Navigating Oral Ulcerative Conditions: When to Treat, Refer, or Reassure

So there's something called a Tugsy traumatic ulcerative granuloma with stromal eosinophilia. Those are ulcers that will persist until removed and they're benign, but they are indistinguishable clinically from a cancer. So any ulcer that's been there for longer than two weeks, we got to cut that out. Welcome to the Phil Klein Dental Podcast. As dental professionals, it's highly likely that we see oral ulcerative lesions fairly regularly in our practice. There probably isn't a week that goes by where a patient doesn't show and or complain about some kind of ulcerative lesion. But although somewhat common, we should keep in mind that these lesions can range from benign, self-limiting conditions to signs of serious underlying diseases. So it is our responsibility to be knowledgeable and up-to-date so that we can accurately identify and manage these lesions so that the patient can expect the best possible clinical outcome. To guide us through the topic of ulcerative conditions of the oral cavity is our guest, Dr. Ashley Clark. She brings a wealth of knowledge about the clinical presentation, differential diagnosis, and management strategies for oral ulcerations. In this episode, we'll share insights into what dentists should look for during routine exams, what to be concerned about, and how to approach treatment or referral. Dr. Clark has been a regular contributor to VivaLearning.com. She's a board-certified oral pathologist, currently serving as the VP of CAMP Laboratory after a decade-long career in academia. She is on the professional board for oral cancer cause and digital dental notes. Dr. Clark has won several teaching awards, has provided over 100 continuing education courses, and has authored more than 40 publications and book chapters. Dr. Clark is open to be reached out to through her email at aclark@camplaboratory.com, and that is listed in the description of this podcast. 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Explore VOCO's full range of composite materials and request a sample at voco.dental. Dr. Clark, it's a pleasure to have you on the show. Thank you so much for having me. It's a pleasure to be here. I always love doing these podcasts with you. Yeah, we love having you. I just want to let the audience know there's several other podcasts that we've done with Dr. Clark. One is on common oral pathology. which is very insightful on some of the things that we as GPs will see routinely in our practice and how to proceed when we see them and what to tell the patient. And also a very important one is leukoplakia because that is very prevalent intraorally. It's one of the most common pathologic entities that GPs will see in the oral cavity. And leukoplakia, 20% of those lesions turn into dysplastic cells. leukoplakia is a very, very important white patch to be aware of. And Dr. Clark covers that very well in one of her podcasts. So today we're going to be talking about ulcerative conditions of the oral cavity. So to begin, Dr. Clark, my first question is, how often does the dental team encounter a patient with ulcerations? Ulcerations are actually pretty common depending on the type. So they're... usually when we talk about ulcers we divide them into acute ulcers and chronic ulcers acute ulcers the common ones are recurrent aphthous ulcers and herpes those are common and then the uncommon one is erythema multiforme that's pretty uncommon but that's an acute process For chronic ulcers, the common one is lichen planus, and the uncommon ones are mucous membrane pimphigoid and pimphigus vulgaris. So about 20% of your patients have aphthystomatitis, about 40% have herpes, and about 1% have lichen planus. So those are the main ulcerative conditions with which I deal. So talking about one of the common ulcers, apthos ulcers. How do we manage that for patients where they're extremely uncomfortable because they are painful, correct? Yeah. The number one thing that we, why we treat apthos ulcers, they're painful. They're just, you know, you're creating a better quality of life for your patient. If the patient is having a minor apthos ulcers, meaning you know, regular ulcers that aren't huge and they go away in one week, they don't scar. The way we treat those, number one, we can do over-the-counter care. Usually that's sufficient, just palliative treatment. If they are coming to you with the chief complaint of, I get these ulcers and they hurt, what I would do is a magic mouthwash, which is a liquid Benadryl, a Maalox. And then with or without viscous lidocaine. If you choose to do it without viscous lidocaine, they can actually buy the Benadryl and Maalox over the counter. And mix it 