2017 Oregon Dental Conference® Course Handout Nasser Said-Al-Naief, DDS, MS Course 8125: “The Mouth as The Body’s Mirror: Oral, Maxillofacial, and Head and Neck Manifestations of Systemic Disease” Thursday, April 6 2 pm - 3:30 pm 2/28/2017 The Mouth as The Body’s Mirror Oral Maxillofacial and Head and Neck Manifestation of Ulcerative Conditions of Allergic & Immunological Systemic Disease the Oro-Maxillofacial Diseases Region Nasser Said-Al-Naief, DDS, MS Professor & Chair, Oral Pathology and Radiology Director, OMFP Laboratory Oral manifestations of Office 503-494-8904// Direct: 503-494-0041 systemic diseases Oral Manifestations of Fax: 503-494-8905 Dermatological Diseases Cell: 1-205-215-5699 Common Oral [email protected] Conditions [email protected] OHSU School of Dentistry OHSU School of Medicine 2730 SW Moody Ave, CLSB 5N008 Portland, Oregon 97201 Recurrent aphthous stomatitis (RAS) Recurrent aphthous stomatitis (RAS) • Aphthous" comes from the Greek word "aphtha”- • Recurrence of one or more painful oral ulcers, in periods of days months. = ulcer • Usually begins in childhood or adolescence, • The most common oral mucosal disease in North • May decrease in frequency and severity by age America. (30+). • Affect 5% to 66% of the North American • Ulcers are confined to the lining (non-keratinized) population. mucosa: • * 60% of those affected are members of the • Buccal/labial mucosa, lateral/ventral tongue/floor of professional class. the mouth, soft palate/oropharyngeal mucosa • Etiopathogenesis: 1 2/28/2017 Etiology of RAU Recurrent Aphthous Stomatitis (RAS): Types: Minor; small size, shallow, regular, preceeded by prodrome, heal in 7-10 days Bacteria ( S. Sanguis) Systemic diseases Immune component) with no scarring. (HLA B12, B51, CW7) - Usually start in childhood and may persist to adulthood - Lining mucosa. (T4/T8 decrease) HSV Major (Sutton’s diseses) ; Larger, deeper, irregular, Pain+, less defined Smokers= no ulcers prodrome, can persist weeks to years+ (pain may not be for full duration), may VZV heal with scarring. Mucosal Barrier; - Usually start > puberty RAU Adenovirus & CMV RAU - Keratinized and non-keratinized mucosa - Aphthous stomatitis and systemic disease. Sensitivity to foods : e.g., to preservatives and agents • Iron, Folate, B12, Zinc such as benzoic acid or •Menstruation / leuteal phase of Menstrual cycle = Herpetiform; numerous, small size, shallow, regular, preceeded by prodrome, cinnamon, chocolates, peanuts Thicker lining = less ulceration heal in 7-10 days with no scarring, > in ♀. • Pregnancy = No ulcers - Keratinized and non-keratinized mucosa (+ in posterior oropharynx) RAU Traumatic Ulcer on Torus Palatinus, with Frictional Keratosis 2 2/28/2017 RAU RECURRENT APHTHOUS STOMATITIS (RAS) • Management/preventive measures: • Rx:____________________________ • Rx:_____________________________ • Amelexanox oral paste 5% • Dexamethasone (Decadron) elixir 0.5 mg/5 ml 1) Plaque reduction, manual • Disp: 5 gram tube • Disp: 320 ml • Sig: Dab on affected area qid until healed. 2) Antimicrobial Mouthwashes/antiseptics: •Sig: • Rx:____________________________ • 1. For 3 days, rinse with 1 tablespoonful (15 ml) 1% chlorhexidine gel t.i.d. after meals x 35 days • Orabase Soothe-N-Seal Protective Barrier (OTC) • Disp: 1 package • qid and swallow. Then, 0.1% hexetidine mouth rinse 15 mL for 1 min t.i.d. after meals x • Sig: Apply as per the package directions • For 3 days, rinse with 1 teaspoonful (5 ml) every • qid and swallow. Then, 6 wk • Six hours when necessary. • For 3 days, rinse with 1 teaspoonful (5 ml) • qid and swallow every other time, Then 0.2% chlorhexidine mouthwash 10 mL for 1 min t.i.d. x 6 wk • Rx:____________________________ • Triamcinolone acetonide (Kenalog) in Orabase • Rinse with 1 teaspoonful (5 ml) qid and spit Listerine mouth rinse (unspecified volume) for 30 sec b.i.d. x 6 •0.1% • out Discontinue medication when mouth • Disp: 5 gm tube • becomes comfortable mo • Sig: Coat the lesion with a thin film after each • Meal and at bedtime 0.5% chlortetracycline 50 mL held in mouth 1 min q.i.d. • Rx:_______________________________ • Rx:____________________________ • Prednisone tablets 10 mg 2.5% chlortetracycline 10 mL held in mouth 1 min q.i.d. • Prednisone tablets 5 mg • Disp: 40 tablets • Disp: 26 tablets 5% tetracycline 1 tsp held in mouth 1 min q.i.d. • Sig: Take 5 tablets in the morning for five • Sig: Take 4 tablets in the morning for • Days, then 5 tablets in the morning every other day five days until gone • Then decrease by 1 tablet on each successive day. RAU TX of CANDIDIASIS (CANDIDOSIS) Management • Rx:______________________ • Rx:__________________________ 5) Other agents (advanced) ; • Nystatin (Mycostatin, Nilstat) oral suspension • Nystatin vaginal