0:06 [Music] so oral medicine exam year five the general approach involves gathering information that's the history of the patient the medical history the social history the dental history the family history any test results or current investigations by other specialties okay and of course extreme intra oral examination most of these things will be already given to you okay so do
0:51 take advantage of you have in your hands the exam skill set being tested throughout the whole of the viva um it can be categorized in the these four categories so recalling information what your knowledge about the condition the specific condition or the differential diagnosis of the condition is what is your understanding about it and whether you can um present clinical reasoning in respect to the condition you have in your hands so basically what we're looking for is to see whether you can graduate and go out in a general dent practice and be a dentist okay as simple as that our focus so what are we looking for in
1:37 all oral med drivers you will need to describe the lesion okay a lot of the details are already given to you so if you have a referral in your hands or if um you have a vibe as i sent it out to you most of the things that you need to describe the lesion are already stated there so you only have to recall them okay then we usually proceed with differential diagnosis differential diagnosis is probably um the most difficult part um because you need to recall conditions that look alike and try and reason which is the most likely diagnosis okay and you have to justify your choice so that's the most difficult part that's the clinical knowledge application part of the exam okay when you're asked to give a differential
2:23 diagnosis name at least three different conditions that come to mind okay if you name three if you just give the name you will get a pass we will see i have a breakdown of these questions later on to see what when we do discuss the viva to see what more you need to say to get to achieve an onus and what more you need to say to achieve a distinction for example when you come to most likely diagnosis you need to think of course not of zebras okay so you need to think of what is the most common condition that look looks like the one you have in the photos all right think of zebras only when you are same with words all right um it means that there might be
3:09 that you have your most likely diagnosis is not one of the most common let's say as in your body you have a white lesion it's not the most common lesion that you can encounter in the mouth but it might be very specific to location um shape size and other characteristics so that puts you in the savannah to think the less likely diagnosis of the differential diagnosis management think of the patient as a person do not um just see the lesion and nothing more behind the lesion think of the patient holistically always further investigations um they could be blood tests they could be x-rays they could be biopsy whatever you
3:57 need to conclude your diagnosis they could be prescribing medication that that's how you manage the patient that depends on the case and of course no important guidelines nice guidelines are the ones that we use in the uk so we have to abide to those as much as possible always bear in mind guidelines are guidelines okay they're not the gospel so um you have to follow them as long as there is clinical reason all of the guidelines give you some kind of flexibility and rely on your clinical judgment to decide what applied applies in your state starts by the first part describe the lesion what do we mean by that
4:44 what do you see the lesions that you will see in the mouth can be grouped in three different categories loss of surface so it could be an erosion and also necrosis depopulation if we have loss of surface on the tongue atrophy they can all be called an ulcer if you like loss of surface if you call them an ulcer everybody would be happy with that gain of surface so a swelling of any shape or a hyperplasia you can use other terms you can call it a mass you call it humor tumor is not cancer okay so it's just a swelling basically you can call it a growth you can call it if you want to be really posh and exophytic lesion okay and then the third main category is the change of
5:29 color so if we have change of color without significant loss or gain of surface it means that our primary lesion falls into one of those categories so it can be white red blue purple brown gray black occasionally yellow okay or yellowish this usually falls under the white but do not forget combinations okay so you can have a white and red lesion all right um the most common combination when it comes um to color and you can have a swelling that is actually ulcerated as with many cancers you have to state the primary lesion so the primary lesion in an ulcerated um tumor is the tumor is the swelling the primary lesion
6:14 in a non-homogenous leukoplakia which is white and red is a leukoplakia so it is a white lesion all right so when you need to describe when you'll be asked prompt to describe the lesion the first thing you have to say state is what you see also i see multiple ulcers i see a red and white lesion i see just as simple as that okay you don't need to do more than that and then take it step by step where is it is it on the lips is it upper lower near the vermilion border is it on the back of mucosa where on the buccal mucosa behind the commissure anterior middle posterior third you can state where it sits in relation to the occlusal plane is it on the tongue again dorsal or ventral surface
7:00 lateral borders again and again which third of the tongue is it on pallet heart or soft gingiva free or attached and other areas like retromoral area uvular tonsils or firings you need to state whether it is on the left or the right hand side or whether it sits on the midline or it sits on one side but extends over the midline okay it can give a position relative to a tooth let's say you have a traumatic ulcer on the tongue and you can say that it's on the left hand side laparopod of the tongue opposite to lower left six for example that's a very accurate description of location okay other details that you need to give size
7:46 enough size we don't you know you have a photograph in your hands no one expects you um to have um a ruler take it out and measure it okay but for example if you have let's say an epilepsy that extends um over both this is a key to uh 2.5 centimeters in diameter it cannot be smaller than that you cannot say that it looks like it's half a centimeter okay so give the size um you have to state whether the lesion is single or multiple unilateral or bilateral roughly if it has a shape so is it like a sphere is it triangular is it rhomboid if you can define this a shape is it elongated whatever it is
8:31 describe the surface texture and the color of the surface so besides the colored or pigmented lesions that already the primary lesion group is determining a color most of the other lesions will have some color alteration so ulcers um quite often will have um an erythematous um either base or and everything that is halos or an everything that does ring around them okay a red ring around them um you can have like blueish color on the swelling so you have to describe that as well and if you have a swelling we need to know whether it's sessile or pedunculated okay sessile means that the base of the swelling the way the swelling arises from the tissues is wider than the rest of it pedunculated means that there is a neck
