Oral Medicine Flashcards
(32 cards)
Patient presents with dental pain without detected pathology which follows a distinct pattern - diagnose and what may you do?
Atypical odontalgia
- referral from primary care to OM Specialist
- aim to reduce chronic pain and reduce outbursts of pain
- high intensity short duration opioid analgesic
- tooth extraction if necessary
Alcohol and oral cancer
- give alcohol and oral cancer risk advice
- give alcohol cessation advice
Oral cancer foundation
- found that alcohol abuse is the 2nd largest risk factor for development of oral cancer
- found that alcohol increases cell permeability allowing further carcinogens such as cigarette smoke to take effect
- nutritional deficiency from drinking also a risk factor
The lancet publication 2018
- describing alcohol use and its relation to 4 types of oral cancer, and even 1 drink per day raises relative risk of developing these
- alcohol damages cells repairing themselves resulting in DNA changes which may result in oral cancer
Alcohol and your health
- increased risk of many cancers
- causes increased tooth decay and tooth wear due to acidity
Limits of alcohol
- 14 units per week is the maximum recommended limit, spread over at least 3 days
- at least 2 alcohol free days per week
Intervention
- ask how much they drink
- advise that they are over the limit, and of the heath risks associated with this
- assess their willingness to quit
- appropriate referral / document referral
Patient presents with this, what is advice and management? Diagnosis?
Oral cancer foundation
- found that alcohol abuse is the 2nd largest risk factor for development of oral cancer
- found that alcohol increases cell permeability allowing further carcinogens such as cigarette smoke to take effect
- nutritional deficiency from drinking also a risk factor
The lancet publication 2018
- describing alcohol use and its relation to 4 types of oral cancer, and even 1 drink per day raises relative risk of developing these
- alcohol damages cells repairing themselves resulting in DNA changes which may result in oral cancer
Alcohol and your health
- increased risk of many cancers
- causes increased tooth decay and tooth wear due to acidity
Limits of alcohol
- 14 units per week is the maximum recommended limit, spread over at least 3 days
- at least 2 alcohol free days per week
Intervention
- ask how much they drink
- advise that they are over the limit, and of the heath risks associated with this
- assess their willingness to quit
- appropriate referral / document referral
Patient presents with lichen planus - explain what it is and treatment options
Oral lichen planus (OLP) is a chronic inflammatory condition that affects the mucous membranes inside the mouth.
- It is considered an autoimmune disorder where the immune system mistakenly attacks the lining of the mouth
- The cause is not fully understood, but it is believed that genetic, immune, and environmental factors may contribute to the condition.
- sometimes there cna be reactions to silver fillings or certain medications - when this is the case it is called an oral lichenoid lesion
Management
- LP can be pre-malignant, so it is important we monitor this along with your symptoms
- start by avoiding SLS containing toothpaste
- symptoms can be managed by difflam spray
- more persisting lesions may require steroid treatment from the oral medicine department
- i will refer you to OM for some diagnostic testing and likely a biopsy
- any questions?
27-year old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size. Using this information and the available lab results (Patient has low iron and folate).
Discuss the lab findings, the diagnosis and management options for this condition with the patient. You do not need to gain any more information from the patient.
Diagnosis - recurrent aphthous stomatitis - minor ulcers
- you previously were in complaining of the ulcers
- would you like me to go through your lab work?
- follwoing tests, you are low in iron and folate, these can typically result in ulcers forming in the mouth
- reassure nothing sinister
Anaemia
- reduction in iron resulting in fewer number of red blood cells
- multiple aetiology such as low iron in diet or stomach ulcers resulting in loss of blood / poor absorption
Management
- increase in iron in diet and take iron supplements
- gp can provide these and monitor your iron
Diet advice
- meat and fish - iron rich
- dark leafy greens - iron rich
- Vit C - help absorb iron
Summary
- reassure pt this is common
- ulcers should go away within 2 weeks
- we know cause and can manage them
- any questions?
Pt diabetic and taking Warfarin - Give findings and explain Tx (6 mins).
A patient has a sore denture and sore palate, test done previously to confirm condition and you have received the results.
Medical history includes diabetes type 2 and on warfarin for atrial fibrillation. Explain findings to the patient, recognise the multifactorial condition and provide oral hygiene advice.
Diagnosis - denture stomatitis
Inform what it is
- fungal infection of the palate - multifactorial
Risk factors
- leaving denture in at night
- poor oral hygiene or denture hygiene
- steroid inhaler
- immunocompromised
Advice
- brush your palate
- brush and clean your denture after meals with non abrasive denture cleaner and soft brush
- take denture out at night, and clean your denture with denture cleaner, and store in water overnight
- if using steroid inhaler, rinse afterwards or use a spacer device
- limit smoking
Antimicrobial prescription
- pt on warfarin so avoid azole
- use nystatin oral suspension or CHX
Take a history of a patient suffering from dry mouth
What are the usual presentations
- what management options can i provide?
History
- how long had dry mouth
- how is it affecting them and in what way?
- what medications are they on? - amitriptyline
- what is their medical history?
