Mucosal Disease


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Lecture presented 2004 to Dentists

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  • 1. Texts are organized differently Example: Neville et al set up chapters on the basis of disease type (e.g. Soft tissue tumors or epithelial pathology) Wood and Goaz list lesions as soft or bony type. The Oral Medicine review focuses on literature review of selected diseases. 2. The Oral Medicine text has excellent tables for drug therapy; for example systemic and topical preparations of steroids and other systemic therapies. 3. Neville and Lynch the most extensive re Oral Med.
  • Increasing Prevalence in younger people (m/f) Diet: NIH: decrease in CA with fruit/veg/vit C, fiber; In males carotene and Vit E decreased risk Charcoal grilled/pickled/smoked fish, meats not correlated Risks: tobacco / alcohol (may permeabilize membrain (also with sodium lauryl sulfate in toothpaste (static studies/ few prospective studies Viral and oncogene influences Infection with HPV or HSV (genital) HPV with oral lesions
  • Mucosal Disease

    1. 2. Oral Pathology Reading List <ul><li>Pindborg: Atlas of diseases of the oral Mucosa </li></ul><ul><li>Shafer: A textbook of oral pathology </li></ul><ul><li>Batsakis: Tumors of the head and neck </li></ul><ul><li>Bhaskar: Synopsis of oral pathology </li></ul><ul><li>Neville: Oral and Maxillofacial pathology </li></ul><ul><li>Millard: 2nd world workshop on oral medicine </li></ul>
    2. 3. State of the Research <ul><li>Few studies assessing mucosal disease in native populations (Canada and US) </li></ul><ul><li>Mucosal lesions potentially increasing in prevalence * </li></ul><ul><li>Problems identified in school children included**: </li></ul><ul><li>**Oral mucosa lesions in Mazahua Indian adolescents; Banderas et al: Acta Odontol Latinoam, 1999 </li></ul><ul><li>* Dental health findings in a Native American settlement; Staley et al: Iowa Dent J, 1993 </li></ul>
    3. 4. State of the Research <ul><li>Pigmented lesions 47.6% </li></ul><ul><li>Lingual anomalies 17.4% </li></ul><ul><li>Developmental tooth alter 6.9% </li></ul><ul><li>Gingival inflammatory </li></ul><ul><li>hyperplasia, ankilosis of tongue, lichen planus, focal epithelial hyperplasia and double lip 24 % </li></ul>
    4. 5. Mucosal Diseases <ul><li>White Lesions </li></ul><ul><li>Vesiculobullous and Desquamative Lesions </li></ul><ul><li>Viral Disorders </li></ul><ul><li>Allergic Disorders </li></ul><ul><li>Immunopathologic Disorders </li></ul><ul><li>Dermatologic Disorders </li></ul><ul><li>Inflammatory Hyperplasias </li></ul><ul><li>Minor Salivary Gland Tumors </li></ul>
    5. 6. White Lesions <ul><li>Dermatoses </li></ul><ul><li>Inflammatory/infectious </li></ul><ul><li>Keratotic lesions </li></ul>
    6. 7. Dermatoses <ul><li>Lichen Planus </li></ul><ul><li>Lupus Erythematosus </li></ul><ul><li>Areata Migrans </li></ul><ul><li>Solar Cheilosis (Actinic Keratosis) </li></ul>
    7. 8. Lichen Planus <ul><li>.1 – 4% of population </li></ul><ul><li>Clinical types: reticular, erosive, ulcerative </li></ul><ul><li>Erosive lesions less common (.16-.56 of LP lesions </li></ul>
    8. 9. Lichen Planus <ul><li>.3-3% with neoplastic conversion </li></ul><ul><li>Fluctuation over time </li></ul><ul><li>Generally seen in older adults but may occur in children </li></ul>
