Diseases of the Oral Cavity and Salivary Glands — MCQs

Diseases of the Oral Cavity and Salivary Glands Indian Medical PG Practice Questions and MCQs

Question 91: What is the most likely diagnosis in a man with a 3-month history of migratory lesions on the tongue?

A. Geographic tongue (Correct Answer)
B. Oral candidiasis
C. Lichen planus
D. Oral hairy leukoplakia

Explanation: ### Explanation **Correct Answer: A. Geographic Tongue (Benign Migratory Glossitis)** The hallmark of **Geographic Tongue** is its dynamic and migratory nature. It is a benign inflammatory condition characterized by areas of dekeratinization (loss of filiform papillae) appearing as smooth, red patches with raised, white/yellowish circinate borders. The "migratory" history is the key clinical clue: the lesions heal in one area and reappear in another over days or weeks, changing the tongue's appearance like a shifting map. It is usually asymptomatic but may cause sensitivity to spicy foods. **Why the other options are incorrect:** * **B. Oral Candidiasis:** Presents as white, "curd-like" plaques that can be scraped off, leaving an erythematous base. It does not migrate and is often associated with immunosuppression or antibiotic use. * **C. Lichen Planus:** Typically presents as **Wickham’s striae** (reticular white lines) or erosive lesions. While chronic, these lesions are relatively stationary and do not shift locations rapidly across the tongue. * **D. Oral Hairy Leukoplakia:** Caused by the **Epstein-Barr Virus (EBV)** in HIV-positive patients. It presents as white, corrugated (hairy) patches on the **lateral borders** of the tongue that cannot be scraped off. It is not migratory. **High-Yield Clinical Pearls for NEET-PG:** * **Histology:** Shows "Munro’s microabscesses" (neutrophils in the stratum corneum), similar to psoriasis. * **Associations:** Often linked with fissured tongue and occasionally associated with HLA-B15. * **Management:** Reassurance is the mainstay. Topical steroids or zinc supplements may be used if symptomatic.

Question 92: Which of the following is not a premalignant lesion or condition?

A. Chronic hypertrophic candidiasis (Correct Answer)
B. Oral submucosal fibrosis
C. Lichen planus
D. Leukoplakia

Explanation: In the context of NEET-PG, it is crucial to distinguish between **Premalignant Lesions** (a morphologically altered tissue in which cancer is more likely to occur) and **Premalignant Conditions** (a generalized state associated with a significantly increased risk of cancer). ### **Why Chronic Hypertrophic Candidiasis is the Correct Answer** While **Chronic Hypertrophic Candidiasis** (Candidal Leukoplakia) is often associated with epithelial dysplasia, it is primarily an **infectious condition** caused by *Candida albicans*. In most clinical classifications (such as those by WHO), it is considered a "high-risk" lesion but is frequently excluded from the standard list of classic premalignant lesions because the dysplasia often resolves after antifungal therapy. In the context of this specific MCQ, it is considered the "least" premalignant compared to the definitive risks associated with the other options. ### **Analysis of Other Options** * **Oral Submucosal Fibrosis (OSMF):** A definitive **Premalignant Condition** strongly linked to areca nut chewing. It has a high malignant transformation rate (approx. 7–13%) due to juxta-epithelial inflammatory reaction and hyalinization. * **Lichen Planus:** Specifically the **erosive and atrophic types** are considered **Premalignant Conditions**. While the reticular type has low risk, the overall disease carries a 1–2% risk of transformation into Squamous Cell Carcinoma (SCC). * **Leukoplakia:** The most common **Premalignant Lesion**. It is a clinical diagnosis of exclusion. Speckled (erythroleukoplakia) and verrucous types have the highest risk of malignancy. ### **High-Yield Clinical Pearls for NEET-PG** * **Highest Malignant Potential:** Erythroplakia (>50% transformation rate) > Speckled Leukoplakia > OSMF. * **Potentially Malignant Disorders (PMD):** This is the modern umbrella term used by the WHO to include both lesions and conditions. * **Other PMDs to remember:** Dyskeratosis congenita, Xeroderma pigmentosum, and Paterson-Kelly (Plummer-Vinson) Syndrome. * **Most common site for Leukoplakia:** Buccal mucosa; **Most dangerous site:** Floor of the mouth/ventral tongue.

