Mouth and Throat disease

In which populations is poor dental hygiene common?

The poor; young; and elderly.

What is the most common childhood disease?

Dental caries.

What is the most common bacterium causing tooth decay?

S. mutans.

Define Gingivitis?

Reversible inflammation of the gingiva due to plaque; can progress to periodontitis.

What causes Periodontitis?

Chronic inflammation of the gingiva and support tissue by gram-negative bacteria.

If periodontitis occurs in pediatric patients or progresses rapidly; what systemic diseases should be considered?

DM; Down syndrome; neutropenia; leukemia; histiocytosis.

How does gingivitis/periodontitis present clinically?

Interdental papillae edema; erythema and bleeding; tartar build up and loose teeth in severe cases.

What systemic conditions are associated with periodontitis as a risk factor?

CVD; DM; poor pregnancy outcomes.

What is the key treatment approach for periodontitis?

Treat w/chlorhexidine mouthwash; professional dental care; periodontal surgery.

What is the majority of oral pain related to?

Inflamed or injured tooth pulp or periodontal disease.

What are common dental causes of oral pain?

Dental caries; abscess.

What are examples of non-dental oral pain conditions listed?

Myofascial pain from muscles of mastication; Bruxism (grinding of teeth); Temperomandibular joint disorder; Osteoarthritis; Rheumatoid arthritis; Migrainous neuralgia; Trigeminal neuralgia; Glossopharyngeal neuralgia; Bell’s palsy; Herpes Zoster; Maxillary sinusitis.

How should dental/oral pain typically be treated conservatively?

Acetaminophen or NSAIDs; consider narcotics sparingly if necessary.

What are listed types of oral (odontogenic) infection?

Caries; Pulpitis; Acute gingivitis; Periodontitis; Dental abscess; Osteomyelitis.

When are antibiotics indicated for oral (odontogenic) infections?

If fever; lymphadenopathy; rapidly progressing disease; or immunocompromised.

What is Leukoplakia caused by?

Hyperkeratosis related to chronic irritation.

What percentage of leukoplakia lesions are dysplastic or early invasive squamous cell carcinoma?

A small percentage.

In whom is leukoplakia most common?

Middle aged and older men.

What are the clinical findings of Leukoplakia?

White lesion on mucosa; Can NOT be rubbed off; Can be very small or up to a few centimeters.

How is Leukoplakia diagnosed and treated?

Diagnosed with punch biopsy; Treatment is excision.

In which patient populations is Hairy Leukoplakia most prevalent?

HIV patients; also s/p organ transplant.

What virus and medication are associated with Hairy Leukoplakia?

Epstein Barr virus (EBV) and long term corticosteroid use.

How does Hairy Leukoplakia present?

Slightly raised areas of leukoplakia develop rapidly on lateral border of tongue w/ “hairy” surface; Waxes and wanes; moderately irritative.

What is the temporary treatment for Hairy Leukoplakia?

Acyclovir or valacyclovir.

What is Erythroplakia related to?

Hyperkeratosis related to chronic irritation.

What risk factors are most often associated with Erythroplakia?

Tobacco and alcohol use.

What percentage of erythroplakia lesions transform into malignancy?

90%.

In whom is Erythroplakia most common?

Older patients.

What are the clinical findings of Erythroplakia?

“fiery” red; well demarcated lesions of the mucosa; May be flat/depressed; Smooth or granular.

How is Erythroplakia diagnosed and treated?

Diagnosed with biopsy; Treatment is excision w/clear margins.

What is Oral Lichen Planus?

Uncommon autoimmune condition related to chronic inflammation.

In whom does Oral Lichen Planus usually occur?

Middle-aged and elderly women.

What systemic disease is Oral Lichen Planus associated with?

Hepatitis C.

What are the variable presentations of Oral Lichen Planus?

Reticular; atrophic/erosive; bullous.

Where does Oral Lichen Planus most commonly occur?

On the buccal mucosa; tongue and gingiva; and occurs bilaterally.

