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Module 7 > Oral Medicine > Flashcards

Oral Medicine Flashcards

Contents: Dry mouth, Oro-facial pain, Oral lichen planus, Aphthous and Aphthous-like stomatitis management, Fungal and Bacterial management.

1
Q

List 16 potential causes of dry mouth:

A
  1. Age-related
  2. Stress
  3. Mouth breathing
  4. Drug-induced
  5. H&N radiation treatment
  6. Chemotherapy
  7. Immunotherapy
  8. Medical conditions:
    - Diabetes
    - Sjögren’s syndrome
    - HIV infection
    - Hepatitis C
    - Sarcoidosis
    - Graft versus host disease
    - Renal failure
    - Salivary gland aplasia
    - Cystic fibrosis
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2
Q

If diabetes is suspected, what tests may be carried out to aid diagnosis?

A
  1. Random blood glucose
  2. Glycosylated haemoglobin
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3
Q

Name some examples of drugs that can cause salivary gland hypofunction and explain the reason why they cause salivary gland hypofunction:

A
  1. Urologicals
    - solefenacin
    - oxybutynin
  2. Nervous system drugs
    - quetiapine
    - duloxetine
    - fluoxetine
    - amitriptyline

*They cause salivary gland hypofunction as a result of their anti-muscarinic properties.

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4
Q

Which types of acini are most likely to be affected by H&N radiation?

A

Serous acini

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5
Q

Approximately how long does it take for dry mouth to resolve following chemotherapy?

A

2-8 weeks post therapy

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6
Q

What immunotherapy drug can cause dry mouth?

A

Nivolumab

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7
Q

What is Sjögren’s syndrome?

A

An autoimmune inflammatory condition caused by polyclonal B cell proliferation.

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8
Q

Why does Sjögren’s syndrome cause dry mouth?

A

As infiltration of lymphocytes causes acinar atrophy.

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9
Q

Which glands are affected by Sjögren’s syndrome

A

All exocrine glands - not just salivary/lacrimal.

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10
Q

What are the 2 different types of Sjögren’s syndrome?

A
  1. Primary Sjögren’s:
    - Dry eyes and dry mouth
  2. Secondary Sjögren’s:
    - Dry eyes, dry mouth, and connective tissue disorder (e.g. Rheumatoid arthritis, Lupus erythematosus, Systemic Sclerosis, Primary Biliary Cirrhosis, Scleroderma etc.)
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11
Q

List some extra glandular manifestations of Sjögren’s:

A
  1. Arthralgia
  2. Arthritis
  3. Myalgia
  4. Neuropathy
  5. Lymphadenopathy
  6. Anaemia
  7. Leukopenia
  8. Renal tubular acidosis
  9. Pulmonary disease
  10. Gatro-intestinal tract disease
  11. Vasculitis
  12. Lymphoma
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12
Q

If a patient is suspected of having Sjogren’s, what must be done before carrying out further investigations?

A
  1. Firstly the patient must score positive in at least 1 domain in the EULAR Sjogren’s Syndrome Disease Activity Index (ESSDAI) OR respond positively to at least one of the following questions:
  • Have you had a daily feeling of dry mouth for more than 3 months?
  • Do you frequently drink fluids to aid in swallowing dry food?
  • Have you had daily, persistent, troublesome eyes for more than 3 months?
  • Do you have a recurrent sensation of sand or gravel in the eyes?
  • Do you use tear substitutes more than 3x/day?
  1. Secondly, exclude any other potential diagnoses:
    - History of H&N radiation tx
    - Active Hep C infection (confirmed by PCR test)
    - AIDS
    - Sarcoidosis
    - Amyloidosis
    - Graft versus host disease
    - IgG4-related disease
  2. Finally, the patient must score 4 or more in the ACR-EULAR 2016 Classification Criteria for Sjogren’s table to undergo clinical trial
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13
Q

What investigations may be carried out for suspected Sjogren’s syndrome?

A
  1. Unstimulated whole salivary flow rate
  2. Lacrimal flow rate - using Schirmer test
  3. Ocular staining score - to assess eye dryness
  4. Serology for connective tissue diseases
  5. Minor salivary gland biopsy - to assess for focal lymphocytic sialadenitis
  6. Ultrasound of salivary glands - To assess for parotid/submandibular gland involvement
    - If US is negative it is unlikely that the pt has Sjogren’s
  7. FBC:
    - To assess for anaemia and lymphopenia
  8. Inflammatory markers:
    - Plasma viscosity, CRP, ESR)
  9. IgG:
    - Levels often increased in primary Sjogren’s
  10. Sialography:
    - Been replaced by US as less invasive and doesn’t involve radiation.
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14
Q

Which classification system is used to aid the diagnosis of Primary Sjögren’s Syndrome?

