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DIFFERENTIAL DIAGNOSIS AND CLINICAL MANAGEMENT EPISODE I:

ORAL LESIONS

ASSOCIATED PROFESSOR SIRIBANG-ON PIBOONNIYOM KHOVIDHUNKIT

ADVANCED GENERAL DENTISTRY DEPARTMENT

FACULTY OF DENTISTRY, MAHIDOL UNIVERSITY

Tissue dessication

Altered cell permeability

Decreased elasticity

Deminished reparative capacity

• The demographic of older adults (i.e., 65 years of age and older) is growing and

likely will be an increasingly large part of dental practice in the coming years.

• Although better than in years past, the typical aging patient’s baseline health state

can be complicated by comorbid conditions (e.g., hypertension, diabetes mellitus)

and physiologic changes associated with aging.

• Older adults may regularly use several prescription and/or over-the-counter

medications, making them vulnerable to medication errors, drug interactions or

adverse drug reactions.

• Potential physical, sensory, and cognitive impairments associated with aging may

make oral health self-care and patient education/communications challenging.

• Dental conditions associated with aging include dry mouth (xerostomia), root

and coronal caries, and periodontitis; patients may show increased sensitivity to

drugs used in dentistry, including local anesthetics and analgesics.

Chaichalermsak S. J Dent Assoc Thai 2010; 60: 11-21.

1787 dental chart records were selected

22.3% (398 patients had systemic diseases)

Most common systemic diseases were

Cardiovascular disease (8.9%)

GI/liver disease (6.4%)

Disease of endocrine system (3.9%)

Most common drugs were

Antihypertensive drug (5.8%)

Analgesic/anti-inflammatory/

antibiotics drugs (5.3%)

Vitamins/supplements (4.5%)

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Shinkai RS. Spec Care Dentist 2006; 26: 116-20.

COMMON ORAL LESIONS IN ELDERLY PATIENTS

• Xerostomia/hyposalivation

• Infections in the oral cavity

• Candidiasis

• Viral infection

• Oral lichen planus / lichenoid reactions

• Burning mouth syndrome

• MRONJ

COMMON ORAL LESIONS IN ELDERLY PATIENTS

• Xerostomia/hyposalivation

• Infections in the oral cavity

• Candidiasis

• Viral infection

• Oral lichen planus / lichenoid reactions

• Burning mouth syndrome

• MRONJ

XEROSTOMIA VS HYPOSALIVATION

• Xerostomia: subjective complaint of dry mouth

• Hyposalivation: objective reduction of saliva

secretion

Xerostomia and hyposalivation may not be correlated

John Kalmar. Oral Manifestations of Drug Reactions. 2004 Zunt S., 2010

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Zunt S., 2010

Spit test

Modified Schirmer’s test

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Frothy saliva

Glassy appearance

No saliva pooling

Fissured tongue

Especially smooth surface caries and root caries

Hyposalivation induced caries

1)Medication

2)Radiation-induced dysfunction

3)Other systemic diseases

4)Sjögren’s syndrome

Common causes of hyposalivation

1)Medication

2)Radiation-induced dysfunction

3)Other systemic diseases

4)Sjögren’s syndrome

Common causes of hyposalivation

• Diuretics ยาขบัปัสสาวะ

• Hypertensive drugs ยารักษาโรคความดนัโลหิตสงู

• Statin drugs ยารักษาโรคไขมนัในโลหิตสงู

• Antihistamine ยาแก้แพ้

• Antireflux ยารักษาโรคกระเพาะ กรดไหลย้อน

• Sedatives ยาคลายเครียด

• Antipsychotics ยารักษาโรคจิตเวช

• Antidepressants ยารักษาโรคซมึเศร้า

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Treatment:

1) Hydration: small and frequent sip of water

2) Artificial lubricants

3) Stimulating agents

Sugar free candy or chewing gum: Xylitol, Trident

Pharmacological agents: pilocarpine hydrochloride (10mg qid)

: cevimeline (30mg tid)

4) Drug modification

5) Abstain from caffeinated drinks

5) Dental caries: fluoride application

6) Oral infection: candidiasis

Management of hyposalivation

• Xerostomia/hyposalivation

• Infections in the oral cavity

• Candidiasis

• Viral infection

• Oral lichen planus / lichenoid reactions

• Burning mouth syndrome

• MRONJ

COMMON ORAL LESIONS IN ELDERLY PATIENTS

Pseudomembranous

candidiasis

Denture stomatitis

Angular cheilitis

Median

rhomboid

glossitis

Erythematous

Hyperplastic candidiasis

(candidal leukoplakia)

