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Mouth problems

Oral medicine specialist Professor Stephen Porter responds to wide-ranging questions from GP Dr Roger Henderson about the common oral conditions that present in primary care

Oral medicine specialist Professor Stephen Porter responds to wide-ranging questions from GP Dr Roger Henderson about the common oral conditions that present in primary care

1. What oral health problems can be associated with diabetes? And how are they best managed in primary care?

It has long been suggested that oral candidal infection (such as thrush, acute pseudo-membranous candidosis) is common in diabetes but it is increasingly recognised as rare and only likely in undiagnosed or poorly managed type 1 diabetes. Most patients with diabetes have oral isolates of similar frequency, strain and virulence to those of healthy people. A risk of systemic mycotic infection in the mouth (such as mucomycosis and aspergillosis) has been suggested, but this is most likely in poorly controlled diabetes.

The notion that diabetes commonly predisposes to aggressive periodontitis has probably been overemphasised. Previously reported oral consequences of diabetes have included xerostomia (secondary to dehydration), altered taste (a loss of sweet sensation – that perhaps favours a sweet diet), geographic tongue and drug-induced lichen planus (such as with sulphonylureas). Primary care team members should ensure patients with diabetes are maintaining good oral hygiene to ensure good glucose regulation.

If patients develop oral thrush, it is likely to reflect a change in diabetes control, and it may be necessary to give topical (usually) antifungal therapy together with a review of diabetes medication. A patient with type 2 diabetes who develops adherent white patches and/or ulcers should be referred to an oral medicine unit to determine whether this is caused by oral lichen planus, and whether it warrants therapy (there is usually no reason to change the diabetes medication).

2. What is the relationship between gum disease and cardiovascular disease?

Plaque-related gum disease is usually either gingivitis (inflammation of the superficial aspects of the gums) or periodontitis (inflammation of the periodontal ligament that connects the teeth to bone). The latter has recently been shown to give rise to systemic inflammation (such as raised C-reactive protein), endothelial dysfunction, an increased risk of atherosclerosis, myocardial infarction and stroke. Additionally periodontal pathogens can promote platelet aggregation, foam-cell formation and atheroma development. There are confounding factors including social status, smoking status and other classic risk factors for atherosclerosis, but a recent prospective study found that intensive treatment of periodontitis reduced periodontal disease and later improved endothelial function.

3. How commonly does leukoplakia occur and what is its significance? How likely is this to indicate cancer?

Leukoplakia, a persistent isolated adherent white patch of the oral mucosa, is uncommon in Europeans and North Americans, although it may be common in residents of the Indian subcontinent as a consequence of chewing Betel nut (also called paan). The significance of leukoplakia is that most lesions represent areas of harmless hyperkeratosis, but about 5% contain oral epithelial dysplasia that may be a precursor to oral squamous cell carcinoma.

Leukoplakia is usually associated with long-term tobacco and/or alcohol usage – the main risk factors of oral cancer – and thus leukoplakia with potential dysplasia may be considered to be a clinical marker of potential malignancy of the mouth. A useful clinical rule is that leukoplakias that are not uniformly white are the ones most likely to transform to malignancy (occasionally such non-homogeneous lesions are cancer).

In primary care, all patients with leukoplakia warrant referral to an appropriate specialist for detailed clinical and histopathological investigation. Additionally patients must be encouraged to reduce tobacco and alcohol habits. Patients should be regularly reviewed as there is a risk of 30% or more that they will develop further lesions.

4. How should severe and persisting oral candidiasis best be tackled?

Severe or persistent candidal infection is likely to be a feature of a longstanding underlying local, or less commonly systemic condition.

Thrush (yellowy-white non-adherent curds typically of the soft palate) is usually the consequence of long-term use of steroid inhalers. This may be lessened by rinsing of the mouth following inhaler use and/or topical antifungal therapy. Systemic therapy should be avoided in view of the potential for developing azole-resistant strains. Thrush may also be a short-term consequence of broad-spectrum antibiotic or systemic steroid therapy – when the candidal infection only warrants therapy if symptomatic (unlikely) or the anti-biotic/steroid therapy is likely to be long term.