9:18 connecting the suit than the swelling to the underlying tissues if it isn't also we need to know about the base and the edge so the margins of the ulcer whether they're hold up margins or anything like that very very important to include palpation so we need to know whether the lesion is soft firm or indurated if there is pain or other symptoms like temperature lymphadenopathy anything else um and time and change so how long has the lesion been present and has it changed in any way most of this information will be given to you prior to your exam so use it okay um you do need to state the type of lesion to get a pass so if you start describing a lesion to me and
10:04 say well we have a lesion on the lateral border of the tongue um so and so size so and so shape it looks red it looks white but you don't state that this is an ulcer okay um you won't get a pass you do need to say this isn't it so basically give as much detail as possible by the information you were already given and by what you can see um on the photos so moving on the differential and most likely diagnosis when you approach a differential diagnosis of a lesion that's usually the most difficult part okay um you cannot recite a whole oral medicine book no one can all right i i cannot so
10:52 think of the anatomy and the histology what tissues do we have in the area we have epithelium connective tissue minor salivary glands teeth and the dental apparatus muscles nerves vessels bones adipose tissue other tissue like melanocytes it could be foreign bodies it could be metastatic disease okay so any of these can give rise to a lesion to the vision that you're actually um seeing so if we break it down and try and see what is um a main differential diagnosis for ulcers all right my personal preference is to kind of um group them in single or multiple because i find that
11:37 easier to remember there is a way of grouping them as primary or secondary and what do i mean by that primary are ulcers that are not preceded by this vesicles secondary are ulcers that are preceded by vesicles so the disease will firstly come as a vesicle that will break and leave and also behind okay i've prepared um slides for both so you can refer to both and pick the one that is more convenient for you um to learn and remember basically so single ulcer the most common um reason for a single ulcer in the mouth is trauma okay so i've put
12:24 everything and that will apply to all my slides according to what is the most likely um reason most likely cause all right so differential diagnosis um in the way of we go from the statistically highest incident to the less likely um diagnosis at the bottom of the slide okay that's why the different colors and everything so trauma in the oral cavity can be chronic or acute tug-c is um falls under the category of trauma but also forms an entity itself taxi it's an acronym for traumatic ulcerative granuloma with stromal eosinophilia um easier to say eosinophilic granuloma
13:09 that is not as common i've just included it there because it is a traumatic um it is initiated by trauma okay but that would be about i would say um below infection all right or the same statistically um the same statistic incident between four and five somewhere in there if we would um examine it separately so burns burns can be chemical or um thermal they fall under the category of trauma necrosis so when you give an la sometimes because of the vasoconstrictor factors in the la uh you can see a little bit of an ulcer um forming at the area a couple of days
13:55 later and the patient is saying it still hurts me and that's um necrosis of the tissue on the area of the anesthetic administration major affect can present as a single ulcer in the mouth okay sometimes it can be more than two or three that often is just the one oral cancer of course do never forget cancer okay it can be drug used drugs like um the likes of nicorandal can induce a single ulcer especially on the tongue infections uh bacterial infections like tuberculosis and primary syphilis primary syphilis looks very much like a major athlete in the mouth spontaneously tb is not that common in the uk but crime but syphilis is on the rise um and people
14:40 with primary usually are unaware that they have contracted the disease and because it heals spontaneously a few weeks later um they usually go about by spreading the disease because they're still contagious themselves um but they don't know that they have it okay and then before the secondary syphilis develops um it could be fungal much more rare of course like histoplasmosis and blastomycosis they can cause single ulcers especially on the tongue necrotizing xylometroplasia usually that is on the posterior third of the buccal mucosa near the retromolar rare condition allergic reactions like contact stomatitis especially to food stuff and sometimes um to toothpaste and mouth horses usually in
15:26 that case the old ulcers are multiple but very rarely they can be single and there are two conditions extremely rare midline lethal granuloma which is a type of lymphoma that can appear on the palate which is a very severe um form of enog that can be quite destructive um i don't think you can see that in the uk but areas um that a lot of malnutrition very poor hygiene conditions it still exists unfortunately so if we move on to multiple ulcers okay so conditions that appear with multiple ulcers can be subdivided to acute and prostate by that there is short duration and sudden onset
16:12 of the appearing ulcers so rash being the king of this group okay so recurrent after stomatitis minor major or herpetic form um and the minor um minor atherosclerosis obviously being the most common of the three most of the viral infections that affect the oral cavity present as atheroscleic ulcers so um as multiple small ulcers including recurrent herpes labialis primary herpetic gingivostomatitis recurrent intraoral herpes simplex infection which is um the same um the same virus that causes recurrent herpes labialis it just affects um usually the palette rather than the lip it's more rare of course
16:57 than maybe labia is herpangina that's a coxsackie virus varicella zoster both primary and secondary so both chicken pox and shingles can present as multiple ulceration um in the mouth again herpes family of viruses and hot hand foot mouth disease um that is a coxsackie virus again um most of them besides the zosta and the herpes labialis um and obviously the recurrent intraoral so the latent the latent um infection of of herpes um and are seen most of the other ones are usually seen in childhood saying that you cannot exclude that an adult can have her vagina
17:43 okay erythema multiformi again um is a condition that um can present with multiple ulceration um it can be even uh sometimes it used to be the same you we used to call erythema multiformer um the stevens uh johnson syndrome but now they are considered two separate conditions um because of positive factors allergic reactions can present as multiple causes bacterial infections like enoch anub anus which is the same bacterial infection affecting the gingiva only affecting uh deeper periodontal tissues or affecting and spreading to the rest of the mucosa so in that case it's called stomatitis rather than gingivitis or periodontitis
18:28 and of course because syndrome um that looks exactly like recurrent after stomatitis but it also affects genitalia and a lot of others and a lot of other systems um on on the body and it is extremely rare in the uk more common um in greece and turkey so um eastern mediterranean is more common for vaccine syndrome ulcers with chronic duration um kings like or awaken planets and nucleus membrane penetrate okay so the ulcerative or erosion whatever you want to call it like in planus type the mucous membrane panthegoid followed by
