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Medical Management of Some Diseases of the Oral Cavity
Medical Management of Some Diseases of the Oral Cavity LESTER W. BURKET, D.D.S., M.D.*
There are relatively few diseases limited to the oral cavity. These include dental caries, periodontal disease (pyorrhea), acute and chronic periapical abscesses, true diseases of the tongue and ulceronecrotic gingivostomatitis (Vincent's). Under ordinary circumstances these diseases are effectively treated by local instrumentive and therapeutic measures. Systemic therapy is necessary, under certain circumstances, to achieve the desired therapeutic result or to minimize complications such as the relatively common transient bacteremias and at times the associated sequelae of subacute bacterial endocarditis. The oral cavity has a warm, moist environment not unlike that of other similar body areas; however, it is in more intimate relationship to the external environment. The functions of simple swallowing, of eating and of speaking expose the soft oral mucosal tissues and the teeth to a wide range of traumatic, thermal and chemical stimuli not experienced usually by other body cavities. In addition, under usual conditions of health, the oral cavity has a high microbial population composed of many pathogenic forms. These environmental factors modify the symptomatology of the oral manifestations of systemic disorders. Much of the pain associated with oral lesions of local or systemic disease arises as a result of this unique environment, especially the microbial factors, and may not be a characteristic of the disease as manifested in other areas of the body. DENTAL CARIES
The treatment of dental caries in the fully developed and erupted tooth consists of surgical removal of the necrotic tissue and the restoration of the original tooth form by means of suitable filling material. The caries-protective action of fluoride administration during tooth
* Lecturer
in Oral Medicine, Jefferson Medical College; Professor of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
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development has been definitely established. The most convenient method of administration is treatment of the community water supply by appropriate fluoride salts to develop a total fluoride level of approximately 1 part per million (ppm.). This will effect a 50 to 60 per cent reduction in the expected dental caries, provided the water is consumed during the entire formative period of the teeth. When treatment of the water supply is not possible, the dinieal evidenee to date indicates that a comparable caries-preventive effect can be aehieved by individual fluoridation (with N aFI) of the drinking and cooking water to approximately a 1 ppm. level. A similar carie8-protective effect can also be achieved by prescribing NaFI in appropriate dosage8 and forms during the formative period of the teeth. The use of fluorides as dietary supplernents should be under professional supervii:lion. In order to avoid any undesirable dental fluorosis when tablets or other concentrated supplements are employed, it is necessary to know the fluoride level in the drinking water furnished the child. There is some evidence to show that optimal amounts of fluorides are necessary during the fiTi:lt eight years of life only. The following regimen* can be employed: ~
Sodium fluoride tablets, 2.2 mg. Dispense 100 Label: Use according to written directions. CAUTION: Store out of reach of children.
1. Before two years of age. Add one fluoride tablet to each quart of water used for
drinking purposes and for the preparation of formulas and other food. 2. From two to three years of age. Every other day, add one fluoride tablet to an amount of fruit juice or drinking water which the child will consume at one time. 3. After three years of age. Administer one tablet each day in an amount of fruit juice or drinking water which the child will consume at one time.
Prescriptions of fluoride solutions may be used more conveniently in a locality where the drinking water contains a known significant level of fluoride but less than 0.7 ppm. The usefulness of prescribing fluorides to expectant mothers has never been clearly demom;trated. There is a more recent trend to combine vitamins and sodium fluoride in fixed combinations in supplements for infants and very young children. These products are not regarded by the Council on Dental Therapeutics of the American Dental Association as rational combinations because of the difficulties involved in their proper use. The caries-protective effect of fluoride incorporated in the tooth during its formation can be augmented by the use of appropriate fluoridecontaining dentifrices and the topical application of fluoride salts during periodic visits to the dentist for health maintenance care. * Prescribing Supplements of Dietary Fluoride, J.A.D.A. 56: 589-590, 1958.
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PERIODONTAL DISEASES
Periodontal diseases are an extremely important group of oral lesions. They affect the gingival tissues and the adjacent alveolodental periosteum that attaches the teeth to the jaws. Multiple etiologic factors, both systemic and local, are usually operative in any patient. Experience has shown that local etiologic factors are far more common and thus are generally more important than systemic factors. Irritation of the gingival tissues and marginal alveolodental periosteum by calcareous deposits (tartar), malposition of individual teeth, inadequate restorative or prosthetic dentistry or obnoxious habits are the most frequent local etiologic factors. The elimination or partial correction of these local forms of irritation by appropriate dental instrumentive therapy will usually result in temporary improvement or regression of the periodontal disease. A more permanent therapeutic result will, in most instances, require appropriate restorative and prosthetic services and the education of the patient in the necessary daily oral physiotherapy. The microbrial flora which are readily demonstrated in most forms of periodontal disease are a constituent of the oral environment. While these microorganisms, or their products of metabolism, may aggravate the periodontal disorder, they are not of major etiologic significance. Hence, medicaments are of comparatively little value in the treatment of periodontal disease and they are infrequently used by the experienced dental practitioner. A small number of periodontal disorders are believed to develop secondary to deranged systemic states. Undiagnosed or uncontrolled diabetes is one of the more frequent systemic causes of periodontosis. Other nutritional and metabolic diseases, hyperthyroidism, severe anemias and derangements of calcium metabolism are less common causes. Effective treatment of this type of periodontal disease will require cooperative and collaborative therapy by the physician and the dentist. It is essential that the underlying systemic disease be controlled or cured by the physician before local therapeutic measures will be effective and the local disease process will be stabilized.