A

The American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 2016 Classification System.

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15
Q

Why is the diagnosis of Sjögren’s syndrome important?

A
  1. Pt likely to require rheumatologist input for management of systemic involvement
    - use of hydroxychloroquine
    - cannot reverse the damage that has already occurred.
  2. Pt is at increased risk of lymphoma if they have primary Sjogren’s
    - markers can be used to assess patient’s risk
    - should advise the patient to contact GDP if there is persistent swelling of salivary glands - this requires urgent referral to oral med specialist for further investigation (ultrasound)
  3. May lead to a further diagnosis of associated connective tissue disorder in cases of Secondary Sjogrens - refer to a rheumatologist for further assessment and management
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16
Q

What is Sarcoidosis?

A

A chronic granulomatous condition that can cause changes in the oral mucosa similar to those in Orofacial Granulomatosis and Crohn’s disease

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17
Q

How does Sarcoidosis normally present?

A

Lip swelling
Dry mouth
Lymphadenopathy
Shortness of breath

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18
Q

What oral presentations of Graft versus host disease mimic?

A

Lichen planus/lichenoid reactions

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19
Q

List some signs and symptoms of dry mouth:

A

Signs:
- Tongue sticking to the mirror
- Fissured/lobulated tongue
- Shortening of the papillae of the tongue
- Wrinkling of the tongue
- Glossy/glassy appearance of the palatal mucosa
- Adherent food debris on mucosa
- Lack of saliva pooling
- Plaque accumulation
- Cervical caries
- Evidence of candidosis (angular cheilitis, erythematous mucosa, thrush, denture stomatitis)
- Traumatic ulceration
- Poor denture retention
- Bacterial sialadenitis

Symptoms:
- Dry mouth
- Difficulty eating, swallowing, denture wearing
- Mucosal surfaces stick to each other and/or teeth
- Bad taste in the mouth/altered taste
- Halitosis
- Sore mouth
- Deteriorating dentition
- Salivary gland swelling persistent/recurrent

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20
Q

What questions should you ask a patient that has dry mouth?

A

General questions:
1. When did it begin?
2. Any initiating factors?
3. Getting worse/better/staying the same?
4. Exacerbating/alleviating factors?
5. Dryness elsewhere?
6. Treatment tried? Any benefit?
7. Other health care professionals seen?

Medical History:
1. Received/currently receiving radiotherapy or chemotherapy?
2. Taking drugs that cause dry mouth? Does dryness worsen when taking the medication/with a dosage increase?

Dental History:
1. Increase in their incidence of caries?
2. Difficulty wearing their dentures?
3. Soreness affecting mouth, when previously symptom-free?

Social History:
1. Smoker?
2. Alcohol intake? - if high can cause dehydration
3. Stressful occupation?

Family History:
1. FH of Type II Diabetes? - oral dryness can be a sign of undiagnosed type II diabetes
2. Does anyone else in the family suffer from a connective tissue disorder? (e.g. Rheumatoid arthritis, Lupus (pt may have Secondary Sjogren’s)

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21
Q

What scale can be used clinically to assess oral dryness and recommends specific management methods?

A

The Challacombe Scale

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22
Q

How might a Challacombe score from 1-3 present?

A

Mild dryness
Mirror sticking to buccal mucosa/tongue
Saliva frothy

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23
Q

What would the ideal management be for a Challacombe scale 1-3?

A

Referral not necessary - monitor at routine check-up appointments
May not require treatment
May be managed sufficiently with sugar-free chewing gum and good hydration.

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24
Q

How might a Challacombe score from 4-6 present?

A

Moderate dryness
No saliva pooling FOM
Generalised shortened papillae on the tongue
Altered gingival architecture - smooth

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25
Q

What would the ideal management be for a Challacombe scale 4-6?

A

Referral to oral med specialist may be necessary for further investigations if the cause of oral dryness isn’t clear.

Can be managed with sugar-free gum or sialogogues.

Consider saliva substitutes and topical fluoride.

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26
Q

How might a Challacombe score from 7-10 present?

A

Severe dryness
Glossy appearance of oral mucosa, especially palate
Tongue lobulated/fissured
Cervical caries (more than 2 teeth)
Debris on palate or sticking to teeth

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27
Q

What would the ideal management be for a Challacombe scale 7-10?

