Oral Medicine

Salivary Glands Important Notes

1. Sialolith is common in the submandibular gland due to

• Tortuous course of Wharton’s duct
• Higher calcium and phosphorous content
• Dependent position of submandibular salivary gland

2. Various terms

3. Mucocele

• Originates due to rupture of salivary duct following trauma
• Results in pooling of saliva
• Types
  • Extravasation
  • Retention

4. Ranula

• Associated with sublingual gland
• Causes swelling in the floor of the mouth below the tongue

5. Syndrome

6. Causes of xerostomia

• Duct calculi
• Sialadenitis
• Drugs like anticholinergic, sympathomimetics, tricyclic antidepressants, bronchodilators, diuretics
• Sjogren’s syndrome
• Patients under radiotherapy
• Ectodermal dysplasia
• Parkinson’s disease
• Diabetes

Oral Medicine Salivary Glands Long Essays

Question 1. Enumerate autoimmune diseases. Discuss clinical features, diagnosis, And management of Sjogren’s syndrome
or
Classify functional disorders of salivary glands. Discuss the etiology, clinical features, diagnosis, and management of Sjogren’s syndrome.

Answer:

Autoimmune Disorders:

• Associated with mucocutaneous lesions « Recurrent aphthous ulcer
  • Behcet’s disease
  • Pemphigus
• Salivary gland
  • Mikulicz’s disease a Sjogren’s syndrome
• Blood disorder
  • Pernicious anemia
  • Purpura
• Collagen disorder
  • Systemic lupus erythematous
  • Scleroderma
  • Rheumatic arthritis
• Miscellaneous
  • Myasthenia gravis
  • Oral submucous fibrosis

Salivary Glands Functional Disorders:

• Sialorrhoea
• Xerostomia

Read And Learn More: Oral Medicine Question and Answers

Sjogren’s Syndrome:

• It is a chronic autoimmune disease
• Characterize by oral and ocular dryness, exocrine dysfunction, and lymphocytic infiltration

Salivary Glands Types:

1. Primary:

• It involves the salivary and lacrimal gland

2. Secondary:

• It also involves other connective tissue diseases (rheumatoid arthritis, scleroderma)

Etiology:

• It is unknown

Salivary Glands Presentation:

• Decreased salivary function
• Dry mouth
• Difficulty in chewing, swallowing, and speech
• Increased risk of caries
• Altered taste
• Diy cracked lips
• Angular cheilitis
• Mucosa is painful and sensitive to species
• Mucosa is pale and dry
• Friable or furrowed
• Minimal salivary pooling
• The tongue is smooth and painful
• Increased dental caries and erosion of enamel
• Susceptible to infection
• Increased risk of developing malignant lymphoma
• Difficulty in wearing dentures
• From one-third to one-half of the patients have diffuse, firm enlargement of major salivary glands
• Swelling is usually bilateral
• Maybe non-painful or slightly tender
• May be intermittent or persistent
• Due to decreased salivary flow, there is a high risk of bacterial sialadenitis

Salivary Glands Lab Investigations:

• Hypergammaglobulinemia
• Autoantibodies: anti-SS-A and anti-SS-B
• Elevated sedimentation rate
• Decreased WBC
• Monoclonal gammopathies
• Hypocomplementemia
• Rose Bengal test:
  • Keratoconjunctivitis sicca is characterized by corneal keratotic lesion, which stains pink when rose Bengal dye is used
• Schirmer’s test:
  • A strip of filter paper is placed in between the eye & eyelid to determine the degree of tears measured in mm
  • If it is < 5 mm in 5 min, it is positive
• Sialometry:
  • It estimates the salivary flow rate
  • In Sjogren’s syndrome, it is reduced to 0.5- ml/min(Nl-1.5)

Radiographic Features:

• Sialography:
  • It typically demonstrates a “cherry blossom” appearance
  • Scintigraphy:
    • It shows the decreased flow and delayed emptying of iso¬tope

Differential Diagnosis:

• Chronic bacterial and granulomatous infection
• Multiple parotid cysts associated with HIV
• Diffuse cervical lymphadenopathy is common in HIV but not in Sjogren’s syndrome

Salivary Glands Management:

• Treated symptomatically
• Dry eyes managed by periodic use of artificial tears
• Conserve the tear film by use of sealed glasses to prevent evaporation
• For Xerostomia: use of sugarless candy or gum
• Use of oral hygiene products that contain lactoperoxidase,
• lysozyme and lactoferrin
• Ex: Biotene toothpaste and mouth rinse, oral balance gel
• Sialogogues such as pilocarpine (dose: 5 mg TDSj are used
• Due to the high risk of caries in these individuals daily fluo¬ride application is done

Question 2. Classify salivary gland disorders. Write in detail about the etiology, clinical features, and management of bacterial sialadenitis.

Answer:

Salivary Glands Classification:

1. Developmental Anomalies:

• Agenesis
• Atresia
• Hypoplasia
• Ectopic

2. Obstructive Lesions

• Mucocele
• Sialolithiasis

3. Infective Lesions:

• Bacterial sialadenitis
• Viral sialadenitis

4. Immune Disorders:

• Sjogren’s syndrome
• Mikulicz’s disease

5. Functional Disorders:

• Ptyalism
• Xerostomia

6. Salivary Glands Tumours:

• Epithelial Tumours:
  • Adenomas
  • Pleomorphic adenoma
  • cystadenoma
  • Basal cell adenoma
  • Warthin’s tumour
• Carcinoma
  • Adenocarcinoma
  • Epidermoid carcinoma
• Non Epithelial Tumours:
  • Fibroma
  • Lipoma
  • Lymphoma
•  Malignant Lymphoma
• Secondary Tumours
• Unclassified Tumours
• Tumour Like Lesions
  • Sialadenitis
  • Oncocytosis
  • Necrotizing sialometaplasia

Bacterial Sialadenitis:

• It is a bacterial infection of the salivary glands

Etiology:

• Microorganism: staphyloma / streptococci
• Decreased host resistance
• Poor oral hygiene
• Dehydration

Clinical Features:

• Age: older age
• Site: common in the parotid

Presentation:

Unilateral enlarged and tender gland
↓
Elevation of ear lobes
↓
Redness of overlying skin
↓
Generalized symptoms
↓
Cervical lymphadenopathy

Management:

• Maintenance of oral hygiene
• Soft diet
• Maintenance of electrolyte balance
• Surgical drainage if the above measures fail

Oral Medicine Orofacial Pain Important Notes

1. Trigeminal neuralgia/ Fothergiirs disease

• Characterized by stabbing or lancinating pain
• Initiated by touching the trigger zones
• These are the vermillion borders of the lip, around the eyes, ala of nose

2. Drugs used in the treatment of trigeminal neuralgia

• Gabapentin
• Pregabalin
• Oxycarbamazepine
• Phenytoin
• Lamotrigine
• Topiramate
• Pimozide

3. Dose of carbamazepine for trigeminal neuralgia

• Initial dose – 200 mg/day
• Increased to 800-1200 mg/day

4. Bell’s palsy

• Manifests as
  • Drooping of the corner of the mouth
  • Drooling of saliva
  • Watering of eye
  • Inability to blink
  • Patient as an expressionless face
  • Speech difficulty
  • Loss of taste in the anterior part of the tongue

5. Frey’s syndrome

• Occurs due to damage of the auriculotemporal nerve following surgery in the parotid or mandibular ramus area
• The patient exhibits flushing and sweating of the involved side of the face

6. Migraine

• It is the most common vascular headache
• Causes pain of the face and jaws
• Occurs due to vasoconstriction of intracranial vessels followed by vasodilation
• Basilar migraine is common in young women
• Drugs used are: ergotamine and sumatriptan

Read And Learn More: Oral Medicine Question and Answers

7. Cluster headache

• It is unilateral
• Most painful of all headaches
• Periorbital pain is common
• Associated with homolateral lacrimation

Oral Medicine Orofacial Pain Long Essays

Question 1. Write a differential diagnosis of orofacial pain. Write a note on the etiology, clinical features, and management of idiopathic trigeminal neuralgia.
OR
Define pain. Describe trigeminal neuralgia including its management.

Answer:

Trigeminal Neuralgia Definition:

Pain is an unpleasant emotional experience initiated by noxious stimuli and transmitted over the specialized neural network to CNS

Orofacial Pain:

• Differential diagnosis

Trigeminal Neuralgia Extracranial Causes:

• Dental and oral
• Dentinal hypersensitivity
• Pain due to pulpal disorders: hyperemia
• Pain due to periodontium disorders
• Mucogingival pain: gingivitis
• Osseouspain: dry socket
• Pain from paranasal sinuses
• Musculoskeletal: eagle’s syndrome

Trigeminal Neuralgia Intracranial Causes:

• Disorders of pain receptors
• Neoplasms
• Edema

Trigeminal Neuralgia Vascular Causes:

• Migraine headache
• Tension headache
• Neurogenic Pain:
• Syndrome Associated: Reiter’s syndrome
• Psychogenic Pain: Anxiety

Idiopathic Trigeminal Neuralgia:

• Etiology:
  • Pathological
  • Environmental
• Dental pathosis -Allergic
• Traction on divisions of the trigeminal nerve.- Irritation to the ganglion
• Ischaemia – secondary lesions
• Aneurysm of internal carotid artery

Trigeminal Neuralgia Clinical Features:

• Age: around 35 years
• Sex: common in female
• Site: right lower portion of the face, usually unilateral
• Duration: a few seconds to a few minutes
• As time passes duration between the cycles decreases
• Nature: stabbing or lancinating
• Aggravating factors: activation of Trigger Zones
• These are the Vermillion border of the lip, around the eyes, ala of nose
• Interference with other activities:
• The patient avoids shaving, washing their face, chewing, and brushing, as these may aggravate pain
• These lead to a poor lifestyle
• Extreme cases: leads to “Frozen Or Mask Like Face”

Trigeminal Neuralgia Management:

1. Medical:

• Carbamazepine: initial dose:100mg twice daily until relief is achieved
• Dilantin: 300-400mg in single or divided doses
• Combination therapy: dilantin + carbamazepine

2. Surgical:

• Injection of alcohol in gasserian ganglion
• Nerve avulsion: performed on the lingual, buccal or mental nerve
• Part of the nerve is sectioned
• Electrocoagulation of gasserian ganglion: diathermy is done
• Rhizotomy: Trigeminal sensory root is sectioned
• Newer technique: Tens
• Low-intensity current is used at high frequency is applied to the skin through electrodes attached by a conduction paste

Oral Medicine Orofacial Pain Short Essays

Question 1. Bell’s palsy.

Answer:

Bell’s palsy

• Idiopathic paralysis of the facial nerve of sudden onset

Etiology: 5 Hypothesis:

• Rheumatic
• Cold
• Ischaemia
• Immunological
• Viral

Bell’s palsy Clinical Features:

• Pain in post auricular region
• Sudden onset
• Unilateral loss of function
• Loss of facial expression
• Absence of wrinkling
• Inability to close the eye
• Watering of eye
• Inability to blow the cheek
• Obliteration of nasolabial fold
• Loss of taste sensation
• Hyperacusis
• Slurring of speech

Bell’s palsy Management:

1. Physiotherapy:

• Facial exercises
• Massaging
• Electrical stimulation

2. Protection to eye

• Covering of eye with a bandage

3. Medical management

• Prednisolone – 60-80 mg per day
  • 3 tablets for 1st 4 days
  • 2 tablets for 2nd 4 days
  • 1 tablet for 3rd 4 days

4. Surgical treatment

• Nerve decompression
• Nerve grafting

Question 2. Atypical facial neuralgia.