    9. 10. Lichen Planus <ul><li>Erosive lesions and systemic disorders </li></ul><ul><ul><li>Malignancies </li></ul></ul><ul><ul><li>Gastrointestinal disease </li></ul></ul><ul><ul><li>Primary biliary cirrhosis </li></ul></ul><ul><ul><li>Chronic active hepatitis (Hepatitis C) </li></ul></ul><ul><ul><li>Ulceratiave colitis </li></ul></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><ul><li>Autoimmune disease </li></ul></ul><ul><ul><li>Drug reactions </li></ul></ul><ul><ul><li>GVHD </li></ul></ul>
    10. 11. Lichen Planus <ul><li>Clinical presentation </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Location </li></ul></ul><ul><ul><ul><li>Buccal mucosa, dorsal tongue, gingiva, lips, floor of the mouth, soft palate, lateral tongue </li></ul></ul></ul><ul><ul><li>Tissue quality </li></ul></ul><ul><ul><ul><li>Keratotic (papular, plaque-like, linear, reticular, annular </li></ul></ul></ul><ul><ul><ul><li>Vesiculo-bullous (atrophic, erosive ) </li></ul></ul></ul>
    11. 12. Lichen Planus
    12. 13. Lichen Planus
    13. 14. Lichen Planus
    14. 15. Lichen Planus
    15. 16. Lichen Planus
    16. 17. Lichen Planus
    17. 18. Dermatoses <ul><li>Areata Migrans (Geographic tongue, benign migratory glossitis </li></ul>Prevalence 1-2% Multiple ‘painless’ circinate erythematous patch with whitened border
    18. 19. Inflammatory/Infectious <ul><li>Acute Pseudomembranous Candidiasis </li></ul><ul><li>Chemical injuries </li></ul><ul><li>Verruca Vulgaris: Condyloma Accuminatum </li></ul><ul><li>Syphilitic mucous patch </li></ul>
    19. 20. Patient CM Lesions Associated with Whiteners
    20. 21. Keratotic Lesions <ul><li>Papilloma </li></ul><ul><li>Benign Keratosis: Verruciform Hyperkeratosis; Linea alba; Cheek biting; Hairy tongue </li></ul><ul><li>Epithelial Atypia; Carcinoma-in-Situ; And Squamous cell carcinoma </li></ul><ul><li>Nicotinic Stomatitis; Tobacco Keratosis; Verrucous carcinoma </li></ul>
    21. 22. Sensitivity and specificity of OraScan toluidine blue mouthrinse in the detection of oral cancer and precancer. J Oral Pathol Med 1996 <ul><li>N = 145 Asian patients </li></ul><ul><li>Ready to use kit: OroScan </li></ul><ul><li>Oral carcinomas = 100% sensitivity </li></ul><ul><li>Oral dysplasias 79% sensitivity </li></ul><ul><li>Specificity 62% </li></ul>
    22. 23. Concomitant Leukoplakia in patients with oral squamous cell carcinoma. Oral diseases. 1999 <ul><li>N = 100 patients with oral squamous cell carcinoma </li></ul><ul><li>47% with concomitant leukoplakia </li></ul><ul><li>36% with leukoplakia adjacent to site </li></ul><ul><li>11% with leukoplakia distant to site </li></ul><ul><li>Conclusion: early detection and management of oral leukoplakia may be preventative </li></ul>
    23. 24. Leukoplakia
    24. 34. Vesiculobullous Lesions <ul><li>Viral disorders </li></ul><ul><li>Allergic disorders </li></ul><ul><li>Immunopathologic disorders </li></ul><ul><li>Dermatologic disorders </li></ul>
    25. 35. Viral Disorders <ul><li>Primary Herpetic Gingivostomatitis </li></ul><ul><li>Recurrent Herpes Labialis </li></ul><ul><li>Intraoral Recurrent Herpes Simplex </li></ul><ul><li>Primary V-Z Disease </li></ul><ul><li>Secondary V-Z Disease </li></ul><ul><li>Herpangina </li></ul>
