Department of Pediatric Dentistry
St Joseph Hospital
Resident’s Name: Joanne Lewis Date: July 17, 2009
Article title: Oral candidiasis in children with immune suppression: Clinical appearance and therapeutic considerations
Author(s): Catherine M. Flaitz, DDS, MS; M. John Hicks, DDS, MS, PhD, MD
Journal: Journal of Dentistry for Children
Month, Year: May-June 1999
Major topic: Oral candidiasis in immuno-suppressed children
Type of Article: review
Main Purpose: to review the clinical appearance, diagnosis, and treatment of oral candidiasis
Key points/Summary: Oropharyngeal candidiasis is of considerable importance in any condition that results in an immune suppressed state; it is particularly important in individuals with HIV infection. The development of oral candidiasis is considered to be an ominous sign, indicative of a severely depressed immune system. Oral candidiasis may present in several forms: 1.) pseudomembranous candidiasis (thrush) – white to yellow plaques overlying the oral mucosa – can be removed with gauze – symptoms include tenderness, burning, and dysphasia. 2.) erythematous (atrophic) candidiasis – marked erythematous mucosa on palate and/or dorsum of tongue – associated with broad-spectrum antibiotics and corticosteroid therapy. 3.) papillary hyperplasia – anterior hard palate, small ovoid nodules raised 2-3 mm above erythematous palatal mucosa – response to a chronic fungal infection. 4.) chronic hyperplastic candidiasis – thickened hyperkeratotic mucosa, looks like a localized area of leukoplakia – seen in long-standing fungal infections – presents on dorsum of tongue or retrocommissural region 5.) angular chelitis – seen at the commissures, may become encrusted secondary to fissuring and erosion – seen commonly in children with a lip-licking habit. 6.) median rhomboid glossitis – lesion surface varies from nodular to fissured to smooth and depapillated. Diagnosis: clinical appearance (most common), exfoliative cytology, biopsy, or culture (when lesions are resistant to anti-fungal therapy). Treatment: 1.) topical – nystatin creams, rinses, pastilles, ketoconazole cream, clotrimazole creams and lozenges, amphotericin B cream and lotion – usually have high sucrose or dextrose content, long term use may increase caries risk. 2.) prophylactic – chlorhexidine rinses. 3.) systemic – clotrimazole, ketoconazole, fluconazole, itraconazole (azole class) – side effects include – nausea, vomiting, pruritus, skin rash, abdominal discomfort, headache, abnormal liver function, drug-induced hepatitis – assess liver function at time of administration. Fluconazole and itraconazole have been more effective at treating oral candidiasis. Prophylaxis with antifungal agents in children and adolescents with HIV infection is not routinely recommended, but may be indicated on a case-by-case basis.
Assessment of article: good review.
Friday, July 17, 2009
Herpesvirus Infections
Dental Residency Program
Literature Review Form
Resident: Adam J. Bottrill Date: 17JUL09 Region:
Article title: HERPESVIRUS INFECTIONS
Author(s): Greenberg, Martin S. DDS
Journal: Infectious Diseases and Dentistry
Volume #; Number; Page #s): Vol. 40; Number 2, pp. 359-367
Year: 1996
Major topic: Herpesvirus
Minor topic(s): NA
Type of Article: Topical Review
Main Purpose: Review various presentations and treatments of multiple forms of the herpesvirus.
Overview of method of research: Literature review and summary.
Findings: N/A
Key points in the article discussion:
A. All 7 herpesviruses have the following common characteristics.
1. Four Layers (DNA, capsid, tegument, lipid envelope)
2. Primary infection followed by latent period.
3. Recurrent infections (symptomatic or asymptomatic)
4. Transmitted through direct contact with saliva or genital secretions.
5. Shed in the saliva of asymptomatic hosts.
6. Known to transform cells in tissue culture.
B. Herpes Simplex Virus: Two major herpes simplex viruses are HSV 1 and HSV2. HSV1 is MOSTLY transmitted via saliva and associated with “upper body” infections. HSV2 is MOSTLY transmitted via genital secretions and associated with anal/genital infections. Rate of HSV1 infection goes up after 6 mo. And peaks between 2 and 3 y.o. HSV2 infection rate increases after sexual activity begins.
1. Primary: Frequently subclinical or are difficult to distinguish from URI’s. Can be preceded by fever, chills, malaise, nasea and lymphadenopathy. Oral manifestations include vesicles and ulcers of oral mucosa.
2. Reactivation: Stimulated by trauma, fever menstruation etc. Recurrences appear most commonly on the lips but can be present on the hard palate and gingiva.
3. Dx: Typically diagnosed clinically but may be done via lab tests. SHOULD ALWAYS BE RULED OUT WRT THE IMMUNOCMPROMISED (IC) PT.
C. Cytomegalovirus: Frequent cause of asymptomatic infection in humans. Clinically significant cases are rare except in neonates and IC Pt’s. Xmitted via genital secretions, breast milk, saliva and blood. CMV can cause potentially fatal congenital infection cytelomegalic inclusion disease. Infant CMV almost always involves enlarged salivary glands. In adults, can cause a mono-like disease with clinical manifestations including hepatitis, pneumonitis, lymphadenopathy, splenomegaly and myocarditis. At-risk individuals include organ transplant, HIV and IC pts. Oral lesions in AIDS pts have been described as slowly enlargening ulcers.
1. Dx: Histologic evaluation and culture of suspected lesions (owl eye cells) or viral culture. Culture can take up to 1 month but is most diagnostic.
D. Varicella-Zoster Virus:
1. Primary: Chicken pox (varicella) is usually a benign illness of children spread by direct contact with lesions or nasopharyngeal secretions. Lesions are typically pruritic macules and papules that become vesicles with erythematous halo.. 10-20 day incubation and pts are infectious for about 1 week after symptoms begin. Adults have 15x higher mortality rate due to increased incidence of encephalitis. Other symptoms include pneumonitis and Reye’s syndrome (progressive encephalopathy).
2. Recurrent: Shingles (herpes zoster) occurs when the latent virus (dorsal root nerve ganglia) becomes reactivated. Typically occurs at C-3, T-5, L-1, L-2. When trigeminal nerve involved, usually involves ophthalmic. Symptoms initially include pain, tenderness and parasthesia. This is followed by unilateral vesicles forming along the course of the affected nerve (Ramsay-Hunt syndrome). 15-20% of trigeminal infections involve 2nd and 3rd division leading to possible intra-oral lesions. Can be life-threatening to IC pts. Course of the zoster can be shortened with large doses of acyclovir. Additional sequela of herpes zoster may take the form of postherpetic neuralgia.
