Oral Medicine Flashcards
(132 cards)
1
Q
Causes of Oral Ulceration
A
Traumatic
Metabolic
Allergic/hypersensitivity
Immunological
Infective
Inflammatory
Drug induced
Idiopathic
Neoplastic
2
Q
What is oral ulceration?
A
Localised defect where there is destruction of epithelium exposing underlying connective tissue
3
Q
What can give a clue as to cause of an ulcer?
A
Site
Size
Pain
Texture
Number
Appearance
Duration
Relieving factors
Predisposing factors
4
Q
Appearance of traumatic ulcers
A
White keratotic borders
Clear causative agent - e.g. fractured cusp
Surrounding mucosa looks normal and ulcer soft
Consider: movement disorders, chemical burns
5
Q
Appearance of metabolic/nutritional ulcers
A
Aphthous like - yellow/white ulcer with red border
Common in children/teenagers - ass with growth
Adults with GU/GI pathology
Malnourishment
Anaemia
6
Q
How does GI disease cause deficiencies
A
Through either malapsorption (crohns, coeliac, UC, pernicious anaemia) or through blood loss (colon cancer, IBD, peptic or duodenal ulcers/colonic polyps)
Iron/b12/folate deficiencies cause atrophy of mucosa, predisposing it to ulceration
7
Q
Appearance of allergic/hypersensitivity ulcers
A
Often associated with features of OFG
Oral lichenoid reactions
8
Q
Name three causative agents of hypersensitivity ulceration
A
Sorbate - baked goods, canned fruits and veg, cheeses, dried meats
Cinnamaldehyde - sweets and gum
Benzoates - fizzy drinks, fruit juices and acidic foods
9
Q
Name some types of inflammatory/immunological oral ulceration
A
Behcet’s - mouth skin eyes genitals
Necrotising sialometaplasia
Lichen planus
Vesiculobullous disease
Connective tissue disease - SLE, rheumatoid arthritis, scleroderma
10
Q
Common features of gut disease
A
Abdominal pain
PR blood/mucus
Altered bowel movements
Unintentional weight loss
11
Q
Common features of connective tissue disease
A
Joint pain and stiffness
Photosensitive rashes
Xeropthalmia/xerostomia
Fatigue
12
Q
What can cause infective oral ulceration
A
Primary or recurrent herpes simplex virus infection
Varicella zoster
Epstein barr
Coxsackie
Echovirus
Treponema pallidum
Mycobacterium tuberculosis
Chronic mucocutaneous candidiasis
HIV
13
Q
Primary herpes simplex virus infection
A
Generally 2-5 year olds
Associated with a fever
Headache, malaise, dysphagia, cervical lymphadenopathy
Short lasting vesicles effective tongue lips buccal palatal and gingival mucosa then forming ulceration
14
Q
How does varicella zoster virus cause oral ulceration?
A
Primary infection with the virus - chicken pox
Virus remains dormant in sensory ganglion
Normally during a time of immunocomprimisation or other acute infection, the virus is reactivates resulting in shingles
The ulcers will present over distribution of a dermatome
Liaise with GP - they may need further investigations
Provide analgesia and difflam if painful
15
Q
What can cause iatrogenic oral ulceration?
A
Chemo
Radio
Graft versus host disease
Drug induced - potassium channel blockers, bisphosphonates, NSAIDs and DMARDs
16
Q
Neoplastic oral ulceration appearance
A
Exophytic
Rolled borders
Hard
Non moveable
Raised
Not always painful
Sensory disturbance
17
Q
Oral ulceration local management
A
HSMW
Antiseptic MW - CHX or hydrogen peroxide
LA - lidocaine or benzydamine
Steroid mouthwash - betamethasone
Onward referral to OM
18
Q
What is microcytic anaemia?
A
Low ferritin associated with low mean cell volume
19
Q
What is normocytic anaemia?
