Common Ulcerative Conditions of the Mouth: How to Treat Them

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing common oral pathology and the management of common oral lesions. Our guest is Dr. Ashley Clark, a board-certified oral pathologist currently serving as associate professor, division chief, and laboratory director at the University of Kentucky College of Dentistry. She has published over 40 papers and abstracts in the field of oral pathology. Before we get started, I would like to thank our sponsor Perel Pharma, maker of Oroblock, the only aseptically manufactured arcticane in the United States. They also offer a very innovative product called Gocceles. It's spelled G-O-C-C-L-E-S. It's an innovative pair of glasses that works directly with a curing light, any curing light, to perform a quick and non-invasive examination. of the oral cavity. It uses autofluorescence and it helps us identify precancerous and cancerous lesions. An excellent product to have in your operatory. Thank you, Perel Pharma, for your support for this podcast. Dr. Clark, it's a pleasure to have you on Dental Talk. Thanks. I'm happy to be here. Thanks for having me. So what is one way to tell the difference between herpetic ulcerations and recurrent aphthous ulcerations and why is it so important that we know this difference? Oh, this is a wonderful question. Thank you for asking that. So a little background on herpes versus apthos ulcers. Herpes ulcerations versus apthos ulcers in the oral cavity. This is, I think, the moment in dental school I fell in love with oral pathology. I thought this was the cool... I mean, I'm going to expose kind of my nerdy side here, but I just thought, how cool is it that you can tell the difference between an ulcer from a virus... versus an apthys ulcer based on location and the herpetic ulcerations happen on keratinized bound tissue so hard palate attached gingiva if the patient is healthy that's the only place they're going to get recurrent herpes ulcerations inside the mouth if they're sick it's a different story so you know if you ever find a biopsy proven herpetic ulcer on like the buccal mucosa that patient is very sick As far as apthys ulcers are concerned, they're on the buccal mucosa. They're on the lateral tongue. They're in the vestibule. So they are there in the soft palate even. So they're on that non-keratinized movable mucosa. So it's basically location. In general, the apthys ulcers tend to hurt and the recurrent herpetic ulcerations don't really hurt. So that's another way you can tell. But the main one is location. So what's the etiology for the most part for recurrent apthus ulcerations? That is the million -dollar question. So there's no one answer for that, right? So there have been a million things that have been cited as potential etiologies. for why people get apthos ulcers. So we do know they tend to occur in kids. So about 80% of people who get apthos ulcers have their first ulcer before they turn age 30. If you get them after that, they're probably syndromic in nature rather than true apthos ulcers. A major one I see in my practice is sodium lauryl sulfate. So this is the detergent in toothpaste that gives it that foaming feeling that makes it really nice in your mouth. And almost every toothpaste on the market has sodium lauryl sulfate. Now, for most people, it's fine. Thins out your mucosa a little bit, but it's okay. But for those of us with apthys ulcers, which is 20% of your patient population, by the way, That slightly thinning of the mucosa makes it more apt to ulcerate. So one huge way I treat aphthous ulcers, switch toothpaste. So that's a really easy fix to make a patient's life a lot better. And, you know, I ignored the second part of your question earlier when you said, what's the difference and why is it important? It's important because these aren't things that kill your patients. These are benign things. But these are things that cause pain to your patients. And these are things that are incredibly common. Forty percent of your patients are going to have a history of a cold sore. Twenty percent of your patients, anywhere from 20 to 60 percent, are going to have a history of recurrent apthous ulcers. So it's very important to know how to treat these things from a patient retention and even practice building type of way. For sure. What about trauma? How does that affect? You know, traumatic ulcers are a little different than apthys ulcers. So if I bite my cheek, I'll certainly get an ulcer there. And it's probably treated in the same way, right? Like I can probably put a steroid on the traumatic ulcer and it'll go away. But apthys ulcers can appear for no reason whatsoever. Or