Oral medicine Flashcards
(21 cards)
Denture induced stomatitis (6 mins)
Patient diabetic and taking warfarin. Give findings and explain treatment.
A patient has a sore denture and sore palate, test done previously to confirm condition and you have received the results.
Denture induced stomatitis affecting the hard palate, providing with picture showing this as well as results of a swab.
Medical history includes diabetes type 2 and on warfarin for atrial fibrillation.
Explain findings to patient, recognise the multifactorial condition and provide oral hygiene advice. You can ask relevant questions to the actor, but you don’t need to take another medical history.
~ introduction
~ Findings
* Lab results have come back from the swab taken in last visit , I can confirm that your diagnosis is something we call denture induced stomatitis
* It is an inflammation of the gum contacting the denture as a result of yeast or fungal infection (which accumulate under the denture)
* It is caused by poor denture and oral hygiene
* Do you clean your denture after every meal ?
* Do you leave your denture out at night?
* Poorly controlled diabetes is linked to a weakened immune system which can increase the risk of developing oral fungal infections
~ Management
- Local measures alone can treat this condition, if this does not work we can prescribe some medication to treat this
- As you are taking warfarin, typical antifungals will interact with it , so you will be precribed nyastatin = remove dentures, rinse and retain around area for 5 mins then swalllow it
- Denture hygiene advice ; leave your denture out as much as possible to allow the area to heal. Soak dentures in chlorhexidine for 15 minutes twice daily. Rinse and brush your denture after every meal with soapy water. Do not wear your denture when sleeping.
- Before brushing rinse your mouth for 1 minute . When brushing your teeth lightly brush the roof of your mouth.
- We can alse assess your denture and modify it if it fits poorly
- A parent brings their child to the clinic. The child is not feeling well and is distressed. [6]
The child has a clear medical history. Below are clinical photographs of the presentation.
Please carry out the following:
a) take a history of the child’s presentation;
b) inform the parent of the diagnosis;
c) discuss the ways in which this condition can be managed;
- History
^ when did the symptoms start
^ Any fever
^ Is the child less active than normal
^ Use of analgesia? did it work? - Symptoms of PHG
Lymphadenopathy, malaise, fever , red gingivae , ulceration, loss of appetite , refuse to eat or brush - Diagnosis from photograph
~ Primary herpetic gingivostomatitis
~ Contagious primary infection caused by herpes simplex virus
~ will disappear within 7-10 days
~ it is very common and there is a high carriage rate in the population
^ most often occurs in children as a first exposure resulting in this diagnosis
~ most initial infections are subclinical but can present as this
^ usually it has no symptoms
^ often will present as blisters on tongue, cheeks, gums , lips and roof of the mouth
^ After the blister pops ulcers will form
^ Other symptoms include pyrexia, difficulty swallowing, drooling and swelling
^ dehydration can occur due to difficulty eating/drinking
~ child may or may not develop cold sores in the future - Management
~ Reassure
~ increase fluid intake
~ Analgesia to control fever and pain ( paracetamol/ ibuprofen/ benzydamine mouthwash)
~ allow plenty time for bed rest and take it easy
~ Clean teeth with damp CR and rub around gums
~ As the child only have symptoms for 3 days and otherwise is fit and healthy; antiviral medication isnt indicated
** if severe or immunocompromised then referred to hospital
- A 27-year old patient presents to your practice at a follow up appointment regarding his soft tissue lesions. He is complaining of sore ulcers throughout the mouth. [6]
On examination there are multiple round ovoid grey base ulcers with an erythematous halo, no larger than 10mm in size which the patient says have persisted for around a week. The patient reports that they frequently get these ulcers and finds it very difficult to eat when they are present, but they completely go away within 2 weeks.
A clinical photograph was taken of the patient at presentation.
A blood test was taken a few days ago as further investigations which is included below.
You do not need to gain any more information from the patient.
