oral medicine

Question 1

aetiological factors for recurrent apthae

Answer 1

• genetic predisposition
• immunological abnormalities
• haematological deficiencies
• stress
• hormonal changes
• gastrointestinal disorders
• infections

Question 2

types of recurrent apthae

how to differentiate

Answer 2

Minor apthae may occur singly or in crops and they affect the non-keratinised and mobile mucosa, usually less than 4mm diameter

Major apthae occur as a single ulcer, which may be greater than 1cm diameter, masticatory mucosa and dorsum of tongue often affected

Herpetiform apthae ususally occur in crops of ulcers which are 1-2mm in diameter, altough they may coalesce to form larger uclers, on non-keratined mucosa

Question 3

tx options for recurrent apthae

Answer 3

• treat underlying systemic disease
• benzydamine (Difflam) mouthwash
• corticosteroids (betnesol mouthwash)
• tetracycline mouthwashes
• CHX mouthwash

Question 4

angulat cheilitis (stomatitis)

Answer 4

inflammation of skin and the labial mucos membrane at the commisures of the lips

Question 5

angular chelitis Vs actinic cheilitis

Answer 5

actinic chelitis is a premalignant condition in which keratosis of the lip is caused by UV radiaition from sunlight

Question 6

predisposing factors for angular chelitis

Answer 6

• wearing dentures
• having denture stomatitis
• nuturional deficies e.g. iron
• immunocompromised
• decreased vertical dimension resulting in infolding of the tissues at the corner of the mouth allowing the skin to become macerated

Question 7

organisms that commonly cause angular chelitis

Answer 7

staphylococcus aureus and candida albicans

Question 8

tx for angular chelitis

Answer 8

• Miconazole cream 2% 20g tube apply to angles of mouth twice daily
  
  • Contraindicated for those on warfarin or statins
• Sodium fusidate ointment 2% 15g tube

Question 9

acute pseudomembranous candiasis appearance

Answer 9

whitish-yellow plaques or flecks cover the mucosa but they can be wiped off leaving erythematous mucosa underneath

Question 10

2 azole drugs and 2 non azole drugs used to treat candida infections

Answer 10

azoles

• miconazole
• fluconazole
• itraconazole
• ketoconazole

non azoles

• nystatin
• amphotercin

Question 11

common white pathces and their causes

Answer 11

frictional keratosis - friction

leukoedma - variation of normal

candidal infection - candida albicans infection

fordyce spots/granules - development (sebaceous glands in the muocsa)

lichen planus - unknown

lichenoid reaction - gold/antimalarials/amalgam

skin grafts

Question 12

white patch that cannot be characterised clincally or pathologically as any other disease and is not associated with any physical or chemical causative agents except smoking tobacco

Answer 12

leukoplakia

Question 13

types of leukoplakias

Answer 13

• homogenous leukoplakia
• nodular leukoplakia
• speckled leukoplakia

Question 14

tx for leukoplakia

Answer 14

• removal of causatve agent (smoking)
• surgical removal (traditional surgical techniques or with a laser)
• photodynamic therapy
• retinoids
• specialist referral
• regular review and biopsy as appropriate

Question 15

causes of dry mouth

Answer 15

• Sjorgens syndrome
• radiotherapy in salivary gland region
• diabetes
• dehydration
• mumps
• HIV infectin
• anxiety states
• diuretics
• sarcoidosis
• amylodosis
• drugs e.g. antimuscarincis, antihistamines, antidepressants, polypharmacy

Question 16

difference between primary and secondary Sjorgens syndrome

Answer 16

primary sjorgens compromises of dry mouth and dry eyes

secondary sjorgens there is dry mouth and eyes in association with a connective tissue disease e.g. rheumatoid arthritis, systemic lupus erythamatous