    26. 36. Primary Herpetic Gingivostomatitis <ul><li>Fever and lymphadenopathy </li></ul><ul><li>Multiple painful erythematous ulcerations </li></ul><ul><li>Localized to the cheek, tongue, lips, palate, and importantly – attached gingiva </li></ul><ul><li>Bilateral </li></ul><ul><li>Confirm with viral culture </li></ul><ul><li>Acyclovir elixir, famcyclovir* and valacyclovir (*may reduce latent infection with simplex 1) </li></ul>
    27. 37. A prospective study of new infections with herpes simplex virus Type 1 and 2. Chiron HSV Vaccine Study Group. N Engl J Med 1999 4;341(19):1432 <ul><li>2393 sexually active HSV-2 seronegative persons monitored for evidence of new HSV infection </li></ul><ul><li>40% of new HSV-2 and 2/3 of new HSV-1 are asymptomatic. </li></ul><ul><li>In sexually active adults new HSV-1genital infections as common as oropharyngeal HSV-1 infections </li></ul>
    28. 38. Primary Herpetic Gingivostomatitis
    29. 39. Primary Herpetic Gingivostomatitis
    30. 40. Viral Disorders <ul><li>Intraoral Recurrent Herpes Simplex </li></ul><ul><ul><li>Clinical Characteristics </li></ul></ul><ul><ul><ul><li>Initial burning sensation </li></ul></ul></ul><ul><ul><ul><li>Multiple punctate ulcers which coalesce </li></ul></ul></ul><ul><ul><ul><li>Localized to the attached gingiva in a well defined area </li></ul></ul></ul><ul><ul><ul><li>Moderate to severe pain </li></ul></ul></ul><ul><ul><ul><li>10-14 day duration with complete resolution/recrudesemce </li></ul></ul></ul>
    31. 43. The probability of in vivo reactivation of herpes simplex virus type 1 increases with the number of latently infected neurons in the ganglia; J virol 1998 <ul><li>Animal study: mice </li></ul><ul><li>The number of animals that experienced virus reactivation was positively correlated with the number of latently infected neurons in the ganglia </li></ul>
    32. 44. Patient M S Severe right face pain and ‘cold’ sores
    33. 48. Vericella Zoster (Shingles ) <ul><li>Unilateral </li></ul><ul><li>Clusters of vesicles </li></ul><ul><li>Dyesthesia initially then severe pain </li></ul><ul><li>7-10 day course with scarring – lesions persisting for up to 5 weeks </li></ul><ul><li>Concern re osteonecrosis and tooth devitalization </li></ul><ul><li>Post-herpetic neuralgia </li></ul>
    34. 49. Allergic Disorders <ul><li>Stomatitis Venenata (contact) </li></ul><ul><li>Stomatitis Medicamentosa (drug) </li></ul><ul><ul><li>Erythema multiforme </li></ul></ul><ul><ul><li>Anaphylactic stomatitis </li></ul></ul><ul><ul><li>Intraoral fixed drug reactions </li></ul></ul><ul><ul><li>Lichenoid drug reactions </li></ul></ul><ul><ul><li>Lupus erythematosus like reactions </li></ul></ul><ul><ul><li>Pemphigus-like drug reactions </li></ul></ul><ul><ul><li>Non-specific vesiculoulcerative lesions </li></ul></ul>
    35. 50. Allergic Disorders <ul><li>Treatment </li></ul><ul><ul><li>Discontinuation / removal of offending drug </li></ul></ul><ul><ul><ul><li>Risks/benefits </li></ul></ul></ul><ul><ul><ul><li>Consult with physician </li></ul></ul></ul><ul><ul><li>Topical corticosteroids </li></ul></ul><ul><ul><li>For anaphylactic – epinephrine, corticosteroids, antihistamines </li></ul></ul>
    36. 51. Immunopathologic Disorders <ul><li>Recurrent Aphthous Stomatitis </li></ul><ul><li>Behcet’s Syndrome </li></ul><ul><li>Pemphigus Vulgaris </li></ul><ul><li>Bullous Pemphigold </li></ul><ul><li>Benign Mucous Membrane Pemphigoid (Circitricial Pemphigoid) </li></ul>