Question 93: Blockage along the course of a minor salivary duct, leading to pooling of saliva behind the obstruction and localized swelling, is known as:

A. Ranula
B. Retention mucocele (Correct Answer)
C. Mucous extravasation mucocele
D. Sialolithiasis

Explanation: **Explanation:** **1. Why Retention Mucocele is Correct:** A **Retention Mucocele** (Mucous Retention Cyst) occurs due to a partial or complete **obstruction** of a minor salivary gland duct (often by a sialolith or scar tissue). This leads to the pooling of saliva within the ductal system, causing it to dilate and form a swelling lined by **epithelium**. The key distinction here is the mechanism: it is a "retention" phenomenon behind an anatomical blockage. **2. Analysis of Incorrect Options:** * **Ranula:** This is a specific type of mucocele occurring in the **floor of the mouth**, usually arising from the sublingual gland. While it involves saliva pooling, the question specifically describes the general mechanism of minor salivary duct blockage. * **Mucous Extravasation Mucocele:** This is the most common type of mucocele. It is caused by **trauma** (e.g., lip biting) that ruptures the duct, causing saliva to leak into the surrounding stroma. Unlike the retention type, it lacks an epithelial lining (it is a pseudocyst). * **Sialolithiasis:** This refers to the formation of a stone (calculus) within the duct. While a stone can *cause* a retention mucocele, the resulting localized swelling of pooled saliva itself is defined as the mucocele. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Site:** The **lower lip** is the most common site for mucoceles (usually extravasation type). * **Histology:** Retention mucoceles are **true cysts** (epithelial lining), whereas extravasation mucoceles are **pseudocysts** (granulation tissue lining). * **Plunging Ranula:** A clinical variant where the mucus extravasates below the mylohyoid muscle, presenting as a swelling in the neck. * **Treatment:** Surgical excision of the cyst along with the involved minor salivary gland to prevent recurrence.

Question 94: Which of the following is not an absolute contraindication for extraction of teeth?

A. Uncontrolled diabetes
B. Uncontrolled hypertension
C. Leukemia
D. Acute abscess with tooth (Correct Answer)

Explanation: ### Explanation The correct answer is **D. Acute abscess with tooth**. In modern dental and ENT practice, an **acute abscess** is considered a **relative contraindication**, not an absolute one. While traditional teaching suggested waiting for the infection to localize, current clinical guidelines advocate for "surgical drainage through extraction." Removing the offending tooth provides an immediate pathway for pus to drain, removes the source of infection, and accelerates healing. If the patient is covered with systemic antibiotics and the site can be adequately anesthetized, extraction is often the treatment of choice. #### Analysis of Incorrect Options: * **A. Uncontrolled Diabetes:** This is an absolute contraindication because hyperglycemia impairs leukocyte function and wound healing. Extraction can lead to severe complications like **osteomyelitis** or life-threatening infections (e.g., Ludwig’s Angina). * **B. Uncontrolled Hypertension:** This is an absolute contraindication due to the risk of intraoperative cardiovascular events (stroke or MI) and the potential for prolonged, uncontrollable post-extraction hemorrhage. * **C. Leukemia:** This is an absolute contraindication because patients are severely immunocompromised and have profound thrombocytopenia. Extraction can lead to fatal septicemia or uncontrollable bleeding. #### High-Yield Clinical Pearls for NEET-PG: * **Absolute Contraindications:** Uncontrolled systemic diseases (Diabetes, HTN, Cardiac failure), Blood dyscrasias (Leukemia, Hemophilia), and recent Myocardial Infarction (within 6 months). * **Radiotherapy:** Avoid extraction in teeth within the field of radiation to prevent **Osteoradionecrosis**. * **Bisphosphonates:** Patients on IV bisphosphonates are at high risk for **MRONJ** (Medication-Related Osteonecrosis of the Jaw) following extraction.

Question 95: What is the recommended treatment for a calculus within the submandibular salivary gland?