Answer:

It refers to a mixed group of conditions which are defined and diagnosed by the exclusion of other typical patterns of facial pain

Atypical facial neuralgia Clinical Features:

• Age and sex: More common sixth-decade women
• Features:
  • Deep, poorly localized pain
  • Pain is often boring, pressing, burning, pulling or aching
  • Pain is constant
  • Pain is referred to the temple, neck, and occipital area
  • The mucosa of the affected area may contain a zone of increased temperature and bone marrow activity

Atypical facial neuralgia Management:

• Opioid analgesic:
• Tricyclic antidepressants like amitriptyline
  • Psychotherapy
  • Behavior modification
  • Transcutaneous electrical nerve stimulation
• Sympathetic nerve block

Oral Medicine Orofacial Pain Short Answers

Question 1. Bell’s sign.

Answer:

Bell’s sign

• Seen in Bell palsy
• The inability to close the eye occurs in it
• On attempting to close the eye, the eyeballs roll upwards
• This peculiar sign is called “Bell’s Sign”

Question 2. TENS therapy.

Answer:

TENS therapy

• It is one of the popular forms of pain control
• It employs low-intensity current at a high frequency of 50 to 100 Hz
• It is applied to the skin via electrodes attached by a conduction paste
• It is used to stimulate nonnociceptive cutaneous afferent neurons that activate descending pain inhibition mechanism without involving opioid peptides
• The analgesic effect ranges from 50 to 70%

Question 3. Classification of headache.

Answer:

Classification Of Headache:

1. Migraine headache
2. Tension-type of headache
3. Cluster headache
4. Miscellaneous headache
5. Traumatic headache
6. Headache due to vascular causes- hematoma
7. Headache due to nonvascular causes- due to increased pressure
8. Headache due to substance abuse- alcohol
9. Headache due to systemic infection
10. Headache due to metabolic disorders
11. Headache due to referred pain- from ear, etc.
12. Cranial neuralgia- trigeminal neuralgia
13. Unclassified headache

Question 4. Alarm clock headache.

Answer:

Alarm clock headache

• It is a feature of sphenopalatine neuralgia
• Its attack develops regularly
• Usually, it develops once at day time over a prolonged period
• Some patients experience it at the same time daily
• Thus it is referred to as an alarm clock headache

Oral Medicine Orofacial Pain Viva Voce

1. Herpetic inflammation of 7 cranial nerves leads to geniculate neuralgia
2. Conjunctival reddening is observed in cluster headache
3. Cluster headache is triggered by smoking
4. Post-herpetic neuralgia can be treated by analgesics and tricyclic antidepressants
5. Auriculotemporal nerve damage leads to Frey’s syndrome
6. Pain in trigeminal neuralgia occurs on touching the trigger zones
7. Cluster headache is the most painful of all headaches
8. Carbamazepine is drug of choice in trigeminal neuralgia

Developmental Disorders Important Notes

1. Developmental defects

2. Syndromes associated with fissured tongue

• Melkerson Rosenthal syndrome
• Down’s syndrome

3. Synonymsforgeographictongue

• Erythema migrans
• Wandering rash
• Benign migratory glossitis

4. Ghost teeth/ Regional odontodysplasia

• Etiology:
  • Defect in mineralization
• Clinical features:
  • Enamel and dentin are very thin
  • The pulp chamber is extremely large
  • Maxillary anterior teeth are more frequently involved

5. Dentinogenesis imperfecta

6. Defect in the papilla of the tongue

7. Submerged teeth

• They are deciduous teeth that are ankylosed
• Prevents subsequent replacement by permanent teeth
• Affected teeth lack mobility
• Gives solid sound on percussion
• X-ray shows partial/ complete absence of periodontal ligament space

8. Dentin dysplasia

9. Talon’s cusp

• Located on the lingual surface of anterior teeth
• Extends half distance for CEJ to incisal edge
• Composed of normal enamel and dentin
• Contains horn of pulpal tissue
• Seen in
  • Mohr syndrome
  • Rubinstein Taybe syndrome
  • Sturge Weber syndrome

10. Teeth involved in different defects

11. Taurodontism

• The body of the tooth is enlarged at the expense of the root
• Pulp chambers are elongated
• Apical displacement of bifurcation/trifurcation
• The Crown has a rectangular shape
• Classification
  • Hypotaurodont – bifurcation is slightly apical. It is a mild form
  • Hypertaurodont – it is in extreme form. Bifurcation is near apices
  • Mesotaurodont- between Hypertaurodont and hypotaurodont

12. Syndromes associated with taurodontism

• Klinefelter syndrome
• Tricho-into-osseous syndrome

13. Turner’s hypoplasia

• Etiology
  • Trauma
  • Periapical infection of deciduous teeth
• Clinical features
  • The teeth affected are – permanent maxillary incisors, maxillary or mandibular premolars
  • Teeth have Hypoplastic crown
  • Range from mild discoloration to severe pitting.

Oral Medicine Developmental Disorders Long Essays

Question 1. Clinical examination of the tongue. Describe clini¬cal features of glossodynia and its treatment plan.

Answer:

Tongue

It is defined as a painful tongue

Etiology:

• Local factors:
  • Excessive use of tobacco
  • Excessive drinking
  • Bruxism
  • Irritating dentures, clasp, prosthesis
  • Referred pain from tonsils
  • Malformed teeth, malocclusion
  • TMJ disturbances
• Systemic factors
  • Multiple myeloma
  • Amyloidosis
  • Pernicious anemia
  • Pellagra
  • Diabetes

Read And Learn More: Oral Medicine Question and Answers

• • Gastric disturbances
  • Xerostomia
  • Prolonged antibiotic activity
• Neurological factors
  • Trigeminal neuralgia
  • Glossopharyngeal neuralgia
  • Cerebrovascular accident
• Idiopathic
  • Depression
  • Cancerophobia
  • Neurosis

Clinical Features:

• Presence of burning, tingling, or numbness of the tongue
• It may occur as isolated features or a group of symptoms
• It may occur with observable changes over the tongue

Management:

• Removal of local cause- construction of plastic retainers
• Treatment of muscular problems- use of muscle relaxants like diazepam
• Treatment of the systemic cause
• Surgical exploration with neuropathy
• Use of topical analgesia- 0.5% lidocaine

Oral Medicine Cysts Important Notes

1. Pseudo cysts are:

• Stafne’s cyst
• Aneurysmal bone cyst
• Hemorrhagic bone cyst
• Mucocele

2. Aneurysmal bone cyst

• It is a lesion of young persons
• Commonly occur in long bones and vertebral column with a history of trauma
• Characterized by excessive bleeding

3. Cysts and their radiographic features

Read And Learn More: Oral Medicine Question and Answers

4. Cyst and their location

5. Cysts and their Origin

6. Nasolabial cyst

• Arises at the junction of the globular portion of the lateral nasal process, medial nasal process, and maxillary process
• It is a soft tissue cyst
• Has no radiographic features

7. Syndromes associated with dentigerous cyst

• Cleidocranial dysplasia
• Maroteaux Lamy syndrome

8. Gorlin Goltz syndrome

• Multiple Odontogenic keratocyst
• Basal cell carcinoma
• Bifid basal rib
• Sexual abnormalities
• Neurological and ophthalmological abnormalities

9. Rushton bodies are seen in

• Periapical cyst
• Dentigerous cyst
• Gingival cyst of infants

Oral Medicine Cysts Short Essays

Question 1. Median mandibular cyst.

Answer:

Median mandibular cyst

They have been derived from epithelium remnants between the fusing mandibular process during the embryonic phase

Median Mandibular Cyst Clinical Features:

• It is a rare lesion
• Site: in the midline of the mandible
• It may cause displacement of the adjacent teeth
• The cystic swelling may be palpable buccally
• The teeth associated with the lesion are vital
• Radiographic Features:
  • Well-defined small radiolucency is seen in the mid-line of the mandible

Median Mandibular Cyst  Management:

• Enucleation of the cyst is done
• Care should be taken not to damage the apices of the teeth

Question 2. Gingival cyst of infants.

Answer:

Gingival cyst of infants

• Gingival cysts of the infant are multiple small, nodular, keratin-filled, cystic lesions seen in the oral cavity
• Depending on their location, they are divided into:
  • Cyst of the dental lamina
    • These are mostly found along the alveolar ridge and are odontogenic in origin
  • Epstein’s pearls
    • These small cystic lesions are found along the mid-palatine raphe
    • They are derived from the epithelium, entrapped along the line of fusion of the palate during embryogenesis
  • Bohn’s nodules
    • These are small cysts usually found along the junction of the hard and soft palate and over buccal and lingual aspects of the alveolar ridge
    • They are derived from remnants of the mucosal glands

Gingival cyst of infants Clinical Features:

• They are usually multiple, asymptomatic
• They are small, discrete, white nodules developing in several parts of the oral cavity
• They may discharge the contents by fusion with the overlying alveolar mucosa
• They may undergo spontaneous regression

Gingival cyst of infants Management:

• No treatment is required

Question 3. Dentigerous cyst.

Answer:

Dentigerous cyst Clinical Features:

• Sex: Common in males
• Age: First and 3rd decade
  • Site: Mandibular 3rd molar, maxillary canines, maxillary 3rd molar
  • Expansion of bone
  • Facial asymmetry
  • Displacement of adjacent teeth
  • Resorption of adjacent teeth

Dentigerous cyst Radiological Features:

• The unilocular, well-defined radiolucency
• Margins- sclerotic

Dentigerous cyst Types:

1. Central: covering the crown of an unerupted tooth
2. Circumferential: covering the crown from all the sides
3. Lateral: covering crown from the side

Dentigerous cyst Management:

• Marsupialization- In children
• Enucleation – In adults

Question 4. Odontogenic keratocyst.
(or)
Question 4. Primordial cyst.

Answer:

Odontogenic keratocyst Clinical Features:

• Age: 2ndand 3rd decade
• Sex: Common in males
• Site: mandible
• Features:
• Asymptomatic
  • If secondary infected, causes expansion of cortical plates
  • Mobility of teeth
  • Pain and tenderness of the site

Odontogenic keratocyst Radiological Features:

• Unilocular or multilocular radiolucency
• Margins: well-defined sclerotic margins
• Expansion of cortical plates
• Soap bubble appearance

Odontogenic keratocyst Management:

• Enucleation of cyst:
  • Smaller single cyst through intraoral approach
  • Unilocular lesions through marginal excision
  • Large multilocular lesions

Resection of involved bone
↓
Reconstruction of the site
↓
Bone grafting

Question 5. Radicular cyst.