A

Should refer to oral med specialist as cause needs to be determined - exclude Sjogren’s Syndrome
Manage with saliva substitutes and topical fluoride

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28
Q

What 2 investigations may be carried out to further investigate dry mouth?

A
  1. Unstimulated salivary flow rate:
    - Uses whole saliva
    - 15 mins
  2. Stimulated whole salivary flow rate
    - Not of therapeutic significance however they can tell us if salivary stimulants are working. If not working, then saliva replacement methods are the best management option for oral dryness
    - Uses whole saliva
    - 15 mins
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29
Q

State a normal unstimulated salivary flow rate?

A

> 0.2ml/min

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30
Q

State a significantly reduced unstimulated salivary flow rate?

A

< or = 0.1ml/min

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31
Q

State a normal stimulated whole salivary flow rate?

A

> 0.4ml/min

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32
Q

What can NHS dentists prescribe if a patients stimulated salivary flow rate is significantly reduced?

A
  1. Artificial saliva pastilles DPF (Salivix)
    - combination of citric/malic acid
  2. SST (saliva-stimulating tablets)
    - can only be prescribed to patients who have impaired salivary function and patent salivary ducts.
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33
Q

List some sensible alternative medicaments (that aren’t provided by NHS dentists) that could be used to help with dry mouth symptoms:

A

Local:
- Sugar-free chewing gum/sweets
- Salivix plus pastilles (contain fluoride)
- Xerostrom pastilles
- Xylimelts

Systemic:
- Pilocarpine (acetylcholine esterase inhibitor) is prescribed by oral med specialists, rheumatologists, ophthalmologists, or GPs. Licensed for treatment of xerostomia following irradiation for H&N cancer, and dry mouth/eyes in Sjogren’s.

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34
Q

List 2 side effects of the drug Pilocarpine that is used to treat xerostomia following irradiation for H&N cancer, and dry mouth/eyes in Sjogren’s:

A
  1. GI disturbance
  2. Facial sweating
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35
Q

What prevention advice should you provide to your patient regarding dry mouth?

A

Explain to the pt that they are at higher risk of decay
Diet advice
Improve and maintain OH
Fluoride:
- Sodium Fluoride Mouthwash 0.05% (alcohol-free)
- Sodium Fluoride Toothpaste 0.619% or 1.1% (2800 or 5000ppm)

36
Q

Name 2 other complications of oral dryness:

A
  1. Bacterial Sialadenitis:
    - Usually an ascending infection
    - Acute onset salivary gland swelling
    - Gland tender to touch
    - Overlying skin may be erythematous
    - May be unpleasant discharge from opening of salivary gland duct
  2. Staphylococcal mucostitis
    - Can affect pts with severe oral dryness
    -
37
Q

What type of bacteria is normally involved in Bacterial Sialadenitis and Staphylococcal mucostitis?

A

Staphylococcus aureus

38
Q

How do you manage Bacterial Sialadenitis?

A
  1. Ideally obtain a sample of the pus by milking the gland to send for Culture and Sensitivity testing
    - not always possible
  2. Flucloxacillin is normally prescribed (targets staph aureus)
39
Q

How do you manage Staphylococcus mucostitis?

A
  1. Swab the affected area for C&S testing
  2. Prescribe antibiotics as appropriate
  3. Chlorhexidine mouthwash may be appropriate in patients with recurrent staphlococcus mucostitis
40
Q

What is Sialorrhoea?

A

Excess saliva production

41
Q

What can cause Sialorrhoea?

A
  1. Medication-related:
    - Strong association with medication that is used to treat schizophrenia, bipolar disorder and depression (Clozapine, Olanzapine, Venlafaxine, Quetiapine, and Risperidone)
    - Moderate association with antihypertensives: Enalapril, Haloperidol and Methyldopa
  2. Swallowing difficulties - seen in Parkinson’s
42
Q

What is Sialadenosis (Sialosis)?

A

Salivary Gland Swelling

43
Q

How might Sialadenosis clinically present?

A

Bilateral, symmetrical, diffuse parotid salivary gland enlargement.

44
Q

What may be the cause of Sialadenosis?

A
  1. Underlying systemic disease
    (diabetes, liver disease, bulimia, malnutrition)
  2. Pregnancy
  3. Idiopathic
45
Q

How is Sialadenosis diagnosed/treated?

A

Diagnosed clinically - doesn’t normally require specialist imaging

No treatment is required, apart from investigation to exclude underlying systemic causes - this may already be apparent in the patient’s MH.

