Feeling a bit down in the mouth? Many a skin disorder (and more than a few internal concerns) can put in an appearance somewhere inside the mouth. Often changes here can provide important diagnostic clues. So don't be surprised if you hear your dermatologist tell you "open wide"

Canker Sores

Twenty percent of the population suffer from canker sores (also known as apthous ulcers or mouth ulcers). Canker sores are responsible for an estimated 7 million doctor visits a year in the U.S. alone. The degree to which canker sores interfere with your life can vary from minor nuisance to major discomfort.

Canker sores tend to be small, shallow ulcerations covered by a white membrane and a minimal red rim. They can arise anywhere inside the mouth including the gums, palate, inner cheeks and tongue. Usually they are few in number and occur 3-4 times a year lasting under a week. Women develop canker sores twice as often as men. And one statistic I came across stated that 90% of patients with canker sores had parents who also suffered from this malady.

What causes canker sores? No one knows for certain, but they are not thought to be caused by microorganisms such as bacteria, yeast or viruses. Canker sores are not contagious and they are not the same as herpes cold sores. An exaggerated inflammatory or immune response to minor trauma or irritation is suspected.

Perhaps up to 80% of canker sores may be prevented by using an irritant-free toothpaste. Detergents (sodium lauryl sulfate and cocamidopropyl betaine), tartar control agents (pyrophosphate), bleach (calcium peroxide and hydrogen peroxide) and flavor (cinnamon and spearmint) may be to blame. If you suffer from canker sores or other forms of oral ulcerations, use Squigle Enamel Saver Toothpaste which is free of these potential irritants.

Squigle also contains 36% by weight of natural Xylitol, which profoundly reduces the amount of plaque in your mouth. Not only does plaque promote tooth decay and gum disease, it generates irritating acids which can initiate canker sores.

Some secondary causes of canker sores include stress and physical trauma. Other factors may also include nutritional deficiencies (Vitamin B12, zinc, folic acid, iron) or pernicious anemia (intestinal malabsorbtion of Vitamin B12).

While there is no proven food allergy link, some patients blame acidic foods, (citrus and tomatoes) as well as chocolate and nuts.

Providing shelter from further trauma helps canker sores and other ulcerations inside the mouth heal more quickly and protects them from inflammation. Orabase is a standard in dermatology and dental care. The base is specially formulated to stick to slick oral surfaces. Orabase Paste with 20% Benzocaine contains a topical anesthetic to rapidly reduce discomfort. Your doctor may prescribe a specially formulated compound of Kenalog (topical steroid) in Orabase when additional therapy is required.

Home remedies to help control discomfort and speed healing include warm (not hot), salt water rinses and applying a home recipe containing a mixture of Maalox and Benadryl Syrup.

For the occasional painful canker sore, I find applying a prescription strength topical steroid gel or ointment frequently throughout the day (3-5 times) helps speed up healing. However, remember that only a tiny dab of product is necessary; it's not going to stick after all. Orabase is a cream made to stick to slippery oral mucosa. Many doctors will have the pharmacist compound a topical steroid such as Kenalog into the Orabase sometimes along with a topical anesthetic like xylocaine for more widespread ulceration relief.

A relatively new prescription product on the market specifically indicated for canker sore treatment is Amlexanox, (brand name Aphthasol 5%), a paste that helps reduce inflammation of the aphthous ulcers. Aphthasol is applied 4 times a day to canker sores. Most patients tolerate this quite well although a few report transient stinging or burning upon application.

Tetracycline rinses seems to be beneficial. I simply have the patient open a single tetracycline 500mg capsule, mix it with a small amount of water, then rinse and spit at least twice daily. This is in addition to other topical therapies.

The use of oral anesthetics such as prescription viscous lidocaine tends to be limited to significant cases of oral erosions, which prevent the patient from eating or drinking. Swallowing even tiny amounts of the anesthetic can numb the back of the throat, which can result in choking.

When all else fails, and canker sores are destroying the quality of your life, prescription systemic steroids (prednisone) may be warranted. Steroids help shut down the exaggerated immune response thought to be responsible for the developement of canker sores. This is not a longterm option nor should you fall back on the use of oral steroids on a frequent basis, due to the risk of a variety of health risks.

