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Oral Medicine pt. 1 (Patient Consultation (E/O Ex (Look, feel,…
Oral Medicine pt. 1
Patient Consultation
Med Hx
Hospitalizations? Illness? Operations?
Review of systems, weight, sleep, energy levels, appetite
Thyroid
Heart, Asthma, COPD, Pneumonia
Pancreas, Liver
Kidney (NSAID damage?)
GI (Diarrhea, Chron's disease)
Rheumatoid Arthritis, osteoporosis/athritis
Current Tx/drug allergies/immunizations/complementary medicine
Interactions, dosage, tx regimes
Family Hx
Diabetes, hemophilia, IHD
Melanoma
Family support
Overseas Travel
sexual hx
Occupation
Social Hx
Alcohol consumption - PD, ANUG, oral cancers, liver cirrhosis
Smoking - method? how much?
E/O Ex
Look, feel, auscultation, percussion, special tests
General: Body weight, breathlessness, physical disabilities, age, complexion
Vital signs: conscious state, temp, pulse, respiratory, BP
Head, face neck Eyes,
Lips - vermilion boarder
Lymphonodes (submental, submand, inferior cervical, supra-cervical, posterior chain, occiptial post-auricular)
Salivary gland
check tenderness, pain, swelling
palapate for hard tissues, stones or swellings
TMJ
Bruxism
ROM
tenderness, locking, crepitus
MOM (pain)
Masseter, Temporalis, lateral/medial pterygoid
I/O Ex
Buccal mucosa
Sulcus
Tongue (ventral, lateral)
FOM
Tonsils
Investigations
Prognosis & diagnosis
1.) Urinalysis
2.) Blood Tests
3.) Skin Testing
4.) Biopsy
Lesions that have neoplastic PMOD features or enlarging. Persistent lesions that are of uncertain etiology
Persistent lesions that are failing to respond to tx
Or a conformational of clinical dx
(i) Labial gland biopsy
(ii) FNA
(iii) Immunofluorescence
(1. Direct (2. Indirect
(iv) Radiography
I/O = PAs, PBWs, Occlusal
E/O = OPG, Lat Obl
CT Scans
Ultra Sound
MRI Scans
Common Medicines
AB Therapy
Amoxycillin (inhibition of cell wall)
penicillin series
When clavulanic acid added =
Augmentin
broad spectrum
Erythromycin (inhibition of protein synthesis)
macrolide series
Gentamicin (inhibition of protein synthesis)
aminoglycosides series
Phenoxymethylpenicillin (inhibition of cell wall) - penicillin series - first choice for odontogenic infections
narrow spectrum
Metronidazole
Specific for gram -ve anerobes
Antifungals
Miconazole [Topical]
Fluconazole [Systemic]
Amphoterician B [Systemic]
Antiviral Therapy
Opiods
Lignocaine [LA]
Benzocaine [Topical]
Corticosteroids
Topical
Hydrocortisone
Triamcinolone acetonide
Oral
Prednisone
Inhaled
Fluticasone
Sedation
Salivary Gland Disease
Anatomy
Normal Variation
Assessment Techniques
Examination
Radiographs
Blood Tests
Biopsy
Labial gland biopsy
Sialography
Scintiscanning
Types of disease
Sialothiasis
Sialodentitis (Viral, Mumps, Bacterial)
Ascending Sialodentitis
Chronic Sialodentitis
Sialosis
Sarcoidosis
Xerostomia
Sjögren's Syndrome
Causes for dry mouth:
Drugs (most common cause)
Irradiation
Dehydration
Cholinergic dysfunction
Rare
Autoimmune diseases
Psychogenic
Investigations
Blood tests (SS-A/Ro or SS-B/La)
Labial gland biopsy
Symptoms
Oral Mucosal Disease
Common Diseases
Oral Candidosis
Actue
Pseudomembranous
Erythmatous
Chronic
Angular Chelitis
Ae: Candida species & Staph aureus
feats: fissuring at the commissure of lips
tx: Miconazole (antifungal and antibacterial)
cessation support, tx systemic disease,
Median Rhomboid Glossitis
Ae: Candida species
feats: well demarcated erythema on tongue
Tx: systemic antifungals
Chronic Hyperplastic Candidosis
Ae: Candida + tobacco
feats: thickened, irregular white plaque, won't rub off
Tx: systemic antifungals 2-3wks
Candida-associated denture-induce stomatits
Aeitology:
(predisposing) Chronic steroid use, immunocompromised, broad spectrum AB
Management (1-4 wks):
CHX rinse
Topical antifungals (nystatin, microazole)
Systemic (Fluconazole, amphoterician B)
Ulcerations
Oral
Ae: Systemic, Malignant neoplasms, Local causes, Apthae, Drugs
Tx: If it lasts longer than 14days get BIOPSY
Traumatic
Ae: [local causes] Sharp teeth/resorations
Tx: Remove the cause
TUGSE
feats: Self-healing solitary ulcer of weeks or months
Tx: Simple surgical excision is the Tx of choice.