19:14 lupus erythematosus then panfigures bulgarias inflammatory bowels disease like crohn's disease and ulcerative colitis when we see the ulcers in the mouth it used to be called especially in the usa they call it biostomatitis vegetans okay granulomatous disease um other than um the crohn's like sarcoidosis vagueness granulomatosis and other facial granulomatosis can present with waters usually in those cases we will have some kind of swelling somewhere as well so it's not going to be ulcers alone and other immunological diseases like epidermolysis bullosa acquisitor angina beloso hemorrhagical leaner iga disease dermatitis herpetiformis which is related to celiac disease they're much more rare conditions and i
20:02 forgot to include drug-induced multiple ulcerations there i'm very sorry um they should be somewhere between five and six okay drugs like methotrexate usually they can cause um after slide if now you will follow the different categorizing so primary and secondary what falls under primary is trauma infection recurrent oral ulcerations immunological or inflammatory disease like lupus erythematosus and lichen planus hypersensitivity reactions drug-induced and neoplasia and what falls under secondary is infection especially with herpes viruses and immunological diseases um
20:49 specifically vesicular boneless diseases like benthicus and penthecoid erythema multiformer and the rest of them that are more rare if we now look at the differential diagnosis of swellings i find that maybe the most complicated one because if we really want to be very precise it's vast it's a swelling it can be anything okay so um because we cannot go by that you cannot go to examine still okay i try to categorize i give you a slide with all like a summary of all possible swellings in the aura cavity okay i'm not going to read through it there is no point you will have it um
21:34 in the end but what i have done then is i tried to categorize two endings by anatomical site so um following this categorization lower lip upper lip buccal mucosa gingiva localized or generalized floor of the mouth tongue heart or soft palate and then multiple swellings rather than single and neck masses what i'm going to give you is what is the most likely swelling to appear at each side okay and then followed by differential diagnosis so swelling on the lower lip high the highest chances is that it's a menucocel all right we have two types of mucosal extravasation mucus retention it doesn't matter if you don't state them both and you just say mucosal everybody will happy with that
22:19 it's followed by fibroepithelial polyp squamous cell carcinoma other mesenchymal tumors such as hemangioma neurofibromine lipoma salivary gland tumor and kerotoacanthoma a much much rarer um condition if we now see the philip it's a bit different to the lower lip okay so the most likely swelling to appear on upper lip is a fiber epithelial polyp followed by a salivary gland humor okay so um be really vigilant and um alert if you see a swelling of the upper lip especially one that looks like a mucosal because quite often um the salivary gland minor salivary gland tumors on the upper lip have very many common uh features to a
23:05 mucosal okay so mucosal actually statistically um comes after the salivary gland tumor and then other mesenchymal tumors follow and nasolabial cysts do not forget near the midline when we're talking about salivary gland tumors here i've just named a few okay so it could be a benign or a malignant tumor the most common of the benign ones is the cleomorphic adenoma and the most common of the malignant ones is the muco epidermoid carcinoma so these are the names that you need to keep okay as i said you not have to learn all the names but these two if your viva is anywhere near that topic you will have to remember
23:52 so if we go to swellings of battle mucosa again fibropathetic polyp by far the most common followed by lipoma mucosal hypoplastic lymph node other mesenchymal tumors squamous cell carcinoma and salivary gland tumor minor salivary gland tumor comes last year again fibroepithelial polyp some people call it fibromyalgia it's the same entity okay is as you will see that's probably the the most common swelling in the mouth by far um followed by squamous cell carcinoma mucosal other mesenchymal tumors pyogenic granulomas and lingual thyroid okay and that's a quite rare swelling of the tongue and it's always
24:37 located at the root of the tongue as we call it so the very very posterior third and it's just um embryonic remains sometimes the thyroid during the embryonic period doesn't descend to its place um and in if we have such a finding um we need to know whether we actually have a thyroid in the right place before we decide to move it because it might be the only thyroid tissue in the body okay so it is rare but it is quite important to know um what it is so it is swelling and it's localized rather than generalized so it's mostly singular the most common one is a fistula so um a draining sinus okay followed by epileus fissuratum that is only for people that have
25:25 dentures because it cannot be caused without a denture followed by pyogenic granuloma peripheral ossifying fibroma peripheral giant cell granuloma and fibroepithelial polyp all the conditions on the right hand side of the screen over there where my cursor is they can present the swellings of the gingiva so squamous cell carcinoma metastatic tumors gingival cyst of the adult traumatic neuroma kaposi's sarcoma peripheral and genital epiless melanotic neuroectodermal tumor of infancy and other mesenchymal humans but they're extremely rare if we now look at gingival enlargement as generalized the most common reason by far is plaque
26:12 induced gingivitis or chronic hyperplastic gingivitis when i was taught that's what we called it okay you're going to be stick with it for the rest of your professional lives day in day out you're gonna see it um saying that it is followed by drug induced gingival hyperplasia which is usually fibrous so in um in contrast to the plaque induced you don't always have the erythema the bleeding you know the the signs of inflammation um so drug-induced interval hyperplasia um certain drugs like nephedipine for example can cause it is followed by that's gingival hereditary condition looks very much like the drug induced gingival hyperplasia but there is a genetic background to that leukemic
27:00 infiltrate so if you have a gingivitis that doesn't look quite right to you um you tried everything you've done your deprivement the patient has followed oral hygiene instructions and is maintaining maintaining a good level of oral health but it's not responding um to treatment basically do have like a full blood count of the patient it's just a full blood count just to exclude um a possible leukemia um it is rare but sometimes especially in adolescence it can start um it can be diagnosed and the first presentation can be the gingivitis um another generalized swelling of the gingiva presents with waginess
27:46 granulomatosis it's called strawberries like this and scarve as well which hopefully we don't see a lot these days so if we proceed to the palette hard or soft the most common swelling is epilate lapses followed by again fiber epithelial polyp which usually is called the lymph fibroma when it's located there followed by exostosis which from all the things that we've mentioned so far um it's a bony protrusion so hard tissue rather than soft tissue mass okay followed by papillary hyperplasia of the palate salivary gland tumors composer sarcoma nasopalatin duct cyst and all the rest are much much more rare about salivary