    37. 52. Aphthous Stomatitis <ul><li>Clinical characteristics </li></ul><ul><ul><li>Minor, major, Herpetiform </li></ul></ul><ul><ul><li>Simple versus complex </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Trauma, smoking cessation, emotional stress, hormones, heredity, food hypersensitivity, immune dysregulation, infectious agents </li></ul></ul>
    38. 54. Aphthous Stomatitis <ul><li>Associated systemic disorders </li></ul><ul><ul><li>Behcet’s disease </li></ul></ul><ul><ul><li>MAGIC syndrome </li></ul></ul><ul><ul><li>FAPA syndrome </li></ul></ul><ul><ul><li>Cyclic neurtropenia </li></ul></ul><ul><ul><li>HIV, Reiter’s syndrome </li></ul></ul><ul><ul><li>Hematinic deficiencies </li></ul></ul><ul><ul><li>Celiac disease (sprue, gluten-sensitivity) </li></ul></ul><ul><ul><li>Inflammatory bowel disease, Chohn’s disease) </li></ul></ul>
    39. 55. Behcet’s Syndrome <ul><li>Clinical characteristics </li></ul><ul><ul><li>Deep ulcerative lesions (25-75% cases); long lasting </li></ul></ul><ul><ul><li>Soft palate, oropharynx </li></ul></ul><ul><ul><li>Ocular (90%) and genital lesions </li></ul></ul><ul><ul><li>Arthritis (knees,wrists, elbows, ankles) </li></ul></ul><ul><ul><li>Central nervous system </li></ul></ul><ul><ul><li>Vasculitis multisystem abnormality </li></ul></ul>
    40. 56. Behcet’s Syndrome <ul><li>Etiology </li></ul><ul><ul><li>Immunodysregulation related to triggers: environmental antigens (strep, virus, pesticides, heavy metals </li></ul></ul><ul><ul><li>Genetic vulnerability (mucocutaneous associated with HLA-b12 and frequently seen in USA; Ocular in Japan and middle eastern countries </li></ul></ul>
    41. 57. Behcet’s Syndrome <ul><li>Diagnosis </li></ul><ul><ul><li>Oral ulcers 3x in prior year + </li></ul></ul><ul><ul><li>Two of the following: </li></ul></ul><ul><ul><ul><li>Recurrent genital ulceration </li></ul></ul></ul><ul><ul><ul><li>Ocular lesions </li></ul></ul></ul><ul><ul><ul><li>Cutaneous lesions or positive pathergy test following injection of inert substance (skin hyperreactivity) </li></ul></ul></ul>
    42. 58. Cicatricial Pemphigoid <ul><li>BMMP, Mucous Membrane Pemphigoid, Desquamative gingivitis </li></ul><ul><li>Etiology: unknown </li></ul><ul><li>Clinical features </li></ul><ul><ul><li>Older adults; females > males </li></ul></ul><ul><ul><li>Oral sites but can involve nasal, esophageal, laryngeal, vaginal mucosa </li></ul></ul><ul><ul><li>Initial vesicles/bullae which rupture and result in generalized denuded mucosa with pain </li></ul></ul><ul><ul><li>Occular involvement (inflammation and scarring) </li></ul></ul>
    43. 59. Cicatricial Pemphigoid <ul><li>Diagnosis </li></ul><ul><ul><li>Clinical presentation </li></ul></ul><ul><ul><li>Laboratory </li></ul></ul><ul><ul><ul><li>Possibly useful to rule out other conditions </li></ul></ul></ul><ul><ul><li>Biopsy </li></ul></ul><ul><ul><ul><li>Direct immunofluorescence (subepithelial immunoreactants) </li></ul></ul></ul>
    44. 60. Cicatricial Pemphigoid <ul><li>Differential diagnosis </li></ul><ul><ul><li>Linear IgA Disease </li></ul></ul><ul><ul><ul><li>Deposition of IgA along the basement membrane zone </li></ul></ul></ul><ul><ul><li>Epidermolysis Bullosa Acquista </li></ul></ul><ul><ul><ul><li>Antibodies directed against type VII collagen </li></ul></ul></ul><ul><ul><ul><li>Localized on the floor of the Bulla (versus the roof) </li></ul></ul></ul>
