Everyday Encounters with Oral Pathology:
Review, Refresh, Discover
NCDHAAS
Fall Meeting
October 24, 2014
Hickory, North Carolina
Presented by: Alice E. Curran, DMD, MS
University of North Carolina School of Dentistry
Division of Oral and Maxillofacial Pathology
Chapel Hill, NC 27599
alice_curran@unc.edu
Differential Diagnoses, Management Plans
And Supplementary Material
Differential Diagnosis for White Lesions
Differential Diagnosis for Mixed Red-and-White Lesions
Differential Diagnosis for Ulcerative Conditions
Differential Diagnosis and Treatment for a Tongue Mass
Differential Diagnosis and Treatment for a Palatal Mass
Differential Diagnosis for Blue/Brown Oral Pigmented Lesions
Differential Diagnosis for a Neck Mass
Managing Xerostomia
Managing Oral Candidiasis
Performing an Oral Cytologic Smear
Clinical Features of Recurrent Aphthous Ulcers versus Herpes Simplex
In Immunocompetent Patients
Managing Recurrent Aphthous Ulcers
Managing Recurrent Herpes Simplex Infection
Prescription Rx Recipes and Formulas
Diseases Associated With Desquamative Gingivitis
Drugs Associated With Osteonecrosis of the Jaws
Syndromes Associated With Hereditary Gingival Overgrowth
Oral Squamous Cell Carcinoma: 5-year Survival by Stage at Diagnosis
Critical Evaluation of Diagnostic Aids for the Detection of Oral Cancer
2
NCDHAAS
Fall Meeting
October 24, 2014
Title: Everyday Encounters with Oral Pathology: Review, Refresh, Discover
Course Description:
Using a series of clinical and radiographic cases, this course will review and expand upon basic oral
pathology what we all learned in school, to include updates on familiar concepts as well as discuss newlyevolving issues facing dental and dental hygiene practice today.
Objectives:
At the end of the course, the participant will be able to:
1) Recognize common oral lesions that are encountered in daily practice, using both clinical photos
and radiographs.
2) Discuss variations of common lesions that affect the periodontium that are unrelated to plaque.
3) Discuss lesions associated with various forms of trauma or irritation.
4) Apply current management protocols for common and not-so-common oral lesions.
5) Discuss HPV-related oropharyngeal cancer; become prepared for changes as new information
evolves in the coming years.
6) Discuss drug-associated osteonecrosis of the jaws and its management in general practice.
About The Presenter
Dr. Alice Curran is originally from Milford, Massachusetts. She began her dental career as a dental
hygienist. She graduated from Cape Cod Community College with an AS in Dental Hygiene and the
University of Rhode Island with a BS in Dental Hygiene. During dental hygiene school, histology and
oral pathology were her favorite courses. She completed the Pathology Education Master’s Degree
Program at Washington University School of Dental Medicine in St Louis, MO, where she was one of
five dental hygienists who studied general and oral pathology for two years. Following graduation with an
MS, she taught oral pathology, histology, periodontics and radiology at the University of Kentucky
Community College System Mobile Dental Hygiene Program for 10 years, during which time she also
practiced dental hygiene part-time. After that, she decided to pursue her DMD degree so that she could
attain certification as an oral pathologist. She graduated from the University of Kentucky College of
Dentistry and then completed the certificate program in Oral and Maxillofacial Pathology at Emory
University School of Medicine in Atlanta, GA. Her first academic position as an oral pathologist was at
the University of Mississippi where she taught dental and dental hygiene oral pathology courses for four
years. She has been on the faculty at UNC for 12 years. She is a Fellow in the American Academy of Oral
and Maxillofacial Pathology and a Diplomate of the American Board of Oral and Maxillofacial
Pathology. In addition to teaching dental hygiene and dental graduate students, she treats patients with
oral pathologic lesions, reads biopsies, conducts research and gives continuing education courses for
dentists and dental hygienists on current topics in oral pathology. Along with her friend and oral
pathology colleague, Dr. Sandra Myers of the University of Minnesota, she co-authored the new textbook
General and Oral Pathology for Dental Hygiene Practice published by FA Davis.
3
Differential Diagnosis for White Lesions
1. Does the lesion wipe off?
Yes :
Pseudomembranous candidiasis (perform smear)
Thermal or chemical burn including aspirin burn
Cotton roll burn
Toothpaste allergy
No
Frictional keratosis
Premalignant epithelial dysplasia
These lesions cannot be separated
by any clinical means; they must be
biopsied.
Squamous cell carcinoma
Hyperplastic candidiasis
Verrucous carcinoma
Others that may be have clinical differentiating features but must be
biopsied for confirmation:
-Reticular Lichen Planus-white lace-like pattern
-Lichenoid mucositis-white lace-like pattern near dental metal or in patient on certain
medications
-Oral hairy leukoplakia-vertical folds; patient will be immunocompromised ie, HIV or
transplant
-White sponge nevus-generalized to most mucosal surface; thick heavy plaques; family
members affected
-Submucous fibrosis- seen in users of betel quid, a tobacco/areca nut concoction
popular in Asia.