Infections of Candida species: Candida albicans

Etiology: Changes in the oral microbial flora

: Predisposing factors

Broad-spectrum antibiotics

Corticosteroid

Xerostomia

Immunodeficiency: HIV infection

Scully, 2004 www.emedicine.com

Nystatin oral suspension 100,000 unit

Sig: swish and spit out 3-5 ml, 3-5 min, 3-4 times/day

Myconazole gel 10 g tube

Sig: apply at affected site tid

Clotrimazole troche 10 mg

Sig: let 1 troche dissolve five times a day, do not chew

Nystatin vaginal suppositories

Sig: let 1 troche dissolve five times a day, do not chew

Fluconazole 100 mg cap

Sig: take 2 caps stat, then 1 cap daily until gone

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Herpes simplex virus infection

Recurrent HSV infection

Herpes labialis

Intra-oral recurrent HSV infection

Keys: Keratinized mucosa

Non-movable mucosa

Attached gingiva

Palate

Multiple small vesicles

or ulcers

Herpes simplex virus infectionSystemic antiviral drugs

CDC recommended regimens

Acyclovir(Zovirax®)

Famciclovir(Famvir®)

Valacyclovir(Valtrex®)

Primary episode 400 mg tid, or200 mg 5 times a day (7-10 days)

250 mg tid(7-10 days)

1 g bid(7-10 days)

Recurrences 400 mg tid, or200 mg 5 times a day, or800 mg bid (5 days)

125 mg bid(5 days)

500 mg bid(5 days)

Suppression(prophylaxis)

400 mg bid(Daily)

250 mg bid(Daily)

500 mg, or 1000mg qd(Daily)

(CDC: sexually transmitted diseases guidelines 2002)

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Topical antiviral drugs

Acyclovir cream 5% (1 g or 5 g tube)

Sig: Apply at affected site 5 times a day

วา่นพญายอ ครมี

Sig: Apply at affected site 5 times a day

วา่นพญายอ ใน กลเีซอรนี

Sig: Apply at affected site 5 times a day

• Xerostomia/hyposalivation

• Infections in the oral cavity

• Candidiasis

• Viral infection

• Oral lichen planus/ lichenoid reactions

• Burning mouth syndrome

• MRONJ

COMMON ORAL LESIONS IN ELDERLY PATIENTS

Lace-like white lesions

1) Oral lichen planus

2) Oral lichenoid contact reaction

3) Oral lichenoid drug reaction

4) Chronic GVHD

5) Hepatitis C virus infection

T cells medicated disease which induced the destruction of basal cells

Etiology

Lichen planusLichenoid drug

reactionLichenoid contact

reaction

No history of fillings, medication

History of medication:

HTNDM

DyslipidemiaAntibioticsAllopurinol

Adjacent to amalgam filling, full

metal crown, PFM crown,

Implant

History Lichen planus

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Etiology: contact allergic reactions

Lichenoid contact reaction Lichenoid drug reaction

Factors implicated in lichenoid lesions

Drugs :

Lipid lowering agents (statin)

Antihypertensive drugs (-ol, -il)

Hypoglycemics (sulfonylurea)

NSAIDs

Antimalarial agents

Antimicrobial agents

Allopurinol (for gout) Scully, 1998, Lodi, 2004

Lichenoid drug reaction

Management

Lichen planus/lichenoid reaction

Lichen planusLichenoid drug

reactionLichenoid contact

reaction

- Change of medication if possible- Topical/systemic steroid (± antifungal drugs)

- Change of restoration

- Topical/systemic steroid(± antifungal drugs)

Topical steroids:

Fluocinolone acetonide 0.1% in orabase

Sig: Apply at affected site, qid

Triamcinolone acetonide 0.1% in orabase

Sig: Apply at affected site, qid

Dexamethasone 0.5 mg tab

Sig: Let one tab dissolve slowly at the site until gone

Sig: dissolve 1 tab in 10 ml water, swish and spit out

Triamcinolone 40mg/ml intralesional injection

Sig: 0.3-0.5 ml/ulcer 1 cm2

Management: Topical corticosteroid/ anti-inflammatory drug

Fluocinolone Triamcinolone Dexamethasone

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• Xerostomia/hyposalivation

• Infections in the oral cavity

• Candidiasis

• Viral infection

• Oral lichen planus/ lichenoid reactions

• Burning mouth syndrome

• MRONJ

COMMON ORAL LESIONS IN ELDERLY PATIENTS

“Burning pain in the tongue or other oral

mucous membranes with the absence of

pathologic lesions or abnormal laboratory

findings”

Grushka M, et al., 2003

Definition

Primary burning mouth syndrome

Burning sensation without abnormal

clinical findings

Secondary burning mouth syndrome

Burning sensation with systemic or

local abnormalities

Lamey PJ and Lamb AB, 1988

Female, postmenopausal women with mean age of 50-60

years

Feeling discomfort without any clinical abnormal findings

Feeling discomfort after delivery of dental prosthesis

Mostly presented with metal placement: full metal crown,

RPD

Grushka M, et al., 2003

Etiologic factorsLOCAL• Dry mouth (salivary gland hypofunction)• Candidal infection• Denture related oral lesion• Parafunctional habits: clenching, bruxism

SYSTEMIC• Hematologic deficiencies• Endocrine: hormonal change (menopause), diabetes• Medications

