PBL 1013 Exam 2 Review

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1

Shirley DeRita, a 40 year old woman, presents to her dentist complaining of ”mouth sores.”

Medical History

  • recurrent lesions on cheeks and palate
  • fatigue and joint pain
  • dry eyes with "gritty sensation"
  • intermittent low-grade fevers
  • chest pain on deep inspiration
  • symptoms worst in the morning
  • history of hypothyroidism

Physical Exam

  • erythematous rash on face and chest
  • diffuse swelling of the hands
  • PIP joints are tender to palpation
  • red-white lesions on buccal mucosa and palate

Laboratory Findings

  • HPX: elongated rete ridges, lymphocytic infiltration
  • CBC: anemia, leukopenia
  • CHEM: normal
  • UA: proteinuria, hematuria
  • HXR: swelling in PIPs and MCPs, but no degeneration
  • IP: low total iron, high TIBC
  • (+) ANA, anti-ds ANA, C3, C4
  • (−) RF

What was the diagnosis?

Systemic lupus erythematosus (SLE) is a serious multisystem disease with a variety of cutaneous and oral manifestations.

  • Women are affected nearly 8 to 10 times more frequently than men.
  • The average age at diagnosis is 31 years.
  • Common findings include fever, weight loss, arthritis, and fatigue.
  • Up to 50% of patients have a "butterfly" rash over the malar area.
  • The kidneys are affected in 40% to 50% of patients.
  • Oral lesions develop in 5% to 25% of patients (often lichenoid).
  • Approximately 95% of patients are positive for ANAs.
  • Anti-dsDNA is noted in 70% of patients (more specific).

For severe, acute SLE involving arthritis, pericarditis, thrombocytopenia, or nephritis, systemic corticosteroids are generally indicated

2

Levothyroxine

  • Thyroid hormone
  • Synthetic isomer of thyroxine involved in normal metabolism, growth, and development, especially of the CNS in infants.
  • Treatment of hypothyroidism, myxedema coma, thyroid hormone,
    replacement, cretinism, and chronic thyroiditis.
  • Reversible hair loss at the start of therapy (in children); dry skin, GI intolerance, rash, hives, pseudotumor cerebri or severe headache
3

Fluocinonide

  • Topical corticosteroid
  • Has antiinflammatory, antipruritic, and vasoconstrictive properties. The exact mechanism is unclear.
  • Treatment of psoriasis, eczema, contact dermatitis, pruritus, oral lichen planus lesions.
  • Itching, redness, irritation, burning, dryness, folliculitis, acneiform eruptions, hypopigmentation.
4

Acetylsalicylic Acid

  • Nonnarcotic analgesic salicylate
  • Inhibits prostaglandin synthesis, acts on the hypothalamus heat-regulating center, and interferes with the production of thromboxane A2.
  • Treatment of mild-to-moderate pain or fever, including arthritis, thromboembolic disorders, and transient ischemic attacks.
  • GI distress (including abdominal distention, cramping, heartburn, and mild nausea); allergic reaction (including bronchospasm, pruritus, and urticaria)
5

Acetaminophen

  • Nonnarcotic analgesic
  • A central analgesic whose exact mechanism is unknown but appears to inhibit prostaglandin synthesis in the CNS.
  • Treatment of mild-to-moderate pain, fever; also used in combination with other ingredients, including opioids.
  • Hypersensitivity reactions; active alcoholism, liver disease, and viral hepatitis, all increase the risk of hepatotoxicity,
6

Prednisone

  • Glucocorticoid, intermediate acting
  • Inhibits accumulation of inflammatory cells at inflammation sites and release of mediators of inflammation.
  • Treatment of severe inflammation, immunosuppression, neoplasms, multiple sclerosis, collagen disorders, and dermatologic disorders.
  • Insomnia, heartburn, nervousness, abdominal distention, increased sweating, acne, mood swings, increased appetite, facial flushing,
7

John Taggart is a 62-year-old caucasian male who presents with the complaint of “a sore spot on my tongue.”

Medical History

  • painful lesion on left side of tongue
  • first noticed 1 week ago
  • pain is getting progressively worse
  • family history of throat cancer
  • past history of smoking and alcohol

Physical Exam

  • BP 138/82 mmHg
  • white ulcerated patch on left lateral tongue
  • lesion does not rub off with gauze

Histopathologic Findings

  • cytologic changes above mid-epithelium
  • thickened parakeratin

What was the diagnosis?

Epithelial dysplasia or carcinoma is found in 5% to 25% of oral leukoplakias.