-Papilloma: finger-like projections
-Verruca vulgaris (common wart): raised with rough surface
4
Differential Diagnosis for Mixed Red-and-White Lesions
Lesions with Characteristic Clinical Features
-Geographic tongue-serpiginous/circinate white lesions with red atrophic centers; can
occur in other mucosal locations other than tongue
-Thermal burns-per patient history
-Nicotine stomatitis-white background with red papules in smokers or hot tea drinkers
-Cinnamon allergy-per patient history of use
-Scarlet fever (strawberry tongue)-per medical history
-Atrophic candidiasis-perform smear to confirm
Lesions with No Characteristic Clinical Features
Must be biopsied to establish diagnosis
-Premalignant epithelial dysplasia
-Carcinoma-in-situ
-Squamous cell carcinoma
-Histoplasmosis and blastomycosis infection (might have central ulcer)
-Traumatic granuloma (might have central ulcer)
-Erosive lichen planus-erosions with peripheral white striae may be seen
5
Differential Diagnosis for Ulcerative Conditions
Ulcers are focal lesions with loss of epithelium covered by a necrotic membrane.
They all appear as yellow/gray lesions with a red halo.
Acute
Short Duration
-Traumatic ulcer including Anesthetic necrosis - per history
-Recurrent aphthous ulcer: single ulcer on nonkeratinized tissue that does not overly bone
with no prodrome
-Herpes labialis or stomatitis: cluster of coalesced ruptured vesicles on keratinized bound
tissue preceded by prodrome
-Allergic reactions
-Herpangina-usually on soft palate as a cluster of small ulcers; fever and pain
-Herpes Zoster-looks like severe HSV but lasts longer and does not cross the midline
-Erythema multiforme-large ulcerated areas and target lesions on the skin
Chronic
Long Duration
-Squamous cell carcinoma- nonpainful ulcer with raised borders
-Traumatic granuloma- nonpainful ulcer with raised borders
-Erosive lichen planus
-Tuberculosis
-Histoplasmosis
-Wegener’s granulomatosis
-Cancers that have metastasized to the oral cavity from other parts of the body
-Major aphthous ulcers: multiple large ulcers with prominent borders; very painful; few
periods of remission; heal with scars; may be caused by Crohn’s disease or
immunosuppression; some cases are idiopathic.
6
Differential Diagnosis and Treatment for a Tongue Mass
Irritation fibroma: firm, dome-shaped mucosal-colored and the papilla on top become
short; usually has a history of injury or you can see the irritating tooth or partial. Biopsy.
Mucocele: we think of these on the lip but they can occur anywhere there are minor
salivary glands. They are fluctuant and usually on the anterior ventral tongue. Usually has a
history of injury to the area. Biopsy.
Granular cell tumor: will look much like a fibroma on the dorsum, with short or absent
papillae on the surface but there may not be a history or signs of trauma. You can feel it
within the body of the tongue but it feels well-defined. Biopsy.
Pyogenic granuloma: usually thought of on the gingiva of women but can occur on any
mucosal surface in anyone; usually red and white with ulceration, sometimes a bleeding
surface; can be tender; often a history of trauma. Biopsy.
Lingual thyroid: mucosal-colored mass behind the circumvallate papillae. Surface will be
intact with no ulcerations; mucosa may be thin and you might be able to see blood vessels
through the thin mucosa. Refer to ENT for thyroid scan. DO NOT REMOVE. This may be the
only functioning thyroid the patient has.
Salivary gland tumor: can be benign or malignant, usually benign; can occur anywhere that
there are minor salivary glands. Biopsy.
Traumatic granuloma: painless lesion with raised red borders with yellow necrotic center;
borders may be indurated; may be a history of repeated trauma to the area; most often
interpreted as a squamous cell carcinoma. Biopsy.
Squamous cell carcinoma: will have a variety of appearance from a flat white plaque to a
raised ulcerated red and white painless mass. Biopsy.
7
Differential Diagnosis and Treatment for a Palatal Mass
Anterior Palate
Nasopalatine duct cyst: soft swelling between #8 and 9; will be seen radiographically.
Biopsy.
Palatal abscess: fluctuant swelling with fistulous tract; test for tooth vitality; can be
associated with any tooth. Treat odontogenic infection.
Odontogenic tumor: not common on the anterior palate but if present will be close to the
teeth. Biopsy.
Note: Salivary gland tumors and mucoceles DO NOT occur in the anterior hard palate.
Posterior Hard Palate and Soft Palate
Torus palatinus: hard bony bump in midline that appears radiopaque on an occlusal film;
surface may be ulcerated if it is traumatized. No treatment.
