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Contemporary Oral Medicine June 2017

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Contemporary Oral Medicine June 2017 Contemporary Oral Medicine Leticia Ferreira, DDS, MS Department of Dental Practice Arthur A. Dugoni School of Dentistry University of the Pacific 7385 Patients Disease Frequency (BCD, July 2010) Lichen planus (897) 12.1% Xerostomia (799) 10.8% Chronic candidiasis (741) 10.0% Sjogren’s syndrome (431) 5.8% Aphthae & other ulcerations (501) 6.8% Allergic reactions (262) 3.5% Burning mouth syndrome (295) 3.9% Mucous membrane (199) 2.7% pemphigoid Hyperkeratosis (156) 2.1% Migratory glossitis (130) 1.7% Oral malignancies (50) 0.7% TOTAL (4461) 60.4% Miscellaneous Disorders (BCD, July 2010) Pemphigus 49 Graft vs. host disease 30 Lupus erythematosus 16 Erythema multiforme 13 Proliferative verrucous leukoplakia 10 Scleroderma 9 Chronic ulcerative stomatitis 8 Sarcoidosis 8 Langerhans cell histiocytosis 4 Epidermolysis bullosa 4 Pyostomatitis vegetans 3 Lichen Planus • Immunologically (T-cell) mediated disorder • Middle-aged females • Affects both skin and oral mucosa • Skin: purple, pruritic, polygonal papules • Oral – Reticular • Wickham’s striae – Erosive (ulcerative) – Atrophic – Bullous – Plaque-like – Papular (Eisen, 2002) (Lodi et al 2005) (Lozada-Nur 1997) Lichen Planus Oral Lichen Planus (BCD, July 2010) Based on 897 patients • 76.5% Female average age 57.2 • 23.5% Male average age 51.8 • Combined average age 56.0 Lichen Planus Oral Lichen Planus (BCD, July 2010) Based on 897 patients • Skin 14% • Genitalia 2.3% Lichen Planus Lichen Planus Clinical Sites (BCD, July 2010) • Buccal Mucosa 62.8% • Gingiva 55.8% • Tongue 33.2% • Lips 8.4% • Palate 7.0% • Gingiva only 20.6% • Buccal Mucosa only 12.4% Desquamative Gingivitis • Lichen planus • Pemphigus • Pemphigoid • Allergy – Toothpaste – Cinnamon – Preservatives Lichen Planus • Diagnosis – Clinical Appearance • Presence of white striae bilaterally on posterior buccal mucosa – Histopathologic examination • Erosive cases • Isolated lichenoid lesions (in order to rule out premalignancy or malignancy – Immunofluorescence • In order to rule out Pemphigus and Pemphigoid, lupus erythematosus and chronic ulcerative stomatitis Lichen Planus • Treatment –Only for symptomatic patients • Topical corticosteroids • Systemic corticosteroids • Retinoids • Cyclosporine • Tacrolimus and Pimecrolimus –Patients should be evaluated at least once a year (Lodi et al 2005) (Al-Hashimi et al 2007) Lichen Planus • High Potency Topical Corticosteroid Rx: Fluocinonide gel 0.05% (Lidex) Disp: 15gm tube Sig: Apply to affected area 4x/day. Do not eat or drink for 45 minutes after application • Highest Potency Topical Corticosteroid Rx Clobetasol 0.05% gel (Temovate) Disp: 15 gram tube Sig: Dry the area and apply a small amount 3-4x/day. Do not eat or drink for 45 minutes after application. • Widespread gingival involvement: – “suck-down” tray filled with gel and used 2x/day for 15-20 min Lichen Planus • Systemic Corticosteroid Rx Prednisone 10 mg tablet Disp: 40 tabs Sig: Two tabs bid x 7 days, then 1 tab bid X 4 days, the 1 tab daily until gone Lichen Planus • Side-effects of topical corticosteroid therapy: –Candidiasis Lichen Planus • Combined Topical Therapy – Topical corticosteroid + Clotrimazole 10 mg Troche 1-3xs daily or Nystatin Oral Suspension 1 tsp 2xs daily Lichen Planus • Pre-malignant potential?? – Controversial issue – Clinical studies and case reports suggest that OLP patients are at a greater risk of developing OSCC • Great variation in source of data, inclusion criteria, length of follow-up and design – Lichenoid dysplasia vs. lichen planus – Large independent controlled retrospective studies have shown a significant risk • 1% over a 5 year period – A minimum of one follow-up visit per year is recommended (Markopoilos et al 1997) ( Lo Muzio et al 1998 ) (Fang et al 2009) (Gandolfo et al 2004) (van der Meij et al 1999)(Al-Hashimi et al 2007) Be suspicious of a lesion that looks like lichen planus but is localized to the lateral border of the tongue Early dysplastic changes, when the epithelium starts to become atypical or dysplastic but is not invasive yet, can evoke a lichenoid reponse of the body’s immune system ag Lichenoid Reactions • Most common lichenoid reactions: – Non-steroidal anti-inflammatory drugs (NSAIDs) – Antihypertensives – Cinnamic aldehyde flavoring – Mercury (Miller et al 1992) (Allen & Blozis 1988) (Issa et al 2005) (Moller 2002) Lichenoid Reactions (BCD) 63 patients (04/05) • NSAIDs 19 • Cardiovascular drugs 10 • Mercury (amalgams) 10 • Cinnamic aldehyde 9 • Antidiabetics 9 • Anti-lipemic 4 • Gold salts 2 Drugs causing lichenoid drug reaction Allopurinol Gold Practolol Amiphenazole Hydroxychloroquine Propanolol Atorvastatin (Lipitor) Ketoconazole Pyrimethamine Captopril Labetanol Quinidine Carbamazetine