Earn

2 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.

Management of Erythematous
Oral Lesions
A Peer-Reviewed Publication
Written by Jeff Burgess, DDS, MSD

Abstract Educational Objectives: Author Profile

Conditions causing oral erythema vary in terms of etiology and At the conclusion of this educational activity Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant
complexity. Erythematous lesions may be the result of systemic as participants will be able to: Professor, Department of Oral Medicine, University of
well as local disease or trauma. Oral conditions reflecting potential 1. Describe interventions used to manage Washington School of Dental Medicine; (Retired) Attend-
systemic disease may need to be co-managed with the patient’s erythematous oral lesions. ing in Pain Center, University of Washington Medical Cen-
medical provider. Nonetheless, regardless of the potential cause of oral 2. Identify the appropriate medication
erythema, local intervention is an important component of the overall for managing viral lesions causing ter; (Retired) Private Practice in Hawaii and Washington;
management of these oral problems. Dental intervention includes the erythema. Director, Oral Care Research Associates. He can be reached
provision of palliative home care instructions for the erythema, local or 3. Implement treatment strategies for at jeffreyaburgess@hotmail.com .
systemic pain management, periodontal surgery and the prescription managing a variety of oral infections and
of medication (e.g. topical analgesics, antibiotics, corticosteroids, conditions. Author Disclosure
antifungal drugs, or salivary substitutes). In the case of allergy, 4. Identify interventions that constitute Dr. Burgess has no potential conflicts of interest to disclose.
removing the offending agent may be recommended. This course palliative home care.
focuses on the management of the oral erythematous conditions
dental professionals are most likely to see in everyday practice.

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Publication date: March 2015
Expiration date: February 2018
Supplement to PennWell Publications
PennWell designates this activity for 2 Continuing Educational Credits
Dental Board of California: Provider 4527, course registration number 02-4527-14092
“This course meets the Dental Board of California’s requirements for 2 units of continuing education.”
The PennWell Corporation is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
program provider are accepted by the AGD for Fellowship, Mastership and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to
(10/31/2015) Provider ID# 320452.
This educational activity was developed by PennWell’s Dental Group with no commercial support.
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Educational Methods: This course is a self-instructional journal and web activity.
Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or
services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or
third party has had any input into the development of course content.
Requirements for Successful Completion: To obtain 2 CE credit for this educational activity you must pay the
required fee, review the material, complete the course evaluation and obtain a score of at least 70%.
CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with
products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.com
Educational Disclaimer: Completing a single continuing education course does not provide enough information
to result in the participant being an expert in the field related to the course topic. It is a combination of many
educational courses and clinical experience that allows the participant to develop skills and expertise.
Image Authenticity Statement: The images in this educational activity have not been altered.
Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and
represents the most current information available from evidence based dentistry.
Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from
the data and information contained in reference section. The research data is extensive and provides direct benefit to
the patient and improvements in oral health.
Registration: The cost of this CE course is $49.00 for 2 CE credit.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full
refund by contacting PennWell in writing.
Educational Objectives:
At the conclusion of this educational activity participants
will be able to:
1. Describe interventions used to manage erythematous
oral lesions.
2. Identify the appropriate medication for managing viral
lesions causing erythema.
3. Implement treatment strategies for managing a variety
of oral infections and conditions.
4. Identify interventions that constitute palliative home
care.
Abstract
Conditions causing oral erythema vary in terms of etiology
and complexity. Erythematous lesions may be the result of
systemic as well as local disease or trauma. Oral conditions
reflecting potential systemic disease may need to be co-
managed with the patient’s medical provider. Nonetheless,
regardless of the potential cause of oral erythema, local inter-
vention is an important component of the overall manage-
ment of these oral problems. Dental intervention includes
the provision of palliative home care instructions for the
erythema, local or systemic pain management, periodontal
surgery and the prescription of medication (e.g. topical
analgesics, antibiotics, corticosteroids, antifungal drugs, or
salivary substitutes). In the case of allergy, removing the of-
fending agent may be recommended. This course focuses on
the management of the oral erythematous conditions dental
professionals are most likely to see in everyday practice.
Introduction
Erythema of the oral mucosa is associated with a number
of systemic and local diseases. The differential diagnosis
includes local conditions such as viral, fungal, and bacterial
infection, burns, trauma, neoplasm, allergy, vesiculo-erosive
or ulcerative diseases and radiation mucositis as well as sys-
temic conditions such as iron deficiency, polycythemia, avi-
taminosis B, erythroplasia, purpura, angioma, and Kaposi’s
sarcoma.1, 2
This continuing education course focuses on manage-
ment of these conditions. In cases where oral erythema is
associated with systemic disease, a comprehensive approach
to therapy including medical consultation and management
should be included in the overall treatment strategy. Treat-
ment of any oral lesion associated with erythema, regardless
of local or systemic etiology, should only be approached after
a diagnosis has been established.
This course provides a limited description of the diseases
capable of causing oral erythema. The course participant is
encouraged to further explore each of the conditions de-
scribed, including their etiology, epidemiology signs and
symptoms prior to initiating therapeutic options.3-10
As a general rule, the rationale for dental management
of oral erythema is to provide relief of symptoms, prevent
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secondary problems arising from the initial lesion, (e.g.,
secondary infection, tissue morbidity, dry mouth, dental
caries, periodontal disease) and support the patient’s
general health if more extensive medical intervention is
necessary. Home care should be an integral component of
therapy and include the following recommendations: hy-
giene maintenance, fluid and nutritional support, adequate
rest and OTC pain control.11 Medical assessment should
be considered when oral erythematous lesions worsen from
dental intervention or systemic symptoms develop during
the course of treatment.