50-50. Yeah, I was going to ask you, what kind of mix are we talking about? So 50-50 on the Maalox and the Benadryl, 50-50. Yep. So that's colliative. That will help soothe it. To help prevent and treat them, you can give a topical steroid. Generally not needed for minor apthys ulcers, but that will help them go away. It will help with healing time. And then what you want to do is get them off of sodium lauryl sulfate toothpaste. So any toothpaste containing sodium lauryl sulfate, you want to try to get them to try a new toothpaste. And a lot of times that will prevent the patient from getting apthys ulcers. Some examples of... SLS is what I'll call it, sodium lauryl sulfate. Some examples of SLS-free toothpaste include Squiggle, S-Q-U-I-G-L-E. You can buy that on Amazon. It has fluoride. It actually has the most mild surfactant available on the market. It's called Paloxamer. It has no irritating flavors. It's just a great toothpaste. The next one, you could try Biotine. Both flavors of biotin are SLS-free. The easiest one to suggest is Sensodyne, but you have to tell the patient to read the ingredients because Sensodyne makes over 21 types of toothpaste, and not all of them are SLS-free. So Squiggle is a safe bet. Biotin is a safe bet. Sensodyne is more easy to find, but you have to do a little bit of patient education. Now, does SLS also cause other tissue irritations in addition to the ulcers? So what SLS does is, for example, I was a dental student when the Oral Health Institute in Indianapolis, Indiana came up with... Press ProHealth and it causes sloughing in about 50% of people who use it. So, or at least that's what I was taught. Meaning you might get like little strings in your mouth and that's just a little bit of tissue sloughing that does not hurt the patient. It's not cancerous. It's not painful. It's just maybe mildly irritating. But in patients who get ulcers, That thins the mucosa out just a little bit to make it more apt to ulcerate. So that's why SLS is free toothpaste are preferable because you don't get that sloughing. My recommendation would be not to use any toothpaste that has SLS in it. That creates the lather, right? The soapy type. Yeah, that's the detergent that gives you that nice foamy feeling that you're really getting in there and cleaning. Now, the other toothpaste that I mentioned, Sensodyne, Biotine, Densify, they all use a surfactant. It is a very long name that starts with a C. I'm not even going to attempt to pronounce it. It's a surfactant or detergent that causes some foaming. And like I said, Squiggle has the poloxomer, so it actually doesn't foam that much. So patients might not like that either, but it's the most mild surfactant least likely to cause that sloughing. So not all ulcerations are the same. Some are very mild and relatively painless. Some are not life-threatening, but painful. But then there's the ominous ones, the ones that can actually be life-threatening. And those are the ones we certainly want to make sure we identify and manage. So what are we looking at as dental professionals as far as those kinds of lesions? So there are three ulcerative conditions that dentists are responsible for catching. And if we don't, the patients either die, go blind or die. So there are, and those are the rare ones, but even though they're rare, they're incredibly important. So erythema multiforme is, we used to teach it as EM minor. And then EM major is the same thing as Stevens-Johnson syndrome. That's not true. So you have EM minor and major, which those don't really have a high mortality rate, maybe one to 2%. But you have Steven Johnson syndrome and Lyle disease. And these are. have a mortality rate, especially Lyle disease of up to 30%, 40% of people will succumb to their condition. And these ulcers present as bloody crusted lips. They never last longer than six weeks, but the patient will not feel good. And then all of a sudden their mouth will break out and diffuse ulcerations and have bloody crusted lips. So if you see that you need to figure out. what's causing this allergic reaction because these are allergic reactions. It's usually an antibiotic. You need to refer them to the appropriate emergency care services. And probably depending on where you live, if you're in a smaller town, especially you are going to have to get the doctor your diagnosis because the doctor will have never seen this before. And then these patients with Lyle disease are treated in a burn unit. My last patient with Lyle disease over. It was like 40% of her body was affected, meaning that skin just falls off. Huge risk for sepsis and infection. So that kind of allergic reaction that causes that crusting of the lip, you would think steroids would