3. Dx: Typically made via characteristic clinical signs and proper medical history. When atypical cases present, tissue culture and viral isolation can confirm.
E. Epstein-Barr Virus: Affinity for B lymphocytes. Virus is spread by infected saliva or blood.
1. Primary: Typically subclinical or mild in children. Young adults present with infectious mononucleosis. Symptoms of “mono” include fever, malaise, pharyngitis, lymphadenopathy and possible splenomegally. Most pts recover within a month.
2. Dx: Based on clinical signs and bloodwork (detection of activated T-lymphcytes and heterophil antibodies).
3. Important note: EBV is associated with: Hairy leukoplakia, Burkitt’s lymphoma, nasopharyngeal carcinoma and possibly B cell lymphoma.
F. Human Herpes Virus 6: Discovered in 1986, has a strong affiliation for CD4 lymphocytes. Causes roseola (common disease among children) which presents with fever and a rash. Suspected the HHV6 is related to mono, pneumonia, meningitis and encephalitis.
G. Human Herpes Virus 7: Most recently discovered herpesvirus detected on CD4 lymphocytes. Distinguishable from HHV-6 by DNA analysis. Can initially infect in the 2nd yr of life (later than HHV-6). Transmitted via saliva.
Summary of conclusions: There are more than 80 known viruses of the herpes group. This article presents brief summaries of seven of them
Assessment of article: Though not an experimental research-based article, it did provide concise summaries of the seven aforementioned herpesviruses. One area not covered was effective treatment methods. It is possible that there may be a more recent summary article with more updated information on this.
Thursday, July 16, 2009
: Juvenile Xanthogranuloma of the Oral Cavity in Children: A Clinico-pathologic study.
Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 7/17/2009
Article title: Juvenile Xanthogranuloma of the Oral Cavity in Children: A Clinico-pathologic study.
Author(s): Flaitz C., Allen C., Neville B., et al
Journal: Oral Surg Oral Med Oral pathol Oral Radiol Endod
Volume (number): 345-52
Date: Sept 2002
Major topic: Clinical and Histochemical evaluation of JXG
Type of Article: Case Reports
Main Purpose: This article reviews 5 cases of oral JXG in children
Review of Cases: JXG is a benign reactive self-healing disorder of children which is classified as a normolipenic, non Langerhans cell disease caused by the proliferation of phagocytoid monocytes. It most commonly affects infants less than 1 year of age with a male predilection. The cutaneous type is most commonly associated with the head and neck region of the skin and occurs as single or multiple lesions in a cluster. The lesion is papulonodular with a color varying from yellow to red to red brown to normal skin color. The lesions are usually asymptomatic and the lesions undergo spontaneous regression after several months leaving a permanent scar.
Systemic JXG can affect several different organ systems, and skin lesions are associated with it in 40-50% of cases. Treatment includes surgical excision. If left untreated, this disorder may be life threatening
Five cases of Oral JXG were studied ranging in age from 5 months to 10 years with a mean age of 6.3 years. Most lesions were solitary affecting the gingival, dorsum of tongue, and buccal mucosa and none were associated with cutaneous lesions. Histopathological examination indicated an increase in histiocytes and dendritic cells in the lesions. Extensive histological evaluation was discussed in the article.
Differential diagnosis with Langherhan cell disease (LCD0 is necessary. Other diseases linked to JXG are neurofibromatosis type I, juvenile chronic myeloid leukemia, ALL, LCD, Diabetes Mellitus, etc.
Key points/Summary : Oral JXG tends to occur in an older age group than the other types of JXG. Cellular analysis of a biopsy is necessary to differentiate it from LCD
Assessment of article: Good article. Too much information about the ultrastuctural and immunocytochemical studies of the lesions.
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 7/17/2009
Article title: Juvenile Xanthogranuloma of the Oral Cavity in Children: A Clinico-pathologic study.
Author(s): Flaitz C., Allen C., Neville B., et al
Journal: Oral Surg Oral Med Oral pathol Oral Radiol Endod
Volume (number): 345-52
Date: Sept 2002
Major topic: Clinical and Histochemical evaluation of JXG
Type of Article: Case Reports
Main Purpose: This article reviews 5 cases of oral JXG in children
Review of Cases: JXG is a benign reactive self-healing disorder of children which is classified as a normolipenic, non Langerhans cell disease caused by the proliferation of phagocytoid monocytes. It most commonly affects infants less than 1 year of age with a male predilection. The cutaneous type is most commonly associated with the head and neck region of the skin and occurs as single or multiple lesions in a cluster. The lesion is papulonodular with a color varying from yellow to red to red brown to normal skin color. The lesions are usually asymptomatic and the lesions undergo spontaneous regression after several months leaving a permanent scar.
Systemic JXG can affect several different organ systems, and skin lesions are associated with it in 40-50% of cases. Treatment includes surgical excision. If left untreated, this disorder may be life threatening
Five cases of Oral JXG were studied ranging in age from 5 months to 10 years with a mean age of 6.3 years. Most lesions were solitary affecting the gingival, dorsum of tongue, and buccal mucosa and none were associated with cutaneous lesions. Histopathological examination indicated an increase in histiocytes and dendritic cells in the lesions. Extensive histological evaluation was discussed in the article.
Differential diagnosis with Langherhan cell disease (LCD0 is necessary. Other diseases linked to JXG are neurofibromatosis type I, juvenile chronic myeloid leukemia, ALL, LCD, Diabetes Mellitus, etc.
Key points/Summary : Oral JXG tends to occur in an older age group than the other types of JXG. Cellular analysis of a biopsy is necessary to differentiate it from LCD
Assessment of article: Good article. Too much information about the ultrastuctural and immunocytochemical studies of the lesions.
Department of Pediatric Dentistry
Lutheran Medical Center
Date: 07/17/2009
Article title: Periodontal and Soft-Tissue Abnormalities
Author(s): Jayne E. Delaney, DDS, MSD
Journal: Dental Care for the Preschool Child
Volume (number): vol 39 num 4
Month, Year: 1995
Major topic: soft tissue and periodontium
Minor topics:
Type of Article: Informative
Main Purpose: Review pertinent clinical information concerning periodontal problems in children as well as proper treatment. Many common soft tissue abnormalities are also reviewed.
Overview of method of research: Review of Literature
Findings:
Gingival and other soft tissues differ from those of adults. Additionally, they frequently present with myriad soft tissue and periodontal problems. Frequent review of these lesions helps providers better care for children and provide proper referral to medical colleagues, should they need to.