Answer:

Etiology:

• Dental caries
• Fractured tooth
• Thermal/ Chemical injury to the pulp
• Iatrogenic injury to the pulp

Radicular cyst Clinical Features:

• Sex: common in males
• Age: Young age
• Site: common in maxillary anterior
• Nonvital tooth
• Smaller cysts are asymptomatic
• Larger lesions produce slow enlarging, bony hard swelling
• Expansion and distortion of cortical plates
• Severe bone destruction
• Springiness of jawbones
• Pain is secondarily infected
• Intraoral or extraoral pus discharge
• Pathological fractures
• Formation of an abscess called “cyst abscess”

Radicular cyst Radiological Features:

• The unilocular radiolucent area around the apex of the nonvital tooth
• Border: sclerotic
• Diameter: less than 1 cm
• Discontinuity of lamina dura

Radicular cyst Treatment:

• Nonvital tooth
• Extraction
• RCT
• Smaller cyst
  • Removed through socket
• Larger cyst
  • Marsupialization

Oral Medicine Cysts Short Answers

Question 1. Residual cyst.

Answer:

Residual cyst

• Any cyst may have an associated periapical or periodontal cyst which is asymptomatic

Residual cyst Clinical Features:

• The patient may complain of tooth pain
• The tooth may be extracted without noticing the presence of a cyst in the region associated with the tooth
• In such cases, the cyst is known as a residual cyst
• It continues to grow even after the tooth is removed as the cystic lining is still present
• The cyst is seen in an edentulous area, in place of the extracted tooth
• Incidence is more in the maxilla than mandible

Residual cyst Treatment:

• Enucleation

Question 2. Globulomaxillary cyst.

Answer:

Globulomaxillary cyst

• A common type of developmental cyst
• Arises in the bone suture, between the maxilla and premaxilla

Residual cyst Clinical Features:

• Asymptomatic
• If the secondary infection causes pain and discomfort
• Small swelling between canine and premolar
• Vital teeth

Residual cyst Radiographic Features:

• The inverted pear-shaped radiolucent area between the roots of the upper lateral incisor and canine
• Divergence of the roots

Residual cyst Treatment:

• Surgical excision

Oral Medicine Cysts Viva Voice

1. A nasolabial cyst is a soft tissue cyst
2. Stafne cyst is due to the developmental inclusion of sali-vary glandular tissue on the lingual surface of the mandible below the mandibular canal
3. A nasopalatine cyst is the most common Odontogenic cyst
4. Globulomaxillary cyst is found within bone
5. A globulomaxillary cyst is present between the maxillary lateral incisor and cuspid
6. Globulomaxillary cyst is fissural cyst
7. A radicular cyst is an inflammatory cyst
8. Botryoid Odontogenic cyst is a multicystic variant of lateral periodontal cyst
9. Eruption cyst is a form of dentigerous cyst

Temporomandibular Joint Important Notes

1. Myofascial pain dysfunction syndrome

• Masticatory muscle tenderness
• Pain in TMJ
• Limitation of motion
• Clicking noise present

Temporomandibular Joint Long Essays

Question 1. Describe the etiology, clinical features, differential diagnosis, and treatment of myofascial pain dysfunction syndrome.
Answer:

Myofascial pain dysfunction syndrome

• It is a disorder characterized by facial pain limited to the mandibular function, muscle tenderness, joint sounds, absence of significant organic and pathologic changes in TMJ
• It may be due to functional derangement of dental articulation, psychological state of mind, or physiological state of the joint
• Coined by Laskin

Etiology:

• Extrinsic factors
  • Occlusal disharmony
  • Trauma
  • Environmental influences
  • Habits
• Intrinsic factors
  • Internal derangement of TMJ
  • Anterior locking of disc
  • Trauma

myofascial pain dysfunction syndrome  Features:

• Unilateral preauricular pain
• Dull constant sound
• Muscle tenderness
• Clicking noise
• Altered jaw function
• Absence of radiographic changes
• Absence of tenderness in ext. auditory meatus

myofascial pain dysfunction syndrome Management:

• Reassurance
• Soft diet
• Occlusal correction: 7 ‘R’s
  • Remove-extract the tooth
  • Reshape grind the occlusal surface
  • Reposition orthodontically treated
  • Restore conservative treatment
  • Replace by prosthesis
  • Reconstruct TMJ surgery
  • Regulate control habits
• Isometric exercises
  • Opening and closing of mouth 10 times a day
• Medicaments
  • Aspirin: 0.3-0.6 gm/ 4 hourly
  • NSAIDS: For 14-21 days
  • Pentazocine: 50 mg/ 2-3 times a day

Read And Learn More: Oral Medicine Question and Answers

• Heat application
  • It increases circulation
• Diathermy
  • Causes heat transmission to deeper tissues
• LA injections
  • 2% lignocaine into trigger points
• Steroid injection
  • As anti-inflammatory
• Anti-anxiety drugs
  • Diazepam-2-5 mg * 10 days
• Tens
• Acupuncture

Question 2. Define trismus. Discuss various causes and management of trismus.
(or)
Define trismus. Discuss various causes and differential diagnoses of trismus.

Answer:

Trismus

It is a condition in which muscle spasm prevents the opening of the mouth

trismus Causes:

• Orofacial infection
• Trauma
• Inflammation
• Myositis
• Tetany
• Tetanus
• Neurological disorders
• Drug-induced
• Extra articular fibrosis
• Mechanical blockage

Pathogenesis:

Injection of inferior alveolar nerve block
↓
Bleeding at the site
↓
Haematoma
↓
Fibrosis
↓
Trismus

trismus Differential Diagnosis:

• Internal derangement of TMJ
• Fracture of mandibular condyle
• TMJ dislocation
• Septic arthritis
• Osteoarthritis
• Ankylosis
• Hematoma
• Acute infections

trismus Treatment:

• May resolve on its own
• Manipulation of the jaw by jaw stretcher

Temporomandibular Joint Short Essays

Question 1. Articular disc disorders of the temporomandibular joint.

Answer:

Articular disc disorders of the temporomandibular joint

In osteoarthritis, an articular disc of TMJ is affected

Etiopathogenesis:

temporomandibular joint Types:

1. Primary: Due to wear and tear
2. Secondary: Due to local and systemic factors

temporomandibular joint Clinical Features:

• Age: Older age
• Site: common in TMJ

temporomandibular joint Presentation:

Unilateral painful joint
↓
Interference in biting and
mandibular movements
↓
Sensitive to palpation
↓
Crepitation of joint
↓
Spasm of muscle
↓
Limitation of joint movements

temporomandibular joint Management:

• Elimination of cause
• Relief of pressure
• Physiotherapy
• Myotherapy
• Doxycycline

Question 2. Internal dearangement of temporomandibular joint.

Answer:

temporomandibular joint Definition:

It is the anteromedial displacement of the interarticular disc associated with the posterosuperior displacement of the condyle in the closed jaw position

temporomandibular joint Features:

• Pain on biting
• Clicking sound over the joint
• Deviation of mandible
• Restricted mouth opening due to pain

temporomandibular joint Management:

1. Anterior repositioning appliances

• Placed on occlusal surfaces

2. Supportive therapy

• NSAIDs to relieve pain
• Heat application

3. Occlusal correction

Question 3. Ankylosis of temporomandibular joint.

Answer:

Temporomandibular Joint Classification:

• False or true ankylosis
• Extra articular or intra articular
• Fibrous or bony
• Unilateral or bilateral
• Partial or complete

Etiology:

• Trauma Congenital
• Infections -Osteomyelitis
• Inflammation osteoarthritis
• Rare causes measles
• Systemic diseases typhoid
• Other causes of prolonged trismus

Temporomandibular Joint Pathogenesis:

Trauma
↓
Extravasation of blood into joint space
[haemarthosis]
↓
Calcification of joint space
↓
Obliteration of joint space
↓
Immobility of joint
↓
Ankylosis of joint

Temporomandibular Joint Features:

• Unilateral:
  • Deviation of the chin on the affected side o Fullness of the face on the affected side
  • Flatness on the unaffected side
  • Crossbite
  • Angle’s class malocclusion
  • Condylar movements absent on the affected side
• Bilateral:
  • Inability to open mouth
  • Neck chin angle reduced
  • Class 2 malocclusion
  • Protusive upper incisors
  • Multiple carious teeth

Temporomandibular Joint Management:

1. Condylectomy

• Pre auricular incision given
• Horizontal osteotomy cut given over condylar neck
• The condylar head is separated
• Smoothened the remaining structures
• Close the wound in layers
• If required bilateral condylectomy done

1. Exposure of the condylar head via a preauricular incision
2. Sectioning of condylar head,
3. Breaking the fibrous adhesions
4. Condylectomy complete
5. Suturing the capsule
6. Final skin suturing

1. Gap arthroplasty:

• Two horizontal cuts are given
• Removal of a bony wedge between the glenoid fossa and ramus

1. Interposition arthroplasty

• • Creation of gap
  • Insertion of barrier (autogenous or alloplastic)

Kaban’s Protocol:

• Early surgical intervention
• Aggressive resection
• Ipsilateral colectomy
• Contralateral colectomy
• The lining of the glenoid fossa with temporalis fascia
• Reconstruction of ramus with a costochondral graft
• Early mobilization
• Regular follow up

Kaban’s  Complications:

• Frey’s syndrome
• Parotid fistula
• Facial palsy

Question 6. Clinical features and management of degenerative arthritis.

Answer:

degenerative arthritis Clinical Features:

• Age and sex: Older aged women are more affected
• Site: Many joints are affected but it is not found often in TM]

Degenerative Arthritis Features:

• Unilateral pain over the joint
• It is sensitive on palpation
• Pain on movement or biting
• Pain aggravates during the evening
• There is the deviation of the jaw towards affected side
• The affected joint is swollen and warm to touch
• There is the presence of crepitation of the joint
• There is a limitation of jaw movements
• It results in stiffness and locking of the jaw

Degenerative Arthritis Management:

• Elimination of the causative agent:
  • Occlusal adjustment or grinding of teeth
  • Replacement of missing teeth
  • Replacement of ill-fitted denture
  • Treatment of caries and periodontal problems
• Drugs
  • Analgesics and anti-inflammatory drugs are given.
• Physiotherapy
• Myotherapy
• Arthroscopic lavage
• A low dose of doxycycline
• Others
  • Glucosamine
  • Chondroitin sulfate

Question 7. Rheumatoid arthritis.

