The correct answer is D. The rest of the answer options are preventative to dental cavity formation to some degree. Consumption of simple sugars and carbohydrates causes the pH within the mouth to decline. Saliva helps to buffer the acidic environment however, with continued carbohydrate or sugar snacking, the pH will eventually decline to < 5.5. At this point, the enamel starts to demineralize resulting in a discolored white spot. The acidic environment also promotes an increase in certain bacteria (Streptococcus mutans, Lactobacilli) which further decrease the pH and result in the enamel becoming more porous. If prompt teeth cleaning, removal of the plaque, and application of topical fluoride occur, remineralization of the enamel can occur. Otherwise, deeper cavities occur which can extend into the dentin where bacterial invasion becomes even more problematic. Once the cavity reaches the pulp, it becomes painful. Pure fruit juices should be avoided for at least the first 12 months of life and sodas for the first five years. Foods that contain both protein and fat, such as milk, meat and cheese can offset the adverse effects of eating carbohydrates alone. Physical exam consists of visual inspection as well as palpation for a rough surface or defect in the enamel. The International Caries Detection and Assessment System (ICDAS) can be used to classify and document caries and is also useful for tracking any progression or regression. Dental x-rays are also beneficial but are performed at a dentist office. Ideally, the first dentist visit should occur around 12-18 months of age. Patient/parent education is an important part of the formal dental visit since prevention is key. The dentist may also evaluate for the need for fluoride. Fluoride is found in municipal sources of water and is also available in topical applications including toothpaste. Fluoride works on a few levels. First, it helps decrease the solubility of the enamel to acids. Next, it promotes remineralization. And finally, it reduces acid production from bacteria. Dental sealants are a common option for preventing or slowing caries of the primary or secondary molars. These coat the tooth in a plastic substance which can remain in place for approximately 2-4 years but up to 10 years in some cases. Once a cavity has formed, preventative measures are still important in order to minimize progression, however, formal treatment may be necessary. Options for treatment include fillings, which can be composed of porcelain, resins, or an amalgam which is a composite of several different substances. Crowns are used for more extensive damage. These cover the normal crown of the tooth after the decayed material is removed. They can be made of gold, porcelain, resin, and other materials. A root canal is generally needed when the cavity has invaded the pulp. The effected pulp is removed and replaced with a filling. If the damage is too extensive, an extraction will be necessary. References: UpToDate https://www.ncbi.nlm.nih.gov/books/NBK551699/
https://www.ncbi.nlm.nih.gov/books/NBK8259/
https://www.oralhealthgroup.com/features/medical-management-of-dental-caries-be-a-knife-doctor-and-a-pill-doctor/

The correct answer is C. The case scenario is consistent with gingivitis. Bacterial biofilm, or plaque, is the most common cause of both gingivitis and periodontitis. Plaque is a gel-like substance containing bacterial colonies which forms around the boarder of the teeth and gums within 24 hours of not brushing. Tartar is the hardened form of plaque which is usually yellow or brown in color. This hardening starts to occur within 48 hours and after several days, it becomes so hard that it is nearly impossible to remove with standard brushing. HIV, certain medications (primarily phenytoin, cyclosporine, and calcium channel blockers) and pregnancy can also cause gingivitis but are less common than plaque. Vitamin C, as opposed to Vitamin D, deficiency is also an etiology.

Periodontitis is the advancement of gingivitis to the point that there is loss of the supportive connective tissues (periodontal ligament) and alveolar bone. This ultimately results in loose teeth and bone loss, eventually resulting in a loss of teeth. When periodontitis is present, gaps can be visualized between the gum and the tooth.

Gingivitis and periodontitis related to plaque is generally managed using appropriate brushing techniques, flossing as well as scaling by the dentist. Chlorhexidine mouth washes can also be added. If gingivitis is managed early and appropriately, it is reversible. Cases of periodontitis that do not improve with appropriate dental hygiene may require systemic antibiotics. Metronidazole is typically the first-line treatment which can be combined with an antifungal to avoid a secondary candidiasis from the antibiotics. Augmentin or clindamycin are alternative antibiotic choices. Advanced cases may require surgical debridement and/or dental extractions. Complications of gingivitis and periodontitis include gingival recession as well as abscesses. Gingival recession can also be caused by excessively large teeth or overly aggressive brushing and results in hypersensitivity. Periodontal abscess are superficial collections of pus and which can seed heart valves and prosthetic joints with bacteria through hematologic spread.

References
UpToDate
https://www.ncbi.nlm.nih.gov/books/NBK557422/
https://www.ncbi.nlm.nih.gov/books/NBK558499/

The correct answer is A. The image is consistent with an aphthous ulcer. These are generally somewhat painful, shallow, oval or round in shape, and mostly filled with a yellow exudate or granulation appearance. These lesions can occur spontaneously or secondary to local trauma (biting one’s own lip or buccal mucosa), however, their presence can also be the result of systemic issues. Inflammatory bowel disorders such as Crohn’s disease or ulcerative colitis, celiac, HIV, lupus, neutropenia, anemia, malnourishment (folic acid, vit. B12 deficiencies), and some medications such as methotrexate.

Bechet disease is a chronic, recurrent systemic vasculitis disorder which presents primarily with multiple oral and genital ulcerations but also manifests with papulopustules, vascular thromboses, and iritis or uveitis. Other systems that can also be affected include neurologic, pulmonary, renal, cardiac, GI and the medium to large joints. There are no specific tests for Behcet’s, instead, it is usually considered when aphthous or genital ulcers frequently reoccur.

Aphthous ulcers are self-resolving within a few weeks however, supportive care measures should be encouraged to minimize symptoms with pharmaceutical treatment started if the patient is experiencing significant discomfort or in the case of frequent recurrence such as in Bechet’s disease. Supportive care education includes avoiding hard/crusty foods, acidic foods like fruit juices and tomatoes, salty or spicy foods, toothpastes which contain sodium lauryl sulfate, alcohol and carbonated drinks. First-line treatment consists of topical steroids such as triamcinolone acetonide cream 0.1% 3-4 times per day. sucralfate can also be used in combination with or as an alternative to topical corticosteroids. Topical sucralfate 1g/10mL four times per day as needed can be administered as a mouthwash alone or in conjunction with a steroid cream. A preventative treatment for recurrent ulcerations such as in Bechet disease is colchicine or apremilast. For lesions refractory to the previously mentioned treatment, oral steroids can be given and tapered over a 2-3 week period. Other medications are available for rare cases that do not respond.

