2Differential Diagnoses and Treatment of Oral Lesions Susan Müller, DMD, MSProfessorDepartment of PathologyDepartment of OtolaryngologyWinship Cancer InstituteEmory University School of Medicine
3Goals Focus on 5 common benign conditions in the oral cavity Mouth Ulcers:Aphthous UlcersHerpes Simplex Virus 1Oral Lichen PlanusGeographic tongueCandidiasisBurning Mouth Syndrome
4GoalsDiscuss clinical presentation, differential diagnosis and treatment
5Oral Ulcers Questions to think about when evaluating oral ulcers Acute vs ChronicMultiple vs SingleLocationDurationAssociated painIndurationOther mucosal lesionsCutaneous lesionsSystemic diseasesMedicationsAny known triggers
10Recurrent HSV-1Reactivation of the virus can be triggered by GI upsets, stress, menses, solar radiation, extreme cold, or other infections.Recurrent lesions are less severe than the primary infection.Recurrent lesions present with a burning sensation, erythema of the affected area, vesiculation, ulceration and crust formation
11Aphthous Ulcer vs HSV Prodrome sometimes usually Duration 10-14 days LocationNonkeratinized - buccal mucosa, ventral tongue, soft palateKeratinized – gingiva, lip, hard palate
12Topical steroids – either rinse or cream/gel Treatment for AphthaeTopical steroids – either rinse or cream/gelSystemic steroid – good for multiple lesions or those in the oropharynxBloodwork
13Aphthae Treatment Dexamethasone elixir 0.5 mg/5ml Dispense 500 ml Sig: 1 tsp quid; hold for 3 mins, spit out, no food or liquid for 30 minsFor easy to reach spots like lips can use a topical steroid such as Lidex gel or cream or more potent steroid like Clobetasol.
14Treatment for AphthaeIntralesional steroid injection-about cc of 40mg/cc triamcinolone
15Treatment Recurrent HSV Infection TopicalRX: Acyclovir 5%ointment (Zovirax)Disp: 15 gmSig: Apply hourly at the onset of symptomsRX: Pencyclovir 1% cream (Denavir)Disp: 2 gmSig Apply every 2 hrs during waking hrs for 4 days at the onset of symptoms
16Recurrent HSV Treatment SystemicRX: Valacyclovir 1 gm (Valtrex)Disp: 4 capletsSig: Take 2 caps at prodrome and 2 caps 12h laterRX: Famciclovir 500 mg (Famvir)Disp: 3 tabletsSig: 3 tablets at first sign of symptomsRX: Acyclovir 400mg (Zovirax)Disp 50 capsulesSig: 1 capsule bid at onset of symptoms for 3-5 days.
17At sick call appointment in the dental clinic, he was told to “brush his teeth with his finger” since a toothbrush was too painful.
19Primary Herpetic Gingivostomatitis In the US, 70-90% of adults have antibodies to HSV-1.Highest incidence of HSV-1 occurs in children aged 6 months to 3 years.99% of affected individuals undergo a subclinical infection – in children may be confused with eruption gingivitis1% of individuals develop full-blown primary herpetic gingivostomatitis: temp, regional lymphadenopathy, difficulty eating
20Primary Herpetic Gingivostomatitis 1º lesions are highly infectious including the saliva1º infection lasts up to 2 weeksAfter the initial infection the virus goes into latency
25Erosive OLP: less common symptomatic Atrophic erythematous areas with central ulcerationbordered by fine, white radiating striae
26Treatment of Erosive OLP Decadron elixir:0.5 mg/ 5mlDisp 500 ml1 tsp qid, hold 3mins, spit out, no food/liquid for 30minsCompounded rinse:Triamcinolone rinse 4mg/mlSevere – systemicprednisone
27Gingival Lichen Planus Treatment In addition to the steroid mouthrinse:Doxycycline 100mg QD for 90 days then reevaluate
28Oral Lichen Planus Differential Diagnosis Oral lichenoid drug reactions to systemic drugsOral lichenoid contact-sensitivity“Lichenoid dysplasia”Chronic graft-versus-host disease
29Geographic TongueClinical lesions generally present on the anterior two-thirds of the dorsal tongue as multiple, well-demarcated zones of erythema due to atrophy of the filliform papillae. These zones may be surrounded by a white circinate border.
33Treatment of Geographic Tongue Usually not treatment is requiredIdentifying triggers which cause symptoms will help in minimizing discomfortFor highly symptomatic patients, topical steroid (rinse or gel) will relieve the pain.
34Oral CandidiasisAn opportunistic organism which tends to proliferate with the use of broad-specturm antibiotics, corticosteroids, cytotoxic agents and medications that reduce salivary output
49Remember to Treat the Denture! Patient should be encouraged to remove denture when sleepingPlace an antifungal cream (eg clotrimazole) inside the denture QD for 30 days.
50Persistent Candidiasis Can be caused by a variety of etiologies:Need blood work to rule out anemia:CBC with differential: low iron in a man or post-menopausal F, need to ask whyB12: low B12 is pernicious anemia which increases with age
58Possible Causes of a Burning Mouth – Need to rule out before making a diagnosis of BMS AllergyMechanical IrritationInfectionMyofascial painOral habitsGeographic tongueMenopauseEsophageal refluxAcoustic neuromaVitamin deficiencyDiabetesXerostomiaMedicationPsychogenic factors
59Epidemiology of BMS Post/peri-menopausal female 18-75 yrs (mean 59 yrs)Reported prevalence of 5.1% in general dental practice populationDuration of symptoms 3-6 yrsAssociated symptoms:HeadachesSleep disturbancesAnxiety, depressionNeuroses
60Epidemiology of BMS 92% - report more than one site 43% - taste disturbance59% - milder after waking75% - worse in the evening61% - parafunctional habits
61Sites of Discomfort in BMS frequencyTongue – most affected siteAnterior hard palateLipsLower denture bearing areaThroatFloor of mouth
62Treatment of BMS Benzodiazepine: Clonazepam 0.5 mg I usually start patients on .25 mg nightly for the first 7 days. If not change then increase to 0.5 mg nightly for first 30 days
63Treatment of BMS Tricyclic antidepressant: Amitriptyline 25-50 mg Nortriptyline mg (better tolerated in elderly
64Treatment of BMS Topical capsaicin: local desensitization Αlpha lipoic acid: 600 mg daily (200mg TID with meals)