    45. 61. Patient F Gingival Bleeding
    46. 62. Dermatologic Disorders <ul><li>Erythema Multiforme </li></ul><ul><li>Stevens-Johnson Syndrome </li></ul><ul><li>Bullous Lichen Planus </li></ul><ul><li>Erosive Lichen Planus </li></ul><ul><li>Dermatitis Herpetiformis </li></ul><ul><li>Epidemolysis Bullosa </li></ul>
    47. 63. Inflammatory Hyperplasias <ul><li>Fibroma </li></ul><ul><li>Pyogenic Granuloma </li></ul><ul><li>Hormonal Tumor </li></ul><ul><li>Epulis Fissuratum </li></ul><ul><li>Inflammatory Papillary Hyperplasia </li></ul><ul><li>Peripheral Giant Cell Granuloma </li></ul><ul><li>Myxofibroma </li></ul>
    48. 64. Minor Salivary Gland Tumors <ul><li>Epithelial </li></ul><ul><ul><li>Adenomas (Pleomorphic, Monomorphic) </li></ul></ul><ul><ul><li>Mucoepidermoid Tumor </li></ul></ul><ul><ul><li>Acinic Cell Tumor </li></ul></ul><ul><ul><li>Carcinoma </li></ul></ul><ul><ul><ul><li>Adenoid Cystic Carcinoma </li></ul></ul></ul><ul><ul><ul><li>Adenocarcinoma </li></ul></ul></ul><ul><ul><ul><li>Epidermoid Carcinoma </li></ul></ul></ul><ul><ul><ul><li>Carcinoma in Pleomorphic Adenoma </li></ul></ul></ul><ul><li>Nonepithelial Tumors </li></ul><ul><li>Other </li></ul>
    49. 65. Mesenchymal Tumors <ul><li>Lipoma </li></ul><ul><li>Myoma </li></ul><ul><li>Nerve Tumors (Neurofibroma, Schwannoma, Traumatic Neuroma) </li></ul>
    50. 66. Tissue Discoloration <ul><li>Nevus </li></ul><ul><li>Melanotic Macule </li></ul><ul><li>Melanoma </li></ul><ul><li>Mucocele </li></ul><ul><li>Black hairy tongue </li></ul><ul><li>Salivary tumor </li></ul><ul><li>Other </li></ul>
    51. 67. Mucocele <ul><li>Descrete non-painful swelling </li></ul><ul><li>M=F </li></ul><ul><li>Children, adolescents, young adults </li></ul><ul><li>Lower labial mucosa, soft palate, retromolar region, buccal mucosa </li></ul>
    52. 68. Oral Melanoma <ul><li>Occur on the palate and gingiva 80% </li></ul><ul><li>Adults; Men>women </li></ul><ul><li>Early recognition improves prognosis </li></ul><ul><li>Clinical features </li></ul><ul><ul><li>Brownish/black discoloration </li></ul></ul><ul><ul><li>Normal surface texture or uleration (but without rolled borders or induration) </li></ul></ul><ul><ul><li>Slight swelling </li></ul></ul><ul><ul><li>Regional nodal involvement </li></ul></ul><ul><ul><li>Metastases to liver or lung </li></ul></ul>
    53. 69. Vegetable and fruit consumption and cancer rusk. Int-J-Cancer. 48:350, 1991 <ul><li>Integrated series of case control studies </li></ul><ul><li>Multivariate relative risks computed </li></ul><ul><li>Strength of patterns interpreted as suggesting that green vegetable intake is with substantial reduction of risk for common epithelial cancers </li></ul><ul><li>Fruit has a favourable effect on upper digestive cancers </li></ul>
    54. 70. Drug Therapy Regimes Established by the Scientific Literature
    55. 71. Management of Lichen Planus <ul><li>To treat or not to treat </li></ul><ul><ul><li>Spontaneous remission 6.5% (Silverman/OOO 1988) </li></ul></ul><ul><ul><li>Malignant transformations (2.3%) </li></ul></ul><ul><ul><li>Will therapy alter conversion to malignancy </li></ul></ul><ul><ul><li>Generally for asymptomatic lesions – no treatment is necessary </li></ul></ul>
    56. 72. Management of Lichen Planus <ul><li>If closely associated with an amalgam: removal of offending restoration </li></ul><ul><li>Dental prophylaxis (Holstrom OOO, 1990) </li></ul><ul><li>If lichenoid drug reaction: cessation of offending medication </li></ul>