Median rhomboid glossitis is usually a painless, red patch in the centre of the dorsum of the tongue. It arises as a consequence of long-term smoking, xerostomia or immunodeficiency (such as HIV). Aside from tackling the underlying problem, topical and/or systemic antifungals should be prescribed.

Denture-associated stomatitis manifests as a painless red patch beneath an upper denture. This usually arises in individuals who wear their dentures while sleeping. The candidal infection is principally harboured within the fitting surface of the denture. This infection is resolved by good hygiene, soaking the denture in a hypochlorite solution during sleep and applying topical miconazole gel to the fitting surface, together with regular use of topical amphotericin or nystatin. If the denture is old it may need replacing.

Other types of candidal infection of the mouth can arise (see below) – indeed, a small number of individuals can have chronic mucocutaneous candidosis that gives rise to persistent or recalcitrant infections of the mouth, other mucosae and skin. Such patients require referral to appropriate specialists. Finally, remember that persistent thrush in an otherwise well person may be the first sign of HIV.

5. Is there any link between osteoporosis and teeth fragility?

No – osteoporosis does not affect the calcified elements of teeth (enamel and dentine). The association between periodontal bone loss (and early tooth loss) and osteoporosis is not clear cut, some but not all, studies suggesting that such loss or losses can arise as a result of osteoporosis. Dental panoramic radiographs may be a simple adjunctive method of screening patients for osteoporosis.

As bisphosphonates are increasingly employed in the treatment of osteoporosis, it must also be remembered that the high potency agents (unlikely to be used in the treatment of osteoporosis) can predispose to post-extraction osteochemonecrosis of the jaws. Before bisphosphonate therapy is started it is a good idea for patients to receive dental care to reduce the need to extract teeth.

6. Is halitosis always a sign of oral problems or can other conditions such as reflux contribute? How should halitosis be managed?

Halitosis (oral malodour) is only rarely a reflection of gastro-oesophageal disease. Investigation of GI disease is not a priority when investigating oral malodour. Poor oral hygiene and associated gingivitis and periodontitis are the most common causes of halitosis and thus are the first disorders that should be investigated in any affected individual.

There is a wide spectrum of systemic disorders that may rarely cause halitosis (for example, upper airway infection/obstruction, lung abscess and/or malignancy, bronchiectasis, diabetic ketoacidosis, end-stage renal or hepatic disease, rare metabolic defects), all of which are likely to have more notable features than oral malodour. Of course altered breath odour may simply reflect dietary habits such as onions and garlic, or be an adverse side effect of drug therapy – with some nitrates, for example. Occasionally patients complain of halitosis yet have no signs of oral malodour – such people may have 'halitophobia' and warrant psychological evaluation.

7. What can be done about the tricky problem of patients with recurrent severe aphthous ulceration of no obvious cause?

There is still no easy solution to this. Recurrent aphthous stomatitis (RAS) is common (affecting up to 66% of teenagers), is of unknown cause and there is no definitive means of stopping the outbreaks. Many of the affected individuals report that mild trauma to the mouth (for example, overzealous teeth cleaning or dental or oral hygiene therapy) worsens their ulceration, so a method of teeth cleaning that is both effective and atraumatic should be instigated.

Although chlorhexidine has been suggested to lessen the duration of ulcers, this agent has an unpleasant taste and can stain the teeth. Topical steroids remain the mainstay of therapy, reducing the pain and duration (but not outbreaks) of ulcers. Agents to consider using are betamethasone (0.5mg dissolved in 10ml water, used as a mouthwash up to four times daily) and perhaps fluticasone nasal spray administered orally when the prodromal symptoms of ulceration start. Topical antibiotics (such as tetracyclines) are not effective and systemic immunosuppression rarely has a place in the management of this troublesome disorder. Thalidomide can cause cessation of ulceration but the associated adverse side-effects outweigh benefits.

8. Should patients presenting with a sore tongue be routinely investigated?

A burning tongue in the absence of signs of abnormality of the tongue warrants assessment of FBC and haematinics as occasionally this symptom is the first feature of an underlying deficiency anaemia.