References:
UpToDate
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4215084/

The correct answer is E. The image is consistent with oral candidiasis, or thrush. Bechet’s disease is associated with lip or mucosal membrane ulcerations known as aphthous ulcers. Coffee generally results in bad breath but not with specific changes to the appearance of the tongue or mouth. Alcoholism can cause dehydration resulting in a white coating on the tongue which can appear somewhat similar to candidiasis. Spicy foods do not cause white discolorations of the tongue. Peroxide use can result in a black, hairy tongue.

In addition to inhaled steroids, other risk factors for developing oral candidiasis in the immunocompetent patient include systemic corticosteroids, denture use, xerostomia (dry mouth), and antibiotic use. Candidiasis in the immunocompromised patient is commonly related to HIV, chemotherapy, transplant patients on antirejection medications, and radiation of the head and neck area. Approximately 30-60% of adults and 45-65% of infants have candida as part of their normal oral flora. The risk factors previously mentioned can result in an overgrowth resulting in visible symptoms. These grey-white plaques can occur anywhere inside the oral cavity and rarely occur on the tongue without occurring elsewhere. Patients who wear dentures may have an erythematous appearance instead of the white plaques. This is referred to as an “atrophic” form as opposed to the more common “pseudomembranous” variety.

Diagnosis is usually made clinically, however, if there is uncertainty, the lesions can be scraped with a tongue depressor and a Gram stain or potassium hydroxide preparation performed. This will show budding yeasts with or without hyphae. In most cases, topical therapy is adequate. Options include clotrimazole troches, miconazole buccal tablets, or nystatin suspension. Gentian violet is also effective but is less desirable due to it’s purple staining. These topical options are usually continued for 7-14 days. Systemic oral fluconazole can be used for unresponsive cases or for those with more moderate or severe disease but should be avoided in pregnancy, especially in the first trimester. Patients with denture candidiasis usually require oral fluconazole and should be advised on proper denture care. This includes removing the dentures at night and soaking them in either chlorhexidine gluconate or a bleach solution created by placing 10 drops in a denture cup and then filled with water. After soaking, allow the denture to air dry, which also slows growth of candida. For breastfed infants, topical treatment of the infant’s mouth and the mother nipples is necessary. Nystatin oral suspension is preferred for the infant and miconazole 2% cream for the mother’s nipples. If the mother’s nipples have visible signs of candidiasis, she should also be treated with oral fluconazole. Most cases resolve without any complications. The primary concern is in the immunocompromised patient where progression to esophageal candidiasis is the primary concern.

References:
https://www.ncbi.nlm.nih.gov/books/NBK545282/
UpToDate

The correct answer is D. The case scenario is consistent with a deep space neck infection, likely the result of a dental infection. Lemierre syndrome is the subsequent formation of septic thrombophlebitis of the internal jugular vein. These emboli can then travel to the lungs and seed joints, skin, kidneys, spleen, liver and the heart. A carotid artery dissection is usually the result of trauma, as opposed to infection. While deep space neck infections can encroach on the esophagus, they are not responsible for changes to the lower esophageal lining, the result of poorly controlled GERD. Cushing syndrome is excess cortisol produced by the adrenal glands usually caused by prolonged use of corticosteroids. Thyrotoxicosis is an excess of thyroid hormones usually triggered by Grave’s disease.

Most deep space neck infections arise from the oral or pharyngeal cavities and therefore are most commonly associated with anerobic bacteria including streptococcus, fusobacterium, haemophilus, and pseudomonas, amongst others. Once introduced, these bacteria can spread from one cervical fascial space to another within the neck and result in rapid progression so symptoms. A puncture wound or other trauma to the neck is also a common cause. A history of congenital abnormalities or immunosuppression places a patient at higher risk of developing these infections and can speed up the progression. Symptoms and exam findings vary widely from patient to patient. A patient may report an initial tooth ache or sore throat which then progressed to fever, dysphagia, neck stiffness, feeling a mass, changes in voice, or a difficulty in swallowing saliva or breathing. The physical exam may show drooling, trismus, visible neck mass or swelling, trachea shift, tenderness or swelling of the floor of the mouth, pharyngitis or posterior pharynx swelling, and stridor or changes in the voice quality might be heard. Infections can also result in chest pain secondary to a spread to the mediastinum or pericardium.

Work-up should include standard labs and blood cultures. A lateral soft tissue neck x-ray and/or ultrasound are useful for evaluating some of the structures, but the gold standard is CT scan with IV contrast. Once diagnosed, a head and neck surgeon should be consulted because an abscess will usually require surgical drainage and these patients can rapidly deteriorate. Alternatively, ENT or general surgery consults may also be beneficial. Broad spectrum IV antibiotics should be started early in the work-up. Options include nafcillin or vancomycin plus gentamycin or tobramycin. Ampicillin/sulbactam or clindamycin can also be used, and metronidazole should be added if fusobacterium is present or suspected. Early recognition is the key to minimizing complications. For patients with infections of dental origin, patient education on proper dental hygiene and annual dental exam should be encouraged.

References:
https://www.ncbi.nlm.nih.gov/books/NBK513262/
UpToDate

The correct answer is F. Ludwig angina refers to an infection in the floor of the mouth, usually the result of bacteria that enter through a cavity in a lower molar. Less common sources include peritonsillar abscess, parotitis, oral trauma including piercings, and infection of the submandibular or sublingual salivary glands. Gingivitis rarely seeds the floor of the mouth. While the term “angina” is almost exclusively thought of in relation to coronary artery disease, the term has a much broader definition meaning “to strangle”, which is very appropriate when describing an infection in the floor of the mouth.

The sublingual area consists of 3 potential spaces, the submandibular, sublingual, and submental. Most bacteria enter the submandibular space from the molars but less commonly, can enter the sublingual space from the premolars or other teeth. Once introduced, the bacteria can spread to the other compartments. Patients may report pain or swelling under the tongue or under the chin. Other symptoms may include fevers, neck stiffness, dysphagia, or drooling. On exam, the patient may appear ill and may be leaning forward to optimize the airway, have a muffled voice, visible or palpable soft tissue swelling to the floor of the mouth or under the chin (referred to as a “bull neck”) with crepitus or what has been described as a “woody” induration. Lymphadenopathy and trismus are less common findings.