    57. 73. Management of Lichen Planus <ul><li>Immunomodulators </li></ul><ul><ul><li>Corticosteroids: topicals, intra-lesional, systemic (40-60 x 7-10 days, tapered dose) </li></ul></ul><ul><ul><li>Cytotoxics: Azathioprine (Immuran 50-100mg) </li></ul></ul><ul><ul><li>Immunosuppressants: Cyclosporin (rinse 500mg/5mls tid) </li></ul></ul><ul><ul><li>Immunostimulants: Levamisole </li></ul></ul>
    58. 74. Management of Lichen Planus <ul><ul><li>Medication combinations </li></ul></ul><ul><ul><ul><li>levamisole and prednisolone (Lev 50mg tid/prednisolone 5mg tid x 3 days) </li></ul></ul></ul><ul><ul><ul><li>Dexamethasone-cyclophosmphamide pulse therapy ( 100 mg dexamethasone x 3 days and 500 mg cyclophosphamide x 1 day repeating every 4 weeks), used for pemphigus </li></ul></ul></ul>
    59. 75. Management of Lichen Planus <ul><li>Anti-microbials </li></ul><ul><ul><li>Antibiotics: Doxycycline, Acromysin </li></ul></ul><ul><ul><li>Antifungals </li></ul></ul><ul><ul><ul><li>Clotrimazole </li></ul></ul></ul><ul><ul><ul><li>Griseofulvin 250mg bid 8-10 days (if candida interaction) </li></ul></ul></ul><ul><ul><li>Anti-malarials: Dapsone (50mg/day) </li></ul></ul><ul><ul><li>Anti-virals: interferon beta or alfa-2b </li></ul></ul><ul><ul><li>Anti-malarial: Hydroxychloroquine sulfate (plaquenil) 200-400mg daily (may require 3-6 months) </li></ul></ul>
    60. 76. Management of Lichen Planus <ul><li>IFN-alpha cream </li></ul><ul><li>Topical Psoralen +UVA radiation </li></ul><ul><li>Ultraviolet irradiation without photosensitizer (320-400nm for 5-10 minutes once a week) </li></ul>
    61. 77. Management of Lichen Planus <ul><li>Retinoids </li></ul><ul><ul><li>Systemic: etretinate (75mg/day) </li></ul></ul><ul><ul><li>Topical: tretinoin </li></ul></ul><ul><ul><li>Other: temarotene (800-4800mg/day) </li></ul></ul><ul><li>Surgery </li></ul><ul><ul><li>Conventional </li></ul></ul><ul><ul><li>Cryosurgery </li></ul></ul><ul><ul><li>Laser surgery </li></ul></ul><ul><ul><li>Excision and grafting </li></ul></ul>
    62. 78. Management of Lichen Planus <ul><li>Pain control </li></ul><ul><ul><li>Benadryl syrup (50/50) with Maalox </li></ul></ul><ul><ul><li>OTC or prescribed medication </li></ul></ul><ul><li>Biobehavioral intervention </li></ul><ul><ul><li>Stress reduction </li></ul></ul><ul><ul><li>Reduction in physical activity </li></ul></ul><ul><ul><li>Management of anxiety and depression (if confounding presentation) </li></ul></ul>
    63. 79. Management of Aphthous <ul><li>No treatment </li></ul><ul><li>Treatment of associated disease (celiac sprue, vitamin deficiencies) </li></ul><ul><li>Topical medications </li></ul><ul><li>Systemic medications </li></ul><ul><li>Conversion of aphthous ulcer to wound </li></ul><ul><li>Palliative treatment (pain) </li></ul><ul><li>Biobehavioral intervention </li></ul>
    64. 80. Management of Aphthous <ul><li>Topical approaches </li></ul><ul><ul><li>Corticosteroids </li></ul></ul><ul><ul><ul><li>Kenalog in Orabase .1%, Lidex in orobase </li></ul></ul></ul><ul><ul><ul><li>Decadron elixir 0.5mg/5mls </li></ul></ul></ul><ul><ul><ul><li>Clobetasol propionate (with or without vehicle) </li></ul></ul></ul><ul><ul><ul><li>Aqueous hydrocortisone mouthwash </li></ul></ul></ul><ul><ul><li>Antibacterials </li></ul></ul><ul><ul><ul><li>Tetracycline rinses (125mg/5mls) </li></ul></ul></ul><ul><ul><ul><li>Listerine / Peridex </li></ul></ul></ul><ul><ul><ul><li>Mouthrinse with triclosan </li></ul></ul></ul>