Children are generally more resistant to periodontal disease than adults. Therefore, when children present with periodontal problems, systemic factors should be investigated.
Key points/Summary :
Periodontium
Localized and generalized periodontitis
At least one study says that 6-7% of children approximately age 5 have been shown to have radiographic peridontal bone loss. Treatment is scaling and root planning as well as antibiotics as needed.
Prepubertal Periodontitis
Often associated with systemic diseases. Most successfully treated when localized.
Neutropenias
Neutrophils play a protective role in the periodontium. In their absence, disease and bone loss can occur quickly; ulcers are a common occurrence. Treatment is scrupulous oral hygiene and antibiotic therapy.
Papillon-Leferve Syndrome
Hyperkeratosis on the palms and soles of teeth and premature loss of teeth are common manifestations of this disease. Primary teeth are often lost by age 5. A treatment modality that has shown some promise is the endulate the child, treat heavily with antibiotics and allow later eruption of any unerupted teeth, which can erupt into an oral environment lacking in periodontal bacteria.
Metabolic disorders
Diabetic children may manifest with early periodontal disease due to altered neutrophil chemotaxis
Histiocytosis X
aka Langerhans cell disease. Mostly a radiographic finding of "teeth floating in space" but gingival inflammation is also common.
Hypophosphatasia
Most common oral finding is early loss of teeth, sometimes with primary tooth exfoliation at age 1.5
Soft Tissue
Ankyloglosia
Most children will have some frenum growth with age, but others may need surgical intervention. A speech pathologist should be consulted in any case affecting speech and before any decision for surgery.
Geographic tongue
aka benign migratory glossitis. Asymtomatic and most common in girls.
Fissured tongue
Associated with geographic tongue, also benign.
Retrocuspid Papillae
Present in most children behind the mandibular cuspids. Not anything to worry about.
Gingival Fibromatosis
Can be drug induced, inherited or associated with leukemia. Poor OH exacerbates this problem.
Hemangioma
Benign tumor of mesenchymal origin. Usually painless. Surgical removal is the usual treatment.
Lymphangioma
Benign tumor of lymphatic origin. Usually present at birth. Tongue is the most common site.
Mucocele
Retention of mucous in subepithelial tissues, most common in children and adolescents. Treatment of choice is surgical removal.
Fibroma
One of the most common benign lesions. Treatment is surgical removal with low recurrence.
Parulis
End point of draining sinus tract associated with an abcessed tooth.
Eruption Cyst and Hematoma
see image
Herpesvirus Infection
I think we all know plenty about this
Herpangina
Acute viral infection usually in summer or early fall. Usually has vesicles on tonsillar fauces.
Hand-Foot-and-Mouth Disease
Caused by coxsackie. Ulcerating and crusting vesicles, treatment is palliative only.
Recurrent Apthous Ulceration
Cause is unknown, but suspect food allergies, trauma, stress and hormonal changes. Mouthrinse and topical anesthetics are treatment.
Candidiasis
Treat with topical application of antifungals.
Impetigo
Perioral purulent bacterial infection. Usually due to strep A or Staph aureus; treat with topical or systemic antibiotics.
HIV
Usually children will present with candidiasis. Parotid swelling is also more common in HIV children than adults.
Leukemias
Leukemic gingival enlargement is most common. But mucositis is also common due to chemotherapy associated with leukemia. Poor OH can really worsen the situation.
Traumatic Ulcer
Most common ulcer in children. Often postanesthesia bites.
Assessment of article: Good review, lots of clinical applicability. I wish it had talked about periodontal defects caused by orthodontic problems, like cross bite.
07/16/2009 Condyloma Acuminatum and HPV Infection in the Oral Mucosa of Children
Resident: Jason Hencler
Date: 07/16/2009
Article title: Condyloma Acuminatum and HPV Infection in the Oral Mucosa of Children
Author(s): Liu Lai Kui, PhD; He Zhi Xiu, MD; Li Yi Ning, DDS
Journal: Pediatric Dentistry
Volume #25; Number 2; Page 149,153
Year: 2003
Major topic: Condyloma Acuminatum (CA), HPV
Type of Article: Investigative
Main Purpose:
Investigate the clinicopathological features of oral condylomas in children and condylomatous lesions in their mothers and to determine the mode of transmission as well as the genotype of HPV oral condylomas in children
Overview of method of research:
9 cases of oral CA in children were reviewed clinically and histologically. Mothers of each child accepted histological exam of lesions from the oral cavity or anogenital regions. DNA in-situ hybridization (ISH) was performed with HPV 6,11,and 16/18 probes. Two genital CA were used as positive controls and negative controls consisted of normal oral tissues.
Findings:
Age range of the 9 children with oral CA lesions was 1yr 4mo-6yr and 6 out of 9 of the children were female. Most common location was the palate, with only 2 cases in the commissure. After surgical excision of oral CA only 1 recurred. Seven of nine of the mothers had vulva and/or oral CA during pregnancy. Social evaluation confirmed sexual abuse in 1 girl and probable sexual abuse in another girl. ISH demonstrated HPV 16/18 being positive in 5 out of 9 cases, HPV 6 and 11 for just one case, both HPV 6 and HPV 16/18 for another single case, and one case positive for only HPV 6 and one case being positive for only HPV 11.
Key points in the article discussion:
CA has been reported to occur in the oral cavity but most published instances are in adults. In this study 9 instances of oral CA were found in children in which the lesion appeared at around 3yrs. The most common location of oral CA in children was the palate which differed from adults which are most often located on the lower lip and tongue. Past data indicate that the primary means of transmission in adults is sexual contact with a person infected with HPV. Previous published reports of children with anogenital CA have been authored by clinicians who work with child protection services and have concluded that the majority of children whose lesions appeared after infancy have been sexually abused. So sexual abuse must be considered as a mode of transmission when children present with CA. Perinatal transmission of HPV to infants and toddlers is possible and as most experts agree that HPV lesions seen on the body of a child younger than 1 yr can be the result of vertical transmission from an infected mother. Contrastingly, in this study the lesion had appeared around 3 yrs, so vertical transmission is considered to be unlikely. A surprising finding in this study was that HPV type in CA between same mother and child were different, which suggested that vertical transmission of HPV to the child is rare. This study demonstrates that HPV 16/18 is the most common type found in oral CA in children. Other studies report a high incidence of HPV 6 and 11 in oral CA in adults. This may suggest a lower incidence of these viruses in the oral cavity of children with CA. The one case that recurred was associated with HPV 16/18. Childhood CA caused by low risk HPV 6 and HPV 11 may resolve spontaneously, while chronic HPV infection may be correlated with the high risk types HPV 16/18 that are highly associated with mucosal carcinoma in adults. This suggests that a prolonged follow up is necessary for HPV 16/18 infections in children.
