Inflammatory mucosal disease Flashcards
Name soem inflammatory mucosal diseases
- Oral lichen Planus
- Vesiculobullous disorders
- Behçet’s disease
- Mucositis
- SLE/DLE
- Plasma cell mucositis/ gingivitis
- Dermatitis herpetiformis
- Graft versus Host Disease
- Paraneoplastic pemphigus
10 Erythema Multiforme Minor - Steven Johnson’s Syndrome aka Erythema Multiforme Major
12, Toxic Epidermal Necrolysis
What is oral lichen planus
An inflammatory mucocutaneous disease
How common is oral lichen planus
Common it affects 1-1.5% of the population
What is oral lichen planus caused by
Auto reactive T lymphocytes that attack the skin and mucosa
What is the trigger for oral lichen planus
There is no trigger
What is it called if there is a trigger causing oral lichen planus
An oral lichenoid reaction
Name the different subtypes of oral lichen planus
- Plaque like
- Papular
- Erosive
- Bullous
- Ulcerative
- Desquamative gingivitis
Describe how oral lichen planus lesions appear clinically
- Bilateral
- Symmetrical
- May involve gingivae or skin
Describe how oral lichenoid reaction appear clinically
- Unilateral
- Asymmetrical
- Don’t involve gingiva or skin
- Closely related to a case eg large amalgam filling
What questions do we need to ask when taking a clinical history of oral lichen planus or oral lichenous reactions
- Is it symptomatic
- Does food or toothpaste irritate
- Which sites are affected
- Are there any clear trigger eg new medication
- Do you smoke
List some anti-hypertensive drug that can trigger oral lichenoid reactions
- Captopril
- Labetalol
- Methyldopa
- Thiazides
- Propranolol
- Tolbutamide
List some anti-inflammatories drug that can trigger oral lichenoid reactions
- Chloroquine
- Dapsone
- Mepacrine
- NSAIDs
- Para-aminosalicylate
- Penicillamine
List a anti-coagulants drug that can trigger oral lichenoid reactions
Dipyridamole
Give examples of drugs used in diabetes treatment that can trigger oral lichenoid reactions
- Chloropropamide
2. Metformin
Give examples of Psychoactive drugs that can trigger oral lichenoid reactions
Lithium
Phenothiazines
Name some antimicrobials that can trigger oral lichenoid reactions
Griseofulvin
Metronidazole
Streptomycin
Tetracycline
List some anti-malarial drug that can trigger oral lichenoid reactions
Quinidine
Quinine
When should we be concerned of a oral lichenoid reactions or oral lichen planus
- It is a high risk site
- High risk lifestyle eg smoker, drinker
- Has medication or dental material triggered it
- Any indicated medical condition
- Was there a rapid/ severe pattern to the onset
Name some sites that can be high risk if affected by ral lichenoid reactions or oral lichen planus
- Lateral / base of tinge e
2. Floor of the mouth
Is oral lichen planus chronic or acute
Chronic it can last a lifetime
Does oral lichen planus have the potential to be malignant
After a decade of having oral lichen planus the risk or oral cancer is 1 in 100
What must we advice a patietn with oral lichen planus
- Smoking cessation
- Alcohol moderation
- Help patient self assess and self examine
How do we manage symptomatic oral lichen planus
- Dietary advice to avoid triggering food
- Avoid SLS in toothpaste
- 0.15% benzydamine hydrochloride (“Difflam”) oromucosal spray or mouthwash - a topical anaesthetic agent
- Gelclair or “Gengigel” (coating agent)
- Smoking cessation and alcohol reduction advice
- Topical corticosteroid prescription
- Intralesional steroid injections
- Systemic immunomodulatory drugs
What is Difflam
A topical anaesthetic agent
Give examples of Topical corticosteroid prescription fro oral lichen planus
betamethasone 500 micrograms to be dissolved in 10mls water and held in the mouth 2-3 minutes then spat out QDS (aka “Betnesol”)
Why might we use Intralesional steroid injections to manage oral lichen planus
solitary erosions or ulcerated patches e.g. triamcinolone acetonide (“Kenalog”)
Give examples of systemic immunomodulatory drugs that can be used to manage oral lichen planus
- Hydroxychloroquine
- Azathioprine
3, Mycophenolate mofetil
How can we manage oral lichenoid reaction
- Remove or treat the underlying cause
- Skin patch if dental material is suspected trigger
- Remove material under rubber dam
What do we aim to achieve if we refer to oral medicine
- Confirm diagnosis
- Take biopsy of tissue diagnosis
- Instigate management
- Continues prescription and monitoring
What are Vesiculobullous disorders
Immune driver mucotanous conditions that involve vesicles and bullae formation
Name the common Vesiculobullous disorders
- Mucous Membrane Pemphigoid (MMP)
2. Pemphigus Vulgaris (PV)
What type of blistering occurs in Mucous Membrane Pemphigoid
Subepithelial blistering
What type of blistering occurs in Pemphigus Vulgaris
Intra epithelial blistering
Describe the cleavage formed in Mucous Membrane Pemphigoid
Hemidesmosomal
Describe the cleavage formed in Pemphigus Vulgaris
Desmosomal
What is Mucous Membrane Pemphigoid caused by
IgG, C3 +/- IgA all deposited on the basement membrane zone
What is Pemphigus Vulgaris caused by
IgG, IgM, IgA, Anti-desmogelin protein and C3 deposited throughout the epithelium in a net like distribution
Describe the bullae formed in Mucous Membrane Pemphigoid
Tense
Resilient
Haemorrhagic
Describe the bullae formed in Pemphigus Vulgaris
Very friable
Rarely found intact clinically
Lots of ulcerations and sloughing
irregular borders
In whom is Mucous Membrane Pemphigoid more common in
Older patents (50-80yr olds)
In whom is Pemphigus Vulgaris more common in
Younger patients (40 yr olds) or young children
What areas can Mucous Membrane Pemphigoid Present at
May present purely as a desquamative gingivitis with no other oral sites affected
What areas can Pemphigus Vulgaris present at
Usually presents in a more dramatic fashion and can cover all of the oral mucosa and extend down the throat
What do we want to find out when taking a history of a Vesiculobullous disorders
- Speed of onset
- Sites in the mouth affected
- Are extra oral sites affected
- Is patient able to eat and drink normally
- Symptoms and how are they affecting patient
What can Paraneoplastic pemphigus be a presentation of
Occult malignancy
What does Erythema Multiforme affect
Various mucosae and cutaneous sites
What is Erythema Multiforme triggered by
Commonly: Infection or medication
Less commonly: connective tissue disease or foot additives
what infection can trigger Erythema Multiforme
HSV or mycobacteria
what medication can trigger Erythema Multiforme
sulphonamide antibiotics,
carbamazepine,
penicillins,
NSAIDs
What do we need to consider before managing Erythema Multiforme
- History
- Examination
- Patients systemic status
- Patients blood
How do we treat Erythema Multiforme
- Supportive measures eg explanations and reassurance
- Simple oral hygiene measures
- Paracetamol and difflam or pain relief
- Chlorhexidene mouthwash
- Referral?
6/ Systemic steroids and maybe antimicrobials - Antiviral medication
- Systemic immunosuppression