What specific clinical findings are characteristic of Oral Lichen Planus?

Wickham striae; Painful/burning; may have ulcerations; Usually associated with dermal lichen planus.

How is Oral Lichen Planus diagnosed?

With punch biopsy or direct immunofluorescence.

What is the treatment goal for Oral Lichen Planus?

To decrease pain.

What is the primary treatment for Oral Lichen Planus?

Daily topical mid/high potency corticosteroid (clobetasol).

What are alternative treatments for Oral Lichen Planus if unresponsive to steroids?

Cyclosporines; Retinoids.

What is the most common histological type of oral cancer?

Squamous cell carcinomas.

What risk factors are associated with oral cancer etiology?

HPV accounts for 26-70% of cases (more common in white men; younger patients); tobacco and alcohol use.

Where is oral cancer most common?

On the tongue; lips; floor of mouth.

What is notable about oral cancer at the time of diagnosis?

Most are advanced at diagnosis.

How is oral cancer diagnosed?

Biopsy any non-healing white or red lesion present > 2 weeks; CT or MRI to determine extent of disease and LN involvement for staging.

What physical characteristics should raise high suspicion for Oral Cavity Squamous Cell Carcinoma (SCC)?

Raised; firm; white lesions with ulceration.

What size lesions are unlikely to metastasize in Oral Cavity SCC?

Lesions <4 mm.

What is the treatment for Oral Cavity SCC lesions <2 cm in diameter?

Cured w/local resection.

What treatment is required for large Oral Cavity SCC tumors?

Resection; neck dissection; and external beam radiation; reconstruction.

When is radiation indicated for Oral Cavity SCC?

For positive margins or metastatic disease.

How does Oropharyngeal SCC tend to present?

Later; lesions tend to be deep in lymphoid tissue or tonsils.

What is Oropharyngeal SCC associated with?

Tobacco; alcohol; and HPV (usually type 16).

Which type of Oropharyngeal SCC has a worse prognosis?

Tobacco/alcohol related.

What are the symptoms of Oropharyngeal SCC?

Unilateral odynophagia; weight loss.

What is Necrotizing Ulcerating Gingivitis (NUG) also known as?

“trench mouth”.

What organisms cause NUG?

Anaerobic Fusobacterium and spirochetes.

How does a patient with NUG present systemically?

Fever; malaise; lymphadenopathy; Foul breath; Metallic taste.

What are the clinical features of NUG in the mouth?

Painful; edematous papillae between teeth; Ulcers w/overlying pseudomembrane; Gingiva is inflamed; friable; and necrotic.

What is the treatment for NUG?

Warm peroxide or chlorhexidine rinses; Topical and oral analgesia; PCN TID x 10 days.

What is the proposed etiology of Aphthous Ulcers (Canker Sores)?

Unclear etiology; HHV6?; associated with stress.

Where do Aphthous Ulcers typically occur?

On buccal mucosa.

What is the clinical presentation of Aphthous Ulcers?

Small round ulcerations w/yellow-gray fibrous center; Surrounded by red halo; Painful.

What is the treatment for Aphthous Ulcers?

Diclofenac 3%; doxycycline-cyanoacrylate; Cimetidine for recurrent cases; Prednisone taper x 1 week.

What is the severity of Herpes Stomatitis in immunocompetent patients?

Very common and mild; no treatment needed.

What oral pathology is caused by Herpes virus reactivation?

Burning; small vesicles that rupture and then scab.

Where are Herpes Stomatitis lesions typically found?

On lip; tongue; buccal mucosa; and soft palate.

What systemic symptoms accompany Herpes Stomatitis presentation?

Painful ulcerations; fever & malaise; lymphadenopathy.

What is the treatment for Herpes Stomatitis?

Acyclovir 5x daily x 7-10 days; Valacyclovir BID x 7-10 days.

What are the most common causes of Viral Pharyngitis?

Rhinovirus; also coronavirus; adenovirus; HSV; parainfluenzae.