There is no justification in investigating for a candidal infection as oral carriage of candida species is very common (60-90%) in healthy people. In any case, candidal infection usually has an underlying cause and is not painful. Burning mouth syndrome (BMS) is common, particularly in older women. It usually reflects some degree of psychological distress (occasionally a needless worry about oral cancer). Therapy depends on the underlying psychological drivers and the degree of upset that the symptom is causing. Referral to psychological counselling or therapy is an effective first-line approach. Anxiolytics and antidepressants have little place in the early management of BMS unless anxiety/depression are the principal symptoms.

9. What are the possible oral presentations of inflammatory bowel disease?

Crohn's disease may manifest with recurrent or persistent enlargement of one or both lips, deep ulceration of the oral mucosa, superficial ulceration (perhaps caused by haematinic deficiency), mucosal tags, swelling of the buccal and intra-oral labial mucosa, gingival enlargement, and, rarely, fissuring of the tongue and a lower motor neurone palsy of the facial nerve.

Persistent cervical lymphadenopathy may arise in more than 25% of affected individuals. These orofacial features may be the first manifestations of undiagnosed ileocaecal Crohn's disease. In addition they can arise in the absence of gastrointestinal disease, when the term 'orofacial granulomatosis' is sometimes applied. Ulcerative colitis gives rise to multiple pustules/small ulcers of the labial mucosa, anterior gingivae and soft palate. The oral features of Crohn's disease and ulcerative colitis can be similar.

10. Are there any risks in using topical preparations long-term?

There are no notable local and/or systemic consequences of long-term use of 0.1% triamcinolone in 1% carbomellose paste. Patients may complain of a 'pasty' or 'gritty' taste and may have difficulties in applying the agent at the back of the mouth.

There is limited evidence on the immunosuppressive effects of more potent topical steroids.

Professor Stephen Porter is professor of oral medicine at Eastman Dental Institute, University College London

Competing interests None declared

Take-home points

• In diabetes, oral thrush is rare, and only likely in undiagnosed or poorly managed type 1 diabetes.

• Periodontitis has recently been shown to give rise to systemic inflammation (such as raised CRP), endothelial dysfunction and an increased risk of atherosclerosis, myocardial infarction and stroke. Periodontal pathogens can promote platelet aggregation, foam-cell formation and the development of atheromas.

• Osteoporosis does not affect the calcified elements of teeth (enamel and dentine).

• Dental panoramic radiographs may be a means of screening for osteoporosis.

• In recurrent oral thrush, systemic therapy should be avoided because miconazole resistant strains have developed.

What i will do now

Dr Henderson responds to the replies to his questions

• I was interested to read that oral thrush developing in diabetes patients is likely to reflect a change in diabetes control so I will now routinely review the medication of my diabetes patients presenting with episodes of oral thrush. I will also certainly remember to be as vigilant as I can be with these patients regarding lichen planus that can be assumed to be candidal if not examined properly.

• The useful clinical rule about leukoplakias is one I have not heard before and is certainly one I will now remember. Although I routinely refer all patients with leukoplakia for further investigation, a non-uniform appearance will ring warning signals for me now. The high incidence of further lesions means I will recall these patients on a regular basis for checking too.

• The tricky problem of recurrent aphthous ulceration remains but I will certainly try the fascinating tip of using fluticasone nasal spray orally when prodromal symptoms of ulceration commence. This is a completely new use of this treatment for me and I am keen to try it out in the unfortunate patients who suffer from this miserable problem.

• As a medical student I was taught that gastro-oesophageal disease was a potent cause of halitosis. The fact that this appears not to be the case will reduce my investigations of this as a potential cause in all but the most extreme cases. I will also try to remember that nitrate treatment can contribute to this problem – something I suspect many other GPs have also forgotten.

• Oral presentations of Crohn's disease are relatively well known but the fact that a relatively high percentage of sufferers will present initially with persistent cervical lymphadenopathy or oral features means I must remember to quiz patients with such features closely about other possible inflammatory bowel problems.

Dr Roger Henderson is a GP in Shropshire

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