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Home , Contact stomatitis, Dental trauma, Erythroplakia, Geographic tongue, Glossitis, Herpangina

Earn 2 CE credits This course was written for dentists, dental hygienists, and assistants.

Management of Erythematous Oral A Peer-Reviewed Publication Written by Jeff Burgess, DDS, MSD

Abstract Educational Objectives: Author Profile Conditions causing oral vary in terms of etiology and At the conclusion of this educational activity Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant complexity. Erythematous lesions may be the result of systemic as participants will be able to: Professor, Department of , University of well as local or trauma. Oral conditions reflecting potential 1. Describe interventions used to manage Washington School of Dental Medicine; (Retired) Attend- systemic disease may need to be co-managed with the patient’s erythematous oral lesions. ing in Center, University of Washington Medical Cen- medical provider. Nonetheless, regardless of the potential cause of oral 2. Identify the appropriate erythema, local intervention is an important component of the overall for managing viral lesions causing ter; (Retired) Private Practice in Hawaii and Washington; management of these oral problems. Dental intervention includes the erythema. Director, Oral Care Research Associates. He can be reached provision of palliative home care instructions for the erythema, local or 3. Implement treatment strategies for at [email protected]. systemic pain management, periodontal surgery and the prescription managing a variety of oral and of medication (e.g. topical , antibiotics, , conditions. Author Disclosure drugs, or salivary substitutes). In the case of , 4. Identify interventions that constitute Dr. Burgess has no potential conflicts of interest to disclose. removing the offending agent may be recommended. This course palliative home care. focuses on the management of the oral erythematous conditions dental professionals are most likely to see in everyday practice.

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This educational activity was developed by PennWell’s Dental Group with no commercial support. Publication date: March 2015 Supplement to PennWell Publications This course was written for dentists, dental hygienists and assistants, from novice to skilled. Expiration date: February 2018 Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 2 CE credit for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information PennWell designates this activity for 2 Continuing Educational Credits to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. Dental Board of California: Provider 4527, course registration number 02-4527-14092 Image Authenticity Statement: The images in this educational activity have not been altered. “This course meets the Dental Board of California’s requirements for 2 units of continuing education.” Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and The PennWell Corporation is designated as an Approved PACE Program Provider by the represents the most current information available from evidence based . Academy of General Dentistry. The formal continuing dental education programs of this Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from program provider are accepted by the AGD for Fellowship, Mastership and membership the data and information contained in reference section. The research data is extensive and provides direct benefit to maintenance credit. Approval does not imply acceptance by a state or provincial board of the patient and improvements in oral health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to Registration: The cost of this CE course is $49.00 for 2 CE credit. (10/31/2015) Provider ID# 320452. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives: secondary problems arising from the initial , (e.g., At the conclusion of this educational activity participants secondary , tissue morbidity, dry , dental will be able to: caries, ) and support the patient’s 1. Describe interventions used to manage erythematous general health if more extensive medical intervention is oral lesions. necessary. Home care should be an integral component of 2. Identify the appropriate medication for managing viral therapy and include the following recommendations: hy- lesions causing erythema. giene maintenance, fluid and nutritional support, adequate 3. Implement treatment strategies for managing a variety rest and OTC pain control.11 Medical assessment should of oral infections and conditions. be considered when oral erythematous lesions worsen from 4. Identify interventions that constitute palliative home dental intervention or systemic symptoms develop during care. the course of treatment.

Abstract Local Infection Conditions causing oral erythema vary in terms of etiology and complexity. Erythematous lesions may be the result of Viral Infection systemic as well as local disease or trauma. Oral conditions Viral conditions such as primary herpetic gingivostomatitis reflecting potential systemic disease may need to be co- (HSV-1 or 2), recurrent intraoral , recurrent managed with the patient’s medical provider. Nonetheless, , primary herpes varicella and regardless of the potential cause of oral erythema, local inter- include mucosal erythema coupled with vesicle formation vention is an important component of the overall manage- and ulceration.12 There may be regional lymphadenitis, fe- ment of these oral problems. Dental intervention includes ver and . Viral infections are typically self-limiting, the provision of palliative home care instructions for the but more serious complications can delay recovery (e.g. erythema, local or systemic pain management, periodontal herpes simplex or viral ). In addi- surgery and the prescription of medication (e.g. topical tion, some infections (e.g. HSV and varicella) may reoccur analgesics, antibiotics, corticosteroids, antifungal drugs, or following reactivation of residual , termed latent virus, salivary substitutes). In the case of allergy, removing the of- residing in the sensory of the . In fending agent may be recommended. This course focuses on these secondary cases, emerging ulcers and erythema will the management of the oral erythematous conditions dental occur in a well circumscribed area within the professionals are most likely to see in everyday practice. of the affected nerve.13 Reactivation of varicella zoster, which causes chicken Introduction pox, is the cause of oral . These lesions develop in Erythema of the is associated with a number approximately 20 percent of infectious cases and some- of systemic and local . The times without skin involvement. The older patient with includes local conditions such as viral, fungal, and bacterial oral shingles is at further risk of developing postherpetic infection, burns, trauma, , allergy, vesiculo-erosive or PHN which causes severe persistent pain. or ulcerative diseases and radiation mucositis as well as sys- When oral shingles is identified the patient should be temic conditions such as iron deficiency, polycythemia, avi- referred for medical management. Medical treatment is taminosis B, erythroplasia, purpura, angioma, and Kaposi’s likely to involve antiviral therapy and high dose cortico- sarcoma.1, 2 steroid prophylaxis.14 In the interim, the same topical and This continuing education course focuses on manage- measures described below for the management ment of these conditions. In cases where oral erythema is of primary HSV-1 infection is useful dental intervention.15 associated with systemic disease, a comprehensive approach to therapy including medical consultation and management Palliative home care should be included in the overall treatment strategy. Treat- Management of HSV-1 includes assurance, information ment of any oral lesion associated with erythema, regardless and caution regarding infectivity. Recommendations in- of local or systemic etiology, should only be approached after clude avoiding biting to reduce the potential develop- a diagnosis has been established. ment of a herpetic and/or touching the oral lesions This course provides a limited description of the diseases and then the eye to prevent corneal infection, oral sexual capable of causing oral erythema. The course participant is activity that might infect others and supportive care. encouraged to further explore each of the conditions de- Instructions for supportive home care include gargling scribed, including their etiology, epidemiology signs and with cold water or sucking on popsicles. The patient should symptoms prior to initiating therapeutic options.3-10 be advised to avoid hot beverages and spicy, salty or citrus As a general rule, the rationale for dental management foods as they tend to aggravate pain. The application of a of oral erythema is to provide relief of symptoms, prevent thin paste of baking soda and water helps to shield lesions