Local Infection
Viral Infection
Viral conditions such as primary herpetic gingivostomatitis
(HSV-1 or 2), recurrent intraoral herpes simplex, recurrent
herpes labialis, primary herpes varicella and herpangina
include mucosal erythema coupled with vesicle formation
and ulceration.12 There may be regional lymphadenitis, fe-
ver and malaise. Viral infections are typically self-limiting,
but more serious complications can delay recovery (e.g.
herpes simplex encephalitis or viral meningitis). In addi-
tion, some infections (e.g. HSV and varicella) may reoccur
following reactivation of residual virus, termed latent virus,
residing in the sensory ganglion of the trigeminal nerve. In
these secondary cases, emerging ulcers and erythema will
occur in a well circumscribed area within the dermatome
of the affected nerve.13
Reactivation of varicella zoster, which causes chicken
pox, is the cause of oral shingles. These lesions develop in
approximately 20 percent of infectious cases and some-
times without skin involvement. The older patient with
oral shingles is at further risk of developing postherpetic
neuralgia or PHN which causes severe persistent pain.
When oral shingles is identified the patient should be
referred for medical management. Medical treatment is
likely to involve antiviral therapy and high dose cortico-
steroid prophylaxis.14 In the interim, the same topical and
analgesic measures described below for the management
of primary HSV-1 infection is useful dental intervention.15
Palliative home care
Management of HSV-1 includes assurance, information
and caution regarding infectivity. Recommendations in-
clude avoiding nail biting to reduce the potential develop-
ment of a herpetic whitlow and/or touching the oral lesions
and then the eye to prevent corneal infection, oral sexual
activity that might infect others and supportive care.
Instructions for supportive home care include gargling
with cold water or sucking on popsicles. The patient should
be advised to avoid hot beverages and spicy, salty or citrus
foods as they tend to aggravate pain. The application of a
thin paste of baking soda and water helps to shield lesions
 and reduces pain. For the patient with severe oral involve-
ment that prevents eating, nutritional supplements can be
recommended. Meritene® and Ensure Plus® are protein,
vitamin, and mineral food supplements that can be pur-
chased over the counter. They are flavored with acceptable
taste and it is recommended that three servings be taken
each day with their preparation per package labeling
Prescribed medications
There are a number of topical anesthetics16 available that
can be used alone or compounded with coating agents that
effectively reduce pain associated with acute viral disease.
When prescribing these formulations the patient should be
cautioned regarding potential aspiration as their gag reflex
may be reduced by the anesthetic.
Topical anesthetic agents (and prescribing information)
include the following:
1. Diphenhydramine syrup (OTC) or Benadryl® elixir
12.5 mg/5mls; Dispense 4 oz bottle; Sig: Rinse with one
teaspoonful for two minutes before each meal and spit
out.
2. Diphenhydramine syrup (OTC) 4 oz. with Kaopectate®
(OTC) 4 oz. to make a 50% mixture of each by volume
(Maalox® – OTC, or sucralfate® suspension can be used
instead of the Kaopectate®); Dispense 8 oz.; Sig: Rinse
with one teaspoonful every two hours and spit out.
3. Dyclonine HCL (Dyclone®).5% or 1% (One oz. of
Dyclone® can be added to the topical mixtures listed
above for improved anesthetic efficacy); Dispense one
once bottle; Sig: Rinse with one teaspoonful before each
meal and spit out.
4. Lidocaine/Prilocaine (EMLA®) 5% cream. Dispense 30
gm tube; Sig: Apply cream to lesions before each meal.
5. Benzocaine 20% gel (Ultracare®, Topex®)
Dispense 30 ml bottle; Sig: Apply on a cotton swab to
specific lesions for 60 seconds before each meal.
6. Lidocaine 2% gel. Dispense 30 ml tube; Sig: Apply the
gel to the lesions before each meal.
The syrups, elixirs and suspensions listed above are
generally more effective for multiple lesions where cov-
erage needs to extend over a broad area of mucosa. The
creams and gels work best as treatment of single or a limited
number of lesions confined to a discrete area of mucosa.
Adverse effects from topical anesthetics are rare when
these medications are used judiciously. However compli-
cations can occur if there is rapid absorption, hypersensi-
tivity or an idiosyncrasy to the prescribed medication. Side
effects include central nervous system excitation or depres-
sion, cardiovascular manifestations, and allergic reactions
(localized or anaphylaxis).17-19
Antiviral medications are not recommended for man-
agement of primary herpetic stomatitis because in the
immune competent individual the condition is self limiting
and the use of antiviral medication potentially increases
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the risk of resistance20. The current FDA recommendation
and best practices is that systemic acyclovir or valacyclovir
should be used only for the treatment of HSV-1 stomatitis
in the immunocompromised patient.