Systemic Significance of Periodontal Disease Physicians and dentists often do not appreciate the systemic implications and significance of periodontal pathology, especially in patients with certain systemic diseases. The involved periodontal tissues have a copious blood and lymphatic supply and they are constantly exposed to the environment of the oral cavity with the ever-present trauma and dense microbial population. Transient bacteremias can be readily demonstrated following massage of the diseased periodontal tissues and following chewing, especially when the teeth are loose or following local instrumentive procedures performed by the dentist. Whenever soft tissue manipulative
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procedures are employed in the mouth, as for periodontal therapy, the effect of transient bacteremias on the patient must be considered. In the healthy patient, these transient bacteremias are of short duration and probably of little consequence. They are of greater significance, however, in patients with valvular heart disease, diabetes, and rheumatic heart disease. These bacteremias are also of greater importance in patients on corticosteroid therapy and in women during the first and third trimesters of pregnancy. There is evidence that in the diabetic, even when his disease is controlled, the transient bacteremias may be of longer duration. For these reasons, concurrent systemic prophylactic antibiotic therapy should be prescribed by the physician or dentist prior to extractions or oral soft tissue manipulative procedures employed in periodontal therapy. The following dosage regimen can be prescribed. Suggested Treatment Schedules for Prophylactic Antibiotics for Patients Undergoing Dental Manipulations or Oral Surgery* Oral Plus Intramuscular Penicillin For Two Days Before Dental Procedure (optional) 500,000 units of buffered penicillin G or phenoxymethyl penicillin (penicillin V), by mouth four times a day. Day of Dental Procedure 500,000 units of buffered penicillin G or phenoxymethyl penicillin (penicillin V), by mouth four times a day, supplemented by 600,000 units crystalline penicillin LM. one hour before surgical procedure. Two Days Following Dental Procedure 500,000 units of buffered penicillin G or phenoxymethyl penicillin (penicillin V), by mouth four times a day. Oral Penicillin Because of practical considerations some physicians and dentists rely on oral penicillin alone when the full cooperation of the patient is assured. Each oral dose: 500,000 units buffered penicillin G or penicillin V. Oral dosage four times a day two days before dental procedure: (optional), on day of procedure, and two days following. CAUTION: For patients who are sensitive to penicillin, employ erythromycin, 250 mg. by mouth four times a day for adults and older children; for small children, 20 mg. per pound per day in three or four evenly spaced doses, not exceeding 1 gram per day. * From "Prevention of Rheumatic Fever and Bacterial Endocarditis Through Control of Streptococcal Infections," statement, revised 1960, by the Committee on Prevention of the Council on Rheumatic Fever and Congenital Heart Disease of the American Heart Association.
ACUTE AND CHRONIC PERIAPICAL DENTAL ABSCESSES
These lesions also involve the alveolodental periosteum attaching the tooth to the jaws; however, the disease process is localized to the tissues about the tooth apices. These abscesses are usually secondary to microbial
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infections that reach these areas through a carious lesion of the crown of the tooth, with subsequent involvement of the dental pulp (nerve) of the tooth. In most instances these abscesses represent mixed microbial infections, with gram-positive forms predominating. Acute periapical dental abscesses, with extension to and involvement of the adjacent alveolar bone, may necessitate the removal of the tooth and the establishment of drainage by this means. Fortunately, in most instances, adequate drainage can be established by means of an intraoral incision or through the root canal of the tooth. These procedures will permit the retention of the tooth, following appropriate local therapeutic procedures. Systemic antibiotic administration in the usual dosages may be of assistance in controlling the acute infectious process if it has to be extended to the tissues beyond the tooth apex. Amelioration of the acute painful symptoms should not be regarded as an indication of successful treatment. Definitive treatment will require the biomechanical cleansing of the root canal followed by the use of appropriate local medication of the root canals. The space formerly occupied by the dental pulp can then be filled with a number of materials. The response of the tissues about the tooth apex can be followed by serial roentgenograms taken at six-month or appropriate intervals. With this treatment regimen, the tooth may continue to serve for many years as a healthy member of the masticatory apparatus. It is not uncommon for a chronic periapical dental abscess (periapical granuloma) to develop without the patient experiencing any symptoms. This type of lesion is often recognized first on routine dental roentgenograms taken for other purposes. These chronic periapical granulomas (dental granulomas) were once considered to be important systemic foci of infection. These lesions are relatively avascular, they are well protected from trauma by the surrounding alveolar bone, and their microbial population is relatively unimportant pathologically. It is now recognized that the chronic periapical dental granuloma is far less likely to be an important oral focus of infection than the periodontal lesion. Systemic antibiotic and chemotherapeutic measures are not effective in the treatment of the chronic periapical lesion. When small, these lesions can be effectively treated through the root canal as described previously. When the lesions are large, the endodontic (root canal) therapy is usually supplemented by procedures designed to remove the granulomatous tissue and diseased bone through oral surgical procedures (root resection). Teeth treated in this manner also may serve many years as healthy and well functioning members of the masticatory apparatus. DISEASES OF THE TONGUE
The true diseases of the tongue are few in number and of minor pathological significance. They are important from a diagnostic standpoint since
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many of the lesions are considered to be precancerous by the laity and occasionally so by the physician and the dentist. The tongue is the most common oral site of pain of psychogenic origin. The papillary lingual changes on the dorsum of the tongue are sensitive indicators of the general health status of the patient though they are rarely diagnostic for any specific disease. Abnormally Fissured Tongue
This condition is usually developmental in nature but at times a familial history is obtained. It has been demonstrated that under certain conditions of protein deprivation and vitamin B complex deficiency, an abnormally fissured tongue will develop through a splitting of the rete pegs. Appropriate nutritional therapy will prevent further progression of the fissures; however, those already formed will not reunite because of their epithelial lining. Irritation of deep lingual fissures resulting from microbial involvement and decomposition of food debris may give rise to inflammatory changes and painful symptoms. These can be treated by rolling the edges of the tongue downward to open up the fissures. They can be swabbed with a 3 per cent hydrogen peroxide solution or any mild nonirritating antimicrobial agent. A warm sodium bicarbonate mouthwash or an occasional coating of the tongue with milk of magnesia is soothing. Benign Migratory Glossitis (BMG)
This common condition was formerly known as geographic tongue or scrotal tongue. The inflamed margins of the ever-changing depapillated areas of the dorsum of the tongue may give rise to painful symptoms when highly seasoned or acid foods or irritating beverages are consumed. Smoking may also aggravate the painful symptoms. Patients having BMG commonly develop a fear of cancer because of the chronic recurrent nature of this disease and its lack of response to any form of therapy. Local palliative treatment consists of the use of a mild alkaline mouthwash such as sodium bicarbonate solution, restriction of irritating agents and repeated assurance that the condition is benign and that its continued presence does not predispose to malignancy. There is some evidence that BMG may be associated in some patients with achlorhydria. Persistent, painful lesions of BMG may justify requesting suitable laboratory procedures to determine whether achlorhydria is present. Supplemental HCI or glutamic acid HCI administration may ameliorate the painful lingual symptoms. Atrophy of the Tongue Coating
The amount of tongue coating varies significantly at different periods of life and at different periods of the day. A wide variety of systemic conditions may be associated with similarly appearing atrophic lingual changes.