2 www.ineedce.com and reduces pain. For the patient with severe oral involve- the risk of resistance20. The current FDA recommendation ment that prevents eating, nutritional supplements can be and best practices is that systemic acyclovir or valacyclovir recommended. Meritene® and Ensure Plus® are protein, should be used only for the treatment of HSV-1 , and mineral food supplements that can be pur- in the immunocompromised patient. chased over the counter. They are flavored with acceptable In terms of secondary lesions, treatment guidelines are taste and it is recommended that three servings be taken suggested by the scientific literature. One recent study sug- each day with their preparation per package labeling gests that frequently occurring secondary (i.e. recurrent) lesions including intra-oral lesions may be suppressed Prescribed successfully with administration of 500 mg of valacyclovir There are a number of topical anesthetics16 available that delivered once a day over four months21. Systematic review can be used alone or compounded with coating agents that of 17 randomized controlled studies further suggests that effectively reduce pain associated with . acyclovir is equally efficacious as valacyclovir in treating When prescribing these formulations the patient should be herpes simplex viral infections.22, 23 cautioned regarding potential aspiration as their gag reflex Recurrent lesions precipitated by sun exposure may may be reduced by the anesthetic. be prevented by high SPF sunscreen application. Topical anesthetic agents (and prescribing information) When oral pain of viral origin is moderate to severe, include the following: systemic pain medication is also indicated. Acetaminophen 1. Diphenhydramine syrup (OTC) or Benadryl® elixir 325mg with codeine is helpful in reducing pain. Medica- 12.5 mg/5mls; Dispense 4 oz bottle; Sig: Rinse with one tion combinations containing aspirin should be avoided in teaspoonful for two minutes before each meal and spit children. out. 2. Diphenhydramine syrup (OTC) 4 oz. with Kaopectate® Fungal Infection (OTC) 4 oz. to make a 50% mixture of each by volume is the predominant organism that (Maalox® – OTC, or sucralfate® suspension can be used causes fungal oral infection. However, in the immuno- instead of the Kaopectate®); Dispense 8 oz.; Sig: Rinse compromised individual other candida species may also with one teaspoonful every two hours and spit out. be involved. Candida albicans is opportunistic and will 3. Dyclonine HCL (Dyclone®).5% or 1% (One oz. of proliferate when normal oral homeostasis is altered via the Dyclone® can be added to the topical mixtures listed use of antibiotics, corticosteroids, cytotoxic drugs and im- above for improved anesthetic efficacy); Dispense one munosuppression or as a consequence of conditions such once bottle; Sig: Rinse with one teaspoonful before each as and . meal and spit out. There are several types of fungal conditions including 4. /Prilocaine (EMLA®) 5% cream. Dispense 30 (thrush), erythematous candidiasis, median gm tube; Sig: Apply cream to lesions before each meal. rhomboid , denture stomatitis and atrophic candi- 5. Benzocaine 20% gel (Ultracare®, Topex®) diasis among other fungal diseases. Dispense 30 ml bottle; Sig: Apply on a cotton swab to Erythematous candidiasis is characterized by general- specific lesions for 60 seconds before each meal. ized tissue redness and pain. When localized to the 6. Lidocaine 2% gel. Dispense 30 ml tube; Sig: Apply the the condition is called median rhomboid glossitis or central gel to the lesions before each meal. papillary . Denture stomatitis or chronic atrophic The syrups, elixirs and suspensions listed above are candidiasis is a more generalized condition.24 generally more effective for multiple lesions where cov- In patients with removable prostheses, dental treatment erage needs to extend over a broad area of mucosa. The should include not only prescription of medication but creams and gels work best as treatment of single or a limited also instruction on the disinfection of appliances. Denture number of lesions confined to a discrete area of mucosa. soaking solutions coupled with application of an antifungal Adverse effects from topical anesthetics are rare when powder or cream to the contacting surface of the appliance these medications are used judiciously. However compli- helps to prevent reinfection. As an example, an appliance cations can occur if there is rapid absorption, hypersensi- can be soaked overnight in a one percent / tivity or an idiosyncrasy to the prescribed medication. Side hypochlorite solution. In the morning this is followed by effects include central excitation or depres- the application of miconazole denture lacquer prior to its sion, cardiovascular manifestations, and allergic reactions insertion. (localized or anaphylaxis).17-19 In the patient with dry mouth and candidiasis, chew- Antiviral medications are not recommended for man- ing gum or candy with xylitol is recommended to stimulate agement of primary herpetic stomatitis because in the daytime salivary flow. Products that improve night (sleep) immune competent individual the condition is self limiting dryness such as Xylimelts® help to stimulate flow and alter and the use of antiviral medication potentially increases the perception of dryness. www.ineedce.com 3 Antifungal medications found to be useful in treating Systemic antifungal agents are usually prescribed when include nystatin (Mycostatin®), the topical agents are not effective or are not practical. They imidazoles such as clotrimazole and ketoconazole, and are well tolerated but should be used with caution in the triazole agents such as fluconazole.25,26 patient with impaired function. Best practices include The following describes dosage considerations for a pre-treatment liver function testing and monthly reassess- number of useful antifungal medications. Topical prepara- ment if ketoconazole or itraconazole is to be prescribed over tions should be taken for 10-14 days. a prolonged period of time.29, 30 Chronic fungal infection is 1. Nystatin oral suspension 500,000 units/tsp (brand typically associated with suppressed immune function and names Mycostatin®, Nilstat®, Nystex®); Dispense 240 debilitating disease so these patients will usually be under mls; Sig: 1 tsp tid; rinse for two minutes and swallow. the care of a medical specialist. If systemic are 2. Ketoconazole cream 2% (brand name Nizoral®); being considered, consultation with the patient’s physician Dispense 15 gm tube; Sig: apply to the affected area is imperative. These systemic drugs include: ketoconazole once daily at bedtime. (Nizoral®), fluconazole (Diflucan®), itraconazole (Sporanox®), 3. Clotrimazole vaginal cream 1% (OTC brand names and amphotericin B (Fungizone®).31, 32 Gyne-Lotrimin®, Mycelex-G®); Dispense one tube; Sig: apply to the denture or partial and the involved oral Bacterial Infection mucosa four times a day. Bacterial infection involving the oral mucosa includes 4. Clotrimazole troches 10 mg (brand name Mycelex®); streptococcal tonsillitis and ; Group A ß- Dispense 70 troches; Sig: dissolve one troche in the hemolytic streptococci (Scarlet ), diphtheria, primary mouth 5 times a day. Do not chew. , , and Cancrum Oris (). Pa- 5. Nystatin Pastilles – 200,000u (brand name Mycostatin® tients with these conditions will likely be under the care of pastilles); Dispense 70 pastilles; Sig: dissolve one a medical infectious disease specialist; but if they are not, pastille in the mouth 5 times a day. Do not chew. the best ‘treatment’ a dentist can deliver is recognition of 6. Miconazole nitrate vaginal cream 2% (OTC – brand the disease and prompt referral to a physician for appropri- name Monistat®); Dispense one tube; Sig: apply to the ate follow-up care. denture and to the involved oral mucosa four times a Periodontal disease is the most common erythematous day. oral disease that is caused by . A complete review Nystatin ointments and powders can be used to treat ap- of periodontal disease is beyond the scope of this course. In pliances per the following instructions: brief, the classic dental management of periodontal disease 1. Nystatin ointment; dispense 15 gm tube; Sig: apply includes removal of local factors (e.g., plaque and calculus), a thin coat to the denture and affected area after each diet and behavior modification and surgical intervention. meal. Antibiotic usage has been studied as an adjunct to nonsurgi- 2. Nystatin topical powder; dispense 15 gm tube; Sig: cal debridement. The research to date suggests that systemic apply to dentures/prostheses after each meal and after amoxicillin and are effective in reducing the cleaning the appliance. of periodontal disease.35 Long-term Antifungal medication has been associated with allergy use of antibiotic is discouraged because of potential adverse and GI problems. Nystatin suspension also contains sugar effects and because of the increased possibility of resistance. so if the patient has teeth, good is important to The National Institute of Dental and Craniofacial Research prevent decay; particularly if treatment is extended over a and the CDC offer some useful periodontal treatment prolonged period of time. A suspension of nystatin can also guidelines on their Web sites.33, 34 be used as a disinfectant for a patient’s acrylic prostheses (see Other localized infections that can be managed in the above). It should be appreciated that ketoconazole absorp- dental office include pyogenic and peripheral tion is reduced when antacid medication is taken concur- giant cell granuloma. These erythematous growths are non- rently. The oral use of vaginal creams (miconazole nitrate neoplastic. Dental treatment is surgical. If surgery is to be vaginal cream or clotrimazole vaginal cream) to treat oral pursued, successful outcome will depend on excising the candidiasis remains controversial. However sugar content gingival tissue down to the periosteum. Both of these tumor (in contrast to clotrimazole troches) is minimal in these for- types often recur and re-excision may be necessary. This is mulations which may be advantageous in cases involving the especially true for if removed during need for long-term application. In addition, antifungal tro- pregnancy. ches may not be well tolerated in the patient with dry mouth. One oral bacterial infection that is best co-managed Pregnant or breast feeding patients should consult with their with the patient’s medical provider is necrotizing stomatitis physician prior to use of any of these antifungal medications. associated with HIV-infection. Lesions associated with this All of the troches described above provide good contact of condition typically respond to topical and systemic gluco- drug with the mucosa over time.27, 28 therapy coupled with systemic antibiotics.

