Oral Medicine Flashcards
(137 cards)
1
Q
patient presents with a large dome shaped swelling in the anterior part of the midline of the palate which also is associated with salty taste. O/E all teeth are vital and there is a bluish swelling in the midline. Radiographically, there is a large radiolucency in the midline - what could this be
A
nasopalatine cyst
2
Q
what is an oral ulcer
A
a full thickness breach in oral epithelium exposing underlying connective tissue
3
Q
name causes of oral ulceration
A
traumatic
metabolic/ nutritional
allergy
infection
inflammatory
immunological
drug induced
neoplasia
idiopathic
4
Q
how do you take an ulcer history
A
site
onset
duration (how long they last and how long between episodes)
number
texture
appearance
size
pain
predisposing factors (cinamon, benzoates, SLS)
relieving factors
5
Q
how would a traumatic ulcer present
A
white keratotic borders
clear causative agent (eg fractured cusp)
thick around the borders
surrounding mucosa is normal
6
Q
how do aphthous (metabolic/ nutritional) ulcers present
A
yellow/ white ulcer with red border
7
Q
what are aphthous like ulcers associated with
A
growth in children and teenagers
GI problems in adults
anaemia
malnourishment
8
Q
what are GI causes of ulceration
A
crohn’s disease
coeliac disease
ulcerative colitis
pernicious anaemia
9
Q
what is the relationship between iron/ folate/ vit B12 deficiency and aphthous ulcers
A
iron/ folate and vit B12 deficiency causes atrophy of the mucosa, predisposing it to ulceration
10
Q
what allergens can attribute to oral ulceration
A
sorbates (baked goods, canned fruits and veg)
cinnamaldehydes (sweets/ chewing gum)
benzoates (fizzy drinks, fruit juice, acidic foods)
11
Q
what are examples of inflammatory/ immunological causes of ulcers
A
behcets disease
lichen planus
vesiculobullous disease
SLE
12
Q
what GI and connective tissue disorders should we ask the patient about when inquiring about ulcers
A
Gut: abdominal pain, blood or mucous in stool, altered bowel movement, unintentional weight loss
CTD: joint pain/ stiffness, photosensitive rashes, xerostomia, fatigue
13
Q
what are infective causes of oral ulcers
A
primary or recurrent herpes simplex virus infection
varicella zoster virus
epstein barr virus
coxsackie virus
HIV
14
Q
how would primary herpes simplex virus infection present
A
generally in children 2-5 years old with a fever, headache, malaise, dysphagia, cervical lymphadenopathy
short lasting vesicles on tongue, lips, buccal, palatal and gingival mucosa that then form ulcers
15
Q
what is varicella zoster infection
A
the primary varicella zoster virus is chicken pox
virus remains latent in cervical ganglion and reactivation results in varicella zoster infection (shingles)
16
Q
how does varicella zoster infection present and how would you manage
A
over the distribution of a dermatome
liaise with pt’s GP for further investigations, provide analgesia and difflam if painful
17
Q
what are iatrogenic causes of oral ulceration
A
chemotherapy and radiotherapy
GVH disease
drug induced
18
Q
how would neoplastic ulcers present
A
rolled borders, exophytic, raised, hard to touch, non moveable, not always painful, sensory disturbance
19
Q
what are rare forms of oral malignancy
A
non-hodgkin lymphoma
Kaposi sarcoma - secondary to HIV and more commonly presents as pigmented lesion
20
Q
what is the local management of oral ulceration
A
- sort sharp restorations, dentures ect - if not resolved in 2 weeks follow referral pathway
- refer for FBC/ B12/ Folate/ ferritin/ Coeliac screen
- simple mouthwash (salty mouthrinse)
- antiseptic mouthwash (hydrogen peroxide or chlorhex)
- local anaesthetic (benzydamine or lidocaine)
- steroid mouthwash (betamethasone)
- onward referral to oral medicine if ulcers persist or are debilitating
21
Q
what does low B12/ ferritin/ folate with or without anaemia result in
A
aphthous ulceration
22
Q
what does low ferritin show in the mean cell volume
A
low mean cell volume - microcytic
23
Q
what does low B12/ folate show in the mean cell volume
A
high mean cell volume
24
Q
what is oral lichen planus
A
CD8+ Tcell mediated basal keratinocyte destruction
25
what are the 6 subtypes and appearances of different oral lichen planus
reticular - white lace like pattern
atrophic - inflamed areas, with thinned red epithelium
