A Closer Look at Oral Medicine
Some oral conditions are not routinely encountered in a general practitioner’s daily practice but may cause patients to have pain, prevent them from performing basic dental hygiene tasks, and potentially compromise their oral health. These conditions can have a profound effect on the oral cavity, teeth, or gums and affect patients’ quality of life. Five of these conditions include oral cancer, osteonecrosis of the jaw (ONJ), temporomandibular disorders (TMDs), oral herpes simplex viral infections, and aphthous ulcers (canker sores). Understanding how to prevent, screen for (when appropriate), and treat these oral health conditions—or realizing when a referral to a specialist is the best course of action—helps dentists take a more comprehensive approach to oral health care.
Implementing Oral Cancer Screening
Oral cancer is a potentially life-threatening condition, and approximately 40,000 cases will be diagnosed in the United States in 2013.1 The disease claims about 8,000 lives a year,1 and it has an overall 5-year survival rate of approximately 43%.2 Although these statistics seem grim, if oral cancer is detected during its early stages, the survival rate significantly improves to greater than 90%.2
The success of early detection is why Thomas Sollecito, DMD, FDS, RCSEd, chair of the Department of Oral Medicine at Penn Dental Medicine, believes that screening for oral cancer should be a top priority for dental clinicians. “Early diagnosis equates closely with improved survival,” says Sollecito. “Clinicians should incorporate oral cancer screening into their daily patient care routines.”
Most commonly, a clinician screens for oral cancer by visual inspection and palpation. According to Sollecito, a lesion that has persisted for more than a couple of weeks should be considered suspicious and needs to be accurately diagnosed. In addition to visual and tactile examination, various adjunctive techniques could possibly help to screen for cancerous and precancerous lesions, although more research is needed. Researchers are also investigating various molecular diagnostic techniques that can predict which lesions are likely to grow into cancer.
Although dental practitioners may be the first to diagnose oral cancer, Sollecito recognizes that most dentists do not treat it. He notes that a “cancer care team” approach often yields better outcomes.
Patients who are being treated or have been treated for oral cancer also present unique challenges to the dental office. Common courses of treatment, such as radiation or chemotherapy, can cause significant xerostomia, which makes the patient more prone to yeast infection, dental caries, and periodontal problems. These patients need ongoing care. “If you are dentally treating a patient who has been treated for oral cancer, you will want to coordinate and communicate with the cancer care team, including the surgeon and the radiation oncologist,” says Sollecito.
Patients who are oral cancer survivors also require comprehensive follow-up appointments to manage their health and monitor for recurrence of the oral cancer. “Patients who have had a prior case of oral cancer are at a greater risk of getting it again,” says Sollecito. “These patients require extra surveillance, and any lesions should be biopsied immediately to ensure the cancer has not returned.”
Because the incidence of oral cancer is rising, Sollecito suggests that all dental clinicians consider incorporating screenings into their patient care routine. “Screening for oral cancer is a part of our dental check-ups, and I believe that as screening technology improves, we will see an improvement in early detection and survival rates,” he says.
Monitoring Patients for ONJ
Bisphosphonates, an antiresorptive drug used to treat patients with osteoporosis and metastatic bone cancers, can have a devastating side effect—ONJ. ONJ is defined as an area of exposed bone in the maxillofacial region that does not heal within 8 weeks. In addition to bisphosphonates, denosumab, another antiresorptive medication, has also been associated with ONJ.
Of all ONJ cases, 60% develop after an extraction, implant placement, root canal procedure, or other dentoalveolar surgery.3Although ONJ is rare, patients taking intravenous bisphosphonate therapy appear to be at highest risk, with studies estimating that 1% to 4% of these patients are affected.3 Sunday Akintoye, BDS, DDS, MS, director of the Oral Medicine Research Program at Penn Dental Medicine, says that although it is still unclear why osteonecrosis from antiresorptive medications targets the jawbone specifically, the correlation is extremely clear, and it is something that clinicians should look for in their patients.
For patients taking intravenous bisphosphonates, ONJ can take weeks, months, or even years to appear. Akintoye says this is because the bisphosphonates can remain bound to the patient’s bones for more than 10 years. “In the end, the lingering effects can lead to dead bone tissue in the jaw,” he explains. For this reason, detailed patient medical histories disclosing previous or current use of bisphosphonate or antiresorptive medications are essential.