4 www.ineedce.com HIV patients can also develop severe recurring aphthous OTC Benadryl® 25 mg/ tsp; swish and spit) to help reduce ulcers. Pain associated with these lesions is best managed pain and chronic . with topical steroids or the topical anesthetic medications is considered in this section with detailed in the list under viral infections. In some cases re- contact allergy, even though the etiopathogenesis is un- calcitrant deep ulcerative lesions can be effectively medically known. This is because there is limited evidence that the managed and suppressed with systemic thalidomide.36-38 condition might represent a reaction to an unknown environmental factor in some individuals. Contact Allergy Although the condition is typically non-painful and self- This section covers the dental treatment of mucosal ery- limiting, in the patient that has moderate to severe pain, thema caused by (stomatitis venenata), management can be problematic. These patients should be geographic tongue (areata migrans) and orofacial granulo- advised to avoid hot or spicy food and to reduce exposure matosis which also causes tongue or lip swelling. In addition to cigarette smoke and certain , including those to erythema and swelling, contact allergy may be associated with whitening chemicals or which are excessively flavored. with lichenoid change of the mucosa and ulceration. Muco- At present the treatment of symptomatic geographic sal contact usually take a long time to develop and tongue is based on empirical evidence rather than ran- are thought to represent a delayed hypersensitivity reaction. domized controlled trials. Topical anesthetics, antihista- Symptoms of allergy typically include a sensation of mu- mine rinses and corticosteroids such as fluocinonide gel cosal burning, or dysesthesia and pain. There may also be applied four times daily can help to reduce symptoms. A increased salivation. recent case study suggests that tacrolimus ointment may Many foods, chemicals, medications and metals have also be an effective therapy.46 The results of this particular been associated with oral allergy. For a list of some of these case study are potentially significant because in a recent offending allergens the reader is referred to the articles by systematic review of studies assessing the efficacy of ta- Wray and colleagues.39, 40 crolimus ointment in the treatment of atopic it If an acute mucosal allergy is suspected, the patient was found that the drug was as effective as corticosteroid should be referred for testing. Sensitivity testing via the in reducing symptoms.47 rinses have also RAST (radioallergosorbent) test is typically performed by been suggested as treatment.48 Another recent study sug- a medical allergy specialist. If intraoral patch testing is being gests that refractory painful cases may be responsive to cy- considered, it should be performed by a dentist familiar with closporine (cyclosporine microemulsion pre-concentrate, such testing (e.g. Oral Medicine) as there is a risk of false 3 mg/kg/day for initial intervention with a reduction to positive results. Solutions with standard percentages of vari- 1.5 mg/kg/day for maintenance).49 Of potential signifi- ous metals can be obtained in a commercial patch test kit. cance, a patient with and geographic tongue may These metal samples are then combined with orabase and see the condition resolve with treatment of the psoriasis placed against the lip or palatal mucosa via a modified splint. skin lesions. The material is allowed to remain for 24 hours, after which The etiology of has not been the tissue can be assessed for reactivity.41 determined and is likely to be complex.50 As the condition Some of the conditions that should be differentiated may spontaneously remit, treatment is only necessary if from mucosal allergy prior to treatment include: candidia- there is pain. If food or medication is determined to be sis, , oral , autoimmune blistering causative, it should be eliminated from the diet or use. In disease, drug reactivity (e.g. lichenoid drug reaction), viral chronic cases involving severe cosmetic deformity or im- infection and other oral ulcerative diseases. paired oral function, surgical intervention may be neces- Allergic contact stomatitis is best treated by removing sary. Corticosteroids, including topical application as well the offending sensitizing agent. This can mean replacing a as systemic delivery, can be helpful. Intralesional cortisone that is the source of the allergy; for example, is indicated for moderate swelling. The literature restorative materials containing nickel, titanium implants or also suggests that oral tetracycline, anaerobic antibiotics mercury found in amalgam.42-44 If a food is the cause of the (e.g. dapsone or metronidazole), and topical tacrolimus allergy the offending agent should be eliminated from the may help to reduce swelling. Other drugs that modulate diet.45 If a drug has been identified as the cause of oral ery- the such as methotrexate and thalidomide thema the patient should be cautioned regarding continued have also been reported to be helpful in reducing swelling use; however, he/she should also be advised to seek medical in severe cases.51 consultation prior to discontinuation of a prescribed drug to avoid potential systemic complications upon withdrawal. Topical anesthetics such as Dyclonine HCL and cortico- Aphthous stomatitis is characterized by the presence of steroid such as fluocinonide gel or dexamethasone elixir can multiple ulcers of the oral mucosa with adjacent tissue be used separately or combined with an antihistamine (e.g. erythema. The treatment of aphthous stomatitis remains www.ineedce.com 5 largely empirical and includes topical or systemic cortico- reduce secondary infection which can complicate healing steroids and/or immunosuppressant drugs.52 Aphthous and increase pain. lesions are self limiting and heal without scarring. Isolated The following list of topical steroids can be used to treat ulcers, if small, do not typically need prescribed interven- oral ulceration. tion and can be managed by OTC preparations. 1. Triamcinolone (brand – Kenalog in Orabase®); Dosage Recurrent severe ulceration requires a more compre- 0.1% (provided in one tube). hensive work up of the patient to rule out systemic disease. 2. Fluocinonide (brand – Lidex® gel or Lidex® ointment); Some of the conditions that should be considered in the Dosage 0.05% (provided in one tube). differential diagnosis include , diabetes mellitus, 3. Clobetasol propionate (brand –Temovate® gel or PFAPA (periodic fever, aphthous stomatitis, pharyngitis, Temovate® ointment; Dosage 0.05% (provided in one and adenitis syndrome), Behcet’s disease, inflammatory tube). bowel disease and immunosuppressive disease. Systemic All three of these corticosteroid mediations should be disease necessitates comprehensive medical and dental applied after each meal and at bedtime. Clobetasol propio- management. nate should be applied for three or four days with a break of If is the cause of ulceration, this should three to four days before reapplication. This approach will be corrected. Other causes such as and food allergy, reduce potential steroid side effects. if deemed contributory, should be treated via stress reduc- For generalized erythema associated with multiple ulcers tion or dietary restriction.53 an oral rinse may be the best way to achieve effective lesion A number of topical OTC strategies for suppressing coverage. Dexamethasone (Decadron® elixir) incorporates developed lesions have been studied and found to be effec- 0.5mg per 5 mls of solution and comes in 100 ml volumes. tive in reducing lesion duration and pain. However these The patient should rinse with one tsp (5 mls) for 3-4 minutes preparations do not appear to alter the frequency of recur- four times a day and spit. For severe cases it may be useful rences or maintain remission. Application of a dissolving to prescribe 320 mls with 15mls swished with swallow four gum-based patch containing glycyrrhiza (licorice) complex times a day for three days followed by 5mls taken in the same herbal extract has been found to reduce lesion duration and manner for three days, then 5 mls used for three days with pain.54 A paste containing Myrtus communis (Myrtle) has swish but with swallowing every other day and finally with also demonstrated an effect on lesion size and pain sever- 5 mls used four times a day as a rinse with expectoration of ity. 55 In a randomized, double-blind, placebo-controlled the medication. With steroid use the patient should be moni- trial, a containing Rosa damascena extract tored carefully for emergence of candidiasis. With low doses also demonstrated efficacy in the treatment of recurrent of steroid potential side effects should be minimal. However aphthous stomatitis.56 they can be problematic and include CNS stimulation, sleep Few drugs have been found to reduce the frequency disturbance, and gastrointestinal abnormality including and severity of reoccurring aphthous ulcers, however, formation and bleeding. Additionally, in the diabetic patient, two studies assessing this potential show promise. In one blood glucose levels should be carefully monitored with long study, Irsogladine prescribed at 2-4 mg/day was found to term use. be effective in reducing ulcer count and preventing reoc- Recurrent severe debilitating aphthous stomatitis may curance.57 In a second study, rebamipide was delivered need to be managed with delivered systemically at 300mg/day to 35 patients with Behcet’s disease in a at higher doses. A Medrol Dosepak® (methylprednisolone) randomized double-blind, placebo-controlled study. It titrates corticosteroid over a 7 to 10 day period. This option was well tolerated, reduced the aphthous lesion count and should only be considered by experienced clinicians in co- improved pain. There were no specific adverse drug reac- operation with the patient’s physician. Azathioprine (Imu- tions.58 ran®) is a prednisone sparing agent that can be prescribed Recurrent aphthous stomatitis has been associated concomitantly with steroid but if this course of therapy is with reduced dietary intake of vitamin B12 and .59 to be implemented, a baseline CBC and liver enzyme panel However vitamin B12 as a cause of aphthous stomatitis should be acquired prior to the start of treatment.64 Addi- remains controversial and no effect has been observed tional preventative management for candidiasis needs to be for multivitamin intervention.60 Nonetheless, vitamin B utilized. 12 supplementation has been found to reduce reoccur- rence of aphthous lesions, even in the absence of clinical Oral deficiency.61, 62 Immunomodulating medications such as Dental involvement in the patient with usually the tetracyclines and amlexanox , when applied involves oral examination and if neoplasm is suspected, topically, have anti-inflammatory activity that appears to of the tissue. Surgical management of reduce the severity of aphthous ulceration.63 Application of is determined by the clinical stage of the disease. Small a tetracycline solution via cotton swab to a lesion may also lesions identified by biopsy such as squamous cell carci-