Given the above information, discuss with the patient:
a) the lab findings and the diagnosis for the patient’s presentation
b) the appropriate management options for the patient’s condition
~ introduction
~ Describe lab findings
* we have a blood test that was taken a few days ago
* low iron and folate
* low Hb , low red blood cells count, low MCV
* What we can see from the lab findings shows that you are showing signs of anaemia due to iron and folate deficiency
~ Diagnosis
* Minor recurrent apthous ulcers which is a condition associated with the development of recurrent ulceration affecting up to 20% of the population, mostly people who are under 30 years old.
* mostly the cause is unkown but it can be associated with anaemia, vitamin deficiencies, stress , smoking
* Symotoms include pain that can be worse with hot/spicy/ hard food and issues with eating and speaking.
~ Management
* Increase intake of foods that are contain iron and folate( leafy greens , fruits ,red meat)
* Avoid spicy, acidic , hard food and SLS containing toothpaste
* For pain relief you can use a numbing mouth wash called difflam (benztdamine)
* You can also use CHX mouthwash to prevent infections
* We can refer you to oral medicine for further investigations ( biopsy, coeliac screen and viral screens)
* In severe cases OM might prescribe topical steroids
* If the lesions persist for more than 3 weeks it need to be investigated by specialist
Other than anaemia , what could cause minor apthous ulcers?
~ Diet ( sorbates and benzoates, cinnamonaldehyde)
~ Systemic disease ( coeliac or crohns)
~ Trauma
~ allergies
~ SLS in toothpaste
White Patch FOM (6mins)
Discuss the need for biopsy and possibility of oral cancer
Discuss patient risk factors (smoking and alcohol)
~ Introduction
~ Findings
* “during the exam i have noticed a white patch in the floor of your mouth”
* “have you noticed it before? does it give you any symptoms?”
~ Causes
* “ several causes , such as rubbing of the lining with hard food or something which can thicken the lining of your mouth , certain fillings may cause a reaction , genetics and some health conditions such as Lupus or cancer”.
* “ The site of youur lesion is in a high risk area for mouth cancer which needs to be investigated just to make sure everything is fine”
* “ also given that you smoke and drink , this increases the risk of oral cancer by 5 times “
* I would make an urgent referral to oral medicine where they will take a biopsy of the lesion (explain how)
~ Management
* Refer to OM for biopsy + today we will take pictures of the lesion to include in the referral form
* Alcohol advice , alcohol makes you at higher risk for developing cancers , heart disease and liver disease , would you be interested in cutting down or stopping drinking?
* Smoking is linked to strokes , heart attacks , lung conditions and cancer , would you be interested in stopping?
Primary Herpetic gingivostomatitis (6mins)
Teen with systemic involvement - prescribe med
- When is aciclovir prescribed
~ immunocompromised or severe infection in the non immunocompromised
^ Refer immunocompromised with severe infection to the hospital - Primary response to herpes simplex
~ Sore throat with enlarged LN
~ Malaise and fever
~ ulcers / blisters
~ self limiting and will heal within 7-10 days - Aciclovir prescription
Aciclovir tablets 200mg
Send 25 tablets
1 tablet 5 times daily for 5 days
Lymph node exam for cancer suspicion , Urgent referral 6 mins
Extra-oral checking for swollen lymph nodes. You should be able to name the different nodes.
You get given a picture of a lesion (probably FOM) and you need to take a brief history from actor and tell them it could be sinister.
Need to console patient and tell them they’ll be referred urgently and what happens next.
- LN palpation
~ Preauricular
~ Posterior auricular
~ Parotid
~ Tonsillar
~ submental
~ Submandibular
~ Deep cervical
~ Supraclavicular
~ Posterior cervical
~ Superficial cervical
~ Occipital - Take history of lesion
1. when did you notice the lesion
2. any symptoms of discomfort
3. is it changing in size/color/ texture
4. Is it present elsewhere?
5. any weight loss, hoarseness of voice or difficulty swallowing?
