Things to remember:

• patients with special needs are prone to soft tissues pathologies due to: poor oral hygiene, medical co-morbidities, complex medical problems, polypharmacy,  trauma, saliva problems, immune deficiencies, c0-existence of denture candidiasis, etc.
• the chance of oral mucosa manifestations is higher compared to the rest of population
• thorough intraoral soft tissues examination and additional investigations are  essential – to check all soft tissues!
• to search for any oral mucosa abnormalities
• lifting and slightly stretching the tongue holding the tip with the use of gauze or dry tissue can be very helpful, some lesion on ventral side of tongue may  not be detected if the patient simply just pops the tongue out!
• both sides of the tongue need to be carefully examined, including portions far back by tongue base which can be easily missed during assessment (oral hairy leukoplakia lesions are located there)
• palpation of submandibular, sublingual and neck area vitally important, including supraclavicular parts (lymph nods)
• palpation of projections of mental, infraorbital and supraorbital foramina to exclude neurological conditions
• oral hygiene instructions to be provided for patient with eg. coated tongue, inform the patient about to avoid ‘excessive tongue cleaning’ as it may irritate and trigger eg. tongue papillae overgrowth, different brush for teeth and tongue and gentle cleaning, not every single day

 

• oral mucosa lesions with different origin can coexist together (eg. candidiasis, lichen planus, atrophic lesions, drugs-induced lesion)
• discrete appearance of lesions, could be slight keratosis, hyperkeratosis, age related atrophy
• cooperation with specialists, dermatologist, pathologist is often essential
• bear in mind and do not underestimate the impact of psychological state/condition on oral health, BMS can be purely psychosomatic
• reassurance and no-intervention in case of non-pathological lesions constitutes an essential part of dental care
• appropriate lighting and in some cases an additional magnification support a proper examination: head light, l0upes/microscope with small magnification (2.5x up to max5 x)
• HP investigation needs to be a routine in case of any suspicion
• be vigilant regarding the biopsy extension, size and place
• always follow up for suspicious-looking lesions, eg. mixed white-red patches areas

 

• increased risk of self-inflicting injuries in patients with special needs, eg. biting hard objects, wedged pieces
• Be ‘oral lesion and oral cancer-sensitive’, ie. pay special attention on even ‘innocent’, benign-looking oral mucosa lesions. Example: epulis-like lesion which clinically seems to be benign overgrowth of gingiva/interdental papilla may mimic a potentially more ‘serious’ problem eg. peripheral giant-cell granuloma according to histopathological diagnosis (real case example).
• giant cell granuloma within gingivae or alveolar bone structure may have an aggressive pattern with rapid destruction of surrounding structures
• distinguish between acute and chronic oral lesions as these two types may need a different management (eg. lichen planus )
• differentiate atrophic dry lip mucosa or  surface/texture chronic trauma vs solar actinic keratosis as a.k. is precancerous condition
• patients suffering from immune deficiency may have the symptoms of disquamative gingivitis, sometimes mimicking oral mucosa lesions (stomatitis)
• simple microscope glass slide helpful to differentiate vascular lesions vs other discoloration, eg. underneath the tongue, when pressing with slide blanching/ischaemic effect apparent
• lichen planus may occur as skin problem far away from patient mouth and can manifest orally (dermatologist plays important role in patient management)
• epidermolysis bullosa does affect mouth area and eg. multi-focal painful lips cracks and lips blisters all over the both upper and lower lips with constricted mouth can be suspected as EB
• painful chronically ‘cracked’ lips often a result of bacterial secondary contamination bacterial contamination following eg. viral/fungal infections
• anti-HSV medications such as abacavir may cause fully symptomatic Stevens-Johnson Syndrome
• provide the patient with information and reassurance which is an vital part of management protocol, especially for conditions which do not require any specific treatment, eg. with psychosomatic components (BMS)
• Fordy’s spots/granules:  whitish-yellow bumps that can occur on the edge of your lips or inside your cheeks. Reassure the patient, this is absolutely normal, non-pathological condition

 

• patients with severe oral mucosa dyskeratosis may better tolerate toothpastes without detergents and sodium laurate sulfate (SLS free)
• do not disagree with ‘organic/herbal’ toothpaste if this is a patient’s preference, following a detailed discussion about pros and cons
• ‘organic/natural’ ingredients can cause allergic reaction, eg. bee products (propolis)
• lip balm based on natural products (propolis) may be a causative factor of acute allergic reactions (lips lesions, swelling, etc.)
• small white round/oval and very painful lesions within alveolar mucosa usually indicate herpes viral infection, antiviral meds recommended, eg. Acyclovir, quite often in children who has a nail biting habit
• warm salt solution for mouth rinsing (half of a teaspoon/one spoon of salt in glass of warm water) can effectively relieve pain and discomfort due to oral mucosa ulceration/laceration/lesion.
• In case of recurrent ulcerations with unknown origin: local analgesics , eg. Benzydamine spray 0.15%, Chlorhexidine mouthwash 0.2%, topical corticosteroids, eg. Hydrocortisone oromucosal tablets 2.5 mg
• acute stomatitis associated with advanced periodontitis and severe symptoms derived from tissues, apart from thorough OHI and basic hygienic measures, may be considered as an indication for systemic antibiotics, mainly tetracyclines (Doxycicline).
• so called liquid bandage (adhesive oral agent based on cyanoarylates) can be very useful for painful oral mucosa ulcerations
• off-licence corticosteroids (inhaler, tablets) can be used to alleviate the acute symptoms of mouth ucerations (pain)
• 2% Fucidic acid cream/ointment should be prescribed in case of Staphylococcus bacteria lips infection (angular cheilitis, lips non-healing cracks)
• Caphosol buffered solution work great in patients with mucositis following chemo-, radiotherapy! Disadvantage: high cost, not easy available. Also can provide an efficient relief for patients suffering from dry mouth due to eg.  constant mouth breathing.
• Photodynamic therapy with laser adjunct therapy to treat/alleviate severe, resistant candidiasis, mild initial leukoplakia lesions, selected cases of lichen planus
• Severe case of oral candidiasis, resistant to local and systemic therapies (miconazoel gel and fluconazole tablets relieve symptoms only temporarily), patient does not wear any dentures – indication for referral, with susp. underlying conditions, eg. immunodeficiency.
• steroids inhalers may exacerbate oral candidiasis and xerostomia
• topical steroids (cream) for the treatment of lip ulceration associated with xerostomia, follow up and monitoring
• hexetidine/octenidine mouthwash as antiseptic agent for oral bacterial/viral infections (not in pregnancy)
• oral mucosa rash is the main sign of denture stomatitis
• metotrexate used for rheumatoid arthrotis treatment affects the immune system