Salivary Gland Tumor: either benign or malignant; soft but firm painless usually slowgrowing mass usually to the right or left of the midline; mucosal colored or red if ulcerated;
sometimes they are blue. Biopsy
Necrotizing sialometaplasia: a reactive response to an injury usually caused by a dental
injection or other injury that led to ischemia of the area; the anesthetic causes a mild
ischemia that causes death of the minor salivary glands near the greater palatine foramen
as well as the surface mucosa; appears as red ulcerated mass shortly after the injury. No
treatment.
Lymphoma: a malignancy that can be mucosal-colored and firm or red and white and
ulcerated with a boggy texture; usually appear over a short period of time; can be mistaken
for necrotizing sialometaplasia. Biopsy.
Neurofibroma: firm mucosal-colored mass; can occur on any oral surface but likes the
posterior hard palate near the greater palatine foramen. Biopsy.
Kaposi’s sarcoma: usually seen in immunocompromised patients (HIV+ or transplants
patients) as a well-defined or diffuse blue-purple mass, often in multiple locations. Biopsy.
8
Differential Diagnosis for Blue/Brown Oral Pigmented Lesions
All pigmented lesions of the oral cavity must be biopsied!
Exceptions: Ethnic Pigmentation and Amalgam Tattoo
But how do you know it is an amalgam tattoo?
Rule of Thumb for Managing an Amalgam Tattoo
If you see what you interpret to be an amalgam tattoo, radiograph it. If you see small
radiopaque bits of amalgam in the area of the oral lesion, then it is an amalgam tattoo. If
you cannot see any amalgam fragments, then the lesion must be biopsied. Sometimes the
amalgam has stained the tissue without leaving fragments. Only a biopsy can determine
this.
We are most concerned about melanoma in the oral cavity. It is rare. When it occurs, it
favors the gingiva and hard palate, but can occur anywhere. The following lesions are
benign but may have very close similarities to the appearance of an early melanoma:
Melanotic macule
Smoker’s melanosis
Melanocytic nevus
Melanoacanthoma
Drug pigmentation (can be differentiated by doing a compete drug history)
Café au lait pigmentation of neurofibromatosis or McCune-Albright syndrome (can be
differentiated from medical history)
9
Blue Lesions
Blue lesions are often confused with pigmented lesions because they are both dark. Blue
lesions are most often vascular (come from blood vessels) and are not pigmented, per se,
because they do not contain melanin pigment or pigment from foreign materials like
amalgam.
One way to differentiate a blue vascular lesion from a grey-brown pigmented lesion is to
use DIASCOPY: this involves putting pressure on the lesion and observing it for BLANCHING
(color fades and comes right back when pressure is released).
If the lesion is DIASCOPY +, then it is vascular. If it is DIASCOPY-, it is most likely pigmented
but some vascular lesions are Diascopy-. A biopsy can determine the difference.
Vascular Blue Lesions:
Varicosity (if there is a small clot in the vein, it may be diascopy+)
Hemangioma (most hemangiomas are congenital. It is unusual for an adult to develop a true
hemangioma.)
Hematoma: a bruise caused by local injury, usually blunt trauma.
Petechiae are usually red but will appear to contain blood. They are less than 1 mm in
diameter and occur in clusters.
Kaposi’s Sarcoma: malignant tumor made up of small blood vessels so it looks blue.
Non-vascular blue lesions
Mucoceles, ranulas and salivary gland duct cysts can occasionally be bluish in color. Never
occur on gingiva or anterior hard palate
Eruption cyst developing over an impacted tooth
Gingival cyst of the adult will be located within the zone of attached gingiva
10
Differential Diagnosis for a Neck Mass
Midline
Upper Neck:
Dermoid cyst
Salivary gland obstruction
Ranula
Salivary gland neoplasm
Thyroid area:
Thyroglossal duct cyst
Thyroid gland enlargement- goiter
Thyroid gland neoplasm
Lateral Neck
Reactive lymph nodes (reacting to infection)
Lymphoepithelial cyst (Branchial cleft cyst)
Cystic hygroma (cervical lymphangioma in children)
Metastasis of oral cancer to lymph nodes
Lymphoma (cancer of lymph nodes)
Lipoma (benign fat tumor)
Salivary gland tumor (upper neck)
11
Managing Xerostomia
Many OTC commercial saliva substitutes and commercial oral moisturizing gels are listed.
Other hints such as avoiding caffeine and cola, avoiding alcohol containing products, avoiding tobacco,
humidifying the area, and coating the lips are included.

