Oral Manifestations of Systemic Diseases — MCQs
A 85-year-old female developed multiple blisters on the trunk and thighs. Nikolsky's sign is negative. The lesions came on and off. The most probable diagnosis is
Plummer-Vinson syndrome is characterized by all of the following except:
A bacterial disease with oral manifestations is
Which of the following is NOT a characteristic of pemphigus vulgaris?
All are common oral manifestations of HIV except?
Which of the following conditions is NOT associated with delayed dentition?
Salt and pepper effect in IOPA is most commonly associated with:
A patient with rheumatoid arthritis mentions to her physician that after many years without dental problems, she has recently had seven dental caries filled. This finding suggests that she should be evaluated for which of the following diseases?
All are true regarding oral hairy leukoplakia except which of the following?
A female presents with persistent painful oral lesions, with acantholytic cells. The most likely diagnosis is?
Oral Manifestations of Systemic Diseases Indian Medical PG Practice Questions and MCQs
Question 1: A 85-year-old female developed multiple blisters on the trunk and thighs. Nikolsky's sign is negative. The lesions came on and off. The most probable diagnosis is
- A. Pemphigus vulgaris
- B. Bullous pemphigoid (Correct Answer)
- C. Lepra reaction
- D. Lichen planus
Explanation: ***Bullous pemphigoid*** - The presence of **multiple tense blisters** on the trunk and thighs in an 85-year-old female, coupled with a **negative Nikolsky's sign**, is highly characteristic of bullous pemphigoid. - This condition tends to wax and wane, causing the lesions to "come on and off," and is more common in the **elderly**. *Lichen planus* - This condition presents with **pruritic, polygonal, purple, planar papules and plaques**, not blisters. - It does not typically involve the formation of **blisters** as the primary lesion nor does it involve a negative Nikolsky's sign. *Pemphigus vulgaris* - Characterized by **flaccid blisters** that rupture easily, leading to erosions, and a **positive Nikolsky's sign**. - This is in contrast to the **tense blisters** and **negative Nikolsky's sign** described in the patient. *Lepra reaction* - Refers to **acute inflammatory episodes** occurring in patients with leprosy, often presenting as **erythematous nodules** or plaques. - It does not typically involve the formation of **blisters** on the trunk and thighs in an elderly patient without a prior diagnosis of leprosy.
Question 2: Plummer-Vinson syndrome is characterized by all of the following except:
- A. Megaloblastic anemia (Correct Answer)
- B. Iron deficiency anemia
- C. Dysphagia
- D. Glossitis
Explanation: ***Megaloblastic anemia*** - Plummer-Vinson syndrome is associated with **iron deficiency anemia**, not megaloblastic anemia [2]. - **Megaloblastic anemia** is caused by deficiencies in **vitamin B12** or **folate**, leading to impairment in DNA synthesis [1]. *Glossitis* - **Glossitis**, or inflammation of the tongue, is a common symptom of Plummer-Vinson syndrome due to **iron deficiency**. - This symptom can contribute to the difficulty in swallowing experienced by patients. *Iron deficiency anemia* - **Iron deficiency anemia** is a primary characteristic of Plummer-Vinson syndrome, leading to various symptoms [2]. - The anemia is thought to contribute to the formation of esophageal webs which cause dysphagia. *Dysphagia* - **Dysphagia**, or difficulty swallowing, is a hallmark symptom of Plummer-Vinson syndrome, usually caused by **esophageal webs**. - These webs are thin mucosal folds that form in the upper esophagus, obstructing **food passage**.
Question 3: A bacterial disease with oral manifestations is
- A. measles
- B. Leishmaniasis
- C. Herpes
- D. Diphtheria (Correct Answer)
Explanation: **Diphtheria** - **Diphtheria** is a bacterial infection caused by *Corynebacterium diphtheriae*, which produces a toxin leading to the formation of a **pseudomembrane** in the throat and tonsils, representing an oral manifestation [1]. - This **pseudomembrane** can cause difficulty breathing and swallowing, and if left untreated, the toxin can lead to systemic complications affecting the heart, kidneys, and nervous system [1]. *measles* - **Measles** (rubeola) is a viral infection characterized by a maculopapular rash and fever, and its classic oral manifestation is **Koplik's spots**, which are small white spots with a red halo found on the buccal mucosa. - Although Koplik's spots are an oral manifestation, measles is a **viral** disease, not bacterial. *Leishmaniasis* - **Leishmaniasis** is a parasitic disease caused by *Leishmania* parasites, transmitted by the bite of infected sandflies, and can present as cutaneous, mucocutaneous, or visceral forms. - While **mucocutaneous leishmaniasis** can affect the nose, mouth, and throat with ulcerative lesions, it is a **parasitic** disease, not bacterial. *Herpes* - **Herpes** is primarily caused by the **Herpes Simplex Virus (HSV)**, which is a **viral** infection, leading to cold sores (herpes labialis) or genital lesions. - Oral manifestations like **herpetic gingivostomatitis** are common, but the causative agent is viral, not bacterial [2].