28:31 gland tumors okay so as you can see when you see a mass on um the palette it's not the highest chances that it's a cyber little tumor but bear in mind that off minor salivary gland tumors the most favorable sight in the mouth is um the heart palette okay or the palette so floor of the mouth swellings um granular which is a mucosal in principle cellulolics suede cell carcinoma um lymphoepithel cysts or branchial cyst epidermoid or dermoid cyst salivary gland tumors again and mesenchymal tumors are the most common entities and then if we see multiple swellings in the mouth there are a few conditions
29:17 that can conditions that can present like that all of them are quite rare okay so papillary hyperplasia of the palette followed by composer sarcoma followed by neurofibromatosis um it's usually neurofibromatosis type one that presents with intraoral lesions um and it could be mass and um usually that has some skin lesions following that as well followed by focal epithelial hyperplasia which looks like multiple squamous cell papillomas basically so multiple warts in the mouth to put it simply amyloidosis granulomatous diseases and men to be syndrome
30:03 by far the most common reason for an egg swelling is reactive lymphadenopathy either to an infection or to a malignancy for whatever reason that's by far the most common reason to um for a neck mass epidermoid cysts thyroid gland enlargement lipomas infectious mononucleosis metastatic carcinomas and lymphomas are more or less um around the same statistical numbers and then all the rest are very very rare conditions as i said swellings is the biggest category for differential diagnosis but from what you've heard so far the word that you've heard
30:48 being repeated epithelial polyp okay so by far the most common swelling if it's not of dental origin to say that is a fibroepithelial polyp okay do never forget that if you see a swelling in the mouth you first of all unless it's on the buccal mucosa very far away no teeth present you first of all have to consider whether it is related to a tooth or not okay and you have um you have your x-ray there you can take an x-ray you can see whether um this is related to a dental condition you have your vitality test you have your clinical examination of the dental tissues as well so bear that in mind okay but if we look at soft tissues fibroepithelial polyp usually followed by epileus
31:34 [Music] different types of fabulouses and pyogenic granuloma and mucosil they they are about on the same statistic followed by squamous cell carcinoma salivary gland humerus cysts again not related to teeth necessarily composes sarcoma and other tumors like hemangiomas um like hormones and things like that so if you want to keep something short in mind keep this table for differential diagnosis of swelling and again never forget to mention dental possible dental origin we'll go ahead to change of color as we've mentioned before we have white red blue purple brown gray and black
32:20 the yellow is very very rare and is usually can be included under the white okay um we can have combinations of those the most prominent combination of usual combination is white and red okay and it's the most alarming combination usually so for the red lesion i've also broken them down to um two categories the second category is what i call the hematology category okay so pategia echimosas and telangiectasias basically have something to do with bleeding spots presenting in the mouth and you will see the breakdown of those um so it was with white okay white lesions as i said four dye spots
33:07 for example they have a slightly yellowish golden color but they could be included under the white category so a generic um and quick differential diagnosis of white lesions would be infection and mainly candidosis and we have to think of all different types of candy doses that can present as white like pseudomembranous and chronic hyperplastic it can be reactive like functional keratosis or keratosis in reaction to injury either thermo or chemical burns basically we can have other reasons like leukoedema or white coated tongue or hairy leukoplakia so leukoedema is associated with race hairy leukoplakia is associated with hiv
33:53 genetic reasons like white sponge nevis and other dyskeratotic syndromes it can be immune mediated diseases like oral liking planus or a lycanoid reaction lupus lupus erythematosus and graft versus host disease and of course to never forget it can be leukoplakia and when we suspect leukoplakia we always need to exclude dysplasia or possible possible malignancy differential diagnosis and we see white lesions that we can actually scrape off by far the most common one is the white coated tongue which is a quite common condition um some of you like if you go in the mirror put your tongue out sometimes you can find that there is a little bit of a white coating in there on there um quite um common amongst
34:40 patients um they just need to be advised to brush it a little bit and that is all it's quite a benign condition and then of course um the next most common is candy doses or candidiasis whatever you want to call it um the detaching one being the pseudomembranous usually acute chronic pseudomembranous candidiasis is more rare and it usually appears in immunocompromised patients um morsi which is cheek chewing and it's different to the linear album okay because it is detaching so don't um confuse the two linear alba which is frictional keratosis as a line on the cheek cannot be detached all right but people that have the habit of um chewing um their cheeks
35:27 it's like it appears like a flaky mucosa okay so thermal mechanical and chemical burn you can usually peel off the white um slough off the top um it can also be a reaction to toothpaste or mouthwash so more like a contact stomatitis secondary syphilis can present as a detaching white lesion and infection with diphtheria but that's quite rare and in only particular areas of the world so white lesions that are non-detaching as you can see they're much more um of those um on this slide so linear alba which is the frictional keratosis leukemia plexia actiniculitis lychem planus
36:15 uh mosicatio it can be non-detaching as well just to confuse us a bit more white-coated tongue that can be not non-detaching as well snuff dipping which is um due to the use of smokeless tobacco i have a an asterisk there the reason why is snuff dipping in some countries is quite um quite common and scandinavian uh scandinavian countries um have quite a lot of people do um use smokeless tobacco and in that case snap dipping uh statistically would be proper probably uh right next to leukoplakia okay um nicotine stomatitis can appear as just white adjusted white lesion four dye spots as we said maybe white yellowish
37:00 and then we have all these other conditions hairy leukoplakia chronic hyperplastic candidosis lupus erythematosus submucous fibrosis white sponge nevis hereditary benign intraepithelial dyskeratosis pahionichia congenita dyskeratosis congenital tertiary syphilis in the form of cyphalitic glossitis and uramic stomatitis can present as non-detaching white lesions but much more rare with a combination of white and red again that is a little bit more limited than the white non-detaching um by far the most common is erythema migrants so geographic tongue basically sometimes geographic tongue can not it's not
37:45 always limited to the tongue so sometimes it can even affect the rest of the mucosa but quite rarely um candy doses so you can have candida that appears as a mixture of white and and red lesions as especially with pseudomembranous they sit on an elephant everything that is based and if you remove them you see that redness the mucosa sometimes indian bleeds okay certain types of lichen planus erosive or atrophic or ulcerative type burns can be white and red acne light is nicotine stomatitis so if um the orifices of the minor salivary glands are quite prominent that would appear as white and red rather than just as a white lesion erythroleukoplakia reaction to cinnamon again a contact stomatitis