A
low B12/folate associated with high mean cell volume
20
Q
What is the difference between lichen planus and oral lichenoid reaction
A
LP is idiopathic
OLR is a lesion that looks like lichen planus but has a cause
21
Q
Typical age for presentation of LP/OLR
A
40+
22
Q
Incidence of LP/OLR
A
0.5-2% (common)
23
Q
Types of lichen planus
A
Reticular
Atrophic
Plaque like
Erosive
Bullous
Papular
24
Q
Name and describe this type of LP
A
Reticular - White lace like pattern
25
Name and describe this type of LP
Atrophic - inflamed areas with thinned red epithelium
26
Name and describe this type of LP
Bullous - blistered appearance, with ulceration
27
Name and describe this type of LP
Erosive - atrophic appearance with ulceration
28
Name and describe this type of LP
Papular - small white papules
29
What type of LP is this?
Plaque-like
30
Is LP more common in males or females?
Females
31
Which parts of the body can lichen planus affect?
Skin
Genital
Mucous membranes
32
What is the long term risk of oral lichen planus?
1% over 10 year risk of malignant change
33
Drugs which can cause lichen planus
Antihypertensives
Antimalarials
NSAIDs
Allopurinol
Lithium
34
Materials which can cause OLR?
Metals - gold, nickel, amalgam
?Composite resin
35
In OLR, if pt has had a recent transplant what would you suspect?
Graft vs host disease
36
What is the management of LP/OLR?
If symptomatic - symptomatic relief, HSMW, LA (benzydamine), avoid triggers such as spicy food and fizzy drinks, topical steroids (oromucosal pellets, mouthwash, inhaler)
? change restorations
Refer for biopsy if persistent, idiopathic or severe
Review 6 monthly
Inform of increased cancer risk
37
3 most common vesiculobullous disorders
Mucous membrane pemphigoid
Pemphigus vulgaris
Erythema multiforme
38
Mucous membrane pemphigoid clinical presentation
Autoimmune process normally 50-60yo
1:2 M:F
- Oral vesicles/blisters -> ulcers
- Desquamative gingivitis
- Ocular lesions
- Anogenital lesions
- Skin lesions
- Nasal mucosa
May also report discomfort on swallowing
39
How is MMP diagnosed?
Biopsy - H+E stain from affected tissue and DIF from perilesional tissue
Indirect immunofluorescence - blood sample
40
Clinical features of pemphigus vulgaris
Autoimmune process
F>M
Blisters/erosions, ulcers
Oral bullae which quickly rupture
Desquamative gingivitis
Ocular involvement
Aerodigestive tract
Anogential blistering
Skin
Pain +++
Potentially lethal
Systemically unwell
41
How can pemphigus vulgaris be potentially lethal?
Secondary infection -> sepsis
Fluid/electrolyte imbalances caused by widespread skin and mucosal lesions
42
What is Nikolsky's sign?
Rubbing mucosa induces a bulla in pemphigus vulgaris
43
How is PV diagnosed?
Nikolsky's sign
Biopsy - H+E from affected tissue and DIF from perilesional
Indirect immunofluorescence - blood sample
44
GDP management of pemphigus vulgaris
Urgent referral to OM and symptomatic relief - betamethasone and difflam
If eye involvement liaise with GP
45
Secondary care management of pemphigus vulgaris
Investigate with biopsy and bloods
Provide long term treatment
Investigate whether systemic involvement
Systemic tx:
- Prednisolone - pulsed
- Dapsone
- Doxycycline
- Azathioprine
- Mycophenolate mofetil
- Methotrextate
46
Erythema multiforme clinical presentation
Acute onset
Hypersensitivity reaction - often identifiable trigger
Ulceration and blistering of mucosa and lips
Skin rash target lesions
Younger 10-40
Spectrum of severity
47
% recurrence of erythema multiforme
up to 25%
48
Aetiology of erythema multiforme
Hypersensitivity
Infective HSV 1 in 15-20%
Drug induced
Following BCG or hep B vaccines
49
Drugs that can cause erythema multiforme
Allopurinol
Carbamazepine
NSAIDs
Phenytoin
Some ABX
50
GDP management of erythema multiform
Refer to OM
Topical steroids for oral lesions
CHX
OHI
Difflam
51
Secondary care management of erythema multiforme
Systemic steroids for more severe disease
Antihistamines for skin itch
Stop any obvious precipitating medication
Consider inpatient admission
Recurrent - consider immunosuppression, azathioprine, mycophenolate mofetil and prophylactic acyclovir(HSV implicated)
52
Possible aetiologies of fungal infections
Immunocompromised - diabetes, anaemia, malignant disease, HIV, medication
Local factors - smoking, dentures, inhaled steroids
Extremes of age
Haematinic deficiency
Xerostomia
Loss of vertical dimension (angular chelitis)
53
Management of fungal infections GDP
Treat local factors first - restore OVD, denture hygiene, smoking cessation, inhaler hygiene such as rinsing or spacer
Antifungal prescription - miconazole gel/cream, sodium fusidate ointment in angular chelitis, fluconazole, nystatin
54
Why is compliance with nystatin less than other antifungals?