46
Q

Which 2 different classification systems classify oro-facial pain?

A
  1. The International Classification of Headache Disorders Edition 3 2018 (ICHD-3)
  2. International Classification of Orofacial Pain 1st edition 2020 (ICOP)
47
Q

Which 6 groups can oro-facial pain be divided into?

A
  1. Orofacial pain attributed to disorders of dentoalveolar and anatomically related structures
  2. Myofascial orofacial pain
  3. Temporomandibular joint pain
  4. Orofacial pain attributed to lesion or disease of the cranial nerves
  5. Orofacial pains resembling presentations of primary headaches
  6. Idiopathic orofacial pain
48
Q

What can myofascial orofacial pain and temporomandibular joint pain be collectively known as?

A

Temporomandibular disorders

49
Q

What does the group ‘Orofacial pain attributed to disorders of dentoalveolar and anatomically related structures’ include?

A
  • Tooth-related pain
  • Pain from the periodontium
  • Pain from the oral mucosa
  • Pain from salivary glands
  • Bone pain
50
Q

Which 2 cranial nerves are most significantly affected by Orofacial pain attributed to lesion or disease of the cranial nerves?

A
  1. Trigeminal nerve
  2. Glossopharyngeal nerve
51
Q

Which 2 different conditions relate to pain attributed to lesion or disease of the Trigeminal nerve?

A
  1. Trigeminal Neuropathy
  2. Painful trigeminal neuropathies
52
Q

List the 3 different types of Trigeminal Neuralgia:

A
  1. Classical Trigeminal Neuralgia
  2. Idiopathic Trigeminal Neuralgia
  3. Secondary Trigeminal Neuralgia
53
Q

What causes Classical TN?

A

Neurovascular Compression (blood vessel contacting the nerve causing the pain)

54
Q

What causes Idiopathic TN?

A

No apparent cause

55
Q

What causes Secondary TN?

A

Underlying disease:
- Space occupying lesion (cyst or tumour in the brain)
- Multiple Scleorosis (causing demyelination)
- Other cause

56
Q

What are the main features of Trigeminal Neuralgia?

A
  1. Unilateral electric shock-like pains (bilateral is very unusual)
  2. Abrupt in onset and termination
  3. Limited to the distribution of one or more divisions of the trigeminal nerve - unlikely to be the ophthalmic division
  4. Can arise spontaneously but likely to be triggered by innocuous stimuli - ie. touch, air etc.
  5. Additionally, may be continuous background pain of moderate intensity within the distributions of the affected nerve divisions
  6. Patient may cry due to pain or have anxiety/depression as a result of the pain
  7. Patient may be anxious about the pain reoccurring once they have come off treatment
  8. May be severe enough to cause suicidal intention
57
Q

What is the role of the GDP when dealing with a patient that may have trigeminal neuralgia?

A
  1. Take a good patient history
  2. Exclude dental pain as a cause for the orofacial pain
  3. Acknowledge TN as a potential other cause
  4. May initiate medical treatment in conjunction with GMP and refer to a specialist service (local oral med department, or local oral maxfax department, or local neurology department) for a definitive diagnosis, investigations and further management.
58
Q

How is Trigeminal Neuralagia diagnosed

A
  1. History - almost exclusively reliant on pain history
  2. Examination - Identify trigger zone, should test the cranial nerves
  3. Investigations - High-resolution magnetic resonance imaging (MRI)
59
Q

What is the diagnostic criteria for Classical TN?

A
  1. Recurrent paroxysms of unilateral facial pain fulfilling the criteria of TN
  2. Evidence of neurovascular compression (MRI or during surgery) with morphological changes in the trigeminal nerve root.
  3. Concomitant continuous or near-continuous lower-grade pain in between attacks in the affected trigeminal distribution
60
Q

What is the diagnostic criteria for Secondary TN?

A
  1. Either purely paroxysmal pain or associated with concomitant continuous or near continuous pain
  2. Underlying disease demonstrated that is known to be able to cause, and explain the neuralgia
  3. Not better accounted to by another ICHD-3 diagnosis
61
Q

What is the diagnostic criteria for idiopathic TN?

A
  1. Either purely paroxysmal pain or associated with concomitant continuous or near-continuous pain
  2. Neither Classical TN nor Secondary TN has been confirmed by adequate investigation including electrophysiological tests and MRI
  3. Not better accounted for by another ICHD-3 diagnosis
62
Q

List 2 potential risk factors for TN?