In terms of secondary lesions, treatment guidelines are
suggested by the scientific literature. One recent study sug-
gests that frequently occurring secondary (i.e. recurrent)
lesions including intra-oral lesions may be suppressed
successfully with administration of 500 mg of valacyclovir
delivered once a day over four months21. Systematic review
of 17 randomized controlled studies further suggests that
acyclovir is equally efficacious as valacyclovir in treating
herpes simplex viral infections.22, 23
Recurrent lip lesions precipitated by sun exposure may
be prevented by high SPF sunscreen application.
When oral pain of viral origin is moderate to severe,
systemic pain medication is also indicated. Acetaminophen
325mg with codeine is helpful in reducing pain. Medica-
tion combinations containing aspirin should be avoided in
children.
Fungal Infection
Candida albicans is the predominant organism that
causes fungal oral infection. However, in the immuno-
compromised individual other candida species may also
be involved. Candida albicans is opportunistic and will
proliferate when normal oral homeostasis is altered via the
use of antibiotics, corticosteroids, cytotoxic drugs and im-
munosuppression or as a consequence of conditions such
as diabetes and xerostomia.
There are several types of fungal conditions including
candidiasis (thrush), erythematous candidiasis, median
rhomboid glossitis, denture stomatitis and atrophic candi-
diasis among other fungal diseases.
Erythematous candidiasis is characterized by general-
ized tissue redness and pain. When localized to the tongue
the condition is called median rhomboid glossitis or central
papillary atrophy. Denture stomatitis or chronic atrophic
candidiasis is a more generalized condition.24
In patients with removable prostheses, dental treatment
should include not only prescription of medication but
also instruction on the disinfection of appliances. Denture
soaking solutions coupled with application of an antifungal
powder or cream to the contacting surface of the appliance
helps to prevent reinfection. As an example, an appliance
can be soaked overnight in a one percent chlorhexidine/
hypochlorite solution. In the morning this is followed by
the application of miconazole denture lacquer prior to its
insertion.
In the patient with dry mouth and candidiasis, chew-
ing gum or candy with xylitol is recommended to stimulate
daytime salivary flow. Products that improve night (sleep)
dryness such as Xylimelts® help to stimulate flow and alter
the perception of dryness.
Antifungal medications found to be useful in treating
oral candidiasis include nystatin (Mycostatin®), the
imidazoles such as clotrimazole and ketoconazole, and
triazole agents such as fluconazole.25,26
The following describes dosage considerations for a
number of useful antifungal medications. Topical prepara-
tions should be taken for 10-14 days.
1. Nystatin oral suspension 500,000 units/tsp (brand
names Mycostatin®, Nilstat®, Nystex®); Dispense 240
mls; Sig: 1 tsp tid; rinse for two minutes and swallow.
2. Ketoconazole cream 2% (brand name Nizoral®);
Dispense 15 gm tube; Sig: apply to the affected area
once daily at bedtime.
3. Clotrimazole vaginal cream 1% (OTC brand names
Gyne-Lotrimin®, Mycelex-G®); Dispense one tube;
Sig: apply to the denture or partial and the involved oral
mucosa four times a day.
4. Clotrimazole troches 10 mg (brand name Mycelex®);
Dispense 70 troches; Sig: dissolve one troche in the
mouth 5 times a day. Do not chew.
5. Nystatin Pastilles – 200,000u (brand name Mycostatin®
pastilles); Dispense 70 pastilles; Sig: dissolve one
pastille in the mouth 5 times a day. Do not chew.
6. Miconazole nitrate vaginal cream 2% (OTC – brand
name Monistat®); Dispense one tube; Sig: apply to the
denture and to the involved oral mucosa four times a
day.
Nystatin ointments and powders can be used to treat ap-
pliances per the following instructions:
1. Nystatin ointment; dispense 15 gm tube; Sig: apply
a thin coat to the denture and affected area after each
meal.
2. Nystatin topical powder; dispense 15 gm tube; Sig:
apply to dentures/prostheses after each meal and after
cleaning the appliance.
Antifungal medication has been associated with allergy
and GI problems. Nystatin suspension also contains sugar
so if the patient has teeth, good oral hygiene is important to
prevent decay; particularly if treatment is extended over a
prolonged period of time. A suspension of nystatin can also
be used as a disinfectant for a patient’s acrylic prostheses (see
above). It should be appreciated that ketoconazole absorp-
tion is reduced when antacid medication is taken concur-
rently. The oral use of vaginal creams (miconazole nitrate
vaginal cream or clotrimazole vaginal cream) to treat oral
candidiasis remains controversial. However sugar content
(in contrast to clotrimazole troches) is minimal in these for-
mulations which may be advantageous in cases involving the
need for long-term application. In addition, antifungal tro-
ches may not be well tolerated in the patient with dry mouth.
Pregnant or breast feeding patients should consult with their
physician prior to use of any of these antifungal medications.