Mercury Quinacrine Chloroquine Methyldopa Spironolactone Chlorpropamide Metopromazine Streptomycin Cyanamide NSAID Tetracycline Dapsone Oxyprenolol Thiazides Enalapril Palladium Tolbutamide Erythromycin Para-amino salicylate Triprolidine Fenclofenac Penicillamine Zoloft Furosemide Phenothiazines Candidiasis • Candida albicans • Dimorphism: yeast and hyphal forms • Most common oral fungal infection Candidiasis • Predisposing factors: ’ – Antibiotic therapy – Newborns immature immune system – Cancer chemotherapy – Advanced malignancy – Corticosteroid therapy – Xerostomia – Dentures – Immunocompromised – Diabetes mellitus states – Pregnancy • HIV/AIDS • Transplant patients – Iron deficiency Candidiasis • Pseudomembranous candidiasis – “Thrush” – White material that can be wiped off – Erythematous mucosa underneath – Burning sensation – Metallic taste Candidiasis • Erythematous “acute atrophic” candidiasis – Often associated with antibiotics • “Antibiotic sore mouth” – Painful – Loss of filiform papillae on tongue Candidiasis • Chronic atrophic candidiasis – “Denture stomatitis” – Erythematous mucosa – Palate and maxillary alveolar ridge – Usually asymptomatic Candidiasis • Angular cheilitis – Labial commissures – Erythema, fissuring and scaling – Reduced vertical dimension Candidiasis • Mucosal smear and tissue culture • Oral antifungal therapy – Nystatin oral suspension, pastilles or ointment • Systemic antifungal therapy – Fluconazole (Diflucan) – Ketoconazole Recurrent Aphthous Stomatitis (recurrent aphthous ulcerations) “canker sores” • Very common: 20% – Affects children and young adults more frequently • Unknown etiology – The cause appears to be “different things in different people” • Immune mediated, self-limiting ulceration – CD8 T-cells produce cytokines which lyse epithelial cells Recurrent Aphthous Stomatitis (recurrent aphthous ulcerations) “canker sores” • Trauma (dental • Immunologic factors procedure) • AIDS • Emotional stress • Endocrine imbalance • Nutritional deficiencies • • Socio-economic level Infectious agents • Genetic predisposition • Allergies • Chemicals in food • Smoking cessation Recurrent Aphthous Stomatitis (recurrent aphthous ulcerations) “canker sores” • Minor • Major • Herpetiform Recurrent Aphthous Stomatitis (recurrent aphthous ulcerations) “canker sores” • Minor aphthae (80%) – Childhood to adolescents – ↑ Females – Less than 1 cm – On moveable mucosa (not covering bone) – Painful ulcer with erythematous border – Heal spontaneously in 7 to 14 days w/o scarring Recurrent Aphthous Stomatitis (recurrent aphthous ulcerations) “canker sores” • Major aphthae (10%) – Larger than 1.5 cm – Deeper than minor aphthae – ↑↑ soft palate, tonsillar fauces, and labial mucosa – Can take several weeks to months heal – May cause scarring Recurrent Aphthous Stomatitis (recurrent aphthous ulcerations) “canker sores” • Herpetiform aphthae (10%) – Adulthood – 1 to 3 mm ulcers occurring in clusters – Any oral mucosal site may be involved – vs. herpes simplex – Heal in 7-10 days Recurrent Aphthous Stomatitis (recurrent aphthous ulcerations) “canker sores” • Diagnosis: – Diagnosis by history and clinical features – Biopsy shows nonspecific ulceration – Patients with severe disease: • Rule out systemic causes • Patch tests for antigen stimuli • Elimination of potential antigens: – Sodium lauryl sulfate in toothpaste – NSAIDs, various beta blockers, nicorandil – Streptococci, Helicobacter pylori, HSV, VZV, and CMV – Many foods: cheese, coffee, cow’s milk, gluten, nuts, strawberries, tomatoes, flavoring agents, preservatives Recurrent Aphthous Stomatitis (recurrent aphthous ulcerations) “canker sores” • Treatment: – High-potency topical steroids – Chlorhexidine – Amlexanox 5% (Aphthasol) Recurrent Aphthous Stomatitis (recurrent aphthous ulcerations) “canker sores” Rx Fluocinonide gel or cream 0.05% (Lidex) Disp: 15 or 30 gram tube Sig: Dry the area and apply a small amount 3-4x/day. Do not eat or drink for one hour after application Rx Amlexanox oral paste 5% (Aphthasol) Disp: 5 gm Sig: Apply to affected area qid Benign Mucous Membrane Pemphigoid • “Cicatricial Pemphigoid” • Chronic, autoimmune disease • 3x as common as pemphigus vulgaris • Average age 50-60, 2x more common in females • Oral, ocular, and genital mucosa ± others • Gingiva (desquamative gingivitis) (Scully et al 1999 )(Bagan et al 2005) Benign Mucous Membrane Pemphigoid • Autoantibodies to hemidesmosomes • Is a family of diseases, different antigens • BP 180, BP 230, laminin-5, etc • Separation of the epithelium from the CT • + Nikolsky’s sign Benign Mucous Membrane Pemphigoid (BCD, July 2010) Based on 199 patients –72.4% Female average age 59.6 –27.6% Male average age 63.8 –Combined average age 60.8 Benign Mucous Membrane Pemphigoid (BCD, July 2010) Clinical sites • Gingiva 96% • Gingiva only 67.2%
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