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When there are associated inflammatory responses, nutritional deficiencies of the B complex type or pernicious anemia are more likely diagnostic possibilities. When the tongue is pale, iron deficiency anemias or some circulatory disturbance should be suspected. Atrophic lingual changes are commonly found in sprue and the anemias associated with parasitic infections. Atrophic glossitis is also a characteristic feature of the Plummer-Vinson syndrome. Patients having marked atrophy of the tongue coating should be carefully studied for an underlying systemic disease, which is almost always present. Iron deficiency anemia is one of the most frequent causes of atrophy of the tongue coating. It usually responds to prolonged administration of ferrous sulfate. ACUTE NECROTIC ULCERATIVE GINGIVOSTOMATITIS (VINCENT'S GINGIVOSTOMATITIS)
In acute necrotic ulcerative gingivostomatitis (ANUG) the fusospiroehetal organisms are observed in overwhelming numbers in the clinical lesion. Local and systemic factors may predispose to the development of the typical acute necrotizing lesions of the marginal gingiva and the interdental tissues. Punched-out ulcerative areas may develop on the palate, the cheek and occasionally on the tongue in association with ANUG. This condition is rare in the edentulous patient. Local irritation secondary to poor oral hygiene, occlusal traumatism and inadequate restorative services are the most common etiologic factors. Systemic predisposing causes such as leukemia or malignant neutropenia, acute B complex deficiency and diabetes must always be considered when a diagnosis of primary ANUG is being considered. The diagnosis of ANUG presents no unusual problems since the rapidly developing, painful, punched-out ulcerations involving the marginal gingiva and the interdental tissues are characteristic. A metallic od or usually accompanies these clinical symptoms and it is an important diagnostic finding. If there are prominent associated constitutional symptoms, a primary blood dyscrasia, nutritional deficiency or metabolic disturbance should be suspected. The treatment of primary ANUG is the responsibility of the dentist. Topical antimicrobial agents are used initially to control the acute bacterial phase of this disease. The elimination of local predisposing factors and patient education in the desired oral hygiene habits are phases of treatment which are essential for the effective control of this disease. Intramuscular or oral penicillin therapy in usual dosages may be indicated as an emergency measure for the relief of pain when local treatment by the dentist is not availahle. Systemic antibiotic therapy or local treatment by mouthwashes may result in amelioration of the painful
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symptoms but will not effectively control or cure this condition. Systemic antibiotic therapy should always be followed by local dental instrumentive treatment and patient education in the desired oral hygiene regimen at home. More Serious Fusospirochetal Infections
VINCENT'S ANGINA. This condition is frequently confused with the less serious lesions of ANUG. A critical analysis is required in making a correct diagnosis since Vincent's angina may exist in the absence of gingival lesions. When there are acute, painful, punched-out ulcerations of the soft palate and pharynx, malignant neutropenia, leukemia, unrecognized or uncontrolled diabetes, carcinoma and diphtheria should be ruled out before a diagnosis of primary Vincent's angina is made. NOMA. Noma is a rapidly spreading gangrenous condition of the mucocutaneous orifices and tissues. The oral cavity is the most common site of involvement. Noma of the oral cavity is usually called cancrum oris. The gangrenous lesions characteristically begin on the mucosal surface and frequently are not recognized until the cutaneous tissues are involved. Most clinicians consider cancrum oris as a particularly rampant and virulent type of fusospirochetal infection. This condition occurs chiefly in infants and the elderly, in whom malnutrition or circulatory inadequacies are important predisposing factors. The treatment of Vincent's angina or cancrum oris is the responsibility of the physician. Penicillin therapy consisting of 600,000 to 1,200,000 units per day by the intramuscular or oral routes of administration should be employed for adult patients. This dosage schedule can be adjusted for infants; however, at least 300,000 units of penicillin per day should be administered to these patients. This systemic therapy can be supplemented by the use of topical antimicrobial agents. These are effective for the relief of pain and the control of the more superficially placed microorganisms even when parenteral therapy is employed. ORAL MANIFESTATIONS OF SYSTEMIC DISEASES
Other lesions of the mouth structures can be regarded as oral manifestations of systemic disease. These can be grouped into oral lesions of (1) the nutritional, metabolic and endocrine disorders, (2) dermatologic disorders, (3) diseases of the blood-forming tissues, (4) the chronic infectious granulomas and (5) allergic reactions. Less frequently bony abnormalities appearing in the jaws may be the first clinical evidence of diseases of the osseous structures or, at times, metastases from tumors arising in remote areas of the body. Space does not permit a discussion of the medical management of oral lesions occurring in all of the preceding systemic disorders. The oral mani-
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festations and the medical management of a few of the dermatologic diseases will be presented. It is not surprising that the oral mucosal tissues are involved in most dermatological disorders, considering the common embryologic origin of the skin and the oral mucosa. The clinical appearance and the associated symptomatology of the oral mucosal lesions vary considerably from those of the skin because of the unique environment of the oral cavity. The mild discomfort, or at times pain, that is a feature of the dermatologic lesions on the skin is usually accentuated in their oral mucosal counterparts because of secondary microbial involvement by the oral flora. For this reason, local antimicrobial agents are usually employed for symptomatic relief of the pain associated with the oral mucosal lesions irrespective of the etiologic nature of the dermal eruption.
Herpetic Diseases of the Mouth Primary and recurrent herpetic infections of the lips and mouth are a common and annoying condition. The viral etiology of these lesions has been definitely established, both by culturing the virus from the local lesion and by following the antibody level of the blood serum following the initial herpetic infection. These herpetic manifestations must be considered separately from the recurrent aphthous eruptions, whose etiology has not yet been clearly established. The herpes simplex virus is readily transmitted by means of salivary droplets, contaminated fingers, or instruments. Herpetic eruptions are usually preceded by premonitory symptoms of burning and itching and a feeling of fullness. The mucocutaneous junction of the lips or nares is the most common location of these vesicular lesions. Intraoral herpetic lesions, in the absence of eruptions at the mucocutaneous border, are very common. The classic herpetic vesicle on the lips is of short duration and those in the oral cavity are extremely transitory. They have usually developed into crateriform ulcerations with regular margins and grayish-yellow pseudomembranous bases by the time the patient seeks professional advice. There is an inflammatory halo about the oral lesion. A diffuse hyperemia and edema of the gingival tissues may accompany the initial herpetic eruptions in children. These gingival changes can be readily differentiated from ANUG by the absence of ulceronecrotic changes of the marginal gingiva and the interdental papillae. The individual herpetic lesion usually disappears within 12 to 14 days, with or without treatment. Treatment is usually directed to supportive and symptomatic measures. Local-acting anesthetic agents, such as dyclonine hydrochloride 0.5 per cent, are effective for relief of pain. General supportive treatment consists of therapeutic amounts of vitamin B complex and vitamin C. The herpes simplex virus is unaffected by antibiotics; consequently, these agents are not indicated. They do not shorten the duration of the lesions. Corticosteroid medications are specifically contraindicated, for their use may result in the development of a generalized herpetic infection.