Requires application 4x daily
55
What types of drugs can azole antifungals interact with?
Immunosuppressants - increase blood conc and can increase toxicity/transplant rejection
Antihistamines - increased risk heat problems
Warfarin - increased blood thinning
Antidepressants - increased side effects
Other drugs
56
When would you refer fungal infection to OM and what for?
If suspicious appearance or fails to respond to tx
Refer for further advice, oral rinse, HbA1c, blood glucose, DBC, haematinics
57
What is HbA1c?
Blood test used to determine average blood glucose over last 2-3 months
<42mmol/mol - normal
42-47 mmol/mol - pre diabetes
48mmol/mol + - diabetes
58
Why would a lesion appear white?
Thickened epithelium
Organic material - candida, food debris
Physiological - tongue coating, desquamation, leukoedema
59
What is CLINK for white patches?
Congenital
Lichenoid
Infection
Neoplastic
Keratosis
60
Red flags for squamous cell carcinoma
>3 weeks duration
>50 years old
Smoker
High alcohol consumption
Oral cancer history
Non homogenous
Non healing ulceration
Induration
Exophytic
Tethering of tissue
Non moveable
Tooth mobility
Non healing XLA sockets
Difficulty swallowing or speaking
Cervical lymphadenopathy
Weight loss/ loss of apetite/fatigue
Numbness/altered sensation
61
Management of suspected SSC
Urgent referral 2 week cancer pathway to MAX FAX (not OM)
Follow local guidelines
Be honest with pt about concern
Explain they will need biopsy and needs to be done promptly
62
Leukoplakia
White patch or plaque that can not be characterised clinically or pathologically
Diagnosis of exclusion
63
Appearance of leukoplakia
Can't be rubbed away
Can be homogenous (uniformly white, flat and thin, smooth surface may show shallow cracks) or verrucous (surface raised, exophytic, wrinkled or corrugated)
64
Malignant potential leukoplakia
Difficult to predict 0.13-34%
65
Disorders that should be excluded before diagnosing leukoplakia
Leukoedema
white sponge nevus
Frictional keratosis
Chemical injury
Acute pseudomembranous candidiasis
Hairy leukoplakia
Lichen planus - plaque type
Lichenoid reaction - local factors and meds
Discoid lupus erythematous
66
What must be done to patch diagnosed as leukoplakia?
Biopsy to confirm diagnosis and assess whether dysplasia
If yes, remove
If no, remove if reasonable
Follow up 6 monthly
67
White patch management GDP
Thorough history, exam, systems enquiry
Exclude red flags
Does it wipe away - fungal
Get photos
If obvious cause, correct and review
No improvement - if unsure or diagnosis refer
Consider does it need biopsy - to confirm diagnosis, exclude dysplasia or malignancy
Decide how often to review, reflecting on risk factors of the individual
68
Why do patches look red?