Diagnosis is usually made clinically and confirmed with CT scan. A bedside soft tissue ultrasound may also be a quick method of screening for an abscess collection. If there is a high suspicion or if the diagnosis is made on imaging, the airway should be closely observed while antibiotics are given time to work. Early intubation may be necessary otherwise an emergent tracheostomy may be required. Antibiotics should be started immediately upon diagnosis. Typical IV antibiotics include ampicillin-sulbactam alone or ceftriaxone plus metronidazole. Levofloxacin plus metronidazole for penicillin allergic patients. If MRSA is suspected or confirmed, vancomycin or linezolid should be added. If a visible abscess is present on imaging, surgical drainage will be necessary. Outcomes are generally good when the disorder is diagnosed and treated early. Potential complications include necrotizing fasciitis, aspiration pneumonia, and mediastinitis. Once the infection has been treated, the patient should seek dental care to address any carious teeth and be encouraged to have regular dental cleanings and be educated on the importance of daily dental hygiene.

References:
UpToDate
https://www.ncbi.nlm.nih.gov/books/NBK482354/

The correct answer is C. The patient most likely has a retropharyngeal abscess which is evident due to the prevertebral soft tissue swelling anterior to cervical vertebrae one and two (see red bracket on 2nd image). The barking cough is associated with croup which can be seen on a lateral soft tissue neck x-ray as a positive steeple sign (not present on this image). Stridor is also associated with croup but can also be heard with some foreign body obstructions. Foreign bodies are seen if they are radiopaque (none on this image). The “bull neck” appearance is associated with Ludwig’s angina which can sometimes be appreciated as a collection of gas in the submental area. Tripod positioning is most commonly associated with epiglottitis although a similar position can be seen with severe cases of retropharyngeal abscess. The epiglottitis and adjacent vallecula appear unremarkable in this image.

A retropharyngeal abscess is most commonly seen in patients age 2-4 but can anywhere from neonate to adult. A recent upper respiratory tract infection is the most common cause with others being bacterial pharyngitis, pharyngeal trauma, and vertebral body osteomyelitis. The infection is usually polymicrobial with streptococcus, staphylococcus, and fusobacterium being the most common. Early presentations of retropharyngeal abscess can be difficult to distinguish from other disorders therefore, a high index of suspicion and close follow-up is required. Patients may present with nonspecific complaints such as dysphagia and odynophagia or more severe symptoms such as neck stiffness, changes in voice, difficulty breathing, or chest pain. Physical exam findings can also vary widely, from mild pharyngeal erythema to trismus, drooling, visible posterior pharynx edema, rigid neck and/or palpable mass, and respiratory distress.

Imaging can aid in making the diagnosis. Plain films offer a quick screening and can be performed without having the patient leave the treatment area. In addition to looking for a retropharyngeal abscess, epiglottitis, croup and some foreign bodies can also be seen on soft tissue neck x-rays. A true lateral x-ray is important. Look at the prevertebral soft tissues just anterior to the spinous processes. In patients less than 5 years of age, this area should generally be less than half the width of the accompanying vertebral body and is considered abnormal if the width is equivalent or greater. The prevertebral soft tissues can also be measured for a more accurate interpretation. Findings are considered abnormal if > 7mm at C2 or > 14mm at C6 in children (>22mm at C6 in adults). The soft tissues should also be evaluated for a possible foreign body that may have punctured the space and the presence of gas or air-fluid levels. Additional findings can include straightening of the neck and evidence of vertebral body osteomyelitis.

The primary treatment is IV antibiotics, usually ampicillin-sulbactam or clindamycin. Vancomycin or linezolid should be started If the patient appears septic or is not responding to initial antibiotic therapy. IV antibiotics should be continued until there is clinical improvement and afebrile for 24 hours. Amoxicillin-clavulanate or clindamycin are the medications of choice once the patient is ready to be discharged home and should be taken for 14 days. If there is any airway compromise, the patient should be immediately intubated. An abscess collection should be drained by an otolaryngologist if the patient is not clinically improving within 24-48 hours unless airway compromise is present, in which case, it should be preformed emergently.

References:
UpToDate
https://www.ncbi.nlm.nih.gov/books/NBK441873/

The correct answer is C. The history, exam, and imaging findings are most consistent with epiglottitis. Laryngotracheitis (croup) is almost always a pediatric diagnosis and is usually associated with a “barking cough” and/or stridor. Ludwig angina is usually caused by poor dentition resulting in a cellulitis or abscess formation of the floor of the mouth. This swelling can occasionally push into the vallecula but the lack of exam findings in the vignette makes the diagnosis very unlikely. A peritonsillar abscess is not visible on x-ray and the exam findings are not consistent with the diagnosis. A retropharyngeal abscess can be seen on x-ray, however, the space just anterior to the spinous processes is the area affected, opposed to the vallecula space which is on the opposite side of the trachea.
Epiglottitis, an infection of the epiglottis, aryepiglottic folds, and arytenoid cartilages, was once a diagnosis made almost entirely in the pediatric population (ages 2-6), however, since the Haemophilus influenza B (Hib) vaccine became a standard component of the vaccination schedule in the late 1980’s, the demographic has shifted to the older adult where the symptoms are generally less severe or in unvaccinated children. In addition to Hib, other bacteria implicated in the disorder include staphylococcus, streptococcus, neisseria, and pasteurella. Viruses are rarely responsible. When epiglottitis occurs in children, especially the unvaccinated, there is a rapid progression of symptoms up to airway compromise. Irritability and fever progress to muffled voice, drooling, a toxic appearance and then stridor, usually instinctively forcing the patient to assume a position of leaning forward onto elbows with the neck hyperextended referred to as a “tripod” posture”. The vaccinated or older patient usually has a slower progression including a lower-grade fever, voice changes, and dysphagia. Stridor is less common.
The diagnosis is confirmed by direct visualization of the epiglottis using fiberoptic nasolaryngoscopy and/or indirect laryngoscopy by anesthesia or otolaryngology but should be reserved for the older or fully vaccinated patient with the anticipation of needing to emergently secure the airway. Those with severe symptoms should not undergo direct visualization until intubated. A soft-tissue lateral neck x-ray is the preferred diagnostic test when epiglottitis is in the differential and the patient does not require emergent intubation. An x-ray can be performed quickly and at the bedside without requiring the patient to lie supine, which could further compromise the airway. The most specific findings on the x-ray include: the “thumb sign” which represents a diffuse enlargement of the epiglottis, a blunting of the normally deep, v-shaped vallecula air space just superior and anterior to the epiglottis, and thickened aryepiglottic folds located inferior to the epiglottis. Obtaining laboratory studies should be delayed until the airway has been secured in patients who have the potential for airway compromise, especially in young children. The pain and anxiety associated with phlebotomy may result in sudden airway closure.
Treatment of the infection should begin with a third-generation cephalosporin plus vancomycin. For patients with a cephalosporin allergy, a fluoroquinolone should be substituted. Providing IV hydration is important since many patients may be hypovolemic due to fever and decreased oral intake. Racemic epinephrine may help reduce upper airway edema. Glucocorticoids have not demonstrated significant benefit but are frequently ordered. The patient should be admitted to the ICU even if they are not initially intubated, with the anticipation that an emergency airway may be necessary early in the treatment period.
References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342809/
UpToDate