  • Dysplastic changes typically begin in basilar and parabasilar layers.
  • As dysplasia progresses, it extends upward through the epithelium.
  • Histopathologic alterations of dysplastic epithelial cells include:
    • enlarged nuclei and cells
    • large and prominent nucleoli
    • increased nuclear-to-cytoplasmic ratio
    • hyperchromatic or pleomorphic nuclei
    • dyskeratosis
    • increased mitotic activity
  • The grade of epithelial dysplasia refers to its “severity” or intensity:
    • mild dysplasia is limited to basal and parabasal layers
    • moderate dysplasia involves up to the mid spinous layer
    • severe involves up to the midpoint of epithelium
    • carcinoma in situ involves the entire thickness of epithelium

Leukoplakia exhibiting moderate epithelial dysplasia or worse warrants complete destruction or removal, if feasible.

8

Simvastatin

  • Antihyperlipidemic
  • A HMG-CoA reductase inhibitor that interferes with cholesterol biosynthesis by inhibiting the conversion of the enzyme HMG-CoA to mevalonate.
  • An adjunct in homozygous familial hypercholesterolemia, mixed hyperlipidemia, and elevated serum triglyceride levels.
  • Generally well-tolerated; headache, abdominal pain or cramps, constipation, upper respiratory tract infection, diarrhea, flatulence, asthenia, or nausea.
9

Nifedipine

  • Calcium channel blocker (dihydropyridine)
  • Inhibits calcium ion movement across cell membranes, depressing contraction of cardiac and vascular smooth muscle.
  • Treatment of chronic stable angina pectoris, vasospastic angina, hypertension (sustained release only)
  • Peripheral edema, headache, flushed skin, dizziness, nausea, shakiness, muscle cramps and pain, somnolence, palpitations, oral gingival enlargement.
10

Yosefina is a 51-year-old Hispanic woman who presents with the chief complaint of “my gums hurt and sometimes bleed”

Medical History

  • painful oral lesions noticed 5 months ago
  • pain is getting progressively worse
  • history of hypertension and type II diabetes
  • allergic to penicillins and sulfa drugs

Physical Exam

  • BP 139/86 mmHg
  • red-white patches on buccal mucosa
  • central ulcer on left buccal mucosa
  • erythematous gingival lesions
  • white plaque on anterior dorsal tongue
  • lesions do not appear to rub off
  • negative Nikolsky sign

Histopathologic Findings

  • surface hyperkeratosis
  • subepithelial separation
  • band-like lymphocytic infiltrate
  • jagged, irregular rete ridges
  • DIF (+) for fibrinogen along basement membrane

What was the diagnosis?

Erosive lichen planus, although not as common as the reticular form, is more significant for the patient because the lesions are usually symptomatic.

  • There are atrophic, erythematous areas with central ulceration.
  • The periphery is usually bordered by fine, white radiating striae.
  • The rete ridges classically have a pointed or “saw-toothed” shape.
  • There is destruction of the basal cell layer (hydropic degeneration).

Erosive lichen planus is often bothersome because of the oral lesions. Because it is an immunologically mediated condition, corticosteroids are recommended.

11

Naproxen

  • Nonsteroidal antiinflammatory
  • An NSAID that produces analgesic and antiinflammatory effects by inhibiting prostaglandin synthesis.
  • Treatment of mild-to-moderate pain, osteoarthritis, rheumatoid, juvenile, gouty arthritis, ankylosing spondylitis, and primary dysmenorrhea.
12

Hydrochlorothiazide

  • Thiazide diuretic
  • As a diuretic, blocks reabsorption of water, sodium, and potassium at the cortical diluting segment of the distal tubule.
  • Treatment of edema, hypertension, diuresis, CHF
  • Increase in urinary frequency and urine volume, potassium depletion, orthostatic hypotension, headache, GI disturbances.
13

Lisinopril

  • Angiotensin-converting enzyme (ACE) inhibitor
  • Suppresses the renin-angiotensin-aldosterone system and prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor.
  • Treatment of mild-to-moderate hypertension, post-MI if hemodynamically stable, and heart failure.
  • Headache, dizziness, postural hypotension, chest discomfort, fatigue, rash, abdominal pain, nausea, diarrhea, upper respiratory infection.
14

Derek Romano, a 19-year-old male, presents to an oral surgeon with the chief complaint of "a bump on the roof of my mouth."