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A wide variety of therapeutic agents have been employed for the prevention if not suppression of the recurrent herpetic eruptions. None have proved to be uniformly effective. Multiple smallpox vaccinations have been reported to reduce the frequency of recurrences in patients susceptible to continual labial vesicle formation. Preparations containing the Lactobacillus have not been generally effective. ID U (idoxuridine, 5-iodo-2'deoxyuridine) has been suggested for the treatment of recurrent herpes labialis because of a possible viricidal action. There is no definite evidence whether IDU acts as a specific antiviral agent or as a nonspecific eell poison. It should again be emphasized that corticosteroid preparations, both topical and parenteral, are definitely contraindicated in the treatment of herpes simplex manifestations. More effective general therapeutie measures must await the development of specific antiviral agents exhibiting the necessary criteria for effc~ tive prophylaxis or treatment for this disease. Herpes Zoster
Current evidence suggests that herpes zoster is usually eaused by a virus, and perhaps one closely related to the virus causing chickenpox. Herpes zoster may involve one or more branches of the fifth cranial nerve. The oral lesions appear identical with those of herpes simplex. The anterior portion of the tongue, the soft palate and the cheek mucosa are the most frequent sites of intraoral lesions. The dermal lesions, found on the areas supplied by the respective segments of the fifth nerve, are similar in appearanee to those eharaeteristic of herpes zoster eruptions in the thoracic areas. These manifestations are usually unilateral. The treatment of this disease is the responsibility of the physician. Topieal anesthetie agents are of only slight value sinee most of the painful burning sensation associated with the intra oral lesions is caused by irritation of the nerve ganglion. Cortisone in a dosage regimen of 100 mg. per day in divided doses has been shown to prevent the annoying postherpetie neuralgia usually experienced by these patients for many weeks after the clinical lesion has disappeared. Prednisone and immune globulin in a series of five injections of 20 ml. each have also been used with reportedly favorable results. High vitamin B complex and vitamin C supportive therapy should also be employed. Erythema Multiforme
This systemic dermatosis is of considerable interest to the dentist because of the severity of the oral lesions in more than 85 per cent of the patients. Frequent limitation to the oral tissues often presents diagnostic problems to dentists and physicians. While the etiology of erythema multiforme has not been clearly established, a virus is suspected. At onset, the oral lesions are vesicular but because of the unique oral environment they are rarely seen in this form. These eruptions are usually
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found on the lips, the cheeks, the palate and the tongue but infrequently on the gingiva. They consist of irregular, reddish, raised areas of varying size. They are larger and have a more extensive distribution than the recurrent aphthous or intraoral herpetic eruptions. Thc lesions appearing; on the vermilion border of the lips characteristically have a bloody, crusted appearance. The oral lesions of erythema multi forme must be differentiated from those associated with drug eruptions and the oral manifestations of pemphigus vulgaris. The treatment of the oral lesions of erythema multiforme is both local and systemic. A bland sodium bicarbonate mouthwash is soothing and tends to cut the mucous film that collects as the result of the inability of the patient to carry out the usual oral hygiene. Anesthetic troches are effective in relieving; the aente painful symptoms and thus permitting the maintenance of adequate nourishment. The systemic treatment of this disease is the responsibility of the physician. It consists of ACTH or cortisone medication. Patients who do not reflpond to ACTH may respond to cortisone. One ACTH therapeutie regimen usually employed for adults consists of 25 mg. intramu:,;cularly every 6 hours for 24 hours and then 25 mg. every 8 hours until a favorable result is obtained. The cortisone dosage usually employed consistfl of 100 mg. every 12 hour:,; for the first 24 hours, then 100 mg. a day. In some patients the administration of corticosteroid preparations is followed by prompt relief of the acute symptoms; in others there is no response. This form of treatment is not curative in the true sen:,;e. It acts by suppressing the acute inflammatory reaction and thus affording the patient considerable relief from the painful symptoms. The preceding dosage regimen should be appropriately adjusted or reduced for children. The maintenance of adequate nutrition and hydration is an important and difficult phase of treatment in infants and children. Parenteral feeding; may be required for these patients.
Pemphigus Pemphigus is a relatively uncommon dermatosis of unknown etiology. This disease i:,; characterized by the formation of excessive crops of bullae or large vesicles. The high incidence of initial lesions on the oral mucosa and the frequent limitation of the bullae to these tissues make this an important disease for the dentist. The early bullous oral mucosal lesions may go unrecognized because of their transitory nature. Well-demarcated eroded areas, whose margins exhibit epithelial tags or remnants, should suggest the possible diagnosis of pemphigus, especially if the disease is of long standing and is accompanied by physical deterioration. The oral lesions associated with pemphigus are painless during; their development and until the mucosa covering the bullae becomes macerated or broken. The base of the bullae now becomes exposed to the environment of the oral cavity, especially the microbial flora. resulting in the acute pain
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which is a characteristic of the oral lesions. Profuse salivation is also a typical finding. The oral lesions of pemphigus are usually found on the lips, the cheeks and the tongue and less commonly on the palate and the gingivae. Oral pemphigus must be differentiated from other generalized bullous eruptions such as dermatitis herpetiformis, erythema multiforme, drug eruptions and benign familial pemphigoid. The presence of bullous lesions in all stages of formation and resolution is a characterisic finding in pemphigus. Biopsy study may be required to establish a diagnosis. The treatment of the oral lesions in pemphigus is the responsibility of the physician. Good oral hygiene should be maintained to lessen the discomfort and pain. A mildly alkaline mouthwash, such as a sodium bicarbonate solution, can be employed for this purpose. When severe pain is experienced, topical anesthetic agents, as recommended for the symptomatic treatment of erythema multiforme, may be prescribed, especially before eating. This will permit the maintenance of adequate nutrition. Prompt and adequate therapy with one of the corticosteroid preparations may not only save the life of the patient but may also prevent or minimize the distressing physiologic and possible toxic side reactions of prolonged therapy with this class of therapeutic agents. The dosage regimen recommended for erythema multiforme can be employed. Some patients respond better to ACTH and others to cortisone or one of the derivatives of cortisone. Some patients fail to respond to any form of corticosteroid therapy and succumb in spite of any form of treatment. Pemphigus lesions of the oral mucosa tend to be more resistant to treatment than those of the skin, probably because of the environment of the oral cavity. The treatment of pemphigus with the corticosteroid drugs is not curative but only suppressive. Consequently these therapeutic agents may be required in high dosages for two or three years, barring complications associated with this form of therapy, until the pemphigus has been "burned out." 4001 Spruce Street Philadelphia, Pennsylvania 19104
