Living with an oral mucosal disease

As the organizers of the International Oral Lichen Planus Support Group at Texas A&M College of Dentistry, Dr. Nancy Burkhart and Terry Rees are well versed in sharing suggestions to minimize symptoms brought on by oral mucosal diseases such as oral lichen planus, pemphigus vulgaris and pemphigoid. And advice isn’t given just to patients. Educators and oral health providers can benefit from this information, too.

Patients

• Patients should have professional cleanings and exams every two to three months. Periodontal patients may need to be seen every two months, depending on status and periodontal health.
• Tartar control toothpastes and those with flavoring agents should be swapped for products such as Xerostom or Biotène, which also are highly effective in patients with xerostomia, or dry mouth. Toothpaste free of additives such as sodium lauryl sulfate is recommended. A children’s toothpaste is usually tolerated well since it has limited ingredients and tends to have less flavoring agents.
• The use of MighTeaFlow chewing gum, lozenges or gel and XyliMelts lozenges helps with xerostomia, which in turn, can keep lesions at bay.
• A soft bristle brush such as the Rx Ultra Suave Red Brush made with super-soft nylon bristles — .003 millimeters in diameter — assists in cases where the mouth is too sore for routine oral hygiene. These can be used until the lesions are controlled and one is able to comfortably return to routine home care procedures.
• Mouth rinses containing alcohol should be avoided to prevent discomfort and tissue irritation.
• Some flavoring agents such as mint or cinnamon found in many dental products, including mouth rinses and toothpaste, may act as an irritant to the tissues and should be discontinued. Patients should also avoid chewing gum, candy and mints that contain these flavoring agents, such as wintergreen, peppermint, spearmint and cinnamon (cinnamaldehyde).
• Flossing is recommended, though some patients prefer the interdental brushes that clean the proximal spaces between teeth.
• It is helpful to document any tissue irritation and keep a log of possible “trigger” mechanisms that may have caused lesions or irritation. The causes may be certain foods, beverages, changes in toothbrushes or oral care products, oral injury, etc.

Providers

• The practitioner should note any areas that are in contact with sharp edges, crowns or restorative materials. This is routinely performed during a dental exam.
• All soft tissue areas should be evaluated. Findings should be described and recorded, and any suspicious areas re-evaluated. Careful evaluation for candida is suggested, especially for patients who are using topical corticosteroids. Candida infection is especially prevalent in long-term steroid use.
• Careful scaling of all teeth should be performed with as little disruption of the tissue as possible. When significant periodontal pocketing is present, multiple appointments with gentle scaling and debridement are preferable to conventional deep scaling and root planing. When quadrant or multiple scaling sessions are necessary, the practitioner should allow a two-week period between appointments for tissue healing and gingival shrinkage to facilitate plaque and calculus removal.
• Ultrasonic scalers should not be used for extensive subgingival debridement to minimize irritation to the tissue. Hand scaling is preferred.
• Air polishers may be too disruptive to the soft tissues if misdirected and should be avoided. If used, caution is advised.
• Any polishing of the teeth should be performed using a mild paste such as the patient’s current toothpaste. This can be applied with a prophy cup. Gently brushing the teeth with the paste in the dental office offers some benefit.
• Polishing paste that is gritty or coarse should not be used because of irritation to the tissue above and below the gingival margin.
• Tissue areas that do not respond to treatment may need further evaluation and possible future biopsy.
• Periodic oral digital photographs for initial and follow-up appointments are suggested. This allows better evaluation of treatment progress. Encourage patients to take photos on their cellphones or with their own digital cameras so that the clinician has a good understanding of how the tissue responds between appointments.

-Tips by Dr. Nancy Burkhart and Dr. Terry Rees