Question 4: Which of the following is NOT a characteristic of pemphigus vulgaris?
- A. Oral erosions
- B. Tzanck smear showing acantholytic cells
- C. Positive Nikolsky’s sign
- D. Subepidermal bulla (Correct Answer)
Explanation: ***Subepidermal bulla*** - Pemphigus vulgaris is characterized by **intraepidermal bullae** resulting from acantholysis (loss of cohesion between keratinocytes), not subepidermal bullae. - **Subepidermal bullae** are characteristic of conditions like **bullous pemphigoid**, where the split occurs below the epidermis. *Positive Nikolsky’s sign* - The **Nikolsky's sign** is positive in pemphigus vulgaris, indicating the fragility of the skin where gentle lateral pressure causes epidermal shearing. - This sign is a direct result of the **intraepidermal blistering** due to weakened cell-to-cell adhesion. *Oral erosions* - **Oral erosions** are a very common and often the initial manifestation of pemphigus vulgaris, frequently preceding skin lesions. - These painful erosions are persistent and heal slowly, sometimes making eating difficult. *Tzanck smear showing acantholytic cells* - A **Tzanck smear** from a fresh blister in pemphigus vulgaris typically reveals **acantholytic cells**, which are detached, rounded keratinocytes with basophilic cytoplasm. - The presence of acantholytic cells confirms the **loss of intercellular adhesion** within the epidermis, a hallmark of pemphigus.
Question 5: All are common oral manifestations of HIV except?
- A. Candidiasis
- B. Aphthous ulcers
- C. Lichen planus (Correct Answer)
- D. Hairy leukoplakia
Explanation: ***Lichen planus*** - While **lichen planus** can affect the oral cavity, it is generally considered to be an **autoimmune condition** and is not specifically or commonly associated with HIV infection. - There is no strong evidence linking HIV directly to the pathogenesis or increased prevalence of oral lichen planus compared to the general population. *Candidiasis* - **Oral candidiasis** (thrush) is one of the most common oral manifestations of HIV infection, especially as the immune system weakens. - It presents as **white patches** that can be scraped off, revealing erythematous mucosa. *Aphthous ulcers* - **Recurrent aphthous ulcers** are frequently observed in individuals with HIV, often becoming larger, more numerous, and more persistent due to **immunosuppression**. - They can be quite painful and significantly impact the patient's quality of life. *Hairy leukoplakia* - **Oral hairy leukoplakia** is a disease specifically linked to **Epstein-Barr virus (EBV)** infection in immunocompromised individuals, particularly those with HIV. - It appears as **white, corrugated, non-scrapable lesions**, usually on the lateral borders of the tongue.
Question 6: Which of the following conditions is NOT associated with delayed dentition?
- A. Down syndrome
- B. Cystic fibrosis (Correct Answer)
- C. Congenital hypothyroidism
- D. Rickets
Explanation: ***Cystic fibrosis*** - **Cystic fibrosis** primarily affects exocrine glands, leading to issues in the respiratory and digestive systems, and does not directly impact tooth development or eruption timing. - While patients with cystic fibrosis may have other oral health concerns due to medications or nutritional deficiencies, **delayed dentition** is not a characteristic feature of the condition itself. *Down syndrome* - Children with **Down syndrome** often experience generalized developmental delays, including delayed eruption of both primary and permanent teeth. - Other common oral manifestations in Down syndrome include **microdontia**, **taurodontism**, and a higher incidence of **periodontal disease**. *Congenital hypothyroidism* - **Congenital hypothyroidism** is associated with significant developmental delays, including skeletal maturation and delayed tooth eruption. - The reduced metabolic rate due to thyroid hormone deficiency impacts bone and tooth development. *Rickets* - **Rickets**, caused by a deficiency in vitamin D, calcium, or phosphate, leads to inadequate mineralization of bone and cartilage, which can affect tooth development and eruption. - Oral manifestations of rickets include **delayed tooth eruption**, enamel hypoplasia, and a higher susceptibility to dental caries.
Question 7: Salt and pepper effect in IOPA is most commonly associated with:
- A. Hyperparathyroidism (Correct Answer)
- B. Condensing osteitis
- C. Sickle cell anemia
- D. Thalassemia
Explanation: ***Hyperparathyroidism*** - The "salt and pepper" effect on intraoral periapical (IOPA) radiographs is a classic sign of **hyperparathyroidism**, reflecting diffuse demineralization and loss of trabecular bone structure. - This appearance is due to increased osteoclastic activity leading to the resorption of bone, particularly in the skull and jaws, creating a mottled or granular pattern. *Condensing osteitis* - **Condensing osteitis** appears as a localized area of **increased bone density** (radiopacity) around the apex of a tooth, often in response to a low-grade chronic infection. - It does not involve diffuse demineralization or a "salt and pepper" pattern; rather, it is a sclerotic reaction. *Sickle cell anemia* - In **sickle cell anemia**, radiographic changes can include a **coarse trabecular pattern** and a "hair-on-end" appearance in the skull, but the "salt and pepper" effect is not a primary or characteristic finding in the jaws. - These changes are mainly due to bone marrow hyperplasia, not diffuse demineralization. *Thalassemia* - **Thalassemia** can also cause **bone marrow hyperplasia**, leading to features like "hair-on-end" skull radiographs and maxillary enlargement. - While it affects bone structure, the "salt and pepper" pattern specific to diffuse demineralization is not the typical presentation in thalassemia.
