2 Differential Diagnoses and Treatment of Oral Lesions Susan Müller, DMD, MSProfessorDepartment of PathologyDepartment of OtolaryngologyWinship Cancer InstituteEmory University School of Medicine
3 Goals Focus on 5 common benign conditions in the oral cavity Mouth Ulcers:Aphthous UlcersHerpes Simplex Virus 1Oral Lichen PlanusGeographic tongueCandidiasisBurning Mouth Syndrome
4 GoalsDiscuss clinical presentation, differential diagnosis and treatment
5 Oral Ulcers Questions to think about when evaluating oral ulcers Acute vs ChronicMultiple vs SingleLocationDurationAssociated painIndurationOther mucosal lesionsCutaneous lesionsSystemic diseasesMedicationsAny known triggers
10 Recurrent 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
11 Aphthous Ulcer vs HSV Prodrome sometimes usually Duration 10-14 days LocationNonkeratinized - buccal mucosa, ventral tongue, soft palateKeratinized – gingiva, lip, hard palate
12 Topical 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
13 Aphthae 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.
14 Treatment for AphthaeIntralesional steroid injection-about cc of 40mg/cc triamcinolone
15 Treatment 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
16 Recurrent 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.
17 At sick call appointment in the dental clinic, he was told to “brush his teeth with his finger” since a toothbrush was too painful.
19 Primary 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
20 Primary Herpetic Gingivostomatitis 1º lesions are highly infectious including the saliva1º infection lasts up to 2 weeksAfter the initial infection the virus goes into latency
25 Erosive OLP: less common symptomatic Atrophic erythematous areas with central ulcerationbordered by fine, white radiating striae
26 Treatment 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
27 Gingival Lichen Planus Treatment In addition to the steroid mouthrinse:Doxycycline 100mg QD for 90 days then reevaluate
28 Oral Lichen Planus Differential Diagnosis Oral lichenoid drug reactions to systemic drugsOral lichenoid contact-sensitivity“Lichenoid dysplasia”Chronic graft-versus-host disease
29 Geographic 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.
33 Treatment 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.
34 Oral CandidiasisAn opportunistic organism which tends to proliferate with the use of broad-specturm antibiotics, corticosteroids, cytotoxic agents and medications that reduce salivary output
49 Remember 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.
50 Persistent 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
58 Possible Causes of a Burning Mouth – Need to rule out before making a diagnosis of BMS AllergyMechanical IrritationInfectionMyofascial painOral habitsGeographic tongueMenopauseEsophageal refluxAcoustic neuromaVitamin deficiencyDiabetesXerostomiaMedicationPsychogenic factors
59 Epidemiology 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
60 Epidemiology of BMS 92% - report more than one site 43% - taste disturbance59% - milder after waking75% - worse in the evening61% - parafunctional habits
61 Sites of Discomfort in BMS frequencyTongue – most affected siteAnterior hard palateLipsLower denture bearing areaThroatFloor of mouth
62 Treatment 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
63 Treatment of BMS Tricyclic antidepressant: Amitriptyline 25-50 mg Nortriptyline mg (better tolerated in elderly
64 Treatment of BMS Topical capsaicin: local desensitization Αlpha lipoic acid: 600 mg daily (200mg TID with meals)