6 www.ineedce.com noma that are without nodal involvement can be surgically ate benefit. Hydrolytic enzymes appear to reduce moderate excised (best practices is by an oral surgeon or ENT physi- and severe mucositis and ice chips can prevent mucositis. cian) using a wide margin technique The treatment of large Other interventions with potential effect (based on only one lesions or lesions with nodal involvement is complicated. study at the time) include calcium phosphate, honey, oral Hence the patient with extensive involvement needs to be care protocols, povidone, and zinc sulphate.69 referred so that they can receive comprehensive manage- In general, a multifocal multi-pharmacy approach is ment by oncology, ENT, and oral (maxillofacial) surgery. necessary in managing oral mucositis, oral pain, dry mouth Treatment may include radiation and/or and opportunistic infection that can be associated with che- and oral reconstruction. motherapy and radiation treatment.70 Head and neck cancer radiotherapy and chemotherapy Topical measures effective in reducing oral pain include can directly impact the oral mucosa and and result in 2% viscous lidocaine HCL (Xylocaine®), dyclonine (Dy- oral mucositis (OM) which is characterized by ulceration, clone®) and diphenhydramine elixir (Benadryl®, Benalin®). tissue slough, erythema, and pain. Mucositis can also follow Mouth rinses that may reduce oral discomfort include chemotherapeutic intervention for other non-oral . alkaline saline (salt/bicarbonate), Biotene®, and sucralfate The oral conditions that may develop secondary to treat- (Carafate®) suspension. Chlorhexidine gluconate mouth- ment of oral as well as other forms of cancer include , wash (Peridex®, Periogard®) at 0.12% may help in reducing , herpetic gingivostomatitis, oral mucositis (OM), gingivitis. In patients with dry mouth a salivary substitute or oral candidiasis, periodontitis, and ulceration.65 Recent evi- stimulant should be included to provide the needed protein dence suggests that the of OM will vary depend- binding to make it effective. Artificial salivas include Sage ing on the type of chemotherapeutic agent used and the type Moist Plus®, Moi-Stir® and Xero Lube®. Oral moisturizers of cancer treated.66 include OralBalance® gel and Sage Mouth Moisturizer®. Dental intervention for patients receiving chemothera- Fluorides should be applied for caries control. These include peutic agents and radiotherapy includes pre-treatment neutral NaF gel (Thera-Flur-N®) 1.0% which can be applied preventative hygiene measures and restorative care. After one drop per or via a custom tray, stannous fluoride lesion development, dental treatment focuses on symp- gel (0.4%) which should be applied in the same manner. tomatic support including pain relief, reducing periodontal Biotene® (OTC), placed on a soft brush that disease and caries and treating opportunistic infection. In can be made softer by placing it under hot water, can help the hospital setting dental intervention may be more com- with plaque control. Antifungal medications previously prehensive and include additional management strategies described will help reduce potential candidiasis.71 for mucositis. For the dentist asked by a treating physician to provide Vesiculoerosive or Ulcerative Disease a recommendation about the management of mucositis the following information may be useful. In the treatment of Benign (BMMP) oral mucositis, recent evidence suggests that Benign mucous membrane pemphigoid (BMMP) is an hydrochloride (0.15%) used as an oral rinse, swished for autoimmune disease that cleaves the . This then 30 seconds four times a day, may be more effective than produces fluid filled bullae which rupture and leave the chlorhexidine and povidone iodine in preventing the devel- mucosal surface raw and erythematous. The condition can opment of severe mucositis.67 affect the eye, so immediate ophthalmology referral is im- Results from systematic review of the research literature portant once the disease is confirmed by biopsy.72, 73 published prior to 2007 (Cochrane report) suggest that sev- Relatively small BMMP oral lesions can be managed eral medications may be more effective in reducing OM than with topical steroids. Severe erosions may require systemic benzydamine HCL, chlorhexidine and the ‘magic’ mouth steroids and/or azathioprine coupled with analgesics and rinse (lidocaine solution, diphenhydramine hydrochloride antifungal medication. Since these lesions have significant and aluminum hydroxide suspension).68 These include al- potential for morbidity, referral should be made to oral lopurinol, granulocyte macrophage-colony stimulating fac- medicine specialists, ophthalmologists, dermatologists and/ tor, immunoglobulin, and human placental extract. In fact, or rheumatologists.74 based on at least one study, allopurinol appears to eradicate mucositis. The authors of this Cochrane review conclude Lichen Planus that the evidence for the use of benzydamine HCL does sup- Although the etiology of erosive oral lichen planus (OLP) port its use as adjuvant treatment. Nonetheless, they further remains unknown, accumulated evidence points to an auto- conclude that the evidence for the above effective medica- immune problem with a genetic predisposition. The condi- tions (e.g. allopurinol, etc.) is also weak and ‘unreliable’. tion appears to involve T-cell mediated inflammation of the A Cochrane review published prior to the 2007 con- tongue, , buccal mucosa, and gingiva which leads to cludes antibiotic pastes or pastilles can also provide a moder- tissue erythema, , and the erosions that char- www.ineedce.com 7 acterize the severe form of the disease.75 There can also be to rinse for 3-4 minutes after each meal with the drug spit dermal involvement. out. The patient should be monitored