Winter Park Dentistry- Canker Sores, Herpes, Oral Cancer (part 1)
Dr. Ramzi Matar (Winter Park Dentistry): Hello everybody, I want to welcome you to today’s podcast episode. Today we are talking to Dr. Indraneel Bhattacharyya. Dr. Bhattacharyya is an associate professor at the University of Florida, he is the director of the residency program for oral pathology. I’ve heard you lecture several times, probably half a dozen times, I was very intrigued, you always present great information and when I came up with the topic of oral lesions, oral sores, oral ulcers… I’m very glad you’re on here. I know you did your training in Indiana, and you’re a huge Colts fan, and all sorts of basketball fan. So Dr. Bhattacharyya thank you so much for being here. I’m just going to get started, our biggest mouth sore that I see on a day in day out basis, is the classic canker sore, what they call it, also known as an aphthous ulcer, so tell people that are watching this why it comes in and how people should treat it.
Dr. Indraneel Bhattacharyya: Sure thing… Canker sores as you mentioned is one of the most oral sores, hits about 20% of the population. That is enormous, it’s close to 2 million to 5 million people on a daily basis that get canker sores just in the US. It’s an enormously common problem. People deal with it most of the time because they know these are transient sores, and lots of our patients ask us “why am I getting canker sores?”. The reason is it’s an ordinary disease, it’s not something you’ve done to yourself, it’s not something you can get or transmit through people, it is purely an autoimmune disease, just like several others. It’s possibly genetically transmitted, so if parents get canker sores, often their children will get canker sores. But some of the other things that can trigger canker sores are stress, so if you’re very stressed, if you haven’t slept well, if you’re under job-related, or mental, physical stress, you can break out. And when I say break out, typically with canker sores, they occur on soft tissue, not on the roof of your mouth, it is mostly the looser tissue, under your tongue, side of your tongue, tip of your tongue, cheeks, the inside of your lower lips, or all the way back on the soft palate, or on the top of the tonsils.
We tend to divide canker sores in major and minor. Minor are the ones that are a little smaller, and they’re typically seen in the front of the mouth, and major are seen in the back of the mouth, and those really are a major pain, they’re very painful. I know patients who have lost twenty pounds of weight in one month because they couldn’t eat or even drink a supplement, a nutritional supplement. So this can be a big pain. Typically again, young people get it, we see across the age groups, we have seen patients across 60 years of age who get canker sores, there are people like myself who get one in maybe five years, or my son who gets one every two, three months, but not that painful, we can manage it with some topical ointments available under the counter, such as Anbesol, there’s several others, like Benzocaine, you can go to your dentist and ask them to write a prescription because you’re in pain, if you get it once in a while. However, there are other patients I know who are never free of one. So they get four or five, get better, before the last one’s better, they have another. These individuals are in severe discomfort, and for those patients, we have to give them topical steroids, or you have to put systemic steroids, which has, you know, many major side-effects, on putting patients on steroids.
There are some papers out these days that say Omega-3 acids, basically fish oil, they can in high doses, and you might say “what is high dose?”. Generally about 6000 milligrams a day, so I wouldn’t recommend it. There are some other studies which have looked at anti-gout medication, like Colchicine, but the problem with Colchicine is that it can cause stomach upsets, so you have to be careful, talk to your dentist, or your physician. Before you start taking something like that, you need to be evaluated well. Canker sores are not something to be afraid of though. Most dentists were trained well, I know our University of Florida graduates, all know about topical steroids, they can write you a topical steroid prescription, and you apply it with a cue tip on your finger. Typically, two to three times a day, and you notice the sores fade away. And then they may come back, depending on, again, your stress level.
Dr. Ramzi Matar (Winter Park Dentistry): What’s the most common topical steroid you’re prescribing, what’s the high on your list?
Dr. Indraneel Bhattacharyya: The one we prescribe the most, the medical name is called Fluocinonide, sold as Lidex, and it’s a cream, or an ointment, or age. The oral form, which is a step higher, more potent, I personally prefer this, is called Clobetasol, it’s pretty powerful, available under cream, ointment, or gel. Some people will get let’s say ten or twelve sores all over the mouth, there are rinses available. The classic one is Decadron, and they can rinse their mouth… But these are all prescription drugs.
Dr. Ramzi Matar (Winter Park Dentistry): So if somebody’s watching this, and they’re looking for their dentist to give them something, these are the ones that you currently can get. There’s a study I’ve just read about, I don’t know if you know anything about it, [someone tried curing] canker sores with honey, this is for people who like organic or homeopathic type relief, and it said that the sores healed either as fast or faster than with steroids. Have you heard of that?