Medical History

  • first noticed bump about 6 months ago
  • seems to be increasing in size
  • last complete dental exam 3 months ago

Physical Exam

  • firm, sessile, nodular swelling of hard palate
  • tooth vitality testing normal
  • pigmented patches of the back, arms and chest
  • well circumscribed, firm nodule of the lower back
  • translucent brown-pigmented spots on the iris

Histopathologic Findings

  • nodular proliferation of connective tissue cells
  • spindle-shaped cells with wavy nuclei
  • cells show scattered positivity for S-100 protein

What was the diagnosis?

Neurofibromatosis type I (NF1) is a relatively common hereditary condition that is estimated to occur in one of every 2,500 to 3,000 births.

  • It is caused by mutations of the NF1 gene (encodes neurofibromin).
  • Patients have multiple neurofibromas, most common on the skin.
  • Another characteristic feature is café au lait pigmentation on the skin.
  • Lisch nodules on the iris are found in nearly all affected individuals.
  • The most common oral finding is enlargement of fungiform papillae.

There is no specific therapy for NF1, and treatment often is directed toward prevention or management of complications.

15

Eric Parkins, a 69-year old male, presents to his dentist with the chief complaint of "pain in my right upper tooth and sinus."

Medical History

  • pain started about one year ago
  • several sinus surgeries and courses of antibiotics
  • reports weight loss and intermittent fevers
  • has had headaches and difficulty sleeping
  • history of cardiac disease and type II diabetes

Physical Exam

  • BT 100.0 °F
  • BP 140/88 mmHg
  • facial swelling of the right malar region
  • gingival recession and exposed bone
  • diffuse, flucuant swelling of anterior hard palate
  • irregular radiolucency in the anterior maxilla

Laboratory Findings

  • Tooth vitality testing normal
  • CT: osseous erosion of right maxillary alveolar bone
  • CBC: leukocytosis
  • CHEM: hyperglycemia
  • ESR: elevated
  • A1C: elevated
  • C/S: (+) for staphylococcus and streptococcus
  • HPX: necrotic bone, broad, ribbon-like non-septate hyphae

What was the diagnosis?

Mucormycosis is an opportunistic, frequently fulminant, fungal infection that is caused by normally saprobic organisms of the subphylum Mucoromycotina.

  • It is noted especially in ketoacidotic diabetics (increases serum iron).
  • If the maxillary sinus is involved, it may present as intraoral swelling.
  • Sinus opacification and effacement may be observed radiographically.
  • Lesional tissue shows necrosis with branching, nonseptate hyphae.

Treatment consists of radical surgical débridement of necrotic tissue and high-dose systemic administration of a lipid formulation of amphotericin B.

16

Amiodarone

  • Antidysrhythmic (class III)
  • Prolongs duration of myocardial cell action potential and refractory period by acting directly on all cardiac tissue.
  • Documented life-threatening ventricular tachycardia; unapproved: ventricular fibrillation not controlled by first-line agents.
  • Corneal microdeposits, constipation, headache, decreased appetite, nausea, vomiting, paresthesias, photosensitivity, muscular incoordination.
17

Pravastatin

  • Antihyperlipidemic
  • Interferes with cholesterol biosynthesis by preventing the conversion of HMG-CoA to mevalonate, a precursor to cholesterol.
  • As an adjunct in homozygous or heterozygous familial hypercholesterolemia, mixed hyperlipidemia, and elevated serum triglyceride levels.
  • Generally well-tolerated; nausea, vomiting, diarrhea, constipation, abdominal pain, headache, rhinitis, rash, pruritus, heartburn, myalgia, dizziness.
18

Digoxin

  • Cardiac glycoside
  • A cardiac glycoside that increases the influx of calcium from extracellular to intracellular cytoplasm.
  • Treatment of CHF, atrial fibrillation, atrial flutter, paroxysmal atrial tachycardia, rapid digitalization in these disorders.
  • There is a very narrow margin of safety between a therapeutic and toxic result, cardiac dysrhythmias, nausea, vomiting, visual scotomas.
19

Irbesartan

  • Angiotensin II receptor antagonist
  • An AT1 antagonist that blocks the vasoconstrictor and aldosterone- secreting effects of angiotensin II.
  • Treatment of hypertension alone or in combination with other antihypertensive drugs; nephropathy in type 2 diabetes.
  • Upper respiratory tract infection, fatigue, diarrhea, cough, heartburn, dizziness, headache, nausea, rash.
20

Dabigatran

  • Anticoagulant, thrombin inhibitor
  • A direct thrombin inhibitor that inhibits coagulation by preventing thrombin-mediated effects and thrombin-induced platelet aggregation.
  • Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation.
  • Dyspepsia, abdominal discomfort and pain, bleeding, GERD, esophagitis, anemia, hematuria, hematoma, epistaxis, wound secretion, anaphylaxis.
21