Apthous Ulcer
Major
Indications:
>
1cm, >14days, scarring present, occurs anywhere include KT
Management:
elminate sources of trauma, investigate vit/mineral definecies
Minor
Indications:
< 1cm, <14 days, Non scarring, occurs on non-KT
Management:
elminate sources of trauma, investigate vit/mineral definecies
Leukoedema
Ae: Unknown cause
feats: diffuse white mucosa, folded or streaky
Tx: no treatment required
Frictional Keratosis
Ae: chronic irritation (ie chewing or eating)
feats: hyperplastic tissue
Tx: remove the cause
Oral Lichen Planus
Ae: T-cell mediated basal cell degeneration
feats: plaque-like, atrophic, erosive, papular, bullous, symmetrical bilateral presentation
nb: can appear on the
flexor surfaces
of the arms/legs
Tx: (BIOPSY), High potency topical steroids, good OH
Oral Lichenoid Reaction
Ae: systemic drugs, Am restorations, ect
feats: solitary/asymmetrical
Tx: change medication, change restorations, topical steroids
Leukoplakia
Ae: A whitish patch or plaque that cannot be
that cannot be characterized clinically/pathologically as anything else
feats: white pathes that cannot be rubbed off
nb: risk of malignant transformation = 1-2%
Tx: BIOPSY
severity = dependent on level of dyspalsia
No dysplasia- No Tx, but periodic review
Mild dysplasia- conservative, elimination of tobacco or alcohol habits, Tx of any candida infection
Moderate to severe dysplasia- consider excision due to the risk of malignant change
Hairy Leukoplakia
Ae: Epstein-Barr Virus (HSV 4)
feats: asymptomatic white hairy
tongue, ie superimposed infections
tx: Treatment of the underlying cause ie HIV/AIDS
Rare Disease
Syphilis
Ae: STD
feats: (1) chancre (indurated swelling), (2) mucous patches, (3) Luekoplakia
Tx: Penicillin injections
Tuberculosis
Ae: M.
tuberculosis
feats: cough for 3wks, ulceration/lesions, nodal involvement
Tx: Refer
Cyclic Nuetropenia
Ae: autosomal dominant, others spontaneously
feats: mouth ulers, severe periodontitis
Tx: Supportive, Perio management
Behect's Disease
Ae: Aeitology = Aetiology is unclear. Strong link with HLA B51
feats: mouth ulcers(70%), tonsillitis, joint pain
Tx:
(Topical) - AB, Steriods, Analgesics
(Systemic) - Oral corticosteroids, NSAIDS
Karposki's Sacrcoma
Ae: HSV 8 , iatrogenic, immunosupressive, AIDS-related
feats: blue-purplish spots
Tx: Excision, low-dose RadTher, if large chemother
Less Common
Mucous Membrane Pemphigoid (MMP)
Ae:
Autoimmune blistering
, unclear?
feats: interepithelial clefting, +ve Nikolsky sign, lesions that burst
Tx:
(correct diagnosis) =
Direct Immunofluorescence
Topical/oral Steroids or sparing or systemic (severity depends)
Erythema Multiforme
Ae: Acute recurrent hypersensitivity reaction
feats: Target lesions on the skin, crusting on the lips, mouth ulceration
nb: SJS would also be a possible (More acute)
Tx: No treatment/pallative care
Oral SCC
Ae:
Established = Smoking, chewing tobacco/betel quid, alcohol, HPV type 16
Strongly suggestive = sunlight, radiation
Feats:
Non-healing lesion for longer than two months
Range: small erythematous patch through to large swelling/ulceration
= Dx: Through a incisional biopsy + inspect nodes
Tx:
Surgery, Radiotherapy or Combination of both
Pemphigus Vulgaris
Ae: Idiopathic? (possible; medications, radiation, surgery, stress)
feats:
blistering
, erosive lesions widespread
Tx:
(correct diagnosis) =
Direct Immunofluorescence
Topical/oral Steroids or sparing or systemic (severity depends)
Geographic Tongue
Ae: Unkown etoiology, can occur at any age
feats: Irregular depapillated, erythematous tongue
Tx: Reassure, for discomfort a topical steroid
Focal Epithelial Hyperplasia
Ae: Viral-induced (HPV 13)
feats: localized proliferation, multiple, non-tender
Tx: self-limiting condition
Varcosities
Ae: degeneration of connective tissue supporting vessels
feats: lips and buccal vessels prominent
tx: None, unless aesthetics concerned
Haemangioma
Vascular lesion, structural deficiencies in the vessels
benign proliferation of vessels
Viscaroties common, bilateral
Assessment:
elicit blancjing from the lesion on pressure
Nicotinic Stomatitis
Ae: tobacco habit
feats: severity related to tobacco use, white lesions w/ red dots
Tx: discontine tobacco use/cessation suppot
Am Tattoo
Ae: Iatrogenic lesions caused during exo, placement, polsihing
feats: grey/black macule
Tx: None
Melanotic Macule - Melanocytic naevus
Ae: accumulation of melanin or increased no. melanocytes feats: flat or elevated smooth papules
nb: ABCDE review for malignacy
ANUG
Ae: Occur in smokers and immunocompromised patients
feats: Ulceration of gingiva papillae + Necrosis + bleeding
Tx: 3 days Metronidazole, debridement, CHX
Solar Keratosis
Ae: skin gets damaged by ultraviolet (UV) radiation from the sun
feats: PMOD, patch of thick, scaly, or crusty skin,
potentially SCC in lower lip/ BCC in upper lip
tx: Avoid direct sun/indoor tanning, use high SPF+, cover!!
