Common Oral Conditions: A Review

Importance

Dry mouth, oral candidiasis, and recurrent aphthous ulcers are 3 of the most common oral conditions that may be associated with patient discomfort, decreased quality of life, and morbidity.

Observations

In a meta-analysis of 26 population-based cohort and cross-sectional studies, the global prevalence of dry mouth symptoms was 23% (95% CI, 18% to 28%), placing individuals at risk of oral candidiasis, dental caries, dysgeusia, masticatory/speech impairment, and oropharyngeal dysphagia. Dry mouth is associated with using more than 3 oral medications per day (odds ratio [OR], 2.9 [95% CI, 1.4 to 6.2]), head and neck radiation, and Sjögren disease. Symptoms may include difficulty swallowing and speaking, thirst, and halitosis. Dry mouth is associated with an 11.5% (95% CI, 3.6% to 27%) higher risk of oral candidiasis, based on a meta-analysis of 6 observational cohorts. Management of dry mouth includes mechanical salivary stimulants, oral moisturizers, and/or systemic sialagogues. Oral candidiasis is an opportunistic fungal infection caused by overgrowth of the Candida genus with C albicans, which accounts for 76.8% of infections. The prevalence of oral candidiasis is higher in patients who are immunosuppressed, for example, those with HIV (35% [95% CI, 28% to 42%]) and those with salivary gland hypofunction (OR, 3.02 [95% CI, 1.73 to 5.28]). Common risk factors associated with oral candidiasis include use of antibiotics (P = .04) and oral mucosal disorders such as lichen planus. Oral burning and dysgeusia are common symptoms of oral candidiasis. Treatment includes addressing risk factors and use of topical and/or systemic antifungal medications. Recurrent aphthous stomatitis is characterized by symptomatic round or oval oral ulcers, which are covered by a gray-white fibrin layer and encircled by an erythematous ring. A meta-analysis of 10 case-controlled studies revealed an increased risk of recurrent aphthous stomatitis associated with polymorphism of IL-1β (+3954C/T) (OR, 1.52 [95% CI, 1.07 to 2.17]) and IL-1β (-511C/T) (OR, 1.35 [95% CI, 1.09 to 1.67]). Another meta-analysis of 9 case-control studies reported that patients with recurrent aphthous stomatitis had a higher frequency of nutritional deficiencies, including vitamin B12 (OR, 3.75 [95% CI, 2.38 to 5.94]), folic acid (OR, 7.55 [95% CI, 3.91 to 14.60]), and ferritin (OR, 2.62 [95% CI, 1.69 to 4.06]). Recurrent aphthous stomatitis can be associated with systemic diseases. A meta-analysis of 21 case-control studies revealed that celiac disease is associated with a higher incidence of recurrent aphthous stomatitis (25% vs 11%; OR, 3.79 [95% CI, 2.67 to 5.39]; P <.001). Topical corticosteroids are first-line agents to manage recurrent aphthous stomatitis; however, systemic medications may be necessary in more severe cases.

Conclusions and Relevance

Dry mouth, oral candidiasis, and recurrent aphthous ulcers are common oral conditions that may be associated with patient discomfort, decreased quality of life, and morbidity. First-line treatment includes over-the-counter sialagogues for dry mouth, topical antifungals for oral candidiasis, and topical corticosteroids for aphthous ulcers. Oral conditions that do not improve with first-line treatment may require treatment with systemic medications.

Oral mucous membrane pemphigoid: updates in diagnosis and management

Mucous membrane pemphigoid (MMP) is a rare, immune-mediated, vesiculobullous disease that predominantly affects the oral cavity and conjunctiva. In MMP, autoantibodies are directed against hemidesmosomal proteins in the basement membrane zone, most commonly BP180. Clinical signs and symptoms include gingival desquamation, erosions, and ulcerations. Differential diagnoses include other immune-mediated blistering diseases, such as bullous pemphigoid. Definitive diagnosis is reached through history taking, physical examination, tissue biopsy and/or serology testing. MMP, although not curable, is typically managed with topical or systemic corticosteroids, in addition to immunosuppressive therapies and biologic agents in recalcitrant cases. Untreated MMP can lead to life-threatening complications, such as blindness. As a condition that affects the oral cavity, it is important that dentists understand how to recognise, diagnose and manage the disease.

Quality of life in patients with oral potentially malignant disorders: oral lichen planus and oral epithelial dysplasia

OBJECTIVE

The aim of this study was to evaluate and compare quality of life (QoL) parameters in patients with oral potential malignant disorders (OPMDs), namely, oral lichen planus (OLP) and oral epithelial dysplasia (OED).

