Title Page
Copyright Page
Foreword
Acknowledgements
Chapter 1 Introduction and Oral Medicine in Clinical Practice
Aim
Outcome
Introduction
The Oral Medicine Consultation
Greeting
Introduction
Information-Gathering
Review and Discussion
Conclusion and Future Planning
Conclusions
Further Reading
Chapter 2 Immunological Problems of the Oral Mucosa
Aim
Outcome
Introduction
Orofacial Allergic Disorders
Type 1 Reactions
Angio-oedema
Type 2 Reactions
Type 3 Reactions
Erythema Multiforme (Fig 2-1 and Fig 2-2)
Type 4 Reactions
Metal Allergies (Fig 2-3)
Dental Materials
Latex (Fig 2-4)
Food Allergies
Fixed Drug Eruptions
Orofacial Granulomatosis (Figs 2-5 to 2-7)
Summary
Lichen Planus (Figs 2-8 to 2-12)
Lichenoid Reactions
Graft-Versus-Host Disease
Recurrent Oral Ulceration (ROU)
Non-Aphthous Ulceration
Traumatic Ulceration
Other Mucosal Disease
Recurrent Aphthous Stomatitis (Fig 2-13 to Fig 2-15)
Management of Aphthous Ulcers
Summary
Vesiculobullous Disorders (Fig 2-16 to 2-21)
Angina Bullosa Haemorrhagica
Mucous Membrane Pemphigoid
Pemphigus Vulgaris
Other Vesiculobullous Disorders
Management of Vesiculobullous Lesions
Summary
Systemic Autoimmune Conditions
Lupus and Associated Syndromes (Figs 2-22 and 2-23)
Organ-Specific Autoimmune Diseases
Vasculitic-Induced Oral Disease
Summary
Further Reading
Chapter 3 Lumps and Bumps
Aim
Outcome
Vascular Anomalies (Figs 3-1 to 3-6)
Haemangioma
Sturge -Weber Syndrome (Trigemino-Encephaloangiomatosis)
Hereditary Haemorrhagic Telangiectasia
Varicosities
Malignant Vascular Swellings
Lymphangioma
Connective Tissue Hyperplasias (Figs 3-7 to 3-10)
Pyogenic granuloma (Fig 3-11)
Pregnancy Epulis
Peripheral Giant Cell Granuloma (Giant Cell Epulis) (Fig 3-12)
Hyperparathyroidism
Chronic Hyperplastic Gingivitis
Drug-Induced Gingival Hyperplasia
Benign Mucosal Neoplasia
Squamous Cell Papilloma (Fig 3-13)
Lipoma (Fig 3-14)
Neurofibroma (Fig 3-15)
Multiple Endocrine Neoplasia Syndrome (MEN)
Miscellaneous Oral Soft-Tissue Swellings
Foliate Papillitis
Sublingual Dermoid (Epidermoid) Cysts
Bone Anomalies
Exostosis and Tori
Tori
Osteoma
Osteosarcoma
Fibro-Osseous Lesions of the Jaws
Cherubism
Fibrous Dysplasia (Fig 3-20)
Diagnosis
Treatment
Paget’s Disease of Bone
Diagnosis
Treatment
Conclusions
Further Reading
Chapter 4 Infections of the Oral Mucosa
Aim
Outcome
Introduction
Bacterial Infections
Acute Ulcerative Gingivitis
Facial Abscess
Streptococcal and Staphylococcal Infections
Mucositis
Angular Cheilitis
Perioral Skin Infections (Fig 4-4)
Syphilis
Tuberculosis
Viral Infections (Figs 4-5 to 4-8)
Herpes Group Viruses
HHV 1 and 2 – Herpes Simplex 1 and 2
HHV 3 – Varicella Zoster
HHV 4 – Epstein-Barr Virus
HHV 5 – Cytomegalovirus
Coxsackie Viruses
Paramyxoviruses
Human Immunodeficiency Virus (Figs 4-9 to 4-11)
Human Papilloma Viruses (HPV)
Fungal Infections
Candidal Infections
Pseudomembranous Candidiasis
Chronic Hyperplastic Candidiasis
Angular Cheilitis
Erythematous Candidiasis
Chronic Mucocutaneous Candidiasis
Summary
Further reading
Chapter 5 White Patches
Aim
Outcome
Introduction
Developmental White Lesions
Traumatic Keratoses (Figs 5-6 and 5-7)
Conclusions
Further Reading
Chapter 6 Oral Cancer and Premalignant Lesions
Aim
Outcome
Introduction
Risk Factors
Other Possible Risk Factors
Clinical Features
Management
Biopsy
Treatment