38:31 lupus erythematosus scarlet fever and varicophobic synthoma scarlet fever very characteristically on the tongue so the tongue has a white coating and it looks like it has red spots on as you see there is a slight overlap of certain conditions that can appear um in many different in many different ways okay do not let that scare you actually that's a bit easier um to remember because if you remember that it applies into more than one it's easier to give more conditions in your you know name more conditions in your differential diagnosis so if we see red lesions now pharyngitis is usually the most common reason um if we examine the far back of the
39:17 mouth if we exclude that then we have traumatic erythema so redness in the mouth basically because of trauma dentistromatitis which is a candidal infection erythematous candidosis that is not associated with a denture it presents on the palate again exact same way it's just that um the the person is not a denture wearer erythema migrants angular colitis thermal burns erythroplakia and of course an anemia that can present with a glossitis so um the tongue can be quite red and shiny hemangioma lupus erythematosus scarlet fever plasma cell gingivitis and radiation mucositis can present as red lesions we focus on red lesions that are
40:04 specific to hepatology so potentiae echomosis and telangiectasias echemosis is a bruise okay patakia are tiny small bleeding spots and telangiectasias are dilation of of vessels of the end of the vessels basically put it simplistically the most common reason for them in non-specific trauma it can be upper respiratory tract infection and also some other conditions can present um with these red lesions like infectious mononucleosis idiopathic thrombocytopenic pulpura hemophilia leukemia hereditary hemorrhagic
40:50 telangiectasia which is otherwise called um oslavurindu syndrome and crest syndrome which is um the limited cutaneous um form of systemic sclerosis and crest is an acronym for i think it's calcinosis reynolds phenomenon esophageal dismobility scleroductili and t stands for um telangiectasia um usually at um the ventral um surface of the tongue the most common reason for the blue and purple lesion submucosal hemorrhage sorry bruise again amalgam tattoo mucosal eruption cysts giant cell
41:36 epileus hemangioma granular caposis sarcoma and then more rare conditions like an enzo palette in duct cysts salivary gland tumors remember when we mentioned that much epidermoid carcinoma can very much look um like a mucosal it's because it can sometimes have that bluish purplish tint to it gingival cyst of the adult blue nevis and malignant melanoma down bey and black so grey pigmentation okay the most common reason followed by amalgam tattoo and black and brown herring tongue melonic macule which is practically a freckle so what we call a freckle on the skin is called the melanotic macule in the mouth smokers melanosis non-amalgam tattoo
42:23 melanocytic nervous malignant melanoma never ever i've i've underlined it there so when you have a pigmented lesion you have to include malignant melanoma in your differential diagnosis always it can also be drug induced the most common drug is the most common drugs are contraceptives especially myocycline um and chloroquine which is very popular now with covid because it has been used in the treatment of covet can cause drug induced pigmentation in the mouth oral heavy metal poisoning poison syndrome addison's disease neurofibromatosis type one again much less neurectomy tumor of infancy can also present as brown ray or black
43:09 lesions in the mouth but they're very very rare so moving forward now to patient management what do you need to do first of all you need to have the general management of the patient we have to look at the overall health of the patient we have to look at their lifestyle choices whether they need a smoking cessation counseling or support for mental health issues alcohol consumption support diet support always enhance oral hygiene and always look at the general approach to the patient from a preventative point of view so let's say you have a patient um that is to undergo a procedure um you
43:56 have to be proactive and anticipate whether that procedure is gonna cause them any more trouble and act preventatively to whatever more trouble that might cause let's say that they can get prescribed a drug that can cause them dry mouth or they can get have radiation or anything like that and then also we have the problem which is specific to the condition so further investigations what they might be medical imaging any type of medical imaging we have our radiographs um pas or opts or whatever ct scans mri scans uh ultrasonic scans uh all sorts of you can have cintigraphy you can have a scintigraphy of the bone you can have radioactive medical imaging
44:41 for the thyroid for example whatever it need be blood analysis so the most common checks that we do are full blood count hematinis renal function um and what we mostly do in oral med is also specific antibodies for certain conditions we do celiac disease um screening um and um and any other blood test that we might need we can ask for microorganism detection testing like uh we take swabs to do cultures to do pcrs like we do with covet soaps usually are used for candida um or if we have a specific bacterial
45:26 infection and we need to see what type of bacteria we have and what antibiotic is best to use we can do a culture and then an antibiogram tissue specimen analysis which can be high cytology or histopathology so we can have azmir uh where we take some um like a few cells of off of the tissue and we put them under the microscope with uh different types of stains or a pop biopsy um and with all the different counterparts you can have an incisional an excisional you can have a punch you can have a fine little aspiration biopsy whatever um needs to be done we have other kinds of tests like um cyanometry or sureness test um drug prescribing so whether we need
46:12 to prescribe any local or systemic agents specific to the condition that we're dealing with and of course the management of the patient does include referrals referrals for specialist advice or referrals for biopsy or to specialist clinics as long as they are needed or appropriate or even um if you go through nice guidelines you will see that in quite a lot of conditions they do say if you're not certain of the diagnosis you are advised to refer so if you're not certain um for what you're looking at please feel free to refer depending on where you will be um you can refer either to an oral medicine clinic or to oral surgery educating the patient is also an important part of the
46:58 approach so especially if people present with chronic conditions or recurrent conditions um they need to know what it is that they have let's say someone presents with or liking planners they need to know that they have to live the rest of their lives with this disease okay but they need to be reassured um that we can help them deal with the symptoms of the disease let's say they have a relative type and they're in pain we can help them deal with that okay and of course again prevention comes into effect as i said um if you have a patient that has been diagnosed with an oral cancer and they are about to have radiotherapy following um their um resection of of the cancer you have to follow certain preventative
47:44 measures um from um extraction of uh teeth that might pose a risk for extraction post post radiotherapy um or prepare the patient for the possible mouth that they will have to deal with okay guidelines and further reading online so nice and sd step have quite a lot of information nhs nhs az and then bdj are very good sources so if you follow these links you can find a lot of information um regarding many of the conditions that um appear in a month further reading so as i said with every every medical every dental school uh have has a