Answer:

Rheumatoid arthritis

It is a systemic disease that usually affects many joints including the TMJ and the disease is characterized by progressive destruction of the joint structures

Rheumatoid arthritis Clinical Features:

• Age and sex: women from 20-50 years of age are affected
• Site: small joints of fingers and toes
• Presentation
  • Bilateral stiffness
  • Crepitus
  • Tenderness and swelling over the joint
  • Fever, malaise, fatigue
  • Weight loss
  • Polyarthritis affecting large and weight-bearing joints
  • Formation of subcutaneous nodules on the pressure points
  • The joint may become red, swollen, and warm to touch
  • Muscle atrophy around the jaw
  •  Bursitis
• TMJ involvement
  • Bilateral stiffness of the joint
  • Deep-seated pain and tenderness on palpation
  • Swelling over the joint
  • There is a limitation of mouth opening
  • Pain on biting is referred to the temporal region, ear, and angle of the mandible
  • There is a deviation of the jaw on opening
  • Inability to perform lateral movements
  • Anterior open bite
  • Fibrous ankylosis of the joint

Rheumatoid arthritis Complications:

• Subluxation
• Secondary arthritis
• Muscular atrophy
• Bird-like face

Rheumatoid arthritis – Radiographic Features:

• Joint space is reduced
• There is a flattening of the head of the condyle
• Erosion of the condyle
• Hollowing of the condylar cartilage
• Bony destruction of the articular eminence
• The condylar outline is irregular and ragged
• Synovial lining resembles a “sharpened pencil” or “mouthpiece of the flute”
• Subchondral sclerosis and flattening of articular surface may occur

Rheumatoid arthritis Management:

• Supportive treatment:
  • Provide adequate rest
  • Advice soft diet
• Medical
  • Local injection of methyl prednisone acetate
  • 20-80 mg for large joint
  • 4-10 mg for small joint
• Salicylates for pain relief
• NSAIDs
  • Phenylbutazone, indomethacin
• Anti rheumatic
  • Hydroxyl chloroquine sulfate sulphasalazine: 500 mg/day
• Local therapy
  • Diathermy
  • Jaw exercises
  • Mouth stretchers
• Surgical
  • Synovectomy: for removal of synovial membrane

Oral Medicine Temporomandibular Joint Short Answers

Question 1. Myositis ossificans.

Answer:

Myositis ossificans

• It is a condition in which fibrous tissue and hetero-tropic bone forms within the interstitial tissue/ muscle as well as in associated tendons and ligaments

Myositis ossificans Types:

• Localized
• Progressive

Question 2. Laskins criteria for MPDS.

Answer:

• Four cardinal signs
  • Unilateral pain – dull ache in the ear or preauricular area or angle of the mandible
  • Muscular tenderness
  • Clicking noise in TMJ
  • Limitation of jaw movements
• Negative characteristics
  • No radiographic changes
  • No tenderness in TMJ on palpation

Oral Medicine Temporomandibular Joint Viva Voce

1. Temporalis and geniohyoid are most often involved in MPDS

Oral Medicine Salivary Glands Short Essays

Question 1. Sialolith.
(or)
Clinical features and Investigations of submandibular sialolithiasis.

Answer:

Sialolith

• Sialoliths are calcified organic matter that forms within the secretory system of the major salivary glands

Sialolith Etiology:

• It is unknown
• Several factors like:
  • Inflammation,
  • Irregularities in the duct system
  • Local irritants and anti-cholinergic medication
• May contribute to stone formation

Sialolith Composition:

• Hydroxyapatite
• Calcium phosphate and carbon
• A trace amount of magnesium, potassium chloride, and ammonium

Salivary Glands Diagnosis:

• Occlusal radiograph for submandibular gland
• AP view of face for parotid
• CT images have 10 folds with greater sensitivity for detect¬ing
• calcification
• FNAC is used when differential diagnosis includes: a cyst or tumor
• Sialoendoscopy:
  • It is a relatively new technique
  • Small probe(<l mm diameter) attached to a specially designed endoscopic unit can explore the primary and sec¬ondary ductal system
  • The unit has a surgical tip to obtain soft tissue biopsy and help to remove calcified material

Sialolith Occurrence:

• Submandibular gland(80-90%): Because
  • The torturous course of Wharton’s duct
  • Higher calcium and phosphate level
  • Position of gland
• Parotid (5-15%)
• Sublingual(2-5%)

Salivary Glands Clinical Presentation:

• Acute, painful, and intermittent swelling
• Eating initiates salivary gland swelling
• Stone totally or partially blocks the flow of saliva, causing salivary pooling within the ductal system
• There is little space for expansion, so enlargement causes pain
• Stasis of saliva may lead to infection, fibrosis, and gland atrophy
• Fistula, sinus tract or ulceration may occur over the stone in chronic cases
• The soft tissue surrounding the duct may show edema and inflammation

Read And Learn More: Oral Medicine Question and Answers

Sialolith Complications:

• Suppurative or non-suppurative retrograde bacterial infection can occur
• Acute sialadenitis
• Ductal stricture
• Ductal dilatation

Differential Diagnosis Of Sialolithiasis:

• Gas bubbles:
  • Introduced during sialography
• Hyoid bone:
  • Seen bilaterally on panoramic film
• Myositis ossificans:
  • Restriction of mandibular movements occurs

Sialolith Treatment:

• Acute phase:
  • Supportive treatment: it includes analgesic, antibiotics, hydration, and antipyretic
• In exacerbation:
  • Surgical interventiondrainage or removal of stone
  • Stones at or near the duct are removed transorally by milking the gland
  • Deeper stones are removed by surgery or sailoendoscope
• Smaller stones are removed by gently massaging the gland
• Sialogogues, moist heat, and increased fluid intake may also promote the passage of stone
• Large sialolith are surgically removed
• Ultrasonography – it will detect stones of diameter >2 mm
• Lithotripsy – it will fragment the stone

Question 2. Mumps.

Answer:

Mumps

• It is an acute viral infection caused by RNA paramyxovirus
• It is transmitted by direct contact with salivary droplets
• Prevention:
• By MMR (measles, mumps, rubella) vaccination
• It is not recommended for severely immunocompromised children as the protective immune response does not develop and may lead to complications

Mumps Presentation:

• Age: 4-6 years
• Incubation period: 23 weeks
• Followed by salivary gland inflammation and enlargement
• Preauricular pain
• Fever
• Malaise
• Headache
• Myalgia
• Edema of the surrounding skin
• Ducts become inflamed but without purulent discharge
• Swelling is usually bilateral and lasts for approx. 7 days

Mumps Complications:

• Mild meningitis and encephalitis
• Deafness
• Myocarditis
• Thyroiditis
• Pancreatitis
• Oophoritis
• In males, epididymitis, and orchitis result in testicular atrophy and infertility

Mumps Diagnosis:

• Demonstration of antibodies against mumps S and V an¬tigens and to the hemagglutination antigen
• An oral fluid assay using a mumps-specific IgM capture enzyme immunoassay has demonstrated good sensitiv¬ity and specificity.
• A salivary test using reverse transcriptase PCR and loop-mediated isothermal gene amplification may help in the calculation of viral loads

Mumps Treatment:

• Symptomatic treatment done

Question 3. Pleomorphic adenoma of the palate.

Answer:

Pleomorphic adenoma of the palate

• It is the most common tumour
• It is a mixed tumour as it contains a both epithelial and mesenchymal component
• The majority found in the parotid, then in the submandibular, sub-lingual, and minor salivary gland

Pleomorphic adenoma of the palate Presentation:

• Palatal tumours almost always are found on the poste¬rior lateral aspect of the palate as smooth-surfaced, dome-shaped masses
• Because of the tightly bound nature of the hard palate, it is immovable

Pleomorphic adenoma Differential Diagnosis:

• Other parotid masses
• If calcification occurs in MRI, it is pleomorphic

Pleomorphic adenoma of the palate Treatment:

• Surgical removal
  • Wide resection to avoid recurrence
• Local enucleation is avoided because the entire tumor may not be removed or the capsule may be violated, resulting in the seeding of the tumour bed
• Tumours of the hard palate usually are excised down to the periosteum, including the overlying mucosa

Question 4. Xerostomia

Answer:

Xerostomia

It refers to a subjective sensation of a dry mouth, but not always, associated with salivary hypofunction

Xerostomia Etiology:

1. Developmental:

• Salivary gland aplasia

2. Water/ metabolic loss:

• Impaired fluid intake
• Hemorrhage
• Vomiting/diarrhea

3. Iatrogenic:

• Medications
• Antihistamines: diphenhydramine
• Decongestants: pseudoephedrine
• Antidepressants: amitriptyline
• Antipsychotic: haloperidol
• Antihypertensive: methyldopa, CCB
• Anticholinergic: atropine

4. Radiation therapy of head and neck:

• Both stimulated and unstimulated salivary flow de-creases with increasing radiotherapy.
  • Systemic Diseases:
    • Sjogren’s syndrome
    • Diabetes mellitus
    • Diabetes insipidus
    • HIV infections
    • Psychological disorders
    • Graft-versus-host disease

5. Xerostomia Local factors:

• Decreased mastication
• Smoking
• Mouth breathing

Xerostomia Clinical Features:

• Reduction in salivary secretion
• Residual saliva is either foamy or thick
• Mucosa appears dry
• The dorsal tongue is fissured with atrophy of filiform pa¬pilla
• Difficulty in mastication and swallowing
• Food adheres to the oral membranes while eating
• Some patients who complaints of dry mouth may appear to have adequate salivary flow
• The degree of saliva production can be assessed by measuring resting and stimulated saliva
• Increased prevalence of candidiasis because of reduction in cleansing and antimicrobial activity
• More prone to dental decay, especially cervical and root caries

Xerostomia Treatment:

• Artificial saliva may help the patient
• Sugarless candy can stimulate salivary flow
• Use of oral hygiene products like Biotene toothpaste, oral balance gel
• If dryness is secondary to medications, discontinue it or reduce its dose
• Systemic pilocarpine is used:
  • It is a parasympathomimetic agonist
  • Doses: 5-10 mg, 3-4 times a day
  • ADR: excessive sweating,
  • Increased heart rate and BP ^ Cevimeline hydrochloride
  • Acetylcholine derivative
  • Approved by U.S. Food and Drug Administration
  • Both these drugs are contraindicated in narrow-angle glaucoma
• To prevent dental decay, office, and daily home fluoride application
• Chlorhexidine mouthwash minimize plaque buildup
• Local stimulation of saliva
• Chewing gums, mints, paraffin, and citric acid

Question 5. Sialometaplasia.

Answer:

Sialometaplasia Description:

• It is a benign, self-limiting, reactive inflammatory dis-order of salivary tissue

Sialometaplasia Etiology:

• Unknown
• It may represent a local ischemic event
• Infectious process or
• Immune response to an unknown antigen

Sialometaplasia Presentation:

• Site:
  • Common on palate
  • Other include anywhere in the salivary gland tissue including lips, retromolar region
• Initially, lesion is present as a tender erythematous nodule
• Once the mucosa breaks, deep ulceration with yellowish base forms
• The lesion can be large and deep
• The lesion can occur shortly after oral surgical procedure, restorative dentistry or administration of LA

Sialometaplasia Diagnosis:

• Adequate biopsy
• Histopathologic diagnosis
• Complete clinical history

Sialometaplasia Treatment:

• Self-limiting condition
• Healing by secondary intention occurs in approx. 6 weeks
• Debridement and saline rinses may help the healing process

Oral Medicine Salivary Glands Short Answers

Question 1. Causes of Sialorrhea.

Answer:

Causes of Sialorrhea

• Sialorrhea Drugs
  • Lithium
  • Cholinergic agonists
• Sialorrhea Local factors
  • Stomatitis
  • AUG
  • Erythema multiforme
• Sialorrhea Systemic diseases
• Paralysis
• Alcoholic neuritis
• Parkinson’s disease
• Epilepsy
• Down’s syndrome
• Protective buffering system
  • Miscellaneous
  • Psychic factor
  • Metal poisoning
  • Facial paralysis

Question 2. Sialosis.

Answer:

• Sialosis Synonym: sialadenosis
• It is a rare chronic inflammatory disease of the sub-mandibular salivary gland

Sialosis Presentation:

• Enlarged, firm and painful unilateral or bilateral salivary gland

Sialosis Treatment:

• No treatment is generally required
• Elimination of causative agent
• In some cases, surgical excision of the gland is required

Question 3. Why is sialolith common in the submandibular gland.