bullous - blistered appearance with ulceration
erosive - atrophic appearance with ulceration
plaque like - white plaques
papular - small white papules
26
what is the risk of malignant change of lichen planus
1% risk over 10 years
27
what are some causative agents of lichenoid reactions
medicines (anti-hypertensions, NSAIDs, antimalarials)
materials - amalgam, gold
lupus
GVH disease
28
what are management options for oral lichen planus
- simple mouthwash (hot salty m/w)
- local anaesthetic (benzydamine or lidocaine)
- avoid trigger factors
- steroid mouthwash (betamethasone m/w, beclometasone inhaler or hydrocortisone oromucosal tablets)
- change restorations
- onward referral to OM
- inform pt of increased cancer risk
29
what are the three vesiculobullous diseased
mucus membrane pemphigoid
pemphigus vulgaris
erythema multiforme
30
what is MMP
autoimmune process
present as erythema or gingiva, blisters that then present as erosion
desquamative gingivitis
31
how is MMP diagnosed
biopsy H&E staining and direct immunofluorescence
indirect immunofluorescence from blood sample
32
what is PV
autoimmune disorder
presents with oral bullae white rupture to leave erosions/ ulcers
desquamative gingivitis
very painful and potentially lethal
33
what is Nikolsky's sign
rubbing mucosa in patient induces a bulla in PV
34
in GDP how is vesicullobullous disease managed
symptomatic relief - difflam or betamethasone m/w
urgent referral to OM
35
what is erythema multiforme
hypersensitivity reaction - often affecting the lips
acute onset
ulceration and blistering of oral mucosa and lips
tends to affect 10-40 year olds
presents as target lesions on skin
36
what are causes of erythema multiforme
hypersensitivity
infective - herpes simplex virus
drugs - carbamazepine, NSAIDs, phenytoin
37
how would you manage erythema multiforme
refer to OM for advice
- topical steroids for oral lesions
- systemic steroids for more severe disease
- hygiene, chlorhex
- stop any obvious precipitating medication
- consider immunosuppression for recurrent EM (azathioprine)
38
what are causes of fungal infections
immunocompromisation - diabetes, anaemia, malignancy, HIV, medication, smoking, steroid use or inhalers
extremes of age
haematinic deficiency
xerostomia
loss of OVD
39
how are fungal infections managed
- denture hygiene advice, smoking cessation, inhaler hygiene (spacer), restore vertical dimension
- miconazole gel/ cream
- sodium fusidate ointment
- fluconazole
- nystatin
if lesion is suspicious or fails to respond to tx - referral to OM for oral rinse
40
what is the surgical sieve approach to figuring out what is causing an oral lesion
CLINK
Congenital
Lichenoid
Infections
Neoplasm
Keratosis
41
what are red flags of a lesion for SCC
more than 3 weeks
high alcohol consumption
smoker
non-homogenous
non0healing
indurated
tooth mobility
42
what is management for lesion that is suspicious of SCC
urgent referral to OMFS
follow local guidelines
explain concerns to pt
explain pt will get a biopsy promptly
43
what is leukoplakia
white patch which cannot be characterised clinically or pathologically
cannot be rubbed away
44
what are the two types of leukoplakia
homogenous - uniformly white, flat and thin, smooth surface, may exhibit shallow cracks
verrucous - surface is raise, exophytic, wrinkled or corrugated
45
how should white patches be managed in general practice
history and examination
exclude red flags
get photos
if obvious cause - remove and review
if no improvement - refer
is biopsy required
review lesion
46
what is erythroplakia
localised
well defined borders
strong associated with tobacco use
higher chance of malignancy
50% malignancy transformation risk
refer urgently to OM
47
what is OFG
a granulomatous disease
granulomas form and block lymphatics
in response to hypersensitivity reaction
presents with - desquamative gingivitis, erythematous lips, gingival tags
48
how is OFG managed
refer to OM
topical steroids from GDP (betamethasone)
avoidance diets (benzoates)
intralesional steroids (OM)
biologics if associated with Crohn's disease from faecal calprotectin test
49
what is trigeminal neuralgia
a disorder characterised by recurrent unilateral brief electric shock like pains, abrupt in onset and termination, limited to distribution of one or more divisions of trigeminal nerve
