oral medicine & Pathology

Treatment of oral diseases: ( Therapeutic protocols )

Updated on: August 4, 2016

Herpetic Infection

 

Herpes zoster

Valaciclovir, 3 g, daily for 7 days.

– Famciclovir 500 mg, daily for 7 days.

– Aciclovir, 4 g, daily for 7-10 days.

Valaciclovir is the drug of first choice.

In the case of immunocompromised patients who are aciclovir-resistant, foscarnet, 40 mg/kg intravenous every 8 hours for 10 days.

Prednisone 60 mg, daily for 7 days, 30 mg may help, daily for 7 days, and 15 mg, daily for 7 days to relieve pain and oedema in the acute phase, but it does not reduce the incidence of post-herpetic neuralgia.

 

Herpes simplex

 

1. Primary herpetic
gingivostomatitis:

Aciclovir, 1g, daily until lesions clear.

– It is also helpful to follow a light diet with adequate hydration; antipyretics/analgesics
(paracetamol/
acetoaminophen); local antiseptics (rinse with chlorhexidine).

2. Labial and intraoral
recurrent herpes:

Penciclovir cream, 6 daily applications (seems to be more effective than aciclovir against labial herpes).

In immunocompromised people, aciclovir, 1-2 g, daily until the lesions clear
(the
dosage depends on the seriousness of the clinical manifestations and on the immune status).

 

Oral Candidosis

 

1. Angular cheilitis in
immunocompetent patients

Miconazole oral gel, 3 applications daily.

2. Prosthesis-induced
Candidosis

Miconazole oral gel, 3 applications daily.

– Treat the removable prosthesis by applying conditioners and soaking the prosthesis
in a solution of hypochlorite
or nystatin (at least for 1 hour per day).

3. Erythematous or pseudomembranous candidosis in immunocompetent patients

Topical therapy: chlorhexidine in water solution, 3 daily mouthwashes plus miconazole oral gel (or fluconazole in suspension), 3 daily applications.

Systemic therapy: (including angular cheilitis).

4. Hyperplastic candidosis in immunocompetent patients

Topical therapy: as in 3 above, plus surgery.

Fluconazole, 50 mg, daily for 14 days, or 10 mg for 3 days and 50 mg for the following 8 days.

5. Erythematous or pseudomembranous candidosis or angular cheilitis in
immunocompromised patients

Fluconazole, 50 mg, daily for 14 days, or 100 mg for 3 days and 50 mg for the following 8 days.

In case of fluconazole-resistant strains: Itraconazole 200-400 mg, daily; in case of resistance to itraconazole use ketoconazole, 200 mg, daily for 3-5 weeks.

– See the relevant algorithm.

 

Recurrent Aphthous Stomatitis

Exclude possible associated diseases.

 

  1. 1. Minor Aphthae

Reassure the patient and only initiate treatment if requested.

– Chlorhexidine solution or gel, 3 times daily ; if there is no response or only a partial response then use triamcinolone acetonide in adhesive (3-6 daily applications), or fluocinonide (3-6, daily) or clobetasol ointment (2, daily) until ulcers clear.

Before applying topical corticosteroids, dry the area in question then apply the drug without pressing and ask the patient to abstain from speaking and/or eating and drinking for an hour.

2. Major Aphthae

Fluocinonide or clobetasol ointment in adhesive gel (2-3 daily applications).

If the treatment lasts any longer than a week, add an antimycotic agent such as
chlorhexidine
solution (3 days) plus miconazole oral gel (1 day).

If there is no response or if lesions are not treatable topically due to their location, then use prednisone 50 mg, daily until there is a reduction of at least 50% of the lesions and then decrease dose slowly.

3. Herpetiform Aphthae

Prednisone 50 mg, daily for 3 days, 25 mg, daily for 3 days, then 3 tablets every other day until there is a reduction of at least 50% of the lesions.

– See the relevant algorithm.

Algorithm for treatment of recurrent aphthous stomatitis.

 

Erythema Multiforme

 

  1. 1. Oral erythema multiforme

Stop any potential triggering drug.

– Clobetasol ointment in adhesive gel (2 daily) with antifungal prophylaxis until it improves by 50%, then 1 daily until the lesion clears completely.

– Before applying topical corticosteroids, dry the area in question then apply the drug and ask the patient to abstain from speaking and/or eating and drinking for an hour.

In case of widespread oral lesions or lesions not amenable to topical treatment,
use prednisone
50 mg, daily for 3 days, 25 mg, daily for 3 days, and then 3 tablets every other day.

2. Minor erythema multiforme

If related to HSV, aciclovir (1-2 g, daily) until the lesions improve by 50%, then decrease.

If not related to HSV, oral lesions to be treated as in 1.

– Cutaneous lesions, hydroxyzine (50 mg, daily) and topical steroids if required.

3. Major erythema multiforme

(Stevens-Johnson’s syndrome)

 If medication-induced, discontinue the drugs and use prednisone, 50 mg, daily for 3 days; 25 mg, daily for 3 days, then 25 mg every other day until there is a 50% healing of the lesions.

