Mouth ulcers.....and more

Oral Medicine in Birmingham, Solihull and Sutton Coldfield

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The consultation was clear and thorough and I was made to feel confident in the treatment I was to proceed with. He made me feel relaxed and confident, explaining what he was going to do from the start.
The Westbourne Centre private patient feedback on 2022

As somebody who is qualified in both dentistry and medicine, I am first and foremost a doctor who operates. As someone who has a role as a Module Lead for undergraduate students in dentistry and is a Senior Academy Tutor for medical students at the University of Birmingham, I have kept in touch with being a physician. I recognise that not all problems are solved by surgery and sometimes it's just as important knowing when not to operate.

I regularly see and treat the following oral medicine conditions in my clinical practice:

  • Lichen planus / lichenoid lesions
  • Burning mouth syndrome / oral dysaesthesia / glossodynia
  • Trigeminal neuralgia
  • Post-herpetic neuralgia
  • Atypical facial pain
  • White patches (leukoplakia) and dysplastic lesions in the mouth
  • Red patches (erythroplakia / erythroplasia) in the mouth
  • Xerostomia (dry mouth) including Sjogren's syndrome
  • Recurrent aphthous ulceration and oral ulceration of other causes
  • Vesciulobullous conditions e.g. pemphigus, mucous membrane pemphigoid
  • Bacterial, fungal and viral infections of the oral cavity e.g. thrush, herpes, oral manifestations of HIV
  • Oral manifestations of systemic diseases e.g. inflammatory bowel disease

What is lichen planus?

Lichen planus is an immune mediated condition with an as yet unidentified initial trigger. Manifestations may vary from patient to patient. Some patients have no symptoms and the differential diagnosis is raised at a routine dental check-up. Others may have symptoms severe enough to limit oral intake due to painful oral mucosa lesions and/or skin manifestations. There are many different subtypes including reticular, atrophic, bullous and ulcerative among others. These may look quite different in appearance.

If the differential diagnosis of oral lichen planus is raised, I will frequently recommend a biopsy. This is a simple local anaesthetic procedure where I take a very small piece of oral mucosa and send this to a laboratory for analysis. The procedure takes around 10 minutes and there will be some dissolving sutures placed if required.

There is no "cure" for lichen planus, but symptoms can be controlled. If the diagnosis is established on histology, if you are asymptomatic I may recommend no treatment but a period of monitoring, as there is a small but significant risk of malignant transformation. If symptomatic, treatment may include topical steroids, systemic steroids and/or immunosuppressant agents. There are medications and dental restorative materials that may incite lichenoid reactions, and if I suspect this to be the case then I will liaise with your General Practitioner and/or General Dental Practitioner to address these risk factors.

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What is Burning Mouth Syndrome?

Burning Mouth Syndrome (BMS) (also termed oral dysaesthesia and glossodynia) is a condition of unknown aetiology which may be termed a "diagnosis of exclusion". This implies that no other primary cause for the sensation can be identified. This may be reassuring for patients (in that no sinister cause is identified) but frustrating in equal measure as treatment is focused on symptom control rather than a "cure".

If BMS is a differential then I will commonly ask for some routine blood investigations to be done, either at one of the private hospitals or via your General Practitioner. I will take a careful medical and drug history to look for possible underlying causes and may recommend a period of avoiding certain substances (e.g. benzoic acid, cinnamaldehyde, sodium lauryl sulphate).

Treatment may vary from person to person but may include topical and systemic medications (e.g. tricyclic antidepressants, selective serotonin reuptake inhibitors, benzydamine hydrochloride) and/or dietary supplements (e.g. alpha lipoic acid). BMS has a correlation with stress, depression and/or anxiety and there is some evidence for treatments such as cognitive behavioural therapy (CBT) being beneficial.

What is trigeminal neuralgia?

Trigeminal neuralgia is intractable neuropathic pain relating to the trigeminal nerve, the nerve which relays sensory impulses from the face. Patient will commonly describe severe shooting pains in one or more distributions of the trigeminal nerve, not responding to over the counter medications and unpredictable in nature.