STUDY DESIGN

A cross-sectional study was completed at the oral maxillofacial surgery/oral medicine practices at University of Pennsylvania. Patients with clinical and histopathologic confirmation of OLP or OED from January to June 2021 were included in the study. The primary predictor variable was the OPMD type. The primary outcome variable was the score of 3 separate surveys: the Chronic Oral Mucosal Disease Questionnaire-26 (COMDQ-26), Oral Potential Malignant Disorder QoL Questionnaire (OPMDQoL), and Hospital Anxiety and Depression Scale. Multiple linear regression was used to determine independent predictors of increased/decreased questionnaire scores.

RESULTS

The final study sample consisted of 100 patients:53 patients had OLP (53.0%), 39 patients had OED (39.0%), and 8 patients had OLP with OED (8.0%). Relative to OED, OLP added 15.7 points to the COMDQ-26 survey score (P < .001). Relative to OED, OLP added 8.9 points to the OPMDQoL survey score (P = .003).

CONCLUSIONS

Oral lichen planus shows significantly poorer QoL specifically within the COMD-26 and OPMDQoL questionnaires, compared with OED. Additionally, patients with OPMDs aged 40 to 64 years were independently associated with higher COMD-26 scores compared with older patients (>65 years).

Oral manifestations of anti-neutrophil cytoplasmic antibody-associated vasculitis: an update and narrative review of the literature

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystem disorder of small blood vessels subdivided into granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Oral manifestations (OMs) have been reported to include mucosal ulceration, gingival enlargement, alveolar bone necrosis, tooth loss, oro-antral communication, palatal perforation, parotitis, and candidal infection mainly in GPA. They may appear during the course of the disease, as a disease flare-up, or as the presenting sign. These OMs are often nonspecific and can mimic an array of conditions, therefore formulating a differential diagnosis can be challenging. This review updates the OMs of GPA, and, for the first, time includes OMs of other AAVs. It provides recommendations for the overall assessment and the diagnosis and management of all AAV OMs with considerations for treatment coordination. The role of oral health care providers in multidisciplinary care is highlighted.

Gastroesophageal reflux disease and oral health: A narrative review

Gastroesophageal reflux disease (GERD) is a clinical condition in which stomach contents leak backward into the esophagus. It affects millions of people worldwide and has a detrimental effect on quality of life. Heartburn and acid regurgitation are typical GERD symptoms, while atypical manifestations include noncardiac chest pain, cough and laryngitis. The oral and maxillofacial manifestations of GERD may include dental erosion, xerostomia, mucositis, aphthous like ulcerations, sour taste, burning mouth, hyperesthesia, bruxism, and/or temporomandibular disorder (TMD). This narrative review provides oral health care professionals with an update to medical aspects of GERD, recognition and management of oral and maxillofacial manifestations of the condition and provision of appropriate dental care for this patient population.

Orofacial Granulomatosis Treated With Combination of Intralesional Steroids and Hydroxychloroquine

This article presents a case of a 39-year-old woman with spontaneous lip swelling with gingival erythema. The case report discusses orofacial granulomatosis, a condition that often poses diagnostic and management challenges. Additionally, the article emphasizes the importance of establishing a definitive diagnosis of this disease, which has similar clinical and histological features to other oral and systemic conditions. Finally, a successful management approach is discussed that uses combination therapy consisting of intralesional steroid injections and oral hydroxychloroquine.

Dental management of a pediatric patient with Kohlschutter-Tonz syndrome: A case report

INTRODUCTION

Kohlschutter-Tonz syndrome (KTS) is a rare, genetic condition, which typically manifests as a triad of symptoms: 1) amelogenesis imperfecta, 2) infantile onset epilepsy, and 3) intellectual disability. The condition poses dental treatment challenges given the manifestation of amelogenesis imperfecta. Additional considerations are needed to medically manage these patients who present with epilepsy and intellectual disability.

CASE REPORT

Our patient presented with multiple restorative needs, was treated under general anesthesia, and maintained good oral outcomes with close follow-up.

DISCUSSION

To the best of our knowledge, this is the first case report which documents comprehensive dental management of a pediatric patient with KTS.