Summary of conclusions:
Most incidences of oral CA in children are caused by HPV 16/18. Sexual abuse is the most common mode of transmission. Prenatal transmission of HPV to children is less common. Genotype, lesion location, and mode of transmission of oral CA in children was different from adults.
Assessment of article:
I thought this was a good article that made some valid points, most importantly, that pediatric dentists should consider sexual abuse as a possibility in a child with oral CA. Different results may have been observed in this study if the sample size was larger although this may not be possible because oral CA in children is not extremely prevalent. More study is needed to investigate the differences in HPV type, location, and mode of transmission between children and those seen in the adult population.
Date: 07/16/2009
Article title: Condyloma Acuminatum and HPV Infection in the Oral Mucosa of Children
Author(s): Liu Lai Kui, PhD; He Zhi Xiu, MD; Li Yi Ning, DDS
Journal: Pediatric Dentistry
Volume #25; Number 2; Page 149,153
Year: 2003
Major topic: Condyloma Acuminatum (CA), HPV
Type of Article: Investigative
Main Purpose:
Investigate the clinicopathological features of oral condylomas in children and condylomatous lesions in their mothers and to determine the mode of transmission as well as the genotype of HPV oral condylomas in children
Overview of method of research:
9 cases of oral CA in children were reviewed clinically and histologically. Mothers of each child accepted histological exam of lesions from the oral cavity or anogenital regions. DNA in-situ hybridization (ISH) was performed with HPV 6,11,and 16/18 probes. Two genital CA were used as positive controls and negative controls consisted of normal oral tissues.
Findings:
Age range of the 9 children with oral CA lesions was 1yr 4mo-6yr and 6 out of 9 of the children were female. Most common location was the palate, with only 2 cases in the commissure. After surgical excision of oral CA only 1 recurred. Seven of nine of the mothers had vulva and/or oral CA during pregnancy. Social evaluation confirmed sexual abuse in 1 girl and probable sexual abuse in another girl. ISH demonstrated HPV 16/18 being positive in 5 out of 9 cases, HPV 6 and 11 for just one case, both HPV 6 and HPV 16/18 for another single case, and one case positive for only HPV 6 and one case being positive for only HPV 11.
Key points in the article discussion:
CA has been reported to occur in the oral cavity but most published instances are in adults. In this study 9 instances of oral CA were found in children in which the lesion appeared at around 3yrs. The most common location of oral CA in children was the palate which differed from adults which are most often located on the lower lip and tongue. Past data indicate that the primary means of transmission in adults is sexual contact with a person infected with HPV. Previous published reports of children with anogenital CA have been authored by clinicians who work with child protection services and have concluded that the majority of children whose lesions appeared after infancy have been sexually abused. So sexual abuse must be considered as a mode of transmission when children present with CA. Perinatal transmission of HPV to infants and toddlers is possible and as most experts agree that HPV lesions seen on the body of a child younger than 1 yr can be the result of vertical transmission from an infected mother. Contrastingly, in this study the lesion had appeared around 3 yrs, so vertical transmission is considered to be unlikely. A surprising finding in this study was that HPV type in CA between same mother and child were different, which suggested that vertical transmission of HPV to the child is rare. This study demonstrates that HPV 16/18 is the most common type found in oral CA in children. Other studies report a high incidence of HPV 6 and 11 in oral CA in adults. This may suggest a lower incidence of these viruses in the oral cavity of children with CA. The one case that recurred was associated with HPV 16/18. Childhood CA caused by low risk HPV 6 and HPV 11 may resolve spontaneously, while chronic HPV infection may be correlated with the high risk types HPV 16/18 that are highly associated with mucosal carcinoma in adults. This suggests that a prolonged follow up is necessary for HPV 16/18 infections in children.
Summary of conclusions:
Most incidences of oral CA in children are caused by HPV 16/18. Sexual abuse is the most common mode of transmission. Prenatal transmission of HPV to children is less common. Genotype, lesion location, and mode of transmission of oral CA in children was different from adults.
Assessment of article:
I thought this was a good article that made some valid points, most importantly, that pediatric dentists should consider sexual abuse as a possibility in a child with oral CA. Different results may have been observed in this study if the sample size was larger although this may not be possible because oral CA in children is not extremely prevalent. More study is needed to investigate the differences in HPV type, location, and mode of transmission between children and those seen in the adult population.
7/17/2009 Peripheral Ossifying Fibroma-a Clinical of 134 Pediatric Cases
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Ray Murphy Date: 7/17/09 Region: St. Joe’s
Article title: Peripheral Ossifying Fibroma-a Clinical of 134 Pediatric Cases
Author(s): Cuisia, E. et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 23:3
Year: 2001
Major topic: Peripheral Ossifying Fibroma(POF)
Minor topic(s): Differential Diagnosis of Soft Tissue Lesions
Type of Article: Clinical Evaluation
Main Purpose: To investigate the clinical features of POF’s in regards to the pediatric population.
Overview of method of research: Detailed clinical and historical information regarding 134 cases of POF’s in children from age 1-19. To evaluate the site occurrence of the POF’s, the maxilla and mandible both divided into three regions, incisor/cuspid, premolar, and molar.
Findings: A peripheral ossifying fibroma is characterized as a gingival nodule, made up of cellular fibroblastic connective tissue, consisting of mineralized products of bone, cementum, or dystrophic calcifications. In the pediatric population, POF’s have a large female predilection.95% of the POF’s were associated with a permanent tooth, or between a primary and permanent tooth. A primary tooth was involved in only 1% of cases(2 cases). The POF presented as a pinkish red, localized, smooth, exophytic lesion with a pedunculated base, ranging from .3cm-3cm in size, with the average being 1.2cm. Ulcers were present in 63% of the lesions. 60% of the lesions were found in the maxilla, with 57% in the incisor region. Etiological factors include local irritation(26%), Orthodontic treatment(7%), Trauma(7%), and unknown/unreported(59%). Only 1% of the cases reported the lesion as being painless. The rest either did not report, or reported no pain(24%). Duration of the lesion varied from two weeks to twenty five months, with two-24months being the norm(79%). Incidence of POF’s peak in the second decade of life, with a decreasing trend in older age groups. Also, there may be a higher incidence of POF’s in the African-American population. Treatment includes excisional biopsy or surgical excision, which should include total excision of the lesion, periosteum, and the affected PDL. Scaling and root planning of adjacent teeth is recommended. Extraction of adjacent teeth is usually not necessary. Of the 134 cases, ten had single recurrences, and one had multiple recurrences. The average time in between lesions was twelve months.
