3. Causes
• Excessive friction (e.g. intertrigo) , mainly from deep commisures or ill
fitting dentures
• Irritant contact dermatitis (also ACD,especially from denture material
or nail polish)
• Nutritional dermatosis (mainly iron, b12, folate, zinc deficiency)
• Infections: candida, impetigo, HSV
4. How to investigate?
History
• recurrent?
• Exacerbating factors?
• Nutritional history?
• Other symptoms of nutritional dermatitis?
• Habitual lip licking (also monitor during history :D)
• History of dentures
• K/C/O diabetes?
9. Candida/ICD/intertrigo
• Very frequently occur together
• Commonest cause of perleche/angular stomatitis
• Excessive saliva and friction around mouth leads to high moisture/maceration
followed by sudden dryness cracks and fissures ideal for candida
colonization
• The excessive saliva could be caused either by excessive lip licking, altered
mechanics/shape of lips from dentures and deep grooves and also open mouthed
sleeping
• Angular cheilitis, part 1: local etiologies Park KK, Brodell RT, Helms SE. Cutis
2011; 87: 289–95.
10. Treatment of candida/ICD/intertrigo
• First lines:
- Topical antifungals after each meal directly on the skin :antifungal and anti-
inflammatory effect
- Topical ointment (e.g. Aquaphor) above the antifungal each time: treats
fissures/cracks and works as a barrier to saliva, preventing ICD and
maceration
- Application of the ointment before sleeping
- Remove dentures every night
• Oral candidiasis and angular cheilitis Sharon V, Fazel N. Dermatol Ther
2010; 23: 230–42.
11. Treatment of candida/ICD/intertrigo
• Second lines:
- Addition of oral antifungal
- Addition of low potency topical steroid to the regimen
- Change dentures
- Filler injections
• Discussion of the evaluation and treatment of angular cheilitisEvren BA,
Uludamar A, Iseri U, Ozkan YK. Arch Gerontol Geriatr 2011; 53: 252–7
- Collagen implant in management of perleche (angular cheilosis)
Chernosky ME. J Am Acad Dermatol 1985; 12: 493–6.
13. Aphthous ulcers
• Most common cause of oral ulceration
• Affects 5-25% of the population
• Divided in two ways:
- Type of lesions: minor, major, herpetiform
- Simplex vs. complex
17. Causes of aphthous ulcers
• Largely idiopathic
• Some cases genetic
• Some from Nutritional deficiencies
• Some from Systemic disorders
• Some due to immunodeficiency (e.g. HIV)
• Some from environmental factors (e.g. stress)
• Some part of another disorder (e.g. IBD/Behcet/SLE) - not part of this
talk
19. DDx of Aphthous ulcers
• Aphthous ulcers in the context of another disorder (e.g. behcet)
• Infections (HSV, EBV, CMV, VZV, Syphilis, gonorrhoea, coxsackie,
Tuberculosis cutis)
• Reactive conditions (EM major/SJS/contact dermatitis)
• Oral LP
• Autoimmune bullous disorders (PV, MMP, EBA)
• Malignancy (e.g. oral SCC)
• Vasculitis
• Other crazy causes (chronic ulcerative stomatitis/trench mouth)
20. Management
• History
• Physical exam
• Labs
• Treat the underlying cause (if available)
• Direct treatment of Aphthous ulcers
21. History
• Determine frequency and location of ulcers, and if also involves the
genitalia
• Determine duration of each ulcer
• Determine if K/C/O any systemic disorder
• Determine if immunocompromised or risk factors for HIV
• Determine if any history of bowel symptoms
• Determine if any history of photosensitivity or joint disease
• Nutritional history and other symptoms of nutritional deficiency
• Determine if any other psychological or physical stressors exist
22. Physical exam
• Note size, distribution and dephth of each ulcer (if available)
• Look for other areas of blistering in the body (??autoimmune
blistering disease)
• Look for signs of LP elsewhere in the body
• Look for signs of other systemic disorder (e.g. discoid lupus lesions)
• Look for any signs of cachexia or wasting (to rule out malignancy)
23. Labs
• Swab/culture any available ulcers
• Full metabolic and hematological workup
• Nutritional lab evaluation
• HIV testing
• Biopsy of oral ulcer for histology and IF (if history/physical exam suggestive)
• Vasculitis screening
• Aphthous ulcers Messadi DV, Younai F. Dermatol Ther 2010; 23: 281–90.