Patients who have ONJ are more susceptible to a number of oral health issues. Depending on the size and location of the dead bone, the patient may be unaware of its existence. As the size of the area grows, however, it will become more painful. This intraoral pain may affect the patient’s ability to brush and floss, as well as eat and drink comfortably. “Sometimes when bone is exposed, it doesn’t particularly bother the patient. However, if a patient has exposed bone in the mouth, the clinician should definitely take special care in treating that area,” Akintoye says.
When treating ONJ, clinicians should be mindful of the size and severity of the dead bone, as treatment options can vary greatly. “Sometimes the osteonecrosis is mild, which would not require immediate surgical intervention. In this case, the clinician should educate the patient on proper techniques to care for this area in the long term. If the osteonecrosis is severe, the patient will likely have pain, and the surrounding soft tissue may also be infected. These cases require surgery,” explains Akintoye. Severe instances of ONJ can also make the patient prone to jawbone fracture, which would further hinder the patient’s ability to function normally. Akintoye notes that sometimes ONJ can be hidden by healthy soft tissue, and bone only becomes exposed after some sort of trauma. “More severe cases of osteonecrosis have the potential to negatively affect the patient’s quality of life,” says Akintoye.
Akintoye’s research has shown that jawbone stem cells have unique properties. He is currently studying their role in the development of ONJ and notes that researchers are attempting to get a better understanding of why the jaw is prone to this potentially serious complication. For now, following up with patients who have used bisphosphonates is a step that every clinician can take so that ONJ can be identified and treated as early as possible.
TMDs: Advances in Diagnosis
Temporomandibular disorders (TMDs) have an array of root causes, but commonly fall into one of 2 categories—muscle-related or joint-related. TMDs can be extremely painful and can have dire consequences for patients’ overall oral health if not identified and treated properly. Symptoms of TMDs are experienced by up to 75% of individuals in the United States, although only 5% to 10% meet the criteria for diagnosis.4 TMDs are disproportionally common in women.4
TMDs can be so painful because problems with the temporomandibular joints and/or their related muscles lead to imbalance in the coordination of facial movements or chewing. According to Mel Mupparapu, DMD, MDS, Dip. ABOMR, director, Division of Oral and Maxillofacial Radiology at Penn Dental Medicine, patients who suffer from this imbalance find it hard to open and close their mouths normally, which generally leads to a worsening of the condition, as well as a myriad of physical and psychological ailments.
“Patients who have TMDs are unable to open their mouths wide enough for proper oral hygiene care, and often they are often unable to properly clean their teeth because brushing and flossing is just too painful,” he explains. Patients who are unable to brush and floss, especially over a long period of time, are at high risk for caries, gingivitis, and other conditions related to poor oral hygiene. Mupparapu also notes that chronic pain and an inability to perform basic hygiene tasks may leave some patients with TMDs feeling depressed. The task gets even more complicated from a management standpoint if the joints are affected with rheumatoid, psoriatic, or gonococcal arthritis. These conditions require that specialists in oral medicine and orofacial pain coordinate care with the physician and general dentist, if there are dental-related issues. TMDs almost always affect occlusion.
Previously, diagnosis of TMD relied on patient history and a physical examination without the benefit of high-quality, low-dose imaging. Clinicians would also take plain x-ray film or sometimes send patients in for a computed tomography (CT) scan. Mupparapu says that joint imaging, especially with a medical CT, was not done routinely because clinicians were conscious of exposing their patients, and the thyroid gland in particular, to too much radiation. The images from plain films or older technology tomograms were not very accurate, and it was often difficult to evaluate the joint in its entirety.
When cone-beam computed tomography (CBCT) became available to clinicians about 15 years ago, however, it revolutionized the process for diagnosing TMDs. Using technology quite similar to a CT scan, CBCT scans offered a clear choice for clinicians. “CBCT is able to take extremely vivid pictures of the joints and really allows the clinician to visualize the bony parts of the patient’s jaw,” says Mupparapu. “And it takes images with much less radiation than anything we have used in the past to see the patent’s joints.” With more information, clinicians are better able to determine the exact cause of a patient’s TMD and prescribe a better, more efficient course of treatment. Magnetic resonance imaging is a good adjunct technology that often complements CBCT for the diagnosis of TMD.
Treating TMDs can range from pharmacotherapy to managing underlying conditions to surgical options. Mupparapu says that the addition of CBCT to the TMD management process can not only help with diagnosis, but can also help ensure that treatment is done properly, especially when there is surgery involved. “CBCT allows us to make sure we can reconstruct the entire joint, and after the surgery, go back and check that everything is in place and working properly,” he explains.