Question 17

tests to dx Sjorgens

Answer 17

• biopsy
  
  • labial salivary gland (minor glands are usually involved at a microscopic level even though they may not be enlarged)
  • focal collections of lymphoids cells are seen adjacent to blood vessels, greater no. = worse
  • also acinar atrophy
• blood tests
  
  • antinuclear antibodies SSA, SSB; rheumatoid factor; erythrocyte sedimentation rate
• parotid salivary flow rate
• Schirmer test
• Sialography

Question 18

erythroplasia

Answer 18

any lesion of the oral mucosa that presents as red velvety plaque, which cannot be characterised clincally or pathologically as any other condition

lesions often show dysplasia or carcinoma in siu or frank carcinoma histologically

Question 19

malignant potential (most to least)

white sponge naevus

erythroplasia

leukoplakia

speckled leukoplakia

Answer 19

erythroplasia

speckled leukoplakia

leukoplakia

white sponge naevus

Question 20

colour of lesion, generalised or localised for

Kaposi sarcoma

Answer 20

reddish purple

localised

Question 21

colour of lesion, generalised or localised for

irradiation muositis

Answer 21

red

generalised in region of irradiation

Question 22

colour of lesion, generalised or localised for

amlagam tattoo

Answer 22

blue/black

localised

Question 23

colour of lesion, generalised or localised for

haemangiona

Answer 23

red/purple

localised to area of haemangioma

Question 24

colour of lesion, generalised or localised for

addison’s disease

Answer 24

brown patches

localised to certain areas e.g. occlusal line

Question 25

lump on palate possible Dx factors about history useful clincial features to help dx investigations needed

Answer 25

possible Dx * torus palatinus * unerupted tooth * dental abscess * papilloma * neoplasm (benign/malignant) - salivary (pleomorphic adenoma/adenocarcinoma); squamous cell carcinoma; lymphoma factors about history * duration * assoaciated features e.g. tooth ache, periodontal involvement * change in size/consitency * exacerbating factors e.g. loose denture, trauma * medical conditions e.g. neurofibromatosis, drugs clincal features of use * position e.g. midline - torus palatinus * consistency * fluid - pus, blood, cystic fluid * soft, firm, hard - tumour * bony hard - tooth, torus palatinus * colour e.g. red - vascular * discharge * surface texture * uniform, nodular, ulcerated investigations needed * imaging - radiographs * CBCT * biopsy * blood test

Question 26

30 y.o. male presents with weakness on the left side of his face possible intracranial and extracranial causes

Answer 26

intracranial * Bell's palsy * malignant parotid neoplasm * post-partotidectomy * sarcoidosis * incorrect administration LA extracranial * stroke * intracranial tumour * multiple sclerosis * HIV * lyme disease * ramsey- hunt syndrome * trauma to base of skull

Question 27

nerve issue causing facual weakness how to tell is lower or upper motor neurone cause

Answer 27

lower motor neroune lesion - pt cannot wrinkel their forehead on the affected side (Bells) upper motor neurone lesion - retain movement of the forehead (stroke)

Question 28

Herpes zoster is caused by the X which lies latent in X tends to affect X pt main complaint is X or X lesions are in the form of X, X or X tx is X at dose of X five times a day for 7 days medication for pain relief is also prescribed and X may also help with the pain and speed healing postherpetic neuralgia is X and persisting more than X months

Answer 28

Herpes zoster is caused by the **varicella zoster virus** which lies latent in **dorsal root ganglia** tends to affect **middle age or older** pt main complaint is **pain** or **tenderness to dermatomes** lesions are in the form of **rash, vesicles or ulcerations** tx is **systemic aciclovir** at dose of **200-800mg** five times a day for 7 days medication for pain relief is also prescribed and **systemic corticosteroids** may also help with the pain and speed healing postherpetic neuralgia is **pain developing during the acute phase of herpes zoster** and persisting more than **6** months

Question 29

localised ginigival swellings causes

Answer 29

* periodontal abscess * fibrous epulis * denture induced granuloma * pregnancy epulis * papilloma * giant cell lesion/epulis * tumour