for yeast infection and Asymptomatic reticular lichen planus that does not in- treated accordingly if infection emerges during steroid use.78 volve erosion, erythema or esthetic concern does not need Topical cyclosporine has shown some promise in lim- intervention. ited trials79. Topical and systemic retinoids (e.g., tretinoin The rationale for treatment of erosive OLP includes and etretinate) do not appear to be particularly useful.80 suppression of oral lesions, pain control and prevention of Alternate-day treatment protocols, low doses, and adjunc- secondary fungal infection. Research data regarding efficacy tive therapy have been suggested by at least one expert if the suggests that there may not be a considerable difference condition is to be treated long-term.77 between current treatment strategies. In a Cochrane review, In a small study, local ultraviolet B phototherapy was 28 randomized controlled clinical trials that assessed symp- found to be effective in treating OLP, suggesting a nonphar- tomatic treatments for OLP were reviewed. There was no macological approach to the management of the disease. A specific therapeutic approach that stood out above the others larger randomized controlled trial is needed, however, be- as a ‘go to’ approach to intervention.76 Topical and systemic fore this approach can be recommended for intervention.81 steroid application is considered a first-line treatment for Pain medications can include acetaminophen prepara- erosive OLP. However, as was noted by the authors of the tions, including codeine (in severe cases) or other narcotics Cochrane review, no randomized controlled trials have com- taken short-term. pared this medication strategy with placebo. A number of other medications have been suggested as Bibliography treatment of erosive LP. Pimecrolimus is one of these drugs. 1. Muñoz-Corcuera M, Esparza-Gómez G, González- The evidence for use of pimecrolimus, an immunomodulat- Moles MA, Bascones-Martínez A.Oral ulcers: clinical aspects. A tool for dermatologists. Part II. Chronic ulcers. ing agent used in the treatment of (eczema), Clin Exp Dermatol. 2009 Jun;34(4):456-61 consists of three clinical trials that suggest that its use is no 2. Gonçalves LM, Bezerra Júnior JR, Cruz MC.Clinical better than placebo in reducing pain associated with OLP. evaluation of oral lesions associated with dermatologic Two trials assessing aloe vera suggest that it may reduce diseases. An Bras Dermatol. 2010 Apr;85(2):150-6). 3. Cavalcante E, Guissa V, Jesus A, Campos L, Sallum pain compared to placebo. In addition, two other small trials A, Aikawa N, Silva C Stevens-Johnson syndrome in a suggest that cyclosporine may reduce pain and the clinical juvenile systemic erythematosus patient. Lupus. signs of OLP. Five trials comparing steroids with calci- 2011;20(13):1439-41 neurin inhibitors (e.g., pimecrolimus, tacrolimus) suggest 4. Int Dent J.Aliko A, Alushi A, Tafaj A, Lela F. Oral mucosa involvement in rheumatoid , systemic no difference between the two in reducing pain. And in 6 and systemic sclerosis. Int Dent J. trials specifically assessing steroid therapy, there was limited 2010 Oct;60(5):353-8 evidence that one steroid worked better than another. Thus, 5. Altenburg A, Krahl D, Zouboulis CCNon-infectious it would appear that there is insufficient evidence to support ulcerating oral mucous membrane diseases. J Dtsch Dermatol Ges. 2009 Mar;7(3):242-57 the effectiveness of any specific treatment as being superior 6. Nanda KD, Mehta A, Marwaha M, Kalra M, Nanda J.A to another in the management of erosive OLP. Given this, a disguised tuberculosis in oral buccal mucosa. Dent Res J prudent approach to management would be to start with a (Isfahan). 2011 Summer;8(3):154-9 minimal application of the lowest dose topical steroid before 7. Villa A, Villa C, Abati S. Oral cancer and oral : an update and implication for clinicians. prescribing stronger acting drugs. Aust Dent J. 2011 Sep;56(3):253-6 One of the more challenging problems in treating OLP 8. Ohta M, Osawa S, Endo H, Kuyama K, Yamamoto H, is that the condition can be refractory to topical steroids Ito T. vulgaris confined to the gingiva: a case and systemic therapy may be necessary to fully control the report. SourceInt J Dent. 2011;2011:207153 77 9. Srirangarajan S, Shetty S, Prasanna D. Necrotic ulcerative disease. As noted by Lozada-Nur and Miranda (1997) , no changes in Fanconi’s anaemia: a case report. Oral Health one single standard protocol has been proven effective in Prev Dent. 2011;9(1):91-7 treating chronic OLP and consequently, the most effective 10. Brennan MT, Valerin MA, Napeñas JJ, Lockhart PB. Oral therapy is topical high-potency corticosteroids coupled with manifestations of patients with lupus erythematosus. Dent Clin North Am. 2005 Jan;49(1):127-41 systemic steroid (prednisone). 11. Gonçalves LM, Bezerra Júnior JR, Cruz MC. Clinical The use of a specific topical steroid preparation is based evaluation of oral lesions associated with dermatologic on lesion size. For isolated lesions, fluocinonide (Lidex®) gel diseases. An Bras Dermatol. Apr, 2010;85(2):150-6 or ointment can be applied after each meal and at bedtime. 12. Edward E. Herschaft, Charles A Waldron. Bacterial ® Infections, Fungal and Protozoal Diseases, Viral If clobetasol (Temovate ) is used, it should be prescribed as Infections. In: Brad W Neville, Douglas D Damm, previously described to prevent potential adrenal suppres- Carl M Allen, Jerry E Bouquot. Oral and Maxillofacial sion. If OLP lesions are extensive, dexamethasone (Decad- . 1st Edition. Philadelphia: W.B. Saunders ron®) elixir may be more effective in providing complete Company; 1995:Chapters 5,6,7 13. See http://www.medical-library.net/herpes_simplex_ lesion coverage. One teaspoonful (5 mls) should be used