• Oral mucosal disease: recurrent aphthous stomatitis Scully C, Porter S. Br J
Oral Maxillofac Surg 2008
24. Management
• Treat underlying causes if available
- Replace deficient enzymes/vitamins
- Treat systemic illness
- Remove stressors
25. Direct management
• Topical steroids cornerstone of treatment
- Topical gels
- Intralesional
- Inhaled
- Oral suspension
• Topical corticosteroids in recurrent aphthous stomatitis. Systematic
review Quijano D, Rodriguez M. Acta Otorhinolaringol Esp 2008; 59:
298–307.
26. Other first line and symptomatic treatments
• Topical lidocaine (symptomatic)
• Tetracycline (250mg/5ml oral suspension)
• Amlexanox 5% gel (topical immunomodulator)
• Oral antimicrobial rinses (chlorhexidine or betadine mouth washes)
• Sucralfate suspension
• Double-blind trial of tetracycline in recurrent aphthous ulceration Graykowski EA,
Kingman A. J Oral Pathol 1978; 7: 376–82.
• Chlorhexidine gluconate mouthwash in the management of minor aphthous ulceration:
a double-blind, placebo-controlled cross-over trial Hunter L, Addy M. Br Dent J 1987;
162: 106–10.
• Sucralfate suspension as a treatment of recurrent aphthous stomatitis Rattan J,
Schneider M, Arber N, Gorsky M, Dayan D. J Intern Med 1994; 236: 341–3.
27. Second line treatments
• Short courses of oral corticosteroids
• Thalidomide (best evidence for major aphthae)
• Dapsone
• Colchicine
• Zinc sulfate
• Systemic interventions for recurrent aphthous stomatitis
• Brocklehurst P, Tickle M, Glenny AM, Lewis MA, Pemberton MN,
Taylor J, et al. Cochrane Database Syst Rev 2012, 9: CD005411.
28. Third line treatments
• Pentoxifyllene
• B12
• Vitamin C (adjunctive)
• Anti-TNF agents (true aphthae or part of IBD/Behcet???)
• Topical cyclosporine
• Silver nitrate cautery (cheap, safe and reduces pain, but not duration, of
ulcers)
• Interferon alpha
• Clofazimine
• Oral monteleukast
30. Burning mouth syndrome
• Primary and secondary
• Primary form Defined as chronic burning in the mouth in the absence
of any systemic or skin/oral disorder-Diagnosis of exclusion,
presumed to be due to damage in CNS/PNS
• Secondary form is much more common, and needs thorough
investigation
• Although primary form is rare, secondary form is quite common!
31. DDx for secondary form
• Divided into local factors and systemic factors
34. Management
• First step is to rule out secondary causes
• Treat secondary causes if found
• Treat primary burning mouth syndrome if unresolved or no cause
found
37. Treatment of primary burning mouth
syndrome
• First line:
- Acknowledge patients symptoms and reassure
- Avoid confounding factors (e.g. remove irritants, stop smoking,
prevent xerostomia)
• Patients complaining of a burning mouth. Further experience in
clinical assessment and management Main DM, Basker RM. Br Dent J
1983; 154: 206–11.
38. Second line treatments
• Topical capsaicin (0.02% rinse)
• Topical clonazepam (1mg tablets ‘’suck and spit’’)
• Oral low dose clonazepam
• Oral antidepressants (SSRI’s or TCA’s)
• Application of a capsaicin rinse in the treatment of burning mouth syndrome Silvestre
FJ, Silvestre-Rangil J, Tamarit-Santafé C, Bautista D. Med Oral Patol Oral Cir Bucal 2012;
17: e1–4.