The correct answer is D. The history and exam are most consistent with herpes simplex type 1. Starting antivirals after 72 hours makes them less effective although still useful in cases were new lesions are still appearing or if the patient is having significant pain impacting eating or drinking.
Herpes simplex virus type 1, usually referred to as HSV-1, is a member of the Herpesviridae group which also includes varicella, Epstein-Barr, and cytomegalovirus. Symptoms usually occur 2-12 days after exposure with the most common symptom being the “cold sore” ulceration on the lips. Ulcers can also occur in the genital area which is more typically associated with HSV-2. Lesions begin as thin-walled round or oval vesicles which burst and then form a yellowish film followed by a crust. The lesion may be preceded by pain, burning or pruritis in the area or by more systemic symptoms such as fever, sore throat, malaise, or lymphadenopathy. Patients with no prior diagnosis of HSV or who present with an atypical vesicle or ulceration should have a confirmatory test. Polymerase chain reaction (PCR) is the preferred test, but culture can also be performed. Direct fluorescent antibody testing or Tzank smears are less desirable due to a lower sensitivity and specificity. To obtain the specimen, the test swab should be applied to the base of the vesicle after a sterile swab has been used to unroof the crust.

The disease is self-limiting within 7-18 days, however, treatment with antivirals is usually provided to shorten the duration and discomfort of the lesions. Oral antivirals such as acyclovir, valacyclovir or famciclovir are more effective than topical antivirals. A 7-10-day course of treatment is generally sufficient but longer durations may be necessary if all the lesions have not reached the dry crust phase. Patients who have frequent, recurrent breakouts may benefit from a daily prophylactic antiviral. Topical viscous lidocaine or benzocaine may also be used for analgesia. Sun exposure and facial surgeries or procedures may be responsible for triggering recurrent breakouts. In general, recurrent ulcers tend to be less painful and resolve within 5-7 days.

Complications of HSV-1 can include impetigo from a secondary bacterial infection, herpetic whitlow via a local inoculation to a finger, herpes gladiatorum if mechanically spread to the face, neck, or arms of athletes (typically wrestlers), erythema multiforme, corneal keratitis, conjunctivitis, or Bell’s palsy. Less common complications can include encephalitis, aseptic meningitis, hepatitis, pneumonitis, and esophagitis.
References:
UpToDate
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8565875/

The correct answer is B. Harsh, rough, raspy, or hoarse are terms usually used to describe what is typically associated with benign laryngitis. Breathy is used to describe an audible excess passage of air without other sound and is usually associated with vocal fold paralysis. “Hot potato” and muffled are used when the patient has poor enunciation and clarity due to soft tissue swelling from disorders like retropharyngeal abscess, epiglottitis, Ludwig’s angina, and peritonsillar abscess.

Acute laryngitis is usually the result of a virus which incites inflammation and congestion in the larynx. White blood cells are recruited to fight the infection which results in edema and interferes with vocal cord vibration. As the edema progresses, the voice becomes quieter and harsher. The second most common cause of laryngitis is mechanical strain due to excess screaming or coughing. These cause microtrauma and hemorrhage which ultimately results in edema. Acid reflux from the esophagus and inhaled irritants should also be considered.

The diagnosis is usually made clinically. Important aspects of the history that make uncomplicated laryngitis most likely include a recent history of an upper respiratory tract infection, having a close contact with someone sick, frequent harsh coughing, or recent screaming or shouting. Symptoms usually resolve within 10-14 days depending on how much the patient is able to rest the voice. Humidification of the environment and maintaining adequate hydration are also helpful. Systemic steroids can speed up the process but should be reserved for patients who are unable to adequately rest the voice until symptoms have resolved due to their profession. A cough suppressant can be prescribed if it is felt to be the primary contributor to the symptoms. If environmental inhaled irritants are the cause, the patient should be kept away from the environment both short and long-term. GERD should be treated in the appropriate setting.

Patients who have red flags, atypical history and risk factors, or unresolving symptoms should have a work-up which usually starts with direct laryngoscopy. Differentials include vocal cord polyps or paralysis, spasmodic dysphonia, cancer, and autoimmune disorders. Neurologic disorders such as Parkinson disease and myasthenia gravis should also be considered. The prognosis for most cases of acute laryngitis is very good and most have no long-term adverse effects.

References:
https://www.aafp.org/pubs/afp/issues/1998/0601/p2775.html
https://www.ncbi.nlm.nih.gov/books/NBK534871/
UpToDate

The correct answer is E. Warton’s duct drains the submandibular salivary gland and exits on the floor of the mouth below the base of the tongue. Stenson’s ducts drain the parotid glands and into the oral cavity just lateral to the upper 2nd molars. Bartholin’s ducts are found at the 4 o’clock and 8 o’clock positions within the female vulva vestibule. Skene’s ducts are exit on either side of the urethra in a female. The thyroglossal duct is an embryonic structure that occurs in the midline of the neck as the thyroid descends from the base of the tongue to its final position in the lower neck. It typically atrophies and closes off before birth.

Sialadenitis refers to inflammation of one of the three salivary glands (parotid, submandibular, and sublingual). Sialolithiasis, a stone within one of the salivary ducts, is the most common cause of acute sialadenitis. Sialosis is a term used to refer to bilateral, noninflammatory, non-neoplastic swelling of the parotid glands secondary to a systemic metabolic disorder. This is less common than sialadenitis or sialolithiasis.

