Konrad Staines

Evaluation of oral ulceration in primary care

This video contains a step by step guide to performing an oral cavity examination Oral ulcers are common, with an estimated point prevalence of 4% in the United States.1 Aphthous ulcers may affect as many as 25% of the population worldwide. Patients with an oral ulcer may present initially to a general practitioner or a dental practitioner. Most ulcers are benign and resolve spontaneously but a small proportion of them are malignant. The incidence and prevalence of oral cancers varies across the world. The five year prevalence of oral cavity cancer in developed countries is 275 373 cases and in less developed countries 464 756 cases.2 Some of the highest incidences are seen in the Indian subcontinent, southern France, and South America. Importantly, the incidence of oral cancer is rising in most populations, particularly in young women. In the United Kingdom, around 2500 cases of oral cavity cancers are seen every year. A community based, cluster randomised intervention trial has shown that early detection of an oral squamous cell malignancy reduces mortality. According to the UK Department of Health’s national referral guidelines for suspected cancer, a generalist may refer an oral ulcer that persists for more than three weeks to a specialist to be seen within two weeks of referral.3 An audit of 1079 such referrals, which showed that only 18% of patients referred had a malignancy, highlighted the difficulties encountered by health care practitioners in differentiating potentially malignant ulcers from benign ones.4 A recent study used a validated theoretical framework to evaluate general medical practitioners’ attitudes towards oral examination and found that lack of confidence, knowledge, and training contributed to difficulties in differentiation.5 The aim of this review is to provide a clinically oriented overview of the common causes of acute oral ulcers and to present …

Oral hairy leukoplakia in a patient on long-term anticonvulsant treatment with lamotrigine.

We describe a case of oral hairy leukoplakia that presented with an atypical appearance in a patient on long-term anticonvulsant treatment with an aromatic antiepileptic, lamotrigine. Recent medical history was also significant for recurrent respiratory tract infections requiring treatment with oral antibiotics. Immunologic investigations revealed inverted CD4/CD8 ratio, mild hypogammaglobulinemia, and poor specific antibody titers. Combined immune deficiency caused by long-term treatment with lamotrigine was suspected after other known factors and conditions (including retroviral infection) leading to acquired immune deficiency were excluded. Withdrawal of lamotrigine resulted in complete resolution of oral hairy leukoplakia. There was no significant improvement in immunoglobulin levels. The effect of lamotrigine and other aromatic antiepileptics on the immune system should be considered in a patient presenting with otherwise unexplained oral hairy leukoplakia.

Three cases of oral syphilis – an overview

Syphilis is an infectious disease caused by the organism Treponema pallidum. There has been a dramatic increase in the number of new cases of syphilis in the UK over the past decade. Intra-oral ulceration is often the only presenting feature of the disease, which then enters a latent period. A missed diagnosis can often lead to serious complications and may result in further spread of the disease. Three cases are discussed in this paper with varying clinical presentations of the disease. Such a significant increase of syphilis and its high infectivity require the dental profession to increase their awareness of sexually infectious diseases and the appropriate dental management.

A Case Of Strawberry Gingivitis

A 67-year-old man presented with a 3-month history of painful and swollen gums. No other symptoms were reported, and the patient was medically fit and well apart from hypertension and gastro-oesophageal reflux. On physical examination of the oral cavity, granular atypical lesions were seen, involving multiple gingival sites (Fig. 1). Routine blood tests were all normal, but anti-neutrophil cytoplasmic antibody (cANCA) was positive, at a titre of 80 U ⁄ mL. Computed tomography of the maxillary and sinonasal regions did not reveal any abnormalities. An incisional biopsy of the gingival tissues on the lower left quadrant was taken.

Treatment of mucous membrane pemphigoid with the combination of mycophenolate mofetil, dapsone, and prednisolone: a case series

Mucous membrane pemphigoid (MMP) is an autoimmune blistering disorder characterized by inflammation, blistering, and scarring and predominantly occurring at mucous membranes. Successful treatment can be challenging, and uncontrolled disease may result in significant morbidity with scarring of the conjunctiva and oropharynx leading to blindness and dysphagia, respectively. We report safe successful treatment of 6 patients with significant MMP-related oral inflammation with the use of a previously unreported combination of mycophenolate mofetil, dapsone, and prednisolone given at relatively low doses. We propose that this combination of treatments should be investigated further.

Is tocilizumab a potential therapeutic option for refractory unicentric Castleman disease

Castleman disease is a rare lymphoproliferative disorder with 2 distinctly defined clinical forms. While multicentric Castleman disease (UCD) poses a potential therapeutic challenge, unicentric variant has historically been considered curable with surgical resection. Hence, little is known to guide management of patients with UCD, refractory to surgical resection and combination chemotherapy. We present a case of a patient, negative for HIV and HHV‐8, who had an unsuccessful surgical intervention and no response to radiotherapy and chemotherapy. He had severe paraneoplastic pemphigus and was treated with tocilizumab, an anti‐interleukin‐6 receptor monoclonal antibody that has demonstrated good response rates in multicentric Castleman disease but demonstrated no clinical response despite 2 months of treatment. Our report is the first to describe a lack of response to tocilizumab in the rare setting of refractory UCD and discuss potential for distinct disease biology.

Oral verruciform xanthoma

Verruciform xanthoma (VX) of the oral cavity is a benign mucosal growth that often presents as a pink, yellow or grey raised plaque or papule with granular, papillary or verrucous surface morphology. Intraorally this often presents on the masticatory mucosa and extraorally often involves the skin and anogenital mucosa. There are several proposed aetiological factors and the clinical features of VX can be misleading; clinically it can resemble malignancy. Histopathological diagnosis is a key for the correct management of this lesion. Excision of this lesion is curative.

Internal carotid artery aneurysm presenting as orofacial pain

OBJECTIVES We report a case of an internal carotid artery aneurysm presenting as orofacial pain. METHOD Case report and discussion. RESULTS A 59-year-old patient presented with a four-year history of chronic oral pain accompanied by a right-sided occipital headache. No local organic pathology was detected, and a provisional diagnosis of persistent idiopathic facial pain was made. A neurosurgery referral was made to exclude neurovascular pathology, which resulted in the detection of an aneurysm originating from the right posterior communicating artery. This was successfully treated by coil embolisation, with subsequent resolution of symptoms. CONCLUSION In this patient, an atypical history of pain with no other neurological signs or symptoms, other than accompanying occipital headache, led to the discovery of an intracranial aneurysm. This case highlights the need for appropriate referral and imaging in cases in which the clinical history and findings are not classical, and also emphasises the need for interdisciplinary management.