Contemporary Oral Medicine June 2017

Contemporary Oral Medicine

Leticia Ferreira, DDS, MSDepartment 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 membranepemphigoid

(199) 2.7%

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

• 76.5% Female average age 57.2

• 23.5% Male average age 51.8

• Combined average age 56.0

Oral Lichen Planus (BCD, July 2010)Based on 897 patients

Lichen Planus

• Skin 14%

• Genitalia 2.3%

Oral Lichen Planus (BCD, July 2010)Based on 897 patients

Lichen Planus

• 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%

Lichen PlanusClinical Sites (BCD, July 2010)

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 tubeSig: 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 tubeSig: 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

• Systemic CorticosteroidRx Prednisone 10 mg tabletDisp: 40 tabsSig: Two tabs bid x 7 days, then 1 tab bid X 4 days, the 1 tab daily until gone

Lichen Planus

Lichen Planus

• Side-effects of topical corticosteroid therapy:–Candidiasis

Lichen Planus

• Combined Topical Therapy–Topical corticosteroid

+Clotrimazole 10 mg Troche 1-3xs daily

orNystatin Oral Suspension 1 tsp 2xs daily

• 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

Lichen Planus

(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

agEarly 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

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

• NSAIDs 19• Cardiovascular drugs 10• Mercury (amalgams) 10• Cinnamic aldehyde 9• Antidiabetics 9• Anti-lipemic 4• Gold salts 2

(BCD) 63 patients (04/05)

Drugs causing lichenoid drug reaction

Allopurinol Gold PractololAmiphenazole Hydroxychloroquine PropanololAtorvastatin (Lipitor) Ketoconazole PyrimethamineCaptopril Labetanol QuinidineCarbamazetine Mercury QuinacrineChloroquine Methyldopa SpironolactoneChlorpropamide Metopromazine Streptomycin Cyanamide NSAID TetracyclineDapsone Oxyprenolol ThiazidesEnalapril Palladium TolbutamideErythromycin Para-amino salicylate TriprolidineFenclofenac Penicillamine ZoloftFurosemide Phenothiazines

Candidiasis

• Candida albicans• Dimorphism: yeast and hyphal forms• Most common oral fungal infection

Candidiasis

• Predisposing factors:

– Antibiotic therapy– Cancer chemotherapy– Corticosteroid therapy– Dentures– Diabetes mellitus– Pregnancy– Iron deficiency

– Newborns’ immature immune system

– Advanced malignancy– Xerostomia– Immunocompromised

states• HIV/AIDS• Transplant patients

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

• 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 procedure)

• Emotional stress• Nutritional deficiencies• Socio-economic level• Genetic predisposition• Chemicals in food

• Immunologic factors• AIDS• Endocrine imbalance• Infectious agents• Allergies• Smoking cessation


“canker sores”

• Minor

• Major

• Herpetiform


“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


“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


“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


“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


“canker sores”

• Treatment:– High-potency topical steroids– Chlorhexidine– Amlexanox 5% (Aphthasol)


“canker sores”

Rx Fluocinonide gel or cream 0.05% (Lidex)Disp: 15 or 30 gram tubeSig: 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 gmSig: Apply to affected area qid


“canker sores”

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)


• 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


–72.4% Female average age 59.6

–27.6% Male average age 63.8

–Combined average age 60.8

(BCD, July 2010)Based on 199 patients


• Gingiva 96%• Gingiva only 67.2%• Buccal Mucosa 18.7%• Gingiva + buccal mucosa mucosa 16.5%• Palate 10.1%• Gingiva + palate 9.6%• Tongue 4.5%• Gingiva + tongue 4.5%• Pharynx 1.1%• Gingiva + pharynx 1.1%

(BCD, July 2010) Clinical sites


• Diagnosis–Histologic appearance:• Subepithelial split with separation at the

basement membrane•Non-specific inflammation

–Direct Immunofluorescence• IgG and/or C3 at basement membrane

zone•Occasionally IgA, IgM


• Treatment– Referral to an ophthalmologist– Topical corticosteroids– Good oral hygiene measures can help to decrease

severity– Carrier trays– Dapsone– Tetracycline or minocycline and niacinamide– Systemic corticosteroids– Systemic corticosteroids + Cyclophosphamide– Intravenous (IV) human immunoglobulin

• Highest Potency Topical Corticosteroid Rx Clobetasol 0.05% gel (Temovate)Disp: 15 gram tubeSig: Dry the area and apply a small amount 3-4x/day. Do not eat or drink for one hour after application.