48:31 favorite or reading um suggestions so follow what your school has suggested at the oral medicine curriculum so in for example um i think these are one you know five of the most common uh books that are suggested as co-reading amongst different dental schools in the uk uh if i forgot anything please uh forgive me as i said i i teach in manchester um i i was taught myself i was trained um with having uh because obviously his reputation was way outside uh the borders of the united kingdom um from the uk and then um different professors from the usa um so i just picked the ones that i think the really good books pick one you don't have to read them all
49:18 okay just pick one and follow your school's oral med curriculum um to help so if we move on the scenario [Music] we had a 52-year mail just to say i've just put the scenario um together based um on on a patient but it's not a specific patient so i find a few things just to have um things to discuss okay the patient complained of a white patch on the buccal mucosa on the left-hand side his medical history is that of high blood pressure non-insulin dependent diabetes mellitus and high cholesterol he takes athenal metformin and simvastatin his mother also had diabetes type 2 and he is an
50:03 ex-smoker that only quit two years ago and he consumes 12 units of alcohol a week he's a high school teacher so sometimes that can be um highly stressful job depends on what position you have and how you deal with with things in life and he's a non-regular dental attender luckily his bp was a one year ago to replace a lost filling but he does brush twice a day um using an electric toothbrush and a fluoride toothpaste so proceeding with examination we have good facial symmetry no sign of limited mouth opening clicking on the right hand side dmj with no other symptoms no lymphadenopathy no muscles of mastication
50:49 and we find a white patch on the back only goes the left hand side behind the commissure at the occlusal level 2.5 centimeters long that cannot be wiped off the patient presents with a similar smaller and less asian right hand side as well so as i said before quite a lot of the information is already being given to you okay so half of the questions to get a pass you have it right there you don't need to look further okay so if we see the photos of clinical examination has anyone picked up anything weird about these two photos that doesn't fit that the description basically
51:44 so both photos are photos of a different patient okay i've put them there to make the case but how can you tell can you see the mucosa there the color of the mucosa okay you can argue that the color is based on how the light goes but can you see the pigmentation there that is probably racial pigmentation that actually is not present there okay so if someone is really really um servative you could see that these were too um different i didn't i didn't do that to trick you okay i didn't see it when i picked them i saw it later so if you're really observative and you see what's in front of you you can you know pick um things around so what are the discussion points as i said the chances are that these
52:31 discussion points this is what we usually ask advisors in manchester but that is what all oral med will look for describe the lesion give a differential diagnosis give the most likely diagnosis consider if any features could suggest this lesion to be sinister in nature and how would you manage the patient in manchester in addition to that you will have an extra question which usually i think is oral surgery it applies to an um a medical emergency which obviously um i it doesn't it goes beyond the purpose of this presentation so i didn't include that and to remind you exam skill set being tested recalling information knowledge understanding and clinical reasoning
53:21 use the information given to you i've copied and pasted it all with color red are the that would give past so a past score you have to state that it is a white patch or a white plaque or a white lesion on the buccal mucosa left hand side behind the commissure at the occlusal level 2.5 centimeters long and that there is a similar lesion on the other side okay um that will give you a pass so you need to state what type of lesion you have one where is it located very very important eight three if you can give either a size or a shape or both that will um guarantee you a pass if then we're
54:09 looking into um getting a bit better scores in this then you can say that there are no accompanying symptoms um reported so there is no lymphadenopathy the lesion cannot be wiped off obviously this is quite important to help you um do a differential diagnosis and then um a most likely diagnosis and that the lesion on the right side is smaller less prominent so the lesion is bilateral but it's not exactly symmetrical okay that's what that implies if we go further you can add details but what you see in the photo all right so i've repeated the first two and then as i said before no other findings extra orally so we
54:55 didn't have any skin problems of pigmentation at the margin of the lesion on the right hand side the surface is not smooth the anterior third of the buccal mucosa is affected in both sides the patient has not complained of pain you cannot there that the lesions look especially the right hand side roughly triangular if you like so any more details that you can give will work on your benefit so green will take you to a distinction to get the distinction you have to say all the red almost all the purple and most of the green okay so that's why i've done that to all the rest of the slides so it's color coded to help you know um
55:42 you know to kind of guide your vision to what your target what your goal is for your finals so differential diagnosis name and justify this is your chance to shine okay so as we said before i use the simple differential diagnosis here if you wish to add more fine you need to name three different conditions to get a pass if you just name three you will get a pass so if you say it's probably candidiasis um it can be candy doses of white lesion it can be frictional keratosis or you can say injury and it can be leukoplakia these are three these will get you a pass okay leukoplakia needs to be included
56:29 antidoses needs to be included because they are the two main conditions that we have to um differential diagnosis between okay so these didn't do need to be mentioned from the other ones you can mention whatever the more you mention the higher your score okay you got your pass you've mentioned let's say five or six conditions and you got your honors but you really want that distinction so the distinction will you will get in um by knowledge and clinical reasoning so what would be that so um you can say it could be um candidosis but as it cannot be wiped off um it could be the type of candidosis called chronic hyperplastic candy doses
57:15 which the usual location is behind the commissure you can give more details you don't have to exhaust the list okay i've just placed there like um this is not an exhaustive list of what you can say i've just given you an example on what to follow for your answers so frictional keratosis the patient doesn't present with parafunction but clicking sound present though asymptomatic the lesion is of the occlusal plane so one could argue um that uh differential diagnosis as well injury um it could be a thermal or a chemical burn to present white but there is no refill reference to an incident prior to the appearance of deletion so this is probably a most likely diagno less likely sorry um diagnosis