Things Aren't Always What They Seem To Be

Because canker sores are so common, other more significant conditions can be overlooked. Flare-ups of Crohn's Disease and Ulcerative Colitis have been associated with a worsening of aphthous ulcers. The intestinal condition Celiac Sprue, is associated with gluten sensitivity and the formation of canker sores.

A variety of blistering diseases including pemphigus vulgaris, paraneoplastic pemphigus (version associated with cancer), bullous pemphigoid, dermatitis herpetiformis, linear IgA disease and certain forms of lupus can all cause painful deep oral erosions. So too can Behcet's, erosive lichen planus, lichen sclerosis et atrophicus (LS et A), oral carcinoma, chemotherapy and immunosuppression. If you find sores that won't heal (make 2 weeks your cut-off) or are plagued by chronic never-ending bouts of ulcer formation, check with your dermatologist. This could be a condition far more complicated than a simple little canker sore concern. Treatment is aimed at the particular medical problem as well as continued supportive oral care to help palliate discomfort and heal the erosions.

A biopsy may be necessary to determine the precise nature of the condition. If one is performed, make sure that a specialty test called DIF (direct immunoflourescence) is also run. This test requires a special transport media for the pathologist, so make sure this is on hand before the biopsy is performed. Otherwise, you may find yourself back for a repeat performance.

Drug Eruptions

Question: What symptom automatically moves a drug eruption into an entirely different category of concern for the dermatologist?

Answer: the development of sores in the mouth or other mucosal areas. Steven's Johnson Syndrome signifies a much more critical status of an allergic reaction to medication, requiring systemic steroids, supportive care and much closer monitoring. If you're at home nursing a "simple" rash caused by an antibiotic (or other medication) and develop ulcerations inside the mouth, this is ample reason to let your dermatologist know right away.

Tongue-Tied

Tongue wagging just isn't what it used to be. The tongue plays an important role in showcasing the presence of a bevy of medical concerns.

Lipstick should be glossy, not your tongue. If your tongue looks bright red, glossy and smooth (the taste buds are flattened out and barely visible), this could be a sign of vitamin B12, zinc or iron deficiency or suggestive of pernicious anemia. A simple blood test should be able to confirm the diagnosis and vitamin supplementation should be able to fix a nutritional problem.

Hairy leukoplakia (a hairy white tongue) is often associated with Epstein-Barr virus, HIV infection or some other cause of immunosuppression. I have read some reports that cigarette smoking may also cause white hairy tongue, which resolves upon cessation of smoking. Hairy leukoplakia is not a common intraoral complaint but one that is truly dramatic for both patient and doctor. The only patient I have ever seen with this condition was a patient who presented with advanced AIDs in the early days of understanding about HIV infection.

Contrast this with black hairy tongue that tends to be antibiotic induced. Tetracyclines and penicillins are the primary culprits. Discontinuation of the antibiotic often results in spontaneous resolution of the condition.

Treatment for white hairy tongue consists of addressing the underlying condition as well as trying to remove the tongue debris. Oral solutions of Nystatin, clotrimazole or even Retin A solution have been used as has systemic ketoconazole.

A thick heavy white coating on the tongue may be a yeast infection known as thrush. This is different than the thin white coating that can be seen after eating, first thing in the morning or due to mild illness. The culprit of thrush is yeast known as Candida albicans. While thrush tends to be more of an annoyance, some patients develop a sore throat or shallow ulcerations in association with the infection.

The most common causes of thrush include a response to antibiotics, inhaled steroids (commonly used in asthma treatment), immunosuppression, chemotherapy and diabetes. The treatment of thrush consists of prescription rinses with Nystatin Oral Solution 3 times daily. Rarely systemic anti-yeast medication such as diflucan may be necessary.

Burning Mouth Syndrome

You may not see anything, and the doctor may not either, but somehow patients with burning tongue inevitably make their way to see the dermatologist.

Burning mouth syndrome (BMS) is a poorly defined disorder primarily affecting postmenopausal women. The most common areas affected include the tip of the tongue, the hard palate and the inside of the lower lip. The precise cause of BMS is unknown but in many cases a neurological disorder due to malfunctioning of the cranial nerve leading to the phantom pain is suspected. There is no cure, but there are some things which can be done to make the patient more comfortable.