8 www.ineedce.com virus.html - title: . Author Ron 33. Periodontal (Gum) Disease: Causes, Symptoms, Kennedy, M.D., accessed 8/9/13. and Treatments. NIDCR. Available at http://www. 14. http://www.nejm.org/doi/full/10.1056/NEJMcp1302 nidcr.nih.gov/OralHealth/Topics/GumDiseases/ 674?query=. Accessed 8/5/13; title: herpes PeriodontalGumDisease.htm. Accessed 8/16/13. zoster; author Jeffrey Cohen. 34. Periodontal Disease. Department of Health and Human 15. Wayne E Anderson, DO. Varicella-Zoster Virus Services CDC. Available at http://www.cdc.gov/ Treatment & Management. Medscape. Available at OralHealth/topics/periodontal_disease.htm. Accessed http://emedicine.medscape.com/article/231927- 12/14/2011 treatment. Accessed 8/11/2013 35. Mombelli A. advances in treating 16. Mary L Windle, PharmD: http://emedicine.medscape. periodontal diseases. Front Oral Biol. 2012;15:133-48. com/article/109673-overview; Title: Topical Anesthesia. 36. Shetty K. Current role of thalidomide in HIV-positive Accessed 8/15/13 patients with recurrent aphthous ulcerations. Gen Dent. 17. Mary L Windle, PharmD. Topical Anesthesia. http:// Nov-Dec 2007;55(6):537-42 emedicine.medscape.com/article/109673-overview. 37. Cheng S, Murphy R. Refractory aphthous ulceration Accessed 12/09/2011) treated with thalidomide: a report of 10 years’ clinical 18. Cetacaine Topical Anesthetic. Available at http:// experience. Clin Exp Dermatol. Oct 18 2011. dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl. 38. Hello M, Barbarot S, Bastuji-Garin S, Revuz J, Chosidow cfm?id=33345&type=display. Accessed 08/20/2013 O. Use of thalidomide for severe recurrent aphthous 19. Topical anesthetics - Advisories, warnings, and recalls stomatitis: a multicenter cohort analysis. Medicine for health professionals. Health Canada. Available at (Baltimore). May 2010;89(3):176-82 http://hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/ 39. Wray D, Rees SR, Gibson J, Forsyth A. The role of allergy prof/_2009/emla_ametop_hpc-cps-eng.php. Accessed in oral mucosal diseases. QJM. 2000 Aug;93(8):507-11.) 08/20/2013. ( http://qjmed.oxfordjournals.org/content/93/8/507. 20. Wang Y, Wang Q, Zhu Q, Zhou R, Liu J, Peng T. full) Identification and characterization of acyclovir-resistant 40. Antonella Tosti. http://emedicine.medscape.com/ clinical HSV-1 isolates from children. J Clin Virol. Oct article/1076589-clinical#a0218 Title: Contact Stomatitis; 2011;52(2):107-12. accessed 8/12/13 21. Simmons A. Clinical manifestations and treatment 41. McParland H, Warnakulasuriya S.Oral lichenoid contact considerations of herpes simplex virus infection. J Infect lesions to mercury and dental amalgam--a review. J Dis. Oct 15 2002;186 Suppl 1:S71-7. Biomed Biotechnol. 2012;2012:589569. 22. Nolan A. Interventions for prevention and treatment 42. Sicilia A, Cuesta S, Coma G, Arregui I, Guisasola C, of herpes simplex virus in cancer patients. Evid Based Ruiz E, Maestro A. Titanium allergy in Dent. 2009;10(4):116-7 patients: a clinical study on 1500 consecutive patients. 23. Glenny AM, Fernandez Mauleffinch LM, Pavitt S, Walsh Clin Oral Implants Res. 2008 Aug;19(8):823-35; T. Interventions for the prevention and treatment of 43. Laeijendecker R, Dekker SK, Burger PM, Mulder PG, Van herpes simplex virus in patients being treated for cancer. Joost T, Neumann MH.Oral lichen planus and allergy Cochrane Database Syst Rev. 2009;(1):CD006706). to dental amalgam restorations. Arch Dermatol. 2004 24. Text: Oral and Maxillofacial Pathology; Editors Brad Dec;140(12):1434-8. Neville, Douglas Damm, Carl Allen, Jerry Bouquot, W. 44. http://www.ncbi.nlm.nih.gov/pmc/articles/ B. Saunders Company, Philadelphia ,1995; Chapter 6. PMC3026973. Authors: David Keinanand Uri Zilberman; 25. Drugs and medications – Nilstat oral. Available title: Absorption of Nickel, Chromium, and Iron by the at http://www.webmd.com/drugs/mono-8206- Root Surface of Primary Molars Covered with Stainless NYSTATIN+SUSPENSION+-+ORAL.aspx?dru Steel Crowns; accessed 8/7/13. gid=52772&drugname=Nilstat+Oral)(Myostatin 45. Georgakopoulou E. Cinnamon contact stomatitis. J pastilles, drugs and treatment. Available at http://www. Dermatol Case Rep. 2010 Nov 19;4(2):28-9. revolutionhealth.com/drugs-treatments/mycostatin- 46. Ishibashi M, Tojo G, Watanabe M, Tamabuchi T, pastilles#how_take. Accessed 08/20/2013 Masu T, Aiba S.Geographic tongue treated with topical 26. Multiple authors. Clinician’s Guide to Treatment of tacrolimus. J Dermatol Case Rep. 2010 Dec 31;4(4):57-9. Common Oral Conditions. The American Academy of 47. Svensson A, Chambers C, Gånemo A, Mitchell S. A Oral Medicine; Spring, 1997 systematic review of tacrolimus ointment compared with 27. http://www.webmd.com/drugs/mono-8206- corticosteroids in the treatment of atopic dermatitis. Curr NYSTATIN+SUSPENSION+-+ORAL.aspx?drugi Med Res Opin. 2011 Jul;27(7):1395-406. d=52772&drugname=Nilstat+Oral; Title: drugs and 48. Reamy BV, Derby R, Bunt CW. Common medications – Nilstat oral. accessed 08/20/13. Tongue Conditions in Primary Care. Am Fam 28. http://www.revolutionhealth.com/drugs-treatments/ Physician. 2010 Mar 1;81(5):627-634). mycostatin-pastilles#how_take; Title: myostatin 49. Abe M, Sogabe Y, Syuto T, Ishibuchi H, Yokoyama pastilles, drugs and treatmen; assessed 08/20/13. Y, Ishikawa OSuccessful treatment with cyclosporin 29. Aids Info – fluconazole. Available at http://aidsinfo.nih. administration for persistent benign migratory glossitis. gov/drugs/5/fluconazole/patient. Accessed 8/15/13. J Dermatol. 2007 May;34(5):340-3. 30. Fluconazole – Oral Diflucan, side effects, medical uses, 50. Grave B, McCullough M, Wiesenfeld D. Orofacial drug interactions. Available at http://www.medicinenet. granulomatosis--a 20-year review. Oral Dis. 2009 com/fluconazole-oral/article.htm. Accessed 8/15/13. Jan;15(1):46-51). 31. http://aidsinfo.nih.gov/drugs/5/fluconazole/patient; 51. http://www.dermnetnz.org/site-age-specific/orofacial- Title: Aids Info – fluconazole. Accessed 8/15/13. granulomatosis.html;accessed 8/12/13 32. http://www.medicinenet.com/fluconazole-oral/article. 52. Baccaglini L, Lalla RV, Bruce AJ, Sartori-Valinotti JC, htm; Title: fluconazole – Oral Diflucan, side effects, Latortue MC, Carrozzo M, Rogers RS 3rd Urban medical uses, drug interactions. Accessed 8/15/13. legends: recurrent aphthous stomatitis. Oral Dis. 2011

