Treatment of Oral Diseases. George Laskaris

should choose the treatment with the optimal outcome and reasonable cost.

      •New drugs must be used with caution.

      •Stomatologists and dentists should avoid undertaking the treatment of the systemic diseases presenting with oral manifestations. The treatment of these diseases must be provided by the respective specialists.

      •Topical treatment of oral manifestations of systemic diseases must always be undertaken in collaboration with the patient’s physician.

      •Several serious oral diseases require hospital care.

      •There should be a good rapport or understanding between the physician and the patient—it is important for most therapeutic measures to be effective.

      This must always be in the mind of the physician before making decisions about diagnosis and treatment.

      Part I

      Diseases

      Actinic Cheilitis

      

Definition

      Actinic cheilitis is a relatively common precancerous disorder typically confined to the vermilion zone of the lower lip.

      

Etiology

      Fair-skinned individuals with high occupational or recreational sun exposure are more commonly affected.

      

Main Clinical Features

      •Chronic mild edema and erythema followed by dryness and fine scaling

      •The epithelium becomes progressively thin and atrophic with hyperkeratotic whitish papules or small plaques intermingled with red areas

      •Later the lip becomes very dry and scaly with erosions

      •Risk of development of leukoplakia and squamous cell carcinoma is increased

      

Diagnosis

      The clinical diagnosis should be confirmed by a biopsy and histopathologic examination.

      

Differential Diagnosis

      •Leukoplakia

      •Discoid lupus erythematosus

      •Lichen planus

      •Scleroderma

      •Contact cheilitis

      •Herpes simplex

      •Cheilitis due to radiation

      •Squamous cell carcinoma

      

Treatment

      Basic Guidelines

      •Sun-protective measures should always be recommended.

      •Patients should use lip lubricants containing sunscreens.

      •Before treatment, a biopsy is necessary to determine histologic changes.

      •Periodic follow-up is necessary because of the increased risk of malignant transformation.

      Suggested Therapies

      •Nonsurgical procedures are recommended for patients without epithelial dysplasia or invasive squamous cell carcinoma

      — Topical 5-fluorouracil cream (0.5-5%) may be applied once or twice daily for 2-3 weeks. However, because of local irritation and relatively poor results this treatment is not included in the first-line therapies.

      — Recently, the topical immunomodulator. imiquimod cream 5% (Aldara) has been used successfully for the treatment of actinic cheilitis. The suggested regimen is to apply two or three times weekly for 4-6 weeks. Local adverse reactions such as erythema, edema, and erosions may occur. Systemic adverse effects, e.g., fever, headache, fatigue, diarrhea, and myalgia may occur in 1-2 % of patients.

      — Carbon dioxide (CO₂) laser ablation has also been used for the treatment of actinic cheilitis with excellent results.

      •Surgical treatment is recommended for patients with epithelial dysplasia, carcinoma in situ, or invasive squamous cell carcinoma. Vermilionectomy is the treatment of choice in such cases.

      Alternative Therapies

      Alternative therapies include photodynamic therapy, i.e., application of 5-aminolevulinic acid followed by exposure to a light source, and cryosurgery. Both methods are indicated for patients without premalignant or malignant foci histologically. Radiation therapy has also been used with success.

      

      References

      Dufresne RG, Curlin MU. Actinic cheilitis: A treatment review. Dermatol Surg 1997;3:15–21.

      Ishida CE, Ramos-e-Silva M. Cryosurgery in oral lesions. Int J Dermatol 1998;37:283–285.

      Kaugars CE, Pillion T, Svirsky JA, et al. Actinic cheilitis. A review of 152 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:181–186.

      Picascia DD, Robinson JK. Actinic cheilitis: A review of the etiology, differential diagnosis and treatment. J Am Acad Dermatol 1987, 17:255–264.

      Smith KJ, Germain M, Yeager J, Skclton II. Topical 5% imiquimod for the therapy of actinic cheilitis. J Am Acad Dermorol 2002;47:497–501.

      Vega-Memije ME, Mosqueda-Taylor A, Irigoyen-Camacho ME, et al. Actinic prurigo cheilitis: Clinicopathologic analysis and therapeutic results in 116 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:83–91.

      Zelickson BD, Roenigk RK. Actinic cheilitis. Treatment with the carbon dioxide laser. Cancer 1990;5:1307–1311.

      Actinomycosis

      

Definition

      Actinomycosis is a chronic granulomatous infectious disease.

      

Etiology

      Actinomycosis is caused by the anaerobic Gram-positive bacterium Actinomyces israelii and rarely by other species.

      

Classification

      There are three main clinical types: a) cervicofacial, b) thoracic, and c) abdominal.

      

Main Clinical Features

      Cervicofacial actinomycosis is the most common type (about 50-60% of cases) of the disease and oral lesions form a part of it. The infection typically follows dental infection, tooth extraction, or trauma to the oral mucosa.

      

Oral Manifestations

      •Painless, slow-growing, hard swelling—the classic features of cervicofacial actinomycosis

      •Multiple abscesses draining to the surface by sinus tracts. Yellow purulent material representing colonies of Actinomyces (sulfur granules) may discharge from