There may be other causes or contributing factors to BMS. Drs. Walter and Dorinda Shelley combed the literature looking for possible causes for this disorder and recommend the following work-up for burning tongue patients in their book Advanced Dermatology Diagnosis:

• Have good blood work to check for anemia, serum ferritin and vitamins B1, B2, B6 and B12. (Supplementation with Vitamin B, B12 and iron has been shown helpful for many patients.)
• Get checked for glucose intolerance. (Correcting diabetic tendencies may help or at least intervene with diabetic neuropathy.)
• Get a salivary gland stimulation test. (Artificial saliva helped 19 patients.)
• Check for low-grade thrush. (Anti-fungal therapy can improve symptoms.)
• Get a specialist's opinion on your dentures. Rule out acrylic allergy to dentures. Rule out teeth grinding, tongue thrusting and other mechanical disorders. (Fixing these concerns can alleviate the problem.)
• Patch test to food related products if the symptoms are intermittent, including ascorbic acid propylene glycol, benzoic acid and cinnamon. (Dietary avoidance can cure the problem for some patients.)
• Are there menopausal symptoms? (No mention if treating with estrogen supplements, soy, etc. helped, but something to keep in mind.)
• History or symptoms of reflux esophagitis? (Eliminating gastric acid damage to the tongue can reduce inflammation.)
• Don't be shy about getting a complete psychological investigation to rule out stress, anxiety, depression or even sleep disorders. It doesn't mean you're crazy or imagining your symptoms, but dealing with underlying contributing conditions or ones which have developed due to the stress of BMS may be helpful.

  It is important to remember that antidepressants have been shown to be beneficial in reducing discomfort due to other neurological concerns (like post herpetic neuralgia) and are certainly worth discussing with the doctor involved in your care.

Above all, don't give up hope.

Dry Mouth

When you're so parched it feels like your tongue is permanently glued to the roof of your mouth, it's time to take control. The most common cause of dry mouth is an adverse response to many medications, ranging from antihistamines to antidepressants. The good news is that most patients will acclimate to this change within a few weeks.

But if you're not in the midst of medication changes, and can't get past uncomfortable cottonmouth, take this up with your doctor. Autoimmune diseases including Sjogren's can present with oral dryness. It's not uncommon for Sjogren's patients tend to suffer from a variety of nonspecific skin sensitivities and dry skin and often see a dermatologist long before they visit a dentist or rheumatologist.

Tips On Treating Dry Mouth

Right now there is no perfect therapy and no true "cure" for dry mouth. Two prescription medications, however, Salagen (pilocarpine hydrochloride) and Evoxac (cevimeline), are able to help stimulate saliva production.

• Avoid caffeine,(coffee, tea, and sodas) and alcohol.
• Stop smoking.
• Chew sugarless gum or suck on sugarless hard candy.
• Add a humidifier to the bedroom at night.
• Soothe the mouth and avoid harsh irritants found in regular toothpaste by using Squigle Enamel Saver Toothpaste.
• Join the Sjogren's Syndrome Association to keep up to date on the latest treatments of dry mouth.

Unusual causes of dry mouth include heavy metal poisoning including lead; cancers such as multiple myeloma or oat cell lung carcinoma; diabetes, and neurological damage to the spinal cord or central nervous system.

Oral Cancer

I have always included an examination of the oral cavity when I do a complete skin examination. Not only does the mouth hold important clues from a dermatology perspective, but also oral cancer can present as painless nodules, which the patient has come to accept as "normal". Smokers and tobacco chewers have an increased risk for developing oral cancer. During the examination the areas under the tongue, the sides of the mouth, the hard palate are all gently but firmly palpated in search of undetected concerns. Another cause of painless nodules and ulcerations of the hard palate; systemic sporotrichosis, a fungal disorder that can be seen in immunosuppressed patients. Ask your doctor to order a fungal culture and special stains for any biopsy of a painless nodule in this area if there is any question.