Answer:

• Sialolith is common in the submandibular gland due to
  • The torturous course of Wharton’s duct
  • Higher calcium and phosphate level e Position of the gland

Question 4. Mucocele.

Answer:

Mucocele Description:

• It is a swelling caused by the accumulation of saliva at the site of a traumatized or obstructed minor salivary gland duct

Mucocele Types:

1. Extravasation:

• It is formed as a result of trauma to a minor sali¬vary gland excretory duct
• It is more common
• It does not have an epithelial cyst wall

2. Retention:

• Caused by obstruction by the calculus of duct

Mucocele Clinical Presentation:

• Site:
• Extravasation: lower lip is more common
• Other sites involve buccal mucosa, the tongue, the floor of the mouth, and the retromolar area
• Retention: palate or floor of the mouth
• Appearance:
  • Discrete, painless, smooth-surface swelling
• Size:
  • Ranges from a few millimeters to a few centimeters
• Color:
  • Superficial lesions have a blue hue
  • Deeper lesions can be more diffuse, covered by nor¬mal appearing mucosa without blue color

Mucocele Treatment:

• Surgical excision to prevent a recurrence
• Aspiration of fluid does not provide long-term benefit
• Surgical management may cause trauma to adjacent structures and can lead to the development of new lesions
• Intralesional injections of corticosteroids.

Question 5. Ranula

Answer:

Ranula

• A special type of mucocele
• Resembles the belly of a frog

Ranula Site:

• The floor of the mouth
• Superficial or deep to the mylohyoid muscle

Ranula Cause:

• Trauma to duct

Ranula Features:

• Slow-growing unilateral lesion
• Soft and freely movable
• Superficial lesions:
• Thin-walled bluish lesion
• Deeper lesions:
• Well circumscribed
• Covered by normal mucosa

Ranula Types:

1. Simple type
2. Plunging ranula

Ranula Treatment:

• Marsupialization

Oral Medicine Salivary Glands Viva Voce

1. Sialolith are common in submandibular glands
2. Mucous extravasation cysts are usually found on the lower lip
3. Sialoadenosis is noninflammatory disease
4. Salt and pepper appearance is seen in Sjogren’s syndrome
5. Pleomorphic adenoma is the most common parotid gland tumour
6. Sjogren’s syndrome shows cherry blossom appearance in sialography
7. In MRI, Sjogren’s syndrome shows salt and pepper appearance
8. The schimmer test is used for Sjogren’s syndrome

Oral Medicine Developmental Disorders Short Answers

Question 1. Causes of angular cheilitis.

Answer:

Causes of angular cheilitis

• Micro-organisms- Candida albicans, staphylococci, and streptococci
• Mechanical factors:
  • Overclosure of jaws in edentulous patients
  • Nutritional deficiency:
  • Due to Riboflavin
  • Folate deficiency
  • Iron deficiency
  • General protein deficiency
• Diseases of the skin:
  • Atopic dermatitis
  • Seborrhoeic dermatitis
• Other factors
  • Hypersalivation
  • Down’s syndrome
  • Large tongue
  • Presence of developmental sinus

Question 2. Concrescence.

Answer:

Concrescence

It is the union of the roots of two or more adjoining teeth due to the deposition of cementum

Etiology:

• Traumatic injury
• Crowding of teeth
• Hypercementosis

Concrescence Clinical Features:

• It is an acquired defect
• It occurs in both erupted or unerupted teeth
• There is no sex predilection
• Union or fusion does not occur between the enamel, dentin or pulp of the involved teeth
• The union mostly occurs between two teeth, however, there may be a union between more than two teeth
• Permanent maxillary molars are usually affected
• It can occur between the normal molar and supernumerary molar
• It rarely involves the deciduous dentition
• The condition is frequently seen in those areas of the dental arch where the roots of the neighboring teeth lie close to each other

Concrescence Significance:

• It may complicate extraction

Question 3. Taurodontism.

Answer:

Taurodontism

• It is a peculiar developmental condition in which the crown of the tooth is enlarged at the expense of its roots

Pathogenesis:

• It occurs due to failure of the Hertwig’s Epithelial root sheath to invaginate at the proper horizontal level

Taurodontism Clinical Features:

• It involves both the sex
• It commonly affects multi-rooted permanent molar teeth and sometimes premolar
• It rarely occurs in primary dentition
• It was relatively common in Neanderthal men
• The affected tooth exhibits an elongated pulp chamber with rudimentary roots
• The teeth are usually rectangular in shape with mini¬mum constriction at the cervical area
• The furcation area of the teeth is more apically placed
• The teeth often have greater apical-occlusal height
• Clinically the teeth exhibit certain morphological changes

Read And Learn More: Oral Medicine Question and Answers

Taurodontism Associated Syndrome:

• Down’s syndrome
• Klinefelter syndrome
• Poly X syndrome

Taurodontism Treatment:

• No treatment required

Question 4. Four Causes of Macroglossia.

Answer:

• Congenital or developmental
  • Mongolism
  • Lingual thyroid
• Inflammatory
  • Syphilis
  • Ludwig’s angina
  • Typhoid
  • Tuberculosis
  • Infected wound
• Neoplasm
  • Neurofibromatosis
  • Lymphangioma
• Systemic
  • Pellagra
  • Down’s syndrome
  • Acromegaly
  • Uremia
  • Amyloidosis
  • Diabetes
  • Scurvy
  • Hurler’s syndrome

Question 5. Bald tongue/ Differential diagnosis of the bald tongue.

Answer:

• Congenital
  • Familial dysplasia
  • Epidermolysis bullosa
  • Endocrine candidiasis
• Developmental
  • Geographic tongue
  • Median rhomboid glossitis
  • Central papillary atrophy
• Chronic trauma
• Nutritional deficiency
  • Pellagra
  • Riboflavin
  • Conditional deficiency
• Medication
  • Antibiotic
  • Cancer chemotherapy
• Peripheral vascular disease
• Chronic candidiasis
• Tumor
  • Squamous cell carcinoma
  • Epidermoid carcinoma
• Miscellaneous
  • Diabetes mellitus
  • Oral submucous fibrosis

Question 6. Supernumerary teeth.

Answer:

Supernumerary teeth

• The presence of any extra tooth in the dental arch in addition to the normal series of teeth is called supernumer¬ary teet
• Mode of Formation:
  • It may develop either from an accessory tooth bud in the dental lamina
  • It may develop due to the splitting of regular normal tooth bud during the initial phase of odontogenesis

Supernumerary Teeth Clinical Features:

• It can occur in both the sex
• It may resemble the corresponding tooth
• However, most of the teeth exhibit a conical shape
• They may be either erupted or impacted

Supernumerary Teeth Types:

• Mesiodens- Located between two upper central incisors
• Distomolars- Located on the distal aspect of the regular molar teeth
• Paramolars- They are located either in the buccal or the lingual aspect of the normal molars
• Extra lateral incisors- they are more common in the maxillary arch

Supernumerary Teeth Significance:

• It may produce crowding or malocclusion
• They may cause cosmetic problems
• They may be directly or indirectly responsible for increased caries incidence and periodontal problems
• The dentigerous cyst may sometimes develop from an impacted supernumerary teeth

Supernumerary Teeth Treatment:

• They are mostly non-functional and they should be extracted
• Impacted supernumerary teeth should be removed surgically since they interfere with normal tooth alignment or can develop some pathology

Question 7. Dilaceration.

Answer:

Dilaceration

• It refers to an angulation or sharp bend or curve anywhere along the root portion of the tooth
• Pathogenesis
  • Trauma to partially calcified tooth germ may cause displacement of the hard calcified crown portion
  • It may occur as a result of continued root formation during curved or tortuous path
  • Idiopathic cause

Dilaceration Clinical Features:

• It may involve both the dentition
• There is no sex predilection
• It is observed at the coronal portion of the teeth

Dilaceration Treatment:

• Such teeth are extracted as they are prone to fracture

Question 8. Fordyce’s granules.

Answer:

Etiology:

• It is a developmental variation
• It is caused by an accumulation of sebaceous glands in the submucosal connective tissue

Fordyce’s granules Features:

• Multiple, small, white to yellow nodules
• Usually located on the Buccal mucosa, occasionally on the labial mucosa
• Commonly bilateral
• It is a painless and persistent lesion

Fordyce’s granules Treatment:

• No treatment is required

Question 9. Name papillae of the tongue.

Answer:

• Fungiform
  • They are round in shape
  • They are situated over the anterior surface of the tongue near the tip
  • The number of taste buds in each is moderate
• Filiform
  • They are small and conical in shape
  • They are situated over the dorsum of the tongue
  • They contain less number of taste buds
• Circumvalate papillae
  • They are large structures present on the posterior part of the tongue
  • They are many in number
  • They are arranged in the shape of’V’
  • They contain up to 100 tastebuds

Question 10. Natal teeth.

Answer:

Natal teeth

• They are the teeth that are present at the time of birth

Etiology:

• Hereditary- superior position of the tooth bud
• Hormonal influence

Natal Teeth Clinical Features:

• Teeth may appear conical or may be normal in size and shape
• They may be opaque or yellow-brownish in color
• They are hypermobile
• Teeth appear to be attached to a small mass of soft tissue
• There may be a danger of aspiration of the teeth
• Riga fede ulcer- develops on the ventral surface of the tongue due to sharp edges of the incisors
• It leads to interference with the proper suckling and feeding activities

Associated Syndromes:

• Ellis van Creveld syndrome

Natal Teeth Management:

• Extraction- to avoid interference with feeding activities
• Rounding of the sharp angles
• Retaining of the tooth- if it doesn’t create any problem

Question 11. Median rhomboid glossitis

Answer:

Median rhomboid glossitis

• It is an asymptomatic, elongated, erythematous patch of atrophic mucosa on the middorsal surface of the tongue

Median rhomboid glossitis Clinical Features:

• Age: it is seen in adults
• Sex: it is common in males

Site:

• Anterior to the foramen cecum and circumvallate papillae
• In the midline on the dorsum of the tongue
• It starts as a narrow mildly erythematous area located along the median fissure of the tongue
• The lesion is asymptomatic
• It enlarges slowly often remaining unnoticed by the patient
• The fully developed lesion appears as a diamond or lozenge-shaped area devoid of the papilla
• The color of the lesion varies from pale pink to bright red
• There is the presence of a white halo
• The surface is usually smooth, flat or slightly raised
• It is sometimes fissured or lobulated
• The lesion exhibits an erythematous and nodular hyperplasia
• Some patients may develop similar lesions over the midline of the palate
• It may cause slight soreness or burning sensation
• It may regress spontaneously

Median rhomboid glossitis Management:

• Antifungal and antiseptic agents are used during irrita¬tion

Question 12. Etiology of median rhomboid glossitis.

Answer:

• Developmental
  • Persistent tuberculum impar
• Fungal infection
  • Candida albicans is many times found in the lesion
• Metabolic
  • It is more common in diabetic patients than in nondiabetic patients

Question 13. Mesiodens.

