Differential Diagnoses and Treatment of Oral Lesions Susan Müller, DMD, MS Professor Department of...
Transcript of Differential Diagnoses and Treatment of Oral Lesions Susan Müller, DMD, MS Professor Department of...
Differential Diagnoses and Treatment of Oral Lesions
Susan Müller, DMD, MSProfessor
Department of PathologyDepartment of Otolaryngology
Winship Cancer InstituteEmory University School of Medicine
GoalsFocus on 5 common benign conditions
in the oral cavity1. Mouth Ulcers:
Aphthous Ulcers Herpes Simplex Virus 1
2. Oral Lichen Planus3. Geographic tongue4. Candidiasis5. Burning Mouth Syndrome
Goals
• Discuss clinical presentation, differential diagnosis and treatment
Oral UlcersQuestions to think about when evaluating
oral ulcers• Acute vs Chronic• Multiple vs Single• Location• Duration• Associated pain• Induration
• Other mucosal lesions• Cutaneous lesions• Systemic diseases• Medications• Any known triggers
Aphthous Ulcers
Recurrent minor
aphthous ulcer
1 cm; fibrinopurulent membrane surrounded by erythema
Aphthous Ulcer - Triggers
1.1. Decrease in the mucosal barrier Decrease in the mucosal barrier Trauma,pernicious anemia
2.2. Increase in antigenic exposureIncrease in antigenic exposure Foods, flavoring agents
3.3. Primary immunodysregulationPrimary immunodysregulation Behcets, Crohns, celiac disease,
cyclic neutropenia, AIDS, stress
Recurrent Orolabial HSV1
Recurrent HSV-1
Reactivation 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
Prodrome sometimes usually
Duration 10-14 days 10-14 days
Location Nonkeratinized - buccal mucosa, ventral tongue, soft palate
Keratinized – gingiva, lip, hard palate
Aphthous Ulcer vs HSV
Treatment for Aphthae
Topical steroids – either rinse or cream/gel Systemic steroid – good for multiple lesions or those in the oropharynx Bloodwork
Aphthae Treatment
Dexamethasone elixir 0.5 mg/5mlDispense 500 mlSig: 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.
Treatment for Aphthae
Intralesional steroid injection-about 0.3-0.5 cc of 40mg/cc triamcinolone
TreatmentRecurrent HSV Infection
TopicalTopical• RX: Acyclovir 5%ointment (Zovirax)• Disp: 15 gm• Sig: Apply hourly at the onset of symptoms• RX: Pencyclovir 1% cream (Denavir)• Disp: 2 gm• Sig Apply every 2 hrs during waking hrs for
4 days at the onset of symptoms
Recurrent HSV Treatment
SystemicSystemic• RX: Valacyclovir 1 gm (Valtrex)• Disp: 4 caplets• Sig: Take 2 caps at prodrome and 2 caps 12h later• RX: Famciclovir 500 mg (Famvir)• Disp: 3 tablets• Sig: 3 tablets at first sign of symptoms• RX: Acyclovir 400mg (Zovirax)• Disp 50 capsules• Sig: 1 capsule bid at onset of symptoms for 3-5 days.
At sick call appointment in the dental clinic, he was told to “brush his teeth with his finger” since a toothbrush was too painful.
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 gingivitis
• 1% of individuals develop full-blown primary herpetic gingivostomatitis: temp, regional lymphadenopathy, difficulty eating
Primary Herpetic Gingivostomatitis
1º lesions are highly infectious including the saliva
1º infection lasts up to 2 weeks
After the initial infection the virus goes into latency
Treatment for Primary HSV-1
RX:Acyclovir 400 mg Disp: 32 capsulesSig: 2 capsules tid for
the first 3 days then 1 capsule bid for 7 days
RX:Famvir 500 mgDisp: 20 tabletsSig: 1 tablet bid for 10
days
Oral Lichen PlanusOral Lichen PlanusOral Lichen Planus
• Reticular form– Most common– asymptomatic– Wickham’s striae– Bilat BM, tongue,
gingiva, palate, vermilion border
• Plaque form– Dorsal tongue
Erosive OLP:Erosive OLP:– less common– symptomatic– Atrophic
erythematous areas with central ulceration
– bordered by fine, white radiating striae
Treatment of Erosive OLPTreatment of Erosive OLP
Compounded rinse:Triamcinolone rinse
4mg/mlSevere – systemicprednisone
Decadron elixir:0.5 mg/ 5mlDisp 500 ml1 tsp qid, hold 3mins, spit out, no food/liquid for 30mins
Gingival Lichen Gingival Lichen PlanusPlanus
TreatmentTreatment
• In addition to the steroid mouthrinse:
• Doxycycline 100mg QD for 90 days then reevaluate
Oral Lichen PlanusDifferential Diagnosis
• Oral lichenoid drug reactions to systemic drugs
• Oral lichenoid contact-sensitivity• “Lichenoid dysplasia”• Chronic graft-versus-host disease
Geographic TongueGeographic Tongue
Clinical 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.
