsy of para-lesional and/or normal tissue
- routine histology
- blood for indirect immunofluorescence
Histology
- intraepithelial clefting + acantholysis
- intact bullae: clumps of acantholytic cells (Tzank cells)
- keratinocytes immunofluorescent+
— auto-IgG against desmoglein 3 in desmosomes in supra/basal keratinocytes
162
Management of pemphigus vulgaris
Systemic corticosteroids: prednisolone, deflazacort
Steroid sparing: azathioprine, cyclosporine, mycophenolate mofetil
Topical: potent corticosteroids
IV Ig
Plasmaphoresis
163
What is mucous membranes pemphigoid?
Chronic rare autoimmune blistering disease
Aetiology: unknown
Affects middle age-elderly; F>M
Circulating + bound Ab against basement membrane zone
- BP180/230 Ag in hemidesmosomes
164
Clinical features of mucous membrane pemphigoid; oral, ocular
Predominately mucosa, skin rare
Full thickness epithelium lifts off connective tissue
Large, tense bullae (blood filled) -> chronic, painful erosion
Oral
- S: any, lip rare
- nikolsky+
- blister rupture rapidly -> irregular pseudomembrane-covered painful erosions
- desquamative gingivitis
- chronic soreness, bleeding, dysphagia
- scarring uncommon
```
Ocular
- lead to blindness
- chronic conjunctivitis
- blurring, irritation, photophobia
- excess tears
- unilateral -> bilateral within 2y
- repeated fibrosis leads to scarring
— symblepharon, entropion, trichiasis, blindness
```
165
Other sites of mucous membrane pemphigoid
Skin: rare 30%
- scalp: scarring alopecia
- face, neck, L trunk
Genital: 30%; sexual + urinary dysfunction
Larynx + oesophagus: infreq.
166
Mucous membrane pemphigoid Dx + Tx
Dx
- exam, histology, biopsy + immunofluorescence
— sub-basilar split
- DIF
— homogenous linear IgG/C3 deposits in BMZ along dermo-epidermal junction
Tx
- often resistant
- topical corticosteroid: betamethasone, clobestasol
- systemic corticosteroid
- dapsone
- anti-inflammatory AB: doxycycline, minocycline
- immunosuppressants: azathioprine, cyclophosphamide
167
Discuss bullous pemphigoid
Auto-Ab against hemidesmosomes
Elderly
Clinical
- skin, mouth rare
- erythema + blisters; last long T
- large, tense blisters
- preceded by itchiness
- erosions, scarring not prominent
Management
- topical/systemic steroids
- anti-inflammatory AB, dapsone
- ocular exam req.
168
Clinical features dermatitis herpetiformis
Rare
Chronic pruritic papulovesicular rash
Younger age group
Associated: coeliac disease
Clinical
- smaller bullae + vesicles (herpetiform appearance)
- small blisters on urticated base
- S: bum, elbows, knees
- oral: superficial transient blisters -> nonspecific tender ulcers
169
Ix + Tx of dermatitis herpetiformis
Histology: localised splitting at BMZ
Speckled/granular IgA immunofluorescence involving BM of dermal papillae
Tx: diet restriction + dapsone
170
Discuss linear IgA disease
Chronic autoimmune blistering disease
Mucocutaneous
Oral + ocular common
DIF: linear IgA deposits are epithelium CT junction w/ separation at BMZ
Tx: dapsone, steroids
171
Discuss angina bullosa haemorrhagica
Aetiology: unclear, old
- genetic: loose adhesion b/w epithelium + corum of mucosa
- inhaled steroid: mucosal atrophy -> dec. epithelium elastic fibres
- DM: vascular fragility
Large, IO blood filled blisters
Feels like choking
172
Clinical features of angina bullosa haemorrhagica
```
Solitary, large (2-3cm) blood filled blister
Develop suddenly
S: H+S palate junction
Burst spontaneously within 24h
Superficial ulcerative area
```
Resolve: 7-10d
Recur 5-10 episodes over few yr
173
Management of angina bullosa haemorrhagica
FBC/coagulation screen
Symptomatic: benzydamine, CHX m/w
Large, intact blisters: incised to avoid respiratory arrest
174
Discuss epidermolysis bullosa
```
Genetic collagen defect disease
Many forms
- lethalis: incompatible w/ life
- dystrophica: recessive, skin/mucosa fragility
- simplex: least severe
```
175
Oral feature of epidermolysis bullosa
```
Mucosal fragility
Minor trauma = mucosa separate from CT
Scarring -> severe deformity
Severe forms
- OH, dental care, eating problematic
```
176
Discuss epidermolysis bullosa simplex
Most common: 92%
Blisters @ sites of friction
- hands, feet common
Multiple types
Dominant: keratin KRT5/14 affected
- keratinisation failure -> red. integrity + ability resist mechanical stress
Management
- no cure
- symptomatic + protection
- topical/systemic corticosteroid
177
Discuss epidermolysis bullosa acquisita
```
30-40y, F>M
Autoimmune: associated
- Crohn’s
- SLE
- amyloidosis
- multiple myeloma
```
Trauma -> widespread blistering w/ scarring
Subepidermal blisters
DIF: linear IgG deposits
Tx
- corticosteroids
- immunosuppressants
- dapsone
178
Define pain
Unpleasant sensory + emotional experience associated w/ actual/potential tissue damage or described in such terms
179
What is orofacial pain?