Inflammation
Mucosal atrophy
Increased vascularisation
Mucosal/submucosal bleeding
69
Differential diagnoses for red patches
Viral infection
Candidal infection
Iatrogenic - mucositis
LP/OLR
Granulomatous disease
Blistering diseases
Allergy
Psoriasis
Geographic tonuge
Leukaemia
Purpura
Trauma
Deficiency states
Erythroplakia
70
Erythroplakia appearance
Atrophic lesion
Localised/focal
Well defined borders
Velvety red texture
Can be speckled - erythroleukoplakia
71
Erythroplakia
Fiery red patch that can not be characterised clinically or pathologically as any other definable lesion
Diagnosis of exclusion
72
Common sites for erythroplakia
Soft palate
Buccal mucosa
FoM
73
Malignancy/dysplasia risk erythroplakia
51% of erythroplakia showed invasive carcinoma
40% carcinoma in situ
9% mild to moderate dysplasia
50% malignant transformation rate
74
Erythroleukoplakia
Speckled red/white patches
Heterogenous appearance
Highly suspicious for SCC or severe dysplasia
75
Red patch management GDP
Thorough history and exam
Exclude red flags
Get photos
If obvious cause - correct and review
Red patches or red speckled have high malignant potential
If red patch not attributed to another cause - biopsy needed for diagnosis
76
What is granulomatous disease?
Granulomas (collection of immune cells) form and block lymphatics, resulting in tissue oedema, typically in response to hypersensitivity reaction
77
Clinical appearance of OFG
Lower lip swelling
Cobblestoning
Ulceration in sulci
Mucosal tags forming
Gingival inflammation/desquamative gingivitis
78
OFG is clinically indistinguishable from ____
Oral crohns
79
If presentation of OFG features, must ask ___
About GI symptoms - consider oral crohns
Ask about diet specifically fizzy drinks, tomatoes, processed foods
80
OFG management GDP
Refer to OM
Consider topical steroids betamethasone
Advise avoidance of potential triggers
81
Secondary care management of OFG
Intralesional steroid triamcinoclone acetonide
Biologics for oral crohns - infliximab, adalimumab
82
3 categories of pain
Nociceptive
Neuropathic
Nociplastic
83
Nociceptive pain
Normal physiological response
Pain that arises from actual or threatened damage to non neural tissue and is due to activation of nociceptors
84
Neuropathic pain
Lesion or disease of the somatosensory nervous systme
85
Nociplastic pain
Results in increased sensitivity from altered function of pain related sensory pathways in the peripheral and CNS
Triggered by non nociceptive stimuli
Chronic exposure to pain may result in this
86
Trigeminal neuralgia presentation
Recurrent unilateral brief electric shock pains
Abrupt in onset and termination
Limited to the distribution of one or more divisions of trigeminal nerve
Triggered by innocuous stimuli
May develop without apparent cause or be result of another diagnosed disorder
Additionally can be concomitant continuous less severe pain within distribution of affected nerve division(s)
87
TN classifications
Classical - on MRI trigeminal nerve being compressed by an artery (usually superior cerebellar)
Secondary - occurs secondary to another condition such as MS or space occupying lesion
Idiopathic - no obvious cause
88
How might pt describe TN pain
Stabbing
Electric shock
10/10
Scary
Severe
Memorable first episode
89
Common TN triggers
Eating
Washing face
Brushing teeth
Cold wind
Smiling
Speaking
Temp change
Stress
90
Red flag features in TN
Sensory motor defects
Deafness
Loss of balance
Optic neuritis
History of cranio facial malignancy
Bilateral TN
Systemic symptoms
<30 y/o
URGENT REFERRAL
91
What guidelines should be followed for TN?
