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At the heart of general practice since 1960

Treating oral diseases

Professor Michael Lewis gives a brief pictorial guide to diagnosis and initial treatment for oral conditions likely to be seen in general practice

Professor Michael Lewis gives a brief pictorial guide to diagnosis and initial treatment for oral conditions likely to be seen in general practice

Recurrent aphthous stomatitis

Although many aetiological theories have been proposed for recurrent aphthous stomatitis, no single causative factor has as yet been identified. Haematinic deficiency involving reduced levels of iron, folic acid or vitamin B12 has been found in a minority of patients with RAS and correction has led to resolution of symptoms. Other predisposing factors implicated include psychological stress, hypersensitivity to foodstuffs, cessation of smoking and penetrative injury. However, in most sufferers it is difficult to identify a definite cause.

All patients with RAS should be advised to avoid foods containing benzoate preservatives (E210-219), potato chips, crisps and chocolate, as many sufferers implicate these in the onset of ulcers.

Any relationship to gastro-intestinal disease, menstruation and stress should be investigated. Blood investigation should include a full blood count and assessment of vitamin B12 corrected whole blood folate and ferritin levels.

Many patients obtain symptomatic relief from use of a mouthwash (sodium bicarbonate in water, chlorhexidine or benzydamine) or application of topical steroid preparations (hydrocortisone, triamcinolone, beclometasone or betamethasone). A mouthwash based on tetracycline (250mg capsule broken into water and used four times daily for one week) has also been found to be useful.

Systemic immunomodulating drugs and other agents such as prednisolone or dapsone can successfully control recurrent aphthous stomatitis though they are best prescribed by specialists.

Recurrent herpes simplex infection

Secondary infection is caused by reactivation of latent HSV. It has long been thought that HSV migrates from the trigeminal ganglion to the peripheral tissues, but it is becoming increasingly apparent that HSV also resides in neural and other tissues. Up to 40 per cent of HSV-positive individuals suffer from recurrent infections. The development of recurrent disease is related to either a breakdown in local immunosurveillance or an alteration in local inflammatory mediators that permits the virus to replicate itself.

Reactivation of HSV characteristically produces herpes labialis (cold sore, fever, blister), usually beginning with a tingle or burning sensation (prodrome) at the border of the lips. However, about 25 per cent of episodes have no prodrome and the lesion presents directly as vesicles. Within 48 hours the vesicles rupture to leave an erosion which subsequently crusts over and heals within 10 days. Predisposing factors include sunlight, trauma, stress, fever, menstruation and immunosuppression.

Reactivation can also produce recurrent intra-oral ulceration. The mucosa of the hard palate is the site most frequently involved but other areas can be affected. It can be difficult to determine whether the lesion(s) were precipitated by trauma or whether the patients chronically shed HSV in their saliva, which subsequently colonise traumatised mucosa.

The clinical appearance is usually diagnostic.

In many cases no active treatment is indicated but the patient should be warned about the infectivity of the lesion. The use of topical aciclovir or penciclovir as early as possible can reduce the duration of herpes labialis. A sunscreen applied to the lips can also be effective in reducing the frequency of sunlight-induced recurrences.

Mucocele

Mucocele is a clinical term that encompasses both a mucus extravasation phenomenon and a mucus retention cyst. Mucus extravasation results from the traumatic severing of a salivary gland duct to produce accumulation of saliva in the surrounding connective tissue, inflammation and a granulation tissue wall.

A mucus retention cyst results from obstruction of the salivary flow from a sailolith, periductal scar, or tumour. In contrast to mucus extravasation, the mucus in a retention cyst is contained in ductal epithelium.

Mucocele occurs most frequently on the lips. Other intra-oral sites that contain minor salivary glands and are prone to trauma may also be affected, such as the buccal mucosa and tongue. Clinically, a mucocele presents as a painless fluid-filled swelling with a blue discoloration and smooth surface. The size of the swelling may range from a few millimetres to several centimetres. Mucus retention cysts develop less frequently than the mucus extravasation phenomenon.

Diagnosis of mucocele is established on history and examination. Ultimately, almost all lesions require surgical excision and this will enable diagnosis. In addition, differentiation between mucous retention and extravasation can only be made histopathologically.

The treatment of both types of mucocele is surgical excision. Mucus aspiration has no lasting benefit since the mucocele will quickly refill. Removal of the associated minor salivary glands forms an important part of the treatment in order to prevent recurrence. Cryotherapy can be employed in children but there is a risk of recurrence.

Angular cheilitis

Angular cheilitis is often associated with the presence of intra-oral candidosis. Candida species can be isolated from approximately two-thirds of patients with angular cheilitis, either alone or in combination with staphylococci or streptococci.

This condition presents as erythema, possibly with yellow crusting at one or more (usually both) corners of the mouth.

A separate smear or swab should be taken from each angle of the mouth, each side of the interior nares, the palate and ­ if present ­ the fitting surface of the upper denture.

Treatment is based on the eradication of the reservoir of candida in the mouth or staphylococci in the nose. Patients should apply a topical antimicrobial, such as miconazole, that has activity against candida and staphylococci every six hours. If appropriate, dental hygiene should be established. If staphylococci alone are isolated from both the angles and anterior nares, then fusidic acid or mupirocin should be prescribed for topical use six-hourly.

Two tubes of medication should be issued and the patient instructed to use one exclusively for the angles and the other for the anterior nares. Investigations for an underlying cause, such as diabetes or haematinic deficiency, should be undertaken if the angular cheilitis persists following the local treatment.

Black hairy tongue

Elongation of the filiform papillae produces a hair-like appearance on the dorsum of the tongue. The cause of the subsequent black pigmentation is unknown, although chromogenic bacteria and Aspergillus species have been implicated. A range of predisposing factors have been suggested, including smoking, antibiotic use, steroid therapy and iron treatment.

The dorsum of the tongue is covered with matted, elongated and thickened filiform papillae. The colour varies from brown to dark brown. Apart from aesthetic problems, there are no symptoms.

The clinical characteristics are so distinct that biopsy is unnecessary.

It is important to seek the cause of black hairy tongue and, if one can be identified, it should be eliminated. The surface of the tongue can be cleaned by vigorously brushing and by the use of a baking soda or water mouthwash. Alternatively, a tongue scraper may be used to remove the surface layers. The patient should be reassured that the condition, although unsightly, is entirely benign.

Professor Michael Lewis isprofessor of oral medicine, University of Wales College of Medicine, Cardiff. The above article is adapted from A Colour Handbook of Oral Medicine by Professor Lewis and Professor Richard Jordan, Manson Publishing, 2004.www.manson-publishing.com

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