• Topical clonazepam in stomatodynia: a randomised placebo-controlled study Gremeau-
Richard C, Woda A, Navez ML, Attal N, Bouhassira D, Gagnieu MC. Pain 2004; 108: 51–7.
• A double-blind study on clonazepam in patients with burning mouth syndrome
Heckmann SM, Kirchner E, Grushka M, Wichmann MG, Hummel T. Laryngoscope 2012;
122: 813–6.
39. Third line treatments
• Oral pregabalin
• olanzapine
• Diode laser (low level energy mode)
• Two cases of burning mouth syndrome treated with olanzapine Ueda N,
Kodama Y, Hori H, Umene W, Sugita A, Nakano H. Psychiatry Clin Neurosci
2008; 62: 359–61.
• Marked response of burning mouth syndrome to pregabalin treatment
Lopez V, Alonso V, Martí N, Calduch L, Jordá E. Clin Exp Dermatol 2009; 34:
e449–50.
• Treatment of burning mouth syndrome with a low-level energy diode
laser Yang HW, Huang YF. Photomed Laser Surg 2011; 29: 123–5.
41. Oral lichen planus
• Found in over half of LP patients
• Many patients have pure oral form
• Several forms
- Reticulated (most common)
- Erosive
- Papular
- Pigmented
- Bullous
• Main DDx is autoimmune blistering diseases, lichenoid drug eruption and
lichenoid contact stomatitis
47. Workup
• History and physical exam for cutaneous lichen planus, HCV, thyroid disease,
amalgam restorations
• Medication review
• Labs to rule out HCV, thyroid disease
• Patch testing
• Biopsy with IF
• IIF
• Thyroid disease and oral lichen planus as comorbidity: a prospective case-
control study Garcia-Pola MJ, Llorente-Pendas S, Seoane-Romero JM, Berasaluce
MJ, Garcia-Martin JM. Dermatology 2016 [Epub ahead of print].
• Diagnosis of thyroid disease was present in 15.3% of 215 OLP patients.
48. First line therapy
• Potent topical steroids
• Intralesional steroids
• Systemic and topical corticosteroid treatment of oral lichen planus: a
comparative study with long-term follow-up Carbone M, Goss E, Carrozzo
M, Castellano S, Conrotto D, Broccoletti R, et al. J Oral Pathol Med 2003;
32: 323–9.
• Efficacy of intralesional betamethasone for erosive oral lichen planus and
evaluation of recurrence: a randomized, controlled trial Liu C, Xie B, Yang
Y, Lin D, Wang C, Lin M, et al. Oral Surg Oral Med Oral Pathol Oral Radiol
2013; 116: 584–90.
49. Second line
• Topical calcineurin inhibitors and Topical cyclosporin
• Mycophenolate mofetil
• MTX
• Oral retinoids (acitretin)
• Azathioprine
• Antimalarials (plaquenil)
• Successful treatment of oral erosive lichen planus with mycophenolate mofetil Dalmau J, Puig L,
Roe E, Peramiquel L, Campos M, Alomar A. J Eur Acad Dermatol Venereol 2007; 21: 259–60.
• Hydroxychloroquine sulfate (Plaquenil) improves oral lichen planus: an open trial Eisen D. J Am
Acad Dermatol 1993; 28: 609–12.
• A comparative treatment study of topical tacrolimus and clobetasol in oral lichen planus Radfar
L, Wild RC, Suresh L. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: 187–93
50. Third line
• Oral cyclosporin
• Anti-TNF
• Thalidomide
• Adalimumab in the management of cutaneous and oral lichen planus
Chao TJ. Cutis 2009; 84: 325–8.
• Etanercept for the management of oral lichen planus Yarom N. Am J Clin
Dermatol 2007; 8: 121.
• Effective treatment of oral erosive lichen planus with thalidomide Camisa
C, Popovsky JL. Arch Dermatol 2000; 136: 1442–3.