OTC: SalivaSure salivary stimulant. Available on-line
Information: http://www.scandinavianformulas.com/salivasure.html
Purchase: www.vitacost.com
OTC: OraMoist Dissolvable Discs
Information
OTC: XyiMelts Mint and regular

OTC: Biotene products from Laclede. Toothpaste and mouthwash feel gentle to irritated
tissues. Lubricating gel and liquid help keep mouth moist. They do not medically treat xerostomia
but provide great comfort for the tender mouth. They will send samples to your office.
http://www.laclede.com/

Address: 2103 East University Drive, Rancho Dominguez, CA 90220

Customer Service Toll-Free: 1-800-922-5856

OTC MedOral Dry Mouth Spray. This was initially recommended by patients who were
given it while in hospital, but it is available for purchase toll free 1-866-887-4867 or
www.BHMLABS.com.

RX: Aquoral spray, a plant lipid based product for dry mouth symptoms. RX: Aquoral
protective oral spray, 40 ml, 2 sprays 3-4x daily. It has a mild citrus flavor.
Information: http://www.aquoral.com/ No Longer Available
RX: Caphosol artificial saliva, New product for dry mouth symptoms and to prevent damage to teeth
(artificial saliva and remineralizing solution) 4 boxes (12-30 days supply @4-10x daily) Rinse as
instructed 4x daily and increase as needed up to 10x daily. Refill one year.
Information :http://www.caphosol.com/new/default.asp
Prescribing information: http://www.caphosol.com/new/03_default.asp
Note: This was developed for cancer patients, but it can be used by anyone with dry mouth and oral
pain or mucositis. Mix solutions together in cup, swirl together, swish with mouthful for one minute
and spit out. Repeat with remainder of the solution. If swallowed accidentally no adverse effects
are anticipated. Do not eat or drink for at 30 minutes after use. No product-related adverse effects
or drug interactions have been reported. It may taste salty to some.
12
CONDITION SHARED BY Managing Oral Candidiasis
Angular cheilitis (perleche):
Vytone cream applied 3-4 times per day or Information: http://products.sanofiaventis.us/Vytone/vytone.html
Alcortin A
Oral candidiasis:
Selection of product depends on compliance issues and drug interactions for the particular patient.
If Diflucan is contraindicated because of a possible drug interaction with another drug the patient is
taking, then an oral rinse or lozenge is indicated. If the patient cannot follow instructions for
swishing or sucking on a lozenge, then systemic medication may be the choice-- if there are no
potential drug interactions.
Topical Antifungals:
-Nystatin oral suspension 100,000 units: Rinse 1 teaspoon for 2 minutes; spit; NPO 30 minutes.
Repeat 4-5 times per day for 2 weeks.
-Mycelex troches 10 mg: Dissolve one troche 4-5 times per day; NPO 30 minutes.
NOTE: If patient wears a denture or RPD, it must be removed while using these medications because
they work by direct contact to kill the fungal organisms. The prosthesis will block the drug from
touching the tissue.
Systemic Antifungals:
Fluconazole 100mg tabs. Take 200 mg on Day 1 and 100 mg for each day thereafter for 2 weeks.
Check for drug interactions before prescribing.
There is no strong research evidence to support soaking a denture or partial in an antifungal soak
to kill candida. However, if this step is desired, use chlorhexidine for any prosthesis that contains
metal framework. For acrylic- based prostheses, use 1:20 solution of household bleach in a denture
cup overnight. Scrub well in the morning. A stronger solution will bleach the acrylic.
13
PERFORMING A CYTOLOGIC SMEAR
1. Do NOT wipe or otherwise disturb the area you wish to sample. This may cause a false
negative result. A smear is best taken at the beginning of an appointment.
2. Write the patient’s name in PENCIL NOT PEN on the frosted end of the glass slide.
3. IF THE PATIENT HAS A VERY DRY MOUTH, have them rinse gently with a little water
without spitting before the specimen is collected.
4. Using a dental cement spatula OR a damp wooden tongue blade, firmly wipe the area.
Use enough strokes to collect a visible accumulation of oral fluids.
5. Transfer the fluids to a clean dry glass slide. Smear the sample across the slide to make a
thin coat. Hold the glass slide up to the light. If you can see the sample on the slide, you
have enough. Do not overload the slide. Repeat in another area if necessary to obtain an
adequate sample.
6. Spray Cytofix on the slide from a distance of about 8 inches. DO NOT spray too closely to
prevent rinsing the cells off the slide. Do not overspray; one or two swipes should be
enough. If you do not have CytoFIX, you can use any hairspray that contains alcohol.