Lifestyle Counselling
Epithelial Dysplasia
Potentially Malignant Lesions
Leukoplakia (Figs 6-4 to 6-7)
Clinical Appearance
Homogenous Leukoplakia
Non-Homogenous Leukoplakia
Speckled Leukoplakia
Erythroplakia (Figs 6-8 and 6-9)
Management
Other Potentially Premalignant Conditions
Chronic Iron Deficiency Anaemia
Erosive Lichen Planus
Oral Submucous Fibrosis
Lupus Erythematosis
Tertiary Syphilis
Actinic Keratosis
Conclusions
Further Reading
Chapter 7 Oral Pigmentation
Aim
Outcome
Introduction
Superficial Staining
Black Hairy Tongue (Fig 7-1)
Amalgam Tattoo (Figs 7-2 and 7-3)
Foreign Material
Heavy Metal Salts
Melanin Pigmentation
Developmental Causes
Racial Pigmentation
Pigmented Naevi
Peutz-Jegher Syndrome
Acquired Causes
Oral Focal Melanosis (Figs 7-5 and 7-6)
Addison’s Disease
Diagnosis
Management
Drug-Induced Hyperpigmentation
Malignant Melanoma (Fig 7-7)
Clinical Features
Diagnosis
Treatment
Conclusions
Further Reading
Chapter 8 Disorders of Salivary Glands and Salivation
Aim
Outcome
Introduction
Salivary Flow Disturbance
Sources of Saliva
Composition and Functions of Saliva
Measurement of Salivary Flow (Sialometry)
‘The Dry Mouth’ (Xerostomia)
Causes for Dry Mouth
Sjögren’s Syndrome (Figs 8-1 and 8-2)
Pathogensis
Diagnosis
Management
Management of Oral Problems
Artificial Salivary Substitutes and Stimulants
Dental Caries and Periodontal Disease
Candidiasis
Bacterial Sialadenitis
Other Causes of Dry Mouth
Increased Salivation (Sialorrhoea)
Diagnosis
Management
Salivary Gland Infections
Mumps
Diagnosis
Management
Recurrent Parotitis of Childhood
Diagnosis
Management
HIV Salivary Gland Disease
Diagnosis
Management
Suppurative Sialadenitis (Fig 8-4)
Diagnosis
Management
Salivary Gland Swellings
Mucocele
Diagnosis
Management
Sialosis
Diagnosis
Management
Sialolithiasis
Diagnosis
Management
Salivary Neoplasms
Pleomorphic Salivary Adenoma (PSA)
Diagnosis
Management
Mucoepidermoid Carcinoma
Diagnosis
Management
Adenoid Cystic Carcinoma
Diagnosis
Management
Miscellaneous Salivary Disorders
Necrotising Sialometaplasia (Fig 8-7)
Diagnosis
Management
Sarcoidosis
Conclusions
Further Reading
Chapter 9 Facial Pain
Aim
Outcome
Chronic Facial Pain
Understanding Pain
Allodynia
Pain Appreciation
Neurogenic and Vascular Facial Pain
Pain without Vasomotor Changes
Trigeminal Neuralgia
Stroke Pain
Neuropathic Pain
Atypical Odontalgia
Pain with Vasomotor Changes
Migrainous Neuralgia
Complex Regional Pain Syndrome
Headache
Classical Migraine
Common Migraine
Tension Type Headache
Temporal Arteritis
Temporomandibular Disorders
Oral Dysaesthesias
Summary
Further Reading
Chapter 10 Neurological Disorders of the Head and Neck
Aim
Outcome
Introduction
Movement Disorders
Cerebral Palsy
Parkinson’s Disease
Sensory Disorders
Intracranial Disease
Multiple Sclerosis
Facial Motor Loss
Motor Neurone Disease
Facial Nerve Palsy (Fig 10-1)
Conclusions
Further Reading
Chapter 11 Complementary Therapies in Oral Medicine
Aim
Outcome
Introduction
Acupuncture
Herbalism
Homoeopathy
Hypnotherapy
Osteopathy/Chiropractic
Amalgam
Other Treatments
Conclusions
Further reading
Appendix A
Appendix B
Quintessentials of Dental Practice – 10
Oral Surgery and Oral Medicine – 3
British Library Cataloguing-in Publication Data
Macleod, Iain, Dr
Practical oral medicine. - (Quintessentials of dental practice ; 10.
