Oral medicine — Update for the dental practitioner - Oral Cancer ...

PRACTICEManagementAlthough patients have spontaneous healingwithin 10-14 days, treatment is indicated particularlyto reduce fever and control pain. Adequatefluid intake is important, especially inchildren, and antipyretics/analgesics such asparacetamol/acetoaminophen elixir help. Asoft bland diet may be needed, as the mouthcan be very sore. Aciclovir orally or parenterallyis useful mainly in immunocompromisedpatients or in the otherwise apparently healthypatient if seen early in the course of the diseasebut does not reduce the frequency of subsequentrecurrences.Recurrent HSV infectionsUp to 15% of the population have recurrentHSV-1 infections, typically on the lips (herpeslabialis: cold sores) from reactivation of HSVlatent in the trigeminal ganglion. The virus isshed into saliva, and there may be clinicalrecrudescence. Reactivating factors includefever such as caused by upper respiratory tractinfection (hence herpes labialis is often termed‘cold’ sores), sunlight, menstruation, trauma andimmunosuppression.Lip lesions at the mucocutaneous junctionmay be preceded by pain, burning, tingling oritching. Lesions begin as macules that rapidlybecome papular, then vesicular for about 48hours, then pustular, and finally scab within 72-96 hours and heal without scarring (Fig. 11).treatment is indicated. Antivirals will achievemaximum benefit only if given early in the diseasebut may be indicated in patients who havesevere, widespread or persistent lesions and inimmunocompromised persons. Lip lesions inhealthy patients may be minimised with penciclovir1% cream or aciclovir 5% cream appliedin the prodrome. In immunocompromisedpatients, systemic aciclovir or other antiviralssuch as valaciclovir (the precursor of penciclovir)may be needed.Websites and patient informationhttp://openseason.com/annex/library/cic/X0033_fever.txt.htmlKey points for patients: cold sores• These are common• They are caused by a virus (Herpes simplex)which lives in nerves forever• They are infectious and the virus can betransmitted by kissing• They may be precipitated by sun-exposure,stress, injury or immune problems• They have no long-term consequences• They may be controlled by antiviral creamsor tablets, best used early onDrug-induced ulcerationDrugs may induce ulcers by producing alocal burn, or by a variety of mechanismssuch as the induction of lichenoid lesions(Fig. 12). Cytotoxic drugs (eg methotrexate)commonly produce ulcers, but non-steroidalanti-inflammatory drugs (NSAIDs), alendronate(a bisphosphonate), nicorandil (acardiac drug) and a range of other drugs mayalso cause ulcers.Fig. 11 Herpes labialisRecurrent intraoral herpes in apparentlyhealthy patients tends to affect the hard palateor gingivae with a small crop of ulcers whichheals within one to two weeks. Lesions are usuallyover the greater palatine foramen, followinga palatal local anaesthetic injection, presumablybecause of the trauma.Recurrent intraoral herpes in immunocompromisedpatients may appear as chronic, oftendendritic, ulcers, often on the tongue.DiagnosisDiagnosis is largely clinical; viral studies areused occasionally.ManagementMost patients will have spontaneous remissionwithin one week to 10 days but the condition isboth uncomfortable and unsightly, and thusFig. 12 Lichenoid reaction to propranololA drug history is important to elicit suchuncommon reactions, and then the offendingdrug should be avoided.Patients to refer:• Severe aphthae• Malignancy• HIV-related ulceration• TB or syphilis• Drug-related ulceration• Systemic disease• Mucocutaneous disorders.264 BRITISH DENTAL JOURNAL VOLUME 199 NO. 5 SEPT 10 2005