 

• some ‘innocent-benign-looking’ lesion may appear to be malignant transformation
• practical skills and competence re: performing a biopsy for HP investigation
• after incision of eg. ‘fibroma-like’ lesion, it is advisable to send it off for HP investigation
• fibroma-like lesions should be excised with an appropriate base margins for HP investigation
• specimen collection has to be standardized

 

• most common oral medicine pathologies: chronic ulceration, denture stomatitis, fibroma, atrophic/hyperplastic/dyskeratotic oral mucosa, desquamative gingivitis, epulis, denture-induced overgrowth, gingival hyperthrophy, oral mucosa traumatic lesions, oral mucosa denture-induced ulcerations
• trauma-induced hypertrophic lesion, eg. overgrowth of cheek mucosa due to sharp edges of carious tooth has to be get incised and sutured.
• Fibroma can be excised within the base easily without extra margins, but papilloma-like lesion may need more deeper excision as base can be embeded deeply.
• ‘cobblestone pattern’ of oral lesion (tongue) can be associated with gastrointestinal diseases
• mucocuteneous manifestations of Cowden’s syndrome: multiple cutaneous papillomatosis, oral fibromas, and fibromas involving multiple organs such as gastrointestinal tract (multiple polyps), thyroid disorders, and breast cancer.

 

• gingival hyperplasia limited to few anatomical groups of teeth – ask about antihypertensive, anticonvulsive, chemotherapeutic medications (cyclosporine), to rule out other potential reasons such as leukemia
• calcium channel blockers: nifedipine (the main) and amlodipine – frequent cause of drugs induced gingival hyperplastic reaction nowadays as large proportion of population on them, ask GP to make the alterations or replace them
• patient with well controlled epilepsy for a long period of time – prone to gingival hyperplasia due to medications
• bilateral ‘reactive’ gingival overgrowth (hyperplasia), often upper and lower (idiopathic fibromatosis) can be associated with anti-convulsive medications (tegretol, carbamazepine)
• unilateral gingival hyperplasia can be caused by local trauma from opposing arch and deep bite
• be aware of systemic related disquamative gingivitis, relatively often in special need patients
• B-cell lymphoma symptoms may appear as a unilateral palate ulceration or enlargement
• GVHD with oral manifestations

 

• clear message to the patient who smokes – pre-cancerous lesion may easily transform into oral cancer
• clear message to carers from care homes re: denture hygiene
• preventative advice re: denture hygiene and not to use denture over the night time
• be aware of auto-immune oral disorders and diseases
• be aware of systemic illnesses linked to oral pathologies
• any suspicion of oral malignancy/cancer – urgent referral

Case report: to excise or not to excise ? Tongue haemangioma: firm texure and borders, well defined, asymptomatic

 

Case report: retromolar ‘overgrowth’, just behind fully erupted third lower molar. pea size, slightly movable, getting bigger as patient noticed. Occasional mechanical trauma due to biting, eating, gets inflamed occasionally. To excise or not? Justification for surgical excision: gets irritated/inflamed and potentially may become dysplastic or metaplastic in future.

‘Epulis looking’ lesion has to be referred for second opinion, HP investigation and excision.

 

Is saliva substitute gel, spray or mouthwash superior and more efficient in xerostomia and dry mouth syndrome?

Efficient and easy to use saliva substitute gel, which includes natural and organic ingredients:

 

Case: Adolescent patient who had radiotherapy and chemotherapy by the age of 3 y.o due to the malignant tumour within the anterior maxillary region. Totally arrested development of upper anterior teeth, only coronal portions present, mobile UR3, UR1, UR2, UL1, unerupted UL3. Patient wears custom-made, individually designed cr-co partial denture replacing missing UL3. Intraorally moderate localized chronic periodontitis within anterior quadrant, anterior teeth grade 1/2 mobile, previously splinted with flow composite. Main concern: long-standing perio problems, mainly plaque accumulation, gross BOP within upper anterior teeth. Perio management: OH advice, regular ultrasonic and hand debridement, chlorhexidene gluconate 0.2% irrigated. 1% chlorhexidine gluconate gel prescribed to brush 2 daily for a month time, also benzydamine spray prescribed. Intraoral irrigator recommended and ultra-soft toothbrush recommended as very ‘tender/sensitive’ gingivae. Long term-treatment plan: xla’s of mobile incisors and addition to existing P/- chrome denture.

Case: adult patient with chronic oropharyngeal candidiasis/non-denture induced stomatitis and unknown aethiology. Burning mouth sensations, significant discomfort while eating, angular cheilitis. Topical miconazole oromucosal gel inefficient. Referral to GP for full blood count test and further investigation of underlying systemic problems eg. immune deficiency, microbiological assessment of oral swabs.  Fluconazole 50mg tablet once daily for 7, up to 10 days, to repeat if justified.