There are relatively few diseases limited to the oral cavity. These include dental caries, periodontal disease (pyorrhea), acute and chronic periapical abscesses, true diseases of the tongue and ulceronecrotic gingivostomatitis (Vincent's). Under ordinary circumstances these diseases are effectively treated by local instrumentive and therapeutic measures. Systemic therapy is necessary, under certain circumstances, to achieve the desired therapeutic result or to minimize complications such as the relatively common transient bacteremias and at times the associated sequelae of subacute bacterial endocarditis. The oral cavity has a warm, moist environment not unlike that of other similar body areas; however, it is in more intimate relationship to the external environment. The functions of simple swallowing, of eating and of speaking expose the soft oral mucosal tissues and the teeth to a wide range of traumatic, thermal and chemical stimuli not experienced usually by other body cavities. In addition, under usual conditions of health, the oral cavity has a high microbial population composed of many pathogenic forms. These environmental factors modify the symptomatology of the oral manifestations of systemic disorders. Much of the pain associated with oral lesions of local or systemic disease arises as a result of this unique environment, especially the microbial factors, and may not be a characteristic of the disease as manifested in other areas of the body. DENTAL CARIES
The treatment of dental caries in the fully developed and erupted tooth consists of surgical removal of the necrotic tissue and the restoration of the original tooth form by means of suitable filling material. The caries-protective action of fluoride administration during tooth
* Lecturer
in Oral Medicine, Jefferson Medical College; Professor of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
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development has been definitely established. The most convenient method of administration is treatment of the community water supply by appropriate fluoride salts to develop a total fluoride level of approximately 1 part per million (ppm.). This will effect a 50 to 60 per cent reduction in the expected dental caries, provided the water is consumed during the entire formative period of the teeth. When treatment of the water supply is not possible, the dinieal evidenee to date indicates that a comparable caries-preventive effect can be aehieved by individual fluoridation (with N aFI) of the drinking and cooking water to approximately a 1 ppm. level. A similar carie8-protective effect can also be achieved by prescribing NaFI in appropriate dosage8 and forms during the formative period of the teeth. The use of fluorides as dietary supplernents should be under professional supervii:lion. In order to avoid any undesirable dental fluorosis when tablets or other concentrated supplements are employed, it is necessary to know the fluoride level in the drinking water furnished the child. There is some evidence to show that optimal amounts of fluorides are necessary during the fiTi:lt eight years of life only. The following regimen* can be employed: ~
Sodium fluoride tablets, 2.2 mg. Dispense 100 Label: Use according to written directions. CAUTION: Store out of reach of children.
1. Before two years of age. Add one fluoride tablet to each quart of water used for
drinking purposes and for the preparation of formulas and other food. 2. From two to three years of age. Every other day, add one fluoride tablet to an amount of fruit juice or drinking water which the child will consume at one time. 3. After three years of age. Administer one tablet each day in an amount of fruit juice or drinking water which the child will consume at one time.
Prescriptions of fluoride solutions may be used more conveniently in a locality where the drinking water contains a known significant level of fluoride but less than 0.7 ppm. The usefulness of prescribing fluorides to expectant mothers has never been clearly demom;trated. There is a more recent trend to combine vitamins and sodium fluoride in fixed combinations in supplements for infants and very young children. These products are not regarded by the Council on Dental Therapeutics of the American Dental Association as rational combinations because of the difficulties involved in their proper use. The caries-protective effect of fluoride incorporated in the tooth during its formation can be augmented by the use of appropriate fluoridecontaining dentifrices and the topical application of fluoride salts during periodic visits to the dentist for health maintenance care. * Prescribing Supplements of Dietary Fluoride, J.A.D.A. 56: 589-590, 1958.
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PERIODONTAL DISEASES
Periodontal diseases are an extremely important group of oral lesions. They affect the gingival tissues and the adjacent alveolodental periosteum that attaches the teeth to the jaws. Multiple etiologic factors, both systemic and local, are usually operative in any patient. Experience has shown that local etiologic factors are far more common and thus are generally more important than systemic factors. Irritation of the gingival tissues and marginal alveolodental periosteum by calcareous deposits (tartar), malposition of individual teeth, inadequate restorative or prosthetic dentistry or obnoxious habits are the most frequent local etiologic factors. The elimination or partial correction of these local forms of irritation by appropriate dental instrumentive therapy will usually result in temporary improvement or regression of the periodontal disease. A more permanent therapeutic result will, in most instances, require appropriate restorative and prosthetic services and the education of the patient in the necessary daily oral physiotherapy. The microbrial flora which are readily demonstrated in most forms of periodontal disease are a constituent of the oral environment. While these microorganisms, or their products of metabolism, may aggravate the periodontal disorder, they are not of major etiologic significance. Hence, medicaments are of comparatively little value in the treatment of periodontal disease and they are infrequently used by the experienced dental practitioner. A small number of periodontal disorders are believed to develop secondary to deranged systemic states. Undiagnosed or uncontrolled diabetes is one of the more frequent systemic causes of periodontosis. Other nutritional and metabolic diseases, hyperthyroidism, severe anemias and derangements of calcium metabolism are less common causes. Effective treatment of this type of periodontal disease will require cooperative and collaborative therapy by the physician and the dentist. It is essential that the underlying systemic disease be controlled or cured by the physician before local therapeutic measures will be effective and the local disease process will be stabilized.
