This course will focus on the interprofessional realtionship of dentistry and medicine. For each session, the medical specialist will present a broad overview of specific disease entity which will be followed by a dental educator discussing the relevant oral manifestations and implications. The final module of each session will be devoted to the interaction between the dental and other health care professionals.
Oral involvement in dermatologic disease - Dr. Tom Sollecito, Dr. Eric Stoopler
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From the course by University of Pennsylvania
The Oral Cavity: Portal to Health and Disease
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From the lesson
Dermatologic conditions of the oral cavity
Week 6 presents an explanation of common dermatologic conditions that can frequently affect the oral cavity. The lectures in this module focus on the three most prevalent autoimmune reactions to occur in the mouth; lichen planus, pemphigoid, and pemphigus. The lectures in this week explain these conditions, comment on some possible treatments, and discuss the importance of co-management between the fields of dentistry and medicine, not to mention some specific examples of interdisciplinary division of treatment.
Meet the Instructors
Dr. Thomas P. SollecitoProfessor and Chairman of Oral Medicine
School of Dental Medicine
Dr. Eric StooplerAssociate Professor of Oral Medicine
School of Dental Medicine
Dr. Uri HangorskyAssociate Dean for Academic Affairs/ Director PASS
School of Dental Medicine
Thank you for joining our session on dermatological conditions of oral cavity. You heard
discussion of Dr. Paine.
So we'd like to continue and discuss some of these oral conditions of the mouth.
So let's start with pemphigoid diseases.
Could you give me a brief description of these conditions?
Yes. So, what Dr. Paine discussed,
were conditions that can be seen on
the skin but can also have a significant oral component.
Many of these diseases, quite frankly,
the oral condition may be
the original manifestation of in essence what is a systemic skin disease.
As you mentioned, or as Dr. Paine had spoken of,
she discussed lichen planus, pemphigus, and pemphigoid.
So there are various subdivisions within each of those disorders.
But, pemphigoid is the question, I believe that you asked,
and in pemphigoid, we do see a significant oral component.
And occasionally, a subtype of pemphigoid known as mucous membrane pemphigoid,
the oral cavity is almost universally affected.
Now, in mucous membrane pemphigoid,
you can also have the eye mucosa affected.
And you do get even skin lesions,
although there's a misnomer in calling it mucous membrane pemphigoid.
But, in essence, what do we see with mucous membrane pemphigoid intraorally?
We see often desquamative gingivitis that's a peeling gingivitis,
that's where the gum tissue is peeling away,
often erythematous, often red,
and atrophic where the tissue is relatively thin.
You can see frank ulcerations associated with some level of inflammation.
As the pemphigoid falls into a broader category known as vesiculobullous disease,
so you can get intraoral findings of vesicles or bulla in the mouth.
Those are intact blisters.
And in pemphigoid, sometimes those could be clear or they could be blood-filled blisters.
Years ago, mucous membrane pemphigoid used to be referred
to a cicatricial pemphigoid or scarring pemphigoid.
So, in some severe cases of oral mucous membrane pemphigoid,
you'll notice some scarring,
when you press on the let's say buccal mucosa or intraorally,
where there's a scarring type of healing repair that goes
on after the ulcer's been somewhat controlled.
So what type of symptoms the patient present with when they have these conditions?
Often, with mucous membrane pemphigoid,
patients will complain about gum bleeding when they perform normal oral hygiene.
So, when they're brushing their teeth,
they'll notice that they're spitting out blood.
These conditions could also be associated with significant oral pain,
mucosal pain, because once again,
if there's an ulcer in the mouth,
anything that affects the situation in the mouth,
anything like an acid food product,
or a salty food product will cause some discomfort, some pain.
In addition, some people will tell you
that they've had oral ulcers for six months chronically,
because pemphigoid tends to be a chronic mucosal, oral mucosal disease.
Okay. How does the inflammation in the mouth generated by
pemphigoid type disease differ from let's say inflammation caused by periodontitis,
by poor oral hygiene?
That's a great question Yuri.
And the inflammation that is generated by conditions like pemphigoid,
we mentioned pemphigus and even oral lichen planus that is immune mediated,
where there are antigens in certain layers of
the skin in the mouth that are targets for antibodies that are generated,
and so they're actually attacked by the immune system.
Whereas periodontitis typically is more infectious in nature has a bacterial etiology,
these vesiculobullous diseases do not have an infectious disease etiology.
Now, how likely are these patients to be seen in a dental practice?