A
  1. Smoking
  2. Hypertension
63
Q

Which division of the trigeminal nerve is it most rare for TN to occur in?

A

The ophthalmic division

64
Q

What pharmacological treatment can be used to treat TN?

A

First line:
1. Carbamazepine (Tegretol)
2. Oxcarbazepine

Second Line:
1. Lamotrigine
2. Baclofen
3. Gabapentin
4. Pregabalin

65
Q

Which guidelines should you use for safe prescribing?

A

SDCEP and BNF

66
Q

What type of drug is Carbamazepine?

A

An anticonvulsant

67
Q

How does carbamazepine work?

A

It works by binding to voltage-dependent sodium channels - this inhibits AP generation

68
Q

Where is Carbamazepine metabolised?

A

In the liver by enzymes from the cytochrome group CYP3A4

69
Q

Why can a reduction of drug efficacy be seen in the first 2 weeks of Carbamazepine treatment?

A

Because Carbamazepine induces its own metabolism.

70
Q

Where is carbamazepine excreted?

A
  • Predominantly excreted in urine
  • The remainder is excreted in the faeces
71
Q

What is Carbamazepine licensed in the use for?

A

Epilepsy and Bipolar Disorder

72
Q

What should patients or their carers be given specific advice about following the prescription of carbamazepine?

A

How to recognise disorders of the liver, skin, and bone marrow.

73
Q

List some known contraindications/interactions of carbamazepine:

A
  1. You should NOT prescribe to patients of Han Chinese or Thai origin without testing for HLAB*1502 allele - this is due to the increased likelihood of Steven Johnsons syndrome (extensive skin and mucosal ulceration and blistering)
  2. Pregnancy (can cause congenital malformations)
  3. Hepatic and renal impairment (caution and monitoring is required)
  4. Cross sensitivity with other anticonvulsants
  5. Interacts with numerous herbal medicines (e.g. St John’s Wort, alcohol and grapefruit)

ALWAYS CHECK BNF BEFORE PRESCRIBING ANYTHING!!

74
Q

What must be carried out before prescribing Carbamazepine and why?

A

Liaise with GMP and arrange for baseline blood tests - FBC, LFT, C&E’s

This is because carbamazepine can adversely affect the bone marrow, liver and renal function.

75
Q

Can GDP’s working for NHS prescribe Carbamazepine?

A

Yes

76
Q

When should you consider reducing a patients dose of Carbamazepine?

A

Once they’ve been pain-free for 4 weeks.

77
Q

How frequently should you monitor the patient’s bloods when they are taking Carbamazepine?

A

No set regime - however suggest FBC, LFTs, and C&Es weekly for the first 4 weeks of treatment, 1-3 months after this

78
Q

When would you consider using Oxcarbazepine?

A

If Carbamazepine is contraindicated, not tolerated by the patient, or provides inadequate pain relief

Note - Unlike Carbamazepine, this cannot be prescribed by GDPs working under the NHS!!!

79
Q

What additional therapeutic management can be prescribed by GDPs working under the NHS?

A
  1. Lidocaine spray for maxillary pain - 10mg/dose
  2. Lidocaine 5% ointment - applied to trigger point as required
  3. Lidocaine 2% 1:80,000 adrenaline as infiltration/block to trigger point
80
Q

Which other services may provide additional support to those suffering from severe pain due to TN?

A
  • Psychological support
  • Nurse specialists in the neurology department or within the local pain service
  • National support groups (Trigeminal Neuralgia Association UK - https://www.tna.org.uk/)
81
Q

When would surgical management be considered for patients that have TN?

A

Where:

  1. Medical management has been ineffective, or the medications have been not tolerated/contra-indicated.
  2. In patients where there is short/no pain-free periods, complications and adverse impact on quality of life
82
Q

Name the 2 types of surgery that can be carried out for patients with TN?

A
  1. Palliative destructive at the level of the grasserion ganglion
  2. Posterior cranial fossa surgery
83
Q

When is palliative destructive surgery at the level of the grasserion ganglion more favourable?

A

When neurovascular compression is NOT evident

84
Q

Which type of TN is posterior cranial fossa surgery most favourable for?

A

For Classical TN where there is evidence of neurovascular compression.

85
Q

Which red flags indicate the need for urgent referral to secondary care in a TN case?

A
  1. 28 sensory or motor deficits
  2. Deafness or other ear problems
  3. Optic neuritis
  4. History of malignancy
  5. Bilateral TN pain
  6. Systemic symptoms (e.g. fever, weight loss)
  7. Presentation in pts under 30
86
Q
A

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