Sialoliths are composed of organic and inorganic materials. The pathophysiology of stone formation is poorly understood but is likely due to either decreased saliva output, saliva stasis from duct stenosis, food impaction within the duct or inflammation, or an increased likelihood of formation due to excess calcium or changes in enzyme function. If a stone causes on obstruction of the duct, the associated gland will rapidly enlarge and become painful which worsens after eating. Stones within a Warton duct can often be visualized at the ampulla or palpated along the course of the duct. Stones in the sublingual or parotid (Stensen) ducts are more challenging to palpate.

Diagnosis is usually made on history and exam. If imaging is desired, plain films can sometimes be useful but 20% of stones may not be radiopaque. Sialography is more accurate but risks a potential contrast reaction. CT scan, MRI and ultrasound are also options. Sialendoscopy offers the advantage of both visibly confirming the stone as well as retrieval. Most cases of sialadenitis due to stones are managed with supportive care, making imaging much less necessary. The patient can be instructed to massage the effected gland which may increase the pressure through the duct and express the stone. Nonsteroidal anti-inflammatories can also be used. If there is visible pus coming from the duct, fever or lymphadenopathy, antibiotics should be started. For stones that do not resolve with supportive care, sialendoscopy, lithotripsy, or surgery may be needed. If antibiotics are indicated, oral options include monotherapy with amoxicillin-clavulanate or cefuroxime plus metronidazole. Ampicillin-sulbactam is a good first-line for IV therapy.

References:
https://www.ncbi.nlm.nih.gov/books/NBK549845/
UpToDate

The correct answer is D. Based on the age, gender, and symptoms, Sjogren syndrome is the most likely cause of the patient’s symptoms. The parotid enlargement is usually bilateral. A buffalo hump, deposition of fatty tissue in the upper back, is associated with Cushing syndrome. Hirsutism, excess facial hair in a woman, is associated with polycystic ovarian syndrome. Nasal polyps are frequently associated with asthma or allergies. Thyroid enlargement is typically associated with having a goiter. None of these typically result in both dry eyes and dry mouth. Sarcoidosis is a disorder that should be considered in a patient with these symptoms.

Parotitis is a general term used to describe any swelling of the parotid gland(s). Traditionally it has been closely associated with a mumps infection, however, this is much less common since the vast majority of western society has been vaccinate against it. More likely causes include a stone obstructing the duct (Stensen’s), viral (including HIV) or bacterial infections, or systemic inflammatory disorders such as Sjogren syndrome, lupus, sarcoidosis and rheumatoid arthritis. Stone formation (sialolithiasis) can be the result of dehydration, food impaction, or the side effect of medications that decrease saliva production. Swelling can be unilateral or bilateral. Depending on the etiology, the swelling and pain can be acute or more gradual. When secondary to an infectious etiology, fever, malaise, myalgias, or lymphadenopathy maybe be present as well.

The diagnosis is usually made based on the history and exam. Occasionally a stone might be palpated near the opening of Stensen’s duct, but this is not always the case. Evaluate the opening for any pus which would signify a bacterial infection. Imaging is rarely necessary, but options include plain films, sialography, CT scan, MRI and ultrasound are also options as well as direct visualization using sialendoscopy which can also be used in stone removal or dilating the duct. Most cases of parotitis are treated with supportive care and when appropriate, managing the underlying systemic disorder that is causing it. Supportive care includes applying moist heat, performing gentle massages of the parotid gland from posterior to superior, analgesics, increasing oral hydration, and use of sialagogues (substances that encourage the production of saliva) like sour foods or lemon candy. When infection is likely, antibiotics should be started immediately. Options include nafcillin, oxacillin, cefazolin, vancomycin, or clindamycin. Complications are unusual but infections or stones can cause scaring and narrowing of the duct which can result in more frequent bouts of parotitis which may take longer to resolve. Fistula formation, facial paralysis and neoplasm are possible but more rare.

References:
https://www.ncbi.nlm.nih.gov/books/NBK560735/
https://www.ncbi.nlm.nih.gov/books/NBK431049/
UpToDate

The correct answer is B. Maxillary fractures are described using the Le Fort classification and divided into types 1-3. The Gustilo-Anderson classification is used when there is an open (compound) fracture. Müller AO is used when describing the functional outcome prognosis of long bone fractures. Salter-Harris is used in describing pediatric fractures involving the growth plate. Young-Burgess is for pelvic fracture description.

Le Fort type I (Guerin fracture) is a horizontal fracture resulting in a separation between the teeth and upper face. This is represented by the red line on the image below. A Le Fort type II extends from the teeth up to the nasofrontal suture, usually forming a triangle shape (blue line). Le Fort type III fractures extend higher up and include the zygomatic arch (green line). These are the most likely to be associated with a cerebrospinal fluid (CSF) leak which is apparent by clear drainage from the nares after trauma.

The physical exam findings may help to distinguish one type of fracture from another. Type I will usually present with swelling of the upper lip, malocclusion of the teeth, and a noticeable mobility of maxilla when pulling, pushing, or applying distracting forces to the teeth. A type II usually results in periorbital ecchymosis (raccoon eyes), nasal instability, and possible areas of numbness. Type III fractures may be present when there is obvious facial lengthening and flattening, ecchymosis of the mastoid (Battle’s sign) in addition to raccoon eyes, hemotympanum, and possible CSF leak from the nose or ear. A CT scan is the best modality for assessing the extent of injuries.

Treatment involves realignment and surgical fixation performed by a maxillofacial surgeon. Prophylactic antibiotics should be considered if there is any evidence of CSF involvement. Attention should also be given to other injuries such as lacerations and dental fractures. In addition to maxillofacial surgery, other consultants to consider include dentistry for any dental trauma, oculoplastic surgery or ophthalmology if not available if ocular muscle entrapment is present, and neurosurgery if CSF leakage is present.

References:
https://radiopaedia.org/articles/le-fort-fracture-classification?lang=us
https://www.ncbi.nlm.nih.gov/books/NBK526060/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556744/

The correct answer is D. The condyle area has traditionally been taught as the most common site for mandible fractures. While this is true, many studies show that the body of the mandible sustains nearly the same amount. The approximate percentages for all locations can be seen in the attached image below.