50
how is trigeminal neuralgia classified
classical (trigeminal nerve compressed by artery)
secondary (occurs with MS or space occupying lesion)
idiopathic
51
how may a patient describe trigeminal neuralgia
stabbing
electric shock
scary
10/10 pain
severe
memorable first episode
52
what are common TN triggers
eating, washing face, brushing teeth, smiling, temperature change, speaking
53
what are red flags of TN
sensory motor defects
deafness
loss of balance
54
how is TN managed
exclude dental and TMD pathology
commence carbamazepine liaise with GP for blood monitoring
consider local anaesthetic if patient in extreme pain
55
can GDPs prescribe carbamazepine
yes but there are many interactions so good practice to liaise with GP anyway
56
how is TN managed in secondary care
MRI scan to view any space occupying lesions or MS
medications - oxcarbazepine
neurosurgery considered in extreme conditions that don't respond to medication
57
what is oral dysaesthesia
burning mouth syndrome
an intraoral burning sensation in the oral mucous membrane and tongue that recur for more than 2 hour per day for more than 3 months without clinically evident cause for lesions
58
what are symptoms of oral dysaesthesia
prickling
burning
numb
shooting
tingling
59
what are red flags for oral dysaesthesia
dysphagia
permanently loss of sensation
loss of balance
hearing change
would be an urgent referral to OM
60
what investigations would OM do for oral dysaesthesia
full blood count - anaemia
haematinics for B12, ferritin or folate deficiency
thyroid function tests - hypo or hyperthyroidism
HbA1c to exclude diabetes
oral rinse to exclude fungal infection
sialometry to determine if dry mouth associated
61
what is the management for oral dysaesthesia in general practice
take history that includes questions on potential triggers
look for other diagnoses
show empathy
provide BISOM leaflet on BMS as an unconfirmed diagnosis
saliva substitutes or difflam m/w
62
what management of oral dysaesthesia in secondary care OM
counselling
CBT
caffeine intake
alcohol
sleep
exercise
explanation of chronic pain
clonazepam
tricyclic antidepressants
63
what are causes of dry mouth
dehydration
drugs
age
smoking
alcohol
anxiety
radiotherapy and cancer treatment and GVHD
salivary gland disease eg Sjogren's
64
what are complications of dry mouth
discomfort
increased caries risk
candidal infection
difficulty swallowing
65
what are the worst medicines for causing dry mouth
anticholinergics
diuretics
lithium
66
what systemic causes of dry mouth
diabetes
renal failure
hypercalcaemia
67
how do you assess dry mouth
gland palpation - express saliva?
duct expression
challacombe scale
68
how is dry mouth investigated in OM
bloods HbA1c
sialometery
ultra-sound scan of glands
correct hydration
avoid caffeine and smoking
modify drug regime
control diabetes
treat somatoform disorder
69
what is preventative care of dry mouth
caries - diet, fluoride, tx planning
candida
angular cheilitis
sore tongue (SLS free toothpaste)
70
what saliva substitutes are used
saliveze (pH neutral)
glandosane (acidic - only to be used in edentulous patients)
71
what information is given to patients to change lifestyle to manage dry mouth symptoms
moist/ oily foods and sauces
humidify home environment
regular exercise
omega 3 supplements
72
what is sialadenitis
inflammation of salivary glands
73
what is sialosis
bilaterally painless swelling of unknown cause
74
how would obstructive sialadenitis present (mealtime syndrome)
pain history
ask if associated with eating food
coming and going or persistent
swallowing problems
bad taste or pus
generally unwell
75
what investigations can be taken to determine salivary gland obstructions
lower occlusal x-ray or OPT to determine calcification - primary care
ultra-sound scan - secondary care
sialography - secondary care
MRI or CT - secondary care
76
what is acute viral sialadenitis
painful parotid welling
no hyposalivation
very rare to only involve submandibular gland
malaise, fever, generally feeling unwell
77
how is acute viral sialadenitis managed
supportive therapy
hydration
analgesia
pyrexia management
isolation for 6-10 days
contact public health
78
what is acute bacterial sialadenitis
most common in parotid gland
typically unilateral