Influence of topical corticosteroids on malignant transformation of oral lichen planus

BACKGROUND

Oral lichen planus (OLP) is considered an oral potentially malignant disorder. While OLP has been associated with the development of oral squamous cell carcinoma (OSCC), little is known about the role of topical corticosteroids therapy (TCT) in the promotion of carcinogenesis. The study aimed to determine if TCT influences the time of malignant transformation of OLP to OSCC. The study also investigates this correlation in the presence or absence of Candida overgrowth, and in the context of conventional OSCC risk factors such as smoking, alcohol use, and male gender.

METHODS

A retrospective analysis of electronic health records at a tertiary care academic medical center was performed. Patients with OLP and OSCC were considered for inclusion. The diagnosis of OLP required both clinical and histological documentation.

RESULTS

Eighty-two patients met inclusion criteria, consisting of 48 women (58.25%) and 34 men (41.5%) and the mean patient age was 65.9 years (SD = 13.25). Forty-five patients (54.9%) received TCT for OLP before they developed OSCC. The time between the OLP and OSCC diagnoses increased by four years in patients who received topical steroid therapy for OLP (p < 0.001) and decreased by three years (p = 0.010) in those with Candida overgrowth. Gender, smoking, and alcohol use did not have a statistically significant influence on the time between OLP and OSCC.

CONCLUSION

The management of OLP using TCT potentially delayed cancer development in our study. Conversely, it appears that Candida may play a role in the field cancerization of OLP patients.

EBV-positive B-cell ulcerative proliferation in the oral cavity associated with EBV-negative follicular lymphoma in a patient with common variable immunodeficiency: A case report and review of the literature

Lymphoproliferative disorders (LPDs) are a group of conditions characterized by excessive production of lymphocytes manifested in various patterns including lymphadenopathy, tumor-like lesions, and lymphomas. LPD may be stimulated by Epstein-Barr virus (EBV) infection that most commonly appears in the setting of immunocompromised status such as long-term use of immunosuppressive medications and in individuals with primary immunodeficiency disorders. EBV mucocutaneous ulcer is a benign LPD reaction that mostly regresses spontaneously but sometimes requires medical or surgical intervention. This article presents a case of oral EBV mucocutaneous ulceration that affected an individual with a history of complex primary immunodeficiency disorders consisted of common variable immunodeficiency disease associated with T-cell dysfunction. This case is unique because the oral lesions led to the diagnosis of concurrent widespread EBV-negative follicular lymphomas, seemingly unrelated to her EBV-positive LPD oral disease. Yet, both occurred in the setting of severe immunosuppression from the primary immunodeficiency disorders.

Systemic sclerosis: Update for oral health care providers

Systemic sclerosis (SSc), also known as scleroderma, is an autoimmune disease of unknown origin characterized by an uncontrolled inflammatory process resulting in fibrosis of the skin, internal organs and vasculopathy. Manifestations of SSc are heterogenous and can include pulmonary, cardiac, neural, renal, muscular, cutaneous and orofacial complications. Recent scientific advances have led to a better understanding of disease etiopathogenesis and the development of a new classification system. Therapeutic management is often multidisciplinary and targeted toward the affected organs. Oral health care providers (OHCPs) should be familiar with SSc, particularly as it relates to its impact on the orofacial region and modifications to delivery of oral health care for patients with this condition.

Analysis of The Oral Cavity: Portal to Health and Disease, a massive open online course in oral medicine

OBJECTIVE

The aims of this study were to (1) analyze the demographic characteristics of learners participating in The Oral Cavity: Portal to Health and Disease (TOC), the first massive open online course in oral medicine, and (2) assess worldwide interest in accessible, high-quality oral medicine education.

STUDY DESIGN

TOC development and design was reviewed in detail to provide background for course organization and content. Learner demographic characteristics were gathered and analyzed to identify course participation and engagement.

RESULTS

TOC premiered on September 17, 2017 as a novel source for oral medicine-based information. By March 1, 2020, TOC had 18,122 learners, of whom 4,641 enrolled. This sample included all age groups and genders, people of varied educational and employment backgrounds, and participants from 6 continents. Learners rated the course 4.9 out of 5 stars and submitted many positive reviews.

CONCLUSIONS

TOC provided oral medicine-based education to individuals with interests in dental, medical, and allied health professions. Interest in oral medicine-related education was supported by high learner engagement in this course with wide global distribution.