6. ask about mh/sh/dh - Discuss the lesion
~ “ The lesion on the FOM have many possible causes, some are harmless but some may be more serious and potentially cancerous”
~ “ As this is area is high risk and you have other risk factors , it would be appropriate to refer you on to have this looked up”
~ “ in order to be sure, i will make an urgent referral to OM where they will take a biopsy - Discuss what they’ll expect in OM
- Give post op advice
- Manage risk factors (smoking and alcohol)
What are the scottish referral guidelines for oral cancer?
- Emergency referral if stridor
- Urgent referral if ;
~ Persistent unexplained head and neck lumps for more than 3 weeks
~ Unexplained ulceration or unexplained swelling/induration for more than 3 weeks
~ persistent white/red/mixed patched for more than 3 weeks
~ persistent hoarseness present for more than 3 weeks
~ persistent pain in the throat or pain on swallowing for more than 3 weeks
SCC - breaking bad news
- ” high my name is X and I am X “
- I am going to speak to you about the lesion we’ve recently discovered in your mouth , are you happy to discuss this with me? what has happened so far?
- We took a biopsy to find out what this could be , have you had any idea what this biopsy might show?
- Lesions that are similar to the one in your mouth could be a result of several things such as trauma or infection but sometimes could be a result of more serious conditions
- I have got the results of your test with me today, is it okay for you discuss these?
- As you know we took a biopsy and unfortunately the results are not as we hoped , i am sorry to tell you this but the results show that you have a type of mouth cancer called squamous cell carcinoma
- I know that this isn’t what you wanted to hear , i can see that this is a huge shock for you, i am so sorry
- Does this makes sense to you? do you have any questions for me?
- would you like me to explain what treatment to expect next?
- I want to reassure you that you will be referred to appropriate people to deal with this (explain what MDT is)
- They will take further samples to get a better understanding of the spread of the disease
- After this the tx options may include radiotherapy, chemotherapy or surgery or a combination of these
Surgery - remove the lesion
Chemo - drugs that kill dividing cells such as growing cancer cells
Radio - high energy rays to treat cancer by destroying cancer cells
- Again , i am so sorry to break this news to you , would you want me to help by telling you family members about the diagnosis?
- I want to highlight that there are support groups on the internet such as forums on cancer research uk
- Do you have any questions for me ?
Giving biopsy results - Epithelial dysplasia - alcohol (6mins)
Biopsy result = dysplasia
Discuss diagnosis and give advice regarding alcohol intake
~ Introduction
* are you aware of what this visit is about?
* We have recieved the lab results back and I can give you the good and bad news today
~ Explain diagnosis
- Sample has come back as positive for epithelial dysplasia
- meaning that the cells in the lesion on your cheeck are replicating abnormally
- The good news is that this condition is not cancerous at the moment and can be treated effectively now
- The bad news is that it has a high risk of becoming cancerous if left untreated, this diagnosis also puts other parts of your mouth at high risk of developing a similar diagnsis
” alcohol and smoking is linked to the development of cancer
~ Alcohol advice
F - Your alcohol consumption coupled with the diagnosis puts you are higher risk of developing cancer if you do not stop or cut down your consumption of alcohol
R - This will not be easy, however nobody can make this choice for you, it is up to you to make a change
A - I strongly advice you limit your drinking or stop altogether to reduce the risk of the lesion becoming cancerous, no more than 14 units per week , with 2 to 3 drink free days, stopping altogether is the best option here
M -
1. Different strategies work for different people , there are some local and online services to help with stopping drinking that you can self refer to.
2. Alcoholics Anonymous is also a free support group that follow a 12 step programme for getting sober
3. You can reach out to your GP or phramacy for further advice
4. we can provide you with a booklet about the different services available locally
E - This will be a difficult change but you are not alone in this, we are here to support you with your journey
S- many people successfully cut down on alcohol / stop. With the right support and information i am sure that you can do it.