All of the troches described above provide good contact of
drug with the mucosa over time.27, 28
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Systemic antifungal agents are usually prescribed when
topical agents are not effective or are not practical. They
are well tolerated but should be used with caution in the
patient with impaired liver function. Best practices include
pre-treatment liver function testing and monthly reassess-
ment if ketoconazole or itraconazole is to be prescribed over
a prolonged period of time.29, 30 Chronic fungal infection is
typically associated with suppressed immune function and
debilitating disease so these patients will usually be under
the care of a medical specialist. If systemic antifungals are
being considered, consultation with the patient’s physician
is imperative. These systemic drugs include: ketoconazole
(Nizoral®), fluconazole (Diflucan®), itraconazole (Sporanox®),
and amphotericin B (Fungizone®).31, 32
Bacterial Infection
Bacterial infection involving the oral mucosa includes
streptococcal tonsillitis and pharyngitis; Group A ß-
hemolytic streptococci (Scarlet fever), diphtheria, primary
syphilis, tuberculosis, and Cancrum Oris (NOMA). Pa-
tients with these conditions will likely be under the care of
a medical infectious disease specialist; but if they are not,
the best ‘treatment’ a dentist can deliver is recognition of
the disease and prompt referral to a physician for appropri-
ate follow-up care.
Periodontal disease is the most common erythematous
oral disease that is caused by bacteria. A complete review
of periodontal disease is beyond the scope of this course. In
brief, the classic dental management of periodontal disease
includes removal of local factors (e.g., plaque and calculus),
diet and behavior modification and surgical intervention.
Antibiotic usage has been studied as an adjunct to nonsurgi-
cal debridement. The research to date suggests that systemic
amoxicillin and metronidazole are effective in reducing the
signs and symptoms of periodontal disease.35 Long-term
use of antibiotic is discouraged because of potential adverse
effects and because of the increased possibility of resistance.
The National Institute of Dental and Craniofacial Research
and the CDC offer some useful periodontal treatment
guidelines on their Web sites.33, 34
Other localized infections that can be managed in the
dental office include pyogenic granuloma and peripheral
giant cell granuloma. These erythematous growths are non-
neoplastic. Dental treatment is surgical. If surgery is to be
pursued, successful outcome will depend on excising the
gingival tissue down to the periosteum. Both of these tumor
types often recur and re-excision may be necessary. This is
especially true for pyogenic granuloma if removed during
pregnancy.
One oral bacterial infection that is best co-managed
with the patient’s medical provider is necrotizing stomatitis
associated with HIV-infection. Lesions associated with this
condition typically respond to topical and systemic gluco-
corticosteroid therapy coupled with systemic antibiotics.
 HIV patients can also develop severe recurring aphthous
ulcers. Pain associated with these lesions is best managed
with topical steroids or the topical anesthetic medications
detailed in the list under viral infections. In some cases re-
calcitrant deep ulcerative lesions can be effectively medically
managed and suppressed with systemic thalidomide.36-38
Contact Allergy
This section covers the dental treatment of mucosal ery-
thema caused by contact stomatitis (stomatitis venenata),
geographic tongue (areata migrans) and orofacial granulo-
matosis which also causes tongue or lip swelling. In addition
to erythema and swelling, contact allergy may be associated
with lichenoid change of the mucosa and ulceration. Muco-
sal contact allergies usually take a long time to develop and
are thought to represent a delayed hypersensitivity reaction.
Symptoms of allergy typically include a sensation of mu-
cosal burning, or dysesthesia and pain. There may also be
increased salivation.
Many foods, chemicals, medications and metals have
been associated with oral allergy. For a list of some of these
offending allergens the reader is referred to the articles by
Wray and colleagues.39, 40
If an acute mucosal allergy is suspected, the patient
should be referred for testing. Sensitivity testing via the
RAST (radioallergosorbent) test is typically performed by
a medical allergy specialist. If intraoral patch testing is being
considered, it should be performed by a dentist familiar with
such testing (e.g. Oral Medicine) as there is a risk of false
positive results. Solutions with standard percentages of vari-
ous metals can be obtained in a commercial patch test kit.
These metal samples are then combined with orabase and
placed against the lip or palatal mucosa via a modified splint.
The material is allowed to remain for 24 hours, after which
the tissue can be assessed for reactivity.41
Some of the conditions that should be differentiated
from mucosal allergy prior to treatment include: candidia-
sis, leukoplakia, oral lichen planus, autoimmune blistering
disease, drug reactivity (e.g. lichenoid drug reaction), viral
infection and other oral ulcerative diseases.
Allergic contact stomatitis is best treated by removing
the offending sensitizing agent. This can mean replacing a
dental material that is the source of the allergy; for example,
restorative materials containing nickel, titanium implants or
mercury found in amalgam.42-44 If a food is the cause of the
allergy the offending agent should be eliminated from the
diet.45 If a drug has been identified as the cause of oral ery-
thema the patient should be cautioned regarding continued
use; however, he/she should also be advised to seek medical
consultation prior to discontinuation of a prescribed drug to
avoid potential systemic complications upon withdrawal.
Topical anesthetics such as Dyclonine HCL and cortico-
steroid such as fluocinonide gel or dexamethasone elixir can
be used separately or combined with an antihistamine (e.g.
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OTC Benadryl® 25 mg/ tsp; swish and spit) to help reduce
pain and chronic inflammation.
Geographic tongue is considered in this section with
contact allergy, even though the etiopathogenesis is un-
known. This is because there is limited evidence that the
condition might represent a hypersensitivity reaction to
an unknown environmental factor in some individuals.
Although the condition is typically non-painful and self-
limiting, in the patient that has moderate to severe pain,
management can be problematic. These patients should be
advised to avoid hot or spicy food and to reduce exposure
to cigarette smoke and certain toothpastes, including those
with whitening chemicals or which are excessively flavored.