Pain in area
- above neck
- ant. to ears
- below orbitomeatal line
Incl. OC
180
What chronic pain?
Pain persisted >3/12, outlived usefulness
Disease of neuromatrix
Cure unlikely; disability caused can be red.
181
Difference b/w chronic + persistent
Chronic: any never go
Persistent: not intractable
182
What are TMDs?
Temporomandibular joint disorders
Musculoskeletal disorder involv. MoM and/or TMJ
Incl.
- myosfacial pain disorder
- TMJ disc interference; displacement w/ or w/o reduction
- TMJ degenerative joint disease
183
Risk factors for TMJD
```
F 18-44
Depression, psychological distress
Exogenous hormones
Facial trauma
Sleep problems
Bruxism
Multiple pain disorders
```
184
Hx of TMJD
```
S: uni/bilateral, TMJ area
C: dull, aching, throbbing
R: pre/post-auricular, MoM
A: stress, clicking, tenderness
T: intermittent/constant
E: opening, chewing, yawning
A: sleep, analgesic
S: mild-mod.
```
185
Indicators of TMJ degenerative change
```
Clicking
Crepitus
Limited movement, locking
Momentary hesitation
Sudden inability to fully close
```
186
Pt self management methods for TMD
```
Empowerment
Warm joints
Attention to parafunctional habits
Jaw exercise
Relaxation
Massage
Simple analgesic
```
187
Pharmacological TMD management
```
Analgesics
- opioids
- NSAIDs
- paracetamol
Corticosteroids
- iontophoresis
- intracapsular injection
```
Antidepressants
Sedatives
Anxiolytics
Muscle relaxants
188
Adjunctive therapies for TMD
```
Splint
Acupuncture
CBT
Physiotherapy
Botox
```
189
What is persistent idiopathic facial pain?
Poorly localised pain w/ widespread radiation
Associated w/ repeated unsuccessful dental Tx (XLA) due to belief that is chronic dental pain
Initiation + persistence
- dental Tx
- prolonged dental pain
- severe dental infection
- stress
190
Associated features and risk factors for PIFP
Associated
- IBS
- head, neck/backache
- dysmenorrhea
- pruritus
- fatigue
- sleep disturbance
Risk: F
- genetic
- widespread pain
- passive coping traits
191
Hx of PIFP
S: uni/bilateral; no anatomical area, poorly localised
C: dull, nagging, throbbing, aching, sharp
R: H+N, down arms
A: pain, personality change, life events
T: constant/intermittent
E: chewing, dental/stress, cold weather
A: rest, relaxation
S: mod-severe
192
What is atypical odontalgia?
Pain associated w/ tooth/edentulous ridge w/o clinical or radiographic finding
193
Hx of atypical odontalgia
```
S: tooth/edentulous ridge; UP/M most common
O: dental Tx (>80%)
R: well localised, may move tooth
T: persistent
S: mod
```
194
Management of atypical odontalgia
Key: convince pt no current dental cause
Stop ongoing dental interventions/XLAs
TCA: amitriptyline, nortryptiline
Gabapentin/pregabalin
195
What is burning mouth syndrome?