we, well, there's a reason. We just don't know what it is. So like I mentioned, SLS and toothpaste is a big one. Some people have food sensitivities. So, you know, it might be milk, strawberries, what have you, that cause them to break out in ulcerations. They might be taking a certain medication that makes them more prone to apthys ulcers. So there's a lot of different etiologies. And again, I mentioned earlier, some are associated with syndromes. So the most... one that dentists know about is Crohn disease. So if you have a young kid who's got a mouthful of ulcers and complains of stomach issues, then that patient needs to be evaluated for irritable bowel syndrome. You mentioned that herpetic ulcerations are not as painful. Right. On the inside, when they're on the inside. Yeah. When you see an ulcer, let's say right on the attached gingiva between eight and nine. that is more likely to be a herpetic ulcer because it's on the attached gingiva than an apthys ulcer? Yeah. So if you see an ulcer between eight and nine on the attached gingiva, it is not an apthys ulcer just because of the location. Apthys ulcers do not occur on bound tissue. Now it might not be a herpetic ulcer. It's still possible that it's trauma. It could be a traumatic ulcer. So, you know, there's still a differential diagnosis, but that's about it. What about lymph node involvement? When you get a breakout of herpetic ulceration, is there a tie-in to lymphadenopathy? On the first outbreak, so of 100 people that are infected with the herpes simplex virus, only about 20% will get lesions. So 80% of people that contract herpes don't even know that they've contracted it. But for those 20%, they will get most commonly what's called acute herpetic gingivostomatitis, which is always involves the gingiva and then may involve other areas. In that scenario, the patient might have some lymphadenitis. But for your typical recurrent herpetic ulceration, especially intraorally, you won't have any other manifestations, including pain sometimes. So I've seen before, you know, my students will say, You know, my patient was drinking orange juice and that brought on this herpetic ulcer. No, it didn't. The ulcer was there. They just didn't notice it until they drank that acidic drink. That's how sort of painless they are. I actually don't even treat intraoral herpetic ulcerations because the patients typically don't know that they even have them. Right. Now, is there a tie-in to Epstein-Barr virus with these herpetic ulcerations? So the herpetic ulcerations are almost always type 1. You know, I can get into type two and the differences, but I'll try not to elaborate. too much. So in the oral cavity, we're typically seeing type 1 herpes simplex virus. Epstein-Barr virus, like you mentioned, that's herpes virus type 4. And in the oral cavity, Epstein-Barr virus most commonly causes infectious mononucleosis, which is manifesting by big tonsils, basically. Other things that Epstein-Barr virus can cause or drive is oral heriolugoplakia in patients who have HIV or AIDS or are otherwise immunocompromised. And then some rare cancers like Burkitt lymphoma and nasopharyngeal carcinoma. But we typically don't see them involved in just your regular herpetic ulcerations. So based on identifying the difference between a herpetic ulceration versus an apthus ulceration, more than anything is the location, right? Not so much of how it physically looks to the eye. It really is. It's the location. Also, I would say here, duration of lesion as well, because cancer can present as a non-healing ulcer on the lateral tongue. So an apthys ulcer should go away within a week. So if any ulcer... that's been there for more than two weeks requires a biopsy. So I think duration of lesion is also important when discussing ulcerations because herpes and apthos ulcers, those are acute ulcers. So when we're talking about acute ulcers, the location is the major way to tell the difference. Right. And as far as the symptoms go for either one, what is the best palliative treatment for that? for the patient? So a patient comes in, they complain of that or the doctor sees it and the patient says, yeah, that's been really, really uncomfortable. What should they do? So if patients are seeing me, right? Because I'm seeing clinical oral pathology. So it's a bit different than a dentist, general dentist who's seeing patients all the time because a lot of these patients will not have symptoms. But if your patient is complaining of symptoms, I always like to address those symptoms. So I give a modified magic mouthwash. Now what that means is I tell them liquid diphenhydramine, which is liquid Benadryl, and a Maalox. And