Question 8: A patient with rheumatoid arthritis mentions to her physician that after many years without dental problems, she has recently had seven dental caries filled. This finding suggests that she should be evaluated for which of the following diseases?
- A. Sjogren's syndrome (Correct Answer)
- B. Polyarteritis nodosa
- C. Oral squamous cell carcinoma
- D. Systemic lupus erythematosus
Explanation: ***Sjogren's syndrome*** - Patients with **rheumatoid arthritis** have an increased risk of developing **secondary Sjogren's syndrome**, a chronic autoimmune disease. - The hallmark of Sjogren's syndrome is **xerostomia** (dry mouth) due to decreased salivary gland function, leading to a higher incidence of dental caries. *Polyarteritis nodosa* - This is a **necrotizing vasculitis** primarily affecting medium-sized arteries, often associated with **hepatitis B**. - It typically presents with **systemic symptoms**, skin lesions, neuropathy, hypertension, and kidney involvement, not primarily increased dental caries. *Oral squamous cell carcinoma* - It is a **malignant tumor** of the oral cavity, which can be associated with tobacco and alcohol use. - While it can cause oral discomfort and lesions, it does not directly lead to a sudden increase in **dental caries** as its primary manifestation. *Systemic lupus erythematosus* - While **rheumatoid arthritis** and **lupus** are both autoimmune diseases, **systemic lupus erythematosus** itself does not directly cause an increased incidence of dental caries. - Lupus is a multisystem autoimmune disease that can affect virtually any organ system and has a wide range of manifestations, but **dry mouth** leading to caries is more characteristic of Sjogren's syndrome.
Question 9: All are true regarding oral hairy leukoplakia except which of the following?
- A. It is a benign condition associated with EBV infection.
- B. Presents with corrugated white plaques
- C. It is premalignant (Correct Answer)
- D. Hyperkeratosis on HPE is not typically seen.
Explanation: ***It is premalignant*** - Oral hairy leukoplakia is associated with **Epstein-Barr virus (EBV)** and is not considered a precancerous condition [1]. - This condition is primarily seen in immunocompromised individuals and does not progress to malignancy [1]. *Hyperkeratosis on HPE* - Histopathological examination typically reveals **keratinized epithelial layers** but is not characterized by prominent hyperkeratosis. - Rather, it shows **ballooning degeneration** of epithelial cells rather than classic hyperkeratotic features [1]. *Associated with EBV infection* - Oral hairy leukoplakia is strongly associated with **EBV**, particularly in immunocompromised patients [1]. - It manifests as white plaques on the lateral borders of the tongue due to **viral replication** of EBV-infected epithelial cells [1]. *Seen in HIV infected patients* - This condition is commonly seen in **HIV-infected individuals**, particularly those with a low CD4 count [1]. - It serves as a clinical marker for **immunosuppression** but is not exclusive to HIV [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 737-738.
Question 10: A female presents with persistent painful oral lesions, with acantholytic cells. The most likely diagnosis is?
- A. Pemphigus vulgaris (Correct Answer)
- B. Dermatitis herpetiformis
- C. Epidermolysis bullosa
- D. Bullous pemphigoid
Explanation: ***Pemphigus vulgaris*** - **Pemphigus vulgaris** is characterized by **painful oral lesions** that precede cutaneous lesions in many cases. - The presence of **acantholytic cells** (separated keratinocytes) on a Tzanck smear or biopsy is a diagnostic hallmark, indicating loss of adhesion between epidermal cells. *Dermatitis herpetiformis* - This condition typically presents with **pruritic, vesicular lesions** on extensor surfaces, not usually painful persistent oral lesions as the primary concern. - Histologically, it shows **subepidermal blisters** with neutrophil accumulation in dermal papillae, and **IgA deposits** in the dermal papillae are characteristic, not acantholysis. *Epidermolysis bullosa* - This is a group of **genetic disorders** characterized by extreme skin fragility and blistering upon minimal trauma, often presenting at birth or early childhood. - While oral lesions can occur, the primary feature is **mechanical fragility** and not typically associated with acantholytic cells in the way pemphigus vulgaris is. *Bullous pemphigoid* - **Bullous pemphigoid** presents with **tense blisters** on erythematous or normal skin, primarily affecting the elderly, and oral involvement is less common and usually milder. - Histology shows a **subepidermal bulla** with inflammatory cells, and **IgG and C3 deposits** along the basement membrane zone, with the absence of acantholysis.
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