Disorders of Oropharynx

Dental caries clinical features?

Painless discoloration, may progress to painful tooth erosion with irritates the nerve and leads to temperature sensitivity & tenderness with percussion.

AKA cavities.

Dental caries tx?

• Good oral hygiene

• Dental referral

• Pain management in acute setting: dental wax, NSAIDs, dental blocks

Dental caries cause?

Erosion of enamel due to bacterial activity.

Gingivitis causes?

Inflamed gingival tissue caused by bacterial plaques at gum line.

Gingivitis clinical features?

• redness/swelling of gums

• bleeding with light touch and brushing

• gum recession, exposed roots

Gingivitis tx?

• Oral hygiene

• Dental referral

• Mouthwash with bactericidal properties and/or antibiotic rinse

  • Chlorohexidine

  • Closys (chlorine dioxide)

Xerostomia clinical features?

Very dry mouth (mucosa/tongue), halitosis and difficulty speaking.

Xerostomia tx?

• usually caused as a side effect of medication, so search for medication.

• Artificial saliva (biotene)

• Referral to ENT, Rheumatology, or Endocrinology to rule out autoimmune disorders.

Antibiotic-associated dental disease clinical features?

• permanent tooth discoloration for children < 8 years

• crosses placenta - permanent discoloration from utero exposure & long tubular bones with growth inhbition

Effects are less likely with doxycycline.

Antibiotic-associated dental disease tx?

• Cease long-term use of tetracyclines

• Only use in severe infection cases like Rocky Mountain Spotted Fever (RMSF)

Dental infections clinical features?

• Redness/swelling of gums or face

• Pain with mastication

• Common bacterial causes:

  • Strep Viridans

  • Bacteroides

  • Peptostreptococcus

Dental infections types of absesses (2)?

Periapical (apex of tooth) absess, peridontal abscess (periodontal soft tissues)

Dental infections tx?

• I&D

• Broad-spectrum ABs: Clindamycin, Augmentin (amoxicillin-clavulnate)

• Dental referral

• Root canal

Septic cavernous sinus thrombosis

When infection spreads via the pterygoid venus plexus, typically S. aureus or MRSA.

Septic cavernous sinus thrombosis clinical features?

HA, fever, proptosis (eye bulging), chemosis (sclera swelling), periorbital swelling, and cranial nerve palsies, extra ocular muscle weakness.

Septic cavernous sinus thrombosis imaging?

Preferred imaging is MRI venogram and MRI w/ contrast; can do CT w/ contrast

Septic cavnernous sinus thrombosis tx?

Broad-spectrum ABs: Vancomycin, Ceftriaxone and Cefepime; and anti-coagulation (heparin infusion)

Temporomandibular Joint Syndrome (TMJ)?

Pain within the TMJ potentially caused by:

• Injury

• Poor head/neck (posture muscular attachments)

• Physiological manifestation of stress

• Jaw clenching and grinding

Ludwig’s Angina caused by?

Submandibular space infection: rapidly spreading cellulitis. Typically a bilateral infection of two compartments in the floor of the mouth (sublingual or submylohyoid)

• Caused by Streptococcus Viridans & Bacteroides

Ludwig’s Angina clinical features?

• Fever/Chills/Malaise

• Mouth pain and muffled voice

• Swelling of jaw/neck

• Airway compromise (may need trach)

Ludwig’s Angina dx?

PE findings and CT scan w/ contrast

Ludwig’s Angina tx?

• I&D

• IV broad spectrum antibiotics:

  • Ampicillin-Sulbactam

  • Ceftriaxone + Metronidazole

  • Clindamycin + Levofloxacin

Temporomandibular Joint Syndrome (TMJ) clinical features?

Pain with TMJ and while chewing, popping or clicking within the TMJ, and headaches.

Sometimes mistaken for ear pain.

Temporomandibular Joint Syndrome (TMJ) tx?

NSAIDs, night guard, muscle relaxers.