Treatment of Geographic TongueTreatment of Geographic Tongue
• Usually not treatment is required• Identifying triggers which cause symptoms will
help in minimizing discomfort• For highly symptomatic patients, topical
steroid (rinse or gel) will relieve the pain.
Oral CandidiasisOral Candidiasis
• An opportunistic organism which tends to proliferate with the use of broad-specturm antibiotics, corticosteroids, cytotoxic agents and medications that reduce salivary output
Candidiasis
Hairy Tongue
Hairy Tongue
A coated tongue does not automatically mean the patient has a yeast
infection
Angular Cheilitis
High-arched palate
Steroid Inhalers Can Cause Oral Candidiasis
Treatment
• Nystatin Suspension 5mg/5ml• Dispense 280 ml (14 day course)• SIG: 1 tsp QID, hold for 3 mins, spit out,
no food, liquid or rinsing for 30 mins
Treatment
• Clotrimazole (Mycelex) 10 mg Troche• Dispense 70 troche• Dissolve in mouth 1 troche 5x day• No eating, drinking or rinsing for 30 minutes• If applicable, remove dentures first
Treatment
• Fluconazole 100mg daily for 14 days– Watch for drug interactions
(coumadin, some cholesterol meds)
• Angular Cheilitis:– Mycolog II– Apply to the corner of lips BID
Erythematous Candidiasis
Remember to Treat the Denture!Remember to Treat the Denture!
• Patient should be encouraged to remove denture when sleeping
• Place an antifungal cream (eg clotrimazole) inside the denture QD for 30 days.
Persistent CandidiasisPersistent Candidiasis
• Can be caused by a variety of etiologies:• Need blood work to rule out anemia:
1. CBC with differential: low iron in a man or post-menopausal F, need to ask why
2. B12: low B12 is pernicious anemia which increases with age
Persistent CandidiasisPersistent Candidiasis
• Check glucose levels: May be undiagnosed diabetic
• Poorly controlled diabetic• Check thyroid levels• Is patient on chronic steroid or antibiotic
use?• Xerostomia
Burning Mouth SyndromeBurning Mouth Syndrome
• Synonyms–Burning Tongue–Glossodynia–Scalded Mouth Syndrome–Glossopyrosis
Possible Causes of aBurning Mouth – Need to rule out before making a diagnosis of BMS
• Allergy• Mechanical Irritation• Infection• Myofascial pain• Oral habits• Geographic tongue• Menopause
• Esophageal reflux• Acoustic neuroma• Vitamin deficiency• Diabetes • Xerostomia • Medication• Psychogenic factors
Epidemiology of BMS• Post/peri-menopausal female• 18-75 yrs (mean 59 yrs)• Reported prevalence of 5.1% in
general dental practice population• Duration of symptoms 3-6 yrs• Associated symptoms:
– Headaches– Sleep disturbances– Anxiety, depression– Neuroses
Epidemiology of BMSEpidemiology of BMS
• 92% - report more than one site
• 43% - taste disturbance• 59% - milder after waking• 75% - worse in the evening• 61% - parafunctional habits
Sites of Discomfort in BMSSites of Discomfort in BMS
• Tongue – most affected site• Anterior hard palate• Lips• Lower denture bearing area• Throat• Floor of mouth
Treatment of BMSTreatment of BMS
Benzodiazepine: Clonazepam 0.5 mgI 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
Treatment of BMSTreatment of BMS
Tricyclic antidepressant: Amitriptyline 25-50 mgNortriptyline 20-40 mg (better tolerated in
elderly
Treatment of BMSTreatment of BMS
Topical capsaicin: local desensitization
Αlpha lipoic acid: 600 mg daily (200mg TID with meals)
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