Management
- alcohol advise
- fruit and vegetable diet
- emergency referral to OMFS for excision
OFG (6mins)
- An adult patient presents to you complaining of lip swelling which he has suffered with all his life. [6]
On examination the patient has numerous deep penetrating ulcers and cobblestone-like buccal mucosa, along with evidence of lip swelling and fissuring.
Discuss with the patient the history of their presentation to gain further insight into their condition. Provide the patient with appropriate advice and management options for their condition.
~ Introduction
~ History taking
- Have you noticed any similar fissuring otherwise in your mouth?
- Do you have bowel problems such as diarrhoea, abdominal pain or blood in your stool?
- Do you have any known food intolerences?
Has anyone in your family suffered with IBS or Crohns?
~ Diagnosis
- “What we are seeing with your mouth is a condition called orofacial granulomatosis “
- which is a collection of immune cells that has built up causing swelling in the mouth. It is a process driven by your immune system which may be overreacting to certain things
- OFG has a very similar presentation to a chronic inflammatory bowel condition called Crohn’s disease.
- Crohn’s disease can affect the whole body and the quality of life, Screening for it might be essential in the management of OFG
~ Management
- I am going to refer you to oral medicine for Crohn’s disease ( Faecal calprotein and endoscopy)
- I also want you to avoid certain foods as they are associated with this disease such as food containing additives , benzoates , sorbic acid , chocolate and cinammon
- For the pain, you can use a numbing mouthwash called difflam which we can prescribe
- We can also prescribe some topical steroids such betamethasone MW
- In severe cases , systemic steroids are prescribed by a specialised dentist
A patient has attended your practice for a routine extraction of their lower left first molar. The patient has been fully consented for the procedure. [6]
You have just finished an inferior-dental block and lingual block of the left hand side of their jaw. As you are waiting for the local anaesthetic to work, the patient starts to report pain in their left ear and gradual slurring of their speech.
Asking the appropriate questions, investigate the symptoms the patient is experiencing and provide the appropriate management for the acute presentation.
~ Introduction
~ Investigations
- Are you able to raise both eyebrows (no)
- Are you able to raise both arms? (yes)
- Can you close your eyes, blow out your cheeck , smile and purse your lips?
- Do you have any history of shingles / Herpes simplex virus / lyme disease? no
- Is this the first time this has happened ? yes
~ Diagnosis
- Bell’s palsey from IDB injection , unfortunately the numbing injection was injected in a nerve bundle which has caused the nerves to be temporarlity paralysed , i want to reassure you that this is not a stroke and can be managed easily.
- As this progresses you can expect the left helf of your face to feel numb and you may not be able to blink, you may also experience drooling and difficulty earting on the LFH
~ management
- We’ll stop the current treatment and continue after this issue is solved with the treatment
- Cover the left eye until you are able to blink again with an eyepatch to protect it , you can also wear sunglasses
- You can use artificial tears every 2 hours in the affected eye
- you can use eye oitments in that eyes following the instructions
- if it becomes worse or both sides are affected then seek immediate advice
- I will review you in a couple of weeks (3 weeks) and if there are no improvement then I will make a referral to a specialist for this to be looked at
Other than LA , what can cause bells palsy?
- Trauma
- Infection (herpes zoster or otitis media
- idiopathic
- Diabetes
Prednisolone would reduce swelling and inflammation caused to the facial nerve
A 58-year old patient presents to you complaining of a dry mouth. [6]
She mentions how the dry mouth is uncomfortable and has woken up at night because of it. She mentions how it has caused he issues with her job as a teacher in a local primary school.
On examination the oral mucosa is glossy and there is generalised mild plaque buildup, with a visible reduction in saliva which has a sticky consistency.
Discuss with the patient their complaint by gathering further C/O history and relevant medical history.
~ Introduction
~ history taking
* When did the symptoms start?
* When is it dry the most during the day?
* Do you have difficulty eating?
* Is there any pain associated with the dryness?
* have you noticed a change in your taste?
* Are you on any medications?
* Do you have any health conditions i should be aware of?