Dr. Indraneel Bhattacharyya: Absolutely. The active ingredient in honey, which most people believe works, is actually a pretty miraculous drug, if we can isolate it. It’s called propolis, and lots of people have done work on propolis. It is a product generated by the honey tree, and propolis, or honey, can be applied directly to all canker sores. You can apply it to wounds on your skin, to wounds in your mouth, you can apply it for other oral diseases, not just canker sores, but the problem is you don’t have very good studies where they compare this product matched against. This is one of the few, but there are a few others if you search on the web, you might find other studies – and you have to get away from using the word honey, and use the word propolis – but most people, again, it’s the same skepticism against other medications, because not everything works well… I’m not retracting away from it, but I’ve seen how well steroids work with patients with pain and discomfort. But for most people, casual canker sores sufferers, by casual I mean they get one or a couple of sores a month, honey’s great. They can find good quality honey… But not again, for children. For children, honey is often contraindicated, but check with your physician.
Dr. Ramzi Matar (Winter Park Dentistry): So I take it honey bees don’t have to worry about getting canker sores, right?
Dr. Indraneel Bhattacharyya: That’s right!
Dr. Ramzi Matar (Winter Park Dentistry): The next, second biggest one I see, and there’s a lot of misinformation out there, is the common cold sore, or herpes. There’s from when I was young above the belt, below the belt, I think new research suggests they’re all the same… Again, if I’m somebody watching this video, and I have a cold sore, a fever blister, whatever you want to call it, herpes labialis I think is the technical term… Tell us a little background about what the virus is, how do we get it, who has it, does everybody have it? Some of the issues with the above the belt, below the belt, and of course, current treatments.
Dr. Indraneel Bhattacharyya: That’s a very important point. I think, very important not only for dental patients to know but I think for most patients to know. Herpetic sores are very different from canker sores. One of the biggest differences is cold sores, or herpetic sores – I’m going to use the word herpetic sores here, and I will distinguish between herpes simplex and non-herpes simplex… Herpes simplex is a virus, that unfortunately humans are the only known reservoirs, so you can’t have experimental animals getting infected with herpes, and therefore, unfortunately, research gets limited, because all the other treatments are tested on animals. There are some mice that you can create herpetic sores on, infect them with… However, there is herpes simplex 1, which causes oral sores. However, does that mean that you can’t get it below the belt? It’s possible to have HSV 1 below the belt. You also have HSV 2, which is the general herpes, same family, just one small difference in the structure, and these are seen typically in the external genitalia, in both men and women. Can they affect the mouth? Yes, but do we see them in the mouth? No, you have to have either genital contact or infection in the mouth before you can establish that. Do they differ between the two? Not really, they look the same. Typically, they happen in bound tissue. The top of the tongue, the roof of the mouth, or the attached gums, the shiny part of the gums. And of course the outside of the mouth, outside of the lips, which we call herpes labialis.
People who wrestle often get them on different places, like behind their knees, and it’s called herpes gladiatorum, from skin contact, spread by contact. The doctor, or the physician, if they have it, they should not typically be treating patients, don’t go kissing children, because you can transmit it. What if the sore breaks open, the blister breaks? It’s no longer infective, you’re okay, you can treat a patient, deliver a crown… If you have an infected patient, can you perform the delivery of a crown? Absolutely, call them back five days later, give them something to treat the discomfort.
The typical treatment is Acyclovir. It’s genetically available, it’s very cheap, even without prescription coverage, most people would be able to afford the cost of Acyclovir. Doses can be different, but you can give it to children with syrup, or you can take it on tables to adults and over. You also have what I prefer, Valacyclovir, this is a newer drug, which was first approved for genital herpes, but now has been approved by FDA for treatment of herpes simplex 1, which is oral herpes. Typically the dose is anywhere from 500 to 1000 to 2000 milligrams, a day. And you can just use it two times, or there times, which is two days or three days. If it’s a very severe infection you can go all the way up to seven days. Herpes simplex also has two kinds of infection. One is called primary infection, children typically get it or young adults get it. It’s spread throughout the whole lip, on the cheek.
Dr. Ramzi Matar (Winter Park Dentistry): Lots of discomfort there, I’ve seen those kids, they are hurting. Fever…
Dr. Indraneel Bhattacharyya: Fever, children refuse to eat or drink because it’s very sore. It lasts anybody from 7 to 10 days, and then the lesions get better. Without the treatment, it will get better, because the virus goes back in, and travels along the nerves. So typically when people cold sores, the secondary kind, it’s that they’ll get one or two sores, they haven’t slept well, they’ve consumed too much alcohol, any of these things that can make it happen, will trigger the virus to travel out of the nerve and affect a particular part of the skin, typically we’re talking about the oral region, it can affect anywhere in the face. Let’s say it happens on the upper lip. You can actually feel a tingling, or a burning sensation, or a numbness. Many people would say it’s a weird sensation. It comes typically with herpetic lesions, and again, if someone gets them frequently, that’s when we treat them, otherwise we tell them to take anything over the counter, to cover it up. And to wash their hands frequently, and if they drink from a cup, to wash it off.
In dental offices, the transmission is much less, in spite of what people think. Because dentists are their assistants are almost always wearing gloves, and we are changing them for every procedure. So chances of transmitting this are thin. However, when you’re using a high speed hand piece, if somebody has it also, it can actually aerosolize. It’s coming in the area of contact and the spray gets in there, so it’s better to wear eye protection, that’s why we have our patients wear eye protection, our assistants and ourselves too.