– Then decrease the dosage slowly.

– If the cause is Mycoplasma pneumoniae then use erythromycin (0.5-1 g, daily).

– See the relevant algorithm.

Algorithm for treatment of erythema multiforme (EM).

 

Lichen Planus

 

Begin by treating symptomatic areas (usually atrophic-erosive), after having considered the elimination of potential predisposing factors.

1. Exclusively oral clinical features amenable to topical treatment

Clobetasol ointment in adhesive gel (twice daily) for 2 months, then once daily for another month with antifungal prophylaxis (chlorhexidine plus miconazole).

– Before applying the topical corticosteroid, dry the area in question then apply the drug
without
pressing and ask the patient to abstain from speaking and/or eating and drinking for an hour.

If lesions are gingival, prepare trays for occlusive therapy.

2. Exclusively oral clinical features not amenable to topical treatment or mucous-cutaneous features

Prednisone 50 mg, daily for 3 days, 25 mg, daily for 3 days, then 25 mg every other day until an improvement of 50% of the lesion and then decrease the dosage slowly.

If necessary combine azathioprine (50 mg, daily).

Maintenance with topical treatment as in 1 above.

3. Lack of response to corticosteroids or contraindications for their use

Tacrolimus 0.03% ointment (twice daily).

– See the relevant algorithm.

Algorithm for treatment of lichen planus (LP).

 

Mucous Membrane Pemphigoid

 

1. Exclusively oral clinical features that are amenable to topical treatment

Clobetasol ointment in adhesive gel (twice daily), with antifungal prophylaxis (chlorhexidine plus miconazole) until at least 75% improvement of the lesions, and then slowly decrease the dosage.

Before applying the topical corticosteroids, dry the area in question then apply the drug without pressing and ask the patient to abstain from speaking and/or eating and drinking for an hour.

If lesions are gingival, prepare trays for occlusive therapy.

2. Lack of response, or progressive
disease, or disease not amenable to topical treatment

 Prednisone 50-100 mg, daily (according to the severity of the clinical features) until there is at least a 50% improvement of the lesions, and then decrease the dosage slowly
and combine it with the topical treatment
described in 1 above.

3. Lack of response, or progressive
disease, or disease not amenable to
topical treatment (oral cavity only) and contraindications to the use of systemic steroids

Minocycline 100 mg, daily or dapsone, 25 mg for the first 3 days, then increasing from 25 mg every 3 days to 150 mg (give cimetidine and vitamin E to minimize haemolysis.

In both cases the aim is to obtain an improvement of at least 50% and then to decrease the dosage and to combine with the topical treatment described in 1 above.

4. Disease involving other
mucosae:

As in 2 above, or azathioprine (1-2 mg/kg) daily or cyclophosphamide (0.5-2 mg/kg, daily) if there are ocular lesions, or dapsone (see 3 above for the dosage), or sulfapyridine (1.5-3 g, daily).

– See the relevant algorithm.

Algorithm for treatment of mucous membrane pemphigoid.

 

Pemphigus Vulgaris

 

Pemphigus vulgaris is a disease that can be potentially fatal.

– For this reason, treatment must be given not just according to the clinical features and the immunological data (antiepithelial antibody titres from indirect immunofluorescence or ELISA), but also to possible associated conditions (see Mucous Membrane Pemphigoid, above), where a systemic corticosteroid in high dosage and for a prolonged period might be contraindicated or where the lesions determine the need for adjuvant treatment.

-This section offers general treatment recommendations. It is important to monitor the patient periodically in terms of blood pressure, haematological profile, electrolytes, blood sugar levels, bone density and the possibility of intercurrent infections.

1. Exclusively oral clinical
features amenable to topical treatment

Clobetasol ointment in adhesive gel (2, daily), with antifungal prophylaxis (chlorhexidine plus miconazole) until the lesions have improved by at least 75%, and then slowly decrease the dosage.

Before applying topical corticosteroids, dry the area in question then apply the drug without pressing and ask the patient to abstain from speaking and/or eating and drinking for an hour.

If lesions are gingival, prepare trays for occlusive therapy.

If there is only a partial response or no response at all to the treatment, add dapsone (see Mucous Membrane Pemphigoid above) or systemic tetracycline or move onto treatment with systemic steroids.

2. In the case of widespread oral
involvement and/or involvement of more mucosal or cutaneous areas

Prednisone 50-100 mg, daily, plus azathioprine (1-2 mg/kg) daily, or cyclophosphamide (0.5-2 mg/kg, daily) (based on the seriousness of the clinical features).

– Once positive results have been obtained, increase the steroid slowly and maintain with the second immunosuppressor and topical steroids.

– Mycophenolate mofetil or ciclosporin are alternatives.

See the relevant algorithm.
Algorithm for treatment of pemphigus vulgaris.

 

Oral Keratosis

See the relevant algorithm.Algorithm for treatment of oral keratosis.

 

Burning Mouth Syndrome

See the relevant algorithm.Algorithm for treatment of burning mouth syndrome.

 

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