15. Allergies and Immune Mediated Disease_integrated

Case Discussion Of Oral Mucosal Discomfort

Patient Profile and Chief Complaint¹

A 63-year-old male presents with a 12-month history of oral mucosal discomfort and irritation. The symptoms are specifically associated with:

• Consumption of food
• Use of toothpaste

Medical and Social History

• Medical History: Hypertension, currently managed with ramipril.
• Smoking History: Past smoker; quit 8 years ago. Previously smoked 20 cigarettes per day for 35 years.
• Alcohol Consumption: Reports an average of 2-4 alcoholic drinks per week.

Clinical Case Description

Dental History

• Heavily restored dentition.
• Last dental visit was 2 years ago.

Clinical Assessment Activity

Clinical Evaluation Tasks²¹²

1. Identify the pathosis and describe the clinical features.
2. What is the differential diagnosis?
3. What are the relevant clinical investigations?
4. What is the diagnosis?
5. How would you manage this patient?

1. Identify the pathosis and describe the clinical features

• ==Clinical Presentation: The patient presents with oral ulceration and inflammation in the background.==
• ==Key Features:==
  • Lesions are typically bilateral and symmetric.
  • The lesions should feel "nice and soft" upon palpation; any thickness or asymmetry is a red flag.
  • ==Lichenoid Reactions: Can be caused by amalgam restorations or medications (specifically blood pressure medication).==
• ==Differentiation from Leukoedema: Unlike leukoedema, these lesions do not disappear when stretched and exhibit inflammation and ulceration, which are not present in leukoedema.==

2. What is the differential diagnosis

• Oral lichenoid lesions
  • could be the amalgam or medications
  • check for this iwth patch testing first (i.e. suspect amalgam first )
• ==Oral Lichen Planus (OLP): The primary consideration, but must satisfy both clinical and histopathological criteria.==
• ==Lichenoid Lesions:==
  • ==Contact Allergy: Specifically to amalgam restorations.==
  • ==Drug-Induced: Reactions to systemic medications like blood pressure drugs (e.g., the patient’s ramipril).==
• ==Lupus Erythematosus: Can present with similar mucosal lesions; requires investigation if skin lesions or medical history suggest autoimmune disease.==
• ==Pemphigus/Pemphigoid: Considered if the patient is not responding to standard treatment.==
• ==Erythema Multiforme (EM): Some mucosal lesions can resemble EM.==
• ==Dysplasia/Squamous Cell Carcinoma: An ulcer can mimic early mouth cancer; dysplasia can exist even in lesions that look like “textbook” lichen planus.==

3. Clinical investigations

• Biopsy
  • needed to satisfy histopathological criteria
  • ==Rationale: Necessary to confirm diagnosis and rule out dysplasia. You cannot have a diagnosis of OLP if dysplasia is present.==
  • need at least tow for the H&E and one for DIF
  • ==Site Selection: If lesions look identical, one side may suffice. If there is asymmetry or a “thick” feeling upon palpation, multiple sites should be biopsied.==
  • ==Histopathological Features of OLP: Keratinized structure, band-like lymphocytic infiltrate (predominantly mature lymphocytes), and degeneration of the basal epithelial cells.==
• Patch testing for diffrential
  • could send to a dermatologist, some immunologists do it too
  • “Please do patch testing to the Dental Series”
  • ==Indication: Used when lesions do not respond to treatment and a contact allergy (e.g., to amalgam) is suspected.==
  • ==Process: Referral to a dermatologist for a “Dental Series” patch test on the back.==
  • ==Interpretation: A negative result does not 100% rule out allergy due to potential delayed reactions (past 5 days) or local irritant reactions.==
• ==Blood Tests==
  • ==Full Blood Exam (FBE): Routine examination.==
  • ==Nutritional Deficiencies: Iron, B12, and folate studies, as deficiencies increase the risk of oral ulceration and candidosis.==
  • ==Autoimmune Markers: Anti-double stranded DNA and anti-skin antibodies if lupus or pemphigoid is suspected.==
  • ==Systemic Associations:==
    • ==Diabetes: Should be checked as it is a common association.==
    • ==Thyroid Disease: Increased risk/association, though not routinely tested unless indicated by history.==
    • ==Hepatitis: Possible association, but only tested if history suggests it.==

4. What is the diagnosis

• ==The diagnosis is confirmed as Oral Lichen Planus (satisfying clinical and histological criteria) or Lichenoid Reaction (if linked to a specific trigger like amalgam or medication).==

5. How would you manage this patient

• ==Observation vs. Medication==
  • ==Observation: Appropriate for widespread, asymptomatic lesions.==
  • ==Active Treatment: Required if the patient is symptomatic (burning/discomfort) or if there is ulceration (due to the risk of dysplasia/cancer).==
• Corticosteroids
  • be careful as thee can speed up dysplasia in dysplastic sessation
  • Kenalog is the only oral preparation in australia but its mild and hard to use
    • Triamcinolone acetonide (Kenalog in Orabase) is a skin preparation used off-label; difficult to apply to wet mucosa.
  • Therapeutic guidelines recommeneds beclamethasone ointment
    • ointments are hard to apply to wet oral mucosa
    • need to tell patient to dry the area
  • can use corticosteroid mouthwash/mouthspray but its expensive and costs $80 a bottle
    • Dexamethasone mouthwash: Effective but expensive.
    • beclamethasone mouthspray dosage
      • 2 sprays 3 times a day
      • use everyday until discomfort goes away , then add 3 extra days
      • Protocol: Use daily until symptoms resolve, then continue for 2–3 extra days to prevent immediate flare-ups.
• Clue for failure of symptom management - super imposed candida
  • “the topical steroids were working then all of a sudden it started to get worse ”
  • Steroid use increases the risk of fungal infection.
  • In this case, give amphoteracin B for the fungal infect
  • ==Management: Combine steroids with an antifungal (e.g., Fungilin/Amphotericin B lozenges).==
• Mildly symptomatic:
  • can use Difflam
  • Difflam (benzydamine) for mild symptoms to avoid steroid side effects.
• ==Refractory Cases: If no response after one month:==
  1. Check compliance.
  2. Rule out fungal infection.
  3. Consider systemic steroids for severe ulceration.
  4. Investigate lichenoid triggers (replace amalgam restorations one at a time).
• ==Follow-up and Review==
  • ==Initial Review: Within one month of starting medication.==
  • ==Long-term: Lichen planus requires lifelong observation. Frequency ranges from every 3 months to once a year depending on disease activity and symptom control.==

: Original PDF page 1: 15. Allergies and Immune mediated disease case 1, p.1 : Original PDF page 2: 15. Allergies and Immune mediated disease case 1, p.2

Footnotes

1. Original PDF page 1 ↩ ↩²

2. Original PDF page 2 ↩ ↩²