A. Removal of sinus
B. Removal of the gland (Correct Answer)
C. Dichotomy
D. Milking of the stone

Explanation: ### Explanation The management of submandibular sialolithiasis (calculi) depends primarily on the **location** of the stone. **1. Why "Removal of the gland" is correct:** When a calculus is located **within the substance of the submandibular gland** (intrastructural/intraglandular), it causes chronic inflammation, recurrent infection, and eventual fibrosis of the glandular parenchyma. In such cases, simple removal of the stone is technically difficult and often fails to restore gland function. Therefore, **submandibular gland excision (Sialadenectomy)** is the definitive treatment of choice to prevent recurrent sialadenitis. **2. Analysis of Incorrect Options:** * **Removal of sinus:** This is irrelevant. While a chronic infection might lead to a cutaneous fistula or sinus, the primary pathology is the stone within the gland, necessitating gland removal. * **Dichotomy:** This is not a standard surgical term for salivary stone management. * **Milking of the stone:** This technique is only applicable for **small, distal stones** located near the punctum (opening) of Wharton’s duct. It is ineffective and potentially traumatic for stones located deep within the gland. **3. High-Yield Clinical Pearls for NEET-PG:** * **Wharton’s Duct:** The most common site for salivary calculi (80%) due to the alkaline pH, high calcium/mucin content, and the upward (antigravity) course of the duct. * **Radiopacity:** 80% of submandibular stones are radiopaque (visible on X-ray), whereas 80% of parotid stones are radiolucent. * **Clinical Presentation:** "Mealtime syndrome"—recurrent pain and swelling of the gland triggered by the sight or smell of food. * **Surgical Landmark:** During submandibular gland removal, the **marginal mandibular nerve** must be protected (it lies superficial to the gland). * **Intraductal Stones:** If the stone is in the duct (not the gland), the treatment is **Sialolithotomy** (incision over the duct).

Question 96: During extraction of an upper first molar, the mesiobuccal root is missing and suspected to have been pushed into the maxillary sinus. To classify a chronic oral-antral communication, what time duration is acceptable?

A. 7 days
B. 14 days (Correct Answer)
C. 21 days
D. 28 days

Explanation: ### **Explanation** **1. Why 14 days is the Correct Answer:** An **Oro-Antral Communication (OAC)** is an abnormal space between the maxillary sinus and the oral cavity, most commonly occurring during the extraction of maxillary molars (especially the first molar) due to the proximity of the roots to the sinus floor. * **Acute OAC:** Refers to a communication identified immediately or within the first few days. * **Chronic OAC (Oro-Antral Fistula):** If the communication fails to close spontaneously and persists for **more than 14 days (2 weeks)**, it becomes epithelialized. Once the tract is lined with epithelium (migrating from the oral mucosa and sinus lining), it is classified as a **fistula**. At this stage, spontaneous healing is unlikely, and surgical intervention (like a buccal flap or palatal rotation flap) is required. **2. Why the Other Options are Incorrect:** * **7 days (Option A):** At one week, the site is still in the early stages of secondary intention healing. While inflammation is present, epithelialization of the tract is usually incomplete. * **21 days & 28 days (Options C & D):** While a communication present for 3 or 4 weeks is certainly chronic, the standard clinical definition for the transition from an acute communication to a chronic fistula is established at the **14-day mark**. Waiting longer increases the risk of maxillary sinusitis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Site:** Maxillary 1st Molar > Maxillary 2nd Molar > 2nd Premolar. * **Diagnosis:** Positive **Nose-blowing test** (Valsalva maneuver) where air or bubbles are seen escaping into the oral cavity through the socket. * **Management:** * **< 2mm:** Usually heals spontaneously with a blood clot. * **2–6 mm:** Requires figure-of-eight sutures and gelatin sponge. * **> 6 mm or Chronic:** Requires surgical flap repair (e.g., **Berger’s Buccal Advancement Flap**). * **Prohibitions:** Patients must be advised not to blow their nose, smoke, or use straws for 10–14 days post-injury.

Question 97: Lymphoid tissue is seen in which parotid tumor?