Systemic Significance of Periodontal Disease Physicians and dentists often do not appreciate the systemic implications and significance of periodontal pathology, especially in patients with certain systemic diseases. The involved periodontal tissues have a copious blood and lymphatic supply and they are constantly exposed to the environment of the oral cavity with the ever-present trauma and dense microbial population. Transient bacteremias can be readily demonstrated following massage of the diseased periodontal tissues and following chewing, especially when the teeth are loose or following local instrumentive procedures performed by the dentist. Whenever soft tissue manipulative
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procedures are employed in the mouth, as for periodontal therapy, the effect of transient bacteremias on the patient must be considered. In the healthy patient, these transient bacteremias are of short duration and probably of little consequence. They are of greater significance, however, in patients with valvular heart disease, diabetes, and rheumatic heart disease. These bacteremias are also of greater importance in patients on corticosteroid therapy and in women during the first and third trimesters of pregnancy. There is evidence that in the diabetic, even when his disease is controlled, the transient bacteremias may be of longer duration. For these reasons, concurrent systemic prophylactic antibiotic therapy should be prescribed by the physician or dentist prior to extractions or oral soft tissue manipulative procedures employed in periodontal therapy. The following dosage regimen can be prescribed. Suggested Treatment Schedules for Prophylactic Antibiotics for Patients Undergoing Dental Manipulations or Oral Surgery* Oral Plus Intramuscular Penicillin For Two Days Before Dental Procedure (optional) 500,000 units of buffered penicillin G or phenoxymethyl penicillin (penicillin V), by mouth four times a day. Day of Dental Procedure 500,000 units of buffered penicillin G or phenoxymethyl penicillin (penicillin V), by mouth four times a day, supplemented by 600,000 units crystalline penicillin LM. one hour before surgical procedure. Two Days Following Dental Procedure 500,000 units of buffered penicillin G or phenoxymethyl penicillin (penicillin V), by mouth four times a day. Oral Penicillin Because of practical considerations some physicians and dentists rely on oral penicillin alone when the full cooperation of the patient is assured. Each oral dose: 500,000 units buffered penicillin G or penicillin V. Oral dosage four times a day two days before dental procedure: (optional), on day of procedure, and two days following. CAUTION: For patients who are sensitive to penicillin, employ erythromycin, 250 mg. by mouth four times a day for adults and older children; for small children, 20 mg. per pound per day in three or four evenly spaced doses, not exceeding 1 gram per day. * From "Prevention of Rheumatic Fever and Bacterial Endocarditis Through Control of Streptococcal Infections," statement, revised 1960, by the Committee on Prevention of the Council on Rheumatic Fever and Congenital Heart Disease of the American Heart Association.
ACUTE AND CHRONIC PERIAPICAL DENTAL ABSCESSES
These lesions also involve the alveolodental periosteum attaching the tooth to the jaws; however, the disease process is localized to the tissues about the tooth apices. These abscesses are usually secondary to microbial
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infections that reach these areas through a carious lesion of the crown of the tooth, with subsequent involvement of the dental pulp (nerve) of the tooth. In most instances these abscesses represent mixed microbial infections, with gram-positive forms predominating. Acute periapical dental abscesses, with extension to and involvement of the adjacent alveolar bone, may necessitate the removal of the tooth and the establishment of drainage by this means. Fortunately, in most instances, adequate drainage can be established by means of an intraoral incision or through the root canal of the tooth. These procedures will permit the retention of the tooth, following appropriate local therapeutic procedures. Systemic antibiotic administration in the usual dosages may be of assistance in controlling the acute infectious process if it has to be extended to the tissues beyond the tooth apex. Amelioration of the acute painful symptoms should not be regarded as an indication of successful treatment. Definitive treatment will require the biomechanical cleansing of the root canal followed by the use of appropriate local medication of the root canals. The space formerly occupied by the dental pulp can then be filled with a number of materials. The response of the tissues about the tooth apex can be followed by serial roentgenograms taken at six-month or appropriate intervals. With this treatment regimen, the tooth may continue to serve for many years as a healthy member of the masticatory apparatus. It is not uncommon for a chronic periapical dental abscess (periapical granuloma) to develop without the patient experiencing any symptoms. This type of lesion is often recognized first on routine dental roentgenograms taken for other purposes. These chronic periapical granulomas (dental granulomas) were once considered to be important systemic foci of infection. These lesions are relatively avascular, they are well protected from trauma by the surrounding alveolar bone, and their microbial population is relatively unimportant pathologically. It is now recognized that the chronic periapical dental granuloma is far less likely to be an important oral focus of infection than the periodontal lesion. Systemic antibiotic and chemotherapeutic measures are not effective in the treatment of the chronic periapical lesion. When small, these lesions can be effectively treated through the root canal as described previously. When the lesions are large, the endodontic (root canal) therapy is usually supplemented by procedures designed to remove the granulomatous tissue and diseased bone through oral surgical procedures (root resection). Teeth treated in this manner also may serve many years as healthy and well functioning members of the masticatory apparatus. DISEASES OF THE TONGUE
The true diseases of the tongue are few in number and of minor pathological significance. They are important from a diagnostic standpoint since
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many of the lesions are considered to be precancerous by the laity and occasionally so by the physician and the dentist. The tongue is the most common oral site of pain of psychogenic origin. The papillary lingual changes on the dorsum of the tongue are sensitive indicators of the general health status of the patient though they are rarely diagnostic for any specific disease. Abnormally Fissured Tongue
This condition is usually developmental in nature but at times a familial history is obtained. It has been demonstrated that under certain conditions of protein deprivation and vitamin B complex deficiency, an abnormally fissured tongue will develop through a splitting of the rete pegs. Appropriate nutritional therapy will prevent further progression of the fissures; however, those already formed will not reunite because of their epithelial lining. Irritation of deep lingual fissures resulting from microbial involvement and decomposition of food debris may give rise to inflammatory changes and painful symptoms. These can be treated by rolling the edges of the tongue downward to open up the fissures. They can be swabbed with a 3 per cent hydrogen peroxide solution or any mild nonirritating antimicrobial agent. A warm sodium bicarbonate mouthwash or an occasional coating of the tongue with milk of magnesia is soothing. Benign Migratory Glossitis (BMG)
This common condition was formerly known as geographic tongue or scrotal tongue. The inflamed margins of the ever-changing depapillated areas of the dorsum of the tongue may give rise to painful symptoms when highly seasoned or acid foods or irritating beverages are consumed. Smoking may also aggravate the painful symptoms. Patients having BMG commonly develop a fear of cancer because of the chronic recurrent nature of this disease and its lack of response to any form of therapy. Local palliative treatment consists of the use of a mild alkaline mouthwash such as sodium bicarbonate solution, restriction of irritating agents and repeated assurance that the condition is benign and that its continued presence does not predispose to malignancy. There is some evidence that BMG may be associated in some patients with achlorhydria. Persistent, painful lesions of BMG may justify requesting suitable laboratory procedures to determine whether achlorhydria is present. Supplemental HCI or glutamic acid HCI administration may ameliorate the painful lingual symptoms. Atrophy of the Tongue Coating
The amount of tongue coating varies significantly at different periods of life and at different periods of the day. A wide variety of systemic conditions may be associated with similarly appearing atrophic lingual changes.