calm it down, but that's obviously contraindicated based on the fact that you want to prevent sepsis. For erythema multiforme minor, I will give steroids. Steroids are actually contraindicated in Lyle disease because they mask the signs of sepsis. So what they'll do is they'll take these patients to the burn unit and treat them that way. It's just, it's a horrible condition. But the important thing is the dentist has to recognize the, you know, sudden onset of diffuse oral and lip ulcers. and correlate that with this very serious condition. The other oral ulcerative conditions that cause problems systemically, number one is pemphigoid. Mucous membrane pemphigoid is where the mucous membranes are involved, and the number one site that's affected is the oral cavity. We are responsible for catching this. When you catch this... These chronic ulcers, they usually appear as intact blisters, which ulcerate and then just get worse. You need to refer to perio or oral surgery to get your biopsy to get this diagnosed. And then every single patient with pemphigoid must go to the ophthalmologist. The entire goal of treating patients with pemphigoid is to prevent blindness. That's not the entire goal, but that's the number one priority is to make sure they don't go blind. And we've got to be the ones to catch this so we can't mess around with it. And that's an autoimmune response? This is an autoimmune disease. That's correct. It's not the same as bolus pimphigoid, which is... much more common about one to two percent of people will have bolus pemphigoid on the skin so the mucous membrane pemphigoid is the one that causes blindness and affects the oral cavity you're allowed to have both but bolus pemphigoid tends to not affect the oral cavity it tends to just affect the skin and mucous membrane pemphigoid tends to not affect the skin and affect the mucous membranes um but You know, in contrast, like lichen planus, that's a mucocutaneous condition. It likes to live on mucous membranes and skin, just like erythema multiforme can affect mucous membranes and skin. You certainly covered a lot there, Dr. Clark. If you would, could you reiterate the oral conditions that would often lead the patient to be treated in a burn unit? Steven Johnson syndrome and Lyle disease. These are under the umbrella of what's called scars, severe cutaneous adverse reactions. Those are the ones where they need to go to the hospital and possibly be seen in a burn unit. I think collectively we just refer to these things as EM because, number one, that's what we were taught. We were taught that EM and Steven Johnson syndrome is the same thing, and that's just not true. But we didn't know that, right? Right. Number two, the lesions look incredibly similar. They're basically the same presentation. Just EM that usually doesn't cause death is triggered most typically by an infection such as herpes. And the severe cutaneous adverse reactions are typically triggered by a medication such as an antibiotic. 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Plus, the Shining 3D Dental digital So in that first visit, Dr. Clark, when we're examining the patient, is there anything in the medical history, the history of that patient that would alert us? to the fact that that patient has a proclivity toward chronic ulcers? Well, you know, it's sort of hard. A history of ulcers would be one indication. The three chronic ulcerative conditions, those don't really hit until adulthood, so around age 50, 60. Those tend to occur in women, so that would be the first checkbox. Pimp and Gus doesn't have a gender predilection, but usually Lycanplanis likes to live in women, like other autoimmune diseases. So being a woman puts you at a higher risk than being a man. Having another autoimmune disease puts you at risk because autoimmune diseases like to occur in pairs. There's never going to be a scenario where I look at a patient's medical history and think, oh, wow, they might get pemphigoid based on a fact that they have rheumatoid arthritis or something like that. What would make me concerned is if they have a history of ulcerations that haven't calmed down or fiery red gingiva that someone has called gingivitis but isn't responding appropriately to therapy. A lot of times patients with pemphigoid, they'll be treated for gingivitis because it looks like gingivitis at first. And then the patient's in so much pain, they won't brush their teeth. So then they'll actually get periodontitis and then be treated for periodontitis. And all the while, this is a disqualment of gingivitis. This is a chronic ulcerative condition that is just affecting the gingiva. And we need a biopsy to diagnose it. So I would say if they have a history of