58:02 leukoplakia give the definition of leukoplakia is a white plaque that cannot be otherwise determined very very important to exclude dysplasia and in this case you can argue that the patient presents with risk factors he's an ex-smoker he only has quit for two years and he's smoked for many many years um and as a rule of thumb um to kind of get away from the effect of of smoking from your body you need to be smoke-free for as many years as you smoked okay and almost borderline alcohol consumption so we know that um um the uh the line for alcohol consumption is 14 units a week but mind you if you have um like a small
58:48 a statue person 12 units would probably be flirting with that uh border okay look edema leucodema is usually more diffuse and less well-defined it usually covers a bigger area it's more common at patients with darkest skin hairy leukoplakia associated with hiv usually lateral border of tongue usually middle of two posterior third where it appears so less likely for this lesion to be heteroleproplagia white sponge nevis um its onset is on childhood as it is a genetic a hereditary disease other discaratory syndromes again on cities on childhood so the chances are that this cannot be them and also there are other areas of the body especially the skin and the nails that are affected
59:34 or unlike in planus all like implants can be argued again in this differential diagnosis by the bilateral presentation and you can refer to the different types of oral complainers the most common one being the reticular pattern but we do have a plaque-like type of oral liking planers we might have possible skin lesions specifics of the rash so where you you usually find it or how does it look mention um the lycanoid reaction especially in relation to the patient um patient take metformin and a tenderloin especially metformin but antenna as well um can cause lycanoid reaction in in the mouth and with lupus we usually have skin lesions the intraoral lesions might also present
1:00:20 as red or combination of white and red and then if you know graft versus horse disease and what it is and give a definition that will definitely give you um extra points graft versus horse disease to explain it simply um when you have a transplant in a host so in a body a solid organ transplant the immediate reaction of the body is to recognize it as foreign and try and attack it attack to destroy it with um with its immune response yeah with its immune system with breath westeros host disease it usually appears patient to patients that had um bone marrow transplant and what happens is that instead of the host attacking the transplant
1:01:06 the transplant creates its own immune response against the host so it produces uh it produces antibodies against certain types of cells of the host can present in the mouth exactly as um or a lichen planus so the more you elaborate as i said this is not an exhaustive list you don't have to mention all of this but if you include you choose to include like four five six conditions in your differential diagnosis and you give reasoning behind why you think this is likely or why you think it's unlikely okay that will give you the highest scores so when we approach most likely
1:01:51 diagnosis we need to name it we need to justify it and we need to discuss it okay so in this case um the most likely diagnosis is chronic hyperplastic candy doses extra points you would um get by mentioning candida leukoplakia which is a term that used to be used in the same way but some some um oral meds um specialists now use them separately some still use them the same some use only the chronic hyperplastic candidates and not at all they can't interleukia if you discuss the controversial nature of the lesion so it is a lesion that is very much debate in the oral med
1:02:37 world about okay so quite a lot of the researchers argue that this is a proper candidal infection and what we see is a reaction of the tissues to um the infection but quite um a lot of researchers support but no it's a leukoplakia that has been secondarily infiltrated by candida okay so what we usually find is that the candida high v invade the parakeratine layer but never penetrate deeper into the prickle cell layer so any additional histology details that um depends again on what university you are and how much histology you do um to a lot
1:03:23 that is your choice um the more you give the higher your scores you can at this point discuss generally candidal infections um give an understanding and show that you understand that candida is a commensal organism so it gives you opportunistic infections um you can say that the most common um species is candida albicans but we have others like candida glabrata kind of the tropicalis that can also others that can also cause um infection in the mouth it is present to up according to nice that number that 45 percent of healthy patients or healthy individuals and that is according to nice guidelines you can also discuss the main candidal infection presentations which is pseudomembranous acute or chronic erythematous acute or chronic and
1:04:10 hyperplastic which is usually chronic okay and that the fact that the hypoplastic is the least common of the three if you want to give the additional um additional conditions that relate to candida like median rhomboid glossitis anguliculitis please feel free to do so and then if you want to generally um give a general description of chronic hyperplastic candy doses um so it comes in two forms if you know the one form which you can call it either homogeneous or plaque-like either either way that will give you a pass you have to know that it doesn't detach or that it touches really really um uh difficult with difficulty but then if you can mention that there is another
1:04:56 form that it can appear in a nodular of speckled form that will give you extra points it is usually bilateral um on the back of mucosa just behind the commissure less common areas that it can present at is posterous or the rest of the battle mucosa tongue and palette that will you know score you higher points as it's not very commonly known and then you can give a specific reasoning why you think this particular lesions that we saw on the photos are the chronic hypoplastic candidaces so it's a white lesion that cannot be wiped off it is bilateral it is located behind the commissary it is roughly triangular there is no reticular pattern present though uh or a lachanoid react uh black planers
1:05:43 can be blocked like an or a lycanoid reaction can be argued higher prevalence in middle-aged men who are smokers okay here you can also discuss risk and predisposing factors so if they are the ones that you know like smoking um broad spectrum antibiotics and inhaled oral costeroids these are the basics and then if you want to go a bit deeper diabetes immunocompromise poor oral hygiene and then even deeper local trauma malnutrition and hematin deficiencies specifically to chronic hypoplastic candidosis and to this case the predisposing factors are smoking possible hematitic deficiency and then the diabetes and can also be argued as well
1:06:28 so as i said this is not an exhaustive list you choose how you want to do the discussion you don't have to mention everything i've put in here but you have to kind of followed as as a rough guideline on what you can discuss so sinister features again name and justify so there is a possible risk for malignant transformation you have to know that okay um and usually that is the persistence of the lesion so if the lesion is still present after treatment or for a specific amount of time that is quite long usually that applies to all types of lesions um that might be a sign um that there might be something sinister going on refer to relevant guidelines and also