Usual features / symptoms
- swallowing difficulty, speech issues, discomfort, altered taste, cervical caries, bad breathe
Management
- small frequent sips of water or such on an ice cube
- chew on sugar free chewing gum
- write to gp to change medication regime
- stop smoking / alcohol
- manage cervical caries with high fluoride toothpaste and fluoride varnish
- reduce caffeine
Prescription
- biotene saliva replacement
- salivix pastilles
- saliva gel
- all on SDCEP
Biopsy results = dysplasia - give results and advice
Inform patient that from biopsy indicates that there is potential for the tissue to be cancerous, but it is not cancerous YET
- ensure they understand the risk of it becoming cancerous
- cancer risk can be reduced by lowering risk factors for cancer
- provide alcohol and smoking cessation advice
- provide oral hygiene instruction
Facial palsy after IDB, how manage
Causes
- injection in parotid sheath, prolonged anaesthesia of facial nerve
How to test
- test branches of facial nerve
Symptoms
- generalised weakness ipsilateral face drooping mout, unable to blink
Inform patient what has occurred, reassure them
- cover eye with eyepatch until blink reflex returns
OFG (6 mins). History of patient given - swollen lips all his life. Chat through history, ask and ascertain local and systemic signs. Chat about how you would manage it going forward.Asked patient about any bowel problems he said yes, informed of potential Crohn’s.
● OF
OFG = orofacial granulomatosis
- blockage of lymphatic drainage causing swelling of the face
Autoimmune disease
- type 4 hypersensitive to additives in food
- benzoates, chocolate, SLS
Symptoms
- swelling lips, cobblestone mucosa, angular chelitis, ulceration
History
- weight loss / bowel issues?
Diagnosis
- refer for patch testing
Management
- dietary avoidance, steroids, azathioprine
Patient mentions yes to bowel problems
- possible crohns - inflammatory disease of GI tract
- refer to GP
Pt with suspected cancer in high risk site, Name the different H+N lymph nodes you would feel in an E/O exam, history I may take and how to inform them.
Pre-auricular
Posterior auricular
Parotid
Submental
Submandibular
Deep cervical - by sternocleidomastoid
History
- how long lesion been there
- is it symptomatic
- hoarse voice, limited mouth opening, tooth mobility /occlusal derangement
- smoker, alcohol
Urgent 2 week cancer referral for
- biopsy
Explain to pt that
- they will give la, take small sample of tissue from the lesion, or take it all.
Risk factor management
- smoking cessation and alcohol consumption advice
What are the urgent cancer referral guidelines?
Persistent unexplained head and neck bumps for >3 weeks
Ulceration or oral mucosa lesion unexplained for >3 weeks
Persistent hoarseness for >3 weeks
Dysphagia for >3 weeks
Persistent throat pain >3 weeks
What are the 5 types of candida infection? Their presentations?
Candida leukoplakia - chronic hyperplastic candidiasis
- commissures of mouth
- white leukoplakia - cannot be rubbed off
Chronic erythematous candidiasis - denture stomatitis
- red erythematous palate under denture bearing area
Acute erythematous / atrophic candidiasis - antibiotic sore mouth
- from chronic steroid inhaler / immune suppression / HIV etc
Acute Pseudomembranous candidiasis - oral thrush
- sleuth that can be rubbed off
Angular chelitis
What are the histological and cytological changes seen in low grade dysplasia?
Low grade dysplasia
- architectural changes only into the bottom third
- easily identifiable squamous epithelium
- cytological atypia or dysplasia may not be prominent
- considerable keratin production
- stratification evident
- well defined tumour islands
- well formed basal cell layer
Whats histologically seen in high grade dysplasia?
- little resemblance to normal epithelium
Upper third architectural changes
Considerable atypia
Non cohesive invasion pattern
Prominent mitotic figures
Prognostic factors of histology in cancer?
Pattern of invasion
Depth of invasion
Perineural invasion
Vessel invasion
Histology of lichen planus?
Civatte bodies - dead keratinocytes
Thick band of lymphocytes under epidermis
Para / orthokeratosis
Saw tooth rete ridges
What is shingles?
Its symptoms?
How you’d identify?
Management?
Shingles is reactivation of VZV - chickenpox when you’re younger
- it is dormant in cranial nerve or dorsal root ganglia
- activation due to immune suppression/stress
Symptoms
- painful unilateral vesicular rash along distribution of the nerve
Presentations to dentist
- unilateral vesicles along nerve branch
- prodromal symptoms that can mimic dental pain or pulpitis
- erythematous rash with clustered vesicles
- Unilateral and respects midline
- local lymphadenopathy common
Tx
- aciclovir
- defer dental tx
- otc pain relief
It is transmissible through contact of vesicles
Shingles is reactivation of VZV - chickenpox when you’re younger
- it is dormant in cranial nerve or dorsal root ganglia
- activation due to immune suppression/stress
Symptoms
- painful unilateral vesicular rash along distribution of the nerve
Presentations to dentist
- unilateral vesicles along nerve branch
- prodromal symptoms that can mimic dental pain or pulpitis
- erythematous rash with clustered vesicles
- Unilateral and respects midline
- local lymphadenopathy common
Tx
- aciclovir
- defer dental tx
- otc pain relief
It is transmissible through contact of vesicles
Give places someone who exceeds weekly alcohol units can be referred to or signposted to
GP
NHS inform - information on alcohol and services across Scotland
With you - free and confidential support, local support groups and online chat
Drinkline - national helpline offering advice and information
Alcoholics Anonymous - free self help 12 step programme
Where can smokers be referred / signposted to?
Quit your way - free confidential advice
Community pharmacies - NRT and advice
NHS quit smoking app - personalised support
GP
What is EM And its presentation?
Acute onset hypersensitivity type 4 reaction
- skin rash with target like lesions
- often from HSV-1, drugs such as allopurinol, carbamazepine, NSAIDS, phenytoin
Minor or major presentation
Often in ages 10-40
Management of EM?
Refer to OM for advice immediately
- topical steroids for minor lesions
- Systemic for more serious
Adjunctive oral care
- CHX, OHI, difflam
Antihistamines for skin itch
Stop any obvious trigger