Mupparapu says that in the future CBCT will continue to play a big part in diagnosing and treating TMDs, and he believes that clinicians will be using it to manage other conditions as well. “It’s an excellent way to deconstruct the patient’s anatomy with low doses of radiation, and will certainly remain an integral part of patient care,” he concludes.
Managing HSV Infections
In addition to causing transient fever blisters or cold sores, oral herpes simplex viral infections may be a chronic, possibly debilitating condition that requires long-term management. Eric Stoopler, DMD, FDS RCSEd, associate professor of Oral Medicine and director of the Postdoctoral Oral Medicine Program at Penn Dental Medicine, says that roughly two thirds of people in the United States have been exposed to herpes simplex virus (HSV), usually at an early age.
Many individuals who have been exposed to HSV do not demonstrate signs and symptoms of active infections. For patients who do present with a primary HSV infection, individuals will initially exhibit classic symptoms, such as fever and tiredness. A few days after development of these symptoms, patients will develop mouth and/or lip lesions. “Whether the lesions are blisters, vesicles, and/or ulcers, which are typically accompanied by inflamed gum tissue, it can be quite painful,” Stoopler says.
If a patient presents with lesions, clinicians may conduct adjunctive studies, including HSV-antibody testing, to determine whether the lesions can be attributed to an HSV infection or another condition. Testing is generally not part of a standard wellness checkup. “A screening test is not typically completed to see if a patient is a carrier for HSV,” says Stoopler. “It is not usually indicated to conduct any additional testing for HSV if the patient is not exhibiting signs and/or symptoms of an infection.”
For most patients, an active HSV infection is inconvenient and uncomfortable, but does not impact their overall oral health. However, a particularly severe infection can affect the patient’s oral health as they may have trouble chewing, swallowing, or speaking due to the pain. These patients may discontinue their oral hygiene routines for the duration of the infection. Stoopler elaborates, “If the mouth is painful, many patients do not want to exacerbate their symptoms by brushing or flossing, which may have important consequences if the patient neglects their oral hygiene for an extended period of time.” Stoopler also mentions that many clinicians will defer dental procedures until HSV lesions have resolved, possibly delaying necessary dental treatment for a patient.
If a patient presents with an active HSV infection, the clinician should be familiar with treatment options, which depend upon whether the patient has a primary or recurrent infection as well as the severity and distribution of the lesions. “For primary infections, patients often use over-the-counter analgesics, such as acetaminophen, and the lesions typically resolve without further interventions. For recurrent episodes of HSV, there are topical and systemic medications available,” explains Stoopler. Systemic antiviral medicines are often more effective than topical agents for patients with recurrent disease.
Stoopler says that is it important for patients to recognize the factors that may trigger development of lesions so they can potentially avoid them. “Prolonged exposure to sunlight, wind, and cold temperatures, as well as high stress and upper respiratory infections, can all act as triggers for an episode of recurrent HSV,” he says. “If the patient is able to identify and avoid known triggers, it can minimize the potential risk of recurrence.”
Currently, active research is focused on gaining a better understanding of the behaviors and mechanisms of the virus and developing better drugs to treat viral-induced disease, Stoopler notes. “The aim,” he says, “is translation of the basic science and clinical research findings to more effective treatments for patients with this condition.”
Treating Canker Sores
phthous ulcers, or canker sores, are common oral health lesions that patients may confuse with cold sores. The difference between canker sores and cold sores, besides their location in the mouth (canker sores occur on cheeks, lips, or tongue), is their etiology.
Most canker sores are single, isolated lesions caused by stress or trauma. Occasionally they may be a manifestation of an underlying systemic health issue. Canker sores may occur several times during year, and unlike herpetic infections, they are not contagious. Typically small, round, flat, and featuring very defined borders, canker sores can be extremely painful. There appears to be a moderated genetic predisposition to the development of these lesions, and up to one third of people with recurring canker sores have family members who experience similar lesions.5
According to Andres Pinto, DMD, MPH, FDS, RCS, chief of Penn Dental Medicine’s Division of Community Oral Health and director of Oral Medicine services, clinicians should be aware if a patient’s issues with canker sores go beyond the occasional lesion. “Canker sores should give clinicians reason for concern if they are large in diameter, last longer than the typical 7 to 10 days, or are constantly appearing rather than a few times a year,” he says. “Any of those reasons could mean the patient has an underlying medical disorder that needs to be addressed.”