Participation in an existing massive open online course in dentistry during the COVID-19 pandemic

The coronavirus disease 2019 (COVID‐19) pandemic presented unprecedented challenges and interruptions to education at all levels. As many across the world were required to stay at home, virtual educational resources were developed and relied upon to provide all levels and subjects of instruction. Introduction to Dental Medicine, a massive open online course in dentistry, experienced an increase in enrollment during the start of the pandemic and learners displayed a positive reception to the information provided. Introduction to Dental Medicine was particularly well positioned as a resource during the pandemic given its availability, established nature, and the wide accessibility of course material. As disruptions to normal activities continue, this and other virtual educational methods may continue to play a central role in education and exposure to dentistry.

Implications of Tattoos That Oral Healthcare Providers Should Consider

Occasionally, a patient may present with an intraoral tattoo, such as the patient in this instance who presented with one on the lower orolabial mucosa. Both extraoral and intraoral tattooing could be considered a potential indicator of risk-taking behaviors and possible increased risk of mental health or sleep disorders in this patient population. This article discusses risks of ornamental tattooing and the role oral healthcare providers can play in early identification of possible systemic diseases.

Introduction to dental medicine: Analysis of a massive open online course in dentistry

OBJECTIVES

This study aims to: (1) assess learner demographics of Introduction to Dental Medicine (IDM), an early Massive Open Online Course (MOOC) developed for the Coursera platform and (2) analyze course enrollment to determine worldwide interest in accessible, high-quality dental education.

METHODS

The authors review the development and organization of IDM and present learner statistics to critically evaluate learner traits and course engagement for IDM.

RESULTS

IDM has been available since June 15, 2015, and as of March 1, 2020, gained 90,374 visitors, of whom 16,739 have enrolled and demonstrate continued monthly and daily engagement. Learners represent all age groups and genders and include participants of all educational and employment backgrounds, reflecting broad interest in dental knowledge. They originate from 6 continents with the largest percentages of learners from countries including the United States, Egypt, India, and the United Kingdom. IDM learners have provided positive feedback, rating the course 4.8/5 stars and often providing individual accounts of the benefit of their experiences.

CONCLUSIONS

IDM presented an opportunity to learn general dental concepts. The course served to increase familiarity in the field for all learners, including health professionals, patients, and anyone with an interest in the subject. It also served as preparation for or to expand education in dental, medical, and allied health professions. High learner engagement with wide global distribution demonstrated interest in dental education worldwide.

Oral Hypersensitivity Reactions

Allergic contact hypersensitivity reactions of the oral mucosa pose a significant medical concern for some patients. Oral hypersensitivity reactions can result from a vast number of allergenic chemicals, but occur commonly from dental materials, flavorings, and preservatives. Clinical presentation is varied and often overlaps with other oral conditions, complicating their diagnosis and management. The most common clinical entities associated with oral hypersensitivity reactions are oral lichenoid reactions and allergic contact cheilitis. In addition to reviewing these conditions and their most common corresponding allergens, this article summarizes the pathogenesis of oral hypersensitivity reactions and addresses patch testing pearls.

Considerations in the evaluation and management of oral potentially malignant disorders during the COVID-19 pandemic

Aim

The COVID‐19 pandemic has resulted in society experiencing unprecedented challenges for health care practitioners and facilities serving at the frontlines of this pandemic. With regard to oral cancer, there is a complete absence of literature regarding the long‐term impact of pandemics on patients with oral potentially malignant disorders (OPMDs). The objective of this article is to put forth an institutional multidisciplinary approach for the evaluation and management of OPMDs.

Methods

A multidisciplinary approach was put formalized within our institution to risk stratify patients based on need for in‐person assessment vs telehealth assessment during the COVID‐19 pandemic.

Results

With judicious risk stratification of patients based on clinical features of their OPMD and with consideration of ongoing mitigation efforts and regional pandemic impact, providers are able to safely care for their patients.

Conclusions

The COVID‐19 pandemic has required health care practitioners to make novel decisions that are new to us with development of creative pathways of care that focused on patient safety, mitigation efforts, and clinical management of disease processes. The care of patients with OPMDs requires special considerations especially as patients at high risk for severe COVID‐19 illness are also higher risk for the development of OPMDs.

Recalcitrant Gingival Lesions in a Patient Previously Diagnosed With Behçet's Disease

Oral mucosal lesions are frequently encountered in a variety of healthcare settings and often present as a diagnostic and management challenge. Several immune-mediated disorders present with overlapping oral and/or cutaneous manifestations. Healthcare providers must establish a specific diagnosis to guide effective disease management. This article describes the case of a patient previously diagnosed with Behçet's disease who presented with recalcitrant gingival lesions. The case report underscores the need for healthcare providers to have a fundamental knowledge of mucocutaneous disorders.