Is this something fairly frequent?
Is it confined to certain populations, certain age groups?
I think it really depends on which condition that we're talking about.
I think for a condition like oral lichen planus,
it is relatively frequent in the general dental population.
Statistics have shown that about 1-2% of
the general population throughout the world has lichen planus.
And as Dr. Sollecito mentioned very often,
it will present initially in the mouth and may only affect the mouth.
And so, that particular condition I think is relatively frequent.
Comparing that to mucous membrane pemphigoid and pemphigus vulgaris,
I think that is less common in the general dental population,
but we still see a fair amount of patients who are diagnosed with
the condition or refer to us for the evaluation and management of these disorders.
So you mentioned oral lichen planus,
could you please tell me what is it?
What type of disease and what type of signs and symptoms?
Sure, of course.
So oral lichen planus again falls into
this bucket of dermatologic conditions that can affect the oral cavity.
And so again, it's an immune-mediated disorder,
where patients will present with bleeding of their gum tissue,
peeling of their gum tissue.
They'll often have ulcers associated with the condition,
but there are folks who are completely asymptomatic,
and this is where you tend to pick it up in the general dental population as well,
where patients have some of the typical signs of
the disease including white lines on the mucosal surfaces,
could be the cheeks, or the tongue,
or the lips, roof of the mouth can be affected as well.
Where it's more of a textural change rather than something that's actually
painful for the patient that's an often used descriptor for the condition.
And so, picking up asymptomatic cases of lichen planus
is something they think is relatively common.
Makes sense too, if lichen planus, is one of the,
if not the most common chronic oral disease.
And although, we all quote the same statistic about 1-2% of the population,
it's probably much higher than that.
It's just that it's not reported because of where it's seen and by whom it's seen.
So this is something that the general practitioner,
a general dentist will almost absolutely see within their practice.
So could you tell me please,
how you manage these conditions,
along with your medical colleagues in the hospital,
or even in your private practice?
Sure. So one of the key things to do is to establish diagnosis first.
And so, there are a variety of diagnostic procedures that a patient will
undergo to determine specifically if a patient has oral lichen planus,
pemphigus vulgaris, or mucous membrane pemphigoid.
They all have a somewhat different disease trajectory,
and so it's important to establish diagnosis.
We usually do that with tissue sampling specifically biopsy of
oral tissue that may be affected and some
normal tissue as well for different types of studies.
So once the diagnosis has been established,
treatment then has to be formulated.
And very often for patients with only oral disease,
we will initiate topical corticosteroid therapy for management of the oral condition,
and most people do quite well with this.
Very often, we will prescribe an anti-fungal medication with
the topical corticosteroid to prevent
a yeast infection from occurring because that can potentially happen.
But very often, we have patients who are referred
from dermatology and other medical services who
have the condition diagnosed previously and yet they develop oral manifestations,
and so, they'll refer the patient to us for management.
And also patients that we manage,
who we feel are not successful with topical management,
we often will at least consult our dermatology colleagues for input
regarding systemic therapy for management of even only oral condition.
Yeah. And I think one other point that I'd like to add is that patients
that are diagnosed with pemphigoid tend to
be older patients usually in the sixth or seventh decade,
whereas those with pemphigus vulgaris it's usually in the fourth decade.
There are certain geographic clusters of pemphigus vulgaris,
particularly around the Mediterranean basin,
which, there is an increased incidence of this particular disease.
And then one other point I think that I've been more inclined to do
is that since most dentists are not performing a complete skin exam.
I will often refer patients that I diagnose with pemphigus vulgaris
for a complete skin examination by a medical dermatologist,
I think that that's an important referral.
And then the second most important referral in terms of
managing these patients is somebody with mucous membrane pemphigoid,
mindful that it could affect the eye,
I would request that the patient be evaluated by a corneal specialist or by
a general ophthalmologist to see if there's any involvement of the ocular mucosa.
Often patients will go on to develop
lesions either in their esophagus and/or respiratory lining.
And so, we inquire about those types of symptoms at each visit,
particularly with our pemphigoid patients.
And so, if there's any indication that this is occurring,
we will refer them to the appropriate healthcare provider,
whether it's their primary care physician or a medical specialist.
To what extent are these diseases,
especially the oral manifestation,
debilitating for the patients?
I mean, is this something quite manageable with treatment or do
these patients suffer a great deal?
I think as with most diseases,
Eric and I'll both tell you,
in managing a wide array of patients,
the disease process differs in different patients.