7. Allow the slide to dry for a few minutes and place in the slide container.
8. Fill out the patient history and submission form.
9. Send to the Oral Pathology Laboratory of your choice.
You may obtain cytology kits from:
Oral Pathology Laboratory
University of North Carolina School of Dentistry
5603 Oral Health Sciences Building
CB 7455
Chapel Hill, NC 27599
919 537-3155
14
Clinical Features of Recurrent Aphthous Ulcers versus Herpes Simplex
In Immunocompetent Patients
Feature
Minor RAU
Etiology
Localized
immune defect
No
Prodrome
Herpetiform RAU
Major RAU
Herpes
Localized immune Systemic immune Herpes simplex
defect
disorder
virus
No
No
Yes
Intraoral
location
Preceding
vesicle
Ulcer
appearance
Nonkeratinized
mucosa
No
Nonkeratinized
mucosa
No
Nonkeratinized
mucosa
No
Keratinized
mucosa
Yes
Single;
less than 5 mm
Cluster
less than 5 mm
Cluster that
coalesces into
large ulcers
Remission
period
Extraoral sites
Yes
Yes
1 - single, large
deep, irregular
rolled border
2 - cluster
No
No
No
No
Yes
Diagnosis
Clinical features
Clinical features
Systemic disease
consultations
Treatment
Topical antiinflammatory
drugs
Topical antiinflammatory
drugs
Yes
Clinical
features;
cytologic
smear
Systemic
Topical
management of
antiviral drugs
underlying
during
disease;
prodrome
Systemic
only;
immunomodulary
Systemic
drugs for
antiviral drugs
idiopathic
for severe
etiology
recurrent cases
15
Managing Recurrent Aphthous Ulcers
Minor recurrent aphthous ulcers are a self-limiting disease.
They resolve 7-10 days without treatment and in 7-10 days with treatment.
The key to successful treatment is to avoid the trigger in the first place!
Many over-the-counter medications are available. Most are either analgesics that reduce the pain or
they are anti-inflammatory agents that reduce the healing time by about 1 day. Products are too
numerous to list. The all work very much the same.
New Product: Avamin Melts
Cauterizing agents “burn” the affected tissue; this reduces pain and speed the healing. The theory is
that a regular “burn” will heal faster than an aphthous ulcer.
These agents CANNOT be given to patients. They must be used in the office
by the dentist.
Available agents:
Debacterol: http://www.debacterol.com/
Silver nitrate sticks: http://www.aafp.org/afp/20010901/letters.html
Hold the solution directly on the ulcer UNTIL IT TURNS WHITE. THEN STOP IMMEDIATELY.
Use these with CAUTION as overuse may actually cause more tissue damage, more pain and longer
healing times.
16
Managing Recurrent Herpes Simplex Infection
Recurrent herpes simplex infection is a self-limiting disease. Lesions heal in 10-14 days without
treatment and 10-14 days with treatment.
The key to successful treatment is to avoid the trigger in the first place!
The key to reducing healing time of the ulcers is to treat skin or mucosa during the PRODROME. This
is the period of itching or tingling that occurs BEFORE there is actual clinical evidence of a lesion (a
small blister also called a vesicle. In herpes, these form in small clusters, then coalesce to form one
or two larger blisters.). This period may last hours or minutes, so the window of opportunity to treat
them is VERY SMALL. NOTHING WORKS AFTER THE LESION APPEARS! Any treatment after that is
palliative only.
Any of the several OTC products available only work in the prodrome.
Several prescription topical agents also are available but do not speed healing by more than 1-2 days
and are most effective during the prodrome. One is Denavir: http://www.denavir.com/
If the patient has frequent serious outbreaks of recurrent herpes labial or herpes stomatitis, then
consider prophylactic antiviral therapy with Valtrex. The recommended dose for VALTREX is 2 grams
taken at the first sign of a cold sore prodrome, and then again about 12 hours later. (One day
therapy ONLY) It’s important to start treatment with VALTREX at the first sign of a cold sore (such as
tingling, itching, or burning). There are no studies that show if VALTREX works when used after the
appearance of a cold sore.
http://www.valtrex.com/coldsores/whatis_coldsore.html
17
Magic Mouthwash
Prescription Rx Recipes and Formulas
There is no standard formula for Magic Mouthwash. You will find many!
When the pharmacy gets a prescription for Magic Mouthwash, the pharmacist
compounds according to the prescribing physician's instructions or recipe.
Many health care providers assume there is ONE formulation and don't know the exact
ingredients or proportions. When a prescription for Magic Mouthwash is given to a
patient, it must contain specific ingredients and amounts, so the pharmacist knows
which one to make.
Here are some of the more common adult formulations
Keep in mind that most of these are low potency.
Adding Nystatin to an elixir for a patient with no evidence of candidiasis may help
promote resistance.
Patients generally DO NOT LIKE viscous lidocaine. Avoid it!!
Swallowing is not recommended. Most ingredients are inactivated in the stomach so
there is no systemic benefit. Besides, they may cause gastric irritation.
These formulations are not potent enough for vesiculoerosive disorders such as
erosive lichen planus and pemphigoid.