painful
overlying erythema
pus from duct
trismus
cervical lymphadenopathy
79
how is acute bacterial sialadenitis diagnosed
clinically
exclude dental cause of infection
exclude pyrexia/ sepsis
exclude airway obstruction
secondary care can do pus swab for bacterial
80
how is acute bacterial sialdenitis managed
antibiotics through GP or OMFS
first choice is flucloxacillin
81
what is a mucocele
swelling that ruptures, partial resolution, recurs, history of trauma or lip biting
82
what is management of mucocele
no tx
excision - cysts are enucleated
83
what are red flags of salivary gland neoplasms
facial palsy
sensory loss
pain
difficulty swallowing
trismus
84
how are salivary neoplasms diagnosed
history and exam
ultrasound guided fine needle aspiration
MRI or CT
sialography
sjogren's disease investigations
85
how is saliva neoplasms managed
surgical excision - facial nerve injury risk
neck dissection
wide excision
chemotherapy
radiotherapy
immunotherapy
86
what are the 8 features you should use to describe a lesion in oral med
size and shape
surface surrounding tissue
colour
consistency
base
bleeding
functional limitation
87
when should a swelling be referred to oral med
symptomatic
abnormal overlying or surrounding mucosa
increasing in size
rubbery consistency
trauma from teeth
unsightly
88
what is description of RAS
recurrent bouts of one or more painful, round or oval shaped ulcers
last for 10-14 days
yellow/ grey base and erythematous margin
89
what is the aetiology of RAS
anaemia, GI blood loss, coeliac, crohn's, UC, trauma, allergy, SLS, infection, stress, NSAIDs
90
what is the treatment for RAS
correct haematinic deficiency
avoid dietary triggers - benzoates
avoid SLS triggers
betamethasone m/w
benzydamine m/w
chlorhex 0.2% to prevent secondary infection
91
what is the description of LP
inflammatory condition of skin and mouth
results in white patches in mouth
cause is unknown but can be immune related
92
what are lichenoid reactions
type 4 hypersensitivity reaction caused by immune response to foreign bodies/ medicines resulting in inflammation
93
what are the types of lichen planus
reticular
atrophic
erosive
bullouos
papular
plaque-like
94
what are symptoms of LP
burning/ stinging when eating
ulcers
desquamative gingivitis
white lace-like patterns on cheek and tongue
95
what is tx for lichenoid reactions/ LP
alter associated medicine - ACE, diuretics, NSAIDs, gold
replacement of amalgam fillings
patch test for allergy
biopsy
correct haematinics
autoantibody screening
avoid SLS
beclomethasone
betamethasone
96
what is description for erythema multiforme
type 3 hypersensitivity reaction by immune system
unknown trigger
acute condition causing painful and widespread infection
lips appear crusty and skin on body can be affected by a rash
97
what are signs and symptoms of EM
target lesions- lasting 2-3 months
flu like symptoms
mouth ulcers similar to PHG
98
how is EM managed
analgesia
encourage hydration
systemic aciclovir
benzydamine/ chlorhex/ betamethasone
99
what is angina bullosa haemorrhagica
benign condition affecting lining of mouth, spontaneous appearance of blood filled blisters in mouth which occur rapidly
100
what is tx of angina bullosa haemorrhagica
drainage of blisters at back of mouth
no tx - burst on their own
benzydamine/ chlorhexidine
101
what constitutes hyposalivation
unstimulated flow is less than 1.5ml in 15mins
102
what are causes of dry mouth
dehydration
side effects of medicine
somatoform disorders
medical conditions - diabetes/ epilepsy
103
what tests are used for a patient with hyposalivation
blood tests
salivary ultrasound
sialography
eye screening - schirmer test
104
what is tx for hyposalivation
enhanced prevention
sipping water/ sugar free gum
saliva substitutes
pilocarpine
contact GP to see if medication can be changed
105
what are causes of hypersalivation
drugs
dementia
CJD
stroke
poor swallowing - anxiety/ MS
106
what is the management of hypersalivation
anti-muscarinic drugs
botox
duct repositioning surgery
107
what is sialosis
painless swelling of parotid glands on both sides
associated with some discomfort and rarely affects other glands
appears like mumps but overlying skin not inflamed
108
what is the aetiology of sialosis
diabetes
chronic alcohol misuse
liver cirrhosis