www.ineedce.com 9 Nov;17(8):755-70. 2011 Jan;2(1):8-12). 53. Wardhana. Datau EA. Recurrent aphthous stomatitis 68. Clarkson JE, Worthington HV, Eden OB. Interventions caued by food allergy. Acta Med Indones. 2010 Oct; for treating oral mucositis for patients with cancer 42(4):236-40. receiving treatment. Cochrane Database Syst Rev. 2007 54. Burgess JA, van der Ven PF, Martin M, Sherman J, Haley Apr 18;(2). J. Review of over-the-counter treatments for aphthous 69. Worthington HV, Clarkson JE, Eden O. Interventions ulceration and results from use of a dissolving oral for preventing oral mucositis for patients with cancer patch containing glycyrrhiza complex herbal extract. J receiving treatment. Cochrane Database Syst Rev. 2006 Contemp Dent Pract. 2008 Mar 1;9(3):88-98. Apr 19;(2) 55. Babaee N, Mansourian A, Momen-Heravi F, 70. Rodríguez-Caballero A, Torres-Lagares D, Robles-García Moghadamnia A, Momen-Beitollahi J. The efficacy M, Pachón-Ibáñez J, González-Padilla D, Gutiérrez- of a paste containing Myrtus communis (Myrtle) in Pérez JLCancer treatment-induced oral mucositis: a the management of recurrent aphthous stomatitis: a critical review. Int J Oral Maxillofac Surg. 2011 Nov 7. randomized controlled trial. Clin Oral Investig. 2010 [Epub ahead of print). Feb;14(1):65-70. 71. Paccitti Symptomatic treatment of radiation-induced 56. Hoseipour H, Peel SA, et al. Evaluation of Rosa mucositis in head and Neck cancer: Current practice, damascene mouthwash in the treatment of recurrent literature review and evidence-based Recommendations. aphthous stomatitis: a randomized, double-blinded, J Radiother Pract. 2004;4:47–5. placebo-controlled clinical trial. Quintessence Int. 2011; 72. Williams DM. Vesiculo-bullous mucocutaneous disease: Jun; 42(6):483-91. benign mucous membrane and . J 57. Nanke Y, Kamatani N, Okamoto T, Ogiuchi H, Kotake S. Oral Pathol Med. Jan 1990;19(1):16-23. Irsogladine is effective for recurrent oral ulcers in patients 73. Burgess JA. Painful Oral Lesions: What to look for, how with Behcet’s disease: an open-label, single-centre study. to treat, Part 2. Consultant. Dec, 2006;46(14):1573-80). Drugs R D. 2008; 9(6):455-9. 74. Burgess JA, Johnson BD, Sommers E. Pharmacological 58. Matsuda T, Ohno S, Hirohata S, Miyanaga Y, Ujihara H, management of recurrent oral mucosal ulceration. Drugs. Inaba G, Nakamura S, Tanaka S, Kogure M, Mizushima Jan 1990;39(1):54-65). Y. Efficacy of rebamipide as adjunctive therapy in the 75. Roopashree MR, Gondhalekar RV, Shashikanth MC, treatment of recurrent oral aphthous ulcers in patients George J, Thippeswamy SH, Shukla A. Pathogenesis of with Behcet’s disease: a randomized, double-blind, oral lichen planus--a review. J Oral Pathol Med. Nov placebo-controlled study. Drugs R D. 2003; 4(1):19-28. 2010;39(10):729-34. 59. Kozlak ST, Walsh SJ, Lalla RV. Reduced dietary intake of 76. Keenan AV, Ferraiolo D. Insufficient evidence for vitamin B12 and folate in patients with recurrent aphthous effectiveness of any treatment for oral lichen planus. Evid stomatitis.J Oral Pathol Med. 2010 May;39(5):420-3. Based Dent. 2011;12(3):85-6. 60. Spivakovsky S, Keenan AV. No effect seen for 77. Lozada-Nur F, Miranda C. Oral lichen planus: topical multivitamin therapy on recurrent aphthous stomatitis and systemic therapy. Semin Cutan Med Surg. Dec patients. Evid Based Dent. 2013 Mar;14(1):26. 1997;16(4):295-300. 61. Burgess J. Am Board Fam Med. 2009 (J Am Board Fam 78. Lozada-Nur F, Miranda C. Oral lichen planus: topical Med. 2009 Sep-Oct;22(5):590-1 and systemic therapy. Semin Cutan Med Surg. Dec 62. Volkov I, Rudoy I, Freud T, Sardal G, Naimer S, Peleg R, 1997;16(4):295-300. Press Y. Effectiveness of vitamin B12 in treating recurrent 79. Conrotto D, Carbone M, Carrozzo M, Arduino P, aphthous stomatitis: a randomized, double-blind, Broccoletti R, Pentenero M. Ciclosporin vs. clobetasol placebo-controlled trial. J Am Board Fam Med. 2009 in the topical management of atrophic and erosive oral Jan-Feb;22(1):9-16. lichen planus: a double-blind, randomized controlled 63. Elad S, Epstein JB, et al. Topical immunomodulators for trial. Br J Dermatol. Jan 2006;154(1):139-45. the management of oral mucosal conditions, a systematic 80. Lozada-Nur F, Miranda C. Oral lichen planus: review; Part II: miscellaneous agents. Expert Opin Emerg epidemiology, clinical characteristics, and associated Drugs. 2011 Mar; 16(1):183-202. diseases. Semin Cutan Med Surg. Dec 1997;16(4):273- 64. Elad S, Epstein JB, von Bültzingslöwen I, Drucker S, 7). Tzach R, Yarom N.Topical immunomodulators for 81. Kassem R, Yarom N, Scope A, Babaev M, Trau H, management of oral mucosal conditions, a systematic Pavlotzky F. Treatment of erosive oral lichen planus with review; Part II: miscellaneous agents. Expert Opin Emerg local ultraviolet B phototherapy. J Am Acad Dermatol. Drugs. 2011 Mar;16(1):183-202. 2012 May;66(5):761-6. 65. Javed F, Utreja A, Bello Correa FO, Al-Askar M, Hudieb M, Qayyum F, Al-Rasheed A, Almas K, Al-HezaimOral Author profile health status in children with acute lymphoblastic . Crit Rev Oncol Hematol. 2011 Dec 1. [Epub Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant ahead of print]. Professor, Department of Oral Medicine, University of 66. Nishimura N, Nakano K, Ueda K, Kodaira M, Yamada S, Washington School of Dental Medicine; (Retired) Attend- Mishima Y, Yokoyama M, Terui Y, Takahashi S, Hatake ing in Pain Center, University of Washington Medical K. Prospective evaluation of incidence and severity of oral mucositis induced by conventional chemotherapy in Center; (Retired) Private Practice in Hawaii and Washing- solid tumors and malignant . Support Care ton; Director, Oral Care Research Associates. He can be Cancer. 2011 Nov 25. [Epub ahead of print]. reached at [email protected] . 67. Roopashri G, Jayanthi K, Guruprasad REfficacy of benzydamine hydrochloride, chlorhexidine, and povidone iodine in the treatment of oral mucositis Author Disclosure among patients undergoing radiotherapy in head and neck malignancies: A drug trail. Contemp Clin Dent. Dr. Burgess has no potential conflicts of interest to disclose.