1:07:13 discuss mixture of white and red possible change to the worst whilst in treatment and the case of speckled leukoplakia okay moving to management [Music] as we said we are trying to do a holistic approach um you can take a swab to confirm the presence of candida you can mention that as a further investigation bear in mind that swabs especially for chronic hyperplastic are of questionable value but you can say that and mention the questionable value it will definitely give you extra points and you need to know that there is some kind of antifungal treatment needed and then if you elaborate on that so we have topical and systemic antifungals and then mention the different types and what is first choice according to
1:07:59 guidelines so we have the main topicals are my console gel which is the first choice of the topicals um and then the other one that we usually use um as a topical is nice starting oral suspension adjust the two okay and systemically we usually use fluconazole so um if you mentioned that we have these choices and um depending on the clinical sidelines we usually start if it's like a mild a mild lesion we can start with only topical if it's more severe we usually give a topical a combination of topical and systemic most cases we really need to give systemic for um chronic hyperplastic um to resolve okay um
1:08:45 so the first choice topical is the micronazole gel but always remember there might be contraindications like the most common one if the patient is on warfarin you might need to think of an alternative and that would be then then i started referral to specialist clinic that is also part of the management you have to state the reasons why if you think the there is a need of referral straight away if you think that um we can try and deal with it at the general dental practice level but then if the um lesion persists or if the patient is severely immunocompromised then we might think off of a referral doesn't it need to be urgent again follow guidelines and trust your clinical judgment as i said like if you have a person that is
1:09:30 severely immunocompromised i would you know you need to refer them um because they probably need treatment and they probably need to be hospitalized for treatment biopsy to exclude dysplasia as we said it is a potentially malignant lesion if and when needed so you can here again mention if you haven't done before different types of biopsy so um give details of preferable location if possible and follow guidelines um so in this case it would be an incisional biopsy okay thus you can mention that and explain that ideally it should be taken by including part of normal tissue and if there are any red lesions include those as well eliminate possible predisposing factors like smoking cessation
1:10:16 the patient has already quit smoking in this case but you can like ask whether there was any relapse let's say two months ago they he they smoked like two cigarettes or anything like that and offer a smoking session um ask for additional investigations like blood tests to exclude a hematitic deficiency educate the patient regarding his condition and empower him to make an informed decision and kind of you're helping him by giving him his options and his choices to choose what suits him best to deal with his condition do not forget the patient has come to you okay um he didn't just come for a general checkup he came for the particular lesion so he already taken um the most important step towards his
1:11:02 treatment explain all possible risks and the important importance of treatment if you need to review or if you need to do um a referral so basically treat the patient if you were sitting in the chair like you had no one else behind it's just you and and the patient um and you need to help them um the more things the more you act like um an already qualified dentist let me put it that way and the more scores the more high scores you will have guidelines specific to um chronic hyperplastic candidosis or most of them are by nice okay um i don't know why um they don't look activated but you can copy and paste them in your browser um and they will take you to the relevant pages
1:11:48 and um general tips all right keep it simple and straightforward or as i like to say short and sweet be confident if you're not sure about question ask again try and keep in mind as much of the information given to you as possible just that information can probably give you a pass in quite a few questions it will sleep well the night before do not forget it is not a life or death situation though it probably feels this way and do not forget you made it this far you definitely can do this okay thank you very much there we are if you excuse me i'll just turn my lights on because it comes quite dark
1:12:34 you're write them in the chat now come to kings please that was amazing i hope i didn't tie you or bored you terribly i'm probably not bored i just need to go revise i think i scared you then no no no okay so there we go we've got our first question uh does dysplasia always indicate malignancy pleasure doesn't indicate malignancy exactly but if you have dysplasia you do need to remove it if it's mild sometimes you might choose to just remove the predisposing factors because in mild cases of dysplasia the mucosa
1:13:22 has the ability to kind of correct them okay by itself without extensive um surgical approach but if you have um moderate or severe dysplasia then if you leave that without doing anything that will definitely um develop into uh malignancy okay even mild dysplasia if you don't do nothing about it it will develop eventually in time um into malignancy with severe dysplasia there is a very fine border between that and actual malignancy and as i said to all my students it's the basal um the basement membrane so severe dysplasia to actual invasive cancer the only difference is that invasive cancer has found one spot and broken that
1:14:10 basement membrane even one cell if one cell has gotten outside that basement membrane you have an invasive cancer and that's the only difference between the two when they first start that not the only the main difference okay so mild dysplasia can might can be dealt with um with predisposing factor control um smoking cessation with smokers again i put a big question mark there on whether um they can really um control like i'm more as a patient myself if i had a dysplasia i would like doubt but of course um it depends um on on the case mild dysplasia can be argued that you can have mild dysplasia with chronic candidal um
1:14:57 leukoplakia um that can be dealt with so you have the antifungal treatment and then you have no dysplasia later on if you repeat the biopsy okay so it has it has been mentioned for example in this particular case um but i'm quite i don't know um i'm not i don't feel safe if i just leave a displeasure there i wouldn't like one in my mouth let's put it that way okay the next one we got is what is the difference between non-detaching morris cathy and linea albia um uh more sication non-detaching okay so the way it looks the linear alba is um they're both a type of frictional keratosis okay so linear alpha is very distinct it's a line so you see the line going like a
1:15:43 little wave a white wave um it can start from behind the commissure and extend all the way back um to on your mucosa so it's a line mostly cartio on the other hand chewing um for um chewing the the the cheek the inside of the cheek extends usually in a bigger area and it looks very much like um a flaky white lesion rather than a line so it's not a line okay that's the main
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