A. Warthin's tumor (Correct Answer)
B. Adenoid cystic carcinoma
C. Mucoepidermoid carcinoma
D. Pleomorphic adenoma

Explanation: **Explanation:** **Warthin’s Tumor (Papillary Cystadenoma Lymphomatosum)** is the correct answer because its hallmark histological feature is a **double layer of oncocytic epithelium** forming cystic spaces and papillary projections, situated within a dense **lymphoid stroma** often containing germinal centers. The presence of lymphoid tissue is explained by the tumor’s pathogenesis: it is believed to arise from salivary gland epithelium that becomes entrapped within intra-parotid or para-parotid lymph nodes during embryological development. **Analysis of Incorrect Options:** * **Pleomorphic Adenoma:** The most common salivary gland tumor. It is characterized by a "mixed" appearance of epithelial/myoepithelial cells and a mesenchymal-like stroma (myxoid, chondroid, or osteoid), but it lacks a primary lymphoid component. * **Mucoepidermoid Carcinoma:** The most common malignant salivary gland tumor. It consists of a mixture of mucus-secreting, epidermoid, and intermediate cells, but does not feature organized lymphoid tissue. * **Adenoid Cystic Carcinoma:** Known for its "Swiss-cheese" (cribriform) appearance and a high propensity for perineural invasion, rather than lymphoid stroma. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Warthin’s tumor occurs **exclusively in the parotid gland** (usually the tail). * **Demographics:** Strongly associated with **smoking** and most common in older males. * **Multiplicity:** It is the most common salivary tumor to be **bilateral** (10%) or multicentric. * **Hot Spot:** On Technetium-99m pertechnetate scan, Warthin’s tumor appears as a **"Hot tumor"** due to the high mitochondrial content of oncocytic cells.

Question 98: What is the most common precancerous lesion for oral malignancy?

A. Chronic hypertrophic candidiasis
B. Leukoplakia (Correct Answer)
C. Dental ulcers
D. Atrophic glossitis

Explanation: **Explanation:** **Leukoplakia** is the most common precancerous (potentially malignant) lesion of the oral cavity. It is clinically defined as a white patch or plaque that cannot be characterized clinically or pathologically as any other disease and cannot be scraped off. The malignant transformation rate ranges from 1% to 5%, though certain types (like non-homogeneous or speckled leukoplakia) carry a much higher risk. Chronic irritation from tobacco (smoking/chewing) and alcohol are the primary etiological factors. **Analysis of Incorrect Options:** * **Chronic hypertrophic candidiasis:** While this is considered a "premalignant condition" with a significant risk of dysplasia, it is far less common than leukoplakia in the general population. * **Dental ulcers:** These are usually traumatic (due to sharp teeth or ill-fitting dentures). While a chronic non-healing ulcer must be biopsied to rule out malignancy, the ulcer itself is not a classic "precancerous lesion" unless it is a manifestation of an underlying malignancy. * **Atrophic glossitis:** This is a clinical finding (smooth tongue) often seen in nutritional deficiencies (Vitamin B12, Iron). While it is associated with the **Plummer-Vinson Syndrome** (which is a precancerous *condition*), it is not the most common lesion. **NEET-PG High-Yield Pearls:** * **Most common site for Leukoplakia:** Buccal mucosa and commissures. * **Highest risk of transformation:** Speckled leukoplakia (Erythroleukoplakia) has a higher risk than homogenous leukoplakia. * **Precancerous Lesion vs. Condition:** A *lesion* is a localized change (e.g., Leukoplakia, Erythroplakia), whereas a *condition* is a generalized state associated with increased risk (e.g., Oral Submucous Fibrosis, Lichen Planus). * **Erythroplakia:** Though less common than leukoplakia, it has the **highest malignant potential** among all oral lesions.

Question 99: Which of the following conditions is characterized by a "hot nodule"?