Key points in the article discussion: There were many key points in the article. POF’s have the highest incidence in the second decade of life. A POF in the first decade of life is very uncommon. POF’s are more common in females, and are usually found in the maxillary incisor/cuspid region. Follow up after surgical removal of a POF is highly recommended to monitor for recurrence. The main key point in the article was trying to determine why there is a predilection for POF’s with permanent teeth as opposed to primary teeth. If POF’s are etiologically derived from local irritation and trauma, why are more primary teeth not involved? The constant exfoliation of primary teeth should cause an increased number of POF’s in the pediatric population. The article surmised that there must be other factors must be present that are lacking in the pediatric population. According to this study, the dentist does not need to take radiographs for the differential diagnosis of a POF. This is in contrast to two previous studies. POF’s in children can exhibit large growth rates in short periods of time. Because of this, early diagnosis is important.
Summary of conclusions: A POF is a well defined lesion with various differential diagnosis, including peripheral giant cell granuloma, pyogenic granuloma, fibroma, and peripheral odontogenic fibroma. With regards to the pediatric population, occurrence in children and primary teeth is rare. When present, POF’s are mostly found in female ages 10-20 in the anterior maxilla. While a POF arising from the PDL of a primary tooth, or localized irritation associated with a primary tooth is possible, it is very uncommon. As previously stated, surgical excision or excisional biopsy is the treatment of choice, with close follow up.
Assessment of article: Overall it was a good article. Methods, results, and conclusions were clearly and concisely stated. There could have been more of a focus on figuring out why primary teeth are not affected as much as permanent teeth are. There was numerous differential diagnosis listed, along with the major sites and patient population who are affected by POF’s.
Dental Residency Program
Literature Review Form
Resident: Ray Murphy Date: 7/17/09 Region: St. Joe’s
Article title: Peripheral Ossifying Fibroma-a Clinical of 134 Pediatric Cases
Author(s): Cuisia, E. et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 23:3
Year: 2001
Major topic: Peripheral Ossifying Fibroma(POF)
Minor topic(s): Differential Diagnosis of Soft Tissue Lesions
Type of Article: Clinical Evaluation
Main Purpose: To investigate the clinical features of POF’s in regards to the pediatric population.
Overview of method of research: Detailed clinical and historical information regarding 134 cases of POF’s in children from age 1-19. To evaluate the site occurrence of the POF’s, the maxilla and mandible both divided into three regions, incisor/cuspid, premolar, and molar.
Findings: A peripheral ossifying fibroma is characterized as a gingival nodule, made up of cellular fibroblastic connective tissue, consisting of mineralized products of bone, cementum, or dystrophic calcifications. In the pediatric population, POF’s have a large female predilection.95% of the POF’s were associated with a permanent tooth, or between a primary and permanent tooth. A primary tooth was involved in only 1% of cases(2 cases). The POF presented as a pinkish red, localized, smooth, exophytic lesion with a pedunculated base, ranging from .3cm-3cm in size, with the average being 1.2cm. Ulcers were present in 63% of the lesions. 60% of the lesions were found in the maxilla, with 57% in the incisor region. Etiological factors include local irritation(26%), Orthodontic treatment(7%), Trauma(7%), and unknown/unreported(59%). Only 1% of the cases reported the lesion as being painless. The rest either did not report, or reported no pain(24%). Duration of the lesion varied from two weeks to twenty five months, with two-24months being the norm(79%). Incidence of POF’s peak in the second decade of life, with a decreasing trend in older age groups. Also, there may be a higher incidence of POF’s in the African-American population. Treatment includes excisional biopsy or surgical excision, which should include total excision of the lesion, periosteum, and the affected PDL. Scaling and root planning of adjacent teeth is recommended. Extraction of adjacent teeth is usually not necessary. Of the 134 cases, ten had single recurrences, and one had multiple recurrences. The average time in between lesions was twelve months.
Key points in the article discussion: There were many key points in the article. POF’s have the highest incidence in the second decade of life. A POF in the first decade of life is very uncommon. POF’s are more common in females, and are usually found in the maxillary incisor/cuspid region. Follow up after surgical removal of a POF is highly recommended to monitor for recurrence. The main key point in the article was trying to determine why there is a predilection for POF’s with permanent teeth as opposed to primary teeth. If POF’s are etiologically derived from local irritation and trauma, why are more primary teeth not involved? The constant exfoliation of primary teeth should cause an increased number of POF’s in the pediatric population. The article surmised that there must be other factors must be present that are lacking in the pediatric population. According to this study, the dentist does not need to take radiographs for the differential diagnosis of a POF. This is in contrast to two previous studies. POF’s in children can exhibit large growth rates in short periods of time. Because of this, early diagnosis is important.
Summary of conclusions: A POF is a well defined lesion with various differential diagnosis, including peripheral giant cell granuloma, pyogenic granuloma, fibroma, and peripheral odontogenic fibroma. With regards to the pediatric population, occurrence in children and primary teeth is rare. When present, POF’s are mostly found in female ages 10-20 in the anterior maxilla. While a POF arising from the PDL of a primary tooth, or localized irritation associated with a primary tooth is possible, it is very uncommon. As previously stated, surgical excision or excisional biopsy is the treatment of choice, with close follow up.
Assessment of article: Overall it was a good article. Methods, results, and conclusions were clearly and concisely stated. There could have been more of a focus on figuring out why primary teeth are not affected as much as permanent teeth are. There was numerous differential diagnosis listed, along with the major sites and patient population who are affected by POF’s.