The vast majority (70-85%) of mandible fractures occur in males age 18-24, usually the result of an assault. In women, the most common causes are falls and motor vehicle accidents. Due to the unique shape of the mandible, it is not unusual to sustain bilateral fractures after an injury. Approximately 40% of these patients will have a bilateral component. The history should include asking about any noticeable changes to the patient’s normal occlusion. Physical exam includes a detailed examination of the teeth and soft tissues, including the floor of the mouth, looking for any fractured or misaligned teeth, lacerations, and swelling in the floor of the mouth. Gentle palpation can be performed to assess for stability. The provider should also assess and document sensation of the lip and chin since the inferior alveolar nerve can also be injured.

Imaging is necessary for determining the location and extent of the fracture(s). This can be accomplished with plain films, panorex, or CT scan. A panorex (see normal x-ray below) is preferred to plain films for initial screening if it is available and a technician is comfortable obtaining the images. A CT scan can provide more details if x-rays are unclear or for operative planning. Antibiotics should be started for any open fractures. If the fracture is stable, many can be treated with supportive care. Surgical options include open reduction and fixation with plates and screws or maxillomandibular fixation, wiring the upper and lower teeth together to prevent opening the mouth. The ultimate goal is to restore the occlusion of the teeth back to the patient’s baseline, pre-trauma state. Most patient will be placed on a non-chew diet for a period of time. Patients should be educated of the significant risk for nutritional issues and may require calorie supplementation. Patients with maxillomandibular fixation also need to pay attention to maintaining good oral hygiene. An oral rinse solution like Peridex is usually prescribed for this purpose. Dental injuries should be addressed by a dentist in coordination with oral surgery. Complications can occur in up to one quarter of the cases with a nonunion fracture being the most common. Other complications can include infection, osteomyelitis, wound dehiscence, and failure of the surgical hardware if used.

References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3324216/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5423793/
https://www.entnet.org/wp-content/uploads/files/Trauma-Chapter-5.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC35032

The correct answer is B. These x-rays demonstrate bilateral dislocation of the temporomandibular joints. The x-ray below shows the dislocations in the 2 center images (red arrows) and the normal alignments (yellow arrows) on the lateral images. There is no visible breach in the cortex of the bone representing a fracture. Also, unless significantly displaced, a fracture does not usually result in an inability to close the mouth, rather, the complaint is usually a feeling of malocclusion. A spasm would usually cause the jaw to remain tightly closed rather than open and there is a clear abnormality on the x-ray, which would not be present if it was strictly a muscle spasm. A diagnosis of TMJ syndrome is based on history and palpating clicking with jaw opening and closing. X-rays are usually unremarkable. The cortex of the bone is smooth, round and appears unremarkable, making the diagnosis of osteoarthritis unlikely.

TMJ, or mandible, dislocations can occur due to trauma, exceeding the normal range of motion, or joint laxity due to genetic ligamentous disorders, torn ligaments, or prior dislocations. Examples of excess range of motion include yawning, laughing, vomiting as well as iatrogenic causes such as during dental procedures, intubations, or endoscopy procedures. Bilateral dislocations are more common than unilateral due to the anatomy and small joint surface area. Once the TMJ is dislocated, spasm of the masseter and pterygoid quickly ensues and prevents the condyle from being able to reduce itself back into the fossa of the mandible.

The inability to completely close the mouth after one of the incidents mentioned above is the hallmark of a TMJ dislocation. The patient will also have difficulty enunciating and may also be drooling. There may be a palpable hollow area or deformity at the area of the TMJ. If only one TMJ has dislocated, the jaw may appear tilted to one side. A panoramic (panorex) x-ray, which extends from one TMJ to the other on a single film, is the ideal diagnostic modality. This will help confirm the diagnosis or dislocation and rule-up any associated fractures. A CT scan would be the next best choice if inconclusive or panorex is unavailable. Once diagnosed, the dislocation should be reduced as soon as possible to minimize further spasm and making reduction more difficult. Most patients will require sedation but attempts can be made prior to giving conscious sedation if the patient is cooperative. Several methods of reduction have been described and being familiar with more than one can help the provider’s success rate. A simple technique that tried first is the syringe method. A 5 or 10mL empty syringe is placed in-between the upper and lower molars. The patient is then told to use only their jaw and roll the syringe backward by thrusting the chin forward, then rolling it forward by retracting the jaw. Repeatedly doing this motion should allow the condyle to move inferiorly and spontaneously reduce. The size of the syringe is chosen based on what is able to be placed most posteriorly. If unsuccessful, the provider will need to attempt a manual reduction using either an intraoral or external technique. The traditional method requires the provider to apply gloves and wrap thumbs with gauze, then place the thumbs inside the mouth on the lower molars. Downward pressure is then applied bilaterally followed by pushing posteriorly and then closing the mouth. Overcoming the spasm with firm, consistent pressure or conscious sedation in usually necessary. There are variations on this technique including having the patient lying supine while approaching them from above or using the index and middle fingers on either side of the lower teeth to pull down and then posterior. Alternatively, an external approach can be attempted. The provider can place their fingers behind the angle of the mandible on one side and over the mastoid on the other (dislocated side if unilateral) with the thumbs resting on the cheeks. The side with the fingers behind the angle is pulled anteriorly while the side with the fingers over the mastoid are used to pull the mandible posteriorly.

After reduction, repeat x-rays may be needed if the patient reports significant pain or is unable to completely close the mouth and feel as though their occlusion is back to normal. Post-reduction instructions include avoiding excess opening of the mouth for 3 weeks, soft diet for a week and analgesics as necessary. If the patient feels that they are going to yawn, they should be advised to support the jaw from below. Once a dislocation has occurred, the patient is more susceptible to another event. Patients with disorders such as Ehlers-Danlos or Marfan syndrome are at high risk for recurrence.

I apologize for the continued edit requests and I hope this will be the last of the suggestions. The topic is great but the paper can be improved with further edits.

Lines 21-24: why does the median age, gender, or ethncitiy matter in the results?  I would delete.

Lines 24-30… this is tough to follow…   Maybe summarizing would work… such as… The majority of PAs with ultrasound access performed 10 or less shoulder, hip, and knee injections utilizing US each month.

Delete the rest of 24-30.