Answer:

Mesiodens

• They are the most common type of supernumerary teeth
• It is located between the two maxillary central incisors

Mesiodens Mode Of Formation:

• It may develop either from an accessory tooth bud in the dental lamina
• It may develop due to the splitting of regular normal tooth bud during the initial phase of odontogenesis

Mesiodens Clinical Features:

• It can occur in both the sex
• It may resemble the corresponding tooth
• However, most of the teeth exhibit a conical shape
• They may be either erupted or impacted

Mesiodens Significance:

• It may produce crowding or malocclusion
• They may cause cosmetic problems
• They may be directly or indirectly responsible for increased caries incidence and periodontal problems
• The dentigerous cyst may sometimes develop from impacted supernumerary teeth

Mesiodens Treatment:

• They are mostly nonfunctional and they should be ex¬tracted
• Impacted supernumerary teeth should be removed surgically since they interfere with normal tooth alignment or can develop some pathology

Question 14. Black hairy tongue.

Answer:

Etiology:

• Formation of excess keratin causes elongation of the filiform papillae on the dorsal tongue
• May be infected with Candida albicans

Black hairy tongue Features:

• Elongation of the filiform papillae
• White to yellow in color
• Located on the posterior dorsal tongue
• Patients often have poor oral hygiene
• Patients may complain of bad taste

Black hairy tongue Treatment:

• Elimination of predisposing factors
• Cleaning the dorsal tongue with a soft toothbrush
• Treat Candidiasis if present

Question 15. Ankyloglossia.

Answer: Ankyloglossia

• It is a result of a short, tight, thick, lingual frenulum

Ankyloglossia Classification:

• Based on the anatomical appearance
  • Type 1: Frenulum attached to the tip of the tongue in front of the alveolar ridge in low lip sulcus
  • Type 2: Attaches 2-4 mm behind tongue tip and at-taches on the alveolar ridge
  • Type3: Attaches to mid-tongue and middle of the floor of the mouth, usually tighter and less elastic the tip of the tongue appears “heart-shaped”
  • Type 4: Attaches against the base of the tongue, is shiny and very inelastic
• Based on the distance of the insertion of the lingual frenum to the tip of the tongue
  • Normal: 16 mm
  • Class 1 [Mild]: 12-16 mm
  • Class 2 [Moderate]: -12 mm
  • Class 3[Severe]: 4- mm
  • Class 4 [Complete]: 0-4 mm

Ankyloglossia Significance:

• In majority of the cases, it resolves spontaneously
• They are asymptomatic
• It may lead to
  • Difficulty in breastfeeding, articulation problems
  • Gingival recession
  • Open bite
  • Abnormal facial development

Ankyloglossia Treatment:

• Frenectomy
• Frenuloplasty

Question 16. Angular cheilitis

Answer:

Etiology:

• It occurs at the angle of the mouth among persons having deep commissural folds secondary to the overclosure of the mouth
• It can occur among persons with lip-licking habits, den¬ture wearing or deficiency of riboflavin, vitamin Bn and folic acid

Angular cheilitis Clinical Features:

• The infection starts due to the colonization of fungi in the skin folds following the deposition of saliva due to re¬peated lip-licking
• Patients often have soreness, erythema, and Assuring at the corner of the mouth
• In some cases, it may extend over the adjacent skin sur¬faces

Question 17. Talon’s cusp.

Answer:

Talon’s cusp

• It is an anomalous projection from the lingual aspect of the maxillary and mandibular permanent incisors

Talon’s cusp Clinical Features:

• This anomalous cusp arises from the cingulum area of the tooth which extends to the incisal edge as a prominent T-shaped projection
• It is usually an asymptomatic condition
• In some cases, it may cause problems in esthetics
• It may be susceptible to caries
• It usually consists of normal-appearing enamel, dentin, and vital pulp tissue
• Occasionally lingual pits develop on either side of the talon’s cusp, where it joins the lingual surface of the tooth

Associated Syndrome:

• Rubinstein Taybi syndrome

Treatment:

• Restorative measures are carried out to prevent caries
• When it interferes with occlusion, it is corrected with endodontic or restorative treatment

Question 18. Neonatal teeth.

Answer:

Neonatal teeth

They are the teeth which are present within 30 days after the birth

Etiology:

• Hereditary- superior position of the tooth bud
• Hormonal influence

Neonatal Teeth Clinical Features:

• Teeth may appear conical or may be normal in size and shape
• They may be opaque or yellow-brownish in color
• They are hypermobile
• Teeth appear to be attached to a small mass of soft tissue
• There may be a danger of aspiration of the teeth
• Riga fede ulcer- develops on the ventral surface of the tongue due to sharp edges of the incisors
• It leads to interference with the proper suckling and feeding activities

Associated Syndromes:

• Ellis van Creveld syndrome

Neonatal Teeth Management:

• Extraction- to avoid interference with feeding activities
• Rounding of the sharp angles
• Retaining of the tooth- if it doesn’t create any problem

Question 19. Fissured Tongue.

Answer:

Synonyms:

• Scrotal tongue
• Lingua plicata

Etiology:

• Hereditary
• Aging
• Chronic trauma
• Vitamin deficiency

Fissured Tongue Features:

• It is seen in childhood
• It becomes prominent with age
• It exhibits multiple grooves or furrows of 2-6 mm depth
• It is of varied patterns on the dorsal surface
• Patients may rarely present with a burning sensation or soreness
• Food debris may get lodged into the furrows and cause irritation

Associated Syndromes:

• Melkersson-Rosenthal syndrome
• Down syndrome

Fissured Tongue Management:

• Advice the patient to use soft bristle brushes over the area
• To cleanse the fissures on a regular basis

Question 20. Actinic cheilitis.

Answer:

Actinic cheilitis

It is a pre-malignant squamous cell lesion resulting from long-term exposure to solar radiation

Actinic cheilitis Clinical Features:

• Site: commonly occurs over the lower lip
• Age and sex: common in adult males
• Features:
  • There may be redness and edema over the area
  • The lips become dry and scaly
  • Tiny bleeding spots are seen
  • Gradually the scales become thick and horny
  • Vertical Assuring and crusting occur
  • There is a blurring of the margins
  • Vesicles are formed which rupture to form superficial erosions
  • Warty nodules may form There is the possibility of malignant transformation

Actinic cheilitis Management:

• Topical fluorouracil
  • Applied in 5% cone. For three times daily for 10 days
• CO₂ snow: used to remove superficial lesions
• Vermillionectomy:
  • Vermillion borders are excised
• Laser ablation- to vaporize Vermillion
• Electrodesiccation- it leads to dehydration by the insertion of electrodes into the tissues.

Oral Medicine Developmental Disorders Viva Voce

1. Micrognathia of the maxilla is due to a deficiency in the pre-maxillary area
2. Ankyloglossia cause difficulty in articulation of 1, r, t, d,n, th, sh and z
3. Ghost teeth is due to defect in mineralization
4. Ghost teeth are seen in regional odontodysplasia
5. Shell teeth are seen in dentinogenesis imperfect
6. Permanent molars are most commonly affected by taurodontism
7. Torus mandibularis is commonly seen on the lingual surface of the mandible opposite to the premolar
8. Mesiodens is the most common supernumerary teeth
9. Deciduous mandibular second molar is the most common ankylosed teeth
10. Commonly missing teeth are
    • Primary – maxillary and mandibular lateral inci¬sors
    • Permanent – third molar
11. Bohn’s nodules are seen at the junction of the hard and soft palate
12. Epstein pearls are seen along the median raphe of the hard palate
13. Dental lamina cysts of new born are seen on alveolar ridges
14. False anodontia is due to multiple extracted teeth
15. Pseudo anodontia is due to multiple unerupted teeth
16. Infusion patient will be having one tooth less than normal
17. In germination, patient has one tooth extra of normal

Oral Medicine Red And White Lesions Definitions

1. Oral submucous fibrosis

• An insidious chronic disease affecting any part of the oral cavity and sometimes the pharynx.
• Although occasionally preceded by and /or associated with vesicle formation, it is always associated with juxtaepithelial inflammation reaction followed by fibroelastic changes of lamina propria with epithelial atrophy leading to stiffness of oral mucosa and causing trismus and inability to eat

2. Leukoplakia

• It is a whitish patch or plaque that cannot be characterized, clinically or pathologically, as any other disease and which is not associated with any other physical or chemical causative agent except the use of tobacco.

3. Premalignant lesions

• It is defined as morphologically altered tissue in which cancer is more likely to occur than its apparently normal counterparts

4. Premalignant conditions

• It is defined as a generalized state or condition associated with a significantly increased risk for cancer development.

5. Erythroplakia

• It is red patch or plaque in the oral mucosa which cannot be characterized clinically or pathologically as any other condition and which has no apparent cause

Red Lesions Classifications

1. Red lesions:

• Inflammatory Conditions:
  • Inflammation associated with traumatic injury
  • Mechanical- cheek biting, ill-fitted denture
  • Chemical- aspirin, formoterol
  • Thermal- hot food, hot beverages
  • Radiation- mucositis
  • Infection
    • Bacterial
    • Scarlet fever
    • Gonococcal stomatitis
    • Vincent infection
    • Fungal
    • Atrophic candidiasis
    • Angular chelitis
    • Viral
    • Measles
    • Herpes simplex infection
    • Herpes zoster
    • Herpangina
    • Chickenpox
    • Allergic
    • Pyogenic granuloma
    • Giant cell epulis
    • Pregnancy tumor
• Congenital:
  • Hemangioma
  • Sturge-Weber syndrome
  • Median rhomboid glossitis
  • Geographic tongue
• Vascular diseases:
  • Purpura
  • Polycythemia
  • Agranulocytosis
  • Leukemia
• Dermatological:
  • Pemphigus
  • Erythema multiforme
  • Steven Johnson’s syndrome
  • Lichen planus
  • Psoriaisis
• Other diseases:
  • Uremic stomatitis
  • Diabetes stomatitis
  • Scurvy
  • Pernicious anaemia
• Premalignant and malignant lesion:
  • Atrophic leukoplakia
  • Erythroplakia
  • Carcinoma in situ
  • Kaposi’s sarcoma

2. White lesions Classifications

• Variation in structure and appearance of normal mucosa
  • Leukoedema
  • Fordyce’s granules
  • Lineaalba
• White lesion with precancerous potential
  • Leukoplakia
  • Erythroplakia
  • Lupus erythematous
  • Carcinoma in situ
  • Lichen planus
• White lesion without precancerous potential
  • Traumatic lesions
  • Focal epithelial dysplasia
  • White sponge nevus
  • Stomatitis nicotina
  • Hairy leukoplakia
• Non keratotic lesion
  • White hairy tongue
  • Burns
  • Pemphigus
  • Desquamative gingivitis
  • Candidiasis
  • Koplik’s spots

3. Premalignant lesions:

• Leukoplakia
• Erythroplakia
• Mucosal changes associated with smoking habits
• Carcinoma in situ
• Bowen’s disease
• Actinic keratosis

4. Premalignant conditions:

• Oral submucous Fibrosis
• Syphilis
• Sideropenic dysplasia
• Dyskeratosis congenital

5. Lupus erthymetosis

• Leukoplakia:
• Homogenous leukoplakia
• Ulcerative leukoplakia
• Nodular or speckled leukoplakia