At present the treatment of symptomatic geographic
tongue is based on empirical evidence rather than ran-
domized controlled trials. Topical anesthetics, antihista-
mine rinses and corticosteroids such as fluocinonide gel
applied four times daily can help to reduce symptoms. A
recent case study suggests that tacrolimus ointment may
also be an effective therapy.46 The results of this particular
case study are potentially significant because in a recent
systematic review of studies assessing the efficacy of ta-
crolimus ointment in the treatment of atopic dermatitis it
was found that the drug was as effective as corticosteroid
in reducing symptoms.47 Antihistamine rinses have also
been suggested as treatment.48 Another recent study sug-
gests that refractory painful cases may be responsive to cy-
closporine (cyclosporine microemulsion pre-concentrate,
3 mg/kg/day for initial intervention with a reduction to
1.5 mg/kg/day for maintenance).49 Of potential signifi-
cance, a patient with psoriasis and geographic tongue may
see the condition resolve with treatment of the psoriasis
skin lesions.
The etiology of orofacial granulomatosis has not been
determined and is likely to be complex.50 As the condition
may spontaneously remit, treatment is only necessary if
there is pain. If food or medication is determined to be
causative, it should be eliminated from the diet or use. In
chronic cases involving severe cosmetic deformity or im-
paired oral function, surgical intervention may be neces-
sary. Corticosteroids, including topical application as well
as systemic delivery, can be helpful. Intralesional cortisone
injection is indicated for moderate swelling. The literature
also suggests that oral tetracycline, anaerobic antibiotics
(e.g. dapsone or metronidazole), and topical tacrolimus
may help to reduce swelling. Other drugs that modulate
the immune system such as methotrexate and thalidomide
have also been reported to be helpful in reducing swelling
in severe cases.51
Aphthous Stomatitis
Aphthous stomatitis is characterized by the presence of
multiple ulcers of the oral mucosa with adjacent tissue
erythema. The treatment of aphthous stomatitis remains
largely empirical and includes topical or systemic cortico-
steroids and/or immunosuppressant drugs.52 Aphthous
lesions are self limiting and heal without scarring. Isolated
ulcers, if small, do not typically need prescribed interven-
tion and can be managed by OTC preparations.
Recurrent severe ulceration requires a more compre-
hensive work up of the patient to rule out systemic disease.
Some of the conditions that should be considered in the
differential diagnosis include anemia, diabetes mellitus,
PFAPA (periodic fever, aphthous stomatitis, pharyngitis,
and adenitis syndrome), Behcet’s disease, inflammatory
bowel disease and immunosuppressive disease. Systemic
disease necessitates comprehensive medical and dental
management.
If dental trauma is the cause of ulceration, this should
be corrected. Other causes such as stress and food allergy,
if deemed contributory, should be treated via stress reduc-
tion or dietary restriction.53
A number of topical OTC strategies for suppressing
developed lesions have been studied and found to be effec-
tive in reducing lesion duration and pain. However these
preparations do not appear to alter the frequency of recur-
rences or maintain remission. Application of a dissolving
gum-based patch containing glycyrrhiza (licorice) complex
herbal extract has been found to reduce lesion duration and
pain.54 A paste containing Myrtus communis (Myrtle) has
also demonstrated an effect on lesion size and pain sever-
ity. 55 In a randomized, double-blind, placebo-controlled
trial, a mouthwash containing Rosa damascena extract
also demonstrated efficacy in the treatment of recurrent
aphthous stomatitis.56
Few drugs have been found to reduce the frequency
and severity of reoccurring aphthous ulcers, however,
two studies assessing this potential show promise. In one
study, Irsogladine prescribed at 2-4 mg/day was found to
be effective in reducing ulcer count and preventing reoc-
curance.57 In a second study, rebamipide was delivered
at 300mg/day to 35 patients with Behcet’s disease in a
randomized double-blind, placebo-controlled study. It
was well tolerated, reduced the aphthous lesion count and
improved pain. There were no specific adverse drug reac-
tions.58
Recurrent aphthous stomatitis has been associated
with reduced dietary intake of vitamin B12 and folate.59
However vitamin B12 as a cause of aphthous stomatitis
remains controversial and no effect has been observed
for multivitamin intervention.60 Nonetheless, vitamin B
12 supplementation has been found to reduce reoccur-
rence of aphthous lesions, even in the absence of clinical
deficiency.61, 62 Immunomodulating medications such as
the tetracyclines and amlexanox sirolimus, when applied
topically, have anti-inflammatory activity that appears to
reduce the severity of aphthous ulceration.63 Application of
a tetracycline solution via cotton swab to a lesion may also
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reduce secondary infection which can complicate healing
and increase pain.
The following list of topical steroids can be used to treat
oral ulceration.
1. Triamcinolone (brand – Kenalog in Orabase®); Dosage
0.1% (provided in one tube).
2. Fluocinonide (brand – Lidex® gel or Lidex® ointment);
Dosage 0.05% (provided in one tube).
3. Clobetasol propionate (brand –Temovate® gel or
Temovate® ointment; Dosage 0.05% (provided in one
tube).
All three of these corticosteroid mediations should be
applied after each meal and at bedtime. Clobetasol propio-
nate should be applied for three or four days with a break of
three to four days before reapplication. This approach will
reduce potential steroid side effects.