bulimia
109
what is management of sialosis
blood tests - glucose, LFTs
biopsy
if no cause identified - no tx
surgery - rare
110
what is sjogrens
chronic autoimmune disease where salivary glands and tear glands affected causing dryness of mouth and eyes
can also affect the joints
111
what are symptoms of sjogrens
dry mouth
oral thrush
dry, sore eyes
fatigue
joint ache
swollen salivary glands
112
how is sjogren's diagnosed
saliva flow test
test for eye dryness
blood tests to look for antibodies
ultrasound scans of major salivary glands
sialography
biopsy of minor salivary glands of lower lips
113
how is Sjogren's managed
enhanced prevention
saliva substitutes
pilocarpine
methotrexate
antifungals if required
114
what is OFG
persistent swelling of lips and face areas within the mouth
granulomas block lymphatic vessels
115
what are signs of OFG
angular cheilitis
lip fissuring
crusting
redness of peri-oral tissues
swelling of lips
full thickness gingivitis
116
how is OFG diagnosed
biopsy
allergy testing
endoscopy - if crohn's suspected
test for sarcoidosis
117
how is OFG managed
exclusion diet
miconazole or hydrocortisone cream for angular cheilitis
prednisolone
azathioprine, mycophenolate
118
what is candidal leukoplakia
condition caused by candida albicans that occurs at angles of mouth
119
what are causes of candidal leukoplakia
poor OH
steroid inhaler
poor diet
diabetes
deficiency
dry mouth
120
what is the tx for candidal leukoplakia
monitor - potentially malignant
encourage smoking cessation and limiting alcohol
check diet
incisional biopsy
correct deficiency
systemic antifungal
topical antifungal
121
what are risk factors for oral cancer
smoking
alcohol
prolonged sun exposure
HPV
poor diet
122
what symptoms of oral cancer prompt referral
non-healing ulcers lasting more than 3 weeks
difficulty moving tongue/ jaw
numbness
occlusal changes
dysphagia
stridor
persistent hoarseness
unexplained tooth mobility
123
what are signs of SCC
non-healing ulcer
indurated
raised rolled margins
bleeds easily
red and white patches
fixed to surrounding tissue
pain
cervical lymphadenopathy
124
what is management for suspicious lesions
inform pt of concern regarding lesion - could be harmless but small risk it could be cancer
biopsy - refer urgently to maxfac
manage risk factors
125
what treatment is used for oral cancer
surgical excision
radiotherapy
chemotherapy
126
what are side effects of chemotherapy
mucositis
dry mouth/ altered taste
re-activation of viruses
candidal infections
delayed healing
increased infection risk
127
what are side effects of radiotherapy
trismus
dry mouth and radiation caries
ORN
128
how would you describe dysplasia to a patient
evidence of change to tissues which has increased risk of transformation to cancer
risk can be reduced by managing risk factors
129
what are the grades of epithelial dysplasia
hyperplasia
mild
moderate
severe
carcinoma in situ
130
what is hyperplasia
increased basal cell numbers
regular stratification
no cellular atypia
131
what is mild dysplasia
mild atypia
present in lower third only
132
what is moderate dysplasia
present in middle third
spacing
pleomorphism
hyperchromatism
round/ bulbous rete ridges
133
what is severe dysplasia
extends into upper third
loss of polarity
widespread hyperchromatism
multiple mitoses
134
what is carcinoma in situ
not invasive - confined to epithelium
affects full thickness epithelium
wide rete pegs
widespread mitotic abnormalities
inflammation of connective tissue
135
what are architectural changes in epithelial dysplasia
irregular stratification
loss of polarity of basal cells
drop shaped rete ridges
increased number of mitotic figures
136
what are cellular changes associated with epithelial dysplasia
abnormal variation in nuclear size
abnormal variation in nuclear shape
abnormal variation in cell size
abnormal variation in cell shape
137
how would you do a cranial nerve exam
olfactory - smell
optic - ask pt to count fingers
oculomotor, trochlear, abducens - eye movement in all directions
trigeminal - clench muscles of mastication
facial - muscles of facial expression
vestibulocochlear - whisper in one ear
glossopharyngeal - check speech, swallow and gag reflex
vagus - deviation of uvula when saying ahh
accessory - shrug shoulders
hypoglossal - tongue movements