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When there are associated inflammatory responses, nutritional deficiencies of the B complex type or pernicious anemia are more likely diagnostic possibilities. When the tongue is pale, iron deficiency anemias or some circulatory disturbance should be suspected. Atrophic lingual changes are commonly found in sprue and the anemias associated with parasitic infections. Atrophic glossitis is also a characteristic feature of the Plummer-Vinson syndrome. Patients having marked atrophy of the tongue coating should be carefully studied for an underlying systemic disease, which is almost always present. Iron deficiency anemia is one of the most frequent causes of atrophy of the tongue coating. It usually responds to prolonged administration of ferrous sulfate. ACUTE NECROTIC ULCERATIVE GINGIVOSTOMATITIS (VINCENT'S GINGIVOSTOMATITIS)
In acute necrotic ulcerative gingivostomatitis (ANUG) the fusospiroehetal organisms are observed in overwhelming numbers in the clinical lesion. Local and systemic factors may predispose to the development of the typical acute necrotizing lesions of the marginal gingiva and the interdental tissues. Punched-out ulcerative areas may develop on the palate, the cheek and occasionally on the tongue in association with ANUG. This condition is rare in the edentulous patient. Local irritation secondary to poor oral hygiene, occlusal traumatism and inadequate restorative services are the most common etiologic factors. Systemic predisposing causes such as leukemia or malignant neutropenia, acute B complex deficiency and diabetes must always be considered when a diagnosis of primary ANUG is being considered. The diagnosis of ANUG presents no unusual problems since the rapidly developing, painful, punched-out ulcerations involving the marginal gingiva and the interdental tissues are characteristic. A metallic od or usually accompanies these clinical symptoms and it is an important diagnostic finding. If there are prominent associated constitutional symptoms, a primary blood dyscrasia, nutritional deficiency or metabolic disturbance should be suspected. The treatment of primary ANUG is the responsibility of the dentist. Topical antimicrobial agents are used initially to control the acute bacterial phase of this disease. The elimination of local predisposing factors and patient education in the desired oral hygiene habits are phases of treatment which are essential for the effective control of this disease. Intramuscular or oral penicillin therapy in usual dosages may be indicated as an emergency measure for the relief of pain when local treatment by the dentist is not availahle. Systemic antibiotic therapy or local treatment by mouthwashes may result in amelioration of the painful
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symptoms but will not effectively control or cure this condition. Systemic antibiotic therapy should always be followed by local dental instrumentive treatment and patient education in the desired oral hygiene regimen at home. More Serious Fusospirochetal Infections
VINCENT'S ANGINA. This condition is frequently confused with the less serious lesions of ANUG. A critical analysis is required in making a correct diagnosis since Vincent's angina may exist in the absence of gingival lesions. When there are acute, painful, punched-out ulcerations of the soft palate and pharynx, malignant neutropenia, leukemia, unrecognized or uncontrolled diabetes, carcinoma and diphtheria should be ruled out before a diagnosis of primary Vincent's angina is made. NOMA. Noma is a rapidly spreading gangrenous condition of the mucocutaneous orifices and tissues. The oral cavity is the most common site of involvement. Noma of the oral cavity is usually called cancrum oris. The gangrenous lesions characteristically begin on the mucosal surface and frequently are not recognized until the cutaneous tissues are involved. Most clinicians consider cancrum oris as a particularly rampant and virulent type of fusospirochetal infection. This condition occurs chiefly in infants and the elderly, in whom malnutrition or circulatory inadequacies are important predisposing factors. The treatment of Vincent's angina or cancrum oris is the responsibility of the physician. Penicillin therapy consisting of 600,000 to 1,200,000 units per day by the intramuscular or oral routes of administration should be employed for adult patients. This dosage schedule can be adjusted for infants; however, at least 300,000 units of penicillin per day should be administered to these patients. This systemic therapy can be supplemented by the use of topical antimicrobial agents. These are effective for the relief of pain and the control of the more superficially placed microorganisms even when parenteral therapy is employed. ORAL MANIFESTATIONS OF SYSTEMIC DISEASES
Other lesions of the mouth structures can be regarded as oral manifestations of systemic disease. These can be grouped into oral lesions of (1) the nutritional, metabolic and endocrine disorders, (2) dermatologic disorders, (3) diseases of the blood-forming tissues, (4) the chronic infectious granulomas and (5) allergic reactions. Less frequently bony abnormalities appearing in the jaws may be the first clinical evidence of diseases of the osseous structures or, at times, metastases from tumors arising in remote areas of the body. Space does not permit a discussion of the medical management of oral lesions occurring in all of the preceding systemic disorders. The oral mani-
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festations and the medical management of a few of the dermatologic diseases will be presented. It is not surprising that the oral mucosal tissues are involved in most dermatological disorders, considering the common embryologic origin of the skin and the oral mucosa. The clinical appearance and the associated symptomatology of the oral mucosal lesions vary considerably from those of the skin because of the unique environment of the oral cavity. The mild discomfort, or at times pain, that is a feature of the dermatologic lesions on the skin is usually accentuated in their oral mucosal counterparts because of secondary microbial involvement by the oral flora. For this reason, local antimicrobial agents are usually employed for symptomatic relief of the pain associated with the oral mucosal lesions irrespective of the etiologic nature of the dermal eruption.
Herpetic Diseases of the Mouth Primary and recurrent herpetic infections of the lips and mouth are a common and annoying condition. The viral etiology of these lesions has been definitely established, both by culturing the virus from the local lesion and by following the antibody level of the blood serum following the initial herpetic infection. These herpetic manifestations must be considered separately from the recurrent aphthous eruptions, whose etiology has not yet been clearly established. The herpes simplex virus is readily transmitted by means of salivary droplets, contaminated fingers, or instruments. Herpetic eruptions are usually preceded by premonitory symptoms of burning and itching and a feeling of fullness. The mucocutaneous junction of the lips or nares is the most common location of these vesicular lesions. Intraoral herpetic lesions, in the absence of eruptions at the mucocutaneous border, are very common. The classic herpetic vesicle on the lips is of short duration and those in the oral cavity are extremely transitory. They have usually developed into crateriform ulcerations with regular margins and grayish-yellow pseudomembranous bases by the time the patient seeks professional advice. There is an inflammatory halo about the oral lesion. A diffuse hyperemia and edema of the gingival tissues may accompany the initial herpetic eruptions in children. These gingival changes can be readily differentiated from ANUG by the absence of ulceronecrotic changes of the marginal gingiva and the interdental papillae. The individual herpetic lesion usually disappears within 12 to 14 days, with or without treatment. Treatment is usually directed to supportive and symptomatic measures. Local-acting anesthetic agents, such as dyclonine hydrochloride 0.5 per cent, are effective for relief of pain. General supportive treatment consists of therapeutic amounts of vitamin B complex and vitamin C. The herpes simplex virus is unaffected by antibiotics; consequently, these agents are not indicated. They do not shorten the duration of the lesions. Corticosteroid medications are specifically contraindicated, for their use may result in the development of a generalized herpetic infection.