A. Adenolymphoma (Correct Answer)
B. Mixed parotid tumor
C. Adenoid cystic carcinoma
D. All of the above

Explanation: **Explanation:** The concept of a "hot nodule" in salivary gland imaging refers to the increased uptake of **Technetium-99m (Tc-99m) pertechnetate** during a radionuclide scan. **1. Why Adenolymphoma is correct:** Adenolymphoma, also known as **Warthin’s tumor**, is unique because it contains a high density of oncocytes and lymphoid stroma. These cells possess an abundance of mitochondria and maintain the ability to concentrate pertechnetate but lack the mechanism to secrete it into the ductal system. This results in the "trapping" of the isotope, appearing as a "hot" (hyperactive) area on the scan. **2. Why other options are incorrect:** * **Mixed Parotid Tumor (Pleomorphic Adenoma):** This is the most common salivary gland tumor. It typically appears as a **"cold nodule"** because the tumor tissue replaces normal acinar cells and does not concentrate the isotope. * **Adenoid Cystic Carcinoma:** As a malignant neoplasm, it lacks the specialized oncocytes required to concentrate Tc-99m. Like most other salivary malignancies and benign tumors (except Warthin’s and Oncocytoma), it appears as a **"cold"** defect. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "Hot Nodule" Duo:** Only two salivary tumors typically show increased uptake: **Warthin’s Tumor** and **Oncocytoma**. * **Warthin’s Tumor Profile:** It is most common in elderly males, strongly associated with smoking, and is the most common salivary tumor to present **bilaterally** (though often metachronous). * **Location:** It almost exclusively occurs in the **parotid gland** (specifically the lower pole/tail). * **Mnemonic:** "Warthin’s is **HOT** (Hot on scan), **OLD** (Elderly), **MEN** (Male predominance), and **SMOKES** (Smoking association)."

Question 100: A leafless fruit-laden tree or cherry-blossom appearance on a sialogram indicates which of the following?

A. Mucoepidermoid cell carcinoma
B. Acinar cell carcinoma
C. Sjogren's syndrome (Correct Answer)
D. Pleomorphic adenoma

Explanation: ### Explanation **Correct Answer: C. Sjogren's syndrome** **Why it is correct:** Sjogren’s syndrome is a chronic autoimmune disorder characterized by lymphocytic infiltration and destruction of the exocrine glands (salivary and lacrimal). On a sialogram, the characteristic **"leafless fruit-laden tree"** or **"cherry-blossom"** appearance occurs due to **punctate sialectasis**. This represents the collection of contrast material in small, globular dilated intralobular ducts. Because the peripheral ductal system is destroyed by the inflammatory process, the main ducts appear bare (leafless), while the globular collections of contrast resemble fruit or blossoms. **Why the other options are incorrect:** * **A & B (Mucoepidermoid and Acinar cell carcinoma):** Malignant tumors typically cause ductal displacement, irregular narrowing, or "puddling" of contrast due to tissue destruction and invasion, rather than uniform globular sialectasis. * **D (Pleomorphic adenoma):** As a benign, slow-growing tumor, it typically presents with a **"ball-in-hand"** appearance on a sialogram. The tumor acts as a mass that displaces and stretches the surrounding normal ducts without invading them. **NEET-PG High-Yield Pearls:** * **Sialogram Patterns:** * **Sjogren’s Syndrome:** Punctate sialectasis (Cherry-blossom/Snowstorm appearance). * **Pleomorphic Adenoma:** Ball-in-hand appearance. * **Sialadenitis (Chronic):** Sausage-string appearance (due to segments of stenosis and dilatation). * **Sjogren’s Clinical Triad:** Keratoconjunctivitis sicca (dry eyes), Xerostomia (dry mouth), and a connective tissue disease (most commonly Rheumatoid Arthritis). * **Diagnostic Gold Standard:** Minor salivary gland biopsy (Lip biopsy) showing lymphocytic aggregates (Focus score >1). * **Risk:** Patients with Sjogren’s have a 40x increased risk of developing **B-cell MALT Lymphoma**.

Practice by Chapter

Stomatitis

Practice Questions

Oral Ulcers

Practice Questions

Oral Leukoplakia

Practice Questions

Oral Cancers

Practice Questions

Sialadenitis

Practice Questions

Sialolithiasis

Practice Questions

Salivary Gland Tumors

Practice Questions

Ranula

Practice Questions

Xerostomia

Practice Questions

Sjögren's Syndrome

Practice Questions

Oral Manifestations of Systemic Diseases

Practice Questions

Temporomandibular Joint Disorders

Practice Questions

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