• Systemic CorticosteroidRx Prednisone 10 mg tabletDisp: 40 tabsSig: Two tabs bid x 7 days, then 1 tab bid X 4 days, the 1 tab daily until gone


Oral Allergic Reactions

• Cinnamon/Toothpaste/Preservatives 59• Drug Lichenoid 53• Dental Restorative Materials 45• Non specific 11

Types of Allergic Reactions (BCD, January 2004)

Allergic Contact Stomatitis

• Acute–Burning, erythema

• Chronic–Erythematous or white

Oral Allergic Reactions

• Clinical:– Involvement of cheek and tongue on same side– Gingival desquamation

• Signs of Dentifrice Allergy

– Generalized or localized gingivitis (desquamativegingivitis)

–Mucositis/glossitis– Cheilitis– Lip edema– Perioral dermatitis

Toothpaste Hypersensitivity

• Flavoring agents as sensitizers:– Cinnamon oil– Cinnamic aldehyde–Menthol (also in pepermint)–Mint/Spearmint– Eugenol (from eucalyptus oil)– Essential oils– L-carvone– Anethole

Toothpaste Hypersensitivity

Xerostomia

• Subjective sensation of a dry mouth• Common problem and in 25% of older

adults• Multiple causes• Complications: – Candidiasis– Prone to cervical and root caries– Alteration of taste

Common Causes for Xerostomia

• Medications• Caffeine/alcohol• Smoking• Radiation therapy to head and neck• Sjögren’s syndrome• Primary Biliary cirrhosis• Diabetes mellitus• Sarcoidosis• Surgery of salivary glands

Diagnosis of Xerostomia

• A positive response to any of the following questions has been associated with reduced saliva:– Does the amount of saliva in your mouth seem to be

too little?– Does your mouth feel dry when eating a meal?– Do you sip liquids to aid in swallowing dry food?– Do you have difficulty swallowing?

(Plemons et al 2014)

Clinical Signs and Symptoms of Xerostomia

• Teeth– Increased incidence of tooth decay (cervical and

incisal)– Enamel demineralization (chalky spots at the cervical

regions of the teeth)– Increased plaque accumulation– Enamel erosion and attrition– Increased tooth hypersensitivity


• Oral mucosa:– Mucositis– Mucosal desquamation– Atrophic mucosa– Allergic or contact stomatitis and lichenoid lesions

(mostly opposing metal restoration)– Recurrent oral candidiasis– Traumatic ulcerations on the lateral border of the

tongue and buccal mucosa– Painful or burning mouth




• Tongue– Dryness, fissuring, lobulation– Atrophy– Erythema– Loss of papillae– Crenations on tongue (scalloped borders)


• Lips– Dryness, chapping– Peeling– Fissuring– Angular cheilitis


• Major salivary glands– Poor salivary output– Frothy saliva– Absent or reduced salivary pooling– Swelling and enlargement of salivary glands– Recurrent sialadenitis affecting major salivary glands

• Oral cavity– Oral allergic or contact reactions– Halitosis– Difficulty talking, chewing or swallowing – Plaque accumulation– Altered taste– Food retention and debris on the teeth or tongue or

along gingival margins• Other– Dry eye accompanied by dry mouth (Sjogren syndrome)


Management of Xerostomia• Patient education–Meticulous oral hygiene regimen– Elimination of alcohol, smoking, caffeine

consumption–Maintaining adequate hydration

• Management of systemic conditions and medication use in consultation with patient’s physician/oncologist

• Salivary stimulants (sialagogues): pilocarpine(Salagen), cevimeline (Evoxac)

Management of Xerostomia

• Sugarless candies, gum• Oral lubricants (mouthwash, gels, spray)• Candidiasis prevention and control • Patients with dry mouth, dry eyes and salivary

gland enlargement should be evaluated for Sjogren’s syndrome– 16-fold increased risk of developing lymphoma

• Oral lubricants– Xylimelts– Dentiva– Salese– Oramoist

• Sialagogues:Rx Pilocarpine (Salagen) 5 mg tablets

Disp: 120 tabletsSig: one tablet PO qid

Rx Cevimeline (Evoxac) 30 mg capsulesDisp: 90 capsulesSig: one capsule PO tid

Management of Xerostomia

Geographic tongue

• “Erythema migrans”• “Benign migratory glossitis”• Common• Unknown etiology

Geographic tongue• Clinical– 2/3 females– Dorsal and lateral tongue– Depapillated erythematous patch surrounded by a

yellow-white border– Heal spontaneously and recur at different site– Often associated with fissured tongue

Geographic tongue

• Treatment: Only for symptomatic patients– Topical corticosteroids

Rx Fluocinonide gel or cream 0.05% (Lidex)Disp: 15 or 30 gram tubeSig: Dry the area and apply a small amount 3-4x/day. Do not eat or drink for one hour after application

Rx Clobetasol 0.05% gel (Temovate)Disp: 15 gram tubeSig: Dry the area and apply a small amount 3-4x/day. Do not eat or drink for one hour after application.