periodontitis that's not responding to appropriate therapy, that would be another red flag if they have bright red gingiva. Another thing to mention is that apthys ulcerations are typically something that happens in the younger population. And as we get older, we tend to not get them as much. So anyone who has their first apthys ulcer after age 30, or anyone who has an increase in severity of aphthous ulcers after age 30 ought to be evaluated for a syndrome that can cause aphthous ulcers. And what syndrome is that? The number one thing people typically think of, Bichette and Crohn are the number one and number two that people typically think of. Crohn disease actually doesn't present with apthos ulcers in the mouth too terribly often. Crohn disease likes to create these sort of cobblestone appearance to the mucosa, sort of tissue overgrowths, but it can lead to apthos ulcers. Bichette disease has ocular, genital, and oral, very deep, deep ulcers in the oral cavity. But there's a whole host of things. There's something called PFAPA syndrome in which patients get... periodic fevers that are unexplained. They get apthys ulcerations and then they get adenitis. So they get these swollen, you know, pharyngitis and adenitis, swollen lymph nodes. And I've seen that occasionally. But there are, these syndromes are so rare, like magic syndrome where they get inflamed cartilage and genital ulcers and mouth ulcers. They're so rare that I wouldn't expect a general dentist to have compiled all the syndromes in their head. So what I would do, just know that you need to reach out to someone if they start getting ulcers after 30 or the severity increases after age 30. Reach out to me, reach out to your favorite oral pathologist or oral medicine person and get them evaluated for a syndrome. Those syndromes sound miserable, absolutely miserable. Yeah, they're pretty bad. Yeah, but they're not life-threatening though. Right? None that I said are life-threatening correct. I had to think about the ones that we talked about. Bichette can be, I think. But I would have to go back and look that up. Yeah, as long as it didn't happen too often. I mean, otherwise the quality of life ain't that great. I think a better answer is they're not imminently life-threatening. So let me ask you this, Dr. Clark, regarding all sort of lesions in the mouth. What types of lesions in appearance? should raise a red flag indicating that they might progress into something more serious like cancer? Any ulcer that is not healing, it should be considered a precursor to malignancy. Now, major apthys ulcers are kind of an exception. They take about six weeks to heal sometimes, two to six weeks, but they'll heal. They just won't heal completely. But any ulcer that is sitting there for two weeks, not changing, does not heal, that must be biopsied. There are types of ulcers that are traumatic, that are longstanding. So there's something called a Tugsy traumatic ulcerative granuloma with stromal eosinophilia. Those are ulcers that will persist until removed and they're benign. but they are indistinguishable clinically from a cancer. So any ulcer that's been there for longer than two weeks, we got to cut that out. Now, what about herpes? Usually what, it's a week to 10 days and it's gone if it's related to an episodic herpes infection? Yeah, seven to 10 days. You're right on the money is a herpes infection. Most people with herpes will get a prodrome, meaning they know when it's coming, they get the tingling or burning sensation, usually on the lip. At that point, if you want to prescribe your patient an antiviral medication, if they take it at prodrome, they can prevent the herpes labialis from coming on. And again, this isn't going to save your patient's life, but this is going to make your patients appreciate you very much if you can prevent them from having a 10-day cold sore. You can either... eliminate the cold sore or drastically reduce its severity. So what you do is you prescribe four, one gram pills of Valsiclovir. Patient takes two when they feel the tingling, when they feel it coming on, and two 12 hours later, and that will drastically help their cold sores. I don't call them herpes. I call them cold sores. Patients just don't like the H word. Is there any side effect to taking Valsiclovir? Or is that proven to be pretty uneventful as far as side effects? I don't know that there is a downside of taking valsiclovir. The only thing is you don't want to prescribe it to someone daily, like a daily prophylactic, unless they're getting like... one a month. Most patients get two cold sores per year. So when I write this prescription, I give them the prescription and then I give them two refills. So that means they should be