6. Candidiasis:

• Acute
  • Acute pseudomembranous candidiasis
  • Acute atrophic candidiasis
• Chronic
  • Chronic atrophic candidiasis
  • Denture stomatitis
  • Median rhomboid glossitis
  • Angular chelitis
  • ID reaction
  • Chronic hyperplastic candidiasis
• Chronic mucocutaneous candidiasis
  • Familial CMC
  • Localized CMC
  • Diffused CMC
  • Candidiasis endocrinopathy syndrome

Oral Medicine Red And White Lesions Important Notes

1. TNM staging

• It is staging of malignancy which measures 3 major parameters of cancer
  • T- size of tumour
  • N- lymph node involvement
  • M- distant metastasis
• T- Primary tumour
  • T_x– Primary tumour cannot be assessed
  • T₀– No evidence of primary tumour
  • T_is– carcinoma in situ e Tl- Tumour size- 2 cm or less in diameter
  • T₂– Tumour size- 2-4 cm in diameter
  • T₃– Tumour size- more than 4 cm in diameter
  • T₄– Tumour invades adjacent structures
• N- Regional lymph node
  • N_x– Regional lymph node cannot be assessed
  • N₀– No regional lymph node metastasis
  • N₁– Metastasis in the single ipsilateral lymph node, 3 cm or less in dimension
  • N₂– Metastasis in the single ipsilateral lymph node, more than 3 cm but less than 6 cm
  • N_2a– Metastasis in the single ipsilateral lymph node, 3-6 cm in dimension
  • N_2b– Metastasis in multiple ipsilateral lymph nodes, not more than 6 cm
  • N_2c– Metastasis in bilateral or contralateral lymph nodes, not more than 6 cm
  • N3- Metastasis in the lymph node, more than 6 cm in dimension
• M- Distant metastasis
  • M_x– The presence of distant metastasis cannot be assessed
  • M₀– No distant metastasis
  • M₁– Presence of metastasis

2. Histological features of lichen planus

• Sawtooth appearance of retepegs
• Liquefaction degeneration of the basal layer
• Presence of civatte bodies
• Characteristic band of T-lymphocytes and histiocytes
• Hyperparakeratosis and Hyperorthokeratosis
• Thickening of the granular layer

3. Lichenoid reactions

• They are drug-induced
• Has the same histological features as lichen planus
• It resolves promptly when the offending drug is eliminated
• Drugs producing it are
  • Antihypertensives
  • NSAIDs
  • Penicillamine
  • Rapwnr
  • Ketoeonarole
  • (‘hfoftttfuine
  • Tetracycline
  • Sulfamethoxazole
  • Oral hypoglytaemic drugs,

4. Grmspan syndrome

• Diabetes melli-uv
• Lichen planus
• Hypertension

5. Nevus

• It is x ongcnital, developmental tumour like malformation of skin and mucous membrane
• It is composed of nevus cells
• The nevus cells aie situated within thr Conner tier tissue and are not in contact with surface epithelium
• The common mole is an intradermal mole
• In junctional nevus, the epithelium is thin and irregular and shows roll crossing the junction and growing dow- into the connective tissue

6. White sponge nevus

• Described by Cannon
• Follows hereditary pattern
• Die oral lesions are widespread
• Appears as thickened and folded or corrugated with s-.ft or spongy texture
• Has a peculiar white opah scent hue
• Removed by gentle rubbing without bleeding

7. Leukoedema

• Mostly occurs bilaterally
• Involves the buccal mucosa along occlusal line in the bicuspid and molar region
• Resembles early leukoplakia
• Disappears on stretching

8. Types of candidiasis

 

9. Id reaction

• It is due to allergic response to Candida antigens
• Patients develop vesiculo popular rash due to allergy
• Lesions will resolve with treatment of Candida infection

Oral Medicine Investigations Important Notes

1. Oral Medicine Investigations Biopsy:

• It is the removal of part of tissue for the purpose of histological examination And Analysis

Oral Medicine Investigations Types:

• Punch Biopsy.
• Incisional Biopsy.
• Excisional Biopsy.
• Needle Biopsy.

2. Oral Medicine Investigations Tests and their uses:

• Schilling test
  • It is done to detect vitamin B12 deficiency as well as to distinguish and detect lack of intrinsic factor and malabsorption
  • The test is performed in three stages
    • Stage 1 – without intrinsic factor
    • Stage 2 – with intrinsic factor
    • Stage 3 – test for malabsorption of vitamin B12
• Paget’s test
  • It is used to examine the swelling
  • Finger pressure is applied over the swelling
• Lugol’s iodine test
  • It is used as an aid to the diagnosis of malignant lesions
  • It contains iodine, potassium iodide, and distilled water
  • Normal cells- stained brown black
  • Inflammatory tissue- stained dark brown
• Schimmertest
  • It is a diagnostic test for Sjogren’s syndrome
  • A strip of filter paper is placed in between the eye And eyelid to determine the degree of tears measured in mm
  • If it is < 5 mm in 5 min, it is positive
• Tzanck test
  • Tzanck smear shows acantholysis of cells
• Patch test
  • It is used to evaluate drug allergy
  • The suspected allergen is placed on normal non-hairy skin i.e. on the upper portion of the back
• Paul Bunnel test
  • It is a diagnostic test for infectious mononucleosis
  • The normal titer is 1:8
  • Butin the diseased person’s titer becomes 1:4096

3. Oral Medicine Investigations Bence Jones proteins:

• It is an unusual protein which coagulates when urine is heated to 40-60 degrees C and disappears when urine is boiled
• It reappears when urine is cooled
• It is also seen in patients with diseases such as
  • Leukemia
  • Polycythemia vera
  • Multiple myeloma
  • Solitary myeloma

Oral Medicine Investigations Short Essays

Question 1. Endocarditis prophylaxis regimen for dental procedures.

Answer:

1. Standard Prophylaxis:

• Amoxycillin
• Dose= Adult -2 gm
• Child- 50 mg 1 hour before surgery

2. Patient unable to take orally:

• Ampicillin
• Dose: Adult – 2 gm IM/4
• Child- 50 mg 1 hour before surgery

3. Patient allergic to penicillin:

• Clindamycin
• Dose: Adult – 600 mg
• Child- 300 mg 1 hour before surgery

Dental Procedures Requiring Prophylaxis:

• Dental extractions
• Periodontal surgeries
• Implant placement
• Endodontic procedures beyond the apex
• Subgingival placement of fibers
• Intraligamentary LA injections

Read And Learn More: Oral Medicine Question and Answers

That Donot Require:

• Nonintraligamentary injections
• Intracanal endo treatment
• Placement of rubber dam
• Suture removal
• Placement of the removable prosthesis
• Making impressions
• Fluoride treatments
• Shedding of primary teeth

Question 2. Biopsy.

Answer:

Biopsy

It is the removal of part of tissue for the purpose of histological examination And Analysis

Biopsy Types:

1. Punch Biopsy:

The sample is obtained with the help of a punch

Biopsy Indications:

• Mucosal lesions
• Inaccessible areas

2. Incisional Biopsy:

• Indication: large lesions
  • Tumours: Edge biopsy is taken where the tumour cells can be compared with the normal cells

3. Excisional Biopsy:

• Indication: Small lesions
• The entire lesion is excised in a single sitting and sent for histological examination

4. Needle Biopsy:

• FNAC
  • Indication: Cystic cavity:
  • 23-26 gauge needle is used to aspirate the contents of the lesion

Question 3. Exfoliative cytology.

Answer:

Exfoliative cytology

Introduced by Papanicolaou And Traunt

Exfoliative cytology Technique:

Scrap the surface of the lesion
↓
Collect it with the help of a wooden spatula
↓
Prepare a smear
↓
Stain it
↓
Observe under microscope Results:
↓
Class 1: Normal
↓
Class 2: atypical
↓
Class 3: Intermediate
↓
Class 4: Suggestive of cancer
↓
Class 5: Positive of cancer

Question 4. Aspiration biopsy.

Answer:

Aspiration biopsy

• Needle Biopsy: technique
• FNAC:
  • 23-26 gauge needle is inserted into the tissues
    • Aspirate the needle
    • Cystic fluid is collected in it
    • Examine the fluid
• Indication: cystic cavity:
• OKC:

Question 5. Schilling test.

Answer:

Schilling test

It is done to detect vitamin B12 deficiency as well as to distinguish and detect a lack of intrinsic factors and malabsorption The test is performed in three stages

Schilling test Stage 1:

• Without intrinsic factor (IF)
• An oral dose of 0.5-1 pg of radioactively labeled vitamin B12 is administered orally
• After 2 hours a large dose(4 mg) of unlabelled vitamin B12 is given parenterally
• In normal individuals, more than 7% of 1 pg of an oral dose is excreted in a 24-hour urinary sample
• Patients with intrinsic factor deficiency excrete a lower quantity of it

Schilling test Stage 2 (WITH IF):

• If the 24-hour urinary excretion of vitamin B12 is low, the test is repeated using the same procedure but with the addition of a high oral dose of IF is administered
• If the 24-hour urinary output is now normal the low value in the first test was due to IF deficiency
• Patients with pernicious anemia have abnormal tests even after treatment with vitamins due to IF defi¬ciency

Schilling test Stage 3:

• Test for malabsorption of vitamin Bt:
• The same patient absorb vitamin HI2 in water as was stipulated in the original test
• In conditions causing malabsorption, the test is repeated after a course of treatment with antibiotics or anti-inflammatory drugs

Question 6. Types and indications of biopsy.
(or)
Question 6. Biopsy

Answer:

Biopsy

It is the removal of part of tissue for the purpose of histological examination and analysis

Biopsy Types:

1. Punch Biopsy:

The sample is obtained with the help of a punch

• Indications:
  • Mucosal lesions
  • Inaccessible areas

2. Incisional Biopsy:

• Indication: large lesions:
  • Tumours: Edge biopsy is taken where the tumour cells can be compared with the normal cells

3. Excisional Biopsy:

• Indication: small lesions:
  • The entire lesion is excised in a single sitting and sent for histological examination

4. Needle Biopsy:

• FNAC:
• Indication: Cystic cavity:
  • A 23-26 gauge needle is used to aspirate the contents of the lesion

Question 7. Paget’s test.

Answer:

Paget’s test

• It is used to examine the swelling
• Finger pressure is applied over the swelling
• It can be done for small swellings
• The center of the swelling becomes soft as it contains fluid
• While the periphery becomes hard

Question 8. Lugol’s Iodine test.

