Stomatitis — MCQs
Which is the most common manifestation of recurrent HSVl infection:
Median rhomboid glossitis is seen in?
Disruption of which of the following oropharyngeal commensals predisposes to candidiasis?
A 7 year old child comes to your clinic with ulcers with indurated margins in the oral cavity and fever with crusting of lips. The probable treatment plan is?
Mouth lesions are seen in:
An otherwise healthy male presents with a creamy curd like white patch on the tongue. The probable diagnosis is
A young child of 7 years of age is seen with indurated ulcers, lymphadenopathy and fever. The likely treatment is:
A 16-year-old patient complains of difficulty in swallowing, difficulty in talking and sometimes difficulty in breathing. On physical examination the presentation is similar to that shown in the picture. What would be the probable diagnosis?
Saroj, a 32-year-old female from a rural background, has a history of chronic tobacco chewing since 14 years of age. She now presents with difficulty in opening her mouth. On oral examination, no ulcers are seen. What is the most probable diagnosis?
What is the most common site of ectopic salivary gland?
Stomatitis Indian Medical PG Practice Questions and MCQs
Question 1: Which is the most common manifestation of recurrent HSVl infection:
- A. Herpetic whitlow
- B. Herpetic keratitis
- C. Recurrent herpes labialis (Correct Answer)
- D. Herpes encephalitis
Explanation: **Recurrent herpes labialis** - **Recurrent herpes labialis**, or **cold sores**, is the most common manifestation of recurrent HSV-1 infection [1]. - It typically presents as vesicles and ulcers on the lips and perioral region due to reactivation of the virus from the **trigeminal ganglia** [1]. *Herpetic whitlow* - **Herpetic whitlow** is an HSV infection of the fingers or toes, often seen in healthcare workers or children, but it is not the most common recurrent manifestation [2]. - It is characterized by painful, vesicular lesions on the digits [2]. *Herpetic keratitis* - **Herpetic keratitis** is a serious ocular infection that can lead to corneal scarring and vision loss, but it is less common than recurrent oral lesions [2]. - It involves the **cornea** and can cause pain, redness, and blurred vision [2]. *Herpos encephalitis* - **Herpes encephalitis** is a rare but severe neurological complication of HSV infection that can cause significant morbidity and mortality. - It involves inflammation of the **brain** and is characterized by fever, headache, altered mental status, and seizures.
Question 2: Median rhomboid glossitis is seen in?
- A. Chronic kidney disease
- B. Mouth breathers
- C. Candidiasis (Correct Answer)
- D. AIDS
Explanation: ***Candidiasis*** - **Median rhomboid glossitis** is a form of **chronic atrophic candidiasis** that appears as a well-demarcated, erythematous, rhomboid-shaped lesion on the dorsum of the tongue. - It is often asymptomatic but can sometimes cause a burning sensation or altered taste. *Chronic kidney disease* - Patients with chronic kidney disease may experience **uremic stomatitis** or **gingivitis**, but this typically does not manifest as median rhomboid glossitis. - Oral findings in CKD are often related to metabolic disturbances and immunosuppression, but not specifically this type of glossitis. *Mouth breathers* - **Mouth breathing** can lead to oral dryness (**xerostomia**) and associated conditions like **gingivitis** or **angular cheilitis**, but it is not directly linked to median rhomboid glossitis. - The dry environment can predispose to fungal infections, but not specifically the characteristic rhomboid shape. *AIDS* - While patients with **AIDS** are severely immunocompromised and highly susceptible to **oral candidiasis** (e.g., pseudomembranous, erythematous, hyperplastic candidiasis), median rhomboid glossitis is not a specific or exclusive manifestation of AIDS. - **Oral hairy leukoplakia** due to Epstein-Barr virus is a more specific and common oral lesion seen in AIDS.
Question 3: Disruption of which of the following oropharyngeal commensals predisposes to candidiasis?