Trigeminal neuralgia may be caused by underlying conditions (e.g. multiple sclerosis, shingles - known as post-herpetic neuralgia) but is often idiopathic (no identified cause). I will commonly ask for cross-sectional imaging to see whether there is any neurovascular conflict with the nerve (pressure from an adjacent blood vessel causing the nerve to "short circuit" due to loss of the protective covering). This may enable patients to be candidates for nerve decompression surgery, but often treatment is medical with anticonvulsant drugs (e.g carbamazepine) which can be titrated up slowly to response.

In a minority of cases where mono therapy is not successful, combinations of drugs may be required, with close monitoring.

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What is leukoplakia?

Leukoplakia is a term ascribed to white patches of the oral mucosa that cannot be otherwise characterised (e.g. lichen planus, thrush, traumatic keratosis). The corresponding term for red patches is erythroplakia.

The key concern with such lesions is that they are not malignant or cancerous. Some can be identified clinically and monitored, but my threshold for biopsy in such cases is generally quite low. A biopsy will enable an accurate diagnosis and also exclude malignancy (cancer).

Unless the lesion can be excised in its entirety then I will usually perform a small (incisional) biopsy. This may demonstrate dysplasia. This is essentially pre-cancerous changes in the surface epithelium that may be low or high grade (also sometimes classed as mild, moderate or severe).

In low grade dysplastic lesions, I will often recommend regular review and watchful waiting. In higher grade lesions, excision is recommended to ensure that the biopsy is representative of the lesion in its entirety (i.e. that there is no cancer "hidden" within the lesion) and also to enact treatment. This can be done with cautery or LASER.

What causes a dry mouth?

Xerostomia (or a dry mouth) may be seen due to a variety of causes. Salivary flow slows down with age and the explanation can be that simple. A number of medications can also cause dry mouth including antidepressant, blood pressure medications, proton pump inhibitors, bronchodilators, antihistamines and diuretics. Previous radiotherapy to the head and neck area may cause quite severe xerostomia.

In many cases the cause is far from clear cut. I will often recommend routine blood tests including autoantibodies to screen for Sjogren's Syndrome, an uncommon but significant potential cause. Sometimes this needs to be augmented with a labial gland biopsy, where a small number of minor salivary glands are harvested from the lower lip under a local anaesthetic and submitted for analysis.

In many instances, regardless of the underlying cause, salivary substitution is all that is warranted. This can take various forms including sprays and gels. In a minority of patients, a muscarinic agonist (pilocarpine) may be warranted.

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What causes mouth ulcers?

Mouth ulcers can be caused by a myriad of reasons and I will take a careful history which combined with a meticulous examination can come to the correct diagnosis in the majority of cases.

Common causes may include traumatic ulceration (e.g. from a sharp tooth) or recurrent aphthous ulceration (RAU, or aphthae). Aphthae are benign, inflammatory ulcers that typically appear in crops rotating around the mouth. The cause is unknown but they can be a nuisance for many patients. We may need to try to identify dietary precipitants and/or toothpastes that make things worse, to avoid these in the first instance. Treatments can include topical and systemic agents (e.g. steroids, immunosuppressants and tetracycline antimicrobials among others).

There is a link between RAU and stress and methods to counteract the latter can be expected to have a beneficial effect on the frequency and severity of oral ulceration in many patients. Aphthae can also be symptomatic of an underlying medical condition such as inflammatory bowel disease (e.g. Crohn's disease).

Oral ulcers may also be seen in certain infections (e.g. herpangina, herpes simplex) and the pattern of these is often indicative of the diagnosis. Many of these are self-limiting conditions (i.e. they will resolve on their own and require no specific treatment).

Perhaps the most concerning differential diagnosis of mouth ulcers is oral cancer. These will often have particular appearances (e.g. induration, rolled borders) but suspicion can come down to pattern recognition as a result of looking in thousands of mouths over many, many years. Ultimately, if I have a suspicion of this, I will arrange an urgent biopsy and appropriate staging scans before making a referral to my colleagues in Head and Neck in Birmingham and Solihull for timely treatment.

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