Oral surgery and oral medicine ; 3)
1. Oral medicine
I. Title II. Crighton, Alexander III. Wilson, Nairn H. F. IV. Meechan, J. G.
617.5′22
ISBN 1850973245
Copyright © 2005 Quintessence Publishing Co. Ltd., London
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.
ISBN 1-85097-324-5
The everyday clinical practice of dentistry includes aspects of oral medicine. Lesions and abnormalities of the soft tissues of the mouth and orofacial region are common, with many conditions being indicative of systemic disease and disorders. Knowledge, understanding and the effective practice of oral medicine are therefore integral to the provision of holistic oral healthcare.
Oral medicine, in common with all other aspects of dentistry, continues to evolve at an ever increasing rate. This volume of the unique Quintessentials of Dental Practice series captures the essence of modern oral medicine for, in particular, the busy practitioner. From immunological problems through lumps and bumps, infections and white patches to premalignant lesions and oral cancers, together with sections on oral pigmentation, disorders of salivary glands and salivation, facial pain, neurological disorders and complementary therapies, this Quintessentials volume provides essential chairside information and guidance. Aficionados of Quintessence books and, in particular, the Quintessentials series will be pleased to recognise all the qualities they have come to expect: succinct, easy to digest, up-to-date text, well illustrated with high quality graphics and images.
This book is both a valuable, close-to-hand reference text and a pleasure to indulge in over the one or two evenings it takes to complete the cover to cover read. A gem of a book in the world-class Quintessentials series. I hope you enjoy and discover new dimensions to oral medicine from this excellent addition to the ongoing series.
Nairn Wilson
Editor-in-Chief
To Enid and Emilia, without whose support over the years this work would not have been possible.
The aim of this chapter is to outline the development of oral medicine and to describe the oral medicine consultation.
After reading this chapter you should understand the importance and structure of an oral medicine consultation.
Oral medicine has been defined as ‘the speciality of dentistry concerned with the health care of patients with acute or chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and medical management. It is also concerned with the investigation, aetiology and pathogenesis of these disorders leading to understanding that may be translated into clinical practice. Oral medicine is a clinical and academic speciality that is dedicated to the investigation, diagnosis, management and research into medically related oral diseases, and the oral and facial manifestations of systemic diseases. These include diseases of the gastrointestinal, dermatological, rheumatological and haematological systems, autoimmune and immunodeficiency disorders, and the oral manifestations of neurological and psychiatric diseases.’
The practice of oral medicine requires a sound knowledge of medical science in order to provide a rational approach to diagnosis and clinical management. It is also essential for the competent provision of dental care to those with special needs – patients with physical, mental or medical disability.
Oral medicine permeates virtually all branches of dentistry and many areas of medicine. It can be regarded as the interface between medicine and dentistry. This book covers in a practical manner the scope of oral medicine most likely to be encountered in a dental setting. It does not pretend to be all-inclusive, and readers are advised to make reference to more specialist publications where appropriate. Some of these are suggested at the end of each chapter. In addition, some conditions more usually managed by maxillofacial, ear, nose and throat (ENT) or plastic surgery have been deliberately excluded.
The initial appointment is often the most important time in patient’s management. This meeting sets the tone for all remaining visits. The patient forms opinions about the expertise and competence of the practitioner. The clinician forms views about the patient and his or her problem. As communication, empathy and trust form a large part of treatment, it is important that the process gets off to a good start on both sides.
An effective practitioner will manage to put patients at their ease. This can establish trust, allowing full disclosure of information relevant to the problem to be obtained. Many factors are important in this. The following can all play a part:
body language
seating position and arrangement
dress
language.
One of the most important lessons for the inexperienced clinician to learn is when not to talk and to encourage the patient to keep providing information. It is important to retain control of the consultation, however, and not be afraid to redirect patients when they digress from pertinent information.
