An Overview of Oral Medicine

1. An Overview of Oral Medicine

2. WHAT IS ORAL MEDICINE? “The specialty of dentistry concerned with the oral health care of patients with chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.”

3. Some conditions are very common e.g. mouth ulcers, white patches and infections (usually viral and fungal) • Some conditions are very distressing e.g. orofacial granulomatosis and Sjogren’s syndrome • Some conditions are persistent and difficult to manage e.g. psychogenic facial pain

4. The mouth - what’s it got to do with medicine? • An entity in its own right – dentistry ! • The upper end of the GIT- gastroenterology ! • In continuity with the skin – dermatology ! • Often reflects haematological problems at an early stage • Oral mucosa not dissimilar to genital mucosa – combinations of oral, genital and conjunctival problems occur • Can frequently be affected by side effects of medication – dryness, ulceration, pigmentation etc. • Has a lot of sensory cortex devoted to it - oral problems are often very distressing– psychiatry !

5. Which One Is Potentially Serious

6. Three key questions • What is it ? • What is its significance ? • What should be done about it ?

7. What is it ? • History • Examination • Investigations • Biopsy • Haematological • Imaging • Etc

8. What is its significance ? • Is it ? • Local (single/multiple) • General (systemic) • Benign (nuisance) • Malignant (serious) • A Syndrome

9. What should be done about it ? • Leave +/- review • Treat • Refer

10. Surgical sieve • Congenital– developmental , hereditary/familial • Traumatic- physical/chemical/thermal • Inflammatory – acute / chronic • Neoplastic– benign / malignant • Other

11. Oral mucosa • Limited ways it can react to an insult • It can breakdown – (ulceration) • It can thicken – (white patches) • It can blister – (vesiculobullous disorders) • It can pigment – (eg. with melanin) • Consequently many oral disorders can appear verysimilar ! History and investigation(eg. Biopsy)areoften essential

12. Oral Ulceration

13. Causes of Oral Ulceration • Traumatic • Recurrent aphthous stomatitis • Viral disease • Dermatological conditions • Malignancy

14. Traumatic • Mechanical (toothbrush, dentures) • Chemical (aspirin burn) • Thermal (pipe smoking, hot food)

15. Traumatic • Mechanical (toothbrush, dentures) • Chemical (aspirin burn) • Thermal (pipe smoking, hot food)

16. Traumatic • Mechanical (toothbrush, dentures) • Chemical (aspirin burn) • Thermal (pipe smoking, hot food)

17. Management of traumatic oral ulceration • Try to identify and remove the cause • Review in 2 weeks • If not healed, reconsider diagnosis e.g. if it is a solitary ulcer, consider carcinoma and requires biopsy

18. Recurrent Aphthous Stomatitis • Occurs in 20% of the population • Definite cause unknown, but some precipitating factors or triggers have been identified • Mainly “minor aphthous stomatitis” (80%) but also “major” & “herpetiform” (20%) stomatitis

19. Minor RAS • < 1cm round/oval ulcers - painful • Occur in crops, variable with ulcer free periods • Last up to 10 days & heal without scarring • Never occur on keratinised mucosa (hard palate or attached gingiva)

20. Major Aphthous Ulceration • > 1cm, irregular, deep ulcers • Heal after several weeks with scarring • Destructive • Occur anywhere on the oral mucosa • Can mimicmalignancy!

21. Genetic Hormonal hypersensitivity Stress/ Smoking cessation Microbial (Viral?) Aetiology • Idiopathic • Complex genetic (multifactorial) disease

22. RAS……known triggers • Haematinic deficiency in 20%, with 60% positive response following appropriate supplementation • Check Hb, ferritin, Vit.B12 & Folate • Psychological factors • Allergies (preservatives e.g. benzoic acid E210-219), fizzy drinks

23. Trauma (penetrating) (crisps, also preservatives!) • Cessation of smoking (reverts mucosa to normal non-keratinised state) • Drugs • Family history (not genetic) • Endocrine • Immunological factors • No microbiological association

24. Bowel problems associated with RAS • Crohn’s disease • Ulcerative colitis • Coeliac disease

25. Gluten Enteropathy – Coeliac Disease • Allergy to wheat products • Starts during early childhood - weaning • Lose villi • Malabsorption • Fatty stools – steatorrhoea • Failure to thrive • Aphthous ulcers • (Dermatitis herpetiformis)

26. Systemic history for RAS • Lassitude • Weakness • Breathlessness • Abdominal pain • Frequency and type of stool • Weight loss ANAEMIA GIT problems

27. Management of RAS • Confirm diagnosis by eliminating any systemic underlying cause • Check for haematinic deficiency • If suspect systemic involvement refer to specialist • Therapy • How severe are the symptoms • How frequent are the ulcers • Location of the ulcer

28. Treatment options • No treatment • Prevention/treatment of/for possible causes • Sodium Lauryl Sulfate-Free Toothpastes • Sharp edges, ill fitting prosthesis, calculus • Topical therapy • Systemic therapy • Referral for severe disease

