Differential Diagnoses and Treatment of Oral Lesions - PowerPoint PPT Presentation

1 / 65
About This Presentation
Title:

Differential Diagnoses and Treatment of Oral Lesions

Description:

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Oral Candidiasis An opportunistic organism which tends to ... – PowerPoint PPT presentation

Number of Views:466
Avg rating:3.0/5.0
Slides: 66
Provided by: agons
Category:

less

Transcript and Presenter's Notes

Title: Differential Diagnoses and Treatment of Oral Lesions


1
(No Transcript)
2
Differential Diagnoses and Treatment of Oral
Lesions
  • Susan Müller, DMD, MS
  • Professor
  • Department of Pathology
  • Department of Otolaryngology
  • Winship Cancer Institute
  • Emory University School of Medicine

3
GoalsFocus on 5 common benign conditions in the
oral cavity
  • Mouth Ulcers
  • Aphthous Ulcers
  • Herpes Simplex Virus 1
  • Oral Lichen Planus
  • Geographic tongue
  • Candidiasis
  • Burning Mouth Syndrome

4
Goals
  • Discuss clinical presentation, differential
    diagnosis and treatment

5
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

6
Aphthous Ulcers
7
Recurrent minor aphthous ulcer
? 1 cm fibrinopurulent membrane surrounded by
erythema
8
Aphthous Ulcer - Triggers
  • Decrease in the mucosal barrier
    Trauma,pernicious anemia
  • Increase in antigenic exposure
  • Foods, flavoring agents
  • Primary immunodysregulation
  • Behcets, Crohns, celiac disease,
  • cyclic neutropenia, AIDS, stress

9
Recurrent Orolabial HSV1
10
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

11
Aphthous Ulcer vs HSV
Prodrome sometimes usually
Duration 10-14 days 10-14 days
Location Nonkeratinized - buccal mucosa, ventral tongue, soft palate Keratinized gingiva, lip, hard palate
12
Treatment for Aphthae Topical steroids either
rinse or cream/gel Systemic steroid good for
multiple lesions or those in the oropharynx
Bloodwork
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 mins
  • For 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 Aphthae
  • Intralesional steroid injection-about 0.3-0.5 cc
    of 40mg/cc triamcinolone

15
TreatmentRecurrent HSV Infection
  • Topical
  • RX Acyclovir 5ointment (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

16
Recurrent HSV Treatment
  • Systemic
  • 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.

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.

18
(No Transcript)
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 gingivitis
  • 1 of individuals develop full-blown primary
    herpetic gingivostomatitis ? temp, regional
    lymphadenopathy, difficulty eating

20
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

21
(No Transcript)
22
Treatment for Primary HSV-1
  • RX
  • Acyclovir 400 mg
  • Disp 32 capsules
  • Sig 2 capsules tid for the first 3 days then 1
    capsule bid for 7 days
  • RX
  • Famvir 500 mg
  • Disp 20 tablets
  • Sig 1 tablet bid for 10 days

23
Oral Lichen Planus
Oral Lichen Planus
24
  • Reticular form
  • Most common
  • asymptomatic
  • Wickhams striae
  • Bilat BM, tongue, gingiva, palate, vermilion
    border
  • Plaque form
  • Dorsal tongue

25
  • Erosive OLP
  • less common
  • symptomatic
  • Atrophic erythematous areas with central
    ulceration
  • bordered by fine, white radiating striae

26
Treatment of Erosive OLP
Decadron elixir 0.5 mg/ 5ml Disp 500 ml 1 tsp
qid, hold 3mins, spit out, no food/liquid for
30mins
  • Compounded rinse
  • Triamcinolone rinse 4mg/ml
  • Severe systemic
  • prednisone

27
Gingival Lichen PlanusTreatment
  • In addition to the steroid mouthrinse
  • Doxycycline 100mg QD for 90 days then reevaluate

28
Oral Lichen PlanusDifferential Diagnosis
  • Oral lichenoid drug reactions to systemic drugs
  • Oral lichenoid contact-sensitivity
  • Lichenoid dysplasia
  • Chronic graft-versus-host disease

29
Geographic 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.

30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
Treatment 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.

34
Oral Candidiasis
  • An opportunistic organism which tends to
    proliferate with the use of broad-specturm
    antibiotics, corticosteroids, cytotoxic agents
    and medications that reduce salivary output

35
(No Transcript)
36
(No Transcript)
37
Candidiasis
38
(No Transcript)
39
Hairy Tongue
40
Hairy Tongue
A coated tongue does not automatically mean the
patient has a yeast infection
41
Angular Cheilitis
42
High-arched palate
43
Steroid Inhalers Can Cause Oral Candidiasis
44
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

45
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

46
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

47
(No Transcript)
48
Erythematous Candidiasis
49
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.

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 why
  • B12 low B12 is pernicious anemia which increases
    with age

51
(No Transcript)
52
(No Transcript)
53
Persistent Candidiasis
  • Check glucose levels May be undiagnosed diabetic
  • Poorly controlled diabetic
  • Check thyroid levels
  • Is patient on chronic steroid or antibiotic use?
  • Xerostomia

54
(No Transcript)
55
(No Transcript)
56
(No Transcript)
57
Burning Mouth Syndrome
  • Synonyms
  • Burning Tongue
  • Glossodynia
  • Scalded Mouth Syndrome
  • Glossopyrosis

58
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

59
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

60
Epidemiology of BMS
  • 92 - report more than one site
  • 43 - taste disturbance
  • 59 - milder after waking
  • 75 - worse in the evening
  • 61 - parafunctional habits

61
Sites of Discomfort in BMS
frequency
  • Tongue most affected site
  • Anterior hard palate
  • Lips
  • Lower denture bearing area
  • Throat
  • Floor 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 20-40 mg (better tolerated in
    elderly

64
Treatment of BMS
  • Topical capsaicin local desensitization
  • ?lpha lipoic acid 600 mg daily (200mg TID with
    meals)

65
OH, NO! Pete is that you???
Write a Comment
User Comments (0)
About PowerShow.com