Royal college of surgeons of England
92
Management of TN in GDP
Obtain accurate diagnosis - exclude dental/TMD pathology
Consider commencing carbamazepine - liaise with GP for bloods, can call OM for advice
Consider LA for extreme pain
Urgent referral to OM/OMFS
93
Considerations when prescribing carbamazepine
- Check BNF for drug interactions
- Care in elderly as increases falls risk
- Care in those operating heavy machinery, driving, childcare
- Requires FBC U+E LFT
94
What would an appropriate prescription for TN patient be at GDP
Carbamazepine 100mg
1 tablet 2x daily
10 days
Send 20 tablets
Advise space doses out as much as possible
Can cause dizziness, blurred vision and unsteadiness
95
Secondary care management of TN
MRI scan - identify space occupying lesion, MS, neurovascular conflict (neurophysical testing or CT considered if MRI contraindicated)
Medication optimisation - lowest dose which controls symptoms, carbamazepine, oxycarbazepine (off label use)
Consider lamotrigine, baclofen, gabapentin, pregabalin in refractory cases
LA in acute episodes
Neurosurgery in severe cases
96
Considerations for neurosurgery for TN
Are meds ineffective
Are meds side effects severe
Is there neurovascular conflict
Is pt medically well
Does pt accept surgical risks
97
Oral dysaesthesia
Burning mouth syndrome
Idiopathic chronic condition characterised by persistent alteration to oral sensation, abnormal or unpleasant
Absence of identifiable local or systemic cause
Burning or dysesthetic sensation of mucous membrane and tongue
More than 2 hour per day more than 3 months
98
Symptoms of oral dysaesthesia
Prickling/burning/numb/tingling/shooting sensation
Tongue tip nips
Sandpaper rubbed on tongue
Cotton wool in mouth
Dry mouth feeling but with normal salivary flow
Tingling roof of mouth
Burning nasty chemical taste
Mouth feels dirty or fluffy
Mouth on fire when trying to sleep
99
Red flags in oral dysaesthesia
Permanently lost sensation
Unilateral symptoms
Dysphagia
Odynophagia
Weight loss
Loss of balance or hearing change
Unexplained motor or other sensory changes
URGENT REFERRAL
100
What to exclude before diagnosis of oral dysaesthesia
Fungal infection
Mucosal disease such as LP
Odontogenic infection
Dry mouth
Parafunction
Tongue thrusting
Cranial nerve exam - normal
101
Investigations for oral dysaesthesia
FBC - anaemia
Haematinics - deficiencies
Thyroid function tests - hypo or hyper could account for symptoms
HbA1c - exclude diabetes
May consider:
Sialometry
Oral rinse to rule out fungal
Patch testing if suspected hypersensitivity
Zinc - if taste disturbance
102
Oral dysaesthesia management GDP
Detailed history asking about potential triggers and affects day to day
Exclude other diagnoses
Provide BISOM leaflet
Consider saliva substitutes, difflam
Empathy, listen and reassure pain is real they are not alone
Refer to OM and ask GMP to consider bloods
103
Oral dysaesthesia management in secondary care
Counselling/CBT
Improve sleep - discuss with GP
Holistic
Explanation and reassurance
Systemic - tricyclic antidepressants, anticonvulsants such as gabapentin or pregabalin, duloxetine/venafaxine, alpha lipoic acid (OTC)
104
Causes of dry mouth
Dehydration
Age
Smoking
Alcohol
Medications
Radiotherapy/cancer tx
Anxiety and somatisation disorders
Salivary gland disease such as sjogrens
105
Complications of dry mouth
Discomfort/pain
Increased caries risk
Candidal infection
Swallowing problems
106
What is DISH and what can cause it?
Drug Induced Salivary Hypofunction
Amphetamines
Anticonvulsants
Antidepressants
Antihistamines
Antineoplastic drugs
Antiparkinsonian
Antipsychotics
Antiretroviral
Diuretics
Antihypertensives
Muscle relaxants
Opioid analgesics
Benzodiazepines
Worst offenders - antimuscarinic (amtryptiline), diuretics, lithium
107
How does cancer therapy cause dry mouth?