29. RAS management • Pain relief – lignocaine lollipops, Gengigel, Aloclair, Difflam • Address precipitating factors e.g. replacement therapy & investigation of underlying cause. Often asking children to eliminate (individually) fizzy drinks, crisps & chocolate helps • Treatment can include Corlan pellets, steroid in orobase (protects and a small amount of steroid) Tetracycline mouthwash in adults (not pregnant)

30. Gengigel (Hyaluronic acid) gives good pain relief and accelerates healing – useful in children as non-irritant • More severe cases require a steroid inhaler or betnesol mouthwashes (occasional use) • Systemic steroids on rare occasions (short course)

31. Systemic therapy • Prednisolone • Burst therapy (5-30mg once in morning for 5 days) • Immunomodulator • Azathioprine • Colchicine • Thalidomide (TNF- inhibitor)

32. Guidelines for prescribing topical steroids for oral lesions • Topical medications are effective on contact therefore anything by mouth should be avoided for ½ -1 hr • Gel applied directly on lesion after meals & at bedtime 3-4 times daily • Could apply it on gauze for large lesions for 15-30 min

33. Guidelines for prescribing systemic steroids for oral lesions • Tapering of prednisolone is not necessary with 5-7 days burst therapy • Tapering of prednisone is not necessary with alternate day therapy if dose did not exceed 20 mg • 30-60 mg AM X 5 days followed by 5-20 mg AM every other day

34. Behcet’s Syndrome • RAS • Ocular – uveitis,optic atrophy,retinal vasculitis • Genital ulceration • Dermatological eg. Pustules • Neurological – symptoms like MS • Joint disease – recurrent arthralgia • Others – eg.depression • Strong association with HLA B5

35. Epidemiology • The usual onset of the disease is in the third and fourth decade of life. • Male to female ratio is approximately equal.

36. Epidemiology • Prevalence in Turkey 80-370:100,000 • Prevalence in UK (0.3-0.5):100,000

37. Behcet’s • Affects persons of Mediterranean, Middle Eastern, or Japanese decent • Easily confused with Stevens-Johnson syndrome or Reiter’s disease • Need referral for systemic treatment

38. Treatment • Multidisciplinary approach • Systemic therapy • Corticosteroid • Azathioprine • Colchicine • Thalidomide (TNF- inhibitor)

39. Viral Oral Ulceration • Tends to be all over the mouth, including keratinised epithelium • Usually extensive ulceration • If primary HSV, may be preceded by flu-like illness and no previous history of cold sores • If secondary HSV, should be history of cold sores

40. Dermatological causes of oral ulceration • Lichen planus • Lupus • Vesiculobullous disorders • Erythema multiforme

41. Oral Lichen Planus • A common chronic inflammatory mucocutaneous disorder which affects the skin and mucous membranes (mainly mouth) • Occurs in approximately 1% of the population, usually in middle age and is slightly more common in females

42. Clinical presentation • Reticular – often symptoms of roughness rather than pain • Papular – raised white areas of 1-2mm in diameter • Plaques – homogeneous leukoplakia, more usual in smokers • Atrophic – thin mucosa, red but not ulcerated and often painful • Erosive – frank painful ulcers • Bullous – vesicles or small blisters within white patches

43. Ulcerative Lichen Planus • Erosive or desquamative types • Intermittent ulcers for up to 20 years • If unilateral may be lichenoid - ? Related to old amalgam or other contact allergy • Can be drug related • Usually striae present

44. If lichenoid try to eliminate allergen, whereas treat LP symptomatically & attempt to eliminate ulceration • Attempt to maintain intact mucosa i.e. revert to white patch or striae • Use potent steroids with caution in case of potential risk of malignant change

45. OLP – malignant transformation risk • Erosive & plaque variants • ~ 1% over 5-10 year period • Dysplastic lichen planus

46. Lupus • Discoid (DLE) • Systemic (SLE) • “Butterfly” rash on face • Oral red/white patches • Sunray appearance • Oral ulceration • Sjogren’s & TMJ disease - autoimmune • Oral malignancies

47. Vesiculobullous disorders • Pemphigus • Pemphigoid • Erythema multiforme (also under allergy)

48. Pemphigus • An autoimmune disorder characterised by widespread bullous or blistering eruptions of skin and mucous membranes • Potentially fatal as there is gross loss of fluids and electrolytes as well as wound infections • 70% present in mouth first (50% in mouth only)

49. Usually the elderly Rarely see blisters – usually irregular ulcers and skin tags Usually on areas of pressure (e.g. denture) May present as a sore throat Ulcers differ from RAS as bigger, present inolder people and are persistent. Most common type of oral presentation is P. vulgaris Need to treat for life as potentially fatal and autoimmune.

50. Pemphigus • Not easily distinguished from pemphigoid, which is not fatal, but can cause blindness as can involve eyes and scarring causes opacity (symblepharon)