Answer:

Lugol’s Iodine test

It is used as an aid to the diagnosis of malignant lesions

Lugol’s Iodine test Action:

• It will hind to glycogen present in the normal epithe¬lium
• It retains in normal squamous epithelial cells
• Thus it differentiates it from the abnormal cells

Lugol’s Iodine test Contents:

• Iodine 2 gm
• Potassium iodide 4 gm
• Distilled water- 100 cc

Lugol’s Iodine test Effects:

• Normal cells- stained brown black
• Proliferating epithelium- inversely proportional to the degree of keratosis
• Inflammatory tissue- stained dark brown

Question 9. Investigation of oral cancer 

Answer:

Investigation of oral cancer – Clinical methods:

1. Toulidlne blue staining:

It is used as an aid to the diagnosis of oral cancer and potentially malignant lesions

Investigation of oral cancer Method of Use:

• Make the patient to rinse the mouth with water twice for 20 seconds each
• Next, rinse with 1% acetic acid for 20 seconds
• Dry the area with the help of a gauze piece
• Apply 1% toluidine blue solution with a cotton swab
• Rinse again with acetic acid and water
• Observe the staining if present

Investigation of oral cancer Advantages:

• Good sensitivity
• Very low false negative results
• It is effective in demonstrating dysplasia and early malignant lesion which is not clinically recognize able

2. Lugol’s iodine test:

• • It is used as an aid to diagnosis ol malignant lesions

Lugol’s iodine test Action:

• It will bind to glycogen present in the normal epithelium
• It retains in normal squamous epithelial cells
• Thus it differentiates it from the abnormal cells

3. Acridine binding test’

• In this method, the uptake of acriflavine by desquamated buccal cells is measured
• Since the DNA content of the dysplastic cells are more, they will stain more intensely than normal cells

Photodiagnosis:

1. Autofluorescence spectroscopy:

• It is a non-invasive method
• It is used for the detection of alteration in the struc¬tural and chemical composition of cells

2. Fluorescence photography:

• It shows reduction and diminution of positive fluorescence associated with cancer regression and vice versa

Histopathological methods:

1. Biopsy:

• It is the removal of part of tissue for the purpose of histological examination and  analysis

2. Exfoliative cytology:

Exfoliative cytology Technique:

Scrap the surface of the lesion
↓
Collect it with the help of a wooden spatula
↓
Prepare a smear
↓
Stain it
↓
Observe under microscope

Exfoliative cytology Results:

• Class 1: Normal
• Class 2: Atypical
• Class 3: Intermediate
• Class 4: Suggestive of cancer
• Class 5: Positive of cancer

Molecular methods:

1. Quantification of nuclear DNA content:

• Quantitative analysis of DNA content reflects the total chromosomal content

2. Tumour markers:

• Tumor markers may be produced by host in response to cancerous substances
• They can be seen in blood circulation, body cavity fluids, cell membrane, and cell cytoplasm

Question 10. Coomb’s test.

Answer:

Coomb’s test

Coomb’s test was devised by Coombs, Mourant, and Race in 1945.

Coomb’s test Method:

Coomb’s test Types:

• Direct Coomb test
• Indirect Coomb test

Coomb’s test Uses:

• Detects anti-Rh antibodies
• Demonstrates incomplete antibody

Question 11. Brush biopsy

Answer:

Brush biopsy

This biopsy method utilizes an improved brush to obtain a complete transepithelial biopsy specimen with cellular representation from each of the three layers of the lesion: the basal, intermediate, and superficial layers.

• When used properly and rubbed against an area of suspect tissue aggressively [to the point of minor bleeding] the biopsy brush penetrates to the basement membrane, removing tissue from all three epithelial layers of the oral mucosa
• The oral brush biopsy does not require topical or local anesthetic and causes minimal bleeding and pain.
• The brush biopsy instrument has two cutting surfaces, the flat end of the brush and the circular border of the brush.
• Either surface may be used to obtain the specimen.
• Brush biopsies are utilized routinely in the detection of precancer and cancer in other organ systems.

Question 1. Bence Jones proteins

Answer:

Bence Jones proteins

• Bence-jones proteins are light chain proteins produced by tumour cells
• Due to it serum protein level raises
• Its presence in urine detects multiple myeloma
• Serum and urinal protein Immunoelectrophoresis is done to detect it
• Bence-Jones protein coagulates when the urine is heated to 42 degrees C to 60 degrees C
• It disappears when the urine is boiled and finally reap¬pears again as urine is cooled
• It is also present in patients with polycythemia or leu¬kemia

Question 2. Vitality Tests

Answer:

Vitality Tests

• Vitality tests are the most useful diagnostic tool used to diagnose an endodontic case

Vitality Tests Types:

1. Heat test:

• It is usually done using
  • Hot gutta percha stick
    • Hot burnisher
    • Hotcompond
    • Hot water
    • Hotair
• Gutta-percha is heated over the flame until it becomes shiny and then it is placed on the middle third of the facial surface of the crown
• At first, a normal contralateral tooth should be tested and then the affected tooth is tested

2. Cold test:

• It is done using ethyl chloride spray, pencil sticks of ice, and carbon dioxide snow at -78 degrees C

3. Electric pulp test:

• Isolate the area of the tooth to be tested with cotton rolls and air dry all the teeth
• Apply an electrolyte on the tooth electrode and place it against the dried enamel of the crown
• Retract the patient’s cheek away from the tooth
• Turn the rheostat slowly and increase the current gradually
• Record the response of the patient

Question 3. Significance of pst medical history

Answer:

Significance of pst medical history

A Complete medical  history must be obtained to

• Determine systemic factors or diseases that will require special considerations before, during or after the treatment
• A complete list of meditations most he obtained In order to Identify the drugs or medications that could adversely interact with  drugs used in dental treatment

Question 4. Pathergy test

Answer:

Pathergy test

Pathergy Test Types:

1. Oral pathergy test:

• Site: lower lip.
• The procedure of oral pathergy test:
  • Prick the mucous membrane of the lower lip to the submucosa using a 20 gauge blunt dispos¬able needle
  • Readings are taken after 48 h, and the test is considered positive if a pustule or ulcer is seen

2. Skin pathergy test:

• Site: A hairless area on the flexor aspect of the forearms is usually chosen as the test site.
• The procedure of skin pathergy test:
  • It can be performed using 1-16 needle pricks.
  • Generally, the needle is inserted vertically or diagonally at an angle of 45° to a depth of 3-5 mm.
  • The needle should reach the dermis for a proper response.
  • Readings are taken after 48 hrs of the needle prick.
  • An l-2mm papule that is usually felt by palpation and which is surrounded by an erythematous halo is formed on the skin.
  • The papule may remain as a papule or transform into a l-5mm pustule.

Read And Learn More: Oral Medicine Question and Answers

Conditions With Positive Pathergy Test:

• Behcet’s disease
• Pyoderma gangrenosum (PG)
• Interferon alpha-treated chronic myeloid leukemia patients
• Inflammatory bowel disease

Question 5. Oral brush biopsy

Answer:

Oral Brush Biopsy:

• The oral brush biopsy was introduced to the dental profession in 1999.
• This biopsy method utilizes an improved brush to obtain a complete transepithelial biopsy specimen with cellular representation from each of the three layers of the lesion: the basal, intermediate, and superficial layers.
• When used properly and rubbed against an area of suspect tissue aggressively (to the point of minor bleeding) the biopsy brush penetrates to the basement membrane, removing tissue from all three epithelial layers of the oral mucosa
• The oral brush biopsy does not require topical or local anesthetic and causes minimal bleeding and pain.
• The brush biopsy instrument has two cutting surfaces, the flat end of the brush and the circular border of the brush.
• Either surface may be used to obtain the specimen.
• Brush biopsies are utilized routinely in the detection of precancer and cancer in other organ systems.

Question 6. Schimmer’s test.

Answer:

Schimmer’s test

• It is a diagnostic test for Sjogren’s syndrome
• A strip of filter paper is placed in between the eye and eyelid to determine the degree of tears measured in mm
• If it is < 5 mm in 5 min, it is positive

Question 7. Two differences between direct & indirect im- munofluorences

Answer:

Differences between direct & indirect im- munofluorences

Question 8. Toluidine blue staining.

Answer:

Toluidine blue staining

• It is used as an aid to the diagnosis of oral cancer and potentially malignant lesions

Toluidine blue staining Mechanism:

• It is an acidophilic, nuclear dye
• It selectively stains the nucleic acid, especially DNA and RNA
• It penetrates into the intracellular canals present in the malignant epithelium

Toluidine blue staining Effects:

• It stains the epithelium surfaces to blue
• However, this stain is lost after the application of 1% acetic acid
• This occurs only to the normal epithelium or the be¬nign lesions
• But in malignant lesions, the stains remain as it is

KIT:

• It contains:
  • 1% toluidine blue 10 ml solution « 1% acetic acid
  • Absolute alcohol
  • Distilled water
  • pH is adjusted to 4.5
• Method Of Use:
  • Make the patient to rinse the mouth with water twice for 20 seconds each
  • Next, rinse with 1% acetic acid for 20 seconds
  • Dry the area with the help of a gauze piece
  • Apply 1% toluidine blue solution with a cotton swab
  • Rinse again with acetic acid and water
  • Observe the staining if present
• Advantages:
  • Good sensitivity
  • Very low false negative results
  • It is effective in demonstrating dysplasia and early malignant lesion which is not clinically recognizable

Question 9. Tzanck test.

Answer:

Tzanck Smear:

Rub the lesion surrounding the area
↓
Puncture the lesion
↓
Absorb the secretion over cotton
↓
Collect this overslide and  stain it
↓
Observe under microscope

Result: lesion shows acantholysis

Question 10. Auspitz sign.

Answer:

Auspitz sign

• It is seen in psoriasis
• If the deep scales on the surface of the lesion are removed, one or two tiny bleeding points are often dis-closed
• This phenomenon is known as the “Auspitz sign”

Question 11. Patch test.

Answer:

Patch test

• It is used to evaluate drug allergy
• The suspected allergen is placed on normal non-hairy skin i.e. on the upper portion of the back
• It remains in contact with the skin for 48 hours
• Then the patch is removed
• Next, the area is examined after 2-4 hours for persistent erythema

Question 12. Examination of ulcer.

Answer:

1. Examination of ulcer Inspection:

• Size and shape:
  • Oval: In tuberculosis
  • Circular/ semilunar: In syphilis
  • Irregular: In carcinoma
• Number: Number of the ulcer is examined

2. Examination of ulcer Position:

• Different ulcers are located at a different position
• This gives a clue for the diagnosis
• Rodent ulcer: confined to the upper part of the face
• Malignant ulcers: present over lips, tongue, breast, and penis

3. Examination of ulcer Edges:

• Spreading ulcers have inflamed and edematous edges
• Tuberculosis ulcers have undermined edges
• Gummatous ulcers have punched-out edges
• Healing ulcers have sloping edges
• Rodent ulcers have raised edges

4. Examination of ulcer Surrounding Areas:

• It may be glossy, red, and edematous

5. Examination of ulcer Palpation:

• Tenderness over the ulcer is palpated
• The temperature of the ulcer is felt

6. Examination of ulcer Edges:

• Edges are palpated for induration

7. Examination of ulcer Base:

• The depth of the ulcer is measured in millimeters
• Bleeding of the ulcer is examined
• Relation to the deeper structures is examined

Question 13. Paul Bunnell test.

Answer:

Paul Bunnell test

It is a diagnostic test for infectious mononucleosis

Paul Bunnell test Procedure:

• Collect sheep’s RBCs and human’s RBCs
• Agglunate both

Paul Bunnell test Result:

• The normal titer is 1:8
• But in a diseased person, titer becomes 1:4096
• Agglutination is observed

Oral Medicine Investigations Viva Voce

1. Paul Bunnel test is for infectious mononucleosis
2. A patch test is for drug allergy
3. Schimmer test is for Sjogren’s syndrome
4. Schilling test is for vitamin B12 deficiency