what you can do is mix that 50-50 at home. Both of those items are over the counter. And you can swish with a couple of teaspoons, one to two teaspoons, and spit six times per day. That's one way to soothe the ulcerations. Now, if you want to provide a prescription, what you can do is give the liquid diphenhydramine, the Maalox, and then you can add a viscous lidocaine. Then it does have to be prescription. But there's a couple of reasons why I don't always go to that. And number one is because you have to go to a special pharmacy. You have to go to a compounding pharmacy. And those aren't readily available in all areas. So it can be a little bit difficult to get. But number two, because you do have to compound it, sometimes these bottles are $10. Sometimes they're $300. Right, yes. I like to say over the counter, you know, five bucks each. You can make it yourself. And then the second reason I don't always like to give this is most patients don't like their whole mouth being numb from the lidocaine. Now, some do. So I ask them. But the diphenhydramine plus Maalox mixed together over the counter, that will soothe. Yeah, that's a really interesting remedy. Yeah. You know, I thought I came up with it. I really did. I thought, oh, I'm like a genius. No. I took my son who had hand, foot, and mouth disease, and the pediatrician said the exact same thing. You know, you can't give lidocaine to small kids. So she said, mix Maalox and Benadryl over the counter. And I thought, oh, of course. I'm not reinventing anything. No, that works. If that works, that's an amazing little concoction there. Yeah. commonly overlooked lesions of the oral cavity? What are we not seeing as GPs and even specialists when the patient comes in? I would say commonly overlooked lesions. The one that I lose sleep about is gingival carcinoma. Gingival carcinoma is a really strong mimicker of other entities. So periodontal disease, reactive lesions. I recently had someone biopsy a gingival carcinoma and the clinician was sure it was just going to be a pyogenic granuloma. But, you know, that's why you biopsy. So I would say the gingival cancers are the ones that I wouldn't say the most commonly overlooked, but that is the one that sort of gives me fits. So my advice would be common things occur commonly. Periodontal disease is most commonly going to. be periodontal disease if that's what you think it is. So treat it as such. But if it doesn't respond appropriately to therapy, do a biopsy. That's my biggest thing. If it's not responding to your diagnosis, then let's re-examine the diagnosis. If nothing changes for two weeks, that's a pretty good sign that it's time to biopsy. So that is the general rule of thumb. And that's based on the fact that it takes about 10 days for something to re-epithelialize if you go back to your histology in dental school. So that's why we have that two-week rule. But yeah, in general, anything that's not healing, not responding appropriately to therapy, that ought to be biopsied. What does genital carcinoma look like? Everything. I mean, I could show you a thousand pictures and they'd look a thousand different ways. I would say it looks... And I know that that's really not the best descriptor. It can look pebbly. It can be completely red. Another thing about gingival carcinoma is it occurs more commonly in females when compared to males. And that is not true of other types of squamous cell carcinoma that affect the oral cavity. And the other thing is It's not really associated with tobacco use or not as strongly associated with HPV or tobacco use as squamous cell carcinoma in other places in the oral cavity are. So you might have a healthy 40-year-old female with a red spot on her gums. She doesn't smoke. She doesn't drink. You know, she's been married since she was 18, let's say. Just no risk factors whatsoever. So that patient might get kicked along because she doesn't fit the profile of a patient who should have oral cancer. So those are the ones that I worry about because that red lesion needs a biopsy. And when you're flossing around that red lesion, does it cause excessive bleeding? You know, it depends. I would say most of the time these cancers do bleed. Because they're growing so quickly, they're generating their own blood supply. But, you know, periodontal disease, it bleeds too. And I'm not trying to scare anyone. And like I said, common things do occur commonly. But when it comes to the gingiva, just keep in mind, if it's not, you know, resolving with appropriate therapy, then let's get a piece of it and send it to me and let's make sure it's not cancer. And what's the, before I go on to my next question, what's the prevalence