Wednesday, July 15, 2009
LUTHERAN MEDICAL CENTER
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Dan Boboia Date: 7/17/09
Article title: Differential Diagnosis of Oral Enlargements in Children
Author(s): Flaitz et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 17:4
Year: 1995
Type of Article: Review
Main Purpose: To review soft tissue and bony enlargements that typically occur in the oral and perioral region in children
SOFT TISSUE LESIONS:
Papillary enlargements:
- Viral-induced epithelial proliferation resulting in pale, spongy-to-firm enlargements with a pebbly or papillary appearance and rough surface texture; painless with limited growth potential; divided into isolated or multiple lesions; spontaneous resolution or protracted course
Acute Inflammatory Enlargements:
- Characterized by sudden onset, rapid progression, and compressible tissue distension; fluid-filled or edematous lesion, frequently tender to palpation and may fluctuate in size; systemic effects such as fever, malaise, and lymphadenopathy may develop as the lesion progress; divided into infectious and noninfectious processes with localized or diffuse tissue involvement
Reactive Hyperplasia:
-A benign group of lesions that frequently mimic neoplastic disease; most develop in response to a chronic reoccurring injury that stimulates tissue repair; exhibit moderate growth, absence of pain, and limited growth potential; divided into primary or multifactorial causes for initiation and growth; if source of injury is removed partial regression of the lesion may occur
Benign Submucosal Cysts and Neoplasm:
-Nodular, well delineated, and freely movable enlargements with intact mucosal surfaces; slow persistent growth pattern causing alteration of tissues; usually asymptomatic unless traumatized or they impinge on adjacent tissues
Aggressive / Malignant Soft Tissue Enlargement:
-Rapid progressive growth, infiltrative margins are defining features of this group; irregular surface changes with areas of erythema and ulceration; early lesion are asymptomatic but as progression occurs pain, paraesthesia, lymphadenopathy, and obstruction can occur; prognosis depends on lesion size, malignancy, and proximity to vital structures.
BONEY ENLRAGEMENTS OF THE MAXILLA AND MANDIBLE:
-Three categories: inflammatory lesions of the jaw, benign cystic and neoplastic lesions, and aggressive and malignant lesions.
Inflammatory lesions of the jaw:
-Rapid enlargement, pain, erythema, and drainage; cause is usually a mobile or nonvital tooth; poorly defined radiolucent or radiolucent-radiopaque; may also notice widened PDL, lamina dura loss, internal or external resorption of the root.
Benign cystic and neoplastic lesions of the jaws:
-locally expansile but slow growing; delayed tooth eruption and facial asymmetry are notice; well-delineated unilocular or multilocular with cortical plate expansion; radiolucent, radiopaque, or mixed; can be accompanied by blunt root resorption or displacement of anatomic structures
Aggressive and malignant neoplasms of the jaw:
-Diffuse enlargement with moderate growth rate; pain mucosal ulceration, extrusion of teeth, and paresthesia are common complaints; poorly defined radiolucent or mixed lesion with cortical destruction; irregular root-resorption, loss of lamina dura, widening of the PDL space, and appearance of floating tooth.
Assessment of article: Great review; excellent flow charts
Dental Residency Program
Literature Review Form
Resident: Dan Boboia Date: 7/17/09
Article title: Differential Diagnosis of Oral Enlargements in Children
Author(s): Flaitz et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 17:4
Year: 1995
Type of Article: Review
Main Purpose: To review soft tissue and bony enlargements that typically occur in the oral and perioral region in children
SOFT TISSUE LESIONS:
Papillary enlargements:
- Viral-induced epithelial proliferation resulting in pale, spongy-to-firm enlargements with a pebbly or papillary appearance and rough surface texture; painless with limited growth potential; divided into isolated or multiple lesions; spontaneous resolution or protracted course
Acute Inflammatory Enlargements:
- Characterized by sudden onset, rapid progression, and compressible tissue distension; fluid-filled or edematous lesion, frequently tender to palpation and may fluctuate in size; systemic effects such as fever, malaise, and lymphadenopathy may develop as the lesion progress; divided into infectious and noninfectious processes with localized or diffuse tissue involvement
Reactive Hyperplasia:
-A benign group of lesions that frequently mimic neoplastic disease; most develop in response to a chronic reoccurring injury that stimulates tissue repair; exhibit moderate growth, absence of pain, and limited growth potential; divided into primary or multifactorial causes for initiation and growth; if source of injury is removed partial regression of the lesion may occur
Benign Submucosal Cysts and Neoplasm:
-Nodular, well delineated, and freely movable enlargements with intact mucosal surfaces; slow persistent growth pattern causing alteration of tissues; usually asymptomatic unless traumatized or they impinge on adjacent tissues
Aggressive / Malignant Soft Tissue Enlargement:
-Rapid progressive growth, infiltrative margins are defining features of this group; irregular surface changes with areas of erythema and ulceration; early lesion are asymptomatic but as progression occurs pain, paraesthesia, lymphadenopathy, and obstruction can occur; prognosis depends on lesion size, malignancy, and proximity to vital structures.
BONEY ENLRAGEMENTS OF THE MAXILLA AND MANDIBLE:
-Three categories: inflammatory lesions of the jaw, benign cystic and neoplastic lesions, and aggressive and malignant lesions.
Inflammatory lesions of the jaw:
-Rapid enlargement, pain, erythema, and drainage; cause is usually a mobile or nonvital tooth; poorly defined radiolucent or radiolucent-radiopaque; may also notice widened PDL, lamina dura loss, internal or external resorption of the root.
Benign cystic and neoplastic lesions of the jaws:
-locally expansile but slow growing; delayed tooth eruption and facial asymmetry are notice; well-delineated unilocular or multilocular with cortical plate expansion; radiolucent, radiopaque, or mixed; can be accompanied by blunt root resorption or displacement of anatomic structures
Aggressive and malignant neoplasms of the jaw:
-Diffuse enlargement with moderate growth rate; pain mucosal ulceration, extrusion of teeth, and paresthesia are common complaints; poorly defined radiolucent or mixed lesion with cortical destruction; irregular root-resorption, loss of lamina dura, widening of the PDL space, and appearance of floating tooth.
Assessment of article: Great review; excellent flow charts
Tuesday, July 14, 2009
Pemphigus Vulgaris in Adolescence: case report
Department of Pediatric Dentistry
Luthern Medical Center
7/17/2009
Residents Name: Tyler Roberts
Article title: Pemphigus Vulgaris in adolescence: case report
Author: Fabio Ramoa Pires, DDS et al
Journal: Pediatric Dentistry
Volume #, pages: 22: 2, 159-162
Year: September 1999
Major topic: Pemphigus Vulgaris
Type of article: case report
Main purpose: review signs and symptoms of Pemphigus Vulgaris (PV) involving a rare case of adolescence.
Method of research: case review
Key pts and findings:
Pemphigus Vulgaris (PV), an autoimmune disease, is an intraepithelial blistering disease caused by auto antibodies against desmosomal antigens. Recently this antigen was cloned and found to be a member of the cadherin family of molecules.