Temporomandibular Joint Syndrome (TMJ) anterior dislocation sx?

Extreme opening of mouth (eating, yawning, laughing, singing, vomiting, dental treatment)

• TMJ ligament weak or torn, or caused by genetic predisposing factors.

  • Ehlers-Danlos or Marfan syndrome (effects CT disorders)

Temporomandibular Joint Syndrome (TMJ) lateral and posterior dislocation sx?

Rare, usually due to high-energy trauma.

Temporomandibular Joint Syndrome (TMJ) clinical features?

Patient cannot close jaw, need to assess for fracture using CT scan or panoramic X-ray.

Temporomandibular Joint Syndrome (TMJ) tx?

Reduction:

• Soft food diet x 2 weeks

• Avoid extreme opening of jaw x 3 weeks

• Warm compress to TMJ x 24 hours

• Support jaw when yawning

• NSAIDS (ibuprofen)

And specialist referral.

Techniques to relocate TMJ dislocation?

Syringe technique (rolling a syringe in mouth forward and backward) or manual technique (using thumbs to push mandible down and back).

Dental crown fractures (2)

Uncomplicated: enamel or enamel + dentin; complicated: exposed pulp

Dental crown fractures clinical features?

Fractured tooth on exam, dental pain and sensitivity

Dental crown tx?

• Urgent Dental referral for complicated

• Routine dental followup for uncomplicated

• Monitor for additional facial trauma/injuries (CT scan)

Dental root fractures?

Need x-ray to diagnose, usually mobile teeth after injury

Dental root fractures clinical features?

Dental pain and wobbly tooth (tooth laxity)

Dental root fracture tx?

• Dental referral

  • Tooth splint

  • Crown removal and root preservation

Tooth avulsion

True dental emergency, need to focus on preservation the periodontal ligament

• Best practice to keep tooth clean and put back into socket

Tooth avulsion clinical features?

Avulsion of tooth, evaluate for possible alveolar injury (maxillofacial CT scan)

Tooth avulsion tx?

Immediate replanation

• Don’t touch periodontal ligament

• Remove debris with gentle rinse of water or saline

• Manually replant tooth

Tooth culture media or cold milk if unable to replant, or saliva

Tooth luxation

Movement of tooth out of socket, usually due to trauma or injury. Can be:

• Intrusion: up into the socket

• Luxation: lateral or posterior

Tooth luxation clinical features?

Tender teeth with bleeding, obvious deformity of tooth in socket, recommend advanced imaging to evaluate alveolar process.

Tooth luxation tx?

Reduce teeth promptly:

• May require local anestheia, splinting or gingival sutures (to save tooth)

• May require root canal

Dental or oromaxillofacial surgery referral neededx

Maxilla and midline fractures

• Usually occurs because of high-energy trauma

• Maxilla/facial bone fractures

• Potentially serious complications to the vasculature, glands, muscles, nerves

Maxilla and midline fractures clinical features?

Need to see mechanism of injury:

• Contusion, ecchymosis (bruising), malocclusion, enopthalmos (sunken eyes), extraocular muscle not intact.

• Bleeding

• Dysphonia (abnormal voice) or edema or oropharynx

  • Risk of airway compromise

• Nasoethmoid fractures - CSF leak (risk of meningitis)

• Lefort fractures

Maxilla and facial fractures tx?

• Evaluate with maxillofacial CT scan

• Repair lacerations

• Plastic surgery/oral maxillofacial surgery consult

Mandibular fracture imaging?

U-shape makes plain film difficult, requires panorex or CT scan.

• Secondary to bone structures it is typical to see multiple fractures

Mandibular fracture clinical features?

Malocclusion, bleeding at gums, step-off, pain with mastication.

Mandibular fractures tx?

Oral maxillofacial or plastic surgery consult, soft and pureed diet.

Herpes Simplex Virus infection

Recurrent vesiculoulcerative lesions around the mouth or genitals.

• Usually painful vesicles or ulcers.

