A.O.C.D. April 25, 2015 Everything you want to know about stuff inside the mouth !!! GOAL That you will all be Even Greater Giants in the field of oral Dermatology !!! Oral Dermatology From Jonathan S. Crane, D.O., F.A.O.C.D. Board-Certified Dermatologist Derm One Dermatology, Wilmington, North Carolina Sampson County Dermatology Residency Program Director Campbell University School of Osteopathic Medicine Dermatology Course Director Pharmaceutical Company Disclosures Dr. Crane has done research, consulted for, and/or is on the speaker’s bureau for the following: 3M Allergan Candella Laser Company Fujisawa Genentech, Inc. Glaxo Smith Klein Novartis Amongst other companies… Credits www.uiowa.edu Oral pathology by John L. Giunta, BS, DMD, MS, Professor of Oral Pathology Otolaryngology - Houston Caused by? Abrasion The stem of the pipe wearing away the lower teeth. - Asymptomatic dark blue-gray macule noted by patient for past 6 months - Not changing since noticed Amalgam tattoo Iatrogenic lesion caused by traumatic implantation of dental amalgam into soft tissue Most common localized pigmented lesion in the mouth 0.4-0.9% of the US adult population Dark gray or blue, flat macule Located adjacent to a restored tooth No additional treatment is necessary except for cosmetic reasons Laser treatment can be tried www.uiowa.edu Aphthous ulcer • Ulcer in the center • No diagnostic microscopic findings • Diagnosis is based on the clinical findings and history • Minor and Major forms described Minor Aphthous Ulcers Most common form www.uiowa.edu Small painful round ulcers 3-6 mm 2-6 lesions can be present Heal w/o scarring 7-12 days Treated with topical steroids, oral steroids, Duke’s Magic Mouthwash, topical immunomodulators, doxycycline and nicomide Major Aphthous Ulcers Deep painful ulcers 1-2 cm in diameter Last 3-6 weeks May cause scarring 1-5 lesions present at one time Treatment •Topical steroids •Intralesional steroid injections •Systemic steroids •Viscous lidocaine •Dapsone 25-50 mg / day •Colchicine 0.6 mg tid •Thalidomide 300 mg QD then taper Lab investigation: CBC, CMP, G6PD, Folate, Iron, B12 HIV patient with this ulcerated lesion on the lateral tongue. States he doesn’t recall biting it. • Thalidomide (Thalomid) • Effective treatment of oral and esophageal aphthous lesions in HIV-infected patients Aphthous Stomatitis • Reserved for severe or corticosteroid-refractory cases In HIV Patient Teratogenic effects • Rx to appropriate patient 68 year-old male Wearing away of teeth Ground down almost to the roots Orange center is secondary dentin with the yellow dentin surrounding it Attrition: Erosion by friction • Rapid Onset, slight fever • painful mouth Ulcers • malodor to her breath • metallic taste • feels the teeth are wedged b/c gums are swollen • Symptoms of fever & Lymphadenopathy can mimic a viral infection The gingival interdental papillae become necrotic and appear cut off Acute Necrotizing Necrotic Tissue acts as a medium For Bacterial infection caused by a fusiform bacillus-spirochete complex plus other oral Gingivostomatitis (ANUG) bacteria Triggered by a decrease in the immune response Local debridement of the necrotic material and careful scaling Dental follow-up important! Antibiotics helpful (PCN) 3% Hydrogen peroxide mouthwash May be a sign of AIDS ANUG Lesions may spread rapidly to involve buccal mucosa, lips, tongue, pharynx and entire respiratory tract A Severe Form Of ANUG Pearl: Characteristic foul fetid odor is always present 15 year-old with this swelling noted recently by the orthodontist Pearl: Swellings on the palate should be respected and make one suspicious Adenoid cystic carcinoma • Salivary gland tumors can affect the young • Serious lesion • Grow very slowly and invade locally along nerves Prognosis: relatively good for 10-15 years and very poor at the 20 year follow up when 80+% of patients have died of their disease Adenocarcinoma Treatment: -Excision - Possible Radiation - Possible Chemo Mass on right hard and soft palate Ulcerated surface Fixed to surrounding structures Bulimia is an eating and psychiatric compulsive disorder characterized by episodic binge eating of large volumes of food, followed by purging behavior such as Female new college student presents to your office self-induced vomiting, vigorous exercise You find increased caries and enamel erosion and laxative or diuretic abuse. Attrition may Small, purplish-red lesions on the palate take place once enamel is worn down. Swollen lymph nodes and salivary glands Xerostomia, dry lips and skin around the mouth Broken scleral blood vessels Provide support and seek psychological assistance Bismuth Line Generalized Pigmentation due to bismuth poisoning. Patient’s mother treated for syphilis while bearing him Gingival margin