In fifty percent of patients affected by PV, oral lesions will be the first sign of the disease. At some point ninety percent of patients will manifest these types of symptoms. Other forms of Pemphigus such as foliaceus, erythematosus, and vegetans almost exclusively affect the skin. PV most often affects middle aged adults in their fifties and sixties and tends to predominate in females. However, much like the case report found in this article it can and does show up in adolescents and even children.
This case report presents a 16 year old Brazilian female, diagnosed with PV. The patient reported that 5 months prior to her first visit to the hospital, she noticed painful oral ulcers. These oral lesions were soon followed by erythemetous and coalescent, irregularly shaped ulcers on her back. In addition, bilateral submandibular lymphadenopathy (swelling of the lymph nodes) was present. Her oral lesions were described as atrophic, erosive, desquamative lesions involving buccal mucosa, soft palate, togue, and buccal gingiva. Initially, the patient was started on 40 mg per day of prednisone, this however, was gradually reduced to 5 mg per day. The patient has since been in stable condition with candidiasis as her only side effect to the medication.
Conclusion: Dentist should be aware that oral lesions are frequently the first sign of complaints in patients with Pemphigus Vulgaris. No standard treatment protocol exist in adolescence and children due to its rarity.
Assessment of article: Interesting and insightful
Monday, July 13, 2009
Ewing’s sarcoma of the mandible: Radiographic features with emphasis on magnetic resonance appearance
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Boboia Date: 7/24/09
Article title: Ewing’s sarcoma of the mandible: Radiographic features with emphasis on magnetic resonance appearance
Author(s): Gorospe et al
Journal: Oral Surgery, Oral Medicine, Oral Path., Oral Radio., Endo
Volume #; Number; Page #s): 91: 6, 729-734
Month / Year: June 2001
Major topic: Ewings sarcoma / Imaging using MRI
Minor topic(s):
Type of Article: Case Presentation
Main Purpose: Review the radiologic features of an ES lesion emphasizing its appearance on MRI
Review of the Case: A 12 y/o female presents with facial swelling x 7 days. Once a diagnosis of ES with extension into the surrounding soft tissues was made, a chemotherapy protocol was commenced. Progress was evaluated using MRI after the second round of chemo. Due to progression of the tumor, radiotherapy was added to the treatment. After the 10th chemotherapy cycle the patient underwent an autologous bone marrow transplantation. The patient was discharged 15 days s/p transplantation. A new MRI revealed a decrease in tumor volume. All lab data normalized 40 days after transplantation. Clinical follow-up revealed the patient is alive and symptom free with no evidence of recurrence or distant metastases. Labs were normal 36 months after diagnosis.
Review of ES: : ES was first described in 1921. This lesion is thought to have neuroectodermal origin, exhibiting some histological similarities as these tumors. This is the second most common primary malignant bone tumor in children and adolescents. 80% of cases occur in the first 2 decades of life with a 2:1 male to female ratio. These lesions account for 4-15% of all primary bone tumors and 1% of all malignant tumors in children. 2/3 of all cases appear in the lower skeleton with a predisposition for long bones of the extremities and the pelvis; the involvement of the facial skeleton is very rare (3%). When the facial skeleton is involved, the mandible is the most commonly affected bone. ES is composed of small round cells with oval / round nuclei and scarce clear cytoplasm arranged in sheets. Differential diagnosis should consider osteosarcoma, lymphoma, neuroblastoma, and other neuroectodermal tumors. Swelling in the invoved area and pain are common symptoms for mandibular ES. Traditional treatment includes surgical excision and local irradiation. Recently chemotherapy and radiotherapy have dramatically improved long term survival rates. Surgery is justified only if tumor control and preservation of function are guaranteed. In this case surgery was not done due to the extension of the tumor into the surrounding tissues as well as pulmonary metastases.
Imaging: Plain radiographs are the first tool for determining presence of bone lesions; ES presents as a lytic, permeative, poorly defined lesion. CT scan provides better visualization yet similar information as that obtained from radiographs. It also provides more detailed information regarding the bone marrow extension of the primary tumor. MRI is the gold standard of imaging the extension of the primary tumor (it therefore remains the method of choice for tumor staging) as well as determining the effects of therapy.
Summary of conclusions: MRI is the diagnostic tool of choice in the local staging of ES and is an imaging technique of great value in monitoring the effects of chemotherapy
Assessment of article: Fair review of ES. MRI has routinely been used to stage and follow the progress of ES tumors for some time now (not exactly front page news).
Dental Residency Program
Literature Review Form
Resident: Boboia Date: 7/24/09
Article title: Ewing’s sarcoma of the mandible: Radiographic features with emphasis on magnetic resonance appearance
Author(s): Gorospe et al
Journal: Oral Surgery, Oral Medicine, Oral Path., Oral Radio., Endo
Volume #; Number; Page #s): 91: 6, 729-734
Month / Year: June 2001
Major topic: Ewings sarcoma / Imaging using MRI
Minor topic(s):
Type of Article: Case Presentation
Main Purpose: Review the radiologic features of an ES lesion emphasizing its appearance on MRI
Review of the Case: A 12 y/o female presents with facial swelling x 7 days. Once a diagnosis of ES with extension into the surrounding soft tissues was made, a chemotherapy protocol was commenced. Progress was evaluated using MRI after the second round of chemo. Due to progression of the tumor, radiotherapy was added to the treatment. After the 10th chemotherapy cycle the patient underwent an autologous bone marrow transplantation. The patient was discharged 15 days s/p transplantation. A new MRI revealed a decrease in tumor volume. All lab data normalized 40 days after transplantation. Clinical follow-up revealed the patient is alive and symptom free with no evidence of recurrence or distant metastases. Labs were normal 36 months after diagnosis.
Review of ES: : ES was first described in 1921. This lesion is thought to have neuroectodermal origin, exhibiting some histological similarities as these tumors. This is the second most common primary malignant bone tumor in children and adolescents. 80% of cases occur in the first 2 decades of life with a 2:1 male to female ratio. These lesions account for 4-15% of all primary bone tumors and 1% of all malignant tumors in children. 2/3 of all cases appear in the lower skeleton with a predisposition for long bones of the extremities and the pelvis; the involvement of the facial skeleton is very rare (3%). When the facial skeleton is involved, the mandible is the most commonly affected bone. ES is composed of small round cells with oval / round nuclei and scarce clear cytoplasm arranged in sheets. Differential diagnosis should consider osteosarcoma, lymphoma, neuroblastoma, and other neuroectodermal tumors. Swelling in the invoved area and pain are common symptoms for mandibular ES. Traditional treatment includes surgical excision and local irradiation. Recently chemotherapy and radiotherapy have dramatically improved long term survival rates. Surgery is justified only if tumor control and preservation of function are guaranteed. In this case surgery was not done due to the extension of the tumor into the surrounding tissues as well as pulmonary metastases.