- A. Staphylococcus
- B. Streptococcus (Correct Answer)
- C. Lactobacillus
- D. Haemophilus influenzae
Explanation: ***Streptococcus*** - **Streptococcus** species, particularly *S. sanguinis* and *S. mitis*, are major commensals in the oral cavity that **inhibit the growth of *Candida albicans*** through competition for nutrients and production of antimicrobial substances. - Disruption of this normal **streptococcal flora**, often by broad-spectrum antibiotics, creates an environment where *Candida albicans* can proliferate, leading to candidiasis. *Staphylococcus* - **Staphylococcus** species are primarily skin and nasal commensals; while *S. aureus* can be found in the oral cavity, it is not a primary competitor against *Candida* in the same way as streptococci. - Their presence or absence is not typically a direct predisposing factor for oral candidiasis compared to the dominant streptococcal flora. *Lactobacillus* - **Lactobacillus** species are common in the gastrointestinal tract and vagina, where they maintain an acidic environment that inhibits pathogen growth; however, they are less dominant in the oropharynx as a defense against *Candida*. - While beneficial for overall host health, their disruption in the oral cavity does not typically precipitate candidiasis as directly as that of the **streptococcal flora**. *Hemophilus influenzae* - *Haemophilus influenzae* is a common inhabitant of the **upper respiratory tract** and can be an opportunistic pathogen, but it is not known to have a significant role in directly inhibiting *Candida* growth in the oropharynx. - Its presence or absence in the commensal flora in the oral cavity does not typically influence the development of candidiasis.
Question 4: A 7 year old child comes to your clinic with ulcers with indurated margins in the oral cavity and fever with crusting of lips. The probable treatment plan is?
- A. Prescribe broad spectrum antibiotic and mouthwash
- B. Symptomatic treatment and observation (Correct Answer)
- C. Clean the mouth with gentle mouthwash
- D. None of the options
Explanation: **Symptomatic treatment and observation** - The described symptoms (oral ulcers with indurated margins, fever, and crusting of lips) are characteristic of **herpetic gingivostomatitis**, a **viral infection** that is usually self-limiting in children. - **Symptomatic treatment** focuses on pain relief (e.g., acetaminophen, ibuprofen), maintaining hydration, and gentle oral hygiene, as the condition typically resolves within 7-14 days without specific antiviral medication unless immunocompromised or severe. *Prescribe broad spectrum antibiotic and mouthwash* - **Broad-spectrum antibiotics** are ineffective against **viral infections** like herpetic gingivostomatitis and their overuse can contribute to **antibiotic resistance**. - While some mouthwashes might offer temporary symptomatic relief, a general prescription for a broad-spectrum antibiotic is inappropriate for this viral condition. *Clean the mouth with gentle mouthwash* - While **gentle oral hygiene** is important, simply cleaning the mouth with a gentle mouthwash is an **incomplete treatment plan** as it doesn't address pain or fever, which are significant symptoms. - It is a part of symptomatic care, but not the sole appropriate treatment. *None of the options* - This option is incorrect because **symptomatic treatment and observation** is a valid and appropriate management strategy for the child's presentation, especially for self-limiting viral infections.
Question 5: Mouth lesions are seen in:
- A. Ichthyosis Vulgaris
- B. Psoriasis
- C. Lichen Planus (Correct Answer)
- D. Basal Cell CA
Explanation: ***Lichen Planus*** - **Oral lichen planus** often presents with characteristic **white, lacy patterns (Wickham's striae)** on the buccal mucosa, tongue, or gingiva. - These lesions can be painful, erosive, or reticular, and are considered a **classic and common manifestation** of the disease. - Oral involvement occurs in **50-70% of lichen planus cases**, making it the most characteristic answer. *Ichthyosis Vulgaris* - This condition is primarily characterized by **dry, scaly skin**, especially on the extremities, due to a problem with keratinization. - **Mouth lesions are not a feature** of ichthyosis vulgaris as it does not affect mucous membranes. *Psoriasis* - While psoriasis primarily affects the skin with **erythematous plaques and silvery scales**, oral manifestations can occur but are **less specific and less common** than in lichen planus. - Associated oral findings include **geographic tongue (benign migratory glossitis)** and fissured tongue, but these are not pathognomonic. - True **oral psoriatic plaques** are rare and non-specific compared to the characteristic Wickham's striae of lichen planus. *Basal Cell CA* - **Basal cell carcinoma (BCC)** is a common skin cancer that rarely appears in the oral cavity. - When it does, it usually presents as a lesion on the **lips** (especially the lower lip at the vermillion border) but is primarily a cutaneous malignancy. - **Not associated with widespread oral mucosal lesions**.