~ Diagnosis
- drug induced dry mouth (xerostomia) , caused by amytriptyline, this medication is linked to reduced saliva production
- There are many risks associated with dry mouth such higher risk of developing decay as normally saliva help washout plaque and buffer acids , also linked to higher risk of gum disease. It can also cause difficulty swallowing and issues with denture retention.
~ Management
- important to clean plaque thoroughly with brushing twice a day with fluoride toothpaste, we can prescribe you with a high F TP , it is important to have regular dental check ups
- Keep well hydrated by taking regular sips of water throughout the day
- Avoid alcohol and caffeiene as they may contribute to dry mouth
- you can chew sugar free gums to stimulate saliva production
- you can also use saliva subtitutes such as biotene
- I will also contact your GP and let them know of this , and see if they can replace your medication with another one.
What are the usual features and symptoms of dry mouth?
- Difficulty swallowing
- Clicking speech
- Discomfort in mouth
- Altered taste
- Cervical caries
- Halitosis
- Candidiasis
- Denture control issues
- Food debris in mouth
- Depapillation of tongue
- Infections of major salivary glands
Management of dry mouth
- Treat cause
^ hydration
^ Chew gum
^ Modify drugs
^ Control diabetes
^ Reduce caffeine/ smoking/alcohol
^ Change to SLS free toothpaste - Prevent disease
^ Caries - OHI
^ Candida infections - CHX MW - Salivary subtitutes
^ Saliva orthana
^ Biotene
^ Bio extra - Salivary stimulants - pilocarpine
- Cantact GP for medication change possibility
A 52-year old patient presents to you complaining of stinging sensation in the mouth, which is most noticeable when eating some fruits. [6]
History taking reveals the symptoms started 2 months ago and is now getting more noticeable. The discomfort is intermittent and worsens with citrus food.
The patient takes lisinopril for high blood pressure. They have no known allergies.
On examination, presence of bilateral erythematous changes of buccal mucosa with white fine striae. There is evidence of desquamative gingivitis in the posterior region.
Your provisional diagnosis is oral lichen planus.
Given the above information:
a) discuss with the patient oral lichen planus and what is causing their symptoms
b) discuss the management options and what you wish to do going ahead
~ Introduction
~ Diagnosis
“ the provisional diagnosis is oral lichen planus which is an immune condition where your body reacts to certain stimuli causing red or white patches in the mouth. It is mainly non concerning but some oral presentations have been linked to higher risk of cancer ( Erosive or atrophic) “
“ It can be painless but sometime may cause pain”
“ This condition acts like an alllergic reaction, meaning certain foods or substances can cause irritation to the mouth lining such as spicy or acidic food”
“ There is 1% risk of it to develop to cancer over 10 years , the risk is increased if you smoke or drink”
~ Management
- Avoid spicy , acidic and alcohol
- Use SLS free toothpaste
- We can prescribe a numbing mouthwash to help with the pain
- We can also prescribe a steroid mouthwash to help with inflammation
- I would take some photographs are refer you to oral medicines where they can take further investigations such as a biopsy or blood tests to confirm the diagnosis
Any questions?
In front of you is a patient who is represented by a phantom head. [6]
Perform an exam of the trigeminal and facial nerve on the simulated patient, mentioning out loud any specific instructions you would normally ask the patient to perform.
~ Trigeminal nerve tests
* Hands on the side of face, tell patient to clench and release
* Open mouth while applying resistance under jaw
* close your eyes and say yes every time you feel ( brush brow, feel zygoma area , lower lip and chin
* Stick tongue out , and brush tongue bilaterally
~ Facial nerve checks
- Raise eyebrows
- close eyes
- puff out cheeks
- smile
- purse your lips
- any changes to taste recently?
- any changes to hearing?