Imaging: Plain radiographs are the first tool for determining presence of bone lesions; ES presents as a lytic, permeative, poorly defined lesion. CT scan provides better visualization yet similar information as that obtained from radiographs. It also provides more detailed information regarding the bone marrow extension of the primary tumor. MRI is the gold standard of imaging the extension of the primary tumor (it therefore remains the method of choice for tumor staging) as well as determining the effects of therapy.
Summary of conclusions: MRI is the diagnostic tool of choice in the local staging of ES and is an imaging technique of great value in monitoring the effects of chemotherapy
Assessment of article: Fair review of ES. MRI has routinely been used to stage and follow the progress of ES tumors for some time now (not exactly front page news).
Friday, July 10, 2009
Recurrent Apthous Stomatitis
Resident’s Name: Brian Schmid Date: 7/17/2009
Article title: Recurrent Apthous Stomatitis
Author(s): Jonathan Ship DMD, Elisa Chavez DDS et al
Journal: Quintessence International
Month, Year: 2000
Major topic: Review of recurrent apthous stomatitis
Type of Article: Review
Findings: RAS is the most common oral mucosal disease in humans with an incidence of 5-25% and much higher in selected populations (50-60% in med/dent students). Minor RAS consists of small (<10mm) painfululcers with a necrotic center and a gray-white pseudomembrane. They typically heal within 10-14 days without scaring and is typically located on nonkeratinized oral mucosa. Major RAS (aka Suttons Disease and periadenitis mucosa necrotica recurrens comprises 10-15% of RAS cases). These lesions are larger than 10mm and often scar. They can also last for months and be a major cause of dysphagia. Major RAS has a predilection for lips, tongue, soft palate and the palatal fauces. It is frequently found in HIV patients. Multiple small clusters of pin point ulcers characterize Herpetiform RAS.
The most common differential for RAS is herpes simplex, which differs from RAS in that the primary form causes fever and erythema and it typically occurs on attached tissue. Varicella Zoster virus can be differentiated by its unilateral patter of following the trigeminal nerve and a prodrom of pain and tingling/burning sensation. Herpangina lesions usually have correlated systemic symptoms like fever and will resolve in 1-2 weeks. Erythema multiforme lesions are accompanied by stargetoid skin lesions and occur on both attached and movable mucosa. Oral lichen planus can resemble RAS but lesions will typically also occur on the gingiva and hard palate, and is often not painful. Systemic lupus erythematosis, Crohns disease, Behcets disease, Reiters syndrome and HIV/AIDS can also present with RAS-like ulcers. While there is no hardline causation of hematological defects with RAS, a significant persentage of patients can be successfully treated with blood elements.
Chronic minor or major RAS can be a concern due to the myriad potential underlying systemic diseases and any chronic RAS patient should be referred for medical workup. Dermatology and internal medicine may be necessary for immunosupressant medications; Otolaryngology for infectious diseases such as pemphigoif and herpangina; GI for IBD and Crohns; Opthamology for Behcets or Reiters disease. Also, allergists, infectious disease and hematology may need to be consulted.
Anti-inflammatory topical gels and ointments are the first line of chemotherapeutic defense. They are most effective when applied early in the outbreak. The topical glucocorticoids of choice is fluocinonide, triamcinolone and clobetasol. These drugs mixed with Orabase can be an effective treatment. 5% amlexanox applied 4 times daily is also an effective and safe treatment. There are also effective topical rinses such as Sucralfate.
Key points/Summary: There are many possible treatments for RAS and even more potential causes. It is essential to cover your medical bases and account for any possible underlying causes.
Assessment of article: A super review of RAS related material.
Article title: Recurrent Apthous Stomatitis
Author(s): Jonathan Ship DMD, Elisa Chavez DDS et al
Journal: Quintessence International
Month, Year: 2000
Major topic: Review of recurrent apthous stomatitis
Type of Article: Review
Findings: RAS is the most common oral mucosal disease in humans with an incidence of 5-25% and much higher in selected populations (50-60% in med/dent students). Minor RAS consists of small (<10mm) painfululcers with a necrotic center and a gray-white pseudomembrane. They typically heal within 10-14 days without scaring and is typically located on nonkeratinized oral mucosa. Major RAS (aka Suttons Disease and periadenitis mucosa necrotica recurrens comprises 10-15% of RAS cases). These lesions are larger than 10mm and often scar. They can also last for months and be a major cause of dysphagia. Major RAS has a predilection for lips, tongue, soft palate and the palatal fauces. It is frequently found in HIV patients. Multiple small clusters of pin point ulcers characterize Herpetiform RAS.
The most common differential for RAS is herpes simplex, which differs from RAS in that the primary form causes fever and erythema and it typically occurs on attached tissue. Varicella Zoster virus can be differentiated by its unilateral patter of following the trigeminal nerve and a prodrom of pain and tingling/burning sensation. Herpangina lesions usually have correlated systemic symptoms like fever and will resolve in 1-2 weeks. Erythema multiforme lesions are accompanied by stargetoid skin lesions and occur on both attached and movable mucosa. Oral lichen planus can resemble RAS but lesions will typically also occur on the gingiva and hard palate, and is often not painful. Systemic lupus erythematosis, Crohns disease, Behcets disease, Reiters syndrome and HIV/AIDS can also present with RAS-like ulcers. While there is no hardline causation of hematological defects with RAS, a significant persentage of patients can be successfully treated with blood elements.
Chronic minor or major RAS can be a concern due to the myriad potential underlying systemic diseases and any chronic RAS patient should be referred for medical workup. Dermatology and internal medicine may be necessary for immunosupressant medications; Otolaryngology for infectious diseases such as pemphigoif and herpangina; GI for IBD and Crohns; Opthamology for Behcets or Reiters disease. Also, allergists, infectious disease and hematology may need to be consulted.
Anti-inflammatory topical gels and ointments are the first line of chemotherapeutic defense. They are most effective when applied early in the outbreak. The topical glucocorticoids of choice is fluocinonide, triamcinolone and clobetasol. These drugs mixed with Orabase can be an effective treatment. 5% amlexanox applied 4 times daily is also an effective and safe treatment. There are also effective topical rinses such as Sucralfate.
Key points/Summary: There are many possible treatments for RAS and even more potential causes. It is essential to cover your medical bases and account for any possible underlying causes.
Assessment of article: A super review of RAS related material.
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