Fall 2001 Presentation Summary:

Pathology Potpourri

Presented by Dr. Barbara Sheller
on February 16, 2001, at the Northern Regional Meeting

Summarized by Dr. Diane Paxton, Northern Region Editor

Aphthous Ulcers (canker sores)

Aphthous Ulcers affect up to 60% of the population and are associated with a high level of pain. They are confined to the oral cavity, located on movable mucosa—the tongue, lips, buccal mucosa, soft palate, and floor of the mouth.

Lesions are generally solitary, small (2–4mm), shallow, and flat with an ulcerated yellowish-white center surrounded by a red halo. Healing occurs spontaneously in 7 to 10 days without scarring.

Etiology - Aphthous ulcers are linked with local factors such as trauma (a slipped tooth brush, potato chip abrasion, poky arch wire) or salivary gland dysfunction due to medications such as antihistamines or steroids. There is also bacterial (streptococci) and viral (varicella zoster and CMN) association.

A genetic predisposition to aphthous ulcers and nutritional influence of gluten sensitivity and deficiencies of iron, folic acid, and B-12 have also been shown. Systemic factors such as stress, Bechet’s disease (an ulcerative condition in young males), HIV, and other immunosuppressor conditions increase the incidence of canker sores.

Prevention - Daily rinsing with Listerine or Chlorhexadine (in more serious cases) may provide antibacterial prevention to aphthous. Dr. Sheller also recommends changing toothbrushes once each month as they harbor high levels of bacteria.

Sodium laurel sulfate, the common sudsing ingredient in toothpaste, is a trigger for aphthous in some patients. Switching to a toothpaste without sodium laurel sulfate such as Biotene Dry Mouth tooth paste or Rembrant Canker Sore Formula may decrease aphthous incidence.

It has been shown that smoking reduces the incidence of canker sores—a small benefit among the many hazards associated with smoking and not a recommended preventive measure Dr. Sheller would advise.

Treatment and Management of Aphthous Ulcers

1. Steroids can be used to decrease inflammation

a. Kenalog in Orabase, topical corticosteriod – Recommend it be applied to the affected area after each meal and before bedtime. Dr. Sheller advises that pedatric patients be given specific instructions on application, including the need to wash hands before and after application and to avoid eye contact. Contraindications are diabetic patients and fungal ulcerations.

b. Amlexanox Oral Paste (Aphthasol) – Anti-inflammatory and anti-allergic topical medication. Aphthasol has been shown to decrease pain and longevity of lesions by 1.8 days.

2. Systemic Therapy

a. Systemic steroids and aminomodulators can be used for short term therapy

b. Nutritional replacements

c. Avoidance of allergens and stress

3. Home Remedies are abundant for aphthae treatment. Everything from peppermint schnapps to ear wax has been reported to heal canker sores.

Differential diagnosis for aphthous ulcers includes traumatic ulcers, herpetic ulcers, Bechet’s syndrome, Chrohn’s disease, neutropenic ulcers and HIV infection.

Angular Cheilitis

Angular cheilitis, an inflammation of the commisures or corners of the mouth, can be unilateral or bilateral and does not bleed. Predisposing factors are drooling, mouth breathing, habitually sucking lips, immunosuppression, headgear use, and malnutrition or loss of vertical dimension in the elderly.

Etiology - Angular cheilitis is a mixed infection of candida, staph, and strep that occurs following a break in the skin.

Treatment - Angular cheilitis lesions need to be treated to avoid scarring as persistent lesions do result in scarring. Elimination of predisposing factors is recommended, as well as treatment with Mycolog II ointment (Nystatin and Triamcinolone), which is a topical antifungal and steroid medication.

Differential dianosis for angular cheilitis includes recurrent herpetic lesions, impetigo (staph infecton), exfoliating cheilitis (chapped lips), and lip-sucking cheilitis.

Recurrent Herpes Lesions
(Cold Sores)

Recurrent herpetic lesions affect 6–14% of the population. They are most commonly found on the upper lip, but can also occur intraorally on attached tissue (as opposed to aphthous ulcers, which occur on unattached tissues) such as the hard palate and attached gingival.

Clinically they first appear as a small vesicles or groups of vesicles that quickly rupture, coalesce, and crust. They are painful and very unesthetic. Herpetic lesions are very infectious until they are completely crusted over.

Etiology - Recurrent herpes lesions occur due to the reactivation of latent Herpes Simplex Type 1 virus in the sensory ganglion. The reactivation occurs due to stress, sunlight, trauma, and during the female menstral cycle.

Prevention and Treatment - The use of sunscreen to the upper lip may be helpful. When the prodromal symptoms begin, Dr. Sheller recommends applying ice to the area for 90 minutes.

Denavir Oral Cream is a topical antiviral agent that inhibits replication of viral DNA and has been show in studies to reduce the duration and symptoms of the lesions. This is the only approved medication in the US; however, studies are being done on other antiviral agents.

Differential Diagnosis for cold sores are aphthous ulcers, traumatic ulcers, neutropenic ulcers and HIV infections.

Head Lice

Head lice infection is reported in 3–10% of the preschoolers in the United States each year, most commonly in three- to ten-year-olds. It is incorrect to associate head lice infection with poverty or poor personal hygiene as it crosses all economic levels.

Head lice are specialized insects that have co-evolved with humans. They eat only human blood and prefer the nape of the neck area and behind the ears.

Head lice spread by crawling, and require direct contact for transmission. This can happen with shared combs, hair accessories or batting helmets.

Lice are found more commonly in girls with long hair. They can be seen on the hair shaft, and in the adult stage, they are about the size of a sesame seed.

Dental Office Precautions - Because of the high prevalence of head lice in the young patient, you may well see them in your office.

Dr. Sheller recommends looking at more than just the teeth, and if you do suspect head lice, the following precautions will help avoid transmission in your office. Have caps (surgical caps or shower caps) available for the patient to wear, cover the chair head rests with plastic, staff should wear long sleeved work attire and pull back long hair to avoid hair-to-hair transfer.

Treatment of Head Lice - Pesticides in shampoo are used to poison the insects so they can be mechanically removed with a fine tooth de-lousing comb. They can also be smothered in a substance such as vaseline or olive oil. Authorities disagree about the wisdom of spraying the home with insecticide.

Tobacco Use

The AAO has recently begun a campaign in conjunction with the American Lung Association, "Let’s Put the Bite on Tobacco Use," targeting our teenage patient population.

There has been a 73% increase in the number of teenage smokers since 1988. Five thousand young people begin smoking every day despite the fact that society has made smoking more difficult and more anti-tobacco education is available than ever before.

It has been shown that the incidence of smoking is increasing, not because smoking is "cool," but because smokers are "cool." Dr. Sheller recommends the book, "The Tipping Point" by Malcolm Gladwell, which discusses this phenomenon.

AAO Suggestions
to Discourage Teenage Tobacco Use

1. Talk about it—Present the facts in a non-judgmental fashion, listen to patients, answer any questions, and avoid moralizing.

2. Emphasize what may be important to the teenagers: Smoking makes their hair, their clothes, and their breath smell bad and —it stains their teeth.

3. Dispel the myth that smokeless tobacco is a safe alternative to cigarette smoking.

4. Have handouts available (the AAO has a reproducible handout with space to add your own office logo).

5. Reward healthy behavior

Lesions Associated with Tobacco Use

• Leukoplakia: Premalignant white lesion
• Erythroplakia: raised red patch
• Squamous cell carcinoma

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