Lines 173-174- delete  “Fewer hip joint injections are performed in the office as compared to shoulder and knee joint injections.”  That was said in sentence before in other words

References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668726/
UpToDate
https://www.ncbi.nlm.nih.gov/books/NBK549809/

The correct answer is D. Dental fractures are described using the Ellis classification, which includes 3 levels of the extent of the injury. Avulsion, intrusion, and subluxation are also terms that are used to describe dental injures other than fractures.

The structure of a tooth is divided into two main components: the root and the crown. The crown is the visible portion, and the root is the portion which is embedded in the bony alveolar process below the gingiva (gums). A single tooth will have between 1-3 roots, depending on the type of tooth. The root has a special hard tissue called cementum, which attaches to the periodontal ligament, which, in turn, attaches to the bone. The centermost portion of the tooth contains the pulp which is made up of odontoblasts and fibroblasts giving it self-reparative potential. Nerves and vessels enter into the pulp through the apical foramen at the proximal-most portion of the root within the alveolar process. The pulp is covered in three layers of a porous, avascular bone-like substance called dentin. The dentin is covered by the hardest tissue in the human body, enamel, at the crown. It extends down the sides of the tooth, eventually merging with the cementum. Enamel is composed mostly of calcium phosphate mineral, allowing it to withstand the ongoing daily use of mastication at the occlusive surface of the crown.

Ellis Class I fractures are used to describe an injury where only the enamel of the tooth has been disrupted. These injuries are minimally painful with the exception or any other injuries that may have been sustained. Ellis Class II describes an injury the breaches the enamel and exposes the yellowish colored dentin beneath. There is generally more pain associated with these injuries. Ellis Class III fractures are characterized by seeing a small red or pink dot or line within the center of the tooth as demonstrated in the attached image. The yellow dentin will also be visible. These are the most painful and urgent of the three classes.

Class I injuries can be managed as an outpatient. Minor disruptions do not require treatment. Larger cracks usually need an application of a bonding resin to minimize the chances of infection and discoloration. In cases where part of the crown is broken but not exposing the dentin, options include reattaching the fragment, recreation of the crown fragment with a resin composite, or simply smoothing over the sharp edges. Dental x-rays should be obtained in 2 and 12 months to assess for any evidence of pulp necrosis, periodontitis, or for the absence of root development in children.

Class II fractures are also suitable for urgent outpatient care and follow-up. If the patient presents with the tooth fragment, it can be stored in tap water until dental follow-up is obtained and the injury can be evaluated for possible reattachment. The dentin on the side of the tooth still attached to the patient should be protected using a bonding agent and composite resin or glass ionomer. If the dentin appears slightly pink in the center but no brighter red discoloration is noted, calcium hydroxide can be applied initially after drying the surface of the tooth, followed by the application of a glass-ionomer. Depending on the extent of the injury, a dentist may choose composite or ceramic restoration. Class III fractures require more emergent evaluation by a dentist or endodontist within 48 hours.

References:
https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/02/19_TraumaGuidelines.pdf
https://www.ncbi.nlm.nih.gov/books/NBK551650/
UpToDate
https://www.ncbi.nlm.nih.gov/books/NBK557543/

The correct answer is E. The diagnosis of avulsion is used when a tooth has been removed from its socket due to a traumatic tearing of the periodontal ligament. The Ellis classification is used to describe dental fractures. Subluxation refers to a loose tooth.

The structure of a tooth is divided into two main components: the root and the crown. The crown is the visible portion, and the root is the portion which is embedded in the bony alveolar process below the gingiva (gums). A single tooth will have between 1-3 roots, depending on the type of tooth. The root has a special hard tissue called cementum, which attaches to the periodontal ligament, which, in turn, attaches to the bone. The centermost portion of the tooth contains the pulp which is made up of odontoblasts and fibroblasts giving it self-reparative potential. Nerves and vessels enter into the pulp through the apical foramen at the proximal-most portion of the root within the alveolar process. The pulp is covered in three layers of a porous, avascular bone-like substance called dentin. The dentin is covered by the hardest tissue in the human body, enamel, at the crown. It extends down the sides of the tooth, eventually merging with the cementum. Enamel is composed mostly of calcium phosphate mineral, allowing it to withstand the ongoing daily use of mastication at the occlusive surface of the crown.

A dental intrusion is defined as “a dislocation of the tooth in an apical direction into the socket”. Percussion of the tooth has been described as producing a “metallic” sound. The primary maxillary central incisors are the most commonly involved teeth. These injuries can involve the gingival seal, ligaments, alveolar bone, and/or the nerves and arterioles that supply the tooth. Because the tooth is impacted into the alveolar bone, intrusions are generally stable and not at risk for the tooth spontaneously falling out and being aspirated or ingested. These injuries significantly disrupt the healing process and can result in complications including damage to the underlying permanent tooth bud, giving it one of the poorest prognoses of all dental injuries. Many intrusion injuries will ultimately end in loss of the tooth due to damage and resorption of the root.

Intrusion injuries should have urgent follow-up with a dentist. These injuries will need repositioning followed by flexible dental splinting for up to three weeks, possibly longer. Relatively new permanent teeth may re-erupt on their own under close observation. A root canal is also frequently needed in the management of intrusions of mature permanent teeth. A root canal is performed to remove and damaged or inflamed pulp in the hopes of keeping the tooth from dying. An endodontist will create a small opening in the crown of the tooth, drill into the central cavity containing the pulp, remove the damaged pulp and then fill the area and seal the opening in the crown.

References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3723284/
UpToDate
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4352940/
https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/02/19_TraumaGuidelines.pdf
https://www.smilesforlifeoralhealth.org/topic/intrusion-of-permanent-teeth/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7939001/
7. https://www.ncbi.nlm.nih.gov/books/NBK557543/

The correct answer is F. A subluxation refers to a tooth that appears to be in its original position but is loose when palpated. A dental intrusion is used to describe a tooth which has been displaced in an apical direction into the socket. The diagnosis of avulsion is used when a tooth has been removed from its socket due to a traumatic tearing of the periodontal ligament. The Ellis classification is used to describe various types of dental fractures.