of gingival carcinoma? So I don't know. So the way oral cancer statistics are compiled is it's even actually hard for me to parse out oral cavity proper versus oropharyngeal. And that's important because the oropharyngeal ones are due to HPV in general. The ones in the front of the mouth in general, 95 to 98% of the time are due to tobacco and stuff like that. But I do know the order of frequency. So the lateral ventral tongue, floor of mouth. Now soft palate has been taken out because now soft palate's in the order of frequency because they want to include that in the back of the throat, HPV driven. But right after that, gingiva. It's very next. So it is not uncommon to get a gingival carcinoma. But in dental school, we make you know three, right? Lateral tongue, ventral tongue, floor mouth, you know three. So I make my students know four. I make them know the gingiva as well. What do you want our listeners to know about oral cancer that they might not know? If you could do that in a couple of minutes. Sure. Number one, every patient, every time, everyone is allowed to get oral cancer. So everyone gets an oral cancer screen every time they sit in your chair. Number two, young women ages 18 to 44 have been getting an increase in tongue cancer with no risk factors. Even if they are someone who smokes, it's not enough to cause cancer by the age of 28. So be cognizant. Please do a biopsy on non-healing ulcerations. And I, just last week, 22-year-old female, tongue cancer. And it had been watched for over a year because she doesn't fit the demographics. So anything that you think needs to be biopsied, listen to your gut. As Dr. Wes Blakeslee says, you know, does it pass the sniff test? If it doesn't, it ought to be biopsied. And then again, the gingival cancer bit. And the pharyngeal cancers associated with HPV, that's difficult to see, right? Because aren't those lesions really tiny and they're kind of buried back there? So what do we do with those as far as trying to get them early? You can't really. So there's no known dysplastic phase for... hpv driven squamous cell carcinoma of the oral cavity that's in contrast to cervical cancers that have a very predictable progression from low-grade dysplasia to high-grade dysplasia to cancer in the oral cavity it's nothing and then bam 80 of the time those cancers are caught by the time they're in the lymph nodes they're so small we can't see them when we do exams and they're so rapidly growing, that they spread really quickly. So like I said, 80% of the time, those are discovered by the time they hit the cervical lymph nodes. So what we can do is make sure we're looking at the cervical lymph nodes and then encourage our patients to be vaccinated with Gardasil 9. It protects against the two strains that cause condylomata and then seven high-risk strains. And we can... Let our patients know that HPV-driven carcinomas, those patients, even though they're already at stage three, at least when they're discovered, usually, 80% overall survival rate, five years. It's a very good survival rate, especially when you compare it to the HPV-negative cancers of the oral cavity, which have less than a 50% overall five-year survival rate, unfortunately. What was the vaccine you mentioned? The vaccine is called Gardasil 9. So the first one was Gardasil that came out, and it came out in 2006 just for girls. But in 2009, it became available for boys, ages 9 to 26 for girls, 9 to 21 for boys. Now we have, then there was Cerebex, and then now we have Gardasil 9, which is the recommended one. That's been around for a few years now. That's for boys and girls, men and women, ages 9 to 45. And like I said, it's 9-valent, meaning it protects against 9 strains of HPV. The two low-risk, 6 and 11, that cause condylomata. and then 16, 18, 31, 33, 45, et cetera, that protect against high-risk HPV. That's the number one thing we can do to protect ourselves from HPV-driven carcinoma. And I'll tell you, more men get HPV-driven oropharyngeal cancer than women get cervical cancer. So even though women have a higher vaccination rate because it was marketed to us for cervical cancer, men need it more. they get more HPV cancers than women do. Yeah, I wonder if dentists are even talking about that to their patients. I doubt it. I think some pediatricians do, but I don't know that general dentists do. And you know, they did a study of family physicians and pediatricians on the medical side. Some of them didn't even know, about half of them didn't even know it could protect against oral cancer. They just knew about the cervical cancer. Right, and that's why I think a general dentist should be right up there. making those