• Typically HSV 1, but can be HSV 2

• Recurrent infections are common because latency period is in the neural ganglia, factors involve: sunlight, trauma, or emotional stress, URI

Herpes Simplex Virus clinical features?

• painful, itchy ulcers or lesions on the oral or genitals that become crusted lesions on the lip

  • gingivostomatitis

• can present as ulceration within the mouth (cold sores)

• fever, HA, cervical or submandibular lymphadenopathy

• self-resolves in 1-2 weeks

Herpes Simplex Virus dx testing?

Viral culture & PCR swab - swab the open sore; or Tzanck smear, that shows giant multinucleate cells

Herpes Simplex Virus tx?

Usually self-resolves but can use OTC tx and some antivirals.

• OTC: abreva, campho-phenique

• Acyclovir or valacyclovir reserved for severe causes

Aphthous Stomatitis aka canker sores

Present as painful ulcers in the oral mucosa and heal within 7-14 days, pathogenesis is known to be multifactoral (immune dysregulation, trauma, or associated with B12 deficiency).

Aphthous Stomatitis clinical findings

Buccal and labial mucosa that turns into a painful ulcer within 1-2 days.

Aphthous Stomatitis dx testing

Hx & PE - can search for additional causes like B12 deficiency, iron levels, skin conditions, or autoimmune diseases

Aphthous Stomatitis tx

First line tx is topical corticosteroids: dexamethasone elixir.

• Reduce aggravating factors/foods

• Pain control

• Abx mouth rinse (chlorhexidine)

• Anbesol - topical coating to encourage epithelization

• Debacterol - helps to debrief ulcer and encourage epithelization

Oral candidiasis (thrush)

Typically infestatiton of Candida albicans

Oral candidiasis clinical findings

• Dry mouth, pain while eating/swallowing, loss of taste

• Infants/elderly are more commonly affected

  • Immunocompromised, dentures, antibiotics, or inhaled corticosteroids, AIDS

Oral candidiasis diagnostic studies

KOH prep slide, can see hyphae or budding yeast

Oral candidiasis tx?

• Pediatrics: Nystain

• Adults: Clotrimazole lozenge

• Adults (severe): Fluconazole

Oral leukoplakia

Painless white patches that can’t be scraped off, irregular with sharply defined borders. Considered precancerous.

Oral erythroplakia

Potentially painful red macule or patch that is soft in texture, considered cancerous.

Oral leukoplakia or erythroplakia diagnostic studies

KOH prep or biopsy (non-healing, nodularity, bleeding, rapid change/growth)

Oral leukoplakia or erythroplakia clinical features

Can lead to SCC and associated with chronic tobacco and ETOH use

Oral leukoplakia or erythroplakia tx

Monitor, cryotherapy abaltion (precancerous), surgical exision (cancerous)

Lichen Planus

Lace-like pattern typically affecting the skin, scalp, oral cavity, genitalia, and nails. Thought to be immune-mediated by activated T-cells.

Lichen Planus clinical features?

Lace-like pattern in the mucous membrane

• Erosive mucous membrane dz - painful

• Loss of appetite due to pain assoc. with eating

Lichen Planus dx?

Hx & physical, need biopsy to support dx but also to rule out malignancy.

Lichen Planus tx?

First line - topical corticosteroids (Clobetasol)

• No cure, just need to alleviate sx

• Oral steroids for those who fail topical (Prednisone)

Graft Versus Host Disease (GVHD)

Associated with a hx of transplant; results as a complication of transplant when immune cells are recognized as foriegn.

Graft Versus Host Disease (GVHD) clinical features

Skin rash & painful mucosa ulcerations

Graft Versus Host Disease (GVHD) tx?

• Topical steroids

• Topical tarcolimus (for transplant rejection)

• Specialist - oncologist (stem cell transplant)

Lupus oral lesions

Chronic autoimmune dz that has multi-organ involvement; 12-45% of lupus patients develop oral lesions

Lupus oral lesions clinical features?

white or erythematous plaques, with punched out ersions/ulcers on the soft or hard palate and/or buccal mucosa.

