Oral Insertable Prosthetic Device as an Aid in Treating Oral Ulcers

Abstract

A 41-year-old woman presented to the dermatologist with a 3-week history of painful oral ulcerations and i ngui nal adenopathy on the right side. In addition, she noted a mild, asymptomatic skin eruption on the extensor surface of her forearms. A review of systems was negative, includi ngthe absence of arthralgias and photosensitivity. Physical examination revealed a well-developed woman with numerous oral erosions (Fig 1). There were faint, illdef i ned erythematous scaling areas over both extensor forearms. Painful right-sided inguinal lymphadenopathy was p r e s e n t .Because of the sparing of the alveolar mucosa, an autoimmune cause of the ulcers was suspected. Initial laboratory findings included a white blood cell count of 3.8\m=x\109/L, an erythrocyte sedimentation rate of 44 mm/h (normal, 0 to 20 mm/h), C3,15 mg/dL (normal, 83 to 177 mg/dL); C4, 3 mg/dL (normal, 15 to 45 mg/dL), singleand double-stranded DNA, positive; and antinuclear antibody, positive at 1:641 (speckled). Pertinent negative findi ng included a negative Thayer-Martin test result and chlamydia cervical cultures, negative rapid plasma reagin testresults, normal hematocrit, and a normal urinalysis. Histopathologic findings of a skin biopsy specimen obtai ned from the right forearm revealed epidermal thinning with vacuolization of the basal cell layer along with a perivascular and periadnexal lymphocytic infiltrate. Direct immunoflourescence revealed a granular band of IgG, IgM, andC3 at the dermoepidermal junction. DIAGNOSIS Pus erythematosus with oral ulcérations. THERAPEUTIC CHALLENGE d¡te gained contact with the surface of the lesion is ''"lit tí^°a cnieve in the mouth. In some cases, this may of 0 fle effectiveness of topical steroids for the treatment al ulcérations and gingivitis of lupus erythematosus. SOLUTIONSince her oral ulcérations were her most significant complaint, the dental consultant constructed a prosthesis to occlude the topical steroid. The prosthesis was made of flexible vinyl (Bioplast, Great Lakes Orthodontics Supply, Lake Bluff, 111) approximately 3 mm in thickness, which was vacuformed from a cast of the patient's mouth (Fig 2). The area of the oral lesions was approximated by drawing it on the casts. The vinyl prosthetic agent was then trimmed so that the edges just covered the ulcers. The edges were smoothed with a chamois wheel and fitted to the patient (Fig 3). Within 4 days the patient experienced significant healing using fluocinonide (Lidex) gel under continuous occlusion four times per day (Fig 4).Over the following 8 weeks she developed periungual telangiectasias, a photosensitive rash with some discoid-appearing lesions, and lower extremity edema. A renal biopsy specimen showed glomerulonephritis. The diagnosis of systemic lupus erythematosus was made and she was placed on high-dose prednisone therapy. She has responded well to systemic treatment. Intermittent brief usage of her vinyl insertable prosthesis controls occasional recurrences of her oral lesions. COMMENT Mucous membrane lesions occur in 25% ...

European Guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology – Part II

“…For gingival lesions, use of a custom‐made, soft drug‐delivery tray covering the gingivae to extend drug contact time and absorption, has been described 126 . This is a method sometimes used in routine clinical practice, though no study has compared its efficacy with other methods of application.…”

The management of mucous membrane pemphigoid and pemphigus

“…Patients should be made aware that such applications are typically off‐label and the products often stipulate “for external use only.” A prosthetic device (such as a dental tray) that fits over the teeth and gingiva can be fashioned by a dentist to make application of a corticosteroid preparation easier. When corticosteroids are applied under dentures or such an appliance, their potency is increased (71). Intralesional corticosteroid injections can be used in the treatment of MMP and PV with some success.…”

Review of traditional and novel modalities that enhance the permeability of local therapeutics across the stratum corneum

“…In addition, a shower cap may be used for the scalp and clear tape for facial lesions. Buccal mucosa occlusion may be performed using custom‐designed dental appliances 6 . Customized cutaneous occlusion appliances have also been described and can be effective 7 .…”