Gum Overgrowth

While unusual, when the gums seem to become enlarged, puffy and even reduce visibility of your pearly whites it's time to seek a dermatologist or dental examination. Causes of gum overgrowth (gingival hypertrophy) include a response to medications like Dilantin, Cyclosporin, Nifedipine and oral contraceptives; infiltration by leukemia or lymphoma; hormonal states like puberty and pregnancy; trauma from braces; and systemic diseases including tuberous sclerosis, sarcoid, Melkersson-Rosenthal Syndrome, scurvy and Crohn's disease.

Discolored Gums

The color of one's gums can reveal much about one's state of health, race and even social habits. Smoker's melanosis seen in 5-22% of smokers. Smoking stimulates the melanocytes to manufacture and deposit melanin on the gums and buccal mucosa.

Certain medications can cause the gums to develop dark areas. Bismuth and Zidovudine (AZT) can result in gingival discoloration. Minocycline can discolor the teeth and bone that then appears blue through the gums. Chronic lead poisoning can be exposed by the presence of a blue-black line (Burtonia line) at the gingival margin. Other heavy metal poisonings can also discolor the gums.

Amalgam used in dental fillings contains mercury, silver and tin. If minute amounts of filling material become accidentally lodged within the gums the result is an amalgam tattoo (localized argyria). The clinical result is bluish gray spotty discoloration.

Abnormalities of the endocrine system can result in darkening of the gums. Addison's disease can cause gums to turn a fairly even brown or black. Blood tests checking serum electrolytes and cortisol levels can help diagnose this condition.

African Americans and other people of color can naturally have dark gums (or the gums can darken slowly with the normal aging process). But if your gums have always been pink and you notice a sudden change in coloration, check with your doctor.

Bleeding Gums

If your gums bleed when you bite a crispy apple or when you brush your teeth, check with your dentist. Poor dental care is unquestionably the most likely cause of bleeding gums. You probably need a good cleaning and a good oral hygiene program. Keep plaque at bay with Xylitol based Squigle Enamel Saver Toothpaste.

But for the rare patient who can't seem to overcome their bleeding gums, a Vitamin C deficiency (scurvy) could be to blame. Today, picky eaters, elderly patients unable to do adequate shopping or cooking chronically ill individuals and alcoholics can and do indeed present with this unusual but not unheard of condition.

Take a multivitamin, multimineral supplement, and make sure you get 500-1000mg of Vitamin C each day.

Viral Disorders

Many a viral infection can cause nonspecific spots, ulcers and blisters inside the mouth. Most often these are common childhood infections like hand-foot-mouth or herpangina (not to be confused with herpes simplex). Accurate diagnosis and palliative treatment are typically all that is required to get patients through an uncomfortable week. Children who are unable to get adequate food intake or become dehydrated may require short-term hospitalization and intravenous rehydration.

Koplick's Spots of Measles

Measles may be one of those childhood diseases long thought eradicated, but every now and then an outbreak occurs or occasional case presents at the emergency room perplexing doctors who have only trained since the introduction of the MMR vaccine. Measles is one of those viral disorders which has a telltale sign known as Koplick's spots. Tiny white spots scattered across the inner cheeks are diagnostic for measles (rubeola) and can help differentiate this from other viral infections. Koplick's spots typically present several days before the rash of measles.

Lichen Planus

Pruritic purple polygonal papules and plaques (a fancy medical way to describe itchy purple bumps) is the classic description for a disorder known as lichen planus. But the presence of delicate lacy white streaking on the inner cheeks (buccal mucosa) is. Lichen planus can also cause painful erosive sores on the gums, tongue and throughout the mouth. Longstanding sores from lichen planus can rarely progress into squamous cell carcinoma so periodic oral examinations at least once or twice annually are encouraged.

Freckles

Freckles on the mucosal (inside) surface of the lips, the gums and the inner cheeks can be the random normal mole, a normal variant in ethnic patients, a hallmark of a potentially cancerous gastrointestinal disorder (Peutz-Jegher's) or even malignant melanoma. If you have brown spots within the mouth, it is safest to have the dermatologist examine them. Better to be safe than sorry.

Who would have thought there was a world of dermatology inside the mouth? If you are experiencing "skin concerns" past your pearly whites, visit your dermatologist and just say "ahhh".

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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