Radiotherapy -> apoptosis then inflammation and fibrosis
Graft vs host effects
Antineoplastic drugs
Radioiodine
108
Chronic systemic diseases causing dry mouth
Diabetes mellitus and insipidus
Renal failure
Cardiac failure
Hypercalcaemia
Addison's disease
109
Acute systemic conditions that can cause dry mouth
Haemorrhage
Persistent vomiting
110
Dry mouth assessment
Gland palpation
Duct expression
Challacombe scale
Discriminating DISH from Sjogren's - can you eat without a drink? Sjogren's can not
111
Secondary care management of dry mouth
Investigate - bloods, sialometry, ultrasound of glands
Treat underlying cause - hydration, avoid caffeine smoking alcohol, modify drug regime, control diabetes, treat somatoform disorder
Prevention - fluoride, diet, OHI, SLS free tp, prevent fungal infections
Symptomatic relief - sprays, lozenges, stimulants
112
Simple lifestyle measures for dry mouth
humidify home, moist oily foods, glasses/goggles, warm eye compresses 10 min daily, regular exercise, omega 3 supplements
113
What is "mealtime syndrome"
Obstructive sialadenitis
Pain and swelling salivary glands associated with mealtimes
Blockage (often salivary gland stone) hinders salivary flow
114
What is sialolithiasis?
This is the condition where stones form in the salivary glands or ducts, obstructing the normal flow of saliva
115
Symptoms of obstructive sialadenitis
Mealtime associate swelling and pain of salivary glands
Can have pus/bad taste
Can be systemically unwell if acute infection
116
Investigations if suspected obstructive sialadenitis
Lower occlusal radiograph/OPT to identify calcification
Ultrasound
Sialography
MRI or CT indicated in some cases
117
Acute viral sialadenitis clinical features
Painful parotid swelling - normally bilateral
No hyposalivation
10% submandibular gland involvement, very rare to have only submandibular
Malaise , fever, generally unwell (likely precedes swelling)
Trismus
Swelling will last approx 7 days
118
Diagnosis of acute viral sialadenitis
Clinical grounds
Serum antibodies can be considered
Viral swab of saliva
119
Management of acute viral sialadenitis
No specific antivirals
Management focuses on supportive care
Hydration
Analgesia
Pyrexia management
Isolate 6-10 days adviseable
Contact public health through GP
120
Clinical presentation acute bacterial sialadenitis
Most commonly affects parotid
Typically unilateral
Painful swelling
Overlying erythema
Pus from ducts
Trismus
Pyrexia
Cervical lymphadenopathy
Often secondary to salivary gland obstruction
121
Diagnosis of acute bacterial sialadenitis
Clinical grounds
Exclude odontogenic infection
Pus swab for cultures
Exclude pyrexia/sepsis
Exclude airway obstruction
122
Management of acute bacterial sialadenitis
ABX through GP or OMFS - first choice flucloxacillin, erythromycin if penicillin allergy
Airway management if needed
Once acute infection resolved, manage causative factors e.g. if obstruction
123
Salivary gland obstruction management
Stimulating saliva flow - sweets, citrus
Hydration
Gentle massage
Massaging the salivary gland in the direction of the duct
Heat and cold - relieve pain and swelling
Analgesia
Removal - sialendoscopy, surgical removal, lithotripsy
124
Mucocele history
Swelling
Rupture
Partial resolution
Recurrence
History of trauma/lip biting
125
Mucocele management
no tx - unlikely to resolve
Excision - ideally cyst enucleated but high recurrence, risk of damage to neighbouring structures
Clinical photos useful
126
Salivary gland neoplasm clinical features
Unilateral swelling
Anywhere where there are major or minor salivary glands
127
Salivary gland neoplasm red flags
Facial palsy
Sensory loss
Pain
Difficulty swallowing
Trismus
Rapid growth
128
Investigations for salivary gland neoplasms
History and exam crucial
Ultrasound useful
Ultrasound guided fine needle aspiration - give histo specimen (risk of facial nerve injury if sampling from parotid)
Sialography
Sjogren's investigations
129
Management of benign salivary gland neoplasm
Surgical excision - major risk of facial nerve injury
130
Management of malignant salivary gland neoplasm
Treatment decided by MDT, can include
Neck dissection
Wide excision
Chemo
Radio
Immunotherapy
131
White patch diff diagnosis
OLR/LP
White sponge nevus
Smokers keratosis
Frictional keratosis
Pseudomembranous candidiasis (wipes off)
Chronic hyperplastic candidiasis
=
132