Question 6: An otherwise healthy male presents with a creamy curd like white patch on the tongue. The probable diagnosis is
- A. Histoplasmosis
- B. Aspergillosis
- C. Lichen Planus
- D. Candidiasis (Correct Answer)
Explanation: ***Candidiasis*** - The classic presentation of **oral candidiasis** (thrush) is a **creamy, curd-like white patch** on the mucous membranes, including the tongue, which can often be scraped off. - This common fungal infection, caused by *Candida albicans*, can occur in otherwise healthy individuals, especially after antibiotic use, or with mild immunosuppression. *Histoplasmosis* - This fungal infection is typically associated with **pulmonary involvement** in endemic areas (e.g., Ohio and Mississippi River valleys). - Oral lesions, if present, are usually **firm, nodular, or ulcerative**, not creamy white patches, and often signify disseminated disease in immunocompromised individuals. *Aspergillosis* - Primarily a **pulmonary infection**, especially in immunocompromised patients, with symptoms like fever, cough, and dyspnea. [1] - Oral manifestations are rare and typically present as **necrotic ulcers** or plaques, not creamy white patches, and are usually seen in severely immunocompromised patients. [1] *Lichen Planus* - Oral lichen planus presents with **white reticular (lace-like) patterns** (Wickham's striae), plaques, or erosions on the buccal mucosa, tongue, or gingiva. - These lesions are typically **non-scrapable** and can be associated with pain or burning, differing significantly from the "creamy curd-like" description.
Question 7: A young child of 7 years of age is seen with indurated ulcers, lymphadenopathy and fever. The likely treatment is:
- A. Excise the lesion
- B. Symptomatic treatment
- C. I.V. fluids
- D. Systemic antibiotics (Correct Answer)
Explanation: ***Systemic antibiotics*** - This clinical triad of **indurated ulcers, lymphadenopathy, and fever** in a child is highly suggestive of **ulceroglandular tularemia** (Francisella tularensis), **cat-scratch disease** (Bartonella henselae), or **atypical mycobacterial infection**. - **Tularemia** presents with a painful ulcer at the inoculation site with regional lymphadenopathy and systemic symptoms - treated with **streptomycin or gentamicin**. - **Cat-scratch disease** may present similarly after feline contact - treated with **azithromycin**. - **Atypical mycobacteria** (M. marinum) cause "swimming pool granuloma" with similar features - requiring **clarithromycin and rifampicin**. - **Systemic antibiotic therapy is essential** to prevent complications and disease progression. *Symptomatic treatment* - **Symptomatic treatment alone is inadequate** for bacterial infections presenting with indurated ulcers and lymphadenopathy. - While fever and pain management may be adjunctive, **definitive antimicrobial therapy is required** for these infectious conditions. - Failure to treat appropriately can lead to **systemic dissemination** and serious complications. *Excise the lesion* - **Surgical excision is not the primary treatment** for infectious ulcers with lymphadenopathy. - Excision may be considered for **localized atypical mycobacterial lymphadenitis** that fails medical therapy, but is not first-line. - The presence of **systemic symptoms (fever)** indicates need for medical rather than surgical management. *I.V. fluids* - **Intravenous fluids are supportive therapy** for dehydration, not definitive treatment. - The clinical presentation requires **antimicrobial therapy**, not just hydration. - IV fluids may be needed as adjunctive therapy if the child is unable to maintain oral hydration, but do not address the underlying infection.
Question 8: A 16-year-old patient complains of difficulty in swallowing, difficulty in talking and sometimes difficulty in breathing. On physical examination the presentation is similar to that shown in the picture. What would be the probable diagnosis?
- A. Ranula
- B. Lingual thyroid (Correct Answer)
- C. Enlarged adenoids
- D. Vallecular cyst
Explanation: ***Lingual thyroid*** - The image shows a **mass at the base of the tongue**, which is typical of a lingual thyroid, an ectopic thyroid tissue. - Symptoms like **difficulty swallowing (dysphagia)**, **difficulty talking (dysphonia)**, and **difficulty breathing (dyspnea)** are common with a lingual thyroid due to its obstructive nature. - Lingual thyroid results from **failure of thyroid descent** during embryological development and is the most common ectopic thyroid location. *Ranula* - A ranula is a **mucus extravasation cyst** found on the **floor of the mouth**, usually unilateral and bluish. - While it can cause speech or swallowing difficulties, its location is distinct from the mass seen at the tongue base. *Vallecular cyst* - A vallecular cyst is a **mucus retention cyst** located in the **vallecula** (between the base of tongue and epiglottis). - Can present with dysphagia and respiratory symptoms, but typically appears more **cystic and translucent** rather than solid tissue mass. - Less common in adolescents compared to lingual thyroid. *Enlarged adenoids* - Enlarged adenoids are located in the **nasopharynx** and typically cause nasal obstruction, mouth breathing, and recurrent ear infections. - They would not present as a visible mass at the base of the tongue nor cause dysphagia or dysphonia to this extent.