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A wide variety of therapeutic agents have been employed for the prevention if not suppression of the recurrent herpetic eruptions. None have proved to be uniformly effective. Multiple smallpox vaccinations have been reported to reduce the frequency of recurrences in patients susceptible to continual labial vesicle formation. Preparations containing the Lactobacillus have not been generally effective. ID U (idoxuridine, 5-iodo-2'deoxyuridine) has been suggested for the treatment of recurrent herpes labialis because of a possible viricidal action. There is no definite evidence whether IDU acts as a specific antiviral agent or as a nonspecific eell poison. It should again be emphasized that corticosteroid preparations, both topical and parenteral, are definitely contraindicated in the treatment of herpes simplex manifestations. More effective general therapeutie measures must await the development of specific antiviral agents exhibiting the necessary criteria for effc~ tive prophylaxis or treatment for this disease. Herpes Zoster
Current evidence suggests that herpes zoster is usually eaused by a virus, and perhaps one closely related to the virus causing chickenpox. Herpes zoster may involve one or more branches of the fifth cranial nerve. The oral lesions appear identical with those of herpes simplex. The anterior portion of the tongue, the soft palate and the cheek mucosa are the most frequent sites of intraoral lesions. The dermal lesions, found on the areas supplied by the respective segments of the fifth nerve, are similar in appearanee to those eharaeteristic of herpes zoster eruptions in the thoracic areas. These manifestations are usually unilateral. The treatment of this disease is the responsibility of the physician. Topieal anesthetie agents are of only slight value sinee most of the painful burning sensation associated with the intra oral lesions is caused by irritation of the nerve ganglion. Cortisone in a dosage regimen of 100 mg. per day in divided doses has been shown to prevent the annoying postherpetie neuralgia usually experienced by these patients for many weeks after the clinical lesion has disappeared. Prednisone and immune globulin in a series of five injections of 20 ml. each have also been used with reportedly favorable results. High vitamin B complex and vitamin C supportive therapy should also be employed. Erythema Multiforme
This systemic dermatosis is of considerable interest to the dentist because of the severity of the oral lesions in more than 85 per cent of the patients. Frequent limitation to the oral tissues often presents diagnostic problems to dentists and physicians. While the etiology of erythema multiforme has not been clearly established, a virus is suspected. At onset, the oral lesions are vesicular but because of the unique oral environment they are rarely seen in this form. These eruptions are usually
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found on the lips, the cheeks, the palate and the tongue but infrequently on the gingiva. They consist of irregular, reddish, raised areas of varying size. They are larger and have a more extensive distribution than the recurrent aphthous or intraoral herpetic eruptions. Thc lesions appearing; on the vermilion border of the lips characteristically have a bloody, crusted appearance. The oral lesions of erythema multi forme must be differentiated from those associated with drug eruptions and the oral manifestations of pemphigus vulgaris. The treatment of the oral lesions of erythema multiforme is both local and systemic. A bland sodium bicarbonate mouthwash is soothing and tends to cut the mucous film that collects as the result of the inability of the patient to carry out the usual oral hygiene. Anesthetic troches are effective in relieving; the aente painful symptoms and thus permitting the maintenance of adequate nourishment. The systemic treatment of this disease is the responsibility of the physician. It consists of ACTH or cortisone medication. Patients who do not reflpond to ACTH may respond to cortisone. One ACTH therapeutie regimen usually employed for adults consists of 25 mg. intramu:,;cularly every 6 hours for 24 hours and then 25 mg. every 8 hours until a favorable result is obtained. The cortisone dosage usually employed consistfl of 100 mg. every 12 hour:,; for the first 24 hours, then 100 mg. a day. In some patients the administration of corticosteroid preparations is followed by prompt relief of the acute symptoms; in others there is no response. This form of treatment is not curative in the true sen:,;e. It acts by suppressing the acute inflammatory reaction and thus affording the patient considerable relief from the painful symptoms. The preceding dosage regimen should be appropriately adjusted or reduced for children. The maintenance of adequate nutrition and hydration is an important and difficult phase of treatment in infants and children. Parenteral feeding; may be required for these patients.
Pemphigus Pemphigus is a relatively uncommon dermatosis of unknown etiology. This disease i:,; characterized by the formation of excessive crops of bullae or large vesicles. The high incidence of initial lesions on the oral mucosa and the frequent limitation of the bullae to these tissues make this an important disease for the dentist. The early bullous oral mucosal lesions may go unrecognized because of their transitory nature. Well-demarcated eroded areas, whose margins exhibit epithelial tags or remnants, should suggest the possible diagnosis of pemphigus, especially if the disease is of long standing and is accompanied by physical deterioration. The oral lesions associated with pemphigus are painless during; their development and until the mucosa covering the bullae becomes macerated or broken. The base of the bullae now becomes exposed to the environment of the oral cavity, especially the microbial flora. resulting in the acute pain
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which is a characteristic of the oral lesions. Profuse salivation is also a typical finding. The oral lesions of pemphigus are usually found on the lips, the cheeks and the tongue and less commonly on the palate and the gingivae. Oral pemphigus must be differentiated from other generalized bullous eruptions such as dermatitis herpetiformis, erythema multiforme, drug eruptions and benign familial pemphigoid. The presence of bullous lesions in all stages of formation and resolution is a characterisic finding in pemphigus. Biopsy study may be required to establish a diagnosis. The treatment of the oral lesions in pemphigus is the responsibility of the physician. Good oral hygiene should be maintained to lessen the discomfort and pain. A mildly alkaline mouthwash, such as a sodium bicarbonate solution, can be employed for this purpose. When severe pain is experienced, topical anesthetic agents, as recommended for the symptomatic treatment of erythema multiforme, may be prescribed, especially before eating. This will permit the maintenance of adequate nutrition. Prompt and adequate therapy with one of the corticosteroid preparations may not only save the life of the patient but may also prevent or minimize the distressing physiologic and possible toxic side reactions of prolonged therapy with this class of therapeutic agents. The dosage regimen recommended for erythema multiforme can be employed. Some patients respond better to ACTH and others to cortisone or one of the derivatives of cortisone. Some patients fail to respond to any form of corticosteroid therapy and succumb in spite of any form of treatment. Pemphigus lesions of the oral mucosa tend to be more resistant to treatment than those of the skin, probably because of the environment of the oral cavity. The treatment of pemphigus with the corticosteroid drugs is not curative but only suppressive. Consequently these therapeutic agents may be required in high dosages for two or three years, barring complications associated with this form of therapy, until the pemphigus has been "burned out." 4001 Spruce Street Philadelphia, Pennsylvania 19104