Necrotizing Sialo metaplasia

D/D: Varicella zoster ulcer

Recurrent major aphthous ulcer
Traumatic ulcer
Verrucous carcinoma
Squamous cell carcinoma
Herpetic gingivostomatitis

Investigations:
Complete blood count
ESR
Biopsy- Anitskow cells
CT- to check for the extent
Occlusal Radiograph

Other sites-
Floor of the mouth
Lateral border of the tongue

Treatment:
Surgical excision
Hemi maxillectomy
Radiotherapy
Chemotherapy

Risk factors:
Smoking
Tobacco
Alcohol
Vit Deficiencies
Underlying systemic conditions: uncontrolled diabetes
HIV
Immunosuppression

Base of ulcer- Indurated

Margins of ulcer- Everted
Sjogren’s syndrome:
Primary Sjogren’s syndrome comprises of dry mouth and dry eyes not associated with any
connective tissue disease. ‘Sicca Syndrome’ poorly defined term that is best avoided
because it can be used for any cause of dry eyes and mouth, as well as primary Sjogren’s
syndrome.
Systemic autoimmune disorder of exocrine glands
No associated connective tissue disorder
More severe sicca complex

Secondary Sjogren’s syndrome, comprises of dry mouth and dry eyes associated with
rheumatoid arthritis or other connective tissue disease.
All symptoms of primary Sjogren’s syndrome
Accompanying autoimmune, connective tissue disorder, usually RA
Slower progression, milder ocular symptoms.

Histopathology of Sjogren’s syndrome: 3 points

Polyclonal infiltration mainly by CD4 lymphocytes

Infiltrate initially periductal
Progressive spread of infiltrate through the glandular tissue
Progressive destruction of secretory acini
Proliferation of ducts to form epimyoepithelial islands.

What is the cause of glandular swelling in Sjogren’s:

Parotid swelling is found at some stage in about 30% of patients but is not a common
finding because it is often intermittent. Swollen glands are not inflamed clinically and are
rarely painful. A hot, tender parotid swelling with red, shiny overlying skin would indicate
suppurative parotitis. Bilateral parotid swelling strongly suggests lymphoma.

Which area is biopsied to confirm Sjogren’s syndrome:

Labial Gland Biopsy: If no definitive diagnosis is yet possible, a labial gland biopsy may be
performed. Pathological changes in labial salivary glands correlate closely with those in the
parotid glands, and lip biopsy avoids the risks of damage to the facial nerve inherent in
parotid gland biopsy. However, this test is considerably overrated. A harvest of 6-8 glands is
required. The usual method for assessment is to count the number of foci for lymphocytes
per 4mm^2 of tissue. Although a score of 1 or more is highly suggestive, it is easy to mis-
interpret non-specific inflammation. The Predictive value is probably no higher than 80%
when correctly interpreted.

Radiograph:
Periapical cyst
Radicular cyst
Odontogenic cyst

Occlusal view.. it is the palate.

Mechanisms of cyst enlargement: Two main mechanisms: expansion under internal

hydrostatic pressure and growth of the wall.
Different Origins of odontogenic cysts:
Derived from epithelial residues of the tooth forming organ
The main cyst types derived from each residue are:
Dental lamina rests/ glands of serres
- Odontogenic Keratocyst
- Gingival cyst of new born
- Gingival cyst of adult
- Lateral periodontal cyst
- Glandular odontogenic cyst
- Reduced enamel epithelium
- Dentigerous cyst
- Paradental cyst
- Eruption cyst
- Rests of malaseez
- Radicular cyst.
- Periapical cyst
- Residual cyst
The Incisive foramen:
Other 2 names of this structure: Nasopalatine foramen or Anterior Palatine foramen.
Common congenital lesion could affect: Incisive canal cyst

Name two structures pass through: It transmits the greater palatine artery and vein from
the oral to nasal cavity and the Nasopalatine nerve in the opposite direction. also
sphenopalatine artery.
3 areas to be anaesthetised when anaesthesia is injected into:
Posterior superior Alveolar nerve
Local Infiltration around the tooth
Nasopalatine nerve
Teeth from Canine to canine
Anterior part of hard palate.
Leaf Fibroma:
Most appropriate diagnosis is : leaf fibroma
Causes: Hyperplasia under denture
Chronic irritation to the mucosa from denture
ill fitting dentures