PSYCHOLOGIC• Anxiety• Depression• Compulsive disorders• Cancerophobia

Lauren L, et al., 2007

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Lauren L, et al., 2007

Pharmacological therapy

Anxiolytics, antidepressant, anticonvulsants, antipsychotics

Non-pharmacological therapy

Psychological therapy, LASER, herbs, acupuncture

Combined pharmacological therapy and psychological therapy

Type Drug Dose Evidence based for use

Anxiolytic Clonazepam 0.25-2.5mg/day- Double-blind, RCT- Open-label, pilot study- Retrospective, pilot study

Tricyclic antidepressants

Amitriptyline 10-150 mg/day - Single-blind, RCT

Nortriptyline 10-75 mg/day- No published evidence for it in BMS but it is used generally for neuropathic pain

Selective serotonin

reuptake inhibitors

(SSRIs)

Paroxetine 10-20 mg/day

- Single-blind, RCT - Single-blind, RCT (no placebo)- Open-label, non-comparative,

prospective study

Sertraline 50-100 mg/day - Single-blind, RCT (no placebo)

Pharmacological therapy

Dentist’s concern:

If the patient has burning

sensation or discomfort without

concomitant clinical findings

BMS should be considered

Referral to oral medicine specialist may be necessary

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• Xerostomia/hyposalivation

• Infections in the oral cavity

• Candidiasis

• Viral infection

• Oral lichen planus/ lichenoid reactions

• Burning mouth syndrome

• MRONJ

COMMON ORAL LESIONS IN ELDERLY PATIENTS

History of osteoporosis, long term systemic steroid, solid

organ malignancies with the use of bisphosphonate or

denosumab

Management: debridement, long-term antibiotics, surgery

Symptoms: chronic non-healing ulcer with bone exposure

may be associated with pain and swelling

Signs: bone sequestrum, infection, often found on palatal

area especially on torus palatinus

Current or previous treatment with

a bisphosphonate or denosumab

Exposed bone in the maxillofacial

region that has persisted for more

than 8 weeks

American Association of Oral and Maxillofacial Surgeons, 2014

No history of radiation therapy to

the jaws.

Extensively used in medicine via 2 routes

Oral

bisphosphonates

Intravenous

bisphosphonates

Non-nitrogen containing

• Etidronate (Didronel) 1-10

• Clodronate (Bonefos) 1-10*

• Tiludronate (Skelid) 50

Nitrogen containing (aminobisphosphonates)

• Pamidronate (Aredia) 100-1000

• Alendronate (Fosamax) 500-1000

• Ibandronate (Boniva) 100-1000

• Risedronate (Actonel) 100-2000

• Zoledronic acid 1000-10000

(Zometa 4 mg, Reclast 5 mg)

Half life is approximately 10 years

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Non-nitrogen containing

• Etidronate (Didronel) 1-10

• Clodronate (Bonefos) 1-10*

• Tiludronate (Skelid) 50

Nitrogen containing (aminobisphosphonates)

• Pamidronate (Aredia) 100-1000

• Alendronate (Fosamax) 500-1000

• Ibandronate (Boniva) 100-1000

• Risedronate (Actonel) 100-2000

• Zoledronic acid 1000-10000

(Zometa 4 mg, Reclast 5 mg)

Half life is approximately 10 years

Fosamax, Boniva, Actonel, Zometa, Reclast

American Association of Oral and Maxillofacial Surgeons, 2014

I. Drug-related risk factors

• Bisphosphonate potencyIV bisphosphonates > oral bisphosphonates

Nitrogen-containing bisphosphonates > non

nitrogen-containing bisphosphonates

• Duration of therapylonger duration appears to be associated

with increased risk. (>4 years)

II. Local risk factors• Dentoalveolar surgery

Extractions, dental implant placement, periapical surgery,

periodontal surgery involving osseous injury

• Local anatomyTorus palatinus, torus mandibularis, exostosis, sharp

mylohyoid ridges

Can be trauma-induced or spontaneous eruption

Marx RE, 2005

II. Local risk factors• Concomitant oral disease

IV bisphosphonates with a history of

inflammatory dental disease: periodontal and

dental abscesses

Hoff AO, 2006

Badros A, 2006

III. demographic factors• Age

Increasing age

• Race

Caucasians have an increased risk for MRONJ

compared with blacks

Corticosteroid therapy, diabetes, smoking,

alcohol use, poor oral hygiene

IV. Other factors

Badros A, 2006

Thickening of lamina dura Narrowing of inferior alveolar canal

Unremodeled bone in socket

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Dentist’s concern:• If the patient has bone

exposure, MRONJ should be considered

• Patient’s medical history is important

• Surgical removal of bone necrosis may be done with caution.

• Referral to oral surgeon may be necessary

ACKNOWLEDGEMENT

•Ministry of Public Health

•Anandamahidol Foundation

• Faculty of Dentistry, Mahidol University