Magic Mouthwash Recipe 1
Use: Minor erosive or ulcerated lesions in patient with or with history of
candidiasis
Rx:






80 ml viscous lidocaine 2% (only with severe pain)
80 ml Mylanta
80 ml diphenhydramine 12.5 mg per 5 ml elixir
100 ml nystatin 100,000U suspension
120 ml prednisolone 15mg per 5ml solution
80 ml distilled water
Sig: Swish, gargle, and spit one teaspoonful every 3-4 hours as needed.
18
Magic Mouthwash Recipe 2
Use: Symptomatic geographic tongue
Rx:



1 Part viscous lidocaine 2% (only with severe pain, otherwise leave it out)
1 Part Maalox (do not substitute Kaopectate)
1 Part diphenhydramine (12.5 mg per 5 ml elixir)
Quantity: 120 ml
Sig: Swish, gargle, and spit one teaspoon every 3-4 hours as needed.
Magic Mouthwash Recipe 3
Use: Minor erosive or ulcerated lesions in patient without candidiasis
Rx:




30 ml viscous lidocaine 2% (only with severe pain)
60 ml Maalox (do not substitute Kaopectate)
30 ml diphenhydramine 12.5 mg per 5 ml elixir
40 ml Carafate 1 gm per 10 ml
Sig: Swish, gargle, and spit one teaspoon every 3-4 hours as needed.
Magic Mouthwash Recipe 4
Use in conjunction with topical corticosteroid application for mild erosive lichen
planus in patient with history of candidiasis
Rx:





120 ml dexamethasone (0.5 mg per 5 ml elixir)
60 ml nystatin 100,000U suspension
100 ml diphenhydramine (12.5 mg per 5 ml elixir)
1000 mg tetracycline (contents of 2 capsules tetracycline 500 mg)
Sig: Swish, gargle, and spit one teaspoonful every 3-4 hours as needed.
19
Patients with erosive lichen planus or other autoimmune vesiculoerosive disorder
should be referred to an oral pathologist for management.
Once the disease is under control, they can be maintained in the general dental
office.
20
Diseases Associated With Desquamative Gingivitis
DISEASE
CLASSIC INTRAORAL
FEATURES
EXTRAORAL SIGNS
Erosive lichen
planus
Wickham’s striae at
border of ulcer or erosion
Mucous
membrane
pemphigoid
Vesicles that rupture;
Purple polygonal
pruritic plaques on skin
of extremities
Symblepharon;
Positive Nikolsky’s sign
Tense bullae on skin
Pemphigus
vulgaris
Additional intraoral sites,
rarely gingiva alone;
Flaccid bullae on skin
Desmosomes
Erosive skin lesions
Basement
membrane zone
Rare
Nuclei of basal and
lower spinous cells
Scaly skin patches;
“butterfly rash”; altered
pigmentation
Basement
membrane zone
Linear IgA
disease
Chronic
ulcerative
stomatitis
Discoid lupus
Positive Nikolsky’s sign
Lesions heal with scarring;
Occasional “blood”
blisters
Similar to erosive lichen
planus but does not
respond to steroids;
No Nikolsky’s sign
White plaques with
papular rimming
TARGET OF
AUTOANTIBODIES*
*Target of T-cells
is bsal cells
Hemidesmosomes
21
Traumatic Ulcerations of the Oral Mucosa
Traumatic ulcer
Traumatic ulcerative
granuloma
Denture ulcer
Anesthetic necrosis
Thermal burn
Electrical burn
Chemical burn
Etiology
Physical injury such as
biting the tongue or
contact with sharp
object
Traumatic ulcer that
receives persistent mild
chronic trauma
New denture with illadapted flange;
prolonged denture
wearing
Ischemia from
epinephrine in local
anesthetic or trauma
during injection
Contact with hot foods
such as pizza
Contact with live
electrical cord or
extension cord
Contact with caustic
medications, dental
materials, improper use
of analgesics, mouth
rinses
Clinical Features
Usually single, well-defined area of erythema
surrounding yellow fibrinopurulent membrane;
slightly raised border; tender/painful; resolves in 7
to 10 days with removal of etiology
Long duration; raised rolled border; crater with
yellow fibrinopurulent membrane; nonpainful or
mildly tender; slow to resolve with removal of
etiology; often requires surgical excision and
healing by primary intention
Ovoid erythematous area with yellow necrotic
center; contacts irregular area of denture; resolves
with denture adjustment
Usually on hard palate at injection site; painful welldefined intense red area with central necrosis; heals
without treatment in 10 to 14 days
Painful yellow to white zone of necrosis of surface
mucosa of palate or buccal mucosa; tissue sloughs;
patient reports etiologic event; resolve with no
treatment
Yellow to black painless area that gradually
becomes edematous; sloughs and bleeds; usually on
lips of children
Superficial white corrugated or “cracked”