The stages of the consultation are as follows:
greeting
introduction
information-gathering
review and discussion
conclusion and future planning.
Each stage is important and will take place at every consultation, but the emphasis on each will vary between initial and review consultations.
This is the first contact between the patient and the clinician. It may occur when collecting the patient from the waiting area or as the patient enters the surgery. The clinician should greet the patient in an open and welcoming manner, introducing himself and all other people present at the consultation by giving their name, position and their role. The patient should be seated comfortably, facing the clinician in preparation for the next stage of the consultation. If the patient has brought a supporter, ideally he or she should be seated able to face and communicate with the patient and the clinician. Where possible all individuals in the consultation room should be easily visible to the patient, as this helps relaxation.
The clinician should outline the purpose of the appointment – for example, a referral from another practitioner, a review of investigation results or treatment progress. An outline of the process of the consultation is appropriate at the initial visit, informing the patient of the different stages to expect – history, review and the possible need for discussion with other health care workers, special investigations and arrangements for management. Many complaints from patients relate to communication failures rather than to treatment problems. It is important that the patient and the clinician are equally clear about the purpose and scope of the consultation at this visit.
The history should follow a standard format to enable reproducibility. A sample history-taking plan is given in Table 1-1. Some aspects of the history process will be identical for all patients and some – in particular, the history of the presenting complaint – will vary according to the problem. Some of the key issues in a patient with recurrent oral ulceration will be of little relevance in someone with chronic facial pain, but a thorough medical and social history will be important for both. In this book, where there is information required for a particular oral complaint, the specific history points to cover will be reviewed in the appropriate chapter. All sources of information including, if appropriate, the opinions of the supporter, can be important and should be canvassed. At the end of the history, it is helpful to read back to the patient the clinician’s understanding of the presenting problem, its course and management to this point. Any misunderstandings or misinterpretations on the part of the clinician can then be set aside at an early stage.
| For each patient the following information must be obtained | |
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Check particularly: |
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Angina, previous myocardial infarction |
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Asthma/chronic obstructive pulmonary disease (use of inhalers?), smoker (what quantity?) |
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Dyspepsia, ulcers, altered bowel habit, bleed PR |
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Prostatism (men!) |
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Rashes, itch, eczema |
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Rheumatic fever, jaundice, diabetes, epilepsy |
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illnesses known in blood relatives? (myocardial infarction, cerebrovascular accident, diabetes) |
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Who is at home? Are they well? |
| Examination, Diagnosis and Treatment | |
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A full clinical examination of the head and neck should then take place. Depending on the differential diagnosis, the expertise of the clinician, local clinical practice and facilities, a more complete physical examination of the patient may also be appropriate (Figs 1-1 to 1-3).
Fig 1-1 Two typical basal cell carcinomas on the left temple area – such a finding can occur during the routine inspection of the face. By permission of Oxford University Press from “Oral Pathology 4/e” edited by Soames, JV & Southam, JC (2005).
Fig 1-2 The hands can reveal a number of physical signs and are easy to examine in the otherwise dressed patient. In this case they show the typical joint changes and deformity of rheumatoid arthritis.
Fig 1-3 Chronic swelling of a buccal lymph node – in most cases this arises in response to dento-facial infection but can also be a manifestation of malignancy, such as lymphoma or, in this case, rhabdomyosarcoma.
After the examination it is useful to summarise the key points elicited in the examination and relate these to the history. From this the patient can see how the clinician has reached the offered diagnosis, or where there is a need for proposed investigations. In most oral medicine problems, the patient will be the ‘key worker’ in the delivery of treatment. It is therefore essential that the patient accepts the diagnosis and treatment plan suggested. In addition, the patient should understand the likely outcome, effects and timescale of the proposed treatment. The patient and, if appropriate, the supporter should be invited to ask questions about the diagnosis and proposed treatment. Where possible, written information should be given. This may be a full information leaflet, if available, but simply writing the name of the diagnosis and proposed treatment on paper to hand to patients can be helpful. This will aid understanding of their condition and ultimately their involvement in and compliance with treatment.