Black Hair Tongue
Ae: Heavy smokers, general debilitation, AB, poor oral hygiene, and a hx of radiation
feats: elongated papillae are usually brown, yellow, or black
Tx:
Avoid tobacco, staining foods + periodic scraping/brushing. + 3% hydrogen peroxide.
Orofacial Pain
Definition
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (International association for study of pain)
Acute = <12 wks duration Chronic = contd. LT pain of >3-6 months
Main causes are dental/odontogenic!
--> If ruled out can consider differentials
Differential orofacial pain
Salivary
Obstruction, infection, trauma, benign and malignant tumours and systemic disorders
Vascular
Tension Type Headache
Most prevalent headache in the general population.
Clinically: Bilateral, pressing, mild- moderate pain
30min-7 days
= Induced by stress, fatigue, disturbed meals, menstruation, alcohol and lack of sleep
Management
Ibuprofen, Naproxen or Amitriptyline
Temporal Arteritis (Giant Cell)
Multifocal, granulomatous vasculitis of cranial arteries, esp superficial temporal artery
Clinically: Unilateral throbbing headache
Pain during mastication (Jaw claudication) or wearing of hats
Fever, malaise, fatigue, nausea, anorexia, vomiting, sore throat and earache
Dx: w/ score from criteria
Management
High dose of Oral prednisolone
A low maintenance dose may be required for 3-6 months
Migrane
Severe episodic headache generally associated with nausea and/or light and sound sensitivity
Associated symptoms may include: nausea, vomiting, and sensitivity to light, sound, or smell. Worse by physical activity. Up to 1/3 of people have an aura
Management:
NSAIDs , Triptans
Prevention:
Beta blockers, antidepressant, anticonvulsants
Bone
Osteitis, BRONJ, Trauma, Paget's, disease
Sinus
Sinusitis (Max, frontal, ethmoid, sphenoid)
TMJ
TMD: Refers to the various conditions affecting the TMJ, masticatory muscles and contiguous tissue components
Myogenous or muscle generated pain
Arthrogenous or joint generated pain
Management:
Pharmacological, Behavioral, Physical, Occlusal Splints
Neurological
Trigeminal Nueralgia
Most common of facial neuralgias
nb: V2, V3 > V1
Unilateral intense, sharp, superficial, or stabbing pain in the distribution of one or more branches of V
Medical therapy:
Carbamazepine
Surgical therapy
Microvascular decompression or Ablative procedures
Infection
Post-Hepetic Neuralgia
Most cases of acute herpes zoster are self-limited
= PHN- pain is persisting for anywhere from 1 to 6 post onset
Is resulted from viral-induced nerve injury
Prevention- Antiviral medication
Treatment: Lignocaine patches, topical capsaicin (0.025%) TCAs, gabapentin, and pregabalin
Psychogenic
Atypical Facial Pain
Persistent idiopathic facial pain, in the absence of a neurologic deficit
Dx of exclusion:
Total lack of objective signs
Negative results from all investigations
No clear explanation as to cause
Poor response to treatment
Management:
TCAs or gabapentin as alternative
Burning Mouth Syndrome
Oral dysaesthesia, a burning sensation experienced in the absence of identifiable organic aetiological factors
Dx w/ criteria
Treatment: TCAs, gabapentin ... ect OR Tabasco mouthwash
Referred Pain
From any structure in the H+N, cervical spine or musculature
Lesion Process
Primary lesions
Macule, Papule, Nodules, Plaque, Pustule, Vesicle, Bulla, hive
Secondary lesions
= Due to progression or irritation or infection or primary lesion
Scales, Crust, Erosion, Fissure, Ulcer, Atrophy, Scar