appearance; epithelium sloughs leaving red painful
surface; resolves without treatment in 10 to 14 days
22
Drugs Associated With Osteonecrosis of the Jaws
Drug
Intravenous
Bisphosphonates
Pamidronate
Zoledronic acid
Trade Name
Aredia
Use
Indications
Metastasis of cancer to bone; multiple
myeloma
Zometa
Metastasis of cancer to bone
Zoledronic acid
Reclast
(once annually)
Osteoporosis
Boniva
(every 3 months)
Osteoporosis
Oral Bisphosphonates
Alendronate
Fosamax
Osteoporosis
Ibandronate
Boniva
Osteoporosis
Risedronate
Monoclonal Antibodies
Denosumab
Actonel
Osteoporosis
Prolia
Metastasis of cancer to bone; multiple
myeloma; osteoporosis
Bevacizumab
Avastin
Breast cancer relapse; prostate cancer
metastasis
Ibandronate
23
Syndromes Associated With Hereditary Gingival Overgrowth
SYNDROME
OROFACIAL CHARACTERISTICS OTHER FEATURES
Rutherford
Delayed eruption; dentigerous
Mental retardation; corneal
cysts
opacities
Defects of ears, nose
Hepatosplenomegaly; defects of
Zimmerman-Laband
fingers
Cowden
Papillomatosis of gingival, oral
Hamartomas; neoplasms
mucosa, and face
Goltz-Gorlin
Gingival, oral papillomatosis;
Poikiloderma; adactyly;
lip and tooth defects
syndactyly; 90% female
Murray-Puretic-
Fibromas of head, trunk, and
Suppuration of skin and
Dresher
extremities
mucosa; mental retardation;
flexion contractures
Cross
Ramon
Microphthalmia;
White hair; mental retardation;
hypopigmentation
athetosis; corneal clouding
Hypertrichosis; cherubism
Juvenile rheumatoid arthritis;
mental retardation; epilepsy
24
Oral Squamous Cell Carcinoma: 5-year Survival by Stage at Diagnosis
Stage I
Stage II
Stage III
Stage IV
Posterior tongue
<t>60%
50%
20%
20%
Anterior tongue
71%
59%
47%
37%
Floor of mouth
73%
60%
36%
30%
Gingiva
90%
90%
90%
35%
Retromolar area
90%
90%
90%
60%
Soft palate
90%
80%
50%
50%
Buccal mucosa
90%
90%
70%
60%
Lip
96%
83%
57%
48%
Tonsil
70%
50%
30%
14%
Maxillary sinus
70%
60%
30%
18%
Site
Retrieved August 2012 from www.cancer.org/.../oral-cavity-and-oropharyngeal-cancer-survivalrates
25
Critical evaluation of diagnostic aids for the detection of oral cancer.
Lingen MW1, Kalmar JR, Karrison T, Speight PM.
1
Oral Oncology. 2008 Jan;44(1):10-22
Abstract
Historically, the screening of patients for signs of oral cancer and precancerous lesions has relied upon
the conventional oral examination. A variety of commercial diagnostic aids and adjunctive techniques are
available to potentially assist in the screening of healthy patients for evidence of otherwise occult
cancerous change or to assess the biologic potential of clinically abnormal mucosal lesions. This
manuscript systematically and critically examines the literature associated with current oral cancer
screening and case-finding aids or adjuncts such as toluidine blue, brush cytology, tissue reflectance and
autofluorescence. The characteristics of an ideal screening test are outlined and the authors pose several
questions for clinicians and scientists to consider in the evaluation of current and future studies of oral
cancer detection and diagnosis. Although the increased public awareness of oral cancer made possible
by the marketing of recently-introduced screening adjuncts is commendable, the tantalizing implication
that such technologies may improve detection of oral cancers and precancers beyond conventional oral
examination alone has yet to be rigorously confirmed.
Am Dent Assoc. 2010 May;141(5):509-20.
Evidence-based clinical recommendations regarding screening for
oral squamous cell carcinomas.
Rethman MP1, Carpenter W, Cohen EE, Epstein J, Evans CA, Flaitz CM, Graham FJ, Hujoel PP, Kalmar
JR, Koch WM, Lambert PM, Lingen MW, Oettmeier BW Jr, Patton LL, Perkins D, Reid BC, Sciubba JJ,
Tomar SL, Wyatt AD Jr, Aravamudhan K, Frantsve-Hawley J, Cleveland JL, Meyer DM; American Dental
Association Council on Scientific Affairs Expert Panel on Screening for Oral Squamous Cell Carcinomas.
Abstract
BACKGROUND:
This article presents evidence-based clinical recommendations developed by a panel convened by the
American Dental Association Council on Scientific Affairs. This report addresses the potential benefits
and potential risks of screening for oral squamous cell carcinomas and the use of adjunctive screening
aids to visualize and detect potentially malignant and malignant oral lesions.