Metoprolol

  • Antihypertensive, selective β1-blocker
  • Selectively blocks β1-adrenergic receptors; high dosages may block β2-adrenergic receptors. Decreases oxygen requirements.
  • Treatment of mild-to-moderate hypertension, acute MI to reduce risk of cardiovascular mortality, angina pectoris, mild-to-moderate heart failure.
  • Diminished sexual function, drowsiness, insomnia, unusual fatigue or weakness, anxiety, nervousness, diarrhea, constipation, nausea, vomiting.
22

Niacin

  • Vitamin B3
  • A water-soluble vitamin needed for tissue respiration, lipid metabolism, and glycogenolysis. Inhibits synthesis of very low-density lipoproteins (VLDLs).
  • Treatment of pellagra, hyperlipidemias, and peripheral vascular disease.
  • Flushing, GI upset, pruritus, dizziness, hypotension, headache, blurred vision, burning or tingling of skin, flatulence, nausea, vomiting, diarrhea.
23

Glimepiride

  • Oral antidiabetic, sulfonylurea (second generation)
  • Promotes release of insulin from beta cells of the pancreas and increases insulin sensitivity at peripheral sites.
  • Treatment of stable adult-onset diabetes mellitus (type 2)
  • Altered taste sensation, dizziness, somnolence, weight gain, constipation, diarrhea, heartburn, nausea, vomiting, stomach fullness, headache.
24

Augmentin

  • Aminopenicillin and β-lactamase inhibitor
  • Amoxicillin inhibits bacterial cell wall synthesis, while clavulanate inhibits bacterial β-lactamase.
  • For treatment of infections caused by susceptible ß-lactamase-producing strains of microorganisms.
  • GI disturbances (mild diarrhea, nausea, vomiting), headache, oral or vaginal candidiasis, generalized rash, urticaria.
25

Amphotericin B

  • Polyene antifungal
  • An antifungal that is fungistatic or fungicidal with high dosages; binds to sterols in the fungal cell membrane.
  • Oral mucocutaneous infections caused by Candida species; treatment of infections caused by fungus.
  • Chills, fever, increased serum creatinine, multiple organ failure, nausea, hypotension, vomiting, dyspnea, diarrhea, headache, hypokalemia.
26

Levofloxacin

  • Fluoroquinolone antibiotic
  • Inhibits the enzyme DNA gyrase in susceptible microorganisms, interfering with bacterial cell replication and repair.
  • Treatment of acute infections caused by susceptible bacterial strains causing maxillary sinusitis, chronic bronchitis, and pneumonia.
  • Diarrhea, nausea, abdominal pain, dizziness, drowsiness, headache, light-headedness, ocular itching, altered tast.
27

Posaconazole

  • Antifungal, triazole
  • Blocks ergosterol synthesis of through the inhibition of lanosterol 14a-α- demethylase and accumulation of methylated sterol precursors.
  • Prophylaxis of invasive Aspergillus and Candida infections in patients who are severely immunocompromised.
  • Diarrhea, nausea, neutropenia, headache, vomiting, abdominal pain, flatulence, QT prolongation, rash, hypokalemia, anemia, fever.
28

Shanta Jackson is a 57-year old African American woman who presents to the emergency room with a complaint of "my lower left tooth hurts."

Medical History

  • intermittent pain in lower left molar for months
  • significantly increased pain in past 24 hours
  • diagnosed with sickle cell anemia
  • history of smoking and alcohol use

Physical Exam

  • BT 101.7 °F
  • BP 150/95 mmHg
  • mild extraoral swelling over left mandible
  • tooth #18 exhibits decay and mobility
  • hyperplastic gingiva around crown
  • unresponsive to pulp vitality testing

Laboratory Findings

  • PANO: focal radiopacity around apex of #18
  • CBC: leukocytopenia
  • CHEM: normal
  • LFT: normal

Histopathologic Findings

  • hypercementosis and fibro-osseous tissue
  • basophilic, spherical, cementum-like material

What was the diagnosis?

Florid cemento-osseous dysplasia exhibits multifocal involvement not limited to the anterior mandible.

  • This form predominantly affects middle-aged to older black females.
  • Tendency for bilateral and symmetrical involvement of the mandible.
  • Patients may have dull pain, alveolar sinus tracts, and bone exposure.
  • Lesions are initially radiolucent, then mixed, then mostly radiopaque.
  • Does not appear neoplastic and generally does not require removal.

Management of the symptomatic patient who has developed secondary osteomyelitis difficult. Antibiotics are indicated but often ineffective.