For generalized erythema associated with multiple ulcers
an oral rinse may be the best way to achieve effective lesion
coverage. Dexamethasone (Decadron® elixir) incorporates
0.5mg per 5 mls of solution and comes in 100 ml volumes.
The patient should rinse with one tsp (5 mls) for 3-4 minutes
four times a day and spit. For severe cases it may be useful
to prescribe 320 mls with 15mls swished with swallow four
times a day for three days followed by 5mls taken in the same
manner for three days, then 5 mls used for three days with
swish but with swallowing every other day and finally with
5 mls used four times a day as a rinse with expectoration of
the medication. With steroid use the patient should be moni-
tored carefully for emergence of candidiasis. With low doses
of steroid potential side effects should be minimal. However
they can be problematic and include CNS stimulation, sleep
disturbance, and gastrointestinal abnormality including ulcer
formation and bleeding. Additionally, in the diabetic patient,
blood glucose levels should be carefully monitored with long
term use.
Recurrent severe debilitating aphthous stomatitis may
need to be managed with prednisone delivered systemically
at higher doses. A Medrol Dosepak® (methylprednisolone)
titrates corticosteroid over a 7 to 10 day period. This option
should only be considered by experienced clinicians in co-
operation with the patient’s physician. Azathioprine (Imu-
ran®) is a prednisone sparing agent that can be prescribed
concomitantly with steroid but if this course of therapy is
to be implemented, a baseline CBC and liver enzyme panel
should be acquired prior to the start of treatment.64 Addi-
tional preventative management for candidiasis needs to be
utilized.
Oral Cancer
Dental involvement in the patient with oral cancer usually
involves oral examination and if neoplasm is suspected,
biopsy of the tissue. Surgical management of carcinoma
is determined by the clinical stage of the disease. Small
lesions identified by biopsy such as squamous cell carci-
 noma that are without nodal involvement can be surgically
excised (best practices is by an oral surgeon or ENT physi-
cian) using a wide margin technique The treatment of large
lesions or lesions with nodal involvement is complicated.
Hence the patient with extensive involvement needs to be
referred so that they can receive comprehensive manage-
ment by oncology, ENT, and oral (maxillofacial) surgery.
Treatment may include radiation and/or chemotherapy
and oral reconstruction.
Head and neck cancer radiotherapy and chemotherapy
can directly impact the oral mucosa and saliva and result in
oral mucositis (OM) which is characterized by ulceration,
tissue slough, erythema, and pain. Mucositis can also follow
chemotherapeutic intervention for other non-oral cancers.
The oral conditions that may develop secondary to treat-
ment of oral as well as other forms of cancer include cheilitis,
gingivitis, herpetic gingivostomatitis, oral mucositis (OM),
oral candidiasis, periodontitis, and ulceration.65 Recent evi-
dence suggests that the incidence of OM will vary depend-
ing on the type of chemotherapeutic agent used and the type
of cancer treated.66
Dental intervention for patients receiving chemothera-
peutic agents and radiotherapy includes pre-treatment
preventative hygiene measures and restorative care. After
lesion development, dental treatment focuses on symp-
tomatic support including pain relief, reducing periodontal
disease and caries and treating opportunistic infection. In
the hospital setting dental intervention may be more com-
prehensive and include additional management strategies
for mucositis.
For the dentist asked by a treating physician to provide
a recommendation about the management of mucositis the
following information may be useful. In the treatment of
oral mucositis, recent evidence suggests that benzydamine
hydrochloride (0.15%) used as an oral rinse, swished for
30 seconds four times a day, may be more effective than
chlorhexidine and povidone iodine in preventing the devel-
opment of severe mucositis.67
Results from systematic review of the research literature
published prior to 2007 (Cochrane report) suggest that sev-
eral medications may be more effective in reducing OM than
benzydamine HCL, chlorhexidine and the ‘magic’ mouth
rinse (lidocaine solution, diphenhydramine hydrochloride
and aluminum hydroxide suspension).68 These include al-
lopurinol, granulocyte macrophage-colony stimulating fac-
tor, immunoglobulin, and human placental extract. In fact,
based on at least one study, allopurinol appears to eradicate
mucositis. The authors of this Cochrane review conclude
that the evidence for the use of benzydamine HCL does sup-
port its use as adjuvant treatment. Nonetheless, they further
conclude that the evidence for the above effective medica-
tions (e.g. allopurinol, etc.) is also weak and ‘unreliable’.
A Cochrane review published prior to the 2007 con-
cludes antibiotic pastes or pastilles can also provide a moder-
www.ineedce.com 7
ate benefit. Hydrolytic enzymes appear to reduce moderate
and severe mucositis and ice chips can prevent mucositis.
Other interventions with potential effect (based on only one
study at the time) include calcium phosphate, honey, oral
care protocols, povidone, and zinc sulphate.69
In general, a multifocal multi-pharmacy approach is
necessary in managing oral mucositis, oral pain, dry mouth
and opportunistic infection that can be associated with che-
motherapy and radiation treatment.70
Topical measures effective in reducing oral pain include
2% viscous lidocaine HCL (Xylocaine®), dyclonine (Dy-
clone®) and diphenhydramine elixir (Benadryl®, Benalin®).