Question 30

features of, additional investigation to aid periodontal abscess

Answer 30

associated with deep periodontal pocket and/or non-vital tooth

Question 31

features of, additional investigation to aid fibrous epulis

Answer 31

firm, pin/red may be associated with poor oral hygiene excisional biopsy

Question 32

features of, additional investigation to aid denture induced granuloma

Answer 32

excisional biopsy and treat the cause i.e. poorly fitting denture

Question 33

features of, additional investigation to aid pregnancy epulis

Answer 33

red lesion associated with pregnancy ginigvitis, excised post partum if still present

Question 34

features of, additional investigation to aid papilloma

Answer 34

white cauliflower like lesion excisional biopsy

Question 35

features of, additional investigation to aid giant cell lesion/epulis

Answer 35

purple red lesion radiograph, excisional biopsy and curettage, blood test to exclude central giant cell granuloma and hyperpathyroidism

Question 36

features of, additional investigation to aid tumour

Answer 36

urgent referral to surgeon for incisional biopsy radiograph/CBCT to look for bony involvement MRI to stage the disease

Question 37

signs/symptoms of primary herpetic gingivostomatitis

Answer 37

multiple vesicles in their mouth, which burst and leave painful ulcers often gingivitis pt feel generally unwell with fever and malaise cervical lymphadenotpathy

Question 38

causative agent of primary herpetic gingivostomatitis

Answer 38

herpes simplex virus (DNA virus)

Question 39

tx for primary herpetic gingivostomatitis

Answer 39

* bed rest, soft diet, fluids, analgesics * CHX or tetracycline mouthwash to prevent secondary infection of the ulcers * aciclovir in severe cases or medically compromised pts

Question 40

primary herpetic gingivostomatitis can be followed by recurrent herpers labalis how?

Answer 40

virus remains dormant in the trigeminal ganglion and can be reactivated by factors such as sinlight, stress, menstruation, immunosuppression, common cold or fever

Question 41

describe lesions of herpes labalis and how to manage them

Answer 41

lesions appear at the mucocutaneous juntion of lips pt often has prodromal itching/prickling sensation prior to the appearance of the lesion, which starts off as a papule and then forms vesicles that burst leaving a scab usually heal withut scarrinng after 7-10 days lesions will health without tx but if given early (i.e. in prodromal phase) antiviral cream such as penciclovir or aciclovir may prevent lesions from occurring or at least speed of healing

Question 42

possible presenatations of lichen planus

Answer 42

* reticular * atrophic * desquamative gingivitis * erosive * papular * plaque like

Question 43

sites for lichen planus lesions

Answer 43

buccal mucosa dorsum of tongue and gingiva

Question 44

possible extraoral sites for lichen planus

Answer 44

* flexor surfaces of wrists (purplish, papular, itchy) * genitals (similar to oral lesions) * nails (ridges) * head (alopecia)

Question 45

drugs which can cause lichen planus

Answer 45

* beta blockers * oral hypoglycaemics * NSAIDs * gld * penicillamine * some tricyclic antidepressants * antimalarials * thiazide diuretics * allopurinol

Question 46

X disease is due to sensititvity to X pts may suffer from malabsorption of X, X and X and may have the following oral signs X, X, and X X disease is a chronic X that may affect any part of teh GI tract, but most commonly affects the X Oral signs may be see such as mucosal tags X, X and X

Answer 46

**Coeliac** disease is due to sensititvity to **gluten** pts may suffer from malabsorption of **vitamin B12**, **folate** and **iron** and may have the following oral signs **oral ulceration**, **angular cheilitis**, and **glossitis** **Crohn's** disease is a chronic **granulomatous** that may affect any part of the GI tract, but most commonly affects the **ileum** Oral signs may be see such as mucosal tags **cobblestone mucosa**, **lip swelling** and **oral ulceration**