Most common complication: May infarct if stalk becomes twisted

Other denture induced lesions: Denture hyperplasia
Denture sore mouth
Denture induced Granuloma
Papillary hyperplasia of the palate
Kaposi’s Sarcoma
Peripheral giant cell granuloma

Management:
Radiation therapy
Cryotherapy
Laser therapy
Surgical excision
Intralesional vinca alkaloid therapy
Topical retinoids
Antiretroviral treatment
Intralesional vincristine

Other common sites intraorally and extraoral:

Intraorally-
Palate
Buccal mucosa
Gingivae

Extra orally: Typically manifests as bluish-purple macules and plaques on the skin,
particularly of the face and lower extremities.

Dental Management on this patient:

Oral hygiene instructions
Surgical excision

Staging of oral cancer: T3 N3 MX

D/D:
Angiolipoma
Liposarcoma and normal soft fatty tissue

Diagnosis: The Histology Shows that it is lipoma. Their overall incidence in the oral cavity is
thought to be less than 4.4 % of all benign oral mesenchymal neoplasms.

Common sites:
Tongue
Lips
Buccal pad fat
The major salivary glands
Palate
Floor of the mouth.

Tickle the characteristics of this kind of lesions:

Smooth
Soft
Asymptomatic
Slow growing
Superficial
Palpable masses which often impart a yellowish colour to the overlying mucosa
May be pedunculated

Note: Lipomas of the oral cavity are rare , 50% of them are in buccal mucosa and less
common sites are tongue, floor of the mouth and lips.
Soft , painless, mobile
Surgical excision is the main treatment. Recurrence is reduced by wide surgical excision.
2 infiltrating lipomas are difficult to extirpate and are liable to recurrence.

Oral thrush(pseudomembranous Candidosis)

Local Factors:
Trauma
Denture wearing
Poor denture hygiene
Xerostomia
Systemic factors:
Radiotherapy
Antibiotic therapy
Corticosteroid therapy
Extremes of life- infancy and old age
Diabetes mellitus
Nutritional deficiency( iron, folate, vit B12)
Immunosuppression
Cigarette smoking
High carbohydrate diet

Investigations:
Swab
Smear
Biopsy
Screen for nutritional deficiencies
And diabetes
FBC
Ferritin
Folate
Vit B12
glucose

Types:
Pseudomembranous
Erythematous
Hyperplastic
Denture induced stomatitis
Angular cheilitis
Median Rhomboid glossitis

What is significant of the medical condition of the patients in your drug selection?

Azole Antifungals are avoided in patients taking warfarin or lipid-regulating drugs, such as
statins, due to clinically significant drug interactions.

Name two reactive lesions?

Frictional Keratosis
Stomatitis Nicotina
1. Oxygen check monthly for leaks and pressures
2. Adrenaline 1:1000, 0.5 ml
3. Aspirin 325 mg
4. Glucagon 1mg
5. GTN 0.4 mg ( three months shelf life once opened) so spray is better
6. Glucose 50ml of 50% or tablets
7. Salbutamol 100 micrograms
8. Hydrocortisone 100mg
9. Chlorpheniramine 10mg
10. Midazolam 10 mg, Diazepam 10 mg
11. Water for injection
What is the major problem with Mandibular infections:
Spread alongside the fascial planes that surround the airway with subsequent narrowing of
the airway and stridor

Which space infection involved:

Spread via the fascial planes to the mediastinum to cause mediastinitis

What is the basic management of any infection?

Removal of the cause, extraction or RCT
Local drainage or debridement via root canal or incision or drainage

Oral Antibiotics if systemic involvement- Amoxicillin. Metronidazole , which is active against

Anaerobes, can be added to either Amoxicillin or penicillin if the infection is severe. Often
the extraction of the abscessed tooth alone will bring about resolution without antibiotic
therapy. It is important that the Antibiotics are not considered unless there is systemic
involvement. In a child a temp. of 39 degree or higher can be considered significant( normal
37 degree ) .
Erythema multiforme

Extra oral lesion would be target lesions of palms , legs , face or neck

Risk factors:
Herpes simplex infection, usually a cold sore
Genital recurrent herpes
Mycoplasmal pneumonia
Varicella zoster infections
Rarely drug , penicillin’s, Carbamazepine, NSAIDs

Investigations:
Complete blood count
Electrolytes
Biopsy
Virological studies

Management:
Self- limiting without treatment in the minor form. However, oral lesions are painful,
interfere with eating and fluid intake must be maintained. Unless already resolving lesions
seem to benefit from corticosteroids. Prednisolone. Severe forms for supportive therapy
with iv hydration
Azathioprine
Chlorhexidine will prevent Secondary mucosal infection and maintain gingival health while
tooth brushing is impossible. Eye lesions require specialist treatment.