29

Hydroxyurea

  • Antineoplastic
  • A synthetic urea analog that inhibits DNA synthesis without interfering with RNA synthesis or protein.
  • Treatment of melanoma, chronic myelocytic leukemia (CML), recurrent or metastatic ovarian cancer, and sickle cell anemia.
  • Nausea, vomiting, anorexia, constipation, or diarrhea, mild, reversible rash; facial flushing; pruritus; fever; chills; malaise.
30

Metronidazole

  • Trichomonacide
  • A nitroimidazole derivative that disrupts bacterial and protozoal DNA, inhibiting nucleic acid synthesis.
  • Treatment of intestinal amebiasis, amebic abscess, trichomoniasis, refractory trichomoniasis, bacterial anaerobic infections, giardiasis
  • Anorexia, nausea, dry mouth, metallic taste, diarrhea or constipation, vomiting, dizziness, erythematous rash, urticaria, reddish brown urine.
31

Amoxicillin

  • Aminopenicillin
  • Inhibits bacterial cell wall synthesis, resulting in death of susceptible bacteria (bactericidal).
  • For treatment of infections caused by susceptible bacterial species in the orofacial region, respiratory tract, and genitourinary tract.
  • Mild GI disturbances (nausea, vomiting, mild diarrhea), headache, oral or vaginal candidiasis, rash, urticaria, allergic reactions, fatal anaphylaxis.
32

Ibuprofen

  • Nonsteroidal antiinflammatory
  • An NSAID that inhibits prostaglandin synthesis. Also produces vasodilation by acting centrally on the heat-regulating center of the hypothalamus.
  • Treatment of rheumatoid arthritis, osteoarthritis, primary dysmenorrhea, gout, mild to moderate pain, fever.
  • Nausea with or without vomiting, dyspepsia, dizziness, rash, diarrhea or constipation, flatulence, abdominal cramps or pain, pruritus.
33

Chlorhexidine

  • Antiinfective-oral rinse
  • Its positive charge reacts with the microbial cell surface, destroys the cell membrane, penetrates into the cell, and precipitates the cytoplasm.
  • Treatment of gingivitis, acute aphthous ulcers, denture stomatitis
  • Altered taste, staining of teeth, toothache
34

Joanie Cunningham is a 25 year old caucasian woman who complains of “swelling on the right side of my mouth.”

Medical History

  • painless swelling of lower right face
  • unresponsive to antibiotic therapy
  • type I diabetes; last A1C was 7.5%

Physical Exam

  • inflamed gingiva around #32
  • mild tenderness to palpation
  • firm, lingual bony expansion of right mandible

Laboratory Findings

  • PANO: large, unilocular radiolucency around crown of #32
  • CBCT: thinning expansion of lingual cortical plate
  • HBX: epithelial lining, thin parakeratin, palisaded basal cells

What was the diagnosis?

The odontogenic keratocyst (OKC) is a distinctive form of developmental odontogenic cyst that arises from cell rests of the dental lamina.

  • 60% of all cases are diagnosed in people between 10 and 40 years of age.
  • There is a slight male predilection.
  • The mandible is involved in 60% to 80% of cases.
  • Small OKCs are usually asymptomatic.
  • Larger OKCs may be associated with pain, swelling, or drainage.
  • OKCs tend to grow in an anteroposterior direction.
  • Multiple OKCs occur in nevoid basal cell carcinoma (Gorlin) syndrome.
  • OKCs demonstrate a well-defined radiolucency with smooth margins.
  • An unerupted tooth is involved in the lesion in 25% to 40% of cases.

Most OKCs are treated by enucleation and curettage. Complete removal of the cyst in one piece is often difficult because of the thin, friable nature of the cyst wall.

35

Penicillin V

  • Semisynthetic penicillin
  • Inhibits cell wall synthesis by binding to bacterial cell membranes.
  • Effective for treatment of gram-positive cocci, gram-negative cocci, gram-positive bacilli, gram-negative bacilli, and spirochetes.
  • Mild hypersensitivity reaction (chills, fever, rash), nausea, vomiting, diarrhea.
36

Insulin Lispro

  • Rapid-acting insulin
  • Acts via membrane-bound receptors on target tissues to regulate metabolism of carbohydrate, protein, and fats.
  • Treatment of diabetes mellitus
  • Hypoglygemia
37

Insulin Glargine

  • Long-acting insulin
  • Acts via membrane-bound receptors on target tissues to regulate metabolism of carbohydrate, protein, and fats.
  • Treatment of diabetes mellitus
  • Hypoglygemia