Lupus oral lesions tx?

• Topical corticosteroids

• Tacrolimus 0.1% ointment

• Hydroxychloroquin

Bullous Pemphigoid

autoimmune dz, subepithelial blister formations

Bullous Pemphigoid clinical findings

Blister formation in the mouth

Bullous Pemphigoid dx?

Tissue biopsy

Bullous Pemphigoid tx?

Topical corticosteroids (Clobetasol propionate)

• Systemic corticosteroid (severe cases)

Erythema multiforme

immune-mediated condition with target-like lesions on skin and erosions in the oral mucosa.

Erythema multiforme clinical features

70% of people with erythema multiforme can develop oral lesions

• Affect the vermillion lip and mucosal surfaces, gingiva and tongue

Erythema multiforme dx?

Hx + physical and recent herpes tx, biopsy

Erythema multiforme tx?

Only focus on sx relief:

• Lidocaine mouthwash (lidocaine, diphenhydramine, aluminum hydroxide)

• Oral glucocorticoid therapy

Steven Johnson’s Syndrome/Topic Epidermal Necrolysis

• Severe mucocutaneous rxn

• Mostly triggered by medications (ABs)

• Mucuous membranes affected 90% of patients

• Less severe (SJS) and more severe (TEN)

Steven Johnson’s Syndrome/Topic Epidermal Necrolysis clinical findings

• painful hemorrhagic erosions

• diffuse

• high risk of bacterial infection (bacteremia & sepsis)

Steven Johnson’s Syndrome/Topic Epidermal Necrolysis tx?

• Supportive care

• Pain control

• Hospitalization/burn unit/ICU

• AB for secondary infection

Glossitis

Inflammation of the tongue, caused by nutritional deficiencies, drug reactions and xerostomia.

• Forms: geographic tongue, strawberry tongue, and atrophic tongue.

Glossodynia

Tongue pain (burning), can occur with glossitis.
aka “burning mouth syndrome”

tx: supportive care

Mucocele

Caused by trauma (lip biting) disrupting the minor salivary glands.

Mucocele clinical findings

Pink/blue soft papule or nodule in varying sizes, typically found on the lower lip.

Mucocele tx?

Can pop or drain with an 18 gauge needle, but is also self-resolving.

Black hairy tongue or Lingua Villosa Nigra

Elongated filiform papillae (due to inadquare desquamation), has yellowish-brown discoloration of tongue surface

• Seen with smoking, AB use and poor oral hygiene

• Benign and often asymptomatic.

Black hairy tongue or Lingua Villosa Nigra clinical features?

Not painful, yellowish-brown discoloration

Black hairy tongue or Lingua Villosa Nigra tx?

Brushing or scraping 2-3x daily and improved oral hygiene.

Oral cancer (squamous cell carcinoma)

90-95% of oral cavity lesions, develops through premalignant changes (leukoplakia/erythroplakia) carcinogen exposure.

Associations with:

• Tobacco/ETOH

• Genetic

• HPV

Oral cancer SCC clinical findings

Mouth/throat cancer can be present with otalgia (ear pain)

• Lesion on mucosa or tongue (hard, firm, non-healing wound)

  • Remove dentures to fully check for complete PE

• Neck mass

Oral cancer SCC tx

• surgical excision, chemo/radiation

• Oncology/ENT referral

Oral cancer melanoma

Most serious form of oral cancer, mucosal has worse prognosis than cutaneous melanoma

Oral cancer melanoma clinical features

Hyperpigmented lesion within the oral cavity and mucosa

Oral cancer melanoma tx?

Wide local surgical resection, risk of morbidity with aggressive resection and balance against risk of metastatic disease

Sialoadenitis

inflammation of one of the three salivary glands: parotid, submandibular or sublingual

• Sudden enlargement & pain along affected gland

• Obstructive, infectious or inflamatory

• Can be viral or bacterial