Mouth rinses that may reduce oral discomfort include
alkaline saline (salt/bicarbonate), Biotene®, and sucralfate
(Carafate®) suspension. Chlorhexidine gluconate mouth-
wash (Peridex®, Periogard®) at 0.12% may help in reducing
gingivitis. In patients with dry mouth a salivary substitute or
stimulant should be included to provide the needed protein
binding to make it effective. Artificial salivas include Sage
Moist Plus®, Moi-Stir® and Xero Lube®. Oral moisturizers
include OralBalance® gel and Sage Mouth Moisturizer®.
Fluorides should be applied for caries control. These include
neutral NaF gel (Thera-Flur-N®) 1.0% which can be applied
one drop per tooth or via a custom tray, stannous fluoride
gel (0.4%) which should be applied in the same manner.
Biotene® toothpaste (OTC), placed on a soft brush that
can be made softer by placing it under hot water, can help
with plaque control. Antifungal medications previously
described will help reduce potential candidiasis.71
Vesiculoerosive or Ulcerative Disease
Benign Mucous Membrane Pemphigoid (BMMP)
Benign mucous membrane pemphigoid (BMMP) is an
autoimmune disease that cleaves the epithelium. This then
produces fluid filled bullae which rupture and leave the
mucosal surface raw and erythematous. The condition can
affect the eye, so immediate ophthalmology referral is im-
portant once the disease is confirmed by biopsy.72, 73
Relatively small BMMP oral lesions can be managed
with topical steroids. Severe erosions may require systemic
steroids and/or azathioprine coupled with analgesics and
antifungal medication. Since these lesions have significant
potential for morbidity, referral should be made to oral
medicine specialists, ophthalmologists, dermatologists and/
or rheumatologists.74
Lichen Planus
Although the etiology of erosive oral lichen planus (OLP)
remains unknown, accumulated evidence points to an auto-
immune problem with a genetic predisposition. The condi-
tion appears to involve T-cell mediated inflammation of the
tongue, palate, buccal mucosa, and gingiva which leads to
tissue erythema, hyperkeratosis, and the erosions that char-
acterize the severe form of the disease.75 There can also be
dermal involvement.
Asymptomatic reticular lichen planus that does not in-
volve erosion, erythema or esthetic concern does not need
intervention.
The rationale for treatment of erosive OLP includes
suppression of oral lesions, pain control and prevention of
secondary fungal infection. Research data regarding efficacy
suggests that there may not be a considerable difference
between current treatment strategies. In a Cochrane review,
28 randomized controlled clinical trials that assessed symp-
tomatic treatments for OLP were reviewed. There was no
specific therapeutic approach that stood out above the others
as a ‘go to’ approach to intervention.76 Topical and systemic
steroid application is considered a first-line treatment for
erosive OLP. However, as was noted by the authors of the
Cochrane review, no randomized controlled trials have com-
pared this medication strategy with placebo.
A number of other medications have been suggested as
treatment of erosive LP. Pimecrolimus is one of these drugs.
The evidence for use of pimecrolimus, an immunomodulat-
ing agent used in the treatment of atopic dermatitis (eczema),
consists of three clinical trials that suggest that its use is no
better than placebo in reducing pain associated with OLP.
Two trials assessing aloe vera suggest that it may reduce
pain compared to placebo. In addition, two other small trials
suggest that cyclosporine may reduce pain and the clinical
signs of OLP. Five trials comparing steroids with calci-
neurin inhibitors (e.g., pimecrolimus, tacrolimus) suggest
no difference between the two in reducing pain. And in 6
trials specifically assessing steroid therapy, there was limited
evidence that one steroid worked better than another. Thus,
it would appear that there is insufficient evidence to support
the effectiveness of any specific treatment as being superior
to another in the management of erosive OLP. Given this, a
prudent approach to management would be to start with a
minimal application of the lowest dose topical steroid before
prescribing stronger acting drugs.
One of the more challenging problems in treating OLP
is that the condition can be refractory to topical steroids
and systemic therapy may be necessary to fully control the
disease. As noted by Lozada-Nur and Miranda (1997)77, no
one single standard protocol has been proven effective in
treating chronic OLP and consequently, the most effective
therapy is topical high-potency corticosteroids coupled with
systemic steroid (prednisone).
The use of a specific topical steroid preparation is based
on lesion size. For isolated lesions, fluocinonide (Lidex®) gel
or ointment can be applied after each meal and at bedtime.
If clobetasol (Temovate®) is used, it should be prescribed as
previously described to prevent potential adrenal suppres-
sion. If OLP lesions are extensive, dexamethasone (Decad-
ron®) elixir may be more effective in providing complete
lesion coverage. One teaspoonful (5 mls) should be used
8 www.ineedce.com
to rinse for 3-4 minutes after each meal with the drug spit
out. The patient should be monitored for yeast infection and
treated accordingly if infection emerges during steroid use.78
Topical cyclosporine has shown some promise in lim-
ited trials79. Topical and systemic retinoids (e.g., tretinoin
and etretinate) do not appear to be particularly useful.80
Alternate-day treatment protocols, low doses, and adjunc-
tive therapy have been suggested by at least one expert if the
condition is to be treated long-term.77
In a small study, local ultraviolet B phototherapy was
found to be effective in treating OLP, suggesting a nonphar-
macological approach to the management of the disease. A
larger randomized controlled trial is needed, however, be-
fore this approach can be recommended for intervention.81
Pain medications can include acetaminophen prepara-
tions, including codeine (in severe cases) or other narcotics
taken short-term.