At the end of the initial consultation the patient should be made aware of investigations planned, the likely duration of the treatment and the planned intervals for review. It is useful to explain why a particular interval is chosen – for example, two-month intervals rather than one month – as this will help the patient understand the treatment process. Similarly it is important to ensure that the patient knows how to contact the clinician should the situation or condition change so that a new review interval or unscheduled appointment can be arranged. If it is decided to refer to a more appropriate specialist, the reason and mechanism for this should be clearly explained. The general medical practitioner can often play a pivotal role in the provision of care for oral medicine conditions, in many cases providing the treatment for the patient according to the treatment plan. If urgent medication is required, it may be necessary to contact the general medical practitioner asking for a particular treatment to be made available quickly or to dispense directly to the patient from the clinic.
At the end of the consultation patients should have a clear understanding of their future care plan. Notes should be completed promptly and letters sent to appropriate people, usually including the general medical practitioner. The general medical practitioner is often the only person aware of the ‘bigger picture’ in the patient’s care and, as a consequence, should routinely be included in all correspondence.
Communication skills are an essential part of oral medicine.
A full history, including a medical and social history are necessary for all patients.
All health-care practitioners should be kept updated with changes in the patient’s care plan.
Schouten BC, Eijkman MA, Hoogstraten J. Dentists’ and patients’ communicative behaviour and their satisfaction with the dental encounter. Community Dental Health 2003;20:1,11–15.
Piasecki M. Clinical Communication Handbook. London: Blackwell Scientific Publications, 2003 (ISBN 0632046465).
The aim of this chapter is to review immunological oral disease, including lichen planus, oro-facial allergic disorders, recurrent aphthous stomatitis, mucocutaneous autoimmune disorders, vasculitis and systemic autoimmune disorders presenting in the head and neck region.
After reading this chapter you should be able to understand the features of immunological disease affecting the head and neck, together with the systemic effects of these diseases and factors influencing their presentation or management.
Immunological oral disease is a very broad subject. Many mucosal and periodontal problems are caused either directly or indirectly by the host’s immune system. Some oral manifestations represent mouth changes as part of a whole body process, and other conditions produce lesions or symptoms mainly or only in the mouth. In this chapter immunological problems, including the oral effects of allergy, will be reviewed together with the oral mucosal effects of immunological reactions to the oral mucosa.
Allergy is usually classified by its four main methods of presentation:
type 1 - immediate (anaphylactic)
type 2 - autoimmunity
type 3 - immune complex disease
type 4 - delayed hypersensitivity.
Many patients presenting with allergy-related disease will have a history of atopy, such as eczema or asthma. The presentation of allergy in the oral soft tissues may be very varied. Gingival hyperplasia may be found in patients with allergic nasopharyngeal reaction, resulting in tissue desiccation secondary to mouth-breathing. Gingival erythema may be the result of a toothpaste allergy, often leading to a significant plasma cell infiltrate and the clinical appearance of a desquamative gingivitis. Allergy can be the basis of many other oral mucosal diseases not primarily considered ‘allergic’ disorders. These include recurrent aphthous ulceration and lichen planus. There is also an association with geographic tongue, but there is no good evidence suggesting a causal relationship.
These are produced by the rapid movement of fluid into the tissues from the circulation and are characterised by rapidly increasing swelling of the tissues and, following removal of the stimulus, gradual resolution over a period of hours. In this condition the transudation of fluid into the tissues from the capillaries is more rapid than the capacity of the lymphatics to drain the fluid away. This can be seen in patients with angio-oedema of the lips or tongue such as may be triggered by ACE-inhibiting drugs or C1 esterase dysfunction.
In this condition the patient will report rapid lip swelling over less than an hour with gradual resolution over the remainder of the day. Most patients with these symptoms do not seem to have a recognisable trigger, and empirical management with a long-acting, non-sedating antihistamine is the mainstay of treatment.
The combination of angio-oedema with bronchospasm, vasodilatation and rapid hypotension suggests another type 1 reaction – anaphylaxis. This reaction may follow dental treatment, such as a reaction to latex containing gloves worn by the dental team, or more rarely a local anaesthetic injection. Environmental triggers, such as a bee or wasp sting, are also possibilities, and an anaphylactic reaction should never be discounted only because no drug has been administered to the patient.
There are no oral conditions commonly associated with a type 2 reaction.