What are the common clinical symptoms of Viral Pharyngitis?

Sore throat; Cough; Rhinorrhea.

What are the clinical findings upon exam for Viral Pharyngitis?

Vesicular or petechial pattern on soft palate; Cervical lymphadenopathy.

What is the treatment for Viral Pharyngitis?

Symptomatic w/hydration; acetaminophen or NSAIDs; rest; IV fluids if unable to tolerate PO fluids or dehydrated.

What organisms are commonly associated with Bacterial Pharyngitis/Tonsillitis?

Group A beta hemolytic strep (GABHS); Neisseria gonorrhea; Mycoplasma; Chlamydia trachomatis.

What is the most common cause of bacterial pharyngitis in children aged 3-14 years?

GABHS.

What are the components of the CENTOR criteria for Strep throat?

Cervical lymphadenopathy; Exudates; NO cough; Temperature >38 ˚C; Age.

What diagnostic tests are used for GABHS and their respective sensitivities?

Rapid antigen (90-99% sensitive); Throat culture (90-95% sensitive).

What are the first-line antibiotic treatments for Streptococcal Bacterial Pharyngitis?

PenVK 500 mg BID x 10 days; cephalexin 500 mg BID x 10 days; Azithromycin 500 mg daily x 3 days.

What causes Scarlet Fever?

Pyrogenic streptococcal exotoxins.

How is the rash of Scarlet Fever described and where does it start/spread?

Scarlatine erythematous rash w/fine red papules creating “sandpaper” rash; Starts on trunk; spreads to extremities; spares palms and soles.

Where is the Scarlet Fever rash most severe?

In groin and axilla (Pastia’s lines).

What specific facial finding is associated with Scarlet Fever?

Circumoral pallor.

What oral finding is characteristic of Scarlet Fever?

“strawberry tongue”.

What is the treatment for Scarlet Fever?

Supportive care; PCN.

What causes Acute Post-Streptococcal Glomerulonephritis (APSGN)?

Nephritogenic strains of GABHS; immune-mediated process.

When does APSGN onset usually occur after pharyngitis?

1-3 weeks.

What is the presentation of APSGN?

Hematuria; Dysuria; Edema; HTN; renal failure; HA; malaise; anorexia; flank pain.

How is APSGN diagnosed?

ASO titers; Anti-DNAse; Anti-hyaluronidase Ab; Biopsy.

What is the treatment for APSGN?

Supportive management; Control HTN; edema; Hemodialysis prn; Antibiotics (PCN).

What is Rheumatic Fever?

Systemic immune response to beta-hemolytic strep.

When does Rheumatic Fever onset typically occur after pharyngitis?

2-3 weeks.

In whom is Rheumatic Fever most common?

Children 5-15 years.

Which heart valve is most often affected by Rheumatic Fever?

Mitral valve (75-80%).

What are the major clinical presentations of Rheumatic Fever (Jones Criteria major manifestations)?

Carditis; Arthritis; Chorea; Subcutaneous nodules; Erythema marginatum.

How is Rheumatic Fever diagnosed using the Jones Criteria?

2 major criteria OR 1 major + 2 minor criteria; Evidence of Streptococcal infection via culture or ASO titers.

What is considered the most definitive manifestation of Rheumatic Fever?

Sydenham chorea.

What is the treatment for Rheumatic Fever?

Bed rest; NSAIDs (for fever and joint pain); Penicillin 1.2 million units IM once.

What is the alternative antibiotic for Rheumatic Fever if the patient is PCN allergic?

Erythromycin.

What are complications of Rheumatic Fever?

Heart failure; rheumatic valve disease; arrhythmias; pericarditis.

What is the key to preventing recurrence of Rheumatic Fever?

Prophylaxis with Penicillin G x 5 years (500 mg once daily OR 1.2 million units IM q 4 weeks).

How is Gonococcal Pharyngitis transmitted?

Via oral sex; and occurs simultaneously with genital gonorrhea.