    65. 81. Management of Aphthous <ul><li>Topical approaches </li></ul><ul><ul><li>Sodium Lauryl sulfate in toothpaste </li></ul></ul><ul><ul><li>Sulcralfate (not efficacious) </li></ul></ul><ul><ul><li>Laser ablation </li></ul></ul><ul><ul><li>Silver nitrate </li></ul></ul><ul><ul><li>Amlexanox oral paste (Aphthasol) </li></ul></ul><ul><ul><li>Benadryl elixir (12.5mg/5mls) or syrup (with kaopectate)/ Rothwell’s solution </li></ul></ul><ul><ul><li>5% 5-aminosalicylic acid as a cream </li></ul></ul><ul><ul><li>Bioadhesive patches </li></ul></ul>
    66. 82. Management of Aphthous <ul><li>Systemic approaches </li></ul><ul><ul><li>Naturopathic preparations </li></ul></ul><ul><ul><ul><li>Longo vital ® (6 herbs) </li></ul></ul></ul><ul><ul><ul><li>Zinc supplementation </li></ul></ul></ul><ul><ul><ul><li>Lactobacillus acidophilus preps(Bacid, Lactinex) </li></ul></ul></ul><ul><ul><li>Immunomodifiers </li></ul></ul><ul><ul><ul><li>Corticosteroid </li></ul></ul></ul><ul><ul><ul><ul><li>Prednisolone – pulse / prednisone 40-60mg with 7 day taper </li></ul></ul></ul></ul><ul><ul><ul><li>Azelastine (azelastine hydrochloride) </li></ul></ul></ul><ul><ul><ul><li>Thalidomide (50-300mg/day) (also for Bechet’s) </li></ul></ul></ul>
    67. 83. Management of Aphthous <ul><li>Other </li></ul><ul><ul><li>Biobehavioral </li></ul></ul><ul><ul><ul><li>Reflexotherapy (Stomatol, 1991) </li></ul></ul></ul><ul><ul><ul><li>Relaxation/imagery training (Psychosom med, 1990) </li></ul></ul></ul><ul><ul><li>Resumption of smoking </li></ul></ul><ul><ul><li>Smokeless tobacco (role of nicotine) </li></ul></ul>
    68. 84. Management of Candida <ul><li>Antifungals </li></ul><ul><ul><li>Nystatin (Mycostatin oral suspension, 100,000units/ml; 5 mls 4-5x/day </li></ul></ul><ul><ul><li>Clotrimazole (Mycelex 10mg; 5x/day </li></ul></ul><ul><ul><li>Miconazole </li></ul></ul><ul><ul><li>Ketoconazole (Nizoral 200mg; 1 tab/day x10d) </li></ul></ul><ul><ul><li>Diflucan 100mg (2tabs initially – 1 tab/day x 14days) </li></ul></ul>
    69. 85. Management of HSV-1 <ul><li>Acyclovir (Zovirax 200mg; 1cap qid x 2 weeks) </li></ul><ul><li>Valacyclovir / famciclovir ( pharmacokinetics different; Prophylaxis pre dental treatment – 500mg bid 1 day pre proc x 14 days) </li></ul><ul><li>Foscarnet (resistant to acyclovir with HIV) </li></ul><ul><li>Immunoglobulin (may permit higher levels of latent infection and in vivo reactivation) </li></ul><ul><li>Interferon (potential protective effect) </li></ul><ul><li>Medicinal Plants (Thai, Turkish, Brazilian, Indonesian, South American) </li></ul>
    70. 86. Management of HSV-1 <ul><li>Benadryl elixir </li></ul><ul><ul><li>12.5 mg/5 mls; 1 tsp 2 minutes before each meal) </li></ul></ul><ul><li>Topical anesthetics </li></ul><ul><ul><li>Viscous xylocaine </li></ul></ul><ul><ul><li>dyclone </li></ul></ul>
    71. 87. Management of HSV-1 <ul><li>Systemic support therapy (fluids, rest, proteins, vitamin and mineral food supplements) </li></ul><ul><li>Narcotics </li></ul><ul><ul><li>Vicodin ( 1 tab qid prn pain) </li></ul></ul><ul><ul><li>Lortab 5-10mg </li></ul></ul><ul><ul><li>Demerol 50 mg </li></ul></ul><ul><ul><li>Percodan </li></ul></ul>