Pharmacologic Management of Oral Mucosal Inflammatory and Ulcerative Diseases

Abstract

Orofacial pain is one of the most common patient complaints encountered in dental practices. After infectious diseases of the teeth and periodontium, oral ulcerative diseases represent one of the most common causes for dental patients presenting with orofacial pain. Oral inflammatory and ulcerative diseases may have similar clinical appearances with different etiopathogenesis including traumatic, infectious, immunologic, and neoplastic origin. Empirical therapy of oral ulcerative and inflammatory diseases without a specific diagnosis is not effective and may have unintended consequences. Diagnostic evaluation of oral mucosal inflammatory and ulcerative diseases includes a detailed dental and medical history, review of systems, clinical examination, and, in selected cases, incisional biopsy. Diagnosis of oral ulcerative diseases begins by determining three important features necessary to distinguish oral ulcers of different etiopathogenesis. The most important is whether the patient presents with a single or solitary ulcer or whether there are multiple ulcers present. The second important distinguishing feature is whether the patient is experiencing a primary ulcer episode or one of many recurrences. Finally, it is helpful to determine the duration of ulceration. Ulcers present for less than 3 weeks are considered acute, whereas those lasting over 3 weeks are considered chronic in nature. Table 1 provides the array of potential diagnoses for oral mucosal inflammatory and ulcerative diseases based on these diagnostic criteria. When a patient with oral ulceration does not benefit from initial therapy chosen on the basis of clinical presentation, an incisional biopsy is indicated for histopathologic evaluation. Direct immunofluorescence testing should be considered if vesiculoerosive diseases are suspected. To optimize an accurate pathology diagnosis, clinicians should ensure that biopsy specimens are properly obtained from affected and non-ulcerated mucosa and promptly submitted to the pathologic laboratory, preferably before the institution of any immunomodulating therapy.