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Questions

1. In cases where oral erythema is associated 8. Which one of the following is not likely to 14. The advantage of using an antifungal with systemic disease the dentist should: be a side effect of topical anesthetic? troche over a rinse is that: a. Manage the condition without establishing a a. Depression a. The troche can be swallowed quickly. diagnosis b. Cardiovascular problems b. A troche such as Mycelex® has no sugar in its b. Prescribe steroids c. CNS excitation formulation. c. Seek medical consultation prior to pursuing local d. ulceration c. A troche provides longer contact with the mucosal management surface. d. Perform a biopsy 9. Which of these statements is true in rela- d. A troche can be taken with antacid medication. tion to the treatment of primary HSV-1 2. Home care should be an integral compo- oral viral infection? 15. Systemic antifungal agents are usually nent of therapy. Which of the following a. Use of an antiviral medication may increase prescribed when: is not included in the ‘best practices’ resistance a. Patients have concomitant liver disease or impaired recommendations? b. Systemic acyclovir should only be used as a liver function. a. Fluid and nutritional support treatment of HSV-1 stomatitis when the patient has a b. When topical agents are not effective or are not b. Adequate rest compromised immune system practical. c. OTC pain medication c. Both a and b c. Both a and b d. Vitamin therapy d. Neither a or b d. Neither a or b 3. Which one of the following viral infections 10. Which of these statements is true in 16. Which of the following is not a systemic is associated with localized reoccurrence relation to the treatment of secondary antifungal medication? secondary to reactivation of latent virus HSV-1 lesions? a. Diflucan within nerve? a. Frequently reoccurring secondary lesions can be b. Sporanox a. Herpes simplex virus (HSV-1 or 2) suppressed with 500 mg of valacyclovir. c. Fungizone b. Morbillivirus d. Monistat c. Human herpes virus 6 (HHV-6) b. Acyclovir is not as effective as valacyclovir in treating d. (CMV) reoccurring lesions. 17. The most common erythematous oral c. Both a and b disease caused by bacteria is: 4. Reactivation of varicella-zoster virus d. Neither a or b a. Streptococcal tonsillitis and pharyngitis (VZV) causes: b. Periodontal disease a. Oral shingles 11. In the patient with a competent immune system which of the following fungal c. Diphtheria b. d. Tuberculosis c. Both of the above organism is most responsible for oral d. None of the above erythema? 18. The standard dental treatment of 5. In patients with HSV-1 lesions, palliative a. Cladosporium pyogenic granuloma and peripheral giant home care should include all of the follow- b. Saccharomycetales cell granuloma is: c. Candida albicans a. Prescription of systemic antibiotic. ing except: d. Aureobasidium b. Surgery a. Gargling with cold water c. Both a and b b. Drinking hot beverages 12. In the patient with removable prostheses d. Neither a or b c. Avoidance of nail biting and erythematous candidiasis, overall d. Use of a nutritional supplement management should include: 19. Which of the following is not considered 6. Which one of the following is not consid- a. Instruction to soak the appliance overnight in a a reasonable treatment of a symptomatic ered a topical medication that can be used mouthrinse allergic stomatitis that is associated with for desensitizing erythematous mucosa? b. Instruction not to use their prostheses during oral mucosal erythema? a. Diclonine HCL intervention a. Prescription of systemic antibiotic b. Lidocaine/prilocaine cream c. Instruction to soak the appliance in a one percent b. Removal of dental fillings or crowns c. Diphenhydramine syrup chlorhexidine/hypochlorite solution c. An elimination diet d. Vitamin C cream d. Instruction to apply an antibiotic denture lacquer d. Prescription of Dyclonine HCL and corticosteroid prior to insertion 7. Topical anesthetic syrups are typically 20. Which of the following has been recom- prescribed as rinses to be used before each 13. Topical antifungal medication should be mended for the treatment of symptomatic meal and: used for how many days? geographic tongue? a. Swallowed a. 10-14 days a. Tacrolimus ointment b. Spit out b. 3-5 days b. Cyclosporine microemulsion c. Both a and b c. 14-21 days c. Both a and b d. Neither a or b d. 6-9 days d. Neither a or b

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13. Was there any subject matter you found confusing? Please describe. ______

14. H ow long did it take you to complete this course? ______AGD Code 730 15. What additional continuing dental education topics would you like to see? ______PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

COURSE EVALUATION and PARTICIPANT FEEDBACK Provider Information RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at www.ada. participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of mailed within two weeks after taking an examination. org/cotocerp/. many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General CANCELLATION/REFUND POLICY All participants scoring at least 70% on the examination will receive a verification form verifying 2 CE Dentistry. The formal continuing dental education programs of this program provider are accepted by the Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from their state dental boards for continuing education requirements. PennWell is a California Provider. The (11/1/2011) to (10/31/2015) Provider ID# 320452. © 2014 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. RED315DIG

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