– Zinc supplement: 220 mg daily

Pharmacologic Therapy for Common Oral Mucosal

Conditions

Anti-inflammatory/Immunosuppressants

• High Potency Topical Corticosteroids– Fluocinonide 0.05% (Lidex)– Fluocinolone 0.20% (Synalar HP)– Triamcinolone Acetonide 0.5% (Aristocort Kenalog)

• Kenalog in orabase 0.1%

– Desoximetasone 0.25% (Topicort)

• Highest Potency Topical Steroids– Clobetasol propionate 0.05% (Temovate)– Betamethasone dipropionate 0.05%

(Diprolene)– Halobetasol propionate ointment 0.05%

(Ultravate)


Rx Fluocinonide gel or cream 0.05% (Lidex)Disp: 15 or 30 gram tubeSig: Dry the area and apply a small amount 3-4x/day. Do not eat or drink for one hour after application.

Rx Bethametasone dipropionate gel 0.05%Disp: 15 gmSig: Apply sparingly to affected areas bid

Rx Decadron Elixir 0.5mg/5mlDisp: two 100 ml bottlesSig: Rinse with 1 tsp for 3-4 min and expectorate after meals and at bedtime


Rx Clobetasol 0.05% gel (Temovate)Disp: 15 gram tubeSig: Dry the area and apply a small amount 3-4x/day. Do not eat or drink for one hour after application.

Rx Prednisone 10 mg tabletDisp: 40 tabsSig: Two tabs bid x 7 days, then 1 tab bid X 4 days, the 1 tab daily until gone

Rx Amlexanox oral paste 5% (Aphthasol)Disp: 5 gmSig: Apply to affected area qid


Antifungals

• Topical antifungal therapyRx: Nystatin (Mycostatin, Nilstat) oral suspension 100,000 U/mLDisp: 240 mlSig: Rinse with 1 tsp. qid for 3 min by the clock. Expectorate.

Clotrimazole (Mycelex) Troche 10 mg Disp: 70Sig: Dissolve one troche slowly in mouth 5Xs daily for 14 days.

Antifungals• Systemic antifungal therapy

Rx: Fluconazole (Diflucan) tablets 100 mg Disp: 15 tabletsSig: Take 2 tablets on day 1, then 1 tablet daily

Antifungals

• Angular cheilitisRx: Ketoconazole (Nizoral) crm 2%Disp: 15 g tubeSig: Apply sparingly to corners of mouth after meals and before bed

Nystatin & triamcinolone acetonide ointment (Mycolog II, Mytrex) ointment Disp: 15 g tubeSig: Apply to affected sites after meals and before bed

Polymyxin B/Bacitracin (Polysporin) ointment (OTC)Disp: 15 g tubeSig: Apply to affected sites after meals and before bed.

Antifungals

• Treatment of dentures in patients with Candidiasis• Reinfection can occur if denture is not also treated• Options include soaking denture in 1:10 solution of

sodium hypochlorite & water overnight 3 times during treatment

Antivirals

• Primary Herpes– Systemic antiviral therapy

Rx: Acyclovir capsules 200 mgDisp: 42 capsulesSig: Take 2 capsules 3 times a day

Rx: Valacyclovir HCL (Valtrex) 1000 mg or Famciclovir(Famvir) 500 mgDisp: 14 capsSig: Take I caplet twice a day

• Recurrent Herpes– Treat during prodromal symptoms

• Topical antiviral therapyRx: Penciclovir cream 1%Disp: 1 tubeSig: Apply to area every 2 hours for 4 days, beginning with first symptoms

Antivirals

• Recurrent Herpes– Treat during prodromal symptoms

• Systemic antiviral therapyRx: Valacyclovir HCL (Valtrex) 1000 mgDisp: 4 capletsSig: Take 2 caplets at first sign of a cold sore, then 2 caplets 12 hours later

Rx: Famciclovir (Famvir) 500 mgDisp: 3 tabletsSig: Take 3 tablets as a single dose

Antivirals

Symptomatic Relief

Rx Mix Dimetapp Elixir 40 mlKaopectate 80 ml

Distilled water 120 mlSig: Rinse with 1 tsp and expectorate as

needed

Rx Benzocaine in Orabase OTC*Rx Xylocaine Viscous 2%*Disp: 100 mlSig: Rinse with 1 tsp as needed and expectorate

*Attention: Vicous lidocaine and topical benzocaine should be avoided in pediatric patients because of reports of lidocaine-induced seizures in children and an association between topical benzocaine and methemoglobinemia.

Symptomatic Relief

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References

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Contemporary Oral Medicine June 2017