Inflammatory mucosal diseases Flashcards
what is oral lichen planus?
an inflammatory mucocutaneous disease - auto-immune condition mediated by T lymphocytes
- attacks the skin and mucosa
what is the difference between oral lichen planus and oral lichenoid reaction?
OLP: no identifiable trigger
OLR: when there is a trigger
generally, how do OLP lesions appear?
bilateral
symmetrical
may involve gingivae or skin
generally, how do OLR lesions appear?
unilateral
assymmetrical
dont involve gingivae or skin
closely related to cause (large occlusal buccal amalgam filling or following starting a new triggering medication
what questions would you ask for suspected OLP/OLR?
- is this symptomatic? or chance finding?
- does food or toothpaste irritate it? (typically spicy and acidic foods burn/sting when eaten in OLP)
- any clear triggers? (new prescription)
- which sites are affected? (skin/scalp/nails)
- have you tried any medication yet?
- SOCRATES
which medications can trigger OLR?
metformin, anti-inflammatories, anti-coagulants, anti-hypertensives, antimicrobials
what would you check if suspected OLP/OLR to rule out suspicions?
- check if it is a high risk site
- consider any high-risk lifestyle factors (tobacco, alcohol)
- is there a rapid/severe/unusual pattern)
how would you manage OLP that’s symptomatic?
- Dietary advice to avoid triggering foodstuffs
- Avoid SLS in toothpaste as it is irritant for inflammatory mucosal conditions
- Palliative measures such as:
- 0.15% benzydamine hydrochloride (“Difflam”) oromucosal spray or mouthwash - a topical anaesthetic agent
- “Gelclair” or “Gengigel” etc - various coating agents improve comfort
- Smoking cessation and alcohol reduction advice
what are vesiculobullous disorders? examples?
immune-driven mucocutaneous conditions that involve VESICLES and BULLAE formation
examples: mucous membrane pemphigoid and pemphigus vulgaris
which ages are more susceptible in mucous membrane pemphigoid and pemphigus vulgaris?
MMP - older patients
PV - younger patients
what are important factors to consider in clinical history taking in vesiculobullous disorders?
- speed of onset
- sites affected
- EO sites? ocular involvement?
- able to drink/eat normally
- impact of symptoms on the pt?
what are erythema multiforme/steven johnson’s syndrome/toxic epidermal necrolysis?
clinical disease spectrum of immunologically mediated inflammatory mucocutaneous diseases
what sites does erythema multiforme affect?
mucosae and cutaneous sites
what is erythema multiforme often triggered by?
infection (most common - HSV or myobacteria) or medication (NSAIDs, antibiotics, penicillins)
50% have no identifiable trigger
what is the management strategy for erythema multiforme?
History
* Inquire about cold sore history (i.e. HSV carriage)
* Find out if a new drug has been started recently including if there have been any recent short courses of things like antibiotics or NSAIDs
Examination
* ‘Examination of the clothed patient’ - refer back to these learning materials
* May be challenging with severe lip and mucosal involvement preventing wide mouth opening
* The classic appearance includes swollen, bloody, crusted lips with large areas of ulceration intraorally
Consider the patient’s systemic status
* Are they well enough to be managed at home?
* Check hydration status
* Do their “Obs” - temp, pulse, BP - where possible
* If in doubt, seek a same-day urgent referral to Oral Medicine/OMFS/A&E
Investigations may include:
* Bloods such as HSV PCR (detection of the Herpes Simplex Virus)
* A biopsy may be needed when diagnosis is in doubt but can be delayed if it won’t add to the management strategy