TYPES OF STUDIES REVIEWED:
The panel members conducted a systematic search of MEDLINE, identifying 332 systematic reviews and
1,499 recent clinical studies. They selected five systematic reviews and four clinical studies to use as a
basis for developing recommendations.
RESULTS:
26
The panel concluded that screening by means of visual and tactile examination to detect potentially
malignant and malignant lesions may result in detection of oral cancers at early stages of development,
but that there is insufficient evidence to determine if screening alters disease-specific mortality in
asymptomatic people seeking dental care.
CLINICAL IMPLICATIONS:
The panel suggested that clinicians remain alert for signs of potentially malignant lesions or early-stage
cancers while performing routine visual and tactile examinations in all patients, but particularly in those
who use tobacco or who consume alcohol heavily. Additional research regarding oral cancer screening
and the use of adjuncts is needed.
27
HPV-Linked Oral Cancers May Not Be 'Contagious'
Kissing doesn't seem to raise rate of viral infection between committed partners, study
finds
WebMD News from HealthDay
By Dennis Thompson
HealthDay Reporter
TUESDAY, April 29, 2014 (HealthDay News) -- Romantic intimacy in long-term relationships often suffers
when one partner gets a diagnosis of mouth or throat cancer caused by HPV, the sexually transmitted
human papillomavirus. But new research suggests these couples can kiss as much and as deeply as they
ever have, without worry.
Spouses and long-term partners of patients with HPV-related oral cancers appear to have no increased
risk of oral HPV infections, according to the results of a new study led by Johns Hopkins investigators.
Saliva samples taken from the partners of oral cancer patients did not contain elevated levels of HPV
DNA, the researchers reported online April 28 in the Journal of Clinical Oncology.
The prevalence of HPV among spouses and partners -- about 1.2 percent -- is comparable to the 1.3
percent prevalence of HPV among the general population of the same age, the researchers found.
Experts welcomed the findings.
"This study does put the risk in perspective. It's not something you need to freak out about, or
substantially alter your lifestyle. You can still smooch your sweetie," said Fred Wyand, spokesman for the
American Sexual Health Association.
HPV-related oral cancers are increasing among white men in the United States, with the virus now
associated with nearly three out of four cases of oropharyngeal cancer, according to a 2011 report in the
Journal of Clinical Oncology. These include cancers of the base of the tongue, tonsils, soft palate and
pharynx. Although sexual behavior is associated with oral HPV infection, it's not fully clear how the
cancer-causing virus is transmitted or progresses, according to background information in the new report.
Once diagnosed, fear of HPV transmission can lead to anxiety, divorce and curtailing of sex and intimacy
among couples, said the study's lead author, Gypsyamber D'Souza, associate professor of epidemiology
at the Johns Hopkins Bloomberg School of Public Health.
New York City oncologist Dr. Dennis Kraus said it's normal for older couples in long-term relationships to
become unsettled by the news that one of them has mouth and throat cancer caused by a sexually
transmitted virus.
"They think, 'What kind of a relationship am I involved in? Who is this person?' Many of them have
grandchildren and even great-grandchildren and now they have to be worried about their progeny being
exposed to this disease," said Kraus, director of the Center for Head and Neck Oncology at Lenox Hill
Hospital.
To confront these concerns, researchers took mouth-rinse samples from 164 patients with HPV-related
oropharyngeal cancer and 93 partners. They then ran DNA tests for 36 strains of HPV.
Nine out of 10 of the oral cancer patients were men, and nearly all had performed oral sex in the past.
They were in their 50s and early 60s. More than half of the cancer patients had detectable HPV in their
saliva at the time of the test, but the virus showed up in only 1.2 percent of the partners tested.
"While oral HPV DNA was common in people with cancer, their spouses did not have an elevated
prevalence," D'Souza said. "That suggests either oral HPV is not being transmitted in the saliva when the
partners kiss, or they have effectively cleared the infections they've been exposed to."
28
D'Souza said that most people clear HPV infections within a year or two, and persistent infections can
take many years to lead to cancer.
"Partners who have been together for many years have already shared any infections they are going to
share," she said.
However, new romantic partners should know that they stand a chance of being infected with oral HPV,
even though the infection may not be long-lasting, said Dr. Snehal Bhoola, a gynecologic oncologist with
Arizona Oncology, a US Oncology Network affiliate in Phoenix.
"It is possible that HPV may be transmitted to new partners, but this appears to be cleared within one to
two years in the majority of patients," Bhoola said. Female partners of HPV-positive patients should
continue routine cervical cancer screening per recommended guidelines, he added.
While most people acquire an oral HPV infection by performing oral sex, researchers have not yet tackled
whether it can work the other way -- a person with oral HPV transmitting the virus to their partner's
genitals during oral sex, D'Souza said.
29