is pigmented bilaterally 83 Foul breath, notices increased salivation Bi Mild renal insufficiency on Chem 7 208.98038(2) Chronic lung infection which has associated skin lesions and occasional chronic mouth ulcers Blastomycosis • Inhaled spores of dimorphic fungus Blastomyces dermatitidis • Prevalent in Southeastern US and Ohio/Mississippi River Basins and Kentucky • Male to female ratio 6:1 • Oral itraconazole 200-400 mg/day for SIX MONTHS • For more severe cases, IV administered amphotericin B Bechets • More common in males than in females (8:1) • second or third decade of life • Oral, genital, and ocular lesions • Recurrent aphthous ulcers 3 bouts per year • Plus any two of the following Recurrent genital ulceration Retinal vasculitis/Uveitis Skin lesions: E.nodosum, Pseudofolliculitis or acne Treatment of Bechet’s Syndrome Mild mouthwash and toothpaste Colchicine 0.6 mg bid to tid by mouth Dapsone Thalidomide Methotrexate Corticosteroids Cyclosporine Totally normal anatomic finding Copyright © 1998 John L. Giunta, DMD, MS Circumvallate papillae The are the largest of the papillae Located at the most posterior dorsal surface forming a V-shape with the point toward the posterior May be exaggerated, rise above the surface to mimic a tumor or tumors. If there were only one swelling in the midline in this region, one could consider lingual thyroid Treatment options include laser destruction, excision or reassurance Congenital hemangioma Herpes Simplex Virus ”Cold Sores” Caused by HSV1 85% adults worldwide are seropositive; 50% with history of orolabial involvement Most cases transmitted during asymptomatic shedding • Topicals: Penciclovir and Acyclovir are minimally effective • Oral antiviral agents: Valtrex, Famvir, Zovirax • New med sticks inside mouth Sitavig 50 mg Pearl: First outbreak • acylovir single dose should be treated at higher doses and for longer course Angular Chelitis Dr. Kevin T. Kavanagh, MD Crusting and cracking at corners of mouth Caused by a yeast organism (C.albicans) Predisposing factors: dentures, overhanging upper lip, and skin laxity resulting in moist environment, diabetes, AIDS, and mucocutaneous candidiasis Anti-yeast creams and topical steroids commonly used Nystatin for oral/buccal yeast Recurrent cases may require surgery for anatomic causes Restalin and Sculptra helpful Condyloma acuminatum www.uiowa.edu Multiple, rough, warty lesions on dorsum of the tongue Oral lesions should be a biopsy diagnosis. Common STD in adults 50 % infectivity rate in some populations May predispose toward cancer Rare in mouth, common around genitals/anus Liquid nitrogen for oral lesions works well Denture trauma www.uiowa.edu An ulcer is present on the anterior mandibular alveolar ridge Refit dentures…. www.uiowa.edu • CAT Scan or MRI needed Dermoid cyst • Consider excision Congenital in origin from improper embryonic growth Occurs along cleavage lines Large, compressible well-circumscribed soft tissue enlargement Present in the floor of the mouth Can elevate the tongue Dental fluorosis 28 year-old male in the military, excellent health Born in the southwest Mottled enamel • Fluoride excess, particularly above 1 ppm • Etiology is drinking water and excess tablet ingestion • Affects developing teeth • Starts as whitened spots on the teeth that later become stained • Fluoride substitutes for the calcium content and with less calcium, the teeth are yellowed • A differential diagnosis could include amelogenesis imperfecta (genetic enamel disorder) which would have radiographic changes and a hereditary pattern Exostoses • Slowly growing nodular growth of dense cortical bone • Commonly located on maxillary or mandibular buccal alveolar bone, usually in the bicuspid / molar area • Occurs in late teen and early adult years, more common in females than in males • Etiology: Genetic prevalence • TREATMENT: Surgical www.uiowa.edu •A brown macule is present on the vermilion zone of the lower lip •Darkens on sun exposure •NOT a benign Labial melanocytic macule or labial lentigo, which do NOT change on sun exposure Ephelides •Ephelides can change with sun exposure •Treatment: Liquid Nitrogen, reassurance, laser (freckle) and/or biopsy Diagnosis: • Clinical appearance & family history • Skin bx using transmission electron microscopy or immunofluorescent antibody/antigen mapping. • Rarely genetic testing of KRT5 gene or the KRT14 gene is needed • Autosomal dominant, rarely autosomal recessive www.uiowa.edu • Genetic counseling and prenatal testing are essential in families that have this Epidermolysis bullosa simplex disease in their family lineage Blister formation after minor trauma to the Management: skin. 4 types described Skin: blisters form: hands, joints, elbows, • Standard non-adherent knees and repetitive