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)

OH, NO! OH, NO! Pete is that you???Pete is that you???