Idiopathic burning pain/discomfort in pt w/ clinically normal mucosa and in which medical/dental cause excluded
196
Hx of burning mouth syndrome
S: lips, tongue, palate (whole mouth)
C: burning, tiring, smarting, annoying, tender
A: dryness, dysgeusia, depression, anxiety, F>50
T: constant/intermittent, worse pm
E: eating, tension
A: eating, rest, distraction
S: mild-mod
197
Pathophysiology of burning mouth syndrome
Hormonal
- menopause: red. gonadal + neuroactive steroids
- chronic anxiety + stress impair HPA a is = red. adrenal steroids
- neuroprotective effect lost
- oral nerve terminal neurodegenerative change
Dysguesia
- neuropathic changes affect gustatory nervous system (esp. chorda tympani)
- lose inhibitory control of small fibre afferents (responsible for burning)
- inhibition of glossopharyngeal nerve lost -> taste phantoms + altered pain/touch
198
Management of burning mouth syndrome
```
Reassurance: physiological cause
Symptomatic
- saliva substitute
- benzydamine m/w
TCA, SSRI
CBT
Allhalipoic acid, gabapentin, clonazepam
```
199
Hx glossopharyngeal neuralgia
```
S: unilateral, RHS more common
C: stabbing
R: ear, base of tongue, tonsillar fossa, beneath angle of jaw
A: syncope, arrhythmias
T: transient, remission may occur
E: swallowing, chewing, speaking, coughing
A: pulling on ear
S: severe
```
200
Difference b/w 1/2ry glossopharyngeal neuralgia + aetiology
2ry has persistent background aching + exacerbations
Aetiology
- 1ry: nerve compression
2ry: congenital vascular abnormality/tumour/aneurysm
201
What is Eagle syndrome?
Glossopharyngeal neuralgia differential
Due to elongation of stylohyoid process (age, trauma) compression CN5/9/1
Clinical
- shooting pain of throat, ear, jaw
- pain of tongue base
- worse on swallowing, turning head
- tinnitus, hypersalivation, feeling of something stuck in throat
Tx: styloidectomy
202
What is trigeminal neuralgia?
Sudden, unilateral, severe, brief, recurrent stabbing pain in 1/+ branches of CN5
Rare: 50-60y
- M: 108/mil
- F: 200/mil
203
Hx of trigeminal neuralgia
S: CN5; unilateral (97%), RHS (60%)
C: flashing, shooting, sharp, unbearable, terrifying
A: trigger zones, weight loss
T: seconds, remission wks/mnths
E: light touch, eating, talking, spontaneous
A: avoid touch, anticonvulsants, sleep
S: mod-severe
204
Aetiology of trigeminal neuralgia
Idiopathic
| Aberrant cerebellar artery compressing nerve root @ root entry zone
205
Discuss multiple sclerosis + post. fossa tumours in relation to trigeminal neuralgia
MS: demyelination of nerve fibres
- 1-5% have TN
- present younger cf TH (20-40)
- likely bilateral
- therapy response poor
Post. Fossa Tumours
- meningiomas, neuromas
- 2% have TN
- facial numbness
- MoM weakness
- may be constant
206
Pharmacological management options for trigeminal neuralgia
Carbamazepine (gold)
Oxcarbazepine
Lamotrigine
Baclofen
207
Discuss carbamazepine use for trigeminal neuralgia
70% pt have pain red.
Failure usually due to inc. severity
Inc. dose slowly
- 300-800mg QTD
Adverse
- drowsiness
- dizziness
- nausea, constipation
- diplopia, blurred vision
- ataxia
208
What is giant cell arteritis?
Granulomatous arteritis affect M/L arteries esp. extracranial branches of carotid
- temporal most freq.