There are patients clearly with lichen planus,
pemphigoid or pemphigus that have relatively mild disease and it doesn't interfere.
And then there are others with such severe disease that it debilitates normal function,
eating, speaking, swallowing, and it becomes very, very problematic.
But I don't think we can categorize
the severity just based upon that because there's
such individual variability in the way it presents.
I agree with that.
Could you please comment about the danger of
misdiagnosing oral cancer when seeing patients with these conditions?
Is this something that the general dentists can pay attention to?
Yeah.
I mean, I think if there's a chronic single oral lesion,
and that lesion needs to be biopsied and proven that it's not
cancer before going beyond that.
But your question is a very, very well-crafted question.
We know that there are patients with oral lichen planus that will
develop an oral cancer in an area that prior
was oral lichen planus or lichenoid mucositis.
And equally, there are patients that have
underlying lymphoma or certain types of leukemia,
chronic lymphocytic leukemia, which might develop what's referred to as
a paraneoplastic syndrome which appears like a mixture
of lichen planus and pemphigus and certainly could even look like pemphigoid.
So, the question is very well posed.
In patients with lichen planus,
patients require lifelong follow up.
In patients that have an underlying disease that persists and is difficult to manage,
those patients probably need to be queried regarding their cancer screenings and
in severe diseases be evaluated for an underlying malignancy like I suggested.
When we interviewed Dr. Paine,
she mentioned several treatment modalities which I may ask you to elaborate on.
One that was fabrication of intraoral trays and the other one was intraoral injections.
Yeah, I'll speak to the trays and then you can speak to the injections.
So in terms of the intraoral trays it can be extremely
helpful for patients with any one of those vesiculobullous diseases.
We tend to use these trays as occlusive dressings almost like a band aid in
order to hold the topical preparation within
the mouth adjacent to the tissue that's affected.
So if somebody has lichen planus affecting their gum tissue,
we could make a medication tray that fits over the teeth,
extends up into the vestibule,
adapted well to the gingival tissue so that when you put medication on
or around the tissue that the medication stays in place.
Equally, particularly with pemphigus and pemphigoid,
not only could it be used as a medication tray,
but there's an understanding that the teeth play a significant role in initiating
the trauma that results in either peeling a blister formation or even scarring.
And just taking away the sharpness of the teeth
by putting a medication or an occlusive tray over the teeth,
it protects the tissue, which is fragile,
from trauma that comes from the sharp dentition.
In addition to these treatment modalities,
another thing to consider are intralesional injections.
And so these were usually reserved for lesions that are
non-responsive to topical corticosteroid therapy which is,
again, the mainstay of how we manage oral lesions.
And so those folks who don't respond well,
we could consider injecting steroid directly into the area of non-healing ulcer.
And so this also can be very helpful for treating
these recalcitrant lesions that may not be responding to some of the topical therapy.
Most commonly patients are administered Triamcinolone,
which is an injectable corticosteroid,
comes in various strengths and again usually effective.
However, there are some risks involved with the procedure,
most notably tissue necrosis.
If there is too much steroid injected into a small area,
it can actually cause necrosis of the tissue.
And so rather than heal the ulcer,
you may actually have more of an ulcer or
more sloughing of the epithelium in that particular area.
So it should be used with caution,
but certainly a treatment modality to consider.
And is there a danger of fungal overgrowth when the patient is on steroids?
Yes, most evidence does support use of an antifungal medication to be used
concurrently with a topical corticosteroid to
prevent the overgrowth of yeast while the patient is using the medication.
At times, patients will be referred to you by a dentist who really strongly
suspects that there is a carcinogenic lesion there,
and the patient is unduly concerned.
How do you go about calming the patient and ruling out cancerous lesion?
Unfortunately, that's a somewhat common occurrence when patients
are referred to either one of us for evaluation of these lesions.
I would just recommend to dentists to not use
the term cancer with patients unless they're absolutely
sure that they've determined that this lesion may be cancerous.
It really sets up a difficult scenario for both the patient who becomes
very worried until they see the specialist for further evaluation,
but it also sets up a difficult relationship between the provider
and the patient because they come in
saying someone else told them that they have cancer in their mouth.
And so I would recommend that dentists or
oral healthcare providers not use that terminology unless they're absolutely sure,
because a lot of these conditions that we're speaking of can
mimic lesions that may look like cancer,
but ultimately they turn out not to be.
Okay, thank you.
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