The structure of a tooth is divided into two main components: the root and the crown. The crown is the visible portion, and the root is the portion which is embedded in the bony alveolar process below the gingiva (gums). A single tooth will have between 1-3 roots, depending on the type of tooth. The root has a special hard tissue called cementum, which attaches to the periodontal ligament, which, in turn, attaches to the bone. The centermost portion of the tooth contains the pulp which is made up of odontoblasts and fibroblasts giving it self-reparative potential. Nerves and vessels enter into the pulp through the apical foramen at the proximal-most portion of the root within the alveolar process. The pulp is covered in three layers of a porous, avascular bone-like substance called dentin. The dentin is covered by the hardest tissue in the human body, enamel, at the crown. It extends down the sides of the tooth, eventually merging with the cementum. Enamel is composed mostly of calcium phosphate mineral, allowing it to withstand the ongoing daily use of mastication at the occlusive surface of the crown.

A subluxation occurs when trauma injures the periodontal ligaments, which connect the root of the tooth to the underlying alveolar bone, and possibly the bone itself. These injuries allow the tooth to be unstable and mobile when palpated but on initial inspection, the alignment should be unremarkable. The tooth may produce a metallic sound when percussed or there may be a small amount of blood at the come line.

Treatment can be conservative if there is minimal mobility but usually a dental split is applied for approximately 2 weeks. The tooth is then monitored with dental x-rays monthly for the first 2 months, then again at 6 months 1 year and annually for up to 5 years to evaluate for evidence of pulp necrosis. Pulp necrosis occurs more commonly in subluxed permanent teeth than primary teeth and may manifest as a gum abscess or discoloration of the tooth. The patient should be educated that if they experience any of these symptoms, they should call their dentist immediately for an appointment. During the first few weeks after the injury, the patient should be reminded on the importance of good oral hygiene and adhering to a soft diet to avoid reinjury while healing.

References:
https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/06/ecfe_summer2014-final.pdf
UpToDate
https://www.ncbi.nlm.nih.gov/books/NBK557543/
https://www.ncbi.nlm.nih.gov/books/NBK557543/

The correct answer is A. The diagnosis of avulsion is used when a tooth has been removed from its socket due to a traumatic tearing of the periodontal ligament. A subluxation refers to a tooth that appears to be in its original position but is loose when palpated. A dental intrusion is used to describe a tooth which has been displaced in an apical direction into the socket. The Ellis classification is used to describe various types of dental fractures.

The structure of a tooth is divided into two main components: the root and the crown. The crown is the visible portion, and the root is the portion which is embedded in the bony alveolar process below the gingiva (gums). A single tooth will have between 1-3 roots, depending on the type of tooth. The root has a special hard tissue called cementum, which attaches to the periodontal ligament, which, in turn, attaches to the bone. The centermost portion of the tooth contains the pulp which is made up of odontoblasts and fibroblasts giving it self-reparative potential. Nerves and vessels enter into the pulp through the apical foramen at the proximal-most portion of the root within the alveolar process. The pulp is covered in three layers of a porous, avascular bone-like substance called dentin. The dentin is covered by the hardest tissue in the human body, enamel, at the crown. It extends down the sides of the tooth, eventually merging with the cementum. Enamel is composed mostly of calcium phosphate mineral, allowing it to withstand the ongoing daily use of mastication at the occlusive surface of the crown.

A complete tearing of the periodontal ligament severs its connection to the alveolar process and allows the tooth to fall out of its socket. The socket is a depression in the bone which accommodates the root of the tooth. Once a tooth has fallen out of the socket, the neurovascular supply to the pulp is severed and time is of the essence if the tooth is to remain viable. Examination should look for any retained portion of the root and the provider should make sure that no other injuries are missed rather than making the mistake of only focusing on the apparent injury. If the patient has brought the avulsed tooth with them, the tooth itself can be examined to make sure it is fully intact as well as evaluating to see if the root apex appears open or closed.

Treatment consists of reimplantation as soon as possible. If this occurs within 30 minutes, the prognosis for a viable tooth is good. If a patient calls for advice on what to do with the avulsed tooth prior to arrival, they should be instructed to place it in a cup of milk. If milk is not available, a small container of saliva is the next best alternative. This will extend the viable period to several hours. Once an avulsed tooth has been dry for one hour, it will likely not survive reimplantation alone and ideally will have a root canal performed prior to reimplantation. If the root apex appears closed, a root canal is usually performed two weeks after reimplantation. Once reimplanted, most teeth need to be stabilized with a physiological splint for at least 2 weeks. Ongoing reevaluation for any signs of tooth demise should be conducted by a dentist or endodontist.

References:
https://www.ncbi.nlm.nih.gov/books/NBK557543/
https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/06/ecfe_summer2014-final.pdf
https://www.ncbi.nlm.nih.gov/books/NBK539876/
UpToDate

The correct answer is E. The image is most consistent with oral leukoplakia. Smoking or chewing tobacco is the most common etiology for developing leukoplakia. Other risk factors include alcohol abuse and human papillomavirus (HPV) infection. Medical providers and dentists should include evaluating for oral leukoplakia during all routine exams.

Oral leukoplakia is painless and presents as a white patch or patches on the oral mucosa. Unlike the white areas of oral candidiasis, the patches of leukoplakia are not able to be scraped off and are not friable. Most diagnoses are made clinically and by eliminating other potential causes. A biopsy of several lesions or areas of a single lesion may be used to confirm the diagnosis. The differential of oral white patches or plaques includes chemical burns, frictional keratosis, lichen planus, discoid lupus, hairy leukoplakia, and lichen planus, among others. Many cases of leukoplakia are ultimately benign; however, it can be a precursor to developing squamous cell carcinoma, which occurs in 1-9% of patients. Factors that place a patient with leukoplakia at higher risk of progressing to malignancy include female gender, long duration of patch, occurrence in non-smoker, larger size, or located on the tongue or floor of the mouth amongst others.

Treatment approaches vary from monitoring to excision but should start with elimination of any risk factors discussed above. If there is minimal dysplasia on biopsy, regular monitoring (every 3-18 months depending on level of concern) for progression is an option. Concerning findings include the development of erythema or ulcers, hardening of the tissues, or cervical lymphadenopathy. If these findings occur or for lesions with moderate to severe dysplasia found on biopsy, more aggressive treatment is recommended, especially for lesions on the tongue, oropharynx, floor of the mouth, or soft palate. Options include surgical excision, laser surgery and cryosurgery.

References:
https://www.ncbi.nlm.nih.gov/books/NBK442013/
UpToDate