suppositories 100,000 u • 100,000 units/ml • Disp: 40 • Disp: 240 ml • Sig: Let 1 suppository dissolve in the mouth • Thalomid, • Sig: 5 ml qid. Rinse for two minutes and swallow. • qid. Do not rinse for 30 minutes. • Acyclovir, • Rx:______________________ • Rx:___________________________ • Nystatin ointment • *Clotrimazole (Gyne-Lotrimin, Mycelex-G vaginal • Azathioprine, • Disp: 15 gm tube • Cream 1% (OTC) • Sig: Apply thin coat to inner surface of denture • Disp: One tube • and to affected area after meals. • Sig: Apply a think layer to tissue side of denture • Interferon alfa, • and/or to infected oral mucosa qid. • Rx:_______________________ • prostaglandin E 2 gel, • Ketoconazole (Nizoral) cream 2% • Rx:____________________________ • Disp: 15 gm tube • *Miconazole (Monistat 7) nitrate vaginal • Sig: Apply tin coat to inner surface of denture • Cream 2% (OTC) • Colchicine, sucralfate, and cyclosporine. • and to affected area after meals. • Disp: One tube • Sig: apply thin layer to tissue side of denture • Trental (pentoxyfylene). • Rx:_________________________ • and/or to infected oral mucosa qid • Mycostatin pastilles 2000,000 u • Glycyrrhiza extract (GX or DGL) in an oral topical time-release • Dis;p: 70 pastilles • Rx:____________________________ • Sig: Let 1 pastille dissolve in mouth five times • Ketoconazole (Nizoral) tablets 200 mg • a day. Do not chew. • Disp: 14 tabs patch held in constant or frequent contact with a new aphthous • Sig: Take 1 tablet daily with a meal or orange ulcer for at least 16 hours per day shortens healing time to 1-3 • Rx:_________________________ • juice. Do not take together with buffered • Clotrimazole (Mycelex) torches 10 mg • Medications or with gastric acid blockers days and relieves pain while in place. • Disp: 70 troches • Sig: Let 1 troche dissolve in mouth five times • Rx:______________________________ • a day. Do not chew. • Fluconazole (Diflucan) tablets 100 mg • Tacrolimus Topical • Disp: 15 tablets • Sig: Take 2 tablets stat, then 1 tablet daily until • gone. 3 2/28/2017 Systemic Disorders Associated with RAU Celiac disease (Sprue) • Celiac Disease / gluten enteropathy. • Immune-mediated enteropathy • Behcet’s syndrome • Cyclic Neutropenia (& immune deficiency including HIV) • Over 99% of people with celiac disease are positive for • Nutritional deficiency human leukocyte antigen (HLA)-DQ2 or DQ8) • IgA deficiency • Inflammatory bowel disease & RAU • In up to 1% of the population. • Magic syndrome (mouth & genital ulcers with inflamed cartilage) (Behcet’s syndrome + Polychondritis) • FAPA syndrome (Periodic fever, aphthous stomatitis, pharyngitis, • Permanent sensitivity to the gliadin protein (fraction of cervical adenitis) gluten) found in cereal grains including wheat, rye, and • Reiter’s disease : Immune mediated arthritis + Nongonococcal barley Urethritis + Conjunctivitis • Sweet’s syndrome • Occurs in genetically susceptible individuals and a family • Ulcus vulvae acutum history of celiac disease (a key indicator for diagnostic testing) in young children with gastrointestinal(GI) symptoms. Celiac disease (Sprue) Behcet’s disease (syndrome) • A complex, multisystem, inflammatory disease • A higher incidence in children with (Juvenile-type 1 • Classically characterized by diabetes, IgA deficiency, Down syndrome, auto immune Recurrent oral ulceration thyroiditis, and rheumatoid arthritis, SLE), & Dermatitis Genital ulceration Herpetiformis/10% = very itchy rash on the extremities, Ophthalmologic inflammation. buttocks, trunk, and scalp and neck • First described by Hulusi Behcet's, a Turkish dermatologist, in 1937 Symptoms include: diarrhea, and abdominal cramping • Long-term; celiac Sprue: • Most frequently in the Middle East Growth retardation, iron deficiency, osteoporosis, oral • Also endemic among populations clustered along the historic silk road (eastern ulcers, coagulopathies, and infertility. Asia to the Mediterranean basin) • In the Middle East, Europe, and the United States: Prevalence for young ♂ Patients with refractory disease; increased risk for non- • Japan and Korea: Slight ♀ + Hodgkin's lymphoma and significant gastrointestinal ulcerations. • The diverse range of clinical findings seems to stem from an underlying vasculitis; however, the ultimate etiologic agent remains unknown. 4 2/28/2017 Behcet’s disease Behcet’s disease Etiology • Clinical Features • Remains unknown • Mucosal/cutaneous finding: • Genetic and environmental factors (familial Behcet's has been reported); • The most common ; oral aphthous ulcerations at least three times Middle East; 0 to 15 % in one year The remainder of the world; 5% . Abnormal neutrophils function; . Pyoderma-gangrenosum-like lesions, erythema-nodosum-like . Alterations in lymphocytes peripheral