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Author profile
Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant
Professor, Department of Oral Medicine, University of
Washington School of Dental Medicine; (Retired) Attend-
ing in Pain Center, University of Washington Medical
Center; (Retired) Private Practice in Hawaii and Washing-
ton; Director, Oral Care Research Associates. He can be
reached at jeffreyaburgess@hotmail.com .
Author Disclosure
Dr. Burgess has no potential conflicts of interest to disclose.
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Questions
1. In cases where oral erythema is associated 8. Which one of the following is not likely to 14. The advantage of using an antifungal
with systemic disease the dentist should: be a side effect of topical anesthetic? troche over a rinse is that:
a. Manage the condition without establishing a a. Depression a. The troche can be swallowed quickly.
diagnosis b. Cardiovascular problems b. A troche such as Mycelex® has no sugar in its
b. Prescribe steroids c. CNS excitation formulation.
c. Seek medical consultation prior to pursuing local d. Stomach ulceration c. A troche provides longer contact with the mucosal
management surface.
d. Perform a biopsy 9. Which of these statements is true in rela- d. A troche can be taken with antacid medication.
tion to the treatment of primary HSV-1
2. Home care should be an integral compo- oral viral infection? 15. Systemic antifungal agents are usually
nent of therapy. Which of the following a. Use of an antiviral medication may increase prescribed when:
is not included in the ‘best practices’ resistance a. Patients have concomitant liver disease or impaired
recommendations? b. Systemic acyclovir should only be used as a liver function.
a. Fluid and nutritional support treatment of HSV-1 stomatitis when the patient has a b. When topical agents are not effective or are not
b. Adequate rest compromised immune system practical.
c. OTC pain medication c. Both a and b c. Both a and b
d. Vitamin therapy d. Neither a or b d. Neither a or b
3. Which one of the following viral infections 10. Which of these statements is true in 16. Which of the following is not a systemic
is associated with localized reoccurrence relation to the treatment of secondary antifungal medication?
secondary to reactivation of latent virus a. Diflucan
HSV-1 lesions?
within nerve? a. Frequently reoccurring secondary lesions can be b. Sporanox
a. Herpes simplex virus (HSV-1 or 2) c. Fungizone
b. Morbillivirus suppressed with 500 mg of valacyclovir.
b. Acyclovir is not as effective as valacyclovir in treating d. Monistat
c. Human herpes virus 6 (HHV-6)
d. Cytomegalovirus (CMV) reoccurring lesions. 17. The most common erythematous oral
c. Both a and b disease caused by bacteria is:
4. Reactivation of varicella-zoster virus d. Neither a or b a. Streptococcal tonsillitis and pharyngitis
(VZV) causes: b. Periodontal disease
a. Oral shingles 11. In the patient with a competent immune
system which of the following fungal c. Diphtheria
b. Postherpetic neuralgia d. Tuberculosis
c. Both of the above organism is most responsible for oral
d. None of the above erythema? 18. The standard dental treatment of
5. In patients with HSV-1 lesions, palliative a. Cladosporium pyogenic granuloma and peripheral giant
home care should include all of the follow- b. Saccharomycetales cell granuloma is:
c. Candida albicans a. Prescription of systemic antibiotic.
ing except: d. Aureobasidium b. Surgery
a. Gargling with cold water c. Both a and b
b. Drinking hot beverages 12. In the patient with removable prostheses d. Neither a or b
c. Avoidance of nail biting and erythematous candidiasis, overall
d. Use of a nutritional supplement management should include: 19. Which of the following is not considered
6. Which one of the following is not consid- a. Instruction to soak the appliance overnight in a a reasonable treatment of a symptomatic
ered a topical medication that can be used mouthrinse allergic stomatitis that is associated with
for desensitizing erythematous mucosa? b. Instruction not to use their prostheses during oral mucosal erythema?
a. Diclonine HCL intervention a. Prescription of systemic antibiotic
b. Lidocaine/prilocaine cream c. Instruction to soak the appliance in a one percent b. Removal of dental fillings or crowns
c. Diphenhydramine syrup chlorhexidine/hypochlorite solution c. An elimination diet
d. Vitamin C cream d. Instruction to apply an antibiotic denture lacquer d. Prescription of Dyclonine HCL and corticosteroid
prior to insertion 20. Which of the following has been recom-
7. Topical anesthetic syrups are typically
prescribed as rinses to be used before each 13. Topical antifungal medication should be mended for the treatment of symptomatic
meal and: used for how many days? geographic tongue?
a. Swallowed a. 10-14 days a. Tacrolimus ointment
b. Spit out b. 3-5 days b. Cyclosporine microemulsion
c. Both a and b c. 14-21 days c. Both a and b
d. Neither a or b d. 6-9 days d. Neither a or b

Notes

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Management of Erythematous Oral Lesions
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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
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Educational Objectives Academy of Dental Therapeutics and Stomatology,
1. Describe interventions used to manage erythematous oral lesions. A Division of PennWell Corp.
2. Identify the appropriate medication for managing viral lesions causing erythema. P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
3. Implement treatment strategies for managing a variety of oral infections and conditions,
4. Identify interventions that constitute palliative home care.
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