protected throughout the year and they should go fill that medicine and keep it with them. Now, the downside of, let's say, you know, someone has a cold sore twice a year. If I would give them daily antivirals, we might risk the virus mutating and becoming immune to that particular medication. when that happens, it's only the peripheral virus that mutates. But that is the downside. I don't really know of any systemic ill effects that taking an antiviral can have. What about that cream that's pretty popular, Abreve? Is that effective? There is a statistically significant but clinically minimal reduction in severity. And in English, what that means is if you have herpes, if you get a lip lesion, And it normally lasts seven days. If you use Abreva, it'll last six days. So statistically significant, clinically minimal. So the creams, the prescription pencyclovir cream works the best, but still not great. Still only a reduction in about an hour or an hour of about a day. The best thing that works is the preventative valcyclovir. Now, if your insurance doesn't want to pay for valcyclovir, What you can also do is 400 milligrams acyclovir five times a day for five days. That is obviously less practical than doing something twice. Now you have to do something 25 times. But sometimes insurance would just not want to pay for vasoclovir, and that's what we have to do. So in your mind, Dr. Clark, you certainly look at this cold sore situation twice a year or something a dentist. should be managing through Valsiclovir. No hesitation in prescribing that for the patient, correct? If your patient has a history of cold sores, the very first thing I ask them is, do you want a medicine to either prevent them from coming or drastically reduce their duration? And I have never had a patient say no to that. So if you would, Dr. Clark, reiterate for our audience the dosage for Valsiclovir in the event a dentist plans to prescribe this drug to their patient. So it is four, how you write it is you give four, one gram pills of Valsiclovir. Valsiclovir is the generic Valtrex. So four, one gram pills. They take two grams. So two of those pills when they feel it coming on and then two pills, 12 hours later. So two grams at prodrome, two grams, 12 hours later. Just curious, for most patients, if they use Valsiclovir as instructed, when the symptoms first start coming on, will it stop the process from progressing completely? If it doesn't prevent it completely, it will drastically reduce it. Well, good to know. And I think every GP, every dentist should be aware of that. That's certainly something the patient would appreciate. And what a great practice builder. for a patient who's suffering with this. Yes, exactly. Your patients are really going to appreciate because cold sores are socially embarrassing. Yeah. And they don't like them. So they really appreciate this. Yeah, no, very good information. Yeah. So there was a lot on all sort of entities that we will see in our practice as we continue to practice. And as I mentioned, Dr. Clark, on a previous podcast, you know, there's only so much a dentist. can remember from dental school. So unless they take a CE course on oral pathology or do some reading on their own, I'm sure there's a lot of stuff online available. And you have a webinar on Viva Learning, right, that you've done in the past, at least a couple of them on oral pathology. Yeah, I've done three. I think they're pretty similar. And they're typically over oral cancer. And they're sponsored. by Perel Pharma. So I do talk about Gockles a little bit, which is an autofluorescent technology to help identify spots that your eyes might not catch. So if you're interested in hearing what Dr. Clark has to say, as far as the webinar goes, just go to VivaLearning.com. Type in Dr. Clark's last name, C-L-A-R-K. You'll see Ashley Clark. And then you'll see all of her webinars and podcasts. She's, again, a board-certified oral pathologist and a dentist. So we're very grateful to have access to her expertise. And if you want to reach out to Dr. Clark, feel free to do so. Her email is listed in the description of this podcast episode. It's at aclark. That's aclark@camplaboratory.com. Again, we're so happy we had the opportunity to have you on the show, Dr. Clark. You offer such great stuff, such an important topic for all of us to get a refresher on. And if anybody is looking for a good pathology lab that understands dental lesions as well as Dr. Clark does, her lab is available. Again, just use the email in the description to find out more information. Dr. Clark, thanks so much for your insight. We look forward to having you on future programs. Yeah, thank you so much for having me. I always appreciate it.