Conditions Associated with the severest forms?

Steven -Johnson’s syndrome
TEN—Toxic epidermal necrolysis.
Port wine stain which is a sign of Sturge weber syndrome

Other manifestations:
Seizures
Paralysis
Glaucoma
Low thyroid

Drug for this condition: Phenytoin

Oral complication: Phenytoin side effects include glaucoma and gingival enlargement

Calcium channel blockers and immunosuppressants cause gingival enlargement

Other two drugs causing gingival enlargement?

Captopril
Cyclosporin
Nifedipine
Amlodipine

Management of oral condition:

Oral complication of Sturge weber is ipsilateral gingival haemangioma

Investigations would be diagnostic:

MRI reveals the CNS abnormalities showing pial vascular enhancement and gyriform
calcifications.
Pyogenic granuloma
Peripheral giant cell granuloma
Papillary hyperplasia

Type of cells in these lesions?

Neutrophils
Giant cells
Plasma cells
Lymphocytes

Final diagnosis: Peripheral Giant cell lesion

Management of this condition: Excision

3 types:
Major
Minor
Herpetiform

This type:
Major Aphthous ulcer

3 drugs can induce:

Nicorandil
Ibuprofen
Oral nicotine replacement therapy
Aspirin
Cocaine

3 systemic diseases associated with ulcers:

Crohn’s disease
Celiac disease
Bechet’s disease
HIV/AIDS

2 associated syndromes?
Behcets syndrome
Chediak Higashi
AIDS
MAGIC syndrome
3 criteria’s for urgent referral
Ulcer more than 3 weeks
Growing in size
Pain and bleeding

Treatment options:
Anti inflammatory treatment
Antiseptic treatment
Antibiotic treatment

Normal number:
150-450 x 10^9 /L
Life span : 8 days ( range 5-9 days)

From where they arise?

Megakaryocytes within bone marrow

Their function in relation to haemostasis:

Platelet Adhesion
Platelet Aggregation

Medical term when they decrease and increase:

Thrombocytopenia, thrombocytosis

Two disorders in which they decrease?

Immune thrombocytopenia
Drug induced thrombocytopenia
Thrombotic thrombocytopenic purpura
Aplastic anaemia
Leukaemia

Other 2 processes of haemostasis?

Vasoconstriction
Coagulation, clotting cascade

Factors for platelet adhesion:

Activated proteins on their surface to allow them to stick to breaks in the vessel wall and
stick to each other
Change shape, extend filaments/ tentacles.
Recruit another platelet to aid plug
Reliant on von- Willebrand factor(vWF)

Diagnosis:
Angioedema due to Anaphylaxis

First line of treatment?

Adrenaline

Dose?500 micrograms (1:1000) IM

Route: IM and
Action of Drugs?
Vasoconstriction in LA
Fight and flight( bronchodilator)
Anaphylactic medication

Lichen Planus

Medications that cause it?

Colloidal gold
Beta blockers
Oral hypoglycaemics
Allopurinol
NSAIDs
Antimalarials
Methyldopa
Penicillamine
Some tricyclic Antidepressants
Thiazide diuretics
Captopril

Treatment
Chlorhexidine mouth wash
Steroids
Immunosuppressants
Retinoic Acid
Histopathology pattern:
Hyperkeratosis
Elongated rete ridges with saw tooth appearance
Dense sub and intra epithelial lymphocyte infiltrate
Degeneration of basal keratinocyte

Types of oral manifestations and suspected Oral Manifestations:

Reticular Pattern of hyperkeratotic epithelia seen bilaterally on the buccal mucosa
Papular
Plaque like
Erosive
Atrophic
Bullous pattern