Oral Disease Processes page 5 Autoimmune Disorders-DoctorSpiller.com

Disease Processes 12345

Geographic tongue

geographic_tongue_2This condition is characterized by the disappearance of the filiform papillae from irregular patches on the top surface of the tongue.  Then, the patches “heal” up and reoccur on another part of the tongue at a later date.  This process keeps going on and on over time, and one can see lesions in varying stages of healing over large expanses of the tongue.  No one knows why some people get this condition.  It is thought to be an oral form of psoriasis (a common skin condition).  Patients who live with this problem frequently complain of pain on eating sharp foods.  Serious outbreaks can be treated with topical application of steroid gels.  Otherwise it is not treated.  It is not a contagious condition.  Recently, it has been noted that this condition may be seen more frequently in AIDS patients, however the presence of geographic tongue certainly does NOT mean that the patient has AIDS.  The reason that it may be more prevalent in persons with HIV is that the immune system deficit seen in AIDS patients may lead to an increase in dermatological abnormalities such as unusual forms of psoriasis.  Click the image above for a larger view.

Aphthous ulcer

Better known as Canker sores, these lesions are very painful (unlike most oral cancers).  The pain can be quite severe involving wide areas of the mouth or head. (See discussion of referred pain.)   Aphthous ulcers occur generally on the soft unattached gingiva, in the vestibule or on the cheek mucosa, on the floor of the mouth, or on the under-surface or lateral borders of the tongue.

Upon rare occasion, they occur on the soft palate (see image below), and click it for a larger view).

aphthousThey are characterized by a white center surrounded by a thin red, inflamed border.  No one knows exactly why some people seem prone to these sores, or why they occur at all.  They are NOT due to a dietary deficiency!  They are related to stress and possibly food sensitivities.  They generally disappear spontaneously within 10-14 days.

Canker sores are not contagious.  For more on aphthous, click on one of the images above.

This condition happens in two varieties, each of which has its own treatment protocol:

Minor aphthous is defined as the occasional, small ulcer that most persons experience no more than once or twice a year.  These lesions are generally small (2-4 mm), and the ulcers are treated as isolated entities (one at a time).

Treatment for Minor Aphthous

Topical applications of steroids such as “Lidex gel”  or “Kenalog in Orabase” ® (Note: Lidex is approximately ten times stronger than Kenalog, but Kenalog has the advantage of the Orabase which acts as a Band-Aid and keeps the steroid in place longer).  These drugs are applied after meals and before bedtime, and both are prescription drugs.  They generally reduce or eliminate pain immediately and bring about resolution of the canker in two to three days.  I prefer Kenalog in Orabase in my own practice

Aphthasol paste ® is a prescription drug that is applied directly to the ulcer four times a day (the same as Kenalog in Orabase).

Cautery using either chemical or laser treatment.  This type of treatment is palliative only, and does not treat the underlying condition.  Cautery is done in the dental office to relieve the pain caused by a specific aphthous ulcer.

Chemical cautery agents  include silver nitrate(generally on a wooden stick) or commercial agents such as Debacterol®, both of which are applied by a dentist or physician and offer immediate pain relief.

Over-the-counter agents such as Zilactin®, Ora5® and Gly-Oxide® are mild cautery agents that work more slowly.

Laser treatment is quick and painless and also offers immediate pain relief.  This is generally done only on small lesions in the dentist’s office.

Major aphthous , also called Sutton’s disease is defined as a chronic condition in which patients are plagued with multiple aphthous lesions occurring several times a month.  These ulcers are generally quite large, on the order of the size of a dime, and they often heal leaving scar tissue behind.   Major aphthous associated with HIV can cause much larger lesions.  Major aphthous has no known cure, but chronic aphthous lesions may be treated using the following methods:

Treatment for Major Aphthous

If you suddenly develop chronic major aphthous lesions, It is wise to check with your physician to see if there is an underlying cause such as an immune problem, or an underlying chronic illness such as Bechet, Chrohn’s or celiac disease.

Vitamin B12 has been found to be effective in reducing the frequency and severity of the lesions in patients suffering from major aphthous.  1 mg is dissolved under the tongue every evening.  Some formulations of vitamin B12 are manufactured specifically for this route of administration.

Other vitamin and mineral supplements such as iron, folic acid and zinc have been known to reduce the number and frequency of aphthous lesions.

Steroid mouth rinse– Betamethasone sodium phosphate (Betnesol mouthwash/Diprolene) one 0.5mg tablet dissolved in 5 to 10 ml of water.  Patients rinse using this solution four times a day (after meals and before bed) whenever lesions are present.  Another method is for the patient to mix about 1/4 inch of Fluocinonide (Lidex) cream or gel in four ounces of water.  This mouth rinse is used the same way that betamethasone is used.  Remember–Never swallow a steroid mouth rinse!  Steroids are powerful drugs and mouth rinses made with them should be used sparingly since they can have systemic effects, even when used topically.

Avoid oral products containing sodium lauryl sulfateas studies have implicated this common ingredient as a causative factor in the formation of aphthous.

More information on treatment modalities for major and minor aphthous can be found by clicking here.

Liken Planus

LikenPlanusLichen Planus is actually a dermatological autoimmune disease that is often first diagnosed by a dentist due to its characteristic appearance in the mouth. In the mouth it appears as a series of filamentous, white, lacy lines on the inside of the cheeks or on nearly any other oral tissue.   Lesions can occur on other parts of the body as well, most notably on the skin of the anticubital space (inside of the elbows). Most of these lesions are painless, but sometimes they occur on attached tissue such as the palate where they can be quite painful.  They can also cause quite a bit of burning in the mouth when eating sharp foods.  The image above is a fairly common presentation, and an obvious diagnosis.

LichenPlanus2The image above shows a more subtle presentation under the tongue.  Click on either image to see it full size.  This condition is thought to be an autoimmune condition associated with exposure to drugs to which the patient may be sensitive.   It is especially associated with certain antihypertensive drugs, NSAIDs, tetracycline and several sulfonamides, as well as a number of “recreational” drugs.  The condition often improves with the cessation of the offending drug.  The condition is more of a nuisance than a disability.  The oral symptoms are often treated with steroid mouth rinses.  If the symptoms are not severe, it is not treated at all.  Lichen planus is not a contagious condition. Chronic lichen planus has been known to (very rarely) morph into squamous cell oral cancer.

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Disease Processes 12345