Candida Leukoplalia / chronic hyperplastic candidosis
Advice and management
- Fungal infection of the cheek side of the mouth
~ seen most commonly on the angles of the mouth
~ caused by candida albicans
~ Can be potentially malignant - Risk factors
~ Poor OH
~ Inhalers
~ Poor diet
~ Diabetes
~ Deficiency
~ Dry mouth
~ ABs
~ immunosuppression
~ Dentures - Management ; potentially malignant so need to refer to OM for systemic antifungals
~ incisional biopsy - refer
~ OHI , diet advice (less carbs) , rinse mouth after inhaler
~ Correct deficiency and control diabetes , stop smoking and correct denture faults
~ Systemic antifungals (7 days) - Fluconazole
Alcohol and oral cancer actor
Discuss publications and papers with patient relating to alcohol limits and oral cancer risk
- Alcohol link with oral cancer
~ The oral cancer foundation have found out that alcohol abuse (more than 21 units per week) is the second largest factor in the development of oral cancer
~ Alcohol has been found out to dehydrate the cell walls enhancing the ability of other toxins such as tobacco carcinogens to penetrate the mouth tissue
~ Nutritional deficiencies associated with heavy drinking can lower the body natural ability to use antioxidants to prevent formation of cancers
~ this establishes that smoking+ poor diet + alcohol can significantly increase the risk of developing cancer
~ The lancet in 2018 also published a paper describing how alcohol use is linked to four types of oral cancer and even one drink a day can increase the risk of developing these , they described how alcohol damages cells which then try to repair themselves leading to DNA changes that could be the step towards oral cancer
- Alcohol health effects
~ Increase risk of multiple cancers “ oral , stomach , liver, colon , rectum”
~ Decay and toothwear due to sugars and acid in alcohol
~ heavy alcohol use can cause injuries and facial trauma - Alcohol limits
~ no more than 14 units a week
~ Spread drinking over 3 days , at least 2 alcohol free days
~ 14 units = 6 pints of beer , 10 wines , 14 shots - Alcohol brief intervetion
~ Raise the issue about drinking , how much do you drink on a weekly basis
~ Screen and give feedback of risks
“ you are having more than the recommended limit which puts at greater risk of several health problems etc….”
~ Ask if they would like help then refer
- A 56-year old patient presents to you complaining of pain on the right hand side of their face for the last three weeks. [6]
She mentions the pain feels like a severe sharp electric-shock-like pain, which happen especially when brushing her teeth or wearing a scarf. OTC pain relief not working.
Medical history reveals she has hypertension which is well controlled with diet, with no history of diabetes or trauma.
On examination, there is mild tenderness on palpation over the right infraorbital region, with hypersensitivity on light touch of the right cheek and upper lip. Patient has normal motor function. There are no signs of autotomic features.
Intraorally there are no abnormalities, including no caries, no TTP, absence of signs of bruxism and no signs of periodontal disease.
Given the above information:
a) discuss with the patient the provisional diagnosis for the above symptoms
b) give the appropriate management option for their symptoms
~ introduction
~ Take pain history ( suspect TN)
~ Explain provisional diagnosis
- TN is a chronic pain dcondition affecting the nerve that supplies your the skin over your face and your teeth as well as the chewing muscles
~ Causes
- It can be caused by compression of the nerve by a blood vessel or due to an underlying health condition such MS or shingles
~Typical symptoms
Sharp electric like pain affecting one side of the face , can be triggered by cold wind or touching the face but sometimes it come on randomly
~ Management
- We can prescribe you caramazepine for 5 days and if the symptoms are resolved then we can confirm the diagnosis
- There are some side effects associated with this medication such as fatigue , confusion, liver toxicity and blood abnormalities
- That is why it is important to take some blood tests to ensure you are suitable for the medication, i will contact your gp about this
- I would also refer you to oral medicine where they can take further investigations and management of your condition.
~ What further investigations will OM do?
- MRI
- Prescribe drigs such as oxcabazepine , lamotrigine
- provide LA for acute exacerbations
- Sugical management ( microvascular decompression, stereotactic surgery , gamma knife surgery)