Question 9: Saroj, a 32-year-old female from a rural background, has a history of chronic tobacco chewing since 14 years of age. She now presents with difficulty in opening her mouth. On oral examination, no ulcers are seen. What is the most probable diagnosis?
- A. Submucous oral fibrosis (Correct Answer)
- B. Carcinoma of buccal mucosa
- C. TM joint arthritis
- D. Trigeminal nerve paralysis
Explanation: **Explanation:** The clinical presentation of a young patient with a long-standing history of tobacco/areca nut chewing presenting with progressive difficulty in opening the mouth (trismus) is a classic description of **Oral Submucous Fibrosis (OSMF)**. **1. Why the correct answer is right:** OSMF is a chronic, insidious, premalignant condition characterized by juxta-epithelial inflammatory reaction followed by **progressive fibrosis of the lamina propria and deeper connective tissues**. The alkaloids in areca nut (e.g., arecoline) stimulate fibroblasts to produce excessive collagen, while flavonoids inhibit collagenase. This leads to the formation of palpable vertical fibrous bands, particularly in the buccal mucosa, resulting in restricted mouth opening (trismus) and a "burning sensation" when eating spicy food. The absence of ulcers in this case further supports a fibrotic rather than an ulcerative/malignant process. **2. Why the incorrect options are wrong:** * **Carcinoma of buccal mucosa:** While tobacco is a risk factor, malignancy typically presents with a non-healing ulcer, proliferative growth, or induration, rather than isolated trismus without a visible lesion. * **TM joint arthritis:** This would present with joint pain, clicking sounds, and tenderness over the pre-auricular area, usually unrelated to tobacco chewing. * **Trigeminal nerve paralysis:** This would result in sensory loss or weakness of the muscles of mastication (motor V3), but not mechanical restriction due to fibrosis. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Areca nut (betel nut) is the primary causative agent. * **Clinical Sign:** "Hockey-stick" appearance of the uvula and restricted tongue protrusion due to fibrosis. * **Pre-malignant potential:** OSMF has a high malignant transformation rate (approx. 7–13%). * **Management:** Cessation of habit, intralesional steroids (to reduce inflammation), and hyaluronidase (to break down collagen). Surgical release is reserved for severe cases.
Question 10: What is the most common site of ectopic salivary gland?
- A. Cheek
- B. Palate
- C. Angle of mandible (Correct Answer)
- D. Tongue
Explanation: **Explanation:** The correct answer is **Angle of mandible (Option C)**. This refers to a specific clinical entity known as a **Stafne’s Bone Cavity** (or Static Bone Cyst). **Why it is correct:** Ectopic salivary gland tissue (also called salivary gland choristoma) refers to normal salivary tissue found in an abnormal anatomical location. The most frequent site is the **mandible**, specifically near the angle, below the inferior alveolar canal. This occurs when a portion of the submandibular gland becomes entrapped during the ossification of the mandible. On a radiograph, this appears as a well-defined, asymptomatic radiolucency near the angle of the jaw. **Analysis of incorrect options:** * **A. Cheek:** While ectopic tissue can occur in the buccal mucosa, it is significantly less common than the mandibular site. * **B. Palate:** The palate is the most common site for **minor salivary gland tumors** (specifically Pleomorphic Adenoma), but it is not the most common site for *ectopic* (choristomatous) tissue. * **D. Tongue:** Ectopic salivary tissue can be found at the base of the tongue (near the lingual tonsils), but this is a rare occurrence compared to the mandibular angle. **High-Yield Clinical Pearls for NEET-PG:** * **Stafne’s Cyst:** It is not a true cyst (no epithelial lining); it is a developmental depression containing ectopic submandibular gland tissue. * **Most common site for Minor Salivary Glands:** Palate. * **Most common site for Sialolithiasis (Stones):** Submandibular gland (Wharton’s duct) due to alkaline pH and high calcium/mucin content. * **Most common Salivary Gland Tumor:** Pleomorphic Adenoma (most common site: Parotid).
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