209
Clinical features of giant cell arteritis
```
Elderly pt new on sent/type of headache
Carotidynia
Superficial temporal arteries
- thickened
- tender
- nodular
- erythematous
Ophthalmic
- diplopia
- blurring
- amaurosis fugax (temp. loss of vision)
- obscuration
```
210
Associated features giant cell arteritis
```
Tongue/jaw claudication whilst chewing
Rare
- necrosis tongue/scalp
- toothache
- trismus
General
- pyrexia
- fatigue
- weight loss
Polymyalgia (50%)
Ischaemic limb pain, angina, thoracic + abdominal aneurysm
```
211
Giant cell arteritis histology
Inflammatory cell infiltrate
Giant cells
Thrombus
Arterial wall hyperplasia
212
Management of giant cell arteritis
Corticosteroids
Ca + VitD supplements
Visual loss improves in only few pts
213
Causative species + transmission of syphilis
```
Causative: treponema palladium
Transmission
- venereal: close contact w/ lesion (main)
- blood: IVDU
- vertical: mother-child
```
214
Discuss 1ry and 2ry syphilis
1ry: 3-4/52 post-infection
- chancres: 1st symptom
— infectious, firm, painless nodule @ inoculation site
— breakdown -> painless sore/ulcer
— resolves spontaneously 2-6/52
— S: genital, oral
- lymphadenopathy: neck, groin, armpits
2ry: 2-6/12
- non-itchy maculopapular rash
- sore throat, several weeks
- condylomata lata
- general
— tiredness, headache
— fever
— weight loss
— patches of hair loss
— joint pain
- followed by latent period; last several years
215
3ry syphilis
3-15 post-infection
Gummatous: eyes, heart, liver (any organ)
- gummas: necrotic centre surrounded by inflammation
— painless
— OC: palate
Neurosyphilis: brain, nerves
CV syphilis: blood vessels
Complications
- blindness, deafness
- dementia
- stroke, heart disease
- paralysis
Potentially life threatening
216
Dx + management of syphilis
Dx
- Hx + exam
- serology: syphilis Ab
- swab: sores/ulcers
```
Management
- referral to GUM
- partners informed
- ABs
— early syphilis: penicillin, doxycycline
— late: IV penicillin
```
217
HIV virus + transmission route
Lentivirus, retrovirus
Transmission
- general
- blood: IVDU
- vertical: perinatal
218
Pathogenesis of HIV
Attach to CD4 R on T helper lymphocytes; gain entry into cell
RNA -> DNA (reverse transcriptase) = viral replication + assembly
Cell lysis -> infect other cells
- cells destroyed or stop functioning
Immune system cells HIV particles and infected cells, lost T cells replace
219
Discuss stage 1 and 2 of HIV infection
1: 1ry infection
- lasts few wks
- short, flu-like illness
- 20%: serious enough to consult Dr; Dx missed
- large amount HIV in peripheral blood
- seroconversion: immune system prod. HIV Ab + cytotoxic lymphocytes
— test before seroconversion = false -ve
2: Clinically Asymptomatic
- 10yrs, no major symptoms (lymphadenopathy)
- peripheral blood HIV drops
— remain infectious, Ab detectable in blood
- not dormant: v active in lymph nodes
- many T cells infected + die, lots HIV prod.
- viral load test: measure HIV escapes lymph nodes (accurate to 50copies/mL)
220
Stage 3 and 4 of HIV
3: Symptomatic
- immune system loses struggle
— lymph nodes + tissues damaged
— HIV mutates: more pathogenic + stronger -> more T cell destruction
— failure to adequately replace T cells
- symptoms develop as immune system fails
4: AIDS
- immune system more damaged + illness more severe
- Dx: HIV+ pt develops 1/+ opportunistic infection/cancer
- CDCP: CD4 <200/microL
221
What opportunistic infections are diagnostic for HIV?
```
Pneumocystis carinii
- most freq.
- pneumocystis carinii pneumonia; rarely disseminates
CMV
HSV
Toxoplasmosis
Fungal
Mycobacterium
```
222
Importance of oral manifestations of HIV
```
Can indicate HIV
Predict progression HIV->AIDS
Entry/endpoint in therapy/vaccine trials
Determinant of anti-opportunistic infection + anti+HIV therapy
Staging/classification
```
223
Group 1 oral manifestations of HIV
Strongly associated w/ HIV
Candidiasis: erythematous (denture), pseudomembranous (wipe off)
Hairy leukoplakia: corrugated tongue (EBV)
Kaposi sarcoma: HHV8, cancer endothelial cells
PD
- linear gingival erythema
- ANUG (interdental papilla tip), NUP (inc. destruction)
Non-Hodgkin’s lymphoma: singular firm nodule
224
Management of HIV
Antiretroviral therapy
- zidovudine
- Retrovir
- tenofovir
225
Effect of ART
Inc. CD4, dec. viral load
Oral: red. prevalence of manifestations
Commencing can cause deterioration/reestablishment of opportunistic infections as immune system strengthens and fights again