Canker sores may be indicative of anemia, autoimmune disorders, inflammatory bowel disease, and celiac disease, among others. When patients present with canker sores on a consistent basis, Pinto believes they should be referred to an oral pathologist or oral medicine specialist to screen for systemic disorders conditions or nutrient deficiencies. “Chronic canker sores should not be downplayed because they may reflect more serious conditions, and patients who have them should be referred to specialists who can help discover if there is an intrinsic cause,” says Pinto.
He states says that there are a number of ways that clinicians can help patients relieve canker sore–related pain, including topical solutions, corticosteroids, and cauterizing the sore. “Cauterization of the ulcer is a relatively common treatment. When the clinician cauterizes the lesion, he or she obliterates nerve endings that are causing the pain. Then the wound heals like normal, but without the intense pain characteristic of the process,” he describes. The clinician may cauterize the sore either surgically or chemically. Pinto notes that this approach is a good option when there is only one lesion, but with multiple lesions it becomes more problematic.
Topical solutions and corticosteroids are less invasive ways to treat canker sores. “Most topical canker sore relief aids come in the form of a thick paste that covers the lesions and protects them from the environment, reducing pain and helping them to heal faster,” explains Pinto. Corticosteroids can be applied topically or injected into the area, and although they help the lesions heal faster, they do not necessarily decrease the patient’s pain.
Pinto says that when patients present with canker sores, the most important consideration for a clinician is to take a careful history of the onset, duration, localization, and symptoms that may accompany the ulcers. “Helping a patient manage their canker sores may involve identifying triggers like stress, food allergies, trauma, or ruling out possible underlying systemic conditions. Treating canker sores isn’t particularly difficult, but identifying the root cause may be,” he says.
Conclusion
The health care environment is shifting, and the definition of primary care is evolving as well. Changes in policy, the aging of the US population, and uncertainty in the economy are all factors that are affecting the delivery of patient care. Today, patients are often seeing their dentists more often than their physicians, and this presents general practitioners with a unique opportunity to play a larger role in patients’ overall health. The time when medical conditions were assessed and addressed exclusively by a physician is over, and dentists, with their accessibility and expertise, are poised to play an increased role in primary care.
References
1. Oral Cancer. National Cancer Institute website. www.cancer.gov/cancertopics/types/oral. Accessed February 15, 2013.
2. The Oral Cancer Foundation. The Oral Cancer Foundation website. https://oralcancerfoundation.org. February 15, 2013. Accessed February 15, 2013.
3. Bisphosphonate-associated jaw osteonecrosis. Mayo Clinic website.
www.mayoclinic.org/medicalprofs/bisphosphonate-associated-jaw-osteonecrosis.html. Accessed February 22, 2013.
4. Gaurdia CF III. Temporomandibular disorders. Medscape Reference website. https://emedicine.medscape.com/article/1143410-overview. January 11, 2012. Accessed February 24, 2013.
5. Mayo Clinic Staff. Canker sore. www.mayoclinic.com/health/canker-sore/DS00354/DSECTION=risk-factors. March 24, 2012. Accessed February 26, 2013.
Acknowledgement
The publishers and staff of Inside Dentistry could not bring the underlying concerns and trends affecting today’s dental practice and the general oral health care profession to the forefront without the insights shared by our knowledgeable interviewees. For their collective generosity of time and perspectives, we share our sincere gratitude.
Sunday Akintoye, BDS, DDS, MS
Director, Oral Medicine Research Program
Penn Dental Medicine
akintoye@dental.upenn.edu
Mel Mupparapu, DMD, MDS, Dip.ABOMR
Director, Division of Oral &Maxillofacial Radiology
Penn Dental Medicine
mmd@dental.upenn.edu
Andres Pinto, DMD, MPH, FDS, RCS
Chief, Division of Community Oral Health
Penn Dental Medicine
apinto@dental.upenn.edu
Thomas Sollecito, DMD, FDS, RCS
Chair and Professor of Oral Medicine
Penn Dental Medicine
tps@pobox.upenn.edu
Eric Stoopler, DMD, FDS, RCSEd
Associate Professor of Oral Medicine
Director, Postdoctoral Oral Medicine Program
Penn Dental Medicine
ets@dental.upenn.edu
