MFDS Oral Medicine — Questions and Answers
Question 1: A 55-year-old female presents with bilateral white lace-like striations on the buccal mucosa with areas of erythema and ulceration. She reports episodes of soreness. What is the most likely diagnosis?
- Oral leukoplakia
- Oral lichen planus (Correct answer)
- Oral squamous cell carcinoma
- Candidiasis
Correct answer: Oral lichen planus
The bilateral white lace-like striations (Wickham's striae) on the buccal mucosa with areas of erythema and erosion are characteristic of oral lichen planus. This chronic mucocutaneous condition affects approximately 1-2% of the population, predominantly middle-aged women. The reticular form is the most common pattern, while the erosive form causes the most symptoms. It requires long-term monitoring due to a small malignant transformation risk (approximately 1-2%).
Question 2: A patient presents with a painful, solitary ulcer on the lateral border of the tongue that has been present for three weeks. There is no obvious local cause. What is the most important next step?
- Prescribe a topical corticosteroid and review in one week
- Arrange an urgent two-week-wait referral for biopsy to exclude malignancy (Correct answer)
- Prescribe antibiotics and review in two weeks
- Reassure the patient and advise warm salt water rinses
Correct answer: Arrange an urgent two-week-wait referral for biopsy to exclude malignancy
A solitary ulcer on the lateral border of the tongue persisting for more than three weeks without an identifiable local cause (such as a sharp tooth or denture) requires urgent investigation to exclude squamous cell carcinoma. Under NICE guidelines, this warrants a two-week-wait urgent referral. The lateral border of the tongue is the most common intraoral site for oral squamous cell carcinoma.
Question 3: Which of the following conditions is MOST commonly associated with a geographic tongue (erythema migrans)?
- Oral cancer
- Psoriasis (Correct answer)
- Diabetes mellitus
- HIV infection
Correct answer: Psoriasis
Geographic tongue (erythema migrans/benign migratory glossitis) shows a strong association with psoriasis, and some authorities consider it an oral manifestation of psoriasis. Both conditions share histopathological similarities including spongiform pustulation. Other associations include fissured tongue and atopy. Geographic tongue is benign, affecting 1-3% of the population, and is characterised by migratory areas of depapillation with raised white borders.
Question 4: A patient with a history of coeliac disease presents with recurrent aphthous ulceration and angular cheilitis. Blood tests reveal a haemoglobin of 10.2 g/dL. Which deficiency is most likely contributing to the oral manifestations?
- Vitamin C deficiency
- Iron deficiency secondary to malabsorption (Correct answer)
- Vitamin D deficiency
- Zinc deficiency
Correct answer: Iron deficiency secondary to malabsorption
Coeliac disease causes malabsorption of iron, folate, and vitamin B12 from the proximal small intestine. Iron deficiency is the most common cause of anaemia in coeliac disease and commonly manifests orally as recurrent aphthous ulceration, angular cheilitis, glossitis (smooth, depapillated tongue), and oral mucosal atrophy. The combination of oral signs with anaemia in a coeliac patient strongly suggests iron deficiency.
Question 5: A 70-year-old male who wears a complete upper denture presents with erythema confined to the denture-bearing area of the palate. He is otherwise asymptomatic. What is the most likely diagnosis?
- Erythematous candidiasis (denture stomatitis) (Correct answer)
- Nicotinic stomatitis
- Pemphigus vulgaris
- Allergic contact stomatitis to denture acrylic
Correct answer: Erythematous candidiasis (denture stomatitis)
Denture stomatitis (chronic erythematous candidiasis) is the most common form of oral candidiasis, classified by Newton into three types: I (pinpoint hyperaemia), II (diffuse erythema of the denture-bearing mucosa), and III (granular/papillary hyperplasia). It is caused by Candida albicans colonising the fitting surface of the denture. Management includes denture hygiene instruction, antifungal treatment (miconazole oral gel or nystatin), and ensuring the denture is removed at night.
Question 6: What is the recommended first-line topical treatment for symptomatic oral lichen planus?
- Topical aciclovir
- Topical corticosteroids such as betamethasone mouthwash or fluocinolone acetonide in Orabase (Correct answer)
- Topical metronidazole gel
- Topical chlorhexidine gluconate mouthwash alone
Correct answer: Topical corticosteroids such as betamethasone mouthwash or fluocinolone acetonide in Orabase
Topical corticosteroids are the first-line treatment for symptomatic oral lichen planus. Options include betamethasone sodium phosphate dissolved as a mouthwash, fluocinolone acetonide 0.025% in Orabase applied directly to lesions, or beclometasone inhaler sprayed onto affected areas. For refractory cases, topical tacrolimus or systemic immunosuppression may be considered. Regular monitoring for candidal superinfection and malignant transformation is essential.
MFDS Oral Medicine
A 55-year-old female presents with bilateral white lace-like striations on the buccal mucosa with areas of erythema and ulceration.
She reports episodes of soreness.
What is the most likely diagnosis?