recommendations. At least have some pamphlets in the waiting room. You know, if you don't have time to mention it to every patient, at least have it advertised, like get this vaccine. HPV can cause throat cancer. Yes, absolutely. So to wrap up this podcast, and it was very interesting. I really enjoy talking to you. You have so much information about this and you have such a passion for oral pathology and how it relates to dentistry and our everyday practices. So do all lesions we see in the mouth have to be biopsied? Now, I know the answer is no, but we talked about this question, and I'm asking it because there's got to be some hidden message here. When in doubt, cut it out, is what I say. When in doubt, cut it out. Any solitary pigmented lesion that you can't prove to be amalgam, it's got to go. Any papillary lesion, fibromas, those need a biopsy. Things that don't need to be biopsied are things you can for sure diagnose clinically, a geographic tongue. You don't need to biopsy that because you've already diagnosed it. But we biopsy things because we cannot diagnose it clinically. It's impossible to diagnose a fibroma clinically because there's no way to tell if it's actually a neurofibroma and the first step in getting the patient diagnosed with a syndrome. So now, does that happen often? No. But you don't want it to be your patient that it happens to and you miss it. When in doubt, cut it out. And I know in dermatology, there's... risk factors. So when you go to the dermatologist, let's say, do you have a history of melanoma? Anybody in your family have melanoma? Is there any medical history questions that should be asked by a general dentist regarding oral pathology as far as higher risk patients? So that depends on who you talk to. So if tobacco use, number of years used, that's helpful information. HPV status, to me is unhelpful information because about 100% of people who have ever been sexually active have contracted HPV. So when my patient tells me they have a history of HPV, that tells me they're on top of going to their doctor's appointments rather than putting them at a higher risk because I assume all of my patients have HPV. Of course, it's important to ask about history of tobacco and all that. Maybe HPV vaccination status would be a good thing to sneak in the medical questionnaire to bring that topic up. But I don't use it to make decisions on whether or not to biopsy. Yeah. And so we're going to end this podcast, but I would like you to tell our audience about your biopsy service at University of Kentucky College of Dentistry. Yeah. I'm the division chief and I'm the laboratory director here at the University of Kentucky. I'm an associate professor and we offer biopsy kits for free. Throughout the country, we provide the FedEx, we pay for the mailing, and we have contributors. At one point, we had them from all 50 states. So it doesn't matter where you are, we can read your tissue. And also we work with basically every health insurance that I can think of under the sun. So that's a really big help to your patients too. So if you're interested in getting a free biopsy kit, please email me at ashley.clark.com. dds at uky.edu there was a lot there so run that one more time and ashley spelled a-s-h-l-e-y clark is clark is c-l-a-r-k so if you can repeat that email one more time by the way could they just could they go to university of kentucky college of dentistry and just look up oral pathology absolutely you can google university of kentucky oral pathology the reason um And I'm happy, just fill in the form that you heard it on this podcast. So that way I know, I will give you my personal cell phone number is why I wanted people to email me directly so I can give them my personal cell phone number. So dentists and surgeons contact me day and night with their pathology inquiries. I've gotten three messages since we started recording this podcast. Wow, that's impressive. Yeah, please provide your email one more time and then we'll call it quits. It's Ashley, A-S-H-L-E-Y. Dr. Clark, always a pleasure to have you on the show. Really great stuff. Such an important topic that a lot of us are not really totally up on. It's just one of those things, you know, that it's kind of a subspecialty of dentistry in many ways that, you know, we're so concerned about doing our... full digital denture workflow and milling in the office and we don't hear a lot of ce on oral pathology so it's really important that these doctors know this i'm not lying i don't know how to place a resin anymore so there's no judgment here all right well thank you very much have a great evening and we hope you're on future podcasts soon thank you thanks so much